N. Capozza

Treatment of vesico-ureteric reflux: a new algorithm based on parental preference

Authors from Rome evaluated parental preference for treatment in children with grade III VUR. Parents were provided with detailed information about the three treatment options: antibiotic treatment, open surgery, endoscopic treatment. Most parents chose endoscopic management; with this in mind, the authors proposed a new treatment algorithm for VUR.

Retrograde ureteroscopy for distal ureteric stone removal in children.

A wide range of topics is covered in the Paediatric Urology section in this months issue: retrograde ureteroscopy for distal ureteric stones, outcomes of continent catheterizable stomas for urinary and faecal incontinence, an exploration of a possible common cause between enuresis in childhood and urinary and faecal incontinence in adult life, and a description of a new surgical procedure, the colpo‐wrap.

Influence of Voiding Dysfunction on the Outcome of Endoscopic Treatment for Vesicoureteral Reflux

PURPOSE Some patients with vesicoureteral reflux also experience voiding dysfunction. Dextranomer/hyaluronic acid copolymer (Deflux, Q-MED AB, Uppsala, Sweden) is an effective endoscopic treatment for vesicoureteral reflux. In an open label study we investigated the effect of voiding dysfunction on the efficacy of endoscopic treatment with dextranomer/hyaluronic acid copolymer in patients with vesicoureteral reflux. MATERIALS AND METHODS A total of 320 children 3 to 11 years old with grade II to IV vesicoureteral reflux confirmed by voiding cystourethrography underwent endoscopic treatment with dextranomer/hyaluronic acid copolymer. Of the patients 50 were re-treated with dextranomer/hyaluronic acid copolymer because of persistent reflux (grade II or greater). The first implantation technique was recorded on videotape. Voiding cystourethrography and micturition details were recorded at the 3 to 6-month followup visit and compared with baseline measurements. RESULTS At baseline 13 patients had known voiding dysfunction and 18 were misdiagnosed as not having voiding dysfunction. Of the 50 patients who required re-treatment, the initial implant was correctly positioned in 45 according to the videotape. Endoscopic observation at the time of re-treatment revealed no evidence of the implant in 15 patients. The implant was displaced in 27 patients and remained correctly positioned in 3. A total of 27 patients had voiding dysfunction, the majority of whom had urgency and frequency incontinence, had not received any anticholinergic therapy and had a displaced implant. CONCLUSIONS Uncontrolled voiding dysfunction contributed to endoscopic treatment failure with dextranomer/hyaluronic acid copolymer in our series. Therefore, we suggest that patients with voiding dysfunction be treated at least 6 months before endoscopic therapy with anticholinergics and/or micturition rehabilitation.

Predictive risk factors for chronic renal failure in primary high-grade vesico-ureteric reflux

To evaluate and define the risk factors predictive of chronic renal failure (CRF) in children with severe bilateral primary vesico‐ureteric reflux (VUR), observed within the first year of life and with a long follow‐up.

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.

Renal damage in vesico-ureteric reflux.

To detect the different extent of renal parenchymal involvement in primary vesico‐ureteric reflux (VUR), and to evaluate the relationship between VUR grade, patient age and different patterns of parenchymal damage.

Endoscopic Treatment of Urinary Incontinence in Pediatric Patients: 2-Year Experience with Dextranomer/Hyaluronic Acid Copolymer

PURPOSE We investigated the effectiveness of dextranomer/hyaluronic acid copolymer (dextranomer microspheres in sodium hyaluronan solution) as a treatment for urinary incontinence due to sphincter incompetence in children and adolescents. MATERIALS AND METHODS Patients with urinary incontinence due to neurogenic and structural causes were given a transurethral injection of dextranomer/hyaluronic acid copolymer to increase bladder outlet resistance. Patients were assessed at 1, 3, 6, 12 and 24 months after injection using a validated questionnaire, 1-hour pad test, ultrasonography, cystography and cystometry. Patients who remained incontinent were offered repeat injections of dextranomer/hyaluronic acid copolymer up to a maximum of 3 injections. RESULTS A total of 16 patients 8 to 22 years old were treated with dextranomer/hyaluronic acid copolymer, including 3 with neurogenic bladder, 8 with bladder exstrophy after 3-stage reconstruction, 4 with penopubic epispadias and 1 with urogenital sinus. Mean volume injected was 2.8 ml. (range 1.8 to 4.0) and mean number of injections received was 2.3 per patient. Dry time interval increased by 43 minutes (p <0.05) and functional bladder capacity increased by 34 ml. (p <0.05) at 6 months after treatment compared with pretreatment values. Improvement in both parameters was maintained at 12 months. At 6 and 12 months of followup 12 (75%) and 8 (50%) patients reported improvements in daytime and nighttime dryness, respectively. A slight decrease in continence parameters was observed in the 13 patients who completed the 24-month followup. No adverse events were reported and no upper urinary tract deterioration was observed as a consequence of endoscopic treatment within the 2-year followup period. CONCLUSIONS Use of dextranomer/hyaluronic acid copolymer as a bulking agent to increase bladder outlet resistance improves symptoms in children and adolescents with incontinence of neurogenic and nonneurogenic origin.

Endoscopic Treatment of Vesico-Ureteral Reflux: Twelve Years’ Experience

Introduction: Over the past 12 years, endoscopic treatment of vesico-ureteral reflux (VUR) has gained in popularity and has proved successful in a high percentage of cases. With improvements in injectable materials and more experience with the technique, the indications for endoscopic treatment have broadened. In the present paper we report our experience on 679 patients and 953 refluxing ureters, treated over the past 12 years. Materials and Methods: Reflux ranged from grade II to grade IV. In the first 14 cases Teflon was injected. After 1989, bovine dermal collagen was used in 442 children and, more recently, the Deflux® system, a nonallergenic, biodegradable dextranomer in sodium hyaluronan in 223 children. All patients were clinically investigated for voiding dysfunctions and all completed a 1-year follow-up. Results: After 1 or 2 injections the 1-year cystogram showed no VUR in 686 ureters (72%). In grade II, III and IV success rates were, respectively, 83, 69 and 41%. Complications were minimal (1%). Conclusions: Our results confirm endoscopic treatment of VUR is a valid alternative to long-term antibiotic prophylaxis and to open surgery in selected patients. The treatment often failed because of injected material displacement possibly due to voiding dysfunction. The short hospital stay, absence of significant postoperative complications, safety of the available injectable materials and high success rate suggest that endoscopic treatment should be offered to all children with grade II and III VUR, whereas it is questionable in patients with grade IV VUR. In patients with voiding dysfunction, appropriate therapy and voiding rehabilitation should precede treatment of VUR.

PERIURETHRAL MUSCLE COMPLEX REASSEMBLY FOR EXSTROPHY-EPISPADIAS REPAIR

PURPOSE Continence is a difficult goal in exstrophy-epispadias complex repair. It is presumed that all anatomical components involved in the exstrophy-epispadias abnormality are present but laterally and anteriorly displaced. The penile disassembly technique for epispadias restores the normal anatomical relationship of the male genital components. Its extension to complete primary bladder exstrophy closure enables deeper positioning of the bladder neck within the pelvic diaphragm. We identified the perineal striated muscular complex and present its appropriate periurethral reassembly as a main step in exstrophy-epispadias complex repair. MATERIALS AND METHODS Bladder exstrophy and epispadias repairs were performed in 10 male and 3 female consecutive patients with the exstrophy-epispadias complex, including 1-stage reconstruction in 2 male newborns and 2 females with exstrophy, and as further surgery in a female with cloacal exstrophy and previous failed 1-stage repair, 4 males with incontinent epispadias (secondary repair in 1) and 4 males with epispadias in whom exstrophy closure had been previously done. In the males after bladder plate closure and corporeal body splitting a sagittal incision was made in the intersymphyseal tissue and extended posteriorly to the perineal body midline. The bipolar electrical stimulator was used to identify pelvic muscle components in the sagittal plane and reapproximate them along the tubularized posterior urethra to form the periurethral muscle complex. In the 3 females the urethral plate and vagina were similarly mobilized posterior through the sagittal incision of the perineal body. No patient underwent bladder neck plasty. RESULTS At 9 months to 4 years of followup cosmesis was good in 12 patients, while 1 required secondary glanular urethroplasty. There was mild pyelectasis in 3 cases but no severe hydronephrosis and no renal function deterioration. Pyelonephritis developed in 6 patients (46%). Cystography at 1 year showed that bladder capacity was 35 to 80 and 65 to 120 cc in exstrophy and epispadias cases, respectively. There was cyclic voiding with 30 to 90-minute dry intervals in 7 patients (54%), of whom 5 had exstrophy and 2 had epispadias. Daytime voiding control with a 2 to 3-hour voiding interval was achieved in 1 female with exstrophy and 2 patients with epispadias (23%). Incontinence was present in 2 patients with previous exstrophy closure and 1 with cloacal exstrophy (23%). CONCLUSIONS Early restoration of a physiological vesicourethral balance of coordinated activity is feasible for the progressive achievement of continence in patients with the exstrophy-epispadias complex. Sagittal splitting of the perineal tissue with identification of the muscle components as well as midline reassembly of the periurethral striated muscular complex helps to reconfigure the pelvic anatomy in a more normal fashion and allows better restoration of coordinated vesicourethral activity.

RETROPERITONEAL LAPAROSCOPIC ACCESS IN CHILDREN USING A DIRECT VISION TECHNIQUE

PURPOSE Retroperitoneal procedures were initiated in 1992 by balloon dissection of the retroperitoneum. More recently a new type of retroperitoneal access has been obtained by directly entering the retroperitoneum using the Visiport visual trocar. We present our initial experience with direct visual access to the retroperitoneum in the pediatric population. MATERIALS AND METHODS A total of 31 children underwent retroperitoneal laparoscopy, including renal biopsy in 22, varicocelectomy in 5, renal cyst ablation in 3 and pyelolithotomy for a staghorn stone in 1. Patients were placed in the full flank position. A maximum of 3 ports was used and the initial trocar was placed under direct vision. The laparoscope was then used to dissect bluntly a working space in the retroperitoneum. RESULTS All procedures were successful. Blood loss was minimal. Operative time was 4 hours for pyelolithotomy and less than 1 for the other procedures. Mean hospital stay was 1.5 days and all patients returned to normal activity at a mean of 6 days. Two minor complications developed. The peritoneum was inadvertently entered in 1 case, in which no further treatment was necessary and convalescence was uneventful and short. In another case severe arrhythmia developed, resulting in an aborted procedure. CONCLUSIONS This technique is simple, safe and does not require extensive laparoscopic experience.