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Biomedical subjects

A B Belman

Publications and source records attributed to A B Belman.

At least 19 recordsLinked to original sources
PubMed2001

Early diuresis renogram findings predict success following pyeloplasty.

PURPOSE: We sought to determine whether drainage across the ureteropelvic junction, as indicated by diuretic renography 3 months after pyeloplasty, is an adequate predictor of surgical success. MATERIALS AND METHODS: The medical records of 150 children who underwent pyeloplasty from 1986 to 1995 were reviewed. After excluding nonevaluable cases a total of 127 renal units remained for investigation. Preoperatively each renal unit was examined with a standardized (well-tempered) furosemide stimulated renal scan. Postoperatively 60 renal units were evaluated with standardized diuretic renal scans at 3 and 12 months, 33 renal units at 3 months only and 34 renal units at 12 months only. Surgical success was defined by half-time less than 20 minutes on a standardized diuretic renogram. RESULTS: Of the 33 renal units with a single postoperative study at 3 months 32 (97%) had halftime less than 20 minutes on diuretic renography. The remaining patient in this group with half-time greater than 20 minutes showed 60% improvement in half-time and did not require reoperation. Excluding those without delayed followup, surgical success was obtained in 93 of the 94 (99%) renal units. Among the 60 renal units evaluated with 2 postoperative renal scans success was noted in 48 (80%) and 59 (98%) at 3 and 12 months, respectively. Stenosis did not recur in 48 renal units with half-time less than 20 minutes 3 months after repair. In 1 case that had been treated for postoperative urinoma half-time was greater than 40 minutes at 3 months and repeat pyeloplasty was required. CONCLUSIONS: Half-time less than 20 minutes 3 months after pyeloplasty predicts surgical success. Most renal units that improve but still have half-times greater than 20 minutes on an early diuretic renogram will demonstrate continued improvement in drainage patterns at 12 months. Those renal units that show no improvement at 3 months may require reoperation and those with half-time less than 20 minutes at 3 months do not require further evaluation.

Child↗
PubMed2001

Is the vanished testis always a scrotal event?

OBJECTIVE: To determine if perinatal testicular torsion resulting in a vanished testis is an event that primarily occurs in the scrotum. PATIENTS AND METHODS: The records of 54 boys identified as having a solitary testis were reviewed. The side of absence, size of the solitary testis, method of surgical evaluation (scrotal, inguinal or abdominal), surgical findings and histology of the tissue removed were noted. RESULTS: The testis was absent twice as often on the left side, the solitary testis was hypertrophic in 25 of 42 boys in whom it was evaluated, and tissue grossly or histologically consistent with a testicular 'nubbin' was removed in 52 boys. Scrotal (47) or inguinal (seven) exploration was carried out in all. Laparoscopy (28) or abdominal exploration (two) was undertaken to confirm that no testicular tissue was present in the abdomen in 30 boys, including the two in whom no tissue was found on scrotal or inguinal exploration. CONCLUSIONS: Perinatal testicular torsion occurs after descent but before fixation of the tunica vaginalis to the scrotal wall. These testes atrophy, leaving a remnant of tissue in the scrotum that can be identified on scrotal exploration in almost all cases. Therefore, it is recommended that the evaluation of the child with a solitary palpable testis start with scrotal exploration. Laparoscopy should be reserved for those in whom no tissue consistent with a testicular nubbin is found in the scrotum.

Atrophy↗
PubMed2001

Abdominoscrotal hydrocele in infancy: a review and presentation of the scrotal approach for correction.

PURPOSE: A simple transcrotal approach to the surgical treatment of abdominoscrotal hydrocele is presented. MATERIALS AND METHODS: Via a scrotal incision the hydrocele sac is drained and the wall is everted and plicated in the manner described by Lord. RESULTS: The hydrocele is eliminated with a decreased risk of damage to the spermatic cord and epididymis. There has been no recurrence. CONCLUSIONS: The scrotal approach to abdominoscrotal hydrocele is a simple, safe and effective method of managing this relatively uncommon problem.

Abdomen↗
PubMed2001

Parental preferences in the management of vesicoureteral reflux.

PURPOSE: We determined parental preferences for the treatment of vesicoureteral reflux in their child. MATERIALS AND METHODS: Parents of children with vesicoureteral reflux were prospectively recruited to evaluate choices in reflux management. In each case a standard questionnaire that described the treatment options for reflux was administered. Parents were asked to choose between long-term antibacterial prophylaxis with annual radiography studies and open or endoscopic treatment at each of 1 to 5 years of followup. They were also given the choice between open or endoscopic treatment. Annual resolution and/or correction rates provided for medical, surgical and endoscopic management were 20%, 95% to 100% and 80% after 1 or 2 injections, respectively. RESULTS: We queried 91 families of female (81%) and male (19%) patients. Average duration of reflux followup was 2 years and mean patient age was 49.8 months. At diagnosis reflux was grades I to II in 65% of cases, grade III in 26% and grades IV to V in 9%. The majority of parents chose daily antibiotics over surgery if the child was predicted to have vesicoureteral reflux for 1 to 4 years. However, the majority chose ureteral reimplantation over daily antibiotics and yearly x-ray if a 5-year course was predicted. In contrast, parents chose daily antibiotics rather than endoscopic treatment if the anticipated interval was 1 to 3 years. After 3 years the majority preferred the endoscopic approach. Also, 60% of parents stated that they would choose endoscopic treatment over reimplantation, although the child may require repeat endoscopic treatment and there was a 20% chance of persistent vesicoureteral reflux. CONCLUSIONS: Parents of children with vesicoureteral reflux prefer antibiotic prophylaxis as initial treatment. However, when daily antibiotics and yearly cystography may be required beyond 3 to 4 years, most parents would choose definitive correction. While endoscopic treatment is less effective than surgery, parents prefer endoscopic treatment, most likely because it is less invasive. Also, when compared directly against each other, the majority of parents stated that they would choose endoscopic treatment over surgery, although it has a lower success rate.

Antibiotic Prophylaxis↗
PubMed1998

The split prepuce in situ onlay hypospadias repair.

PURPOSE: We describe the surgical technique and report the results of the first 100 patients who underwent a modification of the onlay hypospadias repair, which we refer to as split prepuce in situ onlay repair. MATERIALS AND METHODS: We treated 100 boys with a mean age of 11 months at surgery who had coronal to mid shaft hypospadias with split prepuce in situ onlay hypospadias repair. The operative technique varies from that of the standard onlay procedure by preserving the whole blood supply of the half of the prepuce used for the island onlay flap, and using its abundant subcutaneous tissue to cover completely the suture lines used to create the neourethra. RESULTS: Only 5 complications required reoperation, including 1 hematoma evacuation and 4 urethrocutaneous fistulas. No patient had meatal stenosis, urethral stricture, meatal retraction or acquired urethral diverticulum necessitating reoperation. A good cosmetic result was obtained in all cases. CONCLUSIONS: Split prepuce in situ onlay hypospadias repair is applicable in virtually all cases of coronal to mid shaft hypospadias. It optimizes the blood supply to the island flap and provides well vascularized coverage of the neourethra, resulting in a decreased complication rate.

Humans↗
PubMed1997

Vesicoureteral reflux.

The management options outlined earlier are based on the available treatment modalities; however, when a simple, successful, durable, minimally invasive method becomes available to treat vesicoureteral reflux, the approach likely will change. Endoscopic outpatient treatment of reflux has been available for about a decade. Treatment entails injection of a material into the submucosa at the refluxing ureteral orifice to bolster it, thus curing the problem. A suspension of microscopic size polytetrafluoroethylene (Teflon) particles has been used; however, its safety has been seriously questioned, as some evidence shows migration of the particles to other organ systems, including the central nervous system. More recently, cross-linked bovine collagen has been similarly used; however, it does not appear to be as durable. The use of other materials that are safe and will lead to long-term success are being studied. Chondrocytes and other nonbiologic materials, such as microspheres of bioglass and detachable balloons, are being evaluated. It is fairly certain that when a safe material is found, patients with mild to moderate reflux will be endoscopically treated upon recognition, thereby avoiding the use of long-term prophylaxis and periodic radiographic reevaluation.

Child↗
PubMed1996

The influence of small functional bladder capacity and other predictors on the response to desmopressin in the management of monosymptomatic nocturnal enuresis.

PURPOSE: The relationship of functional bladder capacity as well as other variables to the responsiveness to desmopressin in children with monosymptomatic nocturnal enuresis was investigated. MATERIALS AND METHODS: A total of 95 children 8 to 14 years old with monosymptomatic nocturnal enuresis (6 or more of 14 nights wet) were evaluated in a double-blind study followed by open label crossover extension using 20 to 40 mcg. desmopressin. Evaluated predictors of response included patient age, gender, race, family history, number of baseline wet nights, urine osmolality parameters and maximum functional bladder capacity (as a percent of predicted bladder capacity based on the formula, patient age + 2 x 30 = cc). Responders to desmopressin were classified as excellent (2 or less of 14 nights wet) or good (50% or greater decrease but more than 2 of 14 nights wet) and nonresponders were defined by a less than 50% decrease in wet nights. RESULTS: Of the 95 patients 25 (29.5%) achieved an excellent response to desmopressin and 18 (18.9%) had a good response for a cumulative response rate of 45.3%. The remaining 52 patients (54.7%) were nonresponders. There were no significant differences between responders and nonresponders in regard to gender, race, positive family history or baseline urine osmolality parameters. Response to desmopressin was associated with older age, fewer baseline wet nights and larger bladder capacity. Patients with a functional bladder capacity greater than 70% predicted bladder capacity were 2 times more likely to respond to desmopressin. CONCLUSIONS: The responsiveness of children with nocturnal enuresis to desmopressin is adversely affected by reduced functional bladder capacity. The results of this study have implications regarding the potential use of combination pharmacotherapy with desmopressin and an anticholinergic for enuretic patients who are nonresponsive to single drug therapy.

Adolescent↗
PubMed1995

Response to desmopressin as a function of urine osmolality in the treatment of monosymptomatic nocturnal enuresis: a double-blind prospective study.

To determine if urine osmolality parameters can predict whether children with primary monosymptomatic nocturnal enuresis will respond to desmopressin, we conducted a prospective, double-blind, placebo-controlled study in 96 children 8 to 14 years old. Following a 2-week baseline screening interval patients with at least 6 of 14 net nights were randomized to double-blind regimens of desmopressin or placebo. Urine specimens for osmolality were collected at 6 p.m. and 6 a.m. on 3 consecutive days during the baseline and the 2, 14-day treatment periods. A significantly greater proportion of desmopressin treated children had an excellent (2 or fewer wet nights in 14 days) or good (greater than 50% reduction in wet nights) response compared with placebo treated children (p = 0.004 and p = 0.002 for treatment periods 1 and 2, respectively). Children treated with desmopressin reported a significantly lower number of wet nights than placebo treated children during both treatment periods (p = 0.0258 and p = 0.0136, respectively). Children treated with desmopressin had a significantly higher 6 a.m. urine osmolality during both treatment periods and a higher 6 a.m.-to-6 p.m. osmolality ratio (p = 0.004) in the first treatment period compared with the placebo group. Within the desmopressin treatment group clinical responders had a higher 6 a.m. urine osmolality and 6 a.m.-to-6 p.m. urine osmolality ratio than nonresponders during both treatment periods but these differences did not achieve statistical significance. In conclusion, treatment with desmopressin is associated with a significant decrease in the number of wet nights, and a significant increase in nocturnal urine osmolality and nocturnal/diurnal urine osmolality ratios. However, clinical response was not predictable based on baseline or treatment osmolality parameters.

Adolescent↗
PubMed1995

Outcome analysis of pediatric pyeloplasty as a function of patient age, presentation and differential renal function.

PURPOSE: We retrospectively reviewed a consecutive series of patients who underwent pyeloplasty. In all cases preoperative and postoperative isotope renal scans were performed to assess the surgical outcome with particular emphasis on the change in renal function postoperatively. MATERIALS AND METHODS: The clinical records of 108 consecutive children with ureteropelvic junction obstruction were reviewed. Individual renal function was evaluated and obstruction was confirmed by diuretic assisted 99mtechnetium diethylenetriaminepentaacetic acid or mercaptoacetyltriglycine renography. A total of 100 pyeloplasties in 98 children between 5 days and 16 years old was included. Results were analyzed by groups according to patient age and symptoms at presentation. RESULTS: Drainage half-times improved in 98% of patients and only 1 required reoperation. Improved renal function greater than 5% was noted in about a third of each age group. Function remained stable in 68% of the kidneys and decreased in only 1. Of the improved kidneys 77% had impaired function preoperatively (40% or less of the total contribution). Those presenting with a renal mass had the greatest improvement in function. There was no statistically significant difference in improvement in renal function by age group or patient presentation. Regression analysis revealed that preoperative differential renal function was the only statistically significant predictor of improvement in renal function after pyeloplasty. CONCLUSIONS: Pyeloplasty in children is safe and renal functional improvement can be expected in the majority of kidneys with impaired function at presentation. However, there was no indication that early pyeloplasty in infants is more likely to result in improved function than in older children.

Adolescent↗
PubMed1995

A perspective on vesicoureteral reflux.

Prevention of UTI appears to be the most important way to avoid the serious complications of vesicoureteral reflux, which then requires early recognition, ideally prior to bacterial invasion. With early evaluation of children noted to have dilated collecting systems in utero and the screening of siblings and offspring of those with reflux, this prevention becomes possible. This screening should be performed in the first weeks to months after birth, before the first UTI. The choice of management appears to be less important than control of infection, because the results of both medical and surgical management are equal; however, because mild-to-moderate (grades I-III) reflux is likely to resolve, it seems appropriate to pursue an aggressive nonsurgical course in these patients, at least until some minimally invasive, safe interventional treatment becomes available. If reflux remains severe (grades IV and V) beyond 24 to 48 months of age, surgical intervention appears appropriate because resolution is unlikely, assuming, of course, that an experienced surgeon performs the procedure. As was evident from the European branch of the IRS, renal scarring occurred most frequently in the few patients who had ureteral obstruction after failed surgical correction. In those who continued to have mild reflux beyond 5 to 7 years of age, a trial of medication is justifiable. If infection occurs during that time and reflux persists, correction should be considered for those with clinical or scan-documented pyelonephritis. Patients who have reflux plus bacteriuria present a special problem because it is unclear whether their risks are increased. Finally, we must forewarn all our female patients with UTI in childhood that they are at risk for bacilluria during pregnancy and may require prophylaxis regardless of the state of their reflux at that time.

Algorithms↗
PubMed1994

The de-epithelialized flap and its influence on hypospadias repair.

Since its introduction in the 1970s the addition of a complete covering layer over the newly constructed urethra has positively influenced the outcome of hypospadias repairs. Originally applied by Smith during the second stage of a planned 2-stage repair and then to fistula repairs, the de-epithelialized flap has contributed to a marked reduction in post-hypospadias repair complications. The influence of this contribution as well as its application to a variation of the pedicle onlay hypospadias repair is reviewed.

Follow-Up Studies↗
PubMed1994

Pediatric pyeloplasty: is routine retrograde pyelography necessary?

To evaluate the necessity for retrograde pyelography in the preoperative evaluation of children undergoing pyeloplasty, we reviewed the records of 108 consecutive patients (age range 5 days to 18 years, median 1 year) who underwent pyeloplasty at our institution during a 6-year period. The routine preoperative evaluation consisted of a renal/bladder sonogram, furosemide renal scan (99mtechnetium-diethylenetriaminepentaacetic acid or 99mtechnetium-mercaptoacetyltriglycine) and voiding cystogram. No other imaging studies were obtained in 95 patients (88%). Other upper tract studies usually performed before referral included excretory urography in 9 cases and computerized tomography in 5. Preoperative retrograde pyelography was only performed in 1 symptomatic patient before referral to our institution. Surgical findings confirmed obstruction at the ureteropelvic junction in all patients. Undetected ureteral dilatation, which might suggest undiagnosed distal obstruction, was not encountered. After pyeloplasty 2 patients were lost to followup, renal drainage improved in 104 (98%) and drainage failed to improve in 2 of whom 1 (0.9%) required reoperation. All patients who presented with symptomatic uretero-pelvic junction obstruction experienced postoperative resolution of the presenting complaints. Our series demonstrates that routine retrograde pyelography to define the level of obstruction is not necessary for successful primary pyeloplasty. In experienced hands and with careful attention to detail, the combination of renal/bladder sonography and diuretic renography can reliably exclude the possibility of distal obstruction in children with hydronephrosis before pyeloplasty.

Adolescent↗