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We sought to determine the effectiveness of biofeedback therapy and home pelvic floor exercises in children presenting with lower urinary tract dysfunction after posterior urethral valve ablation.Children with urodynamically proved lower urinary tract dysfunction after successful valve ablation were enrolled for biofeedback therapy and home pelvic floor exercises. Detrusor pressure and electromyography findings were visually conveyed to patients on the computer screen. Patients were instructed to interrupt detrusor pressure increments by tensing the pelvic floor musculature in the presence of detrusor overactivity. In the presence of the nonrelaxing pelvic floor patients were first instructed to tighten the pelvic floor musculature and then to relax.A total of 30 children were enrolled for biofeedback therapy and home pelvic floor exercises between October 2005 and December 2006. Median patient age at first session was 5.1 years (range 4.5 to 12). Three patients (10%) had an excellent response, and 18 (60%) had a good response, with an overall consistent response of 70%. Nine patients (30%) had an inconsistent response. Mean number of sessions to achieve consistent urodynamic response was 3.5 (range 2 to 7). Mean baseline cystometric bladder capacity was 65% of normal for age (range 45% to 80%), which improved to a mean of 87.25% (50% to 100%) after treatment (p = 0.001). Of the 21 children who had a consistent response 11 (52%) do not require any further anticholinergics and 15 (71%) are free of clean intermittent catheterization. At a mean followup of 11 months (range 5 to 18) none of the patients had relapse.Biofeedback therapy and home pelvic floor exercises provide significant and durable relief in post-valve ablation persistent lower urinary tract dysfunction.

Balanitis xerotica obliterans (BXO) related strictures are complex and generally managed by 2-staged urethroplasty. We present our results with 1-stage dorsal onlay and 2-stage buccal mucosal urethroplasty for such strictures.Between January 2000 and April 2004, 39 patients underwent buccal mucosal urethroplasty for BXO related anterior urethral strictures. The 25 patients with a salvageable urethral plate (group 1) were treated with 1-stage dorsal onlay urethroplasty using a cosmetic incision. The 14 patients with a severely scarred urethral plate, focally dense segments or active infection (group 2) underwent 2-stage urethroplasty. Outcomes in terms of cosmetic appearance, stricture recurrence and complications in the 2 groups were assessed.At a mean followup of 32.5 months (range 3 to 52) 3 patients (12%) in group 1 had recurrent stricture, of which 2 and 1 were treated with optical urethrotomy and urethral dilation, respectively. All patients had a normal slit-like meatus and none had chordee or erectile dysfunction. Four group 2 patients (28.6%) required stomal revision and 2 had glans cleft narrowing after stage 1 urethroplasty. Following stage 2, 3 patients had recurrent stricture, of whom 2 were treated with optical urethrotomy and 1 underwent repeat urethroplasty.In BXO related strictures with a viable urethral plate 1-stage dorsal onlay buccal mucosal urethroplasty provides excellent intermediate term results. The cosmetic incision described provides a normal, wide caliber, slit-like glans. Two-stage procedures provide satisfactory outcomes but they are associated with a higher revision rate.

Stone fragility is a key factor for the success of shock wave lithotripsy (SWL). Dual x-ray absorptiometry is the gold standard for measuring bone mineral content and density, which helps in determining bone mass and the fracture risk. The same principle was applied to determine the relationship of stone mineral content (SMC) and density (SMD) to predict the fragility of stone before SWL.A total of 102 patients with a solitary renal and upper ureteral stone of less than 3 cm treated at a single center with a lithotriptor were included. Prior to SWL all patients underwent dual x-ray absorptiometry evaluation for SMC and SMD. Plain x-ray documented disintegration after SWL. Stone size and site, the number of shock waves and energy levels were recorded. Failure was defined as no fragmentation to a size of less than 4 mm, which would pass unaided, up to a maximum of 3,000 shock waves.Overall 94 patients with renal stones were included. Mean stone size was 16.68 +/- 7 mm (range 5 to 30). Mean and median SMC was 0.63 +/- 0.83 and 0.34 gm (range 0.01 to 5.54), and mean and median SMD was 0.48 +/- 0.19 and 0.46 gm/cm2 (range 0.05 to 1.12), respectively. Overall 67 patients (71%) had successful fragmentation and clearance at a mean of 1,623.58 +/- 658.77 shock waves (range 355 to 3,000). On logistic regression analysis only SMC was the significant factor affecting the outcome in terms of fragmentation. At a SMC of more than 1.27 gm 95% of the stones would not fragment or needed more than 3,000 shock waves.Patients with high stone mineral content (SMC greater than 1.27 gm) could be directly offered percutaneous nephrolithotomy, thus, avoiding the unnecessary cost of prior SWL.

Background: The effect of an intact fibula on rotational stability after a distal tibial fracture has, to the best of our knowledge, not been clearly defined. We designed a cadaver study to clarify our clinical impression that fixation of the fibula with a plate increases rotational stability of distal tibial fractures fixed with a Russell-Taylor intramedullary nail. Methods: Seven matched pairs of embalmed human cadaveric legs and sixteen fresh-frozen human cadaveric legs, including one matched pair, were tested. To simulate fractures, 5-mm transverse segmental defects were created at the same level in the tibia and fibula, 7 cm proximal to the ankle joint in each bone. The tibia was stabilized with a 9-mm Russell-Taylor intramedullary nail that was statically locked with two proximal and two distal screws. Each specimen was tested without fibular fixation as well as with fibular fixation with a six-hole semitubular plate. A biaxial mechanical testing machine was used in torque control mode with an initial axial load of 53 to 71 N applied to the tibial condyle. Angular displacement was measured in 0.56-N-m torque increments to a maximal torque of 4.52 N-m (40 in-lb). Results: Initially, significantly less displacement (p ≤ 0.05) was produced in the specimens with fibular plate fixation than in those without fibular plate fixation. The difference in angular displacement between the specimens treated with and without plate fixation was established at the first torque data point measured but did not increase as the torque was increased. No significant difference in the rotational stiffness was found between the specimens treated with and without plate fixation after measurement of the second torque data point (between 1.68 and 4.48 N-m). Conclusions: Fibular plate fixation increased the initial rotational stability after distal tibial fracture compared with that provided by tibial intramedullary nailing alone. However, there was no difference in rotational structural stiffness between the specimens treated with and without plate fixation as applied torque was increased. Clinical Relevance: In patients with ipsilateral distal tibial and fibular fractures who are treated with Russell-Taylor intramedullary nailing of the tibia, rotational stability of the tibial fracture can be increased by plate-and-screw fixation of the fibula, which may reduce the risk of valgus malunion.

Internal stenting is an integral part of endopyelotomy. Studies in animals show good healing after 1 to 2 weeks of ureterotomy. Inherent stent related problems warrant a minimum possible duration of stenting without compromising the results of endopyelotomy. We performed a prospective randomized trial to evaluate the optimum duration of stenting after endopyelotomy.A total of 57 consecutive patients with primary ureteropelvic junction obstruction were randomized to undergo 7/14Fr internal endopyelotomy stent placement for 2 (group 1) and 4 (group 2) weeks. A symptom based questionnaire was administered to all patients at stent removal. Followup was done with diuretic scanning at 3, 6, 9 and 12 months and then yearly, and thereafter with diuretic renography.In each group 26 patients were available for evaluation. The 2 groups were comparable in terms of age, sex, symptoms and ipsilateral glomerular filtration rate. Mean followup was 22.3 (range 12 to 36) and 21.3 months (range 12 to 35) in groups 1 and 2, respectively. At the end of 1 year 24 group 1 (92.3%) and 23 group 2 (90.3%) patients had an improved drainage pattern. This difference was not significant. Stent related symptoms were present in a good proportion of patients in groups 1 and 2 but there was a significant difference in the incidence of urinary tract infections (11.5% versus 38.1%, p = 0.04). Of the group 2 patients 64% preferred 2 weeks of stenting.Two weeks seems to be a sufficient duration to allow functional restoration across the ureteropelvic junction after endopyelotomy and decrease stent related complications.

We determined whether the proinflammatory cytokine interleukin-8 (IL-8) can serve as a predictor for the response to standard (120 mg.) and low (40 mg.) dose intravesical bacillus Calmette-Guerin (BCG) (modified Danish 1331 strain) for managing superficial bladder cancer in patients at risk for recurrence and progression.We randomized 26 patients with superficial bladder cancer to receive a 6-week course of standard dose 120 mg. or low dose 40 mg. intravesical BCG. Voided urine samples were collected immediately before and after (2 and 4 hours) BCG instillation. Urine samples were centrifuged at 1,500 rpm for 8 minutes and stored at -80C. IL-8 was measured using a commercial enzyme-linked immunosorbent assay. Patients were monitored for recurrence, progression and side effects of BCG treatment at 3-month intervals.At a median followup of 24 months (range 12 to 30), 5 and 6 patients who received a standard and low dose, respectively had disease recurrence and/or progression (nonresponders). At 4 hours after BCG mean Il-8 levels plus or minus SD were significantly higher in responders than in nonresponders (1,099.33 +/- 708.51 versus 261.82 +/- 182.66 pg./ml., p = 0.001). There was no difference at 4 hours in mean IL-8 levels in the standard and low dose groups (596.92 +/- 546 and 893 +/- 798.67 pg./ml., respectively, p = 0.28). In all patients who remained disease-free IL-8 levels were greater than 400 pg./ml. In 9 of the 11 patients with disease recurrence/progression IL-8 levels were less than 400 pg./ml.IL-8 secretion after the initial intravesical BCG instillation strongly correlates with the possibility of future recurrence/progression. The quantitative IL-8 response to low and standard dose intravesical BCG (Danish 1331) is similar.

It is a concern that elderly donors may have increased risks in the perioperative period due to age related changes in various organ systems. Nephrosclerosis, atherosclerosis and low glomerular filtration rate may portend a poor graft outcome. We performed a study to determine function and outcome of kidneys from elderly donors.A retrospective analysis of our live related transplant program from November 1989 to December 1998 revealed that 112 donors were older than 55 years (range 55 to 81). Of the recipients of these kidneys from elderly donors 98 had a followup of more than 2 years (group 1), and they were compared to a cohort of 87 patients whose kidney donors were younger than 45 years (group 2). Allograft function was evaluated by serum creatinine and differential glomerular filtration rate was determined by (99m)technetium diethylenetriamine pentaacetic acid renal scan. All donors were followed regularly.Mean donor age plus or minus standard deviation was 57.4 +/- 4.3 and 31.4 +/- 7.6 years in groups 1 and 2, respectively. Mean followup plus or minus standard deviation was 42.44 +/- 20.46 months in group 1 and 40.04 +/- 27.28 months in group 2. The 1-year graft survival rate was 91.84% and 88. 51%, and the 5-year graft survival rate was 72.72% and 75.13% in groups 1 and 2, respectively. Serum creatinine was 1.5 +/- 0.65 and 1.7 +/- 1.52 mg./dl. in group 1 and 1.4 +/- 0.55 and 1.5 +/- 1.41 mg. /dl. in group 2 at 1 year and last followup, respectively. Glomerular filtration rate was 37.2 +/- 11.2 and 37.3 +/- 10.7 ml. per minute in group 1 and it was 45.3 +/- 8.6 and 47.7 +/- 11.3 ml. per minute in group 2 at 1 year and last followup, respectively. Acute rejection rate was significantly higher in group 1 (42%) compared to group 2 (19%). Both groups were comparable in terms of infectious episodes, antihypertensive requirement and incidence of acute tubular necrosis. There was no added morbidity for elderly compared to younger donors.In view of acute donor shortage and if properly screened, elderly kidneys can be used without increasing the risk to donor or compromising graft outcome.

Functional bladder neck obstruction has been definitively diagnosed in the last few years due to detailed synchronous pressure flow, electromyography and video urodynamics. Clean intermittent self-catheterization and bladder neck incision are the modalities of treatment. To our knowledge the role of alpha-blockers is not yet defined in women. A new technique was developed to perform bladder neck incision using a pediatric resectoscope.A total of 24 women with obstructive voiding symptoms or retention were evaluated with video pressure flow electromyography, and diagnosed with functional bladder neck obstruction due to high pressure and low flow on silent electromyography and bladder neck appearance on fluoroscopy. Patients were initially treated with clean intermittent self-catheterization and alpha-blockers. Catheterization was stopped when post-void residual was less than 50 ml. and only alpha-blocker therapy was continued. Bladder neck incision was performed in patients who had a poor response to or side effects of alpha-blocker therapy, or when therapy was discontinued due to economic reasons. Clean intermittent self-catheterization was continued in patients who had a poor response to alpha-blockers or refused to undergo bladder neck incision. Bladder neck incision was performed in the initial 2 cases with an adult resectoscope using a Collin's knife and subsequently a pediatric resectoscope (13F). Uroflow and post-void residual measurements were performed in all cases.Of the 24 patients 12 (50%) showed improvement in symptoms, peak flow and post-void residual (p0.01) with alpha-blocker therapy only. Of the 12 patients who had a poor response to alpha-blockers 6 underwent bladder neck incision subsequently and 6 remained on clean intermittent self-catheterization. All 8 patients treated with bladder neck incision, including 2 who had a good response but discontinued alpha-blocker therapy, had sustained improvement in post-void residual and peak flow (p0.01) after a mean followup of 3.8 +/- 2.4 years. Grade 1 stress incontinence in 2 adult resectoscope cases responded to conservative treatment. None of the pediatric resectoscope cases had stress incontinence.Clean intermittent self-catheterization and alpha-blockers are the initial treatment options for functional bladder neck obstruction. The alpha-blockers were successful in 50% of our patients. Bladder neck incision should be offered judiciously with minimal risk of curable stress incontinence. The pediatric resectoscope is useful to make a well controlled incision safely in the female urethra.

STUDY DESIGN Eleven patients with chronic renal failure and destructive spondyloarthropathy of the cervical spine were evaluated with plain radiographs, flexion-extension views, computed tomography myelogram, or magnetic resonance imaging to determine the results of surgical and nonsurgical treatment. OBJECTIVES To determine if cervical spine fusion is an effective method of treatment for patients with chronic renal failure and destructive spondyloarthropathy. SUMMARY OF BACKGROUND DATA Several reports have described the pathogenesis and appearance of this condition, but little has been reported about the orthopedic management of destructive spondyloarthropathy of the cervical spine. METHODS Three patients had no spinal surgery, three patients had laminectomies alone, three patients had laminectomies with anterior fusions, and two patients had laminectomies with posterior fusions. Radiographs, computed tomography myelograms, and magnetic resonance images were evaluated to determine the results of treatment. Histologic examinations were performed in two patients. RESULTS Patients with laminectomy alone had no improvement in pain or neurologic function (one died in the immediate postoperative period), one of three patients with anterior fusions had some improvement (one died in the immediate postoperative period), and both of those patients with posterior fusions improved, although both died within a year of surgery from unrelated causes. CONCLUSIONS Even though the osteopenia present in patients with chronic renal failure tends to allow wire pull-out and makes internal fixation of the spine difficult, successful cervical spinal fusion can relieve pain and improve neurologic deficits in selected patients with chronic renal failure and destructive spondyloarthropathy, allowing them to remain more active for longer periods of time.

We studied 7 men and 6 women (average age 33 years) who presented in renal failure with obstructive voiding symptoms or retention. Of these patients 11 had a dilated upper tract and 2 had shrunken kidneys. Mean serum creatinine at presentation was 7.0 mg./dl. No abnormality was noted on cysto-panendoscopy, retrograde urethrography and voiding cystourethrography. The patients were initially treated with clean intermittent self-catheterization following 7 to 10 days of indwelling catheterization. The majority of patients had low pressure and low flow rate at initial presentation but high end filling pressure (mean 35.3 cm. water), high voiding pressure (mean 118.9 cm. water), high opening pressure (mean 95.3 cm. water) and low peak flow (mean 5.7 ml. per second) on video pressure flow electromyography. The external sphincter was relaxed during voiding but the bladder neck opened intermittently or inadequately. No proper funneling of the bladder neck was seen. Thus, functional bladder neck obstruction was considered to be responsible for obstructive voiding in these patients. Of the patients 3 void to completion with the help of alpha blockers alone, 5 underwent bladder neck incision and are voiding well, and 5 were practicing clean intermittent self-catheterization at last followup. Serum creatinine returned to near normal in 10 patients. End stage renal failure persisted in 2 patients, 1 of whom underwent renal transplantation and is voiding well but the other died without having undergone renal replacement therapy. In the remaining patient serum creatinine was stable at 3.2 mg./dl. Mean serum creatinine at 6 months of followup was 2.33 mg.%. Bladder neck obstruction is a rare cause of renal failure which can be corrected if treated appropriately.

Eighteen children with leg length discrepancies underwent femoral lengthenings using the Ilizarov method. Eight had concomitant tibial lengthening. Nine femoral and no tibial fractures occurred. Eight fractures occurred after lengthenings > 5 cm. Three occurred while in the frame. These healed without complication after frame extension. Six fractures occurred after frame removal. Treatment with spica casting left four patients with minimal angulation and one patient shortened. Five of nine patients lengthened for congenital discrepancies fractured. Only two patients lengthened for posttraumatic discrepancies fractured. We now preferentially lengthen the tibia because of the lower fracture rate. For substantial lengthening, we recommend concomitant tibial and femoral lengthening.

Conventional donor nephrectomy is associated with significant postoperative morbidity. Whether this morbidity is associated with rib resection or a long incision is not clear. We designed a prospective randomized study of subcostal and transcostal mini incision donor nephrectomy and compared the results.We performed 82 donor nephrectomies in the study period of December 2000 to July 2001. Open donor nephrectomies were randomized to subcostal (25) or transcostal (24) mini incision techniques. Results were compared and analyzed using the independent t test.The subcostal and transcostal groups were comparable in terms of patient age, body mass index, nephrectomy side, number of renal vessels and incision length (9.32 vs 9.72 cm). Patients in the subcostal group had a lesser postoperative analgesic requirement (304 +/- 49.8 vs 487 +/- 74.1 mg, p = 0.0001), shorter hospital stay (2.36 +/- 0.7 vs 3.71 +/- 0.81 days, p = 0.0001) and early convalescence (26.56 +/- 4.06 vs 37.46 +/- 6.05 days) compared with the transcostal group. Warm ischemia time and recipient outcome were similar in the groups.Rib sparing, subcostal mini incision donor nephrectomy has significantly less morbidity and a shorter hospital stay compared with the rib resection transcostal technique.

We report 2 cases of percutaneous drainage and alcohol instillation of renal hydatid cysts. The feasibility of percutaneous management of renal hydatidosis, emphasizing its safety, efficacy and obvious advantages, is discussed.

Objectives. In the immediate postoperative period after percutaneous stone removal, body temperature elevations are common. Pyrexia after a percutaneous nephrolithotomy (PCNL) generates concern because of the possibility of urinary extravasation and bacteremia. We reviewed our experience with PCNL to determine the clinical significance of a postoperative fever before discharge from the hospital. Methods. Between July 1994 and December 1996, 63 patients underwent 69 PCNLs. Each had documented negative urine cultures preoperatively and received prophylactic antibiotics at the time of surgery. For each case, clinical and operative charts were reviewed to determine stone composition, fever during hospital stay, postoperative bacteriologic cultures, postoperative white blood cell count (WBC), and clinical course. Results. Complete data were available for 66 procedures. Eight patients (12%) had at least one body temperature reading between 38.0 and 38.5°C. Eleven patients (16.7%) had at least one temperature greater than 38.5°C. Each patient with a temperature greater than 38.5°C was hemodynamically stable with negative blood and urine cultures. No patient with a fever between 38.0 and 38.5°C was cultured. Stone analysis did not demonstrate any association between postoperative fever and stone composition (including 22 struvite stones). Postoperative WBC also did not predict pyrexia. Fever alone did not prolong hospital stay. Conclusions. In patients with negative urine cultures who are prophylaxed with immediate preoperative antibiotics and maintained on postoperative antibiotics, pyrexia after PCNL does not require an immediate bacteriologic evaluation in those who are hemodynamically stable.

During the last 6 years we managed 20 patients with renal failure owing to bilateral ureteropelvic junction obstruction (12) or ipsilateral ureteropelvic junction obstruction with contralateral renal agenesis, hypoplasia or dysplasia (8). Of the patients 11 underwent emergency dialysis for hyperkalemia, fluid overload or metabolic acidosis. Mean serum creatinine at presentation was 6.5 mg. per cent. Preliminary decompression of the obstructed kidney was done in 14 patients (20 renal units) with a serum creatinine of more than 3 mg. per cent at presentation. Reconstruction was done in all patients (31 of 36 renal units) after decompression and control of infection. Pyeloplasty was done in 24 renal units, vesicopyelostomy in 3 pelvic kidneys and calicoureteroplasty in 2 renal units with an intrarenal pelvis. Two renal units were removed. All patients showed improvement in renal function and the mean postoperative serum creatinine value was 2.05 mg. per cent. The postoperative serum creatinine value showed a significant positive correlation with the initial value as well as with the initial blood urea levels. However, the postoperative serum creatinine value showed no correlation with patient age, duration of symptoms, serum creatinine level after preliminary nephrostomy and presence or absence of urinary infection. Postoperative recovery (on the basis of postoperative serum creatinine levels) in patients who had bilateral ureteropelvic junction obstruction was not different from those with a solitary functioning kidney and ureteropelvic junction obstruction.