Enuresis. Diagnóstico diferencial y tratamiento específico / Enuresis. Differential diagnosis and specific treatment

Introducción. A pesar de su gran prevalencia y antigüedad, esta patología tiene importantes interrogantes etiológicos, diagnósticos y terapéuticos. Hay que partir de dos grupos completamente diferentes: la enuresis (E) monosintomática o no complicada y el síndrome (S) enurético o E complicada con sus respectivos subgrupos, cada uno con etiología diferente que además es multifactorial. Diagnóstico diferencial. Se estructura en 3 niveles: 1º ¿E. monosintomática o S. enurético?; 2º ¿Patalogía o malos hábitos?; 3º ¿Disfunción de llenado o vaciado? Historia. Se describen tratamientos utilizados en diferentes culturas y épocas, demostrando la diversidad y a veces antagonismo que persiste hasta hoy, como demostración de la necesidad de un diagnóstico diferencial y un tratamiento etiológico. Tratamiento actual. Tras estudio de metaanálisis y revisiones sistemáticas se han ordenado por nivel de evidencia (NE) y grado de recomendación (GR) los estudios más válidos de tratamientos de E. monosintomática. La desmopresina, la alarma y la asociación de ambas tienen el máximo NE y GR, mientras que los antidepresivos tienen el mismo NE pero el menor GR por riesgo de efectos adversos. Los anticolinérgicos asociados a desmopresina están en el 2º nivel de NE y GR. Tratamiento personalizado. Se expone un tratamiento integral personalizado multidisciplinar. Se expone un tratamiento integral personalizado y multidisciplinar. Se inicia con diagnóstico diferencial y valoración psicológica. En E. monosintomática se inicia 1º un tratamiento básico conductal, seguido de un 2º paso con desmopresina y/o alarma según características personales. Si el resultado con uno de ellos es insuficiente se aconseja un 3º paso asociando el otro o añadiendo anticolinérgicos. Si es necesario un 4º paso se proponer biofeedback. El soporte psicológico de la familia y del niño es importante para la motivación, adhesión al tratamiento y mantenimiento de éxito. Conclusiones. Cada enurético es distinto y precisa un diagnóstico diferencial adecuado, además de una investigación personalizada, identificando sus factores influyentes. En la E. monosintomática el mejor NE y GR actualmente corresponden a la desmopresina, a la alarma y a ambas juntas. Hay que conocer todos los recursos terapéuticos disponibles, para diseñar un tratamiento lo más individualizado posible. Con frecuencia la combinación de tratamiento es efectiva. En la experiencia de los autores, el tratamiento multidisciplinar en equipo puede ser la mejor opción (AU)

Introduction. In spite of its great prevalence and antiquity, this condition has significant etiological, diagnostic and therapeutic questions. Two completely different groups must be considered: monosymptomatic or uncomplicated enuresis (E) and enuretic or complicated E syndrome (S) with their respective subgroups, each one with different etiology that is also multifactorial. Differential diagnosis. This diagnosis is structured into 3 levels: 1) Monosymptomatic E or enuretic syndrome?; 2) Disease or poor habits?; 3) Filling or emptying dysfunction? History. Treatments used in different cultures and periods that demonstrate the diversity and sometimes antagonisms that persists up to the current date are described as a demonstration of the need for a differential diagnosis and etiological treatment. Current treatment. After the meta-analysis study and systematic reviews, the most valid studies of treatments of monosymptomatic E. were ordered by level of evidence (LE) and recommendation grade (RG). Desmopressin, the alarm and the association of both have a maximum LE and while antidepressants have the same LE, but a lower RG, due to the risk of adverse events. The anticholinergics associated to desmopressin are on the second level of the LE and RG. Personalized treatment. A personalized comprehensive and multidisciplinary treatment is explained. It is begun with the differential diagnosis and psychological evaluation. In monosymptomatic E, a first basic behavioural treatment is initiated followed by a second step with desmopressin and/or o alarm according to personal characteristics. If the result with one of them is insufficient, a third step is recommended by means of associating the other or adding anticholinergics. If a four step is necessary, biofeedback is proposed. The psychological support of the family and of the child is important for motivation, treatment adherence, and maintenance of success. Conclusions. Each enuretic is differential diagnoses in addition to a personalized study, identifying their influencing factors. In Monosymptomatic E, the best LE and RG currently correspond to desmopressin, to the alarm and to both of them. It is necessary to know all the therapeutic resources available to design the most individualized treatment possible. The combination of treatments is frequently effective. In the experience of the authors, team multidisciplinary treatment may be the best option (AU)

Estenosis ppieloureteral de diagnóstico prenatal. Nuestro manejo / Pyeloureteral stenosis of prenatal diagnosis. Our management

La estenosis pieloureteral es la anomalía más frecuente del tracto urinario de diagnóstico prenatal. Actualmente la mayoría de los casos se diagnostican prenatalmente, pero algunos aún se hacen postnatalmente por el desarrollo de síntomas (dolor abdominal, infección urinaria, hematuria, tumoración abdominal o retraso en el desarrollo pondo-estatural). Dilatación no es sinónimo de obstrucción y se requieren estudios seriados con ultrasonidos (US) y renograma diurético (RD) para diferenciar la obstrucción de la dilatación sin patología. Los factores de riesgo de obstrucción se basan en los US y del RD y son: a)hidronefrosis de grado 3 o mayor, B) diámetro antero-posterior de la pelvis renal, medido en el plano transversal, mayor de 20 mm, c) tiempo medio de eliminación mayor de 20 minutos y d) función renal diferencial menor del 40% en el RD. El reflujo vesicoureteral existe en el 15% de los caos por lo que el cistograma suele ser necesario. La técnica operatoria de elección es la plastia desmembrada de Anderson-Hynes, que tiene buenos resultados es más del 95% de los casos. La endopielotomía se reserva para las reestenosis postoperatorias. La laparoscopia es la técnica ideal para niños mayores de una años (AU)

The Ureteropelic Junction Obstruction is the most frequent pathology of prenatal diagnosis.l Nowadays, most of the cases are done prenatally, but some of them have to be done after birth because of the symptoms developed/observed (abdominal pain, urinary tract infection, haematuria, abdominal pain, urinary tract infection, haematuria, abdominal mass or failure to thrive). Dilatation is not the same as obstruction, and serial studies with ultrasound (US) and diuretic renogram (DR) are required to make a differential diagnosis between obstruction and dilatation without pathology. The obstruction risk factors are based on US and DR, as follows: a) dilatation grade 3 or higher; b) anteroposterior renal pelvis diameter in transversal plane over 20mmm; c) average half time of elimination of radiotracer (T1/2) greater than 20 minutes; and d) differential renal function less than 40% in the DR. The vesicoureteral reflux is present in 15% of the cases so the voiding cystouretrogram is felt necessary. The gold standard surgical technique is the success. The endopyelothomy is the elective technique for postoperatory restenosis. Laparoscopic approach is ideal for children older than 12 months (AU)

Pérdida de la reducción de la presión arterial sistólica nocturna en el niño obeso / No disponible

La monitorización ambulatoria de la presión arterial (MAPA) permite evaluar no sólo las elevaciones casuales de la presión arterial (PA) durante el día, sino también las alteraciones en el patrón circadiano de la PA a lo largo de las 24horas. El objetivo del presente estudio es evaluar los patrones de PA a lo largo de 24 horas en una población de niños obesos remitidos a la consulta de nuestro hospital, valorando su relación con el grado de obesidad e insulin resistencia. Métodos: Se estudiaron 119 niños obesos (edades 7-15años) a los que se les determinó la PA clínica y ambulatoria, así como un estudio bioquímico para la determinación de glucosa, insulina y cálculo de HOMA, y determinación de microalbuminuria en la primera orina de la mañana. El grado de sobrepeso se estableció según la puntuación z del índice de masa corporal (IMC) acorde a su edad y sexo. Resultados: El 47% de los pacientes presentaban unas cifras elevadas de PA sistólica clínica en la primera y única medida de PA en el tiempo, sin confirmación en visitas sucesivas. La prevalencia global de hipertensión (HTA) medida por MAPA era del 36%. El 14% eran hipertensos sistólicos diurnos, y el33% (n = 39) hipertensos sistólicos nocturnos. De estos últimos, veinticinco de ellos (64%) sólo eran hipertensos sistólicos durante la noche, y el resto (n = 14), también lo eran durante el día. Sólo cuatro pacientes eran hipertensos sistólicos diurnos de manera aislada. Ningún paciente presentó una hipertensión diastólica aislada diurna o nocturna. En el 47% del total de pacientes (n=56) no se producía el descenso nocturno esperado de la PA sistólica. Esta pérdida del patrón circadiano de la PA dependía tanto del grado de obesidad (p <0 001 como de la insulinresistencia p <0 001 expresado según valores de homa conclusiones: en nuestra muestra niños obesos las cifras elevadas pa sistólica nocturna y la atenuación del descenso nocturno fisiológico constituyen forma más frecuente hipertensión este fenómeno se asocia al grado obesidad e insulinresistencia (AU)

Ambulatory blood pressure monitoring (ABPM) allows evaluation not only of casual daytime elevations of blood pressure (BP)but also alterations in the 24-hour circadian patterns of BP. The aim of the present study was to assess 24-hour BP patterns in a population of obese children who were referred to our out patient clinic, in relation to the degree of obesity and insulin resistance. Methods: Office and ambulatory BP measurements, and fasting serum glucose, insulin and HOMA determinations were obtained in 119 obese children (7-15 years old). Urinary albumin excretion was measured in the first morning urine. The extend of obesity was quantified using body mass index z score adjusted by age and gender. Results: The prevalence of office hypertension in only one set of blood pressure measurements was 47%. This value was not confirmed on further separate occasions. The prevalence of global ambulatory hypertension was 36%. Diurnal systolic hypertension was found in 14%, while 39 patients (33%) had nocturnal systolic hypertension. Twenty five of them (64%) were only hypertensive at nightime and the rest (n = 14), were also hypertensive during the day. Only 4 patients were exclusively systolic hypertensive at daytime (table III). None of the patients were exclusively diastolic at day or nightime. Of the total 119 subjects,47% were non systolic dippers. This abnormal BP pattern was associated with the degree of obesity (p <0 001 and insulinresistance homa values p <0 001 the anthropometric and metabolic characteristics of population studied are shown in table i ii respectively correlations coefficients regression analysis between parameters iv v conclusion: reduced nocturnal systolic blood pressure dip nightime hypertension were most frequent forms our cohort severe obese children these alterations 24-hour circadian patterns bp related to degree obesity insulin resistance (AU)

[Reduced nocturnal systolic blood pressure dip in obese children]. / Pérdida de la reducción de la presión arterial sistólica nocturna en el niño obeso.

UNLABELLED: Ambulatory blood pressure monitoring (ABPM) allows evaluation not only of casual daytime elevations of blood pressure (BP) but also alterations in the 24-hour circadian patterns of BP. The aim of the present study was to assess 24-hour BP patterns in a population of obese children who were referred to our outpatient clinic, in relation to the degree of obesity, body fat distribution and insulin resistance, and considering other cardiovascular risk factors. METHODS: Office and ambulatory BP measurements, and fasting serum glucose, insulin and HOMA determinations were obtained in 119 obese children (7-15 years old). Urinary albumin excretion was measured in the first morning urine. The extend of obesity was quantified using body mass index z score adjusted by age and gender. RESULTS: The prevalence of office hypertension in only one set of blood pressure measurements was 47%. This value was not confirmed on further separate occasions. The prevalence of global ambulatory hypertension was 36%. Diurnal systolic hypertension was found in 14%, while 39 patients (33%) had nocturnal systolic hypertension. Twenty five of them (64%) were only hypertensive at nightime and the rest (n = 14), were also hypertensive during the day. Only 4 patients were exclusively systolic hypertensive at daytime (table III). None of the patients were exclusively diastolic at day or nighttime. Of the total 119 subjects 47% non systolic dippers. This abnormal BP pattern was associated with the degree of obesity (p < 0.001) and insulinresistance (HOMA values; p < 0.001). The anthropometric and metabolic characteristics of the population studied are shown in table I and II respectively. The correlations coefficients and regression analysis between anthropometric and metabolic parameters are shown in table IV and V. CONCLUSION: Reduced nocturnal systolic blood pressure dip and nightime systolic hypertension were the most frequent forms of hypertension in our cohort of severe obese children. These alterations in the 24-hour circadian patterns of BP were related to the degree of obesity and insulin resistance.

[Primary vesicoureteral reflux and extravesical ureteral reimplantation in chidren]. / Reflujo vesicoureteral esencial y reimplantación ureteral extravesical en niños.

PURPOSE: to assess the results of the Lich-Gregoire procedure in the treatment of primary vesicoureteral reflux (VUR). MATERIALS AND METHODS: In a 2.5-year period, 141 children with primary VUR underwent a vesicoureteral reimplantation using the Lich-Gregoire procedure in 101 patients (158 ureters) and the Cohen procedure in 48 patients (68 ureters). Patients were evaluated retrospectively in a non randomized fashion and data were recorded about: age, indications for surgery, days with the bladder catheter, length of stay, and short and long-term complications. RESULTS: The control average time was 1.71 years (from 8 months to 3.5 years). A) Early complications. No obstruction was seen in this series. Five children (8.6 of the bilaterally simultaneously operated) showed urinary retention, but only three needed replacement of the bladder catheter and only one of them needed temporary clean intermittent catheterization. Nausea, vomiting, pain and hematuria were sporadic and limited in time. B) Late complications. The long-term results were good (95%). Seven ureters (4.4%) had persistent VUR and 3 children (6.7% of the unilateral cases) had contralateral VUR. Only 3 ureters needed a new surgical treatment (2%) for persistent ipsilateral VUR. Short and long-term complications, days with bladder catheter and length of stay in the hospital were significantly smaller in the group of patients operated with Lich-Gregoire procedure than in patients operated with the Cohen technique. CONCLUSIONS: The Lich-Gregoire procedure is a technique associated with shorter postoperative hospitalization and less discomfort, pain and hematuria than the intravesical technique. Both techniques were effective in correcting VUR. Extravesical reimplantation can cause transitory bladder dysfunction in a small percentage of the bilateral cases.

Reflujo vesicoureteral esencial y reimplantación ureteral extravesical en niños / Primary vesicoureteral reflux and extravesical ureteral reimplantation in children

Objetivos: Conocer los resultados de la reimplantación extravesical de Lich-Gregoire en el tratamiento quirúrgico del reflujo vesicoureteral (RVU) primario. Material y Métodos: En un período de 2,5 años se realizó un estudio retrospectivo no randomizado de 141 niños con RVU esencial sometidos a reimplante ureteral: 101 niños (158 uréteres refluyentes) por la técnica de Lich-Gregoire y 40 (68 uréteres) por la de Cohen. Se analizan los datos de los reimplantes extravesicales y se valoran: edad, indicaciones cirugía, días con sonda vesical, estancia hospitalaria y complicaciones a corto y largo plazo. Resultados: El tiempo medio de control ha sido de 1,71 años (Rango 8 meses a 3,5 años). A) Complicaciones precoces. No hubo ningún caso de obstrucción ureterovesical. Cinco niños (8,6% de los operados bilateralmente de forma simultánea) presentaron retención urinaria pero sólo tres necesitaron recolocación de sonda vesical y uno sólo de sondaje intermitente temporal. Las nauseas y vómitos, el dolor y la hematuria fueron escasos. B) Complicaciones tardías. Los resultados a largo plazo son buenos en el 95%. Se observó RVU persistente en 7 uréteres (4,4%) y RVU contralateral en 3 niños (6,7% de los casos unilaterales). Sólo precisaron nuevo tratamiento quirúrgico 3 uréteres (2%) con RVU ipsilateral persistente. Se compararon los resultados de la técnica de Lich-Gregoire con la de Cohen y se observó que en la extravesical eran significativamente menores el número de complicaciones, dolor, hematuria, días con sonda vesical y estancia hospitalaria. Conclusiones: La técnica de Lich-Gregoire es un procedimiento de corta estancia hospitalaria, efectivo para la corrección del RVU, que origina menos molestias, dolor, hematuria y días de ingreso que las técnicas intravesicales. No obstante puede ocasionar disfunción vesical transitoria en los casos bilaterales

Purpose: to assess the results of the Lich-Gregoire procedure in the treatment of primary vesicoureteral reflux (VUR). Materials and methods: In a 2.5-year period, 141 children with primary VUR underwent a vesicoureteral reimplantation using the Lich-Gregoire procedure in 101 patients (158 ureters) and the Cohen procedure in 48 patients (68 ureters). Patients were evaluated retrospectively in a non randomized fashion and data were recorded about: age, indications for surgery, days with the bladder catheter, length of stay, and short and long-term complications. Results: The control average time was 1.71 years (from 8 months to 3.5 years). A) Early complications. No obstruction was seen in this series. Five children (8.6 of the bilaterally simultaneously operated) showed urinary retention, but only three needed replacement of the bladder catheter and only one of them needed temporary clean intermittent catheterization. Nausea, vomiting, pain and hematuria were sporadic and limited in time. B) Late complications. The long-term results were good (95%). Seven ureters (4.4%) had persistent VUR and 3 children (6.7% of the unilateral cases) had contralateral VUR. Only 3 ureters needed a new surgical treatment (2%) for persistent ipsilateral VUR. Short and long-term complications, days with bladder catheter and length of stay in the hospital were significantly smaller in the group of patients operated with Lich-Gregoire procedure than in patients operated with the Cohen technique. Conclusions: The Lich-Gregoire procedure is a technique associated with shorter postoperative hospitalization and less discomfort, pain and hematuria than the intravesical technique. Both techniques were effective in correcting VUR. Extravesical reimplantation can cause transitory bladder dysfunction in a small percentage of the bilateral cases

[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.

[The first year of life of children with myelodysplasia: a multicenter study of 393 cases]. / El primer año de la vida del niño con mielodisplasia. Estudio multicéntrico sobre 393 casos.

A multicentric study about the first year of life of myelodisplastic children, was done. Family, pregnancy, delivery, newborn somatometry, and anatomical-pathological and terapeuthical aspects were review in 393 patients born before july 1992. Annual prevalence vary from 6 (1973) to 28 (1984). The families clinical history was not significant. There were 9 (2,3%) gemelar pregnancies, but both children were affected only in one case. Prenatal ultrasound was not diagnostic in 61%-84% of patients are meningomyeloceles, the anatomical level of myelodisplasia was lumbar and or sacral in 98%. There was hydrocephalus in 59%, hip dislocation in 24%, feet deformities in 50%, upper urinary tract dilatation in 12%, vesicoureteral reflux in 15%. In total 825 surgical procedures were performed (M = 2); the neurosurgery was 94% of them.

Polyorchidism: an exceptional case of three homolateral testes.

Polyorchidism is an uncommon congenital anomaly defined as the presence of more than two histologically proved testes. The present case of polyorchidism was discovered casually in an 11-year-old boy while performing an orchiopexy. Three testes were found on the left side; we have been unable to find this exceptional anomaly previously published in the medical literature.