Papers by Barbara Ludwikowski
Neuropediatrics, 2014
Abbreviations: RCT, randomized controlled trial. AACPDM, American Academy for Cerebral Palsy and ... more Abbreviations: RCT, randomized controlled trial. AACPDM, American Academy for Cerebral Palsy and Developmental Medicine. Neuropediatrics Use of ITB in Children and Adolescents Berweck et al.
European Journal of Pediatric Surgery, 2013
Fast-track concepts in pediatric surgery were established in a university hospital in consecutive... more Fast-track concepts in pediatric surgery were established in a university hospital in consecutive studies within several years. They significantly reduced the length of hospitalization compared with German institutions without fast-track protocols. The aim of this study was to assess the implementation process of fast-track in a German nonacademic department of pediatric surgery without previous fast-track experience. All patients undergoing four types of operations (appendectomy, hypospadias repair, pyloromyotomy, and fundoplication) from February 2011 to January 2012 were included in this prospective study. Fast-track included detailed clinical pathways and specific pain treatment protocols using validated pain scales according to age. Mobilization and oral nutrition were started 2 hours postoperatively and documented with established scores. The length of hospital stay was compared with data from other hospitals with conventional treatment using information from the German reimbursement system (German diagnosis-related groups [G-DRG]) and with the hospital stay of patients from the corresponding university hospital undergoing fast-track treatment for the same procedures during the same study period. Two weeks after discharge, a questionnaire was completed by the patients/parents. A total of 143 patients with a mean age of 7.9 ± 5.0 years underwent fast-track treatment. The mean pain intensity during the immediate postoperative period was 1.7 ± 2.1 in patients < 4 years and 2.3 ± 2.1 in patients ≥ 4 years on a 10-point scale. Full mobilization was reached after a mean duration of 2.3 ± 2.0 days while full oral nutrition was completed after a mean duration of 1.8 ± 1.4 days. There were no complications associated with fast-track. The mean hospital stay was 5.8 ± 3.4 days which was not significantly different compared with G-DRG data from other hospitals without fast-track. This was in contrast to the mean hospital stay of patients from the corresponding university hospital (5.6 ± 3.0 days vs. G-DRG 6.9 ± 3.2 days, p < 0.05). After 2 weeks, patients/parents were highly satisfied with fast-track (mean score of 8.6 ± 1.4 on a 1-10-point scale) and 95.2% claimed that they would choose it again. Fast-track concepts can be applied in a nonacademic department of pediatric surgery without previous fast-track experience and with excellent patient/parent satisfaction. However, the G-DRG system interferes with concepts of early discharge of patients. Modifications of the reimbursement modalities within the German health care system seem to be mandatory.
Bju Int, 2002
Objective To assess the hypothesis that during fetal development, the external urethral sphincter... more Objective To assess the hypothesis that during fetal development, the external urethral sphincter changes from a concentric sphincter of undifferentiated muscle fibres to a transient ring of striated muscle which regresses caudo-cranially in the posterior urethra during the first year of life, when the sphincter assumes its omega-shaped configuration. Materials and methods The anatomy and development of the external urinary sphincter was assessed in human males and females during fetal life. Plastic-embedded sections (transverse, sagittal and frontal planes; 300-700 mm) of the pelvis of 31 females and 31 males (9 weeks of gestation to newborn) were stained with azure II/methylene blue/basic fuchsin and viewed at r 4-80. The sections of interest were taken from the bladder neck to the perineum. The sections of the membranous urethra were reconstructed three-dimensionally using a computer program. Results In both male and female an omega-shaped external sphincter was apparent in all specimens at >10 weeks of gestation. In the early fetal period (ninth week), there was undifferentiated mesench-yme; in this period the mesenchyme was more dense in the anterior part and loose in the posterior part of the urethra. In females, there was a close connection between the urethra and the anterior wall of the vagina. Conclusion The omega-shaped configuration of the external urethral sphincter was recognisable from 10 weeks of gestation in both sexes. There was no suggestion of a change from a cylindrical to an omegashaped sphincter in the fetal period to birth. Also, a transient 'tail' posterior to the sphincter was not apparent. The rectovesical septum was well developed in neonates. There is no reason to assume that the development of the septum leads to an apoptosis of muscle cells in the posterior part of the external sphincter in males after birth. The anatomical development of the external sphincter does not explain transient outlet obstruction during fetal life. The function of the muscle may change during development because of neuronal maturation.
The Journal of Urology, Sep 1, 2008
Purpose: Retrospective reviews suggest that the functional outcomes of surgery of the urogenital ... more Purpose: Retrospective reviews suggest that the functional outcomes of surgery of the urogenital sinus have often been unsatisfactory and to our knowledge the long-term results of newer surgical techniques have yet to be evaluated. A precise understanding of pelvic fetal neuroanatomy is germane for optimizing surgical correction of the urogenital sinus. Materials and Methods: The pelves of 10 human female fetuses were serially sectioned. Masson's trichrome staining and immunochemistry for the neuronal marker S100 (Dako Corp., Carpinteria, California) along with anatomical computer reconstruction allowed 3-dimensional analysis of the nerves in relation to the pelvic structures as an animated motion picture. Results: Two types of neuronal structures were identified. 1) A dense perivisceral foil of branching nerves closely surrounded the pelvic organs. The localization of most nerves was on the external faces of the viscera with a limited fraction in the rectovaginal and urethrovaginal septa. This innervation was from the anterior cephalad periurethral area to the posterior caudal perirectal area. 2) A significant amount of nerves surrounded the cephalad urethra on its anterior and posterior faces. Conclusions: Based on these anatomical data during surgical repair of a urogenital sinus we would advocate minimal mobilization of the lateral faces of the vagina, avoiding dissection of the proximal urethra above the pubic bone and electing a vaginal flap in severe cases.
The Journal of Urology
Retrospective reviews suggest that the functional outcomes of surgery of the urogenital sinus hav... more Retrospective reviews suggest that the functional outcomes of surgery of the urogenital sinus have often been unsatisfactory and to our knowledge the long-term results of newer surgical techniques have yet to be evaluated. A precise understanding of pelvic fetal neuroanatomy is germane for optimizing surgical correction of the urogenital sinus. The pelves of 10 human female fetuses were serially sectioned. Masson's trichrome staining and immunochemistry for the neuronal marker S100 (Dako Corp., Carpinteria, California) along with anatomical computer reconstruction allowed 3-dimensional analysis of the nerves in relation to the pelvic structures as an animated motion picture. Two types of neuronal structures were identified. 1) A dense perivisceral foil of branching nerves closely surrounded the pelvic organs. The localization of most nerves was on the external faces of the viscera with a limited fraction in the rectovaginal and urethrovaginal septa. This innervation was from the anterior cephalad periurethral area to the posterior caudal perirectal area. 2) A significant amount of nerves surrounded the cephalad urethra on its anterior and posterior faces. Based on these anatomical data during surgical repair of a urogenital sinus we would advocate minimal mobilization of the lateral faces of the vagina, avoiding dissection of the proximal urethra above the pubic bone and electing a vaginal flap in severe cases.
Archivos españoles de urología
ABSTRACT
The study presented here comparing cross-sectional anatomy of the fetal and the adult pelvic conn... more The study presented here comparing cross-sectional anatomy of the fetal and the adult pelvic connective tissue with the results of modern imaging techniques and actual surgical techniques shows that the classical concepts concerning the subdivision of the pelvic connective tissue and muscles need to be revised.
Frontiers in pediatrics, Jan 21, 2013
Total urogenital sinus mobilization has been applied to the surgical correction of virilized fema... more Total urogenital sinus mobilization has been applied to the surgical correction of virilized females and has mostly replaced older techniques. Concerns have been raised about the effect of this operation on urinary continence. Here we review the literature on this topic since the description of the technique 15 years ago. Technical aspects and correct nomenclature are discussed. We emphasize that the term "total" refers to an en-bloc dissection and not to the extent of the proximal dissection. No cases of urinary incontinence have been reported following this operation. It is yet too early to evaluate results regarding sexual function but it is likely that the use of a posterior skin flap to augment the introitus will minimize the development of introital stenosis.
Frontiers in pediatrics, 2014
In order to compare the results of our morphological studies with the planes of modern imaging te... more In order to compare the results of our morphological studies with the planes of modern imaging techniques, both fetal and adult specimens were studied in undisturbed transparent sections of the entire pelvis. To gain the spatial insight into the pelvic floor anatomy that is most important for the operating surgeon, we produced computer- assisted three-dimensional reconstructions of our sections and thus accomplished dissectional impressions.
The anatomy of both the male and female pelvis and perineum shows a lack of conceptual clarity. T... more The anatomy of both the male and female pelvis and perineum shows a lack of conceptual clarity. These regions are best understood when they are clearly described and subdivided according to functional and clinical requirements: The actual clinical subdivision discerns an anterior, a middle, and a posterior compartment. Whereas an anterior and posterior compartment may be found in the male as well as in the female, a middle compartment can only be found in the latter. The term “compartment” is routinely used by radiologists and all surgeons operating on the pelvic floor. This term is not identical with the term “space.” According to former literature, a lot of spaces are supposed to be arranged in the region of the pelvic floor: retrorectal, pararectal, rectoprostatic, rectovaginal, retropubic, paravesical, etc. (Lierse 1984; Pernkopf 1941; Waldeyer 1899). From the point of view of the surgeon, “spaces” are empty (Richter and Frick 1985). They are only filled with loose connective tissue and neither contain large vessels nor nerves. Some years ago, we proposed to drop the term “space” and to speak of compartments instead, taking into account that a compartment may be filled by different tissue components (Fritsch 1994).
The perineal body separates urogenital and anal hiatus. In the male it is situated between the re... more The perineal body separates urogenital and anal hiatus. In the male it is situated between the rectum and urethra (prostate), i.e., between the posterior and anterior compartments. Within the region of the perineal body, the skin is firmly attached to the underlying connective tissue. This becomes obvious in macroscopic dissection as well as in histological sections. As can already be seen in early fetal life, the male’s perineal body consists of dense connective tissue (Fig. 14A). It does not possess its own musculature, but numerous muscles originate or insert within the dense perineal body. The external anal sphincter is attached to it dorsally and the deep transverse perineal muscle, including the bulbourethral glands, abut the ventral portion of the perineal body (Fig. 14B, C). As has already been pointed out above (see posterior compartment), the additional smooth rectal muscle bundles that are situated in the rectoprostatic fascia are integrated and attached to the connective tissue of the perineal body (Fig. 14D). Apart from muscular structures, the cavernous nerves come in close contact to the perineal body. They pass just above its intrapelvic side (Fig. 14E) when leaving the pelvic cavity beside the membranous part of the urethra.
In macroscopic dissection of embalmed cadavers it is nearly impossible to distinguish subcompartm... more In macroscopic dissection of embalmed cadavers it is nearly impossible to distinguish subcompartments within the connective tissue of the posterior compartment. Our comparative study of adult and fetal pelves shows that two subcompartments can be distinguished within the posterior compartment.
Frontiers in Pediatrics, 2014
Frontiers in Pediatrics, 2013
Frontiers in Pediatrics, 2014
Frontiers in Pediatrics, 2014
We revisit the technique of total preputial flap (TPF) and its application for urethroplasty, pen... more We revisit the technique of total preputial flap (TPF) and its application for urethroplasty, penile skin coverage of both and present our results in 43 patients (41 hypospadias, 2 epispadias). There were no instances of flap necrosis. In patients without prior attempts at reconstruction (n = 36), we observed four urethrocutaneous fistulas. TPF allowed the repair of cases of proximal hypospadias in one stage with an acceptable complication rate.
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Papers by Barbara Ludwikowski