Lowell R. King

Suggested terminology for duplex systems, ectopic ureters and ureteroceles.

Recommendations are made for the standardization of nomenclature describing duplex systems, ectopic ureters and ureteroceles. The elimination of some terms and redefinition of others are proposed in the hope to eliminate the ambiguity and confusion that exist currently.

Obstructing anterior urethral valves in children.

Abstract Obstructive uropathy in children often means urethral valves. A discussion of anterior urethral valves, outlining the mode of presentation, systematic evaluation, role of therapy and the results obtained, is presented. The total experience of anterior urethral valves at this hospital is summarized. A classification of anterior urethral valves is introduced, relating this entity to a pathophysiologic progression of urologic deterioration.

Renal Dysgenesis and Cystic Disease of the Kidney: A Report of the Committee on Terminology, Nomenclature and Classification, Section on Urology, American Academy of Pediatrics

We believe that the confusion regarding abnormal renal development could be reduced by more precise terminology. Therefore, we suggest precise definitions for dysgenesis, hypoplasia, dysplasia, hypodysplasia, aplasia and agenesis of the kidney. We suggest the term reflux nephropathy be a generic label for any instance of abnormal renal morphology (gross or microscopic) associated with vesicoureteral reflux. Hypoplasia and hypodysplasia can be subclassified on the basis of associated urological criteria. There have been many previous attempts to classify cystic disease of the kidney but none has been accepted collectively by pathologists, urologists, nephrologists and radiologists. On the basis of known patterns of inheritance, a classification is outlined in which renal cystic disease is divided into 2 major groups: genetic and nongenetic. Each entity is discussed.

Falsely Negative Doppler Examinations in Testicular Torsion

Use of the Doppler ultrasonic flowmeter to assess testicular perfusion has potentially precise application in the evaluation of acute scrotal swelling. Recent reports suggest an almost infallible degree of accuracy in differentiating testicular torsion, with reduced or absent blood flow, from inflammatory processes, with accompanying increased vascular perfusion. This report of 4 falsely negative Doppler examinations confirmed by surgical exploration warns against relying on this as a single test in the diagnosis of testicular torsion. Only thorough clinical assessment of each patient and exploration in doubtful cases will assure maximum testicular salvage.

Micturition Urodynamic Flow Studies in Children

Voiding abnormalities are encountered frequently in pediatric patients. Symptoms of daytime incontinence, frequency and nocturnal enuresis in any combination may indicate underlying neurophysiologic detrusor imbalance. Incomplete evaluation of these symptoms can result in inappropriate medical therapy or even ineffective operations. Within the preceding 7 months 34 children with hard-core voiding abnormalities were evaluated with urodynamic techniques. Several categories of abnormal voiding patterns were identified, including the hyperactive external sphincter, uninhibited pediatric neurogenic bladder, detrusor hyperreflexia secondary to chronic cystitis, hyperactive external sphincter with hypotonic bladder and the hyperactive external sphincter with detrusor irritability. All patients received specific pharmacotherapy based on presenting signs and symptoms, and voiding pattern abnormality. Of the 24 patients who have been treated in this manner and were evaluated 83.5 per cent have had complete remission of symptoms while on therapy, the remainder being improved but still having occasional symptoms. The technique and data demonstrate that children with hard-core voiding abnormalities can achieve rehabilitation with urodynamic assessment.

Reflux in Complete Duplication in Children

Reflux is the most common abnormality associated with complete ureteral duplication. Several authors have emphasized early surgical correction of reflux when it occurs in duplicated systems. because of a negligible success rate in non-operative therapy. Our practice has been to judge an orifice with reflux on its own merit, that is position, appearance and submucosal tunnel length. Realizing that this philosophy is not in total agreement with most of the literature on reflux in ureteral duplication we have reviewed 59 cases to ascertain whether our non-operative approach has justification. In this study early operation was elected in 61 per cent of those patients with reflux in association with total duplication. However, in 48 per cent of patients followed with non-operative surveillance reflux has either stopped spontaneously or is medically stable.

Quantitative nuclear cystogram. Aid in determining spontaneous resolution of vesicoureteral reflux.

The quantatitative data derived from serial nuclear cystograms over a five-year period in 37 children were compared with the clinical course. A direct correlation (92 per cent) between an increasing bladder volume at which reflux occurs was observed in the clinically stable group. In the clinically unstable group, there was a 75-per cent correlation of an unchanged or decreasing bladder volume at which reflux occurs. The quantitative nuclear cystogram provides an objective as opposed to subjective data base for management of patients with vesicoureteral reflux.

Direct and indirect radionuclide cystography

Direct radionuclide cystography, using short half-life radiopharmaceuticals, is considered to be more reliable for detecting vesicoureteral reflux than conventional roentgenographic techniques. In addition to the detection of vesicoureteral reflux, other parameters determined include the bladder volume when reflux occurs, calculation of volume of fluid that has refluxed, accurate calculation of residual urine volume, estimation of reflux drainage time, and the visualization and diagnosis of gross anatomic abnormalities. Currently, a major disadvantage is poor resolution, prohibiting analysis of small bladder defects and urethral abnormalities. The major advantage of nuclear cystography is the small radiation dose delivered with its use. It is estimated that at least 100 radionuclide studies can be performed for the same radiation expense as a single roentgenographic study.

Voiding Pattern Abnormalities in Normal Children: Results of Pharmacologic Manipulation

Urodynamic studies were done on 50 children with voiding pattern abnormalities, characterized by daytime incontinence, damp pants, nocturnal enuresis, frequency and recurrent urinary tract infections. These studies included cystometry, uroflowmetry and pelvic floor/external urethral sphincter electromyography. Of the 50 children studied 37 were treated with various pharmacological agents based on 8 recognized urodynamic patterns. Thirty-one children (84 per cent) became totally asymptomatic while on pharmacotherapy and 4 (11 per cent) demonstrated marked improvement in clinical symptoms during the course of this study. Appropriately directed urodynamic studies and treatment with specific pharmacological agents can treat (retrain) effectively children with voiding pattern abnormalities.

Techniques and Results of Urodynamic Evaluation of Children

Simultaneous recording of intravesical pressure, urine flow rate and anal sphincter electromyography was undertaken in 25 children with a variety of urological problems. Urethral pressure profile measurement was obtained in 3 of these patients and was used as an adjunct to cystometry alone in 5 others. The diagnostic patterns that emerged were useful in selecting specific pharmacologic and surgical therapeutic measures.