Conservative management in congenital severe bilateral hydronephrosis related to uretero-pelvic junction obstruction.

We report our experience in conservative management of patients with prenatal and neonatal diagnosis of severe bilateral ureteropelvic junction obstruction (UPJO), focusing on the actual predictors of renal function impairment or spontaneous resolution. Between 1996 and 2006, 20 patients with bilateral severe hydronephrosis related to UPJO were included in the study. Indications for surgery were an increased hydronephrosis, decreased renal function, onset of symptoms. Conservatively treated patients were followed up for 3 months to 10 years with renal ultrasound, DTPA diuretic, urine culture. At first renal scan, 22 out of 40 renal units had a poor, 10 an intermediary and 8 a good drainage. Pyeloplasty was required in 10 of the 40 kidneys, while 30 out of 40 kidneys were followed conservatively. At the end of follow up, sieric normalized creatinine and estimated glomerular filtration rate were normal in all patients. Our data showed that bilateral severe hydronephrosis related to UPJO can be safely managed in a similar manner of a unilateral case. A poor drainage could be considered a negative predictive factor in the feasibility of a conservative management.

Laparoscopic nephrectomy in children with Wilms tumor. Considerations after 10 years of experience.

Despite laparoscopy in children is considered safe and is routinely used for several procedures, even in neonates and in pediatric oncology, its role in the treatment of pediatric renal tumors is still controversial. This study analyzes the results of laparoscopic nephrectomy for Wilms Tumor (WT) in pediatric age compared with open nephrectomy after 10 years of experience in a single centre. From 1993 in our center of reference for pediatric oncology, 30 patients with WT have been treated. We performed 21 open nephrectomy and in the last 10 years 9 laparoscopic nephrectomy. In all patients treated laparoscopically, the same technique made by the same equip was used. Compared with patients treated by open surgery, we did not find a significant difference in terms of outcome and survival. In the open surgery group, two patients had lung relapse while in the other group there was one local relapse. These three children obtained and maintained a second complete remission with chemotherapy. Open surgery complications were a tumor rupture in two cases, and an episode of pancreatitis 10 days after surgery. In the laparoscopic group, there were two conversions to open surgery not considered as complications but a surgical choice for cystic areas present in the tumor. As far as complications and oncologic outcomes are concerned, both techniques showed similar results. In experienced hands, laparoscopy proves to be an attractive alternative to open surgery for pediatric renal tumors.

[Crossed renal ectopia. Report of two cases and literature review]. / Ectopia renale crociata. Descrizione di due casi e revisione della letteratura.

Renal ectopia is a malformative uropathy classified as simple and crossed. The authors report two patients with renal ectopia (one case of ERC without fusion and one case of ERC with fusion). The authors review the literature about crossed renal ectopia and discuss the importance of early diagnosis and the advantage of thorough investigation in order to exclude associated anomalies.

Gastric motility disorders in patients operated on for esophageal atresia and tracheoesophageal fistula: long-term evaluation.

BACKGROUND/PURPOSE: Disturbed peristalsis is reported frequently after successful repair of esophageal atresia (EA). Delayed gastric emptying could be considered a cause of symptoms of gastroesophageal reflux (GER) in patients with repaired EA. The aim of the current study was to evaluate the incidence of and to characterize gastric motility disorders in a long-term follow-up of patients operated on for EA-tracheoesophageal fistula (TEF) by studying gastric emptying with scintigraphic techniques and comparing the results with gastric manometric data. METHODS: Eleven patients, between 12 and 23 years of age (median, 17) operated on for EA-TEF between 1975 and 1985, were studied. The scinthigraphic study was undertaken using a standard solid meal. The manometric study was performed using a 2.3-mm probe with 3 solid-state transducers. RESULTS: Dysphagia was present in about 20% of patients. Dyspepsia was recorded in 40% of the patients. A pathological reflux was present in 2 patients. Delayed gastric emptying (T1/2 > 90') was present in 4 patients (36%). Manometric data showed alteration of gastric peristaltic activity in 5 patients (45%). CONCLUSIONS: Delayed gastric emptying is frequent in long-term follow-up of patients operated on for EA-TEF. In these patients antral hypomotility also is recorded manometrically. Abnormal gastric motility can be considered as an important factor predisposing to symptoms of GER. A thorough evaluation of gastric function is recommended in symptomatic patients after EA repair.

Conservative treatment in primary neonatal megaureter.

The authors report their experience on 22 neonates (14 males and 8 females) with primary megaureter. In 18 patients a prenatal diagnosis was available, in the other four the diagnosis was suspected during a neonatal ultrasound screening. The dilatation involved the right ureter 7 times and the left 13 times, in 2 patients it was bilateral. Intravenous urography documented a type I ureteral dilatation in 2 renal units (8.3%), a type II in 9 (37.5%) and a type III dilatation in 13 (54.2%). Radionuclide scan (Tc99m DTPA) demonstrated in all the renal units with megaureter a stable function. From diuretic renal scan, non-obstruction appeared in 19 (83%), obstruction in 2 (8.5%) and an equivocal result in the remaining 2. Antibiotic prophylaxis was administered to all patients. Follow-up period ranged from 18 to 54 months. The 2 obstructed megaureter were surgically treated. Other 2 patients with type III dilatation and non-obstructing megaureter underwent surgery at 18 and 24 months of age respectively. The remaining 17 patients were all conservatively treated. The 2 patients with type I dilatation resolved spontaneously. Of 9 patients with type II megaureter the dilatation resolved in 6 patients and 3 patients had a good reduction. In the remaining 8 patients with type III megaureter, the dilatation resolved in 5 cases and 3 patients had only a fair reduction. The renal function (> 40%) remained stable in all the patients.

[Esophagoscopy in pediatric surgery]. / L'esofagoscopia in chirurgia pediatrica.

Esophagoscopy in pediatric surgery represents about 70% of examinations of upper digestive tract. The authors present their experience with pediatric surgical endoscopy. They show the importance of this procedure in pediatric population, which provides clear diagnostic answers and represents a good alternative to traditional surgical procedures.

Bilateral neonatal adrenal abscess. Report of two cases and review of the literature.

Neonatal adrenal abscess is an extremely rare condition. 32 cases, 4 bilateral, have been described in the world literature. We treated successfully other two bilateral cases. We report on this rare condition and review the world literature. In our Department we observed two patients in the neonatal period with abdominal distension, vomiting, irritability and fever. Abdominal ultrasound (US), plain x-ray of the abdomen, intravenous pyelography and computed tomography (CT) of the abdomen were performed. In both cases bilateral suprarenal cystic masses were identified. Vanilmandelic acid, Homovanillic acid and cathecolamines were normal. The two neonates underwent a surgical exploration. Abscesses were found and drained releasing a moderate amount of haemorrhagic and purulent materials from the adrenal glands. Post-operative histology on the surgical specimen showed in both cases an abscess in partial haemorrhagic adrenal glands. No neoplastic cells were observed. The recovery was uneventful and at six months follow-up both patients were well and without signs of adrenal insufficiency. Haematogenous bacteria seeding a normal gland or abscess formation in a previous haemorrhagic gland are the most accredited theories. Neuroblastoma, Wilm's tumor and renal duplication with dilatation of the upper segment must be considered in the differential diagnosis. Percutaneous drainage (+/- biopsy) under CT or US guide should be considered the treatment of choice, followed by surgical exploration when diagnosis is not clear.