Kenneth A. Kropp

Urethral Lengthening and Reimplantation for Neurogenic Incontinence in Children

We describe our experience with a urethral lengthening-reimplantation operation for the correction of incontinence in 13 myelomeningocele children, 11 of whom had failed to achieve continence on a program of intermittent clean catheterization. The procedure involves lengthening the urethra by formation of a bladder tube, which is reimplanted back into the bladder through a submucosal tunnel. This procedure allows a catheter to be passed but prevents urine from leaking. All of the operated cases are included. All of the children are out of diapers and socially dry. Followup ranged from 8 to 36 months and the problems encountered are described.

Preservation of renal function in children with myelomeningocele managed with basic newborn evaluation and close followup

PURPOSEnChildren with myelomeningocele who leak with high intravesical pressures are at risk for upper urinary tract deterioration. Urodynamic study shortly after birth and routinely thereafter has been advocated to predict which newborns are at risk for upper tract deterioration. We hypothesize an approach that excludes routine application of urodynamic evaluation in neonates, reserving this study for use only when clinically indicated, is a safe and effective management option.nnnMATERIALS AND METHODSnOf 188 patients seen in the myelomeningocele clinic 84 underwent initial evaluation at age 6 months or less and comprise the study group. Initial evaluation consisted of a history, physical examination, urine culture and renal ultrasound. Infants with hydronephrosis or evidence of retention were placed into a high risk group and all others were placed into a low risk group. High risk patients underwent prompt urodynamic evaluation. High and low risk patients were followed closely at 2 to 4-month intervals with serial physical examination, upper tract imaging and urine culture. Conversion from low to high risk occurred with new onset hydronephrosis, febrile urinary tract infection, urinary retention or incidental finding of vesicoureteral reflux at the time of evaluation for continence. These findings warranted urodynamic evaluation and appropriate intervention. Upper tract deterioration, defined as new onset hydronephrosis, was distinguished from renal deterioration, defined as cortical thinning or scarring, failure of renal growth or decreased renal function on renal scan.nnnRESULTSnA total of 18 infants were placed into the high risk group at initial evaluation, including 12 for retention and 6 for hydronephrosis. The majority of patients were treated with clean intermittent catheterization or vesicostomy. Of the 65 infants placed into the low risk group 29 were converted to high risk at a mean age of 3.1 years, most commonly for febrile urinary tract infection (45%), and appropriate intervention was instituted. Mean followup is 10.4 years (range 0.25 to 26.5). Despite the occurrence of upper tract deterioration, renal deterioration occurred in only 2 of the 162 total renal units (1.2%).nnnCONCLUSIONSnBasic evaluation of the newborn with myelomeningocele along with careful followup and intervention when indicated results in an excellent rate of renal preservation and represents a safe method of management.

Proximal Ureteral Stent Migration: An Avoidable Complication?

PURPOSEnThe parameters responsible for proximal ureteral stent migration were quantitated.nnnMATERIALS AND METHODSnWe compared 16 patients seen between 1990 and 1993 with stent migration to 32 patients whose stents did not migrate.nnnRESULTSnThe stent indwelling time and number of stents with a proximal curl of less than 180 degrees were similar between the groups. More patients with migration had stents that were shorter than the ideal length, with a distal curl of less than 180 degrees and a proximal curl in the upper calix versus the renal pelvis.nnnCONCLUSIONSnA shorter than ideal stent, inadequate distal curl and a proximal curl in the upper calix appear to be significant factors in the process of stent migration.

Effects of Hypothermia on Testicular Ischemia

The ischemic effects of prolonged testicular torsion have been well documented; however, prevention or arrest of the damaging effects of prolonged ischemia has been incompletely studied. Two groups of Sprague-Dawley rats were subjected to varying lengths of bilateral testicular ischemia. Group I underwent normothermic ischemia for two, four, and six hours. Likewise, Group II underwent similar time periods of ischemia, however, after thirty minutes of normothermic ischemia the scrotum of each animal was placed into an ice bath maintained at 4C. Two weeks postoperatively, bilateral orchiectomy was performed. Histology of the testes of the two groups was compared. Neither group revealed significant destruction of the germinal epithelium after two hours of ischemia. Group I revealed only 25% preservation of the germinal epithelium at four hours and only 8% preservation at six hours of ischemia. In contrast, Group II which received ice showed 90% preservation of germinal epithelium at four hours and 85% preservation at six hours of ischemia. We conclude that external ice application significantly preserves seminiferous tubules at four and six hours of ischemic injury in the rat testicle.

Management of Urinary Incontinence by Bladder Tube Urethral Lengthening and Submucosal Reimplantation

We reviewed the first 25 urethral lengthening and reimplantation procedures done at our institution in 24 patients. All patients had failed to achieve dryness on medical or surgical therapy for total urinary incontinence. A total of 32 patients had neurogenic incontinence. The patients were followed for 1.5 to 7 years. Late complications included catheterization difficulties, vesicoureteral reflux, febrile urinary tract infection, calculi and peritonitis. Reoperations were required in 19 patients primarily because of our initial failure to recognize the necessity of providing a low pressure, high capacity reservoir. The reoperation rate on the continence mechanism was low. Of 24 patients 20 are continent and require no pads or diapers.

Conservative management of suspected bladder rupture after augmentation enterocystoplasty

Bladder rupture after augmentation enterocystoplasty is a potentially life-threatening condition. We reviewed our experience with 13 patients who presented to our institution with 15 episodes of sudden onset of abdominal pain and rebound tenderness, and were diagnosed on clinical grounds to have peritonitis secondary to a suspected bladder augmentation rupture. (Three patients had had similar episodes treated previously elsewhere with abdominal exploration and repair of an augmentation rupture.) These episodes were initially managed with hospitalization, bladder drainage with an indwelling catheter, intravenous antibiotics and serial abdominal examinations. Cystogram and/or computerized tomography was diagnostic in only 3 of 7 cases in which it was performed. In 13 of 15 instances signs and symptoms of peritonitis quickly resolved, and intermittent catheterization was resumed after a mean of 12 days. In the remaining 2 patients delayed surgical repair of a bladder rupture was done in 1, and exploration and repair of an incarcerated internal hernia were done in 1. Although prompt abdominal exploration is the gold standard for suspected bladder augmentation rupture, treatment of peritonitis as bladder rupture in patients with a bladder augmentation by nonoperative techniques was successful in 87% of episodes.

Abdominal Cerebrospinal Fluid Pseudocyst: Occurrence after Intraperitoneal Urological Surgery in Children with Ventriculoperitoneal Shunts

Increasingly, children with ventriculoperitoneal shunts are undergoing urinary tract reconstructive surgery with bowel. The peritoneal end of the ventriculoperitoneal shunt tubing usually is exposed during the procedure, making the system vulnerable to infections and malfunction. The records of 103 myelomeningocele children with ventriculoperitoneal shunts and bowel-bladder reconstructive surgical procedures (27) were reviewed for evidence of an abdominal cerebrospinal fluid pseudocyst (6). Pseudocyst formation occurred in only 1 of 76 ventriculoperitoneal shunt patients (1.3%) who had not undergone versus 6 of 27 (22%) who had undergone an intra-abdominal procedure. The 6 children had a total of 8 pseudocysts, including 7 pseudocysts that developed 8 days to 47 months (average 15.1 months) after the reconstructive surgery and 1 that developed before reconstructive surgery. All patients had abdominal symptoms (pain or mass) or symptoms of increased intracranial pressure. Treatment included computerized tomography-guided needle aspiration or abdominal exploration with cyst evacuation and shunt repositioning or replacement. The walls of the pseudocyst were formed by matted loops of bowel. Additional shunt surgery was required in 5 patients with conversion to ventriculoatrial shunts. We conclude that the development of an abdominal cerebrospinal fluid pseudocyst is at least in part related to the prior abdominal surgery. Thus, pediatric urological and general surgeons caring for children with ventriculoperitoneal shunts should be aware of this complication.

Urethral Lengthening and Reimplantation: Incidence and Management of Catheterization Problems

PURPOSEnCreation of a 1-way catheterizable valve has resulted in dryness for a large group of children with intractable urinary incontinence. We document the incidence, time course and management of catheterization problems in 49 children who underwent urethral lengthening and reimplantation for intractable incontinence.nnnMATERIALS AND METHODSnWe reviewed the records of 21 boys and 28 girls who underwent urethral lengthening and reimplantation between 1982 and 1995. Catheterization problems were defined as the inability of the patient or a family member to pass the catheter, and divided into early only, late only, recurrent and persistent problems.nnnRESULTSnOf the 49 patients 46 had neurogenic incontinence secondary to myelomeningocele and 35 (72%) never had difficulty catheterizing. Of the 14 children (28%) who had difficulty 7 (50%) were boys and 7 (50%) were girls. Two children (4%) with early only difficult catheterization have had no further difficulties during the last 14 and 6 years, respectively. In 3 children (6%) late only difficult catheterization began 17, 24 and 35 months, respectively, after the original bladder neck surgery. These problems were solved by changing to a Coudé catheter and/or avoiding over distension. The 7 patients (14%) with recurrent catheterization problems, some with long intervals between episodes, now catheterize easily. The 2 children (4%) with persistent problems required alternate access to the bladder.nnnCONCLUSIONSnThe majority of children (72%) who undergo urethral lengthening and reimplantation never have any difficulty catheterizing. Those in whom difficult catheterization develops can be treated with minimally invasive methods without compromising the goals of the original surgery.

Pediatric Urolithiasis in Sub–Saharan Africa: A Comparative Study in Two Regions of Cameroon

Objective: To determine the composition of caculi and the predisposing factors for stone nucleation and growth in children from two regions of Cameroon.Methods: This was a cross–sectional study involving 21 children, 17 from the northern and 4 from the southern region, over a 6–year period. Data on age, diet, residence, clinical presentation, location of stone, and results of stone analysis were collated following a preestablished proforma. A computerized analysis of the data was carried out. The constituents of stone sections and nidus were assembled so as to determine the principal causes of stone nucleation and growth.Results: Pediatric urolithiasis was more common in the northern Sahelian belt of Cameroon. Males and rural dwellers were more commonly affected. Endemic (bladder) stone disease was found in the majority of the patients. All stones were mixed. The most frequent constituents of the stones were ammonium urate, struvites, and whewellite in descending order of percentage mean volume per stone. The nidus was available for study in only 10 stones, and its composition revealed heterogeneity of causes of nucleation. The commonest cause for stone formation and growth were infection and hyperuricosuria (malnutrition).Conclusions: Pediatric bladder stone disease is not uncommon in northern Cameroon. Many factors combined to predispose to stone nucleation and growth, but the level of socioeconomic development was preponderant. Stone composition indicated that urolithiasis in children was a heterogeneous disorder, but hyperuricosuria, insufficient diuresis, and infection associated with malnutrition seemed to be the most common causes.

Cryptorchidism in meningomyelocele

investigation, we do not know if these PFT abnormalit ies will persist. Several other childhood illnesses which affect pulmonary function are related to adult chronic lung disease. 11 We do not know if increased or decreased therapy for JRA will alter these abnormal PFT results. Finally, we can only speculate that specific therapy for these pulmonary function abnormalities might improve the patients health. Certainly, in J R A patients who report exercise intolerance, pulmonary function tests including oximetry with exercise should be obtained to see if pulmonary involvement, and not solely joint discomfort, is restricting the patients exercise.