Contractility and phenotype transitions in serosal thickening of obstructed rabbit bladder.

Partial outlet obstruction of rabbit bladder induces serosal thickening and smooth muscle (SM) cell hypertrophy that are accompanied by phenotypic changes in the expression of cytoskeletal and cytocontractile proteins. In the present study, we compare the observed progressive phenotypic changes with the contractile responses of strips of the thickened serosa. At 15 days after partial outlet obstruction, although cells in thickened serosa demonstrate the presence of nonmuscle (NM) myosin of A-like type, vimentin, and SM alpha-actin, no contractile responses of this tissue were noted. At later times (30 days), this tissue expressed in addition SM myosin, and this pattern was paralleled by the development of KCl-stimulated contractility. It is only after 60 days that the serosa demonstrated the expression of desmin, phosphoglucomutase (PGM)-related protein, and was locally negative for NM myosin, indicating a maturation toward adult SM cells. Concomitant to this phenotypic change, the response to KCl increased, and a bethanechol-stimulated contractile response developed. At no time period did the serosal layer react with anti-synaptophysin or anti-neurofilament proteins nor did the strips respond to field stimulation (via release of neurotransmitters), showing that SM cell differentiation and development of contractile responses during serosal thickening are independent of innervation.

Late development of pelviureteric junction obstruction (PUJO) in a girl with previously normal pyelogram: a case report.

A case of ureteropelvic junction obstruction in a girl with previously normal pyelogram is presented. The aetiology of this development is unclear but this report emphasizes the need for a close follow-up of patients with persistent flank pain even if the initial pyelograms are normal.

Unusual, benign asymptomatic scrotal masses in children: case reports and review of the literature.

Asymptomatic scrotal masses (ASM) in children constitute an entity of pathologies, ranging from congenital anomalies to neoplasms. Testicular ultrasound is the imaging modality of choice in the evaluation of ASM, although there is extensive overlap between benign and malignant lesions. Five children with ASM of benign origin are presented: 2 boys had extratesticular mass (one paratesticular lipoma and one voluminous sebaceous scrotal cyst); the remaining 3 patients had testicular mass (one supernumerary testis, one intratesticular cyst and one unilateral testicular hypertrophy). Basing on the ultrasonographic appearance, a certain diagnosis of benign lesion was made only in the last 2 cases; the remaining patients underwent explorative inguinotomy in order to rule out any malignancy. Some guidelines for proper diagnosis of ASM in childhood are proposed by the authors. However, at least in children, testicular preservation should not be based only on the sonographic findings, and surgical exploration is mandatory whenever the nature of the lesion remains unclear.

Stone formation in a female urethral diverticulum. Review of the literature.

A case of stone formation within a female urethral diverticulum is presented together with a brief literature review. Clinical diagnosis may be suspected if a stony hard mass is palpable on the floor of the urethra. The definitive diagnosis depends upon a plain X-ray film and a retrograde positive pressure urethrogram. Surgical excision of the diverticulum together with the calculus is best performed by the vaginal route.

Functional daytime incontinence: pharmacological treatment.

The basis for the treatment of functional daytime incontinence in children is the bladder regimen, i.e. to teach the children to void regularly by the clock. Drug treatment may be needed as an adjunct to the regimen in children with gross detrusor instability. There is no evidence from properly controlled studies that tricyclic antidepressants or anticholinergic drugs are of value for the child with daytime wetting. Terodiline is a new drug combining anticholinergic and calcium-blocking effects. In two randomized, double-blind studies of terodiline compared with placebo in children with urge incontinence (i.e. functional day wetting), continence improved significantly over placebo in the terodiline group. Only a few mild adverse reactions were noted. Children with symptomatic urinary tract infection and day wetting should receive chemotherapy, but covert bacteriuria should best be left untreated. There is no evidence that eradication of the bacteriuria improves continence. Instead, there is a great risk of symptomatic recurrence of the urinary tract infection after antibacterial treatment.

Ambulatory urodynamics: preliminary experience with vesico-urethral holter in children.

Detrusor function was evaluated by vesico-urethral holter (VUH), a computerized recording system (Urodec 500), in 17 children with lower urinary tract dysfunction. Eight had neurogenic bladders, eight had minor voiding dysfunction, and one was incontinent after posterior urethral valve ablation. VUH was technically satisfactory in, and acceptable to, all patients. It was more accurate in evaluating the type of urinary tract dysfunction than conventional urodynamics in 25% of the male patients and in 32.5% of the female patients.

[Chronic renal failure secondary to vesicoureteral reflux: is the prevention possible?]. / Insufficienza renale cronica secondaria a reflusso vescico-ureterale: è possibile la prevenzione?

Vesicoureteral reflux (VUR) is the commonest cause of end-stage renal failure reported by the ITALKID (Italian Register of Chronic Renal Failure) (CRF) in children (0-15 years). Herein we report 131 children (53 M and 78 F) with a diagnosis of VUR made in our Centre between 1987 and 1994. Diagnosis was made in 69% of cases (85/131) during the 1st year of life and in 31% of cases (47/131) afterwards. VUR was demonstrated following a prenatal ultrasonography suspicion in 24/131 and after symptoms such as urinary tract infection (94/131) and poor growth (6/131). 75/131 of patients were treated conservatively (continuous chemoprophylaxis) while 56/131 underwent an antireflux surgery. CRF was found in 14% (19/131) of cases even though the diagnosis of VUR was performed in most of the cases (79%) during the 1st year of life. In conclusion prenatal ultrasonography has a low sensibility in the diagnosis of VUR. In addition, an early diagnosis made during the 1st year of life do not prevent CRF. The study was carried out in a Centre where patients with urological problems are referred from a large part of Northern East of Italy and this may explain the high prevalence of CRF and of children receiving a surgical treatment.

Video-urodynamic studies of minor voiding dysfunctions in children: an overview of 13 years' experience.

By the definition 'minor voiding dysfunctions' is understood children with a history of frequency, urgency, daytime wetting, squatting, and infrequent voiding, singly or in combination. Urinary tract infections (UTI) are often present but symptoms must also be present when the children are free of infection. The upper urinary tract is generally normal or has minor anomalies. Any evidence of infravesical obstruction, frank or occult neurogenic bladder, or emotional disturbances must be excluded. In this study we report 13 years' experience of video-urodynamic evaluation in children with minor voiding dysfunctions, with special reference to clinical information, morphofunctional correlations, relationship with recurrent UTI, vesico-ureteric reflux and dilatation of the upper urinary tract. According to our experience we estimate that about 60% of the patients evaluated in this study would not require a video-urodynamic evaluation today.

[Diagnostic and therapeutic protocol in malformative uropathies prenatally diagnosed]. / Protocollo diagnostico e terapeutico delle uropatie malformative con diagnosi prenatale.

The increased frequency of prenatal detection of urinary tract abnormalities has brought to the attention of the pediatrician a high number of neonates and infants with asymptomatic hydronephrosis, which represents the most common form of uropathy. As it becomes clear that hydronephrosis does not necessarily mean obstruction, the purpose of the evaluation is to identify those infants in whom hydronephrosis will cause progressive renal deterioration, because of an ongoing restriction to urinary outflow. In the present paper, the discussion of the post-natal diagnosis and management focuses on the embryologic background, the pathophysiology of the obstruction and the rationale to utilise the different diagnostic techniques (ultrasonography, associated with the use of the Doppler; intravenous urography; avoiding cystourethrography; renal scintigraphy).

A new 1-stage procedure for clitorovaginoplasty in severely masculinized female pseudohermaphrodites.

A new 1-stage procedure for clitorovaginoplasty in severely masculinized female pseudohermaphrodites is presented. The technique consists of clitoral reduction with preservation of the neurovascular supply to the glans and vaginal formation by joining the inverted penile skin and the divided distal "urethra" (urogenital sinus) to form a cylinder that is then inserted into the perineum and anastomosed to the true vagina. For high and small vaginas Monfort's transtrigonal approach is suggested. This operation, 4 of which have been performed to date, can be done at any age, and it offers excellent cosmetic and functional results.

[Reconstructive surgery in complex hypospadias: therapeutic indications and technical considerations in 93 cases]. / La cirugía reconstructiva de los hipospadias complejos: indicaciones terapéuticas y consideraciones técnicas en 93 casos.

Perineo-scrotal hypospadias and the severe sequelae of a failed repair procedure are complicated cases. The present study describes our experience in the treatment of complex hypospadias, the new therapeutic possibilities, their indications and results. From 1981 to 1992, 93 children with complex hypospadias underwent surgery (53 underwent surgery for the first time and 40 for severe sequelae of a failed procedure). Excellent cosmetic results were achieved by surgery. For those undergoing hypospadias repair for the first time, we used a pedicled preputial flap following the Duckett (12 cases) or Standoli (41 cases) technique. For those with severe sequelae from a failed procedure, we utilized a pedicled skin flap (18 cases) or free flap of bladder mucosa or penile skin (22 cases). The overall complication rate was 50% (47 patients). Surgical repair of complex hypospadias is a relatively long and complicated procedure with a long learning curve and a high complication rate in the initial phase. Fistula is the most common complication, although closure is very simple due to the abundant, well vascularized, healthy tissue. Overall our results have been satisfactory, considering the severity of these cases.

Acquired intravesical ureteral diverticulum: an unusual late complication of ureteroneocystostomy.

An unusual case of late ureteral obstruction following a Politano-Leadbetter ureteroneocystostomy performed 11 years previously is reported. Fibrosis of the distal ureter associated with vascular compression of the extravesical ureter presumably led to development of a ureteral intramural diverticulum. This case illustrates the necessity of careful ureteral placement and emphasizes the importance of close followup for many years, even in asymptomatic patients.

[Urethral advance by the Beck-von Hacker technique: indications and results]. / Avanzamiento uretral según Beck-von Hacker: indicaciones y resultados.

Herein we describe a modification of the Beck-von Hacker procedure which we utilize in the treatment of hypospadias and distal urethrocutaneous fistulas. The indications and the results achieved with this technique are presented.

Endoscopic incision of ureteroceles: intravesical versus ectopic.

A total of 51 children, mostly less than 2 years old, underwent endoscopic incision of ureteroceles as a primary form of treatment. In 73% no further surgery was required. Of the patients 19 were diagnosed by prenatal ultrasound, with a urinary tract infection the usual presenting symptom in the remainder. Of 27 intravesical cases endoscopic incision resulted in decompression of the ureterocele in 93%, with preservation of upper pole function in 96%, and secondary surgical procedures were required in 7%. Reflux was created in 18% and it persisted in 2 of 4 patients. Of 24 cases of ectopic (extravesical) ureteroceles incision resulted in decompression in 75%, with upper pole function preserved in 50%. Reflux was created in 47% and a secondary surgical procedure was performed in 50%. Preservation of upper pole function was significantly better for intravesical versus ectopic ureteroceles (p < 0.01), and the requirement for secondary surgical procedure was greater with ectopic ureteroceles (p < 0.01). Three patients had intermittent bladder outlet obstruction following the incision and required further surgery. The 2 different techniques for incision of intravesical and ectopic ureteroceles are described. The role of endoscopic incision in the overall management of ureteroceles is confirmed by this review, and the need for partial nephroureterectomy may diminish.

Blind ureterocele.

Ureterocele without corresponding renal tissue (blind ureterocele) represents a very rare malformation which is of special interest for the understanding of the embryogenesis of this anomaly. Two cases, the first without corresponding kidney seen in an adult and the second in connection with a small multicystic kidney observed in a boy, are considered. In light of the observation of the disappearance of antenatally diagnosed multicystic kidney, these lesions are considered to represent two different stages of the same anomaly. A somewhat functioning renal tissue is supposed to be necessary for the development of a ureterocele. In the case of blind ureterocele, it is supposed that the renal tissue might subsequently disappear. Ureterocele may result from a combined ureteral bud anomaly and obstruction during fetal development.

Technical options in complex ureteral lesions: 'ureter-sparing' surgery.

From January 1979 to December 1992, 74 patients with ureteral lesions due to ureteral or renal instrumentations, failed gynecological or reconstructive surgery were addressed to our department for a reconstructive program. Fifty-two of them were managed by standard ureteropyeloanastomosis or psoas bladder hitch and ureteral reimplants. Twenty-two patients (12 females, 10 males, age range 28-68 years) suffered from extensive ureteral lesions (5-7 cm) and were managed by major ureteral reconstructive surgery intended to restore urothelial continuity. Three patients had a solitary kidney, and 6 cases suffered from bilateral ureteral injuries. The procedures employed were: psoas kidney hitch with ureteropelvic anastomosis (4 cases), kidney psoas bladder hitch (5 cases), 'extended' psoas bladder hitch (5 cases), transureterouretero-anastomosis+psoas bladder hitch (5 cases), psoas kidney-bladder hitch and transureterouretero-anastomosis (1 case), renal autotransplantation (2 cases). Only 5 minor postoperative complications were observed and all patients but one had satisfactory results with a follow-up ranging from 6 to 84 months. The authors believe that the restoration of urothelial continuity is the best option compared to other technical solutions such as ileal replacement, or diversion and nephrectomy. Autotransplantation should be reserved for rare selected cases.

Ectopia of the vas deferens into the ureter. Case report and review of the literature.

Ectopia of the vas deferens into the ureter is a rare occurrence, frequently associated with anorectal anomalies. To date, 20 cases have been reported, accounting for a total of 26 vasoureteral communications, 6 of which are bilateral. Embryologically, ureteral ectopia of the vas deferens may be explained by an underlying defect in the proximal mesonephric duct or an abnormally cranial origin of the ureteric bud. We add the case of a newborn with an ectopic vas terminating into the ureter of a multicystic kidney.