Jeffrey R. Woodside

Percutaneous Stone Removal in Children

Percutaneous removal of renal and ureteral calculi has become an established and successful procedure in adults. Stone disease in children often is metabolic or infectious in origin and multiple surgical procedures during a long interval may be required. Therefore, percutaneous stone removal could be particularly advantageous in these patients. We have performed percutaneous stone removal successfully in 7 children, none of whom required a second procedure or were discharged from the hospital with a nephrostomy tube.

Urodynamic Evaluation of incontinence in Patients Undergoing Modified Campbell Radical Retropubic Prostatectomy: A Prospective Study

A prospective urodynamic study was performed on 17 consecutive patients undergoing a modified Campbell radical retropubic prostatectomy for prostatic carcinoma. There was 1 postoperative death, leaving 16 evaluable patients. Patients were evaluated preoperatively and at 6 weeks, 3 months and 6 months postoperatively. The only urodynamic parameter 6 months postoperatively that differed significantly from the preoperative value was the functional urethral length, 1.6 and 4.3 cm., respectively. The incidence of clinical and/or urodynamic urinary incontinence preoperatively was 19 per cent and 6 months after the procedure it was 87 per cent. The incontinence rate did not correlate with the pathological stage or histological grade of the tumor. There was a strong trend toward improvement of continence with time but all patients who were incontinent 6 months postoperatively and followed for more than 1 year remained incontinent. While this incontinence rate is the highest reported, we believe that it reflects detailed patient interviews and objective fluoroscopic evidence of urethral urinary loss. These results and those of others suggest that modification of the technique of radical prostatectomy to produce a functional urethral length of at least 2.8 cm. may be desirable.

Suprapubic endoscopic vesical neck suspension for the management of urinary incontinence in myelodysplastic girls.

Urinary incontinence may be a formidable hardship in many girls with myelodysplasia. In those patients who fail treatment with intermittent self-catheterization and pharmacotherapy surgical augmentation of outlet resistance may successfully alleviate incontinence. In patients with less severe degrees of urethral sphincteric incompetence suprapubic endoscopic vesical neck suspension in conjunction with intermittent self-catheterization can be successful. Patients must be selected carefully, with particular attention directed at detecting decreased detrusor compliance. Poor detrusor compliance must be controllable or corrected before augmentation of urethral resistance to prevent postoperative upper urinary tract deterioration.

Management of penile incarceration

A case of penile incarceration is presented. Two steel bushings compromising the penile vascular supply in a young man were removed with the aid of a carbide disk dental drill. Management of this case is described, and guidelines for managing similar cases of penile incarceration are discussed.

Cellulitis and necrotizing fasciitis of the abdominal wall in pediatric patients

Soft tissue infections of the abdominal wall in 14 children were classified as cellulitis (8), necrotizing fasciitis (5), or myositis/myonecrosis (1). These 3 categories were characterized by increasing anatomic depth of infection, clinical severity, and need for more radical surgical treatment. Ten of the 14 children were neonates. The most frequent associations were omphalitis (5), necrotizing enterocolitis (4), and urachal anomalies (3). The severest infections were usually polymicrobial and contained both aerobic and anaerobic bacteria. Important clinical findings in children with necrotizing fasciitis and myositis/myonecrosis were tachycardia, systemic toxicity, severe edema, and, in older children, pain out of proportion to the apparent degree of infection. None of the children had fever or crepitation of the wound. An ominous sign, indicative of the need for immediate, radical debridement was the appearance of a patch of dusky or gangrenous skin. There were two deaths associated with delayed diagnosis of necrotizing fasciitis. One child did not receive radical debridement, and the other received it too late to be of benefit. Although these infections are rare in children, their lethal potential and early diagnostic signs must be recognized.

Management of Bladder Diverticula by Transurethral Resection: Re-Evaluation of an Old Technique

Many surgical techniques have been described for bladder diverticulectomy, including extravesical, intravesical or combined procedures. An alternative therapeutic technique not widely recognized is transurethral resection of the diverticular neck. We have used this procedure on 6 patients, either to promote emptying of a diverticulum or to permit adequate endoscopic examination. Each operation was successful and there were no complications. We herein describe this technique and recommend its use in selected patients.

Pubovaginal Sling Procedure for the Management of Urinary Incontinence in a Myelodysplastic Girl

Urinary incontinence is a formidable social handicap in many children with myelodysplasia. Girls in whom pharmacologic therapy and intermittent catheterization fail to alleviate incontinence present particularly difficult management problems. Permanent catheter drainage of the bladder or supravesical urinary diversion frequently has been used solely for control of incontinence. More recently, the artificial sphincter has been used in selected patients. We herein describe the use of a pubovaginal sling to augment bladder outlet resistance in a girl with myelodysplasia. Postoperatively, she remains totally continent on intermittent catheterization.

Urodynamic Evaluation of Dysfunctional Bladder Neck Obstruction in Men

Dysfunctional bladder neck obstruction in young men has received increasing interest in recent years. The urodynamic characteristics of this disorder include elevated voiding pressure, normal reflex relaxation of the urethral rhabdosphincter, increased pressure gradient between the membranous urethra and the bladder, and inadequate radiographic bladder neck opening during detrusor activity. The functional changes occurring at the internal sphincter in 3 patients with dysfunctional bladder neck obstruction are described herein. It is demonstrated that the obstruction may result from either an active dyssynergic bladder neck contraction or failure of bladder neck relaxation. While the pathophysiology of dysfunctional bladder neck obstruction is uncertain possible mechanisms are discussed.

Segmental renal artery emboli treated with low-dose intra-arterial streptokinase

Herein we describe a sixty-one-year-old man with unilateral segmental renal artery emboli treated with renal intra-arterial streptokinase infusion. The initial infusion rate was 9,000 units/hr. which was decreased to 5,000 units/hr. over the next six hours. Periodic arteriography demonstrated progressive lysis and virtual complete resolution after fifty-two hours of infusion. Intravenous pyelogram (IVP) six weeks later showed almost complete return of functional compared with IVP obtained six years earlier. We have demonstrated successful clot lysis at an infusion rate of 5,000 units/hr., compared with reported rates of 25,000 units/hr. and without the frequently utilized initial large intravenous bolus. Such low-dose streptokinase infusion should, theoretically, limit the incidence of recognized dose-related complications and permit its use in clinical settings where higher dosages are contraindicated. Intra-arterial streptokinase therapy seems particularly suitable for the high surgical risk patient and in arterial lesions not amenable to surgery. The availability of this potentially efficacious therapy suggests that aggressive diagnostic studies be pursued early in patients suspected of having an acute renal arterial embolus.

Large perirenal hematoma after extracorporeal shock-wave lithotripsy

We report a case of a large perirenal hematoma following extracorporeal shock-wave lithotripsy (ESWL) that resulted in compromised renal blood flow and function and necessitated open surgical drainage. Caution is advised and close follow-up recommended in patients who have taken aspirin-containing compounds, are elderly, have hypertension, or exhibit a significant drop in hematocrit following ESWL.