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Behavioral therapy has proved benefit for children with daytime wetting but most studies have used biofeedback techniques and provide no long-term assessment of results. We previously reported similar results using simple behavioral therapy without biofeedback. We report the long-term efficacy of behavioral therapy for daytime wetting.Our program of behavioral therapy included timed voiding, modification of fluid intake, positive reinforcement techniques and pelvic floor (Kegel) exercises to promote pelvic floor strengthening and relaxation. Questionnaires to assess therapeutic efficacy were mailed to patients who had completed therapy more than 1 year previously.A total of 48 patients responded. Mean ages at the time of the initial clinic visit and questionnaire were 8.2 and 12.9 years, respectively. Improvement in symptoms was noted in approximately 74% of the cases during the first year following therapy. At a mean of 4. 7 years after treatment 59.4% of the patients had improved daytime urinary control, 51.1% improved daytime urinary frequency and 45.6% improved daytime urinary urgency. The frequency of urinary tract infections decreased in 56.4% of the cases. Measures of psychological well-being were also noted to be improved in a majority of patients. A total of 77.3% of the patients stated that they would recommend the program to others.Simple behavioral therapy without biofeedback techniques is an effective and durable first line therapy for children with daytime wetting.

Purpose: Bladder stones are common in patients with spinal neural tube defects but there are little data on the incidence of renal calculi in this population. We examined the incidence, nature and risk factors of nephrolithiasis in our clinic population of patients with neural tube defects.Materials and Methods: We retrospectively reviewed the charts and radiological studies of 327 patients followed at our neural tube defects clinic with routine radiological imaging of the urinary tract. Additional confirmatory studies were performed when stones were noted.Results: Renal calculi were identified in 20 patients with neural tube defects (6.1%). The incidence of nephrolithiasis increased with age. Renal stones were noted in 19 patients (10.7%) 12 years old or older. Management of the stones in these patients resulted in overall 53% stone-free and 87% recurrence rates after intervention. Major risk factors for new and/or recurrent renal stone formation were bacteriuria in 95% of the cases, lower urinar...

This review was performed to assess the effect of protecting the collateral circulation between spermatic and vasal vessels by leaving a strip of peritoneum attached to the lower spermatic cord in patients in whom the spermatic vessels needed to be divided to bring the testis into good scrotal position.Between 1983 and 1994, 22 boys were encountered in whom 1 testis was always normal in size and position, and the other was intra-abdominal and would not be in normal scrotal position after complete cord straightening. A strip of peritoneum had been left attached to the spermatic cord before full mobilization. After high division of the spermatic vessels the testes were brought in the mid scrotum during the same operation.All testes remained in scrotal position except 1 which retracted and was subsequently removed. None became atrophic.Division of the spermatic vessels, the Fowler-Stephens maneuver, can safely be performed during an initial operation as long as its possible need is anticipated, and the collateral circulation between the vasal vessels and spermatics is not disrupted. Secondary orchiopexy for inadequate cord length is now rarely required. This type of open orchiopexy for high impalpable testis is safe, is easy to learn, has no increased morbidity and is generally less expensive than a laparoscopic approach.

OBJECTIVE: Our intent was to describe the range of postoperative sonographic appearances of the bladder after endoscopic incision of ureteroceles. CONCLUSION: Preoperative and postoperative sonographic examinations of the bladder were reviewed in 14 patients (15 ureteroceles) who underwent endoscopic ureterocele incision. Five different appearances of the ureterovesical junction after endoscopic incision were found: a pseudomass (5/15), focal mucosal thickening (3/15), residual ureterocele with decrease in size (3/15), persistent unchanged ureterocele (1/15), and no residual abnormality (3/15). The most common postoperative sonographic appearance associated with development of vesicoureteral reflux was a mucosal pseudomass (4/6). The other bladder sonographic appearances had no correlation with development of reflux, degree of hydronephrosis, or success of the surgery.

Purpose: We evaluated the use of renal ultrasound for monitoring pyelocaliectasis after pyeloplasty in children.Materials and Methods: Changes in pyelocaliceal dilatation following pyeloplasty were assessed by serial ultrasound. Of 104 children 0 to 12 years old who underwent pyeloplasty between 1982 and 1992, 44 (47 renal units) were monitored with serial ultrasound for at least 2 years (range 2 to 9, mean 3.8). Patient ages at pyeloplasty were 0 to 3 months (17), 4 to 12 months (8), 1 to 6 years (13) and 7 to 12 years (6). Preoperative and postoperative ultrasound was reviewed by a single pediatric radiologist blinded to the date of surgery. The degree of pyelocaliectasis was graded as 0 to 4 according to the classification of the Society for Fetal Urology.Results: Preoperative ultrasound revealed grade 4 pyelocaliectasis in 26 kidneys (55 percent) and grade 3 disease in 21 (45 percent). Grade was the same or worse 1 month after pyeloplasty in the majority of kidneys (92 percent) studied at this...

It once was relatively simple for most urologists to diagnose ureteropelvic junction obstruction, and it was previously axiomatic that obstruction required repair to preserve and maximize renal function. Modern imaging studies have cast doubt on previously held concepts, leaving the clinician with an enigma. Prolonged follow-up of some non-operated cases has demonstrated late deterioration of function, further compounding the diagnostic uncertainty.

Infertility is common in patients with a history of bilateral cryptorchidism, even after successful prepubertal orchidopexy. Recent data suggest that this defect may be partially due to the existence of hormonal abnormalities in some forms of cryptorchidism. To analyze any potential benefit of hormonal therapy, we have evaluated the immediate and long-term effects of chronic hormonal therapy administered following surgical correction of cryptorchidism. First, using young male rats, we examined the effects of chronic human chorionic gonadotropin (HCG) and a luteinizing hormonereleasing hormone agonist (LHRH-A), alone or combined, on acute pituitary-gonadal axis responsiveness to LHRH administration. High doses of HCG and/or LHRH-A induced deleterious effects on the pituitary-testicular axis in terms of suppression of response to LHRH. Therefore, treatment with a low dose of HCG (50 U/kg./day) for 14 days was used, since it produced a significant increase in intratesticular testosterone (ITT). Second, we tested this hormonal regimen in a cryptorchid rat model. Bilateral cryptorchidism was produced by gubernaculum resection at 14 days of age. Early orchidopexy was performed at age 30 days, and HCG therapy was given from 31 to 44 days of age. Follicle stimulating hormone (FSH), luteinizing hormone (LH) and testosterone (T) levels were determined before and immediately after hormonal therapy, and at sacrifice. Animals were sacrificed at 61 days of age for determination of serum and testicular hormone levels, accessory sex organ weights and testis histology. Five or six animals from each group were retained for breeding studies at the age of 90 days. Hormonal alterations noted immediately following treatment of cryptorchid animals with HCG are not lasting. The data reveal that the fertility defect in bilateral cryptorchidism is partially prevented by early orchidopexy and that adjunctive hormonal therapy is probably of little additional benefit.

Since pyelocalicectasis alone is common in fetuses, we reviewed reports of fetal hydronephrosis that resolved spontaneously or at birth. Severe fetal hydronephrosis with calicectasis or parenchymal thinning rarely resolves spontaneously before or after birth. We also reviewed the clinical and experimental literature on renal hypertrophy. After unilateral nephrectomy in neonatal animals or after birth with congenital absence of one kidney in humans, the remaining kidney hypertrophies very quickly. In infants and young animals, the eventual size of the remaining kidney is inversely proportional to the age at which one kidney is lost. This improvement in residual renal function seen after renal loss in infancy, compared with older children, itself constitutes a strong argument for early relief of obstruction. If contralateral renal hypertrophy has occurred, the treated damaged kidney may resume growth in parallel with its hypertrophied mate but does not become as large or recover normal potential for growth. In other words, if correction of a unilateral obstruction is deferred until contralateral hypertrophy occurs, the obstructed kidney then has less potential for recovery of function.

We report removal of a multicystic dysplastic kidney with a laparoscopictechnique that uses only three trocar sites. Additionally, we have found placement of a ureteral catheter and full mechanical and antibacterial bowel cleansing unnecessary. The role of this surgery in the management of multicystic dysplastic kidney is discussed.

No topic in urology is more contentious than the management of neonatal ureteropelvic junction obstruction. Those favoring early diagnosis and correction of obstruction in early infancy cite excellent return of function and superior surgical results compared with delayed repair. Others believe that hydronephrosis improves or resolves with growth in many instances. In the most widely quoted series, almost all such patients improved. This article attempts to separate opinion from fact. The arguments for early surgery and for observation, even when obstruction has been diagnosed, are reviewed. Several experiences with long-term surveillance are summarized.

The present study was designed to determine whether extravaginal torsion of the spermatic cord (EVT) can be distinguished from intravaginal torsion (IVT) on the basis of gross and histologic examination of the testis. It is traditionally believed that EVT, postulated to occur only in neonates, can be grossly distinguished from IVT, which occurs in older patients, on the basis of adherence between testis and tunica vaginalis. Such adherence is felt to be present in EVT but not IVT. This concept that the two types of torsion can be distinguished in the operating room has important clinical ramifications. In cases of EVT, contralateral orchidopexy theoretically need not be performed, since adhesions develop between tunica vaginalis and dartos by a few weeks of age. This is in contrast to IVT, in which contralateral orchidopexy is necessary due to the bilateral nature of the bell clapper deformity. Using a rat model, we first demonstrated that IVT could produce adherence of the tunica vaginalis to testis. Then, eight rats were operated on, producing right IVT and left EVT. Animals were then sacrificed at intervals of up to one month. Gross and histologic examination showed involvement of the tunica vaginalis in an ischemic and inflammatory response in a majority of testes, regardless of the type of torsion. Attempts to distinguish EVT from IVT on the basis of grossly evident adhesions between tunica vaginalis and testis are of questionable validity. Early contralateral orchidopexy is therefore recommended in all cases of neonatal torsion.

Cloacal exstrophy patients are often difficult to reconstruct. Urinary continence is usually achievable only with a catheterizable stoma of some type. Since cloacal exstrophy is usually associated with omphalocele or gastroschisis, one-stage closure of the abdominal wall defect is frequently impossible. We prefer to incorporate the exstrophic large bowel, which separates the hemibladders, into the closed bladder as a sort of "natural" augmentation to maximize its volume for use as a continent reservoir. If a silastic "silo" or synthetic mesh is required to close the abdominal wall, excessive scarring occurs and later creation of a continent stoma is usually difficult and time-consuming. In all but those with the smallest abdominal wall defects we recommend that the omphalocele and upper abdominal wall be repaired first, replacing the evicted gut into the peritoneal cavity. During nutritional stabilization a tissue expander is placed under the superficial musculature of the chest wall. The flap is enlarged by gradual inflation of the tissue expander until it fills the abdominal wall defect left by subsequent closure of the cloacal exstrophy. The flap is then rotated inferiorly with blood supply intact at the time of bladder closure to make good the remaining abdominal wall defect. This flap improves the appearance of the abdominal wall and reduces scarring. Thus, this approach has the possibility of making subsequent operations to provide continence shorter, simpler, and more successful in most infants with cloacal exstrophy.

We describe the first reported use of an expanded thoracoepigastric myocutaneous flap in the closure of cloacal exstrophy. This approach offers several distinct advantages. The expander increases the available cutaneous surface area of the thoracoepigastric region, improves vascularity, induces a fibrous capsule that augments the abdominal wall, permits primary closure, and avoids prosthetic adjuncts that increase scarring and hinder delayed urinary tract reconstruction. Osteotomy and spica casting may be obviated by using this flap, but mesh may be required eventually. We anticipate its use in all future cases in which the abdomen cannot be closed safely at the primary procedure at this institution. This technique also should be considered for classic bladder exstrophy or any other large congenital or acquired defect of the lower abdomen.

Since the widespread use of real-time ultrasonography in the early 1980s, ureteropelvic junction obstruction has been diagnosed at earlier ages and prenatally on a presumptive basis. However, substantial controversy exists over the diagnosis and treatment of ureteropelvic junction obstruction. We conducted an epidemiological study to determine if modern imaging techniques are leading to the over diagnosis of ureteropelvic junction obstruction. Records were collected retrospectively from 3 hospitals serving 2 adjacent counties to determine the number of pyeloplasties performed in 1970 to 1992. The 2 university hospitals and 1 large private hospital provide a wide variety of services and choice of urologists, and so it was assumed that most patients requiring pyeloplasty in the area would be captured. Of the 555 pyeloplasties 240 (43%) were performed on children 12 years old or younger. Logistic regression analysis revealed an overall increase of pyeloplasties per year of 56.8% in 23 years, which was not markedly different from the population growth in the area in the same period (49.3%). A statistically significant increase in the number of pyeloplasties performed in the first year of life was noted. This trend appeared to begin in 1981: 8 pyeloplasties were performed in the first year of life between 1970 and 1980 compared to 91 between 1981 and 1992. Pyeloplasties in children 1 to 6 years old increased with time at a much lower rate that was not statistically significant and the number of pyeloplasties decreased in those 7 to 12 years old. Therefore, it appears that modern imaging techniques are not leading to an over diagnosis of ureteropelvic junction obstruction but to detection of the disease at an earlier age.

Free grafts of bladder mucosa may be used to bridge long urethral defects in the repair of hypospadias. Strictures, which occur commonly at the proximal anastomotic site with the native meatus and where the bladder mucosa is exposed on the glans, have limited the use of the procedure. We have found that draining the proximal anastomosis prevents most strictures. When the distal most portion of the neourethra is formed from the skin of the ventral penile shaft and glans, no bladder mucosa is exposed and meatal stricture is thereby avoided.

Prior to the advent of fetal ultrasound, multicystic dysplastic kidney (MCDK), defined as a unilateral grossly dysplastic organ with little or no function in which cystic elements predominate, was the most common abdominal, usually flank, mass detected in the neonate by physical examination. Historically, nephrectomy was usually performed in late infancy 1 The incidence was approximately 1 in 4300 live births. 2 The security with which diagnosis can be made--from the characteristic appearance on ultrasound plus nonfunction on renal scan--and the relatively few late complications of MCDK have led to the suggestion that such patients should be managed with surveillance instead of by nephrectomy. 1'3 We review the indications for surgical management of MCDK and focus on the incidence of hypertension in MCDK, which is presently underestimated. Successful cyst aspiration for the rare case of respiratory embarrassment has been reported. 4 Indications for nephrectomy include uncertain diagnosis, pain, urinary tract infection or abscess, malignancy, and hypertension. 3 Specifically, Ambrose 5 reported on 27 adults requiring surgery for pain or infection. Furthermore, 7 cases of malignancy in association with MCDK have been reported since 1957, including 4 cases in children: 2 Wilms' tumors, 1 adenosarcoma, and 1 renal cell carcinoma. 1 Of the 508 patients now entered in the National Multicystic Kidney Registry, misdiagnosis occurred in 6 of the first i 8 i operated cases, but the hydronephrosis was so severe the kidneys were not salvageable, a,6 Thirteen patients in the Registry have had urinary tract infections, and 2 patients had hematuria. One of the patients had pain, but no tumors were reported.

Kegel exercises were used to treat urinary incontinence in 79 children. An average of less than 2 hours of professional time was required. Incontinence was eliminated in 60% of the patients; children who had both day and night wetting tended to show simultaneous improvements in both problems. Research is needed to test the hypothesis that Kegel exercises eliminate involuntary contractions of the detrusor muscle.

We report on 5 babies found to have pyelocaliectasis or hydroureteronephrosis antenatally who were evaluated soon after birth because of persistent mild or moderate upper urinary tract dilatation. In each instance, vesicoureteral reflux was absent and the technetium-99m diethylenetriaminepentaacetic acid renal scan revealed good function in the ipsilateral kidney. Renogram curves, after furosemide, did not show an obstructed pattern. Indeed, allowing for the dilatation, the drainage patterns were thought to be normal. In each instance the patient represented or was found on follow-up to have increased dilatation. Renograms were then repeated, using the same radiopharmaceutical and dose of diuretic. An obstructive pattern was seen in each instance. These significant observations demonstrate that nonobstructive hydronephrosis, diagnosed prenatally, may later convert to obstruction at the ureteropelvic junction (UPJ) or in the juxtavesical ureter (UVJ). Thus, careful follow-up, for a period yet to be determined, is desirable in patients in whom the initial postnatal evaluation does not demonstrate obstruction by current criteria.

A valve of Guerin, or lacuna magna, is a common anatomical finding in young boys. It occasionally causes dysuria and/or bloody urethral discharge or spotting due to its location distal to the external urethral sphincter. We report on 10 patients who underwent transmeatal marsupialization of a valve of Guerin between 1984 and 1991, and review the embryology and clinical presentation. Despite evidence suggesting that a valve of Guerin is a frequent, normal anatomical variant, the incidence of clinical detection is extremely low. While many patients with this condition remain totally asymptomatic, a valve of Guerin should be suspected in boys presenting with bleeding distal to the urethral sphincter with or without voiding symptoms. In most cases physical examination is normal. A carefully performed voiding cystourethrogram visualizing the distal urethra, coupled with endoscopic examination and gentle probing of the fossa navicularis, optimizes the likelihood of correct diagnosis. Treatment is indicated solely to ameliorate symptoms, which are probably caused by distention of the lacuna magna during voiding. Transmeatal incision and marsupialization of the valve leaflet into the urethral lumen usually effectively relieve dysuria and stop the bleeding.

The intussuscepted nipple has proved to be a versatile mechanism to provide continence or prevent reflux in urological reconstructive surgery. Early in its use detussusception of the nipple was recognized as a common complication, which was usually prevented by using several rows of staples to stabilize the nipple. The use of staples has reduced the rate of reoperation for eversion or obstruction but it has led to a higher stone formation rate, ranging from 10 to 18% in recent series. Since 1983 we have used a handsewn intussuscepted ileal nipple stabilized without staples as our antireflux mechanism in bladder augmentations and continent diversions. This technique has been performed in 30 patients with an average followup of greater than 3 years. A small bladder stone developed in only 1 (3%) of the patients, who was completely dependent on intermittent catheterization, while 4 (13%) required reoperation due to eversion of the nipple. This incidence compares well with nipple reoperation rates in recent series, which range from 7 to 28%. We conclude that absorbable sutures are as effective as staples in stabilizing the antireflux nipple, and that they result in a lower incidence of subsequent stone formation.

reloplasty remains the mrapy for ureteropelvic :ion, although recent re: pereutaneous repair in t by endoureteropyelot, ~.2 The optimal time to ruction caused by UPJ and young children has ,eeause of recent clinical lave developed protocols ~ving UPJ obstruction in !fetal hydronephrosis af-6 The reason for the deaaturation, thought posthe interpretation of the ne use arbitrary criteria ~i~Q~gnose obstruction based exclusively on the i t ~ r e t a t i o n of the diuretic-assisted renogram ! ~ e d one month after birth. 3-5 The question i!~ predictive value of the renogram in imi i ~ e kidneys is the primary reason for evaluii obstruction after one month. 6,7 The high anits reported lost or deteriod repair of UPJ obstruction in :5 prompted us to review our long with the literature. As in our data support the efficacy and repair of UPJ obstruction young children to reduce the tion deterioration. s been proponents of relieving aused by UPJ strictures in all "oups as soon as the diagnosis is made. 9 We ieport a ten-year experience with early re!IJPJ obstruction in neonates and young ien below the age of six years A review of

Meatal stenosis is uncommon after hypospadias surgery even when the meatus is placed at the tip of the glans. However, when it occurs. such, stenosis can be quite troublesome. A conventional meatotomy done in the presence of inflammation is often attended by recurrent stenosis. In such. situations we therefore advocate placing a tourniquet around the base of the penis and raising a V-shaped flap of glans with the point of the V at the dorsum of the meatus. The stenosis is then incised along the back wall of the urethra down into non-inflamed tissues. The tip of the flap is sutured to this point and additional absorbable sutures are used to anchor the flap in place so that healthy tissue crosses the stenotic area. Recurrent stenosis after this maneuver is unusual.

Through the use of urodynamic evaluation, the authors have been able to define and categorize internal sphincter dyssynergia as a clinical, obstructive, dysfunctional voiding disorder in children. Treatment with the alpha-adrenergic sympatholytic agent, phenoxybenzamine, was successful in their series of patients.

In a perfused cadaver kidney transplant with two arteries, thrombosis developed in the artery supplying the upper two thirds of the graft. Perfusion had been via the superior artery only. The remaining one third of the kidney supported life and the upper two-thirds became organized scar tissue. The possibility of injury resulting from perfusion is discussed.

We describe a 1-stage procedure that involves use of the ileocecal segment as an intervening urine conduit to the large bowel to achieve a continent diversion. The ureters are anastomosed end to end to the terminal ileum that is intussuscepted into the cecum. The cecum then is joined to the lower sigmoid by an end-to-side anastomosis. Mixed urine and feces are eliminated through the rectum. The results in 5 patients with exstrophy and 1 with epispadias between 5 months and 13 years old are reported. Ureteral reflux was not observed. Urinary tract infection developed in 2 patients. Ileocecal ureterosigmoidostomy is a reasonable alternative to intact ureterosigmoidostomy that may reduce the risk of development of cancer.

SUMMARY Results of treatment of torsion of the testicle can be measured only by determining the rate of testicular salvage, which has been low but has improved in recent years. The Doppler instruments and the technique of scrotal imaging with the gamma camera provide noninvasive and rapid diagnostic aids with a high degree of accuracy. There is evidence that these techniques will aid in the differential diagnosis of equivocal cases, and thus lower the incidence of delay in the diagnosis of torsion, a cause of lower than optimal salvage rates in the past. Fluorescein staining can also be used in the operating room if there is a question of testicular viability. The availability of these new modalities, however, is no substitute for early evaluation. Quick referral from primary physicians and a high awareness of torsion as a cause of acute scrotal pain and swelling are extremely important. Reviews clearly indicate that improved salvage rates are achieved with early evaluation and treatment. Therefore the urologist has a continuing responsibility to educate pediatricians, family practitioners, and emergency room physicians in the urgency of diagnosis and treatment in cases of testicular torsion. Although new diagnostic aids are useful, only early surgical exploration can save a torsive testis.

The 99m technetium-diethylenetriaminepentaacetic acid renal scan allows differentiation of ureter-opelvic junction obstruction from multicystic kidney in most instances. Although renal function usually will improve at least a little after relief of obstruction, the young infant is privileged and more improvement can be expected than occurs usually in older children. Since an operation is as safe and results of pyeloplasty are as good in the neonate as in older infants or children early correction of ureteropelvic junction obstruction is advocated in otherwise healthy infants as soon as the diagnosis is established.

Summary— Ten children have undergone lower urinary tract reconstruction by ileocaecocystoplasty. Four patients had previously been diverted and the other six were reconstructed because of intractable incontinence or deteriorating renal function. Continence was primarily achieved in eight patients and renal function improved or remained stable in all 10. Reflux was prevented by a plicated ileocaecal valve in five of eight patients. Continued pharmacological manipulation, intermittent self catheterisation and secondary surgical intervention were frequently necessary in these patients who required careful counselling and follow-up.

Two children with priapism are presented; one case was secondary to trauma and the other was idiopathic in nature. Both boys were effectively treated by bilateral corporosaphenous shunts. The mechanism of normal erection and the pathophysiology of priapism are discussed.

This workshop was conducted in an attempt to analyze critically the role of reconstruction of the myelodysplastic patient who had undergone urinary diversion and to develop guidelines for selecting those patients in whom urinary undiversion might be undertaken safely. The collective experience initially seems to be acceptable; however, the authors emphasize the gravity of the decision and the complexity of the evaluation which must be undertaken prior to embarking on such reconstructive surgery. Contrary to some reports, we believe that the defunctionalized bladder frequently can be evaluated. Further, many of the contraindications to urinary undiversion have been identified and several of the hazards involved therein can be avoided. We believe that the neurogenic bladder is no longer an absolute contraindication to undiversion. Our experience suggests that undiversion is a reasonable surgical treatment in select patient with neurogenic bladder dysfunction. But, the decision to remove a satisfactorily functioning conduit must not be undertaken lightly. Patients should be selected only after a thorough, detailed, and properly conducted evaluation. A protocol has been developed which will hopefully assist in this evaluation. Perhaps additional shared experience will further refine and delineate the circumstances appropriate for reconstruction of these patients.

We believe that the confusion regarding abnormal renal development could be reduced by more precise terminology. Therefore, we suggest precise definitions for dysgenesis, hypoplasia, dysplasia, hypodysplasia, aplasia and agenesis of the kidney. We suggest the term reflux nephropathy be a generic label for any instance of abnormal renal morphology (gross or microscopic) associated with vesicoureteral reflux. Hypoplasia and hypodysplasia can be subclassified on the basis of associated urological criteria.There have been many previous attempts to classify cystic disease of the kidney but none has been accepted collectively by pathologists, urologists, nephrologists and radiologists. On the basis of known patterns of inheritance, a classification is outlined in which renal cystic disease is divided into 2 major groups: genetic and nongenetic. Each entity is discussed.

Direct radionuclide cystography has proved to be a useful substitute for roentgenological cystography in studying patients with vesicoureteral reflux. Although the initial diagnosis generally is made with x ray, serial follow-up examinations are more feasible with the radionuclide method because of its lower radiation burden. Additional information obtainable from these studies includes determinations of bladder volume at time of reflux, calculation of urine volume that has refluxed as well as residual bladder urine volume, quantification of reflux drainage time from the upper tracts, and visualization of anatomic defects and variants. More recently, indirect nuclear cystography has been evaluated for the detection of reflux. The greater degree of patient cooperation required for this procedure would appear to favor its usefulness in older children. More investigative work, including correlation with direct radionuclide cystography as well as the roentgenologic studies, is needed.

Recording the vesical sphincter electromyogram clarifies abnormal patterns of voiding in children. Since the electromyogram patterns in children with normal voiding patterns have not yet been evaluated, we recorded the sphincter electromyograms during voiding of 39 children with normal voiding patterns. These normal electromyograms were compared to those recorded in 86 children with abnormal voiding patterns. Each of the 39 children with a normal voiding pattern demonstrated synergy of the vesical sphincter during voiding. Of the 86 children with an abnormal voiding pattern 69 per cent demonstrated synergy and 31 per cent demonstrated dyssynergia of the vesical sphincter during voiding. Of the children with dyssynergia 89 per cent were girls and only 11 per cent were boys. Sphincter dyssynergia was demonstrated only by children with an abnormal pattern of voiding and those with a history of a normal pattern of voiding demonstrated only sphincter synergy (p less than 0.005). The electromyographic diagnoses of vesical sphincter synergy and dyssynergia obtained by surface electrode recordings correlated with the clinical voiding patterns of the children.

Urinary cytology from 29 pediatric renal homograft recipients was evaluated for the presence of polyribosomal-rich (pyroninophilic) lymphocytes during an 8-month period. Seven episodes of acute (cell-mediated) rejection occurred in 21 cadaveric renal recipients. No episodes of rejection occurred during this period In the living-related recipients. Each episode of rejection was associated with significant polyrlbosomal-rich lymphocyturia 5 to 11 days before the onset of clinical rejection as diagnosed by conventional methodology. In addition, significant lymphocyturla occurred 1 to 3 days before and simultaneous with a sustained elevation in serum creatinine. Falsely positive assays demonstrating occasional to 1 plus (less than 10 per cent) rlbosomal-rlch lymphocyturia occurred in 10 of 29 patients. None of these falsely positive-reacting patients demonstrated acute rejection. In our experience the urinary assay for polyribosomal-rich lymphocytes proved to be an early Indicator of acute rejection. It Is hoped that by early Institution of antlrejection therapy based on this parameter homograft rejection may be aborted or Its severity diminished.

Lesions of Cowper's gland duct assume various appearances. A system to classify each of these appearances is offered to diagnose these lesions more precisely. The urethrographic and endoscopic characteristics of dilated Cowper's gland ducts noted in 8 boys are grouped as a simple classification. The dilated Cowper's duct is referred to as a syringocele (Greek syringo--tube plus cele--swelling). There are 4 groups of Cowper's syringoceles: 1) simple syringocele--a minimally dilated duct, 2) perforate syringocele--a bulbous duct that drains into the urethra via a patulous ostium and appears as a diverticulum, 3) imperforate syringocele--a bulbous duct that resembles a submucosal cyst and appears as a radiolucent mass, and 4) ruptured syringocele--the fragile membrane that remains in the urethra after a dilated duct ruptures. Marsupialization of the syringoceles cured urine infection and hematuria but voiding symptoms may persist.