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PURPOSE: We compare the diagnostic impact of 2 diuresis renography techniques for evaluation of suspected upper urinary tract obstruction in children. MATERIALS AND METHODS: A total of 72 children were randomly assigned to 1 of 2 standardized diuresis renography protocols. The protocols were identical, except for the time of furosemide (F) injection. In the F+20 scans furosemide was given 20 minutes after the 99mtechnetium pentetic acid radiopharmaceutical. With the modified F-15 scans furosemide was injected 15 minutes before renography. Hydration, bladder catheterization, urine output determination, radiopharmaceutical injection and scan acquisition were identical. Renography outcomes (obstructed, nonobstructed or equivocal) were analyzed for the investigated side(s) and for the contralateral side, which was used as a control in children with suspected unilateral obstruction. Chi-square test was used to compare the percentage of obstructed and nonobstructed scans of both protocols. Fisher's exact test was used to compare the nonobstructed scans and equivocal results of both protocols. RESULTS: Of the 96 scans performed 8 were excluded because of technical problems. The remaining scans included 44 F+20 and 44 F-15. Of the 88 scans 10 were used to evaluate possible bilateral obstruction. A total of 48 boys and 24 girls were evaluated. Because 2 children had a solitary kidney each, the total number of renal units studied for outcome was 174. The F-15 scan showed 7 times more obstruction than the F+20 scan on the investigated side, and this difference was statistically significant. No obstruction was diagnosed on the contralateral side with either technique when used to investigate cases of suspected unilateral obstruction. CONCLUSIONS: The timing of the furosemide injection (F-15 scan versus F+20) has a significant impact on the obstructive versus nonobstructive renography results when evaluating children with suspected upper urinary tract obstruction.

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We report a case of priapism in an 11-year-old boy known to have Fabry's disease. High flow was confirmed by color flow Doppler ultrasound and intracorporal blood gas measurements. Successful treatment was achieved by unilateral percutaneous Gelfoam embolization of the left internal pudendal artery. Previously reported cases of priapism associated with Fabry's disease were identified through a MEDLINE search of the English literature and review of the publications. Five reported cases of priapism associated with Fabry's disease were found, including those of 3 children. A report of a child with high-flow priapism that did not respond to conventional treatment including cavernovenous shunting was noted. Priapsim associated with Fabry's disease may be caused by unregulated high arterial inflow. Early recognition of the underlying pathophysiology may identify those cases that would be amenable to percutaneous embolization therapy and may obviate the need to pursue other ineffective conventional treatments.

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OBJECTIVES: We report the case of a tumor in an intra-abdominal cryptorchid testis of a 7-month-old male infant. Torsion of a testicular teratoma was confirmed by pathologic examination. A review was undertaken to identify and characterize other reports of prepubertal cryptorchid germ cell neoplasms. METHODS: Cases of testicular germ cell neoplasms in association with cryptorchidism in phenotypically normal males were identified through a MEDLINE search of the English literature and review of published bibliographies. RESULTS: A total of 14 cases were identified with testis location provided in 12 patients. Half of the neoplasms were located in abdominal testis, and all of these were associated with torsion, although 2 of 6 patients were asymptomatic. Two patients had tumors in the contralateral normally descended testis. Teratoma was the most frequently encountered tumor type. CONCLUSIONS: Characteristics of prepubertal cryptorchid testicular germ cell tumors reflect those seen in post-pubertal cryptorchid tumors in location but differ in histologic type. Possible pathogenesis is discussed. Follow-up was not provided in all cases although outcome appears to be good. We believe that these lesions are likely underreported.

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Prostatic neoplasms are rare in childhood. We report a case of primary prostatic carcinoid in a 7-year-old boy who was subsequently diagnosed with multiple endocrine neoplasia IIb. To our knowledge this is the first report of either pediatric carcinoid of the prostate or of prostatic carcinoid in conjunction with neuronal intestinal dysplasia and medullary thyroid carcinoma suggestive of multiple endocrine neoplasia IIb. Management and histogenesis regarding this prostatic tumor are discussed as is a possible association with other neuroendocrine tumors.

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The objective of the study was to evaluate liquid cranberry products as prophylaxis against bacterial urinary tract infection in a pediatric neuropathic bladder population. Forty cases managed by clean intermittent catheterization with or without pharmacotherapy were enrolled in a randomized single-blind cross-over study. Subjects ingested 15 mL/kg/day of cranberry cocktail or water for six months followed by the reverse for another six months. Initial catheter urine samples and subsequent monthly and interim cultures were obtained. Associated symptoms were recorded along with follow-up attendance/compliance registry. The number of negative culture months to the number of months contributed was tabulated and compared between interventions. Individual, cumulative and antimicrobial subset analysis was performed. Twenty one patients completed the study;12 dropped out for reasons related to the cranberry (taste, caloric load and cost); seven patients dropped out for other reasons (parents too busy, death, no stated reason). Wilcoxon matched-pairs Signed-ranks analysis revealed no difference between intervention periods (2-tailed P=.5566 [whole group]; p=.2845 [antimicrobial subset]) with respect to infection. Fewer infections were observed in nine patients taking cranberry juice and in nine patients given water; no difference was noted in three. Liquid cranberry products, on a daily basis, at the dosage employed, did not have any effect greater than that of water in preventing urinary tract infections in this pediatric neuropathic bladder population.

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Because the traditional protocol for investigating blunt renal trauma in children has been questioned and because of societal awareness of health care costs, the authors carried out a retrospective review of blunt renal trauma in 138 children over a 5-year period to establish criteria for urgent radiologic investigation of those with suspected renal trauma. From their findings, they recommend that in the absence of the suspected major injuries and hypotension a threshold count of 40 red blood cells per high-power field is necessary before urgent intravenous pyelography should be done.

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An infant who presented with a unilateral renal cystic process underwent nephrectomy due to hypertension. There was no evidence of any other disease process. Family history and investigation were negative for renal cystic disease or other genetic disease process. The pathology most resembled autosomal dominant polycystic kidney disease or a specific entity described as unilateral renal cystic disease.

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Priapism may be classified as the classical veno-occlusive form or the more recently described high flow, arterial type. We report a case of posttraumatic arterial priapism in a 7-year-old boy. The successful management with percutaneous transcatheter embolization of the internal pudendal artery is described.

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Nephrogenic adenoma, an unusual proliferative lesion, often occurs in association with chronic inflammation of the bladder and is rarely found in children. Two cases are reported, one occurring in a young child born with bladder exstrophy, and one in a young female, with both interstitial cystitis and chronic use of immunosuppressive therapy. We believe these are the first case reports of nephrogenic adenoma occurring in this specific clinical setting.

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We report a case of inverted Y duplication of the ureter associated with an ectopic ureterocele.

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We report an adult benign teratoma of the testis in a 12-year-old boy, which, to our knowledge, is the first reported instance of such a tumor developing during puberty. After radical inguinal orchiectomy all pathological sections proved to be consistent with a benign adult teratoma. This child is being followed closely.

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A review of bladder exstrophy experience at our institution was undertaken with reference to penile adequacy and intersymphyseal distance. Drift of the symphysis apart even with iliac osteotomy was noted to occur within two years of initial closure but remained stable after three years. This drift can be prevented if the sacral tuberous and sacral spinous ligaments are sectioned. Further, the adequacy of the phallus seems to depend directly on the intersymphyseal distance. Thus, we suggest a variation in the staged approach to bladder exstrophy repair with these facts in mind.

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In the past, treatment of ectopic ureteroceles with duplicated collecting systems with little or no function in the upper pole segment has been heminephrectomy, often followed by reconstruction of the ureterovesical junction. Herein we review our initial use of transurethral puncture of ureteroceles to initiate drainage with potential return or improvement of function to the upper pole segment. The initial goal was to do pyelopyelostomy rather than heminephrectomy with less potential morbidity to the patient and preservation of functional renal tissue.

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We report 4 cases of 3 different forms of ureteroceles to illustrate spontaneous reflux without any evidence of obstruction. The presence of reflux tends to support those concepts that ureterocele formation is not on an obstructive basis. The obstruction that is oftern associated with ureteroceles is probably caused by the same stimulus as that which created the ureterocele. Obstruction does not necessarily accompany every ureterocele and is not causative of its formation.

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Parameters of the carbon dioxide urethral pressure profilometry were examined in detail previously for reproducibility within subjects. In the current study we have extended that analysis to determine the relationship of these parameters between patient subgroups. Mean values for non-spina bifida male subjects showed the same pattern of increase across age groups, regardless of the measured parameter. These increases were significant for continence and functional lengths but not for closure pressure. Male subjects with spina bifida showed mixed responses across age but age was not a statistically significant factor for any of the 3 parameters. Female subjects were quite uniform in the mean values across age for continence and functional lengths regardless of diagnosis. Mean values for female subjects were not uniform for closure pressure and tended to decrease with age in contrast to continence and functional lengths. The parameter continence length has a between subject standard deviation that is relatively stable across age, sex and pathology, and may be used for a basis of comparison. However, standard deviations for functional length is least variable in most subgroups of sex, age and diagnosis.

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Of 105 boys with posterior urethral valves managed during a 10-year period most were managed by primary valve ablation. However, 39 of these boys required concomitant or additional procedures to 71 massively dilated ureters because of azotemia, infection and/or progressive upper tract deterioration. In 17 boys 25 ureters could be reconstructed primarily by varying degrees of ureteral tailoring. When there was severe infection, azotemia and/or doubt as to the function of the affected renal unit, staged reconstruction was initiated by cutaneous ureterostomy. One-fourth of these ureterostomy diverted children died of azotemia despite free urinary drainage. Those who went on to have staged reconstruction, despite multiple surgical procedures, retained intact urinary systems with acceptable function.

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