The Journal of Urology - Articles in Press

Re: Mucoadhesive Film for Anchoring Assistive Surgical Instruments in Endoscopic Surgery: In Vivo Assessment of Deployment and Attachment - Corrected Proof

Jeffrey A. Cadeddu — 2012-05-16

V. Pensabene, P. Valdastri, S. Tognarelli, A. Menciassi, A. Arezzo and P. Dario Istituto Italiano di Tecnologie, Center for Micro-BioRobotics, Pontedera, Italy

Re: Influence of CIT-Induced DGF on Kidney Transplant Outcomes - Corrected Proof

David A. Goldfarb — 2012-05-16

L. K. Kayler, T. R. Srinivas and J. D. Schold Montefiore Medical Center, Bronx, New York

Re: Sperm DNA Damage and Seminal Oxidative Status After Shock-Wave Lithotripsy for Distal Ureteral Stones - Corrected Proof

Craig Niederberger — 2012-05-16

M. Gulum, E. Yeni, A. Kocyigit, A. Taskin, M. Savas, H. Ciftci and A. Altunkol Department of Urology, Harran University School of Medicine, Sanliurfa, Turkey

Revisions of Mid Urethral Slings Can Be Accomplished in the Office - Corrected Proof

Alyssa Greiman, Stephanie Kielb — 2012-05-16

Purpose: Mid urethral slings occasionally require revision for obstructive voiding symptoms or vaginal extrusion. Our approach has been to offer revision in office or resection done under local anesthesia when the patient is agreeable and deemed an appropriate candidate. The results and complications of these procedures are presented. Materials and Methods: We retrospectively reviewed the charts of patients from January 2003 to October 2010 to determine the subset with mid urethral sling insertion who subsequently underwent revision in the office or operating room, as identified through the Northwestern Medical Enterprise Data Warehouse. The CPT code for female sling insertion (57288) or revision/removal (57287) was used. Results: A total of 41 revisions were performed in 28 of the 118 patients (23.7%) who underwent synthetic sling insertion. Reasons for adjustment were an intravesical sling (1 operating room case), extruded vaginal mesh (7 operating room and 19 office) and obstructive voiding symptoms (7 operating room and 7 office). Obstructive voiding symptoms in 6 of 7 operating room and 6 of 7 office patients improved immediately after sling release. There were no complications in either group but 3 office patients required repeat revision in the operating room due to inability to tolerate the procedure in 2 and to nonrelief of symptoms in 1. A total of 13 operating room adjustments were made according to surgeon preference while 2 patients elected the operating room, although adjustment in office was offered. Conclusions: Sling adjustment due to vaginal mesh extrusion or obstructive voiding symptoms can be successfully performed in the office with good result. When greater adjustment is needed, the operating room may be preferable. Surgeons should make these decisions based on their comfort level and patient preference.

A Prospective Randomized Controlled Trial of the Transobturator Tape and Tissue Fixation Mini-Sling in Patients with Stress Urinary Incontinence: 5-Year Results - Corrected Proof

2012-05-16

Purpose: We present the 5-year results of a randomized controlled trial comparing the efficacy of a transobturator tape operation with an adjustable mini-sling (tissue fixation system) for the treatment of stress urinary incontinence. Materials and Methods: This prospective randomized controlled trial comprised 80 female patients with only urodynamically proven stress urinary incontinence. The participants were randomly allocated to the transobturator tape group or the tissue fixation system group according to a computer program at a maternity research hospital. The patients were reassessed 5 years after surgery. Primary outcome measures were objective and subjective cure rates as well as total failure rate. Results: Total followup was 64 months (range 58 to 70). The objective cure, subjective cure and failure rates in the tissue fixation system group were 83% (30 cases), 6% (2) and 11% (4), respectively. The objective cure, subjective cure and failure rates in the transobturator tape group were 75% (27 cases), 3% (1) and 22% (8), respectively. The difference in objective cure rates was statistically significant in favor of the tissue fixation system (p = 0.029). The difference in decreased cure rates between 5 and 3 years was 7% (90% to 83%) for the tissue fixation system vs 9% (84% to 75%) for the transobturator tape. The relative decrease in cure rates between the 2 groups was not statistically significant (p = 0.16). Conclusions: Contrary to reports in the literature of poor results with mini-slings, the tissue fixation system mini-sling demonstrated a higher cure rate and lower complication rate than the transobturator tape.

Obstetric Complications of Ureteroscopy During Pregnancy - Corrected Proof

2012-05-16

Purpose: During pregnancy a ureteral stone and its management may pose risks for the mother and fetus. Definitive ureteroscopic management of an obstructing stone during pregnancy has been increasingly used without a reported increased incidence of urological complications. However, the rate of obstetric complications of ureteroscopy during pregnancy remains undefined. Materials and Methods: Charts of pregnant women who had undergone ureteroscopy at 5 tertiary centers were reviewed. Patient and procedure characteristics were collected. Records were evaluated for the occurrence of obstetric complications in the postoperative period. Results: A total of 46 procedures were performed in 45 patients at 5 institutions. There were 2 obstetric complications (4.3%), including 1 preterm labor managed conservatively and 1 preterm labor resulting in preterm delivery. There was no fetal loss. No statistically significant characteristics were identified differentiating those patients having obstetric complications. Conclusions: Ureteroscopy performed during pregnancy has been previously reported to be urologically safe and effective for addressing ureteral stones. In our multi-institutional series a 4% rate of obstetric complications was observed. Based on this risk a multidisciplinary approach is prudent for the pregnant patient undergoing ureteroscopy.

Outcomes of Endoscopic Realignment of Pelvic Fracture Associated Urethral Injuries at a Level 1 Trauma Center - Corrected Proof

Laura S. Leddy, Alex J. Vanni, Hunter Wessells, Bryan B. Voelzke — 2012-05-16

Purpose: We examined the success of early endoscopic realignment of pelvic fracture associated urethral injury after blunt pelvic trauma. Materials and Methods: A retrospective review was performed of patients with pelvic fracture associated urethral injury who underwent early endoscopic realignment using a retrograde or retrograde/antegrade approach from 2004 to 2010 at a Level 1 trauma center. Followup consisted of uroflowmetry, post-void residual and cystoscopic evaluation. Failure of early endoscopic realignment was defined as patients requiring urethral dilation, direct vision internal urethrotomy, posterior urethroplasty or self-catheterization after initial urethral catheter removal. Results: A total of 19 consecutive patients (mean age 38 years) with blunt pelvic fracture associated urethral injury underwent early endoscopic realignment. Twelve cases of complete urethral disruption, 4 of incomplete disruption and 3 of indeterminate status were noted. Mean time to realignment was 2 days and mean duration of urethral catheterization after realignment was 53 days. One patient was lost to followup after early endoscopic realignment. Using an intent to treat analysis early endoscopic realignment failed in 15 of 19 patients (78.9%). Mean time to early endoscopic realignment failure after catheter removal was 79 days. The cases of early endoscopic realignment failure were managed with posterior urethroplasty (8), direct vision internal urethrotomy (3) and direct vision internal urethrotomy followed by posterior urethroplasty (3). Mean followup for the 4 patients considered to have undergone successful early endoscopic realignment was 2.1 years. Conclusions: Early endoscopic realignment after blunt pelvic fracture associated urethral injury results in high rates of symptomatic urethral stricture requiring further operative treatment. Close followup after initial catheter removal is warranted, as the mean time to failure after early endoscopic realignment was 79 days in our cohort.

Treatment of Ureteral and Renal Stones: A Systematic Review and Meta-Analysis of Randomized, Controlled Trials - Corrected Proof

2012-05-16

Purpose: We compared the clinical outcomes of patients with ureteral or renal stones treated with ureteroscopy, shock wave lithotripsy using HM3 (Dornier®) and nonHM3 lithotripters, and percutaneous nephrolithotomy. Materials and Methods: A systematic literature search identified 6, 4 and 3 randomized, controlled trials of treatment of distal and proximal ureteral stones, and renal stones, respectively, published between 1995 and 2010. Overall stone-free, re-treatment and complication rates were calculated by meta-analytical techniques. Results: Based on the randomized, controlled trials evaluated the treatment of distal ureteral stones with semirigid ureteroscopy showed a 55% greater probability (pooled RR 1.55, 95% CI 1.13–2.56) of stone-free status at the initial assessment than treatment with shock wave lithotripsy. Patients treated with semirigid ureteroscopy were also less likely to require re-treatment than those treated with shock wave lithotripsy (nonHM3) (RR 0.14, 95% CI 0.08–0.23). The risk of complications was no different between the 2 modalities. Only 2 of the 4 randomized, controlled trials identified for proximal ureteral stones evaluated flexible ureteroscopy and each focused specifically on the treatment of stones 1.5 cm or greater, limiting their clinical relevance. The degree of heterogeneity among the studies evaluating renal stones was so great that it precluded any meaningful comparison. Conclusions: Semirigid ureteroscopy is more efficacious than shock wave lithotripsy for distal ureteral stones. To our knowledge there are no relevant randomized, controlled trials of flexible ureteroscopy treatment of proximal ureteral calculi of a size commonly noted in the clinical setting. Collectively the comparative effectiveness of ureteroscopy and shock wave lithotripsy for proximal ureteral and renal calculi is poorly characterized with no meaningful published studies.

Associations of Commonly Used Medications with Urinary Incontinence in a Community Based Sample - Corrected Proof

2012-05-16

Purpose: We examined the association between the use of medications and the prevalence of urinary incontinence in gender specific analyses of a community based, representative sample. Materials and Methods: A population based epidemiological study was conducted of 5,503 men and women 30 to 79 years old residing in Boston, Massachusetts (baseline data collected from 2002 to 2005). Urological symptoms were ascertained in a 2-hour, in person interview. Urinary incontinence was defined as urine leakage occurring weekly or more often during the last year. Medications used in the last month were considered current use. Associations of 20+ medications and prevalent urinary incontinence were examined using multivariate logistic regression (ORs and 95% CIs) with adjustments for known urinary incontinence risk factors. Results: The prevalence of urinary incontinence in the analysis sample was 9.0% in women and 4.6% in men. For women the prevalence was highest among users of certain antihistamines (28.4%) and angiotensin II receptor blockers (22.9%). For men the prevalence was highest among angiotensin II receptor blocker (22.2%) and loop diuretic (19.1%) users. After final multivariate adjustment there were significant positive associations for certain antihistamines, beta receptor agonists, angiotensin II receptor blockers and estrogens with urinary incontinence in women (all ORs greater than 1.7), and a borderline significant association for anticonvulsants (OR 1.75; 95% CI 1.00, 3.07). Among men only anticonvulsants were associated with urinary incontinence after final adjustments (OR 2.50; 95% CI 1.24, 5.03), although angiotensin II receptor blockers showed an adjusted association of borderline significance (OR 2.21; 95% CI 0.96, 5.10). Conclusions: Although a cross-sectional analysis cannot determine causality, our analysis suggests certain medications should be further examined in longitudinal analyses of risk to determine their influence on urological symptoms.

Holmium Laser Enucleation Versus Photoselective Vaporization for Prostatic Adenoma Greater than 60 Ml: Preliminary Results of a Prospective, Randomized Clinical Trial - Corrected Proof

2012-05-16

Purpose: To our knowledge we report the first single center, prospective, randomized study comparing holmium laser enucleation and high performance GreenLight™ prostate photoselective vaporization as surgical treatment of prostatic adenomas greater than 60 ml. Materials and Methods: A total of 80 patients with a large prostatic adenoma were randomly assigned to surgical treatment with holmium laser enucleation or photoselective vaporization. International Prostate Symptom Score, International Index of Erectile Function-15, maximum flow rate, post-void residual urine, serum prostate specific antigen and transrectal ultrasound volume were recorded. Results: Patient baseline characteristics were similar for holmium laser enucleation and photoselective vaporization. Operative time and catheter removal time were almost equal in the 2 groups (p = 0.7 and 0.2, respectively). Eight vaporization cases were converted to transurethral prostate resection or holmium laser enucleation intraoperatively due to bleeding. A significantly higher maximum flow rate and lower post-void residual urine were noted in holmium laser cases during the entire followup (at 1 year each p = 0.02). However, no significant difference in International Prostate Symptom Score, quality of life or International Index of Erectile Function-15 was detected. Prostate volume and serum PSA decreased 78% and 88% in the holmium laser group, and 52% and 60% in the vaporization group, respectively. Conclusions: Holmium laser enucleation and photoselective vaporization are effective for lower urinary tract symptoms due to a large prostatic adenoma. Early subjective functional results (maximum flow rate and post-void residual urine) of holmium laser enucleation appear to be superior to those of photoselective vaporization. In our hands cases intended to be treated with photoselective vaporization were at 22% risk of conversion to another modality. This could reflect our determination to vaporize to the capsule in all vaporization cases.

Renal Trauma from Recreational Accidents Manifests Different Injury Patterns than Urban Renal Trauma - Corrected Proof

2012-05-16

Purpose: The majority of blunt renal trauma is a consequence of motor vehicle collisions and falls. Prior publications based on urban series have shown that significant renal injuries are almost always accompanied by gross hematuria alone or microscopic hematuria with concomitant hypotension. We present a series of blunt renal trauma sustained during recreational pursuits, and describe the mechanisms, injury patterns and management. Materials and Methods: Database review from 1996 to 2009 identified 145 renal injuries. Children younger than age 16 years, and trauma involving licensable motor vehicles, penetrating injuries and work related injuries were excluded from analysis. Grade, hematuria, hypotension, age, gender, laterality, mechanism, management, injury severity score and associated injuries were recorded. Results: We identified 106 patients meeting the criteria and 85% of the injuries were snow sport related. Age range was 16 to 76 years and 92.5% of patients were male. There were 39 grade 1 injuries, 30 grade 2, 22 grade 3, 12 grade 4 and 3 grade 5 injuries. Gross hematuria was present in 56.7%, 77.2% and 83.3% of grade 2, grade 3 and grade 4 injuries, respectively. None of the patients with grade 2 or greater injuries and microscopic hematuria had hypotension except 1 grade 5 pedicle injury. The nephrectomy and renorrhaphy rate for grade 1 to grade 4 injuries was 0%. Conclusions: Compared to urban series of blunt renal trauma, recreationally acquired injuries appear to follow different patterns, including a paucity of associated injuries or hypotension. If imaging were limited to the presence of gross hematuria, or microscopic hematuria with hypotension, 23% of grade 2 to grade 4 injuries would be missed. Men are at higher risk than women. However, operative intervention is rarely helpful.

Voiding Function in Women with Orthotopic Neobladder Urinary Diversion - Corrected Proof

2012-05-16

Purpose: Most long-term morbidity after radical cystectomy is related to the urinary diversion or reconstruction. While there are benefits to an orthotopic neobladder, there can be a substantial risk of voiding dysfunction in women. We examine the prevalence of postoperative voiding complications in women who underwent orthotopic neobladder diversion. Materials and Methods: We identified all women who underwent radical cystectomy and orthotopic neobladder for bladder cancer at our institution from 1996 to 2011 (51) and included patients with regular clinic followup (49). The presence and severity of incontinence and hypercontinence were evaluated at routine clinic visits. Unadjusted analyses were performed to measure the association between patient variables and voiding symptoms, with p <0.05 considered significant. Results: Daytime incontinence, nighttime incontinence and hypercontinence were reported by 43%, 55% and 31% of women, respectively. A neobladder-vaginal fistula developed in 3 women (6%). On unadjusted analysis having daytime incontinence was associated with a concurrent or previous hysterectomy (p = 0.031), but not with age, disease stage, preoperative incontinence, year of surgery or sparing the vaginal wall. The severity of daytime incontinence was associated with preoperative incontinence only (p = 0.02). The presence and severity of nighttime incontinence were associated with patient age only (p = 0.013, p = 0.005, respectively). Hypercontinence was not associated with any variable. Conclusions: Among women with orthotopic neobladder after radical cystectomy we identified a significant prevalence of voiding dysfunction. We recommend preoperative discussion of these possible complications with any woman interested in orthotopic neobladder to establish realistic expectations. For properly selected women who understand these risks, orthotopic neobladder may be an appropriate diversion choice.

Nonoperative Management of Penetrating Kidney Injuries: A Prospective Audit - Corrected Proof

C. Moolman, P.H. Navsaria, J. Lazarus, A. Pontin, A.J. Nicol — 2012-05-16

Purpose: The role of nonoperative management for penetrating kidney injuries is unknown. Therefore, we review the management and outcome of penetrating kidney injuries at a center with a high incidence of penetrating trauma. Materials and Methods: Data from all patients presenting with hematuria and/or kidney injury discovered on imaging or at surgery admitted to the trauma center at Groote Schuur Hospital in Cape Town, South Africa during a 19-month period (January 2007 to July 2008) were prospectively collected and reviewed. These data were analyzed for demographics, injury mechanism, perioperative management, nephrectomy rate and nonoperative success. Patients presenting with hematuria and with an acute abdomen underwent a single shot excretory urogram. Those presenting with hematuria without an indication for laparotomy underwent computerized tomography with contrast material. Results: A total of 92 patients presented with hematuria following penetrating abdominal trauma. There were 75 (80.4%) proven renal injuries. Of the patients 84 were men and the median age was 26 years (range 14 to 51). There were 50 stab wounds and 42 gunshot renal injuries. Imaging modalities included computerized tomography in 60 cases and single shot excretory urography in 18. There were 9 patients brought directly to the operating room without further imaging. A total of 47 patients with 49 proven renal injuries were treated nonoperatively. In this group 4 patients presented with delayed hematuria, of whom 1 had a normal angiogram and 3 underwent successful angioembolization of arteriovenous fistula (2) and false aneurysm (1). All nonoperatively managed renal injuries were successfully treated without surgery. There were 18 nephrectomies performed for uncontrollable bleeding (11), hilar injuries (2) and shattered kidney (3). Post-nephrectomy complications included 1 infected renal bed hematoma requiring percutaneous drainage. Of the injuries found at laparotomy 12 were not explored, 2 were drained and 5 were treated with renorrhaphy. Conclusions: Penetrating trauma is associated with a high nephrectomy rate (24.3%). However, a high nonoperative success rate (100%) is achievable with minimal morbidity (9%).

The International Prostate Symptom Score Overestimates Nocturia Assessed by Frequency-Volume Charts - Corrected Proof

Ernst P. van Haarst, J.L.H. Ruud Bosch, Eddi A. Heldeweg — 2012-05-16

Purpose: We analyzed differences in nocturia, as estimated by the International Prostate Symptom Score and 7-day frequency-volume charts. Materials and Methods: A total of 398 forms were collected from 500 consecutive urological outpatients willing to record a 7-day frequency-volume chart. All patients completed a general questionnaire, an International Prostate Symptom Score, and a bladder symptom and bother score. Missed recordings were indicated by a coded letter. Patients who lacked essential data, bedtimes or an International Prostate Symptom Score, or who recorded the frequency-volume chart for less than 5 days were excluded from study. Results: A total of 186 men and 115 women with a mean age of 56 years were evaluable. In 10.6% of patients no nocturia occurred. Of those with nocturia 70% and 34% experienced nocturia a mean of 1 or more and 2 or more times, respectively. In 43% of patients the International Prostate Symptom Score equaled calculated categorized nocturia while 50% had a higher International Prostate Symptom Score nocturia score than calculated nocturia. On univariate analysis the correlation of International Prostate Symptom Score question 7 with mean nocturia increased with frequency-volume chart duration (day 1 r = 0.52 to day 3 r = 0.63). On longer duration frequency-volume charts the correlation showed no further increase. Multivariate regression analysis revealed that the nocturia score was determined by mean nocturia in the frequency-volume chart, the nocturia bother score and patient age. Conclusions: The International Prostate Symptom Score nocturia score overestimated nocturia in most patients, as derived from a 7-day frequency-volume chart. When scoring International Prostate Symptom Score nocturia question 7, patients included a degree of bother. The correlation of question 7 with mean nocturia increased with frequency-volume chart duration until day 3.

TachoSil® Sealed Tubeless Percutaneous Nephrolithotomy to Reduce Urine Leakage and Bleeding: Outcome of a Randomized Controlled Study - Corrected Proof

2012-05-16

Purpose: We determined the efficacy and safety of TachoSil® in sealing the tract after percutaneous nephrolithotomy compared to nephrostomy tube placement. Materials and Methods: A total of 100 consecutive patients scheduled for percutaneous nephrolithotomy were randomized 1:1 to receive a 16Fr nephrostomy tube (group 1) or TachoSil in the tract (group 2). All patients received a mono-J ureteral catheter. The primary study end points were bleeding and urinary leakage rates. The secondary end points were pain as assessed by the 0 to 10-point visual analog scale, analgesic requirement and hospital stay. Results: The groups were comparable for preoperative and operative variables. In group 1, 3 patients were excluded intraoperatively because of relevant bleeding, and in group 2, 1 patient was excluded intraoperatively because of hydrothorax. Tract complications were significantly more frequent in group 1 than in group 2 (25.5% vs 2%, p <0.001). However, the difference in urinary leakage reached statistical significance (19.1% vs 2%, p = 0.007), whereas that in perirenal hematoma formation did not (6.4% vs 0%, p = 0.113). There was no difference between the groups in mean ± SD number of analgesic doses (1.17 ± 1.56 vs 1.20 ± 1.69, p = 0.791) and visual analogue scale scores (4.77 ± 2.28 vs 4.24 ± 2.32, p = 0.270). Postoperative hospital stay was significantly shorter in group 2 than in group 1 (5.15 ± 1.74 vs 2.75 ± 1.78 days, p <0.0001). Conclusions: Although failing to reduce pain and analgesic requirement, TachoSil provided better tract control and a shorter hospital stay than nephrostomy tube placement, thus allowing the extension of indications for tubeless percutaneous nephrolithotomy to most procedures.

Surgical Practice Patterns for Male Urinary Incontinence: Analysis of Case Logs from Certifying American Urologists - Corrected Proof

2012-05-16

Purpose: Several options exist for the surgical correction of male stress urinary incontinence including periurethral bulking agents, artificial urinary sphincters and the recently introduced male urethral slings. We investigated contemporary trends in the use of these treatments. Materials and Methods: Annualized case log data for incontinence surgeries from certifying and recertifying urologists were obtained from the ABU (American Board of Urology), ranging from 2004 to 2010. Chi-square tests and logistic regression models were used to evaluate the association between surgeon characteristics (type of certification, annual volume, practice type and practice location) and the use of incontinence procedures. Results: Among the 2,036 nonpediatric case logs examined the number of incontinence treatments reported for certification has steadily increased over time from 1,936 to 3,366 treatments per year from 2004 to 2010 (p = 0.008). Nearly a fifth of urologists reported placing at least 1 sling. The proportion of endoscopic procedures decreased from 80% of all incontinence procedures in 2004 to 60% in 2010, but they remained the exclusive incontinence procedure performed by 49% of urologists. A urologist's increased use of endoscopic treatments was associated with a decreased likelihood of performing a sling procedure (OR 0.5, p <0.0005). Artificial urinary sphincter use remained stable, accounting for 12% of procedures. Conclusions: Incontinence procedures are on the rise. Urethral slings have been widely adopted and account for the largest increase among treatment modalities. Endoscopic treatments continue to be commonly performed and may represent overuse in the face of improved techniques. Further research is required to validate these trends.

The CROES Percutaneous Nephrolithotomy Global Study: The Influence of Body Mass Index on Outcome - Corrected Proof

2012-05-16

Purpose: In addition to more commonly forming stones, obese patients present a number of challenges when undergoing percutaneous nephrolithotomy. We evaluated percutaneous nephrolithotomy outcomes in 3,709 patients stratified by body mass index. Materials and Methods: A prospective database administered by CROES (Clinical Research Office of the Endourological Society) captured data on 5,803 patients treated with percutaneous nephrolithotomy between November 2007 and December 2009. Patients with known solitary kidney, previous percutaneous nephrolithotomy and congenital abnormalities were excluded from analysis. For statistical analysis patients were categorized as normal weight—body mass index 18.5 to 25 kg/m2, overweight—25 to 30, obese—30 to 40 and super obese—greater than 40. Results: During the study period 5,803 patients underwent percutaneous nephrolithotomy, of whom 3,709 met the inclusion criteria. As expected, obesity was associated with significantly higher rates of comorbid conditions and anticoagulant use (p <0.001). Operative time was significantly longer in obese patients and use of a balloon device for tract dilation was more common (each p <0.001). The stone-free rate decreased with obesity (p = 0.009), corresponding to a significantly higher re-treatment rate in this group (p <0.001). No difference was seen in length of stay or the transfusion rate. No significant difference was seen in the overall complication rate among the 4 groups (p = 0.707). Conclusions: Percutaneous nephrolithotomy may be done safely in obese patients, although with a longer operative time, an inferior stone-free rate and a higher re-intervention rate.

Histology Proved Malpositioning of Dextranomer/Hyaluronic Acid in Submucosal Ureter in Patients After Failed Endoscopic Treatment of Vesicoureteral Reflux - Corrected Proof

David Ben-Meir, Sara Morgenstern, Bezalel Sivan, Rachel Efrat, Pinhas M. Livne — 2012-05-16

Purpose: We histologically investigated the cause of failed endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid injections in children. Materials and Methods: A total of 192 children underwent dextranomer/hyaluronic acid injection at our institution between January 2008 and September 2010. The study population consisted of 13 children (22 ureters) with vesicoureteral reflux who underwent ureteroneocystostomy following failed endoscopic injections (1 to 2) of dextranomer/hyaluronic acid. In all cases the dextranomer/hyaluronic acid was implanted in the mucosa of the mid to distal ureteral tunnel following hydrodistention of the ureter. The medical records were reviewed, and specimens of the archived distal ureters removed during surgery were examined histologically. Results: Mean patient age was 4.1 years. Mean dose of dextranomer/hyaluronic acid was 0.9 ml (both treatments) and mean lag between treatments was 13.4 months. Indications for open surgery were recurrent urinary tract infections and/or residual or aggravated reflux grade IV or higher. Histological study revealed that the dextranomer/hyaluronic acid was malpositioned in 21 of 22 ureters, residing in the muscle fibers in 2, adventitia in 14 and periureteral space in 5. Conclusions: This is the first known study to provide a histologically proved cause of failure of endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid injections in children. Malpositioning of the material outside the submucosal ureter was identified in a high percentage of cases. Larger studies are needed to corroborate these findings.

Intractable Hemorrhagic Cystitis after Hematopoietic Stem Cell Tranplantation—Is There a Role for Early Urinary Diversion in Children? - Corrected Proof

2012-05-16

Purpose: Severe hemorrhagic cystitis is a major complication in the pediatric population undergoing hematopoietic stem cell transplantation. Percutaneous nephrostomy tube drainage as a treatment for severe hemorrhagic cystitis has rarely been investigated. We examined children undergoing hematopoietic stem cell transplantation for risk factors associated with severe hemorrhagic cystitis, as well as our experience with percutaneous nephrostomy tube placement as an adjunctive management strategy. Materials and Methods: Using prospectively collected data from the Blood and Marrow Transplant Database at the University of Minnesota, we reviewed 40 pediatric patients with severe hemorrhagic cystitis from 1996 to 2010. Specific treatment for each patient was administered at the discretion of the attending physician and generally included bladder irrigation before bladder fulguration or percutaneous nephrostomy tube placement. A percutaneous nephrostomy tube was placed in 11 patients due to the intractable nature of the hemorrhagic cystitis. Results: Of the 11 patients who underwent percutaneous nephrostomy tube drainage 5 (45%) had improvement of the hemorrhagic cystitis within 30 days and the same number had long-term resolution. Among the patients with long-term resolution hemorrhagic cystitis resolved an average of 12.4 days after percutaneous nephrostomy tube placement, and the tubes were removed an average of 8.8 weeks after placement. Through September 2011 mortality among patients with percutaneous nephrostomy tubes was 55% (6 of 11 patients), which was identical to the overall mortality in the severe hemorrhagic cystitis group (22 of 40). No death could be directly attributed to hemorrhagic cystitis or percutaneous nephrostomy tube placement. Conclusions: Placement of percutaneous nephrostomy tubes for treatment of severe hemorrhagic cystitis results in long-term improvement in intractable hemorrhagic cystitis, and is a safe and viable option for the majority of patients.

Temporal Trends in Incidence of Kidney Stones Among Children: A 25-Year Population Based Study - Corrected Proof

2012-05-16

Purpose: We conducted a population based pediatric study to determine the incidence of symptomatic kidney stones during a 25-year period and to identify factors related to variation in stone incidence during this period. Materials and Methods: The Rochester Epidemiology Project was used to identify all patients younger than 18 years who were diagnosed with kidney stones in Olmsted County, Minnesota from 1984 to 2008. Medical records were reviewed to validate first time symptomatic stone formers with identification of age appropriate symptoms plus stone confirmation by imaging or passage. The incidence of symptomatic stones by age, gender and study period was compared. Clinical characteristics of incident stone formers were described. Results: A total of 207 children received a diagnostic code for kidney stones, of whom 84 (41%) were validated as incident stone formers. The incidence rate increased 4% per calendar year (p = 0.01) throughout the 25-year period. This finding was due to a 6% yearly increased incidence in children 12 to 17 years old (p = 0.02 for age × calendar year interaction) with an increase from 13 per 100,000 person-years between 1984 and 1990 to 36 per 100,000 person-years between 2003 and 2008. Computerized tomography identified the stone in 6% of adolescent stone formers (1 of 18) from 1984 to 1996 vs 76% (34 of 45) from 1997 to 2008. The incidence of spontaneous stone passage in adolescents did not increase significantly between these 2 periods (16 vs 18 per 100,000 person-years, p = 0.30). Conclusions: The incidence of kidney stones increased dramatically among adolescents in the general population during a 25-year period. The exact cause of this finding remains to be determined.

The Effects of Oxybutynin on Urinary Symptoms in Children with Williams-Beuren Syndrome - Corrected Proof

2012-05-16

Purpose: Williams-Beuren syndrome is a genomic disorder caused by a hemizygous contiguous gene deletion on chromosome 7q11.23. Lower urinary tract symptoms are common in children with Williams-Beuren syndrome. However, there are few data on the management of voiding symptoms in this population. We report our experience using oxybutynin to treat urinary symptoms in children with Williams-Beuren syndrome. Materials and Methods: We prospectively analyzed 42 patients with Williams-Beuren syndrome and significant lower urinary tract symptoms due to detrusor overactivity diagnosed on urodynamics in a 12-week, open-label study. Urological assessment included symptomatic evaluation, the impact of lower urinary tract symptoms on quality of life, frequency-volume chart, urodynamics and urinary tract sonography. After 12 weeks of treatment with 0.6 mg/kg oxybutynin per day given in 3 daily doses, patients were assessed for treatment efficacy and side effects. Results: A total of 17 girls and 19 boys completed medical therapy and were assessed at 12 weeks. Mean ± SD patient age was 9.2 ± 4.3 years (range 3 to 18). The most common urinary complaint was urgency, which occurred in 31 patients (86.1%), followed by urge incontinence, which was seen in 29 (80.5%). Compared to baseline, urinary symptoms were substantially improved. The negative impact of storage symptoms on quality of life was significantly decreased from a mean ± SD of 3.3 ± 1.7 to 0.5 ± 0.9 (p <0.001). Mean ± SD maximum urinary flow improved from 14.2 ± 15.0 to 20.5 ± 6.4 ml per second (p <0.001). Conclusions: A total of 12 weeks of therapy with 0.6 mg/kg oxybutynin daily resulted in improvement of lower urinary tract symptoms, quality of life and maximum flow rate in most patients with Williams-Beuren syndrome.

Relationship Among Bacterial Virulence, Bladder Dysfunction, Vesicoureteral Reflux and Patterns of Urinary Tract Infection in Children - Corrected Proof

2012-05-16

Purpose: We hypothesized that virulence levels of Escherichia coli isolates causing pediatric urinary tract infections differ according to severity of infection and also among various uropathies known to contribute to pediatric urinary tract infections. We evaluated these relationships using in vitro cytokine interleukin-6 elicitation. Materials and Methods: E. coli isolates were cultured from children presenting with urinary tract infections. In vitro cytokine (interleukin-6) elicitation was quantified for each isolate and the bacteria were grouped according to type of infection and underlying uropathy (neurogenic bladder, nonneurogenic bowel and bladder dysfunction, primary vesicoureteral reflux, no underlying etiology). Results: A total of 40 E. coli isolates were collected from children with a mean age of 61.5 months (range 1 to 204). Mean level of in vitro cytokine elicitation from febrile urinary tract infection producing E. coli was significantly lower than for nonfebrile strains (p = 0.01). The interleukin-6 response to E. coli in the neurogenic bladder group was also significantly higher than in the vesicoureteral reflux (p = 0.01) and no underlying etiology groups (p = 0.02). Conclusions: In vitro interleukin-6 elicitation, an established marker to determine bacterial virulence, correlates inversely with clinical urinary tract infection severity. Less virulent, high cytokine producing E. coli were more likely to cause cystitis and were more commonly found in patients with neurogenic bladder and nonneurogenic bowel and bladder dysfunction, whereas higher virulence isolates were more likely to produce febrile urinary tract infections and to affect children with primary vesicoureteral reflux and no underlying etiology. These findings suggest that bacteria of different virulence levels may be responsible for differences in severity of pediatric urinary tract infections and may vary among different underlying uropathies.

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