Ventriculoperitoneal shunt infection after bladder augmentation.

OBJECTIVES: To examine the incidence of postoperative ventriculoperitoneal shunt infections in patients after augmentation cystoplasty. METHODS: We retrospectively reviewed the charts of 21 patients with a ventriculoperitoneal shunt who had bladder augmentation (18 ileal and 3 ileocecal) with attention to the preoperative urine culture, perioperative antibiotics, and the length of time drains were maintained. The abdominal end of all shunts was wrapped in an antibiotic-soaked sponge during the procedure. All patients had at least 1 year of follow-up. RESULTS: Seven patients (33%) had culture proven, preoperative urinary tract infections. All patients received at least 24 hours of preoperative and 48 hours of postoperative antibiotics. No postoperative shunt infections occurred during the study period. CONCLUSIONS: The incidence of postoperative ventriculoperitoneal shunt infections after augmentation cystoplasty can be kept low when prophylactic antibiotics and short-term drains are used.

Management of neonatal testicular torsion.

PURPOSE: We evaluated the safety and efficacy of emergency exploration of neonatal torsion. MATERIALS AND METHODS: We retrospectively reviewed the charts of 27 neonates (30 affected testicles) in a 13-year period. RESULTS: Of the 10 testicles that were explored and fixed within 6 hours of discovery 2 (20%) were normal at physical examination at 1 year of followup. Of the remaining 20 testicles 19 were removed. One patient was lost to followup after orchiopexy. No operative or perioperative complications were associated with emergency exploration. CONCLUSIONS: Emergency exploration of neonatal torsion is safe and prudent, and may result in higher testicular salvage rates. Given reports of contralateral torsion, we also recommend contralateral orchiopexy.

Urethroscopy in small neonates with posterior urethral valves and ureteroscopy in children with ureteral calculi.

OBJECTIVES: To describe our recent experience using a 6.9F cytoscope in the fulguration of posterior urethral valves (PUVs) in premature neonates and distal ureteroscopy with stone extraction in children. METHODS: Fulguration of PUVs was performed in 3 premature neonates born at 34 to 36 weeks' gestation with weights of 2480 to 2900 g. The PUVs were fulgurated during a single endoscopic procedure using a 6.9F cystoscope and a 3F bugbie electrode. In addition, 11 children (8 girls, 3 boys; mean age, 11.1 years; range 5 to 16) with symptomatic calculi underwent 15 distal ureteroscopic procedures using the 6.9F cystoscope. RESULTS: In the neonates with fulguration of PUVs, vesicostomy, the only reasonable alternative, was avoided, and each infant now voids with an excellent stream 3 to 16 months later, without evidence of stricture or residual valves. In the children with distal ureteroscopy, the ureteral calculi were retrieved using a 3F four-wire stone basket. With one exception, distal ureteroscopy was performed without dilation of the ureteral orifice. Extracorporeal shock-wave lithotripsy (ESWL) was not recommended because of stone position and difficult radiographic visualization. Nine children were rendered stone free with one procedure. Two procedures were required in 1 child and three in another. In both cases, ureteral edema was present, and the stone was embedded in the ureteral wall. One child underwent separate procedures for bilateral calculi. In all cases general anesthesia was used, with a mean duration of 63 minutes (range 28 to 96). Temporary ureteral stenting was performed in 10 (93%) patients, and 9 (81%) were discharged home on the same day or the next morning. A mean follow-up period of 8.5 months (range, 0.5 to 22) has failed to show any problems related to ureteral stricture or injury. CONCLUSIONS: Endoscopic fulguration of PUVs is now possible in small neonates and is minimally invasive compared with vesicostomy. Distal ureteroscopy with stone retrieval should be considered in children, especially those with calculi that are not suitable for ESWL.

Ultrasound evaluation of normal penile (corporeal) length in children.

Previous studies have established normal penile length for patient age and stage of sexual development. To our knowledge penile length has only been determined to date by measuring the stretched distance from the symphysis to the glans tip. Pilot studies at our institution showed that ultrasound corpora cavernosa length determinations were possible using a 7.5 MHz. linear transducer probe. To determine whether ultrasound is a more accurate modality in assessing penile length, male subjects 0 to 24 months old with normal penile anatomy and palpably descended testicles were enrolled in a prospective analysis. Longitudinal ultrasound images of the flaccid penis were obtained from the dorsal surface. The whole corporeal bodies were easily imaged and measured. In a blinded fashion a separate investigator performed a conventional stretched penile length determination. A total of 27 male subjects 1 week to 22 months old was evaluated and 2 were excluded. Corpora cavernosa measurements using ultrasound revealed a mean length of 32.3 +/- 4.7 mm. (range 22.4 to 44.9). Stretched penile lengths of the same subjects revealed a mean length of 46.8 +/- 8.2 mm. (range 31 to 63). Circumcision status (p = 0.036) and age (p < 0.001) significantly correlated with stretched length determinations. Ultrasound measurements did not significantly vary with patient circumcision status or age. Penile length and race were not correlated when using stretched or ultrasound measurements. Ultrasound determination of corporeal body length is possible in young subjects. From infancy to age 22 months ultrasound measurements are not significantly affected by age or the presence of foreskin. Our experience suggests that corporeal body evaluation by ultrasound may offer a more accurate assessment of functional penile length.

Blunt renal trauma in children with the prune-belly syndrome.

We report significant blunt renal injury resulting from 3 traumatic events in 2 boys with the prune-belly syndrome. Manifestations of the syndrome influenced the clinical and radiographic assessment of the urinary tract injuries. Nonoperative management resulted in excellent outcomes without long-term sequelae.

Ureteropelvic junction obstruction in upper and lower moiety of duplex renal systems.

OBJECTIVES: To review our experience with ureteropelvic junction obstruction in a duplicated renal collecting system. METHODS: The records of 7 patients with ureteropelvic junction obstruction in a duplex collecting system were reviewed. In addition to routine demographics, each case was reviewed for presenting symptoms, site of obstruction, and type of surgical treatment. RESULTS: Three of the 7 cases involved obstruction of the upper pole moiety, and the remaining 4 involved the lower pole segment of a duplex system. Obstruction of the upper and lower pole segments was found in both incomplete and complete duplicated collecting systems. CONCLUSIONS: Careful preoperative evaluation of patients with ureteropelvic junction obstruction will usually identify segmental obstruction in a duplicated system. Treatment should be individualized based on site of obstruction and degree of function remaining in the affected segment.

The bed-wetting child. Current management of a frustrating problem.

Bed-wetting is a frustrating problem experienced by a significant number of children. It is the role of the physician to exclude serious underlying problems and, at the same time, educate the family concerning treatment options that may be best suited to their child. Once parents and child have a better understanding of the problem and realize that the outlook for nighttime bladder control is excellent, it is easier to start long-term care.

Urinary retention secondary to a Gartner's duct cyst.

A 22-month-old child with a large cyst of Gartner's duct suffered from recurrent episodes of urinary retention. Excision of such large symptomatic cysts has been recommended in the past. Marsupialization is discussed as an alternative to extensive excision.

Treatment of complications of cyclophosphamide cystitis.

Since 1976, 23 patients with cyclophosphamide-induced cystitis were treated. These patients presented with a variety of urinary problems, including incontinence, hematuria and vesicoureteral reflux. Vesicoureteral reflux was found in 9 patients, hydronephrosis in 4 and a contracted fibrotic bladder in 3. Of the 23 patients 18 had undergone a combination of radiation and cyclophosphamide therapy. Based on this experience a general outline is developed for evaluation and treatment of patients with cyclophosphamide-induced cystitis and its potentially severe complications.

Biofeedback training for children with bladder sphincter incoordination.

We studied 35 children with voiding dysfunction and detrusor-sphincter incoordination. More than 90 per cent of these patients had a history of repeat urinary tract infections, and medication and surgical treatment of the voiding dysfunction had failed. Of the patients 22 (63 per cent) experienced significant improvement or resolution of the voiding dysfunction when biofeedback was used to teach normal bladder sphincter coordination as part of the over-all treatment regimen. A review of our experience with these patients indicates that with proper patient selection an even higher rate of success may be possible.

An unusual complication of silver nitrate treatment of hemorrhagic cystitis: case report.

A patient with severe cyclophosphamide cystitis was treated with intravesical silver nitrate instillation to control bleeding. This resulted in apparent reflux and extravasation of the silver nitrate solution with secondary retroperitoneal inflammation. Subsequently, the patient required treatment for a small, fibrotic bladder with persistent reflux. The precautions and recommendations for treatment of such difficult patients are discussed.

Condylomata acuminata in the pediatric patient.

Condyloma acuminatum has been recognized as venereal disease in adults but it has not always been similarly identified in children. We review our experience with 30 children with condylomata acuminata. Of the 14 children evaluated more than half have been determined to have a sexual etiology for the lesion. Recommendations for evaluation and treatment of children with condylomata acuminata are reviewed.

Ossifying renal tumor of infancy.

Ossifying renal tumor of infancy is a rare lesion, with only 2 cases reported in the literature. We report an additional case, and review its presentation and histological findings.

Simultaneous occurrence of Wilms tumor and renal calculus.

Nephroblastoma and renal stone disease are seen infrequently in children. We report on a 2-year-old girl with bilateral nephroblastoma and a simultaneous staghorn calculus in 1 kidney.

Unusual presentation of ureteropelvic junction obstruction in an incomplete duplex system.

Ureteropelvic junction obstruction in an incomplete duplex system is seen infrequently. This case represents an unusual presentation of such an obstruction. Recommendations are made for preoperative evaluation and surgical management of these patients.