Patrick H. McKenna

Ureteral Bladder Augmentation

Virtually all segments of the gastrointestinal tract have been used successfully in augmentation cystoplasty. The complications inherent in enterocystoplasty are well described. Megaureters subtending effete kidneys (poorly or nonfunctioning) provide a novel and excellent source of augmentation material with urothelium and muscular backing, free of the electrolyte and acid base disturbances, and mucus production that plague enterocystoplasty. Augmentation cystoplasty using detubularized, reconfigured, otherwise disposable megaureter, with or without ipsilateral total or partial nephrectomy, was performed in 16 patients (mean age 8.8 years, range 1 to 25) with inadequate and dysfunctional bladders. Postoperative followup varied between 8 and 38 months (mean 22). The overall renal function and radiographic appearance of the remaining upper tracts have remained stable or improved in all patients. Of the 16 patients 15 require intermittent catheterization and 1 voids spontaneously. Ten patients are continent day and night, 5 have improved continence (4 damp at night and 1 stress incontinence) and 1 has failed to gain continence despite good capacity and compliance. Complete postoperative urodynamic evaluations in 12 of 13 patients show good capacity, low pressure bladders with no instability. Complications occurred in 5 patients, including transient urine extravasation in 2, contralateral ureterovesical obstruction in 2 and Mitrofanoff stomal stenosis in 1. Augmentation ureterocystoplasty combines the benefits common to all enterocystoplasties without adding any of the untoward complications or risks associated with nonurothelial augmentations.

High Grade Vesicoureteral Reflux: Analysis of Observational Therapy

Between 1981 and 1987, 300 patients with high grade (III, IV and V international classification) vesicoureteral reflux were treated at a single pediatric hospital. Only patients with primary vesicoureteral reflux were included in the study. The guiding principle during this period was that all patients with high grade vesicoureteral reflux would be observed on prophylactic antibiotics (observational therapy) and surgical correction would be reserved for specific indications. Of the 300 patients 132 received observational therapy alone and 168 required surgical correction for specific indications after varying periods of observation. In both groups the duration of persistent reflux was analyzed using a life-table method. In patients with grade V reflux we observed resolution in 3 patients whereas 23 required surgical correction. Of those patients in the observation group with grade IV reflux 83% had persistent reflux at 2 years and 70% still had reflux at 5 years. For those with grade III reflux the persistence rate was 83% and 50%, respectively. Neither age, sex nor side of reflux had a correlation with the rate of resolution. When tested grade of reflux correlated loosely (p = 0.07). During the period of observational therapy new renal scars developed in 23 patients (8%). We conclude that high grade vesicoureteral reflux can resolve in a minority of patients over a protracted interval. On the basis of this analysis, we advocate consideration of surgical correction in these patients after a 4-year period of observational therapy and for specific indications.

Outcome Analysis of the Modified Mathieu Hypospadias Repair: Comparison of Stented and Unstented Repairs

PURPOSEnWe compared surgical outcomes of stented and unstented Mathieu repairs in boys with primary distal hypospadias, and evaluated the efficacy and safety of caudal analgesia relative to other forms of analgesia (penile block and epidural analgesia).nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of 336 consecutive boys who underwent the modified Mathieu repair for primary distal hypospadias. A urethral stent was placed in 114 patients and nonstented repair was performed in 222. Adjunct caudal analgesia was given in 136 cases, a penile block in 158 and continuous epidural analgesia in 42.nnnRESULTSnNone of the unstented cases had urinary retention. Analysis of surgical outcomes revealed no difference in fistula formation between patients with and without stents (2.63 versus 2.70%, respectively, p > 0.999). Overall complication rates in the stented and unstented groups were not significantly different (2.63 versus 3.60%, respectively, p = 0.756). The fistula rate in patients who received adjunct caudal analgesia was no different than in those who received other forms of adjunct analgesia (2.21 versus 3.0%, respectively, p > 0.999).nnnCONCLUSIONSnThese data suggest that successful Mathieu hypospadias repair is independent of the use of a stent. Caudal analgesia, a penile block and epidural analgesia provided effective postoperative pain control with no difference in complication rates. To our knowledge our report represents the largest observational study reported to date comparing stented and unstented repairs. However, because of the small number of complications in each group, a much larger study is required to determine statistically significant differences among these groups.

Extravesical Nondismembered Ureteroplasty with Detrusorrhaphy: A Renewed Technique to Correct Vesicoureteral Reflux in Children

We performed an extravesical nondismembered reimplant to correct surgically primary vesicoureteral reflux in 45 patients (65 renal units) between April 1989 and September 1990. Of the units 6 had grade I reflux, 16 grade II, 23 grade III, 14 grade IV and 6 grade V. Only patients with primary reflux were included in this study. The success rate was 100% for grades I to III, 92.9% for grade IV and 66.7% for grade V. Overall, the reflux was cured in 62 of the 65 operated renal units (95.4%) or 95.6% of the patients (43 of 45). Postoperative morbidity and complications were minimal. No cases of postoperative obstruction were detected on excretory urography 6 weeks postoperatively. Seven children (16%) suffered from transient inadequate bladder emptying as assessed by post-void ultrasound residual evaluations. This problem resolved spontaneously after a maximum of 4 weeks of clean intermittent catheterization. Compared to conventional transvesical technique, the discomfort related to bladder spasms during the postoperative period was subjectively decreased and patients had no prolonged hematuria.

Reduction in tumor burden allowing partial nephrectomy following preoperative chemotherapy in biopsy proved Wilms tumor.

During the last 6 years a treatment protocol of radiographic staging along with percutaneous biopsy to establish a histological diagnosis has been used in 37 patients with Wilms tumor. Combination chemotherapy was given for 4 to 6 weeks before definitive surgical resection. In 9 patients tumor shrinkage was sufficient to permit preservation of a portion of the affected kidney(s). In stage V disease partial nephrectomy was accomplished in 5 patients. In 4 additional patients with unilateral disease downstaging also allowed partial nephrectomy. The radiological and histological changes that allowed this limited surgery are analyzed and compared.

Iliac Osteotomy: A Model to Compare the Options in Bladder and Cloacal Exstrophy Reconstruction

Bladder exstrophy and cloacal exstrophy present challenging reconstructive problems. Traditionally, bilateral posterior iliac osteotomy has been performed in the majority of patients undergoing primary closure for these abnormalities. Recently, 2 anterior osteotomy approaches have been proposed: 1) incision of the ilium transversely above the acetabulum (transverse osteotomy) and 2) incision of the superior ramus of the pubis (superior ramus osteotomy). We devised a new anterior mid-iliac diagonal osteotomy that provides a more functional pelvic closure. To provide a fair comparison of the procedures we developed a pelvic exstrophy model based on data from a 3-dimensional computerized tomogram of a 3-year-old patient with classical bladder exstrophy. The different osteotomies were then performed on the model and the results were compared. Our new anterior mid-iliac diagonal osteotomy correction allowed the best surgical approach, provided the best correction of the flattened ilia bony deformities, was performed in the thinnest area of marrow bone and resulted in the best pelvic symmetry.

Effectiveness of preoperative chemotherapy in the treatment of Wilms tumor with vena caval and intracardiac extension.

Surgical treatment of Wilms tumor with vena caval and intracardiac extension is challenging, often requiring cardiopulmonary bypass. We report the response to preoperative chemotherapy in 3 patients following a protocol at our hospital. The tumor thrombus was limited to the inferior vena cava in 2 patients and extended to the right atrium in 1. All 3 patients had marked reduction or complete eradication of the venous thrombus, facilitating the final surgical procedure. The patients are disease-free 18 months to 7 years after the initial treatment. Our protocol involves initial radiographic staging followed by needle biopsy, chemotherapy, repeat radiographic staging, definitive resection and additional chemotherapy. Our results confirm the effectiveness of this approach, which appears to decrease morbidity associated with intracaval and intra-atrial tumor extension.

Neonatal intervention for severe antenatal pyelocaliectasis

The postnatal management of the antenatally detected ureteropelvic junction obstruction relies on several factors, including the degree of hydronephrosis detected postnatally, the renogram washout curve, and the degree of renal function. It is imperative for the urologist to review all renal scans because of the inherent pitfalls in performing and interpreting these studies. A select population demonstrating severe pyelocaliectasis and poor function exists in which an intraoperative renal biopsy may be a better predictor of future renal function when compared with the preoperative renal scan. We present a patient with poor renal function that normalized with early surgical intervention.

The Effect of Wilms Tumor Chemotherapy on Contralateral Renal Growth After Nephrectomy

PURPOSEnOur aim was to evaluate the effect of current Wilms tumor chemotherapy on renal growth and function after unilateral nephrectomy.nnnMATERIALS AND METHODSnYorkshire piglets were enrolled in 2 study groups: group 1--6 underwent unilateral nephrectomy and placebo infusion, and group 2--10 underwent nephrectomy, and infusion of 7.5 mcg/kg. actinomycin D and 0.75 mcg/m2 vincristine according to the National Wilms Tumor Study 4 protocol. Weekly measurements of renal size by ultrasound and gross specimens at sacrifice at age 11 weeks were examined and weekly laboratory studies were recorded. Growth rates of renal length and volume were evaluated by linear regression analysis. Terminal renal length and volume were compared between groups.nnnRESULTSnMean slope plus or minus standard deviation of the rate of growth in length in the control and chemotherapy groups was 0.067 +/- 0.004 and 0.074 +/- 0.011, respectively (p < or = 0.148, not statistically significant). Mean slope of growth in volume was 1.401 +/- 0.240 versus 1.642 +/- 0.456 (p < or = 0.252), average terminal renal length was 10.71 +/- 1.02 versus 11.58 +/- 1.03 cm (p < or = 0.13, not significant) and mean final volume was 128.67 +/- 32.41 versus 137 +/- 32.52 cc (p < or = 0.65). No differences in final serum creatinine levels were noted.nnnCONCLUSIONSnChemotherapy for Wilms tumor did not adversely affect contralateral renal growth or function in a nephrectomized piglet model.

Citrobacter diversus urosepsis and cerebral abscess in a child with antenatal hydronephrosis.

One percent of all pregnancies are found to have an antenatal abnormality; of these, 20% involve the genitourinary system. Today, controversy still exists regarding the postnatal management of some antenatal abnormalities detected by ultrasound. We present a case in which antenatal hydronephrosis initially detected by ultrasound appeared to resolve in utero. Postnatally, the child developed Citrobacter diversus urosepsis, meningitis, and cerebral abscess. Voiding cystourethrogram obtained after resolution of sepsis revealed grade IV reflux. This case underscores the importance of a full postnatal evaluation for all children with antenatal hydronephrosis and alerts clinicians to a virulent pathogen not commonly associated with urinary tract infection.