José María Garat

Conservative treatment of phimosis in children using a topical steroid

OBJECTIVES From 1997 through 1998, we conducted a prospective study to evaluate the long-term outcome of using topical steroids in the treatment of childhood phimosis. METHODS Both the parents and their children were instructed to apply 0.05% betamethasone cream topically twice a day for 1 month and to retract the prepuce after the fifth day of treatment. Results were evaluated at the end of the treatment and 6 months later. RESULTS One hundred thirty-seven boys were evaluated. The median age was 5.4 years. At initial presentation, 61 boys had a phimotic but retractable prepuce, 37 had a nonretractable phimotic ring, and 39 had a pinpoint opening. Patients with a history of previous forcible foreskin retractions were considered to have secondary phimosis. By 6 months following treatment, 90% (124 children) had an easily retractable prepuce without a phimotic ring. No differences were seen in the response rate between those with primary and secondary phimosis. In all cases, the treatment was well tolerated without local or systemic side effects. All the patients with persistent or recurrent phimosis were found to be noncompliant with the suggested daily foreskin care. CONCLUSIONS Topical steroid for the treatment of phimosis is a safe, simple, and inexpensive procedure that avoids surgery and its associated risks. It is effective both in primary and in secondary phimosis. We emphasize the importance of proper and regular foreskin care and hypothesize on the mechanism of action of the steroids.

Prepubertal testicular tumours and efficacy of testicular preserving surgery

Study Type – Therapy (case series)
Level of Evidence 4

Long-term follow-up of transitional cell carcinoma of the bladder in childhood

BACKGROUND Bladder tumours are rare in children, with only 0.38% of cases occurring in the first two decades of life. OBJECTIVE To describe a long-term follow-up series of nine urothelial bladder tumours in children. PATIENTS AND METHODS We carried out a retrospective study covering the period from 1988 until 2005. We found that during this time, urothelial tumours had been diagnosed at our centre in eight patients (9 tumours) younger than 18 years old who reported an episode of haematuria. Diagnosis was attained through renal and bladder ultrasound in 85% of patients, and through cystoscopy under anaesthesia in 15%. All cases were treated by means of transurethral resection of the bladder, with ensuing follow-up using renal and bladder ultrasound and urinary cytology. MEASUREMENTS Patients characteristics and outcome are evaluated. RESULTS Single exophytic tumours were present in seven (87.5%) of the patients, located either in the lateral wall or in the trigone; one patient showed two small tumours. The pathology was as follows: two G1Ta, one G1T1, one G2T1, and five G2Ta. There were no recurrences. CONCLUSIONS Transitional cell carcinoma in childhood is of low grade and low aggressiveness. It has a good prognosis and recurrences are infrequent. We suggest performing a urinary cytology/cystoscopy every 6 months the first 2 years and urinary cytology/bladder ultrasound once a year.

Can endoscopic balloon dilation for primary obstructive megaureter be effective in a long-term follow-up?

BACKGROUND Ureteral tapering and reimplantation is an established treatment for persistent or progressive primary obstructive megaureter (POM) but may result in complications and morbidity. Use of a less invasive technique involving endoscopic balloon dilation appears very interesting. OBJECTIVE The objective of this report is to determine if endoscopic balloon dilation for POM is effective in the long term as well as to assess complications of the procedure. MATERIAL AND METHODS A retrospective review was done on 19 patients and 20 ureters treated with the endoscopic balloon dilation by POM from June 2000 to February 2010. Surgery was performed solely in those cases in which there was persistence of obstruction in the renogram along with one or all of the following conditions: impairment of the differential renal function <40%, worsening of the renal pelvic dilation, febrile UTI in spite of antibiotic prophylaxis or renal calculi. The patients comprised 16 boys and 3 girls with a mean age at surgery of 17 months (range 1-44 months). Ten cases were left sided, eight right sided, and one bilateral. Under endoscopic and fluoroscopic guidance, a 3-5 Fr dilating balloon was inflated to 12-14 atm, or until disappearance of the stenotic obstructive area. A double J stent was positioned and withdrawn 2 months later. Follow-up recorded the presence of symptoms, number of reintervention procedures registered, and included renal ultrasound and MAG-3 renogram. RESULTS There were no perioperative complications. Eighteen ureters showed a non-obstructive pattern on MAG-3 renogram after the first endoscopic dilation, representing a 90% success rate. One case required a second dilation, which proved successful and two cases of recurrent lithiasis required ureterotomy without instances of obstruction. 2 patients had a febrile UTI and a vesicoureteral reflux was diagnosed in one. Renal function was preserved in 95% of patients. The mean follow-up was 6.9 years (range 3.9-13.3 years). One patient was lost after the procedure. DISCUSSION In an era of minimally invasive techniques, the search for less invasive procedures for treatment of POM has resulted in a variety of surgical options. Angulo et al., in 1998 and our group described the first POM treatment with endoscopic balloon dilation, which is believed to be a definitive, less invasive, and safe treatment. Furthermore, should an endoscopic approach fail, reimplant surgery can be performed. Few publications have reported short series with good results in the short and medium term. Torino et al. presented five cases in children aged less than 1 year, none of these showed evidence of obstruction. García-Aparicio et al. presented a series of 13 patients treated with a success rate of 84.6%. Christman et al. added laser incision in cases of narrowed ureteral segment 2-3 cm long and used double stenting. Good outcomes were presented in 71%. Romero et al. reported improvement of drainage within the first 18 months after treatment in 69% of patients. The potential de novo onset of vesicoureteral reflux may be the source of some controversy. We consider that dilation does not significantly alter the antireflux mechanism. In VCUG is not systematically performed because it is an invasive test. This restricts the conclusions that can be drawn from our findings. Nevertheless, some groups continue to systematically perform VCUG. CONCLUSIONS Endoscopic balloon dilation for POM is a safe, feasible, and less invasive procedure that shows good outcomes on long-term follow-up. However, multicenter studies and prospective trials should be encouraged to provide more definitive evidence on its benefits.

Efficiency of endoscopic treatment for vesico-ureteric reflux in adults.

To evaluate the results of our experience with endoscopic management of vesico‐ureteric reflux (VUR) in adults, and to describe factors and complications that might contribute to the failure of the technique.

Juvenile Granulosa Cell Tumor of the Testis: A Bilateral and Synchronous Case. Should Testis-sparing Surgery Be Mandatory?

Granulosa cell tumor of the testis is an infrequent stromal cell tumor that can be distinguished into adult and juvenile, the latter being more common. Juvenile granulosa cell tumor of the testis is a rare pathologic finding, accounting for 1.2%-3.9% of prepubertal testicular tumors. It is considered as a benign stromal sex cord tumor and is usually unilateral. Although radical surgery was previously considered the treatment of choice, testis-sparing surgery is now recommended in all cases where applicable. We report a bilateral synchronous juvenile granulosa cell tumor in a 6-month-old child treated with testis-sparing surgery and provide a review of the literature.