Yegappan Lakshmanan

Techniques in Endourology—Laparoscopic Extravesicular Ureteral Reimplantation for Vesicoureteral Reflux: Recent Technical Advances

Ureteral reimplantation is an effective treatment for primary vesicoureteral reflux. Recent efforts have been directed toward reducing the perioperative morbidity of open reimplantation. We have refined the technique of laparoscopic extravesical ureteral reimplantation with emphasis on minimal tissue dissection, achieving reliable detrusor closure, and downsizing ports and instruments. With our current technique, excellent results comparable to those of established open procedures are achieved, while postoperative discomfort and the recovery period are significantly reduced. The laparoscopic technique of ureteral reimplantation is described, with emphasis on key technical modifications crucial to the ease of performance and a successful outcome.

Sex prevalence of pediatric kidney stone disease in the United States: an epidemiologic investigation.

OBJECTIVESnTo define the sex prevalence of inpatient hospital discharges for pediatric patients diagnosed with upper urinary tract stone disease.nnnMETHODSnThe study examined inpatient admissions for pediatric urolithiasis in 2003, using the Healthcare Cost and Utilization Project Kids Inpatient Database. We used the International Classification of Disease, 9th edition, Clinical Modification codes, to identify patients with a principal diagnosis of renal (592.0) or ureteral (592.1) calculi. Sex prevalence was assessed, and the results were stratified by age group.nnnRESULTSnIn the 2003 Kids Inpatient Database, the sex distribution among pediatric patients with stone formation varied significantly by age. In the first decade of age, a male predominance was found that had shifted to a female predominance in the second decade. Overall, however, girls in the pediatric population were more commonly affected by stones than were boys.nnnCONCLUSIONSnIn this nationally representative sample, the sex distribution of pediatric urolithiasis varied with age, with boys more commonly affected in the first decade of age and girls in the second decade. Although the reason for this unique epidemiologic finding is not readily apparent, additional studies can build on this hypothesis-generating work.

Valproic acid inhibits invasiveness in bladder cancer but not in prostate cancer cells.

Histone deacetylase inhibitors (HDACIs) represent a promising new class of antineoplastic agents that affect proliferation, differentiation, and apoptosis in both solid and hematologic malignancies. In addition, HDACIs can alter the expression of at least one cellular adhesion molecule, the coxsackie and adenovirus receptor, in bladder cancer. Because HDACIs can increase expression of a known cellular adhesion molecule, we hypothesized that migration and/or invasion may also be affected. We evaluated this hypothesis using valproic acid (VPA), a commonly prescribed anticonvulsant recently shown to have potent HDACI activity, in the bladder cancer cell lines T24 TCC-SUP, HT1376, and RT4. Analyses of cell migration and invasion were both qualitative (fluorescent microscopy) and quantitative (static and dynamic migration/invasion assays). Our results show that acute VPA treatment (72 h) causes a dose-dependent decrease in invasion for all bladder cancer cell lines, except RT4, a noninvasive papilloma. Migration, in contrast, was not affected by VPA treatment. The inhibitory effect of VPA may be cancer type-specific, because there was no difference in invasion between treated and untreated prostate cancer cell lines LNCaP, PC3, and DU145. Furthermore, when administered chronically (34 days), VPA significantly inhibits growth of T24t tumor xenografts. Our data suggest that VPA exerts some of its antineoplastic effects by inhibiting invasion as well as tumor growth, and thus it may represent a novel adjuvant strategy for patients at high risk of recurrence and/or progression of muscle invasive bladder cancer.

DIFFERENTIAL NUCLEAR MATRIX PROTEIN EXPRESSION IN PROSTATE CANCERS: CORRELATION WITH PATHOLOGIC STAGE

PURPOSEnNuclear Matrix Proteins (NMP) have been shown to be tissue and cell-type specific. Several unique NMPs have been investigated in various cancerous tissues, including prostate, bladder and kidney, and some are presently utilized as tumor markers. This study was aimed at characterizing the differential NMP expression in the pathologically more aggressive prostate cancers.nnnMETHODSnHigh resolution two-dimensional gel electrophoresis and silver staining was used to elucidate the NMP distribution of fresh prostate cancer nuclei, obtained from 39 radical prostatectomy specimens, surgically removed from men with clinically localized prostate cancer. Based on the final pathological grading, specimens were grouped according to predicted prognosis: poor--with seminal vesicle (SV) or lymph node (LN) involvement or established capsular penetration (ECP) with gleason score >7; intermediate--organ confined (OC) or focal capsular penetration (FCP) with gleason score 7 or ECP with gleason score 6; and good--with OC or FCP and gleason score <7.nnnRESULTSnA specific charged protein (YL-1) of molecular weight 76 kD and isoelectric range 6.0-6.6 was found to be consistently present in 19 of 19 aggressive cancers. It was present only in 1 of 10 in the group with good prognosis and weakly positive in 9 of 10 in the intermediate group.nnnCONCLUSIONSnWithin this preliminary study, the expression of YL-1 appears to be related to aggressive prostate cancer, suggesting a potential marker of poor prognosis for clinically localized prostate cancer. Further characterization of the identity and function of this NMP is needed to fully ascertain its clinical potential.

Psychosocial Difficulties in Children Referred to Pediatric Urology: A Closer Look

OBJECTIVEnTo assess rates of psychosocial difficulties in children seen in a pediatric urology clinic to determine whether all patients should be screened for psychosocial problems, and to use standardized measures to determine whether the severity of voiding dysfunction and/or enuresis in children is related to their degree of psychosocial difficulties.nnnMETHODSnA retrospective chart review was conducted to collect the Pediatric Symptom Checklist from all children referred to an outpatient urology clinic over a 6-month period. In addition, scores from the childs Dysfunctional Voiding Scoring System were collected for patients referred for voiding dysfunction and/or enuresis.nnnRESULTSnCaregivers of 600 children completed the Pediatric Symptom Checklist as part of their childs outpatient clinic paperwork. Overall, 15.2% of the patients met the clinical cut-off for significant psychosocial difficulties. However, children with voiding dysfunction and/or enuresis were at increased risk for these problems, with the severity of their psychosocial difficulties being related to the severity of their urologic condition.nnnCONCLUSIONnIt is unnecessary to screen all pediatric urology patients, although those referred for voiding dysfunction and/or enuresis should be screened for psychosocial difficulties. Children at greatest risk for psychosocial problems were those who were male, had a high body mass index, had nocturnal enuresis, had an elevated Dysfunctional Voiding Scoring System score, and/or reported frequent episodes of wetting or soaking their underwear when they wet. Importantly, children appear to be most concerned with wetness.

Enuretic children with obstructive sleep apnea syndrome: Should they see otolaryngology first?

OBJECTIVESnTo study: (1) the prevalence of diurnal urinary incontinence (DI) and nocturnal enuresis (NE) in children with obstructive sleep apnea syndrome (OSAS) who underwent surgery for their upper airway symptoms, (2) the postoperative rate of enuresis resolution, and (3) factors that may predict lack of improvement post surgery.nnnPATIENTS AND METHODSnAn observational, pilot study of children 5-18 years of age with OSAS and NE who underwent tonsillectomy and/or adenoidectomy (T&A) between 2008 and 2010 was performed. Study consisted of a phone interview and chart review. Severity of NE and DI, frequency, arousal and sleeping disturbances were assessed pre and post T&A. Factors associated with failure to respond were analyzed using a logistic regression model.nnnRESULTSnAmong the 417 children who underwent T&A, 101 (24%) had NE (61 males, mean age 7.8 ± 2.5 years), and of these 24 had associated DI (6%). Mean postoperative follow-up was 11.7 months. Of the 49 whose NE responded to T&A (49%), 30 resolved within 1 month postoperatively. DI resolved in 4 children (17%). There was a statistically significant difference between responders and non-responders regarding the presence of prematurity, obesity, family history of NE, type of enuresis, enuresis severity, and ability to be easily aroused.nnnCONCLUSIONnNE was present in about one fourth of children with OSAS undergoing surgery, and resolved in about half. Lower response rate was associated with prematurity, obesity, family history of NE, presence of non-monosymptomatic NE, severe NE preoperatively, and arousal difficulties.

From Hypercalciuria to Hypocitraturia—A Shifting Trend in Pediatric Urolithiasis?

PURPOSEnWe analyzed the metabolic abnormalities in children with urolithiasis, and the relationship between diet and hypocitraturia.nnnMATERIALS AND METHODSnA single center, retrospective analysis was conducted in all children with renal and/or ureteral calculi seen at our Multidisciplinary Stone Clinic between January 2010 and July 2011. Data at presentation were extracted from the clinical database.nnnRESULTSnWe analyzed 63 children (37 girls) with urolithiasis with a mean age of 13.43 ± 4.61 years. Of the 45 patients with 24-hour urinalysis, a metabolic risk factor was present in 68.9%, with hypocitraturia (58.1%) and hypercalciuria (48.3%) being the most common. Children with isolated hypocitraturia had lower urinary magnesium and potassium levels (1.06 ± 0.62 mg/kg and 0.53 ± 0.24 mmol/kg per day) than those with no metabolic abnormalities (1.72 ± 0.61 mg/kg and 0.68 ± 0.20 mmol/kg per day) (p = 0.015 and p = 0.132, respectively). Urinary citrate was positively correlated with urinary potassium (r = 0.50, p = 0.002) and urinary magnesium (r = 0.49, p = 0.001). Dietary analysis revealed a lower intake of magnesium and potassium in children with hypocitraturia (28.97% ± 12.25% and 15.42% ± 7.25% recommended dietary index) than in normocitraturic cases (51.06% ± 17.51% and 45.23% ± 29.49% recommended dietary index) (p = 0.042 and p = 0.056, respectively).nnnCONCLUSIONSnThe majority of children had an identifiable metabolic risk factor for urolithiasis, with hypocitraturia being the most common. This shift in metabolic trend may be a significant contributor to the increasing incidence in pediatric urolithiasis. Hypocitraturia appears to be dietary in origin, correlated with a low consumption of potassium and magnesium.

Inflammatory (pseudosarcomatous) myofibroblastic tumor of the bladder

We present a case of inflammatory (pseudosarcomatous) myofibroblastic tumor of the bladder in a child, along with a review of the literature. The benign nature of this rare disorder needs to be recognized so that superfluous radical therapy can be avoided. The clinical features and microscopic, ultrastructural, and immunohistochemical characteristics that help to identify this entity are described. To date, 72 such cases involving the bladder have been reported in the literature including the present one.

Phenotype severity in the bladder exstrophy-epispadias complex: Analysis of genetic and nongenetic contributing factors in 441 families from North America and Europe

OBJECTIVEnTo identify genetic and nongenetic risk factors that contribute to the severity of the bladder exstrophy-epispadias complex (BEEC).nnnSTUDY DESIGNnPatients with BEEC from North America (n = 167) and Europe (n = 274) were included. The following data were collected: associated anomalies, parental age at conception, mode of conception, periconceptional folic acid supplementation, maternal risk factors during pregnancy, and environmental risk factors. The patients were divided into 3 subgroups according to phenotype severity: (i) mild, epispadias (n = 43); (ii) intermediate, classic bladder exstrophy (n = 366); and (iii) severe, cloacal exstrophy (n = 31). These subgroups then were compared with identify factors that contribute to phenotype severity.nnnRESULTSnMales were overrepresented in all subgroups. A relatively high prevalence of cleft lip, with or without cleft palate, was observed. Maternal smoking and medical radiation during the first trimester were associated with the severe cloacal exstrophy phenotype. Compliance with periconceptional folic acid supplementation was associated with the mildest phenotype (epispadias).nnnCONCLUSIONSnPericonceptional folic acid supplementation appears to prevent the development of the severe phenotype of BEEC.

Why does Adenotonsillectomy Not Correct Enuresis in All Children with Sleep Disordered Breathing

PURPOSEnWe analyzed the outcome of nocturnal enuresis after adenotonsillectomy in children with sleep disordered breathing. We also evaluated differences in demographic, clinical, laboratory and polysomnography parameters between responders and nonresponders after adenotonsillectomy.nnnMATERIALS AND METHODSnWe prospectively evaluated children 5 to 18 years old diagnosed with sleep disordered breathing (snoring or obstructive sleep apnea syndrome) on polysomnography and monosymptomatic primary nocturnal enuresis requiring adenotonsillectomy to release upper airway obstruction. Plasma antidiuretic hormone and brain natriuretic peptide were measured preoperatively and 1 month postoperatively.nnnRESULTSnSleep studies were done in 46 children and 32 also underwent blood testing preoperatively and postoperatively. Mean ± SD patient age was 8.79 ± 2.41 years and the mean number of wet nights weekly was 6.39 ± 1.26. Polysomnography revealed obstructive sleep apnea syndrome in 71.7% of patients and snoring in 28.3%. After adenotonsillectomy 43.5% of patients became dry. Preoperative polysomnography findings indicated that responders, who were dry, had significantly more arousals and obstructive apnea episodes but fewer awakenings than nonresponders, who were wet. Significant increases in plasma antidiuretic hormone and significant decreases in plasma brain natriuretic peptide were seen in all children with no difference between responders and nonresponders. No difference between the groups was noted in age, gender, race, body mass index, constipation, preoperative number of wet nights weekly or type of sleep disordered breathing.nnnCONCLUSIONSnNocturnal enuresis resolved after adenotonsillectomy in almost half of the children with sleep disordered breathing. Those who became dry had more frequent arousal episodes caused by apnea events than those who remained wet.