Unilateral open extravesical ureteral reimplanation with contralateral dextronomer/hyaluronic acid injection performed as an outpatient therapy

INTRODUCTION

Historically, patients with unilateral high-grade vesicoureteral reflux (VUR) and contralateral low-grade or resolved VUR have been treated with bilateral intravesical ureteral reimplantation, which requires postoperative admission. If the high-grade VUR side is treated alone, then the contralateral side is at risk of developing recurrent or worsening VUR. Bilateral subureteric injection of dextronomer/hyaluronic acid (DHA) is another option that can be performed as an outpatient therapy, but a single injection is less effective for high-grade VUR.

OBJECTIVE

The safety and efficacy of an outpatient combination of open extravesical ureteral reimplantation (EVUR) and contralateral DHA injection were investigated.

STUDY DESIGN

A retrospective review of children who had concomitant EVUR and subureteric injection of DHA between January 2005 and December 2015 was performed. Exclusion criteria were diagnosis other than VUR, repeat procedures, and patients with no follow-up. Patient characteristics, postsurgical complications, and follow-up imaging were evaluated. Febrile urinary tract infection (fUTI) was defined as ≥50,000 Colony Forming Units (CFU) of an organism from clean-catch or catheterized urine and temperature ≥ 101.5 F. Clinical success is defined as no fUTI for 1 year after the initial operation. Univariate analyses were used to identify risk factors for treatment failure.

RESULTS

A total of 117 patients met inclusion criteria. Mean age at surgery was 6.0 years, and 85% were female. The mean pre-operative grade of VUR was 3.3 on the EVUR side and 0.6 on the contralateral side (42% resolved before treatment). Median follow-up was 12.2 months (interquartile range, 3.1-25.4). Sixteen patients (14%) had documented fUTI within 1 year, with a clinical success rate of 86%. Of these, five had a postoperative imaging showing resolution of VUR, increasing overall success to 91%. Postoperative fUTI was more common in patients with pre-operative bowel and bladder dysfunction (BBD) (P = 0.003), but this was not associated with a higher reoperation rate (P = 0.168). There were 11 total complications, with three grade 3 complications.

DISCUSSION

This study is the first to report safety and outcomes of EVUR and contralateral DHA injection for patients with high-grade VUR with contralateral low-grade or resolved VUR. It was shown that it is an effective and safe treatment that can be performed as an outpatient therapy. Limitations to this study include the retrospective design and the clinical definition of success that is used in a cohort of patients from across the mountain west region without routine postoperative voiding cystourethrogram.

CONCLUSION

Extravesical ureteral reimplantation and contralateral DHA injection can safely be performed as an outpatient therapy and are effective in the treatment of higher grade VUR with contralateral low-grade or resolved VUR. Treatment failure is more likely in patients with BBD.

Sex determination in platypus and echidna: autosomal location of SOX3 confirms the absence of SRY from monotremes

In eutherian ('placental') mammals, sex is determined by the presence or absence of the Y chromosome-borne gene SRY, which triggers testis determination. Marsupials also have a Y-borne SRY gene, implying that this mechanism is ancestral to therians, the SRY gene having diverged from its X-borne homologue SOX3 at least 180 million years ago. The rare exceptions have clearly lost and replaced the SRY mechanism recently. Other vertebrate classes have a variety of sex-determining mechanisms, but none shares the therian SRY-driven XX female:XY male system. In monotreme mammals (platypus and echidna), which branched from the therian lineage 210 million years ago, no orthologue of SRY has been found. In this study we show that its partner SOX3 is autosomal in platypus and echidna, mapping among human X chromosome orthologues to platypus chromosome 6, and to the homologous chromosome 16 in echidna. The autosomal localization of SOX3 in monotreme mammals, as well as non-mammal vertebrates, implies that SRY is absent in Prototheria and evolved later in the therian lineage 210-180 million years ago. Sex determination in platypus and echidna must therefore depend on another male-determining gene(s) on the Y chromosomes, or on the different dosage of a gene(s) on the X chromosomes.

Mapping platypus SOX genes; autosomal location of SOX9 excludes it from sex determining role

In the absence of an SRY orthologue the platypus sex determining gene is unknown, so genes in the human testis determining pathway are of particular interest as candidates. SOX9 is an attractive choice because SOX9 deletions cause male-to-female sex reversal in humans and mice, and SOX9 duplications cause female-to-male sex reversal. We have localized platypus SOX9, as well as the related SOX10, to platypus chromosomes 15 and 10, respectively, the first assignments to these platypus chromosomes, and the first comparative mapping markers from human chromosomes 17 and 22. The autosomal localization of platypus SOX9 in this study contradicts the hypothesis that SOX9 acts as the sex determining switch in platypus.

A model of professional nurse caring: nursing students' experience

Research into caring from the perspective of nursing students is poorly documented. This paper presents a study which described the construct of caring as experienced by students in pre-registration programmes at two universities in New South Wales, Australia. Qualitative data were collected using a questionnaire and semi-structured interviews. From the analysis of the data a model of professional nurse caring from the student's perspective was created. In this model, compassion, as the core of caring is actualized in the students' nursing of patients by communicating, providing comfort, being competent, being committed, having conscience, being confident and being courageous. Communication is not only an actualization of this caring but constitutes an important medium for the expression of caring actions.