Darcie Kiddoo

Gonadotropin-releasing hormone agonist in laparoscopic myomectomy: systematic review and meta-analysis of randomized controlled trials.

A systematic review and meta-analysis of randomized controlled trials was performed to estimate the effects on surgical outcomes of pretreatment with gonadotropin-releasing hormone (GnRH) agonist before laparoscopic myomectomy. The electronic bibliographic databases MEDLINE, EMBASE, Web of Knowledge, Scopus, and Cochrane Library, and reference lists from relevant articles were searched for English-language publications describing randomized controlled trials of GnRH agonist pretreatment vs placebo or no treatment before laparoscopic myomectomy. Three studies including 168 participants were identified. Pretreatment with GnRH agonist did not reduce operative time; however, intraoperative blood loss was statistically lowered (mean difference, 60 mL; 95% confidence interval [CI], 39-82). Statistical difference was also observed in postoperative hemoglobin concentration (mean difference, 1.15 g/dL; 95% CI, 0.46-1.83]) and red blood cell count (mean difference, 0.65 × 10(6) cells/mL; 95% CI, 0.16-1.14]) but not serum iron concentration. None of the patients in the studies experienced any major intraoperative or postoperative complications, and only 1 patient in each group required blood transfusion. This study does not show a difference in operative time with GnRH agonist pretreatment, which clarifies the previous conflicting reports on the effect of GnRH agonist therapy on the duration of laparoscopic myomectomy. Furthermore, despite previously reported decreased bleeding conferred by the laparoscopic approach compared with laparotomy, this meta-analysis demonstrates a further reduction in intraoperative blood loss with GnRH agonist pretreatment in patients undergoing laparoscopic myomectomy. Additional high-quality studies with appropriate power and follow-up are needed to corroborate these findings and to evaluate the treatment effects on short- and long-term outcomes such as perioperative complications and fertility.

Outcomes Following Fecal Continence Procedures in Patients with Neurogenic Bowel Dysfunction

PURPOSE Malone antegrade continence enema and cecostomy button improve quality of life in patients with neurogenic bowel. However, they have not been compared regarding fecal continence outcomes. We compared these 2 procedures with respect to continence, complications and conversions. MATERIALS AND METHODS We retrospectively reviewed the charts of patients who underwent Malone antegrade continence enema or cecostomy at the University of Alberta between January 2006 and January 2011. A total of 26 patients underwent Malone antegrade continence enema, of whom 20 underwent concomitant Monti procedure and bladder augmentation, 5 a laparoscopically assisted procedure and 1 concomitant ileovesicostomy. A total of 23 patients underwent cecostomy, of whom 1 underwent ileovesicostomy, 1 bladder augmentation, 1 a Monti procedure with bladder augmentation and 1 laparoscopic cecostomy. Continence was defined as ability to wear underwear with no accidents at most recent annual followup, which was a minimum of 1 year postoperatively. RESULTS Fecal continence rates were 84.6% for Malone antegrade continence enema and 91.3% for cecostomy. There were no statistically significant differences in continence based on procedure (p = 0.48), age (p = 0.97) or gender (p = 0.54). Of patients who underwent cecostomy 8.7% switched to the Malone antegrade continence enema, while 11.5% with Malone antegrade continence enema switched to cecostomy. Mean length of hospital stay for patients undergoing cecostomy vs laparoscopically assisted Malone antegrade continence enema was 4.0 vs 5.2 days (p = 0.15). Complications included stomal pain (23.1% of patients) and difficulty with catheterizing (19.2%) following Malone antegrade continence enema, and difficulty flushing (26.1%) following cecostomy. CONCLUSIONS There were no significant differences between Malone antegrade continence enema and cecostomy button with respect to fecal continence or complication rates. Each approach poses unique challenges, suggesting that patients and families need to understand the differences to make an individualized choice.

Randomized Crossover Trial of Single Use Hydrophilic Coated vs Multiple Use Polyvinylchloride Catheters for Intermittent Catheterization to Determine Incidence of Urinary Infection

PURPOSE Urinary tract infection is a key issue for long-term intermittent catheterization users. Various catheter designs and methods have evolved to decrease the risk but the evidence remains unclear regarding whether product type improves outcomes. We determined whether single use hydrophilic coated catheters reduced urinary tract infections compared to multiple use polyvinylchloride catheters for children with neurogenic bladder due to spina bifida. MATERIALS AND METHODS This was a randomized crossover 4-center trial with 2 treatment periods of 24 weeks each, consisting of single use hydrophilic coated catheter and multiple use polyvinylchloride catheter (washed with soap and water, and air dried after each use). Each week participants recorded symptoms and urine results (Multistix® 8SG reagent strip). Primary outcome was person-weeks of urinary tract infection, defined as positive leukocytes plus fever, flank pain, increased incontinence, malaise, or cloudy or odorous urine requiring antibiotic treatment. Individuals were included if they were a child or young adult with spina bifida and used intermittent catheterization as the primary method of bladder emptying. RESULTS Calculated sample size was 97. More than 120 patients were screened, of whom 66 were randomized and 45 completed both trial arms. Mean age was 10.6 years. Of the patients 21 were male and 24 were female. Mean ± SD person-weeks of urinary tract infection was 3.42 ± 4.67 in the single use hydrophilic coated catheter group and 2.20 ± 3.23 in the multiple use polyvinylchloride catheter group (p <0.001). There were no statistical differences in weeks of febrile urinary tract infection or antibiotic use. CONCLUSIONS Results are consistent with the Cochrane Review in that single use hydrophilic coated catheters may not decrease the incidence of symptomatic urinary tract infection in community dwelling chronic intermittent catheterization users when compared to clean multiple use polyvinylchloride catheters.

Management of the Urinary Tract in Spina Bifida Cases Varies With Lesion Level and Shunt Presence

PURPOSE The urinary and gastrointestinal tracts remain an enormous burden to the patient with spinal dysraphism. We examined our cases to determine the relationship between the level and type of spinal dysraphism, presence of a ventricular shunt, and urinary and gastrointestinal tract management. MATERIALS AND METHODS After receiving ethics approval we reviewed the charts of 155 patients younger than 17 years with spinal dysraphism. We compiled all pertinent neurological, genitourinary and gastrointestinal outcomes from our pediatric and adolescent spina bifida clinic. RESULTS Of our cohort 43% performed clean intermittent catheterization, including significantly more patients with myelomeningocele vs those with lipomeningocele or tethered cord (73% vs 19%, p <0.01). The intestinocystoplasty rate varied with lesion level and was significantly higher in cases of thoracic and thoracolumbar lesions than in cases of tethered cord, lipomeningocele and sacral myelomeningocele (p <0.005). Of the patients 52% older than 5 years were continent of urine but this varied significantly with lesion level and ventricular shunt presence. The urinary continence rate was highest in patients with a tethered spinal cord (57%), lipomyelomeningocele (65%) or sacral myelomeningocele (60%) (vs thoracic and lumbar myelomeningocele p <0.005). However, there was minimal difference between lumbar and thoracic lesions (25% and 26%, respectively). Of our patients 73% were also continent of feces, which did not vary with lesion level. CONCLUSIONS Our data confirm the association of lesion level, a ventricular shunt and continence.

Global developmental delay, progressive relapsing-remitting parkinsonism, and spinal syrinx in a child with SOX6 mutation.

SOX6, a member of the SOX gene family, plays a key role in the development of several mammalian tissues and organs, including the central nervous system. Specifically, this gene modulates the differentiation and proliferation of interneurons in the medial ganglionic eminence, as well as oligodendrocytes in the spinal cord. We describe the case of a 4-year-old girl with global developmental delay and a spinal cord syrinx who presented with recurrent episodes of parkinsonian symptoms subsequent to febrile illnesses. The symptoms included gait instability, tremor, and dysarthria, with a progressive relapsing-remitting course over the span of 2 years. The patient was later found to have a large deletion-type mutation in the SOX6 gene. This case is the first report in humans implying a role for SOX6 in basal ganglia function, as well as spinal cord development.

Symptomatic versus asymptomatic pyeloplasties: A single institution review

INTRODUCTION Historically, pyeloplasties have been performed after symptoms and radiographic confirmation of an ureteropelvic junction obstruction (UPJO). However, with prenatal ultrasonography, the approach to patients has fundamentally changed. Increasingly, patients are diagnosed and treated before the advent of morbidity, based on imaging findings alone. However, optimum screening strategies and thresholds for intervention vary significantly, are controversial, and are not founded on outcome-based evidence. We examined all pyeloplasties performed at our institution and reviewed their indication for surgery. We hypothesized that, despite ubiquitous screening for UPJO, most pyeloplasties had been performed secondary to symptoms and did not benefit from antenatal screening. METHODS A retrospective chart review was performed of all pyeloplasties performed at the Stollery Childrens Hospital, Edmonton, Alberta, over the past 8 years. Patients were categorized according to indication for surgery: symptomatic or asymptomatic. RESULTS Most (60%) of our pyeloplasties were performed for symptomatic indications. Furthermore, 12% of these patients had antenatally detected hydronephrosis that was thought to have resolved spontaneously during follow-up. Of our symptomatic patients, 37% were undergoing surveillance with the expectation for spontaneous resolution. Of the 29 patients who underwent pyeloplasty, 8 suffered a preoperative loss of function on renal scans; however, only 50% returned to within 90% of their original function. CONCLUSION Despite active surveillance of antenatally detected hydronephrosis, most pyeloplasties at our institution were performed for de-novo symptoms. We believe that this simple observation reinforces that our current surveillance strategies are unable to predict and eliminate all morbidity from UPJO.

Quality of life in children with vesicoureteral reflux

Vesicoureteral reflux (VUR) is commonly diagnosed in children presenting with urinary tract infections. Antibiotic prophylaxis and ureteric surgery are standard treatments for these children. Our aim was to investigate whether health-related quality of life (HRQOL) was altered in children treated for VUR. Children aged 1–5 years with grade III or higher VUR were identified through electronic records at the Stollery Children’s Hospital. Parents of these children were mailed the TNO-AZL Netherlands Organisation for Applied Scientific Research Academic Medical Centre Quality of Life (TAPQOL) questionnaire. QOL scores for this group were compared with normative controls from the instrument’s creators using the Mann–Whitney U test. Thirty-two of the 96 (33%) mailed surveys were returned. Eight children had surgery, and 19 were treated with antibiotic prophylaxis. When comparing the VUR group with the control group, we found that anxiety and social functioning scores were significantly better in patients with VUR (p < 0.01). The VUR group had worse scores in problem behavior, stomach complaints ,and communication (p < 0.01). This study reveals that children with VUR have a reasonable QOL when compared with controls. However, the diagnosis of VUR and its management does have an impact on gastrointestinal complaints, behavior, and communication, which may occur as a result of chronic medical intervention.

Highlighting recognition, management, and treatment of neural tube defects at various stages of development

Neural tube defects in children result in a significant burden from the medical sequelae to the impact in quality of life. The focus years ago was on protecting kidney function and improving lifespan. As care has improved, this has shifted to quality of life for patients. We now face the challenge of transitioning children to the adult world. It is, therefore, increasingly important for all urologists to understand the management strategies used in the current care of children with this condition. Dr. Metcalfe’s review highlights the important steps in recognition, management, and treatment at stages of development. The initial care for infants to preschoolers is on health and prevention of complications. He describes expectant vs. proactive care, highlighting the success of proactive care at his centre. This includes early adoption of clean intermittent catheterization (CIC) and monitoring with urodynamics. This prevents urinary tract infections (UTIs) and identifies bladder changes early. Recognition of bladder changes allows early introduction and maximization of anticholinergic medication. In elementary school and adolescence, most families focus on their desire for continence. Interventions include optimizing medication and catheterization, as well as surgical options. Most surgical interventions, including onabotulinumtoxinA injections, bladder augmentation, and catheterizable channels require motivated patients for success. Dr. Metcalfe also highlights the need to work with the families to ensure the best treatment option for their personal situation. If reliability is a concern, opting for safe alternatives with incontinent diversions are preferred. As children enter adulthood, new issues arise. At this time, health can deteriorate and the lack of support can prove to be a problem. The importance of adult urologists who can provide care becomes critical. Through this review, Dr. Metcalfe summarizes optimum care for patients as they travel through the system in time. With increased knowledge, we can continue to improve on health and quality of life even outside of multidisciplinary clinics.