Preliminary report: Surgical outcomes following genitoplasty in children with moderate to severe genital atypia.

INTRODUCTION: Prior studies of outcomes following genitoplasty have reported high rates of surgical complications among children with atypical genitalia. Few studies have prospectively assessed outcomes after contemporary surgical approaches. OBJECTIVE: The current study reported the occurrence of early postoperative complications and of cosmetic outcomes (as rated by surgeons and parents) at 12 months following contemporary genitoplasty procedures in children born with atypical genitalia. STUDY DESIGN: This 11-site, prospective study included children aged ≤2 years, with Prader 3-5 or Quigley 3-6 external genitalia, with no prior genitoplasty and non-urogenital malformations at the time of enrollment. Genital appearance was rated on a 4-point Likert scale. Paired t-tests evaluated differences in cosmesis ratings. RESULTS: Out of 27 children, 10 were 46,XY patients with the following diagnoses: gonadal dysgenesis, PAIS or testosterone biosynthetic defect, severe hypospadias and microphallus, who were reared male. Sixteen 46,XX congenital adrenal hyperplasia patients were reared female and one child with sex chromosome mosaicism was reared male. Eleven children had masculinizing genitoplasty for penoscrotal or perineal hypospadias (one-stage, three; two-stage, eight). Among one-stage surgeries, one child had meatal stenosis (minor) and one developed both urinary retention (minor) and urethrocutaneous fistula (major) (Summary Figure). Among two-stage surgeries, three children developed a major complication: penoscrotal fistula, glans dehiscence or urethral dehiscence. Among 16 children who had feminizing genitoplasty, vaginoplasty was performed in all, clitoroplasty in nine, external genitoplasty in 13, urethroplasty in four, perineoplasty in five, and total urogenital sinus mobilization in two. Two children had minor complications: one had a UTI, and one had both a mucosal skin tag and vaginal mucosal polyp. Two additional children developed a major complication: vaginal stenosis. Cosmesis scores revealed sustained improvements from 6 months post-genitoplasty, as previously reported, with all scores reported as good or satisfied. DISCUSSION: In these preliminary data from a multi-site, observational study, parents and surgeons were equally satisfied with the cosmetic outcomes 12 months after genitoplasty. A small number of patients had major complications in both feminizing and masculinizing surgeries; two-stage hypospadias repair had the most major complications. Long-term follow-up of patients at post-puberty will provide a better assessment of outcomes in this population. CONCLUSION: In this cohort of children with moderate to severe atypical genitalia, preliminary data on both surgical and cosmetic outcomes were presented. Findings from this study, and from following these children in long-term studies, will help guide practitioners in their discussions with families about surgical management.

Hydrogel coated mesh decreases tissue reaction resulting from polypropylene mesh implant: implication in hernia repair.

PURPOSE: Use of polypropylene mesh (PPM) in hernia repair is associated with tissue reactivity. We examined, in a rat model, a novel non-biodegradable hydrogel coated PPM which may allow for decreased inflammation and a decreased foreign body reaction. METHODS: Through a dorsal midline incision, a 2 cm × 2 cm section of PPM (either coated or uncoated) was placed on the fascial surface 1.5 cm from the incision on the dorsal wall of Sprague-Dawley rats. At 2 and 12 weeks after placement, the PPM and surrounding tissue were harvested. A board-certified dermatopathologist examined H&E stained slides for fibrosis and foreign body reaction. In addition, tissues were stained for apoptotic cells, oxidative damage, macrophages, fibroblasts, neovascularization and metalloproteases. RESULTS: At 2 and 12 weeks, there was a greater than 95 % decrease in foreign body giant cells in coated PPM samples compared to uncoated; fibrosis was decreased by 50 %. At 2 and 12 weeks, oxidative damage, fibroblast accumulation, apoptosis and macrophages were significantly decreased in coated PPM samples compared to uncoated PPM. CONCLUSION: These results demonstrate that a non-biodegradable hydrogel coating of PPM led to significant reduction in foreign body reaction, oxidative stress and apoptosis compared to uncoated PPM in vivo, and suggest that this coating could be clinically useful in hernia repair.

Self-expandable chitosan stent: design and preparation.

Stents are largely used in surgical procedures to relieve pathological obstructions. The purpose of the present study was to design and prepare a biocompatible stent with a self-expandable mechanism. Thin films were prepared from deacetylated chitosan (4% w/v) dissolved in acetic acid solution (2% v/v). The chitosan films were tested by a calibrated tensiometer to measure the Young's module (E). The films were used to manufacture stents by pulling and winding them around a cylindrical rod in a helical fashion. Thirteen stents (diameter = 0.5 +/- 0.05 mm, length approximately 4 mm) were inserted into the vas deferens of wistar rats. Upon stent insertion, the vasal anastomosis was achieved with a laser-soldering technique. The animals were sacrificied 8 weeks later. The stress test showed that the chitosan film was elastic (maximum strain = 105% +/- 6%, E = 0.7655 +/- 0.0288 Mpa). The stents self-expanded by releasing their elastic energy. All the stents but one remained open inside the vasa despite high incidence of sperm granuloma. A biocompatible and self-expandable stent with a helical design is proposed.

Urologic causes of gynecomastia: approach to diagnosis and management.

A 27-year-old man presented with bilateral painful breast enlargement and recent onset right testicular swelling. After appropriate evaluation, a radical orchiectomy was performed, and a Leydig cell tumor was found. The various urologic etiologies for gynecomastia are presented, as are the potential interventions. A rational approach to the patient with new onset breast swelling is presented.

Laparoscopic surgery in children with ventriculoperitoneal shunts: effect of pneumoperitoneum on intracranial pressure--preliminary experience.

OBJECTIVES: We monitored changes in intracranial pressure (ICP) in 2 children with myelodysplasia undergoing laparoscopic bladder autoaugmentation. Both children had ventriculoperitoneal shunts (VPS) secondary to Arnold-Chiari malformations (type II). METHODS: ICP was monitored through a 23-gauge needle placed into the shunt reservoir and connected to a pressure transducer and drainage system. Intraoperative mean arterial pressure, end-tidal CO2 (ETCO2), ICP, abdominal pressure, and cerebral perfusion pressures were all monitored. RESULTS: Both children demonstrated rapid onset and sustained increases in ICP of greater than 12 mm Hg above baseline to a maximum pressure of 25 mm Hg. The average cerebrospinal fluid removed from each patient was 30 cc, thereby lowering ICP with no adverse neurologic sequela. The pCO2 remained constant throughout the procedures, as measured by ETCO2. CONCLUSIONS: We believe that intracranial hypertension (IH) results from a "Valsalva-like" phenomenon, which causes cerebral vascular engorgement. In addition, the pneumoperitoneum may increase the resistance to outflow through the distal peritoneal catheter, causing a partial or complete shunt obstruction. Untreated IH may result in adverse neurologic sequelae from brain herniation in these children with hindbrain anomalies and potentially altered brain compliance. We believe it is prudent to perform intraoperative ICP monitoring in this subgroup of patients undergoing laparoscopic surgery and that IH should be treated by ventricular drainage.

Use of a catheter limiter during intermittent catheterization.

We report on the use of a new device, the catheter limiter, to facilitate clean intermittent catheterization. The device limits the length of catheter entering the urethra. This provides a means to reduce the risk of mechanical injury and perforation, minimizes incomplete emptying, and improves safety and patient acceptance of intermittent catheterization.

Balloon-wire retrieval of a migrated urethral stent in the early postoperative period.

We report on a new endoscopic approach to the removal of a migrated urethral stent following hypospadias repair. A flexible balloon-tipped guide wire allows the effective cystoscopic retrieval of a urethral stent, suggesting potential applications to the removal of other foreign bodies in the urinary tract.

Laser tissue welding in genitourinary reconstructive surgery: assessment of optimal suture materials.

OBJECTIVES: Laser tissue welding in genitourinary reconstructive surgery has been shown in animal models to decrease operative time, improve healing, and decrease postoperative fistula formation when compared with conventional suture controls. Although the absence of suture material is the ultimate goal, this has not been shown to be practical with current technology for larger repairs. Therefore, suture-assisted laser tissue welding will likely be performed. This study sought to determine the optimal suture to be used during laser welding. METHODS: The integrity of various organic and synthetic sutures exposed to laser irradiation were analyzed. Sutures studied included gut, clear Vicryl, clear polydioxanone suture (PDS), and violet PDS. Sutures were irradiated with a potassium titanyl phosphate (KTP)-532 laser or an 808-nm diode laser with and without the addition of a light-absorbing chromophore (fluorescein or indocyanine green, respectively). A remote temperature-sensing device obtained real-time surface temperatures during lasing. The average temperature, time, and total energy at break point were recorded. RESULTS: Overall, gut suture achieved significantly higher temperatures and withstood higher average energy delivery at break point with both the KTP-532 and the 808-nm diode lasers compared with all other groups (P < 0.05). Both chromophore-treated groups had higher average temperatures at break point combined with lower average energy. The break-point temperature for all groups other than gut occurred at 91 degrees C or less. The optimal temperature range for tissue welding appears to be between 60 degrees and 80 degrees C. CONCLUSIONS: Gut suture offers the greatest margin of error for KTP and 808-nm diode laser welding with or without the use of a chromophore.

Laparoscopic laser-assisted bladder autoaugmentation.

OBJECTIVES: The purpose of this study is to examine the feasibility of performing a laparoscopic bladder autoaugmentation and to assess the urodynamic characteristics of an autoaugmented bladder. METHODS: Laparoscopic bladder autoaugmentation was performed in 9 female canines (20 to 30 kg). Following laparoscopic access to the peritoneal cavity, a midline bladder seromyotomy was performed using the potassium titanyl phosphate 532 nm laser. This produced a large bladder diverticulum. Changes in bladder volume and compliance were quantified over a 3-month period of follow-up. RESULTS: Urodynamic evaluation demonstrated an increase in bladder capacity 6 weeks postoperatively in 8 of 9 dogs, with an average volume increase of 45%. Bladder compliance improved in 7 of 9 dogs with an average increase in compliance of 67%. Three months postoperatively, bladder capacity remained increased in 5 of 9 dogs, with an average increase in volume of only 5.3%. An improvement in compliance was sustained in 5 of 9 animals with an average increase of 13.9%. Laparoscopic exploration revealed grossly normal bladders with adhesions of omentum to the seromyotomy site in all canines and the anterior abdominal wall in 2 of 9 canines. Histologically, the seromyotomy site was devoid of muscle with an intact urothelium and a proliferation of loose connective tissue. CONCLUSIONS: The technique of laparoscopic bladder autoaugmentation can be performed easily in the canine model. Although results at 6 weeks show significant improvement, the longer term, 3-month results were not statistically significant. This technique has the potential to offer a minimally invasive correction for patients with low-capacity, high-pressure bladders that have failed pharmacologic treatment.

An unusual cause of duodenal obstruction: ureteropelvic junction obstruction and the renoalimentary relationship.

Ureteropelvic junction obstruction may present with a variety of urologic and gastrointestinal complaints. The constellation of symptoms is most often attributed to shared visceral pathways. In cases of giant hydronephrosis, mechanical obstruction of the gastric outlet or duodenal sweep may play an additional role in presentation. We present an unusual case of duodenal obstruction caused by ureteropelvic junction stenosis. The anatomic and autonomic renoalimentary relationships are reviewed.

CO2 laser welding versus conventional microsuture repair in patch-graft urethroplasty.

This study evaluates the repair of urethral tissue using microsurgery and a combination of laser welding techniques. Using the rat as a model, a patch-graft urethroplasty was performed with either conventional microsuture repair, laser-assisted microsuture repair, or laser-assisted microsuture with protein solder. Repairs were assessed at various time periods (days 0, 1, 7, and 21). Analysis of success rate, bursting strength, histology, and operative time were completed. The laser with protein solder had the highest success rate at each time period and demonstrated advanced healing with the least amount of inflammation. Operative time was decreased by 30 percent using the laser. In conclusion, the laser solder repair was significantly better than either laser alone or conventional microsutures.

Intravesical bacille Calmette-Guérin induces the antiangiogenic chemokine interferon-inducible protein 10.

OBJECTIVES: Intravesical bacille Calmette-Guérin (BCG) induces a variety of cytokines into the urine of patients with superficial transitional cell carcinoma (TCC) of the bladder. Recent data have shown that some cytokines have antiangiogenic activity. We sought to determine whether the potently antiangiogenic chemokine interferon-inducible protein 10 (IP-10) and its inducing antiangiogenic cytokines, interferon-gamma (IFN-gamma) and interleukin-12 (IL-12), are increased during intravesical BCG immunotherapy of bladder TCC. METHODS: Voided urine samples were collected sequentially from 8 patients before and after each weekly intravesical BCG treatment and from 4 patients receiving maintenance BCG treatments. The urinary output of IP-10, IFN-gamma, and IL-12 over 12 post-treatment hours was assessed by enzyme-linked immunosorbent assay. In vitro BCG and cytokine stimulations of human TCC and primary endothelial cell lines were also performed, and their supernatants were studied for IP-10. RESULTS: In all cases after intravesical BCG, patient urine was found to contain significant elevations of IP-10. Urinary IFN-gamma and IL-12 levels also increased in similar patterns after intravesical BCG. The peak weekly cytokine response per patient usually occurred between the fourth and sixth treatment for IFN-gamma and IP-10, but was less predictable for IL-12. Human TCC and endothelial cell lines were able to secrete IP-10 in response to BCG or interferon stimulation in vitro. CONCLUSIONS: Our small series demonstrates that IP-10 and its inducing cytokines are elevated in response to intravesical BCG. These data suggest that, in addition to a cellular immune response, BCG may induce a cytokine-mediated antiangiogenic environment that aids in inhibiting future tumor growth and progression.

Laser tissue welding.

Laser tissue welding is a technologic innovation that is beginning to move from the theoretical laboratory environment to the reality of clinical application. This article reviews the concepts, potential advantages, and techniques involved in laser tissue welding as they apply to urology.

Hand-assisted laparoscopic autoaugmentation gastrocystoplasty.

BACKGROUND: Autoaugmentation gastrocystoplasty has been previously performed successfully. This set of experiments was conducted to determine the feasibility of performing autoaugmentation gastrocystoplasty laparoscopically. METHODS: Hand-assisted laparoscopic autoaugmentation gastrocystoplasty was performed on 15 mongrel dogs. The surgery was carried out with two 10-mm trocars and a 6-cm Pfannenstiel incision. The gastric wedge, supplied by the right gastroepiploic artery, was resected with two applications of an endoscopic gastrointestinal anastomosis (GIA) stapler. The pedicle was demucosalized, and the anastomosis to the bladder was completed through the Pfannenstiel incision. RESULTS: All of the dogs were successfully treated laparoscopically and were eating at 48 h. There was no evidence of anastomotic leak dehiscence at the gastric resection staple line. CONCLUSION: Hand-assisted laparoscopic autoaugmentation gastrocystoplasty can be performed successfully in dogs. This operation may offer a superior alternative to standard bladder autoaugmentation procedures in children suffering from congenital bladder disorders.

Box stitch modification of Hasson technique for pediatric laparoscopy.

Laparoscopy has been recognized as the modality of choice for the treatment of many diseases in urology, gynecology, and general surgery. Although laparoscopy is minimally invasive, the most frequent complications are associated with entry through the abdominal wall. The Hasson (open) technique was developed to minimize the complications by entering the abdomen under direct vision. We have modified the Hasson technique with a stitch that is easy to perform, creates a tight fascial seal, allows easy exchange of trocars, and produces an effect that is cosmetically appealing.

Laser tissue welding: a biotechnological advance for the future.

Laser tissue welding as well as other alternative methods of closure will play a more important role in surgical specialties as laparoscopic, endoscopic, and microsurgical techniques continue to develop. Laser tissue welding uses laser energy to anastomose tissues and is ideally suited for applications in which suturing and stapling is difficult. Recent advances have led to a better understanding of the mechanisms of tissue welding. Additionally, technical achievements including the introduction of protein solders and temperature-controlled feedback systems have led to the acceptance of laser tissue welding in clinical medicine. In this article, we describe the history and development of laser tissue welding and review the current and potential applications of this technology.

Laser tissue welding - poised for the new millenium.

Laser tissue welding is a relatively new technique, which was initially described only about 30 years ago. Over the past 10 years, the implementation of protein solders has redefined the field. Alternative methods of wound closure and of tissue approximation have been quickly accepted in clinical medicine. The techniques and theory involved in performing laser tissue welding may soon be essential knowledge for all surgeons. Just as laparoscopy has become a mainstay for general surgeons and urologists, novel mechanisms of tissue approximation will continue to replace older, less efficacious techniques.

A clinical series of laparoscopic nephrectomy, nephroureterectomy and heminephroureterectomy in the pediatric population.

PURPOSE: Laparoscopic techniques have enabled less invasive surgery in pediatric urology. We report our experience with laparoscopic nephrectomy, nephroureterectomy and heminephroureterectomy in 26 children, and evaluate our series to establish the safety and efficacy of such procedures for benign disease. MATERIALS AND METHODS: Laparoscopic procedures were done in 15 girls and 11 boys 4 months to 11 years old (mean age 37) during a 23-month period. Laparascopic surgery consisted of nephrectomy in 14 (1 horseshoe kidney), nephroureterectomy in 6 and laparoscopic heminephroureterectomy in 6 cases. RESULTS: Mean overall operative time for the laparoscopic procedures was 165 minutes (range 43 to 355). Blood loss was less than 5 cc in all cases and there were no intraoperative complications in our series. Overall postoperative analgesic administration during hospitalization was 0.20 mg./kg. morphine sulfate and 19 mg./kg. acetaminophen as well as 0.9 mg./kg. codeine in 6 patients who did not receive morphine. Three children were discharged home on the day of surgery, while 17, 3, 1 and 2 were discharged home on postoperative days 1, 2, 4 and 5, respectively. Cosmetic results were excellent in all cases. CONCLUSIONS: Nephrectomy, nephroureterectomy and heminephroureterectomy may be performed for benign disease in children using laparoscopy with minimal morbidity, minimal postoperative discomfort, improved cosmesis and a short hospital stay. It may even be done as an outpatient procedure.