RESUMEN
Potential trans-generational influence of diethylstilbestrol (DES) exposure emerged with reports of effects in grandchildren of DES-treated pregnant women and of reproductive tract tumors in offspring of mice exposed in utero to DES. Accordingly, we examined the trans-generational influence of DES on development of external genitalia (ExG) and compared effects of in utero DES exposure in CD-1 and C57BL/6 mice injected with oil or DES every other day from gestational days 12 to 18. Mice were examined at birth, and on 5-120 days postnatal to evaluate ExG malformations. Of 23 adult (>60 days) prenatally DES-exposed males, features indicative of urethral meatal hypospadias (see text for definitions) ranged from 18% to 100% in prenatally DES-exposed CD-1 males and 31% to 100% in prenatally DES-exposed C57BL/6 males. Thus, the strains differed only slightly in the incidence of male urethral hypospadias. Ninety-one percent of DES-exposed CD-1 females and 100% of DES-exposed C57BL/6 females had urethral-vaginal fistula. All DES-exposed CD-1 and C57BL/6 females lacked an os clitoris. None of the prenatally oil-treated CD-1 and C57BL/6 male and female mice had ExG malformations. For the second-generation study, 10 adult CD-1 males and females, from oil- and DES-exposed groups, respectively, were paired with untreated CD-1 mice for 30 days, and their offspring evaluated for ExG malformations. None of the F1 DES-treated females were fertile. Nine of 10 prenatally DES-exposed CD-1 males sired offspring with untreated females, producing 55 male and 42 female pups. Of the F2 DES-lineage adult males, 20% had exposed urethral flaps, a criterion of urethral meatal hypospadias. Five of 42 (11.9%) F2 DES lineage females had urethral-vaginal fistula. In contrast, all F2 oil-lineage males and all oil-lineage females were normal. Thus, prenatal DES exposure induces malformations of ExG in both sexes and strains of mice, and certain malformations are transmitted to the second-generation.
Asunto(s)
Anomalías Inducidas por Medicamentos/patología , Dietilestilbestrol/toxicidad , Genitales Femeninos/anomalías , Genitales Masculinos/anomalías , Efectos Tardíos de la Exposición Prenatal , Anomalías Inducidas por Medicamentos/etiología , Anomalías Inducidas por Medicamentos/fisiopatología , Animales , Femenino , Masculino , Ratones , Ratones Endogámicos C57BL , EmbarazoRESUMEN
The effect of neonatal exposure to diethylstilbestrol (DES), a potent synthetic estrogen, was examined to evaluate whether the CD-1 (estrogen insensitive, outbred) and C57 (estrogen sensitive, inbred) mouse strains differ in their response to estrogen disruption of male ExG differentiation. CD-1 and C57BL/6 litters were injected with sesame oil or DES (200 ng/g/5 µl in sesame oil vehicle) every other day from birth to day 10. Animals were sacrificed at the following time points: birth, 5, 10 and 60 days postnatal. Neonatally DES-treated mice from both strains had many ExG abnormalities that included the following: (a) severe truncation of the prepuce and glans penis, (b) an abnormal urethral meatus, (c) ventral tethering of the penis, (d) reduced os penis length and glans width, (e) impaired differentiation of cartilage, (f) absence of urethral flaps, and (g) impaired differentiation of erectile bodies. Adverse effects of DES correlated with the expression of estrogen receptors within the affected tissues. While the effects of DES were similar in the more estrogen-sensitive C57BL/6 mice versus the less estrogen-sensitive CD-1 mice, the severity of DES effects was consistently greater in C57BL/6 mice. We suggest that many of the effects of DES, including the induction of hypospadias, are due to impaired growth and tissue fusion events during development.
Asunto(s)
Anomalías Inducidas por Medicamentos/patología , Dietilestilbestrol/toxicidad , Estrógenos/metabolismo , Genitales Masculinos/anomalías , Receptores de Estrógenos/genética , Anomalías Inducidas por Medicamentos/etiología , Anomalías Inducidas por Medicamentos/metabolismo , Animales , Femenino , Genitales Masculinos/efectos de los fármacos , Genitales Masculinos/metabolismo , Masculino , Ratones , Ratones Endogámicos C57BL , Embarazo , Receptores de Estrógenos/metabolismo , Especificidad de la EspecieRESUMEN
PURPOSE: We hypothesized that a significant portion of sexual differentiation of mouse external genitalia occurs postnatally. To establish a baseline of normal development to which genital abnormalities could be compared, we determined morphometric measurements and morphological descriptions of the postnatal period of sexual differentiation in mice from birth to 21 days postnatally. MATERIALS AND METHODS: The external genitalia of male and female CD-1® mice were serially sectioned for histological staining. Mice were studied by age group, including ages 0 to 1, 2 to 3, 4 to 5, 10 and 21 days. Three-dimensional reconstructions were created to visually compare differences. Morphometric measurements were made of the distal mouse external genitalia and compared across age groups, and between males and females. RESULTS: The morphology of male and female mouse external genitalia is similar at 0 to 1 days but undergoes dramatic changes during 21 days. The changes include the development of mesenchymal extensions, which in males form the male urogenital mating protuberance and erectile bodies, as well as comparable structures in females. Differences in morphometric measurements in homologous males and females became pronounced during 0 to 21 days, serving as a baseline for recognizing the genesis of malformations of the mouse external genitalia. CONCLUSIONS: Male and female mouse external genitalia are similar morphologically and morphometrically at birth but achieve dramatic differences by age 21 days, suggesting that a significant portion of sexual differentiation in the mouse occurs after birth. We described these changes using novel, accurate morphometric measurements and 3-dimensional reconstruction. These results will be useful for studying abnormal sexual development of the mouse external genitalia.
Asunto(s)
Animales Recién Nacidos/anatomía & histología , Genitales Femeninos/anatomía & histología , Genitales Masculinos/anatomía & histología , Diferenciación Sexual , Animales , Femenino , Estudios de Seguimiento , Masculino , RatonesRESUMEN
The objective of this study was to perform a comprehensive morphologic analysis of developing mouse external genitalia (ExG) and to determine specific sexual differentiation features that are responsive to androgens or estrogens. To eliminate sex steroid signaling postnatally, male and female mice were gonadectomized on the day of birth, and then injected intraperitoneally every other day with DES (200 ng/g), DHT (1 µg/g), or oil. On day-10 postnatal male and female ExG were dissected, fixed, embedded, serially sectioned and analyzed. We identified 10 sexually dimorphic anatomical features indicative of normal penile and clitoral differentiation in intact mice. Several (but not all) penile features were impaired or abolished as a result of neonatal castration. Those penile features remaining after neonatal castration were completely abolished with attendant clitoral development in androgen receptor (AR) mutant male mice (X(Tfm)/Y and X/Y AR-null) in which AR signaling is absent both pre- and postnatally. Administration of DHT to neonatally castrated males restored development of all 10 masculine features to almost normal levels. Neonatal ovariectomy of female mice had little effect on clitoral development, whereas treatment of ovariectomized female mice with DHT induced partial masculinization of the clitoris. Administration of DES to neonatally gonadectomized male and female mice elicited a spectrum of development abnormalities. These studies demonstrate that the presence or absence of androgen prenatally specifies penile versus clitoral identity. Differentiated penile features emerge postnatally and are sensitive to and dependent upon prenatal or pre- and postnatal androgen. Emergence of differentiated clitoral features occurs postnatally in either intact or ovariectomized females. It is likely that each penile and clitoral feature has a unique time-course of hormonal dependency/sensitivity.
Asunto(s)
Andrógenos/deficiencia , Estrógenos/deficiencia , Genitales/crecimiento & desarrollo , Morfogénesis , Diferenciación Sexual , Andrógenos/farmacología , Animales , Castración , Dietilestilbestrol/farmacología , Dihidrotestosterona/farmacología , Estrógenos/farmacología , Estrógenos no Esteroides/farmacología , Femenino , Genitales/anatomía & histología , Masculino , Ratones , Ratones Mutantes , Morfogénesis/efectos de los fármacos , Receptores Androgénicos/genética , Diferenciación Sexual/efectos de los fármacos , Diferenciación Sexual/genéticaRESUMEN
PURPOSE: Estrogenic endocrine disruptors acting via estrogen receptors α and ß have been implicated in the etiology of hypospadias. However, the expression and distribution of estrogen receptors α and ß in normal and hypospadiac human foreskins is unknown. We characterized the location and expression of estrogen receptors α and ß in normal and hypospadiac foreskins. MATERIALS AND METHODS: We prospectively collected excess foreskin from 35 patients undergoing hypospadias repair and 15 patients undergoing elective circumcision. Hypospadias was classified as severe in 18 patients and mild in 17 based on the ectopic position of the meatus. mRNA expression levels in estrogen receptors α and ß were quantified using reverse transcriptase polymerase chain reaction. Receptor location was characterized by immunohistochemical analysis. Additionally immunohistochemical analysis was performed in 4 archived human fetal penises. RESULTS: Mean ± SD ages were similar for the circumcision (9.5±3 months) and hypospadias repair groups (9±3 months, p=0.75). mRNA expression levels in estrogen receptors α and ß were significantly decreased in hypospadiac foreskin cases compared to controls (p<0.001), while no statistically significant differences were seen between foreskins with severe and mild hypospadias. Estrogen receptor ß immunostaining was strong in normal foreskin but weak in hypospadiac foreskin. Estrogen receptor ß immunoreactivity was most intense in the stratum basale and stratum spinosum. Estrogen receptor α immunostaining was weak in normal and mild hypospadias foreskin, and undetectable in severe hypospadias. Fetal penises expressed strong estrogen receptor ß immunopositivity in the urethral plate epithelium, corpus spongiosum, corpora cavernosa and penile skin, while estrogen receptor α immunostaining was not detected. CONCLUSIONS: These data demonstrate a difference in estrogen receptor α and ß expression and location in the foreskin of patients with hypospadias compared to controls. These findings are consistent with aberrant estrogenic effects having a role in the etiology of hypospadias.
Asunto(s)
Receptor alfa de Estrógeno/análisis , Receptor alfa de Estrógeno/biosíntesis , Receptor beta de Estrógeno/análisis , Receptor beta de Estrógeno/biosíntesis , Prepucio/química , Hipospadias/metabolismo , Prepucio/patología , Humanos , Hipospadias/patología , Lactante , Masculino , Estudios ProspectivosRESUMEN
The adult mouse penis represents the end point of masculine sex differentiation of the embryonic genital tubercle and contains bone, cartilage, the urethra, erectile bodies, several types of epithelium, and many individual cell types arrayed into specific anatomical structures. Using contemporary high-resolution imaging techniques, we sought to provide new insights to the current description of adult mouse penile morphology to enable understanding of penile abnormalities, including hypospadias. Examination of serial transverse and longitudinal sections, scanning electron microscopy, and three-dimensional (3D) reconstruction provided a new appreciation of the individual structures in the adult mouse penis and their 3D interrelationships. In so doing, we discovered novel paired erectile bodies, the male urogenital mating protuberance (MUMP), and more accurately described the urethral meatus. These morphological observations were quantified by morphometric analysis and now provide accurate morphological end points of sex differentiation of mouse penis that will be the foundation of future studies to identify normal and abnormal penile development.
Asunto(s)
Ratones/anatomía & histología , Pene/ultraestructura , Animales , Imagenología Tridimensional , Masculino , Ratones Endogámicos C57BLRESUMEN
AIM: Whether or not sacrificing accessory pudendal arteries (APAs) during radical prostatectomy affects potency has been an ongoing source of concern. Herein, we present our potency results relative to sacrificing APAs in normally pre-potent men following robot-assisted radical prostatectomy (RARP). METHODS: The distribution of APAs and clinical characteristics were prospectively recorded in 200 consecutive patients undergoing RARP with a cautery-free technique. Sexual function was assessed using the International Index of Erectile Function 5-item questionnaire (IIEF-5). All APAs were sacrificed due to stapling the dorsal vein complex. MAIN OUTCOME MEASURES: Postoperatively, potency was defined by an affirmative answer to the following two questions: "Were erections adequate for penetration?" and "were the erections satisfactory?" Postoperative IIEF-5 scores and quality of erections (% of preoperative firmness: 0%, 25%, 50%, 75%, 100%) were also obtained. Subgroup analysis of patients age < or =65 years with IIEF-5 score of 22-25 was performed. RESULTS: Eighty patients (40%) had APAs. Preoperatively, there was no association with having an APA and normal/abnormal sexual function. Preoperatively, 58/200 were < or =65 years with self-administered IIEF-5 scores of 22-25. Postoperatively, 53/58 (91%) were potent at 24 months follow-up. Nineteen of 58 patients had a sacrificed APA; 39 patients had no APA. Eighteen of 19 (95%) patients with sacrificed APAs were potent vs. 35/39 (90%) with no APA present (P = 0.53). Multivariate analysis showed no significant correlation between sacrificing an APA and time of potency recovery, quality of postoperative erections (94% vs. 90% P = 0.80) or mean IIEF-5 score (22.4 vs. 20.8, P = 0.13). CONCLUSION: We found no correlation between the presence or absence of APAs and preoperative sexual function. Furthermore, after sacrificing all APAs, we found no correlation with potency return, time to return of potency, quality of erections, or mean IIEF-5 scores at 24 months.
Asunto(s)
Impotencia Vasculogénica/prevención & control , Pene/irrigación sanguínea , Complicaciones Posoperatorias/prevención & control , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Robótica/métodos , Cirugía Asistida por Computador/métodos , Anciano , Arterias/cirugía , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias de la Próstata/patologíaRESUMEN
PURPOSE: To identify surgeon specific factors for preserving sexual function (and minimize patient related factors) we report 2-year potency outcomes in men 65 years or younger with normal preoperative sexual function undergoing nerve sparing robot assisted laparoscopic radical prostatectomy. MATERIALS AND METHODS: Between July 2004 and February 2006, 200 consecutive patients underwent robot assisted laparoscopic radical prostatectomy by 1 surgeon. Inclusion criteria were age 65 years or younger with normal baseline 5-item International Index of Erectile Function score of 22 to 25 and complete 2-year followup. Postoperatively potency was defined by a yes to "erections adequate for vaginal penetration" and "satisfactory erections" on prospective self-administered validated questionnaires with or without phosphodiesterase type 5 medications. Men also reported 5-item International Index of Erectile Function scores and erectile fullness of 0% to 10%, 25%, 50%, 75% or 100% compared to before surgery. RESULTS: A total of 62 patients met the inclusion criteria, and of these 3 were lost to followup and 1 was excluded from study due to receiving hormonal therapy. At 3 months 32.1% reported potency. At 24 months potency was 89.7% (52 of 58) overall, 93.0% (40 of 43) for bilateral and 80.0% (12 of 15) for unilateral nerve sparing. For potent men the mean 5-item International Index of Erectile Function score was 20.4 at 3 months vs 21.3 at 24 months. Mean erectile firmness at 24 months was 91% compared to preoperative baseline, with 34 of 52 (65%) reporting 100% of preoperative fullness. The 5-item International Index of Erectile Function score and fullness at 24 months were equivalent for unilateral nerve sparing and bilateral nerve sparing. CONCLUSIONS: Overall 90% of men reported return of potency at 24 months, and 46% returned to baseline with normal 5-item International Index of Erectile Function scores and 100% firmness. Remarkably there was no difference in 5-item International Index of Erectile Function scores or fullness between unilateral nerve sparing and bilateral nerve sparing.
Asunto(s)
Laparoscopía , Erección Peniana , Prostatectomía/métodos , Robótica , Adulto , Anciano , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios , Factores de TiempoRESUMEN
OBJECTIVES: To analyse the impact of a approximately 50% reduction of cavernous nervous tissue on the qualitative and quantitative recovery of sexual function after unilateral (UNS) and bilateral (BNS) nerve-sparing robotic radical prostatectomy (RALP), by evaluating these differences in two groups treated with cautery and a cautery-free technique (CFT). PATIENTS AND METHODS: UNS was defined as wide-excision of one neurovascular bundle (NVB). Only men aged < or =65 years with preoperative International Index of Erectile Function (IIEF-5) scores of > or =22 were included. The cautery group comprised 42 men (of case numbers 1-125) undergoing RALP with cautery, and the CFT group (62 men of cases 151-350) had a cautery-free technique along the NVB. Data were collected prospectively using validated self-administered questionnaires. Potency was defined as two affirmative answers to: do you have erections 'adequate for vaginal penetration?' and 'Are they satisfactory?'. Patient-reported IIEF-5 scores and quality of erections (i.e. an estimate of erection as 0%, 25%, 50%, 75% or 100% of preoperative fullness) were obtained after surgery. RESULTS: In the cautery group, doubling the nerve volume increased potency by 1.36 times (UNS 50% vs BNS 68%). The results were similar in the CFT group as doubling nerve tissue increased potency by 1.15 times (UNS 80% and BNS 93%). At 24 months, comparing IIEF-5 scores, there was no difference between UNS and BNS for the cautery group, at 19.6 (95% confidence interval 15.7-23.5) vs 18.9 (16.6-21.0), or the CFT group, at 22.0 (20.2-23.8) vs 21.0 (19.8-22.1). CONCLUSIONS: Doubling the nerve volume only increased potency by 1.15-1.36 times for both the CFT and cautery groups. Furthermore, the quality of erections and IIEF-5 scores did not vary appreciably with doubling of nerve tissue.
Asunto(s)
Disfunción Eréctil/prevención & control , Erección Peniana/fisiología , Próstata/inervación , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Adulto , Anciano , Métodos Epidemiológicos , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Próstata/cirugía , Recuperación de la Función , Resultado del TratamientoRESUMEN
PURPOSE: Historically estimating prostate volume by transrectal ultrasound underestimates actual prostate weight. We quantified and determined whether trends could be identified to predict or understand the underestimation. MATERIALS AND METHODS: The characteristics transrectal ultrasound volume, pathological prostate weight and dimensions in 181 patients were entered into an electronic spread sheet. Pathological and transrectal ultrasound volume was estimated using the standard ellipsoid formula, width x height x length x pi/6. In 87 of the 181 cases transrectal ultrasound dimensions were compared to pathological dimensions. RESULTS: Using pathologically determined dimensions the ellipsoid formula accurately (+/-10%) predicted weight in 26.5% of the cases vs 13.3% by ultrasound. Transrectal ultrasound underestimated it by greater than 30% in 55% of cases and overestimated (greater than 10%) it in only 6.4%. Small vs large gland weight did not predict less underestimation. For prostate weight less than 30, 30 to 60 and more than 60 gm transrectal ultrasound underestimated by greater than 20% in 22.2%, 24.7% and 25.7% of cases, respectively. Paired analysis of transrectal ultrasound measurements and pathological dimensions revealed that transrectal ultrasound length was accurate (4.4 vs 4.3 cm) and had a good correlation with prostate weight. Height was underestimated (3.2 vs 3.7 cm) but it correlated with weight. Width was inaccurate (4.8 vs 5.2 cm) and it correlated poorly with weight. Age, prostate specific antigen, stage, Gleason score, American Urological Association symptom score and body mass index were not predictive of the underestimation. Displaced water volume in cc per prostate weight in gm showed a correlation of 0.997. CONCLUSIONS: The primary underlying factor for inconsistency with volume estimation of prostate weight appears to be the ellipsoid formula since pathologically determined dimensions still had a 75% error. Independent of gland size the transrectal ultrasound correlation underestimated weight 80% of the time by greater than 30% in 55% of patients. Contrary to previous reports, transrectal ultrasound width and not length is the least reliable factor.
Asunto(s)
Algoritmos , Tamaño de los Órganos , Próstata/patología , Neoplasias de la Próstata/patología , Humanos , Procesamiento de Imagen Asistido por Computador , Masculino , Valor Predictivo de las Pruebas , Próstata/diagnóstico por imagen , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/cirugía , Reproducibilidad de los Resultados , UltrasonografíaRESUMEN
PURPOSE: To review, compare, and contrast recovery of potency after robot-assisted radical prostatectomy with specific regard to thermal and excisional nerve injury. Our goal was to compare intensity of injury and ability to recover potency in order to stratify risk by injury type. METHODS: We compare potency outcomes in our first 500 consecutive cases of robot-assisted radical prostatectomy. This is a retrospective review of data collected prospectively into an electronic database. Preoperative inclusion criteria were age less than 66 years, International Index of Erectile Function Score of 22-25, and unilateral or bilateral nerve preservation. Potency data were collected via patient-reported validated questionnaires. Potency was defined with two affirmative responses to: "erections hard enough for sexual intercourse" and were they "satisfactory." Results were collated and graphically analyzed so that time-line comparisons of recovery could be evaluated. RESULTS: Time-line curves were generated comparing recovery of sexual function over 2 years after nervesparing techniques using cautery versus cautery-free and unilateral versus bilateral nerve preservation. Use of no cautery improved early return of sexual function 4.7-fold over cautery. Whether using cautery or cautery-free techniques, a doubling of nerve tissue from one nerve to two nerves spared only resulted in a 1.2-fold improvement of potency recovery both early and long-term. CONCLUSIONS: In our experience, avoidance of thermal injury produces nearly a 5-fold improvement in early return of sexual function. Furthermore, thermal injury appears to induce a dense but largely recoverable injury after 2 years. In contrast to common belief, our results demonstrated that preservation of just one nerve will, in the majority of patients, result in similar potency recovery to that with two nerves preserved. Crossover innervation of the one nerve is favored over compensation and hints that techniques that increase nerve volume at the expense of positive surgical margins may need careful introspection.
Asunto(s)
Cauterización/efectos adversos , Disfunción Eréctil/etiología , Pene/inervación , Prostatectomía/efectos adversos , Adulto , Anciano , Disfunción Eréctil/prevención & control , Humanos , Masculino , Persona de Mediana Edad , Prostatectomía/métodosRESUMEN
Positive surgical margins represents incomplete resection by the surgeon, and the elimination of positive margins represents the only clinical feature during radical prostatectomy that can lead directly to improved cancer outcomes. The introduction of new robot-assisted technology and technical refinements has led to declines of positive surgical margins. Although margins induced by incomplete cancer resection by the surgeon have been reduced for organ-confined disease, the 'Holy Grail' of zero margins is not yet attainable in prostatectomy, and is more problematic in cancer that has penetrated beyond the prostate. Intraoperative frozen biopsies are imprecise. The union of real-time optical coherence tomography technology of the da Vinci robotic platform for identification of positive margin sites, and technical advances with wider excisions during surgery may provide promise for further reduction of surgical margins to zero.
Asunto(s)
Laparoscopía , Prostatectomía , Neoplasias de la Próstata/cirugía , Robótica , Cirugía Asistida por Computador , Tomografía de Coherencia Óptica , Humanos , Masculino , Invasividad Neoplásica , Recurrencia Local de Neoplasia/prevención & control , Estadificación de Neoplasias , Prostatectomía/instrumentación , Neoplasias de la Próstata/patología , Robótica/instrumentación , Cirugía Asistida por Computador/instrumentación , Tomografía de Coherencia Óptica/instrumentación , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: During nerve-sparing robot-assisted laparoscopic prostatectomy, nerve injury caused by thermal energy is a concern. Using a porcine model, we studied thermal spread and queried whether vessels such as the prostatic pedicle may act as a heat sink, reducing the spread of thermal energy. MATERIALS AND METHODS: Monopolar (MP) and bipolar (BP) cautery was applied laparoscopically on the anterior abdominal wall surface of six pigs with the da Vinci robot. Using fiberoptic thermometry (Luxtron Inc. Santa Clara, CA), temperatures were recorded with and without the interposed inferior epigastric vessels to evaluate the heat sink effect. RESULTS: Interposition of the inferior epigastric vessels definitively demonstrated a heat sink phenomenon: at 7 mm from the MP/BP energy source, temperatures rose 10.7 degrees C to 13.8 degrees C without interposed vessels versus only 1.9 degrees C to 2.5 degrees C when vessels were interposed (P < 0.001). CONCLUSION: The heat sink phenomenon suggests that the prostatic vascular pedicle should be protective of the neurovascular bundle during transection of the bladder neck during laparoscopic prostatectomy.
Asunto(s)
Electrocoagulación/métodos , Prostatectomía/métodos , Robótica/métodos , Animales , Electrocoagulación/efectos adversos , Calor , Masculino , Próstata/irrigación sanguínea , Próstata/inervación , Porcinos , Conductividad TérmicaRESUMEN
OBJECTIVE: Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA) syndrome is a rare syndrome characterized by mullerian and renal anomalies. Renal agenesis is classically considered to be part of the definition of OHVIRA syndrome. There are increasing reports that the lack of an ipsilateral kidney on imaging studies is not from true renal agenesis but renal dysplasia and atrophy. We have observed cases where this ipsilateral dysplastic and atrophic kidney leads to clinical symptoms. The objective of this study is to report cases of OHVIRA syndrome where an ipsilateral dysplastic and atrophic kidney led to clinical symptoms, and to raise awareness in the pediatric urology community of this variant of OHVIRA syndrome. MATERIAL AND METHODS: All cases of OHVIRA syndrome with an ipsilateral dysplastic and atrophic kidney were identified from January 2010 to June 2013. The patient's presentation, clinical course, surgical management, radiologic findings, and pathologic finding were reviewed. RESULTS: There were three cases of OHVIRA syndrome with a symptomatic ipsilateral dysplastic and atrophic kidney identified. All three of these dysplastic and atrophic kidneys had an ectopic ureter to the obstructed hemivagina and led to persistent vaginal drainage after resection of the vaginal septum. These dysplastic and atrophic kidneys were not visualized on any imaging studies. Laparoscopic removal of the dysplastic and atrophic kidney led to cessation of vaginal drainage in all cases. CONCLUSION: This study reports additional cases to the literature that do not fit the classic definition of OHVIRA syndrome. In the cases in this study, there was no ipsilateral renal agenesis, but an ipsilateral dysplastic and atrophic kidney with an ectopic ureter to the obstructed hemivagina. In addition, these cases demonstrate that the dysplastic and atrophic kidney may cause symptoms such as persistent vaginal drainage after resection of vaginal septum. The dysplastic and atrophic kidneys may not be detected by any imaging modality including MRI and DMSA scan and may be ectopic in location. All three of our cases had persistent vaginal drainage after resection of the vaginal septum which was cured by removal of the dysplastic and atrophic kidney ipsilateral to the obstructed hemivagina. The limitations of this study include the small number of patients and retrospective nature. While the classic definition of OHVIRA syndrome includes ipsilateral renal agenesis, there is increasing evidence that the absence of a kidney on imaging is due to renal dysplasia and atrophy and not true renal agenesis. In addition, we have observed that this dysplastic and atrophic kidney may cause clinically significant issues such as persistent vaginal drainage through an ectopic ureter to the ipsilateral hemivagina after resection of vaginal septum. This small dysplastic and atrophic kidney may not be visualized on imaging studies and laparoscopy can be diagnostic and therapeutic if indicated. Ipsilateral renal anomalies, not ipsilateral renal agenesis, should be considered part of the definition of OHVIRA syndrome. Pediatric urologists need to be aware of the spectrum of renal anomalies in OHVIRA syndrome.
Asunto(s)
Anomalías Múltiples/diagnóstico , Anomalías Congénitas/diagnóstico , Enfermedades Renales/congénito , Pelvis Renal/patología , Riñón/anomalías , Uréter/anomalías , Vagina/anomalías , Enfermedades Vaginales/diagnóstico , Anomalías Múltiples/cirugía , Adolescente , Atrofia/patología , Biopsia con Aguja , Niño , Constricción Patológica/diagnóstico , Femenino , Humanos , Inmunohistoquímica , Enfermedades Renales/diagnóstico , Pelvis Renal/cirugía , Imagen por Resonancia Magnética/métodos , Enfermedades Raras , Síndrome , Tomografía Computarizada por Rayos X/métodos , Enfermedades Vaginales/congénitoRESUMEN
OBJECTIVE: To better understand parental beliefs regarding the etiology and treatment of nocturnal enuresis (NE). METHODS: A self-administered survey queried parental NE beliefs including perceived etiologies and home behavioral treatments. We assessed for associations between demographic characteristics and propensity to seek medical care for NE. RESULTS: Of 216 respondents, 78% were female. The most common causes for NE reported were: deep sleeper (56%), unknown (39%), and laziness (26%). Popular home behavioral therapies included: void prior to sleep (77%) and limiting fluid intake at night (71%). Few reported they would use a bedwetting alarm (6%). Fifty-five percent reported they would seek medical care for NE and 28% reported awareness of effective treatments. On multivariable analysis, females (OR 2.3, 95% CI 1.04-5.0) and those with graduate level education (OR 4.8, 95% CI 1.5-15.7) were more likely to seek medical care for their child with NE. CONCLUSIONS: General parental knowledge of the causes and effective treatments for NE is lacking. Only 55% reported they would seek medical care for their child with NE and only 28% reported awareness of effective treatments. Counseling should focus on dispelling common misconceptions about causes and treatments of NE and focus on proven effective treatments.
Asunto(s)
Actitud Frente a la Salud , Enuresis Nocturna/psicología , Enuresis Nocturna/terapia , Padres/psicología , Aceptación de la Atención de Salud/psicología , Adulto , Niño , Consejo , Recolección de Datos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
Adult external genitalia (ExG) are the endpoints of normal sex differentiation. Detailed morphometric analysis and comparison of adult mouse ExG has revealed 10 homologous features distinguishing the penis and clitoris that define masculine vs. feminine sex differentiation. These features have enabled the construction of a simple metric to evaluate various intersex conditions in mutant or hormonally manipulated mice. This review focuses on the morphology of the adult mouse penis and clitoris through detailed analysis of histologic sections, scanning electron microscopy, and three-dimensional reconstruction. We also present previous results from evaluation of "non-traditional" mammals, such as the spotted hyena and wallaby to demonstrate the complex process of sex differentiation that involves not only androgen-dependent processes, but also estrogen-dependent and hormone-independent mechanisms.
Asunto(s)
Clítoris/anatomía & histología , Pene/anatomía & histología , Diferenciación Sexual , Animales , Clítoris/crecimiento & desarrollo , Clítoris/ultraestructura , Femenino , Humanos , Masculino , Tamaño de los Órganos , Pene/crecimiento & desarrollo , Pene/ultraestructuraRESUMEN
Vesicoureteral reflux (VUR) affects approximately 1% of children and may predispose a child with a bladder infection to develop pyelonephritis and renal scarring. To prevent these potential sequelae, one accepted treatment option for VUR includes low-dose continuous antibiotic prophylaxis (CAP) to maintain urine sterility until the condition resolves. Despite the widespread use of CAP, little data exists regarding adherence to long-term antibiotic therapy. Not only will poor adherence to CAP potentially preclude the intended benefit, but also nonadherence with antibiotic regimens may carry untoward effects including unnecessary treatment changes for presumed antibiotic failure, emergence of resistant organisms, and compromised clinical trial outcomes. We present an overview of medication adherence in children with VUR, discuss possible consequences of nonadherence to antibiotic prophylaxis, and suggest ways to improve adherence. We raise awareness of issues related to nonadherence relevant to healthcare providers, investigators, and the community.
RESUMEN
Open and laparoscopic radical prostatectomy is a safe and effective treatment for organ-confined prostate cancer with excellent cancer control and quality of life outcomes. We present current nerve-sparing techniques used in open, laparoscopic and robot-assisted prostatectomy to maximize postoperative potency. We review the literature and describe important anatomical landmarks and technical aspects that differentiate between approaches. Nerve trauma is inherent to the surgery and cannot be completely avoided. These techniques serve to minimize injury without compromising oncologic outcomes. In combination with postoperative pharmacological and mechanical recuperative approaches, nerve-sparing surgery has made an impact in postprostatectomy quality of life.
Asunto(s)
Próstata/inervación , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Disfunción Eréctil/etiología , Disfunción Eréctil/prevención & control , Humanos , Complicaciones Intraoperatorias/prevención & control , Laparoscopía/efectos adversos , Masculino , Traumatismos de los Nervios Periféricos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Próstata/irrigación sanguínea , Próstata/patología , Próstata/cirugía , Prostatectomía/efectos adversos , Neoplasias de la Próstata/patología , Calidad de Vida , RobóticaRESUMEN
Patients undergoing radical prostatectomy are at increased risk of development of post-operative inguinal hernias (IH). We present the largest series of transperitoneal combined robotic-assisted laparoscopic prostatectomy (RALP) and IH. After IRB approval, data from patients undergoing RALP at two centers were prospectively entered into a database and analyzed. IH were repaired robotically via a transperitoneal route with mesh. Between June 2002 and May 2007, 837 RALPs were performed, 80 of which included combined IH repair (9.6%), by two surgeons, T.A. and D.S. Forty-two patients (52.5%) had IH on pre-operative exam. Twenty-four hernias were left, 32 right, and 24 bilateral. Twenty-two patients had prior ipsilateral or contralateral herniorrhaphy. After dissection of the hernia sac, a swatch of flat Marlex mesh (n = 22), a polypropylene mesh plug (n = 19), an Ultrapro hernia system (n = 7), a Proceed coated mesh (n = 19), a 3D-Max (n = 37), a combination of both umbrella and flat mesh (n = 3), or suture alone (n = 2) was used. Inguinal herniorrhaphy added approximately 15 min of operative time in all cases. There was one hernia recurrence over an average follow-up period of 12.5 months (0.2-52 months). There was one complication attributable to IH repair-a urine leak which was attributed to anastomotic stretch due to reperitonealization. Urological surgeons should perform a thorough inguinal exam during preoperative evaluation and intraoperatively to detect subclinical inguinal hernias. Inguinal herniorrhaphy at the time of RALP is safe and should be routinely performed.
RESUMEN
PURPOSE: We report our 8-year experience with 1-stage open urethral reconstruction in 10 patients with recurrent bulbar and/or membranous strictures after UroLume urethral stent placement. MATERIALS AND METHODS: Ten consecutive referral patients underwent preoperative contrast imaging and urethroscopy followed by primary anastomotic repair or substitution urethroplasty, with concomitant open UroLume removal (when the stent was still present). Postoperative evaluation included contrast imaging 3 weeks after surgery, urethroscopy 4 months after surgery, uroflowmetry, and American Urological Association symptom score assessment. RESULTS: At a medium followup of 51.2 months all patients remain free of bulbar or membranous stricture recurrence. No patient has required dilation or any other intervention. CONCLUSIONS: One-stage open reconstruction with stent extraction offers a definitive treatment option with a high success rate for patients with recurrent bulbar and/or membranous strictures following urethral stent placement.