Late-gestation heat stress in Holstein dams programs in utero development of daughter's germline, triggering skin and hair morphology adaptations of granddaughters.

Homeostasis and thermoregulation are influenced by the interplay of hair coat and skin characteristics. Our previous work indicated that hair and skin adaptations, triggered by in utero heat stress, affect thermoregulation in postnatal life. Herein, we investigate multigenerational carry-over effects of late-gestation heat stress on hair and skin characteristics beyond the first generation. Pregnant Holstein dams (F0, grand-dams) were heat stressed (HT, shade, n = 41) or provided active cooling (CL, shade, fans, and water soakers, n = 41) for the last 56 d of gestation during summer (temperature-humidity index ≥68). The first generation of heifers (F1, daughters) who were in utero heat stressed (HTF1, n = 36) or not (CLF1, n = 37) were born and raised as a cohort from birth to first calving. Thirty second-generation heifers (F2, granddaughters), born to HTF1 (HTF2, n = 12) and CLF1 (CLF2, n = 18), were raised as a cohort from birth to 70 d of age. Hair samples and skin biopsies from HTF2 and CLF2 were collected on postnatal d 70 (n = 6/group). Hair samples were subdivided into topcoat and undercoat, and skin tissue was fixed for ~18 h in 10% formalin, dehydrated, paraffin-embedded, sectioned, and stained with hematoxylin and eosin to visualize morphology. Variables analyzed included hair length and diameter; stratum corneum cross-sectional area and thickness; epidermis thickness; sweat gland depth, number, cross-sectional area, and average size; and sebaceous gland number, cross-sectional area, and average size. Measurements were performed using the ImageJ software and analyzed using PROC MIXED in SAS (SAS Institute Inc.). Hair length and diameter tended to be shorter and thicker in HTF2, compared with CLF2. The HTF2 skin had smaller stratum corneum cross-sectional area and tended to a thinner epidermis. to CLF2, HTF2 skin had more but smaller sebaceous glands, whereas no differences in sweat glands were observed. In summary, we report phenotypic alterations in hair and skin characteristics of granddaughters. Whether these adaptations grant improved postnatal thermoregulatory ability for the granddaughters remains to be investigated.

The changing gender landscape of pediatric urology fellowship: results from a survey of fellows and recent graduates.

INTRODUCTION: Women are entering the subspecialty of pediatric urology at an accelerated rate. Gender differences affecting fellowship and job selection have been identified in other fields of medicine. OBJECTIVE: The objective of this study was to understand gender differences in pediatric urology fellowship and job selection and how they may affect the workforce. STUDY DESIGN: A 47-question electronic survey consisting of questions regarding demographics, residency training, and factors influencing fellowship and job selection was distributed to current fellows and recent graduates in pediatric urology in May 2017. RESULTS: A total of 111 recent and current fellows were contacted, and 72% completed the survey (55% female [F] and 45% male [M]; 61% current fellows and 39% recent fellows). Respondents rated factors important in choosing pediatric urology on a scale of 1-5 (1, not important and 5, extremely important), and the top three for both genders were 1-working with children, 2-influential mentors, and 3-bread and butter cases such as inguinal orchiopexy. During residency, 93% of respondents reported having influential mentors in pediatric urology. However, mentorship was more important in fellowship choice for males than females (3.6 F, 4.1 M; P-value = 0.048), and 45% reported having only male mentors. Rating factors important in job choice on a scale of 1-5, respondents reported the top factors as 1-rapport with partners/mentorship (4.5), 2-geography/family preferences (4.3), and 3-participation in mentoring/teaching (3.8). Although most job selection criteria were rated similarly between genders, females rated call schedule higher than males (3.5 F, 2.9 M, P-value = 0.009). Although most females and males (79% of F, 78% of M, P-value = 0.868) sought primarily academic positions, a smaller proportion of females accepted academic positions (52% of F, 72% of M, P-value 0.26), and females reported lower satisfaction regarding the availability of jobs on a scale of 1-5 (1, very dissatisfied and 5, very satisfied; 3.1 F, 3.7 M; P-value = 0.034), particularly in academic positions (3.1 F, 3.7 M; P-value = 0.06). This difference was more pronounced in current fellows than recent graduates and may represent a worsening trend. CONCLUSION: Although significant gender differences in fellowship and job selection may exist in other fields, we found that women and men choose pediatric urology fellowships and jobs using similar criteria, which include work-life balance. Gender differences exist in the influence of mentors, indicating a need for more female mentors. While men and women sought similar types of jobs, women were less satisfied with the availability of jobs, particularly academic jobs, than men, which warrants further investigation.

Do pediatricians routinely perform genitourinary examinations during well-child visits? A review from a large tertiary pediatric hospital.

BACKGROUND: The male genital examination is a common source of discomfort for the patient and medical provider. Performance of male genital examination is imperative; however, as many treatable diagnoses can be made. Undescended testicles (UDTs), hernias, testicular tumors, and urethral abnormalities are all potentially concerning findings which can be discovered on routine examination. OBJECTIVE: The objectives of this study are to determine the rate at which general pediatricians perform routine genitourinary (GU) examinations in the pediatric population and to determine the rate at which UDT are diagnosed or documented in the patient's history. The authors hypothesize the rate of pediatric GU examination during routine well-child visits to be in line with the previously reported rates in the adult literature. STUDY DESIGN: Nine hundred ninety-six consecutive male well-child visits conducted by general pediatricians at the study institution were reviewed. These visits were evaluated for documentation of a detailed GU examination as well as the presence of UDT from these examinations. In addition, past medical and surgical histories were reviewed to determine if a diagnosis of UDT was noted. RESULTS: Pediatricians at the study institution documented GU examinations 99.1% of the time during male well-child visits. Only 1.1% of the cohort had a documentation of UDT at any time point. Of the 11 patients with UDT, 6 boys (54.5%) had spontaneous descent with no referral to urology, whereas 5 (45.5%) required orchidopexy. DISCUSSION: Prior reports suggest 70-75% of routine office visits include a genital examination. None of these reports reviewed the pediatric population, thus making this review novel in this respect. In addition, the results are vastly different from these prior studies as the authors demonstrated over 99% of male well-child examinations included documentation of a thorough genital examination. A limitation of the study is its retrospective nature, which creates a lack of standardization across the data set. In addition, without being physically present in the examination room, one cannot discern whether an examination is simply being documented without actual performance because of the template format of the electronic medical record (EMR). Furthermore, the study was not designed to best evaluate the true rate of UDTs; therefore, the reported rate of 1.1% cannot be accurately associated with a particular age at diagnosis. CONCLUSIONS: Pediatricians do, in fact, document GU examinations on a routine basis. This finding cannot be taken with complete certainty as verification of actual examination performance is impractical. While the data demonstrated a lower than expected rate of UDT, depending upon age at diagnosis, this could indicate that although examinations are being documented, their accuracy may be diminished because of various factors at play in the healthcare system as a whole, including improper exam performance and EMR templates. Follow-up studies are required to verify these potentially changing rates of UDT and to determine if there is discordance between documentation and performance of GU examinations.

Comparing treatment modalities for transplant kidney vesicoureteral reflux in the pediatric population.

INTRODUCTION: Non-refluxing ureteral reimplantation is favored in pediatric renal transplantation to prevent complications, such as vesicoureteral reflux (VUR) in the transplant ureter. VUR resulting in febrile urinary tract infections remains a problem in this population, leading to repeated hospitalizations and increased morbidity. Revision of the vesicoureteral anastomosis can be a surgical challenge due to scar tissue and tenuous vascularity of the transplant ureter. Therefore, alternative options such as endoscopic injection of Deflux at the neo-orifice and surveillance with prophylactic antibiotics have emerged as potential treatment modalities for transplant ureter VUR. OBJECTIVE: The authors reviewed their experience of the management of VUR in the transplant ureter, comparing outcomes of various modalities. STUDY DESIGN: With Institutional Review Board approval, a retrospective chart review of all renal transplant patients from January 2002 to January 2017 was conducted. All patients with VUR on voiding cystourethrogram (VCUG) after surgery were identified. Indications for end-stage renal disease, urologic comorbidities, pretransplant VCUG, and operative details were recorded. After transplantation, febrile urinary tract infections, ultrasound findings, and any further interventions-surveillance, subureteral endoscopic injection of Deflux, or ureteral reimplantation-were documented along with their outcomes. RESULTS: Overall, VUR was identified in 35/285 (12.3%) transplant patients after a non-refluxing ureteroneocystostomy. VUR was managed with surveillance in 17/35 (49%), intravesical Deflux injection in 11/35 (31%), and immediate redo ureteral reimplantation in 7/35 (20%). Ten out of 11 patients undergoing Deflux injection had a postoperative VCUG. All patients developed VUR recurrence; the majority showed immediate failure and only 1/10 showed late recurrence. Of the immediate failures, 3/9 patients were maintained on prophylactic antibiotics, and 6/9 patients underwent ureteral reimplantation. In these six patients undergoing reimplantation after failed Deflux, 3/6 (50%) patients required additional surgeries: One patient developed recurrence of reflux and two patients developed ureterovesical junction obstruction. In contrast, no complications were seen in patients undergoing primary ureteral reimplantation. DISCUSSION: The study is limited by low numbers and a retrospective design. However, the results of this study differ significantly from the published Deflux series showing a success rate of more than 50% in the treatment of transplant kidney VUR. In fact, post-Deflux redo ureteral reimplantation was associated with an increased risk of postoperative complication. CONCLUSION: The use of Deflux in the post-transplant setting has poor results. In the study series, 11/11 patients demonstrated clinical and radiographic failure. Therefore, as an institution the authors do not recommend Deflux as first-line treatment of VUR in the transplant patient.

Imaging characteristics associated with failure of nonoperative management in high-grade pediatric blunt renal trauma.

INTRODUCTION: Some children who sustain high-grade blunt renal injury may require operative intervention. In the present study, it was hypothesized that there are computed tomography (CT) characteristics that can identify which of these children are most likely to need operative intervention. MATERIALS AND METHODS: A retrospective review was performed of all pediatric blunt renal trauma patients at a single level-I trauma center from 1990 to 2015. Inclusion criteria were: children with American Association for the Surgery of Trauma (AAST) Grade-IV or V renal injuries, aged ≤18 years, and having available CT images with delayed cuts. The CTs were regraded according to the revised AAST grading system proposed by Buckley and McAninch in 2011. Radiographic characteristics of renal injury were correlated with the primary outcome of any operative intervention: ureteral stent, angiography, nephrectomy/renorrhaphy, and percutaneous nephrostomy/drain. RESULTS: One patient had a Grade-V injury and 26 patients had Grade-IV injuries. Nine patients (33.3%) underwent operative interventions. Patients in the operative intervention cohort were more likely to manifest a collecting system filling defect (P = 0.040) (Fig. A) and lacked ureteral opacification (P = 0.010). The CT characteristics, including percentage of devascularized parenchyma, medial contrast extravasation, intravascular contrast extravasation, perirenal hematoma distance and laceration location, were not statistically significant. Of the 21 patients who had a collecting system injury, eight (38.1%) needed ureteral stents. Renorrhaphy was necessary for one patient. Although the first operative intervention occurred at a median of hospital day 1 (range 0.5-2.5), additional operative interventions occurred from day 4-16. Thus, it is prudent to closely follow-up these patients for the first month after injury. Two patients with complex renal injuries had an accessory renal artery resulting in well-perfused upper and lower pole fragments, and were managed nonoperatively without readmission (Fig. B). CONCLUSIONS: Collecting system defects and lack of ureteral opacification were significantly associated with failure of nonoperative management. A multicenter trial is needed to confirm these findings and whether nonsignificant CT findings are associated with operative intervention. In the month after renal injury, these patients should be mindful of any changes in symptoms, and maintain a low index of suspicion for an emergency room visit. For the physician, close follow-up and appropriate counseling of these high-risk patients is advised.

Prenatal detection of primary megaureter using dynamic image ultrasonography.

The detection of primary megaureter at 31 weeks' gestation is reported. The characteristics of this anomaly, namely, dilated ureter and renal pelvis with normal renal cortex, calyceal system, and bladder, can be seen with dynamic image ultrasonography.

Effect of chronic ethanol consumption on the spontaneous contractions, prostaglandin production, triglycerides and glucose metabolism of uterine strips isolated from pregnant rats and in embryos.

The constancy of spontaneous isometric developed tension (IDT) and the metabolism of triglycerides (TGs), U-14C-Glucose and 14C-arachidonic acid (14C-AA) in uterine strips isolated from controls and from chronic ethanol (ETOH) fed pregnant rats were explored. The studies were performed on isolated uterine strips suspended in glucose-containing as well as a glucose-free medium. The spontaneous decrement of IDT as time progressed after tissue isolation and mounting was significantly higher in tissue preparations obtained from pregnant rats drinking 20% ETOH, than the controls. This situation was evident in uterine strips isolated from rats at 10 and at 16 days of pregnancy, both in solutions containing glucose or in glucose-free conditions. On the other hand, uterine strips isolated from control rats at 7, 10 and 16 days of pregnancy exhibited almost no decrement of IDT after 60 min of activity in a solution containing glucose or in a glucose-free medium. The absolute values of TGs in uteri obtained from rats drinking ETOH were significantly greater (p < 0.001) than in non-drinking controls. TG levels did not differ at 0 min (initial or postisolation) to those at 60 min in control uterine preparations obtained from pregnant rats at 7, 10 or 16 days of pregnancy and incubated either in a medium with or without glucose. On the contrary, in strips from ETOH-fed animals isolated on the same day of pregnancy, TG levels determined at 60 min following isolation and mounting were significantly lower, when glucose was present or absent from the suspending solution.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital bladder diverticula causing ureteral obstruction.

Two boys with congenital periureteral bladder diverticula without vesicoureteral reflux but with severe hydronephrosis and ureteral obstruction are described. No bladder outflow obstruction was present. Urinary tract infection was the presenting symptom in both boys, and this is the most common presenting symptom of bladder diverticula. Diverticulectomy, ureteral tailoring, and reimplantation were performed. Three different mechanisms are proposed for the association of bladder diverticula and ureteral obstruction: compression of the extravesical ureter against the detrusor by the full, tense diverticulum, fibrosis resulting from peridiverticulitis, or primary hypomuscularity of the ureterovesical junction and distal ureter.

Urologic management in cloacal dysgenesis.

Eleven cases of cloacal dysgenesis from the experience in the Baylor affiliated hospitals from 1969 to 1977 are reviewed. Clinical features including radiographic studies are presented in representative case reports. Despite the initial urgent need for intestinal surgical intervention in these patients, the long-term morbidity and complications are typically related to the genitourinary system. A review of the literature with emphasis on embryogenesis is given. Recommendations for diagnostic approach, and acute and long-term urologic management are made.

Single-stage reconstruction of urinary tract after loop cutaneous ureterostomy.

Three patients with four renoureteral units have undergone single-stage reconstruction involving ureteroureterostomy and ipsilateral ureteroneocystostomy following temporary loop cutaneous ureterostomy. Preliminary loop cutaneous ureterostomy diversion allowed adequate ureteral recompensation such that ureteral tapering was unnecessary in any of these cases. Rich collateral circulation as well as strict preservation of adventitial ureteral vasculature allows the performance of upper and lower ureteral procedures in a single session.

Current indications for cutaneous ureterostomy.

OBJECTIVE: To assess the current indications for cutaneous ureterostomy in children. METHOD: A total of 32 children underwent cutaneous ureterostomy at Texas Children's Hospital from 1975 to 1990. Medical records were reviewed to determine the urologic diagnosis, the indication for urinary diversion, the type of ureterostomy performed, and the outcome for each patient. RESULTS: Twenty patients underwent loop cutaneous ureterostomy (LCU) or pyelostomy and 12 patients underwent end cutaneous ureterostomy (ECU). The main indication for LCU was obstructive uropathy unresponsive to lower urinary tract drainage, and the most common cause was posterior urethral valves. Other indications for LCU included obstruction requiring delayed surgical correction, high-grade reflux into a solitary kidney, and obstruction with infection. The children who required ECU were an older, more diverse group than those who underwent LCU. The main indication for ECU was poor bladder function secondary to a variety of congenital anomalies, including prune-belly syndrome, posterior urethral valves, bladder exstrophy, and urogenital sinus defect. CONCLUSION: LCU is easy to perform and is an excellent method for achieving temporary upper urinary tract drainage. ECU is suited for long-term or permanent urinary diversion in children with at least one dilated ureter, and can provide a socially acceptable stoma when delayed reconstruction is necessary. Many children who were "permanently" diverted by ECU may be undiverted using newer reconstructive techniques.

Correction of disproportion of corpora cavernosa as cause of chordee in hypospadias.

Correction of chordee is a basic step in hypospadias surgery. In some children with significant chordee, ventral deflection of the shaft will persist after all "chordee tissue" is excised from the surface of the corpora cavernosa. In the flaccid state, this persistent chordee may not be evident but is easily demonstrated with an artificial erection technique. The use of dorsal plication of the tunica albuginea to correct this deformity is emphasized.

Horseshoe kidney with multicystic dysplasia associated with ureterocele.

This is a case report of a horseshoe kidney one side of which contains a multicystic dysplastic element associated with a ureterocele. The surgical management and embryologic basis are reviewed.

Pediatric pyeloplasty: outcome analysis based on patient age and surgical technique.

OBJECTIVES: To analyze our experience with open pyeloplasty, with specific emphasis on procedural outcome on the basis of patient age, surgical technique, complication rate, and complication management. METHODS: All patients from 1974 to 1994 who underwent pyeloplasty at our institution were included in our review. Charts were analyzed for age at presentation, presenting signs and symptoms, type of surgical reconstruction, complications and treatment, and final outcome. RESULTS: From 1974 to 1994, 234 pyeloplasties were performed in 227 patients (108 less than 1 year old, 119 more than 1 year old). The percentage of children less than 1 year old increased throughout: 24% for 1975 to 1980, 37% for 1981 to 1990, and 69% for 1991 to 1994. Presenting signs and symptoms varied according to the age of the child at pyeloplasty. For children less than 1 year old, these were prenatal ultrasound in 86 (79%), urinary tract infection (UTI) in 9 (8%), and abdominal mass in 5 (4.6%). For children more than 1 year old, these were pain in 57 (48%), UTI in 29 (24%), hematuria in 12 (10%), and prenatal ultrasound in 3 (2.5%). Reconstruction was a dismembered pyeloplasty in all cases. The majority of patients in both age groups underwent a nonintubated repair (less than 1 year old, 99 of 114; more than 1 year old, 102 of 120). Postoperative results were evaluated by ultrasound or intravenous urography, with improvement or stable results in 95% of children less than 1 year old and in 96% of children more than 1 year old. Complications included UTI in 18 patients (7.7%), recurrent obstruction in 5 (2.1%), and persistent leak in 4 (1.7%). The complication rate was not related to age. CONCLUSIONS: The nonintubated, dismembered pyeloplasty is an excellent technique for all age groups and has a low complication rate.

Changing concepts in management of pelvic rhabdomyosarcoma in children.

Survival with embryonal rhabdomyosarcoma of all sites has improved dramatically in recent years with the increased use of long-term, cyclic, multidrug chemotherapy. Protocols have been established and are currently being evaluated by the Intergroup Rhabdomyosarcoma Study. The management of embryonal rhabdomyosarcoma of the pelvic viscera, though, remains troublesome. Limited surgical excision is rarely possible and high-dose radiotherapy to the bony pelvis may cause severe and disabling growth disorders. Yet, survival with these lesions is increasing as with rhabdomyosarcoma from all sites and is directly related to a well-planned and aggressive multidisciplinary program. We have seen 12 cases of pelvic rhabdomyosarcoma within the last seventeen years at this institution. These cases will be reviewed in regard to varying modes of therapy and survival. Our current therapeutic approach, based on national and local experience, will be presented.

Urinary undiversion in patients with myelodysplasia and neurogenic bladder dysfunction. Report of a workshop.

This workshop was conducted in an attempt to analyze critically the role of reconstruction of the myelodysplastic patient who had undergone urinary diversion and to develop guidelines for selecting those patients in whom urinary undiversion might be undertaken safely. The collective experience initially seems to be acceptable; however, the authors emphasize the gravity of the decision and the complexity of the evaluation which must be undertaken prior to embarking on such reconstructive surgery. Contrary to some reports, we believe that the defunctionalized bladder frequently can be evaluated. Further, many of the contraindications to urinary undiversion have been identified and several of the hazards involved therein can be avoided. We believe that the neurogenic bladder is no longer an absolute contraindication to undiversion. Our experience suggests that undiversion is a reasonable surgical treatment in select patient with neurogenic bladder dysfunction. But, the decision to remove a satisfactorily functioning conduit must not be undertaken lightly. Patients should be selected only after a thorough, detailed, and properly conducted evaluation. A protocol has been developed which will hopefully assist in this evaluation. Perhaps additional shared experience will further refine and delineate the circumstances appropriate for reconstruction of these patients.

Urologic considerations in the newborn.

The management of the neonate will continue to hold a special interest for the urologic surgeon because of the many unique aspects of neonatal physiology and pathology that must be considered. I would anticipate that the number of referrals will continue to increase, from awareness of familial patterns of urologic disorders, from recognition of obstructive uropathy with prenatal ultrasound, and from improved survival of very sick neonates by our pediatric colleagues. The urologist who wishes to participate in the care of these sick newborns must become familiar with the unique aspects of care that these babies demand. The future promises to be challenging, but exciting.

Alternatives in the management of posterior urethral valves.

The child with posterior urethral valves poses a continuing treatment dilemma because congenital infravesical obstruction may result in long-standing dysfunction of all segments of the urinary tract. Relief of the obstruction may not return bladder pressure to normal or completely resolve abnormalities of ureteral drainage. Dysplastic renal parenchyma cannot recover. Four issues affect the identification of those children who will benefit from therapy beyond transurethral valve destruction: the concept of transitional nephrology, the possibility of coexisting ureterovesical obstruction, the valve bladder syndrome, and prenatal urology.

Reconstruction of the female external genitalia.

The experience of the authors with the surgical reconstruction of female external genitalia is described. In all cases in which these procedures were used, reduction clitoroplasty resulted in satisfactory cosmetic appearance and the preservation of tactile sensation, and posterior flap vaginoplasty provided adequate introital capacity.

Genitourinary trauma in children.

More children die from trauma than from any single disease. In children who sustain multiple injuries, urinary tract trauma is second only to trauma to the central nervous system. Most pediatric trauma is associated with vehicular and pedestrian accidents. However, the increased participation in contact sports and awareness of sports medicine injuries have increased the relative frequency and detection of sports-related injuries as well. Also, the urologist is frequently involved with, and may be legally responsible for, evaluation of children in possible abusive situations. The authors emphasize genitourinary injuries unique to the pediatric age group and update controversies in the management of more complex urologic injuries.