Abstract: Many diagnostic procedures, while necessary and appropriate, may be experienced by a child as a trauma. Health care professionals often perceive invasive procedures such as surgery and needle biops...

Abstract: Printed in J. Urol., 160 1592, 1998 Editorial Comment: The current gold standard for demonstrating significant reflux is the voiding cystourethrogram. However, this study exposes the child to radiation. Radionuclide cystography exposes the patient to less radiation and reveals significant reflux. However, it fails to show the anatomical abnormality that may underline the reflux, such as urethral valves in the male patient. The authors studied whether ultrasonic techniques using an echo contrast medium could be substituted for the current gold standard and, thus, obviate exposure to radiation. A total of 58 neonates were studied with a galactose suspension. These studies were compared to voiding cystourethrography and radionuclide cystography. It should be noted that not all patients had all 3 studies performed. The reasons for the evaluations included pyelectasis in 21 cases and pyelonephritis in 37. Echo sonography detected 76 refluxing units in 50 patients. Eight patients did not undergo voiding cystourethrography. In 43 patients voiding cystourethrogra- phy or radionuclide cystography detected 62 refluxing units. Thus, the authors believe that echo sonography yields results comparable to voiding cystourethrography. If these excellent results are confirmed by others, one could seriously accept echo sonography as an adequate substitu- tion for radionuclide cystography as the study of choice to following these cases. Although the authors claim that echo sonography did not fail to detect any anatomical variance, such as paraureteral diverticula, ureteroceles and duplication anomalies, I believe that posterior ure- thral valves can still be missed. Therefore, I would recommend that the initial study still be voiding cystourethrography. Stanford M. Goldman, M.D.

Abstract: In 4 cases, the clinical presentation of urethral diverticulum (UD) during pregnancy was a paraurethral mass (3), urinary incontinence (2), irritative symptoms (2), urinary tract infection (1), urethral pain and discharge (1) and voiding difficulty (1). The diagnosis of UD during pregnancy was made by transvaginal ultrasonography (2), cystoscopy (1), and after pregnancy by a voiding cystourethrogram (1). Management during pregnancy involved antibiotics (2), diverticulum aspiration (2) and incision and drainage (1). Delivery was by the vaginal route in 2 women with diverticular aspiration being performed during the second stage to aid delivery in 1 woman. Caesarean section was performed in the other 2 women for reasons unrelated to the presence of the UD. Three women had diverticulectomy performed following pregnancy for persisting symptoms. Although uncommon, it is important to diagnose urethral diverticula given the associated morbidity and the potential for causing complications during pregnancy.

Abstract: Urinary tract infections (UTIs) usually occur as a consequence of colonization of the periurethral area by a virulent organism that subsequently gains access to the bladder. During the first few months of life, uncircumcised male infants are at increased risk for UTIs, but thereafter UTIs predominate in females. An important risk factor for UTIs in girls is antibiotic therapy, which disrupts the normal periurethral flora and fosters the growth of uropathogenic bacteria. Another risk factor is voiding dysfunction. Currently, the most effective intervention for preventing recurrent UTIs in children is the identification and treatment of voiding dysfunction. Imaging evaluation of the urinary tract following a UTI should be individualized, based on the child's clinical presentation and on clinical judgment. Both bladder and upper urinary tract imaging with ultrasonography and a voiding cystourethrogram should be obtained in an infant or child with acute pyelonephritis. Imaging studies may not be required, however, in older children with cystitis who respond promptly to treatment.

Abstract: Justin is a 6-year-old boy diagnosed with attention-deficit/hyperactivity disorder who presented with daytime and night-time wetting. He had been toilet trained at the age of 3 years but was back in diapers as a result of the enuresis. His bowel movements were normal. The initial evaluation consisted of a urinalysis, urine culture, serum creatinine level, and renal/bladder ultrasound examination. The urine studies were normal. The serum creatinine level was elevated at 1.0 mg/dL. The ultrasound examination revealed bilateral mild hydronephrosis and a thickened bladder wall. A voiding cystourethrogram was ordered to evaluate anatomy, but Justin would not allow a Foley catheter to be inserted, so the procedure, along with cystoscopy, was performed under anesthesia. Cystoscopy revealed a highly trabeculated bladder, as is seen in either high-grade obstruction or a neurogenic bladder. The cystogram did not show any obstruction or vesicoureteral reflux. Meanwhile, Justin's symptoms continued to increase to the point at which he was constantly wet, and he no longer made any attempts to void on his own. A spinal magnetic resonance imaging study did not show any occult neurologic lesions. Urodynamic studies revealed a high-pressure bladder, poor emptying, and inappropriate voluntary contraction of the striated, urinary sphincter during micturition. Despite institution of anticholinergic medication, psychotherapy, and behavioral therapy, Justin continued to do poorly. He could not tolerate clean intermittent catheterization, and he eventually required a suprapubic tube for urinary drainage and preservation of his kidneys.

Abstract: The analysis presents 622 children in the age ranged from 4 months to 14 years, operated on vesicoureteral reflux. The treatment was carried on in Department of Pediatric Surgery in Poznan between 1983 and 1992. All these children were operated on with antireflux Politano-Leadbetter technique, modified by Sarrazin, protecting reimplanted ureters with stenting catheters. Duplicated ureters were reimplanted "en bloc" according to Bettex technique, also with Sarrazin modification. Preoperative parameters included: history, radiological evaluations: voiding cystourethrogram, intravenous pyelogram or ultrasound imaging, endoscopic evaluations--cystourethroscopy (with meatal calibration in girls), laboratory blood and urine results. The reflux degree was estimated according to international classification IRSC. There were 12 (2%) children with II degree, 498 (80%) with III degree, 101 (16%) with IV degree and 11 (2%) patients with V degree reflux. In order to compare the results of operative treatment, all analyzed children were subdivided into groups: 303 (48.7%) patients with primary reflux, 77 (12%) with reflux to duplicated pyelo-ureteral systems, 17 (2.7%) with refluxing megaureters, 66 (10%) with reflux to hypoplastic kidney, 99 (15.9%) with cystic cystitis and 114 (18%) children with urethral meatal stricture. Good recovery with uncomplicated postoperative course was obtained in 606 (97.4%) patients. Early postoperative complications occurred in 16 (2.6%). In outpatient control the results of urinalysis and urine cultures, ultrasound imaging and voiding cystourethrograms were tested. Urine cultures were negative in 501 (80.5%) patients 3-4 weeks after discharge increasing to above 92% of patients 6 months after operation. In postoperative imaging control, 600 (96.5%) patients presented with normal status of upper urinary tract, in 14 (2.2%) transient dilatation of reimplanted ureters was observed and in 8 (1.3%) ureters had to be reimplanted because of secondary dilatation. After 6 months postoperative voiding cystourethrograms showed cessation of reflux in 589 (94.6%) patients, in 33 (5.2%) recurrent reflux was observed, which disappeared in 20 of them in control. In 13 patients urodynamic evaluation showed vesicourethral dysfunction, medically curable.

Abstract: Cowper’s syringocele has been described as an uncommon cystic dilatation of Cowper’s gland ducts. It is usually asymptomatic and reported in children. To our knowledge, we report the first 2 cases of Cowper’s syringocele, which became symptomatic in adulthood. CASE REPORTS Case 1. A 27-year-old man presented with dysuria, frequency and recurrent urinary tract infection 3 months in duration. During the last month he noticed terminal hematuna. On physical examination there was a painful mass along the perineal midline. Retrograde and voiding cystourethrogram showed compression of the bulbar urethra by a cystic mass inferior to the membranous urethra, which filled with contrast medium (fig. 1). Urethrocystoscopy revealed a dead end space beneath the bulbar urethra, consistent with Cowper’s syringocele. The patient underwent unroofing of the syringocele by incising the thin membrane with a knife electrode passed through a resectoscope. At 3-year followup he had no episodes of urinary tract infection or bleeding, or urinary complaints. Case 2. A 39-year-old man presented with urgency, frequency and post-void dribbling 4 months in duration. He also complained of low back pain due to a herniated L4-5 intervertebral disk. Physical examination was unremarkable. Cystomanometry showed a normal functioning detrusor with detrusor pressure of up to 11 cm. water during the filling phase of 350 ml. and a voiding pressure of 25 cm. water. Uroflowmetry was obstructive with a maximum flow rate of 10.9 ml. per second and an average flow rate of 6.4 ml. per second. The volume voided was 320 ml. Retrograde and voiding cystourethrogram showed a finding similar to that of case 1 (fig. 2). Urethrocystoscopy revealed a 1 mm. opening, followed by a 4 cm. long cavity beneath the ventral wall of the bulbar urethra. Unroofing of the syringocele was performed through video urethrocystoscopy, using the same endoscopic technique as in case 1. The patient is voiding satisfactorily 14 months postoperatively with a maximum flow rate of 18.2 ml.