Search

We determined whether there is a difference in the incidence of urinary continence in cloacal and classic bladder exstrophy after staged bladder neck reconstruction using the Young-Dees-Leadbetter technique.We reviewed the records of patients with cloacal and classic bladder exstrophy who underwent staged bladder neck reconstruction from 1971 to 1997.The Young-Dees-Leadbetter bladder neck reconstruction was completed in 23 patients with cloacal exstrophy, of whom 5 (22%) became continent and 18 (78%) have persistent incontinence. A clinically apparent neurological abnormality significantly hindered the achievement of continence. Specifically 1 of the 13 children (7%) with versus 4 of the 10 (40%) without a neurological abnormality became continent (p0.05). In contrast, staged reconstruction of classic bladder exstrophy resulted in urinary continence in 67 of the 82 patients (82%). Of the 67 continent patients 23 (34%) cannot void and require intermittent catheterization. None of the patients with classic exstrophy had a neurological deficit.The ability of the Young-Dees-Leadbetter bladder neck reconstruction to result in urinary continence significantly differs in the cloacal and classic bladder exstrophy populations (22 versus 82%, p0.001). Our findings also suggest that a coexisting neurological abnormality significantly hinders the ability to reconstruct a functional bladder in patients with cloacal exstrophy.

Vesicoureteral reflux in children with myelodysplasia is usually secondary to abnormal bladder storage. The purpose of this study was to assess the outcome of vesicoureteral reflux in children with myelodysplasia.We retrospectively analyzed the records of 319 children with myelodysplasia who presented to our institution between 1978 and 1985. Of these children 95 presented with or had reflux during followup and they were treated with prophylactic antibiotics. Clean intermittent catheterization and anticholinergic medication were added to the regimen when indicated.Reflux resolved in 63% of these patients with nonsurgical management. Temporary cutaneous vesicostomy was performed in 23 children (24%) with persistent high grade reflux or evidence of upper tract deterioration. Ureteral reimplantation and augmentation cystoplasty were performed in 18 (20%) and 8 (8%) patients, respectively. No patient had progression to chronic renal failure and scars developed in only 14 kidneys (10%).In the majority of cases (63%) reflux resolved with nonsurgical management. Reflux in these patients should not be treated in isolation. The management of reflux is primarily aimed at improving bladder storage. The combination of aggressive nonsurgical therapy and close observation is recommended. This regimen leads to the satisfactory resolution of reflux with minimal renal morbidity.

Vascularized flaps for repeat hypospadias repair are often limited. We report our experience with the dartos flap in children undergoing secondary hypospadias and complex urethral repair.The dartos flap is fibroadipose tissue between the scrotal skin and tunica vaginalis layers with its vascular pedicle based at the penoscrotal angle. The flap reaches the distal penile shaft without tension. Eight patients 1 to 17 years old (mean age 6) underwent urethral surgery and an interposed dartos flap procedure in 1994 to 1995.Of 6 patients cosmesis was excellent in 84%, erections were straight in 100%, and urinary streams were of good quality and without fistula in 100% after repeat hypospadias surgery. Following staged repair for anterior urethral valves a urethrocutaneous fistula developed in 1 patient and following urethral duplication repair results were excellent in 1. Mean followup was 1 year.The dartos flap is easy to mobilize and it provides excellent coverage for repeat proximal hypospadias surgery, since the dartos remains undisturbed. We endorse its use for complex urethral surgery and believe that the extra layer of closure helps to prevent urethrocutaneous fistulas.

We describe creation of a modified umbilical stoma as part of continent urinary diversion using appendicovesicostomy.Umbilical stomas were created using the eversion-inversion principle in 25 patients undergoing appendicovesicostomy.Mean followup was 3 years. Cosmesis of the umbilical stoma was good in all cases. Stomal stenosis required surgical revision in 8% of cases.We recommend our modified umbilical stomal technique for appendicovesicostomy because it allows good cosmesis without compromising stomal function.

Intravesically applied oxybutynin has been reported to have no significant systemic anticholinergic side effects, with excellent efficacy in the treatment of neurogenic bladder dysfunction. Currently, the morphologic effects of intravesical oxybutynin on the local bladder tissue are not well established. It is the purpose of this study to address this issue in an animal model. Thirty-nine New Zealand White female rabbits were catheterized daily and intravesical solutions instilled for as long as 30 days. In part A of the study, the overall histologic effects of intravesical oxybutynin were examined by comparing oxybutynin with saline administration. Part B of this study compared the relative effects of crushed oxybutynin tablets and pure oxybutynin powder. The bladder histology and urine microbiological studies were analyzed in a blinded fashion. We found that the crushed oxybutynin tablets and saline administered intravesically produced similarly mild inflammation in the bladders (p0.05). When we compared the crushed oxybutynin tablets and pure oxybutynin powder, however, the crushed tablet group was found to have a mild eosinophilic infiltrate seen in 5 of 9 animals, which was not observed in any of the animals in the other groups (p = 0.029). Qualitative and quantitative analyses of the microbiological findings were not different among the different groups (p0.05). Our findings support the clinical use of intravesical oxybutynin as being safe for local tissue. However, consideration should be given to the use of the pure powdered form of oxybutynin, since the crushed oxybutynin tablets may lead to allergic reactions.

Twenty-eight hernias occurred in eighteen of seventy-nine pediatric patients on peritoneal dialysis (PD). There was 18 inguinal hernias (6 bilateral) in 12 patients (11 boys and 1 girl) the average age of the male patients with inguinal hernias was 5.2 years vs 9.3 years for the remaining 32 males. Four of the 11 patients were under 2 years old, where as only 3 of the remaining 32 patients were less than 2 (p less than 0.05), and 3 of the 6 patients with bilateral hernias were under 2. A high incidence of recurrent hernias was noted when only high ligation of the hernia sac was performed. We conclude that all candidates for PD should be carefully evaluated for the presence of occult hernias, hernias should be repaired promptly and electively on an inpatient basis, surgical correction of hernias should include a formal Cooper ligament repair and males under 2 should have bilateral repairs done even if they present with a single hernia.

Posterior urethral valves have a broad spectrum of clinical severity determined by the degree and reversibility of the long stepwise sequence of secondary pathology. Neonatal azotemia and severe bilateral reflux are particularly important negative prognostic factors. In the mild cases, valve ablation with or without delayed reconstruction is good therapy. In the very severe cases, our interpretation of all the clinical and experimental information now available suggests that the time interval and the level of decompression are extremely important. Achievement of consistent low caliceal pressure without stasis and infections should be achieved as soon as possible. We do not agree with the philosophy of "valve ablation and wait and see" for secondary reconstruction as applied to the severe cases. An analogous philosophy would be treating all respiratory infections as upper respiratory infections and applying aggressive appropriate therapy for pneumonia only if the patient does not respond clinically. However, all controversy aside, the management of neonatal infants with posterior urethral valves remains a difficult and challenging problem for us all. The real challenge will be to improve published management results to the point that the family faced with decisions regarding an in utero diagnosis of posterior urethral valves will have enough hope to continue the pregnancy.

Urologic problems constitute a very significant percentage of all clinical problems in pediatrics. Incorporation of urodynamic evaluation and followup is important in achieving optimal results in a significant number of these entities. In terms of cost effectiveness, it is particularly efficient in this age of extremely high-priced technology.

Parameters of the carbon dioxide urethral pressure profilometry were examined in detail previously for reproducibility within subjects. In the current study we have extended that analysis to determine the relationship of these parameters between patient subgroups. Mean values for non-spina bifida male subjects showed the same pattern of increase across age groups, regardless of the measured parameter. These increases were significant for continence and functional lengths but not for closure pressure. Male subjects with spina bifida showed mixed responses across age but age was not a statistically significant factor for any of the 3 parameters. Female subjects were quite uniform in the mean values across age for continence and functional lengths regardless of diagnosis. Mean values for female subjects were not uniform for closure pressure and tended to decrease with age in contrast to continence and functional lengths. The parameter continence length has a between subject standard deviation that is relatively stable across age, sex and pathology, and may be used for a basis of comparison. However, standard deviations for functional length is least variable in most subgroups of sex, age and diagnosis.

One hundred and nine children with urinary tract calculi were reviewed and in some cases reinvestigated. Eighteen children had lower urinary tract calculi, which in all cases were associated with an underlying urodynamic abnormality. Sixty percent of 91 children with upper urinary tract calculi could be classified into 4 similarly sized etiological groups: an underlying urodynamic abnormality; urinary tract infection without a urodynamic abnormality; metabolic disorders; idiopathic hypercalciuria. An underlying abnormality was not found in 32% of cases. A painless presentation occurred in 39% of those with upper tract calculi. A family history of urinary calculi occurred in approximately one-half of children with either an idiopathic calculus or a calculus associated with cystinuria or idiopathic hypercalciuria. We conclude that urinary tract calculi, though rare in children, require extensive investigation to rule out urodynamic, infective and metabolic abnormalities. If such abnormalities are not found, the recurrence rate in the remainder is small and conservative treatment can usually be recommended.

Hydronephrosis generally implies ureteropelvic junction obstruction, but may be mimicked by a variety of other disorders. The authors have attempted to determine the relative diagnostic value of diuretic renography and the pelvis perfusion test in children with hydronephrosis by correlating the results with operative findings, renal and ureteral histology, and postoperative results.

Using a model of the urethra designed to ensure a predictable pressure profile along its length, we investigated optimal parameters for gas and water profilometry. In gas profilometry, the response characteristics of the machine, attributable to the highly compressible nature of gas, were shown to be the most important determinants of accuracy. Gas and water profilometry have drawbacks that make clinical results inaccurate. However, if all measuring parameters are carefully recorded and considered when a pressure profile is analyzed, system error can be decreased from 62 to 5% by using the optimal pull and flow rates determined by this study.

Seventy-four patients with posterior urethral valves were evaluated for long-term growth potential and renal function. In those boy diagnosed and treated within the first year of life, initial treatment by temporary supravesical diversion (prior to valve resection) was associated with better growth potential and renal function than was treatment by primary valve resection alone.

We measured indices of the renin-aldosterone system and body-fluid spaces in 11 adolescents who had received a renal transplant after removal of their own diseased kidneys. None had hypervolemia but 6 had hypertension. Renal angiography revealed greater than 50% luminal occlusion by allograft renal-artery stenosis (RAS) in only the 3 patients who had severe hypertension refractory to conventional medical therapy. Excessive peripheral plasma renin activity (PRA) distinguished these patients from those who had less severe stenosis or normal angiogram, and diuretic stimulation heightened the PRA differences. We conclude that significant allograft RAS does not necessarily act like a typical single-kidney Goldblatt model until after volume depletion. Our findings indicate that peripheral PRA values can be used to assess the degree of graft ischemia clinically. This permits early identification of patients who have severe RAS that probably will be difficult to control medically, and, therefore, should be followed closely with a view of reconstructive vascular surgery before further deterioration of renal function.

The treatment of patients with posterior urethral valves has improved dramatically in recent times. Our personal experience with 207 patients with posterior urethral valves between 1957 and 1978 reveals a striking reduction in both mortality and morbidity during the latter decade. We have attempted to identify clearly the incidence, etiologic factors, preventive measures, and surgical treatment of complications arising in these patients. The overall improvement in management is certainly attributable to a growing experience and the constant advancements in the medical and surgical armamentarium. Our next goal at this time is to maximize long-term renal function and growth potential in these patients.

Uroflow studies for 511 normal pediatric subjects (272 boys, 239 girls) were analyzed statistically. Nomograms relating peak flow to volume voided and body surface were established. An acceptable lower limit for peak flow was obtained from the data and a volume voided range was calculated so that both criteria could be used with 90% probability to define the normal voiding situation. Body surface area was found to be a more reliable index than age in the establishment of nomograms. In the male population the 90% probability applied to a significantly greater volume voided reliability. In the female population mean peak flow rate rose with increased body surface. Finally, in both sexes the 10% lower limit was closer to the regression mean, allowing a tighter distribution around this value.

This study shows that the response time between an actual event and a recorded event on a urethral pressure profile is a function of gas flow rate and gas circuit volume. Response times varied from 1.8 to 10.8 sec. Considerable variation was noted between flow setting and actual gas flow; therefore, calibration of the instrument's gas flow meter is recommended.

Uroflow studies in a normal pediatric population were analysed statistically. Single studies for 511 subjects (272 boys and 239 girls) were reviewed. Nomograms relating peak flow to volume voided and age were established. An acceptable lower limit for peak flow was obtained from the data and a volume voided range was calculated so that both criteria could be used with 90% probability to define the normal voiding situation. The mean values of peak flow rate increased with volume voided in both sexes and also with age in the male population. Different sets of nomograms, which are necessary for daily clinical evaluation, are given. They define the normal values in the normal population.

Renal dialysis and transplantation have been used for many years for adults with kidney failure but only recently for children. In May 1967 a renal-dialysis-transplantation program was established at The Hospital for Sick Children, Toronto for patients aged 6 to 18 years living within 240 km of Toronto. In 1973, children aged 1 to 5 years began to be accepted into the program, and by August 1977, 90 children (mean age 11 years) from all parts of Canada had been admitted to the program. The creation of vascular access in very small patients is difficult; the most successful types of access have been central shunts (established above the knee or the elbow) and bovine grafts. Specially made dialysis equipment is necessary for young patients. Young children should only be accepted in a dialysis-transplantation program that has a medical staff expert in meeting the specific needs of such children.

The authors reviewed the records of eight children with renal cell carcinoma and correlated the clinical presentation, pathological and radiologic findings, stage and treatment of the disease with patient survival. Angiography revealed tumours of sparse neovascularity, associated with varied histologic patterns. Patient survival was dependent on the stage of the disease at the time of treatment; treatment of localized disease was effective but of metastatic disease was generally poor. Tumour staging appeared to be the only reliable indicator of prognosis. Children with renal cell carcinoma differ from adults in that a palpable mass in a child does not necessarily indicate that there is metastatic disease.

Thirty-nine cadaveric renal allografts were performed in 28 children under 6 years of age. Common primary renal diseases were glomerulonephritis, dysplasia/hypoplasia, and reflux/obstructive nephropathy. After a mean follow-up of 40 months of patients with surviving grafts, 19 patients had functioning grafts, 3 had returned to dialysis, and 6 had died. These children required an extraordinary amount of care postoperatively because of anorexia, diarrhea, and ileus. Their psychomotor and physical development was retarded prior to transplant; this reversed dramatically after transplant, but catch-up growth occurred in only 4 patients. Many patients were noticeably more active and distractible for 1 to 2 years post-transplant. Major causes of graft failure were primary nonfunction of 5 donor kidneys (4 from donors under 1 year old) and renal vessel thrombosis in 5 recipients (3 with native kidneys in place who received kidneys from donors over 10 years old). Other causes were recurrence of hemolytic uremic syndrome and Wilms tumor, rejection, and sepsis. Kidneys from donors under 1 year old proved unsatisfactory, and large donor kidneys in small children tended to thrombose, especially when native kidneys with high urine output were left in situ.