Is Onabotulinum Toxin-A Combined Injection in the Bowel Patch and the Bladder Remnant a Safe Alternative to Bladder Re-Augmentation?

OBJECTIVE: To assess both the safety and efficacy, in terms of symptomatic improvement, of botulinum toxin injections distributed in the bowel patch and the bladder remnant of failed augmented bladders. MATERIALS AND METHODS: A retrospective study was performed on patients with augmented bladders who had presented with clinical and/or urodynamic failure and had received an onabotulinum1 toxin-A (BTX-A) injection at both the bowel and the bladder level due to refractoriness to oral treatment. The primary variable tested was safety, which was assessed by analysing the adverse effects according to the Clavien-Dindo classification. Subjective improvement was assessed by means of the Treatment Benefit Scale (TBS) as a secondary variable. RESULTS: Eight patients who underwent a total of 23 procedures were analysed. The mean age at first injection was 23 years. The mean interval between bladder augmentation and first BTX-A injection was 65.11 months. The mean interval between BTX-A injections was 11.6 months. No adverse effects due to systemic absorption were recorded. The only postoperative complication was an afebrile urinary infection (Clavien-Dindo 2) in 2 out of 23 procedures (8.7%). Eighty-six percent (19/22) of the procedures yielded a symptomatic benefit (TBS 1 and 2). CONCLUSION: Injection of onabotulinum toxin-A in both the bowel patch and the bladder remnant appears to be a safe and efficient technique for the symptomatic treatment of patients with bladder augmentation who have shown clinical and/or urodynamic failure in response to a conservative treatment. This procedure allows bladder re-augmentation to be delayed or even avoided.

Safety and Outcomes of using ureteric access sheath (UAS) for treatment of Pediatric renal stones: Outcomes from 2 tertiary endourology centers.

OBJECTIVE: To look at the safety and outcomes of using ureteral access sheath (UAS) for pediatric renal stones. The use of UAS is variable in urological practice with very little clinical work on their use in pediatric kidney stone disease. PATIENTS AND METHODS: Data was retrospectively collected from 2 large European tertiary endourology centers for all pediatric patients (≤16 years) with renal stones who underwent flexible ureteroscopy and lasertripsy (FURSL) via UAS. Data was collected on patient details, stone demographics and clinical outcomes of the FURSL procedure. RESULTS: Forty-eight patients with a mean age of 10.7 years were treated with FURSL for a mean single and cumulative stone size of 10.4 mm and 15 mm respectively, with two-third having multiple stones and stones in the lower pole. The initial and final stone free rate (SFR) was 66.7% and 100% respectively with 1.3 procedures/patient. One patient each had intra-operative grade 1 ureteric injury and post-operative UTI, with no other injuries or complications noted. Over a mean follow-up of 17 months, no other complications were noted. CONCLUSION: Ureteral access sheath is safe for treatment of pediatric renal stones with excellent outcomes and are especially useful for larger or multiple stones. While there does not seem to be any medium-term sequalae, to avoid risk of ureteral injury, we would suggest using the smallest size sheath possible. We would argue these procedures are best done in specialist high-volume endourology units for optimal results.

Totally fluoroless retrograde intrarenal surgery technique in prestented patients: tips and tricks.

Treatment of urolithiasis has evolved greatly as retrograde intrarenal surgery (RIRS) has gained popularity nowadays being a gold standard therapy for renal stones up to 2 cm. Endourological procedures are traditionally fluoroscopic guided; thus, an increasing concern is the harm of radiation exposure, especially in the pediatric population. Therefore, performing fluoroless RIRS should be a feasible option for pediatric urologists. Herein, we describe the technique of totally fluoroless RIRS in presented patients and the tips to avoid radiation use at most.

Can endoscopic balloon dilation for primary obstructive megaureter be effective in a long-term follow-up?

BACKGROUND: Ureteral tapering and reimplantation is an established treatment for persistent or progressive primary obstructive megaureter (POM) but may result in complications and morbidity. Use of a less invasive technique involving endoscopic balloon dilation appears very interesting. OBJECTIVE: The objective of this report is to determine if endoscopic balloon dilation for POM is effective in the long term as well as to assess complications of the procedure. MATERIAL AND METHODS: A retrospective review was done on 19 patients and 20 ureters treated with the endoscopic balloon dilation by POM from June 2000 to February 2010. Surgery was performed solely in those cases in which there was persistence of obstruction in the renogram along with one or all of the following conditions: impairment of the differential renal function <40%, worsening of the renal pelvic dilation, febrile UTI in spite of antibiotic prophylaxis or renal calculi. The patients comprised 16 boys and 3 girls with a mean age at surgery of 17 months (range 1-44 months). Ten cases were left sided, eight right sided, and one bilateral. Under endoscopic and fluoroscopic guidance, a 3-5 Fr dilating balloon was inflated to 12-14 atm, or until disappearance of the stenotic obstructive area. A double J stent was positioned and withdrawn 2 months later. Follow-up recorded the presence of symptoms, number of reintervention procedures registered, and included renal ultrasound and MAG-3 renogram. RESULTS: There were no perioperative complications. Eighteen ureters showed a non-obstructive pattern on MAG-3 renogram after the first endoscopic dilation, representing a 90% success rate. One case required a second dilation, which proved successful and two cases of recurrent lithiasis required ureterotomy without instances of obstruction. 2 patients had a febrile UTI and a vesicoureteral reflux was diagnosed in one. Renal function was preserved in 95% of patients. The mean follow-up was 6.9 years (range 3.9-13.3 years). One patient was lost after the procedure. DISCUSSION: In an era of minimally invasive techniques, the search for less invasive procedures for treatment of POM has resulted in a variety of surgical options. Angulo et al., in 1998 and our group described the first POM treatment with endoscopic balloon dilation, which is believed to be a definitive, less invasive, and safe treatment. Furthermore, should an endoscopic approach fail, reimplant surgery can be performed. Few publications have reported short series with good results in the short and medium term. Torino et al. presented five cases in children aged less than 1 year, none of these showed evidence of obstruction. García-Aparicio et al. presented a series of 13 patients treated with a success rate of 84.6%. Christman et al. added laser incision in cases of narrowed ureteral segment 2-3 cm long and used double stenting. Good outcomes were presented in 71%. Romero et al. reported improvement of drainage within the first 18 months after treatment in 69% of patients. The potential de novo onset of vesicoureteral reflux may be the source of some controversy. We consider that dilation does not significantly alter the antireflux mechanism. In VCUG is not systematically performed because it is an invasive test. This restricts the conclusions that can be drawn from our findings. Nevertheless, some groups continue to systematically perform VCUG. CONCLUSIONS: Endoscopic balloon dilation for POM is a safe, feasible, and less invasive procedure that shows good outcomes on long-term follow-up. However, multicenter studies and prospective trials should be encouraged to provide more definitive evidence on its benefits.

[Testicular tumours in infancy and children]. / Tumores testiculares en la infancia.

INTRODUCTION: prepubertal testicular tumours are different from those that appear during adulthood. Traditionally, they were considered to be malignant, however benign testicular tumours are actually more frequent at this age. MATERIALS AND METHODS: we analysed our experience in the treatment of testicular tumours in children ≤ 13, with the intention of evaluating the use of partial orchiectomy. From 1984 to 2008, we diagnosed and treated 15 testicular tumours in children at our centre. We examined the therapeutic approach employed, underlining the possibility of testicular conservation in selected patients and we have analysed the results. RESULTS: the clinical presentation in 80% of the cases was an increase in testicle size with palpable mass. We performed 4 radical orchiectomies (27%) and 11 tumourectomies (73%). All the benign lesions in the final pathological anatomy were treated with tumourectomy: four epidermoid cysts, one hemangioma, one lipoma, one fibrous hamartoma, one juvenile granulosa tumour and one splenogonadal fusion. We also successfully and conservatively treated two cases of teratoma. The cases that received radical treatment were a yolk sac tumour (Stage I), two mixed germ cell tumours and one gonadoblastoma. CONCLUSIONS: there are more cases of benign testicular tumours than malignant tumours during puberty. In the event of a palpable testicular mass with negative tumour markers, conservative treatment by means of a tumourectomy may be considered. However, the lesion must be removed completely to prevent recurrence.

Cutaneous metastases in renal cell carcinoma.

Cutaneous metastases from a renal cell carcinoma are rarely diagnosed during life. We report a case of renal carcinoma metastatic to the skin that occurred 18 months after kidney removal. The cutaneous metastasis was excised. Cutaneous metastases from urological tumors are uncommon and occur in 1% of the patients, and their clinical appearance may mimic other common dermatological disorders affecting patients with advanced malignancies.

Percutaneous management of transplant ureteral fistulae is feasible in selected cases.

INTRODUCTION: Ureteral fistulae in renal transplants may develop as a consequence of compromised ureteral vascularity or from a technical factor related to the ureteroneocystostomy, the latter typically developing within the first 72 hours posttransplant. Recently, percutaneous nephrostomy drainage has been used with increasing frequency for the initial management. It alone can lead to resolution of the fistula in at least some patients. The aim of the study was the evaluation of endourological management of ureteral fistulae in renal transplants. MATERIAL AND METHODS: Between August 1981 and February 2004, 1000 adult recipients underwent renal transplantation. Sixteen out of 29 patients who developed ureteral fistulae were managed endourologically; 13, open surgery. The items recorded on these patients included the type of ureteroneocystostomy, the time to fistula diagnosis, the image technique, the type of ureteral stents, and the clinical evolution. RESULTS: The 13 patients who underwent open surgery did well. Endourological management of ureteral fistula was successfully performed in 10 of 16 cases. In all of them percutaneous nephrostomy drainage with stenting of the ureter with a double-J catheter did not prove any advantage to no stent (66.6% vs 57%). In 13 of these 16 patients in which the passage of contrast into the bladder was demonstrated, the fistula resolved in 10 cases (77%), while none of the three cases with no flow into the bladder were helped by this approach. CONCLUSION: Percutaneous techniques can provide definitive management for 62% of renal allograft patients who develop ureteral fistula beyond 72 hours after renal transplant.

Endourological management is better in early-onset ureteral stenosis in kidney transplantation.

INTRODUCTION: The incidence of ureteral stenosis in kidney transplant recipients is 3%-8%. The treatment of ureteral stenosis has been traditionally operative reconstruction, although such intervention is associated with high rates of serious complications, including graft loss and even perioperative mortality. More recently, endourological treatment has been proposed due to its low morbidity. OBJECTIVE: The objective of this study was to assess the usefulness of balloon percutaneous dilatation as a treatment technique for ureteral stenosis in kidney transplant recipients. PATIENTS AND METHODS: Among 1000 kidney transplantations performed between 1980 and 2004, the coexistence of high creatinine values and urinary tract dilatation in the postoperative period, after discarding concomitant causes, was managed with a percutaneous nephrostomy. Once renal function recovered, antegrade pyelography was performed to confirm the presence and determine the location of ureteral stenosis. Ureteral dilatation was performed using a 5-French balloon-fitted angioplasty catheter. RESULTS: Fifty-six patients were diagnosed with ureteral stenosis during follow-up, an incidence of 5.6%. Transluminal balloon dilatation was the first therapeutic option in 45 cases, whereas surgery was performed directly on 11 patients. Disappearance of the stenosis as well as maintenance of an improved creatinine level was verified in 45% of cases (20 patients). Two patients experienced graft loss. Both a short time to diagnosis after transplantation (P = .06) and the presence of a previous acute rejection episode (P < .05) were good prognosis factors for the endourologic solution of a ureteral stricture. CONCLUSIONS: Balloon dilatation may be considered the definitive procedure for treatment of ureteral stenosis in selected cases. Percutaneous nephrostomy should be used for initial diagnosis and improvement in the renal function before attempting an open procedure.