Glanular Venous Malformation in Pediatric Age: An Uncommon Vascular Disorder.

Glanular venous malformations are uncommon in pediatric patients. The diagnosis can be easily achieved by observation, even if color Doppler ultrasound is useful for a better characterization. Abdomino-pelvic MRI is necessary to assess the extension of complex lesions and check for associated anomalies. Several therapeutic options are reported in literature. We report 3 paediatric cases successfully treated by surgery with no complications and functional sequelae. Cosmetic results were satisfactory, with minimal surgical scarring. In our opinion, surgery for small glanular venous malformations is indicated within puberty to prevent traumatic bleeding and psychological impact.

Whole-Exome Sequencing in the Isolated Populations of Cilento from South Italy.

The present study describes the genetic architecture of the isolated populations of Cilento, through the analysis of exome sequence data of 245 representative individuals of these populations. By annotating the exome variants and cataloguing them according to their frequency and functional effects, we identified 347,684 variants, 67.4% of which are rare and low frequency variants, and 1% of them (corresponding to 319 variants per person) are classified as high functional impact variants; also, 39,946 (11.5% of the total) are novel variants, for which we determined a significant enrichment for deleterious effects. By comparing the allele frequencies in Cilento with those from the Tuscan population from the 1000 Genomes Project Phase 3, we highlighted an increase in allele frequency in Cilento especially for variants which map to genes involved in extracellular matrix formation and organization. Furthermore, among the variants showing increased frequency we identified several known rare disease-causing variants. By different population genetics analyses, we corroborated the status of the Cilento populations as genetic isolates. Finally, we showed that exome data of Cilento represents a useful local reference panel capable of improving the accuracy of genetic imputation, thus adding power to genetic studies of human traits in these populations.

What are the predictive factors leading to ureteral obstruction following endoscopic correction of VUR in the pediatric population?

BACKGROUND: It is extremely important to not only address the short-term success following endoscopic correction of vesicoureteral reflux (VUR) but also the long-term efficacy and safety of the tissue augmenting substance utilized for endoscopic correction. OBJECTIVE: This study retrospectively evaluated all cases of ureterovesical junction (UVJ) obstruction following endoscopic treatment of VUR over the last 5 years utilizing two tissue augmenting substances, with special emphasis on the safety of Vantris®, and performed clinical and histological review of these patients. METHODS: The study population comprised 2495 patients who underwent endoscopic correction of VUR utilizing Deflux® (1790) and Vantris® (705). Tissue sections were stained with hematoxylin & eosin and trichrome, and examined under a light microscope. Nine primary obstructive megaureters after ureteral re-implantation served as controls. RESULTS: Nine (0.5%) children (three female and six male) in the Deflux group and nine (1.3%) (five females and four males) in the Vantris group developed UVJ obstruction and required ureteral re-implantation. Obstruction developed during the period ranging 2-49 months (average 16 months) following endoscopic correction. The primary reflux grade was III in seven, IV in six, and V in six children. The mean volume of the injected material in all obstructed patients was 1.2 ± 0.6 cc (mean ± SD). Histopathological analysis revealed a pseudocapsule composed of fibrous tissue and foreign-body giant cells surrounding the Vantris implant in all patients. The distal part of the ureters demonstrated significant ureteral dilatation without ureteral fibrosis. In all patients, additional biopsies from the muscularis propria adjacent to the injection site were examined and showed no significant abnormalities. There was an increased collagen deposition in the juxtavesical segment of the obstructive ureters following Deflux and Vantris injections, and of primary obstructive megaureter. No significant difference was found in the tissue response between Deflux and Vantris patients and controls. Statistical analysis of the nonhomogeneous population demonstrated higher obstruction rates in patients from the Vantris group. However, no statistical difference was demonstrated regarding the obstruction rate in the homogenous group with relation to gender, age and reflux grade group of patients. Moreover, univariate analysis revealed that Grade V reflux, the presence of beak sign on the reviewed pretreatment, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction. DISCUSSION: This study suggested that the underlining ureteral pathology lead to UVJ obstruction following Vantris injection. There was increased collagen deposition in the juxtavesical segment of the obstructive ureters following Vantris injection. Furthermore, these findings were similar to those discovered in patients who underwent endoscopic correction with Deflux, and in patients who required ureteral reimplantation due to primary obstructive megaureter. Additional biopsies from the muscularis propria adjacent to the injection site showed no significant abnormalities, ironing out the fact that Vantris did not led to adverse tissue reaction following injection. Univariate analysis further ironed out the hypothesis that underlying ureteral pathology was responsible for the increased incidence of UVJ obstruction and demonstrated that Grade V reflux, the presence of beak sign on the reviewed pretreatment VCUG, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction. CONCLUSION: Data showed that Vantris injection did not lead to any different ureteral fibrosis or inflammatory changes to the tissue augmenting substances utilized in past and present clinical practice, and therefore did not seem to increase the incidence of UVJ obstruction. High reflux grade, presence of obstructive/refluxing megaureter and inflamed bladder mucosa were the only statistically significant and independent predictive factors for UVJ obstruction following endoscopic correction of VUR.

Comparison of Native Ureteral Ligation and Open Nephrectomy for Pediatric Renal Transplantation.

PURPOSE: In pediatric renal transplant recipients there are some indications for native nephrectomy, which can be performed before, during or after transplantation. Indications include massive proteinuria resistant to therapy, intractable hypertension, polyuria and chronic or recurrent kidney infections. Several scientific studies of adults have demonstrated a minimally invasive alternative to native nephrectomy, which consists of ligation of the native ureter without removing the kidney. We evaluated the safety and efficacy of this minimally invasive technique in pediatric recipients of renal transplantation. MATERIALS AND METHODS: A total of 29 pediatric kidney transplant recipients underwent unilateral native ureteral ligation during renal transplantation between 2009 and 2013 (group A). In addition, a control group of 21 pediatric renal transplant recipients was enrolled who had undergone unilateral native nephrectomy between January 2005 and December 2008 (group B). Both groups were evaluated preoperatively by Doppler ultrasound of the native kidneys. RESULTS: Statistical analysis of the 2 groups for the 3 main variables considered (surgical time, intraoperative blood loss and length of surgical scar) revealed a significant difference (Mann-Whitney U test, p <0.001). This finding confirmed the hypothesis that during renal transplantation ligation of the native ureter is less invasive than native nephrectomy. CONCLUSIONS: Ligation of the native ureter without removal of the ipsilateral kidney is a feasible procedure in pediatric renal transplant recipients. This method is easy to perform and significantly less invasive than surgical nephrectomy.

Urological complications following kidney transplantation in pediatric age: A single-center experience.

Surgical complications during kidney transplantation can seriously affect renal outcomes. We assess occurrence, risk factors, and results of all urological complications in a series of renal transplants in a single center. Children who underwent renal transplant between January 2008 and December 2014 were retrospectively evaluated. Postoperative urological complications were reviewed. Demographic details, cause of ESRD, donor type, and surgical procedures at transplant were analyzed. For statistical analysis, the chi-square test or Fisher's exact test were used as appropriate. One hundred and twenty-one kidney transplants were performed in 117 children (median age 12 yr). Sixty-two of 121 (53%) had an underlying urological malformation. At a median follow-up of three yr, 28 urological complications were recorded (23%): 12 lymphocele (10%), 10 ureteral obstruction (8%), three urinary leakage (2.5%), two symptomatic VUR (1.7%), and one hydropyonephrosis. When lymphocele was excluded, the complication incidence rate dropped to 13%. Ureteral obstruction mostly occurred late after transplant (more than six months). Presence of urological malformation was the only factor related to increased occurrence of urological complication (p = 0.007) and, in particular, ureteral obstruction (p = 0.018). Children with urological malformations presented a statistically significant risk of developing urological complications after kidney transplantation, ureteral obstruction being the most common complication.

Hypothesis on etiopathogenesis, congenital or acquired, of an imperforate distal ureter: a case report.

INTRODUCTION: Ureteral atresia is a rare disease usually associated with a non-functioning kidney. Its association with other urinary anomalies is rare. CASE PRESENTATION: In this study we discuss the possibility of congenital or acquired etiology of a right imperforate distal ureter. Here we report the case of 11-month-old white boy with a right ureteropelvic junction obstruction. He underwent a right pyeloplasty when he was 11-months old, and 3 weeks after surgery a cystoscopy was performed. Two months after the first operation, he underwent a right ureteral meatoplasty and a new pyeloplasty. CONCLUSIONS: To the best of our knowledge, few cases of imperforate distal ureter have been described in the literature. The suspicion of a non-patent terminal ureter, occurring during upper urinary tract surgery, must be intraoperatively clarified to preserve the renal function and to avoid more complex surgical approaches.

Bladder urothelial neoplasms in pediatric age: experience at three tertiary centers.

INTRODUCTION: Urothelial bladder neoplasms (UBN) typically occur in patients in their sixth or seventh decade of life while they are infrequent in children and young adults. They occur in 0.1-0.4% of the population in the first two decades of life. Their management is controversial and paediatric guidelines are currently unavailable. OBJECTIVE: To further expound the available data on the outcome of patients younger than 18 year old diagnosed with UBN. STUDY DESIGN: We retrospectively reviewed the files of all the consecutive paediatric patients with UBN treated in three tertiary paediatric urology units from January 1999 to July 2013. Lesions were classified according to the 2004 WHO/ISUP criteria as urothelial papillomas (UP), papillary urothelial neoplasm of low malignant potential (PUNLMP), low-grade urothelial carcinoma (LGUC), and high-grade urothelial carcinoma (HGUC). RESULTS: The table shows the results. Management after TURB varied among centres. One centre recommended only follow-up US at increasing intervals whereas another follow-up US plus urine cytologies and endoscopies, every three months in the first year, and at increasing intervals thereafter. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed disease recurrence or progression. DISCUSSION: UBN is an uncommon condition in children and adolescents and, unlike in adults, its incidence, follow-up and outcome still controversial. Paediatric guidelines are currently lacking and management varies among centres. Gross painless haematuria is the most common presenting symptom. Therefore, this symptom should never be underestimated. US is generally the first investigation and additional imaging seems unnecessary. TURB often allows for complete resection. Lesions are generally solitary, non-muscle invasive, and low-grade (mainly UP and PUNLMP). Ideal follow-up protocol is the most controversial point. Reportedly, recurrence or progression during follow-up is uncommon in patients under 20 years, recurrence rate 7% and a single case of progression reported so far. Accordingly, a follow-up mainly based on serial US might be considered in this age group compared to adults where also serial endoscopies and urine cytologies are recommended. In the selection of the follow-up investigations, it should also be taken into consideration that urine cytology has a low sensibility in the detection of low-grade lesions while cystoscopy in young patients requires a general anaesthesia and hospitalization, and carries an increased risk of urethral manipulation. CONCLUSION: UBN is a rare condition in children. Ultrasound is generally accurate in order to visualize the lesion, and TURB can treat the condition. Lesions are generally low-grade and non-muscle invasive, but high-grade lesions can also be detected. In present series, after TURB, follow-up US monitoring at increasing intervals was used at all centres, follow-up cystoscopies were added in two centres, but with different schedules. Urine cytologies were considered only at one centre. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed recurrence or progression of the disease.

Diffuse ganglioneuromatosis and plexiform neurofibroma of the urinary bladder: an uncommon cause of severe urological disease in an infant.

Neurofibromatosis of the urinary tract occurs infrequently: fewer than 70 cases with bladder involvement have been reported to date and of these, only 25 cases occurred in the pediatric population. We describe an unusual case of plexiform neurofibroma and diffuse ganglioneuromatosis of the bladder in a small infant, diagnosed with neurofibromatosis 1 (NF1) at 3 months of age. At the moment, there are no established criteria for the treatment of this rare lesion. Due to the high morbidity, although not very common, bladder involvement should be considered in infants with NF1.

Trends in drug use among students in Brazil: analysis of four surveys in 1987, 1989, 1993 and 1997.

The consumption of psychotropic drugs among Brazilian secondary school students was examined by comparing data from four surveys using a questionnaire adapted from the WHO's Program on Research and Reporting on the Epidemiology of Drug Dependence. Students filled out the form in their classrooms without the presence of teachers. The target population consisted of 10-18-year-old students (on average, 15,000 students responded to each survey) in Brazil's ten largest state capitals: Belém, Belo Horizonte, Brasília, Curitiba, Fortaleza, Porto Alegre, Recife, Rio de Janeiro, Salvador, and São Paulo. Among the legal drugs, lifetime use (use at least once during life) of tobacco was increased in seven cities (the exceptions were Brasília, Porto Alegre and Rio de Janeiro). There was also a significant increase in frequent use of alcohol (six times or more per month) in 6 of the cities, from an average of 9.2% in 1987 to 15.0% in 1997. With respect to illegal drugs, there was a significant increase in lifetime use of marijuana (a 3-fold increase from 2.8% in 1987 to 7.6% in 1997). Cocaine use increased 4-fold over the survey period (0.5% in 1987 to 2.0% in 1997). Lifetime use of cocaine significantly increased in eight capitals (except Recife and Rio de Janeiro). However, frequent cocaine use increased in only three capitals (Belém, Fortaleza and Porto Alegre), from an average of 1.0% in 1987 to 3.6% in 1997. Lifetime use of medications such as anxiolytics and amphetamines increased 2-fold on average over the survey period. Comparing the four studies, the main conclusion is that there were significant increases in the frequencies for lifetime use, frequent use and heavy use of many drugs.

Trends in drug use among students in Brazil: analysis of four surveys in 1987, 1989, 1993 and 1997

The consumption of psychotropic drugs among Brazilian secondary school students was examined by comparing data from four surveys using a questionnaire adapted from the WHO's Program on Research and Reporting on the Epidemiology of Drug Dependence. Students filled out the form in their classrooms without the presence of teachers. The target population consisted of 10-18-year-old students (on average, 15,000 students responded to each survey) in Brazil's ten largest state capitals: Belém, Belo Horizonte, Brasília, Curitiba, Fortaleza, Porto Alegre, Recife, Rio de Janeiro, Salvador, and São Paulo. Among the legal drugs, lifetime use (use at least once during life) of tobacco was increased in seven cities (the exceptions were Brasília, Porto Alegre and Rio de Janeiro). There was also a significant increase in frequent use of alcohol (six times or more per month) in 6 of the cities, from an average of 9.2 percent in 1987 to 15.0 percent in 1997. With respect to illegal drugs, there was a significant increase in lifetime use of marijuana (a 3-fold increase from 2.8 percent in 1987 to 7.6 percent in 1997). Cocaine use increased 4-fold over the survey period (0.5 percent in 1987 to 2.0 percent in 1997). Lifetime use of cocaine significantly increased in eight capitals (except Recife and Rio de Janeiro). However, frequent cocaine use increased in only three capitals (Belém, Fortaleza and Porto Alegre), from an average of 1.0 percent in 1987 to 3.6 percent in 1997. Lifetime use of medications such as anxiolytics and amphetamines increased 2-fold on average over the survey period. Comparing the four studies, the main conclusion is that there were significant increases in the frequencies for lifetime use, frequent use and heavy use of many drugs.

Treatment of vesico-ureteric reflux: a new algorithm based on parental preference.

UNLABELLED: Authors from Rome evaluated parental preference for treatment in children with grade III VUR. Parents were provided with detailed information about the three treatment options: antibiotic treatment, open surgery, endoscopic treatment. Most parents chose endoscopic management; with this in mind, the authors proposed a new treatment algorithm for VUR. OBJECTIVE: To assess parental preference (acknowledged in treatment guidelines as important when choosing therapy) about treatments for vesico-ureteric reflux (VUR, commonly associated with urinary tract infection and which can cause long-term renal damage if left untreated), as at present there is no definitive treatment for VUR of moderate severity (grade III). SUBJECTS AND METHODS: The parents of 100 children with grade III reflux (38 boys and 62 girls, mean age 4 years, range 1-15) were provided with detailed information about the three treatment options available for treating VUR (antibiotic prophylaxis, open surgery and endoscopic treatment), including the mode of action, cure rate and possible complications, and the practical advantages and disadvantages. They were then presented with a questionnaire asking them to choose their preferred treatment. RESULTS: Most parents preferred endoscopic treatment (80%), rather than antibiotic prophylaxis (5%) or open surgery (2%); 13% could not decide among the three options and endoscopic treatment was recommended. CONCLUSION: Given the strong preference for endoscopic treatment we propose a new algorithm for treating VUR; endoscopic treatment would be considered as the first option for persistent VUR, except in severe cases where open surgery would still be recommended.

Nocturnal enuresis in the adolescent: a neglected problem.

OBJECTIVE: To assess the features of adolescent bedwetters, as few data are available on enuresis in this age group. PATIENTS AND METHODS: A specific database for adolescents and young adults was created with the collaboration of various specialists (paediatricians, urologists, gynaecologists, psychiatrists). Questions focused on family and personal history, stressful events, age of attaining urinary and fecal control, characteristics of enuresis (primary vs secondary, monosymptomatic vs enuresis associated with daytime urinary symptoms), school performance, diagnostic examination and physical examinations, and treatment and its response. RESULTS: Data were collected from 107 enuretic adolescents (mean age 15.3 years, median 14, range 13-23; 63 males and 44 females). A positive family history for enuresis was recorded in 82%. Enuresis was primary in 79 patients (74%), secondary in 28 (26%), monosymptomatic in 76 (71%) and associated with daytime urinary symptoms in 31 (29%). In males monosymptomatic enuresis was significantly more frequent than in females (P < 0.01). Urinary tract infections were reported by 13 patients, all females; eating disorders (anorexia, polyphagia) were present in six. In 85 patients (80%) enuresis was considered severe (> or = three nights/week). Of the 107 patients, 27 (20%) had never consulted a doctor about their problem and 43 (40%) had received no therapy; 66 received desmopressin monotherapy, with a good response (half the number of wet nights) in 44 (79%). There was no relation between response to desmopressin and gender, age, type and severity of enuresis or positive family history of enuresis. Eight patients were provided with a nocturnal alarm but this was not tolerated by two. Altogether, 25 patients refused any therapy or did not comply with the given therapy. CONCLUSIONS: Enuresis can persist into adolescence and be a significant problem; 80% of these patients had severe enuresis and 31% also had associated daytime urinary symptoms, with 40% receiving no previous therapy. The treatment of enuresis can be particularly difficult at this age; 22% of patients did not respond to desmopressin and 23% had low compliance with the given therapy. Enuresis in adolescents requires further study; hopefully more enuretic children will receive adequate treatment before reaching adolescence.

Changes in cocaine use as viewed by key informants: a qualitative study carried out in 1994 and 1999 in São Paulo, Brazil.

The characteristics of coca products use in São Paulo, Brazil during the years of 1994 and 1999 were investigated through interviews with 26 key informants (KIs; persons with knowledge of coca product users) in each of these years. The following information was yielded by the KIs: (1) there has been a large increase in coca products use in São Paulo from 1994 to 1999; concomitantly, there has been a decrease of hydrochloride use; (2) the increase has occurred due to the dissemination of crack which became cheap and easily available; (3) reasons for crack use changed greatly: in 1994, use was attributed mostly to pleasurable sensations produced by smoking; in 1999, use was intended to overcome compulsion/dependence or to put up with frustration/family conflicts; (4) crack users in 1999 came from practically all social classes of São Paulo; (5) use of alcohol and/or marijuana to cut down the anxiety and excitement produced by crack increased from 1994 to 1999; (6) even when police repression of traffic was effective, which rarely occurred, it affected only the price of coca products; (7) treatment services available were considered insufficient both in number and quality, and were run by ill-trained health professionals (this situation deteriorated even more in 1999); (8) many KIs heavily criticized the prevention programs because of the use of "scare techniques"; and (9) all KIs in 1999 believed that, unless the government changes its policy toward the drug problem, the situation would become worse in the next few years.

Low-dose desmopressin in the treatment of nocturnal urinary incontinence in the exstrophy-epispadias complex.

OBJECTIVE: To report our experience of the use of desmopressin to improve nocturnal dryness in patients who have undergone a staged reconstruction of the exstrophy-epispadias complex (EEC), who although continent by day, have nocturnal incontinence because their nocturnal urinary output exceeds their bladder capacity. PATIENTS AND METHODS: Seven children (aged 8-12 years) who had undergone a staged reconstruction for EEC (six with classical bladder exstrophy, one with incontinent epispadias) were treated with intranasal desmopressin for persistent nocturnal incontinence despite daytime dryness. Previous additional procedures for continence had been self-augmentation in one and periurethral collagen injection in three others. The criteria for inclusion in the study were: normal renal function, no upper tract deterioration, no urinary tract infections, spontaneous voiding during the day with dry intervals between micturitions, a postvoid residual volume of <10% of bladder capacity and night-time incontinence for 7 nights/week. Desmopressin was administered at bedtime at increasing dosages from 10 to 30 microg until effective. Body weight, arterial blood pressure, and serum electrolytes were measured, and all patients assessed using renal ultrasonography, a voiding diary and a nocturnal pad-test. RESULTS: Desmopressin at doses of 10-30 microg was successful in keeping all the patients dry. The nocturnal urinary output was decreased so that it did not exceed bladder capacity. There was only one minor side-effect (nose bleeding). CONCLUSIONS: In selected patients with EEC, desmopressin is effective in improving nocturnal dryness, with no significant side-effects.

Inappropriate prescribing of compounded antiobesity formulas in Brazil.

Volunteers posing as patients underwent paid medical consultations at the offices of 107 Brazilian doctors (in two Brazilian cities) with the purpose of obtaining an antiobesity prescription. In 80.3% of 71 São Paulo visits, as well as in 47.2% of 36 Recife visits, compounded preparations were prescribed. Four to six active components predominated, but there were prescriptions listing as many as 17 components. All contained anorectic substances and benzodiazepines. Diuretics, thyroid agents, laxatives, medicinal plants, and a variety of other substances were often included. The prescribed doses were frequently above recommended limits, reaching amounts as much as five times the internationally defined standard doses. In some instances two anorectic substances were prescribed simultaneously. Most doctors failed to warn volunteers of the possible occurrence of adverse reactions to the prescribed substances. Furthermore, in the case of all volunteers involved, antiobesity prescriptions would be completely unnecessary, a fact that points to improper medical conduct on the part of doctors. It is concluded that the practice by some Brazilian medical doctors of prescribing manipulation formulas based on anorectic and benzodiazepine drugs is a greater hazard than a benefit to patients.

Long-term results of distal urethral advancement glanuloplasty for distal hypospadias.

PURPOSE: In 1987 we developed distal urethral advancement and glanuloplasty, a surgical technique specifically intended for coronal and subcoronal hypospadias repair that involves moving the distal urethra 0.5 to 1 cm., Y shaped meatoplasty and glanuloplasty. MATERIALS AND METHODS: From January 1987 to December 1992, 271 boys 9 months to 14 years old (mean age 2.5 years) underwent repair of distal coronal and subcoronal hypospadias, including distal urethral advancement and glanuloplasty in 135 (49.8%). RESULTS: Long-term results in 118 cases were determined at 4 to 9 years of followup (mean 6.3). In 112 cases (95%) good functional and cosmetic results were achieved, while in 6 (5%) complications required surgical repair, including meatal stenosis in 3 (2.5%), fistulas in 2 (1.7%) and complete glanuloplasty disruption in 1. We evaluated outcomes in 19 postpubertal patients 15 to 20 years old and noted no psychological or sexual problems as a consequence of hypospadias repair. CONCLUSIONS: Long-term followup confirms the validity of distal urethral advancement and glanuloplasty for correcting a large number of coronal and subcoronal hypospadias cases.

Contralateral ureteral meatal advancement in unilateral antireflux surgery.

PURPOSE: Contralateral vesicoureteral reflux is a well-known development after successful unilateral ureteral reimplantation that is not apparently influenced by the reimplantation technique. We sought to determine whether bilateral reimplantation should be performed routinely in unilateral cases. MATERIALS AND METHODS: From 1984 to 1995 we performed contralateral ureteral meatal advancement in 53 children 1 to 9.5 years old (mean age 2.5) undergoing surgery for unilateral grades II to V vesicoureteral reflux, including 12 with reflux in duplex systems. Ureteral meatal advancement involves a transverse Y shaped mucosal incision from the nonrefluxing orifice to the opposite hemitrigone. The inferior half of the ureteral orifice is then advanced toward the midline using 3 or 4 long-term resorbable sutures. The control group included 98 children who underwent unilateral surgery for grades II to V reflux from 1990 to 1995. RESULTS: No evidence of vesicoureteral reflux was observed in the 53 children who underwent contralateral meatal advancement. There was no obstruction or other complications. At followup contralateral reflux was found in 11 controls after unilateral reimplantation. CONCLUSIONS: Contralateral reflux has been reported in up to 27% of previously reported cases and in 11% of our control group after successful unilateral antireflux surgery. Contralateral ureteral meatal advancement has proved effective for preventing reflux in 100% of cases. It requires minimal invasion of the nonrefluxing ureter, and little additional operative time and cost.

Use of drugs among street children in Brazil.

The purpose of this study has been to assess drug consumption among children in five Brazilian state capitals during 1993. The sample was composed of street children who were given assistance in institutions, and data was collected by means of anonymous individual interviews. Five hundred sixty five boys and girls were interviewed: 74.3% reported having used drugs (not including alcohol and tobacco) at least once in their life. Solvents, followed by marijuana, were the most cited drugs. Important regional differences were observed concerning other drugs. Consumption of cocaine, including crack, seems restricted to the southeast region, whereas psychotropic medication was consumed more in the northeast of the country. Drug initiation among these children seems to be a consequence of street life and is part of their group lifestyle.

[Total agenesis of the sacrum and neurogenic bladder dysfunction]. / Agenesia totale del sacro e disfunzione vescicale neurogena.

Total Sacral Agenesis (TSA) is a rare congenital anomaly of the lower vertebral column, frequently associated with bladder dysfunction. The diagnosis is often delayed until the evidence of neurological disorders addresses at neuro-radiological examination. In the last 9 years we observed 7 children, 3 males and 4 females, with TSA. The average age at diagnosis was 8 years (range: 1-15 years). Maternal diabetes was present only in one case. In 5 patients, urological ones have been the symptoms of presentation. In one case, TSA has been discovered because of the presence of a sacral mass (lipoma) and the subsequent development of club-foot. The neurological screening, performed in all patients with anorectal anomalies, led to the diagnosis of total sacral agenesis in a child with anteriorized anus. All patients have been evaluated by means of Magnetic Resonance Imaging, renal ultrasound, voiding cystography, renal nuclear scan and urodynamics. The functional evaluation of the lower urinary tract has shown a pattern of neurogenic bladder dysfunction in all children, while bilateral vesico-ureteral reflux has been detected in 2 cases. Intermittent clean catheterization (ICC) has been instituted at the diagnosis in all children. Surgery for continence and protection of upper urinary tract (bladder augmentation and bilateral ureteral reimplantation) has been performed in one patient. At a medium follow-up of 3 years (range: 1-5 years) 2 patients have been lost, normal renal function and urinary continence have been achieved in 4 and one child is continent but has renal failure. An early diagnosis and a correct neuro-urological evaluation and treatment are necessary to prevent urinary tract damage and achieve urinary continence in these patients. Symptoms, clinical findings and relationship with maternal diabetes are discussed. The diagnosis can be enough early if physicians pay attention to maternal diabetes, subtle neurological symptoms (voiding disturbance, constipation, club-foot) and careful physical examination of the back.

Nocturnal enuresis and daytime wetting: a multicentric trial with oxybutynin and desmopressin.

OBJECTIVE: Different etiopathological mechanisms of enuresis are today under study, and different therapies and drugs have been proposed. The Italian Multicentric Trial was undertaken in twelve pediatric and urological centers in order to assess the efficacy of two of the most popular drugs, desmopressin (DDAVP) and oxybutynin. METHODS: 114 enuretic patients were enrolled in the study. After a 2-week observation period, 66 patients with primary monosymptomatic enuresis were treated with DDAVP, 30 micrograms/day intranasally, for 6 weeks, 48 patients with enuresis and voiding dysfunction were randomly assigned to a protocol with oxybutynin alone or oxybutynin plus DDAVP. The efficacy of the two drugs was measured in terms of reduction of wet nights per week during the 6-week treatment period and a 2-week follow-up period. Children with 0-3 dry nights/week were considered as nonresponders. RESULTS: Patients with monosymptomatic enuresis treated with DDAVP reported a significantly lower number of wet night during treatment than during the baseline period, with 79% showing a 'good' (6-7 dry nights/week) or 'intermediate' response (4-5 dry nights/week). Of the patients with diurnal voiding disturbances and enuresis, those treated with oxybutynin alone had a 54% success rate. The patients treated with both oxybutynin and DDAVP showed a better response, with a 71% rate of success. CONCLUSIONS: The efficacy of the two drugs is confirmed in patients carefully selected on the clinical basis of voiding disturbances. In patients with enuresis and voiding dysfunction, the reduced urinary output and the lower bladder filling rate due to DDAVP can reduce uninhibited bladder contractions, thus enhancing the oxybutynin action.