[Severe primary vesicoureteral reflux in infants. A follow-up of 203 cases]. / El reflujo vesicoureteral primario severo en el primer año de la vida. Revisión de 203 casos.

OBJECTIVE: The aim of our study is to analyze the clinic characteristics and evolution of the primary reflux in infants. METHODS: We studied retrospectively 203 infants in our hospital, diagnosed of severe primary renal reflux. Renal ecography and cyclic mictional cystography were practiced in all cases. DMSA was carried out in 181 patients. RESULTS: Renal reflux was unilateral in the 23% of the patients, and bilateral in the remaining cases; 72% of the renal reflux were grade IV and 28% grade V. The renal injuries affected to male infants and reflux grade V. The renal injury was focal (27%), global (44%) and atrophic (29%). The 79% of the patients had conservative treatment, while 21% had surgical treatment. 100% infants with surgical treatment and 94.2% infants with conservative treatment were recovered (Test of Kaplan-Meier). The 27% of patients developed one or several urinary infections, but progression of old renal injuries or formation of new ones, were exceptional (3 cases): While the time the study lasted none of the patients developed chronic renal failure nor arterial hypertension. CONCLUSIONS: 1) The fetal severe primary reflux of the patients was characterized by the following features: to be bilateral reflux, to affect mainly to male infants and to be associated in 33% of cases with a severe renal injury of congenital origin (renal displasia) most of them unilateral. 2) The natural evolution of the reflux goes to spontaneous recovery, so treatment must be conservative. 3) Some patients underwent urinary infections, but progression or formation of new renal injuries were inusual. None of the patients had terminal renal failure nor hypertension and 4) Risk patients would be male infants with bilateral injuries although these are infrequent.

[Fetal urinary dilatation due to vesico-ureteral reflux]. / Dilatación urinaria fetal por reflujo vésico-ureteral.

We have retrospectively studied 163 newborns referred to us between 1986 and 1990 for sonographic diagnosis of intra-uterine upper urinary tract enlargement. All were studied by paediatric radiologists on days 5th or 6th after birth by means of sonography and voiding cystourethrogram (VCU). Fifty percent had also IVP. No urinary tract disease could be found in 44 children, obstructive uropathy or cystic disease were diagnosed in 58 children and 61 patients had vesico-ureteric-reflux (VUR). They form the basis of the present report. There was a male-to-female ratio of 3.3 to 1. Neonatal ultrasonography was normal in 11 cases, 42 had pyelectasia (bilateral in eight cases) and eight had ureterohydronephrosis (bilateral in seven). VUR was bilateral in 28 cases, right in 16 and left in 17. Out of the 89 refluxing units, VUR grade was I in 11, II in 16, III in 24, IV in 14 and V in 23. There was intra-renal reflux in 17 units. Some other form of urinary tract disease was detected in 29 babies (47.5 per 100). Twenty-eight patients were operated upon and the remaining are under long-term urinary antisepsis with only five episodes of infection. The considerable proportion of false negatives for VUR in neonatal ultrasonography (30 per 100) and the high grade of some of these cases lead us to strongly advise routine VCU for patients with intra-uterine urinary tract dilatation.

[Intrarenal reflux and kidney damage in essential vesicoureteral reflux]. / Reflujo intrarrenal y daño renal en el marco del reflujo vesicoureteral esencial.

We had reviewed our series of 59 patients with intrarenal reflux selected out of 596 diagnosed of vesicoureteral reflux. The number of renal units affected of intrarenal reflux was 74. We divided our patients into two groups, in an attempt to clarify the relationship between renal damage and urinary infection; a group include there was prenatal diagnosis of urinary tract dilatation and another group diagnosed for bacterial infection of urine after birth. Reflux nephropathy were present in 27 renal units; 9 from 30 units (30%) in the prenatally diagnosed group, and 18 from 44 units (41%) in the other group. Reflux nephropathy was diagnosed by intravenous pyelogram and/or radionuclide renogram. We concluded that intrarenal reflux (IRR) is relatively frequent in our population and that 30% of patients prenatally diagnosed had renal damage without urinary infection, landing support to the previously published existence of a prenatal origin for some newborn.

[Nephro-urologic complications of presacral teratomas]. / Secuelas nefrourológicas de los teratomas presacros.

Neonatal presacral teratoma is a very unusual tumor. Because of its deep pelvic location and huge size, it can cause urinary obstruction and interfere with renal development during prenatal life. We have treated three patients and followed them up for six, three and one years. In all of them hydronephrosis and ureteral ectasia disappeared after excision of the tumor but some degree of calyceal club deformity persists in two patients. VUR persisted in one case for six years and was finally operated upon. Our last case has recently been operated for persistent left megaureter. This patient had also neonatal respiratory distress and mediastinal pneumothorax probably related to some degree of pulmonary hypoplasia. A close urologic follow-up is strongly advised in these patients.

[Primary vesicoureteral reflux. I: Renal growth in kidneys without pyelonephritis]. / Reflujo vesicoureteral primario. I: Crecimiento renal en riñones sin pielonefritis.

We have studied renal growth in 133 children with 195 refluxing ureters (VUR). Average follow-up was 38 (range 12-84) months. Low grade VUR (I-III) were more frequent and left-sided ones predominated among unilateral cases. There was a clear correlation between VUR grade and the presence of reflux nephropathy (RN). Seventy percent of low-grade VUR cured under long-term urine disinfection, whereas surgery was successful in 97.5% of high-grade, often scarred, units. Recurrent urinary infections after cure of VUR were equally frequent in both groups. The growth of the 140 unscarred refluxing kidneys was evaluated by means of renal length, corticorenal index and growth speed measurements. All values remained within ranges considered statistically undistinguishable from those of normal kidneys. Our findings confirm that, in our conditions of treatment, VUR without RN does not impair renal growth for the period of time studied.

[Primary vesicoureteral reflux. II. Renal growth in kidneys with pyelonephritis]. / Reflujo vesicoureteral primario. II: Crecimiento renal en riñones con pielonefritis.

We have studied kidney growth and function in 38 patients with either unilateral (23) or bilateral (15) vesicoureteral reflux (VUR) and reflux nephropathy (RN). Average follow-up was 38 (range 12-84) months. Surgery was performed in 93.3% of units. Renal length measurement alone was not satisfactory for detection of focal scarring, whereas cortico-renal index was much more discriminant. Growth of kidneys with bilateral RN was impaired, but there were no correlations with either VUR grade not with urinary infection relapses after VUR cure. Growth was also impaired in unilaterally scarred kidneys and renal length measurement revealed itself as very unsatisfactory in them. Contralateral unscarred kidneys underwent hypertrophy in some cases and growth patterns suggested that hypertrophy will become more evident as follow-up goes on. Neither glomerular filtration rate nor fractionated Na excretion were useful to detect renal lesions, whereas concentration capacity revealed renal damage in bilateral cases. There was hypertension in only one child, but peripheral blood renin was elevated in 15.62% of patients.

[Prevention of renal injury by means of intermittent catheterization in children with neurogenic bladder secondary to spina bifida]. / Prevención de la lesión renal mediante el cateterismo intermitente en niños con vejiga neurógena secundaria a espina bífida.

We have studied 16 children with spina bifida treated by clean intermittent catheterism (CIC) for at least four years. Those without VUR (5 patients) and those with grades I to III (7 patients) have maintained their kidneys unscared. Furthermore, VUR disappeared in some of them. In 4 children with severe VUR (grades IV and V) a Cohen ureteroneocystostomy was added, and all kept their kidneys stable. Asymptomatic bacteriuria was not modified by CIC and its' eventual relationship with the onset of scarring could not be established. Kidney damage, however, can be detected earlier by decrease of concentration capacity. Continence was obtained in only 30% of the cases, but the addition of some drugs has further improved our results after this study was concluded. CIC should be used as a first choice treatment in most patients with neurogenic bladder due to spina bifida.

[Syringoceles of Cowper's glands in children]. / Siringoceles de las glándulas de Cowper en niños.

Some tubular or cystic diverticula observed in the ventral wall of the male bulbous urethra that originate from dilatation of Cowper's gland ducts have been termed "syringoceles". They can cause dysuria, hematuria and obstruction. We report 14 syringoceles and 1 true diverticulum from segmental absence of spongious urethra. We review embryology, anatomy and diagnosis in order to determine the best therapeutic approach. We performed endoscopic resection of the distal valve-like border of the diverticulum in 6 patients (42.85%) with good results. The remaining 8 patients, in whom surgery was not indicated, were followed clinically and radiologically.

[Urology aspects of adrenogenital syndrome]. / Aspectos urológicos del síndrome adrenogenital.

During the past five years, 10 patients (seven girls and three boys) with virilizing adrenal hyperplasia have been treated in our institution. A thorough urological work-up was preformed in all. We found among the girls one ureteral duplication, three lower urinary obstruction (two of them in girls with high urethro-vaginal confluence) and four bilateral vesico-ureteral refluxes. Two girls required a Hendren operation, and the remaining had a convention cut-back. Obstruction disappeared in all cases, but reflux persists in one of the patients. The plastic results were constantly good. A detailed urological investigation is strongly advised for patients with adrenogenital syndrome.

[Critical evaluation of cystoscopy in pediatric vesico-ureteral reflux]. / Evaluación crítica de la cistoscopia en el reflujo vesicoureteral pediátrico.

Authors report a study on endoscopical evaluation of 110 refluxing ureters in 65 children selected out of a group of 384 with VUR seen between 1977 and 1980. Cystoscopy was only undertaken either in patients with poor response to conservative treatment or in those with associated malformations. Radiologic-endoscopic correlation was rather good: 93% of grade II refluxing orifices were normally located or slightly lateralized, whereas 72% of grade III or IV were so. The length of submucosal tunnel was shorter than 5 mm in 68.75% of refluxing ureters. "Golf-hole" orifices were seen in 2/3 of the cases with grade III or IV reflux. Nevertheless, this correlation was poor in over one third of refluxing units because in these cases cystoscopic evaluation of ureterovesical junction enabled to modify (in either sense) indications for surgery made up only on clinico-radiologic grounds. Endoscopy for evaluation of VUR is justified in selected cases because of this incomplete correlation between radiological and anatomical findings.

[Ureteral duplications with a blind branch. Apropos of 4 cases]. / Duplicaciones ureterales con una rama ciega. A propósito de cuatro casos.

Blind-ending ureteral buds result from a more or less complete duplication of the ureter in which the development of one of the branches is arrested before reaching renal mesenchyma. These malformations are rare, and no more than one hundred cases have been reported. We report four new cases in children. All were studied because of urinary infection and cystogram was diagnostic. All patients were operated upon, the blind ureter was resected, and the remaining complete ureter reimplanted in three cases.

[Combination of drugs and clean intermittent catheterization in the treatment of neurogenic bladder. Effect on continence]. / Asociación de fármacos al cateterismo intermitente limpio en el tratamiento de la vejiga neurógena. Efecto sobre la continencia.

We report the results obtained with the association of drugs with clean intermittent catheterization (CIC) in 13 patients with neurogenic bladder due to spina bifida. The drugs used were bladder muscle relaxants (imipramine), anticholinergic (probanthine) and/or alpha-adrenergic (ephedrine). CIC alone led to acceptable continence in only 24% of cases, whereas with the addition of drugs this proportion increased to 80%. All along the treatment upper urinary tract remained stable in all patients, there were no changes in asymptomatic bacteriuria when present and collateral effects were minimal.