[Show abstract][Hide abstract] ABSTRACT: The surgical management of pediatric stone disease has evolved significantly over the last three decades. Prior to the introduction of shockwave lithotripsy (SWL) in the 1980s, open lithotomy was the lone therapy for children with upper tract calculi. Since then, SWL has been the procedure of choice in most pediatric centers for children with large renal calculi. While other therapies such as percutaneous nephrolithotomy (PNL) were also being advanced around the same time, PNL was generally seen as a suitable therapy in adults because of the concerns for damage in the developing kidney. However, recent advances in endoscopic instrumentation and renal access techniques have led to an increase in its use in the pediatric population, particularly in those children with large upper tract stones. This paper is a review of the literature focusing on the indications, techniques, results, and complications of PNL in children with renal calculi.
Advances in Urology 10/2011; 2011:123606. DOI:10.1155/2011/123606
[Show abstract][Hide abstract] ABSTRACT: Pyeloplasty for ureteropelvic junction obstruction in children has traditionally been performed using an open technique. Although laparoscopic pyeloplasty has been shown to be comparable and possibly superior to open pyeloplasty in adult studies, such results in the pediatric population are limited. We evaluated outcomes between transperitoneal laparoscopic and open pyeloplasty in children.
All children 1 to 18 years old with ureteropelvic junction obstruction requiring operative repair were offered enrollment in the study. Patients were prospectively randomized to either transperitoneal laparoscopic or open pyeloplasty through a flank incision.
We reviewed 20 patients (mean age 7.8 years) who underwent laparoscopy and 19 (7.2 years) who underwent open surgery (p = 0.48). Mean followup was similar between the groups (laparoscopic 8.1 months vs open 11.1 months, p = 0.38). Mean operative time was 151 minutes (range 94 to 213) for laparoscopy and 130 minutes (83 to 225) for open surgery (p = 0.09). Mean hospitalization was 29.3 hours (range 20.5 to 48) for laparoscopy and 36.2 hours (24 to 73) for open surgery (p = 0.06). Analgesic usage was similar between the groups. One failure in the open arm required a revision. Operative, hospital, anesthetic and total charges were similar between the groups.
Laparoscopic pyeloplasty appears to be a safe and effective alternative to open pyeloplasty in children. Although the cost is similar, there is a trend toward longer operative times in the laparoscopic group but a shorter overall hospitalization. As more patients are enrolled in the study, these differences may prove significant.
The Journal of urology 08/2010; 184(2):690-5. DOI:10.1016/j.juro.2010.03.062 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the classic view of bladder development the trigone originates from the mesoderm derived wolffian ducts while the remainder of the bladder originates from the endoderm derived urogenital sinus. Recent molecular developmental studies have questioned the veracity of this received wisdom, suggesting an endodermal origin for the trigone. To shed further light on this issue we observed mesenchymal-epithelial interactions between trigone epithelium and fetal urogenital sinus mesenchyma to infer the trigonal germ layer of origin.
Mouse trigone epithelium was recombined with fetal rat urogenital sinus mesenchyma in tissue recombinant grafts that were placed beneath the renal capsule of athymic mouse hosts. Grafts were harvested at 4 weeks. Control grafts with bladder dome and ureteral epithelium were also examined. Tissues were evaluated with hematoxylin and eosin, and Hoechst dye 33258 to confirm cell species origin. Immunohistochemistry was done with androgen receptor, broad spectrum uroplakin, dorsolateral prostate secretions and seminal vesicle secretions to differentiate prostatic and seminal vesicle differentiation.
Grafts of mouse trigone epithelium with fetal rat urogenital sinus mesenchyma yielded epithelial tissue that stained for dorsolateral prostate secretions but not for seminal vesicle secretions. Control grafts of bladder dome epithelium yielded the expected endodermal prostate differentiation. Control grafts of ureteral epithelium yielded the expected mesodermal seminal vesicle differentiation.
The consistent finding of prostatic epithelium in tissue recombinants of trigone epithelium and fetal urogenital sinus mesenchyma reinforces the hypothesis that the trigone is derived from the endoderm and not from the mesoderm, as commonly accepted.
The Journal of urology 11/2009; 183(1):386-91. DOI:10.1016/j.juro.2009.08.107 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To gain better understanding of ESWL efficacy in children with renal calculi we report our outcomes using this technique.
We reviewed the records of children who underwent ESWL as monotherapy for renal calculi at our institution from 1988 to 2007. Data included clinical characteristics, stone-free rate and its relationship to stone size and location, lithotriptor and complications.
The 33 boys and 29 girls with an average age of 10 years underwent a total of 69 treatments. A 53% and 63% stone-free rate was achieved after 1 and 2 ESWL sessions, respectively. A trend toward a higher stone-free rate (61% to 70%) after 1 ESWL session was seen in children with stones less than 50 mm(2), renal pelvic stones and treatment with the Dornier HM3 lithotriptor. Children with stones greater than 100 mm(2), a caliceal location and those treated with the Dornier MFL 5000 lithotriptor had a higher failure rate (25% to 46%). Five patients (8%) required ureteroscopy after ESWL due to retained distal ureteral stone fragments. Five patients (8%) who were not stone-free after therapy required subsequent endoscopic treatment for the stone during followup.
Smaller renal stones, renal pelvic calculi and treatment with an older generation lithotriptor were independent variables associated with a higher stone-free rate in children. While ESWL is a simple method in children with renal calculi, those with large or caliceal stones may do best with a primary endoscopic approach.
The Journal of urology 09/2009; 182(4 Suppl):1824-7. DOI:10.1016/j.juro.2009.03.018 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Dextranomer/hyaluronic acid injection of ureteral orifices is a popular option in the treatment of vesicoureteral reflux, with success rates ranging from 69% to 89%. We found only 1 study that followed patients beyond the initial postoperative voiding cystourethrogram, which describes a 96% success rate at 2 to 5 years but defines success as "nondilating" reflux. We examined our dextranomer/hyaluronic acid series to evaluate the long-term (1-year) outcome in children who had resolution of reflux on initial postoperative voiding cystourethrography.
We retrospectively reviewed our dextranomer/hyaluronic acid experience from February of 2002 to December of 2005. We determined initial success on early (6 to 12-week) postoperative voiding cystourethrogram. We then evaluated long-term success by obtaining a voiding cystourethrogram at 1 year postoperatively in patients who were initially cured of reflux. In addition, success rates between the first and second halves of our experience were evaluated to account for surgeon experience and modification of technique.
Our total success rate at initial voiding cystourethrogram was 73% (246 of 337 total ureters). The success rate in the first half of our experience was 65.9% (112 of 170 ureters) and in the second half was 80.2% (134 of 167). A total of 150 ureteral units with initial successful dextranomer/hyaluronic acid treatment were evaluated at 1 year by voiding cystourethrogram. Of these ureters 111 had continued resolution of vesicoureteral reflux, for a long-term success rate of 74%. Including initial postoperative failures, the complete 1-year total success rate was 46.1% (111 of 241 ureters).
Although the reflux resolution rates at initial postoperative voiding cystourethrogram approach those of open surgery, there is a significant failure rate at 1 year, which warrants long-term followup.
The Journal of urology 03/2009; 181(4):1869-74; discussion 1874-5. DOI:10.1016/j.juro.2008.12.005 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Methicillin resistant Staphylococcus aureus is a virulent organism that has seen a rapid increase in prevalence. Community associated methicillin resistant S. aureus is discussed frequently in the infectious disease community. However, there has been little mention of this entity in the urological literature.
We reviewed the records of patients presenting with skin/soft tissue infections or documented methicillin resistant S. aureus infection treated at an academic pediatric urology practice between October 2004 and August 2006.
A total of 12 patients were included (33% female, 67% male). Mean patient age was 49 months (range 8 to 202). Of the patients 11 (92%) presented with spontaneous infection and 1 (8%) presented with a wound infection. Abscess location was inguinal in 4 patients (33%), scrotal in 3 (25%), perineal in 2 (17%), perinephric in 2 (17%) and labial in 1 (8%). The most common presenting sign at referral was fluctuance (30%). While all patients eventually required surgical drainage, initial treatment by the primary care physician consisted of observation on oral antibiotics in 7 patients (58%). A total of 10 cultures (83%) revealed methicillin resistant S. aureus and 2 cultures (17%) were negative. Mean hospital stay was 5 days (range 0 to 16). Postoperatively, most patients (58%) were discharged home on oral trimethoprim-sulfamethoxazole. Mean followup was 4 months (range 0 to 15). Recurrence was seen in 3 patients at 1 to 15 months postoperatively (mean 6.3).
Methicillin resistant S. aureus is increasing in the community and will likely be seen more often in pediatric and adult urological practices. The regional differences among bacterial strains make a standardized approach to these cases difficult. However, increased awareness of this virulent organism is necessary to deliver prompt and successful treatment.
The Journal of urology 04/2008; 179(3):1098-101. DOI:10.1016/j.juro.2007.10.086 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The impact of a fellowship on resident operative experience and education is unclear. We sought to address this issue by comparing resident operative case logs and the pediatric portion of the American Urological Association resident inservice examination at our institution before and after establishing a pediatric urology fellowship in 2002.
Pediatric operative case logs of all urological residents from 1998 to 2006 at Vanderbilt University were reviewed. We recorded index and total number of cases as specified by the Accreditation Council for Graduate Medical Education. All residents had completed 6 months of pediatric urology training. Statistical analysis was performed using 2-sample equal variance Student t tests. We compared the 8 index categories and total index cases performed by residents, scores on the pediatric portion of the American Urological Association inservice examination and resident average percentiles for index cases referenced to national data, before and after the implementation of an Accreditation Council for Graduate Medical Education accredited pediatric urology fellowship.
Before implementation of the pediatric urology fellowship residents performed significantly more hypospadias procedures, pyeloplasties, renal surgeries, ureteroneocystostomies and urinary/bowel diversions (p <0.05), while the total number of index cases performed was not significantly affected (p = 0.13). In contrast, after the fellowship was started residents performed more hydrocelectomies/hernia repairs (p = 0.01). Compared to national averages for index cases in 2004 to 2005, residents maintained greater than the 50th percentile in all categories except urinary diversion, which was between the 30th and 50th percentiles. Furthermore, residents were in the 70th to 90th percentile in 3 of 9 categories, and greater than the 90th percentile in 3, including total number of index cases. No statistically significant difference in the area of pediatric urology was observed on the resident inservice examination scores before and after the fellowship was established.
Residents performed significantly fewer index cases in some areas following initiation of a pediatric urology fellowship at Vanderbilt University, although the total number of index cases performed by residents remained unchanged. Despite the presence of a fellow, residents have remained at or well above the national average in all index case categories except urinary diversion. Moreover, establishment of a fellowship did not negatively impact the educational experience as measured by American Urological Association resident inservice examination scores, specifically in the area of pediatric urology. Choosing the optimal time to institute a fellowship should be made with fellow and resident education as the utmost priority. Periodic review of the data should also be performed to maintain consistent, positive experiences for fellowship and residency training.
The Journal of urology 02/2008; 179(2):720-3; discussion 723. DOI:10.1016/j.juro.2007.09.104 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We examined the role of transforming growth factor-beta in urothelial and bladder development. Transforming growth factor-beta signaling was attenuated in the urothelial compartment and the subsequent effects were examined in a tissue recombination model.
Urothelium was cultured from adult rat bladders and transfected with control vector C7Delta or mutant DNIIR (dominant negative transforming growth factor-beta receptor II). Grafts were created by recombining transfected urothelium plus embryonic day 18 bladder mesenchyma and placed beneath the renal capsule of athymic mouse hosts. Grafts were harvested at 21 and 42 days. Final tissues were evaluated with staining and immunohistochemistry using hematoxylin and eosin, Gomori's trichrome strain, broad-spectrum uroplakin, smooth muscle actin-alpha, phosphorylated SMAD2 and Ki67 antigen. Bladder structures were defined as having smooth muscle, suburothelial connective tissue and mature urothelium expressing uroplakin. Urothelial compartment diameters were measured and subcategorized as small--0.10 to 0.40, medium--0.41 to 1.0 and large--greater than 1.1 mm.
At 21 days 14 C7Delta control and 15 DNIIR grafts were evaluated. No bladder tissue was seen in the C7Delta grafts vs 49 in DNIIR tissue, including 30 small, 9 medium and 10 large tissues. At 42 days 14 C7Delta and 12 DNIIR grafts were evaluated. Six bladder structures (5 small and 1 medium) were seen in the C7Delta cohort vs 27 (14 small, 7 medium and 6 large) in the DNIIR group. Immunohistochemical detection of phosphorylated-SMAD2 was significantly attenuated in DNIIR tissue. In addition, Ki67 proliferative indexes were 4.0-fold higher in the DNIIR cohort compared to those in C7Delta tissues.
We successfully observed that primary urothelium cultures can be genetically manipulated and recombined with undifferentiated mesenchyma to grow bladder tissue. By attenuating transforming growth factor-beta signaling in the urothelium superior bladder tissue growth occurred, suggesting that transforming growth factor-beta is a growth inhibitor in this organ system.
The Journal of Urology 11/2007; 178(4 Pt 2):1643-9. DOI:10.1016/j.juro.2007.03.163 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cloacal exstrophy is rare and it represents a reconstructive challenge. Options for managing the urinary tract include primary closure or approximation of the bladder halves in the midline with later closure. We present our observations and evolving thoughts concerning optimal treatment in these patients.
We retrospectively reviewed the records of patients with cloacal exstrophy seen in the last 5 years. Initial management was examined, including complete primary closure vs a staged approach. We noted midline defects, spinal cord abnormalities or other anatomical reasons that precluded primary closure.
Seven patients, including 5 females and 2 males, were identified. An omphalocele noted in all 7 patients was closed in 5 at initial operation. All underwent preservation of the hindgut in the fecal stream. Spinal cord tethering was noted in 7 of 7 cases. Complete primary bladder closure was performed in 3 of the 7 patients, while the size of the bladder plates or a large abdominal wall defect precluded closure in the remainder. Continence was not achieved in the 3 cases closed primarily. All patients achieving urinary continence underwent bladder neck closure and augmentation cystoplasty with a continent catheterizable channel.
Patients with cloacal exstrophy have anatomical issues that can prevent complete primary bladder closure or preclude the achievement of urinary continence. The high incidence of tethered cord places these patients at risk for upper tract changes and bladder decompensation during followup. Despite successful primary closure in 3 of 7 patients all have a tiny bladder and require secondary procedures to become continent. Extensive dissection during the first operation can contribute to more difficult dissection with potential increased morbidity during subsequent surgeries. Therefore, the best initial approach for the typical patient may be closure of the abdominal wall and approximation of the exstrophied bladder halves in the midline. Secondary closure with continent diversion and reconstruction of the external genitalia can be performed at ages 18 to 24 months.
The Journal of Urology 11/2007; 178(4 Pt 2):1632-5; discussion 1635-6. DOI:10.1016/j.juro.2007.03.164 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The incidence of testicular ascent of a previously descended but retractile testis is reported to be between 2% and 45%. It has been our bias that only a small percent of retractile testes ascend and ultimately require orchiopexy.
We performed a retrospective review of all retractile testes diagnosed by any of 4 pediatric urologists at our institution from 1996 to 2005. A retractile testis was defined as one that could be brought to at least the mid scrotum without tension despite a history of maldescent or a retractile nature. Patients were excluded if followup was less than 6 months or they had a history of ipsilateral inguinal surgery. A followup telephone survey was done in patients not reexamined at resolution.
A total of 172 patients met our inclusion criteria and were followed to resolution. A total of 274 retractile testes were initially identified, including 26% unilateral and 74% bilateral testes. A total of 19 testes ascended and ultimately required orchiopexy within a followup of 6 to 101 months. A patent processus vaginalis was identified in 13 cases (68%). Another 235 patients initially seen with a diagnosis of retractile testis who had no followup examination at our institution were contacted via telephone. This set of boys initially had a total of 392 involved testes, of which 2 underwent orchiopexy elsewhere before resolution. The incidence of secondary ascent was 3.2% in the combined set of patients.
Retractile testes can ascend and, therefore, they require followup until resolution. In our experience most retractile testes do not require surgery.
The Journal of Urology 11/2007; 178(4 Pt 2):1722-4; discussion 1724-5. DOI:10.1016/j.juro.2007.05.091 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Manipulatable models of bladder development which interrogate specific pathways are badly needed. Such models will allow a systematic investigation of the multitude of pathologies which result from developmental defects of the urinary bladder. In the present communication, we describe a model in which mouse embryonic stem (ES) cells are directed to differentiate to form bladder tissue by specific interactions with fetal bladder mesenchyme. This model allows us to visualize the various stages in the differentiation of urothelium from ES cells, including the commitment to an endodermal cell lineage, with the temporal profile characterized by examining the induction of specific endodermal transcription factors (Foxa1 and Foxa2). In addition, final functional urothelial differentiation was characterized by examining uroplakin expression. It is well established that ES cells will spontaneously develop teratomas when grown within immunocompromised mouse hosts. We determined the specific mesenchymal to ES cell ratios necessary to dictate organ-specific differentiation while completely suppressing teratomatous growth. Embryonic mesenchyme is well established as an inductive tissue which dictates organ-specific programming of epithelial tissues. The present study demonstrates that embryonic bladder mesenchyme can also steer ES cells towards developing specific endodermal derived urothelium. These approaches allow us to capture specific stages of stem cell differentiation and to better define stem cell hierarchies.
[Show abstract][Hide abstract] ABSTRACT: To report our experience of testicular and paratesticular tumours in children, as such tumours are rare, and historically yolk sac tumour has been described as the most common lesion in children, but recent reports suggest that benign testicular lesions might be more common.
We reviewed retrospectively the records of children treated for testicular tumours from 1998 to 2005. The patients' age, clinical presentation, diagnostic procedures, treatment methods, histopathological findings, and outcome were recorded. Patients aged>144 months and those with non-primary metastatic lesions were excluded.
In all, 11 patients met our criteria, with a mean age of 37 months (range 9 days to 144 months). Pathological analysis revealed teratoma in four patients, yolk sac tumour in two, epidermoid cysts in two, extrarenal nephroblastomatosis in one, and paratesticular rhabdomyosarcomas in two. The most common clinical presentation was a painless testicular mass. Depending on the clinical presentation and pathology, scrotal ultrasonography, tumour markers (alpha-fetoprotein and beta-human chorionic gonadotrophin), and/or staging computed tomography (CT) were obtained in eight patients. All patients had a radical orchidectomy. Three patients had elevated tumour markers that normalized after orchidectomy. CT revealed extensive mediastinal adenopathy in one patient with rhabdomyosarcoma. Chemotherapy was administered to both patients with rhabdomyosarcoma.
Although there were few patients, most of the lesions were benign tumours, with the most common histological subtype being teratoma. As both malignant and paratesticular lesions occurred at a significant frequency, we would continue to advocate an initial radical inguinal approach at which time testis-sparing could be considered if the preoperative evaluation was favourable, and frozen-section analysis at the time of surgery confirms a benign lesion.
BJU International 05/2007; 99(5):1123-6. DOI:10.1111/j.1464-410X.2007.06906.x · 3.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We sought to evaluate the use of subureteral dextranomer/hyaluronic acid copolymer injection for persistent vesicoureteral reflux following ureteroneocystostomy.
We performed a retrospective review of patients who had undergone dextranomer/hyaluronic acid injection between 2002 and 2005 for persistent vesicoureteral reflux following ureteroneocystostomy. Analysis included evaluation of patient demographics, reflux grades, voiding dysfunction, reflux resolution rates and operative complications. Success was defined as no reflux on voiding cystourethrogram at 1 to 6 months postoperatively.
A total of 12 cases with 14 refluxing ureters were reviewed. Of the 12 patients treated 9 (10 ureters) had adequate followup. Mean followup was 10 months. Seven of 10 ureters (70%) demonstrated resolution of reflux after the initial injection. A second dextranomer/hyaluronic acid injection resulted in complete resolution in 2 of the 3 failed ureters (67%). Resolution in the remaining failed ureter could not be assessed due to insufficient patient followup. In children with adequate followup success was ultimately achieved in 9 of 9 ureters (100%) using up to 2 injections. A comparison of clinical factors between patients with success after the initial injection and those requiring 2 injections showed that the presence of persistent voiding dysfunction was the only parameter that was statistically significant. All patients tolerated the procedure without complications.
Considering the difficulties inherent in repeat surgery and the high success rate of dextranomer/hyaluronic acid injection in this series, this treatment is an appealing and reasonable option for patients with persistent vesicoureteral reflux following open ureteroneocystostomy.
The Journal of Urology 02/2007; 177(1):312-5. DOI:10.1016/j.juro.2006.08.084 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE To report our experience of testicular and paratesticular tumours in children, as such tumours are rare, and historically yolk sac tumour has been described as the most common lesion in children, but recent reports suggest that benign testicular lesions might be more common. PATIENTS AND METHODS We reviewed retrospectively the records of children treated for testicular tumours from 1998 to 2005. The patients' age, clinical presentation, diagnostic procedures, treatment methods, histopathological findings, and outcome were recorded. Patients aged >144 months and those with non-primary metastatic lesions were excluded. RESULTS In all, 11 patients met our criteria, with a mean age of 37 months (range 9 days to 144 months). Pathological analysis revealed teratoma in four patients, yolk sac tumour in two, epidermoid cysts in two, extrarenal nephroblastomatosis in one, and paratesticular rhabdomyosarcomas in two. The most common clinical presentation was a painless testicular mass. Depending on the clinical presentation and pathology, scrotal ultrasonography, tumour markers (alpha-fetoprotein and beta-human chorionic gonadotrophin), and/or staging computed tomography (CT) were obtained in eight patients. All patients had a radical orchidectomy. Three patients had elevated tumour markers that normalized after orchidectomy. CT revealed extensive mediastinal adenopathy in one patient with rhabdomyosarcoma. Chemotherapy was administered to both patients with rhabdomyosarcoma. CONCLUSION Although there were few patients, most of the lesions were benign tumours, with the most common histological subtype being teratoma. As both malignant and paratesticular lesions occurred at a significant frequency, we would continue to advocate an initial radical inguinal approach at which time testis-sparing could be considered if the preoperative evaluation was favourable, and frozen-section analysis at the time of surgery confirms a benign lesion.
BJU International 02/2007; 99(5). DOI:10.1111/j.1464-410X.2007.06796.x · 3.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the pediatric population urodynamic evaluation for nonneurological causes has been previously reported as a low yield endeavor when considering patients with a primary diagnosis of dysfunctional voiding. We evaluated the rate of clinically significant urodynamic findings that would drive therapeutic intervention for a spectrum of urological disorders in pediatric patients without neurological deficit in whom initial conventional management had failed.
We retrospectively reviewed the charts of patients who had undergone urodynamics in the last 7 years. Patients with known neurological deficits were excluded.
A total of 805 pediatric urodynamic evaluations were performed from December 1997 to July 2004 at our institution, including 89 in patients with no known neurological diagnosis and charts available for review. Of the urodynamic studies 33 (37.1%) were reported as normal and 56 patients (62.9%) had clinically significant discoveries. Storage phase abnormalities were the predominant finding in 37 patients (66.1%), including uninhibited detrusor contractions in 31 (55.4%). Emptying phase abnormalities were less common (19 patients or 33.9%). There was no difference in the percent of patients with positive urodynamics findings depending on sex.
In our analysis evaluation of all recent urodynamics performed at a single institution revealed a high rate of pathological findings in patients with various nonneurological diagnoses.
The Journal of Urology 11/2006; 176(4 Pt 2):1835-7. DOI:10.1016/j.juro.2006.03.125 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We reviewed our experience with continent catheterizable channels with interest in the timing of conduit related complications.
A retrospective review was performed of the outcome of continent catheterizable channels in all patients between 1998 and 2003 who had undergone construction of an antegrade continence enema and/or a Mitrofanoff procedure using appendix, small bowel or continent cutaneous vesicostomy. We performed a total of 117 such stomas in 37 male and 41 female patients 2.5 to 20 years old (mean age 8.9). For the antegrade continence enema we used appendix in 92% of cases, an ileal Yang-Monti tube in 6% and a cecal tube in 2%. For the continent catheterizable channel we used appendix in 43% of cases, a Yang-Monti tube in 38% and continent cutaneous vesicostomy in 19%.
Continence was achieved in 98% of patients. Followup was 6 to 71 months (mean 28.4). There were 27 channel related complications (23%). Stomal stenosis occurred in 7 antegrade continence enema procedures (14%) within 1 to 10 months (mean 6.2) and in 9 continent bladder channels (13%), including 5 continent cutaneous vesicostomies, within 1 to 24 months (mean 9.4) after surgery. False passages occurred in 5 antegrade continence enema procedures (10%) within 1 to 13 months (mean 3.6) and in 4 continent catheterizable channels (6%) within 1 to 13 months (mean 6.5) after surgery. Of patients with stomal stenosis 50% were treated with surgical revision, while the remainder was successfully treated with dilation. Most false passages were managed by catheter drainage alone. Reasons for revision were contained perforation, colovesical fistula and inability to catheterize. Patient noncompliance appeared to have a role in stomal stenosis.
Continent catheterizable stomas help patients achieve bowel and bladder continence. Stomal incontinence after reconstruction is rare. In our experience most stoma related complications occurred in the first year after reconstruction. Experience with more patients and longer followup will help determine whether such problems continue to accumulate with time or whether continent stomas function well with time, particularly after the initial period of healing.
The Journal of Urology 11/2006; 176(4 Pt 2):1816-20; discussion 1820. DOI:10.1016/S0022-5347(06)00610-0 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Tissue recombination is a powerful method to evaluate the paracrine-signaling events that orchestrate the development of organs using the in vivo environment of a host rodent. Studies have reported the successful generation of primary cultures of rodent bladder urothelium, but none have reported their use to recapitulate bladder tissue with tissue recombination. We propose that primary cultured bladder urothelium, when recombined with inductive embryonic bladder mesenchyme, will form bladder tissue in a recombination model. Adult rat bladders were isolated and urothelium obtained. Sheets of bladder urothelium were re-suspended in collagen and maintained in tissue culture. After expansion (>20 passages), the urothelium was recombined with embryonic day-14 mouse bladder mesenchyme, then grafted beneath the renal capsule of immunocompromised mouse hosts. Grafts were harvested after 28 days. Control grafts were performed with bladder mesenchyme alone, cultured bladder urothelium alone, and collagen matrix alone. Final tissues were evaluated with staining and immunohistochemistry (H&E, Gomori's trichrome, broad-spectrum uroplakin, and smooth muscle actin alpha and gamma). Immunocytochemistry on cultured urothelium for broad-spectrum keratin, vimentin, and broad-spectrum uroplakin confirmed pure populations, void of mesenchymal contaminants. Staining of recombinant grafts demonstrated bladder tissue with mature urothelium and stromal differentiation. Control tissues were void of bladder tissue formation. We have successfully demonstrated that a chimeric bladder is formed from primary cultured bladder urothelium recombined with embryonic bladder mesenchyme. This is a powerful new tool for investigating the molecular mechanisms of bladder development and disease. Future applications may include the in vitro genetic manipulation of urothelium and examining those effects on growth and development in an in vivo environment.
[Show abstract][Hide abstract] ABSTRACT: Spina bifida, the most frequent permanently debilitating birth defect, results in major urological problems of voluntary bladder control and bowel function, which may impair quality of life. We prospectively assessed quality of life in patients with spina bifida using child and parent reports simultaneously. This study had 3 goals, that is to 1) document baseline health related quality of life in patients with spina bifida preoperatively, 2) study health related quality of life, reporting differences between parents and children, and 3) study changes in health related quality of life prospectively at preoperative and postoperative intervals.
Patients with spina bifida who were 2 to 18 years old and required reconstructive urological surgery in 2004 were included in the study. Demographic survey and the validated PedsQL 4.0 health related quality of life questionnaire were used preoperatively and postoperatively. A clinical outcomes data set was completed after the clinician saw the patient. PedsQL 4.0 subscales were scored using the algorithms provided.
The response rate was 100%. Mean participant age was 10.3 years. Preoperatively child physical and psychosocial health and school functioning were significantly higher than parent reports (p <0.001). Overall health related quality of life in patients with spina bifida was lower than in healthy children (62.4 vs 85, p <0.001). Six weeks postoperatively significant differences in health related quality of life reporting between parents and children had lowered. Six months postoperatively child emotional and social functioning scores were higher than parent scores (p <0.001). No correlation was found between health related quality of life, and clinical and demographic factors due to insufficient sample size.
Children with spina bifida recorded higher health related quality of life scores than parents/guardians. This health related quality of life study addresses concerns that impact daily quality of life in patients with spina bifida. Future health related quality of life studies in patients with spina bifida should use child self-reports.
The Journal of Urology 10/2006; 176(4 Pt 2):1878-82. DOI:10.1016/S0022-5347(06)00620-3 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Testosterone administered preoperatively in hypospadiac children increases phallic size and improves skin vascularity. We histologically evaluated the role of postoperative testosterone in tissue remodeling in an animal model.
Hypospadias was created in 18 rabbits and repaired with a preputial onlay graft. Animals were randomized to receive either one intramuscular (i.m.) dose of testosterone postoperatively (n=6), or 2 weeks of daily 1% topical testosterone (n=6). Control animals underwent the urethral operation, but received no testosterone (n=6). Penises were harvested at 2 and 5 weeks, and blindly assessed for collagen formation, re-epithelialization and fibrosis, and complications.
Of the animals sacrificed at 2 weeks, those that received testosterone had a greater incidence of cuboidal epithelium (83%) versus controls (33%). In the 2-week group, animals receiving testosterone had increased fibrosis, periurethral and soft-tissue inflammation compared to controls. By 5 weeks, all differences in fibrosis and inflammation had resolved. No animal developed fistula or diverticulum. Of animals sacrificed at 2 weeks, 67% stained for BrdU, a DNA proliferative marker. At 5 weeks, no non-testosterone rabbit demonstrated positive staining, while 83% of those receiving testosterone were positive. There were no differences between animals that received topical and i.m. testosterone.
Administration of testosterone following hypospadias repair in rabbits changes the histologic composition of the urothelium and leads to an exaggerated inflammatory response in the supportive stroma. Such treatment may prove a useful adjunct in patients undergoing complex genital reconstruction.