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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.

Rhabdomyosarcoma is the most common soft tissue malignant neoplasm involving the pelvis of children. Debate still exists over whether the best treatment is pelvic exenteration, radiation and chemotherapy or chemotherapy as the cornerstone to treatment, with diminished needs for extensive surgery and prolonged radiotherapy. Contrariwise, there is little debate over the combined treatment modality for paratesticular rhabdomyosarcoma. We have evaluated and treated 19 children with rhabdomyosarcoma, including 17 with pelvic rhabdomyosarcoma and 2 with paratesticular rhabdomyosarcoma. This retrospective study was done to evaluate treatment regimens for patients with genitourinary rhabdomyosarcoma. For patients with pelvic rhabdomyosarcoma the study was divided into 2 series. In an early series 6 of 7 children had a pelvic exenteration with or without chemotherapy. Of these 7 children 3 are well 15 to 27 years following diagnosis. In a later series of 10 children, when chemotherapy was used more commonly, none underwent pelvic exenteration. Of these 10 patients 7 had chemotherapy or chemotherapy and biopsy only. Only 1 child, who presented with stage IV disease, died in this series. Another child with stage III disease had progressive disease despite chemotherapy and subsequent cystoprostatectomy. Thus, of 9 remaining patients 8 are well from 1 to 8 years. It appears that pelvic rhabdomyosarcoma can be treated effectively with chemotherapy, and limited surgery and radiation. Fortunately, pelvic exenteration can now be limited to a select few.

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.

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.

From 1973 through 1986, 166 consecutive renal transplants were performed in 143 patients. Urological complications included ureteral leakage/obstruction/necrosis, urinary tract infection, pyelonephritis, pelvic lymphocele, pelvic abscess, pelvic hematoma, infected hydrocele, bladder calculus, labial edema, renal artery/segmental stenosis, hydronephrosis, urinary incontinence, renal allograft malrotation and kidney rupture. Management options and preventive measures to avoid some of these dilemmas are highlighted.

Formation of a mucosal collar from the inner surface of the prepuce offers the surgeon who performs hypospadias repairs the opportunity to create a cosmetically normal-appearing phallus. This technique results in transposition of mucosal membrane type of tissue to the subglandular area to complete the normal repair.

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 polyribosomal-rich lymphocyturia 5 to 11 days before the onset of clinical rejection as diagnosed by conventional methodology. In addition, significant lymphocyturia occurred 1 to 3 days before and simultaneous with a sustained elevation in serum creatine. Falsely positive assays demonstrating occasional to 1 plus (less than 10 per cent) ribosomal-rich 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 antirejection therapy based on this parameter homograft rejection may be aborted or its severity diminished.

This study represents our observations of 50 pediatric patients who underwent urethroplasty for hypospadias and chordee. An indwelling Silastic Foley catheter remained indwelling postoperatively for ten to fourteen days, connected to an antireflux leg drainage bag. Prophylactic antimicrobial therapy was given to all patients from the day of operation until one week after removal of the catheter. Cultures obtained from urine specimens taken directly from the drainage bag revealed that only 16 percent of the cases had a significant bacterial colony count (greater than 100,000/cc). We describe the efficacy of a closed drainage system combined with prophylactic antimicrobials in the management of children after hypospadias surgery.

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.

Rhabdomyosarcoma is the most common tumor of the lower genitourinary tract in children during their first two decades of life. Four patients with genitourinary rhabdomyosarcoma are presented, with ultrasonographic and radiographic findings. The utility of ultrasound in the diagnosis of this pediatric tumor is emphasized.

Some children with vesical sphincter dyssynergia are refractory to conventional pharmacologic therapy. Three such patients were treated using a method of sphincter retraining, biofeedback. They observed the urinary sphincter electromyogram while voiding to appreciate visually the abnormality. Two children learned to suppress voluntarily the inappropriate sphincter contraction during voiding. This normalized the subsequent electromyographic recordings and offered subjective improvement in the voiding symptoms. Retraining the urethral sphincter dysfunction may be approached using biofeedback techniques in selected patients.

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.

Endoscopic subureteral injection of polytetrafluoroethylene (Teflon) was done in 38 patients (55 ureters) to correct vesicoureteral reflux. Followup excretory urograms and nuclear cystograms were available in 28 patients (40 ureters) 2 to 11 months after injection. Nearly 50 per cent of the patients had a neurogenic bladder. Injection was done for all grades of reflux, although the majority of cases had at least grade III reflux. After injection reflux either was eliminated or decreased in 76 per cent of the patients with neurogenic disease and in 87 per cent of those with a normally innervated bladder. This outpatient procedure is simple and brief to perform, and it is associated with minimal morbidity. As with any new antireflux technique longer followup is indicated.

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.

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.

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.

Forty-two children with voiding pattern abnormalities (wetting, incontinence, inappropriate voiding) were evaluated by urodynamic techniques. All patients were urologically evaluated and carefully appraised of the mechanics of the urodynamic testing procedure. All patients demonstrated good cooperation in an anxiety-free atmosphere. Twenty-three abnormal bladder types were identified and characterized. Specific pharmacologic and urologic modalities were applied to achieve improved or normal micturition.

Vesicoureteral reflux is a common clinical problem that we monitor by interval nuclear cystography. Of the children having nuclear cystograms 40% also have voiding abnormalities, including incontinence (damp pants), urgency and infrequent micturition. We have evaluated these symptoms by recording the intravesical pressure during the nuclear cystogram. This combined examination, the cystometric nuclear cystogram, has been done on 46 children. An abnormal cystometrogram was found in 61% of the children with a voiding abnormality and helped to establish a basis for successful therapy. The cystometric nuclear cystogram aids in the diagnosis and rational therapy of childhood voiding abnormalities. It is a practical method to obtain a cystometrogram in children with voiding abnormalities who are being evaluated for ureteral reflux and it has facilitated the management of childhood ureteral reflux.

Previous studies have concluded that surgical exploration is unnecessary in genetic male subjects with nonpalpable tests who fail to respond to human chorionic gonadotropin. Lack of response suggested absent testicular tissue. We report on 2 patients thought to have anorchia because of lack of response to human chorionic gonadotropin stimulation. Testes were found in both patients. Genetic and phenotypic male subjects with nonpalpable testes who fail to have increased testosterone after human chorionic gonadotropin stimulation should undergo laparoscopy. If testicular structures are present at laparoscopy surgical exploration is indicated. Unresponsiveness to human chorionic gonadotropin may be evidence of nonexistent or dysfunctional Leydig cells rather than evidence of complete absence of testicular tissue.

The association of tapetoretinal degeneration with familial juvenile nephronophthisis is a rare oculorenal syndrome. Without treatment all children die of renal failure prior to adulthood. Information regarding renal transplantation is lacking in these children. This article reflects our experience in two children affected with this syndrome who achieved excellent functional results following living-related kidney transplants. Surgery can be done safely in these children with little or no morbidity. We believe that children with this syndrome benefit from transplantation and that this offers a significant improvement in their quality of life.

Congenital urinary tract anomalies are common causes of renal insufficiency and failure in children. Frequently, the hydroureteronephrosis and/or bladder damage from previous reconstructive procedures is so severe that supravesical diversion is required. Renal transplantation in these cases is sometimes avoided because of implied urologic and infectious complications, and the early loss of the homograft. Nevertheless, newer techniques have been developed for transplantation in patients with end stage renal disease and defunctionalized bladders. Herein is described the use of defunctionalized bladders as receptors of renal homografts in 5 of 42 transplant recipients seen during the last 4 years.

The leukocyte aggregation test (LAT) detects the in vitro adhesion of sensitized, but not nonimmune, recipient leukocytes onto donor kidney cell monolayers. The test specifically detects cell-mediated homograft immunity up to 15 days prior to the appearance of clinical signs or alteration of chemical indexes. The presence of a positive reaction always signified incipient homograft rejection, which was usually controlled by intravenously administered, high-dose methylprednisolone sodium succinate (Solu-Medrol) therapy. There was no instance in which methyl-prednisolone treatment effectively reversed rejection in the presence of a negative leukocyte aggregation test. One common form of homograft rejection may be characterized by positive LAT results, a cellular infiltrate on the renal biopsy specimen, and sensitivity to methylprednisolone therapy.

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.

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.

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.

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.

We describe a new technique for posterior urethral valve ablation that was performed easily and successfully in 2 male newborns. Convalescence was uneventful and both patients have thrived postoperatively. The technical details and advantages of this approach are outlined and discussed.

We used a modified extravesical technique, coined detrusorrhaphy, to correct surgically vesicoureteral reflux. By detrusorrhaphy the submucosal ureteral tunnel is opened, the ureteral meatus is advanced and anchored onto the trigone, and the detrusor buttress of the ureter is closed (-rrhaphy). The operation is performed extravesically. The procedure was used in the last 5 years in 79 children, or 120 renal units. Reflux resolved in 93 per cent of the renal units. Postoperative morbidity related to bladder spasms and hematuria was minimal compared to conventional transvesical surgical procedures. Detrusorrhaphy is an effective method to correct vesicoureteral reflux and to minimize postoperative morbidity.

Urodynamic evaluations were done on 37 children to diagnose voiding pattern abnormalities and/or recurrent urinary infections. Each of 25 children had 2 sets of testing to judge a practical method of urodynamic evaluation. Bipolar anal skin electrodes were compared to bipolar perianal muscle needle electrodes as a means of monitoring the urethral sphincter/pelvic floow electromyographic activity. In addition, the urethral catheter was compared to the suprapubic catheter as a means of monitoring intravesical pressure. The results were similar and statistically significant (p less than 0.001). The remaining 12 children were evaluated based only on the results of bipolar anal skin electrodes and uroflowmetry. The results of both groups clearly demonstrated that surface perianal electrodes are practical, accurate and reliable for the diagnosis and treatment of children with voiding pattern abnormalities. We recommend the use of surface electrodes and a urethral catheter as techniques for the urodynamic evaluation of voiding pattern abnormalities of children without overt neuropathology or extensive urethral operation. Preoperative surface electromyography of the urinary sphincters may prove to be a useful screening test to detect occult dyssynergia in patients who have had failed ureteral reimplants.

A patient with an ileal conduit diversion after cystectomy for carcinoma of the bladder is seen with cirrhosis and portal hypertension. Massive bleeding from the peristomal varices developed. Our experiences with conservative treatment is outlined.

In evaluating a child with enuresis, an organized approach to the history leads to a working diagnosis and an appropriate treatment plan. Questions are grouped in nine categories: perinatal complications, complications in infancy, toilet training, voiding pattern (assessed with a voiding diary), micturition pattern, urinary infection, defecation pattern, perineal symptoms and food sensitivities. Structural abnormalities must be evaluated cautiously to assure that a functional problem is not overlooked.

The concealed penis is a long-standing problem that only recently has begun to receive the attention it deserves. We offer a classification for this general disorder, which facilitates the selection of appropriate surgical procedures for these patients. To correct the most common problem, the buried penis, involves removal of localized deposits of fat from the hypogastrium with open surgical or closed suction techniques followed by anchoring of the skin of the base of the penis to the periosteum of the pubis. During the last year we have used this approach successfully in 7 boys with various forms of penile concealment with good results.

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.

Urodynamic studies were done on 50 children with voiding pattern abnormalities, characterized by daytime incontinence, damp pants, nocturnal enuresis, frequency and recurrent urinary tract infections. These studies included cystometry, uroflowmetry and pelvic floor/external urethral sphincter electromyography. Of the 50 children studied 37 were treated with various pharmacological agents based on 8 recognized urodynamic patterns. Thirty-one children (84 per cent) became totally asymptomatic while on pharmacotherapy and 4 (11 per cent) demonstrated marked improvement in clinical symptoms during the course of this study. Appropriately directed urodynamic studies and treatment with specific pharmacological agents can treat (retrain) effectively children with voiding pattern abnormalities.

Voiding abnormalities are encountered frequently in pediatric patients. Symptoms of daytime incontinence, frequency and nocturnal enuresis in any combination may indicate underlying neurophysiologic detrusor imbalance. Incomplete evaluation of these symptoms can result in inappropriate medical therapy or even ineffective operations. Within the preceding 7 months 34 children with hard-core voiding abnormalities were evaluated with urodynamic techniques. Several categories of abnormal voiding patterns were identified, including the hyperactive external sphincter, uninhibited pediatric neurogenic bladder, detrusor hyperreflexia secondary to chronic cystitis, hyperactive external sphincter with hypotonic bladder and the hyperactive external sphincter with detrusor irritability. All patients received specific pharmacotherapy based on presenting signs and symptoms, and voiding pattern abnormality. Of the 24 patients who have been treated in this manner and were evaluated 83.5 per cent have had complete remission of symptoms while on therapy, the remainder being improved but still having occasional symptoms. The technique and data demonstrate that children with hard-core voiding abnormalities can achieve rehabilitation with urodynamic assessment.

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.

An effective, easily fashioned, adherent, long-term X elastic dressing is described. The dressing has been used predominantely in hypospadias operations. It affords excellent compression of the skin and glandular flaps, and reduces edema. The dressing provides for children comfort, freedom of motion without interference with normal bowel movements and effective compression of the genitalia, and it appears to have a broad-spectrum of application in pediatric and adult urologic surgery. Complications are rare.

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.

Voiding abnormalities are encountered frequently in pediatric patients. Symptoms of daytime incontinence, frequency and nocturnal enuresis in any combination may indicate underlying neurophysiologic detrusor imbalance. Incomplete evaluation of these symptoms can result in inappropriate medical therapy or even ineffective operations. Within the preceding 7 months 34 children with hard-core voiding abnormalities were evaluated with urodynamic techniques. Several categories of abnormal voiding patterns were identified, including the hyperactive external sphincter, uninhibited pediatric neurogenic bladder, detrusor hyperreflexia secondary to chronic cystitis, hyperactive external sphincter with hypotonic bladder and the hyperactive external sphincter with detrusor irritability. All patients received specific pharmacotherapy based on presenting signs and symptoms, and voiding pattern abnormality. Of the 24 patients who have been treated in this manner and were evaluated 83.5% have had complete remission of symptoms while on therapy, the remainder being improved but still having occasional symptoms. The technique and data demonstrate that children with hard-core voiding abnormalities can achieve rehabilitation with urodynamic assessment.

In a select group of 6 infants with posterior urethral valves percutaneous antegrade valve ablation was used successfully, obviating vesical or supravesical diversion as an initial form of treatment. The indications for percutaneous valve ablation, important technical aspects of the procedure and the patient series are presented.