Biomedical subjects
Publications and source records attributed to H C Scherz.
Urethral strictures in children, like those in adults, are problems whose management embodies all that is basic to urology. It is helpful to think of strictures according to etiology: congenital, infectious-inflammatory, and traumatic (iatrogenic and noniatrogenic). The treatment options are diversion (nearly always temporary), manipulation, and repair. The authors also review their research on urethral healing.
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During the last 19 years we treated 60 children with ectopic ureteroceles. There was a 4 to 1 female-to-male predominance. Of the patients 47 per cent presented before age 6 months, 66 per cent were diagnosed after a urinary tract infection and 6 were identified antenatally. Based upon a review of the literature and our data, we believe that "total correction" (a single operation designed to correct abnormalities of the upper and lower urinary tract) is superior in most instances to an approach in which just the upper urinary tract pathological condition is treated. Only 4 (14 per cent) of 28 patients in whom "total correction" was used required a second operation (all because of persistent reflux) while 14 of 19 patients (74 per cent) treated with an upper urinary tract procedure intended as definitive therapy have either undergone further surgery or have a residual abnormality that may require further surgery. Marsupialization rather than enucleation of the ectopic ureterocele is effective and safe, risking neither injury to the bladder neck or sphincteric mechanism nor resulting in a vesicovaginal fistula.
We used the Arap hypospadias repair in 31 patients with distal hypospadias with considerable success, achieving an excellent result in 93 per cent of our patients. Improved cosmesis, extension of the scope of the problems that can be addressed with this repair (including treatment of a distal urethrocutaneous fistula) and the ease with which the Arap procedure can be performed are the advantages that this operation has over other 1-stage distal hypospadias repairs.
We report a case of persistent voiding dysfunction caused by an unsuspected penetrating bony spicule 20 years after extraperitoneal bladder rupture and pelvic fracture.
Over a 16 years period, we have treated 34 cases of urethral stricture after hypospadias repair. Seventeen patients were successfully treated with one procedure, while 16 patients required two or more procedures; one patient was lost to follow-up. Eighteen patients who presented with symptoms attributable to their stricture within 3 months of their original operation for hypospadias were designated as having early strictures. Those strictures presenting later than 3 months were termed late strictures. Manipulative therapy (dilation, direct vision internal urethrotomy) was successful in 46% of early strictures, but in only 16% of late strictures. Open surgical procedures were employed primarily in some cases or after failed manipulation in others and were successful in 82% of cases. All 4 failures of open procedures were salvaged with manipulative therapy. We conclude that treatment of post hypospadias repair urethral strictures should initially be manipulative. Open surgical repair will usually be successful but should be reserved for difficult strictures, late strictures, or failures of manipulation.
The Scott sphincter models AS 791 and AS 800 were implanted in 22 men with urinary incontinence. Urethral pressure profilometry was used intraoperatively and postoperatively to measure the urethral closure pressure (UCP) and to improve the rate of continence and reduce the risk of erosion. Success was achieved in 20 of 24 patients. The utility of urethral profilometry in these cases is described.
During a 16-year period we treated 30 patients with urethral stricture after hypospadias repair. Of the patients 16 were treated successfully with 1 procedure, while 13 required 2 or more procedures and 1 was lost to followup. A good result was achieved in 83 per cent of the patients. Fourteen patients who presented with symptoms attributable to the stricture within 3 months of the original operation for hypospadias were designated as having early strictures. Those with strictures presenting later than 3 months were considered to have late strictures. Manipulative therapy (dilation and direct vision internal urethrotomy) was successful in 55 per cent of the early strictures but in only 16 per cent of the late strictures. An open operation was performed primarily in some cases or after failed manipulation in others and it was successful in 79 per cent. All 4 failures of open procedures were salvaged with manipulative therapy. We conclude that treatment of post-hypospadias repair urethral strictures initially should be manipulative. Open repair usually will be successful but should be reserved for difficult strictures, late strictures or failures of manipulation.
Anterior urethral valves are an uncommon cause of lower urinary tract obstruction in children. They have been noted in the bulbous (40 per cent) and penile (30 per cent) urethra, and at the penoscrotal junction (30 per cent). None has been reported in the fossa navicularis. We encountered 3 cases in which anterior valves were located in the glanular urethra. This entity may be misdiagnosed as meatal stenosis and without a high index of suspicion it might be overlooked. The combination of distal obstruction and a normal urethral meatus should lead one to suspect this entity. Observation of the voided stream is extremely helpful in the diagnosis, since voiding urethrography often fails to include the penile tip and urethroscopy of the distal urethra often is unsatisfactory. Treatment can be performed either transurethrally or by excision through the meatus.
The emergence of prosthetic surgery and nonoperative surgical treatment of urolithiasis has seen with it an expanded application of prophylactic antibiotics. The very nature of these procedures with the often increased risk of infectious complications lends itself perfectly to wider but more judicious use of prophylactic antibiotics. Controlled clinical trials that address issues such as dosing, selection, and indications for antibiotic prophylaxis are lacking. Until that information is forthcoming, only recommendations can be made as we have tried to provide in this article.