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Some alternatives to urinary diversion in children.

Many children with severe urologic problems have been treated by urinary diversions, often after unsuccessful operations to correct the original pathology. Urinary diversion should be avoided when possible, since often it is accompanied by chronic infection and quality of life is less good than it could be. Most diversions can be prevented by use of other alternatives including 1) reimplanting 1 ureter and transureteroureterostomy of the other, 2) psoas hitch, 3) wide mobilization and downward displacement of the kidney and ureter, 4) use of bowel as ureter, 5) cecal cystoplasty and 6) early repair of complex pathology. Autotransplantation is probably seldom indicated in childhood.

Adolescent↗

Principles of management of the persistent cloaca in the female newborn.

The persistent cloaca in the female newborn is one of the most complex and challenging developmental malformations that the pediatric urologist will encounter. A review of 5 patients seen at this center and 34 completely documented cases was undertaken to characterize the defects and devise a logical diagnostic and therapeutic approach. Diagnostic steps include the search for associated anomalies, which were present in the upper urinary tract (33 per cent), gastrointestinal tract (13 per cent), cardiovascular system (13 per cent), central nervous system (10 per cent) and respiratory tract (5 per cent). Delineation of the cloaca and its anatomic relationships is determined by abdominal x-rays, injection of contrast material into the cloacal channel, excretory urography and endoscopy with selective catheterization. Surgical treatment begins with a diverting right transverse colostomy in the newborn period followed by rectal pull-through when the patient weighs 25 pounds. Vaginal pull-through should be performed at the same time as the rectal pull-through if the vagina enters the cloaca high. If the cloacovaginal communication is low a vaginoplasty by a posterior flap procedure can be done when the child is 10 to 12 years old. Even is anatomy is reconstructed in an ideal manner urinary and fecal continence cannot be assured since congenital neurologic dysfunction is not uncommon.

Abnormalities, Multiple↗

Management of urinary incontinence with electronic stimulation: observations and results.

The evolution in the management of urinary incontinence with electronic stimulation of the pelvic floor is reviewed. The effect of stimulation is analyzed. Our methods of candidate screening and the contraindications to treatment are discussed. Forty patients were treated for 2 to 15 months. Sixteen patients were post-prostatectomy, 4 had stress incontinence, 4 had upper motor neuron lesions, 1 was incontinent after repair of a rectovesical fistula and 15 were post-bladder exstrophy closure. The success rate in the first group was 45.4 per cent, in the second group 100 per cent, in the third group 50 per cent, in the fourth group 100 per cent and in the fifth group 27.2 per cent. In view of the method having been tried on cases resistant to other forms of treatment the results were encouraging. The most satisfying results were in the post-exstrophy group in which no response was expected.

Adolescent↗

Cloacal exstrophy: 18-year survival of untreated case.

A patient is described who was 18 years old and attending high school when initially treated for cloacal exstrophy. The history, embryology and treatment of cloacal exstrophy are discussed, emphasizing that this congenital anomaly is compatible with a useful and happy life.

Adolescent↗

Penile agenesis.

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Abnormalities, Multiple↗

Advances in neonatal surgery.

Neonatal surgery has reached a high degree of sophistication. We are now entering a new era of widespread screening of the unborn by means of ultrasound, with planned intrauterine, intrapartum, and immediate postpartum interventions. Many pediatric surgical centers are now focusing their investigative efforts on elucidating the cellular, molecular, and biochemical response to disease and therapeutic agents. The author presents the topic of neonatal surgery to some of the newer applications, techniques, and approaches.

Anus, Imperforate↗

Constipation.

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Adolescent↗