Terry D. Allen

The non-neurogenic neurogenic bladder.

The records of 21 children with neuropathic bladder disease are reviewed. The natural history in these cases has been consistent with that of an acquired disorder and the results of urodynamic testing have supported Hinmans contention that the disease is basically a functional one, caused by a discoordination between detrusor contraction and sphincter relaxation. Bladder retraining and specific medication have yielded far better results than were obtained previously by surgical measures alone.

Management of ectopic ureterocele associated with renal duplication: a comparison of partial nephrectomy and endoscopic decompression.

PURPOSEnWe compared the efficacy of primary endoscopic decompression versus partial nephrectomy for treating ectopic duplex ureteroceles.nnnMATERIALS AND METHODSnWe retrospectively reviewed the records of patients with renal duplication and upper pole ectopic ureterocele. Patients were classified according to the initial radiological evaluation. The operation performed was arbitrarily chosen by the surgeon.nnnRESULTSnA total of 54 patients had unilateral upper or bilateral upper pole ureterocele with no associated vesicoureteral reflux. Partial nephrectomy was performed in 26 patients, of whom 4 (15%) required additional surgery for new onset ipsilateral lower pole reflux. Endoscopic decompression was performed in 28 patients, of whom 18 (64%) required additional treatment due to reflux into the ipsilateral lower pole ureter and ureterocele in 9, reflux into the ureterocele only in 4, ipsilateral lower pole reflux only in 3 and persistent ureterocele obstruction in 2 (p<0.01). An ectopic ureterocele with vesicoureteral reflux into 1 or more moieties was identified in 111 patients, including 56 of 67 (84%) treated with partial nephrectomy and 37 of 44 (84%) treated with endoscopy who have persistent reflux or required further surgery for reflux resolution.nnnCONCLUSIONSnIn patients with an ectopic ureterocele and no vesicoureteral reflux partial nephrectomy should be considered the treatment of choice. However, when the initial cystogram reveals vesicoureteral reflux, partial nephrectomy and endoscopic ureterocele decompression have identical definitive cure rates of only 16%. The majority of the latter patients require continued observation and/or additional surgery for managing persistent reflux.

Congenital Ureteral Strictures

There are a number of diseases, evidently congenital in origin, which produce a localized narrowing in the ureter with obstruction to the passage of urine yet which strangely offer little or no resistance to the passage of catheters or probes. Depending upon their location, they are known by any of a wide variety of names such as ureteropelvic junction obstruction (Shopfner), congenital hydronephrosis (Murnaghan), functional stenosis (Backlund), achalasia of the ureter (Hepler), megaureter (Williams), atonic distal segment (Creevy), megaloureter (Caulk), and congenital ureteral strictures (Cambell), but seldom have they been considered together as a single entity. As this study proposes to show however there are valid reasons for believing that they are all examples of the same basic pathological process. For the purposes of this report, they will be referred to as congenital ureteral strictures regardless of their location.

Prostatomembranous Urethral Disruptions: Management by Suprapubic Cystostomy and Delayed Urethroplasty

Management of prostatomembranous urethral disruptions associated with pelvic fractures remains a major controversy in urology. A group of 64 patients who suffered a prostatomembranous urethral disruption in association with a pelvic fracture and who were managed initially by suprapubic cystostomy with delayed urethroplasty was compared to 17 patients managed initially by primary realignment. No statistically significant difference in the incidence of impotence or urinary incontinence was found between the 2 groups (p greater than 0.5) Secondary reconstructions for impassable strictures developed in 95% of the patients treated by a suprapubic tube alone compared to 53% of those treated by primary realignment. Indeed, only 1 patient in the latter group achieved urethral continuity that did not require further intervention. We conclude that while primary realignment is associated with no increase in the instance of impotence and urinary incontinence, it subjects the patient to a major operation at a critical time and provides little in the way of long-term positive gains for the effort expended. In the final analysis the outcome is more dependent upon the nature of the injury and the quality of the repair than upon the order in which the repair is effected.

Endocrine Studies in Patients With Advanced Hypospadias

We evaluated 15 boys less than 4 years old with advanced degrees of hypospadias for the presence of an endocrinopathy by a variety of special tests. There were 6 different endocrine-related abnormalities uncovered in 11 patients. One child had been exposed to progesterone given to the mother during the first trimester of pregnancy, 1 had an abnormal karyotype and 1 had an absent gonad on 1 side. One patient with a family history of Reifensteins syndrome had low receptor numbers and 3 patients exhibited a poor genital response to exogenous testosterone despite normal receptor levels. However, the most striking finding was that of a poor testosterone response to human chorionic gonadotropin injections, which was seen in 7 patients. In several instances this improved with time and even normalized in 2 patients. This experience suggests that hypospadias is a local manifestation of an endocrinopathy rather than a local dysmorphic problem, and that 1 major cause of it may be a delay in maturation of the hypothalamic-pituitary-testicular axis.

Shortcomings of Color Doppler Sonography in Diagnosis of Testicular Torsion

PURPOSEnWe determined the shortcomings of color Doppler sonography for the diagnosis of testicular torsion.nnnMATERIALS AND METHODSnWe reviewed 5 cases of testicular torsion in which findings on color Doppler sonography were inconsistent with surgical findings.nnnRESULTSnColor Doppler sonography showed blood flow in 2 patients who had necrotic testes at surgery. In 3 other patients blood flow was also normal by color Doppler sonography of whom 2 were treated for epididymitis with subsequent loss of the testes and 1 underwent salvage by immediate exploration.nnnCONCLUSIONSnTesticular torsion is a clinical diagnosis requiring consideration of many variables. Color Doppler sonography is helpful but should not be regarded as the definitive discriminator.

Clinical and endocrinological evaluation of patients with congenital microphallus

Eight patients with congenital microphallus were investigated. Plasma luteinizing hormone, follicle-stimulating hormone, testosterone and androstenedione levels were obtained in all cases. In addition, the response to the administration of human chorionic gonadotropin, luteinizing horomone-releasing hormone and adrenocorticotropic hormone, the assessment of testicular histology by electron microscopy and the measurement of dihydrotestosterone formation by preputial skin were determined in some patients. The results of these studies were compared to similar studies in 6 normal prepubertal boys, 4 boys with bilateral cryptorchidism, 1 male infant with anorchia and 1 adult with hypogonadotropic hypogonadism. The clinical and endocrinological findings in the 8 patients with microphallus can be divided into 2 distinct categories. In 5 patients the disorder is familial, gonadotropin levels are low and there is a normal response to stimulation with chorionic gonadotropin. The data are compatible with the possibility that 3 (possibly 5) of the 8 patients with microphallus have hypogonadotropic hypogonadism. In the other group the cases are sporadic, serum luteinizing hormone and follicle-stimulating hormone levels are elevated and plasma testosterone failed to increase after short-term treatment with chorionic gonadotropin. In these patients a primary testicular disorder appears to be responsible. Experimental and clinical evidence suggests that microphallus results from defective testicular function during the second and third trimesters of pregnancy, either as the result of defective gonadotropin secretion or defective androgen synthesis.

The Transpubic Approach for Strictures of the Membranous Urethra

Strictures of the membranous urethra following pelvic fractures pose a challenge in management because of their relatively inaccessible position above the urogenital diaphragm and behind the pubic symphysis. The corrective procedures the pass up from the perineum through the urogenital diaphragm to reach the stricture have the real or theoretical disadvantage of defunctionalizing the external urethral sphincter and leaving continence dependent solely upon the competency of the bladder neck. On the other hand, transpubic surgery allows a direct attack upon the stricture without violating the sphincter. Our experience with 4 such cases has convinced us of the superiority of this approach.

Continence in the myelodysplastic patient following enterocystoplasty

To evaluate the ability of augmentation cystoplasty alone to provide a low pressure bladder and an adequate degree of continence in the myelodysplastic patient, the clinical records and urodynamic data of the last 18 consecutive such patients undergoing augmentation cytoplasty at our institution were reviewed. Two patients underwent colocystoplasty and 16 underwent ileocystoplasty. No patient underwent any procedure on the bladder neck or urethra. The 2 colocystoplasty patients exhibited episodic dampness attributed to contractions of the augmentation but all of the ileocystoplasty patients were dry during the day except 1 who had a urethral resistance of only 19 to 22 cm. water. On the basis of this review, ileocystoplasty alone appears to be sufficient for satisfactory continence in patients with a neurogenic bladder undergoing vesical augmentation if bladder outlet resistance exceeds 25 to 30 cm. water.

The camey procedure: Preliminary results in 11 patients

SummaryEleven patients with bladder cancer underwent radical cystoprostatectomy and urinary diversion by means of an ileal reservoir attached directly to the membranous urethra as described by Camey and Le Duc. There were no postoperative deaths and only one serious complication. Subsequent assessment of these patients revealed that they exhibited adequate urine storage capacity, were able to develop normal urinary continence during the day, and could empty their reservoir to less than two ounces residual urine by voluntary urination, but that they tended to wet themselves at night. Technically, the operation was not difficult, but attention to the urethroileal anastomosis and good drainage were important in avoiding troublesome collections of urine in the deep pelvis.