Brian E. Hardy

Acquired Renal Scars in Children

To determine the important factors involved in the etiology of renal scarring we studied 37 children with renal scars seen at our hospital since 1965. This is the second largest series reported to date. Children who had neurogenic bladders or any structural abnormalities of the urinary tract other than vesicoureteral reflex were excluded. The study group included 36 girls and 1 boy. The average age at first detection of renal scars was 5.7 years. Acute pyelonephritic episodes, which were treated early and aggressively, infrequently led to renal scarring. However, the initial prolonged or poorly treated episode of acute pyelonephritis was followed invariably by the development of renal scarring. The severity of renal scarring was related to the grade of vesicoureteral reflux (p less than 0.05), although some scars did develop in the absence of reflux. Neither the shape and position of the ureteral orifice nor the ureteral tunnel length correlated with the severity of renal scarring. Treatment with prophylactic antibiotics may have lessened the severity of renal scarring (0.1 less than p less than 0.2) but treatment with reimplantation surgery did not appear to alter the course of renal scarring. This study suggests that the key to the prevention of renal scarring is the early and aggressive treatment of acute pyelonephritis.

Surgery for anomalies of the urachus

Thirty-five children with anomalies of the urachus which have required surgical management have been encountered in this institution over a 20-year period. Of these 35, 19 were classified as patent urachus, 12 as urachal cyst, and 4 as urachal sinus. All cases were treated by excision or drainage. There was one death. Gastrointestinal and other genitourinary anomalies were commonly seen in these patients. Intravenous pyelography was helpful in identifying unsuspected associated genitourinary anomalies while cystography was not. Investigation of the gastrointestinal tract does not appear to be warranted in the absence of symptoms.

The Effects of Extracorporeal Shock Wave Lithotripsy on Renal Growth, Function and Arterial Blood Pressure in an Animal Model

The long-term effects of extracorporeal shock wave lithotripsy (ESWL*) on children treated for renal calculi are unclear. To study the long-term bio-effects of this mode of treatment on the immature animal we evaluated 30 New Zealand white rabbits at 7 weeks of age for weight, serum blood urea nitrogen and creatinine, and arterial blood pressure after which they underwent left nephrectomy. Each group of 5 rabbits received ESWL of varying levels (500 to 3,000 shock waves) to the remaining right kidney using the Northgate SD3 lithotriptor (spark gap mediated). One control group received no shock waves. At maturity (16 weeks) the aforementioned parameters were measured again, and the kidneys and any grossly abnormal adjacent organs were examined. We found no significant change in total animal growth, renal growth, renal function or perirenal organs in the post-ESWL groups versus the control group. All post-ESWL groups had an increase in mean arterial blood pressure versus the control group with 3 of 6 groups showing significant increases (p less than 0.05). Histological renal changes, seen at all energy levels of ESWL delivered, included interstitial fibrosis, tubular atrophy, glomeruli destruction, capsular thickening, perivascular fibrosis and mild arteriole wall thickening. Changes were proportional to the number of shocks received. We conclude that ESWL delivered to immature animals does not significantly affect renal growth and function but it can cause significant permanent histological renal changes even at low doses and may result in an increase in adult mean arterial blood pressure.

Risk factors for short- and long-term survival of primary cadaveric renal allografts in pediatric recipients: a UNOS analysis.

Background. Pediatric kidney graft survival rates have improved in the United States. This study evaluates early and late risk factors for cadaveric graft loss in pediatric recipients. Methods. From January 1994 to December 2002, 2,597 primary cadaveric kidney-alone transplants (donor age 5-45 years, recipient age 2–20 years) were reported to the United Network for Organ Sharing (UNOS). The analysis includes follow-up information based on OPTN data as of October 14, 2003. Odds ratio of early graft loss and relative risk of late graft loss are estimated using logistic regression and Cox proportional hazards model, respectively. Results. Graft survival rates significantly improved during 1999–2002 (95% and 79% at 1-year and 3-years, respectively) compared with those of 1994–1998 (88% and 76% at 1-year and 3-years, respectively) (log rank P = 0.02). After adjusting for other variables, the factors that significantly affected early transplant outcome adversely within 3 months posttransplant were prolonged cold ischemia time (>36 hours, odds ratio [OR] = 3.38 vs. 0–36 hours) and young recipient age (2–5 years old, OR = 2.02 vs. 6–12 years). Beyond 3 months, significant risk factors were African-American recipients (relative risk [RR] = 1.93 vs. others), teenage recipients (13–20 yrs, RR = 1.50 vs. 6–12 yrs), and patients with focal glomerulosclerosis (FGS) (RR = 1.27 vs. others). Conclusions. The short-term graft survival rate of pediatric cadaveric kidney transplants has significantly improved, yet the long-term outcome has changed little. The long-term outcomes for teenagers (13–20 yrs), patients with FGS, and African-Americans lag significantly behind other groups. In order to improve long-term graft survival in these high-risk patients, newer preventive or treatment strategies must be developed.

Adrenal hemorrhage in neonates: report of 5 cases and review of the literature.

Abstract The differential diagnosis of masses in the suprarenal area in neonates is discussed in relation to clinical, laboratory and radiologic findings. Neonatal adrenal hemorrhage can be accurately diagnosed clinically. In the neonate neuroblastoma in situ is self-limiting and exploration to exclude it is unnecessary. Operative intervention should be reserved for controlling massive adrenal hemorrhage or if an abscess forms

Human capital gains associated with robotic assisted laparoscopic pyeloplasty in children compared to open pyeloplasty.

PURPOSE Robotic assisted laparoscopic pyeloplasty is an emerging, minimally invasive alternative to open pyeloplasty in children for ureteropelvic junction obstruction. The procedure is associated with smaller incisions and shorter hospital stays. To our knowledge previous outcome analyses have not included human capital calculations, especially regarding loss of parental workdays. We compared perioperative factors in patients who underwent robotic assisted laparoscopic and open pyeloplasty at a single institution, especially in regard to human capital changes, in an institutional cost analysis. MATERIALS AND METHODS A total of 44 patients 2 years old or older from a single institution underwent robotic assisted (37) or open (7) pyeloplasty from 2008 to 2010. We retrospectively reviewed the charts to collect demographic and perioperative data. The human capital approach was used to calculate parental productivity losses. RESULTS Patients who underwent robotic assisted laparoscopic pyeloplasty had a significantly shorter average hospital length of stay (1.6 vs 2.8 days, p <0.05). This correlated with an average savings of lost parental wages of

Neurogenic bladder in infants born with anorectal malformations: Comparison with spinal and urologic status

90.01 and hospitalization expenses of

Surgical treatment of testicular trauma: Effects on fertility and testicular histology

612.80 per patient when excluding amortized robot costs. However, cost savings were not achieved by varying length of stay when amortized costs were included. CONCLUSIONS Robotic assisted laparoscopic pyeloplasty in children is associated with human capital gains, eg decreased lost parental wages, and lower hospitalization expenses. Future comparative outcome analyses in children should include financial factors such as human capital loss, which can be especially important for families with young children.

Laparoendoscopic single-site nephrectomy in pediatric patients: initial clinical series of infants to adolescents.

BACKGROUND/PURPOSE Spinal dysraphism and neurovesical dysfunction (NVD) frequently are associated in children with anorectal malformations (ARM). This study compares the urodynamic data from a selected group of patients with the results of their spinal and urologic imaging studies. METHODS Twenty-six children (20 with isolated imperforate anus and six with persistent cloacal malformations) were investigated. All patients were evaluated with leak point pressures (LPP), renal ultrasound scan, and voiding cystourethrography. Eight children had urodynamics performed before and after posterior sagittal anorectoplasty (PSARP). The spinal cord was assessed using ultrasonography or magnetic resonance imaging. Current urologic status was obtained to provide long-term follow-up. RESULTS Twenty-one of 26 children demonstrated elevated LPPs above the established normal value of 40 cm H2O, and 15 of these children had normal spinal imaging study findings. Uroradiographic studies findings showed that 12 of 21 children with elevated LPPs had hydronephrosis or vesicoureteral reflux with seven of these patients having normal spinal cords. LPPs in the eight patients with pre- and postoperative studies were 74 +/- 14.7 cm H2O and 68 +/- 31.8 cm H2O (mean +/- SD), respectively. CONCLUSIONS These urodynamic and radiographic data confirm that NVD (elevated LPP) is common in patients with anorectal malformations despite normal spinal cords. Bladder dysfunction does not appear to be a sequelae of a properly performed PSARP. Patients with ARM and any uroradiographic or clinical urologic abnormality should undergo urodynamic testing even though the spinal studies are normal.

Bladder Wall Pedicle Wraparound Sling for Neurogenic Urinary Incontinence in Children

Unilateral testicular trauma in the postpubertal male can lead to alterations in semen analysis, but it is not clear what effect this has on fertility. To better understand how surgical treatment of testicular trauma affects both fertility and testicular histology the following study was performed. Eighty postpubertal Lewis rats were divided into eight equal groups with one group serving as a control. In the 70 remaining rats the left testicle was subjected to blunt or penetrating injury. The testicles were either left untreated, were removed, or were repaired with sutures or mesh before being returned to the scrotum. Following recovery, each male was allowed to mate to determine fertility. Fertility rates were significantly lower in all postinjury groups except the postinjury orchiectomy group. Histological analyses showed nonspecific inflammation, smaller tubules, and impaired spermatogenesis in all postinjury testicles regardless of the type of treatment. Contralateral testicles had no evidence of autoimmune injury and were essentially identical to the control group. In the postpubertal Lewis rat, unilateral testicular trauma leads to impaired fertility unless the injured testicle is removed soon after the injury. Various methods of repairing the injury did not improve fertility. In spite of the impaired fertility, the contralateral testicle appears histologically normal.