Howard M. Snyder

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

PURPOSEnThe 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.nnnMATERIALS AND METHODSnThe 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.nnnRESULTSnAvailable 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.nnnCONCLUSIONSnFor 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.

Optimal management of cloacal exstrophy

Classic management of cloacal exstrophy has emphasized primary closure of the omphalocele, end ileostomy, and delayed genitourinary reconstruction. The resultant mortality from short-bowel syndrome and urinary sepsis, and morbidity from inappropriate gender assignment has prompted us to reexamine the operative approach to this problem. Our experience involves 15 cases from 2 days to 21 years after repair. All had initial closure of their omphalocele. Nine of the 15 had closure of the vesicointestinal fistula with preservation of the distal colon segment and creation of an end colostomy; 2 had an initial ileostomy with later conversion to an end colostomy; and 2 have permanent ileostomies. Nine of the 15 were genetic males; six were converted to female, five during the newborn period and one at 9 months. The hemibladders were approximated in 13 of 15 and two had a primary turn-in of the exstrophied bladder. Three had bladder closure with iliac osteotomies delayed beyond the newborn period. Urinary diversion has been utilized in 11 patients, 7 ileal conduits, 1 vesicostomy, 2 cutaneous ureterostomies, and 2 temporary pyelostomies; only one patient remains with an exstrophied bladder. Three patients with closure of the bladder remain incontinent. Of our patients, 13 of 15 are alive and well. One died at age 2 days because of renal agenesis and one was 19 years old when found dead of an unknown cause. There have been no deaths due to short-bowel syndrome or sepsis, and no patients have had upper urinary-tract deterioration. These results prompt us to recommend the following therapy for cloacal exstrophy: (1) early closure of the omphalocele; (2) closure of the vesicointestinal fistula with creation of an end colostomy at the distal end of the blind pouch; (3) reapproximation of the hemibladders; and (4) gender assignment to female. Subsequent procedures in the stable infant would include bladder closure and later reconstruction for continence if the bladder is suitable or appropriate permanent diversion.

Urolithiasis in childhood: Current management

During the past 12 years, 62 children with urinary stones have been treated at the Childrens Hospital of Philadelphia. The most common presenting symptoms were abdominal or flank pain (45%), recurrent or persistent pyuria (35%), and gross hematuria (21%). Twenty-two patients had associated congenital urologic anomalies. Infection-related struvite stones were most common and were found in 18 children, of whom 15 were found to have anatomic abnormalities. Eighteen of 28 children evaluated for a metabolic cause were found to have an abnormality, most frequently hypercalciuria. No predisposing factors could be found in 16 of the 62 patients. Forty-four (87%) children had upper urinary tract stones. Twelve of 15 bladder stones were in children with a neuropathic bladder and all were related to infection. Treatment was directed to the correction of anatomic and metabolic predisposing causes, as well as to removing the stones. Fifteen patients passed stones ranging in size from 2 to 6 mm. Forty-six surgical procedures were performed in 43 children. Pyelolithotomy and cystolithotomy were the most frequent procedures. There were three residual stones and five recurrences. Of the 29 operations for upper urinary stones reviewed, 17 might today be considered suitable for percutaneous nephrostolithotripsy or extracorporeal shockwave lithotripsy. Possible future stone management will be discussed in light of this analysis.

Urodynamic Evaluation of Prostatic Enlargements with Micturitional Vesicourethral Static Pressure Profiles

We studied 58 men with prostatism, who were between 58 and 75 years old, with micturitional vesicourethral static pressure profiles. The study consisted of recording static (lateral) pressures of successive segments of the posterior urethra during voiding, with synchronous monitoring of the vesical pressure activity. An abnormal pressure decrease across the supramontane urethra was considered to be a functional compromise to the prostatic urethra. The studies indicated that the degree of prostatic urethral obstruction was not related to the clinical and endoscopic assessment of prostatic enlargement. Three major patterns emerged from our studies: 1) moderate to severe prostatic enlargement with severe obstruction, 2) moderate to severe prostatic enlargement with minimal or no obstruction and 3) minimal prostatic enlargement with severe obstruction. Also, a good correlation became apparent between micturitional vesicourethral static pressure profilometry and uroflowmetry.

LASER TISSUE SOLDERING FOR HYPOSPADIAS REPAIR:: RESULTS OF A CONTROLLED PROSPECTIVE CLINICAL TRIAL

PURPOSEnLaser tissue soldering has been shown to provide safe and effective tissue closure by creating an immediate leak-free anastomosis with minimal scar formation. We compared the results of laser tissue soldering and conventional suturing for hypospadias repair.nnnMATERIALS AND METHODSnA consecutive group of 138 boys 4 months to 8 years old (mean age 15 months) was divided into a standard suturing (84) and a sutureless laser (54) hypospadias repair group. Urethral repair was defined as simple (Thiersch-Duplay or Snodgrass) and complex (onlay island flap or tube) in 101 and 37 cases, respectively. Laser tissue soldering was performed with 50% human albumin solder doped with 2.5 mg./ml. indocyanine green dye using an 808 nm. diode laser at 0.5 W. In the laser group sutures were used for tissue alignment only. At surgery neourethral and penile length, operative time for neourethral construction and the number of sutures or throws were measured. Postoperatively patients were examined for complications of wound healing, stricture or fistula.nnnRESULTSnMean patient age, urethral defect severity, type of repair, neourethral length and stenting time plus or minus standard error of mean were not significantly different in the 2 groups. Mean operative time was a fifth as long for laser tissue soldering in simple and complex hypospadias repair compared to controls (1.5 +/- 0.1 and 5.1 +/- 0.3 versus 8.5 +/- 0.8 and 26.7 +/- 1.7 minutes, respectively, p <0.001). The mean number of sutures used for tissue alignment in the laser group for simple and complex repair was significantly less than in controls (3.0 +/- 0.2 and 8.2 +/- 0.6 versus 8.5 +/- 0.8 and 23.2 +/- 1.5, respectively, p <0.001). All patients were followed a mean of 12 months (minimum 6, maximum 22). The complication rate was 4.7% in the laser group and 10.7% in controls with fistula in 2 of 54 cases, and fistula and meatal stenosis in 7 and 2 of 84, respectively.nnnCONCLUSIONSnThese preliminary results indicate that laser tissue soldering for hypospadias repair may be performed in almost sutureless fashion and more rapidly than conventional suturing. The ease of the laser technique and the lower complication rate in the laser group indicate that laser tissue soldering is an acceptable means of tissue closure in hypospadias repair.

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.

Urodynamic Localization of Isolated Bladder Neck Obstruction in Men Studies with Micturitional Vesicourethral Static Pressure Profile

Micturitional vesicourethral static pressure profile, a method of recording the static (lateral) component of voiding pressure in the successive urethral segments contiguous with the bladder, has allowed us to establish directly the site and degree of bladder outlet obstruction in 16 men. The diagnosis of isolated bladder neck obstruction was confirmed with greater confidence by using this technique with a 10F trilumen catheter in conjunction with uroflowmetry and radiologic studies. Repeat studies with a 5F single lumen catheter have suggested that the obstructions recognized with the 10F catheter ware not entirely artifactual. Our experience with this technique in several men with non-neurogenic bladder neck obstruction indicates the importance of including this study in the urodynamic armamentarium.

Omphalocele, cryptorchidism, and brain malformations

Nineteen male infants died with a large omphalocele and 52% had associated cryptorchidism. However, two different groups with both omphalocele and cryptorchidism were recognized: (1) Eleven patients with omphalocele without brain malformation and an incidence of undescended testes not significantly different from the normal population; (2) Eight patients with omphalocele and brain malformation all having cryptorchidism. A comparison of the groups indicated that intact intraabdominal pressure during intrauterine life is not a main driving force of testicular descent, whereas normal testicular descent may occur only when the brain is normally developed. Whenever a child with omphalocele and cryptorchidism is examined, careful evaluation of the central nervous system is indicated. This triad of malformations may have prognostic and therapeutic implications.

Isolated bladder neck obstruction of undetermined etiology (primary) in adult male Recognition and management

Varying degrees of isolated bladder neck obstruction of undetermined etiology were identified with micturitional vesicourethral static pressure profiles. Our experience with the urodynamic studies in 15 patients suggests that isolated bladder neck obstruction is a real entity in young adult males. Our experience also suggests that pharmacologic success with alpha-adrenergic blockade of the dosage tolerated by the patients is inconsistent. Successful clinical results achieved with appropriate bladder neck surgery could be confirmed with uroflowmetry and detailed urodynamic studies during postoperative period.

Posterior sagittal exposure for reconstructive surgery for cloacal anomalies

We treated seven girls with a cloacal anomaly through a posterior sagittal exposure. Six patients, aged 5 months to 2 1/2 years, underwent a primary reconstructive operation with urethroplasty, vaginoplasty, and posterior sagittal anorectoplasty as a single procedure. All had undergone diverting sigmoid colostomies as newborns, four had previous vesicostomies, and one had a vaginostomy. The seventh girl, a 9-year-old, had undergone a number of attempts at reconstruction. All underwent endoscopy and contrast studies of the cloaca before definitive reconstruction. This preoperative evaluation gave necessary information regarding the length and caliber of the cloacal channel and the level of confluence of the urinary, genital, and intestinal tracts. However, major decisions regarding reconstruction were often possible only in the operating room. To construct a neoanus with optimal sphincteric control, all seven underwent posterior sagittal anorectoplasty. Two required laparotomies to mobilize additional colonic length. Three developed urethrovaginal fistulae after repair. Critical decisions regarding urethral and vaginal reconstruction depend on the findings at cystoscopy and operation. The posterior sagittal approach gives excellent exposure for these decisions and the subsequent reconstruction of three functioning perineal orifices.