John C. Pope

Endoscopic Therapy for Vesicoureteral Reflux: A Meta-Analysis. I. Reflux Resolution and Urinary Tract Infection

PURPOSE Current American Urological Association treatment guidelines for vesicoureteral reflux do not include any recommendations pertaining to endoscopic therapy (subureteral injection of bulking agent). We performed a meta-analysis of the existing literature pertaining to endoscopic treatment to allow comparison with reports of open surgical correction. MATERIALS AND METHODS We searched all peer reviewed articles published through 2003 pertaining to endoscopic treatment of vesicoureteral reflux. A total of 63 articles were double reviewed by 9 pediatric urologists, and the data were tabulated on data retrieval sheets. A mixed effects logistic regression model was used to obtain overall estimates of event probabilities (eg reflux resolution, ureteral obstruction) together with their 95% confidence intervals. Individual study estimates were obtained with overall estimate and observation characteristics using empirical Bayes calculations. Differences between or among specific groups were assessed using the F-test. RESULTS The database included 5,527 patients and 8,101 renal units. Following 1 treatment the reflux resolution rate (by ureter) for grades I and II reflux was 78.5%, grade III 72%, grade IV 63% and grade V 51%. If the first injection was unsuccessful, the second treatment had a success rate of 68%, and the third treatment 34%. The aggregate success rate with 1 or more injections was 85%. The success rate was significantly lower for duplicated (50%) vs single systems (73%), and neuropathic (62%) vs normal bladders (74%). The success rate was similar among children and adults. Following a previous failed open reimplantation endoscopic treatment was successful in 65% of patients. After endoscopic treatment with variable followup pyelonephritis developed in 0.75% of patients and cystitis in 6%. There were few reports of renal scarring following treatment. CONCLUSIONS Endoscopic treatment provides a high rate of success in children with reflux that decreases with increasing grade, although multiple treatments may be necessary. Future reports of endoscopic therapy should include rates of urinary tract infection and renal scarring.

Clinical outcome of pediatric stone disease

PURPOSE The natural history of stone disease in children is not well defined. We evaluated the clinical outcome in children with urinary calculi. MATERIALS AND METHODS An 8-year retrospective review of 129 pediatric patients with primary urinary lithiasis was performed. Age, renal versus ureteral stone location, stone size, spontaneous passage, recurrence and metabolic evaluation were considered. Patients were divided into groups 1-0 to 5, 2-6 to 10 and 3-11 to 18 years old. RESULTS Of the 25 group 1 patients 17 (68%) had renal and 8 (32%) had ureteral stones. Of the 36 group 2 patients 13 (36%) had renal and 23 (64%) had ureteral stones. Of the 68 group 3 patients 12 (18%) had renal and 56 (82%) had ureteral stones. These differences in stone location according to age were not due to chance (p <0.0001). In groups 1 to 3 renal calculi an average of 6.7, 9.2 and 6.8 mm. spontaneously passed in 24%, 8% and 50% of cases, while ureteral calculi an average of 4.5, 3.5 and 3.2 mm. passed in 63%, 61% and 64%, respectively. The spontaneous passage rate of ureteral stones was consistent in the 3 age groups and for stone size up to 5 mm. Only 1 stone greater than 5 mm. passed spontaneously at any age. The incidence of identifiable metabolic abnormalities believed responsible for stone disease was 50% in groups 1 and 2, and 38% in group 3. In all age groups there was symptomatic and/or radiographic stone recurrence in a third of the patients with an identifiable metabolic abnormality, such as hypercalciuria, hypocitruria, renal tubular acidosis and so forth. In children 10 years or younger this incidence increased to 50%. Less than 10% of those with no identifiable metabolic disorder have had recurrent stones to date. CONCLUSIONS Younger patients are more likely to present with renal calculi and less likely to pass these stones, probably due to the relatively larger stone burden and location. The passage rate for ureteral calculi is surprisingly consistent in all age groups with stones greater than 5 mm. rarely passing spontaneously. Half of the children 10 years or younger who present with urinary calculi have an identifiable metabolic disorder. Thus, all children with stones should undergo metabolic evaluation. In addition, these children are nearly 5-fold more likely to have recurrent stones than those with no identifiable metabolic disorder. Thus, they should be followed aggressively.

Factors That Influence Outcomes Of The Mitrofanoff And Malone Antegrade Continence Enema Reconstructive Procedures In Children

PURPOSE Surgical techniques that provide adequate urinary and fecal continence in children with neurogenic bladder and bowel dysfunction are becoming increasingly used. We reviewed our experience and discuss factors that influence outcome. MATERIALS AND METHODS Between 1994 and 2000, 65 stomal procedures were performed in 47 patients. For the urinary continent catheterizable channel we used appendix in 60% of cases, a continent bladder tube in 20%, a Yang-Monti tube in 16% and ureter in 4%. For the antegrade continence enema continent catheterizable channel we used appendix in 85% of cases, a Yang-Monti tube in 5% and a cecal tube in 10%. In the 19 patients who underwent simultaneous Mitrofanoff and antegrade continence enema procedures the urinary continent catheterizable channel was appendix in 21%, a Yang-Monti tube in 32% and continent vesicostomy in 47%. Patients were divided into 2 groups based on compliance status. In addition, percentile body weight for age was evaluated. RESULTS Stomal continence was achieved in 63 of the 65 cases (97%). Of the patients who underwent the antegrade continence enema procedure 95% achieved continence via the rectum. Except for ureter stenosis rates according to continent catheterizable channel type did not differ greatly, namely 19% for appendix, 11% for the Yang-Monti tube, 22% for the bladder tube, 50% for ureter and 0% for the cecal tube. Infectious complications developed in 16 patients and 4 had stones. The rates of infection (p = 0.004), stomal stenosis (p = 0.001) and revision (p = 0.004) were statistically lower in the compliant group and the stone formation rate showed a trend favoring the compliant group (p = 0.11). No significant difference was noted for incontinence. Percentile weight predicted a higher rate of stomal stenosis with the highest rate of stomal stenosis overall in the greater than 100th percentile group. CONCLUSIONS The Mitrofanoff and antegrade continence enema procedures are reliable and effective. Proper patient selection and surgical technique with a tension-free anastomosis are essential. The choice of tissue for constructing the continent catheterizable channel is not as important as patient compliance, age and possibly body habitus. This report reinforces the importance of careful screening, and rigorous preoperative and postoperative teaching to achieve overall patient success.

The urodynamic profile of myelodysplasia in childhood with spinal closure during gestation.

PURPOSE Spinal dysraphism is the most common cause of neurogenic bladder dysfunction in newborns. Urodynamic findings in these patients include uninhibited bladder contractions, bladder areflexia, decreased compliance and detrusor-sphincter dyssynergia. Early urodynamic studies are recommended for spina bifida to help identify bladder characteristics that may cause a risk of upper tract deterioration. We recently evaluated a new early type of intervention involving closure of the neural tube defect during gestation in 25 patients at our institution. We hypothesize that this procedure results in decreased exposure of the spinal cord to amniotic fluid, which may improve neurological function. To date we have evaluated 16 of the 25 patients with video urodynamics. We compared the results to those in the literature on patients with myelomeningocele and without prenatal intervention. MATERIALS AND METHODS We performed urodynamic testing in 16 patients with a mean age of 6.5 months, including cystometrography, fluoroscopic evaluation of filling and voiding, pelvic floor electromyography and post-void residual urine measurement. In addition, we retrospectively reviewed renal ultrasound, voiding cystourethrography, catheterization need, number of urinary tract infections and medication in these cases. RESULTS Uninhibited detrusor contractions and an areflexic bladder were identified in 6% and 43% of patients, respectively, while 19% had decreased compliance and 75% had leak point pressure greater than 40 cm. water. Mean bladder capacity was 40 cc and 31% of patients had much lower capacity than expected for age. Previous renal ultrasound and voiding cystourethrography showed evidence of upper tract dilatation and reflux in 2 cases, respectively. Intermittent catheterization and anticholinergic therapy were required by 1 patient each and 1 had a significant urinary tract infection. CONCLUSIONS Urodynamic findings in this population are comparable to those previously reported in the literature in patients with spina bifida without prenatal closure of the spinal defect. The lower incidence of urinary tract infection and reflux in our study probably represents more aggressive early urological management rather than neurological improvement. These urodynamic studies were performed early in life and future evaluation may ultimately reveal improved bladder function compared with that in others with myelodysplasia. However, at this time we recommend that patients who undergo spinal cord defect closure during gestation be evaluated and treated in the same manner as those with myelomeningocele but without fetal intervention.

The Ontogeny of Canine Small Intestinal Submucosa Regenerated Bladder

AbstractPurpose: Small intestinal submucosa has previously been shown to promote regeneration of transitional epithelium, smooth muscle and peripheral nerves in rat and dog bladders. The origin of these regenerated components is presently unknown. This study attempts to define the origin of vascular, smooth muscle and peripheral nerve regeneration.Materials and Methods: A total of 22 adult male dogs weighing 25 to 30 kg. underwent partial cystectomy and immediate augmentation with a small intestinal submucosa patch graft. The small intestinal submucosa graft-native bladder interface was marked with permanent marking sutures for future reference. Small intestinal submucosa regenerated bladders were harvested at 2, 3, 4, 6, 8 and 10 weeks after augmentation. The tissue was then studied with routine histology and immunohistochemistry using factor VIII, smooth muscle specific actin (1A4) and neurofilament staining.Results: Results demonstrated that epithelialization of the graft surface was complete by 3 to 4...

Continent Catheterizable Channels and the Timing of Their Complications

PURPOSE We reviewed our experience with continent catheterizable channels with interest in the timing of conduit related complications. MATERIALS AND METHODS A retrospective review was performed of the outcome of continent catheterizable channels in all patients between 1998 and 2003 who had undergone construction of an antegrade continence enema and/or a Mitrofanoff procedure using appendix, small bowel or continent cutaneous vesicostomy. We performed a total of 117 such stomas in 37 male and 41 female patients 2.5 to 20 years old (mean age 8.9). For the antegrade continence enema we used appendix in 92% of cases, an ileal Yang-Monti tube in 6% and a cecal tube in 2%. For the continent catheterizable channel we used appendix in 43% of cases, a Yang-Monti tube in 38% and continent cutaneous vesicostomy in 19%. RESULTS Continence was achieved in 98% of patients. Followup was 6 to 71 months (mean 28.4). There were 27 channel related complications (23%). Stomal stenosis occurred in 7 antegrade continence enema procedures (14%) within 1 to 10 months (mean 6.2) and in 9 continent bladder channels (13%), including 5 continent cutaneous vesicostomies, within 1 to 24 months (mean 9.4) after surgery. False passages occurred in 5 antegrade continence enema procedures (10%) within 1 to 13 months (mean 3.6) and in 4 continent catheterizable channels (6%) within 1 to 13 months (mean 6.5) after surgery. Of patients with stomal stenosis 50% were treated with surgical revision, while the remainder was successfully treated with dilation. Most false passages were managed by catheter drainage alone. Reasons for revision were contained perforation, colovesical fistula and inability to catheterize. Patient noncompliance appeared to have a role in stomal stenosis. CONCLUSIONS Continent catheterizable stomas help patients achieve bowel and bladder continence. Stomal incontinence after reconstruction is rare. In our experience most stoma related complications occurred in the first year after reconstruction. Experience with more patients and longer followup will help determine whether such problems continue to accumulate with time or whether continent stomas function well with time, particularly after the initial period of healing.

DOES EVERY PATIENT WITH PRENATAL HYDRONEPHROSIS NEED VOIDING CYSTOURETHROGRAPHY

PURPOSE Prenatal ultrasound has allowed early identification of urinary tract abnormalities that may require urological followup or early intervention. While all children with prenatal hydronephrosis should undergo ultrasound within the first few weeks of life, we believe that there is a subset of postnatal hydronephrosis for which voiding cystourethrography can be avoided if careful observation is continued. MATERIALS AND METHODS For 5 years 175 infants with a history of prenatal hydronephrosis were evaluated by ultrasound. Of 60 infants with less than Society for Fetal Urology grade II unilateral or bilateral hydronephrosis 44 underwent voiding cystourethrography as part of the early evaluation and 16 were observed without voiding cystourethrography. Four infants for whom we would routinely obtain voiding cystourethrography were excluded from study due to severe prenatal hydronephrosis, renal duplication, hydroureter, ipsilateral small or echogenic kidney and grade II or higher hydronephrosis. RESULTS Voiding cystourethrography was positive in 6 of the 40 infants (15%) with less than grade II hydronephrosis. Of these cases 3 had grade III or higher vesicoureteral reflux and 1 with high grade reflux required reimplantation. None of the 16 patients followed without voiding cystourethrography has required further evaluation or intervention. In all patients with negative or no voiding cystourethrography parenchyma was preserved and hydronephrosis stabilized or resolved. CONCLUSIONS Prenatal and postnatal ultrasound in infants should be used to guide further urological evaluation. Among infants with less than grade II hydronephrosis postnatally 15% had reflux on voiding cystourethrography, which is significantly higher than that reported among normal children (approximately 1%). However, none of the 16 infants observed without voiding cystourethrography on short-term antibiotic prophylaxis had deleterious renal events with 6 months to 4.5 years of followup. Therefore, we question the actual significance of the reflux detected in the first cohort of infants. Voiding cystourethrography can provide a definitive answer. However, we also believe that it is not absolutely mandatory based on the outcome in the observed group. With careful counseling and followup most patients with less than grade II hydronephrosis can be observed without urological sequela.

Management of Ectopic Ureters: Experience With the Upper Tract Approach

PURPOSE The necessity of removing the ureteral stump after upper tract surgery for an ectopic ureter has been debated. We reviewed the records of patients initially treated at the kidney level to evaluate indications for later stump removal. MATERIALS AND METHODS We reviewed the medical records of 32 patients with 33 ectopic ureters treated at the kidney level during the last 10 years. RESULTS Ectopic ureters were associated with duplicated collecting systems in 31 cases and with single systems in 2. Upper pole heminephrectomy and partial ureterectomy were performed in 23 units and upper tract reconstruction was done in 8. Both patients with single systems underwent nephrectomy. Four patients (12%) required repeat surgery at the bladder level, including 1 who underwent ureteral reimplantation for persistent ipsilateral lower pole reflux and simultaneous upper pole stump removal. Preoperative voiding cystourethrography revealed reflux into the ectopic ureter in 1 patient with postoperative reflux and infections. The remaining 2 patients required a repeat operation to remove the stump due to recurrent urinary tract infections and newly detected reflux into the stump, respectively. CONCLUSIONS The majority of patients with ectopic ureters can be treated by addressing only the upper urinary tract. No patient who presented with incontinence required ureteral stump removal. Whether noted preoperatively or postoperatively, reflux into the ectopic ureter necessitated ureteral stump removal. Three of the 6 patients (50%) who had reflux to the ipsilateral kidney required lower tract surgery.

Hydrocele formation following laparoscopic varicocelectomy

PURPOSE Hydrocele is a known complication of varicocelectomy. We evaluated the incidence of hydrocele following laparoscopic varicocelectomy at our institution. MATERIALS AND METHODS A total of 89 boys were treated with laparoscopic ligation of the spermatic vessels for clinically palpable varicoceles between January 2000 and December 2003. Charts were retrospectively reviewed. A total of 10 patients were excluded because they were lost to followup or presented with recurrent varicocele. Followup consisted of office visits with physical examinations at 1 and 12 months postoperatively. Patient charts were reviewed for perioperative variables, operative technique and complications. RESULTS Only 1 of 79 patients (1.3%) had persistent varicocele with a mean of 20.7 months of followup. A total of 18 patients (22.8%) had development of hydrocele postoperatively, of whom 9 required hydrocelectomy. In addition, 2 of these 9 patients needed repeat hydrocelectomy. Of the 57 patients with greater than 6 months of followup 29.8% had development of hydrocele. A higher rate of hydrocele formation (31.1%) was also noted in patients who underwent ligation and division of the spermatic vessels rather than ligation alone (11.8%, p = 0.04). CONCLUSIONS Our series demonstrates a high rate of hydrocele formation following laparoscopic varicocelectomy, particularly in patients with longer followup. The incidence of hydrocele after laparoscopic varicocelectomy may be underreported. However, there appears to be a statistically significant decrease in hydroceles when the internal spermatic vessels are simply ligated rather than ligated and divided. Despite its ease and low failure rate, the standard technique of laparoscopic varicocelectomy requires reexamination, potentially allowing modifications that may decrease hydrocele formation, such as salvaging lymphatics and avoiding division of the vessels.

Pediatric Ureteroscopic Management of Intrarenal Calculi

PURPOSE Data addressing ureteroscopic management of intrarenal calculi in prepubertal children are limited. We reviewed our experience from January 2002 through December 2007. MATERIALS AND METHODS We retrospectively reviewed ureteroscopic procedures for intrarenal calculi in children younger than 14 years. Stone-free status was determined with postoperative imaging. Multiple logistic regression analysis was used to assess the influence of preoperative factors on initial stone-free status and the need for additional procedures. RESULTS Intrarenal calculi were managed ureteroscopically in 52 kidneys in 50 children with a mean age of 7.9 years (range 1.2 to 13.6). Mean stone size was 8 mm (range 1 to 16). Stone-free rate after a single ureteroscopic procedure was 50% (25 of 50 patients) on initial postoperative imaging and 58% (29 of 50) with extended followup. Initial stone-free status was dependent on preoperative stone size (p = 0.005) but not stone location. Additional stone procedures were required in 18 upper tracts. Younger patient age (p = 0.04) and larger preoperative stone size (p = 0.002) were associated with the need for additional procedures. Additional procedures were required in more than half of the stones 6 mm or larger but in no stone smaller than 6 mm. CONCLUSIONS Ureteroscopy is a safe method for the treatment of intrarenal calculi in the prepubertal population. Our ureteroscopic stone-free rate for intrarenal stones is lower than that reported for ureteral stones. Parents should be informed that additional procedures will likely be required, especially in younger patients and those with stones larger than 6 mm.