[Treatment of ruptures of the posterior urethra in children? The value of the symphyseal approach]. / Traitement des ruptures de l'urètre postérieur chez l'enfant? Intérêt de la voie symphysaire.

Eight cases of rupture of the posterior urethra were observed in children and treated via a trans-symphyseal approach. Repair was easy in the cases seen rapidly (2 to 10 days), urethral suture was effective and the result was excellent. On the other hand, in cases seen later (6 cases), between 6 months and 5 years, marked fibrous callus had to be resected. Urethral repair was not always possible (only one failure out of 6 late cases). This approach preserves genital functions.

The value of split renal function in severe neonatal and infant pelviureteric obstruction managed by percutaneous nephrostomy.

A percutaneous nephrostomy (PCN) was inserted as part of the management in 17 newborns and infants with severe pelviureteric junction obstruction between 1981 and 1993. Nephrectomy was performed in eight cases and pyeloplasty in nine cases, successfully in six cases (mean follow-up: 7.7 years). PCN was useful for predicting that no non-functioning kidney on intravenous pyelography (IVP) in this series should have been preserved. Among the kidneys with a high excretion delay on IVP, PCN showed that only those that had a split creatinine clearance of more than 1 ml/min/1.73 m2, or theoretical clearance for age and weight of over 6%, should be preserved.

[Treatment of hypospadias of the glans penis and the prepuce by reconstruction of the urethra and prepuce]. / Traitement de l'hypospadias balanique et balano-préputial, selon la technique de l'avancement avec reconstruction du prépuce.

The treatment of granular and subcoronal hypospadias is necessary mainly for psychological reasons. Anatomical reconstruction has to be perfect. This procedure provides reconstruction of urethra and foreskin thanks to an extensive dissection. No stent is needed. This day-surgery procedure has a low complication rate.

[Treatment of urethral fistulae following management of hypospadias]. / Traitement des fistules urétrales après cure d'hypospadias.

Thirty six fistulas after hypospadias reconstruction, were operated on from 1989 to 1994. The procedure depends on the anatomical aspect of fistula. Simple fistulas of penis (33 cases) were operated by direct suture with two or three layers. In 21 cases, suture with three layers without tube obtained 19 successes. In 12 cases, suture with two layers, with or without tube, obtained 6 successes; complex penile fistulas, after repeated procedures, need a penioscrotal sinking (Leveuf procedure; one case, on success); granular fistulas need excision of tissues between fistula and new meatus. Reconstruction depends on the position of fistula: Mathieu procedure or advancement (two cases with two successes). In conclusion, 90% of fistulas are cured in one intervention without tube, on an outpatient basis.

[Uretero-colonic implantation in children. Late results]. / Implantation urétéro-colique chez l'enfant. Résultats tardifs.

An uretereo-colic anastomosis in children is performed in three occasions: 1) The trans-intestinal cutaneous ureterostomy (Bricker) has a low rate of complications concerning ureterocolic anastomosis. Nevertheless, occurrence of pyelonephrites may oblige to perform an anti-reflux procedure. 2) Implantation of ureters in the intestinal segment of an augmentation colocystoplastys in unusual; when necessary, this type of implantation is safe because colon is appropriate for an antireflux procedure. 3) Ureterocolic diversion (Coffey) is quite comfortable for patients. Risks of renal failure and of adenocarcinoma are minimal thanks to an annual control. Concerning exstrophy of bladder, it seems now that risk of infertility is lower for patients with an ureterocolic diversion than those with a genito-urinary reconstruction.

[Prenatal screening in utero of urinary abnormalities. Management]. / Le dépistage in utero des malformations urinaires. Conduite à tenir.

The major benefit of antenatal ultrasonography is to allow early diagnosis of urinary tract malformations before postnatal infection worsens the prognosis. In the majority of cases, there is a unilateral and moderate dilatation requiring a check-up only during the second week of life; treatment subsequently depends on the etiology of the uropathy and the consequences on the kidney. Unilateral severe dilatations and bilateral, but moderate, dilatations must be managed immediately after birth in a pediatric surgical center. In the rare cases of severe bilateral obstructive uropathy, in utero decompression by catheterisation or surgery is now considered to be uselessly invasive, considering that renal dysplasia is already present when the malformation is detected.

[Ureteroceles]. / Urétérocèles.

Four types of ureteroceles are described: A) ureterocele with single ureter (10%); B) ureterocele with total duplication and intra-vesical development (10%); C) ureterocele with total duplication and extra-vesical development (62%); D) ureterocele with ectopic ureter (3%). Most ureteroceles are now detected by antenatal ultrasonography, allowing early management. The treatment of types A and B is simple depending on the status of the above kidney and ureter: abstention, meatomy, ureterocelectomy with ureteral reimplantation, nephrectomy. In type C, the upper kidney is always destroyed. Two treatments are proposed: upper pole nephrectomy with ureterocelectomy which is a difficult but safe procedure, upper pole nephrectomy with aspiration of the ureterocele which is called the "simplified technique" but requires reoperation in 40% cases. The complicated forms may require either meatotomy for decompression, or diversion by percutaneous nephrostomy. Strangulation of the ureterocele constitutes an emergency.

[Enuresis]. / De l'énurésie.

The word "enuresis" is the greek word for incontinence. Enuresis has to be considered as a symptom and not as a disease. We have to keep in mind that urine leaking may be due to an anatomical anomaly (epispadias, ectopic ureter, spinal coral lesion, urethral obstacle) in which case treatment of the underlying disease constitutes treatment of enuresis. Nevertheless, enuresis is isolated in 95% of cases. Three groups are defined depending on whether the bladder is normal, hyperactive or retentionnist with bladder-sphincter dyssynergia. We emphasize the frequency of coexistence of these three aspects and the gravity of a wrong diagnosis. The onset or presence of bladder-sphincter dyssynergia is a major concern for the pediatric urologist due to its severity and the difficulties of treatment.

[Treatment of idiopathic vesico-ureteral reflux in children]. / Traitement du reflux vésico-urétéral idiopathique de l'enfant.

Vesicoureteral reflux is the principal cause of pyelonephritis in children. Medical treatment is designed to prevent the development of renal parenchymal scars, as these lesions are irreversible and frequently interfere with growth of the kidney. Treatment must therefore be specific and sufficiently prolonged. In infants under the age of 2 years, reflux may resolve in 50% of cases as the ureterovesical junction develops. During this period, treatment consisting of alternating antiseptics should be proposed to prevent the development of pyelonephritis. In all other cases, reflux must be corrected. Two techniques can be proposed at the present time: surgery which gives 98% immediate and permanent good results, using Cohen's technique, and injection of Teflon, which is much less reliable, with risks of distant dissemination, particularly to the brain, and the possibility of developing ureteric stenosis and bladder stones. These problems have led many paediatric urologists to abandon endoscopic treatment.

[Current treatment of bladder exstrophy]. / Traitement actuel de l'exstrophie vésicale.

The treatment of vesical exstrophy has greatly improved over the last twenty years. The most important progresses are: closing the bladder before the 72nd hour of life; iliac osteotomy allowing fusion of the pubis when closing the bladder; lengthening of the penis by liberation of the corpora cavernosa; entero-cystoplasty when the reconstructed bladder is too small. Most surgeons practice the same timing for the different operations. Urinary and genital anomalies can be cured at the same time. In relation to urinary problems, about 80% of cases achieve good continence. An urinary diversion, using "Coffey's" technique, must be performed in the presence of incontinence. Concerning genital problems in boys and girls, reconstructive surgery allows restoration of almost normal genital organs. Intercourse seems to be satisfactory in most cases. There is a high sterility rate in men.

[Cystoplasties in children]. / Les entérocystoplasties chez l'enfant.

Whenever the reservoir function of the bladder is impaired (neuropathic bladder and exstrophy), an enterocystoplasty constitutes a satisfactory solution in children to enlarge the bladder. The various techniques must take into account the degree of alteration of the bladder. The bowel segment must be detubularized, regardless of its origin. The main challenge is to obtain adequate peripheral resistance with easy voiding and filling of the bladder without urine leak, particularly in boys. In girls, the combination of enterocystoplasty and Gobbel-Stockel procedure ensures perfect continence between two self-catheterisations.

[Renal transplantation in children. Surgical aspects]. / La transplantation rénale chez l'enfant. Aspects chirurgicaux.

The renal transplantation in children has some specificities: urologic anomalies (vesico ureteral reflux, posterior urethral valves) are frequently the cause of the renal failure, and necessitate a thorough surgical preparation before transplantation (nephrectomy, reconstitution of urinary tract). The child must have a sterile, compliant and continent urinary tract on the day of the operation. In small children (< 15 kg), it is often necessary to operate through a transperitoneal incision, especially if the donor is an adult: the anastomoses will then concern the aorta and vena cava. The results are good, even better than in adults, except for very young children (under six years of age). Transplantation with living related donor (LRD) give the best results. Currently, the graft survival is 87% to 90% after three years with LRD, versus 65 to 77% with cadaveric donors.

[Testicular ectopy. Current concepts]. / L'ectopie testiculaire. Notions actuelles.

Testicular descent is a complex mechanism influenced by hormonal and anatomical factors. Whatever the age of the patient or the descent technique used for either one or both testes, there is a risk of degeneration and sterility counts. Anatomical studies and the results of sperm are important, hence the importance of establishing a precise anatomical and therapeutic classification.

[Genital prognosis of boys with bladder exstrophy or epispadias with incontinence. Apropos of 14 cases]. / Avenir génital des garçons atteints d'exstrophie vésicale ou d'épispadias avec incontinence. A propos de quatorze cas.

Bladder exstrophy and epispadias with incontinence are associated with urinary tract and genital anomalies. The genital and sexual aspects were studied in 14 adolescent or adult males (12 exstrophies and 2 epispadias). The appearance of the penis was satisfactory in fifty percent of cases. Erections were always preserved but normal ejaculations were present in only one half of cases. Fertility potential was reduced. The improvement of surgical technique, and especially penile lengthening, has greatly improved sexual intercourse for these patients.

[Genital prognosis of girls with bladder exstrophy or epispadias]. / Avenir génital des filles atteintes d'exstrophie vésicale ou d'épispadias.

The authors report ten cases of women with previous exstrophy of the bladder or epispadias with incontinence followed up to child-bearing age. Six of the ten females had urinary diversion and four retained their bladder and were continent. Three key aspects are considered: physical appearance of the external genitalia which was satisfactory in all cases; preservation of sexual function, known in only four of the ten cases and which was reported by these patients to be satisfactory, and finally, the ability to bear children. Three patients became pregnant resulting in four normal births (one patient had twins). Cesarean sections were recommended in patients with pregnancies at term. Cesarean should be performed systematically in patients with bladder reconstruction.

[Obstructive anuria in children. Apropos of 22 cases]. / Anurie obstructive chez l'enfant. A propos de vingt-deux cas.

The authors report twenty-two cases of obstructive anuria observed in children. Causes were diverse: 6 cases were observed during the course of tumors, 4 cases were secondary to bilateral renal stones (or unilateral in a single kidney), 3 cases were observed before surgical correction of latent or well tolerated congenital uropathy, and 9 cases occurred immediately after an operation (including 8 after antireflux surgery). Emergency treatment of obstructive anuria is based on urinary diversion, ideally by percutaneous nephrostomy under ultrasonic control. However, prevention is the best treatment of anuria: treatment of urinary tract infections resulting in renal stones, ultrasonographic monitoring for chronic proximal urinary tract dilatation in tumors: rigorous atraumatic operative technique avoiding oedema.

[Obstructive anuria in children. Apropos of 22 cases]. / Anurie obstructive chez l'enfant. A propos de vingt-deux cas.

The authors report twenty two cases of obstructive anuria observed in children. Causes are diverse: 6 cases were observed during the course of tumors, 4 cases were secondary to bilateral renal stones (or unilateral in a single kidney), 3 cases were observed before surgical correction of latent or well tolerated congenital uropathy, and 9 cases in the immediate postoperative period (including 8 after antireflux surgery). In the emergency situation, treatment of obstructive anuria is based on urinary diversion ideally by percutaneous nephrostomy under ultrasonic control. But prevention is the best treatment of anuria: treatment of urinary tract infections resulting in renal stones, in case of tumor, ultrasonographic survey of chronic upper tract dilatation: rigorous atraumatic operative technique avoiding any oedema.

[Failures observed after repair of the pyeloureteric junction in children based on a series of thirteen cases]. / Echecs observés après cure de jonction pyélourétérale chez l'enfant. A propos de treize cas.

We report a series of 13 infants with failed surgery for pyeloureteric junction (PUJ) obstruction. Failure was defined as the necessity for further surgery, either refashioning of the anastomosis or nephrectomy. These infants were part of a series of 306 with 322 PUJ. Of the 258 surgically treated infants, 232 (90%) had a post operative course without complication or need for reoperation. The failure rate was significantly higher in infants operated before the age of 4 months (8/65: 12.3%) when compared with those over 4 months of age (5/193: 2.59%). The use of postoperative drainage via a nephrostomy significantly reduced the percentage of early complications (e.g. fistula) but did not affect the final failure rate. The severity of the obstruction at presentation correlated with a bad outcome after reoperation. Of the cases which resulted in failure after reoperation (7/258: 2.7%) all occurred in cases of severe obstruction with parenchymal damage. While the failure of surgery is often evident early (persistant fistula, urinoma, non-functioning kidney on IVP) this may only become obvious some years later. Reoperations were successful in half the cases irrespective of the time between the initial operation and the reoperation. Long term follow-up of all infants operated for PUJ obstruction is recommended.