Alan Retik

Three unique cases of urethral duplication, often referred to as congenital posterior urethral perineal fistulae, are presented. Presenting signs and symptoms, evaluation and treatment are discussed and the literature is reviewed. Although labeled as a fistula in the literature, this entity most likely represents a distinct type of urethral duplication. A functional dorsal urethra separates it from the other forms

Purpose: To investigate whether a weekly clinical indications conference has a beneficial effect on patient safety and quality of care, through group review of scheduled surgical cases. Methods: Our department (11 surgeons) holds a weekly clinical indications conference, where surgical cases scheduled for the following week are reviewed and discussed. In 7/2007, in conjunction with our hospital’s Program for Patient Safety and Quality (PPSQ), we began tracking each week’s conference findings, focusing on factors associated with patient safety and quality of care. During review of each surgical case, the fellow records any significant discrepancy in the perioperative plan. Discrepancies were categorized as follows: 1) wrong site/wrong procedure, 2) missing records/data, 3) clinical concerns leading to recommendation of change in management plan, by consensus of attendings present, and 4) other discrepancies. All cases each week are reviewed, except for circumcisions and circumcision ...

Purpose: Identification and evaluation of children with pyelonephritis is crucial, with the presence of fever equal or higher than 100.4 traditionally used to distinguish pyelonephritis from cystitis. We set out to analyze whether this is a clinically appropriate marker to initiate further workup, and whether high temperature is correlated with urological abnormality. We also chose to examine the course of patients after the initial diagnosis of urinary tract infection to better understand referral practices. Methods: We performed a retrospective review of children who presented to a single tertiary care institution for their first workup of any urinary tract infection between 10/01/08 and 09/30/09. Patient demographics and clinical details were evaluated. Follow-up with a pediatric urologist or nephrologist, further workup and final diagnosis were also recorded. Results: Out of 2708 patients diagnosed with any urinary tract infection, we identified 285 who presented for workup of t...

Injection of polytetrafluoroethylene (Teflon) or collagen has been used in the endoscopic treatment of vesicoureteral reflux. Although the principle of an endoscopic treatment is valid, there are concerns regarding the long-term safety and effectiveness of these substances. The goal of several investigators has been to find alternate implant materials that would be safe for human use. Toward this goal we conducted a study to determine the effect of chondrocytes using a biodegradable polymer solution as a template. Hyaline cartilage was obtained from the articular surfaces of calf shoulders and chondrocytes were harvested. Chondrocyte suspensions were concentrated to 20, 30 and 40 x 10(6) cells per cc and mixed with dry alginate powder (a biodegradable polymer) to form a gel. Twelve athymic mice were injected subcutaneously with a chondrocyte-alginate solution. Each mouse had 4 injection sites, consisting of control, 10, 15 and 20 x 10(6) chondrocyte cells (48 injection sites). Mice ...

The lethal feature of male newborns with severe bladder outlet obstruction and oligohydramnios is pulmonary hypoplasia. We report a fetal lamb model of bladder outlet obstruction created in the early second trimester, and morphometric analysis of the profound pulmonary hypoplasia that resulted. At 55 to 65 days of gestation 8 consecutive male fetuses underwent surgical clipping of the urethra and urachus near the abdominal wall. A sham operation was performed in 1 female fetus. The lambs were delivered by cesarean section 10 weeks later. The right lungs were immediately fixed at a distending pressure of 25 cm. water. The results of the morphometric studies were compared to control animals from our earlier study of normal fetal lamb lung development; slides for both studies were scored in a blind, randomized fashion by 1 of us (S. G. D.). Although mean body weights for the groups were similar, mean right lung volume in the operated lambs was 63.8 cM.3 compared to 158 cM.3 in the cont...

An overview of the design and application of a unique mobile hybrid telepresence and virtual reality system is first provided. This is followed by a description of each of the integrated sub-systems. These include the telepresence and teleoperation sub-system comprising display, control, and communication elements together with camera platforms and a mobile vehicle, a virtual reality module capable of modeling

Patients with end-stage bladder disease can be treated with cystoplasty using gastrointestinal segments. The presence of such segments in the urinary tract has been associated with many complications. We explored an alternative approach using autologous engineered bladder tissues for reconstruction. Seven patients with myelomeningocele, aged 4-19 years, with high-pressure or poorly compliant bladders, were identified as candidates for cystoplasty. A bladder biopsy was obtained from each patient. Urothelial and muscle cells were grown in culture, and seeded on a biodegradable bladder-shaped scaffold made of collagen, or a composite of collagen and polyglycolic acid. About 7 weeks after the biopsy, the autologous engineered bladder constructs were used for reconstruction and implanted either with or without an omental wrap. Serial urodynamics, cystograms, ultrasounds, bladder biopsies, and serum analyses were done. Follow-up range was 22-61 months (mean 46 months). Post-operatively, the mean bladder leak point pressure decrease at capacity, and the volume and compliance increase was greatest in the composite engineered bladders with an omental wrap (56%, 1.58-fold, and 2.79-fold, respectively). Bowel function returned promptly after surgery. No metabolic consequences were noted, urinary calculi did not form, mucus production was normal, and renal function was preserved. The engineered bladder biopsies showed an adequate structural architecture and phenotype. Engineered bladder tissues, created with autologous cells seeded on collagen-polyglycolic acid scaffolds, and wrapped in omentum after implantation, can be used in patients who need cystoplasty.

To evaluate the long-term durability of successful ureteral reimplantation (UR) for vesicoureteral reflux (VUR) through a review of late cystography (LC) findings. We performed a retrospective chart review of all children with primary VUR who underwent successful open UR (grade 0 VUR into the reimplanted ureter[s] on initial cystogram) at our institution from January 1990 to December 2002. We identified successful UR patients who underwent LC ≥ 1 year after UR and reviewed the results for the presence of recurrent VUR into the reimplanted ureter(s). Seven-hundred ninety-four patients underwent successful open UR for primary VUR, of whom 60 (7.6%) had a subsequent LC. Preoperative VUR grade was ≤ II in 20 (34.5%) and ≥ III in 38 (65.5%). Median age at UR was 3.5 years (IQR 1.3-6.2 years); 51 (85%) were female. UR was intravesical in 45 (75%) and bilateral in 19 (32%). LC was performed at a median of 38.7 months after UR (IQR 19.6-66.1 months). Indication for LC was febrile urinary tract infection (UTI) in 16 (27%), nonfebrile UTIs in 15 (25%), follow-up of contralateral VUR in 16 (27%), and other clinical indications in 13 (21%). The recurrence rate was 0%; of the 79 reimplanted ureters, 100% (95% CI 95.4-100) had no VUR (grade 0). Among children who underwent successful open UR for primary VUR, there was no VUR recurrence on extended follow-up. This suggests that the late durability of open antireflux surgery is excellent.

Sacral agenesis is a rare congenital anomaly of the lower vertebral column which usually produces lower urinary tract dysfunction. Sixteen children with varying degrees of sacral agenesis and urinary symptoms were extensively evaluated. The neurologic lesion varied from no denervation to a complete loss of sacral motor and sensory function. The treatment instituted was individualized and based on specific urodynamic and radiologic findings. Overall, 12 of the 16 children (75%) achieved continence. Clues to the diagnosis including symptoms, physical findings, and the relationship to maternal diabetes are discussed.

Continent urinary diversion has increasingly become important for treating children and adults with urinary tract pathology that cannot be managed by direct reconstructive techniques. The Mitrofanoff principle, a term that has become synonymous with the flap valve mechanism for promoting the unidirectorial flow of a fluid medium, is a recapitulation of nature's design for the competent ureterovesical junction. Construction of a catheterizable channel using this principle can be performed with a variety of tissues and serves well as a continence mechanism for either the native bladder or intestinal reservoirs. In addition to its utility in managing urinary incontinence, implantation of a catheterizable channel into the cecum can be used to manage fecal incontinence in patients with neurogenic bowel dysfunction.

Clinical significance and management of prenatal hydronephrosis (PNH) are sources of debate. Existing studies are flawed with biased cohorts or inconsistent follow-up. We aimed to evaluate the incidence of pathology in a large cohort of PNH and assess the biases and outcomes of this population. We reviewed 1034 charts of fetuses with PNH. Records of delivered offspring were reviewed at a pediatric center and analyzed with respect to prenatal and postnatal pathology and management. Prenatal resolution of hydronephrosis occurred in 24.7% of pregnancies. On first postnatal ultrasound, some degree of dilatation was present in 80%, 88% and 95% of mild, moderate and severe PNH cases, respectively. At the end of follow-up, hydronephrosis persisted in 10%, 25% and 72% of children, respectively. Incidence of vesicoureteral reflux did not correlate with severity of PNH. Children with postnatal workup had more severe PNH than those without. Despite prenatal resolution totalizing 25%, pelvic dilatation persisted on first postnatal imaging in most cases, thus justifying postnatal ultrasound evaluation. Whereas most mild cases resolved spontaneously, a quarter of moderate and more than half of severe cases required surgery. Patients with postnatal imaging and referral had more severe PNH, which could result in overestimation of pathology.

Seventy-five patients with suspected testicular torsion who had scintiscans and adequate clinical follow-up were analyzed retrospectively. The scintiscans diagnosed 12/13 cases of surgically proven missed torsion and 3/3 cases of surgically proven acute complete torsion. The scintiscans successfully distinguished all 35 cases of epididymo-orchitis, 14 cases of torsion of the appendix testes and 8 other miscellaneous conditions from testicular torsion. The incidence of testicular torsion in our patients undergoing scrotal scintigraphy was approximately 24%.

Laser surgical procedures involving photocoagulation of soft tissue have relied on subjective visual endpoints. The thermal damage to the denatured tissue in these procedures is highly dependent on the tissue temperatures achieved during laser irradiation. Therefore, a system capable of real time temperature monitoring and closed loop feedback was used to provide temperature controlled photocoagulation (TCPC). The TCPC system consisted of a 1.32 microns Nd:YAG laser, an infrared thermometer, and a microprocessor for data acquisition and feedback control. A porcine skin model was used. Tissue welds were completed to evaluate the photocoagulation effects at different predetermined temperatures. A quantitative measurement of tissue photocoagulation was obtained by tensile strength measurements of the laser repairs. Histology of the irradiated tissue was used to determine the extent of thermal injury associated with different photocoagulation temperatures. The TCPC system was capable of maintaining a relatively constant temperatures (+/- 4 degrees C) during laser irradiation. The tensile strengths of acute repairs increased with temperature over the range studied (65-95 degrees C). Tensile measurements made after several days of healing showed that higher temperature (95 degrees C) welds had lower strengths than repairs completed at lower (65 degrees C or 75 degrees C) temperatures and were significantly lower at 3 days. Acute histology showed that the amount thermal damage was strongly dependent on the tissue temperature and increased both in tissue depth and lateral to the repair with temperature. The histologic results suggest that the increase in the acute repair tensile strength as the weld temperature increased was due to an increase in the depth of tissue photocoagulation. The increase in the lateral tissue injury measured histologically for higher temperature welds likely resulted in the decreased chronic tensile strengths, as a healing response to excessive thermal damage. Tissue temperatures can be controlled during laser photocoagulation of skin. The degree of acute and chronic tissue damage is highly dependent on the temperature during welding. By controlling the tissue temperature during laser procedures, the surgical outcome can be more reliably predicted and reproduced, as compared to the conventional open loop methods. In addition, the use of a TCPC system should significantly reduce the learning curve for photothermal surgical procedures.

We describe our experience with 2-stage proximal hypospadias repair. We report outcomes, and patient and procedure characteristics associated with surgical complications. We retrospectively studied patients with proximal hypospadias who underwent staged repair between January 1993 and December 2012. Demographics, preoperative management and operative technique were reviewed. Complications included glans dehiscence, fistula, meatal stenosis, nonmeatal stricture, urethrocele/diverticula and residual chordee. Cox proportional hazards model was used to evaluate the associations between time to surgery for complications and patient and procedure level factors. A total of 134 patients were included. Median patient age was 8.8 months at first stage surgery and 17.1 months at second stage surgery, and median time between surgeries was 8 months. Median followup was 3.8 years. Complications were seen in 71 patients (53%), with the most common being fistula (39 patients, 29.1%). Reoperation was performed in 66 patients (49%). Median time from urethroplasty to surgery for complication was 14.9 months. Use of preoperative testosterone decreased risk of undergoing surgery for complication by 27% (HR 0.73, 95% CI 0.55-0.98, p = 0.04). In addition, patients identified as Hispanic were at increased risk for undergoing surgery for complications (HR 2.40, 95% CI 1.28-4.53, p = 0.01). We review the largest cohort of patients undergoing 2-stage hypospadias repair at a single institution. Complications and reoperation rates were approximately 50% in the setting of complex genital reconstruction.

To elucidate which perioperative patient characteristics are associated with an increased risk of complications in pediatric urological surgery. There are numerous published studies that have correlated comorbidities, preoperative, and intraoperative parameters with postoperative outcomes in adults. However, there is a paucity of similar data in the pediatric population. Between July 2003 and September 2006, a total of 93 children had an adverse or unexpected event within 35 days of urologic surgery. Thirty-eight preoperative patient characteristics and 20 perioperative parameters were evaluated. The severity of the complications was graded based on the Clavien classification. A total of 163 controls were randomly selected. Statistical significance was assessed by univariate and multivariate analysis. The overall complication rate was 1.1%. Most complications were technical in nature, occurred within 3 days after surgery, and classified as Clavien's grade 3 B. On multivariate an...

Vesicoureteral reflux (VUR) is the most commonly inherited disease of the genitourinary tract. Although the majority of evidence supports a genetic cause, the tendency for this condition to spontaneously improve over time has made it difficult to determine the actual mode of transmission. We report the incidence of VUR in siblings of multiple gestation births and for the first time compare the relative incidence of reflux between identical and fraternal twins. A database consisting of all radionuclide cystograms and voiding cystourethrograms performed between the years 1986 and 1996 was searched for multiple gestation births. The medical records of each patient were evaluated for age at presentation, zygosity, reflux grade, and time to resolution. Children with secondary causes of VUR (eg, posterior urethral valves) were excluded. Triplets were treated as 2 pairs of twins for statistical analysis. Forty-six pairs met the inclusion criteria (31 dizygotic and 15 monozygotic). Overall, 23 (50%) of 46 siblings of index cases had demonstrable VUR. Comparison of VUR prevalence between identical and nonidentical twins was revealing with 80% (12/15) of identical twins and 35% (11/31) of fraternal twins having VUR. When only the youngest individuals in each group were considered, 100% (7/7) of the monozygotics and 50% (5/10) of the dizygotics demonstrated this trait. High concordance for VUR in identical twin siblings supports a genetic basis for the transmission of this disease. Results obtained from fraternal twin siblings provides convincing evidence that this trait is transmitted in an autosomal dominant fashion.

The intestinal augmented bladder has an increased propensity to form urinary calculi. Predisposing risk factors include chronic bacteriuria, urinary stasis and mucus production. Gastric reservoirs have negligible mucus production and the ability to acidify the urine. We determined whether they also have a decreased incidence of stones. We retrospectively reviewed the records of all patients undergoing augmentation cyptoplasty (215) or creation of a freestanding reservoir (44) between May 1976 and March 1996. Of these cases 83 were augmented with stomach and 179 were constructed from other intestinal segments, (that is ileal, ileocecal, sigmoid and/or a combination of these). Presenting diagnosis, patient age, gender, additional surgical procedures, interval to stone formation and calculous composition were recorded. Patients were excluded from study when there was less than 1 year of followup, as were those with renal or pre-augmentation bladder calculi. Stones formed in 32 of 207 patients (15%) after an average interval of 3.6 years (range 0.5 to 8.6). The majority of stones were composed of struvite (magnesium ammonium phosphate). Reservoirs containing gastric segments were significantly less likely to form calculi than those augmented with other intestinal segments (2 of 70 versus 30 of 137, p <0.0001 Fisher's exact test). Seven additional patients with pre-augmentation bladder stones who subsequently underwent gastrocystoplasty remain stone-free at an average followup of 3.0 years. Calculous formation is rare in reservoirs that incorporate a gastric segment. In patients with gastric augmentation stones appear only to develop when the patient is on histamine blockade or has a propensity to form stones that only favor an acidic environment, such as uric acid.

Since its inception, robot assisted laparoscopic pyeloplasty has rapidly become the minimally invasive surgical intervention of choice for treating ureteropelvic junction obstruction at our institution. The large initial investment in robot assisted surgery is frequently justified by its association with improved optics and instrument articulation, decreased postoperative pain, shorter length of hospitalization and improved cosmesis. However, there are no data specifically showing patient satisfaction with robot assisted laparoscopic pyeloplasty compared to traditional open surgery. A previously validated satisfaction survey (Glasgow Children's Benefit Inventory) with 14 additional questions specifically addressing postoperative satisfaction was mailed to all parents (as patient proxy) of children who had undergone open or robot assisted laparoscopic pyeloplasty between January 2006 and December 2008. A total of 78 parents responded (response rate 70%). All responses achieving statistical significance favored robot assisted laparoscopic pyeloplasty. Parents of children who underwent robot assisted laparoscopic pyeloplasty reported significantly higher satisfaction with "overall life," confidence, self-esteem, burden of postoperative followup and size of incision scar. Parent satisfaction was greater with robot assisted laparoscopic pyeloplasty than with open surgery regarding amount of cosmesis and recovery. Interestingly the differences in satisfaction were not as large as anticipated, suggesting the impact of confounding factors such as age and preoperative parental expectations. Future large-scale prospective studies using validated surveys specific to pediatric surgery are needed to elucidate further the true benefits of minimally invasive surgical technology such as robot assistance.

We assessed bladder growth and dynamics following complete primary repair of bladder exstrophy (CPRE) compared to the staged approach. We reviewed the records of 16 boys and 7 girls who underwent CPRE within 3 days of life from 1996 to 2004 and compared them to the records of 8 boys and 6 girls treated with a staged repair from 1979 to 1996. Screening methods included voiding cystourethrogram, radionuclide cystogram and urodynamic study. We estimated growth curves for bladder capacity following repair in each group, and compared percent predicted bladder capacity (PPBC), compliance and detrusor overactivity between the CPRE and staged repair groups following bladder neck reconstruction. Bladder capacity in the staged repair group was 69.8 ml (95% CI 46.7-104.4) immediately after bladder neck reconstruction and increased by 15.0% per year thereafter (95% CI 6.2-24.5, p = 0.002). In the CPRE group bladder capacity was 29.0 ml (95% CI 21.3-39.5) initially and increased by 28.9% per year thereafter (95% CI 17.4-41.5, p <0.001). PPBC started at 45.6% (95% CI 35.7-55.5) and increased 1.2% per year (95% CI -1.1-3.5, p = 0.29) following repair for all genders and surgery groups. Compliance was 124.4% (95% CI 22.6-310.7, p = 0.01) greater in the CPRE group at all times following repair. Detrusor overactivity was present in 0 of 19 patients in the CPRE group and 6 of 13 (46%) in the staged group (exact p = 0.002). Within the CPRE group bladder stability was universal, and sphincter electromyography was normal suggesting no neuromuscular compromise of the pelvic floor. At early followup, our results suggest that PPBC is equivalent irrespective of gender or management. Further objective evaluation is needed in both groups.

We assessed bladder growth and dynamics following complete primary repair of bladder exstrophy (CPRE) compared to the staged approach. We reviewed the records of 16 boys and 7 girls who underwent CPRE within 3 days of life from 1996 to 2004 and compared them to the records of 8 boys and 6 girls treated with a staged repair from 1979 to 1996. Screening methods included voiding cystourethrogram, radionuclide cystogram and urodynamic study. We estimated growth curves for bladder capacity following repair in each group, and compared percent predicted bladder capacity (PPBC), compliance and detrusor overactivity between the CPRE and staged repair groups following bladder neck reconstruction. Bladder capacity in the staged repair group was 69.8 ml (95% CI 46.7-104.4) immediately after bladder neck reconstruction and increased by 15.0% per year thereafter (95% CI 6.2-24.5, p = 0.002). In the CPRE group bladder capacity was 29.0 ml (95% CI 21.3-39.5) initially and increased by 28.9% per year thereafter (95% CI 17.4-41.5, p <0.001). PPBC started at 45.6% (95% CI 35.7-55.5) and increased 1.2% per year (95% CI -1.1-3.5, p = 0.29) following repair for all genders and surgery groups. Compliance was 124.4% (95% CI 22.6-310.7, p = 0.01) greater in the CPRE group at all times following repair. Detrusor overactivity was present in 0 of 19 patients in the CPRE group and 6 of 13 (46%) in the staged group (exact p = 0.002). Within the CPRE group bladder stability was universal, and sphincter electromyography was normal suggesting no neuromuscular compromise of the pelvic floor. At early followup, our results suggest that PPBC is equivalent irrespective of gender or management. Further objective evaluation is needed in both groups.

Balanitis xerotica obliterans (BXO) is a chronic dermatitis of unknown etiology most often involving the glans and prepuce but sometimes extending into the urethra. We report our 10-year experience with BXO in pediatric patients. Our pathology database was queried for all tissue diagnoses of BXO from 1992 to 2002. Available charts were reviewed and patient presentation, clinical and referral history, operative procedure(s) and postoperative course were recorded. A total of 41 patients had a tissue confirmed diagnosis of BXO. Median patient age was 10.6 years. Of the patients 85% were 8 to 13 years old and all had referrals available for review. The most common referral diagnoses were phimosis (52%), balanitis (13%) and buried penis (10%). No patient had the diagnosis of BXO at referral. Of the patients 19 (46%) underwent curative circumcision or redo circumcision and had no recurrence at a mean followup of 12.5 months (range 1 to 57). A total of 11 patients (27%) had BXO involvement of the meatus and underwent circumcision combined with meatotomy or meatoplasty. Nine patients (22%) required extensive plastic operation(s) of the penis, including buccal mucosa grafts in 2. The incidence of BXO in pediatric patients may be higher than previously reported, with the diagnosis rarely made by pediatricians. Our study demonstrates that older patients, those with BXO involvement of the meatus and those with a history of surgery for BXO tend to have a more severe and morbid clinical course.

Testicular hypotrophy is the most widely accepted indication for correcting adolescent varicocele. Previous studies in adolescents have shown a relationship between increasing grade of varicocele and the likelihood of testicular hypotrophy. As this relationship has significant clinical implications, we studied the correlation between grade and testicular volume disproportion in our adolescent varicocele population. We reviewed the adolescent varicocele database at our institution. A total of 168 patients 8 to 21 years old were studied. We routinely calculated testis volumes using scrotal ultrasound. Testicular disproportion was calculated using the equation [(size of unaffected testis) - (size of affected testis)]/(size of unaffected testis) x 100%. Disproportion was categorized as less than 10%, 10% to 20% and more than 20%. Varicoceles were graded by an attending urologist with the patient standing, using the system of Dubin and Amelar. Analysis of variance and Pearson chi-square indicated no significant differences in volume differential between varicocele grades. Mean +/- SD volume differential was 18% +/- 15% for grade I, 25% +/- 20% for grade II and 19% +/- 14% for grade III. ANOVA revealed no significant difference in mean volume differential between the 3 varicocele grades (p = 0.10). When categorizing patients into 3 levels of volume differential (less than 10%, 10% to 20%, more than 20%) no significant correlation was observed between varicocele and volume differential (p = 0.48, chi-square test). Grade of varicocele does not correlate with presence or severity of testicular disproportion in adolescent boys with varicocele as measured by scrotal ultrasound.

Testicular hypotrophy is the most widely accepted indication for correcting adolescent varicocele. Previous studies in adolescents have shown a relationship between increasing grade of varicocele and the likelihood of testicular hypotrophy. As this relationship has significant clinical implications, we studied the correlation between grade and testicular volume disproportion in our adolescent varicocele population. We reviewed the adolescent varicocele database at our institution. A total of 168 patients 8 to 21 years old were studied. We routinely calculated testis volumes using scrotal ultrasound. Testicular disproportion was calculated using the equation [(size of unaffected testis) - (size of affected testis)]/(size of unaffected testis) x 100%. Disproportion was categorized as less than 10%, 10% to 20% and more than 20%. Varicoceles were graded by an attending urologist with the patient standing, using the system of Dubin and Amelar. Analysis of variance and Pearson chi-square indicated no significant differences in volume differential between varicocele grades. Mean +/- SD volume differential was 18% +/- 15% for grade I, 25% +/- 20% for grade II and 19% +/- 14% for grade III. ANOVA revealed no significant difference in mean volume differential between the 3 varicocele grades (p = 0.10). When categorizing patients into 3 levels of volume differential (less than 10%, 10% to 20%, more than 20%) no significant correlation was observed between varicocele and volume differential (p = 0.48, chi-square test). Grade of varicocele does not correlate with presence or severity of testicular disproportion in adolescent boys with varicocele as measured by scrotal ultrasound.

We evaluated the impact of tubularized incised plate urethroplasty on primary and repeat hypospadias repair. We retrospectively reviewed the medical records of all boys who underwent hypospadias repair at our institution during a recent 3-year period. The level of the hypospadias defect, technique of repair, primary repair versus reoperation, age at surgery and complications were recorded. A total of 520 hypospadias repairs were done from May 1996 through June 1999. We began to perform tubularized incised plate urethroplasty in November 1996. During the ensuing consecutive 32 months 181 primary and 25 repeat hypospadias repairs were done using this technique. Mean patient age at surgery was 22 months (range 3 months to 30 years). During the 6 months immediately before we began to use this method the Mathieu flip-flap procedure was the most commonly performed technique, accounting for 38% of all hypospadias repairs. In contrast, during the last 6 months reviewed tubularized incised plate urethroplasty accounted for 63% of all repairs, including 41 of 65 primary operations (63%) and 4 of 6 reoperations (67%), while no Mathieu procedures were performed. Postoperative followup was 6 to 38 months for tubularized incised plate repair. Overall meatal stenosis and a urethrocutaneous fistula developed in 1 and 14 boys, respectively (7% complication rate). Tubularized incised plate urethroplasty has become the preferred technique of primary and repeat hypospadias repair at our institution. The technique has few complications as well as proved success and versatility that continues to expand its applicability and popularity.

Normal bladder development is believed to depend on the active work of the bladder for storing and expelling urine. When high urinary diversion is performed in infants and the bladder no longer undergoes normal filling, bladder development may be altered, ultimately resulting in bladder dysfunction. To help better understand this relationship of bladder function with growth at the cellular level we developed a novel laboratory method for applying hydrostatic pressure to cell cultures, and we characterized the response of neonatal bladder smooth muscle cells to physiological levels of sustained hydrostatic pressure. Neonatal ovine smooth muscle cells staining positive for desmin and alpha-smooth muscle actin were exposed to pressures of 0.3 (controls), 2, 4, 6 and 8.5 cm. water for 1, 3, 5 and 7 days. At the end of the experiments the cells were fixed, stained and counted. Mitogenic activity of the supernatant media from bladder smooth muscle cells exposed to 8.5 cm. water for 5 days (conditioned media) was tested before and after treatments of heating, freezing, passing through a heparin-sepharose affinity chromatography column or after the addition of suramin, a nonspecific growth factor inhibitor. Statistical analysis was performed using Student's t test with p <0.05 considered statistically significant. Exposure of bladder smooth muscle cells to sustained hydrostatic pressures of 4, 6 and 8.5 cm. water resulted in increased cell proliferation. Differences became statistically significant (p <0.05) by day 5. Also, conditioned media contained mitogenic activity that was ablated by heating, freezing, passage through a heparin-sepharose affinity chromatography column or with the addition of suramin. We have demonstrated a proliferative response of neonatal bladder smooth muscle after exposure to physiological levels of sustained hydrostatic pressure. This response is partially due to 1 or more transferable mitogenic factors. These data support the hypothesis that pressure associated with bladder filling is an important stimulus for detrusor development.

PurposeThe combination of in utero bladder distension and bilateral hydroureteronephrosis in male fetuses may result from a number of pathological processes. The prenatal and postnatal treatment of patients with an enlarged bladder is dictated by the specific etiology leading to these changes. We propose specific ultrasonographic criteria for differentiating between obstructive and nonobstructive etiologies in these fetuses.

Intermittent testicular torsion (ITT) is a poorly characterized condition but harbors potentially serious implications with regard to testicular viability. We report better characterization of the diagnostic features of ITT. We performed a retrospective review of all patients 1 to 18 years old seen from 1997 to 2003 at our institution diagnosed with ITT. Patients with acute scrotal pain and spontaneous resolution who underwent bilateral testicular fixation were included in the study. A total of 50 patients meeting the inclusion criteria were identified with mean age at presentation of 12.2 years (range 4 to 17). The mean number of painful episodes before surgery was 4.3 (range 1 to 30). The most common presenting features were severe pain of rapid onset and resolution. Nausea and/or vomiting was reported in a quarter of the patients. Finding of a horizontal lie of the testes on examination was significantly associated (p <0.05) with the existence of the bell-clapper deformity. All patients underwent surgical fixation of the testes. There were no postoperative complications. Of 38 patients (97%) for whom followup was available 37 had complete resolution of symptoms (mean followup 7.9 months). ITT should be a diagnostic consideration in patients who present with recurrent acute scrotal pain with rapid spontaneous resolution. Recurrent severe pain with rapid onset and resolution seems to be highly characteristic. Horizontal lie on examination is highly correlated with the bell-clapper deformity at surgical exploration. Surgery may be recommended in these patients as it appears to result in pain relief in the majority, is likely to prevent future testicular infarction and is associated with low morbidity.