Complete duplication of bladder and urethra in the coronal plane in a girl: case report and review of the literature

An unusual case of complete duplication of the bladder and urethra in the coronal plane associated with left ectopic kidney, duplication of the clitoris and a chondrolipomatous malformation in the pelvic region in a girl is reported. The accessory bladder was located posterolateral to the normal bladder and a ureteric opening into the accessory bladder was found. The malformation was initially identified by US and cystography and confirmed by cystoscopy. Received: 8 April 1998 Accepted: 24 September 1998     

Imaging findings of hemorrhagic cystitis in pediatric oncology patients

In pediatric oncology patients, hemorrhagic cystitis may be a life-threatening complication of bone-marrow transplantation, chemotherapy, and/or radiation therapy. The inciting agent in urine can affect the entire urothelium from the renal collecting system to the bladder, and the severity of disease can vary. The radiologist often plays a key role in the diagnosis, follow-up, and occasionally the treatment of hemorrhagic cystitis and its complications. This review discusses the imaging findings in the kidneys and bladder in patients with hemorrhagic cystitis both before and after treatment for this disease. Findings on two-dimensional sonography, color Doppler and power Doppler sonography, computed tomography, magnetic resonance imaging, antegrade pyleography, and cystography are presented. Received: 24 May 1999/Accepted: 20 September 1999     

Pelvic ganglioneuroblastoma totally excised using posterior sagittal and abdominal approach

Neuroblastoma usually presents as an upper abdominal mass arising from the adrenal gland. Recent experience with neuroblastoma of the spermatic cord, bladder, and pelvis demonstrates the propensity of this tumor to arise in unusual areas. A 1-year-old boy was admitted with pollakiuria, acute urinary retention, and chronic constipation. Computed tomographic and ultrasonographic examinations revealed a 5×5.5×4-cm pelvic mass, which was totally excised using a posterior sagittal and abdominal approach. The pathologic diagnosis was ganglioneuroblastoma and 1-year follow-up was uneventful.     

Mesenteric venous thrombosis in a child with type 2 protein S deficiency

A 5-year-old girl presented with abdominal pain and bloody stools 2 weeks after suffering from influenza A infection. Enhanced computed tomographic scan showed widespread splanchnic venous thrombosis and small intestine necrosis. She recovered after the necrotic bowel was resected. The patient continues to receive anticoagulant therapy. Thrombophilia screening after the complete resolution consistently showed mildly decreased protein S (PS) activity with normal PS antigen levels. Sequence analysis detected a heterozygous K196E mutation in the PROS1 gene. Type 2 PS deficiency was diagnosed. This is the first report of mesenteric vein thrombosis in a child with a type 2 PS deficiency.     

Malignant gastric teratoma: case report

Gastric teratomas are rare and usually benign. A 4 month old boy presented with an abdominal mass and computed tomographic and ultrasound examination demonstrated a large multi-loculated tumour which was totally excised. The pathological diagnosis was of a malignant gastric teratoma and 12-month follow-up was uneventful.     

Elevated liver transaminase levels in children with blunt abdominal trauma: a predictor of liver injury

The medical records of 43 hemodynamically stable children with elevated serum transaminase levels (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) who underwent abdominal computed tomographic (CT) scan for blunt abdominal trauma were reviewed. Nineteen patients (44.2%) had AST levels greater than 450 IU/L and ALT levels greater than 250 IU/L, and 17 of these 19 patients had hepatic injury identified on abdominal CT scan. Of the 43 patients, 25 (58.1%) had AST and ALT levels of less than 450 IU/L and 250 IU/L, respectively, and none of these patients had evidence of hepatic injury on CT scan. Elevated serum transaminase levels (AST greater than 450 IU/L and ALT greater than 250 IU/L) identified all of the patients with hepatic injury visible on abdominal CT scan. The sensitivity and specificity of elevated serum transaminase levels were 100% and 92.3%, respectively, for predicting hepatic injury. It is recommended that hemodynamically stable pediatric patients with blunt abdominal trauma and AST levels greater than 450 IU/L and/or ALT levels greater than 250 IU/L undergo abdominal CT scan to determine the presence and extent of hepatic injury. Children with serum transaminase levels below these values are at decreased risk of liver injury.     

Ultrasound diagnosis of ectopic ureterocele

Three children with ectopic ureteroceles were examined with ultrasound, intravenous urography and cystography. In all cases the ultrasound studies outlined the ectopic ureterocele within the fluid-filled bladder and in one case added additional information regarding the non-functional portion of the duplication and its ureter.     

“The intraureteric diverticulum”, a manifestation of ureterocoele intussusception

An ectopic ureterocoele may present as a diverticular-like structure at the bladder base appearing during voiding cystography. The radiological appearances are described and the mechanism of formation as seen in serial 70 mm film is discussed. The conventional intravesical filling defect of an ureterocoele may not be recognised when the bladder is filled by contrast medium. This sign of extra-vesical intra-ureteric invagination is only seen during voiding.     

Cystourethrography: The effect of reservoir height upon intravesical pressure

The effect of infusion height upon intravesical pressure during cystography was studied in three dogs and three patients. Results indicate that during bladder filling the intravesical pressure is independent of the reservoir height.     

Sonographic demonstration of an unusual bladder wall enlargement in a child with non-Hodgkin lymphoma

An enlargement of the wall of the urinary bladder up to 1.5 cm is described within the course of a Non Hodgkin Lymphoma of a 15 years old girl. The development of a spastic neurogenic bladder is most probable due to tumour infiltration into the spinal cord. An additional factor for the enlargement of the bladder wall is a massive fungus cystitis. A cystotatica induced (Vindesin) neurogenic bladder as another cause for the development of this bladder change cannot excluded completely, but this is very unprobable. The cystography is the method of choice in the morphological evaluation of the bladder mucosa, whereas the sonography can visualize the bladder wall directly. This method has a high value in the diagnosis and follow up of pathologic changes of the urinary bladder in children.     

CT localization of occult secretory tumors in children

Three seemingly occult secretory tumors in children (pheochromocytoma, ganglioneuroblastoma and islet cell carcinoma) were localized within the abdomen by computed tomography after other diagnostic imaging procedures had failed. The superb density resolution and tomographic formating of CT images make CT uniquely suited for the demonstration of small abdominal lesions. CT is recommended as a primary imaging modality for secretory tumors in children.     

Pseudosarcomatous myofibroblastic tumor of the urinary bladder with massive intraperitoneal hemorrhage in a child

Abstract A 3-year-old boy presented with persistent abdominal pain, hematuria and facial pallor with progressive anemia. A computed tomography scan showed a massive intraperitoneal hemorrhage and tumor mass in the bladder. Histological examinations of the resected tumor revealed findings of pseudosarcomatous myofibroblastic tumor (PMT). The clinico-pathological features of this case warn us that PMT can cause acute abdomen syndrome with massive intraperitoneal hemorrhage.     

Collateral bladder duplication with exstrophy of one moiety in a female infant

Complete bladder duplication with exstrophy of one moiety is an extremely rare condition. We report an unusual case of complete bladder duplication with exstrophy of one moiety, in which each bladder received one ureter and the internal bladder drained into a urogenital sinus. The patient was treated by combining the two bladder halves and using the bladder neck of the internal bladder, with excellent cosmetic result. This case underscores the importance of ultrasonography and computed tomography to detect the anatomy of the patient with exstrophy in whom the ureteric orifices cannot be clearly identified on both sides of the trigone.     

The presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection

Background: Childhood urinary tract infection (UTI) with or without vesicoureteric reflux (VUR) may predispose to renal scarring. There is no clear consensus in the literature regarding imaging following UTI in infancy. Aims: To define the role of cystography following a first UTI in children aged under 1 year, when urinary tract ultrasonography (US) is normal. Methods: Retrospective data collection of 108 children (216 renal units) aged under 1 year at the time of a bacteriologically proven UTI. All had a normal US and underwent both catheter cystogram and DMSA test. Sensitivity, specificity, likelihood ratios positive and negative, and diagnostic odds ratio were calculated for VUR on cystography versus scarring on DMSA. Results: VUR was shown in 25 (11.6%) renal units. Scarring on DMSA was seen in 8 (3.7 %) kidneys. Only 16% of kidneys with VUR had associated scarring; 50% of scarred kidneys were not associated with VUR. The likelihood ratio positive was 4.95 (95% CI 2.22 to 11.05) and the likelihood ratio negative was 0.56 (95% CI 0.28 to 1.11). The diagnostic odds ratio was 8.9, suggesting that cystography provided little additional information. Conclusion: Since only 16% of children with VUR had an abnormal kidney, the presence of VUR does not identify a susceptible population with an abnormal kidney on DMSA. In the context of a normal ultrasound examination, cystography contributes little to the management of children under the age of 1 year with a UTI. In this context, a normal DMSA study reinforces the redundancy of cystography.     

The role of estrogens in the pathogenesis of bladder dysfunction of the hyperreflexia type and vesico-ureteral reflux in children

Patients with the uninhibited urinary bladder of the hyperreflexia type and the vesicoureteral reflux were subjected to multimodality examinations which included excretory urography, retrograde cystometry, cystography, profilometry of the ureterovesical anastomosis, cytologic investigation of estrogenic saturation, determination of the concentration of follicle-stimulating hormone of the pituitary and estradiol by means of radioimmunoassay. As many as 56 girls aged 4 to 15 years underwent examination. It has been demonstrated that dysfunction of the urinary bladder of the hyperreflexia type is of crucial role as an active mechanism of extra-vesicalization of the intra-vesical part of the ureter, associated with its antireflux function distress.     

The presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection.

BACKGROUND: Childhood urinary tract infection (UTI) with or without vesicoureteric reflux (VUR) may predispose to renal scarring. There is no clear consensus in the literature regarding imaging following UTI in infancy. AIMS: To define the role of cystography following a first UTI in children aged under 1 year, when urinary tract ultrasonography (US) is normal. METHODS: Retrospective data collection of 108 children (216 renal units) aged under 1 year at the time of a bacteriologically proven UTI. All had a normal US and underwent both catheter cystogram and DMSA test. Sensitivity, specificity, likelihood ratios positive and negative, and diagnostic odds ratio were calculated for VUR on cystography versus scarring on DMSA. RESULTS: VUR was shown in 25 (11.6%) renal units. Scarring on DMSA was seen in 8 (3.7 %) kidneys. Only 16% of kidneys with VUR had associated scarring; 50% of scarred kidneys were not associated with VUR. The likelihood ratio positive was 4.95 (95% CI 2.22 to 11.05) and the likelihood ratio negative was 0.56 (95% CI 0.28 to 1.11). The diagnostic odds ratio was 8.9, suggesting that cystography provided little additional information. CONCLUSION: Since only 16% of children with VUR had an abnormal kidney, the presence of VUR does not identify a susceptible population with an abnormal kidney on DMSA. In the context of a normal ultrasound examination, cystography contributes little to the management of children under the age of 1 year with a UTI. In this context, a normal DMSA study reinforces the redundancy of cystography.     

Percutaneous direct radionuclide cystography in children: description of technique and early experience

AIMS: To describe a new test for vesicoureteric reflux in children and assess patient preference compared to indirect radionuclide cystography. MATERIALS AND METHODS: One hundred and three toilet-trained children aged between 2.1 and 15.6 years underwent percutaneous injection of 10-20 MBq of 99m-technetium-labelled mercapto-acetyl-triglycine (MAG3) into the full bladder after the application of anaesthetic cream. Gamma camera images of the bladder and renal areas were recorded during a 5-min resting period and during micturition. RESULTS: All procedures were successful, 97 with a single stab. Fifty-four of the 66 children who expressed a preference preferred percutaneous suprapubic injection to intravenous injection. Images were easy to interpret and there were no indeterminate results. Of 200 renal units, 33 refluxed during the resting phase and 31 during micturition. In 24 renal units, reflux was only demonstrated during the resting phase. Reflux was significantly associated with abnormalities on dimercaptosuccinic acid (DMSA) scans ( P<0.001). CONCLUSIONS: The new technique of direct percutaneous radionuclide cystography is described. It was well tolerated by patients. It detects reflux during the resting phase that would be missed on the indirect study and avoids doubt as to whether activity in the renal areas is due to reflux or excretion. Free pertechnetate could be used and would be much cheaper.     

Congenital seesaw nystagmus

A 14-year-old boy with congenital seesaw and horizontal pendular nystagmus associated with decreased visual acuity, high myopia, esotropia, and normal peripheral visual fields is reported. Neurologic and computed tomographic evaluation, as well as auditory evoked potentials, were normal. The findings in, and recommended evaluation of, seesaw nystagmus in young patients are reviewed.     

Congenital diverticulum of the bladder mimicking tumour

The incidence of bladder diverticula is low and identification is usually straightforward with contrast studies. We present a case of a child who had a clearly identified bladder diverticulum as well as a soft-tissue lesion in the posterior wall of the bladder that was suspected to be a rhabdomyosarcoma. Despite ultrasound scanning, micturating cystourethrogram, computed tomography and cystoscopy, open surgery was required to rule out tumour.     

Diagnosis of vesico-ureteric reflux

The demonstration and grading of reflux is crucial in examination and follow-up of any child with upper urinary tract infection. A variety of factors can influence the occurrence of reflux, e.g. race, genetics, state of maturation of the ureterovesical valve, diuresis, infection and bladder dysfunction, including obstruction and neurogenic disorders. Even when reflux is investigated under strictly standardized conditions, two consecutive bladder fillings frequently show different grades of reflux. Voiding cystourethrography is, to date, the only method with a generally accepted, well-defined grading of reflux. It also allows detection of intrarenal reflux and anatomical and functional information about the bladder and urethra that is unobtainable by other methods. It is therefore usually considered the method of choice. Radionuclide cystography and, possibly, contrast enhanced ultrasonography can be complementary to voiding cystourethrography, but mainly for postoperative follow-up and screening of siblings.