Janelle Fox

Augmentation Cystoplasty and Risk of Neoplasia: Fact, Fiction and Controversy

PURPOSE We determined if ileal/colonic bladder augmentation performed in patients with congenital bladder abnormalities is an independent risk factor for bladder malignancy. MATERIALS AND METHODS We reviewed a registry of patients with bladder dysfunction due to neurological abnormalities, exstrophy and posterior urethral valves. Individuals treated with augmentation cystoplasty were matched (1:1) to a control group treated with intermittent catheterization based on etiology of bladder dysfunction, gender and age (±2 years). RESULTS We evaluated 153 patients with an ileal/colonic cystoplasty and a matched control population. There was no difference (p=0.54) in the incidence of bladder cancer in patients with augmentation cystoplasty (7 patients [4.6%]) vs controls (4 [2.6%]). In addition, there was no difference between the 2 groups regarding age at diagnosis (51 vs 49.5 years, p>0.7), stage (3.4 vs 3.8, p>0.5), mortality rate (5 of 7 [71%] vs 4 of 4 [100%], p>0.4) or median survival (18 vs 17 months, p>0.8). Irrespective of augmentation status patients with a history of renal transplant on chronic immunosuppression had a significantly higher incidence of bladder cancer (3 of 20 [15%]), compared to patients who were not immunosuppressed (8 of 286 [2.8%], p=0.03). CONCLUSIONS In patients with congenital bladder dysfunction ileal/colonic bladder augmentation does not appear to increase the risk of bladder malignancy over the inherent cancer risk associated with the underlying congenital abnormality. In addition, immunosuppression irrespective of bladder treatment is an independent risk factor for malignancy in this patient population.

Annual Endoscopy and Urine Cytology for the Surveillance of Bladder Tumors After Enterocystoplasty for Congenital Bladder Anomalies

PURPOSE It is currently recommended that patients with congenital bladder anomalies managed by enterocystoplasty undergo annual surveillance with urine cytology and endoscopy. We reviewed our experience with this protocol and suggest modifications based on this experience. MATERIALS AND METHODS A total of 65 patients 10 years or more after enterocystoplasty were placed on an annual surveillance protocol consisting of interval medical history, renal-bladder ultrasound, serum B12, electrolytes, creatinine, urinalysis, urine cytology and endoscopy. RESULTS Of the 65 patients 50 (77%) with enterocystoplasty (ileal in 40 and colonic in 10) remain on the protocol. Median age at the initiation of surveillance was 28 years (range 24 to 40) with a median time from augmentation of 15 years (range 12 to 29). During the first 5 years of surveillance 26 of 250 cytology results (10.5%) were suspicious for cancer. Further evaluation revealed no evidence of malignancy. Specificity for cytology was 90% with unknown sensitivity. Of 250 surveillance endoscopic evaluations 4 lesions (1.6%) were identified and biopsied/removed. Pathological evaluation revealed 1 adenomatous polyp, 1 squamous metaplasia and 2 nephrogenic adenomas. Due to the low event rate and high cost routine cytology and endoscopy were discontinued after each patient completed 5 years of followup and annual evaluations were maintained. No tumors developed during the median surveillance interval of 15 years (range 12 to 20). Currently median patient age is 42 years (range 36 to 59) and median time since augmentation is 27 years (range 23 to 40). CONCLUSIONS Due to the low incidence of malignancy, lack of proven benefit and enhanced cost containment we recommend that annual surveillance endoscopy and cytology be discontinued.

Cystoscopic Injections of Dextranomer Hyaluronic Acid Into Proximal Urethra for Urethral Incompetence: Efficacy and Adverse Outcomes

OBJECTIVES To determine whether dextranomer/hyaluronic acid would be more efficacious or would produce fewer complications when using the material in a standard proximal-urethra cystoscopically-directed injection technique. Injectable periurethral bulking agents are an alternative to stress incontinence surgery. Dextranomer, a highly hydrophilic dextran polymer, solubilized in a base of nonanimal stabilized hyaluronic acid, has been approved as an injectable agent for the treatment of childhood vesicoureteric reflux (Deflux, Q-Med AB, Uppsala, Sweden), and in Europe for women with stress urinary incontinence (SUI) (Zuidex, Q-Med AB, Uppsala, Sweden). A previous multicenter trial demonstrated nonequivalence compared with bovine glutaraldehyde cross-linked collagen with a high complication rate. We sought to determine whether the failure of the treatment lay in the material itself or the use of a blind, midurethral injection technique. METHODS A retrospective case series of 56 patients undergoing cystoscopically guided bladder neck injections of dextranomer/hyaluronic acid with follow-up in 42, included 35 women with intrinsic sphincter deficiency (ISD), 4 men with postprostatectomy incontinence, 2 men with sphincteric denervation secondary to spinal cord injury, and 1 woman with sphincteric failure after a neobladder. Outcome assessment used gender-appropriate International Consultation on Incontinence Questionnaire, clinical records, and/or urodynamic assessment. RESULTS Of 35 women with ISD, 4 developed pseudoabscess formation with outlet obstruction requiring multiple operative interventions. Patient-defined treatment failure occurred in all 4 carefully selected postprostatectomy incontinent men, and in 23 of 35 females with ISD. CONCLUSIONS Complications with cystoscopically injected dextranomer hyaluronic acid at the bladder neck occurred at a high rate, and using a validated questionnaire, the efficacy of dextranomer hyaluronic acid applied in this manner for ISD was poor.

Ureteroarterial Fistula Treatment With Open Surgery Versus Endovascular Management: Long-Term Outcomes

PURPOSE Ureteroarterial fistulas can be treated with open vascular or percutaneous arterial stent placement. We compared the long-term outcomes of each treatment. MATERIALS AND METHODS A single center, retrospective review of ureteroarterial fistulas (1996 to 2008) was performed. RESULTS We identified 20 ureteroarterial fistulas in 19 patients. All patients had undergone extirpative surgery with pelvic radiation in 74% and long-term ureteral stents in 84%. At a mean followup of 15.5 months (range 1 to 99) survival was 53%. Of the 70% (14 of 20) treated with percutaneous endovascular iliac artery stenting or embolization, 2 patients later required open vascular graft and 12 were treated with long-term ureteral stenting. Of the 30% (6 of 20) of patients treated with open surgical repair or bypass 2 required bypass revision and/or thrombectomy, and 4 had concomitant ureteral ligation or nephrectomy. Despite undergoing anticoagulation 10 patients (53%) experienced lower extremity morbidity including ulceration, ischemia and amputation. In each treatment group 2 patients had recurrent hemorrhage requiring a secondary procedure, leading to death in 2 for an overall 10% acute mortality rate. Overall noncause specific mortality of ureteroarterial fistulas was 47% and 10% to 20% was related to the fistula or treatment complications. CONCLUSIONS Endovascular stenting is increasingly used in lieu of open techniques due to the high operative risk and comorbidities in patients with ureteroarterial fistulas. This retrospective review fails to identify a clear advantage for endovascular or open vascular surgical management. Thus, endovascular stenting is preferred in most cases. Regardless of therapy, patients are at risk for recurrent bleeding, lower extremity complications and stent/graft complications. The use of antibiotics and long-term anticoagulant therapy appear prudent but not proved.

The Gatekeeper Disparity—Why Do Some Medical Schools Send More Medical Students Into Urology?

PURPOSE Urology continues to be a highly desirable specialty despite decreasing exposure of students to urology in American medical schools. We assessed how American medical schools compare to each other in regard to the number of students that each sends into urological training. We evaluated the reasons why some medical schools consistently send more students into urology than others. MATERIALS AND METHODS We obtained American Urological Association Match data for the 5 match seasons from 2005 to 2009. We then surveyed all successful participants. The survey instrument was designed to determine what aspects of the medical school experience influenced students to specialize in urology. Bivariate and multivariate analysis was then done to assess which factors correlated with more students entering urology from a particular medical school. RESULTS Between 2005 and 2009 a total of 1,149 medical students from 130 medical schools successfully participated in the urology match. Of the 132 allopathic medical schools 128 sent at least 1 student into urology (mean ± SD 8.9 ± 6.5, median 8). A few medical schools were remarkable outliers, sending significantly more students into urology than other institutions. Multivariate analysis revealed that a number of medical school related variables, including strong mentorship, medical school ranking and medical school size, correlated with more medical students entering urology. CONCLUSIONS Some medical schools launch more urological careers than others. Although the reasons for these findings are multifactorial, recruitment of urological talent pivots on these realities.

Stones in special situations

There are several special situations in which urinary lithiasis presents management challenges to the urologist. An in-depth knowledge of the pathophysiology, unique anatomy, and treatment options is crucial in order to maintain good health in these patients. In this review, we summarize the current literature on the management of the following scenarios: bladder stones, stones in bowel disease, during pregnancy, in association with renal anomalies, with skeletal deformities, in urinary diversions, and in children.

CONTINENT URINARY DIVERSION IN CHILDHOOD: COMPLICATIONS OF ALCOHOL ABUSE DEVELOPING IN ADULTHOOD

PURPOSE We reviewed the urological sequelae of alcohol abuse in patients following enterocystoplasty in childhood. MATERIALS AND METHODS We reviewed our patient registry of 385 enteric bladder augmentations. We evaluated patients providing information regarding social habits. Patients were defined as abusing alcohol if they consumed more than 2 alcoholic beverages daily and were compared to a control group consuming 0 to 2 alcoholic beverages daily. RESULTS A total of 203 patients met inclusion criteria. Of the patients 24 (12%) admitted a history of alcohol abuse, of whom 5 (21%) sustained a total of 10 bladder ruptures, all related to alcohol consumption. All 5 patients presented in a delayed fashion, at more than 12 hours to 5 days following rupture. Despite immediate exploration and repair, 3 separate cardiac resuscitations were performed in 2 patients, of whom 1 died. One patient underwent conversion to an ileal conduit for repeated bladder ruptures (4 episodes) and failure to remain sober following 2 rehabilitation treatments. Three patients maintained long-term sobriety (5 to 9 years) after rehabilitation treatments. CONCLUSIONS The incidence of alcohol abuse in patients following enterocystoplasty is 12% (24 of 203) and is not different from the reported lifetime risk of 12% to 18% seen in the United States population. Due to the severe consequences of alcohol abuse in patients with enterocystoplasty, we preoperatively instruct all patients that they will have to limit alcohol consumption following the operation and screen via a social history on subsequent followup visits. If a history of alcohol abuse is noted, immediate consultation for rehabilitation is provided.

Incontinence. Pediatric sacral neuromodulation for refractory incontinence.

New research confirms that sacral nerve stimulation is a feasible option for treating subjective symptoms of urinary and fecal incontinence in children. However, owing to a lack of correlation between objective and clinical response parameters, we require standardized means of assessing outcomes in this patient population.

Response to commentary by Schneck.

Retrospective analyses that seek to determine the incidence of a particular disease are often problematic, especially when the context of testing ordered cannot be determined. Empirically noticing an association of vesicoureteral reflux (VUR) in children treated for urachal anomalies (UA), we embarked on a retrospective review as a pilot study to determine the merit of this theoretical association. Family history of VUR and urinary tract infection are known to be associated with increased risk of VUR, and currently these risk factors are utilized to screen for

Development of late, symptomatic abdominopelvic lymphoceles more than 10 years following pediatric reconstructive urologic procedures.

PURPOSE Rare reports of symptomatic abdominopelvic lymphoceles following pediatric genitourinary reconstruction do exist; however there are no data regarding the development or management of late symptomatic lymphoceles. We report on the clinical presentation of these lymphoceles 10 or more years following initial urologic surgery. MATERIALS AND METHODS We reviewed 480 patients following major intra-abdominal urologic reconstructive procedures from 1986 to 2009 for development of late, symptomatic abdominopelvic lymphoceles. A minimum of 10 years post-surgical follow up was required for inclusion. RESULTS Late symptomatic lymphoceles developed in 4/480 (0.8%) patients. Median length of follow up post reconstruction was 13.5 years (range 10-17). Median time to lymphocele development was 12 years (range 8-16). Symptoms at presentation included abdominal distension (4/4, 100%), nausea and vomiting (3/4, 75%), flank pain/progressive hydroureteronephrosis (3/4, 75%), and obstructive pyelonephritis (1/4, 25%). Additional surgical procedures that may have contributed to lymphocele development were present in 100%. 75% (3/4) of the patients underwent open surgical drainage, with one electing observation for intermittent symptoms. Exploration revealed loculated fluid collections between bowel loops and dense adhesions; symptoms resolved although small asymptomatic recurrences developed in all patients. CONCLUSIONS Late, symptomatic abdominopelvic lymphoceles following major pediatric urinary tract reconstruction or diversion develop in <1% patients. Many undergo subsequent abdominopelvic surgery, which may contribute to development of these late, pathologic lymphoceles. Open surgical drainage is usually required with excellent outcome.