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PubMed1988

Papillary and polypoid cystitis. A report of eight cases.

Eight patients from 20 months to 79 years of age (average, 49 years) with papillary or polypoid inflammatory lesions of the urinary bladder were studied. On cystoscopic examination or initial pathologic examination, several of the lesions were thought to be neoplasms. Their clinical and pathologic features, however, were typical for papillary and polypoid cystitis. Microscopic examination disclosed thin, finger-like papillae or broad-based polypoid lesions with prominent stromal edema typically associated with chronic inflammation. The lesions were covered by, and adjacent to, urothelium that was usually normal but was occasionally metaplastic. A history of recent catheterization was present in only one case. These cases illustrate that occasional papillary or polypoid urothelial lesions are inflammatory rather than neoplastic.

Adolescent↗

PubMed1993

Adenocarcinoma of the colon simulating primary urinary bladder neoplasia. A report of nine cases.

Nine cases of adenocarcinoma of the colon, secondarily involving the urinary bladder mucosa and histologically mimicking primary bladder neoplasia, are reported. Five patients presented with bladder involvement at the time of diagnosis of colon cancer; four developed vesical lesions 9 to 66 months after resection of their colonic primary. The majority (89%) had genitourinary symptoms at presentation; gastrointestinal manifestations were present in only 60% of those with synchronous colonic involvement. The initial clinical impression, largely based on cystoscopic and radiographic studies, was a bladder primary in four cases and colon cancer in five. Of the former, three (75%) were known to have a history of colon cancer. Histologically, all were enteric-type adenocarcinomas and all had features mimicking a villous adenoma of the bladder. Distinguishing a primary bladder adenocarcinoma from spread of a colonic carcinoma to the bladder may not be possible on histopathologic grounds alone. Consideration should be given to the possibility of an extravesical primary even when symptomatology, cystoscopy, radiographic studies, and histopathology suggest a primary bladder neoplasm.

Adenocarcinoma↗

PubMed2006

Inverted papillomas of the prostatic urethra.

Inverted papillomas of the genitourinary tract are uncommon benign neoplasms usually occurring in the urinary bladder and less frequently in the upper urinary tract. To date, there are scant data and no comprehensive studies of inverted papilloma originating in the prostatic urethra. We identified 21 cases and evaluated their demographic, clinical, and histopathologic features. Patients had a mean age of 65.1 years (range: 30 to 89 y), with 10/21 (47.6%) presenting with gross hematuria (n = 8) or irritative symptoms (n = 2) related to the inverted papilloma and 11/21 (52.4%) detected incidentally during work-up/treatment of prostate cancer (n = 6) or benign prostatic hypertrophy (BPH) (n = 5). Fourteen cystoscopically evaluated lesions measured 0.1 to 2.0 cm, and were described as polypoid (n = 9), papillary (n = 4), or an enlarged median lobe (n = 1). Lesions were diagnosed on transurethral resection (n = 8), biopsy/polypectomy targeted to the lesion (n = 6), radical prostatectomy for prostate cancer (n = 4), or biopsy unrelated to the lesion (n = 3). Histologically, 14/21 cases (67%) displayed classic inverted papilloma architecture. The remaining cases showed foci of squamous metaplasia with moderate atypia (n = 4), rare true papillary fronds in a classic inverted papilloma background (n = 2), or both (n = 1). Eleven cases with prostatic tissue revealed adenocarcinoma of the prostate [n = 6; Gleason score 6 (n = 3) or 7 (n = 3)], high-grade prostatic intraepithelial neoplasia (n = 1), benign prostatic hypertrophy (n = 3), or adenosis (n = 1). No patients had a prior history of either inverted papilloma or urothelial carcinoma, whereas 2 patients were diagnosed with high-grade urothelial carcinoma of the bladder synchronous with their inverted papilloma diagnosis. Only 1 of the 18 patients with available follow-up had a recurrence of inverted papilloma in the prostatic urethra. None of the other patients had local recurrences or recurrences at other locations in the urinary tract (mean follow-up 39.9 mo; range: 3 to 120 mo). Inverted papillomas of the prostatic urethra are benign lesions that are commonly detected incidentally and are not associated with a history of urothelial malignancy. Although urothelial carcinoma elsewhere in the genitourinary tract may occur simultaneously, malignant transformation or recurrence as a malignant lesion has not been identified in inverted papilloma of the prostatic urethra.

Adenocarcinoma↗

PubMed1989

Transurethral resection of the prostate, serum glycine levels, and ocular evoked potentials.

Complications of transurethral resection of the prostate (TURP syndrome) when glycine is used as the irrigating fluid include cardiovascular and central nervous system abnormalities that occasionally include transient blindness. Serum sodium, glycine, potassium, chloride, ammonia, osmolality, carbonate, and blood urea nitrogen of 17 patients having TURP and 10 having cystoscopic examination were measured. Electroretinograms and visually evoked potentials (VEPs) were recorded in the preanesthetic preparatory area and in the recovery room immediately after surgery. Four patients reported visual aberrations coincident with increases in serum levels of glycine from a mean before surgery of 137.7 +/- 45.1 to 7,812.2 +/- 2,486.6 microM/l, mean +/- SD, after TURP. These patients also showed a reduction of serum sodium from 138 +/- 4.5 to 122 +/- 8.6 mEq/l that correlated significantly with serum levels of glycine (rho = -0.81). There were no statistically significant changes of serum ammonia and osmolality. Electroretinograms consistently demonstrated complete loss of oscillatory potentials. Thirty hertz flicker-following was also abolished. VEPs were more variably affected with prolongation of component "P100" latency found in both groups and probably resulting from sedative effects of diazepam. Patients experiencing the TURP syndrome showed abolishment of 30 Hz flicker-following in their VEPs. The elevated serum levels of glycine may contribute directly to visual aberrations resulting from glycine's role as an inhibitory transmitter in the retina.

Aged↗

PubMed1987

External ureteroneocystostomy and ureteroureterostomy in renal transplantation.

Reported are 204 primary external ureteroneocystostomies and 16 primary ureteroureterostomies in a series of 220 consecutive renal transplants. A total of 12 (5%) complications occurred; however, only seven (3%) required major operative repair, whereas five (2%) were minor and were repaired by cystoscopic or transvesical procedures. There was no mortality and no allograft loss from these complications, which tend to occur late and be amenable to prompt repair. Since the complications of external ureteroneocystostomy differ from those of the internal ureteroneocystostomy, a discussion of their treatment is provided. A review of literature shows that the external repair is growing in popularity because of its good results. The good results are attributable to the use of a short length of ureter, to the use of a continuous monofilament suture that produces an anastomosis less likely to leak, and to the need of a very small cystostomy.

Absorption↗

PubMed1992

Diagnosis and treatment of bladder cancer.

The primary key to diagnosis of bladder cancer is cystoscopic examination of the bladder, followed by biopsy of suspicious lesions. Bimanual examination under anesthesia is also important for staging, and urinary cytology and intravenous urography provide valuable additional information. Surgical resection in the form of excisional transurethral biopsy is diagnostic, therapeutic and essential for accurate staging, and assessment of tumor grade is vital for determining prognosis and management strategies. Intravesical chemotherapy with Thiotepa, doxorubicin, mitomycin C or ethoglucid has been shown to reduce the incidence of short-term tumor recurrence by 17% but not long-term recurrence or rate of disease progression. Immunotherapy, as exemplified by Bacillus Calmette-Guérin (BCG), has achieved better results: long-term reduction in tumor recurrence, reduction in disease progression and prolongation of patient survival. Newer immunotherapies using interferon-alpha appear to produce response rates comparable to BCG but without the considerable toxicity of BCG. Further research with combination therapies and other immunotherapeutic agents should lead to improved treatment options in the future.

BCG Vaccine↗

PubMed2001

Tc-99m MDP uptake in a calcified bladder tumor.

A 68-year-old man with a history of prostate carcinoma and increasing levels of prostate-specific antigen was referred for a radionuclide bone scan. In addition to a probable metastatic lesion in the right femoral head, focal radiotracer accumulation was seen overlying the left aspect of the urinary bladder. Plain radiographs and pelvic computed tomography confirmed the presence of a calcified mass in the bladder. Cystoscopic examination revealed an exophytic bladder lesion. Biopsy indicated low-grade papillary transitional cell carcinoma, and the patient successfully underwent transurethral resection of this tumor.

Aged↗

PubMed1984

Treatment of recurrent urinary incontinence.

This method of elevating the vesical neck with two permanent nylon sutures is effective for correcting primary or recurrent stress urinary incontinence and even total urinary incontinence in over 90% of patients. The cystoscope guides placement of the nylon sutures, and the buttress supports the tissues to achieve precise functional closure of the bladder neck. The technique causes less blood loss and postoperative morbidity than many other operations because open pelvic surgery is avoided. There is less pain, and the patient can be discharged with supra-public urinary drainage on the second or third postoperative day if desirable. The procedure can be performed easily by a single surgeon in less than an hour in uncomplicated patients and is no more difficult in obese women than in thin women. It is particularly well adapted for patients who have failed other procedures for stress urinary incontinence and those with previous pelvic fracture, pelvic irradiation, or trauma. Simultaneous repair of significant rectoceles or substantial cystoceles can be performed through the same operative field, and hysterectomy is not required for achievement of adequate endoscopic suspension of the bladder neck.

Cystoscopy↗

PubMed1987

Treatment of obliterated membranous and bulbous urethras by direct vision internal urethrotomy.

Acute placement of a suprapubic bladder tube followed months later by open urethroplasty has been the traditional manner for managing traumatic disruption of the proximal urethra. The latter procedure has generally been performed via the transpubic or perineal approach. These procedures have been complicated by excessive blood loss, impotence, incontinence, strictures, and extended hospitalizations. Since 1979, 12 patients with obliterated urethras (ten membranous, two bulbous) have been treated by direct vision urethrotomy using a second cystoscope or sound passed through the previously placed suprapubic tract as a guide. Mean blood loss, hospital stay, and followup were 70 ml, 6 days, and 22 months, respectively. Six patients required at least one additional internal urethrotomy. With the exception of one patient who still requires intermittent self-catheterization, all have stable strictures. Ten are continent (one was incontinent secondary to previous radical prostatectomy before urethrotomy and one became incontinent after a TURP performed 3 years after urethrotomy). Five are potent and none lost potency as a result of urethrotomy. Flow rates range from 15-25 ml/second in the continent patients. This is a reasonable first procedure for restoring continuity of traumatically obliterated membranous and bulbous urethras.

Adult↗

PubMed1995

Results of a multicenter trial using the BTA test to monitor for and diagnose recurrent bladder cancer.

OBJECTIVES: We compare the Bard BTA (bladder tumor antigen) test to voided cytology studies in patients undergoing surveillance cystoscopy for recurrent bladder cancer. MATERIALS AND METHODS: A prospective, blinded, multicenter trial was performed. RESULTS: A total of 499 patients underwent 1,014 cystoscopic examinations and tumor was identified in 151. The bladder tumor antigen test was more sensitive than cytology studies in detecting recurrent cancer (p < 0.001), being positive in 61 cases versus 25 for cytology. The trial in healthy volunteers and nonurological patients estimates bladder tumor antigen test specificity to be 95.9%. CONCLUSIONS: The bladder tumor antigen test is a simple, rapid and inexpensive adjunct to cystoscopy, and the results are equivalent or superior to those of voided cytology as performed in this trial.

Adult↗

PubMed1997

A multicenter trial evaluation of the fibrin/fibrinogen degradation products test for detection and monitoring of bladder cancer.

PURPOSE: Presently there is a lack of effective, noninvasive tests for the detection and monitoring of bladder cancer. Measurement of fibrin/fibrinogen degradation products in urine has been shown to be a useful indicator of bladder carcinoma. The objective of this study was to evaluate the AuraTek FDP rapid immunoassay device for the detection of urinary fibrin/ fibrinogen degradation products associated with bladder cancer. MATERIALS AND METHODS: A prospective multicenter study was conducted to compare AuraTek FDP with urinary cytology and hemoglobin dipstick for the detection of bladder cancer in 192 patients with a history of bladder cancer. RESULTS: AuraTek FDP was significantly more sensitive (68%) than conventional urinary cytology (34%, p < 0.001) or hemoglobin dipstick (41%, p < 0.001) in the detection of bladder tumors, particularly for low stage low grade disease. In subjects with invasive disease (T2-T4) the AuraTek FDP test had a sensitivity of 100%. Specificity of AuraTek FDP was 96% for healthy subjects, 86% in patients with urological disease other than bladder cancer and 80% for patients under surveillance for bladder cancer but with a negative cystoscopic finding at the time of assay. CONCLUSIONS: This simple, rapid (less than 7 minutes) point of care test is superior to conventional urine cytology and hemoglobin dipstick as an aid in the detection of bladder cancer.

Aged↗

PubMed1997

Detachable self-sealing membrane system for the endoscopic treatment of incontinence.

PURPOSE: The endoscopic treatment of urinary incontinence is limited by the injectable substances currently available. The ideal injectable material should be able to conserve its volume, be nonmigratory and nonantigenic. Toward this goal we developed a system for the treatment of incontinence in which a catheter with an inflatable and detachable self-sealing silicone membrane fits through a standard cystoscopic needle. We present our experience with this system. MATERIALS AND METHODS: A total of 20 female beagle dogs underwent cystoscopy and in 15 a self-sealing membrane was placed endoscopically in the submucosal region of the proximal urethra at the 3 and 9 o'clock positions. Each membrane was inflated through the delivery catheter with 0.2 cc povidone. Coaptation of the urethra due to the relative bulking effect of the inflated membrane was confirmed endoscopically in each animal. Five control animals received only an injection of saline. Four animals were sacrificed at 1, 3, 6, 12 and 18 months, respectively. At sacrifice gross and histological examinations were performed. RESULTS: At retrieval up to 18 months after implantation the membrane remained inflated and at the same position at which it had been initially placed. There was no evidence of povidone volume loss or extravasation. Membranes were encapsulated by a fibrous capsule. Only a few inflammatory cells surrounded the capsule by month 1 and there were none by month 3. Histological examination of periurethral tissue and distant organs showed no evidence of particle migration. CONCLUSIONS: The detachable self-sealing membrane system is easily implantable, nonmigratory, nonantigenic and able to conserve its volume. These studies indicate that this system may be effective for the endoscopic treatment of incontinence.

Animals↗

PubMed1998

Retroperitoneal laparoscopic nephrectomy in children.

PURPOSE: We report our experience with retroperitoneal laparoscopic nephrectomy and nephroureterectomy in children, and describe our surgical technique. MATERIALS AND METHODS: Five and 15 children 9 months to 17 years old underwent nephrectomy with cystoscopy plus intravesical ureteral stump fulguration for ureteral ablation and nephrectomy only, respectively. Surgical indications were unilateral multicystic dysplastic kidney in 8 cases (parental preference for surgery), a refluxing, chronic pyelonephritic kidney in 5, renal vascular hypertension in 2, and hydronephrosis and chronic pyelonephritis in 5, including 3 in whom a nephrostomy tube was placed percutaneously before laparoscopic nephrectomy. Access was obtained by a 10 mm. incision made posterior to the anterosuperior iliac spine with dissection into the retroperitoneal space and trochar placement. Two and sometimes 3 additional 5 mm. ports were placed retroperitoneally. RESULTS: Average operative time was 1 hour 42 minutes. The most recent cases were performed in less than 1 hour and in 3 nephrectomy only required 30 minutes. All but 1 procedure were completed laparoscopically. One case was converted to open surgery secondary to obscured visibility due to bleeding. Blood loss in all cases was less than 30 cc (average 5 to 10). A total of 13 children were discharged home immediately postoperatively. Five children underwent concomitant procedures, including contralateral ureteroneocystotomy in 4, circumcision in 1 and cystoscopic fulguration of the ureteral stump in 5. Those who underwent ureteral reimplantation were hospitalized for 48 hours. One patient remained hospitalized for 3 days due to fever of unknown origin and 2 were admitted to the hospital for 23-hour observation. All children returned to full activity within 1 week of surgery. Analgesia consisted of 1 dose of ketorolac, bupivacaine injections at the incisional sites at the completion of the procedure, and acetaminophen postoperatively. CONCLUSIONS: As confirmed by parent questionnaire, patient satisfaction was excellent.

Adolescent↗

PubMed1999

Is transurethral biopsy of the bladder necessary after 3 months to evaluate response to bacillus Calmette-Guerin therapy?

PURPOSE: We assessed the need for transurethral biopsy of the bladder at the 3-month evaluation in patients who have received intravesical bacillus Calmette-Guerin (BCG). MATERIALS AND METHODS: A total of 81 patients collectively received 83, 6-week courses of BCG between 1995 and 1997, and underwent transurethral bladder biopsies 3 months after initiation of immunotherapy. The pretreatment and posttreatment bladder biopsy results, urinary cytology and posttreatment cystoscopic findings were correlated. RESULTS: Transitional cell carcinoma was demonstrated in 5 of 11 patients with erythematous bladder mucosa and a positive cytology compared to none of 37 with an erythematous lesion and a negative cytology. Of 12 patients with a papillary lesion on cystoscopy and a positive biopsy 10 had a negative cytology, and only 1 of 13 patients with a negative cystoscopy had a positive biopsy. CONCLUSIONS: Bladder biopsy is not necessary in patients 3 months after receiving BCG who have a normal office cystoscopy or an erythematous bladder and normal urine cytology.

Adjuvants, Immunologic↗

PubMed1999

The role of 99mtechnetium dimercapto-succinic acid renal scans in the evaluation of occult ectopic ureters in girls with paradoxical incontinence.

PURPOSE: We describe the use of 99mtechnetium (Tc) dimercapto-succinic acid (DMSA) renal scintigraphy to document poorly functioning and/or ectopic renal units associated with occult ectopic ureters. MATERIALS AND METHODS: During the last 8 years 6 toilet-trained girls were referred for lifelong continuous urinary dribbling. Initial radiological evaluation included renal and bladder sonography in 6, excretory urography in 4, a mercaptoacetyltriglycine-3 renal scan in 1 and cystovaginoscopy in 2. Ultimately a 99mTc-DMSA renal scan was performed in all 6 girls before surgical intervention. RESULTS: Sonography failed to establish the diagnosis of ureteral ectopia in all cases, and revealed a normal solitary kidney in 3, normal kidneys in 1, an apparently uncomplicated unilateral duplication without hydroureteronephrosis in 1 and a contralateral uncomplicated duplication in 1. Excretory urography in 4 cases was inconclusive and showed a solitary kidney in 1, ipsilateral duplication without a normal appearing upper pole collecting system in 1, contralateral uncomplicated duplication in 1 and normal kidneys in 1. A mercaptoacetyltriglycine-3 renal scan in another girl with a solitary kidney on sonography failed to demonstrate a contralateral small ectopic kidney. Cystovaginoscopy performed in 2 patients by other pediatric urologists was nondiagnostic. 99mTc-DMSA renal scintigraphy was diagnostic in all 6 cases, and revealed a small poorly functioning ectopic kidney in 3 and a poorly functioning dysplastic upper pole moiety in 3, which were consistent with a diagnosis of ureteral ectopia. An ectopic ureter was confirmed by cystoscopic and surgical findings in all girls. CONCLUSIONS: 99mTc-DMSA renal scintigraphy reliably detects and localizes hypoplastic ectopic kidneys and poorly functioning upper pole moieties associated with occult ectopic ureters in girls with continuous urinary leakage.

Child↗

PubMed2000

Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results.

PURPOSE: We evaluated the efficacy of botulinum-A toxin injections into the detrusor muscle in patients with spinal cord injury, detrusor hyperreflexia and urge incontinence resistant to anticholinergic drugs. The purpose of treatment was to suppress incontinence episodes and increase functional bladder capacity. MATERIALS AND METHODS: Included in our prospective nonrandomized study done at 2 clinics were 31 patients with traumatic spinal cord injury who emptied the bladder by intermittent self-catheterization. These patients had severe detrusor hyperreflexia and incontinence despite a high dose of anticholinergic medication. Pretreatment evaluation included a clinical examination and complete urodynamic investigation. Under cystoscopic control a total of 200 to 300 units of botulinum-A toxin were injected into the detrusor muscle at 20 to 30 sites (10 units per ml. per site), sparing the trigone. Clinical and urodynamic followup was planned for 6, 16 and 36 weeks after treatment. Patients were asked to decrease their intake of anticholinergic drugs during week 1 after treatment. RESULTS: Of the 21 patients 19 underwent a complete examination 6 weeks after the botulinum-A toxin injections, and 11 at 16 and 36 weeks. At the 6-week followup complete continence was restored in 17 of 19 cases in which anticholinergic medication was markedly decreased or withdrawn. Less satisfactory results in 2 cases were associated with an insufficient dose of 200 units botulinum-A toxin. After the injections overall mean reflex volume and mean maximum cystometric bladder capacity plus or minus standard deviation significantly increased from 215.8 +/- 90.4 ml. to 415.7 +/- 211.1 (p <0.016) and 296.3 +/- 145.2 to 480.5 +/- 134.1 (p <0.016), respectively. There was also a significant decrease after treatment in mean maximum detrusor voiding pressure from 65.6 +/- 29.2 cm. water to 35 +/- 32. 1 (p <0.016). Mean post-void residual urine volume catheterized at the end of the urodynamic examination increased significantly from a mean of 261.8 +/- 241.3 ml. to 490.5 +/- 204.8 (p <0.016). Moreover, autonomic dysreflexia associated with bladder emptying that manifested as a hypertensive crisis during voiding disappeared after treatment in the 3 patients with tetraplegia. Satisfaction was high in all successfully treated patients and no side effects were observed. Ongoing improvement in urodynamic parameters and incontinence was already present in all patients reevaluated at 16 and 36 weeks. CONCLUSIONS: Botulinum-A toxin injections into the detrusor seem to be a safe and valuable therapeutic option in spinal cord injured patients with incontinence resistant to anticholinergic medication who perform clean intermittent self-catheterization. Successfully treated patients become continent again and may withdraw from or markedly decrease anticholinergic drug intake. A dose of 300 units botulinum-A toxin seems to be needed to counteract an overactive detrusor. The duration of bladder paresis induced by the toxin is at least 9 months, when repeat injections are required.

Adolescent↗

PubMed2001

Retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels for ureteropelvic junction obstruction.

PURPOSE: We developed a new approach of retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels for ureteropelvic junction obstruction as an alternative to conventional antegrade or retrograde endopyelotomy. MATERIALS AND METHODS: From February 1997 to August 1999 we treated 5 cases of ureteropelvic junction obstruction due to crossing vessels that were diagnosed by helical computerized tomography. Ureterovascular hydronephrosis characterized by a malrotated renal pelvis with anterior crossing vessels was observed in 4 cases and ureteropelvic junction obstruction with a posterior crossing artery was present in 1. After endoureterotomy stent insertion under cystoscopic guidance we performed retroperitoneoscopic endopyelotomy with the kidney in standard position. Crossing vessels were transposed to a higher position to remove obstruction and fixed with peripelvic tissue via retroperitoneoscopy. In all cases a longitudinal incision approximately 1.5 cm. long was made with a potassium titanyl phosphate laser. RESULTS: Convalescence was uneventful in all patients and the endoureterotomy stent was removed 4 to 8 weeks after surgery. Postoperatively helical computerized tomography showed the successful transposition of crossing vessels and significant hydronephrosis resolution in all cases. All patients were asymptomatic during followup of 17 to 28 months. CONCLUSIONS: Despite our small number of patients our results are sufficient to conclude that retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels is a simple and reliable method for treating ureterovascular hydronephrosis and associated conditions.

Adult↗

PubMed2001

The use of radiography, urodynamic studies and cystoscopy in the evaluation of voiding dysfunction.

PURPOSE: Children with dysfunctional voiding disorder often undergo radiological, cystoscopic or urodynamic evaluation to identify an anatomical or organic cause. We determined the role of these studies in the evaluation, management and ultimate outcome of a large patient population with voiding dysfunction at a single institution. MATERIALS AND METHODS: We retrospectively evaluated the records of 1, 153 children with dysfunctional voiding disorder treated from 1990 to 1999. A thorough history and physical examination with specific emphasis on voiding patterns were done and urinalysis was performed in all cases. Ultrasound of the urinary system and excretory urography were done in 1,050 (91%) and 24 (2%) patients, respectively, while voiding cystourethrography was performed in 672 (58%), including 564 with a history of nonfebrile urinary tract infection. Cystoscopy and a formal urodynamic study were performed in 61 (5%) and 40 (3.5%) cases, respectively. RESULTS: Mean patient age at referral was 6 years (range 3 to 14). Of the children 74% were girls and 26% were boys. Physical examination of the abdomen, back, genitalia and neurological system was unremarkable in all cases. Ultrasound of the upper urinary system was normal in 1,018 patients (97%) and showed insignificant pyelectasis in 32 (3%). All 24 excretory urography studies were normal and voiding cystourethrography was normal in 470 of 672 cases (70%). Unilateral and bilateral low grade, and unilateral high grade reflux was present in 108, 19 and 3 patients, respectively. Urodynamic studies were performed in 40 children who did not respond to standard treatment. We noted detrusor instability in 16 patients, detrusor-sphincter dyssynergia in 6 and sensory abnormality in 3, while the study was completely normal in 10. Cystoscopy revealed normal findings in 17 cases, trabeculations in 21, inflammation in 20 and type 1 posterior urethral valves in 2. CONCLUSIONS: The incidence of upper tract changes and positive anatomical findings in children with voiding dysfunction is too low to justify routine radiological evaluation and cystoscopy. However, in those who present with a nonfebrile urinary tract infection there remains an important role for voiding cystourethrography. We do not recommend routine urodynamics in children with voiding disorder because this study does not change therapy or influence the final outcome. Thorough history and physical examination lead to the correct diagnosis and treatment in the majority of children. A focus on correcting faulty voiding behavior with the judicious administration of antibiotics and anticholinergic therapy leads to a favorable outcome in most cases.

Algorithms↗