Antonio Zaccara

Long-Term Efficacy of Percutaneous Tibial Nerve Stimulation for Different Types of Lower Urinary Tract Dysfunction in Children

PURPOSE We evaluated the efficacy of percutaneous tibial nerve stimulation for different types of pediatric lower urinary tract dysfunction. MATERIALS AND METHODS A total of 14 children with idiopathic overactive bladder, 14 with dysfunctional voiding, 5 with underactive bladder, 4 with underactive valve bladder and 7 with neurogenic bladder resistant to conventional therapy underwent percutaneous tibial nerve stimulation weekly for 12 weeks. The stimulation effect was evaluated by comparing bladder diary, flowmetry and urinalysis before and after treatment. Improved patients were followed by bladder diary and urinalysis. Followup data at 1 and 2 years were compared with those obtained after stimulation. Data were analyzed using Fishers exact test. RESULTS Symptom improvement was significantly greater in nonneurogenic than in neurogenic cases (78% vs 14%, p <0.002). Of patients 18% with underactive bladder and 50% with underactive valve bladder were unresponsive. Of 14 overactive bladder cases 12 and all 14 of dysfunctional voiding were improved (p not significant). Of improved patients 5 of 12 with overactive bladder and 12 of 14 with dysfunctional voiding were cured (p <0.01). On uroflowmetry voided volume and post-void residual urine became normal in a greater number of dysfunctional voiding than overactive bladder cases (57% vs 20% and 57% vs 25%, each p not significant). At 1 year of followup the cure rate was greater in dysfunctional voiding than in overactive bladder cases (71% vs 41%) and it remained the same at the 2-year evaluation. Chronic stimulation was necessary to maintain results in 29% of dysfunctional voiding and 50% of overactive bladder cases. CONCLUSIONS Percutaneous tibial nerve stimulation is reliable and effective for nonneurogenic, refractory lower urinary tract dysfunction in children. Efficacy seems better in dysfunctional voiding than in overactive bladder cases. There is evidence that percutaneous tibial nerve stimulation should be part of the pediatric urology armamentarium when treating functional incontinence.

Prenatal diagnosis and clinical outcome of ovarian cysts

Technical refinements of ultrasound (US) have greatly affected the antenatal diagnosis and treatment of ovarian cysts. From 1985 to 1990 25 consecutive fetuses with ovarian cysts were followed-up by US both during pregnancy and postnatally. All cases were diagnosed between the 28th and 39th weeks of gestation. Deliveries were all at term; cesarean section was required only for obstetric complications. Eight fetuses (32%) showed US patterns of cyst torsion, a finding confirmed at surgery in all. In five patients US patterns suggested complications postnatally that were also confirmed at operation. In six cases cysts increased or remained unchanged in size after 15 days of life: in 50% of these surgery showed ovarian torsion. In the remaining six cases spontaneous resolution occurred within 1 to 4 months. One patient required intrauterine needle aspiration. There were two cases of intestinal obstruction. To date, more than 60% of newborns with ovarian cysts require oophorectomy; however, different treatments (cystectomy, needle aspiration, uncapping) combined with a close US follow-up are likely to reduce this percentage.

Endoscopic Manipulation of Ureteral Calculi in Children by Rigid Operative Ureterorenoscopy

To date, rigid operative ureterorenoscopy with ultrasound lithotripsy for the treatment of ureteral calculi has been performed only in adults or older children. The size of the instrument with the working channel for the ultrasound probe has been considered unsuitable for delicate anatomical structures, such as those of children younger than 4 years. We performed 8 ureterorenoscopic examinations in 7 patients (3 boys) 3 to 8 years old and have demonstrated that the 11.5F ureteroscope can be inserted without difficulty into the ureteral meatus of a 3-year-old boy. Introduction of the instrument is facilitated by the use of the Perez-Castro irrigation pump. This procedure does not lead to any urethral or ureteral damage, nor is vesicoureteral reflux shown on a postoperative cystogram. This technique allows extracorporeal shock wave lithotripsy to be extended also to small children, offering the possibility of easy and successful management of any residual steinstrasse.

Stenting for caustic strictures: Esophageal replacement replaced

METHODS From 1983 to 1996, 31 children with caustic esophageal strictures were seen at Bambino Gesù Childrens Hospital; they were all treated conservatively except for two cases complicated by tracheoesophageal fistula. The remaining 29 patients were divided into three groups depending on the treatment, which was modified over the years. Group A (1983 to 1987) consisted of seven patients treated by periodic dilatations; group B (1988 to 1992) consisted of 10 children treated by 40 days of esophageal stenting plus dexamethasone, 0.5 mg/kg/d plus ranitidine plus no oral feeding for 7 to 10 days; group C (1993 to 1996) consisted of 12 cases treated by 40 days of esophageal stenting plus dexamethasone, 1 mg/kg/d plus omeprazole plus early oral feeding resumption. RESULTS No differences were observed between the three groups of patients with regard to the mean age and to the ingested substance, whereas a significant difference (P = .007) was observed in the mean length of the stricture between group A and C (3.4+/-1.3 and 5.6+/-1.6 cm, respectively). In all but one of the patients (96.5%) complete healing of the stenosis was achieved by conservative treatment, with definitive relief of dysphagia. One patient in group C did not improve after a repeated stenting procedure and was surgically treated. However, in group A, resolution of the stricture was obtained after an average of 19.9+/-14.8 dilatations in a mean period of 25.3+/-17.2 months. In group B, a mean of 12+/-11.3 dilatations were required in a mean period of treatment of 14.1+/-10.6 months. In patients in group C, a mean of 3.5+/-3.2 dilatations were necessary in a mean of 5.8+/-4.8 months. A statistically significant difference was observed both with regard to the number of dilatations and to the duration of treatment, between group A and group C (P = .002) and group B and C (P = .03). CONCLUSION Esophageal replacement should be considered only in cases complicated by tracheoesophageal fistula or in the rare patients who do not respond to repeated esophageal stenting.

Antenatal Diagnosis of Surgically Correctable Anomalies: Effects of Repeated Consultations on Parental Anxiety

OBJECTIVE: To assess whether or not a correlation exists between antenatal consultations and parental anxiety.STUDY DESIGN: In total, 31 couples undergoing prenatal consultation after a diagnosis of a surgically correctable anomaly were asked to fill in a questionnaire (Spielberger State-Trait Anxiety Inventory) measuring anxiety levels (AL) both after the first consultation and at birth. Prenatal counselling was done by a perinatal team including paediatric surgeon, obstetrician, and psychologist.RESULTS: Malformations were: eight diaphragmatic hernias, 10 intestinal atresias, four abdominal masses, nine abdominal wall defects. Each fetus was subsequently followed up at regular intervals from diagnosis to birth. AL at birth were then compared with the number of antenatal consultations. A negative correlation (r=−0.688, p<0.001) was found between the number of consultations and the level of anxiety at birth. Patients having at least two consultations had significantly lower anxiety levels at birth.CONCLUSION: Irrespective of the type of malformation, there is evidence that having more than one antenatal consultation may significantly reduce AL at birth. Therefore, early antenatal diagnosis should be encouraged in order to increase as much as possible chances of repeated consultations for the prospective parents.

Current State of Nerve Stimulation Technique for Lower Urinary Tract Dysfunction in Children

PURPOSE A variety of electrical nerve stimulation methods has been used through the years to treat lower urinary tract dysfunction. Relevant literature was reviewed to analyze techniques and available biomedical devices, technique applicability, indications and usefulness in pediatrics. MATERIALS AND METHODS An extensive search was performed on PubMed® and MEDLINE® for scientific publications on intravesical, transcutaneous, sacral spine and root, and tibial nerve stimulation in children with lower urinary tract dysfunction of nonneurogenic and neurogenic origin. Relevant articles and controlled studies in adult patients were also considered. The search covered the period 1990 to 2009 and we found approximately 400 articles, of which 29 related to pediatrics. RESULTS Due to feasibility problems with placebo studies the majority of the studies were noncontrolled, some of them clinical trials on acute urodynamic changes during electrical stimulation or experimental research in animals. Overall only a few randomized trials were found. Regarding types of electrostimulation and indications in children the recent literature emphasizes stimulation far from the anal-genital region, such as sacral transcutaneous electrical nerve stimulation, mainly for refractory overactive bladder. Intravesical stimulation is the procedure of choice to enhance sensation in patients with incomplete neurogenic lesions. Percutaneous tibial nerve stimulation is tolerated by children but has been poorly studied. Sacral neuromodulation using implanted devices remains questionable and needs further clarification of its indications. Magnetic stimulation has rarely been used in children to date. More experimental studies are needed to assess the method of action and refine the parameters of stimulation. CONCLUSIONS Clinical controlled trials vs sham devices and predictable variables for successful response are urgently needed to address an apparently renewed focus on the use of nerve stimulation in the treatment of pediatric lower urinary tract symptoms.

Antenatal diagnosis of congenital anomaly: a really traumatic experience?

Objective:With increasing use of routine prenatal ultrasound, prenatal counseling after diagnosis of congenital malformations is frequently offered to prospective parents. We aimed to assess if the communication of diagnosis of a congenital anomaly in the fetus meets American Psychiatric Association (APA) criteria for trauma in parents.Study Design:In the period ranging from 2003 to 2009 a preliminary investigation was conducted with 165 prospective mothers and 91 prospective fathers being interviewed after communication of diagnosis. Analysis of statements was made independently by two psychologists considering the APA definition of trauma.Result:A total of 145 mothers and 76 fathers experienced the communication of diagnosis in their fetus as a traumatic event. There was no correlation between type of malformation and trauma nor was there statistical difference between mother and father regarding the stressor.Conclusion:Communication of diagnosis of a fetal anomaly can be a traumatic event and should be dealt with consequently. Given the therapeutic value of sharing traumatic experience such practice should be encouraged as part of the consultation process.

Extracorporeal shock wave lithotripsy in ureteral and kidney malformations.

Introduction: Extracorporeal shock wave lithotripsy (SWL) has long been accepted worldwide in the treatment of kidney stone disease. Upper ureter calculi in ureteral and kidney malformations are rather frequent (10–25%). The aims of this retrospective study were to determine whether malformations might impair fragment expulsion. Material and Methods: From 1986 to 1995, 203 patients with ureteral and kidney malformations were treated and followed up for a minimum of 1 year to a maximum of 9 years. Malformations included: ureteropelvic junction stenosis, horseshoe kidney, renal malrotation, renal ectopia, duplicated ureter, nonobstructive megaureter, medullary sponge kidney and caliceal diverticula. As pretreatment workup, all patients underwent conventional studies prior to SWL treatment: X-rays, renal ultrasound, intravenous pyelography, routine blood tests and urinalysis. All examinations were repeated at regular intervals for the first 6 months. Patients with metabolic disorders were excluded from the study. We also excluded patients with a follow-up of under 1 year. We considered three groups of patients: (1) stone-free patients at plain X-rays and ultrasound; (2) >90% elimination, i.e. stone-free patients at plain X-rays and positive at ultrasound; (3) patients with residual fragments at plain X-rays and ultrasound. Results: 96 (55%) patients were in group 1 (stone free), 40 (19%) were in group 2 (>90% elimination) and 67 (26%) were in group 3 (residual). Residual stones were more frequent in patients with medullary sponge kidney (82%). In patients with renal ectopia the residual stone rate accounted for only 13% of cases. Conclusions: There is evidence that SWL should always be offered to patients with ureteral and kidney malformations. These patients should however be considered at high risk for recurrences and so they need to be carefully followed up.

When uncertainty generates more anxiety than severity: the prenatal experience with cystic adenomatoid malformation of the lung

Abstract Aim: To assess reasons for higher levels of anxiety generated by prenatal counselling of a condition with good outcome such as cystic adenomatoid malformation (CCAM) of the lung compared to a life-threatening malformation such as congenital diaphragmatic hernia (CDH). Materials and methods: The Spielberger State-Trait Anxiety Inventory (STAI-S) was used to measure anxiety in two groups of mothers carrying a fetus with the respective malformation. Results: Forty-four mothers completed the questionnaire (CCAM, n=21 and CDH, n=23). Before consultation, the mean STAI-S scores in the CCAM group (44.80±5.92) and in CDH group (44.05±4.96) were not significantly different but was significantly reduced in both groups after consultation (CCAM 44.80 vs. 41.60, P=0.014 and CDH 44.05 vs. 34.35, P=0.0001). The groups were not significantly different regarding gestational age at diagnosis. Conclusions: After initial prenatal counselling, uncertainty about prenatal outcome and lack of defined management plans in CCAM seems to be more important than higher mortality rate occurring in CDH.

IS PREOPERATIVE LAPAROSCOPY USEFUL FOR IMPALPABLE TESTIS

PURPOSE Laparoscopic assessment of pelvic anatomy has gained wide popularity over the years. Today surgical treatment of impalpable testis is nearly always preceded by diagnostic laparoscopy. The actual role of such a procedure remains undefined. We performed a prospective randomized clinical trial in patients with impalpable testis to evaluate the clinical usefulness of laparoscopy before surgical exploration. MATERIALS AND METHODS We studied pediatric, age matched patients with impalpable testis who were randomized to group 1-30 who underwent open surgery only and group 2-31 who underwent laparoscopy and open surgery. Anatomical findings, operative procedures, operative time and cost, number of recurrences and testicular volume at followup were then compared in the 2 groups. RESULTS There were no statistically significant differences in the 2 groups for any of the considered parameters except operative cost and time, which were significantly higher in the laparoscopy group. CONCLUSIONS Preoperative laparoscopy does not provide any significant advantage over open surgery for treating impalpable testis.