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Biomedical subjects

B M Churchill

Publications and source records attributed to B M Churchill.

At least 55 records · Page 3Linked to original sources
PubMed1994

Can previously relocated penile skin be successfully used for salvage hypospadias repair?

Between 1986 and 1992, 39 boys underwent 44 pedicle flap urethroplasties as a salvage procedure using penile skin that had been relocated during prior hypospadias repair(s). All previous operations had resulted in a meatus in an unacceptable position. The salvage pedicle flap procedure used for these boys was either a Mathieu urethroplasty or an island flap repair. Of 28 patients who underwent salvage Mathieu urethroplasty 20 (71%) required no further surgery, 4 had strictures or fistulas repaired and 4 (14%) required further urethral reconstruction, including 1 island flap and 2 Mathieu operations. Of 16 boys who underwent salvage island flap procedures 7 (43%) required no further treatment, 4 had fistulas, 2 had had urethral strictures and 4 had a subcoronal meatus, of whom 3 underwent further urethral reconstruction, including 2 Mathieu and 1 Thiersch-Duplay operations. We defined overall success as ultimately having a functional urethra without persistent fistulas or strictures and a cosmetically acceptable glanular meatus. Excluding 2 patients who are awaiting fistula repair, 34 of 37 evaluable cases (92%) were successfully repaired. We conclude that relocated penile skin can be used successfully to base a pedicle flap for salvage hypospadias repair.

Child, Preschool↗
PubMed1994

The role of retroperitoneal lymphadenectomy in localized paratesticular rhabdomyosarcoma.

Between 1985 and 1990, 10 cases of embryonal paratesticular rhabdomyosarcoma were treated at our institution. Patient age ranged from 5 months to 16 years at presentation (mean 8.7 years). Chest and abdominal computerized tomography (CT) was performed on all patients. Lymphangiography was performed on 2 patients, and 6 underwent retroperitoneal lymphadenectomy, due to suspicious CT (2) and a positive lymphangiogram (1). All 6 patients had pathologically negative nodes, and they received vincristine, actinomycin D and cyclophosphamide for 8 to 13 months (mean 10.6 months). Four patients also received doxorubicin. The 10 patients are alive and the disease is in complete remission for a mean 6.02-year disease-free survival. These data support the hypothesis that retroperitoneal lymphadenectomy can be avoided for paratesticular rhabdomyosarcoma after radical inguinal orchiectomy when CT is negative for nodal involvement.

Adolescent↗
PubMed1994

Iliac osteotomy: a model to compare the options in bladder and cloacal exstrophy reconstruction.

Bladder exstrophy and cloacal exstrophy present challenging reconstructive problems. Traditionally, bilateral posterior iliac osteotomy has been performed in the majority of patients undergoing primary closure for these abnormalities. Recently, 2 anterior osteotomy approaches have been proposed: 1) incision of the ilium transversely above the acetabulum (transverse osteotomy) and 2) incision of the superior ramus of the pubis (superior ramus osteotomy). We devised a new anterior mid-iliac diagonal osteotomy that provides a more functional pelvic closure. To provide a fair comparison of the procedures we developed a pelvic exstrophy model based on data from a 3-dimensional computerized tomogram of a 3-year-old patient with classical bladder exstrophy. The different osteotomies were then performed on the model and the results were compared. Our new anterior mid-iliac diagonal osteotomy correction allowed the best surgical approach, provided the best correction of the flattened ilia bony deformities, was performed in the thinnest area of marrow bone and resulted in the best pelvic symmetry.

Bladder Exstrophy↗
PubMed1994

A modified extravesical technique for megaureter repair.

OBJECTIVE: To report on the use of extravesical detrusorraphy for megaureter repair. PATIENTS AND METHODS: Twenty-three children underwent an extravesical megaureter repair over a 25 month period. There were 17 boys and 6 girls with an average age of 4.4 years. Three children had bilateral megaureters for a total of 26 repairs. Ureters were defined as megaureters if the ureteric diameter exceeded 1.0 cm on pre-operative imaging. There were 14 obstructing and 12 refluxing ureters. Three of the refluxing ureters were tapered while five of the obstructing megaureters were tapered. RESULTS: Twenty-one of the 23 patients were successfully repaired using this method. Complications were minimal. CONCLUSION: The extravesical approach can be used to correct reflux or obstruction in dilated ureters with efficacy equivalent to transvesical repairs.

Adolescent↗
PubMed1993

Hypertension following primary bladder closure for vesical exstrophy.

Since the initiation of staged reconstruction for bladder exstrophy, hypertension has been a known complication of the procedure. The etiology of the elevation in blood pressure was presumably secondary to ureteral dysfunction caused by edema at the ureterovesical junction and secondary renal obstruction. This report details the clinical course of three patients who developed significant hypertension following primary bladder closure with posterior iliac osteotomies and bony immobilization by skin traction. None of the patients had urinary obstruction and all had their hypertension alleviated by removal of the traction. The presumed etiology of the elevated blood pressure within these patients is similar to that experimentally produce by inappropriately applied traction resulting in tension on the sciatic nerve and reflex induced vasoconstriction. The need to maintain appropriately applied traction and the necessity of monitoring the postoperative blood pressure is stressed.

Antihypertensive Agents↗
PubMed1993

Ureteral bladder augmentation.

Virtually all segments of the gastrointestinal tract have been used successfully in augmentation cystoplasty. The complications inherent in enterocystoplasty are well described. Megaureters subtending effete kidneys (poorly or nonfunctioning) provide a novel and excellent source of augmentation material with urothelium and muscular backing, free of the electrolyte and acid base disturbances, and mucus production that plague enterocystoplasty. Augmentation cystoplasty using detubularized, reconfigured, otherwise disposable megaureter, with or without ipsilateral total or partial nephrectomy, was performed in 16 patients (mean age 8.8 years, range 1 to 25) with inadequate and dysfunctional bladders. Postoperative followup varied between 8 and 38 months (mean 22). The overall renal function and radiographic appearance of the remaining upper tracts have remained stable or improved in all patients. Of the 16 patients 15 require intermittent catheterization and 1 voids spontaneously. Ten patients are continent day and night, 5 have improved continence (4 damp at night and 1 stress incontinence) and 1 has failed to gain continence despite good capacity and compliance. Complete postoperative urodynamic evaluations in 12 of 13 patients show good capacity, low pressure bladders with no instability. Complications occurred in 5 patients, including transient urine extravasation in 2, contralateral ureterovesical obstruction in 2 and Mitrofanoff stomal stenosis in 1. Augmentation ureterocystoplasty combines the benefits common to all enterocystoplasties without adding any of the untoward complications or risks associated with nonurothelial augmentations.

Adolescent↗
PubMed1993

Effectiveness of preoperative chemotherapy in the treatment of Wilms tumor with vena caval and intracardiac extension.

Surgical treatment of Wilms tumor with vena caval and intracardiac extension is challenging, often requiring cardiopulmonary bypass. We report the response to preoperative chemotherapy in 3 patients following a protocol at our hospital. The tumor thrombus was limited to the inferior vena cava in 2 patients and extended to the right atrium in 1. All 3 patients had marked reduction or complete eradication of the venous thrombus, facilitating the final surgical procedure. The patients are disease-free 18 months to 7 years after the initial treatment. Our protocol involves initial radiographic staging followed by needle biopsy, chemotherapy, repeat radiographic staging, definitive resection and additional chemotherapy. Our results confirm the effectiveness of this approach, which appears to decrease morbidity associated with intracaval and intra-atrial tumor extension.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1993

A new technique for dynamic analysis of bladder compliance.

We propose an alternative method of measuring compliance that takes into account the multiple phases of bladder filling. We describe our new technique, dynamic compliance analysis, and evaluate its clinical applicability. To perform the analysis we digitized a cystometrogram curve at a sampling rate of 2 samples per second using an MS-DOS computer system. A program designed to retrieve the stored data was used to analyze the subtracted bladder pressure. The result yielded a value of compliance every half second that was then plotted on an x-y graph, with instantaneous compliance as the dependent variable and per cent of total volume infused as the independent variable. To determine the clinical applicability of this technique we chose 63 curves from clinically normal patients. The results of the dynamic compliance analyses were predictable. The dynamic compliance values for the normal group had a minimum that was always greater than 10 ml./cm. water throughout the tonus limb (phase 2) of the cystometrogram. We conclude that dynamic compliance analysis yields more information about bladder response during filling, similar to the stress-strain curve used in the study of solid mechanics.

Biomechanical Phenomena↗
PubMed1993

What volume can a child normally store in the bladder at a safe pressure?

To determine what volume a child can normally store in the bladder at a safe pressure 923 pediatric urodynamic studies were reviewed, and 69 examinations done on 17 boys and 52 girls were considered normal. Patient ages were recorded and body surface areas were calculated. A continuous intermediate flow water cystometrogram had been performed. Total bladder capacity in milliliters, full resting pressures (cm. water), and the volumes (milliliters) and percentages of the total bladder capacity stored at detrusor pressures of less than 10, 20, 30 and 35 cm. water were measured. We found that 98.1% of the total bladder capacity could be stored at a detrusor pressure of less than 20 cm. water in more than 95% of the children independently of age or body surface area and 99.9% could be stored at a detrusor pressure of less than 30 cm. water. An approximation of the minimal acceptable total bladder capacity for age can be calculated by 16(age) + 70 in ml. According to our results, we proposed criteria for good storage characteristics of the bladder in children.

Body Surface Area↗
PubMed1992

Complications of surgical significance in pediatric renal transplantation.

From 1969 to 1986, 303 renal allografts (290 cadaveric) were placed in 215 pediatric recipients. Twenty-three patients (7.6%) had renovascular complications and 16 (5.3%) had nonrenovascular complications. The overall incidence of surgically significant complications was 12.9%. Of these, 54% were felt to be of a technical etiology. The remainder were surgically significant in that their management necessitated operative intervention.

Adolescent↗
PubMed1992

Rapid development of an immunoblastic lymphoma and death in children following cadaveric renal transplantation.

We report on three children who underwent cadaveric renal transplantation and subsequently developed an immunoblastic lymphoma, leading to death in two patients. The development of the lymphoma occurred following a multi-drug immunosuppression regimen ending with monoclonal antilymphocyte (OKT3) treatment for biopsy-proven cellular and vascular acute rejection. These patients represent three of 11 children who received OKT3 treatment for rejection in the last 18 months at this institution. Following the diagnosis of lymphoma, all three patients were treated by transplant nephrectomy, cessation of immunosuppression, and administration of intravenous acyclovir. The first two patients died at 4 days and 4 weeks, respectively, after the definitive diagnosis was made with widespread metastatic disease. The remaining child is a short-term survivor (13 months), free of demonstrable malignancy. Multidrug regimens for immunosuppression have a profound effects on T cell function. These effects, when combined with a primary infection by the Epstein-Barr virus, are implicated in the rapid development of the lymphomas and are responsible for the death of these two children.

Cadaver↗
PubMed1992

Evaluation of factors contributing to mortality in pediatric renal transplant recipients.

From 1969 to 1985, 303 renal allografts (290 cadaveric) were placed in 215 pediatric recipients. A review of actuarial recipient and allograft survival 2 years posttransplant showed good results in patients over 6 years of age (greater than 90% for patients, about 70% for allografts) but less satisfactory results in younger patients (75% for patients, about 45% for allografts). Thirty-nine patients died. Loss of allograft function preceded death in 67% of cases and was due to rejection (61%), renal vascular thrombosis (35%), and recurrence of original disease (4%). On retrospective analysis, 13 deaths might have been preventable with current diagnostic and therapeutic modalities. Allograft dysfunction from thrombosis occurs at a higher frequency in the young child and may be confused with rejection. Treatment of rejection without biopsy, overagressive treatment of a chronically failing graft, and failure to withdraw immunosuppressive therapy in face of infection are poorly tolerated in the very young recipient and are prominent causes of preventable mortality. Transplant nephrectomy and repeated attempts at transplantation are poorly tolerated in very young patients. Patient survival is very dependent on the success of the initial allograft in children.

Age Factors↗
PubMed1992

The efficiency of bladder emptying in the prune belly syndrome.

From 1956 to 1991, 49 cases of the prune belly syndrome were seen at our institution. Voiding information and/or 1 or more urodynamic studies were available in 30 male and 4 female patients. Analysis of multiple urodynamic studies during long-term followup periods ranging from 6 months to 19 years, with particular regard to any reconstructive procedures performed, revealed that voiding in the prune belly syndrome is variable, with 44% of the patients achieving spontaneous voiding and 56% requiring clean intermittent catheterization. The ability to void or need for clean intermittent catheterization was by no means permanent, indicating the need for meticulous followup. The 3 distinct voiding patterns observed included an approximately normal pattern, prolonged voiding with a low peak and an intermittent pattern. These 3 voiding patterns did not correlate with residual volumes. Comparison of urodynamic voiding parameters between reconstructed voiding patients and nonreconstructed voiding patients did not show significant differences.

Adolescent↗
PubMed1992

Extravesical nondismembered ureteroplasty with detrusorrhaphy: a renewed technique to correct vesicoureteral reflux in children.

We performed an extravesical nondismembered reimplant to correct surgically primary vesicoureteral reflux in 45 patients (65 renal units) between April 1989 and September 1990. Of the units 6 had grade I reflux, 16 grade II, 23 grade III, 14 grade IV and 6 grade V. Only patients with primary reflux were included in this study. The success rate was 100% for grades I to III, 92.9% for grade IV and 66.7% for grade V. Overall, the reflux was cured in 62 of the 65 operated renal units (95.4%) or 95.6% of the patients (43 of 45). Postoperative morbidity and complications were minimal. No cases of postoperative obstruction were detected on excretory urography 6 weeks postoperatively. Seven children (16%) suffered from transient inadequate bladder emptying as assessed by post-void ultrasound residual evaluations. This problem resolved spontaneously after a maximum of 4 weeks of clean intermittent catheterization. Compared to conventional transvesical technique, the discomfort related to bladder spasms during the postoperative period was subjectively decreased and patients had no prolonged hematuria.

Adolescent↗
PubMed1992

A surgical model for normotensive chronic renal failure in the growing piglet.

Studying the effects of chronic uremia in children has been hindered by the lack of a suitable large mammalian animal model with normotensive renal failure. We performed nephrectomy with simultaneous contralateral partial nephrectomy using a stapling device and absorbable staples in 22 domestic piglets. Up to 93% of the total renal mass could be excised by this method. A chronic uremic state was reproducibly developed and correlated with the percentage of renal mass excised. There were no associated postoperative complications with the stapled partial nephrectomy. Pigs with moderate renal failure had a significant decrease in growth compared to those with mild renal failure, which represents the successful development of a normotensive large mammalian animal model that could be used to study the effects of chronic renal failure and hyperfiltration during a state of rapid growth. In addition, this study confirms the successful use of a stapling device to perform partial nephrectomy.

Animals↗
PubMed1992

Radiographic and serologic correlates of azotemia in patients with posterior urethral valves.

A retrospective statistical analysis with a minimum followup of 10 years was done on 102 patients who presented in early childhood with posterior urethral valves. All patients were treated with initial bladder drainage. Factors correlating with the development of renal failure were evaluated. No patient with a normal kidney on 1 side had renal failure. Calculated glomerular filtration rate was significantly higher in patients who retained adequate renal function (80.7 +/- 17.8 ml. per minute per 1.73 m.2), as compared with those who had renal failure (18.6 +/- 9.6 ml. per minute per 1.73 m.2). Patients with renal failure also had a significantly higher serum creatinine level at stabilization (2.0 +/- 0.8 mg./dl.) than those who had adequate renal function (0.5 +/- 0.2 mg./dl.). The presence of bilateral high grade vesicoureteral reflux, hydronephrosis and nonfunction was significantly higher in patients with renal failure. Patient age at presentation was not a significant factor. These data represent a guideline for the prognosis and management protocols of infants with dilated upper urinary tracts and posterior urethral valves.

Age Factors↗
PubMed1992

Omeprazole in post-gastrocystoplasty metabolic alkalosis and aciduria.

The use of segments of stomach for bladder augmentation is gaining popularity in pediatric urology due to favorable muscular and secretory properties. However, in a renal failure patient who underwent gastrocystoplasty a high level of acid production within the bladder associated with persistent hypergastrinemia was noted leading to severe systemic metabolic alkalosis. This condition was unresponsive to standard acid-inhibiting or neutralizing therapies but it was treated successfully with omeprazole, a proton-pump inhibitor recently introduced for treatment of peptic ulcer disease.

Alkalosis↗