Charles E. Hawtrey

Pediatric Vesicoureteral Reflux Guidelines Panel Summary Report on the Management of Primary Vesicoureteral Reflux in Children

PURPOSE The American Urological Association convened the Pediatric Vesicoureteral Reflux Guidelines Panel to analyze the literature regarding available methods for treating vesicoureteral reflux diagnosed following a urinary tract infection in children and to make practice policy recommendations based on the treatment outcomes data insofar as the data permit. MATERIALS AND METHODS The panel searched the MEDLINE data base for all articles from 1965 to 1994 on vesicoureteral reflux and systematically analyzed outcomes data for 7 treatment alternatives: 1) intermittent antibiotic therapy, 2) bladder training, 3) continuous antibiotic prophylaxis, 4) antibiotic prophylaxis and bladder training, 5) antibiotic prophylaxis, anticholinergics and bladder training, 6) open surgical repair and 7) endoscopic repair. Key outcomes identified were probability of reflux resolution, likelihood of developing pyelonephritis and scarring, and possibility of complications of medical and surgical treatment. RESULTS Available outcomes data on the various treatment alternatives were summarized in tabular form and graphically, and the relative probabilities of possible outcomes were compared for each alternative. Treatment recommendations were based on scientific evidence and expert opinion. The panel concluded that only a few recommendations can be derived purely from scientific evidence of a beneficial effect on health outcomes. CONCLUSIONS For most children the panel recommended continuous antibiotic prophylaxis as initial treatment. Surgery was recommended for children with persistent reflux and other indications, as specified in the document.

Device for control of female urinary incontinence

pain, gave increasing doses of mnorphine to a moribund patient, he knew that the patient would die from respiratory failure. Technically, therefore, he was guilty of murder. With advances in medicine, however, potent analgesics might be found which did not depress respiration. If, then, a doctor gave increasing doses of morphine to a patient with an incurable or terminal illness, he was open to prosecution and possibly a prison sentence. Under these circumstances doctors might want euthanasia legalized. Professor Williams agreed that patients who were severely ill, or in acute pain or discomfort, and who were unlikely to recover, should be offered euthanasia. Legislation could be introduced for a short period only in order to assess its effects. Safeguards, however, would be necessary, since old people who were a burden to others might be induced to sign away their lives, or a patient who gave consent might not have been of sound mind at the time. Forgery and coercion were also possible.

Urological Injury and Assessment in Patients with Fractured Pelvis

Of 200 patients with pelvic fractures 32 (25 male and 7 female patients) had urological injury. Of these 32 patients 31 had pubic ramus or symphyseal fractures: 29 had gross hematuria and a urine specimen was not obtained in 2. Only 1 of 77 patients with microscopic hematuria had serious urological injury. We believe that excretory urography is not necessary in all cases of pelvic fracture, and that urethrography and cystography are indicated only in cases of gross hematuria or when other clinical signs indicate a high likelihood of bladder or urethral trauma.

Cryosurgery in prostatic cancer: Survival

From 1969 through 1976 we performed cryosurgery in 229 cases of prostatic cancer. This article presents survival in cryosurgery and other treatment groups. In every stage, despite a preponderance of large primary tumors and poor-risk patients, cryosurgery matched total prostatectomy and compared favorably to other modalities, including radiation therapy, at our center and elsewhere. According to previous authors, and in view of the present data, eradication of the local lesion is associated with better survival even in advanced cases. Cryosurgery provides a safe, effective method.

A Comparison Between Lymphangiography and Pelvic Node Dissection in the Staging of Prostatic Cancer

On 40 consecutive patients with prostatic cancer who had pedal lymphangiography during the initial evaluation and, subsequently, underwent pelvic node dissection or biopsy, a surprisingly high number had falsely positive (59 per cent) or negative (36 per cent) x-ray findings. Initially the tumors were considered clinically to be stage B in 24 cases, stage C in 13 and stage D in 3. After lymph node dissection only 17 tumors were still considered to be stage B and 7 were stage C, while 16 tumors were actually stage D. This surgical staging is important for the further management of the patient as well as the prognosis, Pedal lymphangiogrpahy alone is unreliable for accurate assessment of the regional lymph node status in clinically localized prostatic cancer.

Transverse colon conduit: a preferred method of urinary diversion for radiation-treated pelvic malignancies.

In the management of pelvic malignancies treated by radiation the standard ileal conduit is subject to many hazards related to the use of damaged tissues. The transverse colon affords the use of a short isolated segment of non-irradiated bowel as a urinary conduit. The ureters can be dissected well above the field of pelvic irradiation. Eight patients with bladder or cervical carcinoma treated with high doses of external radiotherapy are presented to demonstrate the usefulness of the transverse colon in supravesical urinary diversions.

Symptomatic neurogenic bladder in a cerebral-palsied population.

This study reports the incidence of symptomatic neurogenic bladders in a cerebral‐palsied population. Of the 50 patients screened, 13 underwent routine urological assessment, including cystometrograms. Four were found to have a neurogenic bladder. 18 of the total population had one or more symptoms indicative of a neurogenic bladder: enuresis, stress incontinence and dribbling. The authors speculate that a continuum of the disorder exists. Preliminary follow‐up revealed a significant response to medication in symptomatic patients, both with and without demonstrable neurogenic bladders.

Long-Term Efficacy of Periurethral Collagen Injection for the Treatment of Urinary Incontinence Secondary to Myelomeningocele

PURPOSE The reports of efficacy of periurethral collagen injection (Contigen, Bard, Covington, Georgia) for treatment of urinary incontinence in the myelomeningocele population are limited and variable. We reviewed the efficacy of periurethral collagen in patients with myelomeningocele to provide long-term followup data. MATERIALS AND METHODS From 1994 to 1999, 19 children and 6 adults with myelomeningocele underwent periurethral injections of collagen with an average of 2 treatments per patient. Mean followup +/- SD from last injection in the pediatric and adult groups was 2.9 +/- 1.5 years and 4.7 +/- 2.6 years, respectively. Postoperative continence was defined as dry, improved or unchanged. RESULTS No pediatric patients became dry, 7 (37%) improved and 12 (63%) were unchanged. A single adult was dry (17%), 4 (67%) improved and 1 remained unchanged. Transient improvement was noted in 8 of the 13 patients who reverted to an unchanged status. Response rate was 66% in nonambulatory patients versus 42% in ambulatory patients (p = 0.38). Of 12 patients who responded and 13 who did not 8 in each group required 2 or more treatments. The responding group percentage of predicted bladder capacity was 97.6% versus 89.5% in those who remained unchanged (p = 0.66). CONCLUSIONS The initial transient improvement following collagen injection and the long-term improvement following repeat injections suggest that degradation of collagen decreased its efficacy. The long-term results of this minimally invasive technique are poor.

Variations in practice among urologists and nephrologists treating children with vesicoureteral reflux

To analyze the current management recommendations among physicians treating children with vesicoureteral reflux, the American Urological Association Reflux Practice Guidelines Panel surveyed 100 pediatric urologists, 100 general urologists and 100 pediatric nephrologists by questionnaire, and received a 60% response. In the evaluation of a 4-year-old girl with bilateral grade 2 reflux general urologists were more likely than the other 2 groups to recommend cystoscopy and urethral dilation. At followup nuclear cystography was recommended by 76% of pediatric urologists, 48% of general urologists and 71% of pediatric nephrologists, while the latter 2 groups were less likely to recommend any subsequent upper tract evaluation. Pediatric urologists were significantly more likely to recommend antireflux surgery if the child had 1 breakthrough febrile urinary tract infection, poor compliance with medical management or persistent reflux at age 11 years. In a 6-year-old girl with unilateral grade 4 reflux and detrusor instability 44% of pediatric urologists recommended antimicrobial prophylaxis and anticholinergic therapy compared to 12% of general urologists and 6% of pediatric nephrologists. Antireflux surgery was recommended by 29% of pediatric urologists, 60% of general urologists and 59% of pediatric nephrologists. In older girls with persistent grade 2 or 3 reflux pediatric urologists were much more likely to recommend antireflux surgery. In contrast, they were less likely to recommend surgery in young girls and boys with newly diagnosed grade 4 reflux. These data demonstrate significant differences in therapeutic recommendations among pediatric urologists, general urologists and pediatric nephrologists, and suggest the need for outcomes research to determine the optimal management of children with vesicoureteral reflux.

Biopsy and Clinical Course After Cryosurgery for Prostatic Cancer

Open perineal cryosurgical prostatectomy has been reported previously in 154 consecutive prostatic cancer patients at our center. In 37 of these patients post-cryosurgery biopsies of the prostate were obtained. In the present report we compare this tissue to the preoperative biopsies. The data suggest that well differentiated cancers are associated with advantageous survival in cryosurgery patients. Lymphoid and eosinophilic cell infiltrates may represent post-cryosurgical local immune responses, with improved survival. Estrogen therapy seems to suppress this local immune response. One month or more after cryosurgery cancer in the biopsy correlates with palpable local recurrence but prior to 1 month it does not correlate. Cryosurgery by the open perineal approach has been an effective method to eliminate the primary lesion in localized and extensive prostatic cancer.