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Treating pediatric incontinence can be challenging. Many surgical procedures are available with variable success and complications. Endoscopic injection of bulking agents into an incompetent bladder neck was first described using Teflon and most currently using Deflux. We compared the results of bladder neck injection using Deflux and Teflon to manage urinary incontinence in children.A retrospective study was performed in children who underwent primary endoscopic injection of Teflon or Deflux to the bladder neck. Patients with prior bladder neck surgery were excluded. Data were collected on underlying anatomical pathology, preoperative bladder capacity, endoscopic approach, quantity of bulking agent and outcome. Dry was defined as 3 hours or greater awake without wetting. Wet was defined as the need for a pad or diaper.A total of 34 patients underwent primary injection of bulking agents, including 32 via a retrograde approach and 2 via a combined antegrade-retrograde approach. A total of 20 children with a mean age of 2.7 years were injected with Teflon and 11 were injected with Deflux. One of the 20 Teflon injected patients was dry more than 6 months. One of the 14 Deflux injected patients was dry at 3 months in the daytime, another 2 improved at 3 months (antegrade/retrograde in 1) but worsened at 6 months and another was dry after a second injection. All 4 improved children had age appropriate bladder capacity. The volume of injected agent was 1 to 10 cc. No complications were seen. Five children per group underwent subsequent open continence surgery.Bladder neck injection of bulking agents is a generally ineffective therapy for incontinence. While neither the number of injections nor the bulking agent used affected the results, adequate bladder capacity and antegrade injection with Deflux heralded short-term improvement. Patients with exstrophy consistently did poorly.

Purpose: Extraperitoneal renal transplantation is not routine in small recipients, in whom transperitoneal engraftment is the norm. The outcome of extraperitoneal placement of renal allografts in children weighing less than 15 kg. was evaluated at 2 institutions.Materials and Methods: We retrospectively reviewed all pediatric renal transplantations at 2 institutions from 1988 to 2000 and identified 29 children 14 to 72 months old (mean age 29.2) weighing less than 15 kg. (range 8 to 14.8, mean 11.2). All children underwent allograft placement extraperitoneally via a modified Gibson and low midline retroperitoneal incision in 27 and 2, respectively. A concurrent procedure was done via the same incision during 2 ipsilateral and 2 bilateral nephrectomies.Results: Of the 29 patients 25 have a functioning renal allograft. In 2 cases the initial allograft was lost due to early postoperative thrombosis and acute rejection in 1 each. Two patients with a functioning allografts died of medical complications greater...

Others have demonstrated that inhibition of angiotensin II production partially ameliorates obstructive changes in the neonatal rabbit bladder. We examined the effect of angiotensin II converting enzyme inhibition and receptor antagonism on the obstructed rat bladder.Three groups of animals were investigated. Partial bladder neck obstruction was created in 23 rats by placing a 2-zero silk ligature around the vesicourethral junction. Eight rats were given untreated tap water, 9 were given water supplemented with 50 mg./kg. of the angiotensin-converting enzyme inhibitor captopril and 6 were given water with 30 mg./kg. of the angiotensin II subtype AT1 receptor antagonist losartan potassium. Eight unobstructed rats served as controls. After 2 weeks of partial outlet obstruction the animals were sacrificed and bladders were harvested. Routine histological evaluation and assays for total protein, deoxyribonucleic acid and collagen content were performed.Histological evaluation revealed that administration of captopril or losartan potassium resulted in a mild decrease in the degree of obstructive bladder changes. Biochemically neither captopril nor losartan potassium caused a significant decrease in the amount of total deoxyribonucleic acid, protein or collagen content per bladder compared to untreated obstructed bladders.In contrast to previous studies in neonatal rabbits, neither captopril nor losartan potassium significantly ameliorated the histological or biochemical features of partial bladder outlet obstruction in the rat. Further investigation is necessary into species specific differences to understand better the role that angiotensin II may have in mediating the bladder changes of experimentally induced obstruction.

We evaluated the importance of intraoperative venography and surgical approach on varicocele recurrence after surgical varicocelectomy in male adolescents.The analysis was done using local data and composite data from the literature. We reviewed the records of patients undergoing varicocele ligation between 1986 and 1995 at our institution. Data were stratified by surgical approach and performance of venography, and compared by cross table analysis. Data were then compiled from the literature from series that included cases stratified according to surgical approach and/or performance of venography. The impact of these parameters on recurrence rates was assessed by computing success rates and cross table analysis.At our institution 33 boys underwent ligation via a suprainguinal (27) or inguinal (8) approach. Intraoperative post-ligation venography was performed in 16 cases and omitted in 19. Neither surgical approach nor performance of venography influenced the recurrence rate in these patients (not statistically significant). Similarly, venography did not affect the recurrence rate after stratification by surgical approach (not significant). The overall success rate was 97% (34 of 35 cases). These data were added to those of 3 published studies, totaling 252 varicoceles with comparable groupings. Mean success rate after a suprainguinal and inguinal approach was 95.6 (93.2 to 97.4) and 88.3% (82.7 to 100%), respectively. Recurrence tended to be less common after a suprainguinal than an inguinal approach (p = 0.06). Post-ligation venography did not statistically affect the success rate after stratification according to surgical approach but it was associated with a higher success rate when performed with the inguinal approach.Irrespective of the performance of venography, the suprainguinal surgical approach yields higher success rates than the inguinal approach to varicoceles in adolescents. Post-ligation intraoperative venography fails to affect significantly the success of varicocele ligation but it may be useful during an inguinal approach.

To understand better the significance of pediatric idiopathic nephroureteral dilatation the renal ultrasound images of patients less than 1 year old with hydronephrosis or hydroureteronephrosis were graded and compared to the radiological diagnosis of obstruction as determined by diuresis renography and/or urography. The study included 73 boys and 30 girls with hydronephrosis (76 patients) or hydroureteronephrosis (27). For hydronephrosis obstruction was diagnosed in 56 children (74%) and involved 61 of 97 kidneys (63%). For obstructed kidneys the mean grade of hydronephrosis (3.4 +/- 0.7 standard deviation) was statistically different from that of nonobstructed kidneys (1.6 +/- 0.8 standard deviation) (p less than 0.05). When the value to predict obstruction was set at grade 3 hydronephrosis or greater there was an 88% sensitivity and 95% specificity. For hydroureteronephrosis obstruction was diagnosed in 15 of 27 children (56%) and involved 17 of 34 kidneys (50%). The degree of dilatation was weighted as a score to assess the grades of hydronephrosis and ureteral dilatation, namely hydroureteronephrosis score equals grade of hydronephrosis plus grade of ureteral dilatation. In obstructed megaureters the mean hydroureteronephrosis score (5.8 +/- 1.0) was statistically different from that for nonobstructed megaureters (mean hydroureteronephrosis score 2.7 +/- 1.9) (p less than 0.001). When the value to predict obstruction was set at hydroureteronephrosis score of 5 or greater there was a 94% sensitivity and 80% specificity. Although ultrasound examination alone cannot be used to diagnose urinary obstruction, the radiological diagnosis of obstruction is linked with the grade of hydronephrosis or score of hydroureteronephrosis.

Purpose: Various techniques of reconstruction have been developed to improve the cosmetic and functional status of the abdominal wall in the prune-belly syndrome. We describe a new extraperitoneal plication technique of abdominoplasty that is simplified in comparison to other established procedures in that it obviates the need for a fascial incision and/or entrance into the peritoneal cavity in patients who do not require a concurrent intra-abdominal procedure.Materials and Methods: Since 1980 this technique of abdominoplasty has been performed in 13 patients 9 months to 11 years old (mean age 3.8) at 2 institutions. Seven patients underwent surgery before age 2.5 years. Abdominal wall reconstruction was performed as an isolated extraperitoneal procedure in 5 patients, while 8 had concomitant procedures performed with the abdominoplasty, including bilateral Fowler-Stephens orchiopexy in 7, ureteral reconstruction/reimplantation in 5, excision of urachal diverticulum or cyst in 2, reduction cystopl...

Purpose: We report our experience with the intravesical administration of oxybutynin chloride with particular focus on the incidence and characterization of untoward effects and inconvenience of therapy.Materials and Methods: From 1990 to 1995, 23 children 5 to 11 years old with myelodysplasia were treated with intravesical oxybutynin chloride. Initial dose was 1.25 mg. in 5 cc sterile water instilled during routine catherization 3 times daily, which was increased as tolerated and clinically indicated. Oral anticholinergic, antispasmodic and sympathomimetic medications were discontinued during therapy. We reviewed therapeutic indications, duration, reason for discontinuation and untoward effects. Patients/parents were surveyed for convenience of treatment as well as side effects and their timing with respect to drug administration and dose.Results: In 15 patients (65%) treatment was discontinued and oral formulations were resumed or other therapy was required due to side effects, ineffectiveness o...

Renal vein thrombosis may lead to significant renal impairment, even death, yet therapy remains controversial. Thrombolytic therapy in general may be attended by significant hemorrhagic complications and has not been used widely in children. We treated a 9-year-old boy with antithrombin III deficiency and acute renal vein thrombosis in a solitary kidney with a selective 48-hour infusion of low dose urokinase with return of renal function. Minor bleeding from a fresh surgical incision was the only morbidity. Such use of fibrinolytic agents in children with acute renal vein thrombosis may prevent significant renal impairment and deserves further clinical trials.

Several names have been used to describe a rare multiloculated cystic lesion in the kidney, including benign multilocular cyst, multilocular cystic nephroma, cystic nephroma and others. The abundance of names is partially attributable to an incomplete understanding of the etiology and natural history of this condition. Most authorities believe that this lesion is part of a spectrum of renal cystic disorders with multilocular cyst and cystic Wilms tumor representing the 2 extremes. Whatever the etiology, multilocular cysts have a typical radiographic appearance, are almost uniformly unilateral and are treated with curative nephrectomy. We report a unique case of bilateral multilocular renal cysts treated with bilateral partial nephrectomy. CASE REPORT A 15-month-old Hispanic boy presented with a 3-month history of progressively enlarging bilateral flank masses, and nausea, vomiting and anorexia 1 week in duration. There was no other significant medical history. Physical examination revealed blood pressure of 100/60 mm. Hg and abdominal examination demonstrated bilateral 12 to 14 cm., nontender, nonfixed, firm flank masses. Serum electrolytes, urea nitrogen, creatinine, hemoglobin and urinalysis were normal. Abdominal ultrasound and computerized tomography showed 10 X 12 cm. cystic renal masses with multiple septa (fig. 1). A rim of normal appearing renal parenchyma (right side greater than left side) was displaced inferiorly and medially. 3-Mercaptoacetyltriglycine nuclear renal scan revealed that 80% of renal function was by the right kidney. Abdominal exploration was planned but moderate hypertension developed, which was controlled with oral calcium channel blockers. Subsequently exploration was performed through a transperitoneal midline incision. The left renal mass was approached first, revealing a firm mobile cystic renal mass contiguous with the inferior pole of normal appearing renal tissue. Because of the benign appearance of this mass and bilateral involvement, a nephron sparing procedure was performed involving partial nephrectomy with renal reconstruction. The mass was completely excised en bloc (fig. 2). However, the dilated renal pelvis was opened to extrude the inferior aspect of the mass, which had herniated into the collecting system. Frozen section was consistent with a multilocular renal cyst without evidence of malignancy. Exploration of the right side revealed similar fmdings and an identical procedure was performed. Postoperatively the patient recovered well. He is currently asymptomatic and thriving, and hypertension has completely resolved. Followup renal scan and ultrasound 6 months postoperatively demonstrated excellent function of both remaining renal units with no evidence of any recurrent cystic lesions. The final pathological diagnosis was consistent with bilateral benign multilocular renal cysts.

Undiversion of the urinary tract is now a practical and valued addition to the urologist’s armamentarium. During the preceding 5 years undiversion procedures were done on 20 children. These 20 undiversions were categorized into 2 groups. Group 1 consisted of 11 children who required small bowel interposition between the ileal/jejunal conduit and/or kidney to the bladder. One of these children required an ileocecal cystoplasty because of a contracted bladder. Group 2 consisted of 9 children who required remodeling and rearrangement of the ureters to establish continuity of the urinary tract.All children had an extensive urologic appraisal to ascertain the level of renal function and reserve, and roentgenographic assessment of the kidneys, conduit, ureters and bladder. Every effort was made to identify the precise indication for the initial diversion and the feasibility of undiversion. Cystoscopy was performed uniformly to exclude valvular and/or stricture urethral disease. Bladder capacity determin...

We assessed 18 fetuses who harbored a urinary tract malformation that was diagnosed by antenatal sonography. The antenatal diagnosis corresponded to the postnatal diagnosis in 66 per cent of the cases. We review the course of 6 fetuses who had catheters placed percutaneously to drain dilated urinary tracts that were believed to be caused by posterior urethral valves (5) or an obstructed megaureter (1). Only 2 of these fetuses exhibited valves postnatally. No fetus had any recognized benefit from the antenatal intervention. We found that sonography may not readily differentiate fetuses with hydronephrosis with obstruction from those without obstruction. From this experience we conclude that intervention in pregnancies suspected of harboring a fetus with a malformed urinary tract should be done cautiously. Antenatal sonography is useful to identify the fetus with a dilated urinary tract. This identification permits perinatal specialists to be alerted so that preparations for reconstructive surgery in such cases can be made early postpartum.

Continuous ambulatory peritoneal dialysis has become a highly acclaimed method of maintenance therapy in the management of end stage renal disease in childhood. This type of dialysis affords freedom and comfort, and lessens dependence. Furthermore, the over-all reduction in hospital-related cost of this therapy currently has made continuous ambulatory peritoneal dialysis the recommended procedure of choice at our institution. From July 1980 through May 1986 we offered this form of therapy to 45 patients between 4 days and 17 years old. A total of 68 Tenckhoff catheters were placed. Reasons for catheter removal included persistent peritonitis, tunnel infection, catheter leakage, catheter obstruction, successful kidney transplant, motivational failure, midline nephrectomy and death. Patient and parent instruction and indoctrination were critical factors in catheter survival. Our experience with the specific technical aspects of insertion documented that the single cuff, coiled Tenckhoff catheter and long, subcutaneous tunnel were definite advantages. These factors favored early use and long-term survival. The course of these patients with respect to nutrition, growth, emotional activity, infections and catheter survival is presented.

The cecoureterocele differs from the usual ectopic ureterocele because it extends outside the bladder and may obstruct the urethra. The differentiation requires careful examination of the urethra by a voiding cystourethrogram and cystoscopy. We describe the management of a girl with bilateral cecoureteroceles who presented as a newborn with urinary retention and sepsis. Surgical correction of the cecoureterocele may differ from that required for the usual ectopic ureterocele.

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.

We reviewed our management of children with vesicoureteral reflux and ureteropelvic junction obstruction in the same renal unit. Of the children who underwent pyeloplasty for ureteropelvic junction obstruction 9 per cent also had vesicoureteral reflux. These children were almost exclusively boys. Ureteropelvic junction obstruction was caused mostly by a stricture or fixed kinks of the upper ureter. Vesicoureteral reflux was primarily grade IV and was associated with abnormal morphology of the ureteral orifice. Pyeloplasty was the initial surgical correction and ureteral reimplantation was performed expectantly.

We present the first experience with in-office ultrasonography to further the office evaluation of children with urological problems. Since February 1986 we imaged prospectively the kidneys and bladders of 172 children (100 boys and 72 girls, mean age 6 years) who presented for office evaluation using a portable 5 MHz. real-time linear array scanner. Initially, we gained familiarity with in-office ultrasonography by examining 38 children who presented for evaluation of problems not recognized to be associated with renal malformations (that is undescended testis). In-office ultrasonography showed hydronephrosis in 1 boy with a buried penis that was found later to be owing to ureteropelvic junction obstruction requiring pyeloplasty. Then, in-office ultrasonography was used to supplement the office evaluation of children with a history of urine infection, voiding problems or known malformations of the kidney and/or bladder. The test showed that 12 of 24 children (50 per cent) with a history of urine infection had a thickened detrusor, large bladder capacity with or without residual urine or reduced sensation to void. In-office ultrasonography also showed that 24 of 74 children (32 per cent) with voiding problems had a thickened detrusor, large bladder capacity with or without residual urine, fecal impaction, suspected bladder neck obstruction (which later required internal urethrotomy) or small bladder capacity. In 35 children with known malformations of the urinary tract in-office ultrasonography was useful to assess the progress of hydronephrosis (29) or to clarify the etiology of the hydronephrosis (4). The diagnostic value of this test was evaluated in 98 children in whom enough data were available to compare the results to those of subsequent urography or clinical outcome. In-office ultrasonography had a 98 per cent sensitivity and an 82 per cent specificity rate. We conclude that in-office ultrasonography is a reliable means to identify incomplete bladder emptying in children with urine infection related to dysfunctional voiding, identify detrusor thickening related to the unstable bladder and indicate the likely etiology of hydronephrosis.

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.

The testicular capsule of the human has been prepared for the first time as an isolated tissue suitable for pharmacological investigation. Cholinergic and adrenergic agents caused a contraction of the isolated testicular capsule. In addition, periodic spontaneous contractions of the isolated testicular capsule had been observed in the absence of any added pharmacological agents. The present experiments have demonstrated that the testicular capsule contains smooth muscle, thereby offering a reasonable anatomical explanation for spontaneous and drug-induced contractions of the testicular capsule. Therefore, it appears likely that the rhythmic contractions and relaxations of the testicular capsule provide a pumping action capable of explaining the transport of non-motile sperm out of the testes into the epididymis where they can attain their motility.

Since July 1982, 23 children between 10 and 28 months old underwent correction of hypospadias. After chordee was resected the urethral orifice was in the perineum in 3, at the penoscrotal junction in 5, on the proximal or mid shaft in 10 or at the distal shaft in 5. The neourethra was fashioned from a transverse island pedicle of preputial skin for proximal hypospadias or by using Mustarde's technique for distal hypospadias. A perforated silicone tube was left in the urethra and a feeding tube was passed through the lumen of the urethral stent to drain the bladder. Up to 4 days later the bladder catheter was removed and the children voided per the neourethra. The urethral stent was removed between 6 and 30 days postoperatively. Voiding through a recently constructed urethra was well tolerated. The boys did not experience bladder spasms, urinary extravasation did not occur and cosmetic results were good. Meatal stenosis did not occur. Three children (13 per cent) required closure of a fistula, which was noted 1 to 2 1/2 years later. It appears that briefly diverting bladder urine after hypospadias repair ameliorated postoperative morbidity without compromising the results. This technique was found to be inappropriate in older boys because of significant dysuria.

During the last 4 years lower ipsilateral ureteroureterostomy was performed to treat vesicoureteral reflux and/or obstruction in 11 children with 13 completely duplicated systems. There was reflux only to the lower segment in 11 systems, obstruction only to the upper segment in 1 and reflux with obstruction in 1 system. The procedure is technically easier than ureteroneocystotomy, avoids cystotomy and permits a brief postoperative hospitalization. The postoperative excretory urogram demonstrated improved or stable hydronephrosis in all patients. Vesicoureteral reflux persisted in 1 system associated with a golf hole orifice. Caution should be exercised when children with reflux in duplex systems associated with a golf hole ureteral orifice are treated.

Conventional surgery for the ectopic ureter stresses polar nephrectomy, while preserving a functioning upper pole by ipsilateral ureteroureterostomy is performed less commonly. During the last 15 years we operated on 35 children for ectopic ureter. High ipsilateral ureteroureterostomy (15 patients) was performed when the upper pole cortex appeared to be smooth and pink, and the anastomosis was surgically feasible. Upper pole nephrectomy and upper ureterectomy (21 patients) were performed when the involved segment appeared grossly to be pale, cystic or otherwise abnormal. One low ipsilateral ureteroureterostomy was performed concomitant with contralateral ureteral reimplantation. Complications after ipsilateral ureteroureterostomy and partial nephrectomy were similar. Histological evidence of dysplasia of the polar nephrectomy specimens was focal in 7 patients (33 per cent), marked in 2 (10 per cent) and not detected in 12 (57 per cent). Ipsilateral ureteroureterostomy is an appropriate means to manage the ectopic ureter in selected cases because dysplasia in these upper pole renal units seldom is significant, and because ipsilateral ureteroureterostomy and polar nephrectomy have similar postoperative morbidity rates.

Eight boys with congenital urethral hypoplasia and atresia are described, including 5 with a patent urachus, 2 with an "H" type urethral perineal duplication and 1 with a rectovesical fistula. Of the boys 5 had the prune belly syndrome. The technique of gradual progressive indwelling soft catheter or stent dilation achieved excellent results in 6 boys. This technique is believed to offer the slow stimulus necessary for urethral dilation that is missing in boys with a patient urachus or urethral duplication. The remaining 2 boys were treated with more conventional techniques of urethrotomy or rapid urethral dilation. They eventually achieved a satisfactory result but after significant morbidity. This clinical experience serves to describe and demonstrate how the application of gradual progressive soft, small catheter or stent dilation of severe urethral hypoplasia and atresia results in a functionally normal urethra with minimal morbidity.

Obstructive uropathy in children often means urethral valves. A discussion of anterior urethral valves, outlining the mode of presentation, systematic evaluation, role of therapy and the results obtained, is presented. The total experience of anterior urethral valves at this hospital is summarized. A classification of anterior urethral valves is introduced, relating this entity to a pathophysiologic progression of urologic deterioration.

Standardization of the bladder capacities of children will improve the precision of urodynamic evaluation. In an attempt to develop a practical guide to predict the normal bladder capacity during childhood the bladder capacities of 132 children without a clinically abnormal pattern of voiding were measured. When the bladder capacities are correlated by age the following linear relationship exists: normal bladder capacity (ounces) equals age (years) plus 2.The bladder capacities of 68 children with primary enuresis, frequency or infrequent voiding were then measured. Children with clinically infrequent voiding demonstrated large bladder capacities and those with frequency or enuresis demonstrated small bladder capacities compared to normal children.The formula appears to be a useful guide to predict normal bladder capacity by age and also to aid in the diagnosis of abnormal voiding patterns.

The management of extensive ureteral injury or loss in a renal transplant recipient occasionally requires alternate forms of urinary transport to re-establish urinary tract continuity, salvage the renal homograft and lessen patient morbidity. In 7 of 96 pediatric renal transplant recipients ileal conduit diversion, acute Boari flap, pyelovesicostomy and tube nephrostomy techniques have been used when alternative forms of urinary conveyance were necessary. These forms of urinary diversion achieved satisfactory results and afforded the recipient the opportunity to retain the renal homo, graft and experience a near normal life.

Pelvic lymph accumulation (lymphocele) is a recognized complication of renal transplantation. During a 12-year period 166 renal transplants were performed in 143 children at our institution. From 1973 to 1979, 5 lymphoceles were treated in 64 children. From 1979 until the present a technique of peritoneal fenestration has been performed in 69 children, in whom 1 lymphocele developed. Lymphoceles required surgical treatment in 5 of the remaining 10 cases that were not fenestrated. Our experience with peritoneal fenestration as a method of lymphocele prevention has been excellent, and we recommend it as a prophylactic addition to renal transplant surgery.

Radioisotopic scortal scanning was used as a triage maneuver to assess 18 boys with scrotal and/or testicular complaints. In 4 puberal boys the diagnosis was torsion and treatment consisted of orchiectomy because of testicular necrosis. This technique proved to be of value in studying infants and older children. It appears to be highly reliable and accurate. We believe that it should be used in making the diagnosis of non-operable conditions, such as epididymitis and idiopathic scrotal swelling, thereby avoiding an unnecessary operation.

Intermittent catheterization was used as a method to achieve reflex voiding and a catheter-free status in 111 chronic spinal cord injury patients. Of this group 70 patients achieved reflex (automatic) voiding within 90 days, or a mean of 19 days. Five patients required transurethral incision of the external urethral sphincter after achievement of automatic voiding because of elevated residual urine. Chronic urinary tract infection persisted in 16 per cent of the patients after completion of the program. No sequelae occurred because of the coexistent urinary tract infection. An 18-month followup disclosed stability in renal function and appearance of pyelograms. Urethral, scrotal and bladder complications secondary to chronic indwelling urethral catheters have been eliminated in these patients. Patient endorsement and enthusiasm have been spectacular and have overwhelmingly contributed to an ongoing, successful program.

The reasons for failure of orchiopexy were investigated by reviewing the records of 350 boys with undescended testis. There were 36 boys (10 per cent) who had experienced failure of an initial surgical procedure. We found that the standard surgical techniques of local inguinal dissection, high ligation of a patent processus vaginalis, extensive retroperitoneal mobilization of the spermatic vessels and vas deferens, and/or creation of a dartos pouch were sufficient to correct these failures. Retroperitoneal dissections were required to correct the undescended testes in 58 per cent of the boys. Only 37 per cent of the boys could be treated satisfactorily by localized inguinal dissection. It appears that standard surgical techniques, especially aggressive retroperitoneal dissection, are adequate to correct even troublesome cases of undescended testis.

Venography has been proposed as an aid in preventing persistent varicoceles after internal spermatic vein ligation. Since 1984, 10 patients between 4 and 18 years old underwent successful outpatient varicocelectomy with high ligation and intraoperative internal spermatic venography to assure that all appropriate veins and collaterals had been isolated before ligation.

The majority of testicular tumors in children will be of germ cell origin and the predominant pathologic type is the yolk sac carcinoma. Initial treatment or radical orchiectomy is not in question. However, because of its presumed less virulent character, especially in children less than 2 years old, confusion remains as to adjunctive treatment for yolk sac carcinoma. We have studied retrospectively 21 children with testis tumors encountered within the last 10 years. Of these cases 12 were classified pathologically as yolk sac carcinoma. All children were less than 3 years old and 10 of 12 were less than 2 years old. Of the 12 cases 4 had positive lymph node dissections and 3 of these 4 children were less than 2 years old. Although chemotherapy is so effective its toxicity cannot be minimized. Therefore, adjunctive chemotherapy should be reserved for those patients who have lymphatic spread. Young children with yolk sac tumors are not immune to metastatic disease and should be treated with an extended unilateral lymphadenectomy for staging and appropriate treatment regimens.