Outcomes after dextranomer/hyaluronic acid bladder neck injection in patients with urethral incontinence following bladder neck repair.

INTRODUCTION: Many patients who undergo surgery for bladder neck (BN) incompetence may still experience incontinence postoperatively. Dextranomer/hyaluronic acid (Dx/HA) is widely used for endoscopic treatment of vesicoureteral reflux in children; however, few studies have reported its use in treating incontinence after BN surgery. OBJECTIVE: The aim of this study was to evaluate outcomes after Dx/HA bladder neck injection in patients with persistent outlet incompetency following BN Repair. STUDY DESIGN: We retrospectively reviewed patients at a single pediatric tertiary care center with history of prior bladder neck surgery and reported persistent incontinence who then underwent endoscopic bladder neck Dx/HA injection from 2013 to 2018 and had subsequent follow-up post-injection. We described primary outcomes of reported incontinence as "wet" (leakage similar to before injection), "improved" (wet but leakage improved), and "dry" (no leakage). Our secondary outcome was need for a secondary procedure after Dx/HA injection, including Dx/HA injection or bladder neck closure (BNC). RESULTS: At first follow-up (median 2.3 months post-op), 7/19 were wet, 6/19 were improved, and 6/19 were dry. At last follow-up (median of 34.7 months), only three patients (16%) were dry. Only one patient who received a single surgery for Dx/HA injection was "dry", though nearly 2/3rds (12) were initially "improved" in their continence. Overall, seven patients had another intervention or surgery after first injection. Five patients had multiple Dx/HA injections after first procedure, which resulted in dryness by last assessment in two of these. Four patients (21%) in the overall cohort required subsequent BNC. DISCUSSION: Longer-term follow-up in our study demonstrated that only one patient who received a single procedure of Dx/HA injection remained dry. Several studies had follow up for greater than 1 year after initial bladder neck Dx/HA injection; rates of dryness after a single surgery for injection were variable and reported between 20 and 40% over follow-up times ranging from 1.5 to 7 years (Alova et al., 2012; DaJusta et al., 2013; Lottmann et al., 2006a; Lottmann et al., 2006b; Kitchens et al., 2007). Our st udy does have inherent limitations. This study was performed at a single institution in a retrospective manner, with a single surgeon reviewing the medical record to determine operative techniques and continence outcomes. The patient population is small, although relatively comparable to other previously reported studies. Outcomes were based on documentation of patient reports and are therefore lacking in objectivity. CONCLUSION: In patients with prior unsuccessful BN repair, long-lasting dryness after single Dx/HA BN injection is unlikely, although one-third may demonstrate relatively durable improvement in incontinence.

A Case of Multicystic Dysplastic Kidney Presenting as a Single Midline Pelvic Cyst.

We present an unusual case of a female neonate presenting with a single midline pelvic cyst. Prenatal imaging was suggestive of multicystic dysplastic kidney (MCDK), but postnatal imaging was atypical for this diagnosis given the location and singular cyst noted. The patient ultimately underwent surgical exploration and was diagnosed with an ectopic MCDK. Ectopic MCDK should be considered in the differential diagnosis of unilocular cystic pelvic lesions identified in the perinatal period.

A survey of pediatric urology fellowship applicants: past priorities to guide future possibilities.

BACKGROUND: The number of applicants to pediatric urology fellowships is often lower than the available positions (chart), giving applicants significant influence over where they ultimately match. Historically, interviews were conducted at individual hospitals, in-person, with residents bearing most costs. The objective of this study was to understand the factors associated with where applicants decide to apply, interview, and match for fellowship, as well as barriers within this process. METHODS: A 24-question survey was sent via email to all applicants who successfully matched into pediatric urology fellowship from 2013 to 2019. Questions included: demographics; factors associated with where they applied, interviewed, and ranked; and barriers within the application process. RESULTS: A total of 126 recent and current fellows were contacted, and 73 (60%) completed the full survey (51% male and 49% female). On average, respondents applied to 10 programs, interviewed at 9, and ranked 8. The most important factors in choosing where to apply/interview were: volume of surgical cases, diversity of surgical cases, and advice from mentors. The most important factors when making a rank list were: clinical autonomy, reputation of program, and structure of program. Hospital facilities were only rated "important" by 12% of respondents. 82% (60 respondents) faced at least one personal or professional barrier during the application process. The most common barrier was "cost of interviewing" (59%, 43 respondents). Personal vacation time was used by 61% of applicants during interviews, with 37% using more than 5 days. DISCUSSION: This study is the first to explore the factors that applicants consider when choosing where to apply, interview, and rank for pediatric urology fellowship. This information is important to understand due to the current supply and demand of fellowship positions. We are limited by extrapolating more general conclusions about applicants as a whole from a survey with a 60% response rate and the lack of an available validated survey in this realm. CONCLUSIONS: This study has shown that most pediatric urology fellowship applicants apply to programs primarily based on perceived surgical volume and reputational factors. These same factors are used when making a rank list. Many applicants faced personal or professional barriers during the application process, largely due to costs and time away from work and family. While recent interviews have transitioned to a virtual format by necessity, prior applicants did not rate hospital facilities as important to them. Overall, there is room to improve this process based on such feedback.

Effectiveness of a Practical, At-Home Regimen of Parasacral Transcutaneous Electrical Nerve Stimulation in Pediatric Overactive Bladder.

OBJECTIVE: To describe and evaluate efficacy of a more practical, at-home regimen of parasacral transcutaneous electrical nerve stimulation (TENS) for pediatric overactive bladder (OAB). METHODS: We prospectively enrolled patients with OAB. INCLUSION CRITERIA: age 5-13 years and willingness to try TENS. EXCLUSION CRITERIA: urinary tract anatomic abnormalities, current use of OAB medications, neurologic condition, and elevated post-void residual. Patients were instructed to complete 20-minute sessions 2x/day for 1 month. Patients completed the Vancouver Symptom Score (VSS) and 48-hour frequency-volume chart before/after treatment. Compliance was assessed with a daily log. We recorded patient-reported improvement. Primary outcome was difference in VSS before/after treatment; secondary outcomes included: differences in frequency of voids/24 hours, max voided volume in 48 hours (%EBC), mean voided volume (%EBC), and mean number incontinence episodes/24 hours. RESULTS: We enrolled 21 patients (3 male, 18 female; median age 9.9 years). We had complete VSS data on 17 patients and frequency-volume chart data on 12 patients. Median % of TENS sessions completed was 98%. 8/17 patients reported subjective improvement. There was a significant difference between pre- and post-TENS VSS (median score: 23 pre-TENS and 21 post-TENS, P = .009). There were no differences in secondary outcomes before/after treatment. CONCLUSION: In our cohort of medically-refractory OAB pediatric patients, nearly half reported subjective improvement with our regimen, despite modest objective improvement. Our compliance rates suggest this regimen is practical but may be best used as an adjunct to other therapies.

Promoting patient followup treatment with intra-detrusor onabotulinumtoxinA for overactive bladder.

INTRODUCTION: We aimed to characterize patient-related factors that promote followup of repeat onabotulinumtoxinA treatments for overactive bladder via a mixed-methods approach. METHODS: A retrospective chart review was conducted for patients who received intra-detrusor injection of onabotulinumtoxinA at our institution from 2011-2018, who were then surveyed to evaluate their experience, knowledge, and perceptions regarding onabotulinumtoxinA treatment and followup. Patients who received one onabotulinumtoxinA treatment and patients who underwent multiple treatments were compared to assess followup rates following initial treatment, group characteristics, patient comfort, and patient knowledge of needed retreatment. RESULTS: A total of 29.3% of patients received a single treatment and 70.7% of patients received multiple treatments. There was no difference in clinical, demographic, or intake variables between groups. Patients receiving multiple treatments reported having their first procedure in the operating room and reported greater improvement in symptoms and procedure comfort. This group was also more likely to understand that repeat treatments are necessary than those undergoing one treatment. CONCLUSIONS: No research to date has systematically explored patient-reported factors that promote retreatment of onabotulinumtoxinA for overactive bladder. This novel, mixed-methods approach indicates that patient comfort and patient knowledge were the strongest predictors of previous retreatment and anticipated retreatment, suggesting concrete avenues for improved periprocedural patient counselling and education.

Surgical outcomes are equivalent after pure laparoscopic and robotic-assisted pyeloplasty for ureteropelvic junction obstruction.

INTRODUCTION: Minimally invasive (robotic and pure laparoscopic) pyeloplasty has been increasingly used for treatment of ureteropelvic junction obstruction (UPJO). However, few large-scale studies have compared these two modalities directly. METHODS: We performed a retrospective single-center review of all patients who underwent pure laparoscopic (LP) or robotic pyeloplasty (RALP) between 2007 and 2018. Patients were excluded if the initial surgery at our institution was a redo pyeloplasty or if they lacked follow-up information. Outcomes of interest included operative time, length of stay, and complication rates, including rates of secondary procedures. We compared these outcomes between groups using Student's t test for continuous variables and a Chi-square for categorical variables. RESULTS: A total of 282 patients were identified. Forty-eight were excluded based on study criteria; therefore, our total study cohort was 234 patients: 119 RALP and 115 LP cases. Overall mean postoperative follow-up time was 20.8 months, with no significant differences between groups. Mean operative time was shorter in the LP group when compared the RALP group (3 h 7 min vs. 3 h 41 min, p < 0.001). There were no significant differences between groups in length of stay (1.22 days vs 1.50 days, p = 0.095). Complications occurred in 52 patients (22.2% of overall cohort) with no difference in incidence between groups. Twenty-five patients (14 in the RALP group and 11 in the LP group) underwent unplanned secondary procedures; 19 of these patients (9 in the RALP group and 10 in the LP group) needed a procedure to address secondary obstruction. CONCLUSION: We demonstrated no significant differences between RALP and LP in regards to complication rates. Surgeons performing RALP and LP have the potential to offer the same level of care for the surgical management of UPJO, especially in countries where robotic technology may not be readily available.

Normal pelvic ultrasound or MRI does not rule out neoplasm in patients with gonadal dysgenesis and Y chromosome material.

INTRODUCTION: Patients with gonadal dysgenesis (GD) with a Y chromosome have an increased risk of gonadal neoplasm. Few data exist on the ability of imaging to detect malignancy in intra-abdominal gonads in these patients. OBJECTIVE: We aimed to determine the correlation between preoperative imaging findings and gonadal pathology in GD patients with Y chromosome material. METHODS: A retrospective review was performed of patients with XY or XO/XY GD who underwent gonadectomy at our institution from 2003 to 2017. Patients were assessed preoperatively with ultrasonography; some additionally underwent MRI. RESULTS: The series consisted of 10 patients, all with female gender and non-palpable gonads. Median age was 13.1 years (range 2.4-18.3 years). Overall, four of the ten patients (40%) had a tumor (gonadoblastoma or dysgerminoma) on final pathology. Four patients had a gonad or gonads that were definitively seen on ultrasonography. All visualized gonads were described as "normal" or "small" with the exception of one patient, who had a normal MRI. Three of the four patients in this group had a tumor on final pathology. The remaining six patients had a gonad or gonads that were not definitively visualized on ultrasound; one patient in this group had a tumor on final pathology. Overall, five of seven gonads (71%) definitively visualized on ultrasound had tumor on final pathology, and two of thirteen gonads (15%) not visualized on ultrasound had tumor on final pathology; this difference was statistically significant (p = 0.012). Three patients were imaged with MRI. Of the gonads that could be visualized on MRI, no definitive abnormalities were seen. All patients imaged with MRI had tumors on final pathology. DISCUSSION: Both ultrasound and MRI are relatively poor at identifying and characterizing intra-abdominal gonads in GD patients. The majority of patients who had a neoplasm had normal imaging findings. Gonads that were definitively visualized on ultrasound were more likely to contain neoplasms that could not be visualized, which perhaps because of tumor growth. No other consistent imaging findings of malignancy were found. Our study included ultrasound evaluations that were completed over 10 years ago and not performed by pediatric ultrasonographers, which may have biased the results. However, results suggest that when discussing gonadectomy with GD patients, one should not be reassured by "normal" imaging findings. Neither ultrasound nor MRI should be relied on for surveillance in GD patients who decide against gonadectomy. CONCLUSION: A normal ultrasound or MRI does not rule out neoplasm in GD patients with intra-abdominal gonads.

The use of glucose oxidase and catalase for the enzymatic reduction of the potential ethanol content in wine.

Due to the increase of sugar levels in wine grapes as one of the impacts of climate change, alcohol reduction in wines becomes a major focus of interest. This study combines the use of glucose oxidase and catalase activities with the aim of rapid conversion of glucose into non-fermentable gluconic acid. The H2O2 hydrolysing activity of purified catalase is necessary in order to stabilize glucose oxidase activity. After establishing the adequate enzyme ratio, the procedure was applied in large-scale trials (16L- and 220L-scale) of which one was conducted in a winery under industrial wine making conditions. Both enzyme activity and wine flavour were clearly influenced by the obligatory aeration in the different trials. With the enzyme treatment an alcohol reduction of 2%vol. was achieved after 30h of aeration. However the enzyme treated wines were significantly more acidic and less typical.

Development of indazolylpyrimidine derivatives as high-affine EphB4 receptor ligands and potential PET radiotracers.

Due to their essential role in the pathogenesis of cancer, members of the Eph (erythropoietin-producing hepatoma cell line-A2) receptor tyrosine kinase family represent promising candidates for molecular imaging. Thus, the development and preparation of novel radiotracers for the noninvasive imaging of the EphB4 receptor via positron emission tomography (PET) is described. First in silico investigations with the indazolylpyrimidine lead compound which is known to be highly affine to EphB4 were executed to identify favorable labeling positions for an introduction of fluorine-18 to retain the affinity. Based on this, reference compounds as well as precursors were developed and labeled with carbon-11 and fluorine-18, respectively. For this purpose, a protecting group strategy essentially had to be generated to prevent unwanted methylation and to enable the introduction of fluorine-18. Further, a convenient radiolabeling strategy using [(11)C]methyl iodide was established which afforded the isotopically labeled radiotracer in 30-35% RCY (d.c.) which is identical with the original inhibitor molecule. A spiro ammonium precursor was prepared for radiolabeling with fluorine-18. Unfortunately, the labeling did not lead to the desired (18)F-radiotracer under the chosen conditions.