Application of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement to publications on endoscopic treatment for vesicoureteral reflux.

OBJECTIVE: Following an increasing number of submissions on endoscopic treatment of vesicoureteral reflux (VUR), the Journal of Pediatric Urology sought to establish a quality guideline that would enable reviewers to select the best papers for publication in the journal. The "Strengthening the Reporting of Observational Studies in Epidemiology" (STROBE) Statement, established in 2007, is a 22-item checklist designed to assist with clear reporting of observational studies. This checklist includes a description of methodological items and instructions on how to use them to transparently report observational studies. The aim of the present study was to apply the STROBE principle to observational studies about endoscopic management of VUR, and to establish a "check-list" to assist authors with good-quality submissions. STUDY DESIGN: The 22 STROBE criteria were listed and applied to publications on endoscopic treatment by utilizing examples from the current literature, with additional suggestions about how future studies could build upon the information already published on the subject. RESULTS: Based on this strategy, a checklist that is particular to endoscopic treatment studies was produced as a guideline for authors and reviewers. DISCUSSION: Application of the STROBE statement principles, in combination with key VUR data, will allow better quality submissions and a higher chance of positive reviews and acceptance rates.

Detailed evaluation of the upper urinary tract in patients with prune belly syndrome using magnetic resonance urography.

INTRODUCTION: Magnetic resonance urography (MRU) has proven to be useful in the setting of complex urologic anatomy. Prune belly syndrome (PBS) patients are known to have malformed and highly variable urinary tract anatomy due to significant dilation and renal dysplasia. OBJECTIVE: To further characterize the renal and ureteral anatomy and renal function in patients with PBS via MRU. STUDY DESIGN: Children with PBS undergoing MRU (2006-2011) were identified. Studies were performed to evaluate severe hydronephrosis in all patients. Demographics, previous imaging, and MRU findings were collected. A single radiologist reviewed all studies. RESULTS: MRU was performed on 13 boys, with a median age of 29.3 months (IQR 6-97). Two patients underwent >1 study for ureteropelvic junction obstruction (UPJ obstruction) and calyceal diverticulum with a solitary kidney, respectively. Hydroureteronephrosis (HUN) was identified in 12 boys (92%), while one (8%) did not have ureteral dilation. All patients demonstrated morphologic abnormalities beyond HUN as follows: five (38%) renal dysplasia; five (38%) scarring; four (31%) calyceal diverticula; and three (23%) thickened bladder. The median renal transit time (RTT) was 6 min (IQR 3.5-10.5), and >8 min (range 8.5-35) in six patients; one patient was ultimately diagnosed with obstruction. The mean serum creatinine was 0.5 ± 0.3 mg/dl. This summary figure is a coronal excretory phase T1 MRU image demonstrating absence of well-defined calyces and a 5-cm calyceal diverticulum (white arrow). DISCUSSION: This study reports significant anatomic and functional findings on MRU that were not readily apparent when using standard imaging for children with PBS. The high-resolution images and functional data obtained with MRU allowed for visualization of calyceal diverticula and abnormal renal pelvic anatomy not previously described in PBS. In addition, renal dysplasia could be identified with MRU, which is badly characterized in the PBS population outside of renal biopsy studies. Potential limitations of the study included its nature as a small retrospective case series, which limited the ability to compare imaging modalities. Imaging modalities were based on individual clinical needs; therefore, comparison with diuretic renal scintigraphy was limited. CONCLUSION: MRU provided anatomic and functional details of the urinary tract in children with PBS that allowed for characterization of new renal anatomic abnormalities, including the incidence of calyceal diverticula and renal dysplasia, which have not been previously described. While renal scarring, dysplasia and calyceal diverticula were easily discerned on MRU in ten patients, their clinical significance requires longer follow-up in a larger patient population.

The adaptive ability of transplanted rat small intestine.

This study was performed to determine the extent to which intestinal transplants undergo functional and morphologic compensation. Animals were studied after 25 days to document how rapidly the changes occurred and after 150 days to establish whether the effects were maintained long term. Lewis isografts and Lewis Brown Norway F1 allograft recipient rats had comparable degrees of morphologic (increased bowel diameter, crypt depth, and villus height) and functional (absorption of 3H-glucose, 14C-maltose, and cyclosporine) compensation. These changes were already present by day 25 and persisted until at least day 150. The results were independent of the loss of extrinsic innervation or the intramuscular administration of cyclosporine (5 mg/kg/day). These observations support the usefulness of segmental intestinal transplantation in the treatment of surgically induced short bowel syndrome.

Incidence of external spermatic veins in patients undergoing inguinal varicocelectomy.

OBJECTIVES: To determine the incidence of external spermatic veins at inguinal varicocelectomy. METHODS: A prospective study was performed by making intraoperative observations on 78 varicocelectomies (47 patients) performed by a single surgeon. All patients were referred for evaluation of male infertility and had a palpable varicocele present when examined while performing a Valsalva maneuver in the upright position. Varicocelectomies were performed via the inguinal approach using x 2.5 loupe magnification. Presence of external spermatic veins was defined as visualization (with x 2.5 loupe magnification) of veins on the floor of the inguinal canal traveling posterolateral to the spermatic cord that then subsequently exited the spermatic cord before passing through the internal inguinal ring. Age, anesthetic technique, and need for incision of the external inguinal ring were also recorded for each patient. RESULTS: One third of patients had undergone left-sided varicocelectomies, while two thirds had undergone bilateral procedures. External spermatic veins were identified in 15% of left-sided varicoceles and 19% of right-sided ones. Of 31 patients undergoing bilateral varicocelectomies, 19% had at least 1 external spermatic vein. Of these patients, only 2 (7%) had a unilateral right external spermatic vein, none had a unilateral left external spermatic vein, and 4 (13%) had bilateral external spermatic veins. Overall, of all patients studied, 16% had at least 1 external spermatic vein. Follow-up at 1 year showed no evidence of clinical recurrence in any patient. CONCLUSIONS: These results emphasize the importance of distal gonadal venous anatomy in the surgeon's choice of the proper approach to varicocele repair, since external spermatic veins are only accessible via an inguinal approach.

Rapid construction of right colon pouch: initial clinical experience.

Between December 1992 and July 1993, 7 patients who underwent urinary diversion after cystectomy or bladder augmentation had colon pouches constructed with an "absorbable" staple. Our "one-step" technique of colon pouch construction incorporates standard principles of bowel detubularization and refashioning using absorbable GIA staples. The technique is easily learned and decreases operative time and blood loss. Herein we report follow-up of the first 7 patients undergoing this modification.

Giant multilocular cystadenoma of the prostate.

Giant multilocular prostatic cystadenoma is a rare clinicopathologic entity characterized by benign histology and the ability to enlarge massively. The lesion may arise from the prostate gland either in continuity with the prostatic urethra or separate from it, or it may arise as a lesion distinct from the prostate gland. Obstructive voiding symptoms occur in all reported cases. The use of preoperative radiographic evaluation, such as magnetic resonance imaging, effectively defines the lesion's benign nature and aids in planning surgical extirpation.

Testicular dysmorphism associated with abdominoscrotal hydroceles during infancy.

Abdominoscrotal hydrocele (ASH) in infancy is a rarely reported condition. We present an 11-week-old infant who was born with massive scrotal enlargement. At exploration, he was found to have large bilateral ASHs and bilateral fusiform testes. Gross morphologic testicular changes associated with hydrocele have previously only been reported in adults. Our patient is the youngest to be reported with ASHs.

Operative management of adrenal metastases from lung carcinoma.

Most surgeons consider patients with solitary adrenal metastasis from a primary lung carcinoma incurable and avoid excision of both the adrenal and primary lung tumors. However, several cases of successful surgical management of these patients recently have been reported. We reviewed 12 surgically treated patients with isolated adrenal and lung disease and identified 2 survivors of greater than fifteen years (17%) and 4 additional patients who are still alive following combined resection (34%). This survival rate, albeit in a selected population, represents an improvement over the natural history of nine months' survival. We suggest that if after six to twelve months of following patients with lung cancer and isolated adrenal metastasis no other evidence of spread of disease is evident, the tumor biology may be favorable and resection of both adrenal and lung lesions is reasonable.

Skin flap closure by dermal laser soldering: a wound healing model for sutureless hypospadias repair.

OBJECTIVES: Laser tissue soldering (LTS) with the diode laser and human albumin-hyaluronate-indocyanine green solder is a safe and effective method of providing an immediate leak-free closure during hypospadias repair. In this report, we compare the physiology, histology, and immunohistochemistry of wound healing following LTS and suturing in a rat skin flap model. METHODS: A 4 x 5-cm skin flap was raised and bisected (4 cm) on the dorsum of 48 Sprague-Dawley rats. The central wound was either closed from a dermal approach by suturing or LTS or left open, and studied at 0, 3, 5, 7, 10, 14, and 21 days postoperatively. An intraoperative comparison was made between suturing and LTS with respect to operative time. Postoperatively, flaps were excised for tensiometric analysis, and sections were stained with hematoxylin-eosin to define wound architecture. Resting skin temperature, laser exposed temperature without solder, and maximum temperature with solder (one drop) were measured at the level of the deep dermis, superficial striated muscle layer, and within the solder. Mean peak temperatures were recorded during a 1-minute laser activation time. RESULTS: Mean continuous suturing time (4.9 +/- 1.1 minutes) was significantly (P < 0.001) faster than either LTS (7.7 +/- 0.77 minutes) or discontinuous suturing (8.2 +/- 0.62 minutes). Two seromas (sutured) and two instances of partial wound dehiscence (1 sutured, 1 LTS) were noted. Tensile strength was increased significantly (P < 0.001) for up to 5 days in the LTS group, but was equal to suturing at 7 and 10 days. Immediate tensile strength after LTS was equivalent to a 7-day healed wound. At 14 days, wounds initially left open and those closed by LTS were stronger than sutured wounds (P < 0.05). There was no evidence of thermal injury or foreign body reaction in the LTS group. Solder was incorporated within the dermis in all wounds at 21 days. Laser activation of solder resulted in significant increases in temperature at all three tissue levels: 65.0 +/- 5.2 and 69.9 +/- 6.8 degrees C in the deep and superficial skin (no significant difference between the two), and 101 +/- 15.6 degrees C within the solder (P < 0.001 versus superficial and deep skin). CONCLUSIONS: Our results indicate that sutureless dermal LTS of skin flaps provides increased tensile strength for up to 7 days, with relatively greater tensile strength provided within the first 3 days. Our laser technique does not appear to alter the normal wound healing process. Rather, solder-tissue interaction initially, and extracellular matrix infiltration of solder later, provide the basis for improved wound strength. For hypospadias repair using skin flaps, these wound attributes may permit sutureless surgery.

Renal effects of CO2 insufflation: oliguria and acute renal dysfunction in a rat pneumoperitoneum model.

OBJECTIVE: To determine the mechanism by which oliguria develops during raised intra-abdominal pressure secondary to CO2 insufflation, we created a rat pneumoperitoneum model. METHODS: Male Sprague-Dawley rats (n = 67) were organized into three groups. Each group was subjected to abdominal pressures of 0 (control), 5, or 10 mm Hg, over one, two, and four hours. Fourteen additional rats underwent a two-hour period of 10 mm Hg insufflation pressure followed by desufflation to 0 mm Hg. Urine output (UO) and serum creatinine levels were measured both during insufflation at one, two, and four hours, and two, four, ten, and twenty-two hours following its release. These measurements were compared to control values at each time point. Ultrasonic flow probes placed around both the inferior vena cava (IVC) and abdominal aorta during insufflation characterized the effects of increased abdominal pressure on blood flow. The flow rate was determined at insufflation pressures of 0 (control, 100% flow) to 25 mm Hg. RESULTS: Rats subjected to 10 mm Hg pressure had significant decreases in UO (oliguria) compared to controls for up to four hours (P < 0.01). There were no significant differences in UO in the control or 5 mm Hg groups over each time interval. While a reduction in UO was observed at two, four, and ten hours postrelease, significance was achieved only at ten hours (P < 0.006). By twenty-two hours postrelease, no differences in UO were observed. Serum creatinine elevations declined two hours postdesufflation. IVC flow was reduced by 92.9 percent at 10 mm Hg, while arterial flow decreased by 46.4 percent. Flow was restored to preinsufflation levels after release of pneumoperitoneum. CONCLUSIONS: Oliguria can be produced in rats undergoing pneumoperitoneum. The renal effects of pneumoperitoneum are most likely related to renal vascular insufficiency from central venous compression.

Laser tissue soldering in urinary tract reconstruction: first human experience.

OBJECTIVES: Laser tissue soldering (LTS) in the urinary tract provides an immediate leak-free seal and may avoid complications seen with conventional repair (such as fistula and stricture). We have begun a Phase I clinical trial investigating the use of LTS in performing urologic reconstructive surgery. METHODS: Ten patients (aged 3 months to 38 years) underwent urologic reconstruction using LTS with a protein solder composed of human albumin (42%) and indocyanine green dye. In each case standard microsuture repair preceded laser-soldered suture line reinforcement. Anastomotic closure time and immediate leak pressure were measured. Postoperatively, all patients were evaluated for evidence of complications, including stricture, fistula formation, or impaired healing. RESULTS: Using LTS as an adjunct to suturing added an average of 7.9 +/- 3.0 minutes (28%) to the overall mean anastomotic time of 28.3 +/- 9.4 minutes. Intraoperative leak pressure measurements for laser-soldered anastomoses (> or = 94.2 +/- 24.2 mm Hg) were significantly higher (P < 0.001) than primarily sutured anastomoses (20 +/- 2.9 mm Hg). Two instances of suture disruption (20%) occurred during laser activation, neither of which were repaired with sutures. Average follow-up for all patients was 7.1 + - 2.2 months. There were no intraoperative or postoperative complications, including the 2 patients with suture disruption. CONCLUSIONS: These initial clinical results indicate that LTS is safe, easy to perform, and, contrary to conventional suturing, provides an immediate leak-free closure. Follow-up in these and other patients, as well as those undergoing sutureless and stent-free procedures, will determine whether our method of LTS benefits patients undergoing urologic reconstruction.

Hypospadias repair by laser tissue soldering: intraoperative results and follow-up in 30 children.

OBJECTIVES: We examined the use of laser tissue soldering (LTS) as an adjunct to suturing of, as well as a primary means of, tissue closure in urethral reconstruction. METHODS: Since June 1994, 26 boys ranging in age from 3 months to 14 years (mean 3.0 years) underwent hypospadias repair using LTS techniques. The classification of hypospadias was subcoronal in 13, midpenile in 5, penoscrotal in 7, and scrotal in 1. Laser tissue soldering was used in an additional 4 patients: tunica vaginalis patch graft corporoplasty in 2 (scrotal hypospadias), epispadias fistulae in 1, and urethral diverticulum in 1. Of these cases, 3 hypospadias repairs were completely sutureless. An intraoperative comparision was made between suturing and LTS with respect to operative time and degree of difficulty in performing LTS. Postoperatively, patients were examined to determine complications, including stricture, fistula, or impaired wound healing. An unselected group of 25 consecutive boys undergoing hypospadias repair between 1991 and 1992 served as a historical control group. RESULTS: No intraoperative complications resulted from laser activation. In 5 of the 30 procedures (16.6%), suture disruption was noted to occur, with a higher incidence seen with finer, dyed suture material. For hypospadias repair, the average time to suture was 6.7 min/cm (n = 23), whereas it was 3.1 min/cm for adjunctive LTS (n = 23) and 1.4 min/cm for sutureless urethroplasty (n = 3). Follow-up ranged from 3 to 22 months (average 9.6). Four fistulae were noted (1 onlay, 2 skin tube grafts, 1 Thiersch tube) each following penoscrotal or scrotal hypospadias repair; a fifth fistula developed following a traumatic catheterization in a sutureless repair. The overall complication rate in the LTS group was 19% (5 of 26) versus 24% (6 of 25) for controls, whereas that for the distal forms of hypospadias was 11% (2 of 18) and 13.6% (3 of 22), respectively. CONCLUSIONS: Tissue soldering with laser and chromophore-doped solder is feasible, safe, and easy to perform. Laser tissue soldering may be an alternative to standard microsuture technique for hypospadias repair.

Oliguria during laparoscopic surgery.

Oliguria is infrequently viewed as a complication of laparoscopic surgery. The rate of urine output in six healthy patients undergoing laparoscopic surgery was measured during the period of CO2 pneumoperitoneum and for several hours after desufflation. The average hourly urine output during insufflation was 0.30 +/- 0.14 mL/kg despite an average hourly intravenous infusion rate of lactated Ringer's solution of 13.0 +/- 4.0 mL/kg. After release of pneumoperitoneum, urine output increased 467% to 1.7 +/- 1.1 mL/kg per hour. Patients remained hemodynamically unchanged perioperatively. Preoperative and postoperative blood urea nitrogen and creatinine concentrations did not significantly differ. We discuss the potential etiologic factors in the development of oliguria in the setting of the increased intra-abdominal pressure of pneumoperitoneum and the implications of this acute but reversible renal dysfunction.

Economic evaluation of famciclovir in reducing the duration of postherpetic neuralgia.

The economic impact of famciclovir therapy for postherpetic neuralgia (PHN) in patients with acute herpes zoster was studied. A decision-analytic model of the treatment of herpes zoster and PHN was used to compare the cost of PHN between patients treated with oral famciclovir 500 mg three times daily for seven days and patients not receiving any antiviral therapy. The effects of famciclovir on PHN in the model were based on the results of a randomized, double-blind trial in 419 adult outpatients. The cost of the course of famciclovir therapy (21 tablets) was estimated as the sum of the drug's wholesale acquisition cost and the pharmacy dispensing cost. The cost of treating PHN (physician visits, medications, and miscellaneous nondrug therapy) was estimated by consulting a panel of physicians. According to the model, the cost of treating PHN was $85 lower per famciclovir recipient ($294 for famciclovir versus $379 for no antiviral therapy). The net cost of famciclovir therapy was $23 per patient ($108 for acquisition and dispensing minus the $85 savings). Among patients 50 years of age or older, famciclovir reduced the average cost of PHN by $155 ($414 for famciclovir versus $569 for no antiviral therapy) and yielded a net savings of $7 per patient. A model for the use of famciclovir to treat acute herpes zoster showed that the cost of such therapy was largely offset by savings in the cost of treating this complication.

Dural closure with laser tissue welding.

This study investigates the use of tissue-soldering techniques to substitute or reinforce traditional suture closure of dural incisions. Fresh human cadaveric dura was incised and subsequently closed by use of three techniques: (1) conventional interrupted suture with 4-0 silk (n = 25), (2) laser solder reinforced suture closure (n = 25), and (3) laser solder closure alone (n = 25). Anastomosis tensile strength and hydrostatic leak pressures were measured. Dural repair was also performed in 15 live Lewis rats. Dural closure was accomplished with 9-0 Prolene sutures (n = 5), laser-reinforced suture closure (n = 5), and laser solder closure alone (n = 5). Histologic examination of the closure immediately after soldering and 2 weeks later was performed. Suture closure alone had the lowest leak pressure, 9.4 +/- 1.7 mm Hg, and an intermediate break point, 13.3 +/- 2.1 Kgf/cm2. Measurements with laser solder alone revealed a mean leak pressure of 26.2 +/- 3.7 mm Hg and a break point of 4.6 +/- 1.4 Kgf/cm2. Solder-reinforced suture closure leak pressure measured 64.0 +/- 6.7 mm Hg and 21.4 +/- 2.4 Kgf/cm2. There was a statistically significant increase in leak pressure and tensile strength in the closures performed with laser weld reinforcement of traditional suture technique (p = 0.0001). Dural closure with laser tissue welding alone provided an immediate leak-free closure, but with poor tensile strength. Histologic examination of welded dura and underlying brain tissue showed no evidence of thermal injury in four of five animals studied. Laser welding may significantly decrease the incidence of cerebrospinal fluid leak after dural closure. In addition, laser tissue welding also makes dural closure possible where space constraints make traditional suture closure difficult.

Complete separation of the testis and epididymis.

This report describes an unusual case of separation of the epididymis and testis in a 3-year-old boy.

Comparison of magnetic resonance urography to dimercaptosuccinic acid scan for the identification of renal parenchyma defects in children with vesicoureteral reflux.

OBJECTIVE: The objective of this study was to compare the accuracy of dimercaptosuccinic acid (DMSA) renal scan to magnetic resonance urography (MRU) in the identification of renal parenchyma defects (RPD). MATERIALS AND METHODS: Twenty-five children with history of acute pyelonephritis and vesicoureteral reflux underwent DMSA scan and MRU to determine the presence of RPD. DMSA scans and MRUs were each evaluated by two radiologists and agreement achieved by consensus. Discordant DMSA-MRU findings were re-evaluated in a side-by-side comparison and an ultimate consensus reached. RESULTS: The ultimate consensus diagnosis was 18 kidneys with RPDs in 15 patients, of which five were classified as mild RPDs, six as moderate RPDs, and seven as severe RPDs. Although DMSA scan and MRU were similar in their ability to diagnose RPDs, MRU was considered to represent the true diagnosis in 11 of the 12 discordant cases in consensus review by four pediatric radiologists. MRU showed a much higher inter-observer agreement with a weighted kappa of 0.96 for both kidneys compared to 0.71 for the right kidney and 0.86 for the left kidney by DMSA scan. CONCLUSIONS: Our results suggest that MRU is superior to DMSA scan in the identification of renal parenchyma defects.

Symptomatic cholelithiasis following continent urinary diversion using ileocolonic bowel segments.

Cholelithiasis is uncommon prior to adulthood. Several risk factors have been identified as causing cholelithiasis but continent urinary diversion has not been considered a factor. To our knowledge there has been no other report of cholelithiasis developing after urinary tract reconstruction. Between 1979 and 1992, 116 patients younger than 23 years underwent urinary tract reconstruction at our clinic. Symptomatic cholelithiasis developed in 4 patients (3.4%) following continent urinary diversion with an Indiana pouch.

Posterior urethral valves: pre- and postnatal management.

Posterior urethral valves are a common problem encountered by pediatric urologists. The diagnosis is most frequently suggested by antenatal screening ultrasound. A variety of pre- and postnatal parameters have been identified to aid in predicting ultimate renal outcome. These prognostic tools are invaluable to the clinician for counseling parents and for choosing appropriate management. Several approaches to the treatment of patients with posterior urethral valves exist, and the ideal strategy is debatable. As technology evolves, more options for early intervention become available. Whether early detection and antenatal intervention improve patient outcome remains to be proven.