Jeffrey Wacksman

Report of the Multicystic Kidney Registry: Preliminary Findings

Multicystic kidney was first described in a 7-month-old child. Some physicians advocate nephrectomy in such cases, while others have questioned this procedure. In 1986 the American Academy of Pediatrics, Section on Urology established the Multicystic Kidney Registry to identify and follow patients with multicystic kidney disease. To date 441 patients have been registered, of whom 260 were managed nonoperatively. Based on followup of these patients no kidneys were removed for hypertension, infection, pain or tumor development. Long-term findings show that multicystic kidney disease may take as long as 20 years to resolve, and followup testing will be necessary.

Prenatal Testicular Torsion: Principles of Management

To assess our experience with in utero testicular torsion, we retrospectively studied all newborns presenting in the newborn nursery with a diagnosis of neonatal testicular torsion. A total of 25 consecutive cases of torsion of the spermatic cord in 23 patients was identified and explored on an emergency basis. To our knowledge this represents the largest single institution series and 40% of all of the confirmed cases reported in the literature. No viable testicles were found. We strongly believe that torsion of the testis presenting at birth represents an irreversible intrauterine event best treated in an early elective setting. We suggest an inguinal approach with contralateral orchiopexy in all patients who present with signs and symptoms of prenatal (in utero) testicular torsion.

Results of the Renewed Extra Vesical Reimplant for Surgical Correction of Vesicoureteral Reflux

In 1987 Firlit et al described their results using Hodgsons technique of the modified extravesical Gregoir-Lich procedure. They coined the term detrusorrhaphy or extravesical ureteral advancement to describe this technique. During the last 4 years we performed this reimplantation on 211 ureters in 132 patients. Of the patients 79 had unilateral and 53 had bilateral procedures. Included were 6 megaureters requiring ureteral tailoring and 9 uncomplicated duplications. All but 1 patient were cured of reflux. No postoperative obstruction was encountered. Our results indicate that this is an excellent procedure to repair vesicoureteral reflux with minimal morbidity and short hospital stay.

INGUINAL MICROSURGICAL VARICOCELECTOMY IN THE ADOLESCENT: TECHNIQUE AND PRELIMINARY RESULTS

PURPOSE In large series of adults microsurgical varicocelectomy has been associated with extremely high success rates, combined with minimal incidence of postoperative hydrocele. We report our initial experience of inguinal varicocelectomy using an intraoperative microscope in adolescents. MATERIALS AND METHODS From 1994 to 1996, 32 adolescents (mean age 15.3 years) underwent inguinal microsurgical varicocelectomy. An operative microscope and Doppler probe were used during spermatic cord dissection to identify and preserve the testicular artery and lymphatics. RESULTS All patients were available for followup, which ranged from 2 to 35 months (mean 20). There were no intraoperative complications. A temporary reactive hydrocele, which subsequently completely resolved, was observed in 1 patient. There were no palpable recurrent varicoceles. CONCLUSIONS The operative microscope permits reliable identification of the testicular artery and lymphatics, as well as venous channels in adolescents. As a result, the postoperative development of hydrocele or recurrence of the varicocele may be prevented.

Mathieu hypospadias repair: experience in 202 patients.

PURPOSE The complication rate after Mathieu hypospadias repair was recently reported to be 3.6% in unstented cases. We reviewed our experience and results of the Mathieu repair performed at our institution during the last 5 years. MATERIALS AND METHODS We performed 197 primary and 5 secondary repairs in 202 patients. Reconstruction of the neourethra was done with a 2-layer anastomosis using optical magnification. Urethral stents were placed for postoperative drainage in all but 1 patient. Followup was up to 54 months. RESULTS There were no incidences of stent migration or symptomatic urinary tract infection while the stent was in place and all patients voided spontaneously after stent removal. Excellent cosmetic results were obtained in 201 cases. In 1 patient meatal retraction required subsequent meatoplasty with meatal advancement. In 2 patients pinpoint urethrocutaneous fistulas were successfully repaired. The total rate of reoperation was 1.5% in our series. There was no report of urethral stricture during followup. CONCLUSIONS The well established Mathieu repair provides excellent cosmetic and functional results. The overall complication rate is minimal and compares favorably with stentless repair. A 2-layer neourethral anastomosis performed under sufficient optical magnification produces a watertight closure with minimal risk of fistula formation. Postoperative urethral stenting decreases this risk even further, while adding only minimal morbidity. We believe that in the era of newly reported techniques the well established Mathieu procedure should be the standard by which distal repair is judged.

Laparoscopic correction of vesicoureteral reflux in the pig

Extravesical detrusorrhaphy is a modification of the Lich-Gregoir antireflux procedure that incorporates ureteral advancement into the repair. We report on our use of laparoscopic detrusorrhaphy to correct vesicoureteral reflux in an animal model. Reflux was created by transurethral incision of the roof of each ureteral orifice. In phase 1 of this study, laparoscopic repair was performed 1 week later in 3 pigs and an open technique was done in the remainder. In phase 2 laparoscopic repair was done in 3 pigs 3 weeks after inducing vesicoureteral reflux. All phase 1 repairs successfully corrected reflux but 1 ureter in the laparoscopic group developed obstruction. All phase 2 repairs were successful, which was determined by preoperative and postoperative cystography, and a postoperative excretory urogram. Average time was 2 hours 21 minutes for laparoscopic repair and 1 hour 10 minutes for the open procedure. Complications included bladder perforation and ureteral obstruction in 1 case each with no postoperative deaths. These preliminary results indicate that laparoscopic detrusorrhaphy is a feasible procedure in a porcine model.

Pediatric Ureteroscopy: Technique and Preliminary Results

Ureteroscopic management of ureteral obstruction in children presents a challenge to the urologist because of the use of relatively large instruments in smaller anatomy. The authors present our initial experience and describe the technique and equipment found to be most useful. Eleven ureteroscopic procedures were performed in ten patients, either for stone extraction or diagnostic evaluation of ureteral obstruction. Six of seven patients with ureteral stones became stone free, and the stone load was reduced to 25% in the remaining patient. Diagnostic ureteroscopy for ureteral obstruction was successfully performed in four patients. There were no intraoperative ureteral injuries and no postoperative complications. Pediatric ureteroscopy appears to be safe and effective for the diagnosis and treatment of distal ureteral obstruction. Further studies and longer follow-up are necessary to determine whether this technique will prove as successful in children as it has been in the adult population.

APPENDICEAL VERSUS ILEAL SEGMENT FOR ANTEGRADE CONTINENCE ENEMA

PURPOSE To assess outcomes after the antegrade continence enema procedure, we present our results with an ileal segment or the appendix in children with severe bowel dysfunction. MATERIALS AND METHODS A retrospective review of 45 children who had undergone the creation of a continent cecostomy for severe chronic constipation and fecal incontinence was performed. RESULTS The appendix was used to create the continent cecostomy in 28 patients (group 1) and ileum 17 (group 2). Of 16 patients who underwent simultaneous construction of appendiceal Mitrofanoff neourethra, including continent catheterizable stoma, the appendix was split and used for the cecostomy and neourethra in 11. Overall, acceptable continence was achieved in 39 (87%) patients and total continence 31 (69%). No significant difference was noted in the rate of continence between groups 1 and 2. Nonstomal postoperative complications occurred in 5 patients in group 1 and 3 group 2. Complications that required reoperation related to the continent cecostomy occurred in 10 patients, including stomal stenosis in 8, with 6 group 1 and 2 group 2 (p >0.05), and stricture in 2, with 1 group 1 and 1 group 2. There were 2 patients who had previously undergone colostomy for intractable constipation who were undiverted at the time of the creation of continent cecostomy. Both were continent postoperatively. There were 3 patients, including those 2 who presented with chronic severe constipation of unclear etiology, who underwent colostomy for unrecoverable colonic dys-motility, of whom 1 subsequently required total colectomy. CONCLUSIONS The creation of a continent cecostomy for antegrade continence enema is a successful management option in children with debilitating fecal incontinence, and may enable undiversion of an existing colostomy. The appendix and ileal segment are viable options for the procedure, with no significant difference noted in continence or complication rates.

EXTRAVESICAL COMMON SHEATH DETRUSORRHAPHY (URETERONEOCYSTOTOMY) AND REFLUX IN DUPLICATED COLLECTING SYSTEMS

PURPOSE Various surgical approaches have been used for treatment of vesicoureteral reflux in uncomplicated duplicated collecting systems. We retrospectively evaluated our success with extravesical common sheath detrusorrhaphy in such a setting. MATERIALS AND METHODS Between 1990 and 1997, unilateral and bilateral extravesical nondismembered detrusorrhaphy was performed in 24 and 19 patients, respectively, with 51 duplicated collecting systems, including 8 bilateral, for management of vesicoureteral reflux. Vesicoureteral reflux was present in the moieties of ipsilateral duplicated kidney in 2 patients, and bilateral reimplantation was performed in 2 who had a history of contralateral vesicoureteral reflux that resolved. Patient age ranged from 1 to 16 years (median 3.67). Followup ranged from 36 to 114 months (median 86), and included cystourethrography and renal ultrasound. RESULTS Vesicoureteral reflux resolved in all but 1 duplicated renal moiety, which was a success rate of 98%. In this patient the persistent reflux resolved by 16 months postoperatively on conservative treatment. There were no intraoperative complications and all patients resumed spontaneous voiding before discharge home. No postoperative obstruction of the involved kidney or de novo contralateral reflux developed in any patient. CONCLUSIONS Common sheath ureteral reimplantation with extravesical detrusorrhaphy can be successfully used to treat vesicoureteral reflux in uncomplicated duplicated collecting systems. This approach demonstrates excellent long-term surgical outcome with minimal perioperative morbidity.

Epididymitis in Older Boys: Dysfunctional Voiding as an Etiology

Although male infants and young boys with epididymitis have a high incidence of anatomical pathology, dysfunctional voiding is not a well established cause of epididymitis. In our series 36 boys with epididymitis underwent noninvasive urodynamic studies to determine whether a physiological defect could be assigned as an etiology. The 2 mechanisms proposed are similar to that in children with vesicoureteral reflux associated with dyssynergia or bladder instability and to a cause of recurrent urinary tract infection in children (the infrequent voider syndrome). Urinalysis and urine culture are recommended in all children with epididymitis and urethral swabs are obtained from those who are sexually active. We recommend renal/bladder ultrasound and voiding cystourethrography in all infants and young children with epididymitis. In the older child we advocate detailed questioning regarding voiding symptoms and the performance of noninvasive urodynamic studies.