[Severe primary vesicoureteral reflux in infants. A follow-up of 203 cases]. / El reflujo vesicoureteral primario severo en el primer año de la vida. Revisión de 203 casos.

OBJECTIVE: The aim of our study is to analyze the clinic characteristics and evolution of the primary reflux in infants. METHODS: We studied retrospectively 203 infants in our hospital, diagnosed of severe primary renal reflux. Renal ecography and cyclic mictional cystography were practiced in all cases. DMSA was carried out in 181 patients. RESULTS: Renal reflux was unilateral in the 23% of the patients, and bilateral in the remaining cases; 72% of the renal reflux were grade IV and 28% grade V. The renal injuries affected to male infants and reflux grade V. The renal injury was focal (27%), global (44%) and atrophic (29%). The 79% of the patients had conservative treatment, while 21% had surgical treatment. 100% infants with surgical treatment and 94.2% infants with conservative treatment were recovered (Test of Kaplan-Meier). The 27% of patients developed one or several urinary infections, but progression of old renal injuries or formation of new ones, were exceptional (3 cases): While the time the study lasted none of the patients developed chronic renal failure nor arterial hypertension. CONCLUSIONS: 1) The fetal severe primary reflux of the patients was characterized by the following features: to be bilateral reflux, to affect mainly to male infants and to be associated in 33% of cases with a severe renal injury of congenital origin (renal displasia) most of them unilateral. 2) The natural evolution of the reflux goes to spontaneous recovery, so treatment must be conservative. 3) Some patients underwent urinary infections, but progression or formation of new renal injuries were inusual. None of the patients had terminal renal failure nor hypertension and 4) Risk patients would be male infants with bilateral injuries although these are infrequent.

[Intrarenal reflux and kidney damage in essential vesicoureteral reflux]. / Reflujo intrarrenal y daño renal en el marco del reflujo vesicoureteral esencial.

We had reviewed our series of 59 patients with intrarenal reflux selected out of 596 diagnosed of vesicoureteral reflux. The number of renal units affected of intrarenal reflux was 74. We divided our patients into two groups, in an attempt to clarify the relationship between renal damage and urinary infection; a group include there was prenatal diagnosis of urinary tract dilatation and another group diagnosed for bacterial infection of urine after birth. Reflux nephropathy were present in 27 renal units; 9 from 30 units (30%) in the prenatally diagnosed group, and 18 from 44 units (41%) in the other group. Reflux nephropathy was diagnosed by intravenous pyelogram and/or radionuclide renogram. We concluded that intrarenal reflux (IRR) is relatively frequent in our population and that 30% of patients prenatally diagnosed had renal damage without urinary infection, landing support to the previously published existence of a prenatal origin for some newborn.

[Fetal urinary dilatation due to vesico-ureteral reflux]. / Dilatación urinaria fetal por reflujo vésico-ureteral.

We have retrospectively studied 163 newborns referred to us between 1986 and 1990 for sonographic diagnosis of intra-uterine upper urinary tract enlargement. All were studied by paediatric radiologists on days 5th or 6th after birth by means of sonography and voiding cystourethrogram (VCU). Fifty percent had also IVP. No urinary tract disease could be found in 44 children, obstructive uropathy or cystic disease were diagnosed in 58 children and 61 patients had vesico-ureteric-reflux (VUR). They form the basis of the present report. There was a male-to-female ratio of 3.3 to 1. Neonatal ultrasonography was normal in 11 cases, 42 had pyelectasia (bilateral in eight cases) and eight had ureterohydronephrosis (bilateral in seven). VUR was bilateral in 28 cases, right in 16 and left in 17. Out of the 89 refluxing units, VUR grade was I in 11, II in 16, III in 24, IV in 14 and V in 23. There was intra-renal reflux in 17 units. Some other form of urinary tract disease was detected in 29 babies (47.5 per 100). Twenty-eight patients were operated upon and the remaining are under long-term urinary antisepsis with only five episodes of infection. The considerable proportion of false negatives for VUR in neonatal ultrasonography (30 per 100) and the high grade of some of these cases lead us to strongly advise routine VCU for patients with intra-uterine urinary tract dilatation.

[Syringoceles of Cowper's glands in children]. / Siringoceles de las glándulas de Cowper en niños.

Some tubular or cystic diverticula observed in the ventral wall of the male bulbous urethra that originate from dilatation of Cowper's gland ducts have been termed "syringoceles". They can cause dysuria, hematuria and obstruction. We report 14 syringoceles and 1 true diverticulum from segmental absence of spongious urethra. We review embryology, anatomy and diagnosis in order to determine the best therapeutic approach. We performed endoscopic resection of the distal valve-like border of the diverticulum in 6 patients (42.85%) with good results. The remaining 8 patients, in whom surgery was not indicated, were followed clinically and radiologically.

[Primary vesicoureteral reflux. II. Renal growth in kidneys with pyelonephritis]. / Reflujo vesicoureteral primario. II: Crecimiento renal en riñones con pielonefritis.

We have studied kidney growth and function in 38 patients with either unilateral (23) or bilateral (15) vesicoureteral reflux (VUR) and reflux nephropathy (RN). Average follow-up was 38 (range 12-84) months. Surgery was performed in 93.3% of units. Renal length measurement alone was not satisfactory for detection of focal scarring, whereas cortico-renal index was much more discriminant. Growth of kidneys with bilateral RN was impaired, but there were no correlations with either VUR grade not with urinary infection relapses after VUR cure. Growth was also impaired in unilaterally scarred kidneys and renal length measurement revealed itself as very unsatisfactory in them. Contralateral unscarred kidneys underwent hypertrophy in some cases and growth patterns suggested that hypertrophy will become more evident as follow-up goes on. Neither glomerular filtration rate nor fractionated Na excretion were useful to detect renal lesions, whereas concentration capacity revealed renal damage in bilateral cases. There was hypertension in only one child, but peripheral blood renin was elevated in 15.62% of patients.

[Primary vesicoureteral reflux. I: Renal growth in kidneys without pyelonephritis]. / Reflujo vesicoureteral primario. I: Crecimiento renal en riñones sin pielonefritis.

We have studied renal growth in 133 children with 195 refluxing ureters (VUR). Average follow-up was 38 (range 12-84) months. Low grade VUR (I-III) were more frequent and left-sided ones predominated among unilateral cases. There was a clear correlation between VUR grade and the presence of reflux nephropathy (RN). Seventy percent of low-grade VUR cured under long-term urine disinfection, whereas surgery was successful in 97.5% of high-grade, often scarred, units. Recurrent urinary infections after cure of VUR were equally frequent in both groups. The growth of the 140 unscarred refluxing kidneys was evaluated by means of renal length, corticorenal index and growth speed measurements. All values remained within ranges considered statistically undistinguishable from those of normal kidneys. Our findings confirm that, in our conditions of treatment, VUR without RN does not impair renal growth for the period of time studied.

[Ventral diverticula of the bulbous urethra]. / Divertículos ventrales de la uretra bulbar.

We report 5 male patients with ventral diverticula of the bulbous urethra. There was urinary infection in 4 cases, urethral obstruction in 1 and voiding disturbances in 1. Urethral catheterism had been performed previously for various reasons in three patients. Urethroscopic evaluation was successfully completed with endourethral resection in four instances. Based on our morphologic findings we believe that the relationship between these diverticula and dilatation of Cowper's gland ducts is beyond doubt. The cause of this dilatation remains unclear, but mechanical factors, like catheterism, can play a role.

[Critical evaluation of cystoscopy in pediatric vesico-ureteral reflux]. / Evaluación crítica de la cistoscopia en el reflujo vesicoureteral pediátrico.

Authors report a study on endoscopical evaluation of 110 refluxing ureters in 65 children selected out of a group of 384 with VUR seen between 1977 and 1980. Cystoscopy was only undertaken either in patients with poor response to conservative treatment or in those with associated malformations. Radiologic-endoscopic correlation was rather good: 93% of grade II refluxing orifices were normally located or slightly lateralized, whereas 72% of grade III or IV were so. The length of submucosal tunnel was shorter than 5 mm in 68.75% of refluxing ureters. "Golf-hole" orifices were seen in 2/3 of the cases with grade III or IV reflux. Nevertheless, this correlation was poor in over one third of refluxing units because in these cases cystoscopic evaluation of ureterovesical junction enabled to modify (in either sense) indications for surgery made up only on clinico-radiologic grounds. Endoscopy for evaluation of VUR is justified in selected cases because of this incomplete correlation between radiological and anatomical findings.