Treatment of vesico-ureteric reflux in children with neuropathic bladder: a comparison of surgical and endoscopic correction.

BACKGROUND/PURPOSE: Vesico-ureteric reflux (VUR) is a common problem in children with neuropathic bladder. Lesser-degree VUR may be manageable by intermittent catheterization or by anticholinergics, but higher grades usually require surgical treatment. If left untreated, two thirds of such patients may experience deterioration of the upper renal tracts. The aim of this study was to compare the results of the STING (Subureteric Teflon Injection) technique with surgical ureteric reimplantation as treatment for VUR in neuropathic bladder. METHODS: From January 1981 to December 1996, 58 children with NB (81 ureters) were treated for VUR. STING and Cohen ureteroneocystotomy were performed in 40 and 41 ureters, respectively. Mean age was 4.5 years (STING) and 5.1 years (Cohen). RESULTS: Twenty-nine of 40 refluxing ureters (72.5%) were cured by STING, whereas Cohen eradicated reflux in 39 of 41 ureters (95.5%). No complications were observed in either group. All the ureters in which STING failed were treated successfully by Cohen ureteroneocystostomy. The 2 ureters still refluxing after surgical reimplantation were cured successfully by a single STING. The mean follow-up was 6.8 years in the Cohen group and 4.8 years in the STING group. During follow-up, no recurrence was observed in patients cured by open reimplantation. In the STING group, 2 previously cured ureters showed recurrence of VUR: both were treated successfully by a further STING. CONCLUSIONS: Open ureteral reimplantation is more effective than STING in correcting VUR in children with neuropathic bladder dysfunction. Nevertheless, the good success rate, the relative technical simplicity, outpatient nature, and rapid recovery point to STING as a safe and effective procedure for the initial treatment of VUR. Failure of STING does not preclude a successful open operation.

The antiemetic efficacy of methylprednisolone compared with metoclopramide in outpatients receiving adjuvant CMF chemotherapy for breast cancer: a randomized trial.

A randomized trial was performed comparing the antiemetic efficacy of methylprednisolone (MPN) and metoclopramide (MCP) in 60 breast cancer patients eligible for outpatient adjuvant chemotherapy with cyclophosphamide, methotrexate, and 5-FU (CMF). At the time of their first chemotherapy course patients were randomized to receive either MPN 375 mg or MCP 1 mg/kg both administered in 3 equal doses, IV just prior to chemotherapy and then IM 6 and 12 hours after treatment. Patients receiving MPN experienced significantly less nausea (p less than 0.0005) and vomiting (p less than 0.0005) and antiemetic protection was maintained in patients receiving multiple chemotherapy courses. Complete protection (0 emesis) was observed in 58% of patients receiving MPN as compared with 20% of patients treated with MCP (p less than 0.005). The most frequent side effects were facial flush in 38% of patients and somnolence in 15% of patients receiving MPN and MCP, respectively. Complete protection from CMF-induced gastrointestinal side effects was observed in two-thirds of our patients receiving antiemetic MPN treatment. In these patients administration of the maximum cumulative CMF dose was possible without impairing their quality of life. MPN, at the dose and schedule reported, is an affective antiemetic drug suitable for use in breast cancer outpatients receiving adjuvant CMF therapy.

Ineffectiveness of 5-fluorouracil and cis-platin as second-line chemotherapy in head and neck cancer.

Seventeen patients with heavily pretreated head and neck squamous cell carcinoma were submitted to a combination of 5-fluorouracil, 500 mg/m2 on days 1-4, and cis-platin, 50 mg/m2 on day 5, repeated every 21 days. Before administration of 5-fluorouracil, N5,N10-methyltetrahydrofolate, 200 mg/m2 i.v., was given. Only 1 partial response and 4 stable disease were observed, and the median survival of the entire group was 5 months. Although all patients had been heavily pretreated and a considerable percentage (6/17, 35.2%) of these showed resistance to first-line therapy, this combination seems to be ineffective as second-line therapy in head and neck cancer.

Non-functioning parathyroid carcinoma: a case report.

Non-functioning parathyroid carcinoma is a very rare disease. Only 12 cases have been reported in the literature. The clinical behavior is characterized by the appearance and growth of a neck mass or nodule, which often has been present for many years, and is not accompanied by clinical or laboratory evidence of hypercalcemia or elevated levels of parathyroid hormone (PTH) in peripheral blood. Pathologic findings are similar to those of functioning tumors, and the proof of malignancy is established on the basis of an increased mitotic index only. Data on survival from cases reported in the literature are not conclusive; however, the non-functioning type of parathyroid carcinoma seems to be a more aggressive disease. Radiotherapy seems to be effective in the local control of the disease, but most patients become metastatic. Even if no data are available on response to chemotherapy, the course of the disease is relatively indolent.

Total colectomy and straight ileo-anal soave endorectal pull-through: personal experience with 42 cases.

During the period from 1974 to June 2000 we used the straight ileo-anal Soave pull-through to treat 42 patients (24 affected by total colonic aganglionosis [TCA], 10 with ulcerative colitis and 8 with familial polyposis). The aim of this paper is to show that this operation, associated with total colectomy, is highly recommended, causing a lower number of complications when compared to the various "reservoir" techniques. The mean age of the 24 patients with TCA at the time of the pull-through was 2.8 years; in the ulcerative colitis group, it was 14.3 years and in the familial polyposis group 27.2 years. We always used an ileo-anal deferred anastomosis and never performed temporary loop-diverting ileostomy at the time of the pull-through. In the TCA patients we had no immediate or long-term serious post-operative complications: ileal adaptation, after a frequency of 10 - 12 liquid stools a day, showed a gradual, constant and in some cases amazing improvement in all children. Two years after surgery, the mean stool frequency was 3.6 per 24 hours with no significant differences between the 3 main groups; only 4 children still presented with occasional soiling. After pull-through, all children showed normal growth curves in the long term. There was no malabsorption, no serious electrolyte imbalance, no perianal excoriation, no strictures or intestinal obstruction; their quality of life was considered more than satisfactory by the children's families. We have no direct experience with the various ileal "reservoir" techniques for ulcerative colitis and ileal polyposis nor with colon-sparing operations for TCA; as reported in the literature, all these surgical procedures seem to have a higher number of complications such as pelvic sepsis, pouchitis, enterocolitis, etc. compared with our series; we therefore confirm that total colectomy with the straight ileo-anal Soave pull-through is our treatment of choice, as it is simpler to perform and has fewer short- and long-term complications.

Treatment and follow-up of vesico-ureteral reflux in patients with neuropathic bladder.

Vesico-ureteral reflux (VUR) is a relatively frequent and severe complication in neuropathic bladder, therefore it must be ruled out in every case, and prevented whenever possible. The Spina Bifida Center of our Institute is presently following 220 patients with neuropathic bladder, who undergo a periodical clinical and instrumental evaluation. Urodynamics has proved essential in detecting risk factors for VUR: small capacity bladders with reduced compliance, increased outlet resistance, and detrusor instability. Forty-eight cases of VUR, 38 of which were severe, were detected in a total of 166 patients reviewed for this paper. All patients with VUR were treated conservatively, attaining complete remission or improvement in 21 cases. Ten underwent surgical treatment owing to recurrent pyelonephritis or pyelo-renal reflux with severe dilatation, despite a standard pharmacological trial.

[Surgical strategy in the treatment of infantile ureterocele]. / Strategia chirurgica nel trattamento dell'ureterocele infantile.

The authors describe their experience on the surgical treatment of ureterocele in the pediatric age. The anatomic and clinical features which condition the choice between various therapeutic solutions are presented. All problems concerning any kind of different surgical approach are discussed, stressing the importance of the endovesical radical treatment.

[Simple testicular cysts in children. Presentation of a case]. / Cisti testicolare semplice in età pediatrica. Presentazione di un caso.

A case of simple intraparenchymal testicular cyst in a two and half months old child is reported. Dysplastic cysts of the testicle are exceedingly rare, in children only eight such cases have been described in the Literature, all, except one, treated by orchiectomy. In the herein reported case a conservative approach with cyst enucleation and sparing of the residual testicular parenchyma has been satisfactorily employed.

[Abdominal cystic lymphangiomas and mesenteric cysts: the clinical considerations]. / Linfangiomi cistici addominali e cisti mesenteriche: considerazioni cliniche.

The authors present their experience about intra-abdominal lymphangiomas and mesenteric cysts. The histologic evidence shows that these lesions are different. An exact histologic diagnosis is important because lymphangiomas are more invasive and relapsing than mesenteric cysts. Of 8 cases founded at laparotomy, 6 were lymphangiomas and 2 mesenteric cysts. Larger lesions were caused by lymphangiomas (mean, 11 cm vs 6 cm) when compared with mesenteric cysts. Complete resection was possible in all 8 patients, without recurrence after a mean follow-up of 4 years.

[Sacrococcygeal teratomas: diagnosis and treatment]. / Teratomi sacro-coccigei: diagnosi e trattamento.

The Authors present ten cases of sacro-coccygeal teratomas observed during the last ten years at the G. Gaslini Children Institute, Genova. Two cases was diagnosed in the pre-natal period. Diagnostic methods, histologic aspect and surgical treatments are discussed.

[Acute epididymitis in children]. / Le epididimiti acute in età pediatrica.

Fifteen cases of epididymitis in children are reviewed, six of these occurring in children under twelve months of age, and nine in older children. In five of the six cases occurring in infants a U.T.I. and a malformation of the urinary tract were found, while in children over one year only three infections and two urinary malformations were discovered. Authors recommend that in infants under 1 year presenting with epididymitis a thorough investigation of the urinary tract is performed.

Rationale for combining chemotherapy and hormonal therapy in breast cancer.

Both chemotherapeutic agents and hormones are effective in breast cancer treatment. Their mechanism of action seems to be conflicting: while cytotoxic drugs are active on cycling cells, hormones prolong the G0 phase. Therefore, the concurrent use of hormones and chemotherapy could decrease their expected clinical activity. On the contrary, a review of the literature suggests that there could be some synergistic action with combined therapy. The problem is therefore to assess the efficacy of simultaneous vs sequential administration of hormones and chemotherapy. In advanced disease the general conclusion could be that simultaneous administration of combined therapy: increases, although the difference is not statistically significant, the response rate both in pre and postmenopausal patients; and the most important end point, total survival, is not statistically improved by simultaneous vs sequential administration. In addition, in the adjuvant setting combined treatment appears superior to chemotherapy only in postmenopausal, receptor-positive patients. No definite conclusion is today available in premenopause.

Low-dose metoclopramide versus methylprednisolone in controlling chemotherapy induced nausea and vomiting.

Ninety outpatients with histologically confirmed malignancy receiving chemotherapy entered a randomized crossover trial to assess the antiemetic efficacy of low-dose metoclopramide versus methylprednisolone. Treatment consisted of either metoclorpramide (MCP) 60 mg or methylprednisolone (MPN) 375 mg administered in 3 equal doses just prior to chemotherapy and 6 and 12 hours after treatment. Patients receiving MPN had significantly less nausea (p less than 0.001) and fewer episodes of vomiting (p less than 0.0003) than patients receiving MCP. MPN also proved to be the more effective agent in cross-over trials. Both MPN and MCP were well tolerated. No important side effects were observed. MPN is a safe, effective, antiemetic treatment suitable for use in the outpatient.

Vesical continence in bilateral ectopic single ureters.

PURPOSE: We explore the possibility of gaining suitable vesical capacity and continence in bilateral single ureters without having to resort to urinary diversion or bladder neck reconstruction. MATERIALS AND METHODS: In the last 10 years we treated 6 girls with bilateral ectopic ureters, and 2 with a single kidney and urethral ectopic ureter. Both ureters were ectopic in the urethra in 3 cases, and 1 ureter was inserted in the urethra and 1 in the bladder neck in the other 3. Preoperative examinations included ultrasonography, cystography, excretory urography and endoscopy in all cases, and magnetic resonance imaging in 2. Patient age at intervention ranged from 1 month to 8 years. RESULTS: Cross-trigonal reimplantation of the ectopic ureters through a correctly positioned neomeatus was performed in 7 cases. In 2 patients it was impossible to reach the ureteral insertion from inside the bladder (1 ureter in 1 and both ureters in 1), and so the distal tract of these ureters was resected extravesically as close as possible to the urethra. One patient with a single kidney also had an anorectal malformation and a rectovaginal fistula. She had pelvic renal ectopia and the ureter was inserted beneath the urogenital diaphragm causing minimal bladder capacity. Therefore, a sigmoid neobladder with appendicostomy was constructed according to the Mitrofanoff principle. A Young-Dees bladder neck plasty was done in 2 patients at the same time as ureteral reimplantation and 3 years later in 1. Followup urodynamics revealed more than acceptable continence. Bladder capacity was insufficient in only 1 polyuric patient. CONCLUSIONS: A bladder with bilateral ureteral ectopia is not necessarily useless, and the majority of patients can achieve normal bladder function and capacity along with normal transurethral voiding and satisfactory continence.

[Detection of uropathies in enuresis in children]. / Despistaje de uropatías en la enuresis infantil.

A protocol has been applied to all our patients consulting for nocturnal enuresis who also presented daytime wetting or urge to void, to rule out obstructive uropathies. Our protocol includes voiding cystourethrogram, IVP, cystometry and endoscopy. 64 females and 46 males, 4 to 14 year-old, were studied between 1980 and 1983. Obstructive urethral uropathy was ruled out in 37 females (58%) and 32 males (69%). The most common treatments in these patients were endoscopic resection (Bugbee) of posterior urethral valves in boys and resection of the distal ring in girls. All other associated diseases or malformations were treated according to their etiology. Results, analyzed through a questionnaire sent to parents, were good in 77% of the patients treated for obstruction. In conclusion we think that daytime wetting and urge to void are very frequently the emerging symptoms of a hidden uropathy, in most cases obstructing proximal or distal urethra. Surgical treatment can lead to a good cure rate.