Robert H. Whitaker

An evaluation of 170 diagnostic pressure flow studies of the upper urinary tract.

An analysis of 170 pressure flow perfusion studies reveals that they can be valuable in patients of all ages, but particularly so in children, and in a variety of clinical conditions. The complication rate is low and there are few patients in whom these studies do not provide a clear-cut answer on the degree of obstruction. They can be recommended as useful and, at times, invaluable clinical tools.

A Comparison of Pressure Flow Studies and Renography in Equivocal Upper Urinary Tract Obstruction

The ability of pressure flow studies and renography to assess obstruction was compared in 32 patients with equivocal upper urinary tract obstruction. The renogram failed to confirm the presence or absence of obstruction in 39 per cent of the cases as shown by the pressure flow study. Both studies have advantages, disadvantages and technical pitfalls.

An Improved Hook for Destroying Posterior Urethral Valves

A modified hook has been developed for the destruction of posterior urethral valves. This hook is safe and effective, and avoids the use of an anesthetic in the child. The effectiveness of the valve ablation is seen immediately radiologically and clinically.

THE PATTERN OF CONGENITAL RENAL ANOMALIES ASSOCIATED WITH NEURAL-TUBE DEFECTS

This is a retrospective study of 190 patients with neural‐tube defects for whom there were precise data, both on sensory levels (to pin‐prick) and on the presence or absence of congenital renal anomalies. There were 17 renal anomalies, of which three were renal agenesis, five horseshoe kidneys, eight ureteral duplications and one simple ureterocele. There was a consistent pattern of congenital renal anomalies in relation to the extent of the neurological lesion, as measured by the sensory level. Renal agenesis was associated with a sensory level in the dermatomes T5 to T8, horseshoe kidneys with a T9 to LI level and ureteral duplications predominantly with a sensory level in the sacral dermatomes.

Intermittent catheterisation: simple, safe, and effective but underused.

Twenty five years ago Lapides and coworkers showed that intermittent catheterisation was a safe and effective way of managing patients with urinary retention or incontinence due to neuropathic or hypotonic bladder.1 2 This technique has transformed the lives of people rendered housebound by bladder problems and has preserved the kidneys of children with spina bifida3 4 5 6 7 8 9 10 and of adults with spinal cord injury.11 12 13 14 15 Intermittent catheterisation is a clean but not sterile technique. It entails inserting a catheter into the bladder, emptying out all the urine, and then removing the catheter. This is performed several times a day by the patient or carer. It puts the patient in control of emptying the bladder and safeguards the kidneys by providing drainage.nn#### Summary pointsnnIncomplete emptying of bladder—A bladder that retains a large volume of residual urine soon fills to capacity, causing frequency, urgency, nocturia, or incontinence. Urinary stasis leads to urinary tract infections and calculi. By eliminating residual urine, intermittent catheterisation enables the bladder to function more effectively as a reservoir, relieves symptoms, and reduces the incidence of symptomatic urinary infections.3 9 16 22 25 28nnObstructive uropathy—Many patients with a neuropathic bladder have an overactive sphincter, causing obstruction of the bladder outlet and dilatation of the upper urinary tracts. A combination of a contracting urethral sphincter with hyperreflexic bladder contractions (detrusor-sphincter dyssynergia) accelerates the damage. If the obstruction of the bladder outlet is overcome by intermittent catheterisation then dilatation of the upper urinary tracts is reduced and renal function improved.6 22nnReflux nephropathy—Vesicoureteric reflux associated with neuropathic bladder often causes renal damage. The risk is increased by obstruction of the bladder outlet, high intravesical pressure, or urinary infection. Intermittent catheterisation can reduce or eliminate …

Intermittent catheterisation in the management of children with neuropathic bladder.

Twenty-three children with neuropathic bladder have been treated by intermittent catheterisation during the past 3 years. Twelve are now practically dry, nine are drier than before, and two have remained wet. Urinary infections have not been a major problem, but it is too soon to assess the long-term effects on the upper renal tract. Intermittent catheterisation lightens the burden for the mothers. Four children catheterise themselves and two of them are now independent.

Perineal sensation: an important predictor of long-term outcome in open spina bifida

Objectives: To see if perineal sensation in infants with open spina bifida is associated with a better long-term outcome, particularly in terms of survival, renal-related deaths and incontinence. Methods: We conducted a prospective cohort study on a complete cohort of 117 consecutive patients with open spina bifida, whose backs were closed non-selectively at birth between 1963 and 1971. A meticulous neurological examination in infancy showed that 33 (28%) of them had perineal sensation, defined as intact sensation to pinprick in at least one dermatome on one side in the saddle area (S2–4). Data recorded within 48 h of birth and during six reviews between 1972 and 2002 were used. Details of deaths were obtained from medical records and from the Office of National Statistics. Results: By December 2005, 57% (67/117) of the cohort had died. There were 50 survivors with a mean age 38 years (range 35–41). More of those with perineal sensation survived than those without (23/33 v 27/84, p<0.001). This difference was mainly caused by 19 renal deaths in those lacking perineal sensation. Crucially there were no renal-related deaths in those with perineal sensation (0/33 v 19/84, pu200a=u200a0.003). Among the survivors, those with perineal sensation were more likely than the remainder to be continent of urine and faeces (10/23 v 1/27, p<0.001 and 18/23 v 9/27, pu200a=u200a0.002 respectively). They were also more likely to be able to walk at least 50 m (11/23 v 5/27, pu200a=u200a0.027) and never to have had pressure sores (15/23 v 9/27, pu200a=u200a0.025). Conclusions: A simple assessment of perineal sensation in infancy predicts long-term outcome in terms of survival, renal prognosis and incontinence in open spina bifida.

Does good upper tract compliance preserve renal function.

We reviewed 111 pressure flow studies in an attempt to measure the compliance of each upper tract under study and to assess its clinical implications. Good compliance was seen in 64 dynamically unobstructed renal units as well as in 16 obstructed systems. The latter systems had less significant degrees of obstruction than a group of 31 obstructed systems with poor compliance. Obstruction with good compliance was associated with preservation of renal function as measured by diuresis renography, while impaired function was seen in systems with obstruction and poor compliance. The clinical implications of correlating the degree of obstruction, compliance and renal function are discussed.

Incidence and distribution of renal anomalies in patients with neural tube defects.

In 190 patients with neural tube defects the sensory levels to pin prick were compared with the incidence and distribution of congenital renal anomalies. 17 such anomalies comprised 3 examples of renal agenesis, 5 horseshoe kidneys, 8 ureteral duplications and one simple ureterocele. The pattern of anomalies showed that renal agenesis was associated with a sensory level in the dermatomes T5-8, horseshoe kidneys with T9-L1 and duplications predominantly with the sacral dermatomes.

Investigating wide ureters with ureteral pressure flow studies.

A perfusion study is described and its usefulness in the diagnosis of ureterovesical obstruction is discussed. The study includes 31 children with either primary or secondary non-refluxing wide ureters or ureters that had been reimplanted previously.