Safety of ketorolac in the pediatric population after ureteroneocystostomy.

PURPOSE: Ketorolac has been used to provide effective postoperative analgesia in children and decreases hospitalization for pediatric patients undergoing ureteroneocystostomy. However, it can cause severe side effects, including increased bleeding and renal insufficiency, which can be devastating in a child. Little has been reported on the safety of ketorolac by evaluating creatinine, hematocrit and complications. MATERIALS AND METHODS: An institutional retrospective review was performed during an 18-month period in which 118 patients underwent ureteroneocystostomy. One group containing 50 patients received caudal anesthetic preoperatively and narcotic analgesics postoperatively, while another 68 received caudal anesthetic preoperatively and ketorolac postoperatively. Patient ages, type of procedure, preoperative and postoperative creatinine and hematocrit, and complications were noted in each cohort. RESULTS: Average patient age of the control analgesic and ketorolac groups was 5.3 years (range 1 to 17) and 5.5 (1 to 12), respectively. There was no statistical difference between postoperative creatinine (0.68 and 0.65 mg./dl.) and hematocrit (33% and 34%) between the groups. One patient in each group had increased creatinine postoperatively. Minor complications, for example ileus and bladder spasms, were equivalent in both groups. No patient receiving ketorolac had any allergic or hypersensitivity reaction to the medication, and no major complications were reported. CONCLUSIONS: Ketorolac given after ureteroneocystostomy did not cause a significant decrease in hematocrit, increase in creatinine or overall complications. Because of the safety of ketorolac in our series, and ability to decrease hospital stay and narcotic requirements in children as reported previously, it is used as standard postoperative protocol after ureteroneocystostomy at our institution.

Hypercalciuria and pediatric stone recurrences with and without structural abnormalities.

PURPOSE: This study defines to what extent hypercalciuria represents a risk factor for recurrent calcium oxalate or nonstruvite stones. Long-term followup of children with hypercalciuria after an initial stone episode allowed us to determine the rate of stone recurrence. MATERIALS AND METHODS: A total of 44 pediatric patients with stones were diagnosed with hypercalciuria, including 7 with structural abnormalities and 37 with normal anatomy. Of these patients 27 had adequate long-term followup. RESULTS: There were 9 stone recurrences in the 27 patients who were evaluated long term for an overall recurrence rate of 33%. Recurrences developed 3 to 15 years after the initial episode (average time to recurrence 7.2 years), and none of the patients with structural abnormalities had hydronephrosis at recurrence. Of the 9 patients with stone recurrences 3 were female and 6 were male, and 4 had multiple stone recurrence episodes. Of these 9 cases of recurrent stones 8 had a positive family history for stone disease in a first degree relative, whereas only 8 of 18 cases without stone recurrence had a positive family history (p = 0. 04). CONCLUSIONS: Hypercalciuria is a risk factor for recurrence in the pediatric patient with stones with and without structural abnormalities. New stones can occur several years after the initial episode and can extend through postpuberty.

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.

The risk and risk factors of contralateral reflux following repair of simple unilateral primary reflux.

PURPOSE: A population of patients undergoing unilateral antireflux surgery for simple primary reflux was studied to determine the rate and possible mechanism of new onset contralateral reflux postoperatively. MATERIALS AND METHODS: A total of 107 patients with simple primary reflux were evaluated as to the surgical outcome, possible risk factors and appearance of new contralateral reflux. RESULTS: Contralateral reflux appeared in 7% of this study population, and 3% ultimately had the contralateral ureter reimplanted. Risk factors appear to include younger age at initial repair, number of cystograms performed and presence or development of dysfunctional voiding. CONCLUSIONS: New contralateral reflux following unilateral reimplantation has a low incidence. Risk factors exist that when controlled or treated might even further lower the incidence of contralateral reflux and improve treatment outcome.

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.

Does technique or material used affect bladder tissue reactions when injecting teflon or silicone paste?

OBJECTIVES: Submucosal injections of polytetrafluoroethylene (PTFE) and polydimethylsiloxane (PDMS) paste continue to be used for the correction of vesicoureteral reflux and urinary incontinence. Potential distant particle migration and foreign body tissue reactions are thought to be significantly affected by the technique of injection and the paste material used. A study to determine if injection technique, paste material, or pretreatment of the injection site significantly affects local tissue reaction was performed on 44 New Zealand white rabbits. METHODS: Animals were randomly assigned to undergo four distinct injection treatments into the submucosa or bladder muscularis. Prior to injecting 0.1 cc of the PTFE or PDMS paste, some sites were pretreated with 0.1 cc saline to separate tissue planes, epinephrine to cause vasoconstriction, or doxycycline to provide sclerosis. Pretreatment controls were also performed without injecting PTFE or PDMS paste. Animals were killed, and quadrant bladder biopsies were performed at 1 hour (9), 1 day (9), 7 days (10), 1 month (8), and 6 months (8). A single pathologist, blinded to the injection treatments, performed a histologic evaluation to determine bleb location and the degree of inflammation, fibrosis, and epithelial necrosis. RESULTS: Seven of the 12 submucosal PTFE injection treatments were found on biopsy to be primarily within the muscularis, compared to 1 of 9 with PDMS paste. Three of the 24 PTFE injections could not be found at autopsy. Of these, two were injected into the muscularis, and all were discovered at least 1 month following injection. Particles were present in all 22 PDMS injection sites that were retrieved. Pretreatments, especially with doxycycline, resulted in significant epithelial necrosis at 1 and 7 days. At 1 and 6 months there were no differences in inflammation or fibrosis between PTFE and PDMS or any pretreatment combinations with saline or epinephrine. CONCLUSIONS: Correctly injected, silicone (PDMS) paste appears most likely to remain in the submucosal space. Pretreatment injections may cause early epithelial necrosis. PTFE and PDMS elicit similar foreign body reactions over time.

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.

Prenatal diagnosis of genital anomalies.

OBJECTIVES: This is a report of five cases of abnormal fetal genitalia detected by routine prenatal ultrasound. METHODS: Retrospective review was conducted to identify all cases of abnormal fetal genitalia identified by routine obstetrical ultrasound at our institution in which postpartum follow-up was available. RESULTS: Five cases of prenatal sonographically diagnosed abnormal fetal genitalia were confirmed postnatally. The abnormalities include ambiguous genitalia, severe hypospadias with unilateral cryptorchidism, megalourethra, and concealed penis. In all cases, other anomalies were discovered during the prenatal ultrasound. CONCLUSIONS: Prenatal ultrasound may detect a variety of abnormalities of the fetal genitalia.

The current status of screening for vesicoureteral reflux.

Reflux nephropathy is responsible for a significant percentage of end-stage renal disease in late childhood as well as being the most common cause of severe hypertension in childhood and adolescence. To prevent reflux nephropathy, it is imperative to discover reflux at the youngest age possible and preferably before any urinary tract infections have occurred. Since screening of the general population for reflux is not feasible, we have focused our efforts on the siblings of known refluxers and, more recently, the offspring of known refluxers. We have found high rates of reflux in both groups and have shown in the sibling population that early discovery of sibling reflux has significantly lowered the rate of renal damage compared with the index patients. It is imperative to screen these two risk populations at the youngest age possible, but we have recently made modifications in our recommendations for the older sibling and offspring. The results of these two screening studies are given as well as our current recommendations for screening for reflux in these risk groups.

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.

Radiographically documented fecal impaction causing peritoneal dialysis catheter malfunction.

Peritoneal dialysis catheter malfunction is most commonly caused by infection or omental occlusion. To our knowledge we report the first case of radiologically confirmed fecal impaction resulting in peritoneal dialysis catheter malfunction, which resolved with medical management. In patients undergoing peritoneal dialysis fecal impaction should be considered in the differential diagnosis of catheter malfunction before surgical intervention.

Fat containing renal mass in childhood: a case report of teratoid Wilms tumor.

Renal masses in childhood rarely contain adipose tissue as a major component. We report a case of teratoid Wilms tumor, an atypical variant of nephroblastoma, in which bilateral renal masses were found on computerized tomography to have a high fat content. Previously reported cases have had clinical characteristics in common with our case. However, our patient died of metastatic disease, which to our knowledge has not been previously described.

Long-term effects of polytetrafluoroethylene injected into the rat bladder submucosa.

OBJECTIVE: The use of polytetrafluoroethylene (PTFE) paste in the lower urinary tract for the treatment of vesicoureteral reflux or urinary incontinence is increasing. Its use remains controversial and the long-term consequence of this substance injected into the lower urinary system of humans is largely unknown. When injected into the bladder submucosa, PTFE paste has been shown to elicit a foreign body reaction with chronic inflammation and possibly granuloma formation. Whether these inflammatory changes result in neoplastic changes over the long term has yet to be determined. The purpose of this study was to evaluate histologically the potential for submucosal PTFE paste to induce bladder neoplasia in a rodent model, realizing that others have shown an increased tendency for such alloplastic materials to produce sarcomas in these animals. METHODS: Sixteen experimental animals and 4 control animals were sacrificed at various time intervals and evaluated for systemic and local tumor formation following submucosal injection of PTFE paste in the bladder. A time well beyond the equivalent of the latency period believed to be necessary for the induction of tumors in humans (15 months) was evaluated. RESULTS: On sacrifice, histologic changes consistent with encapsulation and chronic inflammation were evident, but there was no evidence of either epithelial or sarcomatous tumor formation. CONCLUSIONS: A quiescent foreign body reaction occurs when injecting PTFE into the bladder submucosa of rodents. Urologic use of PTFE has never been proven to induce tumors in humans or animals.