Thomas A. Borden

Percutaneous Stone Removal in Children

Percutaneous removal of renal and ureteral calculi has become an established and successful procedure in adults. Stone disease in children often is metabolic or infectious in origin and multiple surgical procedures during a long interval may be required. Therefore, percutaneous stone removal could be particularly advantageous in these patients. We have performed percutaneous stone removal successfully in 7 children, none of whom required a second procedure or were discharged from the hospital with a nephrostomy tube.

Prevention of Urinary Tract Infection and Sepsis Following Transrectal Prostatic Biopsy

Transrectal biopsy is one of the more popular methods for the diagnosis of prostatic cancer. However, there is disagreement as to whether the use of prophylactic antimicrobials decreases the incidence of fever and urinary tract infections, which may follow this procedure. A prospective randomized double-blind study involving 63 patients was instituted to determine the efficacy of carbenicillin indanyl sodium in reducing these complications. The protocol consisted of administration of 2 tablets of 4 times daily of a placebo or the treatment drug 24 hours before and after biopsy. Clean catch urine cultures were obtained 24 hours before biopsy and at 48 hours and 2 weeks after the procedure. Blood cultures were performed 15 minutes after biopsy. In addition, clinical parameters were monitored closely in the hospital for 48 hours after biopsy. A total of 48 patients was considered evaluable. Of 23 patients who received the study drug 2 (8.6 per cent) had positive urine cultures at 48 hours compared to 9 of 25 (36 per cent) from the placebo group. A similar result was observed from the 2-week culture data, in which 2 of 23 patients (8.6 per cent) in the treatment group had positive urine cultures as opposed to 5 of 25 (20 per cent) receiving the placebo. Fever occurred in 48 per cent of the placebo and in 17 per cent of the carbenicillin groups. Our data indicate that prophylactic administration of carbenicillin indanyl sodium decreases the complications of fever and urinary tract infections following transrectal biopsy of the prostate.

Suprapubic endoscopic vesical neck suspension for the management of urinary incontinence in myelodysplastic girls.

Urinary incontinence may be a formidable hardship in many girls with myelodysplasia. In those patients who fail treatment with intermittent self-catheterization and pharmacotherapy surgical augmentation of outlet resistance may successfully alleviate incontinence. In patients with less severe degrees of urethral sphincteric incompetence suprapubic endoscopic vesical neck suspension in conjunction with intermittent self-catheterization can be successful. Patients must be selected carefully, with particular attention directed at detecting decreased detrusor compliance. Poor detrusor compliance must be controllable or corrected before augmentation of urethral resistance to prevent postoperative upper urinary tract deterioration.

Management of penile incarceration

A case of penile incarceration is presented. Two steel bushings compromising the penile vascular supply in a young man were removed with the aid of a carbide disk dental drill. Management of this case is described, and guidelines for managing similar cases of penile incarceration are discussed.

Inflammatory Pseudotumor (Pseudosarcoma) of the Bladder

Inflammatory pseudotumor (pseudosarcoma) of the bladder is a benign proliferative lesion of the submucosal stroma easily mistaken for a malignant neoplasm clinically and histologically. The lesion was first described as a separate entity in a report of 2 patients. Three additional cases have been reported since then. We describe pseudosarcomatous bladder tumors arising in 2 adolescents. Both patients presented with sudden onset of gross painless hematuria related to large polypoid and ulcerated bladder masses found on endoscopy. Initial pathological analysis was interpreted as poorly differentiated sarcoma in both patients but subsequent reviews were consistent with a benign process resembling nodular fasciitis. Simple excision in both patients has been successful in eradicating the lesion. The findings in these 2 patients are described with a discussion of the pathophysiology and review of the literature.

Cellulitis and necrotizing fasciitis of the abdominal wall in pediatric patients

Soft tissue infections of the abdominal wall in 14 children were classified as cellulitis (8), necrotizing fasciitis (5), or myositis/myonecrosis (1). These 3 categories were characterized by increasing anatomic depth of infection, clinical severity, and need for more radical surgical treatment. Ten of the 14 children were neonates. The most frequent associations were omphalitis (5), necrotizing enterocolitis (4), and urachal anomalies (3). The severest infections were usually polymicrobial and contained both aerobic and anaerobic bacteria. Important clinical findings in children with necrotizing fasciitis and myositis/myonecrosis were tachycardia, systemic toxicity, severe edema, and, in older children, pain out of proportion to the apparent degree of infection. None of the children had fever or crepitation of the wound. An ominous sign, indicative of the need for immediate, radical debridement was the appearance of a patch of dusky or gangrenous skin. There were two deaths associated with delayed diagnosis of necrotizing fasciitis. One child did not receive radical debridement, and the other received it too late to be of benefit. Although these infections are rare in children, their lethal potential and early diagnostic signs must be recognized.

Pubovaginal Sling Procedure for the Management of Urinary Incontinence in a Myelodysplastic Girl

Urinary incontinence is a formidable social handicap in many children with myelodysplasia. Girls in whom pharmacologic therapy and intermittent catheterization fail to alleviate incontinence present particularly difficult management problems. Permanent catheter drainage of the bladder or supravesical urinary diversion frequently has been used solely for control of incontinence. More recently, the artificial sphincter has been used in selected patients. We herein describe the use of a pubovaginal sling to augment bladder outlet resistance in a girl with myelodysplasia. Postoperatively, she remains totally continent on intermittent catheterization.

IPSILATERAL URETEROURETEROSTOMY FOR SINGLE URETERAL REFLUX OR OBSTRUCTION IN A DUPLICATE SYSTEM

PURPOSE The traditional treatment for obstruction or reflux involving a single ureter in a duplicated system has been common sheath reimplantation. More recently, ipsilateral ureteroureterostomy has been suggested as an alternative treatment. We reviewed cases with duplicate systems that were treated with ipsilateral ureteroureterostomy at our institution to determine the acceptability of this operation as an alternative to common sheath reimplantation. MATERIALS AND METHODS A total of 22 patients with 24 duplicate systems underwent ipsilateral ureteroureterostomy between March 1986 and December 1996. Patient charts were reviewed and analyzed for patient age, sex, ureteral and renal anatomy, initial presentation, the clinical situation necessitating operation, and the occurrence of early and late complications. Patients were followed for a mean period of 41.4 months. RESULTS Two adults and 20 children 10 years old or younger presented with urinary tract infection (13), hydronephrosis on maternal ultrasound (5), dribbling (2), ureteral calculus (1) and hydronephrosis on neonatal abdominal ultrasound (1). Mean hospital stay was 3 days. There was 1 early and 1 late complication. CONCLUSIONS Ipsilateral ureteroureterostomy is an acceptable alternative to common sheath reimplantation in select patients with single ureteral disease in a duplicate system.

Ureteropelvic junction obstruction in a thoracic kidney treated by dismembered pyeloplasty

Ectopic positioning of the kidney is a relatively common event, with the thoracic location of the ectopic kidney the most unusual. At least 140 cases of thoracic kidney have been described, with no consistent anomalies reported in association with the superior location. The vast majority of patients with thoracic kidney are asymptomatic, with the problem discovered incidentally. We report the first documented case of a thoracic kidney presenting with flank pain and demonstrating ureteropelvic junction obstruction on nuclear scintigraphy treated by open dismembered pyeloplasty through a supra-11th rib incision.

Neurofibromatosis of bladder in a child: Unusual cause of enuresis

This case report describes a five-year-old child who was evaluated for enuresis. He was found to have extensive involvement of the genitourinary system with neurofibromatosis. Bladder involvement with neurofibromas in children is extremely uncommon and a rare cause of enuresis. This childs disease required a supravesical urinary diversion with cystectomy and partial prostatectomy.