Vesicoscopic ureteral reimplantation with a modified Glenn-Anderson technique for vesicoureteral reflux.

INTRODUCTION: Vesicoureteral reflux (VUR), commonly referred to as urinary reflux, is one of the most common congenital urological anomaly to occur during childhood. Historically, open vesicoureteral reimplantation has been the gold standard in the surgical treatment of VUR. Currently, vesicoscopic ureteral reimplantation is used as a minimally invasive alternative to open ureteral reimplantation. Most vesicoscopic procedures are performed using the transtrigonal Cohen technique. As a non-transtrigonal technique, the vesicoscopic Politano-Leadbetter technique is also performed, but requires dissection outside the bladder under a narrow surgical field, and in boy carries a risk of vas deferens injury. OBJECTIVE: This study evaluated surgical outcomes and perioperative findings for vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique in children with VUR. STUDY DESIGN: Eighteen consecutive children who underwent vesicoureteral ureteral reimplantation using a modified Glenn-Anderson technique were included in this study. The surgical procedure was explained and surgical outcomes and perioperative findings were evaluated. RESULTS: Patients comprised 9 boys and 9 girls with 29 cases of ureteral reflux (7 unilateral cases, 11 bilateral cases). All procedures were performed laparoscopically, with no cases requiring conversion to open surgery. Median operative time was 143 min for unilateral VUR and 194 min for bilateral VUR. Only one case showed a complication (Clavien-Dindo grade 1). The remaining 17 cases showed no complications, with removal of the urethral catheter and discharge 2 days postoperatively. Seventeen of the 18 cases underwent postoperative voiding cystourethrography, showing no VUR in all cases. DISCUSSION: Vesicoscopic ureteral reimplantation is a minimally invasive alternative to open surgery, with most procedures performed using a transtrigonal Cohen technique. Regardless of whether the surgery is open or laparoscopic, a disadvantage of the Cohen technique is that postoperative transureteral treatment may not be possible. The Politano-Leadbetter technique has been reported as a non-transtrigonal technique. However, this requires dissection outside the bladder under a narrow surgical field, and carries a risk of vas deferens injury in boys. In this study, vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique provided good surgical outcomes with minimal perioperative complications and easy manipulation under a wide field of view. CONCLUSION: Although many minimally invasive treatments are available, vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique is safe and effective for patients with VUR 4 years old. To demonstrate the further utility of this procedure, long-term outcomes and safety evaluations are needed in a larger number of cases.

The modified Belt-Fuqua procedure using an asymmetric "furisode" sleeve for proximal hypospadias with severe curvature.

INTRODUCTION AND OBJECTIVES: Proximal hypospadias repair is a challenge in the pediatric urology field. Although the previous reports showed that the Belt-Fuqua staged procedure is reliable with a low complication rate for midshaft hypospadias, this procedure has not been generally applied to more proximal hypospadias with severe ventral curvature due to technical limitations. To solve these technical limitations, we developed a modified Belt-Fuqua procedure using an asymmetric long skin sleeve looking like a Japanese long-sleeved Kimono called a "furisode". The aim of this study was to evaluate the outcomes of this new modification of the Belt-Fuqua procedure for the repair of proximal hypospadias with severe curvature in children. STUDY DESIGN: The study retrospectively reviewed consecutive patients with proximal hypospadias with severe curvature underwent this new technique. The major modifications included are proximal degloving beyond the urethral meatus, asymmetrical ventral transposition of dorsal preputial skin like a furisode sleeve, and circumferential proximal anastomosis of preputial skin to native meatus in the first stage. Hypospadias severity was evaluated objectively in two ways: preoperatively by the Glans-Urethral Meatus-Shaft score and intraoperative direct measurement of ventral curvature. The primary outcome was urethroplasty complications. RESULTS: A total of 66 patients completed both stages of the furisode technique. The median Glans-Urethral Meatus-Shaft score was 11. Overall, 60 (91%) patients showed ventral curvature greater than 60 degrees after degloving, and 35 (53%) underwent ventral grafting with a dermal graft in the first stage. Median urethral length constructed at the second stage was 41.5 mm. The median follow-up period was 25 months. Complications occurred in 9 patients (14%); 7 had urethral diverticula, 1 showed a fistula and 1 had a urethral stricture. Neither glans dehiscence nor meatal stenosis occurred. DISCUSSION: There are a couple of advantages of this furisode technique to other tunneled flap techniques like the Ulaanbaatar procedure. The first is the ease of glans reshaping with a Firlit collar at the first stage because of no urethra in the glans. The second is that a long neourethra could be made by the same skin flap with one anastomosis to the native urethra.The weakness of this procedure was that urethral diverticula were prone to occur less than one year after urethroplasty. CONCLUSION: The furisode technique, a new modification of the Belt-Fuqua procedure, provides an alternative staged repair of proximal hypospadias. This technique was easily applied for hypospadias with severe curvature requiring ventral grafting.

A simple screening tool for an unfavorable bladder in children with myelomeningocele: Is the height to width ratio of the cystogram useful to predict high-pressure bladder?

INTRODUCTION: Videourodynamics is the key follow-up examination of children with myelomeningocele. However, it has been performed in specific institutions focused on the urological management of children due to the difficulty in its interpretation. Although a neurogenic bladder frequently appears elongated vertically and trabeculated, no objective study has clearly shown the relationship between bladder shape on the cystogram and urodynamic parameters in children with myelomeningocele. OBJECTIVES: The aim of this study was to investigate the usefulness of the height to width ratio of cystogram (HWR) as a screening tool for finding high-pressure bladder in children with myelomeningocele.Study design the medical records of children with myelomeningocele aged less than 13 years who underwent videourodynamics were reviewed. Maximum detrusor pressure (MDP) was defined as the maximum detrusor pressure at end-filling or at leak. HWR was calculated by the maximum height/maximum width of the cystogram appearance at maximum cystometric capacity (Figure) The children were categorized into two groups: children with high-pressure bladder (MDP≥40 cmH2O) and low-pressure bladder (MDP<40 cm H2O). Age, sex, videourodynamics variables, and HWR were compared between the 2 groups. Using the results of the above, receiver-operating characteristic (ROC) curves were constructed. RESULTS: A total of 81 children who were on clean intermittent catheterization met the study criteria. All children were on CIC, and their median age was 81 months (IQR 54-128 months). The HWR was significantly higher for high-pressure bladders than for low-pressure bladders (median 1.50 vs 1.37, p = 0.004). The sensitivity and specificity of the HWR for discriminating children with high-pressure bladder from all children were 87% and 56.9%, respectively. The area under the curve (AUC) was 0.71 with a cutoff score of 1.40. DISCUSSION: Bladder deformity was objectively evaluated by the HWR, and measurement of the HWR was straightforward. The main drawback of this evaluation method for bladder shape is to disregard the presence or absence of bladder trabeculation, which has been considered a key finding of an unfavorable bladder in this population. Based on the HWR ROC curves, the AUC was 0.71, which meant that the HWR would be considered to be fair at screening for high-pressure bladder. CONCLUSION: The height to width ratio of the cystogram was a useful tool for objectively evaluating bladder shape in children with myelomeningocele, and a cut-off point of 1.40 could be used as a simple screening tool for high-pressure bladder in this population.

[DISSEMINATED CARCINOMATOSIS OF THE BONE MARROW WITH UROTHELIAL CARCINOMA].

Disseminated carcinomatosis of the bone marrow with urothelial carcinoma in a 75-year-old man: A case study. A 75-year-old-man had first medical examination due to gross hematuria. The imaging study and cystoscopy revealed left ureteral and bladder tumor. The patient was referred for a laparoscopic assisted left nephroureterectomy and transurethral resection of a bladder tumor (TUR-Bt). Pathological findings included urothelial carcinoma, high grade, both a pT3 ureteral tumor and a pTa bladder tumor. The patient received 2 courses of gemcitabine and cisplatin and 1 course of methotrexate, epirubicin and nedaplatin as adjuvant chemotherapy. TUR-Bt was performed twice due to recurrence in the bladder and similar pathological findings. The patient received intravesical instillation of pirarubicin (THP 30 mg in 30 mL of saline) to prevent recurrence in the bladder, but discontinued in the 3rd time because of gross hematuria. The patient was then admitted to our hospital due to gross hematuria, general fatigue, and abnormal findings in the blood analysis. On admission, pancytopenia was detected and the serum ALP level had increased to 30,266 IU/L. A biopsy and bone marrow aspiration were performed because a super bone scan image was obtained using a bone scintigram. Diffuse bone marrow metastasis of the urothelial carcinoma was observed in the pathological evaluations. Therefore, our diagnosis was urothelial carcinoma with disseminated carcinomatosis of the bone marrow. Although treatment with zoledronic acid and blood transfusion were performed, the patient died 20 days after the admission. To the best of our knowledge, this is the first case of disseminated carcinomatosis of the bone marrow with urothelial carcinoma.

[A suspected case of extra-gonadal germ cell tumor complicated with choriocarcinoma syndrome].

Our patient was a 31-year-old man who presented with right flank pain. Computed tomography revealed multiple tumors in the liver and lungs, with marked elevation of serum human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) levels. In addition, no testicular abnormalities were detected by palpation or ultrasonography. On the bases of these results, the patient was diagnosed with extragonadal germ cell tumor and was therefore started on chemotherapy with bleomycin, etoposide, and cisplatin (BEP). However, the result of a subsequent blood test showed marked pancytopenia at the initial stage of treatment. We speculated that the cause of anemia was not only bone marrow suppression but also intratumoral hemorrhage, collectively termed choriocarcinoma syndrome. After conservative treatment involving blood transfusion and administration of granulocyte colony-stimulating factor, he recovered. After several chemotherapy sessions, the levels of all tumor markers returned to normal. Finally, the patient underwent hepatectomy for residual tumors ; but, the resected specimen showed no viable cancer cells. Currently, the patient is free from disease since the last chemotherapy session, administered 5 months ago.

[A case of long-term survivor after combined modality therapy for brain metastasis of bladder carcinoma].

A 75-year-old man with advanced bladder cancer (cT4N1M0) received three courses of systemic chemotherapy with Methotrexate, Epirubicin and Nedaplatin (MEN). His metastatic lymph node completely disappeared. We performed total cystectomy. Three months after the surgery, he complained of neck pain and nausea. Brain magnetic resonance imaging (MRI) revealed a 3 cm tumor in his right cerebella and a 5 mm tumor in left parietal lobe. He underwent surgical resection of the right cerebellar tumor and a gamma knife therapy for the left parietal tumor. Pathological diagnosis was metastatic urothelial carcinoma. We performed three additional courses of chemotherapy of MEN. He has been well without local recurrence or distant metastasis for 18 months.

[A case of carcinosarcoma of the penis].

A 64-year-old man presented with gross hematuria. Physical examination showed a mass under the phimotic foreskin. Circumcision revealed a 2cm polypoid tumor on the inner layer of prepuce. Tumor resection was performed and pathological diagnosis was carcinosarcoma which was composed of squamous cell carcinoma and spindle cell sarcoma. Biopsy of the scar lesions revealed residual squamous cell carcinoma and computed tomographic scan revealed swollen inguinal lymph nodes. Partial penectomy and lymph node biopsy were performed. Pathological examination revealed residual squamous cell carcinoma and no lymph node metastasis. There was no recurrence for one year. We report this very rare case of carcinosarcoma of the penis.

In vitro production of functional sperm in cultured neonatal mouse testes.

Spermatogenesis is one of the most complex and longest processes of sequential cell proliferation and differentiation in the body, taking more than a month from spermatogonial stem cells, through meiosis, to sperm formation. The whole process, therefore, has never been reproduced in vitro in mammals, nor in any other species with a very few exceptions in some particular types of fish. Here we show that neonatal mouse testes which contain only gonocytes or primitive spermatogonia as germ cells can produce spermatids and sperm in vitro with serum-free culture media. Spermatogenesis was maintained over 2 months in tissue fragments positioned at the gas-liquid interphase. The obtained spermatids and sperm resulted in healthy and reproductively competent offspring through microinsemination. In addition, neonatal testis tissues were cryopreserved and, after thawing, showed complete spermatogenesis in vitro. Our organ culture method could be applicable through further refinements to a variety of mammalian species, which will serve as a platform for future clinical application as well as mechanistic understanding of spermatogenesis.

In vitro murine spermatogenesis in an organ culture system.

Achieving mammalian spermatogenesis in vitro has a long history of research but remains elusive. The organ culture method has advantages over the cell culture method, because germ cells are in situ albeit the tissue as a whole is in vitro. The method was used in the 1960s and 1970s but encountered difficulties in inducing complete meiosis, i.e., in getting meiosis to proceed beyond the pachytene stage. In the present study, we reevaluated the organ culture method using two lines of transgenic mice, Acr-GFP and Gsg2 (haspin)-GFP mice, whose germ cells express green fluorescent protein (GFP) at the mid and end stages of meiosis onward, respectively. Immature testicular tissues from these mice, ranging from 4.5 to 14.5 days postpartum, were cultured on the surface of the medium, providing a liquid-gas interface. Culturing testicular tissues of all ages tested resulted in the expression of both Acr- and Gsg2-GFP. Round spermatids were identified by a combination of Gsg2-GFP expression, cell size, and the presence of a single nucleus with a dot stained by Hoechst. In addition, the chromosome number of one of such presumptive spermatids was found to be 20 by the premature chromosome condensation method. As our semiquantitative assay system using GFP expression grading was useful for monitoring the effects of different environmental factors, including temperature, oxygen concentration, and antiretinoic molecules, further improvement of the culture conditions should be possible in the future.