Do Routine Preoperative and Intraoperative Urine Cultures Benefit Pediatric Vesicoureteral Reflux Surgery?

Objective. To determine if routine preoperative and intraoperative urine cultures (UCx) are necessary in pediatric vesicoureteral (VUR) reflux surgery by identifying their association with each other, preoperative symptoms, and surgical outcomes. Materials and Methods. A retrospective review of patients undergoing ureteral reimplant(s) for primary VUR at a tertiary academic medical center between years 2000 and 2014 was done. Preoperative UCx were defined as those within 30 days before surgery. A positive culture was defined as >50,000 colony forming units of a single organism. Results. A total of 185 patients were identified and 87/185 (47.0%) met inclusion criteria. Of those, 39/87 (45%) completed a preoperative UCx. Only 3/39 (8%) preoperative cultures returned positive, and all of those patients were preoperatively symptomatic. No preoperatively asymptomatic patients had positive preoperative cultures. Intraoperative cultures were obtained in 21/87 (24.1%) patients; all were negative. No associations were found between preoperative culture results and intraoperative cultures or between culture result and postoperative complications. Conclusions. In asymptomatic patients, no associations were found between the completion of a preoperative or intraoperative UCx and surgical outcomes, suggesting that not all patients may require preoperative screening. Children presenting with symptoms of urinary tract infection (UTI) prior to ureteral reimplantation may benefit from preoperative UCx.

Assessing health related benefit after reconstruction for urinary and fecal incontinence in children: a parental perspective.

PURPOSE: We sought to evaluate health related benefit in children undergoing surgical reconstruction for urinary and fecal incontinence from a parental perspective. MATERIALS AND METHODS: A health related benefit instrument was mailed to the parents or guardians of 300 consecutive patients who had undergone reconstruction for urinary and/or fecal incontinence at our institution between 1997 and 2011. We assessed parent reported health related benefit using the validated Glasgow Children's Benefit Inventory and satisfaction with 6 supplemental questions. One-sample t-tests as well as exploratory univariate and multivariate linear regressions were performed for statistical analysis. RESULTS: Response rate was 40.0% at a mean of 5.5 years (range 0.6 to 13.8) after reconstruction. Spina bifida was the most common primary diagnosis (48 patients, 56.5%). Mean total Glasgow Children's Benefit Inventory score and subscores for each domain were positive, indicating an improved health related benefit after reconstruction (all p <0.0001). Certain patients, possibly based on diagnosis and gender, may particularly benefit from reconstruction (p ≤0.04). Parents believed that the bladder augmentation and/or urinary continent catheterizable channel most changed the life of their child but that achievement of stool continence was most important to themselves. Only 17 families (16.2%) required more than 1 month to become comfortable with catheterizations, and 69 patients (68.8%) required less care or no assistance with daily activities after reconstruction. Only 2 parents (1.9%) would be unwilling to consent to the procedure again. CONCLUSIONS: We observed moderate parental satisfaction and parent reported improvement in health related quality of life for children undergoing surgical reconstruction for urinary and fecal incontinence.

Percutaneous cystolithotomy in the pediatric neuropathic bladder with laparoscopic trocar access: a modified approach useful for the augmented and native bladder, and continent urinary reservoir.

OBJECTIVE: We present our results of percutaneous cystolithotomy with laparoscopic trocar (PCLT) access in children. MATERIALS AND METHODS: PCLT was performed in 13 cases. This includes 2 patients who had this performed twice for recurrent stone 12-24 months after initial surgery. Eight patients had a bladder augmentation, 2 had native bladders, and one a continent urinary reservoir. Nine patients had a reconstructed urethra. Cystoscopy was performed in all cases to assess stone burden. Under direct vision, an 18 gauge angiocatheter was placed into bladder and guidewire placed through the angiocatheter. With the bladder distended, a laparoscopic 10 mm trocar was placed under vision next to the guidewire. A 26Fr nephroscope was used via the trocar to extract the stones, utilizing laser or ultrasonic lithotripsy to fragment larger stones. Stone fragments were removed with graspers and/or the vacuum extraction technique. RESULTS: PCLT was successful in all cases. No complications were noted. Six cases were treated as outpatient, seven discharged home after 12-23 h observation. CONCLUSIONS: PCLT via laparoscopic trocar access is a facile and safe approach for removing stones in the pediatric neuropathic bladder. Advantages include the ability to distend the bladder with continuous flow and the larger working channel permitting use of the nephroscope to treat and extract stones.

IL-18 activation is dependent on Toll-like receptor 4 during renal obstruction.

PURPOSE: Interleukin 18 (IL-18) is a critical mediator of obstruction-induced renal injury. Although previous studies have demonstrated that IL-18 participates in a positive feedback loop via the IL-18 receptor (IL-18R) and localized renal IL-18 and IL-18R production to tubular epithelial cells (TEC), the mechanism of IL-18 activation during obstruction remains unclear. We hypothesized that IL-18 activation is dependent on Toll-like receptor 4 (TLR4) signaling during renal obstruction. MATERIALS AND METHODS: Male C57BL6 TLR4 knockout (TLR4KO) and wild-type (WT) mice were subjected to unilateral ureteral obstruction versus sham operation for 1 wk. The animals were sacrificed, and renal cortical tissue was harvested and analyzed for TLR4 expression (Western blot), active IL-18 production (enzyme-linked immunosorbent assay, real-time polymerase chain reaction), IL-18 receptor expression (real-time polymerase chain reaction), and TLR4/IL-18 versus IL-18R cellular localization (dual immunofluorescent staining). RESULTS: Renal TLR4 expression increased significantly in WT mice in response to obstruction, but remained at sham treatment levels in TLR4KO mice. IL-18 and IL-18R gene expression and active IL-18 production were similarly increased in WT mice in response to obstruction, but decreased significantly to sham treatment levels in the absence of TLR4. Dual immunofluorescent staining revealed co-localization of TLR4 and IL-18 to renal TEC during obstruction. CONCLUSION: IL-18 production and activation during renal obstruction is dependent on intact TLR4 signaling. Co-localization of IL-18 and TLR4 production to TEC during obstruction suggests that TEC are the primary site of IL-18 production and activation. Further characterization of the pathway may be necessary to develop targeted therapy in obstruction-induced renal injury.

Body mass index is weakly associated with, and not a helpful predictor of, disease progression in men with clinically localized prostate carcinoma treated with radical prostatectomy.

BACKGROUND: Several studies have recently suggested an association between body mass index (BMI) and disease progression after radical prostatectomy. In the current study, the authors examined this association and that between the reciprocal of BMI (INVBMI, 1/BMI) and progression-free probability in men treated with radical retropubic prostatectomy (RRP) for clinically localized prostate carcinoma. METHODS: The authors retrospectively studied 2210 patients who underwent RRP at Memorial Sloan-Kettering Cancer Center between September 1986 and May 2003. Clinicopathologic variables analyzed included BMI (kg/m2), preoperative serum prostate-specific antigen level (ng/mL), clinical T classification, year of surgery, race, biopsy-derived primary and secondary Gleason grades, and INVBMI, known to better correlate with percent body fat than BMI. Cox regression analysis was used to examine the possible association between BMI or its reciprocal with disease progression after controlling for the effects of common prognostic factors. The areas under the receiver operating curve (AUC) for models with and without INVBMI were calculated. RESULTS: Of the 2210 patients analyzed, 251 experienced disease progression in a median follow-up time of 25.9 months (range, 0-143 months). After adjusting for all clinical variables, both BMI (P = 0.071; hazards ratio [HR] = 1.027) and INVBMI (P = 0.041; HR < 0.001) were associated with disease progression. However, the areas under AUC for models with and without INVBMI were similar (range, 0.794-0.798). CONCLUSIONS: Although conflicting evidence has been reported regarding the link between obesity and an increased risk of developing prostate carcinoma, as well as an increased risk of developing aggressive disease and prostate carcinoma-related mortality, the authors found weak associations with disease progression for both BMI and INVBMI. These variables were of negligible prognostic value in men who received surgery. Studies with longer follow-up, that examine alternative end points, and that follow treatment(s) besides surgery are needed.

Mucinous adenocarcinoma of the prostate: a case report of long-term disease-free survival and a review of the literature.

A 65-year-old man presented with hematuria, postcoital bleeding, and mucoid-appearing prostatic secretions. The prostate was normal in size, boggy, and with no palpable masses. Cystoscopy revealed a prostatic wall cavity with gelatinous material exuding from the lesion. Extensive transurethral resection was performed, with approximately 37 g of tissue retrieved. Flexible sigmoidoscopy was performed to 60 cm, revealing no lesions, and stool was negative for occult blood. The pathologic diagnosis was mucinous adenocarcinoma of the prostate. Computed tomography and bone scan were negative for metastatic disease. The patient underwent uncomplicated radical prostatectomy. Fifteen years later, the patient was disease free and maintaining a healthy, active lifestyle.

Predicting clinical end points: treatment nomograms in prostate cancer.

Due to the generally indolent nature of prostate cancer, patients must decide among a wide range of treatments, which will significantly affect both quality of life and survival. Thus, there is a need for instruments to aid patients and their physicians in decision analysis. Nomograms are instruments that predict outcomes for the individual patient. Using algorithms that incorporate multiple variables, nomograms calculate the predicted probability that a patient will reach a clinical end point of interest. Nomograms tend to outperform both expert clinicians and predictive instruments based on risk grouping. We outline principles for nomogram construction, including considerations for choice of clinical end points and appropriate predictive variables, and methods for model validation. Currently, nomograms are available to predict progression-free probability after several primary treatments for localized prostate cancer. There is need for additional models that predict other clinical end points, especially survival adjusted for quality of life.

Prognostic factors for survival in patients with hormone-refractory prostate cancer (HRPC) after initial androgen deprivation therapy (ADT).

Androgen deprivation therapy (ADT) is a standard mode of therapy for patients with metastatic prostate cancer. Controversy exists, however, as to the optimal timing of initiation of ADT, as well as whether this form of therapy imparts a survival benefit to patients with advanced disease. Side effects of ADT are not minimal and can seriously compromise a patient's quality of life. Additionally, ADT eventually results in hormone-refractory prostate cancer (HRPC). Despite new chemotherapeutic regimens and hormonal agents, overall survival in these patients remains universally low. Nonetheless, it is valuable to gauge a patient's prognosis to assist in decision making when considering treatment options. Contemporary series analyzing patients with HRPC have identified several factors prognostic of survival outcomes, such as lactate dehydrogenase (LDH), alkaline phosphatase (ALK), hemoglobin (Hgb), and serum prostate specific antigen (PSA) level. Nomograms have been developed that utilize these pretreatment clinical variables to predict clinical outcomes, including 1-year, 2-year, and median survival times in patients with HRPC. These instruments are capable of more accurately predicting survival outcomes than traditional tables of multivariate results or simple analysis of prognostic factors. We believe these nomograms will become indispensable tools for patient counseling and clinical trial design in patients with HRPC.