Isolated penile lymphedema in an adolescent male: a case of metastatic Crohn's disease.

OBJECTIVE: Metastatic Crohn's disease is a rare and complex inflammatory condition distinguished by cutaneous granulomatous lesions outside the gastrointestinal tract. Genital involvement is rare; with less than 10 cases reported involving isolated penile lymphedema. Here, we present a case of isolated lymphedema of the penis as a consequence of extra-intestinal Crohn's disease. CASE REPORT: The patient is an 18-year-old African American male with a complex history of inflammatory bowel disease, who initially presented with a chief complaint of 6 weeks of swelling of his penis at age 13. A modified circumcision and lymphangectomy of the penis were performed; histopatholgy demonstrated a granulomatous infiltrate and interstitial edema of the distal penis. CONCLUSION: Surgical intervention is an applicable therapeutic alternative and last-line therapy for treatment of isolated penile lymphedema in select patients with appropriate pathology, and can be a suitable adjunct to medical management in these cases.

Transverse preputial flap for ventral penile skin coverage in hypospadias surgery.

A dartos-based transverse skin flap for ventral penile skin coverage is used as an adjunct to hypospadias surgery. The technique is simple and reliable. After completing the primary repair of the penis, the ventral skin defect is assessed. A dartos pedicle is developed, and the flap of dorsal penile skin is transferred ventrally along either side of the shaft. To date, 63 boys (ages 6 to 78 months) have undergone this type of penile skin reconstruction. Our transverse preputial flap has been used as an adjunct to hypospadias repair (28 boys), correction of chordee (26 boys), and release of concealed penis (9 boys). During a follow-up period of 6 to 74 months, 52 patients (83%) had a favorable cosmetic result. One patient experienced a significant loss of epithelium in the early postoperative course. Another patient developed a moderate penile torsion, which required subsequent revision of the repair. Two patients developed moderate scar indentations of the repair. Seven patients demonstrated a moderate redundancy of the flap with time. The transverse preputial flap is a reliable and cosmetically superior alternative to ventral skin coverage in hypospadias surgery, repair of chordee, and in the release of concealed penis.

The Hickman peel-away sheath: alternative for pediatric percutaneous nephrolithotomy.

Percutaneous nephrolithotomy presents a therapeutic challenge in children because of the disproportion between the sizes of the instruments and the kidneys. A technique for pediatric nephrolithotomy used on a 2-year-old female child is presented. The patient was born prematurely and developed kidney stones as a complication of furosemide therapy. She failed medical management with hydrochlorothiazide, and the stone did not disintegrate following extracorporeal shockwave lithotripsy (ESWL). A Chiba needle was used to access the renal collecting system percutaneously. Using a guidewire, sequential dilatation was performed to 16F. A 15F Hickman catheter introduction kit was then used, and the sheath was partially peeled away. A 10F pediatric cystoscope and grasper were inserted through the sheath to remove the stones. A 12F catheter was then placed through the sheath; the sheath was peeled away, and the catheter was left indwelling for 48 hours. No complications ensued. A postoperative nephrostogram showed free drainage and absence of residual stones. Utilization of the Hickman peel-away sheath constitutes an excellent alternative nephrolithotomy technique for children with stones unresponsive to more conservative treatment.

In-vivo whole bladder response to anticholinergic and musculotropic agents in spinal cord injured rats.

The purpose of this study was to compare the effect on urodynamic parameters of anticholinergic and musculotropic agents in sham injured and spinal cord injured (SCI) rats. A standard rat SCI model induced by impact trauma was employed. Cystometrograms were performed under urethane anesthesia four weeks after SCI. Bladder capacity and voiding pressure were determined at the point of micturition monitored urodynamically and visually. The effect of oxybutynin chloride (0.01-0.1 mg/kg), propantheline bromide (0.05-0.5 mg/kg) and flavoxate hydrochloride (0.1-1.0 mg/kg) were assessed independently in sham injured and SCI rats (n = 10 in each group). Bladder capacities were 0.6 +/- 0.2 and 7.1 +/- 1.6 ml in sham and SCI rats (p < 0.01), respectively. Maximal filling pressure was 17.5 +/- 5 mmHg in sham and 25 +/- 5 mmHg in SCI rats (p < 0.05). Bladder capacity increased with all three medications. Administration of oxybutynin, propantheline and flavoxate in sham rats resulted in bladder capacities of 0.88 +/- 0.3, 0.71 +/- 0.3 and 0.8 +/- 0.2 ml, respectively (p < 0.01). In SCI rats, these drugs resulted in bladder capacities of 9.8 +/- 1.1, 7.9 +/- 1.3 and 8.8 +/- 2.0 ml, respectively (p < 0.01). No significant change in maximum filling pressure occurred. We conclude that anticholinergic and musculotropic agents caused a similar increase in bladder capacity in both sham and SCI rats. Oxybutynin enhanced bladder capacity more than propantheline or flavoxate.

Gracilis muscle dynamic urethral sphincter myoplasty: rat model experience.

PURPOSE: Dynamic urethral sphincter myoplasty (skeletal muscle urinary sphincter reconstruction) using a neurovascularly intact gracilis muscle was investigated in a rat model. MATERIALS AND METHODS: In female Sprague-Dawley rats, a unilateral gracilis anticus muscle flap was dissected from the medial thigh, preserving the medial muscular insertion, vascular flow, and innervation. This muscle graft was used to completely encircle the urethra and was fixed in position. Urodynamic leak point pressure (LPP) and bladder volume at leakage were measured with cystometry after 1 month, using an 18 gauge catheter placed through the bladder dome with a constant infusion rate of 0.2 ml. per minute. In addition, the effect of electrical stimulation of the gracilis myoplasty (current parameters: 1 to 10 mA, 1 to 60 Hz, 0.05 to 1 msec. duration) on intravesical leak point pressure was noted during cystometry. RESULTS: The gracilis muscle measured 3.8 +/- 0.3 cm. in length, 0.5 +/- 0.1 cm. in width and 0.2 +/- 0.1 cm. in thickness. Blood flow rates to the grafted and contralateral gracilis myoplasty were similar at 43 +/- 26 and 51 +/- 30 g.cm.3, respectively (p = 0.46). The leak point pressure (LPP) of control, unstimulated gracilis myoplasty and gracilis myoplasty with electrical stimulation were 28 +/- 8, 32 +/- 12, and 85 +/- 27 mm.Hg (p < 0.01). Bladder volumes at LPP in the 3 respective groups were 0.5 +/- 0.2, 0.6 +/- 0.3 and 1.2 +/- 0.6 ml (p < 0.01). CONCLUSIONS: Gracilis myoplasty is not obstructive, as substantiated by unchanged leak point pressure and leak point capacity. Myoplasty with low current stimulation, however, significantly increased LPP and leak point capacity.

Comparison of bladder rupture pressure after intestinal bladder augmentation (ileocystoplasty) and myomyotomy (autoaugmentation).

OBJECTIVES: To compare the risk of bladder rupture of bladder augmentation using ileocystoplasty versus that of autoaugmentation with myomyotomy in a rat model. METHODS: Bladder rupture pressure and volume of three groups of female Sprague-Dawley rats were determined by cystometry. The first group of 11 rats had undergone ileocystoplasty using a detubularized 1 -cm segment of ileum. A second group of 9 rats had undergone autoaugmentation with myomyotomy. One month after surgery the animals were studied cystometrically to determine the bladder rupture pressure, then killed. A third group, consisting of 10 nonoperated rats, was studied and served as controls. RESULTS: Nonoperated, control rat bladders were able to sustain 154 +/- 43 mm Hg pressure and 2.5 +/- 2.0 mL volume prior to bladder rupture. Conventional ileocystoplasty was noted to increase bladder capacity to 4.0 +/- 1.9 mL, but decrease rupture pressure to 111 +/- 49 mm Hg. Myomyotomy resulted in a mean bladder rupture volume of 1.2 +/- 0.4 mL, with a rupture pressure of 101 +/- 13 mm Hg. The rupture pressure after myomyotomy is significantly lower than that of the native bladder (P < 0.001), whereas the rupture volume after myomyotomy is significantly lower than either after the ileocystoplasty or with the native bladder (P < 0.001). Bladder rupture occurred at the augmented ileal bladder dome in 7 of 11 ileocystoplasty animals and at the anastomotic suture line in 4 animals. Bladder rupture occurred at the area of bladder diverticulum in all 9 myomyotomy animals. Among controls, no specific site pattern of bladder rupture was noted. CONCLUSIONS: Bladder augmentation with myomyotomy increases vulnerability to urinary extravasation, evidenced by a significantly reduced rupture pressure and bladder volume at rupture when compared to the native bladder.

Enuresis in sickle cell disease.

The prevalence of enuresis and management options for this condition were studied in our population of sickle cell patients. A total of 91 active patients (6 to 21 years old) followed at our regional sickle cell center was surveyed for the symptoms of primary nocturnal enuresis. Of the 91 patients 27 (29.6%) had primary nocturnal enuresis. Of those with enuresis 17 had homozygous sickle cell anemia, 5 had hemoglobin sickle cell disease, 4 had sickle cell beta + thalassemia and 1 had sickle cell beta zero-thalassemia. Of 10 patients who elected to receive intranasal desmopressin acetate 6 (60%) had complete or partial resolution of nocturnal enuresis. Our data confirm the high prevalence of nocturnal enuresis in patients with sickle cell disease and support the role of desmopressin acetate in the treatment of these patients.

Retrieval of ureteral stents in children.

An endoscopic technique to remove ureteral stents in children is described. The technique is simple and reproducible. A snare or lasso is created by looping a polypropylene suture through a ureteral catheter. The snare is advanced under vision through the working channel of a pediatric cystoscope. The loop of the suture is placed over the intravesical portion of the indwelling ureteral stent. It is tied to create a noose, thus securing the stent. The stent can then be removed easily.

A trans-reservoir technique for correction of ureterointestinal obstruction in continent urinary diversion.

Following construction of a continent colonic urinary reservoir, 5 uretero-colonic reimplantations became obstructed at the anastomotic site. In these obstructed units previous percutaneous balloon dilation and stent placement had failed and they were subsequently treated by a new reimplantation procedure. Preoperatively, in all ureteral units a percutaneous ureteral stent was inserted to facilitate intraoperative recognition of the ureteral meatus. The technique included a trans-reservoir approach, which allowed easy localization of the stent and anastomotic site. The ureter was dissected free from the intestinal wall and then was mobilized into the lumen of the reservoir. After excision of the scarred distal ureteral segment and spatulation of the proximal healthy ureter, a new direct mucosa-to-mucosa reimplantation was performed leaving the ureter stented. This trans-reservoir approach (occasionally done through an abdominal transverse muscle splitting incision) allows for shortening of the operation, and avoids the time-consuming and more complicated transabdominal lysis of adhesions. All newly reimplanted ureters (100%) showed evidence of adequate ureteral drainage without residual obstruction on followup excretory urography or furosemide renography up to 45 months postoperatively. The trans-reservoir approach for refractory ureteral reimplantation obstruction in continent colonic reservoirs has been associated with no morbidity or mortality, and facilitates the solution to a difficult clinical problem.

Bladder autoaugmentation.

In this article, the short history and reported results of clinical bladder autoaugmentation are reviewed. In addition, the techniques of both bladder myomyotomy and myomectomy are described in detail. Results of animal research are presented to correlate with clinical results. The applicability of autoaugmentation to those practicing general urology and future perspectives are also addressed.

Acid-base changes following urinary tract reconstruction for continent diversion and orthotopic bladder replacement.

A prospective determination of serum electrolytes, arterial blood gases, urinalysis and urine cultures was done in 31 patients who underwent a successful continent urinary reservoir or orthotopic bladder replacement. The patients who underwent reconstruction with a long detubularized intestinal segment (group 1-50 cm. long) demonstrated the greatest tendency for metabolic hyperchloremic acidosis (35.2%). In group 2 (patients with an orthotopic bladder replacement) only 1 individual (16.7%) had hyperchloremia, which proved to be the sole metabolic derangement encountered. In group 3 (individuals with a continent gastroileac reservoir) 2 patients (25%) had a slight tendency for compensated and asymptomatic alkalosis. Urinalyses and urine cultures in groups 1 and 2 demonstrated a trend toward urine alkalinity (52.1%) and asymptomatic bacteriuria (74%), respectively. On the contrary, among the patients undergoing a gastroileac reservoir (group 3), mild urinary acidity (pH between 5 and 6) was demonstrated in 4 (50%), while asymptomatic bacteriuria was present in 3 (37.5%). In this group symptomatic urinary acidity and/or ulceration of the ileal component has not occurred to date. Metabolic hyperchloremic acidosis predominates when longer colonic segments are used for reservoir construction. This abnormality is magnified in patients in whom an accessory small bowel was resected. The majority of the gastroileac reservoir patients showed electrolytic neutrality. With our surgical technique, the gastric secretory properties predominate over those of the ileum. The differences in homeostatic findings with the use of these varieties of bowel segments suggest that we could modify the final electrolytic environment by using different combinations of bowel and bowel length.

The tapered and reimplanted small bowel as a variation of the Mitrofanoff procedure: preliminary results.

Ten patients with a urethra that could not be catheterized and with absent appendixes underwent neobladder construction using an ileal segment fashioned to serve as the anti-incontinence mechanism. The latter was tapered and reimplanted following the guidelines of the Mitrofanoff procedure. Urinary reservoirs were constructed from detubularized segments of right colon, sigmoid colon and composite gastro-ileal combinations. Followup ranged from 9 to 21 months (mean 14.5). All patients presently catheterize the reservoir satisfactorily and are free of urinary leakage. Three patients (30%) experienced initial catheterization difficulties: 2 required endoscopic procedures and insertion of a stent, and 1 with stomal stenosis was successfully treated with a Y-V stoma plasty. One patient (10%) required a repeat ileal segment reimplantation due to urinary incontinence. The higher reoperation rate and the increased surgical complexity of this procedure compared with reconstructions using the ileocecal valve as part of the anti-incontinence mechanism make this operation a less attractive alternative in the creation of a continent urinary reservoir. However, with comprehension of the need for careful and detailed surgical technique in its creation, the tapered and reimplanted ileal segment is a successful choice as an alternative for the creation of an abdominal wall stoma when the appendix is unavailable.

The gastroileoileal pouch: an alternative continent urinary reservoir for patients with short bowel, acidosis and/or extensive pelvic radiation.

We report on 6 patients who underwent a new type of continent urinary diversion: the gastroileoileal reservoir. These are a select group of patients who presented with the short bowel syndrome, acidosis, borderline diarrhea and/or severe pelvic radiation, which precluded the use of terminal ileum and the ileocecal segment. Considering these factors, and based on the different functional properties of the stomach as well as the need for a large reservoir, a segment of stomach and proximal ileum was used to construct the reservoir. Four patients have been followed for at least 6 months, with the longest followup being 12 months. Temporary dysphagia requiring hydrogen blockers developed in 1 patient. Results indicate excellent function of the continent urinary system, lack of metabolic complications, absent diarrhea and excellent patient tolerance. This procedure could be a useful alternative in some difficult clinical situations when continent urinary diversion is desirable.

Ciprofloxacin versus gentamicin in prophylaxis against bacteremia in transrectal prostate needle biopsy.

Consecutive patients with abnormal rectal examinations underwent transrectal needle prostate biopsy at VA Medical Center, New Orleans. Each patient was randomized to receive either gentamicin 1.5 mg/kg intravenously (IV) or 500 mg ciprofloxacin (Cipro-Miles) p.o., before and after the biopsy. Serum and prostate tissue levels of ciprofloxacin and gentamicin were measured by high-pressure liquid chromatography and by competitive binding immunoassay, respectively. Blood cultures were obtained, and the patients were observed for twenty-four hours after biopsy. After discharge the patients were followed up by telephone. The incidence of bacteremia and postbiopsy symptoms were less with ciprofloxacin. Prostate tissue levels of this drug were higher than gentamicin, while serum levels were roughly equivalent. Ciprofloxacin is less nephrotoxic, can be given orally, and has a better antimicrobial spectrum. We, therefore, recommend it as prophylaxis against bacteremia in transrectal prostate needle biopsy. Furthermore, it appears that prostatic drug levels are more important than serum levels in preventing bacteremia.

Anuria secondary to percutaneous needle biopsy of a transplant kidney: a case report.

Unexplained deterioration of renal function after renal transplantation is often an indication for percutaneous needle biopsy of the allograft. This procedure, even when supplemented by modern radiographic techniques, is not without complications. We report a case of anuria secondary to subcapsular hematoma following an ultrasound-guided needle biopsy. Diagnosis, operative management and postoperative care are discussed.

Malacoplakia of the urethra.

We report a case of urethral malacoplakia associated with disease of the bladder and bladder neck. Treatment consisted of fulguration of the bladder lesions and excision of the urethral lesion. Unlike most other cases of genitourinary malacoplakia, which are associated with chronic urinary tract infection, this patient had sterile urine and no history of urinary tract infections. Urethral malacoplakia is reviewed, and the pathogenesis and treatment of the disease are discussed.