Influencia del inicio precoz del tratamiento conservador en la evolución del paciente pediátrico con vejiga neuropática / Influence in the outcome of neuropathic pediatric patients after early treatment

IntroducciónEl cateterismo limpio intermitente (CI) y el tratamiento anticolinérgico son la base del tratamiento conservador de la vejiga neuropática (VN); sin embargo, todavía no hay acuerdo sobre la edad a la que debería iniciarse dicha terapia.ObjetivoEl objetivo de nuestro estudio fue analizar la influencia del inicio precoz (primer año de vida) del tratamiento anticolinérgico y el CI en la evolución a largo plazo de la función renal y vesical. Nuestra hipótesis es que los niños que iniciaron el tratamiento conservador en el primer año de vida tienen mejor pronóstico en términos de función renal y vesical, así como menos necesidad de tratamiento quirúrgico que aquellos que iniciaron el tratamiento a edades más avanzadas.Pacientes y métodosEstudio retrospectivo de los pacientes con VN tratados en nuestro servicio (1995- 2005) dividiéndolos para su comparación en dos grupos: grupo 1 incluye a aquellos que iniciaron el tratamiento conservador en el primera año de vida, y grupo 2, a aquellos que lo iniciaron entre el primer y el quinto año. Se revisaron las historias clínicas recogiendo datos sobre: edad de inicio del CI y tratamiento anticolinérgico, presencia de reflujo vésico-ureteral (RVU) o ureterohidronefrosis (UHN), función renal, presencia de cicatrices renales, infección del tracto urinario (UTI), presencia de cicatrices renales, comportamiento vesical, necesidad de intervención quirúrgica y continencia urinaria.ResultadosSe incluyeron 61 pacientes: 25 en el grupo 1 y 36 en el grupo 2. Al inicio del estudio, la presencia de RVU e hiperactividad vesical eran más frecuentes en el grupo 2. En el grupo 1, un paciente con vejiga hiperactiva cambió a vejiga de baja acomodación, y en el grupo 2 un paciente con vejiga de acomodación normal y 4 con vejigas hiperactivas cambiaron a vejigas de baja

Background Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients.AimTo analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life.Patients and methodRetrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence.ResultsSixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency.ConclusionsPatients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA

Influence in the outcome of neuropathic pediatric patients after early treatment.

BACKGROUND: Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients. AIM: To analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life. PATIENTS AND METHOD: Retrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence. RESULTS: Sixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency. CONCLUSIONS: Patients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.

Influence in the outcome of neuropathic pediatric patients after early treatment. / Influencia del inicio precoz del tratamiento conservador en la evolución del paciente pediátrico con vejiga neuropática.

BACKGROUND: Clean intermittent catheterization (CIC) and anticholinergic drugs are the mainstay treatment for neuropathic bladder (NB). However, there is not consensus about the time therapy should be started in pediatric patients. AIM: To analyze the impact of early start (first year of life) of CIC and anticholinergic treatment on long-term renal and bladder function. Our hypothesis is that those children who start conservative treatment in the first year of life have better outcome in terms of bladder and renal function and less need of surgical procedures, compared to those who started treatment later in life. PATIENTS AND METHOD: Retrospective study of pediatric patients with NB treated in our hospital (1995-2005) dividing them for comparison in two groups: group 1 started treatment in the first year of life and group 2 between 1 and 5 years old. Collected data included: date of CIC and anticholinergic initiation, presence of VUR or UHN, renal function, UTIs, renal scars, bladder behavior, surgery and urinary continence. RESULTS: Sixty-one patients were included, 25 in group 1 and 36 in group 2. Initially vesico-ureteral reflux (VUR) and overactive bladders were more frequent in group 2. In group 1 one overactive bladder changed to low compliant and in group 2, one normal bladder and 4 overactive bladders changed. At the end of follow-up there were 11 low compliant bladders in group 1 and 17 in group 2. However, in group 1, only 2 patients required bladder augmentation (BA) while in group 2, 12 patients needed it. At the end of the study only 2 patients in group 2 had slight renal insufficiency. CONCLUSIONS: Patients who started conservative treatment in the first year of life have better long-term outcome in terms of UTI, renal scars and surgical procedures. Even if they initially had low compliant bladders, these patients require less BA.

Tratamiento endourológico del muñón ureteral sintomático posnefrectomía / Endourological treatment of symptomatic ureteral stump posnephrectomy

Introducción: El síndrome del muñón ureteral se define como una infección urinaria recurrente, dolor abdominal bajo y hematuria en pacientes con antecedentes de nefrectomía previa. Su incidencia es baja y su sintomatología, inespecífica. El objetivo de nuestro trabajo es presentar nuestros resultados con el tratamiento endoscópico de los restos ureterales sintomáticos. Material y métodos: Realizamos un estudio retrospectivo de los pacientes que presentaban síndrome de resto ureteral tras nefrectomía y que han sido tratados en nuestro centro entre los años 2004 y 2015. Presentamos una serie de 10 pacientes. Los pacientes fueron tratados endoscópicamente con electrofulguración del uréter y de los bordes del meato afectado, con posterior inyección de material de relleno a nivel submucoso subureteral para favorecer la coaptación de las paredes del resto ureteral. Resultados: La media de edad al tratamiento fue de 2 años. El resto ureteral afectado fue derecho en 6 pacientes y en 4 fue el lado izquierdo. Siete meatos fueron ectópicos y 3, ortotópicos. El tiempo de seguimiento fue de 8 años. Tras el tratamiento endoscópico solo 2 pacientes recidivaron. Conclusión: El tratamiento endourológico del síndrome del muñón ureteral supone una opción simple, segura, rápida, ambulante y eficaz, tanto para restos ortotópicos como ectópicos. No compromete, si fuera necesaria, la posterior resección abierta del resto ureteral, por lo que creemos que debe considerarse como una alternativa válida para el tratamiento inicial de esta patología

Introduction: ureteral stump syndrome is defined as a recurrent urinary infection, low abdominal pain and haematuria in patients with a history of nephrectomy. Its incidence is low and the symptoms are non-specific. The aim of our paper was to present our results with endoscopic treatment of symptomatic ureteral remnants. Material and methods: We performed a retrospective study of patients with ureteral remnant syndrome after nephrectomy treated in our centre between 2004 and 2015. We present a series of 10 patients. The patients were treated endoscopically with electrofulguration of the ureter and edges of the affected meatus, with subsequent injection of filler material into the suburetheral submucosa to aid in the coaptation of the ureteral remnant walls. Results: The mean age at treatment was 2 years. The right ureteral remnant was treated in 6 patients and the left in 4. Seven meatuses were ectopic and 3 orthotopic. Follow-up was 8 years. After endoscopic treatment only 2 patients relapsed. Conclusion: Endourological treatment of ureteral stump syndrome is a simple, safe, rapid and effective option that can be performed as an outpatient, for orthotopic and ectopic stumps. It does not compromise subsequent open resection of the ureteral remnant if required, and therefore we believe that it should be considered a valid alternative for the initial treatment of this disorder

Endourological treatment of symptomatic ureteral stump posnephrectomy. / Tratamiento endourológico del muñón ureteral sintomático posnefrectomía.

INTRODUCTION: ureteral stump syndrome is defined as a recurrent urinary infection, low abdominal pain and haematuria in patients with a history of nephrectomy. Its incidence is low and the symptoms are non-specific. The aim of our paper was to present our results with endoscopic treatment of symptomatic ureteral remnants. MATERIAL AND METHODS: We performed a retrospective study of patients with ureteral remnant syndrome after nephrectomy treated in our centre between 2004 and 2015. We present a series of 10 patients. The patients were treated endoscopically with electrofulguration of the ureter and edges of the affected meatus, with subsequent injection of filler material into the suburetheral submucosa to aid in the coaptation of the ureteral remnant walls. RESULTS: The mean age at treatment was 2 years. The right ureteral remnant was treated in 6 patients and the left in 4. Seven meatuses were ectopic and 3 orthotopic. Follow-up was 8 years. After endoscopic treatment only 2patients relapsed. CONCLUSION: Endourological treatment of ureteral stump syndrome is a simple, safe, rapid and effective option that can be performed as an outpatient, for orthotopic and ectopic stumps. It does not compromise subsequent open resection of the ureteral remnant if required, and therefore we believe that it should be considered a valid alternative for the initial treatment of this disorder.

Tratamiento endoscópico del reflujo uretrodeferencial en niños / Endoscopic treatment of urethrodeferential reflux in children

Introducción: El reflujo uretrodeferencial es una entidad infradiagnosticada, no existiendo consenso en su tratamiento. Nuestro objetivo es mostrar nuestra experiencia en el tratamiento mínimamente invasivo de esta dolencia mediante tratamiento endoscópico. Material y métodos: Presentamos 8 pacientes con orquitis supuradas de repetición por reflujo uretrodeferencial tratados de forma endoscópica en el período de 2008-2013. Todos presentaron orquitis unilaterales. El número mínimo de orquitis por paciente anterior a la intervención fue de 3. El tratamiento endoscópico consistía en una uretroscopia con localización de los orificios eyaculatorios y un estudio de contraste intraoperatorio para demostrar el reflujo uretrodeferencial. Posteriormente se inyectó ácido hialurónico/dextranómero subeyaculatorio en todos los casos. Resultados: El tiempo medio de la cirugía fue de 15 min, siendo un procedimiento ambulante en todos los pacientes. No hubo complicaciones postoperatorias. Los pacientes presentaron buena evolución clínica. Solo un caso requirió el uso de una segunda inyección de ácido hialurónico/dextranómero. El seguimiento de estos pacientes mostró la resolución completa de los cuadros de epididimitis y un buen desarrollo testicular, con un seguimiento mayor de 4 años en todos los casos. Conclusión: Proponemos esta forma de tratamiento como una alternativa poco invasiva, fácilmente reproducible y que ha presentado buenos resultados a largo plazo en nuestra pequeña serie de pacientes

Introduction: Urethrodeferential reflux is an underdiagnosed condition, and there is no consensus on its treatment. Our objective is to show our experience in the minimally invasive treatment of this disease using endoscopy. Material and methods: We present 8 patients with recurrent suppurative orchitis due to urethrodeferential reflux treated endoscopically during the period 2008-2013. All patients presented unilateral orchitis. The minimum number of episodes of orchitis per patient prior to the operation was 3. The endoscopic treatment consists of ureteroscopy, locating the ejaculatory orifices and conducting an intraoperative contrast study to demonstrate the urethrodeferential reflux. Subejaculatory dextranomer/hyaluronic acid was subsequently injected in all the cases. Results: The mean surgical time was 15min, and the procedure was outpatient for all patients. There were no postoperative complications, and the patients had good clinical progression. Only one case required a second injection of dextranomer/hyaluronic acid. The follow-up of these patients showed a complete resolution of the epididymitis and good testicular development, with a follow-up longer than 4 years in all cases. Conclusion: We propose this form of treatment as a minimally invasive, easily reproducible alternative that shows good long-term results in our small series of patients

Endoscopic treatment of urethrodeferential reflux in children. / Tratamiento endoscópico del reflujo uretrodeferencial en niños.

INTRODUCTION: Urethrodeferential reflux is an underdiagnosed condition, and there is no consensus on its treatment. Our objective is to show our experience in the minimally invasive treatment of this disease using endoscopy. MATERIAL AND METHODS: We present 8 patients with recurrent suppurative orchitis due to urethrodeferential reflux treated endoscopically during the period 2008-2013. All patients presented unilateral orchitis. The minimum number of episodes of orchitis per patient prior to the operation was 3. The endoscopic treatment consists of ureteroscopy, locating the ejaculatory orifices and conducting an intraoperative contrast study to demonstrate the urethrodeferential reflux. Subejaculatory dextranomer/hyaluronic acid was subsequently injected in all the cases. RESULTS: The mean surgical time was 15min, and the procedure was outpatient for all patients. There were no postoperative complications, and the patients had good clinical progression. Only one case required a second injection of dextranomer/hyaluronic acid. The follow-up of these patients showed a complete resolution of the epididymitis and good testicular development, with a follow-up longer than 4 years in all cases. CONCLUSION: We propose this form of treatment as a minimally invasive, easily reproducible alternative that shows good long-term results in our small series of patients.

Enterocystoplasty in children with neuropathic bladders: long-term follow-up.

OBJECTIVE: This study assesses clinical outcome, after at least 8 years, of augmentation done before or at puberty in neuropathic bladders. PATIENTS AND METHODS: A total of 29 children with neuropathic bladders who did not respond satisfactorily to clean intermittent catheterisation and anti-cholinergic therapy underwent enterocystoplasty at a mean age of 11.8 years (range 3-18). Twenty-one children (72.4%) had vesicoureteral reflux (VUR) and/or ureterohydronephrosis and 22 (75.8%) had dimercapto-succinic acid scars, but all had normal renal function. All patients were followed at regular intervals with urinary tract imaging, serum electrolytes, creatinine, urodynamic evaluation and 24-h urine collection. Urine cytology, cystoscopy and biopsy were performed at the end of follow-up. RESULTS: Mean follow-up was 11 years (range 8-14.5) and mean age at the end of follow-up was 22.2 years (range 13.2-31). Urodynamic studies showed a significant improvement in bladder compliance in all patients. Upper urinary tract dilatation disappeared in all, VUR in 13/17 (76.4%), and no new renal scarring occurred in any patient. At the end of follow-up, renal function was normal in all according to serum creatinine, but cystatin C levels were normal in 27 and elevated in two. Significant proteinuria and low concentrations of renin and aldosterone were present in 80% and 82%, respectively. Only one patient had urinary tract infection, three had bladder stones, and in another a catheterisable channel was made. All patients were dry with normal urine cytology and cystoscopy, and no malignant lesions have been found in the biopsy specimens. CONCLUSION: Enterocystoplasty has preserved renal function and resolved VUR and/or hydronephrosis in most patients. The future implications of proteinuria and the low serum levels of renin and aldosterone, as well as the best indicator for measuring renal function, have yet to be determined. Close, life-long follow-up, including cystoscopy, is necessary to prevent complications.

Creciendo con una ampliación vesical / Growing up with a bladder augmentation

Las estenosis esofágicas son una de las complicaciones más frecuentes de la corrección quirúrgica de las atresias de esófago. Su tratamiento consiste en la dilatación de la estenosis, precisando en la mayoría de los casos más de 1 procedimiento para su corrección. Introducción: Analizamos la evolución a largo plazo de nuestros pacientes con vejiga neuropática a los que se realizó una ampliación vesicalantes de la pubertad. Pacientes y métodos: A 21 pacientes con vejigas neuropáticas de baja acomodación y mala respuesta al sondaje intermitente y/o anticolinérgicos se les realizó una ampliación vesical (edad media 8.3 años, rango;2,5-12). Dieciocho de ellos (86%) tenían RVU y/o ureterohidronefrosis y 17 (81%) cicatrices renales sin afectación de la función renal salvo en un caso. Todos los pacientes fueron seguidos regularmente con estudios de función renal, pruebas de imagen, análisis de orina de 24horas y estudios urodinámicos. A los 18 pacientes ampliados con intestino se les realizó citología urinaria, cistoscopia y biopsia. Resultados: El seguimiento medio fue de 11 años (8-14,5) y la media de edad al final del estudio fue de 19 años (13,2-26,8). Los estudios urodinámicos demostraron una mejoría significativa de la acomodación vesical. La ureterohidronefrosis desapareció en todos los pacientes, el RVU en13 de 15 (86%) y ninguno presentó nuevas cicatrices renales. Al final del estudio, la función renal era normal en 20 de ellos. Un paciente tuvo una ITU y otro un cálculo vesical. Todos están secos y 2 de ellos no necesitan sondaje intermitente. La citología y la cistoscopia fueron normales y no se encontraron lesiones malignas en las biopsias. Conclusión: La ampliación vesical antes de la pubertad preserva la función renal y corrige el RVU y/o la ureterohidronefrosis en la mayoría de los pacientes, sin reimplantar los uréteres. Un seguimiento de por vida, incluyendo la realización de cistoscopias periódicas, es necesario para mejorar los resultados y prevenir las complicaciones (AU)

Introduction: This study assesses long-term outcome of patients with neuropatic bladders who underwent a bladder augmentation before puberty. Patients and methods: A total of 21 patients with low compliant neuropathic bladders who did not respond satisfactory to clean intermittent catheterization and/or anticholinergic therapy underwent bladder augmentation(mean age 8.3 yr, range; 2.5-12). Eighteen patients (86%)had VUR and/or ureterohydronephrosis and 17 (81%) had DMSA renal scars. Renal function was normal in all cases except one. All patients were followed at regular intervals with serum electrolyte and creatinine determination, urinary tract imaging, urodynamic evaluation and 24-hour urine collection. In the 18 cases augmented with intestine, urinecytology, cystoscopy and biopsy were also performed. Results: Mean follow-up was 11 yr (8-14.5) and mean age at the end of follow-up was 19 yr (13.3-26.8). Urodynamic studies showed a significant improvement in bladder compliance. Upper urinary tract dilatation disappeared in all patients, VUR in 13/15p (86%) and no new renal scarring occurred. Renal function was normal at the end of followupin 20. Only 1 patient had UTI and another had a bladder stone. All patients are dry and 2 of them do not need clean intermittent catheterization. Urine cytology and cystoscopy were normal and no malignant lessions have been found in the biopsy specimens. Conclusions: Bladder augmentation done pre-puberty preserves renal function and resolves VUR and/or hydronephrosis in most cases without reimplanting the ureters. Close lifelong follow-up, including a cystoscopy, improves the results and prevents complications (AU)

[Growing up with a bladder augmentation]. / Creciendo con una ampliación vesical.

INTRODUCTION: This study assesses long-term outcome of patients with neuropatic bladders who underwent a bladder augmentation before puberty. PATIENTS AND METHODS: A total of 21 patients with low compliant neuropathic bladders who did not respond satisfactory to clean intermittent catheterization and/or anticholinergic therapy underwent bladder augmentation (mean age 8.3 yr, range; 2.5-12). Eighteen patients (86%) had VUR and/or ureterohydronephrosis and 17 (81%) had DMSA renal scars. Renal function was normal in all cases except one. All patients were followed at regular intervals with serum electrolyte and creatinine determination, urinary tract imaging, urodynamic evaluation and 24-hour urine collection. In the 18 cases augmented with intestine, urine cytology, cystoscopy and biopsy were also performed. RESULTS: Mean follow-up was 11 yr (8-14.5) and mean age at the end of follow-up was 19 yr (13.3-26.8). Urodynamic studies showed a significant improvement in bladder compliance. Upper urinary tract dilatation disappeared in all patients, VUR in 13/15p (86%) and no new renal scarring occurred. Renal function was normal at the end of follow-up in 20. Only 1 patient had UTI and another had a bladder stone. All patients are dry and 2 of them do not need clean intermittent catheterization. Urine cytology and cystoscopy were normal and no malignat lessions have been found in the biopsy specimens. CONCLUSIONS: Bladder augmentation done pre-puberty preserves renal function and resolves VUR and/or hydronephrosis in most cases without reimplanting the ureters. Close lifelong follow-up, including a cystoscopy, improves the results and prevents complications.