Inadvertent concentrated epinephrine injection at newborn circumcision: effect and treatment.
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Circumcision, Male↗
Biomedical subjects
K P McLaughlin
Publications and source records attributed to K P McLaughlin.
Upsizing of the artificial urinary sphincter cuff to facilitate spontaneous voiding.
OBJECTIVES: Following placement of an artificial urinary sphincter (AUS) in the male child, functional and mechanical alterations can ensue, resulting in an inability to void spontaneously. One possible mechanical etiology in the patient entering puberty is prostatic growth within the fixed mechanical confines of the AUS cuff, resulting in progressive bladder outlet obstruction. Unrecognized infravesical obstruction can, in turn, lead to upper urinary tract deterioration, sepsis, or renal failure. We evaluated the effect of somatic growth and maturation of the male urethra on voiding dynamics in boys with an AUS to specifically determine whether revision of the sphincter cuff (ie, upsizing) is beneficial in restoring the ability to void spontaneously. METHODS: A retrospective review of 124 children with an AUS was performed. Eleven boys were identified whose bladder neck cuffs were later upsized in an attempt to improve bladder emptying. All boys were prepubertal at the time of original cuff placement. The average interval between the initial operation and cuff upsizing was 5 years. RESULTS: Following original sphincter placement, 8 patients emptied to completion spontaneously and 3 patients emptied by intermittent catheterization. All eight of the spontaneous voiders experienced progressive difficulty emptying after they entered puberty and ultimately had to rely on clean intermittent catheterization to empty completely. Follow-up subsequent to cuff exchange averaged more than 5 years (range 1 to 10 years). Despite an average increase of 10 mm in cuff size, all patients continued to depend on intermittent catheterization to empty completely. CONCLUSIONS: Upsizing the bladder cuff in the maturing male who experiences difficulty with bladder emptying does not restore the ability to void spontaneously.
Child↗
A combined antegrade and retrograde technique for reestablishing ureteral continuity.
Ureteral injuries are not uncommon and may lead to ureteral stricture, complete obliteration, or urinary fistula. Traditionally, open surgical repair was required to reestablish ureteral continuity. With the development of improved instrumentation and technique, it is now possible to treat these injuries endoscopically. Endoscopic ureteroureterostomy has been demonstrated to be an effective means of treating ureteral strictures and obliterated segments of the ureter. We describe a combined ureteroscopic and fluoroscopic technique to reestablish ureteral integrity. Using this technique we have successfully treated two patients with ureteral injuries. The first patient had a ureterovaginal fistula that occurred after a hysterectomy. The second patient had a completely obstructed distal ureter. These cases and the techniques used to successfully manage them are described.
Adult↗
Endoscopic treatment of continent urinary reservoir calculi.
Formation of calculi is a late complication of continent urinary diversions. The techniques of percutaneous and transstomal treatment of these stones are described. Three patients underwent percutaneous placement of a rigid nephroscope into three different types of continent reservoirs and fragmentation of stones (2-5 cm in size) using ultrasonic lithotripsy. Preoperative CT scan of the abdomen and pelvis with oral and intrareservoir contrast was essential in finding the safest location for percutaneous access. One patient, with small stones, underwent placement of a flexible cystoscope through the continent efferent limb and Holmium laser lithotripsy. There were no instances of reservoir perforation. There was minimal blood loss, with an average operative time of 165 min. Ultrasonic lithotripsy of large stones through a percutaneous approach and Holmium laser lithotripsy for smaller stones via a flexible cystoscope placed through the efferent limb are safe and effective ways to treat calculi within continent urinary diversions.
Adolescent↗
Penile orthoplasty using dermal grafts in the outpatient setting.
OBJECTIVES: To review and evaluate our extensive outpatient experience in the use of dermal grafts for the correction of significant residual chordee in patients requiring penile orthoplasty. METHODS: The medical records of all patients requiring surgical correction for severe penile curvature over the past 5 years were reviewed. Among these, 51 patients were identified in whom dermal grafts were used to correct severe residual chordee. Of these patients, 41 had severe hypospadias, 9 had epispadias, and 1 had urethral atresia. Graft harvest and placement technique, any resulting complications, and parental satisfaction with cosmetic and functional results were all evaluated. RESULTS: The dermal grafts were harvested from the hairless skin of the inguinal area, using one of two techniques. All were used to fill a tunical defect created by incising the tunica at the point of maximal penile curvature. No complications or postoperative hospitalizations resulted from any of the orthoplasty procedures. At a mean follow-up of 27 months, all patients had excellent cosmetic and functional results. CONCLUSIONS: In patients with significant residual chordee, a dermal graft is our preferred method of penile orthoplasty. This technique provides a straight phallus with a very minimal complication rate, it can easily and successfully be performed as an outpatient procedure, and it has assured an excellent cosmetic and functional result.
Ambulatory Surgical Procedures↗
The appendix in reconstructive urology.
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Adolescent↗
Cloacal exstrophy: the neurological implications.
Congenital anomalies commonly accompany the abdominal wall defects of cloacal exstrophy with an incidence as high as 100% in some series. The urological literature cites an incidence of vertebral and/or spinal cord anomalies in 75% of cases. We reviewed the records of the 17 patients with cloacal exstrophy treated at our institution since 1978. Abnormalities of the vertebral column or spinal cord were identified in 16 patients, including 11 of 12 (92%) fully evaluated by myelography, computerized tomography or magnetic resonance imaging of the lumbosacral spinal cord. Nine patients had a lipomeningocele and 4 had a lipomyelocystocele. Spinal exploration, repair and cord untethering were done in 11 patients of whom 2 subsequently underwent reoperation for re-tethering the cord. A total of 15 patients is ambulatory although 5 require lower extremity braces. The incidence of spinal cord or vertebral anomalies in our patients with cloacal exstrophy approaches 100%, which is higher than commonly cited in the urological literature. We recommend magnetic resonance imaging of the spinal cord as part of the initial evaluation of newborns with cloacal exstrophy. Lifelong attention to the risk of spinal cord tethering can optimize neurological outcome in affected individuals.
Abnormalities, Multiple↗
Stomach in combination with other intestinal segments in pediatric lower urinary tract reconstruction.
PURPOSE: We report the results of combining gastric and ileal segments in a small group of predominantly pediatric patients. MATERIALS AND METHODS: We retrospectively reviewed the records of 6 children and 1 adult who underwent lower urinary tract reconstruction using stomach and ileum, including 3 simultaneous and 4 staged procedures. Followup was 13 to 59 months. RESULTS: No patient had deterioration of renal function due to impaired upper tract drainage. One patient had an episode of hyponatremia during a gastrointestinal illness. The adult has the hematuria-dysuria syndrome and receives omeprazole. No ulceration developed in the 6 evaluable patients. CONCLUSIONS: The combined use of stomach and ileum has been effective in this small group of challenging patients. Long-term followup is mandatory.
Adolescent↗