Ureteric Clipping for the Treatment of Urinary Incontinence in Girls With Ectopic Ureters: Predicting Who Is Going to Dilate and Does It Matter?

OBJECTIVE: To assess the effectiveness and midterm follow-up of laparoscopic upper pole ectopic ureteral clipping to treat urinary incontinence in girls with duplex kidneys and non/poorly functioning upper pole moieties. To see if preoperative characteristics increased the likelihood of significant postoperative dilatation and whether this dilation has clinical significance. METHODS: A database review identified children who had undergone ureteric clipping at our institution. Patient details assessed included: age at presentation, age at procedure, significant past medical history, preoperative investigations, operative time, length of stay, postoperative symptoms, postoperative renal tract ultrasound findings and the need for subsequent intervention. RESULTS: Six girls underwent clipping between March 2018 and May 2021. The mean age at presentation and surgery were 77months (39-186) and 86months (44-193), respectively. The mean operative time was 94 minutes (range 66-128 minutes). The median length of stay was 1 day (range 0-3days). All the girls were dry immediately after the procedure. During a mean follow-up of 51months (29-66) all children have remained symptom-free and required no further intervention. Two children have developed significant (>30 mm) but stable ureteric dilatation after clipping but have remained asymptomatic and therefore are continuing on conservative follow-up. Both these children had dilated ureters (>10 mm) preoperatively. CONCLUSION: Ureteric clipping is quick, safe, and effective option in dealing with incontinence due to ectopic upper pole ureters in girls. Children with preoperative ureteric dilation seem to be at increased risk of postoperative dilation. However, as they remain asymptomatic, the clinical significance of this dilatation is unclear.

Too Many Biopsies Performed to Rule Out Hirschsprung's Disease: But It is Worth Doing Them.

INTRODUCTION: The U.K. National Institute for Health and Clinical Excellence (NICE) specify the following indications for performing rectal biopsy to rule out Hirschsprung's disease (HSD): (1) passage of meconium > 48 hours; (2) constipation since first few weeks of life; (3) chronic abdominal distension with vomiting; (4) family history of HSD; and (5) faltering growth in addition to any other indication. The aim of this study was to assess the compliance of a tertiary referral center with the current U.K. NICE guidelines for performing rectal biopsies to rule out HSD. Secondary aims included assessing alternative indications and complication rates. MATERIALS AND METHODS: Retrospective analysis of patients undergoing open or suction rectal biopsies to investigate HSD, from 2009 to 2014. RESULTS: A total of 188 patients underwent 214 biopsies (suction: n = 154, open: n = 60). Note that 128 patients (68.1%) had biopsies indicated by NICE. A total of 84.4% of indicated biopsies were ganglionic versus 91.7% of unindicated biopsies (p = 0.17). Twenty-five patients were diagnosed with HSD (mean age: 13.2 weeks, range: 3 days-3.2 years). Only 80% of HSD patients had NICE-indicated biopsies. Presentations for patients with biopsies not indicated by NICE included constipation, distension, and vomiting that did not strictly meet the guidelines. The majority of biopsies were uncomplicated (suction 82.5% vs. open 95.0%)-inadequate/indeterminate histology was the most common complication (16.2% suction vs. 5% open). CONCLUSION: A significant number of unindicated biopsies were performed, the majority of which were ganglionic. Rectal biopsies are generally safe and strict adherence to the NICE guidelines could have led to missed HSD diagnoses with potential significant morbidity and mortality.

Does activation of the anti proton, rather than concertedness, determine the stereochemistry of base-catalyzed 1,2-elimination reactions? Anti stereospecificity in E1cB eliminations of ß-3-trifluoromethylphenoxy esters, thioesters, and ketones.

As part of a comprehensive investigation on the stereochemical aspects of base-catalyzed 1,2-elimination reactions, we have studied a set of acyclic carbonyl substrates that react by an irreversible E1cB mechanism with largely anti stereospecificity. (2)H NMR data show that these reactions using KOH in EtOH/H(2)O under non-ion-pairing conditions produce a minimum of 85-89% anti elimination on stereospecifically labeled tert-butyl (2R*,3R*)- and (2R*,3S*)-3-(3-trifluoromethylphenoxy)-2,3-(2)H(2)-butanoate, S-tert-butyl (2R*,3R*)- and (2R*,3S*)-3-(3-trifluoromethylphenoxy)-2,3-(2)H(2)-butanethioate, and the related ketones, (4R*,5R*)- and (4R*,5S*)-5-(3-trifluoromethylphenoxy)-4,5-(2)H(2)-3-hexanone. With both diastereomers of each substrate available, the KIEs can be calculated and the innate stereoselectivities determined. The elimination reactions of the ß-3-trifluoromethylphenoxy substrates occur by E1cB mechanisms with diffusionally equilibrated enolate-anion intermediates. Thus, it is clear that anti elimination does not depend solely upon concerted E2 mechanisms. Negative hyperconjugation provides a satisfactory explanation for the anti stereospecificity exhibited by our carbonyl substrates, where the leaving group activates the anti proton, leading to the enolate intermediate. The activation of the anti proton by negative hyperconjugation may also play a role in the concerted pathways of E2 mechanisms. We have also measured the rates of the hydroxide-catalyzed elimination reactions of butanoate, thiobutanoate, and ketone substrates in EtOH/H(2)O, with ß-tosyloxy, acetoxy, and 3-trifluoromethylphenoxy nucleofuges.