Keith Waterhouse

Management of 18 Difficult Vesicovaginal and Urethrovaginal Fistulas with Modified Ingelman-Sundberg and Martius Operations

Our experience in the management of difficult vesicovaginal and urethrovaginal fistulas is presented. The fistulas were secondary to radiation damage and extensive local fibrosis owing to previous attempts to repair surgically. Satisfactory surgical repair of the fistulas was obtained by interposition of viable gracilis muscle and labial fibrofatty tissue at the repair site. The patients have been followed for 1 to 2 years postoperatively.

Observations on persistently dilated ureter after posterior urethral valve ablation

The persistent ureteral dilatation frequently seen months or even years after posterior urethral valve ablation, continues to present a dilemma to the urologist. We have classified these dilated ureters into 3 types: (I) unobstructed with either an empty or filling bladder, (II) unobstructed with an empty bladder but obstructed with a filling bladder, and (III) obstructed with either an empty or filling bladder. The majority of ureters with persistent dilatation were found to be of the type II variety where appropriate treatment is not obvious. Classic ureteral tailoring and reimplantation offers little advantage since in such cases a narrower ureter is passed through a new hiatus in an otherwise unchanged bladder. When high renal pelvic pressures are found only with bladder filling, then consideration must be given to not only reconstructing the ureter but also to affecting the dynamics of the bladder and the large urinary output characteristically found in these patients.

The surgical repair of membranous urethral strictures in children.

Of 18 patients treated for membranous urethral strictures after rupture of the prostatomembranous urethra, 16 have had satisfactory results, 1 has been diverted permanently and the repair in 1 case is not yet complete.

Nephrolithiasis and nephrocalcinosis after renal transplantation: a case report and review of the literature.

Stone formation in renal allografts is rare. Although infection or renal tubular acidosis can predispose to calcium deposition in a renal allograft, hyperparathyroidism is usually an accompanying factor. Parathyroidectomy is recommended as the treatment of choice when stone deposition or nephrocalcinosis occurs after transplantation. The reported case demonstrates that aggressive therapy is also necessary to eliminate calculi from the urinary system to avoid mechanical obstruction, continued infection or renal paraenchymal damage.

Evaluation of Anterior Extra Vesical Ureteroneocystostomy in Kidney Transplantation

We evaluated the anterior extravesical ureteroneocystostomy technique in 184 consecutive renal transplants done in 2 consecutive calendar years. Complications included 5 cases of ureteral and 1 of pelvic necrosis, and 2 of ureteral obstruction, with a ureteral complication rate of less than 4 per cent. All cases of pelvic or ureteral necrosis except 1 were seen in cadaver donor kidneys that were imported from other centers. No bladder complications were seen. Pelvioureteral obstruction, presumably of congenital origin in the cadaver donor, was discovered in the kidney after transplantation in 2 cases and was corrected successfully by pyeloureterostomy to the native ureter. The extraordinary simplicity of this technique, coupled with improvement in the complication rate, makes it our procedure of choice.

Complications of Partial Cystectomy in Patients with High Grade Bladder Carcinoma

We herein analyze the results of partial bladder resection in 61 patients with stage A transitional cell carcinoma. Staging was based on preoperative evaluation, operative findings and postoperative microscopic study of the specimen. In 54% of the patients with high grade malignancies local recurrences were noted and the patients eventually died of the disease. There were no recurrences in patients with low grade tumors. Therefore, the grade of bladder carcinoma should be considered when patients are chosen for this operation.

Diagnosis and treatment of neonatal adrenal hemorrhage

Summary Our experience with a small group of infants with adrenal hemorrhage has shown that the clinical course may vary depending upon the extent of the underlying hemorrhage and the presence or absence of adrenal insufficiency or infection. Increased awareness of the factors leading to adrenal hemorrhage and its subsequent complications should lead to early and prompt therapy. Depending upon the extent of the lesion and the ability to exclude neuroblastoma, therapy will range from nonoperative supportive therapy to immediate surgery.

Correction of adult penile curvature with a Nesbit operation

Nesbits technique of excising ellipses of tunica albuginea has been effective in correcting chordee in children. We have used this technique successfully in adults for the correction of 19 congenital and traumatic curvatures, as well as those resulting from stable Peyronies disease. All patients retained potency and reported excellent correction of the deformities. We believe that Nesbits operation is the procedure of choice for the correction of disabling adult penile curvature.

Intrarenal Reflux and its Relationship to Renal Scarring

Intrarenal reflux found during voiding cystourethrography in children has been suggested to be a significant factor in the production of renal damage. To investigate its incidence and effect on renal growth the records and roentgenograms of 150 children with known vesicoureteral reflux were reviewed. Of these children 15 had evidence of intrarenal reflux. Their IVPs were studied for signs of renal parenchymal damage at the time of the initial voiding cystogram as well as up to 4 years later. Evidence of renal damage was seen in 4 of the 15 patients with intrarenal reflux. These same 4 children had gross vesicoureteral reflux.

Transverse Ureteral Advancement Technique of Ureteroneocystostomy (Cohen Reimplant) and a Modification for Difficult Cases (Experience with 121 Ureters)

We reimplanted 121 ureters by the Cohen technique. A modification is introduced for difficult cases, making the Cohen technique more adaptable for dilated ureters and small bladders. Radiographic studies obtained at least 6 months after reimplantation revealed only 1 case of persistent reflux (grade I), no case of contralateral reflux and no obstruction. Even though the series included 35 ureters with grade V primary reflux and 7 primary obstructive megaureters, only 7 ureters were tapered. This finding suggests that the Cohen method might require tapering in a smaller percentage of cases compared to other reimplantation techniques.