Is Onabotulinum Toxin-A Combined Injection in the Bowel Patch and the Bladder Remnant a Safe Alternative to Bladder Re-Augmentation?

OBJECTIVE: To assess both the safety and efficacy, in terms of symptomatic improvement, of botulinum toxin injections distributed in the bowel patch and the bladder remnant of failed augmented bladders. MATERIALS AND METHODS: A retrospective study was performed on patients with augmented bladders who had presented with clinical and/or urodynamic failure and had received an onabotulinum1 toxin-A (BTX-A) injection at both the bowel and the bladder level due to refractoriness to oral treatment. The primary variable tested was safety, which was assessed by analysing the adverse effects according to the Clavien-Dindo classification. Subjective improvement was assessed by means of the Treatment Benefit Scale (TBS) as a secondary variable. RESULTS: Eight patients who underwent a total of 23 procedures were analysed. The mean age at first injection was 23 years. The mean interval between bladder augmentation and first BTX-A injection was 65.11 months. The mean interval between BTX-A injections was 11.6 months. No adverse effects due to systemic absorption were recorded. The only postoperative complication was an afebrile urinary infection (Clavien-Dindo 2) in 2 out of 23 procedures (8.7%). Eighty-six percent (19/22) of the procedures yielded a symptomatic benefit (TBS 1 and 2). CONCLUSION: Injection of onabotulinum toxin-A in both the bowel patch and the bladder remnant appears to be a safe and efficient technique for the symptomatic treatment of patients with bladder augmentation who have shown clinical and/or urodynamic failure in response to a conservative treatment. This procedure allows bladder re-augmentation to be delayed or even avoided.

Safety and Outcomes of using ureteric access sheath (UAS) for treatment of Pediatric renal stones: Outcomes from 2 tertiary endourology centers.

OBJECTIVE: To look at the safety and outcomes of using ureteral access sheath (UAS) for pediatric renal stones. The use of UAS is variable in urological practice with very little clinical work on their use in pediatric kidney stone disease. PATIENTS AND METHODS: Data was retrospectively collected from 2 large European tertiary endourology centers for all pediatric patients (≤16 years) with renal stones who underwent flexible ureteroscopy and lasertripsy (FURSL) via UAS. Data was collected on patient details, stone demographics and clinical outcomes of the FURSL procedure. RESULTS: Forty-eight patients with a mean age of 10.7 years were treated with FURSL for a mean single and cumulative stone size of 10.4 mm and 15 mm respectively, with two-third having multiple stones and stones in the lower pole. The initial and final stone free rate (SFR) was 66.7% and 100% respectively with 1.3 procedures/patient. One patient each had intra-operative grade 1 ureteric injury and post-operative UTI, with no other injuries or complications noted. Over a mean follow-up of 17 months, no other complications were noted. CONCLUSION: Ureteral access sheath is safe for treatment of pediatric renal stones with excellent outcomes and are especially useful for larger or multiple stones. While there does not seem to be any medium-term sequalae, to avoid risk of ureteral injury, we would suggest using the smallest size sheath possible. We would argue these procedures are best done in specialist high-volume endourology units for optimal results.

Totally fluoroless retrograde intrarenal surgery technique in prestented patients: tips and tricks.

Treatment of urolithiasis has evolved greatly as retrograde intrarenal surgery (RIRS) has gained popularity nowadays being a gold standard therapy for renal stones up to 2 cm. Endourological procedures are traditionally fluoroscopic guided; thus, an increasing concern is the harm of radiation exposure, especially in the pediatric population. Therefore, performing fluoroless RIRS should be a feasible option for pediatric urologists. Herein, we describe the technique of totally fluoroless RIRS in presented patients and the tips to avoid radiation use at most.

Can endoscopic balloon dilation for primary obstructive megaureter be effective in a long-term follow-up?

BACKGROUND: Ureteral tapering and reimplantation is an established treatment for persistent or progressive primary obstructive megaureter (POM) but may result in complications and morbidity. Use of a less invasive technique involving endoscopic balloon dilation appears very interesting. OBJECTIVE: The objective of this report is to determine if endoscopic balloon dilation for POM is effective in the long term as well as to assess complications of the procedure. MATERIAL AND METHODS: A retrospective review was done on 19 patients and 20 ureters treated with the endoscopic balloon dilation by POM from June 2000 to February 2010. Surgery was performed solely in those cases in which there was persistence of obstruction in the renogram along with one or all of the following conditions: impairment of the differential renal function <40%, worsening of the renal pelvic dilation, febrile UTI in spite of antibiotic prophylaxis or renal calculi. The patients comprised 16 boys and 3 girls with a mean age at surgery of 17 months (range 1-44 months). Ten cases were left sided, eight right sided, and one bilateral. Under endoscopic and fluoroscopic guidance, a 3-5 Fr dilating balloon was inflated to 12-14 atm, or until disappearance of the stenotic obstructive area. A double J stent was positioned and withdrawn 2 months later. Follow-up recorded the presence of symptoms, number of reintervention procedures registered, and included renal ultrasound and MAG-3 renogram. RESULTS: There were no perioperative complications. Eighteen ureters showed a non-obstructive pattern on MAG-3 renogram after the first endoscopic dilation, representing a 90% success rate. One case required a second dilation, which proved successful and two cases of recurrent lithiasis required ureterotomy without instances of obstruction. 2 patients had a febrile UTI and a vesicoureteral reflux was diagnosed in one. Renal function was preserved in 95% of patients. The mean follow-up was 6.9 years (range 3.9-13.3 years). One patient was lost after the procedure. DISCUSSION: In an era of minimally invasive techniques, the search for less invasive procedures for treatment of POM has resulted in a variety of surgical options. Angulo et al., in 1998 and our group described the first POM treatment with endoscopic balloon dilation, which is believed to be a definitive, less invasive, and safe treatment. Furthermore, should an endoscopic approach fail, reimplant surgery can be performed. Few publications have reported short series with good results in the short and medium term. Torino et al. presented five cases in children aged less than 1 year, none of these showed evidence of obstruction. García-Aparicio et al. presented a series of 13 patients treated with a success rate of 84.6%. Christman et al. added laser incision in cases of narrowed ureteral segment 2-3 cm long and used double stenting. Good outcomes were presented in 71%. Romero et al. reported improvement of drainage within the first 18 months after treatment in 69% of patients. The potential de novo onset of vesicoureteral reflux may be the source of some controversy. We consider that dilation does not significantly alter the antireflux mechanism. In VCUG is not systematically performed because it is an invasive test. This restricts the conclusions that can be drawn from our findings. Nevertheless, some groups continue to systematically perform VCUG. CONCLUSIONS: Endoscopic balloon dilation for POM is a safe, feasible, and less invasive procedure that shows good outcomes on long-term follow-up. However, multicenter studies and prospective trials should be encouraged to provide more definitive evidence on its benefits.

Espina bífida y vejiga neurógena. Manejo de un caso complejo con esfínter artificial, ampliación vesical y derivación urinaria / Spina bifida and neurogenic bladder. Managing a complex case with artificial sphincter, bladder augmentation and urinary diversion

Se presenta caso de varón de 26 años con antecedente de espina bífida y mielomeningocele. Diagnosticado de vejiga neurógena con sistema de bajas presiones inicialmente debido a incontinencia de orina fue tratado con esfínter artificial. Después de la operación presentó un patrón de sistema de altas presiones que requirió ampliación vesical, derivación tipo Mitrofanoff y retirada del esfínter. Con ello se consiguió que la presión del detrusor se mantenga dentro de límites seguros durante las fases de llenado y vaciado para proteger la función renal. Es de gran importancia el diagnóstico y seguimiento urológico temprano de los niños y niñas con esta enfermedad mediante los estudios urodinámicos para determinar el patrón vesical y esfinteriano y decidir la mejor estrategia de tratamiento posible. La finalidad fundamental es convertir la vejiga en un sistema de baja presión, conseguir la continencia y preservar la función renal (AU)

Twenty-six years old male with a history of spina bifida and myelomeningocele is presented. Neurogenic bladder with initially low pressure system due to urinary incontinence was treated with artificial sphincter. After the operation presented a pattern of high pressure system that required bladder augmentation, Mitrofanoff diversion and removal of the sphincter. Through these measures safe limits during the phases of filling and emptying of the bladder were achieved, to protect renal function. It is very important the early diagnosis and monitoring of urological children with spina bifida with urodynamic study to determine bladder and sphincter patterns and determine the best possible treatment strategy. The main purpose is to convert the bladder in a low-pressure system, achieve continence and preserve renal function (AU)

Esquistosomiasis vesical y en la población pediátrica. Reporte de un caso y revisión de la literatura / Bladder schistosomiasis in the pediatric population. Case report and literatur review

La esquistosomiasis es una enfermedad que afecta a más de 200 millones de personas a nivel mundial. Es poco frecuente en nuestro medio, estando sobre todo distribuida a lo largo de África, en algunas áreas del Oriente Medio, en el oeste de Asia y ciertas zonas de América Latina. Se estima que 88 millones de los infectados son menores de 15 años. La hematuria es el síntoma cardinal, y se debe sospechar en los pacientes provenientes de las áreas de riesgo (sobre todo África subsahariana). Presentamos el caso de un niño de 11 años, originario de Mali, que consultó por presentar durante un año macrohematuria monosintomática; se siguió nuestro método diagnóstico, evidenciando la enfermedad causante del proceso, estableciéndose tras ello la terapéutica pertinente. Se realiza a partir de ahí una revisión de la literatura de la patología que nos ocupa (AU)

Schistosomiasis is a prevalent disease affecting more than 200 million people world wide. Even though is an infrequent disease in our environment, it is endemic trough Africa, some Middle East areas, Western Asia and certain South American areas. There are approximately 88 million children, 15 years old or less, affected. Hematuria is the paramount symptom, and we should suspect this infection in patients who come from this risky area. We report an 11 year old boy, originally from Mali, who complaint about having approximately a year of gross hematuria, discussing the pertinent assessment and treatment. Performing a literature review of the causative pathology (AU)

Tumores testiculares en la infancia / Testicular Tumours in Infancy and children

Introducción: los tumores testiculares prepuberales son distintos a los que se presentan en la edad adulta. Tradicionalmente han sido considerados malignos, pero realmente los tumores testiculares benignos son más frecuentes en esta edad. Material y métodos: revisamos nuestra experiencia en el tratamiento de los tumores testiculares en niños ≤ 13 años con intención de evaluar el empleo de orquiectomía parcial. Desde 1984 hasta 2008 hemos diagnosticado y tratado en nuestro centro 15 tumores testiculares en edad pediátrica. Se revisa la actitud terapéutica empleada con énfasis en la posibilidad de preservación testicular en pacientes seleccionados y se evalúan los resultados. Resultados: la forma de presentación clínica en el 80% de los casos fue aumento del tamaño testicular con masa palpable. Se realizaron 4 orquiectomías radicales (27%) y 11 tumorectomías (73%). Todas las lesiones benignas en la anatomía patológica definitiva fueron tratadas con tumorectomía: cuatro quistes epidermoides, un hemangioma, un lipoma, un hamartoma fibroso, un tumor de la granulosa juvenil y una fusión espleno-gonadal. También fueron tratados con éxito de forma conservadora dos casos de teratoma. Los casos tratados de manera radical fueron un caso de tumor de saco vitelino (estadio I), dos tumores germinales mixtos y un gonadoblastoma. Conclusiones: los tumores testiculares en la edad prepuberal benignos predominan sobre los malignos. Ante una masa testicular palpable con marcadores tumorales negativos se puede plantear un tratamiento conservador mediante tumorectomía. No obstante, la lesión debe ser completamente extirpada para evitar recurrencias (AU)

Introduction: prepubertal testicular tumours are different from those that appear during adulthood. Traditionally, they were considered to be malignant, however benign testicular tumours are actually more frequent at this age. Materials and methods: we analysed our experience in the treatment of testicular tumours in children ≤ 13, with the intention of evaluating the use of partial orchiectomy. From 1984 to 2008, we diagnosed and treated 15 testicular tumours in children at our centre. We examined the therapeutic approach employed, underlining the possibility of testicular conservation in selected patients and we have analysed the results. Results: the clinical presentation in 80% of the cases was an increase in testicle size with palpable mass. We performed 4 radical orchiectomies (27%) and 11 tumourectomies (73%). All the benign lesions in the final pathological anatomy were treated with tumourectomy: four epidermoid cysts, one hemangioma, one lipoma, one fibrous hamartoma, one juvenile granulosa tumour and one splenogonadal fusion. We also successfully and conservatively treated two cases of teratoma. The cases that received radical treatment were a yolk sac tumour (Stage I), two mixed germ cell tumours and one gonadoblastoma. Conclusions: there are more cases of benign testicular tumours than malignant tumours during puberty. In the event of a palpable testicular mass with negative tumour markers, conservative treatment by means of a tumourectomy may be considered. However, the lesion must be removed completely to prevent recurrence (AU)

[Testicular tumours in infancy and children]. / Tumores testiculares en la infancia.

INTRODUCTION: prepubertal testicular tumours are different from those that appear during adulthood. Traditionally, they were considered to be malignant, however benign testicular tumours are actually more frequent at this age. MATERIALS AND METHODS: we analysed our experience in the treatment of testicular tumours in children ≤ 13, with the intention of evaluating the use of partial orchiectomy. From 1984 to 2008, we diagnosed and treated 15 testicular tumours in children at our centre. We examined the therapeutic approach employed, underlining the possibility of testicular conservation in selected patients and we have analysed the results. RESULTS: the clinical presentation in 80% of the cases was an increase in testicle size with palpable mass. We performed 4 radical orchiectomies (27%) and 11 tumourectomies (73%). All the benign lesions in the final pathological anatomy were treated with tumourectomy: four epidermoid cysts, one hemangioma, one lipoma, one fibrous hamartoma, one juvenile granulosa tumour and one splenogonadal fusion. We also successfully and conservatively treated two cases of teratoma. The cases that received radical treatment were a yolk sac tumour (Stage I), two mixed germ cell tumours and one gonadoblastoma. CONCLUSIONS: there are more cases of benign testicular tumours than malignant tumours during puberty. In the event of a palpable testicular mass with negative tumour markers, conservative treatment by means of a tumourectomy may be considered. However, the lesion must be removed completely to prevent recurrence.

Ectasia piélica en diagnóstico prenata / Pyelic ectasia in prenatal diagnosis

La ecografía gestacional demuestra que el 1,4% de los fetos presentan algún grado de hidronefrosis, aunque en el 50%, dicha ectasia habrá desaparecido en el nacimiento. El desconocimiento que aún existe con respecto a las diferentes etapas del desarrollo fetal hace que sea difícil distinguir entre aquellas situaciones fisiológicas y las que son patológicas. La medición de los diámetros de la pelvis renal a lo largo de la gestación y la cantidad de líquido amniótico son datos importantes para establecer un pronóstico. Las válvulas de uretra posterior son las responsables de un buen número de casos de hidronefrosis gestacional significativa. Es importante diagnosticarlas y proceder a su tratamiento para evitar daño renal. Se presenta un caso clínico y se realiza una revisión sobre el tema proponiendo un algoritmo de actuación clínica (AU)

Gestational ultrasound shows that 1.4% of the fetuses have some degree of hydronephrosis, although in 50% renal ectasia will have disappeared at birth. The ignorance that still exists in the different stages of fetal development makes it difficult to distinguish between those situations that are physiological or pathological condition. Measuring the diameter of the renal pelvis throughout pregnancy and amniotic fluid are important data for establishing a prognosis. Posterior urethral valves are responsible for a number of significant cases of gestational hydronephrosis. It is important to diagnose it and provide treatment to prevent kidney damage. We present a case report and a review is made on the issue and we propos an algorithm for clinical intervention (AU)

Persistencia del seno urogenital: técnica quirúrgica mediante genitoplastia / Persistance of the urogenital sinus: surgical technique using genitoplasty

Las anomalías del seno urogenital (genitales ambiguos) consisten en la comunicación persistente de la vagina con el aparato urinario. Esta persistencia se observa en los recién nacidos con estados intersexuales, a los que actualmente se denomina desordenes de la diferenciación sexual (DDS). El tratamiento es quirúrgico. Presentamos un caso clínico de una niña de 4 años que presentaba un seno urogenital bajo, que fue tratada mediante genitoplastia (AU)

Eurogential sinus abnormalities (ambiguous genitalia) consist in the communication of the vagine with the urinary tract. This sinus persistence is observed in new borns with intersex states, which is now called disorders of sexual differentiation (DSD). The treatment is surgical. We present a case of a 4 year old girl who bad a low urogenital sinus, which was treated by genitoplasty (AU)

Persistencia del conducto peritoneo vaginal: revisión conceptual a propósito de un caso clínico / Persistence of the conduit vaginal peritoneum: conceptual review about a clinical case

La persistencia del conducto peritoneo-vaginal escrotal se debe a una falta de cierre del trayecto que, durante las etapas de desarrollo fetal, separan la cavidad peritoneal del escroto. Factores como la prematuridad o el bajo peso al nacer predisponen a esta alteración. Se presenta de diversas maneras: persistencia completa, parcial en forma de quiste de cordón e hidrocele con conducto cerrado. Es posible la asociación a hernia inguinal. Se puede producir su cierre espontánea en los 2 primeros años de vida. El tratamiento es quirúrgico, generalmente vía inguinal. Presentamos un caso clínico y una revisión sobre los aspectos básicos de esta entidad (AU)

The persistence e of the scrotum peritoneal-vaginal duct due to a lack of closure of the journey, during fetal development stages, separating the peritoneal cavity of the scrotum. Factors such as prematurity or low birth weight predispose to this disorder. It comes in different ways: full persistence, partly in the form of hydrocele and cord cyst with duct closed. Possible association with inguinal hernia is possible. Closure can occur spontaneously in the first 2 years of life. Treatment is surgical, usually transinguinal We present a case report and a review on the basic aspects of this entity (AU)

Cutaneous metastases in renal cell carcinoma.

Cutaneous metastases from a renal cell carcinoma are rarely diagnosed during life. We report a case of renal carcinoma metastatic to the skin that occurred 18 months after kidney removal. The cutaneous metastasis was excised. Cutaneous metastases from urological tumors are uncommon and occur in 1% of the patients, and their clinical appearance may mimic other common dermatological disorders affecting patients with advanced malignancies.

Disfunciones no neuropáticas del aparato urinario inferior en la infancia. A propósito de un caso / Non neuropathic dysfunctions of the low urinary system in childhood: one clinical case

Las disfunciones del aparato urinario inferior en la infancia (DNNTI.I) es un campo con gran confusión semántica. No existe una terminología común entre los diferentes grupos, usando distintas definiciones para describir lo mismo. Esta confusión refleja la investigación moderna, que en las últimas décadas nos ha hecho cambiar radicalmente nuestra visión sobre el tema, considerando que los niños son individuos en crecimiento, distintos a los adultos. La ICCS (International Children´s Continence Society), ha publicad las guías para intentar esclarecer esta confusión. Presentamos un caso clínico de hiperactividad del detrusor, y seguidamente un intento de clasificación de las DNNTI-I sin causa orgánica o neurológica (AU)

Lower urinary tract function and malfunction in children is a field rife with semantic confusion. Different groups use different definitions of commonly used terms. This confusion partly reflects modern research, which has radically changed our views of these conditions during the last decades, and partly the fact that children are growing individuals who differ from adults. The ICCS (International Children´s Continence Society), has published guidelines trying to clear-up this confusion. We present a clinical case of detrusor hyperactivity, and afterward an attempt to classify different lower urinary tract dysfunctions without organic or neurogenic cause (AU)

Percutaneous management of transplant ureteral fistulae is feasible in selected cases.

INTRODUCTION: Ureteral fistulae in renal transplants may develop as a consequence of compromised ureteral vascularity or from a technical factor related to the ureteroneocystostomy, the latter typically developing within the first 72 hours posttransplant. Recently, percutaneous nephrostomy drainage has been used with increasing frequency for the initial management. It alone can lead to resolution of the fistula in at least some patients. The aim of the study was the evaluation of endourological management of ureteral fistulae in renal transplants. MATERIAL AND METHODS: Between August 1981 and February 2004, 1000 adult recipients underwent renal transplantation. Sixteen out of 29 patients who developed ureteral fistulae were managed endourologically; 13, open surgery. The items recorded on these patients included the type of ureteroneocystostomy, the time to fistula diagnosis, the image technique, the type of ureteral stents, and the clinical evolution. RESULTS: The 13 patients who underwent open surgery did well. Endourological management of ureteral fistula was successfully performed in 10 of 16 cases. In all of them percutaneous nephrostomy drainage with stenting of the ureter with a double-J catheter did not prove any advantage to no stent (66.6% vs 57%). In 13 of these 16 patients in which the passage of contrast into the bladder was demonstrated, the fistula resolved in 10 cases (77%), while none of the three cases with no flow into the bladder were helped by this approach. CONCLUSION: Percutaneous techniques can provide definitive management for 62% of renal allograft patients who develop ureteral fistula beyond 72 hours after renal transplant.

Endourological management is better in early-onset ureteral stenosis in kidney transplantation.

INTRODUCTION: The incidence of ureteral stenosis in kidney transplant recipients is 3%-8%. The treatment of ureteral stenosis has been traditionally operative reconstruction, although such intervention is associated with high rates of serious complications, including graft loss and even perioperative mortality. More recently, endourological treatment has been proposed due to its low morbidity. OBJECTIVE: The objective of this study was to assess the usefulness of balloon percutaneous dilatation as a treatment technique for ureteral stenosis in kidney transplant recipients. PATIENTS AND METHODS: Among 1000 kidney transplantations performed between 1980 and 2004, the coexistence of high creatinine values and urinary tract dilatation in the postoperative period, after discarding concomitant causes, was managed with a percutaneous nephrostomy. Once renal function recovered, antegrade pyelography was performed to confirm the presence and determine the location of ureteral stenosis. Ureteral dilatation was performed using a 5-French balloon-fitted angioplasty catheter. RESULTS: Fifty-six patients were diagnosed with ureteral stenosis during follow-up, an incidence of 5.6%. Transluminal balloon dilatation was the first therapeutic option in 45 cases, whereas surgery was performed directly on 11 patients. Disappearance of the stenosis as well as maintenance of an improved creatinine level was verified in 45% of cases (20 patients). Two patients experienced graft loss. Both a short time to diagnosis after transplantation (P = .06) and the presence of a previous acute rejection episode (P < .05) were good prognosis factors for the endourologic solution of a ureteral stricture. CONCLUSIONS: Balloon dilatation may be considered the definitive procedure for treatment of ureteral stenosis in selected cases. Percutaneous nephrostomy should be used for initial diagnosis and improvement in the renal function before attempting an open procedure.

Priapismo / Priapism

Se presenta el caso clínico de un paciente de 47 años de edad que acude a urgencias con priapismo no doloroso de 4 años de evolución, diagnosticándose de FAV Arteria Pudenda Interna. Hacemos una revisión bibliográfica; su diagnóstico diferencial y su tratamiento (AU)

Paro cardíaco tras la inducción anestésica en una paciente diabética / Cardiac failure after anaesthetic induction in a diabetic patient

Presentamos el caso clínico de una paciente afectada de diabetes mellitus tipo II y diagnosticada de tumor renal, que tras inducción anestésica, presentó paro cardiorrespiratorio, recuperándose deforma inmediata y decidiéndose posponer la cirugía. Se inicia estudio cardiológico y se le diagnostica de enfermedad coronaria de tres vasos y se interviene un mes después sin presentar complicaciones (AU)