Gunshot wounds to the ureter: a 40-year experience at Grady Memorial Hospital.

PURPOSE: Because of the morbidity associated with missed ureteral injuries, a high index of suspicion must be present to diagnose this type of injury. We reviewed our 40 years of trauma experience at Grady Memorial Hospital. MATERIALS AND METHODS: We retrospectively reviewed the records of 118 patients with ureteral injuries secondary to a gunshot wound to the ureter from 1960 to 1999. All cases were reviewed for the mechanism of injury, location, initial urinalysis, imaging modalities, associated injuries, operative procedures and complications. RESULTS: Our population consisted of patients 14 to 71 years old, of whom 66 had right ureteral, 51 had left ureteral and 1 had bilateral injury. Urinalysis revealed no evidence of blood in the urine in 15% of the patients in whom the test was performed. Excretory urography had a false-negative rate of 33%. The injury was located at the proximal, mid and distal ureter in 43, 38 and 37 cases, respectively. Multiple surgical approaches were used depending on the location and severity of the defect. Only 1 patient had an isolated ureteral injury, while the remainder had associated injuries. Complications were present in 24 cases. CONCLUSIONS: To our knowledge this series of ureteral injuries is the largest reported to date. Because preoperative urinalysis and imaging studies are unreliable for ruling out injury, a high index of suspicion must be present. Furthermore, a predefined trauma protocol, as defined in our algorithm, decreases the number of missed ureteral injuries that may potentially complicate the outcome of an already critical case.

Vaginal reconstruction using a vertical rectus abdominis myocutaneous flap in a child: a case report.

Rhabdomyosarcoma is the most common soft tissue sarcoma in infants and children younger than 15 years old. Multimodal treatment using chemotherapy, radiation, and surgery have increased survival. Because of the potential for long-term survival, the importance of organ preservation and vaginal and pelvic reconstruction has been recognized. The authors report a case in which special circumstances led to vaginal reconstruction concomitantly with exenteration surgery. The authors present the first reported use of a vertical rectus abdominis myocutaneous flap in a child and describe the technique and its potential advantages.

Antenatal hydronephrosis with postnatal resolution: how long are postnatal studies warranted?

We present 2 cases of antenatal hydronephrosis with initial normalization of postnatal studies. Both patients experienced late-onset (6 and 22 months) hydronephrosis secondary to ureteropelvic junction obstruction, necessitating surgical intervention. These cases raise questions about the need for late follow-up imaging in patients with apparent resolution of hydronephrosis diagnosed antenatally.

In utero intervention in a patient with prune-belly syndrome and severe urethral hypoplasia.

Prenatal ultrasound scanning of a 20-year-old woman at 17 weeks of gestation revealed findings suggestive of bladder outlet obstruction, including bladder distension, dilated bilateral ureters, urinary ascites, and oligohydramnios. Vesicoamniotic shunts were placed with decompression of the bladder and correction of the amniotic fluid levels. Labor was induced at 36 weeks' gestation. At birth, the infant was noted to have prune-belly syndrome with severe urethral hypoplasia, a variant usually associated with a poor prognosis, necessitating vesicostomy for bladder drainage. We present a case of a patient with prune-belly syndrome and bladder outlet obstruction in whom early intervention resulted in an excellent outcome with preservation of renal and pulmonary function.

Pseudohypoaldosteronism associated with ureterocele and upper pole moiety obstruction.

A 2-month-old girl was diagnosed with a febrile urinary tract infection. Subsequent studies revealed a right renal duplication anomaly with a poorly functioning upper pole moiety subtended by an intravesical ureterocele. The patient was also found to have hyperkalemia, hyponatremia, and elevated serum aldosterone. After antibiotic therapy, the urinary tract infection resolved, although the electrolyte and hormonal abnormalities persisted. At 4 months of age, a right upper pole heminephrectomy was performed. The patient's electrolyte and hormonal levels normalized. This case represents an unusual case of pseudohypoaldosteronism presenting with urinary tract infection and obstructed upper pole moiety that resolved after surgical intervention.

Increased incidence of hypospadias in small-for-gestational age infants in a neonatal intensive-care unit.

OBJECTIVE: To identify the incidence of hypospadias in children born prematurely and small-for-gestational age (SGA), and to compare this subgroup with infants of similar age and weight without hypospadias. PATIENTS AND METHODS: Records from the neonatal intensive-care unit (NICU) of a major metropolitan hospital active in labour and delivery were reviewed over a 3-year period, specifically examining newborns admitted with the diagnosis of SGA, defined as a birth weight of < 10th percentile for gestational age. In all, 154 patients were identified and their charts reviewed, recording the presence and severity of hypospadias, gestational age, birth weight, placental weight, cord length, cord vessels, maternal age, parity, multiple births, drug exposure and associated comorbidity. A control group of age- and weight-matched infants without hypospadias were also identified and compared. RESULTS: Of the 154 patients, 17 (11%) had hypospadias; the hypospadias was distal in nine, mid-shaft in four and proximal in four. The severity of hypospadias did not correlate with the degree of prematurity or weight for gestational age. Placental weight, fetal weight, fetal to placental weight ratio and cord length were all lower in the hypospadias group than in the control group, but the differences were not statistically significant. The maternal age was evenly distributed (median 32 years, range 20-43). Most mothers were multiparous and births were multiple in five of 17 (30%). Cryptorchidism (three) and inguinal hernia (three) were present in four of the infants. CONCLUSIONS: The incidence of hypospadias in SGA infants admitted to the NICU is > 10 times higher than that reported for the general population. There was a trend to lower placental and fetal weight in SGA infants with hypospadias than in the controls. This finding merits further evaluation using a larger population database and suggests that factors resulting in SGA infants occur at a critical point early in development, affecting both somatic and urethral development.