Biomedical subjects
L R King
Publications and source records attributed to L R King.
A new approach to the closure of cloacal exstrophy.
Cloacal exstrophy patients are often difficult to reconstruct. Urinary continence is usually achievable only with a catheterizable stoma of some type. Since cloacal exstrophy is usually associated with omphalocele or gastroschisis, one-stage closure of the abdominal wall defect is frequently impossible. We prefer to incorporate the exstrophic large bowel, which separates the hemibladders, into the closed bladder as a sort of "natural" augmentation to maximize its volume for use as a continent reservoir. If a silastic "silo" or synthetic mesh is required to close the abdominal wall, excessive scarring occurs and later creation of a continent stoma is usually difficult and time-consuming. In all but those with the smallest abdominal wall defects we recommend that the omphalocele and upper abdominal wall be repaired first, replacing the evicted gut into the peritoneal cavity. During nutritional stabilization a tissue expander is placed under the superficial musculature of the chest wall. The flap is enlarged by gradual inflation of the tissue expander until it fills the abdominal wall defect left by subsequent closure of the cloacal exstrophy. The flap is then rotated inferiorly with blood supply intact at the time of bladder closure to make good the remaining abdominal wall defect. This flap improves the appearance of the abdominal wall and reduces scarring. Thus, this approach has the possibility of making subsequent operations to provide continence shorter, simpler, and more successful in most infants with cloacal exstrophy.
Pediatric urolithiasis: medical and surgical management.
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Use of the expanded thoracoepigastric myocutaneous flap in the closure of cloacal exstrophy.
We describe the first reported use of an expanded thoracoepigastric myocutaneous flap in the closure of cloacal exstrophy. This approach offers several distinct advantages. The expander increases the available cutaneous surface area of the thoracoepigastric region, improves vascularity, induces a fibrous capsule that augments the abdominal wall, permits primary closure, and avoids prosthetic adjuncts that increase scarring and hinder delayed urinary tract reconstruction. Osteotomy and spica casting may be obviated by using this flap, but mesh may be required eventually. We anticipate its use in all future cases in which the abdomen cannot be closed safely at the primary procedure at this institution. This technique also should be considered for classic bladder exstrophy or any other large congenital or acquired defect of the lower abdomen.
Pediatric urology manpower report 1995. Ellen Shapiro on behalf of the American Association of Pediatric Urologists.
PURPOSE: The quality and efficiency of any health care system depend on an appropriate level of manpower. The manpower issues of tomorrow will be influenced by the number of physicians and specialists trained today. The objectives of this manpower survey of pediatric urologists in the United States were to determine anticipated manpower requirements and provide caveats related to the practice of pediatric urology. MATERIALS AND METHODS: A manpower questionnaire was distributed to pediatric urologists at the American Urological Association meeting in Las Vegas, Nevada in April 1995. Of the 234 distributed questionnaires 204 (87%) were completed and entered into a computer program. RESULTS: Of responding pediatric urologists 70% were younger than 50 years, 81% practiced full-time pediatric urology and 45% were university based. The rates of respondents indicating that their present workload was too busy, appropriate or not busy enough were 10, 70 and 20%, respectively. A total of 71% of respondents indicated that they would discourage a newly trained individual from setting up a practice in their area. Of practicing pediatric urologists 26% intended to retire within the next 10 years. In April 1995, 80 respondents (39%) representing 67 practices were considering adding an associate within the next 10 years. By the end of 1995 only 56 practices will remain that will add an associate within the next 10 years. A total of 82% of respondents believed that there was an excess number of pediatric urology training programs. CONCLUSIONS: The pediatric urology community presently trains 10 to 15 pediatric fellows per year. Based on the 1995 manpower survey, if this trend continues an excess of 40 to 90 pediatric urologists will be trained in the next 10 years. The conclusion that there is an overabundance of pediatric urologists in training is supported by the general consensus of practicing pediatric urologists. Policies related to the training of pediatric urology fellows and urology residents should depend, not on the manpower needs at individual medical centers, but on the collective needs of our specialty and the patients whom we serve.
Renal ultrasound changes after pyeloplasty in children with ureteropelvic junction obstruction: long-term outcome in 47 renal units.
PURPOSE: We evaluated the use of renal ultrasound for monitoring pyelocaliectasis after pyeloplasty in children. MATERIALS AND METHODS: Changes in pyelocaliceal dilatation following pyeloplasty were assessed by serial ultrasound. Of 104 children 0 to 12 years old who underwent pyeloplasty between 1982 and 1992, 44 (47 renal units) were monitored with serial ultrasound for at least 2 years (range 2 to 9, mean 3.8). Patient ages at pyeloplasty were 0 to 3 months (17), 4 to 12 months (8), 1 to 6 years (13) and 7 to 12 years (6). Preoperative and postoperative ultrasound was reviewed by a single pediatric radiologist blinded to the date of surgery. The degree of pyelocaliectasis was graded as 0 to 4 according to the classification of the Society for Fetal Urology. RESULTS: Preoperative ultrasound revealed grade 4 pyelocaliectasis in 26 kidneys (55%) and grade 3 disease in 21 (45%). Grade was the same or worse 1 month after pyeloplasty in the majority of kidneys (92%) studied at this interval. Of the 47 renal units assessed 43 (91%) showed improvement in pyelocaliectasis during postoperative followup. Only 38% of the kidneys improved during the first 6 months of followup, while 81% were improved 2 years postoperatively. Improvement to grade 0 or 1 dilatation occurred in only 9 kidneys (19%). The rate of resolution of pyelocaliectasis was not related to preoperative grade or patient age at pyeloplasty. CONCLUSIONS: Improvement on renal ultrasound after pyeloplasty appears to be gradual. Less than half of the patients had improvement in the initial 6 months after pyeloplasty and pyelocaliectasis rarely resolved completely. While renal ultrasound can provide an accurate and cost-effective means of monitoring children on a long-term basis after pyeloplasty, sonographic evaluation in the early postoperative period commonly shows increased or unchanged pyelocaliectasis.
Are modern imaging techniques over diagnosing ureteropelvic junction obstruction?
Since the widespread use of real-time ultrasonography in the early 1980s, ureteropelvic junction obstruction has been diagnosed at earlier ages and prenatally on a presumptive basis. However, substantial controversy exists over the diagnosis and treatment of ureteropelvic junction obstruction. We conducted an epidemiological study to determine if modern imaging techniques are leading to the over diagnosis of ureteropelvic junction obstruction. Records were collected retrospectively from 3 hospitals serving 2 adjacent counties to determine the number of pyeloplasties performed in 1970 to 1992. The 2 university hospitals and 1 large private hospital provide a wide variety of services and choice of urologists, and so it was assumed that most patients requiring pyeloplasty in the area would be captured. Of the 555 pyeloplasties 240 (43%) were performed on children 12 years old or younger. Logistic regression analysis revealed an overall increase of pyeloplasties per year of 56.8% in 23 years, which was not markedly different from the population growth in the area in the same period (49.3%). A statistically significant increase in the number of pyeloplasties performed in the first year of life was noted. This trend appeared to begin in 1981: 8 pyeloplasties were performed in the first year of life between 1970 and 1980 compared to 91 between 1981 and 1992. Pyeloplasties in children 1 to 6 years old increased with time at a much lower rate that was not statistically significant and the number of pyeloplasties decreased in those 7 to 12 years old. Therefore, it appears that modern imaging techniques are not leading to an over diagnosis of ureteropelvic junction obstruction but to detection of the disease at an earlier age.
Acute pancreatitis in children: CT findings of intra- and extrapancreatic fluid collections.
PURPOSE: To determine the location and importance of fluid collections in children with acute pancreatitis. MATERIALS AND METHODS: The authors retrospectively reviewed the abdominal computed tomographic (CT) scans of 28 children with acute pancreatitis. CT scans were evaluated for pancreatic size and distribution of intra- and extrapancreatic fluid collections. Extrapancreatic fluid was classified as (a) peritoneal, (b) retroperitoneal, (c) mesenteric, or (d) ligamentous. RESULTS: Fourteen children (50%) had complicated pancreatitis associated with fluid collections. Intrapancreatic fluid was identified in only two patients (7%), whereas extrapancreatic fluid was seen in 14 (50%). Extrapancreatic fluid was most often seen in the anterior pararenal space, followed by the lesser sac, lesser omentum, and transverse mesocolon. The fluid collections diminished spontaneously in 11 patients (78%). Three patients with persistent fluid collections required surgical intervention for associated abnormalities. CONCLUSION: Intrapancreatic fluid collections are rare in children with pancreatitis. Extrapancreatic fluid collections tend to be extensive, but most diminish spontaneously.
Hydronephrosis. When is obstruction not obstruction?
It once was relatively simple for most urologists to diagnose ureteropelvic junction obstruction, and it was previously axiomatic that obstruction required repair to preserve and maximize renal function. Modern imaging studies have cast doubt on previously held concepts, leaving the clinician with an enigma. Prolonged follow-up of some non-operated cases has demonstrated late deterioration of function, further compounding the diagnostic uncertainty.
Kegel exercises and childhood incontinence: a new role for an old treatment.
Kegel exercises were used to treat urinary incontinence in 79 children. An average of less than 2 hours of professional time was required. Incontinence was eliminated in 60% of the patients; children who had both day and night wetting tended to show simultaneous improvements in both problems. Research is needed to test the hypothesis that Kegel exercises eliminate involuntary contractions of the detrusor muscle.
Bladder mucosal grafts for severe hypospadias: a successful technique.
Free grafts of bladder mucosa may be used to bridge long urethral defects in the repair of hypospadias. Strictures, which occur commonly at the proximal anastomotic site with the native meatus and where the bladder mucosa is exposed on the glans, have limited the use of the procedure. We have found that draining the proximal anastomosis prevents most strictures. When the distal most portion of the neourethra is formed from the skin of the ventral penile shaft and glans, no bladder mucosa is exposed and meatal stricture is thereby avoided.
Fertility after cryptorchidism: a comparative analysis of early orchidopexy with and without concomitant hormonal therapy in the young male rat.
Infertility is common in patients with a history of bilateral cryptorchidism, even after successful prepubertal orchidopexy. Recent data suggest that this defect may be partially due to the existence of hormonal abnormalities in some forms of cryptorchidism. To analyze any potential benefit of hormonal therapy, we have evaluated the immediate and long-term effects of chronic hormonal therapy administered following surgical correction of cryptorchidism. First, using young male rats, we examined the effects of chronic human chorionic gonadotropin (HCG) and a luteinizing hormone-releasing hormone agonist (LHRH-A), alone or combined, on acute pituitary-gonadal axis responsiveness to LHRH administration. High doses of HCG and/or LHRH-A induced deleterious effects on the pituitary-testicular axis in terms of suppression of response to LHRH. Therefore, treatment with a low dose of HCG (50 U/kg/day) for 14 days was used, since it produced a significant increase in intratesticular testosterone (ITT). Second, we tested this hormonal regimen in a cryptorchid rat model. Bilateral cryptorchidism was produced by gubernaculum resection at 14 days of age. Early orchidopexy was performed at age 30 days, and HCG therapy was given from 31 to 44 days of age. Follicle stimulating hormone (FSH), luteinizing hormone (LH) and testosterone (T) levels were determined before and immediately after hormonal therapy, and at sacrifice. Animals were sacrificed at 61 days of age for determination of serum and testicular hormone levels, accessory sex organ weights and testis histology. Five or six animals from each group were retained for breeding studies at the age of 90 days. Hormonal alterations noted immediately following treatment of cryptorchid animals with HCG are not lasting. The data reveal that the fertility defect in bilateral cryptorchidism is partially prevented by early orchidopexy and that adjunctive hormonal therapy is probably of little additional benefit.
The risk of hypertension is underestimated in the multicystic dysplastic kidney: a personal perspective.
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Improved technique of laparoscopic nephrectomy for multicystic dysplastic kidney.
We report removal of a multicystic dysplastic kidney with a laparoscopic technique that uses only three trocar sites. Additionally, we have found placement of a ureteral catheter and full mechanical and antibacterial bowel cleansing unnecessary. The role of this surgery in the management of multicystic dysplastic kidney is discussed.
Nonobstructive dilatation of upper urinary tract may later convert to obstruction.
We report on 5 babies found to have pyelocaliectasis or hydroureteronephrosis antenatally who were evaluated soon after birth because of persistent mild or moderate upper urinary tract dilatation. In each instance, vesicoureteral reflux was absent and the technetium-99m diethylenetriaminepentaacetic acid renal scan revealed good function in the ipsilateral kidney. Renogram curves, after furosemide, did not show an obstructed pattern. Indeed, allowing for the dilatation, the drainage patterns were thought to be normal. In each instance the patient represented or was found on follow-up to have increased dilatation. Renograms were then repeated, using the same radiopharmaceutical and dose of diuretic. An obstructive pattern was seen in each instance. These significant observations demonstrate that nonobstructive hydronephrosis, diagnosed prenatally, may later convert to obstruction at the ureteropelvic junction (UPJ) or in the juxtavesical ureter (UVJ). Thus, careful follow-up, for a period yet to be determined, is desirable in patients in whom the initial postnatal evaluation does not demonstrate obstruction by current criteria.
Fetal hydronephrosis: what is the urologist to do?
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Valve of Guerin as a cause of dysuria and hematuria in young boys: presentation and difficulties in diagnosis.
A valve of Guerin, or lacuna magna, is a common anatomical finding in young boys. It occasionally causes dysuria and/or bloody urethral discharge or spotting due to its location distal to the external urethral sphincter. We report on 10 patients who underwent transmeatal marsupialization of a valve of Guerin between 1984 and 1991, and review the embryology and clinical presentation. Despite evidence suggesting that a valve of Guerin is a frequent, normal anatomical variant, the incidence of clinical detection is extremely low. While many patients with this condition remain totally asymptomatic, a valve of Guerin should be suspected in boys presenting with bleeding distal to the urethral sphincter with or without voiding symptoms. In most cases physical examination is normal. A carefully performed voiding cystourethrogram visualizing the distal urethra, coupled with endoscopic examination and gentle probing of the fossa navicularis, optimizes the likelihood of correct diagnosis. Treatment is indicated solely to ameliorate symptoms, which are probably caused by distention of the lacuna magna during voiding. Transmeatal incision and marsupialization of the valve leaflet into the urethral lumen usually effectively relieve dysuria and stop the bleeding.