Vaginal mucosal immunization for recurrent urinary tract infection: extended phase II clinical trial.
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Adolescent↗
Biomedical subjects
J V Kryger
Publications and source records attributed to J V Kryger.
Long-term results of artificial urinary sphincters in children are independent of age at implantation.
PURPOSE: The long-term success and efficacy of the artificial urinary sphincter for the management of neurogenic incontinence have been well documented. We evaluated if long-term results were affected by patient age at the time of sphincter placement. MATERIALS AND METHODS: A retrospective review of the medical records of patients who underwent artificial urinary sphincter placement and had minimum of 10 years of followup was conducted. All patients with an intact sphincter were interviewed to assess current results. Patients were stratified into groups 1 and 2 if the sphincter was implanted before or after age 11 years, respectively, and the results were compared statistically. RESULTS: An artificial urinary sphincter was placed in 45 children at Children's Hospital of Michigan between October 1978 and August 1986, and medical records and followup were available for 32. Mean followup was 15.4 years. Of the 21 group 1 patients 12 (57%) have an intact sphincter after 26 revisions, and all are dry and 9 (75%) require intermittent catheterization. Of the 11 group 2 patients 7 (64%) have an intact sphincter, and 6 (86%) are dry, 3 (43%) perform intermittent catheterization and 6 required 8 revisions. There was no statistically significant difference in the number of artificial urinary sphincter removals, continence, revision rate, bladder augmentations, complications or upper tract changes. CONCLUSIONS: The artificial urinary sphincter is a successful and durable option for the surgical management of neurogenic incontinence. The long-term results appear independent of patient age at the time of sphincter placement.
Adolescent↗
Surgical management of urinary incontinence in children with neurogenic sphincteric incompetence.
PURPOSE: There are many alternatives for the surgical treatment of children with neurogenic sphincteric incompetence. However, there is no consensus regarding appropriate evaluation and long-term management in these patients. We critically reviewed the literature and compare the outcomes of each technique. MATERIALS AND METHODS: A MEDLINE search was performed to select all relevant peer reviewed publications since 1966. In addition, the bibliography of each article was examined for additional published resources. The results of each technique were compared in 7 objective categories, including continence (defined as complete dryness for 4 hours between voidings or catheterizations), the need for intermittent catheterization, effects on bladder compliance, the need for bladder augmentation, upper tract changes, other complications and the revision rate. RESULTS: Long-term results of artificial urinary sphincter placement were superior and reproducible in terms of continence, preservation of volitional voiding and avoidance of bladder augmentation. Revision rates of various procedures were similar but the incidence of complications was highest with the Kropp procedure. Long-term published data were limited in regard to bladder neck sling, reconstruction, injection, suspension and urethral lengthening techniques. CONCLUSIONS: Long-term published data support artificial urinary sphincter creation as first line surgical management of neurogenic sphincteric incontinence. Girls who already depend on intermittent catheterization may benefit equally from a sling procedure if successful long-term continence is demonstrated in future studies.
Child↗
A simplified technique of upper pole heminephrectomy for duplex kidney.
PURPOSE: We describe a simplified technique of upper pole heminephrectomy in cases of duplex kidney. MATERIALS AND METHODS: The upper pole collecting system is entered and the upper pole is excised. The vascular supply to the upper pole is then easily identified and divided. The upper pole ureter is dissected below the lower pole vessels and distal ureteral dissection is completed. We performed the technique in 11 girls and 3 boys with a mean age of 1. 8 years who had poor or nonfunctioning upper moieties of duplicated kidneys. The diagnosis was ectopic ureter in 11 cases and ureterocele with duplication in 3. RESULTS: Mean surgical time was 95 minutes. Blood loss was not clinically significant in any patient and mean hospitalization was 2.7 days. The only postoperative complication was atelectasis, which resolved promptly with medical treatment. There was no injury to the lower pole ureter or vascular pedicle. CONCLUSIONS: Our technique enables reliable and safe excision of upper pole renal tissue with the maximal preservation of functioning lower pole parenchyma. The chance of inadvertent entry into the lower pole collecting system is significantly decreased since the demarcation of the upper and lower moieties is clearly identifiable. In addition, the avoidance of initial, potentially cumbersome hilar dissection minimizes the risk of injury to the lower pole ureter and vascular supply. This technique may be performed rapidly and requires only brief hospitalization postoperatively.
Female↗
Quantitative nuclear cystography does not predict outcome in patients with primary vesicoureteral reflux.
PURPOSE: Quantitative nuclear cystography has been advocated as a tool for determining the prognosis in children with primary vesicoureteral reflux. We reviewed our data on this technique to assess its usefulness for predicting the outcome in this population. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients with primary reflux in whom findings were positive on at least 2 nuclear cystograms at our institution between 1992 and 1997. Patients followed at least 3 years were stratified according to outcome. Unfavorable prognostic criteria included bladder volume at reflux onset 60% or less of total bladder capacity and calculated volume of reflux 2% or greater of bladder capacity. RESULTS: Of the 107 patients in our study 63 were followed for 3 years or longer, and reflux resolved in 17, was repaired in 24 and persisted in 22. Mean patient age at latest followup, duration of followup and number of cystograms did not significantly differ among groups. Intermittent reflux in 33% of the patients followed 3 years or longer was not associated with outcome or detrusor instability. Bladder and reflux volume varied and was nonpredictive in individuals. CONCLUSIONS: Quantitative nuclear cystography did not predict the outcome in patients followed for primary vesicoureteral reflux at a single institution for 3 years or longer. Intermittent reflux was common. These data suggest that nuclear cystography cannot be used to assess reliably the prognosis in individuals. Strong consideration should be given to using negative findings on 2 cystograms to confirm reflux resolution in patients at high risk.
Adolescent↗
The outcome of artificial urinary sphincter placement after a mean 15-year follow-up in a paediatric population.
OBJECTIVE: To evaluate the long-term outcome in children who had an artificial urinary sphincter (AUS) placed, after a minimum of 10 years of follow-up. PATIENTS AND METHODS: The medical records of patients who had an AUS placed at the Children's Hospital of Michigan were reviewed and a telephone questionnaire was then completed by all patients with an AUS currently in place. RESULTS: Forty-seven children initially had an AUS placed between October 1978 and August 1986; medical records and follow-up were available for 32. After a mean follow-up of 15.4 years, 13 patients had had the AUS removed and 19 currently have an intact AUS. Erosion or infection was responsible for all AUS removals. Possible risk factors for AUS removal were prior AUS erosion, prior bladder neck surgery and a balloon pressure of >70 cmH2O. Eighteen of 19 patients with an intact AUS are dry and seven void volitionally. Revision was the most common reason for additional surgery, but the revision rate has decreased with the most current AS-800 model, to 0.03 revisions per patient-year. Of the 13 patients with an AS-800 model placed after 1987, nine have not required revision. Upper tract changes were mild and uncommon. CONCLUSION: The AUS is a durable and effective surgical option in the management of neurogenic urinary incontinence, and is the only reliable technique that can preserve volitional voiding. With technical improvements to the AUS and a longer follow-up, the revision rate has decreased. Causes of AUS removal may be preventable with improvements in surgical technique and patient selection. AUS placement should be considered as a first choice for the surgical management of neurogenic sphincteric incompetence.
Adolescent↗
Effects of an environmental endocrine disruptor on fetal development, estrogen receptor(alpha) and epidermal growth factor receptor expression in the porcine male genital tract.
PURPOSE: We studied the effect of a potent reproductive tract toxin, 2,3,7,8-tetrachlorodibenzo-rho-dioxin, on fetal development and expression of estrogen receptor alpha and epidermal growth factor receptor (EGFR) in male swine. MATERIALS AND METHODS: Fetal domestic swine and miniswine were injected with 1 microg./kg. dioxin on day 50 of gestation and removed near term (114 days). Germ cell counts were performed on sections of formalin fixed testes. Estrogen receptor a protein, and messenger ribonucleic acid (mRNA) and EGFR mRNA expression were analyzed in frozen tissue using Western blotting and semiquantitative reverse transcriptase polymerase chain reaction. RESULTS: Of 15 dioxin exposed male offspring 8 (53%) had genital anomalies, including cryptorchidism in 4, epididymal detachment in 1, epididymal atresia in 1 and vasal dilatation in 3, while 3 of 17 control male swine (18%) had incompletely descended testes (p = 0.06). High intra-abdominal testes were found in 3 of 4 cryptorchid dioxin exposed but no control male swine. Mean germ cell number per tubule was 4.0+/-1.1 and 2.7+/-0.7 in control and dioxin groups, respectively (p = 0.01). Estrogen receptor a protein and mRNA were identified in fetal uterus, testis, gubernaculum and epididymis. Protein levels were 2 to 3-fold higher in dioxin exposed testis, and mRNA levels were significantly lower in gubernaculum and epididymis. EGFR mRNA expression was similar in treated and control testis and epididymis. CONCLUSIONS: Preliminary data suggest that dioxin produces cryptorchidism and wolffian duct anomalies in male swine exposed just before mid gestation. Germ cell counts and estrogen receptor alpha mRNA expression in gubernaculum and epididymis were significantly reduced, and estrogen receptor a protein expression in testis appeared to be increased by dioxin exposure. Aberrant regulation of estrogen receptor a expression by dioxin may contribute to reproductive tract anomalies in male fetuses.
Animals↗
Outcomes of contemporary percutaneous nephrostolithotomy in morbidly obese patients.
PURPOSE: The surgical management of renal and ureteral calculi presents unique challenges in the obese patient. We reviewed our recent experience with percutaneous nephrostolithotomy in patients with a body mass index greater than 30. MATERIALS AND METHODS: We reviewed the records of 236 patients undergoing percutaneous nephrostolithotomy between August 1994 and March 1997 at 2 university and affiliated hospitals. Among this group 57 patients had a body mass index greater than 30 (mean plus or minus standard deviation 38.9 +/- 7.4). Renal anomalies were present in 21% of patients and more than half (56%) had co-morbidities in addition to obesity. Staghorn calculi were present in 19 patients (31.7%). In the remaining patients the mean cumulative stone size for single or multiple stones was 14.5 +/- 8.7 mm. Stone-free status after the procedure was determined by plain nephrotomograms or noncontrast computerized tomography. RESULTS: A total of 96 procedures were performed on 60 renal units (1.6 procedures per renal unit). Average operative time for the initial procedure was 181.2 +/- 91.4 minutes. Complications occurred in 8 patients (14%) and 5 (8.8%) received a blood transfusion. Average hospital stay was 4.9 +/- 3.1 days. The overall stone-free rate was 88.3%, and stone-free rate for staghorn calculi was 84.2% compared with 90.2% for nonstaghorn calculi. CONCLUSIONS: Percutaneous nephrostolithotomy in obese patients yields a stone-free rate that is comparable to that achieved in an unselected patient population. The complication rate, transfusion rate and hospital stay are also similar. Modifications to standard technique and instrumentation are sometimes necessary to perform percutaneous nephrostolithotomy in this group of patients.
Adult↗
Optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi.
PURPOSE: We compare the efficacy of percutaneous nephrostomy with retrograde ureteral catheterization for renal drainage in cases of obstruction and infection associated with ureteral calculi. MATERIALS AND METHODS: We randomized 42 consecutive patients presenting with obstructing ureteral calculi and clinical signs of infection (temperature greater than 38 C and/or white blood count greater than 17,000/mm.3) to drainage with percutaneous nephrostomy or retrograde ureteral catheterization. Preoperative patient and stone characteristics, procedural parameters, clinical outcomes and costs were assessed for each group. RESULTS: Urine cultures obtained at drainage were positive in 62.9% of percutaneous nephrostomy and 19.1% of retrograde ureteral catheterization patients. There was no significant difference in the time to treatment between the 2 groups. Procedural and fluoroscopy times were significantly shorter in the retrograde ureteral catheterization (32.7 and 5.1 minutes, respectively) compared with the percutaneous nephrostomy (49.2 and 7.7 minutes, respectively) group. One treatment failure occurred in the percutaneous nephrostomy group, which was successfully salvaged with retrograde ureteral catheterization. Time to normal temperature was 2.3 days in the percutaneous nephrostomy and 2.6 in the retrograde ureteral catheterization group, and time to normal white blood count was 2 days in the percutaneous nephrostomy and 1.7 days in the retrograde ureteral catheterization group (p not significant). Length of stay was 4.5 days in the percutaneous nephrostomy group compared with 3.2 days in the retrograde ureteral catheterization group (p not significant). Cost analysis revealed that retrograde ureteral catheterization was twice as costly as percutaneous nephrostomy. CONCLUSIONS: Retrograde ureteral catheterization and percutaneous nephrostomy effectively relieve obstruction and infection due to ureteral calculi. Neither modality demonstrated superiority in promoting a more rapid recovery after drainage. Percutaneous nephrostomy is less costly than retrograde ureteral catheterization. The decision of which mode of drainage to use may be based on logistical factors, surgeon preference and stone characteristics.
Adult↗
Bladder cancer screening.
Transitional cell carcinoma of the bladder possesses several features that make it an ideal candidate for screening: metastases rarely occur before tumors invade the muscularis propria; superficial disease is treated very successfully by relatively inexpensive and nonmorbid means; this malignancy is almost never found incidentally at autopsy so that early detection cannot harm a patient; and almost all tumors cause hematuria if one tests frequently enough. When compared with a contemporary age, geography, and gender-matched unscreened population, bladder cancer screening in healthy men age 50 years and older by repeated home hematuria testing using chemical reagent strips significantly decreases bladder cancer morbidity and mortality and is cost-effective. A randomized prospective trial of bladder cancer screening in this population is recommended. Additionally, other potential means of bladder cancer screening and other target populations are discussed in this article.
Biomarkers, Tumor↗