Management of post-operative bladder spasm.

OBJECTIVE: Pain management following bladder surgery in children is often complicated by bladder spasm. The overall severity of spasm can be reduced with opioids, anticholinergic medication and sedatives, although breakthrough spasms often occur. At the Royal Children's Hospital, Melbourne, intravesical bupivacaine has been used to manage postoperative bladder spasm to good effect. The administration of intravesical bupivacaine is analysed in this prospective audit of locally applied intravesical anaesthetic and compared with other methods. METHOD: From February to August 2003, histories of 58 patients who had intravesical bupivacaine were studied and compared with six other methods of management of postoperative bladder spasm. CONCLUSION: Data showed that epidural anaesthesia was the most effective treatment of pain, with a pain score reduction of 6.6, compared with a reduction of 6.1 with intravesical bupivacaine, and 4.5 using intravenous morphine. However, intravesical bupivacaine was the most effective method for the relief of bladder spasm.

Bowel imbrication in the management of anorectal anomalies.

Four patients who had imbrication of their proximal rectum and distal sigmoid colon as part of the management of constipation following an anorectoplasty for an anorectal anomaly. Three children with an anorectal anomaly presented with constipation and marked dilation of the rectosigmoid portion of the large bowel; each had longitudinal imbrication of the dilated segment, via a left iliac fossa incision. The forth was born with a cloacal anomaly with associated colonic atresia. The small bowel was used to construct the anorectum following a redo anorectoplasty. Subsequently, the small bowel became ectatic, resulting in the patient developing persistent watery diarrhoea and severe perianal excoriation, which was managed with a 30 cm longitudinal imbrication of the distal bowel during an extensive laparotomy. All 4 have patients now have near normal bowel motions with minimal medication, after only a short hospital stay. Residual problematic dilatation of the rectosigmoid colon in patients with a high anorectal anomaly, in the presence of constipation, can be successfully managed by imbrication of the dilated segment, if carefully selected.

Does the endoscopic technique of ureterocele incision matter?

PURPOSE: Endoscopic ureterocele decompression is a well established procedure in children. However, an accurate endoscopic incision may be challenging in large ectopic ureteroceles. We describe a percutaneously assisted technique to facilitate the ease of ureterocele incision and review other described methods. MATERIALS AND METHODS: We reviewed the medical records of 12 children with ectopic ureteroceles subtending a double collecting system who underwent endoscopic, percutaneously assisted incision. Six ureteroceles were on the left side, 5 were on the right side and 1 child had bilateral ureteroceles. Decompression results were evaluated by ultrasound and Tc-mercaptoacetyltriglycine imaging during a mean of 2.8 years of followup. RESULTS: There were 7 girls and 5 boys. Mean age at presentation was 11.6 months (range 1 week to 6 years). The decompression success rate was 84% (11 of 13 renal units), and improved renal function and drainage was noted in 5 of 12 patients (41.6%). Seven of 12 patients had vesicoureteral reflux, of whom 2 were asymptomatic at followup and, hence, were treated conservatively. Five children underwent surgery because of recurrent urinary tract infections. CONCLUSIONS: Although our results are similar to those of other methods, percutaneously assisted cystoscopic incision of ureterocele enables easier and more accurate decompression. However, when comparing the various techniques described, it seems that postoperative results mostly reflect the anatomical and functional characteristics of the urinary system rather than the technique used.

Ulaanbaatar procedure for tubularization of the glans in severe hypospadias.

PURPOSE: We developed a new procedure for the repair of proximal hypospadias in which the distal urethra is constructed as part of the first of 2 stages, and reviewed the results of 34 cases. MATERIALS AND METHODS: We performed stage 1 of the Ulaanbaatar procedure in 35 children 0.6 to 11 years old (average age 2.5), and stage 2 in 20. The meatus was at the posterior third of the shaft in 14 children, at the penoscrotal junction in 16 and in the perineum in 5. Three patients had a previous operation, and none had Byars flaps formed. Followup was less than 2(1/2) years for stage 1 and less than 1(1/2) years for stage 2. In 2 stage 2 procedures a free graft was also used to augment the proximal part of the urethroplasty. RESULTS: Urethral fistula did not develop in any patient, a minor early stricture occurred in 2 patients and 1 urethral diverticulum occurred in 1 patient after stage 2. In all patients the glans and meatus were more normal compared to other 2-stage procedures after the first operation, and the cosmetic result was usually satisfactory. CONCLUSIONS: The Ulaanbaatar technique provides an alternative approach to the formation of the glans urethra in severe hypospadias. It does not have the risks associated with a single stage procedure but has the benefit of enabling tunneling of the urethra through the glans, thus facilitating a favorable cosmetic outcome and an easy stage 2.

Guide wire-assisted urethral dilatation for urethral strictures in pediatric urology.

PURPOSE: The aim of this study was to report the results of 32 cases of dilatation of urethral stricture using a guide wire and sheath dilator technique supplemented by clean intermittent catheterization if further stabilization of the urethral stricture was felt warranted. METHODS: The procedure involves insertion of a straight flexi-tip lubricated guide wire through the urethral stricture under cystoscopic guidance followed by insertion of a series of sheath dilators. Dilatation was followed by insertion of a Foley catheter, which was left in situ for 1 to 3 days. Patients underwent repeat cystoscopy to evaluate the urethra for recurrent stricture and those with a recalcitrant stricture were commenced on clean intermittent catheterization (CIC) to stabilize the narrowing. RESULTS: Thirty-two patients were included. They have been followed up for up to 2(1/2) years after their last cystoscopy (mean, 16 months). Thirteen of 32 patients had more than 4 dilatations under anesthesia. Twelve patients had undergone CIC postoperatively. Complications included a urinary tract infection in 3 boys and bladder spasms in one. No false passage or sepsis occurred with this approach. CONCLUSIONS: Guide wire-assisted urethral dilatation helps avoid risks associated with blind dilatation techniques and appears to be a safe and simple alternative for management of urethral strictures in pediatric urology.

Retained common-duct stones after open cholecystectomy and duct exploration in children.

A retrospective study was performed of 250 patients with cholelithiasis treated at the Royal Children's Hospital, (RCH) Melbourne, over 25 years by open operation; 32 (12.8%) had proven choledocholithiasis on either preoperative imaging, operative cholangiography (OpCG), or postoperative investigation. A further 3 had underlying congenital biliary abnormalities and were excluded from further study. Thirty-one of the 32 were explored at open operation, 27 after OpCG and 4 on clinical grounds. One retained common-bile-duct (CBD) stone was undetected until the postoperative period (1/250, 0.25%). Seven ducts were not cleared, giving a duct exploration failure rate of 22.6% (7/31). All 8 retained CBD stones were identified in the early postoperative period and managed with a variety of techniques, including endoscopic retrograde cholangio-pancreatography (ERCP). The incidence of retained stones after open CBD exploration was high (22.6%), and can be attributed to difficulties in operative technique dealing with the smaller paediatric CBD. In addition, haemolytic disease seems to induce a propensity for choledocholithiasis. Given the small numbers presenting with cholelithiasis to RCH (10 per year), it is suggested that a selective approach to CBD exploration is appropriate in children. With the increasing use of laparoscopic cholecystectomy in children and the inherent technical difficulties of laparoscopic operative cholangiography, ERCP may offer an alternative solution in dealing with CBD stones rather than open or laparoscopic CBD exploration.

The detection of IgG antibodies to silicone.

Following a recent report of an ELISA test for the detection of antibodies to silicone, we attempted to use the same assay in four patients with known exposure to silicone. These patients all gave similar positive results as did a number of control sera with no known silicone exposure. We conclude that this assay does not measure serum levels of antibodies to silicone.

Reconstruction of the hypospadiac hooded prepuce.

PURPOSE: The role of foreskin reconstruction as part of distal hypospadias repair remains uncertain. Thus, we wished to define better the indications with a view to improving the success of this cosmetic alternative. We reviewed the outcome in a group of patients who underwent foreskin reconstruction to highlight the criteria for likely success. MATERIALS AND METHODS: The records of 51 boys who underwent foreskin reconstruction from 1996 to 2001 were reviewed from a total hypospadias repair group of 223. Boys who underwent foreskin reconstruction were 4 months to 9 years old (median age 9.3 months). Surgery included a meatal advancement and glanuloplasty procedure in 22 patients, Mathieu urethroplasty in 2, King-Duplay repair in 2 and a meatotomy in 1, while in 24 with a normal glans meatus foreskin plasty was the only surgery. Cases in which the foreskin was required for chordee release and those in which the gap between the ventral aspects of the foreskin was wide were excluded from foreskin reconstruction. Also, patients were selected by intraoperative assessment of the ability to approximate the foreskin in the midline at the level of the coronal groove. If this maneuver can be performed without placing the foreskin under tension, the foreskin is considered suitable for reconstruction. All patients received regional and general anesthesia plus intraoperative antibiotics. After suitable urethroplasty the technique of foreskin reconstruction was generally similar for all types of the condition. RESULTS: The result was excellent in 36 patients (70.6%) with a normal-appearing foreskin that retracted easily. There was a good result in 8 patients (15.7%) with a satisfactory meatus at the tip of the glans and a retractable foreskin but minor foreskin deformity. Only 3 patients had a minor complication, including a fistula through the prepuce in 2 and wound infection in 1. No boy had a complication due to urethroplasty and there were no urethral fistulas. CONCLUSIONS: Our study shows that foreskin reconstruction is successful, particularly if the proximal, coronal groove portion of the prepuce can be easily approximated manually and the procedure can be combined with a range of distal repairs. We would recommend reconstruction of the prepuce if parents would prefer their son to be uncircumcised, providing that the foreskin is suitable for preservation.

Plastic particle migration during intravenous infusion assisted by a peristaltic finger pump in an animal model.

The contamination of intravenously administered fluid with foreign material has always been of major concern, but the in-vivo impact of silicone embolisation from administration of fluid via a peristaltic finger pump (PFP) has not previously been assessed. To determine whether silicone particles enter the lungs and to review the histological response, 10 rabbits received an IV infusion of 0.9% saline at 10 ml/kg per hour over a 72-h period, via an IVAC 591 PFP. The lungs were analysed for silicone particles with scanning electron microscopy (SEM) and energy-dispersive X-ray analysis (EDXA). These results were compared with a control group of non-infused animals. Silicone particles were found in 8 of 10 animals in the experimental group and in 2 of 9 control animals, indicating that silicone particles are dislodged during pump-assisted IV infusions. The difference between the control and infused animals was statistically significant using Fisher's exact test (P = 0.023). However, silicone plastic particles in control animals suggest that there is also environmental exposure to silicone in addition to those particles that come from a therapeutic source. The additional finding of elemental silicon (which is one of the constituents of silicone plastic) in both infused and control animals in which silicone plastic was not found indicates that not all elemental silicon in animals reflects the presence of silicone plastic. The clinical significance of each of these two findings is yet to be determined.

Revision anorectoplasty in the management of anorectal anomalies.

Twelve patients who had a revision posterior sagittal anorectoplasty (PSARP) were evaluated by questionnaire. They were 11 months to 15 years old (median 5 years) at the time of revision surgery. All were born with an intermediate to high anorectal anomaly (ARM) and had ongoing problems of rectal prolapse (3), stenosis (1), faecal incontinence (9), or severe constipation (4). All but 1 had a huge megarectum with a poor anorectal angle and stool impaction, causing overflow incontinence. After revision surgery, marked improvement occurred in 7 and at least some improvement was achieved in the remaining 5. Previous severe constipation resolved in 2 and improved in another 2 children. The number of soiling episodes significantly decreased in 8 patients: while before surgery 8 had been wearing nappies all the time, only 2 use them postoperatively. The anorectal prolapse has resolved in 3 and sensation improved in 5, and as a group, there has been a reduced need for laxatives and rectal washouts. The favourable outcome of our patients confirms that PSARP is an excellent technique for revision surgery, and tapering of a secondary megarectum plus the formation of an anorectal angle can produce clinical improvement, even in more severe forms of ARM.

Catheter-less Cohen transtrigonal ureteric reimplantation.

OBJECTIVE: To review the profile and outcome of patients in whom it was elected not to insert a bladder catheter as part of the management of Cohen transtrigonal ureteric reimplantation surgery. PATIENTS AND METHODS: Between April 2000 and April 2001, 37 patients underwent ureteric reimplantation by the senior author, using the Cohen transtrigonal technique. The use of the catheter-less protocol began after the blockage of a suprapubic catheter soon after surgery; the catheter was removed with no adverse event. Subsequently, 27 of those undergoing ureteric reimplantation were selected not to have a bladder catheter. Later in the study a greater proportion of patients had no catheter inserted, as confidence with the catheter-less technique increased. Caudal anaesthetic, oral analgesia and a single dose of intravesical bupivacaine were used for pain relief. The children were monitored closely after surgery and a urethral catheter inserted in the one patient who had not voided after 6 h. RESULTS: The patients generally tolerated the lack of a bladder catheter well. Of the 27 patients who did not have a catheter inserted at surgery, one required catheterization (a girl with bilateral duplex systems and large ureteroceles). Two children stayed in hospital for 2 days after surgery, one was discharged on the day of surgery, and the remainder went home on oral analgesia on the first day after surgery. Since starting the catheter-less approach, 10 patients have had a suprapubic catheter because they had more complex surgery, were older or because the approach had not developed sufficiently at the time of surgery. CONCLUSIONS: Intravesical ureteric reimplantation is not only safe when omitting a bladder catheter but, if used selectively, there appears to be a significant decrease in the hospital stay and discomfort after surgery.

Calyx to parenchyma ratio in pelvi-ureteric junction obstruction.

OBJECTIVE: To review the ultrasonography of patients who had undergone pyeloplasty for pelvi-ureteric junction (PUJ) obstruction, and document the changes in calyceal distension and parenchymal thickness after pyeloplasty, to attempt to establish an additional prognostic indicator. PATIENTS AND METHODS: Fifty-eight patients who underwent pyeloplasty for PUJ obstruction were assessed retrospectively. Pre- and postoperative ultrasonograms were analysed for both pyelocaliectasis, graded according to the Society for Fetal Urology criteria, and the ratio of the depth of calyces to the thickness of the parenchyma (C/P ratio). Patients underwent nuclear medicine renography before and 3 months after pyeloplasty. The results were analysed using the paired t-test, Kruskal-Wallis test, Spearman's correlation coefficient by rank test and the Mann-Whitney U-test. RESULTS: There was no significant difference in hydronephrosis grade before and after surgery (P < 0.05) but there was a significant difference in the C/P ratios (P < 0.01). There was no correlation between C/P ratios and the results of diuresis renography. CONCLUSION: Hydronephrosis as measured by an estimate of pelvic volume is an insensitive marker of improvement after pyeloplasty. Reduced calyceal distension correlates well with other favourable prognostic indicators. Therefore, the C/P ratio may be an additional indicator of the appropriateness of surgical intervention, and should be the subject of further study.

Presence of the eggshell sign in obstructive uropathy.

OBJECTIVES: To analyze the relationship between hydronephrosis due to urinary tract obstruction and the presence of the sonographic eggshell sign, which is a recently described crescent of increased echogenicity at the caliceal/parenchymal interface and possibly an indicator of raised intrarenal pressure. METHODS: All patients presenting between 1996 and 1999 for surgical management of pelviureteral junction obstruction or congenital posterior urethral obstruction had films reviewed for the presence of the eggshell sign. RESULTS: Of 94 patients, 40 presented postnatally and 54 had hydronephrosis detected on the antenatal ultrasound scan. Of the postnatal group, 16 (40%) had urethral obstruction, of whom 4 (25%) displayed the eggshell sign; in the 24 with pelviureteral junction obstruction, the echogenic pericaliceal crescent was seen in 5 (20.8%). Of the 54 in the prenatal group, 8 (15.4%) were found to have urethral obstruction, 5 (62.5%) of whom demonstrated the eggshell sign. Of the 46 prenatally diagnosed patients with pelviureteral junction obstruction, 31 (70.5%) displayed the eggshell sign before birth; we were unable to satisfactorily review 2 patients' ultrasound scans. CONCLUSIONS: Antenatally diagnosed hydronephrosis due to significant urinary tract obstruction seems to be related to the appearance of the eggshell sign on ultrasonography, particularly in those patients with pelviureteral junction obstruction. Those patients without significant caliceal distension and those with renal dysplasia or severe hydronephrosis with low-pressure kidneys were less likely to display the eggshell sign. Although the association with other causes of hydronephrosis is unknown, we believe these figures support the need for further investigation of the eggshell sign as a marker of raised intrarenal pressure to possibly provide another data point in the sonographic evaluation of congenital hydronephrosis.

Autoaugmentation peritoneocystoplasty in a sheep model.

OBJECTIVE: To report our experience with autoaugmentation peritoneocystoplasty (AAPC) in a sheep model, and to compare the results with autoaugmentation gastrocystoplasty (AAGC) in a sheep model and in paediatric patients. MATERIALS AND METHODS: Ten 6-month-old male lambs underwent bladder augmentation by detrusorotomy. A flap of parietal peritoneum, dissected from the anterior abdominal wall, was used to cover the bladder mucosa. The sheep were evaluated by urodynamics 6 months after surgery. Bladder compliance (bladder volume/intravesical pressure) was calculated for the bladder capacity at leakage. The urodynamic results were compared with age-matched control sheep and with 12 sheep that had undergone AAGC; the results were assessed using the Mann-Whitney U-test. RESULTS: In two of the 10 sheep, bladder volumes after AAPC increased by > 100%, although for the group, the mean (range) bladder volume after augmentation, at 159 (42-261) mL, was not significantly different from that before surgery (mean 143 mL). Bladder volumes after AAPC were not significantly different from those in the control sheep (mean 205 mL) but were significantly less than in the AAGC group (mean 317 mL; P < 0.05). Bladder compliance at leak capacity in the AAPC group (mean 5.4 mL/cmH2O) was also not significantly different from the controls (mean 9.1 mL/cmH2O), but was lower than the in the AAGC animals (median 14.6 mL/cmH2O; P < 0.05). CONCLUSIONS: AAPC in a sheep model does not result in a reliable increase in bladder volume or compliance. The volume and compliance are inferior to those found in bladders augmented by AAGC.

The clinical and radiological findings in boys with endoscopically severe congenital posterior urethral obstruction.

OBJECTIVE: To assess the clinical and radiological spectrum in boys with endoscopically severe posterior urethral obstruction, as there is a broad clinical spectrum which does not always correlate with the cystoscopic findings. PATIENTS AND METHODS: Between December 1990 and July 2000, 39 boys (newborn to 12 years old) underwent cystoscopy to investigate a urethral anomaly and were found to have a severe obstructing posterior urethral membrane. Their voiding cystograms, video-recorded cystoscopy and presenting signs were reviewed. RESULTS: Of the 39 boys assessed, a voiding cystogram and presenting signs were available in 36. Of these 36 boys, three cystograms were initially reported as normal, eight showed posterior urethral dilatation as the only feature, and the remainder had more severe bladder and upper tract changes. Fourteen were diagnosed after identifying antenatal hydronephrosis, four presented with voiding dysfunction, one with haematuria and 17 were found after investigation of a urinary tract infection. CONCLUSIONS: This study shows that a congenital posterior urethral membrane that has only a small posterior defect endoscopically can have a wide clinical and radiological spectrum. The difference in outcome may be caused by variations in the response of the bladder to the obstruction, resulting in a different effect on the upper tracts.

Left-lung-collapse bronchial deformation in giant omphalocele.

Five infants with giant omphalocele had persistent collapse of the left lung and required prolonged respiratory support. Narrowing of the left main bronchus, reversible with positive end-expiratory pressure, was identified radiographically in 3 infants, and we postulate that this relates to distortion of the bronchus within the constraints of the elongated, narrow thoracic cavity characteristic of these patients. The lung collapse may be precipitated by manipulation (reduction or attempted reduction) of the omphalocele. J Pediatr Surg 36:846-850.

Trans-pyeloureteric anastomosis in the management of pelviureteric junction obstruction.

BACKGROUND: The application of pyeloureteric anastomoses in the management of pelviureteric junction obstruction is described. METHODS: Two patients, one requiring a ureterocystoplasty for bladder augmentation but with a coexistent contralateral pelviureteric junction (PUJ) obstruction and the other with gross hydronephrosis but an atretic ipsilateral ureter, underwent trans-pyeloureteric anastomosis to relieve the obstruction. RESULTS: Both patients demonstrated satisfactory drainage of the upper tracts on postoperative imaging. CONCLUSIONS: Transureteropyeloplasty represents a novel and valid technique of urinary tract reconstruction in complex cases of PUJ obstruction.