Neonatal bladder rupture

Neonatal bladder rupture is rare as a complication of bladder obstruction due to abnormal anatomy or iatrogenic cause such as umbilical catheterization. The present study describes the case of a 27-day old infant with ascites due to bladder perforation secondary to bladder wall necrosis as a result of severe urinary tract infection. The baby was treated aggressively with antibiotics and underwent successful surgical repair of the perforation.     

Accuracy of ultrasonic bladder volume measurement in children

The accuracy of ultrasonography in assessing the bladder volume in 13 children with normal bladder contours was determined using the formula D x H x W (depth x height x width) with a mean error of 15.7%. This formula tends to overestimate the bladder volume in these patients. Multiplication by a correction factor of 0.9 yields a mean error of 11.5%. The accuracy of this evaluation is not dependent upon the bladder volume as the mean error was the same in those children whose bladder volume was either less than or greater than 150 cc. In addition, the accuracy of ultrasonography in assessing bladder volume was evaluated in 7 patients with an abnormal bladder contour (trabeculation, diverticula, etc.); mean error was 14.7%. In these 7 patients there was no predictable under or overestimation of bladder volume. In the children with abnormal bladder contours on ultrasound, the correction factor of 0.9 should not be used, as it does not add to the accuracy of the procedure in any individual patient. This technique is still valuable, however, in children with an abnormal bladder for it allows estimation of the extent of emptying without invasive catheterization.     

Interim report in humans of a previously described technique in an animal model: closure of bladder exstrophy with rectus abdominis muscle flap

The aim of this study was to present the results of a new bladder closure and augmentation technique in children born with bladder exstrophy where primary surgical closure was impossible. The technique was performed in four children with small, noncompliant, inelastic bladders in which secondary changes such as squamous epithelial metaplasia and polypoid transformation had developed. During the opration, a full-thickness rectus abdominis muscle island flap with an intact neurovascular pedicle was prepared from the left abdominal quadrant and rotated to cover the bladder defect and aid in augmentation. The inner layer formed by peritoneum was sutured to the edges of the bladder defect. Postoperative endoscopic and histopathologic investigations revealed the inner, peritoneal layer of the flap to be completely covered by transitional urinary bladder epithelium. Considering the advantages of the technique from this limited experience, the evidence suggests that there is no need for a major gastrointestinal operation for bladder augmentation. A reasonable bladder capacity was available, there was no mucus production from the inner layer of the flap, and metabolic and electrolyte disturbances were reduced.     

无细胞基质组织工程膀胱的实验研究

目的 探讨以膀胱无细胞基质为细胞载体的无细胞基质组织工程膀胱作为膀胱替代材料的可行性.方法 采用叠氮钠、DNase、PBS反复振荡洗涤膀胱组织,形成膀胱无细胞基质.自8只杂交长风白猪手术获取小块膀胱组织,分离出膀胱平滑肌细胞、移行上皮细胞培养、增殖,将增殖的两种细胞种植于膀胱尢细胞基质两面,共培养后回植,大面积替代自体猪的部分膀胱.分别观察1个月(2只)、3个月(3只)、6个月(3只)后处死,HE免疫组化观察替代部分膀胱组织结构,组织浴槽巾研究无细胞基质组织工程膀胱肌条的体外功能情况.结果 无细胞基质中已无细胞成分残留,培养的膀胱细胞可粘附于无细胞基质并生长.细胞-无细胞基质复合物替代膀胱后,3个月、6个月组均见替代处完整的移行上皮细胞覆盖于腔面,其下膀胱肌层形成,均排列良好,与正常膀胱组织无明显区别.组织浴槽研究提示无细胞基质组织工程膀胱肌条具有与正常膀胱肌条相似的体外功能.结论 无细胞基质组织工程膀胱技术有望为临床提供可行的替代材料来源.     

Renal transplantation and congenital anomaly of the kidney and urinary tract

Paediatric renal transplantation in children differs from adult series because of the high incidence of abnormalities of the lower urinary tract. We report our experience concerning five children with end-stage renal disease and associated bladder dysfunction due to posterior urethral valves, and lower urinary tract abnormalities (‘valve bladder’), who underwent renal transplantation without prior correction of the uropathy. Of 151 paediatric patients (aged 34 months to 23 years) who underwent renal transplantation, 58 had lower urinary tract abnormalities, and 42 underwent surgical correction of the uropathy prior to renal transplantation. In 15 patients, the uropathy was fibrotic bladder secondary to posterior urethral valves (‘valve bladder’). After clinical and urodynamic evaluation, all 15 patients were considered as candidates for bladder augmentation. In 10 patients, the bladder augmentation was performed prior to renal transplantation. The remaining five patients presented with oligoanuria at the time of the evaluation, and the decision to consider bladder augmentation was postponed until the post-transplant period. At the time of renal transplantation, 2 of the 5 patients underwent ureterostomy, and three had a ureteral reimplant associated with a suprapubic catheter for 2 months. Periodic assessment of renal function and bladder capacity/compliance was performed, as was renal ultrasound. After 4 months, the five patients were re-evaluated for the need for bladder augmentation. At 1, 2, 3 and 4 months follow-up, the five patients had normal renal function with improvement of bladder capacity and absence of hydronephrosis. In 3 of the 5 children, bladder augmentation was judged to be no longer necessary due to the complete restoration of clinical and urodynamic parameters. Therefore, renal transplantation can be safely performed without pre-emptive reconstruction of the lower urinary tract. When possible, ureteral reimplantation is recommended, even in a very small valve bladder, since the initial indication for bladder augmentation may be modified once normal diuresis has been restored.     

The impact of bladder shape on the ultrasonographic measurement of bladder volume in children

Background US is used for non-invasive assessment of bladder shape and for calculation of bladder volume.Objective To evaluate the impact of bladder shape on the accuracy of US estimation of bladder volume in children and to calculate formulas for US estimation of volume for different bladder shapes.Materials and methods US was performed in 146 children (94 girls, 52 boys, age range 9 months to 17 years, median 7.9 years) referred for urodynamic investigation. Three bladder diameters were measured, and bladder shapes were categorized as round, ellipsoid, cuboid, triangular and undefined. Urine was collected, and total bladder volume calculated. Correction coefficients (k) were calculated for the whole sample and for each bladder shape using linear regression analysis.Results Round bladder shape was present in 23%, 25% showed a cuboid shape, 21% an ellipsoid shape, 25% a triangular shape, and 6% had an undefined shape. Correction (regression) coefficient (k) for the whole sample was 0.66 (SE=0.011); for round bladder 0.561 (SE=0.013), cuboid bladder 0.923 (SE=0.012), ellipsoid bladder 0.802 (SE=0.006), triangular bladder 0.623 (SE=0.007), and for undefined shape 0.749 (SE=0.048). Mean percentage errors when using different correction coefficients were significantly lower than errors when using k=0.5 applied to our data.Conclusions Bladder shape has considerable impact on the accuracy of US estimation of bladder volume in children. Correction coefficients should be used for volume measurements of different bladder shapes.     

Eosinophilic cystitis.

We describe four cases of eosinophilic cystitis in whom no specific cause could be found, and review the literature. Complaints at presentation included urgency, frequency, abdominal pain, and haematuria. In three patients the symptoms and ultrasound pictures suggested a bladder tumour. One patient was treated with anticholinergics and corticosteroids without relief of symptoms; a localised eosinophilic tumour was excised in one patient who remained symptom free; and two patients were managed conservatively with spontaneous resolution of bladder pathology and symptoms. One case was identified by random bladder biopsy in 150 consecutive patients with unexplained irritable micturition complaints. Eosinophilic cystitis is rare in children. After biopsy, we consider a wait and see policy is justified as symptoms tend to disappear spontaneously. Routine bladder biopsies in children with unexplained bladder symptoms is not justifiable.     

Eosinophilic cystitis

We describe four cases of eosinophilic cystitis in whom no specific cause could be found, and review the literature. Complaints at presentation included urgency, frequency, abdominal pain, and haematuria. In three patients the symptoms and ultrasound pictures suggested a bladder tumour. One patient was treated with anticholinergics and corticosteroids without relief of symptoms; a localised eosinophilic tumour was excised in one patient who remained symptom free; and two patients were managed conservatively with spontaneous resolution of bladder pathology and symptoms. One case was identified by random bladder biopsy in 150 consecutive patients with unexplained irritable micturition complaints. Eosinophilic cystitis is rare in children. After biopsy, we consider a wait and see policy is justified as symptoms tend to disappear spontaneously. Routine bladder biopsies in children with unexplained bladder symptoms is not justifiable.     

Hourly fetal urine production rate in the near term fetus: is it really increased during fetal quiet sleep?

Fetal bladder volume and hourly fetal urine production (HFUPR) is calculated on the assumption that the fetal bladder is ellipsoid in shape. A recent validation study demonstrated a progressive overestimation at increasing bladder volumes. This may be due to changes in shape of the fetal bladder at increasing volumes. Two independent papers have shown increased HFUPR during fetal behavioural state 1F (S1F) when compared with S2F. The aim of the present study was to assess whether this increase of HFUPR during S1F, previously observed by others, could be the result of an error introduced by the method of volume calculation. A retrospective evaluation was performed in a series of 208 HFUPR measurements in 123 normal near term pregnant women attending a low-risk antenatal clinic. Adequate bladder filling in both states was identified in 43 recordings. Maximum fetal bladder volumes were greater (>10 ml) during S1F in comparison to S2F in 56% of these recordings and HFUPR was significantly greater during S1F only in these cases. Bladder volumes are usually lower during S2F as a result of fetal voiding, which occurred in association with 22 of 36 transitions from S1F to S2F, and only 1 of 13 transitions from S2F to S1F (P<0.001). When disregarding calculated bladder volumes in excess of 20 ml for the purpose of calculating HFUPR, eleven recordings remained. HFUPR calculated in this way was significantly lower in comparison to measurements where larger bladder volumes were included and no difference was observed between states.

This implies that the differences observed are the result of the greater error in calculating bladder volumes and HFUPR during S1F, where volumes are usually greater and that calculation of fetal bladder volume should not be performed on the assumption that the bladder is ellipsoid in shape. Alternative techniques include limiting measurements to a maximum volume of approximately 20 ml, when the bladder is usually ellipsoid in shape or basing volume calculation on the surface area of a series of sagittal views as suggested by Hedriana and Moore [Hedriana HL, Moore TR. Ultrasonographic evaluation of human fetal urinary flow rate: accuracy of bladder volume estimations. Am J Obstet Gynecol 1994;170:1250–1254; Hedriana HL, Moore TR. Accuracy limits of ultrasonographic estimation of fetal urinary flow rate. Am J Obstet Gynecol 1994;171:989–992.]     

Megacystis secondary to congenital urethral stricture

Functional bladder capacity at a certain age can be accurately estimated and expressed as a function of age. We present a 13-year-old boy with abdominal distention who was presumed to have ascites. Abdominal ultrasound revealed that the bladder was severely distended, and cystoscopy showed a short stricture in the bulbar urethra followed by a large bladder without obvious borders. Under general anesthesia, bladder capacity was 9250 cc. Reduction cystoplasty was performed. At the 2-year follow-up, he voided spontaneously with 20 cc post-void residual urine.     

膀胱重建所需肠管的长度选择

目的探讨应用最短肠段重建基本合乎生理要求的膀胱容量的方法,以防止肠道营养性并发症。方法对膀胱、肠道和非管化肠段进行几何学分析,推导出供全膀胱替代、部分膀胱替代及膀胱扩大术时计算肠管长度的相应公式,并应用于膀胱重建手术。结果行全膀胱替代,部分膀胱替代和膀胱扩大术时,所需肠管长度计算公式分别为：L=1．54/d．（^3Vb^2的平方根）（公式一）,L=1．54．X/d．2（Vb^2的平方根）（公式二）,L=1.54／d2[（V2^2的平方根）-3（V1^2的平方根）]（公式三）。结论应用此三个公式可为膀胱重建所需肠管长度的选择提供一个参考。     

Urethral morphology and bladder instability

In order to calculate the relationship between Spinning top urethra (STU) and bladder instability 160 voiding cystourethrogramms (VCU), performed in 102 girls, have been analysed retrospectively. 28 girls had STU, 16 of those had bladder instability as well (57%). We could not find the highly positive correlation between unstable bladder and STU as reported by other authors, although there was a statistically positive correlation between STU and bladder instability. However the confidence interval was very broad (38%–75%). We conclude that bladder instability may contribute to STU but cannot render the etiological explantation for all cases. STU seems to be a polyetiological sign. In our opinion only the combination of STU and bladder instability has a diagnostic impact, since several therapeutical concepts are available in cases of bladder instability. The finding of STU in the VCU should alert the examiner's attention to functional disorders of the lower urinary tract. If no instability can be found, STU should be considered to be a normal variant.     

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.     

Urinary bladder rupture during voiding cystourethrography

Voiding cystourethrography (VCUG) is a commonly performed diagnostic procedure for the evaluation of vesicoureteral reflux with urinary tract infection or congenital renal diseases in children. The procedure is relatively simple and cost-effective, and complications are very rare. The iatrogenic complication of VCUG range from discomfort, urinary tract infection to bacteremia, as well as bladder rupture. Bladder rupture is a rare complication of VCUG, and only a few cases were reported. Bladder rupture among healthy children during VCUG is an especially uncommon event. Bladder rupture associated with VCUG is usually more common in chronically unused bladders like chronic renal failure. Presented is a case of bladder rupture that occurred during a VCUG in a healthy 9-month-old infant, due to instilled action of dye by high pressure. This injury completely healed after 7 days of operation, and it was confirmed with a postoperative cystography. The patient's bladder volume, underlying disease, velocity of the contrast media instilled, catheter size, and styles of instillation are important factors to prevent bladder rupture during VCUG. Management of bladder rupture should be individualized, but the majority of infants are treated with the operation. In conclusion, bladder rupture is a rare complication, however, delicate attention is needed in order to prevent more dire situations.     

Vesicoureteral reflux in the primate. IV. Infection as cause of prolonged high-grade reflux

High-grade reflux commonly lasts longer than moderate reflux, which disappears with maturation of the ureterovesical junction. It is known that ureteral function is affected by urinary tract infection from studies in experimental animals, as well as through clinical findings in patients with upper tract infection. Whether infection might affect the ability of the ureter to prolong high-grade reflux was questioned. This observation might explain why high-grade reflux does not disappear as rapidly as moderate reflux in children with recurrent urinary tract infections. Vesicoureteral reflux was produced surgically in combination with bladder neck obstruction using infant monkeys. The reflux thus produced was high grade with ureteral dilation and caliectasis. In the group of animals in which the bladder neck obstruction was relieved surgically, the reflux rapidly disappeared. In the other group, a bladder infection was produced with Escherichia coli at the time of release of the bladder neck obstruction. The reflux lasted significantly longer, an average of 18 months. Therefore, it appears that treatment of urinary tract infection rather than vesicoureteral reflux is the most important therapy.     

犬神经性膀胱功能障碍时神经肽类递质的分布变化

目的：观察犬神经性膀胱功能障碍时血管活性肠肽（VIP），酪神经肽（神经肽Y，NPY）和P物质（SP）在膀胱中分布的变化。探讨神经肽同神经源性膀胱功能障碍的关系。方法：采用横断犬腰骶交界处脊髓和破坏浓犬骶段脊髓的方法，建立骶上型（n=3)和骶下型（n=4)神经性膀胱动物模型，另设非脊髓损伤组（n=3)作为对照，采用免疫组织化学的方法检测膀胱颈和膀胱体中VIP、NPY和SP的分布，结果：骶上型组，膀胱体部肌层VIP分分布高于正常组；无论是在膀胱体部，还是在膀胱底部，两神经性膀胱模型组的NPY分布明显降低。SP的分布变化与NPY相似。结论：在神经源性膀胱功能障碍中，膀胱肌层的VIP、NPY和SP分布会发生变化。骶髓是调节膀胱VIP合成或／和释放的中枢，调节NPY和SP合成／释放的中枢位于骶上。另外VIP是协调膀胱和膀胱体活动的递质。     

Bladder papilloma in a 12-year-old girl

Epithelial bladder tumours are rare in childhood. A case of bladder papilloma in a 12-year-old girl is reported. Emphasis is given to the important role of ultrasound in diagnosis. Endoscopic treatment was successful and no evidence of recurrence was found at 5-year follow-up. Exposure to a chemical environmental factor (volatile shoe adhesives) is suggested as a possible cause of the tumour.     

Detection of bladder hemangioma in a child by blood-pool scintigraphy

Bladder hemangioma is a rare cause of gross hematuria. A 5-year-old boy was investigated for recurrent episodes of asymptomatic gross hematuria, but no abnormalities were found. Blood-pool scintigraphy using (99m)technetium-human serum albumin combined with diethylene triamine penta-acetic acid (DTPA) revealed an area of increased activity in the right side of the bladder, which was confirmed by cystoscopy as a bladder hemangioma. Endoscopic laser therapy was used to remove two lesions successfully that were diagnosed histologically as cavernous hemangioma. The patient had no further episodes of hematuria in the 2-year period after this treatment. This case study indicates blood-pool scintigraphy may be a useful technique for detecting bladder hemangiomas.     

Covered exstrophy associated with an anorectal malformation: A rare variant of classical bladder exstrophy

We report the case of a male newborn with covered bladder exstrophy, high anorectal malformation, and rectourethral fistula. The child had a split symphysis and diverging rectus muscles in the infraumbilical region. The ventral part of the bladder was covered with thin, fragile skin and some portions of the bladder bulged out as abdominal-wall hernias. Two of these hernias were located just above the penis, and the overlying skin showed a resemblance to scrotal skin. The penis was small and slightly laterally displaced, but otherwise normal; the child also had unilateral reflux into a dysplastic left kidney. The bladder neck and posterior urethra were patulous, but there was no urinary incontinence. The child underwent a singlestage reconstruction of the exstrophic lesion and a staged repair of the anorectal malformation. The clinical significance of this entity is discussed and the literature reviewed.     

Characteristics of the bladder in infants with urinary tract infections: an ultrasound study

BACKGROUND: Patients with urinary tract infection (UTI) are known to have impaired bladder function as demonstrated by urodynamic (UD) studies. UD is rarely performed in infants. OBJECTIVE: To evaluate bladder function in infants with UTI using a dynamic US protocol. Maximal bladder volume (MaxBV), residual volume (RV) and bladder wall thickness (BWT) were measured and compared with values from normal controls. MATERIALS AND METHODS: A total of 57 consecutive infants (47 males, 10 females; mean age 0.48+/-0.30 years) with proven UTI, and 63 age-matched normal controls (37 males, 26 females; mean age 0.47+/-0.37 years) were recruited. MaxBV was determined just before voiding, and RV and BWT were measured after spontaneous voiding. RESULTS: Infants with UTI had smaller MaxBV (34.89 vs. 42.91 ml), larger RV (3.46 vs. 1.51 ml) and greater BWT (4.21 vs. 3.68 mm) than normal infants (P<0.05, Mann-Whitney test). CONCLUSION: Smaller bladder volume, larger residual volume and thicker bladder wall in infants with UTI can be explained by bladder instability, hypercontractility and infection-induced oedema of the bladder wall during UTI. The US measurement of bladder parameters might serve as an objective guide for clinical diagnosis and allow objective evaluation of bladder function during posttreatment follow-up.