Charles T. Durkee

Bladder cancer following administration of cyclophosphamide

The relationship between cyclophosphamide and hemorrhagic cystitis is well documented; its role in inducing bladder cancer is less clear. To date, 18 cases of cyclophosphamide-associated bladder tumors have been reported. We present 3 additional cases of transitional cell bladder cancer, all preceded by hemorrhagic cystitis. Data implicating cyclophosphamide as a direct carcinogen as well as an immunosuppressive agent allowing bladder tumor development in the compromised host are discussed. While no direct relationship has been established, we suggest patients receiving this drug are at risk for developing bladder cancer, more likely transitional cell rather than squamous cell as has been reported previously.

Results of a 2-Year Multicenter Trial of Endoscopic Treatment of Vesicoureteral Reflux With Synthetic Calcium Hydroxyapatite

PURPOSE With no FDA approved material available for endoscopic treatment of vesicoureteral reflux, in 2001 we began a prospective multicenter trial of synthetic calcium hydroxyapatite as a subureteral bulking agent in children with traditional indications for surgical repair. MATERIALS AND METHODS A total of 98 patients (155 ureters) with grades II to IV reflux were enrolled at 10 sites in the United States to obtain 86 patients with completed protocol end points at 3 months. Of the 86 patients 74 underwent renal and bladder ultrasonography, blood count and serum chemistry analysis, and VCUG at 1 year. A total of 46 patients (47%) completed 2-year study end points, including VCUG. RESULTS At 1 and 2 years 24 of the 74 patients (32%) were cured. Ureteral cure rates were 46% and 40% at 1 and 2 years, respectively. With 35 patients treated and 85% compliance with the required 2-year VCUG the primary center achieved 2-year cure rates of 66% of patients and 72% of ureters. CONCLUSIONS Synthetic calcium hydroxyapatite is a safe, durable and effective material for endoscopic treatment of VUR. Increased experience with the injection of synthetic calcium hydroxyapatite yields improved results.

Metabolic Evaluation of Urolithiasis and Obesity in a Midwestern Pediatric Population

PURPOSE The incidence of urolithiasis has been proved to be increasing in the adult population, and evidence to date suggests that the same holds true for the pediatric population. While adult urolithiasis is clearly linked to obesity, studies of pediatric patients have been less conclusive. We hypothesized that a population of otherwise healthy children with stones would have an increased body mass index compared to a control population, and that obese pediatric stone formers would have results on metabolic assessment that are distinct from nonobese stone formers. MATERIALS AND METHODS We retrospectively reviewed the charts of all patients 10 to 17 years old with upper tract urolithiasis without comorbidities treated between 2006 and 2011. Mean body mass index of our population was compared to state data, and 24-hour urine collection results were compared between obese and nonobese patients with stones. RESULTS The obesity rate in 117 patients with urolithiasis did not differ significantly from the obesity rate derived from the 2007 National Survey of Childrens Health (observed/expected ratio 1.11, 95% CI 0.54-1.95). Using t-test and chi-square comparisons, overall 24-hour urine collection data did not show statistically significant differences. CONCLUSIONS Our results do not confirm obesity as a risk factor for pediatric urolithiasis in otherwise healthy patients. We also found no substantial metabolic differences between healthy nonobese stone formers and obese patients. While the pediatric literature is mixed, our study supports the majority of published series that have failed to establish a link between pediatric urolithiasis and obesity.

Advanced Transitional Cell Carcinoma of the Bladder in a 16-Year-Old Girl With Hinman Syndrome

The present report describes a 16-year-old girl with a history of Hinman syndrome who was found to have invasive transitional cell carcinoma of the bladder. Bladder cancer is rare in children. Typically, the tumors are of low grade and stage. We present the first case of a teenage girl diagnosed with Hinman syndrome who developed an invasive bladder transitional cell carcinoma. The patient with a neurogenic bladder who has undergone bladder augmentation is at increased risk for bladder cancer. This risk may now have to be extended out to the non-neurogenic neurogenic bladder population if further cases are identified.

Urolithiasis in Patients on High Dose Felbamate

PURPOSE We report 4 cases of felbamate urolithiasis. We identified only 1 prior case report of a felbamate stone. Felbamate is an antiepileptic drug used to treat refractory seizures and has minor side effects when given in recommended doses. We analyzed the characteristics, evaluation, treatment and outcomes in this challenging group of patients. MATERIALS AND METHODS Following institutional review board approval, we conducted a retrospective chart review of all patients who presented with a diagnosis of urolithiasis, were on felbamate and had stone analysis consistent with a felbamate origin. RESULTS All 4 patients had refractory seizures and 3 had severe developmental delay. Presentation ranged from an incidental finding to gross hematuria to agitation and pain. Stones were not visible on plain x-ray except in 1 case involving mixed stone composition. Decrease or cessation of the drug has not been feasible in 2 patients, and 3 patients have had recurrent stones. Initial stone analysis did not correctly identify the stone composition as felbamate in 2 cases, suggesting that the origin of these stones may not always be recognized. CONCLUSIONS We report the occurrence of felbamate stones in a series of patients on high dose felbamate therapy. Accurate diagnosis is made more difficult by the clinical complexity of the patient population (including severe developmental delay), the radiolucent nature of the stones and the possibility of inaccurate analysis of stone composition.

Intravesical Botulinum Toxin for Persistent Autonomic Dysreflexia in a Pediatric Patient

Introduction. We present a novel case of persistent autonomic dysreflexia in a pediatric spinal cord injury patient treated successfully with intravesical botulinum toxin. Study Design. A retrospective chart review of one patient seen at the Childrens Hospital of Wisconsin from 2006 to 2012 was performed. Results. A pediatric spinal cord injury patient with known neurogenic bladder presented with severe hypertension consistent with autonomic dysreflexia. His symptoms and hypertension did not improve with conservative measures, and he necessitated ICU admission and antihypertensive drips. He was taken to the operating room for intravesical botulinum toxin for refractory bladder spasms. Following this, his symptoms abated, and he was weaned off IV antihypertensives and returned to his baseline state. His symptoms were improved for greater than six months. Conclusions. There are few treatment options for the management of refractory autonomic dysreflexia. Intravesical botulinum toxin has never been reported for this use. Dedicated research is warranted to assess its efficacy, as it was used successfully to abort autonomic dysreflexia in this patient.

Clinical pathway for early discharge after complete primary repair of exstrophy and epispadias by using a spica cast

INTRODUCTION/OBJECTIVE Secure closure of the pubic diastasis during bladder exstrophy and epispadias repair decreases the abdominal wall tension at the time of reconstruction. Pelvic osteotomies are routinely performed at the time of abdominal wall and bladder reconstruction in order to more easily facilitate pubic symphyseal diastasis approximation. Postoperative pelvic immobilization is performed by methods that include modified Bucks traction, modified Bryants traction, and spica casting. People undergoing closure often require inpatient hospitalization for 2-8 weeks because of the pelvic immobilization. The present study examined the findings from a clinical pathway for early discharge after complete primary repair of exstrophy (CPRE) and proximal epispadias repair with spica casting. METHODS The present study is a retrospective review of patients that underwent pelvic osteotomies with spica casting at the time of CPRE or proximal epispadias repair from November 2006 to March 2013. All patients had anterior innominate osteotomies and spica cast pelvic immobilization. RESULTS Pelvic osteotomies and spica cast pelvic immobilization were performed on 17 children. The median postoperative stay was 6.0 days and the subdivided results are in Table. No children experienced an abdominal or orthopedic complication. A few children required minor cast adjustments to relieve pressure. After cast removal, no skin breakdown, pressure necrosis, or nerve palsy were found. The median length of casting without pinning was 31 (26-48) days. DISCUSSION The use of spica cast pelvic immobilization after exstrophy and epispadias repair is safe and allows for earlier discharge when compared to other methods of pelvic immobilization. However, although the family appreciates early discharge and additional bonding, the priority is the success of the closure. The present findings demonstrate, and are corroborated by other spica cast publications, that spica casting is as effective as modified Bryants traction or modified Bucks traction. The success rates for CPRE with spica casting are similar to published staged repairs and have the benefit of allowing for bladder cycling, which potentially enables better bladder growth and development. If success and complication rates are comparable amongst the different pelvic immobilization groups, then variables including hospital length of stay and cost become appropriate comparisons. CONCLUSION The shortened discharge time, along with a significant decrease in acuity of care leads to significant decreases in hospital costs. Additional hospital stay when using modified Bryants traction or modified Bucks traction with external fixation will accrue significant hospital costs.

Clostridia Sepsis Following Transperineal Needle Biopsy of the Prostate

AbstractThe first case is reported of clostridial prostatitis following transperineal needle biopsy of the prostate. The literature is reviewed and treatment is discussed.

Antibiotic Prophylaxis with Trimethoprim-Sulfamethoxazole versus No Treatment after Mid-to-Distal Hypospadias Repair: A Prospective, Randomized Study

Purpose To evaluate the impact of prophylactic antibiotics after distal hypospadias repair on postoperative bacteriuria, symptomatic urinary tract infection, and postoperative complications in a prospective, randomized trial. Materials and Methods Consecutive patients aged 6 months to 2 years were enrolled at our institution between June 2013 and May 2017. Consenting patients were randomized to antibiotic prophylaxis with trimethoprim-sulfamethoxazole versus no antibiotic. Patients had catheterized urine samples obtained at surgery and 6–10 days postoperatively. The primary outcome was bacteriuria and pyuria at postoperative urine collection. Secondary outcomes included symptomatic urinary tract infection and postoperative complications. Results 70 patients consented to the study, of which 35 were randomized to receive antibiotics compared to 32 who did not. Demographics, severity of hypospadias, and type of repair were similar between the groups. Patients in the treatment group had significantly less pyuria (18%) and bacteriuria (11%) present at stent removal compared to the nontreatment group (55% and 63%; p=0.01 and p < 0.001, resp.). No patient had a symptomatic urinary tract infection. There were 11 postoperative complications. Conclusions Routine antibiotic prophylaxis appears to significantly decrease bacteriuria and pyuria in the immediate postoperative period; however, no difference was observed in symptomatic urinary tract infection or postoperative complications. Clinical Trial Registration Number NCT02593903.