Complete urethral disruption after motor vehicle crash without pelvic fracture.

Urethral injuries are rare among the pediatric population, and the majority occur after trauma. This is the case of an eight-year-old female with complete proximal urethral disruption and ruptured bladder neck without pelvic fracture after a motor vehicle crash. After the accident, her bladder neck was reapproximated and a suprapubic tube was placed. Three months later, she underwent reconstruction for a bladder neck closure and appendicovesicostomy. In managing these patients, focus should first be directed at achieving a safe means of urinary drainage, and next to repair the lower urinary tract to maximize continence and minimize complications.

Spinal versus general anesthesia: Comparing outcomes in pediatric patients undergoing urologic procedures.

INTRODUCTION: Available literature comparing spinal anesthesia (SA) to general anesthesia (GA) in the pediatric population describes multiple benefits in appropriately selected patients including cost reduction, lower incidence of complications, and shorter operative times. In patients undergoing urologic procedures, data are sparse. OBJECTIVE: Our goal was to expand on the paucity of existing urologic literature as SA appears to be uniquely suited for a substantial number of its common pediatric procedures. METHODS: Within a single institution, patients who had a urologic procedure performed under SA between May 2019 and July 2021 and were less than 18 months old were compared with a matched cohort of patients who had GA. The SA and GA groups were compared by two-sample t-tests, chi-square test for independence, and Fisher's exact test. RESULTS: There were a total of 184 SA and 202 GA patients. There was no significant difference in the demographics except that SA patients were younger and weighed less than GA patients. The patients in the SA group needed less opioids both during the surgery (0% vs 26.1% p N/A) and in the immediate postoperative period when compared with GA patients (0% vs 18.2% p N/A). The patients who had SA had fewer complications necessitating PICU admission, or cancellation of surgery (0% vs 6.8% p = 0.03). Total anesthesia and emergence time were lower for SA patients (41 vs 50.2 p = 0.001 & 3.4 vs 6.1 p = 0.001). Both surgery and total OR time were not different between the groups (37.6 vs 35.5 p = 0.35 and 56.3 vs 54.4 p = 0.49). Overall, raw material cost was also found to be lower per procedure in the SA group vs the GA group ($8.90 vs $38.8: 77% reduction). Adjusted total mean costs for the surgery were not different between groups. The reduction in opioid use postoperatively also suggests reduced cost in the management of postoperative pain in the SA group. DISCUSSION: Total anesthesia time, opioid use, and serious complications were all significantly lower in the SA group. We did not find significant difference in total surgery cost between two groups. However, patients who had SA had better pain control and needed less rescue analgesics in the immediate postoperative period. No patients in either group were sent home with opioids. CONCLUSION: Spinal anesthesia was found to be an equally effective and appropriate alternative to GA with many proposed benefits for common pediatric urologic procedures. With further research, SA may prove to be a safer alternative in patients at risk for complications related to GA general anesthesia while also offering a cost benefit.

Nerve stimulation guided bilateral pudendal nerve block versus landmark-based caudal block for hypospadias repair in young children: a prospective, randomized, pragmatic trial.

INTRODUCTION: Caudal block is frequently performed to provide analgesia for hypospadias repair. Literature suggests that pudendal block provides prolonged postoperative analgesia as compared with caudal block in children between 2 and 5 years. We compared the efficacy of pudendal and caudal blocks in children less than 2 years. METHODS: 60 children scheduled for hypospadias repair received standard general anesthesia along with either pudendal or caudal block (groups of 30 each). Variables collected were demographic data, block time, operating room time, intraoperative pain medication need, pain assessment score and medication need in the recovery room and pain assessment at home. RESULT: Groups were demographically similar. No differences were observed in the following recorded times (minutes): block procedure (caudal: 9.5±4.0, pudendal: 10.6±4.1, p=0.30), anesthesia (caudal: 17.3±5.3, pudendal: 17.7±4.3, p=0.75), total OR (caudal: 171±35, pudendal: 172±41; p=0.95) and postanesthesia care unit (PACU) stay (caudal: 88±37, pudendal: 86±42; p=0.80). Additionally, no differences were observed in rescue pain medication need in the operating room (caudal: 0, pudendal: 2 (p=0.49), in PACU (caudal: 4, pudendal: 4, p=0.99), pain assessed at home, time to pain level 2 (caudal: 13.93±8.9, pudendal: 15.17±8.7), average pain scores (p=0.67) and total pain free epochs (pain level of zero) (p=0.80) in the first 24 hours. DISCUSSION: In children less than 2 years, both blocks provide comparable intraoperative and postoperative pain relief in the first 24 hours after hypospadias surgery. TRIAL REGISTRATION NUMBER: NCT03145415.

Urologic Presentations and Management Options in Pediatric Mitochondrial Disease.

OBJECTIVE: To review the evaluation and management of urologic pathology related to mitochondiral diseases (MD) in childhood. METHODS: A retrospective review was performed of patients with MD from 1/1/2000 - 10/8/2020 who were referred for urologic evaluation at a single pediatric hospital. Clinical and demographic information was reviewed including symptomatology, urodynamic evaluation, and medical/surgical management. RESULTS: 15 patients were identified for inclusion. Median age of presentation was 5 years and median follow up was 4 years. Patients presented with numerous urologic concerns including urinary retention/incomplete emptying, incontinence, and recurrent urinary tract infection. Urodynamics demonstrated elevated median bladder capacity at 172% of expected as calculated by age. Detrusor sphincter dyssynergia (DSD) was present in 6 (50%). Progression to surgical intervention occurred in 67% at a median time of 3.5 years after initial referral. This included suprapubic tube (SPT) placement and sacral neuromodulation (SNM). CONCLUSION: Patients in this study were found to have a spectrum of lower urinary tract dysfunction (LUTD) with elevated bladder capacity being common. No singular urodynamic feature prevailed although DSD was found in 50%. Progression of symptoms over time was also common. Most patients (67%) did go on to surgical intervention including SPT and SNM. Clinicians should be aware of the possibility of LUTD in children with MD and they should be promptly referred to pediatric urology when LUTD is suspected.

Robot-assisted repair of a urogenital sinus with an anorectal malformation in a patient with McKusick-Kaufman syndrome.

INTRODUCTION: A urogenital sinus (US) and an anorectal malformation (ARM) are a rare constellation of anomalies, and the optimal surgical approach is unclear. Open and laparoscopic approaches have been described for US and ARM, but no data exist to support robotic assistance in children. CASE: A 20-month-old Amish female presented to the study center with fever and abdominal pain. Abdominal ultrasound showed a large fluid-filled vagina, urinalysis was positive, and she was admitted for antibiotic therapy. Magnetic resonance imaging (MRI) confirmed hydrocolpos. An examination under anesthesia including cystoscopy demonstrated a short perineal body, an anteriorly displaced anus by muscle stimulation, and no vaginal opening. An ultrasound-guided, percutaneous vaginostomy tube was placed, and 650 cc of pus was drained. Vaginal and urine cultures grew similar strains of Escherichias coli. After a course of antibiotics, she underwent a robot-assisted mobilization of the intra-abdominal vagina and uterus, posterior sagittal anorectoplasty, vaginal pull-through, and a diverting colostomy. There were no intra-operative complications. Her Foley catheter was removed on post-operative day #3, and she voided spontaneously and was discharged in good condition. She remained in the hospital for ostomy teaching, but pain control and diet were not barriers to discharge after 12 h. CONCLUSION: Robotic mobilization of the intra-abdominal vagina in a pediatric patient with US and ARM is technically feasible and can be accomplished safely. Further comparative studies to other approaches are lacking. In this case, the robot allowed for good visualization, intra-operative collaboration between multiple specialties for complex patients with aberrant anatomy, and easy dissection in a narrow pre-pubertal pelvis and would be an approach that the study group uses in future cases.

Intermittent Urinary Incontinence Secondary to Inverted-Y Ureteral Duplication With Perianal Ectopia.

Inverted-Y ureteral duplication is one of the rarest anomalies of ureteral branching, which has been found to be more prevalent in females.2 Females commonly present with urinary incontinence often associated with distal limb ectopia to the bladder neck, uterus, or vagina.2 We present the case of a 7-year-old female with intermittent urinary incontinence who was found to have an inverted-Y ureteral duplication with perianal ectopia. We highlight the role of magnetic resonance urography in the evaluation of females with urinary incontinence and a normal renal/bladder ultrasound who are refractory to behavioral therapy.

Cryptorchidism in Boys With Cerebral Palsy Is Associated With the Severity of Disease and With Co-Occurrence of Other Congenital Anomalies.

BACKGROUND: Cryptorchidism is reported in 40-50% of small case series of cerebral palsy (CP) and attributed to hypothalamic-pituitary-gonadal axis abnormalities, intellectual disability (ID), or cremaster spasticity. We collected demographic and clinical data to define the frequency of cryptorchidism and clinical comorbidities in a large CP population. METHODS: Electronic health record data were collected for all male patients ≥7 years of age seen in a large, multidisciplinary CP clinic between 2000 and 2016. Variables including age, testicular position, surgical findings, CP severity, birth history, and comorbidities were tested for association using univariable and stepwise backward logistic regression analyses. RESULTS: Of 839 established patients, testis position was scrotal in 553, undescended in 185 (24%), retractile in 38 (5%), and undocumented in 63 cases. Cryptorchidism were diagnosed at a mean age of 5.8 years, with 20% documented as acquired, and testes were most commonly in the superficial inguinal pouch (41%) and associated with an inguinal hernia (56%). Severity was bilateral in 114/166 (69%) undescended and 24/36 (66%) retractile cases, respectively. Mean birth weight and the frequency of prematurity (55, 58, and 54%) and multiple birth (14, 13, and 9%) were not significantly different among the three groups. We observed a strong ordinal trend in the frequency of comorbidities, including quadriplegia, syndromic features/known genetic disease, intrauterine growth restriction (IUGR), death, brain malformations, seizures, gastrostomy, absent continence, ID and hearing, speech or visual impairment, with the retractile group holding the intermediate position for the majority. The stepwise multivariable analysis showed independent positive associations of cryptorchidism with quadriplegia, syndromic features/known genetic disease, hearing loss, and absent continence, and inverse associations with gestational age and multiple birth. CONCLUSION: These data suggest that cryptorchidism is less common than previously reported in CP cases, but most strongly associated with quadriplegia. Delayed diagnosis may be related to an acquired condition or to the multiple additional functional deficits that occur in this population. Our data suggest that UDT and CP may both be components of malformation syndromes occurring in singleton births whose clinical features are more likely to include earlier delivery, IUGR, hearing loss, and/or global spasticity.

Genomic copy number variation association study in Caucasian patients with nonsyndromic cryptorchidism.

BACKGROUND: Copy number variation (CNV) is a potential contributing factor to many genetic diseases. Here we investigated the potential association of CNV with nonsyndromic cryptorchidism, the most common male congenital genitourinary defect, in a Caucasian population. METHODS: Genome wide genotyping were performed in 559 cases and 1772 controls (Group 1) using Illumina HumanHap550 v1, HumanHap550 v3 or Human610-Quad platforms and in 353 cases and 1149 controls (Group 2) using the Illumina Human OmniExpress 12v1 or Human OmniExpress 12v1-1. Signal intensity data including log R ratio (LRR) and B allele frequency (BAF) for each single nucleotide polymorphism (SNP) were used for CNV detection using PennCNV software. After sample quality control, gene- and CNV-based association tests were performed using cleaned data from Group 1 (493 cases and 1586 controls) and Group 2 (307 cases and 1102 controls) using ParseCNV software. Meta-analysis was performed using gene-based test results as input to identify significant genes, and CNVs in or around significant genes were identified in CNV-based association test results. Called CNVs passing quality control and signal intensity visualization examination were considered for validation using TaqMan CNV assays and QuantStudio® 3D Digital PCR System. RESULTS: The meta-analysis identified 373 genome wide significant (p < 5X10-4) genes/loci including 49 genes/loci with deletions and 324 with duplications. Among them, 17 genes with deletion and 1 gene with duplication were identified in CNV-based association results in both Group 1 and Group 2. Only 2 genes (NUCB2 and UPF2) containing deletions passed CNV quality control in both groups and signal intensity visualization examination, but laboratory validation failed to verify these deletions. CONCLUSIONS: Our data do not support that structural variation is a major cause of nonsyndromic cryptorchidism.

Pathway analysis supports association of nonsyndromic cryptorchidism with genetic loci linked to cytoskeleton-dependent functions.

STUDY QUESTION: What are the genetic loci that increase susceptibility to nonsyndromic cryptorchidism, or undescended testis? SUMMARY ANSWER: A genome-wide association study (GWAS) suggests that susceptibility to cryptorchidism is heterogeneous, with a subset of suggestive signals linked to cytoskeleton-dependent functions and syndromic forms of the disease. WHAT IS KNOWN ALREADY: Population studies suggest moderate genetic risk of cryptorchidism and possible maternal and environmental contributions to risk. Previous candidate gene analyses have failed to identify a major associated locus, although variants in insulin-like 3 (INSL3), relaxin/insulin-like family peptide receptor 2 (RXFP2) and other hormonal pathway genes may increase risk in a small percentage of patients. STUDY DESIGN, SIZE, DURATION: This is a case-control GWAS of 844 boys with nonsyndromic cryptorchidism and 2718 control subjects without syndromes or genital anomalies, all of European ancestry. PARTICIPANTS/MATERIALS, SETTING, METHODS: All boys with cryptorchidism were diagnosed and treated by a pediatric specialist. In the discovery phase, DNA was extracted from tissue or blood samples and genotyping performed using the Illumina HumanHap550 and Human610-Quad (Group 1) or OmniExpress (Group 2) platform. We imputed genotypes genome-wide, and combined single marker association results in meta-analyses for all cases and for secondary subphenotype analyses based on testis position, laterality and age, and defined genome-wide significance as P = 7 × 10(-9) to correct for multiple testing. Selected markers were genotyped in an independent replication group of European cases (n = 298) and controls (n = 324). We used several bioinformatics tools to analyze top (P < 10(-5)) and suggestive (P < 10(-3)) signals for significant enrichment of signaling pathways, cellular functions and custom gene lists after multiple testing correction. MAIN RESULTS AND THE ROLE OF CHANCE: In the full analysis, we identified 20 top loci, none reaching genome-wide significance, but one passing this threshold in a subphenotype analysis of proximal testis position (rs55867206, near SH3PXD2B, odds ratio = 2.2 (95% confidence interval 1.7, 2.9), P = 2 × 10(-9)). An additional 127 top loci emerged in at least one secondary analysis, particularly of more severe phenotypes. Cytoskeleton-dependent molecular and cellular functions were prevalent in pathway analysis of suggestive signals, and may implicate loci encoding cytoskeletal proteins that participate in androgen receptor signaling. Genes linked to human syndromic cryptorchidism, including hypogonadotropic hypogonadism, and to hormone-responsive and/or differentially expressed genes in normal and cryptorchid rat gubernaculum, were also significantly overrepresented. No tested marker showed significant replication in an independent population. The results suggest heterogeneous, multilocus and potentially multifactorial susceptibility to nonsyndromic cryptorchidism. LIMITATIONS, REASONS FOR CAUTION: The present study failed to identify genome-wide significant markers associated with cryptorchidism that could be replicated in an independent population, so further studies are required to define true positive signals among suggestive loci. WIDER IMPLICATIONS OF THE FINDINGS: As the only GWAS to date of nonsyndromic cryptorchidism, these data will provide a basis for future efforts to understand genetic susceptibility to this common reproductive anomaly and the potential for additive risk from environmental exposures. STUDY FUNDING/COMPETING INTERESTS: This work was supported by R01HD060769 (the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD)), P20RR20173 (the National Center for Research Resources (NCRR), currently P20GM103464 from the National Institute of General Medical Sciences (NIGMS)), an Institute Development Fund to the Center for Applied Genomics at The Children's Hospital of Philadelphia, and Nemours Biomedical Research. The authors have no competing interests to declare.

Phenotype specific association of the TGFBR3 locus with nonsyndromic cryptorchidism.

PURPOSE: Based on a genome-wide association study of testicular dysgenesis syndrome showing a possible association with TGFBR3, we analyzed data from a larger, phenotypically restricted cryptorchidism population for potential replication of this signal. MATERIALS AND METHODS: We excluded samples based on strict quality control criteria, leaving 844 cases and 2,718 controls of European ancestry that were analyzed in 2 separate groups based on genotyping platform (ie Illumina® HumanHap550, version 1 or 3, or Human610-Quad, version 1 BeadChip in group 1 and Human OmniExpress 12, version 1 BeadChip platform in group 2). Analyses included genotype imputation at the TGFBR3 locus, association analysis of imputed data with correction for population substructure, subsequent meta-analysis of data for groups 1 and 2, and selective genotyping of independent cases (330) and controls (324) for replication. We also measured Tgfbr3 mRNA levels and performed TGFBR3/betaglycan immunostaining in rat fetal gubernaculum. RESULTS: We identified suggestive (p ≤ 1× 10(-4)) association of markers in/near TGFBR3, including rs9661103 (OR 1.40; 95% CI 1.20, 1.64; p = 2.71 × 10(-5)) and rs10782968 (OR 1.58; 95% CI 1.26, 1.98; p = 9.36 × 10(-5)) in groups 1 and 2, respectively. In subgroup analyses we observed strongest association of rs17576372 (OR 1.42; 95% CI 1.24, 1.60; p = 1.67 × 10(-4)) with proximal and rs11165059 (OR 1.32; 95% CI 1.15, 1.38; p = 9.42 × 10(-4)) with distal testis position, signals in strong linkage disequilibrium with rs9661103 and rs10782968, respectively. Association of the prior genome-wide association study signal (rs12082710) was marginal (OR 1.13; 95% CI 0.99, 1.28; p = 0.09 for group 1), and we were unable to replicate signals in our independent cohort. Tgfbr3/betaglycan was differentially expressed in wild-type and cryptorchid rat fetal gubernaculum. CONCLUSIONS: These data suggest complex or phenotype specific association of cryptorchidism with TGFBR3 and the gubernaculum as a potential target of TGFß signaling.

Congenital urethral polyps in the pediatric population.

Congenital urethral polyps are a rare entity. Most commonly, they present as benign posterior urethral growths in the pediatric male patient. However, reports of urethral polyps in female patients or even those with an anterior urethral location can also be found in the literature. Patients can present with a spectrum of symptoms including dysuria, hematuria, and obstructive type urinary complaints. Diagnosis in these cases includes a combination of medical imaging (e.g. ultrasound, fluoroscopic, CT or MRI), direct endoscopic visualization, and final surgical pathology. Treatment involves surgical removal either via an endoscopic or open approach.

Altered infant feeding patterns in boys with acquired nonsyndromic cryptorchidism.

BACKGROUND: Genetic and environmental factors likely influence susceptibility to nonsyndromic cryptorchidism, a common disease presenting at birth or in later childhood. We compared cases and controls to define differential risk factors for congenital versus acquired cryptorchidism. METHODS: We compared questionnaire and clinical data from cases of congenital cryptorchidism (n = 230), acquired cryptorchidism (n = 182) and hernia/hydrocele (n = 104) with a group of healthy male controls (n = 358). Potential predictor variables (p < 0.2 in univariable analysis) were included in stepwise multivariable logistic regression models. RESULTS: Temporary (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.4-0.8) or exclusive (OR, 0.6; 95% CI, 0.4-0.9) breastfeeding was reduced and soy formula feeding increased (OR, 1.8; 95% CI, 1.2-2.9) in acquired but not congenital or hernia/hydrocele groups. The highest risk estimates were observed for primary soy formula feeding with limited or no breastfeeding (OR 2.5; 95% CI, 1.4-4.3; adjusted OR, 2.7; 95% CI, 1.4-5.4) in the acquired group. Primary feeding risk estimates were equivalent or strengthened when multivariable models were limited to age greater than 2 years, full-term or not small for gestational age, or Caucasian subjects. Pregnancy complications and increased maternal exposure to cosmetic or household chemicals were not consistently associated with either form of cryptorchidism in these models. CONCLUSIONS: Our data support reduced breastfeeding and soy formula feeding as potential risk factors for acquired cryptorchidism. Although additional studies are needed, hormonally active components of breast milk and soy formula could influence the establishment of normal testis position in the first months of life, leading to apparent ascent of testes in childhood. Birth Defects Research (Part A), 2012.

Early administration of oxybutynin improves bladder function and clinical outcomes in newborns with posterior urethral valves.

PURPOSE: Abnormal bladder function following posterior urethral valve ablation can lead to deleterious effects on renal function and urinary continence. We performed a pilot study to determine if bladder dysfunction could be ameliorated by the early administration of oxybutynin. MATERIALS AND METHODS: We enrolled infants who underwent primary posterior urethral valve ablation by the age of 12 months. On initial urodynamics patients demonstrating high voiding pressures (greater than 60 cm H(2)O) and/or small bladder capacity (less than 70% expected) were started on oxybutynin. Urodynamics and ultrasound were performed every 6 months until completion of toilet training, at which time oxybutynin was discontinued. RESULTS: Oxybutynin was started in 18 patients at a mean age of 3.4 months and was continued for a mean of 2.2 years. Urodynamics revealed that initial high voiding pressures improved from a mean of 148.5 to 49.9 cm H(2)O in 15 of 17 patients. All 8 patients with initially poor bladder compliance demonstrated improvement on oxybutynin. All 7 patients with initially low bladder capacity (mean 47.7% expected bladder capacity) demonstrated improvement while on oxybutynin (mean 216% expected bladder capacity). CONCLUSIONS: This pilot study demonstrates that early use of anticholinergic therapy in infants with high voiding pressures and/or small bladder capacity after primary posterior urethral valve ablation has beneficial effects on bladder function.

Reduced expression of androgen receptor and myosin heavy chain mRNA in cremaster muscle of boys with nonsyndromic cryptorchidism.

PURPOSE: To better define the developmental mechanisms of nonsyndromic cryptorchidism, we measured the expression of hormone receptor and muscle type specific mRNAs in target tissues of boys with and those without nonsyndromic cryptorchidism. MATERIALS AND METHODS: Prospectively collected cremaster muscle and/or hernia sac tissues from boys with congenital (79) or acquired (66) nonsyndromic cryptorchidism and hernia/hydrocele (controls, 84) were analyzed for hormone receptor (RXFP2, AR, ESR1, ESR2) and myosin heavy chain specific (MYH1, MYH2, MYH7) mRNA expression using real-time reverse transcriptase polymerase chain reaction. Log transformed mRNA, phenotype and feeding history data were statistically analyzed using Pearson's correlation, ANOVA and 2-sample t tests. RESULTS: AR mRNA expression was higher in cremaster muscle than in sac tissue, and significantly lower in congenital and acquired nonsyndromic cryptorchidism cases vs controls (p <0.01). Type 1 (slow/cardiac) MYH7 mRNA expression was also significantly reduced in both nonsyndromic cryptorchidism groups (p ≤ 0.002), while a reduction in type 2 (fast) MYH2 expression was more modest and significant only for the congenital cryptorchidism group (p <0.05). Cremasteric MYH7 and AR levels were strongly correlated (r(2) = 0.751, p <0.001). MYH7 and ESR1 mRNA levels were higher and lower, respectively, in boys with nonsyndromic cryptorchidism who were fed soy formula. Expression of other genes was not measurable. CONCLUSIONS: Our data suggest that boys with congenital and acquired nonsyndromic cryptorchidism differentially express AR and slow twitch specific MYH7 mRNA in the cremaster muscle, and that MYH7 expression is correlated with AR levels and soy formula use. These differences in gene expression may reflect aberrant hormonal signaling and/or innervation during development with the potential for secondary functional effects and failed testicular descent.

Robot-assisted laparoscopic reoperative repair for failed pyeloplasty in children: a safe and highly effective treatment option.

PURPOSE: Failed pyeloplasty represents a management dilemma, with treatment options including balloon dilation, endopyelotomy and reoperative pyeloplasty. We review our experience with robot-assisted laparoscopic reoperative repair of recurrent/persistent ureteropelvic junction obstruction in children and compare this method to other approaches. MATERIALS AND METHODS: We reviewed in detail all cases of failed prior ureteropelvic junction procedures, either open or laparoscopic, managed by robot-assisted laparoscopic reoperative repair between 2006 and July 2011. RESULTS: Robot-assisted laparoscopic repair was performed in 16 cases for persistent or recurrent ureteropelvic junction obstruction following a prior procedure involving the ureteropelvic junction (12 open pyeloplasties, 4 robot-assisted laparoscopic repairs). Additional interventions had been performed in 12 patients. Reoperative robot-assisted laparoscopic pyeloplasty was performed in 13 patients and reoperative robot-assisted laparoscopic ureterocalycostomy in 3. Patient age ranged from 12 months to 15.3 years (mean 6.1 years). Mean operative time and length of stay were 303 minutes and 1.6 days, respectively. Mean followup was 14.9 months. All symptomatic patients had resolution of symptoms postoperatively. A total of 14 patients (88%) had improved radiological findings. One patient underwent transfusion and conversion to an open procedure due to bleeding. CONCLUSIONS: Robot-assisted laparoscopic reoperative repair of persistent/recurrent ureteropelvic junction obstruction is a safe, highly effective procedure even in the setting of multiple prior procedures. In our series all patients improved symptomatically, 88% improved radiographically and none have required further surgical intervention. Success is greater than with endopyelotomy and comparable to open reoperative repair for this challenging condition during short-term and intermediate followup.

Effectiveness of the computer enhanced visual learning method in teaching the society for fetal urology hydronephrosis grading system for urology trainees.

OBJECTIVE: A novel educational tool, Computer Enhanced Visual Learning (CEVL), has been used to improve resident performance of routine orchiopexy. Our objective was to assess the effect of a CEVL teaching module on the diagnostic accuracy of medical trainees in grading neonatal hydronephrosis on ultrasound using the Society for Fetal Urology (SFU) grading system. METHODS: The authors designed an online-based computerized tutorial to teach the grading of hydronephrosis using multimedia, practice cases and a grading checklist. In a crossover design trial, 29 residents and medical students were asked to grade 16 standard neonatal renal ultrasounds using the SFU grading system before and after viewing the web-based e-learning module. Primary outcome was percent improvement in grading accuracy. RESULTS: The mean percentages of ultrasounds that were graded correctly before and after CEVL intervention were 51% and 72% respectively (mean improvement 21%, 95% CI 3-13%, P < 0.001). Residents graded correctly 56% of ultrasounds before and 74% after CEVL (mean 18%, 7-28%, P = 0.002). Medical students graded correctly 37% before and 69% after CEVL (mean improvement 32%, 95% CI 16-48%, P = 0.002). CONCLUSION: Exposure to a computer-based learning module based on the CEVL platform improved urology residents' and medical students' correct assignment of SFU hydronephrosis grading to newborn renal ultrasounds.

Defined populations of bone marrow derived mesenchymal stem and endothelial progenitor cells for bladder regeneration.

PURPOSE: Autologous sources of bone marrow mesenchymal stem cells and endothelial progenitor cells are attractive alternatives to cells currently used for bladder tissue regeneration. To evaluate the potential use of these cells we determined whether mesenchymal stem cells have contractile protein profiles and physiological functions similar to those of normal bladder smooth muscle cells, and determined the angiogenic potential of endothelial progenitor cells. MATERIALS AND METHODS: Mesenchymal stem cells and smooth muscle cells (Lonza, Gaithersburg, Maryland) underwent proliferation and Western blot analyses. Immunofluorescence imaging was performed using antibodies against smooth muscle cell epitopes. Contractility was assessed by intracellular Ca(2+) release assays and confocal microscopy after carbachol stimulation. Endothelial progenitor cells were evaluated using a chicken chorioallantoic membrane model to determine neo-angiogenic potential. RESULTS: Western blot and immunofluorescence data showed that mesenchymal stem cells endogenously expressed known smooth muscle cell contractile proteins at levels similar to those of smooth muscle cells. Ca(2+) release assays revealed that smooth muscle cells and mesenchymal stem cells responded to carbachol treatment with a mean +/- SD of 8.6 +/- 2.5 and 5.8 +/- 0.8 RFU, respectively, which was statistically indistinguishable. Proliferation trends of mesenchymal stem cells and control smooth muscle cells were also similar. Chorioallantoic membrane assay showed the growth of vasculature derived from endothelial progenitor cells. CONCLUSIONS: Data demonstrate that mesenchymal stem cells and smooth muscle cells express the same contractile proteins and can function similarly in vitro. Endothelial progenitor cells also have the ability to form vasculature in an in vivo chorioallantoic membrane model. These findings provide evidence that mesenchymal stem cells and endothelial progenitor cells have characteristics that may be applicable for bladder tissue regeneration.

Unilateral groin surgery in children: will the addition of an ultrasound-guided ilioinguinal nerve block enhance the duration of analgesia of a single-shot caudal block?

BACKGROUND: Inguinal hernia repair, hydrocelectomy, and orchidopexy are commonly performed surgical procedures in children. Postoperative pain control is usually provided with a single-shot caudal block. Blockade of the ilioinguinal nerve may lead to additional analgesia. The aim of this double-blind, randomized controlled trial was to evaluate the efficacy of an adjuvant blockade of the ilioinguinal nerve using ultrasound (US) guidance at the end of the procedure with local anesthetic vs normal saline and to explore the potential for prolongation of analgesia with decreased need for postoperative pain medication. METHODS: Fifty children ages 1-6 years scheduled for unilateral inguinal hernia repair, hydrocelectomy, orchidopexy, or orchiectomy were prospectively randomized into one of two groups: Group S that received an US-guided ilioinguinal nerve block with 0.1 ml x kg(-1) of preservative-free normal saline and Group B that received an US-guided nerve block with 0.1 ml x kg(-1) of 0.25% bupivacaine with 1 : 200,000 epinephrine at the conclusion of the surgery. After induction of anesthesia but prior to surgical incision, all patients received caudal anesthesia with 0.7 ml x kg(-1) of 0.125% bupivacaine with 1 : 200,000 epinephrine. Patients were observed by a blinded observer for (i) pain scores using the Children and Infants Postoperative Pain Scale, (ii) need for rescue medication in the PACU, (iii) need for oral pain medications given by the parents at home. RESULTS: Forty-eight patients, consisting of 46 males and two females, with a mean age of 3.98 (SD +/- 1.88) were enrolled in the study. Two patients were excluded from the study because of study protocol violation and/or alteration in surgical procedure. The average pain scores reported for the entire duration spent in the recovery room for the caudal and caudal/ilioinguinal block groups were 1.92 (SD +/- 1.59) and 1.18 (SD +/- 1.31), respectively. The average pain score difference was 0.72 (SD +/- 0.58) and was statistically significant (P < 0.05). In addition, when examined by procedure type, it was found that the difference in the average pain scores between the caudal and caudal/ilioinguinal block groups was statistically significant for the inguinal hernia repair patients (P < 0.05) but not for the other groin surgery patients (P = 0.13). For all groin surgery patients, six of the 23 patients in the caudal group and eight of the 25 patients in the caudal/ilioinguinal block group required pain rescue medications throughout their entire hospital stay or at home (P = 0.76). Overall, the caudal group received an average of 0.54 (SD +/- 1.14) pain rescue medication doses, while the caudal/ilioinguinal block group received an average of 0.77 (SD +/- 1.70) pain rescue medication doses; this was, however, not statistically significant (P = 0.58). CONCLUSIONS: The addition of an US-guided ilioinguinal nerve block to a single-shot caudal block decreases the severity of pain experienced by pediatric groin surgery patients. The decrease in pain scores were particularly pronounced in inguinal hernia repair patients.

Bulbar urethral ligation for managing persistent urinary incontinence in young men with myelomeningocele.

OBJECTIVE: To report our experience with ligation of the bulbar urethra for treating refractory stress incontinence in a selected group of young men with neuropathic bladders secondary to myelomeningocele (MM), in whom primary anti-incontinence procedures had failed. PATIENTS AND METHODS: Persistent urethral incontinence leading to chronic perineal skin ulceration can occur in these patients, despite aggressive medical and surgical efforts to decrease wetting by increasing bladder capacity, compliance and outlet resistance. Four young men with MM had bulbar urethral ligation; all had undergone a previous ileocystoplasty and functioning continent catheterizable channels (CCC, three appendicovesicostomies, one Monti procedure). Three patients had primary bladder neck procedures using rectus fascia slings, and secondary attempts were made at urethral bulking in two patients. All patients had persistent incontinence through their native urethra, with dry intervals of <2 h. RESULTS: The bulbar urethra was ligated through a small midline perineal incision at 1 year after augmentation, and successfully resolved incontinence in all four patients. All reported satisfaction with their bladder regimen at a mean (range) follow-up of 49 (20-93) months. There were no perineal wound infections. While one patient developed bladder calculi, no patient developed urethral stones, febrile urinary tract infections, fistulae or bladder perforations. CONCLUSIONS: We report the results of bulbar urethral ligation for resolution of incontinence in patients with MM in whom anti-incontinence bladder neck procedures had failed. Ligation of the urethra is effective, and can be considered an alternative treatment for refractory urinary incontinence in patients with a functional CCC in whom previous bladder neck-supporting procedures have failed.

Do current bladder smooth muscle cell isolation procedures result in a homogeneous cell population? Implications for bladder tissue engineering.

PURPOSE: Conventional techniques used to harvest and culture bladder smooth muscle cells (SMCs) have been thought to yield homogeneous populations of SMCs. In order to delineate the cellular composition of tissue derived bladder cells, this study was conducted to determine whether current culturing techniques result in a uniform population of bladder SMCs that may be utilized for bladder tissue engineering. METHODS: Patient derived bladder muscle was isolated and manually minced followed by enzymatic digestion. Cells were cultured in D: -valine alpha-MEM with decreasing levels of fetal bovine serum then fixed and permeabilized for flow cytometric and immunofluorescent analyses. Antibody staining of cultured cells consisted of alpha-SMA, von Willebrand factor, pan-cytokeratin, CD31, and CD90. Cells were visualized using directly conjugated fluorescein isothiocyanate primary or IgG-Alexa-555 conjugated secondary antibodies. RESULTS: Flow cytometric analyses revealed mixed populations of cells expressing non-SMC epitopes as corroborated by immunofluorescent studies. High density oligonucleotide array analysis revealed expression levels of known bladder SMC genes and the expression of endothelial and fibroblast related markers (P < 0.005). CONCLUSIONS: Phenotypic analyses demonstrate cell heterogeneity when SMCs are acquired and cultured through conventional methods. Standardized criteria based upon objective experimentation need to be established in order to better characterize bladder SMCs that are to be utilized for bladder tissue engineering.