Our experience with laparoscopic Anderson-Hynes ureteropyeloplasty. / Ureteropieloplastia Anderson-Hynes laparoscópica en niños. Nuestra experiencia.

OBJECTIVE: To analyze whether the application of laparoscopic surgery in the treatment of pyeloureteral junction obstruction (PUJO) has been beneficial for pediatric patients. MATERIALS AND METHODS: Medical records of all patients undergoing PUJO surgery from January 1997 to December 2017 were retrospectively reviewed. Patients with <6-month follow-up and patients undergoing video-assisted surgery were excluded. Open surgery was compared with laparoscopic surgery. The following data were collected: surgical approach, need for and type of urinary diversion, operating time, mean hospital stay, complications, and restenosis rate. Ultrasound and diuretic renogram parameters were also retrieved. RESULTS: 328 Anderson-Hynes pyeloplasties were analyzed, 142 of which had been performed laparoscopically. Overall success rate was 96.6%, and complication rate was 11.9%. No significant differences were noted between open and laparoscopic surgery. In 97.5% of surgeries, urine was diverted using an external nephroureteral catheter, a double J stent, or a Salle stent, with significant differences between open and laparoscopic surgery. Mean operating time was significantly longer in laparoscopic surgery. Mean hospital stay was significantly shorter in the laparoscopic surgery group. CONCLUSION: Surgical approach does not play a role in PUJO surgery success. Therefore, in our view, laparoscopic surgery should be the technique of choice in pediatric patients.

OBJETIVO: Analizar si la aplicación de la cirugía laparoscópica en el tratamiento de la estenosis pieloureteral (EPU) han sido beneficiosos para el paciente pediátrico. MATERIAL Y METODO: Hemos revisado de forma retrospectiva las historias clínicas de todos aquellos pacientes intervenidos de EPU desde enero 1997 hasta diciembre 2017. Se excluyeron las que tuvieron seguimiento menor a 6 meses, y las cirugías videoasistidas. Se han comparado la cirugía abierta con la cirugía laparoscópica. Se han recogido los siguientes datos: abordaje quirúrgico, necesidad y tipo de derivación urinaria, tiempo quirúrgico, estancia media, complicaciones, tasa de reestenosis. Los parámetros ecográficos y del renograma diurético también han sido recogidos. RESULTADOS: Se han analizado 328 pieloplastias, 142 se realizaron laparoscópicamente. La tasa de éxito global ha sido del 96,6%, existiendo un 11,9% de complicaciones; sin existir diferencias significativas entre la cirugía abierta y la laparoscópica. En el 97,5% de las cirugías, la orina se derivó mediante catéter nefroureteral externo, catéter doble J o catéter tipo Salle; existiendo diferencias entre cirugía abierta y laparoscópica. El tiempo quirúrgico medio fue significativamente superior en la cirugía laparoscópica. La estancia media fue menor en el grupo de cirugía laparoscópica de forma significativa. CONCLUSION: La vía de abordaje no es un factor que influya en el éxito de la cirugía de la EPU, por ello pensamos que la cirugía laparoscópica es la técnica de elección en pacientes pediátricos.

Randomized clinical trial between polyacrylate-polyalcohol copolymer (PPC) and dextranomer-hyaluronic acid copolymer (Dx/HA) as bulking agents for endoscopic treatment of primary vesicoureteral reflux (VUR).

OBJECTIVE: To compare the radiological and clinical outcomes of endoscopic treatment of primary VUR using polyacrylate-polyalcohol copolymer (PPC-Vantris®) or dextranomer-hyaluronic acid copolymer (Dx/HA-Deflux®). MATERIALS AND METHODS: From October 2014 to April 2017, patients with primary VUR grade III to V that needed endoscopic treatment (ET) were eligible for this randomized clinical trial. We excluded toilet-trained patients with lower urinary tract symptoms. Patients were randomized and allocated into two groups: PPC group and Dx/HA group. After endoscopic treatment a voiding cystourethrography (VCUG) was performed at 6 months; if VUR was still present a second ET was performed. Radiological success was considered if postoperative VUR grade was 0 and clinical success rate was considered if no more fUTI appeared during follow-up. RESULTS: Forty-six patients were eligible but 2 did not accept the trial. Forty-four patients with 73 refluxing ureters were included. PPC: 34 refluxing ureters; and Dx/HA: 39 refluxing ureters. Both groups were statistically homogeneous and comparable. Mean follow-up was 27.6 months. Radiological success rate (82.2%) and clinical success rate (92.3%) were similar in both groups (p > 0.05). The volume of bulking agent used in those successfully treated was greater in Dx/HA group (p < 0.05). Distal ureter was excise in all cases of ureteral reimplantation after PPC treatment; however, distal ureter was preserved in all ureters reimplanted after Dx/HA injection. CONCLUSION: PPC and Dx/HA had similar outcomes, but we must warn that ureteral reimplantation after endoscopic treatment with PPC is difficult because of the periureteral fibrosis.

Routine delayed voiding cystourethography after initial successful endoscopic treatment with Dextranomer/Hialuronic Acid Copolimer (Dx/HA) of vesicoureteral reflux (VUR). Is it necessary? / ¿Es necesario realizar una cistouretrografía miccional seriada (CUMS) tardía tras el tratamiento endoscópico exitoso inicial con copolímero de dextranómreo/ácido hialurónico (Dx/HA) para el reflujo vesicoureteral (RVU)?

INTRODUCTION: Some guidelines recommend an early voiding cystourethrography (VCUG) after endoscopic treatment of vesicoureteral reflux (VUR), but there's no consensus if it's necessary a long-term follow-up in these patients. The aim of our study is analyze if it's necessary a delayed VCUG after initial successful treatment with Dx/HA. MATERIAL AND METHOD: We have reviewed all medical charts of patients that underwent Dx/HA treatment from 2006 to 2010. We have selected patients with initial successful treatment and more than 3 years of radiological and clinical follow-up. We have analyzed late clinical and radiological outcomes. RESULTS: One hundred and sixty children with 228 refluxing ureters underwent Dx/HA endoscopic treatment with a mean follow-up of 52.13 months. Early VCUG was performed in 215 ureters with an initial successful rate of 84.1%. The group of study was 94/215 ureters with more than 3 years of follow-up with a delayed VCUG. VUR was still resolved in 79,8% of the ureters. Clinical success rate was 91.7%. The incidence of febrile urinary tract infection in those patients with cured VUR and those with a relapsed VUR was 8 and 15%, respectively; but there were no significant differences. We have not found any variable related with relapsed VUR except those ureters that initially received 2 injections (P<.05). CONCLUSION: If our objective in the treatment of VUR is to reduce the incidence of febrile urinary tract infection it is not necessary to perform a delayed VCUG even though the long-term radiological outcomes is worse than clinical outcome.

[Anaesthetic management in a paediatric patient with a difficult airway due to epidermolysis bullosa dystrophica]. / Manejo anestésico en paciente pediátrico con vía aérea difícil afectado de epidermólisis ampollosa distrófica.

Dystrophic epidermolysis bullosa (DEB) is a rare inherited disorder characterized by blistering after minimal trauma. These blisters tend to form dystrophic scars, leading to limiting and life-threatening sequelae. The anaesthetic management of patients with DEB is a challenge, even for the most experienced anaesthesiologists, but basic principles can help us prepare the plan of care. The main goals are to prevent trauma/infection of skin/mucous, and to establish a secure airway without causing bullae. Patient positioning and the instruments used to monitor vital signs and administering anaesthetic agents can cause new lesions. It is advisable to lubricate the instruments and to avoid adhesive material and shearing forces on the skin. Besides the implications of the comorbidities, there is a potential difficult intubation and difficult vascular access. Acute airway obstruction can occur due to airway instrumentation. We report the case of a patient diagnosed with EBD difficult airway and undergoing correction of syndactylyl and dental extractions.

Bacterial characteristics and clinical significance of ureteral double-J stents in children.

OBJECTIVE: To determine the incidence of urinary tract infection in those patients that we have used an ureteral double-J stent as internal diversion after urological procedures. MATERIAL AND METHODS: We reviewed all the medical records of patients who had a ureteral double-J stent after a urological procedure from August 2007 to May 2013. We have analyzed the following data: age, gender, type of prophylaxis, incidence of urinary tract infection (UTI), days of internal diversion with double-J stent, surgical procedure, bacterial characteristics, bacterial sensibility to antibiotics and UTI treatment. RESULTS: We have used 73 double-J stents as ureteral internal diversion in 67 patients with a mean age of 44.73±57.23. Surgical procedures were 50 laparoscopic Anderson-Hynes pyeloplasties in 49 patients, and 20 high-pressure balloon dilatation of the ureterovesical junction to treat primary obstructive megaureter in 15 patients; and 3 patients with ureterovesical obstruction after endoscopic treatment of vesicoureteral reflux. Forty three stents showed a bacterial colonization in cultures. Pseudomona aeruginosa was present in 9 (20.9%) stents. Only in 12 stents, bacterial colonization was sensible to antibiotic prophylaxis. Stent colonization was higher in boys and younger patients. Four patients had a febrile UTI. Incidence of UTI in younger patients that underwent HBPD of UVJ is higher. CONCLUSION: Bacterial colonization is frequent in double-J stents but the incidence of UTI is low. Double-J colonization is higher in younger patients. Patients that underwent HPBD have a higher risk of UTI related with ureteral double J stent.

Use of high-pressure balloon dilatation of the ureterovesical junction instead of ureteral reimplantation to treat primary obstructive megaureter: is it justified?

OBJECTIVE: To compare outcomes between high-pressure balloon dilatation of the ureterovesical junction (UVJ) and ureteral reimplantation with ureteral tapering to treat primary obstructive megaureter (POM). PATIENTS AND METHODS: Retrospective review of clinical data from patients who underwent surgical treatment of POM from 2005 to 2010. Patients were divided into two groups: endoscopic treatment (ET) with UVJ dilatation and ureteral reimplantation (UR) with Cohen's or Leadbetter-Politano neoureterocystostomy and Hendren's tapering. Preoperative studies included ultrasound scan (US), voiding cystourethrography, and diuretic isotopic renogram. Outcome parameters were US, differential renal function (DRF), presence of postoperative vesicoureteral reflux, need for secondary reimplantation and complications. RESULTS ET: 13 patients with a median age of 7 (4-24) months; UR: 12 patients with a median age of 14 (7-84) months, with no statistical differences in age and gender between groups. Preoperative US parameters were similar. ET: mean diameter of renal pelvis, calices and ureter was 23.5 mm, 13.46 mm and 15.77 mm respectively. UR: mean diameter of renal pelvis, calices and ureter was 22.25 mm, 11.75 mm, and 19.08 mm, respectively. Preoperative DRF was 45.62% and 39.33% for ET and UR, respectively (p > 0.05). Significant improvement of hydroureteronephrosis was observed in 11/13 patients of ET and 11/12 patients of UR (p > 0.05). Postoperative DRF was 42% and 48% for ET and UR, respectively (p > 0.05). Postoperative vesicoureteral reflux was observed in 2 patients of ET and 1 of UR (p > 0.05). Secondary ureteral reimplantation was needed in 3 patients of ET and 2 of UR (p > 0.05). CONCLUSION: Endoscopic treatment of POM is as effective as ureteral reimplantation but further randomized clinical trials are needed to support these results.

Randomized clinical trial comparing endoscopic treatment with dextranomer hyaluronic acid copolymer and Cohen's ureteral reimplantation for vesicoureteral reflux: long-term results.

PURPOSE: To compare efficacy of Cohen's ureteral reimplantation and endoscopic treatment with Dx/HA in patients with primary VUR grades II, III and IV. METHODS: From April 2002 to June 2004, patients over 1 year old with VUR grade I, II, III or IV were included. Patients were randomized into two groups: endoscopic treatment (ET) or ureteral reimplantation (UR). In the ET group, an ultrasonography study was performed 24 h and 1 month after surgery, and two voiding cystourethrographies at 3 and 6 months post treatment. In the UR group, an ultrasonography study was done 7 days and 1 month after surgery and a micturial cystography 6 months post surgery. A postoperative nuclear direct cystogram was performed 5 years later in both groups. RESULTS: A total of 41 patients were included in this study: in ET 22 patients with 35 refluxing ureters and in UR 19 patients with 32 refluxing ureters. The VUR grades in ET were: 16 grade II, 16 grade III and 3 grade IV; and in UR: 15 grade II, 12 grade III and 5 grade IV. VUR was resolved in 91% (32/35) of ET (28% of ureters needed a second injection), and in 100% of UR group. Five years after the procedure, VUR was still resolved in 30/32 of ET and 32/32 of UR. CONCLUSION: Short- and long-term follow up shows that multiple endoscopic treatment of VUR grades II, III and IV with Dx/HA is as effective as ureteral reimplantation.

Acute and delayed vesicoureteral obstruction after endoscopic treatment of primary vesicoureteral reflux with dextranomer/hyaluronic acid copolymer: why and how to manage.

OBJECTIVE: To present our cases of ureteral obstruction after endoscopic treatment of vesicoureteral reflux (VUR) with dextranomer/hyaluronic acid (Dx/HA). PATIENTS AND METHODS: We collected data from patients who had suffered ureteral obstruction after endoscopic treatment of VUR with Dx/HA in our institution. RESULTS: From April 2002 to April 2011 we treated endoscopically 475 ureters with VUR, and detected 5 ureteral obstructions. Median age at reflux treatment was 39 months. Reflux grade before treatment was III in one patient and IV in four. Three ureterovesical junctions (UVJ) were blocked after a second endoscopic treatment. The median of Dx/HA injected was 1 ml (0.6-1.1). In two patients ureteral obstruction presented acutely and was treated with a ureteral stent. In the other three, the ureteral obstruction appeared gradually and was detected by ultrasound scans and MAG3 diuretic renogram; one underwent nephrectomy because of poor renal function, and the other two were treated with endoscopic dilatation of the UVJ. In all these patients both reflux and obstructions have resolved. CONCLUSIONS: On preoperative cystography, three of the patients had a narrowed distal ureter, and probably had a refluxing and obstructive megaureter. Other causes are not clear, except for those patients with acute presentation in whom edema of the UVJ was found. Ureteral obstruction after endoscopic treatment of VUR is rare. Endoscopic intervention such as ureteral stent placement or high-pressure balloon dilatation of the UVJ has good results as a treatment of acute and delayed obstruction.