Complete Urological Evaluation Research Articles

Assessment and Management of Fetal Hydronephrosis

After completing this article, the reader should be able to: 1. Differentiate genitourinary abnormalities associated with hydronephrosis detected on fetal ultrasonography. 2. Describe the type of fetal hydronephrosis that requires a complete uroradiologic evaluation. 3. Characterize the complete postnatal uroradiologic evaluation of significant fetal hydronephrosis. 4. Delineate the factor that sets the timetable for postnatal uroradiologic evaluation. 5. Describe the neonates for whom diuretic renography is reserved. Ultrasonographic detection of antenatal anomalies in the fetus has increased steadily since its initial widespread use in the 1970s. During these early years, antenatal ultrasonography detected structural abnormalities in approximately 1% to 3% of all pregnancies. (1) Currently, it is estimated that genitourinary anomalies comprise 20% of all antenatally detected fetal anomalies. (2) In a recent British population-based study, fetal genitourinary anomalies were identified in 2.3% of women undergoing routine obstetric ultrasonography between 18 and 23 weeks of gestation. (3) Hydronephrosis clearly has become the most commonly detected antenatal anomaly on fetal ultrasonography. Detection of antenatal dilation of the urinary tract does not always indicate postnatal urinary tract obstruction or even a significant genitourinary anomaly. (4) Among infants diagnosed as having prenatal hydronephrosis or other genitourinary anomalies, the question often is raised about the need for and extent of the postnatal evaluation to assess the magnitude of this commonly detected antenatal anomaly. The purpose of this review is to provide a framework for assessment and management of antenatally detected hydronephrosis. Fetal hydronephrosis is a nonspecific finding that can be associated with multiple congenital anomalies of the genitourinary tract. A thorough understanding of disorders that can result in hydronephrosis postnatally allows the physician to assess the need for postnatal diagnostic tests and guide treatment recommendations. The congenital anomalies that may result in hydronephrosis can be categorized as disorders of urinary reflux and disorders of urinary obstruction. It can be …

Vaginal obstruction.

Congenital anomalies that result in vaginal obstruction often present with an abdominal mass in the newborn period. Knowledge of the embryological development of the genitourinary tract and its variations is needed to properly evaluate the neonatal patient and to initiate therapy. Because of a high incidence of associated anomalies, a complete urologic evaluation should be undertaken before a definitive surgical repair. The methods of treatment for the various causes of vaginal atresia have shown long-term success and have resulted in appropriate psychosocial and sexual maturation.

Low-Dose BCG Instillations in the Treatment of Stage T1 Grade 3 Bladder Tumours: Recurrence, Progression and Success

The aim of this retrospective study was to evaluate the effects and results of low-dose bacillus Calmette-Guérin (BCG) therapy on a selective high-risk population of stage T1, grade 3 (G3) bladder tumours. Recurrence and progression were also analysed.Thirty-five consecutive patients presenting with T1 G3 tumours were treated with intravesical BCG. All patients underwent complete transurethral tumour resection. A course of BCG 75 mg Pasteur strain was begun 4 weeks after the first resection of the diagnosed tumour and continued for a 6-week period. At the end of treatment, a complete urological evaluation was routinely carried out: urine cytology test, cystoscopy with bladder biopsies randomly performed, and any recurrences were resected. In cases of abnormal cytology and/or recurrence an additional course of BCG was initiated, followed by the same tests. Follow-up examination and cystoscopy or fibroscopy were conducted every 3 months for 1 year, semiannually and annually thereafter.Median follow-up was 45 months (range 10–120); 7 patients (20%) did not respond to BCG instillations. Of these patients, 5 underwent cystectomy and in 2 patients the bladder was left in place in spite of recurrence because of age (+80 years). Twenty-eight patients (80%) responded positively, 24 after one single course of BCG, and 4 patients after two courses. During follow-up, recurrence was observed in 8 cases: stage T1 G3 in 4 patients, T1 CIS (carcinoma in situ) in 2 patients, Ta G2 and Ta G1 in 2 patients. Three of these patients were treated by cystectomy and the remaining patients with transurethral resection alone or combined with additional courses of BCG. Overall, 25 patients (71%) were considered free of tumour occurrence after low-dose BCG therapy. Ten patients underwent cystectomy (29%) or remained in occurrence and 2 patients died of the disease.These results can be closely compared to the results of other trials conducted on stage T1 G3 and BCG treatment, using a different dosage and BCG protocol therapy. BCG is an effective prophylactic and therapeutic agent for T1 G3 carcinoma of the bladder responders. The identification of these responders before beginning instillations still remains a challenge.

Posterior cloaca: A unique defect

The authors present nine cases of a unique defect in which urethra and vagina are fused together forming a urogenital sinus that deviates posteriorly and opens in the anterior rectal wall at the anus or immediately anterior to it. The rectum is essentially normal or may be minimally anteriorly mislocated. The authors call this defect posterior cloaca. The diagnosis requires a suspicious observer and a meticulous examination of the female genitalia. A complete urologic evaluation is mandatory because 88% of these patients have important associated urologic defects. Our patients were operated on via a posterior sagittal transanorectal approach, which allowed a full dissection and mobilization of urethra and vagina together to be placed in a normal location. Rectal dissection and mobilization was avoided to preserve bowel control. Seven patients enjoy bowel and urinary control. One patient was lost to follow-up, and one patient with a severely dysplastic sacrum suffers from fecal and urinary incontinence.

Evaluation of asymptomatic microscopic haematuria--influence and clinical relevance of osmolality and pH on urinary erythrocyte morphology.

To determine whether the morphological distinction between 'dysmorphic' and 'eumorphic' erythrocytes in urinary sediment differentiates microscopic haematuria (MH) from reno-parenchymal and post-renal bleeding. The erythrocyte morphology of 2145 urinary sediments from 1391 patients with MH was evaluated by interference-contrast microscopy and compared with the osmolality, pH and specific gravity of the urine samples. Compared with more concentrated urine specimens, samples of < 700 mOsmol/kg showed significantly lower percentages of dysmorphic erythrocytes; there was a similar reduction in this percentage at a pH > or = 7. In addition, erythrocytes lysed in diluted or alkaline urine and therefore, under these conditions, no diagnosis could be made. The assessment of erythrocytes in urinary sediment should be performed only under 'standard conditions', i.e. in concentrated and acidic urine, > or = 700 mOsmol/kg and a pH < 7. The presence of > or = 90% dysmorphic erythrocytes in patients with asymptomatic MH, the absence of proteinuria, a normal blood pressure and normal radiological examination indicates 'reno-parenchymal MH', requiring a long-term follow-up with a routine evaluation twice a year, but no immediate treatment in most cases. In contrast, the presence of > or = 90% eumorphic erythrocytes or even 'mixed' results (10-90% eumorphic erythrocytes) indicates 'post-renal MH', requiring a complete urological evaluation.

Reversible Clinical Outcome After Sphincter Stent Removal

Purpose We determined whether the self-expanding sphincter stent, a potential alternative to conventional external sphincterotomy for the treatment of detrusor external sphincter dyssynergia, causes a permanent effect on the lower urinary tract. Materials and Methods Four spinal cord injured men with voiding symptoms of detrusor external sphincter dyssynergia as noted by complete urological evaluation, including a video urodynamic study, were treated with the self-expanding sphincter stent. However, the device was explanted 6 months or longer after insertion in all 4 cases due to stent migration (3) and difficulty with condom catheter urinary drainage (1). Results All stents were removed completely without damage to the urethra. Mean voiding pressure decreased from 62.5 plus/minus 39.4 to 20.7 plus/minus 6.5 cm. water after sphincter stent placement. One year after stent explanation mean voiding pressure remained unchanged from preoperative values of 58.5 plus/minus 21.5 cm. water. No patient had stress urinary incontinence or endoscopically apparent urethral strictures. Conclusions The stent can be removed even after complete epithelialization and an extended interval without damage to external sphincter function or urethral stricture formation. The urinary sphincter stent is an effective, reversible treatment for patients with detrusor external sphincter dyssynergia.

Interdisciplinary treatment of spina bifida children.

In the Spina Bifida Centre, Niguarda Ca' Granda Hospital (Milan, Italy), from June 1985 to June 1990, 60 spina bifida children have been treated. The results of the rehabilitation programme (including orthopaedic, urological and psychosocial aspects) at the time of the survey were: (a) Neuromotor function: 72% of the patients achieved ambulation, 52% of these being less than 2 years of age, and 20% older than 2 years; 18% were too young for walking. Thus, considering the children's age, about 90% of the subjects achieved the standing position, and 89% achieved ambulation. (b) Bladder function: 83% of the children had a complete urological evaluation; 40% of those with a neuropathic bladder had a hyperreflex type, 54% areflexic, and 6% normoreflexic. Thirty-two percent of the patients had signs of 'high pressure' bladder function. Urinary continence was: 36% > or = 2 hours, 20% < 2 hours, 44% not detectable (age < 2 years). Forty percent of the subjects used intermittent catheterisation. (c) Psychosocial aspect: child adaptation to the disease and to the rehabilitation programme was good in 61% of the patients; family problems were identified in 70% of the patients; enrollment in preschool and school programmes was normal (or with specialist teaching) in about 74%; 33.3% of the subjects had disturbance of affect. The results clearly showed that the interdisciplinary approach favoured the social integration of these children.

Home Screening for Hematuria: Results of a Multi-Clinic Study

The majority of urinary tract tumors cause bleeding in the urine. A program designed to detect hematuria before it is grossly apparent may contribute to earlier detection and more successful treatment of these malignancies. To test this hypothesis a hematuria home screening study was conducted. A total of 1,340 healthy men 50 years old or older used chemical reagent strips for 14 consecutive days to test the urine. Of the men 283 (21.1%) had at least 1 episode of hematuria. Of the 192 hematuria positive men who received a complete urological evaluation 16 (8.3%) had urological cancers and 47 (24.5%) had other hematuria-causing diseases that required immediate treatment. The quantity and frequency of hematuria were not related to disease severity. A hematuria home screening regimen is feasible and economical, and may promote the early detection of urinary tract cancers and other diseases in men more than 50 years old.

Skene's duct cysts in female newborns

The Skene's duct cyst, which presents as a cystic mass just around the urethral meatus, is a rare congenital abnormality in the female newborn. Following a search of available literature we have been able to find Skene's duct cyst reported in only 10 newborns. Herein we report seven cases of Skene's duct cysts in female neonates that were recorded in a 5-year period (June 1984 through May 1989) among 14,518 female births at the Fatima Hospital. In these cases we found that Skene's duct cysts in the female newborn had characteristic morphological and clinical features helpful for diagnosis without a complete urologic evaluation. Needle aspiration of the cyst content provides diagnostic information as well as therapeutic effect. Treatment consisted of partial excision of the cyst wall and needle aspiration. In the initial two cases we performed partial excision of the cystic wall for the purpose of doing tissue examination and drainage of the cyst, but in the following five cases we carried out only needle aspiration. The results of both were excellent without recurrence.

Epidemiology, Natural History, and Management of Urinary Tract Infections in Pregnancy

The urinary tract undergoes profound physiologic and anatomic changes during pregnancy that facilitate the development of symptomatic UTIs in women with bacteriuria. Although the adverse effects of asymptomatic bacteriuria on maternal and fetal health continue to be debated, it is clear that asymptomatic bacteriuria is the major risk factor for developing symptomatic UTI and that symptomatic infections are associated with significant maternal and fetal risks. Because the majority of symptomatic UTIs develop in women with bacteriuria earlier in pregnancy, treatment of bacteriuria is undertaken to prevent symptomatic infections. All women should be screened at the first antenatal visit, which is reliably and inexpensively done with a dipstick culture. Short-course therapy is as effective as prolonged therapy and should be followed with a repeat culture to document clearing of the bacteriuria. Failure to eliminate bacteriuria with repeated therapy or recurrence with the same organism is indicative of renal parenchymal infection or a structural abnormality. All women with persistent bacteriuria or recurrent infection should have follow-up cultures and a complete urologic evaluation after delivery.

A study on six cases of renal cell carcinoma detected by renal ultrasound during health screening

From April 1986 to March 1988, 7,800 subjects (3,887 men and 3,913 women, age from 24 to 80 years, with a mean age of 48.7 years) underwent renal ultrasound during a screening by our Health Service. Of these subjects 29 were suspected to have solid masses in the kidneys. Further examination with computerized tomography (CT) was employed. Four angiomyolipomas and 16 malformations of the kidneys were diagnosed clinically at that time. Among 9 subjects who underwent complete urological evaluation including excretory urography (IVP), CT and renal angiography 6 malignant renal tumors were disclosed. Six patients were treated by radical nephrectomy. In this report we studied the 6 patients whose tumors were pathologically diagnosed as renal cell carcinoma (RCC). The six patients were 48 to 60 years old with a mean age of 55.8 years. There were 4 men and 2 women. There are no signs or symptoms referable to RCC. In 1 patients microscopic hematuria was detected via a laboratory study. Erythrocyte sedimentation rate (ESR) was slightly evaluated in 4 patients. In the 6 patients, the renal tumors were diagnosable by CT and all tumors had positive findings for malignant neoplasms angiographically. An IVP, without nephrotomography, did not reveal a small tumor growing in the upper pole of the right kidney of 1 patient. Surgical specimens were 180-475 g in weight. Tumors, were found in the right kidneys (2) and in the left kidneys (4), were well circumscribed. The size of the tumors measured from 3 to 7 cm in the longest axis. Pathological diagnosis was made as renal cell carcinoma 3 with G1, pT2a, 2 with G2, pT2a and 1 with G2, pT2b.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacteriuria in Pregnancy

The urinary tract undergoes profound physiologic and anatomic changes during pregnancy that facilitate the development of symptomatic urinary tract infections in women with bacteriuria. While the adverse effects of asymptomatic bacteriuria on maternal and fetal health continue to be debated, it is clear that asymptomatic bacteriuria is the major risk factor for developing symptomatic urinary tract infection and that symptomatic infections are associated with significant maternal and fetal risks. Because the majority of symptomatic urinary tract infections develop in women with bacteriuria earlier in pregnancy, treatment of bacteriuria is undertaken to prevent symptomatic infections. All women should be screened at the first antenatal visit, which is reliably and inexpensively done with a dipstick culture. Short-course therapy is as effective as prolonged therapy and should be followed with a repeat culture to document clearing of the bacteriuria. Failure to eliminate bacteriuria with repeated therapy or recurrence with the same organism is indicative of renal parenchymal infection or a structural abnormality. All women with persistent bacteriuria or recurrent infection should have follow-up cultures and a complete urologic evaluation after delivery.

The Evaluation of Microscopic Hematuria: A Population-Based Study

From 1979 until 1983, 2,005 men underwent routine urological examinations. Of these men 85 (4 per cent) had asymptomatic microscopic hematuria. All men underwent complete urological evaluation. Significant urological disease was detected in 22 per cent of the patients. Therefore, complete urological evaluation can be justified in a nonselected group of men with microscopic hematuria.

Epididymitis in Infants and Boys: Underlying Urogenital Anomalies and Efficacy of Imaging Modalities

Of 47 children diagnosed as having epididymitis between 1975 and 1985, 8 of 17 prepubertal patients (47 per cent, or 17 per cent of the total group), including 3 of 4 infants (75 per cent), had an underlying urogenital anomaly. Thus, patients with epididymitis secondary to an underlying anomaly present at an earlier age. The common finding in patients with underlying anomalies was a pathological connection between the urinary tract and the genital duct system or bowel.Coliform urinary infections predominated in patients with underlying anomalies (4 of 6). Although a positive urine culture suggested an underlying anomaly (positive predictive value 0.60), a negative culture virtually ruled out an anomaly (negative predictive value 1.00).Of the 8 patients with underlying anomalies 6 underwent voiding cystourethrography and 6 underwent excretory urography, and the diagnosis was established in 6 (100 per cent) and 4 (67 per cent), respectively. Thus, voiding cystourethrography has the greatest diagnostic yield. Any prepubertal patient with epididymitis merits a complete urological evaluation, including a urine culture, voiding cystourethrography and excretory urography to rule out an underlying urogenital anomaly, which often is amenable to an operation. Surgery often involves severance of the pathological urogenital or urinary-fecal connection and it was successful in 7 of our 8 patients.

Complications and Treatment of Urinary Tract Infections During Pregnancy

Bacteriuria during pregnancy may result in serious complications, including development of acute pyelonephritis in the third trimester and premature labor. Because uninfected women commonly experience symptoms associated with urinary tract infections and many bacteriuric women are asymptomatic, all pregnant women should be screened by quantitative urine cultures. The goal of antimicrobial therapy is complete elimination of bacteria from the urinary tract. Major indications for complete urologic evaluation are failure of a patient with signs of acute upper-tract infection to improve on appropriate treatment and bacterial persistence after initial sterilization of the urine. Either problem may require surgical intervention.

Ectopic Ureter Presenting with Epididymitis in Childhood: Report of 5 Cases

We report 5 cases of an ectopic ureter opening into the seminal tract. All of the patients presented with the clinical features of acute or chronic epididymitis. Our experience has shown that the rare occurrence of epididymitis in prepubertal children necessitates a complete urological evaluation and that an underlying urological problem, including an ectopic ureter, should be sought.

Results of urometabolic evaluation in 127 patients with renal calculous disease

One hundred twenty-seven selected stone formers were evaluated. With the simple ambulatory tests proposed by Pak for metabolic screening and a complete urologic evaluation an anomaly was found in more than 90 per cent of the cases. The patients were divided into three groups: (1) patients operated on for staghorn stones; (2) patients with episodes of spontaneous stone disease. No significant differences were noted except for the occurrence of urinary tract infection disease. No significant differences were noted except for the occurrence of urinary tract infection and for struvite and calcium oxalate occurrence in the different groups. Urinary tract infection combined with a metabolic disorder appear to make the evolution from small kidney stone to staghorn stone a reality.

Comparative Results of Urological Evaluation of Children with Initial and Recurrent Urinary Tract Infection

Complete urologic evaluation was done on male and female children having initial or recurrent urinary tract infection. Of 200 girls having recurrent urinary tract infection 43 per cent showed ureterovesical reflux on the cystogram. Of 39 boys with recurrent urinary tract infection 41 per cent had reflux. Thus, the incidence of reflux is comparable in male versus female patients.Of 47 girls studied after only 1 episode of urinary tract infection 36 per cent had reflux and of 20 boys studied after initial infection 45 per cent had reflux. The data indicate that initial or recurrent urinary tract infection in boys or girls is of equal significance. All other factors being equal, failure to evaluate a patient urologically after 1 or more episodes of urinary tract infection solely because of the sex of the child could mean that a potentially severe urinary tract abnormality can be undetected and untreated.

Paraurethral cysts in female neonate

Paraurethral cysts in the female neonate are uncommon lesions. All reported cases have either ruptured spontaneously or responded to simple marsupialization. However, complete urologic evaluation is mandatory because they simulate ectopic ureteroceles in appearance. Herein is reported our experience with 5 patients. The etiology, embryogenesis, natural history, differential diagnosis, and treatment are discussed.

Urologic problems associated with imperforate anus

A total of 120 children with both high, intermediate, and low types of imperforate anus were evaluated urologically. Genitourinary anomalies were associated with all types of imperforate anus but were found more often in children with high rectal deformities. Because the over-all incidence of genitourinary anomalies was high, early and complete urologic evaluation is necessary to achieve the best functional result.