Biomedical subjects

Paul A Merguerian

Publications and source records attributed to Paul A Merguerian.

7 recordsLinked to original sources

PubMed2006

Voiding ability using propofol sedation in children undergoing voiding cystourethrograms: a retrospective analysis.

PURPOSE: The ability of a child to void during cystourethrography is important in detecting vesicoureteral reflux. The potential effect of sedation on the capacity to void may impair our ability to detect vesicoureteral reflux. Since 2001, most voiding cystourethrograms at our institution have been performed with moderate sedation using propofol. To assess the impact of sedation on the ability of children to void, we retrospectively evaluated a group of patients who underwent sedated voiding cystourethrograms and compared them to a group undergoing nonsedated voiding cystourethrograms. MATERIALS AND METHODS: The nonsedated group consisted of children 2 to 8 years old who underwent voiding cystourethrography between 1996 and 2001. The sedated group consisted of children the same age who underwent voiding cystourethrography between 2002 and 2004. Patient characteristics, presenting symptoms, bladder capacity, emptying ability and diagnoses were recorded. Children were categorized as receiving sedation vs not receiving sedation. All sedated children received propofol deep sedation. Statistical analyses were performed using the 2-sided t test and Fisher's exact test. RESULTS: Of 544 charts reviewed 287 were within the age range defined. Of these children 85% were female. Sex was evenly matched between the sedated and nonsedated groups. Urinary tract infections (65%) and previous vesicoureteral reflux (25%) were the most common factors prompting voiding cystourethrography. Sedation was administered in 146 patients, of whom 80 (55%) were able to void to completion. Of the 141 patients who did not receive sedation 125 (89%) were able to void to completion (p <0.001). CONCLUSIONS: Children who underwent voiding cystourethrography with sedation were less likely to void to completion. This finding may impair our ability to detect vesicoureteral reflux in children accurately. Large prospective studies are needed for better assessment of bladder emptying and sedation when performing voiding cystourethrography.

Child↗

PubMed2006

A meta-analysis of surgical practice patterns in the endoscopic management of ureteroceles.

PURPOSE: We examined the contribution of patient features on reoperation after transurethral incision or puncture in children with ureteroceles. MATERIALS AND METHODS: A systematic review was accomplished using Medline and article bibliographies to obtain articles related to endoscopic management of ureteroceles in English, Spanish, Italian, French and Japanese. Exposures of interest were ureterocele position and anatomy, and preoperative reflux. The outcome was secondary operation. Meta-analysis was done using Mantel-Haenszel calculations. RESULTS: Meta-analysis of 10 studies demonstrated that ectopic ureteroceles are associated with significantly greater reoperation rates than intravesical ureteroceles in patients undergoing ureterocele incision. This remains true with longer followup and systematic ureterocele incision/puncture, in neonates and in patients with single and duplex collecting systems. In addition, a meta-analysis of 3 studies showed that patients with duplex system ureteroceles are more likely to require subsequent operation. A third meta-analysis of 7 studies showed that preoperative reflux increases the risk of reoperation after ureterocele incision. More than 1 risk factor did not appear to increase the risk of secondary operation. CONCLUSIONS: To our knowledge this is the first systematic review of endoscopic ureterocele management. It suggests that ectopic ureterocele location, duplex renal systems and preoperative reflux are proxies for trigonal anatomical distortion, rather than independent risk factors for a secondary operation after incision. Findings reinforce the importance of considering these variables when making management decision in children with ureteroceles.

Child↗

PubMed2004

Efficacy of continuous epidural analgesia versus single dose caudal analgesia in children after intravesical ureteroneocystostomy.

PURPOSE: We compared the effects of single dose caudal injection and continuous epidural infusion of bupivacaine on postoperative pain intensity and supplemental opioid analgesic requirements in children undergoing intravesical ureteroneocystostomy. MATERIALS AND METHODS: Children 6 to 18 years old scheduled for ureteroneocystostomy were recruited for the study. Patients were randomized to group 1--caudal injection of 0.25% bupivacaine before approximately surgical incision and group 2--placement of an epidural catheter with injection of 0.25% bupivacaine, followed by a continuous epidural infusion upon completion of surgery. All patients received intravenous morphine patient controlled analgesic (PCA) as a rescue analgesic, and ketorolac and oxybutynin postoperatively. The epidural catheter was discontinued 48 hours after surgery, with removal of the urinary drainage catheter 4 hours later. Outcome measures included pain intensity rating, supplemental morphine requirements, presence and pain intensity of bladder spasms, analgesia related side effects, time to tolerating a regular diet, and patient and parent satisfaction. RESULTS: There was no statistically significant difference in average daily pain scores between the 2 groups. In the postanesthesia care unit. Significantly more patients in the caudal group required morphine than in the epidural group (56% versus 11%). The total PCA demand was significantly greater in the caudal group on days 1 and 2 postoperatively. Patients in the caudal group took significantly longer to tolerate a regular diet than those in the epidural group. CONCLUSIONS: Continuous epidural analgesia and single dose caudal injection of bupivacaine in conjunction with intravenous morphine PCA and ketorolac provide adequate pain control following intravesical ureteroneocystostomy. Continuous epidural analgesia reduces the need for supplemental intravenous morphine and allows children to tolerate a regular diet earlier.

Analgesia, Epidural↗

PubMed2003

Pediatric genitourinary tumors.

Advances continue to be made in the evaluation and treatment of genitourinary tumors in children. Continued research on the cellular, molecular, and genetic process in tumorigenesis is rapidly evolving. We review the 2002 literature on pediatric genitourinary tumors. Molecular and cellular biology research continues to identify markers that may predict a worse prognosis. This identification will allow a more tailored approach with intensified treatment of aggressive tumors.

Age Factors↗

PubMed2003

Lower urinary tract reconstruction for duplicated renal units with ureterocele. Is excision of the ureterocele with reconstruction of the bladder base necessary?

PURPOSE: Current practice in reconstruction of the lower urinary tract for duplicated renal systems with an associated ureterocele is excision of the ureterocele with reconstruction of the bladder and a common sheath ureteroneocystostomy. For a nonfunctioning upper pole treatment is partial nephroureterectomy. We postulate that lower urinary tract reconstruction can be performed successfully through an extravesical approach without excision of the ureterocele or reconstruction of the bladder base. We present our experience with that approach. MATERIALS AND METHODS: Between 1996 and 2001, 60 patients presented with the diagnosis of ureterocele and obstruction of the upper pole ureter. Partial nephrectomy was performed in 12 cases of which 4 had reflux to the lower pole moiety. Upper pole only dismembered ureteroneocystostomy was performed in 7 of 15 cases reconstructed using the extravesical approach. RESULTS: Average postoperative stay was 3.7 days. The Foley catheter was removed within 24 to 48 hours. Postoperative ultrasound showed decompression of the obstructed system and the ureterocele. Reflux was corrected in all patients. Flow rate with measurement of post-void residual 6 weeks postoperatively in toilet trained children showed complete bladder emptying. CONCLUSIONS: Lower urinary tract reconstruction for duplicated renal systems with obstruction of the upper pole can be accomplished safely with decreased morbidity through the extravesical approach without excision of the ureterocele or reconstruction of the bladder base. Moreover, in instances when there is no reflux to the lower pole moiety, upper pole only extravesical ureteroneocystostomy can be performed.

Child↗

PubMed2003

Safety and efficacy of extracorporeal shock wave lithotripsy in infants.

PURPOSE: Extracorporeal shock wave lithotripsy (ESWL) in older children appears to have comparable results when compared to adults, no study has focused on its use in younger children. We reviewed our ESWL experience in children under age 3.5 years to evaluate its safety, and define optimal treatment parameters. METHODS: We retrospectively reviewed consecutive medical and diagnostic imaging records from three ESWL centers, pertaining to 34 children under 3.5 years of age (36 renal units-RU). The children were from two distinct populations served exclusively by the three centers. We analyzed patient presentation, etiology, age, weight, stone size, preoperative interventions, energy settings, number of shock waves, number of treatments, success (stone fragments < 2 mm), and complications. We performed all forty-nine procedures under general anesthesia and modified the Dornier MFL 5000 table and the Dornier HM3 gantry to improve coupling and localizing of the calculi. RESULTS: In each population, we noted similar presentations, etiologies, and treatment parameters. Patient age ranged from 6 to 40 months (mean 23.4 months). Stone size ranged from 4 mm to 22 mm diameter (average 13 mm). ESWL parameters included an average of 2210 shocks (range 900-3400) at average of 20.9 kV (range 19 kV-25 kV). Preoperative ureteral stent placement was not shown to be beneficial. Our one and multiple treatment ESWL success rates were 66% and 86%, respectively. No major acute or long-term complications occurred. CONCLUSIONS: We successfully performed ESWL using treatment parameters similar to adults in 86% of children under 3.5 years without major complications. Modifications of the positioning device improved coupling and localization in smaller patients. Routine preoperative ureteral stenting for large stones is not recommended.

Child, Preschool↗

PubMed2002

Pediatric genitourinary tumors.

Each year advances are made in the clinical evaluation and treatment of genitourinary tumors in children. Understanding of cellular, molecular, and genetic processes in tumorigenesis is evolving rapidly. In addition, information is accumulating about the long-term outcome and complications associated with treatment modalities. This article reviews the 2001 literature on pediatric Wilms tumor, other renal tumors, rhabdomyosarcoma of the pelvis, paratesticular rhabdomyosarcoma, and testicular tumors. The emphasis in molecular biology is to identify molecular or genetic markers that predict outcome. The National Wilms' Tumor Study Group reported on the complications of surgery and the decreased complication rate when these procedures are performed by pediatric surgical specialists. Long-term complications of treatment are also discussed, including short stature and leukemia. The Intergroup Rhabdomyosarcoma Study Group reported on the results of treatment for nonmetastatic disease and the goals of the upcoming Study V, reduction of chemotherapy and radiotherapy. They also presented data from Study IV and discussed the findings on improved prognosis.

Child↗