Effect of Voided Volume on Voiding Patterns and Reliability of Uroflowmetry-Electromyography Results in Children with Lower Urinary Tract Dysfunction.

OBJECTIVE: To examine whether voided volume (VV) could change the uroflow patterns and result in children with lower urinary tract dysfunction (LUTD). METHODS: Between January 2009 and May 2010, the children with LUTD were enrolled in this study. Uroflowmetry (UF) combined with electromyography (EMG) was performed two times and was reviewed independently by two urologists. UF-EMG curves were classified as bell, staccato, intermittent, plateau, and tower. Patients' expected bladder capacity (EBC) and VV were recorded. Patients were divided into four groups according to their VV and EBC. Group 1, VV <50% of EBC; group 2, VV between 50 and 100% of EBC; group 3, VV between 100 and 125% of EBC; group 4, VV >125% of EBC. RESULTS: A total of 143 patients underwent UF-EMG at least two times and 382 results were obtained. Groups 1, 2, 3 and 4 consisted of 27, 60, 27 and 29 children, respectively. The percentages of normal, intermittent, plateau voiding patterns were 58.5, 12.8, 7.1% in group 1; 79.8, 5.4, 1.8% in group 2; 59.2, 8.5, 2.8% in group 3; and 37.2, 5.1, 2.6% in group 4, respectively. The percentages of staccato and tower pattern were 1.4, 20% in group 1; 9.1, 3.6% in group 2; 30, 0% in group 3; and 55.1, 0% in group 4, respectively. The rate of tower shape curve decreased as voided volume increased, but the rate of staccato curve increased as voided volume increased. CONCLUSIONS: In case of exceeding the EBC, the test should be repeated with normal VV when UF results are being evaluated.

The role of urinary nerve growth factor for the diagnosis and assessment of the biofeedback success in children with dysfunctional voiding.

INTRODUCTION: Dysfunctional voiding (DV) occurs in neurologically normal children who are not able to establish brain control on detrusor muscle contractions (DMCs). It is also reported to be the result of incorrect voiding habits during toilet training. Children contract pelvic floor muscles (PFMs) to suppress DMC and DV begins. Urinary nerve growth factor (uNGF) is necessary for the synthesis and regulation of neurotransmitters, development of dorsal root ganglia (sensory neurons), and development of sympathetic cells during embryonic and post-natal life. uNGF has also a role in the intracellular signal transduction in nerve cells towards the target organ. To our knowledge, no study has investigated the association between uNGF, biofeedback treatment and DV in children. OBJECTIVES: The aim was to examine the potential effect of uNGF in the assessment of the effectiveness of biofeedback success in children with lower urinary tract disorders. STUDY DESIGN: Fifty-two children with the suspicion of DV and 48 children from a primary school reporting no urinary complaints were enrolled in this study from October 2010 to April 2013 in the Urology Department. uNGF levels were compared. RESULTS: The mean uNGF/creatinine (Cr) level was 0.23 ± 0.26 in the control group and 0.96 ± 0.88 in the DV group (p < 0.001). The mean uNGF/Cr levels in the DV group at baseline and at the end of biofeedback therapy at 6 and 12 months were 0.90 ± 0.78, 0.26 ± 0.32, and 0.40 ± 0.50, respectively (p < 0.001) (Figure). DISCUSSION: To our knowledge this study is the first to show the correlations between uNGF levels and biofeedback therapy in children with DV. Tissue NGF in 12 patients with overactive bladder (OAB)/detrusor overactivity and 15 healthy women was previously compared and it was suggested that there was no correlation between bladder tissue NGF and OAB. uNGF levels in the bladder in patients with interstitial cystitis and idiopathic sensorial urgency were evaluated previously, and uNGF levels reported. Similar to these reports, most of the previous studies handled uNGF in patients with diseases such as interstitial cystitis, OAB, urinary tract infections, urolithiasis, spinal cord injury, and prostate cancer, and found significantly higher uNGF levels. These studies were generally in adults. A previous study about uNGF comprised 40 children with OAB, in contrast to other studies. According to this study, 40 children diagnosed with OAB were administered anti-muscarinic therapy (oxybutynin 0.3-0.5 mg/kg/day). It was reported that uNGF/Cr levels of the OAB group were higher than control group. In the current study, we evaluated the uNGF difference in DV and the effect of biofeedback treatment on uNGF levels. CONCLUSIONS: uNGF levels were higher in children with DV and decreased after biofeedback therapy. uNGF levels could be used for the diagnosis and the assessment of biofeedback success in these children.

Ovotesticular disorder of sex development with a prostatic gland and review of literature.

Ovotesticular disorder of sex development (OTDSD) is a rare condition and defined as the presence of ovarian and testicular tissue in the same individual. Most of patients with OTDSD have female internal genital organs. In this report, we present a case in which, we demonstrated prostate tissue using endoscopic and radiologic methods in a 46-XX, sex determining region of the Y chromosome negative male phenotypic patient, with no female internal genitalia. Existence of prostate in an XX male without SRY is rarely seen and reveals a complete male phenotype. This finding is critical to figure out what happens in embryonal period.

A new modification of dismembered pyeloplasty for primary ureteropelvic junction obstruction.

AIM: To present the results of a new modification of dismembered pyeloplasty performed to prevent the occurrence of secondary obstruction. METHODS: Modified dismembered pyeloplasty was performed in 35 children (age range 3 months to 16 years) who had unilateral ureteropelvic junction obstruction. In postoperative follow-up, presence of hydronephrosis on ultrasonography, differential renal function (DRF) and renal drainage half-time on technetium-99m diethylenetriaminepentaacetic acid (DTPA) renography were recorded and compared with preoperative data. RESULTS: Mean anteroposterior renal pelvic diameter, mean preoperative DRF and radioisotope clearance half-time on DTPA renography of the affected kidneys were 61.4 mm, 38.6% and 34.3 min in children with prenatal hydronephrosis, and 67.5 mm, 37.6% and 39.4 min in children that presented with symptoms, respectively. After surgery, mean anteroposterior renal pelvic diameter, mean DRF and radioisotope clearance half-time on DTPA renography of the affected kidneys were 10.9 mm, 45.9% and 11.9 min in children with prenatal hydronephrosis, and 20 mm, 41.9% and 15.2 min in children that presented with symptoms, respectively. No failure was observed in any patient at an average follow-up of 26 months (range 1-5 years). CONCLUSIONS: Open dismembered pyeloplasty is the treatment of choice for intrinsic ureteropelvic junction obstruction. The modification of dismembered pyeloplasty that we performed is an alternative for the prevention of secondary obstruction.

Low sperm recovery from the undescended testis with testicular sperm extraction in postpubertal cryptorchids: preliminary report.

As postpubertal cryptorchid testes are generally atrophic and have high malignancy risk, orchiectomy is recommended as the treatment method. However, a few case reports advocated orchiopexy due to finding sperm afterwards. The present clinical study aimed at determining the possibility of finding spermatozoa in postpubertal cryptorchid testis with testicular sperm extraction (TESE). Initially testicular biopsy and later TESE was performed in the undescended testis of 22 unilateral postpubertal cryptorchids and in one of the testes of three bilateral postpubertal cryptorchids. Histopathological assessment of testicular biopsy specimen showed that three patients had maturation arrest and 22 had seminiferous tubular atrophy. By TESE, spermatozoa were found in only one specimen of 25 testes. Our results show that the expectancy to find spermatozoa in postpubertal cryptorchid testis is extremely low by current sperm recovery methods and orchiectomy is still the accurate method of treatment.

Prevention of colonic mucosal regrowth after seromuscular enterocystoplasty.

PURPOSE: To find answers about preventing the colonic mucosal regrowth after seromuscular enterocystoplasty and the dissection pane, we performed an experimental study in dogs. We also report our experience with mucosal regrowth and bladder function after augmentation colocystoplasty. MATERIALS AND METHODS: This study comprised 10 adult healthy female mongrel dogs. We performed this animal experiment in 2 stages. At stage 1 we constructed a low capacity bladder. Stage 2 was performed 6 months after stage 1. At the end of detrusorectomy a 15 cm. segment of sigmoid colon was detubularized. The animals were randomly divided into 2 groups. In the 5 group 1 dogs de-epithelialization was performed with needle point cautery at a low cut setting, and the mucosa, muscularis mucosa and submucosa were resected, leaving the fibers of the muscularis externa exposed. In the 5 group 2 dogs de-epithelialization was performed by the peeling technique, in which the dissection plane was developed between the mucosa and muscularis mucosa, and the muscularis mucosa and submucosa remained on the colonic muscle. The de-epithelialized patch of bowel was shaped as a cup patch and anastomosed to the edges of the detrusor muscle over the bulging urothelium. The animals were sacrificed at 12 months of followup. All bladders were inspected macroscopically for regrowth of the colonic mucosa. Multiple sections of the augmentation patches were obtained and processed routinely for histological evaluation to determine what happened to the urothelium. RESULTS: We noted good urodynamic results in all dogs and there was no statistical difference in the groups in regard to bladder capacity. Mucosal regrowth did not develop in either group. CONCLUSIONS: When dissection is performed successfully whether or not the submucosa is removed, there is no observed regrowth or loss of bladder capacity in either technique.

Ureterocystoplasty in bilaterally functional kidneys.

OBJECTIVE: Traditional augmentation cystoplasty using gastrointestinal segments is known to be associated with metabolic abnormalities and alterations in the bladder causing potential carcinogenesis. In this respect alternative techniques have been searched preferably lined by urothelium. We performed ureterocystoplasty in 7 patients with a diagnosis of neurogenic bladder and investigated the clinical and functional aspects. PATIENTS AND METHODS: Between 1995 and 1999, ureterocystoplasty was performed using both ureters in 4 male and 3 female children with bilaterally functional kidneys. Patients' ages varied between 1 and 7 (mean 4.7) years. Before the operation all the children were incontinent, had a small-capacity noncompliant bladder, and high-grade (IV-V, International Classification System) reflux on voiding cystouretrography (VCU). Technetium-99m DTPA renal scintigraphy was also performed in all children to evaluate renal function before and after the operation. RESULTS: Before the operation the mean end-filling intravesical pressure was 45.6 (35-60) cm H(2)O which decreased to 18.9 cm H(2)O 3 months postoperatively. The mean bladder capacity 3 months after ureterocystoplasty was found to be 279.3 (250-330) ml. All the children were continent and VCU showed the absence of reflux. There was mild to moderate improvement in renal function after surgery in both kidneys on technetium-99m DTPA renal scintigraphy. Three (43%) patients could void spontaneously with abdominal straining, whereas 4 (57%) children could empty their bladders by clean intermittent catheterization. A double-J stent was inserted in 1 (14%) patient because of a rise in serum creatinine after the removal of the ureteral catheter. Patients were followed for a mean period of 30 (8-50) months and all the children remained continent. The bladder capacity and end-filling pressure measurements were also stable. CONCLUSION: Ureterocystoplasty was found to be an effective method for bladder augmentation in bilaterally functional kidneys with an acceptable complication rate

Combination therapy of imipramine with oxybutynin in children with enuresis nocturna.

PURPOSE: The treatment approach for enuresis is controversial due to the lack of consensus as to the exact causes of nocturnal enuresis. Despite various treatment modalities, pharmacotherapy still appears to be the common choice. The aim of this prospective study was the evaluation of the efficacy of combination therapy (imipramine and oxybutynin) in patients with enuresis nocturna. PATIENTS AND METHODS: This prospective study was done with 77 monosymptomatic nocturnal enuretics between July 1996 and December 1998. RESULTS: Even though there is no statistically significant difference between combination therapy (imipramine plus oxybutynin) and monotherapy, clinical data showed that combination therapy is more effective. CONCLUSIONS: We conclude that combination of imipramine with oxybutynin is a safe and new choice in the treatment of nocturnal enuresis.

Tubularized incised plate urethroplasty for distal and mid-penile hypospadias.

Tubularized incised plate urethroplasty was performed to repair 20 distal and 5 mid-penile hypospadias cases. In distal hypospadias repair meatal stenosis occurred in 1 patient and urethral fistula in another. The overall complication rate in this group was thus 10%. Among midpenile hypospadias cases meatal stenosis was observed in 1 (20%) patient. As a conclusion, tubularized incised plate urethroplasty was found to be a successful method for treating distal hypospadias and encouraging results were obtained in mid-penile hypospadias cases.

A new approach to bladder augmentation in children: seromuscular enterocystoplasty.

OBJECTIVE: To report the use of seromuscular enterocystoplasty (SE) combined with detrusorectomy, in children. PATIENTS AND METHODS: Between 1993 and 1998, SE was performed in 10 children (aged 10-17 years) with a spastic neurogenic bladder resulting from spinal trauma. Before surgery all children were incontinent and despite anticholinergic medication and clean intermittent catheterization, their bladder capacity was 60-100 mL and their intravesical pressure 40-60 cmH2O. RESULTS: Before surgery, the mean end-filling intravesical pressure was 47.7 cmH2O and the mean bladder capacity 82.9 mL. At 3 months after surgery the mean end-filling intravesical pressure was decreased to 21.1 cmH2O and the mean bladder capacity increased to 319.6 mL. One patient (a 14-year-old girl) had urinary retention soon after surgery and has since used clean intermittent catheterization. The other children were able to void successfully using the Valsalva manoeuvre; none were incontinent. All patients were followed and there were no changes in intravesical pressure and bladder capacity. CONCLUSION: In providing most of the desired features of an ideal augmentation segment, SE is a good and effective method of bladder augmentation.

Seromuscular colocystoplasty lined with urothelium: experimental study.

OBJECTIVES: Enterocystoplasty without bowel mucosa would be useful to prevent most complications related to the presence of bowel in the urinary tract. However, past attempts to remove the mucosa from intestinal segments have resulted in fibrosis and contraction of the patch. We designed this study to test the hypothesis that such contraction can be prevented by combining the principle of detrusorectomy and seromuscular colocystoplasty, covering the denuded urothelium with a de-epithelialized colonic segment, a procedure we named seromuscular colocystoplasty lined with urothelium (SCLU). METHODS: SCLU was performed in 14 female mongrel dogs weighing 20 to 25 kg. We performed the procedure with and without preservation of the intestinal submucosa and in animals with intact and previously reduced bladders. We describe a new animal model of reduced bladder capacity. Bladder capacity and histology were evaluated 1 to 6 months after the procedure. RESULTS: Twelve bladder specimens were available for analysis. In all cases, the seromuscular patches remained viable and well vascularized. When the intestinal submucosa was not preserved in the patch, there was moderate contraction of the patch with subepithelial fibrosis and the bladder capacity was not preserved. In contrast, when the submucosa was preserved, there was no fibrosis and the capacity was preserved. In animals with previously reduced bladder capacity by either subtotal cystectomy or talc-induced fibrosis, SCLU effectively augmented bladder capacity. CONCLUSIONS: The results suggest that the contraction of the intestinal patch in seromuscular enterocystoplasty can be avoided by the preservation of both the bladder urothelium and lamina propria, together with the submucosa and muscularis mucosa of the intestinal patch.

The development of tumors in experimental gastroenterocystoplasty.

Bladder augmentation with segments of the gastrointestinal tract is commonly used to treat patients with small or noncompliant bladders. Reliable data on the incidence of tumors in patients with enterocystoplasty are not available. In the small number of cases reported in the literature the mean latency period is approximately 18 years. We designed a study in Sprague Dawley rats to try to determine the risk of carcinogenesis in different types of augmentation cystoplasty and its possible relationship with infected urine, and to investigate the possibility of detecting the tumors by cytological analysis. We performed 30 gastrocystoplasties, 35 sigmoid cystoplasties, 30 ileocystoplasties and 10 sham operations, and used 10 nonoperated animals as controls. The animals were sacrificed upon completing 1 year of followup and bladder urine samples were collected at the time of sacrifice. Of 115 animals 86 were available for histological evaluation (26 gastrocystoplasty, 22 sigmoid cystoplasty, 18 ileocystoplasty, and all sham and control animals). Mean followup was 11.2 months in the gastrocystoplasty, 11.8 months in the sigmoid cystoplasty, and 12 months in the ileocystoplasty, sham and control groups. Multifocal or superficial transitional metaplasia was found in 65.4% of the gastrocystoplasty, 50% of the sigmoid cystoplasty and 55.5% of the ileocystoplasty animals. Proliferations that we classified as papillary hyperplasia were present in 53.8% of the gastrocystoplasty, 40.9% of the sigmoid cystoplasty and none of the ileocystoplasty rats. The proliferations occurred either at or close to the anastomosis between the bladder and the gastric or colonic patch, or in areas of transitional metaplasia. Cytological urinalysis was negative for neoplastic cells in all cases. No correlation was found between the occurrence of papillary hyperplasia and urinary infection. These data indicate that in rats transitional metaplasia is common in gastrocystoplasty, sigmoid cystoplasty and ileocystoplasty, and that papillary hyperplasia may occur near or at the anastomosis, or in areas of transitional metaplasia in either gastrocytoplasty or sigmoid cystoplasty. In contrast to other studies, we observed no examples of papillary hyperplasia in the ileocystoplasty group in this series. No transitional cell carcinomas or adenocarcinomas were identified in this study. It is not known if these papillary lesions have an increased malignant potential, thus further studies with longer followup are warranted.

Intrarenal pressure following pyeloplasty or percutaneous surgery.

In a study of 37 patients it was shown that recording the intrapelvic pressure is a safe and reliable means of judging the best time to remove a nephrostomy tube. No post-operative complications were encountered and the procedure has the added advantage of avoiding the use of X-rays.