Application of magnetic resonance urography in diagnosis of congenital urogenital anomalies in children

Magnetic resonance urography (MRU) has become a useful adjuvant in evaluating urogenital anomalies. In present study, we evaluated the ability of MRU in diagnosis of different congenital urogenital anomalies when the results of conventional imaging modalities were inconclusive. A total of 90 children were included in this series. The children were evaluated with T2-weighted and contrast-enhanced T1-weighted MRU sequences. The results were compared with findings obtained with ultrasonography, intravenous urography, renal nuclide scan, and voiding cystourethrography. MRU was requested in these children because conventional imaging modalities were equivocal or a co-existing urogenital anomaly was suspected. Only those cases that underwent surgery were included in this study and the surgical findings were set as the reference standard in statistical evaluation. The records of 61 boys with mean (range) age of 2.3 years (2 months-12 years) and 29 girls with mean (range) age of 3.3 years (3 months-12 years) were reviewed. The final diagnosis was ureteropelvic junction obstruction (n = 25), vesicoureteral junction obstruction (n = 16), ureterocele (n = 19), ectopic kidney (n = 11), posterior urethral valve (n = 17), and polycystic kidney (n = 2). The overall sensitivity of MRU, intravenous urography, renal nuclide scan, ultrasonography, and voiding cystourethrography in diagnosis of the aforementioned anomalies were 86, 63, 50, 44, and 41%, respectively. MRU was much more sensitive than other imaging modalities in diagnosis of end-ureteral dilation (100%) and ureterocele (89%). MRU provides a reliable noninvasive technique for imaging of the congenital anomalies in the urinary tract of children with T2-weighted MRU sequences providing unenhanced static-water images of the urinary tract as well as depicting adjacent soft-tissue lesions, and T1-weighted MRU technique imitating conventional intravenous urography. Both MRU sequences can be combined for a comprehensive examination of the urinary tract.     

Newborn society of fetal urology grade 3 hydronephrosis is equivalent to preserved percentage differential function

PurposeIn newborn hydronephrosis (HN), the level of differential function (%df) measured by diuretic renography (DR) is used to judge the need for pyeloplasty. As DR testing is complex, we sought to determine if grading the level of HN (Society of Fetal Urology grade, SFU Gr) by a simple ultrasound correlates with percentage differential function (%df) and thereby obviates the need to perform DR.Materials and methodsBetween 1990 and 2003 our institution prospectively enrolled all cases of fetal HN who showed unilateral newborn SFU Gr HN ≥3. The cases underwent standardized testing. DR was done using the method of Well-Tempered Renography which was then followed by ultrasound (US). The US studies were performed while the hydration induced by DR was in effect. The level of %df was categorized as preserved (≥40%) or reduced (<40%). Cases were excluded if there was an additional urological abnormality (e.g. ureterocele).ResultsThere were 71 cases that met our study criteria. The SFU Gr HN was 3 (n = 33) or 4 (n = 38). Kidneys with SFU Gr 3 HN showed preserved %df (33/33,100%) (mean = 50.1 ± 3.6) significantly more often than kidneys with SFU Gr 4 HN (27/38, 71%) (mean = 42.2 ± 13.9) (RR = 1.41, 95% CI (1.15–1.72), p < 0.001).ConclusionIn newborns with a history of fetal HN, the postnatal finding of SFU Gr 3 HN uniformly correlates with preserved %df. Standardized hydration prior to US study is done to assure consistency in measurement of the SFU Gr HN. Determining the duration of the relationship between SFU Gr 3 HN and preserved %df will require prospective, longitudinal studies.     

Long-term follow up of antenatally diagnosed megaureters

AimWe have retrospectively evaluated our 17 years of experience with antenatal diagnosis of hydronephrosis that led to postnatal diagnosis of megaureter, and tried to determine criteria for surgery.Patients and methodsSeventy-nine children (64 boys and 15 girls) with antenatal diagnosis of hydronephrosis that led to postnatal diagnosis of megaureter were followed conservatively over a period of 18 years (1988–2006). Right ureterohydronephrosis was seen in 23 children, left in 30 and 26 had bilateral ureterohydronephrosis comprising a total of 105 renal units (RU). According to SFU (Society for Fetal Urology) classification, 8 RU were grade 1, 57 grade 2, 29 grade 3 and 11 grade 4 postnatal hydronephrosis. Mean ureteral diameter was 1.2 cm. Relative renal function was in 82 RU more than 40%, in 18 RU 30–40% and in 5 RU less than 30%. Functional deterioration of the hydronephrotic kidney of more than 5%, worsening of hydronephrosis (SFU upgrade) and a persistent obstructive curve on radionuclide scans were the main indications for surgery.ResultsTwenty-five (31%) children required surgical correction. Mean age at surgery was 14.3 months (range 3–60). Univariate analysis revealed that gender and side of obstruction are not significant predictive factors for surgery SFU grade 3–4 of postnatal hydronephrosis, Relative renal function less than 30% and ureteral diameter more than 1.33 cm were significant independent risk factors leading to reimplantation.ConclusionsOnly 30% of children with antenatal diagnosis of megaureter required surgical correction. Renal function less than 30%, grades 3 and 4 hydronephrosis, and ureteric diameter more than 1.33 cm are statistically significant and independent predictive factors for surgery.     

Early abnormal amplitude-integrated electroencephalography (aEEG) is associated with adverse short-term outcome in premature infants

BackgroundIn preterm infants with IVH the electrocortical background activity is affected and there is a correlation between the severity of cerebral injury to the degree of depression, however the usefulness of the early aEEG recordings has hardly been determined.AimTo identify early aEEG features that could be used as prognostic markers for severe brain injury in prematures.MethodsIn 115 infants, 25–32 wk GA, aEEG recordings during the first 72 h of life were correlated with head ultrasound findings. Continuity (Co), sleep–wake cycling (Cy) and amplitude of the lower border (LB) of the aEEG were evaluated by semi-quantitative analysis.ResultsThe infants were divided into four groups based on head ultrasound findings: A (n = 72, normal), B [n = 16, grades 1–2 intraventricular hemorrhage (IVH)], C (n = 21, grades 3–4 IVH) and D (n = 6, periventricular leukomalacia). 18 infants (16 of group C and 2 of group D) died during hospitalization. Significantly lower values of all aEEG features were found in group C infants. The presence of pathological tracings (burst-suppression, continuous low-voltage, flat trace) or discontinuous low-voltage (DLV), the absence of Cy and LB < 3 μV in the initial aEEG displayed a sensitivity of 88.9%, 63% and 51.9% respectively, for severe brain injury. Logistic regression of aEEG features and GA to the presence or absence of severe injury revealed that only Co was significantly correlated to outcome. Using this feature 83.19% of cases were correctly classified.ConclusionPathological tracings or DLV in the initial aEEG is predictive for poor short-term outcome in premature neonates.     

Laparoscopic heminephroureterectomy for duplex kidney anomalies in the pediatric population

ObjectiveDespite increasing acceptance of laparoscopy in pediatric urology, few published data are available on laparoscopic heminephroureterectomy in patients with duplex kidney anomalies. In the present study, we report our own experiences with this technique.Patients and methodsFrom August 2003 to January 2006, five laparoscopic heminephroureterectomies were performed in four girls with a mean age of 41 (9–67) months. In all cases, a non-functioning upper pole with an obstructive (n = 4) or refluxing (n = 1) megaureter was found. The upper pole was resected laparoscopically en bloc with the megaureter using three to four trocars.ResultsMean follow-up was 42.4 (±7.9) months. All procedures were performed successfully without conversion to open surgery with a mean operative time of 190 (170–210) min. Blood loss was minimal and no intraoperative complications occurred. Despite chronic inflammation in the resected specimens, the patients showed no clinical signs of infection postoperatively. The average length of hospital stay was 5.6 (4–7) days. All patients were followed using duplex sonography.ConclusionsThese data demonstrate that, even in infants, laparoscopic heminephroureterectomy is feasible and associated with minimal morbidity, a better cosmetic result and a shorter hospital stay compared to open surgery. The main disadvantage of the laparoscopic approach is a longer operative time. Laparoscopic heminephroureterectomy is a technically demanding procedure and should be performed only in specialized centers.     

Diagnostic accuracy of color Doppler sonographic study of the ureteric jets in evaluation of hydronephrosis

ObjectiveHydronephrosis (HN) and obstruction are closely associated, but upper urinary tract dilatation can occur without significant obstruction. Despite some pitfalls, conventional ultrasonography and diuretic renography (DR) are the main means of evaluation of HN in children. Recent reports have demonstrated color Doppler ultrasonography (CDUS) to reliably identify ureteric jets in the bladder. The aim of this study was to evaluate this method as a diagnostic tool to distinguish obstructive from non-obstructive dilatations of the upper tract.MethodsWe evaluated 51 patients (37 boys and 14 girls), aged 3 months to 14 years (median 4 years), who presented with unilateral grade III and IV hydronephrosis with suspicion of pyeloureteral junction obstruction. All patients underwent DR and evaluation of ureteric jets by transverse CDSG of the bladder within a maximum of 2 weeks. Obstruction was considered in the DR when the hydronephrotic unit showed a differential renal function of less than 40%, or when symptomatic intermittent renal colic was present in older children. The number of ureteric jets was counted over a 5-min period and the frequency calculated for each ureteral orifice. Relative jet frequency (RJF) was defined as frequency of the hydronephrotic side divided by total ureteric jet frequency. Receiver-operating characteristic (ROC) plots were constructed to determine the best cut-off for RJF, in order to identify renal units with obstructive hydronephrosis.ResultsTwenty-three (45.1%) hydronephrotic units were considered obstructed. The mean RJF differed between obstructive (0.09 ± 0.15) and non-obstructive hydronephrosis (0.42 ± 0.11) (p < 0.001). ROC analysis revealed that RJF <0.25 was the best threshold, and correctly discriminated obstruction in 91.2% of the children with a sensitivity of 87% (95% CI 78.6–98.2%) and specificity of 96.4% (95% CI 87.8–99%). The positive likelihood ratio was 24.3 and the area under the ROC curve was 0.92 (95% CI 0.86–0.98).ConclusionsRJF <25% was found to be a good indicator of obstruction in children with unilateral hydronephrosis. CDUS evaluation of ureteric jets is an easy and non-invasive method that can be used as an initial diagnostic tool, and in follow-up cases, to differentiate obstructed from non-obstructed hydronephrosis in the pediatric population.     

Evaluating the specificity of a new type of urine collection bag for infants

ObjectiveFor diagnosing urinary tract infection (UTI) in infants, the urine collection bag is a common sampling method. It has several advantages versus other methods but a high risk of contamination makes culture results difficult to evaluate. Previous studies report a specificity ranging from 14% to 84%. The objective of this study was to evaluate the specificity of a new type of urine collection bag.MethodUrine samples were collected from healthy infants with a new type of collection bag. As the urine is expected to be sterile, any bacterial growth would be considered a contamination.ResultsForty-four samples were included: 40 samples showed <10,000 cfu/ml of mixed growth or no growth at all, three samples showed <10,000 cfu/ml of single-strain growth and one sample showed >10,000 < 100,000 cfu/ml of single-strain growth. No samples showed any growth >100,000 cfu/ml.ConclusionAccording to Kass criteria, 97.7% of the samples would exclude a UTI and 2.3% would be considered inconclusive. None of the samples had a contamination level that, falsely, would be interpreted as positive. Further studies will be valuable as a specificity of 97.7% suggests that this collection device could give the clinician a non-invasive option for diagnosing UTI in infants.     

Congenital hydrocephalus – prevalence,prenatal diagnosis and outcome of pregnancy in four European regions

ObjectiveTo describe prevalence, prenatal diagnosis and outcome for fetuses and infants with congenital hydrocephalus.MethodsData were taken from four European registries of congenital malformations (EUROCAT). The registries included are based on multiple sources of information and include information about livebirths, fetal deaths with GA ≥ 20 weeks and terminations of pregnancy for fetal anomaly (TOPFA). All cases from the four registries diagnosed with congenital hydrocephalus and born in the period 1996–2003 were included in the study. Cases with hydrocephalus associated with neural tube defects were not included in the study.ResultsEighty-seven cases with congenital hydrocephalus were identified during the study period giving an overall prevalence of 4.65 per 10,000 births. There were 41 livebirths (47%), four fetal deaths (5%) and 42 TOPFA (48%). Nine percent of all cases were from a multiple pregnancy. Additional non-cerebral major malformations were diagnosed in 38 cases (44%) and karyotype anomalies in eight cases (9%). Median GA at TOPFA was 21 weeks. Among livebirths 61% were diagnosed prenatally at a median GA of 31 weeks (range 17–40 weeks) and median GA at birth was 37 weeks. Fourteen liveborn infants (34%) died within the first year of life with the majority of deaths during the first week after birth.ConclusionCongenital hydrocephalus is a severe congenital malformation often associated with other congenital anomalies. CH is often diagnosed prenatally, although sometimes late in pregnancy. A high proportion of affected pregnancies result in termination for severe fetal anomaly and there is a high mortality in livebirths.     

Leech in urinary bladder causing hematuria

ObjectiveTo estimate efficacy of normal saline in the management of hematuria caused by accidental entry of a leech per urethra into the urinary bladder.MethodsAn intervention study was carried out in the Department of Pediatric Surgery of Sylhet MAG Osmani Medical College between January 1998 and December 2003. A total of 43 boys (mean age 8 years, SD ± 2.6) were enrolled. In all cases, a leech had entered the urinary bladder through the urethra causing hematuria. All patients were equipped with a self-retaining Foley catheter. They were managed by infusing 50 ml of normal saline into the urinary bladder through the catheter that was then clamped for 3 h.ResultsAfter removing the catheter, in all cases the whole leech was spontaneously expelled intact, dead or alive, within 2–24 h during the subsequent act of micturition. Hematuria gradually diminished to a clear flow within the next 6 h in 27 cases, 12 h in 14 cases and 24 h in two cases. All patients were followed up for 2 weeks, and none developed recurrent hematuria.ConclusionCatheterization and irrigation of the urinary bladder with normal saline is a relatively simple, safe and inexpensive method of removing the leech and controlling hematuria.     

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 appendix as ureteral substitute: a report of 10 cases

BackgroundUreteric replacement in part or in total is rarely needed in children. We present our experience in using the appendix to replace the ureter.MethodsA retrospective case note review was carried out at Sheffield Children's Hospital (UK), Ekta Institute of Child Health (Raipur, Chhattisgarh, India) and Christian Medical College Hospital (Vellore, India) of all cases of ureteric substitution using the appendix.ResultsTen patients were identified, operated in 2002–2007: seven males and three females with a median age of 2.5 years (range 2.5 months to 12 years). The reasons for ureteric replacement were traumatic ureteric avulsion (n = 1), congenital ureteric stenosis (n = 5), non-drainage following previous pyeloplasty for pelvi-ureteric junction obstruction (n = 3) and ureteric stricture following reimplantation for vesico-ureteric reflux (n = 1). The appendix was used in an anti-peristaltic manner in all cases, and in one case a transureteroureterostomy was performed. At a median follow up of 16 months (1–72 months), all the patients were well except one whose kidney function had deteriorated.ConclusionsTotal or partial replacement of the ureter using the appendix, even in the first year of life, preserved renal function in nine cases. Ureteric continuity can be successfully restored in children using the appendix.     

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.     

Vesicostomy vs primary ablation for posterior urethral valves: Always a difference in outcome?

ObjectiveA vesicostomy is believed to have a detrimental effect in boys with posterior urethral valves compared to primary valve ablation. We compared the outcomes of boys managed by initial vesicostomy with those undergoing primary fulguration.Materials and methodsThe outcomes of 54 boys (23 vesicostomy, 31 primary valve fulguration) over 1 year of age who had not undergone renal transplant were considered. Outcome parameters identified were ultrasound findings, continence status, glomerular filtration rate (GFR) and 1-year creatinine. Dryness was defined as completely dry both day and night with no need to wear pads. Results are presented with 95% confidence intervals.ResultsUltrasound examinations were normal in 9/19 (47.4%) of the vesicostomy group and 11/24 (45.8%) of the fulguration group. Graded ultrasound results were not significantly different (p = 0.24). The vesicostomy patients were more often dry (79% vs 64%, p = 0.43). The vesicostomy group had on average higher GFR (95.26 vs 85.79) and lower 1-year creatinine (49.58 vs 52.46) values. After accounting for age differences between groups, there was no significant difference in the GFR and 1-year creatinine values (p = 0.16 and p = 0.87, respectively).ConclusionsThere was a tendency for the major outcomes to be more favourable in the vesicostomy group. Although trends were non-significant, confidence intervals were wide and potential differences of clinical importance could not be discounted.     

An alternative grading system to refine the criteria for severity of hydronephrosis and optimal treatment guidelines in neonates with primary UPJ-type hydronephrosis

ObjectiveWe present our alternative hydronephrosis grading system (AGS) in an attempt to establish optimal treatment guidelines, and clarify and refine the criteria for severity of hydronephrosis in neonates.Patients and methodsA total of 162 newborns (228 affected kidneys) with antenatally diagnosed primary ureteropelvic junction-type hydronephrosis were prospectively followed and treated by the same surgeon for a mean of 46 (6–65) months. Ultrasonography and diuretic renogram were used for diagnosis and follow up. Society for Fetal Urology (SFU) grading system, anteroposterior diameter of renal pelvis (APDRP) and our AGS were used to determine the degree of hydronephrosis. AGS: 0, no hydronephrosis; 1, dilatation of renal pelvis alone; 2, plus caliceal dilatation; 3, plus <1/2 (mild-to-moderate) renal parenchymal loss; 4, plus >1/2 (severe) renal parenchymal loss (cyst-like kidney with no visually significant renal parenchyma).ResultsOn the first postnatal ultrasound, the severity of hydronephrosis was SFU ≤ 2 in 152 kidneys (surgery, 0%), SFU-3 in 41 kidneys (surgery, 19.5%) and SFU-4 in 35 kidneys (surgery, 68.6%). The follow up, treatment and outcome of SFU-1 and SFU-2 patients were similar; all resolved spontaneously without renal deterioration (renal function >40%). Renal function ranged between 7% and 39% in SFU-4 patients. Intrarenal pelvis was found in one patient with an APDRP of <15 mm, seven patients of 16–30 mm, and five patients of >30 mm. Overall, 201 hydronephrotic kidneys (88.2%) resolved spontaneously while 27 (11.8%) required pyeloplasty.ConclusionNeither an SFU grading system nor measurement of APDRP is the gold standard in determining the severity of hydronephrosis. Both methods may fail, particularly in children with intrarenal pelvis configuration or SFU-4 hydronephrosis. Our AGS promises easier follow up and more timely treatment.     

Single-stage repair of bladder exstrophy in older children and children with failed previous repair

AimEvaluation of cosmetic and functional outcome of single-stage exstrophy–epispadias complex repair in older children and those with previously failed repair.Materials and methodsThis study comprised 15 children (12 boys and 3 girls) with classic bladder exstrophy and a mean age at repair of 8.6 months (range 2–24 months). Eight children had a previously failed repair. All children underwent complete primary repair using the single-stage Mitchell technique. Half of the boys had complete penile disassembly, while in the others a modified Cantwell–Ransley technique for epispadias repair was used. Anterior iliac osteotomy was performed and hip spica used for immobilization in all children.ResultsOne child had urethral stricture treated by endoscopic visual urethrotomy. Three children had penopubic fistulae that closed spontaneously. No bladder dehiscence or prolapse was encountered. Vesicoureteral reflux was present in 20 renal units but ureteral reimplantation was not performed. Average bladder capacity after closure was 134 cm³ (range 110–160 cm³) with only two partially continent and six incontinent children. Mean follow-up period is 2 years (range 1–3 years).ConclusionsSingle-stage repair was performed in children with previously failed repair and those presenting at an older age with satisfactory results. Acceptable bladder and genital anatomy and function were achieved together with preservation of renal function. The impact of this technique on continence is not encouraging, but needs to be determined in a longer follow-up period.     

Comparative efficacy and safety of extended-release and instant-release tolterodine in children with neural tube defects having cystometric abnormalities

AimTo evaluate the comparative efficacy and safety of extended-release (ER) and instant-release (IR) tolterodine preparations in a pediatric population with neural tube defects having cystometric abnormalities.Materials and methodsTwenty-five patients with neural tube defects and a similar demographic profile underwent a routine hemogram, liver function tests, renal function tests, urine culture, X-ray lumbo-sacral spine, and renal and bladder ultrasound. Vesicoureteric reflux was diagnosed by micturating cystourethrogram under fluoroscopy. Dimercaptosuccinic acid renal scintigraphy was performed to study the presence or absence of renal scars. Patients were treated with tolterodine ER (Group I: 2 mg once daily for 21 days) and tolterodine IR (Group II: 2 mg twice daily for 21 day) in a cross-over study with a 10-day washout period between administrations. Evaluation was by subjective assessment, visual analog scale, urodynamic assessment and adverse drug reaction monitoring.ResultsThere was ultrasound evidence of hydroureteronephrosis in 20% of the patients. One patient out of 25 had impaired renal function and eight patients had renal scarring on dimercaptosuccinic acid scans. Both forms of the drug increased the maximum cystometric bladder capacity, decreased detrusor leak pressures and increased compliance compared to pre-therapy levels (P = 0.0001). Visual analog scale showed a significant clinical improvement with both ER and IR tolterodine. A significant increase in maximum bladder capacity in the group receiving IR tolterodine as compared to the ER preparation was noted (P = 0.0001). The decrease in detrusor leak pressures and improvement in compliance were not significantly different between the groups. No adverse effects of hyperpyrexia, flushing or intolerance to outdoor temperatures, or dryness of mouth were observed in either group. No patient suffered from constipation.ConclusionER tolterodine 2 mg once daily is as effective and well tolerated in children with neurogenic bladder as IR tolterodine 2 mg twice a day. The latter was found to be more effective in terms of urodynamic parameters. ER formulation of tolterodine is less expensive and has the advantage of single dosage.     

Epidemiological study of type 1 diabetes in children under 15 years-old in Castilla-La Mancha (Spain)

IntroductionWe studied the incidence and prevalence of type 1 diabetes in children under 15 years-old in Castilla-La Mancha.Patients and methodsIncidence: All new cases in a 12 months period (2007-2008) were included. To calculate the completeness of ascertainment we used the capture-recapture method. The result is expressed in cases/100,000 inhabitants under 15 years old/year. Prevalence: all children under 15 years diagnosed with diabetes on 31^st of May of 2008 were registered. Results are expressed as cases/1000 inhabitants under 15 years old.ResultsThe incidence in the Castilla-La Mancha was 27.6/100,000/year, but there was a wide variability among the different provinces: Ciudad Real (34.15), Albacete (28.19), Toledo (26.57), Guadalajara (20.3) and Cuenca (17.6).The prevalence was 1.44/1000 children under 15 years old and 0.21/1000 for the whole population. By provinces: Ciudad Real (1.67), Albacete (1.64), Toledo (1.42), Cuenca (1.02) and Guadalajara (1.01).By sex and age, we found a higher incidence (13/7) and prevalence (22/7) in males under 5 years old. The age group with highest incidence was the 4-9 year-olds, and the highest prevalence was in the 10-14 years group.ConclusionsBoth, incidence and prevalence of type 1 diabetes in children under 15 years old in Castilla-La Mancha are high, with a wide range among the different provinces. There is a preponderance in males under 5 years old. The highest prevalence is that of the 10-14 years age group. The highest incidence was in the 5-10 year age group.     

Factors affecting the outcome of foreskin reconstruction in hypospadias surgery

ObjectiveDespite ongoing refinement of numerous techniques, the incidence of complications following hypospadias repair is still significant. The aim of this study is to evaluate the factors that affect the success in childhood of foreskin reconstruction with hypospadias repair.Materials and methodsA retrospective study was carried out of all primary hypospadias repairs with foreskin reconstruction (n = 408) over the last 23 years. The hypospadias was coronal in 160 (39%), glanular in 114 (28%), subcoronal in 78 (19%) and distal penile in 56 (14%) cases. Foreskin reconstruction was included in 362 cases suitable for a meatal advancement (191) or distal urethral tubularization (171), and 46 cases for a flip-flap procedure (37 Mathieu, nine Barcat). Outcome analysis was of foreskin-related complications post surgery.ResultsForeskin repair was successful in 333 cases (92%) that underwent meatal advancement/distal urethral tubularization, and 33 (72%) that underwent a flip-flap operation. Complications related to the foreskin occurred in 10% of the whole group with a urethral fistula rate of 8%. The median age at surgery was 13 months (2–120 months), and the median follow-up period was 11 months (1–100 months).ConclusionsA good cosmetic and functional outcome can be achieved with foreskin reconstruction combined with a variety of hypospadias repairs. The outcome in this series was better in cases of distal hypospadias using interrupted polyglactin sutures.     

Magnetic resonance urography for diagnosis of pediatric ureteral stricture

PurposeUreteral stricture is a rare cause of hydronephrosis in children and is often misdiagnosed on ultrasound (US) and diuretic renal scintigraphy (DRS), requiring intraoperative diagnosis. We evaluated ureteral strictures diagnosed by magnetic resonance urography (MRU) at our institution.Materials and methodsChildren with ureteral stricture who underwent MRU were identified. Patient demographics, prior imaging, MRU findings, and management were assessed. The efficacy of MRU in diagnosis of stricture was compared with US and DRS. Patients with ureteropelvic or ureterovesical junction obstruction were excluded.ResultsTwenty-eight ureteral strictures diagnosed by MRU between 2003 and 2013 were identified; 22% of strictures were diagnosed by DRS ± US. The mean age at MRU diagnosis was 2.4 years (range 4 weeks–15 years). Hydronephrosis was the most common presentation, accounting for 20 (71%) cases. Other etiologies included pain (3), incontinence (2), and urinary tract infection, cystic kidney, and absent kidney, present in one case each. A mean of 2.7 imaging studies was obtained prior to MRU diagnosis. Twenty-one (75%) ureteral strictures required surgical intervention, with the approach dependent upon location.ConclusionsMRU provides excellent anatomic and functional detail of the collecting system, leading to accurate diagnosis and management of ureteral stricture in children.