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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...

Objectives. The mucosal collar was designed to achieve a cosmetically normal-appearing, circumcised phallus during hypospadias surgery. The original technique has been modified and refined since its introduction by Firlit in 1987. Herein, we provide a detailed description of the procedure as it is now performed. Methods. From 1987 to 1998, more than 500 mucosal collars were created by the senior author as a routine component of the hypospadias repair. Results. The mucosal collar produced a cosmetically normal-appearing, circumcised phallus in all cases. No associated morbidities attributable to the collar occurred. Conclusions. The mucosal collar is a simple procedure to master and reproducibly yields a normal-appearing, circumcised phallus. The techniques used for urethroplasty are independent of the creation of the collar and will never preclude its use. We believe that the cosmetic outcome is unequaled by other techniques and that the collar should be used in all hypospadias surgery, regardless of the type of repair.

Objectives. The management of intractable urinary incontinence in the patient with cloacal or bladder exstrophy/epispadias, failed bladder neck plasty, or failed augmentation cystoplasty remains a surgical challenge. The myofascial wrap, a modification of the rectus fascial wrap, was developed to treat intractable urinary incontinence due to sphincteric incompetence in these problematic cases. A full-thickness, vascularized pedicle of anterior rectus sheath, rectus abdominis muscle, and posterior rector sheath is incorporated into a bladder neck wrap to provide support, mucosal coaptation, and active muscular tone. Methods. Eight patients (5 females and 3 males) with total urinary incontinence due to sphincteric incompetence underwent the myofascial wrap. Urinary tract pathology included cloacal exstrophy (2), female epispadias (2), classic bladder exstrophy (1), male epispadias (1), myelomeningocele (1), and a pelvic tumor (1). The procedure is performed by harvesting a full-thickness strip of pedicled rectus muscle along with the anterior and posterior fascial sheaths. The strip is passed underneath and then over the bladder neck in a near 360° wrap. The free end of the wrap is anchored into the pubic bone in an ipsilateral subperiosteal pouch. Results. Six of the 8 patients are completely continent, and 2 patients void spontaneously without the need for catheterization. Conclusions. The myofascial wrap provides support, mucosal coaptation, and muscular tone to an incompetent sphincter and bladder neck. Favorable results in a very difficult population of pediatric patients warrant its continued use.

Objectives To determine if there are measurable quantities of transforming growth factor-beta 1 (TGF-β1) in the urine of children with either normal or pathologic conditions of the urinary tract, specifically vesicoureteral reflux (VUR) and ureteropelvic junction obstruction (UPJO). We also sought to determine if the urine TGF-β level could distinguish between renal obstruction and no obstruction. Methods Preoperative bladder urine from consecutive patients undergoing pyeloplasty (UPJO group; n = 13), ureteral reimplantation (VUR group; n = 11), or circumcision/orchiopexy (control group; n = 19) as well as urine from the renal pelvis of the UPJO group was collected. The urine level of TGF-β1 was measured using a quantitative sandwich enzyme immunoassay technique. Results Urine level of TGF-β1 was detected in each group: control (26.6 ± 6.3 pg/mL), reflux (22.1 ± 9.6), UPJO-pelvic urine (82.4 ± 19.3), UPJO-bladder urine (31.2 ± 8.2). The urine TGF-β1 concentration in pelvic urine in the UPJO group was significantly higher than that in bladder urine in children in the UPJO group (P = 0.03). TGF-β1 concentrations were similar from the bladder of children in all three study groups (P = NS). Conclusions Urine TGF-β1 is detectable in children with normal and pathologic urinary tracts. The level of this urine marker is elevated in the renal pelvis of children with UPJO compared to the level in the bladder of either obstructed or nonobstructed upper urinary tracts.

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 investigate whether angiotensin II has a role in the regulation of bladder smooth muscle growth and function, we developed a model of bladder neck obstruction (BNO) in the neonatal rabbit and investigated the effect of captopril (angiotensin converting enzyme inhibitor) on the obstructive changes in the developing bladder.Partial BNO was induced in a group of 2-day-old rabbits (n = 8) by placing a loose 2-0 silk ligature around the vesicourethral junction. A second group of rabbits subjected to the identical partial BNO procedure (n = 8) was given captopril (1 mg/kg/day). Twelve days postobstruction, bladders from these animals, along with paired controls (n = 8), were harvested and assayed for total protein, DNA, and collagen content.Partial BNO resulted in a 170% increase in wet weight (P0.05), 132% increase in protein/deoxyribonucleic acid (DNA) ratio (P0.05), 75% increase in total DNA (P0.05), and 115% increase in total collagen (P0.05). When compared with obstructed animals, captopril administration significantly inhibited the increase in total DNA (P0.05) and reduced the amount of total collagen (P = 0.054). Examination of histology specimens demonstrated that captopril inhibited the serosal hyperplasia and collagen deposition associated with obstruction.These data demonstrate that captopril partially inhibits the changes in the neonatal rabbit bladder associated with obstruction, supporting the hypothesis that angiotensin II is involved in the regulation of bladder smooth muscle growth and collagen production.

Objectives. To evaluate the management approach for vesicoureteral reflux (reflux) into a solitary kidney. Methods. Outcomes of all children with solitary kidneys and reflux managed between 1981 and 1996 were reviewed. Solitary kidneys were documented by nuclear renography and ultrasonography; reflux was graded after cystography. Management consisted of observation and antimicrobial prophylaxis or surgery by ureteroneocystostomy or subureteric injection of polytetrafluoroethylene (STING). Follow-up ranged from 3 months to 14 years and included serial cystography, sonography, and serum creatinine measurement. Results. Twenty-one patients with a median follow-up of 26 months were identified. Etiologies included contralateral renal agenesis (14 children), multicystic dysplastic kidney (5 children), or nonfunctioning ureteropelvic junction obstruction (2 children). Low-grade (I to II) reflux was identified in 6 children, and high grade (III to V) was identified in 15. Reflux resolved in 20 patients. Five children with low-grade reflux were managed without surgery and demonstrated reflux resolution after a mean of 20.5 months. Renal function deteriorated in only 1 child. Ureteroneocystostomy was performed in 13 children with grades III to V reflux, and STING was performed in 1 child with grade II reflux. Every surgical patient maintained stable renal function and was infection-free during a mean follow-up of 56 months. Management by observation in 2 children with grades IV to V reflux resulted in spontaneous resolution in one and stable grade IV in the other. Conclusions. Reflux into the solitary functioning kidney may be managed by the same strategies used to manage unilateral reflux in children with two normally functioning kidneys: low-grade reflux by observation/chemoprophylaxis until spontaneous resolution occurs, and higher grades by surgery to protect renal function; however, chemoprophylaxis and serial imaging may be used until well-defined indications for surgery are satisfied. Renal function should be monitored diligently.

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.

Objective To discuss an unusual case of occult ureteropelvic junction obstruction. Case A premature male infant with severe, unilateral hydronephrosis presented to the emergency room with 20 h of dry diapers. Placement of urethral catheter did not return urine. Imaging revealed persistent hydronephrosis on the previously affected side and new-onset hydronephrosis with perirenal fluid on the contralateral side. Patient was taken to the operating room and forniceal rupture from occult ureteropelvic junction obstruction with urinary ascites was identified. The obstruction was surgically repaired at that time and his postoperative course was uncomplicated. Discussion While most agree on postnatal evaluation for some children with antenatal hydronephrosis, there is no consensus as to the timing and frequency of evaluation. The risk of significant obstruction in children with low grades of hydronephrosis is very low, and many are not followed. This is a rare case in which low-grade postnatal hydronephrosis resulted in significant clinical obstruction.

With the availability of machines suitable for the office, we studied whether in-office ultrasonography could assist in the management of children with known or suspected hydronephrosis. Of 509 children examined, 81 (16 per cent) had hydronephrosis. In 56 (70 per cent) of these children, ultrasonography was helpful in expediting the diagnosis (9 cases), clarifying the etiology (16 cases), evaluating the condition postoperatively (26 cases), and screening (5 cases). Three incorrect ultrasound diagnoses were encountered. The authors believe that ultrasound is the best initial imaging method for the urinary tract and have shown that it is practical and effective in an office setting.

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...

Now that individuals with spina bifida live well into adulthood erectile dysfunction has become a recognized associated medical disorder. To our knowledge no study has dealt specifically with treatment of erectile dysfunction in men with spina bifida. Therefore, we conducted a prospective, blinded, randomized, placebo controlled, dose escalation, crossover study to determine the ability to treat erectile dysfunction in men with spina bifida with sildenafil citrate.Erectile dysfunction was diagnosed in 15 men 19 to 35 years old with spina bifida who were assigned to take 4 sets of tablets, 5 tablets per set, in a random order. All patients took 25 and 50 mg. sildenafil and 2 identical looking sets of corresponding placebos 1 hour before planned sexual activity. Efficacy was assessed by the effect of treatment compared to baseline, that is before treatment, on rating of erections (scored from 0 to 10), duration of erections, frequency of erections based on response to question 1 (scored from 0 to 5) of the International Index of Erectile Function and confidence to obtain an erection based on response to question 15 (scored from 1 to 5) of the International Index of Erectile Function.Improved erectile function was reported while on sildenafil by 12 (80%) men compared to baseline and placebos. There was a significant dose dependent improvement of erectile function with both 25 and 50 mg. sildenafil compared to baseline (p0.05), as mean erectile score increased by 50% and 88%, mean duration of erections increased by 192% and 266%, mean frequency of erections increased by 61% and 96%, and mean level of confidence increased by 33% and 63%, respectively. Furthermore, 50 mg. sildenafil provided greater improvement in all 4 parameters compared to 25 mg. The placebo results were not significantly different compared to baseline for any of the parameters.Erectile dysfunction in patients with spina bifida is a medically treatable condition. Sildenafil is effective in this patient population and improves level of sexual confidence.

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.

Our aims were to establish primary stromal cell cultures from the neonatal rabbit bladder and investigate the potential mitogenic effects of angiotensin II and basic fibroblast growth factor on these cells.Primary bladder stromal cell cultures were obtained from 3-day-old rabbits, plated at a density of 3 x 10(4) cells per ml. and allowed to grow for 24 hours. Subconfluent cells were growth arrested in serum deficient (0.25% newborn calf serum) or serum-free media for 24 hours and then stimulated with 10(-7) M. angiotensin II or 10 ng./ml. basic fibroblast growth factor for an additional 48 hours. Cell counts and [3H] thymidine incorporation were done to measure cellular proliferation and deoxyribonucleic acid synthesis.Angiotensin II and basic fibroblast growth factor each stimulated neonatal bladder stromal cell proliferation and [3H] thymidine incorporation under serum deficient conditions. Angiotensin II provoked an average 26% increase in cell number (p0.01) and 35% increase in [3H] thymidine incorporation (p0.01) compared to control values. Basic fibroblast growth factor was an even more potent mitogen with a 47% increase in cell number (p0.01) and 180% increase in [3H] thymidine incorporation (p0.01) compared to controls. In contrast, angiotensin II and basic fibroblast growth factor each failed to have significant stimulatory effects under serum-free conditions.Angiotensin II and basic fibroblast growth factor induce a mitogenic response to neonatal bladder stromal cells in vitro. These mitogenic effects require the presence of serum factors. Whether angiotensin II and basic fibroblast growth factor are involved in the in vivo regulation of bladder growth associated with obstructive uropathy requires further investigation.

We reviewed 75 cases of isolated, unilateral pediatric ureteropelvic junction obstruction and 167 diuretic radionuclide renograms performed during the last 8 years. Differential function of the affected kidney was calculated using scintillation count data at 1 and 3 minutes, and the area under the renogram curve between 1 and 3 minutes. There was no significant difference among the 3 measures of per cent differential function for a given patient. Per cent differential function on the first renogram preoperatively neither declined as age at presentation advanced nor did it vary according to the clinical presentation. Similarly, the changes in postoperative per cent differential function were unaffected by the age at initial presentation, manner of presentation, occurrence of postoperative complications or the surgeon. These data do not support the concept that pyeloplasty for the isolated, unilateral ureteropelvic junction obstruction should be performed early to avert loss of renal function.

We retrospectively examined our experience with live-related donor kidney transplants in 66 children during the 7-year period 1984–1990. We compared the clinical courses of 26 children who did not receive any dialytic therapy prior to transplantation with 40 children who were dialyzed (27 via peritoneal dialysis and 13 via hemodialysis). We did not find any statistically significant differences in patient or graft survival between these three groups with a follow-up period of 6–87 months. Based on our results, we conclude that pre-emptive transplantation is an acceptable treatment for children who will inevitably require renal replacement therapy.

Summary We undertook a prospective, blinded, randomised, placebocontrolled, dose escalation, crossover study that showed that erectile dysfunction in spina bifida is medically treatable, specifically with sildenafil citrate.

We have used a vaginal speculum to insert a testicular prosthesis through the inguinal approach over the past four years. We have found this technique to be easily performed and reproducible in allowing the testicular prosthesis to be placed in the normal dependent position in the scrotum.

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.

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

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.

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.

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.

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.

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

A retrospective study was performed of 39 children at the Children's Memorial Hospital, Chicago, Illinois, who underwent technetium-99m glucoheptonate (99mTcGH) scintigraphy for evaluation of possible urinary tract infection. Clinical and laboratory criteria classified the children as having pyelonephritis, cystitis, or no urinary tract infection. Of 28 children classified as having pyelonephritis, 24 (86%) children had abnormalities on 99mTcGH scintigraphy. Only 8 of 19 (42%) renal ultrasound scans and 4 of 17 (24%) intravenous pyelography studies performed in these children demonstrated findings consistent with parenchymal disease. Only 9 of 19 (47%) cystograms demonstrated vesicoureteral reflux. Three children who underwent gallium-67 citrate scintigraphy had localization at the sites of focal defects with 99mTcGH scintigraphy. 99mTcGH scintigraphy is a sensitive and specific indicator of renal parenchymal involvement that helps localize urinary tract infection to the kidney.

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.

A histochemical study of the detached cytoplasm of the maturing spermatid has been carried out. The detached cytoplasm has been designated as the cytoplasmic body and 4 distinct phases in its morphogenesis have been reported. The cytoplasmic tag of stage 11 of spermiogenesis has been designated as phase CB-I in the morphogenesis of the cytoplasmic body. It was found to contain numerous granules of RNA, poly-saccharides, and lipid. During phase CB-2 and CB-3, coalescence and fusion of these granules occurs, which result in a centrally-oriented plaque of RNA and glycogen, peripheral satellites containing polysaccharides, and large globules of lipid. During phase CB-4, the cytoplasmic body membrane becomes approximated to the plaque and at this stage of development the cytoplasmic body can be compared to the ‘residual bodies’ of Regaud. Peripheral migration towards the basement membrane of the seminiferous tubule now occurs. Some of the residual bodies undergo phagocytosis by Sertoli cells, while others eventually occupy a position at the level of the spermatogonia.