Unilateral vasectomy for intractable epididiymo-orchitis in patients with anorectal malformation.

BACKGROUND: Male patients treated for anorectal malformations (ARM) and recto-urethral fistula (RUF) tend to develop recurrent epididymo-orchitis (EO) which occurs approximately in 20% of all them. The optimal management of this condition is unclear because of the extreme its rarity and the unavailability of detailed analysis in literature. To date the majority of this patients benefits from medical treatment and symptoms reduce over time but few data have been published in literature about management of patients with intractable EO. OBJECTIVE: To describe the efficacy of unilateral vasectomy in patients operated on for anorectal malformations with RUF and affected by intractable EO. STUDY DESIGN: We present five patients who met the criteria for intractable EO, and followed at our centre four of whom have undergone unilateral vasectomy. RESULTS: The first episode of EO presented at 42,00 mos ±29.39. Initially, patients were all managed with analgesics and antibiotics. For the failure of therapy, five patients were all offered unilateral vasectomy but only four families accepted procedure. Surgical treatment was performed as a day case without complications. Postoperative follow up was 88,50 mos ±68.36. Prompt and durable resolution of symptoms was observed. DISCUSSION: The long-term effects of recurrent EO in ARM are often underestimated. Prompt and appropriate intervention should prevent this undesirable sequela. Unfortunately, the optimal management of this complication is unclear, partly because of its extreme rarity. The established management needs to follow the route of correcting underlying anomalies and providing long-term analgesic and antibiotics but this may have undesired side effects. We therefore offered families vasectomy for complete symptom resolution and/or drug withdrawal. Vasectomy, as a form of treatment for, can be justified if it can prevent pain, infection and destruction of the testes. Early vasectomy may save enough functional testis tissue. CONCLUSION: To date, the only available treatment to achieve definitive resolution of symptoms in intractable unilateral EO is vasectomy. Long-term effects of such procedure on fertility are unknown. The treatment of recurrent EO in cases without site predilection remains a matter of contention.

What are the predictive factors leading to ureteral obstruction following endoscopic correction of VUR in the pediatric population?

BACKGROUND: It is extremely important to not only address the short-term success following endoscopic correction of vesicoureteral reflux (VUR) but also the long-term efficacy and safety of the tissue augmenting substance utilized for endoscopic correction. OBJECTIVE: This study retrospectively evaluated all cases of ureterovesical junction (UVJ) obstruction following endoscopic treatment of VUR over the last 5 years utilizing two tissue augmenting substances, with special emphasis on the safety of Vantris®, and performed clinical and histological review of these patients. METHODS: The study population comprised 2495 patients who underwent endoscopic correction of VUR utilizing Deflux® (1790) and Vantris® (705). Tissue sections were stained with hematoxylin & eosin and trichrome, and examined under a light microscope. Nine primary obstructive megaureters after ureteral re-implantation served as controls. RESULTS: Nine (0.5%) children (three female and six male) in the Deflux group and nine (1.3%) (five females and four males) in the Vantris group developed UVJ obstruction and required ureteral re-implantation. Obstruction developed during the period ranging 2-49 months (average 16 months) following endoscopic correction. The primary reflux grade was III in seven, IV in six, and V in six children. The mean volume of the injected material in all obstructed patients was 1.2 ± 0.6 cc (mean ± SD). Histopathological analysis revealed a pseudocapsule composed of fibrous tissue and foreign-body giant cells surrounding the Vantris implant in all patients. The distal part of the ureters demonstrated significant ureteral dilatation without ureteral fibrosis. In all patients, additional biopsies from the muscularis propria adjacent to the injection site were examined and showed no significant abnormalities. There was an increased collagen deposition in the juxtavesical segment of the obstructive ureters following Deflux and Vantris injections, and of primary obstructive megaureter. No significant difference was found in the tissue response between Deflux and Vantris patients and controls. Statistical analysis of the nonhomogeneous population demonstrated higher obstruction rates in patients from the Vantris group. However, no statistical difference was demonstrated regarding the obstruction rate in the homogenous group with relation to gender, age and reflux grade group of patients. Moreover, univariate analysis revealed that Grade V reflux, the presence of beak sign on the reviewed pretreatment, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction. DISCUSSION: This study suggested that the underlining ureteral pathology lead to UVJ obstruction following Vantris injection. There was increased collagen deposition in the juxtavesical segment of the obstructive ureters following Vantris injection. Furthermore, these findings were similar to those discovered in patients who underwent endoscopic correction with Deflux, and in patients who required ureteral reimplantation due to primary obstructive megaureter. Additional biopsies from the muscularis propria adjacent to the injection site showed no significant abnormalities, ironing out the fact that Vantris did not led to adverse tissue reaction following injection. Univariate analysis further ironed out the hypothesis that underlying ureteral pathology was responsible for the increased incidence of UVJ obstruction and demonstrated that Grade V reflux, the presence of beak sign on the reviewed pretreatment VCUG, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction. CONCLUSION: Data showed that Vantris injection did not lead to any different ureteral fibrosis or inflammatory changes to the tissue augmenting substances utilized in past and present clinical practice, and therefore did not seem to increase the incidence of UVJ obstruction. High reflux grade, presence of obstructive/refluxing megaureter and inflamed bladder mucosa were the only statistically significant and independent predictive factors for UVJ obstruction following endoscopic correction of VUR.

Vesicoureteral reflux in infants: what do we know about the gender prevalence by age?

OBJECTIVE: Vesicoureteral reflux (VUR) affects up to 1% of Caucasian children. Primary VUR is characterized by failure of the ureterovesicular junction to prevent urine from traveling in a retrograde fashion from the bladder to the ureters and the kidneys. Several reports in the literature describe the prevalence of this condition in pediatric patients; overall, VUR affects more males during infancy and with higher grades. However, a thorough consideration of these articles reveals important contradictions regarding the prevalence by gender and age. We analyzed those contradictions and suggested a possible explanation based on our single center experience with this patient group. In particular, for the age interval 0-2 years: we have found that (1) VUR mostly affects boys; (2) the male/female ratio steadily declines over time; (3) the unequal prevalence between males and females essentially disappears when children reach the age of two years. CONCLUSIONS: The natural history of VUR in infant boys differs from that of infant girls, and therefore requires a gender-specific approach. Available data support the need to redefine the categorization and clinical guidelines for this disease.

Comparison of Native Ureteral Ligation and Open Nephrectomy for Pediatric Renal Transplantation.

PURPOSE: In pediatric renal transplant recipients there are some indications for native nephrectomy, which can be performed before, during or after transplantation. Indications include massive proteinuria resistant to therapy, intractable hypertension, polyuria and chronic or recurrent kidney infections. Several scientific studies of adults have demonstrated a minimally invasive alternative to native nephrectomy, which consists of ligation of the native ureter without removing the kidney. We evaluated the safety and efficacy of this minimally invasive technique in pediatric recipients of renal transplantation. MATERIALS AND METHODS: A total of 29 pediatric kidney transplant recipients underwent unilateral native ureteral ligation during renal transplantation between 2009 and 2013 (group A). In addition, a control group of 21 pediatric renal transplant recipients was enrolled who had undergone unilateral native nephrectomy between January 2005 and December 2008 (group B). Both groups were evaluated preoperatively by Doppler ultrasound of the native kidneys. RESULTS: Statistical analysis of the 2 groups for the 3 main variables considered (surgical time, intraoperative blood loss and length of surgical scar) revealed a significant difference (Mann-Whitney U test, p <0.001). This finding confirmed the hypothesis that during renal transplantation ligation of the native ureter is less invasive than native nephrectomy. CONCLUSIONS: Ligation of the native ureter without removal of the ipsilateral kidney is a feasible procedure in pediatric renal transplant recipients. This method is easy to perform and significantly less invasive than surgical nephrectomy.

Urological complications following kidney transplantation in pediatric age: A single-center experience.

Surgical complications during kidney transplantation can seriously affect renal outcomes. We assess occurrence, risk factors, and results of all urological complications in a series of renal transplants in a single center. Children who underwent renal transplant between January 2008 and December 2014 were retrospectively evaluated. Postoperative urological complications were reviewed. Demographic details, cause of ESRD, donor type, and surgical procedures at transplant were analyzed. For statistical analysis, the chi-square test or Fisher's exact test were used as appropriate. One hundred and twenty-one kidney transplants were performed in 117 children (median age 12 yr). Sixty-two of 121 (53%) had an underlying urological malformation. At a median follow-up of three yr, 28 urological complications were recorded (23%): 12 lymphocele (10%), 10 ureteral obstruction (8%), three urinary leakage (2.5%), two symptomatic VUR (1.7%), and one hydropyonephrosis. When lymphocele was excluded, the complication incidence rate dropped to 13%. Ureteral obstruction mostly occurred late after transplant (more than six months). Presence of urological malformation was the only factor related to increased occurrence of urological complication (p = 0.007) and, in particular, ureteral obstruction (p = 0.018). Children with urological malformations presented a statistically significant risk of developing urological complications after kidney transplantation, ureteral obstruction being the most common complication.

Combined kidney and vascularized total bladder transplantation: experience in an animal model.

BACKGROUND: Few reports have described a partial bladder graft with an en bloc kidney transplantation, mainly to facilitate reconstruction of the urinary tract, but also to augment the native bladder. The present study assessed the feasibility to graft vascularized total bladder in association with a renal transplantation. METHODS: The right kidney, in continuity with the ureter and the entire bladder, was retrieved from three female pigs weighing 20 g. The visceral bloc was transplanted to three recipient pigs of the same weight. The entire bladder was transplanted with its vascular connection to ensure a better blood supply. After 3 days of observation, one recipient was humanely killed to examine the bladder graft. Oxygen saturation in the bladder graft monitored for 8 hours was compared with the native bladder in the other two recipients. All three bladder grafts were examined by a pathologist. RESULTS: All bladder grafts seemed to be macroscopically well-perfused upon removal of the vascular clamps. In case 1, the recipient was clinically well with good urinary output over the first 2 days of observation; is contrast, on day 3 the animal displayed an acute reduced urinary output. Laparotomy on day 3 of observation showed recent thrombosis of the bladder and renal graft vessels. In cases 2 and 3, oxygen saturations of the bladder graft were normal during the 8-hour observation period, without any difference between the graft and the native bladder. CONCLUSIONS: According to our results, vascularized total bladder transplantation is feasible. In combination with renal transplantation, it could be applied as an alternative to bladder augmentation or total bladder replacement.

Renal transplantation in patients with "valve bladder": is bladder augmentation necessary?

INTRODUCTION: Posterior urethral valve is a common cause of renal failure in children. This disorder often results in small bladder and low compliance, which frequently requires bladder augmentation. Herein, we report our experience in 5 children with "valve bladder" who underwent renal transplantation without preliminary bladder enlargement. MATERIALS AND METHODS: Thirteen children with valve bladder undergoing renal transplantation were considered candidates for bladder augmentation. All had oligoanuria at transplantation. In 8 children, bladder augmentation was performed before renal transplantation; in the remaining 5, the decision was postponed until after transplantation. These children underwent transplantation with a ureteral reimplant, and a suprapubic catheter was in place for 2 months. Periodically, renal function, bladder capacity, and compliance were assessed, and renal ultrasonography was performed. RESULTS: At 1-, 2-, 4-, and 6-month follow-up, the 5 children who did not undergo bladder augmentation demonstrated normal renal function, with improved bladder capacity and absence of hydronephrosis. No significant difference was evident between the 2 groups (augmented vs nonaugmented) insofar as renal function, bladder capacity, or hydronephrosis. After transplantation, bladder augmentation was not deemed necessary in any of the 5 children because of complete restoration of clinical and urodynamic parameters. CONCLUSION: Renal transplantation can be performed safely without preemptive bladder augmentation. Ureteral reimplantation is recommended, even in patients with small valve bladders. The decision about the need for bladder augmentation should be made only after normal diuresis is restored.

Arterial changes in children undergoing renal transplantation.

INTRODUCTION: Pathological changes of large arterial walls and the heart have been described in patients with chronic renal failure. The aim of the study was to verify the incidence of arterial changes among our series of pediatric patients with end-stage renal disease undergoing transplantation. PATIENTS AND METHODS: From January 2004 to December 2006, 26 patients (15 boys and 11 girls) of overall mean age of 13.12 years (range=3-27 years) underwent renal transplantation in our department. The pretransplant dialysis treatment was peritoneal in eight and hemodialysis in 18 cases. All patients were divided in two groups according to primary renal disease: group A were 18 patients with congenital urinary malformations; and group B, eight patients with acquired glomerular diseases. In each case, a sample of artery from both donor (aortic patch of kidney) and recipient (iliac patch of graft allocation) was obtained during renal transplantation. The donors were considered to be the control group. RESULTS: Light microscopy showed pathological changes in 12/26 recipient arteries: nine showed light fragmentation of the internal elastic lamina; two, more severe fragmentations; and one, fragmentation of the internal elastic lamina associated with mucopolysaccharide deposits. Pathological changes were more evident in group A than B, but the difference was not significant (P> .05). Among the donor group, 11 patients showed light fragmentation of the internal elastic lamina, but there was no significant difference with the recipients (P> .05). CONCLUSIONS: Among our group of patients, we observed only slight modifications of the arterial wall. These changes were nonspecific, similar to those in a control group of donors matched for age. A possible explanation of these findings may depend on the short time of dialysis before transplantation.

Modification of the sting procedure for vesicoureteral reflux: ureteral repositioning and injection.

OBJECTIVE: Over the past 20 years endoscopic treatment (ET) of vesicoureteral reflux (VUR) has changed the algorithm of reflux management. We describe a modification of the standard subureteral injection (STING) that has contributed to the increased success rate of this procedure. METHODS: Between January 2006 and December 2006 192 children, 5 months to 10 years old (mean age 2.8 years) underwent endoscopic treatment for VUR, with injection of dextranomer/hyaluronic acid copolymer (Dx/HA). Standard STING procedure was used in 165 patients (235 ureters). A modified STING procedure, here described as "ureteral repositioning and injection" (URI) was used in 27 patients (38 ureters). In the URI technique, the needle was inserted as for standard STING; subsequently the distal part of the ureter was raised and levered towards the lumen of the bladder; Dx/HA was then injected. Renal/bladder ultrasound was performed 1 month after treatment and a voiding cystourethrogram (VCUG) at 4-6 months. RESULTS: After a single injection the VCUG showed no reflux in 203 ureters of STING group (86%) and in 34 ureters of URI group (91%). Mean injected volume of Dx/HA was 0.7 ml (0.3-1.8 ml) for STING and 0.4 ml (0.3-0.8 ml) for URI. CONCLUSION: The modified STING we have proposed, presents some advantages. It is very easy to perform and needs less material to inject. The ureteral repositioning into the bladder, with the support of the implanted material, may reconstruct a true flap-valve mechanism, without the risk of ureteral obstruction.

Renal embolization as an alternative to surgical nephrectomy in children.

PURPOSE: Complete renal embolization may be an alternative to surgical nephrectomy. The indications for renal embolization do not differ from those for surgical nephrectomy, but the less invasive nature of the technique is a major advantage. Few case reports are available in the pediatric age group. Our experience showed that complete renal embolization was feasible in pediatric patients with results comparable to those obtained in adults. MATERIALS AND METHODS: Twelve pediatric patients underwent 14 renal embolizations. The indications for embolization were as follows: (1) severe hypertension in 7 patients with end-stage renal failure; in these cases, a unilateral native nephrectomy was recommended prior to renal transplantation; (2) end-stage hydronephrosis in 3 patients with moderate hypertension or recurrent urinary infection; (3) nephrotic syndrome in 1 patient; or (4) ablation of an irreversibly rejected renal allograft in 1 patient. The embolization was performed under epidural anesthesia in 10 patients and under general anesthesia in 2 patients, by means of a polyvinyl alcohol injection with hemostatic gelatin powder and placement of coils. Postembolization course was followed. RESULTS: The embolization was successful in all 12 patients. In 1 patient, the procedure had to be repeated as a small accessory artery had revascularized the upper pole. In another patient, the procedure was bilateral in 2 separate sessions. In 10 patients, severe flank pain required narcotic analgesia. Two patients had fever. None had hypertension peaks. Median hospital stay was 4 days. At mean follow-up of 16 months, the results were stable. CONCLUSION: Renal embolization can avoid surgical nephrectomy also in pediatric patients. The advantages are less morbidity and shorter hospital stay. Our results in the short and medium term were equal to those of surgical removal. The procedure appeared to be safe and minimally invasive.

[Efficacy and safety of endoscopic treatment of ureteral stones in pediatric age].

Ureteroscopy procedures in pediatric age are becoming more and more common thanks to the availability of smaller caliber instruments, and of improved endoscopic techniques. The efficacy of this procedure in pediatric age is still discussed nowadays. This paper aims at reviewing all cases of ureteral lithiasis treated by ureteroscopy plus intracorporeal lithotripsy (ULT), as well as verifying efficacy and safety of this procedure in pediatric age. MATERIALS AND METHODS. From July 2002 to May 2006, 37 patients (26 female, 11 male; mean age 7.4 years; range 2-17) were treated by ULT for ureteral stones: 30 in distal, 4 in middle and 3 in proximal ureter. Median size of stones was 7mm (range 3-13mm). Dilation of the ureteral meatus was necessary in 2 patients only. Endoscopic procedure was similar to adult patients. Outcomes were statistically compared with current literature data. RESULTS. In 36 (97.3%) out of 37 patients ULT proved successful. All patients having stones in distal (30) and middle (4) ureter were stone-free at the end of treatment. Stone migration into the kidney pelvis occurred in 1 patient with proximal ureter stones (66.7% stone-free rate): an ESWL treatment was therefore performed. 1 case only (2.7%) developed a perioperative complication (stone migration). Hematuria and flank pain in 4 patients (10.8%) were the most common reported post-operative complications. A stone-free state was confirmed at 1 and 3 months for all 36 patients. There was no evidence of ureteral strictures and/or ureteral refluxes. CONCLUSIONS. Smaller caliber ureteroscopes confirmed ULT as the first-choice treatment procedure in children affected by ureteral lithiasis, thanks to its efficacy and safety.

In vivo bladder regeneration using small intestinal submucosa: experimental study.

Significant side effects are correlated with bladder augmentation. Recently, small intestinal submucosa (SIS) has been proposed for clinical use. The efficacy of SIS bladder regeneration was studied in a porcine experimental model. Partial cystectomy (40-60% of bladder wall) was performed and replaced by SIS graft. Animals were planned to be killed at 2 weeks, 5 weeks and 3 months. Bladder capacity at 40 cmH(2)O pressure and macroscopic graft morphology were assessed before and after SIS implant. Histological examination was carried out with computer assisted morphometric analysis for collagen/smooth muscle ratio. Student's t test was adopted for statistical analysis. Two piglets died on the 9th and 10th post-operative day due to urinary peritonitis. The remaining piglets were killed after uneventful post-operative period at 5 weeks (two animals) and 3 months (two animals). The bladder capacity was reduced (-18%) at the 5 week follow-up and quite similar to the pre-operative volume (+2.5%) at the 3 months control. No diverticular formation, bladder calculi, mucus and urinary infection were found. The SIS graft resulted not significantly contracted. Histology at 10 days showed SIS membrane lined by transitional epithelium islands with some capillaries. At 5 weeks, transitional epithelium was fully covering the graft; new blood vessels and fibroblasts with smooth muscle cells were observed. At 3 months, the SIS was not evident. Two layers were defined: inner transitional epithelium, outer collagen with fibroblasts and muscular bundles. Computer assisted morphometric analysis showed collagen/muscle ratio 70/30% (normal bladder=56/44%, P<0.05). The SIS was effective as a scaffold for bladder wall regeneration in four out of six animals. Long-term studies are required to confirm the efficacy of the newly developed wall and for eventual clinical use.

First paediatric experience of a new device for "non-endoscopic" periurethral injection in urinary incontinence.

The results of endoscopic treatment for urinary incontinence (ETUI) depend on the condition of the urethral mucosa and on the length of the urethra. ETUI is quite difficult to perform in female patients, and, in general, in cases of scarred urethral mucosa. A new device (Zuidex, Q-Med, Uppsala, Sweden) has recently been designed for the "non-endoscopic" treatment of urinary stress incontinence in women. Three paediatric cases are described hereunder. Three patients were treated using Zuidex: two patients (two girls aged 8 and 18) on intermittent catheterization for neurogenic bladder, and one 11-year-old girl, with epispadias, who had already undergone bladder neck reconstruction (Young-Deese). Zuidex is a special implacer for dextranomer implants. It consists of four syringes filled with dextranomer, one implacer, and four needles (25 gauges). Once the device is positioned, the four injections are performed. At the end of this procedure, four implants are symmetrically positioned at four points of the urethral wall, increasing the outlet resistance. In the follow-up phase (5-13 months), the increase in the continent period was +56, 50 and 36%; the increase in bladder capacity (leak volume point) was 40, 28 and 27% in the three patients. Although the new device for "non-endoscopic" treatment of urinary incontinence has been designed for women, the size of the implacer virtually allows its use in any paediatric patient who is above the age of six. Our early experience indicates that this new device could play an important role in the treatment of urinary incontinence in paediatric age.

Predictive risk factors for chronic renal failure in primary high-grade vesico-ureteric reflux.

OBJECTIVE: To evaluate and define the risk factors predictive of chronic renal failure (CRF) in children with severe bilateral primary vesico-ureteric reflux (VUR), observed within the first year of life and with a long follow-up. PATIENTS AND METHODS: The study comprised 50 patients presenting with grade 3-5 bilateral VUR diagnosed in the first year of life; 12 were suspected prenatally and confirmed shortly after birth, before any urinary tract infection (UTI). The mean (range) follow-up was 6.3 (1-16) years. The variables considered within the first year of life were: gender, prenatal diagnosis with no UTI, number of febrile UTIs, serum creatinine and urea nitrogen levels, metabolic acidosis, proteinuria, 24-h urine output, hypertension, bilateral renal length on ultrasonography and renal scarring on renal scintigraphy. CRF was defined as a creatinine clearance of <80 mL/min/1.73 m(2) at the last follow-up. The results were assessed using univariate and multivariate analyses (backward-stepwise multiple regression) of the selected variables. RESULTS: CRF was detected at the last follow-up in 27 patients (54%), all boys, while renal function was normal in 23 (46%; seven girls). None of the 12 patients with prenatal diagnosis had UTI, but six had CRF. Febrile UTI was the presenting symptom in 38 (76%) patients and 17 (34%) of them had renal scarring. There was no significant difference between the prenatally detected VUR and febrile UTI group in the outcome as CRF. The univariate and multiple regression analysis showed that the first serum creatinine threshold of >6 mg/L before 1 year old was the most significant risk factor for CRF (P < 0.001; odds ratio 1.25). CONCLUSIONS: Children with primary bilateral high-grade VUR and a serum creatinine of > 6 mg/L in the first year of life have a significant risk of developing CRF in the long-term. Prenatal diagnosis and postnatal febrile UTI do not modify the outcome for renal function.

Renal damage in vesico-ureteric reflux.

OBJECTIVE: To detect the different extent of renal parenchymal involvement in primary vesico-ureteric reflux (VUR), and to evaluate the relationship between VUR grade, patient age and different patterns of parenchymal damage. PATIENTS AND METHODS: This blinded retrospective study included 197 consecutive children (mean age 4.26 years, range 1 month to 13 years) with primary VUR detected by voiding cysto-urethrography (VCUG), 99mTc-dimercaptosuccinic acid (DMSA; 120 MBq/1.73 m2) renal scintigraphy, with scanning for 3 h after intravenous injection. An abnormal DMSA scan was classified into three subtypes: cortical defects as a single scar (SS), multiple cortical scarring (MS) and diffuse reduced uptake with small renal size. Renal absolute uptake (AU), and split-kidney relative uptake were evaluated in refluxing and nonrefluxing renal units, and correlated with parenchymal damage and patient age. Student's t-test and the chi-square test were used for the statistical analysis. RESULTS: In all, 282 refluxing and 112 nonrefluxing units were assessed. Renal damage was detected in 188 of 282 units with VUR (67%) and in 18 of 112 (16%) contralateral nonrefluxing kidneys. The mean AU was 18.7% in kidneys with VUR and 29% in nonrefluxing units (P < 0.001). The mean (SD) AU decreased from lower to higher grades of VUR, i.e. grade 0 VUR (group A), 28.97 (9.71); grade 1-3 (group B), 21.28 (8.33); grade 4-5 (group C), 14.78 (8.02). The differences were statistically significant (A vs B, B vs C, both P < 0.001). Renal damage was differently distributed in the three groups: 69 of 109 kidneys (63%) in group C (MS prevalent), 39 of 173 (22.5%) in group B (SS prevalent) and 17 of 112 (15.2%) in group A. There was no significant difference in the distribution of renal damage subtypes in patients aged < or > 2 years (SS 19.6% vs 17.9%, MS 29.6% vs 30.1%, small size 48.2% vs 46.3%). The VUR was severe (group C) in 65% of patients aged < 2 years and in 46% aged > 2 years (chi-square, P = 0.016). CONCLUSIONS: VUR is commonly associated with renal damage. Age (< or > 2 years) did not significantly influence the kidney lesion subtype. Reduced parenchymal function (AU) progressively decreased with the severity of VUR. Focal MS, reduced size and relative uptake were significantly more common in severe VUR, leading to multifocal lesions and hypo-dysplasia. Renal scarring was present in up to 15% of contralateral nonrefluxing kidneys. Severe VUR behaved differently from lesser VUR in the renal scan parenchymal uptake.

[Role of the endoscopic treatment of vesicoureteal reflux. A 16-years' experience]. / Il ruolo del trattamento endoscopico nella cura del reflusso vescico-ureterale. Esperienza di 16 anni.

AIM: Vesico-ureteral reflux (VUR) is the most common urological malformation in pediatric age; nevertheless its optimal management remains controversial. Until early 80s, treatment guidelines for VUR recommended the use of antibiotic prophylaxis as initial therapy, with surgical repair for patients with persistent VUR. Endoscopic treatment of VUR has gained popularity and has proved successful in a high percentage of cases, but its role in the clinical practice remains to be established. METHODS: In this paper, our series of 1029 patients and 1478 refluxing ureters, treated from January 1986 to June 2001, is presented. Reflux ranged from grade II to grade IV. In the first 14 cases Teflon was injected. After 1989 bovine collagen was used in 442 children and, since 1996, Deflux, a nonallergenic, biodegradable dextranomer, in 573 cases. All patients were clinically evaluated for possible voiding dysfunctions. All patients completed a 12 month follow-up period. RESULTS: After 1 or 2 injections, a voiding cystogram showed no VUR (or grade I) in 1123 ureters (76%). In grade II, III and IV success rates were, respectively, 87%, 73% and 48%. Complications were minimal (0.5%). CONCLUSION: These results confirm that endoscopic treatment of VUR is a valid alternative to "open surgery" and to antibiotic prophylaxis. Failure of treatment is usually due to dislocation of the implanted material, secondary to voiding dysfunction. In conclusion, we recommend the endoscopic treatment in the majority of VUR, for the short hospital stay, the absence of significant complications and the high success rate. In grade IV VUR, the use of endoscopic treatment is still questionable. Patients with voiding dysfunction should be identified and treated with appropriate therapy prior to attempt an endoscopic treatment of VUR.

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.

Evolution of male epispadias repair: 16-year experience.

PURPOSE: We review our experience during the last 16 years, adopting different surgical approaches for epispadias repair, and compare the results of complete penile disassembly technique with perineal muscular complex reassembly since 1995 with previous repairs. MATERIALS AND METHODS: From 1984 to 1999, 58 epispadias repairs were performed in 53 male patients 3 days to 13 years old, including 18 with primary penopubic epispadias, 35 with bladder exstrophy and 5 treated with secondary genito-urethroplasty after previous repairs of the exstrophic complex. Cases were divided into 2 periods of the surgical procedure. Different techniques succeeded in 41 patients in the first decade (group 1) while the complete penile disassembly with perineal muscular complex reassembly technique was used in 17 patients during the last 5-year period (group 2). Results of both groups were compared, and Fisher's exact test was used for statistical analysis. RESULTS: Of the 41 group 1 cases complications (mostly fistula and/or urethral stenosis) in 21 (51%) required 1 or multiple operations. Continence was never achieved with urethroplasty alone. Cosmetic appearance of the phallus was not satisfactory in 23 cases (29%) and urethral catheterization was difficult in 8 (19%). Of the 17 group 2 cases only 2 complications (11%) occurred (1 fistula and 1 distal urethral stenosis). Dry intervals or voluntary continence was achieved in 6 of the 10 patients with exstrophy and in all but 1 with epispadias without bladder neck surgery. The penis had a satisfactory cosmetic appearance and no dorsal chordee with an easily catheterizable urethra was noted. The complication rate was significantly different in the 2 groups (Fisher's exact test p = 0.0042). CONCLUSIONS: The complete penile disassembly with perineal muscular complex reassembly technique, with deeper positioning of the urethra in the perineal musculature, seems to guarantee a significant step forward in functional epispadias repair.

Retroperitoneal laparoscopic access in children using a direct vision technique.

PURPOSE: Retroperitoneal procedures were initiated in 1992 by balloon dissection of the retroperitoneum. More recently a new type of retroperitoneal access has been obtained by directly entering the retroperitoneum using the Visiport visual trocar. We present our initial experience with direct visual access to the retroperitoneum in the pediatric population. MATERIALS AND METHODS: A total of 31 children underwent retroperitoneal laparoscopy, including renal biopsy in 22, varicocelectomy in 5, renal cyst ablation in 3 and pyelolithotomy for a staghorn stone in 1. Patients were placed in the full flank position. A maximum of 3 ports was used and the initial trocar was placed under direct vision. The laparoscope was then used to dissect bluntly a working space in the retroperitoneum. RESULTS: All procedures were successful. Blood loss was minimal. Operative time was 4 hours for pyelolithotomy and less than 1 for the other procedures. Mean hospital stay was 1.5 days and all patients returned to normal activity at a mean of 6 days. Two minor complications developed. The peritoneum was inadvertently entered in 1 case, in which no further treatment was necessary and convalescence was uneventful and short. In another case severe arrhythmia developed, resulting in an aborted procedure. CONCLUSIONS: This technique is simple, safe and does not require extensive laparoscopic experience.