Glanular Venous Malformation in Pediatric Age: An Uncommon Vascular Disorder.

Glanular venous malformations are uncommon in pediatric patients. The diagnosis can be easily achieved by observation, even if color Doppler ultrasound is useful for a better characterization. Abdomino-pelvic MRI is necessary to assess the extension of complex lesions and check for associated anomalies. Several therapeutic options are reported in literature. We report 3 paediatric cases successfully treated by surgery with no complications and functional sequelae. Cosmetic results were satisfactory, with minimal surgical scarring. In our opinion, surgery for small glanular venous malformations is indicated within puberty to prevent traumatic bleeding and psychological impact.

Asynchronous Bilateral Ovarian Torsion: Three Cases, Three Lessons.

BACKGROUND: Ovarian torsion (OT) is a serious condition, and delay in surgical intervention may result in loss of the ovary. Children and adolescents who have suffered from ovarian torsion may be at risk for asynchronous torsion of the contralateral ovary. STUDY OBJECTIVE: Three cases of asynchronous bilateral ovarian torsion were reported to analyse clinical history of three patients, to review the current literature, and to draw a conclusion for future treatment. DESIGN: Case reports and review of the literature. RESULT: When a prepubertal girl presents with an ovarian torsion, several considerations have to be taken in account in order to preserve her future fertility; in particular, the pediatric surgeon/gynecologist has to preserve as much as possible the twisted ovary in addition to considering the fate of the contralateral ovary. SUMMARY AND CONCLUSIONS: Pelvic pain in a young girl has always raised the clinical suspect of an ovarian torsion; the possibility of asynchronous bilateral ovarian torsion is rare, but it is described in the literature and has catastrophic consequences; this condition has to be known and treated in the proper way by pediatric surgeons as well as by gynecologists in order to maximize the future fertility of the young patients.

Hypothesis on etiopathogenesis, congenital or acquired, of an imperforate distal ureter: a case report.

INTRODUCTION: Ureteral atresia is a rare disease usually associated with a non-functioning kidney. Its association with other urinary anomalies is rare. CASE PRESENTATION: In this study we discuss the possibility of congenital or acquired etiology of a right imperforate distal ureter. Here we report the case of 11-month-old white boy with a right ureteropelvic junction obstruction. He underwent a right pyeloplasty when he was 11-months old, and 3 weeks after surgery a cystoscopy was performed. Two months after the first operation, he underwent a right ureteral meatoplasty and a new pyeloplasty. CONCLUSIONS: To the best of our knowledge, few cases of imperforate distal ureter have been described in the literature. The suspicion of a non-patent terminal ureter, occurring during upper urinary tract surgery, must be intraoperatively clarified to preserve the renal function and to avoid more complex surgical approaches.

Bladder urothelial neoplasms in pediatric age: experience at three tertiary centers.

INTRODUCTION: Urothelial bladder neoplasms (UBN) typically occur in patients in their sixth or seventh decade of life while they are infrequent in children and young adults. They occur in 0.1-0.4% of the population in the first two decades of life. Their management is controversial and paediatric guidelines are currently unavailable. OBJECTIVE: To further expound the available data on the outcome of patients younger than 18 year old diagnosed with UBN. STUDY DESIGN: We retrospectively reviewed the files of all the consecutive paediatric patients with UBN treated in three tertiary paediatric urology units from January 1999 to July 2013. Lesions were classified according to the 2004 WHO/ISUP criteria as urothelial papillomas (UP), papillary urothelial neoplasm of low malignant potential (PUNLMP), low-grade urothelial carcinoma (LGUC), and high-grade urothelial carcinoma (HGUC). RESULTS: The table shows the results. Management after TURB varied among centres. One centre recommended only follow-up US at increasing intervals whereas another follow-up US plus urine cytologies and endoscopies, every three months in the first year, and at increasing intervals thereafter. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed disease recurrence or progression. DISCUSSION: UBN is an uncommon condition in children and adolescents and, unlike in adults, its incidence, follow-up and outcome still controversial. Paediatric guidelines are currently lacking and management varies among centres. Gross painless haematuria is the most common presenting symptom. Therefore, this symptom should never be underestimated. US is generally the first investigation and additional imaging seems unnecessary. TURB often allows for complete resection. Lesions are generally solitary, non-muscle invasive, and low-grade (mainly UP and PUNLMP). Ideal follow-up protocol is the most controversial point. Reportedly, recurrence or progression during follow-up is uncommon in patients under 20 years, recurrence rate 7% and a single case of progression reported so far. Accordingly, a follow-up mainly based on serial US might be considered in this age group compared to adults where also serial endoscopies and urine cytologies are recommended. In the selection of the follow-up investigations, it should also be taken into consideration that urine cytology has a low sensibility in the detection of low-grade lesions while cystoscopy in young patients requires a general anaesthesia and hospitalization, and carries an increased risk of urethral manipulation. CONCLUSION: UBN is a rare condition in children. Ultrasound is generally accurate in order to visualize the lesion, and TURB can treat the condition. Lesions are generally low-grade and non-muscle invasive, but high-grade lesions can also be detected. In present series, after TURB, follow-up US monitoring at increasing intervals was used at all centres, follow-up cystoscopies were added in two centres, but with different schedules. Urine cytologies were considered only at one centre. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed recurrence or progression of the disease.

Gait analysis in bladder exstrophy patients with and without pelvic osteotomy: a controlled experimental study.

BACKGROUND: The role of bony pelvic anomalies in bladder exstrophy is long established and has generated many papers addressing walking problems. Biomechanical studies and kinematic gait analysis were performed on very young children. AIM: A direct kinetic gait evaluation has never been performed, nor has the effect of pelvis dimorphism on the upper body been studied. DESIGN: Controlled experimental study. SETTING: Outpatients were studied at the time of periodic follow up. POPULATION: Nineteen patients with bladder exstrophy, age 14±8 years, and twenty-five healthy control participants, age 15±8 years, were enrolled in the present gait analysis study. METHODS: Clinical evaluation and standard gait analysis were performed. RESULTS: Gait analysis deviations between exstrophy patients and controls and between patients that received pelvic osteotomy (OT--6 patients) and those that did not (no-OT--13 patients) were analyzed. Bladder exstrophy significantly affects kinematics and kinetics of trunk, spine, pelvis, knee and foot; in particular: in OT, trunk retroversion, pelvic retroversion and rotation, hip adduction angle and moment, knee flexion and its maximum power during loading response increased, whereas in no-OT, spine angle, pelvic posterior tilt, hip extension, and the external rotation of the foot progression angle increased. All the kinetics parameters analyzed in the study showed lower values in the patient group than in controls. CONCLUSION: . Walking in patients with bladder exstrophy is accomplished by retroversion of the pelvis and deviations mainly in the spine angle in no-OT and in knee flexion in OT. CLINICAL REHABILITATION IMPACT: Gait analysis was shown to be an effective tool for the detection of walking deviations that should be identified early, prompting rehabilitative treatment in order to prevent spine and knee diseases.

Diffuse ganglioneuromatosis and plexiform neurofibroma of the urinary bladder: an uncommon cause of severe urological disease in an infant.

Neurofibromatosis of the urinary tract occurs infrequently: fewer than 70 cases with bladder involvement have been reported to date and of these, only 25 cases occurred in the pediatric population. We describe an unusual case of plexiform neurofibroma and diffuse ganglioneuromatosis of the bladder in a small infant, diagnosed with neurofibromatosis 1 (NF1) at 3 months of age. At the moment, there are no established criteria for the treatment of this rare lesion. Due to the high morbidity, although not very common, bladder involvement should be considered in infants with NF1.

Unusual bladder mass in a 14-year-old boy: bladder paraganglioma.

A 14-year-old boy presenting headache crisis, sweating and palpitation was observed. On ultrasound scan, a 3 × 2.5 cm hypoechoic mass, highly vascularized, was observed arising from the left bladder wall. Magnetic resonance imaging confirmed the mass situated close to the ureteral orifice, with intense peripheral enhancement and a central non-enhanced portion. Left partial cystectomy was performed. Large clear cells, presenting cytoplasmatic granules positive for S100 and chromogranin, were observed at histology. Bladder paraganglioma derives from chromaffin tissue of the sympathic system and it is uncommon in children. The estimated prevalence is very low (0.06% of bladder tumors). Symptomatology is related to the catecholamine production. In pediatrics, prognosis is usually good but long-term follow-up is required.

Renal transplantation in patients with "valve bladder": is bladder augmentation necessary?

INTRODUCTION: Posterior urethral valve is a common cause of renal failure in children. This disorder often results in small bladder and low compliance, which frequently requires bladder augmentation. Herein, we report our experience in 5 children with "valve bladder" who underwent renal transplantation without preliminary bladder enlargement. MATERIALS AND METHODS: Thirteen children with valve bladder undergoing renal transplantation were considered candidates for bladder augmentation. All had oligoanuria at transplantation. In 8 children, bladder augmentation was performed before renal transplantation; in the remaining 5, the decision was postponed until after transplantation. These children underwent transplantation with a ureteral reimplant, and a suprapubic catheter was in place for 2 months. Periodically, renal function, bladder capacity, and compliance were assessed, and renal ultrasonography was performed. RESULTS: At 1-, 2-, 4-, and 6-month follow-up, the 5 children who did not undergo bladder augmentation demonstrated normal renal function, with improved bladder capacity and absence of hydronephrosis. No significant difference was evident between the 2 groups (augmented vs nonaugmented) insofar as renal function, bladder capacity, or hydronephrosis. After transplantation, bladder augmentation was not deemed necessary in any of the 5 children because of complete restoration of clinical and urodynamic parameters. CONCLUSION: Renal transplantation can be performed safely without preemptive bladder augmentation. Ureteral reimplantation is recommended, even in patients with small valve bladders. The decision about the need for bladder augmentation should be made only after normal diuresis is restored.

Arterial changes in children undergoing renal transplantation.

INTRODUCTION: Pathological changes of large arterial walls and the heart have been described in patients with chronic renal failure. The aim of the study was to verify the incidence of arterial changes among our series of pediatric patients with end-stage renal disease undergoing transplantation. PATIENTS AND METHODS: From January 2004 to December 2006, 26 patients (15 boys and 11 girls) of overall mean age of 13.12 years (range=3-27 years) underwent renal transplantation in our department. The pretransplant dialysis treatment was peritoneal in eight and hemodialysis in 18 cases. All patients were divided in two groups according to primary renal disease: group A were 18 patients with congenital urinary malformations; and group B, eight patients with acquired glomerular diseases. In each case, a sample of artery from both donor (aortic patch of kidney) and recipient (iliac patch of graft allocation) was obtained during renal transplantation. The donors were considered to be the control group. RESULTS: Light microscopy showed pathological changes in 12/26 recipient arteries: nine showed light fragmentation of the internal elastic lamina; two, more severe fragmentations; and one, fragmentation of the internal elastic lamina associated with mucopolysaccharide deposits. Pathological changes were more evident in group A than B, but the difference was not significant (P> .05). Among the donor group, 11 patients showed light fragmentation of the internal elastic lamina, but there was no significant difference with the recipients (P> .05). CONCLUSIONS: Among our group of patients, we observed only slight modifications of the arterial wall. These changes were nonspecific, similar to those in a control group of donors matched for age. A possible explanation of these findings may depend on the short time of dialysis before transplantation.

Modification of the sting procedure for vesicoureteral reflux: ureteral repositioning and injection.

OBJECTIVE: Over the past 20 years endoscopic treatment (ET) of vesicoureteral reflux (VUR) has changed the algorithm of reflux management. We describe a modification of the standard subureteral injection (STING) that has contributed to the increased success rate of this procedure. METHODS: Between January 2006 and December 2006 192 children, 5 months to 10 years old (mean age 2.8 years) underwent endoscopic treatment for VUR, with injection of dextranomer/hyaluronic acid copolymer (Dx/HA). Standard STING procedure was used in 165 patients (235 ureters). A modified STING procedure, here described as "ureteral repositioning and injection" (URI) was used in 27 patients (38 ureters). In the URI technique, the needle was inserted as for standard STING; subsequently the distal part of the ureter was raised and levered towards the lumen of the bladder; Dx/HA was then injected. Renal/bladder ultrasound was performed 1 month after treatment and a voiding cystourethrogram (VCUG) at 4-6 months. RESULTS: After a single injection the VCUG showed no reflux in 203 ureters of STING group (86%) and in 34 ureters of URI group (91%). Mean injected volume of Dx/HA was 0.7 ml (0.3-1.8 ml) for STING and 0.4 ml (0.3-0.8 ml) for URI. CONCLUSION: The modified STING we have proposed, presents some advantages. It is very easy to perform and needs less material to inject. The ureteral repositioning into the bladder, with the support of the implanted material, may reconstruct a true flap-valve mechanism, without the risk of ureteral obstruction.

Modification of the sting procedure for vesicoureteral reflux: ureteral repositioning and injection / Modificación del procedimiento de inyección subureteral estándar (STING) para el reflujo vesico ureteral: reposicionamiento ureteral e inyección

Objetive: Over the past 20 years endoscopic treatment (ET) of vesicoureteral reflux (VUR) has changed the algorithm of reflux management. We describe a modification of the standard subureteral injection (STING) that has contributed to the increased success rate of this procedure. Methods: Between January 2006 and December 2006 192 children, 5 months to 10 years old (mean age 2.8 years) underwent endoscopic treatment for VUR, with injection of dextranomer/hyaluronic acid copolymer (Dx/HA). Standard STING procedure was used in 165 patients (235 ureters). A modified STING procedure, here described as “ureteral repositioning and injection” (URI) was used in 27 patients (38 ureters). In the URI technique, the needle was inserted as for standard STING; subsequently the distal part of the ureter was raised and levered towards the lumen of the bladder; Dx/HA was then injected. Renal/bladder ultrasound was performed 1 month after treatment and a voiding cystourethrogram (VCUG) at 4-6 months. Results: After a single injection the VCUG showed no reflux in 203 ureters of STING group (86%) and in 34 ureters of URI group (91%). Mean injected volume of Dx/HA was 0.7 ml (0.3 - 1.8 ml) for STING and 0.4 ml (0.3 - 0.8 ml) for URI. Conclusion: The modified STING we have proposed, presents some advantages. It is very easy to perform and needs less material to inject. The ureteral repositioning into the bladder, with the support of the implanted material, may reconstruct a true flap-valve mechanism, without the risk of ureteral obstruction (AU)

Objetivo: Durante los últimos 20 años el tratamiento endoscópico del reflujo vesicoureteral (RVU) ha cambiado el algoritmo del manejo de esta entidad. Describimos una modificación de la inyección subureteral estándar (STING) que ha contribuido a aumentar el porcentaje de éxitos de este procedimiento. Métodos: Entre enero y diciembre del 2006, 192 niños, entre cinco meses y diez años de edad (edad mediana 2,8 años), fueron sometidos a tratamiento endoscópico del reflujo vesico ureteral con inyección de copolímero de dextranomero/ácido hialurónico (DX/HA). El procedimiento STING estándar se utilizó en 165 pacientes (235 uréteres). Un procedimiento STING modificado, descrito aquí como “reposicionamiento ureteral e inyección” (RUI) se utilizó en 27 pacientes (38 uréteres). En la técnica de reposicionamiento ureteral e inyección se inserta la aguja como para un procedimiento STING estándar y posteriormente se eleva la porción distal del uréter haciendo palanca hacia la luz vesical y entonces se inyecta el DX/HA. Se realizó ecografía renal/vesical un mes después del tratamiento y una cistouretrografía miccional seriada (CUMS) a los 4-6 meses. Resultados: Después de una única inyección la CUMS mostró ausencia de reflujo en 203 uréteres del grupo STING (86%) y 34 uréteres del grupo RUI (91%).El volumen medio de DX/HA inyectado fue de 0,7 ml (0,3-1,8 ml) en el STING y 0,4 ml (0,3-0,8 ml) en el RUI. Conclusiones: La modificación del STING que proponemos tiene algunas ventajas. Es muy fácil de realizar y necesita menos material inyectable. El reposicionamiento ureteral hacia la vejiga, con el apoyo del material implantado, puede reconstruir un auténtico mecanismo de válvula-flap sin riesgo de obstrucción ureteral (AU)

Renal embolization as an alternative to surgical nephrectomy in children.

PURPOSE: Complete renal embolization may be an alternative to surgical nephrectomy. The indications for renal embolization do not differ from those for surgical nephrectomy, but the less invasive nature of the technique is a major advantage. Few case reports are available in the pediatric age group. Our experience showed that complete renal embolization was feasible in pediatric patients with results comparable to those obtained in adults. MATERIALS AND METHODS: Twelve pediatric patients underwent 14 renal embolizations. The indications for embolization were as follows: (1) severe hypertension in 7 patients with end-stage renal failure; in these cases, a unilateral native nephrectomy was recommended prior to renal transplantation; (2) end-stage hydronephrosis in 3 patients with moderate hypertension or recurrent urinary infection; (3) nephrotic syndrome in 1 patient; or (4) ablation of an irreversibly rejected renal allograft in 1 patient. The embolization was performed under epidural anesthesia in 10 patients and under general anesthesia in 2 patients, by means of a polyvinyl alcohol injection with hemostatic gelatin powder and placement of coils. Postembolization course was followed. RESULTS: The embolization was successful in all 12 patients. In 1 patient, the procedure had to be repeated as a small accessory artery had revascularized the upper pole. In another patient, the procedure was bilateral in 2 separate sessions. In 10 patients, severe flank pain required narcotic analgesia. Two patients had fever. None had hypertension peaks. Median hospital stay was 4 days. At mean follow-up of 16 months, the results were stable. CONCLUSION: Renal embolization can avoid surgical nephrectomy also in pediatric patients. The advantages are less morbidity and shorter hospital stay. Our results in the short and medium term were equal to those of surgical removal. The procedure appeared to be safe and minimally invasive.

[Efficacy and safety of endoscopic treatment of ureteral stones in pediatric age].

Ureteroscopy procedures in pediatric age are becoming more and more common thanks to the availability of smaller caliber instruments, and of improved endoscopic techniques. The efficacy of this procedure in pediatric age is still discussed nowadays. This paper aims at reviewing all cases of ureteral lithiasis treated by ureteroscopy plus intracorporeal lithotripsy (ULT), as well as verifying efficacy and safety of this procedure in pediatric age. MATERIALS AND METHODS. From July 2002 to May 2006, 37 patients (26 female, 11 male; mean age 7.4 years; range 2-17) were treated by ULT for ureteral stones: 30 in distal, 4 in middle and 3 in proximal ureter. Median size of stones was 7mm (range 3-13mm). Dilation of the ureteral meatus was necessary in 2 patients only. Endoscopic procedure was similar to adult patients. Outcomes were statistically compared with current literature data. RESULTS. In 36 (97.3%) out of 37 patients ULT proved successful. All patients having stones in distal (30) and middle (4) ureter were stone-free at the end of treatment. Stone migration into the kidney pelvis occurred in 1 patient with proximal ureter stones (66.7% stone-free rate): an ESWL treatment was therefore performed. 1 case only (2.7%) developed a perioperative complication (stone migration). Hematuria and flank pain in 4 patients (10.8%) were the most common reported post-operative complications. A stone-free state was confirmed at 1 and 3 months for all 36 patients. There was no evidence of ureteral strictures and/or ureteral refluxes. CONCLUSIONS. Smaller caliber ureteroscopes confirmed ULT as the first-choice treatment procedure in children affected by ureteral lithiasis, thanks to its efficacy and safety.

In vivo bladder regeneration using small intestinal submucosa: experimental study.

Significant side effects are correlated with bladder augmentation. Recently, small intestinal submucosa (SIS) has been proposed for clinical use. The efficacy of SIS bladder regeneration was studied in a porcine experimental model. Partial cystectomy (40-60% of bladder wall) was performed and replaced by SIS graft. Animals were planned to be killed at 2 weeks, 5 weeks and 3 months. Bladder capacity at 40 cmH(2)O pressure and macroscopic graft morphology were assessed before and after SIS implant. Histological examination was carried out with computer assisted morphometric analysis for collagen/smooth muscle ratio. Student's t test was adopted for statistical analysis. Two piglets died on the 9th and 10th post-operative day due to urinary peritonitis. The remaining piglets were killed after uneventful post-operative period at 5 weeks (two animals) and 3 months (two animals). The bladder capacity was reduced (-18%) at the 5 week follow-up and quite similar to the pre-operative volume (+2.5%) at the 3 months control. No diverticular formation, bladder calculi, mucus and urinary infection were found. The SIS graft resulted not significantly contracted. Histology at 10 days showed SIS membrane lined by transitional epithelium islands with some capillaries. At 5 weeks, transitional epithelium was fully covering the graft; new blood vessels and fibroblasts with smooth muscle cells were observed. At 3 months, the SIS was not evident. Two layers were defined: inner transitional epithelium, outer collagen with fibroblasts and muscular bundles. Computer assisted morphometric analysis showed collagen/muscle ratio 70/30% (normal bladder=56/44%, P<0.05). The SIS was effective as a scaffold for bladder wall regeneration in four out of six animals. Long-term studies are required to confirm the efficacy of the newly developed wall and for eventual clinical use.

First paediatric experience of a new device for "non-endoscopic" periurethral injection in urinary incontinence.

The results of endoscopic treatment for urinary incontinence (ETUI) depend on the condition of the urethral mucosa and on the length of the urethra. ETUI is quite difficult to perform in female patients, and, in general, in cases of scarred urethral mucosa. A new device (Zuidex, Q-Med, Uppsala, Sweden) has recently been designed for the "non-endoscopic" treatment of urinary stress incontinence in women. Three paediatric cases are described hereunder. Three patients were treated using Zuidex: two patients (two girls aged 8 and 18) on intermittent catheterization for neurogenic bladder, and one 11-year-old girl, with epispadias, who had already undergone bladder neck reconstruction (Young-Deese). Zuidex is a special implacer for dextranomer implants. It consists of four syringes filled with dextranomer, one implacer, and four needles (25 gauges). Once the device is positioned, the four injections are performed. At the end of this procedure, four implants are symmetrically positioned at four points of the urethral wall, increasing the outlet resistance. In the follow-up phase (5-13 months), the increase in the continent period was +56, 50 and 36%; the increase in bladder capacity (leak volume point) was 40, 28 and 27% in the three patients. Although the new device for "non-endoscopic" treatment of urinary incontinence has been designed for women, the size of the implacer virtually allows its use in any paediatric patient who is above the age of six. Our early experience indicates that this new device could play an important role in the treatment of urinary incontinence in paediatric age.

Predictive risk factors for chronic renal failure in primary high-grade vesico-ureteric reflux.

OBJECTIVE: To evaluate and define the risk factors predictive of chronic renal failure (CRF) in children with severe bilateral primary vesico-ureteric reflux (VUR), observed within the first year of life and with a long follow-up. PATIENTS AND METHODS: The study comprised 50 patients presenting with grade 3-5 bilateral VUR diagnosed in the first year of life; 12 were suspected prenatally and confirmed shortly after birth, before any urinary tract infection (UTI). The mean (range) follow-up was 6.3 (1-16) years. The variables considered within the first year of life were: gender, prenatal diagnosis with no UTI, number of febrile UTIs, serum creatinine and urea nitrogen levels, metabolic acidosis, proteinuria, 24-h urine output, hypertension, bilateral renal length on ultrasonography and renal scarring on renal scintigraphy. CRF was defined as a creatinine clearance of <80 mL/min/1.73 m(2) at the last follow-up. The results were assessed using univariate and multivariate analyses (backward-stepwise multiple regression) of the selected variables. RESULTS: CRF was detected at the last follow-up in 27 patients (54%), all boys, while renal function was normal in 23 (46%; seven girls). None of the 12 patients with prenatal diagnosis had UTI, but six had CRF. Febrile UTI was the presenting symptom in 38 (76%) patients and 17 (34%) of them had renal scarring. There was no significant difference between the prenatally detected VUR and febrile UTI group in the outcome as CRF. The univariate and multiple regression analysis showed that the first serum creatinine threshold of >6 mg/L before 1 year old was the most significant risk factor for CRF (P < 0.001; odds ratio 1.25). CONCLUSIONS: Children with primary bilateral high-grade VUR and a serum creatinine of > 6 mg/L in the first year of life have a significant risk of developing CRF in the long-term. Prenatal diagnosis and postnatal febrile UTI do not modify the outcome for renal function.

Hydronephrosis due to malrotation in a pelvic ectopic kidney with vascular anomalies.

A particular case of hydronephrosis in ectopic kidney due to a malrotation and vascular anomalies in a young girl is described. The patient was previously operated for ureteropelvic junction obstruction at the age of two. Clinic and radiographic and pathologic findings are discussed and the literature is reviewed.

Renal damage in vesico-ureteric reflux.

OBJECTIVE: To detect the different extent of renal parenchymal involvement in primary vesico-ureteric reflux (VUR), and to evaluate the relationship between VUR grade, patient age and different patterns of parenchymal damage. PATIENTS AND METHODS: This blinded retrospective study included 197 consecutive children (mean age 4.26 years, range 1 month to 13 years) with primary VUR detected by voiding cysto-urethrography (VCUG), 99mTc-dimercaptosuccinic acid (DMSA; 120 MBq/1.73 m2) renal scintigraphy, with scanning for 3 h after intravenous injection. An abnormal DMSA scan was classified into three subtypes: cortical defects as a single scar (SS), multiple cortical scarring (MS) and diffuse reduced uptake with small renal size. Renal absolute uptake (AU), and split-kidney relative uptake were evaluated in refluxing and nonrefluxing renal units, and correlated with parenchymal damage and patient age. Student's t-test and the chi-square test were used for the statistical analysis. RESULTS: In all, 282 refluxing and 112 nonrefluxing units were assessed. Renal damage was detected in 188 of 282 units with VUR (67%) and in 18 of 112 (16%) contralateral nonrefluxing kidneys. The mean AU was 18.7% in kidneys with VUR and 29% in nonrefluxing units (P < 0.001). The mean (SD) AU decreased from lower to higher grades of VUR, i.e. grade 0 VUR (group A), 28.97 (9.71); grade 1-3 (group B), 21.28 (8.33); grade 4-5 (group C), 14.78 (8.02). The differences were statistically significant (A vs B, B vs C, both P < 0.001). Renal damage was differently distributed in the three groups: 69 of 109 kidneys (63%) in group C (MS prevalent), 39 of 173 (22.5%) in group B (SS prevalent) and 17 of 112 (15.2%) in group A. There was no significant difference in the distribution of renal damage subtypes in patients aged < or > 2 years (SS 19.6% vs 17.9%, MS 29.6% vs 30.1%, small size 48.2% vs 46.3%). The VUR was severe (group C) in 65% of patients aged < 2 years and in 46% aged > 2 years (chi-square, P = 0.016). CONCLUSIONS: VUR is commonly associated with renal damage. Age (< or > 2 years) did not significantly influence the kidney lesion subtype. Reduced parenchymal function (AU) progressively decreased with the severity of VUR. Focal MS, reduced size and relative uptake were significantly more common in severe VUR, leading to multifocal lesions and hypo-dysplasia. Renal scarring was present in up to 15% of contralateral nonrefluxing kidneys. Severe VUR behaved differently from lesser VUR in the renal scan parenchymal uptake.

[Role of the endoscopic treatment of vesicoureteal reflux. A 16-years' experience]. / Il ruolo del trattamento endoscopico nella cura del reflusso vescico-ureterale. Esperienza di 16 anni.

AIM: Vesico-ureteral reflux (VUR) is the most common urological malformation in pediatric age; nevertheless its optimal management remains controversial. Until early 80s, treatment guidelines for VUR recommended the use of antibiotic prophylaxis as initial therapy, with surgical repair for patients with persistent VUR. Endoscopic treatment of VUR has gained popularity and has proved successful in a high percentage of cases, but its role in the clinical practice remains to be established. METHODS: In this paper, our series of 1029 patients and 1478 refluxing ureters, treated from January 1986 to June 2001, is presented. Reflux ranged from grade II to grade IV. In the first 14 cases Teflon was injected. After 1989 bovine collagen was used in 442 children and, since 1996, Deflux, a nonallergenic, biodegradable dextranomer, in 573 cases. All patients were clinically evaluated for possible voiding dysfunctions. All patients completed a 12 month follow-up period. RESULTS: After 1 or 2 injections, a voiding cystogram showed no VUR (or grade I) in 1123 ureters (76%). In grade II, III and IV success rates were, respectively, 87%, 73% and 48%. Complications were minimal (0.5%). CONCLUSION: These results confirm that endoscopic treatment of VUR is a valid alternative to "open surgery" and to antibiotic prophylaxis. Failure of treatment is usually due to dislocation of the implanted material, secondary to voiding dysfunction. In conclusion, we recommend the endoscopic treatment in the majority of VUR, for the short hospital stay, the absence of significant complications and the high success rate. In grade IV VUR, the use of endoscopic treatment is still questionable. Patients with voiding dysfunction should be identified and treated with appropriate therapy prior to attempt an endoscopic treatment of VUR.