Inhibitory effects of pomegranate concentrated solution on the activities of hyaluronidase, tyrosinase, and metalloproteinase.

Synopsis Botanical antioxidants have attracted much attention as useful preventatives of skin damage. Pomegranate is consumed throughout the world for its beneficial health effects, including its antioxidant and anti-inflammatory activities. We investigated whether pomegranate concentrated solution (PCS) could serve as a potential functional cosmetic ingredient that exerts a skin-whitening effect and antiwrinkle activity. To investigate the moisturizing effect of PCS, hyaluronidase activity was examined in human keratinocytes (HaCaT). Elastase and procollagenase activities were assessed in normal human primary dermal fibroblast-neonatal (HDF-N) cells to determine their antiwrinkle effects. Metalloproteinase 1 (MMP-1) activity was also assessed following ultraviolet A (UVA) irradiation. Whitening effects were measured by a tyrosinase inhibition assay and melanin formation test in mouse melanocytes (Melan-a). In addition, histopathological analysis was performed to determine the number of microfolds formed on the epithelial surface, mean epithelial thickness, mean number of inflammatory cells infiltrating the dermis, and collagen fiber-occupied regions within the dermis. Hyaluronan synthesis was significantly increased by PCS in HaCaT cells, while procollagenase and elastase activities were decreased in HDF-N cells. A significant decrease in UVA-induced MMP-1 activity was also observed in PCS-treated HDF-N cells, compared with UVA-exposed cells. PCS effectively reduced melanin production and mushroom tyrosinase activity in Melan-a cells. Moreover, UVB-induced histopathological dermal sclerosis and inflammatory signs were significantly attenuated in PCS-administered mice compared with UVB-exposed mice. Conclusions: Our results suggest that PCS prevents signs of aging, including those related to photoaging. These effects are associated with enhanced hyaluronan synthesis, as well as suppressed elastase, collagenase, MMP-1, and tyrosinase activities and melanin production. UVB-induced photoaging, such as histopathological dermal sclerosis and inflammatory signs, were effectively reduced on the addition of PCS. These results also suggest that skin aging can be prevented and reduced by the antioxidant effects of PCS.

Effect of Neutron Irradiation on Properties of Pb(Mg(1/3)Nb(2/3))O3-PbTiO3.

The effect of neutron irradiation on the electrical and piezoelectric properties of a PMN-PT [(Pb(Mg(1/3)Nb(2/3))O3-PbTiO3)] single crystal such as permittivity, electrical impedance and piezoelectric constant d33 has been investigated at 1 kHz. The changes of d33 and permittivity depending on the dose of neutron irradiation for all samples of PMN-PT single crystal were found. In all samples, the permittivity, and piezoelectric constant d33 decreased with the increase of irradiation dose. Changes of XRD patterns depending on the dose of neutron irradiation for all samples were found. From the results of XRDs for analyzing the formation of the PMN-PT single crystals in single phase, the neutron irradiation will affect the crystallinity of PMN-PT single crystals.

Congenital small kidney can be an indicator of surgical treatment in children with primary vesicoureteral reflux.

OBJECTIVES: To evaluate the usefulness of congenital small kidney as a treatment indicator in children with primary vesicoureteral reflux (VUR). METHODS: Eighty-five children aged from 1 day to 108 months with primary VUR were analyzed retrospectively. The children were divided into 2 groups: a normal kidney group (n = 45) and a small kidney group (n = 44). VUR grade, age, sex, and bilaterality were compared between the 2 groups. As well, the incidence of spontaneous resolution/improvement in VUR and antireflux surgery were compared between the 2 groups. RESULTS: No differences were observed in either presenting age bilaterality or follow-up period between the 2 groups. The most common grades were III in the normal kidney group (20/45) and IV in the small kidney group (22/44). Spontaneous resolution/improvement in VUR in the normal and small kidney groups occurred in 11 of 20 vs 0 of 6, 6 of 15 vs 1 of 22, and 2 of 10 vs 0 of 16 children with grades III, IV, and V, respectively. Antireflux surgery was performed in the normal and small kidney groups in 9 of 20 vs 6 of 6, 9 of 15 vs 21 of 22, and 8 of 10 vs 16 of 16 children with grades III, IV, and V, respectively. On multivariate analysis, renal size was a statistically significant indicator of an antireflux surgery after adjusting for age, bilaterality, and VUR grade. CONCLUSIONS: Children with primary VUR accompanying small kidney show a lower opportunity of spontaneous resolution or improvement in VUR. Congenital small kidney could be an additional indicator for early surgical correction along with grade, age, sex, and laterality in children with primary VUR.

Embryonal Carcinoma of a Pexed Testis / 대한비뇨기과학회지

A 24-year-old patient who had a history of right-side orchidopexy 16 years ago presented with right testicular pain. A hypoechoic mass was seen on the ultrasonography. Inguinal orchiectomy of the right testis was performed. On microscopic examination, the specimen was identical as an embryonal carcinoma.

Embryonal Carcinoma of a Pexed Testis / 대한비뇨기과학회지

A 24-year-old patient who had a history of right-side orchidopexy 16 years ago presented with right testicular pain. A hypoechoic mass was seen on the ultrasonography. Inguinal orchiectomy of the right testis was performed. On microscopic examination, the specimen was identical as an embryonal carcinoma.

Incidence of Vesicoureteral Reflux for Prepuberty Patients in Daegu City and Gyeongbuk Area according to the Clinical Indications, Gender and Age / 대한비뇨기과학회지

PURPOSE: The prevalence of vesicoureteral reflux (VUR) in prepuberty children with urinary tract infection (UTI) varies among the different racial groups. The purpose of this study was to determine if the incidence of VUR is associated with age, gender and the clinical indications for the prepuberty children with UTI in Daegu city and the Gyeongbuk area, and we wanted to compare our findings to those reported findings for the other racial groups. MATERIALS AND METHODS: The medical records of all 2,474 prepuberty children who underwent a voiding cystourethrogram (VCUG) or radionuclide cystogram (RNC) between 1998 and 2003 were retrospectively reviewed. Age, gender and the clinical indications were recorded for the first VCUG or RNC. For the children with UTI, the highest grade of VUR and the number of UTIs were also examined. We analyzed the data by using chi square test and calculating the odds ratio with using SAS version 8.12. RESULTS: There were 2,037 prepuberty children with UTI (82.5%) among the 2,474 total subjects. Among the participants, 718 (35.2%) were female and 1,306 (64.1%) were male, and 13 were missing data. The overall rate of VUR was 21.2% (432/2,037) with a rate of 22.6% (162/718) for the females and 20.4% (267/1,306) for the males, respectively. With respect to the age distribution, none were younger than 1, 1 was younger than 2, the 2-6 year-olds were 17.3% (257/1,485), and the 7-12 year olds were 35.9% (103/287). Referring to the frequency of UTI, the patients experiencing their first, second. third, fourth, and over five episodes were 16.8%, 34.2%, 36.7%, 42.9% and 56.1%, respectively. As the patients got older, the first VCUG was done for recurrent UTI (p<0.05). CONCLUSIONS: We investigated the rate of VUR based on the clinical indications, age and gender among Korean preadolescents. The rate of reflux was 21.2% for the patients suffering with UTI. The female had VUD 1.1 times more frequent than did the males. The older patient had a higher reflux rate, which suggested that prepuberty children over 1 year of age with recurrent UTI should undergo their first VCUG or RNC.

Necessity of Aggressive Management in Fournier's Gangrene / 대한비뇨기과학회지

Purpose: The mortality of patients with Fournier's gangrene remains at 15-50%, despite the improvement in critical care, the liberal use of broad spectrum antibiotics and the emphasis on aggressive surgical debridement. Therefore, the factors impacting on the survival and necessity for aggressive management were evaluated by comparing the medical records of survivors and non-survivors of Fournier's gangrene. Material and Methods: The medical records of 20 patients with Fournier's gangrene treated over a 12-year period were reviewed. The patients' ages ranged between 20 and 90 years (mean 55). The predisposing factors and extended surface area of necrosis were analysed by outcome. The number of surgical debridements and their timing, with respect to initial presentation and diversions, were analysed according to the extended surface area (3%). The outcome of the surgical treatments of patients with fever or sepsis at the time of the initial hospital visit was analyzed. Results: The predisposing factors included diabetes mellitus (10 cases, 50%), general weakness (7 cases, 35%), alcohol abuse (5 cases, 25%), malignant disease (3 cases, 15%) and hemiplegia (2 cases, 10%). Of the 20 patients, 3 (15%) died and 17 (85%) survived. One patient died due to septic shock before undergoing surgical debridement. The mean surface area involved with the disease among the survivors and non survivors were 3.6 and 3.7%, respectively. The patients with an extended surface below 3% (n=10) had 1.5 times the mean number of debridements. Of these, diversion was performed in one patient, three patients had complications and one patient died. The patients with an extended surface over 3% (n=9) had 2.3 times the mean number of debridements. Of these, five patient was performed diversion, tree patients had complication and one patient died. Of the 11 patient with fever or sepsis, 2 that did not undergone first debridement within 24hr of presentation died. However, all the patients who underwent first debridement within 24hr of presentation survived. Conclusions: The patient's physiological status influenced by the predisposing factors played the important role in the outcome. With aggressive treatment, including early and repeat surgical intervention and diversion, the disease has a reduced mortality.

Two Cases of Pediatric Paratesticular Rhabdomyosarcoma / 대한비뇨기과학회지

Rhabdomyosarcoma is a malignant tumor resulting from the abnormal proliferation of rhabdomyoblasts, which can grow in any part of body that contains embryonal mesenchyme. In general, rhabdomyosarcomas account for 5-10% of all childhood tumors. Of the rhabdomyosarcomas, genitourinary tumors account for approximately 20% of all human rhabdomyosarcomas, but only 7% of all rhabdomyosarcomas are of paratesticular origin. In the Korean literature, only two cases of paratesticular rhabdomyosarcomas in children have been reported. Herein, two cases of unilateral paratesticular rhabdomyosarcomas in children, successfully treated with a radical orchiectomy and chemotherapy, are reported.

An Experience of Endoscopic Polydimethylsiloxane Injection for the Treatment of Vesicoureteral Reflux in Children / 대한비뇨기과학회지

PURPOSE: We evaluated the efficacy of an endoscopic subureteral injection of polydimethylsiloxane (Macroplastique) for the correction of vesicoureteral reflux in children. MATERIALS AND METHODS: The medical records of 15 children (19 refluxing ureters), who had undergone a single endoscopic subureteral injection of polydimethylsiloxane for the treatment of vesicoureteral reflux, were reviewed. After the injection, voiding cystourethrograms were performed after 3 to 10 months to evaluate the results. Renal and bladder ultrasonograms were taken after 3 to 30 months to check for the development of de novo hydroureteronephrosis and the presence of the implant at the bladder base. The follow-up duration was between 7 and 43 months. RESULTS: Of the 15 patients, there were 6 boys and 9 girls, with ages ranging from 12 months to 14 years. The reflux was resolved in 10 of the 19 ureters, in 8 of the 15 children, after a single injection. The resolutions of reflux, by grade, were none in 2, 2 in 4, 5 in 7, 1 in 4 and 2 in 2 of the ureters of grade I to V, respectively. The unilateral reflux was resolved in 7 of the 12, the bilateral reflux in 2 (3 ureters) of the 3 and the reflux in a duplicated system in 1 of the 3 cases (2 ureters out of 4 ureters). In two cases with persistent reflux, ureteral reimplantations were performed due to repeated urinary tract infections and de novo upper pole ureteral refluxes. The remaining 5 cases with persistent reflux were observed with prophylactic antibiotics. Refluxes recurred in 2 of the ureters at 29 and 36 months after the injection, so chemoprophylaxis was restarted. CONCLUSIONS: The single endoscopic subureteral polydimethylsiloxane injections resulted in a low success rate, but at a high cost. This procedure is considered inappropriate as a first line method for the correction of vesicoureteral reflux in children.

Incidence, Risk Factors and Spontaneous Descent of Cryptorchidism / 대한비뇨기과학회지

PURPOSE: We studied the incidence, risk factors and spontaneous descent of cryptorchidism. MATERIALS AND METHODS: A total of 813 consecutive male neonates delivered at Keimyung University Dongsan Medical Center during the period from June 2001 to June 2002 were examined at birth for cryptorchidism. Eighty boys with cryptorchidism and 733 normal boys were enrolled in this study. Fifty-six boys with cryptorchidism (87 testes) were followed at 1, 2, 3 and 6 months of age for evaluation of spontaneous testicular descent. Risk factors included birth weight, gestational weeks, other congenital anomalies, Apgar score, birth order, twin birth, mode of delivery, family history of cryptorchidism, maternal age, parity history, previous abortion history and maternal disease history. Logistic regression analysis was used to estimate the odds ratios. RESULTS: The incidence of cryptorchidism was 4.4% in full term(28 out of 635) and 28.6% in preterm(52 out of 178) newborns. The overall incidence was 9.8%. All of the nonpalpable testes and 87.8% of bilateral undescended testes were found in premature babies. Low birth weight(<2,500g) and preterm deliveries(<37wks) were significant risk factors for cryptorchidism. All of 25 undescended testes in term boys and 50 undescended testes of premature boys had descended by age 6 months. CONCLUSIONS: The incidence of cryptorchidism in this study was higher than that of other studies. The premature newborns had a higher incidence of bilateral and nonpalpable cryptorchidism. Low birth weight and preterm deliveries were significant risk factors for cryptorchidism. There was an 86% chance of spontaneous descent by 6 months of age.

Outcome of Adult Hypospadias Repair / 대한비뇨기과학회지

PURPOSE: The modern era of hypospadias surgery has brought functional and cosmetic results to a high level in children. However, little data are available on the outcome of adult hypospadias repairs. The objective of this study was to evaluate the results of 46 adult patients with hypospadias repairs. MATERIALS AND METHODS: One surgeon performed forty-six consecutive adult hypospadias repairs. The mean age at the time of surgery was 22.1 years (range 13 to 59). Follow up ranged from 3 months to 7 years (mean 11.3 months). We retrospectively analyzed surgical outcomes, with respect to previous repair, surgical procedure and complications. RESULTS: Of 46 adult hypospadias patients, 20 had had previous repairs and 26 had had no previous repairs. Surgical procedures consisted of 7 onlay island flap, 6 pyramid, 4 transverse island flap, 2 King, 3 MAGPI, 2 Mathieu, 3 tubularized incised plate and 1 meatal advance in the group with no previous repairs. In the group that had undergone previous repairs there were 10 Thiersch-Duplay, 2 Johanson, 2 transverse island flap, 1 MAGPI, 1 King, 1 Durham-Smith, 1 Mustard, 1 meatal advance and 1 onlay island flap. Complications developed in 11 patients from the no previous repair group, including 6 fistula, 2 stricture, 4 wound infection, 2 wound dehiscence and 1 ventral curvature, and were as follows for the previous repair group; 12 fistula, 5 stricture, 3 wound infection and 4 wound dehiscence. CONCLUSIONS: For both groups analysed, adult hypospadias repair was much less successful than childhood repair. Further studies are necessary to decrease the complications.

Clinical Analysis of Childhood Renal Transplantation: a Report of 28 Cases / 대한비뇨기과학회지

PURPOSE: Traditionally, renal transplant in children with end stage renal failure has poorer outcome compared to adult renal transplants. The objective of this study was to evaluate the results of childhood renal transplantation. MATERIALS AND METHODS: Twenty eight renal transplants were performed in children aged 18 years and younger in our institute. The follow up periods ranged from 15 to 217 months (mean 73.2). The cause of the end stage renal disease, postoperative complications, graft survival, and growth status were investigated retrospectively. RESULTS: The causes of renal failure were chronic glomerulonephritis in 13 cases, FSGS in 4, IgA nephropathy in 4, VUR in 2, renal dysplasia in 2, and hemolytic uremic syndrome in 1, posterior urethral valve in 1 and Alport syndrome in 1. The postoperative complications included perirenal hematoma in 2, bacterial infection in 2, lymphocele in 2, avascular necrosis of the hip joint in 2, CMV pneumonia in 1, miliary tuberculosis in 1 and hirsuitism in 1. The graft and patient survival rate at 1, 5 and 10 years was 81% and 64%, 40% and 88%, and 81% and 72%, respectively. The mean body weight distribution of the 10 cases under the age of 15 years who had no graft failure was in the 10.2 percentile (3-25 percentile) at transplantation and it increased to the 18.2 percentile (3-50 percentile) 46 months after the transplant. CONCLUSIONS: Childhood renal transplantation was less successful than adult renal transplantation. Early transplantation is recommended to maximize the growth of the children and more effective immunosuppressive therapy is needed for this age population.

Renal Candidiasis in Premature Infants / 대한비뇨기과학회지

Candida is a saprophytic fungus in the human host. However, in an immune- suppressed host, the organism can become pathogenic. The most common site of end organ involvement in premature infants with candidemia is the kidneys. A conglomeration of fibrillar hyphae results in fungus balls, which may cause a urinary tract obstruction and acute renal failure in premature infants. We recently experienced two cases of premature infants who had fungus balls in their urinary tracts. They were treated successfully with percutaneous nephrostomy, in combination with antifungal agents.

Bladder Exstrophy with Successful Initial Closure / 대한비뇨기과학회지

Bladder exstrophy is a rare condition with an incidence of between 1 in 10,000 and 1 in 50,000 live births and the male-to-female ratio ranges 2.3:1 to 6:1. The basic defect of bladder exstrophy is an abnormal overdevelopment of the cloacal membrane, preventing medial migration of the mesenchymal tissue and proper lower abdominal wall development. Although there are some recent successful reports of the one-stage repair of bladder exstrophy that involves complete primary repair of exstrophy and total disassembly of the epispadiac penis, staged repair still represents the most common operation for correction of this anomaly. A successful initial closure of the infant born with bladder exstrophy is the single most important determinant of continence in the staged repair of exstrophy patient. We report a case of bladder exstrophy with successful initial closure of bladder using posterior iliac osteotomy and paraexstrophy skin flap.

Impalpable Testes: An Experience of 97 Surgically Corrected Cases / 대한비뇨기과학회지

PURPOSE: We analyzed our experience of surgically corrected impalpable testes to evaluate our results and to determine the best possible surgical approach for impalpable testes. MATERIALS AND METHODS: Medical records of 97 boys who had undergone surgery for impalpable testes were reviewed with respect to the age at presentation, localization procedure, surgical approach, testicular location and volume. Minimal follow-up was 6 months. RESULTS: The average age at presentation was 47.7 months. Surgical locations of testes included preperitoneum in 46 testes, intraabdomen in 18 testes and inguinal canal in 1 testis. Fifty-three testes were absent at exploration. Surgical procedures consisted of 59 orchiopexies, 53 excision of blind-ended spermatic vessel and 6 orchiectomies. The average volume of abdominal testes was reduced to 44.0% of contralateral normally descended testicular volume. Compensatory hypertrophies were seen in 45 contralateral testes among 53 unilateral absent testes. The inguinal exploration was successful in defining the location of all the testes in the last 41 consecutive boys. Laparoscopy did not help to avoid surgical exploration. Of 38 impalpable testes at office examination, 18 testes turned out to be palpable when examined under anesthesia while ultrasonography detected 14 testes with 1 false positive finding. Of 51 regular orchiopexies 49 testes showed excellent or acceptable results. Of 8 Fowler-Stephens orchiopexies 3 testes resulted in atrophies. CONCLUSIONS: Most pexed impalpable testes showed successful results in terms of testicular position and growth. However, there were more testicular atrophies in cases whose spermatic vessels were ligated. Inguinal exploration with or without intraperitoneal extension was successful in the management of impalpable testes in this series.

A case of Vulvar Rhabdomyosarcoma in a Young Child / 대한비뇨기과학회지

No abstract available.

Differential Renal Function in Children with Ureteropelvic Study with Renal Histology / 대한비뇨기과학회지

No abstract available.

Enuresis and Urine Concentration in Healthy Preschool Children / 대한비뇨기과학회지

PURPOSE: To determine if the urine specific gravity(SG) plays a role in enuresis, the first morning urine SG of the healthy preschool nocturnal enuretic was compared with that of the nonenuretic. The results of desmopressin were analyzed according to the pretreatment urine SG to know if the urine SG can predict the responsiveness of the medication. MATERIALS AND METHODS: Five hundred twenty healthy preschool children aged 3-6 years were entered in this prospective observer-blinded study. A comparison was made between SG of the first morning urine specimen and results of questionnaire concerning the bed wetting and voiding habits of children. The responsiveness to oral desmopressin(0.2-0.4mg h.s.) in 14-day treatment periods was also analyzed according to the urine SG in 28 children with enuresis. The responder group was defined as a reduction of at least 50% from the number of wet night. RESULTS: The incidence of enuresis was 8.6 percent. Stastistically significant difference was found between the bedwetter and nonbedwetter group with regard to the urine SG(p<0.05). The overall response rate of desmopressin was 68 percent. There was no significant difference between the responder and nonresponder group with respect to urine SG. CONCLUSIONS: The first morning urine of the enuretic showed higher probability of lower level of the SG than that of the nonenuretic. Treatment with desmopressin was associated with a significant decrease in the number of wet night, but clinical response was not predictable based on the first morning urine SG.

Onlay Island Flap Hypospadias Repair ; Experience of 45 Cases / 대한비뇨기과학회지

PURPOSE: The onlay island flap urethroplasty, a variation of the transverse preputial island flap, was originally introduced as an alternative to the meatal-based flap urethroplasty for anterior hypospadias. Recently, the indications for use of the onlay island flap urethroplasty have been extended to include repair of more proximal hypospadias with/without moderate degrees of chordee. We evaluated application and outcome of onlay island flap hypospadias repair. MATERIALS AND METHODS: We analyzed medical records of 126 patients who underwent primary hapospadias repair at our hospital during recent 10 years with respect to age at surgery, type of hypospadias, surgical technique and outcome. A minimum follow-up of 6 months was necessary for inclusion of the study. RESULTS: Age ranged from 7 months to 32 years(mean 6.7 years). For 59 patients with anterior hypospadias, 14 onlay island flap, 21 MAGPI, 14 pyramid, 8 Mathieu and 2 tubularized incised plate urethroplasties were performed. For 67 patients with mid to posterior hypospadias, 31 onlay island flap, 29 transverse island flap, 3 King, 3 augmented Duckett (Transverse island flap+hiersch-Duplay) and 1 tubularized incised plate urethroplasty were performed. Out of total 129 patients, 45 patients underwent onlay island flap repairs including combined with 7 dorsal penile plications. Out of 31 patients who underwent onlay island flap repairs, 3 patients developed complications. Out of 29 patients who underwent transverse preputial island flap repair, 13 patients developed complications. During the period of first 5 years, we performed 10 onlay island flap and 21 transverse island flap repairs for 37 mid to posterior hypospadias, whereas during the second 5 years, we did 21 onlay island and 8 transverse island flap repairs for 30 mid to posterior hypospadias. CONCLUSIONS: The onlay island flap hypospadias repair with/without dorsal penile plication was even applied to mid and posterior hypospadias as well as anterior hypospadias. The onlay island flap hypospadias repair maintained its technical advantages and lower complication rate compared to transverse island flap. More favorable results were obtained through as possible as preservation of urethral plate in hypospadias repair.

Orchidopexy: a 10-year Clinical Experience

We analyzed our experience of orchidopexies performed during last 10 years to evaluate results and to determine the possible approach to the treatment of undescended testes. Between 1988 and 1997, we had treated 420 undescended testes (314 palpable and 106 nonpalpable) in 356 boys. Average patient age at presentation was 4.1 years with 40.2% presenting before the age of 2 years. Of 106 nonpalpable testes, 23 testes were intraabdominal, 32 were preperitoneal and 51 were absent at the surgery. During the period of first 5 years, we had performed the surgery through 31 inguinal and 13 midline transabdominal incisions for 44 patients nonpalpable testes, while during the later 5 years, all 47 patients nonpalpable were treated through inguinal incisions. For the nonpalpable testes, the inguinal approach with or without intraperitoneal extension was successful in defining the location of testes and blind-ending vessels in all patients. Laparoscopy was not helpful in avoiding surgical exploration in all our patients with nonpalpable testes. Of 339 inguinal and midline transabdominal orchidopexies without spermatic vessels ligations, 324 testes were placed in the scrotum, 4 in the upper scrotum and 3 in the inguinal area. Eight were resulted in atrophy. Of 13 Fowler-Stephens orchidopexies, 7 were placed in the scrotum and 6 were resulted in atrophy. Testicular growths were noticed in most patients who underwent orchidopexies and the volume of fixed testes became as large as the contralateral normal testes by the mean duration of 43.3 months postoperatively. In conclusion, orchidopexies were successful in most cases of cryptorchidism in terms of testicular position and growth. However, there were more testicular atrophies in patient in whom spermatic vessels were ligated. In cases of nonpalpable undescended testis, the inguinal approach with or without intraperitoneal extension would be recommended.