[Successful treatment of second hepatoblastoma relapse--case report].

INTRODUCTION: The prognosis of hepatoblastoma has changed since effective adjuvant chemotherapy had been introduced in 1980's. There is a general agreement that complete resection is the cornerstone of treatment for children with hepapatoblastoma and the only way for eventual cure. CASE REPORT: We describe a boy with relapsed hepatoblastoma presenting with elevated -fetoprotein (AFP) and no visible tumor by ultrasound and computed tomography (CT). The relapse was treated with chemotherapy. Second relapse occurred shortly after therapy was completed, but this time we waited for tumor mass to appear. Combined surgery and chemotherapy resulted in remission status with 48 months of follow up. CONCLUSION: Hepatoblastoma relapse without evidence of tumor is not unusual but its treatment remains controversial. Radiological investigations should be repeated until site of relapse is identified. Based on our experience it seems of no benefit to treat isolated elevation of AFP.

Surgical treatment of cloacal anomalies.

From 1989-1998 14 patients were treated with cloacal anomalies: 5 typical cloacas (PC), 5 posterior cloacas, and 4 cloacal exstrophies (CE); 12 underwent surgery. Four typical cloacas were resolved with posterior sagittal anorectovagino-urethroplasty (PSARVUP), whereas in the 5th total urogenital mobilization (TUM) was used. Three PCs were managed with transanorectal TUM and 2 with anterior TUM without opening the anal canal and rectum (without a protective colostomy). Two CEs were treated with atypical procedures. Two patients with CE died without surgery and 2 died after surgery due to complex associated anomalies. During postoperative follow-up of 1-8 years, 5 children had voluntary bowel movements and no soiling while the others had soiling with or without enemas; 1 had stress incontinence; 3 were on clean intermittent catheterization due to neurogenic bladder and were dry. PSARVUP provides a satisfactory result if there is no sacral anomaly. TUM makes this operation easier to perform. In patients with a PC it is sometimes possible using TUM to separate the urinary from the genital tract and remove the accessory urethra without opening the anus and rectum.

Surgical treatment of the Müllerian duct remnants.

BACKGROUND: Persistent Müllerian duct tissue in male individuals may result in an enlarged prostatic utricle (utricular cysts and utricle) or a Müllerian duct cysts, either distinctively or synonymously. In intersex patients Müllerian duct remnants (MDR) are an usual occurrence. Surgical excision is the definitive treatment of symptomatic remnants, as well as during the reconstruction of intersexual genitalia. Many approaches have been described. The authors review their experience in intersex patients. METHODS: From 1986 to 1999, the authors treated 111 patients with intersex disorders. The records of 47 patients raised as boys with MDR were reviewed. Based on the symptoms and the size of the remnants, in 32 patients the structures were removed. In 13 patients extirpation was done by perineal approach, in 9 by transperitoneal approach, and in the remaining 9 patients the combined abdominal and perineal approach were undertaken. In one patient the large prostatic utricle was extirpated by a posterior sagittal pararectal approach. Perineal approach was mainly used in younger asymptomatic children, with the prostatic utricle disclosed incidentally during genitography because of intersex disorders. Operation was performed only in cases in which the prostatic utricle was observed by cystoscopy or identified by Fogarty balloon catheter introduction into the prostatic utricle. In older patients these structures were discovered frequently after failed urethroplasty, or after symptoms of urinary infection, urinary retention, or epididymitis. We elected to use the transperitoneal approach based on the extension of these structures into the pelvis. The average age of patients at the time of surgery was 8.6 years, with a range of 1 to 30 years. RESULTS: There were no rectal or bladder injuries during surgery. An older patient had temporary impotence after abdomino-perineal extirpation. The lack of ejaculation, seen in 5 patients, was related to frequent intra-utricular termination of the vas deferens. Posterior sagittal pararectal approach certainly enabled complete exposure and exact visualization of all structures, with considerably decreased bleeding. If gonadal biopsy or gonadectomy were necessary, the transperitoneal approach could not be avoided. CONCLUSIONS: Surgical treatment of MDR in intersex patients varies according to the size of the utricle, and a double approach is often necessary. A high degree of success may be achieved with minimal morbidity. J Pediatr Surg 36:870-876.

[The Lesch-Nyhan syndrome]. / Les-Nijanov (Lesch-Nyhan) sindrom.

Deficiency of hypoxanthine phosphoribosyltransferase (HPRT) has a broad spectrum of clinical manifestations, from the complete enzyme defect, the Lesch-Nyhan syndrome with severe neurological deficiency to the partial defect associated only with uric acid overproduction and its consequences. We present a 5-year old boy with Lesch-Nyhan syndrome. He came to our hospital because of abdominal pain, vomiting and gross haematuria. At the age of 8 months he was categorized as a "cerebral palsy" patient due to involuntary movements and high degree of spastically and tonic spasms. He remained incapable of sitting or standing alone. The patient's brother and two uncles were also categorized as "cerebral palsy" cases and died at the age of 8-14 years. Clinical examination revealed hyperuricaemia and hyperuricosuria, radiolucent renal and urinary bladder stones. HPRT enzyme activity was totally absent, while adenine phosphoribosyl transferase activity was increased compared to control. The patient was treated with allopurinol, urinary alkalization, low-purine diet and adequate hydration while he was in hospital. However, his parents refused further treatment and follow-up. The most important issue is whether the healthy sisters of the patients are heterozygotes for HPRT deficiency. This DNA analysis is now in progress.

[Ultrasound in the diagnosis of hypertrophic pyloric stenosis]. / Ultrasvuk u dijagnostici hipertroficne stenoze pilorusa.

The paper deals with the advantages of ultrasound diagnosis of hypertrophic pyloric stenosis in newborns. Ultrasound decreases the number of radiological examinations of gastroduodenum and reduces diagnostic exposure of children to X-rays. In the last three years 107 children had manifested clinical signs of hypertrophic pyloric stenosis. The ultrasound studies revealed hypertrophic pyloric stenosis in 55 patients (51.4%). There were 48 boys (87.3%) and 7 girls (12.7%). Patients were aged 17 to 75 days (average about 40 days). The sonogram finding was typical for hypertrophic pylorus, which made the diagnosis easier. There were no false positive or false negative ultrasound findings. All patients with hypertrophic pyloric stenosis were operated on and diagnosis was confirmed. Ultrasound is reliable in diagnosis of hypertrophic pyloric stenosis. Ultrasound examination is technically easy and fast, what is important for urgent surgical therapy. In children with persistent projectile vomiting, suspected of hypertrophic pyloric stenosis, ultrasound is the method of choice and should replace X-ray examinations.

[Intestinal intussusception in children. Ultrasonic diagnosis]. / Invaginacija intestinuma kod dece. Dijagnostika ultrazvukom.

The aim of the paper is to demonstrate a successful use of ultrasound in the diagnosis of intestinal intussusception in children. Ultrasound decreases the number of irrigographic examinations and reduces diagnostic exposure of children to X-rays. In the last three years 35 children, aged from 3 months to 15 years (average 2 years), had a suspected clinical diagnosis of intussusception. The ultrasound studies revealed intestinal intussusception in 26 patients (74%). There were no false positive or false negative ultrasound findings. In four patients with secondary intussusception the main symptoms were identified (three solid lesions and two Meckel's diverticula). Intraluminal lesions at the apex of intussusception were confirmed by surgery. In 22 patients intussusception was idiopathic. In 15 of these patients (68%), hydrostatic desinvaginations, under combined ultrasound and radioscopic control, were successful. High grade unsuccessful hydrostatic reductions were associated with long persistence of symptoms (2 to 9 days). Ultrasound is reliable in diagnosis of intestinal intussusception and useful in control of hydrostatic reduction. In patients with expected intestinal perforation ultrasound should be combined with fluoroscopy.

True hermaphroditism: 10 years' experience.

True hermaphroditism (TH) is the rarest variant of intersex malformations. By definition, these patients have both ovarian and testicular tissue. Most present due to ambiguous genitalia and/or gynecomastia. From 1986 to 1996, we treated 97 patients with intersex disorders; there were 4 with TH. In all cases testicular and ovarian tissue was separate. In 3 patients the external genitalia were ambiguous and 1 had hypoplastic male genitalia. Three patients had a 46, XY and 1 a 46, XX karyotype. Three patients had been listed as males and 1 as a female. The number of operations required varied from 3 to 9 (mean 5.7 per patient). Two patients who had been raised as males finished puberty with hypogenitalism and hypoplastic testes. One married and could have erections, but no ejaculation. Two male patients have been on supplementary androgen therapy. The only patient who had been raised as a female after clitorovaginoplasty had a 6-cm-deep, blind-ending vagina that was deepened to 12 cm with bougienage, so that she was capable of having normal intercourse. It is felt at present that most patients with TH should be raised as females. This was confirmed in our patients as well, which underlines the significance of early diagnosis.

[Renal tubular function in children with hypercalciuria]. / Funkcije tubula bubrega kod dece s hiperkalciurijom.

INTRODUCTION: Renal stone disease is commonly due to hypercalciuria [1, 2], which may be assessed either from a 24-hour urinary collection or from the fasting first morning urine. Hypercalciuria during childhood has been defined by a 24-hour calcium excretion greater than 3.5 mg/kg per day and/or calcium to creatinine ratio greater than 0.20 [3]. The alteration in the calcium transporting systems plays a pathogenetic role in promoting hypercalciuria [4, 5]. Since calcium reabsorption along the nephron is intimately related to that of other electrolytes and substances, it can be hypothesized that patients with hypercalciuria may have other renal tubular defects. The aim of the study was to investigate proximal tubular function (tubular reabsorption of sodium, potassium, phosphate and glucose) and distal tubular function (urinary concentrating capacity and acidifying capacity) in children with hypercalciuria. PATIENTS AND METHODS: Two groups of children were studied: hypercalciuric group included 23 children with hypercalciuria (10 males, aged 11.9 +/- 4.1 years), of whom 6 with nephrolithiasis, and control group included 42 healthy children (20 males, aged 11.2 +/- 3.8 years). All subjects had normal serum values for calcium, sodium, potassium, phosphate and glucose, as well as normal renal function. The urinary excretion of calcium, sodium, potassium, phosphate, glucose and creatinine was measured in a 24-hour urine specimen by standard laboratory methods. Urine osmolality and urinary specific gravity were measured following 12-hour water-deprivation test. A short ammonium chloride loading test was performed in 3 patients with urinary pH above 5.5. The fractional excretion of sodium, tubular phosphate reabsorption and renal threshold phosphate concentration were calculated according to standard formula. Statistical analysis was performed using the t-test and analysis of variance (ANOVA). Kruskal-Wallis method was used to compare urinary phosphate excretion between two groups. RESULTS: Table 1 summarizes urinary excretion of electrolytes in children with hypercalciuria compared with healthy controls. We found that urinary sodium excretion was significantly increased in patients with hypercalciuria when compared with controls (p < 0.05). Urinary phosphate excretion was significantly higher in patients with hypercalciuria in comparison to controls, and this was accompanied by a significant lowering of the tubular phosphate reabsorptive threshold (p < 0.05). Urinary potassium excretion tended to be lower, although not significantly, in the hypercalciuric children than in normal subjects. Table 2 shows the mean values +/- standard deviation of urinary specific gravity, urinary osmolality and urinary pH. Urinary specific gravity mean value was significantly lower in patients with hypercalciuria in comparison to controls (p < 0.05). Urinary pH was found below 5.5 in all patients. Glycosuria was detected in 3 patients (13.3%). As shown in Graph. 1, a significant correlation between the urinary excretion of calcium and sodium was demonstrated in both groups of children (r = 0.29; p < 0.01). DISCUSSION: The present study shows that children with hypercalciuria have significantly higher urinary sodium and urinary phosphate excretion in comparison to controls, while urinary potassium excretion is normal in both groups of children. According to some recent reports [6-9], these findings may indicated defects of the renal tubular transport of sodium and phosphate which may be interpreted as a cause or a consequence of the alteration of the calcium transporting system. Defects in both proximal and distal renal tubular functions have been demonstrated in patients with nephrolithiasis, particularly those with hypercalciuria. Proximal renal tubular defects include defects in sodium, fluid, phosphate and glucose reabsorption, which were evident also in our patients. (ABSTRACT TRUNCATED)

[Sodium excretion in children with lithogenic disorders]. / Izlucivanje natrijuma kod dece s litogenim poremecajima.

INTRODUCTION: The causes of nephrolithisis are multifactorial and have not yet been enough investigated [1]. Hypercalciuria is the most common cause of metabolic nephrolithiasis [2-4]. Close relationship between urinary calcium and urinary sodium has been a subject of reported observations in the past, showing that high urinary sodium is associated with high urinary calcium [5-7]. Hyperoxaluria, hyperuricosuria and cystinuria are also metabolic disorders that can lead to nephrolithiasis. Recent studies have indicated that urinary elimination of cystine is influenced by urinary sodium excretion. Based on these observations it has been hypothesised that patients with high urinary sodium excretion are at high risk of urinary stone disease. The purpose of the study was to investigate sodium excretion in a 24-hour urine and first morning urine collected from children with lithogenic metabolic abnormalities (hypercalciuria, hyperoxaluria, hyperuricosuria, cystinuria), both with nephrolithiasis and without it, in order to determine its significance in urinary calculi formation. PATIENTS AND METHODS: Urinary sodium excretion was investigated in 2 groups of children: patients with lithogenic metabolic abnormalities, but without urinary stone disease (L group) and patients with nephrolithiasis (C group). Both groups were divided into 2 subgroups: patients with hypercalciuria and without it. There were 22 patients in group L (mean age 11.97 +/- 4.13 years), of whom 17 formed a hypercalciuric subgroup and 5 formed a non-hypercalciuric subgroup (3 patients with hyperuricosuria and 2 patients with hyperoxaluria). Group C consisted of 21 patients with nephrolithiasis (mean age 12.67 +/- 3.44 years), of whom 6 formed a hypercalciuric subgroup and 15 formed a non-hypercalciuric group (2 patients with cystinuria and 13 patients without lithogenic metabolic abnormalities). Control group consisted of 42 healthy age-matched children. All subjects had a normal renal function. A detailed history and clinical examination were done, and ultrasonography was performed in all patients. A 24-hour urine, first morning urine and serum specimen were analysed for sodium, potassium, calcium, uric acid, urea and creatinine. Fractional excretion of sodium, as well as urinary sodium to creatinin ratio and urinary sodium to potassium ratio, were calculated from the findings. Sodium and potassium levels were determined by flame photometry, calcium was measured by atomic absorption technique (Beckman Atomic Spectrophotometer, Synchron CX-5 model, USA), uric acid by carbonate method and creatinine by Jaffe technique. Cystine and dibasic amino acids were quantified by ion chromatography. Urinary oxalate excretion was determined by enzyme spectrophotometry. Hypercalciuria was defined by 24-hour calcium excretion greater than 3.5 mg/kg per day and/or calcium to creatinine ratio greater than 0.20 [8]. Uric acid excretion was expressed as uric acid excretion factored for glomerular filtration, according to Stapleton's and Nash's formula [9]. Normal values were lower than 0.57 mg/dl of glomerular filtration rate in 24-hour samples. Mean values were statistically analyzed by Pearson's linear correlation and analysis of variance (ANOVA). RESULTS: Urinary sodium concentration values including urinary sodium to potassium ratios, are shown in Table 1. We found that urinary sodium excretion was significantly increased in patients of both L and C groups when compared with controls (p < 0.05). Further analysis of the subgroups showed that urinary sodium excretion was significantly higher only in patients with hypercalciuria of both L and C groups in comparison to controls (p < 0.05) (Table 2). A significant positive correlation was found between 24-hour urinary sodium to creatinine ratio and urinary calcium to creatinine ratio (r = 0.31; p < 0.001) (Graph 1), as well as between urinary sodium to potassium ratio in 24-hour and first morning urine (r = 0.69; p < 0.001) (Graph 2). (A

[Adrenal gland hemorrhage in neonates--radiologic aspects]. / Hemoragija u nadbubreznoj zlezdi kod novorodjenceta--radioloski aspekt.

INTRODUCTION: The relatively large adrenal glands of the newborn are vulnerable to mechanical trauma during delivery. Great birth weight, difficult labor, perinatal hypoxia and prematurity are predisposing factors of adrenal haemorrhage. Minor adrenal haemorrhage may not cause symptoms. Massive adrenal haemorrhage is uncommon. Symptoms include anaemia and jaundice associated with a suprarenal mass. In cases with severe blood loss acute shock may develop. In 5 to 10 per cent of cases the haemorrhage is bilateral. Ultrasonography has replaced urography in the diagnosis of this condition demonstrating the site and size of the lesion and allowing an accurate follow-up. Within a month after haemorrhage the blood and necrotic adrenal tissue are resorbed and thin calcification appears at the periphery of the gland. Surgery is necessary if haemorrhagic pseudocyst is large and does not resorb spontaneously. MATERIAL AND METHODS: From 1992 to 1996, five patients with neonatal adrenal haemorrhage were treated at the University Children's Hospital in Belgrade. Two of them were females. All patients were born at term by vaginal delivery. Their birth weights ranged between 3200 and 4050 g. At hospitalization infants were aged from 6 hours to 18 days. The first symptom of adrenal haemorrhage was an abdominal mass in three patients. One of them had laparoschisis with guts and stomach protruding out; the surgeon discovered a mass in the right retroperitoneum during operation. Two patients had jaundice associated with anaemia, and sepsis another two. Ultrasonography was done in all patients. We punctured the haemorrhagic pseudocyst (diameter above 5 cm) in three patients and made cystography. Liquid components of pseudocysts were aspirated and sent to bacteriological and cytological analyses. RESULTS: The diagnosis of adrenal haemorrhage was confirmed by ultrasonography in all patients, demonstrating a right adrenal mass (unilateral in all patients), mostly hypoechoic, which displaced the right kidney. Calcification at the periphery of the pseudocyst appeared in one patient. The adrenal haemorrhage disappeared spontaneously in two patients after two months. An attempt to support the adrenal hemorrhagic pseudocystic regression by puncturing and aspirating its content in three patients was successful in one infant. The patient with laparoschisis died because of sepsis and thrombocytopenia. In a patient the haemorrhagic pseudocyst persisted (6 cm in diameter) and was surgically removed. DISCUSSION: Ultrasound is the method of choice in the diagnosis of adrenal haemorrhage, antenatally and neonatally. It also allows diagnosis of coexisting complications such as renal vein or inferior vena cava thrombosis and a proper follow-up. Puncture of pseudocyst and aspiration of liquid components may support involution of large haemorrhagic pseudocysts. If it is unsuccessful, surgery is necessary.

[Problems in the diagnosis of obstructive anomalies of the upper urinary tract]. / Problemi u dijagnostici opstrukcionih anomalija gornjeg urotrakta.

Today's diagnostics of hydronephrosis involve the necessary distinction between obstructive and nonobstructive dilatation of the urinary tract. Vagueness either in terminology or in the basic nature cannot be tolerated. Definition problems of partial obstruction of urotract result from the deficiencies of the methods applied when analyzing obstructions. Although the definition of the partial of urinary tract is not sufficiently comprehensive, it is nevertheless possible. Differencies in reliability of the most frequently used methods in the diagnostics of urotract obstruction result from the quality of information presented by the method. By appreciating the limits of the current diagnostical methods, failure in the interpretation of results obtained by their application may be avoided. A diuretic renogram, pressure flow test, usage of Doppler sonography with real-time sonography and well incorporated classical urography are methods of evaluation which make the diagnostics of urotract obstruction reliable and the treatment efficient.

[Percutaneous biopsy of the kidney in children (technical aspects)]. / Perkutana biopsija bubrega kod dece (tehnicki aspekt).

The paper analyzes 111 percutaneous kidney biopsies done over the last six years in 107 children (sixty-two patients were female and forty-five male), aged from 1 to 18 years (mean 9.5 years). The authors evaluate advantages of percutaneous biopsy of kidney in obtained an adequate tissue sample for histopathological diagnosis as compared to technical problems and complications regularly associated with the method. All biopsies were performed under local anaesthesia with Tru-Cut[symbol: see text] needles (14 gauge). In 107 biopsy specimens (96.4%) the tissue sample was adequate for histopathological analysis. Following the biopsy, the kidney was routinely scanned to detect a hemato-urinoma. Complications occur in sixteen patients (14.4%). Percutaneous kidney biopsy in children is a safe an reliable technique for obtaining adequate samples of renal tissue for histopathological analysis.

[Multicystic dysplastic kidney. Therapeutic dilemmas and personal experience]. / Multicisticni displazicni bubreg. Terapijske dileme i nase iskustvo.

A multicystic dysplastic kidney (MCDK) is one of the most frequent causes of abdominal mass in the neonate. Prenatal echography permits early and frequent diagnostics. It is a nonfamilial disease without associated cystic disease of the pancreas, liver or lungs. Indications for elective surgery are clear when there is a symptomatic disease. However, treatment of asymptomatic patients is controversial. A rising number of authors prefer nonsurgical approach, leaving MCDK intact with a close follow-up of patients for possible severe complications (malignancy, hypertension, infection, pain, rupture). We treated 15 patients with MCDK from 1984 to 1994. Diagnosis was passed antenatally in 7 (47%) patients, accidentally in 2, and based on the presence of abdominal mass in 6 patients. Two patients had renal failure due to the abnormal contralateral kidney. Nine patients were operated on and 6 were treated nonsurgically. The risk of complications associated with nonsurgical treatment, easiness of efficient surgery at the age of 3-6 months, avoiding stress in the child and family due to long-term follow-up, all suggest operative treatment. We suggest to parents both operative and nonoperative options, explaining the risk and danger of both. We believe that nephrectomy is the best solution in a child with MCDK who is growing, develops hypertension, with uncertain diagnosis or when adequate follow-up is impossible.

[Ultrasonographic findings of upper urinary tract dilatation after the subureteral teflon injection (STING) anti-reflux procedure in children]. / Ultrasonografski nalaz dilatisanog gornjeg urotrakta posle postupka STING-antirefluks kod dece.

A review of ultrasonographic urotract controls was done in 487 children (390 female and 97 male) in whom subureteral Teflon paste had been endoscopically infected in order to avoid vesicoureteral reflux. Dilatation of the upper urinary tract was visualized in 91 of 732 ureters (12.43%). Upper urotract dilatation may be either a sign of the obstruction of ureterovesical junction caused by Teflon or recurrence of vesicoureteral reflux. Echosonographically, 4 types of dilatation were disclosed, each having, a particular diagnostic or therapeutic approach. Acute dilatations associated with pain (2 patients-0.4%) were subjected to emergency surgery (ureterocystoneostomy). Chronic dilatation, which did not abate even after 4 weeks (6 ureters-0.81%) was identically treated. A temporary dilatation usually withdrew spontaneously after 1-2 weeks (66 ureters-9.01%). Patients with delayed occurrence of intermittent dilatation (17 ureters-2.32%) underwent control micturating cystosonography for suspected reflux recurrence.

Surgical treatment of intersex disorders.

Despite the progress made in understanding the factors regulating sexual differentiation, infants born with ambiguous genitalia face significant problems. The authors reviewed a group of 84 children with ambiguous genitalia managed surgically between 1986 and 1993. The most frequent condition was male pseudohermaphroditism (PM) (58%); 31% had female pseudohermaphroditism. Fifty-seven percent of patients were raised as males and 43% as females. In each group of patients, feminine and masculine reconstructive operations were performed. In only 31% of PM and 60% of PF cases was the diagnosis made within the first 2 months of life. In 41% of PF and 40% of PM patients, treatment was begun before the second year of life, which we consider an acceptable time. The timing and type of vaginoplasty were determined by the point of entry of the vagina into the urogenital sinus. Of the 29 patients reared as females, 22 required perineal vaginoplasty, had pull-through vaginoplasty, and 2 had colovaginoplasty. Since 1986, we have applied Mollard's clitoroplasty, which preserves the neurovascular bundle and is important for experiencing orgasm. Seventeen percent of patients with feminization procedures experienced complications. The optimal time for masculinization procedures is 2 years of age, after obligatory testosterone treatment. If there is utriculus prostaticus (UP) type II or III, it is removed before urethroplasty. This is not done for UP types 0 and 1. In PM cases, the number of feminization and masculinization operations was 2.1 and 4.05 per patient, respectively. It is easier to make a vagina than a phallus, not taking into consideration dimensions, aesthetics, or capability of erection of the phallus.(ABSTRACT TRUNCATED AT 250 WORDS)

[Spontaneous proximal displacement of double-J ureteral catheters--successful ureteroscopic removal]. / Spontana proksimalna migracija ureternih katetra double J kod dece--uspesno ureteroskopsko uklanjanje.

Numerous different complications have been reported after double-J stent placement. We report a spontaneous proximal displacement of double-J catheters in three children that had been succesfully removed ureteroscopically. Double-J indwelling catheters offer an enormous arsenal against different urologic diseases. No stent is ideal, so urologist must be familiar with the indications for usage, modes of insertion and possible complications. Spontaneous proximal or distal stent migration, as complication, has been reported in adult patients, but not in children.

[Diagnosis of ureteral duplication associated with complications]. / Dijagnostika dvostrukog uretera pracenog komplikacijama.

In three patients (mean age about 3 years) we established excretory tract duplication with obstructed ectopic ureter, a function of the upper pole and ectopic ureterocele. Diagnostic procedure was different in each case. Ultrasonography was the most important diagnostic method in all cases; it usually showed all main morphological details, regardless of functional ability of the kidney. To complete diagnosis, we used additional methods: antegrade pyelography and percutaneous nephrotomy. Excretory urography and voiding cystography gave only indirect signs of a functional part of duplicated excretory tract. The methods we used were complementary and they should rationally be combined in order to complete the diagnosis of ureteral duplication with complications.

[Personal experience with the use of percutaneous nephrostomy in children]. / Nasa iskustva sa primenom perkutane nefrostome kod dece.

Over a 3-year period 52 percutaneous nephrostomies (PCN) were performed in 37 children. The youngest patient was 2 months old, the oldest was 16 years. The primary indication was the obstruction of the upper urinary tract; infection in 25 patients and renal failure in 14 patients were evident. By posterolateral approach a sonographically guided antegrade pyelography was first performed with Chiba 22-gauge needle. Under fluoroscopic control a lower polar calix was punctured with 18 G sheathed needle; a guide wire was introduced through the sheet. After dilatation of the tract a pigtail catheter (7-8 French) was placed into the renal pelvis. Catheter placement was performed with local anaesthesia (2% Cystocain). Complications were uncommon. Surgery was needed in all patients for permanent solution of obstruction. PCN is the method of choice for temporary relief of obstruction of the upper urinary tract in children when immediate surgery is hazardous.

[Diagnostic and therapeutic significance of percutaneous nephrostomy in children]. / Dijagnosticki i terapijski znacaj perkutane nefrostomije u dece.

During the period from April 1986 to March 1988 on the Pediatric Clinic in Belgrade a total of 12 percutaneous nephrotomies were performed to relieve obstruction of the upper urinary tract. The youngest patient was a two-month old with giant hydronephrosis, and the oldest was a 12-year old girl with an acute kidney obstruction caused by impaction of wedging the poured off stone. The most common reasons for obstruction of the upper urinary tract were congenital stenoses and postoperative scars, urethrocystoneostomia and pyeloplasty. The most frequent clinical manifestations in patients on whom nephrotomy was carried out as an emergency operation were infection, palpable tumor (cyst) and acute kidney insufficiency. Percutaneous nephrostomy was always performed with basal sedation and local infiltrative anesthesia under X-ray control. Surgery was necessary in all cases, but no complications needing surgical intervention occurred. Mild hematuria can be expected at almost every punction, so it should not be treated as a complication. Dislocation of the nephrostoma catheter immediately after surgery can be a complication which necessitates reintervention, but if this happens after more than ten days, the catheter can easily be replaced through the formed fistulous channel. In one case percutaneous placing of the catheter was not possible, so it was placed surgically in the kidney and skin to enable drainage of the infected urinome a month after rupture of the ureteropyelic segment. Percutaneous placing of a catheter through the nephrostoma is the method of choice for urgent and temporary relief of obstructions of the upper urinary system regardless of etiology, and this procedure achieves immediate therapeutic and, if necessary, diagnostic effect which enables recovery of the patient and preparation for definitive surgery which in such a situation could be hazardous.