Romano T. DeMarco

Continent Catheterizable Channels and the Timing of Their Complications

PURPOSE We reviewed our experience with continent catheterizable channels with interest in the timing of conduit related complications. MATERIALS AND METHODS A retrospective review was performed of the outcome of continent catheterizable channels in all patients between 1998 and 2003 who had undergone construction of an antegrade continence enema and/or a Mitrofanoff procedure using appendix, small bowel or continent cutaneous vesicostomy. We performed a total of 117 such stomas in 37 male and 41 female patients 2.5 to 20 years old (mean age 8.9). For the antegrade continence enema we used appendix in 92% of cases, an ileal Yang-Monti tube in 6% and a cecal tube in 2%. For the continent catheterizable channel we used appendix in 43% of cases, a Yang-Monti tube in 38% and continent cutaneous vesicostomy in 19%. RESULTS Continence was achieved in 98% of patients. Followup was 6 to 71 months (mean 28.4). There were 27 channel related complications (23%). Stomal stenosis occurred in 7 antegrade continence enema procedures (14%) within 1 to 10 months (mean 6.2) and in 9 continent bladder channels (13%), including 5 continent cutaneous vesicostomies, within 1 to 24 months (mean 9.4) after surgery. False passages occurred in 5 antegrade continence enema procedures (10%) within 1 to 13 months (mean 3.6) and in 4 continent catheterizable channels (6%) within 1 to 13 months (mean 6.5) after surgery. Of patients with stomal stenosis 50% were treated with surgical revision, while the remainder was successfully treated with dilation. Most false passages were managed by catheter drainage alone. Reasons for revision were contained perforation, colovesical fistula and inability to catheterize. Patient noncompliance appeared to have a role in stomal stenosis. CONCLUSIONS Continent catheterizable stomas help patients achieve bowel and bladder continence. Stomal incontinence after reconstruction is rare. In our experience most stoma related complications occurred in the first year after reconstruction. Experience with more patients and longer followup will help determine whether such problems continue to accumulate with time or whether continent stomas function well with time, particularly after the initial period of healing.

Hydrocele formation following laparoscopic varicocelectomy

PURPOSE Hydrocele is a known complication of varicocelectomy. We evaluated the incidence of hydrocele following laparoscopic varicocelectomy at our institution. MATERIALS AND METHODS A total of 89 boys were treated with laparoscopic ligation of the spermatic vessels for clinically palpable varicoceles between January 2000 and December 2003. Charts were retrospectively reviewed. A total of 10 patients were excluded because they were lost to followup or presented with recurrent varicocele. Followup consisted of office visits with physical examinations at 1 and 12 months postoperatively. Patient charts were reviewed for perioperative variables, operative technique and complications. RESULTS Only 1 of 79 patients (1.3%) had persistent varicocele with a mean of 20.7 months of followup. A total of 18 patients (22.8%) had development of hydrocele postoperatively, of whom 9 required hydrocelectomy. In addition, 2 of these 9 patients needed repeat hydrocelectomy. Of the 57 patients with greater than 6 months of followup 29.8% had development of hydrocele. A higher rate of hydrocele formation (31.1%) was also noted in patients who underwent ligation and division of the spermatic vessels rather than ligation alone (11.8%, p = 0.04). CONCLUSIONS Our series demonstrates a high rate of hydrocele formation following laparoscopic varicocelectomy, particularly in patients with longer followup. The incidence of hydrocele after laparoscopic varicocelectomy may be underreported. However, there appears to be a statistically significant decrease in hydroceles when the internal spermatic vessels are simply ligated rather than ligated and divided. Despite its ease and low failure rate, the standard technique of laparoscopic varicocelectomy requires reexamination, potentially allowing modifications that may decrease hydrocele formation, such as salvaging lymphatics and avoiding division of the vessels.

Prospective, longitudinal evaluation of health related quality of life in the pediatric spina bifida population undergoing reconstructive urological surgery.

PURPOSE Spina bifida, the most frequent permanently debilitating birth defect, results in major urological problems of voluntary bladder control and bowel function, which may impair quality of life. We prospectively assessed quality of life in patients with spina bifida using child and parent reports simultaneously. This study had 3 goals, that is to 1) document baseline health related quality of life in patients with spina bifida preoperatively, 2) study health related quality of life, reporting differences between parents and children, and 3) study changes in health related quality of life prospectively at preoperative and postoperative intervals. MATERIALS AND METHODS Patients with spina bifida who were 2 to 18 years old and required reconstructive urological surgery in 2004 were included in the study. Demographic survey and the validated PedsQL 4.0 health related quality of life questionnaire were used preoperatively and postoperatively. A clinical outcomes data set was completed after the clinician saw the patient. PedsQL 4.0 subscales were scored using the algorithms provided. RESULTS The response rate was 100%. Mean participant age was 10.3 years. Preoperatively child physical and psychosocial health and school functioning were significantly higher than parent reports (p <0.001). Overall health related quality of life in patients with spina bifida was lower than in healthy children (62.4 vs 85, p <0.001). Six weeks postoperatively significant differences in health related quality of life reporting between parents and children had lowered. Six months postoperatively child emotional and social functioning scores were higher than parent scores (p <0.001). No correlation was found between health related quality of life, and clinical and demographic factors due to insufficient sample size. CONCLUSIONS Children with spina bifida recorded higher health related quality of life scores than parents/guardians. This health related quality of life study addresses concerns that impact daily quality of life in patients with spina bifida. Future health related quality of life studies in patients with spina bifida should use child self-reports.

Endodermal Origin of Bladder Trigone Inferred From Mesenchymal-Epithelial Interaction

PURPOSE In the classic view of bladder development the trigone originates from the mesoderm derived wolffian ducts while the remainder of the bladder originates from the endoderm derived urogenital sinus. Recent molecular developmental studies have questioned the veracity of this received wisdom, suggesting an endodermal origin for the trigone. To shed further light on this issue we observed mesenchymal-epithelial interactions between trigone epithelium and fetal urogenital sinus mesenchyma to infer the trigonal germ layer of origin. MATERIALS AND METHODS Mouse trigone epithelium was recombined with fetal rat urogenital sinus mesenchyma in tissue recombinant grafts that were placed beneath the renal capsule of athymic mouse hosts. Grafts were harvested at 4 weeks. Control grafts with bladder dome and ureteral epithelium were also examined. Tissues were evaluated with hematoxylin and eosin, and Hoechst dye 33258 to confirm cell species origin. Immunohistochemistry was done with androgen receptor, broad spectrum uroplakin, dorsolateral prostate secretions and seminal vesicle secretions to differentiate prostatic and seminal vesicle differentiation. RESULTS Grafts of mouse trigone epithelium with fetal rat urogenital sinus mesenchyma yielded epithelial tissue that stained for dorsolateral prostate secretions but not for seminal vesicle secretions. Control grafts of bladder dome epithelium yielded the expected endodermal prostate differentiation. Control grafts of ureteral epithelium yielded the expected mesodermal seminal vesicle differentiation. CONCLUSIONS The consistent finding of prostatic epithelium in tissue recombinants of trigone epithelium and fetal urogenital sinus mesenchyma reinforces the hypothesis that the trigone is derived from the endoderm and not from the mesoderm, as commonly accepted.

Testicular tumours in children: a single-institutional experience

Authors from the USA present a retrospective review of children in their institution who were treated for testicular cancer. They found that most of the lesions were benign, the commonest being testicular. They also found several malignant and paratesticular lesions, and make recommendations as to the surgical approach.

Bladder tissue formation from cultured bladder urothelium

Tissue recombination is a powerful method to evaluate the paracrine‐signaling events that orchestrate the development of organs using the in vivo environment of a host rodent. Studies have reported the successful generation of primary cultures of rodent bladder urothelium, but none have reported their use to recapitulate bladder tissue with tissue recombination. We propose that primary cultured bladder urothelium, when recombined with inductive embryonic bladder mesenchyme, will form bladder tissue in a recombination model. Adult rat bladders were isolated and urothelium obtained. Sheets of bladder urothelium were re‐suspended in collagen and maintained in tissue culture. After expansion (>20 passages), the urothelium was recombined with embryonic day‐14 mouse bladder mesenchyme, then grafted beneath the renal capsule of immunocompromised mouse hosts. Grafts were harvested after 28 days. Control grafts were performed with bladder mesenchyme alone, cultured bladder urothelium alone, and collagen matrix alone. Final tissues were evaluated with staining and immunohistochemistry (H&E, Gomoris trichrome, broad‐spectrum uroplakin, and smooth muscle actin α and γ). Immunocytochemistry on cultured urothelium for broad‐spectrum keratin, vimentin, and broad‐spectrum uroplakin confirmed pure populations, void of mesenchymal contaminants. Staining of recombinant grafts demonstrated bladder tissue with mature urothelium and stromal differentiation. Control tissues were void of bladder tissue formation. We have successfully demonstrated that a chimeric bladder is formed from primary cultured bladder urothelium recombined with embryonic bladder mesenchyme. This is a powerful new tool for investigating the molecular mechanisms of bladder development and disease. Future applications may include the in vitro genetic manipulation of urothelium and examining those effects on growth and development in an in vivo environment. Developmental Dynamics 235:2795–2801, 2006.

Community Associated Methicillin Resistant Staphylococcal Infections in a Pediatric Urology Practice

PURPOSE Methicillin resistant Staphylococcus aureus is a virulent organism that has seen a rapid increase in prevalence. Community associated methicillin resistant S. aureus is discussed frequently in the infectious disease community. However, there has been little mention of this entity in the urological literature. MATERIALS AND METHODS We reviewed the records of patients presenting with skin/soft tissue infections or documented methicillin resistant S. aureus infection treated at an academic pediatric urology practice between October 2004 and August 2006. RESULTS A total of 12 patients were included (33% female, 67% male). Mean patient age was 49 months (range 8 to 202). Of the patients 11 (92%) presented with spontaneous infection and 1 (8%) presented with a wound infection. Abscess location was inguinal in 4 patients (33%), scrotal in 3 (25%), perineal in 2 (17%), perinephric in 2 (17%) and labial in 1 (8%). The most common presenting sign at referral was fluctuance (30%). While all patients eventually required surgical drainage, initial treatment by the primary care physician consisted of observation on oral antibiotics in 7 patients (58%). A total of 10 cultures (83%) revealed methicillin resistant S. aureus and 2 cultures (17%) were negative. Mean hospital stay was 5 days (range 0 to 16). Postoperatively, most patients (58%) were discharged home on oral trimethoprim-sulfamethoxazole. Mean followup was 4 months (range 0 to 15). Recurrence was seen in 3 patients at 1 to 15 months postoperatively (mean 6.3). CONCLUSIONS Methicillin resistant S. aureus is increasing in the community and will likely be seen more often in pediatric and adult urological practices. The regional differences among bacterial strains make a standardized approach to these cases difficult. However, increased awareness of this virulent organism is necessary to deliver prompt and successful treatment.

The role of postoperative testosterone in repair of iatrogenic hypospadias in rabbits.

INTRODUCTION Testosterone administered preoperatively in hypospadiac children increases phallic size and improves skin vascularity. We histologically evaluated the role of postoperative testosterone in tissue remodeling in an animal model. MATERIALS AND METHODS Hypospadias was created in 18 rabbits and repaired with a preputial onlay graft. Animals were randomized to receive either one intramuscular (i.m.) dose of testosterone postoperatively (n=6), or 2 weeks of daily 1% topical testosterone (n=6). Control animals underwent the urethral operation, but received no testosterone (n=6). Penises were harvested at 2 and 5 weeks, and blindly assessed for collagen formation, re-epithelialization and fibrosis, and complications. RESULTS Of the animals sacrificed at 2 weeks, those that received testosterone had a greater incidence of cuboidal epithelium (83%) versus controls (33%). In the 2-week group, animals receiving testosterone had increased fibrosis, periurethral and soft-tissue inflammation compared to controls. By 5 weeks, all differences in fibrosis and inflammation had resolved. No animal developed fistula or diverticulum. Of animals sacrificed at 2 weeks, 67% stained for BrdU, a DNA proliferative marker. At 5 weeks, no non-testosterone rabbit demonstrated positive staining, while 83% of those receiving testosterone were positive. There were no differences between animals that received topical and i.m. testosterone. CONCLUSION Administration of testosterone following hypospadias repair in rabbits changes the histologic composition of the urothelium and leads to an exaggerated inflammatory response in the supportive stroma. Such treatment may prove a useful adjunct in patients undergoing complex genital reconstruction.

Commentary to ‘Persistent renin-angiotensin system activation after anti-reflux surgery and its management’

The authors present compelling work on a controversial topic: the pathogenesis of renal damage in patients with VUR. The authors propose that renal scarring in patients with VUR is mediated through RAS activation. They report a temporary decline in plasma renin activity following reflux surgery with further improvement in renal function which was maintained with the addition of an ACE-I. The authors recommend ACE-I ‘soon’ after surgery to prevent further renal injury but only have data for patients on medical therapy in the late postoperative period. Should one be surprised that following ACE-I administration an improvement in several renal parameters was seen knowing the renal protective effects of ACE-I in patients with renal dysfunction? Given the high preponderance of boys in the study group and the degree of renal dysfunction found during