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Urologic management in cloacal dysgenesis
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The retrospective analysis of 210 patients between 1 mo and 17-yr-old with 314 primary vesicoureteral units with reflux was reviewed. Our results show that there was a direct correlation between the grade of reflux and the per cent of abnormal ureteral orifices. Medical management of low grade reflux produced successful results in 60% of the cases. Operation was highly successful in grades 1, II, and III reflux as opposed to grade IV. The distal tunnel (Glenn-Anderson) and (Politano-Leadbetter) procedures were equally effective in curing reflux. Postoperative urinary infection occurred equally in all grades and usually was confined to the bladder.--George Holcomb, Jr. The Advantages of Short-Term Vesical Drainage After AntiReflux Operation. E. T. Gonzales, Jr., E. Caffarena, and
C. E. Carlton, Jr. J Urol 119:817-818 (June), 1978. Between 1969 and 1976, 109 children underwent primary ureteral reimplantation without tailoring. In 57 cases (52%), the vesical catheter was removed within 48 hr of operation, but in most instances it was removed on the first postoperative morning (average length of catheterization was 1.3 days). The remaining 52 cases had an indwelling catheter for 3-10 days (4.8 days average). The authors conclude that lengthy postoperative vesical drainage is not required after routine antireflux operation when careful bladder closure is accompl~shed.--George Holcomb, Jr. Childhood Urethral Trauma. Lester Persky. Urology 2:603-
606 (June), 1978. Four severe childhood urethral injuries due to external trauma rather than vehicular injury or pelvic fracture are reviewed. Three were penetrating (two gunshot wounds in boys and one incident of picket fence impalement in a female) and the fourth was due to blunt perineal trauma. Temporary suprapubic cystostomy in two patients permitted a more deliberate approach to delayed management of the urethral injury. Outcome was good in all patients.-M. David Gibbons Response of Micropenis to Topical Testosterone and Gonadotropin. R. C. Klugo and J. C. Cerny. J Urol 119:667-668
(May), 1978. Five patients were treated with gonadotropin and topical testosterone for micropenis associated with hypothalamic hypogonadotropic hypogonadism. All patients received 1000 U of gonadotropin weekly for 3 wk with a 6-wk interval followed by 10% topical testosterone cream twice daily for 3 wk. Serum testosterone levels were measured and remained equivalent for both modes of therapy. Growth of the phallus was significantly greater with topical applications than with gonadotropin, particularly in children less than 10 yr old. The improved response in younger children is consistent with previously published studies of age-related 5 reductase activity.--George Holcomb, Jr. Circumcision Complication: Reaction to Treatment of Local Hemorrhage With Topical Epinephrine in High Concentration.
J. Denton, R. L. Schreiner, and J. Pearson. Clin Pediatr 17:285-286 (March), 1978. A 4100-g male infant underwent circumcision at age 2 days with a regular size Plastibil. Bleeding at the frenulum
ABSTRACTS
was treated with pressure and then 0.1 ml of 1:1000 aqueous epinephrine was sprayed on the site. A tachycardia of 220 and pallor of the penis and base of the shaft were noted. Warm soaks and local application of phentolamine were not helpful. Subcutaneous injections of phentolamine were necessary to resolve the penile pallor. A weak solution of epinephrine (1:100,000) is recommended when treating a newborn infant for h e m o r r h a g e a f t e r a circumcision.--Randall W. Powell Urologic Management in Cloacal Dysgenesis. T. H. Bartho-
lomew and E. T. Gonzales, Jr. Urology 2:549-557 (June), 1978. The embryogenesis of cloacal dysgenesis originates from faulty separation of the urogenital sinus by the urorectal septum, as well as impairment of Mullerian midline fusion. As a result, bladder, vaginal (frequently two), and intestinal drainage is compromised. A single perineal orifice of the urogenital sinus or cloaca is a frequent finding, accompanied by abdominal masses representing distended bladder, hydrocolpos, obstructed bowel, and hydronephrotic kidneys. Endoscopy and genitography is essential in discerning the anatomy. Decompression of all obstructed systems, including ureters, can frequently be accomplished by dilating the stenotic perineal orifice, especially in low defects. In higher defects, particularly when the bladder drains preferentially into the vagina, vesicostomy may be indicated. With adequate drainage, the authors advocate vaginal and rectal pull-through at an older age, rather than in the newborn period. Long-term management is primarily urologic and includes evaluation and correction of reflux, hydronephrosis, incontinence, and vaginal patency.--M. David Gibbons Long-Term Follow-up After Exstrophy Closure: Late Improvement and Good Quality of Life. J. K. Laltimer, L. Beck,
S. Yeaw, P. J. Puchner, M. T. MacFarlane, and M. Krisiloff. J Urol 119:664-666 (May), 1978. The authors have observed the growth and development of 17 anatomically reconstructed exstrophy patients through 20 or more years of follow-up and are convinced that reconstruction should be the preferred primary treatment. The great disadvantage of any type of diversion to the abdominal wall is the damage to the body image created by the stoma and the necessity to wear a urine collecting device permanently. Most of these patients are healthy, attractive, welleducated adults and have achieved emotional maturity and stability despite their many problems. Thus, it is concluded that greater effort should be directed toward achieving an anatomical reconstruction whenever the bladder is large enough.--George Holcomb, Jr. Polyorchidism, W. M. Pelander, G. Luna, and J. R. Lilly.
J Urol 119:705-706 (May), 1978. A left scrotal mass presumed to be a hydrocele since infancy was found to be an accessory testis just above another normal testis in a 13-yr-old boy. The two testes were connected by a continuous vas deferens, artery, and vein. The upper testis was removed and a small indirect inguinal hernia was repaired. Fifty-two cases of polyorchidism have previously been documented in the world literature.--George Holcomb, Jr.
The retrospective analysis of 210 patients between 1 mo and 17-yr-old with 314 primary vesicoureteral units with reflux was reviewed. Our results show that there was a direct correlation between the grade of reflux and the per cent of abnormal ureteral orifices. Medical management of low grade reflux produced successful results in 60% of the cases. Operation was highly successful in grades 1, II, and III reflux as opposed to grade IV. The distal tunnel (Glenn-Anderson) and (Politano-Leadbetter) procedures were equally effective in curing reflux. Postoperative urinary infection occurred equally in all grades and usually was confined to the bladder.--George Holcomb, Jr. The Advantages of Short-Term Vesical Drainage After AntiReflux Operation. E. T. Gonzales, Jr., E. Caffarena, and
C. E. Carlton, Jr. J Urol 119:817-818 (June), 1978. Between 1969 and 1976, 109 children underwent primary ureteral reimplantation without tailoring. In 57 cases (52%), the vesical catheter was removed within 48 hr of operation, but in most instances it was removed on the first postoperative morning (average length of catheterization was 1.3 days). The remaining 52 cases had an indwelling catheter for 3-10 days (4.8 days average). The authors conclude that lengthy postoperative vesical drainage is not required after routine antireflux operation when careful bladder closure is accompl~shed.--George Holcomb, Jr. Childhood Urethral Trauma. Lester Persky. Urology 2:603-
606 (June), 1978. Four severe childhood urethral injuries due to external trauma rather than vehicular injury or pelvic fracture are reviewed. Three were penetrating (two gunshot wounds in boys and one incident of picket fence impalement in a female) and the fourth was due to blunt perineal trauma. Temporary suprapubic cystostomy in two patients permitted a more deliberate approach to delayed management of the urethral injury. Outcome was good in all patients.-M. David Gibbons Response of Micropenis to Topical Testosterone and Gonadotropin. R. C. Klugo and J. C. Cerny. J Urol 119:667-668
(May), 1978. Five patients were treated with gonadotropin and topical testosterone for micropenis associated with hypothalamic hypogonadotropic hypogonadism. All patients received 1000 U of gonadotropin weekly for 3 wk with a 6-wk interval followed by 10% topical testosterone cream twice daily for 3 wk. Serum testosterone levels were measured and remained equivalent for both modes of therapy. Growth of the phallus was significantly greater with topical applications than with gonadotropin, particularly in children less than 10 yr old. The improved response in younger children is consistent with previously published studies of age-related 5 reductase activity.--George Holcomb, Jr. Circumcision Complication: Reaction to Treatment of Local Hemorrhage With Topical Epinephrine in High Concentration.
J. Denton, R. L. Schreiner, and J. Pearson. Clin Pediatr 17:285-286 (March), 1978. A 4100-g male infant underwent circumcision at age 2 days with a regular size Plastibil. Bleeding at the frenulum
ABSTRACTS
was treated with pressure and then 0.1 ml of 1:1000 aqueous epinephrine was sprayed on the site. A tachycardia of 220 and pallor of the penis and base of the shaft were noted. Warm soaks and local application of phentolamine were not helpful. Subcutaneous injections of phentolamine were necessary to resolve the penile pallor. A weak solution of epinephrine (1:100,000) is recommended when treating a newborn infant for h e m o r r h a g e a f t e r a circumcision.--Randall W. Powell Urologic Management in Cloacal Dysgenesis. T. H. Bartho-
lomew and E. T. Gonzales, Jr. Urology 2:549-557 (June), 1978. The embryogenesis of cloacal dysgenesis originates from faulty separation of the urogenital sinus by the urorectal septum, as well as impairment of Mullerian midline fusion. As a result, bladder, vaginal (frequently two), and intestinal drainage is compromised. A single perineal orifice of the urogenital sinus or cloaca is a frequent finding, accompanied by abdominal masses representing distended bladder, hydrocolpos, obstructed bowel, and hydronephrotic kidneys. Endoscopy and genitography is essential in discerning the anatomy. Decompression of all obstructed systems, including ureters, can frequently be accomplished by dilating the stenotic perineal orifice, especially in low defects. In higher defects, particularly when the bladder drains preferentially into the vagina, vesicostomy may be indicated. With adequate drainage, the authors advocate vaginal and rectal pull-through at an older age, rather than in the newborn period. Long-term management is primarily urologic and includes evaluation and correction of reflux, hydronephrosis, incontinence, and vaginal patency.--M. David Gibbons Long-Term Follow-up After Exstrophy Closure: Late Improvement and Good Quality of Life. J. K. Laltimer, L. Beck,
S. Yeaw, P. J. Puchner, M. T. MacFarlane, and M. Krisiloff. J Urol 119:664-666 (May), 1978. The authors have observed the growth and development of 17 anatomically reconstructed exstrophy patients through 20 or more years of follow-up and are convinced that reconstruction should be the preferred primary treatment. The great disadvantage of any type of diversion to the abdominal wall is the damage to the body image created by the stoma and the necessity to wear a urine collecting device permanently. Most of these patients are healthy, attractive, welleducated adults and have achieved emotional maturity and stability despite their many problems. Thus, it is concluded that greater effort should be directed toward achieving an anatomical reconstruction whenever the bladder is large enough.--George Holcomb, Jr. Polyorchidism, W. M. Pelander, G. Luna, and J. R. Lilly.
J Urol 119:705-706 (May), 1978. A left scrotal mass presumed to be a hydrocele since infancy was found to be an accessory testis just above another normal testis in a 13-yr-old boy. The two testes were connected by a continuous vas deferens, artery, and vein. The upper testis was removed and a small indirect inguinal hernia was repaired. Fifty-two cases of polyorchidism have previously been documented in the world literature.--George Holcomb, Jr.