Outcome analysis of vesicoureteral reflux in children with myelodysplasia

PURPOSE: Vesicoureteral reflux in children with myelodysplasia is usually secondary to abnormal bladder storage. The purpose of this study was to assess the outcome of vesicoureteral reflux in children with myelodysplasia. MATERIALS AND METHODS: We retrospectively analyzed the records of 319 children with myelodysplasia who presented to our institution between 1978 and 1985. Of these children 95 presented with or had reflux during followup and they were treated with prophylactic antibiotics. Clean intermittent catheterization and anticholinergic medication were added to the regimen when indicated. RESULTS: Reflux resolved in 63% of these patients with nonsurgical management. Temporary cutaneous vesicostomy was performed in 23 children (24%) with persistent high grade reflux or evidence of upper tract deterioration. Ureteral reimplantation and augmentation cystoplasty were performed in 18 (20%) and 8 (8%) patients, respectively. No patient had progression to chronic renal failure and scars developed in only 14 kidneys (10%). CONCLUSIONS: In the majority of cases (63%) reflux resolved with nonsurgical management. Reflux in these patients should not be treated in isolation. The management of reflux is primarily aimed at improving bladder storage. The combination of aggressive nonsurgical therapy and close observation is recommended. This regimen leads to the satisfactory resolution of reflux with minimal renal morbidity.     

Intermittent trimethoprim-sulfamethoxazole in children with vesicoureteral reflux

One hundred and twelve forearms in 56 preserved cadavers were dissected to assess the incidence of Martin-Gruber connections in a population in South Africa. The connections were found in 13 cadavers (23%) and one was bilateral. There were no significant racial or sexual differences in the incidence. The course of Martin-Gruber connections and their anatomical relationship with the ulnar artery are illustrated.     

Medullary nephrocalcinosis associated with vesicoureteral reflux

A case of medullary nephrocalcinosis developing in the course of vesicoureteral reflux is described. It is suggested that the probable mechanism of nephrocalcinosis was the stagnation of urine in collecting tubules favouring precipitation of calcium salts.     

Results of antireflux surgery in infants with vesicoureteral reflux

The mechanism underlying the reduced Cu status in rats fed on a high-sulphide diet was investigated. Male rats aged 6 weeks were fed ad libitum on purified diets containing either 0 or 500 mg S2-/kg and demineralized water for a period of 2 weeks. The high-sulphide diet had no effect on feed intake, body-weight gain or weight of liver and kidney but significantly reduced Cu concentrations in plasma and kidney. Biliary Cu excretion was decreased significantly in rats fed on the high-sulphide diet. Apparent Cu absorption (Cu intake-faecal Cu) and true Cu absorption (Cu intake-(faecal Cu-biliary Cu)) were significantly lowered after sulphide feeding for 2 weeks. Rats fed on the high-sulphide diet excreted less Cu in urine than did the controls. We conclude that high sulphide intake reduces Cu status in rats through inhibition of Cu absorption which is reflected by a decrease in biliary Cu excretion as a secondary feature.     

Disappearance of vesicoureteral reflux in children

OBJECTIVE: To describe the disappearance of reflux in children with vesicoureteral reflux, in whom there are presently no population-based long-term studies. DESIGN: An unselected cohort of children with reflux detected after their first known symptomatic urinary tract infection was followed up prospectively for up to 15 years. SETTING: A single children's hospital in a distinct geographical area at which most children with symptomatic urinary tract infection were treated. PATIENTS: Two hundred thirty children--173 girls and 57 boys--with unilateral (n=130) and bilateral (n=100) reflux. Dilated reflux (grades III-V) was found in 54 patients (23.5%). The frequency of reflux was 34% in girls and 31% in boys who were examined after urinary tract infection. MAIN OUTCOME MEASURE: Disappearance of reflux. RESULTS: The probability of spontaneous disappearance of reflux was estimated using Kaplan-Meier survival curves based on 164 children who underwent multiple voiding cystourethrographies. There was a marked tendency for disappearance of reflux, with 73% of children with dilated reflux having no or only grade I reflux after 10 years. Shorter persistence of reflux was found in children with undilated reflux at the initial investigation and in boys compared with girls. However, age at first investigation was not related to the rate of disappearance, and there was no difference between children with bilateral compared with unilateral reflux. CONCLUSIONS: This study of an unselected group of children with urinary tract infection shows a favorable long-term outcome concerning disappearance of reflux. In children with dilated reflux, this tendency was more pronounced than previously reported.     

Prevalence of hypertension in children with primary vesicoureteral reflux

The role of aluminum accumulation in articular tissues of patients affected by dialysis-associated arthropathy (DAA) is questioned. The aim of this work is to identify the nature of these aluminum accumulations by the use of secondary ion mass spectrometry (SIMS). Al/Si ratios of about 1, measured by SIMS, strongly suggest for the first time the presence of aluminum silicates and possibly aluminum hydroxides in amyloid synovial tissue and articular cartilage of 1 patient with DAA and aluminum intoxication. This is thermodynamically consistent with the total dissolved Al and Si contents and pH measured in the synovial fluids. These results are similar to the abnormal Al distribution recently found by SIMS in the forebrain of chronic renal dialysis patients and to the amorphous aluminum silicates identified in the core of senile plaques in Alzheimer's disease.     

Evaluation of polydimethylsiloxane as an alternative in the endoscopic treatment of vesicoureteral reflux

Endoscopic correction of vesicoureteral reflux is an attractive alternative to open repair. In terms of effectiveness and long-term successful results polytetrafluoroethylene (Polytef) is the most reliable injectable product. However, legitimate concerns regarding particle migration still exist for polytetrafluoroethylene. Polydimethylsiloxane (Macroplastique) was evaluated as an alternative to polytetrafluoroethylene. Seven mongrel female dogs underwent endoscopic suburothelial injections of 0.35 to 0.50 cc polydimethylsiloxane paste by the O'Donnell technique to a unilateral nonrefluxing ureteral orifice. To facilitate migratory surveillance the paste was mixed with 57carbon monoxide radiolabeled 80 microns. microspheres and injected in 5 of the 7 animals. Animals were sacrificed at 1, 3 and 6-month intervals. All major organs were retrieved and processed. After intensive histological evaluation the remaining tissue underwent dissolution and centrifugation in sodium hypochlorite. The resulting insoluble pellet was further analyzed. In dogs injected with radiolabeled paste tissue samples and insoluble pellets of each organ system were analyzed for gamma counts. Smears of the insoluble pellets of all animals were examined on light and phase contrast microscopy. At autopsy no gross abnormalities were noted. Tissue reaction at injection sites revealed a well encapsulated foreign body reaction with predominantly giant cells, fibroblasts and collagen deposition. Limited local migration of polydimethylsiloxane particles into the periureteral lymphatics of 1 animal sacrificed at 1 month was noted and a single particle visually indistinguishable from polydimethylsiloxane also was found within the splenic capsule. The endoscopic procedure in this animal was complicated in that 2 separate injections were required and histological evaluation confirmed that the injections were performed uniquely deep into the bladder muscularis. Radioactive counts and dissolution of all major organ systems demonstrated no migration in the remaining 6 animals. Endoscopic subureteral injection of polydimethylsiloxane is technically feasible, and it may prove to be biocompatible and without risk of distant migration if injected correctly.     

Hypertension as complication of vesicoureteral reflux in children

Eight cases are reported of female children presenting with hypertension and found to have primary vesicoureteral reflux with chronic pyelonephritis. In 6 patients renal function was essentially normal while 2 had azotemia and progessive renal deterioration. As a result of early surgical intervention in the form of antireflux procedures, occasionally combined with unilateral nephrectomy for renin-dependent lesions, 5 of the 8 had complete disappearance or amelioration of hypertension with stabilization of renal function. The interactions of each member of the triad--vesicoureteral reflux, pyelonephritis, and hypertension--are reviewed with emphasis on pertinent pathophysiologic concepts regarding their roles in the production of progressive renal deterioration.     

Extravesical repair of primary vesicoureteral reflux in children

An operative procedure for the repair of primary vesicoureteral reflux in 51 children (83 renal units) is described, its merits are discussed and its advantages are stressed. Reflux was prevented in 90.2 per cent of the children and 74.5 per cent of the patients remained free of infection. No obstruction has occurred in our series as compared to a 5 per cent incidence rate in cases of ureteroneocystostomy. Our procedure is not recommended for megaureters with reflux or for recurrent vesicoureteral reflux.     

Management considerations for treating vesicoureteral reflux in children with solitary kidneys

OBJECTIVES: To evaluate the management approach for vesicoureteral reflux (reflux) into a solitary kidney. METHODS: Outcomes of all children with solitary kidneys and reflux managed between 1981 and 1996 were reviewed. Solitary kidneys were documented by nuclear renography and ultrasonography; reflux was graded after cystography. Management consisted of observation and antimicrobial prophylaxis or surgery by ureteroneocystostomy or subureteric injection of polytetrafluoroethylene (STING). Follow-up ranged from 3 months to 14 years and included serial cystography, sonography, and serum creatinine measurement. RESULTS: Twenty-one patients with a median follow-up of 26 months were identified. Etiologies included contralateral renal agenesis (14 children), multicystic dysplastic kidney (5 children), or nonfunctioning ureteropelvic junction obstruction (2 children). Low-grade (I to II) reflux was identified in 6 children, and high grade (III to V) was identified in 15. Reflux resolved in 20 patients. Five children with low-grade reflux were managed without surgery and demonstrated reflux resolution after a mean of 20.5 months. Renal function deteriorated in only 1 child. Ureteroneocystostomy was performed in 13 children with grades III to V reflux, and STING was performed in 1 child with grade II reflux. Every surgical patient maintained stable renal function and was infection-free during a mean follow-up of 56 months. Management by observation in 2 children with grades IV to V reflux resulted in spontaneous resolution in one and stable grade IV in the other. CONCLUSIONS: Reflux into the solitary functioning kidney may be managed by the same strategies used to manage unilateral reflux in children with two normally functioning kidneys: low-grade reflux by observation/ chemoprophylaxis until spontaneous resolution occurs, and higher grades by surgery to protect renal function; however, chemoprophylaxis and serial imaging may be used until well-defined indications for surgery are satisfied. Renal function should be monitored diligently.     

Endoscopic correction of vesicoureteral reflux by subureteric Teflon (polytetrafluoroethylene) injection: review of 6-year experience

In literature data, an uncertainty exists whether occurrence of bilateral breast cancer decreases the survival probability of affected patients. Therefore, we analyzed the medical records of 498 postoperatively irradiated (1977-1982) female breast cancer patients (T1-4,N0-3,M0). In the follow-up time, in 36 patients a bilateral breast carcinoma treated by surgery with or without radiotherapy was found. The 10-year overall survival rates were 54% in patients who had unilateral disease, compared with 56% in bilateral carcinoma patients, respectively. The incidence of metastasis did not differ between both groups: 24.2% versus 38.8%. Eleven percent of unilateral cancers recurred; in the other group, local failure of the first and second tumor was observed in 19.4% and 11.1%, respectively. We conclude that the occurrence of bilateral breast cancer has no significant impact on survival, although the development of local failures and metastases seems to be more frequent. The therapeutic strategy in bilateral carcinoma should resemble the treatment procedure in unilaterally affected patients.     

Follow-up results of modified Glenn-Andersen operation in children with primary vesicoureteral reflux

A questionnaire survey covered 11 females with temporal arteritis (CA) and 20 healthy controls. Gastrointestinal, joint and spinal complaints were significantly more frequent in CA patients. Clinical characteristics of joint and spinal disorders in CA patients are close to those of chronic reactive arthritis. It is suggested that Horton's disease may be lacking as a stage of the infectious process in elderly patients (chronic intestinal and/or urinary infection-reactive arthritis-CA). A case is reported where CA developed after intestinal and urinary infection. Administration of antibiotics for treatment of the recurrence induced a continuous remission under reduced doses of glucocorticoids. In another case biseptol + glucocorticoids brought about a persistent remission allowing glucocorticoid discontinuation.     

Endoscopic treatment methods in patients with the postcholecystectomy syndrome

458 patients with postcholecystectomy syndrome have been examined. In 289 (63.1%) of them the reason of complication and location of the lesion in biliopancreatic-duodenal zone have been specified. In 212 (73.4%) patients the endoscopic treatment was used, including papillosphincterotomy with removal of concrements; suprapapillary choledochoduodenostomy; nasobiliary draining, endoprosthesis. In 181 (85.4%) of cases these methods appeared to be efficient and final; in 31 (14.6%) they promoted stabilization of clinical status of patients and performing surgery in more favorable conditions. Complications have been registered in 4 (1.9%) patients, 1 patient (0,47%) died. The authors advocate endoscopic methods as methods of choice in postcholecystectomy syndrome.     

Bladder malfunction, urinary tract infection and vesicoureteral reflux in children

A correlation between urinary tract infection, vesicoureteral reflux and voiding disorders has increasingly been reported. Voiding dysfunction increases the incidence of recurrent urinary tract infection, induces and perpetuates vesicoureteral reflux, even after surgical antireflux treatment, and may result in permanent renal damage. The resolution of the primary cause with voiding normalization is essential to achieve good results in the treatment of secondary problems such as urinary tract infection and vesicoureteral reflux. Thirty seven children with vesicoureteral reflux secondary to voiding disorders were diagnosed and treated between 1990 and 1995 (five years). Forty-nine ureters were studied. The subjects became symptomatic between 1 month and 13 years of age, with the occurrence of urinary tract infection. All children were neurologically and morphologically normal. Symptoms suggesting bladder instability were detected in 34 (91.9%) and dysfunctional sphincter obstruction in three (8.1%). These patients were all evaluated with a renal/bladder sonogram and voiding cystogram, complemented in 17 (45.9%) with urodynamic testing that confirmed clinical diagnosis. 99mTc-dimercaptosuccinic acid renal scans performed on 29 (78.4%) children revealed renal damage in 26 (89.6%). A treatment program of bladder retraining and bowel habit normalization was encouraged in every child, anti-cholinergic drugs were associated in 23 (62.2%), muscle-relaxant drugs in three (8.1%), phenoxybenzamine and intermittent catheterization were used in one child (2.7%). Urinary tract infection prophylaxis was instituted in 34 (91.9%) children. Urinary tract infection was completely resolved in 35 (94.6%) patients, and its frequency decreased in two (5.4%). Thirty-two children (86.5%) with vesicoureteral reflux were cured and four (10.8%) were improved. Evidence of voiding disfunction ceased in 22 (59.5%) cases and improved in 14 (37.8%) with a reduction in the frequency and intensity of complaints. Urgency syndrome and vesicoureteral reflux remained unchanged in one child (2.7%). These findings imply that detection and treatment of bladder/sphincter disfunction are essential in every child with the complex of recurrent urinary tract infection and vesicoureteral reflux.     

Mild renal pelvic dilatation is not predictive of vesicoureteral reflux in children

OBJECTIVE: To determine if mild renal pelvic dilatation at renal ultrasound (RUS) is a reliable sign of vesicoureteral reflux (VUR) at voiding cystourethrogram (VCUG) in children. MATERIALS AND METHODS: All patients less than 10 years of age who had RUS and VCUG on the same day during a 2-year period were identified in a computerized database. The appearance of the collecting system of each kidney was classified into two groups: group 0 - no dilatation (相似文献   

Primary vesicoureteral reflux in childhood. The current aspects and future outlook

OBJECTIVE: To discuss the current aspects and the impact of innovations on the clinical, diagnostic and therapeutic aspects of vesicoureteral reflux (VUR). METHODS: The literature on Medline over the last five years are reviewed and the urodynamic findings in our series of children with VUR are analyzed. RESULTS: Fetal VUR and those diagnosed in children with a family history are currently considered to be the most interesting study groups from the clinical perspective. Renal scintiscanning, isotope-labelled cystography and urodynamic evaluation are well-established diagnostic methods that permit selecting the most appropriate treatment for patients with this anomaly. In our experience, 50.8% of the 128 patients in whom a urodynamic study was performed, showed changes in lower urinary tract function. Innovations in open surgery have been scanty and endoscopic treatment is increasingly utilized, although the search continues for the ideal biological material. CONCLUSIONS: The new diagnostic methods utilized in the evaluation of children with VUR will permit a better understanding of the natural history of this anomaly lead to changes in the protocols that are currently used.     

Endoscopic treatment of vesicorenal reflux in children. Five-year assessment of the use of Macroplastique

Cadmium, unlike zinc, selenium and copper, has no known biological importance, and therefore, it is classified as a carcinogen in humans, as well as in animals. The effect(s) of levels of dermally-administered cadmium on cadmium genotoxicity and cytotoxicity was investigated in Harlan Sprague-Dawley rats for 14, 21, 28, 35 and 42 days at concentrations of 14 and 28 mg/kg/day. Exposure of rats to cadmium via dermal application caused lesions on the skin (hyperkeratosis, acanthosis and scabbing, alopecia and erythema) and tumors in the scrotum. Anatomical changes, such as distention of the stomach, atrophy of kidney and liver and loss of body weight were also observed in these rats. The toxic effects of cadmium on cell ultrastructure were nuclear membrane damage, chromatin condensation, regression of mitochondrial cristae and ultimately cell death. Analyses of the brain, kidney and liver cells of rats exposed to cadmium, clearly showed DNA damage. Of the three organs examined, DNA from kidney cells sustained the most damage followed by DNA in liver cells. There is a positive correlation between Cd dose(s) and duration of exposure and the extent of DNA damage.     

Endoscopic trigonoplasty for primary vesico-ureteric reflux

OBJECTIVE: To investigate the surgical results of endoscopic trigonoplasty in patients with primary vesicoureteric reflux. PATIENTS AND METHODS: Records were reviewed for 12 patients who underwent endoscopic trigonoplasty between February 1992 and February 1994. Of the 12 patients, 11 were female; one was a child and nine had unilateral disease. From 15 renoureteric units, grade I vesico-ureteric reflux was demonstrated in five, grade II in six and grade III in four. The ureteric orifices were approximated close to the midline via the urethral route and two trocars on the abdomen achieved pneumobladder. RESULTS: The mean surgical time was 178 +/- 52 min; this lessened as the learning curve developed. Intra-operative complications in three patients were all caused by trocar placement. Eleven patients required analgesics for one post-operative day only. No post-operative dilatation of the upper urinary tract was demonstrated. Vesico-ureteric reflux was eradicated in all patients. CONCLUSIONS: Endoscopic trigonoplasty is a minimally invasive procedure with a high cure rate. By not destroying the normal vesico-ureteric junction, post-operative obstruction cannot occur. We believe that endoscopic trigonoplasty is a feasible procedure for patients with vesico-ureteric reflux.