Evolution of the management of acquired neurogenic bladder in children using intradetrusor botulinum toxin type A injections: 5-year experience and perspectives.

OBJECTIVE: To report the clinical and urodynamic results of repeated intradetrusor botulinum toxin type A injections in children with an acquired neurogenic bladder. PATIENTS AND METHOD: We reviewed the data of 8 patients presenting an acquired neurogenic bladder treated between 2005 and 2010. Their mean age was 12.4 years old (range: 5-18). They were all on clean intermittent catheterization. All patients presented detrusor overactivity resistant to oral anticholinergic treatment. They received between 2 and 6 injections at a dose of 12 botulinum toxin units (BU)/kg (maximum 300 BU). Cystometry was performed 4-8 weeks after treatment. RESULTS: Five patients became completely dry, 2 were only rarely wet, and data are lacking for 1 patient. Febrile urinary tract infections ceased after 1 or 2 injections. The mean maximal detrusor pressure decreased below 40 cmH(2)O after 1, 2 and 3 injections. The normalized safe capacity rose significantly after 1, 2 and 3 injections. The normalized maximal bladder capacity rose similarly after 1, 2 and 3 injections although not always significantly. CONCLUSION: Intradetrusor botulinum toxin-A injections significantly reduce detrusor pressure and can be repeated with efficacy. They have their place in between anticholinergic treatment and surgery. The procedure could be simplified and the dosage reduced.

Conservative treatment of metanephric adenoma. A case report and review of the literature.

Metanephric adenoma (MA) is a rare kidney tumor, especially in children, with an excellent prognosis and frequent association with polycythemia. We report the case of a 4-year-old girl presenting a MA revealed by polycythemia. Any secondary polycythemia requires checking for a possible kidney tumor even when the erythropoietin level is not elevated. MA is an exclusively epithelial tumor that can be similar to nephroblastoma or papillary renal cell carcinoma; therefore, it requires strict histopathological analysis. There are few radiological characteristics of MA: well circumscribed tumor, slightly enhanced after the injection of an intravenous contrast medium on computed tomography scan or magnetic resonance imaging. Diagnosis can be supported by core-needle kidney biopsy after hemostasis check, following two published cases of associated acquired von Willebrand disease. Chemotherapy can then be avoided and first-line conservative surgical treatment by partial nephrectomy can be considered, as in our patient's case. However, the marginal resection raised the question of frozen sections analysis of the margins. We recommend thorough follow-up visits, combining clinical examination, ultrasonography and, in the case of polycythemia, biological assays.

Surgical management of congenital chylothorax in children.

PURPOSE: Aim of the study was to determine the role of surgery in the management of congenital chylothorax (CC). METHODS: We retrospectively reviewed the data of patients with CC requiring medical or surgical treatment postnatally in our institution between January 2001 and March 2009. RESULTS: Ten patients were treated for CC. We divided our population into 2 groups: group A consisted of patients in whom CC healed after conservative medical treatment (thoracocentesis, pleural drainage, total parental nutrition, somatostatin, intrapleural injections of povidone-iodine), and group B of patients who needed both medical and surgical treatment (pleural abrasion and/or pleurectomy). Conservative postnatal therapy was successful in 50% of cases. Of the 3 patients treated preoperatively with intrapleural injections of povidone-iodine, 2 presented with severe complications. Surgical treatment was successful in all cases, with no surgical complications. Patients in group B had a significantly lower birth term (p=0.0254) and birth weight (p=0.0021) compared to patients in group A. Patients with a massive chylothorax (≥50 mL/kg/day) needed surgery significantly more often than those with chylothorax <50 mL/kg/day (p=0.0119). CONCLUSION: The initial postnatal medical management of CC should consist of thoracocentesis, drainage by tube thoracostomy, and total parenteral nutrition. If this treatment fails after 10 days, we propose using alternative therapies such as somatostatin (although its efficacy is not clear) and surgery. Chemical pleurodesis by intrapleural injection of povidone-iodine must be avoided in infants and small babies. Surgical management by pleural abrasion and/or pleurectomy appears to be safe and effective. Early surgical management is proposed for babies with low birth term, birth weight and massive chylothorax >50 mL/kg/day. Long-term follow-up is needed to evaluate the potential consequences of this therapy.