Influencia del inicio precoz del tratamiento conservador en la evolución del paciente pediátrico con vejiga neuropática / Influence in the outcome of neuropathic pediatric patients after early treatment

IntroducciónEl cateterismo limpio intermitente (CI) y el tratamiento anticolinérgico son la base del tratamiento conservador de la vejiga neuropática (VN); sin embargo, todavía no hay acuerdo sobre la edad a la que debería iniciarse dicha terapia.ObjetivoEl objetivo de nuestro estudio fue analizar la influencia del inicio precoz (primer año de vida) del tratamiento anticolinérgico y el CI en la evolución a largo plazo de la función renal y vesical. Nuestra hipótesis es que los niños que iniciaron el tratamiento conservador en el primer año de vida tienen mejor pronóstico en términos de función renal y vesical, así como menos necesidad de tratamiento quirúrgico que aquellos que iniciaron el tratamiento a edades más avanzadas.Pacientes y métodosEstudio retrospectivo de los pacientes con VN tratados en nuestro servicio (1995- 2005) dividiéndolos para su comparación en dos grupos: grupo 1 incluye a aquellos que iniciaron el tratamiento conservador en el primera año de vida, y grupo 2, a aquellos que lo iniciaron entre el primer y el quinto año. Se revisaron las historias clínicas recogiendo datos sobre: edad de inicio del CI y tratamiento anticolinérgico, presencia de reflujo vésico-ureteral (RVU) o ureterohidronefrosis (UHN), función renal, presencia de cicatrices renales, infección del tracto urinario (UTI), presencia de cicatrices renales, comportamiento vesical, necesidad de intervención quirúrgica y continencia urinaria.ResultadosSe incluyeron 61 pacientes: 25 en el grupo 1 y 36 en el grupo 2. Al inicio del estudio, la presencia de RVU e hiperactividad vesical eran más frecuentes en el grupo 2. En el grupo 1, un paciente con vejiga hiperactiva cambió a vejiga de baja acomodación, y en el grupo 2 un paciente con vejiga de acomodación normal y 4 con vejigas hiperactivas cambiaron a vejigas de baja

Background Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients.AimTo analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life.Patients and methodRetrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence.ResultsSixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency.ConclusionsPatients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA

Influence in the outcome of neuropathic pediatric patients after early treatment.

BACKGROUND: Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients. AIM: To analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life. PATIENTS AND METHOD: Retrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence. RESULTS: Sixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency. CONCLUSIONS: Patients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.

Influence in the outcome of neuropathic pediatric patients after early treatment. / Influencia del inicio precoz del tratamiento conservador en la evolución del paciente pediátrico con vejiga neuropática.

BACKGROUND: Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients. AIM: To analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life. PATIENTS AND METHOD: Retrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence. RESULTS: Sixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency. CONCLUSIONS: Patients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.

Preliminary results of complete delayed primary bladder exstrophy reconstruction in male patients. / Resultados preliminares de la reconstrucción completa primaria diferida de la extrofia vesical en el varón.

INTRODUCTION: The success of primary bladder closure in bladder exstrophy (BE) is the determining factor for future capacity and continence. In recent years, owing to the unsatisfactory results of staged repair, complete delayed primary reconstruction has gained prominence. OBJECTIVE: To analyze short-term results in male patients with BE undergoing delayed primary closure and compare them with early bladder closure as part of staged repair in our healthcare facility. MATERIALS AND METHODS: The success of bladder closure, postoperative management, complications, and hydronephrosis was assessed over a 12-month follow-up period in both groups: early primary closure (group A) and delayed primary closure (group B). RESULTS: In group A (n=13), mean age at closure was 25 hours and mean pubic diastasis was 32 mm. Patients had respiratory support and muscle relaxation for an average of 4 days postoperatively. Closure success was 85%, and 1 patient presented maintained hydronephrosis beyond the first 6 months. In group B (n=6), mean at closure was 58 days, and mean pubic diastasis was 34 mm. Patients had epidural analgesia and no respiratory support postoperatively. Closure success was 100%. 33% had transient hydronephrosis, and 1 patient (17%) presented maintained bilateral hydronephrosis. The same immobilization technique was used in both groups for 3 weeks. CONCLUSIONS: Delayed primary reconstruction is safe as it allows for closure success without increasing complications as compared to staged repair. A long-term follow-up is required to assess urinary continence, esthetic results, and genital functionality.

INTROUCCION: El éxito del cierre primario vesical en la extrofia (EV) es el factor determinante de la capacidad y continencia futuras. En los últimos años, debido a los resultados poco satisfactorios de la reparación por estadios, la reconstrucción primaria completa diferida ha adquirido mayor protagonismo. OBJETIVO: Analizar los resultados a corto plazo en varones con EV sometidos a cierre primario diferido y compararlos con el cierre vesical precoz en la reparación por estadios en nuestro centro. MATERIAL Y METODOS: Evaluamos el éxito del cierre vesical, el manejo postoperatorio, las complicaciones y la presencia de hidronefrosis durante un tiempo de seguimiento de 12 meses en los grupos: cierre primario precoz (grupo A) y diferido (grupo B). RESULTADOS: En el grupo A (n= 13) la edad media al cierre fue de 25 horas y la diástasis púbica media de 32 mm. Permaneció con asistencia respiratoria y relajación muscular una media de 4 días en el postoperatorio. El éxito del cierre fue del 85% y un paciente mantuvo hidronefrosis más allá de los 6 primeros meses. En el grupo B (n= 6), la edad media al cierre fue de 58 días, la diástasis púbica de 34 mm y se mantuvieron en el postoperatorio con analgesia epidural, sin asistencia respiratoria. El éxito del cierre fue del 100%, el 33% presentó hidronefrosis transitoria y un paciente (17%) hidronefrosis bilateral mantenida. En ambos grupos se empleó igual inmovilización durante 3 semanas. CONCLUSIONES: La reconstrucción primaria diferida es segura, permitiendo el éxito del cierre sin aumentar las complicaciones, comparado con la reparación por estadios. Es necesario un seguimiento a largo plazo para evaluar la continencia urinaria, el resultado estético y la funcionalidad genital.

Does bladder augmentation negatively affect renal transplant outcome in posterior urethral valve patients?

OBJECTIVE: Although renal transplant (RT) is a safe and effective treatment for end-stage renal disease, the outcome of RT has been mixed for posterior urethral valve (PUV) patients. In addition, some PUV patients need an augmentation cystoplasty (AC), which may negatively affect their RT outcome. The aim of this study is to compare RT outcome between PUV children with and without AC. MATERIALS AND METHODS: Between 1985 and 2012 a total of 309 children received 369 RTs at our institution. Among these patients, 36 were had classified as having PUV. Of these, 12 underwent an AC before RT (AC group) and 24 did not (controls). Data, including age at transplant, allograft source, urological complications, urinary tract infection (UTI) incidence, the presence of vesicoureteral reflux (VUR), and patient and graft survival, were compared between groups. RESULTS: Mean age at RT and mean follow-up were 7.6 versus 7.9 years and 8.9 versus 7.9 years in the AC group and in the control group, respectively (not significant [NS]). Allografts were from living donors in 50% of the AC group and in 41.6% of the controls (NS). The rate of UTI was 0.02 UTI/patient/year and 0.004 UTI/patient/year in the AC and control group, respectively (p = 0.001). Of the nine patients with UTI in the augmented group, five (55.5%) had VUR, while 5/8 (62.5%) patients in the control group with UTI had VUR. All patients with VUR in either group had UTIs previously. Of the five AC patients with more than three UTIs, two (40%) were non-compliant with clean intermittent catheterization (CIC), and UTI incidence was not associated with either a Mitrofanoff conduit or the urethra being used for CIC. Graft function at the end of study was 87.8 ± 40.5 ml/min/m(2) in the AC group and 88.17 ± 28.20 ml/min/m(2) in the control group (NS). The 10-year graft survival rate was 100% in AC group and 84.8% in controls. Two patients in the AC group lost their grafts (mean follow-up 13.3 ± 0.8 years) and five in the control group (mean follow-up 7.1 ± 4.7 years). CONCLUSIONS: Bladder augmentation does not negatively affect renal outcome in PUV patients undergoing transplantation. However, recurrent UTIs are more frequent in transplanted PUV patients with an AC than in those without AC, and they are generally related to non-compliance with CIC or the presence of VUR but, mostly, they will not result in impaired graft function.

Long-term consequences of posterior urethral valves.

Posterior urethral valves (PUV) are the most common congenital cause of bladder outlet obstruction in infancy, and it is the effect of this obstruction on the bladder and the kidneys that will decide a patient's prognosis. With the improvements in diagnosis and treatments, what was previously a poor prognosis for boys with PUV has improved, and more patients will encounter the long-term sequelae of PUV during puberty and adulthood. In these patients the long-term prognosis in terms of renal and bladder function and fertility, as well as the risk of malignancy in those whose bladders were augmented with gastrointestinal segments, is still a matter of great concern and all of these topics will be discussed in this article.

Long-term bladder function, fertility and sexual function in patients with posterior urethral valves treated in infancy.

OBJECTIVE: To address the issue of sexual function and fertility in PUV patients. PATIENTS AND METHODS: Of 47 patients (age > 18 years) treated for PUV in infancy 28 were contactable. They were sent a standard questionnaire requesting details on voiding dysfunction symptoms, and experience of erection, orgasm and ejaculation. RESULTS: Of the 28, 16 (mean age 24 years) returned the questionnaire. Voiding frequency ranged from 3 to 10 times per day (mean = 5). Two patients had occasional mild diurnal incontinence but none had symptoms of overactivity. Three patients had a weak urinary stream. Renal function was normal in 9, 4 had a glomerular filtration rate <80 ml/min/1.73 m(2), and 3 had undergone renal transplant. Erections and orgasm were experienced by the 15 patients who responded to these questions, with 4 reporting mild or medium erectile dysfunction and 1, on dialysis, reporting slow ejaculation. Post-masturbation samples of semen and urine were collected from 6 patients. One had an alkaline pH, high percentage of immotile sperm and low sperm count. Another had a high concentration of abnormal forms, and seminal fluid was present in the urine of 3 patients. CONCLUSIONS: In long-term follow-up, 44% of PUV patients develop chronic renal failure or end-stage renal disease, but bladder dysfunction symptoms are infrequent. Sexual function is mostly normal. Total semen counts and motility are compatible with paternity in most patients.

Maldescenso testicular / Undescended testicle

El mal descenso testicular o, ausencia del testículo en la bolsa escrotal, es la anomalía más frecuente del tracto genitourinario, afectando al 3% delos niños recién nacidos. El descenso testicular se produce en dos etapas bien diferenciadas: en la primera (8-15 semanas de gestación) tiene lugar la migración intraabdominal del testículo; en la segunda etapa (25-35 semanas), el testículo migra hasta el escroto. Cualquier anomalía que interrumpa alguna de las etapas puede causar un mal descenso, por lo que la etiología continúa siendo desconocida. La importancia de esta anomalía estriba en su repercusión sobre la fertilidad, la mayor incidencia de tumores testiculares y en los posible factores psicológicos. Los pilares fundamentales para el diagnóstico de los testes palpables continúan siendo la anamnesis y la exploración física, siendo la laparoscopia la técnica de elección para el diagnóstico y tratamiento de los testes no palpables. En la actualidad, la orquidopexia entre los 6 a 12 meses de edad es el tratamiento de elección (por vía inguinal para los testes palpables y por laparoscopia para los testes no palpables). Aún está por determinar si la orquidopexia precoz mejora la fertilidad y disminuye el riesgo de cáncer (AU)

Cryptorchidism is the most common anomaly of the male genitalia, affecting 3% of male newborns. Testicular descent takes place in two distinct stages: during the first (between 8-15 weeks of gestation) the intra-abdominal migration of the testicle occurs; during the second stage (25-35 weeks), the testicle migrates to the scrotum. Any anomaly that interrupts any of these stages may cause a cryptorchidism, so the etiology remains unclear. The importance of this abnormality lies in its impact on fertility, increased incidence of testicular tumors and psychological sequelae. Medical history and physical examination are the fundamental pillars for the diagnosis of palpable testes; laparoscopy remains the golden standard for the diagnosis and treatment of non-palpable testes. Currently, orchidopexy at 6 to 12 months of age is the treatment o choice (via inguinal approach for palpable testes and laparoscopy for non-palpable testes). It has yet to be determined whether early orchidopexy improves fertility and lowers the risk of cancer (AU)

Situación actual del trasplante renal en el niño / Current status of renal transplant in the child

El trasplante renal es el tratamiento de elección para los niños que se encuentran en situación de insuficiencia renal terminal. La supervivencia del injerto y la del paciente han mejorado de forma espectacular en las últimas tres décadas. La causa más frecuente de pérdida del injerto es el rechazo crónico. La mortalidad en los cinco primeros años posttransplante es inferior al 6,5%. La infección y las complicaciones cardiovasculares son las causas principales de muerte relacionada con el trasplante. Sin embargo, a pesar de estos importantes avances, es preciso continuar investigando qué importantes avances, es preciso continuar investigando qué factores influyen en el rechazo crónico, la recurrencia de la enfermedad primaria, en los resultados a largo plazo del injerto renal, así como en conseguir reducir el tratamiento inmunosupresor y sus efectos colaterales (AU)

Paediatic renal transplantation has become the therapy of choice for children with end stage renal disease. Over the last three decades, patient and graft survival rates have improved dramatically. The most common cause of renal graft loss is chronic rejection. Overall mortality has decrease to 6.5 in the first five years port-transplant. The most frequent causes of death related to renal transplant are infection and cardiovascular complications. Future challenges for paediatric transplant programs include chronic rejection, disease recurrence, long outcome, and reduction of immunosuppressive treatment and its side effects (AU)

[Laparoscopic resection of the prostatic utricle in children]. / Resección laparoscópica del utrículo prostático en niños.

INTRODUCTION: The prostatic utricle is an embryological remnant from Müllerian duct tissue. Most prostatic utricles are asympomatic, but they may manifest as a urinary tract infection or an incontinence. MATERIAL AND METHOD: Surgery consists in a cysto-urethroscopy and cannulation of the prostatic utricle with a ureteral catheter (Fogarty ner 4) and the cystoscopy left in situ to facilitate identification and mobilization. A 10 mm port through a umbilical incision and two more 5 mm working ports were inserted. After mobilization, the ureteral defect was closed by an absorbable suture and ultrasonic coagulation. RESULTS: Five boys with symptomatic prostatic utricles underwent surgery at a mean (range) age of 7 (2-11) years. The laparoscopic excision was successful in all but one due to a bleeding. The mean (range) operative duration was 165 (120-240) min. CONCLUSION: Laparoscopic excision under cystoscopic guidance offers a good surgical view and allowing easy dissection.

Nefrectomía laparoscópica de donante vivo: Repercusión funcional en el receptor pediátrico / Laparoscopic living donor nephrectomy: Functional repercussion in the pediatric recipient

Objetivo. Analizar el impacto que la nefrectomía laparoscópica(NL) puede tener en la función renal y supervivencia del injerto en el receptor pediátrico. Material y métodos. Estudiamos retrospectivamente 63 receptores de injerto de donante vivo entre 1994 y 2007. Dieciséis pacientes obtuvieron el injerto por NL y 47 por nefrectomía abierta (NA). La edad media del receptor fue de 9,3 ± 5 años y la edad media del donante fue 40,8 ± 7 años. Estudiamos la incidencia del retraso en la función del injerto, el rechazo agudo y la función a medio plazo del injerto en ambos grupos. Resultados. Los datos demográficos del donante y del receptor y (.. )(AU)

Aim. The impact of laparoscopic (LDN) vs. open nephrectomy(ODN) on early graft function and survival in pediatric kidney recipient remains unclear. Material and method. We retrospectively review the records of63 pediatric recipient of living donor renal trasplant from 1994 to 2007.We compared those who recieved allograft recovered by LDN (n: 16)with those by ODN (n: 47). The mean recipient age was 9.3±5 years and the mean donor age was 40.8±7 years. Outcomes of interest included the incidence of delayer graft function, acute rejection and long-termgraft function. Results. Donor, recipient, demographic data and the total time of cold ischemia (1.9±0.3 hours) were similar in both groups. The mean of kidney warm ischemia was (195 LDN vs. 20 ODN seconds). There were not any significant differences between the two groups, not even in the patient survival after 36 months (100% LDN vs. 98% ODN), neither in (..) (AU)

Resección laparoscópica del utrículo prostático en niños / Laparoscopic resection of the prostatic utricle in children

Introducción. La mayor parte de los niños intervenidos de malformaciones anorectales (MAR) presentan algún tipo de disfunción intestinal. Un adecuado seguimiento de este aspecto marcará su calidad de vida. Material y métodos. Seleccionamos una muestra de 20 niños intervenidos de MAR mediante anorectoplastia sagital posterior (ARSP) y cuyo seguimiento no pudo realizarse adecuadamente. Tras contactar telefónicamente con ellos, son citados, entrevistados y explorados en nuestra consulta. Analizamos las variables relacionadas con la continencia y evaluamos la calidad de vida de los pacientes.Resultados. Reunimos 12 niñas y 8 niños. Rango de edad entre (..) (AU)

Introduction. The prostatic utricle is an embryological remnant from Müllerian duct tissue. Most prostatic utricles are a sympomatic ,but they may manifest as a urinary tract infection or an incontinence. Material and method. Surgery consists in a cysto-urethroscopy and can nulation of the prostatic utricle with a ureteral catheter (Fogartyner 4) and the cystoscopy left in situ to facilitate identification and mobilization. A 10 mm port through a umbilical incision and two more (..) (AU)

[Laparoscopic living donor nephrectomy: functional repercussion in the pediatric recipient]. / Nefrectomía laparoscópica de donante vivo: repercusión funcional en el receptor pediátrico.

AIM: The impact of laparoscopic (LDN) vs. open nephrectomy (ODN) on early graft function and survival in pediatric kidney recipient remains unclear. MATERIAL AND METHOD: We retrospectively review the records of 63 pediatric recipient of living donor renal trasplant from 1994 to 2007. We compared those who recieved allograft recovered by LDN (n: 16) with those by ODN (n: 47). The mean recipient age was 9.3 +/- 5 years and the mean donor age was 40.8 +/- 7 years. Outcomes of interest included the incidence of delayer graft function, acute rejection and long-term graft function. RESULTS: Donor, recipient, demographic data and the total time of cold ischemia (1.9 +/- 0.3 hours) were similar in both groups. The mean of kidney warm ischemia was (195 LDN vs. 20 ODN seconds). There were not any significant differences between the two groups, not even in the patient survival after 36 months (100% LDN vs. 98% ODN), neither in the graft survival with proportional hazards Cox analysis. The LDN group needed more days (9.56 +/- 2.3 vs. 4.72 +/- 0.57 ODN) to reach the minimum serum creatinine, but the GF (ml/min/1.73 m2) was similar at 6 months (122 +/- 12 LDN vs. 87 +/- 17 ODN), one year (139 +/- 45 LDN vs. 88 +/- 27 ODN), and two years (110 +/- 64 LDN vs. 82 +/- 30 ODN) after transplant. CONCLUSIONS: LDN delays the recovery of the graft function in pediatric recipient. Pediatric LDN recipient have graft outcomes comparable to those of ODN.

Laparoscopia en urología infantil / Laparoscopy in children´s urology

El empleo de la laparoscopia en la urología pediátrica se ha extendido de forma significativa en los últimos años. Los beneficios de la laparoscopia están bien definidos, acorta la estancia hospitalaria, produce una recuperación más rápida y ofrece un mejor resultado estético. La orquidopexia y la nefrectomía laparoscópica son procedimientos ampliamente aceptados y se ofrecen como alternativas a la cirugía abierta. Aquellos procedimientos que demandan una mayor dependencia técnica, tales como la pieloplastia, la cirugía reconstructiva vesical y la reimplantación ureteral, se realizan en centros especialmente equipados y están a la espera de determinar sus beneficios potenciales (AU)

The use of laparoscopy in pediatric urology has suffered growth significantly over the last years. The benefits of laparoscopic procedures are well defined, shorter hospitalization, quicker return and aesthetic advantages. Laparoscopic orchiopexy and nephrectomy are become widely accepted as alternatives to open surgery. More technically demanding procedures, such as laparoscopic pieloplasty, bladder reconstruction and ureteral reimplantation are being performed at specially equipped centers and have not yet specified its potential benefits (AU)

Are urodynamic studies really needed during bladder augmentation follow-up?

OBJECTIVE: We assessed clinical and urodynamic outcomes, over a minimum 10-year follow-up period, of neuropathic bladder patients treated with a bladder augmentation (BA) to determine if periodic urodynamic studies are needed. MATERIAL AND METHODS: Thirty-two patients with poorly compliant bladders underwent BA at a mean age of 11 years (2.5-18). Mean follow-up was 12 years (10-14.5) and mean patient age at the end of the study was 22 years (12.2-33). During follow-up all patients were controlled at regular intervals with urinary tract imaging, serum electrolyte and creatinine levels, cystoscopy and urodynamic studies. Preoperative, 1-year post-BA and latest urodynamic studies results were compared. RESULTS: Urodynamic studies at 1-year post-BA showed a significant increase in bladder capacity and a decrease in end-filling detrusor pressure compared with preoperative values (396 vs 106 ml; 10 vs 50 cm H(2)O, P<0.0001). The increase in bladder capacity was more significant at the end of the study than after 1 year (507.8 vs 396 ml, P<0.002). Thirteen patients had phasic contractions after 1 year and 11 at the end (not significant, NS), and these contractions were more frequent with colon than with ileum (NS). At the end of follow-up, phasic contraction pressure had decreased while trigger volume had increased (35 vs 28 cm H(2)O; 247 vs 353 ml, NS). All patients are dry and have normal renal function, except one who had mild renal insufficiency before BA. CONCLUSION: BA improves bladder capacity and pressure, and these changes are maintained over time (although phasic contractions do not disappear). Repeated urodynamic studies are only necessary when upper urinary tract dilatation or incontinence does not improve.

[Strategy for high cavoatrial tumor thrombus in children with nephroblastoma]. / Tratamiento del nefroblastoma con trombosis tumoral cavoatrial en niños.

INTRODUCTION: Wilms tumor surgery with intracaval-atrial extension is a challenge. Modern imaging techniques, precise preoperative thrombus location, and multidisciplinary surgical approach is mandatory. We aim to evaluate the outcome of our patients. PATIENTS AND METHODS: Between 1992 and 2005, 52 patients with nephroblastomas underwent surgery in our institution. Nine of them had renal-caval (RC) or cavo-atrial(CA) thrombus extension. Four patients presenting short RC intravascular extension were excluded. RESULTS: All cases were treated with pre-postoperative chemotherapy SIOP protocols. The level of the extension was retrohepatic in 2 cases, atrial in 3 patients and it even reached the ventricle in 2 of them. A multidisciplinary team was necessary to plan surgery and in all patients thrombus and tumor could be removed under cardiopulmonary by-pass in 3 cases (CPBP). One pulmonary tamponade due to thrombus migration (CAV) occurred and was solved by CPBP. Three cases were stage III, one stage IV and 1 stage II. Conclusions. Tumor size can be significantly reduced by preoperative chemotherapy. In case of CA extension, CPBP and right liver displacement to gain access to retro-hepatic cava are mandatory in order to reduce surgical complications.

Enterocystoplasty in children with neuropathic bladders: long-term follow-up.

OBJECTIVE: This study assesses clinical outcome, after at least 8 years, of augmentation done before or at puberty in neuropathic bladders. PATIENTS AND METHODS: A total of 29 children with neuropathic bladders who did not respond satisfactorily to clean intermittent catheterisation and anti-cholinergic therapy underwent enterocystoplasty at a mean age of 11.8 years (range 3-18). Twenty-one children (72.4%) had vesicoureteral reflux (VUR) and/or ureterohydronephrosis and 22 (75.8%) had dimercapto-succinic acid scars, but all had normal renal function. All patients were followed at regular intervals with urinary tract imaging, serum electrolytes, creatinine, urodynamic evaluation and 24-h urine collection. Urine cytology, cystoscopy and biopsy were performed at the end of follow-up. RESULTS: Mean follow-up was 11 years (range 8-14.5) and mean age at the end of follow-up was 22.2 years (range 13.2-31). Urodynamic studies showed a significant improvement in bladder compliance in all patients. Upper urinary tract dilatation disappeared in all, VUR in 13/17 (76.4%), and no new renal scarring occurred in any patient. At the end of follow-up, renal function was normal in all according to serum creatinine, but cystatin C levels were normal in 27 and elevated in two. Significant proteinuria and low concentrations of renin and aldosterone were present in 80% and 82%, respectively. Only one patient had urinary tract infection, three had bladder stones, and in another a catheterisable channel was made. All patients were dry with normal urine cytology and cystoscopy, and no malignant lesions have been found in the biopsy specimens. CONCLUSION: Enterocystoplasty has preserved renal function and resolved VUR and/or hydronephrosis in most patients. The future implications of proteinuria and the low serum levels of renin and aldosterone, as well as the best indicator for measuring renal function, have yet to be determined. Close, life-long follow-up, including cystoscopy, is necessary to prevent complications.

Tratamiento del nefroblastoma con trombosis tumoral cavoatrial en niños / Strategy for high cavoatrial tumor thrombus in children with nephroblastoma

Introducción. El tratamiento quirúrgico del tumor de Wilms con extensión cavo-atrial es aún un reto para el cirujano. Es fundamental el empleo de las técnicas de imagen actuales, la localización preoperatoria exacta del trombo y un equipo quirúrgico multidisciplinar. El objetivo de nuestra revisión es evaluar el resultado en estos pacientes. Pacientes y métodos. Entre 1992 y 2005 se intervinieron en nuestro servicio 52 pacientes con nefroblastomas. Nueve de ellos tenían extensión tumoral cavo-renal o cavo-atrial. Excluimos en nuestro estudio a 4 pacientes con extensión extravascular mínima a vena renal. Resultados. Todos fueron tratados con quimioterapia pre y postoperatoria según el protocolo de la SIOP. La extensión intravascular afectaba vena cava en 2 casos, aurícula en 3 pacientes e incluso llegaba a ventrículo en 2 de ellos. En la planificación quirúrgica intervino un equipo multidisciplinar y se consiguió la extirpación del tumor y el trombo en todos, mediante circulación extracorpórea en 3 de ellos. En un paciente se produjo una embolia pulmonar por migración del trombo, que se resolvió mediante circulación extracorpórea. Tres casos fueron estadio III, 1 estadio IV y 1 estadio II. Conclusión. El tamaño tumoral puede reducirse significativamente mediante quimioterapia preoperatoria. En caso de extensión cavoatrial, la circulación extracorpórea y el desplazamiento del lóbulo hepático derecho que permita acceder a la cava retro-hepática, son necesarios para reducir las complicaciones quirúrgicas (AU)

Introduction. Wilms tumour surgery with intracavalatrial extension is a challenge. Modern imaging techniques, precise preoperative thrombus location, and multidisciplinary surgical approach is mandatory. We aim to evaluate the outcome of our patients. Patients and methods. Between 1992 and 2005, 52 patients with nephroblastomas underwent surgery in our institution. Nine of them hadrenal-caval (RC) or cavoatrial (CA) thrombus extension. Four patients presenting short RC intravascular extension were excluded. Results. All cases were treated with pre-postoperative chemotherapy SIOP protocols. The level of the extension was retrohepatic in 2 cases, atrial in 3 patients and it even reached the ventricle in 2of them. A multidisciplinary team was necessary to plan surgery and in all patients thrombus and tumour could be removed under cardiopulmonary by-pass in 3 cases (CPBP). One pulmonary tamponed due to thrombus migration (CAV) occurred and was solved by CPBP. Three cases were stage III, one stage IV and 1 stage II. Conclusions. Tumor size can be significantly reduced by preoperative chemotherapy. In case of CA extension, CPBP and right liver displacement to gain access to retro-hepatic cava are mandatory in order to reduce surgical complications (AU)