Juan Moldes

New Tissue Bulking Agent (Polyacrylate Polyalcohol) for Treating Vesicoureteral Reflux: Preliminary Results in Children

PURPOSE We report the preliminary results of endoscopic treatment of vesicoureteral reflux in children using polyacrylate polyalcohol copolymer. MATERIAL AND METHODS We performed a prospective multicenter review of pediatric patients treated with subureteral injection of a new nonabsorbable substance. Only patients with 1 year of followup were included. RESULTS A total of 83 patients underwent injection of polyacrylate polyalcohol copolymer at our institutions between 2005 and 2006. Among this group 18 males and 43 females with a median age of 58 months (range 9 months to 18 years) completed 1 year of followup. Reflux was bilateral in 27 patients (44.3%) and unilateral in 34 (55.7%). Number of injected ureters was 88. Reflux grade was V in 3 ureters (3.4%), IV in 12 (13.6%), III in 41 (46.6%) and II in 32 (36.4%). Mean +/- SD injected volume per unit was 0.76 +/- 0.43 ml. Median followup was 20 months (range 16 to 24). Complications after injection included dysuria in 6 patients (9.8%), fever in 3 (4.9%) and lumbar pain in 4 (6.6%). Reflux was eliminated in 78 renal units (88.6%), decreased to grade I in 6 (6.8%) and persisted in 4 (4.5%). Ureteral obstruction developed in 1 patient and was treated operatively. Overall success rate was 83.6%. CONCLUSIONS Polyacrylate polyalcohol copolymer can be used to treat vesicoureteral reflux with comparable efficacy to other substances currently used, with a low rate of complications.

SIGMOID CYSTOPLASTY WITH ARGON BEAM WITHOUT MUCOSA

PURPOSE Intestinal bladder augmentations have well recognized complications, including mucus production, metabolic abnormalities and perforation. These complications may be avoided if the intestinal mucosa is not incorporated in the urinary tract. We report our experience with sigmoid cystoplasty without mucosa using argon beam, and describe the clinical, urodynamic, ultrasound and pathological results. MATERIALS AND METHODS We performed sigmoid cystoplasty without mucosa in 26 patients and with argon beam over the mucosa before it was removed in 6 boys and 4 girls with a mean age of 8 years (range 3 to 14). All patients had neurogenic bladder as the initial disease. Indications for augmentation were poor bladder compliance, low bladder capacity, hydronephrosis and urinary incontinence. Mean followup was 18 months (range 8 to 40) and included ultrasound, urodynamic evaluation, renal function and clinical assessment. In all patients intraoperative biopsies were done. In 8 of the 10 patients endoscopic biopsies of the augmented segment were obtained between 6 months and 2 years postoperatively. The operation consisted of the Goodwin technique without mucosa, which was treated with argon beam before it was removed. RESULTS The 10 patients are dry on intermittent clean catheterization with intervals of greater than 4 hours. There have been no clinical urinary tract infections. Two patients presented with peristaltic contractions and no symptoms. Bladder capacity increased from 80 (range 45 to 200) to 300 (220 to 400) ml., and mean postoperative compliance was 15 ml./cm. H2O (range 9 to 38). There were no significant changes in the urodynamic data between patients treated with sigmoid cystoplasty without mucosa only and with argon beam. Intraoperative biopsies after treatment with argon beam showed damaged mucosa and muscularis mucosa, and intact serosa, muscularis and submucosa layers. On the 8 argon beam postoperative biopsies the sigmoid submucosa was covered with a pseudostratified metaplasia of connective tissue with collagen fibers without scars (trichromic technique). CONCLUSIONS Sigmoid cystoplasty without mucosa with argon beam is easy to perform. The clinical and urodynamic results have been satisfactory, and use of argon beam prevents postoperative bleeding and residual glands.

Kidney transplantation in small children with live related donors: 20 years of experience

OBJECTIVES Kidney transplantation (Tx) with a live related donor is the best option available for the treatment of end-stage renal disease at any age. Modern dialysis has allowed many very young and small children to receive a renal transplant with good results in spite of the limitations of space and the size of the adult kidney. Here, we report our experience with renal Tx with live related donors in this complex group of pediatric patients. MATERIAL AND METHODS From 1978 to 2004 a kidney transplantation was performed in 211 pediatric patients. Of this group, 23 patients between 1 and 10 years of age (16 males and seven females) of less than 17 kg (8.9-16.9 kg) received their first live related donor transplantation between 1985 and 2004. Renal insufficiency was secondary to nephropathy in 11 patients, infravesical obstruction in six and renal dysplasia or renal infarcts in six. RESULTS Patient and graft survival was 100% and 95.6% with an average follow up of 89.6 months (6-231). There were no vascular or urological complications. Urinary infection in five (21.7%) and acute rejection in three (13%) were the most common complications. One patient has returned to dialysis 11 years after Tx. CONCLUSIONS Young pediatric patients with a low body weight did not suffer a higher percentage of postoperative surgical complications, and the follow-up results are similar to those in older patients. A complex urological malformation has not prevented a living related Tx. These results encourage us to perform this procedure more frequently in younger patients when a live donor is available.

Histologic Changes After Urethroplasty Using Small Intestinal Submucosa Unseeded With Cells in Rabbits With Injured Urethra

OBJECTIVE To determine whether small intestine submucosa has the same regenerative capacity when urethroplasty is performed in injured urethras. METHODS Our experiment was conducted in 30 New Zealand male rabbits, all of which had urethral injury. One month after the injury, the animals were randomized into a control group or a group with onlay urethroplasty with small intestine submucosa. The animals were euthanized at 2, 4, 12, 24, and 36 weeks after urethroplasty, and their urethras were removed for histologic and immunohistochemical examination. Before the scheduled euthanasia, urethrography and cystoscopy were performed. RESULTS After 2 weeks, there was evidence of a continuous monolayer of stratified epithelial cells and absence of smooth muscle fibers. One month later, the epithelium showed no changes from the previously observed features, but some smooth muscle fibers (representing newly formed vessels) became apparent. After 3 months, the graft showed increased concentration of smooth muscle fibers. After 6 and 9 months, the density of smooth muscle cells remained unchanged. Fiber arrangement was irregular, particularly at the anastomosis site. Epithelial and smooth muscle phenotypes were confirmed by immunohistochemistry using anti-pan-citokeratin (AE1/AE3) antibodies and anti-α-smooth muscle actin, respectively. CONCLUSION Small intestine submucosa promotes regeneration in traumatized urethras, with slightly delayed epithelialization and abnormal distribution of smooth muscle. Urethral damage caused by trauma interferes with the normal healing process.

Carcinoma transicional de vejiga en adolescentes: un diagnóstico para tener en cuenta

Transitional cell carcinoma of the bladder has a high incidence in adults, but it is uncommon in children and adolescents. Hematuria is the most common symptom of presentation and vesical ecography the preferred diagnostic method. The diagnosis and treatment is performed with cystoscopy and endoscopic resection. We describe two patients: an 18 years old male, who presented with a pediculated tumor on the posterior bladder wall and a 15 years old female with a 1 cm long tumor on the posterior wall too; both were removed under endoscopic control. In both patients superficial transitional cell carcinoma was the final diagnosis and are disease free 3 and 5 years later. A review of the available literature was performed to clarify if this type of tumors must be considered malignant and try to define how long and by which way these patients must be controlled.

Internal mammary artery injury after central venous catheterization.

Objective: We describe an infrequent but potentially lethal complication: an iatrogenic injury of the internal mammary artery after central venous catheterization. Design: Report of cases. Setting: Pediatric intensive care unit. Patients: The first patient we report on is a 3-yr-old girl who was severely neurologically damaged and was admitted to the pediatric intensive care unit for aspiration pneumonia and septic shock. Immediately after vein cannulation on the left internal jugular vein, the patient suffered hypotension and cardiac arrest, secondary to an adequately drained massive hemothorax. Restoration of spontaneous circulation was initially achieved, and the patient was transferred to the angiographic suite. Selective angiography during cardiopulmonary resuscitation for a second cardiac arrest revealed a laceration of the internal mammary artery. Resuscitation was not successful, and the patient died. The second case reported is a 7-yr-old girl admitted for bone marrow transplantation. She was electively taken to the angiographic suite for central venous insertion. An infraclavicular approach of the right subclavian vein was attempted, but radioscopy showed the guidewire inside the pleural space. Soon thereafter, the patient became hypotensive and was in shock. Radioscopy showed a large pleural effusion and a massive hemothorax was drained. Selective angiography demonstrated an injured internal mammary artery was embolized. Hemodynamics improved, and the patient was transferred to the pediatric intensive care unit, where she was extubated 12 hrs later. Interventions: None. Conclusions: Central venous catheter placement in the intrathoracic vein may cause potentially lethal complications in the form of an injury to the internal mammary artery. Hypotension during or immediately after the procedure should be a warning of a serious adverse event, such as massive hemothorax, that may compromise life. Adequate drainage of the pleural cavity may not completely relieve vascular compression if some of the bleeding from an injured internal mammary artery is extrapleural. Early diagnosis and treatment by selective embolization of the injured vessel in interventional radiology is the first therapeutic choice and may be life saving.

Results of Treatment of Grades IV and V Vesicoureteral Reflux with Endoscopic Injection of Polyacrylate Polyalcohol Copolymer.

Purpose: Here we report the results of a review of a prospectively maintained database of the use polyacrylate polyalcohol copolymer (PPC) injection to correct grades IV and V VUR. Materials and Methods: All children with grades IV and V primary VUR that presented with febrile urinary tract infection while on prophylaxis, in a 3-year period, were treated with a sub-ureteral injection of PPC. Institutional ethical approval was obtained. Exclusion criteria were incomplete bladder emptying documented on videourodynamic study, ureteral duplication, paraureteral diverticula, and poor ureteral emptying observed during fluoroscopy and previous open surgical or endoscopic treatment. Pre- and post-operative evaluation included urinalysis, renal and bladder ultrasonography, DMSA scan, and videourodynamic studies. Results: Thirty-three children [36 renal units (RU)] were included with a median age of 57 months (range 7–108). There were 18 boys and 15 girls. Thirty RU had grade IV and 6 grade V VUR. Median follow-up time was 32 months (range 7–58). Reflux was cured in 32/36 RU with the first injection, but another two patients were reimplanted because of dilatation. Complications included early urinary tract infection in seven children, transient lower urinary tract symptoms in five children. Progressive ureteral dilatation was noted in four children and was treated with insertion of a double J stent. Two of these children eventually required an ureteroneocystostomy. Conclusion: The use of PPC to treat grades IV and V vesicoureteral reflux in young children has an overall success rate of 83.3%. Persistent ureteral dilatation was present in 11% associated with high injection volume. Future studies will attempt to maintain a high success rate reducing the volume of injection and the incidence of dilatation.

Simplified Open Approach to Surgical Treatment of Ureteropelvic Junction Obstruction in Young Children and Infants

PURPOSE Indications for laparoscopic pyeloplasty for ureteropelvic junction obstruction are steadily growing but there is still a group of young children in whom open surgery continues to be the procedure most performed by pediatric urologists. We report our results in young children and infants with dismembered pyeloplasty done through a small flank incision on an outpatient basis or during a short hospital stay. MATERIALS AND METHODS Between April 2001 and July 2009, 45 patients with a median age of 11.2 months (range 1 to 50), of whom 72.9% were male, with confirmed ureteropelvic junction obstruction underwent classic Anderson-Hynes dismembered pyeloplasty thorough a 2.5 to 3.5 cm flank incision. Obstruction was on the left side in 51.2% of the patients. Pyeloureteral anastomosis was performed with a continuous 7-zero polydioxanone suture over a 7Fr multiperforated pyelostomy self-designed catheter in 89% of the patients. A Double-J® catheter was used in only 4 patients with other associated conditions. The stent was removed in the office 7 to 12 days after surgery. RESULTS Mean operative time was 92 minutes (range 60 to 150). Median hospital stay was 11.5 hours (range 6 to 35) in the whole group but it decreased to 9.4 hours in the last 22 cases. There was no reoperation due to recurrent ureteropelvic junction obstruction. Mean postoperative followup was 47.5 months. CONCLUSIONS Ureteropelvic junction obstruction surgery in small children can be done safely through a small incision with a short hospital stay without morbidity and with good cosmesis. We believe that open pyeloplasty will continue to be the best standard treatment for ureteropelvic junction obstruction surgery in small children until miniaturization and better laparoscopic instruments allow us to reproduce these results.

Anterior urethral valves: not such a benign condition….

Purpose: Anterior urethral valves (AUVs) is an unusual cause of congenital obstruction of the male urethra, being 15–30 times less common than posterior urethral valves (PUVs). It has been suggested that patients with congenital anterior urethral obstruction have a better prognosis than those with PUV, with less hydronephrosis, and a lower incidence of chronic renal insufficiency (5 vs. 30%). The long-term prognosis of AUVs is not clear in the literature. In this report we describe our experience and long-term follow up of patients with anterior urethral valve. Materials and Methods: We retrospectively identified 13 patients who presented with the diagnosis of AUVs in our institutions between January 1994 and June 2012. Two patients were excluded: one patient had no follow up after intervention; the other had a follow up <1 year. From the 11 patients included, we evaluated the gestational age, prenatal and postnatal ultrasound findings, voiding cystourethrogram findings, age upon valve ablation, micturition pattern, creatinine, and clinical follow up. Results: Between 1994 and 2012 we evaluated 150 patients with the diagnosis of urethral valves. Of this group, 11 patients (7.3%) had AUVs and an adequate follow up. Mean follow up is 6.3 years (2.5–12 years). Five (45.4%) patients had prenatal diagnosis of AUV. The most common prenatal ultrasonographic finding was bilateral hydronephrosis and distended bladder. One patient showed a large perineal cystic mass, which was confirmed to be a dilated anterior urethra. The mean gestational age was 37.6 weeks (27–40 WGA). Postnatally, 90% had trabeculated bladder, 80% hydronephrosis, and 40% renal dysplasia. The most common clinical presentation was urinary tract infection in five patients (45.4%), followed by weak urinary stream found in four patients (36.3%). The age at initial surgical intervention ranged between 7 days and 13 years. Seven (63.6%) patients had primary transurethral valve resection or laser ablation and three patients (27.2%) had primary vesicostomies. One boy (9.1%) had penile urethrostomy with excision of urethral diverticulum. Two (18.2%) patients developed end-stage renal disease. Conclusion: Anterior urethral valve is a rare congenital entity affecting the genitourinary system in males. Early urinary tract obstruction resulted in end-stage renal disease in 18% of our patient population. In our series, the complication rate and the evolution to renal failure are high and similar to patients with PUV. In patients with AUVs we recommend long-term follow up and close evaluation of patient’s bladder and renal function.

Simplified surgical approach to congenital megaprepuce: fixing, unfurling and tailoring revisited.

PURPOSE Megaprepuce is a congenital penile malformation that includes phimosis and severe ballooning of the internal prepuce. We combined the main technical details of 2 previously reported surgical techniques to simplify the surgical approach. We report the key points of this revisited surgical correction for megaprepuce and the long-term results. MATERIALS AND METHODS Penile reconstruction was performed between March 2004 and March 2009 in 26 children 2 to 19 months old (median age 6) with congenital megaprepuce. Surgical repair consisted of limited preputial resection of the phimotic ring, wide dissection of the outer prepuce to the base of the penis, fixation of the proximal outer prepuce to Bucks fascia to create a new penoscrotal junction, and unfurling and wide tailoring of the inner prepuce in the ventral midline to resurface the whole elongated penile shaft. A bladder catheter was left in place for 5 or 6 days. Only patients with at least 6 months of followup were included in analysis. RESULTS All patients underwent surgery on an outpatient basis. Operative time was between 50 and 85 minutes. Median followup was 17.6 months (range 6 to 59). Two patients had slight dehiscence of the ventral suture, which healed spontaneously without a scar. In 1 patient transient urethral meatal stenosis developed. The final cosmesis result was adequate in all patients. CONCLUSIONS It is possible to correct megaprepuce and achieve an adequate genital aspect with a simple approach of resurfacing the penis with the unfurled, tailored inner prepuce.