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Iatrogenic Ureteral Injury: Options in Management
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PEDIATRIC UROLOGY
Captopril: Long-Term Treatment of Hypertension in a Preterm Infant and in Older Children
L. C. HYMES AND B. L. WARSHAW, Department of Pediatrics, Division of Pediatric Nephrology, Emory University School of Medicine, Atlanta, Georgia Amer. J. Dis. Child., 137: 263-266 (Mar.) 1983 Five children with high renin hypertension unresponsive to conventional medications were treated effectively with captopril for 6 to 26 months (mean 14.2 months). The ages of the children ranged from a 33-week gestation pre-term infant with hypertension related to an umbilical artery catheterization to a 13-year-old with renal artery stenosis. Captopril appeared to be effective in controlling hypertension. However, transient renal insufficiency and increased azotemia occurred in these patients. Decreased renal perfusion rather than drug toxicity may be a mechanism for captopril-induced renal dysfunction. In the critically ill neonate who is a poor candidate for nephrectomy or a renovascular reconstruction, captopril may obviate the need for immediate surgical intervention and may be essential for survival in those cases not amenable to surgical repair. Because of potential renal complications and the lack of abundant data on its use in children, captopril should be reserved for those hypertensive children who are unresponsive to other medications. Renal function should be monitored closely in these children, especially during the first several days of treatment. W.D.C. 1 figure, 2 tables, 25 references
Editorial comment. Captopril is an exciting new drug and appears to work well in the long-term to control high renin output hypertension, and some other causes as well. If hypertension is renin-mediated an intense search for a curable cause (that is main renal artery stenosis or localized parenchymal disease) should be made without undue delay. The results of surgical therapy of such lesions are much better if the suitable operation is performed when the hypertension is <5 years in duration. After that time the cure rate decreases to ~40 per cent, possibly because arteriolosclerosis progresses and causes more generalized renal ischemia. L.R.K.
TRAUMA Iatrogenic Ureteral Injury: Options in Management
D. E. FRY, L. MILHOLEN AND P. J. HARBRECHT, Surgical Service, Louisville Veterans Administration Medical Center, and the Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky Arch. Surg., ll8: 454-457 (Apr. ) 1983 The experience of the surgical service with ureteral injuries from 1960 through 1981 is summarized in this review. A total of 25 patients sustained 27 ureteral injuries. There were 19 female patients. Gynecologic procedures accounted for 18 injuries in 17 patients, pelvic colon resections for 7, left colon resection for 1 and lysis of adhesions in an ileal conduit patient for 1 injury. Mechanisms of injury included transection in 17 patients, inadvertent segmental resection in 2, crush injury from surgical clamps in 3, longitudinal strip excision in 2, suture ligation in 2 and ischemic necrosis from devascularization in 1. Ureteroureterostomy was done in 11 cases, reimplan-
tation in 11, nephrectomy in 2, ureteral stent in 1, cutaneous ureterostomy in 1 and reimplantation into an ileal conduit in 1. Four patients died as a result of the failure to repair and subsequent sepsis. Short-term failure occurred in 5 patients and long-term failure occurred in 3. Immediate recognition results in the best outcome. The authors recommend reimplantation for injuries within 4 cm. of the bladder. They believe that prior radiotherapy or intra-abdominal infection should preclude attempts at reconstruction. The necessity of documenting the course and integrity of the ureter at the conclusion of all abdominal procedures is emphasized. The use of miscellaneous methods of reconstruction, such as the Boari flap and transureteroureterostomy, are discussed. An interesting round table discussion by several commentators follows the text. J.H.N. 2 tables, 14 references
PEDIATRIC UROLOGY Posterior Urethral Valves in the British Isles: a Multicenter B.A.P.S. Review J. D. ATWELL, Wessex Regional Center for Paediatric Surgery,
The General Hospital, Southampton, England
J. Ped. Surg., 18: 70-74 (Feb.) 1983 The management of 108 patients with posterior urethral valves from 7 pediatric surgical centers in the United Kingdom is reviewed. All patients were treated in the 10-year interval beginning 1970. Of the patients 53 were <3 months old at presentation, 8 were 3 months to 1 year old, 22 were 1 to 5 years old and 25 were >5 years old. For the children <5 years old urinary tract infection and renal failure were the most common reasons for presentation, while for those >5 years old diurnal and nocturnal enuresis was most common. Endoscopic fulguration of the valves was the most common treatment of choice and, in some cases, repeated fulguration was required. Urethral stricture secondary to resectoscope incision occurred in 2 patients. Tapering and reimplantation of the ureters was associated with the highest complication rate and the authors recommended a conservative approach toward reflux, indicating that spontaneous cessation of reflux occurs in a higher percentage than had been anticipated previously. In addition, it was urged that procedures on the bladder neck be avoided, since they rarely improved the upper tracts and were associated with a high risk of urinary incontinence. Of 8 patients (7.4 per cent) who died 7 were <3 months old. It was suggested that the higher mortality of renal failure in this group was related to renal dysplasia. In summary, the findings of this survey coincide with the collective series treatment of urethral valves in Europe and the United States. W.J.C. 4 figures, 4 tables, 12 references
Editorial comment. This review, pooling data from 7 smaller pediatric centers, documents the improvement in survival of infants presenting with valves, which has occurred largely in the last decade. Most infants, even those with severe degrees of obstruction, can now be stabilized preoperatively during a few days of catheter drainage. The valve then was resected primarily in 86 per cent of the patients, with only 2 urethral strictures resulting. Loop ureterostomy or other forms of high
PEDIATRIC UROLOGY
Captopril: Long-Term Treatment of Hypertension in a Preterm Infant and in Older Children
L. C. HYMES AND B. L. WARSHAW, Department of Pediatrics, Division of Pediatric Nephrology, Emory University School of Medicine, Atlanta, Georgia Amer. J. Dis. Child., 137: 263-266 (Mar.) 1983 Five children with high renin hypertension unresponsive to conventional medications were treated effectively with captopril for 6 to 26 months (mean 14.2 months). The ages of the children ranged from a 33-week gestation pre-term infant with hypertension related to an umbilical artery catheterization to a 13-year-old with renal artery stenosis. Captopril appeared to be effective in controlling hypertension. However, transient renal insufficiency and increased azotemia occurred in these patients. Decreased renal perfusion rather than drug toxicity may be a mechanism for captopril-induced renal dysfunction. In the critically ill neonate who is a poor candidate for nephrectomy or a renovascular reconstruction, captopril may obviate the need for immediate surgical intervention and may be essential for survival in those cases not amenable to surgical repair. Because of potential renal complications and the lack of abundant data on its use in children, captopril should be reserved for those hypertensive children who are unresponsive to other medications. Renal function should be monitored closely in these children, especially during the first several days of treatment. W.D.C. 1 figure, 2 tables, 25 references
Editorial comment. Captopril is an exciting new drug and appears to work well in the long-term to control high renin output hypertension, and some other causes as well. If hypertension is renin-mediated an intense search for a curable cause (that is main renal artery stenosis or localized parenchymal disease) should be made without undue delay. The results of surgical therapy of such lesions are much better if the suitable operation is performed when the hypertension is <5 years in duration. After that time the cure rate decreases to ~40 per cent, possibly because arteriolosclerosis progresses and causes more generalized renal ischemia. L.R.K.
TRAUMA Iatrogenic Ureteral Injury: Options in Management
D. E. FRY, L. MILHOLEN AND P. J. HARBRECHT, Surgical Service, Louisville Veterans Administration Medical Center, and the Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky Arch. Surg., ll8: 454-457 (Apr. ) 1983 The experience of the surgical service with ureteral injuries from 1960 through 1981 is summarized in this review. A total of 25 patients sustained 27 ureteral injuries. There were 19 female patients. Gynecologic procedures accounted for 18 injuries in 17 patients, pelvic colon resections for 7, left colon resection for 1 and lysis of adhesions in an ileal conduit patient for 1 injury. Mechanisms of injury included transection in 17 patients, inadvertent segmental resection in 2, crush injury from surgical clamps in 3, longitudinal strip excision in 2, suture ligation in 2 and ischemic necrosis from devascularization in 1. Ureteroureterostomy was done in 11 cases, reimplan-
tation in 11, nephrectomy in 2, ureteral stent in 1, cutaneous ureterostomy in 1 and reimplantation into an ileal conduit in 1. Four patients died as a result of the failure to repair and subsequent sepsis. Short-term failure occurred in 5 patients and long-term failure occurred in 3. Immediate recognition results in the best outcome. The authors recommend reimplantation for injuries within 4 cm. of the bladder. They believe that prior radiotherapy or intra-abdominal infection should preclude attempts at reconstruction. The necessity of documenting the course and integrity of the ureter at the conclusion of all abdominal procedures is emphasized. The use of miscellaneous methods of reconstruction, such as the Boari flap and transureteroureterostomy, are discussed. An interesting round table discussion by several commentators follows the text. J.H.N. 2 tables, 14 references
PEDIATRIC UROLOGY Posterior Urethral Valves in the British Isles: a Multicenter B.A.P.S. Review J. D. ATWELL, Wessex Regional Center for Paediatric Surgery,
The General Hospital, Southampton, England
J. Ped. Surg., 18: 70-74 (Feb.) 1983 The management of 108 patients with posterior urethral valves from 7 pediatric surgical centers in the United Kingdom is reviewed. All patients were treated in the 10-year interval beginning 1970. Of the patients 53 were <3 months old at presentation, 8 were 3 months to 1 year old, 22 were 1 to 5 years old and 25 were >5 years old. For the children <5 years old urinary tract infection and renal failure were the most common reasons for presentation, while for those >5 years old diurnal and nocturnal enuresis was most common. Endoscopic fulguration of the valves was the most common treatment of choice and, in some cases, repeated fulguration was required. Urethral stricture secondary to resectoscope incision occurred in 2 patients. Tapering and reimplantation of the ureters was associated with the highest complication rate and the authors recommended a conservative approach toward reflux, indicating that spontaneous cessation of reflux occurs in a higher percentage than had been anticipated previously. In addition, it was urged that procedures on the bladder neck be avoided, since they rarely improved the upper tracts and were associated with a high risk of urinary incontinence. Of 8 patients (7.4 per cent) who died 7 were <3 months old. It was suggested that the higher mortality of renal failure in this group was related to renal dysplasia. In summary, the findings of this survey coincide with the collective series treatment of urethral valves in Europe and the United States. W.J.C. 4 figures, 4 tables, 12 references
Editorial comment. This review, pooling data from 7 smaller pediatric centers, documents the improvement in survival of infants presenting with valves, which has occurred largely in the last decade. Most infants, even those with severe degrees of obstruction, can now be stabilized preoperatively during a few days of catheter drainage. The valve then was resected primarily in 86 per cent of the patients, with only 2 urethral strictures resulting. Loop ureterostomy or other forms of high