Pediatric Urology

1153

f'EDii;,_TR.!C WJROLOG"Cl

phase to and after the administration of intracorporal papaverine. Penile counts, images, and time-activity curves were con1puter analyzed in order to determine peak corporal flow and volume changes. Peak corporal flow rates were compared to arterial integrity (determined by angiography) and venosinusoidal corporal leak (determined by cavernosometry). Peak corporal flow correlated well with arterial integrity (r = 0.91) but did not correlate with venosinusoidal leak parameters (r = 0.01). This report focuses on the methodology and the assumptions which form the foundation of this technique. The strong correlation of peak corporal flow and angiography suggests that radioisotope penile plethysmography could prove useful in the evaluation of arterial inflow disorders in patients with erectile dysfunction.

uU:n:asou:r,d is :revierwed accora.n:1..r to the personal feelings of the authors and should be recognized as :representing thei:r opinion. However, the images a:re of such great quality that I recommend it to the urologist. Stanford M. Goldman, 1\/JLD,

Editorial Comment: The authm.'s advocate the inch.1sion of radioisotopes among the multiplicity of tests to evaluate this new and exciting field of erectile dysfunction. The test has the advantage of being a noninvasive technique compared to arteriography. By use of 99 mtechnetium-labeled :red blood cells in a steady state, blood pool phase before and after the administration of papaverin.e, it is suggested that isotope may be useful to demonstrate arterial inflow disorders. Since it will not give anatomical detail and if one must use papaverine, a not entirely benign drug, we would not recommend :routine use of this test until more clinical material has been published. Stanford M. GoldmaHJ., M.D.

In this study an attempt was made to clarify some of the causes of the apparent differences in appearance on ultrasound (US) images of prostate cancer. These differences were correlated with histologic grade and the degree of stromal fibrosis present. Fifty-one cancers (diagnosed and evaluated by means of US-guided biopsy or evaluated by means of radical prostatectomy) were studied. There were 30 hypoechoic, ten echogenically mixed, six isoechoic, and five subtly hyperechoic cancers. The degree of stromal fibrosis was minimal in well-differentiated cancers and increased in poorly differentiated cancers. In addition, the more hypoechoic lesions were, in general, the better-differentiated cancers and had less fibrosis. There was a tendency for the isoechoic cancers and those with subtly hyperechoic areas to more often have poor cellular differentiation and a greater degree of stromal fibrosis, but considerable overlap among histologic types was seen.

Transrectal Ultrasound in the Diagnosis and Staging of Prostatic Carcinoma

F.

LEE, S. T. TORP-PEDERSEN, D. B. SmERS, P. AND R. D. MCLEARY, Departments of Radiology

J. LITTRUP and Pathology, St. Joseph Mercy Hospital, Ann Arbor, Michigan

Radiology, 170: 609-615, 1989 Since its clinical application in 1971 by Watanabe, transrectal ultrasound (TRUS) has now developed into a sophisticated technology. Its widespread acceptance is reflected in increased numbers of scientific publications on prostate imaging in the current literature. Early in the history of TRUS, bistable 3-MHz transverse images n"'"'"''"'"" information about prostate size and shape. In the late 1970s and early 1980s, gray-scale longitudinal and transverse scanners were introduced. Visualization of the internal architecture of the prostate vvas then possible, and two zones we:re identified: the internal and the external gland. At that time, the majority of investigators believed cancers were hyperechoic. In 1985, studies were performed with 5.0 MHz scanning in both transverse and longitudinal planes. The hyperechoic nature of prostate cancer was then challenged. In 1986, 7.0-MHz scanning was introduced. The improvement in resolution allowed visualization of the infrastructure of the prostate corresponding to McNeal's 1981 concept of zonal anatomy. Editorial Comment: The major contributions of this state of the art article on transrectal ultrasound are the excellent color diagrams and anatomical ultrasonic correlations of normal gland tissue. Fm.· th.is reason I would recommend it to the reader. The role of transrectal

EchogenicHy of Prostate Cancer Correlated With Histological Grade and St:romal Fibrosis: Endorectal US Studies

D. RIFKIN, E. T. MCGLYNN AND H. CHOI, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania

M.

Radiology, 1 70: 549-552, 1989

Editorial Comment: The ultYaso:nic appearance of prostatic carcinoma still remain§ an area of controversy in the radiological literatu:re, Although mmit believe that these tumor§ are hypoechoic, the authors believe in. the existence of a mixed echogenic patten:1. and a group of hyperechoic cm1ceirs, They attempt to support their belief in 3 different patterns based on pathological findings, with. the hypoechoic pattern being seen in better differentiated tumor§ with less fibrosis, On the other hand, the isoechoic and the subtly hype:rechoic tumors have more cellular element§, a greater degree of stromal fibrosis and poore:r celluia1· differentiation, They admit to considerable overlap and one still mi.:u;;t ponder whether much of thi§ echogenicity :relates to no:rmal m:m.malignant pro!ltatic til'lsue that is being invaded by the tumor" Thi.s issue is far from resolved and most ultiraso:rwg:raphe:rs believe these tumors to he hypoechoic. St::rn.ford IVL Goldman, MJ).

PEDIATRIC UROLOGY Ultrasound Findings in the Ad:reno-Genital Syndrome (Congenital Adrenal Hyperplasia)

P. J. BRYAN, A. A. CALDAMONE, s. C. MORRISON, B. S. YULISH AND R. OWENS, Department of Radiology, Division of Pediatric Urology, and Department of Pediatrics, Case Western Reserve University, University Hospitals of Cleveland, Cleveland, Ohio

1154

PEDIATRIC UROLOGY

within normal limits. Importantly, there was no correThe adreno-genital syndrome (congenital adrenal hyperpla- lation between adrenal thickness and degree of virilisia) is caused by deficiency of an enzyme (usually C-21 hydrox- zation nor with the presence or absence of salt loss. ylase) necessary for adrenal production of cortisol, which re- Therefore, on the basis of this study, it seems that adsults in excessive accumulation of androgenic precursors. It is renal ultrasound may be strongly indicative of congenthe most common cause of female pseudohermaphroditism. ital adrenal hyperplasia but it cannot be used to rule out There have been a few sporadic reports of ultrasonic demon- the disorder if the adrenals are normal in maximum stration of enlarged adrenals in the adreno-genital syndrome. thickness. Hauffa and associates studied 84 newborns and inTo determine whether ultrasonography could be used to establish or exclude the diagnosis, ultrasonic examinations were fants of various ages, and 4 with congenital adrenal performed on eight newborn infants with ambiguous genitalia hyperplasia. They devised an adrenal size index that who were subsequently proven to have the adreno-genital syn- incorporates the cranio-caudal diameter and maximum drome. The adrenals were found to be enlarged in three pa- adrenal thickness, and found that normally the adrenal tients, at the upper limit of normal in three patients, and in size index gradually decreases with age. They found two infants the adrenals were well within normal limits in size. that in newborns less than 2 weeks old the adrenal The uterus was identified in seven of the eight patients, but almost always was anechoic, at times surrounded by a was not seen for technical reasons in one. It is concluded that thin, highly echogenic outer rim. Beyond a patient age ultrasound is useful in the evaluation of infants with congenital of 3 months, however, the adrenal normally was highly adrenal hyperplasia to establish the presence of a uterus and echogenic. Of the 4 patients with congenital adrenal to demonstrate enlargement of the adrenals, but it should be · hyperplasia the 2 with severe salt wasting had a markcautioned that finding adrenals of normal size does not exclude edly elevated adrenal size index. In the 2 with congenital adrenal hyperplasia who did not have salt wasting the the diagnosis. adrenal size index was at the upper limit of normal. In all 4 patients with congenital adrenal hyperplasia, after Age-Related Changes in Adrenal Size During the First steroid therapy the adrenal size index decreased Year of Life in Normal Newborns, Infants and Pa- promptly to the normal range. tients With Congenital Adrenal Hyperplasia Due to These 2 studies are important because they document 21-Hydroxylase Deficiency: Comparison of Ultra- that ultrasound may be beneficial in the diagnosis of sound and Hormonal Parameters some newborns with congenital adrenal hyperplasia. However, more patients must be studied to verify the B. P. HAUFFA, D. MENZEL AND H. STOLECKE, Klinik fur findings. Kinder- und Jugendmedizin, Abteilung fur padiatrische EnJack S. Elder, M.D. dokrinologie, Universitat GHS Essen, Essen, Federal Republic of Germany Screening for Congenital Adrenal Hyperplasia: DistriEur. J. Ped., 148: 43-49, 1989 bution of l 7a-Hydroxyprogesterone Concentrations Permission to Publish Abstract Not Granted in Neonatal Blood Spot Specimens J. Ultrasound Med., 7: 675-679, 1988

Editorial Comment: The adrenal gland may be detected by ultrasound as early as 21 weeks of gestation. Adrenal size increases rapidly throughout gestation and at birth it may reach adult size, primarily due to growth of the inner fetal zone of the adrenal cortex, which produces dehydroepiandrosterone sulfate. Postnatally, the fetal zone undergoes mild involution but the precise timing of this process has not been well documented. In a female patient with congenital adrenal hyperplasia, particularly the salt-losing form, it would seem logical that the adrenal gland would be larger than normal. These 2 studies address this problem. In the study by Bryan and associates the adrenal ultrasound findings in 8 female newborns with 21-hydroxylase deficiency are reported. They found that the normal neonatal adrenal gland varies between 3 and 6 mm. in maximum thickness and used this parameter rather than adrenal length to document adrenal enlargement, since the length and shape of the normal adrenal vary greatly. In all cases they found that both adrenals were symmetrical and that the right adrenal was easier to identify than the left gland. The maximum diameter of the enlarged gland usually is near the base of the limb. In 3 of the 8 patients the adrenals were enlarged (maximum thickness 8 to 12 mm.), in 3 they were at the upper limits of normal (maximum thickness 6 mm.) and 2 were

THOMPSON, L. SEARGEANT AND J. s. D. WINTER, Metabolic Diseases. Section, Cadham Provincial Laboratory and the Departments of Biochemistry and Paediatrics, University of Manitoba, Winnipeg, Manitoba, Canada

R.

J. Ped., 114: 400-404, 1989 In a retrospective analysis of 24 cases of congenital adrenal hyperplasia (CAH) in neonates born in the province of Manitoba during the last 20 years, we set out to determine whether patients, in particular male infants with salt-losing CAH, were being missed by the usual forms of clinical ascertainment. Although the overall incidence of 1/14,500 live births was similar to that found in several screening surveys, a skewed female/male sex ratio of 2.2:1 suggested probable death among male infants with unrecognized adrenal insufficiency. These results led to a prospective analysis of 17a-hydroxyprogesterone (17-0HP) levels in 1194 neonatal blood specimens by a solidphase direct radioimmunoassay procedure to determine whether this method would be suitable for CAH screening. In 1103 neonates weighing >2500 gm at birth, all 17-0HP values were <30 nmol/L (approximately 1000 ng/dl), with a mean of 8.2 nmol/L; values in male infants were slightly higher than in female infants. In 89 neonates with a birth weight <2500 gm, 17-0HP values were skewed, with nine having levels >30 nmol/ Land two >50 nmol/L. Postnatal age (1 to 24 days) at the time of specimen collection had no effect on 17-0HP levels, although

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higher values occur during the first 24 hours. One unsuspected case of CAH in a male infant was discovered during the trial period. We conclude that neonatal CAH screening can permit diagnosis and therapy of affected male infants who are being missed by normal clinical evaluation. This radioimmunoassay method is relatively simple and inexpensive, and it has the specificity and sensitivity necessary to provide such mass screening. Editorial Comment: Recently, there has been interest in development of a neonatal screening test for congenital adrenal hyperplasia. Although female infants with congenital adrenal hyperplasia geneli."ally are diagnosed because of genital ambiguity, male infants with 21hydroxylase or 11-hydroxylase deficiency are phenotypically normal and they usually are not diagnosed until later in childhood when precocious puberty develops. However, those with the salt-losing form of 21hydroxylase deficiency are at risk for life-threatening metabolic problems during the first few weeks of life. The authors analyzed neonatal heel stick samples obtained at 2 to 4 days of life and developed standards for term newborns as wen as premature neonates. The 1 7 a-hydro:xyprogesterone concentration in cord blood is high, 'but it normally is cleared during the fi:rst 24 hou:rs of life. Therefore, samples obtained after day 1 reflect neonatal adrenal 17-hydn:rn:yp:rogesterone secretion. It is likely that further elucidation of the potentiai benefits of mass screening for congenital adrenal hyperplasia will be reported in the future. Jack S. Elder, M.D.

Voiding Cystou:rethrography as a Predictor of Reflux Nephrop,athy in Children With Urinary-Tract Infection

B. JACOBSSON, S. MARILD AND U. JODAL, Department of Radiology, Sahlgren's Hospital, Gothenburg, Sweden, Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia, and Department of Pediatrics, East Hospital, Gothenburg, Sweden

M. HELLSTROM,

Amer. J. Roentgen., 152: 801-804, 1989 Most children who develop renal damage (scarring) after urinary-tract infection have vesicoureteral reflux. Voiding cystourethrography is therefore usually recommended as the initial radiologic study in children with urinary-tract infection. However, renal damage may occur also in the absence of reflux. The aim of this investigation was to determine the sensitivity and predictive value of reflux during voiding cystourethrography in identifying children at risk for renal damage. Eighty-four consecutive children, 2 months to 6 years old, with nonobstructive, first-known, febrile urinary-tract infection underwent voiding cystourethrography and urography. Twenty-seven (32%) had reflux and 10 (12%) had or developed renal damage. Two of the children and four of the kidneys with renal damage had no reflux at initial examination. The sensitivity of reflux as a marker for renal damage was 80%, specificity was 74%, positive predictive value was 30%, and negative predictive value was 96%. Thus, most children who develop renal damage after urinarytract infection have reflux during voiding cystourethrography.

albeit However, there is a in the absence of reflux. 99

for renal damage to occur

mTc Dimercaptosuccinic Acid (DMSA) Scan as First Investigation of Urinary Tract Infection

I. G. VERBER, M. R STRUDLEY AND S. T. MELLER, Queen Mary's Hospital for Children, Carshalton and Royal Marsden Hospital, Sutton, England Arch. Dis. Child., 63: 1320-1325, 1988 Abstract printed in J. Urol., 142: 231, 1989 Intravenous Pyelography in Children With Urinary Tract Infection and Vesicoureteral Reflux U. ALON, M. BERANT AND M. PERY, Section of Pediatric Nephrology and the Departments of Pediatrics and Diagnostic Radiology, Rambam Medical Center, and the Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Pediatrics, 83: 332-336, 1989 Permission to Publish Abstract Not Granted Editorial Comment: Between 3 and 5% of all girls and approximately 1.5% of all boys have a symptomatic urinary tract infection during childhood, and renal scarring develops in 5 to 15% of these children, primarily in association with refluxo Hellst:rom and associates studied the risk of scarring in children who did or did not have reflux. The patient population included all children whose first febrile urinary tract infection developed between 1979 and 1981. Th.e initial voiding cystourethrogram and excretory urogram (IVP) were performed during the hospitalization for pyeloneph:ritis, following defe:rvescence. These studies were :repeated at 6 months and 2 to 3 years later. A third of the children had reflux and 10 (12%) had reflux nephropathy. In 3 patients ,;earring was apparent during initial investigation, while in the other 7 damage was documented 2 to 4 years after the initial urinary tract infection. Of the 13 renal units with reflux nephropathy 4 had no associated reflux. However, the severity and types of :renal scarring were not de§cli."ibed, and whether those with irnflux had more severe scarring than those without reflux was not mentioned. Furthermore, it was not stated whether the children with §can·i.ng in the absence of reflux were main.tained on antimicrobial supp:rcession and the numhei· of children in the study with recunent urinary tract infections was not revealed. Finally, the ages of the children with scarring were not :reported. It is well known that children less than 1 to 2 years old a:re at greatest risk for renal scarring. Nevertheless, this study documents that children with a history of pyeloneph:ritis should have upper urinary tract imaging for several years to ascertain continued renal growth. The dimercaptosuccinic acid (DMSA) scan is known to be more sensitive than an IVP or renal ultrasound to detect renal involvement with acute infection. The study by Verber and associates attempts to correlate findings on a DMSA scan with the presence or absence of vesicoureteral :reflux. Of the 66 renal units that were abnormal by a DMSA scan 40 had associated reflux, compared to only 20 of the 64 renal units that were normal

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PEDIATRIC UROLOGY

on scan. Of the 21 renal units with associated reflux that was grade 3 or more 18 had an abnormal DMSA scan, whereas less than h.alf had an abnormal IVP or ultrasound. Of 37 patients with unilateral defects on the DMSA scan 22 had reflux on the affected side and 11 on the nonaffected side. Surprisingly, only 65 of the 115 patients (56%) underwent a voiding cystourethrogram. The study is hampered because the number of children with febrile or nonfebrile urinary tract infections was not reported. The authors recommend that the initial imaging studies in children with a urinary tract infection should be a DMSA scan and ultrasonography. They strongly suggest that children with an abnormal DMSA scan undergo a voiding cystourethrogram and they also make the provocative statement that children without scarring by a DMSA scan do not need to undergo a voiding cystourethrogram because they question "whether reflux in the absence of scarring is ever of any long-term importance". The theory may seem logical but they did not adhere to their own recommendations, since 18% of the children with an abnormal DMSA scan did not undergo a voiding cystourethrogram. Furthermore, the theory presumes that a child with a urinary tract infection, reflux and a normal renal scan is unlikely to have pyelonephritis and renal scarring if further infections occur. I do not believe that these recommendations can be supported. Alon and associates reviewed the IVP findings in 52 children with a urinary tract infection and reflux. Of 72 refluxing units 44 were grade 1 or 2, 14 were grade 3 and 14 were grade 4 or 5. In the 44 units with low grade reflux the IVP and renal ultrasound nearly always were normal. However, in the 14 units with gll."ade 3 reflux ultrasonography was normal in 10 but in 6 of these the IVP was abnormal. The ultrasound and IVP were abnormal in ail 14 units with high grade reflux. The authors recommend that the IVP be reserved for children with grade 3 reflux or greater, and that an IVP is unnecessary and can be replaced by ultrasonography in children with grades 1 and 2 reflux. Unfortunately, the authors did not describe the IVP abnormalities that were identified. For example, it was unclear whether the abnormalities were hydronephrosis secondary to reflux, caliceal clubbing, cortical thinning or renal atrophy. Furthermore, this study did not describe the longterm radiological followup of these children with urinary tract infections. Since renal scars often take 1 to 2 years to evolve and since ultrasound is less sensitive in demonstrating reflux nephropathy than an IVP, an IVP or renal scan should be obtained as a long-term followup study on at least 1 occasion. The recommendation of the authors seems reasonable in the initial evaluation of children with reflux. However, as noted in the previous article, a DMSA or glucoh.eptonate scan probably is more accurate to demonstrate the extent of renal involvement. Jack S. Elder, M.D. Suggested Additional Reading: Sfakianakis, G. N. and Sfakianaki, E. D.: Nuclear medicine in pediatric urology and nephrology. J. Nucl. Med., 29: 1287, 1988.

Renal Parenchymal Volume During and After Acute Pyelonephritis Measured by Ultrasonography

s. TROELL AND u. BERG, Departments of Paediatrics and Diagnostic Radiology, Huddinge University Hospital, Huddinge, Sweden

B. JOHANSSON,

Arch. Dis. Child., 63: 1309-1314, 1988 A total of 4 7 children with acute pyelonephritis were investigated using water delay ultrasonographic equipment (Octoson) for determination of renal parenchymal volume by the stepped section technique. Thirty two patients were repeatedly investigated every to every other week up to seven weeks. Median renal parenchymal volume during acute pyelonephritis of the right kidney was 2. 70 cm3/kg body weight and of the left kidney 3.10 cm 3/kg; this was significantly larger than the volume of control kidneys, which was 1.82 and 2.07 cm 3/kg, respectively. The most enlarged kidneys were found among the youngest children. A significant successive decrease in renal size was found during the first four to five weeks after the acute pyelonephritis. Because of enlargement of the kidneys during acute pyelonephritis we suggest that the first renal size determination to be used for following renal growth should be performed after at least four to six weeks.

Editorial Comment: Pyelonephritis in children may result in a 50% mean increase in parenchymal volume during the acute stage of the disease. If ultrasound is the initial renal imaging study and is performed during the acute illness, long-term followup studies to assess renal growth should not be based upon the ultrasound performed during the pyelonephritic episode but on a study performed 6 to 8 weeks later. Jack S. Elder, M.D. Urinary Tract Infections and Circumcision: A CaseControl Study

L. W.

HERZOG, Division of Ambulatory Pediatrics, The Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts

Amer. J. Dis. Child., 143: 348-350, 1989

It has been shown that uncircumcised infants have a higher rate of urinary tract infections in the first few months of life. To investigate further the association between noncircumcision and urinary tract infections, a case-control study was performed of infant boys who had a catheterized or suprapubic urine culture done as part of an acute illness visit. Cases (n = 36) were those infants who had a positive culture (> 105 organisms per milliliter); controls (n = 76) had a negative culture (<103 organisms per milliliter). There were no significant differences found in the two groups in age, ethnic group, and type of medical insurance. All of the cases were uncircumcised, vs 32% of controls. The data were analyzed separately by age, ethnic group, type of insurance, and method of culture, and in all groups the cases were significantly more likely to be uncircumcised. Of the 31 cases who underwent roentgenographic investigations, 6 had abnormal findings. Noncircumcision seems to be a highly significant risk factor for urinary tract infection in infants up to 12 months of age, affects infants regardless of race and socioeconomic status, and is associated with anatomic abnormalities in 26% of cases.

PEDIATRIC UROLOGY

Editorial Comments: The authors reviewed all male infants less than 1 year old who underwent a suprapubic or catheterized urine culture in the emergency department as part of an evaluation for a febrile illness during a 2-year period. Infants with previously diagnosed urinary tract anomalies were excluded. As in previous studies, urinary tract infections occurred almost exclusively in uncircumcised boys. In this series 8 infants (26%) had anatomical abnormalities on urological evaluation, including 6 with reflux, 1 with posterior urethral valves and 1 with a ureteropelvic junction obstruction. The importance of obtaining a urine specimen by suprapubic aspirate or urethral catheterization is emphasized. The authors do not address the long-term management of male infants who have a febrile urinary tract infection. Generally, I have recommended circumcision to prevent against further infections. Furthermore, since the developing kidney is most susceptible to permanent scarring from infection during the first 12 to 24 months of life, I have placed the infants on suppressive therapy until they are 12 months old regardless of the results of the radiological evaluation. Jack S. Elder, M.D.

1157

strict rooming-in of mother and baby or by active colonisation of the baby with his mother's anaerobic gut flora. Editorial Comment: The American Academy of Pediatrics recently modified its firm stance opposing routine neonatal circumcision, 1 partly because of the recent evidence that uncircumcised male newborns are 10 to 15 times more likely to have a urinary tract infection than circumcised infants. The most apparent explanation for this phenomenon is that the foreskin becomes colonized by pathogens that can enter the urinary tract. The authors theorize that if being uncircumcised confers a risk for serious neonatal illness, then male subjects should not have evolved with a foreskin. They believe that the foreskin becomes colonized at birth with hospital uropathogens that inhibit the growth of nonpathogens and propose alternatives to circumcision, which is termed an unphysiological intervention. The hypothesis is fascinating and could be tested by performing serial foreskin cultures in uncircumcised male newborns to determine whether the bacterial pattern changes. Jack S. Elder, M.D. 1. Task Force on Circumcision: Report of the Task Force on

Circumcision. Pediatrics, 84: 388, 1989.

Suggested Additional Reading: Lohr, J. A.: The foreskin and urinary tract infections. J. Ped., 114: 502, 1989.

Laparoscopy and the Management of the Impalpable Testis

Male infants with urinary tract infections are significantly more likely to be uncircumcised than are male infants without infection. This is true in infants up to 12 months old regardless of race and socioeconomic status. Urinary tract infections in uncircumcised neonates frequently are associated with urinary tract abnormalities (half of the patients studied had varying degrees of reflux). Anthony J. Schaeffer, M.D.

E. J. GUINEY, M. CORBALLY AND P. s. MALONE, Children's Research Centre, Our Lady's Hospital for Sick Children, Dublin, Ireland

The Prepuce: A Mistake of Nature?

J.

WINBERG, I. BOLLGREN, L. GOTHEFORS, M. HERTHELIUS K. TULLUS, Department of Paediatrics, Karolinska Hos-

AND

pital, Karolinska Institut, Stockholm, Department of Paediatrics, Sachs's Children's Hospital, Karolinska Institut, Stockholm, Department of Paediatrics, Umea University, Umea and Department of Paediatrics, Danderyds Hospital, Stockholm, Sweden Lancet, 1: 598-599, 1989 Retrospective studies suggest that circumcision of newborn boys will reduce the frequency of male early infantile urinary tract infection (UTI) by about 90%. If they are correct, this will be the first known instance of a common potentially lethal disease being preventable by extirpation of a piece of normal tissue. To reconcile the phenomenon with existing views of evolution and biology, it is suggested that the effects of one unphysiological intervention are counterbalancing those of another-ie, colonisation of the baby's gastrointestinal tract and genitals in maternity units by Escherichia coli strains of nonmaternal origin, to which the baby has no passive immunity. As an alternative to circumcision to prevent early infantile male UTI, more natural colonisation could be promoted by

Brit. J. Urol., 63: 313-316, 1989 We describe the technique of laparoscopy when seeking to locate an impalpable testis. The procedure was used in 86 boys with unilateral or bilateral undescended testes; of the 103 testes which were sought, 64 were present, 39 were absent and 53 were intra-abdominal. Laparoscopy is useful in the management of the impalpable testis. The information gained from the study is valuable when advising parents of the significance of an impalpable testis. For example, there is a 39% chance it will be absent, a 29% chance that it will be easily placed in the scrotum and a 38% chance that a staged procedure may be necessary. Editorial Comment: In boys with an impalpable testis laparoscopy is becoming a common, although certainly not an essential, form of evaluation that is performed at the time of planned inguinal or abdominal exploration. This report of 86 patients is an update of an original study in 1984, and the current report is the largest series to date. The authors discuss their technique in detail, which varies from most in that the initial probe-cannula through which the pneumoperitoneum is created is left in place and the trocar/cannula through which the endoscope is passed is inserted through a separate incision. This method allows the probe-cannula to be used to retract the bowel and facilitates examination of a greater portion of the abdominal cavity. If a vas and vessels are seen to enter the internal ring, then only inguinal exploration is necessary, since the testis is canalicular. If the testis is intra-abdominal then

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the surgeon may choose the approach that seems most suitable, whether it be a single stage or 2-stage standard orchiopexy, a Fowler-Stephens orchiopexy, or microvascular autotransplantation. If the vas and vessels are not found on laparoscopy then formal laparotomy is necessary. Of the 34 instances in which the vas and vessels were seen to enter the inguinal canal only 11 viable testes were found in the canal. The remainder had an atrophic nubbin resulting from testicular torsion in utero. The authors found that these latter patients had hypoplastic vessels, that is they were much smaller. They report that at times they do not perform inguinal exploration in these boys and instead assume that the inguinal testis is atrophic. The authors have had extensive experience with laparoscopy but I believe that inguinal exploration is mandatory if the vas and vessels are visualized to enter the internal ring. In boys who have an absent testis at inguinal or abdominal exploration consideration should be given to inserting a small testicular prosthesis. Jack S. Elder, M.D. Neonatal Renal Dysfunction and Intrauterine Exposure to Prostaglandin Synthesis Inhibitors U. 8IMEONI, J. MESSER, P. WEISBURD, J. HADDAD AND D.

Service de Pediatrie II, Hopital de Hautepierre, Strasbourg, France

WILLARD,

Eur. J. Ped, 148: 371-373, 1989 Permission to Publish Abstract Not Granted

Editorial Comment: Prostaglandin synthesis inhibitors have known nephrotoxicity in adults. They are being used increasingly in the treatment of preterm labor because they reduce prostaglandins E and F mediated uterine contractions. These medications cross the placenta and, thus, may affect the fetus. The authors report on 3 newborns delivered at 30 to 31 weeks of gestation who experienced renal dysfunction, all of whom had been exposed to prostaglandin synthesis inhibitors prenatally, in 1 case on days 2 and 3 prenatally, and in the other 2 from 18 to 22 days prenatally. One of the newborns died of severe hyperkalemia at 3 days after birth. In premature neonates the half-life of indomethacin excretion is prolonged substantially and can induce renal changes that last as long as 2 weeks. Postmortem examination of the neonate who died revealed mildly dilated tubules without tubular necrosis. The other 2 newborns had normal renal function. Prostaglandin synthesis inhibitors also have been used in the treatment of polyhydramnios because they reduce fetal urine output and normalization of amniotic fluid volumes may result with a few days of therapy. However, the potential long-term consequences of this treatment on the fetal kidneys must be assessed. Jack S. Elder, M.D. Genitourinary Rhabdomyosarcoma in Children K. R. LOUGHLIN, A. B. RETIK, H. J. WEINSTEIN, A. H. COLODNY, R. C. SHAMBERGER, M. DELOREY, N. TARBELL, J. R. CASSADY AND W. H. HENDREN, Division of Urology,

Department of Surgery, and the Division of HematologyOncology, Department of Pediatrics, The Children's Hospital, Boston, and the Joint Center for Radiation Therapy and the Division of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts Cancer, 63: 1600-1606, 1989 Although rhabdomyosarcoma of the genitourinary tract occurs infrequently in children, it presents a challenging problem to the surgeon, radiotherapist, and oncologist. Thirty-six children with genitourinary rhabdomyosarcoma were treated at our institutions from 1957 to 1985. The primary site of tumor involved the bladder, prostate, or both in 15 patients, the paratesticular structures in 12, and female reproductive organs in nine. Although treatment modalities and philosophies of care varied over the past 27 years, the majority of patients were treated with a combination of surgery, chemotherapy, and radiation therapy. The event-free survival for all patients is 74%. Patients with paratesticular tumors had the best prognosis (88% event-free survival). Regional nodal radiation therapy is not necessary in this favorable group if the retroperitoneal lymph node dissection is negative. Of 15 children with bladder/prostate tumors nine had initial conservative surgery. Of these nine six are long-term survivors, but only three patients have intact bladders. The girls with tumors of the reproductive organs had an event-free survival of 63%; all patients in this group had hysterectomies. Chemotherapy and radiotherapy have not substituted for radical surgical procedures in most children with bladder or prostate rhabdomyosarcomas. Innovative therapeutic approaches are necessary for this group of patients.

Editorial Comment: Approximately a third of all rhabdomyosarcomas in children affect the genitourinary tract. The authors review their experience with this tumor during 28 years. During this period the treatment of rhabdomyosarcoma changed, with much more dependence on chemotherapy. There have been some longterm cures with chemotherapy alone in children with pelvic genitourinary rhabdomyosarcoma but approximately half of the patients in the Intergroup Rhabdomyosarcoma Study II who were treated with primary chemotherapy and who initially had a complete response eventually required anterior exenteration because of relapse. Thus, surgical resection remains an important aspect in the management of many of these patients. In children with rhabdomyosarcoma involving the bladder, prostate or vagina the authors recommend initial chemotherapy followed by restaging. If the patient has had a greater than partial response to chemotherapy then radiation therapy is recommended, whereas if the response is less than partial then a radical operation is recommended. The authors also emphasize the potential for submucosal extension of tumor into the urethra that is not evident at cystoscopy. Accordingly, they perform urethral biopsies as well as bladder biopsy in patients who have tumors involving the prostate or bladder. Jack S. Elder, M.D. Prospective Management of Neonates With Pelviureteric Junction Stenosis: Therapeutic Strategy Based on 99m Tc-DPTA Studies A. PIEPSZ, M. HALL, H. R. HAM, M. VERBOVEN AND F.

1159 COLUER, wn,nr:nn,mr~ of lWdUJ!S()tOJOes, Pediatrics and Pediatric Urology, Free University of Brussels, Brussels, Belgium

Scand. J. Urol. Nephrol., 23: 32-36, 1989 A prospective therapeutic strategy based on separate glomerular filtration rate (SGFR) was evaluated in 14 prenatally detected asymptomatic neonates, suspected of having pelviureteric junction obstruction. The patients with low SGFR were referred for pyeloplasty with the hope to improve the renal function. A marked improvement occurred in only one patient, although the drainage function (furosemide test) did improve in all cases. A conservative attitude was adopted for those children with normal SGFR. In 6 of them, a progressive increase of SGFR was noted, related to the normal maturation of the function, followed by a stabilization in the normal range. In 1 patient, a sudden decrease of SGFR was observed around 1 year and the patient was shifted into the surgical group. In this patient, an initial partial response of the kidney to a furosemide injection changed into a persistent non-response, whereas in the other non-operated patients, partial or good response was always recorded, although the responses were essentially variable on successive tests. On the basis of these data, the protocol was slightly modified, the patients with persistent non-response to furosemide after 6 months of life being shifted to the surgical group.

tervention occurred in four cases: Three were incorrectly thought to have posterior urethral valves. The increased number of neonates found to have reflux is attributable to the widespread availability of obstetric ultrasonography and early screening of infants at risk for urinary tract abnormalities. Since the pathophysiologic characteristics of reflux are well understood, appropriate postnatal therapy can be instituted without delay.

Editorial Comments: The authm.'s :review 25 neolt!!.ates (84% male neonates) with hydronephrnsis secondary to vesicmu·eteral reflux. Most of the patients had grade 4 o:r 5 reflux. Six patients had an associated renal abnormality, including ectopic ureter or u:reterocele, contralateral primary megamrete:r and a pelvic kidney. Three patients with hyd:ronephrosis detected prenatally were believed to have posterior urethral valves and l underwent an unsuccessful attempt at bladder drainage in ute1·0 at 33 weeks. Congenital obstructions involving the urinary tract, including u:rete:ropelvic junction obstruction., urete:rovesical junction obstruction and, of course, posterior urethral valves, occur more commonly in male patients. Thus, when hydronephrosis is detected in utero in a male fetus the pe1·inatologist commonly assumes th.at the lesion is obstructive, A message of this study is that when hydroneph.rosis is detected in 1.1.te:ro reflux must be considered as an etiology, Jack S. Elder, M.D,

Editorial Comment: The authors evaluated carefully 14 neonates with prenatally detected hydronephrosis secondary to a urete1·opelvic junction obstruction" They computed. separate glomerular filtration rates using 99 mteclmetium-diethylenetriaminepentaacetic acid and obtaining a serum sample 20 minutes after injection. When the initial glomerular filtration :rate of the hydronephrotic kidney was nearly equal to the normal contralateral kidney, in 6 of 7 cases it remained equal with an increasing glomerular filtration rate during the first 6 months of life. This phenomenon originally was described. by Ransley, and has been confirmed by several investigators clinically and in experimental models. An important issue that the autho:rs address is the effect of bladder emptying du:ring the renal scan, which often. substantially improves renal pelvic drainage. Presently, the :renal scan remains the most important method to assess whether a hyd:n.n11eph.rotic kidney is obstructed. Un.fortunately, there is considerable inteY-in.stitutim1.al variability in technique and interpretation., and comparing data from va1·im:m i:mititutim.1s is difficult. Jack§. Elder, M.D.

With the advent of neonatal ultrasound, the antepartum diagnosis of ureteral abnm."malities, especially hydro:nephrosis and outlet obstruction, has become more prevalent. Of these 25 cases 14 were diagnosed prenatally, Most disturbing is the fact that 4 of these cases had maternal/fetal intervention with a mistaken diagnosis of posterior urethral valves, Many currently believe th.at intrauterine decompression of the urinary tract p:robahly does little in th.e way of salvaging patients with true urinary outlet obstruction. More important, one must become increasingly aware of the fact that the u.reterocaliceal dilatation may not he due to an. obst:ruction at all but may merely :reflect ureterovesical reflux. Thus, the authors advocate waiting until dell.veli'Y and th.en immediate evaluation in the post-delivery period. To us this seems a sensible app:roSJ.ch. in these patients, Stanford. M. Goldman, MJ).

Neonatal Hydroneph.rosis Due to P:rima:ry Ves:i.courete:ral Reflux: Trends in Diagnosis and Treatment

Neonatal Urofogicali Ultrasound: Diagnostic Inaccuracies and Pitfalls

H.J. PALTIEL AND R. L. LEBOWITZ, Department of Radiology, The Children's Hospital and Harvard Medical School, Boston, Massachusetts

N. W. CLARKE, D. C. S. GOUGH ANDS. J. COHEN, Department of Paediatric Surgery, Booth Hall and Royal Manchester Children's Hospitals, Manchester, England

Radiology, 170: 787-789, 1989

Arch. Dis. Child., 64: 578-580, 1989

The records were reviewed of the 25 neonates found to have hydronephrosis due to primary vesicoureteral reflux at the authors' hospital in the 6½-year period from January 1981 to June 1987. Modes of discovery and investigation, detection of associated lesions, treatment, and errors in both diagnosis and management were evaluated. Twenty-one of the neonates were boys. Fourteen cases were found at fetal screening, and the infants were asymptomatic. Inappropriate maternal/fetal in-

Ninety one patients with urinary tract abnormalities diagnosed before birth were reviewed. Diagnoses based on prenatal and postnatal ultrasound scans alone were compared with the final diagnoses after full urological investigations, with operative or necropsy confirmation in 79 cases. The results confirmed that ultrasound examination before birth usually detects nonspecific abnormalities and although scanning after birth is more accurate it is not absolutely reliable. A diagnosis of 'multicystic

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PEDIATRIC UROLOGY

kidney' made on ultrasound scan alone is especially prone to error. Such mistakes can be avoided if full urological investigation is undertaken in every case.

Editorial Comment: In the fetus evaluation of urological anomalies is made primarily by ultrasound and in a few selected instances by analysis of fetal urine. In contrast, the postnatal evaluation includes not only ultrasound but also physical examination, renal scan, voiding cystourethrography, excretory urography, serum creatinine and, occasionally, cystoscopy or a Whitaker test. Several reports have claimed a high degree of diagnostic accuracy of prenatal ultrasound when urological anomalies are detected. However, this report places the situation in a much more realistic perspective, namely that ultrasound primarily detects the anomaly. The diagnosis can be inferred from the study but often · it is inaccurate. For example, severe bilateral hydronephrosis in a male fetus may be secondary to posterior urethral valves but it also may represent the prune belly syndrome or bilateral high grade reflux (the megacystismegaureter syndrome). In this study only 28 of91 anomalies (31 %) were diagnosed correctly by prenatal ultrasound and only 46 (51 %) were diagnosed correctly with only the postnatal ultrasound, emphasizing the importance of other radiological studies. A subgroup that the authors emphasized was 13 patients who were misdiagnosed as having a multicystic kidney based on prenatal ultrasound and 9 who were believed to have a multicystic kidney based on postnatal ultrasound. In most cases ureteropelvic junction obstruction or a ureterocele was present. Jack S. Elder, M.D. Epidural Opioids in Children D.

C. TYLER AND S. J. KRANE, Children's Hospital and Medical Center, and the Departments of Anesthesiology and Pediatrics, University of Washington School of Medicine, Seattle, Washington

J. Ped. Surg., 24: 469-473, 1989 Permission to Publish Abstract Not Granted

Editorial Comment: Recently, there has been increasing emphasis on better postoperative pain management in children. The authors review the techniques of epidural opioid analgesia in children as well as its complications. Morphine administered into the epidural space diffuses into the cerebrospinal fluid, where it enters the spinal cord and binds to opioid receptors. Water soluble opioids, such as morphine, do not penetrate the spinal cord rapidly and tend to migrate rostrally, whereas lipid soluble opioids, such as fentanyl and sufentanil, penetrate the spinal cord rapidly and are less likely to migrate. The most common complications are nausea and vomiting (40 to 50%), pruritis (20 to 40%) and urinary retention (25 to 45%). Itching is.controlled with naloxone, which does not diminish the analgesic effects of epidural morphine if it is given in small doses. Nausea and vomiting are managed with antiemetics or naloxone. Urinary retention may not be treated adequately with medication and, therefore, may require catheteri-

zation. For this reason epidural morphine probably should be avoided in patients in whom a urethral catheter may be contraindicated. The greatest concern is delayed respiratory depression, which occurs from rostral spread of opioid in the cerebrospinal fluid. This tends to occur several hours after spinal opioid administration and is reversible by naloxone. The authors report that at their institution epidural morphine is administered on regular nursing floors staffed by specially trained nurses, and patients have cardiorespiratory monitors and pulse oximeters to detect respiratory depression. The use of epidural opioids as well as patient-controlled anesthesia are techniques that deserve further study in children. Jack S. Elder, M.D. Suggested Additional Reading: Fitzgerald, M. and McIntosh, N.: Pain and analgesia in the newborn. Arch. Dis. Child., 64: 441, 1989.

Malignant Hyperthermia: Experience in the Prospective Management of Eight Children J. DUBROW, P.A. WACKYM, I. H. ABDUL-RASOOL AND T. C. MOORE, Department of Surgery, Harbor/UCLA Medical Center; the Department of Surgery, UCLA Medical Center, and the Malignant Hyperthermia Center, Department of Anesthesiology, UCLA School of Medicine, Los Angeles, California

T.

J. Ped. Surg., 24: 163-166, 1989 Permission to Publish Abstract Not Granted

Editorial Comment: Malignant hyperthermia is a syndrome of drug-induced hypermetabolism triggered by depolarizing drugs, such as succinylcholine, as well as potent inhalation anesthetics. Early signs include masseter spasm and muscle rigidity, sweating, mottling or flushing of the skin, cyanosis, tachycardia, tachypnea, cardiac arrhythmias, fluctuation in blood pressure and a rapid increase in temperature as high as 44 to 46C. Late complications include metabolic and respiratory acidosis, renal failure (secondary to rhabdomyolysis), seizures and even death. Interestingly, as many as 25% of the patients with malignant hyperthermia have undergone a previous anesthetic procedure without complication. The incidence is 1 in 15,000 to 50,000 patients, with a higher incidence in children. The disorder is familial, transmitted either as an autosomal dominant trait or, in other families, with multifactorial inheritance. Although malignant hyperthermia has been associated with congenital myopathic conditions no signs of myopathy are apparent in most patients with malignant hyperthermia. It is believed that the syndrome results from an abnormality of the calcium reuptake mechanism of the sacroplasmic reticulum in skeletal muscle, which causes an excessive amount of calcium to accumulate in the myoplasm, resulting in muscle spasm with a marked increase in oxygen consumption and a shift to anaerobic metabolism. The authors report their experience with 5 children who had signs of malignant hyperthermia during previous pediatric operations and in 3 with a positive family history. All underwent biopsy of the vastus lateralis

PEDIATRIC UROLOGY

muscle and had a positive caffeine/halothane contracture test. Although dantrolene, which inhibits calcium release from the sarcoplasmic reticulum, often is used to treat malignant hyperthermia it was not used prophylactically in these 8 patients because of the concern about possible side effects. Anesthesia was induced with sodium thiopental and maintained with nitrous oxide, opiates, tranquilizers and nondepolarizing muscle relaxants. No patient exhibited signs of malignant hyperthermia during the procedure. Patients with known malignant hyperthermia or a positive family history should be evaluated and should wear a Medic-Alert bracelet. Jack S. Elder, M.D.

Nocturnal Enuresis: An Approach to Treatment Based on Pathogenesis J. P. N0RGAARD, 8. RITTIG AND J. C. DJURHUUS, Urological Department K, Aarhus Municipal Hospital and the Institute of Experimental Clinical Research, University of Aarhus, Aarhus, Denmark

J. Ped., 114: 705-710, 1989 No Abstract

Clinical Efficacy and Safety of Desmopressin in the Treatment of Nocturnal Enuresis

G. T. KLAUBER, Departments of Pediatrics and Urology, Tufts University School of Medicine and the Department of Pediatric Urology, New England Medical Center, Boston, Massachusetts

J. Ped., 114: 719-722, 1989 No Abstract

Editorial Comment: At the 1989 American Urological Association meeting in Dallas, Texas, a seminar hosted by a pharmaceutical company was held on enuresis, primarily to introduce a vasopressin analogue, desmopressin, in the treatment of enuresis. A supplement in the April issue of the Journal of Pediatrics is a compilation of a similar symposium held at a pediatrics meeting in 1988. The clinical management of nocturnal enuresis is confusing, primarily because its pathogenesis is not understood. Many have thought that enuresis occurs during certain stages of sleep but more recent studies have indicated that nocturnal enuresis is independent of sleep stage. Furthermore, urodynamic evaluations generally have not demonstrated detrusor instability. N~rgaard and associates believe that enuresis occurs primarily when the bladder fills at night. In their summary of much clinical research, they review their methods to study children, which involve inserting a temporary suprapubic catheter with the patient· under anesthesia followed by a 5-day investigation including nocturnal urodynamics, assessment of nocturnal urinary volumes and electroencephalography. Although unstable bladder contractions occurred in half of the nocturnal studies these uninhibited contractions did not cause enuresis. Instead, enuresis occurred only when the bladder filled. Furthermore, normally there is a diurnal variation in

1161

plasma vasopressin, with a peak between midnight and 4 a.m. They found that children who are enuretic do not exhibit a daily variation in the serum vasopressin level and they believe that children outgrow the enuresis when the diurnal pattern is established. Klauber reviewed 12 placebo-controlled trials of desmopressin, including 3 multi-institutional studies performed in the United States. In most of the reports the patients were resistant to other forms of therapy. Overall, treatment diminished the incidence of enuresis between 10 and 60%. The results were best in patients who had not been treated previously. Importantly, there were no side effects to the medication. Generally, 20 µg. often was ineffective, whereas 40 µg. tended to be much more effective. If the medication is discontinued enuresis usually recurs. Desmopressin is administered by intranasal administration and improved unit dose atomizers have been developed. Rhinorrhea may affect the absorption. N ~rgaard and associates seemed to indicate that nocturnal enuresis without daytime enuresis is a disease with 1 etiology, namely a high urine output at night. However, this theory does not explain why some children wake up at night with a full bladder and void whereas others experience enuresis. In addition, the number of enuretic children who exhibit a normal diurnal pattern of vasopressin is not stated. Finally, the theory of N~rgaard and associates does not account for children with secondary enuresis, that is those who at one point were dry at night but subsequently regressed to a nocturnal enuretic pattern. This often occurs following environmental or psychosocial stresses. Urologists who are considering using desmopressin to treat enuresis are encouraged to read this supplement. To date desmopressin appears to be safe but whether it is sufficiently effective to be used routinely in enuresis has not been determined. Jack S. Elder, M.D. Terodiline in the Treatment of Children With Unstable Bladders A.-L. HELLSTROM, K. HJALMAS AND U. JODAL, Departments of Paediatric Surgery and Paediatrics, University of Gothenburg, Gothenburg, Sweden Brit. J. Urol., 63: 358-362, 1989 A double-blind study of terodiline compared with placebo was performed in 58 children aged 6 to 14 years with urgency or urge incontinence. All had an unstable bladder at cystometry. A bladder regimen was emphasised during the study. Continence was improved according to micturition charting and a pad test in both groups. Terodiline at 25 mg/day, however, gave significantly better results than placebo. In patients with a subnormal bladder capacity (:5150 ml), a significant increase in capacity was recorded on cystometry during medication with terodiline but not with placebo. The improved continence seen in the placebo group was probably due to the non-specific bladder training achieved by the child's increased awareness and adult involvement during treatment. The even better results attained in the terodiline group shows this drug to be a valuable adjunct to a bladder regimen in children with urge incontinence, particularly since

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PERIOPERATIVE CARE

no important adverse effects were noted during an 8-week period.

Editorial Comment: In children with a pediatric unstable bladder anticholinergic therapy in combination with timed voiding is the usual method of treatment. However, side effects of medication are common, including a dry mouth and facial flushing. Terodiline is a calcium channel blocker that also has an anticholinergic effect and has a half-life of 60 hours. Approximately a third of the children in this study had undergone previous unsuccessful treatment. The results show a significant decrease in diurnal incontinence with terodiline. However, it is difficult to determine whether the therapeutic benefit results from the anticholinergic component of the drug. Importantly, side effects were minimal. Presently, terodiline is not available in the United States. Verapamil, another calcium channel blocker, has been used with success to treat uninhibited contractions in adults with spinal cord injuries. However, to date there has been little experience with calcium channel blockers in the treatment of the pediatric unstable bladder. Jack S. Elder, M.D.

graphs are unhelpful and a resting electrocardiogram is not a sensitive indicator for ischemic heart disease. In patients at increased risk for cardiac disease the techniques of echocardiography, radionuclide imaging with 201 thallium and ventriculography are useful to evaluate coronary artery disease and left ventricular function. Preoperative management of patients with cardiac disease includes treatment to reduce myocardial oxygen consumption with nitrates, calcium channel and {1-adrenoceptor blocking agents along with control of untreated hypertension and congestive heart failure. In patients with renal insufficiency it is important to recognize drugs that may cause further renal impairment, most notably antibiotics and radiocontrast agents. Such patients also have an increased risk for hyperkalemia, which may develop rapidly in the presence of oliguria, metabolic acidosis or excessive potassium intake and may be exacerbated by anesthesia if adequate compensatory hyperventilation is not maintained. Charles B. Brendler, M.D. Preoperative Evaluation of the Elderly Surgical Patient

S. S. GALAZKA, Department of Family Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio

PERIOPERATIVE CARE Preoperative Patient Assessment

J.

NORMAN, Department of Anaesthetics, University of Southhampton and the General Hospital, Southampton, United Kingdom

Brit. Med. Bull., 42: 247-268, 1988 Before any operation a patient is entitled to an adequate assessment. Such an assessment has four goals: to acquire the relevant information about the patient's state, to educate the patient, to diminish anxiety and to obtain informed consent from the patient for the proposed procedure. The assessment should determine the nature and extent of the relevant surgical pathology, the nature and extent of any disease which might affect the conduct of the operation and postoperative course and also any specific problems that might affect choice of anaesthesia and postoperative care. The essential components are to take an adequate history and to examine the patient. Ancillary investigations should be undertaken only to confirm and assess the extent of concomitant disease and only exceptionally, where their costs can justify their benefits, should routine screening examinations be performed. Assessment is most efficiently performed early and may use data generated by the patient, the surgeon, a preoperative clinic or the traditional night before visit. Patients undergoing emergency surgery should be assessed using a similar system.

Editorial Comment: The author reviews general assessment of the surgical patient, and includes detailed evaluation of patients with cardiac disease and renal insufficiency. General assessment of operative risk follows the guidelines proposed by the American Society of Anesthesiologists in which patients are graded into 1 of 5 classes. Specific cardiac risks are identified with Goldman's risk index. Generally, routine chest radio-

J. Family Pract., 27: 622-632, 1988 Family physicians are often requested to provide preoperative evaluation of elderly patients. Age independently increases the risk of morbidity and mortality in the perioperative period. In addition, the altered physiology of the older patient, in combination with the increased number of disease processes, increases the potential for complications. A comprehensive preoperative assessment includes an evaluation of the patient's present physiological functioning and attempts to detect the presence and status of any disease processes. Evaluation includes a thorough history, physical examination, and laboratory testing. Special considerations in preoperative assessment of the elderly patient include the assessment of nutrition, functional capabilities, and evaluation of the cognitive and emotional status of the patient. Special concerns include prophylaxis for deep vein thrombosis and pulmonary embolus, and antibiotic prophylaxis for endocarditis and for patients with joint prostheses.

Editorial Comment: Many urological patients are elderly and have an increased risk for perioperative complications. The author begins by reviewing the physiological effects of aging, emphasizing changes in cardiac, pulmonary, hepatic and renal physiology. Special characteristics of the elderly patient, such as the increased frequency of silent myocardial infarction, are discussed. Evaluation of specific risk factors, including ischemic heart disease, hypertension and congestive heart failure, is reviewed. In addition, evaluation of the functional status of the patient, including activities of daily living, nutritional status, and emotional and cognitive status, are discussed. The basic preoperative laboratory evaluation in the elderly patient should include a complete blood count, serum electrolytes, glucose, blood urea nitrogen, creatinine, albumin and urinalysis. A chest radiograph is indicated in patients 70 years or older, approximately 50% of whom have abnormalities. The