Surprising interobserver and intra-observer variability in pediatric testicular ultrasound volumes.

INTRODUCTION: Testicular volume (TV) can be obtained by either scrotal ultrasound (SU) or orchidometer. Scrotal ultrasound allows for a more objective measurement; however, the interobserver and intra-observer variability of TV measurements has not been rigorously studied. OBJECTIVE: The authors measured intra-observer and interobserver variability of SU TV measurements in pediatric patients to assess the reliability and reproducibility of SU. Special attention was paid to how often a 20% discrepancy in TV was noted as this has previously been utilized as an indication for varicocelectomy. DESIGN: Patients with an indication for SU or undergoing an ultrasound for another reason were prospectively recruited. Two different urologic specific ultrasound technicians (A and B) performed SU to assess interobserver variability. A second measurement was taken by technician A within 90 days to assess intra-observer variability (A vs A1). The technicians were blinded to other ultrasound results. RESULTS: Fourteen patients (28 testes, 56 volume measurements) were included in the intra-observer group and 17 patients (34 testes, 68 volume measurements) in the interobserver group. The mean time to repeat intra-observer ultrasound measurements (range) was 46 days (23-84). Mean age (range) in the intra-observer group was 14.3 years (11-19) and 14.1 years (11-19) in the interobserver group. Indication for ultrasound was varicocele (n = 6), scrotal pain (4), hydronephrosis (3), hydrocele (2), epididymal cyst (2), posterior urethral valves (1), and testis asymmetry (1). Utilizing Bland-Altman analysis and plots, variability was seen in both intra-observer and interobserver measurements. The mean values for testicular sizes for technician A and technician B were 13.0 ± 9.7 cm3 vs 13.8 ± 9.9 cm3, respectively. The mean values for TV measurement for technician A's first and second measurements (A, A1) were 14.3 ± 9.7 cm3 and 14.8 ± 8.9 cm3, respectively. An errant 20% difference in TV measurements for the same testis was seen in 25% (7 of 28) of intra-observer measurements and 35% (12 of 34) of interobserver measurements. These 20% differences were more common with a lower body mass index (odds ratio, OR = 0.74, p = 0.01) in the interobserver group, and lower TV was a predictor in the intra-observer group (OR: 0.82, p = 0.009). CONCLUSIONS: Variability exists in both interobserver and intra-observer measurements of TV by dedicated urologic ultrasonographers, and greater than 20% of differences in measured TV in same testicles occurred in over 25% of cases. Caution should be exercised in basing operative decisions and scientific studies on limited measurements of TV.

Spinal anesthesia in children: most pediatric urologists are not on board.

OBJECTIVE: In 2016, the Food and Drug Administration issued a warning on general anesthetic medications used for lengthy procedures (>3 h) in children younger than 3 years. Spinal anesthesia can be a safe alternative to general anesthesia for many pediatric urology procedures. It can shorten total operating room (OR) time, provide excellent pain control, and allow parents to reunite with their child immediately after surgery. However, use of spinal anesthesia can also directly affect the operating surgeon (awake patient, time constraints of spinal, and prolonged preoperative time). Members of the Societies for Pediatric Urology (SPU) and European Society of Pediatric Urology (ESPU) were surveyed to get their opinions on the use of spinal anesthesia for routine pediatric urology procedures. It was hypothesized that half of pediatric urologists would favor spinal anesthesia and that SPU members would be more likely to favor spinal anesthesia than their European colleagues. MATERIALS AND METHODS: A short survey with five clinical scenarios was created. Scenarios assessed physicians' recommendations regarding timing and the type of anesthesia (general or spinal) for common pediatric urology procedures: undescended testicle, inguinal hernia, hypospadias, phimosis, and phimosis with penoscrotal webbing. Surveys were emailed to members of the SPU and ESPU. Responses and demographic information were collected and analyzed. RESULTS: The survey was completed by 113 SPU members (46% response rate for members who opened the invitation) and 109 ESPU members. For all clinical scenarios, < 20% of pediatric urologists from the SPU and <25% from the ESPU favor doing any procedure with spinal anesthesia. The majority of respondents practice in children's hospitals with pediatric anesthesiologists, but roughly half of the responders (54% SPU and 43% ESPU) do not think their anesthesia colleagues would be comfortable performing spinal anesthesia. Furthermore, only 51% of SPU and 36% of ESPU members discuss the possible neurodevelopmental side-effects of anesthesia with parents; similarly, less than half of all respondents think their anesthesia colleagues address these potential side-effects when obtaining consent. The only significant difference between SPU and ESPU responses was that ESPU members tended to delay penile surgery more than SPU respondents. CONCLUSION: Whether general anesthesia has any effect on the developing brain of children undergoing routine pediatric urology procedures is unclear. Yet, few pediatric urologists, independent of their region of practice, prefer spinal to general anesthesia. Collaboration in the OR is the key to success, and it is important that pediatric urologists and pediatric anesthesiologists work together to balance the benefits and risks of general and spinal anesthesia.

Pediatric penile surgery by a nurse practitioner in the operating room.

INTRODUCTION: With the growing shortage of pediatric urological surgeons, it was our aim to streamline our system to get patients with less complex penile procedures performed in a timely manner. To do this, an advanced practice provider (APP) was trained to perform minor penile procedures in children in the operating room(OR). OBJECTIVES: The goal of our study was to show that with proper training an APP could safely perform a circumcision in the OR. STUDY DESIGN: After approval of the study center's credentialing committee, a NP was trained to perform revisions and initial circumcisions in children in the OR. The process involved: (1) observation, (2) first assisting and (3) performing the procedure with direct, and later in-direct, supervision. The first 100 cases were evaluated for surgical complications, post-operative complications and return rates to the OR. RESULTS: 100 independent cases were completed with 90 having only in-direct supervision. There were no operative complications, nor any documented emergency room or urgent care visits in the immediate post-operative period. There were no early returns to the OR and only 1 scheduled follow-up procedure for a penile skin bridge. DISCUSSION: It was demonstrated that with proper training a NP can safely perform minor penile procedures in the OR. This allows us to free up our pediatric urology physicians to see and operate on more complex pediatric urology problems. In addition, it allows those with minor penile issues to be cared for more expeditiously. A concern related to training NPs to do circumcisions could be the loss of control by urologists. In this situation, the attending physician is ultimately responsible from a medico-legal standpoint. That would not be true if the NP was practicing independently. With a shortage of urologists, this significantly expands the ability to care for our patient population. In additional, attending surgeons will have a greater freedom to perform major procedures. A limitation of the study was that a patient satisfaction survey was not obtained to see if there were concerns over a APP doing their circumcision. Personal feedback on 30 of the patients that did not return for the follow-up visit was not obtained. The authors of the study are primary providers of pediatric urology care in the study region, thus any individual with concerns would have been referred. CONCLUSIONS: It was demonstrated that a well-trained APP can safely perform minor penile procedures independently in the OR with indirect supervision.

[Catecholamine excretion in patients with eating disorders].

OBJECTIVE: To compare clinical features of eating disorders and parameters of monoamine metabolism. MATERIAL AND METHODS: Authors examined 21 patients with eating disorders during 2008-2011 using clinical/psychopathological method. To evaluate the status of monoamine neuromediator system, urine levels of dopamine, noradrenalin and adrenaline excretion were measured using high-yield liquid chromatography with electrochemical detection. The reference group included 26 sex- and age-matched volunteers. RESULTS AND CONCLUSION: The common patterns of the pathogenesis of compulsive urges of different origin were identified. The results indicate not only nonspecific changes in catecholamine systems of patients with eating disorders associated with different stress disorders but also demonstrate the pathogenetic correlations between dopaminergic activity and clinical symptoms of addiction.

Natural history of testicular size in boys with varicoceles.

INTRODUCTION: Testicular size is commonly used as a proxy for future fertility in adolescent boys diagnosed with varicoceles. Surgery is often performed based on a 15-20% reduction in volume of the ipsilateral testicle when compared to the unaffected side. Recent European Association of Urology guidelines, however, have highlighted the risk of overtreatment. Data on the natural progression of testicular size discrepancy are limited in this population. To evaluate the role of a non-surgical approach, the present study reports on testicular size progression in 35 boys with left-sided varicoceles managed with observation alone. METHODS: In the present study, 103 consecutive boys who were seen for varicocele were retrospectively evaluated; the 35 who were seen for at least three sequential visits by the same pediatric urologist for a unilateral left varicocele were selected. In the present practice, surgical management of varicoceles in teens is offered, but not recommended unless surgery is being performed for another reason (3/103). The Prader orchidometric testicular volumes that were documented for all visits were recorded and the volume of the left testicle as a percentage of the right was calculated. This analysis was performed for the entire population, and subgroup analysis was conducted for boys with a Grade 3 varicocele, with >10% asymmetry at diagnosis, and by dividing the population into prepubertal and pubertal age groups. Boys with bilateral varicoceles, concurrent testicular masses, or volumes recorded by a nurse practitioner were excluded from the study. RESULTS: The mean left testicular volume in the population was found to measure 96%, 95% and 96% of the right at the first, second and third visit (median interval was 2.0 years), respectively. Among the 26 boys seen for a fourth visit (median 3.3 years) and the 15 seen for a fifth visit (median 4.3 years), the mean left testicular volumes were 98% and 97% of the right at diagnosis and 97% at both the fourth and fifth visits (Figure). Likewise, no differences were seen after dividing the population into prepubertal (9-11 years, n = 9) and pubertal (12-14 years, n = 26) groups. Among the 13 (37%) boys with a Grade 3 varicocele at presentation, the left testicular volume was 95% (SD 11.4) of the right and remained unchanged by the third visit (96%, P = 0.69). In addition, among the 11 boys (31%) with greater than 10% size difference at the first visit, the left testicle measured 82% of the right (SD 5.3) at diagnosis and increased to 92% (SD 6.3) by the third visit (P < 0.001). DISCUSSION: In the 35 boys observed over a median of 2.0 years or three consecutive visits, there was no worsening of testicular asymmetry. This finding is consistent with some previous observational data on pediatric varicoceles, but carries the advantages of a narrower age range and longitudinal follow-up in all patients. At the same time, these results differ from other studies that show no improvement or worsening of asymmetry during follow-up. This difference is attributed to the inherent characteristics of the present study population and the choice of orchidometer for measurement. The present data have the advantage of excluding selection bias. Recognizing that this study is a retrospective, single-operator study with a small sample size, prospective, randomized trials are recommended to weigh surgery vs observation in adolescent varicocele patients. CONCLUSIONS: No progression in atrophy/hypotrophy of the left testis was found in a series of 35 consecutive patients who were followed non-surgically for left-sided varicocele. Our data thus support observation as management for childhood varicocele in younger teens.

Study of photoinduced antitumor activity of phthalocyanin-based nanostructures as pro-photosensitizers in photodynamic therapy of malignant tumors in vivo.

Nanoparticles of aluminum and zinc phthalocyanin and metal-free phthalocyanin (AlPc, ZnPc, and H2Pc), whose molecular forms are photosensitizers, can serve as effective "prophotosensitizers" in photodynamic therapy for malignant tumors. Transition (stimulation) of photo-inert nanoparticles into a photoactive photosensitizer is realized locally in the tumor node by its exposure to potent laser pulses. Systemic injection of AlPc, ZnPc, and H2Pc nanoparticles has not led to accumulation of their photoactive form in the skin, which can lead to the development of skin phototoxicity. Effective protocols of photodynamic therapy with ZnPc nanoparticles are determined. The use of these protocols in mice with S-37 sarcoma led to 92-70% tumor growth inhibition, 48% improvement of survival, and cure in 84% cases.

A comparison of palpable and impalpable cryptorchid testes using CD-99 immunohistochemistry.

OBJECTIVE: To compare the clinical and morphological features of impalpable and palpable cryptorchid testes, as there is debate about how much effort is appropriate to bring an impalpable undescended testicle into the scrotum. PATIENTS AND METHODS: We reviewed retrospectively 189 cases of undescended testicles in 168 patients who were explored surgically by one surgeon between August 1997 and September 2000. Operative findings of palpability, testicular size and location were collected. The mean tubular diameter (MTD), tubular fertility index (TFI) and mean number of germ cells per tubule (MGCT) were calculated using immunohistochemistry for CD-99, a Sertoli-cell marker, to classify germ cells more accurately. RESULTS: Sixty-three testes (33%) were impalpable; the median age at the time of surgical exploration was 23 months for both groups. The mean (sd) testicular volume for the impalpable and palpable groups were 0.83 (0.38) and 1.22 (0.54) mL, respectively. Using fitted curves of size vs age, impalpable testes were smaller than palpable testes at all ages, with the difference nearly statistically significant (P < 0.06). The MTD, TFI and MGCT decreased with age in both groups, with no statistically significant differences between the groups. A sub-analysis of abdominal and extra-abdominal testes confirmed no significant differences. CONCLUSION: Impalpable testes are smaller at the time of exploration than palpable cryptorchid testes. However, histological factors predict that impalpable testes have a significant chance of future fertility and therefore orchidopexy is appropriate. CD-99 immunohistochemistry makes objective morphological information easier to obtain.

Diuretic renogram clearance half-times in the diagnosis of obstructive uropathy: effect of age and previous surgery.

Diuretic renography with radiotracers has been used successfully to diagnose obstruction in patients with hydronephrosis. Controversy persists with regard to the best approach for the interpretation of renogram curves: visual analysis or a quantitative index, i.e. the clearance half-time. The latter is often reported to be in the intermediate or non-diagnostic range. It is important to measure the incidence of equivocal half-times in various subsets of patients with hydronephrosis in order to determine in which settings the measurement of this index may be clinically useful. We performed a retrospective study of diuretic renograms performed at our institution between 1997 and 2000 for the evaluation of suspected uretero-pelvic junction (UPJ) obstruction. Vigorous intravenous hydration, exceeding current guidelines, was employed in these patients. Three hundred and seventy-seven renogram curves in 205 patients were analysed. Patients were divided into three groups: >1 year of age; 20 min) or intermediate (half-time, 10-20 min). In patients >1 year of age, 37% of 101 renograms showed normal half-times before furosemide, 20% showed normal half-times after furosemide, 44% showed prolonged half-times and none (0%) showed an intermediate half-time. In patients 1 year. Caution is advised when interpreting this finding in this age group. The measurement of washout was less useful in patients who had undergone a corrective procedure, because of the high rate of 'indeterminate' and 'abnormal' values in spite of successful surgery. Vigorous intravenous hydration, exceeding current standards, may have contributed to the lower incidence of intermediate half-times than reported previously.

[Catecholamine metabolism in Parkinson's disease with depression]. / Obmen katekhomaminov pri bolezni Parkinsona s depressiei.

Daily urinary catecholamine excretion (DOPA, DA, DOPAC, NA, A) was studied in 66 patients with Parkinson's disease, 38 of them with differently expressed depression. Depression severity correlated with rigid form of disorders (p < 0.001). Biochemical profile of the depressive patients was characterized by noradrenaline (NA) to adrenaline (A) ratio reduction (p < 0.01) and dopamine to NA (p < 0.01) ratio increase on the background of total catecholamines deficit. Changes of NA/A and DOPA and correlation between DOPA and depression severity imply a role of dopamine neuromediator deficit in depression development.

[Catecholamine metabolism in different forms of Parkinson's disease]. / Obmen katekholaminov pri raznykh formakh bolezni Parkinsona.

Catecholamine metabolism was evaluated by daily urine excretion in patients with Parkinson's disease of tremor (18 patients) and rigid (14 patients) types. The group included 16 untreated patients. According to urine analysis, most informative peripheral markers for dopamine metabolism proved to be DOPA excretion, 3,4-dioxyphenylacidic acid (DOPAA) level and DOPA/DOPAA ratio. In the initial disease stage, a marked decrease of free dopamine and noradrenaline as well as dopamine metabolism intensification with corresponding DOPA/DOPAA ratio decrease were found. Significantly lower DOPAA and DOPA excretion was detected in patients with predominance of akinesia and rigidity types compared to tremor ones. In contrast to untreated patients, those treated with drugs containing dopamine revealed correlations between daily urine DOPA excretion as well as DOPA/DOPAA ratio with neurological symptoms severity.

Aspirin treatment improves bladder function after outlet obstruction in rabbits.

OBJECTIVES: To examine whether bladder smooth muscle dysfunction after outlet obstruction could be altered by treatment with aspirin. Long-term outlet obstruction causes contractile and metabolic dysfunction of the bladder in vivo and in vitro. The evidence is growing that a decrease in bladder perfusion is an important cause of this phenomenon. The platelet aggregation inhibitor, acetylsalicylic acid (aspirin), has been used to improve perfusion of the heart for decades. METHODS: Ten male New Zealand white rabbits were obstructed for 4 weeks. Five rabbits received no further treatment (Obs), and 5 rabbits received 2 mg/kg/day aspirin (Obs+aspirin), administered by an osmotic pump implanted subcutaneously 1 week before the surgical obstruction. The bleeding time was measured to confirm the effectiveness of the aspirin treatment. Three different control groups were created: sham-operated rabbits, unobstructed rabbits with pumps containing DMSO (vehicle), and unobstructed rabbits with pumps containing aspirin. The contractile responses of bladder strips to field stimulation, adenosine triphosphate, carbachol, and KCl were determined. A section of each detrusor tissue was fixed in formalin and used to determine the smooth muscle and collagen (connective tissue) volume fraction. RESULTS: No differences were found in the bladder weights or responses to stimuli in the different control groups, which were therefore combined. Partial bladder outlet obstruction caused significant increases in the bladder weight of the obstructed animals (Obs+aspirin, 10.15 +/- 0.87 g; Obs, 10.17 +/- 0.88 g; and controls, 2.87 +/- 0.21 g). The aspirin treatment increased the bleeding time from 1.7 +/- 0.3 minutes to 3.3 +/- 0.1 minutes. The responses to field stimulation were significantly reduced in all of the obstructed rabbits. However, the responses of the bladder strips from the Obs rabbits to field stimulation were impaired to a significantly greater degree than were those from the Obs+aspirin rabbits. The response to 32-Hz stimulation was reduced by 86% in the Obs group but by only 64% in the Obs+aspirin group. The responses to carbachol were significantly reduced by 62% in the strips from the Obs rabbits, but the responses of the strips from the Obs+aspirin rabbits were similar to the responses of the strips from the controls. The responses to KCl and adenosine triphosphate were reduced, although they just failed to achieve statistical significance using Bonferroni's analysis. The ratio of smooth muscle and connective tissue shifted slightly toward smooth muscle after 4 weeks of obstruction, but no difference was found with or without aspirin treatment. CONCLUSIONS: Low-dose aspirin has a small but significant protective effect on the contractile dysfunction induced by bladder outlet obstruction in rabbits, although the increase in bladder mass was not altered. Bladders of the same weight showed improved responses to all forms of stimulation after pretreatment with aspirin. Already used by millions of patients with heart diseases, aspirin could be a useful protection against contractile dysfunction of the obstructed bladder.

Magnetic resonance imaging in the evaluation of congenital anomalies of the external genitalia.

OBJECTIVES: To assess the value of magnetic resonance imaging (MRI) in the anatomic evaluation and management planning of complex congenital genitourinary anomalies. METHODS: Multiplanar T(1) and T(2)-weighted MR images were obtained in 6 pediatric patients with congenital genitourinary anomalies, including aphallia, diphallia, ectopic scrotum, and epispadias. The imaging studies were read by experienced radiologists and discussed with the urologic surgeons in a multidisciplinary conference. RESULTS: Each congenital anomaly was demonstrated in detail by MRI. The MR images of penile agenesis showed hypoplastic corpora cavernosa and a vestigial bulb. In patients with penile duplication, MRI was able to delineate the course of each corporal body and the varying degree of thickness of the tunica albuginea. For the patient with scrotal ectopia, detailed MR images excluded both the possibility of urethral and corporal duplications and the presence of viable testes in the ectopic scrotum. In the case of epispadias, MRI illustrated the precise spatial relationship between the erectile bodies and urethra. Additionally, MRI identified related aberrant pelvic organs and provided images of the external genital structures. CONCLUSIONS: MRI, by rendering excellent anatomic interpretation of complex genital anomalies and associated abnormal pelvic tissues, assists surgeons in conceptualizing the anomalous structures and contributes to their formulation of management approaches.

Increased blood flow after catheterization and drainage in the chronically obstructed rabbit urinary bladder.

OBJECTIVES: To determine the effect of drainage on rabbit bladder blood flow after 4 weeks of partial outlet obstruction. Previous studies have shown that catheterization and drainage of the urinary bladder in control rabbits resulted in a significant nitric oxide-induced increase of blood flow to the bladder. It was also shown that 4 weeks' partial outlet obstruction caused a significant decrease in blood flow to the bladder. METHODS: Male New Zealand White rabbits underwent partial outlet obstruction by standard methods. After 4 weeks, the blood flow to the bladder muscle and mucosa was determined by a microsphere technique. Within 1 to 2 minutes after transurethral catheterization and complete drainage of the bladder, the blood flow was again determined. Unobstructed animals served as controls. Four other control animals underwent a repetitive blood flow study during 10 minutes to determine the time frame of blood flow changes after drainage. Blood flow was also measured in 2 control rabbits after transurethral catheterization without drainage and in 2 control rabbits after drainage by suprapubic puncture. To exclude the possibility that increased intravesical pressure alters the blood flow measurements, the relationship between the intravesical volume and the bladder pressure was examined in the obstructed rabbits. RESULTS: After drainage of the bladder, the blood flow to the bladder muscle increased 4.5-fold in the decompensated obstructed group (bladder weights greater than 15 g) and 2.5-fold in the compensated animals (bladder weights less than 5 g) and control animals. Blood flow to the mucosa followed the same pattern but without reaching significance. Blood flow returned to near baseline values within 5 minutes. Catheterization without drainage did not alter the blood flow. In contrast, drainage by puncture increased the blood flow significantly. Higher intravesical volumes increased the intravesical pressure slightly, but after opening the abdominal fascia, the intravesical pressure did not change with increasing volumes. CONCLUSIONS: Although the previously shown decreased blood flow to the bladder smooth muscle may be an etiologic factor in bladder contractile dysfunction secondary to partial outlet obstruction, the bladder does have the ability to increase the blood flow after drainage. This ability could be a compensatory and possibly protective mechanism after outlet obstruction.

Granulomatous lymphangitis of the scrotum and penis. Report of a case and review of the literature of genital swelling with sarcoidal granulomatous inflammation.

BACKGROUND: Acquired lymphedema of the genitalia is a rare childhood presentation and is more common in elderly individuals secondary to pelvic/abdomenal malignancy or its therapy or worldwide due to filariasis. OBJECTIVE: Herein, we report a case of a healthy 11-year-old boy who presented with a 1-year history of chronic, asymptomatic scrotal and penile swelling. Biopsy revealed edema, lymphangiectases and peri- and intralymphatic sarcoidal type granulomas. This histologic pattern of granulomatous lymphangitis is most commonly associated with orofacial granulomatosis (granulomatous cheilitis and Melkersson-Rosenthal syndrome) and Crohn's disease. Treatment with topical steroids and physical support has resulted in marked improvement. No systemic disease (Crohn's disease) is evident 1 year later. Literature review revealed 44 cases of genital lymphedema with non-infectious granulomas. The majority of these young patients had Crohn's disease, frequently with anal involvement and a minority, both with and without Crohn's disease, had orofacial granulomatosis. CONCLUSIONS: Granulomatous lymphangitis should be considered in the differential diagnosis of chronic idiopathic swelling of the genitalia, particularly in younger individuals. Further clinical examination, additional laboratory studies and close follow-up for co-existing or subsequent development of Crohn's disease should be performed. The overlap between granulomatous lymphangitis of the genitalia, Crohn's disease and orofacial granulomatosis suggest that granulomatous lymphangitis of the genitalia may represent a forme fruste of Crohn's disease.

The response of fetal sheep bladder tissue to partial outlet obstruction.

PURPOSE: We characterized the response of fetal ovine bladder strips to stimulated contraction and relaxation, and compared this response to that of strips from the pregnant mother and those obtained after a short duration of fetal bladder outlet obstruction. MATERIALS AND METHODS: Sham surgery or bladder obstruction was performed in fetal sheep at 90 days of gestation (term 147 days). Bladder tissue was obtained 3 and 5 days later. Isolated strips of full-thickness bladders from fetuses and pregnant females were mounted individually in Tyrode's solution containing glucose. The strips were subjected to electrical field stimulation. Alternate strips were stimulated by adding carbachol, adenosine triphosphate and KCl. Each strip stimulated by carbachol also underwent field stimulation in the presence of carbachol. Relaxation was also tested using isoproterenol and nitroprusside. RESULTS: The response of isolated strips to field stimulation showed phasic contraction or biphasic response, consisting of initial phasic contraction followed by phasic relaxation and a return to control tension after the end of stimulation. In fetal bladder strips field stimulation at all frequencies after carbachol stimulation produced phasic relaxation or a biphasic response with an initial relaxation phase followed by phasic contraction. This field stimulated relaxant response was not present in adult female bladder strips. In addition, field stimulation stimulated relaxation was completely eliminated by pretreatment with N-nitro-L-arginine-methyl ester, indicating that relaxation was nitric oxide mediated. The fetal responses to all forms of stimulation and relaxation were significantly greater than those of pregnant females. After 5 days or greater of obstruction the responses to field stimulation were reduced significantly. In contrast, there were no significant differences in contractile responses to adenosine triphosphate, carbachol or KCl, or the relaxant response to field stimulation after obstruction. However, there was a significant reduction in relaxant responses to isoproterenol and nitroprusside. CONCLUSIONS: In mid gestation sheep fetus contractile responses to field stimulation, adenosine triphosphate, carbachol and isoproterenol are well developed. The fetal ovine bladder shows a strong neuronal nitric oxide response that is not present in the pregnant mother and is maintained after short-term obstruction.

Urethra is more sensitive to ischemia than bladder: evidence from an in vitro rat study.

PURPOSE: Experimental studies have demonstrated that ischemia may induce significant bladder dysfunction. Because multiple causes leading to bladder ischemia also decrease urethral perfusion, we assessed the effect of in vitro ischemia on the contractile responses of the rat bladder and urethra. We evaluated the hypothesis that neurogenic dysfunction in urethral ischemic injury occurs before myogenic dysfunction is present. We also compared contractile responses of the rat bladder and urethra to in vitro ischemia followed by reoxygenation. MATERIALS AND METHODS: Isolated strips of rat bladder detrusor muscle and prostatic urethra were incubated in normal physiological medium and stimulated electrically and chemically. In vitro ischemia was produced by incubating tissue in ischemic medium for 30 or 60 minutes. The maximal tension and maximal rate of tension generated were analyzed digitally before ischemia and after ischemia followed by reoxygenation. RESULTS: We demonstrated that after 30 minutes of ischemia followed by reperfusion the maximal rate of tension generated decreased significantly only in the urethra and only in response to field stimulation. After 60 minutes of ischemia the decrease in urethral contractile responses was greater than the decrease in bladder contractile responses. Ischemia 60 minutes in duration caused a significant decrease in the maximal rate of tension generated as well as maximal tension in the urethra and bladder but only in response to field stimulation. CONCLUSIONS: This experiment demonstrates that the urethra is more sensitive to ischemic injury than the bladder. Our finding may explain the development and symptoms of urinary incontinence secondary to sphincteric damage before bladder dysfunction is present. We also demonstrated that in the bladder and urethra the response to field (neurogenic) stimulation is the most sensitive form of stimulation to ischemia.

Placement of artificial urinary sphincter in children and simultaneous gastrocystoplasty.

PURPOSE: Previous studies have described placement of an artificial urinary sphincter and simultaneous augmentation cystoplasty with a segment of bowel. Conclusions from these studies indicated that infection rates were higher and a staged approach should be undertaken. Others have suggested that concurrent urinary reconstruction with stomach and sphincter placement can be performed safely. Results comparing infection rates of simultaneous sphincter placement and gastrocystoplasty versus staged sphincter placement and augmentation cystoplasty using a segment of ileum or stomach versus sphincter placement alone in a pediatric population have not been previously described to our knowledge. We reviewed these various groups of patients to determine if the difference in infectious complications were clinically and statistically significant. MATERIALS AND METHODS: A retrospective review of medical records from 1986 to 1999 identified 28 pediatric patients (age 18 years or less) who had undergone placement of an AS800dagger artificial urinary sphincter. Data points were collected focusing on etiology of the neurogenic bladder, age at time of surgery, types of surgery performed, length of followup and complication rates. RESULTS: Complete data were available for 27 of the 28 patients. Neurogenic bladder was secondary to myelomeningocele in 25 cases, transverse myelitis in 1 and spinal cord injury in 2. Mean patient age at surgery was 12.7 years (range 6.1 to 18.2) and mean followup was 4.3 years (range 1 month to 13 years). Simultaneous gastrocystoplasty was performed in 7 cases (group 1), staged sphincter placement followed by augmentation cystoplasty with a segment of ileum or stomach was done in 8 (group 2) and 12 did not require bladder augmentation (group 3). Urethral device erosion requiring explantation was the most common complication, occurring in 3 patients in group 1 and 2 in group 3 (p = 0.101). Mean time to erosion was 22.1 months (range 2 to 46.4). Previous surgery (bladder neck or hernia repair) was a common factor in each group with complications. Urine cultures and culture of the explanted device were positive in 2 patients in group 1. CONCLUSIONS: Simultaneous placement of artificial urinary sphincter at the time of gastrocystoplasty can be performed in carefully selected patients, although those undergoing staged procedures did well without complications. Prior bladder neck surgery seems to be a significant risk for infection. A staged approach to lower urinary tract reconstruction would be more advantageous due to the absence of infection and erosion in those undergoing staged sphincter placement and augmentation cystoplasty.