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Biomedical subjects

Jyoti Upadhyay

Publications and source records attributed to Jyoti Upadhyay.

At least 19 recordsLinked to original sources
PubMed2006

Ureteral access sheath for the management of pediatric renal and ureteral stones: a single center experience.

PURPOSE: Ureteral access sheaths were developed to facilitate difficult ureteroscopic access in adults. We report our use of the ureteral access sheath during standard ureteroscopic procedures in the pediatric stone population. MATERIALS AND METHODS: Eight patients underwent flexible ureteroscopy and holmium laser lithotripsy for symptomatic renal and ureteral calculi between October 2003 and October 2004. Average patient age was 9.3 years (range 4 to 13). There were 4 males and 4 females. Five of 8 patients had bilateral stones and underwent bilateral endoscopic stone treatment at the same operation. A 14Fr 20 cm Flexor ureteral access sheath was used for dilation and access of the ureter. Flexible pediatric ureteroscope was used to enter the ureter and collecting system for stone retrieval and fragmentation. RESULTS: All patients were rendered stone-free in a single operative setting. Average operative time was 99 minutes (range 65 to 130). Average total stone burden for the group was 9 +/- 3 mm. All patients received stents after the procedure. There were no perioperative complications. All patients were followed with renal-bladder ultrasound and plain x-ray. All patients were stone-free at a mean followup of 10 months (median 11). CONCLUSIONS: Routine use of a ureteral access sheath in children facilitates flexible ureteroscopy with lithotripsy of multiple renal and proximal ureteral stones. The procedure is safe and time efficient, and is associated with minimal morbidity. Larger prospective studies in children with longer followup are warranted.

Adolescent↗
PubMed2005

Controversies in the diagnosis and management of urinary tract infections in children.

Urinary tract infection (UTI) is one of the most common childhood bacterial infections, after upper respiratory tract and middle ear infections. The current goal of management is to prevent detrimental effects of UTI by early detection and treatment. Recommendations for the imaging of children depend upon age at presentation and sex. All children aged <5 years who have had a febrile UTI require a radiologic evaluation to identify any underlying genitourinary pathology. Older children can undergo a more tailored work-up depending on whether there is a febrile UTI or cystitis-type symptoms. Dysfunctional voiding and urge syndrome significantly increase the risk of developing UTIs in children. Vesicoureteral reflux can increase the risk of pyelonephritis and renal scarring in children with UTIs. For the most part, pyelonephritis can be diagnosed on clinical grounds in the majority of patients and a subsequent (99m)Tc-dimercaptosuccinic acid scan can be reserved to identify post-nephritic renal scarring. When renal scarring is identified, the child and parents need to be educated regarding the possibility of hypertension, proteinuria, progressive nephropathy, and the risk of complications in future pregnancies. Treatment of UTI is started in the unwell child before the culture results are available and subsequently changed to culture-specific antimicrobial therapy. A short course of treatment is required for acute uncomplicated UTIs. A child with acute pyelonephritis requires 10-14 days of antibacterial treatment. The oral route in young children often causes vomiting, which implies therapeutic delay, a well known risk factor for scarring.

Anti-Bacterial Agents↗
PubMed2004

Nerve-sparing retroperitoneal lymphadenectomy using hydro-jet dissection: initial experience.

BACKGROUND AND PURPOSE: Nerve-sparing retroperitoneal lymphadenectomy (RPL) is performed in a significant number of patients to preserve ejaculation after treatment for testicular cancer. Identification and preservation of the sympathetic nerves may be challenging. Hydro-Jet technology has been utilized for various surgical applications. A small high-pressure stream of water is used to delineate surgical planes, with preservation of vascular and neural structures. We have examined the utility of this technology for RPL in a porcine model and in human subjects. MATERIALS AND METHOD: A Helix Hydro-Jet device (Erbe, USA) was used for all procedures. A high-pressure water-jet stream is directed through a small nozzle with a 120-microm inner radius for soft-tissue dissection. The upper pressure limit (range 0-2175 psi) is set using a digital monitor. The jet is initiated using a foot pedal, and the actual pressure is monitored. A pressure of 360 to 400 psi was used for experimental studies, which was decreased to 255 to 300 psi for human use. Three pigs underwent RPL using this technique. Subsequently, RPL was performed in five men with testicular cancer, being primary in two and postchemotherapy in three. The primary diagnosis was seminoma in one and non-seminomatous cancer in four. The patient with seminoma had a residual mass after chemotherapy. RESULTS: The procedures were completed successfully in all subjects. There were no intraoperative or postoperative complications. Hydro-Jet dissection permitted tissue selectivity, with preservation of vascular structures and sympathetic nerves. The soft tissue and lymphatics were removed with the high-pressure water stream assisted by blunt dissection. The nerve fibers were grossly resistant to the pressure used and were isolated individually. Dissection around the great vessels appeared to be safe, and no injury was observed with direct application of the jet. Lumbar arteries and veins and accessory vessels could be isolated safely. The estimated blood loss was minimal in animals and 300 to 800 mL in humans. CONCLUSIONS: Hydro-Jet dissection demonstrated tissue selectivity using a pressure range of 255 to 300 psi in humans. The vascular structures and sympathetic nerves were preserved. Our initial experience with this device for nerve-sparing RPL is encouraging.

Adult↗
PubMed2004

Impact of temporary hilar clamping during laparoscopic partial nephrectomy on postoperative renal function: a prospective study.

PURPOSE: Laparoscopic partial nephrectomy for small renal tumors has been increasingly performed in the last few years. We prospectively evaluated preoperative and postoperative differential renal function by renal scan in patients with contralaterally functioning kidneys who underwent laparoscopic partial nephrectomy with hilar clamping. MATERIALS AND METHODS: From July 2002 to June 2003, 17 consecutive patients were included in this prospective protocol and underwent laparoscopic partial nephrectomy for exophytic tumors using en bloc hilar clamping. Preoperative renal scan with differential function was performed 1 month before and 3 months after surgery in all patients. technetium labeled diethylenetetraminepentaacetic acid scan was performed in all patients. RESULTS: Mean warm ischemia time was 22.50 +/- 9.78 minutes (range 10 to 44). Preoperative differential renal function and glomerular filtration rate (GFR) in the affected kidneys were 50.20% +/- 4.90% (range 43 to 58) and 75.56 +/- 16.45 ml per minutes (range 39.4 to 105). At postoperative month 3 differential renal function and GFR in the affected kidney were 48.07% +/- 7.16% (range 39% to 63%) and 72.03 +/- 18.17 ml per minutes (range 31 to 101). There was a nonsignificant negative association between hilar clamp time and change in renal function (postoperative - preoperative) of the affected kidney (r = -0.26, p = 0.31), and a positive correlation between clamp time and change in GFR (r = 0.39, p = 0.12) that did not reach statistical significance. CONCLUSIONS: In patients with contralaterally functioning kidney, temporary hilar clamping with a mean warm ischemia time of 22.5 minutes results in preservation of renal function in the affected kidney. Larger studies with longer followup are necessary to study the impact of warm ischemia further.

Adult↗
PubMed2003

Subureteral polydimethylsiloxane injection versus extravesical reimplantation for primary low grade vesicoureteral reflux in children: a comparative study.

PURPOSE: We compare the outcome of extravesical ureteral reimplantation to endoscopic polydimethylsiloxane (Macroplastique, Uroplasty, Inc., Minneapolis, Minnesota) subureteral injection for primary low grade vesicoureteral reflux in children. MATERIALS AND METHODS: Between 1997 and 2000, 180 patients underwent polydimethylsiloxane injection (74, 108 ureters) or extravesical ureteral reimplantation (106, 166 ureters) for low grade vesicoureteral reflux. Low grade reflux was defined as grades I to III. Outcome analysis included success rates, de novo hydronephrosis, voiding efficiency, urinary tract infections and complications. RESULTS: Mean patient age at surgery for the injection and surgery groups was 60 and 77 months, and mean followup was 12 and 15 months, respectively. Of the patients who underwent single injection 80.6% were cured of reflux at 3 months and 91.6% were cured at last followup. Success rate after reimplantation was 95.8% at 3 months which improved to 98.8% 1 year later. The success rate was significantly different between the injection and reimplantation groups at 3 and 12 months (p <0.01). Postoperative complications in the reimplantation group included transient urinary retention after bilateral surgery in 2 patients (3.3%), suprapubic fluid collections in 2 and wound seroma in 1. No complications occurred in the polydimethylsiloxane group. CONCLUSIONS: Extravesical ureteral reimplantation has near perfect success with a low but definite complication rate. Polydimethylsiloxane offers high success rates for reflux in an ambulatory setting with no short-term complications. Currently, endoscopic polydimethylsiloxane injection is our preferred mode of therapy for low grade vesicoureteral reflux in children when surgical correction is indicated.

Adolescent↗
PubMed2003

Radical prostatectomy with bladder neck preservation: impact of a positive margin.

PURPOSE: Bladder neck preservation during radical prostatectomy has been correlated with improved continence. However, the hazard of a positive margin at this specific site has discouraged many urologists. We evaluated if preservation of the bladder neck at the time of radical prostatectomy jeopardizes surgical cancer control with consequent deleterious outcomes. MATERIALS AND METHODS: 675 consecutive patients underwent radical prostatectomy (RP) by a single surgeon (J.E.P.) at Wayne State University during the 1990s decade. The bladder neck was preserved. Margin-positivity was categorized by location and number. Preoperative, pathological and disease status data was prospectively collected into the Karmanos Cancer Institute multidisciplinary prostate cancer database. RESULTS: Analysis was performed on 555 patients who had RP as monotherapy. Positive margins were found in 178 (32%) of these patients. Correlation between specimen Gleason score, prostatic specific antigen (PSA) and margin status, was encountered (p=0.001). Apical and bladder neck margin-positivity was detected in 104/555 (19%) and 13/555 (2%), respectively. Of those specimens with a positive margin at the bladder neck eight had Gleason score > or =7, three had seminal vesicle invasion and two nodal disease. Only two patients had a positive bladder neck margin as the sole adverse pathological feature. Significant independent predictors of survival included the Gleason score, PSA, pathological stage and presence of positive margins in more than one location. CONCLUSIONS: Anatomical preservation of the bladder neck does not increase the percentage of positive margins at this anatomical location and does not compromise disease-free survival.

Aged↗
PubMed2003

Integrins expressed with bladder extracellular matrix after stretch injury in vivo mediate bladder smooth muscle cell growth in vitro.

PURPOSE: It is unknown how bladder smooth muscle cells sense extrinsic mechanical stimuli. The integrins are a large versatile family of transmembrane mechanoreceptors that transduce extracellular matrix (ECM) alterations into the cell, thereby, regulating proliferation, differentiation and ECM synthesis. To our knowledge we provide the first evidence that the integrins may be involved in responses to whole bladder distention and bladder smooth muscle cell stretch. MATERIALS AND METHODS: Bladders from 100 to 120 gm. rats were stretched to 40 cm. H2O for 5 minutes. Five to 96 hours after distention whole bladder mRNAs were isolated for analysis of temporal expression of collagen and integrin genes. Separately quiescent primary culture bladder smooth muscle cells from 1-day-old Sprague-Dawley rats were stretched cyclically for 4 hours. Relative expression of select integrin subunit mRNAs was assessed by semiquantitative reverse transcriptase-polymerase chain reaction. Integrin blockade with asparagine-glycine-arginine peptides was used to determine the role of integrins in stretch induced proliferation and the cell cycle in bladder smooth muscle cells. RESULTS: Within 24 hours bladder distention stimulated collagen expression 2-fold (type I) and 5-fold (type III). Collagen levels beyond 24 hours were 8-fold (type I) and 2-fold (type III) greater than in controls, revealing an inverse temporal type I-to-III ratio beyond 24 hours. Coordinate alterations were observed in integrin and collagen expression. In vitro bladder smooth muscle cell integrin beta1, beta3 and alphav subunit expression was increased by mechanical stretch 2.5, 3.8 and 5-fold, respectively, while alpha1 expression decreased. Asparagine-glycine-arginine peptide inhibition of integrin function significantly inhibited stretch induced bladder smooth muscle cell proliferation and exit from the G2/M phase of the cell cycle. CONCLUSIONS: To our knowledge these results demonstrate for the first time that that bladder distention initiates dynamic alterations in ECM expression. The ability of integrin blockade to suppress stretch induced bladder smooth muscle cell proliferation and the coordinate changes in bladder ECM and integrin expression suggest that integrins mediate key responses to mechanical stimuli in the bladder. Furthermore, cell cycle analysis of resting and stretched bladder smooth muscle cells revealed novel avenues for the examination of integrin and stretch regulation of bladder smooth muscle cell growth.

Animals↗
PubMed2003

Use of the dysfunctional voiding symptom score to predict resolution of vesicoureteral reflux in children with voiding dysfunction.

PURPOSE: Dysfunctional voiding influences the presence and persistence of vesicoureteral reflux. We used a standardized published instrument, the dysfunctional voiding symptom score, to evaluate the association of dysfunctional voiding with vesicoureteral reflux. We report its use for monitoring improvement in and resolution of vesicoureteral reflux. MATERIALS AND METHODS: In 1998, 114 patients with dysfunctional voiding were placed on behavioral modification. Of 58 patients (51%) who presented with urinary tract infection 27 (47%) had abnormal voiding cystourethrography, including 19 with reflux only. Baseline and followup dysfunctional voiding symptom score was determined in these 19 patients, who underwent prospective observational therapy and behavioral modification. We correlated the dysfunctional voiding symptom score with the evolution of vesicoureteral reflux. RESULTS: Vesicoureteral reflux was present in 19 of the 58 patients (33%) with dysfunctional voiding and urinary tract infection. All affected patients were female with a mean age of 6.7 years and a mean followup of 24 months. Reflux grade in the 24 units was I to IV in 7, 9, 7 and 1, respectively. Mean dysfunctional voiding symptom score was 13.3 in patients with normal voiding cystourethrography and 11.7 in the vesicoureteral reflux group (p = 0.6). Reflux resolved in 3, 2 and 2 cases of grades I, II and III disease, respectively, while improvement (decrease of 2 or more grades) was noted in 4. Initial dysfunctional voiding symptom score in these 11 cases decreased from a mean of 9.6 (range 4 to 18) to 3.7 (range 0 to 12, p = 0.01). The 8 patients with persistent reflux had an initial dysfunctional voiding symptom score of 14.4 (range 4 to 21), which decreased to 11.1 (range 1 to 19, p = 0.18). CONCLUSIONS: A significant decrease in the dysfunctional voiding symptom score appears to confirm compliance with behavioral modification and predicts ultimate reflux resolution. The dysfunctional voiding symptom score provides a noninvasive means of monitoring compliance with therapy during expectant treatment of patients with vesicoureteral reflux.

Child↗
PubMed2003

Natural history of neonatal reflux associated with prenatal hydronephrosis: long-term results of a prospective study.

PURPOSE: We have previously reported on patients with neonatal vesicoureteral reflux followed conservatively. The current study is a long-term followup of our prospective expectant management protocol for the overall cohort. MATERIALS AND METHODS: Between 1993 and 1998, 31 of 260 patients with prenatal hydronephrosis had vesicoureteral reflux and were followed prospectively. Outcome analysis was done on 25 patients, excluding 6 who underwent surgery, with the end point of complete resolution or improvement of reflux using our previously reported Kaplan-Meier survival curve, urinary tract infection, dysfunctional voiding, and changes in renal function or growth, somatic growth and hypertension. RESULTS: Of the 25 cases reflux was grades I to V in 7%, 20%, 34%, 16% and 23%, respectively. Reflux resolved in 13 patients (52%) and improved in 6 (24%). Grades I to V disease resolved in 100%, 77%, 53%, 28% and 40% of refluxing units, respectively. The improvement rate for grades III to V reflux was 13%, 14% and 30%, respectively. Breakthrough urinary tract infection occurred in 4 patients with grades IV and V reflux, and dysfunctional voiding developed in 5. Followup renal scans showed 19% and 17% decreased differential function in 2 units without new scars. There was no difference in renal length in patients with resolved versus persistent reflux or low versus high grade reflux. All patients had normal somatic growth at the 4-year followup and none had hypertension. CONCLUSIONS: Expectant management was effective in the majority of cases and associated with a low urinary tract infection rate. Neonatal vesicoureteral reflux resolved or improved in 76% of our patients by age 4 years without somatic growth retardation or hypertension. High grade reflux resolved or improved in 59% of the units and showed normal renal growth with expectant management.

Body Height↗
PubMed2003

Long-term evaluation of metabolic profile and bone mineral density after ileocystoplasty in children.

PURPOSE: We evaluated the long-term effects of ileocystoplasty on linear growth, serum electrolytes, acid-base profile and bone mineral density (BMD) in a group of neurologically intact children with a mean followup of 8.9 years. MATERIALS AND METHODS: Between 1988 and 1997, 9 girls and 16 boys with a mean age of 6 years (range 1 month to 14 years) underwent ileocystoplasty for etiologies other than myelomeningocele and neuropathic bladder. Indications for ileocystoplasty were small noncompliant bladder secondary to bladder exstrophy in 12 cases, bladder outlet obstruction in 10 and post-partial cystectomy for rhabdomyosarcoma in 3. All patients underwent clinical evaluation, supine height measurement, serum electrolytes, arterial blood gases and BMD measurement using a fan beam dual energy absorpitometry scan. BMD was measured at L1-L4 and corrected for age and sex. RESULTS: Followup ranged from 4 to 13 years (mean 8.9). Serum creatinine was normal in 20 of the 25 patients. All patients had normal supine height measurement with a mean of 45th (+/- 9) centile on growth charts. Serum electrolytes, calcium, phosphorus and arterial blood gases were normal in all patients. Mean BMD corrected for age and sex was 89 (+/- 10)%. BMD was normal in 17 of 25 (68%) patients. Mild reduction in bone density between 1 and 2 standard deviations below the age/sex mean was documented in 3 (12%) patients and the remaining 5 (20%) showed marked osteopenia of 2 or more standard deviations. Of the latter 5 patients 2 had increased serum creatinine, 1 had a history of radiotherapy for pelvic rhabdomyosarcoma and 2 had cloacal exstrophy and short bowel, all of which might have contributed to the osteopenia. CONCLUSIONS: Ileocystoplasty for children with normal kidney function is not associated with alterations in serum electrolytes or arterial blood gases in the long term. However, 32% of patients showed variable degrees of reduction in BMD. Although marked reduction in BMD was associated with cofactors, 12% of patients had evidence of mild osteopenia in absence of those cofactors. We recommend routine preoperative and longitudinal followup BMD measurements for children undergoing intestinal bladder augmentation.

Adolescent↗
PubMed2003

Polydimethylsiloxane injection versus open surgery for the treatment of vesicoureteral reflux in complete duplex systems.

PURPOSE: We compared the efficacy of subureteral polydimethylsiloxane injection (Macroplastique, Uroplasty, Inc., Minneapolis, Minnesota) versus open surgery for correction of varying degrees of reflux in complete duplex systems. MATERIALS AND METHODS: Between 1997 and 2000 polydimethylsiloxane injection was performed in 15 females (22 refluxing moieties). Mean patient age at presentation and at surgery was 54 and 94 months, respectively. Extravesical common sheath reimplantation (ECSR) was performed in 34 children (bilateral 10) with a mean age at presentation and at surgery of 31 and 57 months, respectively. Voiding cystourethrography and ultrasound were performed at 3 months. In cases of persistent reflux repeat voiding cystourethrography was performed at followup. We then analyzed the surgical outcome for both groups. RESULTS: Mean followup for the injection and ECSR groups was 12 and 15 months, respectively. The success rate per moiety after injection was 68% at 3 months, which increased to 81.8% at 12 months. One patient had contralateral vesicoureteral reflux and none had de novo hydronephrosis, urinary tract infection or complications postoperatively. The success rate of ECSR was 95.5% at 3 months, which improved to 97.7% at an average of 15 months (p <0.04). After ECSR transient contralateral vesicoureteral reflux was seen in 4 renal units, de novo hydronephrosis was seen in 2 units and 4 patients had urinary tract infections. CONCLUSIONS: Although endoscopic subureteral polydimethylsiloxane injection was simple and successful in more than 80% of patients with low grade vesicoureteral reflux in duplex systems, it is less effective than surgery with regard to elimination of reflux.

Administration, Intravesical↗
PubMed2002

Matrix metalloproteinase activity, bone matrix turnover, and tumor cell proliferation in prostate cancer bone metastasis.

BACKGROUND: The metastasis of prostate cancer to bone is associated with a substantial increase in bone matrix turnover. Matrix metalloproteinases (MMPs) play roles in both normal bone remodeling and invasion and metastasis of prostate cancer. This study was designed to determine the role of MMP activity in prostate cancer that has metastasized to bone. METHODS: Single human fetal bone fragments were implanted subcutaneously in immunodeficient mice. Four weeks later, PC3 human prostate cancer cells were injected directly into some of the implants, and daily treatment was begun with batimastat (a broad-spectrum MMP inhibitor). There were six mice (i.e., six implants) in each of four experimental arms: bone alone with and without batimastat and bone injected with PC3 cells with and without batimastat. Bone implants were harvested after 14 days of treatment and analyzed for MMP expression, bone histomorphometry, osteoclast counts, blood vessel density, and tumor cell proliferation and apoptosis. Complementary data were obtained from bone biopsy samples from patients and a bone organ coculture system. All statistical tests were two-sided. RESULTS: MMPs were detected in tumor and stromal cells of clinical specimens and experimental bone implants. In vivo, MMP inhibition reduced the number of osteoclasts per millimeter in PC3-injected implants-from 8.2 (95% confidence interval [CI] = 7.9 to 8.5) to 3.0 (95% CI = 2.3 to 3.7) (P =.006). In addition, it prevented degradation of marrow trabeculae within the bone implants (cross-sectional area of implant occupied by mineralized trabeculae: untreated implant = 29.1% [95% CI = 27.1% to 31.1%], PC3-injected implant = 14.0% [95% CI = 10.9% to 17.1%] [P =.005 versus untreated], and batimastat-treated PC3-injected implant = 27.2% [95% CI = 22.4% to 32.0%] [P =.03 versus PC3 injected alone]). MMP inhibition reduced proliferating tumor cells from 20.8% (95% CI = 19.9% to 21.7%) to 7.4% (95% CI = 5.2% to 9.6%) (P =.006), without affecting angiogenesis or apoptosis. In vitro, MMP inhibition had no toxic effect on PC3 cells but prevented calcium release from bone fragments cocultured with PC3 cells. CONCLUSIONS: MMP activity appears to play an important role in bone matrix turnover when prostate cancer cells are present in bone. Bone matrix turnover and metastatic tumor growth appear to be involved in a mutually supportive cycle that is disrupted by MMP inhibition.

Animals↗
PubMed2002

The fate of the upper urinary tract in exstrophy.

PURPOSE: We evaluated the impact of reconstructive bladder procedures on the upper urinary tract in bladder/cloacal exstrophy. MATERIALS AND METHODS: A total of 57 patients underwent bladder neck procedures for urinary incontinence due to bladder exstrophy between 1988 and 2001. We correlated evidence of renal injury to urinary continence and type of surgery. Renal scarring and moderate/severe hydronephrosis were considered significant upper tract changes. RESULTS: Overall 27 patients (47%) underwent bladder neck closure, 38 (67%) augmentation cystoplasty and 44 (77%) a Mitrofanoff procedure. Mean interval since last continence procedure was 4.5 years and mean patient age at last followup was 11.7 years. Hydronephrosis was noted in 18 patients (32%) at last followup (after bladder neck reconstruction in 15). Renal scarring in 14 cases on dimercapto-succinic acid scan was evenly distributed regardless of the type of bladder neck procedure or presence of augmentation. Of 6 patients with grade 3 to 4 hydronephrosis 5 had renal scarring versus only 1 in the 39 without hydronephrosis (p <0.0001). Serum creatinine remained normal in 55 patients, mild renal insufficiency developed in 1 and renal transplantation was performed in 1. Two patients with persistent incontinence are anticipating an augmentation. CONCLUSIONS: Of our 57 patients with exstrophy 14 (24%) had significant upper tract damage in the form of renal scarring and/or moderate or severe hydronephrosis. The surgical method of achieving continence was not predictive of hydronephrosis or scarring. Bladder neck closure appears to provide better urinary continence and was equally safe with respect to hydronephrosis or scarring compared to patent forms of bladder neck reconstruction.

Bladder Exstrophy↗
PubMed2002

Histology of upper pole is unaffected by prenatal diagnosis in duplex system ureteroceles.

PURPOSE: We determined whether the histology of upper pole nephrectomy specimens vary with prenatal detection or ureterocele position. MATERIALS AND METHODS: Between 1992 and 2000, 95 patients with ureteroceles associated with a duplex system underwent surgical interventions, including upper pole nephrectomy in 60. A total of 55 specimens, of which 25 and 30 involved a prenatal and postnatal diagnosis, and 18 and 37 involved an intravesical and extravesical location, respectively, were available for independent review by a single pathologist. Histological lesions were classified into the 5 categories of chronic interstitial inflammation, fibrosis, tubular atrophy, glomerulosclerosis and dysplasia. Each category was divided into moderate/severe histological lesions (greater than 25% involvement) and minimal/mild lesions (25% or less involvement). RESULTS: A moderate/severe histological lesion was identified in 38 patients (69%) and a minimal/mild lesion was detected in 17 (31%), while dysplasia was present in 35 (64%). There was no significant difference in histological lesions and mode of presentation. In contrast to intravesical ureteroceles, extravesical ureteroceles were associated with severe fibrosis and tubular atrophy (p <0.05). Chronic interstitial inflammation, fibrosis, tubular atrophy and glomerulosclerosis in each specimen were graded moderate/severe (greater than 25% involved) in 55%, 67%, 66% and 53%, respectively. CONCLUSIONS: Prenatally diagnosed ureteroceles were not associated with less severe upper pole histological lesions. We noted pathological differences when comparing specimens according to ureterocele position, but chronic inflammation and dysplasia were similar in intravesical and extravesical ureterocele cases. It appears that the histological lesions observed are not progressive or reversible. Therefore, the goals of clinical management should focus on providing adequate drainage, antibiotic prophylaxis coverage and followup of reflux rather than the preservation or enhancement of upper pole function.

Child↗
PubMed2002

Comparison of costs and complications of radical and partial nephrectomy for treatment of localized renal cell carcinoma.

OBJECTIVES: To compare the complications and costs of radical and partial nephrectomy (PN) and to investigate the impact of increasing experience on costs and complications during a 7-year period. Nephron-sparing surgery has found increasing applications in the past decade. PN has achieved similar long-term results in localized renal cell carcinoma with respect to cancer control compared with radical nephrectomy (RN). However, data are limited on the direct comparison of complications and hospital costs between these two modalities. METHODS: A retrospective case-matched study was performed comparing 60 RNs and 60 PNs during a 7-year period with respect to complications and hospital costs. A longitudinal comparison was also performed between the various periods to assess the impact of surgical experience on these parameters. RESULTS: The mean length of stay was 6.4 +/- 3 days in the RN group and 6.4 +/- 3.3 days in the PN group. The hospital costs were comparable between the two procedures during the observed interval. The mean operative time was 176.6 +/- 51.6 minutes for RN and 220.1 +/- 59.6 minutes for PN (P = 0.0001). This difference was accentuated during the observed period. No differences were found in the blood loss and transfusion rates between the groups. The complication rate was 3.3% and 10% for RN and PN, respectively (P = 0.2). CONCLUSIONS: Our data suggest that RN and PN can be performed with a similar rate of complications and comparable hospital costs. This is of practical importance when comparing these modalities as treatment options for localized renal cell carcinoma.

Adult↗
PubMed2002

Midshaft hypospadias.

The key to successful hypospadias surgery is minimal tissue handling, tension-free reconstruction, the use of well-vascularized tissue, and knowledge of which repairs are indicated. Preservation of the urethral plate along with an onlay graft has a low complication rate and should be attempted for midshaft hypospadias repair. Although tubularized pedicle flaps increase the risk of complications such as urethral strictures, urethral diverticula, and fistulas, they provide a good alternative in the presence of a poorly developed urethral plate. For correction of the penile curvature, we recommend ventral lengthening procedures in cases where simple dorsal plication will result in shortening of an already compromised penile length. Using these principles, excellent cosmetic and functional results can be expected for treatment of midshaft hypospadias.

Catheterization↗
PubMed2002

Impact of prenatal diagnosis on the morbidity associated with ureterocele management.

PURPOSE: We postulated that prenatal detection of ureteroceles has a positive impact on the natural history and clinical outcome of ureteroceles in duplex system. MATERIALS AND METHODS: Between 1992 and 2000, 95 children underwent surgery for a ureterocele in a duplex system. We evaluated the impact of prenatal diagnosis in 40 cases versus postnatal diagnosis in 55 on morbidity, as measured by postoperative urinary tract infection and secondary procedures, while controlling for ureterocele type and the initial surgical approach. RESULTS: Mean followup in the 2 groups was 3.9 years. Preoperatively the reflux rate was 51% in the prenatal and 66% in the postnatal groups. Preoperatively urinary tract infections were less common in the prenatal group (12% versus 84%). Mean age at initial intervention in prenatally and postnatally diagnosed patients was 6 and 31 months, respectively. Postoperatively the urinary tract infection rate was double in postnatally diagnosed patients. Overall postoperatively reflux was similar in the 2 groups and grades III to V reflux with urinary tract infection accounted for 14 of the 21 secondary bladder procedures (67%). After initial endoscopic decompression none of the prenatally diagnosed patients with intravesical ureteroceles required reoperation, whereas 6 (50%) with extravesical ureteroceles required reoperation. All 10 prenatally diagnosed extravesical ureteroceles treated with partial nephrectomy were cured. Overall the secondary procedure rate in the postnatal group was higher than in the prenatal group (46% versus 20%, p = 0.02). Also, there was a difference in the reoperation rate in the endoscopic decompression group according to mode of presentation (p = 0.03) and a difference when comparing endoscopic treatment with partial nephrectomy in all patients (p = 0.02). CONCLUSIONS: Prenatal diagnosis decreases morbidity and potential adverse outcomes related to infection. Overall prenatal diagnosis is associated with a decreased rate of secondary procedures independent of the type of ureterocele. Prenatally diagnosed intravesical ureteroceles may be cured by endoscopic incision alone but for extravesical ureteroceles partial nephrectomy appears to be more definitive.

Child↗