Rafael V. Pieretti

Congenital bladder diverticula in children

BACKGROUND/PURPOSE The authors report their experience with the management of congenital bladder diverticula in children. METHODS The authors reviewed the histories of six boys (mean age, 4.4 years) in whom congenital bladder diverticula was treated from 1980 to 1996. Diverticula were unilateral in four patients and bilateral in two patients. All patients presented recurrent urinary tract infection, and two boys had several episodes of urinary retention. Secondary kidney damage was present in two patients with ureteral obstruction and one with vesicoureteral reflux. Surgical treatment was undertaken in all patients. RESULTS After surgical treatment, none of the patients has had recurrence of the diverticula, and all remain asymptomatic. CONCLUSIONS Congenital bladder diverticula have a wide clinical spectrum and could lead to severe kidney damage. Urinary tract infection and urinary retention are the most frequent presentation forms. Surgical treatment should be indicated in all symptomatic cases according to each anatomic and functional situation.

Late complications of newborn circumcision: a common and avoidable problem

PurposeThe purpose of this paper is to study the types of operative and post-operative late complications resulting from newborn circumcisions and to make recommendations to prevent them.MethodsAfter obtaining IRB approval, a retrospective review of the late complications resulting from newborn circumcisions treated at the MassGeneral Hospital for Children from January 2003 to December 2007 was undertaken. The source used was the consultation notes and operative reports of affected patients. Additionally, cases seen in the outpatient Pediatric Urology Clinic from April 2007 to April 2008 were reviewed.ResultsA total of 8,967 children were operated during the study period, of which 424 (4.7%) were for complications resulting from previous neonatal circumcision. Penile adhesions, skin bridges, meatal stenosis, redundant foreskin (incomplete circumcision with uncircumcised appearance), recurrent phimosis, buried penis and penile rotation were the most frequent complications. At the outpatient clinic of the Section of Pediatric Urology, 127 boys with concerns following newborn circumcision were evaluated, representing 7.4% of the total volume of cases seen in this clinic.ConclusionsOur results indicate the need to undertake a collaborative study to define the incidence of complications following newborn circumcisions, which should be performed by practitioners with adequate training in the technique of their choice and its post-operative care.

The mild end of the clinical spectrum of posterior urethral valves

Posterior urethral valves have a broad clinical spectrum. In this series of 87 patients, 36 had mild valvular obstruction, the most common clinical variety. Boys with mild valves had a greater frequency of diurnal and nocturnal enuresis, super-imposed infection, and a poor stream. The diagnosis was established by a very strict correlation of the radiological and endoscopic findings. Urodynamic studies, although performed in a limited number of patients, add validity to the diagnosis of mild valves. A classification based on the secondary anatomical changes and functional damage, which divides the valves in mild, moderate, and severe is recommended. Results of the endoscopic fulguration were excellent and without complications; 34 of 36 patients were improved or cured of their disturbing symptoms.

Combined abdominal and posterior sagittal transrectal approach for the repair of rectourinary fistula resulting from a shotgun wound

The repair of rectourinary fistulas is frequently a matter of great difficulty. We report the case of a young man who sustained a shotgun wound to his pelvis and developed a fistula from the bladder neck to the rectum, which was repaired by a combined transabdominal and posterior sagittal transrectal approach. We recommend that this procedure should be part of the surgical armamentarium available to deal with such complicated lesions.

Renal Abscess in Previously Healthy Girl

We describe the case of a previously healthy 11-year-old girl with a Staphylococcal aureus renal abscess. The diagnosis was confirmed by renal ultrasonography and abdominal computed tomography. We emphasize the need to obtain an abdominal ultrasound scan and computed tomography scan in patients with abdominal or flank pain, and laboratory evidences of infection to avoid diagnostic and therapeutic delays.

Megacalycosis: a rare condition

Megacalycosis is an extremely rare condition. We report our experience with two cases and discuss its pathogenesis, diagnosis and management in children. Our two patients had presented a prior diagnosis of congenital hydronephrosis. An increased number of calyces with a significant disproportion between the degree of calyceal dilatation and a mildly dilated renal pelvis were found in each case. Megacalycosis must be considered in the differential diagnosis of congenital hydronephrosis, polycalycosis, and infundibular stenosis. The diagnosis is suggested by ultrasound and confirmed by diuretic renography, intravenous pyelography or magnetic resonance urography. Voiding cystourethrography should be performed to rule out vesicoureteral reflux. A high index of suspicion is needed for the diagnosis of this condition.

The transpuboperineal approach for repair of traumatic strictures of the posterior urethra in children

Strictures of the posterior urethra resulting from pelvic fractures in children pose a formidable challenge due to the limitations of perineal exposure. With the transpubic approach, direct access to the involved anatomy is obtained. This technique, combined with perineal mobilization of the distal urethra, allows the performance of a tension-free anastomosis. The use of an omental pedicle wrap graft seems to add safety to the procedure. It is particularly suited for long strictures and after failure of the transperineal approaches. The results reported in the literature are remarkably good. There are no reports of orthopedic sequelae in children. Sexual potency and continence do not seem to be adversely affected. We present two cases successfully operated upon by this technique.

Congenital hydronephrosis in the lower segment of a duplex system

Two cases of hydronephrosis of the lower moiety in duplicated collecting systems, one associated with a complete duplication and another with an incomplete duplex system, are reported. This is a rare anomaly that requires a precise preoperative anatomic diagnosis to allow the planning of the most suitable surgical procedure. Treatment of this entity should follow similar guidelines as single-system hydronephrosis. An end-to-side dismembered pyeloureterostomy is the optimal operative technique.

Late intraperitoneal posterior bladder wall perforation caused by loose percutaneous Stamey suprapubic catheter

Late intraperitoneal perforation of the posterior bladder wall resulting from the use of percutaneous suprapubic cystostomy catheters has not been previously reported. We describe a case where a Stamey-type percutaneous tube was used that developed a late posterior bladder wall perforation. This complication is more likely to occur when the catheter is not tied in at skin level and securely taped, particularly when the catheter material is not soft. The underlying diseased bladder and the presence of infection contributed to the bladder injury. Teaching parents about catheter care following hospital discharge is important in order to prevent such complications.

High-strength Neodymium Magnetic Beads: A Rare Foreign Body in the Bladder of an Adolescent.

This article reports the case of an adolescent who repeatedly inserted high-strength magnetic beads into his urethra for erotic reasons. The beads migrated into his bladder requiring a cystostomy to remove them. The available literature is reviewed.