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R M Decter

Publications and source records attributed to R M Decter.

At least 37 records · Page 2Linked to original sources
PubMed1997

Voiding cystourethrography after uncomplicated ureteral reimplantation in children: is it necessary?

PURPOSE: Our aim was to assess whether a voiding cystourethrogram after uncomplicated ureteral reimplantation is necessary or cost-efficient. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent uncomplicated reimplantation at our institution from 1988 to 1994. We also reviewed the literature to tabulate the reflux resolution rate from all published series of more than 100 ureters reimplanted. RESULTS: At our institution 119 patients (207 ureters) underwent uncomplicated reimplantation and a postoperative voiding cystourethrogram, which documented a 98.6% initial reflux resolution rate. All persistent postoperative reflux resolved spontaneously without treatment for a final resolution rate of 100%. We reviewed 1,494 abstracts using vesicoureteral reflux as a key word and found 19 series of more than 100 ureters reimplanted. The combined results of our series and those 19 from the literature revealed 3,346 patients (5,008 ureters reimplanted). The final reflux resolution rate was 98.58%. Series that included and excluded secondary vesicoureteral reflux documented final reflux resolution rates of 98.4 and 99.04%, respectively. Reflux resolved spontaneously in 85% of the ureters in which it was noted on the initial postoperative cystogram. At our institution the cost of a voiding cystourethrogram is $610 and we perform an average of approximately 20 uncomplicated reimplantations per year. In the United States there are approximately 230 pediatric urologists. If each surgeon performed 20 reimplantations per year at the same cost per voiding cystourethrogram, a cost savings of $2.8 million per year would result if the study were not performed after surgery. CONCLUSIONS: In the hands of experienced pediatric urologists uncomplicated ureteral reimplantation has a success rate of 99.04%. The yield of postoperative voiding cystourethrography is exceedingly low and a cost savings of $2.8 million per year would result by omitting the postoperative voiding cystourethrogram.

Adolescent↗
PubMed1997

Reproductive understanding, sexual functioning and testosterone levels in men with spina bifida.

PURPOSE: We assessed the sexual functioning and understanding in men with myelodysplasia. MATERIALS AND METHODS: Of the 378 patients with myelodysplasia followed at our multidisciplinary clinic 170 are adults, including 58 men older than 18 years. A total of 57 men was available for interview. A questionnaire was administered to determine patient educational level, sexual understanding, sexual function and marital status, and serum testosterone levels were measured. RESULTS: The majority of the patients learned about sexual reproduction from school classes with 48 (84%) having achieved a twelfth grade education or higher. A total of 41 patients (72%) accurately described the basic concepts of reproductive physiology. Penile erections were experienced by 41 men (72%) including 27 (66%) who ejaculated with erection. Three patients ejaculated without erection. Sexual intercourse was attempted by 20 men (35%). Of the 11 patients (19%) who attempted to father children 8 (14%) were successful. Twelve patients (21%) have been married, including 2 who are divorced. Serum testosterone levels in 44 patients were normally distributed. CONCLUSIONS: Sexual reproductive understanding, and erectile and ejaculatory function are present in many men with myelodysplasia. The level of the neurological lesion was not predictive of erectile or ejaculatory function but it appears that reproductive potential is favored by lower and less severe lesions. All but 1 of the 8 patients who fathered children had an L5 or sacral neurological level lesion, each was ambulatory and none had a ventriculoperitoneal shunt at the time of conception. These data may prove useful when counseling patients and their parents about eventual sexual performance.

Adolescent↗
PubMed1994

Transurethral electrical bladder stimulation: a followup report.

Transurethral electrical bladder stimulation (TEBS) initially proposed to rehabilitate the neurogenic bladder has been promoted in the United States since the mid 1980s. The ultimate goal of TEBS is volitional voiding. Since January 1989 we performed 938 sessions of stimulation comprising 64 TEBS series in 25 patients with neurogenic bladders. A cystometrogram was performed before each series of stimulation to monitor progress, and at the time of this review parental impressions of the stimulation were obtained by a telephone interview questionnaire. The initial evaluation cystometrogram before stimulation revealed that 18 patients (72%) had bladder contractions. After TEBS 24 patients (96%) manifest contractions. Before stimulation only 3 children sensed the contractions, while during stimulation half of the patients perceived the contractions. A cystometrogram performed before each series demonstrated a greater than 20% increase in the age adjusted bladder capacity in 6 of the 18 patients (33%) with serial studies. Improvements in the end filling pressure defined by clinically significant decreases were observed in 5 of these patients (28%). Results of the telephone questionnaire revealed that the parents perceived a benefit from stimulation more often than the urodynamic studies could confirm. In our experience TEBS is a time-consuming, labor intensive technique. The limited urodynamic benefits our patients achieved have not materially altered the daily voiding regimen and, because of these factors, we are not enrolling any new patients in our TEBS program.

Adolescent↗
PubMed1993

Pyeloduodenal fistula: a previously undescribed complication of Stamm gastrostomy.

A variety of complications have been described after placement of a Stamm gastrostomy in infants and children, including gastric volvulus, pancreatitis, jaundice, gastroduodenal mucosal intussusception with gastric outlet obstruction, and even aortogastric fistula. However, this is the first report of pyeloduodenal fistula after Stamm gastrostomy in a 4 1/2-month-old boy. The child successfully underwent nonoperative therapy; he was treated by withdrawing the gastrostomy tube (Foley catheter) from the renal pelvis, bowel rest, and total parenteral nutrition. After the case presentation is a brief review of this rare entity, with its clinical presentation and pathophysiological differences between adult and pediatric cases. Various treatment options, both operative and nonoperative, are also described.

Duodenal Diseases↗
PubMed1993

Use of the fascial sling for neurogenic incontinence: lessons learned.

Experience using the fascial sling to manage incontinence in 10 patients with a neurogenic bladder is described. The sling was constructed from rectus abdominus fascia in the first 5 cases. Because of 2 sequential failures attributed to inadequacy of the fascial material fascia lata was used in the last 5 cases. Six patients underwent bladder augmentation concomitant with sling construction. Of the 10 patients 9 were perfectly dry immediately after surgery, although with longer followup several patients became wet. The source of the fascial material used to make the sling did not affect the long-term outcome. Of the 6 patients who underwent augmentation at the time of sling construction 4 remain dry at long-term followup. On the other hand, only 1 of the 4 patients who did not undergo augmentation when the sling was positioned had a good long-term result. Erosion of the fascial sling was suspected in 3 patients who had difficulty with catheterization after surgery. Three patients required bladder augmentation because of changes in detrusor behavior subsequent to sling construction. This series suggests that combining the fascial sling with bladder augmentation appreciably increases the likelihood of achieving dryness and that excessive compression of the urethra by the fascial sling may lead to erosion. The sling, as an isolated procedure for neurogenic incontinence, should only be used in exceptionally capacious compliant bladders.

Adolescent↗
PubMed1993

Intravesical urokinase for the management of clot retention in boys.

We successfully used intravesical urokinase in 2 young boys to relieve clot retention occurring as a consequence of upper tract bleeding. Urokinase clot dissolution appears to offer a simple, minimally invasive, atraumatic solution to this infrequent problem.

Administration, Intravesical↗
PubMed1993

Urologic management of spinal cord injury in children.

This overview of the management of children with spinal cord injury has focused on a program based on bladder dynamics. The bladder is modulated pharmacologically and surgically, if necessary, to create a reservoir that stores urine at low pressure, and emptying is achieved by clean intermittent catheterization. The parent assumes the responsibility for bladder emptying when the child is unable to perform catheterization. Reflex voiding in a balanced fashion is not advocated. The program described not only avoids the deleterious effects of high voiding pressures, it also obviates the wearing of a urinary collection device, which is impractical for most prepubertal boys, and it provides for emptying at predictable intervals in order to make the child more socially acceptable. This approach seems to improve the child's self-image, and it should increase the chances of useful participation in society and a fulfilling life.

Adolescent↗
PubMed1992

Pitfalls in determination of leak point pressure.

To evaluate the influence of the technical aspects of leak point pressure measurement we performed water cystometry and determined the leak point pressure in 23 patients 5 weeks to 21 years old with neurogenic bladders. We initially assessed the influence of catheter size on the leak point pressure and determined that the measured pressure varied in direct proportion to the catheter diameter. We further evaluated the effect of the method of infusion (gravity drip versus pump) and the infusion rate on pressures measured by a transducer in an in vitro setting. Using the gravity drip infusion technique pressure measurement was adversely affected by smaller catheter size and rapid infusion rate. With the pump infusion system neither catheter size nor infusion rate adversely affected pressure measurement. We conclude that the clinical measurement of the leak point pressure during water cystometry is influenced by the catheter size, and it is dependent upon the technique and rate of infusion. We believe that standardization of the technical aspects of leak point pressure determination would provide for reproducible results and facilitate comparisons of reports among different investigators.

Adolescent↗
PubMed1992

Transurethral electrical bladder stimulation: initial results.

Transurethral electrical bladder stimulation to rehabilitate the neurogenic bladder initially proposed by Katona has been promoted in the United States by Kaplan and Richards since the mid 1980s. Encouraged by their results, 2 1/2 years ago we instituted a program patterned on their experience. Since January 1989 we performed transurethral electrical bladder stimulation in 21 patients ranging in age from 4 months to 26 years. The cause of the neurogenic bladder was myelomeningocele in 16 patients, lipomeningocele in 4 and an incomplete spinal cord injury in 1. The stimulation was performed using equipment supplied by Kaplan and Richards, and the stimulation protocol followed their recommendations. The treatments were delivered in daily sessions of 90 minutes with about 20 sessions in a series. Of the patients 11 have undergone 1,6 have finished 2 and 4 have completed 3 series of stimulation. The ultimate objective of the program is to achieve volitional voiding. To reach that goal the stimulation must engender a bladder contraction that must then be perceived and ultimately controlled. Of our patients 20 (95%) achieved bladder contractions during stimulation, including 12 (60%) who had either a definite (7) or probable (5) sense of these contractions. To date, only 1 patient has started the biofeedback program to attempt to modify detrusor activity and he is presently wet on clean intermittent catheterization. Parents of 5 other children report minor positive changes in the child's perception of the bladder activity. Three patients noticed an improvement in the bowel program, although the effect only lasted during the month of stimulation in 1. Cystometrograms were performed before each series of treatments. Of the 10 patients with serial studies 2 had significant increases in bladder capacity and 3 demonstrated a clinically significant decrease in the end filling pressures. We have seen limited encouraging results from transurethral electrical bladder stimulation. This is a time-consuming, labor intensive program, and the parents and patients need to be informed of the actual potential for dramatic improvements.

Adolescent↗
PubMed1991

M inverted V glansplasty: a procedure for distal hypospadias.

Minimal hypospadias is a commonly encountered anomaly. Duckett's innovative meatoplasty and glanuloplasty (MAGPI) procedure has become a standard operation for the correction of these lesions. Although usually successful, the complication of meatal retraction has been recognized at times after a MAGPI. The M inverted V glansplasty was designed to address the factors leading to meatal retraction and the abnormal glans shape sometimes seen after the MAGPI. The M inverted V glansplasty derives its name from the initial M-shaped incision that reconfigures during the course of the procedure into an inverted V. Of 16 boys followed for more than 2 months after an M inverted V glansplasty 14 have achieved good results. The remaining 2 cases had a definite degree of meatal retraction but because of the meatal and glanular relationships they have a good cosmetic result. The technique, its indications and its limitations are described.

Child↗
PubMed1989

Individualized treatment of ureteroceles.

We reviewed 52 children with ureteroceles in an effort to evaluate the various facets of this disorder that influenced our surgical management. There were 12 single system ureteroceles and 40 duplex system ureteroceles. Total reconstruction was performed in 16 duplex system and 8 single system ureteroceles, of which 88 per cent required no further surgery. Upper pole heminephrectomy or ureteropyelostomy with partial ureterectomy was performed in 22 patients with duplex system ureteroceles with the goal of obviating lower tract surgery, of whom 12 (55 per cent) required subsequent surgery. In 6 patients, 4 with single system and 2 with duplex system ureteroceles transurethral incision of the ureterocele was the initial procedure with the expectation that improvement in function and hydronephrosis would facilitate subsequent lower tract surgery. Two of these patients required subsequent reconstruction. Recommendations regarding management are based on initial pathological condition, patient age and the presence of a single or duplex system ureterocele.

Child, Preschool↗
PubMed1988

Vesicoureteral reflux in boys.

The natural history of vesicoureteral reflux in children is well documented. In most series girls comprise the majority of the children followed. We reviewed the presentation and course of 86 boys with primary vesicoureteral reflux to define the nature of reflux in that selected population. Of the boys 25 per cent presented when they were less than 3 months old and the youngest tended to have the most severe reflux. Presentation was usually with urinary tract infection but 14 per cent had dysfunctional voiding symptoms without urinary tract infection. Based upon their presentation and initial evaluation the patients were allocated to 1 of 3 treatment protocols: observation, chemoprophylaxis or surgery. No renal parenchymal loss was detected in the boys on observation. Surgical therapy was free of serious complications. Over-all, this modified approach to the management of reflux in boys is acceptable although further followup will be required to confirm these initial conclusions.

Cystoscopy↗
PubMed1988

Use of the AS800 device in exstrophy and epispadias.

Urinary continence is one of the more difficult goals to achieve in patients with exstrophy or epispadias. The artificial genitourinary sphincter provides an alternative to reconstruction of the bladder neck for management of this problem. Although excellent continence can be obtained with bladder neck reconstruction, results of a second procedure of this type seldom are reported. We used the AS800 device in 16 patients with exstrophy and epispadias, 13 of whom had undergone a prior bladder neck operation. We defined our results as total success and continence success, and have achieved over-all rates of 69 per cent (excludes those awaiting revision) and 90 per cent (those with an active device), respectively. Although the frequency of revision and erosion was significant, the ultimate outcome in this difficult patient group was satisfactory.

Adolescent↗
PubMed1988

Hypospadias repair by bladder mucosal graft: an initial report.

Surgical correction of major hypospadias defects is a challenging problem. Bladder mucosa has been reported as an excellent tissue for construction of a neourethra. We used bladder mucosa in 13 boys to create 15 neourethras when there was inadequate preputial skin to perform a vascularized pedicle flap or a free preputial graft. In 3 cases a bladder mucosa graft was used for initial repair of the hypospadias. All other boys had undergone prior hypospadias surgery. In 4 boys the initial result was satisfactory. Seven minor complications occurred in 5 boys, while 4 had more major complications. In 2 boys severe problems with stricture necessitated graft replacement and a satisfactory outcome has not been achieved. Our problems with stricture and stenosis seem to be related to the use of a subcutaneous tunnel for the graft bed and coring of the glans to create the meatus. Over-all, in 11 of the 13 boys the bladder mucosal graft provided an excellent resolution of the complex problem with easily managed postoperative complications.

Child↗
PubMed1988

Bladder augmentation in the pediatric age group.

In summary, enterocystoplasty has become an effective, safe and very useful addition to management of vesical dysfunction in children. The use of bladder augmentation has become more universally accepted with the recognition of the safety of clean intermittent catheterization and the development of efficient antireflux mechanisms when ureteral reimplantation into the bowel is required. However, the surgeon who wishes to participate in this endeavor must have a solid foundation and understanding of vesical urodynamics and must be committed to offering these children an ongoing program to manage their life-long problems associated with their primary disease as well as the special need associated with augmentation procedures.

Bladder Exstrophy↗
PubMed1987

Small bowel augmentation in children with neurogenic bladder: an initial report of urodynamic findings.

Augmentation cystoplasty is a useful adjunct in the treatment of the neurogenic bladder. After preoperative urodynamic and clinical assessment, 10 children with neurogenic bladders underwent small bowel augmentation. Presenting clinical problems included incontinence and hydronephrosis. Urodynamic studies after small bowel augmentation demonstrated that bladder capacity increased an average of 184 per cent. Maximum intravesical pressures diminished considerably compared to preoperative values and no patient suffered significant uninhibited contractions. Nine children are totally dry and 1 has stress incontinence. Our initial findings demonstrate the efficacy of small bowel augmentation in the treatment of lower urinary tract neurogenic dysfunction owing primarily to alterations in detrusor function.

Adolescent↗