The management of bilateral ureteric injury following radical hysterectomy.

Iatrogenic ureteric injury is a well-recognised complication of radical hysterectomy. Bilateral ureteric injuries are rare, but do pose a considerable reconstructive challenge. We searched a prospectively acquired departmental database of ureteric injuries to identify patients with bilateral ureteric injury following radical hysterectomy. Five patients suffered bilateral ureteric injury over a 6-year period. Initial placement of ureteric stents was attempted in all patients. Stents were placed retrogradely into 6 ureters and antegradely into 2 ureters. In 1 patient ureteric stents could not be placed and they underwent primary ureteric reimplantation. In the 4 patients in which stents were placed, 2 were managed with stents alone, 1 required ureteric reimplantation for a persistent ureterovaginal fistula, and 1 developed a recurrent stricture. No patient managed by ureteric stenting suffered deterioration in serum creatinine. We feel that ureteric stenting, when possible, offers a safe primary management of bilateral ureteric injury at radical hysterectomy.

Continence and classic bladder exstrophy treated with staged repair.

PURPOSE: Urinary continence rates after reconstruction of the urinary tract for classic bladder exstrophy are variable. We review our experience with procedures required to optimize continence. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients with classic bladder exstrophy undergoing staged reconstruction between 1976 and 2001. Continence was reviewed and associated with the procedures performed. Patients were considered continent if dry for greater than 3 hours with no stress incontinence and dry at night. Partial continence required dryness for 1 to 3 hours, minor stress incontinence and occasional nighttime leakage. Incontinent patients were dry for less than 1 hour, had significant stress incontinence or were wet at night. Patients were followed for a median of 12.5 years. RESULTS: Continence was achieved in 43 of 48 patients (90%), partial continence in 4 (8%) and 1 (2%) remains incontinent. Continence occurred before bladder neck repair in 4 patients. Bladder neck repair alone (without augmentation) was performed in 38 patients at a median of 4.25 years, resulting in continence in 13 patients (34%). However, 6 of these 13 patients later required augmentation. Augmentation was performed in 33 patients, with 30 (91%) attaining continence after this procedure. Of those continent patients 10 void per urethra, and 8 void and use clean intermittent catheterization. Of the patients treated with bladder augmentation 93% required clean intermittent catheterization. CONCLUSIONS: Continence can be achieved in most patients with classic bladder exstrophy. However, augmentation was required in 30 of 43 patients (70%). Bladder neck reconstruction alone resulted in continence in only a third of the cases.

Cowper's syringocele causing painful haematuria in an adult.

A Cowper's syringocele in an adult is rare. Ten cases are reported in the world literature. The authors report a case of painful haematuria due to the presence of a Cowper's syringocele in an adult. The classification of lesions of the Cowper's gland is discussed together with common symptoms and differential diagnosis.

Two bladders and two vaginas in two planes: one urogenital sinus.

We report 2 cases of persistent urogenital sinus (UGS) with duplication of the bladder and vagina in different planes. Cystoscopy and vaginoscopy were used to diagnose persistent UGS with bladder and vaginal duplication in 2 infants with recurrent urinary tract infection. Surgical repair was done by way of a midline abdominal and perineal approach using tubularized UGS to reconstruct the urethra. Persistent UGS represents a major anomaly; these patients had the added complexity of duplication of the bladder and vagina. In these complex patients, the true anatomy may only become apparent during the surgical reconstruction, necessitating a flexible, individual approach.

Reconstruction after total penile amputation and emasculation.

Amputation of the penis and testes is a rare injury in the pediatric population. The authors describe a case of traumatic amputation of the penis and testes presenting late for surgical reconstruction. The surgical reconstruction of this phallus involved advancement of the residual erectile tissue by division of the suspensory ligaments of the penis to lengthen the phallus. A glans penis was fashioned using a full-thickness skin graft with shaft skin provided by a split-thickness skin graft. The use of a tissue expander allowed the creation of a scrotum that accepted two testicular prostheses. Reconstruction of the phallus using these techniques allowed the creation of an erectile, esthetically acceptable phallus. In the situation in which residual erectile tissue remains, this technique can be effectively used in place of musculocutaneous transfer flaps or gender reassignment.

Acromioclavicular joint sprains: the post-injury recovery interval.

Acromioclavicular joint (ACJ) sprains occur after injuries to the shoulder girdle. Current practice is to treat such injuries conservatively. This study determines the recovery interval of ACJ sprains treated conservatively. Forty-seven patients with grades I or II ACJ sprains were evaluated in a shoulder clinic and treated conservatively. The average age was 37 years, with the injury being caused by a fall, contact sport or road-traffic accident. At an interval of 12 months or greater these patients were assessed by means of a questionnaire. Six months post-injury, pain was described as significant by 14 (40%) patients, decreasing to 5 patients (14%) at final follow-up. A restricted range of movement was reported by seven patients (20%) 6 months post-injury. There is a positive correlation between patients symptomatic at 6 months and those whose symptoms persist beyond 1 year (r=0.6, 95% CI=0.28-0.76, P<0.01). Three patients (9%) found that symptoms affected their ability to perform activities of daily living and two patients (6%) had to change sporting activities. Patients may continue to experience adverse symptoms beyond 6 months and should be advised accordingly on appropriate treatment should symptoms persist.

Intravesical phallus in cloacal exstrophy.

We report a case of a fused phallus located within the urinary bladder in a child with cloacal exstrophy. Surgical exploration revealed a phallus formed by fusion of the left and right corpus cavernosum and completely covered by bladder urothelium. The phallus was surgically separated from the bladder and mobilized to a more normal position and a neourethra created from tubularized bladder urothelium. Skin coverage was done using perineal skin flaps to cover the penile shaft, with the bladder urothelium covering the tip of the phallus being left intact to provide the appearance of a glans penis.

Liposomal delivery of heat shock protein 72 into renal tubular cells blocks nuclear factor-kappaB activation, tumor necrosis factor-alpha production, and subsequent ischemia-induced apoptosis.

Heat shock protein 72 (HSP72) is a stress-inducible protein capable of protecting a variety of cells from toxins, thermal stress, and ischemic injury. The cytoprotective role and mechanism of action of HSP72 in renal cell ischemic injury remain unclear. To study this, HSP72 was introduced (liposomal transfer) or induced (thermal stress, 43 degrees Cx1 hour) in renal tubular cells (LLC-PK1) with Western blot confirmation. Cells were subjected to simulated ischemia 24 hours after liposomal HSP72 transfer or thermal stress, and the effect of HSP72 on nuclear factor-kappaB (NF-kappaB) activation (electrophoretic mobility shift assay and immunohistochemistry), IkappaBalpha production (Western blot), postischemic tumor necrosis factor-alpha (TNF-alpha) production (RT-PCR), and apoptosis (TUNEL assay) were determined. In separate experiments, the role of TNF-alpha in apoptosis was determined (anti-TNF-alpha neutralizing antibody). Results demonstrated that both liposomal transfer of HSP72 and thermal induction of HSP72 prevented NF-kappaB activation and translocation, TNF-alpha gene transcription, and subsequent ischemia-induced renal tubular cell apoptosis. Furthermore, TNF-alpha neutralization also inhibited ischemia-induced renal tubular cell apoptosis. These results indicate that liposomal delivery of HSP72 inhibits ischemia-induced renal tubular cell apoptosis by preventing NF-kappaB activation and subsequent TNF-alpha production. Further elucidation of the mechanisms of HSP-induced cytoprotection may result in therapeutic strategies that limit or prevent ischemia-induced renal damage.

The Indiana experience with artificial urinary sphincters in children and young adults.

PURPOSE: We reviewed a 22-year single institutional experience with the artificial urinary sphincter in children and adolescents. To our knowledge this report represents the largest series in the world in children. MATERIALS AND METHODS: Between 1980 and 2002, 142 patients underwent implantation of an artificial urinary sphincter, of whom 93 males and 41 females with a median age of 10 years (range 3 to 39) were available for analysis. A total of 59 patients initially received an AMS 742/792 (American Medical Systems, Inc., Minnetonka, Minnesota) artificial urinary sphincter, of whom 33 were subsequently changed to an AMS 800, while 75 initially received an AMS 800 model. Sphincter followup was terminated at device removal or at the last documented contact. The etiology of incontinence was neuropathic bladder in 107 cases (80%), the exstrophy/epispadias complex in 21 (16%) and other in 6 (4%). Outcome measures included continence, mechanical complications (leakage, tube kink and pump malfunction), functioning sphincter revisions (change in cuff size, pump repositioning and bulbar cuff placement), surgical complications (erosion, infection and misplacement) and associated surgical procedures. Mean followup of the pre-800 and 800 models was 6.9 (range 0.2 to 21.5) and 7.5 years (range 0.1 to 17.1), respectively. Fisher's exact test, Kaplan-Meier life analysis and the chi-square test were used for statistical analysis. RESULTS: After artificial urinary sphincter placement in the 134 patients continence was achieved in 86%, improved in 4% and not achieved in 10%. Of those with a sphincter in place 92% were continent. In terms of bladder emptying after artificial urinary sphincter insertion 22% of patients voided, 11% voided combined with clean intermittent catheterization, 48% performed clean intermittent catheterization only via the urethra, 16% performed it via a catherizable channel and 3% used urinary diversion. A mechanical complication developed in 38 of the 59 patients (64%) with pre-800 model compared with 33 of the 109 (30%) with the 800 model (p <0.0001). A mechanical complication occurred every 7.6 versus 16 patient-years for the pre-800 versus 800 models (p = 0.0001). Revision was required in 15 of the 59 patients (25%) with a pre-800 model versus 17 of the 109 (16%) with the 800 model (p = 0.103). Revision was performed every 22.7 versus 44.3 patient-years for the pre-800 versus the 800 model (p = 0.023). The artificial urinary sphincter eroded in 11 of the 59 patients (19%) with the pre-800 versus 17 of the 109 (16%) with the 800 model (p = 0.52). Ten patients experienced a total of 12 perforations of the augmented bladder after artificial urinary sphincter implantation. A total of 164 secondary surgical procedures were performed, including 38 of 134 bladder augmentations (28%). A total of 30 sphincters were permanently removed. CONCLUSIONS: The artificial urinary sphincter is the only bladder neck procedure that allows spontaneous voiding in the neuropathic population, obviates the need for clean intermittent catheterization and yet is compatible with it when necessary. It is also equally versatile in the 2 genders. Mechanical complications occur but they were dramatically decreased by the modifications of the AMS 800 model. In addition, secondary bladder augmentation was required in 28% of our patients. Lifelong followup is mandatory in all patients with an artificial urinary sphincter.