Albaha Barqawi

Laparoscopic Palomo Varicocele Ligation in Children and Adolescents

PURPOSEnWe evaluate our experience using the laparoscopic Palomo varicocele ligation (LPV) technique in male children and adolescents with varicoceles.nnnMATERIALS AND METHODSnBetween September 1994 and September 2002, 122 varicoceles were treated using LPV with either mass cord vascular clip application (68) or LigaSure (Valleylab, Boulder, Colorado) vascular sealing (54). All procedures were performed as day surgery cases and patients were allowed to return to normal activities as soon as they could tolerate them. Followup was scheduled for 6 to 12 weeks and 1 year postoperatively. Testicular size was evaluated using a Prader orchidometer.nnnRESULTSnOf the 122 patients 103 were evaluable at the initial postoperative visit and 96 at 1-year followup. Patient ages ranged from 9 to 19 years (mean 14.6). Operating time was 9 to 52 minutes (mean 28), although in the last 2 years (28 cases) mean operative time has decreased to 14.6 minutes. Indications for surgery included ipsilateral testicular hypotrophy in 84 cases, symptoms in 3 and parental choice in 16. At followup only 1 recurrent varicocele (vascular sealant group) was identified which was subsequently re-treated successfully using vascular sealant LPV. At 1 year 64 of 78 testes (82%) demonstrated catch-up growth and there was no evidence of testicular loss or persistent hypotrophy in the others. Reactive hydroceles were identified in 6 patients equally distributed between the 2 LPV techniques. Surgery was required on 2 of these hydroceles due to size, and the other 4 are small and are being observed. Temporary scrotal emphysema occurred in the vast majority of patients and 1 patient required laparoscopic closure of a small sigmoid serosal tear. No patients required narcotic medications for greater than 48 hours.nnnCONCLUSIONSnLPV is a highly successful method to correct varicoceles in young males with catch-up growth similar to series using other accepted standard techniques. LPV can be performed safely and rapidly as an outpatient and allows early return to activity. As with the open Palomo technique, hydrocele is a bothersome complication that may require a second surgical procedure if correction is warranted.

Lessons learned from stomal complications in children with cutaneous catheterizable continent stomas

To evaluate the impact of various factors that might ultimately influence the stoma complication rate associated with the construction of a continent catheterizable urinary (CCU) and Malone antegrade colonic enema (MACE) stoma in children.

Pediatric urinary tract infections: the role of fluoroquinolones

Infectionsof the urinary tract (UTI) occur commonly in the pediatric population. Because of the high association of pediatric UTI with congenital structural anomalies of the urinary tract and with dysfunctional elimination syndromes, it is far more common for children to be categorized as having complicated UTI than their adult counterparts. And for children more intensive therapy is often required. Early and effective treatment of UTIs in the pediatric patient is considered essential to prevent long term morbidity and potential mortality from end stage renal disease. An oral antimicrobial is more convenient than parenteral therapy and is preferable as long as clinical efficacy and safety can be assured. Oral fluoroquinolones are an attractive alternative for the treatment of complicated UTI in children, and safety must always be a factor in considering their use in this population. Although the role of fluoroquinolones in pediatric UTI is still under investigation, the limited data available demonstrate a likelihood of efficacy and safety.

Males With Down’s Syndrome and Nonneurogenic Neurogenic Bladder

PURPOSEnWe assessed the relationship of trisomy 21 with the most severe dysfunctional elimination syndrome, nonneurogenic neurogenic bladder or the Hinman-Allen syndrome.nnnMATERIALS AND METHODSnWe retrospectively reviewed our experience with children with Downs syndrome (trisomy 21) in a 10-year period and identified a subset who presented for the evaluation and treatment of urinary tract infections associated with severe disorders of urinary and fecal elimination.nnnRESULTSnFour males 9 months, 14 years, 18 years and 21 years old met the criteria for review. All patients underwent radiological and urodynamic evaluation, and were diagnosed with hydronephrosis and prostatic urethral dilatation with pelvic floor spasticity. Renal function studies showed a creatinine of 0.7 mg./dl. in the 9-month-old, 1.2 mg./dl. in the 14-year-old, 1.9 mg./dl. in the 18-year-old and 2.2 mg./dl. in the 21-year-old patient. Three patients underwent surgical treatment to protect the upper urinary tract, including bladder augmentation cystoplasty and an appendiceal Mitrofanoff stoma in 2, and vesicostomy in 1. The remaining patient was treated conservatively with a behavioral modification program that included timed voiding and a bowel regimen.nnnCONCLUSIONSnBoys with trisomy 21 may be at risk for the Hinman-Allen syndrome. Surgical intervention and clean intermittent catheterization for renal preservation and continence can be performed in this population despite intellectual impairment. Further evaluation is necessary to determine whether this relationship is more common than appreciated and whether this syndrome occurs in females with trisomy 21.

Minimally Invasive Surgery in Prostate Cancer: Current and Future Perspectives

Prostate cancer is a leading cause of death for men. Its prevalence increases substantially with advancing age, which coincides with increased incidence of comorbidities. The mainstay therapy for early prostate cancer remains radical surgery and radiotherapy. In the era of prostate-specific antigen and the newly emerging highly specific screening tests, more men are diagnosed earlier in their life and with confined disease. The application of minimally invasive approaches, such as the laparoscopic/telerobotic approach and focal treatments, is becoming more popular, yielding shorter hospital stays and faster recovery, with minimal complications. In part, this is possible due to groundbreaking advances in laparoscopic equipment, prostate imaging modalities, and gained urologic expertise in minimally invasive treatment. In this review we critically discuss the current knowledge and future perspectives of minimally invasive treatment in prostate cancer.

Modalities for Imaging of Prostate Cancer

Prostate cancer is the second most common cause of cancer deaths among males in the United States. Prostate screening by digital rectal examination and prostate-specific antigen has shifted the diagnosis of prostate cancer to lower grade, organ confined disease, adding to overdetection and overtreatment of prostate cancer. The new challenge is in differentiating clinically relevant tumors from ones that may otherwise never have become evident if not for screening. The rapid evolution of imaging modalities and the synthesis of anatomic, functional, and molecular data allow for improved detection and characterization of prostate cancer. However, the appropriate use of imaging is difficult to define, as many controversial studies regarding each of the modalities and their utilities can be found in the literature. Clinical practice patterns have been slow to adopt many of these advances as a result. This review discusses the more established imaging techniques, including Ultrasonography, Magnetic Resonance Imaging, MR Spectroscopy, Computed Tomography, and Positron Emission Tomography. We also review several promising techniques on the horizon, including Dynamic Contrast-Enhanced MRI, Diffuse-Weighted Imaging, Superparamagnetic Nanoparticles, and Radionuclide Scintigraphy.

Application of Statistical Cancer Atlas for 3D Biopsy

Prostate cancer is the most commonly diagnosed cancer in males in the United States and the second leading cause of cancer death. While the exact cause is still under investigation, researchers agree on certain risk factors like age, family history, dietary habits, lifestyle and race. It is also widely accepted that cancer distribution within the prostate is inhomogeneous, i.e. certain regions have a higher likelihood of developing cancer. In this regard extensive work has been done to study the distribution of cancer in order to perform biopsy more effectively. Recently a statistical cancer atlas of the prostate was demonstrated along with an optimal biopsy scheme achieving a high detection rate. In this paper we discuss the complete construction and application of such an atlas that can be used in a clinical setting to effectively target high cancer zones during biopsy. The method consists of integrating intensity statistics in the form of cancer probabilities at every voxel in the image with shape statistics of the prostate in order to quickly warp the atlas onto a subject ultrasound image. While the atlas surface can be registered to a pre-segmented subject prostate surface or instead used to perform segmentation of the capsule via optimization of shape parameters to segment the subject image, the strength of our approach lies in the fast mapping of cancer statistics onto the subject using shape statistics. The shape model was trained from over 38 expert segmented prostate surfaces and the atlas registration accuracy was found to be high suggesting the use of this method to perform biopsy in near real time situations with some optimization.

3-D statistical cancer atlas-based targeting of prostate biopsy using ultrasound image guidance

Prostate cancer is a multifocal disease and lesions are not distributed uniformly within the gland. Several biopsy protocols concerning spatially specific targeting have been reported urology literature. Recently a statistical cancer atlas of the prostate was constructed providing voxelwise probabilities of cancers in the prostate. Additionally an optimized set of biopsy sites was computed with 94 - 96% detection accuracy was reported using only 6-7 needles. Here we discuss the warping of this atlas to prostate segmented side-fire ultrasound images of the patient. A shape model was used to speed up registration. The model was trained from over 38 expert segmented subjects off-line. This training yielded as few as 15-20 degrees of freedom that were optimized to warp the atlas surface to the patients ultrasound image followed by elastic interpolation of the 3-D atlas. As a result the atlas is completely mapped to the patients prostate anatomy along with optimal predetermined needle locations for biopsy. These do not preclude the use of additional biopsies if desired. A color overlay of the atlas is also displayed on the ultrasound image showing high cancer zones within the prostate. Finally current biopsy locations are saved in the atlas space and may be used to update the atlas based on the pathology report. In addition to the optimal atlas plan, previous biopsy locations and alternate plans can also be stored in the atlas space and warped to the patient with no additional time overhead.

Minimally Invasive Management of Calculi in Augmented/Neuropathic Bladders

Calculi in the augmented bladder is a well-reported and troublesome complication of augmentation cystoplasty and neurogenic bladders. Its incidence has been quoted as low as 8%1 and as high as 52%.2 Within either limit, it is safe to say bladder stone management is a common component of the practicing pediatric urologist.

Impact of testosterone levels and treatment on aging men’s health: should we worry?

The impact of testosterone on the general health of aging men has long been the center of attention, mainly due to its mythical association with sexual health and masculinity. However, recent emphasis on the effect of testosterone on the risk of disease, particularly the association between testosterone replacement therapy and the risk of prostate cancer, has renewed interest in both the research community and aging men alike. Epidemiologic evidence links symptoms associated with advancing age with a decline in testosterone levels; however, a clear causal relationship is debatable. In this review, the current evidence of the impact of testosterone levels on quality of life and risk of disease in the modern aging male are discussed. The discussion is focused on the association of testosterone with cardiovascular risk, cognitive function, sense of wellbeing, sexual health and the already proven risks of replacement therapy in the aging male.