Outcome of continence procedures after failed endoscopic treatment with dextranomer-based implants (DEFLUX®).

PURPOSE: To evaluate outcome of further continence procedures after failure of endoscopic injections of dextranomer-based bulking agent. MATERIALS AND METHODS: From 1997, 89 children (3-18 years) and one young adult were treated for incontinence with 145 endoscopic injections of dextranomer. On evaluation, each patient was classified as: dry, significantly improved, or treatment failure. Eighty-five patients had at least 12 months of follow up. Out of 34 (40%) treatment failures, 24 patients had a subsequent bladder neck procedure: artificial urinary sphincter (7), bladder neck plasty (9), bladder neck closure (1), fascial sling (3). Six patients had further endoscopic treatment (including 2 after bladder neck plasty). RESULTS: At surgery, Deflux(®) paste was easily identified with minimal surrounding tissue inflammatory reaction. Artificial urinary sphincter: all 7 dry; bladder neck plasty: 7 dry, 1 improved and 1 still incontinent; 1 bladder neck closure patient dry; fascial sling: 1 significantly improved and 2 dry. Repeated endoscopic treatment: 1 dry, 1 improved and 4 failed. Eleven of the 21 (52%) patients who are either dry or improved have voiding abilities. CONCLUSION: Endoscopic injections with dextranomer do not adversely affect the outcome of further surgical procedures. Repeated injections after a previous endoscopic treatment failure have a low success rate.

Long-term effects of dextranomer endoscopic injections for the treatment of urinary incontinence: an update of a prospective study of 61 patients.

PURPOSE: To treat sphincteric deficiency in children endoscopic bladder neck injections may avoid or salvage more complex procedures. A prospective study to assess the efficacy of bladder neck injections of dextranomer based implants (Deflux(R)) was done in a 7-year period in 61 patients. MATERIALS AND METHODS: From September 1997 to September 2004 we enrolled in the study 41 males and 20 females 5 to 18 years old with severe sphincteric incompetence, including exstrophy-epispadias in 26, neuropathic bladder in 27, bilateral ectopic ureters in 5, and miscellaneous in 3. Preoperative evaluation consisted of medical history, urine culture, urinary tract ultrasound and videourodynamics. This evaluation was repeated 6 months and 1 year after treatment, and yearly thereafter. Of the patients 17 underwent 2 and 4 underwent 3 treatment sessions to achieve a definitive result. At each evaluation the case was considered cured-a dryness interval of 4 hours between voids or CIC, significantly improved-minimal incontinence requiring no more than 1 pad daily and no further treatment required, and treatment failure-no significant, long lasting improvement. Videourodynamics were mainly useful to study the evolution of bladder capacity, activity and compliance. Followup after the last injection was 6 to 84 months (mean 28). RESULTS: Mean injected volume per session was 3.9 cc (range 1.6 to 12). Postoperative complications were temporary dysuria in 2 patients nonfebrile urinary tract infection in 10, orchid-epididymitis in 1 and urinary retention with pyelonephritis in 1. The incidence of dryness or improvement during followup was 79% (48 of 61 patients) at 1 month, 56% (31 of 55) at 6 months, 52% (24 of 46) at 1 year, 51% (18 of 35) at 2 years, 52% (16 of 31) at 3 years, 48% (12 of 25) at 4 years, 43% (9 of 21) at 5 years, 36% (4 of 11) at 6 years and 40% (2 of 5) at 7 years. The success rate according to pathological condition was similar in cases of neuropathic bladder and the exstrophy-epispadias complex (48% and 53%, respectively). The success rate in re-treated cases was 38%. After treatment a contracted bladder developed in 6 patients. Also, of the 35 patients with at least 2 years of followup an increase in capacity of at least 50% was observed in 12 of 18 with an initially small bladder. No side effects related to the substance were observed. CONCLUSIONS: Endoscopic treatment for pediatric severe sphincteric deficiency with dextranomer implant, a nontoxic, nonimmunogenic, nonmigratory synthetic substance, was effective up to 2 years in half of the patients. Subsequently at up to 7 years of followup a slow decrease in efficacy was observed and treatment remained beneficial in 40% of the patients.

Long-term effects of dextranomer endoscopic injections for treatment of urinary incontinence: an update of a prospective study of 31 patients.

PURPOSE: A prospective study was initiated 7 years previously to assess the efficacy of endoscopic dextranomer based implants for pediatric structural incontinence. Preliminary results revealed that at 3 years 50% of the patients were either dry or significantly improved. We report long-term results in the same cohort of patients. MATERIALS AND METHODS: A total of 33 children and adolescents 5 to 18 years old with severe incontinence due to sphincteric incompetence (exstrophy-epispadias complex in 13, neuropathic bladder in 16, bilateral ectopic ureter in 4) were enrolled. Of the patients 13 underwent 2 and 4 underwent 3 treatment sessions to achieve a definitive result. Mean injected volume was 3.9 ml (range 1.6 to 12) per session. At each evaluation patients were considered cured (dryness interval 4 hours), significantly improved (minimal incontinence requiring no more than 1 pad daily and no further treatment required) or treatment failures (no significant improvement). Videourodynamics were used to study the evolution of the bladder capacity, activity and compliance. A total of 31 patients were followed 3 to 7 years after the last injection. RESULTS: At 3 years after treatment 15 of 30 patients (50%) were dry or improved. One patient who had leakage after 3 years of dryness due to bladder deterioration subsequently underwent ileocystoplasty. At 4 years 12 of 25 patients (48%) were dry or improved. At 5 years 9 of 21 patients (43%) were dry, as were 4 of 11 (36%) at 6 years and 2 of 5 (40%) at 7 years of followup. The success rate according to pathological evaluation was comparable in neuropathic bladders (7 of 14, or 50%), exstrophy (3 of 6, or 50%) and epispadias (3 of 7, or 43%). Of 12 patients who underwent bladder neck plasty before the injection of bulking agent 7 (58%) were either dry or improved. The success rate was higher in males (13 of 23, or 57%) than in females (3 of 8, or 38%). Also, at puberty 2 males who were improved became dry. Bladder capacity increased in 12 of 18 initially small bladders and remained normal and stable in 9, while 4 initially dry patients had development of recurrent leakage secondary to bladder deterioration and underwent augmentation. Otherwise, there were no long-term side effects observed related to the injection of the bulking agent. CONCLUSIONS: Endoscopic treatment of severe organic urinary incontinence with dextranomer is durable for up to 7 years of followup in 40% of the patients.

Evaluación de la definición de caso probable de dengue clásico durante el brote de dengue en Lima, 2005 / Assessing the definition of probable cases during the dengue fever outbreak in Lima, 2005

Objetivos: Evaluar la utilidad diagnóstica de la definición de caso probable de dengue clásico (DCPDC) para la identificación de casos definitivos, durante el brote en el distrito de Comas, abril - mayo 2005. Materiales y métodos: Estudio observacional, analítico, no controlado de corte transversal. Se incluyeron pacientes procedentes de Comas que en el periodo de estudio presentaron sospecha de dengue y con resultados de aislamiento viral o ELISA IgM, según el tiempo de enfermedad (≤4 ó ≥5 días respectivamente) realizados en el Instituto Nacional de Salud. Se determinó la sensibilidad (S), especificidad (E), valor predictivo positivo (VPP) y negativo (VPN) de la DCPDC y de los síntomas que la conforman, tomando como prueba de oro al aislamiento viral o ELISA IgM. Resultados: Se incluyeron 316 pacientes, de los cuales se confirmaron 137 (43,4 por ciento) casos de dengue. Se detectaron 60 pacientes mediante aislamiento viral, la DCPDC en pacientes con cuatro o menos días de enfermedad presentó una S=85 por ciento, E=13,40 por ciento, VPP=13,18 por ciento, VPN= 74,29 por ciento. Se detectaron 77 pacientes con cinco o m¿ós días de enfermedad con IgM ELISA, la DCPDC en este grupo presentó S= 68,42, E= 16,28, VPP= 68,42, VPN= 46,67. Conclusiones: La DCPDC aplicada en el brote de dengue en Comas, al igual que los síntomas individuales que la conforman es sensible, pero poco específico.

Objective: To assess diagnostic usefulness of the probable case of classic dengue fever for identifying definite cases during the outbreak in Comas District, April – May 2005. Materials and methods: Observational and analytical non-controlled cross-sectional study. Suspected dengue fever cases from Comas District were included. These persons also had results for viral isolation or IgM ELISA, according to their time of being ill (4 days or e5 days, respectively), laboratory studies were performed at Peruvian National Institute of Health. Sensitivity, specificity, positive predictive value, and negative predictive value for the definition of a probable case of classic dengue fever, including its symptoms, taking as a gold standard viral isolation or IgM ELISA. Results: 316 patients were included, and 137 (43,4%) of them were confirmed as dengue fever cases. Viral isolation was achieved in 60 patients. Probable dengue fever case definition for patients being ill for d4 days had a 85% sensitivity, 13,40% specificity, 13,18% positive predictive value, and 74,29% negative predictive value. 77 patients who were ill for five days or more were diagnosed using IgM ELISA, and the probable dengue fever case definition for these patients had a 68,42% sensitivity, 13,40 specificity, positive predictive value, 68,42%, and 46,67% negative predictive value. Conclusions: probable case definition used in the dengue fever outbreak in Comas District, as well as the assessment of individual symptoms, has good sensitivity, but poor specificity.

Evaluación de la definición de caso probable de dengue clásico durante el brote de dengue en Lima, 2005 / Assessing the definition of probable cases during the dengue fever outbreak in Lima, 2005

Objetivos: Evaluar la utilidad diagnóstica de la definición de caso probable de dengue clásico (DCPDC) para la identificación de casos definitivos, durante el brote en el distrito de Comas, abril - mayo 2005. Materiales y métodos: Estudio observacional, analítico, no controlado de corte transversal. Se incluyeron pacientes procedentes de Comas que en el periodo de estudio presentaron sospecha de dengue y con resultados de aislamiento viral o ELISA IgM, según el tiempo de enfermedad (≤4 ó ≥5 días respectivamente) realizados en el Instituto Nacional de Salud. Se determinó la sensibilidad (S), especificidad (E), valor predictivo positivo (VPP) y negativo (VPN) de la DCPDC y de los síntomas que la conforman, tomando como prueba de oro al aislamiento viral o ELISA IgM. Resultados: Se incluyeron 316 pacientes, de los cuales se confirmaron 137 (43,4 por ciento) casos de dengue. Se detectaron 60 pacientes mediante aislamiento viral, la DCPDC en pacientes con cuatro o menos días de enfermedad presentó una S=85 por ciento, E=13,40 por ciento, VPP=13,18 por ciento, VPN= 74,29 por ciento. Se detectaron 77 pacientes con cinco o m¿ós días de enfermedad con IgM ELISA, la DCPDC en este grupo presentó S= 68,42, E= 16,28, VPP= 68,42, VPN= 46,67. Conclusiones: La DCPDC aplicada en el brote de dengue en Comas, al igual que los síntomas individuales que la conforman es sensible, pero poco específico

The effect of endoscopic injections of dextranomer based implants on continence and bladder capacity: a prospective study of 31 patients.

PURPOSE: A prospective study was conducted to assess the efficacy of dextranomer based implants as a new bulking agent for endoscopic treatment of pediatric structural incontinence. MATERIALS AND METHODS: A total of 33 children and adolescents 5 to 18 years old with severe incontinence due to sphincteric incompetence (exstrophy-epispadias in 13, neuropathic bladder in 16, bilateral ectopic ureters in 4) were enrolled in the study. All but 1 patient wore diapers. Preoperative evaluation consisted of medical history, pad test, urine culture, urinary tract ultrasound and videourodynamics. This evaluation was repeated 6 months and 1 year after treatment and then on a yearly basis. Of the patients 14 had 2 and 1 had 3 treatment sessions to achieve a definitive result. At each evaluation the patient was considered cured-dryness interval of 4 hours confirmed by pad test, significantly improved-minimal incontinence requiring no more than 1 pad a day with less than 10 gm. leakage during pad test; and no further treatment required, and treatment failure-no significant improvement. Videourodynamics were mainly useful to study the evolution of the bladder capacity, activity and compliance. Followup after the last injection ranged from 6 to 36 months (mean 18). RESULTS: The mean injected volume was 3.9 ml. (range 1.6 to 12) and the procedure lasted a mean of 30 minutes (10 to 60). In the postoperative period 2 patients had temporary dysuria and 10 had a nonfebrile urinary tract infection. At 1 month 24 of the 33 patients (73%) were dry or improved. Two patients were subsequently excluded from study for noncompliance with followup. At 6 months 17 of 31 patients (55%), at 1 year 13 of 28 (46%), at 2 years 10 of 23 (43%) and at 3 years 10 of 20 (50%) were dry or improved. Similar success occurred in cases of neuropathic bladder (57%) and exstrophy-epispadias complex (46%). Success rate of re-treated patients was 35%. Of 13 patients with a normal initial bladder capacity 3 had a bladder decompensation requiring augmentation after 6 months. Also an increase of at least 50% in capacity was observed in 12 of 18 patients with an initial small bladder. No side effect related to the substance was observed. CONCLUSIONS: Endoscopic treatment of pediatric structural urinary incontinence with dextranomer implant, a nontoxic, nonimmunogenic, nonmigrant synthétic substance, was effective after 3 years in half of our patients. It may also be beneficial for patients with small bladder functional capacity. As the success rate decreased during the first year of followup, the result observed at 1 year seems to remain stable subsequently.

The Malone antegrade colonic enema isolated or associated with urological incontinence procedures: evaluation from patient point of view.

PURPOSE: Fecal and urinary incontinence in patients with congenital or acquired spinal cord defects represents a handicap that impairs chances of integration in society. Associated with the management of urinary incontinence, the Malone antegrade colonic enema is a generally successful procedure for resolving refractory fecal incontinence. We report the results of the evaluation of this technique from the patient perspective. MATERIALS AND METHODS: A survey was conducted among 19 patients who had undergone a Malone procedure, combined in 14 with urological surgical intervention for urinary incontinence. Patients completed a questionnaire either by mail or during an interview with a urotherapy nurse and/or a psychologist. Questions concerned patient opinion about the quality of preoperative information, perioperative period, stoma, functional result and overall satisfaction. The psychological impact of the procedure was also evaluated during the interviews. No complication occurred related to the Malone procedure or stomal stenosis, and a perfect functional result was achieved in 17 patients, 1 of whom had occasional leakage through the stoma. RESULTS: Of the 19 patients in the study 2 who have abandoned using the Malone procedure, including 1 with a poor result and 1 with a good functional result, did not return the questionnaire. The remaining 17 patients believed they had received adequate preoperative information and expressed no specific complaint about the perioperative period. The 15 with the stoma in the umbilicus were satisfied, although 3 young patients were temporarily disturbed by catheterizing the umbilicus and 2 with the stoma in the right fossa iliaca were disappointed. The 15 patients who had a perfect functional result recognized great improvement in quality of life but 13 complained of pain (12) and/or excessive duration of the procedure (9). The patient with a poor functional result and the other with occasional stomal leakage would not consider the procedure again. These 2 patients had durable postoperative depression while 3 others who ultimately achieved a good functional result experienced temporary depression. CONCLUSIONS: The Malone procedure generally meets the expectations of patients but it is considered by a majority as painful and lengthy. The umbilicus is the preferred stoma site but may prove to be disturbing in young patients. Abandonment of the procedure and postoperative depression experienced by some patients, despite a good functional result, deserve better prevention.

[Pathology of the ureterovesical junction in neurogenic bladders in children and adolescents. A retrospective study of 119 patients]. / Pathologie de la jonction urétéro-vésicale dans les vessies neurologiques de l'enfant et de l'adolescent. Etude rétrospective de 119 patients.

Ureterovesical junction dysfunction in congenital or acquired neurogenic bladders represents a threat for the renal parenchyma. In order to evaluate the incidence, mechanisms of development and preventive and curative treatments proposed in diseases of the ureterovesical junction associated with neurogenic bladders, the files of 119 children were retrospectively evaluated. 68 patients suffered from congenital neurogenic bladder and 51 had an acquired neurogenic bladder. In the congenital neurogenic bladder group, vesico-ureteric reflux was observed in 22 cases (32%) and dilatation was observed in 18 cases (26.5%), while 21 patients had both dilatation and reflux. In the acquired neurogenic bladder group, reflux was observed in 8 cases (16%) and dilatation was observed in 3 cases (10%), one of whom had both reflux and dilatation. The predominant mechanism of decompensation of the ureterovesical junction in the two groups was a combination of low compliance and high peripheral resistance. In patients with abnormalities of the ureterovesical junction, the incidence of associated parenchymal lesions was similar (30%) whether neurogenic bladder was congenital or acquired. The disparities between these two comparable patient groups, the preventive and curative treatments proposed and their results are analysed in comparison with the data reported in the literature.

[Urination disorders in patients with sequelae of perinatal lesions without mental handicap]. / Les troubles mictionnels chez les sujets porteurs de séquelles de lésions périnatales sans handicap intellectuel.

Sixty-three patients with cerebral palsy and micturition disorders were investigated. The age ranged between 5.5 and 38 years (mean 13.5). Half had diplegia: one-third had quadriplegia and were therefore dependent incontinence was the most common symptom: dysuria was noted in half of the cases, mainly in quadriplegic patients. The urodynamic assessment confirmed the dysfunction and showed hyperreflectivity with or without asynergy. However, no therapeutic approach has been validated.