Upper urinary tract deterioration and possible etiologies in intractable voiding dysfunction: Role of occult spinal malformation

Objectives: To evaluate the presence of upper urinary tract deterioration (UUTD) and accompanying pathologies in children treated with the diagnosis of non-neurogenic bladder-sphincter dysfunction (NNBSD). Patients and Methods: We retrospectively reviewed the medical records of 316 consecutive patients with NNBSD who were treated. All cohort were grouped into two: Group I (Treatment success; n=284), Group II (Treatment failure with any form of occult spinal pathology; n=32). Thirty-four children with treatment-failure and normal magnetic resonance imaging (MRI) findings were excluded. Groups were compared for pre- and posttreatment pediatric lower urinary tract symptom score (PLUTSS), presence of UUTD and urodynamic findings. Results: The mean PLUTSS was significantly less in Group I compared with Group II at pre-treatment and 3 months thereafter the initial treatment (12.20 ± 5.90 and 5.20 ± 4.90 vs 20.3 ± 2.14 and 18 ± 3.4, respectively p<0.01). The mean cystometric capacities and detrusor leak point pressure (DLPP) of Group II prior to initial treatment and after 6 months of the untethering surgery were found to be 194, 267 mL and 28, 12cm H2O, respectively (p<0.05). Presence of UUTD was significantly correlated with DLPP >20 cm H2O and presence of vesicoureteral reflux (VUR)

A Survey Study on Evaluation and Management of Nocturnal Enuresis in Pediatricians and Family Physicians

Objective:Nocturnal enuresis (NE) is one of the most common disorders in pediatric urology, and patients often turn to family physicians (FP) and pediatricians (P) initially. The aim of this study was to understand the awareness, self-confidence and suggestions of physicians regarding the management of NE.Materials and Methods:In this study, 360 FP and family medicine residents (FMR), as well as 280 P and pediatrics residents (PR), were contacted through a cellular phone texting system. A simple multiple-choice questionnaire (Surveymonkey®) consisting of 10 questions was used to gather data. The survey included questions about their experience, training, evaluation, and management of NE.Results:A total of 119 FPs and Ps (18.5%) filled the questionnaire. Thirty (25.21%) of the participants were P, 27 (22.69%) PR, 3 (2.52%) FP and 59 (49.58%) FMR. The rate of physicians who encounter at least 5 children with NE per month is 31.33%. The mean self-confidence in the management of NE was 4.5 out of 10. The self-confidence of pediatricians was significantly higher than that of PR and FMR (p<0.001, p<0.001). Most (n=78, 65.55%) of the participants stated that they received training on EN during medical faculty and 62 (52.10%) during residency. Psychological problems (89.92%), sleep disorders (78.15%), and excessive fluid intake (75.63%) were the most frequently considered factors in etiology. While most responders (75.63%) considered dietary regulation and behavioral interventions as the first-line treatment, 25.21% consult a pediatric urologist and only 1.6% recommend medical treatment.Conclusion:Although FP and P admit they had training on NE, they mostly felt incompetent to manage NE and exclusively avoided pharmacological treatment

Miyelodisplazili çocuklarda üst üriner sistem hasarını ve ürodinamik bulguları öngörmede idrar NGF, TGF BETA-, TIMP-2, mesane duvar kalınlığının değeri

İÇİNDEKİLER Sayfalar ÖZET ıv İNGİLİZCE ÖZET (ABSTRACT) vıı 1. GİRİŞ ve AMAÇ 1 2. GENEL BİLGİLER 3 2.1. Tanım 3 2.2. Ürolojik Değerlendirme ve Tedavi 3 2.3. Ürodinamik Çalışmalar 7 2.4. DMSA Böbrek Sintigrafisi 9 2.5. Nerve Growth Factor (NGF) 10 2.6. Matrix Metalloproteinaz Doku İnhibitörü-2 (TIMP-2) 11 2.7. Transforming Growth Factor Beta 1 (TGF Beta 1) 12 3. GEREÇ ve YÖNTEM 14 4. BULGULAR 16 5. TARTIŞMA 26 6. SONUÇLAR 30 7. EKLER 31 Ek.1. Etik Kurul Onayı 31 Ek.2. Hasta Bilgilendirme Formu 32 Ek.3. Hasta Onay Formu 34 8. KAYNAKÇA 35ÖZET Amaç Miyelodisplazili çocuklarda üst üriner sistem hasarını belirlemede USG çoğu zaman yetersiz kalmaktadır. Üst üriner sistem hasarını belirlemede DMSA sintigrafisi, mesane işlev bozukluğunu değerlendirmede ise ürodinamik çalışma altın standarttır. Bu çalışmanın amacı miyelodisplazili çocuklarda üst üriner sistem hasarını ve ürodinamik bulguları öngörmede mesane duvar kalınlığı ile birlikte idrar NGF, TGF Beta-1, TIMP-2 düzeylerinin değerinin saptanmasıdır. Literatürde anlamlı sonuçlar bulunmakla beraber bu belirteçlerle miyelodisplazili çocuk grubunda yapılan bir çalışma bulunmamaktadır. Gereç ve Yöntem Kliniğimizde 1996 – 2011 yılları arasında izlemli 780 miyelodisplazili olgunun dosyası retrospektif olarak incelendi. Takipleri tam olan 80 miyelodisplazili çocuk çalışmaya alındı. Bütün çocuklar fizik inceleme, idrar analizi, idrar kültürü, kreatinin, üriner sistem USG’ si, İSUG, ürodinamik testler ve DMSA böbrek sintigrafisi ile değerlendirildi. Üst üriner sistem USG’ si doğal olan ve DMSA sintigrafisinde skarı saptanmayan çocuklar çalışmamızda kontrol grubu olarak kabul edildi. İdrar örneği idrar kültürü steril olduğu dönemde alındı. İdrar örnekleri RayBioR Human TIP-2 Elisa Kit, RayBioR Human TGF-B1 Elisa Kit, RayBioR Human Beta-NGF Elisa Kit kulanılarak ELİSA yöntemiyle analiz edildi. Literatürde standardize edilmiş şekilde mesane duvar kalınlıkları USG ile ölçüldü. BulgularÇalışmaya 2-17 yaş arasında yaş ortalaması 7,2±3,6 arasında olan 36 (% 45) erkek, 44 (%55) kız olmak üzere 80 çocuk çalışmaya alındı. 54 olgunun tanısı miyelomeningosel, 8’inin gerilmiş kord, 5’inin meningoseldi. Diğer tanılar ise diastometamiyeli, lipomiyelomeningosel, dermal sinüs , hidromiyeli, siringomyeli, split kord malformasyonu şeklindeydi . Lezyondüzeyi 57 çocukta lomber, 14 çocukta sakral, 2 çocukta lumbosakral, 2 çocukta torakal, 4 çocukta torakolomberdi. Skar olmayan grupta mesane duvar kalınlığı; üriner TGF Beta 1, NGF, TIMP-2 düzeyleri skar olan gruptan anlamlı olarak (p 40 cmH20(p 40 cmH20 have significantly high levels of urine TGF- β1, NGF, TIMP- 2 and increased bladder wall thickness. These findings indicate that predicting the upper urinary tract damage and urodynamic findings with these urine markers is feasible in the patients with myelodysplasia who needs life long follow up. It is promising that these can avoid invasive procedures like urodynamics and DMSA scintigraphy. Key words : Myelodysplasia, TGF- β1, NGF, TIMP- 2, renal scar, DLPP, neurogenic bladde

Miyelodisplazili çocuklarda üst üriner sistem hasarını ve ürodinamik bulguları öngörmede idrar NGF,TGF BETA-1, TIMP-2, mesane duvar kalınlığının değeri

İÇİNDEKİLER Sayfalar ıv İNGİLİZCE (ABSTRACT) vıı 1. GİRİŞ ve AMAÇ 1 2. GENEL BİLGİLER 3 2.1. Tanım 3 2.2. Ürolojik Değerlendirme ve Tedavi 3 2.3. Ürodinamik Çalışmalar 7 2.4. DMSA Böbrek Sintigrafisi 9 2.5. Nerve Growth Factor (NGF) 10 2.6. Matrix Metalloproteinaz Doku İnhibitörü-2 (TIMP-2) 11 2.7. Transforming Growth Factor Beta 1 (TGF Beta 1) 12 3. GEREÇ ve YÖNTEM 14 4. BULGULAR 16 5. TARTIŞMA 26 6. SONUÇLAR 30 7. EKLER 31 Ek.1. Etik Kurul Onayı 31 Ek.2. Hasta Bilgilendirme Formu 32 Ek.3. Hasta Onay Formu 34 8. KAYNAKÇA 35 Amaç Miyelodisplazili çocuklarda üst üriner sistem hasarını belirlemede USG çoğu zaman yetersiz kalmaktadır. Üst üriner sistem hasarını belirlemede DMSA sintigrafisi, mesane işlev bozukluğunu değerlendirmede ise ürodinamik çalışma altın standarttır. Bu çalışmanın amacı miyelodisplazili çocuklarda üst üriner sistem hasarını ve ürodinamik bulguları öngörmede mesane duvar kalınlığı ile birlikte idrar NGF, TGF Beta-1, TIMP-2 düzeylerinin değerinin saptanmasıdır. Literatürde anlamlı sonuçlar bulunmakla beraber bu belirteçlerle miyelodisplazili çocuk grubunda yapılan bir çalışma bulunmamaktadır. Gereç ve Yöntem Kliniğimizde 1996 – 2011 yılları arasında izlemli 780 miyelodisplazili olgunun dosyası retrospektif olarak incelendi. Takipleri tam olan 80 miyelodisplazili çocuk çalışmaya alındı. Bütün çocuklar fizik inceleme, idrar analizi, idrar kültürü, kreatinin, üriner sistem USG’ si, İSUG, ürodinamik testler ve DMSA böbrek sintigrafisi ile değerlendirildi. Üst üriner sistem USG’ si doğal olan ve DMSA sintigrafisinde skarı saptanmayan çocuklar çalışmamızda kontrol grubu olarak kabul edildi. İdrar örneği idrar kültürü steril olduğu dönemde alındı. İdrar örnekleri RayBioR Human TIP-2 Elisa Kit, RayBioR Human TGF-B1 Elisa Kit, RayBioR Human Beta-NGF Elisa Kit kulanılarak ELİSA yöntemiyle analiz edildi. Literatürde standardize edilmiş şekilde mesane duvar kalınlıkları USG ile ölçüldü. Bulgular Çalışmaya 2-17 yaş arasında yaş ortalaması 7,2±3,6 arasında olan 36 (% 45) erkek, 44 (%55) kız olmak üzere 80 çocuk çalışmaya alındı. 54 olgunun tanısı miyelomeningosel, 8’inin gerilmiş kord, 5’inin meningoseldi. Diğer tanılar ise diastometamiyeli, lipomiyelomeningosel, dermal sinüs , hidromiyeli, siringomyeli, split kord malformasyonu şeklindeydi . Lezyondüzeyi 57 çocukta lomber, 14 çocukta sakral, 2 çocukta lumbosakral, 2 çocukta torakal, 4 çocukta torakolomberdi. Skar olmayan grupta mesane duvar kalınlığı; üriner TGF Beta 1, NGF, TIMP-2 düzeyleri skar olan gruptan anlamlı olarak (p < 0,05) daha düşüktü (Tablo-1). DLPP değeri 40 cmH2O altı grubun mesane duvar kalınlığı; üriner TGF Beta 1, NGF, TIMP-2 düzeyleri DKAB değeri 40 cmH2O ve üstü gruptan anlamlı (p < 0,05) olarak daha düşüktü (Tablo-2). Sonuç Renal skarı olan, DKAB değeri 40 cm H2O basıncın üzerinde olan riskli çocuklarda anlamlı olarak idrar TGF-Beta 1, NGF ve TIMP-2 değerleri yüksek olduğu, mesane duvar kalınlığının ise arttığı saptandı. Bu bulgular miyelodisplazi gibi ömür boyu izlem gerektiren hastalarda, bu belirteçlerle yapılacak idrar analizleri ile üst üriner sistem hasarının ve riskli ürodinamik bulguların öngörülmesinin mümkün olduğunu göstermektedir. Bu belirteçlerin analizi rutin yapılan ürodinami ve DMSA sintigrafisi gibi invaziv tekniklerden kaçınılması açısından ümit vericidir. Anahtar Kelimeler : Miyelodisplazi, TGF-Beta 1, NGF, TIMP-2, renal skar, DKAB, nörojenik mesane ABSTRACT Aim Urinary ultrasonography(USG) is frequently inadequate to determine upper urinary tract damage in children with myelodysplasia. DMSA scintigraphy for evaluation of upper urinary tract damage and urodynamic study to evaluate bladder dysfunction are gold standard diagnostic tools. The aim of this study is to establish the value of bladder wall thickness together with urine NGF, TGT β1 and TIMP- 2 to predict urodynamic findings and upper urinary tract damage in children with myelodysplasia. Although there are some significant results in the literature there is no study in children with myelodysplasia for these markers. Materials and Methods The charts of 780 children followed up for myelodysplasia in our clinic between 1996- 2011 are retrospectively reviewed. 80 children with complete follow up are included in this study. All children were evaluated with physical examination, urine analysis and culture, blood creatinine, urinary USG, voiding cystourethrography(VCUG), urodynamics and DMSA scintigraphy. Those children with a normal upper urinary tract USG and no finding of scarring on DMSA scintigraphy were assigned to control group. Urine samples were taken after a sterile urine culture. Urine samples were analysed with ELISA method with RayBioR Human TIP-2 Elisa Kit, RayBioR Human TGF-B1 Elisa Kit and RayBioR Human Beta-NGF Elisa Kit. Bladder wall thickness is measured according to standardized procedures in the literature. Findings A total of 80 children aged between 2- 17 years (mean 7,2±3,6) of whom 36(%45) were males and 44(%55) were females are included in this study. Meningomyelocele was the diagnosis in 54, tethered cord in 8 and meningocele in 5 of the children. Other primary diagnoses were diastometamyelia, lipomyelomeningocele, dermal sinus, hydromyelia, syringomyelia and split cord malformation. The level of the lesion was lumber in 57, sacral in 14, lumbosacral in 2, thoracal in 4 and thorocolumber in 4 of the children. Bladder wall thickness, urine levels of TGF- β1, NGF, TIMP- 2 were significantly lower in the children with no renal scar(p 40 cmH20(p 40 cmH20 have significantly high levels of urine TGF- β1, NGF, TIMP- 2 and increased bladder wall thickness. These findings indicate that predicting the upper urinary tract damage and urodynamic findings with these urine markers is feasible in the patients with myelodysplasia who needs life long follow up. It is promising that these can avoid invasive procedures like urodynamics and DMSA scintigraphy. Key words : Myelodysplasia, TGF- β1, NGF, TIMP- 2, renal scar, DLPP, neurogenic bladde

Management of Neonatal Priapism: Report of Two Cases and Review of the Literature

Priapism in a newborn is a rare entity with only 15 cases reported in the literature since 1879. The most commonly detected etiologic factor is polycythemia, but most of the cases are idiopathic. Conservative treatment seems to be sufficient and surgical approach is usually unnecessary. Here, we present a prolonged erection in two newborns which occurred at the first day of life and detumescence was achieved with conservative approach at the 6th and 7th day of life, respectively. We also reviewed the literature to investigate the most adequate evaluation and management criteri

Assessment of Differential Renal Function in Children with Hydronephrosis: Comparison of DMSA and MAG-3

Objective Nuclear imaging techniques such as 99mTc-dimercaptosuccinic acid (DMSA) and 99mTc-mercaptoacetyltriglycine (MAG-3) are widely used for the diagnosis and follow-up of urinary tract obstructions. Both imaging techniques provide the differential renal function (DRF) in slightly different ways. The aim of this study was to assess the MAG-3 scan as an adjunct or alternative to DMSA for evaluating DRF in children with hydronephrosis. Materials and Methods Eighty-one patients with hydronephrosis were enrolled in this study. Patient age, sex, anteroposterior renal pelvis diameter (RPD) at the time of diagnosis, parenchymal thickness and the DRF percentage found by both DMSA and MAG-3 were recorded. DMSA scintigraphy was used for detecting renal scars and estimating DRF. MAG-3 scintigraphy was used for evaluation of renal clearance, the collecting system’s outflow pattern and estimating DRF. Results A total of 102 renal units (38 left, 22 right and 21 bilateral) were evaluated. High correlation rates were found when we compared both tests’ DRF values according to antero-posterior renal pelvic diameter and patient age (p>0.05). In all groups compared in the present study, both tests demonstrated very similar results and DRF values. Statistical analysis of cut-offs (45%, 40%, 10%) were also similar in both methods (p>0.05, kappa >0.7, r=0.926 Pearson). Conclusion DMSA and MAG-3 are tests that are of assistance in the evaluation of hydronephrosis. Compared to DMSA, MAG-3 also provides valuable information to evaluate DRF values in hydronephrotic renal unit (RU). Avoiding unnecessary DMSA imaging will save time and cost and prevent over-radiation of the pediatric population

Can Surgical Technique Affect the Success of Endoscopic Treatment in Children with Vesicoureteral Reflux and Overactive Bladder Syndrome?

Objective “Traditional subureteral transurethral injection” (STING) and “Double hydrodistention-implantation” (Double-HIT) injection techniques for vesicoureteral reflux (VUR) treatment are a less invasive, yet very effective options. The influence of injection techniques in treatment success is not adequately searched in children with overactive bladder syndrome (OAB). The objective of this study to compare the short-term success rates of STING and Double-HIT techniques in children with OAB-VUR complex. Materials and Methods Children who underwent endoscopic injection for VUR between 2010 and 2013 were retrospectively evaluated. Patients were grouped into two groups according to the surgical techniques (STING or Double-HIT). Success of the treatment was defined with a negative voiding cystourethrogram at the 6th postoperative week. Patients were evaluated according to sex, age, pre- and postoperative reflux grades, laterality, type and volume of bulking agent and presence of OAB. Results Both groups were similar in terms of sex, age, lower urinary tract dysfunction, reflux grade and success rates. Surgical technique, score of pediatric lower urinary tract symptom questionnaire, age, sex, laterality of reflux and type of the bulking agent found to have no effect on the overall success rates (p>0.05). Presence of OAB and/or a high grade reflux were identified as statistically significant predictive factors that could affect the treatment results. Conclusion The short-term surgical success of the double-HIT and STING techniques showed no difference in children with OAB. The presence of a high grade reflux and/or OAB seemed to be the main factors for overall success in endoscopic VUR surgery