C.K. Yeung

Evaluation of and Treatment for Monosymptomatic Enuresis: A Standardization Document From the International Children's Continence Society

PURPOSEnWe provide updated, clinically useful recommendations for treating children with monosymptomatic nocturnal enuresis.nnnMATERIALS AND METHODSnEvidence was gathered from the literature and experience was gathered from the authors with priority given to evidence when present. The draft document was circulated among all members of the International Childrens Continence Society as well as other relevant expert associations before completion.nnnRESULTSnAvailable evidence suggests that children with monosymptomatic nocturnal enuresis could primarily be treated by a primary care physician or an adequately educated nurse. The mainstays of primary evaluation are a proper history and a voiding chart. The mainstays of primary therapy are bladder advice, the enuresis alarm and/or desmopressin. Therapy resistant cases should be handled by a specialist doctor. Among the recommended second line therapies are anticholinergics and in select cases imipramine.nnnCONCLUSIONSnEnuresis in a child older than 5 years is not a trivial condition, and needs proper evaluation and treatment. This requires time but usually does not demand costly or invasive procedures.

Retroperitoneoscopic dismembered pyeloplasty for pelvi‐ureteric junction obstruction in infants and children

Objective To report our initial experience of endoscopic dismembered pyeloplasty through a retroperitoneal approach in infants and children with pelvi‐ureteric junction (PUJ) obstruction.

BLADDER DYSFUNCTION IN CHILDREN WITH REFRACTORY MONOSYMPTOMATIC PRIMARY NOCTURNAL ENURESIS

PURPOSEnWe studied bladder dysfunction in children with significant primary nocturnal enuresis refractory to treatment.nnnMATERIALS AND METHODSnWe evaluated 33 Chinese boys and 8 girls with a mean age of 10.4 years, who had significant monosymptomatic primary nocturnal enuresis (3 or more wet nights weekly) after desmopressin treatment with or without an enuretic alarm failed. Daytime cystometry, continuous nighttime cystometry and electroencephalography monitoring during sleep, and detailed recording of daytime and nighttime urinary output were performed.nnnRESULTSnWe recognized 5 patterns of bladder dysfunction and its association with sleep-arousal status. Pattern 1 was normal daytime urodynamics with significant bladder instability at night with normal volume voiding precipitated by unstable detrusor contractions in 14 boys (34%). Pattern 2 was normal daytime urodynamics with frequent small volume voiding at night, probably representing latent bladder instability, in 4 boys (10%). Pattern 3 involved abnormal daytime urodynamics with small bladder capacity, a discoordinated daytime voiding pattern and marked nighttime bladder instability associated with poor sleep in 6 boys (15%). Pattern 4 was abnormal daytime urodynamics with an obstructive pattern, and marked daytime and nighttime detrusor hypercontractility (mean maximum detrusor pressure 178 cm. water) in 8 boys (20%). Pattern 5 was abnormal daytime urodynamics with a dysfunctional daytime voiding pattern and frequent small volume nighttime voiding in 8 girls and 1 boy (22%). In all patients functional bladder capacity was smaller than expected for age and the majority had no nocturnal polyuria. Despite underlying bladder dysfunction a 4-week course of 400 microg. desmopressin orally at bedtime still produced a significant response with a greater than 50% decrease in the number of wet nights during treatment in 47% of the patients, although enuretic symptoms immediately relapsed on cessation of therapy in all. Notably cystourethroscopy in 7 of the 8 boys with pattern 4 dysfunction revealed bladder trabeculations and abnormal urethral lesions, including congenital obstructive posterior urethral membranes in 4, Moormanns ring in 2 and irregular scarring at the bulbous urethra in 1.nnnCONCLUSIONSnAbnormal bladder function, including small functional capacity, instability during sleep and marked detrusor hypercontractility, was common in our enuretic children in whom treatment failed. More importantly, nocturnal enuresis may be the only presenting symptom and there may be a response to desmopressin with a decreased number of wet nights even in cases of significant underlying bladder dysfunction. These findings may have important implications for our management strategy for monosymptomatic primary nocturnal enuresis.

Reduction in nocturnal functional bladder capacity is a common factor in the pathogenesis of refractory nocturnal enuresis.

Objectiveu2002To evaluate the diurnal and nocturnal bladder reservoir function in patients with refractory primary nocturnal enuresis (PNE).

Characteristics of primary nocturnal enuresis in adults: an epidemiological study

To evaluate the prevalence and characteristics of primary nocturnal enuresis (PNE) in adults in Hong Kong, as there are currently limited epidemiological data in adults.

Effects of Structured Versus Usual Care on Renal Endpoint in Type 2 Diabetes: The SURE Study A randomized multicenter translational study

OBJECTIVE Multifaceted care has been shown to reduce mortality and complications in type 2 diabetes. We hypothesized that structured care would reduce renal complications in type 2 diabetes. RESEARCH DESIGN AND METHODS A total of 205 Chinese type 2 diabetic patients from nine public hospitals who had plasma creatinine levels of 150–350 μmol/l were randomly assigned to receive structured care (n = 104) or usual care (n = 101) for 2 years. The structured care group was managed according to a prespecified protocol with the following treatment goals: blood pressure <130/80 mmHg, A1C <7%, LDL cholesterol <2.6 mmol/l, triglyceride <2 mmol/l, and persistent treatment with renin-angiotensin blockers. The primary end point was death and/or renal end point (creatinine >500 μmol/l or dialysis). RESULTS Of these 205 patients (mean ± SD age 65 ± 7.2 years; disease duration 14 ± 7.9 years), the structured care group achieved better control than the usual care group (diastolic blood pressure 68 ± 12 vs. 71 ± 12 mmHg, respectively, P = 0.02; A1C 7.3 ± 1.3 vs. 8.0 ± 1.6%, P < 0.01). After adjustment for age, sex, and study sites, the structured care (23.1%, n = 24) and usual care (23.8%, n = 24; NS) groups had similar end points, but more patients in the structured care group attained ≥3 treatment goals (61%, n = 63, vs. 28%, n = 28; P < 0.001). Patients who attained ≥3 treatment targets (n = 91) had reduced risk of the primary end point (14 vs. 34; relative risk 0.43 [95% CI 0.21–0.86] compared with that of those who attained ≤2 targets (n = 114). CONCLUSIONS Attainment of multiple treatment targets reduced the renal end point and death in type 2 diabetes. In addition to protocol, audits and feedback are needed to improve outcomes.

The relationship between early renal status, and the resolution of vesico-ureteric reflux and bladder function at 16 months.

Objective To examine, in infants presenting with vesico‐ureteric reflux (VUR), the relationship between the presence of initial renal abnormalities with the outcome of VUR and bladder function at 16 months of age.

A new management algorithm for impalpable undescended testis with gadolinium enhanced magnetic resonance angiography.

PURPOSEnWe evaluated the diagnostic accuracy of preoperative localization of impalpable undescended testis using ultrasound and gadolinium (Gd) enhanced magnetic resonance angiography (MRA).nnnMATERIALS AND METHODSnUltrasound and Gd-MRA were performed prospectively in 21 boys (23 impalpable testes) with cryptorchidism before laparoscopy and surgical exploration. Gd-MRA was done using a 1.5 Tesla magnetic resonance scanner with a turbo field echo technique after bolus intravenous injection of 0.4 mmol./kg. body weight of Gd diethylenetriaminepentaacetic acid. A total of 10 dynamic scans were acquired during 15 minutes after Gd injection to cover the early arterial and delayed venous phases. All patients subsequently underwent diagnostic laparoscopy and definitive surgery.nnnRESULTSnUltrasound correctly localized 9 of 10 intracanalicular testes but failed to reveal any intra-abdominal or vanishing testes. In contrast, Gd-MRA correctly localized 4 intra-abdominal, all 10 intracanalicular and 8 canalicular vanishing testes. In 1 patient with an intra-abdominal vanishing testis ultrasound and Gd-MRA failed to make the diagnosis. When correlated with the findings of subsequent laparoscopy and surgical exploration, Gd-MRA had a diagnostic sensitivity of 96% and a specificity of 100% for localizing impalpable undescended testes. Based on Gd-MRA and ultrasound findings laparoscopy could have been avoided in 18 of 23 cases (78%). No adverse effect was associated with Gd use in this study.nnnCONCLUSIONSnGd-MRA accurately diagnoses vanishing testes and reliably differentiates intraabdominal from intracanalicular impalpable testes, allowing definite preoperative planning of the surgical approach and avoiding unnecessary laparoscopy. A new management algorithm for impalpable testis in patients with cryptorchidism is proposed based on ultrasound and Gd-MRA findings.

PinQ: A valid, reliable and reproducible quality-of-life measure in children with bladder dysfunction

OBJECTIVEnRecently, a cross-cultural continence-specific paediatric quality-of-life measurement tool (PinQ) has been developed and tested psychometrically. The aim of this study was to evaluate the test re-test reliability of this new tool in a cohort of children with bladder dysfunction in order to evaluate the reproducibility of scores. A secondary aim was to compare the parent-completed proxy version with child-reported scores.nnnMETHODSnPinQ was translated and back-translated from English into Chinese and Dutch and scrutinized for cultural and linguistic appropriateness or ambiguity. Forty children aged 6-15 years from both countries were asked to self-complete the measure at first consultation and then again 14 days later. No new treatment was implemented between data collection points. On the initial visit, parents also completed a proxy version of PinQ. Intraclass correlations (one-way random effects model) were used to analyze the data.nnnRESULTSnThe intraclass correlation coefficient (ICC) for comparison between items and factors showed little variability in scoring. One item was not reproducible and was removed from the tool. Overall proxy scores varied little from the child-reported scores. However, the impact on the child of his/her parents concern about the bladder problem was poorly perceived (ICC=0.18) as was the impact on the childs sense of self-worth (0.17).nnnCONCLUSIONnPinQ has been shown to be reliable under test re-test conditions when completed by children from the age of 6 years. Proxy PinQ suggests that parents accurately evaluate the effect of bladder dysfunction on wellbeing in their children. A 20-item measurement tool will now be introduced clinically and subjected to sensitivity testing for treatment outcome and diagnostic grouping.

Is Smaller Workspace a Limitation for Robot Performance in Laparoscopy

PURPOSEnRobot or computer assisted laparoscopic surgeries have overcome several impediments of conventional laparoscopy in pediatric urology. However, in our practice we faced difficulties while performing specific tasks using the da Vinci Surgical System in small cavities. Thus, we objectively evaluated the performance of robot assisted laparoscopic skills in different sizes of workspace.nnnMATERIALS AND METHODSnSeven assessors performed 5 different drills in 7 different sizes of cubic boxes (edge size ranging from 40 to 150 mm) with the da Vinci Surgical System. The drills were developed based on the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills. Assessor performance was evaluated by 2 reviewers for the drill achievement, and time to completion was recorded. A global score was then calculated for each drill in accordance to 1 assessor and 1 box.nnnRESULTSnThere were significant collisions while working with the smaller cubes (edges measuring 40 and 45 mm), preventing the surgeon from performing drills. With difficulty, but without collision, the drills were performed in the 50 and 60 mm size cubes. Drills could be accomplished uniformly with ease in the larger cubes (edge 70 mm and greater).nnnCONCLUSIONSnWe found that surgeon ability to perform tasks using the da Vinci Surgical System in a small workspace is restricted. This assessment was confirmed by a statistical analysis of the data collected, demonstrating that with common surgical practice using the da Vinci robot workspace has a major impact on surgeon performance.