Clinical reflux was first visualized over 100 years ago. In the 1950s and early 1960s, the assumption was that surgery to relieve bladder neck obstruction would have a positive effect on bladder function and reflux. By the early 1970s it was understood that the underlying structural problems leading to primary reflux were congenitally abnormal distal ureters and orifices. Researchers in the 1960s and 1970s demonstrated the connection between reflux and renal scarring. More recently, reflux nephropathy in the absence of urinary tract infections has been observed, leading researchers to investigate an association between bladder dysfunction and reflux with resulting nephropathy. The cornerstone of management of the child with vesicoureteral reflux is antibiotic prophylaxis; treatment regimens for various grades of reflux are reviewed. Indications for surgical treatment of reflux are also discussed. Controversies regarding vesicoureteral reflux, including duration of prophylactic treatment, remain to be resolved.

Objectives After completing this article, readers should be able to: Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder upward toward the kidney. Reflux is due to an anatomical or functional abnormality of the normally competent ureterovesical junction. This impairment of the one-way valve mechanism at the ureterovesical junction allows retrograde flow of urine from the bladder into the upper urinary tract (ureters and kidneys). If infected bladder urine refluxes into the upper urinary tract, a renal infection (pyelonephritis) may result. VUR can be diagnosed definitively only by voiding cystography. Voiding cystograms are performed using either iodinated contrast (voiding cystourethrography [VCUG]) or a radiopharmaceutical(voiding nuclear cystography [RNC]) (Fig. 1). The study is performed by placing a catheter through the urethra into the bladder and instilling the testing agent until the bladder is full and the child voids. Unfortunately, at present there is no reliable method of diagnosing VUR without urethral catheterization.The severity of reflux is judged on the voiding study and described by a grading system. The grading system used most commonly is that of the International Reflux Study Group,which grades reflux from I to V (Fig. 2). Grade I describes the most minimal reflux detected on the voiding study, and grade V is the most severe form of reflux. Grades IV and V often are referred to as "dilating reflux" because the VCUG reveals significant dilatation of the ureter, pelvis, and calyces.VUR predisposes to recurrent upper urinary tract infections (UTIs), which can lead to renal parenchymal damage. The sequela of recurrent upper UTIs—renal scarring or thinning—is called reflux nephropathy. This condition once was known as chronic atrophic pyleonephritis, and it remains a frequent cause of end-stage renal disease.The susceptibility to renal damage from a particular infection depends on several factors. A major factor in the predisposition to scarring is the age of the child. Younger children are more susceptible to infection-induced renal parenchymal injury. The likelihood of a neonate or toddler acquiring a scar as a consequence of an attack of pyleonephritis is much greater than if the child is older than 5 or 6 years of age. Another factor predisposing to scarring is delay in treatment; prompt treatment at any age reduces the likelihood of scarring. Renal scarring occurs more frequently if the patient suffers recurring infections or has high-grade reflux.Management for children who have VUR includes surgery (most often ureteral reimplantation) or medical management with antibiotics. Antibiotics usually are administered continuously at a low dose. UTIs occurring in the child who is on a low or chemoprophylactic dose of antibiotics are referred to as breakthrough infections.The incidence of VUR in the general population is not known, but it is probably less than 1%. Almost invariably children are tested for the possibility of VUR in one of two clinical situations: during the assessment of prenatally diagnosed hydronephrosis or in the evaluation of a UTI. Approximately 10% of patients who are evaluated postnatally for antenatally diagnosed hydronephrosis have VUR. Reflux diagnosed in the evaluation of prenatally diagnosed hydronephrosis often is high grade and occurs more frequently in boys than in girls. The incidence of reflux among children evaluated because of UTIs is 25% to 40%. When VUR is diagnosed in this setting, it occurs more frequently in girls, and the diagnosis tends to be in older children.There is a genetic predisposition to VUR. The likelihood that the sibling of a child who has VUR will prove to have reflux if evaluated with a VCUG is 30% to 50%. A girl who had reflux has a risk of having affected offspring as often as 65% of the time. VUR is much more common among Caucasian than African-American children.Reflux is described as being "primary" if it is present when no obvious abnormality of bladder function is perceived. Primary reflux is due to an intrinsic anatomic abnormality of the ureterovesical junction. "Secondary"reflux occurs when overt bladder or outlet pathology alters the function of the ureterovesical junction, causing reflux, such as when seen in association with a neurogenic bladder or posterior urethral valves. Urodynamic studies have revealed that high voiding pressures or high urinary storage pressures may affect the function of ureterovesical junction, resulting in reflux. Management of secondary reflux is usually directed toward the primary bladder pathology, and the reflux often improves as the bladder pressures normalize. Interestingly, the perception of primary reflux has evolved in recent years. Male neonates who have high-grade reflux had been regarded as having primary anatomic defects at their ureterovesical junctions. However, recent urodynamic studies suggest that these boys have very high voiding pressures, which represent the driving force that causes the reflux. Supportive evidence for this thesis comes from studies documenting resolution of reflux with normalization of these boys'voiding pressures.Even minor abnormalities of bladder function may have an impact on reflux. Dysfunctional voiding symptoms manifested by urgency, frequency, and diurnal enuresis are common among children who have VUR. A number of studies have shown that in children who have equal grades of reflux and these symptoms, the rate of reflux resolution improves if the abnormal bladder activity is treated appropriately.Evaluation of children who have prenatally diagnosed hydronephrosis consists of postnatal renal ultrasonography (RUS) and VCUG. If these evaluations reveal reflux,it is often high grade and tends to occur frequently in boys. These patients initially are managed nonoperatively because even though the reflux is high grade, a significant number of children will stop refluxing within the first 2 years of life.The key to diagnosing VUR is to maintain an adequate index of suspicion for a UTI. The symptoms of a UTI in the infant and neonate are often occult. Pediatricians must assess many children who are ill with viral infections, and differentiating those whose symptoms may be due to UTI is challenging. The infant or toddler who is febrile or who has a persistent fever should be considered to have a UTI, and that possibility should be ruled out. The diagnosis of UTI is predicated on the collection of a properly obtained urine specimen for culture. A specimen obtained by urethral catheterization in the infant or toddler is generally the most practical and best quality for culture.The radiologic evaluation of the child who has had a febrile UTI must include a voiding study and upper urinary tract imaging. The radiologic evaluation should be performed after diagnosing the first UTI. Renal ultrasonography is the most widely used modality for assessing the upper urinary tracts. Ultrasonography is painless,radiation-free, and noninvasive, making it ideal for the evaluation of infants and children. If the child who has a UTI is toxic and has been hospitalized, it seems reasonable to obtain the renal ultrasonography shortly after admission to rule out obstructive abnormalities of the upper urinary tract that may require surgical intervention. As noted previously, reflux can be diagnosed definitively only by a voiding study. We prefer a VCUG as the initial study in both boys and girls because of the anatomic detail it provides, but RNC may be used as the initial study in girls. RNC is employed routinely for the follow-up of reflux in both genders. Although it once was taught that performing the VCUG 6 weeks after an infection was appropriate, there seems to be no rationale for delaying the study. The VCUG can be performed safely as soon as the urine is sterile, and some reports suggest a greater likelihood of completing the study when the time from diagnosis of the infection to performance of the study is shorter.Renal scarring frequently is present at the initial diagnosis of VUR. As many as 50% of children who have grade III and IV reflux have evidence of scarring at the time of diagnosis. If the patient is evaluated after his or her first apparent infection, there are several possible explanations for this finding. The child could have had prior undetected infections that injured the kidneys, the initial infection may have damaged the kidneys, or the refluxing kidney may have been intrinsically abnormal at birth in the absence of infections. We now understand from the evaluation of reflux discovered as a consequence of prenatally diagnosed hydronephrosis that some refluxing kidneys are functionally and morphologically impaired even though they never have been infected.The renal scan is an adjunctive study that can be helpful in the diagnosis and management of patients who have VUR. Technetium 99 dimercaptosuccinic acid(DMSA) is the radiopharmaceutical of choice for renal imaging in affected patients. The DMSA scan allows quantification of the differential function of the kidneys,assessment for cortical defects diagnostic of scarring, and visualization of photon-deficient areas suggestive of acute infection (Fig. 3). The cornerstone of managing the child who has VUR is antibiotic prophylaxis. Prophylactic antibiotics are intended to prevent recurring infections whether the patient is being scheduled for surgery or managed nonoperatively. The antibiotics used most commonly for prophylaxis are amoxicillin in the neonate and trimethoprim-sulfamethoxazole or nitrofurantoin in older children. There are few absolute indications for surgery. Most authorities suggest surgery for older children who have grade V reflux, and most agree that a febrile breakthrough UTI mandates surgery. Noncompliance with antibiotic prophylaxis is an indication for surgery. Relative indications for surgery include the persistence of reflux of stable moderate grade over years and reflux that persists into prepuberty. The rationale for nonoperative or medical management is predicated on two principles: sterile reflux does not damage the kidney, and spontaneous resolution of reflux is expected in most children. Conceptually, if the urine can be maintained in a sterile state while waiting for spontaneous resolution of the reflux, the kidney will experience no new damage, and the child will not require an operative procedure.Sterile reflux has not been shown to cause renal damage in either clinical or experimental series involving patients who have normal bladder function. It has been demonstrated that continuous antibiotic prophylaxis is the best method of administering antibiotics to prevent new renal injury in patients being managed nonoperatively. The safety of low-dose continuous antibiotic prophylaxis has been established over the past few decades. Although many parents are justifiably concerned about the possibility of adverse effects from long-term antibiotic prophylaxis, the risk of a breakthrough infection and subsequent renal scarring seems to far outweigh any potential deleterious antibiotic adverse effects. Years ago it was demonstrated that the use of continuous low-dose prophylactic antibiotics to prevent new renal injury was a superior approach to intermittent administration of antibiotics at the first sign of infection.Reflux resolves spontaneously in many children. The likelihood of reflux resolution is greater if the reflux is of lower grade (TableT1), if it is unilateral rather than bilateral,and if the child's bladder function is normal. Appropriate follow-up of the child receiving a medical regime includes serial imaging studies to follow the progress of the reflux. We generally obtain annual radionuclide cystography. Upper urinary tract imaging by renal ultrasonography or a DMSA renal scan may be performed at less frequent intervals, depending on the clinical situation. Annual upper urinary tract imaging may not be required for the older child whose reflux was discovered after a single febrile infection and whose kidneys appeared normal on initial ultrasonography. On the other hand, most authorities suggest annual evaluation of the upper urinary tract for younger children to follow renal growth and detect any evidence of evolving renal scars. It is important to recognize that a renal scar resulting from a UTI may take many months or even years to evolve and that the most sensitive technique for detecting renal scars is the DMSA renal scan. A variety of approaches are used to evaluate whether a child's urine remains sterile while receiving low-dose prophylaxis. Some physicians order urine cultures monthly; others obtain cultures three or four times a year. If the child develops a febrile illness for which there is no obvious focus, a specimen of urine must be obtained for culture and sensitivity. Published data suggest that new scars almost invariably are predated by a febrile UTI. For this reason, we obtain a urine culture to rule out the possibility of a breakthrough infection if the child has an unaccounted-for febrile illness. We do not routinely obtain cultures when the child is asymptomatic.Management of grade I and II VUR is straightforward. Patients are followed on low-dose antibiotic chemoprophylaxis. The reflux resolves in most children over a variable length of time. Virtually all patients who have grade V reflux, except neonates, are offered surgery at diagnosis because this grade of reflux, especially if bilateral, has a very low likelihood of spontaneous resolution. Grades III and IV reflux generally are managed nonoperatively initially.The International Reflux Study group randomized patients who had grades III and IV VUR to operative or nonoperative management. The European arm randomized patients after a second VCUG obtained at 3 months after entry confirmed persistent grade III or grade IV reflux. The rate of reflux resolution in the European arm after 5 years of follow-up was 54% among patients who had unilateral reflux and 12% among those who had bilateral reflux. There was no difference in the rate of resolution between grades III and IV reflux. The conclusion of the international study after 5 years of follow-up was that there was no difference between the outcomes of the two treatment arms. There were, however, some interesting differences in the outcomes of patients undergoing surgery in Europe and North America. The incidence of postoperative ureteral obstruction complicating the reimplantation surgery was 4.2% in Europe. Postoperative ureteral obstruction often is complicated by infection, and the coexistence of obstruction and infection frequently leads to renal parenchymal injury. No cases of ureteral obstruction occurred among patients undergoing surgery in North America, and the incidence of pyleonephritis was significantly lower among American children treated surgically compared with those placed on medical management.VUR is diagnosed commonly following a UTI. The key to diagnosis is to maintain an adequate index of suspicion for a UTI. A VCUG or RNC is required to confirm the diagnosis. The goal of management is to prevent renal parenchymal injury, although many patients have renal scarring at the time of diagnosis. Continuous antibiotic chemoprophylaxis is the cornerstone of VUR management. Many patients who have low- or moderate-grade reflux experience spontaneous resolution with antibiotic chemoprophylaxis. Surgery may be required in patients who have grade V reflux, persistent high-grade reflux, or febrile breakthrough infections or who are not compliant with medications.

Purpose: We summarize the literature and present our experience with genitourinary manifestations of the Klippel-Trenaunay syndrome, which can lead to challenging management problems.Materials and Methods: We report on 2 patients with genitourinary manifestations of the Klippel-Trenaunay syndrome and performed a MEDLINE review of the literature using the key words "Klippel-Trenaunay," "vascular malformation" and "genitourinary."Results: Genitourinary manifestations were cited in 18 articles, including 1,174 cases of the Klippel-Trenaunay syndrome, detailing the presentation and management of bladder, external genitalia and retroperitoneal involvement in the Klippel-Trenaunay syndrome. The overall genitourinary symptoms in patients with the Klippel-Trenaunay syndrome seem to occur in the more severe cases and usually involve cutaneous vascular malformations of the trunk, pelvis and genitalia.Conclusions: Intra-abdominal and intrapelvic extension of the vascular malformations of the Klippel-Trenaunay syndrome frequently occurs concurrently with the lower abdominal, pelvic cutaneous involvement of the external genitalia, as in our 2 cases and in our review of the literature. These data provide a better understanding of the spectrum of genitourinary manifestations in the Klippel-Trenaunay syndrome and provide insight for the clinician to formulate individual therapies for these patients.

Purpose: During the last 10 years we attempted to treat most children presenting with a ureterocele with a single definitive operative procedure. We reviewed the surgical results to assess the success of the preoperative plan in achieving this outcome.Materials and Methods: We retrospectively reviewed the records and diagnostic studies of all children who underwent surgery for a ureterocele during the last 10 years at our institution. The intent of the surgeon as to whether the procedure was intended to be definitive was stated in the clinic notes in all cases.Results: Surgery for a ureterocele was performed in 38 children during the study period. Transurethral incision was used in 7 patients and, although it was intended to be definitive in 2, all 7 required subsequent surgery for vesicoureteral reflux. Isolated upper tract surgery was performed with intent to cure in 20 of 21 patients including upper pole heminephrectomy in 17 and upper to lower ureteroureterostomy in 3. Of the 20 patients initially treated with this simplified approach 17 (85%) did not require subsequent surgery for ureterocele and 12 had vesicoureteral reflux preoperatively, which persisted in 2 (10%) and required subsequent surgery in 3 (15%). Total reconstruction of the ureterocele was performed in 10 patients and 1 of whom required subsequent surgery. We achieved resolution of all problematic aspects of the ureterocele with a single procedure in 26 of 32 patients (81%).Conclusions: A single procedure that definitively treats all problems of a ureterocele can be selected in more than three-quarters of patients. Transurethral incision was unsuccessful at definitively treating these patients in our experience. An isolated upper tract procedure was successful in patients with no or mild associated vesicoureteral reflux. We think that upper tract surgery should be the procedure of choice in this subset of patients, as it usually resolves the problem and does not subject; the patient to the potential morbidities of bladder surgery. Although total reconstruction is a more formidable procedure, it can be performed safely with excellent results.

PURPOSE:We questioned whether it is feasible in the current era of cost consciousness to perform standard open pediatric urological procedures on an outpatient basis while maintaining patient safety and satisfaction. MATERIALS AND METHODS:We report on 51 consecutive patients 2 months to 13 years old (mean age 4 years 3 months) who underwent a standard open pediatric urological procedure between August 1999 and June 2000. The procedures included ureteral reimplantation in 22 cases (tapered in 2), pyeloplasty in 20, partial nephrectomy in 2, nephrectomy in 2, complete ureterocele reconstruction in 1 and other in 4. The expectation that the procedure would be performed on an outpatient basis was discussed with parents preoperatively. We excluded only cases requiring bowel for reconstruction. A caudal block was administered at the start of the procedure using 0.25% bupivacaine with 1:200,000 epinephrine at a dose of 1 cc/kg. The wound was infiltrated with 1 cc/kg. 0.25% bupivacaine and 0.5 mg./kg. ketorolac was administered at the end of the procedure. As soon as the child awakened, an age appropriate diet was started and 0.5 to 1 mg./kg. codeine with acetaminophen was given every 4 hours. RESULTS:Of the 51 children 44 (86%) were discharged home the day of surgery. Average postoperative hospitalization was 7 hours. One of the 44 children discharged home required a single catheterization elsewhere. There were no other complications or repeat hospitalizations. CONCLUSIONS:Our experience shows that standard open pediatric urological procedures may be performed safely and comfortably on an outpatient basis.

No AccessJournal of UrologyPEDIATRIC UROLOGY1 Oct 2000THE TRANSURETHRAL RESECTION SYNDROME: AN UNUSUAL COMPLICATION OF POSTERIOR URETHRAL VALVE ABLATION ROSS M. DECTER and CARL T. REESE ROSS M. DECTERROSS M. DECTER More articles by this author and CARL T. REESECARL T. REESE More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)67193-5AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "THE TRANSURETHRAL RESECTION SYNDROME: AN UNUSUAL COMPLICATION OF POSTERIOR URETHRAL VALVE ABLATION." The Journal of Urology, 164(4), pp. 1345–1346 References 1 : Complications of posterior urethral valve surgery and their prevention. Urol Clin North Am1983; 10: 519. Google Scholar 2 : Urinoma formation in posterior urethral valves: relationship to later renal function. Pediatr Radiol1990; 20: 543. Google Scholar 3 : Transurethral surgery. In: . Philadelphia: W. B. Saunders Co.1998: 1509. chapt. 49. Google Scholar From the Division of Urology, Department of Surgery, Milton S. Hershey Medical Center of Pennsylvania State University, Hershey, Pennsylvania© 2000 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 164Issue 4October 2000Page: 1345-1346 Advertisement Copyright & Permissions© 2000 by American Urological Association, Inc.Keywordsurethraabnormalitiespostoperative complicationsMetrics Author Information ROSS M. DECTER More articles by this author CARL T. REESE More articles by this author Expand All Advertisement PDF downloadLoading ...

The parents of a newborn with myelodysplasia face a constellation of obvious and seemingly insurmountable malformations that will prevent their baby from being “normal.” In the face of this sobering reality, the possibility that a noninvasive, painless therapy might normalize at least one aspect of their child’s handicap has an almost siren-like allure. My initial exposure to intravesical transurethral bladder stimulation occurred when I heard Dr. William Kaplan’s presentation at the annual meeting of the American Academy of Pediatrics in 1987. 1 Kaplan WE, and Richards I: Intravesical electrotherapy in the management of the neurogenic bladder disease. Presented at the American Academy of Pediatrics 56th Annual Meeting, New Orleans, Louisiana, November 2, 1987. Google Scholar The technique offered the hope of a whole new approach to the management of the neurogenic bladder, and I was excited at the possibility of being able to help my patients achieve volitionally controlled voiding. I contacted Dr. Kaplan and his nurse Ingrid Richards shortly thereafter, and with their help we started our own program. We followed the technique that Kaplan had found successful, and his protocol was a precise copy of that of Katona, the originator of the modality. In this commentary, I review the published results of the technique, starting with Katona’s experience and try to reach a conclusion about the efficacy of intravesical electrical bladder stimulation.

Purpose: The optimal approach to correcting ventral chordee associated with severe hypospadias is controversial. Dorsal plication tends to shorten the phallus and ventrally positioned grafts often mandate a staged procedure. An alternative approach is presented using corporal rotation to correct ventral chordee associated with hypospadias.Materials and Methods: In 6 boys with severe hypospadias the urethral plate was divided and the septum between the corpora cavernosa was partially split with a ventral midline incision. This incision facilitates corporal rotation. Access to the dorsal aspect of the corpora cavernosa was achieved by dissecting Buck's fascia with its encased neurovascular bundles, so that the bundles in the area of chordee were completely elevated and preserved. Using artificial erection as a guide nonabsorbable sutures were placed in the area of maximal curvature from the dorsolateral aspect of 1 corpus cavernosum across the midline to the other side such that, as the knots were tied, the corpora rotated toward the dorsal midline. The knots were buried by apposition of the rotated corporal bodies.Results: Excellent straightening of the phallus was achieved intraoperatively in these patients.Conclusions: The split and roll technique for correcting severe chordee does not require incisions into the corporal substance, involve use of grafts or cause shortening of the phallus. The neurovascular bundles are preserved and are not compressed by the rotational sutures. The surgeon may perform 1-stage reconstruction while achieving maximal penile length.

Objective To review previous reports and our experience in assessing the risk of prosthetic infections in patients undergoing bladder augmentation simultaneously with artificial genitourinary sphincter (AGUS) implantation, and in patients with in situ ventriculoperitoneal (VP) shunts, implicated as a cause of shunt infection. Patients and methods The literature was searched to identify the number of prosthetic infections (AGUS or VP shunt) reported in patients who have undergone bladder augmentation. Additionally, the records of 53 myelodysplastic patients at our institution who had undergone bladder augmentation were reviewed to determine the incidence of AGUS and/or VP shunt infections. An AGUS was placed in 17 of these patients, who were then divided into three groups based upon the timing of their AGUS placement relative to bladder augmentation. Of the 53 patients, 47 had an in situ VP shunt at the time of their augmentation. All patients were followed for at least 12 months. Results The reported rate of AGUS infection at the time of simultaneous bladder augmentation was not significantly different from that when these procedures were staged. In the present series, the AGUS became infected in two patients (12%); one infection occurred in each of 10 patients undergoing simultaneous procedures (10%) and one developed in each of the seven patients undergoing staged procedures (14%). Although VP shunt infections have been reported after bladder augmentation, none of the present patients had a VP shunt infection after bladder augmentation. Conclusion These results suggest that bladder augmentation is not associated with an increased risk of prosthetic infection in patients undergoing simultaneous placement of an artificial sphincter or in those who have an in situ VP shunt.

PURPOSE Although vesical calculi are routinely treated transurethrally, open vesicolithotomy is generally performed in patients with an impassable or surgically ablated urethra. We describe a technique of percutaneous vesicolithotomy which we used in patients who had undergone urethral ablation and concomitant continent diversion by appendicovesicostomy. MATERIALS AND METHODS Bladder stones were detected in 3 patients with neurogenic bladder who had undergone continent urinary diversion with bladder neck closure and appendicovesicostomy. To treat the stones access to the bladder was achieved percutaneously and the tract was enlarged using a balloon dilator. An Amplatz sheath was slipped over the inflated balloon and after the dilator was removed the sheath provided a working channel through which stones were fragmented and removed using a nephroscope. RESULTS Each patient was rendered stone-free and discharged home the same day as the procedure. CONCLUSIONS Percutaneous vesicolithotomy provides an alternative approach for bladder stone removal in patients with an impassable urethra with decreased morbidity compared to open procedures.

Purpose: Various techniques have been described to correct distal hypospadias but many are best suited to patients with subtle specific nuances of meatal and/or glanular configuration. We describe a simplified approach to these defects using the modified Thiersch-Duplay technique with or without hinging the urethral plate (the Snodgrass maneuver).Materials and Methods: Between 1990 and 1997 we performed the modified Thiersch-Duplay repair as the primary procedure for repairing hypospadias in 197 boys. We initially performed urethral plate hinging (the Snodgrass maneuver) in 1994. By 1997, 82% of our patients were undergoing repair using the hinge technique. Urethroplasty coverage was provided by a second layer of adjacent local tissue or by a pedicle of subcutaneous tissue.Results: Reoperation was required in 5 boys (2.5%) with fistula and 1 (0.50%) with urinary extravasation. A fistula developed in 4 of the 63 cases (6.4%) in which adjacent local tissue was used to cover the urethroplasty and in 1 of 130 (0.80%) in which a pedicle of subcutaneous tissue was used. Overall 97% of the boys had an excellent result requiring no secondary operative procedure.Conclusions: The modified Thiersch-Duplay technique with or without urethral plate hinging is reliable for correcting distal hypospadias. The risk of fistula is almost eliminated when a vascularized pedicle of subcutaneous tissue is used to cover the repair. This technique has virtually supplanted all other methods that we used in the past to correct distal hypospadias.

OBJECTIVE To document the array of diagnostic modalities, the variety of errant diagnoses and treatments. and the time from initial presentation to ultimate diagnosis in girls with an ectopic single-system ureter draining an ectopic hypoplastic and/or dysplastic kidney. PATIENTS AND METHODS Between 1990 and 1997, seven females were identified who had an ectopic hypoplastic and/or dysplastic kidney with an ectopically draining ureter, and who were treated at our institutions, either initially or upon referral. The nature and number of all diagnostic evaluations, previous diagnoses and treatments, and the time from presentation to definitive diagnosis were recorded. RESULTS All seven females had a classical history of successful toilet training, a normal voiding pattern and continuous urinary incontinence. Typically, a solitary kidney was noted on the initial diagnostic evaluation by ultrasonography and/or intravenous urography. The mean (range) age at initial presentation was 3.2 (2-6) years. Additionally, voiding cysto-urethrography, urodynamics, radionuclide scintigraphy, computed tomography, magnetic resonance imaging and endoscopy were performed. The age at definitive diagnosis was 3-16.5 years and the mean (range) time from initial presentation to diagnosis was 5.7 (1-10) years. Nephroureterectomy was curative and all kidneys were dysplastic. CONCLUSION Continuous urinary incontinence in females with a normal voiding pattern should prompt an evaluation for ureteric ectopia. When the initial evaluation yields the diagnosis of a solitary kidney, clinicians should be aware of the possibility of a hypoplastic and/or dysplastic, often ectopic, contralateral kidney with an ectopically draining ureter. Identification of this entity should allow curative surgical treatment.

Colovesical fistulas in children are most often associated with high anorectal imperforations. Acquired enterovesical fistulas in children only rarely have been reported as a consequence of an inflammatory process. We present a case of an acquired colovesical fistula formed by the erosion of an abscess at the distal end of a colonic duplication in a child who presented with fever of unknown origin.

Purpose: Our aim was to assess whether a voiding cystourethrogram after uncomplicated ureteral reimplantation is necessary or cost-efficient.Materials and Methods: We retrospectively reviewed the records of patients who underwent uncomplicated reimplantation at our institution from 1988 to 1994. We also reviewed the literature to tabulate the reflux resolution rate from all published series of more than 100 ureters reimplanted.Results: At our institution 119 patients (207 ureters) underwent uncomplicated reimplantation and a postoperative voiding cystourethrogram, which documented a 98.6% initial reflux resolution rate. All persistent postoperative reflux resolved spontaneously without treatment for a final resolution rate of 100%. We reviewed 1,494 abstracts using vesicoureteral reflux as a key word and found 19 series of more than 100 ureters reimplanted. The combined results of our series and those 19 from the literature revealed 3,346 patients (5,008 ureters reimplanted). The final reflux resolution rate was 98.58%. Series that included and excluded secondary vesicoureteral reflux documented final reflux resolution rates of 98.4 and 99.04%, respectively. Reflux resolved spontaneously in 85% of the ureters in which it was noted on the initial postoperative cystogram. At our institution the cost of a voiding cystourethrogram is $610 and we perform an average of approximately 20 uncomplicated reimplantations per year. In the United States there are approximately 230 pediatric urologists. If each surgeon performed 20 reimplantations per year at the same cost per voiding cystourethrogram, a cost savings of $2.8 million per year would result if the study were not performed after surgery.Conclusions: In the hands of experienced pediatric urologists uncomplicated ureteral reimplantation has a success rate of 99.04%. The yield of postoperative voiding cystourethrography is exceedingly low and a cost savings of $2.8 million per year would result by omitting the postoperative voiding cystourethrogram.

This article reviews the common pediatric urologic problem of renal duplication and the variety of anomalies associated with duplication. Specifically, the embryology, presentation, evaluation, and comments on management concerning simple duplex systems and those associated with ureteroceles and ectopic ureters are addressed. In addition, the less frequently seen but clinically significant problems of renal fusion and ectopia are reviewed.

Purpose: We assessed the sexual functioning and understanding in men with myelodysplasia.Materials and Methods: Of the 378 patients with myelodysplasia followed at our multidisciplinary clinic 170 are adults, including 58 men older than 18 years. A total of 57 men was available for interview. A questionnarie was administered to determine patient educational level, sexual understanding, sexual function and marital status, and serum testosterone levels were measured.Results: The majority of the patients learned about sexual reproduction from school classes with 48 (84%) having achieved a twelfth grade education or higher. A total of 41 patients (72%) accurately described the basic concepts of reproductive physiology. Penile erections were experienced by 41 men (72%) including 27 (66%) who ejaculated with erection. Three patients ejaculated without erection. Sexual intercourse was attempted by 20 men (35%). Of the 11 patients (19%) who attempted to father children 8 (14%) were successful. Twelve patients (21%) have been married, including 2 who are divorced. Serum testosterone levels in 44 patients were normally distributed.Conclusions: Sexual reproductive understanding, and erectile and ejaculatory function are present in many men with myelodysplasia. The level of the neurological lesion was not predictive of erectile or ejaculatory function but it appears that reproductive potential is favored by lower and less severe lesions. All but 1 of the 8 patients who fathered children had an L5 or sacral neurological level lesion, each was ambulatory and none had a ventriculoperitoneal shunt at the time of conception. These data may prove useful when counseling patients and their parents about eventual sexual performance.

Transurethral electrical bladder stimulation (TEBS) initially proposed to rehabilitate the neurogenic bladder has been promoted in the United States since the mid 1980s. The ultimate goal of TEBS is volitional voiding. Since January 1989 we performed 938 sessions of stimulation comprising 64 TEBS series in 25 patients with neurogenic bladders. A cystometrogram was performed before each series of stimulation to monitor progress, and at the time of this review parental impressions of the stimulation were obtained by a telephone interview questionnaire. The initial evaluation cystometrogram before stimulation revealed that 18 patients (72%) had bladder contractions. After TEBS 24 patients (96%) manifest contractions. Before stimulation only 3 children sensed the contractions, while during stimulation half of the patients perceived the contractions. A cystometrogram performed before each series demonstrated a greater than 20% increase in the age adjusted bladder capacity in 6 of the 18 patients (33%) with serial studies. Improvements in the end filling pressure defined by clinically significant decreases were observed in 5 of these patients (28%). Results of the telephone questionnaire revealed that the parents perceived a benefit from stimulation more often than the urodynamic studies could confirm. In our experience TEBS is a time-consuming, labor intensive technique. The limited urodynamic benefits our patients achieved have not materially altered the daily voiding regimen and, because of these factors, we are not enrolling any new patients in our TEBS program.

We describe an unusual complication of appendicovesicostomy—the development of multiple polyps in the appendiceal conduit—in a patient with spina bifida.

A variety of complications have been described after placement of a Stamm gastrostomy in infants and children, including gastric volvulus, pancreatitis, jaundice, gastroduodenal mucosal intussusception with gastric outlet obstruction, and even aortogastric fistula. However, this is the first report of pyeloduodenal fistula after Stamm gastrostomy in a 4 1/2-month-old boy. The child successfully underwent nonoperative therapy; he was treated by withdrawing the gastrostomy tube (Foley catheter) from the renal pelvis, bowel rest, and total parenteral nutrition. After the case presentation is a brief review of this rare entity, with its clinical presentation and pathophysiological differences between adult and pediatric cases. Various treatment options, both operative and nonoperative, are also described.

We successfully used intravesical urokinase in 2 young boys to relieve clot retention occurring as a consequence of upper tract bleeding. Urokinase clot dissolution appears to offer a simple, minimally invasive, atraumatic solution to this infrequent problem.