Scrotal injuries during neonatal circumcision.

OBJECTIVE: To report very rarely encountered scrotal injuries during neonatal circumcision. Hospitals and physicians in the authors' country are mandated to report circumcision complications to the Ministry of Health. Those reports include the discharge summary from the emergency room or the admitting department. This is believed to be the first case series describing scrotal injuries during ritual circumcision. PATIENTS AND METHODS: Reports of all circumcision complications between 2007 and 2014 were evaluated. Retrieved data on cases of scrotal injuries included patient's age, time between injury and hospital admission, nature of the injury, and administered treatment. RESULTS: Twelve of a total of 489 reports of circumcision injuries involved the scrotum (2.5%). All circumcisions were performed during the neonatal period, and the infants were admitted on the day of injury. The only related genital injury was significant shortage of penile skin reported in six patients. Scrotal exploration and skin closure in the operating room was undertaken in six cases, five under general anesthesia. Suture closure in the emergency department was performed in three patients, and the scrotal skin was left to heal with secondary intention in three other patients. Scrotal content injury that extended to the tunica vaginalis of the testis was noted in one exploration. DISCUSSION: The injuries sustained by the 12 study infants were mostly superficial and are not expected to cause long-term damage, although half of the patients required treatment under general anesthesia in the operating room or under sedation in the emergency department. While all reported patients emerged unscathed from the anesthetic procedures, the possible immediate complications of anesthesia as well as its long-term effects are not to be taken lightly, especially when treating a newborn. Further education of medical providers as well as performers of ritual circumcisions may help lower the risk of this rare injury as well as other more severe complications. CONCLUSION: Scrotal injury during neonatal circumcision is rare. While half of the 12 reported patients required exploration in the operating room, the injuries were mostly superficial and did not involve scrotal content, although they often involved extensive resection of penile skin.

The protein kinase C-related PKC-L(eta) gene product is localized in the cell nucleus.

The tumor promoters phorbol esters are thought to induce changes in cell growth and gene expression by direct activation of protein kinase C (PKC). However, the molecular mechanisms by which PKC molecules transduce signals into the cell nucleus are unknown. In this study, we provide evidence for a direct target for phorbol esters in the nucleus. We demonstrate that the new PKC-related family member, PKC-L, recently isolated by us, is expressed specifically in the cell nucleus. Localization of PKC-L in the cell nucleus is shown both by immunofluorescence staining and by subcellular fractionation experiments of several human cell lines, including the human epidermoid carcinoma line A431. Treatment of these cells by phorbol esters does not induce the down-regulation of PKC-L, in contrast to their effect on classical PKC family members. This is the only PKC isoenzyme described so far that resides permanently and specifically in the cell nucleus. PKC-L may function as an important link in tumor promoting, e.g., as a nuclear regulator of gene expression that changes the phosphorylation state of transcriptional components such as the AP-1 complex.

Augmentation ureterocystoplasty: is it the preferred choice?

BACKGROUND: Various methods of urinary bladder augmentation have been attempted in order to try and achieve adequate bladder capacity, urinary continence, control urinary tract infection and preserve the upper urinary tract; however, long-term complications have been unavoidable. OBJECTIVE: To evaluate our experience with ureterocystoplasty as to whether it is the preferred method for bladder augmentation to achieve continence and preserve the upper urinary tract. DESIGN: Retrospective study. SETTING: Paediatric urology unit, Dana Children's hospital, Tel Aviv Medical Center (affiliated to the Sackler School of Medicine), Tel Aviv University. SUBJECTS: Four children; three girls, one boy, mean age 7.3, range (3-14) years. Two had neurogenic bladder due to occult spinal dysrraphism, the other two had non-neurogenic neurogenic bladder. The indications for surgery were urinary incontinence with recurrent urinary tract infections in all patients, one also had upper tract dilatation. INTERVENTIONS: All underwent augmentation ureteroplasty, two required nephrectomy due to non-functioning kidney, two required clean intermittent catheterizatiom postoperatively. MAIN OUTCOME MEASURES: Urinary continence, bladder capacity, vesicoureteral reflux, renal function tests, urinary tract infection rate and surgical complications encountered. RESULTS: In a mean follow-up period of 24 (6-46) months, all of the patients achieved urinary continence, two of the patients who have a normal bladder outlet are continent and void spontaneously with no residual urine. The other two patients are continent on clean intermittent catheterization. Only one episode of urinary tract infection was seen, none of the patients are currently on prophylactic antibiotics. The urinary bladder in all patients is spherical with good capacity and no vesicoureteral reflux was demonstrated. The upper urinary tracts are stable and the renal function tests are normal. CONCLUSION: Ureterocystoplasty is our preferred choice of bladder augmentation in patients with small, inelastic, poor compliant bladder with at least a moderately dilated ureter. Complications normally seen with enterocystoplasties are minimal.

Criteria for the prenatal diagnosis of classic bladder exstrophy.

OBJECTIVE: To define ultrasonographic criteria for the prenatal diagnosis of classic bladder exstrophy. METHODS: Forty-three prenatal ultrasound scans were studied from 25 pregnancies in which live delivery of an infant with classic bladder exstrophy occurred. The diagnosis of bladder exstrophy could be made retrospectively in 29 prenatal studies from 17 pregnancies. The time of the fetal ultrasound varied from 14-36 weeks' gestation (mean 23). The diagnosis of bladder exstrophy was made before delivery in only three cases. RESULTS: Five factors associated with bladder exstrophy were identified: 1) The bladder was not visualized on ultrasound in 12 of 17 cases (71%); 2) a lower abdominal bulge representing the exstrophied bladder was seen in eight of 17 cases (47%); 3) a small penis with anteriorly displaced scrotum was identified in eight of 14 males (57%); 4) the umbilical insertion was low set in five of 17 cases (29%); and 5) abnormal widening of the iliac crests was seen in three of 17 cases (18%). CONCLUSION: The prenatal diagnosis of bladder exstrophy should be considered any time the bladder is not visualized or any of the aforementioned factors are noted.

Ureteral bladder augmentation using the lower pole ureter of a duplicated system.

Megaureters of nonfunctioning renal segments in a duplex system are commonly available for use in reconstructive procedures secondary to high-grade reflux, ectopic ureter, ectopic ureterocele, or obstructive megaureter. The use of megaureters subtending a nonfunctioning lower pole renal segment for bladder augmentation in 2 patients is reported.

The Cantwell-Ransley epispadias repair in exstrophy and epispadias: lessons learned.

OBJECTIVES: We evaluated our experience with the Cantwell-Ransley epispadias repair to determine the lessons that have been learned with the increased experience and follow-up. METHODS: A total of 75 boys (60 with bladder exstrophy and 15 with complete epispadias) underwent a Cantwell-Ransley epispadias repair at our institute in the last 6 years. Primary repair was performed in 58 boys (45 with exstrophy and 13 with epispadias), and secondary repair was performed after prior failed closure in 17 boys (12 at the secondary exstrophy closure, 3 with exstrophy, and 2 with complete epispadias). RESULTS: At a mean follow-up of 28 months, all patients had a horizontal or downward angled penis while standing. The incidence of urethrocutaneous fistulas in the immediate postoperative state was 21% and at 3 months was 15%. The incidence of urethrocutaneous fistulas was no more in those patients in whom paraexstrophy skin flaps were used at anterior closure than in those in whom the urethral plate was left intact. Two patients developed a urethral stricture at the proximal anastomotic area, and 4 patients had minor skin separation of the dorsal penile skin closure. Catheterization or cystoscopy, or both, has been performed in 60 patients and revealed an easily negotiable urethral channel in all. CONCLUSIONS: The Cantwell-Ransley epispadias repair offers a straighter urethra, better correction of chordee and cosmesis, and a lower fistula rate in the exstrophy or epispadias patient.

The multiple reoperative bladder exstrophy closure: what affects the potential of the bladder?

OBJECTIVES: To define the possible cause of failure and the eventual potential of the bladder in 23 exstrophy patients, who underwent more than two failed prior attempts at closure. METHODS: Twenty-three patients were selected from the exstrophy data base who had two or more prior closures. Eighteen patients had undergone 2 previous closures and 5 patients 3 previous closures for either complete dehiscence or significant prolapse. At the time of initial closure, 19 patients did not have an osteotomy. At secondary closure, 10 underwent osteotomy while at third closure 5 had an osteotomy. At the time of reclosure at our institution all underwent an osteotomy. RESULTS: Reoperative repair at our institution was successful in all patients. Six patients achieved a bladder size suitable for bladder neck reconstruction and of them 3 are dry. The bladder size was inadequate in 9 patients and 8 are being monitored for possible bladder growth. CONCLUSIONS: Tension-free closure with osteotomy and immobilization are important factors both in an initial or any subsequent closure. The chance of obtaining an adequate bladder capacity for bladder neck plasty and eventual continence, following multiple reclosures, is markedly diminished.

Acute scrotum caused by Henoch-Schönlein purpura, with immediate response to short-term steroid therapy.

The authors report a case of acute scrotum caused by Henoch-Schönlein purpura. It involved bilateral swelling of the epididymis and testes, which was documented by scrotal ultrasonography and which responded immediately to systemic steroid treatment.

Bladder exstrophy from childhood into adult life.

Exstrophy of the bladder is rare and the incidence of bladder exstrophy is calculated to be from 1 per 30,000 to 50,000 live births with male to female ratio ranging from 1.5-5 to 1(1-4). It was found that persistence or overgrowth of the cloacal membrane on the lower anterior abdominal area, prevents normal mesenchymal ingrowth. This causes divergence of the lower abdominal muscular structures and forces the genital ridges to fuse caudal to the cloacal membrane. The stage of ingrowth of the urorectal septum at the time of rupture determines whether one will produce an exstrophic urinary tract alone (classic bladder exstrophy or epispadias) or cloacal exstrophy with the hindgut interposed between the hemibladders.

[Artificial sphincter for urinary incontinence].

During the past 4 years 21 patients underwent implantation of the model AS-800 artificial urinary sphincter, 4 of whom underwent simultaneous implantation of an inflatable penile prosthesis. The mean age was 48 years (range 33-73). Incontinence was neurogenic in 12 (57%) and a complication of urologic surgery (mainly prostatectomy) in 9 (43%). In 8, in whom intermittent self-catheterization was planned, the sphincter cuff was implanted around the bladder neck, and in the other 13, around the bulbar urethra. The immediate postoperative course was uneventful in 18 (85%), but 2 (10%) had urinary tract infection and 1 had urinary retention. During a mean follow-up of 20 months (range 1-36), 19 (90%) were found to be continent (in 2 of them the cuff had had to be changed to a smaller size due to tissue atrophy), and 1 had suffered from urgency incontinence which disappeared with anticholinergic medication. In 2 with incontinence due to neurogenic bladder, the sphincter had became infected and had had to be removed; 1 of these 2 had undergone simultaneous augmentation cystoplasty. This experience resulted in a change in our policy: we now implant the sphincter and perform augmentation cystoplasty in 2 separate stages. We find implantation of the artificial urinary sphincter very effective treatment for urinary incontinence.

[Endometriosis of the bladder].

We report a case of endometriosis of the bladder in a 32-year-old healthy woman suffering from longstanding suprapubic pain, and urinary urgency and frequency. The disease, which is uncommon, usually has a high morbidity rate and is difficult to diagnose. A high level of suspicion is necessary for diagnosis, since neither the clinical presentation, nor imaging procedures are pathognomonic for endometriosis.

[Delayed spontaneous rupture of the bladder following augmentation enterocystoplasty].

Delayed spontaneous rupture of the urinary bladder following augmentation enterocystoplasty is a serious life-threatening complication of uncertain etiology. Multiple factors are believed to contribute to the mechanism of bladder perforation. Ruptured augmented bladders share a common urodynamic pattern of high leak point pressure of the urethra, with sensory and mechanical tolerance of high filling pressure. This combination seems to be the main predisposing factor for spontaneous perforation. Other risk factors, including catheter trauma during intermittent self-catheterization, urinary retention due to mucus retention or noncompliance with the catheterization protocol, chronic infection, and decreased sensation of bladder filling, may play roles in the mechanism of rupture. Clinically, patients present with sepsis, abdominal pain and distension, ileus, fever, oliguria and peritoneal irritation. The diagnosis is made on low pressure cystography, although failure of cystography to demonstrate extravasation is not unusual. Aggressive surgical treatment consists of immediate exploration, primary repair of the perforation, drainage of the perivesical space, suprapubic cystostomy and broad-spectrum antibiotics. Longterm management includes a strict intermittent catheterization schedule, anticholinergic therapy and urodynamic evaluation. Failure to achieve a low pressure storage reservoir by conservative means entails an increased risk of recurrent perforation. In such cases further surgical intervention should be considered. We present a 21-year-old paraplegic man 5 months after augmentation enterocystoplasty who required operation because of spontaneous rupture of the augmented bladder. Spontaneous delayed rupture of the bladder should be considered in the differential diagnosis of acute abdomen in patients after augmentation enterocystoplasty. Early surgical treatment and subsequent monitoring of the low pressure reservoir are recommended.

Current management of bladder exstrophy.

This article describes in detail the modern management of the patient born with classic bladder exstrophy. Also, new techniques of prenatal diagnosis and pelvic fixation to secure the initial or secondary closure are discussed. Last, management of the failed closure and the bladder not suitable for closure are described and outlined. A successful initial closure of the infant born with bladder exstrophy is the single most important determinant in the eventual development of continence in the exstrophy patient.

Increased serum alkaline phosphatase activity: a possible indicator of renal damage.

Increased levels of serum alkaline phosphatase (ALP) (E.C.3.1.3.1.) were observed in 25 patients with various urological conditions involving the kidneys: malignancy, complicated nephrolithiasis, and surgical and percutaneous manipulations. Other possible sources for increased ALP level, mainly hepatic and osseous, were excluded by history, laboratory tests, and liver and bone imaging. Studies of isoenzymes of ALP did not show a distinctive pattern. ALP levels returned to the normal range by treating the underlying lesions involving the kidney: nephrectomy, complete removal of stones, or removal of nephrostomy. The increase in serum ALP activity may be derived from the injury to the brush border membrane of the renal tubular cells. Renal function impairment and contrast media induced nephrotoxicity may also be responsible for the increased serum ALP. Serum ALP may be a marker for involvement of the kidneys in pathological processes and an indicator of complete treatment. This clinical observation is worthy of further study.

Deletions in the regulatory or kinase domains of protein kinase C-alpha cause association with the cell nucleus.

We have constructed expression plasmids carrying protein kinase C (PKC) cDNAs with deletions in the coding region. Two truncated molecules, consisting only of the kinase domain of PKC-alpha, were generated by removing parts of the cDNA coding for the regulatory region. Another mutant molecule was created by deleting 95 amino acids from the C-terminal part of the molecule. The full-length cDNA coding for PKC-alpha and its deletion constructs was expressed in COS cells. Using cell fractionation experiments and immunofluorescence staining, we demonstrate here that in contrast to the cytosolic localization of full-length PKC-alpha, the truncated forms, coding only for the kinase domain, were found exclusively in the cell nucleus. Further subfractionation of nuclei isolated from these transfected cells indicated partial association with the nuclear envelopes. Expression of the cDNA lacking the C-terminal part of the molecule in COS cells encoded a truncated molecule that was found both in the cytosol and in the nucleus. We also show that translocation of full-length PKC-alpha molecules to the cell nucleus occurred in response to phorbol ester treatment. Thus, it appears that accumulation of PKC-alpha in the nucleus results either by phorbol ester activation or by deletions of specific regions of the molecule. A molecular mechanism for the nuclear translocation of phorbol ester-activated PKC-alpha or its truncated molecules is suggested.

Glide wires for delayed catheterization of severely obstructed ureters.

OBJECTIVE: Failure to retrogradely catheterize an obstructed ureter may require a nephrostomy. We describe an endoscopic technique to catheterize a severely obstructed ureter when the obstruction does not permit passage of a ureteral catheter over a wire. METHODS: Using a cystoscope, a wire is passed beyond the obstruction. When the attempt to insert a ureteral catheter over the wire fails, the wire is left in place, fixed externally to a Foley catheter. A second attempt to insert a ureteral catheter is carried out 24-48 h later. RESULTS: The procedure was performed in 5 patients. Ureteral catheterization, which was initially impossible, was performed successfully and without complications. CONCLUSIONS: Maintaining a wire in place over a short period of time facilitates a subsequent ureteral catheterization.

Does the use of the ileocecal region in reconstructive urology cause persistent diarrhea?

The ileocecal region (ICR) is used extensively in reconstructive urological surgery. To evaluate whether resection of the ICR may cause protracted diarrhea, 50 patients undergoing ileocecal resection were studied. Fifty patients undergoing left colectomy for cancer were used as controls. No significant change in bowel habits was noted in the control group. Among patients undergoing ICR resection 42% had transient loosening of stools 2 weeks after surgery which improved within 3 months. Twelve months after surgery only 6 patients with solid stools preoperatively had loose stools, and none suffered diarrhea. In conclusion, in the patients studied after resection of the ICR diarrhea gradually resolved. More work is necessary to study other potential metabolic consequences of such resection.

Concealed umbilical stoma: description of a modified technique.

PURPOSE: We describe a technique for creating a concealed umbilical stoma. MATERIALS AND METHODS: The base of the umbilicus is used as a superiorly based skin flap that is incorporated into the spatulated stoma. Six patients have undergone diversion using this technique. The stoma was constructed from appendix in 4 cases, stomach in 1 and tapered ileum in 1. RESULTS: All patients achieved an easily catheterizable hidden umbilical stoma, are dry on clean intermittent catheterization and have had no stomatitis or peristomal hernia. CONCLUSIONS: This technique for creating a concealed umbilical stoma preserves the native appearance of the umbilicus and combines a superior cosmetic result with an easily catheterizable stoma.