PubMed Health⌕ Search

Biomedical subjects

J Wacksman

Publications and source records attributed to J Wacksman.

At least 19 recordsLinked to original sources
PubMed2000

Modified technique of antegrade continence enema using a stapling device.

PURPOSE: We present a stapling technique for constructing an antegrade continence enema (ACE) conduit that is helpful in cases of insufficient appendiceal luminal length or when a concomitant appendiceal Mitrofanoff stoma is required. MATERIALS AND METHODS: In 6 patients with a mean age of 9.5 years who required an ACE procedure the cecum was tubularized in continuation with the orthotopic appendix at its base, using a stapling device to construct an ACE conduit. The tubularized segment was imbricated with permanent suture material. In 3 cases appendiceal length after tubularization was sufficient to allow splitting for the concomitant creation of an appendiceal Mitrofanoff stoma. RESULTS: Patients have been followed an average of 16.5 months. Stomal continence was achieved in all cases as well as reliable catheterization of the appendiceal cecostomy in 6 and the Mitrofanoff conduit in 3. CONCLUSIONS: This modification of the ACE procedure with cecal tubularization in continuation with the appendix using a stapling device is an excellent approach in cases of inadequate appendiceal length. It successfully creates a catheterizable stoma with a reliable flap valve continence mechanism. The complex reconstructive procedure is simplified by eliminating the need to use tapered small intestine, while allowing the creation of a concomitant appendiceal Mitrofanoff stoma as necessary.

Adolescent↗
PubMed1999

Unusual anatomic presentation of ectopic ureteroceles.

The authors describe four patients with unusual anatomic presentation of ectopic ureteroceles and their surgical treatment. Over a 3-year period, four cases of unusual ectopic ureteroceles were encountered. A 6-month-old girl had a complex cloacal anomaly with an ectopic ureterocele within the cloaca. A 10-year-old boy had two large diverticuli within an ectopic ureterocele combined with a blind-ending ipsilateral ureter. A 3-year-old girl had an ectopic ureterocele combined with a periureteral diverticulum and a completely duplicated ipsilateral kidney. A 4-year-old girl was found to have a vaginal ectopic ureterocele. Despite thorough radiological investigation in all patients, a correct assessment of the anatomic defect was achieved only by surgical exploration or endoscopic evaluation. If preoperative radiological evaluation is equivocal, a high index of suspicion and intraoperative recognition of an unusual anatomic presentation of the ectopic ureterocele are essential for appropriate management and a successful outcome.

Child↗
PubMed1999

Mathieu hypospadias repair: experience in 202 patients.

PURPOSE: The complication rate after Mathieu hypospadias repair was recently reported to be 3.6% in unstented cases. We reviewed our experience and results of the Mathieu repair performed at our institution during the last 5 years. MATERIALS AND METHODS: We performed 197 primary and 5 secondary repairs in 202 patients. Reconstruction of the neourethra was done with a 2-layer anastomosis using optical magnification. Urethral stents were placed for postoperative drainage in all but 1 patient. Followup was up to 54 months. RESULTS: There were no incidences of stent migration or symptomatic urinary tract infection while the stent was in place and all patients voided spontaneously after stent removal. Excellent cosmetic results were obtained in 201 cases. In 1 patient meatal retraction required subsequent meatoplasty with meatal advancement. In 2 patients pinpoint urethrocutaneous fistulas were successfully repaired. The total rate of reoperation was 1.5% in our series. There was no report of urethral stricture during followup. CONCLUSIONS: The well established Mathieu repair provides excellent cosmetic and functional results. The overall complication rate is minimal and compares favorably with stentless repair. A 2-layer neourethral anastomosis performed under sufficient optical magnification produces a watertight closure with minimal risk of fistula formation. Postoperative urethral stenting decreases this risk even further, while adding only minimal morbidity. We believe that in the era of newly reported techniques the well established Mathieu procedure should be the standard by which distal repair is judged.

Adolescent↗
PubMed1998

Incidence of contralateral vesicoureteral reflux following unilateral extravesical detrusorrhaphy (ureteroneocystostomy).

PURPOSE: The development of contralateral vesicoureteral reflux following different types of unilateral antireflux surgery has been reported to be as high as 22%. We review our recent experience with unilateral extravesical detrusorrhaphy in regard to the incidence of postoperative contralateral vesicoureteral reflux. MATERIALS AND METHODS: Between 1990 and 1995, 72 children underwent unilateral extravesical detrusorrhaphy. Of 73 refluxing renal moieties (1 patient had reflux in both moieties of a completely duplicated kidney) reflux grade was II in 35 (48%), III in 25 (34%), IV in 11 (15%) and V in 2 (3%). Common sheath reimplantation for complete ipsilateral duplication was performed in 16 patients. RESULTS: One patient had grade I postoperative ipsilateral vesicoureteral reflux resulting in a success rate of 98.6%. In 4 patients (5.6%) contralateral vesicoureteral reflux developed, and was grade II in 3 and grade I in 1. In all patients contralateral reflux resolved at 16, 17, 18 and 31 months of followup. No additional surgery was required in any patient. There was no association between the incidence of contralateral vesicoureteral reflux, and patient age, gender, preoperative ipsilateral reflux grade and presence of ipsilateral duplication. CONCLUSIONS: Unilateral extravesical detrusorrhaphy is a highly successful procedure with a low incidence of postoperative contralateral vesicoureteral reflux. Should reflux develop, it is of low grade with a significant rate of spontaneous resolution.

Adolescent↗
PubMed1998

Voiding dysfunction after bilateral extravesical detrusorrhaphy.

PURPOSE: Extravesical detrusorrhaphy has been successful for correcting unilateral vesicoureteral reflux, although its use in bilateral ureteral reimplantation has been questioned because of a reportedly high incidence of significant postoperative voiding dysfunction. We reviewed the incidence of voiding dysfunction after bilateral extravesical detrusorrhaphy during the last 5 years. MATERIALS AND METHODS: From 1990 to 1995, 123 patients with a mean age of 5.8 years (231 refluxing renal units) underwent bilateral extravesical detrusorrhaphy. Patients requiring anticholinergic therapy or intermittent catheterization at surgery were excluded from study, although in 6 who were included voiding dysfunction had previously resolved. RESULTS: Grades I and II vesicoureteral reflux persisted in 1 and 3 renal units, respectively, representing a 98.3% success rate. There was no postoperative upper urinary tract obstruction. Postoperatively voiding dysfunction developed in 8 patients (6.5%), including 2 with a history of voiding dysfunction. In 3 cases (2.5%) irritative voiding symptoms controlled with oxybutynin chloride resolved 2, 4 and 24 months postoperatively, respectively. In 5 patients (4%) temporary incomplete bladder emptying and/or urinary retention required outpatient Foley catheter drainage or intermittent catheterization for 2 to 21 days. CONCLUSIONS: Bilateral extravesical detrusorrhaphy is a highly successful procedure with a low incidence of significant voiding dysfunction. Should this condition develop, in our experience it is transient and of minimal morbidity. We found an increased rate of postoperative voiding dysfunction in younger patients as well as in those with a history of resolved voiding dysfunction.

Child↗
PubMed1998

Inguinal microsurgical varicocelectomy in the adolescent: technique and preliminary results.

PURPOSE: In large series of adults microsurgical varicocelectomy has been associated with extremely high success rates, combined with minimal incidence of postoperative hydrocele. We report our initial experience of inguinal varicocelectomy using an intraoperative microscope in adolescents. MATERIALS AND METHODS: From 1994 to 1996, 32 adolescents (mean age 15.3 years) underwent inguinal microsurgical varicocelectomy. An operative microscope and Doppler probe were used during spermatic cord dissection to identify and preserve the testicular artery and lymphatics. RESULTS: All patients were available for followup, which ranged from 2 to 35 months (mean 20). There were no intraoperative complications. A temporary reactive hydrocele, which subsequently completely resolved, was observed in 1 patient. There were no palpable recurrent varicoceles. CONCLUSIONS: The operative microscope permits reliable identification of the testicular artery and lymphatics, as well as venous channels in adolescents. As a result, the postoperative development of hydrocele or recurrence of the varicocele may be prevented.

Adolescent↗
PubMed1997

Pediatric ureteroscopy: technique and preliminary results.

Ureteroscopic management of ureteral obstruction in children presents a challenge to the urologist because of the use of relatively large instruments in smaller anatomy. The authors present our initial experience and describe the technique and equipment found to be most useful. Eleven ureteroscopic procedures were performed in ten patients, either for stone extraction or diagnostic evaluation of ureteral obstruction. Six of seven patients with ureteral stones became stone free, and the stone load was reduced to 25% in the remaining patient. Diagnostic ureteroscopy for ureteral obstruction was successfully performed in four patients. There were no intraoperative ureteral injuries and no postoperative complications. Pediatric ureteroscopy appears to be safe and effective for the diagnosis and treatment of distal ureteral obstruction. Further studies and longer follow-up are necessary to determine whether this technique will prove as successful in children as it has been in the adult population.

Adolescent↗
PubMed1997

The infected urachal cyst: primary excision versus a staged approach.

PURPOSE: We compared outcomes following single or 2-stage repair of infected urachal cysts in the pediatric population. MATERIALS AND METHODS: We reviewed the records of 17 patients 1 day to 14 years old (median age 22 months) with a urachal cyst. Immediate cyst excision was performed in 6 patients without infection, while those with an abscess underwent single or 2-stage repair. RESULTS: Median postoperative hospital stay for the urachal abscess group was 14 and 11.5 days for single and 2-stage procedures, respectively. After immediate excision postoperative complications developed in each case, although none occurred with a 2-stage approach. CONCLUSIONS: In the absence of infection, urachal cyst excision affords the most benign postoperative course. However, when infection is present, perioperative drainage with subsequent total excision, including a cuff of bladder, may offer the most effective surgical option.

Abscess↗
PubMed1997

Role of the antegrade continence enema in the management of the most debilitating childhood recto-urogenital anomalies.

PURPOSE: We evaluated the antegrade continence enema for managing the most severely compromised fecal continence mechanisms and the efficacy of nonappendiceal conduits in children when appendix is unavailable. MATERIALS AND METHODS: Ten patients 3 to 25 years old underwent continent cecostomy for the purpose of the antegrade continence enema. Diagnoses included the VATER association in 4 cases, myelomeningocele in 3, cloacal anomaly in 2 and isolated imperforate anus in 1. Eight patients received a tubularized ileal conduit, 2 received an appendiceal conduit and 2 underwent concomitant fecal undiversion. RESULTS: Followup ranged from 4 to 28 months (mean 17.6). All patients have achieved excellent fecal continence and no significant stomal soilage or difficulty with catheterization has been noted. Patients reported a high degree of satisfaction. CONCLUSIONS: Continent cecostomy for the antegrade continence enema is highly effective even in the presence of severe structural anorectal disease. The tapered ileal conduit is an excellent alternative to the appendiceal conduit.

Abnormalities, Multiple↗
PubMed1997

The importance of accurate diagnosis and early close followup in patients with suspected multicystic dysplastic kidney.

PURPOSE: Conservative management of children who have unequivocal multicystic dysplastic kidney with a stable or regressive pattern of disease during close followup is well established. However, a clear diagnosis may prove difficult. We report 3 cases in which the diagnosis was particularly difficult to increase awareness of the importance of applying strict criteria for the diagnosis of multicystic dysplastic kidney. MATERIALS AND METHODS: Three children in whom a diagnosis of multicystic dysplastic kidney was suspected underwent surgical exploration. One patient who did not comply with followup presented with a large retroperitoneal mass suspicious for neuroblastoma 8 months later. In another patient a growing renal cystic mass was suspicious for a multilocular cyst at 3 months of followup. At 2 months of followup a cystic nephroma was suspected in the remaining patient. RESULTS: All patients underwent surgical exploration. The patient with suspected neuroblastoma had extensive stage 3 Wilms tumor. In the child with a suspected multilocular cyst segmental multicystic dysplastic kidney of the lower pole of an ipsilateral duplicated system was found. In the patient in whom cystic nephroma was suspected mesoblastic nephroma was confirmed by the National Wilms Tumor Study Pathology Center. CONCLUSIONS: An unequivocal diagnosis of multicystic dysplastic kidney should be made early in life. The urologist should have an active role in making the initial radiological diagnosis and close followup with renal ultrasound every 3 to 4 months is essential during year 1 of life. Surgical exploration is indicated if the diagnosis becomes equivocal at any point or should concerns exist regarding compliance with followup.

Follow-Up Studies↗
PubMed1997

Unilateral vesicoureteral reflux: association with protected renal function in patients with posterior urethral valves.

OBJECTIVE: The prognosis in patients with posterior urethral valves (PUV) is related to the degree of renal insufficiency. Urinary ascites or urinoma, congenital bladder diverticula, or severe unilateral vesicoureteral reflux has been associated with protected renal function. We present clinical and imaging findings in eight patients with PUV and unilateral reflux who have preserved renal function. Initial and follow-up sonography, voiding cystourethrography, and nuclear imaging were reviewed and compared with long-term serum creatinine levels. CONCLUSION: All eight patients had normal renal function on long-term follow-up, suggesting that unilateral reflux, which occurs in as many as 35% of boys with PUV, is associated with protected renal function. Although early nephrectomy of the refluxing unit has been advocated for patients with PUV and unilateral reflux into a dysplastic kidney (the vesicoureteral reflux and renal dysplasia syndrome), we found that significant renal function may be present in the refluxing kidney and that function may even increase with time. Most of these patients did well without nephrectomy. Therefore, a sufficient interval should elapse before nephrectomy is considered in these patients.

Child, Preschool↗
PubMed1997

A peel away sheath endoscopic technique for difficult pediatric urethral intubation problems.

PURPOSE: We describe a useful technique for overcoming difficult pediatric urethral intubation problems. MATERIALS AND METHODS: An 8F pediatric urethroscope is passed through a peel away sheath, advanced through the urethra into the bladder and removed. An 8F urethral catheter is passed, the balloon is inflated and the peel away sheath is removed. RESULTS: This procedure has been performed in 6 children with difficult urethral problems without complication and with universal success. CONCLUSIONS: The peel away sheath technique offers a more reliable and less traumatic mechanism for difficult infant urethral intubation.

Child↗
PubMed1996

Laparoscopically assisted testicular autotransplantation for management of the intraabdominal undescended testis.

PURPOSE: The intra-abdominal testis continues to present a considerable urological challenge and the approach to its management continues to evolve. We report our initial experience with laparoscopically assisted testicular autotransplantation. MATERIALS AND METHODS: An intra-abdominal testicle was identified laparoscopically in 5 patients who subsequently underwent testicular autotransplantation. RESULTS: The success rate was 100% and median operative time was 5 hours. All patients were discharged home the day after surgery with no complications and a good result. CONCLUSIONS: Because of success with this technique, this procedure offers significant advantages (decreased hospital stay and lower morbidity) than an open or 2-stage Fowler-Stephens approach.

Adolescent↗
PubMed1995

Testicular autotransplantation for the intra-abdominal testis.

Oftentimes patients with intra-abdominal testes require more than the standard procedure to accomplish orchiopexy. Division of the spermatic vessels has been one mainstay of operative approaches for the intra-abdominal testis since Fowler and Stephens (Congenital Malformations of Rectum, Anus, and Genitouriary Tracts, chapter 19, pp 306-320, 1963) provided an anatomically rational basis for this procedure. Silber and Kelly (J Urol, 115:452-454, 1976) first described using a microvascular anastomosis to bring extra blood supply to the testicle after mobilization of a high intra-abdominal testicle into the scrotum; however, this approach has not been adopted by many for a number of reasons. The microvascular skill and instrumentation required for a successful anastomosis are not universally available and there is a misconception that the procedure is a lengthy one (Bianchi, Br J Urol 56:521-524, 1984; Bogaert et al., Urology 42:182-188, 1993). We present our series for testicular autotransplantation used over a 17 year period with a greater than 95% success.

Abdomen↗
PubMed1995

Evaluation of acute scrotum in the emergency department.

A 2-year retrospective review of 238 cases of acute scrotal pain encountered in a children's hospital emergency department is presented. The incidences of testicular torsion, torsion of a testicular appendage, and epididymitis were 16%, 46%, and 35%, respectively. Testicular salvage was critically dependent on the interval between onset of pain and surgical intervention. No testis likely to have been viable at the time of presentation was "lost." The diagnostic error rate on first encounter was 7%, resulting in 10 negative scrotal explorations. With the exception of cases of far-advanced necrotic testes, both color Doppler ultrasound and radioisotope imaging were highly specific diagnostic modalities. Thirty-nine percent of the children with epididymitis who underwent investigation were found to have either structural or functional urinary tract abnormalities. Noninvasive urodynamic studies appear to be useful screening modalities in older children with epididymitis.

Acute Disease↗
PubMed1995

Gastrocystoplasty: technical and metabolic characteristics of the most versatile childhood bladder augmentation modality.

The authors report on 23 patients who underwent complex continent urinary reconstructions, made successful by the selection of gastrocystoplasty as the chosen augmentation modality. The mean patient age was 6.1 years, and the mean weight was 17.9 kg. The minimum follow-up period was 1.5 years. The bladder capacity increased from a preoperative mean of 77.8 +/- 52.2 (SD) mL to a postoperative mean of 303.5 +/- 117.4 mL (P < .000001). No adverse effects on renal function or serum electrolyte composition were encountered, and there were no instances of acidosis or alkalosis. Continence was achieved in 91% of patients. In two patients (0.9%), hematuria-dysuria developed; one case was extremely mild. The other occurred only during a period of severe oliguria and resolved after transplantation. Gastrointestinal complications were minimal. Five patients had end-stage renal disease at the time of reconstruction and have since had successful transplantation. Gastrocystoplasty is particularly applicable to the pediatric population because of its unique anatomic and metabolic characteristics, which bestow tremendous versatility.

Acidosis↗