Richard S. Hurwitz

Pediatric Vesicoureteral Reflux Guidelines Panel Summary Report on the Management of Primary Vesicoureteral Reflux in Children

PURPOSE The American Urological Association convened the Pediatric Vesicoureteral Reflux Guidelines Panel to analyze the literature regarding available methods for treating vesicoureteral reflux diagnosed following a urinary tract infection in children and to make practice policy recommendations based on the treatment outcomes data insofar as the data permit. MATERIALS AND METHODS The panel searched the MEDLINE data base for all articles from 1965 to 1994 on vesicoureteral reflux and systematically analyzed outcomes data for 7 treatment alternatives: 1) intermittent antibiotic therapy, 2) bladder training, 3) continuous antibiotic prophylaxis, 4) antibiotic prophylaxis and bladder training, 5) antibiotic prophylaxis, anticholinergics and bladder training, 6) open surgical repair and 7) endoscopic repair. Key outcomes identified were probability of reflux resolution, likelihood of developing pyelonephritis and scarring, and possibility of complications of medical and surgical treatment. RESULTS Available outcomes data on the various treatment alternatives were summarized in tabular form and graphically, and the relative probabilities of possible outcomes were compared for each alternative. Treatment recommendations were based on scientific evidence and expert opinion. The panel concluded that only a few recommendations can be derived purely from scientific evidence of a beneficial effect on health outcomes. CONCLUSIONS For most children the panel recommended continuous antibiotic prophylaxis as initial treatment. Surgery was recommended for children with persistent reflux and other indications, as specified in the document.

Endoscopic Therapy for Vesicoureteral Reflux: A Meta-Analysis. I. Reflux Resolution and Urinary Tract Infection

PURPOSE Current American Urological Association treatment guidelines for vesicoureteral reflux do not include any recommendations pertaining to endoscopic therapy (subureteral injection of bulking agent). We performed a meta-analysis of the existing literature pertaining to endoscopic treatment to allow comparison with reports of open surgical correction. MATERIALS AND METHODS We searched all peer reviewed articles published through 2003 pertaining to endoscopic treatment of vesicoureteral reflux. A total of 63 articles were double reviewed by 9 pediatric urologists, and the data were tabulated on data retrieval sheets. A mixed effects logistic regression model was used to obtain overall estimates of event probabilities (eg reflux resolution, ureteral obstruction) together with their 95% confidence intervals. Individual study estimates were obtained with overall estimate and observation characteristics using empirical Bayes calculations. Differences between or among specific groups were assessed using the F-test. RESULTS The database included 5,527 patients and 8,101 renal units. Following 1 treatment the reflux resolution rate (by ureter) for grades I and II reflux was 78.5%, grade III 72%, grade IV 63% and grade V 51%. If the first injection was unsuccessful, the second treatment had a success rate of 68%, and the third treatment 34%. The aggregate success rate with 1 or more injections was 85%. The success rate was significantly lower for duplicated (50%) vs single systems (73%), and neuropathic (62%) vs normal bladders (74%). The success rate was similar among children and adults. Following a previous failed open reimplantation endoscopic treatment was successful in 65% of patients. After endoscopic treatment with variable followup pyelonephritis developed in 0.75% of patients and cystitis in 6%. There were few reports of renal scarring following treatment. CONCLUSIONS Endoscopic treatment provides a high rate of success in children with reflux that decreases with increasing grade, although multiple treatments may be necessary. Future reports of endoscopic therapy should include rates of urinary tract infection and renal scarring.

Cloacal Exstrophy: A Report of 34 Cases

A clinical review is presented on 34 patients with cloacal exstrophy who were seen between 1963 and 1986. The patients were separated into 2 main groups: classical cloacal exstrophy (type I) and variant cloacal exstrophy (type II). In the classical cases 3 surface patterns were recognized: A-hemibladders confluent cranial to the bowel, B-hemibladders lateral to the bowel and C-hemibladders confluent caudal to the bowel. Surgical reconstruction was performed in 24 patients, with a 50 per cent survival rate. However, there was marked improvement in survival from 22 per cent between 1963 and 1978 to 90 per cent between 1979 and 1986.

Nonsurgical management of threatened upper urinary tracts and incontinence in children with myelomeningocele.

The 2 major urological objectives in treating the child with myelomeningocele are to preserve renal function and achieve continence. We report our success in managing these cases with nonsurgical therapy. From 1981 to 1991, 45 patients with myelomeningocele 1 to 15 years old were evaluated urodynamically before and after initiating nonsurgical treatment. Pretreatment urodynamics identified 2 groups. Group 1 consisted of 31 patients with leak point pressure of 40 cm. water or more of whom 10 had grades II to V/V vesicoureteral reflux and 4 had moderate or severe hydronephrosis. Group 2 consisted of 14 incontinent patients with leak point pressure of less than 40 cm. water and no reflux or hydronephrosis. Both groups were treated with intermittent catheterization, anticholinergic medications and fluid restriction. Within a mean followup of 5.5 years nonsurgical intervention resulted in lowering maximum detrusor pressure at maximum cystometric capacity to less than 40 cm. water in 22 of 31 group 1 patients (71%), and in resolving vesicoureteral reflux in 7 of 10 (70%) and hydronephrosis in 3 of 4 (75%) group 1 patients. Of 4 patients in group 1 with persistent high grade vesicoureteral reflux or severe hydronephrosis 3 (10%) required augmentation cystoplasty. With nonsurgical management 18 patients (40%) were completely continent, 18 (40%) required 2 or less pads daily and 9 (20%) required more than 2 pads daily. Nonsurgical management alone was effective in preserving the upper urinary tract in 90% of patients and it provided satisfactory continence in 80%. Surgical management should be reserved for the minority of patients whose upper tract changes do not resolve and for those whose degree of continence is not satisfactory with nonsurgical management.

HOW WELL DOES CONTRALATERAL TESTIS HYPERTROPHY PREDICT THE ABSENCE OF THE NONPALPABLE TESTIS

PURPOSE We assessed the accuracy of contralateral testis hypertrophy for predicting monorchia in patients with a nonpalpable testis. MATERIALS AND METHODS From May 1993 to September 1998 we evaluated 60 patients 7 months to 11 years old for a unilateral nonpalpable testis. Four patients were excluded from study who had received human chorionic gonadotropin or had signs of puberty. We correlated contralateral testis hypertrophy, defined as testis volume greater than 2 cc or testis length greater than 2 cm., with presence or absence of the nonpalpable testis. We also recorded the degree to which contralateral testis length less than 2.1 cm. correlated with the presence or absence of the nonpalpable testis. Laparoscopy and open exploration were performed in 52 and 4 cases, respectively. RESULTS Contralateral testis hypertrophy greater than 2 cm. was noted in 16 patients, including 14 (87.5%) with monorchia and 2 (12.5%) with an intra-abdominal testis. Of the 15 patients with a contralateral measurement of 1.8 to 2.0 cm. 14 had monorchia (93%) and 1 had a tiny ovotestis. Of the 25 patients with a contralateral measurement of less than 1.8 cm. 13 (52%) had testes that were intra-abdominal in 11 and canalicular in 2. The optimal cutoff value for contralateral enlargement was 1.8 cm. (p = 0.00061). The most common laparoscopic finding in patients with contralateral testis hypertrophy greater than 2 cm. was blind ending vessels proximal to the internal ring in 56%. CONCLUSIONS Contralateral testis hypertrophy is common in patients with a nonpalpable testis. Hypertrophy 1.8 cm. or greater predicts monorchia with an accuracy of about 90%. The finding of contralateral testis hypertrophy provides useful information for preoperative counseling, allowing us to inform parents that the nonpalpable testis is most likely absent. Exploration is still required. Laparoscopy is particularly advantageous in contralateral testis hypertrophy since it was the only procedure required in about half of our cases.

Variations in practice among urologists and nephrologists treating children with vesicoureteral reflux

To analyze the current management recommendations among physicians treating children with vesicoureteral reflux, the American Urological Association Reflux Practice Guidelines Panel surveyed 100 pediatric urologists, 100 general urologists and 100 pediatric nephrologists by questionnaire, and received a 60% response. In the evaluation of a 4-year-old girl with bilateral grade 2 reflux general urologists were more likely than the other 2 groups to recommend cystoscopy and urethral dilation. At followup nuclear cystography was recommended by 76% of pediatric urologists, 48% of general urologists and 71% of pediatric nephrologists, while the latter 2 groups were less likely to recommend any subsequent upper tract evaluation. Pediatric urologists were significantly more likely to recommend antireflux surgery if the child had 1 breakthrough febrile urinary tract infection, poor compliance with medical management or persistent reflux at age 11 years. In a 6-year-old girl with unilateral grade 4 reflux and detrusor instability 44% of pediatric urologists recommended antimicrobial prophylaxis and anticholinergic therapy compared to 12% of general urologists and 6% of pediatric nephrologists. Antireflux surgery was recommended by 29% of pediatric urologists, 60% of general urologists and 59% of pediatric nephrologists. In older girls with persistent grade 2 or 3 reflux pediatric urologists were much more likely to recommend antireflux surgery. In contrast, they were less likely to recommend surgery in young girls and boys with newly diagnosed grade 4 reflux. These data demonstrate significant differences in therapeutic recommendations among pediatric urologists, general urologists and pediatric nephrologists, and suggest the need for outcomes research to determine the optimal management of children with vesicoureteral reflux.

The Anatomical Course of the Neurovascular Bundles in Epispadias

References on the anatomical course of the neurovascular bundles of the penis in epispadias are rare. We studied the anatomy of the neurovascular bundles in 5 patients undergoing primary epispadias repair and 13 adolescents undergoing correction of erectile deformities. In all primary cases the neurovascular bundles were truly lateral as they ran along the distal and middle portions of the corporeal bodies, and became anterolateral only proximally. The bundles were identified in only 5 of 13 secondary cases and were in the same position as in the primary cases. Knowledge of this anatomy is important to protect these structures from surgical injury in cases of epispadias and exstrophy.

Cloacal Exstrophy and Cloacal Exstrophy Variants: A Proposed System of Classification

A coding system that documents the abnormalities within the cloacal exstrophy complex is presented. Analysis allows the classification of these abnormalities into classical and variant series in a logical manner. The application of the coding system to selected reported material is described and it demonstrates the similarities between apparently divergent cases.

Excessive proliferation of peripelvic fat of the kidney.

Excessive proliferation of the peripelvic fat of the kidney (EPPF) is a benign process with an innocuous effect on the patient. However, this condition may assume major clinical significance by producing pyelocalyceal deformities that may be mistaken for true renal masses. Rarely, EPPF may masquerade as a renal pelvic tumor. We present the second reported case of EPPF simulating a renal pelvic tumor and review the history as well as the characteristic radiographic and sonographic features of this condition.

Resection of advanced stage neuroblastoma with the cavitron ultrasonic surgical aspirator

Current protocols for the treatment of neuroblastoma emphasize total or near total resection of tumor to improve survival. This is preferentially performed as a primary procedure, or is attempted at a second-look operation. Unfortunately, this tumor often grows to large size with invasion of the spinal canal, or encasement of major vascular or other retroperitoneal structures. A primary attempt at complete removal may result in difficult-to-control hemorrhage or injury to, or loss of, vital organs. A second-look procedure carries other intrinsic risks. It often must be performed during a period of chemotherapeutically induced hematologic and immunologic suppression. The presence of adhesions and dense scar tissue increases the complexity of the dissection. The Cavitron Ultrasonic Surgical Aspirator (CUSA) combines continuous fragmentation, irrigation, and aspiration in one instrument. Tissues high in water content are selectively fragmented and aspirated, while tissues high in collagen and elastin (such as blood vessels and pseudocapsular walls) are selectively spared. Five patients, two with large pelvic dumbell tumors, two with large intrathoracic tumors, and one with a seemingly unresectable large right adrenal tumor (crossing the midline with extensive aortocaval nodal involvement) had total or near-total resection accomplished using the CUSA. In these patients, initial resection of the relatively soft inner part of the tumor left a collapsed pseudocapsule, which was then removed under greatly improved exposure in a relatively small field. The constant aspiration virtually eliminated tumor spillage. Since most vessels were skeletonized without penetration, total blood loss was minimized. There were no intraoperative or postoperative complications.