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Late complications of the ileal pouch-anal anastomosis
INTERNATIONAL
ABSTRACTS
gangrene (3), and perforation and peritonitis (4). In contrast to reports in the literature, massaging of worms into the colon where they become inactive was possible in only 4 cases in this study. Other procedures included enterotomy and removal of worms (7), resection anastomosis (14), resection and exteriorization in one patient. In subacute cases, failure of conservative management up to 48 hours is an indication for surgery. The choice of procedures is to massage the worms into the colon without damaging the bowel; otherwise, enterotomy and removal of worms should be done. Resection and primary anastomosis is undertaken for gangrene or perforation. and resection and ileostomy is reserved for patients who are in a poor condition. Important points stressed in this article are avoidance of peritoneal contamination during surgery and the use of nonabsorbable suture to prevent roundworms from penetrating the suture line.--Prem Pun’ Contrast Enemas After Necrotising Enterocolitis: A Case for Prophylaxis? I.R. Brand and R.J. Arthur. Pediatr Radio] 22:571-
572, (December), 1992. Over a 4-year period, 35 patients underwent contrast enema following surgery for necrotizing enterocolitis (NEC). Nine of these patients deteriorated with one death among two who developed Klebsiel/a septicemia. Among various factors studied in patients who deteriorated, the authors identified previous perforation and long line (central venous) in situ as important risk factors. Seventy-eight percent of the patients who deteriorated had previous perforation. On analyzing the data, it appears that 33% of the patients who had previous perforation deteriorated after contrast enemas as compared with 14% who did not have perforation. Similarly 45%, of the patients who had long line in situ deteriorated after contrast enema as compared with 17% who had no long line in situ. The authors conjecture that contrast enema induces bacteraemia, which in some patients will develop into a septicaemia aided by the immature immune system. The presence of a long line acts as a foreign body, colonising the organism and providing a continuing source of bacteria. Because of the small number of patients in the study, the authors note the difficulty in recommending or refuting the commencement of regular prophylaxis prior to contrast enemas.-!? Puri The Prognosis of Very Low Birth-Weight Neonates Operated Upon for Necrotising Enterocolitis. E. Waever, B. Brandt, T. Mortensen, et al. Pediatr Surg Int 8:207-209, (April), 1993.
The authors have summarized their experience in managing 13 very low birth weight (650 to 1,500 g) neonates with necrotizing enterocolitis (NEC). All these patients were initially managed conservatively for 0 to 60 days. Indications for operations included radiologic evidence of free air, impending bowel perforation with discoloration of the abdomen, and radiological signs of progressive disease with clinical deterioration. Eight patients had preoperative perforation with a mortality of 50%. However, data are not provided for whether these patients presented with bowel perforation or perforated while being conservatively managed. Those babies who were born before 28 weeks had 80% mortality as opposed to 12%, in those who were more than 28 weeks at birth. The authors also found that those patients who had Apgar scores of 5 or less at 1 minute had significantly higher mortality. All these neonates in this study had suffered severe asphyxia before the development of the first symptom of NEC. supporting the role of hypoxia and acidosis in the pathogenesis. The authors have put forward the hypothesis that earlier surgery might be beneficial as conservative management does not reverse the weight loss. However, a significant proportion of patients did gain weight on conservative management. It was evident from their study that those patients who have
1513
continued catabolism in spite of adequate parenteral have a poorer prognosis.-Preen Pun’
nutrition
Immunosuppressive Therapy in Pediatric Inflammatory Bowel Disease: Results of a Survey of the North American Society for Pediatric Gastroenterology and Nutrition. .J. Markowitz, K. Cruncher, F. Mandel, et al. Am J Gastroenterol88:44-48, (January),
1993. The membership of the North American Society for Pediatric Gastroenterology and Nutrition was surveyed to determine attitudes toward the use of immunosuppressive therapy for inflammatory bowel disease (IBD) and to assess how these medications are actually being used in treatment of children with IBD. The response rate was 27% and this was generally from physicians who had used immunosuppressive therapy. Eighty-four percent had prescribed 6-mercaptopurine and/or azathioprine, and only a minority had used cyclosporine or methotrexate. Those using immunosuppression had done so in patients with Crohn’s disease but only 50% had prescribed it for patients with ulcerative colitis. The main indications for use were intractable symptoms despite traditional medical therapy and for corticosteroid-sparing effects. In a data base comprised of 165 patients, median age 15.3 years, 68% of patients treated with immunosuppressive agents improved. Complications requiring discontinuation of therapy occurred in only 6% of patients. Most clinicians were unsure of recommendations with respect to use of immunosuppressive therapy prior to and during pregnancy. The authors point out that controlled, prospective trials are warranted to better define the role of immunosuppressive therapy in pediatric patients with IBD.--Richard R. Rick&s Prevention of Postischemic Injury in Immature Intestine by Deferoxamine. J.L. Lelli, Jr, S. Pradhan. and L.M. Cobb. J Surg
Res 54:34-38. (January), 1993. The purpose of this study was to create a histological lesion similar to that of human necrotizing enterocolitis (NEC) through ischemia and reperfusion and to see if deferoxamine, an iron chelator, could ameliorate the bowel injury. The chelating agent was chosen since alterations in iron metabolism have proven to be a critical link between superoxide radicals and postischemic reperfusion injury. One group of dogs had sham laparotomy without vascular occlusion. The second group was subjected to 90 minutes of superior mesenteric artery occlusion prior to reperfusion. The third group received deferoxamine, 15 mgikg, intravenously prereperfusion. The results showed that the iron chelating agent prolonged the survival profile compared to untreated animals. Microscopic tissue damage was significantly ameliorated with deferoxamine. The authors conclude that neonatal bowel ischemia conditions, such as NEC, may be reperfusion injuries wherein free iron plays an important role in tissue injury and that the administration of an iron chelating agent may have beneficial effects on survival and histology.--Richard R. Ricketts Late Complications of the lleal Pouch-Anal Anastomosis. MC. Santos and J.S. Thompson. Am J Gastroenterol 88:3-10,
(January), 1993. This is an excellent review and discussion of long-term problems that can occur after ileal pouch-anal anastomosis for ulcerative colitis and familial polyposis. Pouchitis, characterized by increased frequency of stools, bloody diarrhea, pelvic discomfort, and fever, occurs more frequently with more prolonged follow-up. One series showed an increase from 8% to 29% with longer follow-up. The diagnosis is mainly a clinical one, although endoscopic changes are frequently found. The endoscopic appearance of the pouch, how-
INTERNATIONAL
1514
ever, does not correlate with the severity of the clinical syndrome. Although bacterial overgrowth secondary to stasis and partial obstruction was initially felt to be the underlying etiology, there is evidence now to support the concept of pouchitis as a systemic process rather than a local one. The rate for familial polyposis is 0 to 9%, whereas the incidence in patients with ulcerative colitis is 8% to 31%. The treatment of pouchitis is oral metronidazole at a dosage of 250 mg qid. Intestinal obstruction occurs in 15% to 25% of patients and generally occurs within the first 90 days of operation. Operation is necessary to relieve the obstruction in approximately 40% to 50% of these patients. The superior mesenteric artery syndrome has also been reported following this procedure, probably secondary to weight loss and tension on the SMA produced by the operation. Anastomotic stricture, perforation of the pouch, and ileal pouch vaginal fistulas can also occur following this procedure. There have been a few reports of carcinoma arising in the ileal pouch. In addition, carcinoma can arise in retained rectal mucosa either distal to the suture line or retained within the muscular cuff itself. A variety of metabolic complications including intestinal malabsorption of carbohydrates, amino acids, and bile acids can occur following this operation. Potassium losses are significantly higher following ileoanal anastomosis than with a conventional anastomosis. Vitamin Biz absorption may also be adversely affected by an ileoanal pouch. Although ileal reservoirs are associated with a significant decrease in gall bladder bile concentrations of total bile acids, cholesterol, phospholipids, and calcium, there is no clear evidence that these patients are at greater risk for developing cholelithiasis. Ileal reservoirs may decrease the risk of nephrolithiasis. Other rarer complications include adrenal insufficiency which can be transient during the tapering period or permanent following the procedure. Alopecia has been reported in up to 38% of patients; this occurs more often in females and is self-limited. Retrograde ejaculation occurs in 1% to 10% of males undergoing ileoanal anastomosis; sexual function in females does not seem to be adversely affected. While transient urinary retention is a frequent problem, long-term bladder dysfunction is rare. The reader is referred to this article for an excellent review of the long-term complications involved in this procedure.--Richard R. Rickerts
The Transplantation of Gastrointestinal Todo, A. Tzakis, et al. Gastroenterology
Organs. T.E. Starzl, S.
104:673-679, (March),
1993. The history of transplantation of gastrointestinal organs, specifically the liver and the intestine, is nicely detailed in this short article by one of the pioneers in the field. The first attempt at liver replacement occurred on March 1,1963; this ended tragically when the child with biliary atresia bled to death in the operating room. Between then and January 1964, six more attempts were made and all patients died within 23 days. After an intensive period of laboratory research, a 1’/2-year-old girl with a nonresectable hepatoma underwent a liver transplantation on July 23, 1967 and became the first long-term survivor of this procedure. After cyclosporine was introduced in 1979, the I-year patient survival rate was at least 70% throughout the world. With the substitution of FK 506 for cyclosporine in 1989, the l-year patient survival increased to 85% in centers having this agent available to them. With respect to liver-small bowel transplantation, using FK 506, 13 of 17 patients (76.5%) in the Pittsburgh series are alive after 4% to 30 months, and all but one are off total parenteral nutrition. As late as 1991, it seemed that liver-small bowel transplantation was more effective to treat short-gut syndrome than intestinal transplantation alone. However, the routine survival of cadaveric intestinal
ABSTRACTS
recipients became possible under immunosuppression with FK 506 in Pittsburgh, and the results were better with isolated intestinal transplantation than with the liver-intestine variant. Eight of 9 recipients survive, of whom all but one are off TPN. Long-term graft acceptance seems to occur, especially in liver transplantation, because of chimerism between the transplanted organ and the host. This immune tolerance may be so complete in some cases that immunosuppression can be stopped, particularly after liver transplantation but less constantly with other organs. Intense research in this area of donor specific nonreactivity (tolerance) is currently underway.-Richard R. Ricketts GENITOURINARY
TRACT
Solitary Polyp of Posterior Urethra in Children: Report on Seventeen Cases. R. De Castro, P. Campobasso, G. Belioli, et ai.
Eur J Pediatr Surg 3:92-96, (April), 1993. Seventeen cases of a solitary polyp of the posterior urethra in children (aged 4 months to 12 years) are presented. All patients were treated endoscopically using a 10F pediatric cystoscope, equipped with a straight ahead lens and a Bigbee 3F electrode to fulgurate the stalk of the polyp through the urethra without meatotomy. No complications or relapses ocurred which proves the safety and efficiency of transurethral endoscopic resection in the pediatric age group. All polyps were removed and examined histologically. The dimensions of the polyps ranged from 4 mm to 27 mm. Their shape varied from a long “cordon-like” peduncle to a short stalk, “balloon-like” appendix. The histological features were similar, the main component being an axis of connective tissue and vessels, surrounded by transitional epithelium, usually described as a fibroepithelial polyp.--Thomas A. Angerpoinfner Ureterocystoplasty: A Unique Method for Vesical Augmentation in Children. M.F. Bellinger. J Urol 149811-813, (April), 1993.
Vesical augmentation may be accomplished by using small bowel, large bowel, or stomach, and by detrusor myotomy or the autoaugmentation technique. The use of intestinal segments is associated with variable mucus production, electrolyte absorption, and the risk of malignant transformation. Autoaugmentation is free of these potential risks but may be unsuccessful in creating sufficient improvement in vesical compliance and capacity. Ureterocystoplasty with a bladder based native ureteral flap has been used in neurovesical dysfunction in association with a nonfunctional refluxing kidney, in a noncompliant valve bladder associated with posterior urethral valves and a nonfunctional kidney, and in augmentation of a small bladder after closure of cloaca1 exstrophy. Adequate bladder capacity and compliance have been achieved without the use of extra urinary epithelium. The surgical approach is simple and uncomplicated. Ureterocystoplasty in selected cases will provide for adequate bladder capacity and compliance when augmentation cystoplasty is required. Initial experience with ureterocystoplasty in two patients is presented.-George W. Holcomb, Jr Experience With Duplex System Anomalies Detected by Prenatal Ultrasonography. L.D. Jet: A.M.K. Rickwood, M.P.L. Williams, et al. J Urol 149:808-810, (April), 1993.
Thirty-nine neonates with prenatally diagnosed duplex system anomalies are reviewed. Principal diagnoses were ureterocele (15), ureteral ectopia (15), lower polar vesicoureteral reflux (6) lower pole ureteropelvic junction stasis (2) and yo-yo reflux in an incompletely duplicated system (1). Several patients had other ipsilateral and contralateral urinary anomalies. Ten patients (26%) had relevant physical signs and only one became symptomatic, with urosepsis, neonatally. At initial assessment, before any accounted urinary
ABSTRACTS
gangrene (3), and perforation and peritonitis (4). In contrast to reports in the literature, massaging of worms into the colon where they become inactive was possible in only 4 cases in this study. Other procedures included enterotomy and removal of worms (7), resection anastomosis (14), resection and exteriorization in one patient. In subacute cases, failure of conservative management up to 48 hours is an indication for surgery. The choice of procedures is to massage the worms into the colon without damaging the bowel; otherwise, enterotomy and removal of worms should be done. Resection and primary anastomosis is undertaken for gangrene or perforation. and resection and ileostomy is reserved for patients who are in a poor condition. Important points stressed in this article are avoidance of peritoneal contamination during surgery and the use of nonabsorbable suture to prevent roundworms from penetrating the suture line.--Prem Pun’ Contrast Enemas After Necrotising Enterocolitis: A Case for Prophylaxis? I.R. Brand and R.J. Arthur. Pediatr Radio] 22:571-
572, (December), 1992. Over a 4-year period, 35 patients underwent contrast enema following surgery for necrotizing enterocolitis (NEC). Nine of these patients deteriorated with one death among two who developed Klebsiel/a septicemia. Among various factors studied in patients who deteriorated, the authors identified previous perforation and long line (central venous) in situ as important risk factors. Seventy-eight percent of the patients who deteriorated had previous perforation. On analyzing the data, it appears that 33% of the patients who had previous perforation deteriorated after contrast enemas as compared with 14% who did not have perforation. Similarly 45%, of the patients who had long line in situ deteriorated after contrast enema as compared with 17% who had no long line in situ. The authors conjecture that contrast enema induces bacteraemia, which in some patients will develop into a septicaemia aided by the immature immune system. The presence of a long line acts as a foreign body, colonising the organism and providing a continuing source of bacteria. Because of the small number of patients in the study, the authors note the difficulty in recommending or refuting the commencement of regular prophylaxis prior to contrast enemas.-!? Puri The Prognosis of Very Low Birth-Weight Neonates Operated Upon for Necrotising Enterocolitis. E. Waever, B. Brandt, T. Mortensen, et al. Pediatr Surg Int 8:207-209, (April), 1993.
The authors have summarized their experience in managing 13 very low birth weight (650 to 1,500 g) neonates with necrotizing enterocolitis (NEC). All these patients were initially managed conservatively for 0 to 60 days. Indications for operations included radiologic evidence of free air, impending bowel perforation with discoloration of the abdomen, and radiological signs of progressive disease with clinical deterioration. Eight patients had preoperative perforation with a mortality of 50%. However, data are not provided for whether these patients presented with bowel perforation or perforated while being conservatively managed. Those babies who were born before 28 weeks had 80% mortality as opposed to 12%, in those who were more than 28 weeks at birth. The authors also found that those patients who had Apgar scores of 5 or less at 1 minute had significantly higher mortality. All these neonates in this study had suffered severe asphyxia before the development of the first symptom of NEC. supporting the role of hypoxia and acidosis in the pathogenesis. The authors have put forward the hypothesis that earlier surgery might be beneficial as conservative management does not reverse the weight loss. However, a significant proportion of patients did gain weight on conservative management. It was evident from their study that those patients who have
1513
continued catabolism in spite of adequate parenteral have a poorer prognosis.-Preen Pun’
nutrition
Immunosuppressive Therapy in Pediatric Inflammatory Bowel Disease: Results of a Survey of the North American Society for Pediatric Gastroenterology and Nutrition. .J. Markowitz, K. Cruncher, F. Mandel, et al. Am J Gastroenterol88:44-48, (January),
1993. The membership of the North American Society for Pediatric Gastroenterology and Nutrition was surveyed to determine attitudes toward the use of immunosuppressive therapy for inflammatory bowel disease (IBD) and to assess how these medications are actually being used in treatment of children with IBD. The response rate was 27% and this was generally from physicians who had used immunosuppressive therapy. Eighty-four percent had prescribed 6-mercaptopurine and/or azathioprine, and only a minority had used cyclosporine or methotrexate. Those using immunosuppression had done so in patients with Crohn’s disease but only 50% had prescribed it for patients with ulcerative colitis. The main indications for use were intractable symptoms despite traditional medical therapy and for corticosteroid-sparing effects. In a data base comprised of 165 patients, median age 15.3 years, 68% of patients treated with immunosuppressive agents improved. Complications requiring discontinuation of therapy occurred in only 6% of patients. Most clinicians were unsure of recommendations with respect to use of immunosuppressive therapy prior to and during pregnancy. The authors point out that controlled, prospective trials are warranted to better define the role of immunosuppressive therapy in pediatric patients with IBD.--Richard R. Rick&s Prevention of Postischemic Injury in Immature Intestine by Deferoxamine. J.L. Lelli, Jr, S. Pradhan. and L.M. Cobb. J Surg
Res 54:34-38. (January), 1993. The purpose of this study was to create a histological lesion similar to that of human necrotizing enterocolitis (NEC) through ischemia and reperfusion and to see if deferoxamine, an iron chelator, could ameliorate the bowel injury. The chelating agent was chosen since alterations in iron metabolism have proven to be a critical link between superoxide radicals and postischemic reperfusion injury. One group of dogs had sham laparotomy without vascular occlusion. The second group was subjected to 90 minutes of superior mesenteric artery occlusion prior to reperfusion. The third group received deferoxamine, 15 mgikg, intravenously prereperfusion. The results showed that the iron chelating agent prolonged the survival profile compared to untreated animals. Microscopic tissue damage was significantly ameliorated with deferoxamine. The authors conclude that neonatal bowel ischemia conditions, such as NEC, may be reperfusion injuries wherein free iron plays an important role in tissue injury and that the administration of an iron chelating agent may have beneficial effects on survival and histology.--Richard R. Ricketts Late Complications of the lleal Pouch-Anal Anastomosis. MC. Santos and J.S. Thompson. Am J Gastroenterol 88:3-10,
(January), 1993. This is an excellent review and discussion of long-term problems that can occur after ileal pouch-anal anastomosis for ulcerative colitis and familial polyposis. Pouchitis, characterized by increased frequency of stools, bloody diarrhea, pelvic discomfort, and fever, occurs more frequently with more prolonged follow-up. One series showed an increase from 8% to 29% with longer follow-up. The diagnosis is mainly a clinical one, although endoscopic changes are frequently found. The endoscopic appearance of the pouch, how-
INTERNATIONAL
1514
ever, does not correlate with the severity of the clinical syndrome. Although bacterial overgrowth secondary to stasis and partial obstruction was initially felt to be the underlying etiology, there is evidence now to support the concept of pouchitis as a systemic process rather than a local one. The rate for familial polyposis is 0 to 9%, whereas the incidence in patients with ulcerative colitis is 8% to 31%. The treatment of pouchitis is oral metronidazole at a dosage of 250 mg qid. Intestinal obstruction occurs in 15% to 25% of patients and generally occurs within the first 90 days of operation. Operation is necessary to relieve the obstruction in approximately 40% to 50% of these patients. The superior mesenteric artery syndrome has also been reported following this procedure, probably secondary to weight loss and tension on the SMA produced by the operation. Anastomotic stricture, perforation of the pouch, and ileal pouch vaginal fistulas can also occur following this procedure. There have been a few reports of carcinoma arising in the ileal pouch. In addition, carcinoma can arise in retained rectal mucosa either distal to the suture line or retained within the muscular cuff itself. A variety of metabolic complications including intestinal malabsorption of carbohydrates, amino acids, and bile acids can occur following this operation. Potassium losses are significantly higher following ileoanal anastomosis than with a conventional anastomosis. Vitamin Biz absorption may also be adversely affected by an ileoanal pouch. Although ileal reservoirs are associated with a significant decrease in gall bladder bile concentrations of total bile acids, cholesterol, phospholipids, and calcium, there is no clear evidence that these patients are at greater risk for developing cholelithiasis. Ileal reservoirs may decrease the risk of nephrolithiasis. Other rarer complications include adrenal insufficiency which can be transient during the tapering period or permanent following the procedure. Alopecia has been reported in up to 38% of patients; this occurs more often in females and is self-limited. Retrograde ejaculation occurs in 1% to 10% of males undergoing ileoanal anastomosis; sexual function in females does not seem to be adversely affected. While transient urinary retention is a frequent problem, long-term bladder dysfunction is rare. The reader is referred to this article for an excellent review of the long-term complications involved in this procedure.--Richard R. Rickerts
The Transplantation of Gastrointestinal Todo, A. Tzakis, et al. Gastroenterology
Organs. T.E. Starzl, S.
104:673-679, (March),
1993. The history of transplantation of gastrointestinal organs, specifically the liver and the intestine, is nicely detailed in this short article by one of the pioneers in the field. The first attempt at liver replacement occurred on March 1,1963; this ended tragically when the child with biliary atresia bled to death in the operating room. Between then and January 1964, six more attempts were made and all patients died within 23 days. After an intensive period of laboratory research, a 1’/2-year-old girl with a nonresectable hepatoma underwent a liver transplantation on July 23, 1967 and became the first long-term survivor of this procedure. After cyclosporine was introduced in 1979, the I-year patient survival rate was at least 70% throughout the world. With the substitution of FK 506 for cyclosporine in 1989, the l-year patient survival increased to 85% in centers having this agent available to them. With respect to liver-small bowel transplantation, using FK 506, 13 of 17 patients (76.5%) in the Pittsburgh series are alive after 4% to 30 months, and all but one are off total parenteral nutrition. As late as 1991, it seemed that liver-small bowel transplantation was more effective to treat short-gut syndrome than intestinal transplantation alone. However, the routine survival of cadaveric intestinal
ABSTRACTS
recipients became possible under immunosuppression with FK 506 in Pittsburgh, and the results were better with isolated intestinal transplantation than with the liver-intestine variant. Eight of 9 recipients survive, of whom all but one are off TPN. Long-term graft acceptance seems to occur, especially in liver transplantation, because of chimerism between the transplanted organ and the host. This immune tolerance may be so complete in some cases that immunosuppression can be stopped, particularly after liver transplantation but less constantly with other organs. Intense research in this area of donor specific nonreactivity (tolerance) is currently underway.-Richard R. Ricketts GENITOURINARY
TRACT
Solitary Polyp of Posterior Urethra in Children: Report on Seventeen Cases. R. De Castro, P. Campobasso, G. Belioli, et ai.
Eur J Pediatr Surg 3:92-96, (April), 1993. Seventeen cases of a solitary polyp of the posterior urethra in children (aged 4 months to 12 years) are presented. All patients were treated endoscopically using a 10F pediatric cystoscope, equipped with a straight ahead lens and a Bigbee 3F electrode to fulgurate the stalk of the polyp through the urethra without meatotomy. No complications or relapses ocurred which proves the safety and efficiency of transurethral endoscopic resection in the pediatric age group. All polyps were removed and examined histologically. The dimensions of the polyps ranged from 4 mm to 27 mm. Their shape varied from a long “cordon-like” peduncle to a short stalk, “balloon-like” appendix. The histological features were similar, the main component being an axis of connective tissue and vessels, surrounded by transitional epithelium, usually described as a fibroepithelial polyp.--Thomas A. Angerpoinfner Ureterocystoplasty: A Unique Method for Vesical Augmentation in Children. M.F. Bellinger. J Urol 149811-813, (April), 1993.
Vesical augmentation may be accomplished by using small bowel, large bowel, or stomach, and by detrusor myotomy or the autoaugmentation technique. The use of intestinal segments is associated with variable mucus production, electrolyte absorption, and the risk of malignant transformation. Autoaugmentation is free of these potential risks but may be unsuccessful in creating sufficient improvement in vesical compliance and capacity. Ureterocystoplasty with a bladder based native ureteral flap has been used in neurovesical dysfunction in association with a nonfunctional refluxing kidney, in a noncompliant valve bladder associated with posterior urethral valves and a nonfunctional kidney, and in augmentation of a small bladder after closure of cloaca1 exstrophy. Adequate bladder capacity and compliance have been achieved without the use of extra urinary epithelium. The surgical approach is simple and uncomplicated. Ureterocystoplasty in selected cases will provide for adequate bladder capacity and compliance when augmentation cystoplasty is required. Initial experience with ureterocystoplasty in two patients is presented.-George W. Holcomb, Jr Experience With Duplex System Anomalies Detected by Prenatal Ultrasonography. L.D. Jet: A.M.K. Rickwood, M.P.L. Williams, et al. J Urol 149:808-810, (April), 1993.
Thirty-nine neonates with prenatally diagnosed duplex system anomalies are reviewed. Principal diagnoses were ureterocele (15), ureteral ectopia (15), lower polar vesicoureteral reflux (6) lower pole ureteropelvic junction stasis (2) and yo-yo reflux in an incompletely duplicated system (1). Several patients had other ipsilateral and contralateral urinary anomalies. Ten patients (26%) had relevant physical signs and only one became symptomatic, with urosepsis, neonatally. At initial assessment, before any accounted urinary