Preliminary results of complete delayed primary bladder exstrophy reconstruction in male patients

INTRODUCTION

The success of primary bladder closure in bladder exstrophy (BE) is the determining factor for future capacity and continence. In recent years, owing to the unsatisfactory results of staged repair, complete delayed primary reconstruction has gained prominence.

OBJECTIVE

To analyze short-term results in male patients with BE undergoing delayed primary closure and compare them with early bladder closure as part of staged repair in our healthcare facility.

MATERIALS AND METHODS

The success of bladder closure, postoperative management, complications, and hydronephrosis was assessed over a 12-month follow-up period in both groups: early primary closure (group A) and delayed primary closure (group B).

RESULTS

In group A (n=13), mean age at closure was 25 hours and mean pubic diastasis was 32 mm. Patients had respiratory support and muscle relaxation for an average of 4 days postoperatively. Closure success was 85%, and 1 patient presented maintained hydronephrosis beyond the first 6 months. In group B (n=6), mean at closure was 58 days, and mean pubic diastasis was 34 mm. Patients had epidural analgesia and no respiratory support postoperatively. Closure success was 100%. 33% had transient hydronephrosis, and 1 patient (17%) presented maintained bilateral hydronephrosis. The same immobilization technique was used in both groups for 3 weeks.

CONCLUSIONS

Delayed primary reconstruction is safe as it allows for closure success without increasing complications as compared to staged repair. A long-term follow-up is required to assess urinary continence, esthetic results, and genital functionality.

[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.

[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.

[Contrast-enhanced sonourethrography versus conventional miction cystourethrography in the assessment of the urethra: preliminary study]

BACKGROUND AND AIMS

Voiding cystourethrography (VCUG) is the first choice imaging modality for assessing the urethra, but this technique exposes patients to ionizing radiation. Cystosonography with echocontrast (CS) has proved to be a reliable technique to detect and grade vesicoureteral reflux (VUR) without exposing patients to ionizing radiation, but its capacity to adequately study the urethra has yet to be demonstrate in large series of patients. The aim of this study is to demonstrate the reliability of contrast-enhanced CS for assessing the urethra by comparing the results with those of the VCUG.

MATERIAL AND METHODS

108 patients were studied with ultrasound (US) using a galactose-based contrast agent. This exam was always followed by VCUG. Basal and voiding urethral US studies were performed with. Patients were studied in supine decubitus position. Girls were examined by longitudinal translabial approach, with the probe (a 7.5 MHz liner array transducer) positioned longitudinally at the introitus, to evaluate the bladder neck and urethra. In boys the transducer was initially placed longitudinally in the escrotum at ventral root of the penis to assess the bladder neck and proximal bulbar urethra, and then displaced distally toward the penile urethra. On basal study the echogenic urethral mucosa and the collapsed sonolucent urethral lumen were indentified and measured when distended. The patients were asked to void with the probe in place. During voiding attention was focused on elasticity and distention of urethral walls, as well as in the caliber of the entire urethra. Patients unable to void during either CS or VCUG were excluded.

RESULTS

The bladder neck and the entire urethra were well demonstrate with CS. All females and 43 males showed a normal urethra both in CS and VCUG. Four patients were dignoses of posterior urethral valves (PUV) with CS and confirmed at VCUG, one patient had anterior urethral valves and 5 showed urethral stenosis at both techniques. Three patients with a vesicosphincteric dysinergia, 14 with resected PUV and one with a resected syringocele were adequately evaluated. Twelve girls showed vaginal reflux. The information provided by CS was equivalent to the VCUG in all patients but two with a syringocele (only seen on VCUG).

CONCLUSIONS

CS is a reliable imaging modality sufficiently sensitive and specific to study the urethra, adding dynamic information to VCUG and can be used as a complement to VCUG.

[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.

Abdominal mass: "fetus in fetu"

A female newborn presented a mass in the left upper abdominal quadrant. It was removed by surgery and contained two independent fetuses. Dissection and radiological study of the fetuses showed an axial skeleton and long bones. It corresponds to the generally recognized diagnostic criteria of fetus in fetu.

[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.

[Traumatic diaphragmatic hernia in children]

We have treated three children with traumatic diaphragmatic hernia appearing after blunt abdominal trauma. The hernia was on the right side in two patients and was accompanied by liver and lung injuries. The most common site of diaphragmatic rupture was the postero-lateral area in both sides. Diagnosis was suspected in all of them with chest radiograph before operative management. The transabdominal approach has proven to be efficacious in repairing the defects and often require emergency care. The diaphragmatic repair was performed using non absorbable interrupted mattress sutures. No prosthetic materials were required.