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Biomedical subjects

J R Woodard

Publications and source records attributed to J R Woodard.

At least 19 recordsLinked to original sources
PubMed1998

Voiding function in patients with the prune-belly syndrome after Monfort abdominoplasty.

PURPOSE: We reviewed our experience with patients with the prune-belly syndrome who had undergone Monfort abdominoplasty to assess whether our clinical impression of improved voiding efficiency could be demonstrated objectively. MATERIALS AND METHODS: From 1990 to 1993, 12 patients with the prune-belly syndrome underwent Monfort abdominoplasty with or without concomitant genitourinary reconstruction. All patients completed questionnaires on voiding before and after abdominoplasty, incontinence, bladder sensation, urinary flow, history of urinary tract infections and the ability to defecate. Urodynamic testing was performed in 8 patients before and after abdominoplasty. RESULTS: Subjective changes that occurred after abdominoplasty included resolution of or less double voiding in 9 patients, improved urinary continence in 7, improved bladder fullness sensation in 11, improved urinary flow in 10 and improved defecation in 5. The incidence of urinary tract infections decreased from a preoperative average of 5.7 per patient per year to 1.2 per patient per year postoperatively. Urodynamics demonstrated no significant changes in the measured urinary flow, capacity or maximal detrusor pressure. Compliance decreased on average but it remained in the compliant range. However, post-void residual volumes did significantly decrease from a preoperative average of 40.3% of bladder capacity to 13% after abdominoplasty. If the 5 patients who underwent concomitant urinary reconstruction were excluded, the reduction in average post-void residuals remained approximately the same, which was 40% of bladder capacity preoperatively to 14.3% after abdominoplasty. These data suggest that abdominoplasty alone was responsible for improved micturition. CONCLUSIONS: In addition to the cosmetic benefits and exposure provided for genitourinary reconstruction Monfort abdominoplasty seems to improve voiding efficiency.

Abdominal Muscles↗
PubMed1997

Current urologic management of cloacal exstrophy: experience with 11 patients.

PURPOSE: Since 1980 the authors have treated 12 infants with cloacal exstrophy (10 classical and 2 variants). Eleven patients had repair, and are all surviving. The initial phases of management that led to improved survival have previously been reported. Quality of life is now a major focus for the cloacal exstrophy patient. During the past 10 years, nine of the 11 patients had lower urinary tract reconstructive procedures. This review evaluates experience with reconstructive efforts to achieve bowel and bladder control and to improve the quality of life in this complex group of patients. METHODS: Through review of patient charts and by patient interviews, data were collected to evaluate the ability to provide urinary and bowel control. A continence score was applied to provide a measure of success: voluntary control, 3; control with an enema program or intermittent catheterization, 2; incontinence with a well-functioning stoma, 1; and incontinence without a stoma, 0. The best continence score is 6 (genitourinary and gastrointestinal). Surgical complications, urodynamic and metabolic sequelae of continent urinary diversion were reviewed. RESULTS: At the time of the authors' previous report, eight of 11 patients had a continence score of 2 or less. Currently, eight of 11 patients have a score of 3 or better (five with enteric stoma and continent urinary diversion, two with enema program and continent urinary diversion, and one with enema program and continent bladder). Urinary-diversion procedures have included two gastric augmentations and five gastric reservoirs, two of which have required subsequent bowel augmentation. Gastric augmentations carry a definite risk of metabolic problems with three of our patients demonstrating significant episodes of metabolic alkalosis. In addition, results of urodynamic monitoring suggests that gastric reservoirs may be less compliant than reservoirs formed using other bowel segments. CONCLUSIONS: Modern principles of continent urinary diversion have been successfully applied to the cloacal exstrophy patient further improving their quality of life. Use of gastric flaps with preservation of intestinal length has been central to urologic reconstructive efforts. Use of stomach alone for formation of urinary reservoirs may produce suboptimal compliance, and composite ileogastric construction should be considered if the gastric flap is of marginal size.

Bladder Exstrophy↗
PubMed1996

Submucosal bladder neck injection of bovine dermal collagen for stress urinary incontinence in the pediatric population.

PURPOSE: The surgical management of stress urinary incontinence in the pediatric population includes various surgical techniques of which the simplest is outpatient transurethral or periurethral injection of a bulking agent. Currently purified bovine dermal collagen cross-linked with glutaraldehyde (Contigen) is the only Food and Drug Administration approved bulking agent available. Patients with stable detrusor function are ideal candidates. We review our initial experience with children. MATERIALS AND METHODS: Between January 1994 and June 1995, 23 boys and 9 girls 4 to 17 years old (mean age 9) consecutively underwent submucosal bladder neck injection with cross-linked bovine dermal collagen. Incontinence was secondary to spinal dysraphism in 24 patients, complete epispadias in 4, classic bladder exstrophy in 3 and neurogenic bladder secondary to a sacral teratoma in 1. Preoperative video urodynamics documented intrinsic sphincteric deficiency in all patients with leak point pressure of 15 to 60 cm. water (mean 37). Injection volumes ranged from 2.5 to 17 cc (mean 10). Continence results were defined as dry-requiring no protection while on a 4-hour clean intermittent catheterization program, good-improved but requiring 1 to 5 pads daily and failure-no postoperative improvement or still requiring diapers. RESULTS: Of the children with neurogenic bladder 20% became dry following the first injection and an additional 28% had a good result. Furthermore, of the 6 children with exstrophy or epispadias who underwent a Young-Dees-Leadbetter procedure 50% were dry and 17% had a good result after the first injection. Complications were limited to a febrile urinary tract infection associated with urinary retention in 1 patient and transiently worse continence in 2. CONCLUSIONS: Despite the limited success rate, we believe that transurethral collagen injection therapy has a viable role in the treatment of intrinsic sphincteric deficiency in select pediatric patients, particularly since the procedure has low morbidity and can be performed on an outpatient basis. Preoperative counseling should be given with realistic expectations.

Administration, Intravesical↗
PubMed1996

Outcome of sling cystourethropexy in the pediatric population: a critical review.

PURPOSE: We performed a critical retrospective analysis of the records of all consecutive children who underwent sling cystourethropexy at our institutions. We particularly assessed the incidence and outcome in children who underwent enterocystoplasty in addition to a sling procedure. MATERIALS AND METHODS: Between May 1992 and August 1994, 24 girls and 15 boys 4 to 17 years old (mean age 9) consecutively underwent 1 of 4 techniques of sling cystourethropexy for stress urinary incontinence using rectus fascia via an abdominal approach. Diagnoses included spinal dysraphism in 34 patients, spinal trauma in 2, cecoureterocele in 1, epispadias in 1 and classic bladder exstrophy in 1. All children underwent preoperative video urodynamics. In 4 patients only a sling procedure was performed (group 1), while in 9 others a sling procedure was performed after enterocystoplasty (group 2). In 26 patients a sling procedure and concomitant enterocystoplasty were performed (group 3). RESULTS: Patients who underwent concomitant enterocystoplasty had more hyperactive preoperative urodynamics than those who did not. Postoperative continence was subcategorized in terms of patient age, sex, diagnosis (neurogenic versus nonneurogenic), preoperative video-urodynamics, surgeon technique, group (that is with or without cystoplasty) and type of enterocystoplasty (that is stomach versus ileum). Of these factors only concomitant enterocystoplasty was predictive of postoperative dry continence (73% of group 3, 33% of group 2 and 25% of group 1). In most patients who were not dry postoperative video urodynamics suggested suboptimal outlet resistance overcome by a hyperactive detrusor. No patient had postoperative upper tract deterioration. CONCLUSIONS: These results suggest that concomitant enterocystoplasty should be critically considered for pediatric patients undergoing sling cystourethropexy.

Adolescent↗
PubMed1995

Symptomatic tumors affecting the urinary tract in children with neurofibromatosis.

PURPOSE: We determined the need for urological screening in children with neurofibromatosis. MATERIALS AND METHODS: Of 96 children with neurofibromatosis treated at our institution 6 (6.2%) had a symptomatic tumor that affected the urinary tract. RESULTS: There were 5 plexiform neurofibromas and 1 prostatic rhabdomyosarcoma. Five children had a palpable abdominal mass and 3 required urinary diversion. CONCLUSIONS: Since most morbidity resulted because tumors were advanced by the time symptoms developed, we suggest that children with neurofibromatosis be screened annually with medical history, physical examination, urinalysis and serum chemistry studies for tumors that affect the urinary tract.

Adolescent↗
PubMed1994

The gastric augment single pedicle tube catheterizable stoma: a useful adjunct to reconstruction of the urinary tract.

Since 1990 we have used stomach for bladder augmentation and continent urinary diversions in 73 patients, of whom 15 received a gastric tube catheterizable stoma and are the subject of this report. The gastric tube receives its blood supply from the same vascular pedicle as the gastric patch and, therefore, it can be moved anywhere along with the patch. The tube is then reimplanted in the reservoir or bladder following the Mitrofanoff principle and brought to the skin as a catheterizable stoma. Patient age ranged from 12 to 60 years. Three patients underwent augmentation cystoplasty and 12 received a composite gastrointestinal continent reservoir (in 10 a prior bowel conduit was detubularized and used as part of the reservoir). The appendix was either previously removed (10 patients) or not suitable as a catheterizable limb (4). All patients are continent. Catheters used to empty the reservoir varied from 12F to 18F. Complications included an early traumatic perforation of the tube in 1 patient, distal stenosis in 1 and mucosal redundancy in 1. Of these patients 2 required revision. Two patients had mild peristomal skin irritation without ulceration. Anatomical and technical aspects of this procedure are presented. In summary, we believe the gastric augment single pedicle tube to be a useful tool for the reconstructive urologist, which in select cases may obviate the need for additional bowel anastomosis to create a tapered intestinal catheterizable limb.

Adolescent↗
PubMed1994

Transurethral puncture of ectopic ureteroceles in neonates and infants.

Ten neonates and infants with 11 ectopic ureteroceles prospectively underwent transurethral puncture as the primary form of therapy. Of the 10 patients 6 had a prenatal diagnosis of uropathy and 4 presented postnatally with urinary tract infection. One patient had bilateral single system ectopic ureteroceles and 9 had a single ectopic ureterocele in a duplex system. Significant associated ipsilateral and/or contralateral urological pathology was noted in addition to the ectopic ureterocele in 7 patients. Transurethral puncture adequately decompressed 10 of the 11 ectopic ureteroceles (91%) and improved drainage of nonureterocele moieties in 3 cases. Iatrogenic reflux was found in 3 of the 11 ureterocele ureters. Urinary tract infection developed in 6 infants (4 with fever). Of the 10 patients 8 (80%) eventually required secondary surgical intervention because of recurrent urinary tract infections, persistent or iatrogenic reflux, or unresolving hydronephrosis. Although transurethral puncture rarely constitutes definitive treatment for ectopic ureterocele, there appears to be immediate benefit in cases of bilateral hydronephrosis or significant ipsilateral lower pole hydronephrosis. Decompression of the ureterocele is reliably obtained but it seldom obviates the need for more definitive reconstruction.

Female↗
PubMed1993

The use of stomach in pediatric urinary reconstruction.

We report on 30 consecutive patients (mean age 9 years) who underwent gastrocystoplasty (21) or received a continent urinary reservoir with stomach (9). A successful outcome, defined as complete urinary continence for intervals greater than 3 hours, preservation or improvement of the upper tracts and renal function, and normal electrolyte and acid base balance, was achieved in 90% of the patients who received continent urinary reservoir and 72% of those who underwent gastrocystoplasty. Urodynamic data were obtained in 17 patients in the gastrocystoplasty group and 7 in the continent urinary reservoir group at a mean of 6 months postoperatively. Metabolic alkalosis associated with hypergastrinemia occurred in 2 children. Partial excision of the gastric segment was necessary in 1 patient refractory to medical treatment.

Adolescent↗
PubMed1993

Metabolic complications of the use of stomach for urinary reconstruction.

A total of 34 children with normal renal function underwent either gastrocystoplasty or continent urinary reservoirs with stomach at our institutions. Severe hypochloremic hypokalemic metabolic alkalosis developed in 2 patients, manifested by intractable seizure disorder in 1 and altered mental status with respiratory depression in 1. Symptoms developed at 4 and 6 months, respectively. Despite severe alkalosis, urinary pH was less than 5.0 and fractional excretion of chloride remained high in both patients. Resuscitation with sodium chloride, arginine hydrochloride and potassium chloride restored electrolyte balance in less than 48 hours in both patients. Serum gastrin was slightly elevated in 1 patient (137 pg./ml., normal 0 to 125) who responded to long-term histamine-blocker therapy. The other patient had significant hypergastrinemia (624 pg./ml.) with secondary hyperaldosteronism. Maximum doses of histamine blockers, oral replacement of sodium chloride and potassium chloride, and the proton pump inhibitor omeprazole failed to control recurrent bouts of severe hypochloremic metabolic alkalosis. This patient ultimately underwent removal of three-quarters of the gastric augmentation and replacement with ileum. Postoperatively, serum gastrin levels and electrolytes reverted to normal. The pathophysiology of this potentially lethal complication is further discussed.

Acid-Base Imbalance↗
PubMed1992

The Monfort operation for abdominal wall reconstruction in the prune belly syndrome.

We present our results in correcting the abdominal wall defect in 8 patients with the prune belly syndrome using the Monfort operation. Mean patient age at operation was 10 years. Four patients also underwent significant concomitant operative procedures. There were no early postoperative complications, and the mean postoperative stay for those 4 children undergoing abdominal wall reconstruction alone was 7.7 days. This operation preserves the umbilicus, and strengthens, flattens and thickens the abdominal wall. It produces a narrow-waisted more normal physique and provides excellent transperitoneal exposure for concomitant genitourinary reconstructive procedures.

Abdominal Muscles↗
PubMed1992

The normal and abnormal scrotum in children: evaluation with color Doppler sonography.

The use of color Doppler sonography to evaluate the symptomatic testes in children with scrotal pain or swelling was prospectively studied with a fourth-generation color sonographic unit with a 7-MHz linear transducer. The 32 patients were 1 day to 18 years old (mean age, 8.6 years). Results were correlated with scintigraphic findings in 23 patients, with the final diagnosis established by surgery in 12 patients, and with clinical follow-up in all patients. Eight cases of testicular torsion, including two of acute torsion and six of late torsion, were correctly detected by color Doppler sonography and confirmed surgically. In the remaining patients, perfusion of the testis was correctly detected by color Doppler examination. The final diagnoses in these patients included torsion of the appendix testis (15 patients), epididymitis (five patients), epididymo-orchitis (one patient), yolk sac tumor of the testis (one patient), hydrocele (one patient), and local reaction to an insect bite (one patient). The ability to detect blood flow in the normal contralateral testis was also evaluated in 28 patients. Blood flow was demonstrated in normal testes larger than 1 cm3. Detection of flow in the very small normal prepubertal testis was often difficult, and no flow was identified in one testis. Flow was identified in central arteries in only six of 13 testes smaller than 1 cm3. We conclude that color Doppler sonography is helpful in the initial evaluation of pediatric testes, providing accurate evaluation of the involved hemi-scrotum in our patients and also providing the benefit of both structural and flow information. Until our sensitivity to low-velocity flow improves, we would not suggest the exclusive use of color Doppler sonography in the evaluation of testicular perfusion in the prepubertal patient. We advocate the addition of testicular scintigraphy to corroborate the presence of testicular perfusion when flow in intratesticular arteries cannot be established with certainty by color Doppler sonography.

Adolescent↗
PubMed1991

Modern treatment of cloacal exstrophy.

We have treated 12 newborns with cloacal exstrophy (10 classical and 2 variants) since 1980. Eleven infants underwent repair and they are all surviving; the one nonoperated infant died of pulmonary hypoplasia. There are six genetic females and six genetic males, five of whom are being raised as females. The initial operation consisted of separating the bowel from the bladder to create an intestinal stoma; closing the omphalocele; and reapproximating (5), closing (4), or leaving the exstrophied bladder undisturbed (2). The importance of creating a "tailgutostomy" instead of an ileostomy to prevent problems with diarrhea, dehydration, and acidosis is emphasized. There have been 71 subsequent operations in these 11 patients (28 general surgical, 25 urological, 9 neurosurgical, and 9 orthopedic). Quality of life, rather than survival, is now the major issue facing patients with cloacal exstrophy. All of these patients except one are neurologically normal. The defect is closed in all patients. Three patients wear no appliances, 7 wear one (gastrointestinal [GI]), and one wears two (GI and genitourinary [GU]). We developed a scoring system to analyze bowel and bladder continence: voluntary control = 3; control with an enema program or intermittent catheterization = 2; incontinence with a well-functioning stoma = 1; and incontinence without a stoma = 0. The best continence score is 6 (GU + GI). We currently have 7 patients with a continence score of 1 (colostomy + incontinent bladder); 1 with a score of 2 (ileostomy + incontinent ureteroenterostomy); 2 with a score of 4 (enema program + continent urinary diversion); and 1 with a score of 5 (enema program + continent bladder).(ABSTRACT TRUNCATED AT 250 WORDS)

Bladder Exstrophy↗
PubMed1991

Abdominoperitoneal approach to management of the high, short vagina in the adrenogenital syndrome.

We describe a combined transtrigonal, abdominoperineal approach to the surgical management of the female pseudohermaphrodite with the adrenogenital syndrome and a high, short vagina. Most of our patients had undergone previous clitoral reduction surgery and, therefore, clitoral shaft skin was not available for exteriorization of the vagina. Our operation involves partial mobilization of the vagina through an inverted U flap from the perineum followed by detachment from the urogenital sinus from above by splitting the trigone. Exteriorization is accomplished by mobilizing 2 lateral skin flaps from the perineum and joining them with the inverted U flap to reach the vagina. Cosmetic results have been excellent, although anastomotic stenosis occurred in 1 young infant.

Abdomen↗
PubMed1990

Ureteral tailoring: a comparison of wedge resection with infolding.

A retrospective analysis of 44 consecutive pediatric ureteral reimplantations in 42 patients (51 ureters reimplanted) is presented, in which the ureter was tapered by infolding or wedge resection. Few postoperative complications occurred and the results were essentially comparable for the 2 groups, although slightly more postoperative ureteral obstruction occurred in the wedge resection group. Over-all success rate (no postoperative reflux and no obstruction) was 95% for the infolded group and 90% for wedge resection group. Stent time and hospital stay were significantly less for the infolded group.

Child, Preschool↗
PubMed1990

Current management of the dilated urinary tract in prune belly syndrome.

Upper urinary tract stasis, poor bladder emptying, vesicoureteral reflux, and bacteriuria in various combinations are the factors that have led to a poor long-term prognosis in patients with prune belly syndrome. Whether these factors are best controlled by medical treatment or by surgical correction has been the source of some controversy. Although medical treatment may have improved over the years, so have the results of reconstructive surgery. Because the syndrome is a spectrum disorder, there will certainly be many patients who require little or no surgical intervention. The majority, however, will benefit from carefully planned and well-executed reconstructive surgery. Even in these cases, there should be a period of medical treatment and surveillance with interval re-evaluation. In a few patients, early stabilization will not be possible, and a drainage procedure such as vesicostomy will be necessary in the first days of life. Regardless of how an individual patient might be treated, he will require long-term follow-up surveillance. As more long-term results are reported, the optimal treatment plan should become more obvious.

Dilatation, Pathologic↗