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ABSTRACT: Our goals were to assess long-term outcome for patients with posterior urethral valves (PUV) and determine the impact of the timing of diagnosis.
We reviewed the hospital records for patients with PUV treated in 1994-2008. Only those patients diagnosed, treated surgically, and followed clinically at our center were included.
There were 52 patients with PUV. Thirty-nine were diagnosed by 1 year of age (early diagnosis cohort), while 13 were diagnosed after 1 year (late diagnosis cohort). Mean follow up after valve operation was 7.2 years (range 15 months-14 years). Chronic renal failure rates were not statistically different between the early and late diagnosis groups after surgical intervention: 48% (14/29) vs 25% (3/12), P = 0.30. Among the early diagnosis cases, 10% (3/29) eventually required renal transplant, while no child in the late diagnosis group has developed end-stage renal disease to date (P = 0.55).
Gestational age at diagnosis is an important predictor of postnatal renal outcome. Our results suggest that diagnosis after 1 year of age is associated with a lower risk of developing renal insufficiency on long-term follow up.
Journal of pediatric urology 10/2011; 7(5):538-42. · 1.38 Impact Factor
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ABSTRACT: We report the largest known series of vesicoureteral reflux (VUR) in children with urachal anomalies (UA).
Two institutions' records were reviewed for children with UA (1951‒2007).
Of 30 girls and 36 boys with UA (34 urachal cysts, 14 patent urachus, 10 urachal diverticula, 7 urachal sinuses, and 1 unknown), 57 (86%) underwent surgical resection or drainage. A voiding cystourethrogram was obtained in 22 (33%). VUR was demonstrated in 14 of the 22 children (64%), and rates were similar among the various types of UA. The median age with versus without VUR was not different (1.3 vs 1.7 years, P=0.97). Of 24 refluxing renal units, classification was grade≤3 in 71%, 4‒5 in 12%, and unspecified in 17%. Four children (26%) underwent ureteroneocystostomy and 10 observed patients resolved spontaneously.
To our knowledge, this is the first series of VUR associated with UA. The increased incidence of VUR (64%) in this small subset of patients warrants prospective studies to determine if there is a positive correlation with UA. We believe thorough genitourinary and family histories are important when evaluating children with UA to help detect clinically significant VUR.
Journal of pediatric urology 05/2011; 7(6):632-5. · 1.38 Impact Factor
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ABSTRACT: Prognostic information is limited on children with congenital anterior urethral valves or a diverticulum. We reviewed the literature and examined our clinical database to identify clinical features predicting a poor renal outcome, defined as azotemia, renal failure or death.
We reviewed 97 English language studies of patients 18 years old or younger. Seven patients from our institutions were also included in analysis. After data abstraction we used multivariate models to define factors associated with outcomes of interest.
We identified 239 male patients with anterior urethral valves, of whom 139 had adequate data available for study inclusion. Of these patients 108 (78%) had normal renal function after treatment. On bivariate analysis vesicoureteral reflux (OR 22.4, p <0.0001), pretreatment azotemia (OR 17.1, p <0.0001), urinary tract infection (OR 3.3, p = 0.006), hydronephrosis (OR 10.0, p = 0.0004) and bladder trabeculation (OR 7.3, p = 0.01) were associated with renal failure or death while treatment method (p = 0.9), obstruction type (valve vs diverticulum, p = 0.4) and valve location (p = 0.6) were not. After adjusting for other factors only pretreatment azotemia (p = 0.0005) and vesicoureteral reflux (p = 0.01) remained associated with renal failure and/or death with a trend toward significance for urinary tract infection (p = 0.06). When all 3 factors were present, the odds of a poor renal outcome increased 25-fold (p = 0.005).
Congenital anterior urethral obstruction in children has a generally good prognosis but may occasionally result in a poor renal outcome. The combination of pretreatment azotemia, vesicoureteral reflux and urinary tract infection is highly predictive of a poor renal outcome.
The Journal of urology 10/2010; 184(4 Suppl):1615-9. · 4.02 Impact Factor
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ABSTRACT: • To determine if hyaluronic acid (HA) can be incorporated into porcine small intestinal submucosa (SIS) through poly (lactide-co-glycolide-acid) (PLGA) nanoparticles to improve the consistency of the naturally derived biomaterial and promote bladder tissue regeneration.
• Beagle dogs were subjected to 40% partial cystectomy followed by bladder augmentation with commercial SIS or HA-PLGA-modified SIS. • Urodynamic testing was performed before and after augmentation to assess bladder volume. • A scoring system was created to evaluate gross and histological presentations of regenerative bladders.
• All dogs showed full-thickness bladder regeneration. • Histological assessment showed improved smooth muscle regeneration in the HA-PLGA-modified SIS group. • For both groups of dogs, urodynamics and graft measurements showed an approximate 40% reduction in bladder capacity and graft size from pre-augmentation to post-regeneration measurements. • Application of the scoring system and statistical analysis failed to show a significant difference between the groups.
• SIS can be modified through the addition of HA-PLGA nanoparticles. The modified grafts showed evidence of improved smooth muscle regeneration on histological assessment, although this difference was not evident on a novel grading scale. • The volume loss and graft shrinkage experienced are consistent with previous models of SIS bladder regeneration at the 10-week time point. • Additional research into the delivery of HA and the long-term benefits of HA on bladder regeneration is needed to determine the full benefit of HA-PLGA-modified SIS. In addition, a more objective biochemical characterization will be needed to evaluate the quality of regeneration.
BJU International 10/2010; 108(1):148-55. · 2.84 Impact Factor
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ABSTRACT: To assess our experience with salvage continence procedures in patients with bladder exstrophy.
We retrospectively reviewed our surgical records of patients with bladder exstrophy who had undergone failed modern staged repair elsewhere and underwent salvage continence operations at our institute from 1996 to 2008.
A total of 16 patients had undergone salvage continence operations. Bladder augmentation was performed in 11 patients (68.8%); 14 children (87.5%) received a continent, catheterizable stoma. In 6 children (37.5%) bladder neck injections were done. Three patients (18.8%) underwent bladder neck closure combined with other reconstructive procedures. A total of 49 continence procedures were performed, with an average of 3.06 per patient. We included all 16 children >5 years. After these operations, 13 of 16 (81.3%) became continent. Two children were able to void spontaneously and were dry day and night (12.5%). Of the remaining 14 patients, all of whom used clean intermittent catheterization, 11 (68.7%) were continent during the day and night with augmentation and/or a catheterizable stoma. Three patients were incontinent (18.7%).
Although the need to perform salvage continence procedures after failed bladder modern staged repair is high, when patients are appropriately selected, continence can be achieved eventually.
Urology 05/2010; 76(1):39-42. · 2.43 Impact Factor
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ABSTRACT: Hyaluronic acid-poly(de-co-glycolide) nanoparticles (HA-PLGA NPs) were synthesized to stabilize the porous structure of porcine small intestinal submucosa (SIS), to improve surface biocompatibility and to enhance performance in tissue regeneration. HA-PLGA NPs were characterized for size, zeta potential, surface morphology, and HA loading. Human microvascular endothelial cells responded to HA-PLGA NPs and HA-PLGA modified SIS (HA-PLGA-SIS) with elevated cell proliferation. HA-PLGA-SIS significantly enhanced neo-vascularization in an in ovo chorioallantoic membrane angiogenesis model. The angiogenic capability of the newly fabricated HA-PLGA-SIS was tested in a canine bladder augmentation model. Urinary bladder augmentation was performed in beagle dogs following hemi-cystectomy using HA-PLGA-SIS. The regenerated bladder was harvested at 10 weeks post augmentation and vascularization was evaluated using CD31 immunohistochemical staining. Bladder regenerated with HA-PLGA-SIS had significantly higher vascular ingrowth compared to unmodified SIS. This study shows that HA-PLGA NPs may represent a new approach for modifying naturally derived SIS biomaterials in regenerative medicine.
Journal of Biomedical Materials Research Part A 03/2010; 94(3):712-9. · 2.63 Impact Factor
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ABSTRACT: To characterize aldo-keto reductase 1C3 (AKR1C3) expression in surgically-removed cryptorchid testes. Human AKR1C3 is a monomeric, cytoplasmic, multifunctional enzyme that reduces ketosteroids, ketoprostaglandins, and lipid aldehydes. AKR1C3 expression has been demonstrated in normal adult Leydig cells and peritubular fibromyocytes. No prior studies have evaluated AKR1C3 expression patterns across different age groups.
Surgically excised cryptorchid testes were subjected to hematoxylin-eosin evaluation to review overall testicular pathology. These samples were then evaluated for AKR1C3 distribution via immunohistochemical staining with a monospecific AKR1C3 monoclonal antibody. Single-pathologist grading of AKR1C3 expression was correlated with clinical presentations.
A total of 16 cryptorchid testes were identified from the 2000 to present. Median age at the time of surgery was 9 years (range, 1-17). The testes were excised due to atrophy, poor tissue consistency, and short spermatic cord length. AKR1C3 expression was identified at all ages in fibromyocytes surrounding the testicular tubules. Leydig cell expression was absent at Tanner stages 1 and 2, while strong expression was found at Tanner stage 3 and beyond. No AKR1C3 expression was seen in germ cells at any stage. AKR1C3 expression was identified in 18%-26% of Sertoli cells in patients at Tanner stages 2 and beyond.
AKR1C3 expression occurs in a Tanner stage dependent-fashion. Pre- and peri-pubertal changes appear to promote expression of the enzyme in Leydig cells. In contrast to the normal adult testis, the pediatric cryptorchid testis reveals AKR1C3 expression in Sertoli cells. Additional studies are warranted to determine the involvement of AKR1C3 in testicular descent and development.
Urology 11/2009; 76(1):67-72. · 2.43 Impact Factor
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ABSTRACT: To examine the histological differences in the inflammatory response and regenerative outcomes of distal vs proximal porcine small intestinal submucosa (SIS) grafts in the rat bladder, as SIS from distal small intestine yields reliable and reproducible bladder regeneration, while SIS from proximal portions of small intestine does not provide similar results.
In all, 30 Sprague-Dawley rats underwent hemi-cystectomy followed by anastomosis of a bladder patch of SIS prepared from either distal or proximal small intestine. After bladder harvest, immunohistochemistry was used to quantify mast cells, eosinophils, macrophages, and neutrophils (PMNs). Total cell count per unit area was compared across the time course in univariate and logistic regression modelling.
There were more eosinophils and mast cells in proximal SIS grafts, while there were more macrophages and PMNs in distal SIS grafts (all P < 0.05). Trichrome analysis showed increased collagen deposition in proximal SIS grafts and little smooth muscle regeneration. There was also significant graft contracture in proximal SIS grafts compared with distal SIS grafts (P < 0.05).
We conclude that the location of SIS origin may evoke different inflammatory responses, which results in altered bladder tissue regeneration.
BJU International 10/2009; 105(10):1462-8. · 2.84 Impact Factor
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ABSTRACT: Small intestinal submucosa (SIS) is a biodegradable scaffold that supports bladder regeneration after partial cystectomy. We sought to define the inflammatory response present in a rat bladder augmentation model using distal ileal SIS. Fifteen Sprague-Dawley rats underwent hemi-cystectomy followed by anastomosis of a bladder patch of SIS. Bladders were excised after days 2, 7, 14, 28, and 56. Tissue regeneration was evaluated by standard hematoxylin and eosin. Immunohistochemical staining was used to quantify neutrophils, macrophages, eosinophils, and mast cells. Total cell counts per unit area were compared between native and graft portions of the bladder for each cell type across the entire time course. Statistical analyses were conducted with the Wilcoxon Rank-Sum and Kruskal-Wallis tests. All tests were two-sided with significance set at p < 0.05. These inflammatory responses evolved consistently across all bladders over time. Neutrophil and eosinophil numbers were highest at day 2 and decreased over the 56-day period. In contrast, macrophage and mast cell numbers were low at days 2, 7, and 14; peaked at day 28; and decreased once again at day 56. Cell counts at native and graft sites were equivalent for all cell types, except neutrophils, which were more commonly found in the graft (124 vs. 24 cells/mm(2), p = 0.009). Thus, the inflammatory processes change over time during SIS-mediated bladder regeneration. Similar cell densities are present between the native and SIS portions of the bladder, but neutrophils predominate in the graft areas.
Tissue Engineering Part A 04/2009; 15(11):3241-6. · 4.64 Impact Factor
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ABSTRACT: Infections due to methicillin resistant Staphylococcus aureus are becoming increasingly prevalent in hospitals and in the community. We reviewed our institutional experience to determine whether methicillin resistant S. aureus is becoming a more common cause of bacteriuria and to determine if there are specific risk factors that may predict the development of methicillin resistant S. aureus bacteriuria.
We reviewed all urine cultures with a pure growth of a single organism obtained at our institution from 1997 and 2007. Patients with urine cultures positive for methicillin resistant S. aureus were compared to a cohort with cultures positive for methicillin sensitive S. aureus, and to a third cohort with cultures positive for Escherichia coli to determine patient characteristics and associated risk factors.
We identified 7,100 and 9,985 positive urine cultures performed in 1997 and 2007, respectively. The most common urinary organism was E. coli. The number of patients with methicillin resistant S. aureus bacteriuria increased from 18 (0.3%) to 74 (0.8%) (p <0.001). On multivariate analysis older age (p = 0.004), catheter use (p = 0.004), hospital exposure (p <0.001) and patient comorbidity (p <0.001) were associated with methicillin resistant S. aureus bacteriuria compared with E. coli bacteriuria.
Methicillin resistant S. aureus remains rare as a cause of bacteriuria but its incidence has increased during the last decade. Risk factors for methicillin resistant S. aureus bacteriuria include increased age, patient comorbidity, hospital exposure and catheter use. For patients with these risk factors and new onset urinary symptoms, methicillin resistant S. aureus should be considered a possible cause of urinary tract infection.
The Journal of urology 03/2009; 181(4):1694-8. · 4.02 Impact Factor
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ABSTRACT: Originating from Africa, India, and the Middle East, frankincense oil has been important both socially and economically as an ingredient in incense and perfumes for thousands of years. Frankincense oil is prepared from aromatic hardened gum resins obtained by tapping Boswellia trees. One of the main components of frankincense oil is boswellic acid, a component known to have anti-neoplastic properties. The goal of this study was to evaluate frankincense oil for its anti-tumor activity and signaling pathways in bladder cancer cells.
Frankincense oil-induced cell viability was investigated in human bladder cancer J82 cells and immortalized normal bladder urothelial UROtsa cells. Temporal regulation of frankincense oil-activated gene expression in bladder cancer cells was identified by microarray and bioinformatics analysis.
Within a range of concentration, frankincense oil suppressed cell viability in bladder transitional carcinoma J82 cells but not in UROtsa cells. Comprehensive gene expression analysis confirmed that frankincense oil activates genes that are responsible for cell cycle arrest, cell growth suppression, and apoptosis in J82 cells. However, frankincense oil-induced cell death in J82 cells did not result in DNA fragmentation, a hallmark of apoptosis.
Frankincense oil appears to distinguish cancerous from normal bladder cells and suppress cancer cell viability. Microarray and bioinformatics analysis proposed multiple pathways that can be activated by frankincense oil to induce bladder cancer cell death. Frankincense oil might represent an alternative intravesical agent for bladder cancer treatment.
BMC Complementary and Alternative Medicine 02/2009; 9:6. · 2.24 Impact Factor
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ABSTRACT: Iatrogenic ureteral injury in children is a rare occurrence, with sparse literature available regarding optimal repair techniques. We reviewed our experience in the management of iatrogenic pediatric ureteral injuries, particularly with respect to initial versus delayed diagnoses.
All pediatric iatrogenic ureteral injuries repaired by a single surgeon during 1986-2007 were reviewed.
Ten injuries were repaired over 20 years. Median patient age was 12 years. Injuries occurred during five open tumor resections, three laparoscopic procedures and two ureteroscopies. Diagnosis was immediate in four patients. Median ureteral defect length was 4 cm (range 2-5). All underwent ureteral reimplantation and psoas hitch Boari flap. Median follow up was 1 year, with no obstruction noted. Diagnosis was delayed in six patients by a median of 21 days. Five children (83%) were managed by temporary percutaneous nephrostomy tube and one (17%) by ureteral stent. Delayed repair was performed 1-3 months later. In the patients with laparoscopic or ureteroscopic injuries the median ureteral defect length was 4 cm (range 3-6). All underwent ureteral reimplantation and psoas hitch Boari flap. Median follow up was 1 year, with no obstruction noted. One child had a proximal ureteral defect 8 cm long; delayed ileal ureter was performed with good results 4 years postoperatively.
Pediatric iatrogenic ureteral injuries are rare and may be repaired by both immediate and delayed techniques as circumstances demand. Standard techniques used in the adult population may be employed in children with the expectation of good long-term results.
Journal of pediatric urology 11/2008; 5(1):53-5. · 1.38 Impact Factor
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ABSTRACT: In patients with unilateral vesicoureteral reflux (VUR), it has been suggested that injection of a non-refluxing but cystoscopically abnormal contralateral ureteral orifice (UO) with dextranomer/hyaluronic acid (Dx/HA) should be performed to prevent the development of de-novo contralateral VUR. We evaluate the effectiveness of this practice.
Patients with primary unilateral VUR undergoing injection of Dx/HA from 2002 to 2005 at two institutions were eligible. Patients with unilateral VUR with cystoscopically abnormal contralateral UOs were injected with Dx/HA, while patients with normal appearing UOs received no treatment. Multivariate logistic regression models were used to estimate the impact of prophylactic injection on the development of de-novo contralateral VUR.
In total, 101 patients with unilateral VUR and an abnormal appearing contralateral UO underwent prophylactic injection of Dx/HA while 45 patients with a normal appearing contralateral UO were untreated. In patients receiving prophylactic Dx/HA, 9% (9/101) of the previously non-refluxing ureters developed de-novo VUR. Similarly, 13% (6/45) of patients with a normal appearing UO treated by observation alone developed de-novo VUR (P=0.55). The overall incidence of 10% (15/146) de-novo contralateral VUR matches published results where this protocol was not followed.
Our findings suggest that cystoscopic assessment and prophylactic treatment of an abnormal appearing, non-refluxing contralateral UO with Dx/HA is of little clinical benefit and should be abandoned.
Journal of pediatric urology 08/2008; 4(4):260-4. · 1.38 Impact Factor
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ABSTRACT: The prevalence of methicillin resistant Staphylococcus aureus is increasing. However, little is known about methicillin resistant S. aureus in the genitourinary tract, particularly in children. We assessed the incidence of pediatric genitourinary methicillin resistant S. aureus superficial abscess requiring surgical intervention.
We reviewed the records of all children undergoing surgical debridement of superficial abscess at a single institution between 1995 and 2007. We assessed surgical site, organism identity, patient comorbidity, methicillin resistant S. aureus risk factors, number of procedures and patient outcome.
Surgical debridement of a superficial genitourinary abscess was performed in 60 children. Patient age ranged from 29 days to 17 years (median 3 years). A single debridement was generally curative, with only 5 patients (8.3%) requiring more than 1 procedure. One patient (1.7%) died of sepsis postoperatively due to Pseudomonas infection. One patient had myelomeningocele, 1 had undergone renal transplant and 2 were undergoing chemotherapy at the time of debridement. None of these 3 patients had a methicillin resistant S. aureus infection. Methicillin resistant S. aureus was more common in the groin/genitalia and less common in the perineum (p = 0.007). The incidence of methicillin resistant S. aureus increased during the study period, accounting for none of 40 infections between 1995 and 2003, and 8 of 20 (40%) from 2004 to 2007 (p <0.001).
Methicillin resistant S. aureus has become the predominant organism causing pediatric superficial genitourinary abscesses at our institution, accounting for three-quarters of all surgically managed infections in the last 2 years. Methicillin resistant S. aureus was more common at the groin and genitalia. One debridement was generally curative, and patient morbidity was low with aggressive treatment.
The Journal of urology 08/2008; 180(4):1472-5. · 4.02 Impact Factor
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ABSTRACT: Despite tremendous gains in improving prognosis, 10% of patients with Wilms tumor will ultimately experience disease recurrence. The identification of novel prognostic markers and tumor associated targets for patients at risk could enable clinicians to treat recurrences more aggressively and, thus, optimize outcomes. We have previously shown that tumor expression of the T cell coregulatory ligand B7-H1 portends a poor prognosis for adults with renal cell carcinoma and represents a promising target to improve therapy. We hypothesize that this finding may be true for Wilms tumor.
We identified 81 patients with Wilms tumor treated at 1 institution between 1968 and 2004. Histopathological features, including Wilms tumor B7-H1 expression, were correlated with clinical observations and outcome.
Tumor recurrences were noted in 22% of patients with Wilms tumor and 14% died. B7-H1 was expressed in 11 tumors (14%) and was more likely to occur in anaplastic Wilms tumor (p = 0.03). Tumor B7-H1 expression was associated with a 2.7-fold increased risk of recurrence, although this difference did not achieve statistical significance (p = 0.06). However, in favorable histology tumors B7-H1 expression was associated with a 3.7-fold increased risk of recurrence (p = 0.03).
B7-H1 is expressed by Wilms tumor, correlates with tumor biology and is associated with an increased risk of recurrence in patients with favorable histology tumors. B7-H1 may prove useful in identifying high risk patients who could benefit from more aggressive initial treatment regimens, and may represent a promising therapeutic target. Multi-institutional studies to elucidate the role of B7-H1 in the treatment of Wilms tumor are warranted.
The Journal of urology 06/2008; 179(5):1954-9; discussion 1959-60. · 4.02 Impact Factor
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ABSTRACT: Prostate biopsy remains the gold standard for detection of prostate cancer (PCa). This study was performed to determine whether saturation biopsy (>or= 24 cores) detects more prostate cancer than a standard 12-18 core office biopsy technique.
We conducted a nonrandomized cohort study of a consecutive series of prostate biopsies. The primary outcome assessed by both univariate and multivariate analysis was the detection of PCa, whereas the secondary outcomes of HGPIN (high-grade prostatic intraepithelial neoplasia) and ASAP (atypical small acinar proliferation) were also analyzed.
From September 2005 to June 2006, a total of 469 patients undergoing prostate biopsy were included in this study. A standard office prostate biopsy was performed in 301 men, whereas 168 underwent a saturation biopsy. Age, body mass index (BMI), prostate volume, and family history of PCa were similar. However, patients in the saturation biopsy cohort were more likely to have had prior biopsies, higher prebiopsy PSA, longer PSA doubling times, and to carry more frequent diagnoses of HGPIN or ASAP (all p<0.05). After adjusting for covariates, saturation biopsy did not detect more abnormal pathology than standard office prostate biopsy, including PCa (OR, 1.2; p=0.339), HGPIN (OR, 1.4; p=0.368), or ASAP (OR, 2.2; p=0.201).
Saturation biopsy does not appear to detect more abnormal prostate pathology than standard office biopsy of the prostate. This procedure may be associated with increased cost and patient morbidity.
European Urology 05/2008; 53(5):976-81. · 8.49 Impact Factor
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ABSTRACT: Previous studies have shown that the cure rates after dextranomer/hyaluronic acid (Dx/HA) injection can be decreased in patients with neurogenic bladder, previous ureteroneocystostomy, duplicated ureters, or periureteral diverticula. We attempted to determine whether these factors reduce the efficacy of Dx/HA injection compared with that in otherwise normal patients.
All children with vesicoureteral reflux (VUR) undergoing Dx/HA injection from April 2002 to March 2006 at two institutions were eligible for this study. Multivariate logistic regression models were built to assess the effect of bladder/ureteral anomalies on the success of Dx/HA injection. We adjusted for previously described predictors of injection success, including VUR grade, sex, age, surgeon experience, and injection technique.
A total of 543 refluxing ureters (373 patients) were included, of which 145 (27%) had persistent VUR on postoperative voiding cystourethrography; 86 ureters (16%) had anatomic anomalies. On univariate analysis, the most important predictors of injection failure were increasing VUR grade, male sex, younger age, subureteral injection, ureteral duplication anomaly, increasing Dx/HA volume, and surgeon experience. On multivariate analysis, however, the only significant predictors of injection failure were increasing VUR grade, subureteral injection technique, and surgeon experience. No anatomic or functional abnormalities, considered individually or grouped, significantly affected the probability of injection failure.
In our experience, children with functional and anatomic bladder/ureteral anomalies were no more likely to have Dx/HA injection fail than were children with uncomplicated VUR. The most important predictors of Dx/HA success remained VUR grade, injection technique, and surgeon experience. Dx/HA injection in patients with complex bladders could be a reasonable therapeutic option.
Urology 04/2008; 71(3):435-8. · 2.43 Impact Factor
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ABSTRACT: A prospective, double-blind, 3-arm, parallel group, randomized clinical trial was performed to compare 3 anesthetic techniques for preventing pain during prostate biopsy.
A total of 243 men undergoing a 12-core prostate biopsy were randomized to 1 of 3 anesthetic methods: 1) seminal vesical-prostatic base blockade, 2) intraprostatic blockade, and 3) apical-rectal blockade. Pain was estimated with the 10-point visual analog scale. Multivariate logistic regression evaluated factors predictive of pain. The Kruskal-Wallis test analyzed overall group comparisons and the Steel-Dwass test assessed between-group comparisons in pain scores. Proportional odds ordinal logistic regression quantified the ability of covariates and treatment arms to predict biopsy pain. These values are presented as odds ratios with confidence intervals (OR, 95% CI).
From November 2005 to June 2006, 81 men were randomized to 3 study arms. Lidocaine administration was the most painful element of the procedure, while probe insertion was the least. Apical biopsies were routinely more painful than mid-gland biopsies, which were more painful than base biopsies. The apical-rectal blockade was the most painful to administer, but has lasting effects and led to better pain control than the prostatic base-seminal vesicle blockade. Similarly, the intraprostatic blockade was more effective than the prostatic base-seminal vesicle blockade. Besides pain reported at the time of anesthetic injection, no difference was identified between the intraprostatic and apical-rectal blockades.
Mid and apical biopsies of the prostate are more painful than base biopsies. The seminal vesicle-prostatic base blockade is less effective than intraprostatic and apical-rectal blockade at controlling pain.
Cancer 11/2007; 110(8):1708-14. · 4.77 Impact Factor
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ABSTRACT: Numerous factors have been postulated to increase success rates for dextranomer/hyaluronic acid injection for vesicoureteral reflux. Ureteral hydrodistention combined with intraureteral injection reportedly improves injection success rates. We combined the results of 5 pediatric urologists to evaluate the efficacy of this technique compared to that of subtrigonal-only injection in relation to other factors.
Patients with primary vesicoureteral reflux undergoing dextranomer/hyaluronic acid injection from April 2002 to December 2005 at 2 institutions were eligible. Only patients with primary vesicoureteral reflux were included in the study. Injection success was defined as the complete absence of reflux on followup voiding cystourethrogram or radionuclide cystogram. Predictors of a successful outcome were analyzed statistically with logistic regression. Factors included in our analysis were gender, age, vesicoureteral reflux grade, dysfunctional voiding, amount of injected dextranomer/hyaluronic acid, injection technique (intraureteral vs subureteral) and surgeon.
A total of 301 patients (453 ureters) with a median age of 5.5 years met inclusion criteria, of whom 199 (66%) were cured at 3 months of followup. Of the patients 145 (48%) underwent subureteral injection and 156 (52%) underwent ureteral hydrodistention combined with intraureteral injection. On multivariate analysis only vesicoureteral reflux grade (p <0.001) and surgeon (p = 0.01) were significantly predictive of injection success. There was a trend toward significance with ureteral hydrodistention combined with intraureteral injection (p = 0.056).
In our multivariate model only vesicoureteral reflux grade and surgeon were independently predictive of injection success in patients with primary, uncomplicated vesicoureteral reflux. There was a trend toward improved results with ureteral hydrodistention combined with intraureteral injection, although this did not achieve statistical significance.
The Journal of Urology 11/2007; 178(4 Pt 2):1702-5; discussion 1705-6. · 3.75 Impact Factor
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ABSTRACT: Urachal anomalies are often recognized in children but they may persist into adulthood and cause considerable morbidity. We reviewed the clinical findings associated with these embryological structures and evaluated risk factors for cancer to define the optimal timing for intervention.
We examined the medical records of 176 patients diagnosed with a urachal anomaly between 1951 and 2005. Association of clinicopathological features with malignancy for adults was evaluated using univariate and multivariate logistic regression studies.
Urachal remnants were identified in 46 children and 130 adults. Of the 46 children 20 (43%) presented with umbilical drainage and 23 (50%) could be diagnosed by physical examination. A total of 34 children (74%) underwent simple excision. In contrast, 65 of the 130 adults (50%) presented with hematuria, 78 (60%) required cystoscopy and 53 (41%) required computerized tomography. A total of 66 adults (51%) required more extensive surgical intervention with partial or radical cystectomy. Of adult urachal anomalies 66 (51%) were malignant. Patient age 55 years or older and hematuria were the strongest predictors of urachal malignancy (each p <0.001). Cancer risk increased with advancing adult age.
Urachal anomalies present and progress differently in pediatric and adult populations. Adults are at high risk for urachal cancer but children usually incur lower morbidity. Urachal lesions noted early in childhood should be excised to prevent problems in adulthood.
The Journal of Urology 11/2007; 178(4 Pt 2):1615-8. · 3.75 Impact Factor
