Management of recurrent epididymitis in children: application of neurovascular sparing vas clipping in refractory cases.

PURPOSE: To investigate the efficacy of therapeutic methods for recurrent epididymitis and neurovascular sparing vas clipping in refractory cases. MATERIALS AND METHODS: Fifteen boys with recurrent epididymitis were enrolled: the first group (9) with primary structural anomalies and the second group (6) with voiding dysfunction without structural anomalies. Median age was 4 (29 months to 7 years) and 4.5 (6 months to 11 years) years, respectively. Mean follow up was 7.5 (2-11) and 5.2 (3.5-8) years, respectively. RESULTS: Urethrovasal reflux was detected in all patients of the first group except one. Endoscopic injection of bulking agent was successfully applied in three patients with no recurrent epididymitis. No further episodes of epididymitis were reported after valve ablation or clean intermittent catheterization. In four non-responders, vas clipping was successfully undertaken. Voiding dysfunction was the possible etiology of epididymitis but with no obvious urethrovasal reflux in the second group. No further episodes of epididymitis occurred using bladder retraining and medications for detrusor and sphincter relaxation. CONCLUSIONS: The results suggest that neurovascular sparing vas clipping can be used effectively in children with structural anomalies and urethrovasal reflux who have developed intractable epididymitis.

Single-donor fibrin sealant for repair of urethrocutaneous fistulae following multiple hypospadias and epispadias repairs.

PURPOSE: To evaluate the efficacy of fibrin sealant for repair of urethrocutaneous fistula after multiple failed hypospadias and epispadias surgeries. MATERIALS AND METHODS: The study population comprised 11 boys (mean age 12.18 years) with history of hypospadias or epispadias and at least two failed fistula repair operations leading to recurrent urethrocutaneous fistula. During the operation, single-donor fibrin glue, either from the patient (7) or a parent (4), was applied over the suture lines and beneath the skin. A urethral catheter was kept in place for 7-10 days. Follow up ranged from 6 to 24 months (mean 12.63 months). RESULTS: Nine patients had an uneventful postoperative course. In one patient with a large fistula, partial wound dehiscence occurred. In another patient with complete hypospadias, hematoma formation caused skin dehiscence but the urethra remained intact. Both cases recovered after 6 months with no further intervention. No fistula recurrence was reported during follow up. CONCLUSION: Single-donor fibrin glue could be a useful adjunct to surgical management of patients after multiple failed attempts at hypospadias or epispadias fistula repair. Moreover, this product improves the safety margin regarding the risk of disease transmission.

Urethral hydrodistension for management of urethral hypoplasia in prune belly syndrome: long-term results.

PURPOSE: The aim of the study was to evaluate the efficacy and safety of urethral hydrodistension for management of urethral hypoplasia in prune belly syndrome (PBS). METHODS: During a 10-year period, 7 infants with PBS and urethral hypoplasia presented either with open urachus or surgically created urinary diversion referred to our hospital. Five milliliters of normal saline was pushed via a 22-gauge plastic angiocatheter into the urethra with simultaneous finger pressure on the perineum to occlude the proximal urethra that was repeated with higher volumes of the solution (up to 20 mL). The procedure was continued until a 6F or 8F feeding tube catheter confirmed the urethral patency. Hydrodistension was repeated in 3-month intervals till complete patency was confirmed by imaging. RESULTS: Median age of the infants was 6 (1-8) months. All urethral hydrodistension were successful after 1 to 3 sessions. Follow-up imaging studies showed significant improvement in all patients except one. Natural and surgically created urinary diversions were closed in 6 infants. CONCLUSIONS: The hydrodistension create an equal and constant pressure into the urethral wall without any urethral damage. This technique can be considered along with the other available methods for management of urethral hypoplasia in selected cases of PBS.

Efficacy of transcutaneous functional electrical stimulation on urinary incontinence in myelomeningocele: results of a pilot study.

PURPOSE: To investigate the efficacy of transcutaneous functional electrical stimulation (FES) on voiding symptoms in children with myelomeningocele (MMC) suffering from neuropathic urinary incontinence. MATERIALS AND METHODS: Six girls and 6 boys with moderate to severe urinary incontinence secondary to MMC were included. Median age of children was 5.04 (range: 3-11) years. They underwent a urodynamic study (UDS) before and 3 months after FES with special attention to detrusor leak point pressure (DLPP) and maximal bladder capacity (MBC). Daily incontinence score, frequency of pad changing, and enuresis were also assessed before and three months after treatment. Fifteen courses of FES for 15 minutes 3 times per week were performed with low frequency (40 Hz) electrical current, duration of 250µs, with hold and rest time of 2 seconds. RESULTS: Nine children had improvement on urinary incontinence score, while three children had no improvement. Median DLPP was significantly increased from 38.5 (range: 12-50) cm H2O to 59.5 (range: 18-83) cm H2O (P = 0.003). MBC was significantly increased from median value of 155 (range: 60-250) mL to 200 (range: 110-300) mL (P = 0.007). CONCLUSIONS: This is a pilot study showing that FES therapy might have positive effects on improvement of voiding symptoms of MMC children with neurogenic urinary incontinence in terms of daily incontinence score and UDS parameters.

Efficacy of transcutaneous functional electrical stimulation on urinary incontinence in myelomeningocele: results of a pilot study

PURPOSE: To investigate the efficacy of transcutaneous functional electrical stimulation (FES) on voiding symptoms in children with myelomeningocele (MMC) suffering from neuropathic urinary incontinence. MATERIALS AND METHODS: Six girls and 6 boys with moderate to severe urinary incontinence secondary to MMC were included. Median age of children was 5.04 (range: 3-11) years. They underwent a urodynamic study (UDS) before and 3 months after FES with special attention to detrusor leak point pressure (DLPP) and maximal bladder capacity (MBC). Daily incontinence score, frequency of pad changing, and enuresis were also assessed before and three months after treatment. Fifteen courses of FES for 15 minutes 3 times per week were performed with low frequency (40 Hz) electrical current, duration of 250µs, with hold and rest time of 2 seconds. RESULTS: Nine children had improvement on urinary incontinence score, while three children had no improvement. Median DLPP was significantly increased from 38.5 (range: 12-50) cm H2O to 59.5 (range: 18-83) cm H2O (P = 0.003). MBC was significantly increased from median value of 155 (range: 60-250) mL to 200 (range: 110-300) mL (P = 0.007). CONCLUSIONS: This is a pilot study showing that FES therapy might have positive effects on improvement of voiding symptoms of MMC children with neurogenic urinary incontinence in terms of daily incontinence score and UDS parameters.

Antibody formation following botulinum toxin type A (Dysport) injection in children with intractable bladder hyper-reflexia.

OBJECTIVES: To investigate the pattern of anti-Dysport antibody (ADA) formation after Dysport injection in patients with neuropathic bladder. Antibody formation may lead to failure or allergic reactions in patients undergoing Dysport injection. METHODS: Forty-four children with neuropathic bladder were enrolled and classified into 3 groups: group I, without history of previous injection (n = 8); group II, with history of one or more injections (n = 7); and group III, who had been injected 3-36 months before this study (n = 29). Groups I and II were subjected to Dysport injection. Fifty-five age-matched healthy children were selected as controls. Urinary incontinence score was assessed before and 6 months after injection. Under cystoscopic guidance, Dysport (10 IU/kg) was injected into the detrusor muscle, sparing the trigone and ureteral orifices. ADA level was measured by enzyme-linked immunosorbent assay technique before injection and then monthly for at least 4 months in groups I and II, and for just once in group III and control subjects. RESULTS: ADA level was increased 1-2 months after the last injection in 3 (38%) of group I and 5 (71%) of group II. However, ADA level in group III was not higher than controls. All patients had complete or partial improvement in urinary incontinence score except for 1 patient in group I. No resistance to treatment was detected. CONCLUSIONS: Increment of ADA titer in patients is not permanent. Repeated injections will not boost the immune system to produce higher levels of antibody. Increased levels of ADA may not be associated with treatment failure at follow-up visit.

Intravitreal triamcinolone as an adjunct to standard laser therapy in coexisting high-risk proliferative diabetic retinopathy and clinically significant macular edema.

PURPOSE: To evaluate the efficacy and safety of combined intravitreal triamcinolone acetonide (IVTA) injection plus panretinal photocoagulation (PRP) and macular photocoagulation (MPC) in comparison with PRP and MPC in eyes with coexisting high-risk proliferative diabetic retinopathy (PDR) and clinically significant macular edema (CSME). METHODS: Twenty-three patients diagnosed with both high-risk PDR and CSME were enrolled in our prospective, randomized clinical trial study. One eye of each patient was selected to undergo IVTA injection one week before initial PRP and MPC (IVTA eye), and the other eye was treated with PRP and MPC (control eye) based on block randomization. Panretinal photocoagulation was performed in 3 sessions at 1 week intervals. Baseline characteristics included best-corrected visual acuity (BCVA) using Snellen charts, intraocular pressure and patients were observed at 1, 4, and 6 months of treatment. Main outcome measures included change in central macular thickness (CMT) as measured by optical coherence tomography (OCT), logarithm of the minimum angle of resolution BCVA (logMAR), and complications occurring within the follow-up period. RESULTS: Of 23 enrolled patients, 5 patients did not complete follow-up visits due to dense vitreous hemorrhage, tractional retinal detachment and loss of future follow-up. Mean baseline logMAR BCVA was 0.46 +/- 0.29 and 0.56 +/- 0.27 in IVTA eyes and controls. Final mean logMAR BCVA was 0.39 +/- 0.29 (IVTA eyes) and 0.55 +/- 0.33 (control eyes), which was not significantly different (P = 0.08). Mean baseline CMT was 319.2 +/- 79.1 microm (IVTA eyes) and 345.9 +/- 100.6 microm (control eyes). Significant reduction of CMT in IVTA eyes was observed at 1 month (P = 0.024), which had not remained stable after 6 months showing no significant difference as compared with baseline CMT (P = 0.06). In control eyes, CMT was not significantly reduced at 1 and 6 months of treatment. The standardized change in macular thickening (SCMT) was 29.4 +/- 52.2 (IVTA group) versus 5.66 +/- 31.5 (control group) (P = 0.12) at 1 month. At 6 months, SCMT was 16.8 +/- 55.8 (IVTA group) versus 5.03 +/- 47.4 (control group) (P = 0.51). CONCLUSION: Combined IVTA plus PRP and MPC in coexisting high-risk PDR and CSME eyes do not have a significant beneficial effect on BCVA improvement and CMT reduction compared with standard treatment.