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Biomedical subjects

R C Rink

Publications and source records attributed to R C Rink.

At least 19 recordsLinked to original sources
PubMed2001

Shunt infection and malfunction after augmentation cystoplasty.

PURPOSE: Maintenance of a sterile intraperitoneal environment is critical in patients with ventriculoperitoneal shunts. Recent series have reported a broad discrepancy in the rate of shunt infection (0% to 20%) following augmentation cystoplasty. The need for distal shunt revision has not been well defined. We report the incidence of shunt infection and revision at our institution after bladder augmentation. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients with myelodysplasia and a ventriculoperitoneal shunt who underwent augmentation cystoplasty since August 1990. All patients included in the study had a minimum of 12 months of followup. RESULTS: A total of 55 patients with a ventriculoperitoneal shunt secondary to myelodysplasia required augmentation cystoplasty for management of a neuropathic bladder. Standard perioperative intravenous and oral antibiotic preparation, mechanical bowel preparation and intraoperative shunt isolation were used. Mean postoperative followup was 60.4 months (range 12 to 111). One patient presented with an extruded peritoneal shunt tip and positive cultures from cerebrospinal fluid and urine. Bladder perforation occurred in 2 patients and the shunt was empirically externalized. Revision was required for 5 (9%) distal shunt obstructions, including 1 cerebrospinal fluid pseudocyst. CONCLUSIONS: The incidence of shunt infection after augmentation cystoplasty is low (less than 2% in this large series), and presence of a ventriculoperitoneal shunt should not preclude bladder augmentation. Meticulous perioperative and intraoperative preparation contributes to the low rate of adverse events. Although the rate of distal revision after augmentation is significant, it does not exceed the reported distal failure rate for ventriculoperitoneal shunts in children without a history of urological surgery.

Child↗
PubMed2001

Symptomatic ureteropelvic junction obstruction in children in the era of prenatal sonography-is there a higher incidence of crossing vessels?

OBJECTIVES: To determine whether prenatal sonography and early detection and correction of ureteropelvic junction obstruction (UPJO) has changed the incidence of crossing vessels as the etiology of obstruction in older children presenting with symptomatic UPJO. METHODS: We reviewed the medical records of all children and adolescents who underwent pyeloplasty for symptomatic UPJO between 1986 and 1999, during the era of widespread use of prenatal sonography. Operative notes were used to determine which patients had obstruction due to lower pole crossing vessels. RESULTS: Thirty-eight patients were identified who underwent pyeloplasty for symptomatic UPJO. Lower pole vessels were identified in 22 (58%) of 38 patients (P <0.0001 compared with historical controls). All patients underwent dismembered pyeloplasty and remained asymptomatic after surgery, with renal scans demonstrating excellent drainage and preservation of function. CONCLUSIONS: Prenatal ultrasonography has increased the incidence of crossing vessels as the etiology of UPJO in young children and adolescents presenting with symptomatic UPJO compared with the historical incidence of 11% to 15%. This finding may impact treatment recommendations with respect to endourologic management of the obstruction in this patient population. Currently, we recommend open dismembered pyeloplasty for young children and adolescents presenting with symptomatic UPJO.

Child↗
PubMed2001

Ureterocele prolapse-rare presentation in an adolescent girl.

Ureterocele prolapse is a rare presentation of single system ureteroceles and is usually found early in childhood. We present a rare case of recurrent prolapse of a single system ureterocele that did not present until the patient was 17 years of age.

Adolescent↗
PubMed2001

Multi-institutional experience with the gastrointestinal composite reservoir.

PURPOSE: We evaluated multi-institutional experience with the gastrointestinal composite reservoir in patients with metabolic acidosis, the short bowel syndrome, severe pelvic radiation and/or renal insufficiency. MATERIALS AND METHODS: At 4 institutions 33 patients underwent construction of a gastrointestinal composite reservoir, including 19 with the short bowel syndrome, 13 with metabolic acidosis and 7 who also had renal insufficiency. A total of 16 patients underwent conversion of a previous diversion and the remaining 17 received new urinary diversion. Charts were reviewed for the metabolic impact of the gastrointestinal reservoir as well as any long-term sequelae. RESULTS: At a mean followup of 54 months there was a significant (p < or =0.05) improvement in mean preoperative and postoperative serum chloride (106 versus 102 mEq./l.), serum bicarbonate (23.3 versus 25 mEq./l.) and serum pH (7.36 versus 7.4). Mean serum creatinine did not significantly differ during followup in patients with normal renal function or renal insufficiency. Complications were not different than those of standard intestinal or gastric reservoirs. CONCLUSIONS: The gastrointestinal reservoir has provided an excellent metabolic balance in a large series of compromised patients with few side effects. We believe that the gastrointestinal composite reservoir represents the urinary diversion of choice when standard intestinal urinary reservoirs cannot be created in the setting of metabolic acidosis, the short bowel syndrome and severe pelvic radiation. However, the value of the gastrointestinal composite in the setting of renal insufficiency remains undetermined.

Acidosis↗
PubMed2000

Abdominal wall hernia: an uncommon complication of in utero vesicoamniotic shunt placement.

Three cases are reported in which placement of a vesicoamniotic shunt in utero for the treatment of obstructive uropathy led to the rare complication of abdominal wall hernia. All 3 patients underwent vesicoamniotic shunt placement for severe oligohydramnios and a markedly dilated bladder in an effort to preserve renal function and to prevent pulmonary hypoplasia. All three shunts were initially placed at or above the umbilicus. The abdominal wall hernias were closed postnatally at the time of temporary vesicostomy for urethral obstruction. All 3 patients had sufficient pulmonary development, but 2 of 3 had renal failure, requiring dialysis. Management and potential etiology of this rare complication are discussed.

Amnion↗
PubMed2000

Nephrostomy tube drainage with pyeloplasty: is it necessarily a bad choice?

PURPOSE: Despite continued controversy regarding the optimal method of urinary diversion after dismembered pyeloplasty in children, we have treated the majority of our patients with postoperative nephrostomy tubes and no stents. We report our experience. MATERIALS AND METHODS: The records of all patients who underwent surgery for ureteropelvic junction obstruction from August 1985 to October 1998 and were treated only with a nephrostomy tube after pyeloplasty were reviewed for hospital course, complications and postoperative followup. All patients had a perinephric Penrose drain as well as a Foley catheter placed for bladder drainage. RESULTS: A total of 137 pyeloplasties were performed in 132 patients, including 5 with bilateral ureteropelvic junction obstruction, using only nephrostomy tube drainage with an average followup of 2.1 years. Initial nephrostograms demonstrated good drainage across the repair with no extravasation in 91% of patients. Subsequent nephrostograms revealed a widely patent anastomosis in the remaining cases. No patient had postoperative obstruction, or required secondary pyeloplasty or nephrectomy. Urinary tract infection developed in 2 patients (1.5%). Mean hospitalization was 4.4 days. There was a significant difference in length of stay in the last 5 years compared to that in previous years (3.4 versus 5.8 days, p <0.05) and hospital stay continues to decrease. CONCLUSIONS: Use of only a nephrostomy tube after pyeloplasty resulted in few complications and an open anastomosis in 100% of cases. Nephrostomy drainage not only serves as a protective mechanism, but also allows easy access for radiographic studies before removal of the tube. In addition, nephrostomy tube drainage does not prolong hospitalization and the tube may be easily removed on an outpatient basis without further anesthesia.

Child↗
PubMed2000

Genitourinary rhabdomyosarcoma. Treatment options.

Dramatic improvements have occurred in the treatment and prognosis of the child with rhabdomyosarcoma over the past 2 decades. Increased understanding of tumor behavior has improved survival and focused attention on important quality of life issues. Future therapeutic advances will depend largely on an improved molecular understanding of altered cell behavior and the continued efforts of multi-institutional studies.

Child↗
PubMed2000

How well do patients with exstrophy actually void?

PURPOSE: Achieving continence and preserving renal function are goals in the care of patients with bladder exstrophy. The Young-Dees-Leadbetter bladder neck reconstruction should ideally provide continence and normal voiding dynamics without the need for intermittent catheterization. We review our experience with bladder neck reconstruction in this population with emphasis on voiding dynamics among those patients doing well. MATERIALS AND METHODS: We retrospectively analyzed all patients with the exstrophy-epispadias complex seen at our institutions since 1985. We reviewed staged reconstruction in 53 patients, including 31 with classic bladder exstrophy, 4 with exstrophy variants and 18 with incontinent epispadias. Patients with additional neurogenic dysfunction were excluded from study. Subjective and objective data regarding voiding function and complications were collected. RESULTS: Complete reconstruction for continence was performed in 38 cases, of which 11 that required bladder augmentation with bladder neck reconstruction or who had a different primary continence procedure were excluded from study. The remaining 27 patients treated with the Young-Dees-Leadbetter bladder neck reconstruction had 2 or more years of followup (mean 5.9). Dry intervals of at least 2 hours were achieved by 18 patients and all were considered by parents to void well. Despite near or total subjective continence and "good" voiding, 13 of these 18 patients (72%) have clinical problems related to emptying, which include recurrent urinary tract infections in 10, epididymitis in 2 and bladder calculi in 4. Objective urodynamic parameters confirm poor voiding in most patients. CONCLUSIONS: Bladder neck reconstruction in patients with exstrophy can achieve continence without intermittent catheterization. In our experience patients who achieve these goals have an alarming frequency of clinical and urodynamic problems related to emptying. One must question the normalcy of the voiding pattern and price to achieve continence among patients with exstrophy.

Bladder Exstrophy↗
PubMed2000

Y-to-I wrap: use of the distal spongiosum for hypospadias repair.

PURPOSE: Rather than resecting the distal spongiosum lateral to the open urethra for hypospadias, we mobilized this tissue with the urethral plate away from the corpora cavernosa, subsequently wrapping it around various types of urethroplasty to prevent fistula formation. MATERIALS AND METHODS: The distal spongiosum was preserved and used for coverage in 25 hypospadias repairs in 1 year. We initially applied it in this manner when the distal spongiosum persisted as a pillar of healthy erectile tissue but later when the distal tissue appeared more fibrous in nature. The wrap was used to cover various types of urethroplasty, including advancement in 6 cases, tubularization in 10, flip-flap repair in 6 and an island onlay pedicle graft in 3. RESULTS: All patients have at least 1 year of followup. There has been no fistula formation or residual chordee. In 1 patient minor meatal retraction did not require a secondary procedure. Cosmetic results have been good. CONCLUSIONS: A distal wrap of corpus spongiosum may be used to avoid fistula formation without causing residual or recurrent curvature. It re-creates a nearly normal urethra in some cases.

Adolescent↗
PubMed1999

Congenital dorsal penile curvature: a potential problem of the long phallus.

PURPOSE: We report the results of surgical correction of severe congenital dorsal penile curvature associated with a long slender phallus. MATERIALS AND METHODS: In the last 7 years we treated 16 boys with a mean age of 2 years 10 months who had severe dorsal penile curvature. The series included 5 patients with megameatus variant hypospadias and a full foreskin, 3 who presented with hypospadias and 8 who were referred when dorsal penile curvature was noticed by the family or primary physician. Mean penile length was 6.5 cm. without stretching. In each case length was greater than 2 standard deviations above the mean for patient age. Penile circumference decreased from a mean of 4.2 cm. at the base of the shaft to 4.1 cm. at the mid shaft and 3.7 cm. at the corona. Penile circumference was generally normal for patient age until corrected for length, when it was revealed to be small. Surgical correction of severe curvature was performed in 14 patients, while 2 who presented as newborns had remarkable spontaneous improvement in the first year of life. In each case curvature was due to corporeal disproportion. RESULTS: All patients have erections postoperatively. There has been no residual or recurrent curvature and cosmetic results are good. CONCLUSIONS: Congenital dorsal penile curvature is a potential problem of the long phallus. In severe cases surgical repair improves the appearance of the penis but it must also address the problem of corporeal disproportion.

Child↗
PubMed1999

alpha-Adrenergic blockade in children with neuropathic and nonneuropathic voiding dysfunction.

PURPOSE: Inadequate bladder emptying is a common urinary dysfunction in children. The role of alpha-blockers for managing bladder outlet obstruction remains relatively unexplored in children. Because of the well established impact of alpha-blocker therapy in men, we investigated its use for treating inadequate bladder emptying in the pediatric population. MATERIALS AND METHODS: We treated 17 children 3 to 15 years old with documented poor bladder emptying of various etiologies, including dysfunctional voiding, the Hinman syndrome, the lazy bladder syndrome, posterior urethral valves, myelomeningocele and the prune-belly syndrome, using the alpha-1 adrenergic receptor antagonist, doxazosin. The initial dose of 0.5 to 1.0 mg. nightly was increased according to patient response and as tolerated. Patients were followed weekly to monthly by symptomatic history, and urine flow and/or post-void residual urine volume measurement. Two patients with neurogenic bladder were also followed with cystometrography and leak point pressure determination. RESULTS: Bladder symptomatology and/or emptying improved in 14 patients (82%). Ten patients had decreased post-void residual urine during treatment and in 3 uroflowmetry showed increased maximum flow. Two patients with neuropathic bladder secondary to myelomeningocele had decreased leak point pressure on alpha-blocker therapy and in 2 with a history of posterior urethral valves new onset bilateral hydronephrosis completely resolved. Only 1 patient had mild postural hypotension, which resolved with dose reduction. CONCLUSIONS: Selective alpha-blocker therapy seems to be well tolerated in children and appears effective for improving bladder emptying in various pediatric voiding disorders at short-term followup. Long-term followup and further investigation are warranted to validate the potential role of alpha-blocker therapy in pediatric urinary dysfunction.

Adolescent↗
PubMed1999

The gastrointestinal composite urinary reservoir in patients with myelomeningocele and exstrophy: long-term metabolic followup.

PURPOSE: We investigated the long-term metabolic effects of gastrointestinal composite urinary reservoirs in patients with myelomeningocele or exstrophy. MATERIALS AND METHODS: Seven patients with myelomeningocele or exstrophy who required complex urinary reconstruction in the setting of metabolic acidosis or the short bowel syndrome underwent construction of a gastrointestinal composite reservoir, including a staged and a single procedure in 3 and 4, respectively. Preoperatively and postoperatively serum electrolytes were measured, and urinalysis and urine cultures were performed in all patients. In 5 patients serum pH was compared preoperatively and postoperatively, and in all serum gastrin was measured postoperatively. RESULTS: At an average followup of 62 months (range 52 to 87) serum chloride and bicarbonate significantly normalized (p <0.05) in all 7 patients with bladder exstrophy or myelomeningocele. Serum pH also significantly normalized (p <0.05) in 5 patients at long-term followup. Serum gastrin and creatinine were normal and urinary pH fluctuated insignificantly throughout followup. None of the patients had urolithiasis or symptoms of the hematuria-dysuria syndrome. Periodic symptomatic urinary tract infections developed but none required chronic antibiotic therapy. CONCLUSIONS: Gastrointestinal composite urinary reservoirs appear to be beneficial for patients with myelomeningocele or exstrophy who have preexisting metabolic acidosis or the short bowel syndrome. Serum electrolyte neutrality is achieved during long-term followup. No patient had the hematuria-dysuria syndrome or urolithiasis.

Adult↗
PubMed1999

Concealed penis in childhood: a spectrum of etiology and treatment.

PURPOSE: Concealed penis is an uncommon condition due to poor skin fixation at the base of the penis, cicatricial scarring after penile surgery and excessive obesity. The condition varies in severity and several surgical options are available, such as excision of previous scarring, degloving the penile shaft, reconstructing the penile shaft skin with flaps, fixing the penile skin at the penopubic and penoscrotal angles, and removing excess suprapubic fat. MATERIALS AND METHODS: We reviewed the records of 43 patients treated for concealed penis from 1993 to 1998. We categorized the cases as type 1-congenital concealed penis, type 2-concealed penis due to scarring from previous surgery and type 3-complex cases involving excessive obesity. Cases were reviewed in regard to surgical techniques and outcomes. We identified 18 type 1, 18 type 2 and 7 type 3 cases. Mean age of type 1 patients at surgery was 12.4 months with 1 patient presented at age 7 years. None had previously undergone penile surgery. All patients underwent complete penile degloving. To reconstruct the penile shaft flaps or Z-plasties with penile skin were used in 12 patients and scrotal skin flaps were used in 2. In 12 patients the penile skin was fixed at the penoscrotal and penopubic angles to maintain penile length and in 2 excess fat was excised. Mean age of type 2 patients at surgery was 19.8 months. All had previously undergone surgery, including hypospadias in 1 and circumcision in 17. All patients underwent complete penile degloving and the cicatricial scar that trapped the penis was excised. Penile skin flaps and Z-plasties were used in 12 cases, scrotal skin flaps were used for reconstruction in 2 and skin grafting was done in 1. In 10 patients the penile skin was fixed with sutures to maintain penile length. Mean age of type 3 patients at surgery was 15.8 years. Of the 7 boys 6 had previously undergone penile surgery. All required extensive scar excision and complex reconstruction involving penile skin flaps in 3, scrotal flaps in 5 and penile skin fixation in 6. Excessive suprapubic fat was removed in 5 patients, of whom 3 underwent liposuction. RESULTS: Surgical results were uniformly good in type 1 patients except in 1 who was believed to have excessive suprapubic fat. Results were good in 14 of the 18 type 2 patients, although 2 retained excessive suprapubic fat and 2 had some unsightly scarring. No type 1 or 2 patient required additional surgery. Of the 7 type 3 patients 6 had a good result and required no additional surgery. One patient has recurrent concealed penis after 2 procedures and awaits additional surgery. CONCLUSIONS: Concealed penis has a varied etiology and requires a flexible surgical approach. The common surgical options in all cases include complete penile degloving, excising the scarring due to previous surgery, removing excess suprapubic fat, reconstructing the penile skin with local flaps, and fixing the penile skin at the penopubic and penoscrotal angles.

Child↗
PubMed1999

Appendicovesicostomy and newer alternatives for the Mitrofanoff procedure: results in the last 100 patients at Riley Children's Hospital.

PURPOSE: We present our experience using the various Mitrofanoff techniques to create a continent catheterizable stoma as an adjunct to continent urinary tract reconstruction in children and young adults. MATERIALS AND METHODS: Between 1990 and 1998 a Mitrofanoff procedure was performed at our institution in 55 male and 45 female patients with a mean age of 10.5 years. The etiology of incontinence was diverse but more than 90% of the patients had neurogenic bladder, the epispadias-exstrophy complex or a cloacal anomaly. Surgery included appendicovesicostomy in 57 cases, a Yang-Monti ileovesicostomy in 21, continent vesicostomy in 21 and formation of a tapered ileal segment as a catheterizable channel in 1. Simultaneously bladder augmentation was performed in 52 patients, bladder neck reconstruction was done in 48 and a Malone antegrade colonic enema stoma was constructed for fecal incontinence in 17. RESULTS: The abdominal stoma is continent in 98 of our 100 patients. Mean followup is 2 years (range 2 months to 8 years) with the longer followup in the appendicovesicostomy group. One patient with stomal incontinence who underwent revision is now dry. Postoperative complications requiring an additional procedure developed in 20 patients, including stomal stenosis in 12. Continent vesicostomy was most prone to stomal problems (6 of 21 patients, 29%). CONCLUSIONS: The Mitrofanoff procedure is a reliable technique for creating a continent catheterizable urinary stoma. Appendicovesicostomy continues to be our first option for this procedure, although we have also had good results with the Yang-Monti ileovesicostomy and continent vesicostomy. These newer options have allowed preservation of the appendix for the Malone antegrade colonic enema stoma procedure in patients with urinary and fecal incontinence.

Adolescent↗
PubMed1999

Vaginal stenosis and hydrometrocolpos: late complication of inadvertent perivaginal placement of an artificial urinary sphincter in prepubertal girls(1).

Urinary incontinence in pediatric and adolescent patients has been successfully managed with the artificial urinary sphincter for several decades. Placement of the sphincter can be difficult in the preadolescent girl due to poorly developed vaginal tissue that can result in difficulty establishing the surgical plane between the bladder and vagina. We report 2 patients in whom the sphincter was placed around the urethra and vagina, a complication that has been reported in only 1 patient previously. All 3 patients presented with hematometrocolpos and bloody vaginal discharge. All were successfully managed with replacement of the sphincter cuff around the urethra and delayed vaginoplasty.

Adolescent↗
PubMed1999

Repair of hypospadias complications using the previously utilized urethral plate.

OBJECTIVES: To review our results of patients who underwent repeat hypospadias surgery using local skin flaps with preservation of the urethral plate. METHODS: We retrospectively reviewed the medical records of all patients who underwent a reoperative hypospadias repair using the urethral plate between 1988 and 1996. A total of 53 patients were identified who developed either a large fistula (47 patients) or severe stricture (6 patients) after the initial repair. Seventeen patients underwent a repeat Mathieu flip-flap and 36 an onlay flap. The mean age at the time of surgery was 5.2 years (range 1 to 27). The mean duration of follow-up was 17 months (range 6 to 108). RESULTS: The initial failed hypospadias repair was corrected with a single procedure in 44 (83%) of the 53 patients. The 9 patients who had further complications required 17 additional procedures. A meatal-based flap had been used in 4 of these patients and an onlay flap in 5. Three of the 9 patients who had further complications presented with urethral strictures after the previous repair. CONCLUSIONS: Fistula and stricture are common complications of hypospadias surgery. The use of the urethral plate in primary repairs has helped decrease the complication rate. We report the effectiveness of using local skin flaps and preserving the urethral plate in complex reoperative hypospadias surgery. These techniques were successful in 83% of these challenging patients. Patients with stricture after hypospadias surgery are at increased risk of further complications.

Adolescent↗
PubMed1999

Bladder augmentation. Options, outcomes, future.

Remarkable progress has been made in lower urinary tract reconstruction in children. Nowhere is this more valuable than in augmentation cystoplasty, where there are several available options. This article discusses the current techniques and the benefits and limitations of these procedures. A section on tissue regeneration techniques and the author's current recommendations are included.

Child↗