The syndrome of dysuria and hematuria in pediatric urinary reconstruction with stomach.

Between July 1989 and March 1992 at a single institution 27 male and 30 female patients underwent lower urinary reconstruction with stomach. Mean patient age was 9.9 years (range 1.5 to 28 years). The diagnoses were epispadias/exstrophy complex (19 patients), myelodysplasia (11), cloacal exstrophy (6), posterior urethral valves (6), Hinman syndrome (4), sacral agenesis (3) and other (8). Indications for surgery were urinary incontinence, upper tract deterioration or undiversion. A total of 54 patients underwent augmentation gastrocystoplasty and 3 had total bladder replacement. Mean followup time was 23.2 months (range 12 to 39 months). The syndrome of dysuria and hematuria is defined as 1 or a combination of the following symptoms: bladder spasm or suprapubic, penile or periurethral pain, coffee brown or bright red hematuria without infections, skin irritation or excoriation and dysuria without infections. Telephone and clinic interviews identified 21 patients (36%) with symptoms of the dysuria and hematuria syndrome. The most common symptoms were hematuria (71%) and bladder or suprapubic pain (76%). Of the patients 18 (86%) ranked the severity of symptoms as mild to moderate and 3 (14%) ranked them as severe. No medications were required to control the symptoms in 13 patients (62%) and 3 other patients only required medications on an as needed basis. Overall patients who required no medications had lower symptom scores than those who required medications. Patients with decreased renal function may be more at risk for the dysuria and hematuria syndrome than those with normal renal function. Patients who were wet were more prone to have the dysuria and hematuria syndrome than those who were totally dry. The pathophysiology of the dysuria and hematuria syndrome is currently unknown. Patients who require urinary reconstruction with stomach tissue need to be made aware of the potential of the dysuria and hematuria syndrome.

The use of the AMS800 artificial urinary sphincter in combination with the gastric tube for continence in the canine model.

An experimental canine model was designed to examine the potential use of the artificial urinary sphincter around a gastric tube. The artificial urinary sphincter was placed around a tubularized gastric flap as part of a continent gastric reservoir in 4 dogs and in 2 additional dogs the gastric tube was anastomosed to the native bladder. Two dogs underwent placement of the artificial urinary sphincter around the gastric tube 4 weeks postoperatively and the remainder had the sphincter placed simultaneously with creation of the gastric tube. All dogs with the gastric reservoir underwent urodynamics before and after activation of the sphincter. Only 61 to 70 cm. water pressure balloons were used. All dogs were continent postoperatively on clean intermittent catheterization every 8 hours. There were no erosions or problems with catheterization. Urodynamics confirmed a complaint system and an average increase of capacity of 410% after artificial urinary sphincter activation (4 dogs). There was no leakage at capacity. Histology of the artificial urinary sphincter and neighboring (control) regions, and of the reservoir at 1 (2 dogs), 3 (3 dogs) and 6 months (1 dog) was obtained. Microscopic examination of the cuff site showed mild serosal hyperplasia and fibrosis, a well preserved muscularis and mild to moderate focal mucosal atrophy. These changes were slightly more evident at 6 months. Mucosal folds were well preserved with normal submucosa and lamina propria. In the control region histology was well preserved and similar to native stomach. We conclude that the artificial urinary sphincter around a gastric tube can provide urinary continence. The minimal changes in histology under the cuff are encouraging and support the potential for use of the gastric tube with the artificial urinary sphincter, although longer term effects are unknown.

Lower urinary tract reconstruction using stomach and the artificial sphincter.

We implanted the artificial urinary sphincter at gastrocystoplasty in 13 male and 5 female patients. The diagnoses were classical bladder exstrophy (8 patients), myelodysplasia (8), cloacal exstrophy (1) and bilateral ectopic ureters (1). Mean patient age was 14.3 years (range 7 to 32.5). Six patients (5 with bladder exstrophy and 1 with clocal exstrophy) had failed bladder neck continence procedures, 3 myelodysplastic patients had failed artificial urinary sphincter placement, and 1 exstrophy patient had failed a Young-Dees bladder neck repair and artificial urinary sphincter placement. The sphincter cuff was placed around the reconstructed bladder neck in these patients, while in the remainder the artificial urinary sphincter was placed around the intact bladder neck. Mean followup was 20.3 months (range 1 to 5). Of the patients 16 (88%) are continent day and night, while 2 are wet. A total of 11 patients (61%) use Valsalva's maneuver alone for voiding and the remainder use Valsalva's maneuver and/or clean intermittent catheterization for bladder evacuation. Complications related to the artificial urinary sphincter were recurrent pump erosion requiring conversion to a Mitrofanoff continent stoma in 1 patient, and mechanical dysfunction requiring pump cuff and reservoir replacement in 3. There were no complications due to infection. Our report demonstrates that the combination of augmentation gastrocystoplasty and an artificial urinary sphincter leads to urinary continence and can allow for spontaneous urination. The rate of infectious complications is not increased when the 2 procedures are combined simultaneously.

Urethral polyp presenting as interlabial mass in young girls.

We describe two young girls who presented with an interlabial mass. Histologic examination of each excised mass revealed a benign urethral polyp covered with transitional and squamous epithelium. Urethral polyps should be included in the differential diagnosis of an interlabial mass in young female patients.

Urethral reconstruction using the carbon dioxide laser: an experimental evaluation.

In an effort to test the efficacy of the carbon dioxide laser in urethral reconstruction, patch graft urethroplasty was carried out comparing laser repair to microsurgical repair. The male Sprague Dawley rat was used as the model. An oval defect was created in the ventral urethra in 65 animals and repaired with a full thickness preputial skin graft conventional microsurgical repair, laser assisted microsurgical repair, or laser repair with a protein solder. The success rate, defined as the number of animals surviving without complications at the end of 21 days, was 50, 20, and 65% respectively. In conclusion, laser assisted repair using the protein solder was significantly better than microsurgical repair (p less than 0.05).