Retrograde filling of the renal vein on computerized tomography for blunt renal trauma: An indicator of renal artery injury

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One child with grade V reflux was stable on prophylaxis, and the remaining two patients underwent Ureteroneocystostomy. No child had a urinary tract infection. A significant proportion of white children with a muhicystic kidney have contralateral vesicoureteral reflux, and initial imaging should include a voiding cystourethrogram.--George W Holcomb, Jr

Incidence of Vesicoureteral Reflux in Children With Unilateral Renal Agenesis. J.T. Song, M.L. Ritchey, ZM. Zerin, et al. J Urol 153:1249-1251, (April), 1995. The authors retrospectively reviewed 51 pediatric cases of unilateral renal agenesis to determine the incidence of contralateral vesicoureteral reflux. A voiding cystourethrogram was obtained in 44 cases. Indications for the study included urinary tract infection in 11 patients, bydronephrosis in 18, and screening in 15. Overall, vesicoureteral reflux occurred in 19 of the 51 patients (37%). The highest incidence of contralateral reflux was in patients who had a prenatal abnormality, with or without hydronephrosis (77%), although five of 15 patients (33%) who underwent a screening voiding cystourethrogram had reflux. The mean follow-up period was 50 months. Of the patients with vesicoureteral reflux, reimplantation was performed in nine, reflux spontaneously resolved in three, and reflux persisted in seven. There is a high incidence of vesicoureteral reflux among children who have unilateral renal agenesis, and a voiding cystourethrogram is recommended even in the absence of hydronephrosis or urinary tract infection. Although 50% of children in this series had surgery, a period of nonoperative observation is warranted.--George W. Holcomb, Jr

Endoscopic Trigonoplasty for Primary Vesico-Ureteric Reflux, K. Okamura, Y. Ono, Y. Yamada et al. Br J Urol 75:390-394, (March), 1995. Twelve patients, including an 8-year-old child, underwent endoscopic trigonoplasty, adapted from the Gil-Vernet procedure. There were 15 refluxing renal units: five grade I, six grade II, and four grade III (International Classification). The trigone was resected fanwise with a resectoscope and the ureteric orifices cannulated. Two additional suprapubic transvesieal ports were then inserted, the bladder was insufllated with CO2, and the ureters were sutured endoscopically via the urethra. Suprapubic and urethral catheters were left postoperatively for 3 to 13 days. The cure rate at 1 to 6 months was 100%. Three had intraoperative problems with trocar placement or pneumoperitoneum. There were no early complications, and recovery was rapid.--M.N, de la Hunt

Reflux-Induced Renal Parenchynmal Injury: Evaluation by Urinary Enzyme Management. D.N. Anderson, C.P. Driver, P.H. Whiting, et al. Pediatr Surg Int 10:108-110, (February), 1995. The authors measured urinary enzymes N-acetyl-B-D-glucosaminidase (NAG) and gamma-glutamyltransferase (GGT) in an effort to relate their levels to reflux-associated renal parenchyreal injury. They suggest that the release of these brush-border and intracellular enzymes may predate the development of scars in these kidneys. They note that just as not all children with reflux will have scarring, not all children with reflux have elevated levels of enzymes. They studied four groups of Children. Group 1 (21 children) had severe vesicoureteral reflux (VUR), group 2 (9 children) had urinary infection from other causes, group 3 (84 children) was the control group, and group 4 (21 children) had had VUR corrected by a "Sting" procedure. Group I had a significantly elevated level of enzymes compared with groups 2 and 3; there was no difference between groups 2 and 3. A significant decrease in

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enzyme levels was noted in group 4 patients after their reflux had been corrected. In group 1, those with solitary refluxing units had higher levels than those with duplex moieties. However, enzyme levels did not correlate with duration or severity of reflux; nor was there any correlation with renal function as assessed by isotope studies. Enzyme studies may have a role in the treatment of children with VUR, especially because the studies are noninvasive.--P. Puri

Experience With Ureteroscopy in Children. S. Shroffand G.M. Watson. Br J Uro175:395-400, (March), 1995. Fourteen children (aged 1 to 14 years) underwent 20 ureteroscopic procedures using semirigid 7.2F and flexible 9.5F ureteroscopes. Eighteen procedures were for stone disease, one for investigation of hematuria, and one for retrieval of a migrated stent. Eighteen procedures were retrograde and two were antegrade. In 10 of 13 children, stone removal was straightforward and completed with a single ureteroscopy. Dilatation was needed in only one. The authors conclude that in experienced hands, ureteroscopy can be as successful in children as in adults.--M.N, de la Hunt

Pseudoureterocele: Potential for Misdiagnosis of an Ectopic Ureter as a Ureterocele. ].M. Sumfest, M. W. Bums, M.E. Mitchell. Br J Uro175:401-405, (March), 1995. The authors describe three girls with eetopic ureters draining into Gartner's duct cysts (mesonephric duct cysts). These cysts extend well caudal to the bladder neck and are associated with ipsilateral renal dysplasia. They present with infection or incontinence, but may lie dormant for many years. The radiologieal features closely mimic ureteroceles associated typically with duplex systems. Failure to recognize their true nature and attempted transvesical excision will yield a poor surgical result. Resection of the dysplastic kidney and ureter, marsupialization of the cyst into the vagina, and closure of the vesical fistula is the preferred treatment.--M.N, de la Hunt

Ureteral Graft in Urological Reconstruction: Clinical Experience and Review of the Literature. S.G. Docimo, ].P. Gearhart, andR.D. Jeffs. J Urol 153:1648-1650, (May), 1995. The authors report seven cases in which ureteral grafts were used as tube and patch segments in urethral reconstruction and formation of a continent eatheterizable stoma. The grafts survived, without long-term stricture, in all cases. Meticulous preparation of the graft and recipient bed is required for success, as previously demonstrated experimentally. The use of the ureter in lower tract reconstruction must never compromise the upper tracts. This factor limits its use to select cases, but it is in such complex cases that the possibility should be borne in mind. Although the ureter never will be the first choice for urethral replacement, it appears that it can be used when available, with the expectation that it will perform as well as any of the other free-graft materials.--George W Holcomb, Jr

Retrograde Filling of the Renal Vein on Computerized Tomography for Blunt Renal Trauma: An Indicator of Renal Artery Injury. M.P. Cain, ].M. Matsumoto, and D.A. Husmann. J Urol 153:1247-i248, (April), 1995. Assessment of the traumatically injured pediatric patient through computerized tomography has become standard medical practice. The authors present a case with the unique finding of retrograde flow of intravenous contrast material into the renal vein as a

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diagnostic indicator of traumatic renal artery injury. With the increasing use of high-speed computerized tomography as the initial study to evaluate and stage blunt abdominal trauma, this finding may assist the physician in the early diagnosis of severe renovascular injury.-MS;eorge W. Holcomb, Jr NEOPLASMS

Management and Outcome of Inoperable Wilms' Tumor. l Report of National Wilms' Tumor Study-& M.L. Ritc/~, K.C. [~glc, N.E. Breslow, et al. Ann Surg 220:683-690, (November), 1994. Of 2,496 patients enrolled in the National Wilms' Tumor Study-3 (NWTS) from May 1979 to April 1986, 136 children were deemed to have initially unresectable tumors and underwent preoperative chemotherapy and/or radiation therapy. Five patients were excluded, leaving 131 reported herein. Children with bilateral tumors were not included. The median age at time of diagnosis was 52 months, and the median duration of follow-up was 5.9 years. Sex distribution was equal. The right kidney was involved in 74 patients and the left in 57. Tumors were deemed unresectable as follows: at the time of surgical exploration (69), by clinical evaluation or imaging (51), because of extensive intravascular tumor extension (5), and for other reasons (6). The patients were assigned to a pretreatment stage based on available preoperative information. Eleven patients were assigned to stage II; these cases had local tumor spill from biopsy, capsular penetration, or involvement of extrarenal vessels. Thirty-nine cases were stage III, ie, having lymph node involvement, diffuse surgical spillage, or peritoneal implants. Massive tumors that were found to be unresectable during surgery were classified as stage III in the absence of other criteria. Sixty-six patients had stage IV, ie, involvement of the lung (57), liver (22), or other organs (5). Intracaval tumors were present in 28 patients, with right atrial extension in two. Biopsies were performed for diagnosis in 103 patients (21 needle, 82 open). All but two patients received preoperative chemotherapy; most were given a combination of dactinomycin and vincristine (81), or dactinomycin, vincristine, and doxorubicin (30). Most patients who received more than two drugs had stage III or stage IV disease. The preoperative treatment time varied; 17 children had treatment for less than 30 days, 44 for 30 to 60 days, and 61 for more than 60 days. Preoperative radiation was given to 43 children (concurrent with chemotherapy in 27, after chemotherapy in 14 because of lack of response). Two patients were given preoperative radiation without chemotherapy. Survival percentages were estimated as a function of time lapsed since the diagnosis. The results for these 131 patients were compared with those of 1,981 randomized patients also reported in the NWTS. The children who had preoperative treatment were substantially older and had a much less favorable stage distribution: 47% had stage IV, compared with 12.3% of patients who underwent primary nephrectomy. Response to chemotherapy was recorded as follows: progressive disease, no response, partial response, or complete response. There was a small difference in response between the patients who received dactinomycin/ vincristine (83% response) and those who had dactinomycin/ vincristine/doxorubicin (95%) (P not significant). Response of the primary tumor was assessed after all preoperative treatment. Ninetythree patients (71%) had greater-than-23% reduction in the size of the primary tumor. Of 14 children who receiving radiation because of lack of chemotherapy response, 10 subsequently had a partial response and three had progression of disease. Response to the first trial of chemotherapy correlated with patient survival. All five children with progression of disease during initial chemotherapy and three of the eight with no appreciable response died because of the tumors. The median time from

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diagnosis until nephrectomy was 58.5 days. Eight children died before excision of the primary tumor. Patients were reassigned to a pathological stage after surgical resection, with a downstaging of the tumor in most cases. Soilage from surgical spill was decreased, but the incidence of preoperative tumor rupture was not decreased in patients who received preoperative treatment, compared with those who had primary nephrectomy. Postoperative complications occurred in 25 of the 131 patients. The overall incidence of complications, including bowel obstruction, was similar to that of children who underwent primary nephrectomy, despite having had very large tumors unable to be excised at the time of initial presentation. The survival rate based on pretreatment stage was lower for the preoperatively treated patients than for those who underwent initial nephrectomy. The difference is explained only partially by the difference in stage distribution. There was a slightly higher response rate if three drugs were used rather than two, but there was no difference in survival rates when the regimens were stratified by histology and stage. There was no difference in the survival rate between the cases judged inoperable by imaging studies alone and those found to be unresectable during surgical exploration. Children who received radiation therapy appeared to fare worse. However, when the comparison was restricted to patients who received radiation in conjunction with a trial of chemotherapy (excluding those irradiated because of failure to show response to chemotherapy), the differences were not significant. Survival based on posttreatment stage was analyzed in an attempt to determine whether postchemotherapy stage might lead to undertreatment. Stage IV patients were excluded. Fifty-six patients were available for analysis, and there was a significant difference only for posttreatment stage I patients; overall, there was no significant difference in survival across stages. The authors note that the data must be interpreted with caution because of the small numbers of patients in each group. The percentage of viable tumor in the nephrectomy specimen was found to correlate with survival; the 4-year survival rate exceeded 90% if there was less than 10% viable tumor. The survival rate also was better when viable tumor was not present outside the kidney. This report suggests that "inoperability" is an adverse prognostic factor independent of stage, because the overall survival rate for these patients is lower than that for children who undergo primary nephrectomy. The authors suggest that some patients may have been undertreated, possibly because of reliance on postresection stage, at which time many cases were downstaged. Cases that are staged based on imaging studies alone are at risk for overstaging and understaging. Regardless of the preoperative treatment modality used, the subsequent surgical resection was facilitated by reduction in tumor size. Nephrectomy was possible in 93% of the patients after preoperative treatment. The authors suggest a treatment algorithm. Initial exploration should be performed to assess operability and to obtain a biopsy specimen. Suspicious lymph nodes or metastatic deposits also warrant a biopsy. If one chooses a preoperative therapy based on imaging alone, the local tumor should be considered stage III. Once there is an adequate reduction in the size of the tumor, definitive resection should be completed. Serial imaging is helpful to assess response. Failure of the tumor to shrink could be caused by a predominance of skeletal muscle or benign elements, and a second-look procedure should confirm persistent viable tumor. After surgical resection, patients should continue treatment until they have completed the regimen appropriate for their assigned stage. All patients documented by the surgeon or pathologist to