[Spontaneous urinary bladder perforation after pediatric cystoplasty]. / Perforación vesical espontánea tras cistoplastia en la infancia.

OBJECTIVE: The spontaneous cystoplasty perforation is a serious and potentially fatal problem if a delay in diagnosis and treatment occurs. We pretend: 1) to look for prevention analyzing the risk factors, 2) to identify the main data of diagnostic suspicion and 3) to evaluate the result of the treatments done. MATERIAL AND METHODS: Out of 30 children with cystoplasty 5 of them have presented 8 perforations (16,6%). Several influential factors, the symptoms, the treatments and the evolution are reviewed. RESULTS: The average time between cystoplasty and the perforation was 8,2 years. A urethral resistance that allows continence, and an insufficient intermittent catheterization, have been the main risk factors. In the 8 episodes there were abdominal pain and distension. The ultrasonography showed intraperitoneal extravasation in 5 episodes, multiple peritoneal cysts in one, and suggestive image of appendicular plastron in another one. The cystography showed intraperitoneal extravasation only in 3 cases. The initial management was conservative in the 7 episodes diagnosed before surgery, and 3 had a good evolution (42,8%); the other 4 needed surgery with good evolution in all cases. Two of 5 patients (40%) presented 3 relapses in an average time of 5 years. The survival is 100%. CONCLUSIONS: 16,6% of patients with cystoplasty of this series had one or more episodes of spontaneous bladder perforation. The more significant risk factors are a high urethral resistance and an inadequate intermittent catheterization. The patients with cystoplasty, and their families, must know this complication, their risk factors and symptoms to prevent it, or to facilitate an early diagnosis.

Perforación vesical espontánea tras cistoplastia en la infancia / Spontaneous urinary bladder perforation after pediatric cystoplasty

Objetivos: La perforación espontánea de una cistoplastia es un problema grave y potencialmente fatal, si no se diagnostica y se trata a tiempo. Se pretende: 1) buscar una prevención analizando los factores de riesgo, 2) identificarlos principales datos de sospecha diagnóstica y 3) valorar el resultado de los tratamientos realizados. Material y Método: De 30 pacientes pediátricos con cistoplastia, 5 presentaron 8 perforaciones (16,6%). Se revisan los diversos factores influyentes, la clínica, los tratamientos y la evolución. Resultados: El tiempo medio transcurrido entre la cistoplastia y la perforación fue 8,2 años. Los principales factores de riesgo han sido una resistencia uretral que permitía continencia, y una insuficiente realización temporal del sondaje intermitente (SI). En los 8 episodios hubo dolor y distensión abdominal. La ecografía mostró líquido libre intraperitoneal en 5, múltiples quistes peritoneales en 1, e imagen sugestiva de plastrón apendicular en otro. La cistografía sólo mostró paso de contraste a la cavidad peritoneal en 3. El tratamiento inicial fue conservador, sin cirugía, en los 7 episodios diagnosticados preoperatoriamente, siendo la evolución favorable en 3(42,8%); los otros 4 necesitaron tratamiento quirúrgico, con buena evolución en todos. De los 5 pacientes, 2 (40%) presentaron 3 recidivas en un tiempo medio de 5 años. La supervivencia es del 100 %.Conclusiones: El 16,6% de los pacientes con cistoplastia de esta serie, ha tenido uno o más episodios de perforación vesical espontánea. Los factores de riesgo más significativos son una resistencia uretral alta y la inadecuada realización del SI. Los pacientes con cistoplastia y sus familias deben conocer esta complicación, sus factores de riesgo y sus síntomas, para prevenirla o facilitar un diagnóstico precoz (AU)

Objective: The spontaneous cystoplasty perforation is a serious and potentially fatal problem if a delay in diagnosis and treatment occurs. We pretend: 1) to look for prevention analyzing the risk factors, 2) to identify the main data of diagnostic suspicion and 3) to evaluate the result of the treatments done. Material and Methods: Out of 30 children with cystoplasty 5 of them have presented 8 perforations (16,6%). Several influential factors, the symptoms, the treatments and the evolution are reviewed. Results: The average time between cystoplasty and the perforation was 8,2 years. A urethral resistance that allows continence, and an insufficient intermittent catheterization, have been the main risk factors. In the 8 episodes there were abdominal pain and distension. The ultrasonography showed intraperitoneal extravasation in 5 episodes, multiple peritoneal cysts in one, and suggestive image of appendicular plastron in another one. The cystography showed intraperitoneal extravasation only in 3 cases. The initial management was conservative in the 7 episodes diagnosed before surgery, and 3 had a good evolution (42,8%); the other 4 needed surgery with good evolution in all cases. Two of 5 patients (40%) presented 3 relapses in an average time of 5 years. The survival is 100%. Conclusions: 16,6% of patients with cystoplasty of this series had one or more episodes of spontaneous bladder perforation. The more significant risk factors are a high urethral resistance and an inadequate intermittent catheterization. The patients with cystoplasty, and their families, must know this complication, their risk factors and symptoms to prevent it, or to facilitate an early diagnosis (AU)

Autoembolización espontánea en un niño con priapismo postraumático de alto flujo / Spontaneous self-embolization in a child with postraumatic high flow priapism

Existen dos tipos de priapismo: el venoso o de bajo flujo, que es característicamente doloroso, y el arterial o de alto flujo, indoloro y mucho más raro, especialmente en la infancia. Se expone el caso de un varón de 5 años que 6 días después de sufrir un traumatismo perineal cerrado, presentó un priapismo indoloro, de tipo arterial, con aneurisma y fístula de la arteria dorsal del pene, que se resolvió espontáneamente mediante autoembolización, 11 días después de su inicio. Se hace una revisión bibliográfica de 14 casos de priapismo arterial postraumático en la infancia, no habiendo encontrado ningún otro caso resuelto mediante autoembolización espontánea (AU)

[Spontaneous autoembolization in a child with high-flow post-traumatic priapism]. / Autoembolización espontánea en un niño con priapismo postraumático de alto flujo.

There are two sort of priapism: the venous or low flow priapism, that is usually painful, and the arterial or high flow one, painless and rare, especially in childhood. We present a case of a boy 5 years old, who 6 days after to suffer a perineal closed traumatism, had a painless and arterial priapism, with aneurism and fistula of the dorsal penile arteria, that was resolute spontaneously through self-embolization, 11 days after. We review the bibliography of 14 cases of arterial posttraumatic priapism in childhood, without find any case resolute by spontaneous self-embolization.

[Long-term follow-up of children with neurogenic bladder and artificial urinary sphincter]. / Resultado a largo plazo del esfínter urinario artificial en niños con vejiga neurógena. A propósito de 16 casos en 12 años.

MATERIALS AND METHODS: Since 1986 an artificial urinary sphincter was implanted in 16 children (13 males and 3 females) 4 to 12 years old (median age 9) in order to solve their urinary incontinence. Mean age at implantation was 9 years. In 10 children (63%) only the implant procedure of artificial sphincter was performed without any other procedure associated (Group A), while in 6 children an augmentation cystoplasty simultaneously was performed (Group B). The results were analysed in both groups separately: 1. Group A: 10 patients. Two are functioning excellently after 10 and 11 years of follow up. Eight developed some type of troublesome: Five developed a deterioration of urinary tract and all of five were treated by augmentation cystoplasty; one of them is in a good condition after 11 years, another presented a fail of the device after 10 years, it has been changed, and in the others three the apparatus was removed by diverse causes. Two developed a mechanical fail of device: one was removed due familiar decision and the other has received another device. One urinary fistula developed 6 months later. The device was removed. 2. Group B: 6 patients (artificial sphincter and augmentation cystoplasty simultaneously). Five are functioning without trouble some. One persistent urinary fistula. The device was removed. Actually, of 16 cases (both groups) 8 cases (50%) are good functioning, 6 devices have been removed and 2 are waiting a new implant. CONCLUSIONS: The artificial urinary sphincter is a good solution for children with urinary incontinence in selected cases, but is mandatory a correct follow up because longterm complications can be developed. Results seem better when an augmentation cystoplasty is associated.

[Intermittent catheterization as the basis for treatment of neurogenic bladder during childhood]. / El sondaje intermitente como base del tratamiento de la vejiga neurógena durante la infancia.

OBJECTIVE: Neurogenic bladder (NB) frequently causes incomplete bladder emptying, which can lead to deterioration of the upper urinary tract (UUT), vesico-renal reflux (VRR) and incontinence. The aim of this study is to determine the degree of acceptance, performance and results of treatment of NB in children by intermittent catheterization (IC). METHODS: Of 121 children (50 girls and 38 boys) with NB, 88 were managed by intermittent catheterization. The mean age at treatment was 5.2 years (range 20 days-13 years). PVC catheters were employed and reutilized for 3 or 4 weeks. Catheters were aseptic but not sterile. Antimicrobial prophylactic therapy was not administered except in patients with VRR. The statistical study was descriptive and results were compared using the Pearson chi square test. RESULTS: 90% had 4 or more catheterizations daily. Family and patient cooperation was good in 90% of the cases. Patients were managed by IC for a mean period of 4 years (range 1 month-14 years). Only two cases (2%) showed mild, transient complications (urethral pain and cystitis). Normal UUT remained normal in 85%; 45% with compromised UUT improved and 7% became worse. Of the children with no VRR, 94% did not develop this complication; VRR resolved in 72% of the cases (24% by IC alone and 48% with drugs or surgery). Only 12% were continent for more than 3 hours, which increased to 77% (64% by IC alone and 86% with drug therapy or surgery). Urethral sphincter urodynamics was the most important prognostic factor: patients with a lower urethral resistance showed better results for the UUT (p = 0.00373) and VRR (p = 0.00943). The results were also better in patients with normal UUT (p = 0.0003) and no VRR (p = 0.009). CONCLUSIONS: IC is not limited by patient age, sex or sociocultural level. It preserves normal TUS and prevents VRR when instituted early, on demonstrating residual urine and high urethral resistance. IC alone or in combination with other treatments is the basic therapy in NB.

[Fluid loss pressure in 45 children with congenital neurogenic bladder]. / Presión de pérdida de líquido en 45 niños con vejiga neurógena congénita.

OBJECTIVE: This study analyzed the relation between leak point pressure (LPP) at first urodynamic evaluation and the status of the upper urinary tract (UUT) and renal reflux (RR). METHODS: The study comprised 45 myelodysplastic children, one week to 13 years of age; 19 (42%) were less than one year old. LPP was measured when liquid started to come out through the urethral meatus, around the 5-6 Fr catheter. UUT was evaluated by ultrasound and RR by voiding cystography. RESULTS: 19 children had LPP < 30 cm H2O; all cases had a normal UUT, although 5 (26%) had RR. Twenty-six cases (58%) had LPP > 30 cm H2O; 12 (46%) had abnormal UUT and 6 of these had RR; 7 cases had RR but normal UUT. The group with LPP > or = 30 cm H2O was analyzed according to LPP values. The UUT was abnormal in 31% of cases with LPP 30-60 cm H2O and 37% had RR; UUT was abnormal in 70% of cases with LPP > 60 cm H2O and 70% had RR. Of the 19 patients less than one year old 9 (47%) had LPP < 30 cm H2O, no patient had abnormal UUT and only two (22%) had RR; 10 cases had LPP > or = 30 cm H2O, 6 of these had abnormal UUT and 5 had RR. CONCLUSIONS: In this study UUT was normal when LPP was < 30 cm H2O. Renal impairment and RR increased with LPP. Urethral functional obstruction carries a worse prognosis of pediatric neurogenic bladder. In these cases clean intermittent catheterization is recommended, regardless of patient age and sex.

[The treatment of the primary intrarenal reflux. Is the surgery always necessary?]. / Tratamiento del reflujo intrarrenal primario. Es imprescindible la cirugía?

UNLABELLED: THE AIMS OF THIS STUDY was to evaluate the relationship between intrarenal reflux (I.R.R.) and reflux nephropathy (R.N.) in order to know the results of surgical and non surgical treatment. Fifty one children with 64 kidneys with primary I.R.R. were studied. 53% of them were less than one year of age. Initial examination were: urography, ultrasounds, cystography and DMSA scan; the follow up was done with ultrasounds, DMSA scan and cystography. When no R.N. was present, grade of reflux was < IV, and age < 12 years, a non surgical treatment was indicated. RESULTS: During first examination R.N. was demonstrated in 47% of kidneys; the main difference was the grade of reflux: 16/44 II-III (36%) and 14/20 IV-V (70%). Surgical treatment was performed in 42 (82%) children and non surgical in 9 (18%). Reflux stopped in 98% and 100%, respectively. Only one child, without R.N., developed a new renal scar, and a previous R.N. progressed in two. I.R.R. can be treated successfully without surgery in selected cases.

[Laparoscopy in the non-palpable testicles. Is it always necessary?]. / Laparoscopia en testículos no palpables. Es siempre necesaria?

In order to know the role of diagnostic laparoscopy with non palpable testicles (NPT), 15 children with 16 NPT were studied. Middle age was 7 years (R: 2-12). The surgical procedure was: laparoscopy initially and open inguinal surgery (OIS) after that. Six NPT were discovered with laparoscopy (37.5%). With OIS inguinal hernia was present in 4 cases, with testicle into the inguinal sac in 3 cases; 12 cases had not inguinal hernia, and 6 of them showed spermatic vessel and vas deferent without testicle. Orquidopexy of the 6 located testicles and testicular prothesis implantation in the other 10 cases, were performed. Finding of laparoscopy and OIS were perfectly correlated. Laparoscopy made the diagnosis in 7 cases, which the OIS would have been unable to do it (43.7%). In the other 9 cases, the OIS would have been diagnostic enough (56.2%) without laparoscopy. For those results, the authors prefer to begin the surgical procedure with OIS and if the spermatic vessels are no located, then the laparoscopy is done under the same anesthesia.

[Postnatal differential diagnosis of fetal ureteropelvic dilatation]. / Diagnóstico diferencial postnatal de la dilatación pielocalicial fetal.

UNLABELLED: A clinical study of 51 children with prenatal diagnosis of pielocaliceal dilatation with 65 kidney affected is done. The objective was to assess the accuracy of the postnatal diagnostic studies practiced in order to an early differentiation between obstructive and non obstructive dilatation. MATERIAL AND METHODS: There were evaluated ultrasonography (US), intravenous pielography and diuretic isotopic renogram. The data were statistically analyzed with SPSS program. A regression logistic analysis was carried out between all the significant variables in order to identify the obstruction risk factors. Also the probabilities calculated index and the sensibility and specificity were studied. RESULTS: The obstruction risk factors were: grade III dilatation or greater in the US, differential renal function less of 40%, and half time more than 21 minutes. The probabilities calculated index showed that the probabilties of obstruction are different according to the number of obstruction risk factors presented in every patient. Risk factors have a high sensibility and specificity as diagnostic test.

[Enterocystoplasties: results in 22 children]. / Enterocistoplastias: resultados en 22 niños.

A study of paediatric enterocystoplasty in 22 children of 1 to 14 years of age (M = 8) during 5 years is presented. The diagnoses were: neurogenic bladder 16 (73%), extrophic bladder 3, urethral valves 1, and complex uropathies 2. The intestinal segments used were: ileum 12 cases, sigmoid 8, and ileocaecal region 2 (non myelodisplastic). During the last years sigmoid have been preferred due to its bigger size. The middle follow up is 3.5 years (R 1-6). The results have been good in: renal function 86%, and upper urinary tract 95%. Bladder capacity was 278% higher, bladder pressure was 82% less, and residual urine was 217% more, than preoperatively. Five children developed 6 complications (23%), and 4 reinterventions were performed (18%). When it is indicated, paediatric enterocystoplasty is a good alternative to urinary diversion, and it is useful to prevent the upper urinary tract deterioration; but a frequent and, all the life long follow up is necessary, due to its possible complications.

[Newborn infants diagnosed prenatally with uropathies]. / Estudio de los recién nacidos diagnosticados prenatalmente de uropatías.

UNLABELLED: A clinical study of 111 newborns (NB) with prenatal diagnosis (PD) of urinary tract pathology was performed. The weight and size at birth, physical examination, incidence of uropathies, associated malformations and postnatal diagnostic studies were analyzed. MATERIAL AND METHODS: All data corresponding to 111 neonates with PD of urinary tract pathology were submitted to the Student's t and Chi square tests and contingency tables. RESULTS: Uropathies were more frequent in male NB (69%) and on the left side (2/1). Pyelocaliceal dilatation (PCD) was present in 46% of the patients. The mean weight and size was normal. However, NB with PCD had a mean weight of 249 grams below that observed in the remaining group (p = 0.016). Thirteen newborns (12%) had associated anomalies. An abdominal mass was present in 17 neonates with obstructive uropathies (15%). Serum urea and creatinine were normal in 101 neonates (91%). SUMMARY: 1) PCD is the most frequent uropathy diagnosed prenatally. 2) The incidence of fetal uropathies, diagnosed prenatally, is higher in males. 3) The left side is more frequently involved. 4) The mean weight and size of NB with uropathies is normal. 5) The mean weight of NB with DCP is 249 grams lower than the rest of the group. 6) Serum urea and creatinine were found elevated only in severe bilateral obstructive uropathies.

[Enuresis and urinary pathology]. / Enuresis y patologia urinaria.

The incidence of urinary pathology is studied in 71 pediatric cases of primary nocturnal enuresis. These incidences have been 18.3 per cent, but there are two different groups. After a negative urological anamnesis, incidence goes down to 5.4 for 100 (3 patients of 55). When anamnesis shows suspicious of uropathy, incidence growth to 62.5 for 100 (10 patients of 16). Urological study with ultra sound and XR is recommended in nocturnal enuretic children only when there are suspicions of uropathy after a detailed clinical exploration and anamnesis.

[Pyeloureteral stenosis secondary to Schoenlein-Henoch purpura]. / Estenosis pieloureteral secundaria a púrpura de Schönlein-Henoch.

We present an 8-year-old male suffering from Schönlein-Henoch purpura with multisystemic clinical manifestations, which developed as a complication a pyeloureteral stenosis secondary to vasculitis. He was operated on and a ureteropyeloanastomosis was carried out according to the Anderson-Hynes technique with good results. We discuss the etiology, diagnostic methods and therapeutic possibilities. It is the eighth case in the literature requiring surgical correction as a result of this exceptional complication.

[A technic to avoid postoperative intestinal hypodynamia]. / Técnica para evitar la hipodinamia intestinal postoperatoria.

The hypodynamic postoperative ileus in children, has as main cause the circle gastric distension-reflex intestinal ileus, produced by the swallowed air. The gastric emptying system-through a Levin tube from the stomach is not usually sufficient to get off all the swallowed air. Nevertheless, a continuous suction from the lower third of oesophagus, through a double lumen sump tube is twelve times more effective in the getting off de air before it comes into the stomach, without need of a nasogastric tube.