Catheterizable serous lined urinary outlet in children and adolescents: a choice when other treatments fail.

PURPOSE: We evaluated the functional outcome of continent catheterizable outlet using the serous lined extramural tunnel technique as a continence mechanism in children and adolescents. MATERIALS AND METHODS: We retrospectively studied all patients who underwent continent catheterizable stoma using the serous lined extramural technique between May 1993 and March 2008. Patient records were reviewed for age, sex, indication for surgery, surgical details and postoperative course. All patients were evaluated for continence with emphasis on frequency of clean intermittent catheterization. Urodynamic evaluation was done for patients with leaking stoma. Stoma related complications were also recorded. RESULTS: A total of 37 boys and 23 girls 3 to 18 years old underwent continent catheterizable stoma using the serous lined extramural technique. Total bladder substitution was performed in 13 patients using continent ileal W-shaped reservoir, and 47 patients underwent augmentation ileocystoplasty mounted with serous lined outlet. The outlet channel was appendix in 39 patients (65%), tapered ileal segment in 13 (21.5%) and Monti ileal tube in 8 (13.5%). After a median followup of 43 months (range 10 to 180) 55 patients (91.6%) achieved continence, with catheterization frequency of 3 to 5 times during the daytime and 1 to 2 times at night. Stoma related complications were leaking stoma in 5 patients (8.4%), stomal stenosis in 6 (10%), parastomal hernia in 2 (3.3%) and reservoir stones in 8 (13.3%). Reoperation rate was 18.3% (11 patients). CONCLUSIONS: The serous lined continent outlet seems to be a durable and efficient technique for treating children with incontinence, with an acceptable complication rate.

Safety and efficacy of supracostal percutaneous nephrolithotomy in pediatric patients.

PURPOSE: This study was conducted to evaluate the safety and efficacy of the supracostal approach for percutaneous nephrolithotomy in pediatric patients. MATERIALS AND METHODS: We retrospectively reviewed 60 percutaneous nephrolithotomy procedures done in 50 children (32 boys and 18 girls) between 2000 and 2007. Mean patient age was 7 +/- 4 years (range 9 months to 14 years). Noncontrast computerized tomography was the primary radiological investigation for most of the cases. The subcostal approach was used in 40 procedures, and the supracostal approach (above the 12th rib) was required in 20. We compared both approaches regarding preoperative characteristics, stone-free and complication rates, and the need for auxiliary procedures. RESULTS: The preoperative characteristics of the patients, urinary tracts and stones were comparable for both treatment groups. There were no major complications. Significant bleeding requiring blood transfusion was observed in 3 patients (5%), transient fever in 3 (5%) and urinary leakage through the nephrostomy site in 3 (5%). The distribution of complications among subcostal and supracostal approaches was comparable. Of the 60 renal units 46 (77%) were stone-free after percutaneous nephrolithotomy at discharge from the hospital. Of the remaining 14 units 9 (15%) were stone-free after shock wave lithotripsy and 5 (8%) had insignificant residual stones. Therefore, the overall stone-free rate at 3 months was 92.5%. Comparing the subcostal and supracostal approaches, there were no significant differences between hospital stays, complication rates, unplanned auxiliary procedures, and stone-free rates at discharge home and at 3-month followup. CONCLUSIONS: Percutaneous nephrolithotomy for treating renal stones in children provides a high degree of safety and efficacy whether a supracostal or subcostal approach is used.

Postnatal unilateral pelviureteral junction obstruction: impact of pyeloplasty and conservative management on renal function.

OBJECTIVES: To study the effect of pyeloplasty and conservative management on renal function in children with pelviureteral junction obstruction. METHODS: This prospective study included 65 children postnatally diagnosed with unilateral pelviureteral junction obstruction. On the basis of the patients' symptoms and technetium-99m diethylenetriamine pentaacetic acid renal isotope scan findings, symptomatic patients or those with split function of the corresponding kidney of 40% or less were assigned to group 1 (n = 35) and underwent pyeloplasty. Asymptomatic patients with split function greater than 40% (group 2, n = 30) were treated conservatively. Patients who showed deterioration of renal function underwent pyeloplasty. The effect of both lines of treatment on renal function was evaluated. RESULTS: After pyeloplasty, group 1 had improvement in the glomerular filtration rate (GFR) in 30 (85.7%), stabilization in 2 (5.7%), and deterioration in 3 (8.6%) patients. In group 1, the comparison between the mean value of the baseline GFR (17.1 +/- 7.7 mL/min) and its mean value at follow-up (28 +/- 6.3 mL/min) showed an increase of statistical significance (P <0.01). In the group 2 patients, conservative treatment resulted in improvement in the GFR in 12 (40%), stabilization in 3 (10%), and deterioration in 15 (50%) patients. In group 2, no significant difference was found between the mean baseline GFR (29.8 +/- 9.8 mL/min) and its mean value at follow-up (31.2 +/- 5.6 mL/min). CONCLUSIONS: In patients with postnatal pelviureteral junction obstruction, early pyeloplasty is recommended if the corresponding GFR is 40% or less. Conservative management in patients with better function resulted in deterioration of renal function in 50%. Should this policy of treatment be chosen, meticulous follow-up is mandatory.