Tunica vaginalis pedicle flap for repair of ruptured testis: A single-center experience with four patients.

Management of testicular rupture with a large tunical defect may not be feasible without excision of viable tissue. This study describes the use of a vascularized tunica vaginalis flap, without debridement of viable tissue, in four adolescents. Postoperative ultrasound showed good blood flow and 80% volume of the contralateral testis in two cases. Postoperative exam revealed normal exam and ultrasonographic appearance in three patients, the fourth was demonstrated to be small and undescended during evaluation of contralateral testicular torsion. This approach is recommended in cases of large tunical defects, as it avoids the debridement of viable testicular tissue.

Bladder health across the life course.

Influences on bladder health begin during infancy and continue throughout the lifespan. Bladder anatomy and physiology change as individuals age, and the risk and propensity for bladder conditions, including lower urinary tract symptoms, throughout life are related to factors specific to age, sex, and life events. Bladder habits and dysfunctions at one stage of life may affect bladder health in subsequent stages. However, bladder problems are neither a normal part of aging nor inevitable at any stage of life. Many of the factors that negatively impact bladder health at all ages may be modifiable, and healthy bladder habits may prevent or reverse bladder dysfunctions that can occur naturally or in response to life events. There are opportunities to further define and promote healthy bladder habits through focused research and heightened public awareness of the importance of bladder health, which may lead to improvements in overall health and quality of life. It is our hope that this paper will inform and encourage public health initiatives and research programs aimed at this goal.

A healthy bladder: a consensus statement.

A panel of experts in urology, urogynecology, nursing, and behavioral therapy convened in 2010 to discuss the importance of a healthy bladder on overall health. They determined that a consensus statement was necessary to raise awareness among the general public, healthcare providers, payors, and policymakers, with the goals of minimizing the impact of poor bladder health and stimulating primary prevention of bladder conditions. In this statement, 'healthy' bladder function is described, as well as internal and external factors that influence bladder health. It is suggested that primary prevention strategies should be aimed at providing education regarding normal lower urinary tract structures and functioning to the public, including patients and healthcare providers. This education may promote the achievement of optimal bladder health by increasing healthy bladder habits and behaviors, awareness of risk factors, healthcare seeking, and clinician engagement and reducing stigma and other barriers to treatment. Promoting optimal bladder health may reduce the personal, societal and economic impact of bladder conditions, including anxiety and depression and costs associated with conditions or diseases and their treatment. While adopting healthy bladder habits and behaviors and behaviors may improve or maintain bladder health, it is important to recognize that certain symptoms may indicate the presence of conditions that require medical attention; many bladder conditions are treatable with a range of options for most bladder conditions. Lastly, the authors propose clinical directives based on persuasive and convergent research to improve and maintain bladder health. The authors hope that this statement will lead to promotion and achievement of optimal bladder health, which may improve overall health and help minimize the effects of bladder conditions on the public, healthcare professionals, educators, employers, and payors. The advisors are in consensus regarding the recommendations for improving and maintaining bladder health presented herein.

Conservation of predatory arthropods in cotton: role of action thresholds for Bemisia tabaci (Homoptera: Aleyrodidae).

Studies were conducted in 1994 and 1995 to examine the effects of a range of action thresholds for managing Bemisia tabaci (Gennadius) Biotype B (= B. argentifolii Bellows & Perring) with insecticides in cotton on populations of arthropod predators in Imperial Valley, CA, and Maricopa, AZ. Application of insecticides significantly reduced population densities of spiders, Geocoris punctipes (Say), G. pallens (Stål), Orius tristicolor (White), Nabis alternatus Parshley, Zelus renardii Kolenati, Hippodamia convergens Guerin-Méneville, Spanogonicus albofasciatus (Reuter), Drapetis sp., and Chrysoperla carnea Stephens in one or both years and sites compared with untreated controls. Use of higher B. tabaci thresholds conserved some species and groups relative to lower thresholds. Stepwise regression analyses indicated that reductions in predator populations were generally influenced more strongly by the timing of the first insecticide application than by the total number of sprays necessary to maintain suppression of the pest below any given action threshold. A predation index, which weights the importance of each predator species based on their known frequency of predation on B. tabaci and another key pest, Pectinophora gossypiella (Saunders), was developed and analyzed. Patterns were similar to results based on changes in abundance alone, but the index generally revealed less severe effects of insecticides on overall predator function. The current action threshold for conventional insecticidal control of B. tabaci in Arizona and southern California is five adults per leaf. Results here suggest that predator conservation may be enhanced by raising the initial threshold to delay the first application or initially using more selective materials such as insect growth regulators.

Histological analysis of urethral healing after tubularized incised plate urethroplasty.

PURPOSE: Tubularized incised plate urethroplasty has rapidly gained popularity for treating hypospadias. It is presumed that healing occurs with the postoperative migration of epithelial cells into the incised urethral plate. We describe the time course and histology of the healing urethral wound in an animal model after dorsal incision and stenting. MATERIALS AND METHODS: A procedure was developed for use in an immature porcine model. The ventral aspect of the urethra was opened and a dorsal incision was made in the urethra to the level of the corpus spongiosum. The urethra was then catheterized and closed ventrally. Animals were sacrificed at intervals of 1, 2, 3, 5, 7, 14 and 21 days. Slides were made from multiple cross sections taken from each penis, and stained with hematoxylin and eosin, and Masson trichrome before analysis. RESULTS: Migration of epithelial cells into the dorsal epithelial defect was evident on postoperative day 2 with apparent complete re-epithelialization by postoperative day 5. Regions of increased fibroblastic activity were observed in the subepithelial stroma below the incised area on postoperative day 3 and early collagen deposition was noted in these areas when stained with Masson trichrome. These areas appeared to organize and by postoperative day 21 there was little evidence of increased fibroblastic activity or excess collagen deposition. CONCLUSIONS: Urethral healing after incision and tubularization over a catheter in our model occurred through normal re-epithelialization without excess collagen deposition or scarring.

Cystoscopy at the time of ureteral reimplantation for primary vesicoureteral reflux: is it necessary? Incidence of undetected anomalies and cost.

OBJECTIVES: To evaluate the impact on the planned procedure and associated cost of cystoscopy performed immediately before the surgical repair of vesicoureteral reflux. Cystoscopy is commonly performed at the time of ureteroneocystostomy to rule out a previously unsuspected anomaly such as ureterocele or ureteral duplication. METHODS: We retrospectively reviewed the results of preoperative voiding cystourethrograms and ultrasound studies performed on 128 patients who underwent ureteral reimplantation for primary vesicoureteral reflux between 1994 and 2000. Radiographic findings were compared with observations made at cystoscopy and reimplantation to determine the rate of unsuspected ureterocele or duplication in the presence of a radiologic evaluation considered adequate by the operating surgeon and/or radiologist. We then performed an itemized analysis to determine the cost cystoscopy contributed to the procedure. RESULTS: Of the 128 patients, 1 (0.7%) was found to have a small, undiagnosed ureterocele at cystoscopy. A review of this patient's preoperative evaluation revealed that her ultrasound examination was incomplete, lacking views of the bladder. At our institution, cystoscopy increased the total direct and indirect operating room costs of this procedure by 16.2%, adding $123.77 to the original cost of $762.97. CONCLUSIONS: Routine cystoscopic examination before ureteral reimplantation in the setting of an adequate preoperative radiologic evaluation yields little diagnostic information. In this series, it did not have an impact on the surgical procedure to be performed but did add significantly to the cost. Cystoscopy before ureteral reimplantation for primary reflux should only be considered in those children with suspicious or inadequate radiologic studies.

The retained penile prosthesis reservoir: a risk.

Complications associated with penile prostheses include malfunction, infection, and patient dissatisfaction. We present a rare complication of a retained abdominal reservoir eroding into the bladder and causing irritative voiding symptoms several years after the removal of the penile components of a three-piece penile prosthesis.

Surgical management of vesicoureteral reflux.

Vesicoureteral reflux (VUR) is a urologic condition in which there is a retrograde flow of urine from the bladder through the ureter back up to the upper urinary tract. The condition may be classified as primary or secondary and is more often identified in Caucasian females. The primary goal in the management of VUR is the prevention of pyelonephritis and subsequent renal scarring.

[Treatment of complex hypospadias by the Snodgrass technique]. / Traitement des hypospades complexes par la technique de Snodgrass.

PURPOSE: Successful use of the Snodgrass modification of Tiersch-Duplay urethroplasty for repair of distal hypospadias has been reported. Given the features of the repair: technical simplicity, preservation of the urethral plate, single suture line in the urethroplasty and no need for vascularized pedicle graft, we felt that the technique could be applied to the treatment of proximal hypospadias. METHODS: A retrospective review of the records of 35 patients with either midshaft or penoscrotal hypospadias who underwent a Snodgrass type of hypospadias repair was carried out. Age at surgery was 3 to 54 months (mean age: 8.4 months). No patients with significant chordee were included. All patients had indwelling urethral stents for 5 to 7 days postoperatively. Follow-up ranged from 6 months to 3 years. RESULTS: There were no immediate postoperative complications. Four patients experienced a urethrocutaneous fistula in association with meatal stenosis. After meatal dilatation, 2 of these fistulae closed spontaneously for an overall fistula rate of 5.7%. The overall cosmetic result of the glans and urethral meatus was noted to be excellent. Urinary stream was normal in all cases. CONCLUSION: Our results indicate that the Snodgrass modification of Tiersch-Duplay hypospadias repair provides satisfactory cosmetic and functional results in the treatment of proximal hypospadias with a low surgical complication rate. In young patients, it is our procedure of choice for penile and penoscrotal hypospadias without major degrees of chordee.

Hypospadias repair in the 1990s.

Hypospadias is a congenital anomaly in which the urethral meatus is abnormally located anywhere from the glans to the perineum. Refinements in pediatric anesthesia, surgical technique and instrumentation, and a greater understanding of the psychologic and emotional issues related to hypospadias repair have led to this procedure being performed at an earlier age. The goal of reconstruction is to bring the urethral meatus to the tip of the penis, to correct associated penile curvature if present, to create a conical-shaped glans, and to achieve cosmetically acceptable penile shaft skin coverage. The surgical technique employed varies with the penile anatomy and surgeon's preference. Complications may occur both immediately and long after the surgical procedure, and thus follow-up is necessary.

Comparison of sonicated albumin enhanced sonography to fluoroscopic and radionuclide voiding cystography for detecting vesicoureteral reflux.

PURPOSE: We compared sonicated albumin enhanced sonography to fluoroscopic and radionuclide voiding cystography for detecting vesicoureteral reflux. MATERIALS AND METHODS: After obtaining informed consent we enrolled in our study 20 patients with known or suspected vesicoureteral reflux and no contraindications to intravesical sonicated albumin. All patients underwent albumin enhanced sonography, following which 10 patients each underwent radionuclide and fluoroscopic voiding cystography. Reflux was graded by the observing radiologist and urologist. RESULTS: In 10 patients albumin enhanced sonography demonstrated reflux in 6 of the 7 (83%) ureters in which radionuclide cystography identified reflux. In 2 patients ultrasound studies were inadequate due to excessive movement during the procedure, and the patients were classified as unevaluable. In the remaining 10 patients 12 of 20 ureters (60%) were equal in the absence or presence of and degree of reflux on enhanced sonography and voiding cystourethrography. In 6 ureters voiding cystourethrography detected reflux more readily or revealed a higher grade of reflux. Two ureters had a higher reflux grade on enhanced sonography. No adverse effects were associated with intravesical sonicated albumin. CONCLUSIONS: In experienced hands sonicated albumin enhanced sonography is safe for evaluating vesicoureteral reflux. It provides the simultaneous evaluation of renal contours, parenchyma and size in addition to bladder visualization. This new technique may prove to be useful as a followup study in patients with previously documented reflux or as a primary study for sibling screening.

Histological evaluation of the testicular nubbin in the vanishing testis syndrome.

PURPOSE: We reviewed histopathological studies of the testicular nubbins associated with the vanishing testis syndrome, and determined whether surgical removal is indicated based on the histological findings. MATERIALS AND METHODS: Between 1983 and 1997 a unilateral testicular nubbin consistent with a vanishing testis was excised in 29 patients an average of 28.6 months old. We retrospectively reviewed the gross pathology reports and microscopic slides, and prospectively performed histochemical stain analysis. RESULTS: Gross evaluation of the specimens revealed an identifiable cord structure in the majority of cases with the vas deferens most commonly identified in 72.4%. No recognizable testicular elements were present in any nubbin. In 3 cases the original pathology report identified cells with features consistent with Leydig cells, which immunohistochemical staining revealed to be atrophied cremasteric muscle fibers. CONCLUSIONS: In this series testicular nubbins in vanishing testes contained no viable testicular tissue. Since the risk of testicular cancer in an undescended testis is 8 to 10% and the incidence of viable testicular tissue in these nubbins ranges from 0% in our series to 11% in others, there is only a 0 to 1.1% risk of testicular cancer in the nubbin. Thus, surgical removal may not be warranted.

Through the looking glass darkly? When self-doubts turn into relationship insecurities.

The authors argue that individuals regulate perceptions of their relationships in a self-protective way, finding virtue in their partners only when they feel confident that their partners also see virtues in them. In 4 experiments, the authors posed an acute threat to low and high self-esteem individuals' feelings of self-worth (e.g., guilt about a transgression, fears of being inconsiderate or intellectually inept). They then collected measures of confidence in the partner's positive regard and acceptance (i.e., reflected appraisals) and perceptions of the partner. The results revealed that low self-esteem individuals reacted to self-doubt with heightened doubts about their partners' regard, which then tarnished impressions of their partners. In contrast, high self-esteem individuals reacted to self-doubts by becoming more convinced of their partners' continued acceptance, using their relationships as a resource for self-affirmation.

Treatment of pediatric urolithiasis between 1984 and 1994.

PURPOSE: We report our experience with the management of pediatric urolithiasis during a 10-year period. Our aim was to assess the impact of new technology in the treatment of pediatric urolithiasis. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients up to age 18 years in whom urolithiasis was treated from 1984 to 1994. In 37 cases 24-hour urine collections were available for metabolic evaluation. RESULTS: A total of 100 pediatric patients was treated for urolithiasis. Mean followup was 36 months. A total of 79 patients underwent 115 procedures for symptomatic urolithiasis and 21 were treated nonoperatively. In 42 patients structural anomalies of the urinary tract required additional management. Metabolic abnormalities in 48 patients included hypercalciuria in 19, defined as greater than 4 mg./kg./24 hours calcium by 24-hour urine collection. Only 24 of the 100 patients had no identifiable predisposing factors. Procedures included shock wave lithotripsy in 42 cases, basket extraction with or without ureteroscopy in 20, percutaneous nephrostolithotomy in 11 and litholapaxy in 12. Open surgery included cystolithotomy in 10 cases and other forms of open lithotomy in 15. Thus, open surgical removal was necessary in 1 of 5 cases. CONCLUSIONS: Compared to the traditional mode of stone treatment, fewer patients required open surgery. Our results indicate that a comprehensive approach to the care of pediatric patients with urolithiasis requires attention to metabolic and structural abnormalities.

Modified ASOPA procedure (Hodgson XX) achieves the goals of hypospadias repair.

Several vascularized island flap procedures have been described for the repair of severe hypospadias with chordee. The modified ASOPA (Hodgson XX) procedure, a variant of transverse island flap, employs an inner preputial skin tube for the neourethra while providing simultaneous skin coverage. Since 1988, more than 240 hypospadias repairs have been performed at the authors' institution, including 15 modified ASOPA procedures. All of the patients had proximal hypospadias with chordee. The follow-up of 12 of these patients showed a straight penis, free of chordee, with the meatus at the tip in 11 (92%). One patient had glanular separation and retraction of the meatus to a coronal position. No patient had a urethrocutaneous fistula or urethral diverticulum. Proximal anastomotic strictures were identified in three (25%) patients, which resolved with dilation in two and with internal urethrotomy in the other. The final cosmetic appearance was excellent for 11 patients. Based on these results, the authors conclude that the modified ASOPA procedure reliably achieves the goals of hypospadias repair: release of chordee, urethroplasty, scrotoplasty, and redistribution of skin coverage in one operation, with minimal morbidity.

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In this exclusive panel discussion with H&HN, the CEOs of seven large, integrated health systems take a verbal journey, trekking across country and into inner cities to explore issues ranging from community health to the future of leadership. It's a fictitious journey about the real issues that lie ahead.

Common sheath reimplantation yields excellent results in the treatment of vesicoureteral reflux in duplicated collecting systems.

PURPOSE: We evaluated our 10-year experience with the surgical treatment of vesicoureteral reflux in uncomplicated duplicated collecting systems. MATERIALS AND METHODS: Between 1984 and 1994, 54 refluxing renal units (8 bilateral) in 37 female and 9 male patients required surgery. Patient age ranged from 7 months to 17 years (average 4.9 at surgery). Postoperative followup (average 14.2 months) included voiding cystourethrography and renal sonography or excretory urography. RESULTS: Common sheath ureteral reimplantation via an intravesical approach was performed in 48 of the 54 refluxing renal units. Of the remaining 6 renal units detrussorrhaphy was performed in 4, and ureteroureterostomy combined with ureteral reimplantation and partial lower pole nephrectomy were done in 1 each. Two treated renal units had persistent postoperative vesicoureteral reflux, which resolved after subureteral polytetrafluoroethylene (Teflon) injection. No renal had postoperative hydronephrosis. Contralateral reflux was identified in 1 patient who underwent unilateral reimplantation. Our overall success rate was 96% for the surgical correction of vesicoureteral reflux in uncomplicated duplicated collecting systems. Common sheath reimplantation had a 98% success rate. CONCLUSIONS: Although a duplicated collecting system increases the risk for surgical treatment, the presence of a duplication anomaly does not adversely affect surgical outcome. Modifications of procedures commonly performed in the surgical treatment of single system reflux to accommodate common sheath reimplantation have excellent surgical results with minimal morbidity.

The Malone antegrade colonic enema enhances the quality of life in children undergoing urological incontinence procedures.

PURPOSE: Functional alterations of the gastrointestinal and genitourinary tracts, and physical limitations in children with spina bifida, imperforate anus and spinal cord injury challenge the ability to have independent fecal and urinary continence. Urologists have successfully helped these patients achieve urinary continence. We report our experience with the antegrade colonic enema procedure, which allows select individuals to achieve continence of stool, enhancing quality of life. MATERIALS AND METHODS: Since December 1992, 18 antegrade colonic enema procedures were performed in 12 female and 6 male patients 5 to 31 years old of whom 14 had spina bifida, 2 had imperforate anus and 2 had spinal cord injury. Simultaneous urological continence procedures were performed in 8 patients, including appendicovesicostomy in 4, augmentation cystoplasty in 2 and augmentation cystoplasty plus an ileal Mitrofanoff procedure in 2. Four patients previously underwent urological reconstruction. RESULTS: In 24 months of followup (average 6.6) all patients with a functioning stoma remained continent of stool and 17 were continent of urine. Complications related to the antegrade colonic enema procedure occurred in 4 children (22%) of whom 3 required further surgery. Three patients (17%) had minor stomal stenosis. CONCLUSIONS: The antegrade colonic enema procedure is easily performed and it should be considered for any child with significant physical limitations and/or refractory fecal incontinence before urological continence promoting procedures are done.

Detrusorrhaphy for the repair of vesicoureteral reflux: comparison with the Leadbetter-Politano ureteroneocystostomy.

The authors report their surgical experience for 56 patients (81 ureters) with vesicoureteral reflux using either the extravesical (detrusorrhaphy) approach or the Leadbetter-Politano (intravesical) procedure. The success rate was the same in both. Patients undergoing the extravesical approach required less pain medication and less anticholinergic therapy to control bladder spasms in the postoperative period as compared with the patients undergoing the repair through an intravesical approach. Because the bilateral extravesical approach may be associated with transient urinary retention, the authors recommend that bilateral procedures be performed with minimal dissection of the trigone or that this approach be limited to unilateral repair.