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R M Decter

Publications and source records attributed to R M Decter.

At least 19 recordsLinked to original sources
PubMed2001

Klippel-Trénaunay syndrome: 2 case reports and a review of genitourinary manifestations.

PURPOSE: We summarize the literature and present our experience with genitourinary manifestations of the Klippel-Trénaunay syndrome, which can lead to challenging management problems. MATERIALS AND METHODS: We report on 2 patients with genitourinary manifestations of the Klippel-Trénaunay syndrome and performed a MEDLINE review of the literature using the key words "Klippel-Trénaunay," "vascular malformation" and "genitourinary." RESULTS: Genitourinary manifestations were cited in 18 articles, including 1,174 cases of the Klippel-Trénaunay syndrome, detailing the presentation and management of bladder, external genitalia and retroperitoneal involvement in the Klippel-Trénaunay syndrome. The overall genitourinary symptoms in patients with the Klippel-Trénaunay syndrome seem to occur in the more severe cases and usually involve cutaneous vascular malformations of the trunk, pelvis and genitalia. CONCLUSIONS: Intra-abdominal and intrapelvic extension of the vascular malformations of the Klippel-Trénaunay syndrome frequently occurs concurrently with the lower abdominal, pelvic cutaneous involvement of the external genitalia, as in our 2 cases and in our review of the literature. These data provide a better understanding of the spectrum of genitourinary manifestations in the Klippel-Trénaunay syndrome and provide insight for the clinician to formulate individual therapies for these patients.

Humans↗
PubMed2001

Can a single individualized procedure predictably resolve all the problematic aspects of the pediatric ureterocele?

PURPOSE: During the last 10 years we attempted to treat most children presenting with a ureterocele with a single definitive operative procedure. We reviewed the surgical results to assess the success of the preoperative plan in achieving this outcome. MATERIALS AND METHODS: We retrospectively reviewed the records and diagnostic studies of all children who underwent surgery for a ureterocele during the last 10 years at our institution. The intent of the surgeon as to whether the procedure was intended to be definitive was stated in the clinic notes in all cases. RESULTS: Surgery for a ureterocele was performed in 38 children during the study period. Transurethral incision was used in 7 patients and, although it was intended to be definitive in 2, all 7 required subsequent surgery for vesicoureteral reflux. Isolated upper tract surgery was performed with intent to cure in 20 of 21 patients including upper pole heminephrectomy in 17 and upper to lower ureteroureterostomy in 3. Of the 20 patients initially treated with this simplified approach 17 (85%) did not require subsequent surgery for ureterocele and 12 had vesicoureteral reflux preoperatively, which persisted in 2 (10%) and required subsequent surgery in 3 (15%). Total reconstruction of the ureterocele was performed in 10 patients and 1 of whom required subsequent surgery. We achieved resolution of all problematic aspects of the ureterocele with a single procedure in 26 of 32 patients (81%). CONCLUSIONS: A single procedure that definitively treats all problems of a ureterocele can be selected in more than three-quarters of patients. Transurethral incision was unsuccessful at definitively treating these patients in our experience. An isolated upper tract procedure was successful in patients with no or mild associated vesicoureteral reflux. We think that upper tract surgery should be the procedure of choice in this subset of patients, as it usually resolves the problem and does not subject the patient to the potential morbidities of bladder surgery. Although total reconstruction is a more formidable procedure, it can be performed safely with excellent results.

Child↗
PubMed2001

Can standard open pediatric urological procedures be performed on an outpatient basis?

PURPOSE: We questioned whether it is feasible in the current era of cost consciousness to perform standard open pediatric urological procedures on an outpatient basis while maintaining patient safety and satisfaction. MATERIALS AND METHODS: We report on 51 consecutive patients 2 months to 13 years old (mean age 4 years 3 months) who underwent a standard open pediatric urological procedure between August 1999 and June 2000. The procedures included ureteral reimplantation in 22 cases (tapered in 2), pyeloplasty in 20, partial nephrectomy in 2, nephrectomy in 2, complete ureterocele reconstruction in 1 and other in 4. The expectation that the procedure would be performed on an outpatient basis was discussed with parents preoperatively. We excluded only cases requiring bowel for reconstruction. A caudal block was administered at the start of the procedure using 0.25% bupivacaine with 1:200,000 epinephrine at a dose of 1 cc/kg. The wound was infiltrated with 1 cc/kg. 0.25% bupivacaine and 0.5 mg./kg. ketorolac was administered at the end of the procedure. As soon as the child awakened, an age appropriate diet was started and 0.5 to 1 mg./kg. codeine with acetaminophen was given every 4 hours. RESULTS: Of the 51 children 44 (86%) were discharged home the day of surgery. Average postoperative hospitalization was 7 hours. One of the 44 children discharged home required a single catheterization elsewhere. There were no other complications or repeat hospitalizations. CONCLUSIONS: Our experience shows that standard open pediatric urological procedures may be performed safely and comfortably on an outpatient basis.

Adolescent↗
PubMed1999

Chordee correction by corporal rotation: the split and roll technique.

PURPOSE: The optimal approach to correcting ventral chordee associated with severe hypospadias is controversial. Dorsal plication tends to shorten the phallus and ventrally positioned grafts often mandate a staged procedure. An alternative approach is presented using corporal rotation to correct ventral chordee associated with hypospadias. MATERIALS AND METHODS: In 6 boys with severe hypospadias the urethral plate was divided and the septum between the corpora cavernosa was partially split with a ventral midline incision. This incision facilitates corporal rotation. Access to the dorsal aspect of the corpora cavernosa was achieved by dissecting Buck's fascia with its encased neurovascular bundles, so that the bundles in the area of chordee were completely elevated and preserved. Using artificial erection as a guide nonabsorbable sutures were placed in the area of maximal curvature from the dorsolateral aspect of 1 corpus cavernosum across the midline to the other side such that, as the knots were tied, the corpora rotated toward the dorsal midline. The knots were buried by apposition of the rotated corporal bodies. RESULTS: Excellent straightening of the phallus was achieved intraoperatively in these patients. CONCLUSIONS: The split and roll technique for correcting severe chordee does not require incisions into the corporal substance, involve use of grafts or cause shortening of the phallus. The neurovascular bundles are preserved and are not compressed by the rotational sutures. The surgeon may perform 1-stage reconstruction while achieving maximal penile length.

Child↗
PubMed1999

Distal hypospadias repair by the modified Thiersch-Duplay technique with or without hinging the urethral plate: a near ideal way to correct distal hypospadias.

PURPOSE: Various techniques have been described to correct distal hypospadias but many are best suited to patients with subtle specific nuances of meatal and/or glanular configuration. We describe a simplified approach to these defects using the modified Thiersch-Duplay technique with or without hinging the urethral plate (the Snodgrass maneuver). MATERIALS AND METHODS: Between 1990 and 1997 we performed the modified Thiersch-Duplay repair as the primary procedure for repairing hypospadias in 197 boys. We initially performed urethral plate hinging (the Snodgrass maneuver) in 1994. By 1997, 82% of our patients were undergoing repair using the hinge technique. Urethroplasty coverage was provided by a second layer of adjacent local tissue or by a pedicle of subcutaneous tissue. RESULTS: Reoperation was required in 5 boys (2.5%) with fistula and 1 (0.50%) with urinary extravasation. A fistula developed in 4 of the 63 cases (6.4%) in which adjacent local tissue was used to cover the urethroplasty and in 1 of 130 (0.80%) in which a pedicle of subcutaneous tissue was used. Overall 97% of the boys had an excellent result requiring no secondary operative procedure. CONCLUSIONS: The modified Thiersch-Duplay technique with or without urethral plate hinging is reliable for correcting distal hypospadias. The risk of fistula is almost eliminated when a vascularized pedicle of subcutaneous tissue is used to cover the repair. This technique has virtually supplanted all other methods that we used in the past to correct distal hypospadias.

Child↗
PubMed1999

Bladder augmentation: does it predispose to prosthetic infection of simultaneously placed artificial genitourinary sphincters or in situ ventriculoperitoneal shunts?

OBJECTIVE: To review previous reports and our experience in assessing the risk of prosthetic infections in patients undergoing bladder augmentation simultaneously with artificial genitourinary sphincter (AGUS) implantation, and in patients with in situ ventriculoperitoneal (VP) shunts, implicated as a cause of shunt infection. PATIENTS AND METHODS: The literature was searched to identify the number of prosthetic infections (AGUS or VP shunt) reported in patients who have undergone bladder augmentation. Additionally, the records of 53 myelodysplastic patients at our institution who had undergone bladder augmentation were reviewed to determine the incidence of AGUS and/or VP shunt infections. An AGUS was placed in 17 of these patients, who were then divided into three groups based upon the timing of their AGUS placement relative to bladder augmentation. Of the 53 patients, 47 had an in situ VP shunt at the time of their augmentation. All patients were followed for at least 12 months. RESULTS: The reported rate of AGUS infection at the time of simultaneous bladder augmentation was not significantly different from that when these procedures were staged. In the present series, the AGUS became infected in two patients (12%); one infection occurred in each of 10 patients undergoing simultaneous procedures (10%) and one developed in each of the seven patients undergoing staged procedures (14%). Although VP shunt infections have been reported after bladder augmentation, none of the present patients had a VP shunt infection after bladder augmentation. CONCLUSION: These results suggest that bladder augmentation is not associated with an increased risk of prosthetic infection in patients undergoing simultaneous placement of an artificial sphincter or in those who have an in situ VP shunt.

Artificial Organs↗
PubMed1999

Percutaneous vesicolithotomy: an alternative to open bladder surgery in patients with an impassable or surgically ablated urethra.

PURPOSE: Although vesical calculi are routinely treated transurethrally, open vesicolithotomy is generally performed in patients with an impassable or surgically ablated urethra. We describe a technique of percutaneous vesicolithotomy which we used in patients who had undergone urethral ablation and concomitant continent diversion by appendicovesicostomy. MATERIALS AND METHODS: Bladder stones were detected in 3 patients with neurogenic bladder who had undergone continent urinary diversion with bladder neck closure and appendicovesicostomy. To treat the stones access to the bladder was achieved percutaneously and the tract was enlarged using a balloon dilator. An Amplatz sheath was slipped over the inflated balloon and after the dilator was removed the sheath provided a working channel through which stones were fragmented and removed using a nephroscope. RESULTS: Each patient was rendered stone-free and discharged home the same day as the procedure. CONCLUSIONS: Percutaneous vesicolithotomy provides an alternative approach for bladder stone removal in patients with an impassable urethra with decreased morbidity compared to open procedures.

Adolescent↗
PubMed1998

A single-system ectopic ureter draining an ectopic dysplastic kidney: delayed diagnosis in the young female with continuous urinary incontinence.

OBJECTIVE: To document the array of diagnostic modalities, the variety of errant diagnoses and treatments. and the time from initial presentation to ultimate diagnosis in girls with an ectopic single-system ureter draining an ectopic hypoplastic and/or dysplastic kidney. PATIENTS AND METHODS: Between 1990 and 1997, seven females were identified who had an ectopic hypoplastic and/or dysplastic kidney with an ectopically draining ureter, and who were treated at our institutions, either initially or upon referral. The nature and number of all diagnostic evaluations, previous diagnoses and treatments, and the time from presentation to definitive diagnosis were recorded. RESULTS: All seven females had a classical history of successful toilet training, a normal voiding pattern and continuous urinary incontinence. Typically, a solitary kidney was noted on the initial diagnostic evaluation by ultrasonography and/or intravenous urography. The mean (range) age at initial presentation was 3.2 (2-6) years. Additionally, voiding cysto-urethrography, urodynamics, radionuclide scintigraphy, computed tomography, magnetic resonance imaging and endoscopy were performed. The age at definitive diagnosis was 3-16.5 years and the mean (range) time from initial presentation to diagnosis was 5.7 (1-10) years. Nephroureterectomy was curative and all kidneys were dysplastic. CONCLUSION: Continuous urinary incontinence in females with a normal voiding pattern should prompt an evaluation for ureteric ectopia. When the initial evaluation yields the diagnosis of a solitary kidney, clinicians should be aware of the possibility of a hypoplastic and/or dysplastic, often ectopic, contralateral kidney with an ectopically draining ureter. Identification of this entity should allow curative surgical treatment.

Adolescent↗
PubMed1998

Colovesical fistula resulting from a perforated colonic duplication.

Colovesical fistulas in children are most often associated with high anorectal imperforations. Acquired enterovesical fistulas in children only rarely have been reported as a consequence of an inflammatory process. We present a case of an acquired colovesical fistula formed by the erosion of an abscess at the distal end of a colonic duplication in a child who presented with fever of unknown origin.

Abdominal Abscess↗
PubMed1997

Renal duplication and fusion anomalies.

Renal duplications and fusion anomalies in children often present challenging problems. The diagnostic evolution of these entities often consists of upper tract imaging to evaluate function and help diagnose obstruction, and lower tract imaging to assess reflux and at times voiding dynamics. The clinician needs to be aware of the variable presentations of these lesions, their evolution, and the therapeutic interventions that may be required to resolve problems resulting from them.

Child↗