Unilateral Grade Research Articles

GRAPPA at the European League Against Rheumatism (EULAR) 2008

Launched in the summer of 2003, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) is a nonprofit organization committed to advancing research and understanding of the assessment and treatment of psoriasis and psoriatic arthritis (PsA). This effort meets the need of helping rheumatologists recognize skin symptoms and helping dermatologists recognize joint symptoms for earlier diagnosis and more appropriate treatment of this disease, which affects millions of people throughout the world. GRAPPA members meet several times a year to discuss issues relevant to the organization’s objectives. There are 2 meetings a year adjacent to major rheumatology meetings: the American College of Rheumatology (ACR), which takes place in North America, and the European League Against Rheumatism (EULAR), which takes place in Europe; and adjacent to major dermatology meetings: the American Academy of Dermatology (AAD) in North America and the European Academy for Dermatology and Venereology (EADV) in Europe. Our report summarizes the recent GRAPPA meeting at EULAR, June 11, 2008, at the Paris Convention Center. This meeting was dedicated to defining psoriatic spondylitis. The prevalence of spinal involvement in patients with PsA has varied from 25% to 70%1. The wide variation is due to the lack of a common definition for psoriatic spondylitis. The agenda included presentations by a number of GRAPPA members followed by breakout groups and discussion. Philip Helliwell, of Leeds, UK, presented the background and issues to be addressed by the group. He pointed out that there have been 2 general approaches to the diagnosis of psoriatic spondylitis. One uses the criteria for ankylosing spondylitis (AS), which rely on the presence of signs and symptoms of inflammatory back pain and limitation of lumbar mobility as well as the presence of either bilateral grade 2 or unilateral grade 3 or 4 sacroiliitis. The other …

Diagnostic accuracy of color Doppler sonographic study of the ureteric jets in evaluation of hydronephrosis

Objective Hydronephrosis (HN) and obstruction are closely associated, but upper urinary tract dilatation can occur without significant obstruction. Despite some pitfalls, conventional ultrasonography and diuretic renography (DR) are the main means of evaluation of HN in children. Recent reports have demonstrated color Doppler ultrasonography (CDUS) to reliably identify ureteric jets in the bladder. The aim of this study was to evaluate this method as a diagnostic tool to distinguish obstructive from non-obstructive dilatations of the upper tract. Methods We evaluated 51 patients (37 boys and 14 girls), aged 3 months to 14 years (median 4 years), who presented with unilateral grade III and IV hydronephrosis with suspicion of pyeloureteral junction obstruction. All patients underwent DR and evaluation of ureteric jets by transverse CDSG of the bladder within a maximum of 2 weeks. Obstruction was considered in the DR when the hydronephrotic unit showed a differential renal function of less than 40%, or when symptomatic intermittent renal colic was present in older children. The number of ureteric jets was counted over a 5-min period and the frequency calculated for each ureteral orifice. Relative jet frequency (RJF) was defined as frequency of the hydronephrotic side divided by total ureteric jet frequency. Receiver-operating characteristic (ROC) plots were constructed to determine the best cut-off for RJF, in order to identify renal units with obstructive hydronephrosis. Results Twenty-three (45.1%) hydronephrotic units were considered obstructed. The mean RJF differed between obstructive (0.09 ± 0.15) and non-obstructive hydronephrosis (0.42 ± 0.11) ( p < 0.001). ROC analysis revealed that RJF <0.25 was the best threshold, and correctly discriminated obstruction in 91.2% of the children with a sensitivity of 87% (95% CI 78.6–98.2%) and specificity of 96.4% (95% CI 87.8–99%). The positive likelihood ratio was 24.3 and the area under the ROC curve was 0.92 (95% CI 0.86–0.98). Conclusions RJF <25% was found to be a good indicator of obstruction in children with unilateral hydronephrosis. CDUS evaluation of ureteric jets is an easy and non-invasive method that can be used as an initial diagnostic tool, and in follow-up cases, to differentiate obstructed from non-obstructed hydronephrosis in the pediatric population.

Axial disease in psoriatic arthritis

The definition of axial disease in psoriatic arthritis has varied from isolated unilateral grade 2 sacroiliitis to criteria similar to those used for ankylosing spondylitis. Depending on the definition used, the prevalence of axial disease varies from 25% to 70% of patients with psoriatic arthritis. This article reviews the prevalence, clinical and radiologic features, pathogenesis, prognosis, and treatment of psoriatic spondylitis.

The effect of taping on the proprioception of the ankle in a non-weight bearing position, amongst injured athletes

Background It is hypothesized that the application of adhesive tape prevents further sprains by enhancing proprioceptive acuity via the activation of the skin proprioceptive receptors of the surrounding area. Objectives To investigate the effects of taping on the proprioception of the ankle amongst injured athletes, when tested in a non-weight bearing position. Methods A pretest–posttest, quasi-experimental, same-subject design was applied. Twenty athletes, who had suffered at least one unilateral Grade I or Grade II ankle inversion sprain in the past volunteered to participate in the study. The Angle-reproduction test in two movement planes (inversion and plantar flexion) and four target angles (10° and 30° of plantar flexion, and 5° and 20° of inversion) was applied to all subjects under two conditions; without tape and with the application of the basket-weave heel lock taping technique. For the needs of the test, the Penny & Giles twin axis XM 180 goniometer and torsiometer was used. Results The t-tests yielded statistically significant differences between taped and untaped conditions at each target angle (plantar flexion 10°: p = 0.014, plantar flexion 30°: p = 0.034, inversion 5°: p = 0.009, inversion 20°: p = 0.008). Conclusions Adhesive taping seems to improve the ankle position awareness and thus the proprioceptive capability of the ankle in a non-weight bearing position. Further research, in the mode of a prospective matched controlled study, should explore the long-term effect of ankle taping in athletes involved in high contact sports.

The Use of Botulinum Toxin A Injection for the Management of External Sphincter Dyssynergia in Neurologically Normal Children

Botulinum toxin A has previously been used for neurogenic and nonneurogenic urgency and urge incontinence. We evaluated the effects of sphincteric botulinum toxin A injection in a series of neurologically normal children with evidence of external sphincter dyssynergia with various voiding problems documented by abnormal voiding electromyography as well as voiding cystourethrography to assess its effectiveness for eliminating post-void residual urine. We retrospectively reviewed the charts of 16 dysfunctional voiders who underwent botulinum toxin A injection to the external sphincter between 2002 and 2006, including 1 to 3 injections in 14, 1 and 1, respectively. Of 19 injections 17 were performed with 300 U to the sphincter, while 2 of 19 were done with 200 U. Two patients also received 100 U injected into the detrusor. Mean patient age at surgery was 9.0 years (range 6 to 16). Preoperative clinical data were recorded, including medications, electromyography, uroflowmetry with post-void residual urine, ultrasound and voiding cystourethrography. Before botulinum toxin A injection medical therapies had failed in all patients, including alpha-blockers in 100%, biofeedback in 100%, oxybutynin in 33% and tricyclics in 3 (20%). One patient was on intermittent catheterization. All patients were refractory to bowel regimens and timed voiding. Postoperative parameters consisted of medications, symptoms and post-void residual urine. In the 3 males the resolution of epididymitis symptoms and prevention of recurrence were evidence of success. Before treatment patients experienced symptoms of urge incontinence (14 of 16), recurrent urinary tract infections (66%), voiding postponement (45%) and epididymitis (3 of 16). All patients had external sphincter dyssynergia, as documented by preoperative electromyography or voiding cystourethrography. Average preoperative post-void residual urine was 107 cc (range 49 to 218). Two patients who underwent preoperative voiding cystourethrography had unilateral grade 1 reflux. Of the 16 children 12 (75%) were dry at the first postoperative visit. The remaining 2 patients had decreased enuresis and 13 of 16 were dry at the second postoperative visit. The last patient became dry after treatment for attention deficit disorder was initiated. Average initial postoperative post-void residual urine volume was 43 cc (range 0 to 141) and the average best postoperative visit post-void residual urine was 8 cc (range 0 to 26). Uroflow data revealed no difference in uroflow before or after injections. Neuropsychiatric problems were present in 9 of the 16 patients, including depression in 4, anxiety in 3 and attention deficit disorder in 2. Before our study in the pediatric literature doses between 50 and 100 U were used. We used a significantly higher dose with increased efficacy and no increased morbidity. Endoscopic botulinum toxin A injection of the external sphincter appears to be a safe and efficacious way to treat refractory nonneurogenic voiding dysfunction in children with external sphincter dyssynergia. Long-term followup is necessary and repeat endoscopic injections may be required in select patients.

Relationship of Varicocele Grade and Testicular Hypotrophy to Semen Parameters in Adolescents

Surgical indications for correcting adolescent varicocele include high varicocele grade and testicular hypotrophy. To our knowledge these findings have not been correlated with semen parameters to date. We examined the relationship between unilateral left varicocele grade or the testicular volume differential and semen parameters in adolescents. Semen analyses were done in 57 Tanner stage V adolescent males at ages 14 to 20 years (mean+/-SD 18 +/- 1.6). Varicocele grade was determined by the attending urologist. Testicular volumes were determined by scrotal ultrasound performed by an attending sonologist. Data analysis was performed using nonparametric statistical methods. Boys with testicular volume differentials greater than 10% vs those with differentials less than 10% had significantly lower sperm concentration and total motile sperm counts. For differentials greater than 20% these decreases were more dramatic. Percent motile sperm was significantly lower for boys with volume differentials greater than 20% vs those in the less than 10% and 10% to 20% categories. No significant differences were detected in percent normal morphology among the volume differentials. No significant differences were detected for any semen analysis parameter as a function of varicocele grade. Sonographically derived volume differentials greater than 10% between normal and affected testes correlate with a significantly decreased sperm concentration and total motile sperm count. This finding may serve as a marker to identify adolescents with unilateral left varicocele who are at greatest risk for future infertility. At least semen analysis and close annual followup of these adolescents seem warranted.

New Contralateral Vesicoureteral Reflux After Endoscopic Correction of Unilateral Reflux—Is Routine Contralateral Injection Indicated at Initial Treatment?

As more and more pediatric urologists use endoscopic therapy as a primary treatment option for vesicoureteral reflux, newer indications for this procedure are being considered. Recently it was suggested that contralateral nonrefluxing ureters should be treated prophylactically in patients undergoing unilateral endoscopic correction of vesicoureteral reflux. We analyzed the incidence of newly diagnosed contralateral reflux after endoscopic correction of unilateral reflux and identified possible risk factors for its development. Between 1996 and 2004, 662 patients underwent endoscopic correction of unilateral grades II to V vesicoureteral reflux. Of the ureters 97% had grades III to V reflux. The tissue augmenting substance used for endoscopic treatment was polytetrafluoroethylene from 1996 to 2000 and dextranomer/hyaluronic acid from 2001 to 2004. There were 203 males (30.7%) and 459 females (69.3%) with an age at endoscopic treatment of 2 months to 11 years. Voiding cystourethrograms performed 3 months after endoscopic treatment of unilateral vesicoureteral reflux were analyzed in all patients to document newly diagnosed contralateral reflux. A total of 67 children (10.1%), including 18 boys and 49 girls, showed new contralateral reflux on voiding cystourethrogram after endoscopic correction of unilateral reflux. Contralateral VUR was grades I to IV in 16 (23.9%), 17 (25.4%), 27 (40.3%) and 7 patients (10.5%), respectively. There was no correlation between the severity of ipsilateral reflux and the development of contralateral reflux. Patient age and gender did not influence the development of new contralateral reflux. The low incidence and lower grade of newly diagnosed contralateral vesicoureteral reflux after endoscopic correction of unilateral reflux does not support prophylactic treatment of nonrefluxing contralateral ureters.

The diagnostic value of relative ureteral jet frequency as a predictor of obstruction in a hydronephrotic kidney

Purpose The object of this study was to evaluate Color Doppler Ultrasonography(CDUS) as a diagnostic tool to distinguish obstructive from non-obstructive conditions of the upper tract in children through ultrasonographic evaluation of ureteral jets(UJ) in the bladder. Material and methods We evaluated 51 patients (37 boys-14 girls), aged 1 month to 14 years(median-4ys), who presented with unilateral grade III and IV hydronephrosis suspicious of pyeloureteral junction obstruction. All patients underwent DTPA-Diuretic Renography(DR) and evaluation of UJ by transverse CDSG of the bladder within a maximum of 2 weeks. Obstruction was considered in the DR when the hydronephrotic unit showed differential renal function of less than 40% and obstructive washout curves, or when symptomatic intermittent renal colic was present in older children. The number of UJ was counted over a 5 min period and its frequency was calculated for each ureteral orifice. Relative Jet Frequency (RJF) was defined as the UJ frequency of the hydronephrotic side divided by total UJ frequency. Receiver-Operating Characteristic (ROC) plots were constructed to determine the best cut off for RJF, in order to identify renal units with obstructive hydronephrosis. Results Twenty-three(45.1%) hydronephrotic units were considered obstructed. The mean RJF differed significantly between obstructive (0.09±0,15) and non-obstructive hydronephrosis (0.42±0.11)(p Conclusions In this study RJF

Does the Surface Structure of Implants Have an Impact on the Formation of a Capsular Contracture?

The formation of a fibrous capsule around a silicone breast implant is part of a physiologic foreign body reaction after breast augmentation. In contrast, the formation of a capsular contracture is a local complication of unknown cause. This study aimed to discover whether the surface structure of the implant (textured vs smooth) has any impact on the formation of a capsular contracture. This prospective study included 48 female patients with unilateral capsular fibrosis grades 1 to 4 in Baker's clinical scaling system. Of these patients, 14 received implants with a textured surface (Mentor), and 34 received implants with a smooth surface (Mentor). The implants all were placed in a submuscular position by the same experienced plastic surgeon. The clinical data were assessed using standardized patient questionnaires. For histologic diagnosis, operatively excised capsular tissue was examined. Preoperatively, venous blood samples for determining serum hyaluronan concentrations were taken from the patients. The control group consisted of 20 patients without capsular fibrosis. The separate analysis of clinical data for the patients with textured and those with smooth-surfaced breast implants showed a slightly reduced degree of symptoms for the patients with textured silicone breast implants, as compared with those who had smooth-surfaced implants. The histologic assessment of the fibrosis showed a symmetric distribution for Wilflingseder scores 1 to 3 (29% each), whereas 13% of the capsular tissues could be assigned to Wilflingseder score 4. In contrast, the histologic assessment of the patients with smooth-surfaced implants predominantly showed a Wilflingseder score of 3 (65%). The serologic investigations via enzyme-linked immunoassay (ELISA) showed serum hyaluronan concentrations of 10 to 57 ng/ml (25.0 +/- 11.7 ng/ml). Therefore, no statistically significant differences in terms of serum hyaluronan levels could be determined between the two groups of patients. In comparison with the control group, the patients with implants showed elevated serum hyaluronan levels (p < 0.05). The histologic examination and serum hyaluronan concentration analysis showed no statistically significant difference between smooth-surfaced and textured implants (Mentor) with respect to the development of capsular contracture. On the other hand, the severity of capsular contracture showed a positive linear correlation with the degree of local inflammatory reactions, which were independent of the implant surface.

The Cost-Effectiveness of Dextranomer/Hyaluronic Acid Copolymer for the Management of Vesicoureteral Reflux. 1: Substitution for Surgical Management

We examined the cost-effectiveness of dextranomer/hyaluronic acid copolymer injection in patients who would otherwise undergo ureteral reimplantation. A model for managing vesicoureteral reflux has previously been created. We now update the model to compare the costs of treating vesicoureteral reflux using standard methods (ie ureteral reimplantation after failed medical therapy) with the costs of dextranomer/hyaluronic acid injection. In the first scenario created dextranomer/hyaluronic acid injection is substituted for ureteral reimplantation when surgical intervention would be performed for treatment of breakthrough infection or failure of the reflux to resolve. For dextranomer/hyaluronic acid injection to have equal cost-effectiveness compared to ureteral reimplantation in this scenario success rates for dextranomer/hyaluronic acid injection would need to be 57.8% per ureter for patients with unilateral reflux and 75.3% per ureter for patients with bilateral reflux. However, if increasing grades of reflux require increasing volumes of dextranomer/hyaluronic acid, success rates would need to be 72.5% for patients with unilateral reflux and 93.8% for patients with bilateral reflux. In the second scenario created dextranomer/hyaluronic acid injection is repeated if it fails to resolve the reflux after the first injection. Success rates to obtain equal cost-effectiveness for the repeat dextranomer/hyaluronic acid injection would need to be 0%, 11.4% and 60.3% in patients with unilateral reflux if the respective success rates of the initial injection were 85%, 70% and 55%. Success rates for the second dextranomer/hyaluronic acid injection would need to be 0%, 29.1% and 76.7% per ureter in patients with bilateral reflux if the respective success rates of the initial injection were 85%, 70% and 55%. If increasing volumes of dextranomer/hyaluronic acid were required for increasing grades of reflux, a second dextranomer/hyaluronic acid injection would not be a viable option. Based on our results, dextranomer/hyaluronic acid injection may be more cost-effective than ureteral reimplantation for children who meet standard criteria for surgical therapy, especially for lower grades of reflux. If increasing grades of reflux require an increased volume of dextranomer/hyaluronic acid, then injection would likely be cost-effective only for grades I and II unilateral and bilateral reflux, and perhaps unilateral grade III reflux.

Hyaluronic Acid for the Treatment of Knee Osteoarthritis

Intraarticular hyaluronic acid is indicated for patients with osteoarthritis of the knee. However, clinical experience, especially efficacy and adverse events, with repeated injection series in the long term are limited. Patients were referred to a large primary care center for management of osteoarthritis of the knee. All were naive to intraarticular hyaluronic acid therapy and met our entry criteria, including resting visual analog scale pain of > 45 mm, radiographic confirmation of unilateral knee grade 1-3 osteoarthritis, and willingness to receive intraarticular therapy. Patients received a three-intraarticular injection series with Suplasyn (10 mg/ml, 2-ml injection) over 3 wks. Patients were instructed to return for consideration of repeat injection series based on their perception of pain restricting daily activity and a resumption of severity similar to their initial presentation. This prospective naturalistic cohort was followed for 6.7 yrs. Patients completed baseline assessment of rest and walking visual analog scale pain (primary efficacy variable), completed a 5-point categorical global satisfaction score, and recorded adverse events and concomitant therapeutic modality use at each study visit. Patients returned for consideration of a repeat injection series based on their perception of symptom severity and were eligible if their resting visual analog scale pain was > 45 mm. The three-injection series and data collection were repeated, and again, patients were given similar instructions regarding consideration of a third injection series. Of 897 referral patients, 537 (mean age, 68 +/- 8 yrs; mean duration of symptoms, 7.4 +/- 4.1 yrs) met our criteria, and only 21 patients did not return for a second injection series. The mean time between first and second series was 27 +/- 7 wks. The change in walking visual analog scale pain was significantly improved from baseline after the first series (81.3%, P < 0.001) and second series (86.7%, P < 0.0001). Similarly, resting visual analog scale pain was significantly decreased from baseline after the first (P < 0.001) and second (P < 0.001) series, and patient satisfaction was significantly improved with each injection series (P < 0.03 and P < 0.01). Very few adverse events were recorded and were limited to local pain and swelling. Use of concomitant therapeutic modalities at presentation for a second injection series included: nonsteroidal anti-inflammatory drugs/cyclooxygenase-2 medications (37%), acetaminophen (31%), oral nutraceuticals (12%), and physical therapy and bracing (12%). Intraarticular hyaluronic acid injections were highly effective in improving resting and walking pain in patients with osteoarthritis of the knee on a first and a second treatment series. Duration of symptom control was about 6 mos, and the therapy was highly satisfactory to patients and was associated with very few local adverse events and limited use of concomitant therapeutic modalities. These data support the potential role of intraarticular hyaluronic acid as an effective long-term therapeutic option for patients with osteoarthritis of the knee.

Timing of Follow-up Voiding Cystourethrogram in Children With Primary Vesicoureteral Reflux: Development and Application of a Clinical Algorithm

Of children diagnosed with urinary tract infection, 30% to 40% have primary vesicoureteral reflux (VUR). For the majority of these children, treatment involves long-term prophylactic antibiotics (ABX) and a periodic voiding cystourethrogram (VCUG) until resolution of VUR as detected by VCUG. Radiation exposure and considerable discomfort have been associated with VCUG. To date, no clear guidelines exist regarding the timing of follow-up VCUGs. The objective of this study was to develop a clinically applicable algorithm for the optimal timing of repeat VCUGs and validate this algorithm in a retrospective cohort of children with VUR. Based on previously published data regarding the probability of resolution of VUR over time, a decision-tree model (DTM) was developed. The DTM compared the differential impact of 3 timing schedules of VCUGs (yearly, every 2 years, and every 3 years) on the average numbers of VCUGs performed, years of ABX exposure, and overall costs. Based on the DTM, an algorithm optimizing the timing of VCUG was developed. The algorithm then was validated in a retrospective cohort of patients at an urban pediatric referral center. Data were extracted from the medical records regarding number of VCUGs, time of ABX prophylaxis, and complications associated with either. VUR in patients in the cohort was grouped into mild VUR (grades I and II and unilateral grade III for those < or =2 years old), and moderate/severe VUR (other grade III and grade IV). Kaplan-Meier survival curves were created from the cohort data. From the survival curves, the median times to resolution of VUR were determined for the cohort, and these times were compared with the median times to VUR resolution of the data used for the DTM. The numbers of VCUGs performed, time of ABX exposure, and costs in the cohort were compared with those that would have occurred if the algorithm had been applied to both mild and moderate/severe VUR groups. Using an algorithm that results in a recommendation of VCUGs every 2 years in mild VUR would reduce the average number of VCUGs by 42% and costs by 33%, with an increase in ABX exposure of 16%, compared with a schedule of yearly VCUGs. For moderate/severe VUR, a VCUG performed every 3 years would reduce the average number of VCUGs by 63% and costs by 51%, with an increase in ABX exposure of 10%. Applying this algorithm to the retrospective cohort consisting of 76 patients (between 1 month and 10 years old) with primary VUR would have reduced overall VCUGs by 19% and costs by 6%, with an increase in ABX exposure of 26%. The patterns of VUR resolution, age distribution, and prevalence of severity of VUR were comparable between previously published results and the retrospective cohort. Delaying the schedule of VCUG from yearly to every 2 years in children with mild VUR and every 3 years in children with moderate/severe VUR yields substantial reductions in the average numbers of VCUGs and costs, with a modest subsequent increase in ABX exposure.

Outcome of Endoscopic Treatment for Vesicoureteral Reflux in Children Using Polydimethylsiloxane

We reviewed the outcome of subureteral injection of polydimethylsiloxane as a bulking agent for endoscopic treatment for vesicoureteral reflux in patients younger than 12 years. A total of 40 children (59 ureters) with primary grades II to IV vesicoureteral reflux were treated with a single subureteral injection from 1997 to 2001 and followed an average of 26 months (range 4 to 45). Results in 38 patients (55 ureteral units) were available for review. Each child underwent preoperative voiding cystourethrography, renal ultrasound, dimercapto-succinic acid scan and urine culture. Treatment was done on an outpatient basis. With the patient general anesthesia polydimethylsiloxane implant was injected transurethrally below the ureteral opening of the affected renal unit. Renal ultrasound at 1 week and voiding cystourethrography at 2 months were done to rule out obstruction at the injection site and/or persistent reflux, respectively. Cure was defined as absent vesicoureteral reflux on voiding cystourethrography 2 months after injection. After a single injection polydimethylsiloxane cured vesicoureteral reflux in 45 ureteral units (81.8%), while in 5 (9.1%) the condition was improved. The remaining 5 ureteral units (9.1%) showed no change in reflux grade. In 1 patient (1.9%) with unilateral grade IV vesicoureteral reflux contralateral reflux developed. None of the cured patients had recurrent reflux during followup. In 1 patient ureteral obstruction was successfully treated with ureteral reimplantation. Endoscopic subureteral injection of polydimethylsiloxane implant in children with primary grades II to IV vesicoureteral reflux appears to be an effective, safe and minimally invasive technique.

Effects of unilateral grade I testicular injury in rat

Objectives. The effect of unilateral blunt testicular trauma on subsequent testicular function is still debated. None of the experimental studies had the exact grading of testicular injury and evaluation of hormone status and hence this study was designed. Methods. Twenty male prepubertal (20 days old) Wistar rats were divided into two groups: group 1 (n = 10) underwent sham surgery; group 2 (n = 10) underwent blunt trauma to the right testis by a 5-g sterile weight dropped three times on the testis from a height of 10 cm. T 1-weighted and T 2-weighted magnetic resonance images were taken within 6 hours to confirm grade I injury. At 60 days of age, blood samples were obtained from each rat for follicle-stimulating hormone, luteinizing hormone, testosterone, and estradiol levels, and both testes of each rat were harvested separately for DNA flow cytometric analysis. Results. Group 2 rats had significantly reduced ( P <0.001) haploid cell populations in both right and left testis compared with the corresponding testis of the group 1 rats. Within group 2, the right testis was significantly ( P <0.001) more affected. Serum levels of testosterone were significantly lower ( P <0.05) and follicle-stimulating hormone ( P <0.01) and estradiol ( P <0.05) levels were significantly higher in group 2 rats than in group 1 rats. However, the luteinizing hormone levels were not significantly different. Conclusions. Grade I unilateral blunt testicular trauma in prepubertal rats significantly affected germ cell maturation in both ipsilateral and contralateral testis and altered the sex hormone profile.

Vaginal paravaginal repair: One-year outcomes

Objective: This study was carried out to determine the efficacy and safety of the vaginal approach to paravaginal repair of symptomatic paravaginal defect cystocele. Methods: This study is an observational case series of 100 consecutive women, referred from December 1996 to August 2000, with symptomatic grade II to IV paravaginal defect cystocele. Preoperative and postoperative pelvic evaluations were performed with the Baden-Walker halfway system. The same surgeon performed all repairs. Fourteen patients had prior anterior repairs, and 530 concomitant procedures were performed. The vaginal approach consisted of a thorough entry from the vesicovaginal space under the inferior pubic ramus into the retropubic space, widely exposing the area of the arcus tendineus. A repair was done bilaterally in 95 patients and unilaterally in 5. Between 1 and 6 Gore-tex CV-0 sutures (W. L. Gore and Associates, Inc, Elkton, Md) were placed widely around the arcus tendineus on either side and fixed to appropriate locations on the bladder fascia and anterior vaginal walls. Tying these sutures resulted in dramatic elevation of the lateral superior sulci. Patients were followed up for 1 to 36 months, with a mean of 10.6 months. Criteria for objective cure were defined as the lateral sulci of the anterior vaginal walls being at grade 0 and firmly apposed to the lateral pelvic sidewalls. Results: Of the 100 patients, 34 had grade II, 54 had grade III, and 12 had grade IV paravaginal defect cystocele. Patients were followed up postoperatively for 1 to 36 months: 84 for more than 6 weeks and 55 for 1 year or longer. Our objective cure rate was 98%. Two asymptomatic patients had a unilateral grade I or a bilateral grade II paravaginal defect cystocele. A recurrent midline cystocele occurred in 22 patients between 3 and 11 months after the operation. Twenty-one patients were asymptomatic and one was symptomatic. Twenty-one patients had grade I-II cystocele and one had grade III cystocele. There were 3 major intraoperative hemorrhagic complications; one of the operations was converted to an anterior colporrhaphy. There were a total of 21 major and 14 minor inpatient complications. Twenty-five subsequent complications included various urinary symptoms in 14 patients, long-term lower extremity neuropathy in 2, bloody discharge from intravaginal sutures in 3, absent coital sensation in 1, and recurrent pelvic organ prolapse in 5, all of which included grade III enterocele between 3 and 25 months. Conclusions: The vaginal approach to the correction of paravaginal defect cystocele is highly effective in our population at a mean of 11 months after the operation. Frequent complications do occur but are largely manageable. (Am J Obstet Gynecol 2001;185:1360–7.)

Experiences with the entero-ureteral anastomosis via the extramural serous-lined tunnel: procedure of abol-enein

Objectives. Ureteral reimplantation in any urinary diversion setting should be easy, reproducible, nonrefluxive, and without complications. In this study, we present our experiences with the entero-ureteral anastomosis via the extramural serous-lined tunnel, a technique introduced by Abol-Enein. Methods. In the period between 1995 and 1998 we performed the Abol-Enein technique in 50 patients who underwent radical cystectomy and ileal neobladder construction. Preoperatively 10 patients had unilateral ureteral dilatation. Results. The technique was performed easily, and any serious complications did not occur in the early postoperative period. Leakage of the urethral-intestinal anastomosis was seen in 2 patients and transient hydronephrosis in 2 patients. Among the most serious late complications were two strictures of the urethral-intestinal anastomosis and four unilateral strictures of the ureteral-intestinal anastomosis. Only 1 patient presented with unilateral grade IV urinary reflux. Four patients developed metabolic acidosis. In all cases, renal function was stabilized or improved, and preoperative dilatation of the ureters was alleviated. Conclusions. The low stricture rates of the uretero-intestinal anastomosis, as well as the low reflux rates of the procedure of Abol-Enein, render this procedure a safe method of uretero-intestinal anastomosis when an orthotopic ileal neobladder is formed. The method can be performed with equal or even greater ease in very dilated ureters that in many situations other techniques either cannot deal with or require ureteral tailoring. Although this technique seems to meet most of the criteria for an ideal uretero-intestinal anastomosis, further studies that involve longer follow-up periods are necessary to allow a definitive value of this method.

THE USE OF RADIOGRAPHY, URODYNAMIC STUDIES AND CYSTOSCOPY IN THE EVALUATION OF VOIDING DYSFUNCTION

Children with dysfunctional voiding disorder often undergo radiological, cystoscopic or urodynamic evaluation to identify an anatomical or organic cause. We determined the role of these studies in the evaluation, management and ultimate outcome of a large patient population with voiding dysfunction at a single institution. We retrospectively evaluated the records of 1, 153 children with dysfunctional voiding disorder treated from 1990 to 1999. A thorough history and physical examination with specific emphasis on voiding patterns were done and urinalysis was performed in all cases. Ultrasound of the urinary system and excretory urography were done in 1,050 (91%) and 24 (2%) patients, respectively, while voiding cystourethrography was performed in 672 (58%), including 564 with a history of nonfebrile urinary tract infection. Cystoscopy and a formal urodynamic study were performed in 61 (5%) and 40 (3.5%) cases, respectively. Mean patient age at referral was 6 years (range 3 to 14). Of the children 74% were girls and 26% were boys. Physical examination of the abdomen, back, genitalia and neurological system was unremarkable in all cases. Ultrasound of the upper urinary system was normal in 1,018 patients (97%) and showed insignificant pyelectasis in 32 (3%). All 24 excretory urography studies were normal and voiding cystourethrography was normal in 470 of 672 cases (70%). Unilateral and bilateral low grade, and unilateral high grade reflux was present in 108, 19 and 3 patients, respectively. Urodynamic studies were performed in 40 children who did not respond to standard treatment. We noted detrusor instability in 16 patients, detrusor-sphincter dyssynergia in 6 and sensory abnormality in 3, while the study was completely normal in 10. Cystoscopy revealed normal findings in 17 cases, trabeculations in 21, inflammation in 20 and type 1 posterior urethral valves in 2. The incidence of upper tract changes and positive anatomical findings in children with voiding dysfunction is too low to justify routine radiological evaluation and cystoscopy. However, in those who present with a nonfebrile urinary tract infection there remains an important role for voiding cystourethrography. We do not recommend routine urodynamics in children with voiding disorder because this study does not change therapy or influence the final outcome. Thorough history and physical examination lead to the correct diagnosis and treatment in the majority of children. A focus on correcting faulty voiding behavior with the judicious administration of antibiotics and anticholinergic therapy leads to a favorable outcome in most cases.

Anterior approach bilateral sacrospinous ligament fixation for vaginal vault prolapse

The sacrospinous ligament fixation (SSLF) was first described as a unilateral fixation; however, bilateral fixation, when possible, allows a symmetrical vaginal reconstruction and provides additional vaginal vault support. We evaluated the outcome of treating total vault prolapse using a bilateral SSLF through an anterior vaginal approach. From July 1996 to July 1999, 28 patients (mean age 67) underwent bilateral SSLF procedures through an anterior vaginal approach. All patients had either grade 3 or 4 vault prolapse, and all patients had associated enteroceles, cystoceles, and rectoceles. All patients underwent fluorourodynamic evaluation including an abdominal leak point pressure (ALPP) with reduction of the vaginal prolapse. A pubovaginal sling was performed in 25 patients and all 28 patients underwent an anterior colporrhaphy, rectocele, and enterocele repair. A vaginal paravaginal repair was performed in 22 cases. At a mean follow-up of 17 months (range 5 to 35), 27 of 28 patients were cured, 1 patient had an asymptomatic unilateral grade 1 vault prolapse, 2 patients had developed small asymptomatic cystoceles and there had been no recurrence of rectoceles or enteroceles. Stress incontinence had been cured in all patients; however, 2 patients continued to have mild urge incontinence requiring <1 pad per day. Two patients complained of transient gluteal pain. We believe the anterior approach bilateral SSLF is a safe procedure with excellent medium term results in women with grade 3 to 4 vaginal prolapse.

Urodynamic dysfunction in infants with vesicoureteral reflux

Vesicoureteral reflux (VUR) may result from inadequate length of the intravesical ureteric tunnel and from urodynamic dysfunction. VUR and symptomatic urinary tract infection (UTI) are both more common in male infants and may be related to urodynamic dysfunction and functional intravesical obstruction. We therefore conducted urodynamic studies in 75 infants with primary VUR and retrospectively evaluated their voiding cystourethrogram (VCUG) for evidence of inadequate sphincteric relaxation. High voiding detrusor pressure (>70 cm H(2)O), increased postvoid residual (>2 mL/kg body weight), or detrusor-sphincter dyssynergy were observed in 79% of infants with primary VUR without significant differences between male and female infants or in infants with or without UTI. Infants with bilateral grade IV-V VUR showed a higher prevalence of detrusor hyper-reflexia and higher voiding detrusor pressure than infants with lower grades of VUR or unilateral grade IV-V VUR. On VCUG, inadequate external urethral sphincter relaxation during voiding was noted in 10 of 47 male infants. The findings suggest that high intravesical pressures contribute to the development and severity of VUR, and that high voiding detrusor pressure in some infants with primary VUR may be related to inadequate relaxation of the external urethral sphincter.

CONGENITAL REFLUX NEPHROPATHY AND SEVERE UNILATERAL FETAL REFLUX

When prenatal ultrasound reveals urinary tract dilatation, fetal reflux is suspected. Postnatal voiding cystourethrography confirms the diagnosis. The origin of reflux nephropathy is controversial, and the roles of urinary tract infection and pressure effects of sterile reflux on the developing kidneys are debatable. We evaluate the relationship between sterile reflux and renal scarring. We reviewed the records of 100 infants and children seen during a 15-year period in whom fetal reflux had been diagnosed, including 81 with bilateral and 19 with unilateral vesicoureteral reflux. In 12 of the 19 patients voiding cystourethrography revealed unilateral grade IV or V reflux, and they comprise the study group. Split renal function was measured in all 12 patients by radionuclide renal scan shortly after birth and before urinary tract infection developed. Individual renal function was 0 to 40% in all refluxing renal units. Split renal function was less than 10% in 3 kidneys, 10 to 30% in 5 and 30 to 40% in 4. There were 2 nonfunctioning kidneys. In the remaining 10 kidneys isotope distribution on the nuclear scan indicated decreased renal length and mass. Subsequently 7 patients had breakthrough urinary tract infections while on antibiotic chemoprophylaxis. Nephrectomy, and nephroureterectomy and ureteral reimplantation with or without tapering were performed in 3 and 9 refluxing ureters, respectively. Pathological examination of the 3 nephrectomy specimens revealed severe renal dysplasia consisting of persistent primitive ducts and nests of metaplastic cartilage. Our study supports the notion that renal impairment associated with severe fetal reflux is present at birth, and it is likely due to congenital dysplasia.