Características bacterianas y significado clínico de catéteres ureterales doble J en niños / Bacterial characteristics and clinical significance of ureteral double-J stents in children

Objetivo: Determinar la incidencia de infección del tracto urinario en los pacientes en los que hemos utilizado un catéter ureteral doble J como desvío interno después de procedimientos urológicos. Material y métodos: Se revisaron todas las historias clínicas de los pacientes que tenían un catéter ureteral doble J después de un procedimiento urológico desde agosto de 2007 hasta mayo de 2013. Hemos analizado los siguientes datos: edad, sexo, tipo de profilaxis, incidencia de la infección del tracto urinario (ITU), días de desviación interna con catéter doble J, procedimiento quirúrgico, características bacterianas, sensibilidad de las bacterias a los antibióticos y tratamiento de ITU. Resultados: Hemos utilizado 73 catéteres doble J como desvío interno ureteral en 67 pacientes con una edad media de 44,73 ± 57,23. Los procedimientos quirúrgicos fueron 50 pieloplastias laparoscópicas Anderson-Hynes en 49 pacientes y 20 dilataciones con balón de alta presión de la unión ureterovesical para tratar megauréter obstructivo primario en 15 pacientes, y 3 pacientes con obstrucción ureterovesical después del tratamiento endoscópico del reflujo vesicoureteral. Cuarenta y tres catéteres mostraron una colonización bacteriana en los cultivos. Pseudomona aeruginosa estaba presente en 9 (20,9%) catéteres. Solo en 12 catéteres la colonización bacteriana era sensible a la profilaxis antibiótica. La colonización del catéter era mayor en los niños y los pacientes más jóvenes. Cuatro pacientes tuvieron una ITU febril. La incidencia de ITU en los pacientes más jóvenes que se sometieron a DBAP de UUV es mayor. Conclusión: La colonización bacteriana es frecuente en los catéteres doble J, pero la incidencia de ITU es baja. La colonización doble J es mayor en los pacientes más jóvenes. Los pacientes que se sometieron a DBAP tienen un mayor riesgo de ITU relacionada con el catéter ureteral doble J

Objective: To determine the incidence of urinary tract infection in those patients that we have used an ureteral double-J stent as internal diversion after urological procedures. Material and methods: We reviewed all the medical records of patients who had a ureteral double-J stent after a urological procedure from August 2007 to May 2013. We have analyzed the following data: age, gender, type of prophylaxis, incidence of urinary tract infection (UTI), days of internal diversion with double-J stent, surgical procedure, bacterial characteristics, bacterial sensibility to antibiotics and UTI treatment. Results: We have used 73 double-J stents as ureteral internal diversion in 67 patients with a mean age of 44.73 ± 57.23. Surgical procedures were 50 laparoscopic Anderson-Hynes pyeloplasties in 49 patients, and 20 high-pressure balloon dilatation of the ureterovesical junction to treat primary obstructive megaureter in 15 patients; and 3 patients with ureterovesical obstruction after endoscopic treatment of vesicoureteral reflux. Forty three stents showed a bacterial colonization in cultures. Pseudomona aeruginosa was present in 9 (20.9%) stents. Only in 12 stents, bacterial colonization was sensible to antibiotic prophylaxis. Stent colonization was higher in boys and younger patients. Four patients had a febrile UTI. Incidence of UTI in younger patients that underwent HBPD of UVJ is higher. Conclusion: Bacterial colonization is frequent in double-J stents but the incidence of UTI is low. Double-J colonization is higher in younger patients. Patients that underwent HPBD have a higher risk of UTI related with ureteral double J stent

Bacterial characteristics and clinical significance of ureteral double-J stents in children.

OBJECTIVE: To determine the incidence of urinary tract infection in those patients that we have used an ureteral double-J stent as internal diversion after urological procedures. MATERIAL AND METHODS: We reviewed all the medical records of patients who had a ureteral double-J stent after a urological procedure from August 2007 to May 2013. We have analyzed the following data: age, gender, type of prophylaxis, incidence of urinary tract infection (UTI), days of internal diversion with double-J stent, surgical procedure, bacterial characteristics, bacterial sensibility to antibiotics and UTI treatment. RESULTS: We have used 73 double-J stents as ureteral internal diversion in 67 patients with a mean age of 44.73±57.23. Surgical procedures were 50 laparoscopic Anderson-Hynes pyeloplasties in 49 patients, and 20 high-pressure balloon dilatation of the ureterovesical junction to treat primary obstructive megaureter in 15 patients; and 3 patients with ureterovesical obstruction after endoscopic treatment of vesicoureteral reflux. Forty three stents showed a bacterial colonization in cultures. Pseudomona aeruginosa was present in 9 (20.9%) stents. Only in 12 stents, bacterial colonization was sensible to antibiotic prophylaxis. Stent colonization was higher in boys and younger patients. Four patients had a febrile UTI. Incidence of UTI in younger patients that underwent HBPD of UVJ is higher. CONCLUSION: Bacterial colonization is frequent in double-J stents but the incidence of UTI is low. Double-J colonization is higher in younger patients. Patients that underwent HPBD have a higher risk of UTI related with ureteral double J stent.

Randomized clinical trial comparing endoscopic treatment with dextranomer hyaluronic acid copolymer and Cohen's ureteral reimplantation for vesicoureteral reflux: long-term results.

PURPOSE: To compare efficacy of Cohen's ureteral reimplantation and endoscopic treatment with Dx/HA in patients with primary VUR grades II, III and IV. METHODS: From April 2002 to June 2004, patients over 1 year old with VUR grade I, II, III or IV were included. Patients were randomized into two groups: endoscopic treatment (ET) or ureteral reimplantation (UR). In the ET group, an ultrasonography study was performed 24 h and 1 month after surgery, and two voiding cystourethrographies at 3 and 6 months post treatment. In the UR group, an ultrasonography study was done 7 days and 1 month after surgery and a micturial cystography 6 months post surgery. A postoperative nuclear direct cystogram was performed 5 years later in both groups. RESULTS: A total of 41 patients were included in this study: in ET 22 patients with 35 refluxing ureters and in UR 19 patients with 32 refluxing ureters. The VUR grades in ET were: 16 grade II, 16 grade III and 3 grade IV; and in UR: 15 grade II, 12 grade III and 5 grade IV. VUR was resolved in 91% (32/35) of ET (28% of ureters needed a second injection), and in 100% of UR group. Five years after the procedure, VUR was still resolved in 30/32 of ET and 32/32 of UR. CONCLUSION: Short- and long-term follow up shows that multiple endoscopic treatment of VUR grades II, III and IV with Dx/HA is as effective as ureteral reimplantation.

Acute and delayed vesicoureteral obstruction after endoscopic treatment of primary vesicoureteral reflux with dextranomer/hyaluronic acid copolymer: why and how to manage.

OBJECTIVE: To present our cases of ureteral obstruction after endoscopic treatment of vesicoureteral reflux (VUR) with dextranomer/hyaluronic acid (Dx/HA). PATIENTS AND METHODS: We collected data from patients who had suffered ureteral obstruction after endoscopic treatment of VUR with Dx/HA in our institution. RESULTS: From April 2002 to April 2011 we treated endoscopically 475 ureters with VUR, and detected 5 ureteral obstructions. Median age at reflux treatment was 39 months. Reflux grade before treatment was III in one patient and IV in four. Three ureterovesical junctions (UVJ) were blocked after a second endoscopic treatment. The median of Dx/HA injected was 1 ml (0.6-1.1). In two patients ureteral obstruction presented acutely and was treated with a ureteral stent. In the other three, the ureteral obstruction appeared gradually and was detected by ultrasound scans and MAG3 diuretic renogram; one underwent nephrectomy because of poor renal function, and the other two were treated with endoscopic dilatation of the UVJ. In all these patients both reflux and obstructions have resolved. CONCLUSIONS: On preoperative cystography, three of the patients had a narrowed distal ureter, and probably had a refluxing and obstructive megaureter. Other causes are not clear, except for those patients with acute presentation in whom edema of the UVJ was found. Ureteral obstruction after endoscopic treatment of VUR is rare. Endoscopic intervention such as ureteral stent placement or high-pressure balloon dilatation of the UVJ has good results as a treatment of acute and delayed obstruction.

[Anderson-Hynes pyeloplasty in children under 2 years. Is the laparoscopy the technique of choice?]. / Pieloplastia Anderson-Hynes en menores de 2 años. ¿Es la laparoscopia la técnica de elección?

OBJECTIVE: To analyze if the laparoscopic pyeloplasty is as effective as the open procedure in the ureteropelvic junction obstruction in patients under 2 years of age. PATIENTS AND METHODS: Pyeloplasties performed in children under 2 years of age between 2007 and 2010. Weight, pre and postoperative renal pelvis and calices diameter, operating time, hospital stay and complications were analyzed. RESULTS: We found no statistic differences in weight, complications, or pre and postoperative renal pelvis and calices diameter. However, we found differences in hospital stay and operating time (p<0.05). CONCLUSIONS: Laparoscopic pyeloplasty in children under 2 years of age is a good alternative technique for ureteropelvic junction obstruction, although operating time are still long.

High pressure balloon dilation of the ureterovesical junction--first line approach to treat primary obstructive megaureter?

PURPOSE: We describe the efficacy of dilation of the ureterovesical junction to treat primary obstructive megaureter. MATERIALS AND METHODS: A total of 13 patients with primary obstructive megaureter were treated from May 2008 to December 2010. Of these patients 8 were diagnosed prenatally and the others were diagnosed after a urinary tract infection. Preoperative studies included ultrasonography, voiding cystourethrography despite vesicoureteral reflux and diuretic isotopic renogram (mercaptoacetyltriglycine). With the patient under general anesthesia, high pressure balloon dilation of the ureterovesical junction was performed under direct and fluoroscopic vision until the disappearance of the narrowed ring. A Double-J(®) catheter was positioned, and 2 months later it was withdrawn and the ureterovesical junction was reviewed. A secondary treatment was performed in those in whom the ureterovesical junction was still narrow. Followup was performed with ultrasonography, cystourethrography and isotopic diuretic renography. RESULTS: A total of 18 procedures were performed in 13 patients (median age 7 months, range 4 to 24). Median diameter of the distal ureter was 14 mm (range 10 to 26), and median diameter of the renal pelvis and calyx was 27 mm (range 10 to 47) and 12 mm (range 9 to 26), respectively. Significant postoperative improvement of hydroureteronephrosis was observed in 11 of 13 patients and vesicoureteral reflux was found in 2. Only 3 patients needed ureteral reimplantation after endoscopic treatment due to hydroureteronephrosis in 2 and high grade vesicoureteral reflux in 1. CONCLUSIONS: High pressure balloon dilation of the ureterovesical junction is effective in treating primary obstructive megaureter, but long-term followup is needed.

[Laparoscopìc pyeloplasty in pediatric patients. Our initial cases and lessons learned]. / Pieloplastia laparoscópica en pacientes pediátricos. Nuestros primeros casos y lecciones aprendidas.

OBJECTIVE: To analyze the initial experience in our first patients with ureteropelvic junction obstruction (UPJO) treated by laparoscopic surgery. PATIENTS AND METHODS: All laparoscopic Anderson-Hynes pyeloplasties performed from July 2007 to April 2009 were analyzed. Before surgery, patients underwent a renal ultrasound and isotope renogram. A double J catheter was left in place and subsequently removed. Patients were followed up by ultrasound and renography. RESULTS: Fourteen patients with a median age of 8.6 years were analyzed. Preoperative ultrasound showed a median renal pelvis diameter of 34.5 mm. Median operating time was 235 min, and median hospital stay 5.5 days. Median renal pelvis diameter decreased in all patients (13.5 mm). CONCLUSIONS: Laparoscopy is an effective procedure for UPJO correction in children, although operating times are still long.

Pieloplastia laparoscópica en pacientes pediátricos. Nuestros primeros casos y lecciones aprendidas / Laparoscopìc pyeloplasty in pediatric patients. Our initial cases and lessons learned

Objetivo: Analizar la experiencia inicial en nuestros primeros pacientes afectos de estenosis pieloureteral tratados mediante cirugía laparoscópica. Pacientes y métodos: Se han incluido todas las pieloplastias laparoscópicas tipo Andereson Hynes realizadas entre julio de 2007 y abril de 2009. Los pacientes fueron estudiados preoperatoriamente mediante ecografía renal, renograma isotópico. Se les dejó un tutor doble «J» que se retiró posteriormente. El seguimiento ha sido ecográfico y renográfico. Resultados: Catorce pacientes con una media de edad de 8,6 años El estudio ecográfico prequirúrgico mostró una media del diámetro de la pelvis renal de 34,5mm. El tiempo quirúrgico media ha sido de 235min. La estancia media fue de 5,5 días. En todos los pacientes ha habido una disminución de la media del diámetro de la pelvis renal (13,5mm). Conclusiones: La laparoscopia es técnica eficaz para la corrección de la estenosis pieloureteral en la edad pediátrica; a pesar que los tiempos quirúrgicos aún son elevados (AU)

Objective: To analyze the initial experience in our first patients with ureteropelvic junction obstruction (UPJO) treated by laparoscopic surgery. Patients and methods: All laparoscopic Anderson-Hynes pyeloplasties performed from July 2007 to April 2009 were analyzed. Before surgery, patients underwent a renal ultrasound and isotope renogram. A double J catheter was left in place and subsequently removed. Patients were followed up by ultrasound and renography. Results: Fourteen patients with a median age of 8.6 years were analyzed. Preoperative ultrasound showed a median renal pelvis diameter of 34.5mm. Median operating time was 235min, and median hospital stay 5.5 days. Median renal pelvis diameter decreased in all patients (13.5mm). Conclusions: Laparoscopy is an effective procedure for UPJO correction in children, although operating times are still long (AU)

Irf4 is a positional and functional candidate gene for the control of serum IgM levels in the mouse.

Natural IgM are involved in numerous immunological functions but the genetic factors that control the homeostasis of its secretion and upholding remain unknown. Prompted by the finding that C57BL/6 mice had significantly lower serum levels of IgM when compared with BALB/c mice, we performed a genome-wide screen and found that the level of serum IgM was controlled by a QTL on chromosome 13 reaching the highest level of association at marker D13Mit266 (LOD score=3.54). This locus was named IgMSC1 and covered a region encompassing the interferon-regulatory factor 4 gene (Irf4). The number of splenic mature B cells in C57BL/6 did not differ from BALB/c mice but we found that low serum levels of IgM in C57BL/6 mice correlated with lower frequency of IgM-secreting cells in the spleen and in the peritoneal cavity. These results suggested that C57BL/6 mice have lower efficiency in late B-cell maturation, a process that is highly impaired in Irf4 knockout mice. In fact, we also found reduced Irf4 gene expression in B cells of C57BL/6 mice. Thus, we propose Irf4 as a candidate for the IgMSC1 locus, which controls IgM homeostatic levels at the level of B-cell terminal differentiation.

[Which surgical technique should we perform for benign renal disease in children?]. / Qué técnica quirúrgica hemos de utilizar en la nefrectomía por patología benigna?.

AIM: The aim of this paper is to analyze our experience in different surgical techniques to perform a nephrectomy for benign renal diseases in children. MATERIAL AND METHODS: From 1993 to 2005 we have performed 98 nephrectomies. We have three groups of patients depending on the surgical technique: open nephrectomy (ON), transperitoneal laparoscopic nephrectomy (TLN) and retroperitoneal laparoscopic nephrectomy (RLN). ON was performed in 36 patients. Mean age was 3.3 years. TLN was performed in 39 patients. Mean age was 4.7 years old. RLN was performed in 23 patients. Mean age was 3.6 years old. Criteria to nephrectomy was a renographic function under 19%. We have compared the three surgical techniques in relation with surgical time and mean hospital stay. RESULTS: Mean operative time was 126.2 minutes in ON, 132.3 minutes in TLN and 134.1 minutes in RLN. Mean stay was 5.02 days in ON, 2.35 days in TLN and 1.86 days in RLN. The median hospital stay of the ON group is significantly longer than that of NLT and NR groups (p < 0.05). However, there are no differences related to surgical time between all the groups. CONCLUSIONS: Nephrectomy may be performed for benign disease in children using less invasive surgical techniques. They are associated with minimal morbidity, minimal postoperative discomfort, improve cosmesis and a shorter hospital stay. However, we haven't found differences between TLN and RLN.

¿Qué técnica quirúrgica hemos de utilizar en la nefrectomía por patología benigna? / Which surgical technique should we perform for bening renal disease in children?

Objetivo. El objetivo de este trabajo es analizar nuestra experiencia en las diferentes técnicas quirúrgicas para realizar una nefrectomía en patología renal benigna en el niño. Material y métodos. Desde 1993 hasta 2005 se han realizado 98 nefrectomías. Se han dividido los pacientes en tres grupos: nefrectomía abierta (NA), laparoscópica transperitoneal (NLT) o retroperitoneoscópica (NR). NA se realizó en 36 pacientes. La edad media fue de 3,3 años. NLT se realizó en 39 pacientes. La edad media fue de 4,7 años. NR se realizó en 23 pacientes. La edad media fue de 3,6 años. Se practicó nefrectomía en pacientes con uropatía con función renal inferior al 19%. Se han comparado las tres técnicas quirúrgicas respecto al tiempo quirúrgico y la estancia media. Resultados. La media del tiempo quirúrgico fue de 126,2 min en NA, 132,3 min en NLT y 134,1 min en NR. La estancia media fue de 5,02 días en NA, 2,35 días en NLT y 1,86 días en NR. La estancia media es menor en los grupos NLT y NR respecto al grupo NA con un nivel de significancia p < 0,05, aunque, no hallamos diferencias en cuanto al tiempo quirúrgico. Conclusiones. La nefrectomía por patología renal benigna debe realizarse mediante cirugía mínimamente invasiva. Presentan menor morbilidad, menor disconfort postoperatorio, mejor resultado estético y reduce la estancia media hospitalaria. En nuestra revisión no hemos hallado diferencias entre NLT y NR (AU)

Aim. The aim of this paper is to analyze our experience in different surgical techniques to perform a nephrectomy for benign renal diseases in children. Material and methods. From 1993 to 2005 we have performed 98 nephrectomies. We have three groups of patients depending on the surgical technique: open nephrectomy (ON), transperitoneal laparoscopic nephrectomy (TLN) and retroperitoneal laparoscopic nephrectomy (RLN). ON was performed in 36 patients. Mean age was 3.3 years. TLN was performed in 39 patients. Mean age was 4.7 years old. RLN was performed in 23 patients. Mean age was 3.6 years old. Criteria to nephrectomy was a renographic function under 19%. We have compared the three surgical techniques in relation with surgical time and mean hospital stay. Results. Mean operative time was 126.2 minutes in ON, 132.3 minutes in TLN and 134.1 minutes in RLN. Mean stay was 5.02 days in ON, 2.35 days in TLN and 1.86 days in RLN. The median hospital stay of the ON group is significantly longer than that of NLT and NR groups (p < 0.05). However, there are no differences related to surgical time between all the groups. Conclusions. Nephrectomy may be performed for benign disease in children using less invasive surgical techniques. They are associated with minimal morbidity, minimal postoperative discomfort, improve cosmesis and a shorter hospital stay. However, we haven’t found differences between TLN and RLN

[Continent urinary diversion: the Mitrofanoff principle]. / Derivación urinaria continente: principio de Mitrofanoff.

INTRODUCTION: Continent urinary diversion (based on Mitrofanoff's principle), despite its complexity, is the gold standard in the treatment of those vesicourethral disfunctions that need clean intermittent catheterization (CIC) to achieve complete vesical voiding, in patients with non easily catheterizable native urethra. AIM: To analize our experience in continent urinary diversion at our centre. PATIENTS AND METHODS: We have reviewed the records of the 14 cases of continent urinary diversion in the last 8 years. They were grouped in order to the underliying condition: 1-Bladder exstrophy group (n=5): Mean age at diversion time was 5.5 years (range 3-7). In all patients the original Mitrofanoff s technique was performed (continent cutaneous appendicovesicostomy). Associated procedures were: ureterovesical reimplantation in all 5 cases; bladder neck reconstruction also in all 5 (3 of them needed vesicourethral transection); and bladder augmentation in two cases, using ileum and sigmoid respectively. 2- Myelomeningocele group (n=9, 10 procedures): Mean age was 11.5 years (range 6-16). Appendicovesicostomy was performed in 7 cases and a reconfigured ileum with the Casale technique was used in 3 cases (primarily in 2 and as an alternative in one). Associated procedures were: ureterovesical reimplantetion in 5 cases and bladder augmentation in 7 (using sigmoid in 4, ileum in 2 and urether in one case). RESULTS: In all patients complete continence was achieved. Complications found were: one appendicostomy prolapse, one appendix necrosis (that was then diverted with Casale's technique), one appendicular conduit stenosis and one case with catheterization difficulties that needed a tappering of the ileum conduit. Nowadays, 13 out of 14 pacients follow the CIC program each 3-4 hours without complication. CONCLUSION: Continent urinary diversion improves autonomy and life quality in those patients that need a definitive urinary diversion and have a long life expectancy. We have used these procedure with good results in patients with severe vesicourethral disfunction (of an intrinsic or neuropathic origin) in which clean intermittent catheterization was not possible through native urethra, or in patients with refractary incontinence in which vesicourethral transection was the only effective treatment.

Derivación urinaria continente: principio de Mitrofanoff / Continent urinary diversion: the Mitrofanoff principle

Introducción. La derivación urinaria continente (DUC, basada en el principio de Mitrofanoff), pese a su complejidad, es la técnica de elección en el tratamiento de aquellas patologías vesicouretrales que necesitan de sondaje intermitente limpio (SIL) para conseguir un vaciamiento vesical completo y en los cuales la uretra no es fácilmente cateterizable. Objetivo. Analizar la experiencia en el uso de las derivaciones urinarias continentes en nuestro centro. Material y método. Fueron revisados los 14 casos de DUC en los últimos8 años. Se agruparon según la patología de base: 1) Grupo extrofiavesical (n=5): la edad media en el momento de la derivación fue de5,5 años (rango 3-7). En todos los pacientes se practicó la técnica de Mitrofan off original (apendicovesicostomía cutánea continente). Los procedimientos asociados fueron: reimplante vesicoureteral en los 5casos; reconstrucción del cuello vesical también en los 5 (de los cuales3 precisaron una transección vesicouretral), y enterocistoplastia de aumento en 2 casos (con íleon y colon sigmoide respectivamente). 2) Grupo mielomeningocele (n=9, 10 derivaciones): la edad media fue de11,5 años (rango 6-16). En 7 derivaciones se utilizó la apendicovesicostomía y en tres un segmento ileal retubularizado con la técnica de Casale (en 2 de ellos primariamente y en el otro como alternativa). Los procedimientos asociados fueron: reimplante vesicoureteral en 5 casos y cistoplastia de aumento en 7 casos (con colon sigmoide en 4, con íleon en 2 y con uréter en un caso).Resultados. En todos los pacientes la continencia de la derivación estotal. Como complicaciones se registraron: un prolapso de apendicostomía, que se corrigió quirúrgicamente; una necrosis apendicular(que se re derivó con un conducto ileal), una estenosis del conducto apendicular, y un caso de dificultad de sondaje (que requirió remodelaje del conducto). Actualmente, 13 de los 14 pacientes siguen el programa de SIL cada 3-4 horas sin complicaciones. Conclusión. La DUC mejora la calidad de vida y la autonomía en los pacientes que requieren una derivación urinaria definitiva y tienen una expectativa de vida larga. Hemos utilizado satisfactoriamente esta técnica en pacientes con disfunción vesicouretral grave (de causa intrínseca o neuropática) en los cuales el cateterismo intermitente limpio no se podía realizar a través de la uretra nativa, y en pacientes con incontinencia refractaria en los cuales la transección vesicouretral fue el único tratamiento curativo (AU)

Introduction. Continent urinary diversion (based on Mitrofanoff’sprinciple), despite its complexity, is the gold standard in the treatment of those vesicourethral disfunctions that need clean intermittent catheterization (CIC) to achieve complete vesical voiding, inpatients with non easily catheterizable native urethra. Aim. To analize our experience in continent urinary diversion at our centre. Patients and methods. We have reviewed the records of the 14 casesof continent urinary diversion in the last 8 years. They were grouped inorder to the underliying condition: 1-Bladder exstrophy group (n=5):Mean age at diversion time was 5.5 years (range 3-7). In all patients the original Mitrofanoff’s technique was performed (continent cutaneous appendico vesicostomy). Associated procedures were: uretero-vesical reimplantation in all 5 cases; bladder neck reconstruction also in all 5(3 of them needed vesicourethral transection); and bladder augmentation in two cases, using ileum and sigmoid respectively. 2- Myelomeningocele group (n=9, 10 procedures): Mean age was 11.5 years (range6-16). Appendico vesicostomy was performed in 7 cases and a reconfigured ileum with the Casale technique was used in 3 cases (primarily in 2 and as an alternative in one). Associated procedures were: ureterovesical reimplantetion in 5 cases and bladder augmentation in 7 (using sigmoid in 4, ileum in 2 and urether in one case).Results. In all patients complete continence was achieved. Complications found were: one appendicostomy prolapse, one appendix necrosis(that was then diverted with Casale’s technique), one appendicular conduit stenosis and one case with catheterization difficulties that needed a tappering of the ileum conduit. Nowadays, 13 out of 14 patients follow the CIC program each 3-4 hours without complication. Conclusion. Continent urinary diversion improves autonomy and life quality in those patients that need a definitive urinary diversion and have a long life expectancy. We have used these procedure with good results in patients with severe vesicourethral disfunction (of an intrinsic or neuropathicorigin) in which clean intermittent catheterization was not possible through native urethra, or in patients with refractary incontinence in which vesicourethral transection was the only effective treatment (AU)

Diverticles de la uretra en nenes / Divertículos de la uretra en las niñas / Urethral diverticula in girls

Presentació de tres casos nous de diverticles de la uretra en nenes: tres pacients de 8 mesos, 8 dies i 14 anys d’edat. En els dos primers casos el diagnòstic es va fer en el curs d’una cistouretrografia practicada per estudiar una infecció urinària i una tumoració parauretral d’aspecte quistós, i en el tercer perquè la pacient presentava una tumoració que protrudia a través de la vagina. En els tres casos el diverticle es va tractar per marsupialització per via intrauretral. Els diverticles congènits són una raresa en la infància. Anatòmicament s’assenten en la uretra distal i en la cara inferior. El mecanisme de producció és desconegut, tot i que el més acceptat és que es desenvolupen a partir de les glàndules periuretrals de Skene. El diagnòstic en la nena se sol establir durant l’estudi per algun procés intercurrent, i en l’adolescent o en la dona adulta es presenta en forma d’infeccions urinàries, descàrregues vaginals o com una massa vaginal. En el diagnòstic, els exàmens complementaris són poc útils. En els casos neonatals la conducta pot ser expectant, i en edats posteriors els tractaments són la marsupialització i l’excisió transvaginal (AU)

Presentación de tres nuevos casos de divertículos de la uretra en niñas: tres pacientes de 8 meses, 8 días y 14 años de edad. En los dos primeros casos el diagnóstico se hizo en el curso de una cistouretrografía practicada para estudio de una infección urinaria y de una tumoración parauretral de aspecto quístico, y en el tercero porque la paciente presentaba una tumoración que protruía a través de la vagina. En los tres casos el divertículo fue tratado por marsupialización intrauretral. Los divertículos uretrales congénitos constituyen una rareza en la infancia. Anatómicamente se asientan en la uretra distal y en la cara inferior. El mecanismo de producción es desconocido, aunque lo más aceptado es que se desarrollan a partir de las glándulas periuretrales de Skene. El diagnóstico en la niña se suele establecer durante el estudio por algún proceso intercurrente, y en la adolescente o en la mujer adulta se presenta en forma de infecciones urinarias, descargas vaginales o como una masa vaginal. En el diagnóstico, los exámenes complementarios son poco útiles. En los casos neonatales la conducta puede ser expectante y en edades posteriores los tratamientos son la marsupialización y la excisión transvaginal (AU)

The cases of three girls (ages 8 days, 8 months, and 14 years) diagnosed with urethral diverticula, are presented. In two cases, the diagnosis was performed during a routine cystourethrogram for the evaluation of a urinary tract infection and a paraurethral cystic mass, respectively. In the third case, the patient presented with a mass protruding from the vagina. In the three cases, the diverticulum was treated with urethral marsupialization. Congenital urethral diverticula constitute a rare malformation of the genitourinary tract. They are usually located at the inferior aspect of the distal urethra. The pathogenesis is unknown, but they are believed to arise from the periurethral glands of Skene. In young girls, they are usually asymptomatic, and the diagnosis is made incidentally during the work-up of an intercurrent process. In adolescents and adults, urethral diverticula may cause urinary tract infections or vaginal discharge, or may present as a vaginal mass. In newborns, treatment may not be required, and close follow-up is recommended. At older ages, urethral marsupialization or transvaginal excision are the treatments of choice (AU)

Cyclophosphamide-induced hemorrhagic cystitis in rats that underwent colocystoplasty: experimental study.

PURPOSE: Cyclophosphamide and its derivatives induce hemorrhagic cystitis. A substantial number of patients receive bladder augmentation or replacements using bowel. If patients who have undergone colocystoplasty need treatment with cyclophosphamide before or after the operation, does hemorrhagic cystitis develop? We evaluated the histological changes produced in the colon wall and bladder related to cyclophosphamide and its derivatives in rats that underwent colocystoplasty. MATERIALS AND METHODS: Sprague-Dawley rats of each sex were grouped according to whether they received a single 200 mg./kg. dose of cyclophosphamide, underwent colocystoplasty, underwent each technique or served as controls. The technique of colocystoplasty was the same in all groups. Results were analyzed according to previously reported criteria, by the gross appearance of the bladder and colon segment used for colocystoplasty, and by histological changes. RESULTS: Two weeks after surgery colocystoplasty had not resulted in secondary changes in the implanted colon segment or original bladder, while there were only nonspecific changes of an inflammatory type in the anastomotic area. After cyclophosphamide administration the animals lost considerable weight and in the bladder area we observed hemorrhagic cystitis that was greater in males than in females, and greater in isolated bladder than when the bladder was sutured to the colon segment. In the colon there was no inflammation or hemorrhage damage of the hemorrhagic cystitis type in the bladder. A total of 12 days after colocystoplasty there were no secondary histological changes except in the anastomotic area. A single 200 mg./kg. dose of cyclophosphamide caused substantial weight loss and hemorrhagic cystitis. Cystitis was quantitatively greater in males than in females and greater in isolated bladder than in bladder anastomosed to the colon. CONCLUSIONS: Administering a single dose of cyclophosphamide did not result in lesions in the colon segment used for colocystoplasty analogous to those of the bladder, such as hemorrhagic cystitis.

Treatment of proximal hypospadias with a tubularized island flap urethroplasty and the onlay technique: a comparative study.

BACKGROUND/PURPOSE: The onlay island flap urethroplasty was first described in the repair of mid and distal penile hypospadias. Since then, this technique has been increasingly used in more severe cases of hypospadias, because of the complications of tubularized flaps, mainly megaurethra and proximal anastomotic strictures. The aim of this study was to compare the morbidity of these 2 techniques. METHODS: Between April 1994 and December 1998, 80 patients underwent surgical treatment for hypospadias. A tubularized island flap (Ducketttechnique) was performed in 42 cases, and the onlay island flap technique was used in 38 patients. The authors retrospectively compared the complication rate and type of these 2 procedures. RESULTS: Altogether, fistula was the most frequent complication without any significant difference between the 2 groups (21.4% for Duckett technique and 18.4% for onlay repair; P > .05). However, the anastomotic stricture was much more common in the tubularized flap group (7.14% v 2.63%; P < .05). Moreover, a megaurethra was found only in the Duckett technique group (4.7%). There was no case of chordee recurrence, but 6 patients (15.7%) treated with the onlay technique required urethrolysis including dissection of the chord behind the urethral plate, and in the other 3 patients of the same group (7.9%), a dorsal Nesbit plication also was necessary. In all these cases, the urethroplasty included an island cutaneous flap to provide ventral coverage to the neourethra. CONCLUSIONS: The authors conclude that both techniques present similar complications. However, proximal strictures and megaurethra are more common after the Duckett technique. This procedure is of choice in patients with scrotal hypospadias. Conversely, the onlay repair should be completed with other procedures (urethrolysis, dorsal Nesbit plication) to obtain good results in patients with severe degree of chordee.

Congenital hemangiopericytoma: two cases of familiar presentation.

We report two cases of congenital hemangiopericytoma localized in the abdominal wall in the first patient and scalp in the second. The treatment of both cases consisted in the complete resection of the tumor mass. Four and two years later the patients remain asymptomatic. The special interest in this case report lies in the extremely low incidence of congenital hemangiopericytoma and that this is the first reference to affected siblings.

Xanthogranulomatous pyelonephritis in children: conservative management.

OBJECTIVES: Three new cases of xanthogranulomatous pyelonephritis are described in children. METHODS: Laboratory examinations including white and red blood cell counts, erythrocyte sedimentation rate, renal function, urinalysis and cystography were performed. RESULTS: All of the patients had a palpable abdominal mass. Urine culture was positive (Proteus mirabilis) in only 1 patient. Associated urological abnormalities were found in 2 cases. Urographically a functionless kidney was encountered in 2 children and a renal mass in the other. None could be diagnosed preoperatively. CONCLUSIONS: Although nephrectomy has been said to be the treatment of choice, conservative treatment can be successful as shown by 1 of our patients.

Exophytic urinary bladder lesions in childhood.

A retrospective study of the clinical presentation, diagnosis, and treatment of eight patients whose common characteristic was an exophytic, solid urinary bladder lesion (botryoid rhabdomyosarcoma, transitional-cell carcinoma, nephrogenic adenoma, cystitis cystica, von Brunn's nests, hemangioma, and squamous-cell metaplasia) is presented. Exophytic bladder lesions, some of which are of great importance, are rare entities in childhood and present nonspecific clinical pictures. Therefore, whenever a space-occupying lesion is detected on a complementary study of the lower urinary tract, the differential diagnosis should be considered. Advantages of each of the currently available diagnostic methods are discussed and the essential role of cystoscopy is stressed.