Biomedical subjects

D J Bägli

Publications and source records attributed to D J Bägli.

At least 19 recordsLinked to original sources

PubMed2003

The use of tolterodine in children after oxybutynin failure.

OBJECTIVE: To assess the safety and efficacy of tolterodine tartrate prescribed to children who previously failed to tolerate oxybutynin chloride. PATIENTS AND METHODS: We reviewed 34 children, followed for>1 year, who were prospectively crossed-over from oxybutynin to tolterodine because of side-effects. The initial diagnosis was dysfunctional voiding in 31 patients. All patients were placed on a behavioural modification protocol. When their symptoms did not improve after 6 months, treatment with an anticholinergic agent was considered. Urodynamic studies were conducted in 20 patients, confirming uninhibited contractions in 19. The remaining 14 patients were empirically started on antimuscarinic or anticholinergic agents. The 34 patients were treated with oxybutynin for a median (range) of 6 (2-84) months. When significant side-effects were reported, they were crossed over to tolterodine. The efficacy of tolterodine was assessed as defined by the International Children's Continence Society, with tolerability assessed and side-effects documented using a questionnaire. RESULTS: The mean age at the first dose of tolterodine was 8.9 years; the dose was 1 mg twice daily for 12 patients and 2 mg twice daily for 22. The median treatment with tolterodine was 11.5 months, with 20 (59%) patients reporting no side-effects; six described the same but tolerable side-effects as with oxybutynin. Eight patients discontinued tolterodine because of side-effects after a median (range) of 5 (1-11) months. The efficacy of tolterodine was comparable with that of oxybutynin, as reported by the questionnaire and voiding diaries. The reduction in wetting episodes at 1 year was> 90% in 23 (68%), more than half in five and less than half (or failure) in six patients. CONCLUSION: Tolterodine is tolerated well in children. In this subgroup of patients who could not tolerate oxybutynin, 77% were able to continue tolterodine treatment with no significant side-effects.

Adolescent↗

PubMed2003

The predictive value of diagnostic imaging for histological lesions of the upper poles in duplex systems with ureteroceles.

OBJECTIVE: To compare the diagnostic imaging findings with the histological lesions in upper pole nephrectomy (UPN) specimens of duplex system ureteroceles, using renal ultrasonography (US) and nuclear renal scintigraphy. PATIENTS AND METHODS: Between 1992 and 2000, 86 patients with a ureterocele in a duplex system underwent surgery. The results from US were reviewed in 84 patients by a radiologist, for echogenicity, parenchymal thinning and hydronephrosis; 77 nuclear renal scans describing the differential function of the upper poles were also reviewed. Fifty-five patients underwent UPN (25 antenatal, 30 postnatal; 18 intravesical, 37 extravesical) and the specimens were available for independent review by a pathologist, describing five histological categories, i.e. chronic interstitial inflammation, fibrosis, tubular atrophy, glomerulosclerosis and dysplasia. Histological lesions were categorized as severe (> 25%) or minimal (<or= 25%). Radiological features and the histology of UPN were then analysed, and correlated using Fisher's exact test and multivariate analysis. RESULTS: Severe histological lesions were reported in 38 specimens (69%) and minimal lesions in 17 UPN specimens (31%). Severe parenchymal thinning was associated with a severe pathological lesion (P < 0.02). There was no correlation with the echogenicity or degree of hydronephrosis. Dysplasia, found in 64% of specimens, did not correlate with increased echogenicity. Minimally functioning upper poles on nuclear renal scan (<or= 4% overall function) were significantly associated with severe histological lesions (P = 0.01). There was no correlation between diagnostic imaging features and the mode of presentation or type of ureterocele. CONCLUSIONS: Multivariate analysis, severe parenchymal thinning on renal US and minimal function on nuclear renal scan can be used to predict the severity of histological lesions of the upper pole. These results may be helpful in the making therapeutic decisions for patients with ureteroceles in duplex systems.

Adolescent↗

PubMed2001

Extracellular matrix gene responses in a novel ex vivo model of bladder stretch injury.

PURPOSE: Congenital bladder outlet obstruction from either mechanical or functional causes often results in clinical bladder fibrosis. We tested the hypothesis that early molecular changes relevant to fibrosis occur in response to stretch injury of the bladder wall and that specific extracellular matrix receptors mediate some of these responses. Furthermore, we introduce a novel ex vivo model of bladder injury which has advantages over previously described in vivo bladder outlet obstruction models by uniquely interrogating molecular responses to bladder distention. MATERIALS AND METHODS: The bladders of Sprague Dawley rats were hydrodistended transurethrally, the ureters and bladder neck were ligated, and the whole bladder was excised and incubated in culture medium in the distended state. At fixed time-points control and stretch bladders were snap frozen, RNA was extracted, and semiquantitative reverse transcription polymerase chain reaction for collagens I, III and XII, and RHAMM (receptor for hyaluronic acid) messenger (m) RNA was performed to establish trends in stretch related gene expression. Bladder specimens were also subjected to routine histological evaluation. RESULTS: An average 3-fold reduction in collagen I mRNA expression was seen with 8 hours of static stretch (p <0.05). Bladder stretch increased collagen III mRNA levels approximately 2.5-fold (p <0.05). Whole bladder collagen XII and RHAMM mRNA were elevated as much as 5-fold (p <0.05) with stretch. Blocking RHAMM function significantly attenuated these matrix gene responses (p = 0.01 to 0.005). CONCLUSIONS: The ex vivo model of whole bladder stretch is viable and easily reproducible for the study of molecular pathophysiological mechanisms contributing to maladaptive bladder disease. Furthermore, collagen gene transcription is revealed to be rapidly responsive to stretch injury of the bladder. Intact RHAMM receptor function is involved in these responses. Elucidation of the intermediate steps in this response to injury may allow for the development of novel therapeutic strategies which may prevent pathological matrix remodeling seen in clinical bladder disease.

Animals↗

PubMed2001

A population based analysis of continence outcomes and bladder exstrophy.

PURPOSE: Whereas the literature on bladder exstrophy is replete with outcomes of specific continence surgical procedures in highly select patients, there are no data on the outcomes related to continence for a complete exstrophy population, which is more comprehensive with respect to a variety of surgical procedures performed to achieve continence. To provide urologists and patients with an overview of potential continence outcomes devoid of any selection bias, we report on a comprehensive exstrophy population, focusing on the various procedures required for urinary continence. MATERIALS AND METHODS: We reviewed the charts of all patients with bladder and cloacal exstrophy who underwent a staged repair to achieve urinary continence at a single institution between 1988 and 1998. Urinary continence was then correlated to the types of surgical procedures, and subgroup analysis for predictors of urinary continence was performed. The type of bladder neck reconstruction allowed subgrouping cases into group 1-bladder neck reconstruction only, group 2-bladder neck reconstruction with augmentation and/or appendicovesicostomy and group 3-bladder neck closure. RESULTS: Of the 43 patients identified 26 were male, 4 had cloacal exstrophy and 3 had complex exstrophy variants with ectopic hindgut and spina bifida. Groups 1 to 3 comprised 9, 15 and 19 patients with urinary continence rates of 56%, 67% and 100%, respectively. The age at which patients became continent was delayed in groups 2 and 3 (8.2 and 8.7 years, respectively) compared to group 1 (4.8). Of all the potential variants measured gender was the strongest predictor of continence with 94% of females versus 69% of males achieving it. Of the males those with (57%) compared to those without (83%) a history of bladder neck stenosis or paraexstrophy flaps had worse continence. Repeat bladder neck reconstruction was only successful in 23% of patients. CONCLUSIONS: All patients can be rendered continent but many may achieve this successful outcome by other procedures following initial bladder neck reconstruction. When managing failed bladder neck reconstruction, the type of surgical repair chosen may need to address the need for enhanced bladder storage and the issue of potential bladder augmentation. The advances made in the treatment of the epispadiac urethra may now facilitate clean intermittent catheterization. Earlier recognition of the need for adjunctive storage procedures in addition to bladder neck reconstruction may facilitate the timing of providing enhanced continence, independence and self-esteem, and do so with fewer operative procedures. We speculate that the current complete urethral and bladder repair in newborns will add further to the storage functions of the native bladder tissues and improve the potential of achieving more effective bladder outlet control.

Bladder Exstrophy↗

PubMed2001

Tunica vaginalis for correcting penile chordee in a rabbit model: is there a difference in flap versus graft?

PURPOSE: We compared tunica vaginalis applied as a flap versus a graft for covering defects in the ventral tunica albuginea in a rabbit model. MATERIALS AND METHODS: We used 18 New Zealand White rabbits in the study. The urethra was mobilized off of the corpus cavernosum. A defect was created in the ventral aspect of the tunica albuginea by excising a 1 x 0.5 cm. rectangular area. The defect was covered by the testicular surface of tunica vaginalis as a vascularized flap in 9 animals and as a graft in 9. At 2, 6 and 12-week intervals 3 animals per group were sacrificed. Transverse sections of the penis at the repair site were stained with hematoxylin and eosin, and Masson's trichrome for microscopy. RESULTS: Autopsy revealed no contracture in any of the tunica vaginalis flaps. In contrast, the tunica vaginalis grafts had contracted by a mean of 22% (range 20% to 25%) at 2, 38% (range 30% to 44%) at 6 and 42% (range 38% to 48%) at 12 weeks. Microscopic examination of the tunica vaginalis flaps showed evidence of an intact blood supply and viable cremasteric muscle layer but no evidence of necrosis. Collagen remodeling and maturation was noted at 12 weeks. In tunica vaginalis grafts there was evidence of necrosis of all tunica vaginalis layers at 2 weeks with granulation tissue and active fibrosis at the periphery. At 6 and 12 weeks most necrotic tissue was replaced by fibrosis. Osseous metaplasia was identified in 1 graft at 12 weeks. CONCLUSIONS: The optimal use of tunica vaginalis for correction of chordee is as a flap rather than as a free graft. Grafts were associated with significant necrosis and contracture, of which neither was associated with flaps.

Animals↗

PubMed2001

Reliability of the pediatric dysfunctional voiding symptom score in monitoring response to behavioral modification.

PURPOSE: We previously evaluated the performance of a newly devised dysfunctional voiding symptom score to quantify abnormal voiding behaviors in children. The symptom score ranges from 0 to 30 with higher scores indicating greater severity. In this study, we test the performance of the symptom score in monitoring effectiveness and compliance with a program of behavioral modification. MATERIALS AND METHODS: One hundred four patients (age 3-10 years) were clinically diagnosed as having dysfunctional voiding (DV). At initial visit, after their baseline DV symptom scores were tabulated, they were introduced to a program of behavioral modification that included both verbal and written instructions. After an average follow up of 5 months, all families were mailed questionnaires to: a) assess whether the child was compliant with bladder retraining, and b) request the completion of a second DV symptom-scoring sheet. The change in symptom score was correlated with treatment compliance. Statistical analysis of the data was done using non-parametric method (Mann-Whitney U test). RESULTS: Forty-eight out of 104 children (46%) completed the mailed questionnaires. Twenty-eight (Group A1) were compliant with the behavioral modification program, and the remaining 20 children (Group A2) were not compliant. Although the median score at initial evaluation was similar in both groups (15 versus 14.5 respectively), scores in last follow up were significantly lower in Group A1 than the initial scores (6 versus 14.5 respectively). The scores in last follow-up in Group A2 were not significantly different from their initial symptom scores (median 11 versus 14.5 respectively). CONCLUSION: The DV symptom score reliably and quantitatively reflects improvement in voiding symptoms in patients compliant with behavioral modification. Patients non-compliant with a bladder retraining program may be identified by lack of decrease in their DV symptom score. Key Words: voiding dysfunction, pediatric, behavioral modification, symptom score

Behavior Therapy↗

PubMed2000

Regeneration of functional bladder substitutes using large segment acellular matrix allografts in a porcine model.

PURPOSE: We previously reported on the short-term (4 weeks) morphometric analysis of a large bladder acellular matrix allograft used as a bladder bioprosthesis (average size 24 cm.2). We demonstrated cellular repopulation through the entire thickness of the graft. We now present the long-term (12 weeks) morphometric results of graft regenerated porcine bladders using segments measuring an average of 40 cm.2. MATERIALS AND METHODS: Bladders harvested from pigs were subjected to detergent and enzymatic extractions to render them acellular. Partial cystectomy was performed in 21 pigs and the defect was repaired with a bladder acellular matrix allograft (average size 40.52 cm.2). Of the animals 8 were sacrificed at 1, 2 and 4 weeks and 13 were sacrificed at 8 and 12 weeks. To evaluate cellular repopulation and matrix reorganization the native bladder and graft were analyzed using standard histological and immunofluorescent techniques. To evaluate for calcium deposits in the grafts a radiological evaluation of the graft was performed after explantation. RESULTS: All animals survived the surgical procedure and there were no significant urinary leaks. No stones were noted in any of the bladders. At 1 week there was a diffuse infiltration with acute inflammatory cells. At 2 weeks the luminal surface of the graft was lined with a single layer of urothelium, and there was stromal infiltration with unorganized smooth muscle cells and angiogenesis. At 4 weeks the urothelium was multilayered with organizing groups of smooth muscle cells and angiogenesis. At 8 and 12 weeks there was repopulation throughout the bladder acellular matrix allograft implant with all native cellular components participating. CONCLUSIONS: We present evidence that large patch bladder acellular matrix allograft implantation is technically feasible and may prove to be a viable surgical alternative to bladder augmentation with intestinal segments. Its advantages may include the potential for complete and functional regeneration of a bladder substitute.

Animals↗

PubMed2000

The dysfunctional voiding scoring system: quantitative standardization of dysfunctional voiding symptoms in children.

PURPOSE: Academic research on pediatric nonneurogenic voiding dysfunction has long been hampered by the lack of a standardized reporting system for voiding symptoms. We evaluated the performance of a newly devised, objective instrument to quantify or grade the severity of abnormal voiding behaviors of children. MATERIALS AND METHODS: There were 10 voiding dysfunction parameters that were assigned scores of 0 to 3 according to prevalence, and possible total scores ranged from 0 to 30. The Dysfunctional Voiding Symptom Score was completed by 2 groups of patients. Group 1 consisted of patients 3 to 10 years old presenting to the pediatric urology clinic with a history of diurnal urinary incontinence, urinary tract infections or abnormal voiding habits. Group 2 consisted of an age matched cohort with no history of urological complaints presenting to hospital clinics outside of urology. Patients diagnosed with organic or anatomical disease, such as posterior urethral valves or meningomyelocele, were excluded from our analysis. RESULTS: Group 1 consisted of 104 patients (female-to-male ratio 4:1) with a median symptom score of 14 and group 2 consisted of 54 patients (female-to-male ratio 1.3:1) with a median score of 4. The dysfunctional voiding odds ratio was 2.93 for females compared to that of males. Using receiver operating characteristics the optimum cutoff score was 6.026 (sensitivity 92.77% and specificity 87.09%) for females and 9.02 (sensitivity of 80.95% and specificity of 91. 30%) for males. In addition, we found certain questions to be more reflective than others of dysfunctional voiding symptoms in our population. CONCLUSIONS: The Dysfunctional Voiding Symptom Score appears to provide accurate and objective, that is, numerical, grading of voiding behaviors of children. Comparative research studies of dysfunctional voiding diagnosis and response to therapy as well as objective measurements of treatment efficacy and outcomes analysis should be aided greatly by this system.

Child↗

PubMed1999

Metanephric adenoma of the kidney: a case report.

Metanephric adenoma (MA) of the kidney is an uncommon benign epithelial tumor of the kidney that presents at any age. The histology of the lesion is well established, but the imaging findings have been described in only a few cases. We report the sonographic and computed tomographic appearance of MA in a 9-year-old girl to increase awareness among radiologists of this entity. Its recognition may facilitate nephron-sparing surgery.

Adenoma↗

PubMed1999

Utility of SPECT DMSA renal scanning in the evaluation of children with primary vesicoureteral reflux.

OBJECTIVES: DMSA renal scanning is more sensitive than ultrasound in detecting renal parenchymal scars. We proposed to determine the utility of single-photon emission computed tomography (SPECT) dimercaptosuccinic acid (DMSA) renal scanning in children with primary vesicoureteral reflux (VUR). METHODS: During a 24-month period, we evaluated the charts of 368 patients who had undergone SPECT DMSA renal scanning for primary VUR. Patients were divided into three age groups: (a) less than 1 year, (b) between 1 and 5 years, and (c) older than 6 years. Renal scars were deemed severe or focal. The data were analyzed to evaluate the utility of SPECT DMSA scanning in children with primary VUR and to determine the indications for performing SPECT DMSA. We also evaluated the sensitivity of recent renal ultrasound technology in detecting focal and diffuse scars. RESULTS: One hundred twenty-eight patients were younger than 1 year at presentation. These included 24 cases that were detected prenatally. One hundred eighty-five were between the ages of 1 and 5 years, and 55 were 6 years or older. Reflux nephropathy at presentation was found in 99 (26.9%) of 368 patients. DMSA scanning changed the treatment in only 13 patients (3.5%). When scarring was diffuse, ultrasound examination correlated 100% with DMSA scanning; when focal scarring was present, the correlation was poor. CONCLUSIONS: Our results suggest that DMSA scans should be tailored to children who have ultrasound abnormalities, high-grade reflux, or recurrent breakthrough urinary tract infections. These guidelines will result in a substantial cost savings and a significant decrease in radiation exposure.

Child↗

PubMed1999

The hyaluronic acid receptor RHAMM is induced by stretch injury of rat bladder in vivo and influences smooth muscle cell contraction in vitro [corrected].

PURPOSE: Loss of bladder compliance from hypercontractility and fibrosis may represent an injury response to excessive intravesical pressure. Together, interactions between cell and extracellular matrix components regulate cell response to injury and extracellular matrix remodeling. The receptor for hyaluronic acid mediated motility (RHAMM) is a recently described hyaluronic acid binding protein known to influence multiple types of cell extracellular matrix interaction in development, injury and cancer. We evaluate the role of RHAMM in mediating early events in bladder stretch injury. MATERIALS AND METHODS: An acute stretch injury model was used. The rat bladder was injured by hydrodistention inducing gross hematuria. Tissues were analyzed for temporal and spatial expression of RHAMM in the mucosa and detrusor regions by immunostaining, western and reverse transcriptase polymerase chain reaction analyses. The contractile activity of smooth muscle cell primary cultures was analyzed using a gel contraction assay in the presence of peptide fragments known to block RHAMM function. RESULTS: Acute hydrodistention caused immediate and significant injury to the bladder, with fracturing of smooth muscle cell bundles, edema and hemorrhage. RHAMM immunolocalized to the mucosa and detrusor within 2 hours of injury, peaking by 5 to 10 hours. A shift from low molecular weight (55 kD.) to high (120 kD.) receptor isoforms was prominent during the peak expression period noted by immunolocalization. RHAMM messenger ribonucleic acid increased only slightly (40%) by 5 hours after injury. Smooth muscle cell primary cultures actively initiated and maintained the contraction of collagen gels by more than 75% of baseline in vitro. Blocking RHAMM function significantly inhibited the ability to less than 25% of smooth muscle cells to contract the gels in vitro. CONCLUSIONS: Increased expression of RHAMM is an early event precipitated by stretch injury to the bladder. Since extracellular matrix hyaluronic acid is found early in tissue repair responses, its receptor RHAMM may be mediating initial bladder responses to stretch injury, some of which (contraction) may be experimentally blocked in vitro. Since the receptor directly regulates protein kinase signaling which in turn mediates smooth muscle cell contraction and collagen synthesis, further studies of RHAMM function in bladder pathology are warranted.

Animals↗

PubMed1999

Initial experience with endoscopic holmium laser lithotripsy for pediatric urolithiasis.

PURPOSE: Due to the unavailability of suitable pediatric instruments children have not benefited from advances in endoscopic lithotripsy. This limitation may be overcome by the holmium: YAG laser. We evaluated the indications for, and efficacy and complications of holmium:YAG laser lithotripsy. MATERIALS AND METHODS: We retrospectively reviewed all cases of laser lithotripsy. Access to the calculus was antegrade or retrograde. A solid state holmium:YAG laser was used. RESULTS: Eight patients 4 to 14 years old underwent laser lithotripsy during the study period. Average calculous surface area was 357.13 mm.2 (range 14 to 1,645). Five patients required 1 procedure to render them stone-free, while the remaining 3 required multiple procedures. No complications were associated with laser lithotripsy. CONCLUSIONS: The ability of the holmium:YAG laser to pulverize urinary calculi makes it an alternative choice for lithotripsy. In our series all patients are stone-free with stable renal function. The advantages of the holmium:YAG laser are that it may be precisely applied via small fibers, and it pulverizes calculi with minimal scattering of energy and retropulsion of the calculus, decreasing trauma to tissues at the perioperative site. There is also a lower risk of residual fragments, which is associated with a lower incidence of calculous regrowth. Holmium: YAG laser is safe and effective for treating pediatric urolithiasis.

Adolescent↗

PubMed1998

Modifications of and extended indications for the Pippi Salle procedure.

Total urinary incontinence is a difficult problem faced by the urologist. Several techniques to increase ureteral resistance have been described. The majority of them rely on intermittent catheterization for bladder emptying, especially in neurogenic incontinence. We have developed a new procedure in which a bladder flap is used to create a neourethra. This urethral extension acts as a flap valve to provide continence. Bladder emptying is accomplished by clean intermittent catheterization. Urethral lengthening with an anterior bladder-wall flap was performed in 18 patients aged a mean of 8.9 years who had neurogenic incontinence (14) or exstrophy (4). Patients with previous bladder interventions received a lateralized anterior flap. Bladder augmentation was performed in 14 of the 18 patients [detubularized ileum (11), detubularized colon (3)]. The average follow-up period is currently 29.3 months. Continence was achieved in 13 of the 18 patients (72%). Complications included urethrovesical fistulae, which developed in two patients. Two patients could not perform catheterization due to pain but had no obstruction to passage of catheter (exstrophy). Ureteral lengthening with an anterior bladder-wall flap is a useful alternative for the surgical treatment of urinary incontinence. This technique achieves a good continence rate and presents few problems with catheterization.

Bladder Exstrophy↗

PubMed1998

Outcome analysis of rhabdomyosarcoma of the lower urinary tract.

PURPOSE: Multimodal therapy has resulted in a high cure rate for genitourinary rhabdomyosarcoma. We propose that the strategy of induction chemotherapy followed by excision and reconstruction without radiotherapy may provide a high cure rate without the late sequelae of pelvic radiotherapy. MATERIALS AND METHODS: We reviewed the records of 13 patients with a mean age of 3.3 years diagnosed with rhabdomyosarcoma of the urinary tract from 1986 to 1996. The primary site was the bladder in 4 cases and prostate in 9. After biopsy confirmation of the diagnosis patients were treated with chemotherapy and subsequent surgery, while radiotherapy was reserved for those with residual disease. RESULTS: After induction chemotherapy 8 patients underwent tumor excision via an organ sparing approach, which involved radical prostatectomy and partial cystectomy with or without bladder augmentation. In 5 patients the final pathological analysis showed positive margins. Repeat surgery in 6 patients included complete cystectomy and urinary diversion in 2 who had positive margins and recurrence after radiotherapy, urethrectomy and continent diversion for positive margins in 1, partial cystectomy and continent diversion in 1, and radical prostatectomy, partial cystectomy and continent diversion in 1 with stage IV disease who had local recurrence. In the latter case ileocystoplasty had been performed for a small noncompliant bladder. Six patients with microscopic residual or metastatic disease received radiotherapy. At a mean followup of 5.6 years 11 patients are disease-free. Continence was preserved in all reconstructed cases. Erections were reported in 8 patients, and renal function was maintained in 10. CONCLUSIONS: Our results suggest that urinary tract reconstruction may be safely performed at primary excision surgery, radiotherapy induced morbidity may be minimized by limiting radiotherapy to residual and metastatic disease, frozen section results may be false-negative, potency may be achieved and radiological disappearance of the tumor should be confirmed histologically.

Child↗

PubMed1998

Artificial neural networks in pediatric urology: prediction of sonographic outcome following pyeloplasty.

PURPOSE: Computerized artificial neural networks are analogous to biological neuronal systems. Since they may be trained to recognize the relevance of complex patterns in data, neural networks may be useful for decision making in the multifactorial management of ureteropelvic junction obstruction. We determine the ability of a customized neural network to predict sonographic outcome after pyeloplasty in children with ureteropelvic junction obstruction. MATERIALS AND METHODS: A data set was constructed with 242 demographic, clinical, radiological and surgical elements. We analyzed the available retrospective data in 100 consecutive children who underwent unilateral pyeloplasty for ureteropelvic junction obstruction chosen from all 144 surgically treated for ureteropelvic junction obstruction between 1993 and 1995. One radiologist reviewed all film data and provided a final sonographic outcome designation in each case. We wrote a set of computer programs to construct a neural network. A composite 4-layer network was built with output nodes representing 4 possible sonographic outcomes. The 100 patient data set was randomly divided into 84 training and 16 testing examples. RESULTS: The neural network correctly predicted all 5 of 5 significantly improved, 7 of 7 improved, 2 of 2 same and 2 of 2 worse sonogram results after pyeloplasty. Therefore, sensitivity and specificity were 100% for all 4 outcomes. Linear regression analysis of the data yielded inferior sensitivity and specificity values (52 to 94%), confirming that ureteropelvic junction obstruction is a nonlinear data analysis problem. CONCLUSIONS: The 100% accuracy, sensitivity and specificity of our neural network in this pilot study provide evidence of the value of the neural computational approach for the modern exploration and modeling of the clinical problem of pediatric ureteropelvic junction obstruction.

Child↗

PubMed1997

Urethral lengthening with anterior bladder wall flap (Pippi Salle procedure): modifications and extended indications of the technique.

PURPOSE: We report a clinical case series of an innovative method of urethral reconstruction for the treatment of urinary incontinence. Modifications of our original technique are presented. MATERIALS AND METHODS: Bladder neck repair was done in 17 patients, mean age 9.3, with neurogenic incontinence (13) or exstrophy (4). Average followup is 25.6 months. Of the patients 9 with neurogenic bladder underwent the original procedure using a midline anterior bladder wall flap. In the 4 patients with exstrophy a modified procedure was done using an anterolateral bladder wall flap. In another 4 patients an extended flap of distal mucosa was used to avoid ureteral reimplantation. Augmentation was performed in 13 of the 17 cases (10 detubularized ileum and 3 detubularized colon). RESULTS: Continence (greater than 4 hours) was obtained in 12 of the 17 patients (70%), 2 are dry for 1 to 2 hours and 3 are incontinent. A urethrovesical fistula developed in 2 patients (1 closed successfully), and 3 patients have problems with catheterization. CONCLUSIONS: Urethral lengthening with anterior bladder wall flap is a versatile alternative in the surgical treatment of urinary incontinence. Variations of the original technique resulted in an improved vascular supply and decreased the formation of fistula at the base of the flap. The modified technique was successful in patients with exstrophy, including those who had failed bladder neck surgery.

Bladder Exstrophy↗

PubMed1997

An algorithm for the management of anterior urethral valves.

PURPOSE: We present our management algorithm for patients with anterior urethral valves seen in the last 2 decades with and without the benefit of prenatal sonography. MATERIALS AND METHODS: A case series design was used to study 17 cases of anterior urethral valves. Five patients presented with prenatal hydronephrosis from 1984 to 1993 and 12 presented with predominant voiding symptoms between 1975 and 1996 at a mean age of 6 years. RESULTS: Treatment included supravesical diversion in 1 case, vesicostomy in 5, urethroplasty in 5 and transurethral fulguration in 6. Four of the 5 patients with a prenatal diagnosis of hydronephrosis had moderate to severe hydronephrosis compared to 3 of the 12 who did not undergo prenatal sonography. All 17 patients were continent and infection-free, and had little or no hydronephrosis at a mean followup of 5 years. CONCLUSIONS: We recommend vesicostomy in infants with high grade bilateral vesicoureteral reflux and poor emptying of the urinary tract, transurethral fulguration if the urethra has sufficient caliber and support, and urethroplasty in other patients. Based on our management algorithm patients with anterior urethral valves do not have sequelae due to distal obstruction of the urinary tract.

Adolescent↗

PubMed1997

Basic fibroblast growth factor in the urine of children with voiding pathology.

PURPOSE: Basic fibroblast growth factor is a mediator of tissue response to injury. Voiding pathology often results in bladder abnormalities. We prospectively determined whether basic fibroblast growth factor is elevated in the urine of children with bladder dysfunction compared to that of normal controls. MATERIALS AND METHODS: A total of 97 consecutive children with myelomeningocele and 32 with voiding pathology due to other etiologies underwent urodynamic testing, and 11 children with no bladder symptoms and sterile urine served as controls. Urinary basic fibroblast growth factor levels were assayed by enzyme-linked immunosorbent assay and normalized to urinary creatinine. RESULTS: Mean urinary basic fibroblast growth factor was higher in bladder dysfunction from myelomeningocele (6,673 pg./gm. creatinine, p = 0.0015) and other etiologies (5,665 pg./gm. creatinine, p = 0.0025) compared with urine from normal bladders (2,995 pg./gm. creatinine). In the myelomeningocele group urinary tract infection was associated with higher urinary basic fibroblast growth factor than in sterile urine (9,214 versus 5,642 pg./gm. creatinine, p = 0.018). Patient age, gender, remote bladder surgery, clean intermittent catheterization, detrusor hyperreflexia, detrusor compliance, age adjusted pressure specific bladder volume, low grade reflux and degree of trabeculation did not correlate with levels of basic fibroblast growth factor (p > 0.05). CONCLUSIONS: Urinary elevation of basic fibroblast growth factor, a critical mediator of wound repair, in children with voiding pathology and clinically abnormal bladders supports the paradigm that bladder dysfunction may result from generalized response-to-injury mechanisms. The role of fibrogenic cytokines, such as basic fibroblast growth factor, merits further directed investigation in bladder pathology.

Child↗