Comparison of antegrade and retrograde endoscopic injection techniques for neurogenic sphincteric incontinence in children with neurogenic bladder.

INTRODUCTION/BACKGROUND: Urinary incontinence is common in children with neuropathic bladder. Results of endoscopic injections of bulking agents in the bladder neck are promising but it remains unclear whether they should be performed an antegrade or retrograde fashion. OBJECTIVE: Our aim was to compare the antegrade and retrograde endoscopic injection techniques for the treatment of urinary incontinence. STUDY DESIGN: A prospective study evaluating bladder neck dextranomer-hyaluronic acid polymer injections for urinary incontinence in children with neurogenic bladder was initiated in 1997. Children with normal bladder capacity and compliance and without uncontrolled detrusor overactivity or previous bladder neck surgery were included. Patients were classified as success (dry or significantly improved, the latter defined as no need for more than one pad per day, continent during night, and patient seeking no further treatment) or failure at regular follow-up visits. RESULTS: During 1997-2016, 34 children underwent endoscopic treatment in a retrograde while 17 children in antegrade fashion (mean age 11 years, range 5-20). Most patients (n = 47/51) had neuropathic bladder due to congenital malformations, 13 (25%) had had previous bladder augmentation, and 19 (37%) were in wheelchair. Sex, age, etiology of neurogenic bladder, degree of physical impairment, or era of treatment (1997-2012 vs. 2012-2016) had no influence on success rates (Summary Table). After mean follow-ups of 69 (range 12-156) months, success rates were 71% for the antegrade and 53% for the retrograde technique (p = 0.366). Mean number of injections to obtain success was similar between the techniques (1.4 vs. 1.2). While the proportion of dry patients was similar between the two techniques (35%), the proportion of significantly improved patients tended to be higher after antegrade than retrograde injections (35% vs. 18%, p = 0.181). DISCUSSION: Better visualization of the bladder neck may explain the tendency for improved results of antegrade compared to retrograde technique. Further studies in larger patient samples are needed to define the optimal endoscopic injection technique. CONCLUSION: Long-term results of the antegrade endoscopic bladder neck injections of dextranomer-hyaluronic acid polymer for urinary incontinence in children with neurogenic bladder are promising.

Real-Time Classification of Hand Motions Using Ultrasound Imaging of Forearm Muscles.

Surface electromyography (sEMG) has been the predominant method for sensing electrical activity for a number of applications involving muscle-computer interfaces, including myoelectric control of prostheses and rehabilitation robots. Ultrasound imaging for sensing mechanical deformation of functional muscle compartments can overcome several limitations of sEMG, including the inability to differentiate between deep contiguous muscle compartments, low signal-to-noise ratio, and lack of a robust graded signal. The objective of this study was to evaluate the feasibility of real-time graded control using a computationally efficient method to differentiate between complex hand motions based on ultrasound imaging of forearm muscles. Dynamic ultrasound images of the forearm muscles were obtained from six able-bodied volunteers and analyzed to map muscle activity based on the deformation of the contracting muscles during different hand motions. Each participant performed 15 different hand motions, including digit flexion, different grips (i.e., power grasp and pinch grip), and grips in combination with wrist pronation. During the training phase, we generated a database of activity patterns corresponding to different hand motions for each participant. During the testing phase, novel activity patterns were classified using a nearest neighbor classification algorithm based on that database. The average classification accuracy was 91%. Real-time image-based control of a virtual hand showed an average classification accuracy of 92%. Our results demonstrate the feasibility of using ultrasound imaging as a robust muscle-computer interface. Potential clinical applications include control of multiarticulated prosthetic hands, stroke rehabilitation, and fundamental investigations of motor control and biomechanics.

Giant postsurgical pseudomeningocele by SPECT/CT cisternography.

We describe a case of a 32-year-old man with a giant pseudomeningocele seen on MRI examination 6 months after spinal surgery. Radionuclide SPECT/CT cisternography performed after intrathecal suboccipital injection of In-DTPA identified the site of cerebral spinal fluid leak at the L4 level, and the patient underwent surgical correction of the dural defect. A repeat MRI examination 8 months later showed no signs of recurrence.

Outcome Improvement in RPA I or II Patients With 1 or 2 Brain Metastases by Combined Surgery and Radiotherapy.

BACKGROUND: To evaluate the role of surgery and postoperative radiotherapy in the management of brain metastases (BM): a retrospective analysis for overall survival (OS), local and brain control (LC and BC) of a series of 329 patients with recursive partitioning analysis (RPA) I or II with 1 or 2 BM in a single institution. METHODS: Patients were treated either with combined surgical resection and whole brain radiation therapy (WBRT) in 104 cases (31.6%) or with WBRT alone in 225 cases (68.4%). Ninety-five patients (91.4%) who underwent surgery and WBRT and 147 (65.3%) who underwent WBRT alone benefited from a radiation boost to the metastatic site. RESULTS: The median OS was higher for patients RPA I compared to RPA II: 21.3 and 5.9 months (P < 0.0001), as well as for the surgical group compared to the radiation group: 20.2 vs 5.3 months (P < 0.0001), respectively. After the multivariate analysis, the improved OS was significantly associated with control of primary tumor (P = 0.0002) after surgical resection and with type of primary tumor (P = 0.002), absence of extracranial metastases (ECM) (P = 0.006), and high Karnofsky performance status (90 - 100 vs 70 - 80) (P = 0.003) after radiotherapy alone. The 12-, 24- and 36-months LC rates were 91.1%, 91.1% and 83.9%, respectively, after surgical resection and 81.2%, 63.1% and 57.3%, respectively, after radiotherapy alone (P = 0.005). In a univariate analysis, improved LC for the surgical group was also associated with the absence of ECM (P = 0.01) and for the radiation group, with a radiation boost (P = 0.01). The BC rates at 12, 24 and 36 months were 73.2%, 66.9% and 56%, respectively, in the surgical group and 75.7%, 49.6% and 42.4%, respectively, in the radiation group (P = 0.2). In our univariate analysis, improved BC after surgical resection was associated with control of primary tumor (P = 0.02). For patients in the radiation group, gender (P = 0.03) and a radiation boost (P = 0.0003) were significant prognostic factors in a univariate analysis. In our multivariate analysis, only the radiation boost was significant (P = 0.001). CONCLUSIONS: Surgical resection followed by WBRT leads to a better outcome compared to WBRT alone for RPA I or II patients with 1 or 2 BM.