Simultaneous augmentation cystoplasty and cuff only artificial urinary sphincter in children and young adults with neurogenic urinary incontinence.

PURPOSE: We review our experience with artificial urinary sphincter and augmentation cystoplasty in patients with neurogenic bladder. This is the largest known series to specifically evaluate cuff only artificial urinary sphincter at augmentation cystoplasty. MATERIALS AND METHODS: A total of 18 males underwent simultaneous artificial urinary sphincter and augmentation cystoplasty at our institution between 1982 and 2012, of whom 13 (72%) underwent cuff only artificial urinary sphincter. Outcomes included urinary continence, emptying modality, artificial urinary sphincter status, complications and additional procedures. RESULTS: Of the patients undergoing augmentation cystoplasty and cuff only artificial urinary sphincter 10 (77%) were initially continent. Average time of continence was 52.9 months. Four patients (31%) required no additional procedures and remained continent. Urinary incontinence developed in 3 patients (23%) immediately postoperatively and in 6 (46%) subsequently. Ultimately 9 patients (69%) required conversion to complete artificial urinary sphincter at a mean of 36.9 months postoperatively. Overall 12 patients (92%) were continent at followup. There were no artificial sphincter specific complications in patients undergoing the cuff only procedure with conversion to complete artificial urinary sphincter. After conversion to complete artificial urinary sphincter 3 patients (23%) experienced artificial sphincter specific complications. Reoperation was performed in 10 patients (77%), for 13 total procedures (1.3 per patient). There were no complications with cuff only artificial urinary sphincter and 6 complications with complete artificial urinary sphincter (p = 0.025). Finally, patients undergoing cuff only artificial urinary sphincter requiring revision were younger than those not requiring revision (15.6 vs 30.8 years, p = 0.026). CONCLUSIONS: Simultaneous cuff only artificial urinary sphincter and augmentation cystoplasty appears safe and efficacious in patients with neurogenic bladder, with fewer complications than complete artificial urinary sphincter, and may provide definitive urinary continence in up to a third of patients. This procedure is technically easy, allows for outpatient revision, provides time for the child to mature and may be cost effective in avoiding placement of additional components in this select patient population.

The 2-global flash mfERG in glaucoma: attempting to increase sensitivity by reducing the focal flash luminance and changing filter settings.

PURPOSE: To test a new 2-flash multifocal electroretinogram (mfERG) paradigm in glaucoma using a reduced light intensity of the m-frame flash as opposed to the global flash, as it has been suggested that this may increase the responses induced by the global flash, which has been the part of the mfERG response where most changes have been noted in glaucoma. METHODS: A mfERG was recorded from one eye of 22 primary open angle glaucoma (POAG) patients [16 normal tension glaucoma (NTG), 6 high tension glaucoma (HTG)] and 20 control subjects. A binary m-sequence (2^13-1, Lmax 100 cd/m2, Lmin<1 cd/m2), followed by two global flashes (Lmax 200 cd/m2) at an interval of 26 ms (VERIS 6.0™, FMSIII), was used. The stimulus array consisted of 103 hexagons. Retinal signals were amplified (gain=50 K) and bandpass filtered at 1-300 Hz. For each focal response, the root mean square was calculated. We analyzed 5 larger response averages (central 15° and 4 adjoining quadrants) as well as 8 smaller response averages (central 10° and 7 surrounding response averages of approximately 7° radius each). Three epochs were analyzed: the direct component at 15-45 ms (DC) and the following two components induced by the effects of the preceding focal flash on the response to the global flashes at 45-75 ms (IC-1) and at 75-105 ms (IC-2). Statistical analysis was performed using linear mixed effects models adjusted for age. RESULTS: Responses differed significantly between POAG patients and controls in all central response averages. This difference was larger for the central 10° than for the response average of the central 15°. While these observations held true for all response epochs analyzed, the DC differed least and the IC-1 most when POAG was compared to control. For POAG, the most sensitive differential measure was IC-1 of the central 10° with an area under the ROC curve of 0.78. With a cutoff value of 12.52 nV/deg2, 80% of the POAG patients (100% HTG, 69% NTG) were correctly classified as abnormal, while 77% of the control subjects were correctly classified as normal. When the results of the mfERG were compared to the visual fields, there was a tendency for the mfERG to decrease as the mean defect increased. However, this correlation was only significant in the superior nasal quadrant when the IC-1 of the mfERG was compared to the corresponding area of the visual field. CONCLUSION: When compared to findings from previous studies, reducing the luminance of the m-frame flash in the 2-global flash paradigm did not increase the sensitivity and specificity of the mfERG to detect glaucoma further.

Double-blind placebo controlled study of alpha-adrenergic receptor antagonists (doxazosin) for treatment of voiding dysfunction in the pediatric population.

PURPOSE: We sought to determine whether the alpha-adrenergic antagonist doxazosin could be used as primary therapy in children with voiding dysfunction. MATERIALS AND METHODS: Children were assigned to maintain a voiding diary and then randomly divided into a double-blind placebo controlled protocol (0.5 mg doxazosin or placebo). Duplicate uroflow studies with post-void residual evaluations and assessment of dysfunctional voiding scores were performed on initiation and completion of the study. At the conclusion parents were asked to rank the perceived improvement of the urinary incontinence (ie parental subjective perception of improvement). RESULTS: No significant differences between doxazosin (18) and placebo (20) treated patients were found in the number of incontinent days per week, severity of incontinent episodes or alterations in uroflow patterns. Although not significant, 2 findings suggested a beneficial effect of doxazosin over placebo. Specifically, doxazosin decreased the number of incontinent episodes weekly from a median of 18 to 4, while the number of incontinent episodes weekly in the placebo group remained essentially unchanged, decreasing from 15 to 14 (p = 0.13). Doxazosin also improved the dysfunctional voiding scores over placebo, for an improvement of -3 vs 0 points. Further substantiating a doxazosin effect over placebo was the subjective perception of the parents that doxazosin significantly improved urinary continence (p <0.02). CONCLUSIONS: Compared to placebo, doxazosin did not demonstrate a significant objective benefit, but produced a significant subjective benefit in the treatment of urinary incontinence secondary to voiding dysfunction.

Ureterocystoplasty: indications for a successful augmentation.

PURPOSE: We evaluate the outcome of ureterocystoplasty based on preoperative evaluations. MATERIALS AND METHODS: We reviewed preoperative ultrasound, voiding cystourethrography and preoperative/postoperative urodynamic studies (UDS) in 64 patients undergoing ureterocystoplasty. RESULTS: Augmentation was performed with the distal 5 to 8 cm of a single megaureter in 8 patients without and 16 with grade 4 to 5/5 reflux. Median gain or loss in capacity and compliance was +0.14-fold and -0.11-fold, respectively. Re-augmentation has occurred or is pending in 23 cases (92%). Augmentation was performed in 40 patients with either a complete single or double collecting system. In 9 patients without reflux the diameter of the augmenting system was directly related to success. None of 6 with a ureteral diameter of greater than 1.5 cm required re-augmentation (median increase in bladder capacity and compliance 6 and 50-fold, respectively). Ureterocystoplasty was inadequate in 3 patients with a ureteral diameter of less than 1.5 cm and re-augmentation was required. In 31 patients with reflux, preoperative UDS of the entire system was beneficial. If the system had either normal or mild noncompliance (greater than 20 ml/cm H2O) ureterocystoplasty improved compliance 1-fold (6 cases) and re-augmentation not required. If UDS showed moderately or severely noncompliant system (less than 20 ml/cm H2O, 26 cases) ureterocystoplasty increased capacity and compliance by 0.4-fold (40%) and 0.25-fold (25%), respectively. Re-augmentation has occurred or is pending in 21 of 26 cases (81%). CONCLUSIONS: Ureterocystoplasty with any single or double collecting system is warranted in patients without reflux and a ureteral width greater than 1.5 cm, and in patients with reflux and mild noncompliance (greater than 20 ml/cm H2O) on UDS.

p53 immunopositivity in histologically favorable Wilms tumor is not related to stage at presentation or to biological aggression.

PURPOSE: Previous studies have suggested that increased p53 expression is associated with advanced stage and biologically aggressive (chemotherapy resistant) Wilms tumors. We decided to test the hypothesis that increased immunopositivity of p53 is associated with biological aggressiveness in patients with histologically favorable Wilms tumors. MATERIALS AND METHODS: We reviewed the charts of all patients with unilateral Wilms tumor treated at our institution between 1976 and 2001. Histological characteristics, tumor stage, clinical course and p53 expression as determined by immunohistochemical analysis were determined. All immunohistological evaluations were performed on tissue obtained before administration of chemotherapy. RESULTS: A total of 63 cases of unilateral histologically favorable Wilms tumor were assessed. Five cases (8%) were p53 positive. No significant relationship to p53 expression or stage at presentation was noted in 1 of 21 (5%) stage 1, 3 of 21 (14%) stage 2, 1 of 11 (9%) stage 3 and 0 of 10 stage 4 tumors positive for up-regulation of p53. Of the 5 patients with up-regulated p53 expression 1 (20%) had documented disease progression or relapse while on standard National Wilms Tumor Study chemotherapy. Of the 58 patients who were p53 negative 10 (17%) had disease progression or relapse while on standard National Wilms Tumor Study chemotherapy (p >0.3). CONCLUSION: In contrast to previously published studies, we found no correlation of p53 expression to either tumor stage at presentation (p >0.3) or prognosis (p >0.3) in individuals with histologically favorable Wilms tumor assessed for immunopositivity before administration of chemotherapy.

Is endoscopic decompression of the neonatal extravesical upper pole ureterocele necessary for prevention of urinary tract infections or bladder neck obstruction?

PURPOSE: It has been hypothesized that endoscopic decompression of the duplex extravesical ureterocele is necessary to prevent the complications of urinary tract infections and progressive hydronephrosis. This study was performed to test this premise. MATERIALS AND METHODS: Infants younger than 2 weeks with an extravesical ureterocele associated with a duplex upper pole moiety were assigned to immediate endoscopic puncture of the ureterocele followed by antibiotic prophylaxis or antibiotic prophylaxis with plans for delayed surgical intervention. Radiographic studies and catheterized urine cultures were obtained at ages 3 and 6 months and for fever greater than 38.5C. All patients included in this study were followed through 6 months of life. RESULTS: Of the patients 32 underwent endoscopic puncture of the ureterocele. Median patient age at endoscopy was 5 days (range 3 to 13). During the first 6 months of life complications developed in 4 (12%), including febrile urinary tract infections in 3 (9%) and with progressive hydronephrosis due to incomplete puncture of the ureterocele in 1 (3%). The remaining 40 patients were treated with antibiotic prophylaxis and delayed open surgery. Median time to open surgery was 3 months (range 2 to 6). During the first 6 months of life complications developed in 5 (13%), including 3 (8%) febrile urinary tract infections and progressive hydronephrosis in 2 (5%). No statistical difference was noted between the 2 treatment groups. CONCLUSIONS: In patients with extravesical duplex ureteroceles neonatal complications of urinary tract infection and progressive hydronephrosis are not significantly different between those treated with immediate endoscopic decompression versus delayed open surgical intervention.

Penoscrotal transposition: review of 53 patients.

PURPOSE: Penoscrotal transposition is a rare congenital abnormality of the external genitalia. We determine whether there is a genetic basis for this disorder, define the incidence of coexisting organ system anomalies, and compare the results of surgical techniques to correct transposition and hypospadias. MATERIALS AND METHODS: We report the largest, single institution series of 53 patients 1 day to 30 years old with penoscrotal transposition. RESULTS: Of the patients 13% had a family history of penoscrotal transposition. Interestingly, we identified 1 family in which inheritance occurred in an X-linked recessive manner. There were 17 (32%) patients who had abnormalities in other organ systems, with the genitourinary system in 9 affected most. A total of 79% of patients had hypospadias and 81% chordee. These anomalies were corrected with a single stage Thiersch-Duplay urethroplasty in 6 patients and complex repair with bladder or buccal mucosa, or a staged procedure in 34. Complication rates for urethroplasty were similar. Correction of the transposition included a Glenn-Anderson technique in 37 patients, Singapore rotational flaps in 7 and V-Y procedure in 6. The Glenn-Anderson repair produced the best cosmetic results and was associated with a significantly lower incidence of complications (p = 0.001). CONCLUSIONS: We identified a subgroup of patients with a family history of penoscrotal transposition. Treatment requires an awareness of the association with other organ system anomalies. The Glenn-Anderson technique was the most successful method to correct transposition. Most patients required release of chordee and complex urethroplasty for hypospadias.

Effect of povidone-iodine on wound healing: a review.

For the purpose of providing a summary of current clinical trials to determine whether povidone-iodine is beneficial or detrimental to wound healing, an integrated review was completed. Clinical trials were defined as any study that uses some concentration and form of povidone-iodine in a comparison or evaluation with other products or treatments resulting in an impact of povidone-iodine on wounds. The use of povidone-iodine for cleansing, irrigating, and dressing wounds is controversial. Wound healing is complex and requires safe and effective treatment modalities. Numerous in vitro and in vivo studies have been done with conflicting results on bactericidal effects and cytotoxicity of this antimicrobial agent. Human and animal in vivo studies in the last 10 years were used for this review because often the relevance of in vitro data in clinical conditions are questioned. The varied studies provide evidence that in most instances, povidone-iodine did not effectively promote good wound healing; in fact, most studies showed either impaired wound healing, reduced wound strength, or infection.

Compression wraps for venous ulcer healing: a review.

Compression to the lower extremities is used to increase healing of venous stasis ulcers by improving the blood supply and reducing edema and distension. Compression wraps are available in elastic or non-elastic and in single to multilayer systems requiring varying types of application and exerting different levels of compression. Elimination of edema is so basic and important to venous ulcer healing that the most effective level of compression should be used. Controversy exists regarding the most effective sub-bandage pressure (ranging from 20 mm Hg to 45 mm Hg) for timely healing. Because of differences in compression wraps, selection of the most effective and efficient wrap can be difficult. The purpose of this integrated review was to determine healing rates of venous ulcers with various wraps. The studies reviewed provide reasonable evidence that venous ulcers can be healed with the use of compression wraps and that various wraps are effective when used with correct assessment, application, and fit by the caregiver, along with compliance and mobility of the patient.

Modified pudendal-thigh flap for correction of penoscrotal transposition.

OBJECTIVES: In patients with penoscrotal transposition, an occasional postoperative problem has been a deficiency of skin on the proximal penile shaft that results in penoscrotal fusion and tethering. METHODS: We describe a new operation using a modified neurovascular pudendal-thigh flap for correction of incomplete penoscrotal transposition. RESULTS: This procedure has been used in 6 children, and an excellent cosmetic and functional result has been achieved in each patient. CONCLUSIONS: The flaps provide a reliable blood supply, maintain normal innervation, and correct the problem of postoperative penoscrotal fusion and tethering. This technique preserves sufficient penile skin for a tension-free second-stage urethroplasty.

Genitourinary neurofibromatosis mimicking posterior urethral valves.

A 12-year-old boy, examined after an episode of acute urinary retention, was found to have neurofibromatosis of the bladder neck and prostatic urethra. His symptoms of bladder outlet obstruction and radiographic findings of a dilated prostatic urethra mimicked posterior urethral valves. Complete urologic investigation, including cystourethroscopy, revealed that the dilatation of the prostatic urethra was secondary to neural involvement of the external sphincter and posterior urethra without mechanical obstruction or posterior urethral valves.

Vesical neck reconstruction in patients with the exstrophy-epispadias complex.

PURPOSE: We evaluated the factors critical in achieving urinary medicine continence in patients with the exstrophy-epispadias complex. MATERIALS AND METHODS: A total of 51 patients with epispadias and 33 with classic bladder exstrophy underwent vesical neck reconstruction. Patient records were reviewed to identify factors associated with achievement of continence, including timing of bladder closure and urethroplasty, effect of bladder capacity before and after vesical reconstruction, and effect of enterocystoplasty. RESULTS: Complete urinary continence was achieved in 42 of the 51 patients with epispadias (82%) and in 23 of the 33 with exstrophy (70%). Delayed bladder closure did not affect the ability to gain continence but increased the likelihood of subsequent enterocystoplasty (12 of 19 patients, 63%) compared to early bladder closure (5 of 14 patients, 36%). CONCLUSIONS: Preliminary urethroplasty did not enhance urinary control or reduce the need for enterocystoplasty. Bladder capacity before vesical neck reconstruction did not predict the need for enterocystoplasty or ultimate continence status in individuals. Adequate bladder capacity after vesical neck reconstruction was an important determinant of urinary continence. Approximately half of the patients bladder exstrophy (17 of 33) required augmentation cystoplasty to achieve urinary continence.

Flutamide-induced cryptorchidism in the rat is associated with altered gubernacular morphology.

OBJECTIVES: One of the major controversies regarding descent of the testes is whether androgenic regulation of the gubernaculum testes exists. To determine if antiandrogens can alter the development of the gubernaculum within the fetus, the following experiment was performed. METHODS: Timed pregnant Sprague-Dawley rats were treated with either flutamide, dihydrotestosterone (DHT), or vehicle alone (controls) from gestational day (GD) 15 to 17. Fetal specimens were removed via cesarean section on GD 18 and 20. Serial coronal sections were obtained, and digital microscopy with computer-assisted reconstruction was used to ascertain the morphology of the three components of the gubernaculum, that is, the gubernacular cord and the mesenchymal and muscular components of the gubernacular bulb. RESULTS: Flutamide significantly prevented and DHT significantly enhanced gubernacular cord regression compared with controls (P < 0.01). Flutamide also resulted in a significant inhibition of the gubernacular bulb outgrowth, with diminution of both the mesenchymal and muscular components of the gubernacular bulb. CONCLUSIONS: These data suggest that androgens play an active role in gubernacular cord regression and gubernacular outgrowth within the fetal rodent.

Antiandrogen induced cryptorchidism in the pig is associated with failed gubernacular regression and epididymal malformations.

PURPOSE: Can antiandrogens cause cryptorchidism in an animal model with a strip-like gubernaculum? If so, what anatomical abnormalities are associated with cryptorchidism? MATERIALS AND METHODS: Timed pregnant sows received the antiandrogen flutamide during defined gestational intervals. Fetal pigs were evaluated for the presence of testicular undescent and for morphological paratesticular abnormalities at 110 days of gestation (birth). RESULTS: Of 180 testes 84 (47%) were undescended and 9 (5%) were in the abdominal cavity. No undescended testis (0 of 200 testes) were found in control animals (p < 0.001). Epididymal anomalies were found in all intra-abdominal testes, which was significant when compared to the epididymal abnormalities found with inguinal undescended testes (0%) or descended testes (1%) (p < 0.001). Alterations in gubernacular morphology, in particular failure of gubernacular regression, were also directly associated with cryptochidism (p < 0.001). CONCLUSIONS: Androgens partially control transabdominal and transinguinal descent of the porcine testis. In addition, antiandrogen induced cryptorchidism is associated with epididymal malformation and failure of gubernacular regression. It remains to be determined if these latter findings are only associated with or the cause of testicular undescent.

Continuous epidural anesthesia after ureteroneocystostomy in children.

We retrospectively reviewed the records of 101 pediatric patients who underwent uncomplicated ureteral reimplantation and were treated with postoperative epidural catheters for pain management. A total of 50 pediatric patients treated without epidural anesthesia was used as the control group. Length of hospital stay, time to first bowel activity, doses of narcotics, incidence of postoperative fever and evidence of epidural catheter related morbidities were documented. The costs of postoperative epidural anesthesia versus standard analgesics were compared. There was no significant difference in length of hospital stay or return of bowel function between treatment groups. Total doses of narcotics given during the hospital stay were significantly less for the epidural group (p < 0.05). The children given epidural anesthesia also had a significant increase in the incidence of postoperative fever (p < 0.05) and 25% had catheter related problems that often resulted in early removal of the epidural catheter. The cost of pain management using an epidural catheter was significantly greater than that of the standard narcotic regimen ($708 versus $14, p < 0.001). Continuous epidural infusion provides satisfactory pain control after ureteroneocystostomy in children without delaying hospital discharge. This technique of pain management is associated with a significant increase in the incidence of postoperative fever and overall cost compared to standard methods of postoperative pain management.

Micropenis: does early treatment with testosterone do more harm than good?

Micropenis secondary to hypogonadotropic hypogonadism was induced in the Sprague-Dawley rat using long acting microspheres of the gonadotropic agonist leuprolide acetate. Following the induction of micropenis treatment was initiated with testosterone at day 7, 28, 56 or 84 of life. All treatment protocols resulted in improved phallic growth compared to the untreated animals with micropenis (p < 0.01). Treatment of animals with testosterone beginning on day 7 of life resulted in premature growth of the penis and the redevelopment of micropenis in adulthood. In contrast, delaying testosterone therapy until day 56 (pubertal) or 84 (early postpubertal) resulted in complete penile development. These findings suggest that early exposure of the penis to androgens in childhood may eventually result in a significant reduction of phallic size in adulthood.

Urinary pH and urea concentration correlate to the bacterial colonization rate in gastric, colonic, ileal and myoperitoneal bladder augmentation.

We investigated how various types of augmentation cystoplasty alter the native bacteriostatic properties of urine, particularly urinary urea and pH, in the Sprague-Dawley rat. The augmentation cystoplasties studied included 1 cm.2 and 2 cm.2 patches of colon, ileum and stomach as well as myoperitoneal bladder flaps. Augmentations in order of decreasing incidence of bacteriuria and urinary pH are 2 cm.2 ileal greater than 1 cm.2 ileal greater than 2 cm.2 colonic greater than 1 cm.2 colonic greater than myoperitoneal greater than cystotomy alone greater than 1 cm.2 gastric greater than 2 cm.2 gastric. Urinary urea concentrations were similar between cystotomy alone, and myoperitoneal and gastric augments. In contrast, all colonic and ileal augments had significantly lower urea concentrations compared to the aforementioned groups. Our findings suggest that the type and size of augmentation directly affect urinary pH and urea nitrogen concentration, and the incidence of bacteriuria.