P. Hoebeke

Pelvic‐floor therapy and toilet training in young children with dysfunctional voiding and obstipation

Objective To analyse experience in treating young children (4–5 years old) with urodynamically confirmed voiding dysfunction, using a noninvasive training programme.

Does monosymptomatic enuresis exist? A molecular genetic exploration of 32 families with enuresis/incontinence

Objectives  To confirm linkage to microsatellite markers on chromosome 8q, 12q, 13q and 22q in families with nocturnal enuresis/incontinence segregating with an autosomal dominant pattern, and to determine if there is an association between the clinical subtype and these linked loci.

The Role of Pelvic-Floor Therapy in the Treatment of Lower Urinary Tract Dysfunctions in Children

The pelvic-floor is under voluntary control and plays an important role in the pathophysiology of lower urinary tract (LUT) dysfunctions in children, especially of non-neuropathic bladder sphincter dysfunction. The following therapeutic measures can be applied to try to influence the activity of the pelvic-floor during voiding: proprioceptive exercises of the pelvic-floor (manual testing), visualization of the electromyographic registration of relaxation and contraction of the pelvic-floor by a curve on a display (relaxation biofeedback), observation of the flow curve during voiding (uroflow biofeedback), learning of an adequate toilet posture in order to reach an optimal relaxation of the pelvic-floor, an individually adapted voiding and drinking schedule to teach the child to deal consciously with the bladder and its function and a number of simple rules for application at home to increase the involvement and motivation of the child. In children however with persisting idiopathic detrusor instability additional therapeutic measures may be necessary to improve present urologic symptoms (incontinence problems, frequency, urge) and to increase bladder capacity. Intravesical biofeedback has been used to stretch the bladder and seems to be useful in case of sensory urge. Recently a less invasive technique, called transcutaneous electrical nerve stimulation (TENS), has been applied on level of S3 with promising results in children with urodynamicaly proven detrusor instability, in which previous therapies have failed.

Combined Use of Urinary α1-Microglobulin and 99mTc DMSA Scintigraphy in the Diagnosis and Follow-Up of Acute Pyelonephritis and Cystitis in Children

Objectives: In the absence of specific symptomatology in children and neurogenic bladder disease patients, the early diagnosis of acute pyelonephritis is a challenge. The aim of the present study was to determine if dimercaptosuccinic acid (DMSA) lesion-positive (acute pyelonephritis) patients have elevated urinary α1-microglobulin (α1-MG) excretion (no false negatives) and if DMSA lesion-negative (cystitis) patients have normal urinary α1-MG excretion (no false positives). Methods: A selected population of 62 children above 3 months of age with a proven urinary tract infection were administered a DMSA scan. A control scan was performed after the acute phase of the illness, and the diagnosis of pyelonephritis (n = 44) was made retrospectively. The urinary α1-MG was determined by immunonephelometry. Results: The urinary α1-MG-creatinine ratio was highly sensitive (98%) and specific (100%) and correlated with the DMSA scintigraphy images. Only 1 of the 44 patients with pyelonephritis and all of the cystitis patients (n = 18) had a normal urinary α1-MG (<10 mg/g). The drop in absolute DMSA uptake correlated significantly (r = 0.758, p < 0.001) with the urinary α1-MG-creatinine ratio. The urinary α1-MG-creatinine ratio was significantly higher (p < 0.02) in bilateral than in unilateral pyelonephritis. Conclusion: DMSA lesion-positive (acute pyelonephritis) patients have elevated urinary α1-MG excretion and DMSA lesion-negative (cystitis) patients have normal urinary α1-MG excretion.

The pharmacology of paediatric incontinence

The clinical uropharmacology of the lower urinary tract is based on an appreciation of the innervation and receptor content of the bladder and its related anatomical structures. The anatomy, neuroanatomy and neurophysiology of the bladder is reviewed. Classes of drugs are discussed in relation to the possible functional targets of pharmacological intervention and ®nally some speci®c applications in paediatric voiding dysfunction are discussed.

Impact of Urinary Tract Infection and Detrusor Pressure on Renal Tubular Function in Patients with Vesicoureteral Reflux

Objective: The aim of this study was to evaluate prospectively the impact of bacteriuria with or without pyuria and/or detrusor pressure on renal tubular function in patients with secondary vesicoureteral reflux. Methods: From October 1994 to December1998, we evaluated 54 patients with secondary vesicoureteral reflux (26 men and 28 women; age 30±24 years), of whom 28 had a neurogenic and 26 a nonneurogenic voiding dysfunction. In a reference population (n = 48; 28 men, 20 women; age 38±14 years), 43 had a neurogenic and 5 a nonneurogenic voiding dysfunction. Urinary alpha–1–microglobulin was measured immunonephelometrically. Statistical analysis was performed by multiple regression analysis. Results: Patients with vesicoureteral reflux had a significantly higher urinary alpha–1–microglobulin/creatinine ratio. Urinary alpha–1–microglobulin excretion was related to the grade of vesicoureteral reflux, detrusor pressure and compliance, but not to bacteriuria or pyuria, and was diagnostic for vesicoureteral reflux with a sensitivity of 90%, a specificity of 70% and a negative predictive value of 97%. Conclusion: Urinary alpha–1–microglobulin excretion is diagnostically useful in patients with secondary vesicoureteral reflux. The use of urinary alpha–1–microglobulin excretion in the follow–up of patients with vesicoureteral reflux has yet to be established.

Robot-assisted resection of ectopic kidney in children: anatomical illustration

INTRODUCTION Failure of kidney migration during embryonic life results in an ectopic kidney, with an incidence varying from 1 in 500 to 1 in 1200. Pelvic kidney can be a rare cause of recurrent urinary tract infection (UTI), warranting nephrectomy in some cases. MATERIAL AND METHODS A 7-year-old girl with a history of recurrent UTIs and vaginal discharge was diagnosed with a dysplastic afunctional ectopic kidney located in the pelvis, with ureter draining into the cervix or vaginal wall. RESULTS A robot-assisted approach was chosen, with side docking of the robot to allow concurrent vaginoscopic/hysteroscopic exploration. A uterus bicornis was found. The ectopic ureter was dissected toward its drainage in the vaginal wall, where it was sutured and resected. The dysplastic kidney and ureter were removed. Compared to pure laparoscopic approach, dissection deep into the pelvis toward the vaginal wall is aided by the robotic dexterity and facilitates complete resection of the structure, which avoids leaving a ureteric stump into the vaginal wall. CONCLUSIONS Robot-assisted surgery is a safe and effective option for resection of ectopic kidneys with ectopic ureter in children. Dissection up until the vaginal wall in children is aided by robotic dexterity, making this kind of surgery the ideal indication for robotic-assisted surgery.