[Modified Duplay technique in the treatment of hypospadias. Report of 585 cases]

The surgical repair of anterior hypospadias depends on the surgeon's custom and the anatomical variations of this anomaly. However, most publications agree nowadays on the one-stage surgery. We report on 585 hypospadias operated in our department. Our procedure is based on the Duplay technique, in addition to personal modifications in order to correct the frequently associated penis anomalies. The procedure is described herein. Aesthetic and functional results are reported and seem to be very satisfactory in comparison with the literature and permit the homologation of our technique.

Improved direct measurement of A(b) and A(c) at the Z(0) pole using a lepton tag

The parity violation parameters A(b) and A(c) of the Zb(b) and Zc(c) couplings have been measured directly, using the polar angle dependence of the polarized cross sections at the Z(0) pole. Bottom and charmed hadrons were tagged via their semileptonic decays. Both the electron and muon analyses take advantage of new multivariate techniques to increase the analyzing power. Based on the 1993-1998 SLD sample of 550,000 Z(0) decays produced with highly polarized electron beams, we measure A(b) = 0.919+/-0.030(stat)+/-0.024(syst), and A(c) = 0.583+/-0.055(stat)+/-0.055(syst).

[Two rare case reports of ureteral triplication]

Triplication of the upper urinary tract is rare. It is classified according to its extent and four types have been documented. Since the first description of ureteral triplication by Wrany only about a hundred cases have been reported in the literature. Paediatric cases are very few and female patients seem more concerned. The embryological event resulting in ureteral triplication derives from multiple ureteral buds arising from the Wolffian duct with fissuring of one or more of them. We report on two cases of ureteral triplication. The first one associated with an extravesical ectopic ureter and a dysplasic kidney. Diagnosis was particularly difficult and treatment consisted of total nephrectomy. The second case was associated with an upper pole hydronephrosis and a partial nephrectomy was realized.

High beryllium-stimulated TNF-alpha is associated with the -308 TNF-alpha promoter polymorphism and with clinical severity in chronic beryllium disease

Beryllium (Be)-antigen stimulates tumor necrosis factor-alpha (TNF-alpha) from bronchoalveolar lavage (BAL) cells in chronic beryllium disease (CBD). This study tested the hypothesis that high concentrations of Be-stimulated TNF-alpha are related to polymorphisms in the TNF-alpha promoter and clinical markers of disease severity in CBD. Demographic and clinical information was obtained from patients with CBD (n = 20). TNF-alpha concentrations were measured in BAL cell culture supernatant by ELISA. A priori, we categorized CBD subjects as either high or low TNF-alpha producers using a cutoff of 1,500 pg/ml. The TNF-alpha promoter sequence, +64 to -1045, was determined by direct sequencing. Human leukocyte-associated antigen (HLA)-DPB1 and -DRB1 genotyping was determined by polymerase chain reaction (PCR). High Be-stimulated TNF-alpha was associated with TNF2 alleles, Hispanic ethnicity, presence of HLA-DPB1 Glu69, and absence of HLA-DR4. Be-stimulated TNF-alpha concentrations correlated with markers of disease severity, including chest radiograph, beryllium lymphocyte proliferation, and spirometry. We found no novel TNF-alpha promoter polymorphisms. These data suggest that the TNF2 A allele at -308 in the TNF-alpha promoter region is a functional polymorphism, associated with a high level of Be-antigen-stimulated TNF-alpha and that these high TNF-alpha levels indicate disease severity in CBD.

A new technique of bladder enlargement and continent urinary diversion using the ceco-appendicular unit

The authors developed a new technique using the cecum with in-situ appendix to simultaneously achieve bladder enlargement and continent urinary diversion (CUD) in five cases of neuropathic bladder or serious complications of abdominopelvic trauma. The cecoplasty provides a large-capacity, low-pressure reservoir; the submucosally-embedded appendix gives complete continence with 3 to 5 intermittent catheterizations daily. It is an alternative to the Mitrofanoff principle when bladder augmentation and CUD are necessary, and easier to achieve when faced with a neuropathic bladder where the thickness of the detrusor makes appendicular implantation difficult.

[Endoscopic treatment of vesicorenal reflux in children: short- and long-term results of polytetrafluoroethylene (Teflon) injections]

OBJECTIVE

To retrospectively evaluate the short-term and long-term efficacy and safety of endoscopic treatment of vesicorenal reflux in children by polytetrafluoroethylene injection, based on the largest series published in the literature.

MATERIAL AND METHODS

Six hundred and fifty ureters in 402 children were by subureteric injection of polytetrafluoroethylene from 1986 to 1993. The short-term results were evaluated one month and one year after treatment by physical examination, urine culture, bladder and renal ultrasonography and retrograde cystography. The long-term results were evaluated with a mean follow-up of 116 months by physical examination, renal ultrasonography, questionnaire for the patient's family and urine culture.

RESULTS

86.6% refluxing ureters in 82.1% of children were cured after endoscopic treatment. No serious short-term complications were observed. In the long-term, 97% of children never presented an episode of pyelonephritis. Ultrasonographic assessment did not reveal any dilatation of the upper urinary tract, no any suspicious lesions of the bladder wall. Continuing reflux nephropathy due to chronic pyelonephritis was observed in 4.4% of treated kidneys, despite satisfactory correction of reflux. No local complications related to the biomaterial and no signs suggestive of distant diseases induce by migration of Teflon particles were observed. No malignant degeneration was reported.

CONCLUSIONS

Review of this series demonstrates the short-term efficacy and long-term maintenance of the good results of endoscopic treatment of reflux. No local complication and no complications due to migration of Teflon were observed in this series. This procedure avoided the need for conventional ureteric reimplantation in 92% of treated children.

[Testicular microlithiasis and cryptorchism: ultrasound analysis after orchidopexy]

OBJECTIVE

To evaluate the testicular ultrasound features and frequency of testicular microlithiasis in a population of patients operated several years before for cryptorchidism, in order to define a group at possible increased risk of testicular cancer.

MATERIAL AND METHODS

This was a retrospective study of 202 patients, 63 of whom were reviewed by ultrasound with a mean follow-up of 9 years 3 months (7 years 5 months to 11 years 7 months).

RESULTS

32% of operated testes were hypotrophic compared to the correctly descended side; their mean volume was 9.42 ml versus 11 ml for the nonoperated side. 14.3% of surgically descended testes presented an ultrasonographically heterogeneous parenchyma and microlithiasis were present in 9.52% of cases.

CONCLUSION

The association between microlithiasis and cryptorchidism is not an incidental finding. Apart from the relative hypotrophy of the testis, ultrasound also revealed, in our study, that the presence of microlithiasis is not an extremely rare finding. Annual ultrasound surveillance is therefore required due to the risk of malignant transformation of these microlithiases.

[Post-traumatic complication of trans-appendiceal cystostomy: urinary peritonitis]

Two children who had undergone a transappendicular urinary diversion (type Mitrofanoff) developed bladder rupture, one following abdominal trauma, 4 months after the operation and the other following traumatic self-catheterization at 4 years. The clinical history and standard radiological examinations (ultrasonography, cystography) confirmed the diagnosis of urinary peritonitis. Emergency surgical repair was possible in both cases with an uneventful postoperative course. This serious and rare complication requires emergency surgery and justifies rigorous selection of children suitable for this type of diversion giving preference to increased bladder neck resistance over bladder neck closure.

Improved direct measurement of leptonic coupling asymmetries with polarized Z bosons

We present final measurements of the Z boson-lepton coupling asymmetry parameters A(e), A(mu), and A(tau) with the complete sample of polarized Z bosons collected by the SLD detector at the SLAC Linear Collider. From the left-right production and decay polar angle asymmetries in leptonic Z decays we measure A(e) = 0.1544+/-0.0060, A(mu) = 0.142+/-0.015, and A(tau) = 0.136+/-0.015. Combined with our left-right asymmetry measured from hadronic decays, we find A(e) = 0.1516+/-0.0021. Assuming lepton universality, we obtain a combined effective weak mixing angle of sin (2)theta(eff)(W) = 0.230 98+/-0.000 26.

First symmetry tests in polarized Z0 decays to bbg

We have made the first direct symmetry tests in the decays of polarized Z0 bosons into fully identified bbg states, collected in the SLD experiment at SLAC. We searched for evidence of parity violation at the bbg vertex by studying the asymmetries in the b-quark polar- and azimuthal-angle distributions, and for evidence of T-odd, CP-even or CP-odd, final-state interactions by measuring angular correlations between the three-jet plane and the Z0 polarization. We found results consistent with standard model expectations and set 95% C. limits on anomalous contributions.

Clonidine in preterm-infant caudal anesthesia may be responsible for postoperative apnea

OBJECTIVE

Regional anesthesia without adjunctive general anesthesia or sedation has been recommended for preterm infants to decrease the risk of postoperative apnea. Single-dose caudal local anesthetic has a limited duration, which may be insufficient for long surgery. Addition of clonidine to local anesthetics has been shown to prolong the duration of surgical analgesia. However, respiratory depression related to clonidine may occur in adults. Respiratory depression has not been reported after caudal administration of clonidine in preterm infants. Here we report a case of early postoperative apnea in a waking preterm infant after caudal anesthesia performed with lidocaine, bupivacaine, and clonidine.

CASE REPORT

A male infant, 39 postconceptual weeks old, was administered a single-injection caudal anesthesia without sedation with 5 mg/kg lidocaine plus 2.5 mg/kg bupivacaine and 1.25 microg/kg clonidine for bilateral inguinal hernia repair, and had early postoperative apneic events. Except for gestational age, the patient showed no apparent risk factors for postoperative apnea. The infant was monitored 24 hours in a neonatal intensive care unit, and no other apnea was recorded.

CONCLUSIONS

Our report suggests that clonidine may be responsible for postoperative apnea in a preterm neonate. Further studies are required to determine the useful safe dose of clonidine for single-injection caudal anesthesia in those infants.

Evaluation of caudal anaesthesia performed in conscious ex-premature infants for inguinal herniotomies

Ex-premature infants, before 45 weeks postconceptional age, are at high-risk of apnoea after surgery. General anaesthesia increases the risk of apnoea. We evaluated the tolerance and the efficiency of caudal anaesthesia performed in 25 consecutive conscious ex-premature infants for inguinal herniotomies. N2O/O2 and EMLA cream are used to facilitate caudal puncture. Anaesthesia procedure, patient comfort and complications following the 24 postoperative hours were studied. We report good anaesthesia conditions without compromising the baby's comfort and few perioperative complications. Only two infants with a prior history of apnoea or bronchopulmonary dysplasia had apnoea during and after surgery. A total spinal anaesthesia was the major complication in one infant and prolonged surgery requiring general anaesthesia was the main limitation of this technique in another child. The principal advantage of the procedure is to facilitate and simplify the postoperative management of the babies. The anaesthetic technique does not alter surgical conditions. Caudal epidural anaesthesia performed in awake high-risk preterm infants is beneficial for these infants but requires experienced operators.

High frequency oscillatory ventilation during repair of neonatal congenital diaphragmatic hernia

We evaluated the use of high frequency oscillatory ventilation (HFOV) during congenital diaphragmatic hernia repair. After preoperative stabilization, 22 newborn infants were ventilated with HFOV during surgery. Ventilatory settings, blood gas values and oxygenation index were recorded before, during and after surgical repair. No differences were noted for these variables. No complications related to ventilation were recorded. According to the surgeon, diaphragmatic repair during HFOV is facilitated. This study confirms that CDH can be safely repaired using HFOV during anaesthesia.

High-precision measurement of the left-right Z Boson cross-section asymmetry

We present a measurement of the left-right cross-section asymmetry ( A(LR)) for Z boson production by e(+)e(-) collisions. The measurement includes the final data taken with the SLD detector at the SLAC Linear Collider during the period 1996-1998. Using a sample of 383 487 Z decays collected during the 1996-1998 runs we measure the pole value of the asymmetry, A(0)(LR), to be 0.150 56+/-0.002 39 which is equivalent to an effective weak mixing angle of sin (2)straight theta(eff)(W) = 0.231 07+/-0.000 30. Our result for the complete 1992-1998 data set comprising approximately 537 000 Z decays is sin (2)straight theta(eff)(W) = 0.230 97+/-0.000 27.

The effects of dexamethasone on the differentiation and the fertilisation of the germinal primordium in the chick embryo

We showed that, in the chick embryo, the fertilisation of the attractive germinal epithelium by primary germ cells can be represented by a three-dimensional diagram in which the space and time co-ordinates are graduated in terms of the segmentation of the axial and paraxial mesoderm. We thus established that the differentiation of the coelomic epithelium into an attractive germinal epithelium and the fertilisation of the gonadal primordium both occur by mechanisms that are tightly linked to somitogenesis. In the continuous presence of a constant concentration of Dexamethasone, a marked inhibition of the rate of fertilisation of the gonadal primordium was observed. A mathematical analysis of the mode of action of the inhibitor revealed the progressive establishment of a competition between Dexamethasone and the molecule(s) responsible for the process of attraction. Given the chemical nature of the inhibitor, we propose that the endogenous factor that triggers the first step of the differentiation of the germinal primordium is a steroid-containing complex.

Surgical treatment of diaphragmatic agenesis by transposition of a muscle flap: report on 15 cases

Between 1987 and 1996 the transposition of a muscle flap using the anterolateral abdominal wall (the internal oblique and transversus abdominus muscle) has been used for the surgical treatment of fifteen cases of diaphragmatic agenesis. There are several advantages of this technique: a more accurate reconstruction of the diaphragmatic dome, a better adapted muscle flap, good tolerance and evolution as a result of the use of autologous material with thus less risk of recurrence and/or infection. The disadvantages are represented by the nine cases of abdominal herniation at the site of the muscle flap, three of which necessitated secondary surgical treatment. Nine children survived this treatment, six died following severe cardio-pulmonary complications associated with this malformation.

Delphi-panel analysis of appropriateness of high-dose chemotherapy and blood cell or bone marrow autotransplants in women with breast cancer

BACKGROUND

There is controversy whether high-dose chemotherapy and a blood cell or bone marrow autotransplant is a better treatment than conventional-dose chemotherapy for women with local/regional or metastatic breast cancer. Subject selection and time-to-treatment biases make definitive comparison impossible. Recent results of randomized trials are contradictory.

OBJECTIVE

Determine appropriateness of high-dose chemotherapy and a blood cell or bone marrow autotransplant in women with breast cancer. PANELISTS: Nine breast cancer experts from diverse geographic sites and practice settings.

EVIDENCE

Boolean MEDLINE searches of 'breast cancer' and 'chemotherapy' and/or 'blood cell' or 'bone marrow transplants'.

PROCESS

We used a modified Delphi-panel group judgement process. Clinical variables were permuted to define 2058 clinical settings. Each panelist rated appropriateness of high-dose therapy and an autotransplant versus conventional therapy on a 9-point ordinal scale (1: most inappropriate, 9: most appropriate). An appropriateness index was developed based on median rating and amount of disagreement. The relationship of appropriateness indices to the permuted clinical variables was considered by analysis of variance and recursive partitioning.

CONCLUSIONS

In women with local/regional breast cancer autotransplants were rated: 1) appropriate in those with > or = 10 cancer-involved lymph nodes; 2) uncertain in those with 4-9 cancer-involved nodes; and 3) inappropriate in women with < or = 3 cancer-involved lymph nodes. In women with metastatic breast cancer autotransplants were rated: 1) appropriate in those with metastases to 'favorable' sites (skin, lymph node, pleura) and a complete or partial response to chemotherapy; 2) uncertain in women with metastases to 'unfavorable' sites (lung, liver, or central nervous system) and a complete response to chemotherapy or those with bone metastases and a complete or partial response or stable disease after chemotherapy; and 3) inappropriate in other settings.

Abdominal expansion using a polytetrafluoroethylene prosthesis in the treatment of Pepper syndrome

The authors report three cases of stage IV-S neuroblastoma in infants aged 4, 6, and 8 weeks, who despite chemo- and radiotherapy required surgical intervention to urgently relieve major thoracoabdominal compression secondary to massive hepatomegaly. The results were successful, with abdominal expansion being achieved by the introduction of a polytetrafluoroethylene prosthesis, which was removed during the 2nd, 3rd and 7th postoperative month, respectively, after tumor regression. Two children were in complete remission 32 and 38 months later, the 3rd died after 16 months of tumor progression.

[Modified Dyplay technique in the treatment of anterior hypospadias. Immediate and long term results in 321 cases and review of the literature]

OBJECTIVES

Description of a surgical technique in the treatment of anterior hypospadias, a frequent malformation for which the treatment is not devoid of complications. Evaluation of the short-term as well as the long-term results.

MATERIAL AND METHODS

Retrospective study of 321 patients treated according to this method. 58 patients were reviewed with a mean follow-up of 71 months.

RESULTS

The immediate results were marked by the development of 16 fistulas (5%), 4 of which closed spontaneously. Five cases (1.6%) of meatal retraction and 6 meatal stenoses (1.9%) were observed. The overall complication rate requiring specific treatment was 5.6%. The long-term results showed meatal retraction in 20.7% of cases, meatal stenosis in 1.7% of cases and fistula in 3.5% of cases. This is the series with the longest mean follow-up. Comparison with the currently proposed technique suggests that this technique is indicated in the treatment of anterior hypospadias. Long-term analysis of the results strongly encourages regular and prolonged follow-up of children treated for hypospadias in the first 2 years.

CONCLUSION

The modified Duplay technique is reliable, can be easily performed, and gives perfectly satisfactory results, even in the long-term, for the treatment of anterior hypospadias.

[Cystic dysplasia of the rete testis and ipsilateral kidney agenesis in children]

BACKGROUND

Cystic dysplasia of rete testis, a rare abnormality, is often associated with renal agenesis.

CASE REPORT

A 5-year-old boy was examined because he presented large scrotum. This was initially considered as hydrocele. Surgery showed a cystic dysplasia of the testis that in this patient was associated with ipsilateral renal agenesis.

CONCLUSION

This congenital abnormality, explained on the basis of embryological development, has been reported in 15 children. The testis appears cystic at surgical exploration; echography can affirm diagnosis and MRI can give specific features. A conservative attitude is proposed as this lesion is benign. Long-term follow-up is recommended for possible painful effects or growth of the lesion.

[CO2 laser skin resurfacing. Critical analysis of recent literature]

Over recent years, there appears to have been an explosion of public interest in facial rejuvenation. With the recent development of short-pulsed high-peak power and rapidly scanned carbon dioxide (CO2) lasers, it is now possible to remove photo-damaged skin precisely and reproducibly, while leaving behind a narrow zone of thermal damage. This development has generated tremendous interest in laser skin resurfacing as a technique to reverse photoaging. However, the overall review of the existing literature, except for very few publications, reveals several major methodological problems. The use of CO2 laser for cosmetic purposes is very recent and therefore requires further justification, standardization and regulation based on well designed studies. Most of the recent published data correspond to case reports, rather than well-designed scientific studies. For these reasons, this field needs more clinical trials and epidemiological investigations such as prospective cohorts or case-control studies, to provide new knowledge in this field.

[Endoscopic treatment of vesicorenal reflux in children. Five-year assessment of the use of Macroplastique]

OBJECTIVE

To compare the results of endoscopic treatment of vesicorenal reflux by Macroplastique implantation versus Teflon implantation.

MATERIAL AND METHODS

297 children with 454 refluxing vesicorenal units were treated by endoscopic implantation of Macroplastique (Rplasty)-A.B.S.: 385 cases of primary reflux and 69 cases of secondary or associated reflux. All children were reviewed by ultrasound and cystography 6 weeks and 1 year after implantation.

RESULTS

Regardless of the aetiology and the grade, reflux resolved in 91.2% of children (93.3% of ureters). Complications such as ureteric stasis were rare (3 cases). 161 children (253 ureters) were reviewed 1 year after treatment: reflux had recurred in 8.7% of patients.

CONCLUSION

Although the mean quantity implanted was lower with Macroplastique, the results appeared to be better than those obtained with Teflon (bases on a previous series of 402 children: cure for 87.1% of ureters and 85.7% of children). The advantages of Macroplastique compared to Teflon include the less liquid consistency, the absence of retraction of the product and the presence of larger microparticles without any local or distant inflammatory reaction.

[Urethral fistulas after surgical treatment of hypospadias. Apropos of a series of 74 cases]

OBJECTIVE

To analyse the causes of fistulas following urethroplasty procedures and the principles of their surgical treatment.

MATERIAL AND METHODS

74 fistulas were treated: 6 were on the glans, 17 coronal, 33 on the distal shaft, 6 midshaft, 8 proximal shaft and 4 penoscrotal. More than 75% underwent a simple closure or invagination of the fistula into the urethra, often without urinary diversion. A second-stage urethroplasty was necessary in 15 cases.

RESULTS

The initial success rate was 72.5%. Results obtained with simple closure or invagination were better than extensive surgery (50% failure rate). Seventy two percent of these fistulas without urinary diversion were treated successfully as compared to 53.8% of those which had required a catheter.

CONCLUSION

Of all the complications of hypospadias surgery, fistulas are in most cases the easiest to resolve, provided that some fundamental rules are respected: a minimum of 6 month between both procedures, previous treatment of any concomitant urethral stenosis, use of a tourniquet and loops magnification, and an additional layer of interrupted subcutaneous sutures. A haemostatic dressing reduces the tension of the sutures. An urinary diversion is only necessary for larger fistulas which require a second-stage urethroplasty.