Does urinary tract ultrasonography at hospitalization for acute pyelonephritis predict vesicoureteral reflux?

PURPOSE: We evaluate the correlation between urinary tract ultrasound during hospitalization for acute pyelonephritis with subsequent voiding cystourethrography in children. MATERIALS AND METHODS: Medical records were reviewed of 184 children up to 18 years old who were evaluated with ultrasound during hospitalization for acute pyelonephritis between January 1988 and January 1996. Followup voiding cystourethrography results were compared to the initial ultrasound findings. RESULTS: Ultrasound was performed at mean hospital day 2.1 and voiding cystourethrography was done 39 days later. Of the ultrasound studies 77 (42%) were abnormal, and two-thirds of these abnormalities were upper tract dilatation. Subsequent voiding cystourethrography was performed in 76% of the study population, including 67% of those with normal and 87% of those with abnormal ultrasound. Voiding cystourethrography revealed reflux in 39% of children with upper tract dilatation compared to 35% of those with normal and 36% with abnormal ultrasound for any reason. In addition, the severity of reflux on voiding cystourethrography could not be predicted by ultrasound findings. CONCLUSIONS: Ultrasound findings during acute pyelonephritis do not correlate with and are not predictive of the presence or grade of vesicoureteral reflux on subsequent voiding cystourethrography.

Buccal mucosal grafts for urethral reconstruction.

OBJECTIVES: Patients requiring urethral reconstruction but who have a paucity of usable genital tissue present a considerable technical challenge. Herein we report the experience of three centers in the use of buccal mucosa for urethral replacement. METHODS: From 1991 to 1996, 22 urethral reconstructions were completed using a graft of buccal mucosa. Eighteen of 22 patients had previously failed hypospadias repairs, while three had bulbar urethral stricture and one had penile carcinoma. Grafts were taken from either the inner cheek or the lower lip, and seven were used as a combined graft. Onlay grafts were used in 6 cases and tubularized grafts in 16 cases. RESULTS: Two patients developed complications at the donor site. Nine of 22 patients had complications of the urethroplasty-two had meatal stenosis, four developed a urethral fistula, and three developed urethral stricture. All complications have been managed successfully to date. CONCLUSIONS: Buccal mucosa is an excellent source of graft material for urethral replacement in complex urethroplasties. It is readily available, in abundant supply, and has physical properties beneficial to free graft survival.

Abdominoscrotal hydrocele in infancy.

Abdominoscrotal hydrocele is an uncommon clinical entity. Fewer than 200 cases have been reported in the literature, only two of which described bilateral involvement. We present five cases of abdominoscrotal hydrocele occurring in infancy, three of which revealed bilateral disease. The first case represents the youngest patient ever reported with this condition and the first reported with secondary bilateral upper tract dilatation. The historical background, pathophysiology, diagnosis, and treatment are reviewed.

Prenatal diagnosis of duplex system hydronephrosis: effect on renal salvage.

OBJECTIVES: To determine if prenatal identification of significant renal duplication anomalies affects the management of the patient or the clinical outcome. METHODS: This is a retrospective review of 79 consecutive children with severe hydronephrosis involving a duplex renal collecting system, identified by either prenatal ultrasound (asymptomatic), or symptoms, most often urinary tract infection, but also including abdominal mass, hematuria, or incontinence. An individualized combination of voiding cystourethrogram, ultrasound, intravenous urogram, and nuclear renal scan was used to assess anatomy and function. Ablation of the involved segment was carried out if no or extremely poor function was identified; a definitive reconstructive procedure was elected in the face of easily measureable function. Outcome was determined clinically and by repeat imaging. RESULTS: There was no difference in the rate of renal segment salvage between the prenatally and clinically diagnosed groups. Of the cases analyzed, 20/79 were prenatally identified, of which 13/20 (65%) were reconstructed; 59/79 were identified on clinical grounds, of which 34/59 (58%) were reconstructed. One patient in the prenatal salvage group underwent removal of the affected kidney 5 years later. Another, in the clinical salvage group, underwent a successful secondary procedure for closure of a ureteral fistula. All others have shown improved function, drainage, or both in follow-up. No secondary procedures have been required for the ablation group to date. Follow-up ranges from 4 months to 12 years. CONCLUSIONS: Prenatal identification of significant duplex system hydronephrosis does not improve the rate of renal segment salvage, as determined by standard radiographic means, compared to later identification on clinical grounds. The decision for reconstruction versus ablation in significant duplex system hydronephrosis can be made on the basis of function alone.

Penile block timing for postoperative analgesia of hypospadias repair in children.

PURPOSE: It has been well established that a dorsal penile nerve block immediately after surgery decreases postoperative pain in children undergoing hypospadias repair. However, to our knowledge the efficacy of a penile block immediately before versus immediately after surgery for postoperative pain control has not been previously studied in such children. MATERIALS AND METHODS: We evaluated 98 healthy boys 6 months to 12 years old undergoing hypospadias repair. General anesthesia was induced and maintained in a standard fashion. Patients were randomly assigned to receive a penile block with the same total dose of bupivacaine at the completion of surgery, before the incision or before and at the completion of surgery. No other analgesic was administered intraoperatively. Pain was assessed using a modified objective pain-discomfort scale at 15 minutes, and 3, 12 and 24 hours after surgery. The number of doses of acetaminophen required to control postoperative pain was also recorded. RESULTS: Pain scores were defined in a range of 0-no pain to 6-greatest pain. During recovery median pain scores in the 30, 36 and 32 boys who received a penile block after, before, and before and after surgery were 3, 1.5 and 0 at 15 minutes; 2.5, 1 and 0 at 3 hours; 3, 2 and 0 at 12 hours; and 1, 0 and 0 at 24 hours, respectively. There was no difference in acetaminophen doses required 15 minutes and 3 hours postoperatively in the 3 groups. By 12 hours after surgery the number of acetaminophen doses required for pain control was significantly lower in the before and after, and before groups than in the after group. By 24 hours boys in the before and after group required significantly fewer doses of analgesics than those in the after and before groups. There was no statistically significant difference between the after and before groups. CONCLUSIONS: Two penile blocks performed at the beginning and conclusion of hypospadias repair, respectively, provide better postoperative pain control than 1 penile block done before or after surgery (p < 0.05). These patients require less analgesic than those who receive a penile block only before or only after surgery.

Scrotal cystic lymphangioma: the misdiagnosed scrotal mass.

PURPOSE: We report 7 cases of scrotal cystic lymphangioma and review the literature on this unusual lesion, which is often misdiagnosed as other conditions and treated incorrectly. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 7 patients with scrotal cystic lymphangioma treated from 1984 to 1996 at 5 institutions. RESULTS: Mean patient age at presentation was 3 years and painless scrotal swelling was the most common symptom. Physical examination demonstrated an unusual cystic scrotal mass with a normal testis and cord in most patients, and ultrasound in 4 showed a complex septated cystic mass. Preoperative misdiagnosis in all 7 patients included hernia, hydrocele, hematocele, varicocele and possible torsion. In 6 children the lesions were more extensive than expected with deep perineal and/or inguinal involvement, including 2 who also had pelvic and retroperitoneal extension. Incomplete excision led to recurrence in 4 patients. CONCLUSIONS: Scrotal cystic lymphangioma presents as an unusual cystic scrotal mass. Although misdiagnosis has been common, awareness of the characteristic features of this lesion should lead to the correct preoperative diagnosis. When lymphangioma is suspected, imaging of the adjacent inguinal, perineal and pelvic regions should be performed. Complete excision is mandatory to prevent recurrence.

Late presentation of cryptorchidism: the etiology of testicular re-ascent.

PURPOSE: We reviewed the records of 21 boys who had 23 previously documented descended testes that reascended and who underwent orchiopexy during a 2-year period. MATERIALS AND METHODS: We retrospectively reviewed a 2-year experience in 103 boys (115 undescended testes) who underwent orchiopexy in 1988 and 1989. RESULTS: In our 2-year experience 21 of the 103 boys with undescended testes had multiple recorded confirmations of testicular descent in the past. Of the boys 40% had previously been examined in the office or with general anesthesia by a pediatric urologist or pediatric surgeon for another reason, and 40% had a nurse or physician parent. Surgery was performed at ages 5 to 14 years, an average of 2 years after the initial presentation with reascent. Human chorionic gonadotropin was unsuccessful in causing testicular descent. There was no correlation with a patent processus vaginalis and no association with adhesions. The testis was located in the superficial inguinal pouch in the majority of patients, and the gubernacular attachment was in an abnormal location in all and ectopic in half of the cases. CONCLUSIONS: Our observations confirm that the etiology of this condition is a missed diagnosis at a younger age. The testis is undescended but almost completely descended. With somatic growth the distance between the terminal portion of the gubernaculum of the apparently descended testis and the scrotum increases, making the diagnosis more obvious. The potential for this condition makes it mandatory that intrascrotal testicular location be confirmed by periodic physical examination through puberty.

Prenatal sonographic diagnosis and subsequent conservative surgical management of bilateral ureteroceles.

Prenatal sonographic diagnosis of ureteroceles usually involves clearly duplicated urinary collecting systems associated with ectopic ureters draining the upper renal moieties. We present an unusual case in which an initial sonographic examination was consistent with bilateral orthotopic ureteroceles in association with bilateral single renal systems. The possibility of single systems raised perinatal considerations unique to this anomaly. Repeat prenatal sonography was suggestive of duplex systems and subsequently confirmed as such by neonatal ultrasound and voiding cystourethrogram. At the age of 1 month, the infant underwent bilateral ipsilateral ureteroureterostomy with conservation of the bilateral dilated upper renal moieties. We discuss the possible pathophysiology underlying the different conflicting sonographic findings and address current management of such lesions.

Acute scrotal swelling.

Acute scrotal swelling is a potential emergency. The differential diagnosis includes torsion of the testis or one of the testicular appendages, hydrocele, varicocele, trauma, tumor, idiopathic scrotal edema, and Henoch-Schönlein purpura. Imaging studies, such as radionuclide scanning and color Doppler ultrasonography, are helpful in equivocal cases.

Screening for urinary tract infection in children with neurogenic bladders.

Urinary tract infections (UTIs) are a frequent and potentially disabling problem for children with neurogenic bladders. Frequent monitoring for UTIs using bacterial culture is expensive and troublesome; thus an inexpensive, dependable screening method is desirable. Three hundred and twenty-nine urine specimens were obtained from 141 children with neurogenic bladders, 86% of whom had meningomyelocele. During the 11-month study period, 43% of the children had at least one positive culture (> or = 100,000 CFU/ml). The results of bacterial culture were compared with the occurrence of signs and symptoms, the presence of reflux and the results of a dipstick test for nitrite and leukocyte esterase. Analysis of the data revealed that (1) UTIs were significantly more common in children with reflux; (2) the presence of signs and symptoms was neither sensitive nor specific (positive predictive value (PPV) = 0.44, negative predictive value (NPV) = 0.84); (3) urinalysis was an unreliable screening tool (PPV = 0.63, NPV = 0.73); and (4) the combination of nitrite and leukocyte esterase was more sensitive and specific than either by itself (combined PPV = 0.69, NPV = 0.88). Children with neurogenic bladders who have reflux or have signs and symptoms should continue regular bacterial cultures, whereas others can be screened dependably using the combined leukocyte esterase and nitrite test.

The predictive value of ultrasonography in evaluation of infants with posterior urethral valves.

Between 1981 and 1989, 28 infants less than 6 months old with posterior urethral valves underwent ultrasound evaluation as part of the initial evaluation at our hospital. The single ultrasound feature that correlated with subsequent renal function was the status of corticomedullary differentiation. The presence of corticomedullary junctions in at least 1 kidney in 17 infants was always associated with a serum creatinine level of 0.8 mg./dl. or less in long-term followup. Of 11 patients with absent corticomedullary differentiation 7 had eventual creatinine levels of greater than 0.8 mg./dl. with 5 of them suffering clinically significant renal insufficiency. An association between vesicoureteral reflux and absent corticomedullary junctions was also found.

Perforation and intravesical erosion of a ventriculoperitoneal shunt in a child with an augmentation cystoplasty.

Bladder augmentation has evolved into a common method of management in children with a low capacity and/or poorly compliant bladder secondary to a neuropathic condition. We report on a 4-year-old girl with myelodysplasia who presented with sepsis and who had a perforation of the augmented bladder, which was surgically repaired. She returned for evaluation 1 month after she was discharged from the hospital when the distal component of the ventriculoperitoneal shunt was noted to protrude per urethram after clean catheterization. Distal shunt replacement with prolonged bladder drainage successfully resolved this perforation of the augmented bladder. The patient has had no further difficulties. We discuss the diagnosis and management of this case with reference to the current literature regarding complications of augmentation cystoplasty.

Toxicology of hydrogen sulfide.

Significant progress has been made in determining the action of sulfide on the primary target organs. It is reasonably clear that sulfide causes both K(+)-channel-mediated hyperpolarization of neurons and potentiation of other inhibitory mechanisms. It is not clear whether these processes are similar to those that occur in anoxia. Changes in perinatal and adult brain neurotransmitter content and release may be related to clinical impairment of cognition. H2S exposures at concentrations below the current occupational limits cause physiological changes in pulmonary function, thus suggesting that asthmatics are at risk. Studies of fetal and neonatal brain tissue have shown an abnormal development, and the long-term consequences of these neuronal changes have not yet been assessed. Finally, new approaches to therapy are required, such as the use of agents that actively remove sulfide from its sites of action. This may prove more useful in preventing some of the long-term adverse sequelae than the use of nitrites and hyperbaric O2, although the latter should be used in cases of pulmonary edema.

Testicular imaging.

Clinicians have relied on radionuclide scanning for evaluating acute scrotal pain and on ultrasonography for chronic scrotal pain and anatomic lesions (testicular and paratesticular structures). This review reinforces the utility of these established imaging techniques and also introduces color Doppler ultrasonography as an integral component in the advancement of testicular imaging, particularly in effective and timely diagnosis of spermatic cord torsion. The expanding capability of MR imaging for scrotal disorders is presented.

Neonatal capsaicin treatment alters basal pulmonary mechanics and response to methacholine in F344 rats.

Full methacholine dose-response curves were performed on anesthetized tracheostomized Fischer 344 adult rats treated neonatally with capsaicin (50 mg/kg) or with vehicle alone. Capsaicin, the hot extract of pepper, releases substance P (SP) from nonmyelinated sensory nerve endings and causes acute bronchoconstriction and airway microvascular leakiness. Chronic treatment with capsaicin leads to depletion of SP and other tachykinins from afferent C-fibers and can therefore be used as a tool to investigate the contribution of SP innervation to airway responses. The rats (9 controls and 6 treated with capsaicin) were paralyzed with succinylcholine and mechanically ventilated at a constant tidal volume and frequency. Airway resistance (RL) and dynamic compliance (Cdyn) were determined at each dose of methacholine from measurements of volume, flow, and transpulmonary pressure. Capsaicin-treated rats were found to have a significantly reduced baseline RL [0.150 +/- 0.039 (SD) vs. 0.225 +/- 0.050 cmH2O.ml-1.s, P = 0.009] and a correspondingly significantly elevated Cdyn (0.371 +/- 0.084 vs. 0.268 +/- 0.053 ml/cmH2O, P = 0.012). There was no significant difference in sensitivity to methacholine, but the maximal response to methacholine was significantly greater in the capsaicin-treated rats. In terms of RL, the maximal response for capsaicin-treated rats was 6.03 x baseline +/- 0.98 vs. 4.30 x baseline +/- 1.80 (P = 0.05) for controls, and for Cdyn changes the maximal decrease was 5.75 x baseline +/- 1.22 vs. 3.83 +/- 0.69 (P = 0.002). The observed differences in RL and Cdyn coupled with the differences in maximal responses can be attributed to the selective destruction of a subpopulation of pulmonary afferent C-fibers.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of polar pili in the adherence of Pseudomonas aeruginosa to injured canine tracheal cells: a semiquantitative morphologic study.

Pseudomonas aeruginosa adheres to respiratory epithelial cells in a highly specific fashion. In order to study the role of P. aeruginosa polar pili in the adherence process we conducted a quantitative morphological electron microscopic examination of P. aeruginosa adherence to SO2 injured canine tracheal cells in vitro. A pilin lacking background strain of P. aeruginosa PAK (BLP2) was constructed using a gene replacement and it in turn was engineered to express either the pilin gene of P. aeruginosa PAO, PAK, or no pilin gene. After 30 minutes incubation of these bacterial strains with injured canine tracheal rings the P. aeruginosa strains expressing pili adhered quantitatively more to the injured tracheal cells than did the pili lacking strains. PAO bearing strains adhered in greater numbers than PAK bearing strains. Healthy tracheal cells did not have any bacteria bound to their surfaces. The bacteria bound to the cilia and lateral edge of the exfoliating tracheal cells. Invasion of tracheal cells by piliated P. aeruginosa bacteria and penetration into the submucosa was also demonstrated. These data confirm the role of pili as important adhesins to injured tracheal cells. The difference in the adherence characteristics of pilin types PAK versus PAO may relate to the differences in the primary structure of these two pilin molecules.