Antonio Macedo

Evaluation of and Treatment for Monosymptomatic Enuresis: A Standardization Document From the International Children's Continence Society

PURPOSE We provide updated, clinically useful recommendations for treating children with monosymptomatic nocturnal enuresis. MATERIALS AND METHODS Evidence was gathered from the literature and experience was gathered from the authors with priority given to evidence when present. The draft document was circulated among all members of the International Childrens Continence Society as well as other relevant expert associations before completion. RESULTS Available evidence suggests that children with monosymptomatic nocturnal enuresis could primarily be treated by a primary care physician or an adequately educated nurse. The mainstays of primary evaluation are a proper history and a voiding chart. The mainstays of primary therapy are bladder advice, the enuresis alarm and/or desmopressin. Therapy resistant cases should be handled by a specialist doctor. Among the recommended second line therapies are anticholinergics and in select cases imipramine. CONCLUSIONS Enuresis in a child older than 5 years is not a trivial condition, and needs proper evaluation and treatment. This requires time but usually does not demand costly or invasive procedures.

Hypospadias dilemmas: a round table.

Department of Pediatric Urology, University of Texas, Southwestern Medical Center and Children’s Medical Center, Harry Hines Boulevard, Dallas, Tx 75390, USA Department of Urology, Federal University of Sao Paulo, Rua Maestro Cardim, 560/CJ. 215, 01323-000 Sao Paolo, Brazil Department of Urology, Paediatric Urology and Urogenital Reconstruction, Ghent University Hospital, De Pintelaan 185, B-9000 Gent, Belgium Department of Paediatric Urology, Hopital Mere-Enfants, Groupement Hospitalier Est, 59 Boulevard Pinel, 69500 Bron, France

Prospective randomized controlled trial comparing 2 versions of laparoscopic ileal interposition associated with sleeve gastrectomy for patients with type 2 diabetes with BMI 21–34 kg/m2

BACKGROUND The objective of the present study was to prospectively evaluate the results of 2 versions of laparoscopic ileal interposition (II) and sleeve gastrectomy (SG) for the treatment of patients with type 2 diabetes mellitus and body mass index of 21-34 kg/m(2). METHODS The laparoscopic procedures were prospectively and randomly performed in 38 patients. Of the 38 patients, 18 underwent the first version (II-SG) and 20 underwent the second version in which a diversion of the second portion of the duodenum was applied (II-DSG) and a segment of ileum was interposed into the proximal duodenum. The groups were comparable regarding age (56 and 50 years); gender (13 men and 5 women and 14 men and 6 women); weight (78 and 86 kg); mean BMI (27 and 29 kg/m(2)); duration of type 2 diabetes mellitus (10.1 and 9.2 years); the presence of dyslipidemia (12 and 8 patients), micro- and macroalbuminuria (9 and 9 patients), hypertension (8 and 15 patients), and retinopathy (5 and 8 patients); and the use of antidiabetic medications and the hemoglobin A1c level (8.6% and 8.4%). All patients were followed up for >or=2 years. RESULTS The mean hospital stay was 3.4 days for the II-SG and 3.5 days for the II-DSG group. No patient required reoperation. All patients in both groups achieved lower levels of hemoglobin A1c. In the II-SG group, the mean hemoglobin A1c level was 6.35% (range 4.9-8.1). In the II-DSG group, the mean hemoglobin A1c level was 5.39% (range 4.2-6.5%). The mean BMI decreased in both groups to 22.2 kg/m(2) in the II-SG group and 22.7 kg/m(2) in the II-DSG group. Normal cholesterol levels (<200 mg/dL) were observed in 95% of the II-SG group and 100% of the II-DSG group. The triglycerides were lower than 150 mg/dL in 73% of the II-SG group and 90% of the II-DSG group after 24 months. CONCLUSION Laparoscopic II-SG and II-DSG were safe and effective operations for controlling type 2 diabetes mellitus in a nonobese (BMI 21-34 kg/m(2)) population.

Nonpharmacological treatment of lower urinary tract dysfunction using biofeedback and transcutaneous electrical stimulation: a pilot study.

To report a series of children with lower urinary tract dysfunction (LUTD) whose urge syndrome was treated by electrical stimulation, and their voiding dysfunction by biofeedback; none of the children were using anticholinergic drugs during treatment.

Prospective Study of Transcutaneous Parasacral Electrical Stimulation for Overactive Bladder in Children: Long-Term Results

PURPOSE We evaluated the long-term success of transcutaneous parasacral electrical stimulation for overactive bladder in children. MATERIALS AND METHODS We prospectively evaluated children who underwent transcutaneous parasacral electrical stimulation for overactive bladder. All patients had symptoms of overactive bladder, bell curve in uroflowmetry and low post-void residual urine. The procedure was performed using a frequency of 10 Hz for 20-minute sessions 3 times weekly for a maximum of 20 sessions. Initial and long-term (more than 6 months) success rates were evaluated. RESULTS Transcutaneous parasacral electrical stimulation was performed in 36 girls and 13 boys with a mean age of 10.2 years (range 5 to 17). Mean followup was 35.3 months (range 6 to 80). Before treatment urgency, daytime incontinence and urinary tract infection were seen in 100%, 88% and 71% of cases, respectively. Initial success (full response) was demonstrated in 79% of patients for urgency, 76% for incontinence and 77% for all symptoms. Continued success was seen in 84% of patients for urgency, 74% for daytime incontinence and 78% for all symptoms. If the 30 patients with at least 2 years of followup were considered, treatment was successful in 73%. Recurrence of symptoms after a full response was seen in 10% of cases. Two of 33 patients (6%) with urinary tract infection before the procedure still had infection after treatment. CONCLUSIONS Transcutaneous parasacral electrical stimulation is well tolerated, and demonstrates short and long-term effectiveness in treating overactive bladder in children. Symptoms eventually will recur in 10% of patients.

A continent catheterizable ileum-based reservoir

The development of new techniques of bladder augmentation and clean intermittent catheterization (CIC) have changed the prognosis of end-stage bladder disease in children. The principle of Mitrofanoff, used with the appendix or efferent conduits, offers the possibility of easy access for CIC of the bladder or reservoir [1]. When both augmentation and a suprapubic continent stoma for CIC are required, the ileo-caeal segment can be used, with the appendix in situ for an efferent conduit, or an augmentation with stomach, ileum or colon and the appendix mobilized, or a catheterizable conduit can be created from a small segment of ileum to empty the bladder [2]. We previously proposed a new approach as an alternative to the procedures above [3,4]. We describe herein a new ileal-based reservoir technique using a 30 cm ileal segment with a continent catheterizable stoma made with an isolated ̄ap of ileum from the same segment. The indications for this procedure are clinical situations such as valve and neurogenic bladders, bladder exstrophy or whenever bladder augmentation and suprapubic CIC are needed.

The tunica vaginalis dorsal graft urethroplasty: initial experience

INTRODUCTION Nowadays, buccal mucosa grafts are the most successful method to reconstruct bulbar urethral strictures. Dorsal placement of the graft has been recently proposed, allowing the graft to be spread fixed on the tunica albuginea of the corporal bodies overlying the stricture. The dorsal graft is ingenious and represents a useful addition to the surgical armamentarium, since it offers a better chance for graft take than does the spongiosum when the urethra is diseased and poorly vascularized. We developed an additional reconstructive option using tunica vaginalis grafts, placed dorsally, for the treatment of anterior urethral strictures. SURGICAL TECHNIQUE A total of 11 patients with anterior urethral strictures were treated with a tunica vaginalis graft urethroplasty. The surgical technique was done as described by Barbagli. The urethra was dissected from the corpora cavernosa and rotated 180 degrees. The dorsal urethral surface was exposed and fully opened. Both the distal and proximal lumina were calibrated. The tunica vaginalis graft was sutured, splayed and quilted over the corpora cavernosa using 6-0 PDS running stitches. The left side of the urethral mucosa was sutured to the graft using 6-0 PDS sutures. A 18F silicone Foley catheter was inserted at this point. The urethra was rotated back to its original position and sutured laterally to the right side of the graft. At the end of the procedure, the graft was completely covered by the urethra. With a follow-up ranging from 7 weeks to 5 months, all patients were voiding well (uroflowmetry > 14 mL per second). CONCLUSION This initial experience in 11 patients indicates that tunica vaginalis dorsal graft urethroplasty may be considered within the reconstructive armamentarium of genitourinary surgeons.

Etiology of urinary tract infection in scholar children

OBJECTIVE To prospectively assess the prevalence of vesicourethral dysfunction in children over 3 years old, comparing it with the occurrence rate for other potential factors that cause urinary infection in this age range. MATERIALS AND METHODS 36 girls and 9 boys were assessed, with mean age of 6.4 years, ranging from 3 to 13.9 years. These children were prospectively assessed regarding the presence of symptoms of lower urinary tract dysfunction. These data were compared with the retrospective assessment of other potential risk factors for urinary infection. Ultrasonography was performed in 28 children and voiding cystourethrogram was performed in 26 patients. RESULTS Vesicourethral dysfunction was diagnosed in 39 (87%) of the 45 children with urinary infection. Among these 39 patients, all had voiding urgency, 30 (77%) had urinary incontinence, 12 (31%) pollakiuria and 3 (8%) presented infrequent voiding. Vaginal discharge was evidenced in 8 (22%) girls and phimosis in 2 (22%) boys. Obstipation was diagnosed in 10 (22%) cases. Significant post-voiding residue was detected in 4 (13%) of the 28 cases assessed. Vesicoureteral reflux was evidenced in 5 (19%) of the 26 patients who underwent voiding cystourethrogram. In only 2 (4%) cases there was not an apparent cause for the infection. CONCLUSION Vesicourethral dysfunction is a major cause of urinary infection in children with ages above 3 years old. In cases where voiding dysfunction in not present, other predisposing factors must be assessed. However, only 4% of the patients did not present an apparent urologic cause for the infection.

Long-Term Results with A One-Stage Complex Primary Hypospadias Repair Strategy (The Three-in-One Technique)

PURPOSE Complex primary hypospadias repair that warrants urethral plate division is treated mostly in two steps, not necessarily in two surgeries. Our aim was to review long-term results with a one-stage strategy based on reconstruction of the urethral plate with buccal mucosa graft and onlay transverse preputial flap anastomosis protected by a tunica vaginalis flap (the three-in-one concept). MATERIAL AND METHODS We were able to report on 35 patients operated for primary scrotal, penoscrotal and perineal hypospadias between March 2002 and June 2008. We reviewed all charts and had phone interviews with patients not seen for the last 24 months. We investigated parameters such as UTI occurrence, fistula, residual curvature, meatal stenosis, urethral diverticula, dehiscence, orchitis and parental perception. RESULTS Surgical complications occurred in 13 patients (37%): 4 meatal stenosis, 4 diverticula, 5 fistulae and 2 residual penile curvatures (total 42%). Meatal dilatation was successful in 2 cases, reflected in fistula resolution. The reoperation rate was 31.5% consisting mostly of simple procedures like fistula closure, meatotomy and penile curvature release, and complex diverticula repair in 4 cases. Parental perception was excellent for 57% (20 patients) and good or acceptable for the remaining. Mean follow-up was 4.6 years. CONCLUSIONS The one-step strategy is associated with 68.5% success in a single operation, whereas 31.5% will need a second repair. We recognize that meatal problems are mostly associated with fistulae and diverticula; therefore, we recommend a final acceptable proximal glandar opening that will not compromise the neourethra.

Effects of Urinary Tract Infection in Patients With Bladder Augmentation and Kidney Transplantation

PURPOSE We evaluated the rate of function decline of the renal allograft in patients with augmented bladder. We also evaluated the prevalence of asymptomatic bacteriuria and urinary tract infection in these patients, and to demonstrate if these findings are predictors of allograft function decline, comparing children who underwent bladder augmentation with a control group. MATERIALS AND METHODS Among 170 children and adolescents undergoing renal transplantation at our institution 23 (14%) had previously undergone bladder augmentation. These patients were retrospectively compared (1:2 ratio) to 42 controls matched for gender, age, race, donor type, weight and immunosuppression protocol. The type of donor (living or cadaver), rate of acute tubular necrosis and cold ischemia time during transplantation were also similar between groups. RESULTS Mean followup was 18.0 +/- 13.9 months and 25.2 +/- 14.1 months for the augmented and nonaugmented bladder groups, respectively (p >0.05). The incidence of acute rejection within the first 12 months of kidney transplantation was 9% in the bladder augmentation group and 26% in controls (p >0.05). The rate of urinary tract infection or asymptomatic bacteriuria in the first 12 months after kidney transplantation was higher in the bladder augmentation group (19 patients, 83%) compared to controls (7 patients, 17%, p <0.001). Patients with augmented bladder had a higher number of hospital admissions (14 patients, 61%) compared to the control group (12 patients, 29%, p = 0.004). Despite the higher incidence of urinary tract infection in the augmented bladder group, there was no statistically significant difference in graft function between the groups at 6 months (1.1 +/- 0.3 mg/dl vs 1.0 +/- 0.3 mg/dl) or 12 months (1.0 +/- 0.2 mg/dl vs 1.2 +/- 0.7 mg/dl) after transplantation. CONCLUSIONS Our study demonstrated that patients with transplanted kidney and augmented bladder had more asymptomatic bacteriuria and urinary tract infections than those without bladder augmentation. However, the rate of graft survival was similar between the groups.