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Barrieras D, Lapointe S, Reddy PP, Williot P, McLorie GA, Bägli D, Khoury AE, Merguerian PA. Urinary retention after bilateral extravesical ureteral reimplantation: does dissection distal to the ureteral orifice have a role? J Urol 1999; 162:1197-200. [PMID: 10458465 DOI: 10.1016/s0022-5347(01)68130-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE We evaluated the outcome and incidence of urinary retention after bilateral detrusorrhaphy using 2 modifications of the original Lich-Gregoir procedure. MATERIALS AND METHODS We evaluated the charts of 220 patients who underwent correction of bilateral vesicoureteral reflux using the extravesical approach from January 1991 to December 1997. Inverted Y detrusorrhaphy was performed in 154 patients and the advancing suture modification was done in 66. RESULTS The success rate using the advancing suture technique was 92.4 and 95.4% at 3 and 12 months, respectively. The Y detrusorrhaphy technique was successful in 91.6 and 97.4% of cases at 3 and 12 months, respectively. The difference in the techniques was not statistically significant. Urinary retention developed in 8.4% of the patients who underwent Y detrusorrhaphy compared to 15.2% of those who underwent the advancing suture technique (not statistically significant). However, patients with grades IV and V reflux, children younger than 3 years and boys had significantly (p <0.05) higher postoperative retention rates of 24.6, 35.6 and 20.3%, respectively, when all 220 patients were considered. CONCLUSIONS Each modification of the original Lich-Gregoir technique is highly effective for treating bilateral vesicoureteral reflux and each is associated with a low rate of temporary urinary retention. Although there seems to be a lower incidence of retention with the Y detrusorrhaphy technique, this was not statistically significant. Because of the higher incidence of urinary retention in young children, boys and/or patients with high grade reflux, we recommend that physicians consider a longer period of catheterization regardless of the technique chosen.
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Pugach JL, DiTizio V, Mittelman MW, Bruce AW, DiCosmo F, Khoury AE. Antibiotic hydrogel coated Foley catheters for prevention of urinary tract infection in a rabbit model. J Urol 1999; 162:883-7. [PMID: 10458402 DOI: 10.1097/00005392-199909010-00084] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We developed an antibiotic liposome (ciprofloxacin liposome) containing hydrogel for external coating of silicone Foley catheters and evaluated its efficacy in a rabbit model. Our goal was to create a catheter that would hinder the development of catheter associated nosocomial urinary tract infections. MATERIALS AND METHODS We inserted either an untreated, liposomal hydrogel coated or a liposome hydrogel with ciprofloxacin coated 10F silicone Foley catheter into New Zealand White rabbits. We challenged the system with 5x10(6) virulent Escherichia coli at the urethral meatus twice daily for 3 days. Urine cultures were evaluated twice daily for 7 days. When urine cultures became positive, the rabbits were sacrificed and urine, urethral catheter and urethral tissue were cultured. RESULTS The time to bacteriuria detection in 50% of the specimens was double for hydrogel with ciprofloxacin coated catheters versus untreated and hydrogel coated catheters. A significant (p = 0.04) improvement in average time to positive urine culture from 3.5 to 5.3 days and a 30% decrease in the bacteriuria rate for hydrogel with ciprofloxacin coated catheters were noted compared to untreated catheters. CONCLUSIONS A significant benefit was realized by coating the extraluminal catheter surface with a ciprofloxacin liposome impregnated hydrogel. We believe this procedure will provide a significant clinical advantage, while reducing health care costs substantially.
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Barrieras D, Lapointe S, Reddy PP, Williot P, McLorie GA, Bägli D, Khoury AE, Merguerian PA. Urinary retention after bilateral extravesical ureteral reimplantation: does dissection distal to the ureteral orifice have a role? J Urol 1999; 162:1197-200. [PMID: 10458465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
PURPOSE We evaluated the outcome and incidence of urinary retention after bilateral detrusorrhaphy using 2 modifications of the original Lich-Gregoir procedure. MATERIALS AND METHODS We evaluated the charts of 220 patients who underwent correction of bilateral vesicoureteral reflux using the extravesical approach from January 1991 to December 1997. Inverted Y detrusorrhaphy was performed in 154 patients and the advancing suture modification was done in 66. RESULTS The success rate using the advancing suture technique was 92.4 and 95.4% at 3 and 12 months, respectively. The Y detrusorrhaphy technique was successful in 91.6 and 97.4% of cases at 3 and 12 months, respectively. The difference in the techniques was not statistically significant. Urinary retention developed in 8.4% of the patients who underwent Y detrusorrhaphy compared to 15.2% of those who underwent the advancing suture technique (not statistically significant). However, patients with grades IV and V reflux, children younger than 3 years and boys had significantly (p <0.05) higher postoperative retention rates of 24.6, 35.6 and 20.3%, respectively, when all 220 patients were considered. CONCLUSIONS Each modification of the original Lich-Gregoir technique is highly effective for treating bilateral vesicoureteral reflux and each is associated with a low rate of temporary urinary retention. Although there seems to be a lower incidence of retention with the Y detrusorrhaphy technique, this was not statistically significant. Because of the higher incidence of urinary retention in young children, boys and/or patients with high grade reflux, we recommend that physicians consider a longer period of catheterization regardless of the technique chosen.
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Merguerian PA, Jamal MA, Agarwal SK, McLorie GA, Bägli DJ, Shuckett B, Gilday DL, Khoury AE. Utility of SPECT DMSA renal scanning in the evaluation of children with primary vesicoureteral reflux. Urology 1999; 53:1024-8. [PMID: 10223500 DOI: 10.1016/s0090-4295(99)00049-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES DMSA renal scanning is more sensitive than ultrasound in detecting renal parenchymal scars. We proposed to determine the utility of single-photon emission computed tomography (SPECT) dimercaptosuccinic acid (DMSA) renal scanning in children with primary vesicoureteral reflux (VUR). METHODS During a 24-month period, we evaluated the charts of 368 patients who had undergone SPECT DMSA renal scanning for primary VUR. Patients were divided into three age groups: (a) less than 1 year, (b) between 1 and 5 years, and (c) older than 6 years. Renal scars were deemed severe or focal. The data were analyzed to evaluate the utility of SPECT DMSA scanning in children with primary VUR and to determine the indications for performing SPECT DMSA. We also evaluated the sensitivity of recent renal ultrasound technology in detecting focal and diffuse scars. RESULTS One hundred twenty-eight patients were younger than 1 year at presentation. These included 24 cases that were detected prenatally. One hundred eighty-five were between the ages of 1 and 5 years, and 55 were 6 years or older. Reflux nephropathy at presentation was found in 99 (26.9%) of 368 patients. DMSA scanning changed the treatment in only 13 patients (3.5%). When scarring was diffuse, ultrasound examination correlated 100% with DMSA scanning; when focal scarring was present, the correlation was poor. CONCLUSIONS Our results suggest that DMSA scans should be tailored to children who have ultrasound abnormalities, high-grade reflux, or recurrent breakthrough urinary tract infections. These guidelines will result in a substantial cost savings and a significant decrease in radiation exposure.
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Salle JL, McLorie GA, Bägli DJ, Khoury AE. Modifications of and extended indications for the Pippi Salle procedure. World J Urol 1998; 16:279-84. [PMID: 9775428 DOI: 10.1007/s003450050067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Total urinary incontinence is a difficult problem faced by the urologist. Several techniques to increase ureteral resistance have been described. The majority of them rely on intermittent catheterization for bladder emptying, especially in neurogenic incontinence. We have developed a new procedure in which a bladder flap is used to create a neourethra. This urethral extension acts as a flap valve to provide continence. Bladder emptying is accomplished by clean intermittent catheterization. Urethral lengthening with an anterior bladder-wall flap was performed in 18 patients aged a mean of 8.9 years who had neurogenic incontinence (14) or exstrophy (4). Patients with previous bladder interventions received a lateralized anterior flap. Bladder augmentation was performed in 14 of the 18 patients [detubularized ileum (11), detubularized colon (3)]. The average follow-up period is currently 29.3 months. Continence was achieved in 13 of the 18 patients (72%). Complications included urethrovesical fistulae, which developed in two patients. Two patients could not perform catheterization due to pain but had no obstruction to passage of catheter (exstrophy). Ureteral lengthening with an anterior bladder-wall flap is a useful alternative for the surgical treatment of urinary incontinence. This technique achieves a good continence rate and presents few problems with catheterization.
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DiTizio V, Ferguson GW, Mittelman MW, Khoury AE, Bruce AW, DiCosmo F. A liposomal hydrogel for the prevention of bacterial adhesion to catheters. Biomaterials 1998; 19:1877-84. [PMID: 9855189 DOI: 10.1016/s0142-9612(98)00096-9] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The adhesion of bacteria to medical implants and the subsequent development of a biofilm frequently results in the infection of surrounding tissue and may require removal of the device. We have developed a liposomal hydrogel system that significantly reduces bacterial adhesion to silicone catheter material. The system consists of a poly (ethylene glycol)-gelatin hydrogel in which liposomes containing the antibiotic ciprofloxacin are sequestered. A poly (ethylene glycol)-gelatin-liposome mixture was applied to a silicone surface that had been pre-treated with phenylazido-modified gelatin. Hydrogel cross-linking and attachment to surface-immobilized gelatin was accomplished through the formation of urethane bonds between gelatin and nitrophenyl carbonate-activated poly (ethylene glycol). Liposomal hydrogel-coated catheters were shown to have an initial ciprofloxacin content of 185+/-16 microg cm(-2). Ciprofloxacin was released over seven days with an average release rate of 1.9+/-0.2 microg cm(-2) h(-1) for the first 94 h. In vitro assays using a clinical isolate of Pseudomonas aeruginosa established the antimicrobial efficacy of the liposomal hydrogel. A modified Kirby-Bauer assay produced growth-inhibition zone diameters of 39+/-1 mm, while bacterial adhesion was completely inhibited on catheter surfaces throughout a seven-day in vitro adhesion assay. This new antimicrobial coating shows promise as a prophylactic and/or treatment for catheter-related infection.
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Bägli DJ, Agarwal SK, Venkateswaran S, Shuckett B, Khoury AE, Merguerian PA, McLorie GA, Liu K, Niederberger CS. Artificial neural networks in pediatric urology: prediction of sonographic outcome following pyeloplasty. J Urol 1998; 160:980-3; discussion 994. [PMID: 9719258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Computerized artificial neural networks are analogous to biological neuronal systems. Since they may be trained to recognize the relevance of complex patterns in data, neural networks may be useful for decision making in the multifactorial management of ureteropelvic junction obstruction. We determine the ability of a customized neural network to predict sonographic outcome after pyeloplasty in children with ureteropelvic junction obstruction. MATERIALS AND METHODS A data set was constructed with 242 demographic, clinical, radiological and surgical elements. We analyzed the available retrospective data in 100 consecutive children who underwent unilateral pyeloplasty for ureteropelvic junction obstruction chosen from all 144 surgically treated for ureteropelvic junction obstruction between 1993 and 1995. One radiologist reviewed all film data and provided a final sonographic outcome designation in each case. We wrote a set of computer programs to construct a neural network. A composite 4-layer network was built with output nodes representing 4 possible sonographic outcomes. The 100 patient data set was randomly divided into 84 training and 16 testing examples. RESULTS The neural network correctly predicted all 5 of 5 significantly improved, 7 of 7 improved, 2 of 2 same and 2 of 2 worse sonogram results after pyeloplasty. Therefore, sensitivity and specificity were 100% for all 4 outcomes. Linear regression analysis of the data yielded inferior sensitivity and specificity values (52 to 94%), confirming that ureteropelvic junction obstruction is a nonlinear data analysis problem. CONCLUSIONS The 100% accuracy, sensitivity and specificity of our neural network in this pilot study provide evidence of the value of the neural computational approach for the modern exploration and modeling of the clinical problem of pediatric ureteropelvic junction obstruction.
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Merguerian PA, Agarwal S, Greenberg M, Bägli DJ, Khoury AE, McLorie GA. Outcome analysis of rhabdomyosarcoma of the lower urinary tract. J Urol 1998; 160:1191-4; discussion 1216. [PMID: 9719307 DOI: 10.1097/00005392-199809020-00065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Multimodal therapy has resulted in a high cure rate for genitourinary rhabdomyosarcoma. We propose that the strategy of induction chemotherapy followed by excision and reconstruction without radiotherapy may provide a high cure rate without the late sequelae of pelvic radiotherapy. MATERIALS AND METHODS We reviewed the records of 13 patients with a mean age of 3.3 years diagnosed with rhabdomyosarcoma of the urinary tract from 1986 to 1996. The primary site was the bladder in 4 cases and prostate in 9. After biopsy confirmation of the diagnosis patients were treated with chemotherapy and subsequent surgery, while radiotherapy was reserved for those with residual disease. RESULTS After induction chemotherapy 8 patients underwent tumor excision via an organ sparing approach, which involved radical prostatectomy and partial cystectomy with or without bladder augmentation. In 5 patients the final pathological analysis showed positive margins. Repeat surgery in 6 patients included complete cystectomy and urinary diversion in 2 who had positive margins and recurrence after radiotherapy, urethrectomy and continent diversion for positive margins in 1, partial cystectomy and continent diversion in 1, and radical prostatectomy, partial cystectomy and continent diversion in 1 with stage IV disease who had local recurrence. In the latter case ileocystoplasty had been performed for a small noncompliant bladder. Six patients with microscopic residual or metastatic disease received radiotherapy. At a mean followup of 5.6 years 11 patients are disease-free. Continence was preserved in all reconstructed cases. Erections were reported in 8 patients, and renal function was maintained in 10. CONCLUSIONS Our results suggest that urinary tract reconstruction may be safely performed at primary excision surgery, radiotherapy induced morbidity may be minimized by limiting radiotherapy to residual and metastatic disease, frozen section results may be false-negative, potency may be achieved and radiological disappearance of the tumor should be confirmed histologically.
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Van Savage JG, Churchill BM, Khoury AE. Negative effect of vascular shunt on renal autotransplant in conjoined twins is reversible after separation. J Urol 1998; 159:2108-9. [PMID: 9598550 DOI: 10.1016/s0022-5347(01)63286-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Van Savage JG, Churchill BM, Khoury AE. Negative effect of vascular shunt on renal autotransplant in conjoined twins is reversible after separation. J Urol 1998; 159:2108-9. [PMID: 9598550 DOI: 10.1097/00005392-199806000-00129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Theodorescu D, Balcom A, Smith CR, McLorie GA, Churchill BM, Khoury AE. Urethral replacement with vascularized tunica vaginalis: defining the optimal form of use. J Urol 1998; 159:1708-11. [PMID: 9554398 DOI: 10.1097/00005392-199805000-00098] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Residual urethral defects after failed hypospadias surgery present difficulties in reconstruction. In these situations, repair using vascularized tissue flaps remains ideal, yet challenging. In order to offer more surgical alternatives in these cases, the use of vascularized tunica vaginalis flaps as urethral replacements has recently been established in an animal model. We undertook the following studies to further define the role of tunica vaginalis in urethral reconstruction. MATERIALS AND METHODS A vascularized flap of tunica vaginalis was used to replace an experimentally created 25-30 mm. gap in the anterior urethra of 26 rabbits, either as an onlay or tube flap. A control group consisting of 7 animals underwent only a segmental anterior urethral resection and primary re-anastomosis. RESULTS Satisfactory urethral healing occurred in all control animals that survived the procedure. All 8 animals which had tunica vaginalis tube flap reconstruction underwent contracture of the neourethra probably secondary to the presence of striated cremasteric muscle elements brought with the tunica during mobilization. All 16 animals available for long term study in the onlay flap group had excellent flap viability and 100% urethral patency rates. The mesothelial lining of the tunica was seen to be replaced by a stratified epithelial lining similar to the urothelial lining of the native urethra. CONCLUSION The tunica vaginalis is a viable alternative to other tissues presently used for urethral replacement and can be used successfully as a vascularized onlay flap.
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Fung LC, Churchill BM, McLorie GA, Chait PG, Khoury AE. Ureteral opening pressure: a novel parameter for the evaluation of pediatric hydronephrosis. J Urol 1998; 159:1326-30. [PMID: 9507877 DOI: 10.1016/s0022-5347(01)63609-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The antegrade nephrostogram is an important tool in the evaluation of the upper urinary tract. However, the information currently provided by a nephrostogram is largely limited to anatomical details. To establish a meaningful pressure-flow parameter that may be incorporated into a routine nephrostogram, we evaluated the ureteral opening pressure (defined as the pressure at which contrast material is first seen beyond the suspected site of obstruction) and correlated these findings with the results of pressure-flow studies performed with an external infusion and/or furosemide induced diuresis. MATERIALS AND METHODS A total of 52 renal units were studied under a prospective pressure-flow study protocol. All patients had grade 3 or 4 hydronephrosis (Society of Fetal Urology classification) and patient age range was 0.2 to 12 years (median 1.1). The suspected sites of obstruction were the ureteropelvic and ureterovesical junctions in 42 and 10 renal units, respectively. With the patient under general anesthesia 22 gauge percutaneous nephrostomy needles were inserted. Pressure-flow studies with an external infusion and/or furosemide induced diuresis were then performed. As the renal pelvic pressure progressively increased during the course of the pressure-flow studies, the renal pelvic pressure at which contrast material was first seen to appear distal to the suspected site of obstruction was recorded as the ureteral opening pressure. Ureteral opening pressures were compared to the results of the pressure-flow studies. RESULTS With a positive test defined as renal pelvic pressure greater than 14 cm. water, positive ureteral opening pressures were associated with positive pressure-flow study results in 100% of the cases, regardless of which form of pressure-flow study was used or where the suspected site of obstruction was located. In contrast, negative ureteral opening pressures had specificities and negative predictive values of only 19 to 57%, depending on the form of the pressure-flow study and the suspected site of obstruction. CONCLUSIONS An elevated ureteral opening pressure was 100% predictive of obstruction and may obviate the need for more elaborate pressure-flow analyses. However, if the ureteral pelvic pressure remained low, the possibility of a potentially significant obstruction could not be definitively eliminated and further evaluation was required.
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Abstract
Recent advancements in surgical and medical therapies have improved the life expectancy of children with myelomeningocele. Yet, there has been a contrasting lack of improvement with regards to sexual function and reproductive issues that continue to infantilize this population. This article identifies five major risk factors that contribute to these delays which invariably lead to irreversible emotional trauma if they are not addressed early in childhood. Adequate psychosexual education of myelomeningocele patients and their families is a tremendous societal challenge. But, only with education will there be trends away from policies of isolation to those that reinforce community integration of the physically disabled.
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Homayoon KA, Salle JL, Mclorie GA, Bägli DJ, Agarwal SK, Khoury AE. Correlation of inulin with creatinine clearance in partial unilateral ureteral obstruction for determination of differential glomerular filtration rate in rabbits. CONTEMPORARY TOPICS IN LABORATORY ANIMAL SCIENCE 1997; 36:44-6. [PMID: 16450975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
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Jayanthi VR, Churchill BM, Khoury AE, McLorie GA. Bilateral single ureteral ectopia: difficulty attaining continence using standard bladder neck repair. J Urol 1997; 158:1933-6. [PMID: 9334642 DOI: 10.1016/s0022-5347(01)64184-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE We reviewed the surgical results of the management of bilateral single ureteral ectopia, a rare congenital cause of severe urinary incontinence. MATERIALS AND METHODS We reviewed the records of 6 girls and 1 male infant who presented to 1 institution with this diagnosis in a 10-year period. RESULTS All patients were incontinent and 3 had undergone ureteral reimplantation as an initial procedure with persistent postoperative wetting. Of the 5 patients who underwent a total of 8 attempts at increasing bladder outlet resistance, including 3 Young-Dees-Leadbetter, 2 Kropp, 1 Stamey, 1 Burch and 1 pubovaginal sling procedure, 2 also underwent simultaneous bladder augmentation to increase bladder capacity. However, none of these children had satisfactory continence after the continence procedure. Three of these patients who subsequently underwent appendicovesicostomy with bladder neck closure are continent. The 2 remaining patients underwent initial appendicovesicostomy with bladder neck closure and augmentation, and they are also continent. CONCLUSIONS In our series total day and nighttime continence was only achieved by bladder neck closure, appendicovesicostomy and augmentation. Attempts at increasing bladder outlet resistance in patients with bilateral single ectopic ureters led to suboptimal rates of success even when adequate bladder capacity had been ensured by simultaneous augmentation.
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Khoury AE, Salomon M, Doche R, Soboh F, Ackerley C, Jayanthi R, McLorie GA, Mittelman MW. Stone formation after augmentation cystoplasty: the role of intestinal mucus. J Urol 1997; 158:1133-7. [PMID: 9258156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE We evaluated the role of mucus in urine after bladder augmentation and hypothesize that mucus acts as a possible etiological factor in stone formation. MATERIALS AND METHODS Mucus was collected via centrifugation from the 24-hour urine specimens of 8 stone forming and 10 nonstone forming patients who were randomly selected from our augmentation population. The mucus and stones were lyophilized, and then analyzed via scanning electron microscopy and energy dispersive x-ray spectrometry for calcium, phosphate, magnesium and sodium. The 24-hour urine collections were also analyzed to determine any metabolic differences between the 2 groups. RESULTS Scanning electron microscopy and energy dispersive x-ray spectrometry spectra showed increased calcium, phosphate, and magnesium, and significantly higher (p < 0.05) calcium-to-phosphate ratios in the mucus of stone versus nonstone forming patients. Of the 8 stones examined all had viscous fluid (mucus) centers rich in calcium, phosphate and magnesium. Calcium-to-phosphate ratios in the corresponding mucus recovered from stone centers were similarly high. Urinary citrate levels were low in both groups, and calcium, phosphate and magnesium were within normal ranges. CONCLUSIONS Mucus appears to have an important role in the genesis of bladder stones after augmentation, possibly acting as a nidus. Metabolic changes following augmentation were similar in stone and nonstone forming populations. Our data suggest that mucous calcium-to-phosphate ratios may be predictive of future stone formation. Furthermore, there may be a benefit in instituting more aggressive measures aimed at clearing mucus from the bladder.
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Motta J, Bagli DJ, Savage JV, Khoury AE, McLorie G, Salle JP. Torsion of an indirect hernia sac: an unusual cause of acute scrotal swelling in children. Urology 1997; 50:432-5. [PMID: 9301711 DOI: 10.1016/s0090-4295(97)00297-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES An indirect inguinal hernia is a common cause of inguinoscrotal swelling in young boys. We describe 3 cases of an extremely unusual entity that has a similar clinical presentation to more commonly diagnosed intrascrotal processes. METHODS Two patients presented with acute hemiscrotal enlargement and pain, and a third patient presented with scrotal enlargement only. All patients underwent a scrotal ultrasound evaluation and subsequent inguinoscrotal exploration. RESULTS All patients had a multiseptated peritesticular fluid-filled mass on ultrasound evaluation. Subsequent inguinoscrotal exploration revealed a torsion of the indirect hernia sac in each case. A high ligation and excision of the sac was curative. CONCLUSIONS Torsion of a hernia sac is an extremely rare entity, and current sonographic imaging fails to clearly diagnose this unusual phenomenon. Because pediatric urologists are commonly called to evaluate a child with an acutely swollen scrotum, awareness of this diagnosis is important.
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Van Savage JG, Khoury AE, McLorie GA, Bägli DJ. An algorithm for the management of anterior urethral valves. J Urol 1997; 158:1030-2. [PMID: 9258136 DOI: 10.1097/00005392-199709000-00089] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE We present our management algorithm for patients with anterior urethral valves seen in the last 2 decades with and without the benefit of prenatal sonography. MATERIALS AND METHODS A case series design was used to study 17 cases of anterior urethral valves. Five patients presented with prenatal hydronephrosis from 1984 to 1993 and 12 presented with predominant voiding symptoms between 1975 and 1996 at a mean age of 6 years. RESULTS Treatment included supravesical diversion in 1 case, vesicostomy in 5, urethroplasty in 5 and transurethral fulguration in 6. Four of the 5 patients with a prenatal diagnosis of hydronephrosis had moderate to severe hydronephrosis compared to 3 of the 12 who did not undergo prenatal sonography. All 17 patients were continent and infection-free, and had little or no hydronephrosis at a mean followup of 5 years. CONCLUSIONS We recommend vesicostomy in infants with high grade bilateral vesicoureteral reflux and poor emptying of the urinary tract, transurethral fulguration if the urethra has sufficient caliber and support, and urethroplasty in other patients. Based on our management algorithm patients with anterior urethral valves do not have sequelae due to distal obstruction of the urinary tract.
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Abstract
PURPOSE The nonneurogenic neurogenic bladder has traditionally been believed to represent a disorder of older children. We report on patients in whom congenital dysfunctional voiding may be the underlying cause of nonneurogenic neurogenic bladder in early infancy. MATERIALS AND METHODS We evaluated 5 male and 2 female patients newborn to 30 months old with dysfunctional neurogenic bladder and no evidence of neurological pathology or anatomical outflow obstruction. Presentation included prenatal hydronephrosis in 3 cases, urosepsis in 2 and failure to thrive in 2. Radiological and urodynamic investigations revealed thick walled, poorly compliant bladders in 5 patients and incomplete bladder emptying bordering on urinary retention in 2. There was significant upper tract pathology in all cases, including azotemia in 4, reflux in 4 and hydroureteronephrosis in 6. Due to poor bladder function, manifested by incomplete emptying or high storage pressures, all patients were initially treated with cutaneous vesicostomy. RESULTS Bladder appearance and function subsequently improved in 3 patients and vesicostomy was reversed. Three patients with persistently thickened bladders, including 2 with renal failure, underwent bladder augmentation. The remaining patient had improved bladder storage function but requires intermittent catheterization. CONCLUSIONS The nonneurogenic neurogenic bladder represents a rare, severe form of dysfunctional voiding that may be present even in the neonatal period.
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Bägli DJ, Van Savage JG, Khoury AE, Carr M, McLorie GA. Basic fibroblast growth factor in the urine of children with voiding pathology. J Urol 1997; 158:1123-7. [PMID: 9258154 DOI: 10.1097/00005392-199709000-00110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Basic fibroblast growth factor is a mediator of tissue response to injury. Voiding pathology often results in bladder abnormalities. We prospectively determined whether basic fibroblast growth factor is elevated in the urine of children with bladder dysfunction compared to that of normal controls. MATERIALS AND METHODS A total of 97 consecutive children with myelomeningocele and 32 with voiding pathology due to other etiologies underwent urodynamic testing, and 11 children with no bladder symptoms and sterile urine served as controls. Urinary basic fibroblast growth factor levels were assayed by enzyme-linked immunosorbent assay and normalized to urinary creatinine. RESULTS Mean urinary basic fibroblast growth factor was higher in bladder dysfunction from myelomeningocele (6,673 pg./gm. creatinine, p = 0.0015) and other etiologies (5,665 pg./gm. creatinine, p = 0.0025) compared with urine from normal bladders (2,995 pg./gm. creatinine). In the myelomeningocele group urinary tract infection was associated with higher urinary basic fibroblast growth factor than in sterile urine (9,214 versus 5,642 pg./gm. creatinine, p = 0.018). Patient age, gender, remote bladder surgery, clean intermittent catheterization, detrusor hyperreflexia, detrusor compliance, age adjusted pressure specific bladder volume, low grade reflux and degree of trabeculation did not correlate with levels of basic fibroblast growth factor (p > 0.05). CONCLUSIONS Urinary elevation of basic fibroblast growth factor, a critical mediator of wound repair, in children with voiding pathology and clinically abnormal bladders supports the paradigm that bladder dysfunction may result from generalized response-to-injury mechanisms. The role of fibrogenic cytokines, such as basic fibroblast growth factor, merits further directed investigation in bladder pathology.
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Agarwal SK, McLorie GA, Grewal D, Joyner BD, Bägli DJ, Khoury AE. Urodynamic correlates of resolution of reflux in meningomyelocele patients. J Urol 1997; 158:580-2. [PMID: 9224367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Resolution of reflux in meningomyelocele patients is a reflection of improved bladder storage. We correlated resolution of reflux with changes observed in sequential urodynamic studies. MATERIALS AND METHODS The study included 27 children with meningomyelocele born between 1975 and 1985 who presented with or developed vesicoureteral reflux. Resolution of reflux was observed during the 10-year followup period as they were treated with a regimen of clean intermittent catheterization and pharmaco-therapy. Urodynamic studies were performed when vesicoureteral reflux was present and subsequent to its resolution. The urodynamic parameters compared in the 2 studies included bladder capacity, pressure specific bladder volume, bladder compliance and leak point pressure. RESULTS Significant increases in bladder capacity, pressure specific bladder volume and bladder compliance were noted. Leak point pressure appeared to be decreased subsequent to resolution of reflux. CONCLUSIONS Resolution of reflux in meningomyelocele patients correlates with changes in parameters of bladder storage observed on sequential urodynamic studies.
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Salle JL, McLorie GA, Bägli DJ, Khoury AE. Urethral lengthening with anterior bladder wall flap (Pippi Salle procedure): modifications and extended indications of the technique. J Urol 1997; 158:585-90. [PMID: 9224369 DOI: 10.1097/00005392-199708000-00092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE We report a clinical case series of an innovative method of urethral reconstruction for the treatment of urinary incontinence. Modifications of our original technique are presented. MATERIALS AND METHODS Bladder neck repair was done in 17 patients, mean age 9.3, with neurogenic incontinence (13) or exstrophy (4). Average followup is 25.6 months. Of the patients 9 with neurogenic bladder underwent the original procedure using a midline anterior bladder wall flap. In the 4 patients with exstrophy a modified procedure was done using an anterolateral bladder wall flap. In another 4 patients an extended flap of distal mucosa was used to avoid ureteral reimplantation. Augmentation was performed in 13 of the 17 cases (10 detubularized ileum and 3 detubularized colon). RESULTS Continence (greater than 4 hours) was obtained in 12 of the 17 patients (70%), 2 are dry for 1 to 2 hours and 3 are incontinent. A urethrovesical fistula developed in 2 patients (1 closed successfully), and 3 patients have problems with catheterization. CONCLUSIONS Urethral lengthening with anterior bladder wall flap is a versatile alternative in the surgical treatment of urinary incontinence. Variations of the original technique resulted in an improved vascular supply and decreased the formation of fistula at the base of the flap. The modified technique was successful in patients with exstrophy, including those who had failed bladder neck surgery.
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Landau EH, Jayanthi VR, McLorie GA, Churchill BM, Khoury AE. Renal transplantation in children following augmentation ureterocystoplasty. Urology 1997; 50:260-2. [PMID: 9255299 DOI: 10.1016/s0090-4295(97)00255-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To assess the impact of augmentation ureterocystoplasty on the success of cadaveric renal transplantation in children with dysfunctional bladders. METHODS Two patients with end-stage renal failure secondary to dysfunctional bladders (one myelodysplasia and one posterior urethral valves) underwent augmentation ureterocystoplasty prior to renal transplantation in order to increase bladder capacity and improve compliance. RESULTS Significant improvement of bladder storage function was achieved in both patients. By the use of megaureter for augmentation, untoward sequelae of enteric or gastric augmentation were obviated. Renal transplantation was successful in both patients. Both have normal renal function 4 and 3 years after transplantation. CONCLUSIONS Renal transplantation into bladders previously augmented with megaureters is successful. The use of urothelial-lined biomaterial for augmentation avoids the potential complications of gastro- or enterocystoplasty, which are especially dangerous in transplant patients.
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Agarwal SK, Khoury AE, Abramson RP, Churchill BM, Argiropoulos G, McLorie GA. Outcome analysis of vesicoureteral reflux in children with myelodysplasia. J Urol 1997; 157:980-2. [PMID: 9072629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Vesicoureteral reflux in children with myelodysplasia is usually secondary to abnormal bladder storage. The purpose of this study was to assess the outcome of vesicoureteral reflux in children with myelodysplasia. MATERIALS AND METHODS We retrospectively analyzed the records of 319 children with myelodysplasia who presented to our institution between 1978 and 1985. Of these children 95 presented with or had reflux during followup and they were treated with prophylactic antibiotics. Clean intermittent catheterization and anticholinergic medication were added to the regimen when indicated. RESULTS Reflux resolved in 63% of these patients with nonsurgical management. Temporary cutaneous vesicostomy was performed in 23 children (24%) with persistent high grade reflux or evidence of upper tract deterioration. Ureteral reimplantation and augmentation cystoplasty were performed in 18 (20%) and 8 (8%) patients, respectively. No patient had progression to chronic renal failure and scars developed in only 14 kidneys (10%). CONCLUSIONS In the majority of cases (63%) reflux resolved with nonsurgical management. Reflux in these patients should not be treated in isolation. The management of reflux is primarily aimed at improving bladder storage. The combination of aggressive nonsurgical therapy and close observation is recommended. This regimen leads to the satisfactory resolution of reflux with minimal renal morbidity.
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McLorie GA, Khoury AE, Alphin T. Ischiopagus twins: an outcome analysis of urological aspects of repair in 3 sets of twins. J Urol 1997; 157:650-3. [PMID: 8996392 DOI: 10.1016/s0022-5347(01)65244-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE We assessed the urological components of ischiopagus twins and outcomes of surgical correction. MATERIALS AND METHODS We performed a longitudinal study of 3 pairs of twins who presented to a single institution for repair and analyzed the outcomes of certain aspects of repair. RESULTS Three pairs of twins joined from diaphragm to pelvis and facing each other in an embracing posture were separated in the last 10 years at a single institution. Each pair of twins had a similar constellation of shared organs, including abdominal wall, bony pelvis, liver, bowel, crossed ureters, bladder and genitalia. Followup ranges from 18 months to 10 years. All children are independent and ambulatory with fully healed wounds. Of the 6 kidneys 5 are functioning well. Of the 4 children old enough to undergo continence evaluation all are fully continent and void spontaneously. CONCLUSIONS Conjoined twins can be successfully separated with an effective outcome.
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