[Feminizing genitoplasty in adrenal congenital hyperplasia: one or two surgical steps?]. / Genitoplastia feminizante en hiperplasia suprarrenal congénita; una o dos etapas quirúrgicas?

SUMMARY OBJECTIVES: The best time to perform a genitoplasty in a Congenital Adrenal Hyperplasia (CAH) girl is an issue that has been discussed extensively. The purpose of this study is to find criteria that may help in the decision. METHODS: Charts of all patients with diagnosis of CAH with 21 Hydroxylase deficit who underwent genitoplasty in our institution were reviewed (Jan 1996-Dec 2006). Demographic data, surgery performed and outcomes were analyzed. RESULTS: In the 10 year-period, 25 patients fit the inclusion criteria; 22 had complete data. All patients were classified based on Prader's criteria; Prader 2 (n=3), Pra der 3 (n=13) and Prader 4 (n=6). Mean age at first surgery was 13.5 months (range 2-89 m). In Prader 2 patients, a reduction clitoroplasty with a "cut back" vaginoplasty was performed with no complications. All patients in the Prader 3 group underwent a reduction clitoroplasty. A vaginoplasty was done in 9/13; 5/9 at the same surgery session (4 stenotic) and the other 4 in a 2nd stage with good results; vaginoplasty is still pending for the other 4 girls. In the Prader 4 group, a vaginoplasty pull-through was performed in 4/6 using the posterior sagital approach; one at the reduction clitoroplasty stage which ended stenotic and need dilatations, and the other 3 in a 2nd surgery with a good outcome. The other 2/6 girls are awaiting a vaginoplasty. 22/22 had acceptable results after a mean follow-up of 63 months (range 12-144). CONCLUSIONS: Congenital Adrenal Hyperplasia (CAH) shows different approaches may be used for different degrees of virilization. For less severe cases (Prader 3) a cut-back may be the surgery of choice for vaginoplasty, while in the more complex cases a flap with pull-through or a posterior sagital procedure could be useful. Based on this series, we recommend performing vaginoplasty in a 2nd stage surgery, avoiding complications and further procedures such as di lactations.

Genitoplastia feminizante en hiperplasia suprarrenal congénita; ¿una o dos etapas quirúrgicas? / Feminizing genitoplasty in adrenal congenital hiperplasia: One or two surgical steps?

OBJETIVO: El mejor momento para realizar una genitoplastia en una niña con Hiperplasia Suprarrenal Congénita (HSRC) es un tema que ha sido debatido ampliamente. El objetivo de este estudio es encontrar un criterio que pueda ayudar en esta decisión.MÉTODO: Se revisaron los datos de todos los pacientes con diagnóstico de HSRC con déficit de 21 Hidroxilasa que se sometieron a genitoplastia en nuestra institución (Enero 1996-Diciembre 2006). Se analizaron datos demográficos, cirugía realizada y resultados.RESULTADOS: En el periodo de 10 años, 25 pacientes cumplieron los criterios de inclusión; 22 tenían datos completos. Todos los pacientes fueron clasificados basándose en los criterios de Prader; Prader 2 (n=3), Prader 3 (n=13) y Prader 4 (n=6). El promedio de edad al momento de la primera cirugía fue 13.5 meses (rango 2-89m). En los pacientes Prader 2, una clitoroplastia de reducción con una vaginoplastia “cut back” fue realizada sin complicaciones. Todos los pacientes del grupo Prader 3 se sometieron a una clitoroplastia de reducción. Una vaginoplastia fue hecha en 9/13; 5/9 en la misma sesión quirúrgica (4 estenóticas) y los otros 4 en un segundo tiempo, con buenos resultados; en las otras 4 niñas la vaginoplastia está aún pendiente. En el grupo Prader 4, una vaginoplastia “pull-through” fue realizada en 4/6 usando un abordaje sagital posterior; uno al momento de la clitoroplastia de reducción, con resultados estenóticos y necesidad de dilataciones, y los otros 3 en una segunda cirugía con buenos resultados. Las otras 2/6 niñas están esperando una vaginoplastia. 22/22 tiene resultados aceptables luego de un periodo de seguimiento de 63 meses (rango 12-144m)(AU)

CONCLUSIONES: La Hiperplasia Suprarrenal Congénita (HSRC) muestra diferentes grados de virilización, por lo tanto distintos abordajes pueden ser utilizados. Para los casos menos severos (Prader <3) un “cut-back” puede ser la cirugía de elección para una vaginoplastia, mientras en los casos más complejos un colgajo con “pull-through” o un procedimiento sagital posterior puede ser útil. Basado en esta serie, nosotros recomendamos realizar una vaginoplastia en un segundo tiempo quirúrgico, evitando complicaciones y procedimientos adicionales como las dilataciones(AU)

OBJECTIVES: The best time to perform a genitoplasty in a Congenital Adrenal Hyperplasia (CAH) girl is an issue that has been discussed extensively. The purpose of this study is to find criteria that may help in the decision.METHODS: Charts of all patients with diagnosis of CAH with 21 Hydroxylase deficit who underwent genitoplasty in our institution were reviewed (Jan 1996-Dec 2006). Demographic data, surgery performed and outcomes were analyzed.RESULTS: In the 10 year-period, 25 patients fit the inclu sion criteria; 22 had complete data. All patients were classified based on Prader’s criteria; Prader 2 (n=3), Pra der 3 (n=13) and Prader 4 (n=6). Mean age at first surgery was 13.5 months (range 2-89m). In Prader 2 patients, a reduction clitoroplasty with a “cut back” vaginoplasty was performed with no complications. All patients in the Prader 3 group underwent a reduction clitoroplasty. A vaginoplasty was done in 9/13; 5/9 at the same surgery session (4 stenotic) and the other 4 in a 2nd stage with good results; vaginoplasty is still pending for the other 4 girls. In the Prader 4 group, a vaginoplas ty pull-through was performed in 4/6 using the poste rior sagital approach; one at the reduction clitoroplasty stage which ended stenotic and need dilatations, and the other 3 in a 2nd surgery with a good outcome. The other 2/6 girls are awaiting a vaginoplasty. 22/22 had acceptable results after a mean follow-up of 63 months (range 12-144).CONCLUSIONS: Congenital Adrenal Hyperplasia (CAH) shows di fferent approaches may be used for different degrees of virilization. For less severe cases (Prader <3) a cut-back may be the surgery of choice for vaginoplasty, while in the more complex cases a flap with pull-through or a posterior sagital procedure could be useful. Based on this series, we recommend performing vaginoplasty in a 2nd stage surgery, avoi ding complications and further procedures such as dilatations(AU)

[Endoscopic treatment of vesicoureteral reflux (VUR). Comparison of various substances. Long-term results]. / Tratamiento endoscópico en reflujo vesicoureteral (RVU). Comparacion de diferentes sustancias. Resultados a largo plazo.

OBJECTIVES: The VUR is one of the most frequent pathologies in pediatric urology. Classically it has been managed with medical or surgical treatment depending on age, grade, and other variables. Over the last years, urologists have started to perform endoscopic treatment with various substances, surgery but minimally invasive. The objective of this work is to evaluate our results with this method. METHODS: Between 1996 and 2004 we performed endoscopic treatment on 41 patients (70 ureters) using different substances. We analyze VUR grade and side, improvement with one or more injections, post-operative follow-up with clinical evaluation, bladder ultrasound and voiding cystourethrogram (VCUG), and compare the long-term results of the different substances used, mainly with the evaluation of recurrences and/or urinary tract infections. RESULTS: 41 patients entered the study; collagen was injected in 13 cases, Macroplastique in 14, and Deflux in 14. Twenty-nine patients underwent bilateral injection, adding up to a total of 70 injected ureters. Collagen injection had a success rate of 53% with the first injection and 77% with the second, Macroplastique success rate was 83% with the first injection and 91% with the second, and Deflux 84% on first injection and 88% with the second. Mean post-operative follow-up was 44 months, with a range of 18-86 months. 18% of the patients presented post operative UTI, they were treatment failures. There are no UTI episodes in patients after successful treatment. CONCLUSIONS: Endoscopic treatment is a useful tool in the long-term management of VUR, both as definitive treatment or as on alternative to conventional medical management, with better results when using Macroplastique and Deflux.

Tratamiento endoscópico en reflujo vesicoureteral (RVU). Comparacion de diferentes sustancias. Resultados a largo plazo / Endoscopic treatment of vesicoureteral reflux (VRU). Comparison of various substances. Long-term results

Objetivo: El RVU es una de las patologías más frecuentes en la urología pediátrica, clásicamente se ha manejado con tratamiento médico o quirúrgico dependiendo de la edad, grado u otras variables. En los últimos años se ha comenzado a utilizar el tratamiento endoscópico, con distintas sustancias, el cual siendo quirúrgico es mínimamente invasivo. El objetivo de este trabajo es evaluar nuestros resultados con este método. Métodos: Entre 1996 y el 2004 se utilizó tratamiento endoscópico en 41 pacientes (70 uréteres) usando diferentes sustancias. Se analizó el grado y lateralidad del RVU, mejoría con 1 o más inyecciones, control post operatorio con clínica, ecografía renal vesical y uretrocistografía, y se compararon los resultados con las distintas sustancias usadas a largo plazo, evaluando principalmente las recidivas y/o cuadros de infección urinaria. Resultados: 41 pacientes entraron al estudio, se inyecto colágeno en 13, Macroplastique® en 14 y en 14 Deflux®. 29 pacientes recibieron inyección bilateral, resultando un total de 70 uréteres inyectados Con colágeno hubo 53% de éxito con la primera inyección y 77% con la segunda, con Macroplastique ® hubo 83% de éxito con la primera inyección y 91% con la segunda y con Deflux® 84% de éxito con la primera inyección Y 88% con la segunda inyección. El seguimiento post operatorio fue en promedio de 44 meses, con un rango de 18 a 86 meses. 18% presentó ITU post operatoria la que sé presento en pacientes con falla en el tratamiento. En el seguimiento no hay episodios de ITU en los pacientes con éxito en la aplicación de la sustancia. Conclusiones: El tratamiento endoscopio es una herramienta útil en el manejo del RVU a largo plazo, ya sea como tratamiento definitivo o como alternativa al manejo médico convencional, obteniendo mayor respuesta con Macroplastique® y Deflux® (AU)

Objectives: The VUR is one of the most frequent pathologies in pediatric urology. Classically it has been managed with medical or surgical treatment depending on age, grade, and other variables. Over the last years, urologists have started to perform endoscopic treatment with various substances, surgery but minimally invasive. The objective of this work is to evaluate our results with this method. Methods: Between 1996 and 2004 we performed endoscopic treatment on 41 patients (70 ureters) using different substances. We analyze VUR grade and side, improvement with one or more injections, post-operative follow-up with clinical evaluation, bladder ultrasound and voiding cystourethrogram (VCUG), and compare the long-term results of the different substances used, mainly with the evaluation of recurrences and/or urinary tract infections. Results: 41 patients entered the study; collagen was injected in 13 cases, Macroplastique® in 14, and Deflux® in 14. Twenty-nine patients underwent bilateral injection, adding up to a total of 70 injected ureters. Collagen injection had a success rate of 53% with the first injection and 77% with the second, Macroplastique® success rate was 83% with the first injection and 91% with the second, and Deflux® 84% on first injection and 88% with the second. Mean post-operative follow-up was 44 months, with a range of 18-86 months. 18% of the patients presented post operative UTI, they were treatment failures. There are no UTI episodes in patients after successful treatment. Conclusions: Endoscopic treatment is a useful tool in the long-term management of VUR, both as definitive treatment or as an alternative to conventional medical management, with better results when using Macroplastique® and Deflux® (AU)