Enterocystoplasty: The long-term effects on bone mineral density.

BACKGROUND: Studies show that enterocystoplasty has a negative effect on bone mineral density (BMD). The aim of this study was to investigate the long-term impact of enterocystoplasty on BMD. We used dual energy x-ray absorptiometry (DEXA) scans to determine BMD and identify patients with osteopenia and osteoporosis who are at potential long-term risk for fracture. MATERIALS AND METHODS: We reviewed our database of >200 individuals, who had undergone enterocystoplasty or continent diversion for both neurogenic and non-neurogenic reasons during childhood. We chose to study the non-neurogenic group first for a number of technical reasons, and identified 24 individuals who had undergone the procedure for non-neurogenic reasons, and had more than 15 years of follow-up. In addition we had a control group of 10 individuals born with bladder exstrophy, who had undergone primary closure before the year 2000, without enterocystoplasty. We used DEXA scan T- and Z-scores to identify patients with osteopenia and osteoporosis. RESULTS: Eleven of 24 patients had normal DEXA scans with normal T- and Z-scores; seven had identifiable osteopenia and increased long-term risk for fracture. Six had osteoporosis; three of whom had reduced glomerular filtration rate (GFR). Eight of the 10 individuals in the control group had a normal DEXA scan. CONCLUSIONS: Enterocystoplasty during childhood can lead to loss of BMD. This does not seem to be related to the enterocystoplasty alone. It is more pronounced in individuals who have other risk factors, such as reduced GFR. The identification of BMD loss makes it possible to intervene before osteoporosis occurs and leads to pathologic fracture.

Germ cell tumor in an adolescent with extensive testicular microlithiasis: concerns regarding future management.

We report on a 14-year-old boy with bilateral testicular microlithiasis and a right-sided testicular tumor. Tumor markers alpha-fetoprotein (AFP) and ß-human chorionic gonadrotropin (ß-hCG) levels were elevated and orchiectomy revealed a mixed germ cell tumor consisting of embryonal carcinoma, yolk sac tumor, choriocarcinoma, and mature teratoma. The patient had no evidence of metastatic disease. Although there is a strong association between testicular microlithiasis and testicular tumor, the pediatric literature is varying in the recommended surveillance of these patients. The literature and management of pediatric patients with testicular microlithiasis is herein reviewed.

Colovaginoplasty using the Yang-Monti modification.

OBJECTIVE: Bowel vaginoplasty is particularly difficult in patients who are extremely obese or those with an android pelvis. This report evaluates the use of the Yang-Monti principle as a viable alternative in the reconstruction of these patients. METHODS: Upon retrospective chart review of patients who underwent bowel replacement vaginoplasty between 1980 and 2008, 4/60 were identified who underwent the Yang-Monti modification. The neovagina was created with an 8‒10-cm segment of descending colon which was detubularized and then retubularized using the Yang-Monti principle. This was sewn in place in the perineum. Outcome was evaluated by physical examination data and clinical information on postoperative sexual function. RESULTS: Three of the four patients had an XY karyotype and an android pelvis, and of these two were failures of previous ileovaginoplasties and one was a failed colovaginoplasty. The fourth was a case of primary mullerian failure (XX) in a morbidly obese individual. All four were discharged without complication following surgery. With a median follow-up of 6 years (range 4-9), none showed evidence of introital stenosis or required dilation. Two were engaged in vaginal intercourse at last consultation, and they reported vaginal length was adequate. No further procedures were required in any of the patients at the end of the follow-up period. CONCLUSION: The Yang-Monti modification, when used as an adjunct to colovaginoplasty, can be an effective reconstructive technique in this subset of patients. It allows for lengthening of the neovagina, without perpetuating tension on the vascular pedicle.

Endoscopic management of vesicoureteral reflux in adult women.

OBJECTIVE: • To describe our endoscopic management of adult women with vesicoureteral reflux (VUR) and associated outcomes. PATIENTS AND METHODS: • We retrospectively identified 19 adult women who presented for the endoscopic treatment of VUR from November 2001 to January 2008. • Each patient was diagnosed with VUR by voiding cystourethrogram or nuclear cystourethrogram after an episode of pyelonephritis or recurrent urinary tract infections with renal scarring on ultrasound. • A dimercaptosuccinic acid renal scan was performed prior to treatment. All patients underwent endoscopic treatment with dextranomer/hyaluronic acid copolymer (Deflux). Patients with bilateral VUR received bilateral injections during the same procedure. • Follow-up imaging was obtained and success was strictly defined as no degree of VUR. Patients with residual VUR received repeat endoscopic treatment. RESULTS: • Nineteen patients with a mean age of 22 years old (range 18-33 years old) underwent endoscopic treatment for VUR. A total of 79% (15/19) had pre-existing risk factors for VUR, including prior open anti-reflux surgery (26%), family history of VUR (26%) and childhood diagnosis of VUR (26%). • Imaging revealed that 47% (9/19) had renal scarring and 26% (5/19) had bilateral VUR. The success rate was 79% (19/24) after one treatment, 92% (22/24) after 5 patients received a second treatment, and 96% (23/24) after 2 patients received a third treatment. There were no perioperative complications. CONCLUSION: • Endoscopic management of VUR is both safe and effective in adult women.

Overnight urethral stenting after tubularized incised plate urethroplasty for distal hypospadias.

OBJECTIVES: The duration of urethral stenting after tubularized incised plate (TIP) urethroplasty for hypospadias varies among surgeons. Typically the catheter is left for up to 7 days with the goal of minimizing post-operative complications. We describe our experience with overnight stenting for distal TIP hypospadias repair. MATERIALS AND METHODS: A retrospective chart review was performed on patients who underwent TIP hypospadias repair from 2003 to 2008. Patients who had their urethral catheter overnight were included in this analysis. Outcomes analyzed were the rates of: urethrocutaneous fistula, meatal stenosis, urethral stricture and urinary tract infections. RESULTS: A total of 64 patients underwent outpatient TIP hypospadias repair. Forty-nine patients had overnight urethral stenting with at least 12 months follow-up and were included in the analysis. Five of the 49 patients (10.2%) developed urethrocutaneous fistula. Of these five patients, two had undergone re-do hypospadias repair. The fistula rate in primary repairs was 3/45 (6.7%). There were no incidences of meatal stenosis, urinary tract infections or urethral strictures. CONCLUSION: In our experience, overnight urethral stenting for TIP hypospadias repair does not significantly affect the rates of urethrocutaneous fistula, meatal stenosis and urinary tract infections. Patients who have had a primary TIP hypospadias repair may have their urethral catheter removed safely on post-operative day one.

Endoscopic management of vesicoureteral reflux in women presenting with pyelonephritis.

PURPOSE: Vesicoureteral reflux is not usually considered a major cofactor in acute pyelonephritis in women. However, there is a subset of individuals in whom reflux must be considered in the evaluation of acute pyelonephritis. We sought to evaluate the effectiveness of endoscopic treatment for vesicoureteral reflux in this subset of patients. MATERIALS AND METHODS: We retrospectively reviewed the records of 13 female patients presenting with clinical pyelonephritis between 2001 and 2005. All of these patients had either a history of vesicoureteral reflux in childhood or a family history of reflux, or had previously undergone surgery for reflux. All patients underwent voiding cystourethrogram and dimercapto-succinic acid renal scan as part of the evaluation. RESULTS: Of the 13 individuals evaluated 9 had vesicoureteral reflux. Of these patients 5 had been operated on previously for vesicoureteral reflux, 2 had a strong family history of reflux and 2 had reflux as a child with documented resolution. Six of the 9 patients with reflux exhibited renal scarring on dimercapto-succinic acid renal scintigraphy. Endoscopic correction of reflux was done in all 9 patients and was successful in 8, as shown on voiding cystourethrogram at 3 months postoperatively. One patient required a second procedure, which was successful. Only 1 patient has had a subsequent episode of clinical pyelonephritis, and voiding cystourethrogram following treatment again revealed resolution of reflux. CONCLUSIONS: There is a subset of women presenting with acute pyelonephritis in whom vesicoureteral reflux is a risk factor. When documented, vesicoureteral reflux can be managed effectively with endoscopic treatment.

Sexual function following bowel vaginoplasty.

PURPOSE: We review our 23-year experience with bowel vaginoplasty, with particular attention to postoperative quality of life and sexual function. MATERIALS AND METHODS: We reviewed the records of 57 patients who underwent bowel replacement vaginoplasty between 1980 and 2004. A total of 42 patients had the Mayer-Rokitansky syndrome, of whom 6 had varying forms of intersexuality, 6 had undergone surgery for pelvic malignancy, 1 had aphallia, 1 had cloacal exstrophy and 1 was the survivor of a conjoined twin separation. Replacement vaginoplasty was done using sigmoid colon in 39 patients, ileum in 9 and cecum in 9. Followup ranged from 18 months to 24 years, with a mean of 8.8 years. Outcome was evaluated by retrospective chart review, and the FSDQ, a validated, IRB approved instrument, was used to evaluate postoperative sexual function. RESULTS: Among the 57 patients postoperative sexual function was evaluated in 44, 9 were lost to followup and 4 were considered too young for evaluation. Of the 44 patients 36 responded to the FSDQ, 6 refused and 2 were unable to complete the questionnaire adequately. Of the 36 patients who responded 15 were married and 31 were sexually active. On a scale of 0 to 5, 28 patients (78%) reported sexual desire, 33% sexual arousal, 33% sexual confidence and 28 (78%) sexual satisfaction. In addition, 20 patients (56%) reported frequent orgasms, 8 (22%) occasional orgasms and 8 (22%) no orgasms. A total of 32 patients (89%) reported adequate lubrication for intercourse and 2 reported dyspareunia. Two of the 36 patients performed home dilation and required estrogen suppositories. A total of 34 patients used home douching and 20 required pads for mucus production. CONCLUSIONS: It appears that isolated bowel segments provided excellent tissue for vaginal replacement. For technical reasons we believe that colonic segments, particularly sigmoid, are preferable to small bowel. Sexual function following bowel vaginoplasty appears to be adequate and durable.