Laparoscopic pyeloplasty versus open pyeloplasty for recurrent ureteropelvic junction obstruction in children

INTRODUCTION AND OBJECTIVES

Recurrent ureteropelvic junction obstruction (UPJO) in children is an operative challenge. Minimally invasive endourological treatment options for secondary UPJO have suboptimal success rates; hence, there is a re-emergence of interest about redo pyeloplasty. The present study presented experience with laparoscopic management of previously failed pyeloplasty compared with open redo pyeloplasty in children.

STUDY DESIGN

Twenty-four children with recurrent UPJO who underwent transperitoneal dismembered laparoscopic pyeloplasty were studied. Operative, postoperative, and follow-up functional details were recorded and compared with those of open pyeloplasty (n = 15) carried out for recurrent UPJO by the same surgeon during the same study period.

RESULTS

Demographic data were comparable in the laparoscopic and open groups, except for a significantly lower GFR in the open group (24.8 vs 38.2 ml/min, P = 0.0001). Mean time to failure of the original repair was 20.2 months (23.6 months for redo laparoscopic pyeloplasty, 18.8 months for redo open). The success rate of laparoscopic redo pyeloplasty was 91.7 vs 100% in open redo pyeloplasty. Compared with redo open pyeloplasty, the mean operative time was longer (211.4 ± 32.2 vs 148.8 ± 16.6, P = 0.002), estimated blood loss was higher (102 vs 75 ml, P = 0.06), while hospital stay was shorter and pain score was lower in the laparoscopy group (P = 0.02) in the laparoscopic group. There were no intraoperative complications, while the postoperative complication rate was similar in the two groups (20.8 vs 20.0%).

DISCUSSION

Before the laparoscopic approach became a viable option, endopyelotomy was widely used for managing recurrent UPJO. However, the success rate of endopyelotomy for secondary UPJO was approximately 10-25% lower than for open pyeloplasty. Redo pyeloplasty had excellent results, with reported success rates of 77.8-100%. Laparoscopic redo pyeloplasty is becoming a viable alternative to open redo pyeloplasty in many centers with experience in minimally invasive techniques. The present study revealed that redo laparoscopic pyeloplasty appeared to have advantages over redo open surgery, in that it was associated with shorter hospital stay (4 vs 6 days, P = 0.046), reduced postoperative pain score (P = 0.02), and less need for postoperative analgesia (P = 0.001), still with comparable successful outcomes and patient safety. However, the procedure had a longer operative times and more blood loss.

CONCLUSION

Laparoscopic pyeloplasty is a viable alternative to open pyeloplasty in children with recurrent UPJO, with shorter hospital stays and less postoperative pain. However, the procedure is technically demanding and should be attempted in high-volume centers by laparoscopists with considerable experience in laparoscopic reconstructive procedures.

The embedded nipple: An optimal technique for re-implantation of primary obstructed megaureter in children

Objectives

To present a novel ureteric re-implantation technique for primary obstructed megaureter (POM) that ensures success in the short- and long-term, as conventional techniques are not ideal for megaureters especially in children, with ureteric stenosis and reflux being common complications after re-implantation.

Patients and methods

Between 2009 and 2012, 22 paediatric patients with POM were enrolled. We performed a new technique for re-implantation of these ureters to ensure minimal incidence of ureteric strictures and easy subsequent endoscopic access. We performed follow-up voiding cystourethrography (VCUG) at 6 months postoperatively.

Results

The cohort comprised 14 boys and eight girls, with a median age of 22 months. Six patients underwent bilateral re-implantation. The mean (range) duration of indwelling ureteric catheterisation was 7.8 (4–14) days. There were no complications in the perioperative and postoperative periods. There was no reflux on follow-up VCUG in any of the patients. One patient developed Grade I reflux after 1 year and presented with a urinary tract infection. Diagnostic cystoscopy was performed in 13 patients showing that the nipple was directed similarly to the native ureteric orifice.

Conclusion

The embedded-nipple technique for re-implantation of POM guarantees successful results and permits easy subsequent ureteroscopic access when needed.

Combined low-dose antimuscarinics for refractory detrusor overactivity in children

INTRODUCTION AND AIMS

Behavioral therapy and bowel management are the initial and mainstay treatments for overactive bladder (OAB). Antimuscarinic agents are initiated if these measures fail or symptoms are severe. This study reported the results of treatment with a high dosage of a single drug in children with refractory detrusor overactivity (DO). After the children maintained their previous antimuscarinic medication, a second antimuscarinic drug (trospium chloride) was added as a combination therapy.

MATERIALS AND METHOD

Seventy-two children with DO were enrolled in this prospective study (Figure). They had persistent urgency and urgency urinary incontinence (UUI), even with behavioral bowel therapy, and used an optimized dosage of oxybutynine. All patients demonstrated DO at urodynamic study and started on oxybutynin and trospium chloride at the lowest weight-adjusted dose (10-20 mg/day for trospium chloride). A bladder diary was recorded for 3 days, and urodynamic studies were repeated at 3 and 6 months.

RESULTS

Sixteen children (22.2%) became dry. Thirty-three children (45.8%) attained a significant decrease in incontinence from an average of 5 to 1.3 episodes per day. A statistically significant increase of mean cystometeric bladder capacity (P = 0.006) was also observed at the 6-month follow-up. The overall success rate was 68%, since 23 children (32%) discontinued combined treatment due to persistent symptoms and/or intolerable side effects. A total of 41 children (57%) reported no side effects, 25 (34.7%) reported mild side effects, six (8.3%) reported moderate side effects, and two withdrew from the study due to their side effects.

CONCLUSIONS

The addition of low-dose trospium chloride to oxybutynine seemed to be an effective and safe treatment approach for children with DO who were refractory to high-dosage monotherapy. Different combinations with different antimuscarinics drugs could be evaluated in the future.

Extractable fragment versus dusting during ureteroscopic laser lithotripsy in children: Prospective randomized study

INTRODUCTION AND OBJECTIVES

Complete eradication of stone fragments is an important goal during stone management in children. The mode of fragmentation employed to clear stones during ureteroscopic laser lithotripsy raises concerns related to operative time, associated morbidity, costs, and especially potential endoscope damage. The purpose of this study was to evaluate the outcomes of fragmentation into extractable pieces and stone dusting during ureteroscopic laser lithotripsy in children.

MATERIAL AND METHODS

One hundred children with ureteral stones undergoing ureteroscopic holmium laser lithotripsy were prospectively randomized into two groups: group I in which stones were fragmented to dust (n = 50), and group II in which lithotripsy resulted in extractable fragments (n = 50). Different Holmium laser settings were applied during ureteroscopic lithotripsy for each group: low power (500 mJ) and high frequency (12-15 Hz) for lithotripsy to dust. High power (1000-1500 mJ) and reduced frequency (8-10 Hz) for lithotripsy to extractable fragments. The fragmentation time, operating time, stone-free rate, and perioperative complications were compared (Figure).

RESULTS

The mean age of the patients was 6.8 (1-12) years and 8.2 (1-15) years, in groups I and II respectively. The mean fragmentation time and operating time were statistically significantly lower in group II (p = 0.008 and 0.0069 respectively). Minor complications occurred in eight cases (5 in group I and 3 in group II) in the form of hematuria and urinary tract infection. No major complications were encountered in either groups.

CONCLUSIONS

Fragmenting stones into extractable pieces has a significantly shorter fragmentation time and operative time than stone dusting, with similar stone-free and complication rates. Ureteroscopic laser lithotripsy treatment resulting in extractable fragments seems to be an effective and time-saving procedure in children.

Optimizing prophylactic antibiotic regimen in patients admitted for transrectal ultrasound-guided prostate biopsies: A prospective randomized study

Background

Transrectal ultrasound-guided prostate biopsies (TRUSBx), in spite of being one of the most frequently performed urological office procedures, are associated with a spectrum of complications, most significantly including infection. The aim of the study is to evaluate the prevalence of fluoroquinolone-resistant bacteria in rectal swabs from our local population prior to TRUSBx and to identify risk factors among a patient population harboring fluoroquinolone-resistant organisms.

Methods

We prospectively included 541 men who were submitted for TRUSBx in our center from March 2011 to June 2015. The indications for TRUSBx were an elevated prostate-specific antigen level and/or abnormal digital rectal exam. All patients were randomly divided into two groups: Group 1 (n = 279 cases) who received standard empirical prophylactic antibiotics and Group 2 who received targeted prophylaxis based on a rectal swab culture and susceptibility result. Differences in risk factors between quinolone-resistant and nonresistant patients were compared. Univariate and multivariate analyses were performed to identify independent potential risk factors associated with fluoroquinolone-resistant rectal flora.

Results

Sixteen out of 271 men developed infectious complications after TRUSBx in the group receiving standard empirical prophylaxis (5.7%). No men in the group who received targeted prophylactic antibiotic guided by rectal swab developed infectious complications. Among the 262 patients who underwent prebiopsy rectal swab cultures, 76 men (29%) displayed fluoroquinolone-resistant rectal flora (29%). In the multivariate analysis, a history of antibiotic exposure before prostate biopsy was the only independent factor associated with an increased risk of fluoroquinolone resistance.

Conclusion

Determining the prevalence of fluoroquinolone resistance in rectal flora has important implications in the selection of targeted prophylactic antibiotic regimens. Antimicrobial profiles guided by rectal swabs may prove useful to optimize prophylaxis prior to TRUSBx; this strategy is effective at reducing the rates of infectious complications, including sepsis, especially in men at higher risk of infectious complications.

Ferulic acid, a natural polyphenol, alleviates insulin resistance and hypertension in fructose fed rats: Effect on endothelial-dependent relaxation

Ferulic acid (FER) is a polyphenolic compound contained in various types of fruits. It has a substantial therapeutic effect inhibitory activity against aldose reductase (AR) inhibition. In this study, we examined the effect of FER on fructose-fed rats in comparison to a standard AR inhibitor, zopolrestat (ZOP). We determined the protective role of FER against metabolic syndrome by examining serum insulin/Glucose levels, triglycerides (TGs), cholesterol and advanced glycation end product (AGE) in rats supplied with 10% fructose drinking water. In addition, blood pressure, vascular reactivity of isolated thoracic aortas and acetylcholine-induced NO were all evaluated to estimate the cardiovascular complications of metabolic syndrome (MetS) associated with fructose feeding. Animals were randomly divided into four groups: control, (+10% fructose, Fru), zopolrestat-treated fructose fed (Fru-zop) and ferulic acid-treated fructose fed rats (Fru-Fer). After 12 weeks of FER treatment, we found significant reduction in both hyperinsulinemia and elevated diastolic blood pressure associated with fructose-fed to levels comparable to those achieved with ZOP. Both FER and ZOP significantly augmented the impaired relaxation associated with fructose-fed, whereas neither showed any significant effect on the developed vasoconstriction. Isolated aortas from fructose-fed rats incubated with either FER or ZOP, reinstated normal relaxation response to acetylcholine (ACh). Furthermore, isolated aortas showed attenuated nitric oxide (NO) production following the addition of (ACh), while both FER and ZOP restored normal induction of NO. Taken together, the current study shows that, FER alleviated insulin resistance and hypertension associated with metabolic syndrome compared to the standard AR inhibitor (ZOP). This potential protective effect is at least mediated by restoring endothelial relaxation.

Do flexible acrylic resin lingual flanges improve retention of mandibular complete dentures?

Objectives:

The aim of this study was to compare the retention of conventional mandibular complete dentures with that of mandibular complete dentures having lingual flanges constructed with flexible acrylic resin “Versacryl.”

Materials and Methods:

The study sample comprised 10 completely edentulous patients. Each patient received one maxillary complete denture and two mandibular complete dentures. One mandibular denture was made of conventional heat-cured acrylic resin and the other had its lingual flanges made of flexible acrylic resin Versacryl. Digital force-meter was used to measure retention of mandibular dentures at delivery and at 2 weeks and 45 days following denture insertion.

Results:

The statistical analysis showed that at baseline and follow-up appointments, retention of mandibular complete dentures with flexible lingual flanges was significantly greater than retention of conventional mandibular dentures (P < 0.05). In both types of mandibular dentures, retention of dentures increased significantly over the follow-up period (P < 0.05).

Conclusions:

The use of flexible acrylic resin lingual flanges in the construction of mandibular complete dentures improved denture retention.

Percutaneous Nephrolithotomy vs Retrograde Intrarenal Surgery for Large Renal Stones in Pediatric Patients: A Randomized Controlled Trial

PURPOSE

We compared outcomes of percutaneous nephrolithotomy and retrograde intrarenal surgery in the treatment of children with renal calculi larger than 2 cm.

MATERIALS AND METHODS

A total of 38 patients younger than 16 years with renal calculi larger than 2 cm were randomized to undergo percutaneous nephrolithotomy or retrograde intrarenal surgery between May 2011 and February 2014. Demographic data, stone criteria, operative technique, radiation time, complications, blood transfusion, hemoglobin decrease, stone-free rate and length of hospital stay were compared between the groups. Stone-free status was documented if there were no residual stones after 1 month.

RESULTS

The study included 43 renal units, of which 21 were subjected to retrograde intrarenal surgery and 22 to percutaneous nephrolithotomy. Operative time was comparable for both groups. Mean radiation time and hospital stay were longer after percutaneous nephrolithotomy (p<0.001). Stone-free rate was significantly lower after retrograde intrarenal surgery monotherapy vs percutaneous nephrolithotomy monotherapy (71% vs 95.5%, p=0.046). Patients in the percutaneous nephrolithotomy group had significantly more complications compared to the retrograde intrarenal surgery group (p=0.018). Three patients in the percutaneous nephrolithotomy group received blood transfusions, compared to none in the retrograde intrarenal surgery group (p=0.015).

CONCLUSIONS

For treatment of large or complex renal stones in pediatric patients percutaneous nephrolithotomy monotherapy has the advantage of better stone-free rates, while retrograde intrarenal surgery has the advantages of decreased radiation exposure, fewer complications and shorter hospital stay.

Pattern of prostate cancer presentation among the Egyptian population: A study in a single tertiary care center

INTRODUCTION

Prostate cancer is a common health problem that in the majority of cases starts to develop at the age of 50 years, reaching its peak at 60-70 years of age. A variation in its incidence and prevalence exists between western, Asian and Arabic populations. The aim of our work was to report the pattern of prostate cancer presentation in Alexandria University that as a tertiary referral center provides care for uro-oncology cases.

MATERIAL AND METHODS

Data collection for all patients diagnosed with prostate cancer at Alexandria University in Egypt through the year 2012 was done.

RESULTS

The mean age of the patients was 67. Mean serum total PSA, prostate volume and PSAd were 149 ng/ml, 63 grams and 3.1 ng/ml/gm respectively. 25% of patients were asymptomatic diagnosed accidentally during screening for prostate cancer. The remaining group was presenting with LUTS, including 23 patients who presented initially with back pain.

CONCLUSIONS

Egyptian men with prostate cancer have a markedly high PSA density and Gleason grade at diagnosis.

Baicalein protects against hypertension associated with diabetes: effect on vascular reactivity and stiffness

The present work investigated the possible protective effect of baicalein, a natural lipoxygenase enzyme inhibitor, on both insulin deficiency (ID) and insulin resistance (IR)-induced macro-vascular impairment. ID and IR were induced by STZ or fructose for 8 or 12 weeks respectively while baicalein was administered in the last six weeks. Blood pressure (BP) was recorded and isolated aorta reactivity to phenylephrine (PE) and acetylcholine (ACh) were studied. Blood levels of glucose, insulin, advanced glycation end products (AGEs) and tumour necrosis factor-α (TNF-α) were determined. Aortic nuclear transcription factor-κB (NF-κB) activation was assessed. Both models resulted in elevated BP, increased vasoconstriction and impaired relaxation KCl, elevated TNF-α and AGEs, NF-κB activation, marked infiltration of leukocytes in the adventitia, pyknosis of endothelial cells and marked collagen deposition. Baicalein ameliorated elevations in BP in models, prevented exaggerated vasoconstriction IR model and improved relaxation in ID model. Baicalein reduced AGEs and TNF-α level, decreased NF-κB activation and inhibited histopathological changes in both models. Baicalein offsets the hypertensive and the vascular impairment associated with both diabetic models via ameliorating functional and structural derangements of blood vessels.

Arginase inhibition alleviates hypertension in the metabolic syndrome

BACKGROUND AND PURPOSE

We have previously shown that arginase inhibition alleviates hypertension associated with in a diabetic animal model. Here, we investigated the protective effect of arginase inhibition on hypertension in metabolic syndrome.

EXPERIMENTAL APPROACH

Metabolic syndrome was induced in rats by administration of fructose (10% in drinking water) for 12 weeks to induce vascular dysfunction. Three arginase inhibitors (citrulline, norvaline and ornithine) were administered daily in the last 6 weeks of study before and tail BP was recorded in conscious animals. Concentration response curves for phenylephrine (PE), KCl and ACh in addition to ACh-induced NO generation were obtained in thoracic aorta rings. Serum glucose, insulin, uric acid and lipid profile were determined as well as reactive oxygen species (ROS) and arginase activity.

KEY RESULTS

Arginase activity was elevated in metabolic syndrome while significantly inhibited by citrulline, norvaline or ornithine treatment. Metabolic syndrome was associated with elevations in systolic and diastolic BP, while arginase inhibition significantly reduced elevations in diastolic and systolic BP. Metabolic syndrome increased vasoconstriction responses of aorta to PE and KCl and decreased vasorelaxation to ACh, while arginase inhibition completely prevented impaired responses to ACh. In addition, arginase inhibition prevented impaired NO generation and exaggerated ROS formation in metabolic syndrome. Furthermore, arginase inhibition significantly reduced hyperinsulinaemia and hypertriglyceridaemia without affecting hyperuricaemia or hypercholesterolaemia associated with metabolic syndrome.

CONCLUSIONS AND IMPLICATIONS

Arginase inhibition alleviates hypertension in metabolic syndrome directly through endothelial-dependent relaxation/NO signalling protection and indirectly through inhibition of insulin resistance and hypertriglyceridaemia.

Chrysin and luteolin alleviate vascular complications associated with insulin resistance mainly through PPAR-γ activation

Chrysin and luteolin are two flavonoids with Peroxisome proliferators-activated receptor γ (PPAR-γ) stimulating activity. Here, we investigated the protective effect of chrysin and luteolin from vascular complications associated with insulin resistance (IR). IR was induced in rats by drinking fructose for 12 weeks while chrysin and luteolin were given for 6 weeks with or without PPAR-γ antagonist, bisphenol A diglycidyl ether (BADGE). Then, blood pressure (BP) was recorded and serum levels of glucose, insulin, advanced glycation end products (AGEs) and lipids were measured. Concentration response curves for phenylephrine (PE), KCl, and acetylcholine (ACh) were obtained in thoracic aorta rings. Aortic reactive oxygen species (ROS) and nitric oxide (NO) generation were also studied. Chrysin and luteolin significantly alleviated systolic BP elevations caused by IR, while the co-administration of BADGE prevented chrysin alleviation. Although, neither chrysin nor luteolin affected ACh impaired vasodilatation, they both alleviated exaggerated vasoconstrictions to PE and KCl in IR animals. In addition, incubation of the aorta from IR animals with chrysin or luteolin prevented exaggerated vasoconstrictions to PE and KCl. On the other hand, co-administration of BADGE or co-incubation with GW9662, the selective PPAR-γ antagonist, prevented chrysin alleviation. Both chrysin and luteolin inhibited the developed hyperinsulinemia and increases in serum AGEs, lipids while, BADGE reduced the effect of chrysin on hyperinsulinemia and dyslipidemia. Chrysin and luteolin markedly inhibited elevated NO and ROS in IR aortae while BADGE did not change their effect on NO and ROS. In conclusion, chrysin and luteolin alleviate vascular complications associated with IR mainly through PPAR-γ dependent pathways.

Characterization of vascular complications in experimental model of fructose-induced metabolic syndrome

Vascular dysfunction is an important complication associated with metabolic syndrome (MS). Here we fully characterized vascular complications in a rat model of fructose-induced MS. MS was induced by adding fructose (10%) to drinking water to male Wistar rats of 6 weeks age. Blood pressure (BP) and isolated aorta responses phenylephrine (PE), KCl, acetylcholine (ACh), and sodium nitroprusside (SNP) were recorded after 6, 9, and 12 weeks of fructose administration. In addition, serum levels of glucose, insulin, uric acid, tumor necrosis factor α (TNFα), lipids, advanced glycation end products (AGEs), and arginase activity were determined. Furthermore, aortic reactive oxygen species (ROS) generation, hemeoxygenase-1 expression, and collagen deposition were examined. Fructose administration resulted in a significant hyperinslinemia after 6 weeks which continued for 12 weeks. It was also associated with a significant increase in BP after 6 weeks which was stable for 12 weeks. Aorta isolated from MS animals showed exaggerated contractility to PE and KCl and impaired relaxation to ACh compared with control after 6 weeks which were clearer at 12 weeks of fructose administration. In addition, MS animals showed significant increases in serum levels of lipids, uric acid, AGEs, TNFα, and arginase enzyme activity after 12 weeks of fructose administration. Furthermore, aortae isolated from MS animals were characterized by increased ROS generation and collagen deposition. In conclusion, adding fructose (10%) to drinking water produces a model of MS with vascular complications after 12 weeks that are characterized by insulin resistance, hypertension, disturbed vascular reactivity and structure, hyperuricemia, dyslipidemia, and low-grade inflammation.

Aqueous garlic extract alleviates liver fibrosis and renal dysfunction in bile-duct-ligated rats

There is accumulating evidence that the renin-angiotensin system (RAS) is involved in hepatic inflammation and fibrogenesis. Garlic was found to lower the activity of the angiotensin converting enzyme (ACE) in the serum of rats in a diabetic model. We examined the effect of an aqueous garlic extract (AGE) on the ACE activity, cholestasis-induced liver fibrosis, and associated renal dysfunction in comparison with the effect of the standard drug enalapril. Both AGE and enalapril were administered orally for six weeks starting from the third day after bile duct ligation (BDL). BDL significantly increased the serum activities of liver enzymes, serum lactate dehydrogenase (LDH) activity, an indicator of liver cell death, serum total bilirubin (TB) level, liver myeloperoxidase (MPO) activity, and liver malondialdehyde (MDA) content. BDL was associated with elevation of serum urea and creatinine levels indicating renal dysfunction. BDL also caused an increase in the transcript levels of the genes coding for tumour necrosis factor alpha (TNF-alpha), transforming growth factor beta-1 (TGF-beta1), and matrix metalloproteinase-13 (MMP-13), a collagenase, in liver tissues. A significant decrease in hepatic reduced glutathione (GSH) was observed in BDL rats, while serum ACE activity was increased. Both AGE and enalapril counteracted all these deleterious changes, with the exception that only AGE reduced the MPO activity. These findings suggest that AGE possesses hepato- and renoprotective properties, similar to enalapril, probably by modulating the levels of proteins such as TNF-alpha, TGF-beta1 and MMP-13, and involving a reduction of ACE and of oxidative stress.

BDNF signaling in the VTA links the drug-dependent state to drug withdrawal aversions

Drug administration to avoid unpleasant drug withdrawal symptoms has been hypothesized to be a crucial factor that leads to compulsive drug-taking behavior. However, the neural relationship between the aversive motivational state produced by drug withdrawal and the development of the drug-dependent state still remains elusive. It has been observed that chronic exposure to drugs of abuse increases brain-derived neurotrophic factor (BDNF) levels in ventral tegmental area (VTA) neurons. In particular, BDNF expression is dramatically increased during drug withdrawal, which would suggest a direct connection between the aversive state of withdrawal and BDNF-induced neuronal plasticity. Using lentivirus-mediated gene transfer to locally knock down the expression of the BDNF receptor tropomyosin-receptor-kinase type B in rats and mice, we observed that chronic opiate administration activates BDNF-related neuronal plasticity in the VTA that is necessary for both the establishment of an opiate-dependent state and aversive withdrawal motivation. Our findings highlight the importance of a bivalent, plastic mechanism that drives the negative reinforcement underlying addiction.

Single- vs. multi-stage repair of proximal hypospadias: The dilemma continues

INTRODUCTION

The surgical reconstruction of distal penile hypospadias in a single stage is the standard practice for managing anterior hypospadias. Unfortunately, it is not simple to extrapolate the same principle to proximal hypospadias. There is no consensus among hypospadiologists about whether a single- or multi-stage operation is the optimal treatment for proximal hypospadias. In this review, we assess the currently reported outcomes and complications of both techniques in proximal hypospadias repair.

METHODS

We searched Medline, Pubmed, Scopus and Ovid for publications in the last 10 years (2002-2012) for relevant articles, using the terms 'proximal hypospadias', 'posterior hypospadias' 'single stage', 'multiple stage', and 'complications'. Articles retrieved were analysed according to the technique of repair, follow-up, complications, success rate, number of included children, and re-operative rate.

RESULTS AND CONCLUSIONS

The reported complications in both techniques were similar, including mostly minor complications in the form of fistula, meatal stenosis, partial glans dehiscence, and urethral diverticulum, with their easy surgical repair. The outcomes of single- and multistage repairs of proximal hypospadias are comparable; no technique can be considered better than any other. Thus, it is more judicious for a hypospadiologist to master a few of these procedures to achieve the best results, regardless of the technique used.

Quercetin protects against diabetes-induced exaggerated vasoconstriction in rats: effect on low grade inflammation

Vascular complications are the leading cause of morbidity and mortality in patients with diabetes. Quercetin is an important flavonoid with antioxidant and anti-inflammatory activity. Here, the effect of quercetin on diabetes-induced exaggerated vasoconstriction in insulin deficient and insulin resistant rat models was investigated. Insulin deficiency was induced by streptozotocin while, insulin resistance by fructose. Rats were left 8 weeks or 12 weeks after STZ or fructose administration respectively. Quercetin was daily administered in the last 6 weeks. Then, tail blood pressure (BP) was recorded in conscious animals; concentration-response curves for phenylephrine (PE) and KCl were studied in thoracic aorta rings. Non-fasting blood glucose level, serum insulin level, insulin resistance index, serum tumour necrosis factor-α (TNF-α) and serum C-reactive protein (CRP) were determined. Nuclear transcription factor-κB (NF-κB) was assessed by immunofluorescence technique. Histopathological examination was also performed. The results showed that quercetin protected against diabetes-induced exaggerated vasoconstriction and reduced the elevated blood pressure. In addition, quercetin inhibited diabetes associated adventitial leukocyte infiltration, endothelial pyknosis and increased collagen deposition. These effects were accompanied with reduction in serum level of both TNF-α and CRP and inhibition of aortic NF-κB by quercetin in both models of diabetes. On the other hand, quercetin did not affect glucose level in any of the used diabetic models. This suggests that the protective effect of quercetin is mediated by its anti-inflammatory effect rather than its metabolic effects. In summary, quercetin is potential candidate to prevent diabetic vascular complications in both insulin deficiency and resistance via its inhibitory effect on inflammatory pathways especially NF-κB signaling.

Aldose reductase inhibitors zopolrestat and ferulic acid alleviate hypertension associated with diabetes: effect on vascular reactivity

This study investigated the effect of aldose reductase (AR) inhibitors on hypertension in diabetes. Diabetes was induced with streptozotocin, while AR inhibitors zopolrestat and ferulic acid were administered at 2 weeks after streptozotocin treatment and for 6 weeks afterwards. Then, blood pressure (BP) and serum level of glucose were determined. Concentration–response curves for phenylephrine (PE), KCl, and acetylcholine (ACh) were obtained in isolated aorta. In addition, ACh-induced NO and reactive oxygen species (ROS) generation in aorta and histopathology were examined. Compared with the control animals, diabetes increased diastolic and systolic BP. AR inhibitors reduced diastolic BP elevation without affecting the developed hyperglycaemia. Diabetes increased the contractile response of aorta to KCl, and decreased the relaxation response to Ach, while administering AR inhibitors prevented an impaired response to ACh. Incubation of aorta isolated from diabetic animals with AR inhibitors did not affect the impaired relaxation response to ACh. In addition, AR inhibitors negated the impaired Ach-stimulated NO generation seen in aorta isolated from diabetic animals. Furthermore, diabetes was accompanied with marked infiltration of leukocytes in aortic adventitia, endothelial cell pyknosis, and increased ROS formation. AR inhibitors reduced leukocyte infiltration and inhibited endothelial pyknosis and ROS formation. In conclusion, AR inhibitors negate diabetes-evoked hypertension via ameliorating impaired endothelial relaxation and NO production.

Factors that predict the spontaneous passage of ureteric stones in children

Objective

To study the natural history of stone passage in children with ureterolithiasis and to define factors predictive of spontaneous passage.

Patients and methods

In all, 72 children with ureteric stones were evaluated; patients with ureteric calculi of >10 mm were excluded, as were those with absolute indications for surgical stone removal. Stone size, location, side, presence of hydronephrosis, perinephric stranding and degree of the tissue-rim sign were estimated by unenhanced helical computed tomography (UHCT). All patients were sent home with no administration of an α-blocker. The stone status was evaluated by a plain abdominal film or CT at ≈6 weeks after the initial diagnostic evaluation. The time from the initial complaint to the passage of the stone was recorded for each patient.

Results

In all, 54 (75%) children with ureteric stones of ⩽6 mm eventually passed their stones spontaneously. However, stones of <4 mm and those in the distal ureter had a significantly higher spontaneous passage rate and shorter time to stone passage (P < 0.05). The UHCT findings of a higher degree of the tissue-rim sign, hydronephrosis and perinephric fat stranding were associated with a lower likelihood of stone passage.

Conclusions

The rate of spontaneous passage of ureteric stones in children varies with stone location, and perinephric stranding on UHCT seems to be useful for predicting the possibility of spontaneous passage. In cases with unfavourable signs an early intervention might have better outcomes than conservative therapy.

Ureteroscopy in infants and preschool age children: technique and preliminary results

INTRODUCTION

We present our experience with the use of semirigid ureteroscopy for the treatment of ureteric stones in children less than or equal to 6 years of age.

MATERIAL AND METHODS

The records of 21 children (12 female, 9 male) with an average age of 4.7 years (range 8 months to 6 years) treated with semirigid ureteroscopy between June 2006 and July 2010 were reviewed. In 13 ureteral units 7Fr semirigid ureteroscopy was carried out in a retrograde manner to treat stone disease, while an adult ureteroscope (9.5 fr) was used in the remaining patients. Stones were located in the upper ureter in 2 cases, middle ureter in 2 cases, and lower ureter in 17 cases. Ureteral dilation was not required in all patients.

RESULTS

Stone size varied from 4 to 13 mm (mean 6 mm). The management of stones in 18 (90.7%) children was straightforward and a single ureteroscopy was required to clear the ureters. In 2 (6.2%) children, repeat ureteroscopy was undertaken to render the ureters stone free, and in 1 child (3.1%) it was not possible to remove the stone. Stones were fragmented with pneumatic lithotripsy in 12 cases and stones were removed mechanically without fragmentation in the remaining 9 cases. Intraoperative complications occurred in 2 (9.3%) children and included extravasation (1 patient), which was managed with ureteral stenting and stone upward migration (1 patient). Early postoperative complications included pyelonephritis (1 patient). Mean follow-up was 6.4 (3-36) months. Incidence of stricture at the site of stone impaction was not detected in any patients. None of the patients managed without a post-operative stent required subsequent intervention.

CONCLUSIONS

In the hands of an experienced surgeon, ureteroscopy in young children can be a safe and efficient treatment for ureteral stones that can be performed without ureteral dilation. Routine ureteral stenting is not a requirement when the procedure is relatively atraumatic. Further studies and longer follow-up are necessary to determine the success of this technique.