Charles B. Manley

Pediatric Endopyelotomy: The Washington University Experience

PURPOSE Endopyelotomy has gained acceptance as minimally invasive therapy for ureteropelvic junction obstruction in adults. Its role in the treatment of pediatric ureteropelvic junction obstruction remains controversial. We report our experience with antegrade endopyelotomy for treating pediatric ureteropelvic junction obstruction. MATERIALS AND METHODS A total of 17 patients 3 months to 17 years old underwent endopyelotomy as primary treatment for ureteropelvic junction obstruction (8) and after failed open pyeloplasty with secondary endopyelotomy performed a mean of 12 weeks after open pyeloplasty (9). Standard antegrade percutaneous techniques were used. Electrosurgical incision of the ureteropelvic junction at a posterolateral orientation was done in each case. Internal ureteral stents remained in place for 4 to 6 weeks postoperatively. RESULTS In 5 of the 8 patients (62%) treated primarily the outcome was successful at a mean followup of 38 months (range 25 to 53). Failures occurred at 6 weeks, 3 months. In all 9 patients treated secondarily outcomes were successful at a mean followup of 59 months (range 16 to 110). CONCLUSIONS Endopyelotomy as primary treatment of pediatric ureteropelvic junction obstruction remains controversial but it may be appropriate in select cases. On the other hand, endopyelotomy is safe and effective for pediatric patients in whom open pyeloplasty fails.

Endopyelotomy for Secondary Ureteropelvic Junction Obstruction in Children

Percutaneous endopyelotomy has been shown to be successful in treating ureteropelvic junction obstruction in adults. Little data have been published regarding this procedure in children. We describe 4 patients 6.5 weeks to 5.5 years old who underwent percutaneous endopyelotomy to treat ureteropelvic junction obstruction following failed open dismembered pyeloplasty. Preoperative obstruction was demonstrated by a nephrostogram, diuretic renogram and/or ultrasonography. Percutaneous endopyelotomy was successful in relieving the obstruction in all 4 patients, although 2 required secondary endoscopic procedures. One patient had persistent obstruction 40 days after endopyelotomy at the ureteropelvic junction and, subsequently, required percutaneous resection of a persistent flap of obstructing tissue. In another patient a ureterovesical stricture was noted at the time of stent removal, which was treated by endoscopic incision. All patients have been followed from 1.5 to 3 years postoperatively. Followup diuretic renograms, ultrasound and/or excretory urography demonstrated a patent ureteropelvic junction in all patients and all have remained asymptomatic. Endopyelotomy appears to be safe and effective in treating secondary ureteropelvic junction obstruction in children.

Percutaneous nephrostomy: indications, complications and clinical usefulness.

Our experience with percutaneous nephrostomy in 22 patients is presented. This procedure can be accomplished readily and is safe, reliable and effective for short and long-term urinary diversion in various urologic conditions in children and adults.

Caudal Epidural Anesthesia Reduces Blood Loss During Hypospadias Repair

AbstractWe studied 24 boys who were randomized to receive caudal epidural anesthesia with 0.33ml. kg.-1 0.25% bupivacaine either before (group A) or after (group B) Mathieu repair of distal hypospadias. The 2 groups did not differ in regard to age or weight, and all boys received a standardized anesthetic with halothane and nitrous oxide in oxygen. Intraoperative blood loss was measured with sponge weights and microcalibrated suction canisters. Halothane requirements were reduced in group A (0.5 versus 1.1 plus or minus 0.1%, p <0.001). Measured blood loss was reduced in group A (16 plus or minus 10ml. versus 31 plus or minus 17ml., p <0.01). Operating time was reduced in group A (92 plus or minus 13 minutes versus 103 plus or minus 14 minutes, p <0.05). There was no apparent difference in postoperative pain relief between the 2 groups. We conclude that caudal epidural anesthesia can reduce blood loss and improve surgical conditions during hypospadias repair.

Transitional cell carcinoma of bladder in children and adolescents

Transitional cell carcinoma of the bladder is rare in patients under sixteen years of age. A case is described in a ten-year-old boy, and the literature is reviewed. The diagnosis and treatment of this tumor is the same in childhood as in older patients. Recurrence as well as death have been reported in this age group; therefore, these patients warrant careful long-term follow-up.

Cystic dysplasia of the testis. Sonographic features with pathologic correlation

Testicular cysts are an uncommon in the pediatric population unlike adults where they occur frequently. We describe a case of cystic dysplasia of the testis in a prepubertal boy. The known literature is reviewed and the sonographic appearance of the lesion is correlated with pathologic findings.

ISCHIOPAGUS TETRAPUS TWINS : UROLOGICAL ASPECTS OF SEPARATION AND 10-YEAR FOLLOWUP

Conjoined twins occur once in 50,000 births. Only 6% of conjoined twins are of the ischiopagus type in which the twins are joined symmetrically at the pelvis and fusion begins at the level of the common umbilicus. The longitudinal axis extends in a straight line in opposite directions and the genitourinary and gastrointestinal tracts are shared. Tetrapus is a subtype in which all 4 lower extremities are present and oriented at right angles to the axis of the common trunk. Two sets of female ischiopagus tetrapus twins were born in 1977 and successfully separated at the St. Louis Childrens Hospital in the following year. We describe the genitourinary and associated anomalies, surgical separation and long-term urological followup of these 2 sets of ischiopagus tetrapus twins.

Asymptomatic Progression of Partial Ureteropelvic Obstruction in Children

We report 2 cases of ureteropelvic obstruction, 1 of which was congenital and the other was postoperative with asymptomatic deterioration of the involved kidney.

Acute urinary retention caused by vesical diverticula.

Two children with acute urinary retention due to obstructing bladder diverticula are presented. This is an extremely rare but significant complication of congenital bladder diverticulum. The possible mechanisms of this complication are discussed. Voiding cystourethrography can provide the correct diagnosis.

Accessory Scrotum Located on the Distal Penile Shaft

CASE REPORT An 8-year-old white boy presented for evaluation of a penile lesion that had been present since birth. He had previously been circumcised. Examination revealed a large bilobate structure with a normal rugated scrotal appearance attached to the left side of an otherwise normal phallus (see figure). There was also a normally placed scrotum that contained descended testicles. Abdominal, pelvic and scrotal ultrasound showed normal kidneys and bladder. The structure was empty. Cystourethroscopy at surgery revealed no communication with the urinary tract. The lesion was excised around its irregular base and plastic repair of the skin defect on the phallic shaR was performed. Histological examination revealed connective tissue intermingled with smooth muscle fibers, suggestive of tunica dartos and consistent with scrotal tissue.