James J. Wolpert

Therapeutic Efficacy Of Extended Release Oxybutynin Chloride, And Immediate Release And Long Acting Tolterodine Tartrate In Children With Diurnal Urinary Incontinence

PURPOSE We compare the tolerability and efficacy of extended release oxybutynin chloride, and immediate release and long acting tolterodine tartrate in children with nonneurogenic diurnal urinary incontinence and symptoms of overactive bladder. MATERIALS AND METHODS Children with a history of diurnal urinary incontinence were arbitrarily assigned to extended release oxybutynin, immediate release tolterodine or long acting tolterodine. The dose was titrated until effective (onset of complete diurnal urinary continence), maximal recommended dosage was achieved or bothersome anticholinergic side effects developed. An independent observer recorded the dose used, anticholinergic side effects and efficacy of therapy (incidence of urinary frequency, urgency, posturing and urinary incontinence). RESULTS The study included 86 girls and 46 boys. There were no statistically significant differences among the 3 treatment groups regarding the presence of peripheral or central nervous system anticholinergic side effects. Extended release oxybutynin and long acting tolterodine were significantly more effective at reducing daytime urinary incontinence than immediate release tolterodine (p <0.01 and 0 <0.05, respectively). Extended release oxybutynin was significantly more effective then long acting tolterodine for complete resolution of diurnal incontinence (p <0.05). CONCLUSIONS Extended release oxybutynin and long acting tolterodine are more effective than immediate release tolterodine in decreasing diurnal urinary incontinence. Extended release oxybutynin chloride is more effective than either immediate or long acting tolterodine for control of daytime urinary incontinence and urinary frequency.

Single Center Experience With Endoscopic Management of Vesicoureteral Reflux in Children

PURPOSE Dx/HA copolymer was approved by the Food and Drug Administration in 2001 for the treatment of VUR in children. Published results have varied widely, prompting us to report our single center experience with 300 consecutive patients. MATERIALS AND METHODS All patients undergoing Dx/HA injection (300 children, median age 5.4 years) at our institution were eligible for this study. We examined several parameters to determine which variables influence the success of Dx/HA injection, including preoperative reflux grade, bladder diverticula, neurogenic bladder, ureteral duplication, perioperative urinary tract infection, dysfunctional voiding, laterality of reflux and amount of Dx/HA injected. RESULTS A total of 225 patients (75%) underwent postoperative studies, and, thus, were eligible for study inclusion. Reflux was cured in 144 patients (64%) and improved in 44 (20%). A total of 20 patients had ureteral duplication anomalies. Cure rates in this subgroup were significantly decreased compared to nonduplicated cases (40% vs 66%). Injection in low grade (I to II) reflux was significantly more successful than in high grade (III to IV) reflux (72% vs 54%). A total of 10 patients (8.3%) with unilateral reflux had development of de novo contralateral reflux. Of the patients who failed initial injection 10 (4%) underwent repeat injection, of whom 5 (50%) were cured after the second injection. Two patients (0.9%) had development of temporary ureteral obstruction. CONCLUSIONS We report a large short-term single center experience with endoscopically injected Dx/HA. Although our cure rate of 64% was less than published rates for open surgery, the minimal morbidity and low complication rate of endoscopic treatment make it an attractive first line therapy for patients with VUR. Longer followup is required to better evaluate this technique.

Utility of dextranomer/hyaluronic acid injection in setting of bladder and ureteral anomalies.

OBJECTIVES Previous studies have shown that the cure rates after dextranomer/hyaluronic acid (Dx/HA) injection can be decreased in patients with neurogenic bladder, previous ureteroneocystostomy, duplicated ureters, or periureteral diverticula. We attempted to determine whether these factors reduce the efficacy of Dx/HA injection compared with that in otherwise normal patients. METHODS All children with vesicoureteral reflux (VUR) undergoing Dx/HA injection from April 2002 to March 2006 at two institutions were eligible for this study. Multivariate logistic regression models were built to assess the effect of bladder/ureteral anomalies on the success of Dx/HA injection. We adjusted for previously described predictors of injection success, including VUR grade, sex, age, surgeon experience, and injection technique. RESULTS A total of 543 refluxing ureters (373 patients) were included, of which 145 (27%) had persistent VUR on postoperative voiding cystourethrography; 86 ureters (16%) had anatomic anomalies. On univariate analysis, the most important predictors of injection failure were increasing VUR grade, male sex, younger age, subureteral injection, ureteral duplication anomaly, increasing Dx/HA volume, and surgeon experience. On multivariate analysis, however, the only significant predictors of injection failure were increasing VUR grade, subureteral injection technique, and surgeon experience. No anatomic or functional abnormalities, considered individually or grouped, significantly affected the probability of injection failure. CONCLUSIONS In our experience, children with functional and anatomic bladder/ureteral anomalies were no more likely to have Dx/HA injection fail than were children with uncomplicated VUR. The most important predictors of Dx/HA success remained VUR grade, injection technique, and surgeon experience. Dx/HA injection in patients with complex bladders could be a reasonable therapeutic option.

Tunneled tunica vaginalis flap for recurrent urethrocutaneous fistulae.

The tubularized incised plate (TIP) hypospadias repair is currently the most widely used urethroplasty technique. The most significant post-TIP complication is urethrocutaneous fistula (UCF) development. Tunneled tunica vaginalis flap (TVF) is a well-described technique for the repair of UCF. We retrospectively reviewed all patients undergoing repeat repair of UCF after TIP repair from 2001 to 2005. Twelve boys underwent TVF repair at our institution for recurrent UCF. Fistulae ranged from distal penile to penoscrotal in location. Median surgical time was 45 minutes and no postoperative complications occurred. After a median follow-up of 32 months (range 16–48 months), no patient has yet had a recurrence of UCF. In conclusion, TVF repair is a successful technique for the treatment of UCF after previous failed repair. TVF is technically simple to perform and should be considered for treating UCF following TIP urethroplasty, particularly in a repeat surgical setting.

Unilateral vesicoureteral reflux: Does endoscopic injection based on the cystoscopic appearance of the ureteral orifice decrease the incidence of de-novo contralateral reflux?

OBJECTIVE In patients with unilateral vesicoureteral reflux (VUR), it has been suggested that injection of a non-refluxing but cystoscopically abnormal contralateral ureteral orifice (UO) with dextranomer/hyaluronic acid (Dx/HA) should be performed to prevent the development of de-novo contralateral VUR. We evaluate the effectiveness of this practice. PATIENTS AND METHODS Patients with primary unilateral VUR undergoing injection of Dx/HA from 2002 to 2005 at two institutions were eligible. Patients with unilateral VUR with cystoscopically abnormal contralateral UOs were injected with Dx/HA, while patients with normal appearing UOs received no treatment. Multivariate logistic regression models were used to estimate the impact of prophylactic injection on the development of de-novo contralateral VUR. RESULTS In total, 101 patients with unilateral VUR and an abnormal appearing contralateral UO underwent prophylactic injection of Dx/HA while 45 patients with a normal appearing contralateral UO were untreated. In patients receiving prophylactic Dx/HA, 9% (9/101) of the previously non-refluxing ureters developed de-novo VUR. Similarly, 13% (6/45) of patients with a normal appearing UO treated by observation alone developed de-novo VUR (P=0.55). The overall incidence of 10% (15/146) de-novo contralateral VUR matches published results where this protocol was not followed. CONCLUSIONS Our findings suggest that cystoscopic assessment and prophylactic treatment of an abnormal appearing, non-refluxing contralateral UO with Dx/HA is of little clinical benefit and should be abandoned.