High grade vesicoureteral reflux: analysis of observational therapy.

Between 1981 and 1987, 300 patients with high grade (III, IV and V international classification) vesicoureteral reflux were treated at a single pediatric hospital. Only patients with primary vesicoureteral reflux were included in the study. The guiding principle during this period was that all patients with high grade vesicoureteral reflux would be observed on prophylactic antibiotics (observational therapy) and surgical correction would be reserved for specific indications. Of the 300 patients 132 received observational therapy alone and 168 required surgical correction for specific indications after varying periods of observation. In both groups the duration of persistent reflux was analyzed using a life-table method. In patients with grade V reflux we observed resolution in 3 patients whereas 23 required surgical correction. Of those patients in the observation group with grade IV reflux 83% had persistent reflux at 2 years and 70% still had reflux at 5 years. For those with grade III reflux the persistence rate was 83% and 50%, respectively. Neither age, sex nor side of reflux had a correlation with the rate of resolution. When tested grade of reflux correlated loosely (p = 0.07). During the period of observational therapy new renal scars developed in 23 patients (8%). We conclude that high grade vesicoureteral reflux can resolve in a minority of patients over a protracted interval. On the basis of this analysis, we advocate consideration of surgical correction in these patients after a 4-year period of observational therapy and for specific indications.

Effects of the artificial urinary sphincter on prostatic development and sexual function in pubertal boys with meningomyelocele.

Although sexual development in boys with meningiomyelocele may progress normally through puberty, the effects of surgical correction of incontinence by insertion of an artificial sphincter device around the bladder neck remain unclear. We studied 13 boys who received an artificial urinary sphincter before puberty and compared them to 12 age-matched pubertal controls with meningomyelocele. The prostate morphology was evaluated by means of transrectal ultrasonography, and we compared this finding, as well as sexual development, erectile function and seminal emissions between the 2 groups. Boys in both groups had similar development of secondary sexual characteristics and reported similar erectile function. Ultrasonography demonstrated an imprint of the sphincter cuff on the prostate but patients and controls had equal prostatic growth. In both groups an unexpected finding was the unexplained presence of sonolucent and sonodense lesions within the prostate glands. We conclude that transrectal ultrasonography is an excellent means of examining the prostate in pubertal boys with meningomyelocele. An artificial urinary sphincter placed around the bladder neck does not alter sexual development, function, prostatic growth or prostatic morphology.

Renal angiomyolipoma: 6 case reports and literature review.

We report 6 cases of renal angiomyolipomas and review the pertinent literature concerning this disease. One case involved the rare association of tuberous sclerosis and pregnancy. Another patient without tuberous sclerosis had renal cell carcinoma and later suffered a contralateral angiomyolipoma. The pathological conditions of renal angiomyolipomas with and without tuberous sclerosis are discussed. Since angiomyolipomas present with multiple clinical similarities to renal cell carcinoma, the primary task for the clinician is to differentiate this hamartoma from carcinoma. The distinguishing characteristics and the clinical management of renal angiomyolipomas are discussed.