Management of grade IV renal injury in children.

PURPOSE: Conservative nonsurgical management of major renal trauma in children is well established. However, when blunt trauma is accompanied by significant urinary extravasation, options are less than clearly defined. Endoscopic techniques, such as stents and percutaneous drainage, have not been widely used because of small caliber. We present our experience with endoscopic management of grade IV renal trauma. MATERIALS AND METHODS: From 1983 to 1996, 15 children satisfied the criteria for grade IV renal trauma. We retrospectively reviewed the charts to assess the mechanism of injury, associated injury, treatment, hospital stay and transfusion requirement. Patients were followed clinically with blood pressure and creatinine monitoring, and by radiograph with computerized tomography. RESULTS: Nine patients with isolated kidney injury were successfully treated with observation, 1 underwent early partial nephrectomy for persistent anemia and hypotension, and 5 had a urinoma, which was successfully treated with percutaneous drainage only in 2. The other 3 patients underwent cystoscopy and ureteral stent placement for high drainage output, leading to the resolution of urine leakage. In 1 patient who underwent percutaneous drainage only renovascular hypertension developed, requiring partial nephrectomy 3 months after the original injury. The remaining 13 patients had complete radiographic resolution of the injury and no evidence of hypertension. CONCLUSIONS: In the pediatric population grade IV blunt renal trauma usually resolves without intervention. When a symptomatic urinoma develops, percutaneous drainage, accompanied at times by ureteral stenting provides the complete resolution of persistent urine leakage.

Chordee: varied opinions and treatments as documented in a survey of the American Academy of Pediatrics, Section of Urology.

OBJECTIVES: Consensus has not been established as to the best treatment of congenital chordee. Outcomes analysis of treatment options are limited by the prevailing use of ambiguous terminology. We sought to clarify the frequently used term "significant chordee" and to measure the utilization of current treatment strategies. METHODS: A survey covering current practice patterns concerning congenital chordee with hypospadias was sent to 236 members of the American Academy of Pediatrics, Section of Urology. RESULTS: Correction of chordee was the primary concern in hypospadias surgery of 31 % of those responding, but it was not the primary goal of 54% of respondents. Findings indicate that "significant chordee" is clinically defined as curvature greater than 20 degrees, in that 75% of respondents said they would proceed with further intervention. Placement of plicating sutures was the most common therapy chosen for 20 degrees chordee, with 50% of respondents electing this approach. Consensus was reached at 30 degrees chordee, with greater than 99% intervening at this degree of curvature. At 30 degrees curvature, 48% used an incisional Nesbit procedure. As the degree of curvature increased, division or mobilization of the urethral plate became the most common intervention. With 50 degrees chordee, urethral plate manipulation was used 34% of the time. Sixty percent of the respondents believed the urethral plate did not often contribute to chordee. CONCLUSIONS: "Significant chordee" was believed to be a curvature greater than 20 degrees to 30 degrees. With 20 degrees, 30 degrees , and 40 degrees chordee, correction was most often approached dorsally. With 50 degrees chordee, 54% approached the problem ventrally. We hope to encourage the use of more objective measurements and terminology. Objective measurements and long-term follow-up will improve our understanding of the natural history of chordee and improve outcomes analysis.

Vesical neck reconstruction in patients with the exstrophy-epispadias complex.

PURPOSE: We evaluated the factors critical in achieving urinary medicine continence in patients with the exstrophy-epispadias complex. MATERIALS AND METHODS: A total of 51 patients with epispadias and 33 with classic bladder exstrophy underwent vesical neck reconstruction. Patient records were reviewed to identify factors associated with achievement of continence, including timing of bladder closure and urethroplasty, effect of bladder capacity before and after vesical reconstruction, and effect of enterocystoplasty. RESULTS: Complete urinary continence was achieved in 42 of the 51 patients with epispadias (82%) and in 23 of the 33 with exstrophy (70%). Delayed bladder closure did not affect the ability to gain continence but increased the likelihood of subsequent enterocystoplasty (12 of 19 patients, 63%) compared to early bladder closure (5 of 14 patients, 36%). CONCLUSIONS: Preliminary urethroplasty did not enhance urinary control or reduce the need for enterocystoplasty. Bladder capacity before vesical neck reconstruction did not predict the need for enterocystoplasty or ultimate continence status in individuals. Adequate bladder capacity after vesical neck reconstruction was an important determinant of urinary continence. Approximately half of the patients bladder exstrophy (17 of 33) required augmentation cystoplasty to achieve urinary continence.

Antiandrogen induced cryptorchidism in the pig is associated with failed gubernacular regression and epididymal malformations.

PURPOSE: Can antiandrogens cause cryptorchidism in an animal model with a strip-like gubernaculum? If so, what anatomical abnormalities are associated with cryptorchidism? MATERIALS AND METHODS: Timed pregnant sows received the antiandrogen flutamide during defined gestational intervals. Fetal pigs were evaluated for the presence of testicular undescent and for morphological paratesticular abnormalities at 110 days of gestation (birth). RESULTS: Of 180 testes 84 (47%) were undescended and 9 (5%) were in the abdominal cavity. No undescended testis (0 of 200 testes) were found in control animals (p < 0.001). Epididymal anomalies were found in all intra-abdominal testes, which was significant when compared to the epididymal abnormalities found with inguinal undescended testes (0%) or descended testes (1%) (p < 0.001). Alterations in gubernacular morphology, in particular failure of gubernacular regression, were also directly associated with cryptochidism (p < 0.001). CONCLUSIONS: Androgens partially control transabdominal and transinguinal descent of the porcine testis. In addition, antiandrogen induced cryptorchidism is associated with epididymal malformation and failure of gubernacular regression. It remains to be determined if these latter findings are only associated with or the cause of testicular undescent.

Micropenis: does early treatment with testosterone do more harm than good?

Micropenis secondary to hypogonadotropic hypogonadism was induced in the Sprague-Dawley rat using long acting microspheres of the gonadotropic agonist leuprolide acetate. Following the induction of micropenis treatment was initiated with testosterone at day 7, 28, 56 or 84 of life. All treatment protocols resulted in improved phallic growth compared to the untreated animals with micropenis (p < 0.01). Treatment of animals with testosterone beginning on day 7 of life resulted in premature growth of the penis and the redevelopment of micropenis in adulthood. In contrast, delaying testosterone therapy until day 56 (pubertal) or 84 (early postpubertal) resulted in complete penile development. These findings suggest that early exposure of the penis to androgens in childhood may eventually result in a significant reduction of phallic size in adulthood.