Biofeedback therapy expedites the resolution of reflux in older children.

PURPOSE: In older children the spontaneous resolution rate of low grade vesicoureteral reflux is low and currently its management is controversial in regard to surgery versus prophylaxis versus observation alone. Bladder dysfunction in children with neurogenic bladders and to a less declarative degree in neurologically intact children has a role in the etiology or persistence of reflux. We determine the impact of biofeedback therapy on neurologically intact children with vesicoureteral reflux and detrusor-sphincter dyssynergia. MATERIALS AND METHODS: Vesicoureteral reflux was detected by voiding cystourethrography in children evaluated for urinary tract infections. Children with breakthrough infections or dysfunctional voiding based on history underwent uroflowmetry with concomitant patch electromyography of the external sphincter. Dyssynergia was defined as increased or steady electromyography activity during micturition. Biofeedback was initially performed weekly and the interval increased as indicated. The goals were to eliminate dyssynergia and reduce or eliminate post-void residual urine. Voiding cystourethrography was performed 1 year later to determine the status of the reflux. Ureteral reimplantation was performed during the period of biofeedback when indicated. RESULTS: From February 1997 to March 2001, 25 children 6 to 10 years old (mean age 9) with vesicoureteral reflux and detrusor-sphincter dyssynergia were treated with biofeedback therapy. There were 31 units (5 bilateral) with reflux, which was grade I in 10, II in 15, III in 5 and IV in 1. Children underwent an average of 7 sessions of biofeedback (range 2 to 20). On followup voiding cystourethrography, vesicoureteral reflux resolved in 17 units (55%), grade improved in 5 (16%) and reflux remained unchanged in 9 (29%). All cured vesicoureteral reflux was grade I (8 cases) or II (9). Four children (5 renal units) underwent reimplantation. In cured children there were no breakthrough infections during or since therapy and post-void residual urine decreased from an average of 40% before to 10% after therapy. Symptoms of urgency, daytime wetting and hoarding of urine improved or were eliminated in all children with resolved vesicoureteral reflux. CONCLUSIONS: Treating external detrusor-sphincter dyssynergia in older children with low grade vesicoureteral reflux, with biofeedback results in 1-year resolution rates that are considerably greater than historical resolution rates. External detrusor-sphincter dyssynergia should be screened for in children when surgery or discontinuation of chemoprophylaxis is considered so that biofeedback can be started.

The "long Snodgrass": applying the tubularized incised plate urethroplasty to penoscrotal hypospadias in 1-stage or 2-stage repairs.

PURPOSE: The technique of tubularized incised plate urethroplasty (Snodgrass modification) has gained wide acceptance for hypospadias repair. The reported experience with this surgical modification has been primarily in cases of distal hypospadias. We applied this technique to cases of penoscrotal hypospadias and incised the urethral plate for its entire distance. MATERIALS AND METHODS: In the last 24 months 21 boys 7 months to 8 years old with penoscrotal hypospadias were treated with a Thiersch-Duplay urethroplasty using the Snodgrass modification. The procedure was performed in 7 patients as a primary repair and in 14 at stage 2 of the 2-stage repair. The entire length of the urethral plate was incised along the midline in primary repairs, and the skin flaps and residual urethral plate were incised in the 2-stage repairs. The neourethra was tubularized over a 5 or 8Fr catheter. A layer of de-epithelialized tissue from the dorsal prepuce was used to cover the neourethra. No patient required skin flap to complete the urethroplasty. The urethral stent was removed in 7 to 10 days postoperatively. RESULTS: Of the 21 patients 19 (90%) required no other surgery as the repair provided a normal appearing penis (straight, terminal meatus, cosmetics) without complications such as meatal stenosis, fistula and diverticula, and voiding with a well directed full stream. One child had dehiscence of the glanular portion of the repair and 1 child had a pinpoint fistula, both of which were repaired successfully at a later date. Followup ranges from 5 to 12 months. CONCLUSIONS: The "long Snodgrass" modification to a Thiersch-Duplay repair is an effective technique for penoscrotal hypospadias as a single and 2-stage procedure. The success and complication rates are excellent in the short term. Longer term complications, such as strictures and diverticula, need to be assessed in the future.