Endoscopic management and the role of double stenting for primary obstructive megaureters.

PURPOSE: We determined the efficacy and potential complications of endoscopic incision and balloon dilation with double stenting for the treatment of primary obstructive megaureter in children. MATERIALS AND METHODS: We prospectively reviewed cases of primary obstructive megaureter requiring repair due to pyelonephritis, renal calculi and/or loss of renal function. A total of 17 patients were identified as candidates for endoscopy. Infants were excluded from study. All patients underwent cystoscopy and retrograde ureteropyelography to start the procedure. In segments less than 2 cm balloon dilation was performed, and for those 2 to 3 cm laser incision was added. Two ureteral stents were placed within the ureter simultaneously and left indwelling for 8 weeks. Imaging was performed 3 months after stent removal and repeated 2 years following intervention. RESULTS: Mean patient age was 7.0 years (range 3 to 12). Of the patients 12 had marked improvement of hydroureteronephrosis on renal and bladder ultrasound. The remaining 5 patients had some improvement on renal and bladder ultrasound, and underwent magnetic resonance urography revealing no evidence of obstruction. All patients were followed for at least 2 years postoperatively and were noted to be symptom-free with stable imaging during the observation period. CONCLUSIONS: Endoscopic management appears to be an alternative to reimplantation for primary obstructive megaureter with a narrowed segment shorter than 3 cm. Double stenting seems to be effective in maintaining patency of the neo-orifice. Followup into adolescence is needed.

Prospective long-term analysis of nerve-sparing extravesical robotic-assisted laparoscopic ureteral reimplantation.

OBJECTIVE: To prospectively review our experience with extravesical robotic-assisted laparoscopic ureteral reimplantation to determine whether postoperative voiding dysfunction can be avoided with pelvic plexus visualization and to assess the efficacy of this approach for the treatment of vesicoureteral reflux (VUR). METHODS: We prospectively followed 150 patients who underwent bilateral extravesical robotic-assisted laparoscopic ureteral reimplantation by a single surgeon at an academic institution. Each patient was followed for a 2-year period. All 150 patients had primary VUR of grade 3 or greater bilaterally, with 127 having parenchymal defects found on renal scans. All patients were toilet trained before surgical intervention. The operation was performed with an extravesical transperitoneal approach with robotic assistance using the daVinci Surgical System. All patients underwent voiding cystourethrography at 3 months postoperatively to document the resolution of VUR. Voiding dysfunction was assessed in each patient by uroflow, postvoid residual urine volume, and a validated questionnaire. RESULTS: The operative success rate was 99.3% for VUR resolution on voiding cystourethrography. One patient with bilateral grade 5 VUR that was downgraded to unilateral grade 2 VUR was considered to have treatment failure. This patient ultimately underwent subsequent subureteral injection therapy after an episode of pyelonephritis. No patient experienced de novo voiding dysfunction. CONCLUSION: Bilateral nerve-sparing robotic-assisted extravesical reimplantation has the same success rate as the traditional open approaches, with minimal morbidity and no voiding complications in our series.

The metabolic syndrome and male infertility.

Metabolic syndrome (MetS) is highly prevalent, affecting more than 47 million US residents. This condition is also multifaceted, potentially leading to significant disturbance of numerous physiologic processes. This review article evaluates the literature regarding metabolic syndrome and male reproductive health. Links between obesity, dyslipidemia, hypertension, and insulin resistance are each examined with regard to their associated detrimental effects on male fertility. At the end of this manuscript, we propose a new MetS/male infertility paradigm. Additional studies specifically addressing the components of MetS and their impact on male reproduction will enhance our understanding of the underlying pathophysiology. These studies may also help clarify the role for therapeutic intervention.

Modern management of pheochromocytoma.

BACKGROUND: A 55-year-old male with poorly controlled hypertension and a history of coronary artery disease presented with a large adrenal mass. The patient also reported a long-standing history of profuse sweating, tinnitus, vomiting and headaches. INVESTIGATIONS: Physical examination, 24-hour urine metanephrine level, CT, MRI and bone scan. DIAGNOSIS: Pheochromocytoma of the left adrenal gland. MANAGEMENT: Preoperative alpha-blockade therapy with phenoxybenzamine followed by open left adrenalectomy.

Metabolic syndrome and lower urinary tract symptoms secondary to benign prostatic hyperplasia.

Increasing evidence recently has pointed toward a relationship between lower urinary tract symptoms (LUTS) and the presence of metabolic syndrome. This relationship has been supported by recent epidemiologic findings. Possible pathophysiologic links also have been proposed to explain the relationship between these two syndromes. The increasing prevalence of obesity in the United States makes this an increasingly relevant problem. Animal studies support a link between autonomic nervous system (ANS) overactivity and the development of urinary symptoms, low bladder compliance, compensatory prostatic hyperplasia, and blockage of the same using alpha-blockade. There appears to be a significant link between ANS overactivity as part of the metabolic syndrome and LUTS secondary to benign prostatic hyperplasia (BPH). However, it is unlikely that ANS overactivity could be responsible for the development of LUTS. Rather, ANS overactivity plays a key role in increasing the severity of LUTS above an intrinsic basal intensity that is determined by the genitourinary anatomic/pathophysiologic characteristics of each BPH patient. This paper defines metabolic syndrome as a collection of abnormalities, including being overweight (visceral abdominal fat distribution), dyslipidemia, hypertension, impaired glucose metabolism, elevated C-reactive protein (chronic inflammation), and autonomic-sympathetic overactivity, with insulin resistance as the hypothesized underlying pathogenic mechanisms.

Tau and alpha-synuclein pathology in amygdala of Parkinsonism-dementia complex patients of Guam.

Amyotrophic lateral sclerosis/parkinsonism-dementia complex (ALS/PDC) is a progressive neurodegenerative disorder of Chamorro residents of Guam and the Mariana Islands, characterized by abundant neuron loss and tau neurofibrillary pathology similar to that observed in Alzheimer's disease (AD). A variety of neurodegenerative diseases with tau pathology including ALS/PDC also have alpha-synuclein positive pathology, primarily in the amygdala. We further characterized the tau and alpha-synuclein pathology in the amygdala of a large series of 30 Chamorros using immunohistochemical and biochemical techniques. Tau pathology was readily detected in both affected and unaffected Chamorros. In contrast, alpha-synuclein pathology was detected in 37% of patients with PDC but not detected in Chamorros without PDC or AD. The alpha-synuclein aggregates often co-localized within neurons harboring neurofibrillary tangles suggesting a possible interaction between the two proteins. Tau and alpha-synuclein pathology within the amygdala is biochemically similar to that observed in AD and synucleinopathies, respectively. Thus, the amygdala may be selectively vulnerable to developing both tau and alpha-synuclein pathology or tau pathology may predispose it to synuclein aggregation. Furthermore, in PDC, tau and alpha-synuclein pathology occurs independent of beta-amyloid deposition in amygdala thereby implicating the aggregation of these molecules in the severe neurodegeneration frequently observed in this location.