Correlation between renal sonographic measurements and differential renal function obtained from nuclear renography in children with unilateral hydronephrosis.

INTRODUCTION: Children with higher grades of hydronephrosis often undergo mercaptoacetyltriglycine nuclear renography scans (MAG3) to assess differential renal function (DRF) and drainage. Although MAG3 helps identify the potential need for pyeloplasty, its use incurs increased costs, radiation exposure, and stress for children and families. Several studies demonstrate pyramidal thickness (PT) ≤ 3 mm as a reliable predictive risk factor for pyeloplasty in children with a history of prenatal hydronephrosis. Our hypothesis was that renal sonographic measurements including PT and parenchymal thickness (ParT) correlate with DRF in children with high-grade unilateral hydronephrosis and may be used to better select the need and frequency of MAG3 scans in children at increased risk for diminished relative renal function. The objective of this project was to determine the correlation between sonographic renal measurements and DRF in patients with unilateral hydronephrosis, we assessed: 1) the correlation between PT, ParT, and the ratio of PT/ParT in hydronephrotic kidneys to DRF, 2) the correlation between the ratio of hydronephrotic PT/contralateral non-hydronephrotic PT and DRF, 3) the correlation between the ratio of hydronephrotic ParT/contralateral non-hydronephrotic ParT and DRF, and 4) the correlation between the ratio of (hydronephrotic PT/ParT)/(contralateral non-hydronephrotic PT/ParT) and DRF. MATERIALS AND METHODS: We retrospectively reviewed 71 children with grades 3 or 4 unilateral hydronephrosis. Most patients presented with a history of prenatally detected hydronephrosis at median age (IQR) of 112 days (43-274). Measurements of PT and ParT were completed on 98 renal ultrasounds and DRF was collected from corresponding MAG3 scans. Threshold values were identified visually through scatterplots. Spearman's correlation coefficient and Fisher's p-values were calculated. DISCUSSION: Ratios of PT and ParT in hydronephrotic kidneys to contralateral non-hydronephrotic kidneys were positively correlated with DRF. Ratios of hydronephrotic PT/non-hydronephrotic PT > 0.8 and hydronephrotic ParT/non-hydronephrotic ParT >0.7 occurred more frequently in patients with a DRF >40% (p = 0.11 and p = 0.001, respectively). A PT > 3 mm and ParT >5 mm occurred significantly more frequently in patients with a DRF >40% (p = 0.008 and p = 0.006, respectively). CONCLUSIONS: Renal sonographic measurements including threshold values of PT > 3 mm, ParT > 5 mm, ratio of hydronephrotic PT/contralateral non-hydronephrotic PT (>0.8), and ratio of hydronephrotic ParT/contralateral non-hydronephrotic ParT (>0.7) are good predictors of DRF >40% in unilateral high-grade hydronephrosis. These identified threshold values have potential utility in determining the need for nuclear renal scans in children with high-grade hydronephrosis.

What is the angle of a banana? The difficulty in reliable assessment of hypospadias chordee.

INTRODUCTION: The degree of chordee associated with hypospadias impacts operative management. Unfortunately, poor inter-observer reliability in assessing chordee by multiple methods in vitro has been demonstrated. This variability may be related to the fact that chordee is not a discrete angle, but rather an arc-like curvature similar to that of a banana. On an attempt to improve this variability, we assessed the inter-rater reliability of a novel method of chordee measurement and compared it to measurements with a goniometer both in vitro and in vivo. MATERIALS AND METHODS: In vitro assessment of curvature was performed using 5 bananas. In vivo chordee measurement was performed during 43 hypospadias repairs. On in vitro and in vivo cases, chordee was assessed independently by faculty and resident physicians. Angle assessment was performed in a standard manner with a goniometer and with a smartphone app using ruler measurements of the length and width of the arc (Summary Figure). The proximal and distal aspect of the arc to be measured was marked on the bananas, whereas the penile measurements were taken from the penoscrotal to the sub-coronal junctions. RESULTS: In vitro banana assessment demonstrated strong intra- and inter-rater reliability for length (0.89 and 0.88, respectively) and width measurements (0.97 and 0.96). The calculated angle demonstrated an intra- and inter-rater reliability of 0.67 and 0.67. The banana goniometer/protractor measurements were weak with an intra-rater and inter-rater reliability of 0.33 and 0.21. With hypospadias chordee, the inter-rater reliability was strong for length and width measurements (0.95 and 0.94) and 0.48 for calculated angle. The inter-rater reliability of the goniometer angle was 0.96. Further assessment of inter-rater goniometer reliability was performed relative to degree of chordee as characterized by faculty. The inter-rater reliability for ≤15°, 16-30, and ≥30° was 0.68 (n = 20), 0.34 (n = 14), and 0.90 (n = 9), respectively. When the goniometer angle was classified as ≤15, 16-30, or ≥30° by one physician, it was classified outside of this range by the other physician 23%, 47%, and 25% of the time, respectively. DISCUSSION: Our data demonstrate significant limitations of the goniometer for assessing chordee in vitro and in vivo. We were unable to demonstrate significant improvement in chordee assessment using arc length and width measurements to calculate radians. CONCLUSIONS: Reliable and precise techniques for measuring hypospadias chordee remain elusive and draw into question the validity and usability of management algorithms employing discrete values.

The utility of renal medullary pyramidal thickness measurements on the first and second postnatal ultrasound in infants with congenital hydronephrosis.

INTRODUCTION: Prior studies with postnatal ultrasound measurements of the medullary pyramid thickness (PT) demonstrate a PT < 3 mm as a significant risk factor for the diagnosis of UPJ obstruction and pyeloplasty. These studies used the postnatal ultrasound demonstrating the largest degree of hydronephrosis. Since early identification of children at increased risk of obstruction and pyeloplasty would be clinically useful, we reviewed the PT on the first and second postnatal ultrasound in infants with congenital hydronephrosis. OBJECTIVE: The aims of the study were to determine the prognostic value of: 1) PT on the first and second postnatal ultrasound, 2) a change in PT between first and second ultrasounds, and 3) ratio of PT in the hydronephrotic kidney to the contralateral PT in the normal kidney in those with unilateral hydronephrosis. We hypothesized that a smaller PT on either the first or second ultrasound, as well as a decreasing PT between the first and second ultrasound, and a decreased ratio of hydronephrotic PT to the contralateral normal kidney, would each be early predictors of subsequent pyeloplasty. STUDY DESIGN: A retrospective chart and ultrasound review of children with a diagnosis of isolated high grade (SFU grade 3 or 4) hydronephrosis was performed. This study also analyzed the impact on predictive ability of the PT obtained on an ultrasound obtained before 3 days of life compared to those in which the first ultrasound was obtained after 3 days of life. 91 infants (77 boys and 14 girls) met eligibility criteria (105 kidneys). The median age (IQR) at first ultrasound was 1.5 (1.0-15.0) days and 54.0 (27.5-123.0) days at the second ultrasound. DISCUSSION AND CONCLUSION: For the group overall, a smaller PT on both the first and second ultrasound was associated with increased risk of pyeloplasty, however, a PT obtained on an ultrasound prior to 3 days of life was not demonstrated to be predictive. Of note, PT was predictive in this same group of patients on their second ultrasound. A PT of <3 mm on an ultrasound obtained beyond 3 days of life was associated with higher risk of pyeloplasty. The PT ratio of hydronephrotic to normal contralateral kidney of the children who had their first ultrasound after 3 days of life was also significant in predicting the odds of having surgery. In addition, a decreasing PT between the first and second ultrasound was also identified as a risk factor for pyeloplasty.

Robot assisted laparoscopic partial cystectomy for inflammatory myofibroblastic tumor with simultaneous intraoperative flexible cystoscopy for tumor mapping.

Bladder masses are an infrequent occurrence rarely suspected in cases of pediatric hematuria. Inflammatory myofibroblastic tumors represent one differential diagnosis that is difficult to characterize as purely benign and should therefore be given special consideration. Although uncommon, this is an important entity to recognize for potential bladder sparing and minimally invasive surgical approaches.

Prune belly syndrome in surviving males can be caused by Hemizygous missense mutations in the X-linked Filamin A gene.

BACKGROUND: Prune belly syndrome (PBS) is a rare, multi-system congenital myopathy primarily affecting males that is poorly described genetically. Phenotypically, its morbidity spans from mild to lethal, however, all isolated PBS cases manifest three cardinal pathological features: 1) wrinkled flaccid ventral abdominal wall with skeletal muscle deficiency, 2) urinary tract dilation with poorly contractile smooth muscle, and 3) intra-abdominal undescended testes. Despite evidence for a genetic basis, previously reported PBS autosomal candidate genes only account for one consanguineous family and single cases. METHODS: We performed whole exome sequencing (WES) of two maternal adult half-brothers with syndromic PBS (PBS + Otopalatodigital spectrum disorder [OPDSD]) and two unrelated sporadic individuals with isolated PBS and further functionally validated the identified mutations. RESULTS: We identified three unreported hemizygous missense point mutations in the X-chromosome gene Filamin A (FLNA) (c.4952 C > T (p.A1448V), c.6727C > T (p.C2160R), c.5966 G > A (p.G2236E)) in two related cases and two unrelated sporadic individuals. Two of the three PBS mutations map to the highly regulatory, stretch-sensing Ig19-21 region of FLNA and enhance binding to intracellular tails of the transmembrane receptor ß-integrin 1 (ITGß1). CONCLUSIONS: FLNA is a regulatory actin-crosslinking protein that functions in smooth muscle cells as a mechanosensing molecular scaffold, transmitting force signals from the actin-myosin motor units and cytoskeleton via binding partners to the extracellular matrix. This is the first evidence for an X-linked cause of PBS in multiple unrelated individuals and expands the phenotypic spectrum associated with FLNA in males surviving even into adulthood.

Early Vs. Expectant Management of Spina Bifida Patients-Are We All Talking About a Risk Stratified Approach?

PURPOSE OF REVIEW: Advancements in the care of patients affected by myelomeningocele have flourished in recent years especially with respect to renal preservation and continence. Involvement of urologists both prenatally and early in life has driven many developments in preventative care and early intervention. As of yet, however, the ideal management algorithm that offers these patients the least invasive diagnostic testing and interventions while still preserving renal and bladder function remains ill defined. RECENT FINDINGS: In a shift from prior years where the use of surgical intervention and intermittent catheterization were more liberally employed, some providers have more recently advocated for monitoring patients in a more conservative manner with a variety of diagnostic tests until radiographic or clinical changes are discovered. The criteria used to define the need for catheterization and the timing to initiate CIC or more invasive interventions is disparate across pediatric urology and there is published data to support several approaches. This review presents some of these criteria for use of CIC and some newer evidence to support different approaches along with supporting the trend toward individualized medicine and use of risk stratification in developing clinical treatment algorithms.

Expression of urokinase-type plasminogen activator (uPA), its receptor (uPAR), and inhibitor (PAI-1) in human breast carcinomas and their clinical relevance.

Serine proteases convert plasminogen to plasmin which is involved in tissue remodeling under physiologic and pathophysiologic conditions, including breast carcinoma invasion and progression. Both urokinase-type plasminogen activator (uPA) and pro-uPA associate with uPA receptor (uPAR) on target cells, where plasminogen activator inhibitors (e.g., PAI-1) may modulate their activities. Expression levels of these factors were compared in breast carcinomas relative to patient characteristics, carcinoma features, and clinical outcome. uPA, uPAR, and PAI-1 were quantified by enzyme-linked immunosorbent assay (ELISA) in extracts of 226 biopsies while estrogen receptor (ER) and progestin receptor (PR) were determined by enzyme immunoassay (EIA) or radio-ligand binding. Each set of assays contained a novel reference specimen with known quantities of each of these five analytes. Levels in ng/mg protein of these biomarkers exhibited ranges: uPA (0-12.3); uPAR (0-19.5); PAI-1 (0-91.2). When considered independently, expression of uPA, uPAR, or PAI-1 was unrelated to patient age or menopausal status. Although no correlation was observed between each analyte with stage, grade, or ER/PR status, levels appeared to differ with pathology and nodal status. A dendrogram from hierarchical clustering of uPA, uPAR, and PAI-1 levels in 106 specimens revealed three clusters of breast cancer patients. Kaplan-Meier analyses of uPA, uPAR, and PAI-1 indicated a correlation with overall survival (OS), suggesting collective examination of these biomarkers is useful in predicting clinical outcome of breast cancer.