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We evaluated changes in urodynamic parameters of patients with tethered cord syndrome after detethering surgery and investigated factors predicting long-term urological outcome based on a previously described urodynamic scoring system.A total of 148 patients with tethered cord syndrome underwent detethering surgery at our hospital between January 2005 and March 2011. Of these patients 44 with preoperative and postoperative urodynamic data and a minimum followup of 2 years were included. Urodynamic score was composed of 4 parameters, with the sum ranging from 0 (favorable) to a maximum score of 17 (unfavorable).Mean ± SD age at surgery was 38.0 ± 77.2 months and followup was 57.2 ± 20.6 months. Preoperative symptoms were present in 24 patients. Total urodynamic score at 6 months postoperatively was higher than preoperatively (mean ± SD 5.61 ± 2.71 vs 4.43 ± 3.56, p = 0.033) and remained at a similar value during followup (5.88 ± 3.89). The 6-month postoperative total urodynamic score was significantly lower in the 23 patients with favorable urological outcomes than in those with unfavorable outcomes (3.87 ± 2.02 vs 7.52 ± 1.99, p0.001), whereas the preoperative urodynamic scores did not differ between these groups. The difference in urodynamic scores between favorable and unfavorable outcome groups became more prominent with time. By regression analysis the total urodynamic score at 6-month followup was a predictor of urological symptoms at last followup (OR 2.763, 95% CI 1.514-5.043, p = 0.001).Six-month postoperative urodynamic scores accurately predicted the presence of urological symptoms on long-term followup and may be an important predictor of long-term urological outcomes after detethering surgery.

Urothelium lined seromuscular colocystoplasty is an ideal method of augmentation cystoplasty that avoids various complications caused by the use of gastrointestinal segments. We reviewed the long-term outcomes using this technique at a single institution.We retrospectively analyzed 34 patients who underwent urothelium lined seromuscular colocystoplasty between January 1996 and December 2007. A total of 33 patients, excluding 1 who had previously undergone artificial urinary sphincter implantation, were included in the study. Changes in urodynamic parameters, duration of anticholinergic use, incontinence and surgical complications were analyzed.Mean±SD age at surgery was 10.0±5.7 years (range 3.0 to 26.0) and duration of followup was 6.0±2.3 years (2.7 to 13.4). A total of 17 patients (51.5%) underwent simultaneous anti-incontinence surgery and urothelium lined seromuscular colocystoplasty. Mean bladder capacity increased by a factor of 2.96 and mean percentage of expected bladder capacity for age increased by a factor of 1.96 postoperatively. Of patients who underwent anti-incontinence surgery 4 of 10 whose abdominal leak point pressure was less than 40 cm H2O required additional surgery, whereas none whose abdominal leak point pressure was 40 to 60 cm H2O required reoperation. Two of 16 patients who did not undergo anti-incontinence surgery eventually required continence surgery. A total of 13 patients (39.4%) were able to discontinue anticholinergics at 47.3 months postoperatively. There were no bladder perforations, bowel obstructions or metabolic abnormalities.Urothelium lined seromuscular colocystoplasty can be primarily considered in patients without prior bladder mucosal injury. Constant high bladder outlet pressure to facilitate adhesion of bladder mucosa and seromuscular patch is critical for the best results. We recommend abdominal leak point pressure 60 cm H2O or less as an indication for simultaneous anti-incontinence surgery and urothelium lined seromuscular colocystoplasty.

We analyzed whether newly developed or aggravated hydronephrosis deteriorates differential renal function after extravesical ureteral reimplantation.We performed extravesical ureteral reimplantation in 93 patients with unilateral vesicoureteral reflux between January 2006 and December 2009. Excluding 3 patients with other combined disease, a retrospective cohort analysis of 90 consecutive patients was conducted. We performed ultrasonography before and 1 month after extravesical ureteral reimplantation, and dimercapto-succinic acid scan before and 6 months after extravesical ureteral reimplantation. Of the patients 83 underwent final dimercapto-succinic acid scan at 6 months postoperatively. We analyzed the preoperative studies and perioperative parameters to evaluate the factors affecting newly developed or aggravated hydronephrosis at 1 month, and decrease in differential renal function at 6 months after extravesical ureteral reimplantation.Newly developed or aggravated hydronephrosis was observed in 25 patients (28.4%) 1 month after extravesical ureteral reimplantation. Younger age at surgery was a risk factor (p = 0.003). Of the patients 23 showed improvement on ultrasound 6 months postoperatively. In 12 patients (15.7%) a decrease in differential renal function of more than 5% was observed 6 months postoperatively. Preoperative parenchymal reduction on dimercapto-succinic acid scan was the only significant factor (p = 0.008). There was no correlation between newly developed or aggravated hydronephrosis and final decrease in differential renal function (p0.999).Although newly developed or aggravated hydronephrosis after extravesical ureteral reimplantation is common, especially in younger patients, it is transient and does not affect differential renal function. A postoperative decrease in differential renal function without further urinary tract infection could develop when there is a parenchymal reduction on preoperative dimercapto-succinic acid scan.

In this prospective, randomized, double-blinded study we sought to evaluate the efficacy and safety of combined use of intravenous ketorolac and acetaminophen in small children undergoing outpatient inguinal hernia repair.We studied 55 children 1 to 5 years old who were undergoing elective repair of unilateral inguinal hernia. After induction of general anesthesia children in the experimental group (28 patients) received 1 mg/kg ketorolac and 20 mg/kg acetaminophen intravenously. In the control group (27 patients) the same volume of saline was administered. All patients received 1 microg/kg fentanyl intravenously before incision. We also evaluated the number of patients requiring postoperative rescue fentanyl, total fentanyl consumption, pain scores and side effects.Significantly fewer patients receiving ketorolac-acetaminophen received postoperative rescue fentanyl compared to controls (28.6% vs 81.5%). A significantly lower total dose of fentanyl was administered to patients receiving ketorolac-acetaminophen compared to controls (0.54 vs 1.37 microg/kg). Pain scores were significantly higher in the control group immediately postoperatively but eventually decreased. The incidences of sedation use (55.6% vs 25.0%) and vomiting (33.3% vs 10.7%) were significantly higher in controls.Preoperative intravenous coadministration of ketorolac and acetaminophen is a simple, safe and effective method for relieving postoperative pain, and demonstrates highly significant fentanyl sparing effects in small children after outpatient inguinal hernia repair.

We studied histopathological changes in kidneys with demonstrable ureteropelvic junction obstruction in relation to patient age, differential renal function and urinary tract infection.Renal biopsy was performed in 42 children (44 kidneys) with a mean age of 3 years 6 months who underwent open pyeloplasty due to ureteropelvic junction obstruction. Each specimen was examined for reversible inflammatory cell infiltration and irreversible change, including interstitial fibrosis, arteriolar thickening and glomerular sclerosis. Each pathological finding was scored 0 to 3 in increasing grades of severity, and correlated with patient age, differential renal function and history of urinary tract infection.Of the 44 kidneys 20 (45%) had irreversible change. Correlation study revealed no association between patient age and histological findings, and there was no statistically significant difference in any histopathological category regardless of age. Differential renal function correlated with inflammatory cell infiltration and interstitial fibrosis. There were significantly worse histopathology scores in all categories when differential renal function was less than 30 versus 40% or greater. Interstitial fibrosis was significantly worse in the 30 to 40% group than in the greater than 40% group. The histopathological score of interstitial fibrosis was significantly higher in patients with than without urinary tract infection.Early correction in infants with ureteropelvic junction obstruction may not be necessary when initial differential renal function is greater than 40%. However, any decrease in differential renal function or recurrent urinary tract infections despite antibiotic prophylaxis warrant surgical correction of obstruction.

Purpose: Increasing clinical importance is being placed on the role of differential renal function (DRF) in the management of congenital ureteropelvic junction obstruction. Supranormal DRF of the hydronephrotic kidney on renal scan is a puzzling phenomenon and is hypothesized to be due to an increase in single nephron filtration or nephron volume without sound evidence. We studied the histopathological changes of hydronephrotic kidneys to determine whether glomerular hypertrophy underlies supranormal DRF. Materials and Methods: We retrospectively evaluated the records of 3 females and 32 males with unilateral congenital hydronephrosis who underwent pyeloplasty. Mean patient age at operation was 12.6 months (range 0.1 to 144). Needle biopsies from 3 different sites at the lower pole of the kidney were performed during surgery. To evaluate the presence of glomerular hypertrophy, the maximal planar area of glomeruli was measured under light microscopy using an image analyzer. Tissue samples obtained from kidneys without a history of urinary tract disease at autopsy were used as controls. The mean glomerular areas of the patient and control groups were evaluated according to DRF and age. Results: The mean glomerular area values of the patient group were smaller than those of the control group, except for 4 patients. The glomerular areas of the hydronephrotic kidneys with supranormal DRF were not significantly different from those of the control group. Instead, the probability of larger renal glomeruli increased with decreasing DRF (p = 0.1155). Conclusions: Increased nephron volume can be discounted as a cause of supranormal DRF.

We observed concomitant improvement in fecal incontinence in children with myelomeningocele undergoing intravesical electrical stimulation (IVES) to decrease uninhibited bladder contractions and increase bladder capacity and/or bladder sensation. We retrospectively reviewed the effect of intravesical electrical stimulation on neurogenic bowel dysfunction in these children.A total of 9 boys and 15 girls 3.9 to 13.2 years old (mean age 8.1) completed a mean of 30.3 daily sessions (range 10 to 69) of IVES. Evaluation forms were used to record frequency of fecal incontinence, daily bowel movement and diaper use before and after IVES.The mean number of overall fecal incontinence episodes decreased significantly from 7.36 to 4.8 a week after IVES (p0.05). Greater than 50% decrease in the episodes of fecal incontinence was observed in 75% of the patients. However, there was no significant change in the number of daily bowel movements before (1.8 daily) and after (1.55 daily) IVES.These results demonstrate the therapeutic effect of IVES in children with neurogenic bowel dysfunction and spina bifida. We believe that IVES is another viable option for controlling fecal incontinence in these children.

Purpose: Various factors are involved in testicular descent, and no single factor is elucidated as the cause of cryptorchidism. We prospectively observed the locations of gubernacular attachments in the cryptorchid testis. Materials and Methods: From April 1996 to June 2002, 639 boys underwent surgical correction of cryptorchid testis. Those with complete records of testicular locations and gubernacular attachments were analyzed. Results: A total of 639 boys underwent 732 surgical corrections of inguinal testis (425, 58%), high scrotal testis (165, 23%) and impalpable abdominal testis (142, 19%). Impalpable abdominal testes had gubernacular attachment to either the lateral or upper scrotum in 36 cases (25%) or around the inguinal ring in 83 (58%). The gubernaculum was attached to the bottom of the scrotum in 21 inguinal testes (5%), to the lateral or upper scrotum in 132 (31%) or around the inguinal ring in 268 (63%). In cases of high scrotal testis the gubernaculum was attached usually to the bottom of the scrotum (28, 17%), to the lateral or upper scrotum (109, 66%) or around the inguinal ring (26, 16%). Conclusions: The locations of distal gubernacular attachments in the cryptorchid testis were usually abnormal (93%). In these cases the possible testicular descent induced by hormonal therapy may either be insufficient or unable to prevent future ascent. Thus, early surgical correction rather than hormonal therapy is warranted in boys with cryptorchid testis.

INTRODUCTION AND OBJECTIVES: Plasma renin activity (PRA) has been known to be increased in urinary tract obstruction to compensate decreased local renal blood flow. In pediatric ureteropelvic-junction obstruction (UPJO), PRA has been reported to be increased than control and decreased after surgical correction of UPJO. We compared PRA with the histologic change of renal cortex to analyze the clinical meaning of PRA in pediatric UPJO patients. METHODS: We analyzed 42 consecutive pediatric patients who had been diagnosed with UPJO and undergone pyeloplasty or simple nephrectomy between March 2011 and October 2011. Age at operation, differential renal function (DRF) on diuretric renogram, PRA, and renal histologic change were analyzed. In all patients undergone pyeloplasty, kidney needle biopsies were performed simultaneously. When there was interstitial fibrosis or glomerulosclerosis in renal cortex, it was defined as unfavorable histology. RESULTS: Median age at operation was 5.4 (IQR: 3.3-12.5) months. Pyeloplasty was performed in 40 patients and laparoscopic simple nephrectomy was in 2 patients. Renal cortical histology showed unfavorable histology in 12 patients (28.6%) (Table 1). Gender, laterality, age at operation, blood pressure, serum creatinine, glomerular filtration rate showed no significant difference. Preoperative DRF and PRA were significantly higher in favorable histologic group. CONCLUSIONS: Preoperative DRF and PRA reflected renal histologic change in pediatric UPJO patients. In UPJO, higher PRA was correlated with higher renal function and that could be considered in the management of UPJO patients.

We compared testicular biopsies from retractile and cryptorchid testes to determine the histological effect of testicular retraction and the necessity of treatment for retractile testes.A total of 61 testicular biopsies were performed during orchiopexy in 36 boys 1.3 to 9.8 years old (mean age 5.4) with retractile testes (unilateral in 11, bilateral in 50) and 115 testicular biopsies were done in 83 patients with cryptorchidism (unilateral in 51, bilateral in 64) 0.5 to 14.9 years old (mean age 3.7). Parameters for germ and Sertoli cells were determined in each group.Mean average spermatogonial number (S/T value) and Sertoli cell index were statistically different between retractile and cryptorchid testes with values of 2.96+/-1.33 versus 0.61+/-0.87 and 26.81+/-6.75 versus 23.04+/-5.85, respectively. Average tubular degeneration phase V to VII ratio was 0.23+/-0.18 for retractile testes and 0.22+/-0.17 for cryptorchid testes which was not statistically different.Similar tubular degeneration phase V to VII values between retractile and cryptorchid testes indicate histological change in retractile testes and suggest the need for hormonal or surgical therapy for those patients with retractile testes lacking spontaneous descent.