The role of vesicostomy in the management of anterior urethral valves in neonates and infants

288

INTERNATIONAL ABSTRACTS

seem prone to have more frequent recurrences. The higher recurrence rate observed in children after routine varicocelectomy may actually represent residual varicose communications that had been missed at the primary operation. Routine postligation intraoperative venography has been used to detect these occult communications in 26 children undergoing varicocelectomy. These results indicate a low recurrence rate (3.6%), suggesting that routine use of this procedure with childhood varicocelectomy is beneficial.--George Holcomb, Jr

The Intersex Baby. R.J. Lilford and P.R.F. Dear. Br J Hosp Med

Diagnosis of Varicoeela and Postoperative Evaluation Using Inguinal Ultrasonography. R. Orda, J. Sayfan, H. Manor, et al. Ann Surg

One-Stage Complete Genital Reconstruction for Patients With Congeital Adrenal Hyperplasia. N.K. Bissada, N. Sakati, N.J.Y.

206:99-101, (July), 1987.

Woodhouse, et al. J Urol 137:703-705, (April), 1987.

Real-time ultrasonography of spermatic veins at the inguinal canal level was performed for diagnosis of varicocele and for postoperative evaluation in a prospective controlled study. The varicoeele group was comprised of 20 young men, aged 16 to 23 years, who had clinically diagnosed left varicocele. The mean diameter of the dominant veins in the left spermatic cord during relaxation was 4.5 mm. The mean diameter increased to 5.7 mm during Valsalva maneuver. Postoperatively, the mean venous diameter was 2 mm and during the Valsalva maneuver was 2.8 ram. In the control group the mean diameter of veins at rest and during Valsalva was 2.2 and 2.7, respectively. Varicoceles were further subdivided into small (2.5 to 4.0 ram), moderate (4.0 to 5.0 ram), and large (> 5.0 mm). The ability to provide measurement data is one of the main advantages of this method of varicocele assessment. The difference between the mean diameters of the dominant draining vein during Valsalva and in relaxed standing position ranged between 1.0 and 1.7 ram. These values were objective representatives of the venous reflux into the pampiniform plexus. The preoperative reflux was highly significant and became nonsignificant after surgical treatment. These data suggest that ultrasonography can be useful in the follow-up of treatment results.--Catherine A. Musemeche

A one-stage complete genital reconstruction was performed on 20 female subjects with congenital adrenal hyperplasia. The blood and nerve supply to the glans was retained by preserving the neurovascular bundle, as well as the ventral mucosal strip. Preservation of the neurovascular bundle was simplified. The phallic skin was used to form labia minora and a flap vaginoplasty was performed simultaneously. There were no operative complications, and all 20 patients had satisfactory results.--George Holcomb, Jr

Gastric Transposition for Esophageal Replacement in Children. L.

37:28-34, (January), 1987. About one in 2,000 newborn babies has ambiguous genitalia with no clue to the underlying cause. The authors discuss the intersex disorder (female and male pseudohermaphroditism) and abnormal gonadal differentiation. They emphasise the importance of clinical and investigative aspects of the infant with ambiguous genitalia.-A. Azmy

The Presence Of Intersexuality in Patients With Advanced Hypospadias and Undescended Gonads. M. Rohatgi, P.S.N. Menon, L C.

Verma, et al. J Urol 137:263-267, (February), 1987. Twenty patients with advanced degrees of hypospadias and undescended testes were studied for the presence of an intersex disorder. A comprehensive clinical, cytogenetic, endocrinologic, and surgical evaluation was performed. All patients were found to have an intersex disorder, including ten with male pseudohermaphroditism and ten with a gonadal/genetic intersex disorder. In the latter group, four patients had mixed gonadal dysgenesis, three had dysgenetic male pseudohermaphroditism, one had the 46XX male syndrome, one had true hermaphroditism, and one had Klinefelter's syndrome. Genetic and gonadal intersex disorders were more frequent in patients with a unilateral undescended testis and perineal hypospad i a s . ~ e o r g e Holcornb, Jr

Spitz, E. Kiely, and T. Sparnon. Ann Surg 206:69-73, (July), 1987. This paper presents a review of 34 cases of transhiatal gastric transposition performed at the Hospital for Sick Children in London from 1981 to 1986. Thirty-two patients were diagnosed with esophageal atresia (18 with tracheoesophageal fistula), one had an extensive reflux stricture, and one with esophageal damage from prolonged foreign body impaction. Sixteen patients underwent gastric transposition via the posterior mediastinum without a thoractomy and in 18 patients a thoracoabdominal gastric transposition via the posterior thorax was performed. There were three deaths, all related to chronic respiratory problems. Fourteen children had an uncomplicated course. Seventeen children had one or more postoperative complications, which most frequently involved establishing oral feeding. Late complications included one case of peritonitis from a perforated jejunal feeding tube, two cases of adhesive bowel obstruction, and one case of chronic diarrhea with malabsorption. An excellent result was obtained in 25 patients. Four did well with minor feeding difficulties and two had a fair result. In comparing this series to their series of 112 colon interpositions, the authors found a lower rate of cervical anastomotic leak (6% v 48%) and stricture formation (12% v 30%) in the patients who underwent gastric transposition. The importance of performing a gastric drainage procedure (pyloroplasty or pyloromyotomy) is emphasized. Thoracotomy was used in cases with extensive scarring after failed primary anastomosis and to remove a failed colon interposition.--Catherine A. Musemeche

Persistent Mullerian Duct Syndrome With Transverse Testicular Ectopia. J.M. Hutson, C. W. Chow, and W.D. Ng. Pediatr Surg Int

2:191-194, (May), 1987. A patient with the combined anomalies of persistent mullerian ducts and testicular ectopia presented with a right inguinal hernia. He represents the 14th case to be documented outside Japan. A review of the literature on persistent mullerian duct syndrome has permitted a new classification of the anatomic variants to be determined. It is proposed that the testes have prolapsed into the hernial sac rather than descending in the normal way. Furthermore, the high frequency of transverse ectopia in patients with persistent mullerian ducts may be caused by the absence of round ligaments to immobilize the genital tract.--Prem Purl The Role of Vesicostomy in the Management of Anterior Urethral Valves in Neonates and Infants. H.G. Rushton, T.S. Parrott, J.R.

Woodard, et al. J Urol 138:107-109, (July), 1987. Vesicostomy was performed as the initial form of management in two male newborns and one infant with anterior urethral valves associated with proximal urethral diverticula and bilateral hydronephrosis. Prompt improvement in the degree of hydronephrosis was noted after vesicostomy in all three patients along with improvement in renal function in two who had presented with renal insufficiency. Subsequently, two patients have undergone vesicostomy closure and transurethral valve fulguration. One has also required ureteral

INTERNATIONAL ABSTRACTS

reimplantation for persistent vesicoureteral reflux. The use of vesicostomy in the newborn period rather than transurethral fulguration prevented the potential complications of urethral stricture and inadequate valve resection that can occur owing to the small size of the neonatal urethra. Furthermore, a period of vesicostomy drainage before eventual ureteral reimplantation for severe vesicoureteral reflux obviated the need for ureteral tailoring.--George Holcomb, Jr Fogarty Balloon Catheter Ablation of Neonatal Posterior Urethral

D.A. Diamond and P.G. Ransley. J Urol 137:1209-1211, (June), 1987.

Valves.

A technique is described to ablate posterior urethral valves with a Fogarty balloon catheter. This technique has been used or 14 years in ten cases with a good result in nine. Fogarty balloon catheter ablation of posterior urethral valves would seem to be particularly applicable to the small neonate with a vulnerable anterior u r e t h r a . George Holcomb, Jr Stripping of Posterior Urethral Valves in Neonatal Period With a Fogarty Catheter. G. Levard, Y. .4igrain, A. Politi, et al. Chir

P6diatr 27:196-200, (November), 1986. Stripping of urethral valves using a Fogarty catheter was performed on ten neonates. The balloon was filled with 0.2 mL of water for the Fogarty no. 3, and 0.75 mL for the no. 4. Traction induced rupture of the valve under control by a rectal finger. Eight babies weighed <4 kg. Results after a follow-up of 3 to 22 months were based on the quality of micturition and regression of ureterorenal pathology. Two patients needed a second stripping and two a complementary endoscopic resection. No stenosis was reported. The authors advocate this procedure in premature or low birth weight newborns when the urethral size is too small to allow safe endoscopic resection of the valves.--Jean-Michel Guys Experience With Free Grafts in Urethral Reconstruction. P.R.

Vyas, D.R. Roth, and .4.D. Perlmutter. J UroI 137:471-474, (March), 1987. A total of 33 patients underwent hypospadias or epispadias repair by patch or tubular grafts of skin or bladder epithelium from July 1980 to January 1985. Indications included previous circumcision, proximal primary hypospadias, severe chordee alone, inadequate local skin during extended urethroplasty at two-stage hypospadias repair, multiple previous reconstructions, and failed epispadias repair. Genital skin grafts were used in 25 patients, extragenital skin grafts in four, and bladder epithelial grafts in four. Complications occurred in 13 patients (39.4%): eight required reoperation for a fistula, stricture, or diverticulum; and five underwent internal urethrotomy or urethral dilation. Of the eight patients, three needed more than one revision. These revisions were short and generally uncomplicated. Final results uniformly were good functionally and cosmetically. Based on this experience and that of others, despite a high incidence of minor complications, a free graft serves as an excellent substitute urethra for treatment of a variety of urethral problems in children.--George Holcomb, Jr

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to Young-Dees (2), Thiersch-Duplay procedure (3), whereas four patients were treated according to Williams, five according to Johnston, and one patient according to Ombredanne in reverse. Additionally, seven operations had to be done mainly for prepuce correction and fistula closure following urethroplasty. Three of the 16 children were continent already before operation, four children partially continent, and nine remained incontinent. Free muscle transplantation was performed in four of the incontinent children. A total of 45 operations was carried out in children with bladder exstrophy. There were 12 primary bladder closures, 13 ileum bladder constructions, five cystosigmoidostomies, five ureterosigmoidostomies, one cutaneous ureterostomy, one rectal bladder, and one colonic conduit. Postoperative urinary continence was unsatisfactory in the 12 children with primary bladder closure. Free muscle transplantations were performed in two patients. Additionally, free muscle transplantations were performed in a child with traumatic lesion of the urethra and in another with iatrogenic sphincter lesion, giving a total of eight free muscle transplantations performed. Postoperatively, complete continence was achieved in four cases and improvement with dry periods up to two hours in one case. Two patients with bladder exstrophy remained incontinent, and in one patient final assessment is not yet possible. It is concluded that free muscle transplantation is a good method for treating urinary incontinence. However, it should be used cautiously in patients with bladder exstrophy.--Thomas .4..4ngerpointner The "Congenital" Wide Bladder Neck Anomaly: A Common Cause of I n c o n t i n e n c e in Children. K. Murray, D. Nurse, M. Borzyskowski, et al. Br J Urol 59:533-535, (June), 1987.

In a study of 251 children (108 boys and 143 girls) undergoing videourodynamic studies for the assessment of nonneuropathic bladder dysfunction, 45 (19%) were found to have a wide bladder neck as their primary abnormality. Based on these studies there is evidence that the wide bladder neck anomaly is congenital in origin. In addition to producing significant urinary symptoms in childhood, this anomaly may provide a basis for stress incontinence in later life.--Prem Purl Incontinence in Female Neurogenic Bladders. Resolution by Endoscopic Bladder Neck Suspension. K. Kato, A. Kondo, T. Takita, et

al. Br J Urol 59:523-525, (June), 1987. Five incontinent females with neurogenic bladder diseases underwent endoscopic vesical neck suspension (Stamey procedure). Four patients have become dry on clean intermittent catheterization and one has shown improvement. Bladder capacity was increased to a reasonable size in all patients. There has been no upper tract deterioration during the follow-up period of 3 to 25 months. The authors believe that the Stamey procedure is useful in alleviating urinary incontinence in neurogenic bladders provided that the bladder is drained regularly by intermittent catheterization and that low detrusor compliance of detrusor hyperreflexia is adequately managed.--Prem Purl Non-Neurogenic Discoordinated Voiding in Children. The LongTerm Effect of Bladder Retraining. E. Hanson, A.-L. Hellstr6m,

and K. Hjd'lmas. Z Kinderchir 42:109-111, (April), 1987. Urinary Incontinence in Epispadias and Exstrophy of the Bladder With Special Reference to Free Autoganous Muscle Transplantation. A.M. Holschneider, W.C. Hecker, K. Devens, et al. Z Kinder-

chir 42:81-90, (April), 1987. The authors report on 16 patients with stage II to IV epispadias and on 35 patients with stage III and IV bladder exstrophies. The following surgical procedures were applied in children with epispadias: simple closure of the urethra (1), bladder neck plasty according

Sixteen children with dysfunctional voiding without demonstrable neurologic disturbances were studied 6 months and 5 years after complete bladder training. The initial good effects on voiding symptoms and urinary tract infections/bacteriuria were confirmed. Moreover, the effect seems to last for several years. Bladder retraining can thus be considered a safe, cheap, and effective method in many children with symptoms of bladder dysfunction and recurrent urinary tract infections.-- Thomas .4. Angerpointner