High-grade Vesicoureteral Reflux in Patients With Anorectal Malformation From the ARM-Net Registry: Is Our Screening Sufficient?

BACKGROUND: Vesico-ureteral reflux (VUR) is a common associated urological anomaly in anorectal malformation (ARM)-patients. High-grade VUR requires antibiotic prophylaxis to prevent urinary tract infections (UTI's), renal scarring and -failure. The exact prevalence of high-grade VUR in ARM patients is unknown. Hence, the aim of this study was determining the incidence of high-grade VUR in ARM-patients, and its associated risk factors. METHODS: A multicenter retrospective cohort study was performed using the ARM-Net registry, including data from 34 centers. Patient characteristics, screening for and presence of renal anomalies and VUR, sacral and spinal anomalies, and sacral ratio were registered. Phenotypes of ARM were grouped according to their complexity in complex and less complex. Multivariable analyses were performed to detect independent risk factors for high-grade (grade III-V) VUR. RESULTS: This study included 2502 patients (50 % female). Renal screening was performed in 2250 patients (90 %), of whom 648 (29 %) had a renal anomaly documented. VUR-screening was performed in 789 patients (32 %), establishing high-grade VUR in 150 (19 %). In patients with a normal renal screening, high-grade VUR was still present in 10 % of patients. Independent risk factors for presence of high-grade VUR were a complex ARM (OR 2.6, 95 %CI 1.6-4.3), and any renal anomaly (OR 3.3, 95 %CI 2.1-5.3). CONCLUSIONS: Although renal screening is performed in the vast majority of patients, only 32 % underwent VUR-screening. Complex ARM and any renal anomaly were independent risk factors for high-grade VUR. Remarkably, 10 % had high-grade VUR despite normal renal screening. Therefore, VUR-screening seems indicated in all ARM patients regardless of renal screening results, to prevent sequelae such as UTI's, renal scarring and ultimately renal failure. TYPE OF STUDY: Observational Cohort-Study. LEVEL OF EVIDENCE: III.

Study protocol for a parallel-group randomized controlled multi-center trial evaluating the additional effect of continuous ultrasound bladder monitoring in urotherapy for children with functional daytime urinary incontinence (SENS-U trial).

BACKGROUND: Lower urinary tract dysfunction or functional urinary incontinence is a common condition with a prevalence up to 21% between 6 and 8 year-old children. It is associated with an impaired quality of life, lower self-esteem, and social stigmatization. Urotherapy is the first treatment of choice for functional daytime urinary incontinence (DUI) in children. Alarm therapy can be a part of urotherapy as it provides the child adequate feedback on wetting accidents. Current alarm systems notify either at a set interval or give a notification when wetting has already occurred to prompt the child to go to the toilet. These alarms do not teach the child the interpretation of the bladder sensation preceding wetting accidents. A new wearable bladder sensor, the SENS-U, recently became available. This is a relative small, wireless ultrasonic sensor, which continuously monitors bladder filling. The SENS-U is able to provide an alarm at the exact moment voiding is warranted. It facilitates the child to learn the sensation of bladder filling preceding voiding in an easier way, increasing the learning curve throughout treatment. Its additional effect in urotherapy on continence and cost-effectiveness is to be determined. METHODS/DESIGN: This is a multi-center clinical superiority parallel-group randomized controlled trial including a total of 480 children. Participants between 6 and 16 years of age with functional DUI in which urotherapy is offered as the next treatment of choice are eligible. Four centers, two academic hospitals, and two general care (peripheral) centers are participating. Participants will be randomized at a 1:1:1 ratio into three groups: urotherapy (care as usual), urotherapy with the SENS-U added for 3 consecutive weeks throughout the training, or urotherapy with a SHAM device for 3 weeks. The primary outcome is number of wetting accidents per week after 3 months of training, compared between the SENS-U and the SHAM device. The magnitude of the placebo effect will be assessed by comparing the results of the SHAM group versus the control (care as usual) group. DISCUSSION: To our knowledge, this is the first trial studying not only the effect but also the cost-effectiveness of alarm interventions as commonly added in urotherapy. TRIAL REGISTRATION: ISRCTN44345202 . Registered on March 2022.

Long-term functional and psychosocial outcome in adolescents and young adults treated for lower urinary tract dysfunction in childhood.

BACKGROUND: Lower urinary tract dysfunction (LUTD) in childhood might affect lower urinary tract function and psychological wellbeing later in life. This study presents long-term functional outcome, psychological outcome and quality of life (QOL) of adolescents and young adults treated for childhood LUTD compared to healthy age-matched controls. In addition, association with past treatment outcomes is evaluated. STUDY DESIGN: A single-centre cross-sectional study of former patients treated in childhood (currently 16-26 years old) was conducted. Participants completed a survey composed from validated questionnaires: the Overactive Bladder Questionnaire, the Hospital Anxiety and Depression Scale, the Pediatric Quality of Life Inventory and the Short Form 36 Health Survey. RESULTS: Fifty-two former patients (out of 133) agreed to participate and returned the survey (mean age 21 ± 4.1 years). Sixty-nine control subjects were included (mean age 21 ± 2.9 years). Urinary tract symptoms were more common in former patients than controls. Storage symptoms more frequently reported were (urge) urinary incontinence, stress urinary incontinence (SUI) and nocturia. Voiding symptoms more frequently reported were intermittency and feeling of incomplete emptying, Fig. 1. There were no differences in urinary tract symptoms or urinary incontinence subdivided by childhood treatment outcome (complete response, partial response or no response), respectively p = 0.17 and p = 0.58. Results of the overactive bladder questionnaire revealed higher urinary symptom bother scores (score 14 versus 5 p < 0.01) and lower disease-specific QOL (score 95 versus 98 p = 0.02) in former patients compared to controls. General QOL and psychosocial wellbeing were not significantly different between the two groups. A childhood treatment duration extending 2,5 years was an independent prognostic factor for subsequent urinary tract symptoms later in life (OR = 1.5, 95% CI 1.1-2.0). Psychological comorbidity was more often present in former patients (35%) versus controls (10%), p < 0.01. CONCLUSION: Adolescents and young adults treated for childhood LUTD are more prone to report urinary tract symptoms later in life, especially if treatment duration was extensive. However general QOL and psychosocial wellbeing later in life are not or only mildly affected.

Hypospadias, all there is to know.

Hypospadias is one of the most common congenital anomalies in men. The condition is typically characterized by proximal displacement of the urethral opening, penile curvature, and a ventrally deficient hooded foreskin. In about 70%, the urethral meatus is located distally on the penile shaft; this is considered a mild form that is not associated with other urogenital deformities. The remaining 30% are proximal and often more complex. In these cases, endocrinological evaluation is advised to exclude disorders of sexual differentiation, especially in case of concomitant unilateral or bilateral undescended testis. Although the etiology of hypospadias is largely unknown, many hypotheses exist about genetic predisposition and hormonal influences. The goal of hypospadias repair is to achieve cosmetic and functional normality, and currently, surgery is recommended between 6 and 18 months of age. Hypospadias can be corrected at any age with comparable complication risk, functional, and cosmetic outcome; however, the optimal age of repair remains conclusive. Although long-term overall outcome concerning cosmetic appearance and sexual function is fairly good, after correction, men may more often be inhibited in seeking sexual contact. Moreover, lower urinary tract symptoms occur twice as often in patients undergoing hypospadias repair and can still occur many years after the initial repair. CONCLUSION: This study explores the most recent insights into the management of hypospadias. What is Known: • Guidelines advise referral for treatment between 6 and 18 months of age. • Cosmetic outcome is considered satisfactory in over 70% of all patients. What is New: • Long-term complications include urinary tract symptoms and sexual and cosmetic issues. • New developments allow a more individualized approach, hopefully leading to less complications and more patient satisfaction.

Therapeutic approach to Candida bezoar in children.

INTRODUCTION: Candida bezoar (CB) is a rare finding in neonates and infants with candiduria, presenting as necrotic debris with proliferating mycelia in the collecting system of the kidney. If initial antifungal medical treatment does not result in clearance of candiduria and disappearance of CB on ultrasound in dilated kidneys, invasive interventions like insertion of nephrostomy tubes (NT) or surgical interventions to drain the kidney are sometimes advocated(.). However, NT placement can be a technical challenge, especially in pre- and dysmature neonates, and NT displacement or obstruction by the CB can lead to suboptimal treatment. Identification of those children who will benefit from invasive renal drainage is important. OBJECTIVE: This study evaluates the management of patients with CB in three tertiary referral hospitals to determine criteria for intervention. MATERIALS AND METHODS: A retrospective multicenter chart analysis was conducted of children with candiduria and ultrasonographic demonstration of CB (diagnosed between March 1995 and August 2012). The indication for invasive renal drainage (if performed) and subsequent clinical outcome, serum creatinine levels and ultrasound findings were assessed. RESULTS: A total of 12 children were included, two of which were premature neonates. Eight children had congenital urogenital anomalies. One older child with acute myeloid leukemia had CB during chemotherapy and one ex-premature developed CB following cerebral candidiasis. All children received systemic antifungal medication; in seven children invasive treatment was added. Indications for invasive treatment were clinical deterioration, progressive renal dilation, pyonephrosis, rising creatinine levels and persistence of CB. Two underwent a Y-cutaneous ureterostomy and nephrostomy tubes were inserted in five children. Percutaneous renal drainage by nephrostomy led to complications in 3 of 6 procedures. In all patients, irrespective of therapeutic modality, follow-up ultrasound demonstrated no de novo changes. No additional parenchymal defects or deterioration of split renal function were seen on DMSA or MAG-3 scan. DISCUSSION: In the literature renal drainage is suggested in case of complete obstruction. However dilatation is a frequent finding in children as part of the congenital renal anomaly and does not necessarily mean that there is obstruction of the urinary tract. Even in children without candida infections the diagnosis of obstruction is not straightforward, while the results of a MAG 3 scan can be obscured by compromised kidney function, parenchymal bacterial infiltration and neonatal immaturity of the kidney. If candiduria and CB persist despite intensive medical treatment, intensive consultation is required before renal drainage, because NT insertion might be a surgical challenge. Complications such as displacement of the NT, urinoma development, or NT obstruction can occur and was seen in three of six procedures. Premature neonates seem to be more prone to complications due to their small anatomical proportions, requiring medical equipment with small diameters prone to displacement and obstruction. Some studies describe successful pharmaceutical management in the majority of patients with CB. Other studies describe unilateral surgical intervention in children with bilateral CB where unilateral drainage did not influence overall renal outcome. This is in line with our results. A limitation of the present study is its retrospective design. In this population, the motivation for invasive renal drainage or conservative management was not well documented in all cases, and was mainly based on clinical and diagnostic parameters like creatinine levels and radiographic findings. CONCLUSION: Renal drainage should be considered in selected cases after failure of systemic antifungal treatment. Inserting and maintaining a nephrostomy tube in young children is associated with a high rate of complications; conservative treatment is likely to be sufficient in the majority of patients with candiduria and CB.

The role of radioactive iodine-125 seed localization in breast-conserving therapy following neoadjuvant chemotherapy.

BACKGROUND: Neoadjuvant chemotherapy (NAC) is increasingly used in the framework of breast-conserving therapy (BCT). Localization of the initial tumor is essential to guide surgical resection after NAC. This study describes the results obtained with I-125 seed localization in BCT including NAC. PATIENTS AND METHODS: Between January 2009 and December 2010, 85 patients treated with NAC and BCT after I-125 seed localization were included. Radiological and pathological response and resection margins were retrospectively evaluated. RESULTS: BCT was carried out in 85 patients without secondary local excisions. Nineteen patients with unifocal tumors and seven patients with multifocal tumors showed a complete pathological response (P = 0.18). Tumor-free resection margins were obtained in 78 patients (50 patients with unifocal and 28 patients with multifocal tumors, P = 0.27). Focally involved margins were found in four patients (two patients with a unifocal and two patients with a multifocal tumor, P = 0.27). A subsequent mastectomy was carried out in three patients (two patients with multifocal tumors, P = 0.29). CONCLUSIONS: BCT after NAC can be carried out successfully after initial localization with I-125 seeds in both unifocal and multifocal breast tumors with complete resection rates of >90%.

Ethical issues in vesico-vaginal fistula care and research.

The plight of women in poor nonindustrialized countries who have incurred catastrophic childbirth injuries, such as vesico-vaginal and recto-vaginal fistulas, from prolonged obstructed labor is receiving increased attention from the world medical community. While the good intentions that have prompted this greater concern are not in doubt, intentions by themselves are insufficient guarantees of ethical conduct in programs developed to repair these injuries. Clinical proposals put forward to deal with the problem of fistula must undergo critical analysis to insure that basic ethical requirements are met. This article emphasizes the vulnerability to exploitation of women with obstetric fistulas and reviews the basic principles of medical ethics relevant to fistula care.

Where should obstetric vesico-vaginal fistulas be repaired: at the district general hospital or a specialized fistula center?

Expanded surgical capacities are required to treat obstetric fistulas. Achieving a balance between relative ease of access to services and use of the appropriate clinical setting is difficult. This article asks, "Are obstetric fistulas best repaired locally, at the district hospital where more women would have greater access, or is it necessary to provide these services at a tertiary referral or fistula center, where specialized surgical procedures can be conducted? Each possibility has advantages and disadvantages. The author concludes that 3 critical factors are necessary to provide safe and effective fistula repair services: adequate, long-term funding to cover the costs of all aspects of the care; the presence of a surgeon who is a "fistula champion"; and adequate operating theatre time and supplies. Without external funding, these prerequisites are almost impossible to meet at rural district hospitals.

Intraperitoneal polypropylene mesh hernia repair complicates subsequent abdominal surgery.

BACKGROUND: Prosthetic incisional hernia repair (PIHR) is superior to primary closure in preventing hernia recurrence. Serious complications have been associated with the use of prosthetic material. Complications of subsequent surgical interventions after prior PIHR in relation to its anatomical position were the objectives of this study. PATIENTS AND METHODS: Patients who underwent subsequent laparotomy/laparoscopy after PIHR between January 1992 and February 2005 at our institution were evaluated. Intraperitoneal and preperitoneal mesh was related to complication rates after subsequent surgical interventions. RESULTS: Sixty-six of 335 patients underwent re-laparotomy after PIHR. The perioperative course was complicated in 76% (30/39) of procedures with intraperitoneal placed grafts compared to 29% (8/27) of interventions with preperitoneally positioned meshes (P < 0.001). Small bowel resections were necessary in 21% of the intraperitoneal group (8/39) versus 0% in the preperitoneal group. Surgical site infection rates were higher in the intraperitoneal group (10/39, 26%, versus 1/27, 4%). Enterocutaneous fistula formation was rare and occurred in two patients after subsequent laparotomy (5%). CONCLUSIONS: Re-laparotomy after PIHR with polypropylene meshes are associated with more preoperative and postoperative complications when the mesh is placed intraperitoneally. Therefore 0intraperitoneal positioning of polypropylene mesh at incisional hernia repair should be avoided if possible.

The medical ethics of Dr J Marion Sims: a fresh look at the historical record.

Vesicovaginal fistula was a catastrophic complication of childbirth among 19th century American women. The first consistently successful operation for this condition was developed by Dr J Marion Sims, an Alabama surgeon who carried out a series of experimental operations on black slave women between 1845 and 1849. Numerous modern authors have attacked Sims's medical ethics, arguing that he manipulated the institution of slavery to perform ethically unacceptable human experiments on powerless, unconsenting women. This article reviews these allegations using primary historical source material and concludes that the charges that have been made against Sims are largely without merit. Sims's modern critics have discounted the enormous suffering experienced by fistula victims, have ignored the controversies that surrounded the introduction of anaesthesia into surgical practice in the middle of the 19th century, and have consistently misrepresented the historical record in their attacks on Sims. Although enslaved African American women certainly represented a "vulnerable population" in the 19th century American South, the evidence suggests that Sims's original patients were willing participants in his surgical attempts to cure their affliction-a condition for which no other viable therapy existed at that time.

Urinary incontinence in pregnancy and the puerperium: a prospective study.

OBJECTIVE: Pregnancy and childbirth are commonly thought to be associated with the development of urinary incontinence and lower urinary tract symptoms. The purpose of this study was to assess the relationship, if any, between pregnancy and the development of lower urinary tract symptoms. STUDY DESIGN: A prospective study of lower urinary tract symptoms was carried out in a cohort of pregnant women who answered a series of symptom questionnaires and kept a 24-hour bladder chart on which frequency of urination and volumes voided were recorded throughout pregnancy and for 8 weeks after birth. RESULTS: A total of 123 women participated in the study. Mean daily urine output (P =.01) and the mean number of voids per day (P =.01) increased with gestational age and declined after delivery. Episodes of urinary incontinence peaked in the third trimester and improved after birth (P =.001). White women had higher mean voided volumes and fewer voiding episodes than did black women. Ingestion of caffeine was associated with smaller voided volumes and greater frequency of urination. CONCLUSION: Pregnancy is associated with an increase in urinary incontinence. This phenomenon decreases in the puerperium. Pregnancy and childbirth trauma are important factors in the development of urinary incontinence among women. These findings warrant further investigation.

Birth trauma and the pelvic floor: lessons from the developing world.

Urinary incontinence, fecal incontinence, and pelvic organ prolapse are common stigmatizing conditions that afflict women far more often than they afflict men. It has been suggested that childbirth is the most likely factor to explain this great epidemiologic discrepancy between the sexes. Because the widespread availability of high-quality obstetric care through-out the industrialized world has led to precipitous drops in maternal mortality during the 20th century, many of the pathophysiologic mechanisms by which such injuries might arise are not as obvious as they were in times past. It is suggested that by looking at obstetric complications in the developing world, where the natural history of unrelieved obstructed labor is most obvious, it may be possible to shed new light on the pathophysiology of childbirth injury and its relationship to incontinence and prolapse. The spectrum of childbirth injuries resulting from obstructed labor in developing countries is surveyed, and the potential relevance of these findings to the more subtle forms of pelvic floor dysfunction seen in Western women is discussed.

Stress incontinence diagnosed without multichannel urodynamic studies.

OBJECTIVE: To determine if the clinical diagnosis of stress urinary incontinence made on the basis of simple criteria correlates with the diagnosis of genuine stress incontinence as determined by provocative multichannel urodynamic testing. METHODS: The charts of 652 women who presented for clinical evaluation of a variety of lower urinary tract complaints were reviewed if they met all of the following criteria: 1) a predominant complaint of stress incontinence, 2) positive cough stress-test results, 3) postvoid residual urine volume no more than 50 mL, 4) a functional bladder capacity of at least 400 mL as determined by a completed 24-hour frequency-volume chart, and 5) a full multichannel urodynamic evaluation. Seventy-four patients met all these criteria. The clinical diagnosis of stress incontinence was based on the presence of factors 1-4; this diagnosis then was compared with the results of provocative multichannel urodynamic testing. RESULTS: Genuine stress incontinence was confirmed in 72 (97%) of 74 patients meeting the aforementioned clinical criteria. In one patient, detrusor instability alone was demonstrated during urodynamic testing. In 11 patients with genuine stress incontinence (15%), an element of detrusor instability was also present at the time of urodynamic testing. One patient had normal urodynamic study findings, with no incontinence demonstrated. CONCLUSION: Rigorously defined clinical criteria are highly reliable in predicting the presence of genuine stress incontinence at the time of urodynamic testing. Because of the potential implications of this finding for clinical practice, further investigation is warranted.