Murali K. Ankem

Utility of biofeedback for the daytime syndrome of urinary frequency and urgency of childhood

OBJECTIVES To evaluate in a preliminary study the utility of biofeedback for the treatment of the daytime syndrome of urinary frequency and urgency of childhood, a benign, self-limited condition with symptoms that can last for months or years. Observation is a commonly recommended approach to this syndrome because medications and other forms of therapy are often not effective. METHODS During a 2-year period, 89 children (34 boys and 55 girls) presented with this syndrome. Patient age ranged from 4 to 11 years, and duration of symptoms ranged from 1 to 38 months. All children were evaluated with a history, physical examination, urinalysis and culture, and renal and bladder ultrasound scanning. After the evaluation, the parents were offered either observation or surface patch electromyography biofeedback for the problem. RESULTS Overall, 84 parents (94.3%) selected biofeedback for their child. After 1 month of biofeedback, 34.5% of children were able to achieve a 2 to 4-hour voiding interval. After 2 to 4 months of biofeedback, another 51.2% of patients experienced the same improvement. Overall, 85.7% of children who underwent biofeedback had symptom improvement. In 14.3% of children, no symptom improvement was noted after 4 months of biofeedback and these children were considered nonresponders. CONCLUSIONS The results of this study suggest that biofeedback may be a treatment option for this disorder and warrants further investigation.

Ureteral Fibrin Sealant Injection of the Distal Ureter During Laparoscopic Nephroureterectomy—A Novel and Simple Modification of the Pluck Technique

OBJECTIVES To describe a novel technique to block the distal ureter, thus preventing spillage of tumor cell bearing urine during laparoscopic pluck nephroureterectomy. Currently, there is no consensus on the appropriate management of distal ureter during laparoscopic nephroureterectomy. METHODS A review was performed of patients who underwent modified laparoscopic pluck nephroureterectomy for upper tract transitional cell carcinoma from July 2007 to December 2008. After confirming an absence of bladder tumors, an 8F olive-tipped ureteral catheter was introduced into the ureteral orifice. Five milliliters of Tisseel was injected into the ureter. Five milliliters of indigo carmine was injected intravenously to confirm the presence of ureteral blockage. Using a Collins knife, the ureteral orifice was dissected until the extravesical fat was visualized. A Foley catheter was placed and a laparoscopic nephroureterectomy was then completed. The drain was removed on the 3rd postoperative day and Foley was removed on the 10th postoperative day after a normal cystogram. RESULTS We performed 8 procedures using the above-described technique. The median age was 62 years, all were males; 2 were operated on the right side and 6 on the left. The average operative time and estimated blood loss was 308 minutes and 150 mL, respectively. The average length of stay was 6 days. One major and 2 minor complications (ileus) were noted. Mean cancer follow-up is 11 months. All specimen margins free of tumor. No extravesical or intravesical recurrences were noted. CONCLUSIONS Ureteral fibrin sealant injection produces dependable ureteral obstruction during laparoscopic pluck nephroureterectomy and may prevent tumor spillage in the extravesical tissues.

Laparoendoscopic single site orchiopexy

We report a laparoendoscopic single site orchiopexy in a 2-year-old boy with a right nonpalpable testis. Diagnostic laparoscopy using a 5-mm port revealed a right intraabdominal testis. The 5-mm port site was extended to accommodate the smallest commercially available triport, and orchiopexy was performed. The operative time was 55 minutes, and the estimated blood loss was minimal. There were no complications, and surgical and cosmetic results were excellent. Laparoendoscopic single site surgery is a feasible technique for orchiopexy of the nonpalpable testis.

Abdominal wall urinoma : A complication of anterior urethral injury

Abdominal wall urinoma is a rare complication of anterior urethral injury because most patients present shortly after the traumatic event. 1 Therefore, to our knowledge this particular complication of anterior urethral injury has not been previously addressed in the literature. We discuss the management of a large abdominal wall urinoma after anterior urethral injury. CASE REPORT T. B., an 11-year-old boy, sustained a straddle injury on playground equipment and did not initially report the injury. However, the following day massive scrotal swelling was noticed and he presented to the emergency room with complaints of severe suprapubic pain and the inability to urinate. Abdominal cellulitis extended to the umbilicus. The genitalia, including the penis and scrotum, were massively edematous. The perineal area demonstrated classic butterfly hematoma, suggesting anterior urethral injury. Retrograde urethrography confirmed anterior urethral injury and no contrast material entered the bladder. Broad-spectrum intravenous antibiotics were started. The patient underwent open suprapubic cystotomy. A large urinoma was identified between Scarpa’s fascia and the external oblique fascial layers. Portions of this urinoma were not adequately drained by the cystotomy incision due to the extent of urinary extravasation. To drain the whole urine collection 2 additional incisions were made in the anterior abdominal wall through Scarpa’s fascia (see figure). Two small Penrose drains were placed to facilitate drainage postoperatively. Bilateral scrotal incisions were also made to drain a large scrotal urinoma but the perineal collection was not drained due to small size. Abdominal wall cellulitis resolved by postoperative day 2 and all drains were removed by postoperative day 3. The small perineal collection required operative drainage on postoperative day 12 due to abscess formation. The suprapubic tube remained in place for 8 weeks. Voiding cystourethrography before suprapubic tube removal revealed a normal urethra without stricture. At 6 months of followup the patient continues to void normally. DISCUSSION

Laparoendoscopic Single-Site Varicocele Repair in Adolescents—Initial Experience at a Single Institution

BACKGROUND AND PURPOSE Laparoendoscopic single-site (LESS) varicocele repair is a modification of standard laparoscopic varicocele repair that uses a single port. We describe our initial experience with LESS varicocele repair. PATIENTS AND METHODS During a 1-year period, all patients who presented for varicocele repair underwent LESS repair. We evaluated our initial experience by determining operative time, operative and postoperative complications, and overall cost of the procedure. RESULTS A total of 11 adolescents underwent LESS varicocele repair. There were no intraoperative complications, and there were no conversions to open surgery or traditional laparoscopy. Estimated blood loss was minimal, and mean operative time was 66.9 minutes (range 48-91 min). The varicocele was corrected in all cases. During the 4 to 14 month follow-up, there was no recurrence, testis atrophy, or hernia in any patient. One subclinical hydrocele developed postoperatively that has not been repaired. CONCLUSION Our experience with LESS varicocele repair in adolescents suggests it to be a safe and effective method for varicocele repair in adolescents.