Craig Smith

Sequential urinalysis improves evaluation of fetal renal function in obstructive uropathy

OBJECTIVES The purpose of our study was to determine whether sequential vesicocenteses improve the evaluation of renal damage, compared with single urine sampling in obstructive uropathy. STUDY DESIGN A total of 29 fetuses with complete obstructive uropathy underwent a minimum of three sequential complete vesicocenteses at 48- to 72-hour intervals. First and last urine values were analyzed for multiple parameters. The ability of first versus last urine values to detect the presence of renal damage was compared according to postnatal or fetal autopsy information. RESULTS Fetuses with minimal renal damage had patterns of decreasing hypertonicity and last urine values below cutoff thresholds indicative of favorable prognosis. Fetuses with significant renal damage had higher initial values and patterns of increasing hypertonicity. For five of six parameters, last urine samples were more predictive of renal damage than first urine samples. CONCLUSION Last urine values together with pattern-of-change trend analysis after serial vesicocenteses improve diagnostic precision in fetuses with complete obstructive uropathy.

Fetal Therapy for Obstructive Uropathy: Specific Outcomes Diagnosis

AbstractPurpose: Attempts to evaluate prenatal vesico-amniotic shunt therapy have been hampered by inconsistencies in patient selection, treatment and termination criteria, and outcomes measurement. Outcomes have generally been measured against those of patients with postnatally detected posterior urethral valves. The purpose of this report was to evaluate the influence of the underlying diagnosis on the clinical outcomes of fetuses undergoing evaluation for prenatal intervention for suspected obstructive uropathy. Furthermore, specific outcomes diagnosis was compared to the published natural history of these disorders to begin to establish a basis for measuring the efficacy of prenatal intervention.Materials and Methods: We retrospectively reviewed the outcomes of 55 consecutive patients undergoing prenatal evaluation using structured outcome measures stratified by specific diagnoses to provide a comparison to the reported natural history for each underlying disorder.Results: All fetuses had early onset ...

Is There a Best Alternative to Treating the Obstructed Upper Pole

PURPOSE We addressed whether salvage of upper pole renal units in comparison to partial nephrectomy affects differential renal function in patients with a duplicated obstructed upper pole. MATERIALS AND METHODS We retrospectively reviewed the records of all children who underwent surgery for a unilateral obstructed duplicated kidney at our institution from 1988 to 1995. Patients were evaluated with respect to postoperative complications, reoperation rate and percent change in differential renal function of the obstructed duplicated kidney, as determined by nuclear renography. RESULTS We identified 46 patients with a unilateral obstructed upper pole of a duplicated kidney who were divided into 2 groups. Group 1 (12 patients) underwent an upper pole salvage procedure, that is ureteropyelostomy or ureteroureterostomy, and group 2 (31 patients) underwent partial nephrectomy. Three reoperations (25%) were performed in group 1 and 1 (4%) was done in group 2. Postoperative symptomatic urinary tract infections were diagnosed in 3 group 1 patients (25%) and in 2 (8%) in group 2. Average change in ipsilateral renal function in the 8 patients who underwent upper pole salvage procedures was 2.25 +/- 2.34% (range -6 to 12). In the 8 patients who underwent upper pole nephrectomy and who also had postoperative renal scans average change in function was -1.25 +/- 4.51% (range -23 to +16). CONCLUSIONS There was no statistically significant loss of relative renal function in patients treated with partial nephrectomy and no significant gain in relative renal function in those treated with an upper pole salvage procedure. The reoperation rate was higher in the upper pole salvage than in the partial nephrectomy group (25 versus 4%). While not statistically significant, we believe that this rate is clinically important. We think that partial nephrectomy should remain the preferred treatment for most patients with obstructed duplicated kidneys.

Smooth muscle development in the obstructed fetal bladder.

OBJECTIVES To evaluate changes in the smooth muscle and connective tissue development in the obstructed and normal fetal bladder. METHODS The smooth muscle and connective tissue composition of 19 fetal urinary bladders, including those of 9 fetuses with anatomic obstruction and 10 controls free of urologic disease, were analyzed by light microscopy and computer-assisted color image analysis. RESULTS The bladder wall thickness was markedly increased in obstructed fetuses throughout gestation as compared with that in controls. The disparity in bladder wall thickness increased rapidly during gestation. The percent area density of smooth muscle and connective tissue as well as the ratio of smooth muscle to connective tissue remained the same in the obstructed and normal control fetal bladders. CONCLUSIONS Although bladder outlet obstruction is associated with a marked increase in bladder wall thickness, the percent of smooth muscle and connective tissue comprising the mural histology remains relatively constant as compared with that of normal fetal controls. This study suggests that bladder outlet obstruction in the fetus is not associated with excess collagen deposition but rather with an increased amount of bladder with normal cellular content and a concomitant increase in smooth muscle development.

The White House Speaks: Presidential Leadership as Persuasion.

Preface Presidential Leadership as Persuasion The Interpretive Systems Approach to Presidential Leadership The Coalitionless President and the Pardons The Politics of Division Narrative Conflict and the Panama Canal Treaties Political Jeremiads from the Bully Pulpit Presidential Mobilization for Sacrifice The Presidency in Rhetorical Crisis Conclusions: Presidential Leadership in the 1990s Index

Voiding function in patients with the prune-belly syndrome after Monfort abdominoplasty.

PURPOSE We reviewed our experience with patients with the prune-belly syndrome who had undergone Monfort abdominoplasty to assess whether our clinical impression of improved voiding efficiency could be demonstrated objectively. MATERIALS AND METHODS From 1990 to 1993, 12 patients with the prune-belly syndrome underwent Monfort abdominoplasty with or without concomitant genitourinary reconstruction. All patients completed questionnaires on voiding before and after abdominoplasty, incontinence, bladder sensation, urinary flow, history of urinary tract infections and the ability to defecate. Urodynamic testing was performed in 8 patients before and after abdominoplasty. RESULTS Subjective changes that occurred after abdominoplasty included resolution of or less double voiding in 9 patients, improved urinary continence in 7, improved bladder fullness sensation in 11, improved urinary flow in 10 and improved defecation in 5. The incidence of urinary tract infections decreased from a preoperative average of 5.7 per patient per year to 1.2 per patient per year postoperatively. Urodynamics demonstrated no significant changes in the measured urinary flow, capacity or maximal detrusor pressure. Compliance decreased on average but it remained in the compliant range. However, post-void residual volumes did significantly decrease from a preoperative average of 40.3% of bladder capacity to 13% after abdominoplasty. If the 5 patients who underwent concomitant urinary reconstruction were excluded, the reduction in average post-void residuals remained approximately the same, which was 40% of bladder capacity preoperatively to 14.3% after abdominoplasty. These data suggest that abdominoplasty alone was responsible for improved micturition. CONCLUSIONS In addition to the cosmetic benefits and exposure provided for genitourinary reconstruction Monfort abdominoplasty seems to improve voiding efficiency.

In utero Fetal Urine Analysis and Renal Histology Correlate with the Outcome in Fetal Obstructive Uropathies

We evaluated 8 second-trimester fetuses who had undergone termination because of obstructive uropathies and correlated the renal histopathology with fetal urine biochemical prognostic parameters. Prenatal evaluation included serial vesicocentesis, karyotyping, and sonography. According to the urinary biochemical parameters, 3 fetuses were classified to be in the good prognostic category, 2 in the borderline prognostic category, and 3 in the poor prognostic category. The kidneys were evaluated both grossly and microscopically for hydronephrosis, pelvicaliceal dilatation, cystic changes and fibrosis. Fetuses in the poor prognostic category had severely damaged renal architecture, microcysts, macrocysts, and extensive fibrosis. Fetuses in the good prognostic category had minimal histopathologic changes with preservation of the architecture. Fetuses in the borderline category showed a moderate degree of renal damage but with focally preserved architecture. We conclude (1) that there is a direct correlation between elevation in urinary electrolytes and proteins and extent of underlying renal histopathological damage and (2) that appropriate detailed prenatal evaluation of the renal function can identify fetuses who could potentially benefit from in utero therapy.

Long-term intravesical oxybutynin chloride therapy in children with myelodysplasia.

PURPOSE We evaluated the clinical use of long-term intravesical oxybutynin chloride in the treatment of neurogenic bladder dysfunction in children with myelodysplasia who could not tolerate oral anticholinergics. MATERIALS AND METHODS We retrospectively reviewed the records of all patients recommended for intravesical oxybutynin chloride therapy. A total of 12 girls and 18 boys 1 to 17 years old was recruited for study. Oxybutynin chloride (5 mg.) was instilled 2 times daily and pretreatment cystograms were compared to followup urodynamic studies. Duration of therapy was 2 to 26 months (mean 13, median 12). RESULTS Mean total capacity plus or minus standard deviation increased from 209 +/- 103 to 282 +/- 148 ml. (p < 0.01), mean safe capacity increased from 157 +/- 105 to 234 +/- 147 ml. (p < 0.01) and mean age adjusted safe capacity increased from 76 +/- 36 to 115 +/- 62%. Of the 29 patients who were incontinent 3 (10%) achieved continence and 19 (65%) reported a decreased use of sanitary pads. None of the patients had systemic side effects related to intravesical treatment. CONCLUSIONS We believe that intravesical oxybutynin chloride is a viable treatment option for patients with myelodysplasia in whom oral therapy fails.

Double Onlay Preputial Flap for Proximal Hypospadias Repair

AbstractPurpose: We describe a new technique for primary repair of proximal hypospadias. The double onlay preputial flap combines the principles of onlay urethroplasty and the double face preputial flap, namely preservation of the urethral plate and use of a total preputial flap.Materials and Methods: Common problems of classic onlay urethroplasty, including rotation and asymmetry of the penile shaft when the preputial flap is brought laterally around the shaft and the viability of the Byars flaps after dissecting the pedicle for the onlay flap, are avoided with this technique by passing the penis through a buttonhole incision in the pedicle of the total preputial flap. Onlay urethroplasty is performed using a secondary flap outlined from the total preputial flap. The remainder of the total preputial flap tissue is used to cover the ventral skin defect.Results: Since June 1994, 18 patients 6 months to 9 years old (median age 10 months) underwent primary hypospadias repair with the double onlay preputial f...

The Hofstadter hypothesis revisited: The nature of evidence in politically “paranoid” discourse

This study explores the evidentiary character of politically “paranoid” and “non‐paranoid” discourse. The data suggest that the two types differ with regard to the types of references they make, but do not differ significantly in terms of accuracy or distortion. The results affirm the existence of an evidence‐inference dichotomy and suggest that political “paranoids” are able to construct their unique arguments without distorting evidence about their environment.