Is there a need for endoscopic evaluation in symptomatic boys with an unsuspicious urethra on VCUG? A consideration of secondary radiologic signs of posterior urethral valves.

INTRODUCTION: A significant proportion of PUV becomes symptomatic after the perinatal period. Voiding cystourethrography (VCUG) often fails to identify PUVs. This study evaluates the relationship between the radiological appearance of the posterior urethra, potential secondary radiological signs and endoscopically documented PUV in boys with febrile UTIs, VUR, refractory symptoms of bladder overactivity or suggestive sonography findings. PATIENTS AND METHODS: Data on VCUG findings and endoscopy from 92 boys (mean age 27 months) who underwent endoscopic PUV incision between 2012 and 2017 following a VCUG were reviewed. 24 boys with endoscopically unsuspicious urethras were included as control group (mean age 27.5 months). Statistical analysis was performed using Fisher's exact test. RESULTS: In patients with PUV, the urethra was suspicious on a preoperative VCUG in 45.7%, whereas it appeared normal in 54.3%. Abortive forms of PUV were more frequently found in patients with a radiologically unsuspicious urethra (30%vs.16.7%, p = 0.15). Bladder neck hypertrophy on VCUG (16.7%vs.60.9%, OR 7.5, p < 0.001), a trabeculated bladder on VCUG (72%vs.37.5%, OR 4.3, p < 0.001) and a hypertrophied musculus interuretericus (38%vs.4.2%, OR 11.7, p < 0.001) were more common in patients with PUV and urethras appearing normal on VCUG as compared to controls. CONCLUSION: Unsuspicious findings of the urethra on VCUG cannot exclude a relevant PUV and implicate a risk of disregarding abortive forms. The presence of secondary radiologic signs of infravesical obstruction on a VCUG despite an unsuspicious posterior urethra in boys with recurrent UTI's as well as refractory symptoms of bladder overactivity or suggestive signs on sonography must be further clarified endoscopically.

Orchidopexy for bilateral undescended testes: A multicentre study on its effects on fertility and comparison of two fixation techniques.

To evaluate fertility potential after orchidopexy for bilateral undescended testis and compare two surgical fixation techniques for effect on fertility. Men older than 22 years who had either tunica albuginea orchidopexy (TAO) or "no-touch" technique (NTO) in childhood for bilateral undescended testis (BUDT) were selected. Participants filled out a questionnaire followed by physical examination, had testicular ultrasound, blood sample and semen analysis. Statistical testing was performed using general linear modelling. Sixty-seven out of 166 individuals responded. Forty-nine completed the questionnaire, and nine (18.3%) reported having fathered children. Thirty-six showed up for further examination, 26 had TAO and 10 NTO. Impaired hormonal spermatogenesis regulation (34.6% vs. 20%), higher subfertility rate (46% vs. 20%) and lower means of motile spermatozoa (58.1 × 106 spz vs. 177.9 × 106 spz) were observed in the TAO versus the NTO group; none of these were statistically significant. Four (15.4%) of the TAO and two (20%) of the NTO group have azoospermia. Although the operation technique did not have a significant impact on fertility, unfavourable outcomes were more common after surgery involving the tunica albuginea of the testis. Larger sample sizes are needed to ascertain whether the trends favouring the NTO technique are of any significance.

Proximal hypospadias treated with a transverse preputial island tube: long-term functional, sexual, and cosmetic outcomes.

OBJECTIVE: To study long-term urinary and sexual function, and cosmetic outcomes in adult patients who underwent single-stage transverse preputial island tube (TPIT) for proximal hypospadias repair in childhood. Long-term data on outcomes of patients with proximal hypospadias with severe coexisting curvature and insufficient urethral plate are scarce, but are necessary to decide which repair technique is most beneficial. PATIENTS, SUBJECTS AND METHODS: Patients with proximal hypospadias operated with TPIT (TPIT Group) were compared to patients with distal hypospadias repair (Distal Group) and to a control group of male medical students (Control Group). Participants completed the International Prostate Symptom Score, the International Index of Erectile Function (IIEF-15), additional non-validated questions, and performed uroflowmetry. Cosmesis was assessed in the patients with hypospadias using the Pediatric Penile Perception Score (PPPS); stretched penile length was also measured. RESULTS: Of the 121 eligible patients with hypospadias, 54 with either TPIT or distal hypospadias repairs participated. The TPIT Group comprised 12 patients (median age of 20.0 years) and the Distal Group comprised 42 patients (median age of 19.6 years). The complication rates were similar, at 8 of the 12 patients in the TPIT Group vs 26/42 (62%) in the Distal Group (P = 0.76). Urinary outcomes were similar in the TPIT, Distal, and the Control (comprised of 148 medical students with a median age of 21.0 years) groups. The TPIT Group had a lower maximum urinary flow rate compared to the Control Group, at 24.1 vs 28.6 mL/s (P < 0.05). IIEF-15 scores were similar in the TPIT, Distal and Control groups, except for 'Orgasmic Function' (7.5 vs 10.0 vs 10.0, respectively; P < 0.01). Although the TPIT Group had a smaller penile length compared to the Distal Group (10.1 vs 12.9 cm, P < 0.01), PPPS outcomes were similar. CONCLUSION: In these TPIT patients, long-term urinary, sexual and cosmetic outcomes were similar to those in patients with distal hypospadias repairs and controls.

Long-term effect of conservative treatment versus low threshold endoscopic desobstruction on urine incontinence and urgency in boys with persistent overactive bladder symptoms: A cohort study.

AIMS: To assess the long-term effects of two treatment strategies (low threshold endoscopic desobstruction vs. conservative treatment) on urinary incontinence (UI) and urgency-frequency in boys. METHODS: Boys with persistent overactive bladder symptoms treated in two tertiary referral centers between 2006 and 2009 were included. Treatment strategy in center 1 was urethrocystoscopy (UCS) and in case of obstruction urethral desobstruction and in center 2 conservative. The primary outcome was time to being dry during daytime, secondary outcomes were being dry both day and night and presence of urgency-frequency, using the "provisional" International Consultation on Incontinence Questionnaires Children's Lower Urinary Tract Symptoms (LUTS) questionnaire. RESULTS: Median age at start of treatment was 8.0 (IQR 6.4-9.4) years in center 1 and 8.4 (IQR 6.0-10.1) years in center 2. At baseline daytime incontinence was present in 100/104 children (96%, center 1) and 37/44 (84%, center 2). In center 1, UCS was performed in 98 (93%) boys, with desobstruction in 93 (88%), while in center 2 these numbers were 16 (36%), and 5 (11%). There were no differences between groups after a mean follow-up of 5 years concerning dryness at daytime (HR 0.86, 0.56-1.30), dryness day and night (HR 0.72, 0.51-1.14), and presence of urgency-frequency (HR 0.67, 0.38-1.25). CONCLUSIONS: The benefit of a strategy including low-threshold UCS and endoscopic desobstruction in boys with urge incontinence and suspected infravesical obstruction to prevent LUTS and incontinence on the longer term could not be confirmed.

Psychological and Physical Environmental Factors in the Development of Incontinence in Adults and Children: A Comprehensive Review.

The aim of this review was to identify etiological environmental factors related to incontinence in children and adults. A variety of etiological environmental factors for the development of incontinence were identified. In children, these encompass stressful life events and trauma, family dysfunction, parental psychopathology, school-related stressors, toilet or "potty" training, fluid consumption habits, housing conditions, and the availability of toilets. In adults, physical exercise, obesity, working conditions, fluid intake, and the availability of toilets play a role. Intervening variables such as hormonal variations due to work shifts have also been identified as influencing the likelihood of incontinence. Current research suggests that environmental factors influence the development of incontinence in children and adults. The interactions between biological factors, the immediate environment, and intervening variables need to be explored in greater detail. Practical solutions to reduce barriers to adequate fluid intake and healthy toileting habits should be implemented in school and work settings.

Prioritization and burden analysis of rare variants in 208 candidate genes suggest they do not play a major role in CAKUT.

The leading cause of end-stage renal disease in children is attributed to congenital anomalies of the kidney and urinary tract (CAKUT). Familial clustering and mouse models support the presence of monogenic causes. Genetic testing is insufficient as it mainly focuses on HNF1B and PAX2 mutations that are thought to explain CAKUT in 5­15% of patients. To identify novel, potentially pathogenic variants in additional genes, we designed a panel of genes identified from studies on familial forms of isolated or syndromic CAKUT and genes suggested by in vitro and in vivo CAKUT models. The coding exons of 208 genes were analyzed in 453 patients with CAKUT using next-generation sequencing. Rare truncating, splice-site variants, and non-synonymous variants, predicted to be deleterious and conserved, were prioritized as the most promising variants to have an effect on CAKUT. Previously reported disease-causing mutations were detected, but only five were fully penetrant causal mutations that improved diagnosis. We prioritized 148 candidate variants in 151 patients, found in 82 genes, for follow-up studies. Using a burden test, no significant excess of rare variants in any of the genes in our cohort compared with controls was found. Thus, in a study representing the largest set of genes analyzed in CAKUT patients to date, the contribution of previously implicated genes to CAKUT risk was significantly smaller than expected, and the disease may be more complex than previously assumed.

Do we manage incontinence in children and adults with special needs adequately? ICI-RS 2014.

AIMS: To review studies on the associations of incontinence and special needs in children and adults and to outline future directions in research and clinical care. MATERIALS AND METHODS: A review of literature was conducted. Open questions and future directions were discussed during the ICI-RS meeting in 2014. RESULTS: Special needs comprise a wide variety of conditions and disabilities. Individuals with special needs carry a greater risk for all types of incontinence. There is a high tendency for incontinence to persist from childhood into adulthood. Many people do not receive adequate medical care for their incontinence. CONCLUSIONS: More detailed research is needed, especially in the adult population with special needs. Assessment and treatment of incontinence should be offered routinely to all those with special needs.

Restoring penis sensation in patients with low spinal cord lesions: the role of the remaining function of the dorsal nerve in a unilateral or bilateral TOMAX procedure.

AIMS: The recently developed TOMAX-procedure restores unilateral genital sensation, improving sexual health in men with a low spinal lesion (LSL). It connects one dorsal nerve of the penis (DNP) to the intact ipsilateral ilioinguinal nerve. We proposed bilateral neurotization for full sensation of the glans but this entails cutting both DNPs, risking patients' erection/ejaculation ability. The objective was to select patients for a bilateral TOMAX-procedure by measuring remaining DNP function, and perform the first bilateral cases. METHODS: In 30 LSL patients with no penile- but normal groin sensation selected for a unilateral TOMAX-procedure the integrity of the sacral-reflex-arc and DNP function was tested pre-operatively using bilateral needle electromyography (EMG)-bulbocavernosus reflex (BCR) measurements, and an interview about reflex erections (RE) ability. RESULTS: In 13 spina bifida- and 17 spinal cord injury patients [median age 29.5 years (range 13-59 years), spinal lesion T12 (incomplete) to sacral], seven (23%) patients reported RE, four (57%) with intact BCR, and of nine (30%) patients with intact BCR, four reported RE (44%). CONCLUSIONS: Even patients with a LSL and no penile sensation can have signs of remaining DNP function, but cutting both DNPs to restore full glans sensation in a bilateral TOMAX-procedure might interfere with their RE/ejaculation. To avoid this risk, we propose a selecting-protocol for a unilateral- or bilateral procedure using RE and BCR measurements. Using this protocol, three patients were bilaterally operated with promising preliminary results. Full sensation of the glans could lead to further improvement in sexual function.

Diffusion tensor magnetic resonance imaging and fiber tractography of the sacral plexus in children with spina bifida.

PURPOSE: It is still largely unknown how neural tube defects in spina bifida affect the nerves at the level of the sacral plexus. Visualizing the sacral plexus in 3 dimensions could improve our anatomical understanding of neurological problems in patients with spina bifida. We investigated anatomical and microstructural properties of the sacral plexus of patients with spina bifida using diffusion tensor imaging and fiber tractography. MATERIALS AND METHODS: Ten patients 8 to 16 years old with spina bifida underwent diffusion tensor imaging on a 3 Tesla magnetic resonance imaging system. Anatomical 3-dimensional reconstructions were obtained of the sacral plexus of the 10 patients. Fiber tractography was performed with a diffusion magnetic resonance imaging toolbox to determine fractional anisotropy, and mean, axial and radial diffusivity in the sacral plexus of the patients. Results were compared to 10 healthy controls. RESULTS: Nerves of patients with spina bifida showed asymmetry and disorganization to a large extent compared to those of healthy controls. Especially at the myelomeningocele level it was difficult to find a connection with the cauda equina. Mean, axial and radial diffusivity values at S1-S3 were significantly lower in patients. CONCLUSIONS: To our knowledge this 3 Tesla magnetic resonance imaging study showed for the first time sacral plexus asymmetry and disorganization in 10 patients with spina bifida using diffusion tensor imaging and fiber tractography. The observed difference in diffusion values indicates that these methods may be used to identify nerve abnormalities. We expect that this technique could provide a valuable contribution to better analysis and understanding of the problems of patients with spina bifida in the future.

Cross-sectional study of determinants of upper and lower urinary tract outcomes in adults with spinal dysraphism--new recommendations for urodynamic followup guidelines?

PURPOSE: Although annual urodynamic study is currently recommended for all adults with spinal dysraphism, this followup might be overly intensive. Therefore, in this cross-sectional study we examine which determinants of upper and lower urinary tract outcomes are associated with relevant urodynamic findings. MATERIALS AND METHODS: All patients visiting our specialized outpatient clinic for adults with spinal dysraphism during a 26-month period underwent evaluation of the lower urinary tract by (video)urodynamic study. High end filling pressure (40 cm H2O or greater), poor compliance (less than 10 ml/cm H2O) and high detrusor leak point pressure (40 cm H2O or greater) were classified as relevant findings and together called unsafe bladder. Multivariable analysis was performed to reveal determinants of unsafe bladder (type of spinal dysraphism, being wheelchair bound, hydrocephalus, urological symptoms and renal dilatation) and diagnostic accuracy was calculated for the significant determinants. RESULTS: Of the 134 patients evaluated (median age 31.5 years) 120 underwent complete urodynamic study and were included in this study. In the multivariable model unsafe bladder was significantly associated with being wheelchair bound (OR 5.36, p=0.008). In patients without symptoms who were not wheelchair bound the negative predictive value of urodynamic study for finding an unsafe bladder was high (1.00). CONCLUSIONS: If an adult patient with spinal dysraphism is not wheelchair bound, unfavorable findings at urodynamic study are unlikely. If these patients are asymptomatic, these findings are even more unlikely. In these patients it is probably not necessary to perform urodynamic study as frequently as is currently recommended. Patients with an unsafe bladder need active surveillance and treatment when upper tract safety is threatened.

Spinal cord transection before scoliosis correction in myelomeningocele may improve bladder function.

AIMS: In patients with myelomeningocele (MMC) and coexistent scoliosis, a spinal cord transection (SC-transection) is sometimes performed before scoliosis correction to prevent traction on the myelum after stretching the spinal column. Performing a SC-transection may have positive effects on bladder function, especially in case of refractory detrusor-sphincter dyssynergia. This study investigates the effects of SC-transection on lower and upper urinary tract outcomes. METHODS: All children with MMC who underwent scoliosis correction (1989-2009) were retrospectively reviewed. Cases were defined as those who underwent a SC-transection before scoliosis correction, whereas the control group comprised children who had a scoliosis correction alone. Urodynamic and clinical outcomes were examined. RESULTS: A total of 7 cases and 13 controls were identified. Postoperatively, compared to the control group, cases had relatively more often improvement of compliance (improvement in 6/7 vs. 9/13) and bladder capacity (improvement in 6/7 vs. 8/13). No effect of SC-transection was found on incontinence severity, clean intermittent catheterization frequency, use of antimuscarinic drugs, or signs of renal damage on ultrasound. CONCLUSIONS: SC-transection before scoliosis correction in children with MMC without lower extremity function, may improve bladder function with respect to bladder compliance and bladder capacity. Changes in symptoms or renal ultrasound were not found. No harmful effects of SC-transection were found, indicating that this procedure can be performed safely with respect to bladder function in these patients. Whether or not SC-transection should be recommended during scoliosis correction in patients with MMC to improve bladder function requires further study.

Multi-center randomized controlled trial of cognitive treatment, placebo, oxybutynin, bladder training, and pelvic floor training in children with functional urinary incontinence.

OBJECTIVE: Functional urinary incontinence causes considerable morbidity in 8.4% of school-age children, mainly girls. To compare oxybutynin, placebo, and bladder training in overactive bladder (OAB), and cognitive treatment and pelvic floor training in dysfunctional voiding (DV), a multi-center controlled trial was designed, the European Bladder Dysfunction Study. METHODS: Seventy girls and 27 boys with clinically diagnosed OAB and urge incontinence were randomly allocated to placebo, oxybutynin, or bladder training (branch I), and 89 girls and 16 boys with clinically diagnosed DV to either cognitive treatment or pelvic floor training (branch II). All children received standardized cognitive treatment, to which these interventions were added. The main outcome variable was daytime incontinence with/without urinary tract infections. Urodynamic studies were performed before and after treatment. RESULTS: In branch I, the 15% full response evolved to cure rates of 39% for placebo, 43% for oxybutynin, and 44% for bladder training. In branch II, the 25% full response evolved to cure rates of 52% for controls and 49% for pelvic floor training. Before treatment, detrusor overactivity (OAB) or pelvic floor overactivity (DV) did not correlate with the clinical diagnosis. After treatment these urodynamic patterns occurred de novo in at least 20%. CONCLUSION: The mismatch between urodynamic patterns and clinical symptoms explains why cognitive treatment was the key to success, not the added interventions. Unpredictable changes in urodynamic patterns over time, the response to cognitive treatment, and the gender-specific prevalence suggest social stress might be a cause for the symptoms, mediated by corticotropin-releasing factor signaling pathways.

Assessing the Effects of One-Time Praziquantel Treatment on Urogenital Lesions Detected by Ultrasound in Schistosoma haematobium-Infected Individuals in Chad.

The objective was to determine the impact of a single dose of praziquantel on urogenital lesions caused by Schistosoma haematobium. Ultrasound (US) was performed on three age groups of subjects with a positive test for hematuria, with the first examination performed in November 2017 and a follow-up visit 7 months later. None of the subjects had previously received treatment. The participants were categorized into three distinct age groups: group 1 = 1-15 years, group 2 = 15-30 years, and group 3 = ≥ 30 years. A total of 250 people from these three groups underwent screening: 99 in group 1, 90 in group 2, and 61 in group 3, among whom 131 (52.4%) had at least one detectable lesion of the urogenital tract on US. Follow-up US after 7 months was possible in 60%, 67%, and 77% of the respective groups (with lesions). The anomalies disappeared in 80% of individuals in group 1, 76% of those in group 2, and 65% in group 3. With the exception of calcifications, most visible anomalies had been resolved. The total number of anomalies is low. Severe obstructive uropathy was not detected. We can conclude that single treatment with praziquantel is able to cure visible anomalies, with the exception of calcifications. The low rate of anomalies, compared with levels in the literature, is speculated to be due to undetected death by obstructive uropathy caused by S. haematobium. This requires further investigation.

Hemorrhagic cystitis in a cohort of pediatric transplantations: incidence, treatment, outcome, and risk factors.

Hemorrhagic cystitis (HC) can be a severe complication in hematopoietic stem cell transplantation (HSCT). To identify risk factors and etiology and to improve treatment, a number of factors were analyzed retrospectively in a cohort of 74 consecutive pediatric HSCTs between 2007 and 2009 in a single institution. The 74 transplantations were done in 67 children. Potential risk factors for HC were age, gender, underlying disease, ablative conditioning, graft-versus-host disease prophylaxis, unrelated donor, stem cell source, conditioning regime, acute graft-versus-host disease and cytomegalovirus reactivation. Fourteen patients developed HC (19%). In all but 4 cases (71%), HC appeared after engraftment. Severity was assessed as grade 1 in 1, grade 2 in 8, and grade 3 in 5 cases. In 79% of the patients with HC, urine samples showed BK virus. This may provide guidance for future prevention policies. In 11 children, treatment included forced hydration, spasmolytics, and bladder irrigation. Three children required cystoscopy, intravesical therapy and/or antiviral therapy. Statistical analysis revealed age over six years to be a risk factor for the development of HC. We conclude that current conditioning regimens lead to a still considerable incidence of HC in pediatric HSCT, necessitating the evaluation of screening protocols and preventive measures.

Rectal examination in children: digital versus transabdominal ultrasound.

PURPOSE: We investigate 2 diagnostic tests to assess the rectal filling state. MATERIALS AND METHODS: The rectal filling state was assessed with transabdominal ultrasound or with digital rectal examination by 2 independent investigators in children with urological problems before a scheduled diagnostic or surgical urological procedure. A dilated rectum filled with stool or large amounts of (usually) hard stool were both considered as a rectal fecal mass. All investigations were performed with the patient under general anesthesia. The kappa test was used to evaluate agreement between transabdominal ultrasound and digital rectal examination. RESULTS: A total of 84 children (54 boys) with a median (p25-p75) age of 9.0 years (6.4-11) were eligible candidates. A rectal mass was found on transabdominal ultrasound and digital rectal examination in 32% and 41% of all children, respectively, with agreement between the 2 tests in 82.5%. Cohen's kappa showed good agreement of 0.62 (95% CI 0.45-0.79) between transabdominal ultrasound and digital rectal examination. The median (IQR) diameter of the rectum was 3.3 cm (2.8-3.9) in children with a full rectum, and 2.5 cm (1.8-2.8) and 2.0 cm (1.5-2.2) in patients with a half filled and empty rectum, respectively. CONCLUSIONS: Transabdominal ultrasound is a noninvasive and reliable alternative to assess the rectal filling state, and might replace digital rectal examination in the evaluation of children with constipation.

Functional defecation disorders in children with lower urinary tract symptoms.

PURPOSE: We assessed the prevalence of functional defecation disorders, such as functional constipation and functional nonretentive fecal incontinence, in children referred to a tertiary pediatric urology outpatient clinic for lower urinary tract symptoms. MATERIALS AND METHODS: We reviewed the charts of 4 to 17-year-old patients evaluated due to lower urinary tract symptoms. All patients received a standardized bowel questionnaire and physical examination. We assessed the prevalence of pediatric functional defecation disorders according to Rome III criteria. Transabdominal ultrasound was performed to measure rectal diameter with a diameter of greater than 3 cm considered to indicate a rectal fecal mass. RESULTS: We analyzed the records of 113 patients, including 50 boys, with a median age of 8 years (IQR 6-10) who had lower urinary tract symptoms. Of the patients 46 had dysfunctional voiding and 38 had urge incontinence/overactive bladder. Rome III criteria for functional constipation and functional nonretentive fecal incontinence were fulfilled by 47% and 11% of patients with lower urinary tract symptoms, respectively. Children with dysfunctional voiding were more likely to fulfill the criteria for functional constipation than those with urge incontinence and other urological disorders (63% vs 42% and 28%, respectively, p = 0.009). Children with urge incontinence more likely fulfilled the criteria for functional nonretentive fecal incontinence than those with dysfunctional voiding and other urological disorders (21% vs 2.2% and 10%, respectively, p = 0.02). CONCLUSIONS: More than 50% of children with lower urinary tract symptoms evaluated at a tertiary referral center fulfilled the diagnostic criteria for functional defecation disorders. We recommend evaluating bowel habits as part of the initial assessment of a child who presents with urological symptoms. Future studies of the effect on urological symptoms of treating functional defecation disorders are justified.

Behavioral effects of long-term antimuscarinic use in patients with spinal dysraphism: a case control study.

PURPOSE: We explored possible associations between long-term antimuscarinic use and behavioral problems in children with spinal dysraphism and neurogenic bladder. MATERIALS AND METHODS: Children with open and closed spinal dysraphism were recruited from 2 pediatric hospitals, 1 in Amsterdam and 1 in Utrecht, The Netherlands. At the Amsterdam facility antimuscarinics were prescribed in selected patients with detrusor overactivity. At the Utrecht facility antimuscarinics were prescribed from birth onward in patients with spinal dysraphism beginning in the early 1990s. Parents of study participants were asked to fill out a Child Behavior Checklist. Demographics, data on level and type(s) of lesion, and presence of hydrocephalus with a drain (and, if applicable, number of drain revisions) were retrieved for each patient. Cases and controls (8 boys and 8 girls per group) were matched on a 1-to-1 basis. RESULTS: Data on 32 children were analyzed. Median age was 10.6 years in cases and 10.5 years in controls (p=0.877). In each group 9 of 16 patients had hydrocephalus with a drain. No significant difference in Child Behavior Checklist scores for total problems was found between cases and controls (median 52.0 vs 59.5, p=0.39). No differences were found between the groups on any subdomain of the Child Behavior Checklist. CONCLUSIONS: No significant differences in behavior were found between children with spinal dysraphism with and without long-term use of antimuscarinics.

Enterocystoplasty vs detrusorectomy: outcome in the adult with spina bifida.

PURPOSE: Bladder augmentation by enterocystoplasty or detrusorectomy might prevent renal damage, help achieve dryness and decrease the need for antimuscarinics. We compared the long-term outcomes of enterocystoplasty and detrusorectomy in adults with spina bifida. MATERIALS AND METHODS: A retrospective study using the hospital electronic database was performed. We identified 47 patients with spina bifida (median age at followup 26.8 years) who underwent either enterocystoplasty or detrusorectomy between 1988 and 2004. Median followup was 13.1 years in the detrusorectomy group and 15.3 years in the enterocystoplasty group. RESULTS: In the detrusorectomy group 4 patients with treatment failure were identified. All 4 patients underwent secondary enterocystoplasty. No reoperation was necessary in the enterocystoplasty group. Preoperative bladder volume was approximately 100 ml higher in the detrusorectomy group (not significant). There was a significantly greater improvement of median bladder volume in the enterocystoplasty group (increase of 300 vs 77.5 ml, p = 0.006). No differences in continence rate, antimuscarinic use or condition of the upper tract were found. CONCLUSIONS: In this series of 47 patients long-term outcomes were good after enterocystoplasty and detrusorectomy, although bladder volume exhibited a greater increase in the enterocystoplasty group. No differences were observed among the other outcomes. If preoperative bladder volume is sufficient, detrusorectomy can be considered before enterocystoplasty is done.

Is joint hypermobility associated with vesico-ureteral reflux? An assessment of 50 patients.

OBJECTIVE: To assess whether there is an increased prevalence of joint hypermobility in patients with vesico-ureteric reflux (VUR). MATERIALS AND METHODS: We studied 50 patients with primary VUR and matched controls drawn from a reference population. Joint mobility was assessed using the Bulbena hypermobility score. RESULTS: We identified significantly more patients with VUR with generalized joint hypermobility than controls (24% vs 6.7%, P= 0.007). CONCLUSION: Our findings confirm our clinical observation of an increased rate of joint hypermobility in patients with VUR. We speculate that an altered composition of the connective tissue may contribute to the severity of the (pre-existing) VUR phenotype.