Bladder management for patients with myelodysplasia.
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Child↗
Biomedical subjects
Michael C Carr
Publications and source records attributed to Michael C Carr.
Urethral dilation as treatment for neurogenic bladder.
PURPOSE: We documented the change in bladder physiology and clinical outcomes after urethral dilation for managing neurogenic bladder. MATERIALS AND METHODS: Female patients with neurogenic bladder were identified who underwent urethral dilation due to failure to empty at low pressure or upper tract changes. Urethral dilation was performed using curved sounds to 36Fr (range 18Fr to 36Fr). Clinical charts were reviewed to document urodynamics, infection rates, symptomatology, vesicoureteral reflux and upper tract dilatation before and after dilation. RESULTS: A total of 19 children underwent urethral dilation a mean of 2 times. Mean age at first dilation was 19.3 months. Mean followup was 34.9 months. The indication for dilation was high detrusor leak point pressure in 16 children. The remaining children had recurrent infections (1), poor compliance (1) and bladder spasms (1). Clinical manifestations of increased detrusor leak point pressure in 16 children were vesicoureteral reflux in 11, upper tract dilatation in 9 and recurrent infections in 3. Long-standing improvement occurred in 12 of 16 patients with increased detrusor leak point pressure, in 0 of 1 with infection, in 0 of 1 with poor compliance and in 1 of 1 with bladder spasms. Overall improvement was noted in 13 of 19 cases (68%). Vesicoureteral reflux was identified in 14 of 19 patients. Improvement was seen in 6 of 14 cases, including complete resolution in 5 and improvement in 1. Hydronephrosis was seen in 11 of 19 patients with improvement in 7, including resolution in 1 and improvement in 6. Only 6 children required further surgical intervention, that is vesicostomy in 2 and reimplantation in 4. CONCLUSIONS: Urethral dilation is effective for lowering detrusor leak point pressure in children with neurogenic bladder and for improving upper tract dilatation and vesicoureteral reflux. This procedure may prevent the need for more complicated surgical intervention. It should be investigated further in well designed, prospective studies.
Child, Preschool↗
Urethral strictures incident to bicycle motocross racing.
A dramatic shift from traditional team to alternative or "extreme" sports has given rise to a new generation of nontraditional athletes and sports-related injuries in the pediatric population. We present a case of 2 brothers who developed urethral strictures believed incident to BMX racing. We address current demographics and the general presentation and course of treatment to aid both the pediatric urologist and the general practitioner in prompt and proper diagnosis.
Adolescent↗
Cross-fused ectopic multicystic dysplastic kidney with associated ureterocele.
We describe a case of the unique congenital anomaly of cross-fused ectopic multicystic dysplastic kidney with associated ureterocele and demonstrate the usefulness of magnetic resonance imaging in fetal imaging.
Female↗
Long-term outcomes in children treated by prenatal vesicoamniotic shunting for lower urinary tract obstruction.
OBJECTIVE: Limited information is available about long-term outcomes in children treated prenatally for lower urinary tract obstruction. Our aim was to evaluate outcomes in children treated in utero with vesicoamniotic shunts. METHODS: Clinical outcomes in 20 pregnancies with a singleton male fetus, oligo/anhydramnios, and lower urinary tract obstruction were studied using chart review and phone and written clinical questionnaire for parents, pediatricians, and urologists. RESULTS: Overall 1-year survival was 91%. Two neonatal deaths occurred from pulmonary hypoplasia. Mean gestational age at delivery was 34.6 weeks, mean days from shunting to delivery were 84.4, and mean birth weight was 2,574 g. Prenatal urinary prognosis was good in 13, borderline in 2, and poor in 3 of the survivors. Mean age at follow-up was 5.83 years. Posterior urethral valves were confirmed in 7 males, urethral atresia in 4, and prune belly syndrome in 7. Eight children had acceptable renal function, 4 had mild insufficiency, and 6 required dialysis and eventual renal transplant. Eleven children had normal bladder function with spontaneous voiding, 6 required catheterization, and 1 child still had a vesicostomy. Height and weight were below the 25th percentile in 9 children. Persistent respiratory problems were present in 8, musculoskeletal problems in 9, and frequent urinary tract infections were reported in 9. Health-related quality of life results in our group with lower urinary tract obstruction were similar to those in a healthy child population. CONCLUSION: Male children who underwent prenatal bladder shunting were neurodevelopmentally normal. Although one third of the surviving babies required dialysis and transplantation, the majority have acceptable renal and bladder function and report satisfactory quality of life. LEVEL OF EVIDENCE: III.
Adolescent↗
The danger of intraoperative antegrade cannulation of the ureter in infancy and early childhood.
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Age Factors↗
Prenatally detected primary megaureter: a role for extended followup.
PURPOSE: A high rate of spontaneous resolution of or decrease in urinary tract dilatation is expected for most cases of primary megaureter (PM). We analyzed our results with extended long-term nonsurgical treatment in a group of children diagnosed with prenatally detected PM. We also sought to determine the long-term safety of this approach and the clinical significance of residual hydroureteronephrosis (HUN) when complete resolution does not occur. MATERIALS AND METHODS: We reviewed our experience with 40 infants with prenatally detected hydronephrosis diagnosed as PM who were initially treated nonoperatively between 1986 and 1999. Patients were followed with ultrasonography, nuclear renography and, in some instances, excretory urogram until stable improvement or complete resolution of HUN was noted. Records for patients who specifically returned for long-term followup history and radiological imaging were also reviewed. RESULTS: Of 40 patients with 57 megaureters (17 with bilateral PMs) who were followed 4 infants (10%) with severe HUN were diagnosed with diminished renal function by nuclear renography and underwent surgical repair. A total of 27 infants (67.5%, 40 megaureters) with PM who were followed without surgical intervention returned for followup examination and imaging for a minimum of 24 months after initial diagnosis, for a mean of 6.8 years (range 24 to 210 months). Ultrasonography in these patients revealed complete resolution (Society for Fetal Urology grade 1 or less hydronephrosis) in 21 megaureters (52.5%) at a mean of 2.9 years and improved or stable HUN in 19 megaureters (47.5%). Antibiotic prophylaxis was administered to 12 patients beyond the first month of life and discontinued at a mean age of 19.9 months. A subgroup of 10 patients (16 megaureters) from this cohort returned for extended followup imaging at a mean of 13.4 years (range 84 to 210 months) following initial diagnosis. Four patients with documented resolution of HUN had no recurrence during long-term followup. One male with bilateral PMs diagnosed at birth that had been stable but were not resolved at 8-year followup suffered significant worsening in the degree of HUN, diminished renal function on 1 side and a renal stone on the contralateral renal unit at 14-year followup, despite remaining asymptomatic. CONCLUSIONS: Long-term followup of children with prenatally diagnosed PM with mild to moderate hydronephrosis confirms a high incidence of resolution and improvement. As we have documented 1 case of worsening HUN at 14-year followup, we believe that ultrasonography should be periodically continued until the child reaches adulthood, at least in instances where complete resolution of HUN is not documented.
Adolescent↗
Split onlay skin flap for the salvage hypospadias repair.
PURPOSE: Following failed hypospadias repair absence of the penile foreskin, a shortage of ventral skin and residual chordee may all contribute to poor long-term results. We describe a technique called the split onlay skin (SOS) flap that has improved our surgical outcomes in boys requiring salvage hypospadias repair. MATERIALS AND METHODS: The SOS flap uses a transverse island of penile shaft skin that is mobilized on its vascular pedicle and rotated into position to the ventrum of the penis at the site of the urethral defect. The flap is transected transversely, and half of the flap is used as an onlay to repair the urethra and the other half is used for additional skin coverage where needed on the penile shaft. We treated 11 boys 30 to 124 months old (mean age 60.3 months) who had a mean of 2 previous failed hypospadias repairs. All 11 boys presented with complex combinations of urethrocutaneous fistulas, stricture or urethral diverticula. RESULTS: Of the 11 patients 6 (54.5%) had development of postoperative fistulas. Five of these fistulas were surgically closed with no further complications. One penoscrotal fistula closed spontaneously after 7 months. Mild chordee from contraction of the flap and a urethral diverticulum developed in 1 boy. At a mean followup of 24.5 months all patients, including those who underwent closure of the secondary fistula, were voiding well with excellent appearance. CONCLUSIONS: In cases where little local tissue is present the SOS flap procedure is an excellent way to transfer healthy dorsal tissue to the ventrum for an onlay salvage urethroplasty while providing additional coverage of the urethral defect and a tension-free skin closure. Despite the high fistula rate we encountered following the initial SOS procedure, we endorse this technique because the transferred dartos provides additional tissue, which facilitates subsequent fistula repair. These boys can achieve a successful cosmetic result without incorporation of scrotal tissue or a free graft, which we believe leads to more predictable results.
Child↗
Testicular microlithiasis and antisperm antibodies following testicular biopsy in boys with cryptorchidism.
PURPOSE: Testicular biopsy (TBx) performed during orchiopexy in boys with cryptorchidism can help to predict future semen analyses and possibly identify patients at risk for testicular cancer. It has been theorized that TBx can be detrimental to the long-term health of the testis. We examined testicular microlithiasis (TM) and antisperm antibody (ASA) production in cryptorchid TBx. MATERIALS AND METHODS: A total of 112 males underwent fertility evaluation. These patients had previously undergone orchiopexy and bilateral TBx (mean age 8.6 years) for unilateral or bilateral undescended testis. At a mean age of 19.6 years all patients underwent physical examination and scrotal ultrasound for evaluation of testis size, echotexture and abnormalities. Of 112 patients 57 also underwent direct Immunobead(R) assay with positive controls. Moving sperm free and/or bound to IgG bead complex were counted in the preparation. RESULTS: A total of 29 patients had bilateral and 83 had unilateral undescended testis. Of the 112 patients 26 were black and 86 were white. Four black patients (15.4%) and 4 white patients (4.7%) had testicular microlithiasis. Three patients had bilateral and 5 had unilateral diffuse TM. No tunica albuginea scars or testis masses were noted. In the 57 patients who underwent direct Immunobead assay no semen sample demonstrated evidence of forming bead-sperm complex, ie none had direct ASA. CONCLUSIONS: No patient exhibited evidence of direct ASA. Prepubertal open TBx does not increase the rate of TM. We found no evidence of additive testicular damage associated with TBx at the time of orchiopexy.
Adolescent↗
Overnight catheter drainage in children with poorly compliant bladders improves post-obstructive diuresis and urinary incontinence.
PURPOSE: Overnight catheter drainage (OCD) has been suggested as a treatment for boys with valve bladder syndrome as well as those with polyuric renal failure. We report our experience using overnight catheter drainage in children with poorly compliant bladders. MATERIALS AND METHODS: Between 1999 and 2004 OCD was initiated in 6 boys and 5 girls (median age 7.5 years) with poorly compliant bladders in whom aggressive daytime intermittent catheterization and anticholinergic use had failed. Etiologies of bladder dysfunction included posterior urethral valves in 1 case, The Hinman-Allen syndrome in 4, myelomeningocele in 2, neuroblastoma in 1, prune-belly syndrome in 1, transverse myelitis in 1 and sacral agenesis in 1. The amount of post-obstructive diuresis was calculated during urodynamics as the volume drained minus volume instilled divided by weight per hour. Other parameters evaluated included serum creatinine, degree of upper tract dilatation, and episodes of urinary tract infection (UTI) and incontinence. RESULTS: Median duration of OCD and followup was 28 months, respectively. One patient did not tolerate overnight drainage. Of 9 patients who were incontinent before OCD daytime urinary incontinence resolved in 6 and improved in 3. Recurrent febrile UTIs in 3 children were eliminated. Despite no change in serum creatinine with overnight drainage, 7 of 8 patients (88%) with upper tract dilatation improved on followup ultrasound. CONCLUSIONS: In select children with poorly compliant bladders OCD reduces diuresis, reduces the frequency of UTIs, improves upper tract dilatation and improves continence. Overnight drainage in conjunction with daytime clean intermittent catheterization may prove to be an alternative to bladder augmentation in select children with poorly compliant bladders and early stages of renal compromise.
Adolescent↗
Successful treatment of encrusted cystitis and pyelitis with preservation of renal graft.
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Anti-Bacterial Agents↗
Prenatal management of urogenital disorders.
Antenatal sonography has increased the detection of urogenital anomalies markedly, including conditions that lead to significant morbidity and mortality. Prenatal intervention is feasible to arrest and sometimes reverse the sequelae of bladder-outlet obstruction, but not necessarily renal damage. Myelomeningoceles, the most severe form of spina bifida,can be corrected in utero, with improvements in hydrocephalus and a decreased incidence of ventricular shunting postnatally. Medical therapy to prevent virilization associated with congenital adrenal hyperplasia has been successful, with improved ability to detect its presence prenatally. As techniques evolve to correct underlying disease processes,it becomes important to assess the therapies critically, particularly with long-term outcome data.
Adrenal Hyperplasia, Congenital↗
Initial management of complex urological disorders: bladder exstrophy.
Bladder exstrophy is a rare condition associated with lifelong issues including infection,renal insufficiency, incontinence, and fertility. Despite its seriousness, many affected children lead normal lives. With new operative techniques, children require fewer surgeries and have more hope for continence. With close follow-up, no child should develop renal insufficiency. Families should be reassured that a normal life and parenthood with normal sexual function are possible.
Animals↗
Experience with testis sparing surgery for testicular teratoma.
PURPOSE: Testicular teratoma is a rare neoplasm affecting the pediatric population and has classically been reported to be the second most common testis tumor in children behind yolk sac tumors. Testicular teratomas are benign and partial orchiectomy may be considered. We describe our single institution experience with testicular teratoma and definitive treatment with testis preserving surgery. MATERIALS AND METHODS: We reviewed the pathology records at our institution for all testicular and paratesticular tumors diagnosed between 1976 and November 2002 in males younger than 18 years. We specifically examined the prepubertal incidence of teratoma, including epidermoid cysts, and our experience with testis preserving surgery. Preoperative and postoperative ultrasonography images were used to calculate the atrophy index following surgery. Patients were contacted for long-term followup. RESULTS: Of 77 primary testicular and paratesticular tumors 38 were diagnosed in prepubertal boys (age younger than 13 years) including 11 mature teratomas and 5 epidermoid cysts. Mean patient age at treatment was 34.4 months (range 4 months to 10 years). All boys presented with a painless scrotal mass, cystic foci within an intratesticular mass on ultrasound and a normal alpha-fetoprotein level. Of the 16 boys with benign teratomas 13 (81%) were treated with a testis sparing procedure. At a mean 7-year followup no patient has presented with recurrent tumor in the ipsilateral or contralateral testicle. Postoperative physical examination and scrotal ultrasound were obtained in 9 patients at a median followup of 10.2 months, and there was no evidence of testicular atrophy or persistent discomfort. CONCLUSIONS: Unlike previously published series based on tumor registries, benign teratoma was the most common pediatric testicular tumor treated at our institution. Our single institution experience with testis preservation and long-term followup confirms the role and safety of this technique. Testis sparing surgery remains our technique of choice for testicular teratoma.
Child↗
Juvenile granulosa cell tumor of the testis:: contemporary clinical management and pathological diagnosis.
PURPOSE: Juvenile granulosa cell tumor (JGCT) of the testis is a rarely diagnosed subset of testicular stromal tumors. Although this variant of testicular stromal tumor is predominantly a benign entity in prepubertal patients, limited experience precludes a complete understanding of its clinical presentation and pathological diagnosis. MATERIALS AND METHODS: We reviewed all cases of testicular tumors at Children's Hospital of Philadelphia between 1976 and 2002 in males younger than 18 years. We specifically reviewed our experience with JGCT in terms of presentation, surgical treatment and long-term outcome. We also reviewed the microscopic findings and histochemical techniques used to confirm the diagnosis. RESULTS: We identified 77 tumors during the defined interval, of which 3 (3.9%) were JGCTs. All 3 patients with JGCT were first noted to have a testis mass soon after birth. All presented with a firm, unilateral testicular mass. Ultrasonographic findings were consistent with a complex, multiseptated, hypoechoic mass. Two of the 3 patients underwent radical orchiectomy. Testis sparing mass excision was performed in 1 patient. Grossly the tumors were partially cystic masses. Histologically positive immunostaining with inhibin-alpha and negative staining for alpha-fetoprotein (AFP) reliably differentiated JGCTs from yolk sac tumors. At a mean followup of 8.5 years (range 5 to 14) no metastases or local tumor recurrences have been diagnosed. CONCLUSIONS: To our knowledge we report the first case of testis sparing enucleation of a JGCT with a 5-year recurrence-free followup. Testis sparing enucleation is now our procedure of choice for tumors in neonates and prepubertal children with serum AFP in the normal range for age. JGCT should be suspected in neonates presenting at birth with a complex, cystic mass of the testis. Positive immunostaining for inhibin-alpha and a lack of AFP staining have consistently corroborated the pathological diagnosis in our experience and they should be applied for pediatric testis tumors that may mimic yolk sac tumor pathology.
Adolescent↗
Giant bladder diverticula causing bladder outlet obstruction in children.
PURPOSE: Congenital giant diverticulum of the bladder is a consequence of deficiency in the detrusor musculature and has been reported in male infants as a rare cause of bladder outlet obstruction. MATERIALS AND METHODS: A 10-year retrospective review revealed 4 patients (3 boys and 1 girl) with bladder outlet obstruction due to a giant bladder diverticulum. Prenatal and postnatal clinical and imaging records were reviewed. RESULTS: Prenatal sonography was unremarkable in all patients. Three males (ages 4 months, 10 months and 3 years) had no medical history of voiding dysfunction, and 1 female (11 years) had the Ehlers-Danlos syndrome. While the girl presented with urinary tract infection, all patients presented with progressively decreasing urinary stream and urinary retention. Each patient underwent voiding cystourethrography (VCUG) and ultrasound. In each patient VCUG showed a giant (greater than 7 cm) bladder diverticulum that descended below the bladder neck and compressed the urethra during voiding. Vesicoureteral reflux was seen in 2 patients. Ultrasonography demonstrated moderate unilateral hydronephrosis in 2 patients. Bladder diverticulectomy was successfully performed in all patients, with ureteral reimplantation in 3. CONCLUSIONS: A giant congenital bladder diverticulum, when noted on VCUG to descend below the bladder neck, may lead to bladder outlet obstruction. To our knowledge we report the first case of a female presenting with bladder outlet obstruction due to a giant bladder diverticulum. Children with connective tissue disorders may be predisposed to this disorder, which must be excluded, regardless of gender, in all patients presenting with voiding abnormalities. Surgical diverticulectomy, often with ureteral reimplantation, is the preferred treatment, with excellent long-term results.
Child↗
Blunt renal injuries in children can be managed nonoperatively: outcome in a consecutive series of patients.
BACKGROUND: Nonoperative management of radiographically defined solid organ injuries has proven highly successful in children with blunt splenic and hepatic injuries. The role of nonoperative management protocols is less well defined for blunt renal injuries. The purpose of this study was to review the management and outcome of a consecutive series of children with blunt renal injury. METHODS: The trauma registry from a Level I pediatric trauma center was reviewed to identify all children (age < 19 years) who were treated for a blunt renal injury for the period January 1995 through December 2002. Demographic, anatomic, physiologic, management, and outcome data were analyzed. RESULTS: For the 8 years of review, 101 children with a blunt renal injury were identified, including 95 with accessible and complete data. The renal injury population had a mean age of 10.4 years (range, 0.5-18 years) and was 72.6% male. The renal injuries were distributed as follows: grade 1, n = 22; grade 2, n = 40; grade 3, n = 20; grade 4, n = 11; and grade 5, n = 2. Hematuria was present in 88.1% of children (in whom urinalysis results were available). Four children had underlying congenital renal anomalies. The mean hospital length of stay and intensive care unit stay were 6.0 and 2.6 days, respectively. Overall, 5 children (5.3%) required laparotomy, including 1 nephrectomy (isolated grade 4 injury) and 1 renorrhaphy, for an overall renal salvage rate of 98.9%. In children with isolated renal injuries (n = 48), one child (2.1%) required laparotomy. Seven children required adjunctive urologic procedures (ureteral stenting, n = 5; cystoscopy/cystogram, n = 2). There were seven deaths (7.4% overall; five because of head injury and two because of severe abdominal bleeding at presentation). CONCLUSION: A nonoperative management strategy was advantageous and successful in pediatric blunt renal injuries (94.7% successful nonoperative rate, 98.9% renal salvage rate). Adjunctive urologic procedures (e.g., ureteral stenting) were beneficial in selected cases.
Adolescent↗