John R. Woodard

Prognostic Features in Infants With Obstructive Uropathy Due to Posterior Urethral Valves

The histories of 22 infants presenting during the first year of life with obstructive uropathy due to posterior urethral valves were analyzed to determine outcome and prognostic features. Mean patient age at the time of the initial surgical intervention was 39 days, and the mean duration of followup inclusive of renal function data was 5.8 years. One patient died (5 per cent) and one had end stage renal disease. The mean preoperative and postoperative serum creatinine concentrations during the initial hospitalization were 3.1 and 1.4 mg. per dl., respectively. Neither value was significantly predictive of the creatinine concentration at final followup. In contrast, the nadir creatinine value during the first year of life correlated significantly with final renal function. Children with nadir creatinine values less than or equal to 0.8 mg. per dl. by 12 months of age maintained creatinine levels less than or equal to 1.1 mg. per dl. at the time of final evaluation, whereas children with higher values during the first year of life were likely to have progressive renal failure. Of 19 final creatinine determinations 6 were normal and 5 exceeded 1.5 mg. per dl. Proteinuria, hypertension, renal biopsy findings, urinary infection, unilateral nephrectomy and type of surgery did not correlate significantly with functional outcome. Followup studies of longer duration are needed to determine the ultimate outcome of these patients, more than half of whom had some degree of renal insufficiency at final evaluation.

Modern treatment of cloacal exstrophy

We have treated 12 newborns with cloacal exstrophy (10 classical and 2 variants) since 1980. Eleven infants underwent repair and they are all surviving; the one nonoperated infant died of pulmonary hypoplasia. There are six genetic females and six genetic males, five of whom are being raised as females. The initial operation consisted of separating the bowel from the bladder to create an intestinal stoma; closing the omphalocele; and reapproximating (5), closing (4), or leaving the exstrophied bladder undisturbed (2). The importance of creating a tailgutostomy instead of an ileostomy to prevent problems with diarrhea, dehydration, and acidosis is emphasized. There have been 71 subsequent operations in these 11 patients (28 general surgical, 25 urological, 9 neurosurgical, and 9 orthopedic). Quality of life, rather than survival, is now the major issue facing patients with cloacal exstrophy. All of these patients except one are neurologically normal. The defect is closed in all patients. Three patients wear no appliances, 7 wear one (gastrointestinal [GI]), and one wears two (GI and genitourinary [GU]). We developed a scoring system to analyze bowel and bladder continence: voluntary control = 3; control with an enema program or intermittent catheterization = 2; incontinence with a well-functioning stoma = 1; and incontinence without a stoma = 0. The best continence score is 6 (GU + GI). We currently have 7 patients with a continence score of 1 (colostomy + incontinent bladder); 1 with a score of 2 (ileostomy + incontinent ureteroenterostomy); 2 with a score of 4 (enema program + continent urinary diversion); and 1 with a score of 5 (enema program + continent bladder).(ABSTRACT TRUNCATED AT 250 WORDS)

Reconstruction of the Urinary Tract in Prune Belly Uropathy

Ten patients with prune bell uropathy, including 7 neonates, were treated with extensive surgical tailoring of the upper urinary tracts using primarily the upper ureteral segment. Simultaneous transabdominal orchiopexy, particularly in the neonate, is described as a useful adjunct. Our early results in these patients justify this aggressive approach.

The Role of Vesicostomy in the Management of Anterior Urethral Valves in Neonates and Infants

We performed vesicostomy as the initial form of management in 2 male newborns and 1 infant with anterior urethral valves associated with proximal urethral diverticula and bilateral hydronephrosis. Prompt improvement in the degree of hydronephrosis was noted after vesicostomy in all 3 patients along with improvement in renal function in 2 who had presented with renal insufficiency. Subsequently, 2 patients have undergone vesicostomy closure and transurethral valve fulguration, and 1 also required ureteral reimplantation for persistent vesicoureteral reflux. The use of vesicostomy in the newborn period rather than transurethral fulguration prevented the potential complications of urethral stricture and inadequate valve resection that can occur owing to the small size of the neonatal urethra. Furthermore, a period of vesicostomy drainage before eventual ureteral reimplantation for severe vesicoureteral reflux obviated the need for ureteral tailoring.

Reflux in opposite ureter after successful correction of unilateral vesicoureteral reflux

Reflux developed in the contralateral ureter in 20 per cent of our patients undergoing unilateral ureteral reimplantation for reflux. This occurrence was not predictable from the preoperative evaluation. Bilateral reimplantation may be indicated in some patients requiring surgical correction for demonstrated reflux.

Pyeloplasty in the Young Infant

The urgency, safety and benefits of performing pyeloplasty during the first weeks of life currently are being questioned. We reviewed our experience with 114 pyeloplasties in 103 infants and young children performed between 1983 and 1987. The 34 patients who underwent an operation before they were 3 months old were compared to 69 operated upon after 3 months. The surgical results in the 2 groups were equally good, with 90 per cent of the cases having an improved or stable postoperative excretory urogram or renal scan. Complications were few and were more common in the older age group, in which 7 children required a secondary procedure, including 2 for recurrent obstruction at the ureteropelvic junction. No patient in the younger age group required a secondary procedure for treatment of a complication or recurrent obstruction. Our findings indicate that the success of pyeloplasty performed during the first weeks of life is equal to that performed at a later patient age and were not more likely to be followed by a complication.

Ureteral Tailoring: A Comparison Of Wedge Resection With Infolding

A retrospective analysis of 44 consecutive pediatric ureteral reimplantations in 42 patients (51 ureters reimplanted) is presented, in which the ureter was tapered by infolding or wedge resection. Few postoperative complications occurred and the results were essentially comparable for the 2 groups, although slightly more postoperative ureteral obstruction occurred in the wedge resection group. Over-all success rate (no postoperative reflux and no obstruction) was 95% for the infolded group and 90% for wedge resection group. Stent time and hospital stay were significantly less for the infolded group.

Application of Horton-Devine Principles to the Repair of Hypospadias

We describe the results and complications of the Horton and Devine techniques for repairing hypospadias in 140 children. The V-shaped glandar flap plasty was done in all patients, either as part of a 1-stage operation in some or as the final step in a staged procedure in others. The principles of Horton and Devine were found useful not only in primary repairs but also in achieving a satisfactory result in secondary and complicated cases. Urethrocutaneous fistula was the most common complication. With an average of 1.5 operations per patient the functional and cosmetic results have been excellent.

Segmental renal vein renins and partial nephrectomy for hypertension in children

Hypertension in children often is curable surgically. In many instances the causative lesion will be segmental and either vascular or parenchymal. We report on 5 children with a segmental lesion in whom the elevated segmental renal vein renins correctly predicted cure of the hypertension following partial nephrectomy.

The Expanded Role of Transureteroureterostomy in Pediatric Urology

Transureteroureterostomy was used in 31 patients as a component in urinary undiversions, salvage procedures for failed reimplants/reconstructions and diversions with a sigmoid antirefluxing conduit or end cutaneous ureterostomy, as well as an adjunct to reimplantation procedures complicated by an abnormal bladder that precluded reimplantation of more than 1 ureter. Reconstruction in 29 patients involved procedures that changed the drainage of the recipient ureters for various reasons, including obstruction, reflux, undiversion and diversion. A neurogenic bladder was present in 26 patients and an additional 4 patients had a significant bladder pathological condition. Both ureters were dilated in 17 patients, while 1 was dilated in another 6. This series illustrates the versatility and confirms the success of transureteroureterostomy in high risk, complicated reconstructive urological procedures in children.