Intravesical botulinum type-A toxin (Dysport®) in the treatment of idiopathic detrusor overactivity in children

OBJECTIVE

Botulinum type-A toxin is increasingly used for refractory idiopathic detrusor overactivity (IDO) in children. We reviewed our experience and sought to ascertain the influence of dose and functional bladder capacity on outcome.

PATIENTS AND METHODS

Thirty patients, aged 6-16 years, with urodynamically proven IDO, had intravesical injections of 400-500 iu of Dysport(®). Outcome was assessed clinically at least 5 months after the injection.

RESULTS

Data were available for 27 patients. Urinary frequency was improved in 10; nocturia was improved in 7. Urgency resolved in 10 patients and urge incontinence in 12 (44%). Complications reported were UTI (7), urinary retention (1) and bladder pain (1). The dose of Dysport(®) used was not significantly higher (14 iu/kg v 13 iu/kg) in patients dry at follow up than in those who remained wet (p = 0.45). Functional bladder capacity was not significantly different in patients dry after treatment (p = 0.82).

CONCLUSION

This retrospective study demonstrates similar response to a single treatment with intravesical Botulinum type-A toxin to previous series. We did not demonstrate a correlation between dose or functional bladder capacity and resolution of incontinence. A multi-centre study is required to further investigate this promising treatment.

Aetiology and treatment of symptomatic idiopathic urethral strictures in children

OBJECTIVE

To report the presentation and treatment outcomes on a series of 12 paediatric bulbar or posterior urethral strictures that were possibly congenital in origin, identified in a 9-year period.

METHODS

A retrospective case-note review of all cases of urethral strictures thought to be congenital in origin, prospectively collected into the departmental database.

RESULTS

The age at presentation had a bimodal distribution with 6/12 presenting in the first year of life of which four had antenatal hydronephrosis and 5/12 presenting after the age of 11 years. All six patients under 1-year old had a successful outcome following urethrotomy and urethral dilatation. Four of five over 11 years of age ultimately required an urethroplasty and one 3-year-old may well require an urethroplasty in the future.

CONCLUSION

This outcome, in conjunction with the bimodal age distribution at presentation, would suggest a different aetiology in older children, and we would urge caution in classifying strictures in ambulant children as genuinely congenital, as this population may represent the long-term manifestation of unrecorded bulbar urethral trauma or asymptomatic inflammation. Optical urethrotomy or dilatation is durable when treated in infancy, but older patients do not experience prolonged resolution and we would recommend treatment along adult lines for these.

Femoral nerve neuropathy following the psoas hitch procedure

OBJECTIVE

To present two cases of femoral nerve neuropathy following a psoas hitch procedure performed during Leadbetter-Politano ureteric reimplantation, and emphasize the importance of this rare complication.

PATIENTS

Two 2-year-old boys with complex urological histories underwent Leadbetter-Politano ureteric reimplantations with a psoas hitch using non-absorbable sutures independently in Turkey and the UK. Postoperatively both developed a femoral nerve palsy, which required re-exploration and removal of the sutures. In the first case the femoral nerve was not identified, but in the second case re-exploration revealed the femoral nerve stretched by the nearby suture. Both boys made a full recovery from their neuropraxia.

CONCLUSION

These two cases illustrate the potential for nerve involvement with the psoas hitch manoeuvre, and the importance of early recognition of this complication. It is recommended that if a psoas hitch procedure is performed great care should be taken to identify the nerves, and if none are seen then the sutures are placed superficially into the belly of the muscle as the nerves may be sited deeper within it.

Intrathoracic gastric volvulus mimicking pyloric stenosis

A 5-week-old-infant presented to hospital following the acute onset of non-bilious vomiting with clinical and acid-base features suggestive of pyloric stenosis. A chest radiograph obtained because of intercurrent infection unexpectedly revealed a left-sided congenital diaphragmatic hernia. A barium meal demonstrated the presence of an intrathoracic gastric volvulus, requiring urgent surgical management. We discuss the presentation and management of this rare surgical cause of non-bilious vomiting in infancy.

SYNCHRONOUS BLADDER RECONSTRUCTION AND ANTEGRADE CONTINENCE ENEMA

PURPOSE

We assess the long-term outcome of synchronous bladder reconstruction and antegrade continence enema in a large series of patients.

MATERIALS AND METHODS

We retrospectively reviewed records of the last 50 consecutive patients treated at 1 unit in Southampton and 1 in Denver.

RESULTS

A total of 46 patients were available for analysis, including 24 from Southampton and 22 from Denver. Median patient age at operation was 12 years (range 4 to 30), median followup was 44 months (range 7 to 100), and 80% of patients had neuropathy and anorectal malformation. A variety of bladder reconstructive procedures were performed and 58% of patients underwent a simultaneous Mitrofanoff procedure. Fecal and urinary continence was achieved in 76% of patients but the rate of revision surgery was high. The most common complication was stomal stenosis (17%). Secondary procedures consisted of refashioning urethral length, closure of the bladder neck, bladder augmentation and conduit revision.

CONCLUSIONS

It is now possible to produce double continence in some patients with synchronous combined surgery, a goal that was not achievable without colostomy before the development of the antegrade continence enema in 1990. However, the surgery is demanding with high revision rates and we emphasize that it should only be performed in patients who are highly motivated and have reasonable dexterity and intelligence. This careful patient selection is confirmed by the fact that surgery was performed on 2 to 3 patients a year at each unit. This surgery should only be performed at facilities which can provide long-term patient followup.

Thoracoscopy for empyema in children

METHODS

During a 19-month period, seven children with empyema underwent thoracoscopy. The average age was 7.5 years (range, 3 to 15 years) and the duration of illness before surgery 16.5 days (range, 7 to 42 days). All patients received preoperative antibiotics, underwent ultrasound or CT scan and thoracentesis. Two patients had preoperative intercostal tube drainage. Indications for operations were lack of response to antibiotics of loculation of pleural fluid on imaging. All procedures were performed under general anesthesia with a single lumen tube.

RESULTS

Thoracoscopy allowed for good access and complete clearance in two patients. In the remaining patients, thoracoscopy failed to clear the disease because of difficulty with access, instrumentation, and clearance of thick debris. These patients underwent thoracotomy with two requiring decortication.

CONCLUSIONS

This experience suggests that even in the early stage of empyema formation, thoracoscopy is not as effective as thoracotomy. Larger experience and studies are required to define the place of thoracoscopy in the management of childhood empyema.

The use of the detrusorrhaphy for vesico-ureteric reflux: the way forward?

OBJECTIVE

To assess the outcome of all detrusorrhaphies carried out for simple single-system vesico-ureteric reflux (VUR) in children at one institution over a 4-year period.

PATIENTS AND METHODS

Twenty-nine patients (11 boys, 18 girls, 43 renal units; mean age at presentation 23 months; range, antenatal to 72 months) were analysed in two groups. Group 1 comprised those undergoing asynchronous bilateral procedures (two patients, four units) and unilateral procedures (15 patients, 15 units), and group 2, those undergoing synchronous bilateral procedures (12 patients, 24 units). The mean (range) follow-up was 17 months (6-39) and 15 months (7-24), respectively.

RESULTS

Three patients had antenatal hydronephrosis related to VUR post-natally and 26 had urinary tract infections (13 recurrent, one with haematuria, seven 'breakthrough', one with calculi and four with enuresis). The mean age at operation was 54 months (range 14-167). The mean (range) duration of anaesthesia was 69 min (40-120) in group 1 and 80 min (65-120) in group 2. All patients were catheterized urethrally for a mean (range) duration of 3 days (2-4) in group 1 and 5 days (2-15) in group 2 and the mean hospital stay was 3 days (2-6) and 6 days (4-16), respectively. Post-operative complications occurred in 14 patients including one bladder spasm, five urinary tract infections, two with urinary retention, three with haematuria and one each of pneumonia, epididymo-orchitis, anuria, failure to stent and conversion to Cohen reimplantation. Operative success and clinical success were similar within groups but differed between groups, although not significantly (15 of 17 in group 1 and eight of 12 in group 2).

CONCLUSION

Unilateral but not synchronous bilateral detrusorrhaphy seems an appropriate surgical treatment for VUR.

Urea production in normal breast-fed infants measured with primed/intermittent oral doses of [15N, 15N]urea

Urea kinetics were measured on 11 occasions in six normal, breast-fed infants aged 29-88 days. Prime and intermittent oral doses of [15N, 15N]urea with measurement of enrichment of urea in urine were used. The rate at which urea appeared in the urea pool was 265 mgN/kg per hour, 85% of which derived from endogenous production and 15% from the diet. Urinary excretion of urea was 87 mgN/kg per hour. Therefore, 60% of the urea entering the pool each day was hydrolysed by the metabolic activity of the colonic microflora and the nitrogen was made available for further metabolic interaction. The rate of urea appearance and the extent to which urea nitrogen was salvaged were greater in infants under 6 weeks than in those over 6 weeks, indicating that urea kinetics is a more active process at an early age, and slows with time. With respect to factors influencing urea kinetics, the apparently conflicting results which have appeared in the literature may be explained. The results may help explain the growth of breast-fed infants on low protein intakes.

Gastroschisis bowel in an intact exomphalos: implications for etiology and possible prevention

The etiology of changes in the bowel in gastroschisis is unknown. A case of exomphalos is described, in which the bowel had a gastroschisis-like appearance. The possibility of a vascular mechanism as the cause is discussed.

The STING in the refluxing duplex system

OBJECTIVE

To assess the efficacy of the subureteric Teflon injection (STING) procedure in the refluxing duplex ureter.

PATIENTS AND METHODS

The STING procedure was performed in 23 patients (five boys and 18 girls, mean age 6.5 years, [range 1.5-14]) with six refluxing upper and 31 refluxing lower moieties. Teflon was injected separately into each moiety of the duplex. All patients were assessed by a micturating cystourethrogram and ultrasonography at least 3 months after treatment and the results were analysed retrospectively for the success rate of each refluxing unit and the overall cure rate of patients.

RESULTS

No patient suffered ureteric obstruction. After the first STING the unit cure rate was 57% but only nine of 23 patients were completely cured. This improved to a unit cure rate of 68% and 11 patients cured after a second STING.

CONCLUSION

Because the patient cure rate was poor we do not advocate using the STING to treat vesicoureteric reflux in the duplex kidney.

Wilms' tumour and hypertension: incidence and outcome

OBJECTIVE

To determine the incidence and outcome of hypertension associated with Wilms' tumour and to reduce peri-operative morbidity by appropriate treatment.

PATIENTS AND METHODS

The medical and nursing case-notes of 17 consecutive patients with Wilms' tumour treated over a 5.5 year period (1989-1994) were analysed retrospectively.

RESULTS

Ten of 17 patients had hypertension, with a mean blood pressure of 150/103 mmHg (130-220 mmHg systolic and 85-145 mmHg diastolic). There was no significant difference between the hyper- and normotensive patients in their mode of presentation. Blood pressure was stabilized preoperatively in all the hypertensive patients. Perioperative monitoring in these patients was performed using arterial and central venous pressure lines. No patient had any peri-operative hyper- or hypotensive episodes caused by handling the tumour or after nephrectomy. Thirteen patients had a favourable histological diagnosis and all the hypertensive patients were in this group. The blood pressure of all patients returned to normal within 1 month of surgery.

CONCLUSION

Both the recognition of hypertension and appropriate peri-operative treatment is mandatory for the safe surgical management of this condition.

Thromboembolic events in a severely burned patient

A patient with severe burns suffered spontaneous bilateral peripheral arterial thromboses which were successfully treated with recombinant human tissue plasminogen activator (rt PA) (Actilyse). The patient later died from complications of burns.