Amicur Farkas

The Histrelin Implant: A Novel Treatment for Central Precocious Puberty

Objective. Standard treatment of central precocious puberty (CPP) consists of intramuscular or subcutaneous administration of a gonadotropin-releasing hormone (GnRH) agonist (GnRHa) at 3- to 4-week intervals. Although generally effective in suppressing clinical and laboratory parameters of puberty, GnRHa injections are painful, and the need for monthly clinic visits may contribute to poor compliance. Recently, a subcutaneous implant was developed that releases the GnRHa histrelin at an average rate of 65 μg/day. The aims of this study were to determine if a histrelin implant would suppress gonadotropin and estradiol (E2) in girls with CPP for 1 year and to compare the suppression to standard treatment. Methods. We studied 11 girls with CPP to determine if the histrelin implant can maintain long-term gonadotropin suppression. Mean age at diagnosis was 6 years (range: 2–9 years). GnRH (100 μg intravenously) stimulation tests (GnRH-STs) showed peak luteinizing hormone and follicle-stimulating hormone responses of 23 ± 28 (mean ± SD) and 20 ± 25 mIU/mL, respectively. All subjects were initially treated with depot intramuscular GnRHa triptorelin embonate. Implants were inserted subcutaneously under local anesthesia, and depot GnRHa treatment was discontinued. Six girls were followed for 15 months after insertion (group A). For the remaining 5 girls, the implant was removed after 9 months, and a new implant was inserted at the same incision site (group B). GnRH-STs were performed before depot GnRHa treatment, immediately before implant insertion, at the 6- and 9-month visits for each patient and the 12- and 15-month visit for those girls followed for 15 months. Results. In all girls, breast development regressed, growth velocity decreased, and bone-age advancement was slowed. Basal gonadotropins and their responses to GnRH-STs and E2 levels were suppressed. Peak luteinizing hormone and follicle-stimulating hormone responses to GnRH-STs at preinsertion versus 9 months were 1.30 ± 1.34 vs 0.25 ± 0.08 and 1.68 ± 1.08 vs 1.13 ± 0.55 mIU/mL, respectively. Basal and stimulated gonadotropin levels and E2 level remained suppressed in all 6 patients followed for 15 months after implant insertion. Patients and parents reported less pain and discomfort and less interference with school activity and work with the implant compared with standard monthly injections. Conclusions. The histrelin implant consistently suppresses clinical and laboratory parameters of puberty for 1 year and is a promising new technique for treating CPP without the pain and inconvenience of monthly injections.

Pediatric transperitoneal laparoscopic partial nephrectomy: comparison with an age-matched group undergoing open surgery

We have retrospectively evaluated the effectiveness of laparoscopic transperitoneal partial nephrectomy (LTPN) in children in comparison to an age-matched group of children who underwent open partial nephrectomy (OPN) in terms of safety, operative time, narcotic requirements and the length of hospitalization. All patients were divided into two groups. The first group of 10 children with a mean age of 3.6xa0±xa01.3xa0years (meanxa0±xa0SEM) who underwent LTPN compared with an age and gender matched second group of 10 children with a mean age of 3.9xa0±xa01.4xa0years who underwent OPN (Pxa0=xa00.9119). In the first group, 5 upper poles and 5 lower poles partial nephrectomies were performed while in the second group 6 upper moieties and 4 lower moieties partial nephrectomies were performed, respectively. There was a single complication in each group. Intraoperative injury to the unaffected ureter was recognized during LTPN and required conversion to the open surgery in the beginning of learning curve and persistent urinary leakage from collecting system of the remnant pole in the OPN group, which resolved spontaneously. There was no difference in length of surgery and the intraoperative narcotic requirements (Pxa0=xa00.8182, 0.7638, respectively). However, postoperative narcotic requirements were significantly lower in the first group 0.56xa0±xa00.29xa0mg/kg compared to the second group 2.13xa0±xa00.3xa0mg/kg, Pxa0=xa00.0019. LTPN patients had significantly shorter hospitalization 2.7xa0±xa00.29xa0days compared with the OPN group 5.1xa0±xa00.64xa0days, Pxa0=xa00.0039. Similar findings were also found in the subgroup of patients younger than 2xa0years. Median follow up in each group was 28 and 36xa0months, respectively. Our data show that LTPN is a safe and effective minimally invasive procedure at every age. It has an equivalent operative time, shorter hospitalization and lower postoperative narcotic requirements compared to the open approach.

Endoscopic Bulking Materials for the Treatment of Vesicoureteral Reflux: A Review of Our 20 Years of Experience and Review of the Literature

Purpose. We reviewed our 20 years of experience and the current literature regarding the long-term outcome of endoscopic treatment of vesicoureteric reflux (VUR) using the different tissue bulking substances with a special emphasis on the long-term efficacy. Material and Methods. Our own experience and the current literature on the long-term results after endoscopic treatment using various bulking agents were reviewed. Results. Short-term data following endoscopic treatment of VUR is similar to the various substances and comparable in the majority of the series to the success rate following open surgery. Recently, a relatively high recurrence rate was noticed especially with the use of dextranomer hyaluronic acid (Dx/HA) as a tissue augmenting material which raises the need for further search for alternative substances. Conclusions. Unfortunately, there is a significant shortage of evidence-based literature on the long-term followup after endoscopic correction of reflux with various substances. No doubt, there is a high recurrence rate during long-term followup after Dx/HA injection, and there is probably lack of proper evaluation regarding the long-term efficacy of other bulking materials. These facts demand long-term close observation and long-term studies beyond the routine protocols following endoscopic treatment of VUR and the correct parental counseling upon the endoscopic correction.

Interstitial Cystitis in Adolescent Girls

Two cases of interstitial cystitis with typical, large bladder ulcerations in adolescent girls are reported. The specific diagnosis was confirmed histologically after full-thickness segmental resection of the bladder wall at the site of the ulceration during subsequent operations. Contrary to other reports based on subjective clinical findings, interstitial cystitis in children is rare when rigid criteria, including careful histological study, are applied. Treatment in children is the same as in adults and should be conservative. A conscientious attempt should be made to exclude infection and tuberculosis as possible contributors to the symptoms of urinary frequency and discomfort, as well as other causes of bladder abnormality. If conservative management fails to relieve symptoms the bladder may be enlarged in some cases by using a segment of intestine.

Urinary Prostaglandin E2 in Acute Bacterial Cystitis

The levels of prostaglandin E2 were studied in the urine of 14 female patients with acute bacterial cystitis. Ten healthy female students served as a control group. Results indicated a significant increase of urinary prostaglandin levels with a consistent relationship to the onset and duration of the clinical symptoms.

Relationships between FSH, inhibin B, anti-Mullerian hormone, and testosterone during long-term treatment with the GnRH-agonist histrelin in patients with prostate cancer

OBJECTIVESnMedical castration with long-acting GnRH-agonist (GnRHa) is a well-established treatment for metastatic prostate cancer. Our aim was to explore the relationships between FSH, inhibin B, anti-Mullerian hormone (AMH), and testosterone during treatment with an implant releasing GnRHa.nnnDESIGNnAnalysis of hormone levels in frozen serum samples.nnnMETHODSnTen patients aged 77+/-7 (means+/-S.E.M.) years with prostate cancer were treated with the GnRHa histrelin for at least a year. Two weeks prior to insertion and for 3-4 months following removal the patients were treated with the antiandrogen flutamide. Serum inhibin B, FSH, testosterone, and AMH levels were measured retrospectively.nnnRESULTSnFSH, inhibin B, and testosterone increased during antiandrogen administration and levels fell after implant insertion. Four weeks post insertion, FSH gradually increased while inhibin B and testosterone remained fully suppressed. AMH levels did not change during antiandrogen treatment, but increased following implant insertion and remained elevated for the duration of implant use. Following removal, FSH and testosterone increased, inhibin B remained low, while AMH decreased.nnnCONCLUSIONSnThe secondary increase in FSH following initial suppression with the implant is probably related to impaired inhibin B secretion. The lack of inhibin B response to the secondary increase in FSH suggests that long-term exposure of Sertoli-cells to GnRHa impairs their function. This effect appears to be selective since unlike inhibin B, AMH increased. In the absence of testosterone, FSH has a role in AMH regulation.

Crossed renal ectopia with crossed single ectopic ureterocele.

AbstractA case is reported of crossed renal ectopia associated with a crossed single ectopic ureterocele in a 5-week-old male newborn. No similar case has been reported previously in the English urological literature.

Submucosal Renal Pelvic Calcification Simulating a Pelvic Stone

We report a case of renal pelvic calcification radiologically simulating a renal pelvic calculus. Radiological and histopathological examination of the resected kidney revealed only submucosal calcification in the renal pelvis. This is the first report in the English literature of a renal pelvic calcification unrelated to amyloidosis.

Surgical management of hypospadias cripples

Purpose We retrospectively evaluated our results in patients who were referred to us as hypospadias cripples. Material and methods Over the last 17 years (1988-2005) more than 110 patients were referred to us after failure of multiple hypospadias repair. Out of those we considered 28 children and adolescents with the ages from 8 months to 15 years to be hypospadias cripples. All patients had from 2 to 5 surgical attempts prior to the referral. Patients were divided into two groups. The first group of 5(25%) patients underwent multiple staged repairs and a second group of 23(75%) had a single stage repair. In the first group all patients had a chordee and meatus was located on the proximal part of the penis. In the second group the meatus was located on the midshaft in 4 and in the proximal part in 19 patients. In the second group 14(60.8%) children had penile chordee. Chordee was repaired by excision of the scar tissue and dorsal plication of the tunica albuginea. Results Major complications included breakdown of the repair, multiple fistulas and urethral stricture, while minor complications included small fistula, meatal stenosis or unsatisfactory cosmetic outcome. The results are presented in the table. Groups Type of surgery N° Major complications Minor complications Revision First Staged repair 5 1 1 1 Second Bladder mucosa graft 2 - - - *OPIF (dorsal skin) 10 2 3 2 **TPIF (Dorsal skin) 3 1 1 - *OPIF (lateral skin) 4 1 2 1 Thiersh-Duplay 4 - 1 - All procedures 28 5(17.8%) 8(28.5%) 4(14.2%) *OPIF: Onlay Pedicled Island Flap **TPIF: Tubularized Pedicled Island Flap Conclusions Our data show that there is a place for the use of local penile skin flap with a good vascular supply in the treatment of hypospadias cripples. We prefer Thiersh- Duplay repair in patients with a wide ventral plate, which appears healthy. However the percentage of the complications is relatively high and some patients need repeat revisions in order to achieve good functional results.

Conservative treatment of antenatally diagnosed obstructive megaureters: long-term follow up

Purpose We retrospectively evaluated our 17 years of experience with the antenatal diagnosisxa0of hydronephrosis, which led toxa0a postnatal diagnosis of an obstructivexa0megaureter and tried toxa0determine the criteria for those whoxa0are at risk of surgery. Material and methods 79 children (64 boys and 15 girls) with an antenatal diagnosis of hydronephrosis, which led to a postnatal diagnosis of obstructive megaureter were followed for a period of 17 years (1988-2005). Rt ureterohydronephrosis was seen in 23 children, left in 30 and 26 had bilateral ureterohydronephrosis comprising 105 renal units (RU). According to the SFU classification of hydronephrosis 8 RU were with grade1, 57 with grade 2, 29 grade 3 and 11 with grade 4 postnatal hydronephrosis. Mean ureteral diameter was 1.2 cm. Relative renal function (RRF) was in 82 RU more than 40%, in 18 between 30-40% and in 5 RU less than 30%. Results 25 (31%) children required surgical correction. Mean age at surgery was 14.3 months (range 3-60 months). Univariate analysis revealed that child sex and side of obstruction are not significant predictive factors for surgery. However SFU grade 3-4 of postnatal hydronephrosis (p=0.0057 Odds ratio 0.2892), RRF less than 40% (p=0.0076, Odds ratio 0.2786) and ureteral diameter more than 1.33 cm. (p=0.0188) were significant independent risk factors leading to reimplantation. Conclusions Our data showed that only 30% of children with an antenatal diagnosis of obstructive megaureter required surgical correction. Renal function less than 40%,xa0grade 3 and 4 hydronephrosis andxa0ureteric diameter more than 1.33 cm are statistically significant independent predictive factors for surgery.