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Biomedical subjects

Saul P Greenfield

Publications and source records attributed to Saul P Greenfield.

12 recordsLinked to original sources
PubMed2005

Intractable high-pressure bladder in female infants with spina bifida: clinical characteristics and use of vesicostomy.

OBJECTIVES: To characterize the clinical characteristics of a group of children with neurogenic bladder, high leak point pressures (LPPs), bladder wall changes, and hydronephrosis in whom medical management failed, who then underwent vesicostomy. Medical management can, rarely, fail in children with neurogenic bladder, high LPPs, bladder wall changes, and hydronephrosis. When it does, surgical intervention is necessary. METHODS: Between 1988 and 2001, 8 girls with spina bifida (4 with thoracic and 4 with lumbosacral) underwent vesicostomy after medical management. All had undergone neonatal back closure and five had ventriculoperitoneal shunts. The mean follow-up after vesicostomy was 6 years. RESULTS: High-grade reflux was present at birth in 3 patients and developed later in 3 patients at 1 year. Two had undergone ureteral reimplantation before vesicostomy. Four girls had trabeculation at birth and it developed in three at 1 year and one at 3 years. Hydronephrosis was present at birth in 2 patients and developed later in 6. High LPPs were noted at younger than 10 months of age in 6 patients. Oral oxybutynin was begun in 7 patients before 1 year of age and 5 were later given intravesical oxybutynin. Six patients began clean intermittent catheterization in infancy. The indications for vesicostomy were persistently elevated LPPs and hydronephrosis. Six had recurrent urinary tract infections. The mean age at vesicostomy was 3 years. Hydronephrosis resolved in 7 patients, and only 1 had additional febrile urinary tract infections. Two underwent reversal along with bladder augmentation and were continent at last follow-up. CONCLUSIONS: A small subset of girls with spina bifida are unresponsive to early and intensive medical therapy. Most have high LPPs and bladder wall and upper tract changes early in infancy. Vesicostomy reverses the clinical course. At an appropriate age, these children can undergo reconstruction with a high likelihood of continence.

Cystostomy↗
PubMed2005

2-stage repair in infancy for severe hypospadias with chordee: long-term results after puberty.

PURPOSE: Urinary and sexual functions were assessed in post-pubescent boys who had undergone 2-stage hypospadias repair in infancy for severe hypospadias with chordee. MATERIALS AND METHODS: A total of 44 boys who had undergone 2-stage hypospadias repair from 1985 to 1993 and who were at least 13 years old were contacted. Of the 44 boys 27 (61%) with an average age of 15.4 years (range 13 to 21) responded. Meatal locations were midshaft in 14 cases, penoscrotal in 9 and perineal in 4. Four boys had bifid scrotum and 5 had intersex disorders. Intramuscular testosterone was administered preoperatively to 15 (56%) boys. A Nesbit procedure was performed in 18 boys (67%). Average patient age at stage 2 repair was 2.3 years. Mean followup was 12.7 years (range 10.7 to 17.2). Additional surgery was performed for diverticuli in 5 cases, fistula in 3 and minor strictures in 4. Of the 27 patients 25 presented for examination and 2 responded to questionnaire only. RESULTS: All patients had normal meatal position, normal glanular anatomy, a well-defined coronal sulcus, normal cylindrical shafts without extra skin and well-defined penoscrotal junctions. Ten boys (40%) had minor spraying of stream, all stood to void and 10 (40%) milked the urethra after voiding. None had chordee. Twenty patients were able to ejaculate and 9 (42.9%) had to milk the ejaculate. Two patients (7.7%) had minor pain with erection. All subjects were satisfied with urinary, erectile and ejaculatory functions, and 23 (92%) were pleased with appearance. CONCLUSIONS: The 2-stage approach for severe hypospadias results in excellent function, cosmesis and patient satisfaction after puberty, with no chordee. Minor voiding and ejaculatory problems are to be expected. Late complications are rare. The use of extragenital skin to either primarily repair or salvage a "cripple" has not been necessary.

Adolescent↗
PubMed2005

Pediatric stone disease: an evolving experience.

PURPOSE: The presentation and management of pediatric stone disease have changed due to early identification and treatment of congenital urological conditions, as well as technological advances. Therefore, we reviewed our 12-year experience. MATERIALS AND METHODS: A total of 123 patients with 158 stones presented from 1991 to 2003. The 46 boys and 77 girls were 8 months to 25 years old, including 5 boys (4%) younger than 3 years, 46 (37%) 4 to 12 years old and 72 (59%) older than 13 years. A 24-hour urine collection was done in 50 patients (41%) and serum chemistry studies were performed in 66 (54%). RESULTS: The seasons of presentation were fall in 41% of cases, summer in 24%, spring in 22% and winter in 13%. Of the patients 94 (76%) had loin pain, 10 (8%) had urinary tract infections, 13 (11%) had a history urinary tract infection, 18 (15%) had gross hematuria, 14 (11%) had structural urological abnormalities and 7 (6%) had neurogenic bladder. Metabolic abnormalities were uncommon and included hypercalciuria in 12%, hyperoxaluria in 2% and cystinuria in 2%. A total of 57 patients (46%) passed the stones and 34 (28%) underwent extracorporeal shock wave lithotripsy, of whom 24 (71%) became stone-free. Ureteroscopy was performed in 10 patients (8%) 6 to 19 years old, percutaneous nephrostolithotomy was done in 4 (3%) and 4 (3%) underwent open surgery. Stone analysis showed calcium based in 88% of the cases, struvite in 7% and cystine in 5%. CONCLUSIONS: The majority of patients had no congenital abnormalities. Early diagnosis of urological abnormalities and urinary infection, and appropriate management of neurogenic bladder may have reduced the incidence in those groups. Most stones are calcium based but occur in the absence of metabolic disturbances. More patients presented in the fall, perhaps reflecting the increased concentration of urine in the summer. Half of the patients passed the stones and shock wave lithotripsy was curative in most others. Ureteroscopy, percutaneous nephrostolithotomy and open surgery were rarely required.

Adolescent↗
PubMed2004

Tethered cord in children: a clinical classification with urodynamic correlation.

PURPOSE: Tethered cord was classified based on clinical presentation and correlated with urodynamic and uroradiographic findings. MATERIALS AND METHODS: A total of 54 children underwent cord untethering from 1993 through 2000. Preoperative magnetic resonance imaging, fluorourodynamics and renal ultrasound were performed in all cases, and postoperative (mean 16 months) fluorourodynamics was done in 33. The conus was at L-2 or lower, with or without a thickened filum in 51 patients and 3 older children with voiding dysfunction had normal cords. RESULTS: Children were classified into group 1-19 with orthopedic deformities (scoliosis or lower limb abnormalities, group 2-16 with cutaneous back lesions, group 3-13 with voiding dysfunction (VD) or urinary tract infection without cutaneous lesions and group 4-6 with associated syndromes. In group 1, 3 patients (16%) had preoperative hyperreflexia (HR) which improved postoperatively in 2, HR developed in 1, none had hydronephrosis or reflux (VUR), 5 (26%) had voiding dysfunction (VD) and 4 improved postoperatively. In group 2, 4 patients (25%) had preoperative HR and all improved postoperatively, and 5 (31%) had VUR and 2 improved postoperatively. In group 3, 11 patients (85%) had HR and 2 (15%) were areflexic preoperatively and 6 (areflexic 1, HR 5) improved postoperatively, 3 (23%) had VUR and 2 improved postoperatively, and 7 (54%) had improved VD but 5 (71%) were on anticholinergics. All 3 patients with VD/normal cords had preoperative HR, and 1 improved, 1 had preoperative VUR which resolved and 1 clinically improved but was on anticholinergics. In group 4, 5 patients (83%) had HR and 2 improved, 2 (33%) had VUR and both improved, and 3 (50%) had VD and 1 improved. CONCLUSIONS: Older children who present with orthopedic problems have rare neurourological abnormalities many of which resolve after surgery. Similarly, infants who are diagnosed early with a cutaneous back lesion can have urodynamic abnormalities, which also have a high rate of resolution. Older children who present with VD have the highest incidence of urodynamic abnormalities. While many seem improved clinically after surgery, they require anticholinergics. All patients with VATER's syndrome should be evaluated prospectively for tethered cord.

Child↗
PubMed2003

Two-stage repair for proximal hypospadias: a reappraisal.

Great advances have been made in surgery for the correction of hypospadias. Proximal hypospadias remains the greatest challenge, but, despite many innovations and much progress, surgery can fail. Many authorities have introduced single-stage techniques, which have the purported advantage of correcting the defect with minimal hospitalization and family inconvenience. However, the wider published experience with these approaches would suggest that the ideal single-stage procedure has yet to be devised. A substantial number of children undergoing a single-stage procedure will have to undergo further surgery. A small, but irreducible number of patients will be rendered hypospadias "cripples." A number of these children will be dissatisfied as adults because of cosmetic or functional deficiencies. A two-stage approach for correction of proximal hypospadias and severe chordee remains the most credible and reliable solution for many of these patients. Pediatric urologists should maintain familiarity with these techniques and continue to advocate them for a select group of patients.

Child↗
PubMed2003

Kidney and testicle injuries in team and individual sports: data from the national pediatric trauma registry.

PURPOSE: We define the risk of kidney or testicle injury in children who play contact sports. MATERIALS AND METHODS: National Pediatric Trauma Registry data from 50 United States pediatric trauma centers for 1990 to 1999 were analyzed. The data were from age groups 5 to 11, 12 to 14 and 15 to 18 years. Major abdominal injuries, injuries due to team and individual contact sports, and the site of injury were examined. RESULTS: Of the 81,923 cases 5,439 were sports related. Abdominal injuries occurred in 459 patients (0.56%), and were due to contact sports in 191. Team sports were involved in 184 cases, including football in 44%, hockey in 19%, baseball in 15%, soccer in 12% and basketball in 6%. Abdominal injury rate by age was 16% for 5 to 11-year olds, 42% for 12 to 14-year-olds and 42% for 15 to 18-year-olds. Most common was splenic injury at 50% of cases, kidney injuries occurred in 22% and no testicle injuries were reported. Football accounted for the most kidney injuries (62%). Kidney injuries were more common among older teenagers. No injuries led to nephrectomy. CONCLUSIONS: Abdominal injuries are rare in children who play team and individual contact sports. No testicular injuries were reported. Kidneys are most at risk in football. Splenic injuries are most common overall, although the risk to kidney and spleen is equal in basketball. No kidneys were reported as lost. These data should help families and schools when assessing risk to genitourinary organs during these activities.

Abdominal Injuries↗
PubMed2003

The incidence of recreational genitourinary and abdominal injuries in the Western New York pediatric population.

PURPOSE: We estimate the incidence of recreation related pediatric abdominal, testis and kidney injuries. MATERIALS AND METHODS: Trauma registry data at the regional pediatric trauma center for 1993 to 2000 were analyzed for recreational injuries. The data were divided into the 3 age groups of 5 to 11, 12 to 14 and 15 to 18 years. The recreation, and site and severity of injury were cross referenced. Injury incidence was calculated using United States census data. RESULTS: Of 4,921 children 34 boys and 2 girls (0.73%) had a genitourinary or abdominal injury due to recreation. Kidney injuries were the most common (44.4%), followed by spleen (36.1%) and liver (19.5%). No testicle injuries were reported. Skiing was the most common cause of injury (22.2%). Hockey, football, snowboarding, sledding and bicycling accounted for 83% of all injuries. There were no injuries related to basketball and soccer. The 12 to 14-year-old group had 50% of the injuries. Records were available for 15 kidney injuries, of which 11 were on the left side, 1 was bilateral, 3 required transfusion and 1 required nephrectomy. Injury grades were I in 2 cases, II in 5, III in 4, IV in 3 and V in 1. Kidney and spleen injury incidence due to recreation per year per million children was 6.9 and 5.6, respectively. CONCLUSIONS: Kidney injuries were more common than spleen injuries. Skiing, sledding and snowboarding accounted for more injuries than team sports. Testicle injuries were not seen and are rare. Basketball and soccer caused no injuries. Middle school-age children appear to be at greatest risk.

Abdominal Injuries↗
PubMed2003

Vesicoureteral reflux--current treatment options.

Vesicoureteral reflux has long been recognised as a major child and public health problem. Widespread recognition and screening of at-risk populations has the potential to significantly reduce long-term morbidity in both children and adults. Advances in pharmacotherapy, materials science and surgery, have caused many experts to reassess established dictums of treatment. Concern regarding the overuse of antibiotics and surgery has led to efforts to tailor therapy more narrowly for those who are at the highest risk from recurrent urinary tract infection and pyelonephritis. Children after a certain age, without underlying voiding dysfunction, might not require treatment at all. Newer surgical and anaesthetic techniques have the potential of transforming surgical correction from a painful experience to an ambulatory procedure, with a rapid return to daily activities. Both the promise and pitfalls of these newest advances will be discussed in this review.

Animals↗
PubMed2002

Screening siblings for vesicoureteral reflux.

PURPOSE: Publications on screening the siblings of patients with reflux were reviewed to determine the overall incidence and severity of reflux and renal scarring in siblings, and identify factors that predict siblings more likely to have reflux. MATERIALS AND METHODS: A MEDLINE search for 1985 to the present was performed. Of 34 articles on familial reflux only 11, including 1 abstract, on sibling screening were used in this analysis. RESULTS: The mean incidence of reflux in siblings in all studies was 32% (570 of 1,768). Of the siblings with reflux approximately two-thirds had grades I to II disease. Only 22 of 1,051 siblings (2%) had reflux greater than grade III. Reflux was unilateral in 162 of 307 cases (53%). Certain factors predicted the chance of sibling reflux. Sibling age varied inversely with the incidence of reflux. A twin relationship and absent dysfunctional voiding symptoms in the index patient may predict a higher chance of reflux in a sibling. The mean incidence of renal abnormality in siblings with reflux was 11%. The incidence of reflux and renal abnormality in the sibling population undergoing screening was 3%. In more than half of the siblings with an abnormal renal evaluation there was no history of urinary tract infection. CONCLUSIONS: The studies reveal an incidence of reflux in siblings greater than in the general population. These data do not prove that screening and treating asymptomatic siblings decreases infectious renal scarring. Studies in a control group that consider sibling age are still needed to determine the benefit of screening asymptomatic siblings.

Child↗
PubMed2002

Experience with varicoceles in children and young adults.

PURPOSE: Varicocele ligation in children and adolescents has been advocated for left testicular growth arrest. We report our experience with this population as well as the results of the microscopic inguinal technique. MATERIALS AND METHODS: Between 1994 and 1999, 184 children and young adults presented with unilateral left varicoceles. At presentation 171 patients were asymptomatic and 13 had pain. Testicular measurement was assessed with calipers in 158 cases and ultrasound in 26. Surgery was performed using a microscopic inguinal technique in 58 patients and loupes in 16 of those who presented with left testicular growth arrest initially or who had growth arrest while under observation. Only one child underwent surgery for pain alone. RESULTS: Patient age at presentation ranged from 5 to 22 years, and 70% presented between the ages of 12 and 16 years. Of the 13 patients with pain ages ranged from 13 to 22 years and 6 (46%) also had left testicular growth arrest. Initially, 109 (60%) boys were found not to have left testicular growth arrest and were followed, while 56 (30%) with left testicular growth arrest (ages 9 to 22 years) underwent surgery and 19 were lost to followup. Left testicular growth arrest developed in 17 (15%) of the followed group (ages 11 to 17 years) after 6 to 41 months (average 22) of observation and they underwent surgery. Postoperatively, varicocele disappeared in 66 (89%) patients and it was smaller in 8, in whom 8 loupes were used in 2 and the microscope was used in 6. Of the 36 patients who returned for postoperative measurement 30 (83%) had catch-up growth, while 6 did not. No hydroceles were noted. CONCLUSIONS: Varicoceles can be found in boys as young as 5 years and left testicular growth arrest as early as 9 years. As left testicular growth arrest can develop if not present initially, these boys must be followed with serial testicular measurements before and after puberty until late adolescence. Microscopic inguinal ligation results in complete resolution of the varicocele in almost 90% of patients with no complicating hydroceles. Left testicular catch-up growth can be expected in more than 80% of patients at any age.

Adolescent↗
PubMed2002

Ureteroneocystostomy in children with posterior urethral valves: indications and outcome.

PURPOSE: Ureteroneocystostomy in children with posterior urethral valves represents a surgical challenge. We reviewed our experience with this procedure to assess its indications and outcome. MATERIALS AND METHODS: Between 1996 and January 2000, 106 children with posterior urethral valves were treated of whom 20 (19%) underwent ureteroneocystostomy at a mean age plus or minus SD of 5 +/- 2.6 years. Indications for surgery were recurrent urinary infections despite adequate valve ablation in 14 patients of whom 7 had persistent reflux in 12 renal units and 7 had obstruction in 11 ureterovesical junctions. The remaining 6 patients were initially treated with high loop diversion and obstruction was confirmed in 9 ureterovesical junctions by the Whitaker test. Bladder function was assessed by videourodynamics before surgery. Transureteroureterostomy was performed in 7 ureters, and 25 ureters were tailored and reimplanted using the combined intravesical and extravesical approach, including a psoas hitch in 18 (72%). RESULTS: Mean followup plus or minus SD was 2.3 +/- 1 years. Obstruction and reflux occurred in 1 (4%) and 9 (36%) ureteroneocystostomies, respectively. Obstruction was successfully managed by repeat surgery. Patients with reflux were maintained on chemoprophylaxis. No patient required repeat surgery and reflux did not resolve spontaneously in any. Reflux occurred in all ureteroneocystostomies without a psoas hitch (100%) and in 2 with a hitch (10%) (p <0.004). Dilatation of the upper tracts persisted in all patients. In 2 patients end stage renal disease developed. The remaining 18 patients had serial sterile urine cultures and with a mean serum creatinine plus or minus SD of 0.8 +/- 0.3 mg.%. CONCLUSIONS: Ureteroneocystostomy is indicated for patients with persistent obstruction after high diversion or those with persistent reflux or obstruction and recurrent infections despite adequate valve ablation and a stable bladder. However, the procedure is associated with a high rate of postoperative reflux. Psoas hitch has a significant role in prevention of reflux.

Child↗