Formulation of plant-based food and characterisation of the nutritional composition: A case study on soy-moringa beverage.

Formulation of plant-based food ingredients rich in nutrients is becoming a viable intervention to enhance food security. In this study, a novel soy-moringa beverage was produced using two processing methods. Method I involved blending soymilk and moringa juice, whereas method II dealt with the co-grinding of soymilk together with blanched moringa leaves. The proximate and mineral compositions, pH, total dissolved solids, and viscosity of the soy-moringa beverages were carefully analysed using standard methods. The results showed different nutritional compositions in the soy-moringa beverages formulated. Moreover, method II was found to be the most effective technique to process the soy-moringa beverage. Hence, the proximate compositions were observed to increase significantly (p < 0.05) with an increase in moringa leaves. The amounts of protein, fat, ash, fibre and carbohydrates increased by 49.77%, 8.59%, 84.85%, 85.71%, and 114.56%, respectively with the increase of moringa leaves. The concentrations of ß-carotene, iron, calcium, copper, magnesium, and potassium presented an increasing trend by 147%, 40%, 284%, 30%, 12% and 190%, respectively as moringa leaves increase. The quantitative data on nutritional values and physicochemical properties suggested that the soy-moringa beverages produced with 30 and 40% moringa leaves under method II could be suitable to address undernutrition for vulnerable people.

Proximate composition of fermented cassava meal "mchuchume" fortified with soya bean flour and Moringa oleifera leaves powder.

Mchuchume is a ready to eat meal made from boiled and fermented cassava, which is mainly consumed in Western part of Tanzania. As other fermented cassava foods, it is rich in carbohydrate but deficient of other nutrients. In this study Moringa oleifera leaves powder (MOLP) and soya bean flour (SBF) were used to improve its nutrients. Fortification effects of MOLP and SBF were studied during separate and coetaneous inclusion. Proximate compositions of raw materials and blends were analysed. Mchuchume (control) had moisture, ash, fat, protein, fibre and carbohydrate of 68.138%, 1.090%, 0.589%, 2.068%, 5.738% and 22.367%, respectively, for SBF were 9.522%, 4.990%, 15.436%, 43.807%, 13.751% and 12.486%, respectively and for MOLP were 8.411%, 7.751%, 7.537%, 18.205%, 11.416179% and 46.681%, respectively. Mchuchume-soya had moisture (45.678% and 58.558%), ash (2.398% and 3.664%), fat (2.913% and 5.915%), protein (2.911% and 4.568%), fibre (7.373% and 9.139%) and carbohydrate (22.199% and 27.172%). Mchuchume-moringa had moisture (58.786% and 64.751%), ash (2.248% and 4.184%), fat (0.955% and 1.724%), protein (2.911% and 4.568%), fibre (6.023% and 6.626%) and carbohydrate (29.136% and 30.739%) while mchuchume-soya-moringa had moisture (45.651-58.874%), ash (2.498-4.481%), fat (1.506-4.868), protein (10.722-24.167%), fibre (6.3492-9.408%) and carbohydrate (10.203-21.239%). Mchuchume fortified with both SBF and MOLP are of the most improved nutritive values such that consumption of either of these fortified meals for a day would make an individual to meet his or her recommended dietary allowance for the nutrients analysed at a relatively lesser cost.

Systematic radiologic detection of kidney stones in Canadian children: a new era of asymptomatic stones?

INTRODUCTION: Asymptomatic, or incidental, pediatric kidney stones detected on abdominal imaging pose a clinical challenge as their significance and expected outcome are not well described. OBJECTIVE: Our primary objective was to estimate the incidence of nephrolithiasis in pediatric patients undergoing abdominal ultrasound (US) or computerized tomography (CT), for all indications, in a pediatric tertiary care hospital. Our secondary objective was to determine the clinical outcome of these radiographically detected stones. METHODS: All abdominal US or CT radiology reports for patients younger than 18 years between January 1, 2011, and December 31, 2016, were retrieved. Reports were automatically flagged using textual analysis if they contained one of the 32 keywords potentially indicating nephrolithiasis. Flagged reports, as well as 10% of unflagged reports, were reviewed to confirm the radiologist impression of presence or absence of stones. Patient and stone-related clinical data were extracted. RESULTS: Two thousand four hundred forty-nine (5%) of 53 235 imaging reports cited at least one of the keywords. Manual review of flagged reports identified 498 studies having a radiologist impression of stones (244 unique patients). Stone incidence in children undergoing abdominal imaging more than doubled between 2011 and 2016. Medical record review found that 140 patients (57%) were symptomatic, while the other 104 patients (43%) were asymptomatic. Spontaneous resolution was greater (57% vs 34%) in asymptomatic patients compared to symptomatic patients. Asymptomatic patients were younger with a median age of 0.6 compared to 12.3 years. Asymptomatic and symptomatic stones were followed up for similar lengths of time (2.3 vs 2.0 years, p > 0.05) and had a similar number of follow-up USs (3.9 vs 4.6 studies, p > 0.05). CONCLUSIONS: The incidence of radiologically identified stones in children undergoing abdominal imaging at our center increased over time. Asymptomatic stones follow a benign course with minimal need for intervention; however, they were detected almost as frequently as symptomatic stones. Asymptomatic stones may represent increased healthcare resource utilization due to similar follow-up compared to symptomatic stones. Further research regarding the optimal imaging intervals and long-term follow-up for asymptomatic stones is warranted.

The Prevalence, Clinicodemographics, and Outcomes of Incidental and Symptomatic Renal Cysts in a Pediatric Cohort Undergoing Ultrasonography.

PURPOSE: The growing availability of modern-day imaging has resulted in an increase in the number of renal cysts detected in the pediatric population. Few publications have reported outcomes of these childhood cysts. In this study we assessed the prevalence and evolution of renal cysts in children, and described clinical characteristics, mode of presentation and ultimate outcomes. MATERIALS AND METHODS: Our institutional ultrasound database was searched for all abdominal ultrasound reports from 2006 to 2017. These reports were then cross-referenced with a manual retrospective chart review. Clinical characteristics including mode of presentation, cyst characteristics, and outcomes were analyzed using descriptive and nonparametric statistical methods. RESULTS: Of 70,500 abdominal ultrasound scans during the study period 1,531 (2.2%) met the study inclusion criteria. Overall 26% of cysts were complex and 10.1% of cases were associated with hydronephrosis. Echogenic kidneys were more likely to be associated with simple cysts (p=0.0001). There was no difference between cyst diameter and symptomatology (p=0.82). The conversion of simple to complex renal cysts was less than 1% and 1.8% of complex cysts developed renal cell carcinoma. CONCLUSIONS: In a large cohort of children who underwent abdominal imaging we found a 10-year renal cyst prevalence of 2.2%. Given that nearly all cysts follow a benign course and that simple cysts will invariably grow within 2 years, we believe that these cases could be safely discharged after that point. We continue to recommend surveillance for patients with cysts larger than 15 mm, complex cysts, family history of adult polycystic kidney disease or those with concomitant genitourinary anomalies requiring ongoing followup.

Renal cyst evolution in childhood: a contemporary observational study.

INTRODUCTION: Children with renal cysts often undergo ultrasound (US) monitoring to identify malignant transformation or polycystic kidney disease (PKD). However, the utility of ongoing surveillance is uncertain. OBJECTIVE: The objective of this study was to assess the natural history of simple or minimally complex cysts and the proportion of progression to autosomal dominant polycystic kidney disease (ADPKD), autosomal recessive polycystic kidney disease (ARPKD), or malignancy. STUDY DESIGN: The institutional review board approved retrospective chart review at one institution between 2004 and 2014. Eligible patients had ≤3 simple or minimally complex cyst(s) discovered on US without an initial diagnosis of multicystic dysplastic kidney, genitourinary malignancy, ADPKD, or ARPKD. Patient demographics and cyst details were recorded at identification and follow-up visits. Logistic regression was used to examine univariate association between diagnosis of ADPKD/ARPKD and each recorded variable. RESULTS: Eighty-seven eligible patients were identified. Twenty-two patients were identified antenatally or in the first year of life; the remaining 65 were identified at >1 year of age, median 7.6 years (interquartile range [IQR]: 4.2, 10.6). Most (60/87, 69%) had a solitary cyst at initial US. The median length of follow-up was 4.1 years (IQR: 1.9, 6.8) with median 3 follow-up US (IQR: 2, 5). Eleven patients (12.6%) were diagnosed with ADPKD. One patient (1.2%) was diagnosed with ARPKD. A median 2 follow-up US (IQR: 1, 4) procedures were performed over a median of 2.2 years (IQR: 1.0, 3.9) to obtain diagnoses of ADPKD or ARPKD. No patients developed malignancy. DISCUSSION: This study's results reveal that children identified to have a small number of simple or minimally complex renal cysts on initial US are unlikely to require additional treatment for these cysts as transformation to PKD or malignant condition is rare. Supporting this are results from literature that although simple cysts in childhood may evolve over time, most do not require any surgical or invasive treatment in the long term. Limitations include retrospective design and single institution. CONCLUSIONS: Autosomal dominant polycystic kidney disease/autosomal recessive polycystic kidney disease diagnosis occurs early in follow-up evaluation in children with simple or minimally complex cysts. Malignant transformation did not occur in any patients in this study. PATIENT SUMMARY: This study examines the natural history of renal cysts in childhood. Following up simple renal cysts routinely beyond 2-3 years after initial detection may not be optimal due to the use of limited medical resources.

Active surveillance for antenatally detected ureteroceles: Predictors of success.

INTRODUCTION: Historically, ureteroceles were surgically treated, as patients were diagnosed after developing symptoms. However, with the advance of fetal medicine, antenatal detection has provided an opportunity to look at the natural history of ureteroceles. OBJECTIVES: With data derived from a retrospective chart review of patients with ureteroceles that were detected antenatally, the current study aimed to determine which group of children would be at risk for failure on active surveillance. It was hypothesized that single system ureteroceles (SSU) and male patients with duplex system ureteroceles (DSU) would be ideal for observation. METHODS: Outcomes were assessed by descriptive statistics. Kaplan-Meier curves were utilized to estimate median duration on active surveillance in both single and duplex cohorts. Breakthrough febrile urinary tract infection (fUTI) and surgery were determined by Cox regression in the duplex system cohort. Surgery was considered surveillance failure. RESULTS: A total of 102 patients (64 females/38 males) met the criteria: 78 (76.5%) had DSU and 24 (23.5%) SSU. The overall median observation was 1.2 years (range 0.7-3.1). Follow-up ranged from 0.3 to 11.7 years for SSU, and from 0.02 to 17.3 years for DSU. The predictors of failure of active surveillance (AS) in DSU (surgical intervention) were male gender (HR 1.8, 1.0-3.3, P = 0.037), or fUTI (HR 3.1, 1.7-5.8, P = 0.002). Predictors of fUTI were contralateral hydroureter or ipsilateral hydronephrosis ± hydroureter (OR 9.5, 1.2-71.7, P = 0.028). Interestingly, vesicoureteral reflux (VUR) was not a predictor of fUTI. The SSU patients were ideal for AS, while in DSU, surveillance was successful in 30% of patients who were primarily females without contralateral hydroureter or ipsilateral hydronephrosis ± hydroureter. However, in contradiction to the hypothesis, males were at higher risk for surgical intervention in the DSU cohort. CONCLUSION: Active surveillance is an option for patients with antenatally detected ureteroceles, but careful long term follow up is mandatory. Parents should be advised that surgical intervention may still be necessary, particularly in males with DSU.

Urodynamic testing--is it a useful tool in the management of children with cutaneous stigmata of occult spinal dysraphism?

PURPOSE: Lumbar cutaneous stigmata in infants may be associated with occult spinal dysraphism and often prompt urological evaluation, including urodynamic testing. We examined whether urodynamic testing is useful in this population by evaluating the association between abnormal urodynamic test results and need for tethered cord release. MATERIALS AND METHODS: We reviewed a historical cohort of children with cutaneous stigmata of spinal dysraphism referred to our hospital from 2002 to 2010. We evaluated patient characteristics, imaging, urodynamic studies and neurosurgical interventions. We analyzed the association between urodynamic testing and imaging studies, and neurosurgical intervention. RESULTS: We retrospectively studied 123 patients with a median age of 11 months (IQR 6.5-15.5), including 112 nontoilet trained infants (91%). Of the patients 19% (23 of 123) had abnormal urodynamics, 85% (99 of 116) had abnormal spinal magnetic resonance imaging and 96% (98 of 102) had an abnormal spinal ultrasound. Tethered cord release was performed in 40 of 121 patients (33%). A significant association was found between abnormal urodynamics and neurosurgical intervention (p = 0.002). Abnormal spinal magnetic resonance imaging was also significantly associated with operative intervention (p = 0.05). Ultrasound of the spine (p = 1.0), ultrasound of the abdomen/pelvis (p = 0.68), history of urinary tract infections (p = 1.0) and constipation (p = 0.67) were not associated with intervention for tethered cord release. CONCLUSIONS: Abnormal urodynamic studies in infants with cutaneous stigmata of spinal dysraphism are significantly associated with the requirement for neurosurgical intervention. Urodynamics are an important diagnostic modality aiding the neurosurgeon in determining the need for surgical intervention in this population.

Reliability assessment of Society for Fetal Urology ultrasound grading system for hydronephrosis.

PURPOSE: The Society for Fetal Urology introduced a subjective grading system for classifying hydronephrosis that has important implications in patient diagnosis, treatment and outcome. The grading system is frequently used to standardize the severity of hydronephrosis, and compare results among patients and centers. Despite widespread use to our knowledge no groups have investigated the reliability of the grading system since its introduction. We assessed the intrarater and interrater reliability of the Society for Fetal Urology grading system for hydronephrosis and examined levels of agreement by the degree of hydronephrosis (grades 0 to 4) and level of experience (staff vs trainee). MATERIALS AND METHODS: A series of 50 pediatric renal ultrasound images from patients with a diagnosis of hydronephrosis were assessed by 4 staff individuals and 4 trainees using the Society for Fetal Urology grading system. Ultrasound images included the kidneys, ureters and bladder to be consistent with practice. After 7 to 14 days each rater repeated the assessment. The nonweighted Cohen kappa statistic was used to estimate intrarater and interrater reliability by Society for Fetal Urology grade and training level. RESULTS: Staff and trainee raters independently assigned Society for Fetal Urology grades to 50 patients (99 renal units). The average number of images per ultrasound was 41, including the right and left kidneys. Overall interrater agreement for staff individuals was substantial for grade 0, moderate for grades 1, 2 and 4, and only slight to fair for grade 3. Intrarater agreement was substantial to almost perfect for staff agreement (range 69% to 94%, kappa 0.56 to 0.89) and trainees (range 63% to 90%, kappa 0.48 to 0.85). CONCLUSIONS: Our study suggests that the Society for Fetal Urology grading system has good intrarater but modest interrater reliability. Individual rater interpretations of the grading system may explain the modest interrater agreement. Proposed modifications to the Society for Fetal Urology classification system, such as distinguishing between diffuse and segmental cortical thinning, may improve reliability.

Development of an objective score to quantify the pediatric cystometrogram.

PURPOSE: We developed a reliable tool for quantitative assessment of the pediatric cystometrogram. MATERIALS AND METHODS: Scores for expected capacity (EV), compliance (EV20), activity and sensation were developed according to established formulas for norms. Ordinal scores were derived by calculating observed over expected findings. Based on the derived percents scores of 1 to 5 were assigned. For EV--0 to 5 the formula used was EV = (age + 2) x 30 and for EV20--0 to 5 the formula used was EV20 = 17 x age + 55. Activity was determined as the volume of the first, total number and magnitude of involuntary contractions, each scored 0 to 5 and divided by 3. Sensation was scored as 0 to 3 according to volume at first sensation. A total of 87 blinded cystometrograms in 49 patients were independently scored twice by 3 pediatric urologists. The resultant 522 total and 2,088 component scores were assessed for reliability. RESULTS: Intrarater reliability was strong with 80% of total scores (208 of 261) within +/- 1 point from initial to subsequent retest. Reliability component scores were stronger with 94% (983 of 1,044) within +/- 1 point from test to retest. Spearman's rank correlations for total score was 0.82 to 0.98, indicating a strong relationship between test and retest. Interrater reliability of components was strong with 89% of scores (1,851 of 2,088) between urologists within +/- 1 point. Correlation coefficients for total scores were 0.80 to 0.96, indicating a high degree of consistency between urologist assessments (p <0.05). CONCLUSIONS: This score appears to reliably quantify the pediatric cystometrogram. Its application may be useful for the objective assessment of detrusor behavior before and after intervention. Further applications should allow refinement of this tool.

Long-term followup of pediatric dismembered pyeloplasty: how long is long enough?

PURPOSE: We determined followup for pediatric patients after pyeloplasty based on the risk of late complications and the likelihood of return if discharged early from followup. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients who underwent dismembered pyeloplasty at a single center between 1986 and 1996. Data regarding recurrent ureteropelvic junction obstruction and symptoms suggesting possibly recurrent obstruction were assessed. RESULTS: During the select period 123 pyeloplasties were performed. A total of 77 renal units were followed greater than 5 years. At 1 year postoperatively diuretic renograms showed normal drainage in 87% of the cases and prolonged or incomplete drainage in 13%. Obstruction recurred 8 years postoperatively in only 1 renal unit (0.8% overall, 1.3% of those followed greater than 5 years). Symptoms suggestive of recurrent obstruction developed in 18% of the patients but represented true recurrence in only 1. If one were to consider early followup discharge for these patients, the probability of repeat referral due to such symptoms was significantly higher in year 1 than in year 3. Most symptoms were initially assessed with ultrasound. CONCLUSIONS: Recurrent ureteropelvic junction obstruction is unlikely after unobstructed postoperative diuretic renogram and does not warrant long term followup. Ideal followup would extend to 2 years, covering the period when an initial symptom of recurrence is most likely to present and enabling baseline unobstructed renal ultrasound to be performed.

The utility of buccal mucosa graft in salvage urethroplasty.

OBJECTIVE: To evaluate our results with buccal mucosa free grafts in salvage urethroplasty. PATIENTS AND METHODS: Retrospective chart review of autologous buccal mucosa grafts for urethral reconstruction at Winnipeg Children's Hospital and Children's Hospital of Eastern Ontario between November 1992 and March 2000. RESULTS: Nine patients (median age 4 years) underwent such reconstruction. Seven of the nine patients had experienced failed previous attempts at hypospadias repair. Onlay grafts were used in all but one patient who required a tube graft. Urethrocutaneous fistula was the most common post-operative complication, affecting four of nine patients. Two patients developed urethral strictures and one a meatal stenosis. Satisfactory functional results were ultimately achieved in all patients. Harvest site complications were minimal. CONCLUSIONS: Buccal mucosa is a readily available and useful source for urethral grafting material, but should only be used in patients with insufficient penile skin. Grafts may be used as onlays or tubes. It is our experience that despite precautionary measures, fistulae and strictures are common.

Outcome of hypospadias repair using the tubularized, incised plate urethroplasty.

OBJECTIVE: We reviewed our results using the tubularized incised plate urethroplasty (Snodgrass procedure) for repair of penile hypospadias. MATERIALS AND METHODS: A total of 37 patients (aged 7-72 months, mean 17.5 months) underwent repair by three pediatric urologists at two institutions. The pre-op meatal position was distal in 28, mid-shaft in five, and penoscrotal in three patients. One patient, who did not have hypospadias, had a distal urethral fistula secondary to a previous circumcision. Twenty-six patients had ventral chordee and 12 required a dorsal tunica albuginea plication for correction. Urethroplasty was performed using 6-0 synthetic absorbable suture (PDS, Maxon, Dexon, or Monocryl). Urethroplasty coverage consisted of de-epithelialized dorsal preputial skin flap (32 patients), internal spermatic fascia flap (1 patient), tunica vaginalis flap (2 patients), or no coverage (2 patients). All patients were stented (8, 10 or 12 F silastic) for a mean duration of 9.8 days (range 4-12 days). Either a foam dressing (12 patients) or a Tegaderm sandwich dressing (25 patients) was used. RESULTS: Average length of hospital stay at one institution was 3.1 days (range 1-5 days). Mean follow-up was 8.8 months (range 1.5-20 months). The post-operative results were satisfactory with the meatus in a glanular position in 35 patients and a coronal position in two patients. All had a vertical orientation of the meatus. Complications included urethrocutaneous fistula in six patients, skin dehiscence in two patients, and meatal stenosis in two patients. One of the fistulas healed spontaneously. Urethral strictures have not been encountered thus far. CONCLUSIONS: The tubularized incised plate urethroplasty achieves satisfactory results with acceptable complications. It can be used for both distal and proximal hypospadias, and in the rare situation of fistula post-circumcision. Long term follow-up is needed to ensure that urethral strictures do not result from this technique.

Outcome of gastrocystoplasty in tertiary pediatric urology practice.

PURPOSE: Although the use of stomach for bladder reconstruction has become popular during the last decade, it is not a panacea. We review our experience with gastrocystoplasty. MATERIALS AND METHODS: We completed a retrospective chart review of 11 females and 12 males, 1.5 to 22.5 years old (mean age 10) who underwent gastrocystoplasty at Hôpital Sainte-Justine, Montreal, Quebec and Children's Hospital, Winnipeg, Manitoba, Canada between December 1990 and 1998. Primary diagnoses included spinal dysraphism in 14 patients, posterior urethral valves in 3, cloacal exstrophy in 2, cloacal outlet anomaly in 2, multiple failed ureteral reimplantations with bladder dysfunction in 1 and neurogenic bladder of uncertain etiology in 1. Three patients presented with chronic renal failure. Concurrent reconstructive surgery included ureteral reimplantation in 10 patients, bladder neck plasty in 4 or closure in 4, and continent urinary diversion in 5. RESULTS: Acute postoperative complications included urosepsis in 2 cases, bowel obstruction in 2 and ureteral obstruction in 1. Followup ranged from 4 to 86 months (mean 45). Long-term complications consisted of intractable hematuria-dysuria syndrome in 5 cases, inability to catheterize in 3, perineal urinary fistula in 2, new onset hydronephrosis in 2, continent stomal stenosis in 1 and bladder calculus in 1. Proton pump inhibitors and/or histamine 2 antagonists were used in 16 of the 23 patients to prevent the hematuria-dysuria syndrome. In 5 cases the hematuria-dysuria syndrome was poorly controlled medically and 3 were converted to another form of urinary reconstruction. In 18 of 20 cases voiding cystourethrography revealed no vesicoureteral reflux, and in 18 of 21 ultrasound documented stable or improved upper tracts. Socially acceptable urinary continence was attained in 19 of the 21 patients. CONCLUSIONS: The use of stomach for bladder augmentation may be considered in patients with cloacal exstrophy and/or metabolic acidosis. Histamine blockers and/or proton pump inhibitors may be required to prevent the hematuria-dysuria syndrome. Symptoms of the hematuria-dysuria syndrome may be disabling and may mandate alternative forms of urinary tract reconstruction.

Percutaneous nephrolithotomy in the pediatric population.

PURPOSE: Percutaneous nephrolithotomy is an established technique used in children with renal calculi. We review our experience with percutaneous nephrolithotomy for treating nephrolithiasis in childhood. MATERIALS AND METHODS: We retrospectively reviewed the records of children who underwent percutaneous nephrolithotomy procedures for renal calculi from 1985 to 1996. Antegrade percutaneous access was obtained in all patients and the tract was dilated to 24F. Grasper forceps, ultrasound and/or electrohydraulic lithotripsy was used to remove and disintegrate stones. In all patients a nephrostomy tube was placed intraoperatively, and a plain abdominal x-ray and nephrostogram were done postoperatively. The nephrostomy tube was removed after ensuring free drainage down the ureter and no untoward effects from clamping. Complete anatomical and metabolic evaluation was performed in all cases. Patients were followed 2 to 6 weeks, and 3 and 6 months postoperatively with a plain abdominal x-ray and excretory urography or renal ultrasound. RESULTS: In 5 boys and 3 girls (9 renal units) 4 to 11 years old (mean age 6.4) a total of 10 percutaneous nephrolithotomy procedures were performed. At presentation 6 children had flank and/or abdominal pain, 5 gross hematuria and 3 urinary tract infection. Three patients had associated metabolic abnormalities. One patient with a staghorn calculus had hydronephrosis and multiple infundibular stenoses. No underlying urological anatomical abnormalities were noted in the remaining cases. Four renal units that were obstructed at presentation required initial nephrostomy tube insertion. Average operative time was 131.8 minutes (range 58 to 240). An 87.5% stone-free rate was achieved using percutaneous nephrolithotomy monotherapy. Percutaneous nephrolithotomy was not successful for eradicating a staghorn stone in 1 patient. Hypothermia developed in 2 patients in whom operative time exceeded 150 minutes. No blood transfusions were required. CONCLUSIONS: Percutaneous nephrolithotomy is safe and effective in children, and should be considered a viable management option. However, staghorn calculi may require alternative management, particularly in the setting of underlying anatomical abnormalities. Children with renal calculi should undergo a complete anatomical and metabolic assessment with the institution of medical therapy, as appropriate.

Prenatal diagnosis of hydronephrosis: impact on renal function and its recovery after pyeloplasty.

PURPOSE: We reviewed our experience with corrective surgery for congenital ureteropelvic junction obstruction to assess the impact of mode of presentation on renal function at diagnosis and on postoperative recovery of function. MATERIALS AND METHODS: We reviewed the records of consecutive children who underwent pyeloplasty or nephrectomy for ureteropelvic junction obstruction during a 5-year period at our hospitals. Patients were divided into those with and without a prenatal diagnosis of hydronephrosis. In each group we compared preoperative and postoperative differential renal function, as measured by nuclear renography. RESULTS: We identified 89 patients, of whom 51 (57%) and 38 (43%) presented with prenatal and postnatal hydronephrosis, respectively. Kidneys in which hydronephrosis was diagnosed prenatally had better average differential renal function than those in which the condition was detected postnatally (45 versus 37%). This difference was even more significant in kidneys with less than 40% initial function (31 versus 21%). Presentation with a palpable mass was associated with worst renal function (mean 23%). Postoperatively renal function did not recover significantly in either group. There was a minimal increase in postoperative differential renal function in the subgroup of patients in whom initial differential renal function was less than 40%, although there was no significant difference in the 2 groups (6.5 versus 4.8%). CONCLUSIONS: The early diagnosis of hydronephrosis provided by prenatal ultrasonography is associated with less obstructive nephropathy. Prolonged followup is necessary for studies of the natural history of hydronephrosis because relevant obstruction manifests clinically years later. Despite successful pyeloplasty function recovery is minimal in kidneys with poor function and hydronephrosis diagnosed prenatally. Our findings do not support previous observations that poor function markedly improves after obstruction is relieved.

Ureteroneocystostomy with and without the use of an intravesical catheter.

PURPOSE: Assessment of postoperative pain, analgesic requirements, bladder spasms, nosocomial urinary tract infections, length of hospital stay and outcome of "no catheter" versus catheterized intravesical ureteric reimplantation. MATERIALS AND METHODS: Over a 1 year period, 33 patients (24F, 9M) aged 3-14 years with surgical indications for ureteroneocystostomy were randomly assigned to a "no catheter" or "catheter" group. Intravesical ureteric reimplantation was performed in all patients. Post-operatively patients were given intravenous morphine for pain control and pain was assessed by a pain scale and by interviewing patients and parents regarding pain control. Urine cultures were performed on the day of surgery, and first and third postoperative days. Patients were followed post-operatively at 6 weeks with a renal ultrasound and at 3 months with a voiding or nuclear cystogram. Postoperative analgesic requirements, occurrence of bladder spasms, urinary tract infection rate, length of hospital stay and outcome as regards cure of vesicoureteric reflux were recorded. Student's paired t test was used for evaluation of statistical difference between groups. RESULTS: There was no difference in sex distribution, mean age or body weight, or nosocomial urinary tract infection rate between the 2 groups. Post-operative intravenous morphine requirement was significantly lower (p<0.05) in the "no catheter" group (mean +/- Standard Error of Mean (SEM) 0.51 +/- 0.4 mg/kg) versus the "catheter" group (0.89 +/- 0.5 mg/kg). Bladder spasms occurred in 80% of catheterized patients and 30% of non-catheterized patients. Length of hospital stay was significantly shorter (p<0.05) in the "no catheter" group (87.2+/- 19.4 hours) versus the "catheter" group (109.1 +/- 20.9 hours). All patients had stable kidneys by renal ultrasound at 6 weeks and cure of reflux by cystogram at 3 months, regardless of catheter status. CONCLUSION: Intravesical ureteroneocystostomy without a catheter is safe, well tolerated, and associated with significantly lower postoperative intravenous analgesic requirements, shorter hospital stay and fewer bladder spasms than the use of bladder catheters post-reimplantation. "No-catheter" reimplantation did not alter the expected outcome as regards cure of reflux.

Endoscopic subureteral collagen injection: are immunological concerns justified?

PURPOSE: We evaluated the humoral immune response in children treated with subureteral collagen injection for vesicoureteral reflux by analyzing serum for anticollagen antibodies. MATERIALS AND METHODS: We obtained serum before skin testing and at intervals after subureteral collagen injection in 7 girls and 3 boys with a mean age plus or minus standard error of 9.2+/-1.4 years. Serum antibody titers to bovine collagen, and human collagen types I and III were determined by indirect enzyme-linked immunosorbent assay. Patients were assessed for adverse reactions related to an immune response to collagen. RESULTS: Followup ranged from 14 to 40 months (mean 24.6) after the initial subureteral collagen injection. One to 4 subureteral collagen injections were given with cumulative collagen volume per patient ranging from 0.15 to 5.1 cc (mean 2.1). In 2 cases no baseline serum sample was obtained. Antibody titers measured in the 8 other patients before skin testing revealed equivocal and negative results in 5 and 3 for antibovine collagen, and in 1 and 7 for antihuman collagen types I and III, respectively. At the last followup results were positive, equivocal and negative in 3, 5 and 2 for antibovine collagen, and in 0, 2 and 8 for antihuman collagen types I and III, respectively. Seroconversion developed 13 to 24 months after the initial subureteral collagen injection in antibovine collagen seropositive patients, including 1 with a limited episode of bladder irritability after seroconversion. No other patient had adverse events considered to be immunological. CONCLUSIONS: In 3 of the 10 children treated with subureteral collagen injection for vesicoureteral reflux serum antibodies to bovine collagen developed. The volume of collagen injected was small, suggesting that volume is not a major determinant of immunogenicity. In 1 patient with seroconversion a local reaction may have been immunogenic. No patient had systemic symptoms of autoimmune disease and there was no seroconversion to antibodies cross-reacting with human collagen.

Treatment of urinary incontinence in children by endoscopically directed bladder neck injection of collagen.

PURPOSE: We assessed optimal selection criteria for and expected outcome of bladder neck injection of collagen in children with intrinsic sphincteric deficiency. MATERIALS AND METHODS: We retrospectively reviewed the charts of children with intrinsic sphincteric deficiency treated with bladder neck injection of collagen at 3 pediatric urology centers. RESULTS: We reviewed the records of 12 boys and 6 girls 6 to 18 years old (median age 10.5). The underlying etiology of incontinence was neurogenic bladder in 10 patients, the epispadias-exstrophy complex in 6, ureterocele in 1 and trauma in 1. Previous surgery included bladder augmentation in 4 cases, bladder neck plasty in 7 and epispadias repair in 4, and concurrent medical management comprised anticholinergics in 8, alpha-agonists in 1 and intermittent catheterization in 9. Skin tests in all patients were negative for collagen. Seven patients had 1 injection, 9 had 2 and 2 had 3. The volume of collagen injected ranged from 2.4 to 13 cc (median 5) per treatment and 3 to 28 cc (median 7) per patient. Followup ranged from 5 to 21 months (median 15). Of the 14 patients evaluated 5 are dry, 4 are improved, 1 is unchanged and 4 underwent further continence surgery. No treatment related morbidity was seen. CONCLUSIONS: Endoscopically directed injection of collagen around the bladder neck is successful in 64% of children with intrinsic sphincteric deficiency. It is an outpatient treatment with no significant morbidity. Further continence surgery is not precluded when necessary. Patients with adequate capacity and compliant neurogenic bladders, and those with the exstrophy-epispadias complex and failed bladder neck plasty seem to be optimal candidates for collagen injection.

Early characterization of a novel metastatic disease model of murine neuroblastoma.

PURPOSE: We developed a measurable metastatic disease model of murine neuroblastoma. MATERIALS AND METHODS: Murine neuroblastoma cells (C1300) were cotransfected with plasmids encoding for neomycin resistance and beta-galactosidase. Transfected cells were selected by culture in media containing gentamicin. Monoclonal and polyclonal transfected cell lines were selected from surviving colonies. Three cell lines (M1, P1 and P2) were cultured and inoculated into female A/J mice. A control group was included for analysis. Animals were sacrificed on day 18 after injection, and primary tumors and organs were assayed for beta-galactosidase activity by chemoluminescence assay. Animal livers were stained with hematoxylin and eosin for histological assessment. RESULTS: Transfected primary tumor tissue demonstrated beta-galactosidase activity. Livers from control mice had no beta-galactosidase activity. Of the 3 cell lines tested M1 showed the highest levels of beta-galactosidase activity in liver and lung, suggesting homology with human disease. Kidneys from all experimental groups had elevated beta-galactosidase activity, suggesting that the kidney is a common metastatic site for murine neuroblastoma. Hematoxylin and eosin sections demonstrated normal livers in control mice and micrometastases in the livers of all experimental animals. CONCLUSIONS: A novel metastatic disease model for murine neuroblastoma has been developed. By transfecting tumor cells with genetic material encoding 2 marker proteins distant metastases may be detected by assay for beta-galactosidase or cells can be selected for neomycin resistance, even at a stage when they are difficult to identify by standard histological techniques.