SECTION ON UROLOGY 1996 ANNUAL MEETING PROGRAM

10:15 a.m. Discussion

20) 1:00 p.m.

SECTION

ON

UROLOGY

1996

ANNUAL

MEETING

PROGRAM

October

26-28,

1996

SATURDAY, OCTOBER 26

HilO Section on Urology 7:45 a.m.-5:20 p.m.

Hynes Convention Center, Room 302

7:45 a.m Welcoming Remarks

Robert Kay, M.D., FAAP

ABSTRACT PRESENTATIONS-POSTERIOR URETHRAL

VALVES

Moderators: Gordon A. McLorie, M.D.; An-thony

I.

*1) 8:00 a.m The Management of Unilateral Poorly

Functioning Kidneys in Patients with Pos-terior Urethral Valves

Y. H. Kim, M.D., et a!

2) 8:07 a.m. VURD Syndrome: Fact Or Fiction?

P.M. Cuckow, FRCS, M.D., et a!

3) 8:14 a.m. Progressive Renal Failure in Children

Di-agnosed with Posterior Urethral Valves Despite Proximal Urinary Diversion D. N. Tietjen, M.D., et al

4) 8:21 a.m. Management of Posterior Urethral Valve

Patients on the Basis of Urodynamic Find-ings

Y. H. Kim, M.D., et al

5) 8:28 a.m. Natural Filling Cystometry in Small Boys with Posterior Urethral Valves

G. Holmdahl, M.D., et at

8:35 a.m. Discussion ABSTRACT PRESENTATIONS-ENURESIS

Moderators: Joseph Ortenberg, M.D.; Hal C. Scherz, M.D.

6) 8:50 a.m. Oral Desmopressin (DDAVP): A

Random-ized, Double Blind, Placebo Controlled Study of Effectiveness in Children with Primary Nocturnal Enuresis (PNE)

S.

J.

7) 8:57 a.m. DDAVP for Nocturnal Enuresis in the

Spina Bifida Population M. Horowitz, M.D., et a!

8) 9:04 a.m. Treatment of Refractory

Monosymptom-atic Nocturnal Enuresis with Combination Therapy of Desmopressin and Imipramine

Y. Reinberg, M.D., et al

9:11 a.m. Discussion 9:20 a.m. Break

ABSTRACT PRESENTATIONS-EXSTROPHY,

INCONTINENCE

Moderators: Robert D. Jeffs, M.D.; Douglas A. Canning, M.D.

9) 9:40 a.m. Bladder Exstmphy Is It Possible to Achieve

Continence with Spontaneous Voiding? A Retrospective Study of 57 Cases

H. Lottmann, M.D., et a!

*Abstract number appears in left column.

10) 9:47 a.m. The Artificial Urinary Sphincter in

Chil-dren with Bladder Exstrophy and Epispa-dias

Y. Mor, M.D., et a!

11) 9:54 a.m. Modified Technique for Bladder Neck

Closure as a Salvage Procedure for Intrac-table Incontinence in Children

S. Agarwal, M.D., et al

12) 10:01 a.m. Placement of a Bladder Neck Purse String

Cuff for the Management of Incontinence in Children with Myelodysplasia

I. Kohn, M.D., et a!

13) 10:08 a.m. Self-Sealing Membrane System for the

En-doscopic Treatment of Incontinence

I. I.

ABSTRACT PRESENTATIONS-UROGENITAL SINUS,

INCONTINENCE

Moderators: James P. Mandell, M.D.; Michael Carr, M.D., PhD

14) 10:30 m. Reconstruction of the High Urogenital

Si-nus: Early Posterior Sagittal Approach Without Division of the Rectum R. C. Rink, M.D., et at

15) 1037 a.m. “Pure” Urogenital Sinus Anomalies:

Man-agement and New Classification M.K. Hanna, M.D., et a!

16) 10:44 a.m. Incidence of Genital Malformations in

Pa-tients with Imperforate Anus: A Review of 131 Patients

I.

17) lth5l a.m. The Kropp Bladder Neck Reconstruction

and its Variation in the Incontinent Patient with Neurogenic Bladder

M. A. Koyle, M.D.

18) 10:58 a.m. A Simplified Kropp Procedure for

Incon-tinence

W. Snodgrass, M.D.

19) 11:05 a.m. Urethral Lengthening and Reimplantation: Management of Catheterization Problems K. A. Kropp, M.D.

11:12 a.m. Discussion

11:30 a.m. Business Meeting

12:00 noon Lunch Break

ABSTRACT PRESENTATIONS-BASIC RESEARCH

FINALISTS

Moderators: Stuart S. Howards, M.D.; Mi-chael R. Freeman, PhD

Development and Regenerative Ability of

Bladder in the Transgenic Epidermal

Growth Factor Receptor Gene Knockout Mouse

M. DiSandro, M.D., et a!

21) 1:07 p.m. Gene Therapy Using Urothelial

Tissue-En-gineered Neo-Organs

I. I.

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22) 1:14 p.m. Partial Bladder Outlet Obstruction in the Fetal Rabbit

D. Rohrmann, M.D., et at

23) 1:21 p.m. Direct In Vivo Electrotransection of

Kid-neys and Bladden A Novel Method of Or-gan Confined Gene Therapy

J. J.

24) 1:28 p.m. Creation of Functional Kidney Structures

with Excretion of Urine-Like Fluid In Vivo

J. J.

25) 1:35 p.m. Controlled Formation of Stones in a Pri-mary Renal Cell Culture System

S. Ashkar, Ph.D., et a!

26) 1:42 p.m. Aquaporin (AQP-2) and Vascular

Endothe-hal Growth Factor (VEGF) Gene Expres-sion in Renal Obstruction

M. Kaefer, M.D., et a!

27) 1:49 p.m. The Ureteric Bud Expresses Soluble and

Cell Surface Molecules That Are Required for Normal Renal Development

G.W. McWilliams, MD., et at

1:56 p.m. Discussion

2:20 p.m. National Kidney Foundation Lecture

Arno!d Relman, M.D.

3:00 p.m. Break

POSTER SESSION I

3:20-4:20 p.m.

Moderators: Edwin P. Harmon, M.D.; Hrair-George Mesrobian, M.D.

28)

29)

30)

31)

32)

33)

34)

35)

36)

Practice Patterns of Primary Care Physi-cians in the Evaluation of Pediatric Uri-nary Tract Infections and Vesicoureteral Reflux

T.S. Vates, M.D., et a!

Practice Parameters in Management of

Blunt Renal Trauma in Children A.

J.

Scrotal Cystic Lymphangioma: The Misdi-agnosed Scrotal Mass

R.S. Hurr.vitz, M.D., et at

The Importance of Accurate Diagnosis and Early Close Follow-Up in Patients with Suspected MCDK

E. Minevich, M.D., et at

Renal Preservation of an Upper Pole Sys-tem Associated with a Ureterocele: Is It Associated with Hypertension?

1.

Retractile Testes: Long Term Outcome Analysis

S. K. Agarwal, M.D., et at

Effect of Midazolam on Bladder Physiol-ogy

T. E. Figueroa, M.D., et at

Management of Ectopic Ureters: Experi-ence with the “Upper Tract” Approach

J.

Leuprolide Therapy Prevents Recurrent Priapism in Teenage Boys with Sickle Cell

Anemia

D. H. Ewatt, M.D., et at

37)

38)

39)

40)

Characterization and Incidence of Pria-pism in Boys with Sickle Cell Anemia D H. Ewalt, M.D., et at

Estimating Normal Bladder Capacity in

Children

M. Kaefer, M.D., et at

Feminizing Genitoplasty for CAH: What

Happens At Puberty? N. Alizai, M.D., et a!

Management of 11 Children with Severe latrogenic Penile Injuries

M. Hanna, M.D., et at

3:50 p.m. Discussion

POSTER SESSION II

4:20-5:20 p.m.

Moderators: Ellen Shapiro, M.D.; Julia Spencer Barthold, M.D. 41)

42)

43)

44)

45)

46)

47)

48)

49)

50)

51)

52)

The Seromuscular Colocystoplasty (SCLU) Prevents Metabolic Acidosis During Acid Loading

T. S. Vates, M.D., et a!

Methods to Enhance Urothelial Growth on Seromuscular Colonic Segments in the Ca-nine

T. S. Vates, M.D., et at

Cyclooxygenase 2 (COX-2) Expression in

Fetal Bladder Development and in Acute Bladder Outlet Obstruction

J.

Does Chemotherapy Affect Compensatory Renal Hypertrophy After Nephrectomy in the Growing Piglet Model?

F. A. Ferrer, M.D., et at

The Effect of Testosterone on Androgen Receptors and Human Penile Growth L. S. Baskin, M.D., et a!

Neuroanatomic Changes After Partial Bladder Obstruction

R. S. Sutherland, M.D., et a!

Renal Hemodynamic Changes After Corn-plete Unilateral Ureteral Obstruction in the Neonatal Lamb

K. M. Kim, M.D., et at

Co-Expression of Smooth and Striated Muscle Markers in the Developing Intrin-sic Urethral Sphincter

S. Borirakchanyavat, M.D., et at

Bladder Contraction Following Stretch Stimulation: The Myogenic Response G. E. Dean, M.D., et a!

The Role of a Local Renin-Angiotensin System in the Obstructed Adolescent Rat Bladder

L. S. Palmer, M.D., et at

Basic Fibroblastic Growth Factor in the Urine of Children with Myelodysplasia: A Potential Marker of Bladder Pathology

J.

Bladder Augmentation Using a New Bio-material Composed of Allogenic Bladder Submucosa

J. J.

4:50 p.m. Discussion

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9:10 a.m.

9:40 a.m.

5:20 p.m. Adjourn

7:00 p.m. Banquet-Museum of Fine Arts

(Banquet tickets must be purchased through Ad-vanced Registration or onsite at the AAP Reg-istration Desk.

SUNDAY, OCTOBER 27

H222 Section on Urology 8:00 a.m.-5:30 p.m.

Hynes Convention Center, Room 302

ABSTRACT PRESENTATIONS-VESICOURETERAL

REFLUX

Moderators: Philip G. Ranstey, FRCS; R. Dixon Walker, III, M.D.

53) 8:00 a.m. Vesicoureteral Reflux: The Effect of

Dys-functional Voiding D. A. Canning, M.D., et a!

54) 8:07 a.m. Urodynamic Sequelae of Infant

Reimplan-tation

T. P.V.M. DeJong, M.D., et at

55) 8:14 a.m. GAX 65: A New Injectable Cross-Linked

Collagen for the Endoscopic Treatment of Vesicoureteral Reflux: A Double Blinded Study Evaluating its Efficiency in Chil-dren

P. Frey, M.D., et at

56) 8:21 a.m. Newly Diagnosed Contralateral Reflux Following Successful Unilateral Endo-scopic Correction: Is It Due to “Pop off Valve” Mechanism?

P. Pun, M.D., et at

57) 8:28 a.m. How to Prevent Contralateral Reflux

Fol-lowing Unilateral Antireflux Surgery P. Caione, M.D., et at

58) 8:35 a.m. Contralateral Vesicoureteral Reflux

Fol-lowing Simple and Tapered Ureteroneo-cystostomy-Revisited

D. B. Joseph, M.D., et at

59) 8:42 a.m. Extravesical Repair of the Refluxing

Megaureter Using a Non-Dismembered

Technique Reduces Hospital Stay and

Postoperative Discomfort

J.

60) 8:49 a.m. Clinical Collaborative Care Pathway in the Management of Ureteroneocystostomy

1.

61) 8:56 a.m. Do All Patients Need Radiologic Fol-low-Up After Ureteroneocystostomy

M. D. Bomalaski, M.D., et at

62) 9:02 a.m. Postoperative Voiding Cystourethrogram Following Ureteral Reimplantation: Is It Really Necessary?

R. M. Decter, M.D., et at

Discussion Break

ABSTRACT PRESENTATIONS-IMAGING

Moderators: Mark F. Bettinger, M.D.; Robert M. Weiss, M.D.

63) 10:00 a.m. Use of Longitudinal Renal Parenchymal Area in Children with High Grade Vesi-coureteral Reflux

R. S. Pruthi, M.D., et at

64) 10:07 a.m. Magnetic Resonance Urography of the

Pe-diatric Urinary Tract in Spinal Dysra-phism: Comparison with Ultrasonography D.

J.

65) 10:14 a.m. Reliability of 99mTc-Dimercaptosuccinic

Acid (DMSA) Uptake At 2 Hour Post

In-jection in Hydronephrosis Y. Yamazaki, M.D., et at

66) 10:21 a.m. Technique of Background Subtraction

In-fluences Calculated Renal Function in Pe-diatric MAG-3 Renography

H. T. Nguyen, M.D., et at

67) 10:28 a.rn. Prenatally Detected Posterior Urethral

Valves: Qualitative Assessment of the

Sec-ond Trimester Scans and Prediction of

Outcome

K.A.R. Hutton, F.R.C.S., et at

68) 10:35 a.m. Criteria for Differentiating Between

Ob-structive and Nonobstructive Etiologies of Bladder Distension Using Prenatal Sonog-raphy

M. Kaefer, M.D., et at

69) 10:42 a.m. The Dilated Fetal Bladder on Antenatal

Ultrasound: Diagnosis and Outcome F. M.

J.

10:49 a.m. Discussion

ABSTRACT PRESENTATIONS-HYDRONEPHROSIS

Moderators: Yves L. Homsy, M.D.; Paul A. Merguerian, M.D.

70) 11:10 a.m. Multi-Center Randomized Study

Compar-ing Surgery Versus Observation for In-fants with SFU Grade 3 Obstructive Hy-dronephrosis: An Interim Report From the Society for Fetal Urology

L. S. Palmer, M.D., et al

71) 11:17 a.m. Ureteral Opening Pressure: A Novel

Pa-rameter for the Evaluation of Pediatric Hy-dronephrosis

L.C.T. Fung, M.D., et at

72) 11:24 a.m. Oxybutynin Lowers Elevated Renal Pelvic

Pressures: A Clinical Study

I.

73) 11:31 a.m. The Operative Management of Recurrent

Ureteropelvic Junction Obstruction D. Rohrmann, M.D., et a!

11:38 a.m. Discussion

11:50 a.m. Pediatric Urology Medal

Panayotis P. Kela!is, M.D.

12:00 noon Lunch Break

ABSTRACT PRESENTATIONS-CLINICAL RESEARCH

FINALISTS

. Moderators: Alan B. Retik, M.D.; W. Hardy

Hendren III, M.D.

74) 1:00 p.m. The Timing of Penile Block for

Postoper-ative Analgesia in Hypospadias Repair W. C. Hu!bert, M.D., et a!

75) 1:07 p.m. Varicocelectomy Versus Observation in

Adolescent Varicocele: Prospective Study D. A. Paduch, M.D., et at

76) 1:14 p.m. Psychosexual Dysfunction in Adolescent

Males with Bladder Exstrophy W. G. Reiner, M.D., et a!

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4:00 p.m. Discussion

95)

88)

89)

105)

77) 1:21 p.m. Urodynamics and High Grade

Vesi-coureteral Reflux

M. D. Bomataski, M.D., et at

78) 1:28 p.m. The Role of Intestinal Mucous in

Lithe-genesis Following Augmentation

Cysto-plasty

A. E. Khoury, M.D., et a!

79) 1:35 p.m. XX Sex Reversal: A Molecular Analysis of

the SRY/ZFY Regions P. P. Reddy, M.D., et at

80) 1:42 p.m. Growing Renal Lesions in Children with

Tuberous Sclerosis Complex D. H. Ewalt, M.D., et at

81) 1:49 p.m. Genotyping of the Renin Angiotensin

Sys-tern: Identifying Potential Risk Factors Linked to Progressive Renal Failure in Childhood Urologic Disease

J.

82) 1:56 p.m. Insurability of Children with Congenital

Urologic Anomalies J.A. Stock, M.D., et at

2.03 p.m. Discussion

2:30 p.m. AUA Guest Lecture

Donald Coffey, PhD

3:20 p.m. Break

POSTER SESSION III

3:30-4:30 p.m.

Moderators: Anthony Atala, M.D.; George F. Steinhardt, M.D.

83) Mesenchymal-Epithelial Interactions in

Bladder Smooth Muscle Development M. DiSandro, M.D., et at

84) The Ontogeny of Canine SIS-Regenerated

Urinary Bladder

J.

85) The Role of Platelet-Activating Factor in

Testicular Ischemic Injury

J.

86) Comparison of Blood Flow and Histologic Changes in Animal Models of Testicular Torsion

J.

87) Biocompatible Membranes and Knittings:

Cell Carriers for Cultured Urothelial and Bladder Smooth Muscle Cells

P. Frey, M.D., et at

Bovine Demineralized Bone Matrix Is a

Safe, Non-Immunogenic Injectable Bulk-ing Material Associated with Excellent Volume Preservation

L. C. T. Fung, M.D., et at

Renal Apoptotic Cell Death Induced By

Acute Renal Pelvic Pressure Elevation is Associated with Up-Regulation of Medul-lary VEGF and Down -Regulation of Cor-tical VEGF

L.C.T. Fung, M.D., et at

90) Renal Hyperplasia Occurs in Response to

Contralateral Nephrectomy C. K. Lee, M.D., et at

91) Reconstitution of EGFr-Poor Renal Epithe-hal Cells Into Tubular Structures on Bin-degradable Polymer Scaffold

L. C. T. Fung, M.D., et at

92) Total Cessation of Blood Flow Prevents

Testicular and Renal Cells From Initiating the Apoptotic Cell Death Cycle

J. J.

93) Enteric Mucosal Regrowth After Bladder

Augmentation Using Demucosalized Gut

Segments

P. A. Dewan, M.D., et at

94) Reconstitution of Human Urothelium

From Monolayer Tissue Cultures: Its Use in Composite Enterocystoplasty Produc-tion

S. D. Scriven, F.R.C.S., et at

POSTER SESSION IV

4:30-5:30 p.m.

Moderators: Bruce H. Broecker, M.D.; Patrick Duffy, FRCS Evaluation of the Incidence, Etiology, Pro-vention and Management of Hemorrhagic Cystitis in Pediatric Bone Marrow Trans-plantation

P. I. E!tsworth, M.D., et at

96) Undiversion of the Short or Severely

Di-lated Uretec The Antireflux Ileal Nipple Revisited

R. Gosatbez, M.D., et at

97) Factors Contributing to Local Recurrence

of Wilms’ Tumon A Retrospective Review

J.

98) Management and Outcome of Anterior

Urethral Valves in the Era of Antenatal Sonography

I.

99) Stone Formation Following Augmentation

Cystoplasty: The Role of Urinary Constit-uents

M. Salomon, M.D., et at

100) Ten Years Experience with Urachal

Anom-alies in Children

H-G. Mesrobian, M.D., et at

101) The Mesonephric Duct-Ectodermal Ring

Relationship in the Embryology of the Ep-ididymal-Testicular Descent in Humans: A Computer Assisted Three Dimensional Reconstruction Study

D. S. Huff, M.D., et at

102) Prenatally Diagnosed Neuroblastoma:

Clinical and Biological Features

S.

J.

103) Testicular Teratomas in Prepubertal Boys

R. W. Grady, M.D., et at

104) The Role of Percutaneous

Nephrolithot-omy in the Management of Pediatric Renal Calculi

Y. Mor, M.D., et at

99m-Tc DMSA to Evaluate the Potential Long Term Parenchymal Damage

Associ-ated with Extra Corporeal Shock Wave

Lithotripsy (ESWL) in Children H. Lottmann, M.D., et at

106) Urolithiasis in the Exstrophy-Epispadias

Complex

R. I. Silver, M.D., et at

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107) 8:00 a.m.

124) 1:35 p.m.

9:33 a.m. 10:00 a.m.

5:00 p.m. Discussion 11:45 a.m. Clinical and Basic Research Prizes

5:30 p.m. Adjourn 12:00 noon Lunch Break

MONDAY, OCTOBER 28

H314 Section on Urology 8:00 a.m.-5:00 p.m.

Hynes Convention Center, Room 302

ABSTRACT PRESENTATIONS-ANDROLOGY

Moderators: Stanley

I.

Treatment with a LH-RH Analogue Fol-lowing Successful Orchiopexy Markedly Improves the Chance of Fertility Later in Life

F. Hadzisetimovic, M.D., et at

108) 8:07 a.m. Epididymal Cysts in the Pediatric

Popula-tion: Implications on Fertility A. Lois, M.D., et at

109) 8:14 a.m. Cryptorchidism and Hypospadias: No

Ev-idence of Additive Endocrinopathy H. M. Snyder, M.D., et at

8:21 a.m. Discussion

ABSTRACT PRESENTATIONS-HYPOSPADIAS

Moderators: Ronald Rabinowitz, M.D.; Gian-antonio Manzoni, M.D.

110) 8:30 a.m. The Bulbar Elongation Advancement

Mea-toplasty (BEAM) Procedure for Hypospa-diac Neo-Meatoplasty

H. Parkhouse, F.R.C.S., et at

111) 8:37 a.m. Long Term Results of “DUAGO”

Proce-dure for Distal Hypospadias P. Caione, M.D., et at

112) 8:44 a.m. Onlay Preputial Flaps Have Better

Out-comes in Comparison to Tubularized Flaps for the Repair of Severe Hypospadias

I.

113) 8:51 a.m. Nephrogenic Adenoma Following

Ure-thral Reconstruction Using Bladder Mu-cosa

K. Weingartner, M.D., et at

114) 8:58 a.m. Stentless Thiersch-Duplay Hypospadias

Repair with the Snodgrass Modification R. E. Steckler, M.D., et a!

115) 9:05 a.m. Tubularized, Incised Plate Urethroplasty for Proximal Hypospadias

W. Snodgrass, M.D., et at

116) 9:12 a.m. Autologous Fibrin Glue-Assisted Hypo-spadias Repair

P. 1. E!tsworth, M.D., et at

117) 9:19 a.m. Modified Corporoplasty for Congential Penile Curvature or Chordee

D. Rohrmann, M.D., et at

118) 9:26 a.m. Penile Orthoplasty Using Dermal Grafts in

the Outpatient Setting

I.

Break

10:15 a.m. Video Forum

Moderators: Anthony A. Caldamone, M.D., and George T. Ktauber, M.D.

ABSTRACT PRESENTATIONS-NEURO BLADDER

Moderators: Frank R. Cerniglia, Jr., M.D.; Hossein A. Aliabadi, M.D.

119) 1:00 p.m. “Normal” Age-Related Bladder Growth in Children with Myelodysplasia

L. S. Palmer, M.D., et at

120) 1:07 p.m. A Renal Size Nomogram for the

Myelome-ningocele Patient

R. W. Sutherland, M.D., et at

121) 1:14 p.m. Using Opening Pressure to Assess the

Va-lidity of Urodynamic Data Obtained From Standard Cystometrography

M. Kaefer, M.D., et at

122) 1:21 p.m. External Sphincter Dilation Improves

Bladder Compliance and Promotes Conti-nence: Validation with Toronto Bladder Nomogram

J.

123) 1:28 p.m. Initial Experience with Home Therapeutic

Electrical Stimulation for Bladder and

Bowel Continence in the Myelomeningo-cele Population

A. H. Batcom, M.D., et a!

Role of the Antegrade Continence Enema (With or Without Fecal Undiversion) in Managing the Most Debilitating Child-hood Recto-Urogenital Anomalies

C. A. Sheldon, M.D., et at

125) 1:42 p.m. The ‘Nonneurogenic’ Neurogenic Bladder

of Early Infancy

V. R. Jayanthi, M.D., et at

126) 1:49 p.m. Biofeedback Therapy for Dysfunctional Voiders

A.

J.

127) 1:56 p.m. The Urological Manifestations of the Hol-low Visceral Myopathies in Children R. Ghavamian, M.D., et at

2:03 p.m. Discussion

2:30 p.m. John K. Lattimer Lecture Robert L. Lebowitz, M.D.

3:10 p.m. Break

ABSTRACT PRESENTATIONS-TESTIS

Moderators: Stephen R. Shapiro, M.D.; Yuri Reinberg, M.D.

128) 3:20 p.m. Management of Neonatal Torsion

K.

J.

129) 3:27 p.m. Critical Analysis of the Clinical Presenta-tion of the Acute Scrotum: A 9 Year Expe-rience at a Single Institution

L. M. Perez, M.D., et at

130) 3:34 p.m. Influence of Surgical Approach and

Intra-operative Venography on the Recurrence of Adolescent Varicoceles: A Current Study and Outcome Analysis of the Liter-ature

L. S. Palmer, M.D., et at

3:41 p.m. Discussion

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133) 4:04 p.m.

134) 4:11 p.m.

ABSTRACT PRESENTATIONS-LAFAROSCOPY

Moderators: Craig A. Peters, M.D.; Steven G. Docimo, M.D.

131) 3:50 p.m. Laparoscopic Evaluation for Contralateral Patent Processus Vaginalis-Ill

E. B. Yerkes, M.D., et at

132) 3:57 p.m. Two-Stage Fowler-Stephens Orchidopexy

with Laparoscopic Clipping of the Sper-matic Vessels

D. B. Joseph, M.D., et a!

Laparoscopy for the Impalpable Testis: A Case for the Jones Approach

EL. Gheiter, M.D., et at

Retroperitoneoscopic Partial Nephrectomy in Infants and Children

P. A. Borzi, M.B.B.S., et at

135) 4:18 p.m. Laparoscopic Assisted Two Stage

Uretero-cystoplasty with Preservation of the Renal Units: A Pig Model

J.

4:40 p.m. Adjourn

ABSTRACTS

1

THE MANAGEMENT OF UNILATERAL POORLY

FUNCTIONING KIDNEYS IN PATIENTS WITH

POSTERIOR URETHRAL VALVES.

Young H. Kim, MD, Mark Horowitz, MD, AndrewJ. Combs, PA, Kenneth I. Glassberg, MD, FAAP. State University of New York, Health Science Center at Brooklyn, Brooklyn, NY

Background: In boys with posterior urethral valves (PUV’s), nonfunctioning and poorly functioning kidneys are frequently removed early in life to improve voiding dynamics when associ-ated with vesicoureteral reflux (VUR) and for control of infections. We have encountered boys with PUV’s and unilateral poorly functioning kidneys usually associated with varying degrees of VUR and have managed these patients with nephrectomy, reim-plantation and/or observation. We analyzed the eventual out-come of these patients in terms of clinical and urodynamic (UD) parameters in order to make some recommendations regarding their management.

Methods: Over a 5 year period, we studied 33 patients with PUV’s after valve ablation with serial multichannel urodynamic (UD) studies. Fourteen (42%) patients had unilateral poorly func-tioning kidneys (<10% of total renal function on nuclear renal scans) (8 left. 6 right), 12 of whom had VUR upon initial presen-tation. Only these 14 patients were included in this report. Six of the 14 (43%) had been initially treated with transurethral valve ablation (TURV). 6 (43%) by vesicostomy followed by closure and TURV, and 2 (14%) by pyelostomy followed by closure and TURV.

The 12 patients with ipsilateral VUR on initial presentation includes 7 grade 5, 2 grade 4 and 3 grade 3 VUR. All patients were followed as closely as possible with serial UD studies and aggres-sive medical management (anticholinergics, CIC, timed voiding, etc.) of abnormal UD parameters.

Results: There were no clinical sequelae from not removing I I of 14 kidneys with poor function. Three of 14 boys (21%), all initially treated with vesicostomy, required nephrectomy at a mean age of 21 months after a mean period of observation of 20 months be-cause of recurrent infections and ipsilateral grade 5 VUR. One of

these 3 required nephrectomy prior to vesicostomy closure. Four boys with ipsilateral grade 4-5 VUR underwent ureteral reim-plantation without sequelae. Another 5 had resolution of VUR with pharmacologic treatment of their UD abnormalities, with I of these 5 additionally requiring augmentation cystoplasty. Leaving the poorly functioning kidney in the 2 boys without VUR did not lead to any clinical problems.

Conclusion: On the basis of our findings, we feel that unilateral poorly functioning kidneys in PUV patients can often be safely preserved in the majority of patients without clinical sequelae including hypertension and pyelonephritis. In some patients, be-cause the contralateral kidney may not be optimal, it may be preferable to do a reimplantation rather than a nephrectomy. If attention is paid to treating abnormal UD findings prior to sur-gery, reimplantation can be safely performed. In fact, treating

abnormal UD findings may lead to spontaneous resolution of

VUR, as it did in 5 of the 12 reflux patients.

2

VURD SYNDROME; FACT OR FICTION?

Petor M, Cuckow FRCS, M.D., Dinneen MS FRCS, R.A. Risdon FRCPath, P.G.Duffy FRCSI, P.G. Ransley FRCS. Departments of Urology and Histopathology, Great Ormond Street Hospital for Sick Children NHS Trust, London, UK

Background: Persistent unilateral reflux into a non functioning dysplastic kidney following ablation of posterior urethral valves (PUV) is referred to as the Vesico-ureteral Reflux Dysplasia (VURD) syndrome. It is claimed that this “pop off” mechanism confers a protective effect on the contralateral non refluxing kid-ney and the prognosis for renal function is excellent. We have reviewed our experience of this condition over a 10 year period to examine this hypothesis.

Methods: The case notes of boys who presented with posterior urethral valves between 1980 and 1989 and who subsequently had

unilateral nephrectomy were reviewed (n=31). Non function was the indication for nephrectomy in all cases and their histology was reviewed by a single pathologist (R.A.R.). 12 of these patients had unilateral VUR persisting after valve ablation and fulfilled the

criteria for the VURD syndrome. Serum creatinine and glomerular

filtration rate (GFR) on follow up were analysed.

Results: Kidneys were resected between I and 72 months of age

and all were small, severely hydronephrotic and dysplasia. Plasma creatinine in the second year of life was normal in 8 of the 12 patients (67%) and abnormal in 4 (33%). GFR however, avail-able in 10 patients, was only normal (>100 ml/min/1.73m2) in 2 and was significantly reduced (<68ml/min/1.73m2) in the re-mainder (80%).

Conctusion: The VURD syndrome does exist but our data does not support its protective effect on contralateral renal function. We believe that the concept of preserved renal function may be incor-rect and confer a false sense of security in terms of the long term outlook. Patients with VURD syndrome, as with all cases of pos-terior urethral valves, require vigilant short and long term follow up.

3

PROGRESSIVE RENAL FAILURE IN CHILDREN

DIAGNOSED WITH POSTERIOR URETHRAL VALVES

DESPITE PROXIMAL URINARY DIVERSION.

Douglas N. Tietjen, M.D., James M. Gloor, M.D., FAAP,

Doug-las A. Husmann, M.D., FAAP. Rochester MN and Dallas TX

Purpose: Controversy persists regarding the management of posterior urethral valves (PUV) in infants who fail to normalize

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renal function following decompression of the lower urinary tract. In these instances, many authorities advocate proximal urinary diversion via cutaneous ureterostomy or pyelostomy for pro-sumed concomitant ureterovesical junction (UVJ) obstruction. In an effort to determine the true incidence of UVJ obstruction and the renal prognosis of these patients the following study was performed. Materia!s and Methods: We retrospectively reviewed the medical records of twenty-six male infants with a history of PUV that were referred to us for ureteral reconstruction following proximal urinary diversion between 1982-1996.

Results: All of the children involved in this study had their PUV diagnosed prenatally. Mean gestational age at time of delivery was 35 weeks, (range 27-40 weeks). All underwent initial lower urinary tract decompression via an indwelling urethral catheter. However, after an average of 7 days of drainage, (range 4-18 days) a persistently high serum creatinine was present, mean 2.5, range 1.9-3.5. All of the infants subsequently underwent proximal urinary diversion via cutaneous pyelostomy or ureterostomy. One month following diversion, the infants demonstrated an improved creatinine level, mean I .3, range 0.5-2.8. At one year of life a mean nadir creatinine level of 1.0 (range 0.3-2.5) was present. This improvement was limited in 11 infants (42%) who proceeded to develop advancing renal failure with 7 (27%) ultimately requiring renal transplantation, median follow up interval of 9 years, range 1-14 yrs.

At the time of ureteral reconstruction and/or nephrectomy (approx. 18 months of age), a standard Whitaker test was per-formed via the cutaneous pyelostomy in all 26 patients (52 renal units). Only two renal units (8%), both in the same patient, dem-onstrated obstruction. Interestingly, this patient has not yet dem-onstrated progressive renal failure. All I I infants with progressive renal failure demonstrated normal Whitaker test results.

Conclusion: In infants with a history of PUV and persistenfly elevated creatinines, proximal urinary diversion was associated with a high incidence of progressive renal failure during pro-longed follow up. This finding coupled with the relative absence of UVJ obstruction in these patients lead us to question the neces-sity of proximal diversion. Indeed, progressive renal failure in these infants may very well be the result of renal dysplasia inde-pendent of post-natal intervention.

4

MANAGEMENT OF POSTERIOR URETHRAL VALVE

PATIENTS ON THE BASIS OF URODYNAMIC FINDINGS.

Young H. Kim, MD, Mark Horowitz, MD, Andrew

J.

Background: The urodynamic (UD) findings of boys with pos-tenor urethral valves (PUV’s) has been previously reported. How-ever, there are no reports on the results of treatment of abnormal UD findings. We wished to determine the outcome of aggressive treatment of UD parameters.

Methods: Following valve ablation, twenty boys had multichan-nel UD studies both before and after therapy was started for abnormal parameters. The indications for these studies included lower urinary tract symptoms, persistent upper tract dilatation and routine follow-up. Impaired compliance or detrusor instabil-ity was treated with anticholinergics. Impaired bladder emptying was managed with clean intermittent catheterization (CIC). For each patient, we compared the initial UD study prior to starting treatment with the latest study after starting therapy. At the time of the initial UD study, vesicoureteral reflux (VUR) was noted in 12 boys, either by videourodynamics or voiding cystourethro-gram, including 2 bilateral grade 5, 5 unilateral grade 4-5, 1

bilateral grade 3, and 4 unilateral grade 2-3 VUR.

Results: Of the 20 boys, none had normal compliance (>30 ml/cm H2O); 2 had mildly impaired compliance (21-30 nil/cm H20); 2 had moderatedly impaired compliance (11-20 nil/cm H20); and 16 had severely impaired compliance (<10 nil/cm H20). Seven had impaired bladder emptying. All 20 boys were treated with anticholinergics and 7 were started on CIC. Following treatment, 7 had normal, 3 had mildly impaired, 5 had moderately impaired and 5 had severely impaired compliance. Detrusor in-stability was present in 16 patients (80%) prior to starting treat-ment and in 7 (35%) after treatment. Mean and median serum creatinine was 1.7 (0.4-6.8) mg% and 0.9 mg%, respectively, prior to starting therapy and 1.5 (0.5-7.2) mg% and 0.8 mg%, respec-tively, after treatment.

Out of 11 patients who presented with urinary incontinence, 8 (73%) became dry with therapy. All 20 patients presented with hydronephrosis, which resolved or improved in 16 (80%). Overall, 4 (20%) boys progressed to chronic renal failure (CRF). Of the 12 boys with VUR at the time of the initial UD study, VUR resolved spontaneously in 4 (2 unilateral grade 5, 1 unilateral grade 3 and 1 unilateral grade 2) and improved to grade I in 4 boys (1 bilateral grade 5, 1 unilateral grade 4, 1 bilateral grade 3 and I unilateral grade 3). In 3 patients (1 bilateral grade 5, 2 unilateral grade 4-5), VUR did not improve and required ureteral reimplantation. Two boys eventually underwent augmentation cystoplasty. An addi-tional boy was planned for augmentation but improved on anti-cholinergics and CIC to such a degree that augmentation was no longer considered.

Conclusion: In post valve-ablation patients, appropriate therapy including anticholinergics and CIC can be very effective in im-proving UD bladder parameters while decreasing lower urinary tract symptoms, upper tract dilatation and VUR, even of high grade on occasion. Only a longer follow-up will determine if this improvement in UD parameters will result in a decreased rate of progression to CRF. We recommend serial UD studies and aggres-sive management of abnormal bladder parameters with anticho-linergics and CIC in these patients.

5

NATURAL FILLING CYSTOMETRY IN SMALL BOYS WITH

POSTERIOR URETHRAL VALVES.

G. Holmdahl, U. Sill#{233}n,M. Bertilsson, G. Hermansson, K. Hj#{228}lm&s.Departments of Ped. Surgery and Ped. Chin. Physiology. Children’s Hospital, Goteborg, Sweden

Infant boys with posterior urethral valves (PUV) have a bladder dysfunction often characterized by hypercontractility and low bladder capacity. With time the pressure decrease, the capacity increase but instability remains unchanged, shown by repeated standard cystometries (CMG). In clinic, these boys often show frequent small voidings during daytime, few or no voidings dur-ing night and high bladder volumes in the morning. In order to understand this voiding pattern, which could not be demon-strated by CMG, we performed 24 hour urodynamic registrations.

Patients and method

Natural filling cystometry was performed in 15 boys, mean age 3.2 years (1-6), with PUV diagnosed as infants. Two suprapubic microtip catheters were inserted in the bladder and extravesically respectively, and connected to an ambulatory recorder for a mean time of 20 hours. The investigation started with a CMG.

Results: Instability was noted in all 15 boys. During day-time the number of unstable contractions were high, with high or moderate pressure levels, in 2/3 of the boys. During sleeping hours 4 of the boys were stable, I showed moderate and the remaining minimal instability, all with low pressure.

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Seven boys were unstable at CMG.

Voiding frequency was higher during day-time with a mean of 1.4 voidings/hour compared to 0.1 during sleep (5 boys did not void during night). In half of the patients it was difficult to distinguish between unstable contractions and polyphasic mic-turition contractions.

Voiding detrusor pressure was higher when the child was

awake, with a variation between 100 and 215 cm H20 (mean

lowest-highest), compared to voidings during sleep which varied between 80 and 130 cm H20. Mean voiding detrusor pressure at CMG was 80 cm H2O (20-180). Maximal voided volume during day-time was mean 95 ml (25-200) and less than the night-time voidings (including the first void in the morning) with a mean of 180 ml (40-415).

Conclusion

The natural filling cystometry in small boys with PUV reveals a pronounced instability with high detrusor pressure at the unstable contractions and micturitions during day-time, which is shown in only half of the cases with CMG. During sleep the bladders were mainly stable with low pressure at contractions. This instability during day versus night is probably an important factor contrib-uting to the frequent, small voidings during day and the dry nights with high bladder volumes. The polyuria, seen in more than half of boys with PUV, accentuates this bladder dysfunction.

6

ORAL DESMOPRESSIN (DDAVP): A RANDOMIZED,

DOUBLE BLIND, PLACEBO CONTROLLED STUDY OF

EFFECTIVENESS IN CHILDREN WITH PRIMARY

NOCTURNAL ENURESIS (PNE).

Steven

J.

Background: DDAVP nasal spray has proven efficacy in the treatment of PNE. Oral DDAVP tablets would provide a vehicle more easily used and convenient to our patients and their parents. This study evaluates the effectiveness of oral DDAVP in reducing the number of wet nights in patients with PNE. Methods: A double blind, placebo controlled, parallel group, multicenter trial of oral DDAVP in children, ages 5-17 years, with documented PNE was conducted. Patients were screened for number of wet nights for two weeks prior to study entry. A minimum of 3/7 wet nights per week for two consecutive weeks was required for study entry. Patients were randomized to one of four treatment groups: 200, 400, 600 mcg of DDAVP or placebo, given before bedtime. Fluids were restricted based on body weight, two hours prior to bedtime. The primary efficacy variable was the mean reduction in the number of wet nights recorded during the last two-week treat-ment period. The percentage of responding patients and mean reduction from baseline in number of wet nights at 2, 4, and 6 weeks were also assessed. Results: 141 patients from 14 centers were evaluated. The percent reduction in wet nights was 9% for placebo, and 20%, 30%, and 36% for the oral DDAVP, 200 400, and 600 mcg/day, respectively. The 600 mcg/day dose of oral DDAVP was statistically, significantly different from placebo in reducing wet nights (p = 0.006). A complete or near complete response (0-2

wet nights) was noted in 5% of the placebo group and 20%, 32% and 24% in the 200, 400, and 600 mcg/day oral DDAVP groups, respectively. The 400 mcg and 600 mcg treatment groups were statistically significantly different from placebo (P = 0.005, P =

0.039) A less than 50% reduction in wet nights was noted in 84%

of placebo and 77%, 62%, and 59% of the 200, 400, and 600

mcg/day oral DDAVP groups respectively. Oral DDAVP

exhib-ited a dose response in the treatment of PNE. The linear trend for the reduction in wet nights was statistically significant (p = 0.004).

Conclusion: Oral DDAVP at daily dosage of 600 mcg/day, when administered for six weeks significantly lowered the mean num-ber of wet nights. Higher dosage of Oral DDAVP may be

neces-sary for improved response. This study was funded by a grant from Rh#{244}ne-Poulenc Rorer.

7

DDAVP FOR NOCTURNAL ENURESIS IN THE SPINA

BIFIDA POPULATION.

Mark Horowitz, M.D., Dawn Libretti, RN, Andrew

J.

RPA-C. State University of New York, Health Science Center at Brooklyn, Brooklyn, NY

Background: Treatment of patients with spina bifida (SB) has evolved such that urinary continence is achieved with preserva-tion of upper tracts. Patients on clean intermittent catheterization-(CIC) and anti-cholinergics can usually stay dry and maintain detrusor pressures(Pdet) less than 40 cm of H2O if they do CIC every 4-6 hours. Patients that can not achieve continence or keep Pdet less than 40 cm of H2O while on this schedule of CIC ± anti-cholinergics, require bladder augmentation. Despite high suc-cess rates in both groups with respect to daytime continence and lowering bladder pressures, we have treated 14 patients over the past 2 years with persistent nocturnal enuresis. At this time the options for these patients are waking in the middle of the night to catheterize, wearing diapers/pads or leaving a catheter in over-night. Little has been written about nocturnal enuresis (? primary) in this group of patients.

Methods: Over the past two years we treated fourteen spina bifida patients with day and night urinary incontinence. All pa-tients that were dry between CIC despite the compliance, capacity and leak point pressure of their bladders were excluded. All

patients were evaluated with renal/bladder sonography and

videourodynamics(VUDS). Patients not already on medical ther-apy were treated with C!C ± anti-cholinergics and those that failed medical therapy or were already on maximum therapy required bladder augmentation ± sling/sphincter. Patients with good bladders that wet because of poor outlets were treated with a bladder outlet enhancing procedure only. All patients were then reevaluated with VUDS, renal/bladder sonography and voiding

calendars. Patients with daytime continence between CIC that had

nocturnal enuresis were treated with DDAVP(20-4omcg qhs).

Morning catheterized amounts were recorded to insure that pa-tients evening volumes were not high enough to cause dangerous Pdet.

Results: The mean age of patients was I 0.5 years with a range of 7-14 years. Of the 14 patients, 9 achieved daytime continence on medical therapy and 5 went on to augmentation (1 with a bladder neck sling). All 14 had persistent nighttime wetting and 12 of 14 patients were dry at night on DDAVP with a mean dosage of 30 mcg qhs. The other two patients were kept dry by having them wake in the middle of the night to catheterize. All twelve patients had AM. catheterized volumes that corresponded to low Pdet on their VUDS and all had unchanged renal sonograms.

Conclusions: DDAVP should be considered in the spina bifida patient with persistent nighttime wetting. Patients are much hap-pier and no longer need to wear pad/diapers at night or to wake in the middle of the night to catheterize.

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8

TREATMENT OF REFRACTORY MONOSYMPTOMATIC

NOCTURNAL ENURESIS WITH COMBINATION THERAPY

OF DESMOPRESSIN AND IMIPRAMINE.

Yuri Reinberg, MD, FAAP, Mary Vaughn, RN. Pediatric Surgical Associates, Ltd., Children’s Health Care, Minneapolis, MN

Background: To determine if monosymptomatic nocturnal en-uresis previously refractory to either imipramine or desmopressin can be alleviated using combination therapy, we conducted a prospective study of 15 children who previously failed therapy with each of the study medications used separately.

Methods: Fifteen children, 8 boys and 7 girls (age range 8 to 16 years; mean age of 11), entered the study. All patients previously failed monotherapy of either desmopressin or imipramine. Eight patients failed oxybutynin therapy as well. All of the patients had a normal urologic evaluation. None of the patients suffered from diurnal enuresis. All of the patients had a normal EKG. One patient had encopresis and one had previous ureteral reimplan-tation.

Results: Eleven children are dry (2 or fewer wet nights in 14 days). In three children, the symptoms are improved (greater than 50% reduction in wet nights). Side effects induded fatigue in two patients and headache in two patients and were not significant enough to stop the medications. The only nonresponder (encopre-sis patient) did not have side effects from medications.

Conclusion: Combination therapy of desmopressin and imipra-mine appears to be effective in patients who previously failed monotherapy with the same agents. We did not encounter any significant side effects with a desmopressin dose of up to 50 mcg and imipramine doses of up to 50 mg at nighttime. Combined therapy of desmopressin and imipramine should be considered in patients who previously failed either of these agents.

9

BLADDER EXSTROPHY : IS IT POSSIBLE TO ACHIEVE

CONTINENCE WITH SPONTANEOUS VOIDING? A

RETROSPECTIVE STUDY OF 57 CASES.

Henri Lottmann, MD, Yves Melin, MD, Pierre Beze-Beyrie, MD, Jean Cendron, MD. Dept of Pediatric Urology, St. Joseph Hospi-tal. Paris, France

Background: Achieving a complete reconstruction in the exstro-phy epispadias complex is a technical challenge and criteria for success are still not well defined. Amongst a cohort of 150 patients treated at our institution for bladder exstrophy during the last 35 years, most patients had a cutaneous or intestinal diversion; how-ever we could review retrospectively the files of 57 patients (42 males-15 females) who had a complete reconstruction. Methods: The usual sequence for reconstruction was: bladder closure, anti-reflux procedure, bladder neck reconstruction (BNR) and finally in the male population epispadias repair; only a few years ago we started to perform the antireflux procedure at the time of BNR and 5 male patients had an epispadias repair (according to Cantwell Ransley) prior to BNR. Except 7 patients closed on the first day of life and 2 patients closed at I week, the mean age for bladder closure was 1.7 year (1 month-13 years); 10 patients had a pelvic osteotomy at the time of bladder closure; 13 patients needed 2 and 5 patients needed 3 closures. The mean age for BNR was 10 years (6.5-20 years); 9 patients had 2 BNR. The technique chosen for BNR was a classical Young Dees (YD-48) or a Mollard modified YD (18); 4 patients needed subsequently a urethral dilatation and 3 patients had a “bladder neck” endoscopic resection ;7 patients needed a bladder augmentation (sigmuid 4, ileon 3). Results : With a mean follow up of 12 years after BNR(1-28 years), 22 patients

(39%) have a good result (interval of dryness of 3 hours or more during the day, dry at night with 0-1 nocturnal micturation-normal upper tract). 16 patients (28%) have an acceptable result (minimal stress incontinence, nocturnal leakage, normal upper tract); amongst these patients 5 have a short follow up (less than 2 years) and are still improving and one patient is dry but under CIC. Finally, 19 patients (33%) have a poor result and 13 have been diverted for upper tract dilatation, major dysuria or persisting severe incontinence. During the long term follow up bladder stones was the main encountered complication (13 patients) and 3 patients had a loss of continence (complete in one case) after epispadias revision. Considering criteria to achieve a good or acceptable continence, the results were better in the male (71%) than in the female population (53%); a delayed closure was not a pejorative factor and a reclosure slightly reduced the success rate (from 67% to 61%); a pelvic osteotomy allowed to achieve a good or acceptable result in 9 upon 10 cases (90%). Both techniques for BNR gave similar good or acceptable results (Yound Dees : 67%-Mollard 80%); it was more difficult to achieve continence when the BNR was performed before the age of 8 years and repeated BNR gave disappointing results (4 acceptable, 5 poor). Conclusion: to our opinion it is possible to achieve a good continence, spontane-ous voiding, no residue, associated with a normal upper tract in the exstrophy patients; an experienced team, a good familial sup-port and strong motivations from the child are essential; however, it is difficult to analyze the features of success and failure, and the final result is most of the time unpredictable.

10

THE ARTIFICIAL URINARY SPHINCTER IN CHILDREN

WITH BLADDER EXSTROPHY AND EPISPADIAS

Mor Y., Nauth-Misir R.R., Keeble S.J.H., Lungley A.J.G, Ransley P.G. The Institute of Urology and Nephrology, St. Peter’s Hospi-tal, London, UK

Background: To review the long term experience of implantation of artificial urinary sphincter (AUS) in exstrophy-epispadias pa-tients whose bladder necks had been prepared for the procedure by being wrapped with omentum and silastic sheath.

Methods: Twenty artificial urinary sphincters were implanted into children with bladder exstrophy (13) or epispadias (7) be-tween 1984 to 1992. There were 17 males (11 exstrophy, 6 epispa-dias) and 3 females (2 exstrophy, I epispadias). Age at operation ranged from 7 to 20 years with a median of 11 years. In 17 patients the operation was performed for persistent incontinence following bladder neck reconstructions (BNR) including 15 Young-Dees re-constructions and 2 bladder neck plications. Omental and silastic wrap had been undertaken as a preliminary stage to sphincter placement in 14 children. In 12 cases the AUS was implanted in a one stage operation while in the remaining 8 children a 2 stage operation was used. Twelve patients have bladder augmentation.

Results: Follow up period ranged between 36 to 126 months. Of the 20 devices implanted 4 (20%) had to be removed 6-38 months after AUS activation. In 3 patients, mechanical problems were detected during follow-up requiring replacement of the whole system or components of it. Other complications included an artificial sphincter infection which was successfully conservatively treated (1), development of a poorly compliant bladder and bilat-era! hydronephrosis (1), unilateral hydronephrosis and functional loss (1) and major voiding difficulties requiring creation of a Mitrofanoff channel (1). In terms of function, there are 16 of the original 20 sphincters still in place (in 1 case only the cuff is still in situ) after an average follow-up period of 75 months. Twelve of those patients void spontaneously while 4 patients empty their bladders by clean intermittent catheterisation (CIC).

Conclusion: The AUS has a small but definite role in the

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agement of patients with bladder exstrophy and epispadias. Care-ful selection and surgical preparation may improve the success rate even further and widen its application allowing more patients with augmented bladders to void spontaneously.

11

MODIFIED TECHNIQUE FOR BLADDER NECK CLOSURE

AS A SALVAGE PROCEDURE FOR INTRACTABLE

INCONTINENCE IN CHILDREN.

Sanjiv K. Agarwal, MD, Antoine E. Khoury, MD, FAAP, Darius

J.

Background: Effective bladder neck closure is a challenge in children with intractable incontinence. It is often fraught with significant complications such as leak or fistula. We describe a modification in the technique that has overcome these complica-lions. Methods: 10 patients (myelomeningocele (5), exstrophy (4), and VATER syndrome with atretic urethra (1)) with either multi-pie previous procedures or poor quality urethral tissue underwent the modified bladder neck closure, Mitrofanoff appendicovesico-stomy with or without augmentation. Previous procedures in-cluded: bladder neck reconstruction (3), vaginal sling (2), artificial urinary sphincter (1), urethropiasty (1). At the time of bladder neck closure, 9 patients underwent concomittent augmentation, and 4 patients bilateral reimplantation. Modification in the stan-dard technique of bladder neck closure included an anterior in-verted T shaped bladder incision and wide mobilization of the bladder neck from the vagina in females and the rectum in males. This modification provided at least a 2 cm. posterior leaf of blad-der neck, helped bring the suture line anteriorly in a transverse fashion without tension. In patients who received an augment, small bowel was anastomosed to the mobilized posterior shelf thereby forming the anterior suture line. This tension free closure was specially important considering the extensive scar from pro-vious surgeries resulting in poor quality of tissue available. Omen-tal or perivesical vascularised tissue was used to cover the suture line. Results: All the 10 patients who underwent the above proce-dure in the last 5 years (mean follow up = 30 months) are

conti-nent. In the follow up period none of the patients developed fistula or leak. Three patients formed bladder stones, 3 developed Mitrofanoff stenosis requiring revision, and 1 developed an in-fected VP shunt requiring removal. The cosmetic and functional results of the umbilical stoma have been satisfactory. Conclusion: This technique of modified bladder neck closure is an extremely gratifying procedure in this complex group of patients resulting in continence with minimum complications.

12

PLACEMENT OF A BLADDER NECK PURSESTRING CUFF

FOR THE MANAGEMENT OF INCONTINENCE IN

CHILDREN WITH MYELODYSPLASIA.

Ira Kohn M.D., Roy Balsara M.D., Hyman Rabinovitch M.D., F.A.A.P. Division of Urology, St. Christopher’s Hospital for Chil-dren, Philadelphia, PA

Background: Numerous surgical procedures have been devel-o_ in an attempt to increase bladder compliance and/or outlet resistance for the treatment of intractable incontinence in children with neurogenic lower urinary tract dysfunction. Injection of peri-urethral bulking agents, fascial slings, artificial urinary sphincters and bladder neck reconstruction procedures have been reported with variable rates of continence and longevity. We report our

experience with the development of a biocompatable pursestring cuff to increase outlet resistance by providing circumferential compression at the bladder neck.

Methods: A total of 12 children (6 male, 6 female) with myelo-dysplasia and persistent incontinence despite clean intermittent catheterization (CIC) and pharmacotherapy underwent urody-namic testing and cystoscopy that revealed small capacity neuro-gemc bladders with concomitant intrinsic sphincter deficiency. At the time of augmentation cystoplasty through an anterior ap-proach the bladder neck was mobilized and wrapped with 5mm Goretex tubing. 5mm mersilene tape was then placed circumfer-entially within the Goretex tubing lumen, pursestringed under tension with a silastic tubing shod to appose the mucosa of the bladder neck, and secured under such tension with a surgical clip. Results: I I of 12 children (age range at time of operation 2.5-16 years old) are totally continent on CIC without need for additional pharmacotherapy in follow-up ranging 3 months to I I years. One cuff had to be surgically removed secondary to transvaginal ero-sion. One child with recurrent post operative incontinence had the cuff retightened through a minor surgical procedure and has remained dry. Annual renal ultrasounds reveal stabilization of upper urinary tracts throughout follow-up. Post-operative urody-namic studies reveal increased bladder capacity, decreased intra-vesical pressures, and increased leak point pressures.

Conclusion: This pursestnng bladder neck cuff in combination with augmentation cystoplasty provides excellent, durable conti-nence rates in children with myelodysplasia and neurogenic blad-ders. Attributes of the cuff are: it is relatively inexpensive and easy to construct; it does not change the angle of the bladder neck making catheterization easy; and it is adjustable in cases of recur-rent incontinence.

13

SELF-SEALING MEMBRANE SYSTEM FOR THE

ENDOSCOPIC TREATMENT OF INCONTINENCE.

James

J.

Background: The endoscopic treatment for urinary incontinence in children is limited by the injectable substances currently avail-able. The ideal injectable material should be able to conserve its volume, be nonmigratory and non-antigenic. Towards this goal, we developed a catheter with an inflatable and self-sealing sili-cone membrane which would fit through a 19G cystoscopic nee-dle. Polyviny!pyrrolidone (PVP), a hydrophilic carrier which is a biologically compatible substance, was chosen as the filling mate-rial. Herein we present our experience with this system.

Methods: 22 female beagles were utilized. All dogs underwent cystoscopy and 16 had a self-sealing membrane placed endoscop-ically in the submucosal region of the proximal urethra at the 3 and 9 o’ clock positions. Each membrane was inflated through the delivery catheter with 0.2cc of PVP. The delivery catheters were withdrawn, leaving the self-sealing membrane in place. Coapta-tion of the urethra, derived by the relative bulking effect of the inflated membrane, was confirmed in each animal. 6 animals served as controls, receiving only a saline injection. 12 animals were sacrificed at 1,3, and 6 months. Other animals were followed for a total of 12 months. At the time of sacrifice, gross and histological examinations were performed.

Results: At retrieval, the membrane remained inflated at the same position as the initial placement. There was no evidence of PVP volume loss or extravasation. The membranes were encap-sulated by a fibrous capsule. There were only a few inflammatory cells surrounding the capsule by I month and none by the third month. Histological examination of periurethral tissue and distant

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