Impromptu micturitional flow parameters in normal boys.

Nonintrusive measurement of the hydrodynamic properties of the urinary stream (uroflowmetry) has been included in many adult urological evaluations as an objective diagnostic tool. Measurement and behavioral problems interfere with practical applications in children. We describe a standard procedure for obtaining "impromptu" micturitional flow parameters in clinical pediatric practice. Statistical correlations of these flow parameters in an unselected group of 142 normal boys between 2 and 12 years old are presented. Useful linear regression equations were derived from the sample to assist the clinician in predicting deviations from normal values. Limitations of the methodology are noted.

Human monorchism: a clinicopathological study of unilateral absent testes in 65 boys.

We reviewed the medical records of 65 boys with surgically and pathologically proved monorchism. A striking laterality to the left side was identified. In 83 per cent of the patients wolffian structures were present and in 20 per cent microscopic evidence of a terminal nubbin of hyalinized, calcified or hemosiderin-containing tissue was noted. These findings strongly suggest that in most instances of monorchism a testis had been present and had undergone subsequent in utero degeneration. Characterization of the hormonal changes associated with unilateral absent testes was done by determining fasting morning levels of luteinizing hormone and follicle-stimulating hormone. In a subgroup of monorchid boys and age-matched prepubertal unilateral cryptorchid boys luteinizing hormone release factor stimulation also was performed to determine if endocrine analysis could predict the absence of 1 testis.

The effect of unilateral testicular torsion on the contralateral testicle in prepubertal Chinese hamsters.

Recent studies of experimental testicular torsion in rats, rabbits, and guinea pigs have demonstrated conflicting evidence regarding contralateral testicular damage. Those studies in which cellular damage has been found are postulated to result from an immunological mechanism whereby the blood-testis barrier is disrupted with subsequent autoantibody formation. In this study, the histologic and immunologic effects of testicular torsion on the contralateral testicle were investigated in prepubertal Chinese hamsters. Four study groups were established; (1) Left orchiectomy only, (2) sham surgery (scrotal incision), (3) 720 degrees left testicular torsion with left orchiectomy 24 hours later, (4) 720 degrees torsion of left testicle with detorsion after 24 hours. The initial procedure was performed at 1 month of age with subsequent biopsies of the contralateral testicle at 1 week, 1 month, and 6 months after the initial procedure. Testicular tissue was examined for immunofluorescent activity using fluorescent labeled goat anti-hamster IgG. Positive controls were established by rabbit immunization (rabbit anti-hamster immunoglobulin) which was subsequently combined with fluorescent labeled goat antirabbit IgG. There was no appreciable difference in immunologic activity between control and experimental animals. Representative sections were examined histologically and no tubular damage was demonstrated and active spermatogenesis was noted at 6 months in all groups. We believe that our results support the premise that testicular torsion in the prepubertal period has no effect on the contralateral testicle.

A neo-urethral enteroplication for urinary continence in a case of cloacal exstrophy.

A four-year-old female, born with cloacal exstrophy, returned for evaluation of her urinary incontinence two years after her initial repair. Her bladder had been turned in at her first operation and had a capacity of approximately 15 cc. Her ureters exited close to the reconstructed introitus. At reoperation, her bladder measured 3.5 cm in length and appeared to be well healed and of normal consistency. An anterior wall bladder flap was created which was based at the dome and was reflected 180 degrees cephalad. The bladder was then tubularized over a #10 french catheter to create a "neo-urethra" of 6 cm in length. Both ureters were reimplanted into an intestinal conduit, constructed 18 cm long, in a nonrefluxing fashion. The distal, oversewn, end of the conduit was sewn down into the pelvis, at the level of the bladder neck and posterior to the "neo-urethra." The end of the neo-urethra was anastomosed to the anterior wall of the intestinal reservoir, which was then plicated circumferentially around the neo-urethra in a manner very similar to the construction of a Nissen fundoplication for gastro-esophageal reflux. Pressure in the reservoir serves to keep the neo-urethra closed so that urine cannot escape until the neo-urethra is intubated. She is currently continent of urine with a successful program of clean intermittent catheterization. Her upper tracts remain undilated and are free of intestinal-ureteral reflux. Her urine is sterile.

Current concepts in the management of common urologic problems in infants and children.

Vesicoureteral reflux has the potential to cause irreversible renal damage if undiagnosed and untreated. It is important to have a high index of suspicion for the existence of a urinary tract infection in infants and children with any nonspecific generalized illness. Once a UTI is documented, appropriate antibiotic therapy must be started and continued until the urinary tract has been adequately evaluated radiographically. If vesicoureteral reflux is found to exist, appropriate medical or surgical therapy must be instituted to prevent further episodes of pyelonephritis.

Ileal segment replacement of ureter. I. Effects on kidney of refluxing vs nonrefluxing ileovesical anastomosis.

Unilateral partial ureteral obstruction was induced in 32 dogs followed by total ileal replacement of the obstructed ureter. The morphologic and functional effects on the kidney using a freely refluxing versus a nonrefluxing ileovesical anastomosis were compared, as well as the effect of total tapering of the reimplanted ileal segment. The tapered ileovesical anastomosis proved more reliable for prevention of reflux than the nontapered technique. Reflux prevention does not appear necessary for maintaining renal morphology and function when bladder function is normal and the observation period short. Total tapering of the ileal segment did not prove to be advantageous in protecting against hyperchloremic acidosis in this short-term canine study.

Ileal segment replacement of ureter. II. Dynamic characteristics of refluxing, nonrefluxing, and totally tapered ileal ureter.

The pressure characteristics and cinefluoroscopic appearances of a refluxing, nonrefluxing, and totally tapered ileal " neoureter " were compared in 22 dogs with normal bladder function. The totally tapered ileal segment with a reflux preventing ileovesicostomy simulates normal ureteral peristalsis most closely on cinefluoroscopic evaluation. Pressure gradients across the ileovesical junction though were similar in refluxing and nonrefluxing ileovesicostomies , as well as in totally tapered ureters.

Dermal graft correction of extraordinary chordee.

Severe degrees of primary chordee and persistent or recurrent chordee following previous surgical attempts at correction present a challenging problem. Inadequate resection of involved tissues, which may involve all layers of the penile investiture, or recurrent scarring of the ventral skin, Buck's fascia and tunica albuginea is usually the cause. Reoperation to achieve penile straightening often is unsuccessful unless all chordee-bearing tissue is resected extensively. Excision of large segments of tunica albuginea or wide separation of the margins creates a defect that tends to heal by dense scarring unless the defect is bridged by a graft. Various autogenous materials have been used, including blood vessel, fascia, free fat graft, dermis and tunica albuginea, as well as prosthestic materials, such as polytetrafluoroethylene, with varying results. A series of patients with extensive chordee is presented in whom tunical resection was necessary to achieve penile straightening. The results of free dermal graft replacement of the tunica are reported.

Subtunical total reduction clitoroplasty: a safe modification of existing techniques.

Subtunical resection of hypertrophied cavernous tissue of the enlarged clitoris allows for maintenance of an intact blood supply to the glans and is an alternative safe method of diminishing shaft and glans size.

Dysfunctional voiding in children secondary to internal sphincter dyssynergia: treatment with phenoxybenzamine.

Through the use of urodynamic evaluation, the authors have been able to define and categorize internal sphincter dyssynergia as a clinical, obstructive, dysfunctional voiding disorder in children. Treatment with the alpha-adrenergic sympatholytic agent, phenoxybenzamine, was successful in their series of patients.

Adenocarcinoma in multilocular renal cyst.

The fifth case of a patient with a multilocular cystic nephroma with an associated adenocarcinoma is reported. The histology of the tumor and biochemical analysis of the cyst fluid are presented and the literature summarized.

Voiding pattern abnormalities in normal children: results of pharmacologic manipulation.

Urodynamic studies were done on 50 children with voiding pattern abnormalities, characterized by daytime incontinence, damp pants, nocturnal enuresis, frequency and recurrent urinary tract infections. These studies included cystometry, uroflowmetry and pelvic floor/external urethral sphincter electromyography. Of the 50 children studied 37 were treated with various pharmacological agents based on 8 recognized urodynamic patterns. Thirty-one children (84 per cent) became totally asymptomatic while on pharmacotherapy and 4 (11 per cent) demonstrated marked improvement in clinical symptoms during the course of this study. Appropriately directed urodynamic studies and treatment with specific pharmacological agents can treat (retrain) effectively children with voiding pattern abnormalities.

Micturition urodynamic flow studies in children.

Voiding abnormalities are encountered frequently in pediatric patients. Symptoms of daytime incontinence, frequency and nocturnal enuresis in any combination may indicate underlying neurophysiologic detrusor imbalance. Incomplete evaluation of these symptoms can result in inappropriate medical therapy or even ineffective operations. Within the preceding 7 months 34 children with hard-core voiding abnormalities were evaluated with urodynamic techniques. Several categories of abnormal voiding patterns were identified, including the hyperactive external sphincter, uninhibited pediatric neurogenic bladder, detrusor hyperreflexia secondary to chronic cystitis, hyperactive external sphincter with hypotonic bladder and the hyperactive external sphincter with detrusor irritability. All patients received specific pharmacotherapy based on presenting signs and symptoms, and voiding pattern abnormality. Of the 24 patients who have been treated in this manner and were evaluated 83.5% have had complete remission of symptoms while on therapy, the remainder being improved but still having occasional symptoms. The technique and data demonstrate that children with hard-core voiding abnormalities can achieve rehabilitation with urodynamic assessment.

Followup of cutaneous ureterostomy in children.

Thirty-two children with cutaneous ureterostomies are reviewed, of whom 27 were evaluated with an average followup of 3 years 8 months. Of these 27 patients 26 had successful stabilization of the upper tracts as determined by gross radiographic and renal function parameters. The incidence of stomal stenosis and revisions is no worse than the reported rates in cases of ileal conduits followed for a comparable length of time. Proper patient selection and careful long-term followup are mandatory for the successful application of this procedure in children.

Micturition urodynamic flow studies in children.

Voiding abnormalities are encountered frequently in pediatric patients. Symptoms of daytime incontinence, frequency and nocturnal enuresis in any combination may indicate underlying neurophysiologic detrusor imbalance. Incomplete evaluation of these symptoms can result in inappropriate medical therapy or even ineffective operations. Within the preceding 7 months 34 children with hard-core voiding abnormalities were evaluated with urodynamic techniques. Several categories of abnormal voiding patterns were identified, including the hyperactive external sphincter, uninhibited pediatric neurogenic bladder, detrusor hyperreflexia secondary to chronic cystitis, hyperactive external sphincter with hypotonic bladder and the hyperactive external sphincter with detrusor irritability. All patients received specific pharmacotherapy based on presenting signs and symptoms, and voiding pattern abnormality. Of the 24 patients who have been treated in this manner and were evaluated 83.5 per cent have had complete remission of symptoms while on therapy, the remainder being improved but still having occasional symptoms. The technique and data demonstrate that children with hard-core voiding abnormalities can achieve rehabilitation with urodynamic assessment.