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Objective This study identifies trajectories of parent depressive symptoms after having a child born with genital atypia due to a disorder/difference of sex development (DSD) or congenital adrenal hyperplasia (CAH) and across the first year postgenitoplasty (for parents who opted for surgery) or postbaseline (for parents who elected against surgery for their child). Hypotheses for four trajectory classes were guided by parent distress patterns previously identified among other medical conditions. Methods Participants included 70 mothers and 50 fathers of 71 children diagnosed with a DSD or CAH with reported moderate to high genital atypia. Parents were recruited from 11 US DSD specialty clinics within 2 years of the child’s birth and prior to genitoplasty. A growth mixture model (GMM) was conducted to identify classes of parent depressive symptoms over time. Results The best fitting model was a five-class linear GMM with freely estimated intercept variance. The classes identified were termed “Resilient,” “Recovery,” “Chronic,” “Escalating,” and “Elevated Partial Recovery.” Four classes have previously been identified for other pediatric illnesses; however, a fifth class was also identified. The majority of parents were classified in the “Resilient” class (67.6%). Conclusions This study provides new knowledge about the trajectories of depressive symptoms for parents of children with DSD. Future studies are needed to identify developmental, medical, or familial predictors of these trajectories.

Summary Introduction Caregivers of female infants with congenital adrenal hyperplasia (CAH) often confront complex medical decision-making (e.g., early feminizing genitoplasty). Objective This study aimed to evaluate the relevant medical decisions and subsequent decisional regret of caregivers following their child's genitoplasty. Study design Caregivers (N = 55) were recruited from multidisciplinary treatment programs for participation in a longitudinal study. Qualitative data was collected at 6–12 months following feminizing genitoplasty to evaluate caregiver-reported decision points across their child's treatment. Quantitative exploratory analysis evaluated pre-operative predictors of subsequent decisional regret. Discussion When prompted about their decision-making and potential regret, most caregivers (n = 32, 80%) reported that their daughter's genital surgery was their primary medical decision. Specific themes regarding genital surgery included the timing and type of surgery. Most caregivers reported no decisional regret (62%), with 38% reporting some level of regret. Greater pre-operative illness uncertainty predicted heightened decisional regret at follow-up, p = .001. Conclusion Two-thirds of caregivers of female infants with CAH reported not regretting their decision-making. Nevertheless, over one-third of caregivers reported some level of regret, suggesting the need for improvements in shared decision-making processes. Many, but not all, families reported that this regret was related to surgical decision-making. Reducing caregiver illness uncertainty (e.g., providing clear information to families) may increase their satisfaction with decision-making. Further research is needed to determine how the evolving care practices surrounding early genitoplasty will impact families. Download : Download high-res image (307KB) Download : Download full-size image Summary Figure . Levels of Caregiver Decisional Regret measured by the Decisional Regret Scale. Note. Conventional categorical classification of scores was used: 0 = “no regret”, 1 to 25 = “mild regret,” 26 to 100 = “moderate to severe regret”.

Parents of children with Disorders of Sex Development (DSD) report significant psychological distress, including posttraumatic stress symptoms (PTSS), with mothers consistently reporting higher rates of psychological distress than fathers. However, psychological factors contributing to PTSS in both parents are not well understood. The present study sought to fill this gap in knowledge by examining PTSS and illness uncertainty, a known predictor of psychological distress, in parents of children recently diagnosed with DSD. Participants were 52 mothers (M(age) = 32.55 years, SD = 5.08) and 41 fathers (M(age) = 35.53 years, SD = 6.78) of 53 infants (M(age) = 9.09 months, SD = 6.19) with DSD and associated atypical genital development. Participants were recruited as part of a larger, multisite study assessing parents’ psychosocial response to their child’s diagnosis of DSD. Parents completed measures of illness uncertainty and PTSS. Mothers reported significantly greater levels of PTSS, but not illness uncertainty, than fathers, and were more likely than fathers to report clinical levels of PTSS (21.2% compared to 7.3%). Hierarchical regression revealed that parent sex, undiagnosed or unclassified DSD status, and illness uncertainty were each associated with PTSS. The overall model accounted for 23.5% of the variance associated with PTSS. Interventions targeting illness uncertainty may be beneficial for parents of children with newly diagnosed DSD.

The impact of parent-reported stigma due to their child's disorder/difference of sex development (DSD) on parent psychosocial adjustment is poorly understood. In other pediatric populations, perceived interference of medical conditions into daily activities (i.e., illness intrusiveness ) mediates the relationship of stigma to adjustment. This study assessed relationships between parent-focused and child-focused stigma → illness intrusiveness → depressive and anxious symptoms . Exploratory analyses sought to identify patient characteristics associated with stigma.Caregivers (59 women and 43 men) of 63 children diagnosed with a DSD up to age 4 years completed measures of demographics, parent-focused and child-focused stigma, illness intrusiveness, and depressive and anxious symptoms.Increased parent-focused and child-focused stigma were associated with increased illness intrusiveness, which, in turn, was associated with increased depressive and anxious symptoms for parents nested within dyads. Among children with DSD family histories, parents reported greater child-focused stigma.Parents who experience DSD-related stigma report greater interference of their child's DSD into their daily activities, which is associated with poorer psychosocial adjustment. Findings support developing clinical interventions related to parents' perceptions of stigma and illness intrusiveness to improve parent adjustment.

Summary Introduction Differences of sex development (DSD) are congenital conditions in which there is atypical chromosomal, gonadal and/or phenotypic sex. A phenotype of severe genital atypia in patients raised as male is a relatively rare occurrence and standards for management are lacking. Decision making for early surgical planning in these rare cases includes, but is not limited to, degree of atypia, location of testes, and presence of Mϋllerian remnants. In this study we describe surgical approaches and short-term outcomes for masculinizing genitoplasty in moderate to severe genital atypia in young patients raised male, for whom parents opted for early surgery. Methods This NIH-sponsored study is an ongoing, observational, multicenter investigation assessing medical, surgical and psychological outcomes in children and their parents affected by atypical genitalia due to DSD. Participants were prospectively enrolled from 12 children's hospitals across the United States that specialize in DSD care. Criteria for child enrollment were a Quigley score of 3–6 in those with a 46, XY or 45,X/46, XY chromosome complement, age Results Of the 31 participants, 30 underwent hypospadias repair and 1 patient did not undergo a genitoplasty procedure. The majority of participants (22) received a staged hypospadias repair. Seventeen complications were identified in 12 of the 31 children (41%) at 12 months of follow up. Glans dehiscence and urethrocutaneous fistula were the most common complications. Orchiopexy was performed in 14 (44%) and streak gonads were removed in 4 (13%) participants. Both parents and surgeons reported improved cosmesis after surgery when compared to baseline. Conclusion Genitoplasty was chosen by parents for the majority of children eligible for study. No single surgical approach for masculinizing moderate to severe genital ambiguity in young patients with 46, XY or 45,X/46, XY DSD was adopted by all surgeons. Complications occurred in 41% of those who underwent genitoplasty for severe hypospadias. Overall, appearance of the genitals, as determined by parents and surgeons, improved following genitoplasty. Outcomes of early genitoplasty are needed to guide families when making decisions about such procedures for their young children. Download : Download high-res image (286KB) Download : Download full-size image Summary Figure . River plot comparing Likert cosmesis score over time for mothers, fathers, and surgeons. Panel A includes all patients in the cohort.

Objective A subset of parents of children with disorders/differences of sex development (DSD) including ambiguous genitalia experience clinically elevated levels of anxious and depressive symptoms. Research indicates that uncertainty about their child’s DSD is associated with parent psychosocial distress; however, previous studies have been cross-sectional or correlational in nature. The current study is the first to examine the longitudinal trajectory of the relationship between caregiver-perceived uncertainty about their child’s DSD and caregiver anxious and depressive symptoms across the first 12 months following genital surgery in young children, or if surgery was not performed, the first 12 months following study entry. Methods One hundred and thirteen caregivers (Mage = 32.12; 57.5% mothers; 72.6% Caucasian) of children (N = 70; Mage = 9.81 months; 65.7% female) with DSD were recruited from 12 DSD specialty clinics in the United States. Caregivers completed psychosocial measures at baseline, 6 and 12 months following genitoplasty, or study entry if parents elected not to have surgery for their child. Results Caregiver illness uncertainty and both anxious and depressive symptoms were highest at baseline and decreased over time (ps < .05). Caregiver illness uncertainty predicted symptoms of anxious and depressive symptoms across all time points (ps < .05). Conclusions Caregivers’ perceptions of uncertainty about their child’s DSD are highest soon after diagnosis, and uncertainty continues to predict both anxious and depressive symptoms across time. Thus, the initial diagnostic period is a critical time for psychological assessment and intervention, with parent illness uncertainty being an important clinical target.

Urologic causes of end-stage renal disease are estimated between 25% and 40% of causes. The goal of renal transplantation in chronic kidney disease patients is to provide renal replacement therapy with less morbidity, better quality of life, and improved overall survival compared with dialysis. A patient's urologic history can be a significant source of problems related to infections, recurrence of disease, and surgical complications. Many of the urologic risks are modifiable. Proper evaluation and management can mitigate the potential problems after transplantation, and these patients with complex urologic problems are seen to have similar graft function outcomes.

Background/Aims: Parents of children born with disorders of sex development (DSD) often experience anxiety, but risk factors, including parental perception of the severity of their child’s DSD, have not been examined. We hypothesized that severity of illness (SOI) ratings would relate to parental anxiety, and would be higher for parents of children with a potentially life-threatening DSD (e.g., 21-hydroxylase deficiency). Methods: Eighty-nine parents (Mage = 33.0, 56.2% mothers) of 51 children (Mage in months = 8.7) with a DSD including ambiguous genitalia were recruited from 12 specialized DSD clinics. Parents completed questionnaires prior to genitoplasty, 6 months post-genitoplasty, and 12 months post-genitoplasty (if completed). Data were analyzed with linear mixed modeling. Results: Parental anxiety decreased over time, χ2(1) = 10.14, p < 0.01. A positive relationship between SOI and anxiety was found, with SOI being a strong predictor of anxiety (b = 0.53, p < 0.01; χ2[1] = 5.33, p < 0.05). An SOI by time interaction indicated SOI had an increasing effect on anxiety over time, b = 0.06, p < 0.05; χ2(1) = 6.30, p < 0.05. There was no diagnosis by SOI interaction. Conclusion: Parental anxiety decreased over time, but those with higher SOI ratings reported greater initial anxiety followed by slower resolution over time. Underlying etiology of DSD had no effect on the relationship between SOI and anxiety.

To assess the outcomes of "watering can" ureterocele puncture (WCP), a technique previously associated with decreased incidence of de novo vesicoureteral reflux (VUR), as a durable option for management of ureteroceles and to determine the need for subsequent surgery for VUR following watering can puncture.We retrospectively reviewed records of 55 consecutive endoscopic ureterocele procedures performed at our institution from 1999 to 2015. The WCP was performed using a holmium laser fiber to make 10-20 puncture holes through the ureterocele. Follow-up data were collected on infection, de novo VUR in the affected renal moiety and the need for further treatment and surgery.Of 55 patients who underwent endoscopic ureterocele management, 34 underwent WCP and 21 patients underwent either incision or puncture. Median follow-up was 3.4 and 2.8 years in the incision and puncture groups, respectively. Both groups had similar rates of ureterocele decompression (88% vs 90%; P .05) and improvement in hydronephrosis (82% vs 81%; P .05). The WCP group had a significantly decreased rate of de novo VUR (32% vs 67%; P .05) and of subsequent surgery due to de novo VUR (38% vs 71%; P .05). The average grade of de novo VUR was lower in the WCP group (1.4 vs 2.8; P .05).Our study shows that the endoscopic WCP successfully decompresses the obstructing ureterocele and results in a decreased incidence of de novo VUR and ultimately in fewer invasive procedures for the patient. This update demonstrates the durable outcomes of this novel technique.

Robot-assisted laparoscopic extravesical ureteral reimplantation has been proposed as a minimally invasive alternative to open ureteral reimplantation for correcting primary vesicoureteral reflux in children. However, in the current literature there are conflicting data regarding the safety and efficacy of this approach. Amid ongoing debate we analyzed outcomes and complications from this procedure in a large multi-institutional cohort.We reviewed the records of children who underwent robot-assisted laparoscopic extravesical ureteral reimplantation at 9 academic centers from 2005 to 2014. Radiographic failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram. Complications were graded using the Clavien-Dindo scale.A total of 260 patients (363 ureters) underwent robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux during the study period. The cohort included 90 patients with either duplex ureter (42), failed endoscopic treatment (40) or concomitant diverticulectomy (8). Of the 280 ureters with postoperative voiding cystourethrogram or radionuclide cystogram available radiographic resolution was seen in 246 (87.9%). There were 25 complications overall (9.6%), with 7 grade 3 complications (2.7%) and no grade 4 or 5 complications. Four patients (3.9%) had transient urinary retention following bilateral reimplantation.Robot-assisted laparoscopic extravesical ureteral reimplantation has a low complication rate consistent with published series of open ureteral reimplantation. Radiographic success rates are approaching those of the open procedure but continue to fall short of the gold standard approach. These findings necessitate critical thinking regarding potential technique improvements and further prospective investigation into the efficacy of this procedure.

Objective To assess the effect of contrast height during the voiding cystourethrogram (VCUG). The VCUG is the gold standard diagnostic test for vesicoureteral reflux (VUR). Variation in parameters may affect detection and grade of reflux. Materials and Methods In a multicenter, prospective, nonrandomized, observational study, patients undergoing VCUG were selected. VCUG was performed per study protocol except for a change in contrast height. The initial fill was performed at 50 cm and the second at 100 cm. Data collected included presence and grade of VUR and volume filled. The actual bladder volume filled was normalized to the estimated bladder capacity (EBC) as a percentage. A Cohen's kappa coefficient of agreement was used to test for difference in the incidence of reflux and grade between contrast heights. A Wilcoxon signed-rank test was used for differences in the percent EBC filled between heights. Results From May 2012 to November 2013, 184 patients were enrolled. Seventy-one patients (39%) exhibited VUR at 50 cm and 80 patients (43%) at 100 cm. The kappa coefficient of agreement between 50 cm and 100 cm showed substantial agreement, with no significant difference in VUR grade. The percent of EBC filled at each height was significantly different: %EBC filled at 50 cm: 101 ± 46 (range 9.2-228.3), and %EBC filled at 100 cm: 130 ± 56 (range 37.8-280.6) ( P Conclusion No significant difference was noted in the detection of VUR with different contrast heights. A significantly larger bladder volume was instilled at 100 cm.

INTRODUCTION: Individuals with bladder and cloacal exstrophy are at increased risk for kidney disease, renal failure, and bladder complications. Given the social implications and sensitive nature of the disease, these patients are also at risk for psychosocial problems. Lack of regular medical follow-up visits may pose serious risks to their long-term health status. The aim of this study is determine what factors place an affected individual at risk for limited long term follow up. MATERIALS AND METHODS: We identified all patients with bladder or cloacal exstrophy seen by the pediatric urology department at the Oklahoma University Health Sciences Center (OUHSC) between January 1996 and August 2016. Patient data included demographics, insurance coverage, distance from patient’s home to the clinic, medical and surgical history, and the date of their last clinic visit. Two groups for comparison were (1) those that had been seen within the last 2 years, and (2) those that were counted as failing to maintain follow-up because 2 or more years had passed since their last clinic visit. These groups were compared using the Student t-test, the chisquare test, or the Fisher exact test and p < 0.05 was treated as significant for the purposes of discussion. RESULTS AND DISCUSSION: Ninety-one patients with bladder or cloacal exstrophy were seen by the pediatric urology department between January 1996 and August 2016. Of the 91 patients, 24 left the clinic for known reasons thus leaving 67 patients that were considered for analyses: 51 had been seen within the last 2 years while 16 were counted as lost to follow-up. These two groups (active and lost to follow-up) did not differ significantly for age at last clinic visit, distance between family’s home and clinic, history of bladder reconstruction, sex, or insurance status. There was a significant difference between the two groups in the medical complexity of their condition. The group active in urological care had more patients with cloacal exstrophy and additional anomalies than the group lost to follow-up. CONCLUSIONS: Patients with bladder exstrophy and cloacal exstrophy are less likely to maintain annual follow-up visits with their urologist if they have a simpler diagnosis requiring fewer surgical interventions. For patients with exstrophy, regular clinic visits prioritizing education and psychosocial support may prevent hospitalizations, emergency interventions, and poor overall health outcomes. To maintain contact with the medical team and promote optimal health outcomes, a social worker or care coordinator/educator may play an integral part in addressing the unique needs of this population.

There is a demand for tissue engineering of the bladder needed by patients who experience a neurogenic bladder or idiopathic detrusor overactivity. To avoid complications from augmentation cystoplasty, the field of tissue engineering seeks optimal scaffolds for bladder reconstruction. Naturally derived biomaterials as well as synthetic and natural polymers have been explored as bladder substitutes. To improve regenerative properties, these biomaterials have been conjugated with functional molecules, combined with nanotechology, or seeded with exogenous cells. Although most studies reported complete and functional bladder regeneration in small-animal models, results from large-animal models and human clinical trials varied. For functional bladder regeneration, procedures for biomaterial fabrication, incorporation of biologically active agents, introduction of nanotechnology, and application of stem-cell technology need to be standardized. Advanced molecular and medical technologies such as next generation sequencing and magnetic resonance imaging can be introduced for mechanistic understanding and non-invasive monitoring of regeneration processes, respectively.

PURPOSE: We examined the psychological adjustment of parents of children born with moderate to severe genital atypia 12 months after their child underwent genitoplasty. MATERIALS AND METHODS: Parents were recruited longitudinally from a multicenter collaboration of 10 pediatric hospitals with specialty care for children with disorders/differences of sex development and/or congenital adrenal hyperplasia. Parents completed measures of depressive and anxious symptoms, illness uncertainty, quality of life, posttraumatic stress and decisional regret. RESULTS: Compared to levels of distress at baseline (before genitoplasty) and 6 months after genitoplasty, data from 25 mothers and 20 fathers indicated significant improvements in all psychological distress variables. However, a subset of parents continued endorsing clinically relevant distress. Some level of decisional regret was endorsed by 28% of parents, although the specific decision that caused regret was not specified. CONCLUSIONS: Overall the majority of parents were coping well 1 year after their child underwent genitoplasty. Level of decisional regret was related to having a bachelor’s level of education, increased levels of illness uncertainty preoperatively and persistent illness uncertainty at 12 months after genitoplasty but was unrelated to postoperative complications.

Neuroblastoma (NB) is the most common extra-cranial solid tumor in children and the most common malignancy in infants, with complete resection being curative in low-stage disease. The previous standard of treatment for many abdominal NBs involving the adrenal gland had been open surgery; however, there have been numerous descriptions of the safety and feasibility of a laparoscopic approach to resect adrenal masses in the pediatric population in benign and malignant disease, including improved cosmetic results, decreased length of stay, decreased surgical morbidity, and comparable oncological outcomes to open surgery. Despite these reported advantages over open surgery, the newer robot-assisted laparoscopy (RAL) offers benefits over the conventional laparoscopic approach that could further improve outcomes and expand the use of minimally invasive surgical approaches for pediatric adrenal masses. RAL offers many additional advantages over conventional laparoscopy, such as 3D visualization, increased range of motion of surgical instruments, tremor control, and a shorter learning curve compared with traditional laparoscopic surgery, while still maintaining the advantages of minimally invasive surgery. The body of literature concerning robot-assisted oncological surgery involving the adrenal gland in children is quite small, and to our knowledge no case reports have been published describing robot-assisted removal of an adrenal NB in a pediatric patient. We present our experience and technique of an RAL approach for lymph-node dissection and radical resection of a low-stage NB involving the adrenal gland with no image-defined risk factors in a 15-month-old infant.

Summary Introduction Testicular torsion (TT), a common surgical emergency worldwide, is typically treated with orchiectomy or orchiopexy. It is widely accepted that the chance of salvaging the testicle declines with time and degree of torsion. The impact of ethnicity on outcome is less well understood, and the association between weather and onset of TT remains a controversy. Objectives It is important to know the signs of TT so that appropriate treatment can be given quickly. The purpose of this study was to provide a detailed analysis of registered cases of TT in adolescent patients diagnosed at a single institution to better understand the association between clinical indicators and surgical outcomes and to examine some remaining controversies in the literature on TT. Study design A retrospective chart review was conducted, using medical records from the present institution. Data were collected for 165 patients who met the following inclusion criteria: 1) adolescent males between 10 and 18 years of age at the time of diagnosis, and 2) TT between January 2001 and June 2013. Results Of the 165 patients, 38% had orchiectomies. Patients with orchiectomies had longer wait times for surgery ( p p = 0.02). Assuming that patients without reference to presence of bell clapper deformity in their medical notes did not have the deformity, those with orchiectomies were less likely to have bell clapper deformity than were those with orchiopexies ( p p = 0.02). Discussion and conclusion Wait time to surgery positively correlates with orchiectomy. Early identification and intervention is vital to testicular salvage. As the degree of torsion increases, the blood supply to the affected testis decreases and the time required to inflict testicular vascular damage decreases. Our results showed the presence of the bell clapper deformity moderated the relationship between temperature and TT: Those without the deformity had torsions on colder days than did those with the deformity. A comprehensive multi-centered study could help draw further conclusions regarding temperature correlation and the bell clapper deformity. Table . Differences in clinical characteristics by surgical outcome. Variable Orchiopexy Orchiectomy p Triage to provider, minutes 27.55 ± 30.47 31.12 ± 28.27 0.47 Triage to surgery, minutes 216.63 ± 110.23 334.29 ± 250.51 Driving distance, miles 26.37 ± 43.56 39.83 ± 169.37 0.54 Driving time, minutes 31.42 ± 38.93 41.78 ± 141.75 0.57 Degree of torsion, degrees 458.29 ± 179.51 505.10 ± 173.13 0.15 Bell clapper Yes 34 (33%) 9 (14%) No 68 (67%) 54 (86%) Temperature, Fahrenheit 64.05 ± 15.62 61.54 ± 18.73 0.36

Summary Background The birth of a child with a disorder of sex development (DSD) and atypical genitalia can be traumatizing and isolating for families. Parents of children with DSD are at risk for increased levels of psychological distress, including depression, anxiety, illness uncertainty (IU), post-traumatic stress symptoms (PTSS), and impairments in quality of life (QOL). Our previous report indicated that although the majority of parents of children with atypical genitalia were coping well prior to the child's genitoplasty, approximately 25% of them reported experiencing some type of psychological distress. Objective The current study sought to examine the trajectory of parental psychological distress prior to, and 6 months after their child underwent genitoplasty. Methods Parents were recruited as part of an ongoing, prospective, multi-site study involving 10 pediatric hospitals with specialized care for children with atypical genitalia. Results from 49 parents (27 mothers, 22 fathers) of 28 children (17 female sex of rearing, 11 male sex of rearing) born with atypical genitalia (Prader rating of 3–5 in 46,XX DSD or by a Quigley rating of 3–6 in 46,XY DSD or 45,XO/46,XY) were included in the study. Results There were no significant changes in level of depressive or anxious symptoms or quality of life between baseline and 6-month post-operative follow-up, although mothers continued to report significantly higher levels of depressive symptoms than fathers, and as a group, these parents reported lower QOL than published norms. The level of PTSS significantly decreased for all parents, suggesting that parents may have come through the acute stress phase associated with their child's diagnosis. Finally, while there were no significant changes in IU over the time period, the level of IU for parents of boys actually increased, while parents of girls reported no change (Figure). Conclusion Six months after their child has undergone genitoplasty, the majority of parents report minimal levels of psychological distress. However, a subset of these parents continue to experience significant distress related to their child's diagnosis. Specifically, parents of boys appear to be at increased risk for difficulties, which may be related to either the lack of clinical diagnosis for almost half of these children or the necessity of two-stage surgeries for the majority of them. We will continue collecting data on these families to better understand the trajectory of these adjustment variables. Download : Download high-res image (173KB) Download : Download full-size image Figure . Graphs of significant changes.

Little data exist about the surgical interventions taking place for children with disorders of sex development (DSD). Most studies that have evaluated cosmetic outcomes after genitoplasty have included retrospective ratings by a physician at a single center.The present study aimed to: 1) describe frequency of sex assignment, and types of surgery performed in a cohort of patients with moderate-to-severe genital ambiguity; and 2) prospectively determine cosmesis ratings by parents and surgeons before and after genital surgery.This prospective, observational study included children aged2 years of age, with no prior genitoplasty at the time of enrollment, moderate-to-severe genital atypia, and being treated at one of 11 children's hospitals in the United States of America (USA). Clinical information was collected, including type of surgery performed. Parents and the local pediatric urologist rated the cosmetic appearance of the child's genitalia prior to and 6 months after genitoplasty.Of the 37 children meeting eligibility criteria, 20 (54%) had a 46,XX karyotype, 15 (40%) had a 46,XY karyotype, and two (5%) had sex chromosome mosaicism. The most common diagnosis overall was congenital adrenal hyperplasia (54%). Thirty-five children had surgery; 21 received feminizing genitoplasty, and 14 had masculinizing genitoplasty. Two families decided against surgery. At baseline, 22 mothers (63%), 14 fathers (48%), and 35 surgeons (100%) stated that they were dissatisfied or very dissatisfied with the appearance of the child's genitalia. Surgeons rated the appearance of the genitalia significantly worse than mothers (P 0.001) and fathers (P ≤ 0.001) at baseline. At the 6-month postoperative visit, cosmesis ratings improved significantly for all groups (P 0.001 for all groups). Thirty-two mothers (94%), 26 fathers (92%), and 31 surgeons (88%) reported either a good outcome, or they were satisfied (see Summary Figure); there were no significant between-group differences in ratings.This multicenter, observational study showed surgical interventions being performed at DSD centers in the USA. While parent and surgeon ratings were discordant pre-operatively, they were generally concordant postoperatively. Satisfaction with postoperative cosmesis does not necessarily equate with satisfaction with the functional outcome later in life.In this cohort of children with genital atypia, the majority had surgery. Parents and surgeons all rated the appearance of the genitalia unfavorably before surgery, with surgeons giving worse ratings than parents. Cosmesis ratings improved significantly after surgery, with no between-group differences.

Total and partial urogenital mobilization procedures are the most common contemporary vaginoplasty surgeries for patients with congenital adrenal hyperplasia, urogenital sinus and cloacal anomalies. There is controversy regarding the urinary continence outcomes of these procedures. We reviewed the urinary continence outcomes of children who underwent total or partial urogenital mobilization at our institution and reviewed the literature to determine the continence rates of these procedures.We retrospectively reviewed 25 patients who underwent total or partial urogenital mobilization with a focus on postoperative continence status. Continence was defined as parental report of full toilet training with no accidents during the day and rare accidents (fewer than 2 per month) at night after age 3 years.A total of 14 congenital adrenal hyperplasia, 5 urogenital sinus and 6 cloacal anomaly cases were managed by total (18) or partial (7) urogenital mobilization procedures with a mean followup of 4.41 years (range 0.21 to 12.1). In our cohort 21 of 22 patients (95.5%) were continent by age 3 years and there were no urinary complications. A total of 111 patients were identified in the literature with congenital adrenal hyperplasia or urogenital sinus, with 107 in 7 studies being continent (96.4%) by age 3 to 4 years. In 4 studies 32 patients were identified with cloacal anomalies who underwent total or partial urogenital mobilization, of whom 28 (87.5%) were continent by age 3 to 4 years.There was no significant difference between total and partial urogenital mobilization procedures regarding postoperative urinary continence in our cohort and the literature. The urinary continence rate was 96% in the congenital adrenal hyperplasia/urogenital sinus group and 89.5% in the cloacal group.

Boys with undermasculinized external genital and/or 46,XY disorders of sex development (DSD) often receive masculinizing genitoplasty. Such procedures are done to correct ventral curvature of the phallus, reposition a proximally located urethral meatus, and cosmetically correct the appearance of labioscrotal folds. No studies to date have assessed if patients with a specific DSD diagnosis have worse outcomes for severe proximal hypospadias procedures or whether or not these patients require more extensive surgical maneuvers than severe proximal hypospadias patients without a specific DSD diagnosis. We retrospectively reviewed consecutive proximal hypospadias repairs performed at our institution from 1998 to 2010 and compared the anatomy, surgical technique required for repair, and outcomes in patients with and without a definitive DSD diagnosis. Boys with a specific DSD diagnosis do have significantly more atypical anatomy when undergoing proximal hypospadias masculinizing genitoplasties. They are more likely to require associated gonad procedures but do not have an increased risk of complications or number of surgeries when compared to other proximal hypospadias patients without a specific DSD diagnosis. The risk of complications is consistent with reports in the literature, and the mean number of procedures in this contemporary study is fewer than in historic reports.

This is a report of an upper tract invasive urothelial carcinoma in a horseshoe kidney successfully managed with a combined hand-assisted laparoscopic nephroureterectomy and isthmusectomy with cystoscopic en-bloc excision of the distal ureter and bladder cuff., Upper tract invasive urothelial carcinoma and horseshoe kidneys are familiar to the practicing urologist but relatively rare individual entities. The complication of managing them when they coexist in the same patient can be challenging. Herein, we present the first reported case in which an upper tract invasive urothelial carcinoma in a horseshoe kidney was successfully managed with a combined hand-assisted laparoscopic nephroureterectomy and isthmusectomy with cystoscopic en-bloc excision of the distal ureter and bladder cuff. This highlights the fact that complex anatomy can be managed in a completely minimally invasive fashion, and sound oncologic principles can still be maintained.

The endoscopic injection of Dx/HA in the management of vesicoureteral reflux (VUR) has become an accepted alternative to open surgery. In the current study we evaluated the value of cystography to detect de novo contralateral VUR in unilateral cases of VUR at the time of Dx/HA injection and correlated the findings of immediate post-Dx/HA injection cystography during the same anesthesia to 2-month postoperative VCUG to evaluate its ability to predict successful surgical outcomes. The current study aimed to evaluate whether an intraoperatively performed cystogram could replace postoperative studies. But a negative intraoperative cystogram correlates with the postoperative study in only 80%. Considering the 75–80% success rate of Dx/HA implantation, the addition of intraoperative cystograms cannot replace postoperative studies. In patients treated with unilateral VUR, PIC cystography can detect occult VUR and prevent postoperative contralateral new onset of VUR.

OBJECTIVE To examine the histological differences in the inflammatory response and regenerative outcomes of distal vs proximal porcine small intestinal submucosa (SIS) grafts in the rat bladder, as SIS from distal small intestine yields reliable and reproducible bladder regeneration, while SIS from proximal portions of small intestine does not provide similar results. MATERIALS AND METHODS In all, 30 Sprague-Dawley rats underwent hemi-cystectomy followed by anastomosis of a bladder patch of SIS prepared from either distal or proximal small intestine. After bladder harvest, immunohistochemistry was used to quantify mast cells, eosinophils, macrophages, and neutrophils (PMNs). Total cell count per unit area was compared across the time course in univariate and logistic regression modelling. RESULTS There were more eosinophils and mast cells in proximal SIS grafts, while there were more macrophages and PMNs in distal SIS grafts (all P

PurposeWe examined the psychosocial characteristics of parents of children with disorders of sex development at early presentation to a disorders of sex development clinic. Parental anxiety, depression, quality of life, illness uncertainty and posttraumatic stress symptoms were assessed. Additionally we evaluated the relationship of assigned child gender to parental outcomes.Materials and methodsA total of 51 parents of children with ambiguous or atypical genitalia were recruited from 7 centers specializing in treatment of disorders of sex development. At initial assessment no child had undergone genitoplasty. Parents completed the Cosmetic Appearance Rating Scale, Beck Anxiety Inventory, Beck Depression Inventory, SF-36, Parent Perception of Uncertainty Scale and Impact of Event Scale-Revised.ResultsA large percentage of parents (54.5%) were dissatisfied with the genital appearance of their child, and a small but significant percentage reported symptoms of anxiety, depression, diminished quality of life, uncertainty and posttraumatic stress. Few gender differences emerged.ConclusionsAlthough many parents function well, a subset experience significant psychological distress around the time of diagnosis of a disorder of sex development in their child. Early screening to assess the need for psychosocial interventions is warranted.

Summary Introduction It is unclear how clinicians learn to grade pediatric hydronephrosis (HN) and how effective their training has been. We sought to: 1. Assess how clinicians learn to grade HN and their confidence in their training and abilities and 2. To assess Computer Enhanced Visual Learning (CEVL) e-Learning to learn the Society for Fetal Urology (SFU) grading system for pediatric HN. Methods and materials A multi-institutional online survey was distributed to pediatric urologists, nephrologists, and radiologists. Respondents used a 6-point Likert scale (0 = not confident to 5 = very confident) to assess their confidence in knowledge of the criteria, indications, and ability to grade HN, and how they learned to grade. Participants assigned SFU grades to 15 neonatal ultrasounds (US). A CEVL module on the SFU grading system was accessed and a post-CEVL survey completed. Changes in confidence and accuracy of grading were compared before and after CEVL e-Learning. Results The most common method of learning was “casually during training” (44.5%). Significant increases in confidence in knowledge of criteria, indications, and ability to grade, as well as the accuracy of grading were seen following CEVL e-Learning (Figure A and B). Discussion Although the SFU grading system is considered the predominant grading system for HN, its application in clinical practice has been inconsistent. While this may be due to the grading system itself, it is possible that deficient training and confidence are the root causes. Our data supports this by demonstrating that most clinicians receive only casual training and accordingly, report low confidence in their knowledge and ability to grade HN. Therefore, we conclude that there exists a strong need to improve the teaching of the SFU grading system. e-Learning has been shown to be effective in teaching difficult topics and skills. We demonstrate that e-Learning with CEVL is effective in increasing both the confidence and accuracy of SFU grading of pediatric HN. Limitations of our study include a small sample size, low response rate, and discrepant participation. Furthermore, we did not assess the extent to which the CEVL module was used or include a control group learning through traditional means. Therefore, we were unable to evaluate the efficiency of learning or be certain that the improvements seen were derived exclusively from CEVL. Conclusion Current training in SFU grading of HN is mostly unstructured and inaccurate grading is common. Learners who use CEVL show improvements in their confidence and ability to SFU grade HN. Download : Download high-res image (201KB) Download : Download full-size image Figure . Confidence (A) and accuracy of grading (B) before and after CEVL e-Learning. a Confidences are expressed on a 6-point Likert scale (0 = no confidence to 5 = very confident) b Number of correctly graded US are out of 15. * p-value

Hyaluronic acid (HA), a non-sulfated glycosaminoglycan, is an essential component of the extracellular matrix (ECM). Since HA is involved in many phases of wound healing and may play a key role in tissue repair and regeneration, this study was intended to understand temporal and spatial expression of HA and HA receptors (HARs) during the course of bladder regeneration in rats.Sprague-Dawley rats were subjected to partial cystectomy followed by augmentation with porcine small intestinal submucosal (SIS) prepared from distal sections of the small intestine. SIS-augmented bladders were harvested between postoperative days 2 and 56.Bladder regeneration proceeded without complications. All augmented bladders had complete urothelial lining and smooth muscle bundles by day 56 post-augmentation. Temporal and spatial distributions of HA and HARs were studied by immunohistochemistry in regenerating bladders. The strongest HA immunoreactivity was observed in the ECM on postoperative days 28 and 56. Cluster of differentiation 44 (CD44) immunoreactivity was detected in the cytoplasm of urothelial cells on day 56; and LYVE-1 immunoreactivity was exclusively limited to lymphatic vessels on days 28 and 56.We demonstrated that HA was synthesized throughout the course of bladder wound healing and regeneration; and HA deposition coincided with urothelial differentiation. Expression of CD44 and LYVE-1 followed the same temporal pattern as HA deposition. Therapeutic modalities through local delivery of exogenous HA to improve the outcome of SIS-mediated bladder regeneration might need to be coordinated with HAR expression in order to achieve maximal regenerative responses as opposed to fibrosis.

Within the chronic medical illness literature, associations exist between caring for an affected child and parent mental health. The few studies examining both mothers and fathers provide mixed results. The purpose of this study is to examine associations between caregiver anxiety, depression, and parenting variables in caregivers of youth with SB as these relate to marital status, age, education, household income, work status, and child's severity of SB.The aim of this study is to examine associations between anxiety, depression, and parenting variables in caregivers of youth with spina bifida and how they relate to demographic and disease variables. Exploratory analyses examined the relationship between participation in support activities and depressive and anxious symptomatology and parenting characteristics.Eighty-four primary caregivers (49 mothers) of 51 youth with spina bifida completed measures of depressive and anxious symptomology, parenting stress, parent overprotection, and perceived child vulnerability.There were differences between mothers and fathers on several parenting characteristics; however, these were related more to marital status and employment than to gender of the caretaker per se. In the 33 married/remarried couples for whom both spouses participated, stress for the mothers was correlated with stress for the fathers. This correlation was strongest in the 12 married couples in which the mother works. Higher perceived vulnerability scores were reported in parents of SB patients in the younger age group, especially preschoolers (0-4 years). Parents of children with shunts reported more anxiety, depression and perceived child vulnerability. Both male and female caregivers of younger children reported significantly higher protectiveness scores. Involvement in recreational activities with other families affected by SB was associated with more positive parenting characteristics for mothers.Stress and protectiveness were found to be positively correlated (r0.6); depression, anxiety, and perceived vulnerability were not (0.3r-0.3). Overall, mothers reported more stress and anxiety than fathers. Higher perceived vulnerability scores were reported in parents of SB patients in the younger age group, especially preschoolers (0-4 years). Parents of children with shunts reported more anxiety, depression and perceived child vulnerability. Both male and female caregivers of younger children reported significantly higher protectiveness scores compared to caregivers of older children. Involvement in recreational activities with other families affected by SB was associated with more positive parenting characteristics for mothers. There were differences between mothers and fathers on several parenting characteristics; however, these were related more to marital status and employment than to gender of the caretaker per se. Limitations to the current study qualify our results and conclusions. Associations do not prove causation. Our measure of parent protection had a lower Cronbach's alpha score for male caregivers (0.68) than female caregivers (0.83), consistent with an examination of the factor structure of the PPS that found the measure to have a poor factor structure and limited reliability in samples with a chronic medical condition.Anxiety, depression, and parenting characteristics were differentially impacted by variables such as caregiver and child age, shunt status, and employment status/income for parents of youth with SB. Interventions to improve parenting skills and mental health of these caregivers can be designed to target specific needs of parents. Groups such as the Greater Oklahoma Disabled Sports Association (GODSA) offer real-world support to improve the lives of caregivers of SB children, and should be studied further to optimize outcomes for children.

INTRODUCTION AND OBJECTIVES: Hyaluronic acid (HA), a non-sulfated glycosaminoglycan and an essential component of the extracellular matrix (ECM), plays critical roles in phases of wound healing and tissue regeneration. This study was designed to characterize temporal and anatomical HA deposition and its major receptors (CD44, LYVE-1, RHAMM, and HARE) expression in a rat bladder regeneration model and to understand the effectiveness of HA in promoting angiogenesis. METHODS: Fifteen Sprague-Dawley rats were subjected to partial cystectomy with interposition of distal sections of porcine small intestinal submucosa (SIS). SIS-augmented bladders were harvested on post-operative days 2, 7, 14, 28, and 56 for histological studies. Effectiveness of HA in stimulating endothelial cell proliferation, tube formation, and angiogenic activity were determined in vitro cell and ex ovo chick chorioallantoic membrane (CAM) models. RESULTS: Bladder regeneration proceeded without complications; and all regenerated bladders had complete urothelial lining and smooth muscle bundle formation by day 56 post-augmentation. As determined by immunohistochemistry, strong positive HA staining was observed on days 28 and 56 post-operation in the ECM of the stroma. CD44 immunoreactivity was detected on days 28 and 56 in the cytoplasm of urothelial cells and LYVE-1 immunoreactivity was detected exclusively in lymphatic vessels at days 28 and 56. RHAMM mRNA increased within 2 days post-operation, whereas HARE mRNA level did not change during the course of bladder regeneration. Exogenous HA significantly stimulated growth and tube formation of cultured endothelial cells, and enhanced angiogenesis in CAM assay. CONCLUSIONS: During bladder regeneration HA is synthesized throughout the course of regeneration processes. HA deposition coincides with urothelial differentiation. Temporal regulation and spatial distribution of two major HARs (CD44 and LYVE-1) follow the same temporal pattern as HA deposition. Therapeutic modalities through local delivery of exogenous HA can be viable to significantly improve angiogenesis and enhance the outcome and completeness of bladder regeneration.

We present a young girl with an exceedingly rare case of a duplicated bladder, urethra, vulva, vagina, cervix, uterus, appendix, colon and anus, as well as a lipomyleomeningocele. This complex of anomalies has been referred to in the literature as caudal duplication syndrome. This particular case was complicated with urinary and fecal incontinence, vesicoureteral reflux, and recurrent rectovaginal fistulas. We report the successful surgical management of her condition with resulting urinary and fecal continence and resolution of reflux and fistulas.

Traditional resources now used to train healthcare procedures such as SFU grading of pediatric hydronephrosis largely include textbooks, journals, and casual conversations with colleagues. In 2003 the CEVL platform began its development as internet accessed e-learning to promote training for healthcare procedures. Specifically, the platform approaches the promotion of procedure training to grade hydronephrosis by supplementing presentation of static content, such as an ultrasound image, with user interactivity. Herein, we show how we apply this approach to train Grading of SFU pediatric hydronephrosis. CEVL presents samples of SFU grades 0e4 as grayscale images along with interactive colored overlays which denote pyelocalyceal ultrasound anatomy. A self test promotes user confidence in ultrasound grading. Opportunity to upload images for “expert” review is offered.

Neuropathic bladders are the result from damages to the central or peripheral nervous system, and ultimately may require surgical reconstruction to increase bladder volumes and to reduce the risk of damages to the kidneys. Surgical reconstruction through bladder augmentation has traditionally been practiced using a segment of the ileum, colon, or stomach from the patient through enterocystoplasty. However, the use of gastrointestinal segments can lead to serious adverse consequences. Porcine small intestinal submucosa (SIS), a xenogeneic, acellular, biocompatable, biodegradable, and collagen-based bioscaffold is best known to encourage bladder regeneration without ex vivo cell seeding before implantation in various experimental and preclinical animal models. Although it has been demonstrated that SIS supports bladder cell growth in vitro, and SIS-regenerated bladders are histologically and functionally indistinguishable from normal functional tissues, clinical utilization of SIS for bladder augmentation has been hampered by inconsistent preclinical results. Several variables in SIS, such as the age of pigs, the region of the small intestine, and method of sterilization, can have different physical properties, biochemical characteristics, inflammatory cell infiltration, and regenerative capacity due to cellular responses in vitro and in vivo. These parameters are particularly important for bladder regeneration due to its specific biological function in urine storage. Clinical application of SIS for surgical bladder reconstruction may require graft materials to be prepared from a specific region of the small intestine, or to be further formulated or processed to provide uniform physical and biochemical properties for consistent, complete, and functional bladder regeneration.

Pediatric urology patients often present with congenital or acquired tissue and organ dysfunction that requires surgical reconstruction to recreate the normal genitourinary systems functions. The traditional methods have varying degrees of donor site morbidity or inherent side effects. Tissue engineering is a developing field that aims to replace or regenerate these dysfunctional tissues and organs with cells, biomaterials, or a combination thereof. A tremendous amount of work has been done to these ends in terms of preclinical work, and some clinical trials have resulted. This review highlights the status of these studies in pediatric urology for the use of tissue engineering and reconstruction of the corporal bodies, urethra, and bladder.

In 2006, a consensus statement was jointly produced by the Lawson Wilkins Pediatric Endocrine Society (LWPES) and the European Society of Paediatric Endocrinology (ESPE) concerning the management of disorders of sex development (DSD) [1]. A recommendation provided by this consensus was that evaluation and long-term care for people affected by DSD should be performed at medical centers with multi-disciplinary teams experienced in such conditions. Here we provide our team's interpretation of the 2006 consensus statement recommendations and its translation into a clinical protocol for individuals affected by 46 XY DSD with either female, or ambiguous, genitalia at birth. Options for medical and surgical management, transitioning of care, and the use of mental health services and peer support groups are discussed. Finally, we provide preliminary data to support the application of our model for delivering multi-disciplinary care and support to patients and their families.

Voiding cystourethrogram is the gold standard for evaluating and diagnosing vesicoureteral reflux. Reflux detection can potentially be affected by many parameters during voiding cystourethrogram.A 29-item survey was sent via e-mail through SurveyMonkey® to the chairperson of pediatric radiology at 65 national pediatric hospitals. This survey included questions on institutional protocols for performing voiding cystourethrogram.Responses were received from 41 institutions from across North America, including 17 of 19 Randomized Intervention for Children with Vesicoureteral Reflux study sites. Many aspects of the reports of voiding cystourethrogram protocols were similar with 90% or greater agreement in allowing parents in the room, contrast infusion by gravity, catheter or feeding tube use without balloons, no contrast dilution and voiding without a catheter in place. The height at which contrast medium was raised for infusion was 40, 60, 80, 100 and greater than 100 cm at 2.4%, 17.1%, 17.1%, 39.0% and 12.2% of sites, respectively, while the height was not measured or it varied at 12.2%. The infilling phase stopped when the bladder appeared full at 2.4% of sites, infusion stopped itself at 12.2%, patient voided at 61.0%, volume attained age expected capacity at 12.2%, the patient was uncomfortable at 4.9% and results varied at 7.3%.Data reveal that voiding cystourethrogram is performed differently across North America and no standard protocol exists for the procedure. These differences could significantly impact voiding cystourethrogram results among institutions and taint our ability to compare results in the literature.

The optimal endoscopic technique to manage an obstructing ureterocele would reliably relieve obstruction without creating de novo vesicoureteral reflux. The classic incision achieves decompression but invariably creates new vesicoureteral reflux. We compared a new endoscopic puncture technique to assess its superiority to endoscopic incision.We retrospectively reviewed 27 consecutive endoscopic ureterocele procedures at our institution. Patients who underwent an endoscopic incision or watering can puncture procedure had their records reviewed for preoperative radiological and clinical data, operative description, and postoperative radiological and clinical outcomes.Of the 15 patients with endoscopic ureterocele incision 11 underwent a watering can puncture. All ureteroceles were associated with grade 3 or 4 hydronephrosis. Incision successfully decompressed the ureterocele in 14 of 16 cases (87.5%) and hydronephrosis in 14 (87.5%) on postoperative renal ultrasound. De novo reflux was detected in 12 of 16 patients (75.0%) on postoperative voiding cystourethrogram. Puncture successfully decompressed the ureterocele in 10 of 11 cases (90.9%) and hydronephrosis in 9 (81.8%). De novo vesicoureteral reflux was detected in 4 of 11 patients (36.4%).Our initial review shows that the endoscopic watering can procedure successfully decompresses the obstructing ureterocele and its associated hydronephrosis. This technique also results in a decreased incidence of de novo vesicoureteral reflux and ultimately in fewer invasive procedures for the patient.

Penile strangulation is a rarely described medical emergency, especially in the adolescent population. This case demonstrates the successful removal of a constricting metal ring from the penis of a 14-year-old male with a diamond blade equipped orthopedic oscillating saw while under ketamine anesthesia in the emergency department.

To examine the histological differences in the inflammatory response and regenerative outcomes of distal vs proximal porcine small intestinal submucosa (SIS) grafts in the rat bladder, as SIS from distal small intestine yields reliable and reproducible bladder regeneration, while SIS from proximal portions of small intestine does not provide similar results.In all, 30 Sprague-Dawley rats underwent hemi-cystectomy followed by anastomosis of a bladder patch of SIS prepared from either distal or proximal small intestine. After bladder harvest, immunohistochemistry was used to quantify mast cells, eosinophils, macrophages, and neutrophils (PMNs). Total cell count per unit area was compared across the time course in univariate and logistic regression modelling.There were more eosinophils and mast cells in proximal SIS grafts, while there were more macrophages and PMNs in distal SIS grafts (all P0.05). Trichrome analysis showed increased collagen deposition in proximal SIS grafts and little smooth muscle regeneration. There was also significant graft contracture in proximal SIS grafts compared with distal SIS grafts (P0.05).We conclude that the location of SIS origin may evoke different inflammatory responses, which results in altered bladder tissue regeneration.

Small intestinal submucosa (SIS) is a biodegradable scaffold that supports bladder regeneration after partial cystectomy. We sought to define the inflammatory response present in a rat bladder augmentation model using distal ileal SIS. Fifteen Sprague-Dawley rats underwent hemi-cystectomy followed by anastomosis of a bladder patch of SIS. Bladders were excised after days 2, 7, 14, 28, and 56. Tissue regeneration was evaluated by standard hematoxylin and eosin. Immunohistochemical staining was used to quantify neutrophils, macrophages, eosinophils, and mast cells. Total cell counts per unit area were compared between native and graft portions of the bladder for each cell type across the entire time course. Statistical analyses were conducted with the Wilcoxon Rank-Sum and Kruskal-Wallis tests. All tests were two-sided with significance set at p < 0.05. These inflammatory responses evolved consistently across all bladders over time. Neutrophil and eosinophil numbers were highest at day 2 and decreased over the 56-day period. In contrast, macrophage and mast cell numbers were low at days 2, 7, and 14; peaked at day 28; and decreased once again at day 56. Cell counts at native and graft sites were equivalent for all cell types, except neutrophils, which were more commonly found in the graft (124 vs. 24 cells/mm(2), p = 0.009). Thus, the inflammatory processes change over time during SIS-mediated bladder regeneration. Similar cell densities are present between the native and SIS portions of the bladder, but neutrophils predominate in the graft areas.

Summary Objective The current study evaluates whether the preoperative scrotal examination in children with non-palpable testes is sufficient in all cases or if laparoscopy is necessary to confirm the examination findings. Are the findings different amongst physicians depending on their level of experience? Materials and methods This retrospective study was done between October 2009 and May 2013. Children with non-palpable testes underwent an examination under anesthesia prior to surgery to feel for a testis or nubbin, followed by a diagnostic laparoscopy to validate the scrotal examination. The test was considered correct if the laparoscopic findings supported the scrotal examination. It was considered incorrect if laparoscopy revealed a different finding. Results A total of 74 testes were evaluated. All patients underwent examination under anesthesia by the surgeon and senior resident. The findings were recorded separately. Despite careful examination by experienced surgeons under anesthesia, the scrotal examination was incorrect in 14 patients. Four viable testes would have been missed if laparoscopy had not been performed. Conclusion Laparoscopy should be considered in case of palpable scrotal nubbins to ensure no testis is left within the abdominal cavity. Download : Download high-res image (269KB) Download : Download full-size image Figure . Algorithm for the preoperative presence or absence of a scrotal nubbin.

BACKGROUND Low birth weight remains the primary cause of neonatal morbidity and mortality in the United States. We examined whether maternal happiness about a pregnancy, in addition to her report of the father’s happiness, predicts birth weight and risk for low birth weight (

Background: Intra-abdominal hypertension (IAH) has been recognized as a source of morbidity and mortality in the injured patient. Research concerning this entity has focused predominantly on the pathophysiology. We developed a model of IAH to determine whether gene expression is altered in the presence of this condition. Methods: Using general anesthesia, adult Sprague-Dawley rats were intubated and instrumented with a carotid and jugular catheter. Three pairs of rats (three control; three IAH 25 mm Hg) were used at each time interval. Continuous measurements of heart rate, blood pressure, cardiac output, and temperature were recorded. Arterial blood gases were measured every 30 minutes. A catheter was placed in the peritoneum and warm saline was infused up to a pressure of 25 mm Hg that was measured through this catheter continuously. At 30 and 60 minutes, the kidneys were harvested and standard protocols were used to extract nucleic acid and perform cDNA microarray analysis screening for 4,000 genes. Each experimental rat was paired with a control rat and each set underwent individual cDNA array analysis. Results: Hemodynamic changes occurred that were consistent with IAH, including depression of cardiac output and acidosis. Although widespread changes in gene expression were identified, only genes that were up-regulated and down-regulated by a ratio of fivefold, a difference in magnitude of 150 molecular dynamic counts, and p < 0.05 were considered significant. When comparing IAH of 25 mm Hg at 30 and 60 minutes, there was a surprising decrease in up-regulated genes from 10 to 1. In addition, there was an increase in down-regulated genes from zero to five genes. Conclusion: IAH causes changes in gene up- and down-regulation in the kidney. The number and types of genes change in magnitude and type over time. Further investigation into renal gene expression may offer insight into the molecular pathophysiology of IAH.

Priapism is a medical emergency. An idiopathic case can be a difficult clinical problem in the pediatric emergency room. This case highlights the successful use of penile irrigation and injection of phenylephrine in a 13-year-old boy with idiopathic ischemic priapism 12 h after sexual intercourse.