Search

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. [ABSTRACT FROM AUTHOR]

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 than 2 years after transplantation. One child required reexploration secondary to fascial dehiscence and an additional recipient required pyeloureterostomy due to ureteral necrosis after living related donor transplantation., Conclusions: Extraperitoneal renal transplantation is technically feasible in children who weigh less than 15 kg. This approach preserves the peritoneal cavity, limits potential gastrointestinal complications and allows the confinement of potential surgical complications, such as bleeding and urinary leakage. In addition, this approach provides complete access to the retroperitoneum to enable concurrent retroperitoneal surgery, such as nephrectomy, to be performed safely. We recommend that extraperitoneal renal engraftment should become routine in children weighing less than 15 kg. rather than using the more common transperitoneal approach for allograft placement.

Purpose: 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., Materials and Methods: 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., Results: 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 (p <0.05), 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., Conclusions: 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.

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.

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 cystoplasty in 1 and Tenckhoff catheter placement in 1., Results: In all cases the cosmetic result was excellent and satisfactory to patients, parents and surgeons. Since the first procedure was performed 17 years ago, only 1 patient has returned with abdominal wall laxity or bulging in the area of repair., Conclusions: Our method of abdominal wall reconstruction in the prune-belly syndrome produces a cosmetically excellent and durable result. In contrast to other techniques of abdominoplasty, the need for a fascial incision and/or entrance into the peritoneal cavity is avoided. We believe that this modified procedure offers distinct technical and anatomical advantages over other existing techniques.

Objectives: To determine if there are measurable quantities of transforming growth factor-beta 1 (TGF-beta 1) 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-beta 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-beta 1 was measured using a quantitative sandwich enzyme immunoassay technique., Results: Urine level of TGF-beta 1 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-beta 1 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-beta 1 concentrations were similar from the bladder of children in all three study groups (p = NS)., Conclusions: Urine TGF-beta 1 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.

Purpose: 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., Materials and Methods: 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., Results: 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., Conclusions: 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.

Purpose: We evaluated the importance of intraoperative venography and surgical approach on varicocele recurrence after surgical varicocelectomy in male adolescents., Materials and Methods: 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., Results: 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., Conclusions: 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.

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 catheterization 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, doses, frequency 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 or inconvenience. Seven patients had untoward effects, ranging from facial flushing and dizziness to agoraphobia and hyperactivity. Six patients discontinued therapy due to side effects after 1 day to 2 years (mode 1 month) at doses of 1.25 to 5 mg., including 5 who previously had side effects from oral oxybutynin chloride. Inconvenience of therapy was noted irrespective of the degree of independence of the child for performing intravesical therapy., Conclusions: Untoward effects and inconvenience are the most common reasons for discontinuing intravesical oxybutynin chloride therapy for neurogenic bladder dysfunction. Children who previously had side effects from oral oxybutynin chloride are more likely to have them during intravesical therapy.

Purpose: 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., Materials and Methods: 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., Results: 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 (p < 0.01) and 35% increase in [3H] thymidine incorporation (p < 0.01) compared to control values. Basic fibroblast growth factor was an even more potent mitogen with a 47% increase in cell number (p < 0.01) and 180% increase in [3H] thymidine incorporation (p < 0.01) compared to controls. In contrast, angiotensin II and basic fibroblast growth factor each failed to have significant stimulatory effects under serum-free conditions., Conclusions: 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.

The pediatric health care practitioner is a valuable resource of information for the family of an infant with hypospadias prior to the child and family's first visit to the pediatric urologist. Pediatric nurses are involved in the preoperative and postoperative care of children with surgical correction of hypospadias and should be aware of the newest advances in surgical techniques and improvements in postoperative care, particularly dressings and urethral stents. These advances have improved the outcome for children, including diminished pain and discomfort, minimal hospital stay and decreased complications. Minimal postoperative intervention is required. The current management of these children will ensure the optimum resolution with minimum physical and psychological problems for the child and family.

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.

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.

Recent successful introduction of selective rhizotomy in the management of lower extremity spasticity in patients with myelodysplasia has prompted us to use it as a means of managing high pressure neurogenic bladders occasionally encountered in myelodysplastic patients. During the last 1 1/2 years 8 children have undergone selective sacral rhizotomy in an attempt to avert urinary diversion or bladder augmentation. Patient age ranged from 6.5 to 18.5 years. The level of the respective lesions was evenly distributed throughout the spine. At spinal surgery each patient had an electrode placed in the detrusor of the bladder via a suprapubic approach, electromyography electrodes were placed in the perineum and slow fill water cystometry was performed throughout the procedure. Standard electrophysiological stimulation of the nerve roots was performed to identify the rootlets that would only affect the detrusor and spare the external sphincter. Postoperative followup has been obtained on all patients. Of the patients 4 have exhibited significant improvement and they have not required augmentation, 2 have not shown any further deterioration in bladder function, 1 has demonstrated deterioration and 1 still lacks urodynamic followup. Postoperative cystometric studies have revealed a bladder capacity increase of 69% for the group. Uninhibited bladder contractions were abated in all but 1 patient. No patient has been rendered incontinent of urine from the procedure and no patient has had a problem with stool continence as a result of the rhizotomy. It appears that selective rhizotomy of the sacral roots has been able to increase bladder capacity as well as compliance in patients who normally would have been relegated to either bladder augmentation or urinary diversion. While these are encouraging results, some further followup is required to ascertain if the early improvements will be long-lasting.

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.

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.

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.

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.

More than 75 per cent of the patients with spinal dysrhaphisms followed at our hospital are on intermittent catheterization. A previous report indicated that 62 per cent of 200 children with reflux and a neurogenic bladder either ceased to have reflux or reflux was downgraded while on intermittent catheterization and chronic antibiotics. We report on those children in whom either reflux did not stop while on the program, or who presented with high grades of reflux not amenable to cure by intermittent catheterization. During the last 4 years 25 children (40 ureters) required antireflux surgery. The criterion of repair was persistent reflux of at least grade IIB, associated with recurrent episodes of infection. A modified Leadbetter-Politano technique was used in 5 children (7 ureters) and the Cohen cross-trigonal technique was used in 20 children (33 ureters). A successful result, that is cessation of reflux and no obstruction, was achieved in 96 per cent of the patients. During the last 2 years the Cohen cross-trigonal technique has been used exclusively and there have been no failures. This successful result in 96 per cent of the children with neurogenic bladder indicates that while clean intermittent catheterization should be used primarily to relieve reflux, in a select group of children antireflux surgery should be done and clean intermittent catheterization should be continued.

A major cause of urinary incontinence and/or recurrent urinary infections in neurologically intact children is vesical voluntary sphincter/urogenital diaphragm dyssynergia and/or "strain" dyssynergia. These acquired or learned mechanisms are characterized by increased striated muscle tone during micturition, residual urine, daytime wetting and/or urinary infections. Generally, pharmacotherapy is prescribed and manipulated to achieve modification of these dysfunctions. Recently, urodynamic biofeedback has surfaced as a suitable therapeutic alternative. We selected 10 children, between 6 1/2 and 16 years old, for biofeedback therapy because of age, intelligence, commitment and conviction to improve. Following inpatient biofeedback 8 of the 10 children demonstrated complete abatement of signs and symptoms in long-term surveillance (6 to 19 months after biofeedback), while 2 moderately improved. Our experience with biofeedback therapy demonstrated that all patients convert to synergistic voiding within 48 hours of therapy. Urodynamic biofeedback appears to be an extremely useful tool in the armamentarium of the urologist treating neurologically normal children with voiding disorders. The possibility that this modality may be useful for adults is intriguing.

Nine boys were found to have hypospadias despite the presence of a complete prepuce. The urethral meatus was in the subcoronal position in six boys, the distal shaft position in one boy and on the corona glandis in two boys. Although it is generally thought that boys with hypospadias have a dorsal hooded prepuce resulting from incomplete development of the ventral phallus, we have found hypospadias in boys with complete preputial development. Thus, physicians who perform circumcision should fully retract the prepuce to detect occult hypospadias before completing the procedure. Parents of newborns with hypospadias and a complete prepuce should be told, before circumcision, that preputial tissues may be needed to repair the hypospadias.

Varicella-zoster infections developed in ten of 76 children receiving a renal transplant during 1973 to 1978. Two children had varicella and one died during this infection. Eight children had herpes zoster and one experienced encephalitis. In the latter group, reduction of prednisone and azathioprine therapy resulted in rejection and loss of the graft in two of three patients in whom this drug therapy was altered.

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.

Many women suffer a constellation of urinary and pelvic symptoms commonly referred to as the urethral syndrome. Numerous medical, surgical and psychological treatment modalities have been used to alleviate the symptoms. Urodynamic techniques were used to study a group of women with the urethral syndrome. Based on the findings of external urethral sphincter spasm and/or pelvic floor hyperactivity the institution of diazepam therapy not only has provided clinical relief but also sphincter synergy as demonstrated by post-treaatment urodynamics.

Metoclopramide, a procainamide derivative that markedly stimulates peristalsis in a variety of gastrointestinal tissues, demonstrated a significant dose-dependent effect on rat, canine, and human ureters studied in vitro. A moderate increase in phasic activity was seen at low concentrations with striking inhibition noted at higher concentrations. In the dog, atropine 0.6 microgram/ml inhibited the former while procaine 400 micrograms/ml stimulated the latter. Surgically produced, chronically dilated canine ureters were also stimulated by metoclopramide. Metoclopramide may be useful in states of disordered ureteral motility.

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.

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.

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.

Simultaneous recording of intravesical pressure, urine flow rate and anal sphincter electromyography was undertaken in 25 children with a variety of urological problems. Urethral pressure profile measurement was obtained in 3 of these patients and was used as an adjunct to cystometry alone in 5 others. The diagnostic patterns that emerged were useful in selecting specific pharmacologic and surgical therapeutic measures.