Massive inguinal herniation of the bladder with bilateral hydronephrosis, complicated by psychosis.

Massive inguinal herniation of the bladder is rare. This case was made more dramatic by the late presentation and simultaneous psychiatric condition. A man in his 70s was found in his burning house and admitted for smoke inhalation. Initially refusing examination or investigation, on the third day, he was found to have massive inguinal bladder herniation, bilateral hydronephrosis and acute renal failure. After urethral catheterisation, bilateral ureteric stent insertion and resolution of postobstructive diuresis, the patient underwent open right inguinal hernia repair and return of the bladder to its orthotopic position. He also diagnosed with schizotypal personality disorder with psychosis, malnutrition, iron deficiency anaemia, heart failure and chronic lower limb ulcers. Four months later and after multiple failed trial of voids, the patient underwent transurethral resection of prostate with successful resumption of spontaneous voiding.

Evaluation of Renal Function Recovery After Holmium Laser Enucleation of the Prostate in Patients with Chronic Kidney Disease.

Introduction: Holmium laser enucleation of the prostate (HoLEP) has become a new surgical gold standard treatment for benign prostatic hyperplasia (BPH). It is known that untreated BPH can lead to bladder outlet obstruction (BOO). A positive correlation exists between BOO and chronic kidney disease (CKD), but stability or recovery of renal function after HoLEP remains unknown. We sought to describe changes in renal function after HoLEP in men with CKD. Methods: A retrospective study was conducted of patients who underwent HoLEP with glomerular filtration rates (GFRs) <60, CKD stages III to V. Pre- and postoperative GFRs were selected within 3 months before the operation and within 1 year postoperatively. The presence of an indwelling catheter, preoperative hydronephrosis, history of kidney stones, and prostate size were also reviewed. Data were analyzed in accordance with preoperative CKD stage. Results: Of the reviewed patients, 138 met inclusion criteria with CKD stages III to V. Each CKD group was without significant postoperative complications. There was a significant increase between pre- and postoperative GFR for patients in CKD stages III (n = 116) and IV (n = 17) (p < 0.0001 and p = 0.010, respectively). The mean increase between pre- and postoperative GFR for the CKD stages III and IV patients were 6.4 and 6.49, respectively. There was no correlation between presence of preoperative hydronephrosis, history of kidney stones, catheter dependency, nor prostate size on change in postoperative GFR (p > 0.05). Conclusion: These findings suggest that patients in CKD stages III or IV undergoing HoLEP experience an increase in GFR. It is noteworthy that there appears to be no decline in renal function postoperatively in any group. HoLEP represents an excellent surgical option for patients with preoperative CKD and may prevent further renal decline.

Robotic-assisted laparoscopic pyeloplasty (RALP), for ureteropelvic junction obstruction (UPJO), is an alternative to open pyeloplasty in the pediatric population.

We aimed to evaluate the safety and efficacy of RALP for UPJO in a heterogeneous pediatric population. The medical records of all patients with UPJO who underwent RALP over the last 6 years and completed at least 6 months of follow-up, were retrospectively reviewed. Data included age, sex, laterality, weight, preoperative and postoperative ultrasound and renal scintigraphy results, operation time, complications, length of hospital stay. We separately examined two groups: low-weight children (< 10 kg) and those who underwent RALP after failed pyeloplasty. One hundred patients with a median age of 18 months (range 2-216) underwent RALP. The median weight was 10 kg (range 4-90). The median operative time, including docking and console time, was 75 min (range 40-183). The median hospital stay was one day (range: 1-3). Ninety-eight percent of the patients showed improvement or stable hydronephrosis on postoperative imaging, with a better drainage curve on dynamic radionuclide scans. In two patients, the hydronephrosis worsened. One patient's ipsilateral UVJ was obstructed, and the other patient's UPJO recurred. The operative time was shorter in the low-weight group (p < 0.001), but the length of hospital stay and success rate were not different. Neither the hospital stay nor the success rate of redo RALP patients differed significantly from a control group of primary RALP patients. Our data show that RALP might be utilized as a universal approach in pediatric patients with UPJO.

Hidden incision endoscopic surgery (HIdES) trocar placement for pediatric robotic pyeloplasty: comparison to traditional port placement.

Robotic assisted laparoscopy pyeloplasty (RALP) has been associated with shorter recovery, less pain and improved cosmesis. To minimize visible scars, the hidden incision endoscopic surgery (HIdES) trocar placement has been previously developed. Our aim was to compare outcomes between the HIdES and traditional port placement (TPP) for pediatric RALP. A retrospective study was performed on patients under 15 years of age who underwent RALP at a single institution between August 2011 and November 2013. Patient demographics, intraoperative details, narcotic administration, and complications were reviewed. A total of 49 patients were identified (29 in HIdES, 20 in TPP). There was no difference in median age (p = 0.77) or median height (p = 0.88) between the two groups. Median operative time was 180 min for HIdES and 194 min for TPP (p = 0.27). Eleven patients (11/29, 37.9%) in the HIdES group and fourteen patients (14/20, 70%) in the TPP group received postoperative narcotics (p < 0.05). Median follow-up was 42 months for HIdES and 41 months for TPP (p = 0.96). There were two complications (2/29, 6.9%) with HIdES, and one complication (1/20, 5.0%) with TPP (p = 1.00). The success rates were 96.6% (28/29) for HIdES and 100% (20/20) for TPP (p = 1.00). HIdES trocar placement for pediatric robotic pyeloplasty is a safe and viable alternative to TPP. HIdES is comparable to TPP regarding operative time, narcotic administration, hospital stay, and complication rate, without compromising success.

Hydronephrosis and crossing vessels in children: Optimization of diagnostic-therapeutic pathway and analysis of color Doppler ultrasound and magnetic resonance urography diagnostic accuracy.

INTRODUCTION: Ureteropelvic junction obstruction (UPJO) is one of the most frequent urological diseases affecting the pediatric population. It can be due to both intrinsic stenosis of the junction and extrinsic causes such as the presence of crossing vessels (CVs), which can be detected by color Doppler ultrasound (CD-US). Magnetic resonance urography (MRU) is a good alternative, but sedation and infusion of a contrast agent are required. OBJECTIVE: The aim of this study was to analyze the diagnostic accuracy of CD-US and MRU in visualizing CVs in pediatric hydronephrosis, in order to decide the correct diagnostic pathway in the pre-operative phase. MATERIAL AND METHODS: A retrospective review was performed of medical records for all patients who underwent surgical treatment for hydronephrosis from August 2006 to February 2016. Ultrasound and scintigraphy had been performed on all patients. Data about CD-US and MRU were collected. A high-level technology ultrasound scanner and a 1.5 T MR scanner were used. The presence of CVs at surgery was considered the gold standard. Sensitivity, specificity, positive and negative predictive values (NPV) were calculated and reported for both of the imaging techniques. RESULTS: A total of 220 clinical charts were reviewed. Seventy-three CVs were identified at surgery (33.2% of UPJO). The median age was statistically higher in the group with CVs compared to the group without CVs (P < 0.001). The sensitivity and NPV of CD-US in detecting CVs were higher than MRU (sensitivity 93.3% vs. 71.7%, NPV 95.7% vs. 77.6%, respectively). DISCUSSION: According to the data, CD-US had higher sensitivity and NPV than MRU, resulting in superior detection of CVs. It is important for a surgeon to know that a child has a CV, especially in older children in which the incidence of extrinsic UPJO is higher. The main limitation of this study was the presence of incomplete data, due to the retrospectivity. CONCLUSIONS: In the pre-operative phase, the CD-US should be considered as the investigation of choice to detect CVs in children with hydronephrosis (Summary Fig). Moreover, CD-US has lower costs than MRU, and sedation with infusion of contrast agent is unnecessary. For the future, it could be useful to lead a prospective comparison between the two imaging techniques.

Horseshoe kidney and uretero-pelvic-junction obstruction in a pediatric patient. Laparoscopic vascular hitch: A valid alternative to dismembered pyeloplasty?

Horseshoe kidney (HSK) is a congenital defect of the urinary tract that occurs in 0.25% of the general population. Laparoscopic Vascular Hitch (LVH) according to Hellstrom-Chapman represent an alternative approach in treatment of extrinsic hydronephrosis by crossing vessels (CV) in pediatric age. In our Department from 2006 to 2016, 36 children with extrinsic-Uretero-Pelvic-Junction (UPJ)-Obstruction (UPJO) underwent laparoscopic vessels transposition. Over the last 4years, we have treated three patients with extrinsic hydronephrosis in HSK; two males and one female respectively of 6, 7 and 8years. The side affected was the left in all patients; symptoms of onset: recurrent abdominal pain, vomiting with associated intermittent hydronephrosis at ultrasonography. The preoperative examinations performed were: ultrasound/Doppler scan, MAG3-renogram, functional-magnetic-resonance-urography (fMRU). Mean operative time was 120'; median hospital stay 3- days. Intraoperative diuretic-test (DT) confirmed an extrinsic-UPJO in all patients. No JJ-stents and drain were used and there were no perioperative complications. Clinical and ultrasound follow-up (18 months-4 years) show resolution of symptoms and decrease in hydronephrosis grade in all patients. Our series is the largest in pediatric population by a revision of the literature. We believe that LVH is feasible in patients with symptomatic hydronephrosis by CV in HSK. Intraoperative-DT and the correct selection of patients are crucial to the success of the technique. According to us, this procedure is appropriate in those cases where the UPJ-anatomy is disadvantageous to a resection/re-anastomosis between ureter and renal pelvis. Our initial results are encouraging, although long-term follow- up and a more significant patient sample are required.

[Treatment of specific complications of locally advanced prostate cancer]. / Behandlung von spezifischen Komplikationen des lokal fortgeschrittenen Prostatakarzinoms.

Despite improved screening methods and earlier detection of prostate carcinoma, the complications of locally advanced disease remain a challenge for urologists. The spectrum of possible complications includes subvesical obstruction, hydronephrosis, hematuria, pain, and local invasion of adjacent organs. Urinary diversion, palliative transurethral resection of the prostate, and endoscopic diathermy are classic procedures. Urethral stenting, laser evaporation, and selective arterial embolization are alternate approaches for treating these complex cases. Cystoprostatectomy and pelvic exenteration are ultimate options for patients with chronic pain and debilitating local symptoms.

Continent orthotopic ileal neobladder after kidney transplantation in a patient with urothelial cell carcinoma associated with Chinese herb nephropathy.

A 58-year-old man underwent kidney transplantation on November 14, 2002 for end-stage kidney disease after Chinese herb nephropathy. Immunosuppressive therapy was maintained with tacrolimus, mycophenolate mofetil, and methylpredonisolone. He was diagnosed with right ureteral cancer and underwent right nephroureterectomy on December 13, 2003. Then, he underwent left nephroureterectomy for left ureteral cancer on March 5, 2004. Subsequently, he was diagnosed with multiple bladder cancers and carcinoma in situ. On August 31, he underwent radical cystectomy with an orthotopic ileal neobladder (Studer's method). The postoperative course was uneventful. After 3 years follow-up, this patient shows no evidence of recurrence and his serum creatinine level is stable (1.7 mg/dL). The continence is maintained during both day and night; he voids without intermittent self-catheterization. We suggest that an orthotopic ileal neobladder is a safe method of urinary diversion after cystectomy in kidney transplant recipients.

Presentación de un caso de hipertermia maligna con diagnóstico ratificado por el puntaje de NAMHR (North American Malignant Hyperthermia Registry) / Presentation of a case of malignant hyperthermia ratified by NAMHR's (North American Malignant Hyperthermia Registry) score

Introducción: Desarrollo de cuadro clínico de hipertermia maligna en un paciente anestesiado con anestesia endovenosa total. Diagnóstico a través del puntaje del North American Malignant Hyperthermia Registry. Caso clínico: Se presenta un caso clínico de hipertermia maligna acontecido en nuestro servicio, con la particularidad de haberse desencadenado durante el intraoperatorio de una cirugía bajo anestesia intravenosa total. Paciente de 30 años, con diagnóstico de hidronefrosis; se anestesió con midazolam, remifentanilo y mivacurio. Luego de 1 hora de cirugia y sin causa clínica aparente, comenzó con hipotensión. Simultánea y progresivamente, se taquicardizó alcanzando valores de 155'. Se tomó 37.8 §C de temperatura axilar. La ETCO2 era de 75 mmHg. Luego, la temperatura se elevó a 43 §C y se decidió tratar con dantrolene. Discusión: La carencia de un método precoz de diagnóstico de HM, sumada a cambios metabólicos rápidos, hipermetabolismo marcado y excesiva producción de calor, nos enfrenta al dilema de iniciar el tratamiento específico -dantrolene-, que evite secuelas irreversibles o la muerte. Conclusiones: Creemos que la clasificación con el puntaje del North American Malignant Hyperthermia Registry, por la simplicidad de su diseño y facilidad de aplicación, puede ser un método útil e indispensable como método de screening en aquellos pacientes en que por alguna causa se sospecha una susceptibilidad o un cuadro de HM.

Presentación de un caso de hipertermia maligna con diagnóstico ratificado por el puntaje de NAMHR (North American Malignant Hyperthermia Registry) / Presentation of a case of malignant hyperthermia ratified by NAMHRs (North American Malignant Hyperthermia Registry) score

Introducción: Desarrollo de cuadro clínico de hipertermia maligna en un paciente anestesiado con anestesia endovenosa total. Diagnóstico a través del puntaje del North American Malignant Hyperthermia Registry. Caso clínico: Se presenta un caso clínico de hipertermia maligna acontecido en nuestro servicio, con la particularidad de haberse desencadenado durante el intraoperatorio de una cirugía bajo anestesia intravenosa total. Paciente de 30 años, con diagnóstico de hidronefrosis; se anestesió con midazolam, remifentanilo y mivacurio. Luego de 1 hora de cirugia y sin causa clínica aparente, comenzó con hipotensión. Simultánea y progresivamente, se taquicardizó alcanzando valores de 155. Se tomó 37.8 ºC de temperatura axilar. La ETCO2 era de 75 mmHg. Luego, la temperatura se elevó a 43 ºC y se decidió tratar con dantrolene. Discusión: La carencia de un método precoz de diagnóstico de HM, sumada a cambios metabólicos rápidos, hipermetabolismo marcado y

Lysis of a right atrial thrombus of more than a week's duration by high dose urokinase in a one-year-old child.

The case of a one-year-old child in whom a large catheter-related right atrial thrombus of more than a week's duration was dissolved by urokinase is presented. After one week of unsuccessful heparin treatment, urokinase, via a central venous catheter, was added at a dose of 1500 IU/kg/h. Urokinase was subsequently increased by 1000 U/kg/h every day up to a maximum of 4500 IU/kg/h on the basis of thrombus size reduction as assessed by daily cross-sectional echocardiography. One week later the thrombus was almost completely dissolved. No major bleeding occurred. Warfarin was given for the next three months and the international normalized ratio (INR) was maintanied between 2 and 3. At the end of warfarin treatment echocardiography was negative for right atrial thrombosis. This case suggests that local high dose urokinase therapy can be safely and successfully used to dissolve large right atrial thromboses of more than a week's duration.

[The treatment of hydronephrosis in children]. / Lechenie gidronefroza u detei.

The paper presents the analysis of hydronephrosis treatment performed within 1987-1993 in 76 children. Special attention is paid to surgical techniques, methods of drainage with regard to hydronephrosis degree and pelvic contractility. The drainage system of the renal calicopelvic system using double-opening tube with continuous drop lavage is designed, the scheme of the patients' postoperative management is described. Good outcomes of pelvic electrostimulation are reported.

Renal function in idiopathic hydronephrosis in children. Follow-up after conservative and surgical treatment.

In 64 children (age 1-15, mean 7.3 years) with unilateral idiopathic hydronephrosis, measurements were made of glomerular filtration rate (GFR), separate glomerular filtration rate (SGFR, measured as 51Cr-EDTA clearance combined with renography) and renal concentrating capacity. Onset symptoms were urinary tract infection in 34 children and abdominal pain in 25, while 5 were asymptomatic. Surgery was performed soon after the first investigation in 34 children and during the follow-up period in 14, and 16 children received only conservative treatment. The mean follow-up time was 4.4 years. At the time of diagnosis the total GFR and the SGFR of the affected kidney were normal or almost normal in all the children (respective means 108 +/- 16 and 50 +/- 12 ml min-1 X 1.73 m2(-1)). The total GFR remained normal at follow-up, but SGFR became subnormal in two conservatively and two surgically treated children. The concentrating capacity was initially lower in the children with, than in those without urinary tract infection. The former values had increased significantly at follow-up examination. The study indicates that the parenchymal function in unilateral idiopathic hydronephrosis in children more than 1 year old usually is normal, but may deteriorate due to urinary tract infection. Such infection should be carefully searched for and treated. Since very few of these children seem to have pelvic obstruction, surgery seldom is primarily necessary.

Management of ureteropelvic obstruction in the first year of life.

From July 1971 until December 1978 we treated 19 male and 5 female children less than 1 year old for ureteropelvic junction obstruction. Diagnosis was based on high dose excretory urography with delayed films. Ultrasound was performed in some cases to confirm hydronephrosis. Cystoscopy and retrograde pyelography were not required. Of 32 obstructed kidneys 27 were repaired by dismembered reduction pyeloureteroplasty. Of 8 patients with bilateral involvement 3 underwent unilateral repair only because of lesser contralateral obstruction and 1 underwent unilateral nephrectomy. Of the 27 repairs 20 were protected by nephrostomy or pyelostomy drainage plus a small caliber silicone rubber or polyvinyl stent. Of the 6 non-stented repairs 2 had delayed opening of the repair. A frozen section renal biopsy aided in a decision to repair the kidney in 4 of 6 instances and in 10 other instances a renal biopsy was obtained for prognostic purposes. There were no secondary nephrectomies, although 2 boys required reoperations for a successful result. Instillation pyelography with fluoroscopic monitoring was used to determine when the tubes could be removed. Generally, we removed the stent 4 or 5 days postoperatively and the nephrostomy at a variable time after demonstration of patency of repair. In this group of small children pyelostomy or nephrostomy and intubation of the repair are useful additions to the surgical technique to prevent obstruction of the tiny and delicate infant ureter by anastomotic edema or kinking of the repair.