Clinical outcome and follow-up of prenatal hydronephrosis

Between 1987 and 1991, 160 hydronephrotic kidneys were diagnosed prenatally and confirmed postnatally in 100 infants. The aim of the study was to describe the natural history and management of primary hydronephrosis detected prenatally. We devised a new classification of obstructive uropathy outcome using ultrasonography and the diethylenetriamine penta-acetic acid scan. Accordingly, we classified the patients as having mild, moderate or severe hydronephrosis. Nine patients had pyeloplasties and 5 had ureteric reimplantations. We conclude that in most cases there is no need for immediate surgery, and that the initial approach to the management of congenital hydronephrosis should be conservative. We suggest that anti-bacterial prophylaxis be conventionally given to infants with vesicoureteral reflux and for the first 6 months of life to infants demonstrating moderate to severe newborn primary hydronephrosis.Presented by A.B. in partial fulfillment of the requirements for the M.D. degree at the School of Medicine, Soroka Medical Center-Ben Gurion University of the Negev, Beer-sheva, Israel.     

Treatment program for erectile dysfunction in patients with cardiovascular diseases

The present study assesses the effectiveness of our progressive treatment program for erectile dysfunction in patients with cardiovascular diseases. The study sample included 453 patients aged 36 to 91 years. Therapy in all patients was begun with sildenafil citrate 25 to 100 mg. Those with contraindications, drug adverse effects, or a negative response (erection insufficient for vaginal penetration) were given intracavernous injections of a cocktail of vasoactive drugs (dimix, trimix, or quadmix), followed by the addition of sildenafil citrate to the trimix in case of failure, and then a penile prosthesis. Patients were followed for 2 years; in cases of treatment ineffectiveness during follow-up, drug dosages were increased or a penile prosthesis was suggested. Sildenafil citrate was offered to 417 patients of whom 205 (49.2%) responded positively. The remaining 248 patients received intracavernous injections: 135 (54.4%) had a positive response to the dimix, 85 (75.2%) to the trimix, and 16 (57.1%) to the quadmix. Four of the other 12 patients (0.9%) responded to sildanefil citrate + trimix, and 2 (0.4%) agreed to a penile prosthesis. At the 2-year follow-up of 447 patients, 131 (29.3%) were successfully treated with sildanefil citrate, 92 (20.6%) with dimix, 122 (27.3%) with trimix, 12 (2.7%) with quadmix, and 2 (0.4%) with sildanefil citrate + trimix; 5 patients (1.1%) had a penile implant. Forty-eight patients (10.7%) achieved spontaneous erection, of whom 46 were taking aspirin. Twenty-six patients (5.8%) stopped treatment because of health and family reasons and 9 (2%) had a negative response. Our progressive treatment program for erectile dysfunction has a high success rate in patients with cardiovascular disease: Overall, 98.7% achieved an erection sufficient for vaginal penetration immediately after the trial and 92.2% on follow-up; 10.7% achieved spontaneous erections.     

Empirical management of urinary tract infections complicating transrectal ultrasound guided prostate biopsy

PURPOSE: Although urinary tract infection is a recognized complication of transrectal ultrasound guided prostate biopsy, to our knowledge there are no recommendations in the literature for its management. We studied the unique features of this infection and provide management recommendations. MATERIALS AND METHODS: A prospective design was used. The study group was composed of patients admitted to the emergency department from 2000 to 2001 with complaints suggestive of urinary tract infection after transrectal ultrasound guided prostate biopsy. The indication for biopsy, prophylactic regimen used and clinical manifestations were documented. Urine and blood cultures were obtained at hospital admission and bacterial susceptibility was examined for all positive cultures. RESULTS: All 23 patients enrolled in the study underwent biopsy for acceptable indications and 95.7% had received antibiotic prophylaxis, including 69.5% with fluoroquinolones. Infection was typically accompanied by high fever (mean +/- SD 39.1 +/- 0.6C), chills in 78.3% of cases and leukocytosis in 56.5%. All positive blood cultures and 92.9% of positive urine cultures yielded Escherichia coli. Bacterial isolates showed high resistance to fluoroquinolones and trimethoprim-sulfamethoxazole, and 100% susceptibility to second and third generation cephalosporins, amikacin and carbapenems. CONCLUSIONS: The successful management of urinary tract infection complicating transrectal prostate biopsy depends on the recognition of its unique features, the pathogens involved and their antimicrobial susceptibility. The recommended empirical treatment is a second or third generation cephalosporin, amikacin or a carbapenem.     

Human DNA topoisomerase-IIalpha expression as a prognostic factor for transitional cell carcinoma of the urinary bladder

OBJECTIVE: To investigate the immunohistochemical expression of topoisomerase II-alpha (TII-alpha, a nuclear enzyme, the expression of which increases rapidly at the end of the S to G2/M phase and declines when mitosis ends) in bladder urothelial neoplasms (transitional cell carcinoma), and its correlation with grade, stage and survival. PATIENTS AND METHODS: Histological sections from 57 urothelial neoplasms were stained immunohistochemically for TII-alpha expression; the percentage of positive cells in the area of greatest staining was recorded as the TII-alpha index. RESULTS: TII-alpha nuclear staining was positive in all the samples except one. The mean (sd) TII-alpha index was 10.7 (5.9) in urothelial neoplasms of low malignant potential (grade 1), 15.5 (5.0) in low-grade (grade 2) and 42.1 (13.4) in high-grade urothelial carcinoma (grade 3). The mean TII-alpha index was 10.7 (5.9), 26.3 (14.8) and 44 (19) in stages pTa, pT1 and pT2, respectively. The TII-alpha index was significant for predicting death from cancer, independently of the stage or grade of the disease (P = 0.019, hazard ratio 1.1). CONCLUSIONS: A higher TII-alpha index indicates a greater probability of recurrence of disease and lower overall survival. Therefore TII-alpha expression has prognostic value in bladder carcinoma.     

Haemophilus influenza type b vaccine in Israel: experience in a paediatric ambulatory clinic

In Israel, vaccination are the overall responsibility of the government. We were the first in Israel to give the Hib (Haemophilus influenza type b) vaccine to the population, through independent means, without government control. The aim of the study was to follow longitudinally the specific group of children vaccinated in our ambulatory clinic. In this study, 1,497 children between 2 and 52 [mean (SD) 13 (9)] months of age at the time of first vaccination were vaccinated with Hib vaccine. Over the next 7 years, they were followed up by repeated phone calls when parents were asked about hospitalisation and any serious infectious diseases. Of the 1,497, 1,444 were followed during the years 1992 to 1999 and 36 were hospitalised during this time. All blood and cerebrospinal fluid cultures were negative. No proven case of Hib infection could be demonstrated. Despite the small sample size, this study justifies the continued use of the vaccine along with maintaining surveillance for Hib infection.     

The effect of cholinergic enhancement during filling cystometry: can edrophonium chloride be used as a provocative test for overactive bladder?

PURPOSE: Overactive bladder, a highly prevalent disorder, is suspected of having a low detection rate due to the lack of sensitive diagnostic tools. Recent studies imply the involvement of the cholinergic system in the pathophysiological mechanism underlying overactive bladder. We determined whether in vivo enhancement of cholinergic activity with edrophonium chloride, a potent cholinesterase inhibitor, would serve as a provocative maneuver to increase the sensitivity of filling cystometry. MATERIALS AND METHODS: A total of 27 patients underwent a multichannel video urodynamic evaluation, followed by filling cystometry with the intravenous administration of 10 mg. edrophonium chloride. The response to edrophonium was defined as a significant change in sensation and decreased bladder capacity, the induction or amplification of involuntary detrusor contractions, or significantly decreased detrusor compliance. Findings were compared in responders and nonresponders. RESULTS: We identified 11 responders and 16 nonresponders. A response was noted in 78% of the patients with the symptomatology of overactive bladder but in none with no specific complaints suggesting bladder overactivity. In 7 of the 12 responders (64%) baseline cystometry was interpreted as normal. In 6 of the 11 responders (54%) uninhibited urinary leakage was observed in response to edrophonium. There were no serious adverse reactions to the drug. CONCLUSIONS: This preliminary study implies that edrophonium may serve as a novel, practical and safe drug for provocative cystometry. By significantly increasing cystometry sensitivity the drug would facilitate the identification of the subset of patients with overactive bladder who are currently classified with sensory urgency.