New tissue bulking agent (polyacrylate polyalcohol) for treating vesicoureteral reflux: preliminary results in children.

PURPOSE: We report the preliminary results of endoscopic treatment of vesicoureteral reflux in children using polyacrylate polyalcohol copolymer. MATERIAL AND METHODS: We performed a prospective multicenter review of pediatric patients treated with subureteral injection of a new nonabsorbable substance. Only patients with 1 year of followup were included. RESULTS: A total of 83 patients underwent injection of polyacrylate polyalcohol copolymer at our institutions between 2005 and 2006. Among this group 18 males and 43 females with a median age of 58 months (range 9 months to 18 years) completed 1 year of followup. Reflux was bilateral in 27 patients (44.3%) and unilateral in 34 (55.7%). Number of injected ureters was 88. Reflux grade was V in 3 ureters (3.4%), IV in 12 (13.6%), III in 41 (46.6%) and II in 32 (36.4%). Mean +/- SD injected volume per unit was 0.76 +/- 0.43 ml. Median followup was 20 months (range 16 to 24). Complications after injection included dysuria in 6 patients (9.8%), fever in 3 (4.9%) and lumbar pain in 4 (6.6%). Reflux was eliminated in 78 renal units (88.6%), decreased to grade I in 6 (6.8%) and persisted in 4 (4.5%). Ureteral obstruction developed in 1 patient and was treated operatively. Overall success rate was 83.6%. CONCLUSIONS: Polyacrylate polyalcohol copolymer can be used to treat vesicoureteral reflux with comparable efficacy to other substances currently used, with a low rate of complications.

14 years of experience with the artificial urinary sphincter in children and adolescents without spina bifida.

PURPOSE: The efficacy of the artificial urinary sphincter to treat sphincteric incontinence in pediatric patients with spina bifida has been clearly reported. The possibility of maintaining spontaneous voiding has usually been the main reason for prosthetic device surgery. We reviewed our experience with the artificial urinary sphincter in patients without spina bifida who had had previous surgery of the bladder neck or proximal urethra. MATERIALS AND METHODS: From 1990 to 2004, 112 children and adolescents underwent implantation of an AMS 800 artificial urinary sphincter. Of the patients 19 males and 4 females (20.5%) between ages 4 and 17 years (mean 8.1) had no spina bifida. Instead there were bladder exstrophy in 12 patients, anorectal malformation with a rectourethral or vesical fistula in 7 and epispadias in 4. A bladder neck cuff between 5.5 and 7.5 cm, and a 61-70 balloon were used in all patients. RESULTS: Only 1 patient was lost to followup. In 22 patients (95.6%) mean followup was 80 months (range 4 to 155). Three sphincters in patients with exstrophy were removed because of erosion and/or infection 5, 49 and 60 months after initial surgery, respectively. A total of 19 sphincters remained in place (86.3% survival rate) with 5 revisions (26.3%) because of the pump (2), the cuff (2) or balloon fluid leakage. In this group 13 patients (68.4%) voided spontaneously and 6 (31.6%) performed clean intermittent catheterization, although 3 also voided spontaneously. Overall continence was good in 87% of patients because 2 were still incontinent at night. CONCLUSIONS: The artificial urinary sphincter is a good long-term solution to urinary incontinence secondary to sphincter incompetence despite multiple previous surgeries of the bladder neck or proximal urethra. Patients with bladder exstrophy and many previous bladder procedures are more exposed to complications such as erosion compared with patients with epispadias or anorectal malformation. The high percent of patients maintaining spontaneous voiding and the good rate of continence are the most important benefits of this type of surgical option for sphincter incompetence.

Sigmoid cystoplasty with argon beam without mucosa.

PURPOSE: Intestinal bladder augmentations have well recognized complications, including mucus production, metabolic abnormalities and perforation. These complications may be avoided if the intestinal mucosa is not incorporated in the urinary tract. We report our experience with sigmoid cystoplasty without mucosa using argon beam, and describe the clinical, urodynamic, ultrasound and pathological results. MATERIALS AND METHODS: We performed sigmoid cystoplasty without mucosa in 26 patients and with argon beam over the mucosa before it was removed in 6 boys and 4 girls with a mean age of 8 years (range 3 to 14). All patients had neurogenic bladder as the initial disease. Indications for augmentation were poor bladder compliance, low bladder capacity, hydronephrosis and urinary incontinence. Mean followup was 18 months (range 8 to 40) and included ultrasound, urodynamic evaluation, renal function and clinical assessment. In all patients intraoperative biopsies were done. In 8 of the 10 patients endoscopic biopsies of the augmented segment were obtained between 6 months and 2 years postoperatively. The operation consisted of the Goodwin technique without mucosa, which was treated with argon beam before it was removed. RESULTS: The 10 patients are dry on intermittent clean catheterization with intervals of greater than 4 hours. There have been no clinical urinary tract infections. Two patients presented with peristaltic contractions and no symptoms. Bladder capacity increased from 80 (range 45 to 200) to 300 (220 to 400) ml., and mean postoperative compliance was 15 ml./cm. H2O (range 9 to 38). There were no significant changes in the urodynamic data between patients treated with sigmoid cystoplasty without mucosa only and with argon beam. Intraoperative biopsies after treatment with argon beam showed damaged mucosa and muscularis mucosa, and intact serosa, muscularis and submucosa layers. On the 8 argon beam postoperative biopsies the sigmoid submucosa was covered with a pseudostratified metaplasia of connective tissue with collagen fibers without scars (trichromic technique). CONCLUSIONS: Sigmoid cystoplasty without mucosa with argon beam is easy to perform. The clinical and urodynamic results have been satisfactory, and use of argon beam prevents postoperative bleeding and residual glands.

Single distal ureter for ureterocystoplasty: a safe first choice tissue for bladder augmentation.

PURPOSE: Recently, the use of ureter for bladder augmentation has gained wide acceptance due to a lower complication rate compared to gastrointestinal segments. Unfortunately, the presence of a severely dilated urinary tract implicates loss of function of a renal unit which is often not demonstrated at diagnosis. Conversely, many patients present with 1 or both ureters mildly dilated because of vesicoureteral reflux or functional obstruction. In these cases the use of a single distal ureter seems to be a good option. We report our experience and long-term followup with this subset of patients. MATERIALS AND METHODS: Between December 1994 and November 1998, 17 females and 5 males 1.5 to 15.7 years old (mean age 7.2) with a low capacity, poorly compliant bladder underwent ureterocystoplasty with a single distal dilated ureter. Diagnosis included myelomeningocele in 13 cases, central neurogenic bladder in 3, neurogenic nonneurogenic bladder in 2, congenital spinal cord injury in 2, sacral agenesis in 1 and giant sacral teratoma in 1. All but 2 patients complained of recurrent febrile urinary tract infections. Variable degrees of hydronephrosis were observed in all patients. Vesicoureteral reflux was detected in 14 patients and was bilateral in 3. Five patients presented with chronic renal failure. Before surgery 19 patients were on clean intermittent catheterization and prophylactic antibiotics. The segments of ureter used for augmentation ranged from 9 to 14 cm. long (mean 11) and from 0.8 to 2.5 cm. in diameter (mean 1.3). The more distal piece of the ureter was kept unopened to preserve vascular supply. Simultaneous procedures included transureteroureterostomy in all 22 patients, appendicovesicostomy in 10, bladder neck continence procedures in 4 and ureteroneocystostomy in 3. Clinical, radiological and urodynamic evaluation was done 6 months postoperatively and yearly thereafter. RESULTS: Followup ranged from 12 to 60 months (mean 22). Of the patients 19 are dry on clean intermittent catheterization at 4-hour intervals and 6 have had 9 symptomatic urinary tract infections. Hydronephrosis resolved in 14 patients, improved in 6 and remained unchanged in 2. On urodynamics median increase in capacity less than 30 cm. pressure was 177% (range 11% to 560%). When comparing capacity less than 30 cm. water to normal expected capacity for age and weight, 50% of the cases reached or exceeded theoretical capacity while the rest reached 63% to 89% (mean 76%). Long-term complications included persistent reflux in 1 case, deterioration of bladder function without clinical impairment in 1 and spontaneous perforation of the ureteral patch in 1 requiring colocystoplasty. CONCLUSIONS: Although increase in bladder capacity is not always optimal with the use of a distal dilated ureter, it is good enough to ensure a good clinical outcome and allow an adequate catheterization interval with a low complication rate in the long term, thus avoiding use of a piece of gut or stomach to perform bladder augmentation in nearly all patients.

Clinical and urodynamic evaluation after ureterocystoplasty with different amounts of tissue.

PURPOSE: Ureter is one of the best tissues for bladder augmentation. The amount of ureteral segment available is extremely variable among patients. We compared results in patients who underwent ureterocystoplasty with 2 ureters, 1 complete ureter or a distal segment only after transureteroureterostomy. MATERIALS AND METHODS: During a 6-year period we performed 32 ureterocystoplasties at 2 pediatric centers in Argentina (16) and Chile (16). Median patient age at surgery was 9 years (range 4 months to 20 years). Clinical presentation included urinary infection, hydronephrosis, incontinence and undiversion. The diagnosis was neurogenic bladder in 20 cases, infravesical obstruction in 7, massive reflux in 3 and ureterocele in 2. All patients had poor bladder compliance and vesicoureteral reflux. We used different options to augment the bladder, including 2 ureters in 5 patients, bilateral nephrectomy in 3, a complete duplex system in 1 and a bilateral partial ureter in 1 (group 1); a complete ureter in 14 (group 2), and a distal segment of ureter with transureteroureterostomy in 13 (group 3). When transureteroureterostomy was performed, a suprapubic tube remained indwelling for 2 weeks and a Double-J stent was placed for 1 month. Median followup was 16 months (range 4 months to 6 years). Clinical and radiological evaluations, including ultrasound, cystography, urodynamics, renal scan and renal function measurement, were done 4 months postoperatively and twice yearly thereafter as needed. RESULTS: We noted no significant difference in bladder capacity when 1 or 2 ureters were used. Median increase in bladder capacity in groups 1 and 2 was 375% (range 80 to 800). All patients who received a complete segment of ureter had clinical improvement, decreased hydronephrosis and resolution of reflux with improved bladder compliance. When a partial segment of ureter was used median capacity increased 230% (range 40 to 400) with clinical improvement in 12 patients (92.3%). Compliance improved, which led to longer intervals between clean intermittent catheterizations. No patient has needed repeat augmentation to date. CONCLUSIONS: There is a difference in median increased bladder capacity when a segment of distal ureter is used to augment the bladder versus 1 or 2 whole ureters. However, the use of distal ureter still represents a safe alternative for augmenting the bladder and simultaneously resolving massive reflux. Ureterocystoplasty is an excellent choice for increasing bladder capacity and improving bladder compliance despite the different amounts of tissue available.

Tratamiento de apendicitis aguda: evaluación prospectiva / Acute appendicitis treatment: prospective study

Antecedentes: la apendicitis aguda constituye una patología muy frecuente en la población pediátrica. El uso de drenaje y los esquemas antibióticos a utilizar constituyen modalidades modalidades de tratamiento sujetas a discusión. Objetivo: analizar los resultados de un protocolo terapéutico en apendicitis aguda complicada o no con peritonitis. Diseño: protocolo terapéutico prospectivo. Población: 324 pacientes consecutivos con diagnóstico presuntivo de apendicitis aguda operados durante el período comprendido entre enero de 1984 y enero de 1994. Métodos: diagnóstico clínico, laboratorio y exámenes complementarios. Esquema terapéutico antibiótico prequirúrgico: Penicilina, Aminoglucósido y Metronizadol. La hidratación por vía endovenosa, la corrección del medio interno y sonda nasogástrica de acuerdo a los requerimientos del paciente. Cirugía incisión de Mac Burney o Jalaguier y apendectomía según técnica convencional. Lavado peritoneal con solución salina tibia en los pacientes con peritonitis. Cierre de cavidad sin drenaje peritoneal. Tratamiento antibiótico postoperatorio: el mismo esquema con una duración variable en relación a si la apendicitis fuera complicada o no complicada con peritonitis. En las peritonitis se completó el tratamiento antibiótico por vía oral con sulfametaxazol-trimetoprina y metronidazol. El criterio de alta se basó en la evolución clínica favorable, ausencia de fiebre y tolerancia oral adecuada. Las piezas quirúrgicas se enviaron todas para estudio anatomopatológico. El control alejado de los pacientes se efectuó entre los 8 meses y 10 años de la cirugía. Resultados: Edad: dispersión 2-17 años. De los 301 pacientes con apendicitis aguda, 126 (41,8 por ciento) presentaron peritonitis, 83 (65,8 por ciento) de ellos fueron localizadas y 43 (34,1 por ciento) generalizadas. La media de los días de internación para los pacientes con apéndice normal fue de 36 horas y para aquellos con apendicitis no complicada de 2,5 días. Para las peritonitis localizadas se observó una media de 5 y en peritonitis generalizadas la media fue de 7,5 días. El 3,1 por ciento de los pacientes presentaron alguna complicación indeciosa menor (absceso de herida, secreción serosa en herida) sólo hubo un paciente (0,3 por ciento) que cursó con un abcdos del Dolugla...

Tratamiento de apendicitis aguda: evaluación prospectiva / Acute appendicitis treatment: prospective study

Antecedentes: la apendicitis aguda constituye una patología muy frecuente en la población pediátrica. El uso de drenaje y los esquemas antibióticos a utilizar constituyen modalidades modalidades de tratamiento sujetas a discusión. Objetivo: analizar los resultados de un protocolo terapéutico en apendicitis aguda complicada o no con peritonitis. Diseño: protocolo terapéutico prospectivo. Población: 324 pacientes consecutivos con diagnóstico presuntivo de apendicitis aguda operados durante el período comprendido entre enero de 1984 y enero de 1994. Métodos: diagnóstico clínico, laboratorio y exámenes complementarios. Esquema terapéutico antibiótico prequirúrgico: Penicilina, Aminoglucósido y Metronizadol. La hidratación por vía endovenosa, la corrección del medio interno y sonda nasogástrica de acuerdo a los requerimientos del paciente. Cirugía incisión de Mac Burney o Jalaguier y apendectomía según técnica convencional. Lavado peritoneal con solución salina tibia en los pacientes con peritonitis. Cierre de cavidad sin drenaje peritoneal. Tratamiento antibiótico postoperatorio: el mismo esquema con una duración variable en relación a si la apendicitis fuera complicada o no complicada con peritonitis. En las peritonitis se completó el tratamiento antibiótico por vía oral con sulfametaxazol-trimetoprina y metronidazol. El criterio de alta se basó en la evolución clínica favorable, ausencia de fiebre y tolerancia oral adecuada. Las piezas quirúrgicas se enviaron todas para estudio anatomopatológico. El control alejado de los pacientes se efectuó entre los 8 meses y 10 años de la cirugía. Resultados: Edad: dispersión 2-17 años. De los 301 pacientes con apendicitis aguda, 126 (41,8 por ciento) presentaron peritonitis, 83 (65,8 por ciento) de ellos fueron localizadas y 43 (34,1 por ciento) generalizadas. La media de los días de internación para los pacientes con apéndice normal fue de 36 horas y para aquellos con apendicitis no complicada de 2,5 días. Para las peritonitis localizadas se observó una media de 5 y en peritonitis generalizadas la media fue de 7,5 días. El 3,1 por ciento de los pacientes presentaron alguna complicación indeciosa menor (absceso de herida, secreción serosa en herida) sólo hubo un paciente (0,3 por ciento) que cursó con un abcdos del Dolugla...(AU)

New application of the gastrostomy button for clinical and urodynamic evaluation before vesicostomy closure.

PURPOSE: We report use of the Bard gastrostomy button to occlude vesicostomy and provide access for intermittent catheterization before closure in children with vesicostomy. Evaluation of bladder function in such children usually relies on radiographic and urodynamic studies, which may fail to predict bladder compliance, emptying and continence after closure. MATERIALS AND METHODS: Buttons were placed before vesicostomy closure in 1 boy with the prune-belly syndrome and 2 girls with cloacal anomalies 2.5 to 10 years old. The patients had undergone vesicostomy using the Blocksom technique soon after birth because of urinary infection, and impairment of bladder emptying and renal function. RESULTS: With the button in place bladder emptying, compliance, continence and possible upper tract changes could be evaluated during several weeks. Button coaptation to the vesicostomy was complete with no urine leakage around the device, allowing easy intermittent drainage through its channel. After 4 weeks the buttons did not have any encrustation or lithiasis and patients were free of urinary infection. Vesicostomy was closed in each patient and the period of temporary closure provided by the button was predictive of future bladder behavior. CONCLUSIONS: This new and original application of the gastrostomy button as a temporary vesicostomy closure may be useful to predict the clinical and urodynamic responses of a defunctionalized bladder in patients with vesicostomy who are candidates for urinary undiversion.