Implications of antenatal ultrasound screening in the incidence of major genitourinary malformations.

Over the past 3 decades, infant mortality has decreased nearly 50%. Although neonatal intensive care deserves much of the credit, the recent increase in prenatal ultrasonography use, from 33% of pregnancies in 1980 to 78% in 1987, has improved early detection. The authors wished to evaluate the impact on major genitourinary malformations. Data obtained from the Malformations Surveillance Program at Brigham and Women's Hospital between 1974 and 1994, tracked 163,431 pregnancies and termination rates of fetuses with spina bifida, bladder exstrophy, prune belly syndrome, and posterior urethral valves. Hospital data showed 65% of fetuses with spina bifida, 46% with posterior urethral valves, 31% with prune belly syndrome, and 25% with exstrophy, were terminated electively. Clearly, surveillance programs and improved accuracy of antenatal ultrasound has allowed early diagnosis of major genitourinary malformations. Many factors influence decision making in these affected fetuses, including the financial and emotional impact of these major anomalies over a lifetime. Future societal decisions, and the reduction in these anomalies may influence our training programs, manpower needs, medical facility requirements, and the character of our practices. These findings may have significant implications in the field of pediatric urology.

Comparison of the durability of cadaveric and autologous fascia using an in vivo model.

OBJECTIVES: To assess the durability of both autologous and cadaveric fascia using an animal model. The pubovaginal sling procedure can be performed using autologous, cadaveric, or synthetic materials. Few data are available about the strength and durability of these materials. METHODS: Rectus abdominus fascia harvested from 6 female Sprague-Dawley rats was processed by Tutogen Medical. In 20 female Sprague-Dawley rats, three different types of fascia were implanted subcutaneously into each animal: autologous rectus abdominus fascia harvested at the time of surgery; rat cadaveric fascia processed by Tutogen; and human cadaveric fascia (Tutogen). The rats were killed at 2 months (10 rats) and 4 months (10 rats) after implantation. The mechanical properties of the tissue were assessed using the trouser tear test, and the fracture toughness was calculated. RESULTS: Compared with the fracture toughness before implantation, the implanted rat autologous fascia decreased in toughness from 1763 to 1243 J/m(2) (P = 0.12), the implanted rat cadaveric fascia decreased in toughness from 1539 to 1022 J/m(2) (P = 0.02), and the implanted human cadaveric fascia decreased in toughness from 2120 to 1145 J/m(2) (P = 0.09). The fracture toughness of the implanted rat cadaveric fascia and rat autologous fascia did not differ significantly (P = 0.29). CONCLUSIONS: The changes in strength or elasticity can be detected using the trouser tear test to calculate the fracture toughness. Both cadaveric and autologous fascial grafts may decrease in toughness with time. The long-term durability of the graft may only be a minor factor in determining the success of the pubovaginal sling procedure.

Infant mortality from congenital malformations in the United States, 1970-1997.

OBJECTIVE: We examined a trend in infant mortality caused by congenital malformations in the United States, particularly for the racial disparity between whites and nonwhites. METHODS: We used US annual summary data on cause-specific infant mortality for 1970-97 and detailed birth and infant death linked data for 1985-87, 1989-91, and 1995-97. RESULTS: Congenital malformations became a more prominent cause of infant mortality in 1997 and accounted for 22.1% of all infant deaths compared with 15.1% in 1970. Congenital malformations of nervous, cardiovascular, and respiratory systems accounted for more than 60% of all malformation deaths. Malformations incompatible with life (anencephaly, encephalocele, hypoplastic lungs, renal agenesis, and trisomies 13 and 18) were the cause of one-third of all malformation deaths. In 1970-71, infant mortality caused by congenital malformations in nonwhites was lower, 2.6 (confidence interval [CI] 2.5, 2.7) per 1000, compared with whites, 3.1 (CI 3.0, 3.1) per 1000. However, in 1996-97, the rate of congenital malformation-specific infant mortality was higher in nonwhites, 1.7 (CI 1.7, 1.8) per 1000, compared with whites, 1.6 (CI 1.5, 1.6) per 1000. This trend was most pronounced with central nervous system malformations. Although whites had an almost two-fold higher infant mortality rate from central nervous system malformations compared with nonwhites in 1970-71, this disparity was no longer present by 1996-97. CONCLUSION: Congenital malformations have become a leading cause of infant mortality in the 1990s. Over the last several decades, this mortality declined more slowly in nonwhites than in whites.

Implications of prenatal ultrasound screening in the incidence of major genitourinary malformations.

PURPOSE: During the last 3 decades infant mortality has decreased nearly 50%. While neonatal intensive care deserves much of the credit, the recent increase in prenatal ultrasound from 33% of pregnancies in 1980 to 78% in 1987 has improved early detection. We evaluate the impact of prenatal ultrasound on major genitourinary malformations. MATERIALS AND METHODS: Data obtained from the Malformations Surveillance Program at Brigham and Women's Hospital between 1974 and 1994 tracked 163,431 pregnancies and termination rates of fetuses with spina bifida, bladder exstrophy, the prune belly syndrome and posterior urethral valves. RESULTS: Hospital data revealed that pregnancy was electively terminated due to spina bifida in 65% of cases, posterior urethral valves in 46%, the prune belly syndrome in 31% and exstrophy in 25%. CONCLUSIONS: Clearly, surveillance programs and improved accuracy of prenatal ultrasound have allowed early diagnosis of major genitourinary malformations. Many factors influence decision making in these affected fetal cases, including the financial and emotional impact of these major anomalies during lifetime. Future societal decisions and reduction in these anomalies may influence our training programs, manpower needs, medical facility requirements and character of our practices. These findings may have significant implications in the field of pediatric urology.

The undescended testicle: diagnosis and management.

Early diagnosis and management of the undescended testicle are needed to preserve fertility and improve early detection of testicular malignancy. Physical examination of the testicle can be difficult; consultation should be considered if a normal testis cannot be definitely identified. Observation is not recommended beyond one year of age because it delays treatment, lowers the rate of surgical success and probably impairs spermatogenesis. By six months of age, patients with undescended testicles should be evaluated by a pediatric urologist or other qualified subspecialist who can assist with diagnosis and treatment. Earlier referral may be warranted for bilateral nonpalpable testes in the newborn or for any child with both hypospadias and an undescended testis. Therapy for an undescended testicle should begin between six months and two years of age and may consist of hormone or surgical treatment. The success of either form of treatment depends on the position of the testicle at diagnosis. Recent improvements in surgical technique, including laparoscopic approaches to diagnosis and treatment, hold the promise of improved outcomes. While orchiopexy may not protect patients from developing testicular malignancy, the procedure allows for earlier detection through self-examination of the testicles.

Retrograde ureteroscopic endopyelotomy for the treatment of primary and secondary ureteropelvic junction obstruction in children.

The use of endopyelotomy in children with ureteropelvic junction (UPJ) obstruction remains controversial. Although most investigators reported good results with percutaneous or retrograde balloon cautery incision, there are distinct advantages associated with a ureteroscopic approach. Three male children, ages 11, 12 and 17 years, underwent ureteroscopic endopyelotomy for treatment of UPJ obstruction (one primary and two secondary). The procedures were performed using 6F to 8.5F semirigid instruments and the holmium laser. All three patients underwent endopyelotomy without complication. The mean operative time was 80 minutes. Two patients were discharged home the day of the procedure, and the third patient was hospitalized for less than 24 hours postoperatively. With follow-up of 6 to 11 months, two patients are asymptomatic, with no radiographic evidence of obstruction. The 12-year-old boy had continued obstruction following endopyelotomy. At the time of open pyeloplasty, a large crossing vessel was noted, which appeared to be the source of obstruction. Ureteroscopic endopyelotomy can be performed with minimal morbidity and hospitalization in children. Further clinical experience is needed to assess the relative efficacy of this procedure in comparison with other forms of endopyelotomy in children.

Endoscopic management of ureteropelvic junction obstruction in children.

A variety of endoscopic methods are available for managing ureteropelvic junction obstruction in children, and these methods can be considered for use in selected circumstances.

Dorsal band traction for reduction of paraphimosis.

Reduction of paraphimosis can be a painful and difficult process. Methods thus far proposed focus on decreasing the edema before reduction. We have used the basic surgical principle of traction and countertraction by applying a pair of Adson forceps directly to the band formed by the retracted preputial opening. To date we have successfully used this technique on 6 children and 3 adults.

Heterotopic bone formation in association with pelvic fracture and urethral disruption.

PURPOSE: The initial and secondary management of pelvic fracture associated with disruption of the membranous urethra is the subject of a wide literature containing varied and controversial viewpoints. We have noted the presence of heterotopic bone formation surrounding the area of urethral injury in patients undergoing delayed repair. We investigated the etiology, incidence and risk factors associated with such an injury, as well as potential means of prophylaxis. MATERIALS AND METHODS: We reviewed the current literature on heterotopic bone formation with similar traumatic injury. While instances of severe urethral disruption of this type are fortunately rare in children we describe prepubertal boys with such an injury complicated by heterotopic ossification. RESULTS: The incidence of heterotopic ossification reported in children and adolescents is 3 to 15%, which is less than 15 to 80% reported in adults. Risk factors associated with traumatic heterotopic ossification include prolonged operating time, hematoma formation, degree of bony debris, devitalized muscle and concomitant infection. Prophylaxis with single low dose radiation or nonsteroidal anti-inflammatory drugs has been shown to be effective in the prevention of heterotopic ossification and may be beneficial in this patient population. CONCLUSIONS: Heterotopic bone formation associated with severe traumatic injury in the presence of devitalized tissue resulting in the pathological formation of new bone is rare. This complication is only associated with the most severe pelvic fractures. Prophylaxis in these most severe cases with low dose radiation or nonsteroidal anti-inflammatory drugs can prevent the formation of heterotopic bone.

Possible mechanisms for epididymal sparing during testicular ischemia.

OBJECTIVES: Although extensive research has been conducted on the normal anatomy and physiology of the epididymis, the effects of ischemia on the organ have not been primarily investigated. The aim of the present study was to investigate the macroscopic and microscopic effects of prolonged ischemia on the epididymis and the factors that may contribute to its resistance to ischemia. METHODS: Six groups of male Sprague-Dawley rats (6 rats/group) were studied. Groups 1, 2, and 3 underwent a sham operation of 4, 8, and 12 hours, respectively, and groups 4, 5, and 6 underwent 4, 8, and 12 hours of ischemia, respectively. The ipsilateral testes and epididymides were monitored throughout the experiment. At the conclusion of the experiment, bilateral orchiectomy was performed, and structures were histologically evaluated. RESULTS: There were no abnormal macroscopic findings of the bilateral epididymides of groups 1, 2, and 3 or of the contralateral, control epididymides of groups 4, 5, and 6. Macroscopically, there was a direct correlation between the length of ischemia and the degree of hemorrhagic discoloration of the proximal caput. The degree of hemorrhagic infiltration noted microscopically was consistent with the macroscopic observations. The epithelia of the ischemic epididymides remained intact with numerous microvilli. CONCLUSIONS: The results of this study suggest that the epithelium of the epididymis is relatively resistant to ischemic damage compared with the gonad during testicular ischemia.

Anatomical alignment for the correction of buried penis.

PURPOSE: We report a straightforward surgical technique for the correction and anatomical alignment of the skin in patients with various degrees of buried penis. MATERIALS AND METHODS: A combined series of 74 patients 7 months to 10 years old who were treated for buried penis at 2 institutions during a 7-year period. Patients presented with various symptoms, including balanitis, urinary tract infection, painful voiding, ballooning of the foreskin and urinary retention. In 29 patients (38%) trapped penis was due to previous circumcision. In our estimation the major anatomical defect in buried penis is an insufficient attachment of the dartos fascia and penile skin to Buck's fascia. Our technique involves making a circumferential incision of the inner preputial skin layer proximal to the corona, unfurling it from the shaft skin and leaving a coronal collar of approximately 1 cm. The annular band that usually constricts the corpora on retraction of the penile skin is incised, and the remaining proximal penile skin and dartos fascia are dissected off Buck's fascia proximally to the base of the penis. The penile dermis is sutured to the lateral aspect of the tunica albuginea at the penopubic junction and mid shaft of the penis. This technique restores normal anatomical relationships with excellent cosmetic results and negligible complications. RESULTS: At a median 5-year followup cosmesis was excellent in all cases. Two patients with micropenis who required revision responded to endocrine therapy. CONCLUSIONS: Excellent cosmetic results were obtained in all cases using this surgical technique.

Surfactant administration reduces testicular ischemia-reperfusion injury.

PURPOSE: The mechanism of testicular ischemia-reperfusion injury has not been well delineated. We determined the efficacy of a biocompatible surfactant (tetronic 1107) to reduce tissue injury and evaluated cell membrane integrity as reflected by calcium ion permeability in an in vivo animal model of testicular ischemia-reperfusion. MATERIALS AND METHODS: Three groups of male Sprague-Dawley rats (6 per group) were studied. Group 1 was the nonoperative control, and groups 2 and 3 underwent 4 hours of unilateral testicular ischemia followed by 4 hours of reperfusion. Ten minutes after reperfusion 0.4 ml. saline was administered intravenously to group 2 and 180 mg./kg. surfactant tetronic 1107 to group 3. 99mTechnetium pyrophosphate was used to monitor calcium ion uptake by the ipsilateral and contralateral testicles. Both testicles were also examined histologically. RESULTS: The surfactant treated animals had markedly diminished hemorrhagic discoloration and vascular congestion compared to saline treated animals. These results were confirmed microscopically with improved nuclear chromicity and disarray of germ cell layers of the seminiferous tubules. The surfactant treated group also had a statistically significant (p <0.05) reduction in radiotracer uptake compared to the saline treated animals, confirming a reduction in calcium ion permeability. CONCLUSIONS: The results of this study suggest that tetronic 1107 is effective in reducing tissue damage in a testicular ischemia-reperfusion animal model.

Comparison of blood flow and histological changes in rat models of testicular ischemia.

PURPOSE: Our aim was to quantify objectively the degree of vascular insufficiency produced by twisting versus clamping the spermatic cord, and determine the contribution of the vasal vessels to these changes using the laser Doppler flowmeter. MATERIALS AND METHODS: Three groups of 12 male Sprague-Dawley rats each were studied. Group 1 underwent 720-degree torsion of the spermatic cord, group 2 underwent vascular clamping of the spermatic cord with 1 clamp, excluding the anatomically separate vasal vessels, and group 3 underwent vascular clamping of the entire spermatic cord and vasal vessels with 2 clamps. Blood flow and histological changes were determined. RESULTS: Vascular clamping of the spermatic cord in groups 2 and 3 resulted in a significant decrease in testicular blood flow compared to 720-degree torsion (p < 0.05). These flow changes correlated with more severe and reproducible gross changes, and histological features of seminiferous tubule degeneration compared to spermatic cord twisting. CONCLUSIONS: In the rat clamping the spermatic cord is a more severe and reproducible model of testicular torsion than 720-degree torsion. The contribution of the vasal vessels to the decrease in blood flow and resulting histological degeneration after testicular ischemia is negligible in the rat.

A platelet activating factor antagonist attenuates the effects of testicular ischemia.

PURPOSE: Platelet activating factor, a biochemical marker and lipid mediator of ischemic injury, has been demonstrated in several organ systems. The objective of this study was to investigate the possible role of platelet activating factor in testicular ischemic injury. MATERIALS AND METHODS: Five groups of 6 male Sprague-Dawley rats were studied, including group 1-nonoperated controls, group 2-sham operated controls, group 3-those that underwent administration of 10 micrograms./kg. exogenous platelet activating factor into the left testicular artery, group 4-those that underwent 4 hours of testicular ischemia and group 5-those that received pretreatment with 0.4 mg./kg. of the platelet activating factor antagonist CV-6209 intravenously before 4 hours of testicular ischemia. Ipsilateral and contralateral testes were examined histologically and seminiferous tubular diameters were measured. RESULTS: Exogenous platelet activating factor administration in group 3 and 4 hours of ischemia in group 4 resulted in a similar extent of histological degeneration of the experimental testicle. Pretreatment with CV-6209 in group 5 resulted in a marked decrease in hemorrhagic discoloration, vascular congestion and histological changes noted with ischemia in group 4. CONCLUSIONS: The results of this study suggest that platelet activating factor has a biochemical role in tissue injury associated with testicular ischemia. Also, administration of a platelet activating factor antagonist before the ischemic event decreases seminiferous tubule degeneration.

Randomized, prospective, double-blind study of the effects on pain perception of lidocaine jelly versus plain lubricant during outpatient rigid cystoscopy.

PURPOSE: There is no clear evidence that intraurethral lidocaine jelly decreases pain and/or makes rigid cystoscopy more tolerable for patients. Since lidocaine jelly is significantly more expensive than plain lubricant, we attempted to assess the true benefit of this agent. MATERIALS AND METHODS: We performed a randomized, prospective, double-blind study to compare the anesthetic effects of intraurethral 2% lidocaine jelly versus plain lubricant in patients undergoing rigid cystoscopy. Unlike previous studies, we ensured adequate urethral filling by using 30 cc of each agent and we waited 20 minutes after instillation of the agent before performing cystoscopy to allow adequate absorption. Cystoscopy was performed using a 17 to 21F rigid instrument. A total of 189 patients was entered into the study but 10 were excluded from analysis due to incomplete questionnaires. A 10-point scale (1-least to 10-most painful) was used to measure pain perception. RESULTS: In men pain perception was significantly decreased when lidocaine jelly was used (mean plus or minus standard error 3.00 +/- 0.21 versus 4.36 +/- 0.37 points, p = 0.002). In women there was no observed difference in pain perception when lidocaine jelly or plain lubricant was used (3.21 +/- 0.38 versus 3.11 +/- 0.30 points, p = 0.823). Patient race, performance of a related procedure, cystoscope size or history of cystoscopy did not significantly affect reported pain scores. There was a slight decrease in pain perception with increasing age (-0.23 +/- 0.10 points per decade, p = 0.021). The level of patient anxiety before cystoscopy was also significantly associated with pain perception (p < 0.001). CONCLUSIONS: Lidocaine jelly offers no advantage over plain lubricant in regard to pain control during rigid cystoscopy in women. However, when used in adequate amounts and allowed to dwell in the urethra for 20 minutes before cystoscopy, lidocaine jelly can significantly decrease pain in men.

Laparoscopic creation of a continent cecal tube for antegrade colonic irrigation.

UNLABELLED: OBJECTIVES; The antegrade continence enema (ACE) procedure has been used for the treatment of overflow fecal incontinence or constipation inpatients with spina bifida. The procedure requires an appendiceal reimplantation into the cecum with creation of a continent abdominal stoma for antegrade colonic washout. To preserve the appendix for potential use in urinary diversion, we developed two surgical techniques for tubularizing an antimesenteric cecal segment to use in place of the appendix. METHODS: The surgery was performed in 6 dogs. The first two procedures used an open surgical technique through a 10-cm midline laparotomy. The cecum was isolated, and a small cecotomy was made. A 10F red rubber catheter was introduced into the cecotomy, and a 4-cm length of cecum was tubularized along its antimesenteric border with a gastrointestinal anastomosis stapler over the catheter. A nipple was created at the base of the tube to enhance continence, and the tubular segment was brought through the lower abdominal wall to create a catheterizable stoma. After our success, four subsequent procedures were performed laparoscopically to create the same tubularized cecal segment. A 4-cm antimesenteric tubularized cecal segment with sufficient lumen to accommodate a 10F to 12F catheter was constructed using a laparoscopic gastrointestinal anastomosis stapler. Rather than creating a nipple at the base of the tubular segment, continence of the stoma was achieved by tunneling the cecal tube through a 2-cm lower quadrant subcutaneous tunnel. A flush stoma was then created and secured to the skin. RESULTS: Stoma viability was grossly confirmed in all 6 dogs during the postoperative period, with no incidence of bowel obstruction. Slight fecal leakage through the stoma was observed in 1 dog with a laparotomy but not in those with laparoscopy. Catheterization was easily performed in all dogs with a 10F red rubber catheter during the postoperative period. The dogs were killed on postoperative day 10, and gross anatomic and histologic examination of the cecal segment confirmed luminal patency and viability. CONCLUSIONS: Open and laparoscopic continent cecostomies were successfully constructed in a canine model and are likely to be applicable to humans with neuropathic constipation.