Genoa G. Ferguson

Combination Therapy With Desmopressin and an Anticholinergic Medication for Nonresponders to Desmopressin for Monosymptomatic Nocturnal Enuresis: A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVE. Desmopressin is an approved medical therapy for the treatment of monosymptomatic primary nocturnal enuresis. In cases of limited response to desmopressin, we have added anticholinergic therapy to desmopressin (combination therapy). To evaluate this treatment strategy, we examined the efficacy of combination therapy for primary nocturnal enuresis in desmopressin-nonresponders. METHODS. Only patients with primary nocturnal enuresis refractory to the maximal dosage of desmopressin were enrolled. Children with lower urinary tract symptoms or bowel dysfunction were excluded, on the basis of a 3-day, 24-hour, frequency-volume chart and elimination record. Children continued to take desmopressin and were assigned randomly, in a double-blind manner, to receive either extended-release anticholinergic medication or placebo. Patients were reassessed after 1 month of therapy, with a 1-week nocturnal record. RESULTS. Forty-one desmopressin-nonresponders were enrolled, and 7 patients were excluded because of noncompliance. The treatment groups were equally matched with respect to age, gender, functional bladder capacity, and number of wet nights per week. After 1 month of treatment, there was a significant reduction in the mean number of wet nights in the combination therapy group, compared with the placebo group. With a generalized estimating equation approach, there was a significant 66% decrease in the risk of a wet episode, compared with the placebo group. CONCLUSIONS. This study represents the first prospective, placebo-controlled trial examining the effect of desmopressin in combination with long-acting, anticholinergic, bladder-relaxing therapy for monosymptomatic primary nocturnal enuresis.

The Sexual Lives of Medical Students: A Single Institution Survey

INTRODUCTION Little is known about the personal sexual lives of medical students. AIM To assess sexual habits and determine the presence of sexual dysfunction among medical students. MAIN OUTCOME MEASURES Demographic and sexual experience data and domain scores on validated sexuality surveys. Instruments selected included the International Index of Erectile Function, the Index of Premature Ejaculation, and the Self Esteem and Relationship Quality Survey for male medical students and the Female Sexual Function Index (FSFI), and the Index of Sex Life for female medical students. METHODS Medical students at our institution were invited to complete a demographic questionnaire and gender- appropriate sexuality surveys. Results were compared with established normative data and validated cut-off scores when available. Linear regression and Pearson coefficient were used to assess relationships between variables. RESULTS There were 132 responses (78 female mean age 24 years, 54 male, mean age 25 years). Condoms and oral contraceptives were the most popular form of contraception. Among men, 81.5%, 37%, and 93% were in a relationship, married, and heterosexual, respectively. Among women, 64%, 18%, and 95% were in a relationship, married, and heterosexual. Erectile dysfunction was reported by 30% of men. Proxy measures of other sexual problems in men revealed a 28% prevalence of dissatisfaction with sex life, a 28% prevalence of problems controlling ejaculation, an 11% prevalence of orgasmic dysfunction, and a 6% prevalence of low sexual desire. Based on validated FSFI scoring, 63% of women were at high risk of sexual dysfunction. Proxy measures of other problems in women indicated disorders of pain, orgasms, desire, sex satisfaction, lubrication, and arousal in 39%, 37%, 32%, 28%, 26%, and 24% of female respondents, respectively. CONCLUSIONS These data provide insight into the sexual lives of medical students. Rates of sexual dysfunction are higher than expected based on normative data. Further research is required.

Longterm Changes in Creatinine Clearance after Laparoscopic Renal Surgery

BACKGROUND Controversy exists about the impact of ischemia on renal function. We evaluated the creatinine clearance of patients having undergone laparoscopic renal extirpative and ablative surgery. STUDY DESIGN The records of patients undergoing laparoscopic procedures for renal masses from February 2000 to March 2004 were examined. Creatinine clearance (CrCl) for each patient was determined using the Cockcroft-Gault equation and ideal body weight. We compared CrCl changes of patients undergoing laparoscopic partial nephrectomy (without renal ischemia [LPN-none], with warm ischemia [LPN-warm], and with cold ischemia [LPN-cold]) with patients undergoing laparoscopic radical nephrectomy (LRN) and laparoscopic cryoablation. Patients predisposed to medical renal disease were substratified and evaluated. RESULTS All patients who underwent LRN or LPN-warm sustained a significant drop in CrCl on the first postoperative day, compared with patients who had LPN without ischemia or cryoablation (p < 0.01). The CrCl decrease correlated directly with warm ischemia time. Six months postoperatively, CrCl changes were no longer significant. Patients with medical renal disease risk factors were more likely to sustain longterm (1 year postoperatively) renal damage if they had renal ischemia, trending toward statistical significance. CONCLUSIONS Ischemia causes acute renal damage, which is apparently reversible in patients without evidence of medical renal disease. Patients with known medical renal disease have substantial longterm changes in renal function associated with unilateral renal ischemia. Considering the insensitivity of creatinine-based renal function metrics, only eliminating ischemic time will realize the goal of maximal nephron preservation, particularly in patients with preexisting medical renal disease.

Management of the Bladder During Surgical Treatment of Enterovesical Fistulas from Benign Bowel Disease

BACKGROUND Management of the bladder in enterovesical fistulas from benign bowel disease is not well described in the literature and there is no clear consensus. STUDY DESIGN A retrospective chart review was done of all patients with benign bowel disease and an enterovesical fistula who underwent definitive surgical management between January 1993 and December 2005. Patients were excluded if they had any history of abdominal cancer or pelvic radiation. Surgical management protocol for enterovesical fistulas included a period of perioperative bowel rest, surgical exploration, separation of the fistulized bowel from the bladder, resection of the diseased bowel segment, and Foley catheter placement for 1 week. RESULTS Seventy-four patients were eligible for the study. The average patient age was 54.3 years (range 19 to 88 years old). Twenty-six women and 48 men underwent celiotomy and segmental resection of the offending bowel and bowel side of the fistula. The bladder side of the fistula was managed by Foley catheter alone in 68% and by surgical repair in 32%. Fifty-two patients had diverticulitis (70.3%) and 22 had Crohns disease (29.7%). Mean followup was 26.4 months, and median followup was 6.45 months. One patient developed a colocutaneous and vesicocutaneous fistula after celiotomy. The remaining bladder defects healed within 1 week. CONCLUSIONS Successful surgical management of most enterovesical fistulas from diverticulitis or Crohns disease requires only resection of the diseased bowel, with minimal need for repair or resection of the bladder side of the fistula. Indwelling Foley catheter placement alone is typically sufficient for bladder healing. Only when there are overt defects into the bladder should formal repair be undertaken.

The Efficacy of Oral Midazolam for Decreasing Anxiety in Children Undergoing Voiding Cystourethrogram: A Randomized, Double-Blind, Placebo Controlled Study

PURPOSE Voiding cystourethrogram is an invasive test that evokes anxiety. Our primary aim was to determine whether midazolam is beneficial in decreasing anxiety in children who undergo voiding cystourethrogram. Secondary aims were an examination of parent anxiety, health care professional perceptions and post-procedure behavioral outcomes in children after voiding cystourethrogram. MATERIALS AND METHODS A total of 44 children were randomized to placebo or oral midazolam before voiding cystourethrogram in double-blind fashion. The Modified Yale Preoperative Anxiety Scale was used to evaluate child behavior before and during voiding cystourethrogram, and the Post Hospitalization Behavior Questionnaire was used to investigate any short-term and intermediate-term behavioral outcomes. The State-Trait Anxiety Inventory was used to evaluate parent personal anxiety during voiding cystourethrogram. A separate questionnaire was administered to radiology staff. Statistical analysis included the 2-sample t and Fisher exact tests. RESULTS There was no difference in Modified Yale Preoperative Anxiety Scale scores in children randomized to midazolam or placebo. There was also no significant difference in parent anxiety. Radiology care providers identified no reliable benefit when blinded to sedation vs placebo. We did not note any post-procedural behavior issues after voiding cystourethrogram at up to 6 months of followup. CONCLUSIONS Midazolam may not significantly help with child or parent anxiety during voiding cystourethrogram. No reliable benefit was noted according to radiology health care provider perception and there was no significant post-procedural behavior benefit. Midazolam may not provide a significant benefit in decreasing anxiety during voiding cystourethrogram.

Antegrade Endoscopic Removal of Retained Urethral Sling Mesh in the Bladder

The midurethral sling has emerged as an effective, minimally invasive treatment for patients with stress urinary incontinence. Bladder penetration is a known complication that, if unrecognized, may result in retained intravesical mesh. This rare complication can cause patient discomfort as well as become a nidus for infection and bladder calculi. Because of the technique of sling passage, the site of retained sling material is often along the anterior bladder wall, making evaluation and treatment via traditional retrograde cystoscopy prohibitively difficult. We describe a novel and minimally invasive method to remove the sling material using antegrade access into the bladder in conjunction with holmium laser vaporization. In our series of six patients in whom retrograde cystoscopic treatment had failed, all were successfully treated with antegrade cystoscopy and reported improved urinary symptoms. This new technique provides a simple, minimally invasive, and effective method for removal of exposed sling mesh.