Ipsilateral ureteroureterostomy for single ureteral reflux or obstruction in a duplicate system.

PURPOSE: The traditional treatment for obstruction or reflux involving a single ureter in a duplicated system has been common sheath reimplantation. More recently, ipsilateral ureteroureterostomy has been suggested as an alternative treatment. We reviewed cases with duplicate systems that were treated with ipsilateral ureteroureterostomy at our institution to determine the acceptability of this operation as an alternative to common sheath reimplantation. MATERIALS AND METHODS: A total of 22 patients with 24 duplicate systems underwent ipsilateral ureteroureterostomy between March 1986 and December 1996. Patient charts were reviewed and analyzed for patient age, sex, ureteral and renal anatomy, initial presentation, the clinical situation necessitating operation, and the occurrence of early and late complications. Patients were followed for a mean period of 41.4 months. RESULTS: Two adults and 20 children 10 years old or younger presented with urinary tract infection (13), hydronephrosis on maternal ultrasound (5), dribbling (2), ureteral calculus (1) and hydronephrosis on neonatal abdominal ultrasound (1). Mean hospital stay was 3 days. There was 1 early and 1 late complication. CONCLUSIONS: Ipsilateral ureteroureterostomy is an acceptable alternative to common sheath reimplantation in select patients with single ureteral disease in a duplicate system.

Crossed fused renal ectopy in children with myelodysplasia.

The medical records of 151 patients with myelodysplasia ranging in age from 3 months to 22 years were reviewed to determine the incidence of crossed fused renal ectopy. Five patients (3.3%) were identified. This figure is considerably higher than the reported incidence of 1:200 (0.5%) to 1:7500 (0.013%) in the general population.

Splenogonadal fusion.

Splenogonadal fusion is a rare condition wherein splenic tissue is found attached to or within the testis. There are two anatomic types: continuous and discontinuous. We report a case of splenogonadal fusion that presented in an adult man with bilateral cryptorchid testes.

Inflammatory pseudotumor (pseudosarcoma) of the bladder.

Inflammatory pseudotumor (pseudosarcoma) of the bladder is a benign proliferative lesion of the submucosal stroma easily mistaken for a malignant neoplasm clinically and histologically. The lesion was first described as a separate entity in a report of 2 patients. Three additional cases have been reported since then. We describe pseudosarcomatous bladder tumors arising in 2 adolescents. Both patients presented with sudden onset of gross painless hematuria related to large polypoid and ulcerated bladder masses found on endoscopy. Initial pathological analysis was interpreted as poorly differentiated sarcoma in both patients but subsequent reviews were consistent with a benign process resembling nodular fasciitis. Simple excision in both patients has been successful in eradicating the lesion. The findings in these 2 patients are described with a discussion of the pathophysiology and review of the literature.

Suprapubic endoscopic vesical neck suspension for the management of urinary incontinence in myelodysplastic girls.

Urinary incontinence may be a formidable hardship in many girls with myelodysplasia. In those patients who fail treatment with intermittent self-catheterization and pharmacotherapy surgical augmentation of outlet resistance may successfully alleviate incontinence. In patients with less severe degrees of urethral sphincteric incompetence suprapubic endoscopic vesical neck suspension in conjunction with intermittent self-catheterization can be successful. Patients must be selected carefully, with particular attention directed at detecting decreased detrusor compliance. Poor detrusor compliance must be controllable or corrected before augmentation of urethral resistance to prevent postoperative upper urinary tract deterioration.

Percutaneous stone removal in children.

Percutaneous removal of renal and ureteral calculi has become an established and successful procedure in adults. Stone disease in children often is metabolic or infectious in origin and multiple surgical procedures during a long interval may be required. Therefore, percutaneous stone removal could be particularly advantageous in these patients. We have performed percutaneous stone removal successfully in 7 children, none of whom required a second procedure or were discharged from the hospital with a nephrostomy tube.

Intracorporeal cavernosa streptokinase as adjuvant therapy in the delayed treatment of idiopathic priapism.

Late treatment of priapism may be associated with unsuccessful aspiration and irrigation of the corpora cavernosa. In such cases intracorporeal instillation of streptokinase resulted in dramatic improvement in detumescence. A subsequent venous shunt procedure achieved good results.

Management of penile incarceration.

A case of penile incarceration is presented. Two steel bushings compromising the penile vascular supply in a young man were removed with the aid of a carbide disk dental drill. Management of this case is described, and guidelines for managing similar cases of penile incarceration are discussed.

Adult respiratory distress syndrome complicating percutaneous nephrolithotripsy.

In an otherwise healthy thirty-six-year-old man adult respiratory distress syndrome developed following percutaneous nephrolithotripsy. Absorption of a large volume of irrigating solution occurred during the procedure and resulted in respiratory compromise, neither of which was appreciated intraoperatively. Close intraoperative monitoring of irrigation fluid input and output is necessary, and if a significant discrepancy develops, we believe the procedure should be terminated and diuresis instituted. In a difficult procedure, consideration should be given to establishing a maximum operating time and shortened if patient risk factors so warrant.

Central nervous system lesion causing urethral instability and urinary incontinence.

We report on a girl in whom urinary incontinence developed after surgery for a cerebral arteriovenous fistula. Urodynamic evaluation demonstrated periodic decreases in urethral pressure and external anal sphincter electromyographic activity. These episodes were associated with entry of radiographic contrast material into the urethra and urinary incontinence. Treatment with ephedrine sulfate prevented entry of urine into the proximal urethra and resulted in complete daytime continence, despite persisting urodynamic evidence of urethral and electromyographic abnormalities.

EMG biofeedback for functional bladder-sphincter dyssynergia: a case study.

The present study utilized EMG biofeedback in the treatment of functional bladder-sphincter dyssynergia, a learned incoordination of bladder and urethral sphincter activity during voiding. The condition is usually associated with a history of painful urination due to bladder infections, surgery, or harsh toilet training. The subject was an 8-year-old girl with chronic diurnal urinary frequency, urge incontinence, and nocturnal enuresis. Treatment consisted of intensive instruction in alternately tensing and relaxing her lower pelvic musculature, as well as relaxing during voiding. These exercises were accompanied by EMG biofeedback from perianal and perivaginal surface electrode sites. Home practice consisted of the tense-relax exercise, relaxation during voiding, and self-monitoring and record-keeping. There were 17 sessions over a period of 9 months. No medication was used. Marked reduction (to normal levels) in diurnal urgency and frequency occurred by the 3rd week of therapy, and complete recovery of normal function, including nocturnal continence without waking, occurred by the 13th therapy session, 5 months after therapy began. Follow-up 1 year after therapy revealed that these gains were being maintained. Pre- and posttherapy urodynamic studies corroborated the achievement of normal urinary function.

Upper urinary tract deterioration in patients with myelodysplasia and detrusor hypertonia: a followup study.

We report on 6 patients with myelodysplasia who had undergone previously urodynamic evaluation that demonstrated detrusor hypertonia. At the time of the initial studies no patient had vesicoureteral reflux or significant upper urinary tract dilatation. Subsequently, upper urinary tract deterioration and/or vesicoureteral reflux developed in all patients and persisting detrusor hypertonia was demonstrated on followup urodynamic testing. Marked clinical and radiographic improvement followed treatment by intermittent catheterization with concomitant pharmacologic therapy. Our experience indicates that detrusor hypertonia can lead to ureteral complications in patients with previously radiographically normal upper urinary tracts. We believe that detrusor hypertonia should be treated with anticholinergic medication, frequently in conjunction with intermittent catheterization. The clinical presentation of upper tract deterioration after many years of normality, and occurring as late as the mid teenage years, demonstrates that these patients require prolonged and careful urologic and radiographic followup.

Mild unilateral proteinuria and renal vein thrombosis associated with oral contraceptive usage.

A previously healthy 15-yr-old female taking oral contraceptives presented with acute, isolated, unilateral renal vein thrombosis as documented by arteriography and venography. Mild proteinuria (760 mg/24 hr) was localized solely to the thrombosed kidney by selective ureteral collections. The case illustrates an oral contraceptive associated renal vein thrombosis in the absence of either inferior vena cava thrombosis, bilateral proteinuria, or the nephrotic syndrome. This patient's proteinuria and clinical course suggest that nephrotic syndrome is a cause of renal vein thrombosis rather than an effect of renal vein thrombosis. The finding of localized, unilateral proteinuria is discussed.

Urinary lactic dehydrogenase and serum C-reactive protein as means of localizing the site of urinary tract infection in patients with ileal conduits.

Many patients with ileal conduit urinary diversion have infected urine but far fewer have clinical pyelonephritis. A noninvasive diagnostic test to distinguish renal bacteriuria from conduit colonization in these patients would seem desirable. Urine total lactic dehydrogenase and lactic dehydrogenase isoenzymes, and serum C-reactive protein have been useful to distinguish pyelonephritis from cystitis in patients with intact urinary tracts. We used these tests in patients with ileal conduits who had urine containing more and less than 10(5) organisms per ml. All patients had elevated urine total lactic dehydrogenase-5 isoenzyme, and serum C-reactive protein. No statistically significant difference in any of these parameters existed between the groups. These results may indicate that all patients with conduits have pyelonephritis but only intermittently demonstrate bacteriuria, or that the conduit mucosa contributes lactic dehydrogenase to the urine. However, it does not appear that these tests alone can distinguish accurately renal bacteriuria from conduit colonization.

Determination of true intravesical filling pressure in patients with vesicoureteral reflux by Fogarty catheter occlusion of ureters.

Ureteroneocystostomy is a highly successful procedure for the correction of vesicoureteral reflux. However, postoperative vesicoureteral reflux or ureterovesical junction obstruction will develop in some patients and elevated intravesical filling pressure might be a significant factor. Reflux, itself, might act as a safety release valve and mask vesical hypertonia. We herein describe a technique to determine the true intravesical filling pressure in the presence of vesicoureteral reflex by occlusion of the ureters with reflux using Fogarty catheters. Our preliminary experience suggests that it is an easily performed and clinically useful test to identify patients with vesical hypertonia who should be treated postoperatively with anticholinergic medication.

Pubovaginal sling procedure for the management of urinary incontinence in a myelodysplastic girl.

Urinary incontinence is a formidable social handicap in many children with myelodysplasia. Girls in whom pharmacologic therapy and intermittent catheterization fail to alleviate incontinence present particularly difficult management problems. Permanent catheter drainage of the bladder or supravesical urinary diversion frequently has been used solely for control of incontinence. More recently, the artificial sphincter has been used in selected patients. We herein describe the use of a pubovaginal sling to augment bladder outlet resistance in a girl with myelodysplasia. Postoperatively, she remains totally continent on intermittent catheterization.

Prevention of urinary tract infection and sepsis following transrectal prostatic biopsy.

Transrectal biopsy is one of the more popular methods for the diagnosis of prostatic cancer. However, there is disagreement as to whether the use of prophylactic antimicrobials decreases the incidence of fever and urinary tract infections, which may follow this procedure. A prospective randomized double-blind study involving 63 patients was instituted to determine the efficacy of carbenicillin indanyl sodium in reducing these complications. The protocol consisted of administration of 2 tablets of 4 times daily of a placebo or the treatment drug 24 hours before and after biopsy. Clean catch urine cultures were obtained 24 hours before biopsy and at 48 hours and 2 weeks after the procedure. Blood cultures were performed 15 minutes after biopsy. In addition, clinical parameters were monitored closely in the hospital for 48 hours after biopsy. A total of 48 patients was considered evaluable. Of 23 patients who received the study drug 2 (8.6 per cent) had positive urine cultures at 48 hours compared to 9 of 25 (36 per cent) from the placebo group. A similar result was observed from the 2-week culture data, in which 2 of 23 patients (8.6 per cent) in the treatment group had positive urine cultures as opposed to 5 of 25 (20 per cent) receiving the placebo. Fever occurred in 48 per cent of the placebo and in 17 per cent of the carbenicillin groups. Our data indicate that prophylactic administration of carbenicillin indanyl sodium decreases the complications of fever and urinary tract infections following transrectal biopsy of the prostate.

Urinary undiversion in patients with myelodysplasia and neurogenic bladder dysfunction. Report of a workshop.

This workshop was conducted in an attempt to analyze critically the role of reconstruction of the myelodysplastic patient who had undergone urinary diversion and to develop guidelines for selecting those patients in whom urinary undiversion might be undertaken safely. The collective experience initially seems to be acceptable; however, the authors emphasize the gravity of the decision and the complexity of the evaluation which must be undertaken prior to embarking on such reconstructive surgery. Contrary to some reports, we believe that the defunctionalized bladder frequently can be evaluated. Further, many of the contraindications to urinary undiversion have been identified and several of the hazards involved therein can be avoided. We believe that the neurogenic bladder is no longer an absolute contraindication to undiversion. Our experience suggests that undiversion is a reasonable surgical treatment in select patient with neurogenic bladder dysfunction. But, the decision to remove a satisfactorily functioning conduit must not be undertaken lightly. Patients should be selected only after a thorough, detailed, and properly conducted evaluation. A protocol has been developed which will hopefully assist in this evaluation. Perhaps additional shared experience will further refine and delineate the circumstances appropriate for reconstruction of these patients.