Does the type of bladder augmentation influence the resolution of pre-existing vesicoureteral reflux? Urodynamic studies.

AIMS: The type of bladder augmentation on pre-existing vesicoureteral reflux (VUR) was assessed. The effects of urodynamic changes on the resolution of VUR following augmentation cystoplasty performed with various gastrointestinal segments were examined. It was queried whether elimination of high-pressure bladder is sufficient to resolve pre-existing reflux. METHODS: A retrospective record review of patients who underwent bladder augmentation between 1987 and 2004. Patients were divided into two groups. Group I included patients who had a simultaneous augmentation and ureteral reimplantation. Group II included patients with reflux in whom only a bladder augmentation was performed. Pre-and post-augmentation urodynamic results were compared in both groups. The outcome of VUR and the role of various gastrointestinal (GI) segments on the resolution of VUR were studied. RESULTS: Sixty-three patients underwent bladder augmentation during the study period. Twenty-six of them had VUR before augmentation. There were 10 patients in Group I and 16 patients in Group II. In Group I, VUR ceased in all patients, while in group II, VUR resolved in 14 patients and persisted in two patients. Small and large bowel segments used for augmentation had no effect on the resolution of VUR but the results of gastrocystoplasties were less favorable. Urodynamically there was no significant difference between the various augmentation cystoplasties. CONCLUSIONS: Bladder augmentation alone without simultaneous antireflux repair is usually sufficient for the resolution of pre-existing reflux. The various GI segments used for augmentation have no effect on urodynamic results and the resolution of VUR.

Nonparasitic splenic cysts in children: a multicentric study.

PURPOSE: Nonparasitic splenic cysts (NPSCs) are uncommon in children. The aim of this multinational and multicentric study was to present the authors' experience as well as the changing trends in the management of NPSCs over the last 25 years. MATERIAL AND METHODS: From 1981 to 2005, 50 children or adolescents were surgically treated for NPSCs in 6 paediatric surgical centres in four European countries. The medical records of these 50 patients with NPSCs were reviewed retrospectively. RESULTS: Twenty-six male and 24 female patients were operated on. Age at surgery ranged from 1 to 17 years (mean 11.9). Seventeen patients were symptomatic. Six total (4 open and 2 laparoscopic) and 26 partial (22 open and 4 laparoscopic) splenectomies were performed. Laparoscopic fenestration or deroofing and open cystectomy was carried out in 9 patients, respectively. Histological findings revealed the lesion to be an epidermoid cyst (n = 28), a pseudocyst (n = 15) or a mesothelial cyst (n = 2). In 5 patients haemangioma or lymphangioma was the pathological diagnosis. At a mean follow-up of 2.9 years, residual cysts were found in 8 laparoscopically treated patients, 4 of whom required re-do laparoscopy or open surgery. CONCLUSIONS: Over the last two decades, the surgical treatment of NPSCs has changed from a formerly customary total splenectomy to spleen-conserving procedures, such as total cystectomy with or without partial splenectomy or partial cystectomy. These therapeutic modalities can be performed laparoscopically, if technically possible. Fenestration or deroofing of the cyst resulted in a high recurrence rate (7/9).

Cutaneous vesicostomy revisited--the second 15 years.

UNLABELLED: The aim of this paper was to review the authors' experience with cutaneous vesicostomy (CV) over the last 15 years including indications, results, and complications of CV. MATERIALS AND METHODS: The records of 31 patients treated by CV between 1987 and 2002 were reviewed. There were 20 boys and 11 girls. The two main primary pathologies were neuropathic bladder (19 patients) and posterior urethral valve (PUV) (7 patients). All patients underwent a Blocksom-type operation at a mean age of 23 months (range 14 days-9 years). Pre- and postoperative conventional uromanometry was performed in 18 patients (58%) and bladder function was assessed. RESULTS: In 23 patients (74%) the CV provided a successful diversion with improvement of the upper urinary tract and/or stabilization of the renal function. In 5 patients (16%) with PUV, the improvement was temporary. In 3 patients (10%) the CV did not result in an improvement. Twenty-four patients underwent CV closure after a mean duration of 23 months (range, 1 month-7 years) of diversion. In 2 patients with myelomeningocele (MMC) and severe somato-mental developmental delay, CV was not closed and is being considered as a permanent treatment option. Urodynamic studies in 5 PUV patients showed impaired compliance and high intravesical pressure following a successful valve ablation and closure of CV. In the neuropathic bladder group the bladder function improved following closure of CV and commencement of anticholinergic medication and clean intermittent catheterization (CIC). Our augmentation ratio in the neuropathic bladder group was 22%. Complications of CV included: stenosis in 7 patients (22%), prolapse in 2 (6%), and cellulitis in 2 (6%). The revision rate was 16%. CONCLUSIONS: In young infants CV had a less favourable result in the PUV patients than in cases with high-pressure neuropathic bladder with upper tract dilatation and severe urinary tract infection (UTI), where CV provided decompression and prevented deterioration of the renal function. Cutaneous vesicostomy has stood the test of time in our changing paediatric urological practice and it remains a valuable weapon in the armoury of paediatric urologists in selected patients.

Metabolic findings after colocystoplasty in children.

OBJECTIVES: To investigate whether colocystoplasty has resulted in metabolic changes in the growing child during long-term follow-up according to whether cecum with ascending or sigmoid colon was used. METHODS: Twenty-eight patients (mean age at surgery 11 years) were included in the study and divided into two groups: group 1, cystoplasty with cecum and ascending colon (12 patients) and group 2, sigmoid cystoplasty (16 patients). Patients' linear growth, body mass index, and the following parameters were estimated before surgery and at 3, 6, and 12 months, and then yearly after surgery: blood and urine electrolytes (sodium, potassium, chloride, calcium, phosphorus, magnesium), creatinine, urea, blood gases, blood pH, urine pH, and blood alkaline phosphatase (ALP). All the data were statistically analyzed. RESULTS: In group 1, the blood ALP increased significantly (P = 0.026) during follow-up. Severe metabolic acidosis with or without hyperchloremia was found in 7 patients. In group 2, the serum sodium and serum calcium levels decreased significantly (P = 0.014 and P = 0.003, respectively); however, the blood ALP, urine sodium, and urine phosphorus levels increased significantly (P = 0.033, P = 0.027, and P = 0.026, respectively) during follow-up. A statistically significant decrease in blood pH (P = 0.022) was found after surgery. Severe metabolic acidosis with or without hyperchloremia was detected in 5 patients. The average linear growth decreased significantly (P = 0.001 and P = 0.016, respectively) 1 and 2 years postoperatively. CONCLUSIONS: The statistically significant increase in blood ALP and decrease in serum calcium indicate bone demineralization after colocystoplasty. Our investigations in children suggest that bone demineralization is more frequent after sigmoid cystoplasty than after the use of cecum and ascending colon.

Histological findings after colocystoplasty and gastrocystoplasty.

PURPOSE: We conducted a prospective, long-term assessment of the histological changes that can occur following bladder augmentation with colon or stomach. MATERIALS AND METHODS: Histological evaluations of biopsies from 44 consecutive patients undergoing augmentation (colocystoplasty in 26, gastrocystoplasty in 18) were performed. Patients underwent endoscopic assessment and tissue sampling at 2 or 4-year intervals following the initial augmentation procedure. Patients with less than 2 years of followup were excluded from the analysis. Specimens were taken from the native bladder, the augment segment (large bowel or stomach) and the anastomotic line. Sections (4 mu.) were examined using standard histological staining methods (hematoxylin and eosin and periodic acid-Schiff) and immunohistochemistry was performed for different markers of neoplasia, cellular proliferation and blood group antigens. Histological findings were correlated with the incidence of stone formation and urinary tract infection. RESULTS: Group 1 consisted of 20 patients undergoing colocystoplasty who met the criteria for study inclusion. Of the patients 10 (50%) had stones, 19 (95%) had a positive urine culture and 6 had no histological changes. While no cases of malignancy were identified, other forms of pathological change were noted in 14 of the 20 patients (70%). Group 2 included 15 patients undergoing gastrocystoplasty who met the criteria for study inclusion. No stones or malignancy were identified in this group. Positive urine cultures were recorded in 2 patients (13%), no histological changes were found in 6 and 9 (60%) had pathological changes. CONCLUSIONS: Periodic prospective biopsy evaluation of children who have undergone either colocystoplasty or gastrocystoplasty failed to reveal any histological evidence of malignancy after 10-year followup. However, histological evidence of a premalignant lesion 13 years after followup suggests that screening for premalignant lesions should be initiated no later than 6 to 10 years following enterocystoplasty.

Colorectal carcinoma in children and adolescents--a report of seven cases.

Between 1981 and 1997 seven children and adolescents (5 boys and 2 girls) were treated for colorectal carcinomas in two paediatric centres. The case notes of the patients were studied to determine the presentation, clinical findings, prognosis and the differences of colorectal carcinomas in the young patients compared to adults. Carcinoma of the colon and rectum is uncommon in this age group and has a poor prognosis. The age range was 9 - 15 years, mean age 11.8 years. All segments of the large bowel were represented as sites of the primary tumour. Vague abdominal pain, vomiting and weight loss were the commonest presenting symptoms. The duration of symptoms varied from one month to twelve months (median: four months). Contrast enema was the most useful diagnostic investigation. Five patients had Dukes' stage C and two had Dukes' stage D tumour. Mucin-secreting adenocarcinoma was the commonest histological diagnosis. Five patients had complete resection, two had palliative procedures. Post-operative chemotherapy was given to six patients and two had post-operative radiotherapy.

Giant ureteral stone in a 4-year-old boy.

A 4-year-old boy presented with sudden onset of fever, pyuria, and bacteriuria. Ultrasound revealed left hydronephrosis and hydroureter. A plain abdominal radiography and excretory urogram showed a giant ureteral stone measuring 9 cm causing ureteral obstruction. Underlying anatomic or metabolic abnormalities were not detected. Extraction of the stone resulted in complete disappearance of the hydronephrosis and hydroureter.

The relationship of smooth muscle damage to age, severity of pre-operative hydronephrosis and post-operative outcome in obstructive uropathies.

OBJECTIVE: To determine the relationship, in patients with pelvi-ureteric junction (PUJ) obstruction, of histopathological abnormalities to their age at surgery, the severity of pre-operative hydronephrosis and the post-operative outcome. MATERIALS AND METHODS: Surgical specimens from 60 consecutive PUJ complexes excised at pyeloplasty were evaluated histologically. RESULTS: There was a close relationship of smooth muscle abnormality and fibrosis with the severity of pre-operative hydronephrosis and post-operative outcome, with no significant correlation between histopathological abnormality and patient age. CONCLUSION: This study appears to support the practice of the initial non-operative management of congenital PUJ obstruction, potentially reducing the number of early and/or unnecessary interventions. Further investigations and research are necessary to direct appropriate management.

Does the posterior sagittal approach with perirectal dissection impair fecal continence in a normal rectum?

The aim of this study was to determine, using human material and animal experiments, whether the posterior sagittal approach with perirectal dissection (PSAPD) in patients with an intact anorectum is a suitable means of exposure for the correction of complicated anomalies of the genitourinary tract without impairment of fecal continence. Over the last 6 years, the authors have performed PSAPD in seven children with an intact anorectum. At the time of operation, their ages ranged from 8 months to 14 years. All patients showed normal fecal continence at the end of follow-up (averaging 32 months). Only after completion of the study did the authors read that Peña et al had found that PSAPD provoked severe changes in bowel control in dogs. This contradiction prompted the authors to repeat the animal experiments, and they could not reproduce the favorable results obtained in children. This might be explained by the following factors: the surgical dissection used in the dogs was more extensive, anatomic differences between man and dog, the relatively much younger age of the animals (versus the patients), and the shorter follow-up and lack of educability of the dogs. The authors conclude that PSAPD is a suitable approach for selected lesions of the genitourinary tract in children who have a normal rectum and it does not impair fecal continence.

Routine bilateral exploration for inguinal hernia in infancy and childhood.

Whether to explore the contralateral side is a real question regarding the management of unilateral inguinal hernias in infants and children. The surgeon can easier make a decision if he knows the true incidence and prevalence of the bilateral involvement in different ages. During the years 1982 to 1991 the authors could find 138 contralateral hernias developed after unilateral herniorrhaphy in 2554 children (5.4%). Fifty-five percent of these children (76 patients) were younger than 1 year of age, 74% of them (102 patients) were younger than 3 years of age at the time of the initial repair. The interval between the operations was less than 1 year in 54% of the cases. To get more precise data, we explored 148 children younger than 3 years of age bilaterally during 1992. The result was positive in 104 cases (70.3%). The bilateral involvement was most frequent under the first 6 months of life (83.5%), then it dropped gradually. We found a patent processus vaginalis on the asymptomatic side in 74.3% of girls and in 61.1% of boys. The overall contralateral involvement of unilateral hernias was 64.8%, independently of which side the hernia had appeared on. The patent processus vaginalis can be regarded as a precursor of indirect hernias, so the contralateral exploration can prevent the development of a later hernia. The authors conclude that bilateral exploration is mainly justified during infancy, but in case of girls they suggested applying it until three years of age.

Alimentary tract duplications in infants and children.

This is a review of 30 duplications of the alimentary tract in 28 patients treated at the Surgical Unit of the Children's Department of the Medical University of Pécs, Hungary, and at the Department of Pediatric Surgery of the Medical Academy of Dresden, Germany, from 1964 to 1989. The ages of patients ranged from 1 day to 13 years, 80 percent were less than 2 years of age at initial presentation. There were 6 thoracic, 20 abdominal and 2 thoraco-abdominal duplications. Distended abdomen, vomiting, bowel obstruction and palpable abdominal mass were most frequently encountered. Plain thoracic and abdominal x-rays, ultrasonography, barium esophagogram, barium meal and enema were the most common diagnostic procedures. Emergency operative intervention was required in 18 patients. One infant died of an unrelated disease. Twenty-three duplications were cystic and 3 tubular. One patient had an appendiceal duplication, and another patient a flat lumenless duplication located on the perineum close to the anal opening. The surgical procedure--removal of the duplication--should not be more radical than necessary to eliminate the potential complaints and prevent recurrence. During surgery the common blood supply shared between the duplication and the native bowel must be carefully protected to avoid undue sacrifice of normal bowel.

Urethral duplication with single bladder and multiple genitourinary abnormalities: an example of continent urinary diversion.

A 13-year-old girl with multiple genitourinary malformations, incomplete bladder exstrophy, urethral duplication with single bladder, septate vagina, and total urinary incontinence is presented. Prior to admission she had undergone surgery for teratoma and calculi of the bladder and partial fecal incontinence. A continent urinary diversion was done by bladder augmentation using a cecal-colonic segment and by surgical closure of the bladder neck. The distal end of the appendix was brought to the skin as an inconspicuous, easily catheterizable, watertight stoma, our modification of the Mitrofanoff procedure. Excision of the vaginal septum, creation of an introitus, and unification of the split clitoris improved the cosmetic appearance of the external genitalia and improved the outlook for a normal sexual life and pregnancy.

Medical treatment of vesicoureteral reflux detected in infancy.

Between 1970 and 1982, 41 neonates and infants with grades II and III vesicoureteral reflux (international classification) but with no medical or urological complications were treated medically and followed for an average of 7.5 years. In 33 of the 41 patients the vesicoureteral reflux resolved (group 1) and in 8 it persisted (group 2). The severity and frequency of urinary infection decreased to a greater degree in group 1 (p less than 0.0005) than in group 2 (p less than 0.05). There was no difference in endogenous creatinine clearance between the 2 groups. Comparison of kidney length and bipolar parenchymal thickness revealed that bipolar parenchymal thickness was significantly less in group 2 patients (p less than 0.01). Body weight tended to increase in both groups but it was greater in group 1. In both groups height was lower at the time of detection of reflux and it approached nearly normal values during followup. It is tempting to conclude that early recognition of mild forms of vesicoureteral reflux (grades II and III) and systematic medical treatment can preserve renal function and promote renal and somatic growth. However, this tendency is less pronounced in patients with persistent reflux.

Abdominal calcifications in infants and children.

Abdominal and pelvic calcifications are usually incidental findings and require further measures to determine their origin. Most laboratory investigations are of little help. Plain anteroposterior and lateral x-rays are essential. The time of appearance and localisation of a calcification is of diagnostic importance. Amorphous, granular and irregular calcification can be an early sign of malignancy. Mobility of a calcification also helps to clarify its origin. Over the past 15 years abdominal and pelvic calcifications, excluding urological radiodensities, have been found in 63 patients up to fourteen years of age at our institute. A migrating deposit in the omentum, a spontaneously amputated calcified ovary mimicking a vesical calculus and a congenital retroperitoneal xanthofibroma caused the greatest difficulty in establishing a preoperative diagnosis.

Renal abscess in infancy.

Renal abscess is a rare occurrence in infancy. Its differentiation from an infected renal cyst may be difficult, especially if a perinephric abscess develops. This report illustrates a hitherto unrecorded unusual presentation of renal abscess as a tumour arising from the left lumbocostal region in an infant.