Assessment of serum prostate specific antigen in childhood.

OBJECTIVE: To investigate serum prostate specific antigen (PSA) levels with age and sex in childhood. SUBJECTS AND METHODS: This prospective study included 205 children (123 boys, 82 girls; mean age 59.27 months, sd 3.78, range 2 days to 204 months) with no urogenital or endocrine disorders. PSA levels were measured using a highly sensitive, "third-generation" PSA (time-resolved immunofluorometric) assay, able to detect PSA levels of > or = 1 ng/L (0.001 ng/mL). Children were divided into four groups by age, i.e. A (0-12 months; 34 boys/20 girls); B (13-48, 37/21); C (49-144, 41/32); and D (> 144, 11/9). The data were analysed statistically using analysis of variance. RESULTS: An accurate measurement of PSA was possible in both sexes using the assay. The median (sd, range) PSA level in boys was 38.41 (1.318, 1-2768) ng/L, and in girls 4.059 (1.392, 1-287) ng/L. There were no significant differences between girls at all age groups, or between the sexes for groups A-C, but levels were significantly higher in boys in group D (30 times that in girls), at 142.59 (1.53) and 4.85 (1.58) ng/L (P < 0.01). CONCLUSIONS: PSA levels do not differ significantly between boys and girls until 12 years old, after which there is a significant and steep increase in PSA in boys, reflecting the development of the prostate. Assessing PSA in children could be used as a potential marker in the diagnosis and follow-up of urogenital disorders.

Pelvi-ureteric junction obstruction by crossing renal vessels: clinical and imaging features.

OBJECTIVE: To present the characteristic clinical and imaging findings of pelvi-ureteric junction (PUJ) obstruction caused by crossing renal vessels (CRV), as it presents particular features within the spectrum of congenital hydronephrosis. PATIENTS AND METHODS: Between April 1982 and December 2000, 384 children underwent surgery for PUJ obstruction. In 71 (18.5%; mean age 8.5 years, range 2 months to 14 years; 49 aged> 5 years), the obstruction was caused by CRV. The data collected from the medical records of these patients were analysed for their clinical presentation and imaging findings, i.e. ultrasonography (US), intravenous urography (IVU) and diuretic renography. RESULTS: The main presenting symptom was recurrent renal colic (pain, nausea, vomiting) in 59%, followed by urinary infection (UTI) in 20%, gross haematuria in 11% and an incidental diagnosis in 10%. By contrast, in the 313 children with intrinsic PUJ obstruction, renal colic was present in only 10.5%. Moreover, from 1991 to 2000, when the use of prenatal US became widespread, hydronephrosis was detected prenatally in 42 of 212 children (20%) with intrinsic PUJ obstruction, but in only two of 31 (6%) with obstruction by CRV. However, in 10 children with CRV operated on during this period, prenatal US had shown mild hydronephrosis (< 15 mm), which during the follow-up decreased until the children became symptomatic after 5-9 years (eight renal colic, two UTI). US during acute symptoms showed significant hydronephrosis (> 25 mm), and colour Doppler US of two patients directly showed the CRV. In all 71 children with CRV obstruction diuretic IVU and renography during the acute symptoms had an obstructive pattern, and in 24 renal colic was reproduced during the examination. The differential kidney function was < 40% in 11 children who presented with UTI; two required nephrectomy and in the remaining 69 an Anderson-Hynes pyeloplasty, after which none had an episode of renal colic or UTI during a mean (range) follow-up of 10.2 (2-20) years. CONCLUSIONS: PUJ obstruction by CRV should be suspected in older children presenting with recurrent renal colic and hydronephrosis. Good kidney function is expected in most of these children, despite their age, because the vascular obstruction is intermittent. Mild prenatal hydronephrosis that could decrease postnatally does not exclude the possibility of vascular obstruction, which may later become symptomatic. Imaging (US, diuretic IVU and renography) during an episode of pain is essential and colour Doppler US could help to establish the diagnosis in these cases. Knowing that a child has a CRV is important for choosing an open surgical approach rather than endoscopic pyelotomy, to avoid potential complications

The long-term outcome of bilateral Cohen ureteric reimplantation under a common submucosal tunnel.

OBJECTIVE: To analyse the results of bilateral Cohen reimplantation under a common submucosal tunnel, over an 18-year period. PATIENTS AND METHODS: We retrospectively examined 102 children (35 boys and 67 girls, median age 5.5 years, range 0.5-13.5) who underwent bilateral antireflux ureteric reimplantation from 1983 to 2000 with a modified Cohen technique, re-implanting both ureters under a common submucosal tunnel in the mid-trigonal area, to treat primary vesico-ureteric reflux (VUR, 99 patients) or obstructive megaureter (three). The mean (range) follow-up was 10.6 (2-18) years. RESULTS: The operation was successful in 198 of 204 (97%) ureters. One patient had vesico-ureteric stenosis in one ureter and was re-operated successfully. In two ureters in two different patients there was transient stasis after surgery caused by oedema within the tunnel, which gradually resolved. Two ureters in two other patients had reflux after surgery, which resolved spontaneously after 12 and 24 months, respectively. A 6-month old baby had anuria after surgery because of acute compression of both ureters within a narrow tunnel; this patient was re-operated, the tunnel widened and the obstruction resolved. None of 82 patients who had reached school age by the time of their last follow-up showed signs of voiding dysfunction. CONCLUSIONS: The modified bilateral Cohen reimplantation with both ureters under a common submucosal tunnel offers very good long-term results in curing VUR or obstructive megaureter. Crossing one ureter upon the other within the tunnel does not predispose to long-term obstruction. From these results we recommend it as a reliable technique for surgically treating bilateral VUR or obstructive megaureter.

Outcome of the distal ureteric stump after (hemi)nephrectomy and subtotal ureterectomy for reflux or obstruction.

OBJECTIVE: To assess the outcome of the distal ureteric stump (DUS) after (hemi)nephrectomy with subtotal ureterectomy. PATIENTS AND METHODS: The records of 89 patients (median age 2.7 years, range 0.25-12) who underwent nephrectomy (24) or heminephrectomy (65) with subtotal ureterectomy between 1982 and 1996 were reviewed retrospectively for symptoms caused by the DUS. The mean follow-up was 9.8 years. Nephrectomy was undertaken for a poorly functioning dysplastic (in nine), scarred (in 10) or hydronephrotic (in five) kidney, and heminephrectomy for a poorly functioning upper moiety associated with ectopic ureterocele (in 26) or stenotic hydroureter (in 15), or for a poorly functioning lower moiety associated with reflux (in 24). There were 38 refluxing and 51 non-refluxing ureteric stumps. Two additional patients primarily operated elsewhere were referred with DUS symptoms. RESULTS: Only one patient had a symptomatic DUS, with recurrent haematuria and bacteriuria. The two patients referred from elsewhere presented with febrile UTIs. The first had been left with a long refluxing stump opening ectopically into the urethra, and the second with a long stump which was converted from nonrefluxing to a refluxing stump when he developed dysfunctional voiding. Surgical excision of the distal stump was curative in each case. CONCLUSIONS: The risk of a symptomatic DUS in patients who undergo subtotal ureterectomy in conjunction with (hemi)nephrectomy is very low, with no difference between refluxing and nonrefluxing stumps. Long ureteric stumps and dysfunctional voiding may cause symptoms. Because of the low morbidity associated with a short ureteric stump, we recommend subtotal ureterectomy in children who undergo (hemi)nephrectomy for reflux, vesico-ureteric obstruction or ectopic ureterocele associated with a poorly functioning kidney or kidney moiety.

Renal cell carcinoma in children under 14 years old: long-term survival.

OBJECTIVES: To assess the treatment and long-term survival of children under 14 years old operated upon for renal cell carcinoma (RCC). PATIENTS AND METHODS: The records of five patients (aged 2, 4, 6, 9 and 13 years) who had been treated for RCC between 1982 and 1993 were reviewed. All had undergone nephrectomy with (two) or without (three) regional lymphadenectomy. After surgery four patients received chemotherapy (vincristine with actinomycin-D, three, vinblastine, one), and two with advanced-stage disease received other agents (interferon alpha, interleukin-2). They were followed for 5 to 15 years. RESULTS: Three patients with stage I-II RCC were well at 13, 15 and 15 years after treatment. Of the two patients with regional lymph node involvement (stage III), one was well 5 years after surgery while the other developed hepatic, lung and bone metastases, and died 2 years after presentation. CONCLUSION: The prognosis and long-term survival of children under 14 years old with RCC is very good for those with low-stage tumours. Nephrectomy with complete tumour extirpation is the main mode of treatment. For advanced-stage tumours, the role of adjuvant chemotherapy and/or biological agents must be defined more clearly.

Effects of submucosal Teflon paste injection in vesicoureteric reflux: results with 1- and 2-year follow-up data.

One hundred refluxing ureters with grades II (n = 65), III (n = 27) and IV (n = 8) vesicoureteric reflux (VUR) were treated with endoscopic submucosal polytetrafluoroethylene (Teflon) paste injection. Reflux stopped in 77 ureters after a single injection and in 13 ureters following a second injection. Two ureters remained with minimal (grade I) residual reflux, whilst in another 5 improvement from grades III and IV to grade II reflux was noted. In 3 ureters reflux remained unchanged, because of lateral ectopia of the refluxing ureteric ostium, hindering the injection of Teflon into the correct position. Re-evaluation at 1 year postinjection, of 48 previously cured ureters showed recurrence of reflux in 1 (2%), but no further recurrences were noted in 19 ureters reevaluated after 2 years.

Urothelial tumors of the bladder.

Neoplasms originating from the transitional epithelium of the urinary bladder are rare in children. This paper examines the clinical, epidemiological and histopathological characteristics of 3 such cases. The patients were males aged 4, 8 and 14 years at the time of diagnosis. Total painless hematuria was the presenting symptom in all of them. There was no history of previous exposure to dyes or other chemicals, but 1 patient was a systematic cigarette smoker. All tumors were solitary, noninfiltrating, grade 1 neoplasms. Following their local resection, no recurrences were noted 3-8 years postoperatively. This review supports the contention that transitional cell neoplasms of the bladder are less aggressive in children and, therefore, their local management constitutes an adequate therapeutic approach.

Paediatric urolithiasis in Greece.

A group of 44 patients, aged from 10 months to 14 years, underwent surgery for urinary calculi over a 7-year period (1982-1989). Eleven patients had bilateral or multiple calculi (total number of stones = 55, 20 of which were staghorn). Metabolic disorders (n = 25) and Proteus urinary infection (n = 15) were the 2 factors most often associated with lithiasis. Of the 55 stones, 51 were removed by open surgery. Complete stone clearance was achieved in 29 of 36 kidneys. Follow-up periods in the remaining 7 renal units (with small residual fragments) ranged from 3.5 to 7.5 years (mean 6.2) and revealed stone recurrence in only 2 patients. Evaluation of childhood urolithiasis should include thorough metabolic investigation and sound surgical judgment; effective management requires prolonged post-operative follow-up.

Ostioplasty: a simple technique for ureterovesical reconstruction following intravesical ureterocelectomy.

A simple operation for the management of simple, i.e. intravesical, ureteroceles, which we have named 'ostioplasty', is presented. After unroofing the ureterocele, the retracted, gaping ureteric ostium is advanced and fixed medially to the center of the bladder trigone with three 5-0 polyglycolic acid sutures. The exposed intravesical ureter is covered with a new mucosal layer formed from the mobilized lateral edges of the unroofed ureterocele, sutured together over the ureter with 5-0 polyglycolic acid. Ostioplasty has been used in 5 patients so far with excellent anatomic and functional results. It is a simple and valuable surgical option to standard ureterovesical reimplantation after excision of a simple ureterocele, provided that the ureterocele is of moderate size and the bladder trigone retains good muscular support.

Surgical treatment of ectopic ureteroceles and the role of heminephrectomy with subtotal ureterectomy.

We evaluated 16 patients, 2 weeks to 8 years of age (median: 18 months), operated on for ectopic ureterocele. Five patients, in whom the upper kidney, drained by the ureter with the ureterocele, was viable, were submitted to excision of the ureterocele with reimplantation of the double ureter (n = 4) or high ureteroureterostomy (n = 1). A 2-week-old baby with a non-functioning kidney was treated by nephroureterectomy. The remaining 10 children with a non-functioning upper part of a duplex kidney were submitted to heminephrectomy with subtotal ureterectomy. In this group of patients no problems arose from the retained ureteral stump or the decompressed ureterocele, and vesicoureteral reflux accompanying the ureterocele resolved postoperatively in 6 of 10 ureters.

Evaluation of open surgery for staghorn calculi in children.

We evaluated the results of open surgery in 19 children with staghorn calculi. The median age was 3.5 years (range 10 months to 14 years). One patient had bilateral calculi, hence 20 renal units were operated upon. Stone clearance was achieved in 19 cases by means of a Gil-Vernet pyelocalycolithotomy, alone (n = 10) or in combination with limited radial nephrotomies (n = 9). Extended nephrolithotomy was performed in only 1 case. Complete stone clearance was achieved in 13 kidneys (65%). Long-term follow-up showed that there was no stone recurrence in any of the 13 renal units rendered completely stone free at surgery. There was symptomatic stone recurrence in 1 of the remaining 7 renal units with small residual fragments left behind, while in 2 others the residual fragments were voided spontaneously. Preoperative and postoperative assessment with 99mTc-DMSA renal scans confirmed that no functional loss resulted in any of the operated kidneys. Open surgery proved to be safe and effective in the treatment of staghorn calculi in children.

Microvascular changes in the early stage of reflux pyelonephritis. An experimental study in the pig kidney.

Renal microvascular changes were studied in the pig kidney during the initial stage of reflux pyelonephritis. In 10 piglets vesicoureteric reflux was surgically induced. The animals were then infected with a strain of Escherichia coli and sacrificed 2 weeks following the initiation of infection. Following injection of the kidneys with Microfil, microvascular changes were investigated by a combined stereomicroscopic, microradiographic and histological technique. Renal microcirculation was found to be impaired in the areas involved in the acute inflammatory process, owing to the compression of glomeruli, small peritubular capillaries and vasa rectae by the ensuing interstitial oedema. These findings indicate that acute focal ischaemia caused by microvascular obstruction could be an important factor in the mechanism of renal damage in reflux pyelonephritis.

Coincident vesical transitional cell carcinoma and prostatic carcinoma. Clinical features and treatment.

Twenty-two patients with vesical urothelial carcinoma associated with prostatic carcinoma were reviewed. They represented 1.5% of the bladder and prostatic tumours treated in our department within a 12-year period from 1968 to 1979. Their management included several treatment policies, based on the separate assessment of each tumour variant. For non-infiltrating bladder tumours, transurethral tumour resection was combined with hormonal treatment, external radiotherapy or resection of the prostate depending on the stage of the prostatic tumour. Radical cystoprostatectomy was performed for two cases of infiltrating bladder tumour with well localised prostatic tumours. A conservative primary approach seems justifiable in the management of double carcinoma of the bladder and prostate. The coincidence of bladder urothelial carcinoma and prostatic carcinoma per se is not an adverse prognostic factor; prognosis is more closely related to the pathological stage and grade of the bladder tumour. Cystoprostatectomy for patients with infiltrating bladder tumours could be curative, in selected cases, for the prostatic cancer as well.

Multilocular cyst of the kidney.

The case of a 17-month-old girl with a multilocular renal cyst is presented. Clinically and radiologically the cyst simulated a Wilm's tumor and was treated by nephrectomy. Simple excision may be equally effective in a few cases provided a correct preoperative diagnosis of the nature and extent of the lesion can be made.