Tratamiento de las infecciones urinarias en pediatrían con extracto de arándano rojo americano / Treatment of pediatric urinary infections with North American red cranberry concentrated extract

Introducción: En la búsqueda de alternativas a la quimioprofilaxis antibiótica en la prevención de las infecciones urinarias (ITU) en el niño, hemos comenzado a utilizar un extracto de arándano rojo americano con 118 mg de proantocianidinas. Éstas inhiben la adherencia a la pared de la vía urinaria de Escherichia coli fimbriada tipo P. Objetivos: Observar la eficacia y la tolerancia de un extracto de arándanos en niños con ITU frecuentes. Material y métodos: Se seleccionan grupos de pacientes con ITU recidivantes frecuentes sin patología orgánica malformativa ni vejiga neuropática, litiasis o insuficiencia renal. El estudio observacional se efectuó durante 1 año en 62 niños de 5-17años de edad. Resultados: Se obtuvo un 100% de prevención de la pielonefritis aguda y un 92% de ausencia de infecciones sintomáticas. Conclusiones: Hemos observado una gran eficacia del producto, ausencia de efectos adversos y una muy buena aceptación por parte de los padres y los pacientes para realizar un tratamiento prolongado, así como una baja tasa de abandonos. Será necesario realizar estudios prospectivos, doble ciego, aleatorizados y controlados con placebo para poder establecer recomendaciones con un alto grado de evidencia (AU)

Introduction: In our search for alternatives to antibiotic chemoprophylaxis to prevent pediatric urinary infections, we have started to use a concentrated extract of North American red cranberries containing 118 mg of proanthocyanidins, the before mentioned inhibit the adherence of P-fimbriated Escherichia coli to the urinary tract wall. Objectives: To observe the effectiveness and tolerance of a concentrated extract of cranberries in children with frequent urinary tract infections. Material and methods: We selected groups of patients with frequently recurrent urinary infections, with no malformative systemic pathologies and either neuropathic bladder, lithiasis or renal failure. The observational study was conducted over one year in 62 children from 5 to 17 years old. Results: The results were quite satisfactory: 100% prevention of acute pyelonephritis, and 92% absence of symptomatic infections. Conclusions: We have been able to confirm the high effectiveness of the product, the absence of adverse effects, an excellent acceptance by the parents and patients regarding along-term treatment, and a very low rate of dropouts. Prospective double-blind randomized and placebo-controlled trials will be required in order to issue recommendations supported by a high degree of evidence (AU)

[Adenocarcinoma in a ileal conduit after cystectomy for bladder exstrophy]. / Adenocarcinoma en conducto ileal después de cistectomía por extrofia vesical.

Exstrophy of the urinary bladder is an uncommon congenital anormaly for wich cystectomy was recommended because of a high risk of developing carcinoma. We report a patient treated by cystectomy and ileal loop diversion, who, 34 years later, developed carcinoma of the ileal loop. It is the third report of a tumor developing in a ileal conduit constructed after cystectomy for bladder exstrophy.

Adenocarcinoma en conducto ileal después de cistectomía por extrofia vesical / Adenocarcinoma in a ileal conduit after cystectomy for bladder exstrophy

La extrofia vesical es una patología congénita poco frecuente. Hace años se recomendó la realización decistectomía profiláctica por el riesgo de desarrollar carcinoma en la vejiga extrófica. Presentamos un caso de extrofia vesical tratado con cistectomía y conducto ileal, desarrollando 34 años después, un adenocarcinoma tipo intestinal en el asa del conducto ileal. Éste es el tercer caso de tumor descrito en un conducto ileal construido después de la cistectomía por extrofia vesical (AU)

Exstrophy of the urinary bladder is an uncommon congenital anormaly for wich cystectomy was recommended because of a high risk of developing carcinoma. We report a patient treated by cystectomy and ileal loop diversion, who, 34 years later, developed carcinoma of the ileal loop. It is the third report of a tumor developing in a ileal conduit constructed after cystectomy for bladder exstrophy (AU)

[Retroperitoneal ganglioneuroma in the infancy]. / Ganglioneuroma retroperitoneal en la infancia.

Specific management guides for suprarenal incidentalomas detected after birth do not exist for children, but due to the high proportion of malignant tumors, surgical resection is recommended. We present the case of a 7-year-old patient with a non-functioning left suprarenal incidentaloma. Surgical resection and subsequent anatomopathologic analysis of the mass confirmed the diagnosis of ganglioneuroma in process of maturation. Most ganglioneuromas are incidental and have a good prognosis due to their benign behaviour, even though malignant transformation has also been described, for which reason postoperative controls to detect local recurrence and occurrence of new foci are recommended.

Ganglioneuroma retroperitoneal en la infancia / Retroperitoneal ganglioneuroma in the infancy

En la infancia, no existen guías específicas para el manejo de los incidentalomas suprarrenales detectados postnatalmente, pero dada la alta proporción de tumores malignos se recomienda su resección quirúrgica. Presentamos el caso de una paciente de 7 años diagnosticada de un incidentaloma suprarrenal izquierdo no funcionante. La exéresis quirúrgica de dicha masa y el posterior estudio histopatológico confirmaron el diagnóstico de ganglioneuroma en proceso de maduración. La mayoría de ganglioneuromas son incidentales y presentan un buen pronóstico dado su comportamiento benigno, aunque está descrita la transformación maligna, recomendándose realizar controles postoperatorios para detectar las recidivas locales y la aparición de nuevos focos (AU)

Specific management guides for suprarenal incidentalomas detected after birth do not exist for children, but due to the high proportion of malignant tumors, surgical resection is recommended. We present the case of a 7-yearoldpatient with a non-functioning left suprarenal incidentaloma. Surgical resection and subsequent anatomopathologic analysis of the mass confirmed the diagnosis of ganglioneuroma in process of maturation. Most ganglioneuromas are incidental and have a good prognosis due to their benign behaviour, even though malignant transformation has also been described, for which reason postoperative controls to detect local recurrence and occurrence of new foci are recommended (AU)

Guía para el diagnóstico y tratamiento de la enuresis nocturna monosintomática en Atención Primaria / Guide for the diagnosis and treatment of monosymptomatic nighttime enuresis in Primary Health Care

La enuresis nocturna monosintomática es una entidad nosológica benigna, muy frecuente en la infancia, que puede favorecer la aparición de importantes problemas psicológicos y de autoestima a medida que se va incrementando la edad de los niños que no corrigen su problema. En la presente Guía se repasan los criterios diagnósticos, los exámenes complementarios que se recomiendan inicialmente y los tratamientos disponibles en la actualidad. Al tratarse de un proceso benigno, el tratamiento de la enuresis debe realizarse con medios terapéuticos eficaces y con una baja tasa de efectos secundarios potenciales. Se recomienda iniciar el tratamiento con desmopresina o con alarmas sonoras. La ausencia de eficacia de uno de los dos remedios o de ambos debe ser criterio de remisión de los jóvenes pacientes a un centro especializado (AU)

The Monosyptomatic nocturnal enuresis is a benign entity very frequent in childhood that can trigger the appearance of important psychological problems and of selfesteem, especially, when the children do not correct this problem grow older. In the present paper we review the diagnostic criteria, the complementary exams initially recommended and the current available treatments. Being a benign process, the nocturnal enuresis treatment should be carried out with effective therapeutic means and with a low rate of potentials secondary effects. The treatment should begin with desmopressin or with sound alarms. The lack of effectiveness of either or both remedies should be a criterion for remission of the patient to a specialized Center (AU)

[Treatment of bladder instability (non-neurogenic hyperactive bladder) in children, with tolterodine]. / Tratamiento de la inestabilidad vesical (vejiga hiperactiva no neurógena) en niños, con Tolterodina.

INTRODUCTION: Overactive bladder (OB) is one of the no-neurogenic voiding dysfunctions whose prevalence has been precisely defined among the general population but not so among the paediatric population. Its clinical manifestations are various, and its association with other pathologies like enuresis, vesico-ureteral reflux (VUR) and recurrent infections is particularly significant in children. OB is basically managed with anticholinergic drugs. The efficacy of oxybutynin chloride has been sufficiently proved; however its dosage and side effects, although scarce in children, usually cause treatment discontinuation. OBJECTIVES: Tolterodine has been successfully used as an alternative therapy of OB in adults, however its use has not been sufficiently evaluated in children. Our objective is to determine tolterodine's efficacy and tolerability in the paediatric population suffering from OB. MATERIAL AND METHODS: A retrospective study of 72 children who were diagnosed no-neurogenic OB and who received no previous treatment. A concomitant urological pathology diagnostic protocol was applied to all cases, as well as a urodynamic test (UDT) and a neurological examination. Post-treatment UDT was performed to one group of patients. RESULTS: The mean age was 10.9 years and the children were assessed between 4 and 31 months after treatment initiation. Healing was proved through cistomanometry in 67% of the cases, there was improvement in 14% and 19% of the patients showed no changes in the UDT. Following the criteria of the International Children's Continence Society (ICCS) applied to those children with no post-treatment UDT, 51% were healed, 27% improved and 22% experienced no changes. None of the patients had to discontinue the treatment due to side effects. CONCLUSIONS: Tolterodine's tolerability and efficacy are good within the paediatric population, which turns it into an alternative to the traditional anticholinergics for the treatment of OB.

Presente y futuro de la urología pediátrica / Present and future of pediatric urology

No disponible

Anomalías renales congénitas en neonatos con reflujo vesicoureteral fetal. Detección con gammagrafía renal-99mTc-DMSA / Congenital renal abnormalities in neonates with fetal vesicoureteral reflux. Detection by 99M-technetiumM-Dimercaptosuccinic acid renal scintigraphy

Antecedentes: El reflujo vesicoureteral (RVU) "fetal" se caracteriza por una preponderancia masculina, reflujo de alto grado y anomalías parenquimatosas renales, estableciéndose una asociación entre RVU estéril y lesión renal. Objetivos Determinar, mediante gammagrafía renal con 99m tecnecio ácido dimercapto-succínico (99mTc-DMSA), la incidencia de anomalías renales congénitas en lactantes con RVU detectado posnatalmente por hidronefrosis prenatal o por cribado familiar, y especular sobre los mecanismos de acción de estas lesiones. Métodos: Se han revisado retrospectivamente las gammagrafías renales de lactantes con RVU y sin antecedentes de infección del tracto urinario (ITU), considerando anomalías renales: captación diferencial menor o igual al 40 por ciento o presencia de defectos corticales. Los hallazgos gammagráficos se han correlacionado con los de la ecografía posnatal. Resultados: Dieciocho pacientes cumplieron los criterios de inclusión; 15 niños y 3 niñas con RVU grado V, IV, III y II en 5, 10, 6 y 6 de las 36 unidades renales. La gammagrafía mostró alteraciones parenquimatosas en el 50 por ciento (9/18) de los pacientes y el 33 por ciento (9/27) de las unidades renales refluyentes; la mayoría fueron niños (7 niños, 2 niñas) con RVU de GV o GIV (6/9; 66 por ciento). La sensibilidad de la ecografía posnatal para detectar signos de lesión renal fue baja (22 por ciento). Conclusiones: Lactantes con RVU estéril, especialmente varones con RVU de alto grado, pueden presentar ya al nacimiento anomalías parenquimatosas renales, lo cual sugiere una etiopatogenia congénita de lesión renal independiente de la ITU. Estos defectos identificados por gammagrafía con frecuencia no son detectados en la ecografía posnatal. Por ambos motivos recomendamos la gammagrafía renal DMSA en la evaluación inicial de lactantes con RVU fetal (AU)

[Role of direct radionuclide cystography and renal study by dimercaptosuccinic acid (DMSA) in the diagnosis and follow-up of vesicoureteral reflux]. / La cistografía isotópica directa y la gammagrafía renal con ácido dimercaptosuccínico (DMSA) en el diagnóstico y seguimiento del reflujo vesicoureteral.

AIM: To evaluate the role of isotopic studies in the diagnosis and follow-up of vesicoureteral reflux (VUR) and to present the results of our current protocol. MATERIAL AND METHODS: Forty three patients with VUR were retrospectively studied with a mean follow-up of 43 years (1-11 years). VUR was diagnosed by voiding cystourethrography and followed-up by direct radionuclide cystography. During the follow-up all patients were studied by means of renal DMSA scintigraphy (21 were also studied during the acute phase of febrile urinary tract infection). RESULTS: Eighty three renal units were examined. Voiding cystourethrography was positive for VUR in 49 renal units (59%; 8 grade I, 18 grade II, 15 grade III, and 8 grade IV). During the follow-up, direct radionuclide cystography showed decrease or disappearance of VUR in 29 renal units (35%; 4 grade I, 16 grade II, 7 grade III, and 2 grade IV). DMSA studies performed during the follow-up showed cortical lesions in 17 renal units (5 with VUR grade II, 7 with grade III, and 5 grade IV). Nine of 21 patients examined by DMSA during the acute phase of febrile urinary tract infection showed cortical damage (43%), and 6 of them (67%) progressed to cortical lesion in the follow-up DMSA. CONCLUSIONS: The present protocol allows for the correct diagnosis and control of VUR, the early detection of acute renal damage, and the control of its evolution.

La cistografía isotópica directa y la gammagrafía renal con ácido dimercaptosuccínico (DMSA) en el diagnóstico y seguimiento del reflujo vesicoureteral / Role of direct radionuclide cystography and renal study by dimercaptosuccinic acid (DMSA) in the diagnosis and follow-up of vesicoureteral reflux

Objetivo: Valorar la utilidad de la cistografía isotópica directa (CID) y de la gammagrafía renal con ácido dimercaptosuccínico (DMSA) en el diagnóstico y seguimiento del RVU, según los resultados obtenidos a partir del protocolo actual de nuestro centro. Material y Métodos: Se han estudiado retrospectivamente 43 pacientes diagnosticados de RVU con un período de seguimiento medio de 4 ñ 3 años (1-11 años). El diagnóstico de RVU se realizó mediante cistografía radiológica (CUMS) y el seguimiento mediante CUMS y/o CID. Durante el seguimiento se realizó gammagrafía renal con DMSA a todos los pacientes. Veintiún pacientes también fueron estudiados con DMSA durante la fase aguda de la infección urinaria febril. Resultados: Se exploraron 83 unidades renales. En el momento del diagnóstico la CUMS fue positiva para RVU en 49 unidades renales (59 per cent; 8 grado I, 18 grado II, 15 grado III y 8 grado IV). Durante el seguimiento por CID se observó disminución o desaparición del RVU en 29 unidades renales (35 per cent; 4 grado I, 16 grado II, 7 grado III y 2 grado IV). Durante el seguimiento el DMSA mostró lesiones corticales en 17 unidades renales (5 con RVU grado II, 7 grado III y 5 grado IV). Nueve de los 21 pacientes estudiados con DMSA durante la fase aguda de la infección urinaria febril presentaron afectación cortical (43 per cent), de los cuales 6 evolucionaron a lesión cortical en el DMSA de control (67 per cent). Conclusiones: El protocolo descrito permite diagnosticar y controlar el RVU, identificar precozmente la afectación renal y controlar su evolución (AU)

[The use of desmopressin as an alternative in the treatment of nycturia in patients with benign prostatic hyperplasia (BPH)]. / Uso de la desmopresina como alternativa en el tratamiento de la nicturia en pacientes con hiperplasia prostática benigna (HPB).

OBJECTIVE: Evaluating in patients with benign prostatic hyperplasia (BPH), the effects of a synthetic analog of vasopressin (Desmopressin) in the nycturia. METHODS: 20 patients with BPH, with a mean age of 68 years that they referred marked nycturia of 4 to 10 voiding episodes in the night, they were subject treatment with Desmopressin 20 mcg given intranasally before bedtime. RESULTS: The nycturia diminishes in the patient, the volume of evacuated urine diminishes but in the night that in the day. They were not observed side effects. CONCLUSIONS: The desmopressin is an alternative but in the aid to the patient with BPH that they presented a marked nycturia.

[Vesico-ureteral reflux associated with detrusor instability]. / Reflujo vesicoureteral asociado a inestabilidad del detrusor.

OBJECTIVE: The aim of this study was to determine the urodynamic characteristics of patients with vesico-ureteral reflux (VUR) and detrusor instability (DI) followed by medical treatment. PATIENTS AND METHODS: The urodynamic and cystographic findings in a group of 24 patients between 4 and 18 years of age (mean 7.6 years) with a simultaneous diagnosis of VUR and DI were reviewed. All of them presented with recurrent urinary tract infections. Twenty were female of whom eight also had enuresis and daytime symptoms. Mean follow-up was 40 months (range 18-97 months). VUR was diagnosed by voiding cystourethrogram and classified according to the grades proposed by the "International reflux study on children". RESULTS: All but 6 patients had at least a 15% reduction in age-adjusted capacity. No relationship was observed between the severity of VUR (measured as the addition of reflux grades in both units of each patient) and reduction in bladder capacity or compliance. Seven patients had upper tract damage (either scars or a decrease in size or function on the renogram). Upper tract damage was significantly more frequent in patients with bilateral reflux (regardless of the type of DI). Patients with unilateral reflux and sustained instability had significantly less upper tract damage. Results of treatment are reported separately. CONCLUSIONS: In these patients, the severity of VUR did not seem to have an impact on bladder capacity or compliance. The risk factors for upper tract damage in this series differ from those found by other authors.

[Efficacy of oxybutynin chloride in children with vesico-ureteral reflux and detrusor instability]. / Eficacia del cloruro de oxibutinina en niños con inestabilidad del detrusor y reflujo vesicoureteral.

OBJECTIVE: The purpose of this study was to assess the urodynamic (UD), radiological (VCUG) and clinical outcome in patients with detrusor instability (DI) and vesico-ureteral reflux (VUR). PATIENTS AND METHODS: UD and VCUG findings in 24 patients between 4 and 18 years of age (mean 7.6 years) with a simultaneous diagnosis of VUR and DI were reviewed. All presented with recurrent urinary tract infections (UTI). Twenty were female of whom 8 also had enuresis and daytime symptoms. Ten had bilateral VUR, making a total of 34 units. Mean follow-up was 40 months (range 18-97 months) and at least 2 UD studies were done. Treatment consisted of oxybutinin chloride (OC) and chemoprophylaxis. RESULTS: Treatment lasted an average of 31 months with an average dose of 11 mg/day. There was a statistically significant improvement in UTI rate, enuresis score and UD parameters [CysCap, volume at 1st contraction, maximum contraction and compliance (comp)]. Thirteen patients achieved stable bladders and 9 had some UD improvement (3 with low compliance and 2 with less severe DI), leaving 2 with unchanged DI. Reflux disappeared in 20 units and was downgraded in 6. VUR improvement coincided with the cases of UD improvement. Persistence of DI was always associated with persistent VUR. CONCLUSIONS: Oxybutinin treatment can be long, but UD and VUR improvement run parallel in most cases. The rare discrepant cases point towards a multifactorial ethology in this condition.

[Scintigraphic diagnosis of crossed renal ectopia]. / Diagnóstico gammagráfico de la ectopía renal cruzada.

OBJECTIVES: Crossed renal ectopia is an uncommon congenital anomaly with little or no clinical repercussion. An empty renal fossa is not an infrequent ultrasound finding and an anomalous contralateral ectopic kidney can be seen occasionally. METHODS/RESULTS: We report on three clinical cases with an empty renal fossa detected by ultrasound. Scintiscanning with 99mTc DMSA permitted precise diagnosis of the existing malformation. CONCLUSIONS: 99mTc DMSA permits precise diagnosis of the empty renal fossa, type of malformation, functional status of the ectopic kidney and the status of its parenchyma.