Long-term consequences of posterior urethral valves

Posterior urethral valves (PUV) are the most common congenital cause of bladder outlet obstruction in infancy, and it is the effect of this obstruction on the bladder and the kidneys that will decide a patient's prognosis. With the improvements in diagnosis and treatments, what was previously a poor prognosis for boys with PUV has improved, and more patients will encounter the long-term sequelae of PUV during puberty and adulthood. In these patients the long-term prognosis in terms of renal and bladder function and fertility, as well as the risk of malignancy in those whose bladders were augmented with gastrointestinal segments, is still a matter of great concern and all of these topics will be discussed in this article.

[Laparoscopic living donor nephrectomy: functional repercussion in the pediatric recipient]

AIM

The impact of laparoscopic (LDN) vs. open nephrectomy (ODN) on early graft function and survival in pediatric kidney recipient remains unclear.

MATERIAL AND METHOD

We retrospectively review the records of 63 pediatric recipient of living donor renal trasplant from 1994 to 2007. We compared those who recieved allograft recovered by LDN (n: 16) with those by ODN (n: 47). The mean recipient age was 9.3 +/- 5 years and the mean donor age was 40.8 +/- 7 years. Outcomes of interest included the incidence of delayer graft function, acute rejection and long-term graft function.

RESULTS

Donor, recipient, demographic data and the total time of cold ischemia (1.9 +/- 0.3 hours) were similar in both groups. The mean of kidney warm ischemia was (195 LDN vs. 20 ODN seconds). There were not any significant differences between the two groups, not even in the patient survival after 36 months (100% LDN vs. 98% ODN), neither in the graft survival with proportional hazards Cox analysis. The LDN group needed more days (9.56 +/- 2.3 vs. 4.72 +/- 0.57 ODN) to reach the minimum serum creatinine, but the GF (ml/min/1.73 m2) was similar at 6 months (122 +/- 12 LDN vs. 87 +/- 17 ODN), one year (139 +/- 45 LDN vs. 88 +/- 27 ODN), and two years (110 +/- 64 LDN vs. 82 +/- 30 ODN) after transplant.

CONCLUSIONS

LDN delays the recovery of the graft function in pediatric recipient. Pediatric LDN recipient have graft outcomes comparable to those of ODN.

[Laparoscopic resection of the prostatic utricle in children]

INTRODUCTION

The prostatic utricle is an embryological remnant from Müllerian duct tissue. Most prostatic utricles are asympomatic, but they may manifest as a urinary tract infection or an incontinence.

MATERIAL AND METHOD

Surgery consists in a cysto-urethroscopy and cannulation of the prostatic utricle with a ureteral catheter (Fogarty ner 4) and the cystoscopy left in situ to facilitate identification and mobilization. A 10 mm port through a umbilical incision and two more 5 mm working ports were inserted. After mobilization, the ureteral defect was closed by an absorbable suture and ultrasonic coagulation.

RESULTS

Five boys with symptomatic prostatic utricles underwent surgery at a mean (range) age of 7 (2-11) years. The laparoscopic excision was successful in all but one due to a bleeding. The mean (range) operative duration was 165 (120-240) min.

CONCLUSION

Laparoscopic excision under cystoscopic guidance offers a good surgical view and allowing easy dissection.

[Soft tissue sarcomas (1991-2004)]

BACKGROUND

The aim of this study is to review the results of the treatment of soft tissue sarcomas (STS) in our Department during the last 13 years.

MATERIAL AND METHODS

Fifty-seven children (39 rhabdomyosarcomas (RMS) and 18 other types of sarcomas) have been treated. Nineteen RMS were excluded because they were treated by oher departments. The charts of 39 chidren were analysed evaluating several parameters (age, sex, location, histology, initial stage, clinical and surgical treatment and results) as prognostic factors using actuarial survival analyses and log-rank tests.

RESULTS

1. RMS: Median age at diagnosis was 2.3 years (range 6 m-16y). Twelve were genitourinary, 3 thoracic, 3 abdominal, 1 was located in limb and 1 in the neck. Histologically, 13 were embryonal, 5 botryoid, 1 alveolar and 1 fusiform. At diagnosis, 74% were in stages I or II. Fine needle aspiration biopsy (FNAB) was made in 5 children and the result was always imprecise or mistaken. Surgical biopsy was made before the definitive surgery in 12 cases. In the remaining 8 children the diagnosis was made only after surgical resection. With an mean follow-up of 70 +/- 43 moths, 6 children died. The prognostic factors associated with poor outcomes were genitourinary location, non radical excission, the presence of distant metastases at onset and alveolar histology. 2. Other sarcomas: Median age at diagnosis was 10.9 years (range 4 days-15 years). Among this group, there were 6 fibrosarcomas, 4 indifferentiated sarcomas, 3 synovial sarcomas, 2 abdominal desmoplastic small round cell tumours, 2 neurofibrosarcomas and 1 leiomyosarcoma. Only 9 received chemotherapy and one radiotherapy. All but one were operated. Five out ot the 19 died.

CONCLUSIONS

Although the role of surgery is crucial, it is necessary to refine the initial histological diagnosis, because neither the PAAF or the biopsy have always been correct. The negative prognostic factors in our series were metastases present at diagnosis, genitourinary location and alveolar (RMS), desmoplastic or indifferenciated histology.

Can urodynamic studies predict bladder behaviour changes after artificial urinary sphincter implantation?

OBJECTIVE

To assess whether preoperative urodynamic studies can predict bladder behaviour changes that will necessitate bladder augmentation in patients with neuropathic incontinence after undergoing artificial urinary sphincter (AUS) implantation.

PATIENTS AND METHODS

We analysed 17 patients, with a mean age of 14.4 years at AUS implantation, who did not undergo bladder augmentation either before or at implantation. All patients were followed at regular intervals before and after implantation. Urodynamic studies were done at least three times before implantation and yearly thereafter. Bladder capacity and compliance were evaluated preoperatively and during the follow up, in order to determine whether these urodynamic measurements could predict the eventual need for bladder augmentation.

RESULTS

After a mean follow up of 7.5 years bladder behaviour was unchanged in 11 patients while six required augmentation. In these six patients, normal bladder capacity and compliance decreased from 67 to 39.6% of age expected capacity (AEC) (P=0.004) and from 31.6 to 13.5 ml/cm of water (P=0.001), respectively. Four of the six had no clinical symptoms to suggest the change in bladder behaviour. The differences in the average preoperative and follow up values for both normal bladder capacity (72.4 vs 83.5% of AEC) and compliance (30 vs 33.7 ml/cm of water) were not significant in the non-augmented patients (P=0.2 and P=0.3, respectively). Preoperative normal bladder capacity and compliance were 72% of AEC and 30 ml/cm of water, respectively, in the 11 non-augmented patients and 67% and 31 ml/cm of water in the six patients with augmentation. These differences between the two groups were not significant (P=0.06; P=0.1).

CONCLUSION

Preoperative urodynamic studies do not predict bladder function outcome after AUS implantation. These patients require long-term careful observation to detect any asymptomatic change in detrusor behaviour.

Initial and long-term management of posterior urethral valves

Posterior urethral valves are the most common cause of congenital obstructive uropathy, resulting in renal failure in childhood. Nowadays, in most cases, diagnosis is suggested by antenatal ultrasound. However, antenatal intervention has not resulted in a significantly improved outcome. Endoscopic valve ablation is the initial treatment in most of these neonates, but others procedures, like vesicostomy or ureterostomy, can also be justified in some particular cases in order to improve renal function prognosis. Different factors like bladder dysfunction, VUR, polyuria and proteinuria, can be responsible for the slow and progressive deterioration in renal function that some of these patients show over the years. By treating them all, we may prevent or delay the onset of end stage renal disease.

[Pyeloplasty follow-up. How and how long?]

INTRODUCTION

Some controversies still persist about the pueloplasty follow-up and this study aims to determine which test should be done in these patients during the follow-up and for how long these patients should be under control.

PATIENTS AND METHODS

Forty six children who underwent to pueloplasty were retrospectively reviewed and those with contralateral renal abnormalities were excluded from study. Six children were lost to follow-up and were excluded. Of 40 p (25 M, 14 F) who fulfilled the requirements of this study, 28 were diagnosed prenatally and 28 had a left UPJ obstruction. All children were diagnosed by renal ultrasound, diuretic renography and excretory urogram (except 2). Mean age at Anderson Hynes pyeloplasty was 5.1 months and mean follow-up was 6.1 years. Renal ultrasound at 3 months and every year, and a diuretic renography at 1 year were performed in all children during follow-up. In some of them diuretic renography was repeated.

RESULTS

At 3 months renal ultrasound demonstrated a significant hydronephrosis decrease in all children (p < 0.0001) but not in further controls. Differential renal function remained unchanged after pyeloplasty and during follow-up. However, there was a significant UPJ drainage improvement after pyeloplasty and during follow-up (p < 0.0001, p < 0.005). Any child needed a second pyeloplasty procedure and all of them showed a normal UPJ drainage in the antegrade ureterogram performed on the 5th postoperative day, except one.

CONCLUSIONS

Differential renal function did not improve after pyeloplasty in our children. If renal ultrasound 3 months after pyeloplasty demonstrated a significant hydronephrosis decrease and at 1 year diuretic renography reveals a normal UPJ drainage any change should be expected in the long-term follow-up.

Posterior urethral valves: prognostic factors

OBJECTIVE

To determine which variables besides bladder dysfunction can help to predict the outcome of renal function in boys with posterior urethral valves (PUV).

PATIENTS AND METHODS

All 40 patients with PUV in this retrospective study were diagnosed and began treatment in our hospital within the first 3 months of life, and have had >or= 5 years of follow-up. At the time of diagnosis, 33 were in renal insufficiency (RI) and seven had normal renal function (RF). At the time of the study 16 were in chronic renal failure (CRF) and 24 had normal RF. We compared their RF (initial and during follow-up), vesico-ureteric reflux (VUR), urinary tract infection (UTI), proteinuria, hypertension, renal echogenicity, final patient age and initial management.

RESULTS

The mean serum creatinine values before and after initial treatment were worse in boys who developed CRF than in those who did not (P = 0.08); the mean glomerular filtrate rate (GFR) at 1 year old was 52 mL/min/1.73 m2 in the former and 102 in the latter (P < 0.001). Proteinuria was present during the follow-up in 79% of patients in CRF and in only 17% of those with normal RF. All patients who developed CRF had echogenic renal changes while only 53% of the others had (P < 0.01). Other variables showed no statistically significant differences (VUR, UTI, hypertension and final patient age). Of 33 patients in RI at diagnosis, nine were treated by valve ablation and 24 by temporary pyelo-ureterostomy. The initial mean serum creatinine value was worse in the latter than in the former (20.8 vs 13.0 mg/L). However, at 1 year old the mean GFR was better in the latter than in the former (P < 0.05). These GFR differences persisted during the first years of life but had disappeared by the fifth.

CONCLUSIONS

The most significant prognostic factor for the future development of CRF is the GFR at 1 year old. The onset of proteinuria during the follow-up is associated with a worse prognosis. Echogenic renal changes may help to identify those dysplastic kidneys that will develop RI. Neonatal boys in RI who underwent pyelo-ureterostomy had better RF during the first years of life than those who underwent valve ablation.

Bladder dysfunction as a prognostic factor in patients with posterior urethral valves

OBJECTIVE

To investigate the extent to which different types of bladder dysfunction can affect long-term renal function in boys with posterior urethral valves (PUV).

PATIENTS AND METHODS

Renal and bladder function were retrospectively assessed in 59 boys with PUV (mean age 10 years, range 5-17). All patients included in the study had at least 4 years of follow-up and their bladder behaviour had been evaluated in at least two urodynamic studies. At the time of the study, of the 59 PUV boys, 37 had normal renal function and 22 had end-stage renal disease (ESRD).

RESULTS

Of the 59 boys with PUV evaluated by urodynamic studies, 25 had normally behaving bladders (42%) and 34 had some type of bladder dysfunction (58%). Of the 22 in ESRD, 15 had abnormally behaving bladders (68%) and only seven had bladders with normal behaviour (32%). Of the 37 boys with normal renal function, 19 had dysfunctional bladders (51%) and 18 had normal bladders (49%). Instability was found in 17 of 19 boys with bladder dysfunction and normal renal function. On the contrary among 22 boys with ESRD, poor compliance was the most frequent urodynamic pattern (eight, 53%) while instability was only found in five. Overall, eight of nine boys with poorly compliant bladders, two of three with myogenic failure and a five of 22 with instability were in ESRD, and this situation occurred at an earlier age in patients with poorly compliant bladders.

CONCLUSION

Bladder dysfunction should be considered as a prognostic factor in renal failure. Those with poor bladder compliance and myogenic failure have the worst outcome, while bladder instability was associated with the lowest incidence of renal failure.

SHOULD WE TREAT VESICOURETERAL REFLUX IN PATIENTS WHO SIMULTANEOUSLY UNDERGO BLADDER AUGMENTATION FOR NEUROPATHIC BLADDER?

PURPOSE

If high pressure is responsible for vesicoureteral reflux in neurogenic bladders, eliminating the high pressure should resolve reflux in noncompliant bladders. Nevertheless, the need for simultaneous ureteral reimplantation and bladder augmentation remains controversial in patients with a noncompliant bladder and vesicoureteral reflux.

MATERIALS AND METHODS

Bladder augmentation was performed in 8 boys and 8 girls with a noncompliant bladder and vesicoureteral reflux at a mean age of 10 years (range 2 to 17) because they had not responded satisfactorily to clean intermittent catheterization and anticholinergic therapy alone. No effort had been made to correct reflux surgically in these patients. Before bladder augmentation reflux was grade II to III in 4 ureters (3 patients) and IV to V in 18 (13). The bladder was augmented with intestine in 14 patients and with ureter in 2. Mean followup was 5.2 years (range 2.8 to 7.5).

RESULTS

After bladder augmentation bladder compliance improved in all patients. Of the 18 ureters with high grade reflux 2 were used for bladder augmentation, and reflux resolved in 13, was downgraded in 1 and persisted in 2. Of the 4 ureters with low grade reflux, reflux disappeared in 2 and was down graded in 2. The rate of high and low grade vesicoureteral reflux resolution or improvement was 87.5% and 100%, respectively. At the end of the study only 3 patients had persistent reflux, which was downgraded in 2. No urinary tract infections developed in any patient and none was receiving chemoprophylaxis 6 months postoperatively.

CONCLUSIONS

Our experience indicates that antireflux procedures are not routinely needed in patients with a noncompliant bladder and associated vesicoureteral reflux who undergo bladder augmentation.

Should we treat vesicoureteral reflux in patients who simultaneously undergo bladder augmentation for neuropathic bladder?

PURPOSE

If high pressure is responsible for vesicoureteral reflux in neurogenic bladders, eliminating the high pressure should resolve reflux in noncompliant bladders. Nevertheless, the need for simultaneous ureteral reimplantation and bladder augmentation remains controversial in patients with a noncompliant bladder and vesicoureteral reflux.

MATERIALS AND METHODS

Bladder augmentation was performed in 8 boys and 8 girls with a noncompliant bladder and vesicoureteral reflux at a mean age of 10 years (range 2 to 17) because they had not responded satisfactorily to clean intermittent catheterization and anticholinergic therapy alone. No effort had been made to correct reflux surgically in these patients. Before bladder augmentation reflux was grade II to III in 4 ureters (3 patients) and IV to V in 18 (13). The bladder was augmented with intestine in 14 patients and with ureter in 2. Mean followup was 5.2 years (range 2.8 to 7.5).

RESULTS

After bladder augmentation bladder compliance improved in all patients. Of the 18 ureters with high grade reflux 2 were used for bladder augmentation, and reflux resolved in 13, was downgraded in 1 and persisted in 2. Of the 4 ureters with low grade reflux, reflux disappeared in 2 and was down graded in 2. The rate of high and low grade vesicoureteral reflux resolution or improvement was 87.5% and 100%, respectively. At the end of the study only 3 patients had persistent reflux, which was downgraded in 2. No urinary tract infections developed in any patient and none was receiving chemoprophylaxis 6 months postoperatively.

CONCLUSIONS

Our experience indicates that antireflux procedures are not routinely needed in patients with a noncompliant bladder and associated vesicoureteral reflux who undergo bladder augmentation.

Does neonatal pyeloureterostomy worsen bladder function in children with posterior urethral valves?

PURPOSE

We determine whether long-term bladder dysfunction is more frequent in children with posterior urethral valves who undergo early supravesical urinary diversion (pyeloureterostomy) than in those who undergo valve ablation.

MATERIALS AND METHODS

Urodynamic studies were performed in 59 boys with severe posterior urethral valves who were divided into 2 groups based on initial treatment of valve ablation (30) and bilateral pyeloureterostomy (29).

RESULTS

Of the 59 boys 25 (42%) had a normal bladder, including 11 with an over distended bladder and 34 (58%) had bladder dysfunction, including instability in 22, poor compliance in 9 and myogenic failure in 3. Of the 30 boys initially treated with valve ablation 14 (46.6%) had a normal bladder, including 7 with an over distended bladder and 16 (53.4%) had bladder dysfunction, including instability in 10, poor compliance in 4 and myogenic failure in 2. Of the 29 boys initially treated with temporary bilateral pyeloureterostomy 11 (38%) had normal bladders, 4 with an over distended bladder and 18 (62%) had bladder dysfunction, including instability in 12, poor compliance in 5 and myogenic failure in 1. There were no statistically significant differences in the number or type of bladder dysfunction between the diversion and valve ablation groups.

CONCLUSIONS

Therefore, temporary pyeloureterostomy did not affect bladder function adversely in the long term.

Does treatment of bladder dysfunction prior to renal transplant improve outcome in patients with posterior urethral valves?

Fourteen patients with posterior urethral valves and end-stage renal failure were urodynamically evaluated in order to identify and correct any bladder dysfunction before renal transplant. Of the 14 patients, during filling, six had normal bladder function, two had an over-distended bladder (one with instability), one had instability, four had poor compliance, and one had a very reduced bladder capacity. During the voiding phase, one had a myogenic failure and another had detrusor-sphincteric dyssynergia. Four patients underwent bladder augmentation. Three were managed with anticholinergic therapy and two required clean intermittent catheterization owing to post-voiding residual urine. A renal transplant was performed in all of these patients at a mean age of 8.2 years. We compared outcome in these 14 patients with bladder dysfunction treated before transplantation with outcome in a matched control group of 14 transplant patients. Graft function and survival were similar in both groups. We believe that urodynamic studies must be included in the pretransplant evaluation of patients with posterior urethral valves in order to diagnose any bladder dysfunction and commence appropriate treatment to avoid any negative influence on graft function.

[The effectiveness of the trigonoplasty in the treatment of the primary vesicoureteral reflux]

Trigonoplasty is a minor surgical procedure to treat vesicoureteral reflux that preserves the integrity of the vesicoureteral junction. This technique was introduced in 1984 by Gil Vernet. Between 1989 and 1995 we performed trigonoplasty in 20 children from 6 to 15 years old with primary vesicoureteral reflux. In our study 15 patients had bilateral vesicoureteral reflux and five were unilateral, they had 35 refluxing units. Gil Vernet's trigonoplasty was performed after a five year observational treatment and it was always indicated in children with special wide trigone (1 grade I, 14 grade II, 17 grade III and 3 grade IV). Surgery was successful in 94% of the patients controlled one year after. Unilateral reflux recurrence in two patients. We consider that trigonoplasty is a good procedure with indication in patients with vesicoureteral reflux with wide trigone. The procedure shorten the postoperative hospital stay and offers a similar percentage of good results as other techniques.

[The Mitrofanoff principle in the lower urinary tract reconstruction]

Since its description in 1980, the Mitrofanoff principle has become a widely utilized and successful technique for the management of patients with a variety of urological disorders. We report our experience with this procedure in 12 patients (8 M, 4F). The age range was 3.5 years to 17 years (average 13y) and follow-up was from 6 months to 3 years (average 1.7y). Patients were classified in 2 groups: I. When this procedure was done because of the patient was unable to perform urethral catheterization (6p). II. Concomitant bladder neck transection and Mitrofanoff diversion (6p). The appendice was used in 8 p and ureter in 4. Bladder augmentation was performed with ureter in 2 p and colon sigmoid in 3. In 1p, ileocecal segment and in other colon + ileum, were used to replace the bladder. All patients catheterize the Mitrofanoff channel easily, there were no cases of stomal stenosis and the conduit was continent in all. We consider that Mitrofanoff principle is a very successful technique and it can be used as the primary continence mechanism or as an adjunct of major urinary tract reconstruction, to ensure complete bladder emptying, in patients unable to perform urethral catheterization.

[Multicystic renal dysplasia and Wilms tumor]

We review a case of multicystic right dysplasia containing nodular renal blastema in a 3-year-old girl with left Wilms tumor. In relation to this finding the management of the asymptomatic multicystic dysplastic kidney in discussed.

[Are there a neuro-urological symptomatology improvement after spinal cord untethering?]

Changes in bladder behaviour and neurological symptoms were evaluated in 47 patients underwent untethered spinal cord because of tethered cord syndrome secondary to myeloneningocele closure. Patients were located in 3 categories (A < or = 5 years, B = 6-10 years and C > 10 years) in relation to age of treatment. After untethering 77% improved neurologically and the best results were evident in children whose condition was repaired promptly (90%). Urodynamic studies were performed in 33 patients before and after surgery. Fifteen had hyperreflexic bladders, six low complicance and 12 hyperreflexia plus low compliance. After treatment in 6 patients bladder dysfunction improved (18%), hyperreflexia disappeared in 4 and sphinteric resistance increased in 2. In patients with tethered cord syndrome, untethering is recommended treatment in preventing further, sometimes rapid neurologic dysfunction and better results are got in childs whose condition is repaired at an early ages.

[A new method for assessing sphincter resistance, in patients with low compliant bladder]

Since 1990, in our department we have planned out a test to find out the grade of sphincteric resistance in patients with low compliant bladders. In order to know which patients will have a sufficient sphincteric resistance to achieve satisfactory continence after bladder augmentation and which patients will not have sufficient sphincteric resistance, needing procedures to increase outlet resistance along with bladder augmentation. This test consisted in: to determine what volume the bladder can admit at a detrusor pressure of 10 cm H2 O, we fill the bladder at that volume and then, we check if the patient had leaks with abdominal pressure increases. The study was carried out in 15 patients with low compliant bladders and suffering from incontinence, who had not responded to I.C. and anticholinergic therapy, who was to undergo bladder augmentation. In 12 patients the test was negative and in 3 was positive. After bladder augmentation, all patients with negative tests, are completely dry, and the three patients whose test was positive, in spite of having urodynamically normal neobladder they remain incontinent. In our opinion, this test is simple to perform and very useful diagnostic tool to known which patients beside bladder augmentation, may need procedures to increase outlet resistance.

[Treatment of vesico-ureteral reflux in low compliance bladder]

Ten patients with noncompliant bladders and vesicoureteral reflux who did not respond to I.C. and anticholinergic therapy, underwent bladder augmentation and no effort was made to correct reflux surgically, because in these patients, in theory, reflux is secondary to bladder dysfunction. In 8 patients bladder augmentation was made with the intestine and in 2 with the ureter. All patients had a normal compliance after treatment and of the 10 patients with reflux (14 renal units) it disappeared in 7 (11 renal units) and in the 90% of the patients with grades III and IV. In the 3 patients where reflux remained, in 2 it was a unilateral low grade reflux (II) and in 1, had improvement from grade IV to grade II. In these patients reflux only appearing when the bladder got too full, which under normal conditions patients do not get with the I.C. Our experience indicates the antireflux procedures are not routinely needed in this group of patients.

[Neuro-urologic impact of spinal cord untethering in patients with myelomeningocele and tethered cord]

Changes in bladder behaviour and neurological symptoms were evaluated in 47 patients underwent untethered spinal cord because of tethered cord syndrome secondary to myeloneningocele closure. Patients were located in 3 categories (A < or = 5 years, B 6-10 years and C > 10 years) in relation to age of treatment. After untethering 77% improved neurologically and the best results were evident in children whose condition was repaired promptly (90%). Urodynamic studies were performed in 33 patients before and after surgery. Fifteen had hyperreflexic bladders, six low compliance and 12 hyperreflexia disappeared in 4 and sphinteric resistance increased in 2. In patients with tethered cord syndrome, untethering is recommended treatment in preventing further, sometimes rapid neurologic dysfunction and better results are got in childs whose condition is repaired at an early ages.

[The prognosis of patients with posterior urethral valves according to the initial treatment and their urodynamic behavior]

Long-term outcome of 35 boys with severe posterior urethral valves is reviewed, with intention to know if the course of renal function depended on initial treatment and bladder dysfunction. Diagnosis was established during the first month in 15 patients, before one year in 16 and later in 4. Surgical management was initially, upper urinary tract diversion (pyeloureterostomy) in 19 patients (group A) and valve ablation in 15 (group B). The average age for closure of temporary urinary diversion was 17 months. Follow-up ranged from 4-19 years (mean 8.3 years). Twenty one patients had a urodynamic study years after initial treatment and this study showed 8 normal bladder, 7 unstable and 6 non-compliant. In group A, at the end of study, 13 patients (70%) have a glomerular filtration of more than 80 ml/min/1.72 m2 while in group B only 6 (37.5%) and average height after treatment was higher in patients of group A. Noncompliant bladders had worst prognosis (66% renal failure) than unstable bladders (25%) and the prognosis was improved in these types of bladders when initial treatment was upper tract diversion. The results of our study suggest that in patients with severe posterior urethral valves, the renal function improved with early diversion (pyeloureterostomy) and irreversible bladder dysfunction worsen the prognosis in these patients.

[The pediatric kidney transplant in recipients under 2 years old]

We report our experience with renal transplantation in 7 infants less than 2 years of age. The mean duration of follow-up was 32.4 m. except one who died in the immediate postoperative period. Immunosuppressive therapy consisted of methyl prednisolone, azathioprine, cyclosporin. No patient showed either vascular or lymphatic complications however the infections were frequent. All except one, have their graft functioning well. Graft and patient survival rates were 85% at 36 m. We conclude that renal transplantation in this age group is technically feasible although it needs a team with wide experience in the management of pediatric renal transplantation.

[Changes in the flow of the stable renal graft following cyclosporin administration]

To evaluate whether oral CyA may produce changes in the renal vascular bed of the graft, a prospective study was made in 16 children with kidney transplant and normal renal function. A exam with echo-Doppler was realized pre and post two hour after CyA was administered. The doses of CyA was 6.1 +/- 2.7 mg/kg/days (3 doses). The results show that CyA produced in the children with kidney transplant an increase of vascular resistance (renal and interlobar) and a decrease transient of urinary flow. The finding changes in relation to time of administration of the CyA.

[Enterocystoplasty: the results with our first 21 patients]

The use of intestinal segments for bladder replacement or augmentation is an alternative in the management of urologic patients. Twenty-one patients (13 M, 8 F) underwent enterocystoplasty by different reason, neurogenic bladder (NB) (10 p), bladder exstrophy (7 p), cloaca exstrophy (3 p) and posterior urethral valves (PUV) (1 p) are presented. Mean age at operation was 12 years (range: 6-19) and the average followed was 3 years. Five patients undergone external urinary diversion. All patients had reflux and 3 chronic renal failure. Bowel segments employed were ileum (11 p), sigma (7 p) and ileocaecal (3 p). Average bladder capacity has been of 354 ml. (range: 200-510). The reflux disappeared in 14 patients and none of them had impaired renal function. In all patients has improved continence and 71% are dry.

[Outcome of conservative treatment of high-degree vesicoureteral reflux]

We performed a retrospective study to evaluate the results of a nonsurgical approach of primary high grade vesicoureteral reflux (VUR). 241 patients (209 III and 32 IV) were reviewed during and average time of 9.4 years. 55% of them were under 6 months and 52% had bilateral reflux (50% III and 63% IV). During the observation period spontaneous resolution of reflux was observed in 126 (60%) with grade III at 5 years and 26% in patient with grade IV at 4 years. In both grades the duration of persistent reflux was analyzed using life-table method. When age at presentation was compared with duration of reflux there was a shorter time of reflux in those patients presenting from age 0 to 6 months. New renal scars developed in 5 patients during the period of observational therapy. We conclude that high grade VUR can resolve over a protracted interval. On basis of this analysis, we advocate the surgical correction in these patients after 5-year period to grade III and 2-year to grade IV.

[Topical treatment with oxybutynin chloride in neurogenic incontinence]

Intravesical oxybutynin chloride was administered to 12 children with neurogenic bladder and incontinence who had unacceptable side effects. Urodynamic studies showed hyperreflexia was eliminated or improvement in 100% of them and low compliance was improved (88%), with a mean increase in bladder volume to 123% and a mean decrease of filling pressure to 24 cm H2O. Six patients became completely dry (50%), 4 continent period was increased and 2 did not improve. No systemic effects were observed.

[Urodynamic diagnosis and treatment in neurogenic bladder dysfunction]

A group of 55 patients (28M,27F) with neurogenic bladder dysfunction was studied. Patient age ranged from 1m. to 20 years (mean age 9.1 years). Most of the patients had neurogenic bladder secondary myelomeningocele (70%). The urodynamic investigations demonstrated detrusor hyperreflexia in 50 (poor compliance in 28p) detrusor arreflexia in 3 and normal bladder in 2. Six patients hadn't incontinence and didn't need treatment. The rest (49p), couldn't be dry more than 2 hours. After treatment (anticholinergic, alpha adrenergic agonist, alpha-betha adrenergic agonist, I. C. and bladder augmentation), the continence was improved satisfactorily in 38 patients (77.5%). In conclusión, we think that early treatment from neonatal period, supported with urodynamic studies may prevent lon-term renal damage and most patients with neurogenic bladder do not require surgical intervention to improve continence because it can be controlled satisfactorily by other means.

[Urodynamic diagnosis and treatment of neurogenic bladder dysfunction]

A group of 55 patients (28M, 27F) with neurogenic bladder dysfunction was studied. Patient age ranged from 1m. to 20 years (mean age 9.1 years). Most of the patients had neurogenic bladder secondary myelomeningocele (70%). The urodynamic investigations demonstrated detrusor hyperreflexia in 50 (poor compliance in 28p) detrusor areflexia in 3 and normal bladder in 2. Six patients hadn't incontinence and didn't need treatment. The rest (49p), couldn't be dry more than 2 hours. After treatment (anticholinergic, alpha adrenergic agonist, alpha-beta adrenergic agonist, I. C. and bladder augmentation), the continence was improved satisfactorily in 38 patients (77.5%). In conclusion, we think that early treatment from neonatal period, supported with urodynamic studies may prevent long-term renal damage and most patients with neurogenic bladder do not require surgical intervention to improve continence because it can be controlled satisfactorily by other means.

Histomorphometric study of experimental extramucosal ureteroureterostomy

The reconstruction of the urinary tract is still nowadays a controversial issue. This study is based on the use of histomorphometric techniques to describe the changes which take place in extramucosal ureteroureterostomy. A medial laparotomy was performed in 41 Wistar rats. The left ureter was sectioned and an extramucosal anastomosis was performed. All rats were sacrificed 25 days postsurgery. Histomorphometric studies were performed on the sutured ureters as well as on the contralateral (unrepaired) ureters. Two of the 41 cases operated died. Five others developed hydronephrosis and/or urinary fistula. Histomorphometric studies gave an average cross-sectional area of 98,662.5 +/- 31,927 mu 2 for the anastomosed ureters versus 75,176.3 +/- 16,732.4 mu 2 for the control ureters (P less than or equal to 0.01). Sutured ureters showed an increase in the area of the muscular layer (P less than or equal to 0.001) and the submucosa (P less than or equal to 0.01) compared with control ureters. Mucosa and lumen areas showed no significant differences between the groups. Sectioned ureters show an increase in total area and width based on a hypertrophy of the muscular and submucosal layers.

[Diversion reversal, colocystoplasty and kidney transplantation]

A patient with severe nephropathy from reflux within the context of a non-neurogenic neurogenic bladder underwent diversion in an attempt to preserve her severely deteriorated renal function. Eight years following the procedure the patient had progressed to end-stage renal failure. As a previous step to renal transplantation, the patient was submitted to undiversion and bladder augmentation. Six months thereafter, she received a cadaver kidney graft. Twenty-four months after the transplant procedure, the patient maintains a normal renal function, is continent day and night and is on intermittent catheterization.

Priapism and Fabry disease: a case report

A 10-year-old boy presented with priapism of 10 h duration which after unsuccessful conservative measures, was relieved by a saphenocorporeal shunt. A 4-year history of intermittent vague aching of fingers and toes accompanied by low-grade fever was reported. Fabry disease was confirmed by the lack alpha-galactosidase activity in serum and leucocytes. Other characteristic features of Fabry disease were not present. The condition was also diagnosed in his 14-year-old brother and suspected in his maternal grandfather who died at the age of 49 from renal failure of unknown aetiology.

[Posterior urethral valves: prognosis related to the initial surgical treatment]

Long-term outcome of 32 boys with severe posterior urethral valves is reviewed. Diagnosis was established during the first month of life in 14 patients, along the first year in another 14 and later in five. Surgical management was, initially, bilateral upper urinary tract diversion (cutaneous ureterostomy or pyelostomy) in 17 patients (Group A), and valve ablation alone or vesicostomy in 15 children (Group B). Eight months was the mean age of patients at initial surgery (40% before the first month of life). The average age for closure of the temporary urinary diversion was 17 months. Eleven patients underwent later unilateral nephrectomy and eighteen antireflux surgical procedures. Follow-up ranged from 1 to 15 years (mean 6 years). Fifteen patients have a Glomerular Filtration Rate (G.F.R.) of more than 80 ml./min./1.73 m2. Eleven (73%) of them underwent early upper urinary tract diversion, and the remaining four (27%) underwent valve ablation or vesicostomy. Two children among the 32 have developed end stage renal disease. Average height and weight posttreatment values were higher in those patients treated with ureterostomy or pyelostomy. The results of our study suggest that renal function improved in patients with early upper urinary tract diversion.

[Experimental study of reconstruction of the vas deferens in the rat]

We performed vasectomy and microsurgical repair of the vas deferens in 20 rats utilizing absorbable and non-absorbable 10-0 sutures. At 40 days the results of the repair procedure were evaluated by seminal fluid and fertility analyses, deferentography, and histologic examination of the anastomoses. The procedure failed in one case that presented occlusion of the spermatic cord from a granuloma.

Morbid musculoskeletal sequelae of thoracotomy for tracheoesophageal fistula

The standard surgical approach for tracheoesophageal fistula (TEF) is right dorso-lateral thoracotomy. The late musculoskeletal consequences of the operation have been evaluated only rarely. Two hundred and seventy-seven patients with TEF were operated upon during the past 16 years, 117 of whom were available for long term (3 to 16 year) study. Twenty-nine of the patients had significant musculoskeletal deformities: (1) Twenty-one patients (23.8%) had prominent elevation of the right shoulder or "winged" scapula secondary to partial paralysis of the latissimus dorsi muscle; (2) Eighteen (20%) had marked asymmetry of the thoracic wall from atrophy of the serratus anterior muscle; (3) Nine (10%) had fusion of the ribs, in one of whom major respiratory dysfunction was a consequence; (4) Seven (7.8%) had severe thoracic scoliosis. The deformity was not of sufficient severity to warrant surgical correction but all patients required physiotherapy; (5) In two children (2.2%), fixation of the skin cicatrix to the bony thorax limited the mobility of the ipsilateral shoulder; (6) And finally, in three girls (3.3%), the thoracotomy scar disfigured the right breast leading to mammary maldevelopment in one adolescent. The latter child required plastic release of the entrapped breast. The dorso-lateral thoracic incision for tracheoesophageal atresia may lead to significant musculoskeletal complications and, since other alternatives are available, should be reevaluated as the recommended surgical approach.

[Pathogenic factors and therapeutic criteria in 82 newborn infants with necrotizing enterocolitis]

Sixty newborn infants with necrotizing enterocolitis (NEC) were retrospectively studied in 1979. The incidence was 0,49/1.000 living newborns: 81% were under 2,500 g and 30% under 1.500 g. We found a very low incidence of the so-called pathogenic factors. Feeding started in this group on the 24 h of life, with adapted formulas; 28% underwent surgery with a postoperative mortality of 62% and an overall mortality of 28%. Ten out of the 17 deceased were under 1.500 g. From 1979 with a similar medical treatment we introduced a prospective study consisting of a protocol of 10 different parameters including clinical, radiological and analytical values, the aim being a more objective way of indicating when to operate the patient. Special meticulous care of the nutrition of the low-weight babies was taken; 22 patients were treated til 1982, only 4,5% were under 1.500 g. The initial feeding time in all high risk babies under 1.250 g being 7 days with gastric gavage and elementary diets. All the infants with more than 60% values in the protocol underwent surgery (38%). The postoperative mortality was 37% with an overall mortality of 19%. A look back to our series suggests a clear usefulness of the protocol and the suspicion that the delay on feeding with intragastric continuous perfusion in low weight babies reduces NEC.

[Sacrococcygeal tumors. Experience of 42 cases]

From 1966 to 1981, at "La Paz" Children's Hospital, Madrid, 42 patients with ST were studied. We exclude 4 stillborn, the remaining 38 underwent 40 surgical operations, 69% in the first week of life. The aim of the study is to classify and organize from the clinical and pathological points of view the usual equivocal terminology. From a clinical point of view, sex, localization and age at diagnosis were the usually described for these tumors. The relationship of age with malignancy is pointed out. Special emphasis is made on the pathological information about undifferentiated blastodermic tissues, like neuroblasts pointing out their low influence in prognosis. 79% were mature teratomas and 21% malignant tumors (Yolk sac and embrional carcinoma).

[Tolazoline in postoperative period of diaphragmatic hernia (author's transl)]

During the last ten year period, 78 newborns with congenital diaphragmatic hernia were seen at the Clinica Infantil "La Paz", Madrid. Twenty seven cases died immediately after delivery and 51 were operated. Necropsy findings showed pulmonary hypoplasia and patent ductus arteriosus. Mortality rate in operated cases was 29%. It seems that pulmonary hypoplasia increases pulmonary vascular resistance resulting in a state of fetal circulation with right-to-left shunting through ductus arteriosus. In these cases right to left shunt with umbilical and temporal artery catheters measuring pre and postductal pO2 must be demonstrated. Authors show their experience with two cases of newborns with Bockdalek hernia treated with tolazoline in postoperative period. Both survived.

[Hemihepatectomy with I.V.C. by-pass. Experience of 11 cases (author's transl)]

22 malignant tumors of the liver in children have been treated so far at the "La Paz" Childrens Hospital. 11 cases underwent hemihepatectomy with intracaval by-pass. This technique is described and its advantages underlined.

[Digestive associated malformations in esophageal atresia. A study of 125 patients (author's transl)]

The incidence of digestive malformations associated to esophageal atresia and tracheoesophageal fistula is reviewed in a series of 125 surgically treated patients during the last five years' period. A correlation is drawn with other associated malformations. Its influence upon the mortality rate is stressed.