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Endoscopic management of vesico-ureteric reflux in children with neuropathic bladder secondary to myelomeningocele
INTERNATIONAL ABSTRACTS
performed clean intermittent catheterization and who experienced urinary reservoir perforation. One of these perforations was fatal. Two patients were adolescent girls with myelodysplasia and two were prepubertal boys with bladder exstrophy. One patient experienced two separate reservoir perforations. Rupture occurred 15 to 48 months (mean, 30.2 months) after reconstruction. Diagnosis was made by a static cystogram, which demonstrated extravasation in two of four patients, and ultrasound. In two patients the cystogram was normal. Management included intravenous antibiotics and open abscess drainage in all patients. In patients who have undergone augmentation cystoplasty or continent diversion and in whom abdominal pain and distension develop, reservoir perforation should be considered in the differential diagnosis.--George Holcomb, Jr Primary Vesico-ureteric Reflux Treated by Antireflux Ureterocystostomy at the Vertex of the Bladder. A 12 Year Follow Up and Analysis of Operative Failure. 1. Bradic, S. Batinica, and J. Husar.
Br J Urol 62:531-536, (December), 1988. The authors studied 618 children with primary vesico-ureteric reflux over a 12-year period treated by anti-reflux ureterocystostomy at the vertex of the bladder. Most children had grade 3 or 4 reflux. Successful correction of reflux was achieved in 792 units. Ten patients developed postoperative stenosis and 17 had recurrent reflux. The causes of postoperative complications were obstructions of the submucosal ureter after tailoring (five), stricture of the new ureteric orifice (three), necrosis of the terminal part of the ureter (two), a submucosal ureter that was either too short or too long (12), and fibrosis of the detrusor muscle over the submucosal ureter (five). A second operation to correct such complications was successful in 84% of cases.--Amir Azmy Endoscopic Management of Vesico-Ureteric Reflux in Children With Neuropathic Bladder Secondary to Myelomeningocale.
F.M.J. Quinn, T. Diamond, and V.E. Boston. Z Kinderchir 43 (Supp111):43-45, (December), 1988. Vesicoureteric reflux (VUR) is a major cause of morbidity and mortality in children with neuropathic bladders secondary to myelomeningocele. The majority deteriorate with age, and early treatment is necessary to avoid this. Endoscopic subureteric Teflon injection (STING) allows correction of reflux in small children who would otherwise be difficult to manage. The results of treatment o f VUR in 41 ureters in 24 children with neuropathic bladders using STING are reported. All ureters had grade III-V VUR. Thirty ureters (73%) showed disappearance of reflux after one injection. O f the remaining 11, V U R disappeared in seven after a second injection. Apart from failure, the only other major complication was septicemia in one patient. The mean hospital stay was 1.4 days (one to eight days). At a mean follow-up time of 22 months there was radiological improvement in the upper renal tracts in 27 of the 37 children (73%) in which V U R disappeared. None has deteriorated and there has been only one relapse. These results suggest that STING should be considered as the method of choice in the management of VUR in children with neuropathic bladder in view of the problems associated with open operation in these c h i l d r e n . Thomas A. Angerpointner Urologic Aspects of Tethered Cord. R.C. Flanigan, D.P. Russell, and J.W. Walsh. Urology 33:80-82, (January), 1989.
Tethered cord syndrome, a form of spinal dysrhaphism, may involve vesical neurologic dysfunction. The authors reviewed 60 cases of tethered cord syndrome, including 24 patients who underwent preoperative urodynamic studies. Preoperative cystometrography revealed areflexic bladders in 71% of cases and hyperreflexic
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bladders in 29%. Eight patients had serial pre and postoperative urodynamics testing. Slight improvement was noted in postoperative urodynamic studies performed on four of six areflexic bladders and in the only hyperreflexic bladder studied. In addition, of the three patients in the serial urodynamics group who had urinary symptoms preoperatively, two noted clinical improvement postoperatively. No specific correlation could be found between the etiology of cord tethering and the presence or absence of urinary s y m p t o m s . George W. Holcomb III Multicystic Dysplastic Kidney: Is Nephrectomy Still Appropriate?
A.C. Gordon, D.F.M. Thomas, R.J. Arthur, et al. J Urol 140:12311234, (NGvember), 1988. Twenty-five cases of multicystic kidney were evaluated to assess the impact of prenatal diagnosis on the management of this condition. The incidence of unilateral multicystic kidney was one in 4,300 live births. O f the 23 children with unilateral multicystic kidneys only three (13%) had a readily palpable lesion. These findings suggest that multicystic kidney is a more common renal anomaly than was previously recognized and that the majority of cases remained undiagnosed before the advent of prenatal diagnosis. Ultrasound re-evaluation in 11 children suggests that the natural history of multicystic kidneys is toward spontaneous involution. Two kidneys were not identifiable by follow-up ultrasound. Hypertension and malignancy complicating multicystic kidney are reported infrequently. The literature on hypertension does not generally support the view that multicystic kidney poses a significant risk of hypertension in later childhood or adult life. The authors believe that the routine removal of multicystic kidneys in infancy is no longer appropriate.--George Holcomb, Jr MUSCULOSKELETAL SYSTEM Arthroscopic Meniscectomy for Discoid Lateral Meniscus in Children. L.K. Hayashi, H. Yamaga, I. Kunio, et al. J Bone Joint Surg
(Am) 70:1495-1500, (December), 1988. Forty-six patients with discoid lateral menisci involving 53 knees were evaluated, with a 4 to 15 year follow-up, (11.1 years average). The series included 17 males and 29 females. Most of the children were between 10 to 15 years of age with a duration of symptoms from 1 to 72 months (average, 17.4 months). The knees were evaluated arthroscopically, occasionally using a needle scope, with care to identify the type of meniscus and the shape of any tear and to measure the intact part of the rim. Forty-six tears were classified as complete and seven incomplete with no tears involving the Wrisberg ligament. Twenty-five tears were longitudinal, 17 being horizontal and one a bucket-handle type. Two of the tears extended to the peripheral attachments. Partial meniscectomy was performed where feasible and total meniscectomies were similarly performed when necessary using a percutaneous Metzembaum scissors under arthroscopic control. Subtotal excisions were performed with the intent of leaving a 4-mm residual limb and precautions, where necessary, to protect the popliteus tendon. One patient required repeat arthroscopy for what was felt to be a new tear in a retained medial segment of the meniscus necessitating the need for a total meniscectomy. There were no additional complications. The evaluation of the data found the best results were in patients who had subtotal meniscectomy for complete or incomplete type subtears. Partial meniscectomy patients had lower ratings by the authors' scoring technique. The authors conclude that partial meniscectomy has potential problems because the anatomy of the posterior attachment of the discoid lateral meniscus is not normal. Partial meniscectomy remains a theoretical possibility, though only after careful evaluation of the meniscus. Arthritis was not seen as a result
performed clean intermittent catheterization and who experienced urinary reservoir perforation. One of these perforations was fatal. Two patients were adolescent girls with myelodysplasia and two were prepubertal boys with bladder exstrophy. One patient experienced two separate reservoir perforations. Rupture occurred 15 to 48 months (mean, 30.2 months) after reconstruction. Diagnosis was made by a static cystogram, which demonstrated extravasation in two of four patients, and ultrasound. In two patients the cystogram was normal. Management included intravenous antibiotics and open abscess drainage in all patients. In patients who have undergone augmentation cystoplasty or continent diversion and in whom abdominal pain and distension develop, reservoir perforation should be considered in the differential diagnosis.--George Holcomb, Jr Primary Vesico-ureteric Reflux Treated by Antireflux Ureterocystostomy at the Vertex of the Bladder. A 12 Year Follow Up and Analysis of Operative Failure. 1. Bradic, S. Batinica, and J. Husar.
Br J Urol 62:531-536, (December), 1988. The authors studied 618 children with primary vesico-ureteric reflux over a 12-year period treated by anti-reflux ureterocystostomy at the vertex of the bladder. Most children had grade 3 or 4 reflux. Successful correction of reflux was achieved in 792 units. Ten patients developed postoperative stenosis and 17 had recurrent reflux. The causes of postoperative complications were obstructions of the submucosal ureter after tailoring (five), stricture of the new ureteric orifice (three), necrosis of the terminal part of the ureter (two), a submucosal ureter that was either too short or too long (12), and fibrosis of the detrusor muscle over the submucosal ureter (five). A second operation to correct such complications was successful in 84% of cases.--Amir Azmy Endoscopic Management of Vesico-Ureteric Reflux in Children With Neuropathic Bladder Secondary to Myelomeningocale.
F.M.J. Quinn, T. Diamond, and V.E. Boston. Z Kinderchir 43 (Supp111):43-45, (December), 1988. Vesicoureteric reflux (VUR) is a major cause of morbidity and mortality in children with neuropathic bladders secondary to myelomeningocele. The majority deteriorate with age, and early treatment is necessary to avoid this. Endoscopic subureteric Teflon injection (STING) allows correction of reflux in small children who would otherwise be difficult to manage. The results of treatment o f VUR in 41 ureters in 24 children with neuropathic bladders using STING are reported. All ureters had grade III-V VUR. Thirty ureters (73%) showed disappearance of reflux after one injection. O f the remaining 11, V U R disappeared in seven after a second injection. Apart from failure, the only other major complication was septicemia in one patient. The mean hospital stay was 1.4 days (one to eight days). At a mean follow-up time of 22 months there was radiological improvement in the upper renal tracts in 27 of the 37 children (73%) in which V U R disappeared. None has deteriorated and there has been only one relapse. These results suggest that STING should be considered as the method of choice in the management of VUR in children with neuropathic bladder in view of the problems associated with open operation in these c h i l d r e n . Thomas A. Angerpointner Urologic Aspects of Tethered Cord. R.C. Flanigan, D.P. Russell, and J.W. Walsh. Urology 33:80-82, (January), 1989.
Tethered cord syndrome, a form of spinal dysrhaphism, may involve vesical neurologic dysfunction. The authors reviewed 60 cases of tethered cord syndrome, including 24 patients who underwent preoperative urodynamic studies. Preoperative cystometrography revealed areflexic bladders in 71% of cases and hyperreflexic
951
bladders in 29%. Eight patients had serial pre and postoperative urodynamics testing. Slight improvement was noted in postoperative urodynamic studies performed on four of six areflexic bladders and in the only hyperreflexic bladder studied. In addition, of the three patients in the serial urodynamics group who had urinary symptoms preoperatively, two noted clinical improvement postoperatively. No specific correlation could be found between the etiology of cord tethering and the presence or absence of urinary s y m p t o m s . George W. Holcomb III Multicystic Dysplastic Kidney: Is Nephrectomy Still Appropriate?
A.C. Gordon, D.F.M. Thomas, R.J. Arthur, et al. J Urol 140:12311234, (NGvember), 1988. Twenty-five cases of multicystic kidney were evaluated to assess the impact of prenatal diagnosis on the management of this condition. The incidence of unilateral multicystic kidney was one in 4,300 live births. O f the 23 children with unilateral multicystic kidneys only three (13%) had a readily palpable lesion. These findings suggest that multicystic kidney is a more common renal anomaly than was previously recognized and that the majority of cases remained undiagnosed before the advent of prenatal diagnosis. Ultrasound re-evaluation in 11 children suggests that the natural history of multicystic kidneys is toward spontaneous involution. Two kidneys were not identifiable by follow-up ultrasound. Hypertension and malignancy complicating multicystic kidney are reported infrequently. The literature on hypertension does not generally support the view that multicystic kidney poses a significant risk of hypertension in later childhood or adult life. The authors believe that the routine removal of multicystic kidneys in infancy is no longer appropriate.--George Holcomb, Jr MUSCULOSKELETAL SYSTEM Arthroscopic Meniscectomy for Discoid Lateral Meniscus in Children. L.K. Hayashi, H. Yamaga, I. Kunio, et al. J Bone Joint Surg
(Am) 70:1495-1500, (December), 1988. Forty-six patients with discoid lateral menisci involving 53 knees were evaluated, with a 4 to 15 year follow-up, (11.1 years average). The series included 17 males and 29 females. Most of the children were between 10 to 15 years of age with a duration of symptoms from 1 to 72 months (average, 17.4 months). The knees were evaluated arthroscopically, occasionally using a needle scope, with care to identify the type of meniscus and the shape of any tear and to measure the intact part of the rim. Forty-six tears were classified as complete and seven incomplete with no tears involving the Wrisberg ligament. Twenty-five tears were longitudinal, 17 being horizontal and one a bucket-handle type. Two of the tears extended to the peripheral attachments. Partial meniscectomy was performed where feasible and total meniscectomies were similarly performed when necessary using a percutaneous Metzembaum scissors under arthroscopic control. Subtotal excisions were performed with the intent of leaving a 4-mm residual limb and precautions, where necessary, to protect the popliteus tendon. One patient required repeat arthroscopy for what was felt to be a new tear in a retained medial segment of the meniscus necessitating the need for a total meniscectomy. There were no additional complications. The evaluation of the data found the best results were in patients who had subtotal meniscectomy for complete or incomplete type subtears. Partial meniscectomy patients had lower ratings by the authors' scoring technique. The authors conclude that partial meniscectomy has potential problems because the anatomy of the posterior attachment of the discoid lateral meniscus is not normal. Partial meniscectomy remains a theoretical possibility, though only after careful evaluation of the meniscus. Arthritis was not seen as a result