Bilateral testicular masses: an unusual presentation of neuroblastoma.
We describe a rare occurrence of an 11-month-old male infant with metastatic bilateral testicular neuroblastoma presenting with bilateral scrotal swelling.
Humans↗
Biomedical subjects
Christopher S Cooper
Publications and source records attributed to Christopher S Cooper.
Calcification of glutaraldehyde cross-linked collagen in bladder neck injections in children with incontinence: a long-term complication.
PURPOSE: We report the incidence of calcifications developing at the bladder neck/urethra in pediatric patients treated with glutaraldehyde cross-linked collagen for urinary incontinence. MATERIALS AND METHODS: We reviewed charts of patients treated with glutaraldehyde cross-linked collagen injections for urinary incontinence between 1994 and 1999. Etiology of incontinence, pertinent medical history, operative details and postoperative imaging were examined. RESULTS: Of 31 patients 4 (13%) had development of submucosal calcifications in the bladder neck/urethra. All 4 patients had received multiple injections of glutaraldehyde cross-linked collagen for incontinence secondary to neurogenic bladder. The calcifications were confirmed surgically. Pathology reports available for 2 of 4 patients showed chronic inflammation without dysplasia or malignant changes. Mean followup was significantly different between calcified and noncalcified cases (10.3 vs 7.2 years, p = 0.009), as was total volume of collagen injected (21 vs 12 cc, p = 0.012). Mean time to diagnosis of calcifications was 8.8 years (range 7 to 11) after first injection. A total of 24 patients without calcification underwent bladder imaging at a mean of 6.8 years (+/-2.2) after glutaraldehyde cross-linked collagen injection, which was not significantly different than the time to diagnosis (p = 0.089). The number of injections was not significantly different between the 2 groups (p = 0.426). CONCLUSIONS: Of our patients 13% had development of calcifications at the site of prior glutaraldehyde cross-linked collagen injections for incontinence. These calcifications were surrounded by chronic inflammation. Patients who have undergone glutaraldehyde cross-linked collagen injections may benefit from long-term followup with bladder imaging to detect and follow calcifications at prior injection sites.
Adolescent↗
Frequency of wetting is predictive of response to anticholinergic treatment in children with overactive bladder.
OBJECTIVES: To examine the variables relative to the response of oxybutynin treatment in children with daytime urinary incontinence. METHODS: The records of patients seen for voiding problems between 1999 and 2003 were reviewed. Patients taking oxybutynin for 3 months or longer were included in the study. Patients with structural or neurologic bladder abnormalities and those taking oxybutynin at the initial visit were excluded. Age, sex, uroflowmetry findings, postvoid residual urine volume, duration and severity of symptoms before oxybutynin, urinary tract infection history, constipation, and the duration, dosage, and adverse effects of oxybutynin treatment were evaluated. Data were analyzed using Fisher's exact test for categorical variables, the two-sample t test or Wilcoxon rank-sum test for continuous and ordinal variables, and the linear mixed model analysis for uroflow data. RESULTS: Eighty-one patients met the inclusion criteria. After an average follow-up of 1.2 years, 31 (38.3%) were dry, 25 (30.9%) had experienced significant improvement, 19 (23.5%) had experienced slight improvement, and 6 (7.4%) were unchanged. No significant differences were detected between those who became dry and those with little to no improvement with respect to age, sex, duration of symptoms, follow-up, uroflow pattern, postvoid residual urine volume, or bladder capacity. Those children presenting with decreased frequency of wetting episodes were significantly more likely to obtain daytime continence. The most common side effects were constipation (18.5%), dry mouth (17.3%), and flushing (13.6%). CONCLUSIONS: Children with daytime incontinence presenting with the lowest frequency of wetting were most likely to achieve continence. The frequency of wetting should be considered a significant prognostic variable when assessing the results of therapeutic intervention trials.
Adolescent↗
Improved efficacy of extended release oxybutynin in children with persistent daytime urinary incontinence converted from regular oxybutynin.
OBJECTIVES: To examine the response to conversion from regular oxybutynin (Ditropan) to an extended-release form (Ditropan XL) in children with persistent daytime urinary incontinence. METHODS: A retrospective review of patients with daytime wetting who switched from Ditropan to Ditropan XL included patient age, sex, reason for the change in medication, uroflowmetry findings before and after the change, side effects, and duration and dosage of the medication. The data were analyzed using a paired, two-tailed t test, with P <0.05 considered significant. RESULTS: Twenty-seven patients were followed up for an average of 35.8 months. A lack of improvement (n = 11), convenience (n = 6), side effects (n = 2), and a dislike of the taste (n = 2) were identified as reasons for changing to the extended release form. The mean dosage of Ditropan and Ditropan XL did not differ significantly (0.40 and 0.38 mg/kg/day, respectively). After the change to Ditropan XL, 6 patients had a resolution of side effects and 7 developed new side effects. Of the 27 patients, 13 became dry or had significant improvement by the first visit after the change to Ditropan XL. Significant increases in voided volume (38% versus 53%; P <0.01) and total bladder capacity (55% versus 70%; P = 0.03), normalized for age-expected bladder capacity, occurred by the first clinic visit after beginning Ditropan XL. No significant changes in the postvoid residual urine volume occurred. CONCLUSIONS: The frequency of wetting decreased and the voided volume and bladder capacity increased after a change to Ditropan XL in children with persistent wetting when taking Ditropan.
Child↗
Bladder volume at onset of reflux on initial cystogram predicts spontaneous resolution.
PURPOSE: Reflux grade is the factor most commonly used to predict spontaneous reflux resolution. We evaluated other potential predictive factors aside from reflux grade relative to spontaneous resolution. MATERIALS AND METHODS: We reviewed the records of 20 males and 98 females who were diagnosed with primary vesicoureteral reflux between ages 0 and 7 years between 1990 and 2000. Age, sex, height, weight, reflux grade, bladder volume at onset of reflux and laterality were recorded for the first, second and most recent voiding cystourethrogram or nuclear cystogram before spontaneous resolution or operative intervention. RESULTS: Of 118 patients 75 (64%) had spontaneous resolution, 27 (23%) underwent corrective surgery and 16 (13%) are still being followed. Average age at diagnosis was 2.3 years (range 1 day to 7.7 years) and average followup was 4.3 years (range 0.2 to 14). Average time to spontaneous resolution was 2.2 years (range 0.5 to 10.3) vs a time to operative treatment of 3.6 years (range 0.2 to 11.2). There was a significantly higher spontaneous resolution rate for lower reflux grades (p = 0.0004). Reflux occurring at greater than 75% of predicted bladder capacity had a significantly higher resolution rate (p = 0.0005). The initial height and weight percentile was not significant for predicting spontaneous resolution. Breakthrough urinary tract infections were negative predictors of spontaneous resolution (p <0.0001). CONCLUSIONS: In addition to grade, bladder volume relative to predicted bladder capacity at the onset of reflux appears to provide additional prognostic information regarding the likelihood of spontaneous resolution of primary vesicoureteral reflux.
Child↗
What good or harm comes from prophylactic antibiotics in children with vesicoureteral reflux?
Explore the source record for details and available documents.
Journal Article↗
Kidneys with reflux nephropathy maintain relative renal function after ureteral reimplantation.
PURPOSE: In children with severe unilateral reflux nephropathy and diminished relative renal function (RRF) a dilemma exists between the choice of treatment with ureteral reimplantation or nephrectomy. Limited followup data are available regarding relative renal function or postoperative complications after ureteral reimplantation in kidneys with significant unilateral reflux nephropathy. MATERIALS AND METHODS: We retrospectively reviewed the records of 460 patients who underwent ureteral reimplantation between 1980 and 2002, and identified children with primary vesicoureteral reflux and severe unilateral reflux nephropathy (RRF 30% or less on renal scintigraphy). The postoperative outcomes were assessed for relative renal function and complications including hypertension, pyelonephritis or persistent reflux. RESULTS: A total of 18 girls and 14 boys with a mean preoperative relative renal function of 20.1 +/- 7.8% (range 2% to 30%) met the inclusion criteria. Reflux grade in the poorly functioning kidney was II in 4 children (13%), III in 14 (44%), IV in 11 (34%) and V in 3 (9%). Reflux was unilateral in 15 children (47%) and bilateral in 17 (53%). Mean followup from surgery was 3.7 years (range 0.3 to 12.9). In 28 children with both preoperative and postoperative renal scans, mean preoperative RRF was 20.3 +/- 7.4% and mean postoperative RRF was 20.5 +/- 8.6% with a mean time between renal scans of 2.3 years. No statistically significant change was noted from preoperative to postoperative relative renal function with a mean change of +0.2 +/- 3.7% (range -6.5% to +10%, p=0.82). Postoperative complications occurred in 7 of the 32 children (22%), including hypertension (1), pyelonephritis (3) and persistent reflux (4). Pyelonephritis occurred in 1 child with persistent reflux. No statistically significant difference existed in mean preoperative relative renal function between those with and without complications (24.6 +/- 8.9% vs 18.8 +/- 7.2%, p = 0.09). CONCLUSIONS: Children who underwent ureteral reimplantation in association with unilateral reflux nephropathy maintained stable relative renal function.
Adolescent↗
Vesicoureteral reflux: who benefits from surgery?
Increased recognition of the association between urinary tract infections and reflux, sibling screening, and the evaluation of antenatal hydronephrosis have resulted in an increase in the diagnosis of reflux early in life. Although many children would sustain no untoward affects of their condition if reflux were left untreated, the disease can be severe and even life threatening. Although antireflux operations have been refined and improved, it remains difficult to determine which individuals truly benefit from these operations. A large prospective randomized placebo-antibiotic-operation study with long-term follow-up is needed, as is the development of nomograms, to assess the individual child's risk of adverse outcomes.
Child↗
Vesicoureteral reflux: surgical approaches.
The treatment of vesicoureteral reflux has evolved over the past half-century from primarily surgical to nonoperative treatments. Although the benefits of surgical correction versus medical management are debated, the surgical techniques that have evolved are highly effective in correcting vesicoureteral reflux. Recently, the US Food and Drug Administration has approved an injectable implant of dextranomer/hyaluronic acid copolymer for use in children, making the endoscopic treatment of reflux a potential alternative to open surgical correction. This article reviews the different surgical techniques,postoperative management, and complications, as well as the various implants used in the endoscopic correction of vesicoureteral reflux and their outcomes.
Animals↗
Long-term outcome analysis of Starr plication for primary obstructive megaureters.
PURPOSE: The Starr technique of tapering megaureters was first reported in 1979. Although this method of ureteral plication is well known, to our knowledge there are no clinical studies regarding outcomes. We report the first long-term outcome results with the Starr technique for primary obstructive megaureters. MATERIALS AND METHODS: Three girls and 10 boys with a total of 16 primary obstructive megaureters (3 bilateral) underwent reimplantation with Starr plication between 1988 and 2000. Baseline and followup renal function (average followup 6.2 years) was determined with renal scan and/or 24-hour urinary creatinine clearance. Average age at operation was 5.6 years (range 2 months to 13 years). All ureters were plicated using the Starr technique with interrupted polydioxanone sutures performed by a single surgeon (CEH). Reimplantation methods were the Hendren technique in 7 and Politano-Leadbetter in 9. RESULTS: No ureter demonstrated obstruction postoperatively. One ureter refluxed, which resolved with subureteral collagen injection. Seven patients had mean preoperative and postoperative creatinine clearance +/- SD 72.9 +/- 14.8 and 102.1 +/- 10.9 cc per minute, respectively (p <0.05). Six patients underwent preoperative and postoperative renal scans. Average preoperative relative renal function on renal scan in the kidney with a megaureter was 53.0% +/- 6.7% (range 37% to 84%). Long-term followup (average 4.1 years) renal scan revealed a relative function of 53.3% +/- 9.2% (range 37% to 100%). CONCLUSIONS: Our data demonstrate that Starr plication is a safe procedure that provides long-term stabilization of renal function in the management of primary obstructive megaureter.
Adolescent↗
Improved uroflow parameters and post-void residual following biofeedback therapy in pediatric patients with dysfunctional voiding does not correspond to outcome.
PURPOSE: We evaluated pediatric patients who were treated with biofeedback for dysfunctional voiding with respect to clinical outcome and objective changes in uroflow parameters and post-void residual. MATERIALS AND METHODS: We retrospectively reviewed 81 patients treated for dysfunctional voiding and/or urinary tract infections with biofeedback. Conservative management had previously failed in all patients. Uroflow data and symptoms were reviewed, and clinical outcomes were recorded. For analysis, patients were stratified by symptoms of incontinence or presence of urinary tract infections. RESULTS: Of 73 patients with incontinence 22 (30%) became dry, 36 (49%) had improvement and 15 (21%) reported no change following biofeedback. In 39 (78%) of 50 patients with recurrent urinary tract infections resolved. Overall, there was a significant (p <0.002) increase in peak flow and average flow rate, and a significant decrease in post-void residual and post-void residual as a percent of predicted bladder capacity. There was no significant change in voided volume following biofeedback. Overall, there was no significant difference in uroflow parameters and post-void residual following biofeedback between patients with incontinence or infections, except for a higher maximum flow rate in patients who continued to have infections. CONCLUSIONS: Treatment of children with pelvic floor muscle biofeedback is associated with improved urinary continence and decreased urinary tract infections in the majority. It results in improvement in uroflow curves and parameters, and a decreased post-void residual. Posttreatment results of these parameters did not correlate with improvement in continence and urinary tract infections.
Adolescent↗
Coping, commitment, and attitude: quantifying the everyday burden of enuresis on children and their families.
OBJECTIVE: To develop and evaluate a parent-completed questionnaire for use by clinicians as part of routine care to assess the burden of diurnal and nocturnal enuresis on children and their families. METHODS: The questionnaire consisted of items that measure the impact on the child and his/her parent, the child's coping ability and commitment to treatment, previous treatment success, family frustration and overall cohesion, and parental attitudes about enuresis and its treatment. Questionnaires (n = 208) were completed by parents during the child's scheduled office visit for enuresis at 5 specialty clinics across the United States. Traditional criteria were used to assess reliability and validity of the questionnaire, including analysis of variance. RESULTS: Success rates provide evidence that many of the items in the child scale (79%) and all items in the parent scale (100%) met stringent criteria. alpha values were.62 and.77, respectively. Statistically significant differences were observed for the scales across responses on all but 1 global item, the majority of parental attitude items, whether the child urinated at bedtime, and the number of pads used. These findings suggest that the child's coping ability and commitment and the family's overall cohesion and frustration with the problem influence parental perceptions about the impact of enuresis on the child and the family. CONCLUSIONS: Findings about the performance of the new measure were satisfactory and suggest that, after further refinement, it should prove as a useful tool for clinicians treating enuresis in children.
Adaptation, Psychological↗
Laparoscopic upper pole heminephrectomy for ectopic ureter: initial experience.
OBJECTIVES: To determine the feasibility, clinical outcomes, and complications of laparoscopic upper pole heminephrectomy for ectopic ureter. The standard treatment for a duplex kidney with a poorly functioning upper pole moiety is an upper pole heminephrectomy. We review our technique and experience with laparoscopic upper pole heminephrectomy. A brief review of the literature is provided. METHODS: A retrospective review of clinical records from three patients who underwent laparoscopic upper pole heminephrectomy was performed. Two of the three patients presented with lifelong urinary incontinence and were diagnosed with an ectopic ureter associated with a poorly functioning upper pole moiety. The third patient presented with recurrent episodes of pyelonephritis and was found to have a duplex kidney with a poorly functioning upper pole segment draining into a ureterocele. RESULTS: All three patients underwent laparoscopic upper pole heminephrectomy through the transperitoneal approach. Mean operative time, including ureteral stent insertion, was 198 minutes. Two of the three patients were discharged within 24 hours of surgery. The third patient had a urinary leak secondary to a small amount of residual upper pole parenchyma which resolved with superselective renal arterial embolization. All three patients are well at 5.3 months follow-up. CONCLUSIONS: Laparoscopic upper pole heminephrectomy for ectopic ureter is safe and reproducible and offers the patient the typical postoperative benefits of laparoscopic surgery.
Adolescent↗
Long-term efficacy of periurethral collagen injection for the treatment of urinary incontinence secondary to myelomeningocele.
PURPOSE: The reports of efficacy of periurethral collagen injection (Contigen, Bard, Covington, Georgia) for treatment of urinary incontinence in the myelomeningocele population are limited and variable. We reviewed the efficacy of periurethral collagen in patients with myelomeningocele to provide long-term followup data. MATERIALS AND METHODS: From 1994 to 1999, 19 children and 6 adults with myelomeningocele underwent periurethral injections of collagen with an average of 2 treatments per patient. Mean followup +/- SD from last injection in the pediatric and adult groups was 2.9 +/- 1.5 years and 4.7 +/- 2.6 years, respectively. Postoperative continence was defined as dry, improved or unchanged. RESULTS: No pediatric patients became dry, 7 (37%) improved and 12 (63%) were unchanged. A single adult was dry (17%), 4 (67%) improved and 1 remained unchanged. Transient improvement was noted in 8 of the 13 patients who reverted to an unchanged status. Response rate was 66% in nonambulatory patients versus 42% in ambulatory patients (p = 0.38). Of 12 patients who responded and 13 who did not 8 in each group required 2 or more treatments. The responding group percentage of predicted bladder capacity was 97.6% versus 89.5% in those who remained unchanged (p = 0.66). CONCLUSIONS: The initial transient improvement following collagen injection and the long-term improvement following repeat injections suggest that degradation of collagen decreased its efficacy. The long-term results of this minimally invasive technique are poor.
Adult↗
Comparison of relative renal function by renal scintigraphy and lateralized creatinine clearance in children with bilateral vesicoureteral reflux.
OBJECTIVES: To evaluate the relative renal function on preoperative and postoperative renal scintigraphy with lateralized creatinine clearance. Multiple factors affect renal blood flow and glomerular filtration that alter the relative renal function calculated by renal scintigraphy. The relative renal function according to renal scintigraphy in children with bilateral vesicoureteral reflux has not been compared with lateralized creatinine clearance. METHODS: We retrospectively reviewed the charts of 45 children treated surgically for bilateral vesicoureteral reflux. The average age at time of reimplantation was 5.3 years. Bilateral ureteral catheters were placed intraoperatively. Lateralized creatinine clearance was measured with 24-hour urine collections postoperatively from each catheter. Bladder catheterization was not performed during the renal scans. RESULTS: Thirty-six of 45 children had preoperative 1 to 3-minute relative renal function assessed by scintigraphy, 28 had a postoperative assessment, and 24 had both. Preoperative relative renal function ranged between 51% and 94% (mean 61.3%) in the higher functioning kidney. Postoperative renal function ranged from 47% to 90% (mean 60.5%) in the higher functioning kidney. A strong correlation existed between preoperative relative renal function and lateralized creatinine clearance (P <0.0001). Similarly, a significant correlation existed between the postoperative assessment and lateralized creatinine clearance (P <0.0003). No significant difference occurred between the preoperative and postoperative 1 to 3-minute relative renal function (P = 0.3552). CONCLUSIONS: The 1 to 3-minute relative renal function determined by renal scintigraphy accurately reflects the relative renal function determined by lateralized creatinine clearance. Bladder catheterization does not appear necessary for accurate determination of relative renal function by renal scan even in the presence of bilateral reflux.
Adolescent↗
Laparoscopic upper-pole heminephrectomy for ectopic ureter: surgical technique.
A duplex kidney associated with a poorly functioning upper-pole segment is commonly associated with incontinence, voiding dysfunction, and urinary tract infections. A standard treatment option for this condition is upper-pole heminephrectomy. With the continued development of minimally invasive urology, this technique can now be safely performed laparoscopically. This report details step by step our technique of laparoscopic upper-pole heminephrectomy. Key points include placement of a catheter in the normal ureter at the start of the case, full mobilization of the upper-pole ureter away from the renal hilum, and precise identification of the vasculature supplying the upper pole. Laparoscopic upper-pole heminephrectomy for ectopic ureter is safe and reproducible and offers the patient the typical postoperative benefits of laparoscopic surgery.
Humans↗
Effectiveness of lidocaine lubricant for discomfort during pediatric urethral catheterization.
PURPOSE: Many children with urinary tract infections and vesicoureteral reflux require catheterization. Catheterization can be a painful experience, and a desire to avoid this experience may affect patient care. We evaluated the effectiveness of lubricant containing lidocaine for minimizing patient pain and distress during catheterization. MATERIALS AND METHODS: We conducted a prospective, double-blind, placebo controlled trial. Twenty children (16 girls and 4 boys, mean age 7.7 years) had urethral lubricant with or without lidocaine placed within 10 minutes before urethral catheterization. In all children pre-procedure anxiety, and pain and distress during catheterization were recorded. Pre-procedure anxiety was measured using a visual analog scale, pain was measured with the Oucher Pain Scale and distress was recorded by 2 independent observers with a simple 7-point Likert-type scale. RESULTS: There were no significant group differences for age, number of previous catheterizations or pre-procedure anxiety. The group receiving lubricant with lidocaine had significantly lower pain (21 +/- 19.69 versus 65.5 +/- 26.29) and distress (2.65 +/- 1.97 versus 4.7 +/- 2.07) (p = 0.001 and 0.007, respectively). CONCLUSIONS: The use of lubricant with lidocaine significantly decreases pain with pediatric urethral catheterization and is recommended with pediatric catheterizations.
Anesthetics, Local↗
Bimanual digital rectal examination for the evaluation of the nonpalpable testis.
PURPOSE: In the evaluation and treatment of the nonpalpable testis open surgical exploration and laparoscopy are methods used to differentiate abdominal, infrainguinal (below the internal ring) and atrophic or absent testes. We sought to evaluate the use of bimanual digital rectal examination as an additional tool to localize the nonpalpable testis. MATERIALS AND METHODS: Forty-one consecutive patients with 45 nonpalpable testes were evaluated in a prospective fashion. Bimanual digital rectal examination was performed with the patients under general anesthesia just before diagnostic laparoscopy or open inguinal exploration. Palpability, location, length and contralateral testicular length were recorded. RESULTS: Twenty-five gonads or spermatic cords (56%) were palpable using the bimanual technique. All positive examinations were confirmed laparoscopically or by open exploration, and the majority of gonads were intra-abdominal (17 of 25, 68%). Seventeen normal appearing gonads underwent orchiopexy and 8 were removed secondary to atrophy, dysgenesis or poor position. Twenty testes (44%) were not palpated using this method. Of these gonads 10 normal appearing testes were found at exploration and underwent orchiopexy. Of the 10 remaining gonads 6 atrophic testes were removed, and 4 hemosiderin laden remnants were thought to represent "vanished testes." Overall, 26 gonads or remnants were intra-abdominal, 10 were "peeping" or canalicular and 9 were infrainguinal. The overall specificity was 100%, with a sensitivity of 60%. The positive predictive value was 100%. CONCLUSIONS: Bimanual digital rectal examination is a valuable tool in the evaluation of the nonpalpable testis, and identified the presence and position of the testis in the majority of our cases. Although sensitivity is low, when the testis is palpated by this method, diagnostic laparoscopy to localize the testis may be avoided.
Algorithms↗