[Posterior approach to the bladder for implantation of the 800 AMS artificial sphincter in children and adolescents: techniques and results in eight patients]. / La voie d'abord rétro-vésicale pour l'implantation du sphincter artificiel AMS 800 chez l'enfant et l'adolescent: technique et résultats chez huit patients.

Blind dissection of the bladder neck during implantation of an artificial urinary sphincter (AMS 800) may lead to injury of either the bladder, genital tract or even the rectum. Significant bleeding may occur. A posterior approach to the bladder neck allowing visual control of the anatomical structures is described. From November 1995 to February 1998, 8 adolescents (12-19 years old) underwent AMS 800 artificial urinary sphincter implantation for the treatment of severe incontinence associated with neurogen bladder; one patient had had a previous augmentation. Three had a simultaneous ileocystoplasty and another patient had a simultaneous bilateral extravesical ureteric reimplant. The procedure consisted of separation of the bladder from the peritoneum, allowing the development of a dissection plane between the rectum and genital tracts posteriorly and the ureters and bladder neck anteriorly; the dissection is extended to the base of the prostate. The endopelvic fascia is then incised laterally and on both sides the neurovascular bundles are perforated under visual control and the cuff is positioned safely around the bladder neck, above the prostate and in front of the genital tract. The bladder was opened only in the case of associated ileocystoplasty, thus avoiding prolonged bladder drainage. The mean operating time was 2.5 hours and the blood loss never exceeded 300 cc. This route was not found to be convenient in the case of the patient with a previous augmentation; 7 sphincters function normally with a follow-up of 18 to 44 months; one was never activated and the patient is dry under CIC. This route for exposure of the bladder neck allows visual control of the anatomical structures, accurate positioning of the cuff, avoids bladder opening and reduces bleeding. It can be used for other procedures such as bladder neck suspension or Müllerian cavity removal.

Male epispadias repair: surgical and functional results with the Cantwell-Ransley procedure in 40 patients.

PURPOSE: We present our experience using the Cantwell-Ransley epispadias technique, particularly focusing on postoperative anatomical and functional complications. MATERIALS AND METHODS: Between 1989 and 1997, 40 patients 1 to 28 years old underwent the Cantwell-Ransley technique for epispadias at our institution. The condition was isolated in 17 cases and associated with exstrophy in 23. Surgery involved a primary and secondary procedure in 29 and 11 patients, respectively. Cavernocavernostomy was performed in only 16 cases. RESULTS: At a mean followup of 3 years 18 patients (45%) had complications and needed further procedures, and 3 (7.5%) had major wound dehiscence. The complication rate was higher in the exstrophy than in the isolated epispadias group (65 versus 28%) and urethral complications were consistently associated with previous urethral plate sectioning. In 1 patient major and persistent loss of continence was probably related to prolonged transurethral bladder drainage. All 17 patients in the postpubertal group report erections, although 1 who did not undergo cavernocavernostomy still complains of dorsal curvature. In 36 patients (90%) a fully satisfactory anatomical and functional result was achieved. CONCLUSIONS: The Cantwell-Ransley technique of epispadias repair allows successful reconstruction in most patients. However, postoperative complications, some of which are serious, may develop that are more associated with previous procedures that compromise the blood supply to the urethral plate than the Cantwell-Ransley technique.

[Etiological work-up of complex voiding disorders (CVD) in boys; evaluation of the imaging strategy based on a retrospective study of 58 files]. / Bilan etiologique des troubles mictionnels complexes (TMC) du garçon: evaluation de la strategie d'imagerie a partir d'une etude retrospective de 58 dossiers.

The strategy of radiological investigations in males with severe voiding disorders has not been clearly established. To define the most effective strategy, a retrospective study of 58 files of boys investigated for severe voiding disorders (excluding neurogenic bladder) was performed. The following investigations were performed in this series: intravenous urography (IVU) completed by voiding cystourethrogram (VCUG) (41%), VCUG alone or associated with urinary ultrasound (30%), IVU alone (20.5%) ultrasound alone (1.5%) and ultrasound completed by VCUG or IVU (7%). When prescribed first, VCUG was always sufficient for accurate diagnosis; in contrast, a second investigation was usually necessary when IVU (66%) or ultrasound (80%) were performed first. The interpretability of the voiding urethrogram was also higher with VCUG (90%) than with IVU (66%); the sensitivity was 94% for VCUG and only 69% for IVU and 8% for ultrasound. This study confirms that VCUG combined with urinary ultrasound is the most reliable way to radiologically investigate male severe voiding disorders.

[Surgical repair of male epispadias by the Cantwell-Ransley procedure: technical aspects and functional results in a series of 40 patients]. / Cure chirurgicale de l'épispadias masculin par la technique de Cantwell-Ransley: aspects techniques et résultats fonctionnels sur une série de 40 patients.

From 1989 to 1997, 40 patients underwent primary (n = 29) or a secondary (n = 11) epispadias repair according to the Cantwell Ransley Procedure. 23 patients had bladder exstrophy, 6 had penopubic epispadias, and 11 had penile epispadias. The mean age at surgery was 5 years (1-28 years); 23 patients were prepubertal and 17 were postpubertal. The procedure associated an IPGAM meatoplasty, ventral transposition of the urethra, and dorsal rotation and approximation of the corpora with (16) or without (24) caverno-cavernostomy. With a mean follow-up of 4 years, 19 patients (47.5%) achieved a good cosmetic and functional result after a single procedure. 18 patients (45%) developed complications that required minor revision (8 patients) or a more major procedure (10 patients). Finally 3 patients (7.5%) had a complete failure. 3 patients also had a loss of continence (complete in one case) after the procedure. The complication rate was slightly higher in the postpubertal group (58%) than in the prepubertal group (47%). A prior urinary diversion did not increase the complication rate. All 17 patients in the postpubertal group reported satisfactory erections. All 16 patients who had minor to major urethral complications had previously undergone transection of the urethral plate. Overall 35 patients (87.5%) achieved a satisfactory cosmetic and functional result. The Cantwell Ransley procedure is an excellent procedure for the repair of male epispadias. However the complication rate is significant, mainly related to previous operations compromising the blood supply to the posterior penile urethra.

[Reconstruction of bladder exstrophy: retrospective study of 57 patients with evaluation of criteria in favor of the acquisition of continence]. / Reconstruction de l'exstrophie vésicale: étude rétrospective de 57 patients avec évaluation des critères favorisant l'acquisition de la continence.

In order to evaluate the results of staged surgical reconstruction in terms of urinary continence, spontaneous voiding and preservation of the upper urinary tract, we reviewed the charts of 42 boys and 15 girls treated at Hôpital Saint-Joseph for bladder exstrophy between 1965 and 1995. All patients underwent staged repair, associating bladder closure, bladder neck plasty, then genitoplasty, including bladder augmentation in 7 cases (12%). Criteria for good outcome in terms of continence are defined and factors influencing outcomes are reviewed. A total of 38 patients (67%) achieved good or acceptable urinary continence (22 or 39% and 16 or 28%, respectively). Outcome was poor in 19 patients, including 13 (23%) who underwent secondary urinary diversion. Bladder stones, which developed in 13 patients (23%), were the commonest long-term complication of bladder exstrophy reconstruction. Ten patients who underwent pelvic osteotomies ultimately had better continence and 9 are dry. Bladder neck reconstruction was performed at a later age overall (mean 10 years). Repeat bladder neck reconstruction was generally associated with poor results. The technique of bladder neck reconstruction did not appear to influence outcome. This retrospective study confirms that a carefully planned surgical reconstruction for bladder exstrophy can lead to satisfactory long-term urinary continence in most patients. Factors contributing to successful results include early bladder closure, pelvic osteotomy, adequate bladder neck reconstruction with bladder neck suspension in girls, and a motivated child and family. Alternatives to surgical reconstruction should be discussed. Ultimate predictors of outcome in bladder exstrophy repair are difficult to ascertain.

Bladder exstrophy: evaluation of factors leading to continence with spontaneous voiding after staged reconstruction.

PURPOSE: We performed a long-term retrospective review of patients with bladder exstrophy to evaluate the results of staged surgical reconstruction in regard to urinary continence, spontaneous voiding and preservation of the upper urinary tract. MATERIALS AND METHODS: We reviewed the charts of 42 boys and 15 girls treated at Hôpital St. Joseph for bladder exstrophy between 1965 and 1995. All patients underwent staged repair, including bladder augmentation in 7 (12%) and secondary urinary diversion in 13 (23%). Criteria for good outcome in terms of continence are defined and factors influencing outcomes are reviewed. RESULTS: A total of 38 patients (67%) achieved good or acceptable urinary continence (22 or 39% and 16 or 28%, respectively). Outcome was poor in 19 patients, including 13 (23%) who underwent secondary urinary diversion. Bladder stones, which developed in 13 patients (23%), were the most common long-term complication of bladder exstrophy reconstruction. Ten patients who underwent pelvic osteotomies ultimately had better continence and 9 are dry. Bladder neck reconstruction was performed at a later age overall (mean 10 years). Repeat bladder neck reconstruction was generally associated with poor results. The technique of bladder neck reconstruction did not appear to influence outcome. CONCLUSIONS: A carefully planned surgical reconstruction for bladder exstrophy can lead to satisfactory long-term urinary continence in most patients. Factors contributing to successful results include early bladder closure, pelvic osteotomy, adequate bladder neck reconstruction with bladder neck suspension in girls, and a motivated child and family. Alternatives to surgical reconstruction should be discussed. Ultimate predictors of outcome in bladder exstrophy repair are difficult to ascertain.

Evaluation of a hydrocolloid dressing.

A hydrocolloid dressing was compared to adhesive skin tapes on children's postoperative wounds. A total of 170 children of varying ages were randomised in two parallel groups, in nine centres of plastic, thoracic, gastrointestinal, urogenital and orthopaedic surgery. Skin closure was satisfactory in both groups, with 76 (89.4%) healthy closures without dehiscence in the hydrocolloid group and 81 (95.3%) in the control group; a relationship was found between partial closures/dehiscence and the type of surgical procedure. No product-related maceration, infection or adverse event was reported during the study and both groups showed very satisfactory cosmetic results.

Artificial urinary sphincter implantation for neurogenic bladder: a multi-institutional study in 107 children.

OBJECTIVES: To evaluate the outcome of implantation of the AMS 800 artificial urinary sphincter in children with neurogenic bladder. PATIENTS AND METHODS: The records of 107 children (74 boys and 33 girls) treated for neurogenic urinary incontinence by implantation of the AMS 800 artificial sphincter between 1983 and 1993 were reviewed retrospectively. The underlying cause of incontinence in 92 patients was spina bifida, the mean age at implantation was 13.7 years and 30 patients had undergone previous bladder neck surgery. Implantation was carried out in combination with another surgical procedure in 24.3% of patients. The mean follow-up was 61 months (minimum 12). RESULTS: The mean operational life of the sphincter was 56 months. No deaths occurred but removal of the artificial sphincter was necessary in 20 patients (19%). Surgical revision was not required in 44 patients (41%) but at least one revision was performed in 63 and more than one in 42. There were 21 mechanical failures, 40 surgical complications and 39 cases involving changes in the dynamics of bladder function. Of the 87 children (81%) in whom the device is still in place, 72 are completely continent (83%), 10 are slightly wet, and five are incontinent. The overall success rate was 77%. CONCLUSIONS: The results emphasize that for successful implantation of an artificial urinary sphincter in children, the pre-operative bladder capacity must be sufficient and previous surgery should not have been performed on the bladder neck, the site of choice for implantation in children. Sphincterotomy is not always necessary in paediatric patients. Children and parents should be informed of the high complication rate and the need for long-term follow-up.

[Extracorporeal shockwave lithotripsy in children. Study of the effectiveness and renal consequences in a series of eighteen children]. / Lithotripsie extracorporelle par ondes de choc chez l'enfant. Etude de l'efficacité et des conséquences rénales sur une série de 18 enfants.

17 children from 18 months to 16 years old were treated by ESWL for calculi of the upper urinary tract using a Sonolith 3000 lithotriptor. 31 calculi (5 to 60 mm) have been treated on 16 renal units and 3 pelvic ureters. The renal parenchyma of all treated kidneys was considered normal on preoperative ultrasound and IVU; 8 patients had a preoperative DMSA. The treatment required 1 to 4 sessions delivering 400 to 3000 shocks per session and 400 to 6000 shocks per treatment at 14 kV. Within three months post treatment, 14 patients (88.23%) were stone free and 3 patients had residual fragments (2 needed further surgical extraction). With a follow up of three months to five years, all patients have a normal blood pressure, serum creatinine and sterile urine. In no instance, IVU or ultrasound revealed a lesion imputable to ESWL. Seven patients had a DMSA six months or more after the last session; 4 of these were normal but the three other patients had a loss of function and an heterogeneous fixation on the treated side. These preliminary results confirm that ESWL is efficient for upper urinary tract calculi destruction in children. However ESWL seems to be susceptible to induce parenchymal damage, detected by DMSA, whose incidence and long term effects particularly on blood pressure need further evaluation.

[Varicocele in children and adolescents. Review of a series of 58 cases]. / Varicocèle de l'enfant et de l'adolescent. Mise au point à propos d'une série de cinquante-huit cas.

5 to 25% of male adolescents present with a varicocele; only those cases inducing serious discomfort or affecting the development of the testis require surgical treatment. Nevertheless, the results of surgery are disappointing, with a high recurrence rate. Based on a better knowledge of testicular venous drainage, it appears that conventional high ligation of the spermatic vein (s) might not be sufficient to cure varicocele. Fifty-eight patients were operated upon using four different procedures. Only complete, proximal ligation of all of the visibly dilated veins seems to prevent recurrences with a follow-up of at least one year. However, out of eleven cases treated with this original procedure, one patient, already operated upon twice without success, developed secondary atrophy.

[Varicocele in childhood and adolescence. Evaluation apropos of a series of 58 cases]. / Varicocèle de l'enfant et de l'adolescent. Mise au point à propos d'une série de cinquante-huit cas.

5 to 25% of the male adolescents present with a varicocele; only those cases inducing serious discomfort or affecting the development of the testis require surgical treatment. Nevertheless the results of surgery are disappointing with a high recurrence rate. Based on a better knowledge of the testicular venous drainage, it appears that the conventional high ligation of the spermatic vein(s) might not be sufficient to cure the varicocele, fifty-eight patients were operated upon using four different procedures. Only a complete and proximal ligation of all of the visibly dilated veins seems to prevent recurrences with a follow-up of at least one year. However, out of eleven cases treated with this original procedure, one patient, already operated upon twice without success, developed secondary atrophy.

[Transureteroureterostomy. Results in a series of 42 children and young adults]. / Transurétérourétérostomie. Résultats d'une série de quarante-deux enfants et adultes jeunes.

Forty two TUU have been performed from 1974 to 1986 in children and young adults: the youngest was 10 years, the oldest 26. The mean follow-up has been more than 5 years: 23 bladder exstrophies, 12 neurogenic bladders, 5 mega-ureters and 2 retroperitoneal tumors. TUU were performed after failure of uretero-cysto-neostomies (8/42) ou uretero-sigmoid reimplantation (19/42). The technique with details about drainage (16/42) is described. In 5 cases, complications appeared early: 3 fistulae, 2 sweelings of the anastomosis. tests done 3 months after the operation did not show any other complication in relation with the TUU. Nevertheless one reflux and 3 stenoses of the end of the recipient ureter caused dilatation of two upper urinary tracts. During the long term follow-up, it was necessary to perform 2 nephrectomies of the donor ureter and 5 operations on the end of the recipient ureter. These complications were independant of the TUU. The final result of TUU was excellent.

[Ureteral reimplantation using the psoas bladder hitch. Apropos of 42 cases]. / Réimplantation urétérale avec fixation de la vessie au psoas (vessie psoïque). A propos de 42 observations.

42 cases of ureterocystoneostomy with psoas hitch were performed: 22 boys, 20 girls. The majority of the cases were done between ages 4 and 6. Initially 8 cases presented with reflux, 9 with megaureter and reflux, 20 with megaureter without reflux, 5 cases of ureterocele with duplication. 2 cases were done as a primary procedure, 4 cases as a part of undiversion, 36 after failure of a reimplantation either for reflux (13) or for stenosis (23). The technique is described: four cases were done bilaterally. Another procedure accompanied the psoas hitch: 20 ureteral modelage, 3 transuretero-ureterostomies. Follow up varied from 1 to 13 years with good results in 27 cases, fair results in 10 and poor results in 5.

[Management of uropathies diagnosed prenatally. Discussion based on a series of 53 cases]. / Prise en charge des uropathies de diagnostic pré-natal. Discussion à partir d'une série de 53 cas.

From 1982 to 1986, 53 newborns (26 boys and 27 girls) were referred to the authors for the management of a congenital anomaly of the urinary tract, following a prenatal ultrasonographic diagnosis. The postnatal diagnosis was hydronephrosis in 27 children (10/27 bilateral cases), unilateral multicystic dysplasia in 11, ureteral duplication in 6, primary megaureter or orthotopic ureterocele in 5 (1/5 bilateral case) and posterior urethral valves in 4. An early urinary tract infection was noticed in 5 cases only and 2 boys with urethral valves had an altered renal function at birth. Eight children with a mild lesion were not operated. A radical procedure was performed in 15 cases: excision of a multicystic kidney (10 cases) or heminephrectomy of an upper non-functioning pyelon (5 cases: 3 with heterotopic ureterocele and 2 with ectopic ureter). Thirty children were submitted to a corrective procedure: electrocoagulation of urethral valves (4 cases), ureteroneocystostomy (6 cases) or pyeloplasty (19 unilateral and 1 bilateral procedure). Except in a case of pyeloplasty the result of the reconstructive surgery was considered as good or satisfactory from a radiological point of view, with a mean follow-up of 1.5 year. The essential point of discussion is the evaluation of the factors which must be taken in account to plan an early reconstructive surgical treatment. The main factor, I.e. the natural history of these congenital anomalies remains at yet difficult to predict in a great number of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of vesico-renal reflux in congenital neurogenic bladder]. / Traitement du reflux vésico-rénal de la neurovessie congénitale.

Surgical treatment of vesico-renal reflux was performed in 20 children (6 boys and 14 girls) with congenital neurogenic bladder. A total of 32 ureteral reimplantations was done according to the Cohen's technique between 10 months and 15 years of age. With a follow-up ranging from 2 to 12 years, the result remained good in 15 children while a failure of the surgical correction was noted in 5. A precise urodynamic evaluation of the neurogenic bladder is important prior to the decision of antireflux surgery.

[The valves of the posterior urethra]. / Valves de l'urètre postérieur.

75 cases of posterior urethra valves have been seen and treated from 1952 to 1984. The average follow-up is 11 years. The clinical symptomatology is described and the different treatments are analyzed from a critical point of view. A the present time the progress made by pediatric intensive care, minimization of endoscopes, better understanding of lesions, indicate that the only treatment has to be the valves. A urinary diversion is to be considered only if the life of the boy is in danger. It is rare to have to reimplant the ureters. 3 boys died. From the cases with long follow-up, 4 have high blood pressure, 16 have renal insufficiency, of these one had a successful renal transplant, 6 are dialyzed. The problems of urinary continence and fertility are discussed.

[Polyp of the posterior urethra. Apropos of 6 cases]. / Polype de l'urètre postérieur. A propos de 6 cas.

Polyp of posterior urethra is a rare cause of urinary obstruction. Attached by a pedicle to the superior part of the veru montanum, such a polyp is mobile and can move in the bulbar urethra, causing urinary retention. If can also bleed provoking either hematuria or urethrorrhagia. Urinary infection can be present. Vesico-urethral ultrasound examination can show the polyp. But the diagnosis is made on a voiding cystourethrogram either at the end of an intravenous pyelogram or after suprapubic puncture of the bladder. Cystourethroscopy can also diagnose the lesion, and can treat it by electrocoagulation of the pedicle. Surgery by suprapubic incision and cystostomy is another method of treatment. It is perhaps less dangerous that the endoscopic treatment because the pedicle is very close to the ejaculatory ducts. Pathology of polyp of posterior urethra is variable but benign. The most frequent lesion is a fibrous polyp specially in children. Recurrency of such a lesion is very exceptional.