Does KUB play a role in the diagnosis of bladder bowel dysfunction?

INTRODUCTION

Kidney ureter bladder radiography (KUB) is widely used for the evaluation of constipation in children with bladder and bowel dysfunction (BBD); however, there is varying evidence to support its routine diagnostic use. One drawback to KUB is radiation exposure. The dangers of radiation in children are well-documented, and per As Low As Reasonably Achievable, non-beneficial radiation should be avoided. This risk is especially high in children who undergo repeated imaging in the follow up of constipation treatment.

OBJECTIVE

We sought to assess the utility of KUB in diagnosing children with BBD by comparing it to four diagnostic tests and/or validated instruments: the Dysfunctional Voiding Symptom Score (DVSS), Rome IV criteria, rectal diameter on ultrasound (RD), and the Bristol Stool Form Score (BSFS).

STUDY DESIGN

We prospectively enrolled a cohort of patients presenting to an academic pediatric urology practice with symptoms of BBD. Severity of stool burden on KUB (mild, moderate, or severe), RD on ultrasound (≥3.4 cm), DVSS, Rome IV, and BSFS were obtained for each patient. All imaging was interpreted by a pediatric radiologist and pediatric urologist. Primary outcomes were the association between the four diagnostic tests and KUB stool burden. Bivariate analysis of all individual variables versus KUB was performed, as well as multivariate regressions to determine if multiple measures were predictive of KUB stool burden when combined.

RESULTS

Between October 2020 and May 2022, 50 patients were enrolled. All children were under the age of 18, with a median age of 8 years (IQR 3-13). 38 % were male. Median BMI-for-age-percentile was 80.8 (IQR 50.3-98.3). When comparing individual variables to KUB in bivariate analyses, it was found that RD on ultrasound is predictive of significant stool burden on KUB (p = 0.03). No other individual variables were predictive. In the multivariate analyses, no combination of tests was found to be predictive of KUB.

DISCUSSION

We compared the effectiveness of four commonly used diagnostic tests in children with BBD to validate the use of KUB. In conclusion, our results support the use of RD on ultrasound as a non-radiating alternative to KUB to assess stool burden. Data also suggest that KUB for fecal load does not correlate with urinary (DVSS) or bowel (Rome IV, BSFS) symptoms in BBD, and that symptoms scores should still be used independently for diagnosis and monitoring of treatment response.

CONCLUSION

In conclusion, KUB has a limited role in the diagnosis of BBD.

Contemporary disparities in progression to orchiopexy for cryptorchidism as reported in the Pediatric Health Information System (PHIS) database

INTRODUCTION

When evaluating the timeliness of orchiopexy for cryptorchidism, health disparities are apparent among Hispanic and African American males and those with public insurance. Since the publication of these data, the COVID-19 pandemic has stressed our healthcare system and significantly affected the provision of pediatric urology care.

OBJECTIVE

We sought to assess if certain groups were disproportionately affected in progression to orchiopexy after the diagnosis of cryptorchidism during and after the pandemic in US freestanding children's hospitals.

STUDY DESIGN

Using the PHIS database, pediatric patients ≤5 years who underwent orchiopexy between January 2018 and December 2022 were retrospectively analyzed. Exclusion criteria included prematurity, retractile testes, and testicular torsion. Primary outcomes were age at orchiopexy and the proportion of individuals undergoing timely orchiopexy for cryptorchidism.

RESULTS

Over the study period 3140 patients ≤5 years old underwent orchiopexy for cryptorchidism. Non-Hispanic Blacks and Hispanics were significantly less likely to have timely orchiopexy and underwent orchiopexy 2.13 and 3.60 months later compared to whites (p < 0.01). As compared to pre-COVID-19, during the pandemic the proportion of patients who had timely surgery was higher and the median age was significantly lower (p = 0.01 and p < 0.01, respectively) in white patients only. Over the study period, patients with public insurance were less likely to have timely orchiopexy and underwent orchiopexy 2.94 months later (p < 0.01) than patients with private insurance. Compared to during the pandemic, post-pandemic a significantly lower proportion of publicly insured patients have since undergone timely orchiopexy (p = 0.04). Patients in the West were less likely to have timely orchiopexy and had a higher age at time of orchiopexy (p < 0.01) than other regions. However, in the West during the pandemic, the proportion of children who had timely surgery was higher compared to pre-and post-COVID-19 (p < 0.01).

DISCUSSION

Overall, regardless of insurance status, race, or location, a significant proportion of patients did not undergo timely orchiopexy. During the pandemic white patients had a lower median age and an increased proportion underwent timely orchiopexy, despite the number of orchiopexies remaining constant. Disparities in the post-COVID-19 era have been further exacerbated for publicly insured patients, who a significantly lower proportion of have since undergone timely orchiopexy. Specific efforts are required across the United States to increase timely orchiopexy for all boys.

CONCLUSIONS

Progression to timely orchiopexy remains low for all boys in the era surrounding COVID-19; certain groups appear to be more adversely affected.

Inter-disciplinary provider development of an online, interactive adolescent varicocele decision aid prototype

BACKGROUND

Decision-making regarding varicocele management can be a complex process for patients and families. However, to date, no studies have presented ways to mitigate the decisional conflict surrounding varicoceles.

OBJECTIVE

To facilitate a discussion among physicians in order to develop a framework of the decision-making process regarding adolescent varicocele management, which will inform the development of the first online, interactive decision aid.

MATERIALS AND METHODS

Semi-structured interviews with pediatric urologists and interventional radiologists were conducted to discuss their rationale for varicocele decision-making. Interviews were audio recorded, transcribed, and coded. Key themes were identified, grouped, and then qualitatively analyzed using thematic analysis. Utilizing the common themes identified and the Ottawa Decision Support Framework, a decision aid prototype was developed and transformed into a user-friendly website: varicoceledecisionaid.com.

RESULTS

Pediatric urologists (n = 10) and interventional radiologists (n = 2) were interviewed. Key themes identified included: (1) definition/epidemiology; (2) observation as an appropriate management choice; (3) reasons to recommend repair; (4) types of repair; (5) reasons to recommend one repair over another; (6) shared decision-making; and (7) appropriate counseling. With this insight, a varicocele decision aid prototype was developed that engages patients and parents in the decision-making process.

DISCUSSION AND CONCLUSIONS

This is the first interactive and easily accessible varicocele decision aid prototype developed by inter-disciplinary physicians for patients. This tool aids in decision-making surrounding varicocele surgery. It can be used before or after consultation to help families understand more about varicoceles and their repair, and why intervention may or may not be offered. It also considers a patient and family's personal values. Future studies will incorporate the patient and family perspective into the decision-making aid as well as implement and test the usability of this decision aid prototype in practice and in the wider urologic community.

Epoxyeicosatrienoic acid administration or soluble epoxide hydrolase inhibition attenuates renal fibrogenesis in obstructive nephropathy

Epoxyeicosatrienoic acids (EETs) are arachidonic acid metabolites with biological effects, including antiapoptotic, anti-inflammatory, and antifibrotic functions. Soluble epoxide hydrolase (sEH)-mediated hydrolysis of EETs to dihydroxyeicosatrienoic acids (DHETs) attenuates these effects. Recent studies have demonstrated that inhibition of sEH prevents renal tubulointerstitial fibrosis and inflammation in the chronic kidney disease model. Given the pathophysiological role of the EET pathway in chronic kidney disease, we investigated if administration of EET regioisomers and/or sEH inhibition will promote antifibrotic and renoprotective effects in renal fibrosis following unilateral ureteral obstruction (UUO). EETs administration abolished tubulointerstitial fibrogenesis, as demonstrated by reduced fibroblast activation and collagen deposition after UUO. The inflammatory response was prevented as demonstrated by decreased neutrophil and macrophage infiltration and expression of cytokines in EET-administered UUO kidneys. EET administration and/or sEH inhibition significantly reduced M1 macrophage markers, whereas M2 macrophage markers were highly upregulated. Furthermore, UUO-induced oxidative stress, tubular injury, and apoptosis were all downregulated following EET administration. Combined EET administration and sEH inhibition, however, had no additive effect in attenuating inflammation and renal interstitial fibrogenesis after UUO. Taken together, our findings provide a mechanistic understanding of how EETs prevent kidney fibrogenesis during obstructive nephropathy and suggest EET treatment as a potential therapeutic strategy to treat fibrotic diseases.NEW & NOTEWORTHY Epoxyeicosatrienoic acids (EETs) are cytochrome P-450-dependent antihypertensive and anti-inflammatory derivatives of arachidonic acid, which are highly abundant in the kidney and considered renoprotective. We found that EET administration and/or soluble epoxide hydrolase inhibition significantly attenuates oxidative stress, renal cell death, inflammation, macrophage differentiation, and fibrogenesis following unilateral ureteral obstruction. Our findings provide a mechanistic understanding of how EETs prevent kidney fibrogenesis during obstructive nephropathy and suggest that EET treatment may be a potential therapeutic strategy to treat fibrotic diseases.

The Assessment of TikTok as a Source of Quality Health Information on Varicoceles

OBJECTIVE

To evaluate the quality of varicocele information on TikTok, a popular video platform that adolescent patients are now turning to as a source of medical information before visiting a doctor.

METHODS

Using the key word "varicocele," we retrieved the top 225 videos listed on TikTok in May 2022. We extracted general video and engagement data. Video information was coded and analyzed for the completeness of different types of content (definition, symptoms, evaluation, management, and outcomes). The quality of consumer health information was rated using the DISCERN instrument.

RESULTS

Thirty-six videos met inclusion criteria; 17 were created by general users, 16 by healthcare professionals or systems (2 by urologists), and 3 by scientific communities. Healthcare professionals had more views than non-healthcare (P = .05). The quality of health information using the DISCERN instrument was "poor" from health care professional videos and "very poor" from non-health care professionals. However, the quality of information provided by healthcare professionals was statistically better than that of non-healthcare (P< .05). Video content mainly focused on symptoms: 50% of videos from healthcare providers had some or extensive content and 41% of non-healthcare had some content. 23% of videos had misinformation.

CONCLUSION

The overall quality of information for varicoceles on TikTok is not acceptable and does not meet patient needs. It is imperative that urologists create robust, accurate content, and partner with these platforms to connect users with higher quality information. TikTok users should also be mindful that information may not be medically accurate.

Hepatic and proximal tubule angiotensinogen play distinct roles in kidney dysfunction, glomerular and tubular injury, and fibrosis progression

Components of the renin-angiotensin system, including angiotensinogen (AGT), are critical contributors to chronic kidney disease (CKD) development and progression. However, the specific role of tissue-derived AGTs in CKD has not been fully understood. To define the contribution of liver versus kidney AGT in the CKD development, we performed 5/6 nephrectomy (Nx), an established CKD model, in wild-type (WT), proximal tubule (PT)- or liver-specific AGT knockout (KO) mice. Nx significantly elevated intrarenal AGT expression and elevated blood pressure (BP) in WT mice. The increase of intrarenal AGT protein was completely blocked in liver-specific AGT KO mice with BP reduction, suggesting a crucial role for liver AGT in BP regulation during CKD. Nx-induced glomerular and kidney injury and dysfunction, as well as fibrosis, were all attenuated to a greater extent in liver-specific AGT KO mice compared with PT-specific AGT KO and WT mice. However, the suppression of interstitial fibrosis in PT- and liver-specific AGT KO mouse kidneys was comparable. Our findings demonstrate that liver AGT acts as a critical contributor in driving glomerular and tubular injury, renal dysfunction, and fibrosis progression, whereas the role of PT AGT was limited to interstitial fibrosis progression in chronic renal insufficiency. Our results provide new insights for the development of tissue-targeted renin-angiotensin system intervention in the treatment of CKD.NEW & NOTEWORTHY Chronic kidney disease (CKD) is a major unmet medical need with no effective treatment. Current findings demonstrate that hepatic and proximal tubule angiotensinogen have distinct roles in tubular and glomerular injury, fibrogenesis, and renal dysfunction during CKD development. As renin-angiotensin system components, including angiotensinogen, are important targets for treating CKD in the clinic, the results from our study may be applied to developing better tissue-targeted treatment strategies for CKD and other fibroproliferative diseases.

Bilateral Ureterovesical Junction Obstruction Resulting in Anuria in a Three-Week-Old Infant

Bilateral megaureter with ureterovesical junction obstruction is exceedingly rare. We present a case of a 3-week-old boy who presented in acute renal failure and found to have bilateral megaureter. He was initially decompressed with bilateral percutaneous nephrostomy tubes and once stable underwent bilateral ureterostomy. At 6 months old, renal ultrasound showed stable mild right sided hydronephrosis.

Hypospadias in toddlers: a multivariable study of prognostic factors in distal to mid-shaft hypospadias and review of literature

Background

Tubularized incised plate urethroplasty is the most common hypospadias repair technique. However, there are unanswered questions and debates about the anatomical prognostic factors affecting the repair outcomes. This study tried to address some of the problems in the studies compromising the results of the current body of literature.

Methods

A prospective cohort of 101 males aged 1–3 years undergoing primary distal to mid-shaft hypospadias repair were enrolled in the study. Complications including edema, erection, inadvertent removal of the urethral stent, surgical wound infection, bladder spasm, hematoma, and hemorrhage were evaluated. Studies in the current literature were reviewed to achieve a better perspective for future investigations.

Results

Persistent complications were found in 16 cases (15.8%) including fistula formation, the persistence of chordee, meatal stenosis, glans, and urethral dehiscence. The mean follow-up time was 6.6±3.4 months. In the single-variable analysis, the meatal location, the length and width of the urethral plate, and the reversible acute postoperative events were significantly associated with the complications. Furthermore, fistula formation was associated with acute surgical site infection (p<0.001). However, the multivariable regression study revealed the presurgical meatal location to be the only statistically significant factor (p=0.03). Notably, the glans diameter or glanular groove shape, urethral plate dimensions, or presence of mild chordee were not independently associated with the outcomes (p>0.05).

Conclusions

Our study on the toddlers with hypospadias surgery revealed that the location of urethral meatal was the main predicting factor in the development of major complications. Furthermore, the fistula formation at the infected surgical site emphasizes the importance of postsurgical care.

A novel urinary biomarker protein panel to identify children with ureteropelvic junction obstruction - A pilot study

INTRODUCTION AND OBJECTIVE

Reliable urinary biomarker proteins would be invaluable in identifying children with ureteropelvic junction obstruction (UPJO) as the existing biomarker proteins are inconsistent in their predictive ability. Therefore, the aim of this study was to identify consistent and reliable urinary biomarker proteins in children with UPJO.

METHODS

To identify candidate biomarker proteins, total protein from age-restricted (<2 years) and sex-matched (males) control (n = 22) and UPJO (n = 21) urine samples was analyzed by mass spectrometry. Proteins that were preferentially identified in UPJO samples were selected (2-step process) and ranked according to their diagnostic odds ratio value. The top ten proteins with highest odds ratio values were selected and tested individually by ELISA. The total amount of each protein was normalized to urine creatinine and the median with interquartile ranges for control and UPJO samples was determined. Additionally, fold change (UPJO/Control) of medians of the final panel of 5 proteins was also determined. Finally, we calculated the average + 3(SD) and average + 4(SD) values of each of the 5 proteins in the control samples and used it as an arbitrary cutoff to classify individual control and UPJO samples.

RESULTS

In the first step of our selection process, we identified 171 proteins in UPJO samples that were not detected in the majority of the control samples (16/22 samples, or 72.7%). Of the 171 proteins, only 50 proteins were detected in at least 11/21 (52.4%) of the UPJO samples and hence were selected in the second step. Subsequently, these 50 proteins were ranked according to the odds ratio value and the top 10 ranked proteins were validated by ELISA. Five of the 10 proteins - prostaglandin-reductase-1, ficolin-2, nicotinate-nucleotide pyrophosphorylase [carboxylating], immunoglobulin superfamily-containing leucine-rich-repeat-protein and vascular cell adhesion molecule-1 were present at higher levels in the UPJO samples (fold-change of the median protein concentrations ranging from 2.9 to 9.4) and emerged as a panel of biomarkers to identify obstructive uropathy. Finally, the order of prevalence of the 5 proteins in UPJO samples is PTGR1>FCN2>QPRT>ISLR>VCAM1.

CONCLUSION

In summary, this unique screening strategy led to the identification of previously unknown biomarker proteins that when screened collectively, may reliably distinguish between obstructed vs. non-obstructed infants and may prove useful in identifying informative biomarker panels for biological samples from many diseases.

Proximal tubule cyclophilin D regulates fatty acid oxidation in cisplatin-induced acute kidney injury

Regardless of the etiology, acute kidney injury involves aspects of mitochondrial dysfunction and ATP depletion. Fatty acid oxidation is the preferred energy source of the kidney and is inhibited during acute kidney injury. A pivotal role for the mitochondrial matrix protein, cyclophilin D in regulating overall cell metabolism is being unraveled. We hypothesize that mitochondrial interaction of proximal tubule cyclophilin D and the transcription factor PPARα modulate fatty acid beta-oxidation in cisplatin-induced acute kidney injury. Cisplatin injury resulted in histological and functional damage in the kidney with downregulation of fatty acid oxidation genes and increase of intrarenal lipid accumulation. However, proximal tubule-specific deletion of cyclophilin D protected the kidneys from the aforementioned effects. Mitochondrial translocation of PPARα, its binding to cyclophilin D, and sequestration led to inhibition of its nuclear translocation and transcription of PPARα-regulated fatty acid oxidation genes during cisplatin-induced acute kidney injury. Genetic or pharmacological inhibition of cyclophilin D preserved nuclear expression and transcriptional activity of PPARα and prevented the impairment of fatty acid oxidation and intracellular lipid accumulation. Docking analysis identified potential binding sites between PPARα and cyclophilin D. Thus, our results indicate that proximal tubule cyclophilin D elicits impaired mitochondrial fatty acid oxidation via mitochondrial interaction between cyclophilin D and PPARα. Hence, targeting their interaction may be a potential therapeutic strategy to prevent energy depletion, lipotoxicity and cell death in cisplatin-induced acute kidney injury.

Local Control of Perineal Rhabdomyosarcoma: Are Current Recommendations Adequate?

Rhabdomyosarcoma (RMS) is a rare malignancy that can develop in nearly any soft-tissue of the body. Location of the primary tumor affects treatment strategy and prognosis, and RMS of the perineal areas can be especially difficult to treat successfully. RMS is treated systemically with chemotherapy. Local control options include surgical excision, radiation treatment, or a combination of the 2. Treating RMS with radiation treatment can be challenging due to the absence of standardized dosage protocols, along with the presence of conflicting recommendations in the literature. Each case of perineal RMS may benefit from a more individualized treatment plan.

Cell-intrinsic sphingosine kinase 2 promotes macrophage polarization and renal inflammation in response to unilateral ureteral obstruction

Sphingosine Kinase-2 (Sphk2) is responsible for the production of the bioactive lipid Sphingosine-1 Phosphate, a key regulator of tissue repair. Here we address the in vivo significance of Sphingosine Kinase -2 in renal inflammation/fibrosis in response to unilateral ureteral obstruction using both genetic and pharmacological strategies. Obstructed kidneys of Sphk2^-/- mice showed reduced renal damage and diminished levels of the renal injury markers TGFβ₁ and αSMA when compared to wild type controls. We found a consistently significant increase in anti-inflammatory (M2) macrophages in obstructed Sphk2^-/- kidneys by flow cytometry and a decrease in mRNA levels of the inflammatory cytokines, MCP1, TNFα, CXCL1 and ILβ₁, suggesting an anti-inflammatory bias in the absence of Sphk2. Indeed, metabolic profiling showed that the pro-inflammatory glycolytic pathway is largely inactive in Sphk2^-/- bone marrow-derived macrophages. Furthermore, treatment with the M2-promoting cytokines IL-4 or IL-13 demonstrated that macrophages lacking Sphk2 polarized more efficiently to the M2 phenotype than wild type cells. Bone marrow transplant studies indicated that expression of Sphk2^-/- on either the hematopoietic or parenchymal cells did not fully rescue the pro-healing phenotype, confirming that both infiltrating M2-macrophages and the kidney microenvironment contribute to the damaging Sphk2 effects. Importantly, obstructed kidneys from mice treated with an Sphk2 inhibitor recapitulated findings in the genetic model. These results demonstrate that reducing Sphk2 activity by genetic or pharmacological manipulation markedly decreases inflammatory and fibrotic responses to obstruction, resulting in diminished renal injury and supporting Sphk2 as a novel driver of the pro-inflammatory macrophage phenotype.

PSMA redirects cell survival signaling from the MAPK to the PI3K-AKT pathways to promote the progression of prostate cancer

Increased abundance of the prostate-specific membrane antigen (PSMA) on prostate epithelium is a hallmark of advanced metastatic prostate cancer (PCa) and correlates negatively with prognosis. However, direct evidence that PSMA functionally contributes to PCa progression remains elusive. We generated mice bearing PSMA-positive or PSMA-negative PCa by crossing PSMA-deficient mice with transgenic PCa (TRAMP) models, enabling direct assessment of PCa incidence and progression in the presence or absence of PSMA. Compared with PSMA-positive tumors, PSMA-negative tumors were smaller, lower-grade, and more apoptotic with fewer blood vessels, consistent with the recognized proangiogenic function of PSMA. Relative to PSMA-positive tumors, tumors lacking PSMA had less than half the abundance of type 1 insulin-like growth factor receptor (IGF-1R), less activity in the survival pathway mediated by PI3K-AKT signaling, and more activity in the proliferative pathway mediated by MAPK-ERK1/2 signaling. Biochemically, PSMA interacted with the scaffolding protein RACK1, disrupting signaling between the β₁ integrin and IGF-1R complex to the MAPK pathway, enabling activation of the AKT pathway instead. Manipulation of PSMA abundance in PCa cell lines recapitulated this signaling pathway switch. Analysis of published databases indicated that IGF-1R abundance, cell proliferation, and expression of transcripts for antiapoptotic markers positively correlated with PSMA abundance in patients, suggesting that this switch may be relevant to human PCa. Our findings suggest that increase in PSMA in prostate tumors contributes to progression by altering normal signal transduction pathways to drive PCa progression and that enhanced signaling through the IGF-1R/β₁ integrin axis may occur in other tumors.

Proximal tubule proteins are significantly elevated in bladder urine of patients with ureteropelvic junction obstruction and may represent novel biomarkers: A pilot study

PURPOSE

Ureteropelvic junction obstruction (UPJO) is the major cause of hydronephrosis in children and may lead to renal injury and early renal dysfunction. However, diagnosis of the degree of obstruction and severity of renal injury relies on invasive and often inconclusive renal scans. Biomarkers from voided urine that detect early renal injury are highly desirable because of their noninvasive collection and their potential to assist in earlier and more reliable diagnosis of the severity of obstruction. Early in response to UPJO, increased intrarenal pressure directly impacts the proximal tubule brush border. We hypothesize that single-pass, apically expressed proximal tubule brush border proteins will be shed into the urine early and rapidly and will be reliable noninvasive urinary biomarkers, providing the tools for a more reliable stratification of UPJO patients.

MATERIALS AND METHODS

We performed a prospective cohort study at Connecticut Children's Medical Center. Bladder urine samples from 12 UPJO patients were obtained prior to surgical intervention. Control urine samples were collected from healthy pediatric patients presenting with primary nocturnal enuresis. We determined levels of NGAL, KIM-1 (previously identified biomarkers), CD10, CD13, and CD26 (potentially novel biomarkers) by ELISA in control and experimental urine samples. Urinary creatinine levels were used to normalize the urinary protein levels measured by ELISA.

RESULTS

Each of the proximal tubule proteins outperformed the previously published biomarkers. No differences in urinary NGAL and KIM-1 levels were observed between control and obstructed patients (p = 0.932 and p = 0.799, respectively). However, levels of CD10, CD13, and CD26 were significantly higher in the voided urine of obstructed individuals when compared with controls (p = 0.002, p = 0.024, and p = 0.007, respectively) (Figure).

CONCLUSIONS

Targeted identification of reliable, noninvasive biomarkers of renal injury is critical to aid in diagnosing patients at risk, guiding therapeutic decisions and monitoring treatment efficacy. Proximal tubule brush border proteins are reliably detected in the urine of obstructed patients and may be more effective at predicting UPJO.

Objective pain assessment after ureteral reimplantation: comparison of open versus robotic approach

INTRODUCTION

While open ureteral reimplantation is the gold standard of surgical intervention for vesicoureteral reflux (VUR), minimally invasive approaches offer the potential benefits of decreased postoperative pain, improved cosmesis, and shorter hospital stay and convalescence. Studies comparing open and minimally invasive surgery with respect to postoperative pain in children have been inconclusive.

OBJECTIVE

We sought to compare postoperative pain in children undergoing open versus robotic ureteral reimplantation by using age-appropriate, validated pain assessment scales.

METHODS

A prospective cohort of all patients enrolled in an Institutional Review Board-approved VUR surgery registry between July 2010 and February 2013 was analyzed. Patients who underwent endoscopic treatment or who received caudal or epidural anesthesia were excluded. Age-appropriate, validated pain scales ranging from 0 to 10 were utilized for pain assessment. Pain scores and narcotic doses administered on the first postoperative day were analyzed.

RESULTS

Of the 34 subjects included, 11 underwent open intravesical reimplantation, while 23 patients underwent robotic extravesical reimplantation. Table 1 displays patient characteristics and results of pain assessment. Robotic surgery was associated with lower narcotic requirement compared to open surgery (P < 0.05). The difference in pain scores between the two cohorts approached, but did not reach, statistical significance (P = 0.12). However, the percentage of patients with mild or no pain (57% robotic, 27% open) versus severe pain (9% robotic, 45% open) was notably different between the two cohorts.

DISCUSSION

Previous studies addressing the effect of surgical modality on pediatric postoperative pain are limited by their reliance on narcotic administration as an indirect surrogate for measuring pain. In the present study, postoperative pain was assessed with narcotic requirements and consistently collected validated pain scores, which more accurately reflect a patient's perceived pain. Although there was no significant difference in subjective pain scores between patients undergoing open versus robotic reimplantation, the percentage of patients with mild or no pain (57% robotic, 27% open) versus severe pain (9% robotic, 45% open) was notably different between the two cohorts. This study was limited by a lack of randomization as well as small sample size, which did not allow for age sub-group analysis or small differences to be statistically significant.

CONCLUSIONS

In the present study, robotic ureteral reimplantation was associated with lower narcotic requirement compared to open surgery, and lower intensity of postoperative pain according to a direct pain assessment tool. Larger sample sizes are necessary to strengthen statistical comparisons.

Feasibility of using CT volume as a predictor of specimen weight in a subgroup of patients with low risk Wilms tumors registered on COG Study AREN03B2: implications for central venous catheter placement

OBJECTIVE

Patients with stage I Wilms tumor, age ≤ 2 years, tumor ≤ 550 g may not require therapy beyond nephrectomy. This study's aims were to determine: (1) if a linear relationship exists between tumor weight and computed tomography (CT) estimated volume; (2) describe the accuracy of a slope-intercept equation in estimating weight; and (3) determine the potential impact of weight estimation on port placement decisions.

MATERIALS AND METHODS

Tumor weight and port placement information were abstracted from 105 patients, age ≤ 2 years, with tumors ± 550 g, enrolled in COG AREN03B2. One radiologist estimated tumor size from CT scan. Prolate ellipse volume (PEV) was calculated, linear regression performed, slope-intercept equation calculated, equation estimated weight determined, and potential impact of the on port placement evaluated.

RESULTS

A strong relationship exists between PEV and weight (R(2) = 0.87). The slope-intercept equation for weight was: weight = 1.04(PEV) + 58.75. Overall median relative error for the equation was 0.9%, and -3% in tumors weighing 350-750 g. Fifty-five ports were placed, 29 in patients with tumor weight ≤ 550 g, and six not placed in patients with tumor weight > 550 g.

CONCLUSIONS

The relationship between PEV and weight produced a reliable weight prediction equation. Preoperative consideration of specimen weight may diminish the number of ports placed in this population.

Treatment with the immunomodulator FTY720 (fingolimod) significantly reduces renal inflammation in murine unilateral ureteral obstruction

PURPOSE

The S1P signaling pathway represents an important potential target for the modulation of tissue inflammation/injury. The immunomodulator FTY720, also known as fingolimod, is a potent agonist for multiple S1P receptors that was approved by the Food and Drug Administration to treat multiple sclerosis. We examined the therapeutic role of FTY720 for renal injury secondary to unilateral ureteral obstruction.

MATERIALS AND METHODS

CB57BL/6 mice underwent a sham procedure or unilateral ureteral obstruction and were treated with FTY720 by gavage for 1, 3 and 5 days. Control groups received vehicle. Ligated and unligated renal tissue was examined for histopathological changes, inflammatory and fibrotic markers, TGF-β1, α-SMA, and macrophage infiltration by Western blot and immunohistochemistry. Proinflammatory and profibrotic cytokines were profiled by quantitative reverse transcriptase-polymerase chain reaction.

RESULTS

Pathological evaluation revealed that FTY720 treatment resulted in a significant reduction in inflammatory infiltration in obstructed kidneys compared to controls. Immunohistochemical and Western blot showed that TGF-β1 and α-SMA protein levels were similarly decreased, as was macrophage infiltration into the renal interstitial space, compared to untreated mice. In agreement with these observations quantitative reverse transcriptase-polymerase chain reaction revealed that inflammatory and fibrotic cytokines (MCP-1, IL-1β, CXCL1, TNF-α and TGF-β1) were also significantly decreased in the FTY720 group.

CONCLUSIONS

This study suggests that in a murine ureteral obstruction model FTY720 significantly inhibited the production of inflammatory cytokines and factors regulating interstitial fibrosis and extracellular matrix accumulation. These findings were associated with decreased evidence of renal injury on pathological examination, suggesting that FTY720 or related compounds may be valuable modulators of obstruction induced renal injury.

Image based feasibility of renal sparing surgery for very low risk unilateral Wilms tumors: a report from the Children's Oncology Group

PURPOSE

Nephrectomy with lymph node sampling is the recommended treatment for children with unilateral Wilms tumor under the Children's Oncology Group protocols. Using radiological assessment, we determined the feasibility of performing partial nephrectomy in a select group of patients with very low risk unilateral Wilms tumor.

MATERIALS AND METHODS

We reviewed imaging studies of 60 patients with a mean age of less than 2 years with very low risk unilateral Wilms tumor (mean weight less than 550 gm) to assess the feasibility of partial nephrectomy. We evaluated percentage of salvageable parenchyma, tumor location and anatomical features preventing a nephron sparing approach.

RESULTS

A linear relationship exists between tumor weight and computerized tomography estimated tumor volume. Mean tumor weight in the study population was 315 gm. Partial nephrectomy was deemed feasible in only 5 of 60 patients (8%).

CONCLUSIONS

When considering a select population with very low risk unilateral Wilms tumor (lower volume tumor), only a small percentage of nonpretreated patients are candidates for nephron sparing surgery.

Oncology: the role of partial nephrectomy in Wilms tumor

Wilms tumor represents the most common pediatric renal malignancy and the fourth most common childhood cancer overall. Overall survival from Wilms tumor has increased to over 90 % secondary to multidisciplinary therapy and multi-institutional cooperative group trials. Recent therapeutic focus has shifted to reduction in treatment morbidity and renal preservation while maintaining the high survival rates. Partial nephrectomy is an integral component of the multimodal treatment protocols for Wilms tumor patients with bilateral disease, solitary kidney, or predisposing syndromes. Recent consideration has been given to utilization of nephron sparing surgery (NSS) in carefully selected patients with nonsyndromic unilateral Wilms tumor. While long-term, prospective data in this subgroup of patients is not yet available, case series demonstrate comparable oncologic outcomes after partial versus radical nephrectomy. The relative rarity of Wilms tumor, especially those amenable to upfront partial nephrectomy, presents a challenge to conducting controlled trials.

Primary nephrectomy and intraoperative tumor spill: report from the Children's Oncology Group (COG) renal tumors committee

PURPOSE

Initial Children's Oncology Group (COG) management for Wilms' tumor (WT) consists of primary nephroureterectomy with lymph node sampling. While this provides accurate staging to define further treatment, it may result in intraoperative spill (IOS), which is associated with higher recurrence rates and therefore requires more intensive therapy. The purpose of this study is to determine current rates and identify factors which may predispose a patient to IOS.

METHODS

The study population was drawn from the AREN03B2 renal tumor banking and classification study of the Children's Oncology Group. All children with a first time occurrence of a renal mass were eligible for the study. At the time of enrollment and prior to risk stratification, the institution is required to submit operative notes, pathology specimens, a chest computed tomography scan (CT), and a contrast-enhanced CT or magnetic resonance imaging (MRI) of the abdomen and pelvis for central imaging review. These data are then used to determine an initial risk classification and therapeutic protocol eligibility. Patients who had a unilateral nephroureterectomy for favorable histology WT underwent further review to assure data accuracy and to clarify details regarding the spill. Analyses were performed using chi square and logistic regression. Odd ratios (OR) are shown with 95% confidence intervals.

RESULTS

There were 1,131 primary nephrectomies for unilateral WT with an IOS rate of 9.7% with an additional 1.8% having possible tumor spill during renal vein or IVC tumor thrombectomy. IOS correlated with diameter (>12 cm, p<0.0001) and laterality (right, p=0.0414). Simple logistic regression indicated that IOS increased 2.7% [p=0.0240, OR 1.027 (1.004, 1.052)] with each 1 cm increase in diameter (3 - 21 cm) and 4.7% [p=0.0147 OR 1.047 (1.009, 1.086)] with each 100 g increase in weight (80 - 1800 g). Multiple logistic regression indicated that laterality [right p=0.048, OR 1.46 (1.004, 2.110)] and weight (p=0.03, OR 1.039 (1.003, 1.075) were predictive of IOS when diameter was included as a continuous variable. Diameter as a binary variable was highly prognostic of IOS (p=0.0002), while laterality and weight were not significant.

CONCLUSIONS

Intraoperative tumor spill occurs in about one out of every ten cases of primary nephroureterectomies for WT. Right-sided and larger tumors are at higher risk of IOS.

Fetal hydronephrosis as a predictor of neonatal urologic outcomes

OBJECTIVES

The ability to predict surgically relevant fetal renal hydronephrosis is limited. We sought to determine the most efficacious second- and third-trimester fetal renal pelvis anteroposterior diameter cutoffs to predict the need for postnatal surgery.

METHODS

We retrospectively reviewed the medical records of mothers and neonates who had a prenatal sonographic examination in our Perinatal-Pediatric Urology Clinic and received follow-up care. Hydronephrosis was defined as a renal pelvis anteroposterior diameter of 5 mm or greater in the second trimester and 7 mm or greater in the third trimester. Hydronephrosis was subdivided into mild, moderate, and severe.

RESULTS

Of 8453 fetuses, 96 met the criteria and were referred to our clinic. Isolated hydronephrosis was diagnosed in 74 fetuses, of which 53 received postnatal follow-up evaluations. The areas under the receiver operating characteristic curves for predicting postnatal surgery in the second and third trimesters were 0.770 and 0.899, respectively. The second-trimester renal anteroposterior diameter threshold that best predicted post-natal surgery was 9.5 mm (sensitivity, 71.4%; specificity, 81.1%). The third-trimester threshold that best predicted postnatal surgery was 15.0 mm (sensitivity, 85.7%; specificity, 94.6%).

CONCLUSIONS

The fetal renal anteroposterior diameter on second- and third-trimester sonography is predictive of an increased risk for neonatal urologic surgery. Surgical risk is best predicted by a third-trimester renal anteroposterior diameter threshold of 15 mm.

Primary renal synovial sarcoma in a 13-year-old boy

Primary renal synovial sarcoma is a rare entity with fewer than 40 cases reported in the literature. Its clinical presentation and radiographic features, namely, its often complex cystic appearance, make it difficult to differentiate from other benign or malignant renal lesions. Although there are certain consistent morphological and immunohistochemical features, diagnosis ultimately depends on molecular studies. Prognosis is poor, and there currently exists no defined treatment protocol. Herein, we describe the youngest reported case of primary renal synovial sarcoma in the literature.

Comparison of outcomes based on treatment algorithms for rhabdomyosarcoma of the bladder/prostate: combined results from the Children's Oncology Group, German Cooperative Soft Tissue Sarcoma Study, Italian Cooperative Group, and International Society of Pediatric Oncology Malignant Mesenchymal Tumors Committee

The purpose of this study was to determine patient characteristics and outcomes for bladder/prostate (BP) rhabdomyosarcoma (RMS) using an international cohort of prospectively treated patients comparing different treatment algorithms. Data were collected from 379 patients (1979-1998) treated on protocol; Intergroup Rhabdomyosarcoma Study, IRS-IV (n = 239 patients), International Society of Pediatric Oncology Malignant Mesenchymal Tumors (MMT) Committee MMT-84 and -89 (n = 74), Italian Cooperative Group, RMS-79 and RMS-88 Studies (n = 37) or German Cooperative Soft Tissue Sarcoma Study CWS-91 protocols (n = 29). A total of 322 (85%) patients had localized embryonal RMS (ERMS) and 27 had metastatic disease. Thirty patients (21 local disease; 9 metastatic) had nonembryonal BP RMS. Patients with localized ERMS had large tumors (64% >5 cm) that were invasive (54%) with uninvolved regional lymph nodes (N0, 93%). The 5-year failure-free survival (FFS) was 75% and the overall survival (OS) was 84%, with 89% of deaths attributed to disease. Treatment failures were usually local disease recurrence (60%). Predictors of FFS included T-stage (invasiveness), size, and histology. FFS was decreased for patients not receiving initial radiotherapy but this did not translate into a decreased OS. The 21 patients with localized nonembryonal BP RMS had a FFS and OS of 47%. The 36 patients with metastatic disease were more likely to be older and had large tumors that were invasive with alveolar histology and regional lymph node involvement. The 5-year FFS and OS were 41 and 44%, respectively. In conclusion, the majority of BP RMS patients had localized ERMS with a resultant good prognosis using current treatment algorithms. There were differences in FFS between treatment protocols but this did not result in an altered OS.

Pediatric urologic oncology: organ-sparing surgery in kidney and testis

Technological advances in imaging as well as increased knowledge of tumor-specific biology have promoted the role of organ-sparing approaches to pediatric renal and testicular tumors. Application of these techniques continues to evolve as data on long-term follow-up become available and as protocol-guided investigation provides answers to therapeutic outcomes of these approaches. Optimally, organ-sparing surgery will continue to provide increased potential for preservation of both renal function and fertility.

Bladder/Prostate Rhabdomyosarcoma: Past, Present and Future

PURPOSE

The last few decades have witnessed substantial improvement in outcomes in children with bladder/prostate rhabdomyosarcoma. We reviewed relevant historical aspects of treatment, current treatment strategies and new developments. Most importantly we identified areas of existing controversy, which will provide direction for future studies and continued improvements in therapy.

MATERIALS AND METHODS

A database (PubMed, MEDLINE, etc) search was performed from 1966 through January 2005. Approximately 500 citations were identified. Relevant citations were reviewed in detail.

RESULTS

While the reported cure rate has improved to approximately 70% to 80% and bladder preservation rates as high as 60% are reported, substantial controversy continues in certain areas. Specifically the long-term function of preserved bladders, the contribution of radiotherapy to bladder dysfunction, the timing of reconstruction and molecular markers of disease progression are among the areas that require further investigation.

CONCLUSIONS

Substantial progress has been made as a result of multi-institutional collaborative trials. Future combined studies are required to further the treatment of this childhood malignancy.

Nocturnal enuresis: medical management

Nocturnal enuresis is a problem that affects many children and their families. The etiology seems to be multifactorial and may include a combination of genetic factors,abnormal urodynamics, alterations in vasopressin secretion, sleep factors, psychologic factors, organic disease, and maturational delay. Generally, a complete history and physical examination, with a specific focus on the genitourinary, gastrointestinal, and neurologic systems, is all is that is needed in the evaluation of a patient with enuresis.Currently, the mainstays of medical therapy are DDAVP, imipramine, and oxybutynin. Medications can help to control the symptoms of enuresis, but they generally do not provide a cure; therefore, behavioral therapy is often recommended in conjunction with pharmacotherapy.

Continent urinary diversion and the exstrophy-epispadias complex

PURPOSE

The use of continent urinary reservoirs has gained wide acceptance, particularly in urinary reconstruction in children with a small capacity or neuropathic bladder. When augmentation cystoplasty is combined with clean intermittent catheterization, patients are often able to achieve continence with low intravesical filling pressures and renal preservation. Often this approach requires fashioning a continent cutaneous stoma, which remains the most challenging aspect of continent urinary reservoirs. We analyzed our experience with continent diversion in patients with exstrophy-epispadias to determine complications and long-term results.

MATERIALS AND METHODS

We performed a retrospective database review of 704 cases of exstrophy-epispadias. Medical records were then used to identify those patients who had undergone creation of a continent urinary reservoir. Charts were reviewed to determine initial diagnosis, augmentation technique, continence mechanism, age, preoperative and postoperative bladder capacity, continence status and complications.

RESULTS

Of the 91 patients identified (68 male, 23 female) who had undergone continent urinary diversion classic bladder exstrophy was present in 80, cloacal exstrophy in 8, complete male epispadias in 2 and female epispadias in 1. The most common techniques for augmentation and continent diversion were ileocystoplasty (41 patients [45%]) and sigmoid cystoplasty (30 [33%]), respectively. Appendix was used in 67 patients (74%) and variants of the Mitrofanoff procedure using segments of tapered ileum or ureter were used to create a continent stoma in 10 (11%). Bladder neck transection was performed in 59 patients (65%). Mean age at augmentation and continent diversion was 8 years (range 2 to 25), with a mean preoperative bladder capacity of 77 cc (15 to 220). Mean followup was 6 years (range 6 months to 12 years). Of the 91 patients 85 (93%) were continent with clean intermittent catheterization per stoma. Of these 85 patients 13 required anticholinergics and alpha-agonists to achieve continence. Six patients (7%) were incontinent after the procedure. Analysis of bladder capacity measurements after augmentation and continent diversion revealed that mean postoperative volume and mean volume increase were 404 cc (range 250 to 640) and 524%, respectively. The most common complications were bladder stone formation (24 patients [26%]) and stomal stenosis (21 [23%]). Bladder stones recurred in 9 patients and stomal stenosis in 3. Other less common complications were vesicourethral fistula (3 patients) and a small bladder perforation (2).

CONCLUSION

Augmentation and continent diversion procedures can increase the functional capacity of the small contracted noncompliant exstrophic bladder, and allow the vast majority of patients to achieve continence and preserve renal function. Bladder calculi and stomal stenosis pose the most significant long-term complications in these patients.

Poor predictability of prenatal ultrasonography for a nonfunctional kidney

We present 2 cases in which the diagnosis of a unilateral nonfunctioning kidney was not anticipated. The first case appeared to be simple, antenatally diagnosed, unilateral hydronephrosis with adequate parenchyma. However, at 3 months postnatally, it was found to be nonfunctional, most likely secondary to early high-grade obstruction. The second case presented prenatally as a left hydronephrotic kidney with parenchymal cysts, and the right kidney showed only mild parenchymal cystic changes. By 6 months, however, the right kidney was nonfunctional. These cases emphasize the need for coordinated prenatal and postnatal care. The sonographic appearance of renal dysplasia is variable (in size, number of cysts, and degree of hydronephrosis), depending on the point at which it is evaluated during the disease course. Subtle signs of dysplasia, such as increased echogenicity, may be the only warning sign of a nonfunctioning kidney, for which one should have a high index of suspicion.

Gene therapy for urologic cancer

Advances in molecular technology and the completion of the human genome project have ushered in a new era of medicine, that of gene therapy. In every field of medicine, investigators are developing gene therapeutics in an attempt to cure diseases. Urologic oncology is no exception. Herein, we review the current status of gene therapy for urologic malignancy. Included is an overview of advances in gene delivery systems and immunology, which are driving forces for gene therapy research. Finally, we review the current gene therapy trials and experimental approaches for urologic malignancy.

Modified Young-Dees-Leadbetter bladder neck reconstruction: new concepts about old ideas

INTRODUCTION

The modern Young-Dees-Leadbetter bladder neck reconstruction is a procedure that has evolved during the past 82 years. During this time, the modifications and contributions of several urologic surgeons have improved the procedure and ultimate patient outcomes. We review the evolution and describe in detail our version of the Young-Dees-Leadbetter bladder neck reconstruction procedure.

TECHNICAL CONSIDERATIONS

Optimally, patients should have a minimal bladder capacity of 85 mL and be mature enough to participate in a postoperative voiding program. Adequate radical exposure of the lateral aspects of the bladder and bladder neck are important. Cephalotrigonal or cross-trigonal ureteral reimplantation is typically performed to mobilize the ureters in relation to the proposed bladder neck and correct reflux. A mucosal template 15 mm wide by 30 mm long is created that will serve as the reconstituted posterior urethra and bladder neck. Triangular lateral bladder mucosal wedges are marked and demucosalized. The neourethra is closed over an 8F Firlit tube. The demucosalized flaps are brought over the urethra sequentially in a "vest-over-pants" fashion with the final layer consisting of suspension sutures. Finally, ureteral stents and a suprapubic tube are used, but no urethral catheter is left in place.

CONCLUSIONS

The modern Young-Dees-Leadbetter bladder neck reconstruction is the result of the contributions of various urologic surgeons during 82 years. When patients are appropriately selected, it is an effective method of lower urinary tract reconstruction in cases of congenital urinary incontinence.

Prostate cancer gene therapy

Cancer-specific gene therapy is still in its infancy. Although the first gene therapy trials were initiated in the late 1980s, it was only more recently that the first successful treatment of a genetic disease was reported.3 The current problems with low efficiency of gene transfer coupled with the immunologic difficulties with certain vectors indicate that more effort needs to be directed at the basic science of gene transfer. Ultimately, successful cancer-specific gene therapy will require combinations of the lessons learned from the ex vivo and in vivo paradigms. The next generation of gene therapy trials likely will focus on combination therapy with conventional chemotherapeutic agents, differentiating agents, or radiation therapy. The obstacles to the development of gene-based human therapeutics (i.e., molecular medicine) are formidable, but the benefits are so great that eventually the technical issues of gene transfer methodology will be worked out, and ultimately this will become the standard of care, not only for inborn errors of metabolism, but also for cancer.

Survey results on medical and surgical followup of patients with vesicoureteral reflux from American Association of Pediatrics, Section on Urology members

PURPOSE

Little data are available on the appropriate followup protocols for patients treated medically or surgically for vesicoureteral reflux. We surveyed urologists who primarily practice pediatric urology to determine current practice patterns for following patients treated for vesicoureteral reflux.

MATERIALS AND METHODS

A 1-page survey was mailed to the 225 members of the American Academy of Pediatrics, Section on Urology. The mailing roster and labels were provided by the American Academy of Pediatrics. The survey included questions on the followup of patients with low and high grade reflux treated medically or surgically. Returned surveys were blindly tabulated by 2 independent reviewers (F. A. F. and P. H. M.).

RESULTS

Of the 225 surveys 155 were returned and analyzed for an overall response rate of approximately 61%. Urine culture is routinely performed by 64% and 71% of respondents to follow children with uncorrected low grade reflux and those with high grade reflux undergoing medical treatment, respectively, generally at 3 to 6-month intervals. To follow patients with reflux voiding cystourethrography or radionuclide scan is performed yearly by 99% of study participants, while 77% perform ultrasound. Renal scan and excretory urography are done infrequently. The timing of the surgical correction of unresolved asymptomatic reflux and/or when to discontinue antibiotics in these cases varied significantly among survey respondents. After antireflux surgery 92% and 91% of respondents perform voiding cystourethrography and ultrasound, respectively. Recommended followup after ureteroneocystotomy varied greatly among survey participants.

CONCLUSIONS

The overwhelming majority of practitioners agree on the timing and type of radiographic studies to be used to follow children treated for reflux and the majority routinely perform urine culture. Opinion on the continuation of antibiotics and timing of surgical intervention for asymptomatic unresolved reflux is divided. Wide variation exists on the recommended followup after reimplantation.

Coexpression of hypoxia-inducible factor 1-alpha and vascular endothelial growth factor in Wilms' tumor

BACKGROUND/PURPOSE

Hypoxia-inducible factor 1 alpha (HIF-1alpha) is an important transcriptional factor responsible for regulating expression of the angiogenic cytokine, vascular endothelial growth factor (VEGF). Little information is available regarding factors involved in the hypoxic cascade, such as HIF or VEGF in Wilms' tumor. We concomitantly evaluate the expression of HIF-1alpha and VEGF in ex vivo human Wilms' tumor specimens.

METHODS

Immunohistochemical analysis (IHC) utilizing a monoclonal human anti-HIF-1alpha or a polyclonal anti-VEGF antibody was performed on ex vivo specimens of Wilms' tumor (n = 18). Predominant tumor histologic subtype was divided equally between epithelial (n = 6), blastemal (n = 6), and mixed (n = 6). Specimens were scored on a predetermined scale for distribution (percent positive cells) and intensity of HIF-1alpha/VEGF expression within areas of tumor.

RESULTS

IHC analysis found that HIF-1alpha and VEGF were expressed in all Wilms' tumor specimens. Strong nuclear staining for HIF-1alpha was seen in all samples evaluated, (n = 18), mean score 2.7 (>50% cells exhibiting nuclear HIF-1alpha expression). Cytoplasmic staining for HIF-1alpha also was seen in 15 of 18 samples (83%). Distribution of VEGF was equivalent between blastemal and epthelial components, mean score 2.23 versus 2.35.

CONCLUSIONS

HIF-1alpha and one of its regulatory end-products, the angiogenic cytokine VEGF, are simultaneously expressed in human Wilms' tumor. In Wilms' tumor, intratumoral hypoxia may stimulate tumor conversion to the angiogenic phenotype and incite production of VEGF. Strategies targeting the hypoxic cascade ultimately may prove efficacious against Wilms' tumor.

Angiogenesis and neuroblastomas: interleukin-8 and interleukin-8 receptor expression in human neuroblastoma

PURPOSE

Studies have demonstrated that the pro-angiogenic cytokine interleukin-8 (IL-8) and the IL-8 receptors likely have a role in the growth and metastasis of various solid tumors. We hypothesized that in vivo neuroblastoma expresses IL-8 and the IL-8 receptors A and B, and that factors known to regulate IL-8 expression are present and active in the neuroblastoma microenvironment.

MATERIALS AND METHODS

To confirm the presence of IL-8/IL-8 receptors in neuroblastoma, immunohistochemical analysis for IL-8 and its receptors was performed on 10 archival specimens, including benign adrenal and well to poorly differentiated neuroblastoma samples. Immunohistochemical analysis was also performed for interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha. Cultured neuroblastoma cells SK-N-MC and SK-N-SH were stimulated with 10 ng./ml. IL-1beta or tumor necrosis factor-alpha and control media (15 each). Cell culture supernatants were analyzed with enzyme-linked immunosorbant assay for IL-8 levels at 24 and 48 hours.

RESULTS

Minimal expression of IL-8 was noted in benign adrenal tissue but expression for IL-8 was present in all neuroblastoma specimens. Microvessel staining was present in 30% of the specimens. All tumor specimens expressed IL-8 receptor B, and both receptors were expressed in the tumor microvasculature. Immunohistochemical analysis confirmed the presence of IL-1beta and tumor necrosis factor in the neuroblastoma microenvironment. In vitro studies demonstrated that SK-N-MC and SK-N-SH cells express low levels of IL-8 under normal conditions and that IL-1beta and tumor necrosis factor-alpha significantly increased expression of IL-8 at 24 and 48 hours.

CONCLUSIONS

Our results indicate that IL-8 and its receptors are expressed in neuroblastoma tumor specimens. In addition, the fact that IL-1beta and tumor necrosis factor-alpha are expressed in the neuroblastoma microenvironment combined with our in vitro results suggests that these cytokines may be involved in in vivo regulation of IL-8 in human neuroblastoma. Understanding the angiogenic factors and regulatory cascade promoting angiogensis in neuroblastoma may lead to the development of effective anti-angiogenic strategies.

Consensus on the prenatal management of antenatally detected urological abnormalities

PURPOSE

The incidence of an antenatally detected genitourinary abnormality is 0.5% of all pregnancies assessed, and rarely is antenatal intervention indicated. A survey of pediatric urologists was undertaken to evaluate current practice patterns and recommendations regarding the need to intervene in the antenatal period.

MATERIALS AND METHODS

A survey instrument was mailed to all members of the Society for Fetal Urology. There were 7 case scenarios that addressed critical decision points in patients with antenatally detected genitourinary abnormalities.

RESULTS

A total of 112 of 188 Society for Fetal Urology members (60%) completed the survey. Observation with serial ultrasound was recommended for a 32-week fetus with ureteropelvic junction obstruction. For a 36-week fetus with suspected posterior urethral valves without oligohydramnios most respondents elected no intervention with a minority favoring early delivery. For a 23-week fetus with suspected posterior urethral valves and oligohydramnios with normal bladder electrolytes most respondents agreed with a vesicoamniotic shunt. There was no clear consensus for a 20-week fetus with suspected posterior urethral valves, oligohydramnios and a nonfunctioning right kidney. Most respondents recommended serial ultrasound to follow an 18-week fetus with suspected posterior urethral valves and normal amniotic fluid. Antenatal intervention was not recommended for a 20-week fetus with bilateral renal cystic disease, and most respondents elected no intervention for a 28-week fetus with a solitary kidney with suspected ureteropelvic junction obstruction and normal amniotic fluid.

CONCLUSIONS

Situations that warrant antenatal intervention for a genitourinary abnormality are exceedingly low and may include cases of oligohydramnios, suspected favorable renal function and the absence of life threatening congenital abnormalities. In cases with normal amniotic fluid antenatal intervention is not recommended regardless of the detected abnormality. There is an emerging trend toward early delivery of fetuses with severe genitourinary abnormalities, normal amniotic fluid and confirmed lung maturity.

Angiogenesis and neuroblastomas: interleukin-8 and interleukin-8 receptor expression in human neuroblastoma

PURPOSE

Studies have demonstrated that the pro-angiogenic cytokine interleukin-8 (IL-8) and the IL-8 receptors likely have a role in the growth and metastasis of various solid tumors. We hypothesized that in vivo neuroblastoma expresses IL-8 and the IL-8 receptors A and B, and that factors known to regulate IL-8 expression are present and active in the neuroblastoma microenvironment.

MATERIALS AND METHODS

To confirm the presence of IL-8/IL-8 receptors in neuroblastoma, immunohistochemical analysis for IL-8 and its receptors was performed on 10 archival specimens, including benign adrenal and well to poorly differentiated neuroblastoma samples. Immunohistochemical analysis was also performed for interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha. Cultured neuroblastoma cells SK-N-MC and SK-N-SH were stimulated with 10 ng./ml. IL-1beta or tumor necrosis factor-alpha and control media (15 each). Cell culture supernatants were analyzed with enzyme-linked immunosorbant assay for IL-8 levels at 24 and 48 hours.

RESULTS

Minimal expression of IL-8 was noted in benign adrenal tissue but expression for IL-8 was present in all neuroblastoma specimens. Microvessel staining was present in 30% of the specimens. All tumor specimens expressed IL-8 receptor B, and both receptors were expressed in the tumor microvasculature. Immunohistochemical analysis confirmed the presence of IL-1beta and tumor necrosis factor in the neuroblastoma microenvironment. In vitro studies demonstrated that SK-N-MC and SK-N-SH cells express low levels of IL-8 under normal conditions and that IL-1beta and tumor necrosis factor-alpha significantly increased expression of IL-8 at 24 and 48 hours.

CONCLUSIONS

Our results indicate that IL-8 and its receptors are expressed in neuroblastoma tumor specimens. In addition, the fact that IL-1beta and tumor necrosis factor-alpha are expressed in the neuroblastoma microenvironment combined with our in vitro results suggests that these cytokines may be involved in in vivo regulation of IL-8 in human neuroblastoma. Understanding the angiogenic factors and regulatory cascade promoting angiogensis in neuroblastoma may lead to the development of effective anti-angiogenic strategies.

Consensus on the prenatal management of antenatally detected urological abnormalities

PURPOSE

The incidence of an antenatally detected genitourinary abnormality is 0.5% of all pregnancies assessed, and rarely is antenatal intervention indicated. A survey of pediatric urologists was undertaken to evaluate current practice patterns and recommendations regarding the need to intervene in the antenatal period.

MATERIALS AND METHODS

A survey instrument was mailed to all members of the Society for Fetal Urology. There were 7 case scenarios that addressed critical decision points in patients with antenatally detected genitourinary abnormalities.

RESULTS

A total of 112 of 188 Society for Fetal Urology members (60%) completed the survey. Observation with serial ultrasound was recommended for a 32-week fetus with ureteropelvic junction obstruction. For a 36-week fetus with suspected posterior urethral valves without oligohydramnios most respondents elected no intervention with a minority favoring early delivery. For a 23-week fetus with suspected posterior urethral valves and oligohydramnios with normal bladder electrolytes most respondents agreed with a vesicoamniotic shunt. There was no clear consensus for a 20-week fetus with suspected posterior urethral valves, oligohydramnios and a nonfunctioning right kidney. Most respondents recommended serial ultrasound to follow an 18-week fetus with suspected posterior urethral valves and normal amniotic fluid. Antenatal intervention was not recommended for a 20-week fetus with bilateral renal cystic disease, and most respondents elected no intervention for a 28-week fetus with a solitary kidney with suspected ureteropelvic junction obstruction and normal amniotic fluid.

CONCLUSIONS

Situations that warrant antenatal intervention for a genitourinary abnormality are exceedingly low and may include cases of oligohydramnios, suspected favorable renal function and the absence of life threatening congenital abnormalities. In cases with normal amniotic fluid antenatal intervention is not recommended regardless of the detected abnormality. There is an emerging trend toward early delivery of fetuses with severe genitourinary abnormalities, normal amniotic fluid and confirmed lung maturity.

Orchiopexy using 2 mm. laparoscopic instruments: 2 techniques for delivering the testis into the scrotum

PURPOSE

We describe modified techniques of laparoscopic orchiopexy using 2 mm. instruments that enable straightforward delivery of the testis into the scrotum.

MATERIALS AND METHODS

The preferred technique involves a radially dilating trocar advanced over the 2 mm. grasper placed antegrade through the new internal ring. The other method is similar but Amplatz dilators are used when a radially dilating trocar system is not available.

RESULTS

We used these techniques with complete success to deliver 18 testes into the scrotum.

CONCLUSIONS

The testis may be safely and effectively delivered to the scrotum using 2 mm. instruments and disposable fascial dilators or a radially dilating trocar system.

Cloacal outlet obstruction with an ectopic ureter

Cloacal malformation occurs in approximately 1 in 50,000 live female births. Prenatal ultrasound may lead to the diagnosis in selected cases. We report an unusual case of prenatally detected single-system hydronephrosis with a nonvisible bladder and worsening oligohydramnios. Labor was induced at 35 weeks' estimated gestational age. On physical examination, a single perineal opening was noted consistent with cloaca. Endoscopy revealed an obstructed ectopic ureter at the level of the sphincter, an undeveloped bladder and vagina, and a fistula to the rectum. A low loop cutaneous ureterostomy and right upper quadrant loop colostomy were performed. The absence of a typical fluid-filled pelvic structure may confound the prenatal diagnosis of cloaca.

A complex urologic problem demonstrates how far pediatric urology has progressed

OBJECTIVE

We present the experience at Connecticut Children's Medical Center (CCMC) with single-system bilateral ectopic ureters (SSBUE), a rare clinical entity which continues to challenge the pediatric urologist. Innovative diagnostic and reconstructive techniques are utilized in an effort to preserve renal function and develop urinary continence in a select group of patients.

METHODS

A review of the English language literature was performed to identify all female patients with SSBUE and evaluate their treatment and outcomes. In addition, we present our experience with three cases of SSBUE at CCMC and describe the recent advances in the management of such patients.

RESULTS

From 1937 to 1999, 25 articles described 54 female patients with SSBUE. Patients were treated with a variety of reconstructive procedures that resulted in a low overall continence rate of 20% (eight of 39 reported outcomes). We evaluated three patients with SSBUE at CCMC. Our first patient had undergone three previous operations prior to her successful procedure at CCMC utilizing a new technique to achieve urinary continence in which a portion of the anterior bladder wall is used for bladder neck reconstruction. Our last patient was identified antenatally by the maternal-fetal obstetrician, evaluated postnatally by the pediatric urologist, and underwent formal urodynamics and proximal urinary diversion for an obstructed upper collecting system. No previous reports focus on antenatal identification, accurate postnatal diagnosis, urodynamic assessment and early intervention including upper urinary tract diversion, and staged Pippi Salle bladder neck reconstruction.

CONCLUSION

The CCMC experience with SSBUE demonstrates the recent achievements in complex urinary tract reconstruction that have taken place in pediatric urology. We describe diagnostic studies such as formal urodynamics and the growing trend to identify urologic problems antenatally. A team approach involving the obstetrician, pediatric urologist, neonatologist, and the pediatrician has been beneficial. As pediatric urology moves into the new millennium there are prospects for even more innovative diagnostic and therapeutic options for children with urologic problems.

Citrobacter diversus urosepsis and cerebral abscess in a child with antenatal hydronephrosis

One percent of all pregnancies are found to have an antenatal abnormality; of these, 20% involve the genitourinary system. Today, controversy still exists regarding the postnatal management of some antenatal abnormalities detected by ultrasound. We present a case in which antenatal hydronephrosis initially detected by ultrasound appeared to resolve in utero. Postnatally, the child developed Citrobacter diversus urosepsis, meningitis, and cerebral abscess. Voiding cystourethrogram obtained after resolution of sepsis revealed grade IV reflux. This case underscores the importance of a full postnatal evaluation for all children with antenatal hydronephrosis and alerts clinicians to a virulent pathogen not commonly associated with urinary tract infection.