Endoscopic balloon dilation of primary obstructive megaureter: is fluoroscopic guidance necessary?

OBJECTIVE: To compare the long-term effectiveness, complications, and outcomes of primary obstructive megaureter (POM) treated by endoscopic balloon dilation under fluoroscopic guidance versus not using radioscopy during the procedure. PATIENTS AND METHODS: A comparative study between POM cases treated at our institution by endoscopic balloon dilation (EBD) under fluoroscopic guidance (FG) (n = 43) vs no fluoroscopic guidance (NFG) (n = 48) between the years 2004 and 2018 was conducted. The procedure in FG consisted of performing a retrograde pyelography before dilation. Then, a guidewire is introduced to the renal pelvis, and the dilation of the vesicoureteral junction is performed using high-pressure balloon catheters under fluoroscopic vision. Finally, a double-J stent is placed between the renal pelvis and bladder. The procedure in NFG was performed exclusively under cystoscopic vision without radiological exposure. Complications, outcomes, and success rates were analyzed using Spearman's correlation test. Mean follow-up was 12.5 ± 2.2 years in FG and 6.4 ± 1.3 years in NFG. RESULTS: MAG-3 showed significant differences in renal drainage before and after endoscopic treatment in both groups (p < 0.001 T-test). Statistical analysis did not reveal differences between groups in initial technical failure (r: - 0.035, p = 0.74), early postoperative complications (r: - 0.029, p = 0.79), secondary VUR (r: 0.033, p = 0.76), re-stenosis (r: 0.022, p = 0.84), long-term ureteral reimplantation (r: 0.065, p = 0.55), and final outcome (r: - 0.054, p = 0.61). The endoscopic approach of POM had a long-term success rate of 86.5% in FG VS 89.6% in NFG. CONCLUSIONS: Endoscopic balloon dilation of POM can be done with no radiation exposure with similar results, effectiveness, and outcomes.

Long Term Outcome of 112 Pediatric Patients With Ureteroplevic Junction Obstruction Treated by Endourologic Retrograde Balloon Dilatation.

Purpose: To analyze the effectiveness, complications and long-term outcome of the patients with ureteropelvic junction obstruction (UPJO) treated by endoscopic retrograde balloon dilatation (ERBD) in the largest series reported. Materials and Methods: Between years 2004 and 2018, 112 patients with primary unilateral UPJO were treated by ERBD. Endoscopic treatment consisted on a retrograde balloon dilatation of the ureteropelvic junction (UPJ), through cystoscopy and under fluoroscopic guidance, using high-pressure balloon catheters. In case of persistence in the balloon notch, a Cutting Balloon™ catheter was used. Double-J stent was placed after dilatation. Results: Mean age at surgery was 13.1 ± 21.3 months, 92 cases being younger than 18 months. Mean operative time was 24.4 ± 10.3 min; hospital stay was 1 day in 82% of patients. No intraoperative complications occurred. UPJ was calibrated at time of stent removal with cystoscopy 39.1 ± 13.7 days after dilatation. ERBD was not possible in 11 cases. An additional procedure was needed in 24 cases: second ERBD (n = 11, seven during the stent withdrawal), a third dilatation (n = 3) due to persistent hydronephrosis, and percutaneous endopyelotomy (n = 3) or open pyeloplasty (n = 7) in cases of technical failure. Significant improvement in postoperative ultrasound measures were observed (p < 0.05, T-test). Long-term success rate was 76.8% after one dilatation, and 86.6% in those who required up to 2 dilatations. Mean follow-up was 66.7 ± 37.5 months. Conclusions: ERBD is a feasible and safe option for the minimally invasive treatment of UPJ obstruction in infants. Long-term outcome is acceptable with a very low complication rate.

Surgical approach to prune-belly syndrome: A review of our series and novel surgical technique.

INTRODUCTION: Surgical management of children with Prune-belly syndrome (PBS) can be divided into three categories: urinary tract reconstruction, abdominal wall reconstruction, and orchidopexy. Adequate repair of the abdominal wall by abdominoplasty at an early age, allows an adequate aesthetic appearance, but also allows a correct development of walking, breathing, defecation and urination. OBJECTIVE: To present a novel surgical technique for abdominal wall reconstruction, which combines plication with complete overlap of the fascia and neoumbilicoplasty with an island flap rotated on itself. STUDY DESIGN: A retrospective review of the patients with PBS who underwent surgery in our center between 2009 and 2020. A new abdominoplasty technique was performed, which consists of plication with complete overlap of the fascia, as well as a neoumbilicoplasty with an island flap rotated on itself. The skin is then well freed from the rest of planes, and the plication is performed with complete overlapping of the muscle-aponeurotic plane from one side to the other. At this time, the interposition of some type of reinforcement material (mesh) may be required in the event of complete absence or insufficient presence of the fascia and muscle. RESULTS: Abdominoplasty was performed in four patients. In all patients, bilateral orchidopexy was performed in the same surgical procedure for intra-abdominal testicles. The mean age of the patients at the time of surgery was 10,5 years and the average admission time was 4 days. There were no short-term or long-term complications. Average follow-up time was 7 years. All patients and their families are satisfied with the aesthetic result obtained. DISCUSSSION: Abdominoplasty in patients with PBS in addition to aesthetic reconstruction, brings significant improvements to wandering, breathing, urination and defecation, improving the quality of life of the patient. Compared to the techniques described, the abdominoplasty we propose makes it possible to easily improve the abdominal wall support by means of meshes or synthetic devices if necessary and allows the evaluation and correction of cryptorchidism or other associated renal abnormalities in the same surgical act, as it allows full abdominal exposure. Likewise our modified abdominoplasty allows the creation of the new umbilicus in a more anatomical way, rectifying its natural position. CONCLUSION: In our experience, this modified surgical technique for abdominal wall repair is a novel procedure in the PBS approach, easily reproducible, which provides good aesthetic results in our series of cases.

Micro-Ureteroscopy as a Treatment of Renal Pelvis Lithiasis in Young Children.

Aim: Miniaturization of endoscopic instruments has allowed to improve the efficacy of kidney stone treatment in young children. Aim of the study is to evaluate the usefulness of microureteroscopy with 4.85F sheath in the treatment of renal stones in children. M&M: We present 4 cases of microureteroscopy in 3 younger than 3 years patients with renal pelvic stones. Lithiasis was unilateral in 2 female patients and bilateral in 1 male patient. Microureteroscopy was performed using a MicroPerc set 4.85F sheath, without placing a safety guide or dilating the meatus in 3 procedures. The lithotripter system used was Ho:YAG Laser with 200-µm fiber in all cases. Results: Mean operating time was 100 ± 16 min. There were no intraoperative complications. In all procedures, complete pulverization of the lithiasis was achieved, except in the coraliform lithiasis in which 5 mm residual lithiasis remained in the lower calyx. All patients were discharged 24 h after the intervention. Conclusion: Microureteroscopy can be considered a new alternative for treatment of selected cases of renal pelvic stones in infants and children.

Endourologic Treatment in Two Cases of Ureteral Valves.

Introduction: Congenital ureteral valves are a rare cause of ureteral obstruction that may lead to renal function deterioration. We present two clinical cases treated endoscopically by monopolar electrocautery and laser fiber ablation. Presentation of Case: The first case is a 13-year-old male with several episodes of abdominal pain and was found to have severe left hydronephrosis. Ultrasonography showed a dilated ureter and pelvicaliceal system with an obstructive renogram curve. We performed a retrograde pyelogram, finding a dilated ureter 5 cm up from the vesicoureteral junction with ureteral valves in that place. Ablation of the valves was conducted using monopolar electrocautery. The second case is a 2-year-old male with left ureterohydronephrosis shown in abdominal ultrasonography. In the radiologic findings, a high-risk pyelocaliceal dilatation with renal parenchyma thinning and a diameter of 3.3 cm for the left ureter is described, with an obstructive renogram. We performed a cystoscopy, observing the presence of valves in the ureter at 3 cm that conditioned an obstruction. The complete section of the valves was performed through a 270µm holmium laser fiber. Our patients made an uneventful postoperative recovery and continue to remain completely asymptomatic. A significant decrease in renal dilation was observed and renal function recovered in both cases. Conclusion: Ureteral valves are an uncommon cause of ureteral obstruction. Advances in endourologic techniques allow us to give a minimally invasive approach to these diseases, obtaining good long-term results in our small series of patients.

Micropercutaneous endopyelotomy for the treatment of secondary ureteropelvic junction obstruction in children.

INTRODUCTION: The management of recurrent pyeloureteral junction obstruction (PUJO) is controversial, as there is no suitable technique for its correction. Percutaneous endopyelotomy shows better results in recurrent PUJO compared to primary PUJO. Micro-percutaneous approaches reduce damage to renal parenchyma and facilitate access to renal pelvis. OBJETIVE: To present our experience in the use of this minimally invasive technique for the treatment of recurrent PUJO. STUDY DESIGN: A retrospective study was performed collecting data of patients with recurrent PUJO treated in our hospital using the percutaneous approach between July 2014 and January 2018. Micropercutaneous access was performed in all patients. In Valdivia position, a 5 or 6 mm high-pressure ballon is placed in the renal pelvis under cystoscopic and fluoroscopic guidance. The 4.8 or 8 Fr microperc puncture needle is placed into the pelvicalyceal system. Endopyelotomy is performed with a laser fiber or monopolar hook on a high-pressure balloon. To improve the exposure of the cutting area, the high-pressure balloon is placed at the pyeloureteral junction. Double J stent is left for weeks. RESULTS: The ages of the patients were 4, 8 and 18 months, and 2 and 4 years. All patients had previously undergone pyeloplasty due to pyeloureteral junction obstruction. Operative time was 50 ± 21 min. Hospital stay after surgery was 24 h and hematuria disappeared within the 24 postoperative hours. DISCUSSION: The number of patients with recurrent PUJO is small, making it difficult to establish a standard surgical approach for failed pyeloplasty. Redo pyeloplasty is considered the gold standard by some authors but alternative methods, such as endourological techniques, may also have a role in the treatment of failed pyeloplasty. The percutaneous approach has shown very good results in this treatment and the miniaturization of percutaneous surgery has improved with the micropercutaneus access. We consider micropercutaneous approach helped with a high pressure balloon in the pyeloureteral junction is an alternative and minimally invasive technique that has shown good results in our small cases series. However, we must take into account the limitation of the study considering the low number of patients. We need prospective studies to support our results. CONCLUSION: Micropercutaneous endopyelotomy is a fairly effective technique to treat recurrent UPJO after failed pyeloplasty in children. In our experience, it reduces kidney damage without increasing complications.

Faloplastia suprapública: nueva técnica quirúrgica para el pene enterrado / Suprapubic falloplasty: new surgical technique for the buried penis

INTRODUCCIÓN Y OBJETIVO: El pene enterrado es un motivo de consulta frecuente en la práctica clínica pediátrica. En general, los cuerpos cavernosos y el glande son normales, pero el pene está enterrado por el exceso de grasa suprapúbica, sin fijación de los ángulos peno-púbicos. Presentamos nuestra serie de pacientes intervenidos mediante una alternativa al tratamiento quirúrgico clásico. MATERIAL Y MÉTODO: Descripción de técnica quirúrgica, modificada en los últimos 10 años, que incluye Z-plastia suprapúbica para obtener suficiente piel para cubrir la base del pene, lipectomía suprapúbica y sección del ligamento suspensorio del pene con fijación de ángulos penopúbicos. Estudio retrospectivo de pacientes con recopilación de datos sobre edad, complicaciones y resultado estético obtenido. RESULTADOS: Fueron intervenidos 16 pacientes con edad media de 9 años. La técnica quirúrgica modificada se aplicó a todos los pacientes, retirando vendaje y sonda vesical a las 24 horas de la cirugía en todos los casos. Las complicaciones a corto plazo fueron: pérdida parcial del colgajo de la Z-plastia en 2 pacientes que curó por segunda intención; edema significativo de la mucosa prepucial en 6 pacientes. El seguimiento medio fue superior a 5 años en todos los casos. A largo plazo, tanto los pacientes como los padres mostraron satisfacción con los resultados. CONCLUSIONES: El abordaje quirúrgico del pene enterrado no está estandarizado y es un tema cuestionado. En nuestra experiencia, la intervención quirúrgica con abordaje suprapúbico en los pacientes con hipertrofia de grasa púbica aporta mejor aspecto estético, con menos recidivas a largo plazo y clara mejoría psicológica de los pacientes

BACKGROUND AND OBJECTIVE: Buried penis is a frequent claim in pediatric outpatient clinic. Usually the cavernous bodies and the gland are normal but the penis is buried in the excess suprapubic fat, with no fixation of the peno-pubic angles. We present our series of patients treated with an alternative to the classic surgical treatment. METHODS: Our surgical technique has been modified in the last 10 years to include a suprapubic Z-plasty in order to get enough skin to cover the base of the penis, lipectomy with section of the suspensory ligament of the penis and fixation of the penopubic angles. We conduct a retrospective study of our patients, collecting data about age, complications and aesthetic results. RESULTS: Sixteen patients with a mean age of 9 years were operated. The modified surgical technique was applied to all patients; bandage and bladder catheter were removed after 24 hours in all cases. Short-term complications were partial los of the Z-plasty flap that cured by secondary intention in 2 patients and in 6 patients a significant edema of the preputial mucosa was observed. Mean follow-up was longer than 5 years in all cases. At the end of follow-up, both patients and parents were satisfied with the results. CONCLUSION: The gold-standard surgical technique for the buried penis is still controversial. In our experience, the suprapubic approach in patients with pubic fat hypertrophy, provides better aesthetic appearance with fewer long-term relapses and a clear psychological impact

Long-Term Outcomes in Primary Obstructive Megaureter Treated by Endoscopic Balloon Dilation. Experience After 100 Cases.

Aim: To assess long-term effectiveness, complications, and outcomes of primary obstructive megaureter (POM) treated by endoscopic balloon dilation (EBD) in the largest series reported. Patients and Methods: Hundred POM in 92 consecutive patients were treated by EBD between years 2004 and 2016. A total of 79 POM (73 patients) with more than 18 months of follow-up after treatment have been analyzed. EBD of the vesicoureteral junction was performed with semicompliant high-pressure balloon catheters (2.7FG) with minimum balloon diameter of 5 mm, followed by temporary Double-J stent placement. Follow-up protocol included periodical clinical reviews, US and MAG-3 renogram scans. Results: Median age at surgery was 4 months (15 days-3.6 years), with median operating time of 20 min (10-60) and hospital stay of 1 day (1-7). Initial renal function was preserved in all patients with significant improvement in renal drainage on the MAG-3 diuretic renogram after endoscopic treatment (p < 0.001 T-test). Significant post-operative differences were observed in hydronephrosis grade and ureteral diameter that were maintained in the long-term (p < 0.001 T-test). Endoscopic approach of POM had a long-term success rate of 87.3%, with a mean follow-up of 6.4 ± 3.8 years. Secondary VUR was found in 17 cases (21.5%), being successfully treated by endoscopic subureteral injection in 13 (76.4%). Nine cases developed long-term re-stenosis (12.2%) that were successfully treated with a new EBD in 8. Endoscopic management of POM failed in 10 cases (12.7%) that required ureteral reimplantation. Five were early failures (4 intraoperative technical problems and 1 double-J stent migration with severe re-stenosis), and 5 long-term (4 persistent VUR and 1 re-stenosis recurrence). Conclusion: EBD has shown to be an effective treatment of POM with few complications and good outcomes at long-term follow up. Main complication was secondary VUR that could also be treated endoscopically with a high success rate. In our opinion, EBD may be considered first-line treatment in POM.

Urethral Triplication Without Bladder Duplication: Endourologic Diagnosis and Management.

Urethral triplication is a rare congenital anomaly of the lower urinary system, with <15 cases reported so far. We present a 24-month-old boy with accessory hypoplastic urethra ending in glans. At the beginning of toilet training, urine output was observed along the rectum. Rigid cystoscopy shows a perineal urethra starting in the posterior urethra. Subsequently, flexible cystoscopy showed entry of epispadic urethra in the bladder immediately superior to the bladder neck. It was running parallel to primary urethra. Then, we observed two most frequent types of urethral duplication in the sagittal plane in a single patient.

Endoscopic Urinary Diversion As Initial Management of Symptomatic Obstructive Ectopic Ureter in Infants.

AIM: Definitive surgery of ectopic ureter in infants is challenging. We propose an endoscopic urinary diversion (EUD) as a novel surgical technique in the initial management of symptomatic obstructive ectopic ureter. PATIENTS AND METHODS: Sixteen obstructive ectopic ureters (14 patients) were initially treated by EUD between 2006 and 2015. All patients had urinary tract dilatation worsening at preoperative US scans and at least two febrile urinary tract infection (UTI) or urinary sepsis despite antibiotic prophylaxis. Ectopic ureter was confirmed by cystoscopy. When ectopic meatus was not found, EUD consisted in the creation of a transurethral neo-orifice (TUNO) performed by needle puncturing of the ureterovesical wall, under fluoroscopic and ultrasound control. If ectopic meatus was identified in the posterior urethra, "intravesicalization procedure" was done opening the urethral-ureteral wall to create a new ureteral outlet into the bladder. RESULTS: EUD was done at a median age of 3.5 months (0.5-7) with median follow-up of 48 months (24-136). TUNO was performed in six patients and "intravesicalization" in eight patients. Significant differences were observed in ureteral diameter and anteroposterior pelvis diameter before and after endoscopic treatment (p < 0.005). Initial renal function was preserved in all cases. Postoperative complications were UTI in four patients and TUNO stenosis in one patient, treated by endoscopic balloon dilation. Definitive treatment was further individualized in each patient after 1 year of life. CONCLUSION: EUD is a feasible and safe less-invasive technique in the initial management of symptomatic obstructive ectopic ureter. It allows an adequate ureteral drainage preserving renal function until definitive repair if necessary and does not invalidate other surgical options in case of failure or future definitive treatments.

Retrograde Endopyelotomy with Cutting Balloon™ for Treatment of Ureteropelvic Junction Obstruction in Infants.

PURPOSE: The aim of this study is to analyze results of retrograde endopyelotomy with cutting balloon for treatment of ureteropelvic junction obstruction (UPJO) in infants. METHODS: We routinely treat patients with UPJO under 18 months of age with retrograde high-pressure balloon dilatation of the pelviureteric junction (PUJ). During the procedure, in these cases where narrowing at the PUJ persists, endopyelotomy with cutting balloon is performed. Endopyelotomy is performed over guidewire with 5-mm Cutting Balloon™ under fluoroscopic control. Double-J stents is left in situ for 4 weeks. We retrospectively analyzed the postoperative, clinical, and radiological outcome infants treated with cutting balloon endopyelotomy between 2007 and 2015. RESULTS: Sixteen patients required cutting balloon endopyelotomy to achieve complete resolution of narrowing of the waist observed during high-pressure balloon dilatation of the PUJ. Mean operative time was 35 ± 21 min (mean ± SD) and hospital stay was <24 h in all patients. Complete resolution of the narrowing at the PUJ under fluoroscopy was achieved in all cases, with no perioperative complications. One patient presented with urinary tract infection, postoperatively (Clavien grade II). Preoperatively, all cases had grade IV SFU hydronephrosis with parenchymal thinning. During follow-up, resolution of the hydronephrosis was observed in 11 patients (grade I SFU). In four infants, there was an improvement of the hydronephrosis (grade II SFU) and the renogram curve. In one case, an open pyeloplasty was required due to persistent hydronephrosis and obstructive curve. CONCLUSION: We believe that endopyelotomy with cutting balloon could be a valid and safe option in minimally invasive management of UPJO in infants.

High-pressure balloon assessment of pelviureteric junction prior to laparoscopic "vascular hitch".

AIM: To assess if calibration of the ureteropelvic junction (UPJ) using a high-pressure balloon inflated at the UPJ level in patients with suspected crossing vessels (CV) could differentiate between intrinsic and extrinsic stenosis prior to laparoscopic vascular hitch (VH). MATERIALS AND METHODS: We reviewed patients with UPJO diagnosed at childhood or adolescence without previous evidence of antenatal or infant hydronephrosis (10 patients). By cystoscopy, a high-pressure balloon is sited at the UPJ and the balloon inflated to 8-12 atm under radiological screening. We considered intrinsic PUJO to be presente where a 'waist' was observed at the PUJ on inflation of the balloon and a laparoscopic dismembered pyeloplasty is performed When no 'waist' is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. Patients with absence of intrinsic PUJ stenosis documented with this method are included for the study. RESULTS: Six patients presented pure extrinsic stenosis. The mean age at presentation was 10.8 years. Mean duration of surgery was 99 min and mean hospital stay was 24 hours in all cases. We found no intraoperative or postoperative complications. All children remain symptoms free at a mean follow up of 14 months. Ultrasound and renogram improved in all cases. CONCLUSION: When no 'waist' is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. In these patients, laparoscopic transposition of lower pole crossing vessels ('vascular hitch') may be a safe and reliable surgical technique.

High-pressure balloon assessment of pelviureteric junction prior to laparoscopic "vascular hitch"

ABSTRACT Aim To assess if calibration of the ureteropelvic junction (UPJ) using a high-pressure balloon inflated at the UPJ level in patients with suspected crossing vessels (CV) could differentiate between intrinsic and extrinsic stenosis prior to laparoscopic vascular hitch (VH). Materials and Methods We reviewed patients with UPJO diagnosed at childhood or adolescence without previous evidence of antenatal or infant hydronephrosis (10 patients). By cystoscopy, a high-pressure balloon is sited at the UPJ and the balloon inflated to 8-12 atm under radiological screening. We considered intrinsic PUJO to be present where a ‘waist’ was observed at the PUJ on inflation of the balloon and a laparoscopic dismembered pyeloplasty is performed When no ‘waist’ is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. Patients with absence of intrinsic PUJ stenosis documented with this method are included for the study. Results Six patients presented pure extrinsic stenosis. The mean age at presentation was 10.8 years. Mean duration of surgery was 99 min and mean hospital stay was 24 hours in all cases. We found no intraoperative or postoperative complications. All children remain symptoms free at a mean follow up of 14 months. Ultrasound and renogram improved in all cases. Conclusion When no ‘waist’ is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. In these patients, laparoscopic transposition of lower pole crossing vessels (‘vascular hitch’) may be a safe and reliable surgical technique.

Primary obstructive megaureter: the role of high pressure balloon dilation.

BACKGROUND AND PURPOSE: There is a growing interest in minimally invasive treatment of primary obstructive megaureter (POM) in children. The absence of long-term follow-up data, however, makes it difficult to establish the indication for an endoscopic approach. The aim of our study is to determine the long-term efficacy of endourologic high-pressure balloon dilation of the vesicoureteral junction (VUJ) in children with POM that necessitates surgical treatment. METHODS: We retrospectively reviewed the clinical records from children with POM who were treated with endourologic high-pressure balloon dilation of the VUJ from March 2003 to April 2010. To determine the long-term, a cohort study was conducted in November 2011. Endourologic dilation of the VUJ was performed with a semicompliant high-pressure balloon (2.7 FG) with a minimum balloon size of 3 mm, followed by placement of a Double-J stent. RESULTS: We have treated 29 (32 renal units, left [n=16], right [n=10] and bilateral [n=3]) children with a diagnosis of POM within this period. The median age at the time of the endourologic treatment was 4.04 months (range 1.6-39 months). In three cases, an open ureteral reimplantation was needed, in two cases because of intraoperative technical failure and postoperative Double-J stent migration in one patient. The 26 children (29 renal units) who had a successful endourologic dilation of the VUJ were followed with ultrasonography and MAG-3-Lasix (furosemide) studies that showed a progressive improvement of both the ureterohydronephrosis and drainage in the first 18 months in 20 patients (23 renal units) (69%). In two patients who were treated with a 3 mm balloon, a further dilation was needed, with an excellent outcome. The cohort study (at a median follow-up of 47 months) showed that in all patients who had a good outcome at the 18-month follow-up after endourologic balloon dilation remained asymptomatic with resolution of ureterohydronephrosis on the US and good drainage on the renogram, in the children with some persistent hydronephrosis. CONCLUSIONS: Our study shows that children with POM who were treated with high-pressure ballon dilation of the VUJ who have satisfactory appearance at 18 months maintain these results over time.

Management of ureteropelvic junction obstruction with high-pressure balloon dilatation: long-term outcome in 50 children under 18 months of age.

OBJECTIVE: To analyze the usefulness of dilatation in the treatment of ureteropelvic junction obstruction (UPJ) in children <18 months of age, including newborns and infants. METHODS: Patients (n = 50; <18 months of age) were diagnosed using abdominal ultrasound, cystogram, and diuretic renography. Treatment was with endourologic retrograde balloon dilatation under fluoroscopic guidance. The balloons were, in all cases, semicompliant with a profile of 5 mm, 6 mm, or 7 mm. Follow-up was for 42.9 ± 23.2 months (mean ± SD). Double-J stents were inserted postdilatation, the caliber and length depending on the patient's body weight. RESULTS: Intervention duration was 22 ± 19 minutes. Dilatation was not possible in 5 patients, and pyeloplasty was the alternative treatment. Hospital stay was 24 hours in 44 patients. Analgesic needs were met exclusively by nonsteroidal anti-inflammatory drugs. The double-J stent was withdrawn using cystoscopy and the UPJ was calibrated.Residual stenosis was found in 7 patients. A second dilatation was required in 3 patients 6-18 months after surgery because of the lack of improvement of hydronephrosis. During follow-up, resolution of the hydronephrosis was observed in 45 cases (anterior-posterior diameter of the renal pelvis 7 ± 5 mm). The diuretic renography improved in 45 infants; the shape of the curve being normal in 44 cases and semi-obstructive in 1. CONCLUSION: We believe that high-pressure balloon dilatation could be a valid and safe option in the minimally invasive treatment of UPJ obstruction in infants. The outcome is acceptable with a low complication rate.

Is intraoperative surgeon's opinion an accurate tool to assess the outcome of endoscopic treatment for vesicoureteral reflux?

OBJECTIVE: Our experience in the endoscopic treatment of vesicoureteral reflux (VUR) has significantly increased during the last decade. To help develop diagnostic tests to check the success of this procedure, we evaluated the accuracy of surgeons' intraoperative observations as a predictor of treatment results. METHOD: We performed a prospective study of patients with VUR who were endoscopically treated during 1 year (106 renal units). Patients' age and gender, laterality, material used, grade of reflux, presence of ureteral duplication or associated pathology, and morphology of ureteral orifice were recorded as predictive factors related to the success rate. Surgeon and assistant indicated at the end of the endoscopic procedure whether the VUR was cured or not for each renal unit. These estimations were compared with postoperative voiding cystourethrogram results. RESULTS: Overall cure rate was 75.5%. Positive predictive value (PPV) for surgeon's opinion was 0.79 and negative predictive value (NPV) was 0.40. Statistical analysis demonstrated that the association between the surgeon's opinion and the cure rate was low with a Kappa value of 0.171 (p = 0.30). PPV of assistant's opinion was 0.80 and NPV was 0.40, with a Kappa value of 0.2 (p = 0.13). Concordance of surgeon and assistant's opinion resulted in PPV of 0.79 and NPV of 0.53 (Kappa = 0.261). Kappa value did not improve when surgeon's opinion was related to other factors such as the material employed, grade of reflux, presence of ureteral duplication or associated pathology and morphology of the ureteral orifice. CONCLUSION: In our experience, surgeon's opinion is not an accurate tool to predict the outcome of endoscopic treatment of VUR.

Endourological management in a newborn with incomplete bladder duplication.

We report an unusual case of a newborn with incomplete bladder duplication and a complete sagittal septum. This malformation was associated with dysplasia of the right kidney, right cryptorchidism, single urethra, and no other genital or gastrointestinal anomalies. At birth, we found severe ureterohydronephrosis in a solitary left kidney caused by the collapse of the left bladder when the right bladder was filled. We performed a neonatal puncture of the bladder septum. At 3 months of life, the patient underwent complete resection of the septum by cystoscopy with monopolar electrocautery. There are no previously reported cases of a newborn with obstructed uropathy. This is the first reported case of incomplete bladder duplication with endourological management.

Percutaneous endopyelotomy with electrocautery: modified techniques in the treatment of ureteropelvic junction obstruction in a child under 2 years.

OBJECTIVE: In recent years new techniques in minimally invasive treatment of congenital stenosis of ureteropelvic junction have been developed. We report the treatment of pyeloureteral stenosis in children by percutaneous endopyelotomy. METHODS: In the work up study of a child (18 months) with abdominal palpable mass, a severe left hydronephrosis with a renal pelvis diameter of 65 mm and severely thinned renal parenchyma was found. The diuretic renogram showed an obstructive pattern with impaired renal function. Initially, a retrograde dilatation balloon was placed in the ureteropelvic junction under cistoscopic control. With the patient in modified Valdivia position, percutaneous access to the renal pelvis was performed. By Seldinger technique and under fluoroscopy guide, a 5 mm laparoscopic trocar was placed in the renal pelvis. We performed a percutaneous electrical endopyelotomy of the pyeloureteral junction over the 6 mm retrograde balloon dilator passed through. We placed an antegrade double J stent that was removed at 4 weeks uneventfully. RESULT: Good results were assessed without perioperative or postoperative complications with great improvement in renal dilatation two years after the intervention. The renogram showed improvement in the pattern of the curve with a slight increase in differential renal function. CONCLUSIONS: Percutaneous endopyelotomy in children has important issues due to the lack of appropriate material. However it is possible to get good results as a minimally invasive technique. In fact, it could be the ideal technique in severe hydronephrosis with large renal pelvis that prevents the surgical or endourological approach.

Endopielotomía percutánea con electrobisturí en un lactante: modificaciones técnicas / Percutaneous endopyelotomy with electrocautery: modified techniques in the treatment of ureteropelvic junction obstruction in a child under 2 years

OBJETIVO: Las técnicas mínimamente invasivas de tratamiento de la estenosis pieloureteral desarrolladas en adultos tienen grandes dificultades para su aplicación en niños por la ausencia de material adecuado. Presentamos mejoras técnicas de la endopielotomía percutánea para su aplicación en un lactante. MÉTODO: Paciente de 18 meses con severa hidronefrosis izquierda que cruza línea media con pelvis renal de 65 mm. Se sitúa retrógradamente un balón de alta presión en unión pieloureteral tras pielografía retrógrada y paso de guía a pelvis renal. Con el paciente en posición de Valdivia modificado, se realiza el acceso percutáneo mediante técnica de Seldinger guiado por radioscopia hasta colocar un trocar de 5 mm en pelvis renal. Se realiza una endopielotomía percutánea con corte eléctrico sobre el balón. Se deja colocado un stent doble J anterógradamente que se retira a las 4 semanas. RESULTADO: Buena evolución postoperatoria sin complicaciones perioperatorias ni postoperatorias. Gran mejoría de la dilatación renal al año y dos años de la intervención. El renograma muestra clara mejoría en el patrón de la curva con leve ascenso de la función renal diferencial. CONCLUSIONES: La endopielotomía percutánea presenta dificultades en niños por la ausencia de material adecuado. Sin embargo es posible su realización con buenos resultados sin contraindicar otras técnicas posteriores. Podría ser la técnica ideal en severas hidronefrosis con grandes pelvis renales que dificultan su abordaje quirúrgico o endourológico(AU)

OBJECTIVE: In recent years new techniques in minimally invasive treatment of congenital stenosis of ureteropelvic junction have been developed. We report the treatment of pyeloureteral stenosis in children by percutaneous endopyelotomy. METHODS: In the work up study of a child (18 months) with abdominal palpable mass, a severe left hydronephrosis with a renal pelvis diameter of 65 mm and severely thinned renal parenchyma was found. The diuretic renogram showed an obstructive pattern with impaired renal function. Initially, a retrograde dilatation balloon was placed in the ureteropelvic junction under cistoscopic control. With the patient in modified Valdivia position, percutaneous access to the renal pelvis was performed. By Seldinger technique and under fluoroscopy guide, a 5 mm laparoscopic trocar was placed in the renal pelvis. We performed a percutaneous electrical endopyelotomy of the pyeloureteral junction over the 6 mm retrograde balloon dilator passed through. We placed an antegrade double J stent that was removed at 4 weeks uneventfully. RESULT: Good results were assessed without perioperative or postoperative complications with great improvement in renal dilatation two years after the intervention. The renogram showed improvement in the pattern of the curve with a slight increase in differential renal function. CONCLUSIONS: Percutaneous endopyelotomy in children has important issues due to the lack of appropriate material. However it is possible to get good results as a minimally invasive technique. In fact, it could be the ideal technique in severe hydronephrosis with large renal pelvis that prevents the surgical or endourological approach(AU)