Treatment of vesico-ureteric reflux: a new algorithm based on parental preference.

UNLABELLED: Authors from Rome evaluated parental preference for treatment in children with grade III VUR. Parents were provided with detailed information about the three treatment options: antibiotic treatment, open surgery, endoscopic treatment. Most parents chose endoscopic management; with this in mind, the authors proposed a new treatment algorithm for VUR. OBJECTIVE: To assess parental preference (acknowledged in treatment guidelines as important when choosing therapy) about treatments for vesico-ureteric reflux (VUR, commonly associated with urinary tract infection and which can cause long-term renal damage if left untreated), as at present there is no definitive treatment for VUR of moderate severity (grade III). SUBJECTS AND METHODS: The parents of 100 children with grade III reflux (38 boys and 62 girls, mean age 4 years, range 1-15) were provided with detailed information about the three treatment options available for treating VUR (antibiotic prophylaxis, open surgery and endoscopic treatment), including the mode of action, cure rate and possible complications, and the practical advantages and disadvantages. They were then presented with a questionnaire asking them to choose their preferred treatment. RESULTS: Most parents preferred endoscopic treatment (80%), rather than antibiotic prophylaxis (5%) or open surgery (2%); 13% could not decide among the three options and endoscopic treatment was recommended. CONCLUSION: Given the strong preference for endoscopic treatment we propose a new algorithm for treating VUR; endoscopic treatment would be considered as the first option for persistent VUR, except in severe cases where open surgery would still be recommended.

Endoscopic treatment of vesico-ureteral reflux: twelve years' experience.

INTRODUCTION: Over the past 12 years, endoscopic treatment of vesico-ureteral reflux (VUR) has gained in popularity and has proved successful in a high percentage of cases. With improvements in injectable materials and more experience with the technique, the indications for endoscopic treatment have broadened. In the present paper we report our experience on 679 patients and 953 refluxing ureters, treated over the past 12 years. MATERIALS AND METHODS: Reflux ranged from grade II to grade IV. In the first 14 cases Teflon was injected. After 1989, bovine dermal collagen was used in 442 children and, more recently, the Deflux system, a nonallergenic, biodegradable dextranomer in sodium hyaluronan in 223 children. All patients were clinically investigated for voiding dysfunctions and all completed a 1-year follow-up. RESULTS: After 1 or 2 injections the 1-year cystogram showed no VUR in 686 ureters (72%). In grade II, III and IV success rates were, respectively, 83, 69 and 41%. Complications were minimal (1%). CONCLUSIONS: Our results confirm endoscopic treatment of VUR is a valid alternative to long-term antibiotic prophylaxis and to open surgery in selected patients. The treatment often failed because of injected material displacement possibly due to voiding dysfunction. The short hospital stay, absence of significant postoperative complications, safety of the available injectable materials and high success rate suggest that endoscopic treatment should be offered to all children with grade II and III VUR, whereas it is questionable in patients with grade IV VUR. In patients with voiding dysfunction, appropriate therapy and voiding rehabilitation should precede treatment of VUR.

Preliminary report of electrogastrography in pediatric gastroresection: can it be predictive of alteration of gastric motility?

BACKGROUND/PURPOSE: Gastric resection is an infrequent surgical procedure in childhood. However, the use of the stomach for bladder augmentation and substitution is well documented. Partial gastrectomy performed in gastrocystoplasty (GCP) involves the greater curvature of the stomach, the same area in which gastric pace-maker cells are known to be placed. The aim of this study was to assess, by electrogastrography (EGG), if subtotal gastric resection can alter gastric motility in children submitted to partial gastrectomy for GCP. METHODS: Gastric electrical activity (GEA) was evaluated in 25 children using EGG: 10 patients (4 boys, 6 girls; mean age, 11.6 years) previously submitted to GCP, and 15 normal subjects (12 boys, 3 girls; mean age, 8.62 +/- 2.77 years) as controls. All patients were submitted to cutaneous EGG; recording GEA for 30 minutes before and after a standard test meal. The percentage of 3 cycles per minute (3CPM), bradygastria, tachygastria, DFIC (dominant frequency instability coefficient), DPIC (dominant power instability coefficient), PDP (period dominant power), PDF (period dominant frequency) were recorded and analyzed using Wilcoxon matched-pair test. Data were considered statistically significant if P <.05. RESULTS: Normal subjects as well as operated patients showed a statistically significant difference in bradygastria (P =.05), PDP and PDF (P =.05) percentage, comparing pre versus postprandial period. In the normal group, 3CPM (P =.0012) and DFIC (P =.0008) were statistically different between the pre- and postprandial period. Patients who underwent GCP did not show any statistically significant difference in 3CPM and DFIC pre- and postprandial. CONCLUSIONS: In normal subjects, GEA showed a complete variation after the meal, whereas in operated patients GEA was impaired and only partially modified after the meal. This observation suggests that in patients with gastric resection, adaptation of the stomach to food ingestion is present but incomplete with respect to normal subjects; it can be caused by surgical removal of the pace-maker cells of the greater curvature. For this reason a follow-up analysis of gastric function is recommended for all patients undergoing GCP.

Periurethral muscle complex reassembly for exstrophy-epispadias repair.

PURPOSE: Continence is a difficult goal in exstrophy-epispadias complex repair. It is presumed that all anatomical components involved in the exstrophy-epispadias abnormality are present but laterally and anteriorly displaced. The penile disassembly technique for epispadias restores the normal anatomical relationship of the male genital components. Its extension to complete primary bladder exstrophy closure enables deeper positioning of the bladder neck within the pelvic diaphragm. We identified the perineal striated muscular complex and present its appropriate periurethral reassembly as a main step in exstrophy-epispadias complex repair. MATERIALS AND METHODS: Bladder exstrophy and epispadias repairs were performed in 10 male and 3 female consecutive patients with the exstrophy-epispadias complex, including 1-stage reconstruction in 2 male newborns and 2 females with exstrophy, and as further surgery in a female with cloacal exstrophy and previous failed 1-stage repair, 4 males with incontinent epispadias (secondary repair in 1) and 4 males with epispadias in whom exstrophy closure had been previously done. In the males after bladder plate closure and corporeal body splitting a sagittal incision was made in the intersymphyseal tissue and extended posteriorly to the perineal body midline. The bipolar electrical stimulator was used to identify pelvic muscle components in the sagittal plane and reapproximate them along the tubularized posterior urethra to form the periurethral muscle complex. In the 3 females the urethral plate and vagina were similarly mobilized posterior through the sagittal incision of the perineal body. No patient underwent bladder neck plasty. RESULTS: At 9 months to 4 years of followup cosmesis was good in 12 patients, while 1 required secondary glanular urethroplasty. There was mild pyelectasis in 3 cases but no severe hydronephrosis and no renal function deterioration. Pyelonephritis developed in 6 patients (46%). Cystography at 1 year showed that bladder capacity was 35 to 80 and 65 to 120 cc in exstrophy and epispadias cases, respectively. There was cyclic voiding with 30 to 90-minute dry intervals in 7 patients (54%), of whom 5 had exstrophy and 2 had epispadias. Daytime voiding control with a 2 to 3-hour voiding interval was achieved in 1 female with exstrophy and 2 patients with epispadias (23%). Incontinence was present in 2 patients with previous exstrophy closure and 1 with cloacal exstrophy (23%). CONCLUSIONS: Early restoration of a physiological vesicourethral balance of coordinated activity is feasible for the progressive achievement of continence in patients with the exstrophy-epispadias complex. Sagittal splitting of the perineal tissue with identification of the muscle components as well as midline reassembly of the periurethral striated muscular complex helps to reconfigure the pelvic anatomy in a more normal fashion and allows better restoration of coordinated vesicourethral activity.

Is primary obstructive megaureter repair at risk for contralateral reflux?

PURPOSE: Contralateral vesicoureteral reflux occurs after successful unilateral reflux repair in a significant proportion of patients without correlation to the surgical approach. Unilateral congenital obstructive megaureter was compared to primary vesicoureteral reflux with regard to the risk of onset of contralateral reflux after unilateral ureteral reimplantation. MATERIALS AND METHODS: Unilateral congenital obstructive megaureter was diagnosed in 58 consecutive patients 2 to 10 years old (mean age 3.2). Cross-trigonal ureteroneocystostomy was performed in 57 cases and longitudinal ureteral reimplantation, according to the Politano-Leadbetter technique was done in 1. Longitudinal tapering according to Hendren was performed in 44 ureters, and the Kalicinski folding was used to repair 11 ureters. All patients underwent serial renal ultrasound, diethylenetetraminepentaacetic acid nuclear scan, excretory urogram and voiding cystourethrogram. The control group was composed of 98 age matched children with unilateral vesicoureteral reflux who underwent unilateral reimplantation with or without tapering. Fisher's exact test and Student's t test were used for statistical analysis. RESULTS: Followup ranged from 1 to 5 years. All patients in both groups underwent a voiding cystourethrogram at 6 months, and renal ultrasound at 3, 6 and 12 months postoperatively. Grade 2 reflux developed in 1 study group patient after contralateral Kalicinski ureteral folding and cross-trigonal reimplantation (1.7%). In the control group new onset contralateral reflux developed in 11 cases (11.2%). The difference was statistically significant (p <0.005, Fisher's exact test p = 0. 033). CONCLUSIONS: Ureteral reimplantation for unilateral congenital obstructive megaureter is not correlated with the development of contralateral reflux. The occurrence of contralateral reflux after successful unilateral reflux repair is high (11.2%), and is not correlated with age, sex and technique of reimplantation or tapering. These results support the hypothesis that the functional anatomy of the trigone is preserved in congenital obstructive megaureter but is impaired on both sides in cases of unilateral vesicoureteral reflux. The surgical management of unilateral primary vesicoureteral reflux and congenital obstructive megaureter should be differentiated based on these results.

Retroperitoneal laparoscopy for renal biopsy in children.

PURPOSE: We report our experience with the retroperitoneal laparoscopic approach for treating pediatric patients and when the percutaneous needle approach is not possible due to uncontrolled hypertension, bleeding disorders, anti-clotting medications and anatomical abnormalities. MATERIALS AND METHODS: Retroperitoneal laparoscopic renal biopsy was performed in 20 patients 2 to 18 years old (mean age 9.7) during a 16-month period. At the same time 53 percutaneous needle biopsies and 1 open biopsy were performed. The child is in a flank position, and 2 trocars are used via a direct vision approach. The first trocar is 12 mm. in diameter and positioned on the posterior axillary line, and the second trocar is 5 mm. in diameter and is entered 4 cm. anteriorly. Gentle dissection is done to free the lower pole of the selected kidney, biopsy forceps are used to grasp the specimen under direct vision and the biopsy site is fulgurated using bipolar electrocautery. RESULTS: Biopsy was performed successfully in all cases except 1, which was converted to an open procedure. Mean operative time was 40 minutes, blood loss was minimal and mean hospital stay was 1.2 days postoperatively. No pain medication was required postoperatively, and all patients returned to their usual activities within 3 to 5 days. A minor intraoperative complication, which was a peritoneal tear with no postoperative sequelae, occurred in 1 case. CONCLUSIONS: The retroperitoneal laparoscopic technique is simple and safe, and does not require extensive laparoscopic experience. We believe that this approach is reliable, and has less morbidity and several advantages compared to open surgery. It should be selected as the first choice for treating pediatric patients when percutaneous needle renal biopsy is contraindicated.

Long-term results of distal urethral advancement glanuloplasty for distal hypospadias.

PURPOSE: In 1987 we developed distal urethral advancement and glanuloplasty, a surgical technique specifically intended for coronal and subcoronal hypospadias repair that involves moving the distal urethra 0.5 to 1 cm., Y shaped meatoplasty and glanuloplasty. MATERIALS AND METHODS: From January 1987 to December 1992, 271 boys 9 months to 14 years old (mean age 2.5 years) underwent repair of distal coronal and subcoronal hypospadias, including distal urethral advancement and glanuloplasty in 135 (49.8%). RESULTS: Long-term results in 118 cases were determined at 4 to 9 years of followup (mean 6.3). In 112 cases (95%) good functional and cosmetic results were achieved, while in 6 (5%) complications required surgical repair, including meatal stenosis in 3 (2.5%), fistulas in 2 (1.7%) and complete glanuloplasty disruption in 1. We evaluated outcomes in 19 postpubertal patients 15 to 20 years old and noted no psychological or sexual problems as a consequence of hypospadias repair. CONCLUSIONS: Long-term followup confirms the validity of distal urethral advancement and glanuloplasty for correcting a large number of coronal and subcoronal hypospadias cases.

Contralateral ureteral meatal advancement in unilateral antireflux surgery.

PURPOSE: Contralateral vesicoureteral reflux is a well-known development after successful unilateral ureteral reimplantation that is not apparently influenced by the reimplantation technique. We sought to determine whether bilateral reimplantation should be performed routinely in unilateral cases. MATERIALS AND METHODS: From 1984 to 1995 we performed contralateral ureteral meatal advancement in 53 children 1 to 9.5 years old (mean age 2.5) undergoing surgery for unilateral grades II to V vesicoureteral reflux, including 12 with reflux in duplex systems. Ureteral meatal advancement involves a transverse Y shaped mucosal incision from the nonrefluxing orifice to the opposite hemitrigone. The inferior half of the ureteral orifice is then advanced toward the midline using 3 or 4 long-term resorbable sutures. The control group included 98 children who underwent unilateral surgery for grades II to V reflux from 1990 to 1995. RESULTS: No evidence of vesicoureteral reflux was observed in the 53 children who underwent contralateral meatal advancement. There was no obstruction or other complications. At followup contralateral reflux was found in 11 controls after unilateral reimplantation. CONCLUSIONS: Contralateral reflux has been reported in up to 27% of previously reported cases and in 11% of our control group after successful unilateral antireflux surgery. Contralateral ureteral meatal advancement has proved effective for preventing reflux in 100% of cases. It requires minimal invasion of the nonrefluxing ureter, and little additional operative time and cost.

[Retractile testis and gliding testis. Two distinct clinical entities]. / Testicolo retrattile e gliding testis. Due entità cliniche distinte.

The gliding testis is a testicle located below the external ring, can be manipulated to the upper scrotum, but is prone to ascend to its original position. Histologic changes can be detected in these gonads by 7 years of age. We evaluated 427 consecutive prepubertal boys referred for cryptorchidism. One hundred and twenty-three had classical undescended, 71 ectopic, 55 retractile, and 178 (mean age 6 years 2 moths) gliding testes. The gliding testes were smaller than controlaterals in 24% of boys. All gliding testes were unilateral whereas bilaterality was 85% in the retractile group (p < 0.0001), 17.5% in the undescended (p < 0.001), and 10% in the ectopic group (p < 0.01). A history for one or more of the following: orchidopexy (3), hormonal treatment (5), late testicular descent (9), spermatic cord torsion (5), testicular pain (10), actual retractile testes (20) or actual gliding testis (58), was present in 93 (52.2%) of the fathers of the gliding group. Forty-seven (81%) paternal gliding testes were hypotrophic. Seventy-five boys with gliding testis underwent initial hormonal therapy with transient benefit, and 57 were operated on. Two anatomical findings are typical of the gliding testis: the absence of the gubernaculum and a processus vaginalis partially patent from the upper scrotum to the mid groin area. This feature explains the mobility of the gliding testis from the external ring to the upper scrotum. The absence of the gubernaculum may be responsible for a higher incidence of spermatic cord torsion in this population. The gliding testis is a distinct entity, representing the mildest degree of a true undescended testis. As hormonal treatment gives only transient results, orchidopexy should be considered before testicular damage occurs.

Tourette's Syndrome Treated with ACTH and Prednisone: Report of Two Cases.

ABSTRACT Two cases of Tourette's syndrome in young boys presented with initial symptoms that coincided with the onset of an infectious disease. Standard treatment with neuroleptics yielded weak therapeutic effects, and provoked significant adverse effects at low doses, in both cases. Based on additional clinical and laboratory findings, it was hypothesized that an allergic process was affecting immunological mechanisms of the brain, and the patients were treated with ACTH and prednisone. In one case, this treatment led to remission of the tic symptoms, which remained improved through lengthy follow up. In the other case, tics resurfaced repeatedly at times of demonstrable recurrent bacterial infections, and required multiple courses of ACTH and prednisone to obtain a complete remission of the symptoms. These findings may provide a new area for research into the etiology and treatment of Tourette's syndrome. The presence of streptococcal infections in these two cases of TS is reminiscent of the findings of antistriatal antibodies in Sydenham's chorea produced by streptococcus, and raises the speculation that some cases of Tourette's syndrome may represent an autoimmune phenomenon directed to parts of the central nervous system following infection and may respond to treatments with hormones that have an anti-allergenic action.

Mesosigmoidoplasty in the treatment of sigmoid volvulus in children.

Sigmoid volvulus is a rare disease of childhood, which requires surgery. The case of a 12-year-old boy is reported. The main aetiopathogenetic causes and the proper surgical approach are also described with particular reference to the so-called mesosigmoidoplasty, which consists of shortening the mesosigmoid by incision along its axis and transverse suture.

[Influence of the family situation on the form of expression of neuroses]. / Influência da situaçâo familiar na forma de expressão das neuroses.

In this research were investigated the conditions of the family environment and the contact with the parents in 3 different groups of children and adolescents who presented respectively conversion neurosis, other types of neurosis and behavior disorders of the aggressive type. The analysis of the results obtained indicated a positive correlation between the tendency to manifest emotional conflicts under the form of conversion symptoms and the course of childhood in a family inadequate environment, with the absence of one or both parents. This fact was not found in the two other groups.

InfluÛncia da situaþÔo familiar na forma de expressÒo das neuroses. / [Influence of the family situation on the form of expression of neuroses]

In this research were investigated the conditions of the family environment and the contact with the parents in 3 different groups of children and adolescents who presented respectively conversion neurosis, other types of neurosis and behavior disorders of the aggressive type. The analysis of the results obtained indicated a positive correlation between the tendency to manifest emotional conflicts under the form of conversion symptoms and the course of childhood in a family inadequate environment, with the absence of one or both parents. This fact was not found in the two other groups.

Influencia da situacao familiar na forma de expressao das neuroses. / Influence of the family situation in the form of expression of neuroses

Nesta pesquisa foram investigadas as condicoes do ambiente familiar e o convivio com as duas figuras parentais em 3 grupos de criancas e adolescentes que apresentavam, respectivamente, neurose de conversao, neurose de outros tipos e disturbios de conduta da linha agressiva. A analise dos resultados obtidos indicou correlacao positiva entre propensao a esteriorizar conflitos emocionais sob a forma de sintomas de conversao e o transcurso de infancia em ambiente familiar inadequado, com ausencia de uma ou de ambas as figuras parentais, fato que nao foi constatado nos outros dois grupos

Influencia da situacao familiar na forma de expressao das neuroses. / Influence of the family situation in the form of expression of neuroses

Nesta pesquisa foram investigadas as condicoes do ambiente familiar e o convivio com as duas figuras parentais em 3 grupos de criancas e adolescentes que apresentavam, respectivamente, neurose de conversao, neurose de outros tipos e disturbios de conduta da linha agressiva. A analise dos resultados obtidos indicou correlacao positiva entre propensao a esteriorizar conflitos emocionais sob a forma de sintomas de conversao e o transcurso de infancia em ambiente familiar inadequado, com ausencia de uma ou de ambas as figuras parentais, fato que nao foi constatado nos outros dois grupos

Por que nao uma UTI em hospitais psiquiatricos? / Why not a I.C.U. in psychiatric hospital?

A era dos neurolepticos, iniciada na decada de 50, permitiu uma completa reformulacao no conceito de hospital psiquiatrico; hospital aberto, hospital-dia, unidades psiquiatricas em hospitais gerais sao as formulas mais preconizadas, atualmente para a internacao do doente mental. E inegavel o beneficio que parte desses pacientes recebeu com a modernizacao dos hospitais psiquiatricos.Entre tanto, uma parcela dos doentes, os psicoticos graves - justamente os mais necessitados de assistencia medica foi alijada desses centros e relegada aos hospitais tradicionais, em decorrencia das caracteristicas de suas manifestacoes, incompativeis com a liberdade existente nos hospitais modernos. Para evitar que esta situacao se perpetue, propoe a Autora a criacao de unidades de terapia intensiva dentro de enfermarias ou hospitais psiquiatricos, semelhantes, na estrutura, as UTIs clinicas e cirurgicas. Nessas UTIs os pacientes permaneceriam ate que seu comportamento se tornasse compativel com a permanencia em hospitais abertos ou em regime de hospital-dia