[Extracorporeal lithotripsy in children - the efficacy and long-term evaluation of renal parenchyma damage by DMSA-99mTc scintigraphy]. / Litotricia extracorpórea en niños. Eficacia y evaluación a largo plazo de la lesión del parénquima renal mediante gammagrafía con DMSA-99mTc.

PURPOSE: To determine the effectiveness of extracorporeal shock-wave lithotripsy (ESWL) and possible deleterious effects on renal parenchyma of children subjected to treatment of renal lithiasis, using renal scintigraphy with 99mTc dimercapto-succunic acid (DMSA). PATIENTS AND METHODS: From January 2004 to November 2007, 18 children (age 3-10 years) underwent ESWL (Philips-Dornier) for kidney urolithiasis. All patients underwent preoperative evaluation, including physical examination, urine culture, image exams and renal scintigraphy with Tc99-DMSA. Evaluation after treatment consisted of a clinical examination, blood pressure measurement, urine culture, renal ultrasound and Tc99-DMSA, repeated at 3, 6 and 12 months, which were compared to the scans obtained before ESWL to determine possible morphological or functional changes. RESULTS: Success in the stones fragmentation was achieved in all cases - in 9 patients (50%) with one session of ESWL, in 6 (33%) with two sessions and in 3 patients (17%) with 3 sessions of ESWL. Only one patient (5%), after three sessions of ESWL and 6 months of follow-up showed change in size of right kidney with a decrease in tubular function, without hypertension or other major changes. In the other cases, there was absence of hypertension up to 12 months of follow-up, absence of renal hematomas detected by ultrasound or significant renal scars in scintigraphic examinations. CONCLUSION: ESWL is effective and safe for treating renal lithiasis in children. Renal parenchyma lesions may occur early after treatment, but these lesions are transients and resolve spontaneously in virtually all cases; generally, there are no irreversible renal lesions associated with ESWL, even after the follow-up period with clinical examination, ultrasound examination and 99mTc-DMSA scintigraphy.

[Postnatally hydronephrosis (HN) in children with antenatally diagnosed hydronephrosis: surgery or medical treatment?]. / Hidronefrosis (HN) neonatal en niños con hidronefrosis diagnosticada prenatalmente: cirugía o tratamiento médico?

OBJECTIVES: There is no formal agreement or criteria utilized to establish a standard of treatment in children with antenatally diagnosed HN. METHODS: We analyzed our own experience in addition to the protocols attending to this subject. Twenty eight (28) children with unilateral HN were assessed from October 1999 through October 2005 and the anteroposterior diameter of renal pelvis (APDP) was measured. RESULTS: Patients underwent surveillance with US and cintilography in 3, 6, 12 and 24 months. The treatment results were reviewed following the classification of Society of Fetal Urology: slight (2 to 5 mm), moderate (6 to 10 mm) and severe (> 10-15 mm). CONCLUSIONS: We concluded that slight HN would never be operated on while the severe ones would always be. The moderate HN, on the other hand, would remain under surveillance with US and cintilography for two years.

[Dilemma in the treatment of angiomyolipoma]. / Dilema en el tratamiento del angiomiolipoma.

OBJECTIVE: To present our experience with renal angiomyolipoma. METHODS: The series comprised 27 patients (26 female, 1 male) with renal angiomyolipoma. Twenty-three (85%) had unilateral renal involvement and of the 4 remaining patients (15%) with bilateral involvement, three (10%) had tuberous sclerosis. RESULTS: Due to the complications, three patients with bilateral and one patient with unilateral renal involvement required surgery. Mean patient follow-up was 38 months. CONCLUSIONS: Surgery is warranted in patients with tumors of more than 4 cm, symptomatic or associated with tuberous sclerosis. Regular control evaluation is indicated for tumors less than 4 cm.

Dilema en el tratamiento del angiomiolipoma / Dilema in angiomiolipoma treatment

En el período de marzo de 1985 a mayo de 1996, fueron tratados 26 pacientes del sexo femenino y uno del sexo masculino con diagnóstico de angiomiolipoma renal. Veintitres pacientes presentaban compromiso renal unilateral (85 por ciento) y, de las 4 pacientes con compromiso bilateral (15 por ciento), tres tenían asociación con esclerosis tuberculosa (10 por ciento). Debido a complicaciones, tres tenían asociación con esclerosis tuberculosa (10 por ciento). Debido a complicaciones, tres pacientes con compromiso bilateral y uno con unilateral necesitaron tratamiento quirúrgico. Los pacientes están en seguimiento, por un período mediano de 38 meses

Antegrade endopyelotomy for pelvi-ureteric junction obstruction in children.

OBJECTIVE: To compare the results of repairing pelvi-ureteric junction (PUJ) obstruction by percutaneous endopyelotomy in children with a similar series carried out in adults. PATIENTS AND METHODS: Nine children with primary (six) or secondary (three) PUJ obstruction were treated using a one-stage cold-knife percutaneous endopyelotomy. The success and morbidity rates were compared with a series of 61 adults with primary (46) or secondary (15) PUJ obstruction treated similarly. RESULTS: In children, endopyelotomy was successful in five of six with primary and two of three with secondary PUJ obstruction, with a mean follow-up of 30 months (range 18-56). In the adults, endopyelotomy was successful in 38 of 46 (83%) with primary and 12 of 15 with secondary PUJ obstruction, an overall success rate of 82%, with a mean follow-up of 42 months (range 9-86). There was no statistical difference in the success rates with primary and secondary endopyelotomy between adults and children (P = 0.58). Failures were associated with high-grade hydronephrosis, a stenotic segment > 1.5 cm long and technical problems. Morbidity occurred in one of nine children and 3.2% of the adults. CONCLUSION: This early experience suggests that percutaneous endopyelotomy can be performed safely and successfully in children with primary PUJ obstruction. However, in secondary stenosis, the results were less than optimal. Larger series should be analysed to form definitive conclusions on the role of endopyelotomy for the treatment of PUJ obstruction in children, given the high rate of success of open pyeloplasty and its minimal morbidity.

Subureteric lipoinjection for vesicoureteral reflux in renal transplant candidates.

OBJECTIVE: Vesicoureteral reflux is a risk factor predisposing to infection after renal transplantation. Endoscopic correction of vesicoureteral reflux, a minimally invasive therapy, has been increasingly used with encouraging results. Although recent reports have described the successful use of Teflon paste in the endoscopic treatment of reflux, the choice of the material to be used is controversial. There is a need for finding an ideal substance for endoscopic injection for a simple and safe treatment of reflux. METHODS: Based on the good results of autologous lipoinjection in other situations, we performed lipoinjection for vesicoureteral reflux in 12 renal transplant candidates. There were 10 female and 2 male patients with grade III reflux or higher, accounting for 17 ureters treated by endoscopic lipoinjection. Voiding cystourethrography was performed in the operating room immediately after the procedure and again three months later. RESULTS: In 2 patients (16.2%) there was reduction of the grade of reflux, including the unique ureter that stopped refluxing. In the remaining 10 patients (83.3%) there was no change in the grade of reflux. CONCLUSIONS: These results suggest that although simple and attractive, lipoinjection alone is not a good alternative for endoscopic correction of vesicoureteral reflux.

Percutaneous treatment of bladder stones.

A total of 36 patients with bladder stones underwent percutaneous suprapubic cystolithotripsy. The successful rate was 89%. There were 11% failures due to nonfragmentation of the stones by the ultrasound probe. According to the presence of associated diseases 3 groups of patients were established. Two groups underwent concomitant treatments for benign prostatic hyperplasia and urethral stricture. No complications occurred even in patients with concomitant treatment. There was no statistically significant difference when these groups were compared (p > 0.05). Fluoroscopy was not necessary during the procedure. Since the technique is simple, safe and effective, it represents an alternative in the management of bladder stones.

Oral or intravesical bacillus Calmette-Guerin immunoprophylaxis in bladder carcinoma.

A total of 71 patients with superficial transitional cell carcinoma underwent transurethral resection of bladder tumor. All patients had stage pTa or pT1 transitional cell carcinoma or carcinoma in situ without other concurrent malignancies. The patients were assigned to 3 treatment groups: control group--transurethral resection discontinued within the study, oral bacillus Calmette-Guerin (BCG) group--transurethral resection of bladder tumor plus BCG (Moreau) and intravesical BCG group--transurethral resection of bladder tumor plus BCG. Of 9 patients in the control group 8 (89%) experienced tumor recurrence during a mean followup of 20 months. Of the 28 patients in the oral BCG group 11 (39.3%) had recurrence during a mean followup of 36 months. Of the 34 patients in the intravesical group 6 (18%) had recurrence in a 24-month mean followup. The incidence of complications was higher in the intravesical (41.2%) than in the oral BCG group (28.5%). These results show that intravesical BCG is a more effective immunotherapy; however, oral BCG can be used in patients who do not accept intravesical BCG administration.

Internal urethrotomy of the prostatic urethra or transurethral resection in benign prostatic hyperplasia.

Transurethral resection of the prostate is the most common technique for the treatment of benign prostatic enlargement. The inconveniences of prostatic resection are retrograde ejaculation and bladder neck stenosis in small prostates. A randomized prospective trial was done to compare the results of conventional transurethral resection of the prostate in 22 patients and urethrotomy of the prostatic urethra in 27 with respect to postoperative retrograde ejaculation, persistent urinary symptomatology and maximal flow rates. After a mean followup of 25 months we concluded that internal urethrotomy of the prostatic urethra is the operation of choice in patients with a prostate of up to 30 gm.

Percutaneous nephrectomy in nonfunctioning kidneys: a preliminary report.

Nephrectomy is indicated for the removal of highly damaged kidneys. Several times patients are asymptomatic, and although the operation has a low morbidity rate they will refuse it. The development of new endourological techniques of percutaneous access to the kidney in experimental studies on liquefaction and aspiration of tissues, and the idea taken from the old resectoscope models using nonelectrical aids served to inspire our technique of percutaneous nephrectomy. Our patient presented with a nonfunctioning kidney due to ureteral obstruction and ultrasound demonstrated a severe decrease in renal parenchyma. Percutaneous access to the kidney was performed through the conventional manner and the remaining parenchyma was removed with biopsy and Lowsley forceps. Bleeding was minimum and a 22F nephrostomy Foley catheter was kept in place for 72 hours. As far as new instruments are developed, percutaneous nephrectomy represents a surgical option to remove nonfunctioning kidneys in highly selected patients.

Is routine dilation of the ureter necessary for ureteroscopy?

The results of transurethral ureteroscopic stone removal in 144 patients were reviewed. Patients were treated by two different techniques according to the dilation of the ureterovesical junction before the introduction of the ureteroscope. Group 1 was represented by 71 patients submitted to ureteral dilation and in group 2 there were 73 patients treated without ureteral dilation. There was only one failure in introducing the instrument without ureteral dilation. In patients submitted to transurethral ureteroscopy with previous ureteral dilation, the success of ureteroscopic stone removal was 91.6% and complications occurred in 6.9%, and, in the cases not submitted to ureteral dilation, the success rate was 99.4% and the complication rate 4.1%. The success rate achieved in removing upper third stones was 100.0% middle third 90.5% and lower third stones 95.6%. Of the 144 patients treated, 8 (5.5%) had ureteral injury, but only 1 (0.6%) needed open surgery. We do not believe that ureteral dilation prevents complications or improves the results of ureteroscopic lithotripsy.

Approach for treatment of subcoronal meatus with excessively deep glanular groove.

We report on 9 children with subcoronal meatus and an excessively deep glanular groove who underwent a simple surgical repair. All the procedures were done on an outpatient basis, and there was no urinary diversion. The surgical results have been satisfactory, with no fistula formation, or urethral or meatal stenosis. The technique described is useful in selected cases.

Endourologic approach of ureteral gunshot lesion.

We report a case which demonstrates that to approach an ureteral gunshot lesion endourologically may be an alternative to surgical intervention. We believe that drainage of a damaged ureter should, in selected cases, constitute the first option. This procedure often is successful, but may not be feasible in all cases. We do not believe that simple catheter drainage should replace standard surgical procedures. However, it presents a less invasive treatment alternative which still adheres to conventional surgical principles if a proper patient selection is made.