Comparison of traditional enterocystoplasty and seromuscular colocystoplasty lined with urothelium

ObjectiveTo evaluate long-term outcomes between various methods of augmentation cystoplasty.MethodsA retrospective analysis was performed of patients undergoing seromuscular colocystoplasty lined with urothelium (SCLU, n = 26), and their outcomes compared to a similar population of patients in the same institution who had received traditional forms of bladder augmentation (colocystoplasty and ileocystoplasty, n = 32). Measurements included efficacy of the procedure in increasing bladder capacity and achieving urinary continence, and the need of subsequent surgery for complications.ResultsThere was no statistically significant difference in achieved bladder capacity, subjective urinary continence and the rates of subsequent surgery for stones, vesicoureteral reflux, augment failure, bladder neck continence and catheterizable channel. None of the patients in the SCLU group had spontaneous perforation or small bowel obstruction.ConclusionPatients with SCLU are at decreased risk for bowel obstruction and spontaneous perforation, but are not devoid of other long-term complications including bladder stones, vesicoureteral reflux and augment failure. Most of the risks and benefits of augmentation cystoplasty performed using ileum, colon, or SCLU appear similar.     

Influence of type of conduit and site of implantation on the outcome of continent catheterizable channels

ObjectiveContinent catheterizable channels (CCC) using the Mitrofanoff principle are essential for pediatric urinary tract reconstruction. There is controversy over the influence of type of CCC (appendix vs. Yang–Monti) and site of implantation (augmentation vs. native bladder) on outcome.Patients and methodsA retrospective record review was conducted of all patients undergoing CCC since 1999, excluding patients who underwent seromuscular colocystoplasty. We analyzed the type of channel, site of implantation, complications requiring re-operation, and the revision rate according to type of CCC, type of stoma, site of implantation (bladder vs. augmentation) and segment used for augmentation (ileum vs. sigmoid colon).ResultsThere were 41 patients with a mean age of 11.2 years and a mean follow-up of 33.3 months. Of these, 33 CCC were constructed with appendix and eight with a Yang–Monti technique (4 ileal, 4 sigmoid); 31 patients also had an enterocystoplasty (19 sigmoid, 9 ileal and 3 others). Overall revision rate was 27%; revision was required in 8/33 (24%) appendiceal and 3/8 (38%) Yang–Monti CCC (P = 0.7). Revisions were required in 4/21 CCC implanted in the native bladder and 7/20 implanted in augmented bladder (P = 0.3). The majority of revisions were at skin level.ConclusionsAlthough there was no statistical difference in revision rate according to type of CCC, type of stoma or site of implantation, complications appeared to be more common in patients requiring a more complex reconstruction.     

The prognostic value of relative renal function greater than 51% in the pelvi-ureteric junction-obstructed kidney on 99mtechnetium mercaptoacetyltriglycine study

ObjectiveObstructed kidneys with relative function (RRF) estimates >50% are occasionally noted in ^99mtechnetium mercaptoacetyltriglycine renal studies. It is thought that increased RRF might confer some benefit and/or permit delayed intervention. We compared the RRF and absolute renal function, as defined by effective renal plasma flow (ERPF), of obstructed kidneys in the ranges >51%, 40%–50% and <40% RRF before and after pyeloplasty.MethodsTwenty children, median age 13.5 months (range 3 weeks–126 months), satisfied criteria for the diagnosis of PUJ obstruction and estimated function >51% (group 1). Their pre- and post-intervention data were compared with 21 children, median age 2 months (range 1 week–126 months), with PUJ obstruction and 40%–50% RRF (group 2); and 21, median age 6 months (range two days–110 months), with RRF below 40% (group 3). Kidneys showing signs of continuing obstruction after surgery were excluded.ResultsFinal ERPF was negatively related to age: younger children, and those with a higher preoperative ERPF, recovered better than older children and those with a lower ERPF (p < 0.05). Pre- and postoperative mean ERPF in group 1 was 76 (range 21–203) and 102 (6–240) ml/min/1.73 msq respectively. In group 2, these values were 75.2 (30–187) and 130.9 (44–306) ml/min/1.73 msq, and they were 42.6 (5–179) and 80.2 (17–205) ml/min/1.73 msq in group 3. When adjustment was made for preoperative ERPF, there was no evidence that RRF grouping was related to ERPF outcome. The postoperative ERPF of seven of 20 kidneys from group 1 (>51%) was lower than the ERPF before surgery compared to 2/21 in group 2 and 4/21 in group 3, but these differences were not statistically significant (p = 0.25).ConclusionsMost kidneys in each functional range improved when obstruction was relieved. An RRF >51% in the obstructed kidney was not always prognostically beneficial, and may be a warning of impending decompensation in a minority.     

Are urodynamic studies really needed during bladder augmentation follow-up?

ObjectiveWe assessed clinical and urodynamic outcomes, over a minimum 10-year follow-up period, of neuropathic bladder patients treated with a bladder augmentation (BA) to determine if periodic urodynamic studies are needed.Material and methodsThirty-two patients with poorly compliant bladders underwent BA at a mean age of 11 years (2.5–18). Mean follow-up was 12 years (10–14.5) and mean patient age at the end of the study was 22 years (12.2–33). During follow-up all patients were controlled at regular intervals with urinary tract imaging, serum electrolyte and creatinine levels, cystoscopy and urodynamic studies. Preoperative, 1-year post-BA and latest urodynamic studies results were compared.ResultsUrodynamic studies at 1-year post-BA showed a significant increase in bladder capacity and a decrease in end-filling detrusor pressure compared with preoperative values (396 vs 106 ml; 10 vs 50 cm H₂O, P < 0.0001). The increase in bladder capacity was more significant at the end of the study than after 1 year (507.8 vs 396 ml, P < 0.002). Thirteen patients had phasic contractions after 1 year and 11 at the end (not significant, NS), and these contractions were more frequent with colon than with ileum (NS). At the end of follow-up, phasic contraction pressure had decreased while trigger volume had increased (35 vs 28 cm H₂O; 247 vs 353 ml, NS). All patients are dry and have normal renal function, except one who had mild renal insufficiency before BA.ConclusionBA improves bladder capacity and pressure, and these changes are maintained over time (although phasic contractions do not disappear). Repeated urodynamic studies are only necessary when upper urinary tract dilatation or incontinence does not improve.     

Modern staged repair of bladder exstrophy: a contemporary series

ObjectiveMany changes have occurred in the treatment of bladder exstrophy over the last few years and many repairs are now offered. The purpose of this study was to evaluate long-term outcomes in a select group of patients in whom modern staged repair (MSRE) was undertaken.Patients and methodsFrom an institutionally approved database were extracted 189 patients who had undergone primary closure between 1988 and 2004. The records of 131 patients (95 males) who underwent MSRE with a modified Cantwell-Ransley repair by a single surgeon in 1988–2004 were reviewed with a minimum 5-year follow up.ResultsSixty-seven patients with a mean age of 2 months (range 6 h to 4 months) underwent primary closure, and 18 underwent osteotomy at the same time. Mean age at epispadias repair was 18 months (8–24). Mean age at bladder neck reconstruction (BNR) was 4.8 years (40–60 months) with a mean capacity of 98 cc (75–185). Analysis of bladder capacity prior to BNR revealed that patients with a mean capacity greater than 85 cc median had better outcomes. Seventy percent (n = 47) are continent day and night and voiding per urethra without augmentation or intermittent catheterization. Social continence defined as dry for more than 3 h during the day was found in 10% (n = 7). Six patients required continent diversion after failed BNR. Seven patients are completely incontinent. The mean time to daytime continence was 14 months (4–23) and the mean time to night-time continence was 23 months (11–34). No correlation was found between age at BNR and continence.ConclusionsPatients with a good bladder template who develop sufficient bladder capacity after successful primary closure and epispadias repair can achieve acceptable continence without bladder augmentation and intermittent catheterization.     

Ureteric stents in pyeloplasty: a help or a hindrance?

ObjectiveTo examine whether routine ureteric stenting influences outcome of pyeloplasty for pelvi-ureteric junction obstruction (PUJO).Patients and methodsA 10-year review was conducted of 105 consecutive open Anderson–Hynes dismembered pyeloplasties performed for PUJO, covering two periods: (1) pyeloplasties performed without ureteric stents (1994–1998) and (2) pyeloplasties performed with ureteric stents (1999–2003). Outcomes (expressed as means ± SEM) of unstented patients (UPs; n = 47) and stented patients (SPs; n = 58) were compared and results analysed using ANOVA and chi-square tests.ResultsFifty-five patients (53.9%) presented with antenatal hydronephrosis, whilst 47 (46.1%) presented postnatally (at mean age 88.4 ± 7.1 months) with one or more of the following: pain (n = 30, 63.8%), urinary tract infection (n = 16; 34.0%), haematuria (n = 3, 6.4%), abdominal mass (n = 3, 6.4%), acute renal failure (n = 2, 4.3%), incidental finding (n = 4, 8.5%). Pyeloplasty was performed (at mean age 58.9 ± 5.3 months) for one or more of the following: pain (n = 40, 38.1%), haematuria (n = 6, 5.7%), urinary tract infection (n = 18, 17.1%), poor initial or deteriorating function (n = 29, 27.6%), severe or deteriorating hydronephrosis (n = 41, 39.0%), calculus (n = 1, 0.95%). Recognised complications of surgery were significantly higher in UPs (5 of 47; 10.6%) than SPs (0 of 58); P = 0.016. These were leakage (n = 4, 8.5%) and obstruction by blood clot (n = 1, 2.1%). Nine SPs (15.5%) developed stent-related complications, including stent migration (n = 5, 8.6%), infection (n = 3, 5.2%) and calculus (n = 1, 1.7%). SPs had significantly shorter hospital stay (2.71 ± 0.25 days) than UPs (4.30 ± 0.38 days); P < 0.01. Preoperative renal pelvis antero-posterior diameter in SPs (3.24 ± 0.25 cm) and UPs (3.21 ± 0.28 cm) was comparable (P = 0.80). Following pyeloplasty, a significant improvement from these preoperative baselines occurred earlier in SPs (at 3.10 ± 0.46 months) than UPs (at 15.71 ± 3.05 months); P < 0.01.ConclusionStented pyeloplasty significantly reduces complications from surgery, particularly leakage, and results in shorter hospital stay and earlier resolution of hydronephrosis, but at the expense of stent-related complications which could be avoided in future by the use of external stents.     

The role of laparoscopic surgery for urinary tract reconstruction in infants weighing less than 10 kg: a comparison with open surgery

PurposeTo compare the outcome of laparoscopic urinary tract reconstruction (LUTR) in children weighing 10 kg or less with a weight-matched cohort undergoing open urinary tract reconstruction surgery (OUTR).Materials and methodsWe conducted a retrospective chart review of patients weighing 10 kg or less at the time of surgery who underwent open or laparoscopic pyeloplasty, transuretero-ureterostomy and ipsilateral uretero-ureterostomy between January 2000 and May 2007. The following information was recorded: body weight, age, sex, diagnosis, type of procedure, operative time, estimated blood loss, pre- and postoperative hemoglobin levels, length of hospitalization, length of follow up, use of drains and stents, intraoperative and postoperative analgesic requirement, need for readmission, subsequent procedures, costs, complications and reoperations.ResultsThere were 52 patients divided into two groups: LUTR (n = 23) and OUTR (n = 29). Median weight (range) and follow up was 6.2 kg (3.9–10) and 9 months and 6.5 kg (4.7–9.6) and 31 months for LUTR and OUTR, respectively. Mean operative time for LUTR (including cystoscopy and stent placement) was 237 min and for OUTR 128 min (P < 0.01). There were no differences in blood loss, intra- or postoperative analgesic requirement, results or complications. Mean hospitalization time was shorter for LUTR than OUTR (2 and 3 days, respectively). There were no differences in hospital costs between the two groups.ConclusionsLaparoscopic reconstructive surgery for congenital urological anomalies is safe and effective in small infants and can be performed with outcomes comparable to that of open surgery.     

The modern staged repair of bladder exstrophy in the female: a contemporary series

ObjectiveMany changes have occurred in the treatment of bladder exstrophy over the last few years and several repairs are now offered, but there is a lack of long-term follow-up data. The purpose of this study was to evaluate long-term outcomes in a select group of female patients in whom modern staged repair was undertaken.Patients and methodsFrom an institutionally approved database 41 patients were identified. All had undergone primary bladder exstrophy closure in 1988–2005, at a mean age of 2 months (range 4 h to 3 months), with or without an osteotomy by a single surgeon, and all were followed up for a minimum of 5 years. Twelve patients underwent osteotomy at the time of primary closure. Eight had a classic transverse innominate and vertical iliac osteotomy, and four a transverse innominate only. Mean age at the time of bladder neck repair (BNR) was 4.2 years (39–65 months). Mean measured bladder capacity under gravity cystograms at the time of repair was 109 cc (80–179 cc).ResultsThirty patients (74%) were continent day and night, and voiding per urethra without augmentation or intermittent catheterization. Social continence, defined as dry for more than 3 h during the day but damp at night, was found in a further four cases (10%). Seven patients are completely incontinent with dry intervals of less than 1 h day and night. The mean time to daytime continence was 12 months (4–16 months) and to night-time continence was 19 months (10–28 months). Patients with a mean capacity greater than 100 cc had better outcomes. Six of the 30 patients achieved dryness after primary closure only, and all six had transverse innominate and vertical iliac osteotomy at the time of primary closure.ConclusionsFemale classic exstrophy patients with a good template who develop adequate capacity after a successful primary closure can achieve acceptable continence without bladder augmentation and intermittent catheterization. A select group will develop continence with closure alone without the need for bladder neck repair.     

Enterocystoplasty in children with neuropathic bladders: long-term follow-up

ObjectiveThis study assesses clinical outcome, after at least 8 years, of augmentation done before or at puberty in neuropathic bladders.Patients and methodsA total of 29 children with neuropathic bladders who did not respond satisfactorily to clean intermittent catheterisation and anti-cholinergic therapy underwent enterocystoplasty at a mean age of 11.8 years (range 3–18). Twenty-one children (72.4%) had vesicoureteral reflux (VUR) and/or ureterohydronephrosis and 22 (75.8%) had dimercapto-succinic acid scars, but all had normal renal function. All patients were followed at regular intervals with urinary tract imaging, serum electrolytes, creatinine, urodynamic evaluation and 24-h urine collection. Urine cytology, cystoscopy and biopsy were performed at the end of follow-up.ResultsMean follow-up was 11 years (range 8–14.5) and mean age at the end of follow-up was 22.2 years (range 13.2–31). Urodynamic studies showed a significant improvement in bladder compliance in all patients. Upper urinary tract dilatation disappeared in all, VUR in 13/17 (76.4%), and no new renal scarring occurred in any patient. At the end of follow-up, renal function was normal in all according to serum creatinine, but cystatin C levels were normal in 27 and elevated in two. Significant proteinuria and low concentrations of renin and aldosterone were present in 80% and 82%, respectively. Only one patient had urinary tract infection, three had bladder stones, and in another a catheterisable channel was made. All patients were dry with normal urine cytology and cystoscopy, and no malignant lesions have been found in the biopsy specimens.ConclusionEnterocystoplasty has preserved renal function and resolved VUR and/or hydronephrosis in most patients. The future implications of proteinuria and the low serum levels of renin and aldosterone, as well as the best indicator for measuring renal function, have yet to be determined. Close, life-long follow-up, including cystoscopy, is necessary to prevent complications.     

Bladder augmentation and artificial sphincter implantation: urodynamic behavior and effects on continence

ObjectiveTo quantify changes in bladder capacity, pressure and compliance after isolated bladder augmentation or augmentation associated with implantation of an artificial sphincter, and to compare the various types of augmentation.Patients and methodsPreoperative and postoperative urodynamic studies were performed in a group of 38 patients (18 males and 20 females; age range 2–19 years), who underwent a type of bladder augmentation.ResultsThe bladder improved in capacity in all patients (mean values: initial 137 ml, final 336 ml, individual increase 229 ml; 434%) except two, in which the augmentation was done with ureter. The mean pressure improved (initial 32 cm of H₂O, final 14, decrease per patient 18 cm of H₂O; 49%). The curve of compliance, progressively increasing typical of hyperreflexia and poor compliance, present in 70% of the cases preoperatively, improved in 78% cases postoperatively, although there were several different patterns. Urodynamic behavior was analyzed with regard to the tissue used for augmentation (ileum, ureter or sigmoid colon). In the sigmoid colon group, there were no significant differences in the urodynamic behavior of the bladder neo-reservoir in relation to the configuration used.ConclusionWith bladder augmentation comes an increase in bladder capacity, a reduction in pressure, and an improvement in compliance and continence. The level of change in capacity, pressure and compliance varies with the tissue used and the length and caliber of the insert. When the procedure is carried out using sigmoid colon tissue, there are no noteworthy differences among the various possible configurations.     

Laparoscopic heminephrectomy in infants and children: first 54 cases

ObjectiveHeminephrectomy in the pediatric population remains a popular open surgical procedure. We describe our experience with laparoscopic heminephrectomy using a retroperitoneoscopic approach.Materials and methodsData were collected retrospectively and prospectively on all patients undergoing laparoscopic heminephrectomy by a single surgeon using a prone retroperitoneoscopic approach. Information relating to the age, sex, laterality, duration of surgery, analgesic requirements, duration of hospital stay, postoperative complications and outcome was recorded.ResultsBetween March 2001 and August 2005 54 laparoscopic heminephrectomies were performed in 48 children (34 girls and 14 boys). The median age at surgery was 14 months (range 2–112 months). Forty-four upper and 10 lower moieties were removed. The median operative time was 105 min (range 50–150 min). There were no intraoperative complications and no conversions. There were four minor complications, comprising haematuria (n = 1) and postoperative pyrexia (n = 3). The median length of follow up was 22 months (range 3–57 months). All patients remained asymptomatic at last follow up. Ultrasound findings included presence of a visible ureteric stump (n = 7) and cysts at the resection margin of the remaining remnant (n = 17); none of these patients manifested clinical symptoms (e.g. infection, pain).ConclusionsWith advanced laparoscopic skills, laparoscopic heminephrectomy is a feasible operation for the treatment of non-functioning duplex renal units in children and infants.     

Tubeless percutaneous nephrolithotomy in children

ObjectiveTo assess the effectiveness of tubeless percutaneous nephrolithotomy (PCNL) as an alternative to extracorporeal shock-wave lithotripsy (ESWL) in the management of urolithiasis in children.Materials and methodsIn 2003–2005 we operated on 20 cases that met the inclusion criteria. Extensive follow-up tests were performed in all patients; stone clearance was defined as the absence of residual fragments on plain abdominal X-ray and renal ultrasound. Pain-scale ruler (0–10) was used to evaluate pain postoperatively. Comparison was made with a group of 10 patients with very similar criteria operated upon with PCN tube.ResultsMean follow-up period was 9 months (3–18 months) and mean age 7.5 years (4–15 years). Mean operative time was 115 min (45–180) with no significant bleeding intra- or postoperatively. Conversion to open surgery was necessary in one case. There were no major perioperative complications. In the tubeless group the pain score was 3–6 (mean 4.6), there was no need for IV analgesia, and median hospital stay was 1.7 days (1–4 days); urine leakage occurred in one patient. In the group with PCN tube the pain score was 5–8 (mean 5.5), IV analgesia was mandatory in four patients, and median hospital stay was 2.8 days (3–4 days); urine leakage occurred in five patients and a small residual stone was detected in one child.ConclusionTubeless PCNL in children has the advantages of being less painful, less troublesome and shortening the hospital stay of the child. The decision to use this procedure is best made intraoperatively and depends on the experience of the surgeon.     

Testicular torsion: Orchiectomy or orchiopexy?

ObjectiveTo evaluate the impact on testicular function of the surgical approach used to treat testicular torsion.Patients and methodsSeventeen males operated on for testicular torsion at a median age of 14 years were investigated. Serum follicle-stimulating hormone (FSH), testosterone and inhibin B as well as testicular volume were measured early (median 36 days) and/or late (median 1.1 years) after operation.ResultsOrchiectomy was performed in six, and testicular detorsion and orchiopexy in 11 patients. The duration of the preoperative symptoms in the detorsion group was 15 h (range 6–168) and in the orchiectomy group 42 h (range 24–96) (P = 0.03). Preoperative colour Doppler ultrasonography showed some circulation in 40% of the patients. At 1 month the median serum inhibin B level was significantly higher after preserving surgery (P = 0.01). At 1 year postoperatively, the median serum FSH level tended to be lower after testicular preservation (P = 0.09). Abnormal inhibin B or FSH values were observed in 35% of the patients.ConclusionsTesticular function is often compromised in patients with testicular torsion. Testis-preserving surgery yields better testicular function than orchiectomy in the short term if the testis is not obviously necrotic. Testicular torsion does not necessarily cause the circulation to cease completely, and preserving surgery can also sometimes be attempted after delayed diagnosis.     

Angiotensin-converting enzyme gene polymorphism in North-west Indian children with posterior urethral valves

PurposeTo investigate the association of angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and other risk factors with renal scarring in patients with posterior urethral valves (PUV).Materials and methodsForty consecutive patients from North-west India were treated for PUV in 1997–2004. The patients were divided into group 1 (no renal scarring, n = 12) and group 2 (renal scars present, n = 28) based on dimercato-succinic acid scans. ACE I/D polymorphism was determined by polymerase chain reaction in PUV patients and unrelated healthy controls (n = 100).ResultsMean age at presentation was 23.7 ± 37.2 months and mean follow up was 4.8 ± 1.5 years. Preoperative mean serum creatinine levels for group 1 (non-scarred) and group 2 (scarred) were 1.1 ± 1.6 mg/dl and 1.7 ± 1.6 mg/dl, respectively. One year after treatment, the serum creatinine levels had decreased to 0.6 ± 0.1 mg/dl and 0.8 ± 0.3 mg/dl in group 1 and group 2, respectively. ACE genotype distribution in children with PUV was no different from that of controls. The occurrence of D allele was significantly (p = 0.04) higher in patients of group 2. Multivariate logistic regression analysis showed that D allele had a significant impact on renal scar formation, introducing a 4.6-fold risk (odds ratio 4.6, 95% confidence interval 1.03–20.38, p = 0.04). A highly significant correlation between the occurrence of renal scarring and presence of breakthrough urinary tract infection (odds ratio = 7.5, 95% confidence interval 1.60–35.07, p = 0.006) and serum creatinine at follow up (odds ratio = 0.6, 95% confidence interval 0.47–0.81, p = 0.03) was observed. The mean values for glomerular filtration rate (GFR) after 1 year of treatment (p = 0.006) and at follow up (p = 0.027) were significantly different between the patients with II genotype and ID/DD genotype. Hypertension was observed in 13 patients and proteinuria in nine patients with no significant difference between the patients having II/I D/DD genotypes.ConclusionThe presence of D allele is associated with progression of renal scarring and reduced GFR in PUV patients.     

Outcome of surgical management of concealed penis

ObjectiveTo review the etiological factors, clinical presentations and outcome of our surgical technique to correct the anomaly of concealed penis.Patients and methodsThirty consecutive patients were treated in 2000–2004. Mean age at operation was 6.7 years (range 13 months–15.4 years). They underwent penoplasty alone (22 patients) or penoplasty with liposuction of prominent prepubic fat pad (eight patients). The medical records of all the patients were retrospectively reviewed, and 23 patients were interviewed, examined clinically and questioned about their initial complaint and the results of our technique. Mean follow up was 28 months (range 6 months–5 years).ResultsThe patients most commonly presented with cosmetic (60.0%), voiding (56.6%) and psychosocial (50.5%) concerns. Three underlying anatomic defects contributing to concealment were observed: fibrotic dartos fascia with poor skin attachment at the base of the penis (93%), prominent prepubic fat pad (40%) and postoperative phimosis leading to trapped penis (26%). Early postoperative complications occurred in 4 patients (13.3%) and all were treated conservatively and successfully. Fourteen patients (46.6%) underwent secondary minor day-case operations, the majority for excision of redundant subcoronal preputial collar. Clinical examination of 23 patients showed very good results in terms of general appearance and accessibility. The older boys were generally more satisfied with the results of surgery than the parents of younger children, whose main source of dissatisfaction was the final circumcised appearance of the penis.ConclusionThe surgical approach used to correct concealed penis alleviates the initial complaint and provides good cosmetic and functional results with greater satisfaction in older patients. Our technique had a low early complication rate but a significant number of patients needed a secondary procedure to improve the final cosmetic results.     

Plasma renin activity for monitoring vesicoureteric reflux therapy: mid-term observations

ObjectiveTo study plasma renin activity (PRA) as an early marker for monitoring treatment of vesicoureteric reflux (VUR).Patients and methodsFifty-nine children (35 males and 24 females), mean age 43.3 ± 26.5 (range 4.5–89) months, with various grades (I–V) of primary VUR were enrolled. PRA, renal scars, split renal function (SRF), glomerular filtration rate (GFR), serum creatinine, blood pressure and episodes of breakthrough urinary tract infection were monitored at regular intervals. Surgery was performed as per currently accepted criteria. PRA values were used for post-hoc analysis of results.ResultsThirty-eight children (64.4%) underwent anti-reflux surgery during the mean follow up of 17.1 ± 3.1 months; 21 (35.6%) continued on non-operative follow up. Rise in PRA up to the time of surgery was seen in all patients. It normalized after surgery in 86%, and reduced but plateaued at a higher level than normal in 13.8% in the surgical group. While improvement in SRF and GFR was seen only in 2/38 (5.2%) and 12/38 (31.6%), respectively, blood pressure stabilized in 30.7% and serum creatinine showed inconsistencies. In non-operatively managed cases, improvement in SRF was seen in only one case and GFR in 14.2% of cases. However, 80.9% children showed a progressive rise in PRA throughout the period of non-operative follow up.ConclusionCurrent end points of non-operative management already cause irreversible renal damage by the time surgery is indicated. Our results suggest that serial measurement of plasma renin activity may help in better stratification of patients with moderate to high grade (III–V) VUR with respect to management and prognosis.     

Does the multicystic dysplastic kidney really involute? The role of the retroperitoneoscopic approach

ObjectiveTo assess the role of video-assisted retroperitoneoscopy in the follow up of multicystic dysplastic kidney (MCDK) that has involuted – disappeared? – on serial renal ultrasonography (US).Patients and methodsProspectively, we performed a retroperitoneoscopy in 14 patients, nine girls and five boys, with unilateral MCDK that had involuted on serial US. MCDK was diagnosed in utero (80%) and confirmed postnatally by US and Tc99m dimercaptosuccinic acid radionuclide scan. Follow up US examinations were performed at 1 month, 5 months and 12 months in the first year of life and every 6 months from then on. US showed complete involution at a mean age of 13 months (range 5–18 months). Retroperitoneoscopy was then indicated, at a mean age of 23 months (range 8–24 months), to confirm the disappearance of the kidney dysplastic remnant.ResultsRetroperitoneoscopy detected persistence of anomalous kidney tissue in 100% of cases. The mean length of the renal remnant was 2 cm (range 1–3.5 cm). Two cases showed a pelvic ectopic location that was not detected by US before involution. The remnant was removed during the same procedure. Anatomo-pathological findings were found to be compatible with dysplastic renal tissue. There were no intra- or postoperative complications. All patients had a mean length of stay of less than 24 h.ConclusionsComplete resolution on US does not mean disappearance of MCDK, as US does not detect renal dysplastic remnants after cyst involution has occurred. The retroperitoneoscopic approach to the renal and pelvic area is a minimally invasive, safe and effective procedure to diagnose and treat the renal dysplastic remnant in US-involuted MCDK.     

Long-term follow up of enteric bladder augmentations: the risk for malignancy

ObjectiveTo determine the risk of bladder cancer following enteric bladder augmentation.Materials and methodsPatients followed for care after an enteric bladder augmentation have been entered into a registry; individuals followed for a minimum of 10 years were evaluated.ResultsThe study criteria were met by 153 patients. Indications for bladder augmentation were neurogenic bladder in 97, exstrophy in 38 and posterior urethral valves in 18. There was a median follow-up interval of 27 years (range 10–53). A total of seven cases of malignancy developed. Median time to tumor development following augmentation was 32 years (range 22–52). Two patients with neurogenic bladder developed transitional cell carcinoma; both were heavy smokers (>50 pack per year history). Two patients with a history of posterior urethral valves and renal transplantation developed adenocarcinoma of the enteric augment. Three patients with bladder exstrophy developed multifocal adenocarcinoma of the augmented bladder. Two patients remain alive, 5 and 6 years following radical cystoprostatectomy; five died of cancer-specific causes.ConclusionsMalignancy following enteric bladder augmentation arose in 4.5% (7/153) of our patients and was associated with coexisting carcinogenic stimuli (prolonged tobacco/chronic immunosuppressive exposure), or alternatively with the inherent risk of malignancy existing with bladder exstrophy.     

The role of the Lich-Gregoir procedure in refluxing duplicated collecting systems: experience from long-term follow up of 45 children

ObjectiveThe need for surgical correction of vesicoureteral reflux (VUR) is increased in duplicated systems. The aim of this study was to evaluate the outcome of the Lich–Gregoir procedure (LG) with regard to VUR persistence, contralateral de-novo VUR, hydronephrosis, preservation of split renal function, urinary tract infections (UTI) and postoperative side effects.Patients and methodsBetween 1993 and 2007, 45 children (mean age 3.2 years) underwent a unilateral common sheath LG. A combined number of at least 75 episodes of febrile UTI had occurred in 39 children prior to surgery. VUR grades I to V were present in two, nine, 16, 16 and two children, respectively. Hydronephrosis was present in 18 children. Mean split renal function was 44.03% (range 15–63%). Indications for surgery were febrile breakthrough UTI in 11 children and abscessing pyelonephritis in two. The remainder underwent surgery due to renal scars, reduced split renal function (<45%), VUR persistence and/or parental desire.ResultsPersistent ipsilateral and de-novo contralateral VUR were detected in three children (ipsilateral in one, contralateral in one, bilateral in one), resulting in a 4.4% rate of persistent ipsilateral VUR. One year post surgery, low-grade hydronephrosis persisted in six patients without impact on split renal function. Mean split renal function remained stable at 44.06% (range 15–68%). During follow up (mean 41 months), six febrile UTIs occurred in five girls (92.4% risk reduction, P < 0.00000005). Neither urinary retention nor any other side effect was observed.ConclusionPerformed unilaterally, common sheath LG is a safe and effective technique to cure VUR, prevent febrile UTI and maintain split renal function in duplicated systems with otherwise uncomplicated anatomy.     

School-based control of urinary schistosomiasis on Zanzibar, Tanzania: monitoring micro-haematuria with reagent strips as a rapid urological assessment

ObjectiveTo evaluate micro-haematuria, detected by Haemastix^® reagent strips, for diagnosis of urinary schistosomiasis during a 3-year period of school-based control on Zanzibar.Patients and methodsA sub-set of school children, from a total of 135,000 who were receiving treatment for urinary schistosomiasis and soil-transmitted helminthiasis, were monitored by parasitological and questionnaire methods for Schistosoma haematobium infections: at treatment baseline in 2004 (n = 2002), follow up with re-treatment in 2005 (n = 3278) and further follow up with re-treatment in 2006 (n = 3993). Standard diagnostic scores for micro-haematuria were calculated against parasitological assessment.ResultsDiagnostic scores of Haemastix^® remained strong throughout the 3-year period. In 2006, scores were: sensitivity (SS) = 0.86 (95% CI: 0.86–0.88), specificity (SP) = 0.99 (0.98–1.00), positive predictive value (PPV) = 0.90 (0.88–0.91), negative predictive value (NPV) = 0.98 (0.98–0.99) in boys; and SS = 0.84 (0.82–0.86), SP = 0.98 (0.98–0.99), PPV = 0.77 (0.75–0.79) and NPV = 0.99 (0.99–1.00) in girls. By comparison, reported blood in urine and pain upon urination were much lower and not as informative.ConclusionAt a cost of approximately £0.20/test, further use of reagent strips for monitoring of urinary schistosomiasis during ongoing control programmes should be advocated as a rapid, cost-effective and informative disease surveillance tool.