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The impact of a fellowship on resident operative experience and education is unclear. We sought to address this issue by comparing resident operative case logs and the pediatric portion of the American Urological Association resident inservice examination at our institution before and after establishing a pediatric urology fellowship in 2002.Pediatric operative case logs of all urological residents from 1998 to 2006 at Vanderbilt University were reviewed. We recorded index and total number of cases as specified by the Accreditation Council for Graduate Medical Education. All residents had completed 6 months of pediatric urology training. Statistical analysis was performed using 2-sample equal variance Student t tests. We compared the 8 index categories and total index cases performed by residents, scores on the pediatric portion of the American Urological Association inservice examination and resident average percentiles for index cases referenced to national data, before and after the implementation of an Accreditation Council for Graduate Medical Education accredited pediatric urology fellowship.Before implementation of the pediatric urology fellowship residents performed significantly more hypospadias procedures, pyeloplasties, renal surgeries, ureteroneocystostomies and urinary/bowel diversions (p0.05), while the total number of index cases performed was not significantly affected (p = 0.13). In contrast, after the fellowship was started residents performed more hydrocelectomies/hernia repairs (p = 0.01). Compared to national averages for index cases in 2004 to 2005, residents maintained greater than the 50th percentile in all categories except urinary diversion, which was between the 30th and 50th percentiles. Furthermore, residents were in the 70th to 90th percentile in 3 of 9 categories, and greater than the 90th percentile in 3, including total number of index cases. No statistically significant difference in the area of pediatric urology was observed on the resident inservice examination scores before and after the fellowship was established.Residents performed significantly fewer index cases in some areas following initiation of a pediatric urology fellowship at Vanderbilt University, although the total number of index cases performed by residents remained unchanged. Despite the presence of a fellow, residents have remained at or well above the national average in all index case categories except urinary diversion. Moreover, establishment of a fellowship did not negatively impact the educational experience as measured by American Urological Association resident inservice examination scores, specifically in the area of pediatric urology. Choosing the optimal time to institute a fellowship should be made with fellow and resident education as the utmost priority. Periodic review of the data should also be performed to maintain consistent, positive experiences for fellowship and residency training.

Methicillin resistant Staphylococcus aureus is a virulent organism that has seen a rapid increase in prevalence. Community associated methicillin resistant S. aureus is discussed frequently in the infectious disease community. However, there has been little mention of this entity in the urological literature.We reviewed the records of patients presenting with skin/soft tissue infections or documented methicillin resistant S. aureus infection treated at an academic pediatric urology practice between October 2004 and August 2006.A total of 12 patients were included (33% female, 67% male). Mean patient age was 49 months (range 8 to 202). Of the patients 11 (92%) presented with spontaneous infection and 1 (8%) presented with a wound infection. Abscess location was inguinal in 4 patients (33%), scrotal in 3 (25%), perineal in 2 (17%), perinephric in 2 (17%) and labial in 1 (8%). The most common presenting sign at referral was fluctuance (30%). While all patients eventually required surgical drainage, initial treatment by the primary care physician consisted of observation on oral antibiotics in 7 patients (58%). A total of 10 cultures (83%) revealed methicillin resistant S. aureus and 2 cultures (17%) were negative. Mean hospital stay was 5 days (range 0 to 16). Postoperatively, most patients (58%) were discharged home on oral trimethoprim-sulfamethoxazole. Mean followup was 4 months (range 0 to 15). Recurrence was seen in 3 patients at 1 to 15 months postoperatively (mean 6.3).Methicillin resistant S. aureus is increasing in the community and will likely be seen more often in pediatric and adult urological practices. The regional differences among bacterial strains make a standardized approach to these cases difficult. However, increased awareness of this virulent organism is necessary to deliver prompt and successful treatment.

We examined the role of transforming growth factor-beta in urothelial and bladder development. Transforming growth factor-beta signaling was attenuated in the urothelial compartment and the subsequent effects were examined in a tissue recombination model.Urothelium was cultured from adult rat bladders and transfected with control vector C7Delta or mutant DNIIR (dominant negative transforming growth factor-beta receptor II). Grafts were created by recombining transfected urothelium plus embryonic day 18 bladder mesenchyma and placed beneath the renal capsule of athymic mouse hosts. Grafts were harvested at 21 and 42 days. Final tissues were evaluated with staining and immunohistochemistry using hematoxylin and eosin, Gomori's trichrome strain, broad-spectrum uroplakin, smooth muscle actin-alpha, phosphorylated SMAD2 and Ki67 antigen. Bladder structures were defined as having smooth muscle, suburothelial connective tissue and mature urothelium expressing uroplakin. Urothelial compartment diameters were measured and subcategorized as small--0.10 to 0.40, medium--0.41 to 1.0 and large--greater than 1.1 mm.At 21 days 14 C7Delta control and 15 DNIIR grafts were evaluated. No bladder tissue was seen in the C7Delta grafts vs 49 in DNIIR tissue, including 30 small, 9 medium and 10 large tissues. At 42 days 14 C7Delta and 12 DNIIR grafts were evaluated. Six bladder structures (5 small and 1 medium) were seen in the C7Delta cohort vs 27 (14 small, 7 medium and 6 large) in the DNIIR group. Immunohistochemical detection of phosphorylated-SMAD2 was significantly attenuated in DNIIR tissue. In addition, Ki67 proliferative indexes were 4.0-fold higher in the DNIIR cohort compared to those in C7Delta tissues.We successfully observed that primary urothelium cultures can be genetically manipulated and recombined with undifferentiated mesenchyma to grow bladder tissue. By attenuating transforming growth factor-beta signaling in the urothelium superior bladder tissue growth occurred, suggesting that transforming growth factor-beta is a growth inhibitor in this organ system.

We reviewed our experience with continent catheterizable channels with interest in the timing of conduit related complications.A retrospective review was performed of the outcome of continent catheterizable channels in all patients between 1998 and 2003 who had undergone construction of an antegrade continence enema and/or a Mitrofanoff procedure using appendix, small bowel or continent cutaneous vesicostomy. We performed a total of 117 such stomas in 37 male and 41 female patients 2.5 to 20 years old (mean age 8.9). For the antegrade continence enema we used appendix in 92% of cases, an ileal Yang-Monti tube in 6% and a cecal tube in 2%. For the continent catheterizable channel we used appendix in 43% of cases, a Yang-Monti tube in 38% and continent cutaneous vesicostomy in 19%.Continence was achieved in 98% of patients. Followup was 6 to 71 months (mean 28.4). There were 27 channel related complications (23%). Stomal stenosis occurred in 7 antegrade continence enema procedures (14%) within 1 to 10 months (mean 6.2) and in 9 continent bladder channels (13%), including 5 continent cutaneous vesicostomies, within 1 to 24 months (mean 9.4) after surgery. False passages occurred in 5 antegrade continence enema procedures (10%) within 1 to 13 months (mean 3.6) and in 4 continent catheterizable channels (6%) within 1 to 13 months (mean 6.5) after surgery. Of patients with stomal stenosis 50% were treated with surgical revision, while the remainder was successfully treated with dilation. Most false passages were managed by catheter drainage alone. Reasons for revision were contained perforation, colovesical fistula and inability to catheterize. Patient noncompliance appeared to have a role in stomal stenosis.Continent catheterizable stomas help patients achieve bowel and bladder continence. Stomal incontinence after reconstruction is rare. In our experience most stoma related complications occurred in the first year after reconstruction. Experience with more patients and longer followup will help determine whether such problems continue to accumulate with time or whether continent stomas function well with time, particularly after the initial period of healing.