The clinical utility and safety of the endoscopic treatment of vesicoureteral reflux in patients with duplex ureters.

OBJECTIVE: A systemic review of published literature on the use of bulking agents in the treatment of vesicoureteral reflux (VUR) in patients with duplex systems was performed in order to evaluate the diagnostic challenges; determine success rates, and compare with use in single systems; and evaluate safety, in particular of Deflux. METHODS: A PubMed/Medline search was conducted for index articles discussing duplex ureters published in 1963-2007. All types of publications were included. A multiple linear regression analysis was performed. RESULTS: Overall, 28 different treatment arms originating in 17 separate studies (19 publications) satisfied the inclusion criteria for linear regression efficacy analysis. Data were available on 2879 patients: 2400 with single and 479 with duplex systems. Ten publications provided information on the frequency of failure to diagnose duplex systems using specific techniques. An overall 18% failure rate to detect duplex systems was reported for combined techniques. For patients in whom favorable anatomic location of ureters allowed successful endoscopic injection of a bulking agent, correction of VUR was achieved in 53-100% of cases. A univariant analysis showed no difference in success rate between single and duplex systems with the use of Deflux, or other bulking agent. The predicted probability of success in a single system was 68% and in a duplex system 64%. CONCLUSIONS: There is significant potential for failing to detect duplex systems prior to preparing an individual for either open or endoscopic treatment. From the studies available, endoscopic injection of bulking agents is highly successful in correcting mild-to-moderate VUR in duplex systems, with no reports of serious or clinically significant adverse effects. At a minimum, duplex systems would not seem to be a contraindication to the use of Deflux or any other bulking agent.

Preventing reservoir calculi after augmentation cystoplasty and continent urinary diversion: the influence of an irrigation protocol.

OBJECTIVE: To evaluate the influence of an irrigation protocol in preventing reservoir calculi forming after augmentation cystoplasty and continent urinary diversion. PATIENTS AND METHODS: Between 1985 and 1995, 91 patients had an augmentation cystoplasty and/or continent urinary diversion (group 1; 54 females and 37 males, mean age 11.1 years, range 1-31); these patients were not routinely instructed to use irrigation after surgery. The segments used included ileum (44), colon (36), stomach (eight) and ureter (three). Between 1995 and 2000, 42 patients (group 2) underwent urinary reconstruction (22 females and 20 males, mean age 14.8 years, range 4-27), the segment used being ileum (30), colon (five), ureter (five) and stomach (two) but in contrast to group 1 they then were placed on a standard prophylactic irrigation protocol. The occurrence of stones in the reservoir was then assessed. RESULTS: Thirty-nine of the 91 patients (42.8%) in group 1 presented with reservoir calculi after reconstruction and 22 had several episodes. The mean time to presentation was 30 months. The incidence of stone formation by underlying diagnosis included: myelomeningocele, 32/48 (66%), exstrophy five/25 (25%), posterior urethral valves two/20 (10%) and rhabdomyosarcoma, none of three. Fifty of the 91 patients had an abdominal stoma, with stone formation in 33 (66%), while 41 used the native urethra, with stone formation in six (15%). Three (7%) of the 42 patients in group 2 developed reservoir calculi after reconstruction, two in patients with myelomeningocele and one in a trauma patient who had residual bone spicules in the bladder; the mean time to presentation was 26.5 months. CONCLUSIONS: These data suggest that the irrigation protocol used in group 2 significantly reduced the number of reservoir calculi after urinary tract reconstruction when bowel was used as part of the reconstruction (43% vs. 7%). The most calculi in both groups were in immobile patients with sensory impairment. Also, patients with an abdominal stoma had a greater risk of reservoir calculi (66%) than those using the native urethra (15%).

The urological care and outcome of pregnancy after urinary tract reconstruction.

OBJECTIVE: To assess the obstetric and urological outcomes during and after pregnancy following urinary tract reconstruction, as pregnancies after such surgery can have a significant effect on the function of the reconstructed urinary tract, and the reconstruction can significantly affect the delivery of the fetus. PATIENTS AND METHODS: We retrospectively reviewed the obstetric and urological history of 11 patients (12 pregnancies; 10 singletons and one twin) with previous urinary reconstruction, delivered between 1989 and 2003. Antepartum and postpartum urological function and obstetric outcomes were investigated. RESULTS: All the patients had some difficulty with clean intermittent catheterization (CIC) during pregnancy, and four needed continuous indwelling catheters. During pregnancy 10 women had several bladder infections and all received antibiotic suppression. There were eight Caesarean sections, two vaginal deliveries and one combined delivery. Six Caesareans were elective and three were emergent. The use of CIC returned to normal in all patients after delivery. CONCLUSIONS: Women with a urinary reconstruction can have successful pregnancies. The complexity of the surgery and the concern for possible emergency Caesarean section resulted in most patients having an elective Caesarean delivery before term. Antibiotic prophylaxis is recommended and patients may require indwelling dwelling catheters while pregnant but normal CIC can be resumed after delivery.

Testicular growth and gonadotrophin response associated with varicocele repair in adolescent males.

OBJECTIVE: To measure testicular volume and the gonadotrophin response to gonadotrophin-releasing hormone (GnRH) stimulation in adolescents undergoing left varicocelectomy. PATIENTS AND METHODS: Thirteen adolescents undergoing varicocelectomy had their testicular volume and endocrine function evaluated before and after surgery. RESULTS: The initial left testicular volume was consistently smaller than the right but after surgery both increased. Baseline follicle-stimulating hormone (FSH) levels and the FSH response to GnRH stimulation increased after surgery. There were no differences in luteinizing hormone and testosterone levels, and no changes in Tanner staging. CONCLUSIONS: Unilateral varicocelectomy with ipsilateral testicular atrophy results in bilateral testicular growth and increased FSH levels. In adolescent development, elevated FSH levels in conjunction with an increased response to the GnRH stimulation test represent a normal physiological response. The GnRH stimulation test cannot be used to determine which adolescent would benefit from surgical repair.

Laparoscopically assisted ureterocystoplasty.

OBJECTIVE: To assess the efficacy and safety of laparoscopically assisted ureterocystoplasty (LAU) in children. PATIENTS AND METHODS: From 1999 to 2001, five patients (mean age 7 years, range 3.5-13) from four centres underwent LAU with laparoscopic mobilization of the small kidney and upper ureter combined with ureterocystoplasty, with exposure of the bladder through a Pfannenstiel incision. The details and outcomes are reviewed. RESULTS: The LAU was successful in all five patients; there were no complications. A large midline incision was avoided and the LAU carried out through the better tolerated and less painful Pfannenstiel incision. CONCLUSION: LAU is an appealing technique that is safe with the added benefit of a reduced abdominal incision and acceptable operative duration. This represents the first published report of LAU.

Psychosocial adaptation of middle childhood boys with hypospadias after genital surgery.

OBJECTIVE: To compare the psychosocial adaptation of boys with hypospadias after genital surgery to a community sample. METHODS: Boys (6 to 10 years) with a history of hypospadias repair (n = 175) were compared with a community sample (n = 333) in a postal questionnaire survey using the Child Behavior Checklist. RESULTS: Few significant differences between cases and controls emerged. Boys with hypospadias were (slightly) lower in social involvement but did not perform more poorly in school. Boys with hypospadias displayed fewer externalizing behavior problems than controls, but a significant difference in nocturnal enuresis was not detected. Level of behavior problems did not differentiate hypospadias severity subgroups, but greater surgical and hospitalization experiences were associated with increased internalizing problems. Poorer cosmetic appearance of the genitals was associated with worse school performance. CONCLUSIONS: Surgically corrected hypospadias should not be considered a risk factor for poor psychosocial adaptation in childhood, but emotional problems increase with the number of hospital-related experiences.

Maternal age as a risk factor for hypospadias.

PURPOSE: Hypospadias incidence rates have been widely reported to be increasing. During the last 20 years there has been a significant increase in the number of women who delay childbearing until their mid 30s. Therefore, it was of interest to determine if increasing maternal age is an independent risk factor for hypospadias. MATERIALS AND METHODS: Data from the New York State Department of Health and California Birth Defects Monitoring Program were analyzed from 1983 to 1996 by maternal age groups of less than 20, 20 to 24, 25 to 29, 30 to 34, and 35 or greater years. A Poisson model was fitted to the data from each state using maternal age and year of birth from which relative rates were calculated. RESULTS: Our analysis revealed that advancing maternal age is significantly associated with hypospadias and is most evident for severe cases. For example, in California a 50% increase in severe cases was demonstrated for children of mothers older than 35 years compared to mothers younger than 20 years (p <0.05). CONCLUSIONS: Hypospadias is significantly associated with increasing maternal age. Women who elect to delay childbearing until their mid 30s or later should be aware that their offspring are at increased risk of hypospadias.

Incidence and surgical repair rates of hypospadias in New York state.

OBJECTIVES: To determine the trend of hypospadias incidence in New York State (NYS) by retrospectively evaluating both the incidence and surgical repair rates of hypospadias. Epidemiologic studies in the United States and Europe have suggested an observable trend in the incidence of hypospadias during the past 30 years. A comparison of the results from these studies, however, revealed inconsistent trends. METHODS: The incidence and surgical repair rates of hypospadias between 1983 and 1995 were extracted from the Congenital Malformations Registry and State Wide Planning Research Cooperative System of NYS. Pearson's correlation coefficient was used to determine the direction and magnitude of change. RESULTS: Neither the incidence nor the repair rates of hypospadias in NYS between 1983 and 1995 changed significantly during the course of these 12 years (r = -0.225, P = 0.45 and r = -0.010, P = 0.92, respectively). CONCLUSIONS: The results demonstrated no statistically observable trend in either the incidence or surgical repair rates of hypospadias in NYS between 1983 and 1995.

Hypospadias repair in adults: adventures and misadventures.

PURPOSE: To evaluate long-term results and complications we reviewed the records of 42 consecutive men 18 to 47 years old (mean age 22.5) who underwent hypospadias repair between 1979 and 1999. MATERIALS AND METHODS: The study population was divided into groups 1 consisting of 8 patients without previous hypospadias surgery, 2 consisting of 12 who underwent 1 or more procedures in childhood but in whom local tissue was relatively intact and 3 consisting of 22 who underwent multiple unsuccessful hypospadias repairs with various degrees of penile deformity and loss of local tissue. RESULTS: Complications were noted in 3 of 8 (37.5%), 5 of 12 (41.67%) and 14 of 22 (63.6%) patients in groups 1 to 3, including 3 (100%), 4 (80%) and 10 (71.4%), respectively, in whom secondary surgery was successful in the long term. A patient in group 2 and 2 in group 3 await further surgery, while 2 in group 3 were lost to followup. Overall primary complications developed in 22 of the 42 men (52.3%) and 5 of the 22 (22.7%) had secondary complications. There was long-term success in 37 of 42 cases (88.1%). CONCLUSIONS: The results of hypospadias repair in adulthood differ from the results of similar procedures in childhood. Although the various techniques are similar, there is clearly a difference in terms of wound healing, infection, complication rates and overall success. Adults undergoing hypospadias repair must be counseled on all of these variables to avoid unreasonable expectations.

Reconstructive surgery for children with pelvic rhabdomyosarcoma.

Rhabdomyosarcoma is the most common soft-tissue sarcoma found in children and can arise almost anywhere skeletal muscle is found. It represents 4% to 8% of malignant solid tumors in children, ranking behind central nervous system tumors, lymphoma, neuroblastoma, and Wilms' tumor. Reconstructive surgery has become an integral part of the total plan in patients undergoing radical surgery for rhabdomyosarcoma. Advances in surgical techniques can often provide a reasonable lifestyle for patients.

Vaginal reconstruction.

Absence of the vagina presents a challenging problem for the reconstructive urologist. This article reviews the pertinent diagnostic and pretreatment considerations and the surgical options, in particular, bowel vaginoplasty, for these patients.

[Vaginal reconstruction in girls and young adults]. / Reconstrucción vaginal en niñas y jóvenes adultas.

OBJECTIVE: There are many different approaches to vaginal reconstruction. Methods include simple dilatation, skin grafts techniques, amnion grafts and the use of bowel segments for vaginal replacement. METHOD: We herein discuss the most common surgical techniques and present our series of 15 patients who underwent intestinal vaginoplasty with either sigmoid colon or cecum. RESULTS: The complication rate was low, with two patients requiring revision for prolapse. Ten patients are sexually active with only one describing any degree of dyspareunia. CONCLUSION: When dealing with vaginal aplasia, intestinal vaginoplasty seems to have clear advantages with an excellent surgical success rate and low incidence of complications.

Ureteral tissue expansion for bladder augmentation: a long-term prospective controlled trial in a porcine model.

PURPOSE: We recently described a technique that iatrogenically produces segmental megaureter while preserving renal function. In our initial report in 5 of 8 pigs that underwent this procedure bladder augmentation with the expanded ureter was successful. Throughout the expansion and reconstructive process renal function was preserved and all 5 animals that underwent augmentation had increased bladder capacity at sacrifice 1 month postoperatively. In the present study we evaluated the long-term durability and performance of the ureteral segment used for augmentation. MATERIALS AND METHODS: We performed a prospective, controlled, double armed study in 8 pigs, including 4 control animals that underwent subtotal cystectomy only (group 1) and 4 animals that underwent subtotal cystectomy followed by bladder augmentation using the expanded ureteral segment (group 2). End point measurements included cystography, and measurement of bladder capacity, serum creatinine and random bladder residual urine volumes. All cystograms were performed using passive filling conditions at a standard filling pressure of 32 cm. water. RESULTS: Bladder capacity throughout the study revealed consistently higher volumes in group 2 than in group 1. In 3 of the 4 group 1 subjects vesicoureteral reflux developed compared to no reflux in group 2. Creatinine levels were elevated at sacrifice in 50% of the animals in group 1 compared to none in group 2. Random bladder residual urine was less than 150 cc in 3 of the 4 group 2 subjects. CONCLUSIONS: Serial cystograms in pigs after ureteral augmentation suggest that the tissue does not contract with time. Animals that underwent ureteral augmentation had significantly greater bladder capacity than controls. Random bladder residual urine volume remained low throughout the study period. Ureteral tissue expansion for bladder augmentation appears to be feasible and durable in this animal model. In addition, it may be protective against the deleterious effects associated with small capacity bladders.

Ureteral obstruction secondary to indinavir in the pediatric HIV population.

Indinavir sulfate is a protease inhibitor used in the treatment of the human immunodeficiency virus (HIV). This case report describes the radiographic and urologic manifestations of indinavir urolithiasis in two pediatric patients with acquired immunodeficiency syndrome (AIDS). Management involves aggressive hydration and surgical intervention when indicated.

The Malone antegrade continence enema procedure in the management of patients with spina bifida.

BACKGROUND: In patients with spina bifida, traditional bowel management programs such as suppositories, retrograde enemas, and manual disimpaction have been largely unsatisfactory. The Malone antegrade continence enema (ACE) procedure has largely changed our approach to bowel management in this patient group. STUDY DESIGN: Over a 3-year period between January 1994 and January 1997, 27 patients with spina bifida underwent the Malone ACE procedure at our institutions. At the time of their ACE procedure, four patients underwent simultaneous continent urinary diversion and three had simultaneous small-bowel bladder augmentation. All the patients were evaluated for 9 months or more after their procedure, and 10 of the patients have been followed for more than 2 years. RESULTS: Postoperatively, predictable bowel control and continence were achieved in 19 of the 27 patients, but 6 had some rectal soiling requiring a sanitary pad. All patients were out of diapers and none reported stomal leakage. Eighteen of the 27 patients were able to manage independently and 9 required assistance. Two patients had stopped using their ACE stoma despite good technical results. The appendix was used as a catheterizable stoma in 15 of the 27 patients. The appendix was not available in 12 patients, so a tubularized cecal flap was used in 9 and a small-bowel neoappendix was created in 3. Complications included stomal stenosis in 5 patients, cecal-flap necrosis in 1, and stomal granulations in 3. CONCLUSIONS: We believe that the ACE procedure provides reliable colonic emptying and avoids fecal soiling in the majority of individuals, and we find it widely and enthusiastically accepted by patients with spina bifida.

Ureteral tissue expansion for bladder augmentation.

PURPOSE: Ureteral augmentation is an effective method of bladder reconstruction using the native urothelium of a megaureter. Clinically this procedure is contingent on the presence of an enlarged ureter. We have iatrogenically produced a segmental megaureter, while preserving renal function in a pig model. The urothelium of the enlarged ureter was then used for augmentation cystoplasty. MATERIALS AND METHODS: A tissue expander suitable for insertion into the lumen of the ureter was constructed. The tissue expander was passed antegrade through a flank incision of 8 pigs, and a separate nephrostomy tube was left in place. During the ensuing 1 to 4 weeks the pigs underwent daily dilation of the tissue expander without anesthesia. After dilation the pigs underwent ureteral augmentation of the bladder. The segment of expanded ureter was isolated from the native ureter, opened and anastomosed to the bladder. The continuity of the left ureter was restored by primary ureteroureterostomy. The animals underwent cystograms at 1 and 4 weeks and were sacrificed 4 weeks after augmentation. Tissue was harvested for gross and microscopic histology. RESULTS: Of the 8 pigs starting the protocol 5 underwent successful ureteral tissue expansion followed by bladder augmentation. Tissue expansion was performed from 1 to 4 weeks, and volumes of 150 to 1,000 cc were obtained. Two to 3 weeks of dilation was optimal to achieve ease of dilation, and no animal showed evidence of discomfort or failure to thrive. All 5 animals underwent successful ureteral augmentation with primary ureteroureterostomy. Tissue expansion volumes of approximately 250 cc were optimal for tissue management and ease of augmentation. Cystograms of all augmented animals showed increased bladder capacity with filling of the ureteral segment. Histological examination of the ureteral augmentation revealed preservation and regeneration of the urothelial mucosa. CONCLUSIONS: The use of a tissue expander in the lumen of the ureter is a novel method of generating urothelium for use in bladder augmentation. It may provide an alternative to bowel in patients who require bladder augmentation. Long-term studies are currently under way.

Vaginal replacement in children and young adults.

PURPOSE: Absence of the vagina in the pediatric population most commonly results from congenital abnormalities, such as the Mayer-Rokitansky syndrome but it may also be seen after treatment for pelvic tumors, such as rhabdomyosarcoma, and in patients who have had previous gender reassignment. We review our experience using bowel for vaginal replacement in a group of children and young adults to assess outcome and satisfaction. MATERIALS AND METHODS: From 1980 to 1996 we evaluated 31 patients 1 to 20 years old who required vaginal replacement. Presenting diagnoses included müllerian failure (the Mayer-Rokitansky syndrome) in 20 patients, androgen insensitivity syndrome in 5, rhabdomyosarcoma in 3, penile agenesis in 1, cloacal exstrophy in 1 and 1 previously separated conjoint twin. A questionnaire was given to 26 of the 31 patients to assess postoperative sexual function and satisfaction. RESULTS: A total of 33 bowel segments in 31 patients were used for vaginal reconstruction, including sigmoid colon in 20, ileum in 8 and cecum in 5. Of the 31 patients 20 were sexually active, 8 were married and 3 had been previously married and divorced. Only 1 patient described chronic dyspareunia. Three patients were on chronic home dilation, while 4 required sanitary pads for vaginal secretions. There were 8 complications in the 31 patients, including stenosis of the bowel segment in 6. Three patients required a second procedure after total stenosis of the small bowel vagina (2) and prolapse of the neovagina (1), which required retroperitoneal fixation. CONCLUSIONS: Experience with this group of patients leads us to believe that isolated bowel segments provide excellent tissue for vaginal replacement. Furthermore, we believe that colon segments, particularly sigmoid, are preferable to small bowel for creation of the neovagina. In many instances the small bowel mesentery may be too short to provide an adequate, tension-free anastomosis in the perineum, particularly in obese patients. Our results would also suggest that sexual activity is more compatible with isolated bowel segments for vaginal replacement than with any of the more traditional methods, such as passive dilations and split thickness skin graft vaginoplasty.