Peter Metcalfe

The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis

The evaluation and management of fetuses/children with antenatal hydronephrosis (ANH) poses a significant dilemma for the practitioner. Which patients require evaluation, intervention or observation? Though the literature is quite extensive, it is plagued with bias and conflicting data, creating much confusion as to the optimal care of patients with ANH. In this article, we summarized the literature and proposed recommendations for the evaluation and management of ANH.

Spontaneous bladder perforations: a report of 500 augmentations in children and analysis of risk.

PURPOSE The spontaneous perforation of an augmented bladder is an uncommon but serious complication. To our knowledge our institution has the largest reported series of bladder augmentations. We examined our data to determine the incidence of spontaneous bladder perforation and to delineate associated risk factors. MATERIALS AND METHODS We performed a retrospective chart review of 500 bladder augmentation procedures performed during the preceding 25 years with a minimum followup of 2 years. RESULTS Spontaneous perforations occurred in 43 patients (8.6%), for a total of 54 events. The calculated risk was 0.0066 perforations per augmentation-year at risk. Approximately a third of the cases had perforated within 2 years of surgery, a third between 2 and 6 years postoperatively, and a third at more than 6 years after augmentation. Patients who underwent augmentation between 1997 and 2003 had a higher rate of perforation within 2 years of surgery than those operated on between 1978 and 1987. Increased risk of perforation was observed with the use of sigmoid colon and bladder neck surgery. A decreased risk was associated with the presence of a continent catheterizable channel. CONCLUSIONS We believe that this large and comprehensive series gives valuable insight into this serious complication. The delineation of these potential risk factors serves as a guide for further discussion and investigation.

Partial urogenital mobilization: A limited proximal dissection

INTRODUCTION The treatment of urogenital sinus malformations is complex and controversial. Despite numerous and significant contemporary surgical advances, the dissection of the urogenital sinus remains technically challenging. METHODS Based on total urogenital mobilization, we describe a technique whereby this dissection is limited to the pubourethral ligament. Our short-term results with partial urogenital mobilization (PUM) performed on 15 patients are retrospectively reviewed. RESULTS There were no intraoperative complications and the short-term cosmetic results are excellent. No patients have developed voiding dysfunction or urinary tract complications. CONCLUSIONS While total urogenital mobilization is a very effective procedure, we believe that the PUM approach limits potential morbidity in the reconstruction of these complex problems.

Sex Differences and the Role of Sex Steroids in Renal Injury

PURPOSE There is growing evidence that significant sex differences exist in the response of the kidney to injury. In this review we explored the cumulative clinical knowledge and experimental evidence of this phenomenon. MATERIALS AND METHODS The current clinical evidence of increased male susceptibility to acute and chronic renal injury, and experimental data elucidating potential mechanisms of this phenomenon were reviewed. RESULTS Renal damage induced by nephron reduction, patient age and renal ischemia is tolerated differently by the sexes. Sex differences in disease susceptibility have historically been attributed to the protective effects of estrogen but recent evidence suggests that male hormones also have an important role in these differences. Vascular mediators, such as endothelin, nitric oxide and angiotensin II, appear to be influenced by sex and sex steroids. Additionally, inflammatory mediators, such as transforming growth factor-beta1, tumor necrosis factor-alpha and p38 mitogen activating protein kinase, similarly show differential expression and activity based on sex and the presence of sex steroids. These mediators have a significant impact on the kidney response to inflammation and injury. CONCLUSIONS Greater understanding of the specific role of sex steroids in renal injury may provide new therapeutic strategies to protect against inflammatory injury and renal damage in the future.

Urinary incontinence and quality of life in children

OBJECTIVE Urinary incontinence (UI) negatively affects childrens quality of life (QOL). It is not known if parents are reliable informants on impact and QOL nor if lower urinary tract symptoms (LUTS) are related to QOL. We wished to determine the association between LUTS measured by the Dysfunctional Voiding Symptom Score (DVSS) and QOL measured by the Pediatric Urinary Incontinence QOL tool (PIN-Q), and to test the relationship between parent and patients responses. SUBJECTS AND METHOD Forty children (10 males, 30 females), aged 5-11 years with non-neurogenic daytime wetting, and their parents completed DVSS and PIN-Q as well as responding to open-ended questions about the effect of incontinence. RESULTS Child DVSS: mean 12.6 (3 (very mild) to 21 (severe)); parent DVSS: mean 12.8 (3-20). Child PIN-Q: mean 37.6 (8 (no effect) to 70 (severe effect)); parent PIN-Q: mean 38.7 (15-61). Parents indicated a major effect of UI on family function and dynamics, as well as on the child. CONCLUSIONS UI has a major effect on the child and the family. The PIN-Q and DVSS are complementary and provide a clinically appropriate picture of LUTS and impact on QOL. Parents understood the effect of incontinence and could act as proxy for the child.

The concealed penis: management and outcomes.

Purpose of review Management of the concealed penis continues to evolve, with several manuscripts having been published over the last several years. Each describes a novel surgical approach, as well as outcome data. Recently a non-surgical, conservative, approach has also been published. Our goal with this review is to examine the most recent work, highlight the commonalities and differences in technique and compare their results. Recent findings The surgical techniques all adhere to several common principles, and all accompany excellent results. The different manuscripts highlight the importance of classification based upon the underlying cause, as this directs surgical technique. The recent report by Radhakrishnan et al. is the first to describe the successful use of conservative management in select cases, a very appealing approach. Summary Appropriate management requires a solid understanding of the variable causes of the concealed penis. This allows a more tailored surgical approach and improved outcomes. Accordingly, the management of concealed penis can include a successful non-surgical approach.

Stem Cell Therapy: Current Applications and Potential for Urology.

Stem cell therapy holds the potential to revolutionize the treatment of a number of chronic conditions. Stem cells ability to home in on injured sites of the body, stimulate angiogenesis, tissue regeneration, immunomodulation, anti-inflammatory, and anti-fibrotic factors have attracted their use in the treatment of many conditions. Urology has registered one of the highest experimental successes using stem cell therapy. However, the rate of clinical applications is comparatively lower. This review takes a look at our efforts so far and what needs to be done in order to maximize the clinical benefit we can derive from stem cells.