Hal C. Scherz

Dynamic Contrast-Enhanced MR Urography in the Evaluation of Pediatric Hydronephrosis: Part 1, Functional Assessment

OBJECTIVEnThe purpose of our study was to derive time-intensity curves for the renal cortex and medulla from 3D dynamic MR urography and to assess whether these curves are predictive of obstruction.nnnMATERIALS AND METHODSnFifty-nine examinations were performed in 53 pediatric patients and the degree of obstruction assessed using the renal transit time. The cortex and medulla were segmented using a semiautomatic method, and mean time-intensity curves were derived for the segmented volumes. The basic parameters of the curves (amplitude, washout) were assessed, as was the presence of certain characteristic features of the curves.nnnRESULTSnThe images allowed clear visualization of three phases of the uptake of contrast material in the cortex, the medulla, and the collecting system. Both the amplitude of the curves and the washout of the contrast material were predictive of obstruction. The distal tubular peak was reliably detected in the cortex of nonobstructed kidneys.nnnCONCLUSIONnCombining signal-intensity-versus-time-curve analysis with the other parameters that can be derived from the same MR urography data set provides a powerful tool for the diagnosis of obstruction.

Dynamic Contrast-Enhanced MR Urography in the Evaluation of Pediatric Hydronephrosis: Part 2, Anatomic and Functional Assessment of Uteropelvic Junction Obstruction

OBJECTIVE. The purpose of our study was to retrospectively review our experience using MR urography in the diagnosis of ureteropelvic junction (UPJ) obstruction in children.MATERIALS AND METHODS. Sixty-one studies were performed in 50 children with hydronephrosis but without hydroureter. Anatomic criteria assessed included degree of hydronephrosis, morphology of the renal pelvis, atrophy of medulla, swirling contrast material, fluid levels, and the presence of fetal folds and crossing vessels. Functional criteria included renal transit time, differential renal function, and time-intensity curves when available.RESULTS. Thirty-one kidneys were classified as obstructed, 15 as equivocal, and 15 as nonobstructed. Obstructed systems had more marked hydronephrosis, more extensive medullary atrophy, more fluid levels, and more swirling contrast material. Fetal folds were seen in only the equivocal and nonobstructed groups. Crossing vessels were seen in all groups. Obstructed systems also showed greater functiona...

An Alternative Approach to Myelodysplasia Management: Aggressive Observation and Prompt Intervention

We have adopted an approach to the management of myelodysplasia patients which is contrary to that most commonly supported by the existing literature. We screen patients shortly after birth with ultrasound, urine culture and serum creatinine, and then follow patients at 3 to 6-month intervals with similar studies. Cystography and urodynamics are done only as required clinically or by a change in the sonogram. Clean intermittent catheterization is indicated for continence or medical reasons. With this approach of aggressive observation and prompt intervention, we observed a rate of renal deterioration (diminished function on renal scan or parenchymal loss on imaging studies) of 5%. Renal deterioration was associated statistically with urinary tract infections and reflux. Patients started on clean intermittent catheterization for medical indications had greater risk for renal deterioration than those started on it for continence. Renal deterioration occurred with equal frequency between patients with abnormal and normal urodynamic studies, that is urodynamics did not predict renal deterioration. Our data show a rate of renal deterioration similar to other reports. We believe that aggressive observation with prompt intervention for problems once identified represents a reasonable alternative to managing patients with myelodysplasia.

Genitourinary trauma in the pediatric patient

Trauma is the major source of mortality in the pediatric population. A retrospective review was performed on patients admitted to the Childrens Hospital and Health Center Trauma Program, San Diego, California, from August 1984 to May 1990. The purpose of this review was to evaluate pediatric trauma and to determine the best treatment and evaluation for genitourinary injuries. Blunt trauma was responsible for 98 percent of the injuries, with renal injuries being the most common. Bladder (7) and male urethral (2) injuries, and vaginal lacerations (8) also occurred. The most severe renal injuries (70%) and all significant bladder and urethral injuries were associated with gross hematuria. Hypotension was present in 31 percent of patients but rarely required surgical exploration for correction. Eighty-six patients underwent radiographic imaging. Computerized tomography (CT) scans demonstrated the most information about intra-abdominal solid organ injuries but was inaccurate in detecting bladder or urethral injuries. Genitourinary injury is common in children but rarely requires surgical management. CT scan is the best study to determine extent of solid-organ injury but is inferior to cystourethrography to diagnose bladder or urethral injuries.

FERTILITY INDEX ANALYSIS IN CRYPTORCHIDISM

We report on 226 male patients with cryptorchidism 6 months to 16 years old who underwent open testis biopsy at orchiopexy or orchiectomy at Childrens Hospital and Health Center from 1986 to 1990. A total of 355 specimens was obtained. Tissues were preserved in Bouins solution and examined on light microscopy for fertility index measurements. Several biopsies prepared using Bouins preserved paraffinized tissue and glutaraldehyde preserved semi-thin cut tissue were found to have comparable fertility index measurements. Of 184 patients with unilateral undescended testes 87 also underwent biopsy on the contralateral descended testis. A total of 42 patients had bilateral undescended testes. Age matched comparisons were made between fertility index measurements of the undescended testes and those previously reported of normal testes. Additional case matched comparisons of fertility indexes were made in those children who underwent biopsy of the undescended testis and its descended mate. Statistical analysis was performed using the independent Student t-test. When comparing undescended to descended testes, there was no significant difference in the fertility index of patients 1 year old or younger but fertility index differences were statistically significant in all of the other age groups. Fertility index measurements were significantly decreased from normal expected values in all age groups with unilateral cryptorchidism and in all but the 13 to 18-month-old group with bilateral cryptorchidism. The fertility index in the descended testis was similar to previously reported normal testis measurements in boys between 13 months and 6 years old. Our data suggest that potential fertility in the cryptorchid testis may be significantly impaired compared to normal testicular fertility regardless of patient age at the time of discovery of the undescended testis. The fertility index of the descended mates of unilateral undescended testes may also be somewhat impaired in certain age groups. Orchiopexy in the first year of life may be indicate to preserve available fertility potential.

Ectopic Ureteroceles: Surgical Management with Preservation of Continence—Review of 60 Cases

During the last 19 years we treated 60 children with ectopic ureteroceles. There was a 4 to 1 female-to-male predominance. Of the patients 47 per cent presented before age 6 months, 66 per cent were diagnosed after a urinary tract infection and 6 were identified antenatally. Based upon a review of the literature and our data, we believe that total correction (a single operation designed to correct abnormalities of the upper and lower urinary tract) is superior in most instances to an approach in which just the upper urinary tract pathological condition is treated. Only 4 (14 per cent) of 28 patients in whom total correction was used required a second operation (all because of persistent reflux) while 14 of 19 patients (74 per cent) treated with an upper urinary tract procedure intended as definitive therapy have either undergone further surgery or have a residual abnormality that may require further surgery. Marsupialization rather than enucleation of the ectopic ureterocele is effective and safe, risking neither injury to the bladder neck or sphincteric mechanism nor resulting in a vesicovaginal fistula.

Dynamic hydrodistention classification of the ureter and the double HIT method to correct vesicoureteral reflux

OBJECTIVESnThe objective of this monograph is to familiarize the reader with dynamic hydrodistention classification of the ureter and Hydrodistention Implantation Technique (HIT) methodology for the endoscopic correction of vesicoureteral reflux (VUR). The indications, current success rates, complications, and potential future applications of these methods are reviewed.nnnMETHODSnHydrodistention (HD) of the ureteral orifice and distal ureter permits visualization of the intraureteral submucosal injection site and assessment of the degree of ureteral coaptation. We have designated 4 levels of HD. HO denotes absence of ureteral dilation, H1 indicates dilation of the ureteral orifice only. H2 allows visualization of the intramural ureter, and H3 allows visualization of the extramural ureter. The Double HIT method is a systematic technique that utilizes HD to both classify the ureter and gauge the degree of ureteral coaptation secondary to bulking during endoscopic injection. The needle is inserted at the mid ureteral tunnel at the 6 oclock position. The first injection coapts the detrusor tunnel (until H1 or H0 is achieved), while a second implant within the most distal intramural tunnel leads to complete coaptation of the ureteral orifice (H0).nnnRESULTSnHD grade correlated significantly with VUR grade. Normal ureters rarely hydrodistended. While non-refluxing contralateral ureters demonstrated low HD grades, all contralateral ureters that subsequently developed VUR showed H2 or H3. The HIT method has not only been employed for primary VUR (90% cure), but also for repeat endoscopic injections (90%), VUR associated with paraureteral diverticula (81%), complex cases such as post-reimplantation (88%), neurogenic bladders (78%), duplication anomalies (80%), and in adults (88%). Furthermore, injection of contralateral VUR-negative but hydrodistending ureters may be treated to prevent new contralateral VUR. While decreasing success was seen with increasing VUR grade with the STING method, superior success rates have been realized with the HIT method.nnnCONCLUSIONSnThe dynamic hydrodistention classification reflects the competency of the ureterovesical junction. The HIT and Double HIT methods achieve superior cure rates and are likely to become the method of choice for the treatment of primary as well as complex cases of VUR.

Microvascular autotransplantation of the intra-abdominal testis.

The operative management of intra-abdominal testes is controversial, largely because there is no method of orchiopexy that can reliably produce good results. We report our results on the use of microvascular autotransplantation of intra-abdominal testes. We performed 12 autotransplants in 10 boys ranging in age from 10 months to 14 years (median age 30 months). In each instance the testis had been localized previously by laparoscopy or it was known to be intra-abdominal and was believed to be grossly normal in appearance. The vascular anastomoses of the spermatic to the inferior epigastric vessels were performed by an experienced microvascular surgeon using 10-zero nylon suture and 40 times magnification. Biopsies were taken at operation in 9 patients. Followup of 6 to 30 months is available in 7 patients and all 8 testes are palpably normal and in good scrotal position. This approach is feasible even in small children and the results seem to be superior to the expected results reported with division of the spermatic vessels.

Is Urinary Tract Screening Necessary for Patients with Cerebral Palsy

Patients with cerebral palsy are prompted to seek urological evaluation when urinary tract infection, socially unacceptable incontinence or hematuria occurs. We attempted to determine the prevalence of urinary tract structural changes by prospectively screening on sonography the kidneys and bladder of 90 patients 1 to 25 years old (mean age 8 years) who had cerebral palsy with or without urological symptoms. Uncooperative patients or those who would require sedation were excluded. Of the patients 66 were incontinent and used diapers, 18 were completely dry and 6 had nocturnal enuresis with daytime dryness. Sonographic abnormalities were detected in 7 patients, including renal size discrepancy in 2 (1 with severe scoliosis and 1 with a history of renal artery thrombosis), mild to moderate hydronephrosis with thickened bladders suggestive of neurogenic bladder dysfunction in 3 and a nonvisualized kidney in 2. However, repeat sonography confirmed 2 normal kidneys in the latter patients. Thus, urinary tract abnormalities were detected unexpectedly in 2% of patients studied. This relatively low proportion suggests that routine urinary tract screening in cerebral palsy patients may not be warranted.

Post-Hypospadias Repair Urethral Strictures: A Review of 30 Cases

During a 16-year period we treated 30 patients with urethral stricture after hypospadias repair. Of the patients 16 were treated successfully with 1 procedure, while 13 required 2 or more procedures and 1 was lost to followup. A good result was achieved in 83 per cent of the patients. Fourteen patients who presented with symptoms attributable to the stricture within 3 months of the original operation for hypospadias were designated as having early strictures. Those with strictures presenting later than 3 months were considered to have late strictures. Manipulative therapy (dilation and direct vision internal urethrotomy) was successful in 55 per cent of the early strictures but in only 16 per cent of the late strictures. An open operation was performed primarily in some cases or after failed manipulation in others and it was successful in 79 per cent. All 4 failures of open procedures were salvaged with manipulative therapy. We conclude that treatment of post-hypospadias repair urethral strictures initially should be manipulative. Open repair usually will be successful but should be reserved for difficult strictures, late strictures or failures of manipulation.