Securing certification by the American Board of Urology.
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Certification↗
Biomedical subjects
A D Perlmutter
Publications and source records attributed to A D Perlmutter.
Acquired rectourethral fistula: methods of repair.
Rectourethral fistulas are a rare but devastating complication of urinary or rectal surgery, trauma or inflammation. Historically repair has posed a challenge because of technical difficulties and the high incidence of recurrent fistulas. We report 7 cases of acquired rectourethral fistulas of varying etiology (3 after prostatectomy, 3 after trauma and 1 after recurrent perineal abscess), which were managed by various means. Our data and those in the literature suggest that the first attempt at repair is the best and subsequent repairs become increasingly difficult; the York Mason approach allows easy accessibility with minimal risk of complications and the best chance for a functionally successful outcome when a vascularized flap is not required, and some cases may have such a low probability of successful resolution of the fistula as well as maintenance of urinary continence that cystectomy and supravesical diversion are appropriate considerations.
Adolescent↗
Reduction cystoplasty in the prune belly syndrome: a long-term followup.
The role of reduction cystoplasty in the management of severe prune belly syndrome is controversial. From 1973 to 1990, 11 boys with severe prune belly syndrome underwent comprehensive urinary tract reconstruction, including overlapping reduction cystoplasty. Followup ranged from 1.5 to 18 years and 6 boys are now older than 18 years. Nine had sepsis or progressive renal failure as neonates; 7 had upper tract diversion as an initial procedure, of whom 2 have chronic renal failure. Currently 9 boys are voiding, including 1 who could not void preoperatively, with less than 50 cc residual after double or triple voiding. One boy underwent transplantation to an ileal conduit and 1 continues on intermittent catheterization. In the 9 cases in which bladder volume data were available average reduction in volume at operation was 52%. At an average of 7.7 years later (range 1.5 to 14) bladder volumes corrected for age were essentially unchanged or greater than corrected preoperative volumes. Since reflux was corrected in 7 of 9 boys it cannot account for the redevelopment of large bladder capacities (range 740 to 2,300 cc). In cases of the prune belly syndrome reduction cystoplasty has helped to improve voiding and minimize infection during early childhood but it does not seem to decrease bladder capacity or improve voiding dynamics in the long-term.
Child↗
Acute renal failure secondary to ciprofloxacin use.
We report on a 22-year-old woman with a continent urinary diversion in whom acute renal failure developed on ciprofloxacin therapy for pelvic osteomyelitis. Renal failure resolved rapidly once the drug was withheld. Because ciprofloxacin is used extensively by the urological community, we believe that it is important to be aware of this potential complication of therapy. We review the literature on the association of ciprofloxacin and renal failure.
Acute Kidney Injury↗
Early cystometrograms can predict the response to intravesical instillation of oxybutynin chloride in myelomeningocele patients.
Recent reported experiences with intravesical medications in neurogenic bladder patients prompted us to evaluate this form of therapy in 28 myelomeningocele patients who could not tolerate oral anticholinergic agents or did not have adequate control on these agents. A pretreatment cystometrogram was performed followed by intravesical administration of oxybutynin chloride, with a repeat cystometrogram 3 hours later. Patients then began twice daily intravesical oxybutynin for a minimum of 4 months. The mean bladder capacity increased by 41%, the mean intravesical pressure decreased by 47% and compliance improved. Five patients achieved continence and 62% had less wetting while on intravesical therapy. The immediate posttreatment cystometrogram was predictive of the response to intravesical therapy on followup studies. Unfortunately, patient compliance was poor, with only 13 of the 28 patients remaining on therapy for the duration of the study.
Administration, Intravesical↗
Infected multicystic displastic kidney.
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Escherichia coli Infections↗
Vesical neck reconstruction in patients with epispadias-exstrophy complex.
The achievement of satisfactory continence in the management of patients with the epispadias-exstrophy complex remains a challenge. Between 1971 and 1989, 22 children underwent vesical neck reconstruction at our hospital. Satisfactory continence was achieved in 17 of the 22 patients (77%), including 8 (36%) who are continent after a single vesical neck reconstruction and 9 of 13 who achieved continence after additional and/or adjunctive procedures. Additions and/or adjunctive procedures included revision of the vesical neck reconstruction, bladder augmentation and/or placement of an artificial urinary sphincter. We conclude that vesical neck reconstruction with or without additional and/or adjunctive procedures can result in an acceptable continence rate in patients with the epispadias-exstrophy complex.
Adolescent↗
Sleeve advancement distal hypospadias repair.
We report the technique and late results of a procedure for selected cases of distal hypospadias called sleeve advancement urethroplasty. This procedure incorporates correction of chordee, distal urethral mobilization and glans plasty in patients with coronal or distal subcoronal hypospadias. A total of 69 boys underwent this procedure at our institution: 59 as a primary repair and 10 for correction of meatal retraction after a previous failed reconstruction. Cosmetic results were excellent in most patients. Complications included meatal retraction in 2 patients and mild meatal stenosis in 2 in the primary repair group, and meatal stenosis in 3 (with associated fistula in 1) in the secondary repair group. Although not a replacement for meatal-based flap procedures, and more tedious to perform than the meatal advancement and glanuloplasty procedure, we have been impressed with the superior cosmetic results and minimal morbidity of the sleeve advancement urethroplasty.
Child↗
Experience with 81, 1-stage hypospadias/chordee repairs with free graft urethroplasties.
We performed 81, 1-stage hypospadias/chordee repairs with preputial free graft urethroplasty between January 1981 and July 1988 using a modified Horton-Devine technique. Of the free grafts 37 were fashioned as patches, 42 as tubes, and 4 as a combination patch and tube. Of the patients 58 (72%) underwent single or multiple dorsal plications, in addition to the usual procedures, to correct chordee completely. A total of 35 patients (43%) required a second procedure: 28 (34%) for persistent fistula and 7 (9%) for stricture. These reoperations were typically minor outpatient procedures. All patients had an excellent functional and cosmetic outcome. Although the need for reoperation unfortunately is high, we believe the use of free grafts allows for a better functional and cosmetic outcome because the secondary torsion and bulkiness of the penile shaft caused by the vascular pedicle are eliminated. This is especially noticeable in patients with a small penis.
Child, Preschool↗
Management of obstructing ectopic ureteroceles.
Ectopic ureteroceles are a common pediatric urologic problem requiring thoughtful management decisions. Although management algorithms have been proposed, they should serve only as a framework for therapy. More important is a thorough understanding of the problem and its implications. The authors discuss their management approach and provide several cases illustrating the spectrum of problems presented by ectopic ureteroceles and the variety of management options.
Female↗
Optimal use of 99mtechnetium-glucoheptonate scintigraphy in the detection of pyelonephritic scarring in children: a preliminary report.
Renal scintigraphy represents the optimal modality for the detection of renal scars. 99mTechnetium-glucoheptonate is rapidly accumulated by the kidney through glomerular filtration and active transport by renal tubular cells. This permits rapid visualization of the renal parenchyma in the early phase (1 to 3-minute images) and subsequent imaging of the collecting system and ureters. About 10 to 15 per cent of the injected activity remains in the kidney, labeling the cells of the proximal convoluted tubules (late phase or 1 to 2-hour images). The late phase has been used more commonly to assess renal parenchymal damage. Early and late phase glucoheptonate scanning was performed in 42 children as part of the evaluation of recurrent febrile urinary tract infections with or without a history of vesicoureteral reflux. Inter-observer reliability to interpret glucoheptonate scans was good (early, 83 per cent agreement and late, 93 per cent agreement). The ability of glucoheptonate scanning to detect renal scarring in children with febrile urinary tract infections was equivalent with the early or late phase of the study. In 6 patients renal scarring was detected on only the early phase scan and in 7 scarring was detected only in the late phase. Although the detection rates are equivalent the over-all detection of scarring is improved by using both phases. Therefore, the early phase of the glucoheptonate scan may be a valuable adjunct to conventional glucoheptonate scan methodology used for the detection of renal scarring in children with recurrent urinary tract infections.
Adolescent↗
Follow-up studies of multicystic dysplastic kidneys.
Thirty cases of multicystic dysplastic kidney (MCDK) were diagnosed over 11 years. Nine patients underwent nephrectomy: three for increasing kidney size (classic MCDK) and six because of an inconclusive diagnosis (hydronephrotic MCDK). Of the remaining 21 patients, 19 were followed up for a mean of 33.5 months (range, 2-101 months). Follow-up ultrasound examinations revealed that 16 kidneys did not change in size, one decreased in size after cyst puncture, and two disappeared (one after cyst puncture). This series included one case of non-renin-producing hypertension that was controlled medically, one case of nephroblastomatosis found in the removed dysplastic kidney, and one case of pyelonephritis in the contralateral kidney. When the diagnosis of classic MCDK is made with imaging modalities, the lesion may not have to be removed unless there is growth of the mass during the 1st year of life. Nine percent of these lesions will disappear within the first 3 years of follow-up, and the authors recommend an even longer period of follow-up.
Child↗
Renal dysgenesis and cystic disease of the kidney: a report of the Committee on Terminology, Nomenclature and Classification, Section on Urology, American Academy of Pediatrics.
We believe that the confusion regarding abnormal renal development could be reduced by more precise terminology. Therefore, we suggest precise definitions for dysgenesis, hypoplasia, dysplasia, hypodysplasia, aplasia and agenesis of the kidney. We suggest the term reflux nephropathy be a generic label for any instance of abnormal renal morphology (gross or microscopic) associated with vesicoureteral reflux. Hypoplasia and hypodysplasia can be subclassified on the basis of associated urological criteria. There have been many previous attempts to classify cystic disease of the kidney but none has been accepted collectively by pathologists, urologists, nephrologists and radiologists. On the basis of known patterns of inheritance, a classification is outlined in which renal cystic disease is divided into 2 major groups: genetic and nongenetic. Each entity is discussed.
Classification↗
Experience with free grafts in urethral reconstruction.
A total of 33 patients underwent hypospadias or epispadias repair by patch or tubular grafts of skin or bladder epithelium from July 1980 to January 1985. Indications included previous circumcision, proximal primary hypospadias, severe chordee alone, inadequate local skin during extended urethroplasty at 2-stage hypospadias repair, multiple previous reconstructions and failed epispadias repair. Genital skin grafts were used in 25 patients, extragenital skin grafts in 4 and bladder epithelial grafts in 4. Complications occurred in 13 patients (39.4 per cent): 8 required reoperation for a fistula, stricture or diverticulum, and 5 underwent internal urethrotomy or urethral dilation. Of the 8 patients 3 needed more than 1 revision. These revisions were short and generally uncomplicated. Final results uniformly were good functionally and cosmetically. Based on our experience and that of others we believe that despite a high incidence of minor complications a free graft serves as an excellent substitute urethra for treatment of a variety of urethral problems in children.
Adolescent↗
Reflux nephropathy.
This article reviews current concepts of reflux nephropathy, including the pathophysiology, diagnosis, relationship to infection, role in causing end-stage renal disease, and appropriate treatment and management. The condition is defined from a epidemiologic point of view herein, and attention also is given to possible progressions this condition can take.
Adolescent↗
Outpatient surgery in pediatric urology.
Indications for ambulatory pediatric urological surgery have been broadened to include most inguinal and scrotal surgery, many endoscopic procedures and distal hypospadias repairs with or without chordee or urethroplasty. We have reviewed a 1-year experience with the 440 outpatient urological procedures performed at Children's Hospital of Michigan in 1984, and found a low (3.4 per cent) incidence of postoperative hospitalization and only a single complication. We conclude that outpatient surgery in well selected patients and procedures is safe, timely and economical.
Adolescent↗
Urinary tract deterioration associated with the artificial urinary sphincter.
In most recent series of artificial sphincter implantations there has been a reduction in mechanical and surgical complications, with continence rates approaching 90 per cent. Despite initially excellent results in 47 children, with increasing durations of followup we noted a transient hydronephrosis related to incomplete bladder emptying in 5 and a persistent physiological alteration of detrusor dynamics consisting of a rigid, noncompliant bladder in 7. Preoperatively, all patients had had indepth radiological studies and most had a urodynamic evaluation, and were considered to be excellent candidates. The etiology of these alterations is not understood at this time. Bladder and even upper tract deterioration can occur without the appearance of urinary leakage. Therefore, children with an artificial sphincter must be monitored indefinitely with semiannual assessment of the upper tracts and periodic urodynamic evaluation.
Adolescent↗
Tunica vaginalis free graft for the correction of chordee.
Tunica vaginalis free grafts were used to correct severe chordee not amenable to other surgical maneuvers in 11 boys. Postoperatively, the penis was straight in 10 patients and had some degree of downward angulation in 1 boy. The tunica vaginalis free graft seems to be a useful technique for the correction of severe chordee.
Child, Preschool↗