Obese-derived ASCs show impaired migration and angiogenesis properties

Efficient delivery of stem cells to target tissues is a major problem in regenerative medicine. Adipose derived stem cells have been proposed as important tools in cell therapy for recovering tissues after damage. Nevertheless, the ability of these ASCs to migrate or invade in order to reach the tissue of interest has not been tested so far. In this study we present evidence that the ASCs derived from obese subjects present a detrimental ability to migrate and invade in comparison with ASCs derived from control subjects. Besides, obese-derived ASCs are unable to respond to certain stimuli and to form enough capillaries after stimulation. We propose that the use of specific cytokines could overcome these deficiencies of the obese environment, offering a tool to optimize cell therapy.

Metabolic rescue of obese adipose-derived stem cells by Lin28/Let7 pathway

Adipose-derived stem cells (ASCs) are promising candidates for autologous cell-based regeneration therapies by virtue of their multilineage differentiation potential and immunogenicity; however, relatively little is known about their role in adipose tissue physiology and dysfunction. Here we evaluated whether ASCs isolated from nonobese and obese tissue differed in their metabolic characteristics and differentiation potential. During differentiation to mature adipocytes, mouse and human ASCs derived from nonobese tissues both increased their insulin sensitivity and inhibition of lipolysis, whereas obese-derived ASCs were insulin-resistant, showing impaired insulin-stimulated glucose uptake and resistance to the antilipolytic effect of insulin. Furthermore, obese-derived ASCs showed enhanced release of proinflammatory cytokines and impaired production of adiponectin. Interestingly, the delivery of cytosol from control ASCs into obese-derived ASCs using a lipid-based, protein-capture methodology restored insulin sensitivity on glucose and lipid metabolism and reversed the proinflammatory cytokine profile, in part due to the restoration of Lin28 protein levels. In conclusion, glucose and lipid metabolism as well as maturation of ASCs is truncated in an obese environment. The reversal of the altered pathways in obese cells by delivery of normal subcellular fractions offers a potential new tool for cell therapy.

Method for obtaining committed adult mesenchymal precursors from skin and lung tissue

Aims

The present study reports an easy and efficient method for obtaining adult mesenchymal precursors from different adult mouse tissues.

Materials and Methods

We describe the isolation and expansion of mesenchymal precursors from skin and lung by a non-enzymatic method. Skin and lung mesenchymal precursors isolated by a modified explant technique were characterized in vitro by defined morphology and by a specific gene expression profile and surface markers.

Results and Conclusions

Our results show that these precursors express stem cell and mesenchymal surface markers as well as epithelial markers. However, they are negative for markers of endothelium, cardiac and skeletal muscle or adipose tissue, indicating that they have initiated commitment to the tissues from which were isolated. These precursors can migrate without any stimulus and in response to stimuli as SDF1, MCP1 and TNFα and can be differentiated into epithelial lineages. Based on the properties of these precursors from adult tissues, we propose their use as tools for regenerative biomedicine.

A new microtitre plate screening method for evaluating the viability of aerobic respiring bacteria in high surface biofilms

AIMS

It is difficult to determine the effects of bactericidal compounds against bacteria in a biofilm because classical procedures for determining cell viability require several working days, multiple complicated steps and are frequently only applicable to cells in suspension. We attempt to develop a compact, inexpensive and versatile system to measure directly the extent of biofilm formation from water systems and to determine the viability of respiring bacteria in high surface biofilms.

METHODS AND RESULTS

It has been reported that the reduction of tetrazolium sodium salts, such as XTT (sodium 3,3'-[1-[(phenylamino)carbonyl]-3,4-tetrazolium]Bis(4-methoxy)-6-nitro)benzene sulfonic acid hydrate), during active bacterial metabolism can be incorporated into a colorimetric method for quantifying cell viability. XTT is reduced to a soluble formazan compound during bacterial aerobic metabolism such that the amount of formazan generated is proportional to the bacterial biomass.

CONCLUSIONS

We show here, for the first time, that this colorimetric approach can be used to determine the metabolic activity of adherent aerobic bacteria in a biofilm as a measure of cell viability. This technique has been used to estimate viability and proliferation of bacteria in suspension, but this is the first application to microbial communities in a real undisturbed biofilm.

SIGNIFICANCE AND IMPACT OF THE STUDY

This simple new system can be used to evaluate the complex biofilm community without separating the bacteria from their support. Thus, the results obtained by this practice may be more representative of the circumstances in a natural system, opening the possibility to multiple potential applications.

Participation of the phosphoinositide metabolism in the hypersensitive response of Citrus limon against Alternaria alternata

Lemon seedlings inoculated with Alternaria alternata develop a hypersensitive response (HR) that includes the induction of Phenylalanine ammonia-lyase (PAL, E. C. 4.3.1.5) and the synthesis of scoparone. The signal transduction pathway involved in the development of this response is unknown. We used several inhibitors of the Phosphoinositide (PI) animal system to study a possible role of Inositol-1,4,5-triphosphate (IP3) in the transduction of the fungal conidia signal in Citrus limon. The HR was only partially inhibited by EGTA, suggesting that not only external but internal calcium as well are necessary for a complete development of the HR. In this plant system, Alternaria alternata induced an early accumulation of the second messenger IP3. When lemon seedlings were watered long term with LiCl, an inhibitor of the phosphoinositide cycle, the IP3 production was reduced, and the LiCl-watered plants could neither induce PAL nor synthesize scoparone in response to fungal conidia. Furthermore, neomycin, a Phospholipase C (PLC, E. C. 3.1.4.3) inhibitor, also inhibited PAL induction and scoparone synthesis in response to A. alternata. These results suggest that IP3 could be involved in the signal transduction pathway for the development of the HR of Citrus limon against A. alternata.

Accuracy of renal-bladder ultrasonography as a screening method to suggest posterior urethral valves

PURPOSE

We determine the usefulness of ultrasonography as a screening modality to support the diagnosis of posterior urethral valves.

MATERIALS AND METHODS

A retrospective chart analysis was performed of 93 consecutive boys with newly diagnosed posterior urethral valves from August 1985 through February 1999. Of the 93 boys 65, including 62 who underwent renal and bladder ultrasonography, had preoperative renal sonography available and constitute our study population. Patient age range at presentation was newborn to 13 years, with 33 of the 65 boys presenting as infants (age 1 year or younger). Presentation included fetal hydronephrosis in 13 cases, urinary tract infection in 18, voiding dysfunction in 9, abdominal mass in 6, renal insufficiency in 5, failure to thrive in 4, hematuria in 1 and other in 9.

RESULTS

Preoperative sonography identified bilateral hydronephrosis in 48 boys (74%), unilateral hydronephrosis in 9 (14%) and no hydronephrosis in 8 (12%). Bladder sonography revealed an abnormal bladder (thickened, trabeculated and/or significantly distended) in 54 boys (87%). An abnormal bladder was seen in 43 of the 46 boys with bilateral hydronephrosis, 6 of 8 boys with unilateral hydronephrosis and 5 of 8 with normal upper tracts. Only 3 of the 62 boys (5%) had a normal upper tract and bladder. The sensitivity of renal ultrasonography in suspecting posterior urethral valves was 88%, while sensitivity of renal-bladder ultrasonography was 95%. When stratifying for age younger than 4 years and 4 or older, the sensitivity of predicting posterior urethral valves with renal-bladder ultrasonography was 87% and 98%, respectively.

CONCLUSIONS

While voiding cystourethrography remains the imaging gold standard for the diagnosis of posterior urethral valves, renal-bladder ultrasonography is an appropriate screening study for a boy suspected to have the condition. Renal-bladder ultrasonography may prove particularly useful in the evaluation of the boy with significant voiding dysfunction before deciding on a more invasive study, such as voiding cystourethrography.

Accuracy of renal-bladder ultrasonography as a screening method to suggest posterior urethral valves

PURPOSE

We determine the usefulness of ultrasonography as a screening modality to support the diagnosis of posterior urethral valves.

MATERIALS AND METHODS

A retrospective chart analysis was performed of 93 consecutive boys with newly diagnosed posterior urethral valves from August 1985 through February 1999. Of the 93 boys 65, including 62 who underwent renal and bladder ultrasonography, had preoperative renal sonography available and constitute our study population. Patient age range at presentation was newborn to 13 years, with 33 of the 65 boys presenting as infants (age 1 year or younger). Presentation included fetal hydronephrosis in 13 cases, urinary tract infection in 18, voiding dysfunction in 9, abdominal mass in 6, renal insufficiency in 5, failure to thrive in 4, hematuria in 1 and other in 9.

RESULTS

Preoperative sonography identified bilateral hydronephrosis in 48 boys (74%), unilateral hydronephrosis in 9 (14%) and no hydronephrosis in 8 (12%). Bladder sonography revealed an abnormal bladder (thickened, trabeculated and/or significantly distended) in 54 boys (87%). An abnormal bladder was seen in 43 of the 46 boys with bilateral hydronephrosis, 6 of 8 boys with unilateral hydronephrosis and 5 of 8 with normal upper tracts. Only 3 of the 62 boys (5%) had a normal upper tract and bladder. The sensitivity of renal ultrasonography in suspecting posterior urethral valves was 88%, while sensitivity of renal-bladder ultrasonography was 95%. When stratifying for age younger than 4 years and 4 or older, the sensitivity of predicting posterior urethral valves with renal-bladder ultrasonography was 87% and 98%, respectively.

CONCLUSIONS

While voiding cystourethrography remains the imaging gold standard for the diagnosis of posterior urethral valves, renal-bladder ultrasonography is an appropriate screening study for a boy suspected to have the condition. Renal-bladder ultrasonography may prove particularly useful in the evaluation of the boy with significant voiding dysfunction before deciding on a more invasive study, such as voiding cystourethrography.

Urological outcome of patients with cervical and upper thoracic myelomeningocele

PURPOSE

We determined the incidence of voiding disorders and upper tract deterioration in children with cervical and upper thoracic level myelomeningocele.

MATERIALS AND METHODS

We retrospectively reviewed the neurosurgical and urological presentation, evaluation and treatment of 11 patients of whom 8 had cervical and 3 had upper thoracic myelomeningocele. There were 7 female and 4 male patients 10 months to 39 years old (mean age 12 years). All patients were ambulatory and 5 of 11 (45%) had hydrocephalus. Although a voiding history was obtained by a neurosurgeon in all patients, only 9 had undergone a formal urological evaluation, including video urodynamic assessment in 5.

RESULTS

No patient had an increased post-void residual and none had ever been placed on intermittent catheterization. Tethered spinal cords from caudal fixation (thickened filum terminale and a lipomyelomeningocele) were present in 2 patients with urinary incontinence of whom 1 had recurrent cystitis. Imaging studies of the upper tracts were normal in all 9 patients and video urodynamics were normal in 3 of 5. No patient has required urological operative intervention.

CONCLUSIONS

To our knowledge, this study represents the largest reported series of patients with cervical and upper thoracic myelomeningocele who have undergone urological evaluation. Our experience suggests that patients with cervical and upper thoracic myelomeningocele have a low risk of voiding disorders and upper tract deterioration unless other conditions, such as a congenital tethered cord, are present. Additional reports of children with cervical and upper thoracic myelomeningocele are necessary to confirm these findings.

Pediatric inflammatory bladder tumors: myofibroblastic and eosinophilic subtypes

PURPOSE

Benign bladder tumors are rare in children. A number of descriptive terms have previously been used to describe inflammatory tumors with myofibroblastic proliferation or eosinophilic infiltration. We present our experience with these tumors and review the literature.

MATERIALS AND METHODS

We retrospectively reviewed the records of all children presenting with a benign focal bladder mass during the last 5 years, including 2 girls and 3 boys 2 to 12 years old (mean age 7).

RESULTS

Presenting symptomatology included irritative voiding symptoms, suprapubic pain and hematuria. All bladder masses were diagnosed by ultrasonography and all patients underwent transurethral resection. Three children who had an inflammatory bladder tumor with myofibroblastic features required open tumor excision with preservation of the bladder. In the 2 remaining children urine culture was positive preoperatively and the diagnosis was an inflammatory bladder tumor with eosinophilic infiltration. Transurethral resection of the mass was performed without partial cystectomy.

CONCLUSIONS

Inflammatory myofibroblastic and eosinophilic tumors represent forms of focal cystitis with a tumefactive component. Differentiation from the malignant bladder neoplasms of childhood has important consequences for therapy. Management of these benign but aggressive inflammatory lesions involves local control by endoscopic or open surgery with bladder preservation. We encourage refined use of the terminology for inflammatory myofibroblastic and eosinophilic tumors.

Xanthogranulomatous pyelonephritis in an infant with an obstructed upper pole renal moiety

We report a case of xanthogranulomatous pyelonephritis in an infant involving the upper renal pole moiety of a duplicated system associated with an obstructed ectopic ureter. It was successfully managed by an upper pole heminephroureterectomy. We also review the published reports of xanthogranulomatous pyelonephritis in pediatric patients.

Tunica vaginalis onlay urethroplasty as a salvage repair

PURPOSE

We review our experience with tunica vaginalis onlay urethroplasty for urethral repair after multiple previous hypospadias repairs.

MATERIALS AND METHODS

From January 1992 through December 1997 we repaired the urethra in 10 boys and 1 man using a tunica vaginalis onlay flap. The tunica vaginalis was placed as a patch on the urethra that was proximal to the glans or brought out to the urethral meatus.

RESULTS

No intraoperative complications or difficulties were associated with harvesting the tunica vaginalis. Of the 4 children and 1 adult in whom the onlay flap was brought out to the urethral meatus meatal stenosis developed in 3 (60%), while 2 void without problems. In 6 children the onlay flap was placed proximal to the glans and in 1 who was lost to followup 2 discontinuous patches were placed. In 3 of the 5 remaining boys (60%) stricture developed, while 2 void without problems.

CONCLUSIONS

Tunica vaginalis onlay urethroplasty results in a substantial complication rate. We did not confirm any advantage of its use.

Tunica vaginalis onlay urethroplasty as a salvage repair

PURPOSE

We review our experience with tunica vaginalis onlay urethroplasty for urethral repair after multiple previous hypospadias repairs.

MATERIALS AND METHODS

From January 1992 through December 1997 we repaired the urethra in 10 boys and 1 man using a tunica vaginalis onlay flap. The tunica vaginalis was placed as a patch on the urethra that was proximal to the glans or brought out to the urethral meatus.

RESULTS

No intraoperative complications or difficulties were associated with harvesting the tunica vaginalis. Of the 4 children and 1 adult in whom the onlay flap was brought out to the urethral meatus meatal stenosis developed in 3 (60%), while 2 void without problems. In 6 children the onlay flap was placed proximal to the glans and in 1 who was lost to followup 2 discontinuous patches were placed. In 3 of the 5 remaining boys (60%) stricture developed, while 2 void without problems.

CONCLUSIONS

Tunica vaginalis onlay urethroplasty results in a substantial complication rate. We did not confirm any advantage of its use.

[Determination of proximal chemical composition of squid (dosidicus gigas) and development of gel products]

The good nutritional properties of meat from big squid (Dosidicus gigas) living on the Chilean coast, was determined through its proximal composition 70 cal/100 g fresh meat; 82.23 +/- 0.98% moisture; 15.32 +/- 0.93% protein; 1.31 +/- 0.12% ashes; 0.87 +/- 0.18% fat and 0.27% NNE (non-nitrogen extract). The big squid meat was used to develop a gel product which contained NaCl and TPP. It was necessary to use additives for gel preparation, such as carragenin or alginate or egg albumin, due to the lack of gelation properties of squid meat. Formulations containing egg albumin showed the highest gel force measured by penetration as compared to those that contained carragenin or alginate.

A comparative study of fish species identification by gel isoelectrofocusing two-dimensional gel electrophoresis, and capillary zone electrophoresis

A comparative study of fish species identification was accomplished using three different electrophoretic techniques. Sarcoplasmic proteins were extracted from three related fish species and subjected to gel isoelectrofocusing (IEF), two-dimensional polyacrylamide gel electrophoresis (2D-PAGE), and capillary zone electrophoresis (CZE). The fish species--Genypterus chilensis, Genypterus blacodes, and Genypterus maculatus--were from the Ophidiidae family. The three electrophoretic techniques provided suitable fish species identification. Nevertheless, CZE demonstrated several advantages over the other two conventional techniques. Some of the benefits include the use of small amounts of reagents; short separation times, permitting fast comparative analysis; data reproducibility; and ease with which the technique is performed.

Outcome and cost analysis of operative versus nonoperative management of neonatal multicystic dysplastic kidneys

PURPOSE

We determine whether nephrectomy or observation is the more appropriate treatment of neonates with multicystic dysplastic kidney in terms of medical care and cost-effectiveness.

MATERIALS AND METHODS

We retrospectively reviewed our 10-year clinical experience with 17 female and 32 male neonates presenting with multicystic dysplastic kidney who were followed with serial renal ultrasound. The literature also was reviewed.

RESULTS

Nephrectomy was performed in 12 patients (24%) for various reasons, of which family request at concomitant surgery was the most common (7). No kidney was removed due to hypertension or tumor. In the remaining 37 patients followup continues (mean 42 months) with involution developing in 9 multicystic dysplastic kidneys (24%) and 9 patients (24%) lost to followup. The total cost of 1-hour outpatient simple nephrectomy was estimated at $5,000 to $7,000 and, when performed as a concomitant procedure, it cost $2,000 to $5,000, the equivalent charges incurred for 17 to 28 serial ultrasound studies performed by a radiologist. Our review of the literature revealed that children with multicystic dysplastic kidney are at minimal risk for hypertension, pain and infection. The most important reason to perform screening renal ultrasound in this condition is to detect earlier stage Wilms tumor (3 to 10-fold the general pediatric population risk of 1/10,000 cases). With a maximum risk of 0.1% for Wilms tumor controversy exists as to whether any screening program is necessary. When screening is instituted, options include monthly parental abdominal palpation versus serial renal ultrasound. Because Wilms tumor has a rapid growth rate, when screening renal ultrasound is instituted, it must be performed no less than every 3 months until age 8 years (total of 32 studies) to screen effectively for early stage tumors.

CONCLUSIONS

The risks associated with multicystic dysplastic kidney are slight. Early nephrectomy is more cost-effective than observation in neonates with multicystic dysplastic kidney only when observation involves screening with ultrasonography every 3 months until age 8 years. Extensive parental counseling should be provided on the slight but definite risks of this condition.

Renal transplantation in children with posterior urethral valves revisited: a 10-year followup

PURPOSE

Renal transplantation is safe and effective for end stage renal disease in children with posterior urethral valves. We previously reported our 5-year post-transplantation results in boys with posterior urethral valves and matched controls. Graft survival was similar. However, we were concerned about elevated serum creatinine and the potential detrimental effects of hostile bladder dynamics in these children. We performed this study to determine whether our concern would be substantiated.

MATERIALS AND METHODS

We retrospectively analyzed the clinical records and computerized transplantation database in 268 boys younger than 19 years who underwent renal transplantation from May 1968 through November 1988. The 18 children with posterior urethral valves were compared to a nonobstructed cohort of 18 boys in regard to age, number of transplants, donor type and immunosuppression. All children had at least 10 years of followup (range 10 to 19).

RESULTS

The 10-year post-transplant patient survival in the posterior urethral valves and control groups was 94 and 100%, while 10-year graft survival was 54 and 41%, respectively. There was no statistically significant difference in graft survival when comparing immunosuppression type, donor source and pre-transplant proximal urinary diversion. The 10-year mean serum creatinine was 2.3 and 2.0 mg./dl. in the posterior urethral valve and control groups, respectively (not statistically significant).

CONCLUSIONS

Our renal transplantation results in children with posterior urethral valves are comparable to those in children with nonobstructive end stage renal disease. The 10-year graft survival was better but not statistically significant in the posterior urethral valve group, while serum creatinine was similar. Our concern regarding renal transplantation in children with posterior urethral valves was not substantiated.

The relationship between the profile of severity of addiction and the retention of patients in the ambulatory program of DDTP

OBJECTIVES

The authors described some variables related to the retention of drug dependent veterans receiving outpatient treatment at San Juan V.A.M.C. and compared the profile of addiction severity with retention using a global dysfunction scale.

METHODS

The clinical charts of 74 patients were examined at random using a 16-item questionnaire based on the ASI scale. The data was processed and analyzed using the Epi Info V6.2 computer program, utilizing chi square as the main statistics.

RESULTS

The patient's retention in treatment for > or = to 3 months was associated with some specific variables such as: more than 12 years of education, being Catholic, divorced, living with parents, use of more than one drug of preference, having a negative urine toxicology result before treatment and after treatment, and showing a favorable change in urine toxicology results. In terms of severity of dysfunction, a considerable substance problem and an extreme legal problem were associated with a retention of > or = to 3 months, as well as no evidence of occupational problems.

CONCLUSION

The strong correlation between specific variables and the retention of patients in treatment for > or = to 3 months should create awareness of the importance of available and effective treatments in the fight against substance abuse and mental health problems as well as to educate and integrate family members in patients treatment, since a supportive family member is one of the best tools that patients and therapist can have to help maintain patient's sobriety.

Hematuria. An integrated medical and surgical approach

The need to perform a detailed work-up of microscopic hematuria is based on the following set of questions: Does the history or physical examination findings suggest systemic or renal disease? Is the patient able to acidify and concentrate urine? Is proteinuria present? Do other family members have hematuria or other renal problems? Does the microscopic analysis show casts, crystals, or WBCs? Are the RBCs eumorphic or dysmorphic? Using this scheme of questions, most children do not require laboratory tests or radiographic studies. In the case of gross or macroscopic hematuria, the initial evaluation may require only a urine culture, urine calcium-to-creatinine ratio, and renal and bladder sonography or a very detailed evaluation for renal parenchymal disease, stones, tumors, or anatomic abnormalities. In these instances, consultation with a pediatric nephrologist, urologist, or both is necessary.

Contralateral vesicoureteral reflux after simple and tapered unilateral ureteroneocystostomy revisited

PURPOSE

We reviewed our experience with contralateral vesicoureteral reflux following unilateral ureteroneocystostomy.

MATERIALS AND METHODS

We retrospectively identified 88 children who underwent unilateral ureteroneocystostomy from 1986 through 1995, including standard repair in 69 and tapered repair in 19. Cystoscopy was performed in all cases immediately before repair.

RESULTS

Grades IV to V vesicoureteral reflux was identified preoperatively in 34% of the patients, including 13 (19%) and 14 (74%) who underwent standard and tapered repair, respectively. Renal duplication was noted in 24% of the cases, including 18 standard (26%) and 3 tapered (16%) repairs. An abnormal contralateral nonrefluxing ureteral orifice was present in 8 of the 53 standard (15%) and 3 of the 14 (21%) tapered cases. Ipsilateral reflux was corrected in all children undergoing standard repair but it persisted in 4 (21%) in the tapered repair group. Postoperatively contralateral vesicoureteral reflux developed in 1 child (1.4%) in the standard and 1 (5.3%) in the tapered repair group.

CONCLUSIONS

Contralateral vesicoureteral reflux is rare and does not appear to be influenced by preoperative reflux grade, a duplicated system or the endoscopic appearance of the ureteral orifice.

Two-stage Fowler-Stephens orchiopexy with laparoscopic clipping of the spermatic vessels

PURPOSE

We report the outcome of a staged approach to the intra-abdominal testicle and provide baseline data on operative time, postoperative course and testicular survival.

MATERIALS AND METHODS

We retrospectively reviewed the records of 441 boys (547 undescended testes). There were 105 boys (24%) with 124 nonpalpable testes (23%). All patients underwent laparoscopy. Ligation of spermatic vessels was performed as stage 1 on 20 abdominal testes (4%) in 18 boys (4%). Stage 2 orchiopexy was done using an open technique.

RESULTS

Two-stage orchiopexy in 18 boys included a bilateral procedure in 2, of which 1 was asynchronous and 1 was synchronous. Average operative time was 55 minutes for stage 1 and 67 minutes for stage 2. Stage 1 and 2 procedures were performed on an outpatient basis in 18 and 17 (94%) boys, respectively. There were no complications after stage 1 and 1 wound infection developed after stage 2. One testis with no vas deferens was determined to be nonviable at stage 2. The remaining 19 testes (95%) were considered viable at a followup of 6 months or greater. Viability was based on testicular size and consistency similar to those of the contralateral testis.

CONCLUSIONS

Laparoscopic ligation of spermatic vessels as a stage 1 procedure is a natural extension of laparoscopy. A staged approach provides adequate viability of the intra-abdominal testis.

Critical analysis of the clinical presentation of acute scrotum: a 9-year experience at a single institution

PURPOSE

We assessed the significance of the clinical presentation of boys who underwent surgical exploration for acute scrotum.

MATERIALS AND METHODS

We retrospectively analyzed the records of 115 consecutive boys who underwent surgical exploration for acute scrotum between October 1986 and January 1996. We divided the children into group 1-83 with spermatic cord torsion a mean of 14.4 years old, group 2-27 with torsion of a testicular appendage a mean of 9.4 years old and group 3-5 with epididymo-orchitis a mean of 14.1 years old. Particular attention was given to nausea and vomiting, patient age and duration of pain.

RESULTS

Nausea and vomiting occurred in 69 and 60% of the boys in group 1, 8 and 4% in group 2 and none in group 3. Nausea and vomiting had positive predictive values of 96 and 98%, respectively, for spermatic cord torsion. Only 6 of the 83 boys (7%) with spermatic cord torsion were younger than 11 years, whereas 15 of the 27 (56%) with torsion of a testicular appendage were younger than 11 years. Of the 83 boys with spermatic cord torsion the testes were salvaged in 51 (61%) and the duration of pain was 40 minutes to 12 hours (mean 4 hours). The testes were not salvaged in any patient with greater than 12 hours of pain.

CONCLUSIONS

We believe that any boy 11 years old or older with scrotal pain less than 12 hours in duration that is associated with nausea or vomiting should be considered to have torsion of the spermatic cord. In this day of cost-effective medical management it is not necessary to perform imaging in this subset of boys before surgical exploration.

Outcome of sling cystourethropexy in the pediatric population: a critical review

PURPOSE

We performed a critical retrospective analysis of the records of all consecutive children who underwent sling cystourethropexy at our institutions. We particularly assessed the incidence and outcome in children who underwent enterocystoplasty in addition to a sling procedure.

MATERIALS AND METHODS

Between May 1992 and August 1994, 24 girls and 15 boys 4 to 17 years old (mean age 9) consecutively underwent 1 of 4 techniques of sling cystourethropexy for stress urinary incontinence using rectus fascia via an abdominal approach. Diagnoses included spinal dysraphism in 34 patients, spinal trauma in 2, cecoureterocele in 1, epispadias in 1 and classic bladder exstrophy in 1. All children underwent preoperative video urodynamics. In 4 patients only a sling procedure was performed (group 1), while in 9 others a sling procedure was performed after enterocystoplasty (group 2). In 26 patients a sling procedure and concomitant enterocystoplasty were performed (group 3).

RESULTS

Patients who underwent concomitant enterocystoplasty had more hyperactive preoperative urodynamics than those who did not. Postoperative continence was subcategorized in terms of patient age, sex, diagnosis (neurogenic versus nonneurogenic), preoperative video-urodynamics, surgeon technique, group (that is with or without cystoplasty) and type of enterocystoplasty (that is stomach versus ileum). Of these factors only concomitant enterocystoplasty was predictive of postoperative dry continence (73% of group 3, 33% of group 2 and 25% of group 1). In most patients who were not dry postoperative video urodynamics suggested suboptimal outlet resistance overcome by a hyperactive detrusor. No patient had postoperative upper tract deterioration.

CONCLUSIONS

These results suggest that concomitant enterocystoplasty should be critically considered for pediatric patients undergoing sling cystourethropexy.

Submucosal bladder neck injection of bovine dermal collagen for stress urinary incontinence in the pediatric population

PURPOSE

The surgical management of stress urinary incontinence in the pediatric population includes various surgical techniques of which the simplest is outpatient transurethral or periurethral injection of a bulking agent. Currently purified bovine dermal collagen cross-linked with glutaraldehyde (Contigen) is the only Food and Drug Administration approved bulking agent available. Patients with stable detrusor function are ideal candidates. We review our initial experience with children.

MATERIALS AND METHODS

Between January 1994 and June 1995, 23 boys and 9 girls 4 to 17 years old (mean age 9) consecutively underwent submucosal bladder neck injection with cross-linked bovine dermal collagen. Incontinence was secondary to spinal dysraphism in 24 patients, complete epispadias in 4, classic bladder exstrophy in 3 and neurogenic bladder secondary to a sacral teratoma in 1. Preoperative video urodynamics documented intrinsic sphincteric deficiency in all patients with leak point pressure of 15 to 60 cm. water (mean 37). Injection volumes ranged from 2.5 to 17 cc (mean 10). Continence results were defined as dry-requiring no protection while on a 4-hour clean intermittent catheterization program, good-improved but requiring 1 to 5 pads daily and failure-no postoperative improvement or still requiring diapers.

RESULTS

Of the children with neurogenic bladder 20% became dry following the first injection and an additional 28% had a good result. Furthermore, of the 6 children with exstrophy or epispadias who underwent a Young-Dees-Leadbetter procedure 50% were dry and 17% had a good result after the first injection. Complications were limited to a febrile urinary tract infection associated with urinary retention in 1 patient and transiently worse continence in 2.

CONCLUSIONS

Despite the limited success rate, we believe that transurethral collagen injection therapy has a viable role in the treatment of intrinsic sphincteric deficiency in select pediatric patients, particularly since the procedure has low morbidity and can be performed on an outpatient basis. Preoperative counseling should be given with realistic expectations.

Prostate cancer screening before and after abdominoperineal resection: recommendations, biopsy, and therapeutic techniques

BACKGROUND

The purpose of this study was to determine the incidence and mortality rate of prostate cancer in men without a rectum at a single institution. The usefulness of serum prostate specific antigen (PSA) to screen for prostate cancer in men without a rectum was defined. Improved biopsy techniques and therapeutic options were developed in those with elevated levels.

METHODS

We undertook a retrospective review of 65 men who underwent an abdominoperineal resection. Twenty-five of these men underwent serum PSA determinations (mean age, 68 years).

RESULTS

Four (16%) of 25 patients had elevated PSA levels. Three of these four men and two additional patients (one before the availability of PSA and one with normal serum PSA level) were found to have biopsy-proven prostate cancer. Two men (3% of the 65 patient population) died of metastatic prostate cancer.

CONCLUSIONS

We believe that men about to undergo an abdominoperineal resection should have a preoperative serum PSA measurement. Moreover, we recommend that men older than 49 years of age (older than 39 years for those with positive family histories) without a rectum should have annual serum PSA determinations as if recommended for the general male population at large. If an elevated serum PSA level is discovered, the transperineal ultrasonogram-guided biopsy technique offers an effective method to detect peripheral zone prostate cancers.

Synchronous management of anastomotic contracture and stress urinary incontinence following radical prostatectomy

Of 77 patients presenting for artificial urinary sphincter implantation due to incontinence following radical prostatectomy 26 had a significant associated urethrovesical anastomotic contracture. Synchronous endoscopic contracture incision with electrocautery and implantation of an artificial urinary sphincter (AMS800) were performed in all cases. A total of 25 patients void with a good subjective flow, with an average followup of 32 months. In 1 patient symptomatic stenosis recurred 6 months after incision and reincision was successful at the time of sphincter revision. No infection or erosion developed and 24 patients are socially continent (0 to 1 thin pad per day). During this time 5 patients underwent 8 revisions of the artificial sphincter. Synchronous contracture incision with electrocautery and artificial urinary sphincter implantation are safe and provide satisfying results in patients with complex post-prostatectomy incontinence.

Urological dysfunction in patients with diastematomyelia

Little information exists concerning voiding dysfunction associated with diastematomyelia (splitting of the spinal cord). We present 27 patients 4 days to 62 years old (mean 13 years) who underwent neurosurgical intervention for treatment of this disorder. Of these patients 14 had urological evaluation, with 11 having undergone video urodynamics. Nine patients had minimal urological manifestations. No patient had a urodynamically proved hostile bladder nor evidence of upper urinary tract deterioration. In our experience, patients with a spinal cord fixation syndrome resulting from diastematomyelia not associated with a meningomyelocele appear to have a relatively benign course in terms of the urological manifestations. However, due to the lack of reports concerning the urological findings in this occult dysraphic state, we still suggest upper and lower urinary tract evaluation and followup.

Successful outcome of artificial urinary sphincters in men with post-prostatectomy urinary incontinence despite adverse implantation features

A total of 75 men with post-prostatectomy urinary incontinence underwent artificial urinary sphincter implantation with a mean followup of 3.7 years. Average patient age at implantation was 67 years, with 30 men being 70 years old or older. In only 15 men (20%) was there no adverse implantation feature, while the remainder had adverse features, such as detrusor hyperactivity (44), bladder neck or urethral stricture disease (27), previous radiation therapy (11) and metastatic prostate cancer (11). Although men with ideal implantation characteristics, men with normal detrusors and men who underwent prostatectomy for benign disease had slightly better outcome in terms of urinary continence, in general each group of men with and without adverse features had satisfactory urinary continence. Other than men with a benign prostate, who fared better, each group of men with and without adverse features had equal need for device revisions. In conclusion, men with post-prostatectomy urinary incontinence should not be excluded from consideration for artificial urinary sphincter implantation based on the failure to meet ideal implantation criteria provided such adverse features are recognized and appropriately addressed.