Biomedical subjects

G A McLorie

Publications and source records attributed to G A McLorie.

At least 19 recordsLinked to original sources

PubMed2003

Renal pseudoaneurysm after blunt renal trauma in a pediatric patient: management by angiographic embolization.

Renal pseudoaneurysm is a rare complication after blunt renal trauma. Only 18 cases have been reported in English-language published reports. We present a case of blunt renal trauma in an 11-year-old boy, complicated by delayed bleeding from a renal artery pseudoaneurysm. The patient was initially treated with conservative measures and was later treated with selective embolization of the pseudoaneurysm. The clinical presentation, management options, and clinical decisions are discussed.

Aneurysm, False↗

PubMed2003

The use of tolterodine in children after oxybutynin failure.

OBJECTIVE: To assess the safety and efficacy of tolterodine tartrate prescribed to children who previously failed to tolerate oxybutynin chloride. PATIENTS AND METHODS: We reviewed 34 children, followed for>1 year, who were prospectively crossed-over from oxybutynin to tolterodine because of side-effects. The initial diagnosis was dysfunctional voiding in 31 patients. All patients were placed on a behavioural modification protocol. When their symptoms did not improve after 6 months, treatment with an anticholinergic agent was considered. Urodynamic studies were conducted in 20 patients, confirming uninhibited contractions in 19. The remaining 14 patients were empirically started on antimuscarinic or anticholinergic agents. The 34 patients were treated with oxybutynin for a median (range) of 6 (2-84) months. When significant side-effects were reported, they were crossed over to tolterodine. The efficacy of tolterodine was assessed as defined by the International Children's Continence Society, with tolerability assessed and side-effects documented using a questionnaire. RESULTS: The mean age at the first dose of tolterodine was 8.9 years; the dose was 1 mg twice daily for 12 patients and 2 mg twice daily for 22. The median treatment with tolterodine was 11.5 months, with 20 (59%) patients reporting no side-effects; six described the same but tolerable side-effects as with oxybutynin. Eight patients discontinued tolterodine because of side-effects after a median (range) of 5 (1-11) months. The efficacy of tolterodine was comparable with that of oxybutynin, as reported by the questionnaire and voiding diaries. The reduction in wetting episodes at 1 year was> 90% in 23 (68%), more than half in five and less than half (or failure) in six patients. CONCLUSION: Tolterodine is tolerated well in children. In this subgroup of patients who could not tolerate oxybutynin, 77% were able to continue tolterodine treatment with no significant side-effects.

Adolescent↗

PubMed2003

The predictive value of diagnostic imaging for histological lesions of the upper poles in duplex systems with ureteroceles.

OBJECTIVE: To compare the diagnostic imaging findings with the histological lesions in upper pole nephrectomy (UPN) specimens of duplex system ureteroceles, using renal ultrasonography (US) and nuclear renal scintigraphy. PATIENTS AND METHODS: Between 1992 and 2000, 86 patients with a ureterocele in a duplex system underwent surgery. The results from US were reviewed in 84 patients by a radiologist, for echogenicity, parenchymal thinning and hydronephrosis; 77 nuclear renal scans describing the differential function of the upper poles were also reviewed. Fifty-five patients underwent UPN (25 antenatal, 30 postnatal; 18 intravesical, 37 extravesical) and the specimens were available for independent review by a pathologist, describing five histological categories, i.e. chronic interstitial inflammation, fibrosis, tubular atrophy, glomerulosclerosis and dysplasia. Histological lesions were categorized as severe (> 25%) or minimal (<or= 25%). Radiological features and the histology of UPN were then analysed, and correlated using Fisher's exact test and multivariate analysis. RESULTS: Severe histological lesions were reported in 38 specimens (69%) and minimal lesions in 17 UPN specimens (31%). Severe parenchymal thinning was associated with a severe pathological lesion (P < 0.02). There was no correlation with the echogenicity or degree of hydronephrosis. Dysplasia, found in 64% of specimens, did not correlate with increased echogenicity. Minimally functioning upper poles on nuclear renal scan (<or= 4% overall function) were significantly associated with severe histological lesions (P = 0.01). There was no correlation between diagnostic imaging features and the mode of presentation or type of ureterocele. CONCLUSIONS: Multivariate analysis, severe parenchymal thinning on renal US and minimal function on nuclear renal scan can be used to predict the severity of histological lesions of the upper pole. These results may be helpful in the making therapeutic decisions for patients with ureteroceles in duplex systems.

Adolescent↗

PubMed2001

A population based analysis of continence outcomes and bladder exstrophy.

PURPOSE: Whereas the literature on bladder exstrophy is replete with outcomes of specific continence surgical procedures in highly select patients, there are no data on the outcomes related to continence for a complete exstrophy population, which is more comprehensive with respect to a variety of surgical procedures performed to achieve continence. To provide urologists and patients with an overview of potential continence outcomes devoid of any selection bias, we report on a comprehensive exstrophy population, focusing on the various procedures required for urinary continence. MATERIALS AND METHODS: We reviewed the charts of all patients with bladder and cloacal exstrophy who underwent a staged repair to achieve urinary continence at a single institution between 1988 and 1998. Urinary continence was then correlated to the types of surgical procedures, and subgroup analysis for predictors of urinary continence was performed. The type of bladder neck reconstruction allowed subgrouping cases into group 1-bladder neck reconstruction only, group 2-bladder neck reconstruction with augmentation and/or appendicovesicostomy and group 3-bladder neck closure. RESULTS: Of the 43 patients identified 26 were male, 4 had cloacal exstrophy and 3 had complex exstrophy variants with ectopic hindgut and spina bifida. Groups 1 to 3 comprised 9, 15 and 19 patients with urinary continence rates of 56%, 67% and 100%, respectively. The age at which patients became continent was delayed in groups 2 and 3 (8.2 and 8.7 years, respectively) compared to group 1 (4.8). Of all the potential variants measured gender was the strongest predictor of continence with 94% of females versus 69% of males achieving it. Of the males those with (57%) compared to those without (83%) a history of bladder neck stenosis or paraexstrophy flaps had worse continence. Repeat bladder neck reconstruction was only successful in 23% of patients. CONCLUSIONS: All patients can be rendered continent but many may achieve this successful outcome by other procedures following initial bladder neck reconstruction. When managing failed bladder neck reconstruction, the type of surgical repair chosen may need to address the need for enhanced bladder storage and the issue of potential bladder augmentation. The advances made in the treatment of the epispadiac urethra may now facilitate clean intermittent catheterization. Earlier recognition of the need for adjunctive storage procedures in addition to bladder neck reconstruction may facilitate the timing of providing enhanced continence, independence and self-esteem, and do so with fewer operative procedures. We speculate that the current complete urethral and bladder repair in newborns will add further to the storage functions of the native bladder tissues and improve the potential of achieving more effective bladder outlet control.

Bladder Exstrophy↗

PubMed2001

Wilms' tumor (nephroblastoma).

Wilms' tumor (nephroblastoma) is a subject which continues to challenge clinicians in their attempts to achieve the best survival of their patients, while minimizing morbidity. Overall survival of over 85% of all children can now be achieved using combination therapy with chemotherapy, surgery, and in some cases radiotherapy. Recent reviews of two multi-institutional, multinational trials (the International Society of Pediatric Oncology and the National Wilms' Tumor Study Group) are discussed in this article, in which their current approaches to therapy are presented. In addition to these clinical advances, the genetic and molecular features of Wilms' tumor continue to provide insight into the biology of nephroblastoma and into neoplasia in general. A recent review of these aspects of the field is provided.

Child↗

PubMed2001

Tunica vaginalis for correcting penile chordee in a rabbit model: is there a difference in flap versus graft?

PURPOSE: We compared tunica vaginalis applied as a flap versus a graft for covering defects in the ventral tunica albuginea in a rabbit model. MATERIALS AND METHODS: We used 18 New Zealand White rabbits in the study. The urethra was mobilized off of the corpus cavernosum. A defect was created in the ventral aspect of the tunica albuginea by excising a 1 x 0.5 cm. rectangular area. The defect was covered by the testicular surface of tunica vaginalis as a vascularized flap in 9 animals and as a graft in 9. At 2, 6 and 12-week intervals 3 animals per group were sacrificed. Transverse sections of the penis at the repair site were stained with hematoxylin and eosin, and Masson's trichrome for microscopy. RESULTS: Autopsy revealed no contracture in any of the tunica vaginalis flaps. In contrast, the tunica vaginalis grafts had contracted by a mean of 22% (range 20% to 25%) at 2, 38% (range 30% to 44%) at 6 and 42% (range 38% to 48%) at 12 weeks. Microscopic examination of the tunica vaginalis flaps showed evidence of an intact blood supply and viable cremasteric muscle layer but no evidence of necrosis. Collagen remodeling and maturation was noted at 12 weeks. In tunica vaginalis grafts there was evidence of necrosis of all tunica vaginalis layers at 2 weeks with granulation tissue and active fibrosis at the periphery. At 6 and 12 weeks most necrotic tissue was replaced by fibrosis. Osseous metaplasia was identified in 1 graft at 12 weeks. CONCLUSIONS: The optimal use of tunica vaginalis for correction of chordee is as a flap rather than as a free graft. Grafts were associated with significant necrosis and contracture, of which neither was associated with flaps.

Animals↗

PubMed2001

High resolution ultrasound characterization of early allograft hemodynamics in pediatric living related renal transplantation.

PURPOSE: Allograft vascular thrombosis occurs in 5% to 10% of pediatric renal transplants. The hemodynamics of renal allograft immediately after implantation is unclear. High resolution Doppler ultrasound of the renal allograft performed in the operating room after incision closure is an effective and objective method to advance our understanding of baseline renal allograft hemodynamics, and identify unsuspected vascular complications early enough to ensure prompt surgical repair. MATERIALS AND METHODS: Between September 1998 and July 2000 high resolution, color power Doppler ultrasound was prospectively performed on 21 living related renal transplants in the operating room immediately after incision closure. Each ultrasound described allograft anastomotic blood flow, direction of diastolic flow, parenchymal perfusion and resistive indexes. RESULTS: There were 20 (95%) allografts with good power Doppler perfusion that had satisfactory immediate function with no vascular complications at 9 to 26-month followup. Initially, anastomotic turbulence was described in 15 (71%) allografts, and resistive indexes were abnormal in 8 (38%). Turbulence and abnormal resistive index normalized in all allografts by 1-month followup. Ultrasound of 1 allograft identified unsuspected poor perfusion and reversal of diastolic flow in the operating room after incision closure. In another allograft in which a 4-hour post-transplant ultrasound was compared with the baseline study in the operating room an unsuspected thrombosis of the right common iliac vein was confirmed. CONCLUSIONS: Good parenchymal perfusion and forward diastolic flow after renal reperfusion correlated well with immediate graft function. Initial turbulence and abnormal resistive index in the presence of favorable perfusion are misleading and not independent predictors of graft function. Ultrasound performed in the operating room identified 2 unsuspected major vascular complications facilitating prompt surgical correction.

Adolescent↗

PubMed2001

Reliability of the pediatric dysfunctional voiding symptom score in monitoring response to behavioral modification.

PURPOSE: We previously evaluated the performance of a newly devised dysfunctional voiding symptom score to quantify abnormal voiding behaviors in children. The symptom score ranges from 0 to 30 with higher scores indicating greater severity. In this study, we test the performance of the symptom score in monitoring effectiveness and compliance with a program of behavioral modification. MATERIALS AND METHODS: One hundred four patients (age 3-10 years) were clinically diagnosed as having dysfunctional voiding (DV). At initial visit, after their baseline DV symptom scores were tabulated, they were introduced to a program of behavioral modification that included both verbal and written instructions. After an average follow up of 5 months, all families were mailed questionnaires to: a) assess whether the child was compliant with bladder retraining, and b) request the completion of a second DV symptom-scoring sheet. The change in symptom score was correlated with treatment compliance. Statistical analysis of the data was done using non-parametric method (Mann-Whitney U test). RESULTS: Forty-eight out of 104 children (46%) completed the mailed questionnaires. Twenty-eight (Group A1) were compliant with the behavioral modification program, and the remaining 20 children (Group A2) were not compliant. Although the median score at initial evaluation was similar in both groups (15 versus 14.5 respectively), scores in last follow up were significantly lower in Group A1 than the initial scores (6 versus 14.5 respectively). The scores in last follow-up in Group A2 were not significantly different from their initial symptom scores (median 11 versus 14.5 respectively). CONCLUSION: The DV symptom score reliably and quantitatively reflects improvement in voiding symptoms in patients compliant with behavioral modification. Patients non-compliant with a bladder retraining program may be identified by lack of decrease in their DV symptom score. Key Words: voiding dysfunction, pediatric, behavioral modification, symptom score

Behavior Therapy↗

PubMed2000

Acellular bladder matrix allografts in the regeneration of functional bladders: evaluation of large-segment (> 24 cm) substitution in a porcine model.

OBJECTIVES: To evaluate the use of a large-segment (> 24 cm2) bladder substitution with porcine bladder acellular matrix allograft (BAMA) in a large animal model. Materials and methods Bladders were harvested from pigs at the time of necropsy and subjected to detergent and enzymatic extractions to render them acellular. The BAMA produced had the surgical handling and suture-retaining properties of normal bladder tissue. Six pigs had BAMA segments implanted under general anaesthesia, through a low midline abdominal incision and after partial cystectomy. The defect was repaired with a BAMA patch (mean size 43.88 cm2, range 12-72), with no urinary diversion. Two animals each were then killed at 9, 16 and 30 days and the bladders explanted. The native bladder and BAMA patch were analysed morphometrically to evaluate cellular re-population and matrix re-organization. RESULTS: All animals survived surgery; there were no urinary leaks and no stones detected in any of the bladders. At 9 days there was a diffuse infiltration with acute inflammatory cells, but no areas of necrosis. There were isolated areas of smooth muscle cell (SMC) infiltration of the BAMA. At 16 days the luminal surface was lined with a single layer of urothelium, there was stromal infiltration with disorganized SMC and angiogenesis, with mature vessels in the BAMA patch. At 30 days the urothelium was multilayered with organizing groups of SMCs and angiogenesis. The highest cell density was at the periphery of the repopulated BAMA patch, decreasing towards the centre. CONCLUSIONS: The implantation of large patches of BAMA is technically feasible and may prove to be a viable surgical alternative to bladder augmentation with intestinal segments. The advantages of BAMA include the potential for complete and functional regeneration of a bladder substitute. This model provides a tool with which to obtain a better understanding of the cellular and molecular aspects of matrix re-population.

Animals↗

PubMed2000

Regeneration of functional bladder substitutes using large segment acellular matrix allografts in a porcine model.

PURPOSE: We previously reported on the short-term (4 weeks) morphometric analysis of a large bladder acellular matrix allograft used as a bladder bioprosthesis (average size 24 cm.2). We demonstrated cellular repopulation through the entire thickness of the graft. We now present the long-term (12 weeks) morphometric results of graft regenerated porcine bladders using segments measuring an average of 40 cm.2. MATERIALS AND METHODS: Bladders harvested from pigs were subjected to detergent and enzymatic extractions to render them acellular. Partial cystectomy was performed in 21 pigs and the defect was repaired with a bladder acellular matrix allograft (average size 40.52 cm.2). Of the animals 8 were sacrificed at 1, 2 and 4 weeks and 13 were sacrificed at 8 and 12 weeks. To evaluate cellular repopulation and matrix reorganization the native bladder and graft were analyzed using standard histological and immunofluorescent techniques. To evaluate for calcium deposits in the grafts a radiological evaluation of the graft was performed after explantation. RESULTS: All animals survived the surgical procedure and there were no significant urinary leaks. No stones were noted in any of the bladders. At 1 week there was a diffuse infiltration with acute inflammatory cells. At 2 weeks the luminal surface of the graft was lined with a single layer of urothelium, and there was stromal infiltration with unorganized smooth muscle cells and angiogenesis. At 4 weeks the urothelium was multilayered with organizing groups of smooth muscle cells and angiogenesis. At 8 and 12 weeks there was repopulation throughout the bladder acellular matrix allograft implant with all native cellular components participating. CONCLUSIONS: We present evidence that large patch bladder acellular matrix allograft implantation is technically feasible and may prove to be a viable surgical alternative to bladder augmentation with intestinal segments. Its advantages may include the potential for complete and functional regeneration of a bladder substitute.

Animals↗

PubMed2000

The dysfunctional voiding scoring system: quantitative standardization of dysfunctional voiding symptoms in children.

PURPOSE: Academic research on pediatric nonneurogenic voiding dysfunction has long been hampered by the lack of a standardized reporting system for voiding symptoms. We evaluated the performance of a newly devised, objective instrument to quantify or grade the severity of abnormal voiding behaviors of children. MATERIALS AND METHODS: There were 10 voiding dysfunction parameters that were assigned scores of 0 to 3 according to prevalence, and possible total scores ranged from 0 to 30. The Dysfunctional Voiding Symptom Score was completed by 2 groups of patients. Group 1 consisted of patients 3 to 10 years old presenting to the pediatric urology clinic with a history of diurnal urinary incontinence, urinary tract infections or abnormal voiding habits. Group 2 consisted of an age matched cohort with no history of urological complaints presenting to hospital clinics outside of urology. Patients diagnosed with organic or anatomical disease, such as posterior urethral valves or meningomyelocele, were excluded from our analysis. RESULTS: Group 1 consisted of 104 patients (female-to-male ratio 4:1) with a median symptom score of 14 and group 2 consisted of 54 patients (female-to-male ratio 1.3:1) with a median score of 4. The dysfunctional voiding odds ratio was 2.93 for females compared to that of males. Using receiver operating characteristics the optimum cutoff score was 6.026 (sensitivity 92.77% and specificity 87.09%) for females and 9.02 (sensitivity of 80.95% and specificity of 91. 30%) for males. In addition, we found certain questions to be more reflective than others of dysfunctional voiding symptoms in our population. CONCLUSIONS: The Dysfunctional Voiding Symptom Score appears to provide accurate and objective, that is, numerical, grading of voiding behaviors of children. Comparative research studies of dysfunctional voiding diagnosis and response to therapy as well as objective measurements of treatment efficacy and outcomes analysis should be aided greatly by this system.

Child↗

PubMed2000

Are postoperative studies justified after extravescial ureteral reimplantation?

PURPOSE: We evaluated the usefulness of postoperative imaging studies after extravesical ureteroneocystostomy and identified patient subsets in which these studies are necessary. MATERIALS AND METHODS: Records of 438 patients who had undergone extravesical ureteroneocystostomy from 1991 to 1997 were reviewed retrospectively. Study inclusion criterion was primary reflux with at least 1 year of postoperative followup. Grades I to III reflux were defined as low, and grades IV and V were defined as high. All patients were on prophylactic antibiotics. Evaluation included ultrasound and a voiding cystourethrogram 3 months postoperatively, and if reflux persisted the studies were repeated at 12 months. RESULTS: A total of 438 patients (723 renal units) underwent extravesical ureteral reimplantation. At 3 months the procedure was successful in 93.2% of ureters (91.3% patients), and at 12 months the success rate increased to 97.9% of ureters (95.4% patients). There were 49 renal units in 38 cases that were refluxing at 3 months, 11 of which were contralateral. At 12 months reflux resolved spontaneously in 20 of 38 ipsilateral and 8 of 11 contralateral ureters. Of the remaining 18 ipsilateral units reflux was high grade preoperatively in 12 and persisted postoperatively in 4. There was a statistically significant difference in the success rate at 1 year between high (94%) versus low (99%) grade reflux (p = 0.007). Age and preoperative bladder function did not significantly affect the success rates but males had a lower success rate. Hydronephrosis was noted in 7.2% of ureters at 6 weeks and in only 0.005% at 12 months. CONCLUSIONS: Extravesical reimplantation is successful in treating vesicoureteral reflux. Postoperative voiding cystourethrogram should be reserved for high grade reflux. Limiting these studies will help reduce patient discomfort and the cost of treatment.

Child↗

PubMed2000

Lessons learned from laser tissue soldering and fibrin glue pyeloplasty in an in vivo porcine model.

PURPOSE: We compared sutured pyeloplasty to 2 newer techniques of tissue anastomosis, including laser soldered pyeloplasty using a diode laser with 50% albumin solder mixed with indocyanine green and fibrin glue. MATERIALS AND METHODS: We performed 53 pyeloplasties in 50 pigs using suture, laser or fibrin glue. In the immediate group anastomotic leak pressure was measured immediately postoperatively, and then animals were euthanized. At 1, 3 and 4 weeks postoperatively a pressure flow study at 10 cc per minute in cm. H2O was performed, and tissue was sent for histological and collagen content analysis. RESULTS: In the immediate studies laser soldering achieved a significantly higher mean anastomotic leak pressure (50.5 +/- 15.1 cm. H2O) than sutured (17.3 +/- 5.4) or fibrin glued (3.5 +/- 1.5) repairs. In the 1, 2 and 4-week studies animals in the sutured pyeloplasty group had no complications, and all pressure flow studies except 1 were normal. However, in the laser soldered groups we observed 8 urinomas in 19 animals, and most occurred during the first part of our study. This complication was prevented by stopping urine flow at the anastomotic site at laser irradiation and by improving application of the solder. Of the 11 animals in which pressure flow studies were performed only 2 were obstructed. Of the 7 chronic fibrin glue group 4 animals had urinomas and 2 had unobstructed pressure flow studies. Histological studies and immunohistochemical staining for collagen showed no differences in collagen distribution among the 3 procedures. CONCLUSIONS: Laser soldering and fibrin glue pyeloplasties are not superior in the long-term compared to sutured pyeloplasty. Fibrin glue in our animal model had the highest failure rate. Further improvements in the technical aspect of laser tissue welding need to be made to benefit from its theoretical advantages in minimally invasive surgery.

Anastomosis, Surgical↗

PubMed1999

Urinary retention after bilateral extravesical ureteral reimplantation: does dissection distal to the ureteral orifice have a role?

PURPOSE: We evaluated the outcome and incidence of urinary retention after bilateral detrusorrhaphy using 2 modifications of the original Lich-Gregoir procedure. MATERIALS AND METHODS: We evaluated the charts of 220 patients who underwent correction of bilateral vesicoureteral reflux using the extravesical approach from January 1991 to December 1997. Inverted Y detrusorrhaphy was performed in 154 patients and the advancing suture modification was done in 66. RESULTS: The success rate using the advancing suture technique was 92.4 and 95.4% at 3 and 12 months, respectively. The Y detrusorrhaphy technique was successful in 91.6 and 97.4% of cases at 3 and 12 months, respectively. The difference in the techniques was not statistically significant. Urinary retention developed in 8.4% of the patients who underwent Y detrusorrhaphy compared to 15.2% of those who underwent the advancing suture technique (not statistically significant). However, patients with grades IV and V reflux, children younger than 3 years and boys had significantly (p <0.05) higher postoperative retention rates of 24.6, 35.6 and 20.3%, respectively, when all 220 patients were considered. CONCLUSIONS: Each modification of the original Lich-Gregoir technique is highly effective for treating bilateral vesicoureteral reflux and each is associated with a low rate of temporary urinary retention. Although there seems to be a lower incidence of retention with the Y detrusorrhaphy technique, this was not statistically significant. Because of the higher incidence of urinary retention in young children, boys and/or patients with high grade reflux, we recommend that physicians consider a longer period of catheterization regardless of the technique chosen.

Child↗

PubMed1999

Utility of SPECT DMSA renal scanning in the evaluation of children with primary vesicoureteral reflux.

OBJECTIVES: DMSA renal scanning is more sensitive than ultrasound in detecting renal parenchymal scars. We proposed to determine the utility of single-photon emission computed tomography (SPECT) dimercaptosuccinic acid (DMSA) renal scanning in children with primary vesicoureteral reflux (VUR). METHODS: During a 24-month period, we evaluated the charts of 368 patients who had undergone SPECT DMSA renal scanning for primary VUR. Patients were divided into three age groups: (a) less than 1 year, (b) between 1 and 5 years, and (c) older than 6 years. Renal scars were deemed severe or focal. The data were analyzed to evaluate the utility of SPECT DMSA scanning in children with primary VUR and to determine the indications for performing SPECT DMSA. We also evaluated the sensitivity of recent renal ultrasound technology in detecting focal and diffuse scars. RESULTS: One hundred twenty-eight patients were younger than 1 year at presentation. These included 24 cases that were detected prenatally. One hundred eighty-five were between the ages of 1 and 5 years, and 55 were 6 years or older. Reflux nephropathy at presentation was found in 99 (26.9%) of 368 patients. DMSA scanning changed the treatment in only 13 patients (3.5%). When scarring was diffuse, ultrasound examination correlated 100% with DMSA scanning; when focal scarring was present, the correlation was poor. CONCLUSIONS: Our results suggest that DMSA scans should be tailored to children who have ultrasound abnormalities, high-grade reflux, or recurrent breakthrough urinary tract infections. These guidelines will result in a substantial cost savings and a significant decrease in radiation exposure.

Child↗

PubMed1999

Urinary continence after staged bladder reconstruction for cloacal exstrophy: the effect of coexisting neurological abnormalities on urinary continence.

PURPOSE: We determined whether there is a difference in the incidence of urinary continence in cloacal and classic bladder exstrophy after staged bladder neck reconstruction using the Young-Dees-Leadbetter technique. MATERIALS AND METHODS: We reviewed the records of patients with cloacal and classic bladder exstrophy who underwent staged bladder neck reconstruction from 1971 to 1997. RESULTS: The Young-Dees-Leadbetter bladder neck reconstruction was completed in 23 patients with cloacal exstrophy, of whom 5 (22%) became continent and 18 (78%) have persistent incontinence. A clinically apparent neurological abnormality significantly hindered the achievement of continence. Specifically 1 of the 13 children (7%) with versus 4 of the 10 (40%) without a neurological abnormality became continent (p <0.05). In contrast, staged reconstruction of classic bladder exstrophy resulted in urinary continence in 67 of the 82 patients (82%). Of the 67 continent patients 23 (34%) cannot void and require intermittent catheterization. None of the patients with classic exstrophy had a neurological deficit. CONCLUSIONS: The ability of the Young-Dees-Leadbetter bladder neck reconstruction to result in urinary continence significantly differs in the cloacal and classic bladder exstrophy populations (22 versus 82%, p <0.001). Our findings also suggest that a coexisting neurological abnormality significantly hinders the ability to reconstruct a functional bladder in patients with cloacal exstrophy.

Bladder Exstrophy↗

PubMed1999

Initial experience with endoscopic holmium laser lithotripsy for pediatric urolithiasis.

PURPOSE: Due to the unavailability of suitable pediatric instruments children have not benefited from advances in endoscopic lithotripsy. This limitation may be overcome by the holmium: YAG laser. We evaluated the indications for, and efficacy and complications of holmium:YAG laser lithotripsy. MATERIALS AND METHODS: We retrospectively reviewed all cases of laser lithotripsy. Access to the calculus was antegrade or retrograde. A solid state holmium:YAG laser was used. RESULTS: Eight patients 4 to 14 years old underwent laser lithotripsy during the study period. Average calculous surface area was 357.13 mm.2 (range 14 to 1,645). Five patients required 1 procedure to render them stone-free, while the remaining 3 required multiple procedures. No complications were associated with laser lithotripsy. CONCLUSIONS: The ability of the holmium:YAG laser to pulverize urinary calculi makes it an alternative choice for lithotripsy. In our series all patients are stone-free with stable renal function. The advantages of the holmium:YAG laser are that it may be precisely applied via small fibers, and it pulverizes calculi with minimal scattering of energy and retropulsion of the calculus, decreasing trauma to tissues at the perioperative site. There is also a lower risk of residual fragments, which is associated with a lower incidence of calculous regrowth. Holmium: YAG laser is safe and effective for treating pediatric urolithiasis.

Adolescent↗

PubMed1999

Concomitant modified bladder neck closure and Mitrofanoff urinary diversion.

PURPOSE: We describe a modification of bladder neck closure for managing urinary incontinence in children. MATERIALS AND METHODS: In 11 patients with intractable urinary incontinence that persisted after multiple failed surgical procedures we performed modified bladder neck closure with construction of a catheterizable continent conduit. RESULTS: Mean followup is 3 years. All patients were continent after the procedure and none had a fistula or urinary leakage. One patient required stomal and conduit revision, and bladder stones in 3 necessitated endoscopic removal. CONCLUSIONS: We recommend this modified technique of bladder neck closure as an option for managing urinary incontinence in a complex group of children because it allows the achievement of continence with minimal morbidity.

Adolescent↗