From Clinic Room to Zoom: Delivery of an Evidence-Based, Parent-mediated Intervention in the Community Before and During the Pandemic

Disruptive behaviors (DBs) are common in children with autism, affecting child and family quality of life. Parent-mediated interventions (PMIs) are a cost-effective and accessible way to decrease DBs. COVID-19 increased need for telehealth interventions. This study explored a group delivery of an evidence-based PMI (RUBI), delivered face-to-face and virtually in Israel, before and during the pandemic. Fifty-five families of children with autism and DB participated, 24 receiving face-to-face intervention and 31 receiving virtual. Outcome measures included the Aberrant Behavior Checklist and Home Situations Questionnaires. Results indicate reduction of DBs across groups, with > 50% of treatment-responders showing reliable change. This study is the first to assess RUBI outside the US among a sociodemographically diverse population, in both in-person and virtual contexts.

Ureteric stent versus percutaneous nephrostomy for acute ureteral obstruction - clinical outcome and quality of life: a bi-center prospective study

BACKGROUND

To compare quality of life (QoL) indices between ureteral stent (DJS) and nephrostomy tube (PCN) inserted in the setting of acute ureteral obstruction.

METHODS

Prospective bi-centered study. Over the span of 2 years, 45 DJS and 30 PCN patients were recruited. Quality of life was assessed by 2 questionnaires, EuroQol EQ-5D and 'Tube symptoms' questionnaire, at 2 time points (at discharge after drainage and before definitive treatment).

RESULTS

Patients' demographics and pre-drainage data were similar. There were no clinically significant differences in patient's recovery between the groups, including post procedural pain, defeverence, returning to baseline renal function, and septic shock complications. More DJS patients presented to the emergency room with complaints related to their procedure compared to PCN patients. At first, DJS patients complained more of urinary discomfort while PCN patients had worse symptoms relating to mobility and personal hygiene, with both groups achieving similar overall QoL score. At second time point, PCN patients' symptoms ameliorated while symptoms in the DJS group remained similar, translating to higher overall QoL score in the PCN group.

CONCLUSIONS

The two techniques had a distinct and significantly different impact on quality of life. Over time, PCN patients' symptoms relieve and their QoL improve, while DJS patients' symptoms persist. Specific tube related symptoms, and their dynamics over time, should be a major determinant in choosing the appropriate drainage method, especially when definitive treatment is not imminent.

Postoperative Urinary Leakage Following Partial Nephrectomy for Renal Mass: Risk Factors and a Proposed Algorithm for the Diagnosis and Management

OBJECTIVES

To evaluate the current incidence, risk factors, management, and long-term follow-up of urinary leakage following partial nephrectomy, in order to propose an algorithm for diagnosis and evaluation of postoperative urinary leakage.

MATERIALS AND METHODS

The study included 752 patients who underwent elective partial nephrectomies for renal masses between the years 1988 and 2013. Patients' demographics, clinico-pathologic variables, and operative details were collected retrospectively. The associations between urinary leakage and patients' variables were assessed by univariate and multivariate analyses.

RESULTS

Of the 752 patients, 21 (2.8%) experienced urinary leakage; 4 of the 21 patients with urinary leakage had spontaneous resolution, 1 patient underwent nephrectomy, and 16 patients were treated by retrograde ureteral stents insertion. One of them necessitated insertion of an additional percutaneous nephrostomy and another one deserved concomitant percutaneous drainage of a perirenal urinoma. The average period of time that elapsed from the operation until the insertion of stent was 8.5 ± 4.5 days. Stents were removed 68 ± 20.5 days postoperatively. None of the patients had either persistent or repeated leakage. On univariate analysis, hilar renal masses (p < 0.04) and higher preoperative creatinine levels (p < 0.01) were found to be associated with higher rates of urinary leakage. None of these variables was significant on a multivariate analysis. Review of the urinary leakage rate over time revealed it has been constantly decreasing over time, from 4% in early cases to 1.3% among the most recent ones.

CONCLUSION

None of the preoperative variables that were examined in this study was significantly associated with increased risk of urinary leakage. However, cumulative surgical experience was associated with lower rates of urinary leakage, suggesting that the decrease in its incidence is related to the improved surgical skills, rather than to differences in tumors' or patients' characteristics.

Has the data efflux regarding the promising outcome following injection of deflux changed the management of adult vesicoureteral reflux?

Primary vesicoureteral reflux (VUR), traditionally considered a problem of childhood, can also be detected during adulthood. However, while the concept regarding the therapeutic management of VUR in children has undergone revolutionary changes, moving from surgical to conservative approach, the optimal therapeutic approach in adult reflux is poorly addressed and is still unknown. Herein, we review clinical and therapeutic approaches of VUR in pediatric population as published throughout the years. With the introduction of Deflux injection as a minimally invasive procedure, we identify a beginning of a new trend that further extends the indications for endoscopic injections, including its introduction to adult patients as well.

Testicular prosthesis insertion following testicular loss or atrophy during early childhood--technical aspects and evaluation of patient satisfaction

INTRODUCTION

The absence of a testis may be a major traumatic experience with possible consequent negative behavioral impact. The current study is aimed to assess young adults who had lost their testicles early in childhood and subsequently underwent testicular prosthesis (TP) implantation at the end of their adolescence.

MATERIALS AND METHODS

Nineteen patients aged 19.4 years on average underwent TP implantation following testicular loss at early childhood. A postal anonymous questionnaire was sent to the patients and 13 (68%) replied.

RESULTS

Average follow-up was 50 months. Sixty-two percent of patients believed TP size were equal or close to the size of their native testicle, while 23% claimed it was too small. Similarly, 54% had the impression its weight was appropriate, while 38% claimed it was too heavy and 38% supposed its location was too high in the scrotum. However, 85% considered it "very comfortable" or "comfortable" and 77% got used to its presence within 1-4 weeks following surgery. All patients precluded any obstacle in intimate relationships. In accordance, all of them would recommend the operation to a friend with a similar problem.

CONCLUSIONS

TP implantation in adolescents with an undeveloped scrotum is a highly successful surgical procedure. The operation positively influences self-confidence, inter-personal interactions and intimate relationships.

Analysis of Rhythmic Patterns Produced by Spinal Neural Networks

A network of spinal neurons known as central pattern generator (CPG) produces the rhythmic motor patterns required for coordinated swimming, walking, and running in mammals. Because the output of this network varies with time, its analysis cannot be performed by statistical methods that assume data stationarity. The present work uses short-time Fourier (STFT) and wavelet-transform (WT) algorithms to analyze the nonstationary rhythmic signals produced in isolated spinal cords of neonatal rats during activation of the CPGs. The STFT algorithm divides the time series into consecutive overlapping or nonoverlapping windows and repeatedly applies the Fourier transform across the signal. The WT algorithm decomposes the signal using a family of wavelets varying in scale, resulting in a set of wavelet coefficients presented onto a continuous frequency range over time. Our studies revealed that a Morlet WT algorithm was the tool of choice for analyzing the CPG output. Cross-WT and wavelet coherence were used to determine interrelations between pairs of time series in time and frequency domain, while determining the critical values for statistical significance of the coherence spectra using Monte Carlo simulations of white-noise series. The ability of the cross-Morlet WT and cross-WT coherence algorithms to efficiently extract the rhythmic parameters of complex nonstationary output of spinal pattern generators over a wide range of frequencies with time is demonstrated in this work under different experimental conditions. This ability can be exploited to create a quantitative dynamic portrait of experimental and clinical data under various physiological and pathological conditions.

The effect of working memory capacity limitations on the intuitive assessment of correlation: Amplification, attenuation, or both?

This article challenges Yaakov Kareev's (1995a, 2000) argument regarding the positive bias of intuitive correlation estimates due to working memory capacity limitations and its adaptive value. The authors show that, under narrow window theory's primacy effect assumption, there is a considerable between-individual variability of the effects of capacity limitations on the intuitive assessment of correlation, in terms of both sign and magnitude: Limited capacity acts as an amplifier for some individuals and as a silencer for others. Furthermore, the average amount of attenuation exceeds the average amount of amplification, and the more so, the smaller the capacity. Implications regarding the applicability and contribution of the bias notion in this context and the evaluation of the adaptive value of capacity limitations are discussed.

Dysfunctional implications of narrow window theory: variability in the intuitive assessment of correlation

Narrow Window theory, suggested by Y. Kareev ten years ago, has so far focused on one central implication of the limited capacity of working memory on intuitive correlation estimation, namely, overestimation of the distal population correlation. This paper points to additional and perhaps more dramatic implications due to the large dispersion of intuitive estimates: (a) large estimation errors, possibly causing overestimation of negligible rhos, misses of strong rhos, and distorted hierarchies of the rhos between different pairs of variables; and (b) large interpersonal differences in the estimation of any given rho and highly incongruent hierarchies of estimated correlations between different pairs of variables. These implications impede both individuals' adaptation to the empirical world and communication among themselves.

Expression of cyclooxygenase-2 in Wilms tumor: immunohistochemical study using tissue microarray methodology

PURPOSE

Cyclooxygenase-2, a key enzyme in prostaglandin biosynthesis, has been shown to be involved in the modulation of cell growth, inflammation and apoptosis. Its involvement in the development of several human neoplasms has also been documented as well as the significant antitumor effects of its inhibitors. To our knowledge cyclooxygenase-2 expression in Wilms tumor has not been studied.

MATERIALS AND METHODS

A tissue microarray multitissue block was prepared from 14 samples of Wilms tumor, each from a different patient, from xenografts derived thereof, and from normal human lung, liver, renal cortex and medulla tissues as controls. Each sample was represented in the block by 3 or 4 cores 0.6 mm in diameter. After serial slicing to 4 mum the histological slides were stained with hematoxylin and eosin, and immunostained with anti-cyclooxygenase-2 antibodies. Immunostaining was graded semiquantitatively according to the percent of stained cells with the cytoplasmic pattern of staining and according to staining intensity.

RESULTS

All authentic human pathological samples except 1 anaplastic Wilms tumor as well as Wilms tumor xenografts expressed cyclooxygenase-2 in all Wilms tumor cellular components except the stroma. Expression was also observed in Wilms tumor lung metastasis and in tumors that overgrew chemotherapy. In comparison, cyclooxygenase-2 expression in normal kidneys was less prominent than in Wilms tumor samples and it was confined to the tubular epithelium in the cortex and medulla.

CONCLUSIONS

Cyclooxygenase-2 expression is characteristic of all nonanaplastic Wilms tumors at all stages. It is similar to the previously observed pan-expression of ErbB2 receptors in these tumors. The potential therapeutic role of cyclooxygenase-2 inhibitors should be evaluated for Wilms tumor.

Testicular Fixation Following Torsion of the Spermatic Cord—Does it Guarantee Prevention of Recurrent Torsion Events?

PURPOSE

Patients with history of testicular torsion who have undergone orchiopexy may rarely present with acute scrotum due to recurrent episodes of torsion. Most of the reports in the literature regarding this scenario refer to the era when absorbable sutures were used for testicular fixation. Herein, we review our experience in recent years, focusing upon the surgical technique and sutures' material.

MATERIALS AND METHODS

Between 1991 and 2003, 179 patients were operated on at our institute with the clinical diagnosis of unilateral testicular torsion. They ranged in age between neonates to 45 years old (average age 18). In a comprehensive retrospective study we managed to locate 8 patients who experienced recurrent intravaginal testicular torsion following previous fixation performed in our institute.

RESULTS

The patients who experienced repeat torsion have initially presented at the mean age of 18.5 years old (range 12 to 30) with unilateral twisted testicle (left 3, right 5). Urgent explorations were generally performed, apart from in 2 cases that underwent spontaneous detorsion which was followed by an elective surgery. Testicular fixation was conducted by suturing of the tunica albuginea to the dartos layer by 2 sutures at each side, using chromic 3-zero in the 3 more early cases, followed by the usage of polyglactin 3-zero stitches in 4 subsequent cases and 3 sutures of polypropylene 4-zero for each testicle, thereafter, in the most recent case. The patients presented with repeat torsion, 0.5 to 23 years subsequently (average 7 years), involving either the ipsilateral testicle in 4 cases or the contralateral gonad in 4.

CONCLUSIONS

Recurrent torsion following previous testicular fixation may appear many years following the primary procedure, even in cases in which either polyglactin or, notwithstanding, polypropylene sutures have been applied, in accordance with the common practice used in the last 2 decades. Increased awareness regarding this possibility is imperative for early diagnosis and prevention of testicular loss.

ErbB2 is a tumor associated antigen and a suitable therapeutic target in Wilms tumor

PURPOSE

The modern multimodality therapeutic approach to Wilms tumor (WT), combining surgery with radiotherapy and chemotherapy results in high cure rates even for high stage disease. However, the combination of radiotherapy and chemotherapy is associated with severe early and late complications such as neutropenic sepsis, growth retardation and secondary malignancies. Therefore, novel therapeutic strategies, which would decrease the treatment burden, are required. We studied the expression of erbB2 growth factor receptor in WT cells as well as its role as a tumor therapeutic target in an in vivo xenograft model of Wilms tumor.

MATERIALS AND METHODS

Paraffin embedded pathological samples from 14 different WT cases as well as xenografts derived thereof were immunostained with anti-erbB2 monoclonal antibody. The immunostaining was graded in comparison to a known positive control (breast cancer) and was scored by the intensity of staining (0 to +3) multiplied by the percentage of cells expressing the antigen. The expression of erbB2 in the human WT xenograft was verified also by fluorescence activated cell sorter analysis. In addition, nude mice bearing established subcutaneous human WT xenografts were treated with either 3 intraperitoneal injections of N29 anti-erbB2 monoclonal antibody or irrelevant antibody.

RESULTS

All of the authentic human pathological samples, except 1 anaplastic WT as well the WT xenografts (at different stages), expressed erbB2. Expression was also observed in WT metastasis and in tumors which out grew chemotherapy. Systemic administration of anti-erbB2 monoclonal antibody inhibited and even prevented the growth of WT xenograft in vivo.

CONCLUSIONS

ErbB2 is a tumor associated antigen in WT. Being expressed in almost all tumor stages, our in vivo model suggests that erbB2 may serve as a WT therapeutic target. Further work is needed to establish the role of erbB2 in the disease and its potential use in decreasing current treatment burden.

Analysis of the long-term outcome of surgically corrected vesico-ureteric reflux

OBJECTIVE

To review patients who had vesico-ureteric reflux corrected surgically by ureteric reimplantation during childhood, and thus assess their long-term outcome.

PATIENTS AND METHODS

Between 1970 and 1979, 322 children underwent ureteric reimplantation; 100 (79 women and 21 men) were re-assessed and the long-term results evaluated using a questionnaire, a review of the patients' current medical records and an appointment in the outpatient clinic. The evaluation focused on the frequency of late urinary tract infections (UTIs), current renal function tests, related complications during pregnancy and the incidence of hypertension at least 20 years after surgery.

RESULTS

Of the study group, 51% (66% of men and 47% of women) had no long-term urological complications. The incidence of UTIs was 43% in women and 24% in men, and of pyelonephritis 27% and 9.5%, respectively. Hypertension was detected in 6% of the patients during assessment. There were new renal scars, despite surgery, in 20% of the patients. Forty-seven women had been pregnant, 28% reporting UTIs during pregnancy. In 7% of 94 pregnancies the women also had pre-eclampsia and two women had transient gestational ureteric obstruction which required drainage. Renal functional tests were worse in one man and one woman who developed end-stage renal disease and had a renal transplant.

CONCLUSIONS

This series shows that even patients who were treated successfully by ureteric reimplantation during childhood are prone to recurrent UTIs, progressive renal scarring, hypertension and complications during pregnancy. There is a need to establish a protocol for the long-term follow-up of such patients.

Extensive necrosis in renal cell carcinoma specimens: potential clinical and prognostic implications

BACKGROUND

Extensive necrosis is rare in primary renal cell carcinoma. This finding may reflect the biological characteristics of the carcinoma and therefore could be of prognostic and clinical value.

OBJECTIVES

To assess the incidence of necrosis in renal cell carcinoma and its potential prognostic value.

METHODS

We conducted a consecutive retrospective study of 173 patients after radical nephrectomy for renal cell carcinoma. Clinical and pathological data were collected from hospital medical records and compiled into a computerized database.

RESULTS

Extensive necrosis was found in 31 tumor specimens (17.9%). Univariate analysis showed that the specimens with extensive necrosis were significantly larger and manifested more perirenal and venous extension than the tumors without necrosis. The size of the renal tumor was the only parameter that remained significant in multivariate analysis (P = 0.0001). Overall disease-free survival did not differ significantly between patients with necrotic tumors and those without (68% and 66% respectively).

CONCLUSIONS

The finding of extensive necrosis in renal cell carcinoma specimens does not seem to be related to tumor biology but rather may reflect the relation between size and vascularity of the tumor.

[Nephrogenic adenoma--benign lesion of urinary tract system]

Nephrogenic adenoma is a rare metaplastic benign lesion of the urinary tract caused by chronic irritation to the urinary epithelium. The appearance of this lesion is usually characterized by hematuria and irritative symptoms. Nephrogenic adenoma may be found most commonly in the bladder and the urethra and less frequently in the renal pelvis and ureters. We present 5 patients who underwent surgery due to bladder or urethral nephrogenic adenoma. Despite the fact that nephrogenic adenoma is a benign lesion, long term follow-up is needed due to the high recurrence rate and the potential, though rare, malignant transformation.

Routine cystoscopy before radical prostatectomy: is it justified?

OBJECTIVES

The extent of the required preoperative workup of patients who are candidates for radical prostatectomy is still controversial. Traditionally, cystoscopy has been reserved only for those patients who present with hematuria. However, several investigators have reported significant incidental cystoscopic findings among these patients and advocated the routine use of cystoscopy before radical prostatectomy. In view of the conflicting recommendations, we elected to assess the role of routine cystoscopy in a series of patients with prostate cancer at our institute.

METHODS

We retrospectively reviewed the cystoscopic findings of 225 consecutive patients with organ-confined prostate carcinoma scheduled for radical prostatectomy. Rigid cystoscopy was performed before surgery either in an outpatient setting or on the operating table just before the operation.

RESULTS

Significant cystoscopic findings were noted in 3 (1.3%) of 225 patients. These included a bladder stone in 1 patient, superficial bladder tumor in 1 patient, and a post-sphincteric urethral polyp containing prostatic adenocarcinoma in a third patient. This polyp was resected transurethrally and the patient was treated thereafter with irradiation because of local extension. None of the 3 patients had microscopic hematuria on urinalysis to suggest the findings. Cystoscopy was uneventful in all patients, apart from occasional mild hematuria.

CONCLUSIONS

These results show that the treatment of patients who were candidates for radical prostatectomy was affected by the findings of preoperative cystoscopy in less than 1% of the cases. We believe that in view of the low yield of cystoscopic findings in these patients, in an era in which cost effectiveness is a major issue, the routine use of cystoscopy before radical prostatectomy is not justified.

Management of urethral erosion caused by a pubovaginal fascial sling

Urethral erosion by a fascial sling is a rare postoperative complication, and its repair can become a major surgical endeavor. We present a case of autologous fascial sling erosion into the mid-urethra in a 46-year-old woman that was diagnosed after traumatic urethral catheterization. After 3 months of conservative management failed, we released the sling tension surgically by bilateral excision of the graft, leaving the midline structures undisturbed. This allowed resumption of normal voiding, with complete long-term symptomatic relief.

Is only meatoplasty a legitimate surgical solution for extreme distal hypospadias? A long-term follow-up after adolescence

OBJECTIVE

To review the long-term outcome of glanular hypospadias repair for extreme distal hypospadias based on simple dorsal Browne meatoplasty and circumcision, with particular attention to patient satisfaction.

PATIENTS AND METHODS

A review of medical records identified 124 patients who underwent surgery for hypospadias between 1970 and 1979. Their age at operation ranged from 3 months to 13 years. The operation, performed as a day-case, included dorsal Browne meatoplasty for meatal advancement, based upon the Heineke-Mikulicz principle, using three absorbable sutures and often circumcision. There were no immediate complications. A questionnaire was sent to 111 patients whose present address was available. Two patients had died since the operation and of the 109 remaining patients, 43 (39%) replied.

RESULTS

The patients were aged 16-31 years at the time of assessment, giving a follow-up of 18 (13-23) years. Seven of the 43 patients were married. Seven patients had complained of some difficulties with urination, four reporting a poor urinary flow. The stream was directed forward in 32 patients and to some degree downwards in 11, still enabling all the patients to urinate while standing with a single stream. Thirty-two patients had had sexual experience, with no functional problems. Twenty-three defined their penile appearance as normal and 20 as abnormal. Overall, 24 (56%) reported complete satisfaction, 11 (25%) partial satisfaction and eight (19%) were dissatisfied with the surgical result.

CONCLUSION

As there are few published reports about the long-term outcome and patient satisfaction after hypospadias repair, it is difficult to draw clear conclusions. However, this simple procedure is a legitimate surgical option for extremely distal glanular hypospadias.

Traumatic testicular dislocation: a case report and review of published reports

Testicular dislocation after blunt scrotal trauma is a rare event. Its diagnosis depends on the awareness of the physician of its possible occurrence. It is usually a late finding during treatment of a motorcyclist brought to the emergency room because of multitrauma injury and is sometimes demonstrated in an abdominal computed tomography scan. We describe a typical case and discuss the chain of events leading toward the correct diagnosis and treatment based on a review of published reports.

[Malignant lymphoma of the bladder]

Urinary tract lymphoma is usually reported when the secondarily stem is affected by widespread non-Hodgkin lymphoma. We describe an 83-year-old woman who presented with secondary lymphoma of the bladder 3 years after diagnosis when it initially infiltrated her breast. Treatment included local transurethral excision followed by chemotherapy, during which she died of disseminated disease.

[Can preoperative urodynamic examination allow us to predict the risk of incontinence after radical prostatectomy?]

OBJECTIVES

To verify whether bladder dysfunction detected by urodynamic studies prior to radical prostatectomy can predict postoperative continence status.

MATERIAL AND METHODS

Twenty patients diagnosed with prostate cancer had multichannel subtracted filling and voiding videocystometry before undergoing radical retropubic prostatectomy. Postoperatively, all patients had periodic clinical assessment of continence status.

RESULTS

On preoperative filling cystometry, detrusor instability with a maximal detrusor pressure greater than 15 cm H2O was demonstrated in 12/20 patients (60%). Postoperatively, 11/20 patients (55%) were continent, 4 (20%) had mild stress incontinence and 5 (25%) complained of episodic urge incontinence. However, only 5 of the 12 patients with preoperatively diagnosed detrusor instability manifested clinical urge incontinence after surgery (positive predictive value = 41.6%).

CONCLUSION

The incidence of preoperative detrusor instability in our series was high, but little correlation was found between this finding and postoperative incontinence.

[The Mitrofanoff pouch in lower urinary tract reconstruction]

The Mitrofanoff principle, first described in 1980, consists of implanting a tubular organ such as the appendix, ureter, or fallopian tube into the wall of the bladder (or urinary reservoir) to create a non-refluxing, catherizable urinary conduit. Between 1993-1996, 7 men and 1 woman (aged 48-64, average 59) underwent radical cystectomy and urethrectomy combined with the creation of a MAINZ I urinary reservoir (based on the Mitrofanoff principle). In men the indication for the procedure was the diagnosis of invasive transitional cell carcinoma of the bladder with involvement of the prostatic urethra. All patients had refused urinary diversion to an ileal conduit because of its deleterious effect on the quality of life. In all patients the postoperative course was uneventful, apart from intraperitoneal urinary leakage from the reservoir in 1, successfully managed conservatively. The patients have gained full control of urinary drainage, performing intermittent self-catheterizations every 4-5 hours. In 3 patients there were difficulties with catheterization due to stenosis of the conduit, usually at the skin level. None have suffered leakage from the reservoir, during the day, even when it was full. Our experience shows that creation of a continent urinary reservoir according to the MAINZ I technique is an excellent surgical solution for patients in whom the creation of an orthotopic reservoir is impractical. The use of the umbilicus as a stomal site preserves normal body image and thus does not interfere with quality of life as in those undergoing radical cystectomy.

The role of percutaneous nephrolithotomy in the management of pediatric renal calculi

PURPOSE

Minimally invasive techniques for the treatment of urinary calculi in children are recommended due to an increased probability of recurrence. Percutaneous nephrolithotomy is well established in adults but to our knowledge this procedure has not been reported previously in a large series of children. We review our experience with percutaneous nephrolithotomy in children.

MATERIALS AND METHODS

From 1987 to 1995 percutaneous nephrolithotomy was performed in 25 children 3 to 16 years old (median age 8). Indications for percutaneous nephrolithotomy were an obstructed kidney in 10 cases, large stone size or staghorn calculus in 8, failed extracorporeal shock wave lithotripsy in 4 and residual stones after open surgery in 3. There were 15 solitary renal, 4 staghorn and 2 upper ureteral stones, and 5 children had multiple renal calculi.

RESULTS

Percutaneous nephrolithotomy was performed once in 22 patients, and 2, 3 or 5 times in the remainder. Of the 25 patients 17 (68%) were stone-free at hospital discharge or shortly thereafter following a single session of percutaneous nephrolithotomy. Retained calculi after a single percutaneous nephrolithotomy treatment were much more common with staghorn stones (2 of 4 cases or 50%) and multiple stones (3 of 5 or 60%) compared to solitary renal stones (2 of 15 or 13.3%). With subsequent extracorporeal shock wave lithotripsy or repeat percutaneous nephrolithotomy the stone clearance rate was as high as 92%. At a 2 to 66-month followup (average 23) no late complications were noted. Radioisotope scans available in 10 cases before and after percutaneous nephrolithotomy revealed unchanged differential function and evidence of significant renal scars in only 1.

CONCLUSIONS

Percutaneous nephrolithotomy is a suitable and safe procedure for treating renal stones in children.

Combined Mitrofanoff and antegrade continence enema procedures for urinary and fecal incontinence

PURPOSE

Fecal soiling or intractable constipation frequently occurs in association with urinary incontinence in children undergoing major reconstructive urological operations. To treat double incontinence or the combination of wetting and severe constipation, we constructed a Mitrofanoff conduit and a channel for antegrade continence enemas in 18 patients between 1989 and 1995. We review the underlying pathological conditions, various surgical techniques and outcomes of these operations.

MATERIALS AND METHODS

Underlying abnormalities mainly included spinal lesions, bladder exstrophy, imperforate anus and various cloacal anomalies. Patient age ranged from 2 to 18 years (average 8.4). In 13 patients both procedures were done simultaneously. The appendix was used to construct the antegrade continence enema channel in 8 cases and the Mitrofanoff channel in 5. It was long enough to be divided and used for both procedures in 2 cases but it was missing or unsuitable in 3. Alternative antegrade continence enema conduits were cecal flap in 7 patients and ileum in 1, while the ureter, ileum and detrusor tube were used to establish Mitrofanoff channels in 5, 5 and 1, respectively. Stomas were constructed according to the V-flap or V. Z. Q. technique and situated in close proximity in the right lower abdominal quadrant in 13 cases.

RESULTS

Convalescence was uneventful except for 1 abscess near an antegrade continence enema stoma. Ten patients needed dilation or minor revisions due to difficulty in catheterizing the antegrade continence enema (5), Mitrofanoff (3) or both conduits (2). Subsequently 3 patients underwent repeat operations for reconstruction of 2 antegrade continence enema channels (cecal flap and ileum) and 1 detrusor tube Mitrofanoff channel. Currently 15 patients are dry on regular clean intermittent catheterization using 10 to 12F catheters. Outcomes of the antegrade continence enema channels are satisfactory in 15 patients who are clean or rarely soil. Failure occurred in 1 patients with severe constipation necessitating colostomy and 2 (1 noncompliant who stopped catheterizing regularly) in whom the channels subsequently closed.

CONCLUSIONS

Synchronous construction of antegrade continence enema and Mitrofanoff channels is successful in the majority of doubly incontinent patients. Selection of patients with high motivation is important to obtain satisfactory results.

Bladder hemangioma as a cause of massive hematuria in a child. A case report and literature review

A 12-year-old girl with bladder hemangioma presenting with massive hematuria is described. The patient was previously operated for removal of cystic hygroma from the chest wall. The association of those two pathological entities suggests possible common etiology and pathogenesis and the various therapeutic options are reviewed.

Transurethral hyperthermia for relieving obstructive voiding symptoms in patients with hormone refractory prostate cancer

Transurethral thermal treatment has been used to relieve obstructive voiding symptoms in 10 patients with prostate cancer. All patients failed previous endocrine treatment for the relief of obstructing urinary symptoms. Temperature ranging from 46 degrees C to 47 degrees C was applied transurethrally using Thermex II thermal system. Treatment was given in a single session for a duration of 180 minutes on an outpatient basis without sedation. Mean duration of follow-up was 8.5 months (range 4-13 months). Maximal urine flow rate, post-voiding residual volumes and changes in subjective symptoms were used to assess treatment response. Removal of an indwelling catheter was possible in all 3 patients with chronic retention. Urinary infection (2 patients) and temporary retention (3 patients) were the only complications recorded. The preliminary results suggest that transurethral hyperthermia is a well-tolerated, safe and effective procedure for obstructive voiding symptoms in patients with hormone refractory prostate cancer. Longer follow-up and a larger group of patients is required to assess this alternative modality.

The role of ureter in the creation of Mitrofanoff channels in children

PURPOSE

Since 1980 numerous variations of the Mitrofanoff principle have been described. We report on 22 children in whom a ureteral Mitrofanoff channel was created.

MATERIALS AND METHODS

Between 1986 and 1995 a ureteral Mitrofanoff channel was constructed as a catheterizable conduit in 22 children 2 to 15 years old (average age 6.5) with various abnormalities of the lower urinary tract, mainly exstrophy and neurogenic bladder. Indications included unavailability or unsuitability of the appendix, preference for appendix as a catheterizable colonic stoma for antegrade washouts or concomitant removal of a nonfunctioning kidney, leaving the ureter available for use. Surgical technique was based on the principles of appendicovesicostomy and in 9 cases the ureteral Mitrofanoff channel was reimplanted.

RESULTS

Followup ranged from 1 to 72 months (average 30.5). Complications included stenosis of the conduit that caused difficult catheterization in 3 patients, necessitating dilation or minor revision in 2 and complete replacement by appendix in 1. Urinary leakage from the Mitrofanoff channel in 5 patients was treated with polydimethylsiloxane injection or oxybutinin. In 1 patient the channel was reimplanted, since the catheter struck the bladder neck during catheterization and caused severe pain.

CONCLUSIONS

Results of the ureteral Mitrofanoff channel seem somewhat less satisfactory than those of appendicovesicostomy but they remain acceptable and even comparable, strongly supporting its use in certain circumstances.

Treatment of experimental mouse bladder tumour by LPS-induced epithelial cell shedding

The purpose of the present study was to explore the therapeutic potential of serial administration of shedding-inducing endotoxin in a mouse tumour bladder model. The studies were conducted with two variants derived from the MBT-2 tumour namely, T5 and T50, the latter being far more aggressive than the former. It was found that T5 tumours responded to intravesical lipopolysaccharides (LPS) instillation by a considerable reduction in their pace of growth (P < 0.0001) when treatment was initiated 3 days after tumour implantation, but not when started after 7 days. The T50 variant did not respond to LPS when treated 3 days after implantation, but a considerable reduction in rate of growth occurred when treatment was started after 1-2 days. Shedding induced by intravesically instilled LPS was found to retard considerably the progression rate of experimental bladder tumour.

Bladder neck reconstruction: long-term followup of reconstruction with omentum and silicone sheath

PURPOSE

In 1986 we reported the placement of a silicone sheath sandwiched between layers of omentum around a newly reconstructed bladder neck. We now present long-term followup of 94 cases of silicone sheath bladder neck reconstruction.

MATERIALS AND METHODS

A total of 94 silicone sheaths was placed in 84 patients between August 1983 and October 1992. We retrospectively reviewed our results and divided the reconstructions into 3 groups according to modifications in surgical technique. We report the results of each modification and current recommendations for use.

RESULTS

Each sequential modification of silicone sheath bladder neck reconstruction significantly reduced the risk of erosion from 100%, 32% and 7%, respectively (p < 0.05). Erosion was independent of patient age, sex, pathological condition or whether bladder neck reconstruction was a repeat procedure. Patients who had silicone sheath erosion did not have different continence or loss of urethral continuity than those with no erosion. In 13 patients (16%) artificial sphincter placement was clearly facilitated by the silicone sheath.

CONCLUSIONS

Modifications in the surgical technique of silicone sheath placement around a reconstructed bladder neck have resulted in a decrease in the erosion rate to 7%. The primary benefit of silicone sheath placement is ease of subsequent sphincter placement. Currently we reserve silicone sheath placement for a small subset of patients who are most likely to benefit from subsequent artificial sphincter placement.

Lower pole heminephrectomy: its role in treating nonfunctioning lower pole segments

PURPOSE

We assessed the role and long-term outcome of lower pole heminephrectomy in the treatment of nonfunctioning lower renal moieties in children with duplex kidneys.

MATERIALS AND METHODS

Between 1979 and 1994, 54 lower pole heminephrectomies were performed in 53 patients 1 to 192 months old (mean age 54) with duplex systems. A total of 15 patients was prenatally diagnosed, while the others presented with a urinary tract infection (36), orchiepididymitis (1) and failure to thrive (1). The surgical technique was essentially similar to that of upper pole heminephrectomy.

RESULTS

Operative course was uneventful except for intraoperative bleeding in 5 cases, which necessitated blood transfusion, and a postoperative urinary tract infection in 1. Followup ranged from 3 to 168 months (mean 56.9). Postoperative renograms available in 34 cases showed unchanged differential function in 12 and an ipsilateral 2 to 14% decrease (mean 5.65%) in 22. No late complications were detected except in 1 patient, who had postoperative urinary tract infections and subsequently underwent removal of the ureteral stump. Our series includes 4 patients with solitary ipsilateral upper poles (after the contralateral kidney was removed or nonfunctioning) who had good renal function at long-term followup despite the reduced parenchymal mass.

CONCLUSIONS

Based on our experience it seems that lower pole heminephrectomy is the treatment of choice in cases of nonfunctioning dilated lower segments of duplicated kidneys.

Testicular seminoma: clinical significance of nuclear deoxyribonucleic acid ploidy pattern as studied by flow cytometry

PURPOSE

We evaluated the clinical significance of deoxyribonucleic acid (DNA) ploidy pattern as a predictor of prognosis in patients with testicular seminoma.

MATERIALS AND METHODS

Flow cytometric nuclear DNA analysis was performed on archival specimens from 65 patients with pure seminoma who underwent radical orchiectomy between 1970 and 1992.

RESULTS

A total of 42 specimens (65%) exhibited a DNA diploid pattern, while 23 (35%) were DNA aneuploid. Diploidy was manifested in 73% of the stage I tumors versus 31% of stage II cancers (p = 0.004). No correlation was found between ploidy and histological type, size or local extension of the tumor. Tumor progression was observed in 5 patients, exclusively displaying aneuploid histograms (p = 0.0017), and 3 of them subsequently died of the disease.

CONCLUSIONS

DNA ploidy pattern may provide important prognostic information for patients with testicular seminoma.

Reconsidering the necessity of ipsilateral adrenalectomy during radical nephrectomy for renal cell carcinoma

OBJECTIVES

Ipsilateral adrenalectomy is traditionally advocated as part of radical nephrectomy performed for renal cell carcinoma. The current study addresses the controversy of whether ipsilateral adrenalectomy should be performed routinely during radical nephrectomy.

METHODS

A total of 225 patients were treated surgically for renal cell carcinoma over an 18-year period. Of these patients, 158 underwent nephrectomy and simultaneous ipsilateral adrenalectomy and the other 67 had sparing of the ipsilateral adrenal gland. A retrospective analysis of the medical records and assessment of the clinical and the pathologic data were performed. Rates of survival and progression were evaluated in a subgroup of 109 patients, further subdivided into 54 patients who underwent concomitant adrenalectomy and 55 patients with the ipsilateral adrenal preserved during surgery.

RESULTS

Histopathologic abnormalities were detected in seven adrenal specimens (4.4%); however, only 3 patients (1.9%) had involvement of the adrenal by renal cell carcinoma. All cases of adrenal involvement were detected by the preoperative imaging modalities. Ipsilateral adrenalectomy did not improve the outcome in comparison to adrenal preservation.

CONCLUSIONS

In view of the rarity of ipsilateral adrenal metastasis, the questionable prognostic merits of concomitant adrenalectomy, and the availability of accurate imaging modalities, we conclude that ipsilateral adrenalectomy is not necessary in the majority of the patients undergoing radical nephrectomy for renal cell carcinoma.

Genetic predisposition and cyclophosphamide treatment in a girl with bladder carcinoma?

Transitional cell carcinoma of the bladder rarely occurs in young female patients. We present a case of bladder carcinoma which appeared after treatment with cyclophosphamide, in a 14-year-old girl genetically predisposed to bladder cancer.

Flow cytometric DNA analysis of classic and steroid-induced Kaposi's sarcoma

Flow cytometric DNA analysis of various tumours has indicated a correlation between the degree of malignancy and ploidy; results which could have clinical significance. We analysed the ploidy of Kaposi's sarcoma (KS) tumours, and classified the results according to clinical history and histological findings. We found that patients on steroid treatment had an aneuploid pattern, and most of the patients with classic-type KS had a diploid pattern on flow cytometry.