Complaints of Men with Uncorrected Distal Hypospadias

Purpose

The few available reports regarding adults living with distal hypospadias give disparate views of the functional and aesthetic impact of this penile birth defect when it is not corrected. We reviewed symptoms and findings in consecutive men with unrepaired distal hypospadias and report those observations.

Material and Methods

Men with uncorrected hypospadias were queried regarding urinary symptoms, sexual dysfunction, and aesthetic concerns. Glans fusion around the meatus was measured. Penile curvature was confirmed by photographs of erections, and its degree objectively measured in those undergoing surgery.

Results

There were 51 men with a mean age of 42 years (18-63). None had glans fusion around the meatus, and the main symptom was urine spraying in 81%. Penile curvature was present in 33%. Painful sexual activity was reported by 34% due to penile curvature, exposed urethral mucosa, or a scrotal web. All but one man experienced functional problems. In addition, 60% were bothered by their abnormal appearance.

Conclusion

All but one of these men with uncorrected distal hypospadias had penile dysfunction, and 60% were additionally concerned about the atypical appearance of their penis. These results offer a different perspective than earlier reports which said that most men with uncorrected distal hypospadias were not bothered by their condition, and many were not aware of it.

Insulin-Like Peptide 3 (INSL3) Serum Concentration During Human Male Fetal Life

Context: Insulin-like peptide 3 (INSL3), a protein hormone produced by Leydig cells, may play a crucial role in testicular descent as male INSL3 knockout mice have bilateral cryptorchidism. Previous studies have measured human fetal INSL3 levels in amniotic fluid only. Objective: To measure INSL3 serum levels and mRNA in fetal umbilical cord blood and fetal testes, respectively. Design: INSL3 concentrations were assayed on 50 μl of serum from male human fetal umbilical cord blood by a non-commercial highly sensitive and specific radioimmunoassay. For secondary confirmation, quantitative real-time PCR was used to measure INSL3 relative mRNA expression in 7 age-matched human fetal testes. Setting: UT Southwestern Medical Center, Dallas, TX and Medical University of South Carolina, Charleston, SC. Patients or other Participants: Twelve human male umbilical cord blood samples and 7 human male testes were obtained from fetuses 14-21 weeks gestation. Male sex was verified by leukocyte genomic DNA SRY PCR. Interventions: None. Main Outcome Measures: Human male fetal INSL3 cord blood serum concentrations and testicular relative mRNA expression. Results: INSL3 serum concentrations during human male gestational weeks 15-20 were 2-4 times higher than published prepubertal male levels and were 5-100 times higher than previous reports of INSL3 concentrations obtained from amniotic fluid. Testicular fetal INSL3 mRNA relative expression was low from weeks 14-16, rose significantly weeks 17 and 18, and returned to low levels at week 21. Conclusions: These findings further support the role of INSL3 in human testicular descent and could prove relevant in uncovering the pathophysiology of cryptorchidism.

Pre-incision urethral plate width does not impact short-term Tubularized Incised Plate urethroplasty outcomes

INTRODUCTION

Two reports have found that urethral plate (UP) widths <8 mm before tubularized incised plate (TIP) incision increased urethroplasty complications. The present study measured pre-incision UP width in consecutive boys undergoing TIP to determine if it affected outcomes.

METHODS

The present study followed the method previously used by Holland and Smith, and Sarhan et al. to measure UP width before creating glans wings or performing midline plate incision in consecutive patients with primary hypospadias and ventral curvature <30°, who all underwent TIP repair (Summary Fig.). Glans width at its widest point was also measured. Multiple logistic regression assessed urethroplasty complications (fistula, glans dehiscence, meatal stenosis/urethral stricture, diverticulum) based on pre-incision UP width, glans width, patient age, and meatal location.

RESULTS

The UP widths were determined in 224 consecutive primary TIP repairs during 2012-2015: 200 distal, 11 midshaft, and 13 proximal. The UP width was <8 mm in 192/224 (86%) patients. Mean pre-incision width was 6.1 mm (SD 1.5, range 2-11), without difference in UP widths according to meatal location (P = 0.06). Mean post-incision UP width was 12 mm (SD 2.2, range 10-16). Mean change in width after incision (delta/original UP width) was 116% (SD 63, range 20-250). There was follow-up in 186 patients for a mean of 6 months. Urethroplasty complications (five fistulas, six glans dehiscence) were diagnosed in 11 (6%): 9/165 distal, 1/9 midshaft, and 1/12 proximal repairs. There was no difference in those <8 vs ≥8 mm (11/160 vs 0/26, P = 0.17). Similarly, UP width was not different between patients with and without urethroplasty complications. Multiple logistic regression in these 186 patients - including meatal location, UP width, glans width, and age - found only glans width <14 mm was associated with increased odds of urethroplasty complications (OR 19.2, 95% CI 3.5-106, AUC = 0.799).

DISCUSSION

The data show that pre-incision UP width is not an independent risk factor for urethroplasty complications. However, it is possible that technical factors, such as how deeply the dorsal incision is made or size of the urethral stent, might contribute to this finding by other authors. After watching the TIP repair, Smith stated that the plate incision was deeper than he made. Sarhan et al. reported a mean change of 57% in UP width after incision, whereas the present one was double at 116% (i.e. from 6 mm pre-incision to 12 mm post incision), and they used an 8-Fr catheter. While they stated that they incised the plate deeply, the lower percentage increase in width suggests that it was not as deep as was recommended.

CONCLUSIONS

The UP width before incision did not increase urethroplasty complications. Surgeons do not need to measure or categorize the UP to determine suitability for TIP repair, as long as the plate incision is made deeply to the corpora.

Re-operative urethroplasty after failed hypospadias repair: how prior surgery impacts risk for additional complications

PURPOSE

The primary aim of this report was to compare urethroplasty complications for primary distal and proximal repairs with those after 1, 2, 3, and 4 or more re-operations.

METHODS

Prospectively collected data on consecutive hypospadias repairs (tubularized incised plate (TIP), inlay, two-stage graft) from 2000 to 2015 were reviewed. Isolated fistula closures were excluded. Extracted information included patient age, meatal location, repair type, primary vs. re-operative surgery, number of prior operations, any testosterone use, glans width, and urethroplasty complications. Pre-operative testosterone stimulation was used during the study period until 2012. Initially, it was given for a subjectively small-appearing glans, but from 2008 to 2012 use was determined by glans width <14 mm. Patients initially managed elsewhere were queried for any testosterone treatment. The number of prior operations was determined by patient history and confirmed by review of records. Calibrations, dilations, cystoscopies, and/or isolated skin revisions were not considered as prior urethroplasty operations. Multiple logistic regression was performed for all patients, and for the subset of patients undergoing re-operation, using stepwise regression for the following potential risk factors: meatal location (distal vs. midshaft/proximal), number of prior surgeries (0, 1, 2, 3, ≥4), pre-operative testosterone use (yes/no), small glans (<14 vs. ≥14), surgery type (TIP, inlay and two-stage graft), and age (continuous in months), with P-values <0.05 considered statistically significant.

RESULTS

In contrast to the 135/1085 (12%) complication rate in patients undergoing primary distal and proximal TIP repair, re-operative urethroplasty complications occurred in 61/191 (32%) TIP, 16/46 (35%) inlay, and 49/124 (40%) two-stage repairs, P<0.0001. Data regarding testosterone use was available for 1490 (96%) patients. A total of 139 received therapy, of which 65 (46%) had urethroplasty complications vs. 229 of 1351 (16%) without treatment, P = 0.0001. Logistic regression in 1536 patients demonstrated that each prior surgery increased the odds of subsequent urethroplasty complications 1.5-fold (OR 1.51, 95% CI 1.25-1.83), along with small glans <14 mm (OR 2.40, 95% CI 1.48-3.87), mid/proximal meatal location (OR 2.54, 95% CI 1.65-3.92), and use of pre-operative testosterone (OR 2.57, 95% CI 1.53-4.31); age and surgery type did not increase odds (AUC = 0.739).

DISCUSSION

Urethroplasty complications doubled in people undergoing a second hypospadias urethroplasty compared with those undergoing primary repair. This risk increased to 40% with three or more re-operations. Logistic regression demonstrates that each surgery increases the odds for additional complications 1.5-fold. Mid/proximal meatal location, small glans <14 mm, and use of pre-operative testosterone also significantly increase odds for complications. These observations support the theory that previously operated tissues have less robust vascularity than assumed in a primary repair, and suggest additional adjunctive therapies are needed to improve wound healing in re-operations. The finding that even a single re-operative urethroplasty has twice the risk for additional complications vs. a primary repair emphasizes the need for hypospadias surgeons to 'get it right the first time'. The fact that 40% of the re-operative urethroplasties in this series followed distal repairs emphasizes that there is no 'minor' hypospadias.

CONCLUSIONS

A single re-operative hypospadias urethroplasty has twice the risk for additional complications vs. the primary repair, which increases to 40% with three or more re-operations. These results support a theory that vascularity of penile tissues decreases with successive operations, and suggest the need for treatments to improve vascularity. The higher risk for complications during re-operative urethroplasties also emphasizes the need to get the initial repair correct.

Recurrence after management of meatal balanitis xerotica obliterans

INTRODUCTION

We review outcomes after management of meatal balanitis xerotica obliterans (BXO). The primary outcome was recurrent meatal BXO.

METHODS

A database comprising mostly hypospadias patients was queried for meatal BXO. The disease was confirmed histologically in all cases. Management included topical steroids and/or immunosuppressants, and/or surgical excision of BXO with two-stage oral mucosa graft circumferential replacement urethroplasty.

RESULTS

A total of 12 patients had meatal BXO (8 boys and 4 adults). Of these, 10 had hypospadias, two presenting without prior surgery and eight returning 5-30 years after one or multiple (n = 2) repairs. Another two boys did not have hypospadias: one developing BXO 10 years after newborn circumcision and the other having persistent meatal BXO following therapeutic circumcision. Topical and intraluminal steroids (1% betamethasone or clobetasol) and tacrolimus were used for ≥12 weeks each as primary therapy or for meatal recurrence in a total of six cases. Complete response with resolution of white discoloration and relief of stranguria only occurred in two of the three receiving clobetasol, with follow up ≤12 weeks. BXO excision and urethroplasty was done in 11 patients, 10 using oral mucosa grafts; one with a focal lesion and a negative frozen section had reoperative TIP. Of the 10 undergoing excision with two-stage replacement urethroplasty, six remain disease free at a mean follow-up of 23 months (8-48 months), and four had recurrent stranguria and visible meatal BXO at a median of 26 months (22-105 months). Three of the four with recurrences had additional treatment and one was lost to follow-up. All initially had topical steroids, and two also used tacrolimus, without clinical resolution. These three then underwent a second BXO excision and two-stage oral graft replacement urethroplasty. In two recurrences, BXO was found invading from the meatus proximally within oral mucosa (Figure). Of these three with secondary urethroplasties, two are free of disease at 6 and 18 months, and the third had another meatal recurrence 6 months after the second stage.

DISCUSSION

We found topical steroids and immunosuppressants to have limited efficacy, with two clinical complete responses achieved only with clobetasol in patients with short follow-up. Forty percent of patients recurred at 2-9 years after visually complete BXO excision and two-stage oral mucosa graft replacement urethroplasty, and in two cases disease invaded into oral mucosa, the first well-documented cases of this occurrence.

Non-absorbable sutures are associated with lower recurrence rates in laparoscopic percutaneous inguinal hernia ligation

INTRODUCTION

Laparoscopic hernia repair with percutaneous ligation of the patent processes vaginalis is a minimally invasive alternative to open inguinal herniorrhaphy in children. With the camera port concealed at the umbilicus, this technique offers an excellent cosmetic result. It is also faster than the traditional laparoscopic repair with no differences in complication rates or hospital stay. The goal of this study was to describe a series of consecutive patients, emphasizing the impact of suture materials (absorbable vs. non-absorbable) on hernia recurrences.

METHODS

A retrospective review was performed of consecutive transperitoneal laparoscopic subcutaneous ligations of a symptomatic hernia and/or communicating hydrocele by 4 surgeons. Patients > Tanner 2 or with prior hernia repair were excluded. The success of the procedure and number of sutures used was compared between cases performed with absorbable vs. non-absorbable suture. Risk factors for surgical failure (age, weight, number of sutures used, suture type) were assessed with logistic regression.

RESULTS

94 patients underwent laparoscopic percutaneous hernia ligation at a mean age of 4.9 years. Outcomes in 85 (90%) patients with 97 hernia repairs at a mean of 8 months after surgery revealed 26% polyglactin vs 4% polyester recurrences (p = 0.004) which occurred at mean of 3.6 months after surgery, Table 1. Repairs performed with non-absorbable suture required only 1 suture more often than those performed with absorbable suture (76% vs 60%, p = 0.163). Logistic regression revealed suture type was an independent predictor for failure (p = 0.017). Weight (p = 0.249), age (p = 0.055), and number of sutures (p = 0.469) were not significantly associated with recurrent hernia.

DISCUSSION

Our review of consecutive hernia repairs using the single port percutaneous ligation revealed a significantly higher recurrent hernia rate with absorbable (26%) versus non-absorbable (4%) suture. This finding remained significant in a logistic regression model irregardless of number of sutures placed, age, and weight. Though the authors acknowledge the drawback of the potential for learning curve to confound our data, we still feel these findings are clinically important as this analysis of outcomes has changed our surgical practice as now all providers involved perform this procedure with exclusively non-absorbable suture. We thus suggest that surgeons who perform this technique, especially those newly adopting it, use non-absorbable suture for optimal patient outcomes.

CONCLUSIONS

Recurrent hernia after laparoscopic percutaneous hernia ligation was significantly lower in repairs performed with non-absorbable suture. Based on this data, we recommend the use of non-absorbable suture during laparoscopic ligation of inguinal hernias in children.

Renal damage detected by DMSA, despite normal renal ultrasound, in children with febrile UTI

OBJECTIVES

2011 American Academy of Pediatrics guidelines recommended renal-bladder ultrasound (RBUS) as the only evaluation after febrile urinary tract infection (FUTI) in infants aged 2-24 months. We determined the sensitivity, specificity, and false negative rate of RBUS to identify DMSA-detected renal damage in this age group as well as in older children.

METHODS

Consecutive patients referred to pediatric urology with a history of FUTI underwent DMSA ≥ 3 months after FUTI. Abnormal RBUS was defined as: Society of Fetal Urology hydronephrosis grades I-IV; hydroureter ≥ 7 mm; renal scar defined as focal parenchymal thinning; and/or size discrepancy ≥ 1 cm between kidneys. Abnormal DMSA was presence of any focal uptake defects and/or split renal function < 44%. We calculated sensitivity, specificity, positive and negative predictive values, and false negative rates of RBUS compared to DMSA.

RESULTS

618 patients (79% female), median age 3.4 years, were referred for FUTIs. Of the 512 (83%) with normal RBUS, 99 (19%) had abnormal DMSA. Children with normal RBUS after their first FUTI had abnormal DMSA in 15/151 (10%) aged ≤ 24 months and 23/119 (19%) aged > 24 months. RBUS had poor sensitivity (34%) and low positive predictive value (47%) to identify patients with renal damage. 99/149 (66%) children with renal damage on DMSA had normal RBUS.

CONCLUSION

After FUTI, 66% of children with reduced renal function and/or renal cortical defects found by DMSA scintigraphy had a normal RBUS. Since abnormal DMSA may correlate with increased risk for VUR, recurrent FUTI and renal damage, our data suggest RBUS alone will fail to detect a significant proportion of patients at risk. The data suggest that imaging after FUTI should include acute RBUS and delayed DMSA, reserving VCUG for patients with abnormal DMSA and/or recurrent FUTI.

Coronal fistula repair under the glans without reoperative hypospadias glansplasty or urinary diversion

BACKGROUND

Coronal fistulas present a potential dilemma in management. Successful closure requires reoperative glansplasty when there is only a thin band of tissue separating the urethral meatus from the fistula, indicating glans dehiscence. However, we avoided reoperative glansplasty during coronal fistula repair when the glans wings remained well-fused, given the increased risk for complications, including recurrent fistula, following reoperative glansplasty.

PURPOSE

We report coronal fistula closure without reoperative glansplasty in patients with preserved fusion of the glans wings. We also compare this closure done with versus without postoperative urinary diversion. The primary outcome was recurrent fistula.

MATERIALS

Consecutive patients with coronal fistula and no glans dehiscence (Figure) underwent repair by dissecting the fistula tract under the glans rather than re-opening the glans wings. A midline incision facilitated creation of a ventral dartos barrier flap, used in all cases, as well as selective skin revision when needed. Initial patients had postoperative urinary diversion, whereas later consecutive patients did not. Data was recorded prospectively at the time of service into a database.

RESULTS

WS performed 122 fistula repairs from 2001 to 2013, of which 78 were coronal. Of these, 33 had glans dehiscence with only a thin band of skin separating the fistula from the distal meatus and underwent reoperative hypospadias repair. The other 45 met inclusion criteria with maintained glans wings fusion and had only fistula closure. These 45 patients all had fistulas </= 3 mm, and none had evidence of meatal stenosis, defined as calibration <8 Fr in prepubertal and <12 Fr in pubertal males. Median age at fistula closure was 3 y (1-51), and mean follow up in 37 of the 45 patients was 18 m (1.6-84). Recurrent fistulas occurred in 2 (5%), with no difference in those with versus without urinary diversion.

DISCUSSION

There was a 5% fistula recurrence rate after dissecting under the glans and closing the urethral defect without reopening the glans in patients with well-fused glans wings. All patients had a ventral dartos barrier flap which covered the urethral defect. There was no difference in outcomes based on use of urinary diversion or not, and so we no longer use postoperative catheter drainage. Ours is the first report on fistula repair using a standardized protocol in consecutive patients, and it is difficult to compare our results to other published series which included fistulas in various locations, heterogeneity in decision-making based on "simple vs "complex" designations, and varied use of urinary diversion. Other reported recurrence rates vary from 4% to 30%. All our patients had primary fistulas <3 mm in size, and so we cannot comment on use of this technique for recurrent fistulas and/or larger defects. We report outcomes during a mean of 18 months follow up, and it is possible there will be additional recurrences with longer follow up.

CONCLUSIONS

This study is the first on fistula repair using a standardized procedure in consecutivepatients with prospectively recorded data. We found coronal fistulas ≤3 mm under well-fused glans wings can be repaired with low risk for recurrence by elevating the glans rather than re-opening the wings for reoperative glansplasty. Postoperative urinary diversion did not impact the recurrence rate and so is no longer used.

Objective use of testosterone reveals androgen insensitivity in patients with proximal hypospadias

OBJECTIVE

We report preoperative testosterone stimulation based on glans width measurements in patients with midshaft and proximal hypospadias, revealing androgen resistance in those with proximal hypospadias.

METHODS

Patients had maximum glans width measured preoperatively. Those <14 mm initially received 2 mg/kg testosterone cypionate intramuscularly for two to three doses, with the aim of increasing glans width ≥ 15 mm. Not all patients achieved targeted growth, and some were subsequently treated with escalating doses of testosterone.

RESULTS

5/15 midshaft patients had two to three doses of 2 mg/kg testosterone, with all increasing glans width to ≥ 15 mm. 29/47 proximal patients had testosterone, with 13 (57%) not reaching desired glans width. Six of these and another six patients had escalating doses from 4 to 32 mg/kg testosterone, with 11 then achieving targeted glans width. Relative androgen resistance was found in 19/29 (66%) proximal cases, including all treated patients with perineal hypospadias.

CONCLUSIONS

39/62 (63%) patients met objective criteria for preoperative testosterone stimulation based on glans width <14 mm, which is less than the average normal newborn glans diameter. Evidence of relative androgen resistance was found in 19 (49%), all with proximal hypospadias.

Glans penis width in patients with hypospadias compared to healthy controls

PURPOSE

There are no reports of systematically-measured penile dimensions in boys with varying extents of hypospadias. To determine reference values, we prospectively measured maximum glans width in patients undergoing distal and proximal hypospadias repair as well as newborns undergoing elective circumcision.

METHODS

The maximum glans diameter was measured in consecutive boys aged 0-24 months presenting for newborn circumcision (controls), or repair of distal (distal shaft or glanular) and proximal (proximal shaft to perineal) hypospadias. Patients with proximal hypospadias and glans diameter <14 mm received intramuscular testosterone 2 mg/kg injection once monthly for 2-3 treatments, with measurements recorded prior to the first injection, and again intra-operatively 3-4 weeks after the final injection.

RESULTS

Data were obtained in 240 controls, 188 boys with distal hypospadias, and 39 boys with proximal hypospadias. Median ages were 1, 9 and 9 months, respectively. Males undergoing newborn circumcision were younger than both cohorts of hypospadias patients (p < 0.0001), but no difference in age was noted in those with distal and proximal hypospadias (p = 0.194). Average maximum glans diameters were significantly different: 14.3, 14.8, and 12.9 mm, respectively, for controls, distal and proximal hypospadias (p < 0.0001). Despite mean older age, 46 (24.5%) boys with distal hypospadias and 24 (61.5%) with proximal hypospadias had small glans diameter <14 mm. Increasing age was not correlated with increasing glans size in patients with distal or proximal hypospadias (r = -0.136, p = 0.062 and r = -0.089, p = 0.580) at 3-24 months of age.

CONCLUSION

Some boys with distal and the majority of those with proximal hypospadias have a glans width less than that of the average normal newborn. Glans size does not correlate with age in patients with hypospadias between 3 and 24 months old, supporting the decision to operate as early as 3 months in some centers.

Prevalence and spot urine risk factors for renal stones in children taking topiramate

INTRODUCTION

Topiramate (TPM), an anti-epileptic drug with >4 million users, increases renal stones in adults. We screened outpatient TPM-treated children without history of stones to estimate the prevalence of renal stones and to characterize urine stone-risk profiles.

METHODS

Children taking TPM ≥1 month underwent an interview, renal ultrasound, and spot urine testing in this prospective study. Normal spot urine values were defined as: calcium/creatinine ratio ≤0.20 mg/mg (>12 months) or ≤0.60 mg/mg (≤12 months), citrate/creatinine ratio >0.50 mg/mg, and pH ≤ 6.7.

RESULTS

Of 41 patients with average age of 9.2 years (range 0.5-18.7), mean TPM dose of 8.0 mg/kg/day (range 1.4-23.6), and mean treatment duration of 27 months (range 1-112), two (4.9%) had renal stones. The majority of children taking TPM had lithogenic abnormalities on spot urine testing, including 21 (51%) with hypercalciuria, 38 (93%) with hypocitraturia, and 28 (68%) with pH ≥ 6.7. Hypercalciuria and hypocitraturia were independent of TPM dose and duration; urine pH increased with dose. 24-h urine parameters improved in 1 stone-former once TPM was weaned.

CONCLUSIONS

Asymptomatic stones were found in 2/41 (4.8%) children taking TPM. Risk factors for stones were present in the spot urine of most children, including hypocitraturia (93%) and hypercalciuria (51%), independent of TPM dose and duration. High urine pH, found in 68%, correlated with TPM dose. Pediatric specialists should be aware of increased risks for stones, hypercalciuria, hypocitraturia, and alkaline urine in children taking TPM.

Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair

INTRODUCTION

We previously described urethral plate (UP) dissection and urethral mobilization from the corpora cavernosa to achieve or facilitate straightening ventral curvature while preserving the UP for TIP in boys with proximal hypospadias. The original patients had similar complications to those undergoing proximal TIP without UP elevation. Subsequently an increased occurrence of neourethra strictures in those with UP elevation and urethral mobilization was recognized, and is now reported.

MATERIALS

Information on consecutive patients with proximal TIP repair with and without UP elevation and urethral mobilization by a single surgeon was reviewed in a database with pre-determined data points entered on the day of service.

RESULTS

There were 76 proximal TIP patients with follow up, 29 with and 47 without UP elevation and urethral mobilization, with strictures developing in 5 (17%) and 0, respectively, p = 0.01. All strictures were symptomatic (UTI, urinary retention), 0.1-1.0 cm long, and diagnosed at ≤1.5 years after surgery.

CONCLUSIONS

UP elevation and urethral mobilization with TIP resulted in focal devascularization of the neourethra with symptomatic stricture development. Although most patients with these straightening maneuvers did not have stricture, we no longer recommend UP elevation and urethral mobilization with proximal TIP repair.

Randomized, double-blind, placebo-controlled trial of polyethylene glycol (MiraLAX®) for urinary urge symptoms

OBJECTIVE

Polyethylene glycol (PEG) is common first-line therapy for urinary symptoms despite minimal evidence-based support. We performed a randomized, double-blind, placebo-controlled study of PEG for initial treatment of overactive bladder (OAB) symptoms in children.

PATIENTS AND METHODS

Patients aged >3 years underwent baseline urinary symptom questionnaire (USQ, scored 0-16), bowel symptom questionnaire (scored 0-20) and abdominal X-ray (KUB). Patients were randomized to placebo/PEG regardless of parent's perception of constipation. After 1 month, patients completed follow-up questionnaires and KUB. Improvement was defined as decrease in USQ (ΔUSQ) ≥ 3 points. Secondary analyses compared urinary and bowel symptoms to KUB.

RESULTS

Of 138 enrolled patients, 71 (51.4%) completed 1 month of therapy. Analyses of those randomized to placebo vs. PEG and non-completers demonstrated similar demographics, baseline symptoms, and KUB. Patients treated with placebo and PEG both had significant improvement in USQ scores (p < 0.0001). Patients treated with placebo and PEG responded similarly to placebo (ΔUSQ 3.7 vs. 3.4, p = 0.773), with improvement in nearly half (48.5% PEG vs. 44.7% placebo). There was no correlation between KUB and urinary or bowel symptoms.

CONCLUSIONS

Nearly 50% of patients with urinary urge symptoms treated with either placebo or PEG for 1 month had improvement in urinary symptoms. KUB did not correlate with baseline or follow-up urinary or bowel symptoms.

Initial results for combined orchiectomy and prosthesis exchange for unsalvageable testicular torsion in adolescents: description of intravaginal prosthesis placement at orchiectomy

PURPOSE

Historically the placement of testicular prosthesis during orchiectomy for torsion is delayed despite reports of safe prosthesis placement during mastectomy and orchiectomy for cancer as well as the removal of infected penile prostheses. We describe our experience with intravaginal testicular prosthesis at orchiectomy in adolescents with torsion.

MATERIALS AND METHODS

Consecutive pubertal patients undergoing exploration for torsion from 2010 to 2011 were offered orchiectomy with staged prosthesis or combined orchiectomy and prosthesis exchange for nonsalvageable testis. Through a midline scrotal incision the ipsilateral tunica vaginalis was opened, testis detorsed and contralateral orchiopexy performed. When verified as unviable, the ipsilateral spermatic cord was suture ligated within the tunica vaginalis and preplaced sutures secured the saline filled prosthesis in the tunica vaginalis. Patients were discharged home on the day of surgery with 5 days of oral antibiotics and narcotics. Demographic, surgical and postoperative measures were prospectively recorded.

RESULTS

Of 19 patients 6 had testes deemed salvageable at surgery with a median time to presentation of 6 hours (range 4 to 48) vs 96 (range 14 to 168, p = 0.002) in the 13 patients with nonsalvageable torsion. Of these patients 12 (median age 15 years, range 12 to 16) elected combined orchiectomy and prosthesis exchange. With a median followup of 4.8 months (range 1.5 to 16) there were no infectious complications or extrusions. Eleven (91.7%) patients had a symmetric appearing scrotum with the prosthesis located in a mid to dependent scrotal position.

CONCLUSIONS

We demonstrate the feasibility of intravaginal prosthesis placement for immediate scrotal reconstruction in adolescents with nonsalvageable testicular torsion. Advantages of combined orchiectomy and prosthesis exchange include orthotopic prosthetic position, extra tunica vaginalis barrier layer and avoidance of a second anesthetic.

Hospitalizations for pediatric stone disease in United States, 2002-2007

PURPOSE

Although more common in adults, urolithiasis recently has been occurring with increasing frequency in children. Single institution reviews from 1950 to 1990 revealed that urolithiasis accounts for 1 in 7,600 to 1 in 1,000 pediatric hospitalizations. Stone prevalence and risk factors for hospitalization are less defined in children in North America compared to adults. To identify pediatric hospital admissions due to a diagnosis of urinary stones, we examined Pediatric Health Information System data from 41 freestanding pediatric hospitals.

MATERIALS AND METHODS

We retrospectively studied patients younger than 18 years hospitalized between 2002 and 2007. The Pediatric Health Information System database, a validated collection of pediatric hospital data, was searched for inpatients with a primary ICD-9 diagnosis of urolithiasis.

RESULTS

Among more than 2.7 million pediatric inpatients from 2002 to 2007, 3,989 hospitalizations were for 3,815 patients with urolithiasis. In contrast to adults, girls had a 1.5-fold greater likelihood of being hospitalized for stones. More than half of the children (53.1%) were younger than 13 years (mean 12.3, SD 4.23). Most patients (88%) were white. Stone hospitalizations were more common in the North Central region compared to the South. Hospitalizations for stones increased slightly in August and September. Nephrectomy was performed in nearly 1% of stone hospitalizations (29 of 3,170).

CONCLUSIONS

Children with stones now account for 1 in 685 pediatric hospitalizations in the United States. Surprisingly more than half of the patients are younger than 13 years at hospitalization. Similar to findings in adults, white race and occurrence in late summer months increase the risk of stone hospitalization. However, male gender and geographic location in the Southeast are not risk factors, demonstrating the unique aspects of pediatric stone hospitalization.

Properties of yeast cells depleted of the OSCP subunit of mitochondrial ATP synthase by regulated expression of the ATP5 gene

OSCP is a subunit of the FA stalk sector of yeast mitochondrial ATP synthase complex. Cells of a null mutant for OSCP, constructed by disruption of the chromosomal ATP5 gene of Saccharomyces cerevisiae, exhibited a high level of genetic instability (petite formation). Study of the effects of ablation of OSCP required the development of a progressive depletion strategy. Introduction of a vector bearing an ATP5 gene cassette under GAL1 transcriptional control into null mutant cells gave rise to a stable yeast strain from which OSCP could be depleted in a controlled manner by manipulation of the level of galactose in the growth medium. Cells progressively depleted of OSCP exhibited properties of cellular respiration indicative of a decline in the functional coupling of the catalytic F1 sector to the proton channel F0 sector (normally linked by FA). Cells depleted of OSCP also exhibited a physical uncoupling of F1 from other subunits of the complex such that other FA subunits and F0 subunit 6 were not recovered in immunoprecipitates of ATP synthase complexes. Thus, OSCP plays a role in the assembly as well as function of the enzyme complex.