Renal transplantation in augmented bladders.

Not many years ago, children with congenital abnormalities of the lower urinary tract or with bladder dysfunction were denied renal transplantation because they were considered very high-risk recipients. However, in the past few decades, we learned that in children with poorly compliant, low-capacity bladders, augmentation cystoplasty (AC) can create a compliant, low-pressure reservoir that helps preserve the kidney graft. Although the incidence of symptomatic urinary tract infection (UTI) may be greater in pediatric transplant recipients with an AC than in those without, UTI is related more to noncompliance with clean intermittent catheterization or vesicoureteral reflux to the native kidney or graft than to the AC itself, and usually does not lead to impairment of graft function. Today, children with a bladder reconstruction may undergo transplantation with the same outcome (graft survival and function) as those with normal bladders, although there is some possibility of malignant transformation in the intestinal segment used to augment the bladder in these patients.

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.

Bladder changes after several coverage modalities in the surgically induced model of myelomeningocele in lambs.

OBJECTIVE: To assess the presence of early bladder abnormalities in a prenatally corrected and uncorrected animal model of Myelomeningocele (MMC). METHOD: A MMC-like lesion was surgically created in 18 fetal lambs between the 60th and the 80th day of gestation. Eight of them did not undergo fetal repair (group A), three were repaired with an open two-layer closure (group B), three using BioGlue® (groupC) and four fetoscopically (group D). At term, bladders were examined macroscopically and histopathological changes were assessed using H-E and Masson Trichrome. RESULTS: Five animals in group A (5/8, 62%), two in group B (2/3, 66%), one in group C (1/3, 33%) and one in group D (1/4, 25%) survived. Macroscopically bladders in group A were severely dilated and showed thinner walls. Microscopically they showed a thin layer of colagenous tissue (Blue layer. BL) lying immediately subjacent to the urothelium. The muscular layers were thinner. Non compliant pattern with thick wall and low capacity was also found in the non corrected model. Group B and the control showed preservation of muscular layers and absence of BL. Groups C and D presented BL but also preservation of muscular layers. CONCLUSION: Bladder changes in a surgically-induced model of MMC can be described using histopathological data. Both extremes of bladder changes can be observed in the model. These changes were completely prevented with open fetal surgery and partially with other coverage modalities.

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.

[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.

[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.

[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.

[Soft tissue sarcomas (1991-2004)]. / Sarcomas de partes blandas 1991-2004.

BACKGROUND: The aim of this study is to review the results of the treatment of soft tissue sarcomas (STS) in our Department during the last 13 years. MATERIAL AND METHODS: Fifty-seven children (39 rhabdomyosarcomas (RMS) and 18 other types of sarcomas) have been treated. Nineteen RMS were excluded because they were treated by oher departments. The charts of 39 chidren were analysed evaluating several parameters (age, sex, location, histology, initial stage, clinical and surgical treatment and results) as prognostic factors using actuarial survival analyses and log-rank tests. RESULTS: 1. RMS: Median age at diagnosis was 2.3 years (range 6 m-16y). Twelve were genitourinary, 3 thoracic, 3 abdominal, 1 was located in limb and 1 in the neck. Histologically, 13 were embryonal, 5 botryoid, 1 alveolar and 1 fusiform. At diagnosis, 74% were in stages I or II. Fine needle aspiration biopsy (FNAB) was made in 5 children and the result was always imprecise or mistaken. Surgical biopsy was made before the definitive surgery in 12 cases. In the remaining 8 children the diagnosis was made only after surgical resection. With an mean follow-up of 70 +/- 43 moths, 6 children died. The prognostic factors associated with poor outcomes were genitourinary location, non radical excission, the presence of distant metastases at onset and alveolar histology. 2. Other sarcomas: Median age at diagnosis was 10.9 years (range 4 days-15 years). Among this group, there were 6 fibrosarcomas, 4 indifferentiated sarcomas, 3 synovial sarcomas, 2 abdominal desmoplastic small round cell tumours, 2 neurofibrosarcomas and 1 leiomyosarcoma. Only 9 received chemotherapy and one radiotherapy. All but one were operated. Five out ot the 19 died. CONCLUSIONS: Although the role of surgery is crucial, it is necessary to refine the initial histological diagnosis, because neither the PAAF or the biopsy have always been correct. The negative prognostic factors in our series were metastases present at diagnosis, genitourinary location and alveolar (RMS), desmoplastic or indifferenciated histology.

Can urodynamic studies predict bladder behaviour changes after artificial urinary sphincter implantation?

OBJECTIVE: To assess whether preoperative urodynamic studies can predict bladder behaviour changes that will necessitate bladder augmentation in patients with neuropathic incontinence after undergoing artificial urinary sphincter (AUS) implantation. PATIENTS AND METHODS: We analysed 17 patients, with a mean age of 14.4 years at AUS implantation, who did not undergo bladder augmentation either before or at implantation. All patients were followed at regular intervals before and after implantation. Urodynamic studies were done at least three times before implantation and yearly thereafter. Bladder capacity and compliance were evaluated preoperatively and during the follow up, in order to determine whether these urodynamic measurements could predict the eventual need for bladder augmentation. RESULTS: After a mean follow up of 7.5 years bladder behaviour was unchanged in 11 patients while six required augmentation. In these six patients, normal bladder capacity and compliance decreased from 67 to 39.6% of age expected capacity (AEC) (P=0.004) and from 31.6 to 13.5 ml/cm of water (P=0.001), respectively. Four of the six had no clinical symptoms to suggest the change in bladder behaviour. The differences in the average preoperative and follow up values for both normal bladder capacity (72.4 vs 83.5% of AEC) and compliance (30 vs 33.7 ml/cm of water) were not significant in the non-augmented patients (P=0.2 and P=0.3, respectively). Preoperative normal bladder capacity and compliance were 72% of AEC and 30 ml/cm of water, respectively, in the 11 non-augmented patients and 67% and 31 ml/cm of water in the six patients with augmentation. These differences between the two groups were not significant (P=0.06; P=0.1). CONCLUSION: Preoperative urodynamic studies do not predict bladder function outcome after AUS implantation. These patients require long-term careful observation to detect any asymptomatic change in detrusor behaviour.

Initial and long-term management of posterior urethral valves.

Posterior urethral valves are the most common cause of congenital obstructive uropathy, resulting in renal failure in childhood. Nowadays, in most cases, diagnosis is suggested by antenatal ultrasound. However, antenatal intervention has not resulted in a significantly improved outcome. Endoscopic valve ablation is the initial treatment in most of these neonates, but others procedures, like vesicostomy or ureterostomy, can also be justified in some particular cases in order to improve renal function prognosis. Different factors like bladder dysfunction, VUR, polyuria and proteinuria, can be responsible for the slow and progressive deterioration in renal function that some of these patients show over the years. By treating them all, we may prevent or delay the onset of end stage renal disease.

[Pyeloplasty follow-up. How and how long?]. / Seguimiento de la ureteropieloplastia: Cómo y cuánto tiempo?

INTRODUCTION: Some controversies still persist about the pueloplasty follow-up and this study aims to determine which test should be done in these patients during the follow-up and for how long these patients should be under control. PATIENTS AND METHODS: Forty six children who underwent to pueloplasty were retrospectively reviewed and those with contralateral renal abnormalities were excluded from study. Six children were lost to follow-up and were excluded. Of 40 p (25 M, 14 F) who fulfilled the requirements of this study, 28 were diagnosed prenatally and 28 had a left UPJ obstruction. All children were diagnosed by renal ultrasound, diuretic renography and excretory urogram (except 2). Mean age at Anderson Hynes pyeloplasty was 5.1 months and mean follow-up was 6.1 years. Renal ultrasound at 3 months and every year, and a diuretic renography at 1 year were performed in all children during follow-up. In some of them diuretic renography was repeated. RESULTS: At 3 months renal ultrasound demonstrated a significant hydronephrosis decrease in all children (p < 0.0001) but not in further controls. Differential renal function remained unchanged after pyeloplasty and during follow-up. However, there was a significant UPJ drainage improvement after pyeloplasty and during follow-up (p < 0.0001, p < 0.005). Any child needed a second pyeloplasty procedure and all of them showed a normal UPJ drainage in the antegrade ureterogram performed on the 5th postoperative day, except one. CONCLUSIONS: Differential renal function did not improve after pyeloplasty in our children. If renal ultrasound 3 months after pyeloplasty demonstrated a significant hydronephrosis decrease and at 1 year diuretic renography reveals a normal UPJ drainage any change should be expected in the long-term follow-up.

[Contrast-enhanced sonourethrography versus conventional miction cystourethrography in the assessment of the urethra: preliminary study]. / Uretrocistosonografía contrastada versus cistouretrografía miccional convencional para el estudio de la uretra: estudio preliminar.

BACKGROUND AND AIMS: Voiding cystourethrography (VCUG) is the first choice imaging modality for assessing the urethra, but this technique exposes patients to ionizing radiation. Cystosonography with echocontrast (CS) has proved to be a reliable technique to detect and grade vesicoureteral reflux (VUR) without exposing patients to ionizing radiation, but its capacity to adequately study the urethra has yet to be demonstrate in large series of patients. The aim of this study is to demonstrate the reliability of contrast-enhanced CS for assessing the urethra by comparing the results with those of the VCUG. MATERIAL AND METHODS: 108 patients were studied with ultrasound (US) using a galactose-based contrast agent. This exam was always followed by VCUG. Basal and voiding urethral US studies were performed with. Patients were studied in supine decubitus position. Girls were examined by longitudinal translabial approach, with the probe (a 7.5 MHz liner array transducer) positioned longitudinally at the introitus, to evaluate the bladder neck and urethra. In boys the transducer was initially placed longitudinally in the escrotum at ventral root of the penis to assess the bladder neck and proximal bulbar urethra, and then displaced distally toward the penile urethra. On basal study the echogenic urethral mucosa and the collapsed sonolucent urethral lumen were indentified and measured when distended. The patients were asked to void with the probe in place. During voiding attention was focused on elasticity and distention of urethral walls, as well as in the caliber of the entire urethra. Patients unable to void during either CS or VCUG were excluded. RESULTS: The bladder neck and the entire urethra were well demonstrate with CS. All females and 43 males showed a normal urethra both in CS and VCUG. Four patients were dignoses of posterior urethral valves (PUV) with CS and confirmed at VCUG, one patient had anterior urethral valves and 5 showed urethral stenosis at both techniques. Three patients with a vesicosphincteric dysinergia, 14 with resected PUV and one with a resected syringocele were adequately evaluated. Twelve girls showed vaginal reflux. The information provided by CS was equivalent to the VCUG in all patients but two with a syringocele (only seen on VCUG). CONCLUSIONS: CS is a reliable imaging modality sufficiently sensitive and specific to study the urethra, adding dynamic information to VCUG and can be used as a complement to VCUG.

Posterior urethral valves: prognostic factors.

OBJECTIVE: To determine which variables besides bladder dysfunction can help to predict the outcome of renal function in boys with posterior urethral valves (PUV). PATIENTS AND METHODS: All 40 patients with PUV in this retrospective study were diagnosed and began treatment in our hospital within the first 3 months of life, and have had >or= 5 years of follow-up. At the time of diagnosis, 33 were in renal insufficiency (RI) and seven had normal renal function (RF). At the time of the study 16 were in chronic renal failure (CRF) and 24 had normal RF. We compared their RF (initial and during follow-up), vesico-ureteric reflux (VUR), urinary tract infection (UTI), proteinuria, hypertension, renal echogenicity, final patient age and initial management. RESULTS: The mean serum creatinine values before and after initial treatment were worse in boys who developed CRF than in those who did not (P = 0.08); the mean glomerular filtrate rate (GFR) at 1 year old was 52 mL/min/1.73 m2 in the former and 102 in the latter (P < 0.001). Proteinuria was present during the follow-up in 79% of patients in CRF and in only 17% of those with normal RF. All patients who developed CRF had echogenic renal changes while only 53% of the others had (P < 0.01). Other variables showed no statistically significant differences (VUR, UTI, hypertension and final patient age). Of 33 patients in RI at diagnosis, nine were treated by valve ablation and 24 by temporary pyelo-ureterostomy. The initial mean serum creatinine value was worse in the latter than in the former (20.8 vs 13.0 mg/L). However, at 1 year old the mean GFR was better in the latter than in the former (P < 0.05). These GFR differences persisted during the first years of life but had disappeared by the fifth. CONCLUSIONS: The most significant prognostic factor for the future development of CRF is the GFR at 1 year old. The onset of proteinuria during the follow-up is associated with a worse prognosis. Echogenic renal changes may help to identify those dysplastic kidneys that will develop RI. Neonatal boys in RI who underwent pyelo-ureterostomy had better RF during the first years of life than those who underwent valve ablation.

Bladder dysfunction as a prognostic factor in patients with posterior urethral valves.

OBJECTIVE: To investigate the extent to which different types of bladder dysfunction can affect long-term renal function in boys with posterior urethral valves (PUV). PATIENTS AND METHODS: Renal and bladder function were retrospectively assessed in 59 boys with PUV (mean age 10 years, range 5-17). All patients included in the study had at least 4 years of follow-up and their bladder behaviour had been evaluated in at least two urodynamic studies. At the time of the study, of the 59 PUV boys, 37 had normal renal function and 22 had end-stage renal disease (ESRD). RESULTS: Of the 59 boys with PUV evaluated by urodynamic studies, 25 had normally behaving bladders (42%) and 34 had some type of bladder dysfunction (58%). Of the 22 in ESRD, 15 had abnormally behaving bladders (68%) and only seven had bladders with normal behaviour (32%). Of the 37 boys with normal renal function, 19 had dysfunctional bladders (51%) and 18 had normal bladders (49%). Instability was found in 17 of 19 boys with bladder dysfunction and normal renal function. On the contrary among 22 boys with ESRD, poor compliance was the most frequent urodynamic pattern (eight, 53%) while instability was only found in five. Overall, eight of nine boys with poorly compliant bladders, two of three with myogenic failure and a five of 22 with instability were in ESRD, and this situation occurred at an earlier age in patients with poorly compliant bladders. CONCLUSION: Bladder dysfunction should be considered as a prognostic factor in renal failure. Those with poor bladder compliance and myogenic failure have the worst outcome, while bladder instability was associated with the lowest incidence of renal failure.

Should we treat vesicoureteral reflux in patients who simultaneously undergo bladder augmentation for neuropathic bladder?

PURPOSE: If high pressure is responsible for vesicoureteral reflux in neurogenic bladders, eliminating the high pressure should resolve reflux in noncompliant bladders. Nevertheless, the need for simultaneous ureteral reimplantation and bladder augmentation remains controversial in patients with a noncompliant bladder and vesicoureteral reflux. MATERIALS AND METHODS: Bladder augmentation was performed in 8 boys and 8 girls with a noncompliant bladder and vesicoureteral reflux at a mean age of 10 years (range 2 to 17) because they had not responded satisfactorily to clean intermittent catheterization and anticholinergic therapy alone. No effort had been made to correct reflux surgically in these patients. Before bladder augmentation reflux was grade II to III in 4 ureters (3 patients) and IV to V in 18 (13). The bladder was augmented with intestine in 14 patients and with ureter in 2. Mean followup was 5.2 years (range 2.8 to 7.5). RESULTS: After bladder augmentation bladder compliance improved in all patients. Of the 18 ureters with high grade reflux 2 were used for bladder augmentation, and reflux resolved in 13, was downgraded in 1 and persisted in 2. Of the 4 ureters with low grade reflux, reflux disappeared in 2 and was down graded in 2. The rate of high and low grade vesicoureteral reflux resolution or improvement was 87.5% and 100%, respectively. At the end of the study only 3 patients had persistent reflux, which was downgraded in 2. No urinary tract infections developed in any patient and none was receiving chemoprophylaxis 6 months postoperatively. CONCLUSIONS: Our experience indicates that antireflux procedures are not routinely needed in patients with a noncompliant bladder and associated vesicoureteral reflux who undergo bladder augmentation.

Does neonatal pyeloureterostomy worsen bladder function in children with posterior urethral valves?

PURPOSE: We determine whether long-term bladder dysfunction is more frequent in children with posterior urethral valves who undergo early supravesical urinary diversion (pyeloureterostomy) than in those who undergo valve ablation. MATERIALS AND METHODS: Urodynamic studies were performed in 59 boys with severe posterior urethral valves who were divided into 2 groups based on initial treatment of valve ablation (30) and bilateral pyeloureterostomy (29). RESULTS: Of the 59 boys 25 (42%) had a normal bladder, including 11 with an over distended bladder and 34 (58%) had bladder dysfunction, including instability in 22, poor compliance in 9 and myogenic failure in 3. Of the 30 boys initially treated with valve ablation 14 (46.6%) had a normal bladder, including 7 with an over distended bladder and 16 (53.4%) had bladder dysfunction, including instability in 10, poor compliance in 4 and myogenic failure in 2. Of the 29 boys initially treated with temporary bilateral pyeloureterostomy 11 (38%) had normal bladders, 4 with an over distended bladder and 18 (62%) had bladder dysfunction, including instability in 12, poor compliance in 5 and myogenic failure in 1. There were no statistically significant differences in the number or type of bladder dysfunction between the diversion and valve ablation groups. CONCLUSIONS: Therefore, temporary pyeloureterostomy did not affect bladder function adversely in the long term.

Does treatment of bladder dysfunction prior to renal transplant improve outcome in patients with posterior urethral valves?

Fourteen patients with posterior urethral valves and end-stage renal failure were urodynamically evaluated in order to identify and correct any bladder dysfunction before renal transplant. Of the 14 patients, during filling, six had normal bladder function, two had an over-distended bladder (one with instability), one had instability, four had poor compliance, and one had a very reduced bladder capacity. During the voiding phase, one had a myogenic failure and another had detrusor-sphincteric dyssynergia. Four patients underwent bladder augmentation. Three were managed with anticholinergic therapy and two required clean intermittent catheterization owing to post-voiding residual urine. A renal transplant was performed in all of these patients at a mean age of 8.2 years. We compared outcome in these 14 patients with bladder dysfunction treated before transplantation with outcome in a matched control group of 14 transplant patients. Graft function and survival were similar in both groups. We believe that urodynamic studies must be included in the pretransplant evaluation of patients with posterior urethral valves in order to diagnose any bladder dysfunction and commence appropriate treatment to avoid any negative influence on graft function.