Unidad de asistencia coordinada a pacientes con anomalías del tubo neural y sus familias / Coordinated care unit for patients with neural tube anomalies and their families

La Espina Bífida es una malformación multisistémica incurable y transmisible, con múltiples secuelas importantes, unas tratables y otras evitables, que afectan y limitan tanto la salud como la vida socio-laboral. El objetivo principal debe ser la prevención. La primaria, es decir la no ocurrencia, se puede realizar conociendo los posibles factores etiológicos implicados en la población. Esto es una responsabilidad de política sanitaria basada en la evidencia científica y la opinión de los expertos. La prevención secundaria es intentar disminuir las secuelas y mejorar la calidad y expectativa de vida de los nacidos con EB. En la actualidad las personas nacidas con Espina Bífida, tienen una prolongada expectativa de vida, con una serie de necesidades específicas durante toda su existencia. Son fundamentales los primeros años de vida. En la adolescencia y la adultez hay un gran riesgo si se abandona cualquier aspecto socio-sanitario a la evolución natural, dejando los controles y cuidados propios de la asistencia coordinada pediátrica, ya que la tendencia será a producirse complicaciones totalmente evitables. El paciente con Espina Bífida es fundamentalmente una persona, no una suma de patologías. Es imprescindible tener una visión holística e integral de cada persona con EB, y no como una serie de diferentes especialidades inconexas. La intervención independiente de los múltiples profesionales implicados pueden interferirse perjudicialmente, pero pueden lograr la máxima eficiencia (costo-eficacia) y calidad asistencial si lo hacen de manera continua y coordinada. Los esfuerzos realizados y los objetivos conseguidos en la edad pediátrica pueden mejorarse con la Asistencia Coordinada Multidisciplinar, pero pueden perderse si no se continúan durante toda la vida, produciéndose un deterioro evitable, en la calidad de vida y una perdida de los elevados recursos sanitarios invertidos

Bifid Spine is a multisystem malformation incurable and transmissible with a lot of important sequelae, some of them with treatment and some other avoidable. They affect and limit not only health but social-work life too.The main objective must be prevention. The primary prevention, meaning not occurrence, could be done by recognizing the possible etiologic factors that affect the population. This is a responsibility of health policies based in scientific evidences and expert's opinions. Secondary prevention would be to make efforts to decrease the consequences and improve newborns with bifid spine life`s quality and life expectancy. Actually, persons born with bifid spine, have a long-term life expectancy with specific necessities during their lives. The first two years of life are very important. During their adolescence and adult life, risk increases if any social-health aspect is abandoned giving up follow and self-care from the pediatrics coordinated assistance team, as it follows its natural evolution. It will cause totally avoidable complications. A patient with bifid spine is basically a person, not a group of diseases. It is essential to have a holistic and total look for each person with bifid spine and not consider the patient like a collection of troubles treated with different non coordinated specialities. The individual intervention of each medical doctor could damage and it could be better if they work coordinated for a long time. This strategy would allow improved efficiency (cost/efficacy) and quality of assistance.Every effort done and the objectives reached in childhood can be improved with the multidisciplinary coordinated assistance, but it can be lost if it does not continue during all life. It may cause a serious and evitable damage in life quality with loss of spent health resources

[Coordinated care unit for patients with neural tube anomalies and their families.] / Unidad de asistencia coordinada a pacientes con anomalías del tubo neural y sus familias.

Bifid Spine is a multisystem malformation incurable and transmissible with a lot of important sequelae, some of them with treatment and some other avoidable. They affect and limit not only health but social-work life too. The main objective must be prevention. The primary prevention, meaning not occurrence, could be done by recognizing the possible etiologic factors that affect the population. This is a responsibility of health policies based in scientific evidences and expert's opinions. Secondary prevention would be to make efforts to decrease the consequences and improve newborns with bifid spine lif's quality and life expectancy. Actually, persons born with bifid spine, have a longterm life expectancy with specific necessities during their lives. The first two years of life are very important. During their adolescence and adult life, risk increases if any social-health aspect is abandoned giving up follow and self-care from the pediatrics coordinated assistance team, as it follows its natural evolution. It will cause totally avoidable complications. A patient with bifid spine is basically a person, not a group of diseases. It is essential to have a holistic and total look for each person with bifid spine and not consider the patient like a collection of troubles treated with different non coordinated specialities. The individual intervention of each medical doctor could damage and it could be better if they work coordinated for a long time. This strategy would allow improved efficiency (cost/efficacy) and quality of assistance. Every effort done and the objectives reached in childhood can be improved with the multidisciplinary coordinated assistance, but it can be lost if it does not continue during all life. It may cause a serious and evitable damage in life quality with loss of spent health resources.

Ureteral meatotomy as an option in the management of primary obstructive megaureter in neonates and infants. / Meatotomía ureteral como opción para gestión del megauréter obstructivo primario en neonatos y lactantes.

Differentiating between the cases of megaureter that require surgery and the ones in whom treatment can be delayed is challenging. A large number of surgical techniques for the treatment of POM been proposed aiming mainly to reduce renal damage by relieving the affected ureter. Resection of the affected ureteral segment followed by vesicoureteral reimplantation either with or without reduction ureteroplasty is the classic treatment, however posing a high rate of complications when performed in patients aged less than one year. Endoscopic techniques have also been described to avoid external diversion. Recently, refluxing ureteral reimplantation has been proposed as a temporary treatment for patients with POM. OBJECTIVE: To describe the ureteral meatotomy technique as an alternative to the refluxing ureteral reimplantation for POM in patients aged less than one year. METHOD: Retrospective study of patients with POM undergoing ureteral meatotomy, aiming to temporarily relieve the ureter. The procedure consists of a 1.5 cm-long cut made with scissors on the upper edge of the ureteral ostium at the 12 o'clock position, until the dilated portion of the ureter was found and abundant urine drainage was observed. The edges of the incision were sutured, joining together the ureteral mucosa and the bladder mucosa. RESULT: From 2011 to 2015, three patients with POM underwent ureteral meatotomy, with four renal units treated altogether. None of the patients presented complications and, as a sign of obstruction relief, all showed reduced dilatation at the ultrasound. No patient had complications. CONCLUSIONS: Ureteral meatotomy is a safe and effective technique in the initial treatment of POM in patients aged less than one year.

Meatotomía ureteral como opción para gestión del megauréter obstructivo primario en neonatos y lactantes / Ureteral meatotomy as option in the management of primary obstructive megaureter in neonates and infants

La diferenciación de los casos de megauréter que requieren cirugía de los que se pueden conducir de forma expectante es un desafío. Numerosas técnicas operatorias para el tratamiento del MOP han sido propuestas, teniendo como principal objetivo la reducción del daño renal desbloqueando el uréter afectado. La resección del segmento comprometido seguido del reimplante vesicoureteral con o sin ureteroplastia reductiva es el tratamiento clásico, pero tiene alta tasa de complicaciones cuando se realiza en niños menores de un año de edad. Las técnicas endoscópicas también han sido descritas para evitar la derivación externa. Recientemente se ha propuesto llevar a cabo el reimplante ureteral refluyente como un tratamiento temporal para pacientes con MOP. OBJETIVO: Describir la técnica de meatotomía ureteral como alternativa al reimplante ureteral refluyente para tratamiento del MOP en niños menores de un año de edad. MÉTODO: Estudio retrospectivo de los pacientes con MOP que se sometieron a meatotomía ureteral, con objetivo de la desobstrucción ureteral temporal. El procedimiento consiste en una sección del ostium ureteral con tijeras en su borde superior a las 12 horas, por una extensión de 1,5 cm hasta alcanzar la parte dilatada del uréter y observar abundante drenaje de orina. Los bordes de la sección son suturados, juntando la mucosa ureteral a la mucosa vesical. RESULTADO: En el período 2011-2015, tres pacientes con MOP fueron sometidos a meatotomía ureteral, por un total de cuatro unidades renales tratadas. Ningún paciente presentó complicaciones y todos tuvieron reducción de la dilatación al ultrasonido, como señal de desobstrucción. Ningún paciente presentó complicaciones. CONCLUSIONES: La meatotomía ureteral es una técnica segura y eficaz para el tratamiento inicial del MOP en niños menores de un año de edad

Differentiating between the cases of megaureter that require surgery and the ones in whom treatment can be delayed is challenging. A large number of surgical techniques for the treatment of POM have been proposed aiming mainly to reduce renal damage by relieving the affected ureter. Resection of the affected ureteral segment followed by vesicoureteral reimplantation either with or without reduction ureteroplasty is the classic treatment, however posing a high rate of complications when performed in patients aged less than one year. Endoscopic techniques have also been described to avoid external diversion. Recently, refluxing ureteral reimplantation has been proposed as a temporary treatment for patients with POM. OBJECTIVE: To describe the ureteral meatotomy technique as an alternative to the refluxing ureteral reimplantation for POM in patients aged less than one year. METHOD: Retrospective study of patients with POM undergoing ureteral meatotomy, aiming to temporarily relieve the ureter. The procedure consists of a 1.5 cm-long cut made with scissors on the upper edge of the ureteral ostium at the 12 o’clock position, until the dilated portion of the ureter was found and abundant urine drainage was observed. The edges of the incision were sutured, joining together the ureteral mucosa and the bladder mucosa. RESULT: From 2011 to 2015, three patients with POM underwent ureteral meatotomy, with four renal units treated altogether. None of the patients presented complications and, as a sign of obstruction relief, all showed reduced dilatation at the ultrasound. No patient had complications. CONCLUSIONS: Ureteral meatotomy is a safe and effective technique in the initial treatment of POM in patients aged less than one year

[Palpable undescended testicle: Surgical treatment by pre-scrotal incision Bianchi's Technique]. / Testículo no descendido palpable. Tratamiento quirúrgico mediante incisión para-escrotal: "Técnica de Bianchi".

OBJECTIVE: To present a retrospective, descriptive and observational study performed on a group of patients diagnosed with palpable undescended testicle (PUT) and surgically treated by pre-scrotal access, the "Bianchi technique". METHODS: The sample consists of a group of patients from 6 to 168 months old, diagnosed with palpable undescended testicle and treated by orchidopexy through pre-scrotal access Bianchi type (4), from January 2008 to June 2015 by the Pediatric Urology Equipment of Malaga, where the authors belong. To be part of the sample, the patients must meet the following requirements: male, diagnosis PUT, older than 6 months old and a minimum of 6 months of postoperative follow. RESULTS: The sample is comprised of 200 testicles and 157 patients diagnosed with PUT, aged between 6 and 168 months old and treated by the same main surgeons. In a 72.62% of the patients the anomaly was unilateral. From the 200 testicles intervened, a 51.5% had PUT on the right side. Localization of the undescended testis was in the inguinal canal in a 64.5% of cases, 22.5% in the superficial inguinal canal and a 13% in the deep one. There weren't significant complications but in 4.5% of the cases there were minor complications that did not require treatment (cutaneous scrotal hematoma, 2.5%; scrotal skin edema, 1.5%, and partial dehiscence, 0.5%). Regarding the state of the scar, in 15.5% it's not visible, in 16% excellent, very good in 12.5% and only 1% had a bit of an hypertrophic aspect. CONCLUSIONS: This is a easy technique, which presents good surgical results, with minimum surgical complications, its short, medium and long term results are excellent and with a great aesthetic appearence.

Testículo no descendido palpable. Tratamiento quirúrgico mediante incisión para-escrotal: 'Técnica de Bianchi' / Palpable undescended testicle: Surgical treatment by pre-scrotal incision Bianchi's Technique

OBJETIVO: Es presentar un estudio retrospectivo, descriptivo y observacional realizado sobre un grupo de pacientes diagnosticados de testículo no descendido palpable (TNDP) y tratados quirúrgicamente mediante la incisión para-escrotal, técnica 'Bianchi'. MÉTODOS: La muestra está formada por un grupo de pacientes de entre 6 y 168 meses de edad, diagnosticados de testículo no descendido palpable y tratados mediante orquidopexia a través de incisión para-escrotal tipo Bianchi (4), desde enero de 2008 a junio de 2015 por el Equipo de Urología Pediátrica de Málaga, al que los autores pertenecen. Para formar parte de la muestra los pacientes debían de cumplir los siguientes criterios: sexo masculino, diagnóstico de TNDP, edad mayor de 6 meses y tiempo mínimo de seguimiento postoperatorio de 6 meses. RESULTADOS: La muestra la componen 200 testículos y 157 pacientes diagnosticados de TNDP, con edades comprendidas entre los 6 y 168 meses y tratados por los mismos cirujanos principales. En un 72,62% de los pacientes la anomalía fue unilateral. De los 200 testículos intervenidos, un 51,5% presentaba el TNDP en el lado derecho. Localizándose el teste no descendido en un 64,5% de los casos en el conducto inguinal, un 22,5% en el conducto inguinal superficial y un 13% en el profundo. No hubo complicaciones significativas si bien se registraron un 4,5% de complicaciones leves que no requirieron tratamiento (hematoma cutáneo escrotal, 2,5%; edema cutáneo escrotal, 1,5% y dehiscencia cutánea parcial, 0,5%). Con respecto al estado de la cicatriz, en un 15,5% no se visualizaba, 16% excelente, muy bien 12,5% y sólo en 1% presentaron un aspecto algo hipertrófico. CONCLUSIONES: Es una técnica de sencilla ejecución y fácilmente reproducible, que presenta buenos resultados, mínimas complicaciones quirúrgicas. Sus resultados a medio y largo plazo son excelentes y con magnífico aspecto estético

OBJECTIVE: To present a retrospective, descriptive and observational study performed on a group of patients diagnosed with palpable undescended testicle (PUT) and surgically treated by pre-scrotal access, the 'Bianchi technique'. METHODS: The sample consists of a group of patients from 6 to 168 months old, diagnosed with palpable undescended testicle and treated by orchidopexy through pre-scrotal access Bianchi type (4), from January 2008 to June 2015 by the Pediatric Urology Equipment of Malaga, where the authors belong. To be part of the sample, the patients must meet the following requirements: male, diagnosis PUT, older than 6 months old and a minimum of 6 months of postoperative follow. RESULTS: The sample is comprised of 200 testicles and 157 patients diagnosed with PUT, aged between 6 and 168 months old and treated by the same main surgeons. In a 72.62% of the patients the anomaly was unilateral. From the 200 testicles intervened, a 51.5% had PUT on the right side. Localization of the undescended testis was in the inguinal canal in a 64.5% of cases, 22.5% in the superficial inguinal canal and a 13% in the deep one. There weren't significant complications but in 4.5% of the cases there were minor complications that did not require treatment (cutaneous scrotal hematoma, 2.5%; scrotal skin edema, 1.5%, and partial dehiscence, 0.5%). Regarding the state of the scar, in 15.5% it's not visible, in 16% excellent, very good in 12.5% and only 1% had a bit of an hypertrophic aspect. CONCLUSIONS: This is a easy technique, which presents good surgical results, with minimum surgical complications, its short, medium and long term results are excellent and with a great aesthetic appearance

[Ventral corpora cavernosa corporoplasty for the treatment of severe penile incurvation in Pediatric Urology]. / Corporoplastia ventral de cuerpos cavernosos para el tratamiento de la incurvación severa de pene en Urología Pediátrica.

Hypospadias is a congenital pathology of the male genitalia that we diagnose and treat more every day. Due to an increase of case load we must have at hand a large quantity of surgical techniques for its correct treatment. Ventral corporoplasty of the corpora cavernosa is one of them that will help us to successfully treat the most severe cases within this variety which is the pathology itself. We performed a prospective study in Malaga, Spain between 2010-2015. We review the technic and its indications, and the authors personal series with 20 cases performed by 2 surgeons using the same protocol and technics. The outcomes showed good results without complications in all cases. Corporoplasty is one of the surgical technique for the treatment of the most sever cases of penile incurvation.

Docencia virtual (e - learning) en Urología Pediátrica. Programa de cursos master y experto / Virtual teaching (e-learning) in Pediatric Urology. Master and expert course programme

INTRODUCCIÓN: Actualmente se ha hecho necesaria una formación específica y una especial dedicación a la Urología Pediátrica (UP). Sin embargo, falta un programa de formación continuada, que debe ser específico y multidisciplinar. OBJETIVO: crear un programa de formación complementaria en UP con las siguientes características diferenciales: 1) universitario de postgrado, 2) con acreditación internacional, 3) multidisciplinar, 4) teórico y práctico, 5) mediante enseñanza virtual, 6) con apoyo presencial, 7) académicamente dirigido y tutelado, 8) basado en el auto aprendizaje individual y grupal, 9) internacional en profesorado y alumnado y 10) objetivamente evaluable. MÉTODO: Se han desarrollado dos proyectos originales de cursos de formación virtual con prácticas, en UP, Máster y Experto según normativa de la Universidad Internacional de Andalucía (UNIA) y con el apoyo de Colegio de Médicos de Málaga (COM). El Máster tiene carácter general con una duración de un curso académico y se repetirá cada año. El Experto tiene carácter monográfico, con duración de medio curso y se repetirá anualmente con diferentes argumentos. Están acreditados con 60 y 30 créditos ECTS respectivamente. El curso consta de 3 partes bien diferenciadas en desarrollo y objetivos: 1) enseñanza virtual, 2) prácticas presenciales hospitalarias y 3) trabajo final. A mitad del Máster el alumnado respondió al cuestionario para valoración del mismo. RESULTADOS: La UNIA ha considerado viables y ha aprobado los 3 proyectos presentados: I Máster UP (2014 - 2015), II Máster UP (2015 - 2016) y Experto en Incontinencia pediátrica (2015 - 2016). Datos del I Máster UP.- Solicitud de matriculación: 60 alumnos. Alumnos admitidos 40; edad media 37 años; de 8 nacionalidades, españoles 57%, extranjeros 43%; especialidades de origen Urología 14 (35%), Cirugía Pediátrica 24 (60%), Pediatría: Nefrología Pediátrica 1, Medicina General 1. Valoración del alumnado a mitad de Máster: (0 - 100). Dificultad 60; Calidad de los Temas 92; del material complementario 90; de los docentes 90; del Campus Virtual UNIA 89. CONCLUSIONES: La solicitud de matriculaciones demuestra la necesidad y el interés de un programa de formación en UP, mediante cursos de Máster y Experto. La docencia virtual, e-learning dentro del Campus Virtual de la UNIA, es viable. Este modelo de auto aprendizaje está siendo muy bien valorado por el alumnado internacional. Se oferta un complemento interesante en la formación continuada en UP

INTRODUCTION: Currently there is a need for specific training and special dedication to pediatric urology (PU). Nevertheless, we lack of a continuous education program, which must be specific and multidisciplinary. OBJECTIVES: To create a complementary training program in PU with the following differential characteristics: 1) University postgraduate, 2) internationally accredited, 3) multidisciplinary, 4) theoretical and practical, 5) through virtual teaching, 6) with on-site support, 7) academically directed and mentored, 8) based on individual and group self learning, 9) with international faculty and alumni 10) objectively evaluable. METHODS: We developed two original projects of virtual training courses with practices in PU, Master and Expert following the International University of Andalucía (UNIA) regulations and with the support of the Medical College of Malaga. The Master has a general content one year duration and will be repeated yearly. The Expert course has monographic character, half-year duration and will be repeated yearly with different topics. They are credited 60 and 30 ECTS credits respectively. The course has 3 parts well differentiated in objectives and development: 1. Virtual training 2. On-site hospital practices and, 3. Final work. The alumni answered a questionnaire to evaluate the master at the midpoint. RESULTS: The UNIA has considered viable and approved all 3 projects presented: I PU MASTER (2014- 2015), II PU MASTER (2015-2016) and Expert Course on pediatric incontinence (2015-2016) First PU MASTER data.- Registration applications: 60 alumni. Admitted alumni 40; mean age 37 years; 8 nationalities, 57% Spanish, 43% Foreigners. Specialities: Urology 14(35%), Pediatric Surgery 24 (60%), Pediatrics (Pediatric nephrology 1), General Medicine 1. Mid term Master evaluation by the alumni (0-100). Difficulty 60. Quality of the topics 92; complementary materials 90; faculty 90; UNIA virtual Campus 89. CONCLUSIONS: The demand of registrations demonstrates the need and interest of a pediatric Urology training program, through Master and Expert Courses. Vir tual Training, e-learning, within the Virtual Campus of the UNIA is viable. This self-learning model is being highly valued by the international alumni. We offer an interesting supplement for continuous education in PU

[Virtual teaching (e-learning) in Pediatric Urology. Master and expert course programme]. / Docencia virtual (e-learning) en Urología Pediátrica. Programa de cursos master y experto.

INTRODUCTION: Currently there is a need for specific training and special dedication to pediatric urology (PU). Nevertheless, we lack of a continuous education program, which must be specific and multidisciplinary. OBJECTIVES: To create a complementary training program in PU with the following differential characteristics: 1) University postgraduate, 2) internationally accredited, 3) multidisciplinary, 4) theoretical and practical, 5) through virtual teaching, 6) with on-site support, 7) academically directed and mentored, 8) based on individual and group self learning, 9) with international faculty and alumni 10) objectively evaluable. METHODS: We developed two original projects of virtual training courses with practices in PU, Master and Expert following the International University of Andalucía (UNIA) regulations and with the support of the Medical College of Malaga. The Master has a general content one year duration and will be repeated yearly. The Expert course has monographic character, half-year duration and will be repeated yearly with different topics. They are credited 60 and 30 ECTS credits respectively. The course has 3 parts well differentiated in objectives and development: 1. Virtual training 2. On-site hospital practices and, 3. Final work. The alumni answered a questionnaire to evaluate the master at the midpoint. RESULTS: The UNIA has considered viable and approved all 3 projects presented: I PU MASTER (2014-2015), II PU MASTER (2015-2016) and Expert Course on pediatric incontinence (2015-2016)First PU MASTER data.- Registration applications: 60 alumni. Admitted alumni 40; mean age 37 years; 8 nationalities, 57% Spanish, 43% Foreigners. Specialities: Urology 14(35%), Pediatric Surgery 24 (60%), Pediatrics (Pediatric nephrology 1), General Medicine 1. Mid term Master evaluation by the alumni (0-100). Difficulty 60. Quality of the topics 92; complementary materials 90; faculty 90; UNIA virtual Campus 89. CONCLUSIONS: The demand of registrations demonstrates the need and interest of a pediatric Urology training program, through Master and Expert Courses. Virtual Training, e-learning, within the Virtual Campus of the UNIA is viable. This self-learning model is being highly valued by the international alumni. We offer an interesting supplement for continuous education in PU.

Comentario editorial de Desafíos quirúrgicos de las anomalías del desarrollo sexual / Publishing comment of The surgical challenges of disorders of sex development (DSD)

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[Embryology and genetics of primary vesicoureteral reflux and associated renal dysplasia]. / Embriología y genética del reflujo vesicoureteral primario y de la displasia renal asociada.

OBJECTIVES: The main reasons of this review are: To determine some of the embryological and genetic mechanisms of vesicoureteral reflux (VUR) and associated congenital reflux nephropathy (NR); recognize different patterns of familiar clustering and identify appropriate cases where genetic counselling and investigations might be indicated; and finally, to establish the association of these phenomena (VUR and NR). METHODS: Bibliographic search of related articles until June 2007. RESULTS: There are two kinds of primary VUR: isolated VUR and syndromic VUR; the last one has an inherited Mendelian transmission and we know the mechanisms. Epidemiological studies seem to demonstrate that isolated VUR also presents familiar clustering and its inheritance pattern is the main object of interest in some studies; most authors support the hypothesis that VUR is genetically heterogeneous and is caused by a number of different genes acting with random environmental effects. There are lots of candidate implicated genes. The characteristics of VUR (incomplete penetrance, variability of expression, spontaneous resolution...) make difficult to configure a selection of patients subsidiary of genetic study. Despite different treatment options, the incidence of renal chronic failure secondary to VUR has not decreased. Some of the candidate genes identified regulate the position of ureteral budding, a critical step in both kidney and urinary tract development. Analysis of data from humans and mice suggests that some of the renal damage associated with VUR is congenital and is due to a kidney malformation. Therefore, in these cases, the association of VUR and renal failure may be caused by a genetic defect affecting the formation of the kidney and the urinary tract and not by evolution of VUR. Investigation in animals is fundamental to know more about this issue (candidate genes and VUR-NR association). CONCLUSION: It is important to learn patterns of familiar clustering of isolated and syndromic VUR to offer genetic counselling if possible. For this reason, we should be screening carefully all patients suffering from VUR. It is known that limitations in actual indications of genetic study exist. Prenatal diagnosis may be realized if there is a syndromic VUR with known mutation, invariable expressivity or if clinical manifestations involve risk of death. Epidemiological data and laboratory studies may give us guidance to elicit new cases of nephropathy associated to severe VUR.

[Endoscopic treatment of complicated vesicoureteral reflux grades III-V in infants under the age of one year]. / Tratamiento endoscópico del reflujo vesico ureteral III-V complicado en lactantes menores de 1 año.

OBJECTIVES: Our aim is to know the results of Endoscopic Treatment (ET) in infants with recurrent pyelonephritis and high grade (G) Vesicoureteral Reflux (VUR). INCLUSION CRITERIA: infants 2-12 months old with G III-V VUR and at least 2 pyelonephritis, one of them during antibiotic prophylaxis (AP). N = 27 infants: 19 males (70%) and 8 females. VUR was primary in 17 (63%) and secondary in 10. VUR Grade was III in 12 ureters (U) (32%), IV 16 (42%) and V 10 (26%). Polydimethylsiloxane, Hydroxiapatite and Dextranomer/ Hyaluronic Acid (DAH) were the bulking agents employed. Results Classification: Solved: G 0-I.; Improved: G II (control without AP); Persistence: III-V Open Surgery (OS) or repeated ET (1-2) was done depending on cystoscopic findings. RESULTS: 34 ureters are available for final results; 1 G III, 2 G IV and 1 G V are waiting for a new injection. G III 11 U: 11 first and 4 second injections (1.36 Injections / ureter): Solved 9 (81.8%), Improved 1, OS 1 (9%). G IV 14 U: 14 first 3 second and 1 third injection (1.28 injections / ureter): Solved 10 (71.4%), Improved 4. No OS. G V 9 U: 9 first, 4 second and 1 third injections (1.55 injections / ureter): Solved 5 (55.6%), Improved 1, OS 3 (33.3%). Overall results: Solved: 24 U (70.58%), Improved: 6 (17.6%), OS 4 (11.8%). OS avoided 30 (88.2%): G III 91%, IV 100% and V 66.7%. Results of G III are better than G V. The only complication was 1 ureteral obstruction treated successfully with open surgery. CONCLUSIONS: ET can be considered the first therapeutic option in infants with G III-V VUR and pyelonephritis in spite of PA, because ET has solved VUR in 70.58% and avoided OS in 88.2% with a minimally invasive procedure and low incidence of complications.

[Contralateral vesicoureteral reflux after endoscopic treatment of primary unilateral reflux]. / Obstruccion ureteral postoperatoria después de antirreflujo endoscópico.

OBJECTIVES: The endoscopic treatment (ET) of vesicoureteral reflux (VUR) is considered by many urologic and pediatric surgeons as the first treatment option in the event of being required, because it is a minimally invasive procedure, of short duration, ambulatory in many cases, with good results and few complications. Ureteral obstruction is the most serious but less frequent complication. The objective is know the incidence, treatment and evolution of patients with ureteral obstruction as complication of the ET of VUR. METHODS: Evaluation of the medical literature using Pubmed and Ovid. Revision of the clinical report of children (CH) under ET of VUR between March of 1998 and July of 2007, to find those cases that presented ureteral obstruction after ET. RESULTS: A total of 377 children (CH) with VUR in 598 ureters (U), were treated with TE, during the mentioned period of 9 years, between March 1998 and July 2007. Only 2 U (0.33%), in 2 CH (0.5%) presented Ureteral Obstruction with dilatation of the upper urinary tract that need open surgical ureteral reimplantation, with good results in both patients. CONCLUSION: The risk of ureteral obstruction after ET of VUR is low, less than 0.5% of U. The treatment of this complication can be endoscópic or by open surgery both of them with good results.

[Postoperative ureteral obstruction after endoscopic antireflux therapy]. / Reflujo vesicoureteral contralateral despues del tratamiento endoscópico del reflujo unilateral primario.

OBJECTIVES: To know the incidence of new contralateral VUR and its evolution in children with primary unilateral vesicoureteral reflux (VUR) managed with endoscopic treatment (ET). METHODS: During 7.5 years a total of 228 children with primary VUR underwent endoscopic implantation of bulking material, 90 of them (39.5%) have been unilateral. The inclusion criterion was: unilateral primary VUR managed with ET, without previously contralateral VUR. Collected data included: patient age, gender, indications for surgery, number of preoperative cystourethrograms, preoperative and new contralateral postoperative VUR grades, nephropathy in the ipsilateral or contralateral sides, type and volume of bulking material used, and VUR outcome. An update bibliographic review with methanalysis is also performed to compare results. RESULTS: Six children (6.7%) developed new contralateral VUR. Mean age was 3.3 years. Four patients were females and 2 males. The bulking material used was polydimethylsiloxane in one and Dextranomer/Non animal stabilished hyaluronic acid in 5. The initial grades of primary VUR were: II in 1 case, III in 3, and IV in 2. Four patients had previous history of bladder dysfunction. The new contralateral VUR was II in 5 and III in one. In 5 patients initial VUR persisted, always of lower grade than previously, and new contralateral VUR appeared. In one patient initial VUR disappeared and appeared in the contralateral side. Five patients were reinjected and VUR was cured, except one who is waiting for a new endoscopic procedure. One patient with grade II contralateral VUR is under observation. In the metanalysis performed nine issues have been found with an incidence of 8.2%. CONCLUSION: Contralateral VUR is a relatively frequent complication in unilateral primary VUR treated by endoscopic procedures (6.7%), but not enough as to perform bilateral endoscopic treatment in all unilateral VUR. Contralateral VUR etiology is not clear but bladder dysfunction can be an important factor.

[Symptomatic vesicoureteral reflux in the adult age. A patient's testimony]. / Reflujo vésico ureteral sintomático en la vida adulta. Testimonio de una paciente.

OBJECTIVES: There is a general opinion about that vesicoureteral reflux (VUR) rarely produces symptoms during adulthood. But it is possible to find active VUR over 20 years of age. A case report of a woman 28 years old with symptomatic VUR is presented with description of the "Reflux Pain" by herself. The objective of this article is to study the clinical aspects of symptomatic VUR in an adult woman with impairment in her quality of life. METHODS/RESULTS: She was a 33 years old female patient, with chronic and febrile breakthrough urinary tract infections (UTI) since she was 28 years of age. Then an unknown bilateral VUR was diagnosed. It was grade III in an incompletely duplicated right side and grade II in the left one. She recived antibiotic prophylaxis (AP) for 4 years, in spite of it she had a temperature over 37 degrees, with frequent peaks over 38 degrees, and she lost 8 KG of weight. She also had lumbar pain and "Reflux Pain", which was described by the patient as: "acute, intense, excruciating, ascending, located in the ureters and kidneys, beginning some minutes before urinating and finishing some minutes later. During these 4 years many others pathologies were ruled out looking for other etiology of the temperature of "unknown origin". Finally she was sent to urology for treatment of VUR. Bilateral Endoscopic Treatment (ET) with non animal stabilized Hyaluronic acid/ Dextranomer (DX/NASHA) gel was performed, with good result after the first injection. "Reflux Pain" disappeared few days after ET and after one month the temperature was under 37 degrees. She remains asymptomatic after 4 years of follow up. CONCLUSIONS: VUR can produce symptoms during adulthood, with a very typical pain easy to identify, chronic pyelonephritis with temperature and progressive deterioration. ET can eliminate VUR, stop the symptoms and improve quality of life.