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Biomedical subjects

D A Bloom

Publications and source records attributed to D A Bloom.

At least 55 records · Page 3Linked to original sources
PubMed1998

Laparoscopy for the nonpalpable testis.

Cryptorchidism represents one of the most common childhood disorders with the incidence of testicular maldescent being 0.8% by 1 year of age. Nonpalpable testis occurs in approximately 20% of patients with cryptorchidism. Laparoscopy for diagnosis and management of nonpalpable testis has shown to be highly effective with few complications. This article reviews some of the special considerations in performing laparoscopy in children with descriptions about the unique features of a child's anatomy and physiology. The role of laparoscopy in the evaluation and management of nonpalpable testis is discussed, along with some of the controversies about how laparoscopy may be changing our approach to a child with a nonpalpable testis.

Cryptorchidism↗
PubMed1998

The cystometrogram at 70 years.

PURPOSE: The origin and the development of the cystometrogram are described. MATERIALS AND METHODS: We reviewed and analyzed the published literature on cystometrography. RESULTS: The cystometrogram originated in the latter half of the nineteenth century, an age of intense clinimetric investigation. Early investigators studied fundamental aspects of bladder function with meticulous techniques using relatively crude equipment. The first clinical cystometer was designed by Dalton K. Rose in 1927. He was followed by Nesbit, McLellan, Muschat and Munro, who brought the cystometrogram to its current key role in modern urology. CONCLUSIONS: Numerous investigators have advanced the knowledge of bladder function using the cystometrogram, a key urological tool.

Europe↗
PubMed1997

Correlation of cystographic bladder morphology and neuroanatomy in boys with posterior urethral valves.

PURPOSE: We have observed a difference in the radiographic appearance of the body of the bladder (trabeculated) and its base (smooth) in boys with severely obstructing posterior urethral valves. We wanted to determine if (1) this was a reproducible finding and (2) there was an anatomic and/or physiologic explanation for it. MATERIALS AND METHODS: We reviewed the initial voiding cystourethrogram in 47 boys with severe posterior urethral valves. The interureteric ridge was used as the division between the body and base of the bladder. The presence of trabeculation for each region was recorded. RESULTS: Ages ranged from 1 day to 6 years at the time of initial cystographic evaluation (median 14 days). The body of the bladder was trabeculated and the base smooth in 72 % (34 patients). In the remaining patients, both the body and base were smooth. In no patient was the base trabeculated. CONCLUSIONS: The cystographic morphology of the urinary bladder in boys with posterior urethral valves can be explained by its neuroanatomy. The body of the bladder, which contracts during voiding because of parasympathetic (cholinergic) stimulation, becomes trabeculated. The bladder base relaxes during voiding due to sympathetic (alpha adrenergic) stimulation and remains smooth. Thus, this difference in the cystographic appearance of the two parts of the urinary bladder reflects the normal innervation and the mechanics of micturition in boys with urethral obstruction.

Child↗
PubMed1997

Hippocrates and urology: the first surgical subspecialty.

Hippocrates, who is generally considered a focal point for the start of western medical tradition, left behind a corpus of medical writings that constituted the first recorded comprehensive health system. The pivotal point of the Hippocratic corpus was the Hippocratic Oath, which outlined the duties of healers of his school, but demarcated lithotomy as a practice that was off limits to his fellow physicians. Surgery for bladder stone, urology in essence, was thus the first specifically identified surgical subspecialty.

Hippocratic Oath↗
PubMed1997

Bladder management in patients with pediatric onset neurogenic bladders.

Our objective was to determine which clean intermittent catheterization (CIC) methods and supplies were used by patients with pediatric onset neurogenic bladders and to relate methodology and materials to reported urinary tract infections. Data were collected via questionnaires distributed by mail and at clinic visits at our university tertiary care outpatient pediatric rehabilitation clinic. Questionnaires were given to 165 patients. Fifty-nine percent were returned (68 patients with myelomeningocele, 27 with pediatric onset spinal cord injury (SCI) and two with other diagnoses). Mean age was 12 years (range 1-27). Fifty-four percent of patients participated in their own CIC. Only two percent used sterile catheterization technique, whereas 98 percent used CIC. A sterile catheter was employed with clean technique by 22 percent. Catheters were reused by 76 percent. Subjects used a wide ranging number of catheters per month, with a median of 5.3. There was no correlation between the number of urinary tract infections (UTIs) per year and the type of catheter used or the use of prophylactic antibiotics. Compared with patients with myelomeningocele, subjects with SCI were significantly more likely to use sterile catheters (p = 0.04), > 10 catheters per month (p = 0.01) and gloves (p < 0.001). Subjects who used gloves or more catheters were more likely to experience UTI. These data suggest that clean reused supplies are not related to an increased likelihood of UTI and should be considered a way to lower costs in these populations.

Adolescent↗
PubMed1997

What imaging studies are necessary to determine outcome after ureteroneocystostomy?

PURPOSE: After ureteroneocystostomy we have performed renal ultrasonography within the first 3 months to exclude hydronephrosis, voiding cystography after 3 months to exclude vesicoureteral reflux and subsequent ultrasonography to monitor the upper tracts. This study attempted to determine those patients at risk for hydronephrosis or recurrent vesicoureteral reflux. MATERIALS AND METHODS: We studied the records of patients who underwent ureteroneocystostomy in the last decade at our institutions to find the incidence and degree of preoperative and postoperative hydronephrosis and vesicoureteral reflux. Results of initial postoperative imaging were compared to radiological imaging throughout followup (mean 2.3 years). Patients with postoperative reflux were evaluated for risk factors that differentiated them from others. RESULTS: Excluding patients with neuropathic bladder or ureterocele, 167 underwent 278 ureteroneocystostomies at a mean followup of 26.5 months. Persistent vesicoureteral reflux was noted in 4 kidneys (1.4%) and contralateral reflux developed in 3 of the 48 cases (6.3%) of unilateral ureteroneocystostomy. There was no statistical difference in success rates among cross-trigonal, ureteral advancement or extravesical techniques. New onset mild hydronephrosis in 13 kidneys (4.7%) at the initial followup study (mean 1.6 months) completely resolved in 12 and remained mild in 1. No patient had progression of existing hydronephrosis and 1 had recurrent vesicoureteral reflux after initial negative cystography. Risk factors for postoperative reflux or hydronephrosis were preoperative dysfunctional voiding, preoperative hydronephrosis or scarring on sonography and postoperative urinary tract infection. None of the 88 patients without these risk factors had postoperative hydronephrosis or reflux. All patients with persistent, contralateral or recurrent reflux were selected using these criteria (p < 0.003). CONCLUSIONS: Complication rates after nontapered ureteroneocystostomy in children without neuropathic bladder are quite low. Mild postoperative hydronephrosis was not clinically significant in our patients. Children with abnormal preoperative ultrasound or dysfunctional voiding are identified as a high risk group for postoperative hydronephrosis or recurrent reflux. All other patients received little benefit from postoperative imaging, suggesting that further evaluation of this group is necessary only in the presence of a postoperative urinary tract infection.

Child↗
PubMed1997

Urodynamics and massive vesicoureteral reflux.

PURPOSE: Urodynamic studies are the key to management and reconstruction of bladder pathology. In the face of high grade vesicoureteral reflux measured pressures and volumes reflect the combined storage characteristics of the upper and lower tracts. We examined the influence of high grade reflux on measured volume and compliance (change in volume/change in pressure). MATERIALS AND METHODS: A total of 18 children with high grade vesicoureteral reflux underwent urodynamic evaluation with and without ureteral occlusion. Occlusion was created in the operative suite using ureteral occlusion balloons. After fluoroscopic confirmation of the absence of reflux bladder pressure was measured during filling at a rate of 12.5 cc per minute. During ureteral occlusion bladder capacity was defined as leakage around the urethral catheter, bladder pressure greater than 40 cm. water or volume exceeding estimated bladder capacity for age, as determined by the formula, bladder capacity in ml. = (age + 2) x 30. The ureteral occlusion balloons were removed and similar measurements were obtained in the presence of reflux. Compliance was calculated for the first and last 50% (initial and terminal compliance, respectively) of bladder capacity. RESULTS: Mean initial compliance without and with ureteral occlusion was 19.6 versus 13.2 cm. water (33% decrease). Mean terminal compliance without and with occlusion was 12.9 versus 8.6 cm. water (33% decrease, p < 0.005). Bladder capacity decreased a median of 16%. Underlying bladder pathology was evaluated to determine the patients who would benefit most from ureteral occlusion studies. Patients with neurogenic bladder, posterior urethral valves and primary reflux had similar changes in measured compliance with ureteral occlusion. Patients with poor terminal compliance without occlusion and those with bilateral vesicoureteral reflux had greater changes in compliance with occlusion but these changes were not statistically significant (p < 0.05). Age was indicative of a significant decrease in terminal compliance with ureteral occlusion, since older patients had the greatest change in terminal compliance (p < 0.005). CONCLUSIONS: High grade vesicoureteral reflux influences measured lower tract volume and compliance.

Adolescent↗
PubMed1997

Vesicoureteral reflux and ureteropelvic junction obstruction: association, treatment options and outcome.

PURPOSE: We investigated the association, treatment options and outcomes of patients with ureteropelvic junction obstruction and concomitant vesicoureteral reflux. MATERIALS AND METHODS: We analyzed 6,790 consecutive pediatric urology records at our university. Treatment options included observation, and primary pyeloplasty, ureteroneocystostomy and nephroureterectomy. Hydronephrosis, reflux and obstruction were judged as resolved, improved, unchanged or worse. RESULTS: A total of 1,140 patients had vesicoureteral reflux, 224 had ureteropelvic junction obstruction and 41 had both conditions (39 ipsilateral and 6 contralateral kidneys). There was no increased risk of obstruction in patients with reflux when all grades of reflux were grouped (odds ratio 1.26, confidence interval 0.91 to 1.71). In contrast, subgroup analysis of patients with high grade reflux demonstrated a 5-fold increased risk of obstruction (odds ratio 5.0, confidence interval 2.4 to 10.8). One patient was lost to followup. Observation of 6 kidneys led to resolution of reflux in 3 (50%), resolution of obstruction in 3 (50%) and resolution or improvement of hydronephrosis in 4 (67%). Primary pyeloplasty was done on 29 kidneys with 10 (35%) requiring subsequent ureteroneocystostomy. At latest followup hydronephrosis resolved or improved in 24 patients (83%), vesicoureteral reflux resolved or improved in 19 (66%) and ureteropelvic junction obstruction resolved in all. Primary ureteroneocystostomy was performed on 5 kidneys, all of which required subsequent pyeloplasty. Hydronephrosis resolved in 3 patients (60%), and reflux and obstruction resolved in all. Two patients treated with primary nephroureterectomy, and 1 who underwent concomitant pyeloplasty and ureteroneocystostomy have had no subsequent urological problems. One patient awaits primary pyeloplasty. CONCLUSIONS: High grade vesicoureteral reflux is associated with ureteropelvic junction obstruction. No association with low or intermediate grade reflux was demonstrated. While some patients may be monitored expectantly, in our series pyeloplasty or nephrectomy was required in 81% and ureteroneocystostomy was required in 36%. In no case did primary ureteroneocystostomy protect against the subsequent need for pyeloplasty.

Child, Preschool↗
PubMed1996

William T. Bovie and electrosurgery.

For thousands of years human beings have used heat in the form of cautery to treat trauma and disease. By the late nineteenth century, as technology advanced, heat could be produced by electric current. In 1920 William T. Bovie, an eccentric inventor with a doctorate in plant physiology, developed an innovative electrosurgical unit that Harvey Cushing, the founder of modern neurosurgery, introduced to clinical practice. The Bovine unit passes high frequency alternating current into the body allowing the current to cut or coagulate. After 75 years this basic device remains a fundamental tool in the practice of surgery.

Electrosurgery↗
PubMed1996

Localization of Tc-99m MDP in neuroblastoma metastases to the liver and lung.

Localization of skeletal tracer in a neuroblastoma primary is common but localization in extraskeletal metastatic sites has not received recognition. Tc-99m MDP concentration in hepatic or pulmonary metastases was noted in three of ten patients with such metastases. Lesion size appears to be important for demonstrating these metastases with Tc-99m MDP. This was particularly true for hepatic metastases, which were identified only when they were 5 cm or greater in diameter.

Bone and Bones↗
PubMed1996

Glutaraldehyde cross-linked collagen in the treatment of urinary incontinence in children.

PURPOSE: Prospective analysis was done to assess the efficacy of glutaraldehyde cross-linked collagen in the treatment of pediatric structural urinary incontinence. MATERIALS AND METHODS: A total of 40 pediatric patients (average age 12.1 years) with structural urinary incontinence received 70 glutaraldehyde cross-linked collagen injections. Of the 40 patients 25 had spina bifida, 12 had the exstrophy/epispadias complex, 2 had continent reservoirs and 1 had bilateral ureteral ectopia. Average followup was 2.1 years (range 3 months to 6.3 years), and included urodynamic evaluation and assessment of change in continence grade, daily pad use and dry interval. Patient satisfaction was evaluated by questionnaire concerning self-esteem, activity level and patient assessment of overall benefit. RESULTS: Complete cure of incontinence was reported by 22% of patients, improvement by 54% and no change by 24%. There was statistically significant postoperative improvement of continence grade (exstrophy/epispadias p < or = 0.004, spina bifida p < or = 0.0001), decreased daily use of pads (exstrophy/epispadias p < or = 0.008, spina bifida p < or = 0.002) and dry interval (exstrophy/epispadias p < or = 0.008, spina bifida p < or = 0.004). Greater success occurred in cases of the exstrophy/epispadias complex (91%) than spina bifida (71%). No patient had unsafe bladder pressures as a result of collagen treatment. Reevaluation of a 1992 study group with an initial 88% cure or improvement rate showed that after a mean followup of 4.5 years the cure or improvement rate remained 86%. CONCLUSIONS: Collagen improves continence in the majority of children with anatomically based urinary incontinence. Exstrophy/epispadias patients have the best outcome from collagen treatment. Glutaraldehyde cross-linked collagen is durable in most patients who have an initially positive outcome.

Adolescent↗
PubMed1996

The remnant orchiectomy.

PURPOSE: We examined and characterized the histological features of remnant testicular tissue distal to the internal inguinal ring in boys who underwent exploration for a nonpalpable testis. MATERIALS AND METHODS: The medical records and histology of 48 boys (50 remnants) who underwent exploration for a nonpalpable testis during a 10-year period were reviewed in detail. RESULTS: Remnant tissue was characterized by evidence of ischemia and necrosis (scar, calcification, hemosiderin and hyalinization) suggestive of a vascular accident. Viable germ cells were identified in 5 remnants. CONCLUSIONS: A 10% incidence of viable germ cells in remnant testicular tissue warrants exploration and removal of all remnant tissue in boys who undergo exploration for a nonpalpable testis.

Adolescent↗