Early urodynamic findings after complete primary repair of exstrophy.

INTRODUCTION: Detrusor contraction in bladder exstrophy (BE) patients following reconstruction is poorly understood as there are few published studies assessing urodynamic findings in this population. Understanding the ability of the detrusor to contract in BE patients early after closure may be able to inform the longer-term management and potential for the development of future continence in this population. OBJECTIVE: We sought to evaluate early detrusor contraction using urodynamic studies (UDS) in children who had previously undergone complete primary repair of bladder exstrophy (CPRE). We hypothesized that a majority of children with BE would display the presence of normal detrusor contractile function after CPRE. STUDY DESIGN: A retrospective review of our prospectively collected database was performed for all patients with a diagnosis of classic BE who underwent primary CPRE between 2013 and 2017. From this cohort we identified patients with at least one post-operative UDS at 3 years of age or older who had undergone an initial CPRE. Our primary outcome was the presence of a detrusor contraction demonstrated on UDS. RESULTS: There were 50 children (31 male, 19 female) with CBE who underwent CPRE between 2013 and 2017.There were 26 (13 male, 13 female) who met inclusion criteria. Median age was 3.5 (IQR: 3.2-4.7) years at the time of UDS Sixteen of the 26 (61.5%) generated a sustained detrusor contraction generating a void, with a median peak voiding pressure of 38 cm H20 (IQR: 28-51). The median bladder capacity reached was 48 ml, which represented a median of 30% of expected bladder capacity. The median post void residual (PVR) for the entire cohort was 26 ml (IQR: 9, 47) or 51% (IQR: 20%-98%) of their actual bladder capacity, while the median PVR for those children with a sustained detrusor contraction was 18 ml (IQR: 5, 46) or 33% (IQR: 27%, 98%) of their actual bladder capacity. Intraoperative bladder width and bladder dome to bladder neck length did not correlate with the presence of voiding via a detrusor contraction (p = 0.64). DISCUSSION: We present the first study assessing early UDS finding of detrusor contraction in BE patients after CPRE. In our cohort, 61.5% of patients were able to generate a sustained detrusor contraction on UDS which is a higher percentage than has been reported in previous series. A difference in initial surgical management may account for these findings. CONCLUSION: At short term follow up, the majority of children in our cohort were able to produce sustained detrusor contractions sufficient to generate a void per urethra with a modest post void residual volume. Long-term follow-up and repeated UDS will be needed to track detrusor contractility rates, bladder capacities, compliance, post void residuals and ultimately continence rates over time.

Demonstration of plasma mirror capability for the OMEGA Extended Performance laser system.

A plasma mirror platform was developed for the OMEGA-EP facility to redirect beams, thus enabling more flexible experimental configurations as well as a platform that can be used in the future to improve laser contrast. The plasma mirror reflected a short pulse focusing beam at 22.5° angle of incidence onto a 12.5 µm thick Cu foil, generating Bremsstrahlung and kα x rays, and accelerating ions and relativistic electrons. By measuring these secondary sources, the plasma mirror key performance metrics of integrated reflectivity and optical quality are inferred. It is shown that for a 5 ± 2 ps, 310 J laser pulse, the plasma mirror integrated reflectivity was 62 ± 13% at an operating fluence of 1670 J cm-2, and that the resultant short pulse driven particle acceleration and x-ray generation indicate that the on target intensity was 3.1 × 1018 W cm-2, which is indicative of a good post-plasma mirror interaction beam optical quality. By deriving the plasma mirror performance metrics from the secondary source scalings, it was simultaneously demonstrated that the plasma mirror is ready for adoption in short pulse particle acceleration and high energy photon generation experiments using the OMEGA-EP system.

The family planning "know-do" gap among married women of reproductive age in urban Pakistan.

OBJECTIVE: To examine the prevalence and predictors of family planning (FP) know-do gaps among married women of reproductive age (MWRA) in low socio-economic urban areas of Karachi, Pakistan. DESIGN: This was a cross-sectional survey of randomly selected 7288 MWRA (16-49 years) to identify predictors of the know-do gap in FP using a logistic regression model. RESULTS: More than one third (35.5%) of MWRA had FP know-do gap, i.e., despite having a knowledge of contraceptives and desire to limit or delay childbearing, they were not using contraceptives. Women were less likely to use FP if they were getting older (25-35 years: OR 1.45, 95% CI 1.09-1.94; >35 years: OR 3.02, 95% CI 1.90-4.80), from certain ethnicities (Sindhi: OR 1.64, 95% CI 1.11-2.42; Saraiki: OR 1.66, 95% CI 1.01-2.71; other minorities: OR 2.37, 95% CI 1.63-3.44); did not receive FP counselling: OR 1.43, 95% CI 1.13-1.80; and had not made a joint decision on FP: OR 1.44, 95% CI 1.06-1.98). Conversely, women were more likely to use contraceptives if they had >10 years of schooling (OR 0.66, 95% CI 0.46-0.94), with each increasing number of a living child (OR 0.68, 95% CI 0.62-0.75) and each increasing number of contraceptive method known (OR 0.93, 95% CI 0.88-0.98). CONCLUSION: The predictors associated with the FP know-do gap among MWRA should be considered when planning future strategies to improve the contraceptive prevalence rate in Pakistan.

OBJECTIF: Étudier la prévalence et les variables explicatives du fossé entre informations et actions en matière de planification familiale (FP) chez les femmes mariées en âge de procréer (MWRA) dans les quartiers urbains socio-économiquement défavorisés de Karachi, Pakistan. PLAN: Enquête transversale réalisée auprès de 7 288 MWRA (16­49 ans) sélectionnées de manière aléatoire visant à identifier les variables explicatives du fossé entre informations et actions en matière de FP en utilisant un modèle de régression logistique. RÉSULTATS: Un fossé entre informations et actions en matière de FP a été observé chez plus d'un tiers (35,5%) des MWRA, c.-à-d., qu'en dépit de connaissances sur les moyens de contraception et d'un souhait de limiter ou retarder les grossesses, ces femmes n'utilisaient aucun moyen de contraception. Les femmes étaient moins susceptibles d'avoir recours à la FP en vieillissant (25­35 ans : OR 1,45 ; IC 95% 1,09­1,94 ; >35 ans : OR 3,02 ; IC 95% 1,90­4,80), si elles appartenaient à certains groupes ethniques (Sindhi : OR 1,64 ; IC 95% 1,11­2,42 ; Saraiki : OR 1,66 ; IC 95% 1,01­2,71 ; autres minorités : OR 2,37 ; IC 95% 1,63­3,44), si elles ne bénéficiaient d'aucune aide en matière de FP (OR 1,43 ; IC 95% 1,13­1,80), et si la décision relative à la FP avait été prise unilatéralement (OR 1,44 ; IC 95% 1,06­1,98). À l'inverse, les femmes étaient plus susceptibles d'utiliser des contraceptifs si elles avaient été scolarisées pendant >10 ans (OR 0,66, ; IC 95% 0,46­0,94), à mesure que leur nombre d'enfants vivants augmentait (OR 0,68 ; IC 95% 0,62­0,75) et à mesure que le nombre de moyens contraceptifs qui leur étaient connus augmentait (OR 0,93 ; IC 95% 0,88­0,98). CONCLUSION: Les variables explicatives associées au fossé entre informations et actions en matière de FP chez les MWRA devraient être prises en compte lors de la planification de futures stratégies visant à améliorer le taux de prévalence des contraceptifs au Pakistan.

Impact of bilateral ureteral reimplantation at the time of complete primary repair of bladder exstrophy on reflux rates, renogram abnormalities and bladder capacity.

INTRODUCTION: Bilateral ureteral reimplantation at the time of the complete primary repair of bladder exstrophy (BUR-CPRE) has been proposed and has demonstrated favorable outcomes in the past. However, the potential benefits, including prevention of vesicoureteral reflux (VUR) and renal scarring must be tempered with any risks of reimplantation, persistent VUR, and the potential for overtreatment. We aimed to determine the impact of BUR-CPRE on reflux rates, renogram findings and bladder capacity. METHODS: An IRB approved registry of children treated for bladder exstrophy epispadias complex (BEEC) during a long-term international collaboration hosted in a region with high prevalence of BEEC was queried. Children undergoing primary CPRE for bladder exstrophy (BE) were identified. Surgical procedure and outcome measures nuclear medicine dimercaptosuccinic acid (DMSA) scintigraphy scans, voiding cystourethrogram (VCUG), and urodynamic study (UDS) were assessed for presence and degree of VUR, renogram abnormalities, and bladder capacity. RESULTS: A total cohort of 147 patients with BEEC was queried; 52 children (37 males, 71%) underwent primary CPRE for BE between 2009 and 2019 at median age of 1.1 years (IQR 0.6-1.9 years) with median follow up 4.4 years (IQR 2.4-6.4 years). BUR-CPRE was performed in 22/52 (42%). After BUR-CPRE, children were less likely to have VUR (any VUR present in 9 of 20 with imaging (45%) compared to 23 of 26 with imaging (82%) in the CPRE alone group (p = 0.007)). VUR in the BUR-CPRE group tended to be unilateral and lower grade in comparison to the CPRE alone group. DMSA abnormalities were less common in the BUR-CPRE group (4/19 (21%) vs.12/27 (44%)), although the difference did not reach statistical significance (p = 0.1). At 4 years follow-up, the BUR-CPRE group had a larger bladder capacity (p = 0.016). DISCUSSION: After BUR-CPRE, children had a lower rate of VUR, and when present, VUR was more often unilateral and lower grade compared to the CPRE alone group. Fewer numbers of children in the BUR-CPRE group depicted DMSA abnormalities. No children developed obstruction after BUR-CPRE and none have undergone repeat reimplantation. We documented a larger bladder capacity at the time of maximum follow-up available (4 years)-but further data are needed to confirm this observation. CONCLUSION: BUR-CPRE decreases the incidence and severity of VUR after CPRE, but the clinical significance of this remains unclear. We are encouraged by these initial results, but since BUR-CPRE does not uniformly eliminate VUR, we continue to proceed carefully in the well selected patient.

A health equity methodology for auditing oral health and NHS General Dental Services in Sheffield, England.

OBJECTIVES: To describe a method used in a health equity audit (HEA) of oral health and National Health Service (NHS) General Dental Services. METHODS: Need, demand and provision of NHS General Dental Services were estimated by electoral ward using readily available data. Need was estimated using five-year-old dmft data. Scheduled and unscheduled demand were differentiated; scheduled demand was estimated using NHS dental registration data and unscheduled demand using emergency clinic and NHS Direct call activity data. Provision was estimated using self-declared dentist NHS hours and NHS Units of Dental Activity practice allocations. All variables were correlated with socioeconomic deprivation in each electoral ward, estimated by rates of receipt of Income Support. SETTING: Sheffield, England. RESULTS: Estimated need in electoral wards varied and correlated positively with increasing socio-economic deprivation. Scheduled demand tended to be lower and unscheduled demand higher in more deprived wards. Estimates of NHS General Dental Service provision indicated marginally higher provision in more deprived wards, though the correlation was weak. A synthesis of the findings estimated where need was least well met by provision. CONCLUSION: A HEA of oral health and NHS General Dental Services can be undertaken using readily available data. However, data used to estimate need, demand or provision may have to change for future audits as the data routinely collected changes.

Chondroitin sulfate as a regulator of neuronal patterning in the retina.

Highly sulfated proteoglycans are correlated with axon boundaries in the developing central nervous system which suggests that these molecules affect neural pattern formation. In the developing mammalian retina, gradual regression of chondroitin sulfate may help control the onset of ganglion cell differentiation and initial direction of their axons. Changes induced by the removal of chondroitin sulfate from intact retinas in culture confirm the function of chondroitin sulfate in retinal histogenesis.

Tunica vaginalis flap for salvaging testicular torsion: A matched cohort analysis.

INTRODUCTION: In testicular torsion, ischemia time from pain onset impacts testicular salvage. A tunica albuginea fasciotomy to relieve compartment pressure followed by a tunica vaginalis flap (TVF) may enhance salvage. OBJECTIVE: To define the optimal window of ischemia time during which TVF may be most beneficial to avoid orchiectomy. STUDY DESIGN: A retrospective cohort study of males presenting with testicular torsion at a single tertiary-care institution from January, 2003 to March, 2017. Ischemia time was defined as duration of pain from onset to surgery. Because TVF would be an option to orchiectomy, and it was found that ischemia time was longer in testicles that underwent orchiectomy, matching was performed. Cases of torsion treated with TVF were matched 1:1 with cases treated with orchiectomy on age at surgery, and ischemia time. Outcomes included postoperative viability, defined as palpable testicular tissue with normal consistency, and atrophy, defined as palpable decrease in size relative to contralateral testicle. Sensitivity analyses were performed restricting to the subgroups with postoperative ultrasound, >6 months' follow-up, and additionally matching for degrees of twist. RESULTS: A total of 182 patients met eligibility criteria, of whom 49, 36, and 97 underwent orchiectomy, TVF, and septopexy alone, respectively. Median follow-up was 2.7 months; 26% of patients had postoperative ultrasound (61% of TVF group). In the orchiectomy, TVF, and septopexy groups, respectively, median ischemia times were 51, 11, and 8 h, postoperative viability rates were 0, 86, and 95%, and postoperative atrophy rates were 0, 68, and 24%. After matching, 32 patients with TVF were matched to 32 patients who underwent orchiectomy. In the TVF group, postoperative viability occurred in 95% (19/20) vs 67% (8/12) of patients with ischemia times ≤24 and >24 h, respectively. Atrophy occurred in 67% (12/18) vs 83% (10/12) of these same respective patients. Sensitivity analysis by ultrasound and longer follow-up found similar viability results, although atrophy rates were higher. Additional matching for degrees of twist showed lower viability and higher atrophy rates for increasing ischemia times. DISCUSSION: Patients who presented with testicular torsion with ischemia times ≤24 h and who were being considered for orchiectomy may have benefitted most from TVF, albeit at high risk of atrophy. However, for ischemia times >24 h, TVF may still have preserved testicular viability in two-thirds of cases. A limitation was short follow-up. CONCLUSION: A TVF was a valid alternative to orchiectomy for torsed testicles, albeit with high testicular atrophy rates.

Back to the future: The Cecil-Culp technique for salvage penile reconstructive procedures.

INTRODUCTION: Re-operative penile reconstruction is challenging and requires tension-free skin closure. The repair popularized by Cecil and Culp in the 1940s, using the scrotum to provide a temporary vascularized bed for complex hypospadias repairs, fell out of favor due to temporal trends towards single-stage repairs and concern for utilizing hair-bearing skin on the penile shaft. OBJECTIVE: It was hypothesized that a modified Cecil-Culp (CC) concept of penile scrotalization, leaving the penis attached to the scrotum for 1 year rather than 6 weeks as originally described, improves outcomes with this reconstruction for ventral skin deficiency or poor vascular support. METHODS: Institutional Review Board-approved registries were reviewed to identify patients who underwent a CC repair during 1987-2016 at two institutions. Cecil-Culp technique was utilized in multi-stage hypospadias complication repairs or for insufficient ventral penile shaft skin coverage. Anatomic abnormality, number and type of prior surgeries, and complications before and after CC were recorded. RESULTS: Thirty-nine patients underwent CC: 23 failed hypospadias repairs, three hypospadias after bladder exstrophy, 10 penile curvature following circumcision, and three with skin loss from trauma. Mean age at CC was 61.8 months (hypospadias), and 59.8 months (non-hypospadias). Hypospadias patients underwent a mean of 3.6 surgeries (range 1-9) prior to CC. Four of the 39 patients (10.3%) had perioperative complications after CC, including scrotal abscess, skin infections, and difficulty removing the urethral stent. Eight of 37 (21.6%) patients had longer-term complications related to their hypospadias repair, including fistulae, diverticula, dehiscence, and stricture. Mean time from CC placement to release was 345 and 473 days for hypospadias and non-hypospadias cases, respectively. There was no apparent scrotal skin transferred to the penile shaft at the final take-down. Mean follow-up was 22.3 months. DISCUSSION: Embedding the penis into the scrotum for added vascularity and ventral skin coverage has been used effectively in cases of the most tenacious fistulas and for significant skin loss and trauma. Limitations of this study were its retrospective approach at two institutions over an extended period of time by multiple surgeons, so patient selection and procedure may have varied. CONCLUSIONS: Modification of CC repair by delaying 9-12 months before CC take-down enhanced the benefits of a robust vascular bed for wound healing, and helped to avoid transfer of hair-bearing scrotal skin to the penile shaft. The CC technique is an important tool for penile reconstructive surgery of complex hypospadias repairs with inadequate skin, and for traumatic injuries.

Large-aperture grating tiling by interferometry for petawatt chirped-pulse-amplification systems.

A tiled-grating assembly with three large-scale gratings is developed with real-time interferometric tiling control for the OMEGA EP Laser Facility. An automatic tiling method is achieved and used to tile a three-tile grating assembly with the overall wavefront reconstructed. Tiling-parameters sensitivity and focal-spot degradation from all combined tiling errors are analyzed for a pulse compressor composed of four such assemblies.

Genitourinary involvement and management in children with Stevens-Johnson syndrome and toxic epidermal necrolysis.

BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are devastating hypersensitivity disorders that cause epidermal cell death and can affect all epidermal surfaces, including the urethra, vagina, labial and scrotal skin. Despite the well-described ocular and orofacial manifestations of SJS/TEN, there is a paucity of reports on the genitourinary (GU) symptoms and their management. Specifically, consulting services often ask the pediatric urology team if it is safe to place a urethral catheter, but there is no data in the literature to help guide management. The present study sought to review all pediatric cases of SJS/TEN in a tertiary care hospital to determine the incidence and optimal management of GU manifestations, including the use of urethral catheters. METHODS: With IRB approval, cases of SJS and TEN that were managed as an inpatient between January 2008 and June 2015 were retrospectively reviewed in order to identify the extent of GU involvement/manifestations, the treatment provided, use of urethral catheterization and long-term follow-up or complications. RESULTS: Thirty-one patients (15 female, 16 male; age range 2-18 years) presented with SJS or TEN over the study period. Etiologies for SJS/TEN included mycoplasma infection (48%) and medications (45%). Incidences of GU manifestations at presentation and their management are shown in Summary Table. Overall, 74% of patients had genital involvement of skin lesions. In 12 cases (39%), urology consultation was obtained. Twenty patients (61%) complained of dysuria and one child had gross hematuria in the setting of meatal lesion. Petroleum jelly was used in the majority of patients. A urethral catheter was placed in eight patients (25.8%, four female, four male) with a range of duration of 7-23 days. No patient developed hematuria or any other complications (i.e. strictures or urinary symptoms) after catheter removal. One boy required lysis of penile adhesions in the short-term. One of each gender developed penile and labial adhesions on long-term follow-up that self-resolved. CONCLUSIONS: GU involvement in SJS/TEN occurred in almost three-quarters of patients and was managed conservatively like other skin/mucosal manifestations. Long-term sequelae were rare and urethral catheterization appeared to be safe, without any short-term or long-term complications.

Short-term outcomes of the multi-institutional bladder exstrophy consortium: Successes and complications in the first two years of collaboration.

INTRODUCTION/BACKGROUND: Bladder exstrophy is a rare diagnosis that presents major reconstructive challenges. To increase experience and proficiency in the care of bladder exstrophy (BE), the Multi-Institutional BE Consortium (MIBEC) was formed, with a focus on refining technical aspects of complete primary repair of bladder exstrophy (CPRE) and subsequent care. OBJECTIVE: Outcome measures included successful CPRE (absence of dehiscence), complications, and integrated points of technique and care over the short-term. STUDY DESIGN: Boston Children's Hospital, Children's Hospital of Philadelphia and Children's Hospital of Wisconsin alternately served as the host, with observation, commentary and critique by visiting collaborating surgeons. CPRE with bilateral iliac osteotomy was performed at 1-3 months of age. High-definition video capture of the surgery allowed local and distant broadcast to facilitate real-time observation and teaching, and recording of all procedures. RESULTS: From February 2013 to February 2015, MIBEC participating surgeons performed CPRE on 27 consecutive patients (22 classic BE, five epispadias). There were no dehiscences in 27 patients (0%, 95% CI 0-12.5%). Thirteen girls and 14 boys underwent CPRE at a median age of 2.3 months (range 0.1-51.6). One boy had a hypospadiac urethral meatus at CPRE completion. Hydronephrosis of mild or moderate grade was present postoperatively in eight girls and two boys. Additional results, per gender, are presented in the Summary table below. DISCUSSION: Absence of dehiscence in this cohort was comparable or compared favorably with the literature. However, several girls had significant obstructive complications following CPRE. The rate of bladder outlet obstruction (BOO) in girls was increased compared with published reports. A low complication rate was noted in the boys following CPRE, which was comparable to reports in the literature, and early signs of continence and spontaneous voiding were noted in some boys and girls. Limitations included variation in patient age at presentation, thereby introducing a wide age range at CPRE. Outcome data were limited by short follow-up regarding voiding with continence. CONCLUSION: This collaborative effort proved beneficial regarding significantly increased surgeon exposure to CPRE, refinement of CPRE technique, surgeon learning and expertise. Technical refinement of CPRE is ongoing.

Hypospadias: Are we as good as we think when we correct proximal hypospadias?

OBJECTIVE: Hypospadias surgery is a humbling art form. Although outcomes with distal hypospadias are favorable, recent publications have suggested that the complication rates are much higher than previously anticipated for proximal hypospadias. The present review examined the literature concerning proximal hypospadias, to explore some of the inadequacies and identify some of the reasons behind these shortfalls in the reported data. METHODS: A systematic review of the published literature was conducted using keywords relevant to proximal hypospadias and long-term outcomes. RESULTS: The literature for hypospadias was reviewed, and outcomes for distal vs proximal variants were compared. The quality of the literature for proximal hypospadias was examined, and the shortcomings that led to underreporting of the surgical outcomes were identified. Special focus was on the lack of standardized documentation, the subsequent inability to objectify the severity of the phenotype, and the underestimation of complications due to lack of long-term follow-up. There was also a great deal of variability in the utilized techniques, and the literature was filled with small case series from single institutions. To enable scientific assessment of outcomes, it is proposed that the following be implemented: acceptance and incorporation of standardized phenotype assessment scores in the pre-operative period, objective intraoperative hypospadias characterization, and postoperative score assessment. CONCLUSIONS: Treatment of proximal hypospadias is much less successful than the distal variant. A specialty wide commitment to standardize the hypospadias language is required to make advancement in surgical outcomes. Boys need to be followed through puberty into adulthood, and honest reporting of outcomes must be discussed so that surgical techniques for this complicated disease process can be advanced.

Parents' attitudes and patients' behavior: a prospective study.

The authors studied the behavior of 67 psychiatric inpatients and the attitudes of their parents toward their hospitalization. They found that certain parental concerns at admission correlated with particular aspects of patient behavior and ability to engage in treatment during the first 6 weeks of hospitalization. These findings have implications for the management of inpatient treatment.

Autosomal dominant "Opitz" GBBB syndrome due to a 22q11.2 deletion.

We report on a family with autosomal dominant paternally inherited "Opitz" GBBB syndrome and an additional case with findings which have been reported in that syndrome. In each case the propositus presented with a vascular ring. Since a vascular ring may be a sign of a 22q11.2 deletion [Zacki et al., 1995], FISH (fluorescence in situ hybridization) studies were performed. These studies demonstrated a 22q11.2 deletion in the 3 affected individuals. Review of Opitz GBBB syndrome and the 22q11.2 microdeletion syndrome demonstrates significant overlap of manifestations including both facial characteristics and structural anomalies. Based on the phenotypic overlap and the presence of a 22q11.2 deletion in our patients with Opitz GBBB syndrome and the presence of a deletion in a patient with lung hypoplasia, absent pulmonary artery, and long segment tracheomalacia, we propose that, in some cases, the Opitz GBBB syndrome may be due to a 22q11.2 deletion. This enlarges the list of "syndromes" associated with the 22q11.2 deletion, which presently includes most patients with DiGeorge, velocardiofacial, and conotruncal anomaly face syndrome.

A rapid whole blood solubility test to differentiate the sickle-cell trait from sickle-cell anaemia.

A simple and rapid screening test which differentiates sickle-cell trait and sickle-cell anaemia is described. The test utilizes 0.1 ml of whole blood and is based on the low solubility of reduced sickle haemoglobin. Results intermediate between the sickle-cell trait and sickle-cell anaemia are obtained in unusual cases of sickle-cell anaemia with high foetal haemoglobin. The need to supplement the results with haematological and electrophoretic techniques is discusses.

An automated screening technique for the detection of sickle-cell haemoglobin.

An automated technique is described which is capable of detecting sickle-cell haemoglobin and differentiating the sickle-cell trait from sickle-cell anaemia. The method is based upon the Itano solubility test and utilizes Technicon equipment.

Predictors of recurrent clinical stage I nonseminomatous testicular cancer. A prospective clinicopathologic study.

A prospective clinicopathologic study of 60 patients with clinical Stage I nonseminomatous testicular cancer (NSTC) has been reported. Of 60 patients with clinical Stage I NSTC who underwent retroperitoneal lymphadenectomy (RPLA), 6 proved to be Stage II, a staging error of 10 per cent. In 4 patients of the remaining 54, metastases developed in the lungs. In 1 patient metastases developed both in the lung and in retroperitoneal lymph nodes. There was no death in these groups of patients. These 10 patients with staging error and/or recurrence after RPLA have been analyzed for the causes of treatment failure utilizing a set of prognostic criteria (tumor cell type, vascular or lymphatic invasion in the primary tumor, extension to the spermatic cord, and size of the primary tumors). It has been concluded that embryonal carcinoma (P less than 0.001), vascular invasion (P less than 0.001), and extension of the tumor to the spermatic cord (P less than 0.001) are significant predictors of metastases and/or recurrence after RPLA in Stage I NSTC. A plan of management is suggested based on these criteria.

Skin flap closure by dermal laser soldering: a wound healing model for sutureless hypospadias repair.

OBJECTIVES: Laser tissue soldering (LTS) with the diode laser and human albumin-hyaluronate-indocyanine green solder is a safe and effective method of providing an immediate leak-free closure during hypospadias repair. In this report, we compare the physiology, histology, and immunohistochemistry of wound healing following LTS and suturing in a rat skin flap model. METHODS: A 4 x 5-cm skin flap was raised and bisected (4 cm) on the dorsum of 48 Sprague-Dawley rats. The central wound was either closed from a dermal approach by suturing or LTS or left open, and studied at 0, 3, 5, 7, 10, 14, and 21 days postoperatively. An intraoperative comparison was made between suturing and LTS with respect to operative time. Postoperatively, flaps were excised for tensiometric analysis, and sections were stained with hematoxylin-eosin to define wound architecture. Resting skin temperature, laser exposed temperature without solder, and maximum temperature with solder (one drop) were measured at the level of the deep dermis, superficial striated muscle layer, and within the solder. Mean peak temperatures were recorded during a 1-minute laser activation time. RESULTS: Mean continuous suturing time (4.9 +/- 1.1 minutes) was significantly (P < 0.001) faster than either LTS (7.7 +/- 0.77 minutes) or discontinuous suturing (8.2 +/- 0.62 minutes). Two seromas (sutured) and two instances of partial wound dehiscence (1 sutured, 1 LTS) were noted. Tensile strength was increased significantly (P < 0.001) for up to 5 days in the LTS group, but was equal to suturing at 7 and 10 days. Immediate tensile strength after LTS was equivalent to a 7-day healed wound. At 14 days, wounds initially left open and those closed by LTS were stronger than sutured wounds (P < 0.05). There was no evidence of thermal injury or foreign body reaction in the LTS group. Solder was incorporated within the dermis in all wounds at 21 days. Laser activation of solder resulted in significant increases in temperature at all three tissue levels: 65.0 +/- 5.2 and 69.9 +/- 6.8 degrees C in the deep and superficial skin (no significant difference between the two), and 101 +/- 15.6 degrees C within the solder (P < 0.001 versus superficial and deep skin). CONCLUSIONS: Our results indicate that sutureless dermal LTS of skin flaps provides increased tensile strength for up to 7 days, with relatively greater tensile strength provided within the first 3 days. Our laser technique does not appear to alter the normal wound healing process. Rather, solder-tissue interaction initially, and extracellular matrix infiltration of solder later, provide the basis for improved wound strength. For hypospadias repair using skin flaps, these wound attributes may permit sutureless surgery.