Meatotomía ureteral como opción para gestión del megauréter obstructivo primario en neonatos y lactantes / Ureteral meatotomy as option in the management of primary obstructive megaureter in neonates and infants

La diferenciación de los casos de megauréter que requieren cirugía de los que se pueden conducir de forma expectante es un desafío. Numerosas técnicas operatorias para el tratamiento del MOP han sido propuestas, teniendo como principal objetivo la reducción del daño renal desbloqueando el uréter afectado. La resección del segmento comprometido seguido del reimplante vesicoureteral con o sin ureteroplastia reductiva es el tratamiento clásico, pero tiene alta tasa de complicaciones cuando se realiza en niños menores de un año de edad. Las técnicas endoscópicas también han sido descritas para evitar la derivación externa. Recientemente se ha propuesto llevar a cabo el reimplante ureteral refluyente como un tratamiento temporal para pacientes con MOP. OBJETIVO: Describir la técnica de meatotomía ureteral como alternativa al reimplante ureteral refluyente para tratamiento del MOP en niños menores de un año de edad. MÉTODO: Estudio retrospectivo de los pacientes con MOP que se sometieron a meatotomía ureteral, con objetivo de la desobstrucción ureteral temporal. El procedimiento consiste en una sección del ostium ureteral con tijeras en su borde superior a las 12 horas, por una extensión de 1,5 cm hasta alcanzar la parte dilatada del uréter y observar abundante drenaje de orina. Los bordes de la sección son suturados, juntando la mucosa ureteral a la mucosa vesical. RESULTADO: En el período 2011-2015, tres pacientes con MOP fueron sometidos a meatotomía ureteral, por un total de cuatro unidades renales tratadas. Ningún paciente presentó complicaciones y todos tuvieron reducción de la dilatación al ultrasonido, como señal de desobstrucción. Ningún paciente presentó complicaciones. CONCLUSIONES: La meatotomía ureteral es una técnica segura y eficaz para el tratamiento inicial del MOP en niños menores de un año de edad

Differentiating between the cases of megaureter that require surgery and the ones in whom treatment can be delayed is challenging. A large number of surgical techniques for the treatment of POM have been proposed aiming mainly to reduce renal damage by relieving the affected ureter. Resection of the affected ureteral segment followed by vesicoureteral reimplantation either with or without reduction ureteroplasty is the classic treatment, however posing a high rate of complications when performed in patients aged less than one year. Endoscopic techniques have also been described to avoid external diversion. Recently, refluxing ureteral reimplantation has been proposed as a temporary treatment for patients with POM. OBJECTIVE: To describe the ureteral meatotomy technique as an alternative to the refluxing ureteral reimplantation for POM in patients aged less than one year. METHOD: Retrospective study of patients with POM undergoing ureteral meatotomy, aiming to temporarily relieve the ureter. The procedure consists of a 1.5 cm-long cut made with scissors on the upper edge of the ureteral ostium at the 12 o’clock position, until the dilated portion of the ureter was found and abundant urine drainage was observed. The edges of the incision were sutured, joining together the ureteral mucosa and the bladder mucosa. RESULT: From 2011 to 2015, three patients with POM underwent ureteral meatotomy, with four renal units treated altogether. None of the patients presented complications and, as a sign of obstruction relief, all showed reduced dilatation at the ultrasound. No patient had complications. CONCLUSIONS: Ureteral meatotomy is a safe and effective technique in the initial treatment of POM in patients aged less than one year

Apple-peel intestinal atresia: enteroplasty for intestinal lengthening and primary anastomosis.

Apple-peel atresia (or Type-IIIb intestinal atresia) is an unusual type of jejunoileal atresia. They present with jejunal atresia near the ligament of Treitz and a foreshortened small bowel. Many surgical options have been used, but the optimal method of repair remains unclear. We present a case of a newborn with apple-peel intestinal atresia managed by enteroplasty for intestinal lengthening and primary anastomosis.

Urethral duplication--a wide spectrum of anomalies.

OBJECTIVE: Urethral duplications are rare lower urinary tract anomalies, with multiple anatomical variants described. This paper aims to separate this complex anomaly into different diseases, each with distinct clinical forms according to the disturbance during embryogenesis, yet noting a few similarities that may be helpful in their management. The classification system of urethral duplication is also discussed. MATERIAL AND METHODS: Twelve urethral duplication cases over a 14-year period were reviewed. Clinical presentation, the imaging studies used to ascertain anatomical details, type of urethral duplication and surgical correction used in the treatment of patients are presented. RESULTS: Nine patients had urethral duplication in the sagittal plane and three patients in the coronal plane. Of the patients with sagittal urethral duplication, 3 had pre pubic sinus, 3 had epispadiac urethral duplication, 1 had a dorsal urethral duplication deviated from the midline and 2 had hypospadiac urethral duplication. All the patients with coronal urethral duplication had associated bladder duplication. The surgical correction of the patients with sagittal urethral duplication included excision of the pre pubic sinus, excision of the duplicated urethra, and urethroplasty. Excision of the hemibladders' septum and closure of one bladder neck was the treatment for patients with coronal urethral duplication and bladder duplication. CONCLUSION: Urethral duplication is a complex anomaly and the different manifestations probably have different embryological origins. Each group, sagittal or coronal, has a few similarities that may be helpful in their management, although every diagnosed case presents a unique anatomy and surgical treatment must be individualized.

Pelvic fracture urethral distraction defects in children managed by anterior sagittal trans anorectal approach: a facilitating and safe access.

PURPOSE: Trauma injuries of the posterior urethra resulting from pelvic fracture in children tend to be complete ruptures, with upper dislocation of the prostate. This paper aims to show our experience in using an anterior sagittal transanorectal approach (ASTRA) in the treatment of such injuries. MATERIALS AND METHODS: The medical records of 11 patients with pelvic fracture urethral distraction defects who had undergone anastomotic urethroplasty through ASTRA between 1997 and 2009 were reviewed. Ages ranged from 1 year and 6 months to 23 years (mean age 11 years). Of the 11 patients, 8 had previously undergone failed urethroplasties. RESULTS: In 10 patients it was possible to perform tension free urethroplasty. One patient required inferior pubectomy and separation of the corpora cavernosa. Patients' follow-up time varied from 10 months to 10 years and 9 months (mean 41 months). One patient had a urethral fistula and evolved with a urethral diverticulum successfully managed by diverticulectomy. One patient presented a urethral stenosis managed by urethral dilatation. Of the 11 patients, 9 presented functional urethral flow and are continent. Two patients had no urethral flow. One is undergoing bladder catheterization through the Mitrofanoff principle and the other one through the urethra. No patient presented fecal incontinence or rectourethral fistula. CONCLUSION: This access, which is increasingly being used to approach posterior urethral diseases, has proved to be safe and effective in the treatment of pelvic fracture urethral distraction defects.