Disorders of sex development: summaries of long-term outcome studies

Existing outcomes for DSD individuals are inadequate because reports are based upon information collected retrospectively. This paper is presented to review existing data emphasizing information needed to lead to better future care, is based on presentations and discussions at a multi-disciplinary meeting on DSD held in Annecy in 2012, and is not intended to define the present status of management of each of the various DSD diagnoses. Rather it is intended to provide information needed to do studies regarding outcome data from the treatment of children with DSD by providing a summary of recommendations of 'patient-centered' topics that need investigation. The hope is that by being concerned with what is not known, new protocols will be developed for improving both early management and transition to adult life.

Review of recent outcome data of disorders of sex development (DSD): emphasis on surgical and sexual outcomes

This paper is a review of some of the recent publications regarding outcome of DSD patients, with an emphasis upon surgical and sexual outcomes. Currently available outcome studies of patients with DSDs have limitations because of multiple factors, including lack of representative patient sampling, and lack of adequate information concerning both medical and surgical care, and psychological, social and family support. The most frequent reports involve females with 21-α-hydroxylase deficiency congenital adrenal hyperplasia (CAH). This most common form of DSD, if one excludes hypospadias and cryptorchidism, is an excellent example of a form of DSD in which all aspects of outcome, regarding surgery, sexual functionality and sensitivity, psychological input and endocrine hormonal therapy, carry a major role. The goals of therapy include a surgical outcome with a good cosmetic appearance and functionality with potential for sexual intercourse with sufficient sensitivity for satisfactory responsiveness. Endocrine replacement therapy should provide a normal adrenal hormonal milieu, while sex steroid therapy may be indicated. Psychological care should be provided from birth with gradual transition primarily to the patient, including basic counseling with full disclosure, although adjustment depends upon the patient's personality and parents' abilities and acceptance. Among forms of DSD involving gonadal insufficiency, hormonal replacement therapy should provide physiologic levels. Among females, estrogen therapy enhances healing after feminizing surgery and is required from puberty throughout adult life to maintain femininity, sexual organs and bone health, and enhance gender and sexuality. Among males, appropriate testosterone therapy maintains stamina, muscle tone, bone health, libido, sexual potency and general well-being, while benefit for healing after genital surgery is unclear. Further, outcome is clearly related to predominant cultural factors. Outcome studies should include evaluation of all of these factors.

Adenine phosphoribosyltransferase deficiency: an underdiagnosed cause of lithiasis and renal failure

We describe an infant affected by adenine phosphoribosyltransferase (APRT) deficiency diagnosed at 18 months of age with a de novo mutation that has not been previously reported. APRT deficiency is a rare defect of uric acid catabolism that leads to the accumulation of 2,8 dihydroxyadenine (2,8-DHA), a highly insoluble substance excreted by the kidneys that may precipitate in urine and form stones. The child suffered from renal colic due to a stone found in the peno-scrotal junction of the bulbar urethra. Stone spectrophotometric analysis allowed us to diagnose the disease and start kidney-saving therapy in order to avoid irreversible chronic kidney damage. APRT deficiency should always be considered in the differential diagnosis of pediatric urolithiasis.

Functional living skills assessment: a standardized measure of high-order activities of daily living in patients with dementia

AIM

Performance measures are tools aimed to directly evaluate social function in older adults. The authors present the standardization of a new direct performance measure for patients with dementia, the functional living skills assessment (FLSA).

METHODS

FLSA was conceived to detect functional impairment in very mild to moderate patients and to pick up functional modification due to intervention. The patient is asked to perform an activity, and the performance is scored according to completeness and level of assistance required. Eight areas of interest are evaluated (Resources, Consumer Skills, Public Transportation, Time Management, Money management, Leisure, Telephone Skills, Self-Care and Health). Subjects included 54 patients with dementia and 36 normal controls.

RESULTS

Total and partial FLSA scores significantly differed for the two groups (P<0.0001). Performance on FLSA could divide clinical dementia rating (CDR) 0 from CDR 1, CDR 2 e CDR 3 groups. Both sensitivity and specificity were 94%; inter-rater and test-retest reliability was good (P>0.9). Correction scores for education were calculated, while age influence was only marginally significant. Mini Mental State Examination (MMSE) and CDR highly influenced FLSA score (P< 0.0001); FLSA was highly correlated with another performance measure (the Direct Assessment of Functional Status; P=0.821), and with the Instrumental Activity of Daily Living (IADL) scale (P=-0.612), while no significant correlation was present with the Geriatric Depression Scale.

CONCLUSION

FLSA evidences construct, concurrent and discriminative validity. We suggest that this tool could be possibly useful when a high sensibility to different levels of functional impairment is needed, as evaluation of treatment efficacy (both non-pharmacological and pharmacological) identification of relatively intact functional areas to plan cognitive rehabilitation, and confirmation of dementia in the initial phase when there are doubts about functional decline.

Reoperative hypospadias

PURPOSE OF REVIEW

To review recent publications on the surgical treatment of hypospadias failures, including prognostic factors, which may influence final outcome in hypospadias surgery.

RECENT FINDINGS

Interim good outcomes for single-stage dorsal inlay grafting in patients with multiple failed repairs would suggest a greater role for this new technique over other available options. Slowly emerging long-term data confirm our suspicion that a good result early on is not necessarily indicative of a satisfactory long-term outcome.

SUMMARY

Hypospadias surgery remains a considerable technical challenge and improvement will come from the development of specialized units.

Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction

OBJECTIVES

We describe a technique for bulbar urethral reconstruction using a combined dorsal plus ventral double buccal mucosa graft (BMG).

METHODS

From March 2002 to June 2006, 48 men, mean age 35 yr, with bulbar strictures underwent patch urethroplasty using a dorsal plus a ventral double BMG. Average stricture length was 3.65 cm (range: 2-10 cm). The stenotic urethral segment was opened along its ventral surface; the exposed dorsal urethra was incised in the midline to create an elliptical area over the tunica albuginea where the dorsal inlay BMG was placed and quilted to the corpora to augment dorsally the urethral plate. Subsequently, the ventral onlay BMG was sutured to the urethral lateral margins to complete the augmented urethroplasty. Finally, the spongiosum was closed over the graft. Successful reconstruction was defined as normal voiding without the need for any postoperative procedure including dilation.

RESULTS

Mean follow-up was 22 mo (range: 13-59 mo). At the catheter removal 3 wk after surgery, in three patients the voiding cystourethrography showed a fistula, which recovered after a prolonged catheterization. Of 48 cases, 43 (89.6%) were successful and 5 (10.4%) failures with recurrence of the stricture; 4 were treated with internal urethrotomy and 1 with a temporary perineal urethrostomy.

CONCLUSIONS

Preliminary results with a combined double BMG urethroplasty for severe bulbar stricture are encouraging. The double dorsal and ventral graft may provide a simple and reliable solution to achieve an adequate urethral lumen in selected patients.

Hypospadias surgery: when, what and by whom?

Hypospadias is repaired by paediatric surgeons, paediatric urologists, adult reconstructive urologists and plastic surgeons. This review is unique in representing all four specialities, to provide a unified policy on the management of hypospadias. The surgeon of whichever speciality should have a dedicated interest in this challenging work, ideally having an annual volume of at least 40-50 cases. The ideal time for primary repair is at 6-12 months old, although when this is not practicable there is another opportunity at 3-4 years old. A surgical protocol is presented which emphasises both functional and cosmetic refinement. Using a logical progression of a very few related procedures allows the reliable correction of almost any hypospadias deformity. A one-stage repair is used when the urethral plate does not require transection and its axial integrity can be maintained. Occasionally, when the plate is of adequate width and depth, it can be tubularized directly using the second stage of the two-stage repair. When (usually) the urethral plate is not adequately developed and requires augmentation before it can be tubularized, then that second-stage procedure is modified by adding a dorsal releasing incision +/- a graft (alias Snodgrass and 'Snodgraft' procedures). The two-stage repair offers the most reliable and refined solution for those patients who require transection of the urethral plate and a full circumferential substitution urethroplasty. From available evidence this protocol combines excellent function and cosmesis with optimum reliability. Nevertheless, it would be complacent to assume that these gratifying results will be maintained into adult life. We therefore recommend that there is still a need for active follow-up through to genital maturity.

Voiding cystourethrosonography for the diagnosis of vesicoureteral reflux in a developing country

The primary causes of renal insufficiency in Albanian children are reflux nephropathy and obstructive uropathies. The poor availability and technical quality of conventional radiological imaging in detecting vesicoureteral reflux (VUR) and lower urinary tract obstruction stimulated this pilot study, with the aim of evaluating the diagnostic efficacy of voiding cystourethrosonography (CUS). The study included 34 patients (aged 0.1-14 years) with acute pyelonephritis, 7 of whom already had renal insufficiency. In 22 patients voiding cystourethrography (VCUG) was also performed and a diagnostic concordance of 66.6% between the two techniques was found. Overall CUS showed a sensitivity superior to VCUG in detecting VUR, partly due to technical problems in performing the fluoroscopic examination. For the same reasons, VCUG missed 1 diagnosis of posterior urethral valves, while CUS correctly identified all 4 patients with this diagnosis. In 34 patients, CUS diagnosed 55 cases of grade II-V VUR and 11 urinary tract malformations; 12 patients underwent surgical intervention, some of them on the basis of CUS only. The follow-up of 31-81 (mean 53) months after CUS was completed by 94% of patients, excluding complications due to missed diagnoses. CUS was demonstrated to be a safe, reliable, and reproducible imaging modality without X-ray hazards that could be useful in developing countries. The potential limiting factors of the technique include the operator's training and experience and the costs of the contrast medium.

Laparoscopic approach to postoperative adhesive obstruction

BACKGROUND

Some authors have assessed the feasibility of laparoscopy in the treatment of postoperative adhesive obstruction, but conclusions about its effectiveness are related to different selection criteria used for surgery. This paper reports on our experience in laparoscopic adhesiolysis and analyses the results on the basis of the selection criteria used.

METHODS

From January 1993 to December 2001, 65 patients were submitted to laparoscopic adhesiolysis for small bowel obstruction according to specific selection criteria. Of the 65 patients, 40 were admitted for acute obstruction and 25 for chronic or recurrent transit disturbances. Correlation between historical and clinical data and the results of surgical treatment were statistically analyzed.

RESULTS

The procedure was completed by laparoscopy in 52 patients (conversion rate: 20%). Mean postoperative stay was 4.4 days with a 12.3% morbidity and no mortality. Recurrence rate was 15.4%; a single correlation was found between recurrence and age.

CONCLUSIONS

Laparoscopic adhesiolysis in the treatment of small bowel obstructions seems to be effective; further studies are required to define selection criteria for surgery and confirm real advantages in terms of recurrences.

Laparoscopically assisted ureterocystoplasty

OBJECTIVE

To assess the efficacy and safety of laparoscopically assisted ureterocystoplasty (LAU) in children.

PATIENTS AND METHODS

From 1999 to 2001, five patients (mean age 7 years, range 3.5-13) from four centres underwent LAU with laparoscopic mobilization of the small kidney and upper ureter combined with ureterocystoplasty, with exposure of the bladder through a Pfannenstiel incision. The details and outcomes are reviewed.

RESULTS

The LAU was successful in all five patients; there were no complications. A large midline incision was avoided and the LAU carried out through the better tolerated and less painful Pfannenstiel incision.

CONCLUSION

LAU is an appealing technique that is safe with the added benefit of a reduced abdominal incision and acceptable operative duration. This represents the first published report of LAU.

Alpha-dihydroergocryptine in the prophylaxis of migraine: a multicenter double-blind study versus flunarizine

This multicenter, double-blind, clinical study was designed to compare the efficacy and safety of alpha-dihydroergocryptine and flunarizine in the prophylaxis of migraine without aura. One hundred thirty-five patients fulfilling the diagnostic criteria of the International Headache Society were enrolled at five neurologic centers. The study design included a 1-month pretreatment phase with placebo; a 6-month, double-blind, double-dummy treatment phase with alpha-dihydroergocryptine (10 mg twice daily) or flunarizine (5 mg once daily); a further 3-month follow-up phase without treatment. Efficacy was assessed using the patient's diary. Laboratory tests, vital signs, and adverse events were monitored. Analysis of covariance for repeated measures was performed on the intent-to-treat sample. Both treatments led to a significant reduction in the frequency of migraine, days with headache, and use of relief medication. Overall, 51% of those treated with alpha-dihydroergocryptine and 49% of those treated with flunarizine were responders (50% or greater reduction in attack frequency), the average percentage of reduction being 64% with alpha-dihydroergocryptine and 51% with flunarizine. There was no significant difference between the two groups in terms of incidence of adverse events; dizziness and weight gain were the most frequent observed adverse events with alpha-dihydroergocryptine and flunarizine, respectively. Based on the overall improvement in migraine parameters, alpha-dihydroergocryptine can be recommended for use in migraine prophylaxis.

Psychiatric comorbidity and psychosocial stress in patients with tension-type headache from headache centers in Italy. The Italian Collaborative Group for the Study of Psychopathological Factors in Primary Headaches

A multicenter study was carried out in 10 Italian Headache Centers to investigate the prevalence of psychosocial stress and psychiatric disorders listed by the IHS classification as the "most likely causative factors" of tension-type headache (TTH). Two hundred and seventeen TTH adult outpatients consecutively recruited underwent a structured psychiatric interview (CIDI-c). The assessment of psychosocial stress events was carried out using an ad hoc questionnaire. The psychiatric disorders that we included in the three psychiatric items of the fourth digit of the IHS classification were depressive disorders for the item depression, anxiety disorders for the item anxiety, and somatoform disorders for the item headache as a delusion or an idea. Diagnoses were made according to DSM-III-R criteria. At least one psychosocial stress event or a psychiatric disorder was detected in 84.8% of the patients. Prevalence of psychiatric comorbidity was 52.5% for anxiety, 36.4% for depression, and 21.7% for headache as a delusion or an idea. Psychosocial stress was found in 29.5% of the patients and did not differ between patients with and without psychiatric comorbidity. Generalized anxiety disorder (83.3%) and dysthymia (45.6%) were the most frequent disorders within their respective psychiatric group. The high prevalence of psychiatric disorders observed in this wide sample of patients emphasizes the need for a systematic investigation of psychiatric comorbidity aimed at a more comprehensive and appropriate clinical management of TTH patients.

Congenital reflux nephropathy: a follow-up of 108 cases diagnosed perinatally

OBJECTIVE

To determine: (i) the proportion of vesicoureteric reflux (VUR) associated with congenital renal damage and whether it can be severe enough to cause renal impairment from birth: (ii) to evaluate the distribution of males and females affected; and (iii) to describe the course of congenital damage in the first years of life.

PATIENTS AND METHODS

A total of 108 children (76 male and 32 female, M:F 2.3:1), whose VUR was diagnosed before any infection, were followed from birth for a mean (range) of 4.3 (1-10) years. Renal damage was defined by serum creatinine concentration, creatinine clearance and renal imaging (ultrasonography and renal scintigraphy) performed within the first month of life and periodically thereafter.

RESULTS

Of the 108 children, 58 had bilateral and 50 unilateral reflux (total number of refluxing units, 166). High-grade VUR (grade > or = 4) was found in 96 (58%) refluxing renal units (RRUs). Males had a prevalence of bilateral severe (> or = grade 4) reflux (M:F 5.2:1), while in those wit unilateral VUR, the M:F ration was 1.5:1. At birth, mild to moderate damage was present in 56 (36%) RRUs and only associated with VUR of grade > or = 3. Bilateral reflux of grade > or = 4 was associated with congenital moderate/severe renal failure in nine neonates (seven males). In infants with grade > or = 4 VUR who underwent surgical correction, VUR resolved in 92% of cases. In infants with VUR of grade > or = 4 followed medically, the reflux spontaneously resolved in 42% and ameliorated in 16% after 18 months. Serial renal scans during the follow-up showed no progression of renal damage.

CONCLUSIONS

VUR diagnosed at birth on prenatal ultrasonography is associated with congenital damage, with males affected more often than females. The damage involves both kidneys in a consistent proportion and is an important cause of chronic renal impairment from birth. It does not progress in the first years of life if infections are prevented. It is suggested that males with this condition may constitute a major group at risk of developing chronic renal failure in later life.

Tubularized incised plate hypospadias repair for proximal hypospadias

PURPOSE

We report a multicenter experience using tubularized incised plate urethroplasty for proximal hypospadias.

MATERIALS AND METHODS

From August 1993 to December 1996 tubularized incised plate urethroplasty was performed in 27 boys 6 months to 3 years old with mid shaft and penoscrotal hypospadias. In 7 other boys complex reconstruction combined the tubularized incised plate technique for the glanular urethra with other repairs for the proximal urethra.

RESULTS

Tubularized incised plate surgery created a functional neourethra even in penoscrotal hypospadias. Complications of the primary repair developed in only 3 of 27 patients (11%). No complications were attributed to use of the technique for the glanular urethra in complex repairs.

CONCLUSIONS

Tubularized incised plate urethroplasty is a versatile operation that corrects proximal hypospadias defects with few complications and superior cosmetic results.

Tubularized incised plate hypospadias repair for proximal hypospadias

PURPOSE

We report a multicenter experience using tubularized incised plate urethroplasty for proximal hypospadias.

MATERIALS AND METHODS

From August 1993 to December 1996 tubularized incised plate urethroplasty was performed in 27 boys 6 months to 3 years old with mid shaft and penoscrotal hypospadias. In 7 other boys complex reconstruction combined the tubularized incised plate technique for the glanular urethra with other repairs for the proximal urethra.

RESULTS

Tubularized incised plate surgery created a functional neourethra even in penoscrotal hypospadias. Complications of the primary repair developed in only 3 of 27 patients (11%). No complications were attributed to use of the technique for the glanular urethra in complex repairs.

CONCLUSIONS

Tubularized incised plate urethroplasty is a versatile operation that corrects proximal hypospadias defects with few complications and superior cosmetic results.

Tubularized incised plate hypospadias repair: results of a multicenter experience

PURPOSE

We report a multicenter experience using tubularized incised plate urethroplasty to correct distal hypospadias.

MATERIALS AND METHODS

A total of 148 patients underwent repair by 6 pediatric urologists at different institutions in the United States and Europe.

RESULTS

Tubularized incised plate repair created a functional neourethra with a vertically oriented meatus. Complications, including meatal stenoses and fistulas, occurred in 10 patients (7%).

CONCLUSIONS

Tubularized incised plate urethroplasty can be performed in most cases of distal hypospadias. Cosmetic results are superior to those of other popular techniques.

Serum lipoprotein(a) and coronary artery disease in uremic patients on chronic hemodialysis

There is convincing clinical and experimental evidence to support the notion that lipoprotein(a) [Lp(a)] is atherogenic. Patients undergoing chronic hemodialysis have an increased risk of atherosclerotic cardiovascular complications. In the present study, we investigated the possible relation between the alteration, if any, in serum Lp(a) and coronary artery disease in such patients. The mean serum concentration of Lp(a) tended to be higher in the 64 hemodialysis patients than in the 30 normal controls (15.1 +/- 15.2 vs. 9.7 +/- 10.4 mg/dl). However the difference did not reach statistical significance. The prevalence of levels above 30 mg/dl was 14% (9/64) and 10% (3/10), respectively, and the difference was also not statistically significant. Eleven hemodialysis patients with coronary artery disease had a significantly higher mean serum concentration of Lp(a) than the unaffected 53 (33.7 +/- 18.4 vs. 11.1 +/- 11.2 mg/dl, p < 0.001). Elevated levels were present in 63.6% (7/11) and 3.8% (2/53), respectively (p < 0.01). Other parameters of lipid metabolism were not different between the two groups. We observed statistically significant positive correlations of Lp(a) to total cholesterol, LDL cholesterol and apolipoprotein B in controls, in hemodialysis patients as a whole and in those without coronary artery disease. No such correlations were obtained when hemodialysis patients with coronary artery disease were analysed separately. It is concluded that firstly, high serum levels of Lp(a) in hemodialysis patients are strongly associated with coronary artery disease, as well as in the general population; and secondly, abnormalities in the metabolism of Lp(a) may underlie atherogenesis in these patients, independently of alterations in other lipid constituents.