Biomedical subjects

N Capozza

Publications and source records attributed to N Capozza.

At least 19 recordsLinked to original sources

PubMed2006

In vivo bladder regeneration using small intestinal submucosa: experimental study.

Significant side effects are correlated with bladder augmentation. Recently, small intestinal submucosa (SIS) has been proposed for clinical use. The efficacy of SIS bladder regeneration was studied in a porcine experimental model. Partial cystectomy (40-60% of bladder wall) was performed and replaced by SIS graft. Animals were planned to be killed at 2 weeks, 5 weeks and 3 months. Bladder capacity at 40 cmH(2)O pressure and macroscopic graft morphology were assessed before and after SIS implant. Histological examination was carried out with computer assisted morphometric analysis for collagen/smooth muscle ratio. Student's t test was adopted for statistical analysis. Two piglets died on the 9th and 10th post-operative day due to urinary peritonitis. The remaining piglets were killed after uneventful post-operative period at 5 weeks (two animals) and 3 months (two animals). The bladder capacity was reduced (-18%) at the 5 week follow-up and quite similar to the pre-operative volume (+2.5%) at the 3 months control. No diverticular formation, bladder calculi, mucus and urinary infection were found. The SIS graft resulted not significantly contracted. Histology at 10 days showed SIS membrane lined by transitional epithelium islands with some capillaries. At 5 weeks, transitional epithelium was fully covering the graft; new blood vessels and fibroblasts with smooth muscle cells were observed. At 3 months, the SIS was not evident. Two layers were defined: inner transitional epithelium, outer collagen with fibroblasts and muscular bundles. Computer assisted morphometric analysis showed collagen/muscle ratio 70/30% (normal bladder=56/44%, P<0.05). The SIS was effective as a scaffold for bladder wall regeneration in four out of six animals. Long-term studies are required to confirm the efficacy of the newly developed wall and for eventual clinical use.

Animals↗

PubMed2005

First paediatric experience of a new device for "non-endoscopic" periurethral injection in urinary incontinence.

The results of endoscopic treatment for urinary incontinence (ETUI) depend on the condition of the urethral mucosa and on the length of the urethra. ETUI is quite difficult to perform in female patients, and, in general, in cases of scarred urethral mucosa. A new device (Zuidex, Q-Med, Uppsala, Sweden) has recently been designed for the "non-endoscopic" treatment of urinary stress incontinence in women. Three paediatric cases are described hereunder. Three patients were treated using Zuidex: two patients (two girls aged 8 and 18) on intermittent catheterization for neurogenic bladder, and one 11-year-old girl, with epispadias, who had already undergone bladder neck reconstruction (Young-Deese). Zuidex is a special implacer for dextranomer implants. It consists of four syringes filled with dextranomer, one implacer, and four needles (25 gauges). Once the device is positioned, the four injections are performed. At the end of this procedure, four implants are symmetrically positioned at four points of the urethral wall, increasing the outlet resistance. In the follow-up phase (5-13 months), the increase in the continent period was +56, 50 and 36%; the increase in bladder capacity (leak volume point) was 40, 28 and 27% in the three patients. Although the new device for "non-endoscopic" treatment of urinary incontinence has been designed for women, the size of the implacer virtually allows its use in any paediatric patient who is above the age of six. Our early experience indicates that this new device could play an important role in the treatment of urinary incontinence in paediatric age.

Adolescent↗

PubMed2004

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

OBJECTIVE: To evaluate and define the risk factors predictive of chronic renal failure (CRF) in children with severe bilateral primary vesico-ureteric reflux (VUR), observed within the first year of life and with a long follow-up. PATIENTS AND METHODS: The study comprised 50 patients presenting with grade 3-5 bilateral VUR diagnosed in the first year of life; 12 were suspected prenatally and confirmed shortly after birth, before any urinary tract infection (UTI). The mean (range) follow-up was 6.3 (1-16) years. The variables considered within the first year of life were: gender, prenatal diagnosis with no UTI, number of febrile UTIs, serum creatinine and urea nitrogen levels, metabolic acidosis, proteinuria, 24-h urine output, hypertension, bilateral renal length on ultrasonography and renal scarring on renal scintigraphy. CRF was defined as a creatinine clearance of <80 mL/min/1.73 m(2) at the last follow-up. The results were assessed using univariate and multivariate analyses (backward-stepwise multiple regression) of the selected variables. RESULTS: CRF was detected at the last follow-up in 27 patients (54%), all boys, while renal function was normal in 23 (46%; seven girls). None of the 12 patients with prenatal diagnosis had UTI, but six had CRF. Febrile UTI was the presenting symptom in 38 (76%) patients and 17 (34%) of them had renal scarring. There was no significant difference between the prenatally detected VUR and febrile UTI group in the outcome as CRF. The univariate and multiple regression analysis showed that the first serum creatinine threshold of >6 mg/L before 1 year old was the most significant risk factor for CRF (P < 0.001; odds ratio 1.25). CONCLUSIONS: Children with primary bilateral high-grade VUR and a serum creatinine of > 6 mg/L in the first year of life have a significant risk of developing CRF in the long-term. Prenatal diagnosis and postnatal febrile UTI do not modify the outcome for renal function.

Adolescent↗

PubMed2004

Renal damage in vesico-ureteric reflux.

OBJECTIVE: To detect the different extent of renal parenchymal involvement in primary vesico-ureteric reflux (VUR), and to evaluate the relationship between VUR grade, patient age and different patterns of parenchymal damage. PATIENTS AND METHODS: This blinded retrospective study included 197 consecutive children (mean age 4.26 years, range 1 month to 13 years) with primary VUR detected by voiding cysto-urethrography (VCUG), 99mTc-dimercaptosuccinic acid (DMSA; 120 MBq/1.73 m2) renal scintigraphy, with scanning for 3 h after intravenous injection. An abnormal DMSA scan was classified into three subtypes: cortical defects as a single scar (SS), multiple cortical scarring (MS) and diffuse reduced uptake with small renal size. Renal absolute uptake (AU), and split-kidney relative uptake were evaluated in refluxing and nonrefluxing renal units, and correlated with parenchymal damage and patient age. Student's t-test and the chi-square test were used for the statistical analysis. RESULTS: In all, 282 refluxing and 112 nonrefluxing units were assessed. Renal damage was detected in 188 of 282 units with VUR (67%) and in 18 of 112 (16%) contralateral nonrefluxing kidneys. The mean AU was 18.7% in kidneys with VUR and 29% in nonrefluxing units (P < 0.001). The mean (SD) AU decreased from lower to higher grades of VUR, i.e. grade 0 VUR (group A), 28.97 (9.71); grade 1-3 (group B), 21.28 (8.33); grade 4-5 (group C), 14.78 (8.02). The differences were statistically significant (A vs B, B vs C, both P < 0.001). Renal damage was differently distributed in the three groups: 69 of 109 kidneys (63%) in group C (MS prevalent), 39 of 173 (22.5%) in group B (SS prevalent) and 17 of 112 (15.2%) in group A. There was no significant difference in the distribution of renal damage subtypes in patients aged < or > 2 years (SS 19.6% vs 17.9%, MS 29.6% vs 30.1%, small size 48.2% vs 46.3%). The VUR was severe (group C) in 65% of patients aged < 2 years and in 46% aged > 2 years (chi-square, P = 0.016). CONCLUSIONS: VUR is commonly associated with renal damage. Age (< or > 2 years) did not significantly influence the kidney lesion subtype. Reduced parenchymal function (AU) progressively decreased with the severity of VUR. Focal MS, reduced size and relative uptake were significantly more common in severe VUR, leading to multifocal lesions and hypo-dysplasia. Renal scarring was present in up to 15% of contralateral nonrefluxing kidneys. Severe VUR behaved differently from lesser VUR in the renal scan parenchymal uptake.

Adolescent↗

PubMed2003

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

UNLABELLED: Authors from Rome evaluated parental preference for treatment in children with grade III VUR. Parents were provided with detailed information about the three treatment options: antibiotic treatment, open surgery, endoscopic treatment. Most parents chose endoscopic management; with this in mind, the authors proposed a new treatment algorithm for VUR. OBJECTIVE: To assess parental preference (acknowledged in treatment guidelines as important when choosing therapy) about treatments for vesico-ureteric reflux (VUR, commonly associated with urinary tract infection and which can cause long-term renal damage if left untreated), as at present there is no definitive treatment for VUR of moderate severity (grade III). SUBJECTS AND METHODS: The parents of 100 children with grade III reflux (38 boys and 62 girls, mean age 4 years, range 1-15) were provided with detailed information about the three treatment options available for treating VUR (antibiotic prophylaxis, open surgery and endoscopic treatment), including the mode of action, cure rate and possible complications, and the practical advantages and disadvantages. They were then presented with a questionnaire asking them to choose their preferred treatment. RESULTS: Most parents preferred endoscopic treatment (80%), rather than antibiotic prophylaxis (5%) or open surgery (2%); 13% could not decide among the three options and endoscopic treatment was recommended. CONCLUSION: Given the strong preference for endoscopic treatment we propose a new algorithm for treating VUR; endoscopic treatment would be considered as the first option for persistent VUR, except in severe cases where open surgery would still be recommended.

Adolescent↗

PubMed2003

[Role of the endoscopic treatment of vesicoureteal reflux. A 16-years' experience].

AIM: Vesico-ureteral reflux (VUR) is the most common urological malformation in pediatric age; nevertheless its optimal management remains controversial. Until early 80s, treatment guidelines for VUR recommended the use of antibiotic prophylaxis as initial therapy, with surgical repair for patients with persistent VUR. Endoscopic treatment of VUR has gained popularity and has proved successful in a high percentage of cases, but its role in the clinical practice remains to be established. METHODS: In this paper, our series of 1029 patients and 1478 refluxing ureters, treated from January 1986 to June 2001, is presented. Reflux ranged from grade II to grade IV. In the first 14 cases Teflon was injected. After 1989 bovine collagen was used in 442 children and, since 1996, Deflux, a nonallergenic, biodegradable dextranomer, in 573 cases. All patients were clinically evaluated for possible voiding dysfunctions. All patients completed a 12 month follow-up period. RESULTS: After 1 or 2 injections, a voiding cystogram showed no VUR (or grade I) in 1123 ureters (76%). In grade II, III and IV success rates were, respectively, 87%, 73% and 48%. Complications were minimal (0.5%). CONCLUSION: These results confirm that endoscopic treatment of VUR is a valid alternative to "open surgery" and to antibiotic prophylaxis. Failure of treatment is usually due to dislocation of the implanted material, secondary to voiding dysfunction. In conclusion, we recommend the endoscopic treatment in the majority of VUR, for the short hospital stay, the absence of significant complications and the high success rate. In grade IV VUR, the use of endoscopic treatment is still questionable. Patients with voiding dysfunction should be identified and treated with appropriate therapy prior to attempt an endoscopic treatment of VUR.

Adolescent↗

PubMed2001

Evolution of male epispadias repair: 16-year experience.

PURPOSE: We review our experience during the last 16 years, adopting different surgical approaches for epispadias repair, and compare the results of complete penile disassembly technique with perineal muscular complex reassembly since 1995 with previous repairs. MATERIALS AND METHODS: From 1984 to 1999, 58 epispadias repairs were performed in 53 male patients 3 days to 13 years old, including 18 with primary penopubic epispadias, 35 with bladder exstrophy and 5 treated with secondary genito-urethroplasty after previous repairs of the exstrophic complex. Cases were divided into 2 periods of the surgical procedure. Different techniques succeeded in 41 patients in the first decade (group 1) while the complete penile disassembly with perineal muscular complex reassembly technique was used in 17 patients during the last 5-year period (group 2). Results of both groups were compared, and Fisher's exact test was used for statistical analysis. RESULTS: Of the 41 group 1 cases complications (mostly fistula and/or urethral stenosis) in 21 (51%) required 1 or multiple operations. Continence was never achieved with urethroplasty alone. Cosmetic appearance of the phallus was not satisfactory in 23 cases (29%) and urethral catheterization was difficult in 8 (19%). Of the 17 group 2 cases only 2 complications (11%) occurred (1 fistula and 1 distal urethral stenosis). Dry intervals or voluntary continence was achieved in 6 of the 10 patients with exstrophy and in all but 1 with epispadias without bladder neck surgery. The penis had a satisfactory cosmetic appearance and no dorsal chordee with an easily catheterizable urethra was noted. The complication rate was significantly different in the 2 groups (Fisher's exact test p = 0.0042). CONCLUSIONS: The complete penile disassembly with perineal muscular complex reassembly technique, with deeper positioning of the urethra in the perineal musculature, seems to guarantee a significant step forward in functional epispadias repair.

Adolescent↗

PubMed2001

Endoscopic treatment of vesico-ureteral reflux: twelve years' experience.

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

Adolescent↗

PubMed2001

Retroperitoneal laparoscopic access in children using a direct vision technique.

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

Adolescent↗

PubMed2000

Prevalence of hypercontractility in male and female infants with vesico-ureteral reflux.

PURPOSE: To establish whether infants with vesico-ureteral reflux (VUR) have bladder dysfunction, with difference in gender, age at presentation and severity. PATIENTS AND METHODS: 37 infants (24 male and 13 female) aged 2 to 24 months with II degrees to V degrees degree VUR underwent cystometry. Of those, 10 underwent natural filling cystometry. We considered: instability and maximal voiding detrusor pressure (VDP) to be "high" when it exceeded 90 cm H2O. We defined hypercontractility as high VDP and/or instability. RESULTS: The prevalence of hypercontractility was 75% (18/24) in male and 46% (6/13) in female infants (p<0.004). High VDP was found in 50% (12/24) of male and 7% (1/13) of female patients (p < 0.001); no significant difference was found between male (25%) and female ones (38%) with instability alone. The mean VDP was significantly higher in male than in female infants (p < 0.001), in patients < 1 year of age than in older ones (p<0.001) and in severe than in moderate reflux (p<0.006). The mean voiding detrusor pressure of male infants was higher in severe (108+/-46cm H2O) and bilateral (101.3+/-44cm H2O) than in moderate (76+/-24 cm H2O) and unilateral (73.7+/-24 cm H2O) and in infants < 1 year of age (101.7+/-42 cm H2O) than in older ones (70.2+/-21 cm H2O). Natural filling cystometry confirmed the results of standard urodynamic studies. CONCLUSIONS: Bladder dysfunction is confirmed also in infants with reflux, particularly in male younger patients, and it differs in gender. The pathogenesis of congenital reflux is not always a feature of malformation of the vesico-ureteral junction; therefore, patients with bladder dysfunction must be identified early.

Female↗

PubMed2000

Is primary obstructive megaureter repair at risk for contralateral reflux?

PURPOSE: Contralateral vesicoureteral reflux occurs after successful unilateral reflux repair in a significant proportion of patients without correlation to the surgical approach. Unilateral congenital obstructive megaureter was compared to primary vesicoureteral reflux with regard to the risk of onset of contralateral reflux after unilateral ureteral reimplantation. MATERIALS AND METHODS: Unilateral congenital obstructive megaureter was diagnosed in 58 consecutive patients 2 to 10 years old (mean age 3.2). Cross-trigonal ureteroneocystostomy was performed in 57 cases and longitudinal ureteral reimplantation, according to the Politano-Leadbetter technique was done in 1. Longitudinal tapering according to Hendren was performed in 44 ureters, and the Kalicinski folding was used to repair 11 ureters. All patients underwent serial renal ultrasound, diethylenetetraminepentaacetic acid nuclear scan, excretory urogram and voiding cystourethrogram. The control group was composed of 98 age matched children with unilateral vesicoureteral reflux who underwent unilateral reimplantation with or without tapering. Fisher's exact test and Student's t test were used for statistical analysis. RESULTS: Followup ranged from 1 to 5 years. All patients in both groups underwent a voiding cystourethrogram at 6 months, and renal ultrasound at 3, 6 and 12 months postoperatively. Grade 2 reflux developed in 1 study group patient after contralateral Kalicinski ureteral folding and cross-trigonal reimplantation (1.7%). In the control group new onset contralateral reflux developed in 11 cases (11.2%). The difference was statistically significant (p <0.005, Fisher's exact test p = 0. 033). CONCLUSIONS: Ureteral reimplantation for unilateral congenital obstructive megaureter is not correlated with the development of contralateral reflux. The occurrence of contralateral reflux after successful unilateral reflux repair is high (11.2%), and is not correlated with age, sex and technique of reimplantation or tapering. These results support the hypothesis that the functional anatomy of the trigone is preserved in congenital obstructive megaureter but is impaired on both sides in cases of unilateral vesicoureteral reflux. The surgical management of unilateral primary vesicoureteral reflux and congenital obstructive megaureter should be differentiated based on these results.

Child↗

PubMed2000

Retroperitoneal laparoscopy for renal biopsy in children.

PURPOSE: We report our experience with the retroperitoneal laparoscopic approach for treating pediatric patients and when the percutaneous needle approach is not possible due to uncontrolled hypertension, bleeding disorders, anti-clotting medications and anatomical abnormalities. MATERIALS AND METHODS: Retroperitoneal laparoscopic renal biopsy was performed in 20 patients 2 to 18 years old (mean age 9.7) during a 16-month period. At the same time 53 percutaneous needle biopsies and 1 open biopsy were performed. The child is in a flank position, and 2 trocars are used via a direct vision approach. The first trocar is 12 mm. in diameter and positioned on the posterior axillary line, and the second trocar is 5 mm. in diameter and is entered 4 cm. anteriorly. Gentle dissection is done to free the lower pole of the selected kidney, biopsy forceps are used to grasp the specimen under direct vision and the biopsy site is fulgurated using bipolar electrocautery. RESULTS: Biopsy was performed successfully in all cases except 1, which was converted to an open procedure. Mean operative time was 40 minutes, blood loss was minimal and mean hospital stay was 1.2 days postoperatively. No pain medication was required postoperatively, and all patients returned to their usual activities within 3 to 5 days. A minor intraoperative complication, which was a peritoneal tear with no postoperative sequelae, occurred in 1 case. CONCLUSIONS: The retroperitoneal laparoscopic technique is simple and safe, and does not require extensive laparoscopic experience. We believe that this approach is reliable, and has less morbidity and several advantages compared to open surgery. It should be selected as the first choice for treating pediatric patients when percutaneous needle renal biopsy is contraindicated.

Adolescent↗

PubMed2000

Periurethral muscle complex reassembly for exstrophy-epispadias repair.

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

Bladder Exstrophy↗

PubMed1999

Low-dose desmopressin in the treatment of nocturnal urinary incontinence in the exstrophy-epispadias complex.

OBJECTIVE: To report our experience of the use of desmopressin to improve nocturnal dryness in patients who have undergone a staged reconstruction of the exstrophy-epispadias complex (EEC), who although continent by day, have nocturnal incontinence because their nocturnal urinary output exceeds their bladder capacity. PATIENTS AND METHODS: Seven children (aged 8-12 years) who had undergone a staged reconstruction for EEC (six with classical bladder exstrophy, one with incontinent epispadias) were treated with intranasal desmopressin for persistent nocturnal incontinence despite daytime dryness. Previous additional procedures for continence had been self-augmentation in one and periurethral collagen injection in three others. The criteria for inclusion in the study were: normal renal function, no upper tract deterioration, no urinary tract infections, spontaneous voiding during the day with dry intervals between micturitions, a postvoid residual volume of <10% of bladder capacity and night-time incontinence for 7 nights/week. Desmopressin was administered at bedtime at increasing dosages from 10 to 30 microg until effective. Body weight, arterial blood pressure, and serum electrolytes were measured, and all patients assessed using renal ultrasonography, a voiding diary and a nocturnal pad-test. RESULTS: Desmopressin at doses of 10-30 microg was successful in keeping all the patients dry. The nocturnal urinary output was decreased so that it did not exceed bladder capacity. There was only one minor side-effect (nose bleeding). CONCLUSIONS: In selected patients with EEC, desmopressin is effective in improving nocturnal dryness, with no significant side-effects.

Bladder Exstrophy↗

PubMed1998

Detrusor hypocontractility in children with posterior urethral valves arises before puberty.

OBJECTIVES: To assess prepubertal boys with posterior urethral valves (PUV) using an analysis of pressure-flow studies to evaluate the voiding phase and thus determine if myogenic failure (hypocontractility) arises before puberty and if it can be detected early. PATIENTS AND METHODS: Eleven boys (8-13 years old) with PUV underwent urodynamics and the results were analysed using pressure-flow mathematical analysis (PFA) of the following variables of detrusor activity: contraction velocity (Vdet), detrusor contractile power expressed as power factor (WF) and Schafer's diagram, which differentiates a 'strong', 'normal' and 'weak' detrusor. Vdet and WF were compared with normal values previously determined in boys of similar age and considered 'low' if more than 2 SDs below the mean. The results of PFA were compared with standard pressure-flow studies and the three classical urodynamic patterns in boys with PUV, as determined by voiding symptoms. The subsequent PFA of seven of the 11 boys were also assessed as they had undergone previous urodynamics when < 8 years old. RESULTS: As assessed by the three patterns of dysfunction, two boys had bladder instability, two had low compliance and three had hypocontractility, with four boys being normal. From the PFA, the Vdet and WF were lower than normal, respectively, in seven and nine of the 11 boys; Schafer's nomogram showed a 'weak' detrusor in seven boys. The PFA suggested a pathology in four of five boys with symptoms and in three of six with no symptoms (two of the six showing a 'low' WF). Moreover, in older (11-13 years) boys, all five had a 'weak' detrusor, a 'low' WF and four a 'low' Vdet. Of the seven patients who underwent repeat PFA, three had a stable WF 3 years later, one (normal) worsened slightly and two were clearly worse, while one, who underwent late (at 3 years old) valve ablation, had an increased WF. CONCLUSIONS: The PFA showed hypocontractility in two-thirds of prepubertal boys with PUV, including asymptomatic patients. These findings confirm the hypothesis that bladder dysfunction in boys with PUV eventually causes detrusor myogenic failure and finally a postpubertal overdistended bladder.

Adolescent↗

PubMed1997

Combined heart and kidney transplantation in a child: will we need it more in the future?

A 12-year-old girl affected by idiopathic dilated cardiomyopathy and renal failure was referred to our institution for cardiac transplantation. A simultaneous heart-kidney transplantation from the same donor was decided. The immunosuppression schedule consisted of azathioprine, antithymocyte globulin, steroids, and cyclosporine. At a follow-up visit at 24 months after transplantation, no episodes of heart or kidney rejection had occurred and cardiac and renal function were good. Concomitant failure of heart and kidney is well known in the literature, but it appears to be more frequent in adult as compared with the pediatric population. This is the first case of combined heart and kidney transplantation in a child. Because of the successful outcome and good follow-up, the number of combined organ transplantations will most likely increase in the future.

Cardiomyopathy, Dilated↗

PubMed1997

Occult spinal dysraphism: neurogenic voiding dysfunction and long-term urologic follow-up

From 1976 to 1994, we followed 55 children with occult spinal dysraphism (OSD). The average age at diagnosis was 4.5 years (range: 24 days - 21 years). In 13 cases the OSD was associated with anorectal anomalies. Urologic symptoms were present at diagnosis in 24 children (43%), but urinary incontinence affected all patients in the evolution of the OSD. At diagnosis, all children underwent complete neurourologic and urodynamic evaluation. Nine required early neurosurgical correction, before 3 years of age. During follow-up, intermittent clean catheterization was started in all patients. Vesicoureteral reflux was present or developed in 17 patients: 15 underwent endoscopic procedures and 2 required bladder augmentation because of upper-tract and renal-function deterioration. Endoscopic treatment for urinary incontinence was performed in 3 children. At long-term follow-up (6 to 18 years), socially acceptable continence was achieved in 78% of the children; renal failure occurred in 8. The long-term results were analyzed in order to compare the evolution of urinary continence and renal function in children with OSD with or without neurosurgery.

Journal Article↗

PubMed1997

Contralateral ureteral meatal advancement in unilateral antireflux surgery.

PURPOSE: Contralateral vesicoureteral reflux is a well-known development after successful unilateral ureteral reimplantation that is not apparently influenced by the reimplantation technique. We sought to determine whether bilateral reimplantation should be performed routinely in unilateral cases. MATERIALS AND METHODS: From 1984 to 1995 we performed contralateral ureteral meatal advancement in 53 children 1 to 9.5 years old (mean age 2.5) undergoing surgery for unilateral grades II to V vesicoureteral reflux, including 12 with reflux in duplex systems. Ureteral meatal advancement involves a transverse Y shaped mucosal incision from the nonrefluxing orifice to the opposite hemitrigone. The inferior half of the ureteral orifice is then advanced toward the midline using 3 or 4 long-term resorbable sutures. The control group included 98 children who underwent unilateral surgery for grades II to V reflux from 1990 to 1995. RESULTS: No evidence of vesicoureteral reflux was observed in the 53 children who underwent contralateral meatal advancement. There was no obstruction or other complications. At followup contralateral reflux was found in 11 controls after unilateral reimplantation. CONCLUSIONS: Contralateral reflux has been reported in up to 27% of previously reported cases and in 11% of our control group after successful unilateral antireflux surgery. Contralateral ureteral meatal advancement has proved effective for preventing reflux in 100% of cases. It requires minimal invasion of the nonrefluxing ureter, and little additional operative time and cost.

Child↗