Bladder reconstruction in children

Bladder reconstruction in children attempts to provide for a low pressure reservoir of urine that is continent and may be emptied completely at appropriate intervals. The most common underlying causes of bladder dysfunction that may require reconstruction include neuropathic bladders associated with spina bifida, posterior urethral valves, and bladder exstrophy. Indications and patient selection for reconstruction have greatly improved and a variety of methods are available; each with its own advantages and drawbacks. The recent increased application of gastric segments in augmenting the bladder to increase size and compliance has been very successful, and particularly in patients with impaired renal function. The continent catheterizable stoma (Mitrofanoff principle), using appendix or ureter, has gained widespread acceptance in reconstructive procedures and provides a reliable, convenient, and well-accepted means of achieving continence. Although advances have been made in reconstructive techniques, new complications are being experienced, including stone formation and metabolic abnormalities. Gastrocystoplasty, although an excellent option in reconstruction, has produced a symptom complex of hematuria and dysuria in some patients, at times to a significant degree. With experience, these complications are becoming better understood and new strategies for management are being developed. On the horizon, new approaches to bladder replacement are being explored, and new investigation into the pathophysiology of pediatric bladder dysfunction is ongoing.

Bowel injury in open technique laparoscopic cannula placement

Open trocar placement is used by many surgeons during laparoscopy to avoid some of the potential complications of Veress needle and sharp trocar insertion. We describe a case of serosal bowel injury with a holding stitch placed to obtain an airtight peritoneal cavity during open laparoscopic trocar placement in a two-year-old patient. The importance of inspection of the initial umbilical puncture site is emphasized and a rapid, simple technique for repair of minor bowel injuries is described.

Laparoscopic evaluation of the nonpalpable tests: a prospective assessment of accuracy

To assess diagnostic accuracy, laparoscopy and surgical exploration were prospectively performed in 104 children with 126 nonpalpable testes. Laparoscopic localization of the testis was correct in 90% (114 of 126 testes) and was nondiagnostic in 8% largely due to preperitoneal insufflation. No surgical complications occurred. Using the criteria of blind-ending vas deferens and spermatic vessels as diagnostic of an intra-abdominal vanishing testis, the accuracy of diagnosis was 100% but the inability to identify either vas or vessels was associated with intra-abdominal testes in 2 of 3 cases. Identification of canalicular vas deferens and spermatic vessels was associated with testes in 36 of 75 cases (48%). Bilateral nonpalpable testes were significantly less likely to have an absent testes (5%) than a unilateral nonpalpable testis (59%), suggesting the possibility of different pathophysiological mechanisms in those entities. Diagnosis and surgical management of nonpalpable testes were directly impacted by laparoscopy in 42 of 117 testes (36%) by identifying intra-abdominal vanishing testis, the location of an intra-abdominal testes or the need for retroperitoneal exploration when vas deferens and spermatic vessels were not found. Accurate knowledge of testis location in 97% of the testes facilitated development of an appropriate surgical strategy (that is laparoscopic/laparoscopic assisted versus open procedure).

Urinary levels of the renal tubular enzyme N-acetyl-beta-D-glucosaminidase in unilateral obstructive uropathy

Elevated urinary levels of the renal tubular enzyme, N-acetyl-beta-D-glucosaminidase (NAG), have been shown to be associated with reversible tubular damage and, therefore, may serve as an indicator of tubular damage in the setting of presumed obstruction uropathy. This study compares urinary NAG levels in children with apparent upper tract obstruction with normal children to assess the sensitivity of this assay for the detection of possible renal tubular damage. The study included 40 children 3 weeks to 16 years old with unilateral ureteropelvic junction obstruction (30) or primary obstructive megaureter (10). Urine was obtained from the bladder in all children and from the renal pelvis or ureter in 30 patients at surgery. Pelvic and ureteral urinary NAG levels were consistently higher than bladder levels. In patients with ureteropelvic junction obstruction NAG levels were 7 times higher than normal (76 units per mg., p < 0.0001) and 3 times higher than normal in patients with obstructive megaureter (29 units per mg., p < 0.001). The mean bladder urinary NAG levels in patients with ureteropelvic junction obstruction (17.6 units per mg. creatinine, standard error of mean 2.01, p < 0.001) and megaureters (19.2 units per mg. creatinine, standard error of mean 3.6, p < 0.049) were elevated above control patients (10.6 units per mg. creatinine, standard error of mean 1.02). Elevated urinary NAG levels in the renal pelvis, ureter and bladder may be helpful in identifying upper tract obstruction, which if left untreated, might cause progressive renal deterioration.

Experimental fetal tracheal ligation reverses the structural and physiological effects of pulmonary hypoplasia in congenital diaphragmatic hernia

Infants with congenital diaphragmatic hernia (DH) and profound pulmonary hypoplasia are currently unsalvageable. The authors previously demonstrated that tracheal ligation (TL) accelerates fetal lung growth and reverses the pulmonary hypoplasia of fetal nephrectomy. The purpose of this study was to determine if the pulmonary hypoplasia of experimental DH could be similarly reversed and, if so, whether the resulting lungs would show better function than those of their DH counterparts. Eighteen fetal lambs were divided into three experimental groups of six animals each. In group 1, DH was created at 90 days' gestation. In group 2, DH was created at 90 days' gestation and TL performed during the same operation. Group 3 consisted of sham-operated controls. These animals were delivered near full-term, and their lungs analyzed by standard morphometric techniques. Ten additional fetal lambs were divided into two experimental groups of five animals each. In group 4, DH was created at 90 days' gestation. In group 5, DH was created at 90 days' gestation and TL performed 20 days later, at 110 days' gestation. These animals were pressure-ventilated via tracheostomy over a 2-hour period in which PaO2, PaCO2, and compliance were measured. Intratracheal pressure (ITP) was measured at the time of delivery in all groups. Upon retrieval, DH animals had abdominal viscera in the chest and small lungs; in contrast, DH/TL animals had the herniated viscera reduced from the chest by enlarged lungs. DH/TL lungs showed markedly increased growth, with significant increases in lung volume:body weight ratio (LV:BW; P = .0001), alveolar surface area (ALV.SA; P = .0001), and alveolar number (ALV#) (P = .0001) when compared with those of the DH or control group. This growth was associated with a normal maturation pattern based on histological appearance, normal airspace fraction, and normal alveolar numerical density. ITP in the DH/TL group was increased when compared with that of DH and control animals (P = .0001). Total lung DNA and protein were both elevated in the DH/TL animals (P = .0001). However, the DNA:protein ratio remained normal, suggesting lung growth had occurred through cell proliferation, not by hypertrophy. When ventilated over a range of settings, DH/TL lungs were more compliant (P = .0001) and achieved higher PaO2s (P < .003) and lower PaCO2s (P = .0001) than their DH counterparts. From these data, the authors conclude: (1) Experimental fetal DH produces hypoplastic lungs that are not capable of adequate gas exchange with conventional ventilation.(ABSTRACT TRUNCATED AT 400 WORDS)

Axial distribution of arsenic in individual human hairs by solid sampling graphite furnace AAS

In cases of arsenic poisoning, the distribution of arsenic along the length of a hair can be used to distinguish between chronic and acute exposure. Individual 5-mm segments of a hair were analyzed for their arsenic content by solid sampling graphite furnace atomic absorption spectrophotometry with a mixed Pd-Mg(NO3)2 matrix modifier. Results obtained using arsenic calibration solutions and standard additions to uncontaminated hairs are analytically indistinguishable, allowing aqueous standards to be used for hair analysis. The characteristic mass is 24 pg, and the 3 sigma detection limit is approximately 10 pg. Results obtained for hairs from two victims of arsenic poisoning are in good agreement with those obtained using neutron activation analysis.

Laparoscopic pyeloplasty

A 24-year-old woman presented with symptomatic right ureteropelvic junction obstruction due to anomalous lower pole renal vessels. A dismembered pyeloplasty of the ureteropelvic junction was performed completely laparoscopically.

Experimental fetal tracheal ligation prevents the pulmonary hypoplasia associated with fetal nephrectomy: possible application for congenital diaphragmatic hernia

Pulmonary hypoplasia has a definite clinical impact in a variety of congenital diseases such as renal dysplasia and congenital diaphragmatic hernia. These diseases have in common inadequate growth and development of fetal lungs. Previous reports have demonstrated increased lung growth with in utero tracheal ligation. The purpose of this study was to determine if lung growth can be accelerated in the setting of experimental pulmonary hypoplasia. Ninety-five-day gestation fetal sheep were divided into four experimental groups: nephrectomy, nephrectomy with tracheal ligation, tracheal ligation alone, and sham-operated control animals. Animals were delivered near term and their lungs inflation fixed at 25 cm H2O. Total alveolar number (Alv#), total alveolar surface area (AlvSA), and lung volume to body weight ratios (LV:BW) were determined for apical and basilar segments of each animal and then averaged. Total lung DNA and protein content were also analyzed. The nephrectomy group had smaller lungs than control animals with decreased Alv#, AlvSA, and LV:BW. In contrast, nephrectomy with tracheal ligation produced large lungs which had increased Alv#, AlvSA, and LV:BW when compared with both the nephrectomy and the control group (P < .01). Total lung DNA and protein concentrations were both markedly elevated in the tracheally obstructed groups. However, the DNA/protein ratios remained constant in all four groups, suggesting that lung growth had occurred through cell multiplication. Photomicrographs of the lung demonstrated a histologically immature appearance in the nephrectomy group and a histologically mature appearance in the tracheally obstructed groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Fetal compensatory renal growth due to unilateral ureteral obstruction

To determine whether fetal compensatory renal growth occurs in response to early gestational unilateral renal obstruction and to help elucidate the characteristics of this response, a fetal lamb model was developed in which unilateral ureteral obstruction was created at 60 days of gestation (term 135 to 140 days) and the effects of the obstruction were studied at varying periods thereafter. Kidneys were retrieved at 2 weeks (75 days in 3 cases), 5 weeks (95 days in 4) and 10 weeks (135 days in 9) after obstruction, weighed and preserved for histology and biochemical studies. Deoxyribonucleic acid (DNA), ribonucleic acid and protein were quantitated using standard assays. Morphometric studies to estimate glomerular number were performed using standard stereological methods. Contralateral kidney weight was increased compared to normals in 55 cases at all ages. The relative difference increased from 75 to 95 days. The fractional increase at 135 days (49.5%, p < 0.001 versus normal) was not different from 95 days (46.4%, p = 0.87), indicating that growth rate acceleration occurred predominantly before 95 days. Total renal DNA was increased above normal at each time point, with an ultimate increment proportionate to weight. Protein concentration was unchanged, suggesting that weight increase was not due to changes in renal water. Protein/DNA ratios were unchanged, indicating a predominantly hyperplastic process. Ribonucleic acid/DNA ratios decreased, possibly indicating a high rate of proliferation. Total glomerular number at term did not increase with in utero compensatory renal growth. Unilateral ureteral obstruction created early in gestation produced compensatory renal growth of the intact kidney in the fetal lamb. This process demonstrates an early but transient growth rate acceleration, hyperplasia and no increase in total glomerular or nephron number. The occurrence of compensatory renal growth in the fetal kidney with minimal functional renal demand would suggest that its mechanisms may be independent of functional demand. This model is unique and well suited to study compensatory renal growth.

Laparoscopic correction of vesicoureteral reflux

Major advances have been made in the area of laparoscopic surgery. The advantages of this approach include smaller incisions, shorter hospitalizations, a more rapid convalescence and decreased postoperative discomfort. To explore the technical feasibility of performing antireflux surgery laparoscopically, we conducted a pilot study in 4 mini-pigs in which bilateral vesicoureteral reflux had been created surgically. We applied a modification of the Lich extravesical ureteral approach to perform laparoscopic antireflux surgery. All mini-pigs underwent successful unilateral mobilization, creation of a bladder wall trough and creation of a new ureteral tunnel laparoscopically. Examinations were performed postoperatively, and then serially at 1, 2, 3 and 5 months after repair. Fluoroscopic cystograms demonstrated the resolution of reflux in the corrected ureters and persistence of reflux in the uncorrected control ureters in all animals. Excretory urography showed no evidence of obstruction. Laparoscopic correction of vesicoureteral reflux appears to be technically feasible in the animal model. Long-term followup is necessary to determine the possible applicability of this technique in humans.

Human fetal compensatory renal growth

The occurrence of prenatal compensatory renal growth has remained in question, despite the general acceptance of this phenomenon postnatally. We measured by ultrasound imaging the renal length of 22 human fetuses with a solitary kidney or contralateral multicystic dysplastic kidney, and compared it to measurements in 40 normal control fetuses. Renal length was normalized to fetal biparietal diameter. Analysis of covariance showed that the solitary kidneys were significantly larger than normal controls (p < 0.0001), although the rate of growth was not significantly increased above normal. These data document the presence of compensatory renal growth in human fetuses with solitary or functionally solitary kidneys.

Unilateral nerve-sparing radical prostatectomy and hemicystectomy in management of prostate sarcoma

A patient with sarcoma of the prostate was treated with radical prostatectomy including wide excision of the ipsilateral neurovascular bundle and hemicystectomy. Six years postoperatively he is free of disease, continent with a bladder capacity of 350 cc, voids to completion, and is potent.

Does the system of Papanicolaou test nomenclature affect the rate of referral for colposcopy? A survey of family physicians

OBJECTIVE

To determine whether a new system of Papanicolaou test nomenclature (the Bethesda system) or other physician variables influence recommendations for colposcopy and biopsy for women with borderline to moderately abnormal Papanicolaou test results. We hypothesized that physician demographic and practice variables, in addition to Papanicolaou test nomenclature, would influence recommendations for colposcopy.

DESIGN

A survey was mailed to a random sample of 510 active members of the American Academy of Family Physicians.

PARTICIPANTS

Three hundred thirty-five (66%) of the eligible physicians responded, representing all 50 states. Of those in active practice, 78% were in private practice, with a mean age of 44 years and a mean time in practice of 10 years. Ninety-three percent of respondents in active practice performed Papanicolaou tests.

MAIN OUTCOME MEASURE

Rates of recommendation for colposcopy and biopsy in response to abnormal Papanicolaou test reports framed by a single clinical scenario.

RESULTS

Physicians recommended colposcopy more often when the Bethesda nomenclature system was used to describe the results of the Papanicolaou test. These differences were significant for four specific Papanicolaou smear pairs. Inclusion of recommendations for further evaluation strongly influenced physicians to recommend colposcopy. In multivariable analyses, demographic and practice variables were not associated with recommendations for colposcopy.

CONCLUSIONS

The Bethesda system of nomenclature, when compared with a traditional descriptive nomenclature system, influenced family physicians to recommend colposcopy and biopsy more often for abnormal Papanicolaou test results presented in a clinical scenario. Greater utilization of technology and higher medical care costs may result from use of the Bethesda system. Guidelines for evaluation of abnormal Papanicolaou test results are needed for use in conjunction with the Bethesda system guidelines for Papanicolaou test reports.

Laparoscopy in pediatric urology

Laparoscopy has been used in pediatric urology for the diagnosis of nonpalpable testes for more than fifteen years. Expansion of pediatric urologic applications of laparoscopic surgical techniques is inevitable with the recent explosion of urologic laparoscopy. While the needs are distinct and at times divergent from those in the adult population, many benefits may be realized with this developing technology in children. Refinement of diagnostic capabilities as well as interventional procedures for the undescended testis are being developed. Increased use for varicocele treatment and intersex evaluation can be expected. Potential applications of laparoscopic techniques for the pediatric urologist include nephrectomy for various benign diseases, ureteral surgery for reflux, bladder autoaugmentation, and hernia repair. Laparoscopic possibilities are limited only by imagination and technology. A skeptical approach is justified and judicious application of these technologies in children is essential. Just as the child is not a small adult, pediatric laparoscopy is not just the use of smaller instruments.

Prenatal diagnosis of the megacystis-megaureter association

A total of 11 male neonates with hydronephrosis and a large bladder in utero had the megacystis-megaureter association. Prenatal ultrasound findings included bilateral hydroureteronephrosis; a large, smooth, thin-walled bladder, and normal volume of amniotic fluid. Postnatal studies demonstrated grades 4 to 5 bilateral reflux, a large bladder without obstruction and in 2 infants nonfunction of a kidney or renal moiety. Of 7 infants initially managed nonoperatively 5 have undergone surgery due to persistent reflux or breakthrough urinary infections. The prenatal diagnosis of the megacystis-megaureter association can be suspected with reasonable accuracy. Prompt postnatal continuous antibiotic prophylaxis and uroradiological confirmation allow for nonemergency management of this condition with excellent results.

The effect of obstruction on the developing bladder

Congenital bladder obstruction causes significant immediate and long-term consequences yet its pathophysiology remains poorly understood. A model of early fetal bladder obstruction in sheep has been developed to study the response of the developing bladder to high grade obstruction, with particular emphasis on the regulation of growth and development. Congenital bladder obstruction was produced in fetal sheep at 60 days of gestation and studied at 95 days of gestation (14 sheep) or term (12 sheep). A total of 24 age-matched normal sheep served as controls. Bladders were analyzed by total weight, stereological estimation of smooth muscle cell size, number and total mass, deoxyribonucleic acid concentration, muscarinic cholinergic receptor density, myosin isoform analysis and/or passive cystometrics. Congenital bladder obstruction caused a 4.6 times increase in bladder weight at term reflecting a 5.8 times increase in smooth muscle mass. This increase was predominantly that of cellular hypertrophy and less so of hyperplasia, based upon increased cell volume, increased protein-to-deoxyribonucleic acid ratio, and no significant increase in total cell number. Muscarinic cholinergic receptor number per smooth muscle cell increased 3.2 times but it did not change relative to myosin content. The ratio of myosin heavy chain isoforms SM1:SM2 is developmentally regulated and was seen to change from 1.6 at 100 days of gestation to 1.13 at term in normals. After 5 weeks of obstruction SM1:SM2 was 1.27 and it was 1.25 at term, indicating an effect on the developmental regulation of smooth muscle. Rapid fill cystometry in vivo measured the rate of stress relaxation to assess accommodative properties. The half-decay time was increased in all 3 obstructed bladders tested to greater than 15 seconds at 50% capacity (normal less than 5 seconds), suggesting reduced compliance. This study shows that an in utero model of bladder obstruction is feasible. Congenital bladder obstruction produces a variety of structural, biochemical and functional changes in the developing bladder indicative of alterations in the regulation of growth and differentiation.

The response of the fetal kidney to obstruction

In a fetal ovine model the renal effects of different anatomic levels of fetal urinary obstruction were studied. Parameters of prenatal renal growth and differentiation were characterized and correlated with the patterns of renal response to in utero obstruction. Complete ureteral or urethral obstruction was produced in the sheep fetus at 55 to 60 days of gestation. Animals were delivered and sacrificed at near term (140 days), and the kidneys were removed and prepared for analysis. Parameters examined included weight, histology, glomerular number and total surface area, as well as urinary sodium, creatinine, osmolarity and N-acetyl glucosaminidase. Three patterns of response were identified, producing hydronephrotic, cystic or dysgenetic kidneys. Hydronephrotic kidneys were usually the result of bladder outlet obstruction or ureteral obstruction with spontaneous urinary decompression. These kidneys were large (20.7 gm. versus normal 10.8 gm., p less than 0.0001), with thinning of cortical parenchyma that was structurally intact. Glomerular number and surface area were normal. Cystic kidneys were large (14.2 gm., p less than 0.05) with grossly visible cysts and an effaced medulla. Cortical structure was distorted by cysts but basic elements were intact. Glomerular number and surface area were not reduced. Dysgenetic kidneys were small (3.9 gm., p less than 0.0001) with markedly abnormal cortical structure and little recognizable medulla. Histological elements similar to fetal structures were present, including cuboidal/columnar tubular epithelium and peritubular mesenchymal collars. Glomerular number and surface area were significantly less than normal (p less than 0.001). The kidneys contralateral to unilaterally obstructed kidneys were significantly larger than normal (16.2 gm., p less than 0.0001), with normal histology, glomerular number and surface area, indicating in utero contralateral renal hypertrophy. Urinary sodium was variably affected in the hydronephrotic kidneys and was identical to plasma in the dysgenetic kidneys. These results indicate the technical feasibility of in utero models of urinary obstruction. Renal growth and patterns of differentiation were markedly affected by in utero obstruction. They should be a major focus in the investigation of congenital obstructive uropathy, since normal processes of renal growth and differentiation form the basis for postnatal function.

Late onset severe oligohydramnios associated with genitourinary abnormalities

We evaluated the diagnosis, gestational age at presentation, timing and mode of delivery, and ultimate outcome in those fetuses with third trimester onset of severe oligohydramnios who also had urinary tract abnormalities. A total of 8 fetuses with obstructive uropathy or cystic renal disease was seen during a 2-year period with the onset of severe oligohydramnios noted between 27 and 33 weeks. Immediate and late postnatal pulmonary function was excellent in 5 of the 8 subjects. Three neonates had respiratory distress but only 1 died at birth. Ultimate renal function varied in the 7 survivors. Those with supravesical obstructive uropathy achieved a normal serum creatinine, while the neonates with renal cystic disease and infravesical obstruction did not.

Endoscopic treatment of vesicoureteral reflux with a self-detachable balloon system

There is controversy about the use of polytetrafluoroethylene (Teflon) paste in children for the endoscopic treatment of vesicoureteral reflux due to evidence of particle migration. However, there are definite advantages in treating patients endoscopically. It is evident that the ideal substance should be able to be delivered endoscopically, conserve its volume, and be nonmigratory and nonantigenic. Towards this goal we developed a catheter with an inflatable, detachable and self-sealing silicone balloon that would fit through a 19 gauge cystoscopic needle. Hydroxy-ethyl-methyl acrylate, a hydrophilic polymer that solidifies within 60 minutes after the addition of ferrous sulfate, was chosen as the filling material for the balloon. Conceptually, the sealed balloon would prevent the migration of hydroxy-ethyl-methyl acrylate and the solidified polymer would prevent volume loss. To test this system reflux was created in 6 Hanford mini-pigs by unroofing the ureters bilaterally. In 2 pigs a previously described method of open surgery was used and in the other 4 reflux was created endoscopically using the resectoscope and laparoscopic scissors. The presence of bilateral reflux was confirmed 4 weeks later with a cystogram and the balloon was implanted unilaterally through a cystoscope. The opposite ureter served as an internal control in all animals. A repeat cystogram was performed 2 to 4 weeks after implantation, demonstrating resolution of reflux in the treated side and persistence of reflux in the opposite untreated ureter. Serial cystograms, ultrasound and excretory urography showed no reflux on the implanted side nor any evidence of obstruction. Tissue sections from various organs showed no evidence of particle migration, granuloma formation or inflammatory reaction. Short-term results show that the balloon implants are able to correct reflux without evidence of obstruction.

Formation of urothelial structures in vivo from dissociated cells attached to biodegradable polymer scaffolds in vitro

The use of autologous urothelium would be advantageous for urothelial replacement in many genitourinary reconstructive procedures. Urothelial tissue grafts might be created using isolated populations of transitional epithelium or tissue in concert with an appropriate synthetic substrate. We describe the results of experiments designed to determine the feasibility of using biodegradable polymers as delivery vehicles for the creation of new urothelial structures in vivo from dissociated cells. Primary cultures enriched in uroepithelial cells were obtained from New Zealand white rabbits using a new technique of cell harvest. Cells were seeded onto nonwoven meshes of polyglycolic acid polymers in culture and, after 1 to 4 days in vitro, the cell-polymer scaffolds were implanted into the mesentery, omentum or retroperitoneum of athymic mice. Polymers implanted without cells served as controls. Animals were sacrificed at 5, 10, 20 and 30 days after implantation and 75 implants were examined histologically. Ten days after implantation isolated single cell layers were seen lining the polymer fibers. At 20 and 30 days polymer degradation was evident and urothelial cells lined the polymer in continuous layers of 1 to 3-cell thickness. Anticytokeratin western blots demonstrated the presence of a urothelium-associated cytokeratin in cell-polymer implants recovered after 30 days. These results demonstrate that urothelial cells can be successfully harvested, survive in culture and attach to artificial biodegradable polymers. The urothelial-polymer scaffolds can be implanted into host animals and the implanted cells can achieve spatial orientation as the polymer undergoes biodegradation. These findings suggest that it may be possible to use autologous urothelium, reconfigured on a synthetic substrate, in reconstructive procedures involving the ureter, bladder and urethra.

Effect of in utero vesicostomy on pulmonary hypoplasia in the fetal lamb with bladder outlet obstruction and oligohydramnios: a morphometric analysis

A model of early gestation bladder outlet obstruction and oligohydramnios in the fetal lamb is characterized by small, immature lungs (pulmonary hypoplasia). The current study examines how in utero relief of urinary tract obstruction produced early in gestation modifies pulmonary hypoplasia. Bladder obstruction was created at 60 days gestation in fetal sheep (term = 140 days); 11 fetuses then underwent in utero decompression at 95 to 100 days; six were left obstructed. Five normal fetuses served as controls and two underwent sham obstruction and vesicostomy. All were delivered and sacrificed near term (135 days), the right lung was inflation-fixed and its volume determined. Relative volumes of alveoli, alveolar ducts, and tissue, alveolar surface area, and alveolar numerical density were estimated morphometrically. Kidneys were examined histologically. In all animals persistent bladder obstruction produced oligohydramnios. Bladder obstruction to term produced pulmonary hypoplasia with a mean right lung volume-to-body weight ratio (LV:BW) of 14.3 cc./kg. (normal = 36.4, p less than 0.001). Structural immaturity was evidenced by an airspace fraction of only 57% (normal = 68%, p less than 0.05). Kidneys in these animals were not dysplastic; there was hydronephrosis or evidence of spontaneous urinary decompression. In eight of the 11 animals, decompression improved the LV:BW ratio to 28.4 cc./kg. (vs. obstructed, p less than 0.001; vs normal, p less than 0.05) and normalized maturity. All had increased amniotic fluid at delivery; kidneys in 7/8 animals were normal, and the other had moderate hydronephrosis. One of the 11 animals had normal kidneys, oligohydramnios, immature lungs, but with normal volume. Oligohydramnios was present in the other two of 11 fetuses despite successful decompression and they had markedly dysmorphic kidneys and profoundly hypoplastic and immature lungs (LV:BW 5.1 cc./kg.). Even after 35 days (25% gestation) of obstruction, in utero urinary tract decompression permits better lung growth and maturation than in persistently obstructed animals. The degree of renal damage from obstruction appears to be a critical determinant in the correction of pulmonary hypoplasia.

Efficacy of chlorhexidine gluconate use in the prevention of perirectal infections in patients with acute leukemia

The frequency of rectal infections is increased in patients with acute leukemia. Complications associated with rectal lesions may be severe enough to cause life-threatening septicemia. Clinical research evaluating the effects of preventive perirectal skin care is scarce. This study's purpose was to determine whether using chlorhexidine gluconate (CHG) in a prophylactic perirectal skin-care regimen decreases perirectal infections and whether it produces more skin irritation than a nonmedicated skin cleanser. The sample consisted of 40 patients, 16 of whom were randomized to use chlorhexidine and 24 of whom were randomized to use nonmedicated skin cleanser. Chi-square and t-tests were used to analyze the incidence of skin breakdown and rectal infections; the correlation between the two factors; a positive history of rectal infections, fissures, or hemorrhoids; presence of hemorrhoids; severity of diarrhea; and duration and severity of granulocytopenia. A positive relationship was found between the severity of granulocytopenia and the incidence of rectal infections (p = 0.02). No significant difference was seen in the occurrence of perirectal infections (p = 0.35) or skin breakdown (p = 0.18) between the two groups. The data suggest that CHG does not offer increased protection against perirectal infections in patients undergoing intensive chemotherapy, nor is it more irritating than a nonmedicated skin cleanser. Further studies are needed to examine the efficacy of hygienic measures such as using skin disinfectants to prevent infections in patients who are immunocompromised.

The role of the kidney in lung growth and maturation in the setting of obstructive uropathy and oligohydramnios

The contribution of the kidneys to lung development, which includes growth and maturation, is uncertain but it appears to be complex. Obstructive uropathy with oligohydramnios produces pulmonary hypoplasia characterized by small lungs (decreased lung volume/body weight) and retarded maturation (reduced total airspace). Lung growth and maturation were studied in a model of early gestation obstructive uropathy to understand better their relationship and their prenatal regulation. Of 26 fetal sheep studied at near term (135 days of gestation) 9 had bladder obstruction created at 60 days of gestation, 11 had bladder obstruction at 60 days with in utero decompression at 95 days, and 6 served as controls and shams. Amniotic fluid volume was measured, kidneys were prepared and evaluated histologically, lungs were inflation-fixed and volumes were measured, and airspace volume percentage was measured morphometrically. Experimental and serendipitous variations in the condition of the kidneys and amniotic fluid at delivery permitted an analysis of the contribution of the kidneys and the amniotic fluid to lung growth and maturation. Impairment of growth and maturation was dissociated in certain animals, and this dissociation was referable to the histological status of the kidneys and the presence or absence of amniotic fluid at delivery. Growth was normal when amniotic fluid was present or likely to have been present in late gestation, even with structurally damaged kidneys. With severe renal damage amniotic fluid was not restored even with in utero decompression and it resulted in severely impaired lung growth. Maturation was normal only in the presence of amniotic fluid and intact kidneys. The dissociation of lung growth and structural maturity suggests their independent regulation. The data suggest that the kidneys are important in early lung growth, while the presence of amniotic fluid contributes to growth later in gestation. Lung maturity requires both factors, suggesting a primary kidney contribution with the amniotic fluid acting in a permissive or supportive role.

Urinary levels of renal tubular enzyme N-acetyl-beta-D-glucosaminidase in relation to grade of vesicoureteral reflux

Elevated urinary levels of the renal tubular enzyme N-acetyl-beta-D-glucosaminidase (NAG) have been shown to be associated with tubular damage. To determine whether urinary levels of NAG would be abnormal and/or vary with the severity of vesicoureteral reflux, bladder urine was obtained from 31 children without reflux and 32 children with various grades of reflux. Nonrefluxing controls were obtained from children undergoing evaluation for a history of infection, hematuria or voiding abnormality. Patients with evidence of obstruction, neuropathic bladder dysfunction, urinary tract infection or renal failure were excluded. Bladder (32 cases) and ureteral (5 cases) urine from children with reflux was obtained at cystography or at antireflux surgery. Control and reflux patients were not significantly different with regard to sex or age. The mean urinary NAG level in nonrefluxing control patients was 10.63 IU/mg. (range 0.94 to 26.61, standard error of mean 0.43). Mean urinary NAG for all patients with reflux was 16.47 IU/mg. (range 2.85 to 52.02, standard error of mean 0.9). Two children with intrarenal reflux had urinary NAG levels of 52 and 48 IU/mg. Urinary NAG levels are elevated with higher grades of reflux and this relatively simple assay may have clinical usefulness in the assessment of tubular dysfunction associated with reflux.

Effect of reversible androgen deprivation on hemoglobin and serum immunoreactive erythropoietin in men

To examine the role of testosterone in the maintenance of hemoglobin levels, we studied the effect of reversible androgen deprivation on hemoglobin, serum immunoreactive erythropoietin, and serum testosterone in seven men treated with a luteinizing hormone-releasing factor (LHRH) agonist for 6 months and then followed for an additional 6 months. The mean serum testosterone level was 4.35 +/- 1.05 ng/ml initially and it decreased to castrate levels in all patients by 6 months. After stopping therapy, there was a rapid increase in serum testosterone such that by 12 months the mean concentration was normal. The pretreatment hemoglobin was 15.2 +/- 0.9 g/dl (mean +/- SD); after 6 months of androgen deprivation it had fallen to 14.1 +/- 0.4 g/dl (P less than 0.05). Six months after stopping therapy, the hemoglobin rose to pre-treatment levels. Before treatment, serum immunoreactive erythropoietin was 9.5 +/- 4.6 mu/ml (mean +/- SD) and did not change significantly during or after the 6 month period of androgen deprivation. No significant inhibition of burst-forming unit-erythroid (BFU-E) or colony-forming unit-granulocyte macrophage (CFU-GM) was observed at the serum level of nafarelin acetate obtainable in vivo. These data suggest that, within the normal range of hemoglobin in men, androgens are a determinant of the red cell mass.

Endoscopic injection of glutaraldehyde cross-linked bovine dermal collagen for correction of vesicoureteral reflux

From November 1986 through May 1989, a Food and Drug Administration approved investigational study was done to assess the safety and efficacy of glutaraldehyde cross-linked bovine dermal collagen in the endoscopic treatment of vesicoureteral reflux. Over-all, 57 patients (92 ureters) were treated. The majority of ureters (68.5%) had grade II to III/V vesicoureteral reflux (international classification). One treatment was given in 61.4% of the patients, while 33.3% required 2 and 5.3% required 3 treatments. Nonduplicated/primarily refluxing ureters comprised 68.5% of the total, while 13% were duplex/primarily refluxing and 18.5% were surgical failures. The procedures were performed on an outpatient basis in all but 3 patients. Patients were evaluated by voiding cystourethrogram and renal/bladder sonography before and after treatment at 1 month and 1 year. Cure at 1 month after the last treatment was achieved in 75% of the ureters. Among the ureters cured at 1 month the cure persisted in 79% at 1 year after treatment. Cure at 1 year was achieved in 65% of all ureters evaluated, regardless of the status at 1 month. Procedure-related morbidity was minimal and there were no adverse reactions to the implant substance. Thus, glutaraldehyde cross-linked bovine dermal collagen appears to be safe and effective in the endoscopic treatment of vesicoureteral reflux.

Structural genitourinary defects detected in utero

Fetal genitourinary anomalies are detected with increasing frequency due to the large numbers of fetuses that undergo screening ultrasonography (US) for nonspecific indications. One hundred seventy-seven patients were evaluated for fetal urinary abnormalities over a 2-year period. Fetal hydronephrosis accounted for 154 (87%) of the cases, with the remaining diagnoses including multicystic dysplastic kidney, autosomal recessive polycystic kidney disease, and renal agenesis or hypodysplasia. Ureteropelvic junction obstruction was the most common postnatal anatomic abnormality (29%), with a large number of cases of prenatally diagnosed hydronephrosis resolving either prenatally (33%) or postnatally (24%). Prenatal US findings were retrospectively analyzed with regard to the degree of hydronephrosis at different stages of gestation. Data showed that there is a gradual rise in anteroposterior renal pelvic diameter during gestation and that there is a correlation between this diameter and the ultimate renal outcome in regard to surgical repair. This information can provide guidance in making recommendations to parents and physicians.

Barium and antimony distributions on the hands of nonshooters

Barium and antimony levels from selected areas of the left and right hands of 269 nonshooters provide a database for interpretation of gunshot residue swab analysis results. The database represents a variety of activities of individuals sampled by collectors throughout the United States. Nonshooting exposure to barium and antimony can generally be distinguished from firearms-associated exposure by considering the relative levels of the elements, location on the hands, and condition of the swabs. Consistent definition of sampling procedures and accurate analytical results make this database applicable for interpretation of data generated by most gunshot residue swab examiners.

Flow cytometric evaluation of multicystic dysplastic kidneys

The most appropriate management of the multicystic dysplastic kidney remains controversial. At issue is the long-term risk of the development of malignancy in the multicystic dysplastic kidney. The association between renal dysplasia and neoplasia has not been confirmed, with only 6 cases of malignancy reported. Nephroblastomatosis, a probable precursor of Wilms tumor, has been found in 5 to 7% of the cases of multicystic dysplastic kidney when specifically sought. In an attempt to determine whether a relationship exists between renal dysplasia and neoplasia in terms of abnormalities of cellular deoxyribonucleic acid content we performed flow cytometric evaluation on 30 formalin fixed, paraffin embedded archival specimens of multicystic dysplastic kidneys. None of the kidneys had evidence of malignancy. Nuclear deoxyribonucleic acid ploidy studies were performed on single dissociated nuclei prepared by the technique of McLemore and associates and stained with propidium iodide. All specimens demonstrated a diploid pattern of deoxyribonucleic acid, including 3 specimens with nephroblastomatosis or extensive papillary growth, and no specimen demonstrated a tetraploid or aneuploid pattern. The mean G0/G1 fraction was 85.94% (standard deviation 4.59) and the mean S/G2/M fraction was 12.54% (standard deviation 4.72). These findings do not support or negate the potential for neoplasm associated with multicystic dysplastic kidney, since a diploid deoxyribonucleic acid pattern does not eliminate the possibility of the future development of malignancy.

The urodynamic consequences of posterior urethral valves

We evaluated urodynamically 41 patients with posterior urethral valves because of signs or symptoms of incontinence (35), frequency (3), hydronephrosis (2) and infection (1). Findings included normal urodynamic evaluations in 3 patients, 2 had high voiding pressures secondary to outlet resistance and 1 had incontinence on the basis of external urethral sphincter damage. In the remainder 3 patterns of bladder dysfunction were identified. Myogenic failure with overflow incontinence occurred in 14 patients. In this group clean intermittent catheterization or Valsalva's voiding was used for emptying. Hyperreflexic bladders were seen in 10 patients. Pharmacological suppression of instability was effective in 5 of 7 patients treated; 1 required bladder augmentation. Eleven children had a small capacity bladder and poor compliance. Post-void residuals were low and these bladders were generally but not always stable. Pharmacological bladder relaxation was successful in 3 patients, 3 underwent augmentation, 1 did well with alpha-agonists and followup is unavailable on the other 4. These 3 patterns of bladder dysfunction represent an overlapping constellation of residual urodynamic abnormalities due to previous bladder outlet obstruction. Individual patients may show facets of several types of dysfunction associated with 1 predominant pattern.

Experimental congenital obstructive uropathy

Continued experimental work in congenital obstructive uropathy is essential to support the rapidly advancing field of fetal medicine. It is possible to reproduce the clinically relevant obstructive lesions in an experimental model. On the basis of data from these models, the tentative conclusion is that in utero intervention is beneficial in severe congenital obstructive uropathy associated with oligohydramnios. The limited human experience provides insufficient data to confirm this hypothesis but has demonstrated the technical feasibility of prenatal interventions. There is a critical need for further refinement in understanding the complex pathophysiology of congenital obstructive uropathy, not only the renal consequences, but also the pulmonary and systemic effects. There remains the particular need to resolve the determinants and indicators of functional salvageability of the kidneys and lungs in congenital obstructive uropathy.

Current concepts in the perinatal diagnosis and management of hydronephrosis

Perinatal urology has become a significant facet of pediatric urologic practice. This article reviews the approaches to the diagnosis of prenatal hydronephrosis and its typical sonographic appearances in relation to the underlying pathology. A review of the outcomes of prenatal uropathology serves as a basis on which to interpret reports of prenatal intervention for hydronephrosis. A critical review of the experience of prenatal intervention is conditionally supportive of its benefits, but this view must be tempered by a recognition of the inherent risk to the mother and fetus. Included within this view is a recognition that not all hydronephrosis is caused by obstruction. More specific prognostic indicators of renal and pulmonary functional reserve are critically needed to permit appropriate patient selection. This must be coupled with more rigorous assessment of outcomes and complete reporting of the results. Continued basic and clinical research is important in developing these data. A management strategy for hydronephrosis in the prenatal and postnatal periods is presented, based on the goal of permitting maximal renal as well as pulmonary development in utero and in the newborn period.

Evaluation and management of urinary incontinence after surgery for posterior urethral valves

Posterior urethral valves lead to an overlapping constellation of urodynamic abnormalities, often many years after the initial diagnosis and valve ablation. Voiding dysfunction and urinary incontinence in boys with a history of valves are seldom the result of sphincteric incompetence. Three major categories of bladder dysfunction may cause voiding symptoms: myogenic failure, detrusor hyperreflexia, and bladder hypertonia. The interaction of the severity and duration of valve obstruction may be important factors, but the determinants of ultimate bladder function in the setting of urethral valves remain unclear. A careful urodynamic assessment is needed to define the abnormal bladder and to select and evaluate therapy. Therapy should be designed to provide low-pressure urinary storage for a socially acceptable period of time as well as complete emptying of the bladder. Success may require several lines of treatment and demands patience, not only of the patient and his family, but of the physician.

Splitting the pubis for exposure in difficult reconstructions for incontinence

We have presented our technique for and experience with splitting the symphysis to provide wide exposure in reconstructive surgery for incontinence. Our experience has demonstrated that the technique is widely applicable to many reconstructive situations in patients of all ages. We believe that spreading the pubic symphysis provides access to the urethra and bladder neck not otherwise possible and regard it as an important factor in the success of many difficult operations to correct incontinence. Although seemingly a radical maneuver, it did not cause complications in any of 51 cases.

Congenital obstructed megaureters in early infancy: diagnosis and treatment

Fetal screening during maternal ultrasonography has changed the mode and age of presentation of congenital uropathies, particularly congenital obstructed megaureter. We studied 47 infants less than 8 months old with primary obstructed megaureter. Surgical correction in 42 patients with moderate to severe obstruction was performed at a mean age of 1.8 months in those detected prenatally and 3.8 months in those presenting after birth. All infants showed functional and structural urographic improvement with a mean followup of 2.3 years. Reflux was seen postoperatively in 8 patients, which subsided spontaneously in 3, continues to be followed in 2 and resulted in repeat reimplantation in 3. Five infants had mild obstruction, which was managed nonoperatively and 2 showed progressive obstruction, which required repair at ages 20 and 28 months. Repair of obstructed megaureters in early infancy improves renal drainage and offers the potential for preventing renal damage before the development of symptoms or infection. With proper attention to detail, excellent results may be achieved.

The use of rectus fascia to manage urinary incontinence

The surgical management of urinary incontinence in children is one of the most difficult challenges facing pediatric urologists today. We have critically looked at our experience using a rectus fascial sling to prevent incontinence. Eleven girls (6 to 22 years old) with urinary incontinence from neurogenic bladder dysfunction (9), surgical injury to the bladder (1) or urogenital sinus abnormality (1) comprise this study. All had failed regimens of pharmacological therapy and intermittent catheterization. Three patients had undergone prior bladder neck reconstruction and 2 an augmentation cystoplasty in an attempt to control the incontinence. Urodynamic studies revealed several reasons for the continued wetting in these individuals: a changing neurological lesion leading to a loss of innervation and concomitantly lowered urethral resistance in 2 patients, adequate urethral resistance at rest but decreasing resistance with bladder filling in 4, no increase in urethral resistance with increases in abdominal pressure in 4 and urethral instability (a decrease in resistance following a cough or Valsalva's maneuver) in 1 apparently neurologically normal girl. Eight patients are dry 3 to 24 months postoperatively on intermittent catheterization. All have demonstrated either an increase in urethral resistance at rest or an adequate level of resistance during filling of the bladder or a sudden increase in abdominal pressure. Of the remaining 3 patients 1 is dry for 2 to 3 hours but then leakage occurs, 1 is improved but damp and 1 patient is wet 3 months postoperatively. The use of rectus fascia to improve outlet resistance seems to be a viable alternative in the management of incontinence in selected female subjects.

Congenital obstructed megaureters in early infancy: diagnosis and treatment

Fetal screening during maternal ultrasonography has changed the mode and age of presentation of congenital uropathies, particularly congenital obstructed megaureter. We studied 47 infants less than 8 months old with primary obstructed megaureter. Surgical correction in 42 patients with moderate to severe obstruction was performed at a mean age of 1.8 months in those detected prenatally and 3.8 months in those presenting after birth. All infants showed functional and structural urographic improvement with a mean followup of 2.3 years. Reflux was seen postoperatively in 8 patients, which subsided spontaneously in 3, continues to be followed in 2 and resulted in repeat reimplantation in 3. Five infants had mild obstruction, which was managed nonoperatively and 2 showed progressive obstruction, which required repair at ages 20 and 28 months. Repair of obstructed megaureters in early infancy improves renal drainage and offers the potential for preventing renal damage before the development of symptoms or infection. With proper attention to detail, excellent results may be achieved.

Congenital obstructed megaureters in early infancy: diagnosis and treatment

Fetal screening during maternal ultrasonography has changed the mode and age of presentation of congenital uropathies, particularly congenital obstructed megaureter. We studied 47 infants less than 8 months old with primary obstructed megaureter. Surgical correction in 42 patients with moderate to severe obstruction was performed at a mean age of 1.8 months in those detected prenatally and 3.8 months in those presenting after birth. All infants showed functional and structural urographic improvement with a mean followup of 2.3 years. Reflux was seen postoperatively in 8 patients, which subsided spontaneously in 3, continues to be followed in 2 and resulted in repeat reimplantation in 3. Five infants had mild obstruction, which was managed nonoperatively and 2 showed progressive obstruction, which required repair at ages 20 and 28 months. Repair of obstructed megaureters in early infancy improves renal drainage and offers the potential for preventing renal damage before the development of symptoms or infection. With proper attention to detail, excellent results may be achieved.

Splitting the pubis for exposure in difficult reconstructions for incontinence

In the last 13 years splitting the pubic symphysis has been used in 46 patients 1 to 32 years old for wide access to the bladder neck and entire urethra in female, or the bladder neck and urethra down into the bulb in male patients. Each patient had a complex problem to reconstruct and most had undergone a prior operation. Underlying pathological conditions included exstrophy in 16 patients, epispadias in 11, cloacal exstrophy in 6, posterior urethral valves in 3, severe trauma in 2, bilateral single ectopic ureters in 2, radical surgery for sarcoma in 2, myelodysplasia in 2, cloacal anomaly in 1 and iatrogenic injury of the urethra in 1. The pubis, or interpubic ligament in exstrophy cases, was divided in the midline. The pubic rami were spread with a laminectomy spreader to create a gap sufficient to operate on that segment of the urethra, which is usually not accessible with an intact pubis. No patient had a problem of nonunion or pubic osteitis after using this approach. This series includes 2 patients undergoing simultaneous iliac osteotomies for a widened symphysis pubis. In no patient was a segment of pubis resected, as has been used in transpubic repair of certain traumatic urethral strictures.

The influence of reversible androgen deprivation on serum prostate-specific antigen levels in men with benign prostatic hyperplasia

This study was designed to investigate the relationship of serum prostate-specific antigen to prostatic size and hormonal stimulation. Seven patients with benign prostatic hyperplasia were treated for six months with nafarelin acetate and then followed for an additional six months. Nafarelin acetate is a potent luteinizing-hormone-releasing hormone agonist which causes reversible testosterone deprivation resulting in involution of the prostate. During therapy and follow up, serum prostate-specific antigen correlated with: 1) serum testosterone (p less than 0.001); 2) quantity of prostatic epithelium (p less than 0.001); and 3) prostatic size (p less than 0.05). Before therapy, serum prostate-specific antigen (mean +/- SD) was 0.43 +/- 0.2 ng./ml. per gram of epithelium. This did not change significantly after six months of androgen deprivation (0.48 +/- 0.36), although the ratios of prostate-specific antigen to testosterone and to prostatic size each changed significantly. Despite testosterone levels in the castrate range at six months, five of seven patients had serum prostate-specific antigen concentrations above the female range and three of seven patients had prostatic biopsies containing columnar epithelium which stained positively for prostate-specific antigen. These results demonstrate that serum prostate-specific antigen is related to prostatic size, prostatic epithelial weight, and testosterone stimulation. However, prostatic size is not a good predictor of serum prostate-specific antigen because there is tremendous variation in the relative amount of epithelium in a prostate; in this study the ratio of prostatic size to epithelial weight varied threefold. Furthermore, although testosterone determines prostatic size and amount of prostatic epithelium, it may not totally control prostate-specific antigen production.

Myths of antiemetic administration

Chemotherapy as a treatment modality for cancer has dramatically improved outcomes for patients. However, to attain therapeutic benefit, side effects and toxicities must be endured. Among the most frequent and distressing side effects are nausea and vomiting. The experience of nausea and vomiting may become so devastating that patients will discontinue curative treatment modalities. The major responsibility of the nurse caring for a patient receiving chemotherapy treatment is to prevent or treat nausea and vomiting effectively. To accomplish this, the nurse needs to understand how nausea and vomiting occur, the action of antiemetics, and how to administer them. There are myths, beliefs, and/or practice behaviors that influence interventions for antiemetic administration. Successful nursing interventions to control nausea and vomiting may be less than optimal when myths instead of correct facts affect the interventions.

Hearing impairment as a predictor of cognitive decline in dementia

Thirty-eight patients with dementia of various etiologies were studied longitudinally to determine the change in cognition over time in subjects with and without hearing impairment. Hearing impaired subjects were older (P less than .0001), but subject groups were otherwise comparable with respect to living arrangements, medical illness, number of drugs taken, mood, years of education, and cognitive functioning at the beginning of the study period. Decline in cognitive functioning at follow-up was greater in hearing impaired subjects and this difference persisted after adjustment for the greater age of hearing impaired subjects (P less than .009). Further division of subject by diagnosis showed that only in the Alzheimer's group did hearing impairment predict more rapid cognitive decline at follow-up.

Epispadias and incontinence: the challenge of the small bladder

The 12-year experience at our hospital with epispadias and incontinence is reviewed and attention is focused on the approach to patients with a small bladder capacity. Of 29 children 20 had incontinence associated with the epispadias (13 boys and 7 girls). A total of 15 patients underwent definitive management of the incontinence with a Young-Dees bladder neck reconstruction with or without ureteral reimplantation and they are evaluable. Nine patients (6 boys and 3 girls) had a bladder capacity that was believed to be inadequate for satisfactory bladder neck reconstruction (less than 60 ml.). To date, 7 of these children have undergone staged reconstruction with urethroplasty for epispadias as the initial operation. Bladder capacity increased 95 ml. on the average (range 60 to 140 ml.) after the urethroplasty. No child had hydronephrosis before or after bladder neck reconstruction. Review of the results of bladder neck reconstruction in all patients with a mean followup of 2.9 years (range 7 months to 13 years) demonstrates an 87 per cent satisfactory continence rate (9 of 9 boys and 4 of 6 girls). In the patients who underwent staged reconstruction the results were similar, with a 100 per cent continence rate in evaluable patients (5 of 5 boys and 2 of 2 girls). In conclusion, urethroplasty before bladder neck reconstruction in the epispadiac child with a small bladder allows an increase in capacity, thus, obviating for the most part the need for procedures such as bladder augmentation in the majority of these patients.

Stimulation of neutrophil production in CSF-1-responsive clones

The hematopoietic growth factor CSF-1 has been considered relatively lineage specific for the production of macrophages, whereas GM-CSF elicits a predominance of neutrophils. It is likely that in vivo, individual clones are stimulated by the two CSFs, although the effect of dual stimulation on progenitors and their progeny has not been completely explored. We found that in cultures initiated with low concentrations of CSF-1 or GM-CSF, alone or in combination, production of macrophages predominated. Maximally stimulatory concentrations of CSF-1 elicited a predominance of macrophages, whereas maximal GM-CSF elicited many more neutrophil/macrophage colonies and pure neutrophil colonies. A combination of maximal CSF-1 and GM-CSF elicited the same differentiation as GM-CSF alone. Delayed addition of GM-CSF to cultures initiated with CSF-1 elicited colonies indistinguishable from GM-CSF alone, suggesting that neutrophil production had been switched on by GM-CSF. In mapping studies, colonies initiated by CSF-1 increased or switched on neutrophil production when GM-CSF was added as a second stimulus. These studies show that individual clones are responsive to both CSFs, and that the differentiating influence of GM-CSF predominates over that of CSF-1. In cultures to which only CSF-1 was added, a population of progenitors was sustained that produced neutrophils only after a GM-CSF stimulus. Thus, CSF-1 may participate in maintaining a reserve of progenitors for neutrophils during periods of increased neutrophil demand.

The effect of nafarelin acetate, a luteinizing-hormone-releasing hormone agonist, on benign prostatic hyperplasia

We examined the influence of androgens on benign prostatic hyperplasia, using nafarelin acetate, a potent luteinizing-hormone-releasing hormone agonist, to achieve reversible androgen deprivation in men with benign prostatic hyperplasia. Nine patients with bladder-outlet obstruction due to benign prostatic hyperplasia were treated with subcutaneous nafarelin acetate (400 micrograms per day) in an open trial for six months. In all patients, serum testosterone decreased to castrate levels. Objective observations included uroflowmetry, measurement of residual urine volume, determination of prostatic size by ultrasonography, and prostatic biopsy. In all patients, the prostate regressed to a mean (+/- SEM) of 75.8 +/- 3 percent of the initial size (range, 52 to 86; P less than 0.005); the regression reached a plateau after four months. Morphologic analysis of biopsy specimens showed regression of glandular epithelium. Three of nine patients had clinical improvement with treatment. Six months after the cessation of treatment, plasma testosterone levels had returned to normal and the size of the prostate had increased to 99 +/- 5.5 percent of the initial size. These findings suggest that androgens have an important supportive role in established benign prostatic hyperplasia and that testicular suppression will benefit some patients. However, this form of treatment could be applicable only in carefully selected patients who were not surgical candidates, and it would need to be maintained indefinitely.

A new method for labeling and autoradiographic localization of androgen receptors

We have used a novel receptor labeling and autoradiographic technique to localize androgen receptors in the intact rat ventral prostate at the morphological level. Frozen slide-mounted prostate tissue sections (10 micron thick) were incubated with increasing concentrations of [3H]-R1881 in the absence and presence of excess unlabeled R1881. Tissue sections labeled in this way were subjected to concurrent biochemical and autoradiographic analysis. After incubation and washing to remove free [3H]-steroid, some of the sections were wiped from the slides for scintillation counting in order to characterize and quantitate [3H]-R1881 binding. Androgen receptors could indeed be labeled in slide-mounted tissue sections, and specific [3H]-R1881 binding to these receptors was high-affinity (Kd = 1 nM), saturable, and androgen-specific. All cellular androgen receptors appear to be retained, because receptor content in sections was comparable to the sum of receptors in subcellular fractions of homogenized tissue. Replicate labeled slide-mounted tissue sections were dried rapidly, apposed to dry emulsion-coated coverslips, and exposed in the dark for autoradiography. Silver grains were counted over nuclei or cytoplasm of epithelium or stroma to evaluate specific androgen receptor location. Autoradiographic analysis demonstrated androgen receptor localization almost exclusively in the epithelial nuclei, with little or none in the stroma. We discuss here the unique features and advantages of labeling androgen receptors in slide-mounted frozen tissue sections for autoradiographic localization.