The spectrum of urinary tract fibroepithelial polyps in children

A fibroepithelial polyp is a benign neoplasm that occurs throughout the urinary tract. In children less than 18 years old only 12 cases of upper tract polyps have been reported. We report 2 additional pediatric cases of upper tract fibroepithelial polyps and a rare case of a fibroepithelial polyp in the bladder. At 2 to 7-year followup there has been no recurrence or further development of the polyps. A benign natural history and conservative therapy should be emphasized when fibroepithelial polyps of the upper or lower urinary tracts are encountered in children.     

输尿管镜气压弹导碎石术治疗儿童下尿路结石

目的：探讨儿童下尿路结石的治疗方法。方法：应用输尿管镜气压弹导碎石术经尿道或膀胱穿刺造瘘通道治疗儿童下尿路结石22例。结果：22例均一次成功击碎结石，治愈率100％。其中2例经膀胱穿刺造瘘通道碎石，术中即将结石取净。20例经尿道膀胱内碎石，术后结石均排净。无一例有并发症。结论：输尿管镜下气压弹导碎石治疗儿童下尿路结石，创伤小，成功率高，并发症少，为一种较理想的治疗方法。     

Duplications of the lower urinary tract in children

Seven cases of bladder duplication are described, and compared with 27 cases of urethral duplication. Bladder duplication was collateral while urethral duplication was usually in the sagittal plane. The conditions may coexist when the duplication of the bladder extends caudally to produce a collateral urethral duplication, but in one boy bladder duplication was associated with 4 urethrae in the sagittal plane. In 5 cases the bladders were united; in 2 cases, one bladder was excised. The results were satisfactory in 6 and in one the bladder failed to empty. The basic defects that lead to duplication are unknown. Several features of the conditons suggest that there are different aetiologies in each type. There are similarities with the exstrophy epispadias complex. Even when there are major abnormalities in other systems the general and urological prognosis is good.     

Prevalence of lower urinary tract symptoms in school-age children

Epidemiological studies have demonstrated rates of incontinence and enuresis as high as 20% in school-age children. This cross-sectional study aimed to investigate the prevalence of lower urinary tract (LUT) symptoms in 739 children aged 6–12 years enrolled in three government schools with different socioeconomic levels in Minas Gerais, Brazil. Symptoms of LUT were evaluated using a modified version of the Dysfunction Voiding Scoring System in which the cutoff point considered as an indicator of LUT dysfunction is >6 for girls and >9 for boys. Children with a score indicative of symptoms received an educational booklet on the functioning of the LUT and were sent for clinical evaluation. LUT dysfunction symptoms were detected in 161 (21.8%) children. Symptoms were most frequent in girls (p < 0.001), children aged 6–8 (p < 0.028), and attended the school with the lowest social level (p < 0.001). Intestinal constipation was the most prevalent finding (30.7%), independent of LUT score. The most common urinary symptoms in children with an elevated score were diurnal urinary incontinence (30.7%), holding maneuvers (19.1%), and urinary urgency (13.7%). Stress factors were associated in 28.4% of children. Our findings suggest that LUT symptoms must be investigated carefully at routine pediatric visits.     

Management of lower urinary tract infections and cystitis

It is possible to understand the pathophysiology, diagnostic laboratory methodology, and appropriate medical and surgical management of urinary tract infections in today's modern medical world. The foundation of success lies within an appropriate determination of the presence of mitigating complications, careful documentation of invading organisms, and judicious selection and administration of modern antimicrobial agents. Virtually all urinary tract infections begin in the lower system through bacterial exposure and adherence phenomena, creating simple uncomplicated infections in otherwise healthy hosts and serious complicated infections in others. Not all bacteriuria should be treated, and not all infections should be treated equally; knowing the difference is the secret.     

Congenital lower urinary tract obstruction and enuresis in children

We reviewed enuretic children among patients with congenital lower urinary tract obstructions experienced in the Department of Urology, Hyogo College of Medicine during 16 years from 1974 to 1989. Among 612 patients with congenital lower urinary tract obstructions, 139 (22.7%) had enuresis nocturna and/or diurna. The incidence of enuresis was 24.7% with posterior urethral valve (77 cases), 50.0% with anterior urethral valve (6 cases), 23.8% with congenital bulbar urethral stenosis in boys (303 cases) and 19.9% with congenital distal urethral stenosis in girls (226 cases). Diurnal enuresis was more common in enuresis associated with congenital lower urinary tract obstructions than in usual enuresis. In urodynamic examinations, more than half of enuretic children with congenital lower urinary obstructions showed hyperactive detrusor activity. Treatment of congenital lower urinary tract obstructions through operation resulted in cure or amelioration of enuresis in about 80% of the patients. Enuresis associated with lower urinary tract obstruction or neurogenic bladder is sometimes called complicated enuresis and it is an important role of a urologist to differentiate complicated enuresis from simple enuresis.     

Renal transplantation in children with abnormal lower urinary tract

OBJECTIVE: This retrospective study reports the outcomes as well as pre- and posttransplant urologic treatments of renal transplantation for children with an abnormal lower urinary tract (LUT). METHODS: Between March 1981 and December 2001, 195 children (< or =18 years of age) received live-donor kidney transplants. The 15 recipients (14 boys and 1 girl, mean age 13.5 +/- 3 years) who had lower urinary tract disorders included posterior urethral valves (PUV) with valve bladder (n=12) and neuropathic bladders secondary to meningomyelocele (n=3). These children were evaluated by voiding cystourethrogram, cystourethroscopy, and cystometry. The children with PUV were maintained on clean intermittent catheterization (CIC) and a detrusor relaxant at least 3 months before transplantation. Augmentation ileocystoplasty or continent cutaneous diversion were used in three patients. The graft and patient survivals as well as complications in this cohort was compared with a group of children with normal LUT, who underwent renal transplantation during the same period. RESULTS: One child died in the early posttransplant period due to rupture of the external iliac artery. Follow-up ranged from 6 months to 16 years (mean=4.5 years). During the same period the graft and patient survival rates were comparable between the group of children with versus without abnormal LUT. Furthermore, mean serum creatinine and creatinine clearance values were also comparable. The group with an abnormal LUT showed a higher incidence of urinary fistula (3/14) and recurrent UTI and/or bacteremia (4/14). CONCLUSIONS: Renal transplantation is feasible with good results for children with abnormal LUT. Pre- and posttransplant urologic management is critical for a successful outcome. However these children display a high incidence of urologic and infectious complications.     

Cellular pseudosarcomatous fibroepithelial stromal polyps of the lower female genital tract: an underrecognized lesion often misdiagnosed as sarcoma

Fibroepithelial stromal polyps of the vulvovaginal region are benign lesions that, when bland or hypocellular, are readily recognized. However those that exhibit bizarre cytomorphology, atypical mitoses, or hypercellularity, raising the possibility of malignancy, continue to be underrecognized. The authors reviewed a series of fibroepithelial stromal polyps to characterize further the morphologic features that can lead to a misdiagnosis of sarcoma. A total of 33 of 65 consecutive cases of fibroepithelial stromal polyps retrieved from the authors' consultation files were remarkable for marked hypercellularity (33 of 33), marked cytologic pleomorphism (21 of 33), mitotic counts of more than 10 mitoses per 10 high-power fields (12 of 33), and the presence of atypical mitoses (14 of 33). A total of 16 of 33 lesions had three or more of these features. Important morphologic clues to the diagnosis (shared with usual polyps at this site) were lack of an identifiable lesional margin, extension of abnormal stromal tissue up to the mucosal-submucosal interface, and the frequent presence of individually scattered multinucleate stromal cells, most often located close to the surface epithelium. Immunohistochemically, seven of 12 cases were desmin positive and one of 11 cases were smooth muscle actin positive. The age range of patients was 16 to 75 years (median, 32 years), and 21 patients (64%) were premenopausal. Sites included the vagina (18 of 33), cervix (seven of 33), and vulva (eight of 33). A total of 14 of 33 patients were pregnant, three patients were taking Tamoxifen, and one patient was on oral progesterone. Eight of 33 patients had multiple lesions at the time of presentation, of whom five were pregnant. Clinical follow-up was available in 21 of 33 patients. Three of 21 patients with follow-up had local, nondestructive recurrence. Two of these patients had multiple recurrences. None of the patients followed developed metastases. Cytologic atypia has been a previously recognized feature in these lesions; however, the occurrence of marked stromal cellularity and a mitotic rate of more than 10 mitoses per 10 high-power fields have not been emphasized previously. Moreover, the combination of these features has only rarely been documented. Awareness of the spectrum of histologic features that these lesions can exhibit is crucial in their accurate recognition, thus avoiding potential overtreatment.     

Endourological management of fibroepithelial polyps

Two cases of fibroepithelial polyps of the upper urinary tract are reported, the conservative management of this benign tumor is described.     

Fibrous polyps of the urinary tract

The authors report five cases of fibrous polyps of the urinary tract, which is a rare disease, as Mazeman only reported 12 cases in his review in 1972. These cases confirm the polymorphic nature of the clinical presentation and the site of these tumours of mesodermal origin, essentially composed of richly vascular connective tissue covered with surface epithelium. Treatment is surgical and conservative. The authors performed two junctional resections, one ureterotomy, one ureteroscopic resection and one nephro-ureterectomy for a partially destroyed kidney.     

Renal transplantation in children with severe lower urinary tract dysfunction

PURPOSE: Renal transplantation in children with end stage renal disease due to congenital urological malformations has traditionally been associated with a poor outcome compared to transplantation in those with a normal urinary tract. In addition, the optimal urological treatment for such children remains unclear. To address these issues, we retrospectively reviewed our experience with renal transplantation in this population. MATERIALS AND METHODS: Between 1986 and 1998, 12 boys and 6 girls a mean age of 8.4 years with a severe dysfunctional lower urinary tract underwent a total of 15 living related and 6 cadaveric renal transplantations. Urological anomalies included posterior urethral valves in 8 cases, urogenital sinus anomalies in 4, the prune-belly syndrome in 2, and complete bladder duplication, ureterocele, lipomeningocele and the VATER syndrome in 1 each. In 11 children (61%) bladder augmentation or continent urinary diversion was performed, 2 (11%) have an intestinal conduit and 5 (28%) have a transplant into the native bladder. RESULTS: In this group patient and overall allograft survival was 100 and 81%, respectively. These values were the same in all children who underwent renal transplantation at our center during this era. In the 17 children with a functioning transplant mean serum creatinine was 1.4 mg./dl. Technical complications occurred in 4 patients (22%), including transplant ureteral obstruction in 2 as well as intestinal conduit stomal stenosis and Mitrofanoff stomal incontinence. CONCLUSIONS: Renal transplantation may be successfully performed in children with end stage renal disease due to severe lower urinary tract dysfunction. Bladder reconstruction, which may be required in the majority of these cases, appears to be safe when performed before or after the transplant. A multidisciplinary team approach to surgery is advantageous.     

Prostaglandins in lower urinary tract

The search for noncholinergic, nonadrenergic neurotransmitters in the lower urinary tract has recently focused on the prostaglandins (PG). Prostaglandin E₂ (PGE₂) and, to a lesser degree, prostaglandin F_Zα (PGF_zα), are produced by the bladder in response to mechanical and nerve stimulation. In vitro stimulation of detrusor smooth muscle, using the same two compounds, produces a slow, prolonged contraction which is independent of nervous activity. In contrast, in urethral smooth muscle PGF_2α causes contraction while PGE₂ causes relaxation. Clinically, intravesical or intravenous administration of PGE₂ or PGF_2α may produce improved bladder tone or uninhibited contraction. Similarly, inhibitors of PG synthesis may produce improvement of unstable bladder.     

Management of lower urinary tract symptoms of elderly men in Austria

OBJECTIVES: The aim of this nation-wide study was to determine the current management of elderly men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) and benign prostatic enlargement (BPE) in Austria, and to assess changes over a 4-year study period from 1995 to 1998. METHODS: The annual figures of prostatectomies performed in Austria from 1995 to 1998 were collected from the Austrian Institute for Health Affairs. Sales figures for finasteride, alpha(1)-receptor blockers and plant extracts were obtained from IMS market sales and Austrian regional compulsory insurance companies. These data were correlated with the number of males living in Austria during the study period and to the estimated numbers of elderly men with moderate and severe LUTS in this country. RESULTS: The annual number of transurethral resections of the prostate (TURPs) decreased from 6,302 in 1995 to 5,297 in 1998 (-16%), and the number of open prostatectomies from 506 to 469 (-7%). Extrapolation of these data to 100,000 men aged > or = 55 years revealed that 0.76% underwent TURP in 1995, this figure decreased to 0.59% in 1998. Market sales of alpha(1)-receptor blockers increased by 497% during the study period and those of finasteride by 1.6%, while plant extract market sales declined by 18.2%. In 1998, plant extracts comprised 43.3% of the total BPH market, alpha(1)-receptor blockers 41.5% and finasteride 15.2%. CONCLUSIONS: During the years 1995-1998, significant changes in medical and surgical BPH therapy were observed in Austria. These data provide the basis for a comparison to the situation in other countries and serve as a baseline investigation for future studies in this country.     

Management of children with unobstructed urinary tract infection

There are two major considerations when taking care of children with urinary tract infection (UTI): firstly to prevent renal damage and secondly to relieve symptoms. A distinction should always be made between these two aims, since they often concern separate populations that may need different treatment and follow-up strategies. Acute pyelonephritis is a common disorder of infancy and early childhood which is easily overlooked. In all infants and children in whom the cause of fever is not apparent and in all those failing to thrive, urine should be examined by dip slide culture and by an estimation of leucocyte content. With adequate care the immediate and long-term prognosis of acute pyelonephritis is excellent. Thus prevention of kidney damage is mainly a matter of putting existing knowledge into practice. Uncomplicated recurrent lower UTI involves a low risk of renal damage. Short courses of antibiotic treatment easily eradicate most such infections but have no effect on the mechanisms underlying the susceptibility to recurrence. Singledose therapy should be considered in such instances. Long-term antibiotic prophylaxis is mainly indicated in children with a high risk of renal scarring. Treatment is not recommended for children with asymptomatic bacteriuria.     

Treatment of bilateral fibroepithelial polyps in a child

Ureteral fibroepithelial polyps are extremely rare benign lesions composed of stroma with a surface of normal transitional epithelium. Traditionally, symptomatic polyps were treated with open exploration and segmental resection. We describe the first case of bilateral polyps in a child. One was removed by segmental resection and the other by ureteroscopic laser surgery.     

Case of mid-ureteral fibroepithelial polyps in a child

A 11-year-old boy showed gross hematuria and left flank pain. Ultrasonography and CT revealed left hydroureteronephrosis, and he was referred to us for the further evaluation. MRI revealed left hydroureteronephrosis with filling defect at the distal end of the dilated ureter suggesting ureteral polyp. Open surgery was performed with the diagnosis of mid-ureteral obstruction. In the operative findings, multiple stalks of ureteral polyps arose from the entire ureteral wall over 5 cm in length at the site of ureteral obstruction. Mid-ureter with polyps was completely resected, and end-to-end anastomosis was performed. The pathological diagnosis was fibroepithelial polyp of the ureter.     

Bilateral fibroepithelial polyps of ureter in a child

Presented here is the first case of bilateral ureteral polyps in a patient under eighteen years of age, with vivid colored intraoperative photographs. The importance of careful identification of the base of the polyp to reduce operative morbidity and the necessity of ureteral reanastomosis rather than simple excision of the polyp in children is emphasized.