Results of a vesicoureteral reflux practice pattern survey among American Academy of Pediatrics, Section on Pediatric Urology members.

PURPOSE: We evaluated practice patterns among urologists managing vesicoureteral reflux, and identified areas of consensus and controversy requiring further research. MATERIALS AND METHODS: A 1-page questionnaire addressing various aspects of reflux management, including screening, diagnosis, treatment and followup, was mailed to a cohort of 225 practicing urologists identified by the membership roster of the American Academy of Pediatrics, Section on Pediatric Urology. Coded returned mailers were blindly analyzed and tabulated by 2 reviewers. Questionnaires were subdivided using a coding system by decade (1970s or earlier, 1980s and so forth) of participant membership in the American Urological Association. Select questions were analyzed to determine whether time of training affected the response. RESULTS: Of 225 surveys 155 were returned and usable (overall 60.8% response rate). General agreement exists regarding several important points in the management of vesicoureteral reflux, including evaluation of patients at the initial urinary tract infection (78.1% of respondents), use of voiding cystourethrography and ultrasound at the initial evaluation (99.4 and 96.8%, respectively), and evaluation of sibling reflux (83.2%). Certain absolute and relative indications for surgical intervention require further clarification. Various reimplantation techniques are used today, stents are not placed by the majority of practitioners and significant variations exist in the duration of postoperative hospital stay. CONCLUSIONS: Today there is substantial consensus among urologists on many issues regarding vesicoureteral reflux management. However, the areas of controversy will only be clarified by further scientific and clinical outcomes based research.

Postoperative pain following outpatient pediatric urologic surgery: a comparison of anesthetic techniques.

OBJECTIVES: To evaluate and compare the efficacy of caudal and local nerve blocks in preventing pain following outpatient pediatric urologic surgery. METHODS: Seventy-seven boys undergoing outpatient urologic surgery were randomized into one of three groups: general anesthesia alone, general anesthesia and caudal nerve block, or general anesthesia and local nerve block. Pain scores, frequency of medication, and total dosage of medication were recorded in the immediate postoperative period. Long-term pain and discomfort were measured using a 24-hour and 1-week questionnaire. RESULTS: The caudal and local groups had lower pain scores and significantly lower medication requirements than the control group in the short-term postoperative period. The caudal group had lower pain scores than the local group in all categories; however, the only significant difference was at 24 hours postoperatively. At 1 week postoperatively, the only difference among the three groups was a lower pain score in the caudal group compared with the control group. CONCLUSIONS: This study demonstrates that for outpatient pediatric urologic procedures, both caudal and local nerve blocks significantly reduce pain and medication given in the immediate postoperative period and indicates that caudal block may decrease pain for up to 1 week following surgery.

Histological distribution of polymerase chain reaction--amplified human papillomavirus 6 and 11 DNA in penile lesions.

The purpose of this study was to ascertain the histological pattern of distribution of human papillomavirus (HPV) 6 and 11 DNA in penile lesions by in situ hybridization after amplification by the polymerase chain reaction (PCR). HPV DNA was routinely detected by in situ hybridization with or without PCR amplification in granular layer cells that showed perinuclear halos and nuclear atypia. Cells that lack these histological features rarely exhibited HPV DNA with conventional in situ hybridization. However, after PCR amplification, in situ analysis showed that many of the cells that lacked halos and atypia contained HPV DNA. The hybridization signal often localized to crevices in the epithelium where there was relative hyperkeratosis and a thickened granular layer. HPV DNA was not noted in the basal cells and was rarely identified in other parts of the lesion. It is concluded that penile tissues may contain HPV DNA when lacking the diagnostic features of a condyloma/low-grade intraepithelial lesions and that such tissues usually demonstrate specific histological changes characterized by a focally thickened granular layer often associated with epithelial crevices.

Detection of human papillomavirus DNA in penile lesions histologically negative for condylomata. Analysis by in situ hybridization and the polymerase chain reaction.

The purpose of this study was to analyze penile lesions that lacked the histological features of condylomata for human papillomavirus (HPV) DNA. Most of these lesions were detected in men whose partners had an HPV-related lesion. Sequences homologous to HPV DNA were detected in 12 of 84 (14%) lesions using in situ hybridization analysis; nine of these lesions contained HPV 6 or 11. HPV DNA was found in 25 of 26 (96%) penile condylomata, all but two of which contained HPV 6 or 11. Using the highly sensitive polymerase chain reaction (PCR), we also detected HPV DNA in four of 20 (20%) of the penile lesions that lacked the histological features of condylomata negative for HPV by in situ analysis. Most of the lesions that were identifiable only after the application of an acetic acid solution were HPV negative when tested with either technique. We conclude that HPV DNA can be found in penile biopsy specimens that do not demonstrate the unequivocal histological features of condylomata but that the detection rate is much lower than for condylomata even when analyzing tissues in men at high risk for HPV-related lesions by PCR. This study underscores the need for caution when interpreting such tissues and the usefulness of in situ analysis for detecting assumed viral proliferation in noncondylomatous lesions.

Erosion of an inflatable penile prosthesis reservoir into the bladder, presenting as bladder calculi.

We report a case of erosion of an inflatable penile prosthesis reservoir int the bladder 4 years after implantation for organic impotence. In contrast to previously reported cases this complication was not associated with incontinence, urinary tract infection or a revision procedure. Microscopic hematuria was present but there was no pyuria. Diagnosis evaded radiographic and cystoscopic confirmation. Bladder erosion of the reservoir was discovered incidentally during treatment of bladder calculi.

Vitamin D resistance and alopecia: a kindred with normal 1,25-dihydroxyvitamin D binding, but decreased receptor affinity for deoxyribonucleic acid.

A new kindred exhibiting vitamin D resistance and alopecia is described. Clinically, three of seven sisters demonstrated rickets, hypocalcemia, elevated serum 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3] levels, and alopecia. Biochemical analysis of cultured fibroblasts from skin biopsy explants in two affected and one normal sister revealed normal [3H]1,25-(OH)2D3 binding to receptors (Kd = 0.05 nM; Nmax = 30-50 fmol/mg protein). Despite normal steroid binding, cells from the two affected sisters failed to respond to 1,25-(OH)2D3 in vitro, as measured by induction of the enzyme 25-hydroxyvitamin D-24-hydroxylase. The cells from the normal sister showed a response within the range of five normal cell lines. Sucrose gradient analysis yielded a typical 3.2S protein under high salt conditions in extracts from the three siblings, but with reduced capacity to aggregate to a 6S moiety in low salt gradients in the two affected cells. Whole cell [3H]1,25-(OH)2D3 binding studies revealed nearly normal localization of bound receptor to the nuclear compartment. Elution of bound receptors by KCl gradients from both DNA-cellulose or fibroblast nuclei demonstrated that the receptors from the affected sisters exhibited decreased affinity for DNA compared to those from normal subjects. We conclude that 1,25-(OH)2D3 receptors from these resistant fibroblasts have a normal steroid-binding domain, but a defective nuclear binding domain. We believe that this abnormality may be responsible for the vitamin D resistance observed both in vivo and in vitro.

Precocious puberty and hypothalamic hamartoma.

A 3-year-old boy with true precocious puberty and hamartoma of the hypothalamus is described. Preliminary diagnosis was established by the presence of unusually advanced puberty and skeletal age without other evidence of central nervous system dysfunction, elevated blood gonadotropin and testosterone concentrations, and positive computed tomography scans. Pneumoencephalography further delineated the tumor. Hypothalamic-pituitary-gonadal and adrenal functions were studied. Release of gonadotropins after the injection of synthetic luteinizing hormone-releasing hormone and the suppression of luteinizing hormone and of testosterone by oral fluoxymesterone were comparable to maximal responses of normal men. The diagnosis was confirmed by histologic and electron microscopic study of an excised portion of the tumor. Immunofluorescence studies indicated the presence of luteinizing hormone-releasing hormone in the hamartoma and radioimmunoassays detected thyroid-stimulating hormone-releasing hormone and somatostatin. The hamartoma resembles an autonomously functioning accessory hypothalamus. The ectopic neuroendocrine pathways, however, are responsive to hormonal stimulation and feedback. The clinical, endocrinologic, and pathologic features of published cases of precocious puberty and hypothalamic hamartoma are reviewed. Advanced or rapidly progressive true precocious puberty in the very young with elevated concentrations of blood gonadotropins and gonadal steroids and positive pneumoencephalography appear to be characteristic.

Chloride losing diarrhoea and metabolic alkalosis in an infant with cystic fibrosis.

A case of hypochloraemic metabolic alkalosis in an infant with chloride losing ileostomy drainage and cystic fibrosis is described. It is speculated that intestinal loss of chloride played a major role in the development of metabolic alkalosis.

Studies in type I glycogenosis: the paradoxical effect of ethanol on lactate.

Paradoxically, ethanol, which raises lactate in normal individuals, lowers the elevated levels of lactate in patients with Type I glycogenosis. We found that, although lactate levels fell, pyruvate proportionately declined even more, resulting in an increased L/P ratio which indicates that, as in the normal, the oxidation of ethanol had generated NADH. In type I glycogenosis, the increased level of pyruvate-lactate derives from glycogenolysis. We found that, despite continued glycogenolysis, ethanol had caused less pyruvate-lactate to form. The effect of an increased NADH/NAD+ ratio on the flow of carbon through the Embden-Meyerhof pathway could account for the finding, presumably by its effect on the oxidation-reduction couples with diversion of carbon toward formation of triglyceride rather than pyruvate-lactate.