Outcomes of lumbar to sacral nerve rerouting for spina bifida.

PURPOSE: Restoring bladder and bowel function in spina bifida by creation of a skin-central nervous system-bladder reflex arc via lumbar to sacral nerve rerouting has a reported success rate of 87% in China. We report 1-year results of the first North American trial on nerve rerouting. MATERIALS AND METHODS: Nine subjects were enrolled in the study. Intradural lumbar to sacral nerve rerouting was performed. Subjects underwent urodynamic testing with stimulation of the cutaneous dermatome and careful neurological followup. Adverse events were closely monitored along with changes in bowel and bladder function. RESULTS: At 1 year 7 patients (78%) had a reproducible increase in bladder pressure with stimulation of the dermatome. Two patients were able to stop catheterization and all safely stopped antimuscarinics. No patient achieved complete urinary continence. The majority of subjects reported improved bowel function. One patient was continent of stool at baseline and 4 were continent at 1 year. Of the patients 89% had variable weakness of lower extremity muscle groups at 1 month. One child had persistent foot drop and the remainder returned to baseline by 12 months. CONCLUSIONS: At 1 year a novel reflex arc with stimulation of the appropriate dermatome was seen in the majority of subjects. Improvements in voiding and bowel function were noted. Lower extremity weakness was mostly self-limited, except in 1 subject with a persistent foot drop. More patients and longer followup are needed to assess the risk/benefit ratio of this novel procedure.

Venous malformations of the genitals: a therapeutic dilemma.

Venous malformations may occur anywhere in the body but are rare in the genitourinary tract and external genitalia. The authors report a case of a venous malformation in the glans penis and discuss the controversy over optimal management.

Varicocelectomy in adolescent boys: long-term experience with the Palomo procedure.

PURPOSE: We report our long-term experience with the Palomo technique for varicocele ligation in the pediatric population. MATERIALS AND METHODS: Between August 1986 and December 2006, 312 patients 7 to 21 years old (median age 14.6) underwent varicocele ligation using the Palomo technique for complete retroperitoneal ligation of the internal spermatic veins and artery. In 234 patients the varicocele was grade III, in 75 it was grade II and in 3 it was grade I. Indications for surgery were relative left testicular volume loss compared to the right testicle in 248 patients, bilateral palpable varicoceles in 8 and pain or parental preference in the remainder. Postoperative followup was 2 weeks to 10.6 years (mean 17.4 months). A total of 233 patients had at least a 6-month followup. RESULTS: Persistent varicocele was noted in 9 of 233 patients (3.9%). Of the 233 patients 68 (29%) presented with a secondary hydrocele an average of 14 months (range 18 to 1,964 days) following surgery, of whom 12 (17.6%) underwent hydrocele correction. The 12 patients who underwent hydrocelectomy represented 5% of the patients with varicocelectomy. Postoperative testicular atrophy was not documented in any patient and no other surgical complications were noted. CONCLUSIONS: The Palomo procedure for adolescent varicocele repair is safe and effective with a high success rate and low complication rate. Postoperative hydrocele formation developed in 29% of our patients. However, most secondary hydroceles were small, asymptomatic and did not require surgical correction.

US Pilot Study of Lumbar to Sacral Nerve Rerouting to Restore Voiding and Bowel Function in Spina Bifida: 3-Year Experience.

Objective. To report our experience with creating a skin-central nervous system-bladder reflex arc with intradural lumbar to sacral motor root microanastomosis to restore bladder/bowel function in spina bifida patients. Methods. Urinary/bowel changes from baseline to three years were evaluated with questionnaires, voiding diaries, urodynamics (UDS), and renal function studies. Treatment response was defined as CIC ≤ once/day with stable renal function, voiding efficiency > 50%, and no worsening of motor function. Results. Of 13 subjects (9 female, median age 8 years), 3 voided small amounts at baseline, one voided 200 cc (voiding efficiency 32%), 4/13 reported normal bowels, and 2/13 were continent of stool. Postoperatively, all had transient lower extremity weakness; one developed permanent foot drop. Over three years, renal function remained stable and mean maximum cystometric capacity (MCC) increased (P = 0.0135). In the 10 that returned at 3 years, 7 were treatment responders and 9 had discontinued antimuscarinics, but most still leaked urine. Only 2/8 with baseline neurogenic detrusor overactivity (NDO) still had NDO, all 3 with compliance <10 mL/cm H2O had normalized, 7/10 considered their bowels normal, 5/10 were continent of stool, and 8/10 would undergo the procedure again. Conclusion. Lumbar to sacral nerve rerouting can improve elimination in spina bifida patients. This trial is registered with ClinicalTrials.gov NCT00378664.

History and physical examination findings predictive of testicular torsion: an attempt to promote clinical diagnosis by house staff.

OBJECTIVE: To standardize the history and physical examination of boys who present with acute scrotum and identify parameters that best predict testicular torsion. MATERIALS AND METHODS: Over a 5-month period, a standardized history and physical examination form with 22 items was used for all boys presenting with scrotal pain. Management decisions for radiological evaluation and surgical intervention were based on the results. Data were statistically analyzed in correlation with the eventual diagnosis. RESULTS: Of the 79 boys evaluated, 8 (10.1%) had testicular torsion. On univariate analysis, age, worsening pain, nausea/vomiting, severe pain at rest, absence of ipsilateral cremaster reflex, abnormal testicular position and scrotal skin changes were statistically predictive of torsion. After multivariate analysis and adjusting for confounding effect of other co-existing variables, absence of ipsilateral cremaster reflex (P < 0.001), nausea/vomiting (P < 0.05) and scrotal skin changes (P < 0.001) were the only consistent predictive factors of testicular torsion. CONCLUSION: An accurate history and physical examination of boys with acute scrotum should be primary in deciding upon further radiographic or surgical evaluation. While several forces have led to less consistent overnight resident staffing, consistent and reliable clinical evaluation of the acute scrotum using a standardized approach should reduce error, improve patient care and potentially reduce health care costs.

A prospective, single-blind, randomized crossover trial of sacral vs pudendal nerve stimulation for interstitial cystitis.

OBJECTIVE: To compare sacral nerve stimulation (SNS) with pudendal nerve stimulation (PNS) for interstitial cystitis (IC). PATIENTS AND METHODS: Twenty-two patients with well-documented, refractory IC had a tined lead placed at S3 and a second electrode implanted at the pudendal nerve via a posterior approach. In a blinded, randomized design, each lead was tested for 7 days. The best lead was implanted to a pulse generator and patients were followed at 1, 3 and 6 months. RESULTS: The time required to place a sacral lead was 27.4 min, and a pudendal lead 19.6 min (P = 0.039). Of the 22 patients, 17 (77%) responded and had a permanent implant placed. PNS was chosen as the better lead in 77% and SNS in 24%. The order in which the lead was stimulated had no effect on the final lead implanted and there was no 'carry-over' effect. The overall reduction in symptoms was 59% for PNS and 44% for SNS (P = 0.05). At 6 months after implantation, voids improved by 41% (PNS) and 33% (SNS), and mean voided volume increased 95% and 21%, respectively; validated IC questionnaires improved markedly and complications were minimal. CONCLUSIONS: This is the first 'blinded' study of SNS vs PNS for IC. A pudendal lead was implanted successfully in all patients, and most chose PNS as better than SNS; the improvement was sustained over time.

Sacral versus pudendal nerve stimulation for voiding dysfunction: a prospective, single-blinded, randomized, crossover trial.

AIMS: The objective of the study was to compare sacral nerve stimulation (SNS) to pudendal nerve stimulation (PNS) for voiding dysfunction. METHODS: Thirty subjects with voiding dysfunction had a tined lead placed at S3 and a second electrode implanted at the pudendal nerve via a posterior approach. In a blinded, randomized fashion, each lead was tested for 7 days. Voiding diaries and questionnaires were completed and outcomes monitored. RESULTS: The time to place a sacral lead was 25.85 min, pudendal lead 23.71 min (P = 0.57). Twenty-four of 30 (80%) subjects responded and had a permanent implant placed. PNS was chosen as a superior lead in 79.2%, SNS was superior in 20.8%. The order in which the lead was simulated had no impact on the final lead implanted and no carry over effect was seen. Overall reduction in symptoms was 63% for PNS and 46% for SNS (P = 0.02). On a 7-point scale from markedly worse to markedly better, the pudendal lead was superior to sacral for pelvic pain (P = 0.024), urgency (P = 0.005), frequency (P = 0.007), and bowel function (P = 0.049). Complications were minimal. CONCLUSIONS: This is the first blinded study of sacral versus pudendal stimulation for voiding dysfunction. Successful implantation of a pudendal lead was achieved in all subjects. The majority of subjects chose PNS to be superior to SNS. More patients and longer term data is needed to confirm these promising results.