Evidence Of Obstruction Research Articles

A 42-Year-Old Woman With Flaccid Paralysis

A 42-Year-Old Woman With Flaccid Paralysis

Biventricular noncompaction in a patient with dextrocardia/dextroversion diagnosed with cardiac magnetic resonance imaging

A five-year-old boy was referred for follow-up of a surgical correction of partial anomalous pulmonary venous return. Echocardiography and magnetic resonance imaging (cMRI) showed visceral heterotaxy with bilateral left atrial appendage morphology. The ventriculoarterial connection was concordant with dextrocardia/dextroversion. Multiple muscular ventricular septal defects near the apex were also observed. There were no ventricular outflow tract or aortic arch obstructions. A slightly increased flow was observed in the repaired pulmonary veins but there was no evidence of obstruction. The patient’s left ventricle (LV) demonstrated extensive trabeculations with flow into the deep intertrabecular recesses, which suggested the presence of LV noncompaction (Figure 1). cMRI confirmed the diagnosis of myocardial noncompaction in the LV (Figure 2). Most of the LV was affected, except for the basal part of the septum, with a noncompacted to compacted layer ratio of 4:1. The involved area showed significant thinning of the compact layer of the myocardium. Furthermore, there was involvement in the apical part and inferior wall of the right ventricle (RV) (Figure 2). Figure 1) Colour Doppler echocardiogram in parasternal short-axis view, showing penetration of colour into the deep intertrabecular recesses Figure 2) Short-axis fast cine magnetic resonance image of the ventricles shows typical lacy pattern of noncompacted left ventricular (LV) myocardium (arrows). Note that the LV free wall is more extensively involved than the ventricular septum. The compact layer ... Despite these findings, systolic function was within normal limits and the patient was asymptomatic. The patient continues to follow up on a regular basis. He remains off medications and has a normal level of activity with no symptoms or signs of heart failure, arrhythmia or thromboembolic events. Noncompaction of the ventricles is a newly recognized cardiomyopathy (1) that is believed to arise from arrested endomyocardial development during embryogenesis. The incidence of this cardiomyopathy in all pediatric patients receiving echocardiograms is 0.05%, but was found to be 2% in those patients with congenital heart disease (up to 22% in patients with single left ventricle) (2). Noncompaction has primarily been described in the LV; however, there have been reports of biventricular or isolated RV involvement (3). Because of increased trabeculations normally found in the RV, RV noncompaction is more difficult to diagnose than LV noncompaction. Ventricular noncompaction has been most extensively studied using two-dimensional and colour Doppler echocardiography. cMRI is increasingly being used to more accurately diagnose LV noncompaction. Borreguero et al (4) suggested the potential role of cMRI in the evaluation of the RV with noncompacted myocardium. Our patient represents an example of biventricular noncompaction in which cMRI aided the diagnosis. To our knowledge, the present patient is the first to be described with biventricular noncompaction in the presence of dextrocardia/dextroversion since the official description of this cardiomyopathy. A case with a similar biventricular “bizarre trabecular pattern” was published almost 30 years previously (5). However, in that case, there was no clear description regarding the extension and the ratio between the compacted and noncompacted myocardium. Furthermore, that case was associated with anomalies that generate significant intraventricular pressure overload.

Hydralazine-Induced Cholestatic Hepatitis

Hydralazine has been widely used for treating hypertension, particularly in patients with renal failure. We report a case on a patient in whom we believe the drug was implicated in an otherwise unexplained disturbance of liver function. A 63-year-old African-American female with medical history of hypertension and end-stage renal disease (on hemodialysis) was admitted to the hospital with epigastric pain and jaundice. The symptoms started about 1 week ago. Initial laboratory tests showed abnormal liver enzymes with elevated conjugated bilirubin and alkaline phosphatase suggestive of cholestatic jaundice. Amylase and lipase were normal. Abdominal ultrasound showed normal caliber common bile duct without evidence of obstruction. Abdominal CT scan does not show any evidence of intra- or extrahepatic biliary ductal dilatation, and no mass lesions were seen in the pancreas. Further blood chemistry showed worsening of liver enzymes and increased bilirubin over the next 2-3 days. Magnetic resonance cholangiopancreatography failed to show any evidence of intra- or extrahepatic biliary ductal dilatation. No other laboratory evidence of cholestatic jaundice was found. Before proceeding for invasive diagnostic procedure, that is, endoscopic retrograde cholangiopancreatography, the patient's drug history was reviewed. She was on hydralazine 75 mg 3 times per day, started 5 months ago. At that time, her liver function tests were normal. As we could not find any other cause of cholestatic jaundice, we attributed this as a side effect of hydralazine. A trial was given by stopping the hydralazine. It was seen that there was significant improvement in the liver function enzymes over the next week. Complete clinical and biochemical recovery occurred over the next 4 weeks. Liver injury after long-term therapy with hydralazine and after short-term therapy with hydralazine (2-10 days) has been described. Hydralazine-induced hepatotoxicity may manifest as hypersensitivity-type injury, mixed hepatocellular injury, acute hepatitis, cholestatic jaundice, or centrilobular necrosis. The Hydralazine-induced cholestatic liver injury seems to be fully reversible. Complete clinical and biochemical recovery occurs after discontinuation of the drug. Also, the differential diagnosis of any patient with hepatocellular injury should include medications. This will prevent unnecessary diagnostic tests.

An unusual presentation of immotile-cilia syndrome with azoospermia: Case report and literature review

Immotile-cilia syndrome is a rare disorder characterized by chronic recurrent sino-pulmonary infection, impaired tracheobronchial clearance, situs inversus in about 50% of cases, and living but immotile spermatozoa of normal morphology in semen analysis. In this report, we describe an unusual presentation of immotile-cilia syndrome with azoospermia in a 32-year-old male patient. The diagnosis was based on history of recurrent respiratory tract infection, bronchiectasis, maxillary sinusitis, hypoplasia of frontal sinuses, dextrocardia with situs inversus, impaired nasal mucociliary clearance, etc. Semen analysis revealed azoospermia without any evidence of obstruction in epididymides or vas deference. Normal spermatogenesis was seen on testicular biopsy.

Novel use of a tracheobronchial stent in a patient with uterine didelphys and obstructed hemivagina

To describe a novel use for a tracheobronchial stent to maintain patency after vaginal septum excision in a patient with an obstructed hemivagina and uterine didelphys. Description of a novel technique. University-affiliated children's hospital. One patient with an obstructed hemivagina and uterine didelphys who presented with hematometria and hematocolpos. To maintain patency and decrease stenosis risk after vaginal septum excision, a coated tracheobronchial stent was deployed and left in place for 6 weeks. To evaluate ease of stent placement and removal, reepithelialization and patency of the neovagina, and postoperative assessment of pain and recurrent obstruction. The tracheobronchial stent was easily positioned and deployed with vaginoscopic guidance. Six weeks later it was removed without any tissue ingrowth or granulation tissue noted. The vaginal walls were nicely epithelialized. Twelve months postoperatively, the patient remained pain free with regular cycles and no evidence of obstruction or abnormality on ultrasound. Use of a coated tracheobronchial stent to maintain patency after septum excision in a patient with an obstructed hemivagina presents a safe, easy, and effective option to diminish stenosis risk and avoid infectious complications or hysterectomy.

Index of Suspicion

Index of Suspicion

Sinusitis and chronic progressive exercise-induced cough and dyspnea

We present the case of a 47-year-old man with exercise-induced dyspnea, cough, chest tightness, and recalcitrant chronic rhinosinusitis. Evaluation revealed IgE sensitization to grass, tree, and weed pollen, no evidence of obstruction on spirometry, and a negative methacholine challenge. Diagnostic considerations included allergic and nonallergic rhinitis, asthma, aspirin-exacerbated respiratory disease, vocal cord dysfunction, extra-esophageal manifestations of acid reflux, and vasculitits. Further evaluation with sinus imaging, laryngoscopy, ambulatory pharyngeal pH testing, upper endoscopy, and bronchoscopy led to a diagnosis. Key issues surrounding the diagnostic and therapeutic approaches to this patient's condition are reviewed.

Surgical management of failed pyeloplasty in children: Single-center experience

To evaluate the outcome of secondary surgical procedures for the management of failed pyeloplasty in children. Between 1996 and 2007, 590 cases of primary ureteropelvic junction (UPJ) obstruction underwent open dismembered pyeloplasty at our center. Of these patients, 18 (3%) with recurrent UPJ obstruction (14 males, 4 females; age range: 2-15 years) have undergone management of failed pyeloplasty. Secondary intervention was by open operative procedure in all cases. Clinical and radiological outcomes were assessed. Success was defined as both symptomatic relief and radiographic resolution of obstruction at last follow up. Follow up ranged from 8 to 41 months (mean 28). The overall salvage rate was 89%. Secondary reoperative surgery was successful in 16 patients: dismembered pyeloplasty in 14 patients (78%) and ureterocalyceal anastomosis in 2 (11%). Nephrectomy was necessitated in 2 patients (11%). No perioperative complications were encountered. All patients showed stability of renal function on radiological follow up without evidence of obstruction and with no further symptoms. Persistent UPJ obstruction after pyeloplasty is an uncommon complication. Secondary procedures have a very high success rate with excellent functional results. Nephrectomy is indicated in rare cases of severely deteriorated renal function.

Predicting Differential Renal Function Using Computerized Tomography Measurements of Renal Parenchymal Area

We evaluated any correlation between measured renal parenchymal area on computerized tomography and differential function on (99m)technetium-mercaptoacetyltriglycine renal scan to ascertain whether computerized tomography measurements could predict differential renal function. Between 2005 and 2007 we identified 111 patients who underwent computerized tomography and renal scan. Average renal parenchymal thickness was calculated by measurements made at the upper and lower poles of each kidney. The product of average renal parenchymal thickness and renal length was calculated bilaterally and the ratio of parenchymal area was compared to the differential shown on renal scan. The average difference between predicted and observed renal function was 4.73% (Pearson's correlation coefficient 0.959). Patients with positive urine cultures at renal scan were compared to the other 89. The average functional difference was 6.54% vs 4.28% (Pearson's correlation 0.955 vs 0.965, p = 0.0045). The 89 uninfected patients were then compared based on contrast vs noncontrast computerized tomography and obstructed vs unobstructed renal units. No statistical difference was found with contrast administration. When compared based on evidence of obstruction, unobstructed kidneys resulted in a lower Pearson correlation (0.743 vs 0.975) but they had a statistically significant average functional difference in favor of unobstructed units (3.28% vs 5.10%, p = 0.0036). No difference was found in the obstructed group with prior drain placement. Differential renal parenchymal area measured by computerized tomography strongly correlates with differential function on renal scintigraphy and it may obviate the need for nuclear renal scan in some circumstances.

‘Eat Your Heart Out!’- a Gastric Cause of Cardiac Valvular Dysfunction

Purpose: Extrinsic left atrial compression is an uncommon source of hemodynamic compromise that can be caused by many mediastinal structures. To date, however, few cases of hemodynamically significant left atrial compression secondary to gastric compression have been reported. An 85-year-old woman with past medical history of GI bleed presented with hematemesis and malena, shortness of breath and palpitations. Physical examination was positive for rapid, irregularly irregular pulse, variable intensity heart sounds, bilateral basal crepitations and moderate epigastric tenderness. ECG revealed atrial fibrillation with rapid ventricular rate. Shortly after her arrival to the emergency department, the patient's respiratory distress worsened and she had to be intubated. Patient was admitted to the Cardiac Intensive Care Unit. Chest X-ray revealed bilateral pulmonary edema, bilateral pleural effusions and significant air fluid level. Echocardiography revealed severe extrinsic compression of the left atrium with maximum left atrial diameter of 1.28 cm. There were Doppler markers of tamponade physiology including respiratory variation in mitral inflow velocity (89 cm/sec and 123 cm/sec). In addition, the trans- mitral valve gradient was 4.63 mmHg suggestive of moderate mitral stenosis due to external compressing mass. There was mild MR with some chordal SAM without significant LVOT obstruction. CT chest confirmed the presence of a large hiatal hernia compressing the left atrium. Following this patient had a single contrast upper GI series, which revealed organoaxial gastric volvulus with evidence of obstruction. Initially patient was medically managed with diuretics and gastric decompression. Definitive surgical treatment was undertaken thereafter. This case illustrates an uncommon presentation and interesting mechanism of ‘mitral stenosis’ physiology (with structurally normal valves) produced by a large hiatal hernia due to compressive effects on the heart.

Gastric Outlet Obstruction Caused by Replacement Gastrostomy Tube

3 90-year-old woman was admitted for a 2-week history of fever and persistent peristomal leakage. A percutaneous enoscopic gastrostomy (PEG) was placed a year earlier as a result of ultiple strokes resulting in dysphagia. During the ensuing year, he gastrostomy tube was replaced multiple times at the bedside as result of minor complications. The physical exam revealed a acerated peristomal site with surrounding erythema, induration, nd serosanguineous drainage. The abdominal exam was otherise normal without evidence of obstruction. An upper endoscopy as performed for placement of a new PEG; however, on examiation, absence of the pyloric opening was noted (Figure A).1 urthermore, the PEG tube was extending from the gastrocutaneus site to the opposite wall, with torsion of the distal stomach Figure B). A subsequent gastrostomy tube study revealed contrast xtrusion into the duodenum, suggesting the balloon was inflated n the small bowel. It was suspected that as a result of persistent anipulation of the PEG tube, torsion of the distal stomach and uodenum ensued, with a resultant anatomic gastric outlet obtruction. The wound dehiscence and cellulitis were believed to be result of leakage of gastric secretions around the peristomal site aused by the obstruction. Repeat esophagogastroduodenoscopy fter deflation of the balloon bumper revealed normal anatomy. ntubation of the duodenum noted a clean based ulcer attributed o pressure necrosis from the inflated balloon. A replacement PEG ube was inserted through the tract and anchored securely to the bdominal wall without any complication. The localized wound nfection has since healed. PEG tube placement is a low-risk procedure routinely erformed for patients who are unable to take food orally. ommon indications for placement include neurologic conitions with associated impaired swallowing, oropharyngeal, aryngeal, and esophageal neoplasms, facial trauma, and the eed for supplemental feedings in patients with miscellaeous catabolic conditions. Overall, the complication rate anges from 3%–14%, and mortality approaches 1%.1 Various ajor and minor complications have been described in the iterature. Commonly encountered problems include pain at he insertion site, leakage around PEG tube, tube displaceent by patient or health care personnel, tube obstruction, nd local ulceration or wound infection.2 This case is an example of an anatomically created gastric outlet bstruction, without the typical symptoms of nausea, vomiting, nd distention. Two theories have been postulated to explain the bove. As described by Lamont and Rode,3 passage of a gastrosomy tube past the pylorus into the small bowel with insufflation f the balloon can result in fixation within the small bowel. The econd theory implicates migration of the PEG tube through the ylorus as a result of improper anchoring to the abdominal wall. ortunately in this patient, absence of obstruction at the distal tip f the gastrostomy tube allowed for unimpeded feedings, and the toma provided an exit for air release and excess gastric secretions.

Not All Pseudomembranous Colitis is Caused by Clostridium difficile

A 43-year-old woman presented to hospital with a two-day history of acute left lower quadrant pain, nonbloody diarrhea and one episode of bilious emesis. She had a history of complicated systemic lupus erythematosus including end-stage renal disease requiring chronic hemodialysis. She had a remote history of pulmonary tuberculosis that had been appropriately treated. Four months earlier, she was admitted with community-acquired pneumonia and treated with 10 days of levofloxacin. There was no recent travel history, infectious contacts or suspicious food consumed, and no family history of inflammatory bowel disease. She immigrated to Canada from Cambodia in 1988, but had never returned to visit. Her medications included long-standing prednisone (15 mg daily), azathioprine, levothyroxine, carvedilol, pantoprazole, acetylsalicylic acid and pravastatin. Her examination revealed a fever of 39°C, pulse rate of 103 beats/min, a left sternal heave, a grade 2/6 systolic murmur at the left lower sternal border radiating to the apex with an S4, and a tender abdomen in the left lower quadrant without rebound or guarding. Laboratory results revealed a total leukocyte count of 12.4×109/L with a normal differential, and normal liver enzymes and serum lipase. Her blood cultures were negative. Abdominal x-rays showed mural thickening in the splenic flexure and descending colon, but no evidence of obstruction. An abdominal computed tomography scan revealed evidence of pancolitis. She underwent sigmoidoscopy which demonstrated only pseudomembranes on rectal biopsy. However, stool enzyme immunoassays for Clostridium difficile toxins A and B (C difficile ToxA-BII, Techlab, USA) were repeatedly negative; she did not respond clinically to oral metronidazole, and a repeat sigmoidoscopy one week later was unchanged. A diagnostic test was performed. What is the diagnosis?

Prenatally Diagnosed Abdominal Cystic Mass

A newborn presents with prenatal diagnosis of abdominal cystic mass according to fetal ultrasonography. ### Prenatal and Birth Histories: ### Presentation: The infant was crying and vigorous at birth. He was transferred to the neonatal intensive care unit for further evaluation. An abdominal radiograph showed air-filled bowel within the left abdomen. What is your assessment of the radiograph? Because the infant had just been born, the small bowel was considered to have a normal appearance, with no evidence of obstruction, free air, or pneumatosis. However, the …

Transperitoneal Laparoscopic Pyeloplasty in Children

Ureteropelvic junction (UPJ) obstruction remains the most common cause of hydronephrosis in newborns and children. Open pyeloplasty has been the gold standard for management of UPJ obstruction in these patients. We report our technique and outcome with laparoscopic transperitoneal dismembered pyeloplasty in children. Nineteen patients, ages 2 to 14 years, underwent laparoscopic pyeloplasty at our center between June 2004 and December 2006. Thirteen pyeloplasties were on the left side and six on the right side. A transmesocolic approach was used in five left-sided UPJ obstructions. All operations were performed by the transperitoneal route using either three or four ports. Sixteen patients underwent dismembered (Anderson-Hynes) pyeloplasty, while three had a nondismembered Foley's Y-V pyeloplasty. Mean operative time was 198 minutes (range 105-300 min). Mean estimated blood loss was 45 mL (range 30-130 mL). Mean length of stay was 4 days (range 3-5 d). Mean followup was 13.8 months (range 2-30 mos). Postoperatively, one child had a urinary tract infection that necessitated hospital admission and administration of intravenous antibiotics. Eighteen of 19 patients demonstrated improved drainage with no evidence of obstruction on diuretic renography and/or excretory urography. One patient is awaiting follow-up. There was no conversion to open surgery. Laparoscopic pyeloplasty in children is a safe, minimally invasive treatment option that duplicates the principles and techniques of definitive open surgical repair. It is technically challenging; with increasing expertise, operative times are reduced significantly.

Clinical Utility and Safety of Methacholine Challenge in Children with Sickle Cell Disease.

Introduction: Lung disease is major cause of morbidity in children with sickle cell disease (SCD), yet understanding of lung pathophysiology is lacking. The diagnosis of asthma in children with asthma has become an important consideration in clinical management because of its association with a twice greater the rate of painful and acute chest syndrome (ACS) episodes when compared to children without asthma. Provocation challenges with methacholine have been used in both clinical and research settings to evaluate the presence of degree of airway hyperresponsiveness (AHR) in studies of asthma; however, no such evaluation has been described in children with SCD.Methods: As part of routine clinical care, 21 children with SCD multiple or severe acute chest syndrome (ACS) episodes were challenged with methacholine to determine if AHR was a component of their recurrent respiratory tract symptoms.Results: A total of fourteen of the children had a positive challenge, none of whom had evidence of obstruction or bronchodilator reactivity on spirometry. Ten of fourteen patients were previously on inhaled corticosteroids and had their asthma diagnosis confirmed and four were given a new diagnosis of asthma. In each positive challenge, forced expiratory volume in one second reversed to at least 90% of baseline after bronchodilator treatment. No patient developed a painful or ACS episode temporally related to the challenge.Conclusion: Evaluation of AHR with methacholine challenge in patients with SCD appears to be well tolerated and may elucidate the basis of lung morbidity in a subgroup of children with repetitive or serious ACS episodes.

Transurethral resection of ejaculatory ducts in the treatment of complete ejaculatory duct obstruction

To evaluate the value of transurethral resection of the ejaculatory duct (TURED) in the treatment of complete ejaculatory duct obstruction (EDO) as a treatable cause of male factor infertility. We retrospectively evaluated 12 azoospermic infertile men who were diagnosed as having complete EDO. The mean age of the patients was 32 years (range 24-40). Inclusion criteria were EDO in patients with azoospermia, normal serum levels of gonadotropins and testosterone and evidence of obstruction on transrectal ultrasonographic (TRUS) images. The definitive diagnosis was based on the absence of an efflux of methylene blue injected through the seminal vesicles during cystoscopy. All patients were treated by TURED. Before TURED, all patients were azoospermic and had been considered as candidates for in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). Following the operation, sperms were seen in the ejaculates of 11/12 patients. After a mean follow-up period of 12 (range 4-36) months, five (41.6%) pregnancies were noted (three spontaneous, one with intrauterine insemination and one with IVF/ICSI). Transurethral resection was found to be a safe and somewhat effective approach for the treatment of EDO. After TURED, a significant improvement was achieved in semen parameters, and spontaneous pregnancy resulted in three cases. In addition, TURED can reduce the need for expensive procedures such as IVF/ICSI as this modality allows IVF/ICSI to be performed with ejaculated instead of surgically retrieved sperm.

Radiographic Changes Following Excisional Tapering and Reimplantation of Megaureters in Childhood: Long-Term Outcome in 46 Renal Units

Despite the routine use of renal ultrasonography to document progressive improvement in hydronephrosis following ureteral tailoring and reimplantation of megaureters, there have been few reports characterizing the serial radiographic changes to be expected following this procedure. We evaluated the radiographic outcomes following surgical repair of megaureters at single institution, and assessed potential preoperative factors for predicting outcome. We conducted a retrospective analysis of all patients who underwent surgical correction of clinically significant megaureters at our center between 1996 and 2003. Demographic data, indications for surgery, and preoperative and postoperative radiographic imaging data were recorded. A total of 46 megaureters (39 patients) were tapered and reimplanted. Average patient age at surgery was 4.0 years (range 5 months to 19 years). Indications for surgery included recurrent or breakthrough urinary tract infections, decreased renal function and increased hydroureteronephrosis. Mean followup was 3.9 years (range 4 months to 7 years). Postoperative voiding studies showed vesicoureteral reflux in 3 reimplanted ureters (7%). There was no evidence of obstruction on postoperative nuclear renal scans in any patient. Renal ultrasonography revealed improvement or resolution of hydroureteronephrosis in 29 reimplanted units (63%). In general, male patients, those operated on at a younger age and those with a lower preoperative grade of hydronephrosis were most likely to demonstrate improvement or resolution of hydronephrosis. The best results were seen in ectopic megaureters, followed in decreasing order by refluxing megaureters, megaureters associated with ureteroceles and primary obstructive megaureters. Despite functional improvement on postoperative radiographic imaging, it is not uncommon to see persistent hydroureteronephrosis following excisional tapering and reimplantation of megaureters in childhood.

A 4-Year Review of Balloon Dilation of Ureteral Strictures in Renal Allografts

Ureteral obstruction necessitating intervention occurs in 2% to 7.5% of all renal allograft recipients. Conventional management includes open surgical repair, although more recently, percutaneous ureteral dilation has been performed. The management and outcome of all seven allograft ureteral strictures treated with balloon dilation in our unit over a 4-year period were reviewed. Half (55%) of these strictures occurred in the proximal ureter. Four strictures were dilated successfully with a requirement for five dilations in total. These patients have stable graft function with no evidence of obstruction. Five strictures persisted despite 11 dilations. There were no significant complications from balloon dilation. Definitive surgical management should be considered if obstruction persists after one attempt at ureteral dilation, as multiple dilations have a low success rate (25%).

Salvage Extravesical Ureteral Reimplantation After Failed Endoscopic Surgery for Vesicoureteral Reflux

Open intravesical ureteral reimplantation has been reported to be uncomplicated following dextranomer/hyaluronic acid implantation. However, there are no known reports regarding extravesical ureteral reimplantation following dextranomer/hyaluronic acid failure. We reviewed our experience with extravesical ureteral reimplantation after dextranomer/hyaluronic acid failure. We reviewed the charts of 30 patients who underwent extravesical ureteral reimplantation after dextranomer/hyaluronic acid failure. If reflux was initially bilateral and only a unilateral cure was achieved, the cured ureter was not reimplanted. Intraoperative complications, need for stenting or prolonged bladder catheterization, length of hospitalization and radiographic results were noted. At cystoscopy the dextranomer/hyaluronic acid implants were not seen in half of the patients. In the remaining 15 patients the blebs had moved caudally and/or were seen extravesically at the ureteral hiatus or along Waldeyer's sheath. Unilateral extravesical ureteral reimplantation was performed without difficulty in all patients and there were no intraoperative complications. Stents were left indwelling only in those patients who had undergone dismembered ureteral reimplantation. No patient required prolonged bladder drainage. All patients except 2 who had undergone additional procedures were discharged home within 24 hours postoperatively. There was no evidence of obstruction on postoperative renal sonography, and extravesical ureteral reimplantation was confirmed to be successful in all 24 patients with postoperative voiding cystourethrograms. Extravesical ureteral reimplantation can be performed without difficulty following dextranomer/hyaluronic acid implantation. Since extravesical ureteral reimplantation is less morbid and better tolerated than intravesical reimplantation, it is an excellent treatment option for patients with persistent unilateral vesicoureteral reflux following dextranomer/hyaluronic acid implantation. Furthermore, in cases in which vesicoureteral reflux is initially bilateral our data suggest that reimplantation of the successfully treated contralateral ureter can be avoided.

Periurethral cellular injection: Comparison of muscle-derived progenitor cells and fibroblasts with regard to efficacy and tissue contractility in an animal model of stress urinary incontinence

Objectives To compare muscle-derived cells (MDCs) and fibroblasts with regard to their potential for restoration of urethral function on injection in a previously established animal model of stress urinary incontinence. Methods The animals were divided into four (dosage) or five (cell concentration) experimental groups: normal, nontreated controls (normal group) or bilateral sciatic nerve transection with either periurethral injection of saline (saline group), MDCs (MDC group), fibroblasts (fibroblast group), or MDC/fibroblast mixture (mixed group). At 4 weeks after injection, the leak point pressure (LPP) was measured and contractility testing and histologic analysis were performed. Results The histologic examination demonstrated muscular atrophy in the saline group and new striated muscle fibers at the sites of MDC injection in the MDC group, but not in the fibroblast group. Denervation of the urethra resulted in a significant decrease of maximal fast-twitch muscle contraction amplitude to only 9% of normal. MDC injection into the denervated urethra significantly improved the fast-twitch muscle contraction amplitude to 73% of normal. The LPP of the normal, saline, MDC, fibroblast, and mixed groups at 4 weeks after treatment was 43.3 ± 2.5, 25.8 ± 1.4, 38.2 ± 4.2, 38.3 ± 1.2, and 34.5 ± 3.3 cm H 2O, respectively. In the cell dosage experiment, the LPP increased with increases in the injected cell number. Evidence of obstruction was observed in the high-dose (1 × 10 7 cells) fibroblast group. Conclusions Although both MDCs and fibroblast injection increased the LPP in a stress urinary incontinence rat model, only MDCs significantly improved urethral muscle strip contractility. Moreover, urinary retention developed with high-dose fibroblast injection, but not with MDC injection.