Edward S. Tank

The Ureteral Stump after Nephroureterectomy

Herein we review 70 cases of transitional cell carcinoma of the upper urinary tract. When complete nephroureterectomy was not performed transitional cell carcinoma developed in 30 per cent of the remaining ureteral stumps. Single incision nephroureterectomy did not include the intramural ureter in 50 per cent of the cases in which it was performed. When nephroureterectomy is selected as treatment for carcinoma of the renal pelvis or ureter a cuff of bladder, which includes the ureteral orifice, should be removed. A second incision may be required for adequate exposure.

Surgical Aspects of Continuous Ambulatory Peritoneal Dialysis in Infants, Children and Adolescents

The importance of surgical contributions to successful pediatric continuous ambulatory peritoneal dialysis demonstrated in this review of our experience with 9 pediatric patients maintained on such dialysis for 2 to 21 months (mean 11.3 months). Specific surgical procedures for pediatric peritoneal catheter placement have been developed that ensure proper catheter position, establish a watertight seal at the peritoneum and provide for intraoperative demonstration of good catheter function. Peritoneography at the time of catheter placement had predicted accurately later clinical hernia development and may be used to repair prophylactically subclinical inguinal and umbilical defects that are only demonstrable by intraoperative peritoneography. Partial omentectomy also has been helpful in certain instances. Since institution of the techniques described in this report, our 9 young patients have accumulated 101 patient-months on continuous ambulatory peritoneal dialysis without a single catheter failure. The benefits of this as yet unrestricted extension of peritoneal catheter functional life span may be attributed to the catheter-protective features of the continuous ambulatory peritoneal dialysis method itself and the involvement of interested surgeons as active members of the pediatric continuous ambulatory peritoneal dialysis program.

Bilateral spermatic cord torsion in the neonate.

A case is reported of torsion of the spermatic cord in a newborn. This experience re-emphasizes the necessity of a careful and complete examination of the newborn immediately after delivery. The presence of a scrotal mass that does not transmit light represents torsion of the spermatic cord until proved otherwise, and demands immediate surgical intervention if their is to be any hope of testicular salvage. If torsion is present contralateral fixation is necessary.

Transureteroureterostomy: 25-Year experience with 100 patients

During the last 25 years 100 patients have been subjected to transureteroureterostomy. In 2 cases postoperative death was attributable to other pathologic processes. We treated 94 donor units successfully in this manner. An additional 2 units, normal for several years after transureteroureterostomy, had periureteral fibrosis and stricture owing to the inferior mesenteric artery syndrome and required another definitive surgical procedure. Ninety-seven recipient kidneys remained normal after the procedure.

Principles of Management of the Persistent Cloaca in the Female Newborn

The persistent cloaca in the female newborn is one of the most complex and challenging developmental malformations that the pediatric urologist will encounter. A review of 5 patients seen at this center and 34 completely documented cases was undertaken to characterize the defects and devise a logical diagnostic and therapeutic approach. Diagnostic steps include the search for associated anomalies, which were present in the upper urinary tract (33 per cent), gastrointestinal tract (13 per cent), cardiovascular system (13 per cent), central nervous system (10 per cent) and respiratory tract (5 per cent). Delineation of the cloaca and its anatomic relationships is determined by abdominal x-rays, injection of contrast material into the cloacal channel, excretory urography and endoscopy with selective catheterization. Surgical treatment begins with a diverting right transverse colostomy in the newborn period followed by rectal pull-through when the patient weighs 25 pounds. Vaginal pull-through should be performed at the same time as the rectal pull-through if the vagina enters the cloaca high. If the cloacovaginal communication is low a vaginoplasty by a posterior flap procedure can be done when the child is 10 to 12 years old. Even is anatomy is reconstructed in an ideal manner urinary and fecal continence cannot be assured since congenital neurologic dysfunction is not uncommon.

Neoplasms Associated With Hemihypertrophy, Beckwith-Wiedemann Syndrome and Aniridia

Hemihypertophy and the Beckwith-Wiedemann syndrome are associated with Wilms tumor and adrenocortical carcinoma. These conditions also have a relationship with nodular renal blastema, nephroblastomatosis and adrenocortical adenomas, all of which are pre-malignant lesions. children with aniridia also are predisposed to development of Wilms tumors.

Management of neonatal urinary ascites

Four cases of neonatal urinary ascites are added to the previous reported 46 cases. Three are males with posterior urethral valves, and one is a female whose bladder was ruptured during traumatic breech extraction. The renal site of urine extravasation was verified by retrograde pyelogram in one instance and operative exploration in another. If relief of the lower urinary tract obstruction does not resolve the ascites, percutaneous or open nephrostomy tube placement on the side of extravasation is advised. With this approach all the patients have survived and now have normal renal function.

Polypoid Renal Pelvic Lesions in Children

A case is presented of gross hematuria and a large polypoid renal pelvic mass in a 15-month-old boy. Operation revealed a Wilms tumor with limited parenchymal involvement and rupture into the collecting system. This rare presentation of nephroblastoma and its differentiation from other rare benign and malignant renal pelvic lesions occurring in the pediatric patient are discussed. The advantages and disadvantages of radical and conservative surgical approaches to these rare lesions are reviewed. Preoperative cystoscopy and retrograde pyelography are mandatory in all patients with renal tumors presenting with gross hematuria, regardless of age. Radical nephrectomy with total ureterectomy is recommended for Wilms tumor with extension into the collecting system.

The Current Management of Bilateral Wilms Tumor

The good prognosis of synchronous bilateral Wilms tumor seems inappropriate for the magnitude of the disease process. Our experience with 11 cases demonstrates the unusual tumor response to chemotherapy and limited preservative surgery. Although 2 patients died 2 with metastatic disease have responded to chemotherapy and are alive at 5 and 8 years after treatment. In addition, 1 patient has survived with biopsy only and no definitive surgery. Although all surgical options have been used, ranging from biopsy alone to bench surgery with autotransplantation to bilateral nephrectomy, our experience demonstrates the effectiveness of a conservative approach with initial biopsy, chemotherapy and subsequent partial nephrectomy if needed. Our survival data and the histological examination of the tumors after chemotherapy suggest a strong relationship of bilateral Wilms tumor to the nodular renal blastema-nephroblastomatosis complex, and a mechanism to explain the excellent tumor response to chemotherapy.

Adrenocortical Carcinoma in Children

Adrenocortical carcinoma in childhood is a rare, potentially fatal disease. Despite its often-dramatic presentation, there typically has been a distressingly long delay between the onset of symptoms and the time of diagnosis, which undoubtedly has contributed to the poor prognosis in these children by permitting the disease to reach an advanced stage before treatment is started. It is therefore imperative that the physician recognize the endocrine manifestations of these tumors. Although biochemical evaluation is helpful, it often cannot differentiate benign from malignant neoplasms and therefore should not unduly delay intervention. Aggressive surgical resection continues to be the mainstay of treatment as the role of adjuvant therapy continues to evolve. It is hoped that increased familiarity with this unusual tumor will result in earlier detection, prompt intervention, and improved survival for children with adrenocortical carcinoma.