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1.
J Pediatr Urol ; 2020 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-32340883

RESUMO

INTRODUCTION: After unsuccessful repair of bladder exstrophy, when to repeat surgical intervention is unclear. One must balance time required for tissue healing with the damaging effects of an exposed urothelium to the environment. OBJECTIVE: The authors aim to study whether a relationship exists between bladder growth/capacity and time till eventual successful closure. STUDY DESIGN: An institutional database of exstrophy-epispadias complex patients was queried for failed exstrophy closure with successful repeat reconstruction, at least three consecutive bladder capacity measurements, and measurements obtained at least three months following successful closure. Patients closed successfully in the neonatal period were used as a comparative group. Linear mixed effects models were used to study the effect of time and age on bladder capacity. RESULTS: Forty-seven patients requiring reclosure and 117 who had successful neonatal closures were included. Two models were created. The first linear mixed effects model found that for a given age, the bladder capacity declined approximately 9.6 mL per year (p = 0.016). The second model found that when time to successful closure was grouped by quartiles, compared to neonates, those in the fourth quartile had significantly decreased bladder capacity of 28.8 cc (p = 0.042). An interaction model comparing neonates and those requiring reclosure did not demonstrate a significant change in bladder growth rate (p = 0.098). A model stratified by quartiles similarly did not find any significant impact to bladder growth rate. DISCUSSION: From the general linear mixed effects models, the authors conclude when compared to neonates, (1) there was an approximate 9.6 cc loss of total bladder capacity per year taken until successful closure, and that (2) those who were delayed the longest had the most significant difference in bladder capacity. This study required stricter inclusion criteria compared to previous publications, and therefore the conclusions that can be drawn regarding bladder growth rates may be more reliable. Future studies will examine the effects of delayed closure on the bladder at the cellular level. CONCLUSIONS: There is a demonstrable significant impact on overall bladder capacity with increasing delay to successful reclosure. One should be cautious when prolonging reconstruction of the bladder as these data demonstrate a time dependent decline in overall capacity.

2.
J Pediatr Urol ; 2020 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-32299766

RESUMO

INTRODUCTION: While evaluation and management options for classic bladder exstrophy (CBE) patients are numerous and varied, little is known regarding the relative utilization of these different methods throughout the world. A large group of exstrophy surgeons practicing globally was surveyed, seeking to document their methods of care. METHODS: A list of international exstrophy surgeons' email addresses was compiled using professional contacts and referral networking. An online survey was sent to each email address. Surgeons who had not performed a CBE closure within the previous 5 years were excluded. Survey questions queried the respondents' surgical practice type, years since training, and their preferred methods of preoperative evaluation, operative management, and postoperative management. Survey invitations were sent out starting in December 2014 and responses were collected for approximately 6 months. RESULTS: A total of 1152 valid email addresses were invited, resulting in 293 respondents (25%) from 39 countries and every American Urological Association (AUA) section. Seventy-six were excluded, leaving 217 respondents (Table). Respondents reported a median of 17 years since finishing their surgical training (IQR 8-25 years). Practice types included pediatric urology (n = 209), general urology (n = 9), pediatric surgery (n = 59), and other practice makeup (n = 3). On subgroup analyses, there were no significant regional practice differences, with the exception of complete primary repair of exstrophy (CPRE) and oral opioid prescribing being significantly higher in North America compared to other regions. DISCUSSION: Findings indicate that there may be diversity in CBE practice patterns globally. While most responding surgeons from regions outside of North America indicated modern staged repair of exstrophy (MSRE) as their preferred closure technique, a relatively equal distribution of respondents from North America selected CPRE and MSRE. A majority of North American surgeons chose performing osteotomies for both newborn and delayed closures, while an appreciable number of respondents from other regions selected never using osteotomies in their closures. Limitations to this study include a low survey response rate, particularly from surgeons outside of the United States, which may have significantly impacted the ability to draw meaningful global comparisons. CONCLUSIONS: Global variation among practices of surgeons performing CBE closures may exist. The wide range of methods demonstrated by this survey suggests the need for more conclusive comparative studies to elucidate whether an optimal standard exists. Local social factors, access to surgical expertise and transportation to referral centers, and finances play a role in what constitutes the best operative approach.

3.
Eur Urol Focus ; 6(2): 383-389, 2020 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-30292419

RESUMO

BACKGROUND: A failed closure of classic bladder exstrophy (CBE) has a negative long-term impact on the patient and the health care system. OBJECTIVE: To investigate the outcomes of CBE patients with failed primary bladder closure. DESIGN, SETTING, AND PARTICIPANTS: A database of 1317 exstrophy-epispadias complex patients was retrospectively reviewed for CBE patients with failed primary bladder closure from 1965 to 2017 with subsequent repeat closure. INTERVENTION: Repeat bladder exstrophy closure and subsequent continence procedure. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Failed exstrophy closures are defined as occurrence of bladder prolapse, dehiscence, vesicocutaneous fistula, outlet obstruction, or combination of these factors. Successful repeat closures are defined as closures that require no further operative intervention as a consequence of these factors. Kaplan-Meier to determine time to successful repeat closure and receiver operator characteristic curve to determine the optimal time for secondary closure were determined. RESULTS AND LIMITATIONS: In total, 170 CBE patients had at least one repeat closure following a failed primary closure (115 male/55 female). With continued closure attempts, 166/170 (97.6%) patients were successfully closed. The median time to successful closure from birth was 12.9 mo (95% confidence interval: 11.7-15.7). Furthermore, 52/153 (34%) patients had more than one osteotomy. Of 215 total osteotomies, 50 (29.4%) were performed during the 170 failed primary closures, 128 (75.3%) during the 170second closures, and 27 (64.3%) during the 42 third closures. Of 96 patients with available continence data, 74 (77.1%) achieved urinary continence. CONCLUSIONS: A successful repeat closure is possible, especially when used in conjunction with a pelvic osteotomy. Continent urinary diversion yielded the highest continence rate in this cohort. PATIENT SUMMARY: We looked at outcomes of classic bladder exstrophy closure in a large population. Successful repeat closure is possible in the majority of cases when used with pelvic osteotomy. A majority of patients achieved urinary continence using a continent diversion.

4.
Urology ; 136: 231-237, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31730942

RESUMO

OBJECTIVE: To describe the use of additional tissue recruited for coverage after penile lengthening in male exstrophy-epispadias complex patients using either local skin from tissue expansion (TE) or extragenital skin with a skin graft (SG) and report their respective outcomes. METHODS: An institutionally approved database of exstrophy-epispadias complex patients was retrospectively reviewed for male patients who received penile reconstruction. This included a penile lengthening procedure and the subsequent use of TE and/or a full thickness skin graft to provide cutaneous coverage of gained corporal length. RESULTS: A total of 50 patients (mean age 18.1 years) underwent penile reconstruction. TE was used in 27 patients, SG in 19, and 4 received a combination of TE and SG. The mean number of previous penile operations was 2.7 for patients that received TE and 3.1 for SG. A successful outcome from primary reconstruction was achieved in 35 patients (70%) and overall successful reconstruction was achieved by 48 patients (96%). CONCLUSION: TE and SG are useful techniques in providing soft tissue coverage following penile lengthening. TE is the preferred technique for primary reconstruction in a lengthening procedure. When genital skin is not expandable or coverage from TE is insufficient after lengthening, extragenital skin (SG) is recruited.


Assuntos
Extrofia Vesical/cirurgia , Epispadia/cirurgia , Pênis/cirurgia , Transplante de Pele , Expansão de Tecido , Adolescente , Adulto , Criança , Humanos , Masculino , Procedimentos Cirúrgicos Reconstrutivos/métodos , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos Masculinos/métodos , Adulto Jovem
5.
J Urol ; 203(1): 200-205, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31437120

RESUMO

PURPOSE: We investigated surgical approaches to urinary incontinence and long-term continence outcomes after successful bladder reconstruction in a heterogeneous patient population with classic bladder exstrophy. We hypothesized that while most patients will achieve urinary continence after surgery, only a select group will void volitionally per urethra. MATERIALS AND METHODS: An institutional database of 1,323 patients with exstrophy-epispadias complex was reviewed for patients with classic bladder exstrophy who underwent successful bladder closure and a subsequent continence procedure between 1975 and 2017. Procedures included bladder neck reconstruction, bladder neck reconstruction with augmentation cystoplasty or continent catheterizable stoma, and bladder neck closure with continent catheterizable stoma. Cloacal exstrophy, epispadias and variant exstrophy cases were excluded from analysis. Continence at last followup was defined as a dry interval of 3 or more hours without nighttime leakage. Those patients with more than 3 months of followup were assessed. RESULTS: Overall 432 patients underwent successful bladder closure (primary 71.5%, repeat 28.5%) and a urinary continence procedure. At last followup 162 (37%) underwent bladder neck reconstruction, 76 (18%) underwent bladder neck reconstruction with augmentation cystoplasty or continent catheterizable stoma, 173 (40%) underwent bladder neck closure with continent catheterizable stoma and 18 underwent other procedures. Median followup from the first continence procedure was 7.2 years (IQR 2.3-13.7). Continence was assessed in 350 patients. After isolated bladder neck reconstruction 91 of 142 patients were continent (64%, 95% CI 56-72). After bladder neck closure with continent catheterizable stoma 124 of 133 patients evaluated were continent (93%, 95% CI 87-97). CONCLUSIONS: Most patients with classic bladder exstrophy require multiple reconstructive procedures to achieve continence. Only about 25% of patients are expected to void normally per urethra without reliance on catheterization or urinary diversion.


Assuntos
Extrofia Vesical/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Incontinência Urinária/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Masculino
6.
Urology ; 137: 146-151, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31887351

RESUMO

OBJECTIVE: To explore a series of classic bladder exstrophy (CBE) cases referred to the authors' institution where primary closure with penile disassembly epispadias repair was complicated by penile injury. The penile disassembly technique is frequently combined with bladder closure in patients with CBE undergoing the complete primary repair of exstrophy (CPRE). Penile disassembly has been posited as a risk for penile injury by ischemic mechanisms. METHODS: A prospectively-maintained institutional database of 1337 exstrophy-epispadias complex patients was reviewed for CPRE cases referred to the authors' institution, and those with injury to the penis were identified. The location, extent of injury, and subsequent management is reported. RESULTS: One hundred and thirteen male CBE patients were referred after prior CPRE. Twenty-six (20%) were identified with penile loss and reviewed. Eighty-one percent were closed in the neonatal period, and 54% had a pelvic osteotomy. Median follow-up time was 9.9 years (range 0.6-21.3). Of 26 patients with penile loss, 77% had unilateral loss and in 23% had bilateral loss involving the glans and/or one or both corpora cavernosa. Three patients were successfully managed with myocutaneous neophalloplasty. CONCLUSION: Complete penile disassembly during bladder exstrophy closure may lead to penile injury. This major complication questions the continued application of complete penile disassembly in the reconstruction of bladder exstrophy.


Assuntos
Extrofia Vesical/cirurgia , Epispadia/cirurgia , Complicações Intraoperatórias , Doenças do Pênis , Pênis , Procedimentos Cirúrgicos Urológicos , Atrofia , Criança , Humanos , Recém-Nascido , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/cirurgia , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Doenças do Pênis/diagnóstico , Doenças do Pênis/etiologia , Doenças do Pênis/cirurgia , Pênis/irrigação sanguínea , Pênis/lesões , Pênis/patologia , Pênis/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Reoperação/métodos , Fatores de Risco , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos Cirúrgicos Urológicos/métodos , Adulto Jovem
7.
Int Urol Nephrol ; 2019 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-31807974

RESUMO

PURPOSE: Currently, there is a dearth of data concerning the impact of hypogonadism on prostate cancer detection by imaging. In this study, we evaluated the performance of multiparametric MRI (mpMRI) and mpMRI-TRUS fusion biopsy in hypogonadal patients. MATERIALS AND METHODS: Clinical and pathologic data from a prospectively maintained, single-institution database of patients who underwent 3T mpMRI and fusion biopsy between 2007 and 2016 were analyzed. Hypogonadism was defined by an institutional cutoff of serum testosterone ≤ 180 ng/dL; T2, DWI, and DCE scores were calculated from mpMRI. Cancer detection rates were compared by Chi-square tests. Multivariate logistic regression was undertaken to evaluate the impact of hypogonadism on clinically significant cancer detection by systematic and fusion biopsy. RESULTS: We included 522 patients in our study who had total testosterone levels measured within 90 days of mpMRI. Of these, 49 (9.4%) were hypogonadal. Median total testosterone was 148 ng/dL (IQR 41) in the hypogonadal group, and 304 ng/dL (IQR 132) in the normogonadal group (p < 0.001). Imaging results were comparable between the hypo and normogonadal groups. In the hypogonadal group, systematic biopsy detected clinically significant cancer in 28.6% of patients compared to 40.8% with fusion biopsy. In the normogonadal cohort, systematic and fusion biopsy detected 37.3% and 43.2% CS cancer, respectively. In the hypogonadal cohort, fusion biopsy detected 12.2% more CS cancers compared to systematic biopsy, while it detected only 5.9% more in the normogonadal cohort. On multivariate analysis, hypogonadism was found to be an independent predictor of decreased CS cancer detection on systematic (p = 0.048), but not on fusion biopsy (p = 0.170). CONCLUSIONS: Hypogonadism is an independent predictor of lower CS cancer detection on systematic biopsy. However, it fails to significantly impact CS detection on fusion biopsy with comparable cancer detection rates in both groups. Patients with hypogonadism may benefit more from fusion biopsy than normogonadal patients.

8.
Curr Urol Rep ; 20(9): 48, 2019 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-31286274

RESUMO

PURPOSE OF REVIEW: The exstrophy-epispadias complex (EEC) represents a group of congenitally acquired malformations involving the musculoskeletal, gastrointestinal, and genitourinary systems. Classic bladder exstrophy (CBE) is the most common and best studied entity within the EEC. In this review, imaging features of CBE anatomy will be presented with surgical correlation. RECENT FINDINGS: Magnetic resonance imaging (MRI) has emerged as a useful modality for pre- and postnatal assessment of the abdominal wall, pelvic floor, and gastrointestinal and genitourinary systems of children with CBE. The authors' experience supports use of preoperative MRI, in conjunction with navigational software, as a method for identifying complex CBE anatomy. Imaging facilitates surgical approach and improves visualization of complex anatomy, potentially helping to avoid complications. Continued investigation of imaging guidance in CBE repair is needed as surgical techniques improve.


Assuntos
Extrofia Vesical/diagnóstico por imagem , Extrofia Vesical/cirurgia , Epispadia/diagnóstico por imagem , Epispadia/cirurgia , Feminino , Humanos , Lactente , Recém-Nascido , Imagem por Ressonância Magnética , Masculino , Procedimentos Cirúrgicos Urológicos
9.
Urology ; 131: 211-216, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31176739

RESUMO

OBJECTIVE: To compare the surgical subspecialties performing bladder exstrophy closures and characterize their practice patterns using both a national and institutional database. METHODS: The National Surgical Quality Improvement Program Pediatric (NSQIPP) database was reviewed for all bladder exstrophy closures performed from 2012 to 2017. A single institutional exstrophy-epispadias complex database of 1337 patients was reviewed for patients with a bladder closure at a referring institution from 1975 to 2018. Patients with cloacal exstrophy were excluded. The subspecialties of the surgeons performing the closures were identified. Practice patterns such as the use of a pelvic osteotomy and postoperative immobilization, and perioperative outcomes were compared for each subspecialty group. RESULTS: A total of 84 bladder exstrophy patients from NSQIPP and 263 from the author's institutional database met the inclusion criteria. From NSQIPP, 88% of closures were performed by pediatric urologists while 12% were done by other subspecialists. From the institutional database, 75% of referred bladder exstrophy closures were done by a pediatric urologist, and 25% by other services. Gender, race, operation time, length of stay, and postoperative complications were not significantly different between the groups. In one database, pediatric surgeons performed closures earlier, and in another database, pediatric urologists had greater utilization of osteotomy with different immobilization techniques. Pediatric urologists had a higher success rate. CONCLUSION: Pediatric urologists performed the most bladder exstrophy closures in both databases; they operated on more delayed closures with a greater use of adjunctive procedures and a higher success rate. Differences in surgical training may contribute to the differences in practice patterns.


Assuntos
Extrofia Vesical/cirurgia , Padrões de Prática Médica/normas , Especialidades Cirúrgicas , Procedimentos Cirúrgicos Urológicos/normas , Urologia/normas , Bases de Dados Factuais , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Melhoria de Qualidade , Estudos Retrospectivos , Estados Unidos
10.
Int Urol Nephrol ; 51(8): 1349-1355, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31098818

RESUMO

PURPOSE: Index tumor volume (ITV) measured on radical prostatectomy (RP) specimens has been shown to be associated with adverse pathologic and oncologic outcomes. We evaluate the value of ITV calculated from prostate multiparametric MRI (mpMRI) in predicting adverse clinical and pathologic outcomes. MATERIALS AND METHODS: Data from a prospectively maintained, single-institution database were analyzed for patients who underwent mpMRI prior to RP (2007-2016). Index tumor was defined as a T2-visible lesion with the longest diameter. Adverse pathologic outcomes were extraprostatic extension (EPE), lymph node invasion (LNI), seminal vesicle invasion (SVI), and positive margins (PM). Logistic and Cox proportional hazard regression were used to assess associations with adverse pathology and biochemical recurrence (BCR), respectively. RESULTS: Of the 455 patients included, EPE, LNI, SVI and PM were present in 23.5%, 6.2%, 5.5% and 15.7% patients, respectively. Patients with adverse pathologic outcomes had larger median ITV. ITV was found to be an independent predictor of EPE (OR 1.22, p = 0.010), LNI (OR 1.39, p = 0.001), and SVI (OR 1.28, p = 0.009), but not PM (OR 1.03, p = 0.522). Combination of ITV and PSA was found to have predictive ability comparable to that of modified Partin tables (EPE:ITV + PSAAUC = 0.71 vs. PartinAUC = 0.71; LNI:ITV + PSAAUC = 0.92 vs. PartinAUC = 0.90, SVI:ITV + PSAAUC = 0.78 vs. PartinAUC = 0.82). 5 year BCR-free survival (median follow-up 24.9 months) was higher for patients with ITV < 2 cc (84.1% vs. 58.5%, p = 0.001). However, ITV was not found to be an independent predictor of BCR (HR 1.69, p = 0.130). CONCLUSIONS: We demonstrate that ITV measured on mpMRI is a predictor of adverse pathologic and clinical outcomes and can aid in preoperative risk assessment.


Assuntos
Imagem por Ressonância Magnética , Prostatectomia , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/patologia , Carga Tumoral , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias da Próstata/cirurgia , Estudos Retrospectivos , Resultado do Tratamento
11.
J Pediatr Surg ; 54(11): 2408-2412, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31079865

RESUMO

PURPOSE: Due to the large abdominal defect from the omphalocele and extreme pubic diastasis in cloacal exstrophy (CE), bioprosthetic material may be used to bridge this gap during abdominal closure in CE. This study examined presurgical factors associated with the use of bioprosthetic materials in CE closure and complications in these patients. METHODS: An institutional database of exstrophy-epispadias complex patients was reviewed for CE. Inclusion criteria included CE and primary closure performed at the host institution from 1998 to 2018. Data collection included demographics, presurgical factors, use of bioprosthetic material, complications, and outcomes. RESULTS: All 32 patients had a staged closure and pelvic osteotomy prior to bladder closure. Ten of the 32 patients incorporated a bioprosthetic material during abdominal wall closure. There is at least 3 months follow up for all patients, all had successful bladder closure without any postoperative hernias. Those who underwent closure without bioprosthetic material were younger at the time of closure (565 vs 693 days, p = 0.043). The differences in complication rates and mean pubic diastasis was not statistically significant, p = 0.079 and p = 0.457 respectively. CONCLUSIONS: The use of bioprosthetic material is associated with older age at abdominal wall and bladder closure. The use of bioprosthetic material is a useful adjunct for secure abdominal wall closure in the reconstruction of CE. TYPE OF STUDY: Prognostic. LEVEL OF EVIDENCE: III.


Assuntos
Abdominoplastia/métodos , Anus Imperfurado/cirurgia , Bioprótese , Extrofia Vesical/cirurgia , Hérnia Umbilical/cirurgia , Escoliose/cirurgia , Anormalidades Urogenitais/cirurgia , Parede Abdominal/cirurgia , Pré-Escolar , Epispadia/cirurgia , Feminino , Humanos , Lactente , Masculino , Osteotomia , Estudos Retrospectivos
12.
J Pediatr Surg ; 54(9): 1761-1765, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31003729

RESUMO

INTRODUCTION: A successful abdominal wall and bladder closure is critical in the management of cloacal exstrophy (CE). This study examines closure outcomes and practices over the last 4 decades at the authors' institution. Beginning in 1995, the authors' institution standardized CE closure and management with the Dual-Staged Pathway (DSP). The DSP consists of a staged bladder closure, a staged or concurrent osteotomy, and postoperative immobilization with external fixation. The authors hypothesize that the DSP has provided better outcomes in CE closures. METHODS: A prospective database of 1332 Exstrophy-Epispadias Complex (EEC) patients was reviewed for CE patients closed between 1975 and 2015. The DSP consists of a staged osteotomy and a staged bladder closure in CE patients with a diastasis greater than 4 cm. To evaluate the DSP, outcomes of closure at the authors' institution were compared between two equal, twenty-year periods before and after its implementation. Data on timing of closure, postoperative management, surgical complications, and outcomes were collected. RESULTS: There are 142 CE patients in the database. In this study, 49 CE patients with 50 closures met inclusion criteria. The overall success rate of closures from 1975 to 1994 was 88% (14 of 16), while the success rate of the DSP was 100% (n = 34), p = 0.098. Twenty-two (65%) primary and 12 (35%) secondary closures were performed using the DSP. Overall complication rates of the DSP remained similar to previous closures, (29% vs 19%, p = 0.508). Since incorporation of the DSP, patients referred for closure have generally had a larger preclosure diastasis (7.2 cm vs 5.1 cm, p = 0.011). CONCLUSION: The standardized DSP closure has proven successful in 34 primary and reoperative cloacal closures in the past 20 years. With this approach, the authors feel that the DSP offers greater patient safety and better outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative study.


Assuntos
Extrofia Vesical/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Humanos , Estudos Retrospectivos
13.
J Urol ; 202(2): 406-412, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30840542

RESUMO

PURPOSE: We determined the safety and efficacy of intraoperative magnetic resonance imaging guided surgical reconstruction of bladder exstrophy for the identification of the urogenital diaphragm fibers and the thickened muscular attachments between the posterior urethra, bladder plate and pubic rami. MATERIALS AND METHODS: Institutional review board and U.S. Food and Drug Administration approval was obtained for the use of Brainlab (Munich, Germany) intraoperative magnetic resonance imaging guided navigation of the pelvic floor anatomy during closure of classic bladder exstrophy and cloacal exstrophy at our institution. Preoperative pelvic 3-dimensional magnetic resonance imaging was obtained 1 day before closure in patients undergoing pelvic osteotomies. Intraoperative registration was performed after preoperative planning with a pediatric radiologist using 5 anatomical landmarks immediately before initiation of surgery. Accuracy of pelvic anatomy identification was assessed by 2 pediatric urological surgeons and 1 pediatric radiologist. RESULTS: In 43 patients with classic bladder exstrophy and 4 patients with cloacal exstrophy closed at our institution, Brainlab technology was used successfully to navigate and guide the dissection of the pelvic floor intraoperatively. In all patients there was 100% accuracy in the correlation of gross anatomical landmarks with 3-dimensional magnetic resonance imaging identified landmarks intraoperatively, and all patients had successful closure without any major complications. CONCLUSIONS: Brainlab intraoperative 3-dimensional magnetic resonance imaging guided pelvic floor navigation and dissection is an effective way to accurately identify pelvic anatomy during classic bladder exstrophy and cloacal exstrophy closure. This technology offers a unique opportunity for surgical skill education in this complex reconstructive operation.


Assuntos
Extrofia Vesical/diagnóstico por imagem , Extrofia Vesical/cirurgia , Imageamento Tridimensional , Imagem por Ressonância Magnética , Diafragma da Pelve/diagnóstico por imagem , Diafragma da Pelve/cirurgia , Cirurgia Assistida por Computador , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Imagem por Ressonância Magnética/métodos , Masculino , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos Cirúrgicos Urológicos/métodos
14.
J Pediatr Surg ; 54(11): 2416-2420, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30879754

RESUMO

PURPOSE: Cloacal exstrophy (CE) is the most severe presentation of the Exstrophy-Epispadias Complex (EEC) and is associated with an omphalocele, making the bladder and abdominal wall closure difficult. If the bladder closure fails, a secondary closure is necessary. The objective of this study is to identify patient or surgical factors associated with a successful secondary closure. METHODS: The institution's EEC database was reviewed for CE patients between 1975 and 2015. Inclusion criteria included a failed primary bladder closure with a secondary closure. Patient demographics, surgical factors and outcomes of the secondary bladder closure were reviewed. RESULTS: Twenty-four patients met inclusion criteria. 8/8 patients had a successful two-staged closure at the author's institution (100%); 2/16 patients had a successful closure at an outside institution (12.5%). Older median age at secondary closure was associated with outcome, p = 0.045. Pelvic osteotomy was associated with successful secondary closure, p = 0.013. Using Buck's immobilization with external fixation was associated with a higher proportion of successful secondary closures compared to Spica cast, p = 0.012. CONCLUSION: Successful reclosure in CE patients is associated with the use of osteotomy as well as Buck's immobilization with external fixation. While successful reclosure can be achieved, it is often at the cost of multiple procedures and, therefore, all efforts should be expended to achieve a successful primary closure. TYPE OF STUDY: Prognostic. LEVEL OF EVIDENCE: III.


Assuntos
Anus Imperfurado/cirurgia , Extrofia Vesical/cirurgia , Hérnia Umbilical/cirurgia , Escoliose/cirurgia , Anormalidades Urogenitais/cirurgia , Procedimentos Cirúrgicos Urológicos , Epispadia/cirurgia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Osteotomia , Prognóstico , Estudos Retrospectivos , Falha de Tratamento
15.
Urology ; 125: 190, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30798969
16.
Urol Oncol ; 37(3): 182.e1-182.e8, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30522903

RESUMO

INTRODUCTION AND OBJECTIVE: Focal therapy (FT) for localized prostate cancer (CaP) has been shown to have encouraging short-term oncological outcomes, excellent preservation of functional outcomes and is increasing in popularity in urologic community. We aim to evaluate the preferences and practice trends among urologists regarding this treatment strategy. METHODS: A 20 item online questionnaire was designed to collect information on urologists' views and use of FT. The survey was sent to the members of the Endourological Society and the American Urological Association. Multivariate logistic regression analysis was done to determine predictors for utilization of FT. RESULTS: A total of 425 responses were received [American Urological Association: 319, Endourological Society: 106]. Mean age of respondents was 53(SD: 11.3) years. Although half of the respondents (50.8%) believed FT to be moderate to extremely beneficial in the treatment of CaP, only 24.2% (103) of the respondents currently utilize FT in their practice. Respondents who were fellowship trained in urologic oncology were more likely to consider FT to be at least moderately beneficial (P < 0.001). Surgeon's experience (greater than 15 years in urology practice) (P = 0.025) and seeing more than 10 patients with new CaP diagnosis per month (P = 0.002) were independent predictors of FT utilization for localized CaP. While the most common setting for utilization of FT was in patients with unilateral intermediate-risk (72.8%) CaP, a small percentage of respondents also used FT for patients with unilateral high-risk CaP and bilateral intermediate risk (21.4% and 10.7%, respectively). Most common reasons for not using FT were the lack of belief in 'index lesion theory' (63.2%), lack of experience (41.3%), lack of belief in FT's efficacy (41.1%), lack of infrastructure (35.8%), difficult salvage treatment in cases of recurrence (22.7%) and high cost (21.8%). About 57.6% would use FT more often in an office or outpatient setting if they had access to reliable and cost-effective options. CONCLUSIONS: Only a quarter of our respondents utilize FT in their practice with surgeon's experience being the important independent predictor for using FT. Majority of respondents though consider FT to be beneficial in CaP management, would use it more often if provided more reliable and cost-effective options. Over time, experience and accessibility to reliable methods to perform FT may lead to further utilization of this novel treatment strategy.


Assuntos
Técnicas de Ablação/estatística & dados numéricos , Tratamentos com Preservação do Órgão/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Próstata/cirurgia , Neoplasias da Próstata/cirurgia , Técnicas de Ablação/métodos , Técnicas de Ablação/tendências , Adulto , Humanos , Masculino , Pessoa de Meia-Idade , Tratamentos com Preservação do Órgão/métodos , Tratamentos com Preservação do Órgão/tendências , Seleção de Pacientes , Padrões de Prática Médica/tendências , Inquéritos e Questionários/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos , Urologistas/estatística & dados numéricos , Urologistas/tendências , Urologia/tendências
17.
Urology ; 125: 184-190, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30576745

RESUMO

OBJECTIVE: To investigate the diagnosis, surgical management, and outcomes in patients with variant EEC. Variant presentations of the exstrophy-epispadias complex (EEC) span a wide range of abnormalities. The rarity and diversity of EEC variants can lead to challenges in the diagnosis and subsequent management of this population. METHODS: The authors reviewed an institutional database of 1336 EEC patients from 1975 to 2018 for variant presentations of EEC. Variant presentations included those with skin covered bladder exstrophy (BE), duplicate bladders, superior vesical fistula, and epispadias with major bladder prolapse. Surgical management and outcomes were assessed. RESULTS: In total, 44 EEC variants were identified. Nineteen (43%) presented with a skin-covered BE variant. Five patients presented with duplicate BE, while 6 presented with superior vesical fistula. Fourteen patients (32%) presented with epispadias with major bladder prolapse. Overall, 36 (82%) EEC variants underwent primary bladder closure, at a median of 135 days after birth (range 1-2010), with 21 (58%) undergoing pelvic osteotomy. Primary closures were successful in 89% of cases. Continence procedures were performed in 17 patients. This includes 5 patients who underwent bladder augmentation. However even without a continence procedure, continence with volitional voiding was found in 8 patients. CONCLUSION: The most common EEC variant is the skin-covered form of BE. In order to expedite appropriate management, accurate diagnosis upon initial presentation is crucial. Still, successful surgical reconstruction often results in continence that is similar to, or better than, nonvariant EEC presentations.


Assuntos
Extrofia Vesical/diagnóstico , Extrofia Vesical/cirurgia , Epispadia/diagnóstico , Epispadia/cirurgia , Extrofia Vesical/classificação , Pré-Escolar , Epispadia/classificação , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Fatores de Tempo , Resultado do Tratamento
18.
J Pediatr Surg ; 54(3): 491-494, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30029844

RESUMO

PURPOSE: To investigate the factors affecting primary bladder closure in cloacal exstrophy (CE). A successful primary closure is important for optimizing reconstructive outcomes, and it is a critical first-step in the reconstruction of CE. The authors' hypothesize that a smaller diastasis and use of an osteotomy are independent predictors of a successful closure. METHODS: A prospectively maintained database of 1332 exstrophy-epispadias complex (EEC) patients was reviewed for CE patients closed between 1975 and 2015. Univariate and multivariable analyses were performed to identify significant factors associated with CE primary bladder closure. RESULTS: Of 143 CE patients identified, 99 patients met inclusion criteria. Median follow-up time was 8.82 [IQR 5.43-14.26] years. In the multivariable model, the odds of having a successful closure are about 4 times greater for the staged cloacal approach compared to the 1-stage approach (OR, 3.7; 95% CI 1.2-11.5; p-value = 0.023). Also, having an osteotomy increases the chance of a successful closure by almost six-fold (OR, 5.8; 95% CI 1.7-19.6; p-value = 0.004). CONCLUSIONS: Using the staged approach with a pelvic osteotomy is paramount to a successful primary closure in CE. The authors strongly recommend using the staged approach and osteotomy as these factors independently increase the chance for a successful primary bladder closure. STUDY TYPE: Therapeutic study. LEVEL OF EVIDENCE: Level III, Retrospective comparative study.


Assuntos
Extrofia Vesical/cirurgia , Cloaca/anormalidades , Osteotomia/métodos , Bexiga Urinária/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Cloaca/cirurgia , Epispadia/complicações , Feminino , Humanos , Masculino , Análise Multivariada , Estudos Retrospectivos , Resultado do Tratamento
19.
World J Urol ; 37(3): 419-427, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29943220

RESUMO

OBJECTIVES: Recent advances have led to the use of magnetic resonance imaging (MRI) alone or with fusion to transrectal ultrasound (TRUS) images for guiding biopsy of the prostate. Our group sought to develop consensus recommendations regarding MRI-guided prostate biopsy based on currently available literature and expert opinion. METHODS: The published literature on the subject of MRI-guided prostate biopsy was reviewed using standard search terms and synthesized and analyzed by four different subgroups from among the authors. The literature was grouped into four categories-MRI-guided biopsy platforms, robotic MRI-TRUS fusion biopsy, template mapping biopsy and transrectal MRI-TRUS fusion biopsy. Consensus recommendations were developed using the Oxford Center for Evidence Based Medicine criteria. RESULTS: There is limited high level evidence available on the subject of MRI-guided prostate biopsy. MRI guidance with or without TRUS fusion can lead to fewer unnecessary biopsies, help identify high-risk (Gleason ≥ 3 + 4) cancers that might have been missed on standard TRUS biopsy and identify cancers in the anterior prostate. There is no apparent significant difference between MRI biopsy platforms. Template mapping biopsy is perhaps the most accurate method of assessing volume and grade of tumor but is accompanied by higher incidence of side effects compared to TRUS biopsy. CONCLUSIONS: Magnetic resonance imaging-guided biopsies are feasible and better than traditional ultrasound-guided biopsies for detecting high-risk prostate cancer and anterior lesions. Judicious use of MRI-guided biopsy could enhance diagnosis of clinically significant prostate cancer while limiting diagnosis of insignificant cancer.


Assuntos
Biópsia com Agulha de Grande Calibre/métodos , Biópsia Guiada por Imagem/métodos , Próstata/patologia , Neoplasias da Próstata/patologia , Biópsia , Endossonografia , Humanos , Imagem por Ressonância Magnética , Masculino , Próstata/diagnóstico por imagem , Neoplasias da Próstata/diagnóstico por imagem
20.
J Pediatr Urol ; 14(5): 427.e1-427.e7, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29909193

RESUMO

INTRODUCTION: Newborns with classic bladder exstrophy (CBE) may present with a bladder template that is inadequate for closure in the neonatal period (figure). In these cases, a delayed primary closure (DPC) is conducted to permit growth of the bladder template. This study reports the surgical and long-term urinary continence outcomes of poor template CBE patients undergoing DPC and compares them to patients who underwent DPC for reasons unrelated to bladder quality (i.e., prematurity, comorbidities, or a late referral). METHODS: An institutionally approved, prospectively maintained database of 1330 exstrophy-epispadias complex patients was reviewed for CBE patients who underwent DPC at the authors' institution. A bladder template was considered inadequate for neonatal closure if found to be inelastic, <3 cm in diameter, and/or covered in hamartomatous polyps. RESULTS: In total, 63 patients (53 male and 10 female) undergoing DPC were identified. Of these, 36 had poor bladder templates (group 1). The remaining 27 patients (group 2) had adequate templates and their bladder closure was delayed for reasons unrelated to bladder quality. At the time of DPC, those in group 1 were relatively than those in group 2 (median of 229 vs. 128 days, p = 0.094). All 36 group 1 patients and 26 (96%) group 2 patients underwent pelvic osteotomy during DPC (p = 0.429). All patients in this study had a successful primary closure. There was little difference in longitudinal bladder capacities between group 1 and group 2 (p = 0.518). Also, there was minimal difference in the median number of continence procedures between groups, with both groups having 1 (IQR 1-1) continence procedure (p = 0.880). Eight patients in group 1, and three patients in group 2 underwent a bladder neck transection with urinary diversion. Of the 13 and 16 patients who have undergone a continence procedure in group 1 and 2, respectively, 11 (84.6%) and 13 (81.3%) are continent of urine. The age of first continence procedure was different between groups 1 and 2 at 8.0 years (5.8-9.9 years) and 4.8 (3.5-6.0 years), respectively p = 0.009. The majority of patients in group 1 established continence at a relatively later age when compared to those in group 2, at 11.4 (8.0-14.8) years and 7.9 (2.6-13.2) years of age respectively p = 0.087. DISCUSSION: In the authors' view, neonatal bladder closure is ideal for CBE patients as it minimizes potential damage to exposed bladder mucosa. However, prior studies indicate that the rate of bladder growth for patients undergoing a delayed primary closure does not differ from patients with a neonatal closure. Results from this study show continued evidence that patients with poor templates who undergo delayed closure have excellent primary closure outcomes, which is critical for further management. Furthermore, this study shows that an inadequate bladder does not affect DPC outcomes or the continence outcomes in DPC patients. However, the inadequate template does affect the type of continence procedure available to a DPC patient, the age of first continence procedure, and the age of continence. CONCLUSIONS: DPC of the exstrophic bladder has a high rate of success when pelvic osteotomy is utilized as an adjunct. Patients having a DPC for reasons of an inadequate bladder template have comparable rates of bladder growth when compared to DPC of an adequate bladder template. The inadequate bladder template affects the type of continence procedure, with the majority of patients requiring urinary diversion for continence. Patients with an inadequate bladder template have a later age of first continence procedure and a relatively later age of continence, because of an inherently smaller bladder template at birth. The inadequate bladder template patients require a longer period of surveillance to access bladder growth and capacity in preparation of a continence procedure. Furthermore, as the majority of inadequate bladder template patients require a catheterizable channel for continence, the age of continence is also likely influenced by the patient's preparation as they transition from volitional voiding to catheterization.


Assuntos
Extrofia Vesical/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Recém-Nascido , Masculino , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Bexiga Urinária/fisiologia , Bexiga Urinária/cirurgia , Micção , Procedimentos Cirúrgicos Urológicos/métodos
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