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Biomedical subjects

M L Ritchey

Publications and source records attributed to M L Ritchey.

At least 55 records · Page 3Linked to original sources
PubMed1995

Percutaneous endopyelotomy in infants and young children after failed open pyeloplasty.

PURPOSE: We assessed the efficacy and safety of percutaneous endopyelotomy in infants and young children with secondary ureteropelvic junction obstruction after previous open pyeloplasty. MATERIALS AND METHODS: Three boys and 2 girls with persistent ureteropelvic junction obstruction after open pyeloplasty underwent percutaneous antegrade cold knife endopyelotomy via an 18F nephrostomy tract. RESULTS: Percutaneous endopyelotomy was successfully performed in all 5 children with minimal complications. At a mean followup of 2.5 years endopyelotomy was successful in 4 of the 5 children based on the absence of symptoms, normal pressure-perfusion studies and normal or improved diuretic renal scintigraphy studies. One child in whom endopyelotomy failed underwent successful ureterocalicostomy. CONCLUSIONS: Percutaneous antegrade endopyelotomy is a safe and efficacious method of treating secondary ureteropelvic junction obstruction in children. This method offers a minimally invasive alternative to conventional repeat open pyeloplasty.

Child, Preschool↗
PubMed1995

High flow priapism associated with sickle cell disease.

Priapism associated with sickle cell disease is classically described as a low flow state. We report 2 cases of high flow priapism associated with sickle cell disease. High flow priapism has previously been reported almost exclusively in patients with traumatic rupture of the cavernous artery. Neither of our patients had historical or radiographic findings consistent with injury to the penile vasculature. One patient was treated unsuccessfully with intracorporeal injection of methylene blue and 1 underwent successfully bilateral pudendal artery embolization. The pathophysiological mechanism(s) responsible for the production of high flow priapism in patients with sickle cell disease is not known.

Adolescent↗
PubMed1995

Incidence of vesicoureteral reflux in children with unilateral renal agenesis.

We retrospectively reviewed 51 pediatric cases of unilateral renal agenesis to determine the incidence of contralateral vesicoureteral reflux. Initial diagnosis of unilateral renal agenesis was made by evaluation of associated congenital abnormality in 21 patients, evaluation of prenatally detected abnormality in 11, evaluation of urinary tract infection in 7, sibling screening in 3, hypertension in 2 and other methods in 7. A voiding cystourethrogram was obtained in 44 cases. Indications for the study included urinary tract infection in 11 patients, hydronephrosis in 18 and screening in 15. Overall, vesicoureteral reflux occurred in 19 of the 51 patients (37%). The highest incidence of contralateral reflux was in those with a prenatal abnormality with or without hydronephrosis (77%) although 5 of 15 patients (33%) who underwent a screening voiding cystourethrogram had reflux. Mean followup was 50 months. Of the patients with vesicoureteral reflux reimplantation was performed in 9, reflux spontaneously resolved in 3 and reflux persisted in 7. There is a high incidence of vesicoureteral reflux in children with unilateral renal agenesis and a voiding cystourethrogram is recommended even in the absence of hydronephrosis or urinary tract infection. Although 50% of children in our series underwent surgical intervention, a period of nonoperative observation is warranted.

Child, Preschool↗
PubMed1995

The management of synchronous bilateral Wilms tumor.

There has been a distinct evolution in the treatment philosophy for patients with BWT. Initial attempts at radical surgery have given way to the current use of preoperative chemotherapy to preserve as much kidney tissue as possible. With preoperative treatment, usually chemotherapy only, overall survival has become quite favorable in this group of patients, approaching 83% at 2 years. This has facilitated the use of parenchymal-sparing operations, with the potential advantage of decreasing the incidence of end-stage renal disease. The development of renal insufficiency in children with synchronous BWT nonetheless remains a concern. It is important that long-term survivors have systematic follow-up, with measurements of blood pressure, urine protein, serum creatinine, renal clearance, and renal size. Finally, despite the mentioned achievements, the management of children with synchronous BWT still needs standardization. The limited number of patients affected by BWT makes an international effort desirable to address this need.

Diagnostic Imaging↗
PubMed1994

Intravesical oxybutinin chloride in children with intermittent catheterization: sonographic findings.

The sonographic findings in the bladder are presented in four children with myelomeningocele and neurogenic dysfunction of the bladder, who were treated with intermittent self-catheterization and intravesical oxybutinin chloride. All were referred for routine sonography of the urinary tract. Each had infused a crushed tablet of oxybutinin chloride intravesically 30-120 min before the examination. In two children, brightly echogenic, non-shadowing particles were suspended in the bladder urine. In one of these, the particles swirled giving the impression of a "snowstorm"; in the other, most of the particles gradually settled forming an irregular clump on the bladder base. In the remaining two children, the urine appeared diffusely hazy with innumerable tiny particles giving the impression of a fine mist filling the bladder. The sonographic appearance of the urine in the bladder after intravesical instillation of crushed tablets can be dramatic and can simulate pus, blood, fungus, or other debris in the bladder lumen. In the absence of clinical symptoms or hematuria, a history of recent infusion of medication into the bladder should be sought.

Administration, Intravesical↗
PubMed1994

Ureterocele associated with a single collecting system of the involved kidney.

OBJECTIVE: This is a study concerning ureteroceles associated with a single collecting system of the involved kidney. METHODS: Over an eight-year period 9 children (5 boys, 4 girls) had a ureterocele subtending a single collecting system, whereas 63 children had duplex ureteroceles. Malformations of other organ systems were present in only 1 patient. RESULTS: Three patients have undergone surgical interventions: a transurethral incision of bilateral obstructive ureteroceles in 1 and nephroureterectomy in 2. In 4 cases cystic/dysplastic kidneys involuted and were reabsorbed with collapse of the ureteroceles. The last 2 patients have received antibiotic treatment for single episodes of a urinary tract infection. CONCLUSIONS: Earlier reports of a high incidence of concomitant anomalies and male predominance in patients with single-system ectopic ureteroceles could not be verified by our experience. Our current policy for a patient is careful evaluation, individualized therapy, and long-term surveillance.

Adolescent↗
PubMed1994

Intravesical instillation of gentamicin sulfate: in vitro, rat, canine, and human studies.

OBJECTIVE: Intravesical instillation of gentamicin sulfate has been used empirically as prophylaxis and to treat bacilluria in spinal-cord-injured patients undergoing clean intermittent catheterization. To assess the risks of absorption and the effects of storage conditions on antimicrobial potency, a series of studies were conducted. METHODS: Four studies were carried out: (1) An infected fulgurated rat bladder model was created to determine the effects of inflammation and infection on absorption. (2) A canine model with bilateral vesicoureteral reflux and elevated bladder pressures (> 40 cmH2O) assessed the effects of reflux and storage pressure. (3) The effects in patients with associated conditions including renal transplantation, myelomeningocele, vesicoureteral reflux, and bladder augmentation, were analyzed. (4) To determine the effects of storage conditions, solutions of gentamicin sulfate (480 mg gentamicin sulfate in 1 L 0.9% NaCl) were made that controlled for pH, storage temperature, and duration. RESULTS: (1) Increased absorption was found in 43 percent of rat serum samples. (2) None of the dogs demonstrated measurable absorption. (3) None of the patients likewise had measurable absorption. (4) All solutions were equally potent when tested against a panel of common urinary pathogens. Storage up to two months at room temperature without alkalinization had no effect on potency. CONCLUSIONS: Instilled intravesical gentamicin sulfate has a low risk of absorption and is highly effective. Severe bladder inflammation can increase transvesical absorption. It has prolonged stability without special storage conditions and should be considered as a route of prophylaxis in patients who perform intermittent catheterization.

Absorption↗
PubMed1994

Outcome of reflux in children with myelodysplasia managed by bladder pressure monitoring.

From June 1984 to December 1992 voiding cystourethrography performed on 209 patients with myelodysplasia revealed vesicoureteral reflux in 57 (27%). High grade reflux (3 to 5/5) occurred in 33 patients (58%). Bladder pressure at typical capacity, defined as the pressure at average catheterization volume or bladder leak point pressure, was determined urodynamically. After a mean of 56 months vesicoureteral reflux resolved or improved in 55% of patients and remained unchanged in 28%. There was no correlation between the grade of reflux and the rate of spontaneous resolution. Pressure at typical capacity of 40 cm. water or more was significantly more common in patients with reflux (44%) than in those with no reflux (20%) (p < 0.001). There was a strong association between pressure at typical capacity of 40 cm. water or more and upper tract deterioration (p < 0.0001). However, there was no correlation between pressure at typical capacity and grade of reflux (p = 0.18). Treatment of pressure at typical capacity of 40 cm. water or more led to resolution or improvement of vesicoureteral reflux in 8 of 10 reevaluated patients. Hydronephrosis resolved (7) or improved (1) in 8 of 9 cases. Measurement of intravesical pressure is of paramount importance in the management of spina bifida patients with vesicoureteral reflux. Maintaining the pressure at typical capacity at less than 40 cm. water is associated with increased spontaneous resolution of vesicoureteral reflux and a lower incidence of upper tract deterioration.

Child↗
PubMed1994

Significance of spina bifida occulta in children with diurnal enuresis.

We reviewed retrospectively 456 patients with diurnal enuresis to determine the relationship between spina bifida occulta and attainment of continence. Of these patients 127 had undergone x-rays of the spine and 48 children (48%) had spina bifida occulta. The clinical course of these patients was compared to 79 enuretic children with normal spine films. All patients were initially treated with a timed voiding program and 28 with persistent enuresis were given anticholinergic medication. Findings on urodynamic studies were similar for both groups. Uninhibited bladder contractions were found in the majority of patients and 2 children in each group had hypertonic filling curves. Of 10 children with spina bifida occulta magnetic resonance imaging or ultrasound of the spine revealed lipoma and tethering of the cord in 1. Mean followup for both groups was 3 years. The outcome for enuretic children with spina bifida occulta was comparable to those with normal spine x-rays. The majority of patients had resolution of the enuresis with conservative management. Spinal ultrasound or magnetic resonance imaging may be warranted in those children with abnormal neurological findings on examination or hypertonic filling curves, or those who fail to respond to medical treatment. However, neurosurgical intervention to achieve continence appears necessary in only a small percentage of enuretic children with spina bifida occulta.

Child↗
PubMed1994

Pubovaginal slings for the management of urinary incontinence in female adolescents.

A pubovaginal sling is an effective treatment for type III incontinence secondary to poor proximal urethral sphincter function. We used a pubovaginal sling to treat incontinence in 15 female adolescents. The etiology of incontinence was spinal dysraphism in 10 patients and prior trauma in 3. Simultaneous bladder augmentation was performed in the remaining 2 patients for poor bladder compliance. Three patients required additional procedures including repeat slings in 2 and repeat augmentation in 1. Of 13 patients followed for more than 6 months 11 remain dry, 1 leaks small amounts and wears 1 pad per day, and 1 did not achieve acceptable continence and was subsequently managed with bladder augmentation and a Mitrofanoff procedure. The upper urinary tracts have remained normal in all 13 patients. The pubovaginal sling has proved to be safe and successful in these children. The overall continence rate of 92% compares favorably to other available modalities.

Adolescent↗
PubMed1994

Congenital fistula of the penile urethra.

Congenital fistula of the penile urethra is rare. We report a case associated with glandular hypospadias without chordee, and discuss the possible etiology and management of this unusual anomaly.

Humans↗
PubMed1994

Normal and abnormal pelviscopic anatomy at the internal inguinal ring in boys and the vasal triangle.

OBJECTIVES: We sought to explain and define normal and abnormal laparoscopic pelvic anatomy, which has only recently become the target of much attention. METHODS: The embryology, normal anatomic landmarks, and abnormal findings of the male pelvis, as discerned from more than 350 laparoscopic investigations in boys, were analyzed. RESULTS: The medial umbilical ligament, the wishbone at the internal inguinal ring, the transverse vesical fold, and the vasal triangle are principal laparoscopic landmarks of the male pelvis. Deficient spermatic vessels, abnormal gonadal locations, patent processus vaginalis, single medial umbilical ligament, and transverse testicular ectopia were the abnormal findings. CONCLUSIONS: Laparoscopic familiarity with the male pelvis permits safe and efficient diagnostic and therapeutic navigation in this new surgical arena.

Child↗
PubMed1994

Urologic manifestations of Goldenhar syndrome.

OBJECTIVE: Goldenhar syndrome (oculoauriculovertebral dysplasia) is associated with anomalies in multiple organ systems. Renal abnormalities have also been reported with the complex, but the incidence of associated genitourinary malformations has not been defined. METHOD: We have reviewed our experience with 28 children with Goldenhar syndrome evaluated during the past twelve years. Twenty children underwent imaging evaluation of the urinary tract and 14 (70% of those imaged) children had urinary tract anomalies. RESULTS: The majority of anomalies presented as an incidental finding on a screening ultrasound (8 patients) or during cardiac catheterization (2 patients). Two children presented with urinary tract infection, 1 child presented with renal failure, and another was diagnosed antenatally. The genitourinary anomalies included the following: ectopic and/or fused kidneys (8 patients), renal agenesis (7), vesicoureteral reflux (5), ureteropelvic junction obstruction (2), ureteral duplication (2), and multicystic kidney (1 patient). Four children have undergone surgical intervention. CONCLUSION: Our experience in children with Goldenhar syndrome suggests that the incidence of genitourinary anomalies is higher than previously reported. A screening ultrasound in the neonatal period allows for early intervention in those children with significant urologic abnormalities.

Abnormalities, Multiple↗
PubMed1994

Management and outcome of inoperable Wilms tumor. A report of National Wilms Tumor Study-3.

METHODS: The authors reviewed 131 children enrolled in National Wilms Tumor Study-3 (NWTS-3) who received preoperative treatment for tumors unable to be resected at surgery or judged inoperable by imaging evaluation. Preoperative biopsies were performed on 103 patients. Patients were assigned a pretreatment stage: stage II (11 patients), stage III (39 patients), stage IV (66 patients), and unknown (15 patients). The chemotherapy regimen included dactinomycin and vincristine (81 patients), dactinomycin, vincristine, and doxorubicin (30 patients), dactinomycin, vincristine, doxorubicin, and cyclophosphamide (10 patients), and other (8 patients). Preoperative radiation therapy was started concurrently with chemotherapy (27 patients) or because of lack of response (14 patients). Two patients were given preoperative irradiation without chemotherapy. RESULTS: Response to therapy was assessed after the first trial of chemotherapy. Partial responses were noted in 110 patients (85%), 3 had complete responses, 13 had no response or progression of disease, and 5 patients were not able to be evaluated. There were no significant differences in preoperative response to the different chemotherapy regimens. Median time interval from diagnosis to nephrectomy was 58.5 days. When compared with NWTS-3 patients not receiving preoperative treatment, survival was reduced for patients treated preoperatively (88% vs. 74%, respectively, 4-year survival), which was only partially explained by differences in stage distribution. Median duration of follow-up was 5.9 years. Lack of response to the preoperative treatment was associated with a poor prognosis. Eight children died before removal of the primary tumor. All eight had either progressive disease or no response to the preoperative treatment. CONCLUSIONS: The use of preoperative treatment can facilitate subsequent surgical resection in selected patients with inoperable Wilms tumors. Although these very large tumors--judged unable to be resected--have a somewhat worse prognosis, nephrectomy was completed in 93% of patients after preoperative treatment. However, preoperative treatment will lead to less accurate surgical and pathologic staging, and undertreatment should be avoided in these high-risk patients.

Child, Preschool↗
PubMed1993

Congenital mesoblastic nephroma metastatic to the brain.

BACKGROUND: Congenital mesoblastic nephroma (CMN) is generally considered to be a benign neoplasm requiring only total excision. Rare local recurrences have usually been related to incomplete removal, and distant metastases to the lung have been reported three times. METHODS: The authors reported the first case of CMN metastatic to the brain, illustrating a comparison of the histopathology of the primary and secondary lesions. RESULTS: The gross appearance of the renal tumor was that of a benign CMN. On histopathologic examination, there was a single nodule of more cellular tissue with focal necrosis. This area was diagnosed as within the designation "cellular" mesoblastic nephroma. The appearance of the brain metastasis corresponded to that of the cellular nodule. CONCLUSIONS: This report expands the spectrum of metastatic potential of CMN. Though a rare event, this case underscores the need for close follow-up of infants with CMN.

Brain Neoplasms↗
PubMed1993

Preoperative therapy for intracaval and atrial extension of Wilms tumor.

BACKGROUND: Primary surgical management of Wilms tumor with intravascular tumor extension is associated with significant morbidity. Retrospective analysis of a group of Wilms tumor patients with intravascular tumor extension treated with preoperative therapy was performed to evaluate the feasibility of this approach. METHODS: Thirty children with caval (15 patients) or atrial (15 patients) extension of Wilms tumor who received preoperative therapy were reviewed. Patients were classified according to the stage of the disease as follows: (1) Stage III, 7 patients; (2) Stage IV, 18 patients; and (3) Stage V, 5 patients. The histologic type was favorable in 20 patients, anaplastic Wilms tumor in 7, and unknown in 3. All of the children received preoperative chemotherapy, ranging from 1-16 weeks with an average of 7.2 weeks. RESULTS: One child died of progressive disease and another from toxicity before surgery. In 23 patients, a decrease in the size of the intravascular extension was noted preoperatively, without tumor embolization in any case. There was complete resolution of tumor thrombus in seven patients. Two-year survival for the entire group is 70%, with a median follow-up period of 21 months. CONCLUSIONS: The use of preoperative therapy is appropriate in selected patients with extensive intravascular tumor involvement. Surgical management was facilitated in the majority of cases due to shrinkage of the primary tumor and reduction in the size of the tumor thrombus.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1993

Comparison of different techniques of stapled bowel anastomoses in a canine model.

OBJECTIVE: To evaluate different methods of creating a stapled enteroanastomosis and to determine which method would create a larger anastomosis. DESIGN: Prospective comparison of three groups with a total of 17 mongrel dogs. SETTING: Clinical investigation facility. MAIN OUTCOME MEASURES: Stapled side-to-side enteroanastomoses were created with the stapled edges touching or separated. Anastomoses were created in both functional bowel and in a defunctionalized limb. The anastomotic circumference was measured in a blinded fashion after 28 days. The third group had anastomoses created and measured the same day. Groups were compared using the t test. RESULTS: There was significant narrowing after healing with both types of anastomoses. Anastomoses created by separating the stapled lines were larger than those fashioned with the cut edges touching, both immediately and after healing. CONCLUSIONS: While clinically significant narrowing of a stapled anastomosis is uncommon, separating the staple lines of a functional end-to-end anastomosis may be the preferable method.

Anastomosis, Surgical↗