John G. Van Savage

ANTICOAGULANT ASSOCIATED HEMATURIA: A PROSPECTIVE STUDY

We studied prospectively 32 consecutive patients with new onset of gross or microscopic hematuria while on anticoagulant therapy. Of the patients 19 men and 11 women (mean age 65 years) underwent urological evaluation. Of 6 patients with microscopic hematuria 3 with nephrolithiasis subsequently underwent extracorporeal shock wave lithotripsy. Two of 24 patients (7%) with gross hematuria had neoplastic disease invading the bladder, 1 had benign prostatic hyperplasia requiring resection, 1 had urethral stricture, 1 had ureteropelvic junction obstruction and 1 had nephrolithiasis. Thus, significant urinary tract disease was present in 9 patients (30%). Hematuria resolved in more than 90% of the patients after treatment. Based upon these observations, we believe that gross or microscopic anticoagulant associated hematuria is frequently precipitated by a significant genitourinary pathological condition and its prompt evaluation is recommended.

Fracture-Dislocation of the lumbosacral spine: Case report and review of the literature

This report describes an extensively comminuted fracture of the sacrum and the L-5 vertebral body with complete anterior dislocation of the lumbar spine on the sacrum that occurred in a 19-year-old man ejected from a motor vehicle. Lumbosacral dissociation was characterized by computed tomography with three-dimensional and multiplanar reconstruction, and definitively managed by posterior instrumentation using locking hook spinal rods attached to the pelvis with hockey stick attachments by the Galveston technique. Implications of this case and a review of the literature are presented.

Pediatric Urology: The Impact of Prenatal Sonography on the Morbidity and Outcome of Patients With Renal Duplication Anomalies

Historically, most patients with a renal duplication anomaly associated with upper pole hydronephrosis underwent upper pole nephrectomy and partial ureterectomy. Prenatal sonography has resulted in increased recognition of these anomalies and, therefore, earlier urological referral and evaluation. We investigated whether as a result more upper pole moieties were preserved by performing alternative procedures, such as ureteroureterostomy. In addition, the impact on overall morbidity of the disease and its treatment is assessed. Since 1984, of 29 patients treated for ectopic ureter or ureterocele 13 presented initially with a diagnosis of prenatal hydronephrosis. Of these patients, 5 (38.5%) underwent a renal sparing procedure consisting of ureteroureterostomy in 4 and excision of ureterocele with common sheath ureteral reimplantation in 1. The remaining 8 patients underwent upper pole nephrectomy and partial ureterectomy for a nonfunctioning upper pole moiety. In contrast, of 16 patients who presented without having undergone prenatal sonography only 2 (12.5%) underwent a renal preserving procedure. Initial treatment in the remaining 14 patients was upper pole nephrectomy and partial ureterectomy. The average age at initial treatment in the prenatally detected group was 3 months, compared with 5 years in the other group. Only 1 of the 13 patients (8%) in the prenatally detected group had symptoms, whereas 14 of 16 in the other group (87.5%) presented with significant symptoms consisting of sepsis in 12, an abdominal mass in 1, urinary incontinence in 1, and an incidental diagnosis made during evaluation of an associated anomaly in 2. Although there is still controversy regarding the impact of prenatal detection of hydronephrosis on the preservation of renal function in patients with a single system, our results show a beneficial effect in patients with duplication anomalies. This was reflected in our ability to salvage the upper pole moieties 3 times more frequently than was previously possible with minimal morbidity. More importantly, the potential serious clinical manifestations of these duplication anomalies in later life were eliminated by virtue of early treatment.

Torsion of an indirect hernia sac: An unusual cause of acute scrotal swelling in children

OBJECTIVES An indirect inguinal hernia is a common cause of inguinoscrotal swelling in young boys. We describe 3 cases of an extremely unusual entity that has a similar clinical presentation to more commonly diagnosed intrascrotal processes. METHODS Two patients presented with acute hemiscrotal enlargement and pain, and a third patient presented with scrotal enlargement only. All patients underwent a scrotal ultrasound evaluation and subsequent inguinoscrotal exploration. RESULTS All patients had a multiseptated peritesticular fluid-filled mass on ultrasound evaluation. Subsequent inguinoscrotal exploration revealed a torsion of the indirect hernia sac in each case. A high ligation and excision of the sac was curative. CONCLUSIONS Torsion of a hernia sac is an extremely rare entity, and current sonographic imaging fails to clearly diagnose this unusual phenomenon. Because pediatric urologists are commonly called to evaluate a child with an acutely swollen scrotum, awareness of this diagnosis is important.

Indications for and Outcomes of Clean Intermittent Catheterization in Children With Normal Genital Sensation

PURPOSE Clean intermittent catheterization is generally accepted by parents and children with neurogenic bladder. We analyzed the indications for and feasibility of clean intermittent catheterization in children with normal genital sensation. MATERIALS AND METHODS We reviewed the records of 2 girls and 15 boys 15 months to 15 years old (mean age 8 years) on clean intermittent catheterization with normal genital sensation. Indications for clean intermittent catheterization were urinary retention and poor urodynamic compliance with or without hydronephrosis. Parents evaluated the protocol via a questionnaire and the children were studied with age appropriate standard instruments to assess the consequences of clean intermittent catheterization on psychological development. RESULTS There were no medical complications related to clean intermittent catheterization. Four of the 7 children with urinary retention and 7 of the 10 with poor bladder compliance continued the protocol. There was no difference in the results of psychological testing for patients who had success or failure (mean followup 5 years). Parent and patient comfort levels were most important for the success of clean intermittent catheterization. CONCLUSIONS Our results show that clean intermittent catheterization is feasible in children with normal genital sensation but successful in only two-thirds.

Primary adenocarcinoma of the penis.

To our knowledge we report the first case of primary adenocarcinoma of the penis. After extensive evaluation to rule out metastatic disease from other sources, partial penectomy for primary adenocarcinoma of the penis was performed. Select histological stains of the tumor failed to reveal an extra penile origin.

Bilateral spontaneous steinstrasse and nephrocalcinosi associated with distal renal tubular acidosis.

Bilateral spontaneous steinstrasse from the ureteropelvic junction to the distal ureter complicating distal renal tubular acidosis has not been described. We report a case and discuss the clinical presentation, radiographic and metabolic findings, and treatment. Relief of obstructive uropathy with extracorporeal shock wave lithotripsy led to the resolution of the heavy steinstrasse burden.

Transurethral incision of the ectopic ureter for relief of obstruction

Abstract A 32-week-gestation female fetus presented with a diagnosis of left hydroureteronephrosis. Both the right kidney and the amniotic fluid volume were normal. Spontaneous term delivery occurred and postnatal imaging revealed Society for Fetal Urology grade IV hydroureteronephrosis of the left upper pole. Cystoscopy revealed an ectopic ureteral orifice at the bladder neck; this was incised back onto the trigone of the bladder. Follow-up imaging studies revealed resolution of the upper pole hydroureteronephrosis and absence of vesicoureteral reflux. The patient was continent. Select cases of ectopic ureters may be incised transurethrally (as is the ectopic ureterocele) in the neonate.

Effects of α-adrenergic agonist on neobladder water and electrolyte transport

Abstract Objective. Nocturnal urinary incontinence and nocturia are problematic for patients with continent neobladders. Clonidine, an a2-adrenergic agonist, increases water absorption across rabbit ileum; human intestine contains a substantial density of α 2 -adrenergic receptors. We studied the effect of neobladder clonidine instillation and catheterization (to reduce urine-bowel contact time) on nocturnal water and electrolyte reabsorption. Methods. A total of 8 patients with Indiana neobladders constructed after radical cystectomy were studied at a mean of 11.3 months postoperatively under standardized diet and fluid intake. Results. Topical clonidine or catheterization failed to alter nocturnal urine volume, freewater clearance, or absolute excretions of electrolytes in Indiana neobladders; however, the absolute excretion of urine urea nitrogen and osmoles was significantly increased in the catheterized urine collections compared with the baseline urine collections (paired t -test, p = 0.0022 and 0.0091, respectively). Conclusions. Bowel comprising neobladders loses its capacity to significantly alter urinary electrolyte composition by prolonged contact, which may explain the rarity of significant acid-base disturbances in patients with continent neobladders. Unfortunately, topical clonidine does not diminish nocturnal urine volumes, but increased excretion of urea and osmoles with overnight neobladder catheterization may prove beneficial in patients who suffer azotemia or hyperosmolarity.