Pollination in the Chilean Mediterranean-type ecosystem: a review of current advances and pending tasks.

We conducted a systematic review of the scientific literature published on plant-pollinator interactions, from both the plant and pollinator perspective, in the Chilean Mediterranean-type ecosystem (MTE hereafter). Our search identified 69 published papers on 235 native plant species from 62 families. Less than 7.9% of the flowering species inhabiting the Chilean Mediterranean have been studied, and most studies were restricted to only one locality and one reproductive season. The geographic location of the studies differed from a random pattern, showing two well-defined areas where most studies were conducted. Likewise, most studies in the Andes Range were performed above 2000 m a.s.l. The number of species of flower visitor per plant species was low (4.25 ± 0.22), which probably results from the historical and biogeographic isolation of Chile. This literature survey shows that studies relating floral traits with pollinator attraction and plant reproduction are the most frequent topics of research, reaching 37.6% of studies, followed by studies that examine pollination in relation to human impact (16.1%), micro- and macroevolution (14.0%), relationships between pollination and other ecological interactions (10.8%), community and network assessments (11.8%), and effects of abiotic variables on pollination interactions (9.7%). Our review highlights a lack of research on the effects of pollination for anthropogenic land use especially as agricultural practice is one of the most salient features of the Chilean MTE. Future directions to increase our understanding of the role of plant-pollinator relationships for biodiversity maintenance should include: to extend the taxonomic and geographic scope of research, to increase the number of spatial and temporal replicates, to increase the number of studies on pollination networks as they provide estimates of community complexity and putative stability, to develop studies that estimate the importance of pollination for plant demographic parameters and conservation, and to conduct studies that estimate the ecological service provided by Chilean native pollinators for crop yield and sustainable agriculture.

Angiolymphoid hyperplasia with eosinophilia of the eyelid and orbit: the Western cousin of Kimura's disease?

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon disease most frequently occurring in the head and neck region. It occurs in all races. In spite of a clear distinction between ALHE and Kimura's disease on histological grounds for almost 20 years now, confusion and misdiagnosis still exist to date. Three Spanish patients presented to our institution over a 6 year period with mass lesions in the superior orbit, medial orbito-nasal wall and eyelid, respectively. All patients were of Caucasian extraction and were diagnosed with epithelioid haemangioma on histological tissue analysis. We report on the history and management of these patients which resulted in good functional and cosmetic outcome with no subsequent evidence of disease recurrence.

Utility of intraoperative angiography during subaxial foramen transversarium decompression for bow hunter's syndrome.

Bow hunter's syndrome is an uncommon cause of vertebrobasilar insufficiency resulting from rotational compression of the extracranial vertebral artery. While positional compression of any portion of the extracranial vertebral artery has been reported to result in bow hunter's syndrome, the most common site of compression is the V2 segment as it passes through the foramen transversarium of the subaxial cervical spine. A 43-year-old woman presented with increasingly frequent pre-syncopal and syncopal episodes upon leftward head rotation. Pre-operative angiographic studies with the neck rotated to the left demonstrated occlusion of the left vertebral artery by a C4-5 osteophyte arising from the C4 uncinate process. The patient underwent microsurgical decompression of the vertebral artery at C4-5 through a standard anterior transcervical retropharyngeal approach. Selective vertebral artery intraoperative angiography performed with the head passively rotated to the left before and after left vertebral artery decompression showed marked improvement in the luminal diameter and blood flow. The patient's symptoms resolved post-operatively. This case illustrates the second instance of intraoperative angiography used to confirm adequate vertebral artery decompression for bow hunter's syndrome. Intraoperative angiography can be safely used to decrease the extent of vertebral artery decompression in order to minimize the risk of operative complications.

Effects of sampling completeness on the structure of plant-pollinator networks.

Plant-animal interaction networks provide important information on community organization. One of the most critical assumptions of network analysis is that the observed interaction patterns constitute an adequate sample of the set of interactions present in plant-animal communities. In spite of its importance, few studies have evaluated this assumption, and in consequence, there is no consensus on the sensitivity of network metrics to sampling methodological shortcomings. In this study we examined how variation in sampling completeness influences the estimation of six network metrics frequently used in the literature (connectance, nestedness, modularity, robustness to species loss, path length, and centralization). We analyzed data of 186 flowering plants and 336 pollinator species in 10 networks from a forest-fragmented system in central Chile. Using species-based accumulation curves, we estimated the deviation of network metrics in undersampled communities with respect to exhaustively sampled communities and the effect of network size and sampling evenness on network metrics. Our results indicate that: (1) most metrics were affected by sampling completeness but differed in their sensitivity to sampling effort; (2) nestedness, modularity, and robustness to species loss were less influenced by insufficient sampling than connectance, path length, and centralization; (3) robustness was mildly influenced by sampling evenness. These results caution studies that summarize information from databases with high, or unknown, heterogeneity in sampling effort per species and should stimulate researchers to report sampling intensity to standardize its effects in the search for broad patterns in plant-pollinator networks.

Angiographic vasospasm is strongly correlated with cerebral infarction after subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: The long-standing concept that delayed cerebral infarction after aneurysmal subarachnoid hemorrhage results exclusively from large artery vasospasm recently has been challenged. We used data from the CONSCIOUS-1 trial to determine the relationship between angiographic vasospasm and cerebral infarction after subarachnoid hemorrhage. METHODS: We performed a post hoc exploratory analysis of the CONSCIOUS-1 data. All patients underwent catheter angiography before treatment and 9±2 days after subarachnoid hemorrhage. CT was performed before and after aneurysm treatment, and 6 weeks after subarachnoid hemorrhage. Angiograms and CT scans were assessed by centralized blinded review. Angiographic vasospasm was classified as none/mild (0%-33% decrease in arterial diameter), moderate (34%-66%), or severe (≥67%). Infarctions were categorized as secondary to angiographic vasospasm, other, or unknown causes. Logistic regression was conducted to determine factors associated with infarction. RESULTS: Complete data were available for 381 of 413 patients (92%). Angiographic vasospasm was none/mild in 209 (55%) patients, moderate in 118 (31%), and severe in 54 (14%). Infarcts developed in 6 (3%) of 209 with no/mild, 12 (10%) of 118 patients with moderate, and 25 (46%) of 54 patients with severe vasospasm. Multivariate analysis found a strong association between angiographic vasospasm and cerebral infarction (OR, 9.3; 95% CI, 3.7-23.4). The significant association persisted after adjusting for admission neurological grade and aneurysm size. Method of aneurysm treatment was not associated with a significant difference in frequency of infarction. CONCLUSIONS: A strong association exists between angiographic vasospasm and cerebral infarction. Efforts directed at further reducing angiographic vasospasm are warranted.

Return to work and school: a model mentoring program for youth and young adults with spinal cord injury.

STUDY DESIGN: This is a prospective study. OBJECTIVES: Young individuals with spinal cord injury (SCI) need support to actively participate in the community after their injuries. The 'Back on Track' mentoring program was developed to match mentees with SCI with mentors to assist with post-injury adjustment. The objectives of this study were to improve the percentage of youth and young adults with SCI, who access post-secondary education or employment opportunities and to improve quality of life. SETTING: This study had a community-based setting. METHODS: Each mentee with SCI was matched with a community-based mentor, with or without a disability. The mentoring relationship was planned for 2 years. Participants were evaluated with standardized questionnaires at intake, at the time of post-secondary education or employment entry and 4 months post entry. RESULTS: In total, 39 individuals with SCI, age 16-26 years, were enrolled. Average age of mentees was 19.8 years (s.d.=3.0). In total, 29 participants were matched with mentors, and 10 participants (34%) completed the program, with seven (24%) returning to school, two (6.9%) returning to work and one individual (3.4%) attending school part time. CONCLUSION: Although multiple barriers to success occurred, this program demonstrated that it could assist the youth and young adults with SCI to obtain post-secondary education and employment. This type of support system should be encouraged in order to improve the quality and satisfaction of life for young adults with disabilities.

Genitoplastía feminizante en pacientes con defectos de la diferenciación sexual: resultados actuales y controversias / Feminising genitoplastic in patients with disorders of sexual differentiation: news results and controversys

Determinar los resultados anatómicos, estéticos y las complicaciones de una técnica quirúrgica estandarizada, a través de un acceso perineal para reconstruir los genitales externos e internos virilizados en pacientes con defectos de la diferenciación sexual (DDS) asociados a una confluencia uretravaginal alta, utilizando la movilización parcial del seno urogenital (SUG). Material y métodos:Diez y seis pacientes con DDS y un SUG significativamente virilizado (Prader IV) fueron tratados a una edad mediana de 1,45 años (rango: 0,4-5,3) con una genitoplastia que incluye: vaginoplastia, labioplastia y clitoroplastia. El SUG movilizado –por debajo de los ligamentos pubouretrales– se utilizó para confeccionar la cara anterior distal de la vagina y el vestíbulo vaginal. Se empleó un colgajo cutáneo perineal para la plástica de la cara posterior distal de la vagina. Seguimiento mediano 7,4 años (rango 2-13). Once pacientes padecían hiperplasia suprarrenal congénita, 4 insensibilidad parcial a los andrógenos y 1, disgenesia gonadal mixta. El seguimiento se realizó cada 4 meses el primer año y anualmente después. En las historias clínicas se registró la opinión de los padres y la de los médicos participantes sobre el aspecto femenino posoperatorio de los genitales. Resultados: En las 16 pacientes el introito vaginal se ubicó en el vestíbulo, por debajo del meato uretral. Dos pacientes sufrieron atrofia del glande. Los padres y médicos participantes coincidieron que la genitoplastia brindó un aspecto estético femenino en todas las pacientes. Se consideraron insatisfactorios los resultados en las dos pacientes con atrofia del glande. Una paciente sufrió incontinencia de orina, tratada con éxito con una inyección endoscópica de una sustancia biomédica y la otra paciente, una estrechez de la plástica vaginal. Conclusiones: Este estudio afirma la eficacia de la técnica descripta para tratar pacientes con DDS que presentan genitales virilizados, con una confluencia vaginal alta. Los autores tienen presente que estos resultados iniciales prometedores deben ser evaluados a largo plazo en la adolescencia.

Pollinator-mediated selection in a specialized pollination system: matches and mismatches across populations.

Most studies on pollinator-mediated selection have been performed in generalized rather than specialized pollination systems. This situation has impeded evaluation of the extent to which selection acts on attraction or specialized key floral traits involved in the plant-pollinator phenotypic interphase. We studied pollinator-mediated selection in four populations of Nierembergia linariifolia, a self-incompatible and oil-secreting plant pollinated exclusively by oil-collecting bees. We evaluated whether floral traits experience variable selection among populations and whether attraction and fit traits are heterogeneously selected across populations. Populations differed in every flower trait and selection was consistently observed for corolla size and flower shape, two traits involved in the first steps of the pollination process. However, we found no selection acting on mechanical-fit traits. The observation that selection occurred upon attraction rather than mechanical-fit traits, suggests that plants are not currently evolving fine-tuned morphological adaptations to local pollinators and that phenotypic matching is not necessarily an expected outcome in this specialized pollination system.

Concurrent stenting of multiple cerebrovascular stenotic lesions: technical note.

INTRODUCTION: Until recently, the treatment of intracranial atherosclerosis has remained limited. Due to advances in endovascular technology and technique, angioplasty and stenting has become an accepted treatment for medically-refractory intracranial atherosclerosis. Patients with intracranial atherosclerosis frequently have multiple lesions, however, the clinical significance of each individual lesion is not always evident. In these instances the treating physician must decide which lesions should be managed conservatively, and which should be treated. TECHNIQUE: Emphasizing decision-making, we describe a patient in whom 3 separate atherosclerotic lesions in the same vascular territory underwent endovascular treatment in one treatment session. Each of the lesions was treated with angioplasty and stent placement. CONCLUSION: This may be a relatively safe and efficacious technique that allows for the treatment of multiple lesions without the risks associated with multiple cerebral angiograms.

First Report of Armillaria Root Disease Caused by Armillaria tabescens on Araucaria araucana in Veracruz, Mexico.

In September 2007, bark samples were collected from the root collar of a single Araucaria araucana tree that had recently died and was suspected of being killed by Armillaria root disease. Disease symptoms and signs included a thinning crown and fruiting bodies at the tree base over a several-year period before tree death. The tree was located in an isolated street-tree planting within a business district on Maestros Veracruzanos Street, Xalapa, Veracruz (19°31'52''N, 96°54'25''W, elevation 1,392 m). One fungal isolate (MEX21WF) was obtained, which possessed two sequence repeat types from the intergenic spacer-1 (IGS-1) region (GenBank Accession Nos. GQ335541 and GQ335542). On the basis of these IGS-1 sequences, this isolate from Mexico possessed 99% nucleotide sequence identities with North American Armillaria tabescens isolates (GenBank Accession Nos. AY695410 ≈ GQ335541 and AY773966 ≈ GQ335542). Somatic pairing tests of the isolate with other North American Armillaria species also identified it as A. tabescens (2). In addition, fruiting bodies were produced on the stump base in 2009 that matched morphological features of A. tabescens, e.g., exannulate, cespitose growth in clusters, brown-gray stipe to blackish toward the base, longitudinally fibrillose, basidiospores (6-) 7 to 9 × 4 to 5 (-5.5) µm, and other general morphology. On the basis of these three lines of taxonomic evidence, it was concluded that the isolate was A. tabescens. To our knowledge, this is the first confirmed report of A. tabescens causing Armillaria root disease in Mexico. Furthermore, this note represents the first report of A. tabescens on Araucaria araucana, which is native to Chile and Argentina. The other previous reports of A. tabescens in Mexico are based on herbarium specimens collected in 1965 (BPI 753040) from Valle de Bravo (approximately 350 km west of Xalapa) in the state of México and 1973 (BPI 753041) from near Monterrey (approximately 760 km north-northwest of Xalapa) in the state of Nuevo León (1). However, no host information or confirmation of taxonomic identification was reported for these herbarium specimens. Although this note confirms the presence of A. tabescens in Mexico, more surveys and monitoring are needed to determine the full distribution of this pathogen in Mexico. Because the climate and tree communities of eastern Mexico are similar to those of the southeastern United States, where A. tabescens has been reported as a common pathogen of oaks and fruit trees (3,4), it seems reasonable that A. tabescens may represent an existing or potential threat in eastern Mexico. References: (1) D. F. Farr and A. Y. Rossman. Fungal Databases. Systematic Mycology and Microbiology Laboratory. Online publication. ARS, USDA, 2010. (2) K. I. Mallett and Y. Hiratsuka. Can. J. Bot. 64:2588, 1986. (3) F. Miranda and A. J. Sharp. Ecology 31:313, 1950. (4) G. Schnabel et al. Mycol. Res. 109:1208, 2005.

Conjunctival cytology in floppy eyelid syndrome: objective assessment of the outcome of surgery.

AIMS: Upper eyelid shortening is the main surgical procedure in floppy eyelid syndrome (FES). The efficacy of surgery is assessed by improvements in the symptoms, since objective evaluation is difficult. Conjunctival impression cytology was assessed as an objective method for the evaluation of the effectiveness of surgery for FES. METHOD: The study was a prospective interventional study in 16 patients (26 eyelids) with FES, who were enrolled over a period of 8 months. Patients were examined 1-4 weeks before surgery and 16 weeks after surgery. Cases were classified into three groups according to the severity of symptoms and papillary reaction. A full-thickness pentagonal wedge resection was performed in the upper eyelid. Impression cytology was performed in all patients at 1-4 weeks before surgery and 16 weeks after surgery. RESULTS: Postoperative improvements in cellular morphology and goblet cell count were found in 20 of 22 eyelids (91%) and this led to a decrease of least one grade in Nelson's classification. In two cases (9%) the Nelson grade remained stable. Postoperative improvement on cytology was statistically significant with the Wilcoxon signed ranks test (p<0.001). CONCLUSION: Conjunctival cytology provides an objective method for the evaluation of the efficacy of surgical techniques proposed for the treatment of eyelid laxity syndromes.

Phylogenetic analysis of floral integration in Schizanthus (Solanaceae): does pollination truly integrate corolla traits?

To assess whether floral integration patterns result from the action of pollinator selection on functionally related traits, we compared corolla integration patterns in eight Schizanthus species differing in pollination systems and in their degree of pollinator dependence across a molecular phylogeny. Integration patterns differed among species and these differences were not related to their phylogenetic relatedness. When the putative original function of some corolla traits was lost in pollinator-dependent species, the integration among nonfunctional characters and the rest of the corolla traits was disrupted. This pattern was not presented in species adapted for late autonomous selfing, which exhibited higher corolla integration than their pollinator-dependent relatives. These results suggest that corolla integration in pollinator-dependent species was shaped by pollinator-mediated selection. Decoupling of nonfunctional traits in these species may result from a relaxation of correlational selection or from selection acting against a default covariation provided by genetic and developmental connections.

Quiste de vesícula seminal con litiasis / Seminal vesicle cyst with lithiasis

Presentamos un caso de quiste de vesícula seminal (VS) con macrolitiasis en un paciente prepúber. Se trata de un niño de 11 años de edad, que consulta por IUR asociadas con dolor perineal, con antecedentes de epididimitis aguda derecha; descubriendo como hallazgo en los estudios por imágenes, agenesia de riñon derecho y una formación litiásica en vesícula seminal derecha. Se realiza la exéresis de la vesícula seminal derecha con la litiasis en su interior, evolucionando sa-tisfactoriamente. Se analizan los distintos métodos diagnósticos para evaluar las vesículas semi-nales y las opciones de tratamiento, haciendo hincapié en los distintos abordajes quirúrgicos.

Quiste de vesícula seminal con litiasis / Seminal vesicle cyst with lithiasis

Presentamos un caso de quiste de vesícula seminal (VS) con macrolitiasis en un paciente prepúber. Se trata de un niño de 11 años de edad, que consulta por IUR asociadas con dolor perineal, con antecedentes de epididimitis aguda derecha; descubriendo como hallazgo en los estudios por imágenes, agenesia de riñon derecho y una formación litiásica en vesícula seminal derecha. Se realiza la exéresis de la vesícula seminal derecha con la litiasis en su interior, evolucionando sa-tisfactoriamente. Se analizan los distintos métodos diagnósticos para evaluar las vesículas semi-nales y las opciones de tratamiento, haciendo hincapié en los distintos abordajes quirúrgicos. (AU)

Bladder function associated with posterior urethral valves after primary valve ablation or proximal urinary diversion in children and adolescents.

PURPOSE: We retrospectively reviewed 2 series of patients with posterior urethral valves treated initially with valve ablation preceded by bilateral cutaneous ureterostomies or valve ablation alone to evaluate and compare bladder function behavior of each treatment group. MATERIALS AND METHODS: From 1970 to 1983, 19 males 22 days to 21 months old with posterior urethral valves were treated with 1 of 2 initial surgical approaches, including upper tract diversion, delayed undiversion and ablation in 11 (group 1), and primary valve ablation only in 8 (group 2). Median patient age at the time of cutaneous urinary diversion and primary valve ablation for groups 1 and 2 was 7 and 9 months, respectively. Median duration of bladder defunctionalization was 48 months. All patients were evaluated urodynamically after initial ablation or re-functionalization of the bladder using standard rapid fill cystometry. Median patient age for groups 1 and 2 was 14 and 9.5 years, respectively, at the time of urodynamic testing 16 and 12.6 years, respectively, at followup. RESULTS: Urodynamic assessment revealed detrusor instability in 5 group 1 patients but in only group 2 1 patient. Group 2 patients had significantly lower median end filling pressure (4 versus 15 cm. water, p <0.03) and higher maximum bladder capacity (1.4 versus 0.8, p <0.005) than those in group 1. Group 1 patients had lower compliance than those in group 2 (median 15 versus 82 cm. water, p <0.05). Further analysis showed no difference between groups 1 and 2 in overall median voiding detrusor pressure at maximum flow (51 versus 52.6 cm. water, respectively). Cystometric detrusor under activity patterns were noted in 5 group 1 and 2 group 2 patients. Residual urine volumes were 17%, 31%, 19% and 8% of bladder capacity, respectively, in 2 group 1 and 2 group 2 patients. At final followup 5 group 1 and 2 group 2 patients had renal function deterioration. Two other group 1 patients and group 2 had progression to end stage renal failure. A higher ureteral reimplantation rate was noted in group 1 (63%) than group 2 (6%). CONCLUSIONS: This retrospective study revealed that long-term bladder function of patients with posterior urethral valves treated with temporary supravesical diversion is affected more adversely than those treated with valve ablation alone.

Detrusor after-contractions in children with normal urinary tracts.

OBJECTIVE: To assess the clinical significance of after-contractions (A-Cs) in children with normal urinary tracts. PATIENTS AND METHODS: Urodynamic records obtained in 315 children with urinary infection or enuresis were reviewed retrospectively; 184 were selected for analysis of A-Cs. All patients had normal urinary tracts and none showed signs of an overt neuropathy. The urodynamic method comprised standard measurements of pressures and flowmetry (42 had video-urodynamic studies). RESULTS: After-contractions occurred in 151 of the 184 patients; the incidence tended to decrease with age. The mean amplitude of the A-Cs was 77.9 cmH2O; in 36% of the records it was higher than the voiding contraction. Residual urine was found in 12 of 151 records with A-Cs, but in only one patient was such residual urine confirmed in control voids. The patterns were assessed in 131 patients: in 36% they resembled stop-test responses, in 31% they were preceded by brief peaks of pressure or had jagged limbs, and in 33% they were grossly irregular. In 137 records the content of the bladder was estimated at the start of A-Cs; in 51% the bladder was empty or had evacuated >95% of its content, in 39% 95-80% and in 10% <80%. In only 7% of the patients had the A-Cs started after the voiding contraction had completely subsided. There was no difference in the incidence of A-Cs in girls with enuresis (84%) and girls with a history of urinary infections (85%). Detrusor instability was detected in 81% of the children with A-Cs and in 70% of those without; there was no correlation between the amplitudes of uninhibited detrusor contractions and of A-Cs. Characteristic images of external sphincter activity were found in only three of 14 video-urodynamic recordings with A-Cs. CONCLUSION: After-contractions are common in children with normal urinary tracts but they tend to disappear with age. In clinical urodynamics they are of limited practical use because their appearance is unpredictable and there are artefacts related to recording the final phase of micturition. The relationship with detrusor instability may be explained as a coincidence of two common but unrelated findings, and A-Cs are unrelated to urinary infection. External sphincter activity is not the only cause of A-Cs and when it occurs it does not alter the course of voiding, as it does in neuropathic dysfunctions. As their clinical significance is uncertain, treatment of A-Cs is not advocated.

10-Year experience with artificial urinary sphincter in children and adolescents.

PURPOSE: We evaluate specific indications, patient selection and complications of the AMS800 artificial sphincter in children and adolescents with sphincteric incontinence. MATERIALS AND METHODS: Between 1987 and 1997, 39 males and 10 females with a mean age of 14 years (range 7 to 20) with sphincter deficiency underwent artificial urinary sphincter placement. The underlying etiology of incontinence was myelodysplasia in 38 patients, exstrophy-epispadias complex in 7 and urethral trauma in 4. All patients underwent preoperatively conventional urodynamic investigations. Augmentation cystoplasty was done in 9 patients before sphincter implantation and both procedures were performed simultaneously in 2 cases. The cuff was adjusted around the bladder neck in 37 patients and around the bulbar urethra in 12. Followup ranged from 2 to 11 years (mean 7.5). RESULTS: There were 54 sphincter implants in 49 patients. Of the 49 patients 33 (67%) achieved continence, 9 had substantial improvement and 7 remained unchanged after surgery. Erosion occurred in 10 patients due to sphincter infection in 2, mechanical failure in 6 and postoperative changes in bladder behavior in 2. Of these 10 patients with erosion 5 are incontinent and awaiting sphincter replacement, 2 required bladder neck closure and appendicovesicostomy, and 3 are dry without prosthetic replacement. Mean time to erosion was 24.9 months (range 1 month to 9 years), and 3 erosions occurred within 3 months of sphincter placement. Of the 6 patients with mechanical problems 5 regained continence after successful replacement of the sphincter. Only 2 of the 49 cases had postoperative detrusor overactivity requiring augmentation after surgery. Of the 29 patients who performed clean intermittent catheterization preoperatively 3 no longer needed it after implantation of the prosthesis. Finally, 25 (86%) of the 29 patients with a cuff placed around the bladder neck and with no previous surgical repairs at this site achieved continence after implantation whereas only 3 (37.5%) of 8 patients who had undergone prior bladder neck surgical procedures became continent. CONCLUSIONS: This study supports previous reports that the artificial urinary sphincter is effective therapy for sphincteric incontinence. Additionally, in our study previous surgical procedures on the lower urinary tract before sphincter placement increased significantly the rate of postoperative complications.

Bladder functional outcome after delayed vesicostomy closure and antireflux surgery in young infants with 'primary' vesico-ureteric reflux.

OBJECTIVE: To evaluate bladder function by conventional urodynamic investigations in young infants with primary vesico-ureteric reflux (VUR) who had undergone an initial temporary cutaneous vesicostomy followed by later antireflux surgery and vesicostomy closure. PATIENTS AND METHODS: From 1983 to 1990, nine boys (10-360 days old) with primary VUR were treated with an initial vesicostomy, followed by delayed closure of the vesicostomy and the simultaneous surgical correction of reflux. Severe VUR was detected bilaterally in seven and unilaterally in two infants at the time of the initial diagnosis. The mean (SD, range) age at vesicostomy was 12.4 (8, 3-23) months and the duration of bladder defunctionalization 38.7 (25.5, 18-90) months. All patients were assessed urodynamically after closing the vesicostomy, using rapid-fill cystometry with normal saline solution at room temperature. The mean (range) age at the time of urodynamic testing was 7.3 (5-15) years; the mean (SD, range) follow-up was 10.1 (4.1, 5-17) years. RESULTS: Six boys with bilateral VUR underwent successful ureteroneocystostomy; nephroureterectomy was required in one patient. In two patients the VUR resolved with time. After re-functionalization, the mean (SD, range) maximum cystometric capacity, expressed as a percentage of the mean bladder capacity for age, was 1.4 (0.5, 0.6-2.2)%. In three patients the bladder capacity was higher (> or = 40%) than expected for age, while one had diminished (< 70%) bladder capacity. The mean (range) end-filling detrusor pressure was 14.5 (5-42) cmH2O and the mean (SD, range) compliance 24 (13.9, 4-44) mL/cmH2O. Two patients had a compliance of < 10 mL/cmH2O, one of whom had associated unstable detrusor contractions of 90 cmH2O. The mean (SD, range) detrusor voiding pressure at peak flow was 47.3 (16.8, 5-76) cmH2O. One patient had a residual urine volume of 8% of bladder capacity. At the follow-up, only one patient (aged 5 years) with detrusor instability had urinary incontinence. CONCLUSION: This study shows that the bladder of young infants with primary VUR treated with temporary vesicostomy regained normal function after re-functionalization of the lower urinary tract.

Urodynamic findings in boys with posterior urethral valves after treatment with primary valve ablation or vesicostomy and delayed ablation.

PURPOSE: Primary valve ablation and temporary vesicostomy with delayed valve ablation are alternative initial management procedures in neonates and infants with posterior urethral valves. To investigate whether initial vesicostomy followed by delayed valve ablation and simultaneous vesicostomy closure may lead to more alterations in bladder function than primary valve ablation only we retrospectively compared postoperative urodynamic findings in 2 small groups of patients. MATERIALS AND METHODS: From 1980 to 1990, 15 male infants 19 days to 34 months old with posterior urethral valves were treated with 1 of 2 initial surgical approaches, including valve ablation only in 8 (group 1), and primary vesicostomy and delayed valve ablation associated with concomitant vesicostomy closure in 7 (group 2). Mean age at valve ablation and vesicostomy in groups 1 and 2 was 10.8 +/- 11.2 months (range 1 to 35) and 55.4 +/- 43.3 days (range 19 to 151), respectively. Average duration of vesicostomy diversion was 33.6 +/- 18.8 months (range 14 to 70). All patients underwent conventional urodynamics postoperatively using normal saline at room temperature. In groups 1 and 2 mean age at followup was 11.5 +/- 6.6 (range 5 to 16.2) and 9. 4 +/- 3.1 (range 4.10 to 14) years, respectively. Controls comprised 46 age matched males who underwent urodynamics using similar methodology. RESULTS: Postoperative urodynamic assessment of maximum cystometric bladder capacity and the incidence of detrusor instability in each treatment group were not statistically different. In group 1 bladder capacity was significantly higher than that in controls (p <0.0001). In group 2 mean end filling detrusor pressure was increased compared with that in group 1 (29 cm. water, range 15 to 60 versus 8, range 4 to 21). Compliance was significantly lower in group 2 than in group 1 (p <0.0005). Analysis of detrusor voiding pressure at maximum flow was not significantly different in the 2 groups. We noted detrusor under activity in 1 group 1 and 2 group 2 cases. In these patients post-void residual urine volume was 8% to 66% of cystometric bladder capacity. However, only 1 of these 3 patients who required augmentation cystoplasty needed intermittent catheterization. Urodynamic patterns of outflow obstruction developed in 1 patient in each group, including urethral stricture and bladder neck obstruction. At followup we observed no difference in renal function impairment in the 2 groups. CONCLUSIONS: Our retrospective study of rapid filling cystometry suggests that primary valve ablation for posterior urethral valves is associated with a better bladder function outcome than that in patients treated with vesicostomy and delayed valve ablation. Therefore, although cutaneous vesicostomy may be performed as initial management of posterior urethral valves, primary valve ablation is the most effective surgical option in these cases.

Esfinter urinario artificial en Pediatria: análisis de los resultados y complicaciones en 10 años de experiencia / Artificial urinary sphincter in Pediatrics: analysis of the results and complications in 10 years of experience

El Esfinter Urinario Artificial (EUA) AMS 800 es una opción terapéutica eficaz para el tratamiento de la incontinencia de orina esfintérica (IOE). Este estudio analiza las indicaciones del implante protésico,la selección de los pacientes apropiados para su uso y las coplicaciones inmediatas y alejadas inherentes a esta técnica. Material y Métodos: Entre 1987 y 1997 se trataron 49 pacientes(39 varones y 10 niñas)con un EUA AMS 800. La edad media de los pacientes al realizar la cirugía fue de 14 años (rango 7-20). En esta revisión la IOE obedeció a una disfunción vesical de etiología neurogénica por mielodisplasia en 38 pacientes, al complejo extrofiaepispadias en 7 y a traumatismos urogenitales en 4. El seguimiento postoperatorio varió entre 2 y 10 años (x 6,5). Resultados: Treinta y tres (67 por ciento) de los 49 pacientes están continentes luego del implante del EUA; 9 (18 por ciento) mejoraron su incontinencia pero todavía requieren el uso de uno o más apósitos protectóres y 7 (14 por ciento) permanecen incontinentes después de la cirugía. Diez (20 por ciento) pacientes evolucionaron con erosiones, siendo necesaria la estracción de la prótesis. Cinco (12 por ciento) pacientes con fallas mecánicas del EUA requirieron la reposición de una nueva prótesis mientras que un niño, con fallas en la bomba, logró el arreglo del desperfecto sin necesidad de sustituir el EUA. A 9 pacientes se les practicó una enterocistoplastia antes de la colocación del EUA y a 2 se les realizó la cistoplastia en forma concomitante con el implante protésico. Conclusiones: El 67 por ciento de éxito a largo plazo obtenido con el EUA AMS 800 en nuestra serie de 49 pacientes avalan la utilidad de este método para el tratamiento de la IOE