Julian Wan

Sibling Reflux: A Dual Center Retrospective Study

PURPOSEnSiblings of index patients with vesicoureteral reflux are known to have an increased incidence of reflux. Previous reports may be biased due to significantly more female siblings undergoing screening. In addition, it has been suggested that screening is unnecessary in older children.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of probands with vesicoureteral reflux. A total of 422 families comprising 622 siblings was identified at our centers from 1985 to 1994. Of the 255 boys and 277 girls newborn to 16 years old (mean age 6.2 years) 85% were evaluated. Almost 43% of the probands (225) were older than 7 years.nnnRESULTSnVesicoureteral reflux was noted in 144 siblings (52 boys and 92 girls, 27%). The majority had low grade reflux but in 111 (77%) maximum reflux grade was II or III. Reflux nephropathy was demonstrated on a nuclear renal scan in 18 of the 132 tested siblings (13.6%). In all of these children reflux was grades II to IV and 27% were older than 10 years.nnnCONCLUSIONSnWhen vesicoureteral reflux is discovered, all siblings should be considered for screening. The evaluation of older siblings remains controversial, since they comprise only a small fraction of all siblings with reflux but may have a significant portion of reflux nephropathy. There was a 27% overall incidence with a 33% rate in girls. The incidence of reflux in siblings decreased after age 7 years but reflux nephropathy was identified even in the older children.

Two-stage repair for severe hypospadias

In 39 patients a 2-stage modified Belt-Fuqua repair was performed for severe hypospadias and chordee. Patient age at initial surgery averaged 2 years and stage 2 was done 7 months later. Testosterone was given before stage 1 to 22 patients (56%) and before both stages to 13 (33%). Of 5 patients with intersex 2 had mixed gonadal dysgenesis, 1 was a true hermaphrodite and 2 were 46 XX male subjects. The preoperative meatal location was subglanular in 9 cases, mid shaft in 8, proximal shaft in 2, penoscrotal in 15 and perineal in 5. Those with subglanular meatus had hypoplastic distal urethras and severe chordee. A dorsal Nesbit procedure for chordee correction was done in 24 cases (62%). Neourethral length ranged from 3 to 7 cm. (average 4 cm.) and average followup was 16 months. Neourethral diverticula developed in 8 cases (21%) and they were repaired uneventfully an average of 7 months (range 2 to 24) after stage 2. Minor urethral strictures (3 distal and 4 proximal) were treated with a single visual internal urethrotomy and there was 1 (2.5%) urethrocutaneous fistula. All children had excellent cosmetic and functional outcomes. A staged approach allows for cosmetic reconstruction of the glans and mucosal collar during stage 1 and offers 2 opportunities to augment penile size with testosterone. Bladder or buccal mucosal grafts are avoided since the prepuce is always adequate. There are no hypospadias deformities, penile shaft torsion or asymmetry. Fistula formation is minimal and strictures are minor. The 2-stage repair remains a safe, reliable alternative for boys with severe hypospadias.

Experience With Vesicoureteral Reflux in Children: Clinical Characteristics

PURPOSEnWe reviewed our 9-year experience with a large population of children with vesicoureteral reflux who were evaluated and treated according to contemporary concepts.nnnMATERIALS AND METHODSnFrom 1985 to 1993 we followed 288 boys and 752 girls with vesicoureteral reflux. If surgery was not performed, patients were on antibiotic prophylaxis and evaluation was done every 18 months with contrast voiding cystography and radionuclide renal imaging. Urine cultures were obtained every 4 months. Two negative voiding cystourethrograms 1 year apart were required to discontinue prophylaxis.nnnRESULTSnThe major reasons for initial evaluation were urinary tract infection in 560 children (54%), voiding dysfunction without urinary tract infection in 156 (15%), sibling surveys in 122 (12%) and prenatal hydronephrosis in 23 (2%). In 150 kidneys (10%) in 132 children scarring at presentation was grade 0 in 10 (7%), I in 18 (12%), II in 27 (18%), III in 30 (20%), IV in 48 (32%) and V in 17 (11%). Of these 132 patients 17 presented at ages less than 1 year (13%), 29 at ages 1 to 3 (22%), 50 at ages 4 to 6 (38%), 24 at ages 7 to 9 (18%) and 12 at ages greater than 10 (9%). No new scars were seen in children on prophylaxis without breakthrough infection. After 1 negative voiding cystourethrogram reflux was noted again in 27% of the cases. Breakthrough infections developed in 62 children of whom a third were older than 7 years. Reimplantation in 205 children (20%) was performed for grade IV to V reflux (101), breakthrough infection (62), advanced age (18), large periureteral diverticulum (12) and noncompliance (3). Five boys and 57 girls (30% of all children) had urinary tract infections after successful reimplantation.nnnCONCLUSIONSnAlmost half of the children with vesicoureteral reflux have no history of culture proved urinary tract infection. Scarring may be associated with any reflux grade and it may be initially diagnosed at any age. Only half of the scars are noted with higher grades of reflux (IV and V). Continuous prophylaxis prevents new scarring. Breakthrough infections are rare but they can occur at ages greater than 7 years. Two consecutive negative cystograms are necessary before discontinuing prophylaxis. Children should be monitored after reimplantation for recurrent urinary tract infection.

Vesicoureteral reflux: practical aspects of evaluation and management

Abstract. The efficacy of both medical and surgical therapy for vesicoureteral reflux (VUR) has been well established. Controversy remains, however, regarding who should be evaluated for the presence of VUR, who should undergo corrective surgery, who should be treated medically and for how long. Medical treatment requires many years of continuous antibiotic prophylaxis, so compliance with therapy is essential. Many children are lost to follow-up, however, and remain untreated after a medical regimen is started. This large number of untreated children raises issues of the appropriateness of blanket therapeutic recommendations for all children with VUR and challenges the clinician to devise more effective treatment strategies.

TOILET HABITS OF CHILDREN EVALUATED FOR URINARY TRACT INFECTION

The toilet habits of 77 girls and 24 boys who were evaluated after having a urinary tract infection were examined prospectively. Children with known urological conditions that can predispose to urinary tract infections were excluded. A voiding cystourethrogram and renal ultrasound were performed, and a diary of toilet habits was obtained for all patients. Six children were lost to followup. Of the remaining 95 children imaging studies were negative in 60 (negative imaging group) and positive in 35 (positive imaging group). Only 10% of the negative imaging group were without constipation or abnormal voiding compared to 60% of the positive imaging group (p = 0.0001). Toilet habits can affect the development of urinary tract infections. Our data suggest that the evaluation of urinary tract infection should include an inquiry into these habits. Among children with negative imaging studies there may be functional problems that promote the development of urinary tract infections.

Expanded Followup of Intravesical Oxybutynin Chloride Use in Children with Neurogenic Bladder

PURPOSEnWe evaluated the long-term results of intravesical oxybutynin chloride use in children with neurogenic bladders who could not tolerate or whose conditions were refractory to oral therapy.nnnMATERIALS AND METHODSnWe reviewed our experience with 28 children (myelomeningocele in 27 and imperforate anus in 1) who presented with urinary incontinence and/or elevated bladder pressures refractory to intermittent catheterization and oral anticholinergic medication. Intravesical oxybutynin was administered to each child by instillation of 5 mg. crushed oxybutynin chloride in 10 cc sterile saline 2 times daily during catheterization.nnnRESULTSnSeven patients (25%) could not tolerate intravesical oxybutynin secondary to anticholinergic side effects. The remaining 21 children have been followed on intravesical oxybutynin for a mean of 35 months (range 3 to 67). Of these 21 children 12 (57%) became completely dry day and night, 5 (24%) achieved daytime continence between catheterizations and 4 (19%) remained clinically unchanged with 2 in diapers. On urodynamics these 21 patients had increased bladder capacity of up to 1,150% (mean 237%, p < 0.0001) and decreased mean maximum filling pressures of -31% (p = 0.002).nnnCONCLUSIONSnAlthough a number of patients continued to have anticholinergic side effects, a majority had significant improvement in urodynamic parameters and continence. The response appears to be durable, and it spares many of these children from undergoing bladder augmentation.

Resolution Rates of Low Grade Vesicoureteral Reflux Stratified by Patient Age at Presentation

PURPOSEnMost children with grades I to III primary vesicoureteral reflux are monitored for years on antibiotic prophylaxis until reflux resolves. While the overall resolution rate of these grades is known, the rates for various patient ages at presentation are unknown. Therefore, we examined resolution rates of these grades for different ages at presentation.nnnMATERIALS AND METHODSnFrom 1985 through 1990, 168 boys (245 ureters) and 433 girls (590 ureters) with all grades of reflux were enrolled in the study and monitored through the end of 1993. Urine cultures were obtained every 4 months and contrast voiding cystourethrography was repeated every 18 months. Age at presentation was stratified into groups younger than 1, 1 to 3, 4 to 6, 7 to 9, and 10 years and older. Resolution rates were then calculated for grades I to III reflux for each age at presentation. Time to resolution was also evaluated for each age and grade.nnnRESULTSnThere were no significant differences between rates of resolution at different ages for each grade. Children less than 10 years old had as high a likelihood of resolution as infants. Neither sex nor bilaterality versus unilaterality was a helpful predictor of resolution. Time to resolution varied widely and it was also not helpful for identifying the cases of reflux that resolved.nnnCONCLUSIONSnLow grade vesicoureteral reflux may not resolve until adolescence and age at presentation is not a reliable predictive factor. Children should remain on prophylaxis for many years unless definitive correction is undertaken.

An analysis of social and economic factors associated with followup of patients with vesicoureteral reflux

PURPOSEnNonsurgical treatment of vesicoureteral reflux requires antibiotic prophylaxis and long-term surveillance. We examined factors that affect followup compliance and influence quality of care in these children.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of 288 boys and 742 girls with vesicoureteral reflux.nnnRESULTSnOf the children treated nonsurgically for vesicoureteral reflux 34% were lost to followup and the majority (80%) were not monitored beyond the 1-year followup appointment. Older maternal age (36 years or older) was significantly associated with improved followup compliance. Paternal age, primary physician type, medical insurance type, income, education level and environment (urban, suburban or rural) were not significant.nnnCONCLUSIONSnApproximately a third of children treated nonsurgically for vesicoureteral reflux will be lost to followup. Only older maternal age predicts for good compliance. Preconceptions about compliance on the basis of other factors, such as socioeconomic status and primary physician type, may be incorrect. Furthermore, the notion that certain forms of medical insurance plans may help to promote followup may also be unsupported. These children would benefit from efforts to improve compliance with a medical regimen or early correction of reflux.

Intrascrotal Epidermoid Cyst With Extension into the Pelvis

An 8-year-old boy presented with an asymptomatic extratesticular, scrotal epidermoid cyst with extension across the urogenital diaphragm into the pelvis. While routine contrast studies and ultrasound were performed, magnetic resonance imaging was most useful in depicting the anatomical boundaries of the lesion, including the intrapelvic extension. Complete excision was performed transcrotally. The lesion is histologically indistinguishable from epidermoid cysts found elsewhere in the external genitalia, that is the penis, scrotum or testis. The etiology is unknown but it may represent a monolayer teratoma of germ cell origin or abnormal embryological closure of the median raphe.

Renal growth characteristics in children born with multicystic dysplastic kidneys

OBJECTIVESnTo report on the growth characteristics of the affected and contralateral kidneys in children born with multicystic dysplastic kidneys (MCDKs).nnnMETHODSnThirty-three patients were enrolled from 1970 to 1995: 23 were initially managed nonoperatively (mean follow-up 3.39 years), and 10 underwent nephrectomy. Patients underwent radionuclide renal imaging and contrast voiding cystography. Serial ultrasonography was used to obtain measurements of the affected and contralateral kidneys. Blood pressure measurements and serum creatinine levels were available in some patients.nnnRESULTSnAmong the 23 nonoperative patients, the affected MCDK involuted in 4 patients during a mean follow-up of 4.5 years at a rate of 1.02 cm/yr (24% annually); 7 kidneys decreased in size at a mean rate of 0.38 cm/yr (5.8% annually); 6 grew at a mean rate of 1.16 cm/yr (9.9% annually); 1 kidney did not change in size; and 5 children were lost to follow-up. The mean size of the contralateral kidneys at birth was 5.3 cm, 2 standard deviations larger than normal. Over time, this relative hypertrophy was maintained at a growth rate of 0.89 cm/yr (18.5% annually). Two patients who had undergone nephrectomy also had serial postoperative ultrasonic renal measurements, and contralateral growth was 0.61 cm/yr (12.16% annually). All but 1 patient had normal blood pressure measurements and serum creatinine levels.nnnCONCLUSIONSnMost MCDKs involute or decrease in size over time, although this may take many years. Contralateral hypertrophy is seen at birth and is maintained during childhood growth, regardless of whether the affected kidney is removed. There is no associated hypertension or malignancy when the dysplastic kidney is left in place.