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Ureterocystoplasty: A unique method for vesical augmentation in children
INTERNATIONAL
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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
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