The Importance of Cystoscopy in Diagnosis and Treatment of Urethral Stricture Following Transurethral Prostatectomy.

BACKGROUND: Transurethral prostatectomy is the gold standard surgical treatment of bladder outlet obstruction due to benign enlargement of the prostate, with more than 30,000 procedures performed annually in the United States alone. The success rate of this minimally invasive procedure is high and the results are durable. The development of urethral stricture is a long-term complication of the procedure and is noted in about 2% of patients. The stricture narrows the urethral lumen, leading to re-appearance of obstructive urinary symptoms. Traditionally, the evaluation of the stricture was performed by retrograde urethrography. Advancements in the fields of flexible endoscopy allowed rapid inspection of the urethra and immediate dilatation of the stricture in selected cases. OBJECTIVES: To compare the efficacy of urethrography versus cystoscopy in the evaluation of urethral strictures following transurethral prostatectomy. METHODS: A retrospective review was conducted of a series of 32 consecutive patients treated due to post-transurethral resection of prostate (TURP) urethral stricture. RESULTS: Twenty patients underwent both tests. In 16 there was concordance between the two tests. Four patients had no pathological findings in urethrography but had strictures in cystoscopy. All strictures were short (up to 10 mm) and were easily treated during cystoscopy, with no complaints or re-surgery needed in 24 months follow-up. CONCLUSIONS: Cystoscopy was superior to urethrography in the evaluation of post-TURP strictures. Strictures where often short and treated during the same procedure. We recommend that cystoscopy be the procedure of choice in evaluating obstructive urinary symptoms after TURP, and retrograde urethrography be preserved for selected cases.

IDEAL study: magnetic resonance imaging for suspected deep endometriosis assessment prior to laparoscopy is as reliable as radiological imaging as a complement to transvaginal ultrasonography.

OBJECTIVE: To compare the value of using one-stop magnetic resonance imaging (MRI) vs standard radiological imaging as a supplement to transvaginal ultrasonography (TVS) for the preoperative assessment of patients with endometriosis referred for surgery in a tertiary care academic center. METHODS: This prospective observational study compared the diagnostic value of the standard preoperative imaging practice of our center, which involves expert TVS complemented by intravenous urography (IVU) for the evaluation of the ureters and double-contrast barium enema (DCBE) for the evaluation of the rectum, sigmoid and cecum, with that of expert TVS complemented by a 'one-stop' MRI examination evaluating the upper abdomen, pelvis, kidneys and ureters as well as rectum and sigmoid on the same day, for the preoperative triaging of 74 women with clinically suspected deep endometriosis. The findings at laparoscopy were considered the reference standard. Patients were stratified according to their need for monodisciplinary surgical approach, carried out by gynecologists only, or multidisciplinary surgical approach, involving abdominal surgeons and/or urologists, based on the extent to which endometriosis affected the reproductive organs, bowel, ureters, bladder or other abdominal organs. RESULTS: Our standard preoperative imaging approach and the combined findings of TVS and MRI had similar diagnostic performance, resulting in correct stratification for a monodisciplinary or a multidisciplinary surgical approach of 67/74 (90.5%) patients. However, there were differences between the estimation of the severity of disease by DCBE and MRI. The severity of rectal involvement was underestimated in 2.7% of the patients by both TVS and DCBE, whereas it was overestimated in 6.8% of the patients by TVS and/or DCBE. CONCLUSIONS: Complementary to expert TVS, 'one-stop' MRI can predict intraoperative findings equally well as standard radiological imaging (IVU and DCBE) in patients referred for endometriosis surgery in a tertiary care academic center. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Running water sound technique in contrast-based voiding cystourethrogram: A case-control study.

BACKGROUND: An intervention that can reduce the patient void time during a voiding cystourethrogram (VCUG) procedure can reduce the total radiation dose to the patient. This is because a delay in voiding leads to a high number of intermittent screenings to monitor if voiding occurs. This study assessed the impact of running-water sound (RWS) upon patients' voiding parameters and fluoroscopy screening times during VCUG examinations among children and adults. MATERIALS AND METHODS: A case-control study involving 252 patients was undertaken which consisted two groups (control and test) of adults and children. The test groups underwent VCUG with RWS technique while the control groups underwent the procedure normally. T-test was used to compare the study parameters between the two groups and a p-value less than 0.05 was interpreted as significant. RESULTS: The mean screening times (s) for children who underwent VCUG with and without RWS were 17.15 ± 2.5s and 30.61 ± 5.1s respectively (p = 0.0024). For adults, the RWS technique recorded a mean screening time of 37.36 ± 4.4s while the non-RWS procedures recorded 49.80 ± 5.2s (p = 0.001). The participants who received RWS intervention also felt the urge to void earlier than those who received no RWS intervention. The differences were also statistically significant for both children and adults. CONCLUSION: The study being one of the first in this subject area indicates that the application of RWS technique induces early urge of iodinated-contrast voiding, and reduces voiding and fluoroscopy screening times during VCUG among children and adults. This simple technique can potentially enhance current practice.

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.

Cicatrices renales en menores de 36 meses ingresados por pielonefritis aguda / Renal scarring in children under 36 months hospitalised for acute pyelonephritis

INTRODUCCIÓN: Una de las causas más frecuentes de infección bacteriana grave en lactantes es la pielonefritis aguda (PNFA), cuya secuela más prevalente a largo plazo es la instauración de cicatrices renales. OBJETIVOS: Revisar la incidencia de cicatrices renales a los 6 meses de un episodio de PNFA en niños menores de 36 meses y su relación con la clínica, las pruebas de imagen y la bacteriología. MÉTODO: Estudio retrospectivo de pacientes de uno a 36 meses previamente sanos ingresados por un primer episodio de PNFA, con un seguimiento mínimo de 6 meses. Se recogieron las variables demográficas junto con bacteriología, ecografía, cistourografía miccional seriada, recidivas y gammagrafía-DMSA. RESULTADOS: Se incluyeron 125 pacientes, 60% varones, la mayoría febriles al ingreso (92%), debido a E. coli (74,6%). Existía antecedente de alteración ecográfica prenatal solo en el 15,4%. La ecografía detectó dilatación de la vía urinaria en el 22,1%. En 70 pacientes se indicó cistourografía miccional seriada: 54,3% sin anomalías, 12,8% con reflujo vesicoureteral (RVU) grado i-iii y 32,9% con RVU iv-v. Seis pacientes presentaban RVU iv-v con ecografías normales. La adherencia a la gammagrafía DMSA a los 6 meses fue solo del 61% de los indicados. De los efectuados (60 casos), en un 44,3% se hallaron cicatrices renales, relacionadas significativamente con la recurrencia y el RVU iv-v, pero no con la bacteriología ni con la elevación de reactantes. CONCLUSIONES: El 44% de las gammagrafías-DMSA de pacientes de uno a 36 meses hospitalizados por PNFA desarrolla cicatrices renales a los 6 meses. Estas se relacionaron con las recurrencias y el RVU grave, pero no con la bacteriología y los reactantes inflamatorios

INTRODUCTION: Acute pyelonephritis (APN) is one of the most common causes of serious bacterial infection in infants. Renal scarring is the most prevalent long-term complication. OBJECTIVES: To review the incidence of renal scarring within 6 months after an episode of APN in children under 36 months and its relationship with imaging studies, clinical settings, and bacteriology. Method. A retrospective study of previously healthy patients aged one to 36 months, admitted for a first episode of APN, with a minimum follow-up of 6 months. Demographic and clinical variables were collected along with bacteriology, renal and bladder ultrasound scan, voiding cystourethrography, DMSA-scintigraphy, and re-infection events. RESULTS: A total of 125 patients were included in the study, of which 60% were male, the large majority (92%) febrile, and due to E. coli (74.6%). There was a history of prenatal ultrasound scan changes in 15.4%. Ultrasound scan found dilation of the urinary tract in 22.1%. Voiding cystourethrography was performed on 70 patients: 54.3% no abnormalities, 12.8% vesicoureteral reflux (VUR) grade i-iii, and 32.9% iv-v grade VUR. Six patients had iv-v grade VUR with a normal ultrasound scan. Adherence to DMSA-scintigraphy at 6 months was only 61% of that indicated. Renal scarring was found in 44.3% of those in which it was performed (60 cases). CONCLUSIONS: Almost half (44%) DMSA-scintigraphy in children aged one to 36 months hospitalised for APN show renal scarring at 6 months, which was found to be associated with the re-infection events and the iv-v grade VUR. There was no relationship between scarring and the bacteriology or the elevations of inflammatory biochemical markers

Urinary MCP-1、HMGB1 increased in calcium nephrolithiasis patients and the influence of hypercalciuria on the production of the two cytokines.

The study aims to observe the urinary excretion of monocyte chemoattractant-1 (MCP-1) and high-mobility group box 1 (HMGB1) in patients with calcium nephrolithiasis and to determine the influence of hypercalciuria on the production of the two cytokines. 81 cases of patients with calcium nephrolithiasis (group CN) and 30 healthy controls (group C) were involved in this study. To observe the influence of urinary calcium on the excretion of those cytokines, the patients were subdivided according to their 24-h urinary calcium level: ≥4 mg/kg/day (group H) and <4 mg/kg/day (group N). MCP-1 and HMGB1 in urina sanguinis were determined for all subjects. In addition, in vitro study was done to determine the production of the two cytokines and index of apoptosis and oxidative injuries in human kidney epithelial cells (HK-2) exposed to three high levels of calcium. Data showed that both urinary MCP-1 and HMGB1 in group CN were higher than that of group C. When the patients were subdivided, comparisons among the three groups showed that both MCP-1 and HMGB1 in group H and group N were higher than group C, but there was no significant statistical difference between the two stone groups. In vitro study, the apoptosis rate of cells, the lactate dehydrogenase activities, the hydrogen peroxide, and 8-isoprostane concentrations in the medium all increased in accordance with the increased concentration of calcium supplemented. Compared with the control, mRNA expressions of MCP-1 and HMGB1 in cells and the protein concentrations of the two cytokines in the medium of calcium-supplemented groups increased significantly. Results showed that urinary MCP-1 and HMGB1 increased in calcium nephrolithiasis patients and hypercalciuria might affect the identical pathways (through the reactive oxygen species) with other factors in stimulating the production of MCP-1 and HMGB1 in vivo.

Changing Abdominal Imaging Utilization Patterns: Perspectives From Medicare Beneficiaries Over Two Decades.

PURPOSE: To assess changing utilization patterns of abdominal imaging in the Medicare fee-for-service population over the past two decades. METHODS: Medicare Physician Supplier Procedure Summary master files from 1994 through 2012 were used to study changes in the frequency and utilization rates (per 1,000 Medicare beneficiaries per year) of abdominal CT, MRI, ultrasound, and radiography. RESULTS: In Medicare beneficiaries, the most frequently performed abdominal imaging modality changed from radiography in 1994 (207.4 per 1,000 beneficiaries) to CT in 2012 (169.0 per 1,000). Utilization rates of abdominal MR (1037.5%), CT (197.0%), and ultrasound (38.0%) all increased from 1994-2012 (but declined briefly from 2007 to 2009). A dramatic 20-year utilization rate decline occurred for gastrointestinal fluoroscopic examinations (-91.9% barium enema, -80.0% upper gastrointestinal series) and urologic radiographic examinations (-95.3%). Radiologists were the dominant providers of all modalities, accounting for >90% of CT and MR studies, and >75% of most ultrasound examination types. CONCLUSIONS: Medicare utilization of abdominal imaging has markedly changed over the past two decades, with overall dramatic increases in CT and MRI and dramatic decreases in gastrointestinal fluoroscopic and urologic radiographic imaging. Despite these changes, radiologists remain the dominant providers in all abdominal imaging modalities.

Radiation exposure contribution of the scout abdomen radiograph in common pediatric fluoroscopic procedures.

BACKGROUND: Contrast enema, voiding cystourethrography and upper gastrointestinal studies are the most common fluoroscopic procedures in children. Scout abdomen radiographs have been routinely obtained prior to fluoroscopy and add to the radiation exposure from these procedures. Elimination of unnecessary routine scout radiographs in select studies might significantly reduce radiation exposure to children and improve the overall benefit-to-risk ratio of these fluoroscopic procedures. OBJECTIVE: To determine the radiation exposure contribution of the preliminary/scout abdomen radiographs with respect to the radiation exposure of the total procedure. MATERIALS AND METHODS: We retrospectively collected demographic information and radiation exposure values of dose area product (in Gy-cm(2)) and entrance air kerma (in mGy) - initially for the scout abdomen radiographs done prior to fluoroscopy and subsequently the total procedural radiation values (the combined values of the scout radiograph and fluoroscopic radiation exposure) - in children who underwent contrast enemas, voiding cystourethrograms and upper gastrointestinal studies in a 4-month period. The radiation parameters, including fluoroscopy time, dose area product and entrance air kerma, were available in the log book maintained in the fluoroscopy suite. Fluoroscopy procedures were performed on a single fluoroscopy machine using four frames per second pulse rate and other radiation-minimizing techniques. Usage of the grid to obtain scout radiographs was also recorded. The proportion of radiation exposure from the scout radiograph relative to that of the total procedure was calculated by dividing the individual parameters of the scout to the total procedural values and multiplied by 100 to express these values as a percentage. We calculated mean, median and range and performed statistical analysis of the data. RESULTS: A total of 151 procedures performed on 71 males and 80 females qualified for the study. The age range of the patients was 2 days to 18 years, with a mean of nearly 3.5 years (40 months) and median of 15 months. There were 63 upper gastrointestinal studies, 65 voiding cystourethrography studies and 23 contrast enema studies. The fluoroscopy time for all procedures combined ranged from 0.1 min (6 s) to 2 min, with mean and median values of 0.4 min and 0.3 min, respectively. The fractional radiation exposure contribution for the dose area product of scout abdomen radiograph to the total procedure ranged from 4% to 98%, with mean and median values of 51% and 49%, respectively. The fractional contribution of the scout radiograph to the total procedure for the entrance air kerma values ranged from 6% to 97%, with mean and median values of 29% and 26%, respectively. There was a significant negative correlation (P<0.001) between fluoroscopy radiation time and the proportion of radiation parameters of scout radiograph to total procedural values. CONCLUSION: Scout radiographs can contribute a significant proportion (median values of approximately 50% for the dose area product and 26% for the entrance air kerma) of radiation exposure in common fluoroscopy procedures in children.

Management of complications after surgical outlet reduction for benign prostatic obstruction.

INTRODUCTION: Lower urinary tract symptoms are a common complaint. Surgery to debulk hyperplastic prostate tissue is indicated for men with symptoms refractory to medical therapy, or for those who cannot tolerate first-line medications. In recent decades, new endoscopic techniques have been developed to reduce the morbidity of transurethral resection of the prostate (TURP). Nonetheless, complications are still frequently encountered in the immediate, early, and remote postoperative setting. MATERIALS AND METHODS: In this review, we perform an in-depth examination of contemporary treatment strategies for long term complications of surgical outlet reduction procedures. Complications encountered in the remote postoperative setting such as erectile dysfunction (ED), urethral stricture, refractory incontinence, and bladder neck contracture were identified in the literature. RESULTS: Treatment strategies for ED after TURP do not differ from algorithms applied for ED due to other causes. Management of urethral stricture following TURP depends on the size and location of narrowing and can range from simple dilation to complex excision with grafting techniques or perineal urethrostomy. Refractory urinary incontinence requires a full diagnostic evaluation, and artificial urinary sphincter placement is efficacious for cases that do not respond to first-line medical therapy. Finally, numerous therapies for bladder neck contracture exist and vary in their invasiveness. CONCLUSION: Endoscopic reduction of the prostate for the male with benign prostatic obstruction via most contemporary modalities is a safe and effective means to decrease outlet resistance to urinary flow. However, late complications from these procedures still exist. Management of remote morbidity following TURP can be diagnostically and therapeutically complex, necessitating prompt referral to a genitourinary reconstruction specialist.

Long-term ultrasound appearance of concomitant autologous blood and dextranomer/hyaluronic acid copolymer implants: is it associated with successful correction of vesicoureteral reflux?

OBJECTIVE: To find the association between mound appearance on ultrasound imaging and successful correction of vesicoureteral reflux (VUR). METHODS: We retrospectively reviewed the ultrasound and voiding cystourethrogram (VCUG) results of patients who underwent dextranomer/hyaluronic acid injection via the hydrodistention injection technique (HIT) or HIT with concomitant autologous blood injection (HABIT) for 5 years postoperatively. VUR resolution at postoperative VCUG was considered as a success. Retained volumes of implants were measured and compared between HABIT and HIT and successful and failed treatments. Presence of mound on ultrasound imaging was also evaluated as a predictor of VUR resolution on VCUG. RESULTS: Measured mound volume was significantly higher in treatments that were successful than in those that were failures (P <.05). During 5-year follow-up, measured mound volumes in the HABIT group were significantly higher than in the HIT group (P <.05). Sensitivity, specificity, positive predictive value, and negative predictive value of mound visualization on the first-month sonography to predict success were 97.7%, 21.5%, 89.6%, and 60%, respectively. These results were dramatically changed for the 50 patients with further VCUG after 1 year of follow-up, with 95.7% sensitivity, 37.0% specificity, 54.0% positive predictive value, and 90.9% negative predictive value. CONCLUSION: Reduction or absence of the mound after implantation is more frequent among failed treatments in which visualization of the mound on postoperative sonography can predict VUR resolution. Autologous blood injection concomitant with dextranomer/hyaluronic acid implantation results in better immediate and long-term mound preservation, which could possibly be the reason for the higher success rate in HABIT group.

Is bowel preparation necessary before kidney-ureter-bladder radiography and intravenous urography?

PURPOSE: To assess whether bowel preparation prior to kidney-ureter-bladder (KUB) radiography and intravenous urography (IVU) are of value in improving visualization of the urinary system. MATERIALS AND METHODS: A total of 186 patients participated in this study. Thirty-nine patients with chronic constipation based on Rome III criteria and 147 patients with normal bowel habits were included. All the patients were randomly divided into two groups. Patients in group 1 received castor oil before imaging and had to eat or drink nothing after midnight. Patients in group 2 were allowed to eat and drink before the examination and received no bowel preparation. Kidney-ureter-bladder radiographies were obtained in all the patients and IVUs were indicated in 77 patients. To assess the image quality, radiographic images were divided into 5 anatomical regions and each region was scored from 0 to 3 based on obscurity of the images by the bowel gas or fecal residue. RESULTS: Mean total score for visualization of the urinary system on plain and contrast images did not differ significantly between the two groups (P = .253). However, patients with chronic constipation who received bowel preparation revealed a significantly better visualization score on plain images (P = .001). CONCLUSION: Bowel preparation prior to KUB and IVU does not improve the quality of the images in patients with normal bowel habits. However, a significantly better visualization of KUB was noted among patients with chronic constipation who had received bowel preparation.

Effects of neuromodulation with sacral magnetic stimulation for intractable bowel or bladder dysfunction in postoperative patients with anorectal malformation: a preliminary report.

BACKGROUND AND PURPOSE: The effects of neuromodulation with sacral magnetic stimulation (SMS) were examined in postoperative patients with bowel or bladder dysfunction. PATIENTS AND METHODS: SMS was performed at the S3 level using a MagPro® instrument (Medtronic Inc., USA) while the patients were under light sedation. One treatment course consisted of stimulation delivered at 15 Hz for 5 s, 10 times over an interval of 1 min. Three patients with bladder or bowel dysfunction refractory to conservative treatment were examined. RESULTS: Case 1 is a 7-year-old male with a rectourethral fistula. This patient developed a hyperdynamic bladder after a laparoscopic pull-through operation at the age of 7 months. The administration of an anticholinergic agent slightly improved the condition. SMS was started at the age of 4 years with one trial each year. A marked expansion of bladder volume from 20 ml before trial to 120 ml after the third trial was obtained. Case 2 (a 4-year old female with a recto-vaginal fistula) and Case 3 (a 8-year-old female with an ano-vestibular fistula) showed severe constipation after radical surgery during infancy. Case 2 needed appendicostomy. After SMS, bowel movements could become controllable with enemas. No adverse effects were observed for any of the three cases. CONCLUSIONS: These results suggest that SMS might be a useful modality to improve postoperative bowel or bladder dysfunction.

Diagnóstico y evolución de las malformaciones congénitas del riñón y vías urinarias: 1999-2005: Holguín 2007 / Diagnosis and evolution of congenital malformations of the kidney and urinary tract

Con el objetivo de evaluar la experiencia clínica en los Servicios de Nefrología y Urología del Hospital Pediátrico Provincial Docente Octavio de Concepción y de la Pedraja de Holguín se realizó un estudio descriptivo de 351 pacientes atendidos entre enero 1999 y diciembre 2005. En esta serie de 351 pacientes fueron diagnosticadas 535 malformaciones congénitas del riñón y vías urinarias de 19 tipos. El reflujo vesico ureteral primario, la estenosis de la unión ureteropiélica y el doble sistema excretor fueron en ese orden, las malformaciones más frecuentes, siendo la edad más común de diagnóstico durante el primer año de vida. La mayoría de los pacientes se presentaron con infección del tracto urinario y un número importante fueron asintomáticos. La ultrasonografía y la uretrocistografía miccional convencional resultaron una combinación efectiva para el diagnóstico de estas. La mayoría de los pacientes a los que se les realizó diagnóstico prenatal tenían una Hidronefrosis Congénita. La valva de uretra posterior fue la principal causa de insuficiencia renal crónica. Los grados I, II y III de reflujo vesico ureteral primario casi siempre desaparecen espontáneamente, siendo el tratamiento médico o conservador la piedra angular en el manejo de estos pacientes. Apreciamos una relación directa entre la nefropatía de reflujo y el grado de esta entidad.

Diagnóstico y evolución de las malformaciones congénitas del Riñón y las Vías Urinarias. 1999-2005.Holguín.2007 / Diagnosis and evolution of congenital malformations of the kidney and urinary tract

Con el objetivo de evaluar la experiencia clínica en los Servicios de Nefrología y Urología del Hospital Pediátrico Provincial Docente Octavio de Concepción y de la Pedraja de Holguín se realizó un estudio descriptivo de 351 pacientes atendidos entre enero 1999 y diciembre 2005. En esta serie de 351 pacientes fueron diagnosticadas 535 malformaciones congénitas del riñón y vías urinarias de 19 tipos. El reflujo vesico ureteral primario, la estenosis de la unión ureteropiélica y el doble sistema excretor fueron en ese orden, las malformaciones más frecuentes, siendo la edad más común de diagnóstico durante el primer año de vida. La mayoría de los pacientes se presentaron con infección del tracto urinario y un número importante fueron asintomáticos. La ultrasonografía y la uretrocistografía miccional convencional resultaron una combinación efectiva para el diagnóstico de estas. La mayoría de los pacientes a los que se les realizó diagnóstico prenatal tenían una Hidronefrosis Congénita. La valva de uretra posterior fue la principal causa de insuficiencia renal crónica. Los grados I, II y III de reflujo vesico ureteral primario casi siempre desaparecen espontáneamente, siendo el tratamiento médico o conservador la piedra angular en el manejo de estos pacientes. Apreciamos una relación directa entre la nefropatía de reflujo y el grado de esta entidad. (AU)

Indicación actual de la cirugía abierta en el tratamiento de la litiasis renal. Ureterocalicostomía como tratamiento definitivo de litiasis en mujer con patología renal / Current indications of open surgery for the treatment of renal lithiasis. Ureterocalycostomy as definitive treatment for lithiasis in a female with recurrent dis

OBJETIVO: Presentamos un caso de litiasis recidivante asociado a alteración anatómica de la pelvis renal secundaria a cirugía.MÉTODOS/RESULTADOS: La paciente presenta un episodio de infección urinaria complicada con pionefrosis y septicemia. En la urografía intravenosa se observa litiasis radiodensa infecciosa, pielolocalicial múltiple compleja, sobre riñón con hidronefrosis grado III-IV por importante esclerosis piélica secundaria a cirugía previa sobre dicha unidad renal. Se realiza nefrectomía polar inferior con nefrolitotomía y reconstrucción de la vía urinaria superior mediante uréterocalicostomía. Dos años y medio después de la cirugía la urografía de control refleja ausencia de litiasis y leve retraso de la función renal.CONCLUSIONES: La ureterocalicostomía está indicada en casos de obstrucción de la unión ureteropiélica asociada a una pelvis intrarrenal por alteraciones de la fusión, rotación o localización renal, y en casos de fibrosis peripiélica severa secundaria a una pieloplastía fallida o cirugía renal previa. En el caso presentado además del componente infeccioso de las litiasis, una alteración anatómica, probablemente secundaria a la cirugía previa, provocaba una perpetuación de la clínica litiásica. Ante tal sospecha se impuso una solución de tipo quirúrgico que solucionara en un tiempo tanto la eliminación de la litiasis como una correcta derivación de la zona funcionante del riñón para evitar recidivas posteriores(AU)

OBJECTIVE: We describe one case of recurrent lithiasis associated with anatomical alteration of the renal pelvis related to previous surgery.METHODS/RESULTS: The patient presented a urinary tract infection episode, complicated with pyonephrosis and septi-cemia. In the intravenous urography, infectious radiopaque pyelocaliceal multiple and complex lithiasis can be seen, as well as kidney hydronephrosis grade III-IV. Important pyelic sclerosis secondary to previous surgery on the renal unit was seen. Nephrectomy was performed with lower pole nephro-lithotomy and reconstruction of the upper urinary tract through ureterocalicostomy. Two and a half years after surgery, control urogram shows absence of urolithiasis and a slight delay of renal function.CONCLUSIONS: Ureterocalicostomy is indicated in cases of ureteropelvic junction obstruction associated with intrare-nal pelvis caused by alterations of fusion, rotation or location of kidney. It is also indicated in cases of severe peripyelic fibrosis secondary to previous pyeloplasty failure or renal sur-gery. In our case, in addition to the infectious component of lithiasis, an anatomical alteration, probably secondary to previous surgery, caused the chronification of lithiasis. Fa-cing such suspicion a surgical management was undertaken to eliminate the lithiasis and get a correct derivation of the working area of the kidney, in order to prevent further recu-rrences(AU)

Aplicación de la tecnología láser en el tratamiento de la litiasis ureteral / Application of laser technology in the treatment of ureteral lithiasis

Objetivo: Valorar las aportaciones del láser, fundamentalmente de holmio, en el tratamiento endourológico de la litiasis ureteral. Método: Analizamos la experiencia acumulada en 154 tratamientos endourológicos con láser holmio de litiasis ubicadas a nivel ureteral, realizado de forma continuada en nuestra Unidad desde junio 2005 a diciembre 2007. Resultados: Se consiguió la fragmentación litiásica en el 100% de los casos. El uso asociado de la pinza de rama larga al láser de holmio, nos permitió alcanzar tasas de ausencia de litiasis residual en el 91% de los pacientes. Conclusiones: El tratamiento de la litiasis ureteral se ha beneficiado de los procedimientos endoscópicos, siendo el láser de holmio la fuente de energía de elección en el momento actual. La tasa de fragmentation alcanzada fue del 100%. Las complicaciones fueron escasas y en ningún momento de importancia (AU)

Objectives: To evaluate the contribution of laser, mainly holmium laser, to the endourological treatment of ureteral lithiasis. Methods: We analyze our experience in 154 endourological treatments of ureteral lithiasis with holmium laser performed in our Unit from June 2005 to December 2007. Results: Stone fragmentation was achieved in 100% of the cases. The use of long jaw forceps associated with the holmium laser enabled us to reach a stone free rate of 91%. Conclusions: The treatment of ureteral lithiasis has benefit from the development of endoscopic procedures, being the holmium laser the energy source of choice nowadays. The fragmentation rate was 100%. Complications were rare and never important (AU)

Pediatric voiding dysfunction: current evaluation and management.

Voiding dysfunction and urinary incontinence in children is common. Both are associated with significant effects on quality of life and comorbidities, including urinary tract infections (UTIs) and constipation. A thorough history, physical examination, and non-invasive evaluation are essential in determining the etiology. Interventions, such as behavioral therapy/biofeedback and pharmacologic therapies, are primary treatments. Prevalence rates, current evaluation, and management techniques are discussed in this article.

Diagnostic radiation procedures and risk of prostate cancer.

Exposure to ionising radiation is an established risk factor for many cancers. We conducted a case-control study to investigate whether exposure to low dose ionisation radiation from diagnostic x-ray procedures could be established as a risk factor for prostate cancer. In all 431 young-onset prostate cancer cases and 409 controls frequency matched by age were included. Exposures to barium meal, barium enema, hip x-rays, leg x-rays and intravenous pyelogram (IVP) were considered. Exposures to barium enema (adjusted odds ratio (OR) 2.06, 95% confidence interval (CI) 1.01-4.20) and hip x-rays (adjusted OR 2.23, 95% CI 1.42-3.49) at least 5 years before diagnosis were significantly associated with increased prostate cancer. For those with a family history of cancer, exposures to hip x-rays dating 10 or 20 years before diagnosis were associated with a significantly increased risk of prostate cancer: adjusted OR 5.01, 95% CI 1.64-15.31 and adjusted OR 14.23, 95% CI 1.83-110.74, respectively. Our findings show that exposure of the prostate gland to diagnostic radiological procedures may be associated with increased cancer risk. This effect seems to be modified by a positive family history of cancer suggesting that genetic factors may play a role in this risk association.

Ureteroscopic removal of mildly migrated stents using local anesthesia only.

PURPOSE: In the outpatient office setting we evaluated the feasibility and efficacy of ureteroscopic removal of upward migrated ureteral stents using local or no anesthesia. MATERIALS AND METHODS: Prospectively 37 patients with mild upward stent migration underwent ureteroscopic stent removal under local or no anesthesia. Stent migration was always below the pelvic brim. It was diagnosed by plain x-ray of the kidneys, ureters and bladder, and flexible cystoscopy. Semirigid ureteroscopy was performed in the office outpatient setting. After each procedure patients graded the discomfort and/or pain level experienced by completing 2 separate 5-scale visual analog pain scores, including 1 for flexible cystoscopy and 1 for the ureteroscopic procedure. Pain scores were compared between the 2 procedures. RESULTS: Stent removal was successful in 34 of 37 patients (91.9%). Successful procedures were never interrupted due to pain intolerance. No complications occurred. The mean visual analog pain score for ureteroscopic stent removal was 1.73 and it was similar in men and women (p = 0.199). The mean visual analog pain score for flexible cystoscopy was 1.27. This procedure was significantly more painful in men than in women (p = 0.018). Ureteroscopic stent removal was more painful than flexible cystoscopy overall and in women (each p <0.01) but not in men (p = 0.3). All patients were discharged home within 1 hour after the procedure and no patient required hospital admission or a new hospital visit. CONCLUSIONS: Ureteroscopic removal of a migrated stent using local anesthesia is effective, safe and tolerable in select patients. Preventing the complications and costs associated with general or spinal anesthesia makes this option appealing to patients and it should be offered when possible.