Pyeloplasty vs. nephrectomy for ureteropelvic junction obstruction in poorly functioning kidneys (differential renal function <20%): a multicentric study.

INTRODUCTION: Management of poorly functioning kidneys with ureteropelvic junction obstruction (UPJO) is controversial, with some recommending direct nephrectomy and others direct pyeloplasty, and others temporary diversion. This study aimed to determine whether pyeloplasty is associated with higher complication rate than nephrectomy under these circumstances and whether it allows for functional recovery. METHODS: A retrospective review of 77 patients undergoing surgery for UPJO associated with a differential renal function (DRF) < 20% at 4 centres between January 2000 and December 2015 was conducted. Short- and long-term complications between pyeloplasties (n = 47) and nephrectomies (n = 16) and the changes in the DRF after pyeloplasty were compared. RESULTS: Patients undergoing nephrectomy had significantly lower median pre-operative DRF (p < 0.001) and were significantly more likely to undergo a minimally invasive approach (p = 0.002) than those undergoing pyeloplasty. No postoperative variable was statistically different between groups. After a mean follow-up of 63 (10-248) months, no statistically significant difference was found in intra-operative, early, late, and overall complications between pyeloplasty and nephrectomy. Pyeloplasty failed in 3% (2/62) of cases. Of the patients undergoing successful pyeloplasty, 36 had a pre-operative and a postoperative renogram, and functional recovery >5% was observed in 13 (36%), whereas the DRF remained unchanged in 16 (45%). Only postnatal diagnosis was associated with a significantly higher chance of functional recovery (odds ratio [OR] = 4.13, p = 0.047). DISCUSSION: Nephrectomy was more commonly performed using a minimally invasive approach and required less-intense follow-up than pyeloplasty. Moreover, complications after pyeloplasty, although occasional, required additional surgery which was never required after nephrectomy. Moreover, it should be considered that conservative treatment might be a third option in some of these patients. CONCLUSIONS: In the study patients, pyeloplasty was not associated with significantly higher morbidity than nephrectomy. Need for deferred nephrectomy seems exceptional in decompressed kidneys even though renal function remains poor. Of the pyeloplasty cases not requiring additional surgery, one-third showed an improvement in DRF and a postnatal diagnosis was the only predictive factor for renal functional recovery.

The role of renal biomarkers to predict the need of surgery in congenital urinary tract obstruction in infants.

INTRODUCTION: The diagnosis of renal function impairment and deterioration in congenital urinary tract obstruction (UTO) continues to be extremely challenging. The use of new renal biomarkers in this setting may favor early renal injury detection, allowing for a reliable choice of optimal therapeutic options and the prevention or minimization of definitive renal damage. OBJECTIVE: The aim of the study was to investigate a selection of promising biomarkers of renal injury with the intention of evaluating and comparing their profile with clinically based decisions for surgical intervention of infants with congenital obstructive uropathies. STUDY DESIGN: The first-year profile of renal biomarkers, serum creatinine (sCr), serum and urine cystatin C (CyC), neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), transforming growth factor beta-1 (TGF-ß1), retinol-binding protein (RBP), and microalbuminuria (µALB), was analyzed in a cohort of 37 infants with congenital UTO, divided into three subgroups, 14 cases with grade III unilateral hydro(uretero)nephrosis, 13 cases with grade III bilateral hydro(uretero)nephrosis, and 10 cases with low urinary tract obstruction (LUTO), compared with 24 healthy infants matched by gestational age and birth weight. Serum and urine samples were stored at -70 °C and thereafter analyzed by quantitative enzymatic immunoassay. RESULTS: Compared with the control group (Figure), all renal biomarker values were significantly increased in patients (P ≤ 0.02). In the unilateral hydronephrosis and LUTO group, RBP (P ≤ 0.043), NGAL (P ≤ 0.043), KIM-1 (P ≤ 0.03), and TGF-ß1 (P ≤ 0.034) values dropped significantly after surgery. Neutrophil gelatinase-associated lipocalin alone and in combination with urine and serum CyC demonstrated the best performance in determining the need for surgery (area under the curve, 0.801 and 0.881, respectively). Biomarker profile analysis was suggestive of surgical intervention in 55.4% (7/13) of non-operated cases, and most of the biomarker values were above the cutoff levels within at least 3 months before the clinically based surgical decision in 58% (14/24) of all operated patients. DISCUSSION: To the best of the authors' knowledge, this is the first study to present the clinical use of selected group of serum and urinary biomarkers in the setting of UTO to distinguish between patients who would benefit from surgery intervention. The most promising results were obtained using NGAL, RBP, TGF-ß1, and KIM-1, especially in the unilateral hydro(uretero)nephrosis and LUTO subgroups when compared with the control group. CONCLUSIONS: Urine biomarkers, alone and in combination, demonstrated high potential as a non-invasive diagnostic tool for identifying infants who may benefit from earlier surgical intervention.

Abdominoplasty in Prune Belly Syndrome.

INTRODUCTION: Many patients with Prune Belly Syndrome (PBS) require abdominoplasty alone or in combination with correction of any urogenital abnormalities. This video presents a simplified technique with which to treat the abdominal flaccidity in PBS. METHODS: A longitudinal xypho-pubic fusiform figure is drawn on the abdomen, based on the area of skin and subcutaneous tissue to be removed. This is performed with preservation of the musculo-fascial layer and the umbilicus. A lateral elliptical single xypho-pubic line is drawn in the most lax side of the fascia, which is incised along this line. After urinary tract reconstruction and orchidopexy, closure is initiated by suturing the medial edge of the wider fascial flap laterally to the peritoneal side of the contralateral flap. Next, the now outer fascial flap is laid over the inner flap, and a buttonhole is made to expose the umbilicus. The subcutaneous tissue of the inner flap is laterally undermined to gain extra distance for the suture of the outer flap over the inner flap. The subcutaneous tissue and skin are sutured in the midline, incorporating the umbilicus. RESULTS: In a 30-year period, 43 PBS patients underwent this procedure with good cosmetic and long-term functional results. CONCLUSION: This abdominoplasty technique is simple and presents good functional and cosmetic results in PBS patients.

Diagnostic work-up and laparoscopic correction of an ectopic ureter.

INTRODUCTION: A duplex renal collecting system is a common congenital anomaly in children. Continuous dribbling (especially if after the toilet-training period) should raise suspicion of the presence of an ectopic ureter, which is most often associated with ureteral duplication. This video will demonstrate the complete diagnostic work-up necessary in these cases. CASE REPORT: A 10-year-old girl presented with continuous dribbling. Ultrasonography and computerized tomography depicted a duplex system on the left side, with the upper pole ureter ectopically inserting into the vaginal cavity and good upper pole renal parenchyma. A careful urethrocystoscopy showed a topic right ureteral orifice and a topic lower pole left ureteral orifice. Retrograde pyelography was performed and displayed normal left lower pole anatomy. A vaginography was performed, which showed reflux to the ectopic ureter. Vaginoscopy clearly identified the ectopic ureteral orifice. A guide wire was introduced through this meatus and retrograde contrast injection confirmed the diagnosis of an ectopic ureter. RESULTS: At laparoscopy, a larger upper pole ureter and a normal lower pole ureter on the left side were identified. A termino-lateral ureteroureteral anastomosis was performed. After the procedure, the child reported immediate resolution of urinary dribbling. CONCLUSION: In order to optimize its surgical correction, efforts should be made to appropriate localization of the ectopic ureter.

27 years of experience with the comprehensive surgical treatment of prune belly syndrome.

INTRODUCTION: Prune belly syndrome (PBS) presents with three main features: abdominal wall flaccidity, urological abnormalities and cryptorchidism. As a result, urologists must consider the eventual repair of the abdominal wall flaccidity and urinary tract abnormalities, and the mandatory correction of cryptorchidism, as well as decide whether to perform the procedures in a single comprehensive approach or in multiple steps. OBJECTIVES: To report experiences with comprehensive surgical management of prune belly syndrome. MATERIAL AND METHODS: From 1987 to 2014, 46 children with PBS were submitted for comprehensive surgical treatment. According to individual needs, treatment aimed to correct the abdominal flaccidity, reconstruct the urinary tract, and perform bilateral orchiopexy and circumcision, which were performed in one procedure. Urinary tract reconstruction was indicated whenever pyelo-ureteral dilatation with evidence of significant stasis and/or vesicoureteral reflux was associated with recurrent urinary tract infections (UTI). Treatment for this cohort included: 44 abdominoplasties, 40 upper urinary tract reconstructions, 44 cystoplasties associated with three appendico-vesicostomies, 46 bilateral orchiopexies and 36 circumcisions. The median age at surgery was 16 months and children were followed for a median of 143 months. RESULTS: Abdominal appearance and tonus were improved in 90% of the children after the primary surgery and 100% after reoperation. Upper urinary tract reconstruction was performed in most children and long-term follow-up showed functional stabilization of the urinary tract in about 90% of the children, with progression to renal failure in 10%. Lower urinary tract reconstruction was performed in most children (95.6%); on late follow-up, continence was observed in 81% of them, while incontinence was present in 19% and usually associated with polyuria. Adequate bladder emptying was possible in most boys (82.6%), while the remaining required clean intermittent catheterization. Pre-operative UTI was present in 89.1% and urinary sepsis in 15.2%. Postoperatively, the incidence of laboratorial UTI was significantly reduced to 39.1%, while urinary sepsis was absent. Bilateral orchiopexy was performed in all children, with 85% of the testes becoming normal in size and well located in the scrotum. CONCLUSIONS: Comprehensive surgical treatment is feasible and has good long-term results. A considerable incidence of reoperations due to complications or progression of the disease was observed. The long-term results for reno-ureteral anatomy and function, bladder function, infection, testicular size and location, as well as abdominal aspect and tonus, show that comprehensive surgery is an adequate method for managing children with PBS.

Long-term reduction in poly(dimethylsiloxane) surface hydrophobicity via cold-plasma treatments.

Poly(dimethylsiloxane), PDMS, a versatile elastomer, is the polymer of choice for microfluidic systems. It is inexpensive, relatively easy to pattern, and permeable to oxygen. Unmodified PDMS is highly hydrophobic. It is typically exposed to an oxygen plasma to reduce this hydrophobicity. Unfortunately, the PDMS surface soon returns to its original hydrophobic state. We present two alternative plasma treatments that yield long-term modification of the wetting properties of a PDMS surface. An oxygen plasma pretreatment followed by exposure to a SiCl4 plasma and an oxygen-CCl4 mixture plasma both cause a permanent reduction in the hydrophobicity of the PDMS surface. We investigate the properties of the plasma-treated surfaces with X-ray photoelectron spectroscopy (XPS) and contact angle measurements. We propose that the plasma treated PDMS surface is a dynamic mosaic of high- and low-contact-angle functionalities. The SiCl4 and CCl4 plasmas attach polar groups that block coverage of the surface by low-molecular-weight groups that exist in PDMS. We describe an application that benefits from these new plasma treatments, the use of a PDMS stencil to form dense arrays of DNA on a surface.

New tissue bulking agent (polyacrylate polyalcohol) for treating vesicoureteral reflux: preliminary results in children.

PURPOSE: We report the preliminary results of endoscopic treatment of vesicoureteral reflux in children using polyacrylate polyalcohol copolymer. MATERIAL AND METHODS: We performed a prospective multicenter review of pediatric patients treated with subureteral injection of a new nonabsorbable substance. Only patients with 1 year of followup were included. RESULTS: A total of 83 patients underwent injection of polyacrylate polyalcohol copolymer at our institutions between 2005 and 2006. Among this group 18 males and 43 females with a median age of 58 months (range 9 months to 18 years) completed 1 year of followup. Reflux was bilateral in 27 patients (44.3%) and unilateral in 34 (55.7%). Number of injected ureters was 88. Reflux grade was V in 3 ureters (3.4%), IV in 12 (13.6%), III in 41 (46.6%) and II in 32 (36.4%). Mean +/- SD injected volume per unit was 0.76 +/- 0.43 ml. Median followup was 20 months (range 16 to 24). Complications after injection included dysuria in 6 patients (9.8%), fever in 3 (4.9%) and lumbar pain in 4 (6.6%). Reflux was eliminated in 78 renal units (88.6%), decreased to grade I in 6 (6.8%) and persisted in 4 (4.5%). Ureteral obstruction developed in 1 patient and was treated operatively. Overall success rate was 83.6%. CONCLUSIONS: Polyacrylate polyalcohol copolymer can be used to treat vesicoureteral reflux with comparable efficacy to other substances currently used, with a low rate of complications.

Comparación entre la cirugía videolaparoscópica y la cirugía abierta para las enfermedades renales benignas en el niño / Comparison of videolaparoscopic versus open surgery for benign renal diseases in Children

Introducción: La nefrectomía laparoscópica en niños se ha convertido en una alternativa razonable a la nefrectomía abierta y ha sustituido a la cirugía abierta en muchas enfermedades renales. El objetivo de nuestro estudio es evaluar los procedimientos videolaparoscópicos transperitoneales en las enfermedades renales benignas en comparación con el abordaje quirúrgico abierto. Pacientes y método: 34 niños de edades comprendidas entre los 17 días y los 15 años (media, 6, 14 años) fueron divididos en dos grupos de nefrectomía; el primero fue sometido a nefrectomía videolaparoscópica transperitoneal y estaba compuesto por 21 pacientes (12 mujeres y 9 varones) con edades comprendidas entre los 2 meses y los 15 años (media, 7, 42 años). El segundo grupo fue sometido a nefrectomía abierta y estaba compuesto por 13 pacientes (6 mujeres y 7 varones) con edades comprendidas entre los 17 días y los 11 años (media, 3,91 años). Los grupos se compararon respecto al tiempo de anestesia, el tiempo operatorio, la duración de la estancia hospitalaria, el dolor postoperatorio y el tiempo de reinstauración de la ingesta oral. También se evaluaron las complicaciones acorto y largo plazo. El análisis estadístico se llevó a cabo mediante la prueba de la t de Student, y se estimó significativo el valor de p < 0,05. El Comité de Ética Científica de nuestra institución aprobó previamente el estudio. Resultados: Se observaron diferencias estadísticamente significativas sólo en cuanto a la variable duración de la estancia hospitalaria. Ningún caso del grupo a laparoscopia se convirtió en cirugía abierta. No se observaron complicaciones inmediatas ni tardías. La pérdida de sangre fue insignificante y no fue necesario administrar transfusiones. Conclusiones: Según nuestra experiencia, la nefrectomía videolaparoscópica transperitoneal presenta resultados similares a los de la nefrectomía abierta, excepto en lo que respecta al tiempo de hospitalización (AU)

Introduction: Laparoscopic nephrectomy in children has become a reasonable alternative to open nephrectomy and has replaced open surgery for many renal diseases. The purpose of our study is to evaluate transperitoneal videolaparoscopic procedures in renal benign diseases in comparison to an open surgery approach. Patients and methods: 34 children aged between 17 days and 15 years old (mean 6.14) were divided into two groups in order to be submitted to nephrectomy. The first one underwent transperitoneal videolaparoscopic nephrectomy and was composed by 21 patients aged from 2 months to 15 years (mean 7.42), from which 12 were females and 9 males. The second group was submitted to open nephrectomy and was composed by 13 patients aged from 17 days to 11 years (mean 3.91), 6 females and 7 males. The groups were compared regarding anesthesic time, operative time, length of hospital stay, postoperative pain and time of reintroduction of oral intake. Short and long term complications were also evaluated. Statistical analysis was performed by Student t-test with the level of significance set at P < 0.05. The study was previously approved by the Committee on Ethics in Research of our institution. Results: Significant statistical difference was observed only for the variable length of hospital stay. No laparoscopy group case was converted to open surgery. There was no immediate or late complication. Blood loss was negligible and no transfusion was required. Conclusions: In our experience, transperitoneal videolaparoscopic nephrectomy has similar results to open nephrectomy, except for time of hospitalization (AU)

Transformations in wrinkle patterns: cooperation between nanoscale cross-linked surface layers and the submicrometer bulk in wafer-spun, plasma-treated polydimethylsiloxane.

We demonstrate control of the topography of strain-induced wrinkle patterns through the interplay between the bulk and the nanoscale cross-linked top layer of plasma treated, spin-coated polydimethylsiloxane (PDMS) thin films. The different morphological phases observed, varying from herringbones to caps, are in agreement with recent theoretical predictions. The cap phase exhibits short-range 3-fold-symmetric close-packed self-organization, demonstrating a bottom-up pathway toward the wafer-scale production of ordered, nanoscale patterns on surfaces.

Comparison of videolaparoscopic versus open surgery for benign renal diseases in children.

INTRODUCTION: Laparoscopic nephrectomy in children has become a reasonable alternative to open nephrectomy and has replaced open surgery for many kidney diseases. The aim of our study is to evaluate transperitoneal videolaparoscopic procedures in benign renal disease compared with the open surgical approach. PATIENTS AND METHODS: 34 children aged between 17 days and 15 years (mean, 6.14 years) were divided into two nephrectomy groups. The first underwent transperitoneal videolaparoscopic nephrectomy and was composed of 21 patients (12 female and 9 male) aged between 2 months and 15 years (mean, 7.42 years). The second group underwent open nephrectomy and was composed of 13 patients (6 female and 7 male) aged between 17 days and 11 years (mean, 3.91 years). The groups were compared for time of anaesthesia, operating time, length of hospital stay, postoperative pain and time to restore oral intake. Short and long term complications were also evaluated. Statistical analysis was performed by a Student's t test, with a p value < 0.05 being considered significant. The study was approved beforehand by the Scientific Ethics Committee in our institution. RESULTS: Statistically significant differences were observed only for the length of hospital stay. No cases in the laparoscopic group were converted into open surgery. There were no immediate or late complications. Blood loss was negligible and so it was not necessary to administer any transfusions. CONCLUSIONS: In our experience, transperitoneal videolaparoscopic nephrectomy has similar results to those of open nephrectomy, except for hospitalisation times.

Plasma-enhanced synthesis of bactericidal quaternary ammonium thin layers on stainless steel and cellulose surfaces.

We have investigated bottom-up chemical synthesis of quaternary ammonium (QA) groups exhibiting antibacterial properties on stainless steel (SS) and filter paper surfaces via nonequilibrium, low-pressure plasma-enhanced functionalization. Ethylenediamine (ED) plasma under suitable conditions generated films rich in secondary and tertiary amines. These functional structures were covalently attached to the SS surface by treating SS with O 2 and hexamethyldisiloxane plasma prior to ED plasma treatment. QA structures were formed by reaction of the plasma-deposited amines with hexyl bromide and subsequently with methyl iodide. Structural compositions were examined by electron spectroscopy for chemical analysis and Fourier transform infrared spectroscopy, and surface topography was investigated with atomic force microscopy and water contact angle measurements. Modified SS surfaces exhibited greater than a 99.9% decrease in Staphylococcus aureus counts and 98% in the case of Klebsiella pneumoniae. The porous filter paper surfaces with immobilized QA groups inactivated 98.7% and 96.8% of S. aureus and K. pneumoniae, respectively. This technique will open up a novel way for the synthesis of stable and very efficient bactericidal surfaces with potential applications in development of advanced medical devices and implants with antimicrobial surfaces.

Plasma-enhanced synthesis of thin fluoropolymer layers with low Raman and fluorescence backgrounds.

Radio-frequency (RF) plasma enhanced chemical vapor deposition (PECVD) provides a promising way to deposit extremely hydrophobic, highly adherent nanometer- to micrometer-thick films with thermal stability, a low coefficient of friction, a low dielectric constant, and a low value of surface energy. We describe the synthesis of these fluorinated thin films using hexafluoropropene as starting material and discuss their properties. These coatings, applied to stainless steel, provide ideal substrates for Raman spectroscopy, when extremely low backgrounds are required. Raman spectroscopy measurements of a low-concentration protein film are used to demonstrate sensitivity and level of detectability.

Cold-plasma modification of oxide surfaces for covalent biomolecule attachment.

While many processes have been developed to modify the surface of glass and other oxides for biomolecule attachment, they rely primarily upon wet chemistry and are costly and time-consuming. We describe a process that uses a cold plasma and a subsequent in vacuo vapor-phase reaction to terminate a variety of oxide surfaces with epoxide chemical groups. These epoxide groups can react with amine-containing biomolecules, such as proteins and modified oligonucleotides, to form strong covalent linkages between the biomolecules and the treated surface. The use of a plasma activation step followed by an in vacuo vapor-phase reaction allows for the precise control of surface functional groups, rather than the mixture of functionalities normally produced. By maintaining the samples under vacuum throughout the process, adsorption of contaminants is effectively eliminated. This process modifies a range of different oxide surfaces, is fast, consumes a minimal amount of reagents, and produces attachment densities for bound biomolecules that are comparable to or better than commercially available substrates.

Laparoscopic management of intersexual states.

Laparoscopy has gained acceptance as the ideal method of surgical treatment of the internal [figure: see text] genital organs in patients with intersex disorders. The intersexual states for which laparoscopy is needed are female and male pseudohermaphroditism, true hermaphroditism, and Turner's syndrome. In these patients, the indications for laparoscopy are the removal of normal gonads and ductal structures that are contrary to the assigned gender and the removal of dysgenetic gonads that are nonfunctional and that present potential for malignancy. In addition to being a minimally invasive surgery, one of the main advantages of this method is the lack of scars, a fact much appreciated by patients and their parents. Generally, gonadectomy is a straightforward operation because the gonads present with an accessible pedicle. Laparoscopic orchidopexy has been standardized and can be performed in patients in whom the testis must be relocated to the scrotum. The removal of ductal structures is also easily performed in most cases, whereas hysterectomy with resection of the vagina may present some difficulties owing to the location of these structures. In patients with a long vaginal component of the urogenital sinus, the distal segment must be removed by a retrograde perineal access, usually performed simultaneously with genitoplasty. Endocrinologists must be aware of the application of this method of treatment in intersex patients, and urologists proficient in laparoscopic techniques must extend their field of work in this area.