Hrair-George O. Mesrobian

Bypass pyeloplasty: Description of a procedure and initial results

INTRODUCTION AND OBJECTIVE Dismembered pyeloplasty is the surgical technique of choice for open, laparoscopic and/or robot-assisted repair of ureteropelvic junction obstruction (UPJO). We describe a new technique, bypass pyeloplasty, ideally suited for the high inserting ureter, and present initial results. PATIENTS AND METHODS A wide 1-2-cm side-to-side anastomosis is created between the dilated and elastic portion of the ureter just distal to the UPJO and the lower and dependent portion of the hydronephrotic renal pelvis. The UPJ is not disturbed and the renal pelvis is not surgically reduced. Since 2004, of 27 patients requiring surgery for UPJO, 7 underwent bypass pyeloplasty. The indications for surgery included increasing hydronephrosis or decreasing individual renal function in four, pain in two and pyelonephritis in one. The remaining 20 underwent a classic dismembered pyeloplasty. RESULTS During a mean follow-up of 26 months, the anteroposterior diameter of the repaired kidney decreased by a mean of 55%. The individual renal function in the repaired kidney improved in two and remained stable in the remainder. CONCLUSION These favorable initial results justify further exploration of this simplified technique and its adaptation for laparoscopic and robot-assisted approaches. Bypass pyeloplasty may be a more physiologic procedure in patients with mid to high insertion of the ureter.

Hydronephrosis: A View from the Inside

Unilateral ureteropelvic junction obstruction (UPJO) is the most common prenatally detected disease leading to hydronephrosis. The obstructive anatomic lesion leads to varying degrees of hydronephrosis, ranging from no apparent effect on renal function to atrophy. Furthermore, the natural course of hydronephrosis varies from spontaneous resolution to progressive deterioration and may take upwards of 3 years for a kidney to declare itself. The objectives of this article are to update our knowledge regarding the evaluation and management of UPJO in depth and to discuss the emerging value of urinary proteome analysis to the clinical arena.

Urinary Proteome Analysis in Patients With Stable SFU Grade 4 Ureteropelvic Junction Obstruction Differs From Normal

OBJECTIVE To evaluate and analyze the urinary proteome in infants with stable grade 4 ureteropelvic junction obstruction (UPJO) and compare to age-matched normal controls. METHODS Bladder urine specimens were obtained from 21 healthy infants with normal maternal/fetal ultrasound and 25 infants with grade 4 unilateral UPJO. All patients had >40% ipsilateral individual kidney function by renal scanning and the anteroposterior (AP) diameter of the hydronephrotic kidney ranged from 1.6-3.9 cms at presentation. Over a 5-year follow-up period, the disease progressed in 7 infants (28%), resolved in 4 (16%), and remains stable in the majority (56%). The urinary specimens were prepared using standard methods and subjected to LC/MS/MS analysis. The normalized data were annotated utilizing the Ingenuity Pathways Analysis (IPA; www.Ingenuity.com) knowledge platform. RESULTS In the stable UPJO group, the urinary proteomes obtained in infancy differed significantly from the age-matched controls. Analysis revealed important differences in a number of biologic functions including inflammation, apoptosis, tubular injury and fibrosis, and reactive oxygen species response. CONCLUSION The urinary proteomes from the bladder in patients with stable grade 4 UPJO (by imaging criteria) are significantly different at birth and during the first year of life and seem to indicate the presence of an ongoing active renal response to UPJO. The imminent discovery of surrogate urinary biomarkers may result in reconsideration of the watchful waiting strategy during this critical period of renal maturation and development in infancy.

Complete Primary Repair of Bladder Exstrophy Is Associated With Detrusor Underactivity Type of Neurogenic Bladder

OBJECTIVE To test the hypothesis that complete primary repair of bladder exstrophy (CPRE) is associated with detrussor underactivity. For this purpose, we review (1) our experience, (2) the results of the published literature as it pertains to bladder function, and (3) the known anatomic basis on which the mechanism of the observed outcome can be understood. METHODS The medical records of all patients who underwent CPRE by the author between 2004 and 2010 were reviewed. Attention was focused on the clinical, imaging, and urodynamic findings. RESULTS Four men and 2 women underwent CPRE. Follow-up ranges from 2 to 8 years. Four underwent bilateral ureteral reimplantation combined with bladder neck repair in 3. Detrusor activity (or overactivity) was not recorded in the 5 patients who underwent urodynamic studies. Four patients achieved short periods of urinary continence. The percent predicted bladder capacity, adjusted for age, ranged from 25 to 70, with a median of 60. Of the 68 publications on CPRE since 1999, none reports the presence of detrusor activity. A description of the pelvic plexus anatomy by Walsh and Donker provides a basis for the mechanism of injury resulting in the previously mentioned results: (1) complete penile disassembly eliminates the distal fixation point of the bladder-urethral plate, (2) the subsequent dissection and mobilization result in shearing injury to the microscopic pelvic plexus branches to the bladder, external sphincter, and prostatic urethra. CONCLUSION CPRE results in disruption of the branches of the pelvic plexus and a neurogenic bladder (detrussor underactivity).

Surgical technique for antegrade dissection of the preputial vascular pedicle during hypospadias repair

OBJECTIVE Both layers of the prepuce can be used as vascularized flaps in hypospadias repair. The aim of this communication is to describe an antegrade approach to the harvesting of the vascular pedicle. SURGICAL TECHNIQUE The vascular pedicle is isolated at the level of the penopubic junction where it is most robust. Dissection then proceeds distally towards the prepuce fanning laterally. RESULTS Of 306 boys presenting for hypospadias repair in 2002-2008, this approach was utilized in 235 (77%). The vascularized flap was used as 1) a classic single or double faced onlay flap in 95, 2) a vascularized layer to cover a tubularized incised plate urethroplasty in 68, 3) a tube-onlay in 39, 4) a tubularized urethroplasty in 23, 5) for ventral skin coverage alone in 7, and 6) for a planned first stage repair in 3. Age at repair averaged 12 months (range 2-160) and follow up 36 months (range 2-68). CONCLUSIONS Antegrade dissection of the vascular pedicle is a simple, expeditious and reliable way of isolating the prepuce on its blood supply. The versatility of the resulting flaps allows the repair to be adapted to the individual anatomic conditions as opposed to one type of repair being used for all variants.

Bilateral Scrotal MASSES in an Infant: Remote Presentation of an Inflammatory Reaction to Surgical Glove Powder

Foreign body reactions can be induced following abdominal surgery, resulting in adhesions and subsequent intestinal obstruction. Foreign materials such as glove powder, lint from surgical packs and sutures have been implicated as causative agents in addition to infection, intraoperative tissue damage or ischemia and spillage of organ contents. 1 We report on a 2-month-old male with bilateral scrotal masses resulting from a foreign body reaction to cornstarch surgical glove debris. CASE REPORT A 58-day-old male presented with bilateral scrotal masses 1 day in duration. The appearance of the masses was preceded by nonspecific irritability several days in duration. There was no history of vomiting, diarrhea, fever or change in feeding habits. Medical history was remarkable for pyloric stenosis requiring a pyloromyotomy. Physical examination demonstrated bilateral firm scrotal masses separate from the testes. These masses did not transilluminate and could not be reduced despite their mobility. The scrotal skin had lost its rugae and was erythematous. Urinalysis was normal. On scrotal ultrasound the masses were interpreted to represent marked bilateral epididymal enlargement with increased vascularity (fig. 1). Both testes were normal in size and surrounded by small hydroceles. Because of the uncertainty raised by the bilateral nature of the masses and associated inflammatory process, inguinal exploration was undertaken. A patent processus vaginalis and a distinct paratesticular mass were identified on the left side, and frozen section analysis was consistent with fibrous tissue and perivascular chronic inflammation. The mass was removed and the inguinal hernia was repaired. Although exploration of the right side did not reveal the presence of a hernia, a similar paratesticular mass was found. Final pathological diagnosis was foreign body reaction. No neoplasia was identified. Many of the giant cells in the pathological specimen contained foreign birefringent material that was irregular in outline and ranged in size from 3 to 20 . Under polarized microscopy this material had a Maltese cross configuration and stained strongly positive with periodic acid-Schiff and Giemsa (fig. 2). The surrounding proliferative fibroblastic tissue contained scattered collections of histiocytes forming foreign body giant cells admixed with