[Posterior urethral valves: prenatal diagnosis, neonatal data and outcome]. / Les valves de l'urètre postérieur. Etat des lieux en Languedoc-Roussillon de 1998 à 2007 : données anténatales, néonatales et devenir à moyen terme.

AIM OF THE STUDY: To evaluate the impact of prenatal diagnosis on the epidemiology and outcome of children with posterior urethral valves (PUV), considering that today termination of pregnancy may be proposed in the most severe cases. PATIENTS AND METHODS: Forty-three cases of patients with PUV were diagnosed between 1998 and 2007 in the Languedoc-Roussillon region. In this study, we detailed the prenatal data and postnatal outcome of those patients with a mean follow-up period of 7.6 years. RESULTS: Medical interruption of pregnancy was performed in 15 severe cases. One death in utero was also observed. Twenty-seven patients were managed postnatally and one child died during the neonatal period because of lung hypoplasia. For the 26 remaining patients at the end of the follow-up period, 5 had mild renal insufficiency with a creatinine clearance calculated with the Schwartz formula of less than 80 ml/min/1.73 m2. One reached end-stage renal failure at the age of 7 years. Proteinuria and hypertension were rare. DISCUSSION AND CONCLUSION: Today, because of the increase in medical termination of pregnancy in the most severe cases, most of the children born alive with PUV experienced a better renal prognosis when compared with previous data. Prenatal diagnosis and therapeutic progress significantly modified the epidemiology and outcome of this disease. Nevertheless, the best predictor of renal outcome remains renal function at 1 year of age.

Ultrasonography of the spermatic cord in children with testicular torsion: impact on the surgical strategy.

PURPOSE: Many surgeons advocate systematic exploration for acute scrotum rather than risking a misdiagnosis of testicular torsion. Study of testicular vascularization with color Doppler sonography (CDS) can be inaccurate, leading to dangerous false-negative results. We determine whether direct visualization of the twisted cord during emergency high resolution ultrasonography (HRUS) is a reliable sign to diagnose the torsion and whether its absence can dispense with unnecessary surgery. MATERIALS AND METHODS: From 1993 to 2002 an average of 35 patients per year presented with acute scrotum, and 44 patients had spermatic cord torsion. CDS and HRUS were performed in all cases. Transversal and longitudinal scans on both sides of the scrotum permitted comparison of testicular echogenicity, size and vascularization. The spermatic cord was studied along its complete length to detect spiral twist. The surgical findings were correlated with the preoperative results. RESULTS: Spermatic cord torsion at surgery was confirmed in all 44 cases. The time lost by the examination was never more than 30 minutes. Intratesticular blood flow was absent in the affected testis in 31 cases, and CDS was unreliable in the others. In all cases, regardless of CDS findings, HRUS succeeded in detecting the twist as a snail shell-shaped mass measuring 11 to 33 mm. CONCLUSIONS: The finding of a twisted spermatic cord is a highly reliable sign for the diagnosis of testicular torsion. Whereas normal intratesticular perfusion does not dispense with emergency exploratory surgery, direct and complete visualization of a nontwisted spermatic cord strongly indicates that surgery is unnecessary. Strict conditions are required, including time spent on HRUS should not exceed 30 minutes, which generally can only be achieved by a senior pediatric radiologist.

[Cryptorchidism: the point of view of a pediatric urologist]. / La cryptorchidie: le point de vue de l'urologue pédiatre.

Cryptorchidism is a very common anomaly of testicular migration, different from ectopy, anorchidy or retractile testis. Physiopathology of cryptorchidism is now well known. Hypogonadotrophic hypogonadism during pregnancy is mostly admitted. Recent epidemiologic studies show a significant increase due to toxic environmental factors, in particular pesticide. Cryptorchidism is most often isolated but polymalformatives entities must be eliminated, requiring sometimes hormonal or genetic investigations. Diagnosis is firstly clinical but coelioscopy adds accuracy and fiability. Infertility and cancer are the two majors risks of cryptorchidism, but their physiopathological mechanisms are still debated. It is not yet clear, in particular as far as the risk of infertility is concerned, if the testicular damage is primitive or (and) deteriorates with age. Medical and surgical treatments are now rather well codified. If, so far, there is no consensus about the age of management of cryptorchidism, many data of the literature lead pediatric urologists to manage these boys as soon as they are two or three.

[Lower pole pedicle in a series of 84 pyelo-ureteral junction syndromes surgically treated in children]. / Le pédicule polaire inférieur dans une série de 84 syndromes de la jonction pyélo-urétérale opérés chez l'enfant.

OBJECTIVE: To evaluate the involvement and consequences of the lower pole pedicle (LPP) associated with ureteropelvic junction syndrome. MATERIAL AND METHOD: Retrospective study in 81 children presenting a total of 84 ureteropelvic junction syndromes operated consecutively between 1994 and 1998. Urinary tract ultrasound and cystography were systematically performed. Renal scintigraphy (DTPA or MAG 3) was performed in 80 children. Preoperative intravenous urography was performed in 60 children. LPP was considered to be present when its participation in the obstruction was confirmed intraoperatively (Anderson Hynes technique with uncrossing of the vascular pedicle). RESULTS: Group I: a LPP was revealed in 24 kidneys (28.5% of cases), 17 left kidneys and 7 right kidneys, in 14 boys and 10 girls, with a mean age of 4 years (range: 2 months-14 years). Group II: 60 kidneys without LPP (71.5% of cases), 32 left kidneys and 28 right kidneys, in 40 boys and 17 girls, with a mean age of 2 years (range: 1 month-15 years). The most frequent presenting complaint was recurrent low back pain in 58% of cases in group I (14/24) and 5% of cases in group II (3/60). The mean age at diagnosis was 6 years. Hydronephrosis was detected by antenatal ultrasound in 33% of cases in group I (8/24) and in 72% of cases in group II (43/60). Kidney function in group I was greater than 40% in 19 patients, between 20 and 39% in 2 patients and less than 20% in 2 patients. These results were not influenced by age at diagnosis and were not significantly different from those observed in group II. Renal malrotation was observed in 2 cases in group I and in 12 cases in group II. Histology of the junction revealed nonspecific fibrosis in the same percentage of cases (91%) in the two groups. The mean follow-up was 15 months (range: 2 months-5 years). No surgical failure was observed. CONCLUSION: Ureteropelvic junction syndrome associated with a LPP appears to present later with recurrent low back pain in older children. It does not worsen the functional prognosis of the affected kidney. LPP can be visualized by duplex ultrasound. It may act as an inducer of obstruction by aggravating a pre-existing abnormality of the ureteropelvic junction. When LPP is associated with isolated dilatation of the pyelocaliceal cavities, the risk of subsequent decompensation requires closer ultrasound surveillance, until puberty.

[Diabetes and urination disorders]. / Diabète et troubles mictionnels.

Diabetic neuropathy of can induce multi-organ dysfunction. The diabetes simultaneously has profound repercussions on gastrointestinal, sexual and erectile functions. One of the main sequelae of diabetic neuropathy is autonomic neuropathy affecting the vesicosphincteric control. The objective of this study was to review the epidemiological, clinical, laboratory and therapeutic data concerning voiding disorders observed in diabetes. Although the therapeutic management of an isolated voiding disorder in diabetics still remains symptomatic, it raises aetiological problems due to the comorbidity, particularly prostatic obstructive syndromes in men, pelvic dysfunction in women and ageing. Diabetic patients in renal failure also present specific vesicosphincteric disorders which are reviewed. Diabetic patients should be more systematically screened for the development of diabetic bladder disease, especially for associated factors which participate in its clinical expression. This implies extreme caution in the management of benign prostatic hyperplasia in the case of comorbidity, to avoid deteriorating a sometimes fragile detrusor-sphincter equilibrium. Diabetic detrusor hyperactivity must be better known in order to be more effectively detected. Pharmacological treatment of this condition raises problems related to detrusor hypocontractility also related to diabetic bladder disease. Clinical examination should be able to select those patients requiring further urodynamic studies in order to assess the individual detrusor-sphincter equilibrium. These investigations are required when surgical treatment of an associated urological or gynaecological disorder is considered.

[Prenatal diagnosis of bilateral polycystic kidney disease in a twin pregnancy]. / Lésions rénales multikystiques bilatérales de diagnostic anté-natal au cours d'une grossesse gémellaire.

Polycystic renal dysplasia is a lethal malformation when it is bilateral. The authors report a rare case of polycystic dysplasia observed in both foetuses of a twin pregnancy, one of whom survived despite bilateral polycystic kidney disease. These biamniotic monoplacental twins were delivered prematurely at 33 weeks of amenorrhoea. The diagnosis was made by antenatal ultrasound. The first twin presented bilateral renal lesions: right polycystic kidney, segmental polycystic dysplasia of the superior pole of the left kidney on a completely duplicated system. The second twin presented a right polycystic kidney. In the light of this case report, the authors describe the various antenatal presentations of polycystic kidney and the associated urological malformations. Involvement of both foetuses of a twin pregnancy raises a discussion of the aetiopathogenesis of polycystic renal dysplasia.

[Pressure-flow urologic analysis in children: reflections after 20 years of practice]. / L'instantané mictionnel chez l'enfant: réflexions après 20 ans de pratique.

Pressure-flow analysis in children allows optimal definition of the main urodynamic parameters of micturition and clarifies certain aspects of physiology and functional disorders. This examination has allowed urologists to establish reliable relationships between the findings of the clinical interview and clinical examination and the reality of urodynamic parameters, so that, after being widely used for more than 20 years, its indications have now become exceptional, limited to the detection of detrusor-sphincter pathophysiology and a few rare voiding disorders, poorly defined by clinical findings or imaging.

[Varicocele in adolescents. Treatment by sclerotherapy and percutaneous embolization: reflections on the method. Apropos of 23 cases]. / Varicocèle de l'adolescent. Traitement par sclérothérapie et embolisation percutanée: réflexions sur la méthode. A propos de 23 cas.

OBJECTIVE: The authors report their experience of the treatment of varicocele in adolescents. As a result of progress in interventional radiology and embolization techniques, they have used a technique combining sclerotherapy and percutaneous embolization since 1993. MATERIAL AND METHODS: Since 1993, twenty three adolescents between the ages of 11 and and 17 years (mean = 14.5 years) were treated percutaneously for grade II and II left varicocele. The operation was performed under local anaesthesia and/or neuroleptanalgesia. Phlebography by selective catheterization of the left spermatic vein was performed for anatomical assessment (ostial incontinence, collateral vessels). Embolization was then performed under fluoroscopic control by injection of a sclerosing liquid, sodium tetradecyl sulphate (Trombovar), and systematically completed by insertion of endovascular occlusive metal coils. RESULTS: The follow-up ranged from 6 to 48 months (mean = 30 months). The follow-up clinical and ultrasound examination showed complete disappearance of the varicocele in 22 cases (95% of cases), with a persistent grade I asymptomatic left varicocele in 1 case. No complications were observed. The mean hospital stay was 48 hours. CONCLUSION: This constitutes a rapid method, which is minimally traumatic for the adolescent. Its efficacy is comparable to that of classical surgical techniques with lasting results. Insertion of coils is the endovascular equivalent of surgical ligation of the pathological vein. The liquid embolus is particularly useful as it diffuses and scleroses collateral veins, responsible for recurrence. The advantage of this method resides in a better understanding of the reflux mechanisms, allowing the procedure to be adapted to the venous anatomy. This technique ensures treatment of complex varicoceles, such as postsurgical recurrences.

[Evaluation of 20 years' experience of enuresis in children]. / Bilan de 20 ans de réflexion sur l'énurésie de l'enfant.

The clinical and urodynamic approach to enuretic children over a period of more than 20 years has allowed the authors to develop a multifactorial pathophysiological concept of this disorder. The main factors involved are psychological, familial, genetic, vesical, due to bladder immaturity, hormonal, due to a defect of nocturnal ADH secretion, hygiene and dietary habits, etc. The sleep factor is predominant in the majority of cases. Although nocturnal enuresis is apparently isolated in many cases, it is often associated with a state of bladder immaturity, sometimes latent during the day, but occurring at night with episodes of detrusor hyperactivity, occurring during various phases of sleep. In practice, the recognition, in children, of these factors, some of which require specific treatments, implies a management combining several of these therapeutic modalities.

[Fibroepithelial polyps of the ureter and the kidney pelvis. Report of 3 cases]. / Les polypes fibro-épithéliaux de l'uretère et du bassinet. A propos de 3 observations.

The authors report 3 cases of fibroepithelial polyps, one of which was an incidental finding and 2 were symptomatic, presenting in the form of macroscopic haematuria and chronic back pain, respectively. These lesions required 2 nephroureterectomies because of their renal repercussions or their multifocal nature, combined with segmental resection of the ureter, including the base of the tumour. In the light of these cases, the authors review the literature and analyse the current management of this rare disease, in particular the indications for endourological techniques which appear to have a major diagnostic contribution as a complement to IVU and retrograde urography, but whose therapeutic value has yet to be defined.

Childhood urolithiasis: urological management of upper tract calculi in the era of extracorporeal shock-wave lithotripsy.

OBJECTIVE: To evaluate the management of urolithiasis in children since the development of extracorporeal shock-wave lithotripsy (ESWL). METHODS: Between 1988 and 1994, 37 children, aged from 2 to 15 years (mean 10), with upper tract urolithiasis were evaluated and treated. Lithogenic metabolic disorders or anomalies of the urinary tract were present in 11 children (30%) Urolithiasis was multiple in 9 cases and bilateral in 2 cases. A total of 47 renal (30) or ureteral (17) stones were managed, of which 5 were partial or complete staghorn calculi. Initial treatment was surgery in 4 cases (1 nephrectomy, partial nephrectomy and 2 pyelolithotomies) and piezoelectric ESWL in 43 cases. RESULTS: The overall ESWL success rate was 82.2%, with auxillary endoscopic procedures in 3 cases. ESWL failures required surgical stone removal in 5 cases, endoscopic ureterolithotripsy in 1 case and electrohydraulic ESWL in 1 case. Residual fragments after pyelolithotomies were also treated by ESWL. CONCLUSION: ESWL is the mainstay of treatment of childhood upper tract urolithiasis, but other therapeutic methods retain specific indications. Its application requires great vigilance and its long-term effects are uncertain. It is therefore important to rule out any underlying pathology and where possible to prevent further stone formation.

The management of upper urinary tract calculi by piezoelectric extracorporeal shock wave lithotripsy in spinal cord injury patients.

From May 1988 to September 1994, 15 spinal cord injury patients were treated by piezoelectric extracorporeal shock wave lithotripsy. Aged from 23 to 71 years (mean = 39), they presented with a total of 23 stones, of which 18 were located in the calyces, three in the renal pelvis and two in the proximal ureter. The maximum dimensions of calculi varied from 5 to 35 mm (mean = 11). Patients were placed in a dorsal decubitus position during the sessions, three being sedated with diazepam, while the other 12 remained unsedated. All were treated routinely with systemic antibiotics. Auxiliary procedures consisted of two pyelocalyceal flushings, three double J ureteral stenting and three ureteroscopies with fragment removal with a Dormia basket. No episode of autonomic dysreflexia was observed. Short term side effects were limited to a few cases of gross haematuria which regressed spontaneously. Overall, eight successes (53%), and seven failures (47%), were registered. Of the failures, one was the result of a partial fragmentation, while six were related to intrarenal retention of residual fragments resulting in four cases in rapid recurrences. Extracorporeal shock wave lithotripsy can be easily applied to spinal cord injury patients. Its usefulness and limitations need to be well understood and a global consideration must be applied to the prevention and early detection of the upper urinary calculi in this exposed population of patients.