Long-term management of patients who have had urinary diversions into colon

Long-term management of patients who have had urinary diversions into colon

685 INTERNATIONAL ABSTRACTS diagnosis varied from 7 months intrauterine to 7 years postnatal, and the mean duration of follow-up was 9 years. Of the...

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685

INTERNATIONAL ABSTRACTS

diagnosis varied from 7 months intrauterine to 7 years postnatal, and the mean duration of follow-up was 9 years. Of the children, 40% had retardation of growth by the end of the follow-up period, and 44% had end stage renal disease. Of the various factors, delay in diagnosis and the association of persistent vesicoureteral reflux seem to predict eventual end stage status. In 18 of 25 children the diagnosis of posterior urethral valves was made before they were 2 years old. Only five of these children have reached end stage disease status. In comparison, of seven children whose diagnosis was delayed beyond 2 years, six have end stage disease (P < .01). Similarly, seven of nine children with persistent reflux had end stage disease compared with four of 16 who did not have persistent reflux (P < .Ol ).--George Holcomb, Jr Massive Vesicoureteral Reflux Mimicking Posterior Urethral Valves in a Fetus. K.L. Reuter and R.L. Lebowitz. J Clin Ultrasound

13:584-587, (October), 1985. A case of fetal bilateral hydronephrosis with an unchanging bladder volume over eight hours led to the presumptive diagnosis of posterior urethral valves by maternal ultrasound at 24 weeks gestation. Weekly ultrasound examinations showed no change until a study at 34 weeks indicated a slight increase in the fullness of the pelves and calyces. Amniotic fluid volume remained normal. Because of the slight increase in dilatation of the fetal urinary collecting system, early delivery was recommended and a cesarean section was subsequently performed. Postnatal evaluation revealed duplex collecting systems, lower pole dilatation, and massive reflux into each lower collecting system. There was no evidence of obstruction. It is incorrect to assume that dilatation of the fetal urinary tract necessarily means obstruction, and this sole diagnostic criteria should not govern perinatal management of the affected fetus and m o t h e r . ~ c o t t Adzick Endoscopic Correction of Primary Vesicoureteric Reflux: Results in 9 4 Ureters. B. O'Donnell and P. Purl. Br Med J 293:1404-1406,

(November), 1986. Sixty-one patients with primary vesicoureteric reflux were treated by endoscopic injection of Mentor Polytef paste. Seventy-six of the 94 treated ureters showed complete disappearance of vesicoureteric reflux after one injection. Eight refluxing ureters required a second injection, one required a third, and one a fourth. Six ureters showed improvement in the grade of reflux after the first injection. Two ureters did not show any change in the grade of reflux after endoscopic injection. The amount of paste injected to correct reflux in the 94 ureters varied from 0.1 to 1.0 mL (mean 0.33 mL). Patients were followed up for 3 to 25 months (mean 13.4 months). Follow-up micturating cystograms in the 94 ureters showed absence of reflux in 83. Eleven ureters showed recurrence of reflux. Recurrence of reflux was attributed to early technical difficulties and to insufficient amounts of polytef paste used in some cases. Follow-up urograms did not show evidence of ureteric obstruction in the treated ureters. Endoscopic injection of polytef paste is a safe, simple, and effective procedure for primary vesicoureteric reflux and averts the need for open operation.--Takao Fujimoto Comparative Results of Ileal and Colonic Conduits--Analysis of 50 Children with Extrophy of the Bladder, M. Gharib, R. Engelskir-

chen, J.A. Bliesener, et al. Z Kinderchir 41:214-218, (August), 1986. The authors report on a series of 50 children who were operated on for bladder extrophy. Fifteen received ileal conduits and 12 colonic conduits. Late complications, such as stomatostenosis, conduit elongation, stenosis of the ureterointestinal anastomosis, stone formation in the conduit, and recurrent urinary infections occurred only in ileal conduits. No late complications requiring reoperation were seen in

colonic conduits. One adenocarcinoma with fatal outcome was seen secondary to ureterosigmoidostomy. The authors recommend, therefore, the colonic conduit as method of choice in children with bladder extrophy where primary closure is not possible or the bladder area is too small or already epithelialized. This approach offers the safest long-term protection of the primarily normal upper urinary t r a c t . Thomas A. Angerpointner Long-term Management of Patients Who Have Had Urinary Diversions Into Colon. S.H. Silverman, C.R.J. Woodhouse, J.R. Stra-

chan, et al. Br J Urol 58:634-639, (December), 1986..~ Thirty-four patients with urinary-colonic diversions have been following for 13 to 41 years (mean 20.3). The most common long-term complication was hyperchloraemic acidosis (50%). The most serious was neoplasm at the anastomotic site: benign lesions occurred in three patients (9%) and carcinomas in two (6%). Staining for sialomucins in colonic biopsies adjh'cent to the anastomoses was positive in 17 of 19 patients. It has been suggested that this represent a premalignant change. Analysis of fecal flora in 17 diverted patients and 27 controls revealed a significant difference in the carriage rate and viable count of Peptostreptococcus species. This finding has not been reported previously, and the species could have a role in the etiology of the neoplasms.--Prem Purl Sonographic Detection of Fetal Urinary-Tract Anomalies. R.W.

Quinlan, A.C. Cruz, and J.F. Huddleston. Obstet Gynecol 67:558565, (April), 1986. This report details 19 cases of fetal urinary tract malformation diagnosed during a 30-month period. Early onset and more complete obstruction, oligohydramnios, renal dysplasia, and pulmonary hypoplasia occurred frequently in this series. Before the consideration of any corrective in utero procedure, intensive evaluation of fetal renal function and a search for associated structural and functional problems should be performed.--Scott Adzick Catheter Shunts for Fetal Hydronephrosis and Hydrocephalus. F.

Manning, M.R. Harrison, C. Rodeck, et al. N Engl J Med 315:336340, (July), 1986. This is a summary report of catheter decompression for fetal hydronephrosis and hydrocephalus from the International Fetal Surgery Registry. In the period 1982 to 1985, 73 placements of catheter shunts for fetal obstructive uropathy and 44 drainage procedures for obstructive hydrocephalus were reported to this voluntary registry. The attempts to decompress the obstructed fetal urinary tracts resulted in the survival of 30 fetuses (41%), with a procedure-related death rate of 4.6%. Of 21 fetuses with posterior urethral valves, 16 (76.5%) survived. Pulmonary hypoplasia was the major cause of death in both treated and untreated fetuses with obstructive uropathy. Of the 29 neonatal deaths, 27 (all of which occurred within six hours of delivery) were due to pulmonary hypoplasia with respiratory insufficiency. Improved understanding of the pathophysiologic aspects of pulmonary hypoplasia is crucial to the selection of appropriate cases for therapy in utero. Although the natural history of fetal obstructive uropathy has not been well studied, the outcome for intervention for selected fetuses with posterior valves is encouraging. The results of shunt procedures for obstructive hydrocephalus were less encouraging. Although 34 of 44 fetuses (77%) survived, the procedure-related death rate was 10.25%. Eighteen of the 34 survivors (52.9%) have serious neurologic handicaps, 4 (11.8%) have less severe handicaps, and only 12 are developing normally. The authors note that analysis of data from this registry has guided the early development of fetal surgery, but it cannot establish the efficacy of the procedures because of selection bias. It is now mandatory to put these experimental treatments to the test of prospective controlled trials.--Scott Adzick