Kidney transplantation in children and adolescents: an analysis of United Network for Organ Sharing Database.

Specific pediatric allocation schemes can not only lead to minimization of waiting time, but also to better clinical outcomes for children with end-stage renal disease. The outcome of 4125 deceased donor kidney transplants (DDKT) aged 5-35 years were compared with those of 6456 living donor kidney transplants (LDKT) using univariate and multivariate Cox regression analyses. Unadjusted graft survival rates of DDKT were significantly lower than those of LDKT (hazards ratio [HR] = 1.53; P < .001). Chronic rejection was reported in 416 (10.1%) of 4125 in the DDKT group compared with 537 (8.3%) of 6456 in the LDKT group (P < .001). Among African American recipients, 67 (3.4%) grafts were lost due to noncompliance as a contributory cause of failure compared with 126 (1.5%) among other races (P < .001). A significantly lower incidence of noncompliance was observed in children (0.9%) compared with adolescents (2.2% in ages 10-14; P < .001) and high teens (2.0% in ages 15-20; P < .001). Multivariate analysis showed that adjusted graft survival rates of LDKT were superior to DDKT (HR = 1.22; P < .001) after adjusting for recipient race, recipient age, regraft status, and HLA mismatch. The differences of long-term graft survival rates between DDKT and LDKT have not been reduced (4% at 1 year, 10% at 3 years, and 12% at 5 years for unadjusted survival rates and 3% at 1 year, 6% at 3 years, and 9% at 5 years adjusted survival rates). In our analysis presented here the difference in graft survival between LDKT and DDKT has doubled compared with earlier analysis. Therefore, we recommend LDKT whenever possible as a first choice for pediatric transplant recipients.

Venous ischemia as a cause of ureteral necrosis in transplanted ureters.

BACKGROUND: Urologic complications after pediatric renal transplantation can adversely effect the outcome and may result in decreased graft survival. Efforts to prevent these complications are worthwhile. This study investigates the incidence of these complications in a clinical transplant program and reports on an animal model used to investigate one possible cause. METHODS: In the clinical study, the results of a pediatric renal transplant program at a large children's hospital for a 5(1/2)-year period were reviewed with special attention paid to patients suffering ureteral necrosis. In the experimental study, 9 swine underwent laparotomy, bilateral complete infrahilar ureteric dissection, and extravesical ureteroneocystostomy. On the left side only, the renal and adrenal veins were ligated. The arterial supply remained intact. The right side did not undergo vessel ligation and served as the control. Three pigs each were killed at 3, 8, and 15 days. Kidneys, ureters and a cuff of bladder were examined histologically. RESULTS: In the clinical study 75 renal transplants were performed with a total of 5 cases of early ureteral necrosis. Two of these 5 displayed venous congestion and ischemia, and 2 were associated with kidneys displaying primary nonfunction of the graft. Seventy-one of 75 grafts are continuing to function. One of the 4 early graft losses also had an ischemic ureter. In the experimental study all right kidneys and ureters were normal. All left kidneys had complete hemorrhagic necrosis. Necrosis also was found in 5 of 9 proximal left ureters and in 7 of 9 distal left ureters. Viable left ureters displayed moderate to severe submucosal and periureteric hemorrhage. Four of 9 ureters displayed more damage distally than proximally. The extent of necrosis was similar at 3, 8, and 15 days. CONCLUSION: In both clinical and experimental studies, venous congestion and subsequent ischemia have been shown to be important causes of ureteral necrosis after renal transplantation.

Right intrathoracic renal ectopia: a case report and review of the literature.

We report a case of right intrathoracic renal ectopia associated with a previously unreported congenital anomaly (trisomy 21) and review of the literature.

Neurogenic bladder in infants born with anorectal malformations: comparison with spinal and urologic status.

BACKGROUND/PURPOSE: Spinal dysraphism and neurovesical dysfunction (NVD) frequently are associated in children with anorectal malformations (ARM). This study compares the urodynamic data from a selected group of patients with the results of their spinal and urologic imaging studies. METHODS: Twenty-six children (20 with isolated imperforate anus and six with persistent cloacal malformations) were investigated. All patients were evaluated with leak point pressures (LPP), renal ultrasound scan, and voiding cystourethrography. Eight children had urodynamics performed before and after posterior sagittal anorectoplasty (PSARP). The spinal cord was assessed using ultrasonography or magnetic resonance imaging. Current urologic status was obtained to provide long-term follow-up. RESULTS: Twenty-one of 26 children demonstrated elevated LPPs above the established normal value of 40 cm H2O, and 15 of these children had normal spinal imaging study findings. Uroradiographic studies findings showed that 12 of 21 children with elevated LPPs had hydronephrosis or vesicoureteral reflux with seven of these patients having normal spinal cords. LPPs in the eight patients with pre- and postoperative studies were 74 +/- 14.7 cm H2O and 68 +/- 31.8 cm H2O (mean +/- SD), respectively. CONCLUSIONS: These urodynamic and radiographic data confirm that NVD (elevated LPP) is common in patients with anorectal malformations despite normal spinal cords. Bladder dysfunction does not appear to be a sequelae of a properly performed PSARP. Patients with ARM and any uroradiographic or clinical urologic abnormality should undergo urodynamic testing even though the spinal studies are normal.

Surgical treatment of testicular trauma: effects on fertility and testicular histology.

Unilateral testicular trauma in the postpubertal male can lead to alterations in semen analysis, but it is not clear what effect this has on fertility. To better understand how surgical treatment of testicular trauma affects both fertility and testicular histology the following study was performed. Eighty postpubertal Lewis rats were divided into eight equal groups with one group serving as a control. In the 70 remaining rats the left testicle was subjected to blunt or penetrating injury. The testicles were either left untreated, were removed, or were repaired with sutures or mesh before being returned to the scrotum. Following recovery, each male was allowed to mate to determine fertility. Fertility rates were significantly lower in all postinjury groups except the postinjury orchiectomy group. Histological analyses showed nonspecific inflammation, smaller tubules, and impaired spermatogenesis in all postinjury testicles regardless of the type of treatment. Contralateral testicles had no evidence of autoimmune injury and were essentially identical to the control group. In the postpubertal Lewis rat, unilateral testicular trauma leads to impaired fertility unless the injured testicle is removed soon after the injury. Various methods of repairing the injury did not improve fertility. In spite of the impaired fertility, the contralateral testicle appears histologically normal.

Endoscopic treatment of pediatric urolithiasis.

Children have been slow to benefit from the improvements in stone therapy. Despite the success of less invasive techniques, open surgery for pediatric urolithiasis is still commonly practiced. The authors' goal was to evaluate the indications, efficacy, and complications of endourologic surgery in the treatment of pediatric urolithiasis. They reviewed the treatment of 53 children who had upper tract calculi. Open nephro- and ureterolithotomy were avoided in all cases. The management of 25 children whose stones were not amenable to extracorporeal shock wave lithotriopsy is presented. Seventeen children (19 stones) were treated with miniature ureteroscopes and lasertripsy. Only one (6%) of the patients required ureteral dilation, and only five (29%) needed a postoperative internal stent. Eight children with large renal calculi were treated percutaneously, without transfusion, complication, or evidence of persistent renal damage. All 25 patients were rendered stone-free. The hospital stay was shorter and secondary procedures were less common in comparison to other series of endoscopic lithotripsy. With significant experience in adult endourology and proper instrumentation, one can apply the same techniques to children and achieve equal if not greater benefit. Nephrolithiasis in children is uncommon and should be managed in an institution where endourologists and multiple treatment modalities are available.

Use of tubularized peritoneal free grafts as urethral substitutes in the rabbit.

As an alternative to bladder mucosa, free grafts of tubularized peritoneum were used as urethral substitutes in a rabbit model of hypospadias. In group 1, six mature rabbits underwent partial penile urethrectomy followed by interposition of a 2-cm-long peritoneal-lined tube graft. These animals had urethrograms performed at 3 months and were killed at 6 (n = 4) or 12 (n = 2) months. In group 2, six rabbits underwent total penile urethrectomy with placement of 3-cm-long grafts. These animals were killed 1 to 4 weeks after surgery. Clinical assessment and gross examination of the 12 rabbits showed no urinary retention, two small fistulas at the proximal anastomosis, and no strictures or diverticular. At 6 and 12 months (group 1) the urethra had healed completely and the graft edges were not visible. In group 2, 1 to 4 weeks after surgery the graft was intact and the interface between the graft and native urethra was visible. Histological studies of the grafts were compared with control peritoneum. At 1 week, a high-density single-cell layer was present. Beginning at 2 weeks, a multilayered epithelium was present, which became more organized in the older grafts. Neovascularity became visible in the subepithelial layer at 2 weeks. Acute inflammatory cells were present early and were replaced by a palisading layer of lymphocytes and plasma cells in the older grafts. Minimal fibrosis was observed. Tubularized peritoneal free grafts are a promising new urethral substitute. Graft placement is technically simple. Replacement of the peritoneum by a multilayered epithelium resembling transitional epithelium occurs early after graft placement. As much as 1 year later, minimal scarring is present.

Bladder wall pedicle wraparound sling for neurogenic urinary incontinence in children.

PURPOSE: To improve the results of current bladder neck reconstruction a modification was developed to provide tapering, circumferential compression and suspension of the bladder neck. MATERIALS AND METHODS: Nine female and 15 male patients with spinal dysraphism and incontinence, despite intermittent catheterization and pharmacotherapy, and low outlet resistance underwent surgery. The procedure involves wrapping a pedicle strip of anterior bladder wall around the bladder neck and suspending it to the pubic symphysis. RESULTS: All 9 girls are completely continent, whereas 10 boys are dry and 5 have stress incontinence after 9 to 14 months of followup. Subjective symptoms correlate with changes in leak point pressure. CONCLUSIONS: This technique is an efficacious addition to bladder augmentation in female patients with poor compliance and low outlet resistance.

Blunt renal trauma in the pediatric population: indications for radiographic evaluation.

OBJECTIVES: The purpose of this study was to define more clearly the clinical indications for radiographic evaluation of blunt renal injury in the pediatric population. METHODS: Children evaluated for blunt abdominal trauma at the Children's Hospital of Los Angeles and Los Angeles County/University of Southern California Medical Center undergo routine physical examination, laboratory analysis, and computed tomography (CT) scan of the abdomen and pelvis regardless of urinalysis results. We retrospectively evaluated the abdominal and pelvic CT scans of 412 children sustaining blunt abdominal trauma between June 1985 and June 1990. A total of 48 children, ages 6 months to 14 years (mean 5.6 years), with CT-documented renal injuries secondary to blunt trauma were identified. The radiographic findings were correlated with clinical presentation in this group of patients. RESULTS: Of the 48 children sustaining renal injuries (12% of the group), 23 (48%) had renal contusions and 25 children (52%) sustained more serious (significant) renal injuries. Of the children with significant renal injuries, 17 (68%) had minor renal lacerations and 8 (32%) had major renal lacerations. No child sustained a renal pedicle injury. All 25 children sustaining significant renal injuries presented with hematuria: 17 (68%) had microscopic (more than 3 red blood cells per high-power field) and 8 (32%) had gross hematuria. In the 23 children with renal contusions, 4 (17%) had no hematuria, 13 (57%) had microscopic hematuria, and 6 (26%) presented with gross hematuria. Hypotension occurred in 2 of the 25 children with significant renal injuries and in 2 of 23 children with renal contusions. Fifteen of the 25 patients (60%) with significant renal injuries had associated organ injuries, and 17 of the 23 children (74%) with renal contusions had associated organ injuries. CONCLUSIONS: In adults, gross hematuria and microscopic hematuria with hypertension following blunt trauma have been correlated with significant renal injuries requiring radiographic investigation. We conclude that these clinical criteria proposed to guide the radiographic evaluation of the adult population with blunt trauma do not apply to children. In our study, the degree of hematuria did not correlate with the degree of renal injury, and significant renal injury did occur with microhematuria in the absence of hypotension. We suggest that any child with a history of blunt abdominal trauma and any evidence of hematuria should undergo abdominal and pelvic CT scanning for the proper diagnosis and staging of renal and other associated intra-abdominal injuries.

Infant pyeloplasty is a low-risk procedure.

Early pyeloplasty for the treatment of congenital ureteropelvic junction obstruction to maximize nephron salvage is only justified if the potential hazards of operating on small infants are avoided. The records of all infants who underwent pyeloplasty by the authors over a 7-year period were analyzed. The outcome of surgery in the younger infant group (YIG; patients less than 2 months of age) was compared with that of the older infant group (OIG; patients more than 2 months of age). Preoperative evaluation in cases of mild or moderate hydronephrosis was directed toward ruling out a nonobstructed collecting system and included voiding cysto-urethrography and serial ultrasonography and/or dual isotope diuretic renography. Open pyeloplasty was performed if collecting systems had deteriorated or were demonstrated to be obstructed; it was also performed for severe cases of hydronephrosis. Postoperative assessment consisted of serial ultrasonography and/or nuclear imaging to confirm decompression and relief of obstruction. Thirty three pyeloplasties were performed in 31 patients in the YIG (two bilateral), and 33 were performed in 32 infants in the OIG (one bilateral). The only significant differences between the groups were as follows. Patients in the YIG were more likely to present in utero (87% v 53%; P < .01), whereas those in the OIG were more likely to present with a urinary tract infection (44% v 0%; P < .01). The YIG was more likely to have nephrostomy drainage postoperatively (67% v 45%; P < .01). In the overall series, there were five complications, all of which were postoperative infections requiring intravenous antibiotic therapy. Two occurred in the YIG and three in the OIG.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical management of traumatic posterior urethral strictures in children.

We review our recent experience with the treatment of traumatic strictures of the posterior urethra in children. Five males, ages six to seventeen years with dense posterior urethral strictures, have required open reconstructive procedures. Four patients had injury secondary to pelvic fractures, and 1 patient had an iatrogenic injury from surgery for imperforate anus. Two patients were repaired perineally, 2 with a combination retropubic-perineal approach, and 1 patient required a transpubic approach. Excision and direct anastomosis was achieved in 3 patients, and a foreskin interposition tube graft was used in 2 patients. Excellent results were achieved with return of urethral voiding and preservation of continence in all patients. Complications were seen in 3 patients. One secondary internal urethrotomy was required. Erectile capability was preserved in all patients who were potent before surgery. Posterior urethral strictures in children can be successfully managed with a variety of surgical approaches. This experience demonstrates that the surgical procedure must be individualized depending on the anatomy of the injury.

The effects of extracorporeal shock wave lithotripsy on renal growth, function and arterial blood pressure in an animal model.

The long-term effects of extracorporeal shock wave lithotripsy (ESWL*) on children treated for renal calculi are unclear. To study the long-term bio-effects of this mode of treatment on the immature animal we evaluated 30 New Zealand white rabbits at 7 weeks of age for weight, serum blood urea nitrogen and creatinine, and arterial blood pressure after which they underwent left nephrectomy. Each group of 5 rabbits received ESWL of varying levels (500 to 3,000 shock waves) to the remaining right kidney using the Northgate SD3 lithotriptor (spark gap mediated). One control group received no shock waves. At maturity (16 weeks) the aforementioned parameters were measured again, and the kidneys and any grossly abnormal adjacent organs were examined. We found no significant change in total animal growth, renal growth, renal function or perirenal organs in the post-ESWL groups versus the control group. All post-ESWL groups had an increase in mean arterial blood pressure versus the control group with 3 of 6 groups showing significant increases (p less than 0.05). Histological renal changes, seen at all energy levels of ESWL delivered, included interstitial fibrosis, tubular atrophy, glomeruli destruction, capsular thickening, perivascular fibrosis and mild arteriole wall thickening. Changes were proportional to the number of shocks received. We conclude that ESWL delivered to immature animals does not significantly affect renal growth and function but it can cause significant permanent histological renal changes even at low doses and may result in an increase in adult mean arterial blood pressure.

Nonrefluxing ileal ureteral replacement using the intussuscepted ileal nipple: laboratory studies.

A new technique for nonrefluxing ureteral replacement using ileum has been developed. Five adult mongrel dogs were operated using this nonrefluxing ileal ureteral technique. Subsequent reoperation showed in every case the preservation of renal function, a nonrefluxing system and no evidence of pyelonephritis or hydronephrosis. Based on the intussuscepted ileal nipple used in the Kock continent ileostomy, this technique has application in candidates for urinary undiversion, situations of ureteral loss due to trauma and fibrosis, and in patients with tuberculous strictured ureters.

A juvenile animal model to study the growth potential of bowel segments in the urinary tract.

A juvenile animal model has been developed to study the growth potential of ileum in the urinary tract. Patch ileocystoplasties of known surface area were constructed in dogs of Group 1. Nonrefluxing ileal nipple valves of known length were created to replace one ureter in dogs of Group 2. After the juvenile animals grew and at minimum doubled their weight, they were reoperated and augmentation surface areas were remeasured at various physiologic intravesical pressures. Nipple valve lengths were remeasured after cystograms ruled out reflux. Results show that the bowel augmentation and an identical control segment increased in surface area proportionate to animal growth and that hydrostatic dilation caused further surface area increase. Nipple valves did not grow and in fact shortened, but remained nonrefluxing. The conclusion is that in the pediatric population, consideration should be given to downscaling the size of bladder augmentations or diversions in anticipation of future bowel growth, but that one should not shorten the ileal nipple valves.

Age related flow rate nomograms in a normal pediatric population.

Uroflow studies in a normal pediatric population were analysed statistically. Single studies for 511 subjects (272 boys and 239 girls) were reviewed. Nomograms relating peak flow to volume voided and age were established. An acceptable lower limit for peak flow was obtained from the data and a volume voided range was calculated so that both criteria could be used with 90% probability to define the normal voiding situation. The mean values of peak flow rate increased with volume voided in both sexes and also with age in the male population. Different sets of nomograms, which are necessary for daily clinical evaluation, are given. They define the normal values in the normal population.

Body surface related flow rate nomograms in a normal pediatric population.

Uroflow studies for 511 normal pediatric subjects (272 boys, 239 girls) were analyzed statistically. Nomograms relating peak flow to volume voided and body surface were established. An acceptable lower limit for peak flow was obtained from the data and a volume voided range was calculated so that both criteria could be used with 90% probability to define the normal voiding situation. Body surface area was found to be a more reliable index than age in the establishment of nomograms. In the male population the 90% probability applied to a significantly greater volume voided reliability. In the female population mean peak flow rate rose with increased body surface. Finally, in both sexes the 10% lower limit was closer to the regression mean, allowing a tighter distribution around this value.

Acute appendicitis mimicking pelvic neoplasm.

Acute appendicitis can be difficult to diagnose when it presents in an atypical manner. We report a case of perforated appendicitis mimicking a pelvic neoplasm.

Modification of the Kock pouch urinary diversion in a child.

We constructed a continent ileal urinary reservoir (Kock pouch) in a 9-year-old boy. The length of bowel required to achieve a satisfactory outcome was scaled down for this young, small child.

Neoplastic potential in patients with disorders of sexual differentiation.

The occurrence of tumors was determined in 157 patients with disorders of sexual differentiation at a major pediatric hospital from 1960 to 1980. Gonadoblastoma developed in 2 of the 4 patients with mixed gonadal dysgenesis (MGD) who had not had bilateral gonadectomy; this indicates the need for early gonadectomy in such cases. Gonadal embryonal carcinoma developed in 1 child with Turner's syndrome (1 of 71). Four cases of nephroblastoma occurred, 1 in a child with MGD (1 of 18) and 3 in male pseudohermaphrodites (3 of 35). The nature of the defect linking male pseudohermaphroditism with Wilms tumor remains to be established.