Influence in the outcome of neuropathic pediatric patients after early treatment.

BACKGROUND: Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients. AIM: To analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life. PATIENTS AND METHOD: Retrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence. RESULTS: Sixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency. CONCLUSIONS: Patients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.

Influence in the outcome of neuropathic pediatric patients after early treatment. / Influencia del inicio precoz del tratamiento conservador en la evolución del paciente pediátrico con vejiga neuropática.

BACKGROUND: Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients. AIM: To analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life. PATIENTS AND METHOD: Retrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence. RESULTS: Sixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency. CONCLUSIONS: Patients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.

[Laparoscopic resection of the prostatic utricle in children]. / Resección laparoscópica del utrículo prostático en niños.

INTRODUCTION: The prostatic utricle is an embryological remnant from Müllerian duct tissue. Most prostatic utricles are asympomatic, but they may manifest as a urinary tract infection or an incontinence. MATERIAL AND METHOD: Surgery consists in a cysto-urethroscopy and cannulation of the prostatic utricle with a ureteral catheter (Fogarty ner 4) and the cystoscopy left in situ to facilitate identification and mobilization. A 10 mm port through a umbilical incision and two more 5 mm working ports were inserted. After mobilization, the ureteral defect was closed by an absorbable suture and ultrasonic coagulation. RESULTS: Five boys with symptomatic prostatic utricles underwent surgery at a mean (range) age of 7 (2-11) years. The laparoscopic excision was successful in all but one due to a bleeding. The mean (range) operative duration was 165 (120-240) min. CONCLUSION: Laparoscopic excision under cystoscopic guidance offers a good surgical view and allowing easy dissection.

[Laparoscopic living donor nephrectomy: functional repercussion in the pediatric recipient]. / Nefrectomía laparoscópica de donante vivo: repercusión funcional en el receptor pediátrico.

AIM: The impact of laparoscopic (LDN) vs. open nephrectomy (ODN) on early graft function and survival in pediatric kidney recipient remains unclear. MATERIAL AND METHOD: We retrospectively review the records of 63 pediatric recipient of living donor renal trasplant from 1994 to 2007. We compared those who recieved allograft recovered by LDN (n: 16) with those by ODN (n: 47). The mean recipient age was 9.3 +/- 5 years and the mean donor age was 40.8 +/- 7 years. Outcomes of interest included the incidence of delayer graft function, acute rejection and long-term graft function. RESULTS: Donor, recipient, demographic data and the total time of cold ischemia (1.9 +/- 0.3 hours) were similar in both groups. The mean of kidney warm ischemia was (195 LDN vs. 20 ODN seconds). There were not any significant differences between the two groups, not even in the patient survival after 36 months (100% LDN vs. 98% ODN), neither in the graft survival with proportional hazards Cox analysis. The LDN group needed more days (9.56 +/- 2.3 vs. 4.72 +/- 0.57 ODN) to reach the minimum serum creatinine, but the GF (ml/min/1.73 m2) was similar at 6 months (122 +/- 12 LDN vs. 87 +/- 17 ODN), one year (139 +/- 45 LDN vs. 88 +/- 27 ODN), and two years (110 +/- 64 LDN vs. 82 +/- 30 ODN) after transplant. CONCLUSIONS: LDN delays the recovery of the graft function in pediatric recipient. Pediatric LDN recipient have graft outcomes comparable to those of ODN.

Preliminary results of complete delayed primary bladder exstrophy reconstruction in male patients. / Resultados preliminares de la reconstrucción completa primaria diferida de la extrofia vesical en el varón.

INTRODUCTION: The success of primary bladder closure in bladder exstrophy (BE) is the determining factor for future capacity and continence. In recent years, owing to the unsatisfactory results of staged repair, complete delayed primary reconstruction has gained prominence. OBJECTIVE: To analyze short-term results in male patients with BE undergoing delayed primary closure and compare them with early bladder closure as part of staged repair in our healthcare facility. MATERIALS AND METHODS: The success of bladder closure, postoperative management, complications, and hydronephrosis was assessed over a 12-month follow-up period in both groups: early primary closure (group A) and delayed primary closure (group B). RESULTS: In group A (n=13), mean age at closure was 25 hours and mean pubic diastasis was 32 mm. Patients had respiratory support and muscle relaxation for an average of 4 days postoperatively. Closure success was 85%, and 1 patient presented maintained hydronephrosis beyond the first 6 months. In group B (n=6), mean at closure was 58 days, and mean pubic diastasis was 34 mm. Patients had epidural analgesia and no respiratory support postoperatively. Closure success was 100%. 33% had transient hydronephrosis, and 1 patient (17%) presented maintained bilateral hydronephrosis. The same immobilization technique was used in both groups for 3 weeks. CONCLUSIONS: Delayed primary reconstruction is safe as it allows for closure success without increasing complications as compared to staged repair. A long-term follow-up is required to assess urinary continence, esthetic results, and genital functionality.

INTROUCCION: El éxito del cierre primario vesical en la extrofia (EV) es el factor determinante de la capacidad y continencia futuras. En los últimos años, debido a los resultados poco satisfactorios de la reparación por estadios, la reconstrucción primaria completa diferida ha adquirido mayor protagonismo. OBJETIVO: Analizar los resultados a corto plazo en varones con EV sometidos a cierre primario diferido y compararlos con el cierre vesical precoz en la reparación por estadios en nuestro centro. MATERIAL Y METODOS: Evaluamos el éxito del cierre vesical, el manejo postoperatorio, las complicaciones y la presencia de hidronefrosis durante un tiempo de seguimiento de 12 meses en los grupos: cierre primario precoz (grupo A) y diferido (grupo B). RESULTADOS: En el grupo A (n= 13) la edad media al cierre fue de 25 horas y la diástasis púbica media de 32 mm. Permaneció con asistencia respiratoria y relajación muscular una media de 4 días en el postoperatorio. El éxito del cierre fue del 85% y un paciente mantuvo hidronefrosis más allá de los 6 primeros meses. En el grupo B (n= 6), la edad media al cierre fue de 58 días, la diástasis púbica de 34 mm y se mantuvieron en el postoperatorio con analgesia epidural, sin asistencia respiratoria. El éxito del cierre fue del 100%, el 33% presentó hidronefrosis transitoria y un paciente (17%) hidronefrosis bilateral mantenida. En ambos grupos se empleó igual inmovilización durante 3 semanas. CONCLUSIONES: La reconstrucción primaria diferida es segura, permitiendo el éxito del cierre sin aumentar las complicaciones, comparado con la reparación por estadios. Es necesario un seguimiento a largo plazo para evaluar la continencia urinaria, el resultado estético y la funcionalidad genital.

[Growing up with a bladder augmentation]. / Creciendo con una ampliación vesical.

INTRODUCTION: This study assesses long-term outcome of patients with neuropatic bladders who underwent a bladder augmentation before puberty. PATIENTS AND METHODS: A total of 21 patients with low compliant neuropathic bladders who did not respond satisfactory to clean intermittent catheterization and/or anticholinergic therapy underwent bladder augmentation (mean age 8.3 yr, range; 2.5-12). Eighteen patients (86%) had VUR and/or ureterohydronephrosis and 17 (81%) had DMSA renal scars. Renal function was normal in all cases except one. All patients were followed at regular intervals with serum electrolyte and creatinine determination, urinary tract imaging, urodynamic evaluation and 24-hour urine collection. In the 18 cases augmented with intestine, urine cytology, cystoscopy and biopsy were also performed. RESULTS: Mean follow-up was 11 yr (8-14.5) and mean age at the end of follow-up was 19 yr (13.3-26.8). Urodynamic studies showed a significant improvement in bladder compliance. Upper urinary tract dilatation disappeared in all patients, VUR in 13/15p (86%) and no new renal scarring occurred. Renal function was normal at the end of follow-up in 20. Only 1 patient had UTI and another had a bladder stone. All patients are dry and 2 of them do not need clean intermittent catheterization. Urine cytology and cystoscopy were normal and no malignat lessions have been found in the biopsy specimens. CONCLUSIONS: Bladder augmentation done pre-puberty preserves renal function and resolves VUR and/or hydronephrosis in most cases without reimplanting the ureters. Close lifelong follow-up, including a cystoscopy, improves the results and prevents complications.

[A new method for assessing sphincter resistance, in patients with low compliant bladder]. / Un nuevo método para valorar la resistencia del esfínter, en pacientes con vejigas de baja acomodación.

Since 1990, in our department we have planned out a test to find out the grade of sphincteric resistance in patients with low compliant bladders. In order to know which patients will have a sufficient sphincteric resistance to achieve satisfactory continence after bladder augmentation and which patients will not have sufficient sphincteric resistance, needing procedures to increase outlet resistance along with bladder augmentation. This test consisted in: to determine what volume the bladder can admit at a detrusor pressure of 10 cm H2 O, we fill the bladder at that volume and then, we check if the patient had leaks with abdominal pressure increases. The study was carried out in 15 patients with low compliant bladders and suffering from incontinence, who had not responded to I.C. and anticholinergic therapy, who was to undergo bladder augmentation. In 12 patients the test was negative and in 3 was positive. After bladder augmentation, all patients with negative tests, are completely dry, and the three patients whose test was positive, in spite of having urodynamically normal neobladder they remain incontinent. In our opinion, this test is simple to perform and very useful diagnostic tool to known which patients beside bladder augmentation, may need procedures to increase outlet resistance.

[Neuro-urologic impact of spinal cord untethering in patients with myelomeningocele and tethered cord]. / Repercusiones neuro-urológicas tras el desanclaje medular en pacientes con mielomeningocele y médula anclada.

Changes in bladder behaviour and neurological symptoms were evaluated in 47 patients underwent untethered spinal cord because of tethered cord syndrome secondary to myeloneningocele closure. Patients were located in 3 categories (A < or = 5 years, B 6-10 years and C > 10 years) in relation to age of treatment. After untethering 77% improved neurologically and the best results were evident in children whose condition was repaired promptly (90%). Urodynamic studies were performed in 33 patients before and after surgery. Fifteen had hyperreflexic bladders, six low compliance and 12 hyperreflexia disappeared in 4 and sphinteric resistance increased in 2. In patients with tethered cord syndrome, untethering is recommended treatment in preventing further, sometimes rapid neurologic dysfunction and better results are got in childs whose condition is repaired at an early ages.

[Treatment of vesico-ureteral reflux in low compliance bladder]. / Tratamiento del reflujo vésico-ureteral en vejigas de baja acomodación.

Ten patients with noncompliant bladders and vesicoureteral reflux who did not respond to I.C. and anticholinergic therapy, underwent bladder augmentation and no effort was made to correct reflux surgically, because in these patients, in theory, reflux is secondary to bladder dysfunction. In 8 patients bladder augmentation was made with the intestine and in 2 with the ureter. All patients had a normal compliance after treatment and of the 10 patients with reflux (14 renal units) it disappeared in 7 (11 renal units) and in the 90% of the patients with grades III and IV. In the 3 patients where reflux remained, in 2 it was a unilateral low grade reflux (II) and in 1, had improvement from grade IV to grade II. In these patients reflux only appearing when the bladder got too full, which under normal conditions patients do not get with the I.C. Our experience indicates the antireflux procedures are not routinely needed in this group of patients.

[The use of a continent urinary stoma in complex reconstructions of the lower urinary tract in children]. / La utilización en el niño de un estoma urinario continente en las complejas reconstrucciones del tracto urinario inferior.

Since its description in 1980, the Mitrofanoff principle has become a widely utilized and successful technique for the management of patients with a variety of urological disorders. We report our experience with this procedure in 14 patients (10 M, 4 F). The age range was 3.5 years to 17 years (average 12 y) and follow-up was from 6 months to 3 years (average 1.7 y). Patients were classified in 2 groups: I) When this procedure was done because of the patient was unable to perform urethral catheterization (8p). II) Concomitant bladder neck transection and Mitrofanoff diversion (6p). The appendice was used in 9p, ileum in 1 and ureter in 4. Bladder augmentation was performed with ureter in 2p and colon sigmoid in 4. In 1p, ileo-cecal segment and in other colon+ileum, were used to replace the bladder. All patients catheterize the Mitrofanoff channel easily, there were no case of stomal stenosis and the conduit was continent in all. We consider that Mitrofanoff principle is a very successful technique and it can be used as the primary continence mechanism or as an adjunct of major urinary tract reconstruction, to ensure complete bladder emptying, in patients unable to perform urethral catheterization.

[Cystic cystitis in childhood]. / Cistitis quística en la infancia.

Cystic cystitis is a benign entity highly uncommon throughout childhood and which, from a clinical and radiological point of view, can simulate an intravesical malignant neoplasia (rhabdomyosarcoma); thus an accurate differential diagnosis is required, a biopsy of the lesions being necessary to confirm their nature. The paper presents 2 patients with cystic cystitis discussing the condition's etiology, pathogenesis, signs and symptoms as well as its evolution.

[Comparative study of the degree of patient satisfaction in intermittent catheterization with Lofric and polyvinyl chloride catheters]. / Estudio comparativo del grado de satisfacción del paciente en cateterismo intermitente con el uso de las sondas Lofric y las de cloruro de polivinilo.

PURPOSE: To assess the grade of satisfaction in children on intermittent catheterization with the use of LoFric and PVC conventional catheters. MATERIAL AND METHODS: A total of 40 p with experience in CIC were included in this study. An anonymous questionnaire was sent to all patients after 2-months using the LoFric catheter. Patients were divided in 3 groups (bladder augmentation, artificial sphincter, Mitrofanoff) because of major differences in CIC discomfort between these groups. RESULTS: The questionnaire was completed by 87.5% of the patients (35 p). In 86% (30 p) LoFric catheter training was easy or very easy but in 14% (5 p) it was difficult. Four patients had some difficulty during conventional catheter insertion, in 3 (75%) the difficulty disappeared with the use of LoFric catheter. Of the 51% (18 p) who reported some discomfort during the insertion of conventional catheter, 72% said it was eliminated when the LoFric catheter was used. Of 6 p with some discomfort when removing the conventional catheter, 5 (83%) said it disappeared with the new catheter. Th LoFric catheter was favored by 70% of patients because it reduced the discomfort caused by conventional catheters, bladder insertion was easier and smoother, and gel lubrication was not needed. The 17% of patients reported some difficulty dealing with this slippery catheter. CONCLUSIONS: The use of the LoFric catheter could be justified in patients who report with conventional catheters have some discomfort. It can also be recommended in patients with artificial sphincter, bladder augmentation and Mitrofanoff procedure, in whom any complication related to CIC would have serious consequences.

[Obstruction caused by anterior urethral valves in childhood]. / Obstrucción por válvulas de uretra anterior en la infancia.

Presentation of 3 patients (aged 11 years, 9 months and 9 years old) with diaphragm-like valves in the anterior urethra. Haematuria, urinary tract infection and thin voiding stream were the most common symptoms. Transurethral endoscopic resection with cold blade solved the problem appropriately in two cases, though the youngest patient required resection of stenotic area and end-terminal by-pass of the urethra.

[Renal angiomyolipoma in childhood: a clinical case]. / Angiomiolipoma renal en la infancia: caso clínico.

The renal angiomyolipomas are unusual benign tumors which more than 50 per cent, are associated with tuberous sclerosis or intestinal linphangiomatosis. They can be discovered in a radiologic study by chance or to be associated with flank and abdominal pain and hematuria. The ultrasonographic imagen is characteristic and its management is conservative.

[Augmentation cystoplasty for severe uropathy in children]. / Cistoplastia de aumento en la uropatía severa del niño.

We present our experience in seven patients (three boys and four girls) with bladder augmentation. Two patients had a neurogenic bladder, two a "nonneurogenic" neurogenic bladder and three a bladder exstrophy. Between the exstrophy patients, two had a rectocistoplasty and one a colon conduit diversion. The rest of patients (two neurogenic bladders and two "nonneurogenic" neurogenic bladder) had a colon conduit diversion. The intestinal segment used for bladder augmentation were ileocecal sement (two patients), ileon (one patient) and colon sigmoid (four patients). Bladder augmentation were tubularized in four patients and detubularized in three. In the follow-up, five patients have a normal renal function (one transplanted), one patient his function is unchanged and other is waiting for the transplant. Of the seven patients, six are fully continente day and night (two with CI and one with anticholinergic drugs) and one has a diurnal continence no more than two hours.

[The Mitrofanoff principle in the lower urinary tract reconstruction]. / El principio de Mitrofanoff en la reconstrucción del tracto urinario inferior.

Since its description in 1980, the Mitrofanoff principle has become a widely utilized and successful technique for the management of patients with a variety of urological disorders. We report our experience with this procedure in 12 patients (8 M, 4F). The age range was 3.5 years to 17 years (average 13y) and follow-up was from 6 months to 3 years (average 1.7y). Patients were classified in 2 groups: I. When this procedure was done because of the patient was unable to perform urethral catheterization (6p). II. Concomitant bladder neck transection and Mitrofanoff diversion (6p). The appendice was used in 8 p and ureter in 4. Bladder augmentation was performed with ureter in 2 p and colon sigmoid in 3. In 1p, ileocecal segment and in other colon + ileum, were used to replace the bladder. All patients catheterize the Mitrofanoff channel easily, there were no cases of stomal stenosis and the conduit was continent in all. We consider that Mitrofanoff principle is a very successful technique and it can be used as the primary continence mechanism or as an adjunct of major urinary tract reconstruction, to ensure complete bladder emptying, in patients unable to perform urethral catheterization.

[The effectiveness of the trigonoplasty in the treatment of the primary vesicoureteral reflux]. / Efectividad de la trigonoplastia en el tratamiento del reflujo vesico-ureteral primario.

Trigonoplasty is a minor surgical procedure to treat vesicoureteral reflux that preserves the integrity of the vesicoureteral junction. This technique was introduced in 1984 by Gil Vernet. Between 1989 and 1995 we performed trigonoplasty in 20 children from 6 to 15 years old with primary vesicoureteral reflux. In our study 15 patients had bilateral vesicoureteral reflux and five were unilateral, they had 35 refluxing units. Gil Vernet's trigonoplasty was performed after a five year observational treatment and it was always indicated in children with special wide trigone (1 grade I, 14 grade II, 17 grade III and 3 grade IV). Surgery was successful in 94% of the patients controlled one year after. Unilateral reflux recurrence in two patients. We consider that trigonoplasty is a good procedure with indication in patients with vesicoureteral reflux with wide trigone. The procedure shorten the postoperative hospital stay and offers a similar percentage of good results as other techniques.

[Are there a neuro-urological symptomatology improvement after spinal cord untethering?]. / Existe una mejoría de la sintomatología neuro-urológica tras el desanclaje medular?

Changes in bladder behaviour and neurological symptoms were evaluated in 47 patients underwent untethered spinal cord because of tethered cord syndrome secondary to myeloneningocele closure. Patients were located in 3 categories (A < or = 5 years, B = 6-10 years and C > 10 years) in relation to age of treatment. After untethering 77% improved neurologically and the best results were evident in children whose condition was repaired promptly (90%). Urodynamic studies were performed in 33 patients before and after surgery. Fifteen had hyperreflexic bladders, six low complicance and 12 hyperreflexia plus low compliance. After treatment in 6 patients bladder dysfunction improved (18%), hyperreflexia disappeared in 4 and sphinteric resistance increased in 2. In patients with tethered cord syndrome, untethering is recommended treatment in preventing further, sometimes rapid neurologic dysfunction and better results are got in childs whose condition is repaired at an early ages.