Urological outcome with the use of salvage continent vesicostomy in pediatric reconstructive surgery. A single tertiary center experience.

PURPOSE: To report our experience and results in terms of complications, reoperation rate and urinary continence with the Salvage Continent Vesicostomy (SCV) technique in pediatric patients with history or need of enterocystoplasty and absent appendix. METHODS: Retrospective review of all patients with a history of a continent catheterizable channel surgery performed in our institution between June 2016 and January 2022. Only patients with a SCV surgery with a minimum 6-month post operative follow up were included in this cohort and divided in group 1 (history of previous bladder augmentation) and group 2 (simultaneous bladder augmentation and SCV). Primary outcome of the study was to assess both continence and postoperative complication rates. Early complications were assessed using the Clavien-Dindo classification (I-V). Late complications were focused on the need of further subfascial revision. RESULTS: 84 patients with a history of a continent stoma creation surgery were identified. In 20 of them (12 males) a SCV was performed. The mean age at surgery was 10.38 (range 4.87-15.6) years and the median postoperative follow-up time was 32 (range 6-64) months. Eleven patients were included in Group 1, while 9 patients in Group 2. Early complications occurred in 4 patients (20%), two of them required a re-intervention (Clavien-Dindo IIIb). Stoma subfascial revision was further required in 2 patient (10%). Continence rate at last follow up was 95%. CONCLUSIONS: In our early experience, the salvage continent vesicostomy has proven to be a simple continent stoma technique with acceptable both continence and complication rates that can be used in selected patients with a history or need of bladder augmentation and absent appendix.

Nephro-urological outcomes of a proactive management of children with spina bifida in their first 5 Years of life.

INTRODUCTION: The proactive management of spina bifida (SB), especially of its severe form, myelomeningocele (MMC), has contributed to decreasing chronic kidney disease (CKD). The objective of this study is to present the evolution of 5-year-old patient with MMC followed from birth with a proactive approach. MATERIAL AND METHODS: This retrospective study included 55 cases with MMC of up to 5 years of age. All of them were admitted at birth and followed by a multidisciplinary group, with a proactive approach: CIC and anticholinergics. In the same group, the variables were compared within the first year and the within the fifth year of life. Chronic kidney disease (CKD) was defined by: alterations on renal DMSA scintigraphy; alterations in microalbuminuria/creatininuria ratio, proteinuria 24 hs and decrease in glomerular filtration rate (GFR) calculated with Schwartz bedside equation. RESULTS: Although overactivity, UTI and VUR decreased throughout the first 5 years (49, 9 and 12%), reduced cystometric capacity, DLPP >40 cm of water and end-filling pressure (Pdet) >20 cm of water increased (41, 27 and 61%). All patients at 5 years of age required CIC. Reduced cystometric capacity and VUR were more significant with abnormal DMSA (36%) at 5 years old ( p: 0.03). Proteinuria and CKD increased to 25% and 49%. Similarly, the need for enalapril increased from 10% to 27%. The microalbuminuria/creatininuria ratio was pathological in 27.3%. 48 patients (87%) remained unchanged on DMSA scan and the other 7 underwent modifications (4 new cases with altered DMSA) over time. Of the 32 normal DMSA cases without changes, 81% did not present proteinuria and 88% continued to respond favorably to oxybutynin. GFR <90 ml/min/1.72m 2 was found in only 3 cases with abnormal DMSA. There was a RR 1.91 (IC95% 1.15-3.16) greater of renal compromise in cases that were anticholinergic-resistant compared to non-refractory cases. DISCUSSION: Over time, some patients suffered loss of bladder wall compliance, despite the proactive approach. There is an association between abnormal renal DMSA, reduced bladder capacity, and VUR at 5 years of age. Although proteinuria, CKD and enalapril requirement increased over 5 years, almost 90% did not show changes in renal DMSA status. CONCLUSIONS: Over time, some patients suffered loss of bladder wall compliance. Hence, even if a proactive approach is followed since birth, it is essential to continue with the ongoing monitoring of the renal status and thus avoid greater renal deterioration.

Laparoscopic Upper-pole Heminephrectomy for the Management of Duplex Kidney: Outcomes of a Multicenter Cohort.

OBJECTIVE: To analyze the outcomes of patients undergoing upper-pole heminephrectomy surgery and to assess the different variables that may have an impact on outcome, specifically regarding morbidity and the need for further surgeries. MATERIALS AND METHODS: A retrospective study of patients who underwent laparoscopic upper-pole heminephrectomy for a nonfunctional moiety between August 2007 and December 2019 was conducted at 3 centers. A total of 130 patients met the inclusion criteria. A transperitoneal approach was used. The following variables were evaluated: (1) preoperative: presentation, presence of ureterocele and history of ureterocele incision, hydronephrosis grade, presence of vesicoureteral reflux (VUR), and differential renal function (DRF) on renal scintigraphy; and (2) postoperative outcomes: Doppler ultrasound, renal scintigraphy, complications, febrile urinary tract infection, lower urinary tract symptoms, and need for further surgery. Findings were considered statistically significant at P <.05. RESULTS: Postoperative complications were observed in 5 patients (3.8%). Six patients (4.6%) needed further surgeries after heminephrectomy. The presence of ureterocele and VUR was related with the need for further surgeries odds ratio (OR) 4.91, P = .0415) and the occurrence of postoperative febrile urinary tract infection (OR 2.81, P = .0376). A 13.9% incidence of lower urinary tract symptoms was found with no difference between patients with ureterocele and those with an ectopic ureter. Renal scintigraphy showed a median decrease in DRF of 2.7%. No patient had complete loss of function. CONCLUSION: Laparoscopic upper-pole heminephrectomy showed to be a feasible and safe procedure. In most patients this surgery will be the definitive procedure. Patients with both VUR and ureterocele will need special consideration. No significant loss of function in the remaining lower moiety was found.

Long-term urological assessment and management of cloaca patients: A single tertiary institution experience.

PURPOSE: Preserving renal function and achieving urinary continence are the most important urological goals in the management of cloaca patients. Many prognostic factors have been described, such as the length of the common channel (CC) and urethra, the presence of spinal dysraphism, and associated urological anomalies. The aim of this study was to analyze urinary continence status and need for reconstructive procedures and their correlation with urological risk factors in a series with a long-term follow-up. MATERIAL AND METHODS: The institutional database of patients with anorectal malformations was reviewed. Patients with cloaca who underwent cloacal reconstructive surgery at our institution between January 1995 and May 2015 and who had a minimum postoperative follow-up of 5 years with complete urological care were included. Urologic and spinal anomalies, length of the CC, renal function, urodynamic study patterns, continence status, and urologic reconstructive surgeries were assessed. A CC was defined as long CC when its measure was longer than 3 cm in the cloacogram and then confirmed by cystoscopy. Descriptive statistical analysis was performed. RESULTS: Fifty-five cloaca patients with a mean follow-up of 12 years (5-20) were included. A long CC was documented in 38 patients (69%). The sacral ratio (SR) was <0.4 in the AP projection in 30 (54.5%). Urodynamic evaluation revealed an inadequate detrusor contraction pattern in 65.4% of the cases. A CC >3 cm and SR <0.4 were significantly correlated with this urodynamic finding. A total of 50 patients (91%) achieved urinary continence, but only 30.9% had volitional voiding and 56% needed major urological reconstructive surgeries. Eighteen patients (32.7%) were in stage 2 or more of chronic kidney disease (<90 ml/min/1.73 m2) at the last follow-up visit. CONCLUSION: Cloacal management requires a multidisciplinary and long-term follow-up. Early assessment of prognostic urological factors and accurate stratification of each patient are essential to avoid renal impairment and achieve urinary continence in the future. The length of the common channel and the presence of spinal dysraphism were correlated with the presence of neurovesical dysfunction specifically an abnormal bladder contraction efficiency. A significant number of these patients will need catheterization and reconstructive urinary tract surgeries to attain urinary continence. TYPE OF STUDY: Retrospective study. LEVEL OF EVIDENCE: Level 3. Retrospective comparative study.

Bladder Volume Assessment in Pediatric Patients With Neurogenic Bladder: Is Ultrasound an Accurate Method?

OBJECTIVE: To define the accuracy of ultrasound to determine bladder volume in pediatric patients with neurogenic bladder (NB). METHODS: Retrospective analysis of children with NB in treatment with urethral clean intermittent catheterization. EXCLUSION CRITERIA: bladder surgeries, and catheterization through a channel different than urethra. Bladder volume was measured with ultrasound using the formula: anteroposterior bladder diameter by side to side diameter by distance from dome to outlet tract by 0.523 (cm3). In the same act, the patient was performed urethral catheterization and the drained volume was measured in millimeters. Finally, postvoid residual volume (PVR) was assessed with ultrasound. RESULTS: We performed 318 measurements in 299 patients, mean age was 9.95 years (standard deviation: 4.6), 59% were female. Most frequent etiologies of NB were myelomeningocele and lipomyelomeningocele. Mean ultrasound-determined bladder volume was 213.9cm3 (range: 20-899 cm3) and mean bladder volume drain through catheterization was 336.4 mL (range: 30-1480 mL; P : .0001). In 67.3% of the patients (n: 214) PVR was not significant, and their mean ultrasound volume was 212.7 mL and the volume evacuated by catheterization was 339.9 mL (P : .0001). In all age groups ultrasound-determined bladder volume was statistically lower than catheterized bladder volume (P : .0001). The mean percentage error of the ultrasound-determined bladder volume was 15.58% ± 44.09. Linear regression analysis and Bland-Altman plot showed low agreement between both measurement techniques. CONCLUSION: In children with NB, ultrasound-determined bladder volume was statistically lower than catheterized bladder volume measured at the same moment, and this relation persisted regardless of sex, age, and the presence of PVR.

Pediatric Urodynamic Study Without a Preprocedural Urine Culture, Is It Safe in Clinical Practice?

OBJECTIVE: To prove that incidence of UTI after a pediatric urodynamic study (UDS) is low, and that patients without urine culture (UC) analysis prior to a UDS will not have a significant increase in the incidence of UTI (post-UDS UTI). METHODS: Prospective cohort study including consecutive pediatric patients undergoing UDS in a single center for 1 year. Patients were divided in 2 groups: (G1) UDS with a previous negative UC and (G2) UDS without a previous UC analysis. A clean UC was obtained in all patients at the moment of the UDS (UDS-UC). Primary outcome was post-UDS UTI. Secondary outcome was to compare UC cost per patient and cancellation rates in each group. All patients were followed 15 days after the UDS to detect onset of UTI symptoms. RESULTS: Four hundred two patients were included, 198 patients in G1 and 204 patients in G2. Median age was 9 years old. Both groups were similar in terms of demographic and clinical records data except for a proportion of patients on CIC which was larger in G2 (P <.008). Overall incidence of post-UDS UTI was 0.7% (3/402), G2 incidence (0.98%) being slightly higher than G1 (0.50%; P <.58). UDS-UC was positive in 32% of G1 vs 55% in G2 (P <.001). About 98% of patients with positive UDS-UC did not progress to symptomatic UTI. G1 cost was 140% higher than G2. CONCLUSION: Overall incidence of post-UDS UTI is low (0.7%). Patients without UC prior to UDS did not have a significant increase in post-UDS UTI.

Efficacy and safety of Mirabegron as adjuvant treatment in children with refractory neurogenic bladder dysfunction.

INTRODUCTION: When patients with neurogenic bladder become refractory, there are different alternatives, such as the use of ß3-adreceptor agonists. The aim of the present study is to evaluate efficacy and safety of Mirabegron as adjuvant treatment. MATERIAL AND METHODS: 37 patients under 18 years of age who underwent Mirabegron were retrospectively studied. The inclusion criteria were: cases with neurogenic bladder who were under clean intermittent catheterization (CIC) programs and refractory to oral oxybutynin (Group A) and/or onabotulinumtoxinA (Group B). Once refractory neurogenic bladder was confirmed by clinical and/or urodynamic studies, Mirabegron 25 mg/day was indicated and evaluation was performed in the third month without stopping therapy. Systolic/diastolic blood pressure and transaminases were monitored. Paired t test and Pearson's chi - squared test were used. RESULTS: Maximum cystometric capacity increased significantly by 125 mL, from 322 to 446 ml (p < 0.0001). End-filling detrusor pressure decreased significantly by 12 cm H2O, from 44 to 31 cm H2O (p < 0.0001). The variation in both parameters was significant in Groups A and B. The presence of detrusor overactivity increased globally from 21 to 32% after starting Mirabegron, but the intensity of contractions was reduced in 20 cm H2O. Of the 18 patients who were incontinent before, 13 cases (72%) remained dry after initiating therapy with Mirabegron. None of the patients stated having suffered any adverse effects. Blood pressure and transaminases showed no significant difference. None of the patients discontinued treatment due to intolerance to Mirabegron (Summary Table). DISCUSSION: In our study the treatment with Mirabegron improved significantly the clinical and urodynamic parameters. A significant increase in bladder capacity and a significant decrease in end-filling detrusor pressure were observed in both groups. The intensity of overactivity was attenuated. According to the records of the voiding diary, over 70% of the incontinent patients became dry after the administration of Mirabegron. We did not observe any adverse effects. The most important limitations of the present study are its retrospective design, the small size of the sample population and of each group, and the use of only one dose of Mirabegron. CONCLUSIONS: Mirabegron as adjuvant treatment in children with refractory neurogenic bladder increased bladder capacity, reduced intravesical pressure and helped achieve continence in more than two thirds of the sample population. Mirabegron was safe and well tolerated by children.

Laparoscopic Nephro-Sparing Surgery of a Reninoma Tumor in a Pediatric Patient.

OBJETIVE: Reninoma, or juxtaglomerular cell tumor, is a benign neoplasm which causes severe hypertension with elevated plasma renin activity.1-3 Usually, it is well localized on computed tomography scan or magnetic resonance images, and complete resection of the tumor with renal function preservation is the optimal treatment.2-4 To describe the technique of a transperitoneal nephron-sparing laparoscopic surgery in a pediatric patient. MATERIAL AND METHODS: Describe the technique of a minimally invasive nephron-sparing surgery for resection of a reninoma tumor in a child. RESULTS: In a 14-year-old girl with history of severe high blood pressure, ultrasound detected a hypoechoic lesion in right kidney. Angio computed tomography scan confirmed a 20-mm diameter lesion in the anterior surface of the lower pole of right kidney and also informed a lower pole renal artery. Transperitoneal laparoscopic approach was performed using 4 ports. After mobilization of the colon, Gerota's fascia was opened and the tumor identified. Both polar and principal renal arteries were dissected and secured with vessel loops. The tumor was resected using an ultrasonic energy device. Selective clamping of the lower pole renal artery was performed during 8 minutes. The transected renal surface was closed with two continuous barbed sutures and the tumor was removed using a handmade endobag. Perirenal drainage was left for 4 days, there were no perioperative complications and the patient was discharged 2 days after surgery. Pathology confirmed typical reninoma immunohistochemical features. Blood pressure and plasma renin levels returned to normal. Postsurgical scintigraphy informed 40% differential function of the right kidney. CONCLUSION: Reninoma is a benign renal tumor and because of its nature and localization, minimally invasive nephron-sparing surgery should be considered. Strategic planning of the surgery based on preoperative images is essential. If vessel clamping is imperative, minimizing ischemia time and/or selective clamping, when possible, help preserve renal function.

Creation of a professional network to improve spina bifida care: Argentina case.

The purpose of this paper is to render an account of the experience of a group of healthcare providers and to propose innovative solutions for patients with Spina Bifida (SB) in Argentina. Based on our practice, patients reach specialists too late (40% already undergoing chronic kidney disease stage 1). However, several strategies were implemented in order to reverse this trend, among which were: the setting up of a professional network (via emails and Google groups), team training at different locations, videoconferences, and calling the Ministry of Health to action. Additionally, we developed a project through telemedicine to inform patients and empower caregivers throughout Argentina.

Initial urological evaluation and management of children with neurogenic bladder due to myelomeningocele.

INTRODUCTION: The proactive management of children with myelomeningocele (MMC) has contributed to decreasing their progression to end-stage renal disease, thanks to early urological evaluation and timing implementation of treatments. OBJECTIVE: To demonstrate that early urological evaluation of the urinary tract in MMC shows functional alterations in most cases, and that it requires medical intervention, even when in some cases the complementary imaging studies do not show any abnormalities. MATERIAL AND METHODS: A retrospective study including 60 patients aged <1 year with MMC who were followed by a multidisciplinary team. All of them underwent renal/bladder ultrasound, videourodynamic studies, renal scintigraphy/dimercaptosuccinic acid (DMSA), and laboratory tests for kidney function. The studied variables were: bladder capacity and pressure, presence of overactivity, vesicoureteral reflux (VUR), urinary dilations and abnormalities on renal scintigraphy/DMSA. All the patients received clean intermittent catheterization (CIC). RESULTS: See Summary Table all the patients showed alterations in at least some of the assessed urodynamic variables: reduced cystometric capacity, 21.6%; detrusor overactivity, 55%; end filling detrusor pressure >20 cm H2O, 43.3%; inefficient bladder voiding, 98.3%; indirect dyssynergic patterns, 28.8%. The high-risk videourodynamic findings were observed in 28 cases (46.6%). DMSA was abnormal in 30%. Renal impairment was detected in 6.6% of cases. A total of 66% of cases received oxybutynin. DISCUSSION: Almost all the children in this sample population showed urinary dysfunction, and approximately half of them had high-risk videourodynamic findings. Although many cases showed reflex urinary contractions, almost the entire sample had inefficient bladder voiding. An important limitation of this work was the lack of simultaneity in obtaining each of the requested studies. CONCLUSIONS: In the initial urological evaluation of patients with myelomeningocele, almost all the urodynamic studies showed abnormalities and one-third showed abnormal DMSA, which led to therapeutic actions being initiated, although imaging studies were normal in a great number of patients. CIC alone, starting immediately after birth, is not sufficient. To eliminate or decrease upper tract damage, oxybutynin should be started in addition.

The use of polyacrylate-polyalcohol copolymer hydrogel in the endoscopic treatment of primary vesicoureteral reflux in children.

BACKGROUND/PURPOSE: It is still under discussion which is the best tissue augmenting substance for the endoscopic treatment of children with vesicoureteral reflux (VUR). We describe our preliminary experience (September 2009-November 2011) with polyacrylate-polyalcohol copolymer hydrogel (PPCH). METHODS: This is an observational, descriptive, prospective study which included 81 female and male patients (age 1-14 years) diagnosed with unilateral (n=45) and bilateral (n=36) primary VUR comprising a total of 117 refluxing renal units (RRU). Complex cases were excluded from the study. All patients were clinically and radiologically evaluated and those who met the inclusion criteria were treated endoscopically with a single subureteral injection of PPCH by a single surgeon. 11 patients (13.5%) had a pathological 99mTc-DMSA before treatment. The volume of injected product was measured in all cases. Results were considered successful if 6months postinjection, conventional voiding cystourethrogram (VCUG) revealed VUR was cured (Grade 0). Follow-up ranged from 7 to 32months. RESULTS: The overall resolution rate based on the number of RRUs studied was 92.3% (108/117). The mean injected volume of PPCH per patient was 0.6ml. One patient with obstructive anuria required vesicoureteral reimplantation. Other complications were persistent, self-limiting hematuria (n=2); lumbar pain (n=4) and urinary tract infection with normal VCUG (n=4). CONCLUSIONS: Our short term data show PPCH provides a high level of reflux resolution in selected patients. Long term follow-up is required.

Multicenter survey of endoscopic treatment of vesicoureteral reflux using polyacrylate-polyalcohol bulking copolymer (Vantris).

OBJECTIVE: To evaluate an outcome of endoscopic correction of vesicoureteral reflux (VUR) using Vantris (Promedon, Cordoba, Argentina) in terms of its effectiveness and morbidity in a multicenter study. MATERIALS AND METHODS: From 2009 to 2013, 611 patients (210 boys and 401 girls) with a mean age of 3.56 years (range, 1 month-18 years) were treated at 7 centers worldwide endoscopically with Vantris injection. VUR was unilateral in 413 and bilateral in 198 patients comprising 809 renal refluxing units (RRUs). Of these, primary VUR was present in 674 RRUs (83.3%) and 135 (16.7%) were complex cases. Reflux was grades I-V in 24 (2.96%), 123 (15.2%), 451 (55.8%), 158 (19.5%), and 53 (6.6%) RRUs respectively. The follow-up continued from 6 to 54 months. RESULTS: Reflux resolved in 759 RRUs (93.8%) after first Vantris injection, in 26 (3.1%) after second, and in 6 (0.7%) after third injection, respectively. VUR improved to grade I after 1 or 2 injections in 5 ureters (0.6%), which needed no further treatment. Thirteen ureters (1.6%) failed endoscopic correction and required ureteral reimplantation. Vesicoureteral junction obstruction requiring ureteral reimplantation developed in 6 ureters (0.7%) and in 4 (0.5%) required stent insertion. Twenty-three patients (3.8%) suffered afebrile urinary tract infection. Seven (1.2%) developed febrile urinary tract infection. None of the studied patients demonstrated VUR recurrence on voiding cystourethrography. CONCLUSION: The results of this multicenter survey confirm that endoscopic subureteral Vantris injection is a simple, safe, and effective outpatient procedure for treating all grades of VUR.

Repeated injections of intradetrusor onabotulinumtoxinA as adjunctive treatment of children with neurogenic bladder.

AIM: To evaluate the effects of repeated injections of onabotulinumtoxinA in children with neurogenic bladders refractory to conventional treatment. PATIENTS AND METHODS: A total of 26 children with neurogenic bladder were prospectively studied. Some patients received up to four repeat injections. Patients were reinjected if they showed improvement in voiding diary, score of urinary incontinence and/or urodynamic studies; otherwise, augmentation cystoplasty was indicated. RESULTS: Of the 26 patients, 12 were reinjected a second time, 6 patients were reinjected a third time and 2 patients received a repeat injection for the fourth time. Six months after the first, second and third injection, the urinary incontinence score 0 (dry) was 50, 77 and 75 %, respectively. After each injection, the mean bladder capacity in voiding diary and the mean maximum cystometric capacity increased. The mean detrusor pressure at the end of filling decreased. Only compliance after the first injection improved significantly. Detrusor overactivity (n: 4), improved during 3 months and reappeared in three children after the first injection, but at greater cystometric volumes. In the fourth case, it reappeared 11 months after the third injection. Five patients underwent cystoplasty. CONCLUSION: After treatment with onabotulinumtoxinA, urinary continence achieved was 50-77 %. There were favorable changes in urodynamic variables, but they were insufficient. Detrusor overactivity was attenuated, but did not disappear completely.

Laparoscopic Mitrofanoff procedure using single 'U-Stitch' anastomosis: a way to make it simple.

OBJECTIVE: to describe and incorporate a modification of the fully laparoscopic Mitrofanoff (LM) procedure with the aim of diminishing operative time and technical difficulties, and to reproduce functional results. PATIENTS AND METHODS: Retrospective review of six patients with voiding dysfunction with indication for clean intermittent catheterization who did not require bladder augmentation and who underwent a fully LM procedure between January and November 2011. RESULTS: The mean operative time was 183.3 min with a mean hospital stay of 6.15 days. No complications were recorded during the surgical procedure. Postoperative hematuria is the most frequent complication associated with this technique. One patient presented appendicovesical anastomotic leak that resolved spontaneously after 8 days with abdominal drainage. There were no other postoperative complications on an average 6.8-month follow up. CONCLUSION: We believe fully LM is a feasible and reproducible approach. The U-Stitch appendix implantation technique reduces total operative time and makes the procedure technically easier.

Pharmacotherapy in pediatric neurogenic bladder intravesical botulinum toxin type a.

When the neurogenic bladder is refractory to anticholinergics, botulinum toxin type A is used as an alternative. The neurotoxin type A reduces bladder pressure and increases its capacity and wall compliance. Additionally, it contributes to improving urinary continence and quality of life. This novel therapy is ambulatory with a low incidence of adverse effects. Due to its transitory effect, it is necessary to repeat the injections in order to sustain its therapeutic effect. In these review article we talk about Mechanism of Action, Indications, effects, administration and presentations of the Botulinum Neurotoxin Type A in pediatric patients. Also, we make references to controversial issues surrounding its use. A bibliographic search was done selecting articles and revisions from Pubmed. The key words used were botulinum toxin A, neurogenic bladder, and children. The search was limited to patients younger than 18 years of age and reports written in English in the past ten years.

Ureteral replacement with appendix in pediatric renal transplantation.

Ureteral necrosis is an uncommon complication following RT which can adversely affect outcome. Even though authors agree that the native ureter ought to be preserved, there are cases in which graft function can only be salvaged by ureteral substitution. The scant references in the literature on the use of the appendix for left ureteral replacement in children prompted us to report the following two cases in whom the technique was employed and to assess the evolution of graft function in these patients.

High flow priapism: diagnosis and treatment in pediatric population.

PURPOSE: To present three cases of arterial high flow priapism (HFP) and propose a management algorithm for this condition. MATERIALS AND METHODS: We studied three children with post-traumatic arterial HFP (two patients with perineal trauma and one with penis trauma). RESULTS: Spontaneous resolution was observed in all the patients. The time of resolution by a return to a completely flaccid penis was different: 14, 27 and 36 days in each case. CONCLUSIONS: Absence of long-term damaging effects of arterial HFP on erectile tissue combined with the possibility of spontaneous resolution associated with blunt perineal trauma are suggestive signs for the introduction of an observation period in the management algorithm of HFP. Such a period may help to avoid unnecessary surgical intervention. Thus, these cases reinforce the decision to manage these patients conservatively and avoid angiographic embolization as a first therapeutic choice.

Outcome of renal transplant in patients with abnormal urinary tract.

PURPOSE: To determine whether surgical procedures of the lower urinary tract in patients with uropathies affect evolution of the graft in renal transplantation. METHODS: 156 kidney transplantations were performed in 150 patients with end-stage renal failure due to urologic disorders. The patients were classified into three groups: A, patients who did not require surgery in the lower urinary tract; B, required surgery and preserved adequate bladder function, and C, required surgery due to vesical dysfunction. RESULTS: Graft survival rates at 1 year were 93.38% in group A, 95.45% in group B and 93% in group C. Rates at 5 years post-transplantation were 82.45, 79.85 and 86.58% for each group, respectively (not significant). Complications were vesicoureteral stenosis: 2 in group A, 3 in B and 1 in C; vesicoureteral reflux: 1 in group A, 1 in B and 10 in C; distal ureteral necrosis: 2 cases in group A, 2 in B and 1 in C; upper urinary tract infection: 12, 23.1 and 42.2% in each group, respectively. CONCLUSION: Children with reconstructed urinary tract may be good candidates for kidney transplantation despite the higher frequency of urinary infections. Thus, careful and strict post-surgical urologic follow-up is mandatory.

Transforming growth factor-beta1 in congenital ureteropelvic junction obstruction: diagnosis and follow-up.

OBJECTIVE: To assess the role of transforming growth factor-beta1 (TGF-beta1) in congenital ureteropelvic junction obstruction at diagnosis and during postoperative follow-up. MATERIALS AND METHODS: We conducted a case-control study including 19 patients with a mean age of 6.7 years and 19 matched controls. All patients presented negative voiding cystourethrography, obstructive diuretic renogram and underwent dismembered pyeloplasty. Urinary TGF-beta1 and other markers were measured pre-, intra- and postoperatively. RESULTS: The mean bladder urine TGF-beta1 concentration in obstructed patients prior to pyeloplasty was higher than in controls (92.5 pg/mL +/- 16.8 vs. 35.8 pg/mL +/- 16.2; p = 0.0001). The mean renal pelvic urine TGF-beta1 concentration in the hydronephrotic kidney was higher than in the preoperative bladder urine sample (122.3 pg/mL +/- 43.9 vs. 92.5 pg/mL +/- 16.8; p = 0.036). Postoperative mean TGF-beta1 concentration was significantly lower than preoperative TGF-beta1 (48.7 pg/mL +/- 13.1 vs. 92.5 pg/mL +/- 16.8; p = 0.0001). CONCLUSION: TGF-beta1 is a cytokine leading to renal fibrosis. The measurement of urinary TGF-beta1 could become a useful tool for the diagnosis of obstructive hydronephrosis and the evaluation of the parenchyma function status, pre and postoperatively.