Alan D. Perlmutter

Acquired Rectourethral Fistula: Methods of Repair

Rectourethral fistulas are a rare but devastating complication of urinary or rectal surgery, trauma or inflammation. Historically repair has posed a challenge because of technical difficulties and the high incidence of recurrent fistulas. We report 7 cases of acquired rectourethral fistulas of varying etiology (3 after prostatectomy, 3 after trauma and 1 after recurrent perineal abscess), which were managed by various means. Our data and those in the literature suggest that the first attempt at repair is the best and subsequent repairs become increasingly difficult; the York Mason approach allows easy accessibility with minimal risk of complications and the best chance for a functionally successful outcome when a vascularized flap is not required, and some cases may have such a low probability of successful resolution of the fistula as well as maintenance of urinary continence that cystectomy and supravesical diversion are appropriate considerations.

Urinary Tract Deterioration Associated with the Artificial Urinary Sphincter

In most recent series of artificial sphincter implantations there has been a reduction in mechanical and surgical complications, with continence rates approaching 90 per cent. Despite initially excellent results in 47 children, with increasing durations of followup we noted a transient hydronephrosis related to incomplete bladder emptying in 5 and a persistent physiological alteration of detrusor dynamics consisting of a rigid, noncompliant bladder in 7. Preoperatively, all patients had had indepth radiological studies and most had a urodynamic evaluation, and were considered to be excellent candidates. The etiology of these alterations is not understood at this time. Bladder and even upper tract deterioration can occur without the appearance of urinary leakage. Therefore, children with an artificial sphincter must be monitored indefinitely with semiannual assessment of the upper tracts and periodic urodynamic evaluation.

Experience with Free Grafts in Urethral Reconstruction

A total of 33 patients underwent hypospadias or epispadias repair by patch or tubular grafts of skin or bladder epithelium from July 1980 to January 1985. Indications included previous circumcision, proximal primary hypospadias, severe chordee alone, inadequate local skin during extended urethroplasty at 2-stage hypospadias repair, multiple previous reconstructions and failed epispadias repair. Genital skin grafts were used in 25 patients, extragenital skin grafts in 4 and bladder epithelial grafts in 4. Complications occurred in 13 patients (39.4 per cent): 8 required reoperation for a fistula, stricture or diverticulum, and 5 underwent internal urethrotomy or urethral dilation. Of the 8 patients 3 needed more than 1 revision. These revisions were short and generally uncomplicated. Final results uniformly were good functionally and cosmetically. Based on our experience and that of others we believe that despite a high incidence of minor complications a free graft serves as an excellent substitute urethra for treatment of a variety of urethral problems in children.

URINARY TRACT INFECTIONS AND PREGNANCY IN WOMEN WHO UNDERWENT ANTIREFLUX SURGERY IN CHILDHOOD

PURPOSEnFor several decades ureteroneocystostomy has been performed in children to correct primary vesicoureteral reflux. A purported indication for antireflux surgery is to prevent significant upper urinary tract infection during pregnancy. We performed a long-term followup of women who underwent antireflux surgery during childhood to determine outcome in regard to urinary tract infection history and pregnancy.nnnMATERIALS AND METHODSnWe identified 227 women of childbearing age who underwent ureteral reimplantation for primary vesicoureteral reflux from 1964 through 1981. Of the 122 women contacted 41 had been pregnant (77 total pregnancies). Cystitis or asymptomatic bacteriuria and pyelonephritis developed during 18 and 5 pregnancies, respectively. The 77 pregnancies resulted in 57 term births, 7 voluntary pregnancy interruptions and 13 spontaneous abortions.nnnRESULTSnPatients who previously underwent successful antireflux surgery continued to have a significant number of urinary tract infections through the intervening years. Despite a higher than expected incidence of pyelonephritis, they had relatively little hypertension and renal insufficiency. During pregnancy the incidence of pyelonephritis was only slightly higher than that of the general population. However, severe complications of pregnancy, such as preeclampsia, premature birth and acute renal failure, occurred more frequently in women with a history of renal scarring or hypertension (7 of 12) than in those with a history of recurrent infection alone (3 of 10).nnnCONCLUSIONSnWhen renal scarring is present, reflux should be corrected before pregnancy to minimize maternal and fetal morbidity. When scarring is not present, the literature suggests that women with a history of reflux are at increased risk for pyelonephritis during pregnancy whether or not ureterocystostomy was performed. Pregnant women with a history of reflux may benefit from prophylactic antibiotics and women with reflux nephropathy should be followed throughout life.

Tunica Vaginalis Free Graft for the Correction of Chordee

Tunica vaginalis free grafts were used to correct severe chordee not amenable to other surgical maneuvers in 11 boys. Postoperatively, the penis was straight in 10 patients and had some degree of downward angulation in 1 boy. The tunica vaginalis free graft seems to be a useful technique for the correction of severe chordee.

Is There a Best Alternative to Treating the Obstructed Upper Pole

PURPOSEnWe addressed whether salvage of upper pole renal units in comparison to partial nephrectomy affects differential renal function in patients with a duplicated obstructed upper pole.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of all children who underwent surgery for a unilateral obstructed duplicated kidney at our institution from 1988 to 1995. Patients were evaluated with respect to postoperative complications, reoperation rate and percent change in differential renal function of the obstructed duplicated kidney, as determined by nuclear renography.nnnRESULTSnWe identified 46 patients with a unilateral obstructed upper pole of a duplicated kidney who were divided into 2 groups. Group 1 (12 patients) underwent an upper pole salvage procedure, that is ureteropyelostomy or ureteroureterostomy, and group 2 (31 patients) underwent partial nephrectomy. Three reoperations (25%) were performed in group 1 and 1 (4%) was done in group 2. Postoperative symptomatic urinary tract infections were diagnosed in 3 group 1 patients (25%) and in 2 (8%) in group 2. Average change in ipsilateral renal function in the 8 patients who underwent upper pole salvage procedures was 2.25 +/- 2.34% (range -6 to 12). In the 8 patients who underwent upper pole nephrectomy and who also had postoperative renal scans average change in function was -1.25 +/- 4.51% (range -23 to +16).nnnCONCLUSIONSnThere was no statistically significant loss of relative renal function in patients treated with partial nephrectomy and no significant gain in relative renal function in those treated with an upper pole salvage procedure. The reoperation rate was higher in the upper pole salvage than in the partial nephrectomy group (25 versus 4%). While not statistically significant, we believe that this rate is clinically important. We think that partial nephrectomy should remain the preferred treatment for most patients with obstructed duplicated kidneys.

The Role of Adjunctive Drug Therapy for Intermittent Catheterization and Self-Catheterization in Children with Vesical Dysfunction

Thirty-nine children with vesical dysfunction were managed with clean intermittent catheterization. Most children achieved effective urinary continence, the majority with the help of adjunctive drug therapy to relax the detrusor, contract the bladder neck or both. Intermittent catheterization had a generally favourable effect on infection, reflux and hydronephrosis. Intermittent catheterization in childhood is a perferred alternative to urinary diversion in cases of neurogenic bladder dysfunction.

Early Cystometrograms Can Predict the Response to Intravesical Instillation of Oxybutynin Chloride in Myelomeningocele Patients

Recent reported experiences with intravesical medications in neurogenic bladder patients prompted us to evaluate this form of therapy in 28 myelomeningocele patients who could not tolerate oral anticholinergic agents or did not have adequate control on these agents. A pretreatment cystometrogram was performed followed by intravesical administration of oxybutynin chloride, with a repeat cystometrogram 3 hours later. Patients then began twice daily intravesical oxybutynin for a minimum of 4 months. The mean bladder capacity increased by 41%, the mean intravesical pressure decreased by 47% and compliance improved. Five patients achieved continence and 62% had less wetting while on intravesical therapy. The immediate posttreatment cystometrogram was predictive of the response to intravesical therapy on followup studies. Unfortunately, patient compliance was poor, with only 13 of the 28 patients remaining on therapy for the duration of the study.

Progressive penile amputation: Tourniquet injury secondary to hair

In the past three years we have treated 5 cases of penile strangulation secondary to entrapment by human hair in the coronal groove. All patients had been circumcised and were between fourteen months and five years of age. Total urethral transection occurred in 2 children. Their presentation and our method of management are discussed.

Priapism Associated with Sickle Cell Hemoglobinopathy in Children: Long-Term Effects on Potency

PURPOSEnChildren with sickle cell priapism have traditionally been treated conservatively with surgery done as a last resort. Only sparse subjective data are available on the long-term assessment of potency in these patients.nnnMATERIALS AND METHODSnWe retrospectively reviewed the charts of all pediatric patients with sickle cell priapism who presented to Childrens Hospital of Michigan between 1972 and 1992, and subsequently assessed erectile capabilities subjectively by questionnaire and objectively by RigiScan.nnnRESULTSnOf the 15 patients interviewed 5 had undergone shunt procedures. The return of potency tended to vary inversely with patient age at onset and duration of priapism.nnnCONCLUSIONSnShunts performed within 48 hours, especially in postpubertal children, seemed more likely to preserve potency.