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PURPOSE: We retrospectively reviewed 2 series of patients with posterior urethral valves treated initially with valve ablation preceded by bilateral cutaneous ureterostomies or valve ablation alone to evaluate and compare bladder function behavior of each treatment group. MATERIALS AND METHODS: From 1970 to 1983, 19 males 22 days to 21 months old with posterior urethral valves were treated with 1 of 2 initial surgical approaches, including upper tract diversion, delayed undiversion and ablation in 11 (group 1), and primary valve ablation only in 8 (group 2). Median patient age at the time of cutaneous urinary diversion and primary valve ablation for groups 1 and 2 was 7 and 9 months, respectively. Median duration of bladder defunctionalization was 48 months. All patients were evaluated urodynamically after initial ablation or re-functionalization of the bladder using standard rapid fill cystometry. Median patient age for groups 1 and 2 was 14 and 9.5 years, respectively, at the time of urodynamic testing 16 and 12.6 years, respectively, at followup. RESULTS: Urodynamic assessment revealed detrusor instability in 5 group 1 patients but in only group 2 1 patient. Group 2 patients had significantly lower median end filling pressure (4 versus 15 cm. water, p <0.03) and higher maximum bladder capacity (1.4 versus 0.8, p <0.005) than those in group 1. Group 1 patients had lower compliance than those in group 2 (median 15 versus 82 cm. water, p <0.05). Further analysis showed no difference between groups 1 and 2 in overall median voiding detrusor pressure at maximum flow (51 versus 52.6 cm. water, respectively). Cystometric detrusor under activity patterns were noted in 5 group 1 and 2 group 2 patients. Residual urine volumes were 17%, 31%, 19% and 8% of bladder capacity, respectively, in 2 group 1 and 2 group 2 patients. At final followup 5 group 1 and 2 group 2 patients had renal function deterioration. Two other group 1 patients and group 2 had progression to end stage renal failure. A higher ureteral reimplantation rate was noted in group 1 (63%) than group 2 (6%). CONCLUSIONS: This retrospective study revealed that long-term bladder function of patients with posterior urethral valves treated with temporary supravesical diversion is affected more adversely than those treated with valve ablation alone.

Assuntos

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OBJECTIVE: To assess the clinical significance of after-contractions (A-Cs) in children with normal urinary tracts. PATIENTS AND METHODS: Urodynamic records obtained in 315 children with urinary infection or enuresis were reviewed retrospectively; 184 were selected for analysis of A-Cs. All patients had normal urinary tracts and none showed signs of an overt neuropathy. The urodynamic method comprised standard measurements of pressures and flowmetry (42 had video-urodynamic studies). RESULTS: After-contractions occurred in 151 of the 184 patients; the incidence tended to decrease with age. The mean amplitude of the A-Cs was 77.9 cmH2O; in 36% of the records it was higher than the voiding contraction. Residual urine was found in 12 of 151 records with A-Cs, but in only one patient was such residual urine confirmed in control voids. The patterns were assessed in 131 patients: in 36% they resembled stop-test responses, in 31% they were preceded by brief peaks of pressure or had jagged limbs, and in 33% they were grossly irregular. In 137 records the content of the bladder was estimated at the start of A-Cs; in 51% the bladder was empty or had evacuated >95% of its content, in 39% 95-80% and in 10% <80%. In only 7% of the patients had the A-Cs started after the voiding contraction had completely subsided. There was no difference in the incidence of A-Cs in girls with enuresis (84%) and girls with a history of urinary infections (85%). Detrusor instability was detected in 81% of the children with A-Cs and in 70% of those without; there was no correlation between the amplitudes of uninhibited detrusor contractions and of A-Cs. Characteristic images of external sphincter activity were found in only three of 14 video-urodynamic recordings with A-Cs. CONCLUSION: After-contractions are common in children with normal urinary tracts but they tend to disappear with age. In clinical urodynamics they are of limited practical use because their appearance is unpredictable and there are artefacts related to recording the final phase of micturition. The relationship with detrusor instability may be explained as a coincidence of two common but unrelated findings, and A-Cs are unrelated to urinary infection. External sphincter activity is not the only cause of A-Cs and when it occurs it does not alter the course of voiding, as it does in neuropathic dysfunctions. As their clinical significance is uncertain, treatment of A-Cs is not advocated.

Assuntos

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PURPOSE: Urethral duplication is a rare congenital anomaly. We report the clinical presentation, imaging findings and surgical treatment in 7 boys with incomplete sagittal duplication of the urethra. MATERIALS AND METHODS: Duplication involved hypospadias in 5 cases (group 1) and a bifid urethra with an accessory preanal tract (Y duplication) in 2 (group 2). Group 1 was treated with 1-stage urethroplasty, including marsupialization of the dorsal orthotopic urethra, ventral-to-dorsal urethrourethrostomy and penile island flap onlay repair to cover the open dorsal urethra. In contrast, group 2 was treated with 2-stage urethral reconstruction with detachment and mobilization of the accessory preanal branch in association with a scrotal tubed neourethra followed by urethroplasty, as in group 1. In all cases the dorsal penile urethra was located between the corpora cavernosa and surrounded by the tunica albuginea. RESULTS: A urethrocutaneous fistula developed in 1 of the 5 group 1 patients. In group 2, 1 patient had recurrent penoscrotal meatal stenosis after the 1-stage procedure and 1 had a urethral diverticulum with calculi at the scrotal tubed neourethra 7 years after urethral reconstruction. Six of the 7 patients now void spontaneously through a meatus located normally at the tip of the glans. The remaining patient with a neurogenic bladder is on intermittent catheterization via appendicovesicostomy due to difficult catheterization of the irregular and sensitive neourethra. CONCLUSIONS: While the ideal surgical management of urethral duplication anomalies remains uncertain, we used a combination of surgical techniques to correct this severe malformation.

Assuntos

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OBJECTIVE: To assess urodynamic and clinical data in patients with primary enuresis for potential prognostic indicators of detrusor instability. PATIENTS AND METHODS: The records of 33 patients (mean age 8.8 years, range 5-14) with monosymptomatic primary enuresis (MPE, bedwetting as the sole symptom) and 47 patients (mean age 7.1 years, range 5-12) with complicated primary enuresis (CPE, bedwetting associated with diurnal urinary loss, squatting and urge incontinence) were reviewed. The children underwent urodynamic studies to detect detrusor instability and the prevalence was compared with the type of enuresis. RESULTS: Of 33 patients with MPE, 17 (49%) showed either typical unstable detrusor contractions (16) or low-compliance bladders (one); in the remaining 16 patients, filling cystometry was normal and micturition was normal in all. Of the 47 patients with CPE, 35 (79%) showed detrusor instability and two decreased bladder compliance; the remaining 10 had stable bladders and micturition was also normal in all patients. CONCLUSION: The type of primary enuresis and the maximum cystometric bladder capacity were good indicators of bladder dysfunction.

Assuntos

Assuntos