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Purpose: For several decades ureteroneocystostomy has been performed in children to correct primary vesicoureteral reflux. A purported indication for antireflux surgery is to prevent significant upper urinary tract infection during pregnancy. We performed a long-term followup of women who underwent antireflux surgery during childhood to determine outcome in regard to urinary tract infection history and pregnancy.Materials and Methods: We identified 227 women of childbearing age who underwent ureteral reimplantation for primary vesicoureteral reflux from 1964 through 1981. Of the 122 women contacted 41 had been pregnant (77 total pregnancies). Cystitis or asymptomatic bacteriuria and pyelonephritis developed during 18 and 5 pregnancies, respectively. The 77 pregnancies resulted in 57 term births, 7 voluntary pregnancy interruptions and 13 spontaneous abortions.Results: Patients who previously underwent successful antireflux surgery continued to have a significant number of urinary tract infections ...

Purpose: We evaluated the clinical use of long-term intravesical oxybutynin chloride in the treatment of neurogenic bladder dysfunction in children with myelodysplasia who could not tolerate oral anticholinergics.Materials and Methods: We retrospectively reviewed the records of all patients recommended for intravesical oxybutynin chloride therapy. A total of 12 girls and 18 boys 1 to 17 years old was recruited for study. Oxybutynin chloride (5 mg.) was instilled 2 times daily and pretreatment cystograms were compared to followup urodynamic studies. Duration of therapy was 2 to 26 months (mean 13, median 12).Results: Mean total capacity plus or minus standard deviation increased from 209 plus/minus 103 to 282 plus/minus 148 ml. (p less than 0.01), mean safe capacity increased from 157 plus/minus 105 to 234 plus/minus 147 ml. (p less than 0.01) and mean age adjusted safe capacity increased from 76 plus/minus 36 to 115 plus/minus 62 percent. Of the 29 patients who were incontinent 3 (10 percent) achi...

Purpose: Patients with intra-abdominal testes represent a small but challenging group who require innovative therapy. We report our 17-year experience with testicular autotransplantation.Materials and Methods: Testicular autotransplantation was performed in 23 patients with 27 intra-abdominal testes.Results: The success rate was 96 percent and average operative time was 4.25 hours with 40 to 90 minutes for vascular anastomoses. A contralateral Fowler-Stephens procedure had previously failed in 3 cases.Conclusions: Since the variability of collateral blood supply in patients with high undescended testes may potentially compromise the Fowler-Stephens procedure, we believe that testicular autotransplantation should be strongly considered in such patients, particularly those with bilateral undescended testicles.

The role of reduction cystoplasty in the management of severe prune belly syndrome is controversial. From 1973 to 1990, 11 boys with severe prune belly syndrome underwent comprehensive urinary tract reconstruction, including overlapping reduction cystoplasty. Followup ranged from 1.5 to 18 years and 6 boys are now older than 18 years. Nine had sepsis or progressive renal failure as neonates; 7 had upper tract diversion as an initial procedure, of whom 2 have chronic renal failure. Currently 9 boys are voiding, including 1 who could not void preoperatively, with less than 50 cc residual after double or triple voiding. One boy underwent transplantation to an ileal conduit and 1 continues on intermittent catheterization. In the 9 cases in which bladder volume data were available average reduction in volume at operation was 52%. At an average of 7.7 years later (range 1.5 to 14) bladder volumes corrected for age were essentially unchanged or greater than corrected preoperative volumes. Since reflux was corrected in 7 of 9 boys it cannot account for the redevelopment of large bladder capacities (range 740 to 2,300 cc). In cases of the prune belly syndrome reduction cystoplasty has helped to improve voiding and minimize infection during early childhood but it does not seem to decrease bladder capacity or improve voiding dynamics in the long-term.

Multimodality treatment of metastatic renal cell carcinoma with biological response modifiers and cytoreductive surgery has produced durable responses. The timing and impact of cytoreductive surgery on the success of immunotherapy require further study. We reviewed the treatment of 62 patients with metastatic renal cell carcinoma and primary tumors in place who qualified for multimodality treatment comprising adjuvant nephrectomy and biological response modifier protocols at our institution between 1987 and 1992. Of the patients 37 were scheduled to undergo initial adjuvant nephrectomy followed by biological response modifier therapy. A total of 25 patients underwent initial biological response modifier therapy with planned delayed adjuvant nephrectomy if a response to treatment was demonstrated. Of the 37 patients undergoing initial adjuvant nephrectomy, 8 (22%) were unable to enter induction of immunotherapy because of perioperative complications (1), medical contraindications (2), tumor progression (4) or death (1). Three patients in the initial adjuvant nephrectomy group (8%) had a partial response and the median survival in this group was 12 months (range 1 to 57). In the initial biological response modifier group 3 patients (12%) with an objective response (2 complete and 1 partial) to biological response modifier therapy underwent nephrectomy. The median survival for the initial biological response modifier group was 14 months (range 1 to 48). These results add to our understanding of the impact of adjuvant nephrectomy on patients with metastatic renal cell carcinoma considered for immunotherapy protocols.

We evaluated the efficacy of human chorionic gonadotropin (HCG) for identifying and treating nonpalpable testis. We then compared the cost-effectiveness of this approach to that of laparoscopy.We reviewed patient charts during a 15-month period and identified 51 boys (64 testes) who underwent surgery to correct cryptorchidism. There were nonpalpable testes in 17 cases and bilateral cryptorchidism in 2 for a total of 19 impalpable testes. All patients were offered a full course of HCG. Those electing hormonal treatment received intramuscular injection of 2,000 IU/m.2 HCG (maximum 1,500 IU/injection) 3 times weekly for 3 weeks.A full course of HCG was given in 8 patients (10 testes). Of the 10 testes 8 became palpable after HCG treatment, including 1 atrophic nubbin located in the inguinal canal. Of the 2 testes that remained impalpable 1 discovered at the level of the renal vessels had complete epididymal nonunion and 1 was located closer to the inguinal ring. All 9 untreated patients underwent laparoscopy, which identified 3 intra-abdominal, 3 vanished and 2 peeping testes, and 1 atrophic testis in the inguinal canal.HCG therapy is valuable for identifying and treating nonpalpable testis. Using this agent enabled the testicle to be detected while avoiding the risks and cost associated with the laparoscopic procedure.

Purpose: We report use of the Bard gastrostomy button to occlude vesicostomy and provide access for intermittent catheterization before closure in children with vesicostomy. Evaluation of bladder function in such children usually relies on radiographic and urodynamic studies, which may fail to predict bladder compliance, emptying and continence after closure.Materials and Methods: Buttons were placed before vesicostomy closure in 1 boy with the prune-belly syndrome and 2 girls with cloacal anomalies 2.5 to 10 years old. The patients had undergone vesicostomy using the Blocksom technique soon after birth because of urinary infection, and impairment of bladder emptying and renal function.Results: With the button in place bladder emptying, compliance, continence and possible upper tract changes could be evaluated during several weeks. Button coaptation to the vesicostomy was complete with no urine leakage around the device, allowing easy intermittent drainage through its channel. After 4 weeks the bu...

Purpose: We addressed whether salvage of upper pole renal units in comparison to partial nephrectomy affects differential renal function in patients with a duplicated obstructed upper pole.Materials and Methods: We retrospectively reviewed the records of all children who underwent surgery for a unilateral obstructed duplicated kidney at our institution from 1988 to 1995. Patients were evaluated with respect to postoperative complications, reoperation rate and percent change in differential renal function of the obstructed duplicated kidney, as determined by nuclear renography.Results: We identified 46 patients with a unilateral obstructed upper pole of a duplicated kidney who were divided into 2 groups. Group 1 (12 patients) underwent an upper pole salvage procedure, that is ureteropyelostomy or ureteroureterostomy, and group (31 patients) underwent partial nephrectomy. Three reoperations (25 percent) were performed in group 1 and 1 (4 percent) was done in group 2. Postoperative symptomatic urinar...

Penile revascularization is a relatively new treatment for impotence. Glanular hypervascularization is a known complication of a venous arterialization procedure and it requires surgery for cure. A case in which delayed glanular hypervascularization caused urinary retention is presented. Ligation of the distal deep dorsal vein via the retro-coronal plexus resulted in cure.

The prognostic value of the pathological response to combination chemotherapy of deeply invasive transitional cell cancer of the bladder was retrospectively assessed in 147 patients. Data were collected from 8 different centers. Patients were eligible if they had received intravenous combination chemotherapy followed by partial, total or radical cystectomy, and if they had a minimum followup of 2 years after the start of chemotherapy. Of the patients 90% received methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) or cisplatin plus methotrexate for a median of 3 courses (range 1 to 6). Of the 83 patients who were alive at analysis actuarial median followup was 30.5 months (range 13.2 to 85.6 months). A major pathological response (stage P0, Pis, Pa or P1) was achieved in 41.5% of the patients. Patients with a major pathological response (p stage less than 2) had a 5-year survival of 75% in contrast to 20% for the remaining nonresponding patients (p stage 2 or more). The survival of patien...

Ten patients with disseminated renal cell carcinoma have been treated with transfer factor as an immunostimulant. In 5 patients with metastatic disease evident at the time of initial diagnosis treatment involved removal of the primary tumor followed by transfer factor therapy. Of these patients 3 had a temporary stabilization of metastatic disease. Three patients with recurrent metastatic disease after previous nephrectomy were treated, 2 of whom showed a temporary stabilization of metastatic disease. There were 2 additional patients without clinically evident metastases but at a high risk for recurrent disease who were treated and remain free of disease. We used 5 immunologic parameters to evaluate the clinical effects of transfer factor. No objective clinical regression was noted in any patient treated with measurable disease.