Intraurethral catheter placement does not change the external circumferential measurement of the urethra during AUS placement: A prospective observational trial.

AIMS: Measuring the urethral circumference accurately during artificial urethral sphincter (AUS) placement is an important technical aspect to optimize the selection of cuff size. Differing methods exist for this step with some experts recommending measurement with no urethral catheter in place. In this prospective observational trial, we compared urethral measurements with and without an indwelling catheter to determine if the presence of a catheter affects the circumferential measurement. METHODS: With IRB approval, we prospectively collected data on consecutive cases of transperineal male AUS implantation. Urethral circumference was measured with no urethral catheter (0 French [Fr]), 12Fr, and 16Fr Foley catheters in the urethra. The final measurements and cuff size chosen were recorded. A comparison was made between each measurement using Spearman's correlation coefficient. RESULTS: A total of 54 patients were included, the majority of whom (92.6%) underwent AUS placement for postprostatectomy incontinence. The three urethral circumference measurements were highly correlated (0Fr vs 12Fr, ρ = 0.96, P < .001, mean difference 1 mm) (0Fr vs 16Fr, ρ = 0.94, P < .001, mean difference 2 mm) (12Fr vs 16Fr, ρ = 0.96, P < .001, mean difference 1 mm). Patients with a history of radiation had a lower mean urethral circumference than those who had never been radiated (4.78 cm vs 5.3 cm, P = .01). CONCLUSIONS: Urethral circumference measurement during AUS implantation is not influenced by the presence of a 12 or 16Fr Foley catheter when compared to no catheter in the urethra. Measurement of the urethral circumference can, therefore, be accurately performed with or without a catheter in place, depending on the surgeon's preference.

Contemporary analysis of management of isolated pendulous urethral strictures using pedicled skin flap urethroplasty repair.

OBJECTIVES: To evaluate contemporary outcomes of urethroplasty employing a pedicled skin flap for isolated pendulous urethral strictures. SUBJECTS/PATIENTS: Inclusion of males > 18 years of age with isolated pendulous urethral strictures treated between 1996 and 2012. RESULTS: A total of 81 patients with isolated pendulous urethral stricture were identified. Twenty-eight patients underwent repair with a pedicled skin flap during the study period. The median age of the patients treated with a pedicled skin flap was 47 years old (range 21-74). The etiology of the strictures was considered to be idiopathic in 10 patients (35.7%), iatrogenic in 9 patients (32.1%), as a complication of prior hypospadias repair in 6 patients (21.4%), infectious in 2 patients (7.1%), and traumatic in 1 patient (3.6%). The median follow-up was 27 months (range 1-214). Urethroplasty success was noted in 19/21 patients (90.5%). Urethral stricture recurrence occurred in 2 of the 21 patients (9.5%). CONCLUSIONS: The pedicled skin flap repair for pendulous urethral strictures remains a durable and safe technique in patients without LS.

Inflammatory response to Escherichia coli urinary tract infection in the neurogenic bladder of the spinal cord injured host.

PURPOSE: Urinary tract infections cause significant morbidity in patients with spinal cord injury. An in vivo spinal cord injured rat model of experimental Escherichia coli urinary tract infection mimics human disease with enhanced susceptibility to urinary tract infection compared to controls. We hypothesized that a dysregulated inflammatory response contributes to enhanced susceptibility to urinary tract infection. MATERIALS AND METHODS: Spinal cord injured and sham injured rats were inoculated transurethrally with E. coli. Transcript levels of 84 inflammatory pathway genes were measured in bladder tissue of each group before infection, 24 hours after infection and after 5 days of antibiotic therapy. RESULTS: Before infection quantitative polymerase chain reaction array revealed greater than twofold up-regulation in the proinflammatory factor transcripts slc11a1, ccl4 and il1ß, and down-regulation of the antimicrobial peptides lcn2 and mpo in spinal cord injured vs control bladders. At 24 hours after infection spinal cord injured bladders showed an attenuated innate immune response with decreased expression of il6, slc11a1, il1ß and lcn2, and decreased il10 and slpi expression compared to controls. Despite clearance of bacteriuria with antibiotics spinal cord injured rats had delayed induction of il6 transcription and a delayed anti-inflammatory response with decreased il10 and slpi transcript levels relative to controls. CONCLUSIONS: Spinal cord injured bladders fail to mount a characteristic inflammatory response to E. coli infection and cannot suppress inflammation after infection is eliminated. This may lead to increased susceptibility to urinary tract infection and persistent chronic inflammation through neural mediated pathways, which to our knowledge remain to be defined.

Cross-sectional evaluation of parental decision making factors for vesicoureteral reflux management in children.

PURPOSE: Parental decision making in children with vesicoureteral reflux has potentially become more complex with the evolution of ethnic diversity in the United States, the Internet, the publication of contradictory clinical data and the emergence of minimally invasive surgery. We performed a cross-sectional study of parental management for pediatric vesicoureteral reflux. MATERIALS AND METHODS: We administered a 26-item questionnaire to parents of children with vesicoureteral reflux seen at Texas Children's Hospital urology offices or undergoing antireflux surgery at that institution. Univariate and multivariate analysis was done on patient disease characteristics, demographics, predicted reflux duration, surgery success rate, antibiotic cessation, complication risk, financial considerations, urologist recommendations, Internet information, friend recommendations, and postoperative voiding cystourethrography, renal ultrasound and recovery. RESULTS: Enrolled in the study were 15 boys and 49 girls with a mean age of 3.5 years and a mean reflux grade of 2.8. Of the cases 37 were bilateral. Parents chose endoscopic treatment in 38 children, open ureteroneocystostomy in 9, antibiotic prophylaxis in 14 and observation without antibiotics in 3. Univariate analysis suggested that Hispanic parents rated ultrasound and financial considerations as more important than white parents (p <0.05). Multivariate analysis revealed that differences seen on univariate analysis may have been due to an association between race and income. Finally, 93.6% of parents rated urologist opinion as very or extremely important. CONCLUSIONS: Data indicate that the parents of our patients highly value the opinion of the pediatric urologist when choosing treatment for their children with vesicoureteral reflux. Despite social changes the physician-parental relationship remains critical. Differences in parental decision making may be linked to associations between race and income.

Factors associated with delayed treatment of acute testicular torsion-do demographics or interhospital transfer matter?

PURPOSE: Testicular torsion is a true urological emergency. We determined whether a delay in treatment due to hospital transfer or socioeconomic factors would impact the orchiectomy rate in children with this condition. MATERIALS AND METHODS: We retrospectively evaluated the records of boys seen at a single institution emergency department who proceeded to surgery for a diagnosis of acute testicular torsion from 2003 to 2008. Charts were reviewed for transfer status, symptom duration, race, insurance presence or absence and distance from the hospital. Orchiectomy specimens were evaluated for histological confirmation of nonviability. RESULTS: We reviewed 97 records. The orchiectomy rate in patients who were vs were not transferred to the emergency department was 47.8% vs 68.9%, respectively (p = 0.07). Symptom duration was greater in the orchiectomy group with a mean difference of 47.9 hours (p <0.01). The mean transfer delay was 1 hour 15 minutes longer in the orchiectomy group (p = 0.01). Boys who underwent orchiectomy were 2.2 years younger than those who avoided orchiectomy (p = 0.01). Multivariate analysis showed that symptom duration and distance from the hospital were the strongest predictors of orchiectomy. CONCLUSIONS: Data suggest that torsion is a time dependent event and factors that delay time to treatment lead to poorer outcomes. These factors include distance from the hospital and the time delay associated with hospital transfer.

Ataxia telangiectasia-mutated damage-signaling kinase- and proteasome-dependent destruction of Mre11-Rad50-Nbs1 subunits in Simian virus 40-infected primate cells.

Although the mechanism of simian virus 40 (SV40) DNA replication has been extensively investigated with cell extracts, viral DNA replication in productively infected cells utilizes additional viral and host functions whose interplay remains poorly understood. We show here that in SV40-infected primate cells, the activated ataxia telangiectasia-mutated (ATM) damage-signaling kinase, gamma-H2AX, and Mre11-Rad50-Nbs1 (MRN) assemble with T antigen and other viral DNA replication proteins in large nuclear foci. During infection, steady-state levels of MRN subunits decline, although the corresponding mRNA levels remain unchanged. A proteasome inhibitor stabilizes the MRN complex, suggesting that MRN may undergo proteasome-dependent degradation. Analysis of mutant T antigens with disrupted binding to the ubiquitin ligase CUL7 revealed that MRN subunits are stable in cells infected with mutant virus or transfected with mutant viral DNA, implicating CUL7 association with T antigen in MRN proteolysis. The mutant genomes produce fewer virus progeny than the wild type, suggesting that T antigen-CUL7-directed proteolysis facilitates virus propagation. Use of a specific ATM kinase inhibitor showed that ATM kinase signaling is a prerequisite for proteasome-dependent degradation of MRN subunits as well as for the localization of T antigen and damage-signaling proteins to viral replication foci and optimal viral DNA replication. Taken together, the results indicate that SV40 infection manipulates host DNA damage-signaling to reprogram the cell for viral replication, perhaps through mechanisms related to host recovery from DNA damage.

Short-term Complication Rates Following Anterior Urethroplasty: An Analysis of National Surgical Quality Improvement Program Data.

OBJECTIVE: To determine the characteristics and predictors of perioperative complications after male anterior urethroplasty. MATERIALS AND METHODS: The American College of Surgeons-National Surgical Quality Improvement Program is a validated outcomes-based program comprising academic and community hospitals in the United States and Canada. Data from 2007 to 2015 were queried for single-stage anterior urethroplasty using Current Procedure Terminology codes. The primary outcome was frequency of complications within the 30-day postoperative period. Preoperative and intraoperative parameters were correlated with morbidity measures, and univariate and multivariate regression analyses were used. RESULTS: A total of 555 patients underwent anterior urethroplasty, of whom 180 (32.4%) had graft or flap placement. Of the patients, 127 (22.9%) went home the same day after surgery, 255 (45.9%) stayed for 1 night, and 173 (31.2%) stayed for 2 or more nights. No deaths, cardiovascular complications, or sepsis were noted. Forty-seven patients (8.5%) had complications in the 30-day period. The most common complications were infection (57.4%), readmission (42.9%), and return to the operating room (17%). On univariate analysis, patients who had substitution urethroplasty (P = .04) and longer operative times (P = .002) were more likely to have complications, but only longer operative time showed significance on multivariate analysis (P = .006). Age, American Society of Anesthesiologists score, and length of stay were not predictive of complication frequency. CONCLUSION: Anterior urethroplasty has low postoperative morbidity. Longer operative times were associated with increased rate of complications. Longer hospital stay after surgery is not protective against perioperative complications.

Effect of Lichen Sclerosis on Success of Urethroplasty.

Lichen sclerosis (LS) is a chronic, relapsing disease with a variable presentation. In men, genitourinary LS may affect the penile foreskin, glans, meatus, and urethra. Treatment is multifaceted, ranging from pharmacotherapy to surgery. Urethral reconstruction due to stricture disease from LS is frequently plagued by a high recurrence rate. At the authors' institution, the high recurrence rate has shifted their practice toward potent steroids and minimally invasive surgical techniques. Management of recurrence includes dilation, meatotomy/meatoplasty, 1-stage and 2-stage repairs. Recalcitrant cases may necessitate abandonment of most of the urethra resulting in a perineal urethrostomy.

Risk Factors Associated With Recurrent Urinary Tract Infection in Neurogenic Bladders Managed by Clean Intermittent Catheterization.

OBJECTIVE: To identify risk factors for recurrent urinary tract infection (UTI) in patients who perform clean intermittent catheterization (CIC). METHODS: A 6-year retrospective chart review of patients with spina bifida or tethered cord who perform clean intermittent catheterization (8 months to 58 years) was conducted. A strict case definition for UTI was applied, and per-subject UTI events, demographic, and clinical data were abstracted. Data were compared between groups defined by no or infrequent UTI (≤1.0 UTI/study year) and frequent UTI (>1.0 UTI/study year). RESULTS: Of 194 total patients, 146 (75%) had no UTIs or infrequent UTIs, and 48 (25%) patients had frequent UTIs. On univariate analysis, only younger age and suprasacral cord lesions were associated with frequent UTIs (P = .002 and P = .007, respectively). Among the 128 patients with urodynamic studies, bladder capacity, compliance, detrusor overactivity, and detrusor leak point pressure were not associated with frequent UTI on univariate analysis. On multivariate analysis, increasing age was found to be associated with decreased odds of UTI by 7% per year (odds ratio 0.93, P = .016). CONCLUSION: The risk of UTI among individuals with spina bifida or tethered cord declines with increasing age. Bladder function based on urodynamic parameters did not correlate with frequent UTIs.

Efficacy of Fluoroquinolone/Probiotic Combination Therapy for Recurrent Urinary Tract Infection in Children: A Retrospective Analysis.

PURPOSE: Children with normal urinary tract anatomy and function and highly recurrent urinary tract infection (rUTI) may have a lack of alternatives when antibiotic prophylaxis and "watchful waiting" approaches fail. This retrospective review reports the outcomes in children who received a fluoroquinolone/probiotic combination in an attempt to quantify a reduction in rUTI that was perceived by both clinicians and patients' families. METHODS: Data from all children with rUTIs previously managed with a fluoroquinolone/probiotic combination at the Pediatric Infectious Diseases Clinic at Duke University Medical Center (Durham, North Carolina) were identified and analyzed. FINDINGS: Data from 10 children were eligible for inclusion. Compared with before therapy initiation, total UTI episodes were significantly fewer after therapy initiation (57 vs 4; P = 0.0001). Seven (70%) were free of rUTIs during the follow-up period. Of the 8 patients with known compliance, 7 (88%) were free of rUTIs. IMPLICATIONS: Given the chronic nature of these patients' symptoms, the significant decrease in UTI after the initiation of therapy, and the increase in the interval without an infection and/or its symptoms, this treatment regimen has the potential to improve overall quality of life, decrease antibiotic courses, and decrease health care costs in children with rUTI. These results will be validated with a larger cohort of patients in a prospective, randomized trial.

Evaluation of cold ischemia for preservation of testicular function during partial orchiectomy in the rat model.

OBJECTIVE: We hypothesized that cold ischemia during partial orchiectomy would lead to higher serum testosterone levels and preservation of testicular architecture than warm ischemia in a prepubescent rat model. MATERIALS AND METHODS: Eighteen prepubescent male Sprague-Dawley rats were randomized to three different surgical groups: sham surgery, bilateral partial orchiectomy with 30 min of cord compression with cold ischemia, or bilateral partial orchiectomy with 30 min of cord compression with warm ischemia. Animals were killed at puberty, and serum, sperm, and testicles were collected. Histological tissue injury was graded by standardized methodology. RESULTS: Mean serum testosterone levels were 1445 ± 590 pg/mL for the sham group, 449 ± 268 pg/mL for the cold ischemia group and 879 ± 631 pg/mL for the warm ischemia group (p = 0.12). Mean sperm counts were 2.1 × 10(7) for sham, 4.4 × 10(6) for cold ischemia, and 9.9 × 10(6) for the warm ischemia groups (p = 0.48). Histological evaluation revealed significant difference in tissue injury grading with more injury in the cold ischemia than in the warm ischemia group (p = 0.01). CONCLUSIONS: In our preclinical rat model, we found no benefit for cold ischemia over warm ischemia at 30 min.

Resolution rate of isolated low-grade hydronephrosis diagnosed within the first year of life.

OBJECTIVE: Diagnosis of low-grade hydronephrosis often occurs prenatally, during evaluation after urinary tract infection (UTI), or imaging for non-urologic reasons within the first year of life. Its significance in terms of resolution, need for antibiotic prophylaxis, or progression to surgery remains uncertain. We hypothesized that isolated low-grade hydronephrosis in this population frequently resolves, UTIs are infrequent, and progression to surgical intervention is minimal. PATIENTS AND METHODS: Children < 12 months old diagnosed hydronephrosis (Society for Fetal Urology [SFU] grade 1 or 2) between January 2004 and December 2009 were identified by ICD9 code. Patients with other urological abnormalities were excluded. Stability of hydronephrosis, UTI (≥ 100,000 CFU/mL bacterial growth) or need for surgical intervention was noted. RESULTS: Of 1496 infants with hydronephrosis, 416 (623 renal units) met inclusion criteria. Of 398 renal units with grade 1 hydronephrosis, 385 (96.7%) resolved or remained stable. Only 13 (3.3%) worsened, of which one underwent ureteroneocystostomy. Of 225 renal units with grade 2 hydronephrosis, 222 (98.7%) resolved, improved or remained stable, three (1.3%) worsened, of which one required pyeloplasty. Only 0.7% of patients in the ambulatory setting had a febrile UTI. CONCLUSIONS: Low-grade hydronephrosis diagnosed within the first year of life remains stable or improves in 97.4% of renal units. Given the low rate of recurrent UTI in the ambulatory setting, antibiotic prophylaxis has a limited role in management.

Reviewing definitions of urinary continence in the contemporary spina bifida literature: a call for clarity.

BACKGROUND: Urinary continence is a common goal for children with spina bifida and their physicians. However, definitions of urinary continence vary widely across published studies. We systematically assessed the utilization of common definitions of urinary continence in the spina bifida literature. METHODS: We searched library databases for reports (2000-2012) describing urinary continence outcomes in children with spina bifida. We assessed various patient-level factors such as age, lesion level, surgical history, and use of additional therapies, as well as study-level factors such as study design, country of origin, continence definition(s), and method of data collection. RESULTS: Of 473 identified articles, 105 met inclusion criteria, comprising a total of 3209 patients. Of these, 1791 patients (56%) were deemed continent by the study authors. Only 60 studies (57%) clearly defined what they considered to be "continent". The most common definition, used in 24% of all reports, was "always dry". There was no association between journal of publication (p = 0.13), publication year (p = 0.86), study size (p = 0.26), or study country (p = 0.43) and likelihood of a continence definition being included in the manuscript. CONCLUSIONS: The most frequent definition of urinary continence in the spina bifida literature is "always dry". However, definitions were highly variable, and many authors did not define continence at all. Clinicians and researchers alike would be better able to apply research findings toward improving patient care if continence definitions were more explicitly reported and less variable.

The Publication Ranking Score for pediatric urology: quantifying thought leadership within the subspecialty.

OBJECTIVES: Clinical care parameters are frequently assessed by national ranking systems. However, these rankings do little to comment on institutions' academic contributions. The Publication Ranking Score (PRS) was developed to allow for objective comparisons of scientific thought-leadership at various pediatric urology institutions. METHODS: Faculty lists were compiled for each of the US News & World Report (USNWR) top-50 pediatric urology hospitals. A list of all faculty publications (2006-2011) was then compiled, after adjusting for journal impact factor, and summed to derive a Publication Ranking Score (PRS). PRS rankings were then compared to the USNWR pediatric urology top-50 hospital list. RESULTS: A total of 1811 publications were indexed. PRS rankings resulted in a mean change in rank of 12 positions, compared to USNWR ranks. Of the top-10 USNWR hospitals, only 4 were ranked in the top-10 by the PRS. There was little correlation between the USNWR and PRS ranks for either top-10 (r = 0.42, p = 0.23) or top-50 (r = 0.48, p = 0.0004) hospitals. CONCLUSIONS: PRS institutional ranking differs significantly from the USNWR top-50 hospital list in pediatric urology. While not a replacement, we believe the PRS to be a useful adjunct to the USNWR rankings of pediatric urology hospitals.

Treatment of pediatric vesicoureteral reflux using endoscopic injection of hyaluronic acid/dextranomer gel: intermediate-term experience by a single surgeon.

OBJECTIVES: Endoscopic injection of non-animal-stabilized hyaluronic acid/dextranomer gel is an increasingly recognized treatment option for vesicoureteral reflux. The procedure is minor compared with open surgery and, when successful, avoids the need for long-term antibiotic prophylaxis. We present data from 3 years of using non-animal-stabilized hyaluronic acid/dextranomer gel to treat children with vesicoureteral reflux. METHODS: Pediatric patients aged 16 years with uncomplicated primary vesicoureteral reflux were recruited for endoscopic treatment with non-animal-stabilized hyaluronic acid/dextranomer gel. A follow-up voiding cystourethrogram was scheduled at 2 weeks after treatment, and vesicoureteral reflux resolution was defined as grade 0. Repeat non-animal-stabilized hyaluronic acid/dextranomer gel treatment was offered to patients with persistent vesicoureteral reflux. RESULTS: Of 178 patients treated, 12 were lost to follow-up or yet to undergo post-treatment voiding cystourethrogram. The 166 remaining patients (efficacy population) had a mean age of 4.21 years (range: 0-16), and the median reflux grade was 3 (range: 1-5). Vesicoureteral reflux was resolved in 81.9% of patients and 86.4% of ureters after initial endoscopic treatment with non-animal-stabilized hyaluronic acid/dextranomer gel. The overall reflux resolution rate for patients increased to 89.6% after a second treatment in 19 patients, and 90.2% after a third treatment in 1 patient. No adverse events were reported. Five patients underwent open ureteral reimplantation after failed endoscopic injections. CONCLUSIONS: Endoscopic treatment with non-animal-stabilized hyaluronic acid/dextranomer gel is effective in a high proportion of children with vesicoureteral reflux and, in our opinion, should be considered as a first-line treatment option.

Urologic diagnoses among infants hospitalized for urinary tract infection.

OBJECTIVES: To determine the prevalence of urologic disease among infants hospitalized for urinary tract infections (UTIs) at our institution. The prevalence of urologic anomalies among infants (<400 days old) hospitalized for UTIs has not been previously reported. METHODS: We retrospectively examined the records of all infants hospitalized for UTI at our institution, a free-standing children's hospital in the United States, for a 10-year period. Race, sex, and subsequent urologic diagnosis (using codes from the 9(th) edition of the International Classification of Diseases [ICD-9] were tabulated. Individual charts were reviewed to confirm documentation and workup of UTI. RESULTS: We identified 914 infants hospitalized at our institution from January 1996 to December 2007, with an ICD-9-coded diagnosis of UTI. Of these 914 infants, 258 were subsequently given a urologic diagnosis. However, only 130 of these patients had well-documented UTI (14.2% of 914 children). Of this cohort, 55.4% were boys. The most common diagnoses were hydronephrosis (37.7%), vesicoureteral reflux (69.2%), and obstructive uropathy (23.1%). CONCLUSIONS: Our data have indicated that > or =14% of all infants hospitalized for UTI have urologic anomalies. Vesicoureteral reflux, obstructive uropathy, and hydronephrosis are common diagnoses. We therefore conclude that infants admitted with a diagnosis of UTI should undergo screening for anatomic abnormalities.