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Biomedical subjects

B M Churchill

Publications and source records attributed to B M Churchill.

At least 19 recordsLinked to original sources
PubMed1992

Complications of surgical significance in pediatric renal transplantation.

From 1969 to 1986, 303 renal allografts (290 cadaveric) were placed in 215 pediatric recipients. Twenty-three patients (7.6%) had renovascular complications and 16 (5.3%) had nonrenovascular complications. The overall incidence of surgically significant complications was 12.9%. Of these, 54% were felt to be of a technical etiology. The remainder were surgically significant in that their management necessitated operative intervention.

Adolescent↗
PubMed1992

Rapid development of an immunoblastic lymphoma and death in children following cadaveric renal transplantation.

We report on three children who underwent cadaveric renal transplantation and subsequently developed an immunoblastic lymphoma, leading to death in two patients. The development of the lymphoma occurred following a multi-drug immunosuppression regimen ending with monoclonal antilymphocyte (OKT3) treatment for biopsy-proven cellular and vascular acute rejection. These patients represent three of 11 children who received OKT3 treatment for rejection in the last 18 months at this institution. Following the diagnosis of lymphoma, all three patients were treated by transplant nephrectomy, cessation of immunosuppression, and administration of intravenous acyclovir. The first two patients died at 4 days and 4 weeks, respectively, after the definitive diagnosis was made with widespread metastatic disease. The remaining child is a short-term survivor (13 months), free of demonstrable malignancy. Multidrug regimens for immunosuppression have a profound effects on T cell function. These effects, when combined with a primary infection by the Epstein-Barr virus, are implicated in the rapid development of the lymphomas and are responsible for the death of these two children.

Cadaver↗
PubMed1992

Evaluation of factors contributing to mortality in pediatric renal transplant recipients.

From 1969 to 1985, 303 renal allografts (290 cadaveric) were placed in 215 pediatric recipients. A review of actuarial recipient and allograft survival 2 years posttransplant showed good results in patients over 6 years of age (greater than 90% for patients, about 70% for allografts) but less satisfactory results in younger patients (75% for patients, about 45% for allografts). Thirty-nine patients died. Loss of allograft function preceded death in 67% of cases and was due to rejection (61%), renal vascular thrombosis (35%), and recurrence of original disease (4%). On retrospective analysis, 13 deaths might have been preventable with current diagnostic and therapeutic modalities. Allograft dysfunction from thrombosis occurs at a higher frequency in the young child and may be confused with rejection. Treatment of rejection without biopsy, overagressive treatment of a chronically failing graft, and failure to withdraw immunosuppressive therapy in face of infection are poorly tolerated in the very young recipient and are prominent causes of preventable mortality. Transplant nephrectomy and repeated attempts at transplantation are poorly tolerated in very young patients. Patient survival is very dependent on the success of the initial allograft in children.

Age Factors↗
PubMed1992

The efficiency of bladder emptying in the prune belly syndrome.

From 1956 to 1991, 49 cases of the prune belly syndrome were seen at our institution. Voiding information and/or 1 or more urodynamic studies were available in 30 male and 4 female patients. Analysis of multiple urodynamic studies during long-term followup periods ranging from 6 months to 19 years, with particular regard to any reconstructive procedures performed, revealed that voiding in the prune belly syndrome is variable, with 44% of the patients achieving spontaneous voiding and 56% requiring clean intermittent catheterization. The ability to void or need for clean intermittent catheterization was by no means permanent, indicating the need for meticulous followup. The 3 distinct voiding patterns observed included an approximately normal pattern, prolonged voiding with a low peak and an intermittent pattern. These 3 voiding patterns did not correlate with residual volumes. Comparison of urodynamic voiding parameters between reconstructed voiding patients and nonreconstructed voiding patients did not show significant differences.

Adolescent↗
PubMed1992

Extravesical nondismembered ureteroplasty with detrusorrhaphy: a renewed technique to correct vesicoureteral reflux in children.

We performed an extravesical nondismembered reimplant to correct surgically primary vesicoureteral reflux in 45 patients (65 renal units) between April 1989 and September 1990. Of the units 6 had grade I reflux, 16 grade II, 23 grade III, 14 grade IV and 6 grade V. Only patients with primary reflux were included in this study. The success rate was 100% for grades I to III, 92.9% for grade IV and 66.7% for grade V. Overall, the reflux was cured in 62 of the 65 operated renal units (95.4%) or 95.6% of the patients (43 of 45). Postoperative morbidity and complications were minimal. No cases of postoperative obstruction were detected on excretory urography 6 weeks postoperatively. Seven children (16%) suffered from transient inadequate bladder emptying as assessed by post-void ultrasound residual evaluations. This problem resolved spontaneously after a maximum of 4 weeks of clean intermittent catheterization. Compared to conventional transvesical technique, the discomfort related to bladder spasms during the postoperative period was subjectively decreased and patients had no prolonged hematuria.

Adolescent↗
PubMed1992

A surgical model for normotensive chronic renal failure in the growing piglet.

Studying the effects of chronic uremia in children has been hindered by the lack of a suitable large mammalian animal model with normotensive renal failure. We performed nephrectomy with simultaneous contralateral partial nephrectomy using a stapling device and absorbable staples in 22 domestic piglets. Up to 93% of the total renal mass could be excised by this method. A chronic uremic state was reproducibly developed and correlated with the percentage of renal mass excised. There were no associated postoperative complications with the stapled partial nephrectomy. Pigs with moderate renal failure had a significant decrease in growth compared to those with mild renal failure, which represents the successful development of a normotensive large mammalian animal model that could be used to study the effects of chronic renal failure and hyperfiltration during a state of rapid growth. In addition, this study confirms the successful use of a stapling device to perform partial nephrectomy.

Animals↗
PubMed1992

Radiographic and serologic correlates of azotemia in patients with posterior urethral valves.

A retrospective statistical analysis with a minimum followup of 10 years was done on 102 patients who presented in early childhood with posterior urethral valves. All patients were treated with initial bladder drainage. Factors correlating with the development of renal failure were evaluated. No patient with a normal kidney on 1 side had renal failure. Calculated glomerular filtration rate was significantly higher in patients who retained adequate renal function (80.7 +/- 17.8 ml. per minute per 1.73 m.2), as compared with those who had renal failure (18.6 +/- 9.6 ml. per minute per 1.73 m.2). Patients with renal failure also had a significantly higher serum creatinine level at stabilization (2.0 +/- 0.8 mg./dl.) than those who had adequate renal function (0.5 +/- 0.2 mg./dl.). The presence of bilateral high grade vesicoureteral reflux, hydronephrosis and nonfunction was significantly higher in patients with renal failure. Patient age at presentation was not a significant factor. These data represent a guideline for the prognosis and management protocols of infants with dilated upper urinary tracts and posterior urethral valves.

Age Factors↗
PubMed1992

Omeprazole in post-gastrocystoplasty metabolic alkalosis and aciduria.

The use of segments of stomach for bladder augmentation is gaining popularity in pediatric urology due to favorable muscular and secretory properties. However, in a renal failure patient who underwent gastrocystoplasty a high level of acid production within the bladder associated with persistent hypergastrinemia was noted leading to severe systemic metabolic alkalosis. This condition was unresponsive to standard acid-inhibiting or neutralizing therapies but it was treated successfully with omeprazole, a proton-pump inhibitor recently introduced for treatment of peptic ulcer disease.

Alkalosis↗
PubMed1991

Reduction in tumor burden allowing partial nephrectomy following preoperative chemotherapy in biopsy proved Wilms tumor.

During the last 6 years a treatment protocol of radiographic staging along with percutaneous biopsy to establish a histological diagnosis has been used in 37 patients with Wilms tumor. Combination chemotherapy was given for 4 to 6 weeks before definitive surgical resection. In 9 patients tumor shrinkage was sufficient to permit preservation of a portion of the affected kidney(s). In stage V disease partial nephrectomy was accomplished in 5 patients. In 4 additional patients with unilateral disease downstaging also allowed partial nephrectomy. The radiological and histological changes that allowed this limited surgery are analyzed and compared.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1991

Continence in bladder exstrophy: determinants of success.

We evaluated 19 female and 18 male patients with bladder exstrophy, who had completed staged reconstruction, had required no further surgery and underwent urodynamic studies. Of the male population 61% were continent based on a significantly higher urethral continence length (25.8 +/- 6.4 mm., mean plus or minus standard error) and a higher urethral closing pressure (69.4 +/- 5.8 cm. water) compared to the incontinent male population (11.4 +/- 3.1 mm. and 43.4 +/- 4.6 cm. water). No significant difference was noted in the bladder capacity of these 2 groups. Of the female population 57.9% were continent. They also demonstrated a higher urethral continence length (21.1 +/- 4.4 mm.) and a higher urethral closing pressure (62.7 +/- 10.2 cm. water) compared to the incontinent female subjects (8.4 +/- 2.5 mm. and 32.7 +/- 6.9 cm. water). Moreover, those who were continent had a significantly higher bladder capacity (201.2 +/- 39.5 ml.) compared to those who were incontinent (84.3 +/- 23.6 ml.). These findings support a multifactorial mechanism in achieving continence but they suggest that of all the factors urethral length may be the most important.

Bladder Exstrophy↗
PubMed1991

Hernias associated with CAPD in children.

Twenty-eight hernias occurred in eighteen of seventy-nine pediatric patients on peritoneal dialysis (PD). There was 18 inguinal hernias (6 bilateral) in 12 patients (11 boys and 1 girl) the average age of the male patients with inguinal hernias was 5.2 years vs 9.3 years for the remaining 32 males. Four of the 11 patients were under 2 years old, where as only 3 of the remaining 32 patients were less than 2 (p less than 0.05), and 3 of the 6 patients with bilateral hernias were under 2. A high incidence of recurrent hernias was noted when only high ligation of the hernia sac was performed. We conclude that all candidates for PD should be carefully evaluated for the presence of occult hernias, hernias should be repaired promptly and electively on an inpatient basis, surgical correction of hernias should include a formal Cooper ligament repair and males under 2 should have bilateral repairs done even if they present with a single hernia.

Adolescent↗
PubMed1990

Inguinal pathology and its association with classical bladder exstrophy.

One hundred thirty-four cases of classical bladder exstrophy, managed at our institution, were reviewed. Fifty-six percent of the boys and 15% of the girls developed inguinal hernias over an average follow-up time-span of 10 years. Thirty-one percent of the patients with hernias underwent repair at the time of initial bladder closure. Forty-six percent of the patients who developed a hernia were diagnosed during the first year following their initial procedure. More than 50% of the individuals in the latter category presented with an incarcerated hernia, and required emergent management. Boys managed by staged reconstruction had a statistically significant risk of developing an inguinal hernia (P less than .001) compared with boys undergoing primary cystectomy and diversion. We believe the increased incidence of herniation with this congenital anomaly is secondary to a lack of obliquity of the inguinal canal, due to pubic diastasis along with an increased elevation of intraabdominal pressure following initial closure of the abdominal wall and bladder plate. To decrease the attendant morbidity of incarcerated hernias in this population, we stress the need for careful physical examination of the inguinal region and spermatic cord prior to surgery, along with repair of the patent processus vaginalis at the time of initial repair.

Bladder Exstrophy↗
PubMed1990

Factors predisposing to renal scarring: following staged reconstruction of classical bladder exstrophy.

Preservation of renal function is one of the major goals of staged reconstruction of bladder exstrophy. In 68 exstrophy patients who have completed staged reconstruction, 10 (14.7%) have developed renal scarring. A multiple factorial analysis of these patients showed the following factors to be statistically related to the development of renal scarring: (1) one or more febrile urinary tract infections prior to bladder neck reconstruction (P less than .001); (2) failure to utilize antibiotic prophylaxis following initial bladder closure (P less than .005); (3) elevated urinary residuals greater than 50 mL (P less than .02); (4) a diagnosis of elevated urinary residuals greater than 6 months following the onset of continence (P less than .001); and (5) one or more febrile urinary tract infections following bladder neck reconstruction (P less than .005).

Anti-Bacterial Agents↗
PubMed1990

Duplicate bladder exstrophy: a new variant of clinical and embryological significance.

A case of duplicate exstrophy of a nature not previously encountered is reported, which we believe has important clinical and embryological implications. The patient presented with what appeared to be classical exstrophy. The inability to identify the ureteral orifices at operation led to the discovery of a previously unrecognized subjacent bladder of normal size and configuration except for a patulous bladder neck and associated epispadias. On excision of the duplicate bladder plate a coloniform projection was discovered that was lined with colonic mucosa. The surgical and potential embryological significance of this rare entity is described.

Bladder Exstrophy↗
PubMed1990

Occult spinal dysraphism: clinical and urodynamic outcome after division of the filum terminale.

A highly select group of 31 patients presenting with urinary incontinence failed to respond to conservative management and were found to have unstable bladders and spina bifida occulta. After thorough evaluation they were suspected of having neurogenic bladder dysfunction possibly due to a tethered cord. Following division of the filum terminale daytime incontinence resolved in 72%, urodynamic detrusor hyperreflexia disappeared in 59% and bladder compliance improved in 66% of the patients. The operation was well tolerated and did not result in any neurological complications. The clinical, radiological and urodynamic characteristics of these patients before and after treatment are reported.

Adolescent↗
PubMed1990

Effects of the artificial urinary sphincter on prostatic development and sexual function in pubertal boys with meningomyelocele.

Although sexual development in boys with meningiomyelocele may progress normally through puberty, the effects of surgical correction of incontinence by insertion of an artificial sphincter device around the bladder neck remain unclear. We studied 13 boys who received an artificial urinary sphincter before puberty and compared them to 12 age-matched pubertal controls with meningomyelocele. The prostate morphology was evaluated by means of transrectal ultrasonography, and we compared this finding, as well as sexual development, erectile function and seminal emissions between the 2 groups. Boys in both groups had similar development of secondary sexual characteristics and reported similar erectile function. Ultrasonography demonstrated an imprint of the sphincter cuff on the prostate but patients and controls had equal prostatic growth. In both groups an unexpected finding was the unexplained presence of sonolucent and sonodense lesions within the prostate glands. We conclude that transrectal ultrasonography is an excellent means of examining the prostate in pubertal boys with meningomyelocele. An artificial urinary sphincter placed around the bladder neck does not alter sexual development, function, prostatic growth or prostatic morphology.

Adolescent↗
PubMed1990

Lithostar extracorporeal shock wave lithotripsy in children.

The Siemens Lithostar lithotriptor was used to treat 20 children (4 to 17 years old) with renal or ureteral calculi. Two patients had bilateral renal and 2 had ureteral calculi. Of 34 calculi treated 47% were in the renal pelvis, 29% in the lower calix, 12% in the upper calix, 3% in the middle calix and 9% in the upper ureter. Stone size ranged from 2 X 2 to 40 X 20 mm. and averaged 10 X 7 mm. Of the children 60% were treated while they were under neuroleptic anesthesia. No major complications were encountered. The 3-month rate free of stones after 1 treatment was 60% and increased to 80% with multiple treatments. The success rate, defined as being either free of stones or with residual fragments equal to or less than 4 mm. in diameter, was 95%. We conclude that lithotripsy with the Lithostar device in children, at least for the short term, is safe and effective.

Adolescent↗