Do repeat ultrasounds affect orchiectomy rate in patients with testicular torsion treated at a pediatric institution?

INTRODUCTION: Testicular torsion is a urological emergency; as the testicular salvage rate decreases with time, prompt intervention is required to restore the blood flow. Interhospital transfers and ultrasound examinations, while clinically essential to proper treatment and diagnosis, may adversely affect outcomes by delaying surgical intervention. Patients transferred to another institution for treatment of testicular torsion may experience a further time delay by undergoing two ultrasound examinations: one at the initial admitting institution and one at the receiving institution. To the knowledge of the authors, no study has yet explored the time delays and outcomes associated with these repeat ultrasounds. OBJECTIVE: The objective was to investigate the impact of repeat ultrasound imaging on time to treatment and patient outcomes in patients with testicular torsion. STUDY DESIGN: A retrospective chart review of 133 patients, aged 0-20 years, treated at the authors' institution for testicular torsion was conducted. Neonate patients and patients who did not receive ultrasound were excluded. Demographic and clinical variables were collected from the electronic medical record. Pearson Chi-squared and t-tests were used for univariate comparisons, and multivariate logistic regression analysis was performed to measure the relationships between variables. RESULTS: Forty-nine percent of patients were primary patients, and 51% were transfer patients. Fifty-two percent of transfer patients received repeat ultrasounds. In comparison to salvaged patients, those who underwent orchiectomy experienced a greater delay between presentation at the institution and surgical intervention (229 min vs 177 min, p = 0.048). The transfer status does not appear to be related to the outcome, i.e. orchiectomy versus salvage. Patients who underwent orchiectomy were more likely than salvaged patients to have received repeat ultrasounds (p = 0.008). Repeat ultrasound patients had three times the likelihood of orchiectomy of single ultrasound patients. In a subset analysis of transfer patients, repeat ultrasound patients were more likely than single ultrasound patients to receive an orchiectomy (p = 0.03). DISCUSSION: In agreement with previous studies, patients who underwent orchiectomy were found to experience greater treatment delays and trend toward transfer. Specifically, repeat ultrasound and time between presentation and intervention appear to influence patient outcomes. The effect of repeat ultrasound on outcomes appears to be independent of the transfer status. The study was limited by its retrospective nature and small sample size. CONCLUSION: The analysis suggests that efforts to prevent repeat ultrasounds and minimize the time between presentation and intervention would improve patient outcomes. It is proposed that standardized clinical decision-making procedures, such as the TWIST scoring system, be incorporated into hospital protocols.

Preclinical experiences with magnetic drug targeting: tolerance and efficacy.

Although site-specific direction of drugs within an organism would benefit patients with many diseases, active drug targeting is clinically not yet possible. To overcome some of the problems associated with active drug targeting, we have developed a magnetic fluid to which drugs, cytokines, and other molecules can be chemically bound to enable those agents to be directed within an organism by high-energy magnetic fields. In the first part of this study, various concentrations of the magnetic fluid were tested in rats and immunosuppressed nude mice with regard to subjective and objective tolerance. In the second part, the same parameters were evaluated after administration of the ferrofluid to which epirubicin (4'-epidoxorubicin) was chemically bound. Finally, two forms of therapy with the magnetic fluid were tested: tumor treatment by mechanical occlusion with the ferrofluid in high concentrations; and magnetic drug targeting, using small amounts of the ferrofluid as a vehicle to concentrate epirubicin locally in tumors. As a result, the ferrofluid did not cause major laboratory abnormalities; there was no LD50. With very high concentrations of the ferrofluid, animals showed lethargy for 1-2 days. There were no intolerances with the epirubicin-bound ferrofluid as well. Both forms of treatment led to complete tumor responses in an experimental human kidney as well as in a xenotransplanted colon carcinoma model. Thus, the magnetic fluid is a safe agent, which can be used in different ways for local forms of cancer treatment in conjunction with high-energy magnetic fields.

Proteomic method for the quantification of methionine sulfoxide.

Glycoxidation and lipoxidation reactions contribute to the chemical modification of proteins during the Maillard reaction. Reactive oxygen species, produced during the oxidation of sugars and lipids in these processes, irreversibly oxidize proteins. Methionine is particularly susceptible to oxidation, yielding the oxidation product methionine sulfoxide (MetSO). Here we describe a method for the analysis of MetSO using proteomic techniques. Using these techniques, we measured MetSO formation on the model protein RNase during aerobic incubations with glucose and arachidonate. We also evaluated the susceptibility of MetSO to reduction by NaBH4), a commonly used reductant in the analysis of Maillard reaction products.

Polychlorinated biphenyl serum levels in pregnant subjects with diabetes.

OBJECTIVE: Polychlorinated biphenyls (PCBs) are persistent pollutants that are ubiquitous in the food chain; detectable amounts are in the blood of nearly everyone. Their effect on humans at background levels of exposure is an area of active investigation. Increased blood levels of dioxin (2,3,7,8-tetrachlorodibenzo-p-dioxin), a PCB-like compound, have recently been reported among subjects with diabetes, suggesting that PCB levels could be similarly elevated. To test this hypothesis, we examined a group of pregnant women whose serum PCB levels had been measured and whose diabetes status had been previously recorded. RESEARCH DESIGN AND METHODS: Using stored serum from a large birth cohort study, we conducted a cross-sectional study of 2,245 pregnant women, of whom 44 had diabetes (primarily type 1) and 2,201 were control subjects. RESULTS: The adjusted mean serum level of PCBs among the subjects with diabetes was 30% higher than in the control subjects (P = 0.0002), and the relationship of PCB level to adjusted odds of diabetes was linear. CONCLUSIONS: The possibility exists that PCBs and diabetes are causality related; alternatively, the pharmacokinetics of PCBs could be altered among patients with diabetes. At any event, if the association is replicated in other studies, increased serum levels of PCBs in subjects with diabetes or their offspring may put them at increased risk of PCB-induced changes in thyroid metabolism or neurodevelopment.

Interdisciplinary pain management is beneficial for refractory orchialgia in children.

INTRODUCTION: Idiopathic testicular/groin pain can be a difficult entity for children, their families, and caregivers. The role of interdisciplinary pain management has previously been demonstrated in treating chronic orchialgia at the present pediatric pain clinic. OBJECTIVE: To evaluate the role of interdisciplinary pain management in managing refractory orchialgia. It was hypothesized that children with refractory orchialgia might respond well. Interdisciplinary care was defined as that which crosses two medical disciplines such as a surgical specialty and specialist in analgesia. SUBJECTS AND METHODS: Pediatric patients were identified who were: ≥ 10 years old; evaluated in the pediatric urology clinic between 2002 and 2012; were diagnosed wtih ICD code 608.9 or had the diagnosis of male genital disorder NOS. Children were included if they presented with orchialgia without an identifiable cause and failed conservative management (rest, scrotal support, Sitz bath, timed voiding, constipation avoidance) including conventional anti-nociceptive analgesics (acetaminophen, non-steroidal anti-inflammatory drugs, opioids). Patient electronic medical records were reviewed retrospectively. RESULTS: Twenty-two children met inclusion criteria. Mean age was 13.7 years (range 10-17). Nearly half (45%) of the children had chronic medical conditions such as asthma, allergies, and obesity. Twenty-one of the 22 children were referred to the pediatric pain clinic; 15 were evaluated, and one refused treatment. All children evaluated in the pediatric pain clinic were initially offered an empiric anti-neuropathic anti-convulsant (i.e. gabapentin) and/or an anti-depressant (i.e. amitriptyline) before being offered a nerve block. Of the 14 children accepting treatment in the pediatric pain clinic, six were treated solely with an empiric anti-neuropathic anti-convulsant and/or anti-depressant; eight received medications followed by nerve block (seven ilioinguinal-iliohypogastric blocks, one spinal and ilioinguinal-iliohypogastric block) (see Fig. 1). A total of eight of the 14 children (57%) treated by the pain clinic had resolution of pain, with 50% of those treated with medications alone (three out of six children) responding (two responding to gabapentin and a tricyclic antidepressant, one to gabapentin alone); and five out of eight (63%) treated with medications and then nerve block (ilioinguinal-iliohypogastric block) responding. Of the eight children undergoing nerve block, five required more than one block. The time between each block ranged from 4 to 22.6 weeks. Response to nerve block required an average of 1.4 procedures (range 1-2); mean follow-up after nerve block was 2.4 months (range 0.1-4.8). DISCUSSION: Children with refractory orchialgia often have comorbidities that suggest a multidisciplinary approach would be useful for treating them. The present study found that the majority of children with refractory orchialgia treated in the pediatric pain clinic responded to management. Major limitations, however, included small cohort size and short follow-up, particularly in those children undergoing nerve block. There was also no objective assessment of pain improvement or improvement in quality of life, which could be rectified with a prospective study. CONCLUSION: Collaboration and early referral for interdisciplinary pain management as one of these multidisciplinary approaches may help to coordinate care and ease patient suffering.

Pancreatic cancer and serum organochlorine levels.

Occupational exposure to p,p'-dichlorodiphenyltrichloroethane (DDT) has been associated with increased pancreatic cancer risk. We measured organochlorine levels in serum obtained at the study enrollment from 108 pancreatic cancer cases and 82 control subjects aged 32-85 years in the San Francisco Bay Area between 1996 and 1998. Cases were identified using rapid case-ascertainment methods; controls were frequency-matched to cases on age and sex via random digit dial and random sampling of Health Care Financing Administration lists. Serum organochlorine levels were adjusted for lipid content to account for variation in the lipid concentration in serum between subjects. Median concentrations of p,p'-dichlorodiphenyldichloroethylene (DDE, 1290 versus 1030 ng/g lipid; P = 0.05), polychlorinated biphenyls (PCBs; 330 versus 220 ng/g lipid; P<0.001), and transnonachlor (54 versus 28 ng/g lipid; P = 0.03) were significantly greater among cases than controls. A significant dose-response relationship was observed for total PCBs (P for trend <0.001). Subjects in the highest tertile of PCBs (> or =360 ng/g lipid) had an odds ratio (OR) of 4.2 [95% confidence interval (CI) = 1.8-9.4] compared to the lowest tertile. The OR of 2.1 for the highest level of p,p'-DDE (95% CI = 0.9-4.7) diminished (OR = 1.1; 95% CI = 0.4-2.8) when PCBs were included in the model. Because pancreatic cancer is characterized by cachexia, the impact of this on the serum organochlorine levels in cases is difficult to predict. One plausible effect of cachexia is bioconcentration of organochlorines in the diminished lipid pool, which would lead to a bias away from the null. To explore this, a sensitivity analysis was performed assuming a 10-40% bioconcentration of organochlorines in case samples. The OR associated with PCBs remained elevated under conditions of up to 25% bioconcentration.

K-ras and p53 in pancreatic cancer: association with medical history, histopathology, and environmental exposures in a population-based study.

Pancreatic cancer is a highly fatal cancer with few identified risk factors. Increased risk of pancreatic cancer in tobacco smokers and among diabetic patients is well established, and some reports have suggested associations with coffee consumption and occupational exposure to organochlorines. At present, there is little information regarding the possible association of these risk factors with the known genetic alterations found in pancreatic cancers, such as activation of the K-ras oncogene and inactivation of the p53 tumor suppressor gene. Knowledge of such relationships may help to understand the molecular pathways of pancreatic tumorigenesis. We investigated the association between these molecular defects and risk factors for pancreatic cancer in 61 newly diagnosed patients identified through an ongoing study of pancreatic cancer in the San Francisco Bay Area. Interview information was obtained regarding environmental exposures, medical history, and demographic factors. Serum levels of dichlorodiphenyltrichloroethylene (DDE) and polychlorinated biphenyls were available on a subset of 24 patients. Tumor blocks were located from local hospitals and used for K-ras mutational analysis at codon 12 and for p53 protein immunohistochemistry. The molecular analyses were facilitated through the use of laser capture microdissection, which provides a reliable method to obtain almost pure populations of tumor cells. Mutations in K-ras codon 12 were found in 46 (75%) of 61 pancreatic cancers. A prior diagnosis of diabetes was significantly associated with K-ras negative tumors (P = 0.002, Fisher's exact test). The absence of this mutation was also associated with increased serum levels of DDE, although this association was not statistically significant (P = 0.16, Wilcoxon's test). There was no difference in polychlorinated biphenyl levels between the K-ras wild-type and mutant groups. Immunohistochemical staining for p53 protein did not differ by patient characteristics or clinical history, but significant associations were found with poor glandular differentiation (P = 0.002, chi2 trend test), severe nuclear atypia (P = 0.0007, chi2 trend test), and high tumor grade (P = 0.004, chi2 trend test). Our results are suggestive of the presence of K-ras codon 12 mutation-independent tumorigenesis pathways in patients with prior diabetes and possibly in patients with higher serum levels of DDE. Our results also support a role for the p53 tumor suppressor protein in the maintenance of genomic integrity.

Serum concentrations of organochlorine compounds and the subsequent development of breast cancer.

A nested case-control study was conducted to examine the association between serum concentrations of 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene (DDE), the primary metabolite of 1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane (DDT), and polychlorinated biphenyls (PCBs) and the development of breast cancer up to 20 years later. Cases (n = 346) and controls (n = 346) were selected from cohorts of women who donated blood in 1974, 1989, or both, and were matched on age, race, menopausal status, and month and year of blood donation. Analyses were stratified by cohort participation because median DDE and PCB concentrations among the controls were 59 and 147% higher in 1974 than 1989, respectively. Median concentrations of DDE were lower among cases than controls in both time periods [11.7% lower in 1974 (P = 0.06) and 8.6% lower in 1989 (P = 0.41)]. Median concentrations of PCBs were similar among cases and controls [P = 0.21 for 1974 and P = 0.37 for 1989 (Wilcoxon signed rank test)]. The risk of developing breast cancer among women with the highest concentrations of DDE was roughly half that among women with the lowest concentrations, whether based on concentrations in 1974 [odds ratio (OR), 0.50; 95% confidence interval (CI), 0.27-0.89; P(trend) = 0.02] or in 1989 (OR, 0.53; 95% CI, 0.24-1.17; P(trend) = 0.08). The associations between circulating concentrations of PCBs and breast cancer were less pronounced but still in the same direction (1974: OR, 0.68; 95% CI, 0.36-12.9; P(trend) = 0.2; and 1989: OR, 0.73; 95% CI, 0.37-1.46; P(trend) = 0.6). Adjustment for family history of breast cancer, body mass index, age at menarche or first birth, and months of lactation did not materially alter these associations. These associations remained consistent regardless of lactation history and length of the follow-up interval, with the strongest inverse association observed among women diagnosed 16-20 years after blood drawing. Results from this prospective, community-based nested case-control study are reassuring. Even after 20 years of follow-up, exposure to relatively high concentrations of DDE or PCBs showed no evidence of contributing to an increased risk of breast cancer.

Levels of seven urinary phthalate metabolites in a human reference population.

Using a novel and highly selective technique, we measured monoester metabolites of seven commonly used phthalates in urine samples from a reference population of 289 adult humans. This analytical approach allowed us to directly measure the individual phthalate metabolites responsible for the animal reproductive and developmental toxicity while avoiding contamination from the ubiquitous parent compounds. The monoesters with the highest urinary levels found were monoethyl phthalate (95th percentile, 3,750 ppb, 2,610 microg/g creatinine), monobutyl phthalate (95th percentile, 294 ppb, 162 microg/g creatinine), and monobenzyl phthalate (95th percentile, 137 ppb, 92 microg/g creatinine), reflecting exposure to diethyl phthalate, dibutyl phthalate, and benzyl butyl phthalate. Women of reproductive age (20-40 years) were found to have significantly higher levels of monobutyl phthalate, a reproductive and developmental toxicant in rodents, than other age/gender groups (p < 0.005). Current scientific and regulatory attention on phthalates has focused almost exclusively on health risks from exposure to only two phthalates, di-(2-ethylhexyl) phthalate and di-isononyl phthalate. Our findings strongly suggest that health-risk assessments for phthalate exposure in humans should include diethyl, dibutyl, and benzyl butyl phthalates.

Organochlorine exposure and breast cancer survival.

Recent research suggests that exposure to organochlorines, such as dieldrin that possess estrogenic properties, may increase the risk of breast cancer by promoting growth of malignant cells. Whether this potential also affects malignant cells not eradicated by treatment, and thereby survival, is unknown. To evaluate this blood samples from female participants in the Copenhagen City Heart Study, Denmark, were analyzed for organochlorines. A total of 195 breast cancer cases, who each provided two blood samples that were taken in 1976-78 and 1981-83, respectively, were included in the survival analysis. Dieldrin had a significant adverse effect on overall survival and breast cancer specific survival (RR, 2.78, 95% CI, 1. 38-5.59, P trend < 0.01; RR, 2.61, 95% CI, 0.97-7.01, P trend < 0. 01). This association was strengthened when exposure was assessed as the average serum concentration of the two measurements. These findings suggest that past exposure to estrogenic organochlorines such as dieldrin may not only affect the risk of developing breast cancer but also the survival.

Evaluation of renal resistive index, maximum velocity, and mean arterial flow velocity in a hydronephrotic partially obstructed pig model.

RATIONALE AND OBJECTIVES: The authors investigate, in a controlled pig model, the usefulness of Doppler sonographic measurements of resistive index (RI), maximum velocity (Vmax), and mean velocity (Vmean) in diagnostic evaluation of the partially obstructed kidney. METHODS: Seven female pigs underwent surgical partial unilateral renal obstruction at the ureteropelvic junction. Doppler parameters of RI, Vmax, and Vmean were measured preoperatively and postoperatively in obstructed and contralateral nonobstructed kidneys. The General Linear Model multivariate analysis of variance was used for statistical analysis of data. RESULTS: There was no significant difference in the preoperative control values of RI (P = 0.71), Vmax (P = 0.27), and Vmean (P = 0.12). There was a statistically significant decrease in the Vmax and Vmean after postoperative day 5 in the obstructed kidney compared with the contralateral nonobstructed kidney (P = 0.01 and 0.03, respectively). There was no statistically significant difference in RI during the study. CONCLUSIONS: In this study, RI was not a reliable indicator of partial renal obstruction. Measurements of maximal and mean blood flow velocities reached discriminatory significance only after the fifth postobstructive day, proving insensitive in the immediate postobstructive period. Vmax and Vmean demonstrated a decrease in the partially obstructed renal collecting system after 5 days of obstruction and may serve as useful parameters in the evaluation of obstruction after the immediate acute period, when compared with a nonobstructed contralateral system.

Evidence for genetically mediated dysfunction of the central dopaminergic system in the stargazer rat.

The stargazer rat is an autosomal recessive mutant (homozygous stg/stg) that displays abnormal behavior, characterized by stereotypic head-movement, circling, and a high level of ambulatory activity. Heterozygous (stg/+) littermates display normal spontaneous behaviors. In this study, stargazers and their unaffected littermates were compared in their behavioral responses to both stimulation and inhibition of dopamine D2/D3 receptors, using quinpirole and haloperidol. Stargazers were observed to yawn a significantly fewer number of times than littermates in response to (--)-quinpirole (50 mu g/kg, IP). Haloperidol (HAL 0.1 mg/kg and 0.3 mg/kg, SC) caused a decrease in stereotypic head-movement in the mutants that was both time- and dose-dependent. In normal littermates, HAL inhibited locomotor activity and produced catalepsy in a time- and dose-dependent manner. In stargazers, both doses of HAL inhibited locomotor activity to a similar degree as in the littermates. However, no catalepsy was detectable in the mutants using 0.1 mg/kg of HAL. A dose of 0.3 mg/kg HAL was only weakly cataleptogenic. Overall, the spectrum of abnormal behaviors expressed by the stargazers and the present evidence of D2/D3 receptor subsensitivity suggest that stargazers possess a genetically mediated dysfunction of the central dopaminergic system.

Role of angiotensin in the congenital anomalies of the kidney and urinary tract in the mouse and the human.

The role of angiotensin in fluid and electrolyte and blood pressure homeostasis is well known. Recent developments indicate that angiotensin has a profound role not only in the developing urinary tract but also in the response of the urinary tract to specific noxious stimuli. Furthermore, the role of angiotensin II and its receptor has been understood quite poorly with respect to the developing renal unit. Knockout mice for the ATR2 gene show a significant incidence of congenital urinary tract anomalies. The congenital anomalies of the kidney and urinary tract (CAKUT) seen in these mice are very similar to the anomalies observed in humans. This has been supported further by the finding of an abnormality in the genetic sequence in patients with CAKUT. This article reviews experimental laboratory data as well as the potential implications for humans.

Met-enkephalin-induced vasoconstriction in the microcirculation of rat striated muscle.

Sprague-Dawley rats were anesthetized with pentobarbital (50 mg/kg) and the arterioles of the cremaster muscle were observed using television microscopy. Methionine (Met)-enkephalin was added to give bath concentrations of 10(-11) to 10(-7) M. Met-enkephalin caused a decrease in the diameter of first-order (127 +/- 7 microns), second-order (57 +/- 7 microns), and third-order (18 +/- 2 microns) arterioles, with the third-order arterioles showing the greatest reactivity. The effects of Met-enkephalin were attenuated by the opiate antagonist, naloxone, by the alpha-adrenergic receptor antagonists, phentolamine and prazosin, and by chemical sympathectomy with 6-hydroxydopamine. These results suggest that Met-enkephalin causes vasoconstriction in the striated muscle microcirculation by stimulating norepinephrine release from local nerve terminals.

Neural release of substance P causes dilation of arterioles in rat striated muscle.

Substance P, which is present in small nerve terminals and proximal to microvessels in rat strated muscle, may have a vasodilator role if released into the microcirculation. Male, Sprague-Dawley rats were anesthetized with sodium pentobarbital (50 mg/kg, i.p.) and the cremaster muscle, with intact blood supply and innervation, was suspended in a bath containing a physiological salt solution. The major autonomic innervation to the cremaster (genito-femoral nerve) was isolated and its cut, distal end was stimulated (3-5 Hz, 2 ms, 10-20 V). Diameters of third order arterioles (14-23 microns) were measured by television microscopy. Stimulation after a 20-min pretreatment with the alpha-adrenergic receptor antagonist phentolamine (2.10(-5) M) unmasked a moderate vasodilation, which was attenuated by treatment with the substance P receptor antagonist [D-Arg1,D-Pro2, D-Trp7,9,Leu11]-substance P (1.10(-6) M). This neurogenic vasodilation was not sensitive to muscarinic receptor blockade by atropine (1.10(-4) M), but was partially blocked by the beta-adrenergic receptor antagonist propranolol (1.10(-5) M). These data suggest that the rat striated muscle microvasculature is innervated with nerves containing substance P, and the release of substance P from the nerve terminals causes arteriolar dilation.

The frequency and frequency dysuria syndromes of childhood: hypercalciuria as a possible etiology.

OBJECTIVES: The syndromes of frequency and frequency dysuria of childhood are believed to have multifactorial etiologies. Hypercalciuria has been reported to be associated with the frequency dysuria syndrome and a direct cause and effect relationship has been postulated due to a positive response to treatment with hydrochlorothiazide. This study was designed to compare the urinary calciums of children with the frequency syndrome and the frequency dysuria syndrome. METHODS: Calcium screening in 30 consecutive patients with the frequency syndrome and 39 consecutive patients with the frequency dysuria syndrome is reported. RESULTS: There was no statistical difference in the urinary calcium excretion in the two groups. CONCLUSIONS: There was no significant difference in the calcium excretion in children with isolated urinary frequency or frequency dysuria. No definite cause and effect relationship to hypercalciuria could be identified in these two groups.

Autologous buccal mucosal graft for urethral reconstruction.

OBJECTIVES: The search for an adequate tissue for reconstruction of the urethra in those patients with a paucity of local skin continues. Over the past 18 months, the use of buccal mucosa as a substitution for urethra was evaluated. METHODS: Six patients who had complex hypospadias had buccal mucosa grafts for urethral reconstruction. All patients had had previous surgery for repair of chordee or significant complications from previous surgery with a result of lack of penile skin. Patients were operated on and followed for 8 to 17 months. RESULTS: Buccal mucosa was used as a rolled tube in 4 patients, an onlay graft in 1, and a folded tube in 1. A urethrocutaneous fistula that was repaired 6 months after the buccal surgery was the only complication. CONCLUSIONS: By virtue of its tissue characteristics, ease of handling, and ease of harvest, buccal mucosa is an excellent tissue for urethral reconstruction.

Isolated ureteral injury caused by blunt trauma.

OBJECTIVES: Ureteral injury is rare after blunt trauma. Herein is presented this unusual scenario of ureteral trauma in addition to the pathophysiology of this injury. METHODS: A 12-year-old boy sustained a rupture of the right ureter 6 cm below the ureteropelvic junction after a car accident. No other injuries or fractures were identified. RESULTS: Ureteral injury was immediately diagnosed and repaired primarily. Intravenous urography performed 8 weeks after surgery revealed normal ureteral healing without stricture formation. CONCLUSIONS: To our knowledge, the isolated avulsion of the ureter in this location has not been reported previously, but must be considered in those patients with severe blunt trauma and hyperextension injuries.

Medullary renal dysplasia mimicking renal tumor in the Beckwith-Wiedemann syndrome.

The known association of Wilms' tumor with the Beckwith-Wiedemann syndrome has prompted a surveillance regimen for children with this problem. Herein we report a case of medullary renal dysplasia that was a new onset by documented ultrasound. The association of medullary renal dysplasia with Beckwith-Wiedemann syndrome is discussed as well as the management of this problem.

Ureteral reimplantation: postoperative management without catheters.

We reviewed the medical records of 34 consecutive children with reflux who underwent simple ureteroneocystostomy at our institution and an affiliated hospital between 1991 and 1992. Fourteen patients were managed with ureteral and urethral catheters during the initial postoperative period, and 20 patients were managed with a "catheterless" technique employing neither of these devices. The latter group had a 50 percent decrease in length of hospital stay with 20 percent decrease in hospital costs when compared with the former. They also seemed to have less postoperative discomfort as evidenced by a 50 percent decrease in administered pain medicine. Complete follow-up was obtained in all cases, and there were no complications or failures.