Urolithiasis in childhood: surgery and lithotripsy.

From 1982 through 1993, 174 interventions in 160 infants and children with urolithiasis were performed at our department. There were 101 boys and 59 girls, mean age 8.9 years. The main causes of the interventions were congenital malformations in 62, followed by recurrent urinary tract infections in 29, previous operations in 17, and hypercalciuria in 35 patients. In 17 children, the cause of urolithiasis remained unknown. As a therapeutic option, extracorporeal shock-wave lithotripsy (ESWL) has become available since 1988. The malformations and postoperative conditions are surgically corrected, and the calculi removed in the same act. For post-infectious, idiopathic or hypercalciuric calculi, ESWL has been used in the majority of patients since 1988. Thus, a total of 129 calculi were removed by operation and 47 by ESWL, whereas 18 calculi were endoscopically extracted. There were no complications after either ESWL or open surgery. Calculi in congenital malformations or as a result of operation are still removed by open surgery. In other cases, ESWL is the method of choice.

Our 10-year experience with embolized Wilms' tumor.

In the Department of Pediatric Surgery, Clinical Hospital Center Rebro in Zagreb, during the last 10 years a new method of invasive diagnostic and at the same time therapeutic procedure for the treatment of Wilms' tumor has been introduced. The treatment is preoperative Percutaneous Transcatheter Intraarterial Embolization (PTIE) of the renal artery. The aim of this procedure is to reduce vascularization, to decrease the mass of kidney affected by the tumor, to separate it from the surrounding tissue, to decrease intraoperative spillage of malignant cells into the blood stream and their metastasizing. As a result nephrectomy is easier to perform. It has been confirmed that it is best to perform nephrectomy 48 hours after embolization. The authors present their own experience with 33 patients, ranging from 1 to 16 years of age.

[Modern diagnosis and treatment of pheochromocytoma in children]. / Suvremena dijagnoza i lijecenje feokromocitoma djece.

Pheochromocytoma is a rare tumor of chromaffin tissue of the adrenal gland that synthesizes, stores and releases cathecolamines. In 10% of the patients it arises outside the adrenal gland, and has been called paraganglioma. The following study describes our experience in the diagnostic process and treatment of pheochromocytoma in two children, a 8-year-old boy with the right ureteral paraganglioma, and a 8-year-old girl with pheo-chromocytoma of the leftsuprarenal gland. Characteristic clinical features with predominant signs of hypertension, as well as the diagnostic flow diagram, have been presented. We have analysed recent diagnostic possibilities, sensitivity of diagnostic methods (ultrasonography, CT, selective angiography and J131 MIBG scintigraphy), indications for their use, and the importance of appropriate preoperative management. The major role of the J131-metaiodobenzilguanidine scintigraphy in diagnostic assessment, especially in precise preoperative localization and postoperative verification of tumour removal, has been stressed.

Cloacal exstrophy: a case report.

A case of an extremely rare type of cloacal exstrophy in a male infant with a normally developed subvesical part of the urinary system and external genitalia but absent distal colon segment is presented. The patient also had omphalocele, upper urinary tract anomalies and sacrococcygeal teratoma.

Congenital pulmonary arteriovenous fistula: a rare cause of cyanosis in childhood.

Two children (both females) aged 15 months and 4 years are described as very rare cases of central cyanosis in childhood being caused by a congenital pulmonary arteriovenous fistula. The initial diagnosis was made based on cyanosis and chest radiographs, with normal physical, ECG, and radiological findings of the heart. They had no family history of the Rendu-Weber-Osler syndrome. The patients underwent cardiac catheterization and pulmonary angiography, where the diagnosis was confirmed. After the surgery, both were symptom-free, and had no evidence of the disease.

[The present status of treatment of splenic injuries in children]. / Danasnji stav o lijecenju ozlijedene slezene u djece.

Small but very dangerous risk of postsplenectomic sepses gave rise to the examination of surgical attitudes of medical treatment of damaged and ruptured spleen. Some new ideas of immunology revealed the importance of the spleen in the protection of the host and serious defect of immunologic system if the spleen is removed. According to those ideas, ruptured spleen is to be retained by all means. Some minor lesions and hemorrhages that are easily controlled by conservative measures, are not to be operated. In case of serious ruptures and massive hemorrhages necessitating more than 20 ml/kg of fresh blood to replace lost volume, penetrated abdominal injuries and with polytraumatic patients, laparotomy, surgical hemostasis and preservation of the spleen are indicated if possible. In the period of the last eight years, 90 children were treated because of the possibility they had injured spleen. Thirty-eight patients (42%) were under observation. Hemodynamic indicators were normal, so we did not make any aggressive diagnostic examinations. Other 47 patients had splenic scintigraphy, computed tomography (CT) of the abdomen or ultrasound examination. The findings were positive with 32 (69%) patients. Of those patients, 14 (44%) were immediately operated since serious rupture of the spleen was diagnosed and clinical signs suggested the presence of severe abdominal bleeding. To this number of operated patients, four polytraumatic patients and one suffering from penetrated injury are to be added. They were indicated the exploration of the abdomen without previous diagnostics. There were 19 surgical treatments of ruptured spleen; three of them included splenectomy while the other patients underwent splenic preservation.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal renal angioplasty (PTRA) as a method of therapy for renovascular hypertension in children.

The results of PTRA in treatment of renovascular hypertension in four children aged 5, 7, 13 and 15 are presented. All patients suffered from severe hypertension. Tests showed all of them to have fibromuscular dysplasia stenosis of the main renal artery and significant lateralization of renin levels. One suffered from associated polycystosis of kidneys and in another the renal artery stenosis was bilateral. In all patients successful patency was achieved. In one patient, the arterial pressure after PTRA was normalized, while in the others it was considerably improved. Two patients, tested 8 and 12 months after PTRA, were lost to further follow-up. In one of the remaining two, stenosis and hypertension reappeared 5 years after PTRA. After autotransplantation the patient was normotensive. In the other, also 5 years later, recurrent hypertension appeared related to the associated polycystosis.

Congenital ureteric diverticula in children and adults: classification, radiological and clinical features.

To date, about 100 cases of a blind-ending branch of a bifid ureter have been reported. We present 13 clinically, radiologically and histologically evaluated cases of congenital ureteric diverticulum. We believe this anomaly is not as rare as hitherto believed and suggest the term congenital ureteric diverticulum for a blind-ending branch of a bifid ureter.

Primary vesicoureteric reflux treated by antireflux ureterocystostomy at the vertex of the bladder. A 12-year follow-up and analysis of operative failure.

A total of 618 children with primary vesicoureteric reflux (VUR) were examined preoperatively and 6, 9 and 24 months after an antireflux ureterocystostomy of the vertex of the bladder (AUVB); 206 children were operated on bilaterally, so that 824 AUVBs were performed. Most patients had grade 3 or 4 reflux and only 5% had grade 2 reflux. Successful results were noted in 792 ureteric units; in 10 cases of post-operative stenosis and 17 cases of recurrent VUR a second AUVB was performed. The following causes of operative failure were found: obstruction of the submucosal ureter after tailoring (5 cases), stricture of the new ureteric orifice (3), necrosis of the terminal part of the ureter (2), submucosal ureter too short or too wide (12) and fibrosis of the detrusor muscle over the submucosal ureter (5); a success rate of 84% was noted after the second procedure.

[Retroperitoneal hematoma in children with hemophilia]. / Retroperitonealni hematom u djece s hemofilijom.

The cases of two boys with hemophilia and retroperitoneal haematoma are presented; the diagnosis was confirmed by means of ultrasound scanning. The clinical picture of retroperitoneal haematoma can not be distinguished from other acute abdominal conditions (retroperitoneal infiltrate, or abscess). These pathological processes require surgical treatment, whereas such one in the patients suffering from haemophilia with retroperitoneal haematoma is contraindicated. The diagnosis of retroperitoneal haematoma can be confirmed with a great certainty by means of ultrasound scanning.

Bladder diverticula in children - a clinical, radiologic and endoscopic study.

We have described the clinical, radiologic and endoscopic findings in 84 children with bladder diverticula and 9 children with posterolateral pouch-like protrusions of the bladder wall. Cystoscopically, a new bladder diverticulum is described, resembling a walnutshell. The majority of children had symptoms of urinary tract infection, the walnutshell-like diverticula was frequently associated with haematuria. In 66 or 84 children with bladder diverticula and in 9 children with posterolateral pouches no obstruction of the lower urinary tract was found. Diverticula caused by obstruction were found in 18 cases. Vesicoureteral reflux was present in 34 of 66 children with diverticula without obstruction of the lower urinary tract, in 20 of these there were saccules (diverticula smaller than 2 cm in diameter). Vesicoureteral reflux was found in 8 of 9 children with posterolateral pouches of the bladder wall. Long term follow-up suggests that any protrusion of the bladder wall, regardless of the size of cavity and the shape of the opening, may become a diverticulum associated with further abnormalities of the urinary tract. In 3 patients with postero lateral pouches a transformation from pouches into true diverticula together with the development of vesicoureteral reflux was observed.