Biomedical subjects
Publications and source records attributed to M D Gibbons.
We report a case of anuria in a premature neonate secondary to bilateral ureteropelvic junction obstructions related to Candida bezoars. Percutaneous decompression and drainage of both kidneys contributed significantly to the successful management of renal candidiasis in this patient. A review of the literature is presented.
We reviewed our experience with percutaneous nephrostomy placement in children less than one year of age during a five-year period. Placement was successful in 8 of 9 cases. There were no complications. The procedure favorably altered the outcome for each patient and was useful for reversing azotemia prior to surgical intervention for repair of an obstructed system (2 renal units), for providing drainage of pyonephrotic kidneys (3 renal units), for demonstrating inadequate recovery of renal function after relief of obstruction (2 renal units), and for replacing a surgically placed nephrostomy that was dislodged (1 renal unit). Our experience has encouraged us to accept the technique, and we believe that it is a valuable nonsurgical alternative that should be available to urologists managing infants with urinary tract pathology.
The 99mtechnetium-dimercapto-succinic acid renal scan has become the gold standard for evaluating renal parenchymal pathology. The traditional pinhole technique provides 2-dimensional imaging. Recent application of high resolution single photon emission computerized tomography (SPECT) has provided the means to obtain even greater cortical detail. With 360-degree imaging and computer reconstruction, SPECT provides coronal, sagittal and transaxial imaging. We prospectively compared the SPECT and pinhole techniques in 33 patients (65 renal units) ranging in age from 2.5 months to 18 years. Both scans were obtained in all patients. All scans were reviewed by an independent interpreter. Using SPECT imaging, diagnostic information was enhanced in 46 of the 65 kidneys (71%). Of the 24 kidneys that appeared "normal" by pinhole imaging 15 (63%) had defects on SPECT imaging. High resolution SPECT imaging improves the ability to identify cortical defects and visualize asymmetry of cortical thickness compared to standard pinhole imaging.
We report a case of neonatal urinary ascites in a newborn, presenting with a large communicating hydrocele. Initial diagnostic evaluation revealed high-grade ureteropelvic junction obstruction in a solitary functioning kidney with a nonobstructive megaureter. After pyeloplasty and with changing transitional nephrology, the megaureter became obstructive requiring tailoring and reimplantation. The unifying concept of ureteral valves explaining this case is presented.
Antenatal hydronephrosis involving 49 renal units in 35 infants seen since 1984 was studied. Postnatal sonography performed in the first few days after birth confirmed upper tract dilatation in 39 kidneys (80 per cent) in 29 neonates and it was normal in 10 kidneys (20 per cent) in 6 neonates. Of the 6 neonates with a normal postnatal sonogram 5 underwent repeat renal sonography at an average of 2 months after birth, all showing moderate hydronephrosis (7 kidneys). Furosemide-enhanced diethylenetriaminepentaacetic acid renography was performed in 4 infants (5 kidneys) with ureteropelvic junction or megaureter obstruction, of whom 2 had persistent unilateral obstruction and underwent successful reconstructive surgery (1 pyeloplasty and 1 megaureter reimplantation). Two infants (3 kidneys) with nonobstructive dilatation are being followed while 1 infant with bilateral vesicoureteral reflux is being managed medically on long-term antimicrobial prophylaxis. Thus, 50 per cent of neonates with antenatal hydronephrosis and a normal postnatal sonogram performed during the first few days of life subsequently were found to have either significant obstruction (2 requiring surgery) or reflux. This study underscores the absolute necessity of followup sonography in all newborns with antenatal hydronephrosis that is not confirmed on the initial postnatal ultrasound.
We report a case of ureteral dilatation associated with septic arthritis of the ipsilateral sacroiliac joint in an infant. Recognition, diagnosis and management of this uncommon entity are discussed.
Hypospadias is a common congenital problem in boys. Neonatal recognition is essential, and circumcision must be avoided. Although there is no increase in risk of other genitourinary anomalies, hypospadias, when associated with cryptorchidism, warrants further evaluation to exclude an intersex disorder. Surgical reconstruction ideally should be performed when the child is between six and nine months of age.
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There is healthy debate over the management and timing of surgical reconstruction in the neonate with hydronephrosis. We have seen 23 neonates (35 renal units) with antenatal or neonatal hydronephrosis secondary to ureteropelvic junction obstruction or megaureter since 1984. All renal units with postnatally confirmed hydronephrosis (78 per cent) were studied initially and serially with diuretic 99mtechnetium-diethylenetriaminepentaacetic acid renography and entered into a delayed management protocol. A total of 23 renal units followed for an average of 7 months before any surgical procedures were done demonstrated maturation of renal function. Of these cases 9 obstructed renal units (half-time greater than 20 minutes) underwent delayed reconstruction (6 with ureteropelvic junction obstruction and 3 with megaureter) at an average patient age of 6 months. In this group there was no compromise in renal function nor were any complications encountered. Two units with initially obstructive patterns on renography demonstrated improved drainage and have not required an operation to date. Twelve renal units with indeterminant (half-time 10 to 20 minutes) and nonobstructive (half-time less than 10 minutes) half-times also showed stable, maturing renal function. Delayed reconstruction in the neonate with ureteropelvic junction or megaureter obstruction and normal diethylenetriaminepentaacetic acid function is safe. In addition, a period of observation may obviate the need for an operation in some cases when ureteropelvic junction stabilization results in improved drainage. These as well as the added benefits of diminished anesthetic risk, enhanced technical ease, noninterrupted maternal-infant bonding and lower operative complication rate make this approach desirable in properly selected patients.
Factors determining the likelihood of urinary tract infection in children include host susceptibility, such as the presence of obstructive uropathy, neuropathic bladder or dysfunctional voiding. Bacterial virulence, as in infection by fimbriated Escherichia coli, is also a factor. With a few exceptions, diagnostic evaluation should be performed following the first infection. Early aggressive therapy has the goal of preserving renal function.
We report 3 cases of renal dysplasia related to congenital obstructive uropathy and associated with nodular renal blastema. The literature is reviewed in regard to this relationship, as well as the relationship of nodular renal blastema with Wilms tumor and Wilms tumor with congenital genitourinary anomalies. The possible implication of nodular renal blastema associated with dysplasia and obstructive uropathy is emphasized with respect to the risk of neoplastic change.
A case of perirenal neuroblastoma causing intrarenal obstruction of the pelvis of the kidney presented as a small hydronephrosis at 3 days of age. The tumor grew rapidly over the next 48 hr, diagnosis was confirmed by ultrasonography, and the mass was removed surgically.
Of the orchiopexies performed for abdominal undescended testicles 85 per cent have resulted in satisfactory testicular growth and position. Three-fourths of these cases were in boys with the prune belly syndrome. We are satisfied with our recent experience using the Fowler-Stephens procedure to salvage intra-abdominal undescended testicles. An analysis of the failures in 5 testes early in this series, resulting in partial atrophy, has helped us to avoid technical errors through attention to the following details: 1) preservation of a broad pedicle of peritoneum overlying the mobilized vas, 2) avoidance of any dissection of the spermatic cord and 3) high ligation of the spermatic vessels well above the point of confluence of the vas and spermatic vessels. Although the Fowler-Stephens procedure has some risk of testicular ischemia and atrophy we believe it to be the preferred way to gain mobility on a short tethering gonadal vascular pedicle.
The syndrome of acute post-obstructive nephrogenic diabetes insipidus is a rare phenomenon. The lesion is acquired during the pre-diuretic phase, owing to antidiuretic hormone resistance of the distal tubule as well as a severe concentrating defect. The diuretic phase after relief of obstruction can result in a massive, sustained and life-threatening diuresis. Sodium restriction and thiazide diuretics produce a mild volume contracted state, enhancing sodium and water reabsorption, primarily in the proximal tubule and possibly in the distal tubule owing to aldosterone. The recognition and differentiation of this unique pyloric syndrome from other more common post-obstructive diuretic states are important for all urologists who are responsible for the care of children.
Our experience with urethral strictures in boys during a 15-year period confirms the findings of others that the most common etiology is iatrogenic. Traumatic and inflammatory strictures are rare. The congenital stricture differs fundamentally from acquired types of urethral strictures and would be termed more appropriately congenital urethral membrane. Urethral dilation and/or urethrotomy was unsuccessful in 47% of our patients, leading to secondary formation of a new stricture in 2 instances. However, urethroplasty was successful in 83% of our cases and seems to be indicated when 2 or more dilations are required.
The fifteenth reported case of paratesticular liposarcoma is presented, together with a review of the literature. The prognostic and therapeutic implications of this particular neoplasm are discussed.
The seventh case of a female subject with a single, unilateral ectopic ureter draining to the vagina is reported. The renal unit was located in the renal fossa, wheras in 3 of the 7 cases reported it was within the pelvis. Although ectopia with ureteral duplication is not an uncommon anomaly the single ectopic ureter in the female subject is the rarest form of ureteral ectopia. Use of phenazopyridine hydrochloric acid as an excertory marker was most helpful in locating the vaginal orifice.
Two infants with ectopia of the vas deferens are described. To date 11 cases have been reported, comprising a total of 13 ectopic vas insertions, 2 of which are bilateral. A classification of 2 types of ectopic vas is presented with a discussion of their relationship to ureteral ectopias. An embryological hypothesis of a proximal vas precursor segment of the wolffian duct is related closely to Stephens' theory of ureteral development.