Endoscopic diagnosis and management of ureteral endometriosis.

It is estimated that 1% of patients with endometriosis have involvement of the urinary tract, with the bladder being the most common location. Ureteral endometriosis is a rare entity, and the majority of cases are found at exploratory laparotomy for extensive involvement of the pelvic organs. Obstruction of the ureter may be caused by extrinsic or intrinsic disease, with the extrinsic form occurring four times as often. Progressive ureteral obstruction can be insidious in onset and ultimately lead to renal failure. Hormone therapy has had variable success, and open surgery has been the mainstay of treatment. Only one case of ureteral endometriosis, both intrinsic and extrinsic, diagnosed at ureteroscopy has been reported previously. We present a case of ureteral obstruction secondary to isolated intrinsic endometriosis diagnosed at ureteroscopy and treated endoscopically with holmium laser ablation and leuprolide therapy.

Beta-defensin 126 on the cell surface protects sperm from immunorecognition and binding of anti-sperm antibodies.

Beta-defensin 126 (DEFB126), formerly known as epididymal secretory protein 13.2 (ESP13.2), coats the entire primate sperm surface until completion of capacitation, and it is a candidate for providing immune protection in the female reproductive tract. To further examine the potential role of DEFB126 as a means of protection from immune recognition, cynomolgus macaque sperm were exposed to a number of treatments that are known to alter sperm surface coats, including capacitation. We used a novel in vivo assay to determine immune recognition: aldehyde-fixed whole sperm injections into rabbits. Following booster injections, immunoblot analyses of whole sperm prepared in various manners was conducted. On Days 60 and 80 post-initial immunization, the antisera showed a remarkably strong reaction to a single 34-36 kDa protein, which was shown to be DEFB126. Sera from rabbits that were immunized with sperm washed more rigorously using Percoll gradients showed an increase in the number and intensity of proteins recognized on whole sperm Western blots, although DEFB126 was still the major immune response. When capacitated sperm, from which most DEFB126 had been released, were used as the immunogen, there was a dramatic increase in the immune recognition to a variety of protein bands. Sperm treated with neuraminidase to remove sialic acid on DEFB126 before fixation were shown to still possess DEFB126, but lacked the sialic acid component of the glycoprotein. These sperm were as immunogenic as capacitated sperm even though the desialylated DEFB126 still covered the entire cell surface. These sperm lost their highly negative charge (the isoelectric point of DEFB126 shifted from pI 3.0 to pI 6.4). Experiments using different sperm plasma membrane protein-specific Igs showed that recognition did not occur when DEFB126 was present, but following capacitation these Igs readily recognized the exposed sperm membrane. Our data suggest that DEFB126 protects the entire primate sperm surface from immune recognition and that the sialic acid moieties are responsible for the cloaking characteristic of this unique glycoprotein.

Bilateral infundibulopelvic stenosis without renal insufficiency: is surgery necessary?

The following case describes the clinical course of a patient with bilateral infundibulopelvic stenosis from her initial presentation at age 2 through the age of 14 years. This condition is associated with hypoplasia of segments of the upper collecting system and is characterized by dilated calyces that drain through stenotic infundibulae. Our patient is unique in that, although her renal function has slowly deteriorated with time, she has a persistently non-obstructive pattern on dynamic imaging studies. Only a minority of patients reported in the literature with this condition progress to renal insufficiency or failure. Although some patients have undergone surgery for presumed obstruction, surgical intervention has no proven benefit. Patients are at risk for hyperfiltration injury and should be followed for the development of hypertension, proteinuria and renal insufficiency. Without evidence of obstruction, medical management remains the cornerstone of treatment.

Spinal cord injury in children: long-term urodynamic and urological outcomes.

PURPOSE: Urological complications in adults with spinal cord injuries (SCIs) are well documented. We sought to determine the effect of SCI on the developing bladder and kidneys in the child. MATERIALS AND METHODS: We retrospectively reviewed cases of SCI with 1-year minimum followup. We identified 42 children with an average age at injury of 5.3 years (range 1 day to 14 years). Mean followup was 5.5 years (range 1 to 15.5). Videourodynamics, sonograms, infection, medications and continence were reviewed. Safe bladder capacity was defined as the pressure specific volume at 40 cm water or less. Patients were divided into 3 groups based on level of injury-cervical (10), thoracic (26) and lumbar (6). RESULTS: Bladder management included clean intermittent catheterization in 40 of 42 patients and antispasmodics in 37. No patient had reflux, hydronephrosis or renal scarring. In the cervical group safe bladder capacity was less than the expected capacity in 80% of patients but all patients undergoing multiple urodynamics had increasing capacity with time. In the thoracic group 58% of patients had a safe bladder capacity less than expected and 76% of those undergoing multiple urodynamics had increasing capacity. In the lumbar group 50% of patients had a safe bladder capacity less than expected and 67% of those undergoing multiple urodynamics had increasing capacity. CONCLUSIONS: To our knowledge this is the largest and longest urological study of young children with SCI. Early clean intermittent catheterization and use of anticholinergics appear to prevent upper tract deterioration, improve continence and decrease infections. Serial urodynamics confirm increasing safe capacity with growth in most children. Close followup is necessary as bladder characteristics may change with time.