Ipsilateral ureteroureterostomy for the treatment of vesicoureteral reflux or obstruction associated with complete ureteral duplication.

PURPOSE: We reviewed our experience with ureteroureterostomy as definitive treatment for vesicoureteral reflux or obstruction associated with ureteral duplication to determine the efficacy and morbidity of this procedure and identify factors that affect outcome. MATERIALS AND METHODS: We performed a total of 100 ureteroureterostomies in 94 children with an average age of 28 months during the 23-year period ending May 1999. Four patients (4 kidneys) failed to return for postoperative evaluation. Followup was 2.5 to 206 months (mean 33). Indications for surgery were vesicoureteral reflux in 53 cases, obstructing ureterocele in 19, ureterocele with upper pole reflux in 4, an ectopic obstructed upper pole ureter in 18 and other in 2. In 23 kidneys ureteroureterostomy was combined with reimplantation of the recipient ureter. Surgery was considered successful when postoperative imaging revealed no reflux or obstruction and a patent ureteroureterostomy anastomosis. RESULTS: Ureteroureterostomy with or without ureteroneocystostomy was successful for treating 94% of kidneys, including 51 of 53 with reflux, 21 of 23 (91%) with ureterocele and 17 of 18 (94%) with an ectopic obstructed upper pole ureter. Significant ureteral size disparity, defined as a donor ureter diameter greater than 2-fold that of the recipient ureter, was noted in 69 kidneys. The most common complication (13 patients) was prolonged output from the Penrose drain. However, this complication did not result in a failed procedure in any case. CONCLUSIONS: Ipsilateral ureteroureterostomy is safe and efficacious for treating abnormalities associated with ureteral duplication. A significant discrepancy in ureteral size does not preclude ureteroureterostomy.

Megacystis microcolon intestinal hypoperistalsis syndrome: bladder distension and pyelectasis in the fetus without anatomic outflow obstruction.

We report a case of a 46,XY male infant with a history of normal amniotic fluid levels who was delivered by elective cesarean section at 38.5 weeks' gestation because of progressive bladder distension, hydroureteronephrosis, and what was thought to be a dilated posterior urethra. The child died at 19 days of age of cardiovascular complications. The autopsy revealed megacystis, bilateral megaureters and pyelocaliectasis, congenital absence of ganglion cells in the bladder wall, renal dysplasia, and a microcolon. No dilation or anatomic obstruction of the posterior urethra was found. These findings strongly suggest the diagnosis of megacystis microcolon intestinal hypoperistalsis syndrome. We discuss the ultrasound findings of in utero bladder distension with hydronephrosis and one of its rare etiologies.

Unenhanced computerized axial tomography to detect retained calculi after percutaneous ultrasonic lithotripsy.

PURPOSE: We report our experience with unenhanced computerized axial tomography (CT) after percutaneous ultrasonic lithotripsy in patients thought to be at high risk for retained calculi. MATERIALS AND METHODS: CT was obtained in 121 patients (124 kidneys) within 12 to 36 hours of percutaneous ultrasonic lithotripsy for staghorn or large nonstaghorn renal calculi. Cases were grouped according to the CT findings as no retained calculi, insignificant retained calculi (fragments 1 to 3 mm.), retained calculi amenable to shock wave lithotripsy and retained fragments requiring second look percutaneous ultrasonic lithotripsy or flexible nephroscopy. RESULTS: No calculi were seen in 73 kidneys (59%) and retained calculi were identified in 51 (41%). Shock wave lithotripsy was used to treat 8 patients and another percutaneous ultrasonic lithotripsy or flexible nephroscopy was performed in 23 to remove retained stones. Insignificant calculi were noted in the remaining 21 patients. CONCLUSIONS: We believe that postoperative unenhanced CT is superior to plain renal tomography and is the best method to determine if a patient is stone-free after percutaneous ultrasonic lithotripsy. It helps to locate precisely those stones requiring a second percutaneous ultrasonic lithotripsy or nephroscopic extraction. An unenhanced renal CT devoid of calculi obviates routine postoperative second look flexible nephroscopy. We encourage others to consider this technique to define more accurately kidney stone status after percutaneous ultrasonic lithotripsy for large staghorn calculi or in any patient at high risk for retained calculi after percutaneous ultrasonic lithotripsy.

Kidney transplantation in children: a single center experience.

PURPOSE: We reviewed our most recent 10-year experience with kidney transplantation in children to determine the morbidity and mortality of the procedure, and to identify factors that affected outcome. MATERIALS AND METHODS: A total of 107 renal transplants were done in 95 children 1 to 17 years old (mean age 10.9) during the 10-year period ending January 1, 1997. The 4 most common causes of end stage renal disease were renal dysplasia, reflux nephropathy, obstructive uropathy and systemic immunological diseases. Cyclosporine based immunosuppression was used in all but 2 recipients. After April 1991 antilymphocyte antibody induction, coagulopathy screening, systemic anticoagulation and cytomegalovirus prophylaxis were incorporated into the protocols. The effects of kidney source, recipient gender, recipient age, preformed anti-HLA antibody level, preemptive renal transplantation, cytomegalovirus risk, antilymphocyte antibody induction therapy and date of renal transplantation on kidney graft survival were examined with the log rank test. RESULTS: The 1-year graft and patient survival rates were 91 and 99%, respectively. The most common causes of graft failure were rejection and recurrence of primary renal disease. The only factors that significantly (p < 0.05) influenced graft survival were antilymphocyte antibody induction immunosuppression and kidney transplantation after April 1991. Three urological complications required surgical correction. Medical morbidity included hypertension in 48.6% of the cases, short stature in 46.6% and obesity in 58.9%. CONCLUSIONS: Pediatric renal transplantation can be done with acceptable morbidity, a low rate of technical complications and low mortality. Hypertension, chronic rejection and abnormal body habitus continue to be problematic.

A rational approach to managing stage I nonseminomatous germ cell cancer.

Regardless of the treatment option selected for management of low-stage germ cell cancer, ultimate survival is nearly identical. Treatment-related morbidity is very low regardless of management modality and the individual patient can expect similar physical limitations owing to therapy. The overall difference in loss of productivity between treatment programs varies by little more than 1 week. The cost of treatment is similar for all methods, although there is a definite financial advantage to surveillance, less so for selective surveillance, when compared with other forms of management. Socioeconomic factors are of importance when managing limited resources for a large population, but are of less concern to an individual, especially when the mean differences in per patient costs vary by only $5000. Because of these close similarities in efficacy, morbidity, and costs treatment decisions should be individualized. A responsible and reliable patient can be managed safely by selective surveillance. Those individuals considered to be less self-motivated to pursue intensive care should be managed by primary therapy. Without more information regarding the long-term outcomes associated with primary adjuvant chemotherapy, primary adjuvant RPLND, where experienced surgical support is available, is the preferred management for low-stage germ cell cancer in patients selected for, or electing, active treatment rather than surveillance. Active investigations examining the role of medical management in this population should be continued. Our preferred choice of initial management is to offer selective surveillance to appropriate patients and modified RPLND to the remainder.

Urologist-acquired renal access for percutaneous renal surgery.

OBJECTIVES: In most endourology programs an interventional radiologist is employed to acquire renal access for percutaneous renal surgery. Over the last 13 years the senior endourologist at Oregon Health Sciences University has acquired access without employing a radiologist. We report our experience with urologist-acquired renal access for percutaneous renal surgery in 522 cases. METHODS: We reviewed the records of all patients at our hospital who underwent percutaneous renal surgery between August 1983 and December 1996 with renal access being obtained in the operating room by a urologist. RESULTS: Four hundred fifty-six patients underwent 522 procedures. Indications for percutaneous renal surgery were renal and proximal ureteral calculi (n = 516), retained ureteral stent (n = 3), and intrarenal collecting system tumor (n = 3). We were successful in gaining access to 513 of 522 kidneys (98.3%). Access was obtained via a subcostal approach in 344 procedures, over the 12th rib in 152 procedures, over the 11th rib in 15 procedures, and transabdominally in 2 procedures. Sixty-five patients (12.7%) required a second or multiple sites to facilitate complete removal of calculi. Our overall complication rate was 15.3%. Blood transfusion was required in 5.4% of the cases, ileus developed in 1.9%, pneumothorax in 1.1%, intraoperative hydrothorax in 1.1%, postoperative pleural effusion requiring aspiration in 0.9%, and septic shock in 0.9%. Our overall success rate for stone removal was 94.5%. CONCLUSIONS: In our experience, the urologist is able to safely and effectively obtain percutaneous access to the collecting system for percutaneous renal surgery as a one-stage procedure without the aid of interventional radiologists.

Bleeding ileal conduit stomal varices: diagnosis and management using transjugular transhepatic angiography and embolization.

An uncommon complication of ileal conduit urinary diversion is bleeding varices at the stoma site. Variceal formation is a complication of portal hypertension, which is most commonly due to intrinsic liver disease. Problematic recurrent bleeding is usually managed locally or by portosystemic shunt. We report a case of recurrent, massive ileal conduit variceal hemorrhage in a patient without a significantly elevated portosystemic gradient. Therefore, this patient was not a candidate for a shunt procedure. Using a transjugular transhepatic approach to the portal vein, the varices were embolized to stasis without any complications. The patient has subsequently experienced no further bleeding episodes.