Michael H. Hsieh

3-Dimensional Neuroanatomy of the Human Fetal Pelvis : Anatomical Support for Partial Urogenital Mobilization in the Treatment of Urogenital Sinus

PURPOSE Retrospective reviews suggest that the functional outcomes of surgery of the urogenital sinus have often been unsatisfactory and to our knowledge the long-term results of newer surgical techniques have yet to be evaluated. A precise understanding of pelvic fetal neuroanatomy is germane for optimizing surgical correction of the urogenital sinus. MATERIALS AND METHODS The pelves of 10 human female fetuses were serially sectioned. Massons trichrome staining and immunochemistry for the neuronal marker S100 (Dako Corp., Carpinteria, California) along with anatomical computer reconstruction allowed 3-dimensional analysis of the nerves in relation to the pelvic structures as an animated motion picture. RESULTS Two types of neuronal structures were identified. 1) A dense perivisceral foil of branching nerves closely surrounded the pelvic organs. The localization of most nerves was on the external faces of the viscera with a limited fraction in the rectovaginal and urethrovaginal septa. This innervation was from the anterior cephalad periurethral area to the posterior caudal perirectal area. 2) A significant amount of nerves surrounded the cephalad urethra on its anterior and posterior faces. CONCLUSIONS Based on these anatomical data during surgical repair of a urogenital sinus we would advocate minimal mobilization of the lateral faces of the vagina, avoiding dissection of the proximal urethra above the pubic bone and electing a vaginal flap in severe cases.

Medical Malpractice in American Urology: 22-Year National Review of the Impact of Caps and Implications for Contemporary Practice

PURPOSE Of the economic pressures on physicians practicing in the United States medical malpractice and associated costs are a major component. State tort reform in the form of caps on noneconomic awards has been pursued to control insurance premiums and improve patient access to care. We comprehensively examined jury verdicts involving urologists and determined the nature of these cases and their relationship to changes in tort reform. MATERIALS AND METHODS We searched the LexisNexis database for all malpractice cases involving urologists using the search terms urologist and malpractice. The query included all cases between 1984 and 2005, which were categorized by state, year, amount and the nature of the injury. RESULTS We identified 322 jury verdict cases, of which 175 (54%) were in favor of the defendant. In states with caps the median verdict settlement within or outside the periods of caps was

Treatment of pediatric vesicoureteral reflux using endoscopic injection of hyaluronic acid/dextranomer gel: intermediate-term experience by a single surgeon.

350,000 and

Increasing incidence of neuroblastoma and potentially higher associated mortality of children from nonmetropolitan areas: analysis of the surveillance, epidemiology, and end results database.

150,000, respectively. States without caps had a median verdict or settlement of

Bladder injuries during laparoscopic orchiopexy: incidence and lessons learned.

491,500. However, the number of suits and the size of the verdict/settlement in states with and without caps during this period did not appear to be related to tort reform. Common clinical situations, such as prostate cancer and transurethral prostate resection, accounted for most suits. CONCLUSIONS Although the concept and goals of malpractice caps seem desirable, there is little evidence that decreased physician premiums and improved access to care have been achieved via tort reform. Thus, while state and national legislative efforts to limit the economic burden on urologists continue, the specialty of urology must look to other approaches to improve the situation.

Obesity Does Not Decrease the Accuracy of Testicular Examination in Anesthetized Boys With Cryptorchidism

OBJECTIVES Endoscopic injection of non-animal-stabilized hyaluronic acid/dextranomer gel is an increasingly recognized treatment option for vesicoureteral reflux. The procedure is minor compared with open surgery and, when successful, avoids the need for long-term antibiotic prophylaxis. We present data from 3 years of using non-animal-stabilized hyaluronic acid/dextranomer gel to treat children with vesicoureteral reflux. METHODS Pediatric patients aged 16 years with uncomplicated primary vesicoureteral reflux were recruited for endoscopic treatment with non-animal-stabilized hyaluronic acid/dextranomer gel. A follow-up voiding cystourethrogram was scheduled at 2 weeks after treatment, and vesicoureteral reflux resolution was defined as grade 0. Repeat non-animal-stabilized hyaluronic acid/dextranomer gel treatment was offered to patients with persistent vesicoureteral reflux. RESULTS Of 178 patients treated, 12 were lost to follow-up or yet to undergo post-treatment voiding cystourethrogram. The 166 remaining patients (efficacy population) had a mean age of 4.21 years (range: 0-16), and the median reflux grade was 3 (range: 1-5). Vesicoureteral reflux was resolved in 81.9% of patients and 86.4% of ureters after initial endoscopic treatment with non-animal-stabilized hyaluronic acid/dextranomer gel. The overall reflux resolution rate for patients increased to 89.6% after a second treatment in 19 patients, and 90.2% after a third treatment in 1 patient. No adverse events were reported. Five patients underwent open ureteral reimplantation after failed endoscopic injections. CONCLUSIONS Endoscopic treatment with non-animal-stabilized hyaluronic acid/dextranomer gel is effective in a high proportion of children with vesicoureteral reflux and, in our opinion, should be considered as a first-line treatment option.

Urologic Diagnoses Among Infants Hospitalized for Urinary Tract Infection

Geographic variations in cancer incidence and mortality can yield clues regarding etiology and healthcare access. We examined pediatric neuroblastoma incidence and mortality in metropolitan counties (containing a core urban area of 50,000 or more people) versus nonmetropolitan counties. We identified cases through the Surveillance, Epidemiology, and End Results database. We analyzed age, race, sex, year of diagnosis, mortality, and county type (metropolitan or nonmetropolitan). In total, 1777 neuroblastoma cases were identified. From 1973 to 2003, the incidence of pediatric neuroblastoma in nonmetropolitan counties has risen from 0.8 to 1.2 cases per 100,000 person-years (annual percent change, 2.09%, P<0.05), whereas the incidence in metropolitan counties remained stable at 1.1 cases per 100,000 person-years over the same interval. The numbers of White children, an at-risk group for neuroblastoma, have increased in nonmetropolitan counties more than in metropolitan counties. Mortality rates were higher in nonmetropolitan versus metropolitan counties [hazard ratio 1.28 (95% confidence interval: 1.02-1.62), log-rank test P=0.0357]. The incidence of pediatric neuroblastoma in nonmetropolitan counties seems to be increasing, possibly due to demographic or environmental factors. Mortality seems to be higher in children from nonmetropolitan versus metropolitan counties. However, this study is limited by sample size. These concerning trends warrant further study through means other than Surveillance, Epidemiology, and End Results.

The Genetic and Phenotypic Basis of Infertility in Men With Pediatric Urologic Disorders

PURPOSE Laparoscopic orchiopexy is a safe operation. However, the bladder can be injured during creation of the transperitoneal tunnel for the cryptorchid testis. We reviewed our experience with this complication. MATERIALS AND METHODS We searched the operative notes of patients who had undergone laparoscopic orchiopexy between August 15, 2002 and October 1, 2008, and identified bladder injuries and their treatment. RESULTS A total of 93 patients underwent laparoscopic orchiopexies for 101 undescended testes during the study interval, with 3 procedures resulting in bladder injuries. The 3 operations varied with regard to whether the injury was recognized intraoperatively or postoperatively, and repaired in an open or laparoscopic fashion. CONCLUSIONS Bladder injury during laparoscopic orchiopexy is a rare but serious complication that can be managed by an open or laparoscopic approach. We recommend placement of a urethral catheter and syringe assisted drainage of all urine from the bladder at the beginning of the operation, careful perivesical dissection particularly in children with prior inguinal surgery, filling and emptying of the bladder during the procedure, and maintaining a high index of suspicion especially when hematuria is observed.

46,XX SRY-negative true hermaphrodite siblings.

PURPOSE Given that the prevalence of childhood obesity is increasing in the United States, we tested the timely hypothesis that obesity hinders physical examination based localization of the cryptorchid testis. MATERIALS AND METHODS Body mass index and percentiles of weight for height and body mass index for age were calculated for boys undergoing surgery for cryptorchidism at the University of California San Francisco Childrens Hospital and Childrens Hospital of Oakland. Two definitions of obesity were examined, ie greater than 85% or greater than 95% for either percentile. Patients were examined in the office and under general anesthesia before the skin incision. Intraoperative testicular location was recorded for each patient. The numbers of correct and incorrect preoperative determinations of testicular location were stratified by weight classification. Results were analyzed using contingency tables and Fishers exact test. RESULTS A total of 161 boys were recruited, accounting for 171 testes. The predictive value of palpating a suspected testis preoperatively with patients under anesthesia was greater than 95% for all weight classifications (p <0.0001). The predictive value of not palpating a testis preoperatively under anesthesia was greater than 56% for obese boys and greater than 42% for nonobese boys (p <0.0001). The concordance rates between examinations in the office and those performed under anesthesia were 90.9% and 82.7% for obese and nonobese boys, respectively (p = 0.51). The predictive value of not palpating a suspected cryptorchid testis in the office was higher in nonobese boys than in obese boys (81% vs 22%, p <0.0001). CONCLUSIONS In our series childhood obesity did not make preoperative testicular examinations under anesthesia less accurate. However, office examinations may be more accurate in nonobese boys.

Outcomes and Cost Analysis of Pyeloplasty for Antenatally Diagnosed Ureteropelvic Junction Obstruction Using Markov Models

OBJECTIVES To determine the prevalence of urologic disease among infants hospitalized for urinary tract infections (UTIs) at our institution. The prevalence of urologic anomalies among infants (<400 days old) hospitalized for UTIs has not been previously reported. METHODS We retrospectively examined the records of all infants hospitalized for UTI at our institution, a free-standing childrens hospital in the United States, for a 10-year period. Race, sex, and subsequent urologic diagnosis (using codes from the 9(th) edition of the International Classification of Diseases [ICD-9] were tabulated. Individual charts were reviewed to confirm documentation and workup of UTI. RESULTS We identified 914 infants hospitalized at our institution from January 1996 to December 2007, with an ICD-9-coded diagnosis of UTI. Of these 914 infants, 258 were subsequently given a urologic diagnosis. However, only 130 of these patients had well-documented UTI (14.2% of 914 children). Of this cohort, 55.4% were boys. The most common diagnoses were hydronephrosis (37.7%), vesicoureteral reflux (69.2%), and obstructive uropathy (23.1%). CONCLUSIONS Our data have indicated that > or =14% of all infants hospitalized for UTI have urologic anomalies. Vesicoureteral reflux, obstructive uropathy, and hydronephrosis are common diagnoses. We therefore conclude that infants admitted with a diagnosis of UTI should undergo screening for anatomic abnormalities.