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Biomedical subjects

M A Koyle

Publications and source records attributed to M A Koyle.

At least 19 recordsLinked to original sources
PubMed2006

Vaginal discharge and bleeding in girls younger than 6 years.

PURPOSE: Persistent unexplained vaginal discharge or bleeding in the pediatric population may be the only manifestation of a serious underlying medical or social problem. Therefore, these symptoms require careful and complete evaluation to identify the primary pathology accurately. We retrospectively reviewed charts of patients who presented for evaluation of persistent vaginal discharge or bleeding to determine if noninvasive imaging was a sensitive means of screening for gynecological pathology. MATERIALS AND METHODS: The records of 24 girls younger than 6 years who presented with vaginal discharge or bleeding were reviewed retrospectively. All patients were evaluated with noninvasive imaging, a pelvic examination while under anesthesia, vaginoscopy and cystoscopy. RESULTS: Noninvasive imaging was useful in identifying 5 of 7 vaginal foreign bodies. However, noninvasive imaging identified only 2 of 6 malignancies. These malignancies consisted of rhabdomyosarcoma (3 patients) and endodermal sinus tumor (3). Two girls also had benign vaginal mullerian papillomas that were not identified by noninvasive imaging. Noninvasive imaging did not aid in the diagnosis of sexual abuse. CONCLUSIONS: Based on these data, we recommend that all girls younger than 6 years who present with persistent vaginal discharge or bleeding be evaluated with pelvic examination while under anesthesia, to be followed by vaginoscopy and cystoscopy if no readily identifiable pathology is found by simple genital examination alone, regardless of the results of noninvasive imaging studies.

Child, Preschool↗
PubMed2004

Ureterocystoplasty: indications for a successful augmentation.

PURPOSE: We evaluate the outcome of ureterocystoplasty based on preoperative evaluations. MATERIALS AND METHODS: We reviewed preoperative ultrasound, voiding cystourethrography and preoperative/postoperative urodynamic studies (UDS) in 64 patients undergoing ureterocystoplasty. RESULTS: Augmentation was performed with the distal 5 to 8 cm of a single megaureter in 8 patients without and 16 with grade 4 to 5/5 reflux. Median gain or loss in capacity and compliance was +0.14-fold and -0.11-fold, respectively. Re-augmentation has occurred or is pending in 23 cases (92%). Augmentation was performed in 40 patients with either a complete single or double collecting system. In 9 patients without reflux the diameter of the augmenting system was directly related to success. None of 6 with a ureteral diameter of greater than 1.5 cm required re-augmentation (median increase in bladder capacity and compliance 6 and 50-fold, respectively). Ureterocystoplasty was inadequate in 3 patients with a ureteral diameter of less than 1.5 cm and re-augmentation was required. In 31 patients with reflux, preoperative UDS of the entire system was beneficial. If the system had either normal or mild noncompliance (greater than 20 ml/cm H2O) ureterocystoplasty improved compliance 1-fold (6 cases) and re-augmentation not required. If UDS showed moderately or severely noncompliant system (less than 20 ml/cm H2O, 26 cases) ureterocystoplasty increased capacity and compliance by 0.4-fold (40%) and 0.25-fold (25%), respectively. Re-augmentation has occurred or is pending in 21 of 26 cases (81%). CONCLUSIONS: Ureterocystoplasty with any single or double collecting system is warranted in patients without reflux and a ureteral width greater than 1.5 cm, and in patients with reflux and mild noncompliance (greater than 20 ml/cm H2O) on UDS.

Child↗
PubMed2001

Kidney transplantation in children with urinary diversion or bladder augmentation.

PURPOSE: Urinary tract anomalies or dysfunction leaves the bladder unsuitable for urine drainage in a significant proportion of children presenting for kidney transplantation. We reviewed a multi-institutional experience to determine the ramifications of kidney transplantation in children with bladder augmentation or urinary diversion. MATERIALS AND METHODS: During a 28-year period 18 boys and 12 girls 1.7 to 18 years old (mean age 12.1) received 31 kidney transplants. Cause of end stage renal disease was renal dysplasia in 8 cases, posterior urethral valves in 5, obstructive uropathy in 5, neurogenic bladder/chronic pyelonephritis in 4, spina bifida/chronic pyelonephritis in 3, prune belly syndrome in 3 and reflux in 2. RESULTS: Of the patients 17 had augmented bladder (ileum 9, ureter 5, sigmoid 2 and stomach 1), 12 had incontinent urinary conduits (8 ileum, 6 colon) and 1 had a continent urinary reservoir. Surgical complications included 1 case each of stomal stenosis, stomal prolapse, renal artery stenosis, urine leak, enterovesical fistula and wound dehiscence. Medical complications included urinary tract infection in 21 cases and metabolic acidosis in 5. A bladder stone developed in 1 patient. There was no correlation between the incidence of symptomatic urinary tract infections and type of urinary drainage. Acidosis was more common in patients with augmented bladder (4 of 17 versus 1 of 14) but there was no correlation between the bowel segment used and the occurrence of acidosis. Graft survival was 90% at 1 year, 78% at 5 years and 60% at 10 years. Etiology of graft loss included chronic rejection in 6 cases, noncompliance in 4 and acute rejection in 1. There were no deaths. CONCLUSIONS: Drainage of transplanted kidneys into an augmented bladder or urinary conduit is an appropriate management strategy when the native bladder is unsuitable or absent. Patients with kidney transplants drained into augmented bladder or urinary conduit are at increased risk for urine infection. Graft survival is not adversely affected compared to historical controls when a kidney transplant is drained into a urinary conduit or augmented bladder.

Adolescent↗
PubMed2001

Synchronous bladder reconstruction and antegrade continence enema.

PURPOSE: We assess the long-term outcome of synchronous bladder reconstruction and antegrade continence enema in a large series of patients. MATERIALS AND METHODS: We retrospectively reviewed records of the last 50 consecutive patients treated at 1 unit in Southampton and 1 in Denver. RESULTS: A total of 46 patients were available for analysis, including 24 from Southampton and 22 from Denver. Median patient age at operation was 12 years (range 4 to 30), median followup was 44 months (range 7 to 100), and 80% of patients had neuropathy and anorectal malformation. A variety of bladder reconstructive procedures were performed and 58% of patients underwent a simultaneous Mitrofanoff procedure. Fecal and urinary continence was achieved in 76% of patients but the rate of revision surgery was high. The most common complication was stomal stenosis (17%). Secondary procedures consisted of refashioning urethral length, closure of the bladder neck, bladder augmentation and conduit revision. CONCLUSIONS: It is now possible to produce double continence in some patients with synchronous combined surgery, a goal that was not achievable without colostomy before the development of the antegrade continence enema in 1990. However, the surgery is demanding with high revision rates and we emphasize that it should only be performed in patients who are highly motivated and have reasonable dexterity and intelligence. This careful patient selection is confirmed by the fact that surgery was performed on 2 to 3 patients a year at each unit. This surgery should only be performed at facilities which can provide long-term patient followup.

Adolescent↗
PubMed2001

Vesicoureteral reflux after ureteroneocystostomy: indications for postoperative voiding cystography.

PURPOSE: The aim of this study was to determine the risk factors for vesicoureteral reflux following ureteral reimplantation to identify a population that can be safely excluded from postoperative voiding cystography. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 273 patients who underwent ureteroneocystostomy for vesicoureteral reflux between 1990 and 1998 and recorded the postoperative renal ultrasonography and voiding cystography results. RESULTS: There were 273 patients (534 ureters) who underwent ureteral reimplantation. We recorded the grade of preoperative hydronephrosis and vesicoureteral reflux and noted several preoperative and intraoperative variables, such as dysfunctional voiding, breakthrough infections, renal scarring, bladder trabeculations, type of reimplant, and postoperative urinary tract infections. With a mean follow-up of 20.6 months, persistent postoperative vesicoureteral reflux was noted in 11 patients (4%). Persistent postoperative reflux was noted in 11 patients (4%) or 12 renal units (2.2%). Reflux resolution rates for 534 renal units and 273 patients after routine follow-up voiding cystourethrogram (VCUG) was 97.8% (renal units) and 96% (patients), respectively. Contralateral vesicoureteral reflux developed in 4 (5.1%) of the 78 patients who underwent unilateral reimplantation. Two patients (0.7%) had postoperative ureteral obstruction. The risk factors for persistent postoperative reflux were identified as preoperative and postoperative hydronephrosis, renal scarring, and tapered reimplantations. The type of reimplant did not correlate with outcome. CONCLUSIONS: Vesicoureteral reflux after ureteral reimplantation is uncommon (4%). Because of the high success rate of ureteral reimplants and the benign course of those patients with persistent low-grade postoperative reflux, it is safe and efficient to eliminate postoperative VCUG in most patients who had a simple ureteral reimplantation for reflux. However, in some higher-risk patients, such as those with preoperative hydronephrosis, renal scarring, and ureteral tapering, postoperative voiding cystography may be indicated to assure resolution of vesicoureteral reflux.

Cystostomy↗
PubMed2001

Extraperitoneal placement of renal allografts in children weighing less than 15 kg.

PURPOSE: Extraperitoneal renal transplantation is not routine in small recipients, in whom transperitoneal engraftment is the norm. The outcome of extraperitoneal placement of renal allografts in children weighing less than 15 kg. was evaluated at 2 institutions. MATERIALS AND METHODS: We retrospectively reviewed all pediatric renal transplantations at 2 institutions from 1988 to 2000 and identified 29 children 14 to 72 months old (mean age 29.2) weighing less than 15 kg. (range 8 to 14.8, mean 11.2). All children underwent allograft placement extraperitoneally via a modified Gibson and low midline retroperitoneal incision in 27 and 2, respectively. A concurrent procedure was done via the same incision during 2 ipsilateral and 2 bilateral nephrectomies. RESULTS: Of the 29 patients 25 have a functioning renal allograft. In 2 cases the initial allograft was lost due to early postoperative thrombosis and acute rejection in 1 each. Two patients with a functioning allografts died of medical complications greater than 2 years after transplantation. One child required reexploration secondary to fascial dehiscence and an additional recipient required pyeloureterostomy due to ureteral necrosis after living related donor transplantation. CONCLUSIONS: Extraperitoneal renal transplantation is technically feasible in children who weigh less than 15 kg. This approach preserves the peritoneal cavity, limits potential gastrointestinal complications and allows the confinement of potential surgical complications, such as bleeding and urinary leakage. In addition, this approach provides complete access to the retroperitoneum to enable concurrent retroperitoneal surgery, such as nephrectomy, to be performed safely. We recommend that extraperitoneal renal engraftment should become routine in children weighing less than 15 kg. rather than using the more common transperitoneal approach for allograft placement.

Body Weight↗
PubMed2001

Long-term urological complications in survivors younger than 15 months of advanced stage abdominal neuroblastoma.

PURPOSE: We evaluated the long-term urological complications in survivors of infant advanced stage abdominal neuroblastoma. MATERIALS AND METHODS: The records of patients who presented during an 8-year period with surgical problems related to the kidney and who had survived advanced stage (IV and IV-S) neuroblastoma were reviewed. RESULTS: Of 7 patients identified 3 had complications of obstruction from retroperitoneal fibrosis and 4 had renal cell carcinoma. In the renal cell carcinoma group 3 patients had synchronous, multifocal, bilateral tumors and 1 had a tumor in a solitary kidney. Pathological examination of renal cell carcinoma revealed oncocytoidy with solid and papillary patterns. One patient underwent bilateral nephrectomy but in the remaining 3 renal preservation surgery was performed. All 7 patients have no progression of secondary complications 2 to 8 years after initial presentation. CONCLUSIONS: Survivors of advanced stage abdominal neuroblastoma may be predisposed to long-term urological complications well after initial diagnosis. Because of the risk of renal damage from obstruction secondary to retroperitoneal fibrosis, and the propensity to have renal cell carcinoma, close long-term followup using abdominal imaging is recommended.

Abdominal Neoplasms↗
PubMed2000

Squamous cell carcinoma of the bladder in a pediatric patient.

A 16-year-old North American girl with a prior history of a bladder calculus removed by open cystolithotomy 8 years earlier, subsequently had squamous cell carcinoma of the bladder along the site of the previous incision. The authors believe that this child is the youngest documented patient with squamous cell carcinoma of the bladder not associated with schistosomiasis.

Adolescent↗
PubMed2000

Single scrotal incision orchiopexy for the palpable undescended testicle.

PURPOSE: We prospectively evaluated the Bianchi single high scrotal incision technique for orchiopexy in boys with palpable undescended testis distal to the external inguinal ring. MATERIALS AND METHODS: A total of 60 Bianchi orchiopexies were performed in 48 patients. We identified a group with primary undescended and secondary ascended testis, and a trapped testicle associated with previous inguinal surgery, respectively. Testicular position and size were assessed at 6 weeks of followup. RESULTS: We evaluated group 1-34 patients with bilateral (8), right (17) and left (9) primary undescended testis, group 2-3 with secondary ascended testis and group 3-11 with bilateral (4), right (4) and left (3) trapped testis. Average surgical time was 15, 35 and 35 minutes, respectively. Four patients required conversion to a traditional inguinal incision to achieve adequate cord length. All but 2 patients had a palpable testicle of acceptable size compared with the contralateral mate in the dependent scrotum at the end of the operation and 6 weeks postoperatively. Those returning for 1-year followup had identical findings. In groups 1 and 2 a single testicle normal to palpation resided in a high scrotal position and 1 testis required secondary orchiectomy for infarction, respectively. Scrotal hematoma resolved spontaneously without injury to the testis in 1 case. No hernias were evident. CONCLUSIONS: A single high scrotal incision for palpable primary, secondary ascended or even trapped testis is well tolerated, cosmetically pleasing and associated with a short operative time. The complication rate is acceptably low.

Child, Preschool↗
PubMed1999

Scrotal (Bianchi) approach to patent processus vaginalis in children.

Ligation of an indirect inguinal hernia or communicating hydrocele is the most frequent operation performed on children by pediatric surgeons and urologists. We describe our experience with the scrotal (Bianchi) approach to these problems rather than the traditional inguinal approach.

Adolescent↗
PubMed1999

Congenital anterior urethrocutaneous fistula.

PURPOSE: Congenital anterior urethrocutaneous fistula is a rare anomaly that may present in an isolated fashion or in association with other penile abnormalities, such as chordee or hypospadias. There have been 18 cases of congenital anterior urethrocutaneous fistula reported in the literature. We present 14 additional cases of congenital anterior urethrocutaneous fistula. MATERIALS AND METHODS: We treated 14 patients with congenital anterior urethrocutaneous fistula, of whom 9 were uncircumcised at presentation. Two patients had evidence of chordee and 4 had distal hypospadias. RESULTS: The type of repair was determined by the anatomical variations of this anomaly. All cases were corrected electively by various techniques based on the degree of the defect, including primary closure via a Thiersch-Duplay urethroplasty, pedicle flap urethroplasty, hinged flap urethroplasty and interpositioned island pedicle tube or onlay urethroplasty. CONCLUSIONS: To our knowledge the embryological events that cause anterior urethrocutaneous fistula are unclear but they likely result from a defective urethral plate or an abnormality of the infolding of the urethral groove. Surgical technique must be individualized to fit the defect. While there has been considerable skepticism regarding the existence of congenital urethrocutaneous fistula, the fact that 9 of our 14 patients were uncircumcised confirms the congenital nature of this lesion.

Child↗
PubMed1998

Buccal mucosal grafts for urethral reconstruction.

OBJECTIVES: Patients requiring urethral reconstruction but who have a paucity of usable genital tissue present a considerable technical challenge. Herein we report the experience of three centers in the use of buccal mucosa for urethral replacement. METHODS: From 1991 to 1996, 22 urethral reconstructions were completed using a graft of buccal mucosa. Eighteen of 22 patients had previously failed hypospadias repairs, while three had bulbar urethral stricture and one had penile carcinoma. Grafts were taken from either the inner cheek or the lower lip, and seven were used as a combined graft. Onlay grafts were used in 6 cases and tubularized grafts in 16 cases. RESULTS: Two patients developed complications at the donor site. Nine of 22 patients had complications of the urethroplasty-two had meatal stenosis, four developed a urethral fistula, and three developed urethral stricture. All complications have been managed successfully to date. CONCLUSIONS: Buccal mucosa is an excellent source of graft material for urethral replacement in complex urethroplasties. It is readily available, in abundant supply, and has physical properties beneficial to free graft survival.

Adolescent↗
PubMed1998

Transversely tubularized ileal segments for the Mitrofanoff or Malone antegrade colonic enema procedures: the Monti principle.

OBJECTIVE: To assess the use of a transverse tubularized segment(s) of ileum in the Mitrofanoff or Malone antegrade colonic enema (MACE) procedures. PATIENTS AND METHODS: Eleven patients in three centres underwent the formation of a continent conduit to bowel (MACE, eight patients) and/or bladder (Mitrofanoff, four) using either a single segment of transverse tubularized ileum (10 patients) or two segments of ileum anastomosed and tubularized into a single conduit (two). RESULTS: Within a follow-up of 8 weeks to 6 months, all conduits were continent and catheterized easily. One stomal stenosis required a revision procedure. CONCLUSION: This method for forming a continent catheterizing conduit, based on the Mitrofanoff principle, appears to be effective and is recommended in cases where the appendix cannot be used or where a second conduit is required.

Adolescent↗
PubMed1998

Laparoscopic nephrectomy in children.

Using the techniques for laparoscopic nephrectomy developed in adults, pediatric nephrectomy results in equivalent surgical outcomes compared with open surgery. To date, both transperitoneal and retroperitoneal laparoscopic approaches to nephrectomy for benign renal disease have been described. Controversy exists among pediatric urologists, however, regarding the advantages of laparoscopic nephrectomy in children because convalescence from an open nephrectomy is also rapid. This article reviews the current indications and techniques for laparoscopic nephrectomy in children as well as other surgical applications of laparoscopy with respect to the pediatric patient.

Adolescent↗
PubMed1997

Mayer-Rokitansky-Kuster-Hauser syndrome diagnosed by magnetic resonance imaging in a 15-year-old girl.

STUDY OBJECTIVE: Mayer-Rokitansky-Kuster-Hauser syndrome diagnosed by magnetic resonance imaging (MRI) in a 15-year-old girl with primary amenorrhea is reported. DESIGN: The presentation, MRI, and the subsequent evaluation and treatment of an adolescent female patient with Rokitansky syndrome are described. Correlation is made with previous clinical, pathologic, and imaging reports in the literature. SETTING: An adolescent girl with primary amenorrhea was referred to our institution for completion of her diagnostic work-up. Previous limited evaluations suggested the presence of anomalies of the genitourinary tract. Further delineation of the suspected congenital defects was necessary. PARTICIPANT: The 15-year-old female patient was evaluated by the gynecology service. Diagnostic radiology and pediatric urology were consulted. INTERVENTIONS: MRI, physical examination under anesthesia, and cystoscopy were performed. After initial nonoperative treatment, the patient underwent hysterectomy and sigmoid vaginoplasty. MAIN OUTCOME MEASURES: The patient's primary amenorrhea was explained. Mayer-Rokitansky-Kuster-Hauser syndrome was diagnosed. Vaginal agenesis and widely separated rudimentary uterine horns were well shown by the MRI. Associated skeletal anomalies were noted. A treatment plan was initiated based on a good understanding of the anatomic defects. RESULTS: The MRI and physical examination firmly established the diagnosis. The patient was counseled and managed conservatively at first. Hysterectomy and vaginoplasty were subsequently performed. CONCLUSIONS: Mayer-Rokitansky-Kuster-Hauser syndrome is an unusual müllerian-duct anomaly that is a cause of primary amenorrhea. It can be confidently and noninvasively diagnosed with MRI. The MRI demonstration of vaginal, cervical, and uterine morphology contributes significantly to treatment planning and patient management.

Abnormalities, Multiple↗
PubMed1995

The Malone antegrade continence enema for neurogenic and structural fecal incontinence and constipation.

Problems of fecal elimination are commonly encountered by the pediatric urologist and surgeon. The Malone antegrade continence enema has been described as a means to administer a large volume enema via a continent catheterizable appendicocecostomy, resulting in reliable fecal elimination. Of 22 patients undergoing this procedure 16 reported total continence 4 months or longer after surgery. Complications are relatively minor and tap water appears to be a safe solution for the antegrade continence enema. A nonrefluxing, imbricated appendicocecostomy is preferable to prevent cutaneous fecal or gas leaks.

Adolescent↗
PubMed1995

Renal-portal vein shunt for renal failure after left renal vein ligation in children: a review.

PURPOSE: Interruption of the inferior vena cava and left renal vein in the patient with a solitary left kidney without permanent renal damage has been reported in the past. We assess the risks of similar venous interruption in children and establish guidelines for the management of those cases when collateral drainage of the kidney is uncertain. MATERIALS AND METHODS: We compared our case with a review of all previous reports in the literature concerning ligation of the vena cava and left renal vein in patients with a solitary left kidney. RESULTS: Ligation of the left renal vein in an isolated left kidney in children has been shown to carry the risk of significant renal damage. Renal-portal vein shunt provided adequate drainage of the left kidney after inferior vena caval ligation in our case. CONCLUSIONS: While there have been reported cases of successful inferior vena cava or left renal vein ligation in the isolated left kidney with good renal function, adequate renal drainage should be established in cases where collateral drainage is uncertain, especially in children. Renal-portal vein shunt is a viable therapeutic option to establish left renal drainage in select circumstances.

Anastomosis, Surgical↗