Long-term bladder function, fertility and sexual function in patients with posterior urethral valves treated in infancy

OBJECTIVE

To address the issue of sexual function and fertility in PUV patients.

PATIENTS AND METHODS

Of 47 patients (age > 18 years) treated for PUV in infancy 28 were contactable. They were sent a standard questionnaire requesting details on voiding dysfunction symptoms, and experience of erection, orgasm and ejaculation.

RESULTS

Of the 28, 16 (mean age 24 years) returned the questionnaire. Voiding frequency ranged from 3 to 10 times per day (mean = 5). Two patients had occasional mild diurnal incontinence but none had symptoms of overactivity. Three patients had a weak urinary stream. Renal function was normal in 9, 4 had a glomerular filtration rate <80 ml/min/1.73 m(2), and 3 had undergone renal transplant. Erections and orgasm were experienced by the 15 patients who responded to these questions, with 4 reporting mild or medium erectile dysfunction and 1, on dialysis, reporting slow ejaculation. Post-masturbation samples of semen and urine were collected from 6 patients. One had an alkaline pH, high percentage of immotile sperm and low sperm count. Another had a high concentration of abnormal forms, and seminal fluid was present in the urine of 3 patients.

CONCLUSIONS

In long-term follow-up, 44% of PUV patients develop chronic renal failure or end-stage renal disease, but bladder dysfunction symptoms are infrequent. Sexual function is mostly normal. Total semen counts and motility are compatible with paternity in most patients.

[Strategy for high cavoatrial tumor thrombus in children with nephroblastoma]

INTRODUCTION

Wilms tumor surgery with intracaval-atrial extension is a challenge. Modern imaging techniques, precise preoperative thrombus location, and multidisciplinary surgical approach is mandatory. We aim to evaluate the outcome of our patients.

PATIENTS AND METHODS

Between 1992 and 2005, 52 patients with nephroblastomas underwent surgery in our institution. Nine of them had renal-caval (RC) or cavo-atrial(CA) thrombus extension. Four patients presenting short RC intravascular extension were excluded.

RESULTS

All cases were treated with pre-postoperative chemotherapy SIOP protocols. The level of the extension was retrohepatic in 2 cases, atrial in 3 patients and it even reached the ventricle in 2 of them. A multidisciplinary team was necessary to plan surgery and in all patients thrombus and tumor could be removed under cardiopulmonary by-pass in 3 cases (CPBP). One pulmonary tamponade due to thrombus migration (CAV) occurred and was solved by CPBP. Three cases were stage III, one stage IV and 1 stage II. Conclusions. Tumor size can be significantly reduced by preoperative chemotherapy. In case of CA extension, CPBP and right liver displacement to gain access to retro-hepatic cava are mandatory in order to reduce surgical complications.

[Contrast-enhanced sonourethrography versus conventional miction cystourethrography in the assessment of the urethra: preliminary study]

BACKGROUND AND AIMS

Voiding cystourethrography (VCUG) is the first choice imaging modality for assessing the urethra, but this technique exposes patients to ionizing radiation. Cystosonography with echocontrast (CS) has proved to be a reliable technique to detect and grade vesicoureteral reflux (VUR) without exposing patients to ionizing radiation, but its capacity to adequately study the urethra has yet to be demonstrate in large series of patients. The aim of this study is to demonstrate the reliability of contrast-enhanced CS for assessing the urethra by comparing the results with those of the VCUG.

MATERIAL AND METHODS

108 patients were studied with ultrasound (US) using a galactose-based contrast agent. This exam was always followed by VCUG. Basal and voiding urethral US studies were performed with. Patients were studied in supine decubitus position. Girls were examined by longitudinal translabial approach, with the probe (a 7.5 MHz liner array transducer) positioned longitudinally at the introitus, to evaluate the bladder neck and urethra. In boys the transducer was initially placed longitudinally in the escrotum at ventral root of the penis to assess the bladder neck and proximal bulbar urethra, and then displaced distally toward the penile urethra. On basal study the echogenic urethral mucosa and the collapsed sonolucent urethral lumen were indentified and measured when distended. The patients were asked to void with the probe in place. During voiding attention was focused on elasticity and distention of urethral walls, as well as in the caliber of the entire urethra. Patients unable to void during either CS or VCUG were excluded.

RESULTS

The bladder neck and the entire urethra were well demonstrate with CS. All females and 43 males showed a normal urethra both in CS and VCUG. Four patients were dignoses of posterior urethral valves (PUV) with CS and confirmed at VCUG, one patient had anterior urethral valves and 5 showed urethral stenosis at both techniques. Three patients with a vesicosphincteric dysinergia, 14 with resected PUV and one with a resected syringocele were adequately evaluated. Twelve girls showed vaginal reflux. The information provided by CS was equivalent to the VCUG in all patients but two with a syringocele (only seen on VCUG).

CONCLUSIONS

CS is a reliable imaging modality sufficiently sensitive and specific to study the urethra, adding dynamic information to VCUG and can be used as a complement to VCUG.

[The long-term behavior of the valve bladder as a function of the initial treatment and its effect on early kidney failure]

In approximately 25-40% of infants presenting with posterior urethral valves (PUV) renal insufficiency will develop before adolescence. In some these patients, renal dysplasia, bladder dysfunction and mismanagement may precipitate renal failure at even earlier age. The goals of this study were to determine whether long-term bladder dysfunction was more frequent in children who underwent early temporary pyelostomy than in those who underwent valve ablation, and to know if bladder dysfunction and mismanagement, in some patients, could be responsible of early renal failure. Urodynamic studies were performed in 59 boys with severe PUV divided into two groups based on initial treatment. A) Valve ablation (30 p.); B) Cutaneous pyeloureterostomy (29 p.). At the end of the study 22 boys had chronic renal failure. Of the 59 boys, 42% (25 p.) had bladders with overdistended or normal behaviour, 58% (34 p.) had bladder dysfunction (instability 37%, low compliance 15%, myogenic failure 5%). The 89% of low compliance bladders, 66% of myogenic failure and 23% of those with instability were in CRF. No difference at all was found in bladder function between boys treated as neonates by high diversion or valve ablation. Of the group in chronic renal failure (22 p.), only 7 patients (32%) had bladders with normal behaviour and in five of these patients a mismanagement was directly related with a quicker renal deterioration. The 58% of our boys with severe PUV have some type of bladder dysfunction. Neonatal pyelo-ureterostomy does not increase long-term bladder dysfunction. Surgical mismanagement should be added to bladder dysfunction as contributors to earlier renal failure.

[Augmentation cystoplasty for severe uropathy in children]

We present our experience in seven patients (three boys and four girls) with bladder augmentation. Two patients had a neurogenic bladder, two a "nonneurogenic" neurogenic bladder and three a bladder exstrophy. Between the exstrophy patients, two had a rectocistoplasty and one a colon conduit diversion. The rest of patients (two neurogenic bladders and two "nonneurogenic" neurogenic bladder) had a colon conduit diversion. The intestinal segment used for bladder augmentation were ileocecal sement (two patients), ileon (one patient) and colon sigmoid (four patients). Bladder augmentation were tubularized in four patients and detubularized in three. In the follow-up, five patients have a normal renal function (one transplanted), one patient his function is unchanged and other is waiting for the transplant. Of the seven patients, six are fully continente day and night (two with CI and one with anticholinergic drugs) and one has a diurnal continence no more than two hours.

[Midterm evolution in the uropathy patient receiving a kidney transplant]

The outcome of renal transplantation was examined in 17 pediatric patients, whose primary renal disease was uropathy. The results indicate that the outcome of renal transplantation in patients with posterior urethral valves, reflux nephropathy, neurogenic bladder or bilateral ureterocele is similar to that the other transplant recipients. Urologic complications will not occur with increased frequency. Allograft survival rate during a period of four years is comparable to that of our entire transplant population.

[Should kidney grafts from donors less than 3 years old be used?]

In order to determine the results of renal transplantation using pediatric donors younger than three years of age, a retrospective analysis of a series of 43 transplant recipients was carried out. Methods of immunosuppressive regimen were similar for all patients. They are divided into two groups. Whose donors where younger than three years of age and older than three years. Actuarial graft and patient survival, causes of graft failure, surgical and postoperative complications were compared without significant differences between groups. The results support the contention that pediatric patients younger than three years should be considered to be potential cadaveric kidney donors.

[Ectopic ureter in the seminal vesicle. An unusual presentation]

An unusual case is presented of an ectopic ureter opening into a seminal vesicle associated with ipsilateral renal dysplasia in a 17-month-old boy. During the neonatal period, he had been diagnosed as having right renal agenesia. The patient presented with a rapidly growing tumor, a rare presenting symptom that led to misdiagnosis.