Treatment of primary nocturnal enuresis persisting into adulthood

PURPOSE

We evaluate the therapeutic effectiveness of treating monosymptomatic primary nocturnal enuresis (PNE) that has persisted into adulthood.

MATERIALS AND METHODS

Patients older than 18 years with persistent monosymptomatic primary nocturnal enuresis were treated with 20 to 40 microg. desmopressin (DDAVP) nightly for 6 months. If the patients remained incontinent on maximal pharmacotherapy or if they became incontinent after cessation of DDAVP we initiated treatment with an enuretic alarm for 6 months. Patients not responsive to DDAVP or the enuresis alarm were given a trial of 50 mg. imipramine nightly. All patients were reassessed for continence 18 months after initiation of the treatment protocol.

RESULTS

We treated 29 patients of a median age of 20 years (range 18 to 33) who were enuretic more than 4 nights per week. With the initial DDAVP treatment 19 (66%) became continent (enuresis 0 or 1 night a month) but after discontinuation of DDAVP only 2 (7%) remained continent. Of the 27 patients subsequently treated with an enuretic alarm 9 (33%) became continent and 18 had persistent enuresis. Of these 18 patients 11 resumed DDAVP and became dry, while 7 nonresponsive to DDAVP were given imipramine and 2 (29%) are continent.

CONCLUSIONS

Overall, 83% of patients (24 of 29) achieved continence, including 38% (11 of 29) who are continent off all treatment modalities and 45% (13 of 29) who are currently continent on pharmacotherapy (11 on DDAVP and 2 on imipramine). The remaining 17% of patients (5 of 29) have persistent primary nocturnal enuresis recalcitrant to all therapeutic attempts.

Late onset recurrent penile chordee after successful correction at hypospadias repair

PURPOSE

Artificial erections are induced at hypospadias repair to prevent recurrent chordee. We describe the development and etiology of late onset recurrent chordee greater than 10 years after the initial surgery.

MATERIALS AND METHODS

We reviewed the medical records of 22 patients with a median age of 4 years at surgery who were referred for evaluation of chordee 10 years after successful hypospadias repair.

RESULTS

Of the 22 patients with recurrent chordee 13 had penoscrotal and 9 had proximal penile hypospadias at the initial operation. All originally required corporoplasty for the release of chordee, including Nesbit procedure in 19 and tunica vaginalis graft in 3. Successful artificial erections were induced after corporoplasty in all cases. Urethral reconstruction was performed with full-thickness preputial free grafts in 11 cases, bladder mucosal grafts in 7 and transverse island flap urethroplasty in 4. Although chordee developed during puberty (median age of onset 16 years, range 12 to 18), the median age at presentation for surgical correction was 21 years. Recurrent chordee was due to extensive fibrosis of the reconstructed urethra in 7 cases (32%), corporeal disproportion in 8 (36%) and both conditions in 7 (32%).

CONCLUSIONS

A successful artificial erection induced at hypospadias surgery does not prevent the delayed onset of recurrent chordee. Recurrent chordee may be secondary to the redevelopment of corporeal disproportion and/or extensive urethral fibrosis.

Micropenis in hypogonadotropic hypogonadism: response of the penile androgen receptor to testosterone treatment

PURPOSE

We determine whether testosterone therapy alters penile androgen receptor expression within the hypogonadotropic hypogonadal (HPG) micropenis.

MATERIALS AND METHODS

In protocol 1 a strain of mice with micropenis due to congenital HPG and wild type litter mates were divided into testosterone treated and untreated groups. Treatment was initiated on day 15 of life. On day 90 of life (day 75 of treatment) the mice were sacrificed, and the penises were removed and weighed. In protocol 2 microphallic mice treated with testosterone were sacrificed on days 0, 6, 30, 60 and 75 after the initiation of treatment. Untreated HPG and wild type litter mates served as controls. At autopsy the penis was removed and weighed, and androgen receptor content was determined by Western immunoblotting.

RESULTS

Testosterone treatment resulted in 6-fold up regulation in HPG penile androgen receptor, approximately 1.4-fold higher than in the normal wild type pubescent penis. Testosterone induced and wild type pubescent penile androgen receptor up regulation was maintained for approximately 75 and 60 days, respectively. Despite improved HPG penile androgen receptor expression penile growth did not become normal. Average total penile weight plus or minus standard deviation was 7.2+/-3.5 mg. in untreated HPG mice. Testosterone significantly improved average HPG penile weight to 23.5+/-1.8 mg. (p <0.001). However, the testosterone treated micropenis failed to reach average normal penile size (38.6+/-2.6 mg., p <0.001).

CONCLUSIONS

Testosterone increases the concentration and duration of penile androgen receptor expression within the HPG micropenis. Despite this improvement microphallic HPG penile growth does not become normal.

Characterization of penile androgen receptor expression in micropenis due to hypogonadotropic hypogonadism

PURPOSE

The recommendation to treat micropenis with androgen early in infancy and childhood is based on the fact that the normal penile androgen receptor decreases in concentration 2 to 3-fold in early adulthood. Hypothetically the early administration of androgen takes advantage of elevated penile androgen receptor concentration, resulting in optimal penile growth. We verify that there are similar patterns of androgen receptor expression in micropenis and the normal penis.

MATERIALS AND METHODS

We used a strain of mice with micropenis due to congenital hypogonadotropic hypogonadism (HPG). Affected mice and normal controls were sacrificed before puberty, and during puberty and early and late adulthood (15, 30, 60 and 90 days, respectively). At autopsy the penis was removed, weighed, pooled and processed for protein extraction. Androgen receptor concentration was determined by Western blot analysis.

RESULTS

In controls penile androgen receptor expression increased 2-fold from before puberty (0.49 fmol./microg. protein) to puberty (0.92 fmol./microg.). At adulthood a 3-fold decrease in penile androgen receptor occurred with the receptor decreasing to 0.33 fmol./microg. in early adulthood and 0.27 fmol./microg. in late adulthood. In HPG animals the penile androgen receptor concentration increased throughout development from 0.20 fmol./microg. before puberty 0.33 fmol./microg. in adulthood.

CONCLUSIONS

Androgen receptor expression in the microphallic HPG penis does not mimic normal developmental penile androgen receptor expression. It remains to be elucidated whether hormonal therapy reverses these deficiencies.

Multi-institutional study of testicular microlithiasis in childhood: a benign or premalignant condition?

PURPOSE

Testicular microlithiasis, a rare ultrasonographic diagnosis in children, has been shown to coexist in benign and malignant conditions. The natural history of incidentally discovered testicular microlithiasis has not been well defined in the pediatric population. The concern that testicular microlithiasis may be a premalignant condition has been raised. Reports indicate as much as a 45% association of germ cell tumors with testicular microlithiasis at the time of tumor diagnosis and there have been 4 cases of interval testicular tumor development associated with preexisting testicular microlithiasis. To address this issue we performed a multi-institutional study to evaluate children with incidentally diagnosed testicular microlithiasis.

MATERIALS AND METHODS

Data on 26 patients with a mean age of 12.3 years at presentation with incidentally discovered testicular microlithiasis were collected from 7 institutions. Presenting scrotal conditions were reviewed. Two children with a previous testicular malignancy were excluded from study.

RESULTS

Followup ranged from 1 month to 7 years (mean 27.6 months). Testicular biopsy and tumor marker (alpha-fetoprotein and beta-human chorionic gonadotropin) determinations were performed in 9 and 15 patients, respectively. To date no testicular tumor has developed during clinical followup.

CONCLUSIONS

Our multi-institutional study has not yet shown a trend toward the malignant degeneration of incidentally diagnosed testicular microlithiasis in children. However, we still advocate close surveillance of patients with testicular microlithiasis, such as yearly testicular ultrasound, physical examination, and judicious tumor marker determinations. We propose that a registry be started to follow prospectively patients with testicular microlithiasis to define its significance better.

Bladder dysfunction and management in multiple sclerosis

Symptomatic bladder dysfunction occurs at some time in most patients with multiple sclerosis. The relapsing-remitting course and progressive loss of mobility associated with multiple sclerosis make management of urinary urgency and incontinence difficult. Urodynamic evaluation serves as a guideline for appropriate treatment. After accurate diagnosis of bladder dysfunction, a management program is developed with use of fluid schedules, voiding techniques, neuropharmacologic manipulation, intermittent catheterization, surgical treatment, and other adjunctive measures as indicated. The goals of treatment are to protect and preserve renal function, relieve symptomatic voiding dysfunction, and avoid subsequent urinary complications. A management program should be individualized, dynamic, and monitored with periodic, systematic urologic review to maintain these goals.

Hypertension after surgical management of renal duplication associated with an upper pole ureterocele

PURPOSE

Duplicated upper pole systems associated with a ureterocele frequently have areas of segmental renal dysplasia. Since dysplasia has been related to the development of renin mediated hypertension, we hypothesized that preservation of functional upper pole moieties may result in an increased incidence of high blood pressure.

MATERIALS AND METHODS

We evaluated 115 patients with a history of renal duplication and an ipsilateral upper pole ureterocele. Patients were separated into group 1-nonfunctional upper pole managed by partial nephrectomy, group 2-functional upper pole moiety managed by partial nephrectomy and group 3-functional upper pole moiety managed by a nephron sparing procedure. All charts were reviewed for hypertension, febrile urinary tract infection, vesicoureteral reflux and renal scarring.

RESULTS

At a median followup age of 15 years (range 1 to 33) hypertension developed in 13 of the 115 patients (11%), including 8 of the 87 (9%) with nonfunctional upper pole systems managed by partial nephrectomy, 1 of the 12 (8%) with a functional upper pole moiety managed by partial nephrectomy and 4 of the 16 (25%) with a functional upper pole system managed by an upper pole salvage procedure. Statistical evaluations failed to reveal any relationship between hypertension and preservation of the upper pole system or between hypertension and vesicoureteral reflux. Rather, elevation in blood pressure was found to be related to development of a renal scar after a febrile urinary tract infection.

CONCLUSIONS

Hypertension in patients with a history of renal duplication associated with a ureterocele is directly related to renal scarring.

Intestinal metaplasia is not a strong risk factor for bladder cancer: study of 53 cases with long-term follow-up

OBJECTIVES

Intestinal metaplasia often coexists with adenocarcinoma of the urinary bladder, suggesting to some investigators that it is premalignant. However, the natural history and long-term outcome of intestinal metaplasia in isolation are unknown. We report 53 cases of intestinal metaplasia of the urinary bladder followed for more than 10 years.

METHODS

We reviewed the Mayo Clinic surgical pathology files between 1926 and 1996 and all patients with exstrophic bladder recorded in the files of the Hospital for Sick Children (Toronto, Ontario, Canada) and Dallas Children's Hospital (Dallas, Texas) between 1953 and 1987, and identified all patients with intestinal metaplasia of the bladder.

RESULTS

A total of 53 cases were identified from both series, and none of the patients developed adenocarcinoma of the bladder. The Mayo Clinic series consisted of 24 patients. Nineteen of the 24 (79.1%) were alive without evidence of cancer (median follow-up 14 years, range 0.9 to 53), and 5 patients died of intercurrent disease (at 0.9, 4, 8, 11, and 53 years after diagnosis) without evidence of bladder cancer. The Dallas Children's Hospital and the Hospital for Sick Children series consisted of 29 patients. Twenty-seven of the 29 (93.1%) were alive without evidence of cancer (median follow-up 13 years, range 3 to 23.9). Two patients died of trauma (at 10.9 and 12 years after diagnosis) and at autopsy had no evidence of bladder cancer.

CONCLUSIONS

Intestinal metaplasia of the urinary bladder is not a strong risk factor for adenocarcinoma or urothelial cancer.

Proximal urinary diversion in the management of posterior urethral valves: is it necessary?

PURPOSE

In infants with posterior urethral valves in whom renal function fails to normalize following decompression of the lower urinary tract supravesical urinary diversion is customarily recommended for presumed concomitant ureterovesical junction obstruction. We determined the true incidence of fixed or permanent ureterovesical junction obstruction and the renal prognosis for infants treated with proximal urinary diversion.

MATERIALS AND METHODS

We evaluated 26 patients with posterior urethral valves treated with supravesical urinary diversion. Mean gestational age at birth was 35 weeks (range 27 to 40). After initial decompression via an indwelling catheter for a median of 7 days (range 4 to 18) persistently high serum creatinine was present (median 2.5 mg./dl., range 1.9 to 3.5). One month after proximal urinary diversion median creatinine was 1.3 mg./dl. (range 0.5 to 2.8). At 1 year, median nadir creatinine was 1.0 mg./dl. (range 0.3 to 2.5). At reconstruction a Whitaker test in all 26 patients (52 renal units) demonstrated fixed ureterovesical junction obstruction in 2 units (4%).

RESULTS

Renal biopsy in 44 of the 52 renal units (85%) revealed renal dysplasia. At a median followup of 9 years (range 1 to 14) end stage renal disease developed in 11 patients (42%).

CONCLUSIONS

In neonates with posterior urethral valves who undergo proximal urinary diversion fixed ureterovesical junction obstruction is rare, renal biopsy invariably demonstrates areas of renal dysplasia and end stage renal disease frequently develops despite proximal diversion. These findings lead us to question the necessity of supravesical urinary diversion.

Endoscopic management of infected enlarged prostatic utricles and remnants of rectourethral fistula tracts of high imperforate anus

PURPOSE

Infected enlarged prostatic utricles and infected remnant fistula tracts of high imperforate anus are usually managed by a suprapubic, transtrigonal or posterior sagittal approach. We describe a minimally invasive endoscopic approach to these entities.

MATERIALS AND METHODS

We treated 12 patients with infected enlarged prostatic utricles and 4 with infected remnant fistula tracts using endoscopic techniques. Specifically a resectoscope with a bulb electrode or a cystoscope with a Bugby electrode was used to fulgurate circumferentially the dilated utricle or remnant fistula. After fulguration a Councill catheter was placed in the lesion for 3 to 5 days and urine was diverted via a suprapubic tube for 2 to 3 weeks. Obliteration of the abnormality was verified by a voiding cystourethrogram.

RESULTS

Using this technique median postoperative hospital stay was 2 days (range 0 to 7). The enlarged prostatic utricle or remnant fistula tract was completely obliterated in 87% of the cases (62% after 1 and 25% after 2 treatments). Of our patients 13% had a significant (greater than 50%) decrease in utricular cyst size although a urethral abnormality persisted. Postoperative morbidity was minimal. One patient (6%) had a fever for 3 days postoperatively and none has had a urethral stricture during a median followup of 2 years (range 3 months to 4 years).

CONCLUSIONS

Although it is not a panacea, electrofulguration of an enlarged prostatic utricle and/or remnant fistula of imperforate anus is a simple procedure that has a high rate of success, does not require prolonged hospitalization and is associated with minimal morbidity.

Nocturnal enuresis: a guide to evaluation and treatment

Nocturnal enuresis has several possible causes, including genetic inheritance, reduced bladder capacity, sleep disorders, abnormal secretion of antidiuretic hormone, psychologic abnormalities, neurologic dysfunction, bacteriuria, and diet. A through assessment of the patient's voiding history is of major importance in the management of nocturnal enuresis. Whether the patient has monosymptomatic or polysymptomatic nocturnal enuresis must be determined. Treatment options include pharmacotherapy, behavioral modification with an alarm system, or a combination of these modalities. In order for treatment to be successful, the physician, patient, and patient's parents must be involved in the decision-making process.

Ureteropelvic junction obstruction with concurrent renal pelvic calculi in the pediatric patient: a long-term followup

PURPOSE

We determined the long-term prognosis of the pediatric patient presenting with simultaneous ureteropelvic junction obstruction and a renal calculus.

MATERIALS AND METHODS

We retrospectively reviewed all individuals younger than 17 years who presented to our institutions with simultaneous ureteropelvic junction obstruction and an ipsilateral renal calculus.

RESULTS

Simultaneous ureteropelvic junction obstruction with nonstruvite calculi was present in 22 patients, while 6 had struvite calculi. Median age at diagnosis was 11 years (range 5 to 16). During a median followup of 9 years (range 2 to 38) renal calculi recurred in 19 patients (68%), including 10 (36%) with 1 and 9 (32%) with 2 or more recurrences. Median time to first stone recurrence was 11 years (range 2 to 38). Of the 22 patients with nonstruvite calculi 15 (68%) had recurrence. An identifiable metabolic etiology for renal lithiasis was found in 13 of these patients (87%). In contrast, only 2 of the 7 patients (29%) with nonstruvite calculi and no recurrent stones had an identifiable abnormality. This finding suggests that the presence of an identifiable metabolic abnormality significantly predisposes to recurrent nonstruvite renal lithiasis (p < 0.01).

CONCLUSIONS

Of the pediatric patients presenting with simultaneous ureteropelvic junction obstruction and a renal calculus 68% will have recurrent renal lithiasis. It remains to be determined whether active treatment of coexisting metabolic abnormalities could prevent or reduce the incidence of recurrent stone disease.

Congenital adrenal hyperplasia: is there an effect on penile growth?

PURPOSE

Experimental evidence in rodents suggests that prepubertal exposure to excess androgens may prematurely down regulate the penile androgen receptor and cause micropenis in adulthood. To evaluate the effect of prepubertal androgens on human penile growth we reviewed phallic development in male patients with congenital adrenal hyperplasia.

MATERIALS AND METHODS

We retrospectively reviewed the records of 12 patients with 21-hydroxylase deficiency. Stretched penile length was recorded at diagnosis and at last followup. Bone age, height and weight were recorded at each visit.

RESULTS

At diagnosis mean z-score for stretched penile length (z-score equals the number of standard deviations above or below the mean, that is z-score for micropenis equals -2.5) was 2.95 (1.23 to 4.88). Final mean z-score for stretched penile length in adulthood was -1.70 (-2.96 to 1.87). Mean decrease in z-score for diagnosis until the last followup was -4.68 (-1.08 to -6.82). Only 2 of the 12 patients (17%) had micropenis in adulthood. Notably excessive adrenal androgen production resulted in diminutive stature with median height in adulthood in the 10th percentile.

CONCLUSIONS

These findings suggest that excessive prepubertal androgen exposure due to congenital adrenal hyperplasia is associated with a reduction in adult somatic height but it does not routinely result in micropenis.

The effects of androgen administration on phallic androgen receptor expression

PURPOSE

Whether androgens down regulate the androgen receptor during penile development is controversial. We investigated the effects of androgens on penile androgen receptor expression.

MATERIALS AND METHODS

We injected prepubertal hypogonadotropic hypogonadal microphallic rats with testosterone or dihydrotestosterone. Specimens were obtained at 3 (prepuberty), 9 (puberty to early postpuberty) and 12 weeks (late postpuberty). At necropsy we compared penile size and androgen receptor expression of these animals to those of age matched nontreated hypogonadotropic hypogonadal and normal controls.

RESULTS

At age 3 weeks prepubertal androgens up regulated androgen receptor expression and significantly increased penile size compared to normal and untreated hypogonadotropic hypogonadal controls. By 9 weeks the normal down regulation of androgen receptor that occurs with maturation was present. Prepubertal androgens failed to accelerate or exaggerate the normal maturational loss of the androgen receptor. At 9 weeks penile size of normal controls and prepubertal androgen treated animals was identical. Interestingly despite down regulation of the penile androgen receptor, normal animals continued to have increases in penile size between 9 and 12 weeks, while the prepubertal androgen treated animals had no penile growth.

CONCLUSIONS

Prepubertal androgen administration in hypogonadotropic hypogonadal animals resulted in diminutive penises in adulthood. However, the decrease in penile size was not associated with an accelerated or exaggerated down regulation of the androgen receptor. This finding coupled with continued growth of the normal control penises after androgen receptor down regulation suggests that cessation of penile growth may not be solely related to down regulation of the penile androgen receptor.

Micropenis secondary to growth hormone deficiency: does treatment with growth hormone alone result in adequate penile growth?

PURPOSE

Congenital growth hormone deficiency is associated with aberrant androgen physiology and micropenis. We investigated whether treatment with growth hormone alone is adequate to restore normal phallic growth.

MATERIALS AND METHODS

In all patients the diagnosis was isolated growth hormone deficiency and micropenis, and growth hormone was the only therapy. Stretched penile length, and somatic height and weight measurements were available from diagnosis through puberty for all patients.

RESULTS

Eight patients diagnosed with isolated congenital growth hormone deficiency and micropenis were treated and evaluated. Mean z-score (number of standard deviations below mean stretched penile length) at diagnosis was -4.25 (range 3.1 to -6.6) with -2.5 representing micropenis. In adulthood mean final stretched penile length z-score was -1.73 (range -0.91 to -2.66). Seven of the 8 patients (87.5%) had stretched penile length within normal range.

CONCLUSIONS

Our findings suggest that growth hormone therapy alone can result in normal phallic size in patients with micropenis secondary to isolated congenital growth hormone deficiency.

Vesical neck reconstruction in patients with the exstrophy-epispadias complex

PURPOSE

We evaluated the factors critical in achieving urinary medicine continence in patients with the exstrophy-epispadias complex.

MATERIALS AND METHODS

A total of 51 patients with epispadias and 33 with classic bladder exstrophy underwent vesical neck reconstruction. Patient records were reviewed to identify factors associated with achievement of continence, including timing of bladder closure and urethroplasty, effect of bladder capacity before and after vesical reconstruction, and effect of enterocystoplasty.

RESULTS

Complete urinary continence was achieved in 42 of the 51 patients with epispadias (82%) and in 23 of the 33 with exstrophy (70%). Delayed bladder closure did not affect the ability to gain continence but increased the likelihood of subsequent enterocystoplasty (12 of 19 patients, 63%) compared to early bladder closure (5 of 14 patients, 36%).

CONCLUSIONS

Preliminary urethroplasty did not enhance urinary control or reduce the need for enterocystoplasty. Bladder capacity before vesical neck reconstruction did not predict the need for enterocystoplasty or ultimate continence status in individuals. Adequate bladder capacity after vesical neck reconstruction was an important determinant of urinary continence. Approximately half of the patients bladder exstrophy (17 of 33) required augmentation cystoplasty to achieve urinary continence.

Treatment of extensive urethral hemangioma with KTP/532 laser

BACKGROUND AND OBJECTIVE

Urethral hemangiomas are rare. They vary in size from pinpoint masses to extensive honeycomb-shape deformities leading to significant hematuria. For extensive lesions, therapeutic options have included extensive surgical resection and reconstruction or multistaged neodymium:yttrium-aluminum-garnet (Nd:YAG) laser photocoagulation. We report our experience with the use of potassium titanyl phosphate (KTP/532) laser for treatment of the extensive form.

STUDY DESIGN/MATERIALS AND METHODS

A 7-year-old boy presented with a 2-week history of urethral bleeding. He had extensive hemangiomas of the genital and perineal regions. Cystourethroscopy disclosed diffusely scattered honeycomb-shape hemangiomatous malformation of the anterior urethra. KTP/532 laser energy was delivered transurethrally to the hemangiomatous areas until they blanched.

RESULTS

The Foley catheter was removed 24 hours postoperatively, and the patient voided clear urine without difficulty. He has remained trouble-free for more than 2 years.

CONCLUSION

Judicious endoscopic single-stage therapy with KTP/532 laser may obviate open surgical intervention in most cases of extensive and symptomatic urethral hemangiomas. In view of our observation and the literature, KTP/532 laser therapy should be considered the first line of treatment.

The hormonal control of testicular descent

Descent of the testes is a complex event mediated by hormonal and mechanical factors. At present we hypothesize that testicular descent occurs as the result of the secretion of descendin from a normal testicle. Descendin secretion results in selective growth of the gubernacular cells. Gubernacular outgrowth results in masculinization of the inguinal canal. At the beginning of testicular descent, the patent processus migrates into the inguinal canal, transmitting intraabdominal pressure to the gubernaculum. The gubernaculum in turn applies traction to the testicle to introduce the testicle into the inguinal canal. Descent of the testes into and through the inguinal canal is an interplay between intraabdominal pressure transmitted by a patent processus vaginalis and androgen-induced gubernacular regression. Specifically, we hypothesize that androgens under control of an intact fetal hypothalamic-pituitary axis alter the viscoelastic properties of the gubernaculum. Reductions in the turgidity of the gubernaculum allow intraabdominal pressure to push the testicle into the scrotum. Functional abnormalities in any of the above factors will result in cryptorchidism.

Flutamide-induced cryptorchidism in the rat is associated with altered gubernacular morphology

OBJECTIVES

One of the major controversies regarding descent of the testes is whether androgenic regulation of the gubernaculum testes exists. To determine if antiandrogens can alter the development of the gubernaculum within the fetus, the following experiment was performed.

METHODS

Timed pregnant Sprague-Dawley rats were treated with either flutamide, dihydrotestosterone (DHT), or vehicle alone (controls) from gestational day (GD) 15 to 17. Fetal specimens were removed via cesarean section on GD 18 and 20. Serial coronal sections were obtained, and digital microscopy with computer-assisted reconstruction was used to ascertain the morphology of the three components of the gubernaculum, that is, the gubernacular cord and the mesenchymal and muscular components of the gubernacular bulb.

RESULTS

Flutamide significantly prevented and DHT significantly enhanced gubernacular cord regression compared with controls (P < 0.01). Flutamide also resulted in a significant inhibition of the gubernacular bulb outgrowth, with diminution of both the mesenchymal and muscular components of the gubernacular bulb.

CONCLUSIONS

These data suggest that androgens play an active role in gubernacular cord regression and gubernacular outgrowth within the fetal rodent.

Continuous epidural anesthesia after ureteroneocystostomy in children

We retrospectively reviewed the records of 101 pediatric patients who underwent uncomplicated ureteral reimplantation and were treated with postoperative epidural catheters for pain management. A total of 50 pediatric patients treated without epidural anesthesia was used as the control group. Length of hospital stay, time to first bowel activity, doses of narcotics, incidence of postoperative fever and evidence of epidural catheter related morbidities were documented. The costs of postoperative epidural anesthesia versus standard analgesics were compared. There was no significant difference in length of hospital stay or return of bowel function between treatment groups. Total doses of narcotics given during the hospital stay were significantly less for the epidural group (p < 0.05). The children given epidural anesthesia also had a significant increase in the incidence of postoperative fever (p < 0.05) and 25% had catheter related problems that often resulted in early removal of the epidural catheter. The cost of pain management using an epidural catheter was significantly greater than that of the standard narcotic regimen ($708 versus $14, p < 0.001). Continuous epidural infusion provides satisfactory pain control after ureteroneocystostomy in children without delaying hospital discharge. This technique of pain management is associated with a significant increase in the incidence of postoperative fever and overall cost compared to standard methods of postoperative pain management.

Urinary pH and urea concentration correlate to the bacterial colonization rate in gastric, colonic, ileal and myoperitoneal bladder augmentation

We investigated how various types of augmentation cystoplasty alter the native bacteriostatic properties of urine, particularly urinary urea and pH, in the Sprague-Dawley rat. The augmentation cystoplasties studied included 1 cm.2 and 2 cm.2 patches of colon, ileum and stomach as well as myoperitoneal bladder flaps. Augmentations in order of decreasing incidence of bacteriuria and urinary pH are 2 cm.2 ileal greater than 1 cm.2 ileal greater than 2 cm.2 colonic greater than 1 cm.2 colonic greater than myoperitoneal greater than cystotomy alone greater than 1 cm.2 gastric greater than 2 cm.2 gastric. Urinary urea concentrations were similar between cystotomy alone, and myoperitoneal and gastric augments. In contrast, all colonic and ileal augments had significantly lower urea concentrations compared to the aforementioned groups. Our findings suggest that the type and size of augmentation directly affect urinary pH and urea nitrogen concentration, and the incidence of bacteriuria.

Current concepts in the pathophysiology of testicular undescent

At present, we believe that descent of the testes within the human is a complex event mediated by both hormonal and mechanical factors. We hypothesize that descent of the testes occurs as a result of the secretion of an androgen-independent factor from a normal testis (descendin). This paracrine factor is responsible for the rapid proliferation (outgrowth) of the ipsilateral gubernaculum. The development of the gubernaculum results in creating a dilated inguinal canal, the width of which matches the testicular width. Descent of the testes through the inguinal canal is an interplay between abdominal pressure, a patent processus vaginalis, and androgen-induced gubernacular regression. We hypothesize that androgens (under control of an intact hypothalamic pituitary axis) alter the viscoelastic properties of the gubernaculum, reducing the turgidity of the gubernaculum and allowing intra-abdominal pressure to push the testis into the scrotum. Cryptorchidism can therefore result when any one or more of the involved factors malfunction.