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The rarity of bladder-neck obstruction in children
Volume 69
Number 5
part 1
Editor's column
8 53
The rarity of bladder-neck obstruction in children SURGICAL PROCEDURES on children with vesical neck obstructions have been performed at leading medical centers in the past few years?, s At some centers the decision to revise the bladder neck has been based on cineradiography or studies of bladder-urethral pressures. M a n y surgeons and urologists routinely perform a plastic operation on the neck of the bladder in children who show ureteral reflux. Less commonly, the bladder outlet is revised for a supposed obstruction thought to be the cause of a poststenotic dilation of the proximal urethra. Finally, a significant number of operations are done on the bladder neck of children who develop recurrent cystitis but no ureteral reflux. These decisions to widen the bladder neck are based on conjectural and speculative reasoning that recurring infections and reflux must be equated with obstructions which are too slight to be demonstrated. Anatomically, the objective criteria of obstruction which have proved diagnostic for adults have been discarded in dealing with childhood infections. One reason for the frequency of operative intervention on the bladder outlet is the erroneous idea that no harm is done and only beneficial effects can result. I believe, as does a minority group of urologists, that bladder-neck obstruction is a rare entity in children?, * hi following 217 children with recurring infections of the urinary tract, I could find only 3 instances of definite obstruction of the vesical outlet as judged by adult criteria. M a n y children were examined over a fourteen-year period with no evidence that even a low-grade obstrucMANY
tion of the neck was present or progressed. One important key to the problem has been the curative results in ureteral reflux of ureteral reimplantation alone without a Y-V plasty on the neck of the bladder. In low See related article, p. 744 pressure reflux of nonneurogenic origin, when conservative measures failed, ureteral reimplantation alone has produced a high percentage of cures without requiring subsequent antimicrobial therapy. Such favorable results do not support the possibility of a coexisting bladder-neck obstruction, but support the impression that the reflux itself represented a primary defect of the ureterovesical juncture. If widening of the bladder neck caused no harmful effects, then objection to its use in conjunction with other appropriate operations perhaps would not be at issue. However, an important defect is created in boys which results in sterility from retrograde ejaculation. In girls the widening of the neck and proximal urethra increases susceptibility to recurrent cystitis. M y associates and I have shown that a congenital dilation of the female urethra without evidence of distal urethral stenosis is a common cause for recurring cystitis and a secondary ureteral reflux? Likewise, the surgical creation of a dilated proximal urethra in girls will enhance ascending bladder infections via the lumen of a urethra which has in effect been considerably shortened. The a b o v e examples of ureteral reflux a n d / o r recurrent cystitis should be carefully:differentiated at cystos-
854
November 1966
Editor's column
copy from a dilated proximal urethra due to distal urethral stenosis, for which extensive meatotomy rather than bladder-neck surgery is the proper treatment. Cineradiography has been utilized at Variety Children's Hospital, but has only infrequently been advantageous. Increased bladder-urethral pressures and cine studies demonstrating indentations at the bladder neck o r a "spinning top" deformity of the neck and urethra have all too often been interpreted as bladder-neck obstruction and have led to m a n y inappropriate operations. A more fruitful diagnostic technique is the voiding cystourethrogram without anesthesia. It is not a complicated procedure and can be performed with standard radiographic equipment. Results are usually reproducible and use of the technique has led to a better understanding of urethral lesions in children; misinterpretations have occurred, but by correlation with the clinical picture and by appropriate utilization of cystoscopy such mistakes should be unusual. T h e evidence indicates that plastic operations at the neck of the bladder should not
be performed on children unless unequivocal evidence of obstruction is present. It is safer to delay the operation in questionable instances, because there is adequate time to observe the patient and prevent renal deterioration even when an actual obstruction is present. B E N E D I C T R. H A R R O W , M.D. D E P A R T M E N T O F UROLOGY MERCY A N D VARIETY C H I L D R E N ' S
HOSPITALS
MIAMI, ]FLA.
REFERENCES
1. King, L. R.: Contracture of the bladder neck, S. Clin. North America 44: t537, 1964. 2. Leadbetter, G. W., Jr., and Leadbetter, W. F.: Ureteral reimptantation and bladder neck reconstruction, J. A. M. A. 175: 349, 1961. 3. Ambrose, S. S., and Nicolson, W. P.: The causes of vesico-ureteral reflux in children: Vesicoureteral reflux secondary to anomalies of the ureterovesical junction, J. Urol. 87: 688, 1962. 4. Hutch, J. A., Miller, E. R., and Hinman, F., Jr.: Perpetuation of infection in unobstructed urinary tracts by vesico-ureteral reflux, J. Urol. 90: 88, 1963. 5. Harrow, B. R., Sloane, J. A., and Witus, W. S.: Congenital dilatation of the female urethra, J. Urok 95: 58, 1966.
Number 5
part 1
Editor's column
8 53
The rarity of bladder-neck obstruction in children SURGICAL PROCEDURES on children with vesical neck obstructions have been performed at leading medical centers in the past few years?, s At some centers the decision to revise the bladder neck has been based on cineradiography or studies of bladder-urethral pressures. M a n y surgeons and urologists routinely perform a plastic operation on the neck of the bladder in children who show ureteral reflux. Less commonly, the bladder outlet is revised for a supposed obstruction thought to be the cause of a poststenotic dilation of the proximal urethra. Finally, a significant number of operations are done on the bladder neck of children who develop recurrent cystitis but no ureteral reflux. These decisions to widen the bladder neck are based on conjectural and speculative reasoning that recurring infections and reflux must be equated with obstructions which are too slight to be demonstrated. Anatomically, the objective criteria of obstruction which have proved diagnostic for adults have been discarded in dealing with childhood infections. One reason for the frequency of operative intervention on the bladder outlet is the erroneous idea that no harm is done and only beneficial effects can result. I believe, as does a minority group of urologists, that bladder-neck obstruction is a rare entity in children?, * hi following 217 children with recurring infections of the urinary tract, I could find only 3 instances of definite obstruction of the vesical outlet as judged by adult criteria. M a n y children were examined over a fourteen-year period with no evidence that even a low-grade obstrucMANY
tion of the neck was present or progressed. One important key to the problem has been the curative results in ureteral reflux of ureteral reimplantation alone without a Y-V plasty on the neck of the bladder. In low See related article, p. 744 pressure reflux of nonneurogenic origin, when conservative measures failed, ureteral reimplantation alone has produced a high percentage of cures without requiring subsequent antimicrobial therapy. Such favorable results do not support the possibility of a coexisting bladder-neck obstruction, but support the impression that the reflux itself represented a primary defect of the ureterovesical juncture. If widening of the bladder neck caused no harmful effects, then objection to its use in conjunction with other appropriate operations perhaps would not be at issue. However, an important defect is created in boys which results in sterility from retrograde ejaculation. In girls the widening of the neck and proximal urethra increases susceptibility to recurrent cystitis. M y associates and I have shown that a congenital dilation of the female urethra without evidence of distal urethral stenosis is a common cause for recurring cystitis and a secondary ureteral reflux? Likewise, the surgical creation of a dilated proximal urethra in girls will enhance ascending bladder infections via the lumen of a urethra which has in effect been considerably shortened. The a b o v e examples of ureteral reflux a n d / o r recurrent cystitis should be carefully:differentiated at cystos-
854
November 1966
Editor's column
copy from a dilated proximal urethra due to distal urethral stenosis, for which extensive meatotomy rather than bladder-neck surgery is the proper treatment. Cineradiography has been utilized at Variety Children's Hospital, but has only infrequently been advantageous. Increased bladder-urethral pressures and cine studies demonstrating indentations at the bladder neck o r a "spinning top" deformity of the neck and urethra have all too often been interpreted as bladder-neck obstruction and have led to m a n y inappropriate operations. A more fruitful diagnostic technique is the voiding cystourethrogram without anesthesia. It is not a complicated procedure and can be performed with standard radiographic equipment. Results are usually reproducible and use of the technique has led to a better understanding of urethral lesions in children; misinterpretations have occurred, but by correlation with the clinical picture and by appropriate utilization of cystoscopy such mistakes should be unusual. T h e evidence indicates that plastic operations at the neck of the bladder should not
be performed on children unless unequivocal evidence of obstruction is present. It is safer to delay the operation in questionable instances, because there is adequate time to observe the patient and prevent renal deterioration even when an actual obstruction is present. B E N E D I C T R. H A R R O W , M.D. D E P A R T M E N T O F UROLOGY MERCY A N D VARIETY C H I L D R E N ' S
HOSPITALS
MIAMI, ]FLA.
REFERENCES
1. King, L. R.: Contracture of the bladder neck, S. Clin. North America 44: t537, 1964. 2. Leadbetter, G. W., Jr., and Leadbetter, W. F.: Ureteral reimptantation and bladder neck reconstruction, J. A. M. A. 175: 349, 1961. 3. Ambrose, S. S., and Nicolson, W. P.: The causes of vesico-ureteral reflux in children: Vesicoureteral reflux secondary to anomalies of the ureterovesical junction, J. Urol. 87: 688, 1962. 4. Hutch, J. A., Miller, E. R., and Hinman, F., Jr.: Perpetuation of infection in unobstructed urinary tracts by vesico-ureteral reflux, J. Urol. 90: 88, 1963. 5. Harrow, B. R., Sloane, J. A., and Witus, W. S.: Congenital dilatation of the female urethra, J. Urok 95: 58, 1966.