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In 1986 Kropp et Angwafo described a technique of urethral lengthening for the treatment of urinary incontinence in children with neurogenic bladders. We have used a modified version of this procedure in 22 girls between 1986 and 1990. Here we report its mid and long term effects on continence. The problems we have encountered in these patients are discussed.

The aim of this work was to discuss general ideas concerning the factors which should be taken into account for the treatment of hypospadia including: anatomy, preoperative work-up, analysis of the anatomic type, patient status, search for an underlying more complex malformation. Precise indications for per and post-operative care should provide good results. Two major ideas predomination in these recommendations: operate early (at about 2 years) in a single procedure for both anatomic and psychological reasons. This latter point is particularly important. Operative technique is illustrated and described together with complications and their management.

35 children and adolescents were submitted to ureterocalicostomy for PUJ obstruction. The surgical procedure is explained and specially the importance of performing a regular, muco-mucosal anastomosis to avoid its secondary stenosis. 9 patients have an excellent result with absence of clinical symptoms, sterile urinalysis and normal IVP. 20 patients have a good result with absence of clinical symptoms, sterile urinalysis and improvement of the dilatation of the cavities. 2 secondary nephrectomies have had to be performed because of a dysplastic kidney (1 patient) or of a parenchymal infection (1 patient). 2 patients have no clinical symptoms but have no improvement of their IVP. 3 kinds of indications have been distinguished: failures of previous surgery of the PUJ (5 patients); PUJ obstruction associated with congenital kidney abnormalities as horseshoe kidney (15 patients) and malrotation (3 patients); severe PUJ obstructions with a very thin parenchyma (12 patients). Ureterocalicostomy appears to be a helpful procedure in some defined situations where a declive drainage of the urine essential. No late deteriorations have been recorded in this series.

In order to clarify the indications of MAGPI procedure (Meatal Advancement and Glanuloplasty Incorporated), 18 patients operated upon have been reassessed after a long follow-up (mean: 30 months). The cosmetic and functional results are good in 16 cases, 2 non-satisfactory results are noticed with a wrong meatal position. The initial position of the meatus (glanular or coronal), the absence of chordee and the initial aspect of the glans (broad and flat) are the three main conditions to obtain a good result.

We found silicone foam elastomer (produit by C.M.H. lab.) to be an excellent post-operative penile dressing. Although compressive the material is elastic enough to avoid ischemia and to allow slight swelling of the penis. Soft, light, it is never adherent to the wound and, thus, is removed easily without discomfort to the patient.

Unlabelled: Continent vesicostomy using appendix has been performed in 30 incontinent children (myelo-meningocele). Surgical technique is described laying stress on the closure of the bladder neck and the appendix arrangement: appendix is implanted in the bladder with an antireflux sub-mucosal tunnel and the other end is hemmed to the skin. Self-catheterization is very easy. All patients are dry but the rate of complications was very high: 77%--8 leakage through the bladder neck imposing one or two re-operations. 10 uretero-hydronephrosis related to a small and hypertonic bladder: enterocystoplasty with good results--5 lithiasis--2 perforations. Success of this technique is closely linked to the construction of a large and low pressure bladder: 11 enterocystoplasty have been performed secondarily and 4 during the first operation. Actually 26/30 patients are well with normal kidneys and excellent comfort., Follow-Up: 1 to 7 years.

The aim of surgery for hypospadias is to reconstruct in one stage, at about 2 years of age, a penis that will be functionally and cosmetically, as close to normal as possible. We described the various techniques that we use depending on the degree of meatal ectopia and the presence or absence of chordee. We have treated hypospadia that is strictly glandular either with Duckett's Magpi procedure (54 cases, 49 long-term follow-up, 47 good results, retraction of the meatus in two), or Koff's advancement procedure if there is a grow in glans (13 cases, 12 good results, on requiring meatostomy). Although these meatoplasties do give good results, they hide the malformation rather than correct it and must therefore be reserved for those forms that are strictly glandular. We have treated coronal and distal shaft hypospadias without chordee by the technique of Mathieu combined with the Byars method of coverage (50 cases, 4 fistulae successfully corrected at a second one-day surgery, no stenosis--only one poor cosmetic result. In all other form of hypospadias one must first correct the chordee. The incision and the correction of the various elements that contribute to the chordee are described in detail. After straightening if the meatus is distal to the mid-point of the phallus the Devine-Horton "flip-flap" procedure is used (240 cases, 17 fistulae, (17%), 10 meatal stenosis (4%), 95 excellent cosmetic result). If, after straightening, the meatal opening is proximal to the phallus grafting is necessary.(ABSTRACT TRUNCATED AT 250 WORDS)

A study of stenosis of the meatus, torsion, deviation of the penis, embedding and transposition is made, with emphasis on anatomical lesions and in particular the skin folds of the covering of the penis, relevant to incisions and surgical technique.

One stage hypospadias repair -- 66 cases. The authors used Devine and Horton's technique with some modifications : 1. If the meatus is located forward of the mid penile, a rectangular flap based on the urethral meatus is reflected anteriorly and sutured with the glans flap (Devine and Horton) but when the glans flap does not meet the hypospadic meatus a part of the new urethra, between the tip of the glans flap and the meatus, has a strip of skin as a roof, while the rest of the circumference is raw and unclosed. This strip will form a complete canal by epithelialization. 54 cases : 3 fistulas required further operation. 7 fistulas healed spontaneously, 2 meatal stenosis were treated by a single dilatation. The cosmetic result was excellent in 45 cases, good in 13 cases (the meatus remaining a little short of the tip of the penis). 2. Therefore the authors used a full-thickness skin graft tube only for the more posterior cases in which the meatus was behind the mid part of the penis. 9 cases : 1 good result - 8 fistulas.

Intermittent clean catheterization (CIC) has been proposed in 1975 for treatment of neurogenic bladder in children and tean-agers. We report herein the results of our experience from 1976 to 1986 with this method in a large number of patients with bladder dysfunction. 165 patients were included in this study (111 girls and 54 boys). 9 patients were lost for follow-up. Myelomeningocele was the cause of the neurogenic bladder in 132 cases. The effects on continence, upper tracts, and urinary tract infection are studied. Incontinence was managed by CIC in all 156 patients, with CIC alone (40 patients) or in association with oxybutynin (21 patients), enterocystoplasty, (20 patients), one method of increasing peripheral resistances (i.e. urethral lengthening, (8 patients), abdominal transposition of the urethra) (2 patients]. 40 very young children remain incontinent, 84 became continent; there were four technical failures, and an other method was used in 28 patients. Status of the upper urinary tracts was determined by IVP and cystography in 156 patients. IVP was normal in 123 cases (there was no change in 95%), and abnormal in 33 cases (there was improvement in 28 cases or no change in 3 cases). These data confirm those found in our previous study: this technique appears simple, harmless and effective for protection of the upper urinary tract and for control of urinary incontinence.

26 cases of urachus anomalies are reviewed. Embryological, clinical and therapeutic problems are discussed. The authors point out the importance of a systematic urinary tract evaluation. Relationship between urachus anomalies and "prunebelly" syndrome is considered.

One hundred and twelve cystomanometric investigations were carried out in 86 children, 67 of them were suffering from a neurological bladder. Measurement of the vesical pressure was carried out by the suprapubic route, furthermore the rectal pressure and pneumogram were recorded. This technique enables the study of vesical tonus and activity, and also permits estimation of peripheral resistance.

As shown by Stephens the only element of the sphincteric mechanism which persists in case of high imperforate anus is the pubo rectalis sling of the levator. It is essential that the néo rectum be brought down to the perineum throught the sling which must be meticulously dissected and preserved. An operative technique with definition of the sling by an anterior perineal approach was described by the author. Results of the procedure in 43 patients are reported: early post operative complications (1 death, 4 occlusions, 2 ischemia of the neo rectum), anal complications (stricture, prolapses and ectropion) and urinary complications. Concerning the continence the author studied 19 patients: 16 children operated over 10 years ago and 3 adults. Of these 19: 2 are failures with stool incontinence, 10 are excellent and 7 fair. A "perfect" result was never obtained but many are compatible with a normal social life. Age is of great importance (our 3 adults became continent within several months), morning evacuations, diet, cleanliners, some drugs such a imodium are helpful adjuncts. Then the paper discusses 16 patients with desastrous results after previous surgery in another hospital. In 10 patients the new ano-rectum has been placed some that it missed a portion or all of the pubo-rectalis muscule. A further operation with re-routing resulted in marked improvement in 7 patients. A poor result with the neo-rectum in a good position means that the incontinence is related to a hypoplastic or denervated sling. A free autogenous muscle transplantation (Hakelius and Grotte) gave 4 excellent, 2 fair and 2 poor results.

Sixty-one patients with classical bladder exstrophy were seen at our institution over the last twenty-two-years. Five patients underwent primary urinary diversion, in six reconstruction according Couvelaire--Arap method was attempted without success. For fifty patients a staged approach to functional closure was elected. A review of the success, failures and complications provides the bases for treatment now being used on new patients. The technical aspects of this treatment that provide the best chance for continence without renal damage and satisfactory external genitalia are discussed. An excellent surgical result, defined as achievement of a day time dry interval for 3 hours with normal social life and without renal damage was achieved in 74% of children (100% of girls).

810 patients have been operated from 1960 to 1986 for gastroesophageal reflux. The surgical management has always been the same by an abdominal approach: dissection and repositioning of lower esophagus, closure of the columns, fixation of the esophagus to the columns, fixation of the gastric tuberosity to the esophagus and making an anterior valve. 59% of the patients have less than one year and 14.5% have been operated for respiratory syndromes. Mortality was 1.2% and 7% of patients developed post-operative complications. Because geographic diversity of the patients only one year results have been studied. 56 patients have been lost for follow up. 90.4% of patients have a clinical and radiological good result.

Ketoconazole an imidazole derivative used in clinical practice as an antifungal medicine interferes with the phospholipid dependent "second messenger" pathway. In this work we show that in the GH3 clonal cell line, ketoconazole (10 microM) inhibits part of the complex pattern of electrical activity induced by Thyrotropin-Releasing Hormone (TRH, 10 nM). The phase blocked by ketoconazole represents the Ca2+ -activated K+ conductance.

The encouraging success of replacement of the detrusor for contracted bladder due to a tuberculosis or other causes prompted an attempt to reconstruct bladder in a patient with neuropathic bladder. Colocystoplasty has been used by the authors in a total of 12 children with neurogenic bladder: 8 with a sufficient follow-up (6 months to 10 years). Technical data are given with some details. The sclerosed detrusor inducing elevated bladder pressure must be resected and the sigmoid is anastomosed to the trigone of the bladder. The sigmoid conduit is extraperitonized. The new colonic bladder give ample and supply cystern allowing protection of ureters and kidneys. The incontinence is not modified. Simultaneously with colocystoplasty the patient must be managed by self-catheterization or by urinary artificial sphincter or by a continent cystostomy. The initial results are very encouraging.

A case of severe anal incontinence after multiple surgical repairs for ano-rectal imperforation is presented. A successful formation of a new puborectalis sling by means of free autogenous palmaris longus muscle transplantation according to Hakeliuis is reported. The clinical success is confirmed radiologically and electromyographically. The authors discussed the principles and the results of this new method. They believe that this case pleads in favour of true muscle autotransplant re-innervation.

The study of 62 bladder neck and urethral obstructions among 210 neurogenic bladder in children, allow to give an urologic definition, corroborated by urodynamic exploration.--28 boys show lesions of external sphincer as described in traumatic paraplegia in adult. The treatment in external sphincterotomy: by perineal approach (5 cases : 1 success--4 failures), or retropubic (3 cases : 2 successes--1 failure) and mainly endoscopic (12 successes over 21 primary resections, and 8 successes over 10 repeated interventions). The results are given according to the obstruction, the continence and urinary upper tract. Ureteroneocystostomy il allowed by obstruction release. The pathogeny of obstruction is discussed according to the paralysis of the sphincter, as well as the therapy with the comparison between sphincterotomy and self-catheterism.--34 girls present 3 kinds of obstruction;--bladder neck dysectasia (5 cases) with obvious radiologic findings: YV plasty was done with in 2 cases ureteroneocystostomy;--posterior downfall of the bladder where intermittent catheterization provides excellent results;--pure urethral obstruction is also observed, like in boy's external sphincter lesion. Various types of therapy are discussed, specialy TV plasty extented to the urethral meatus, but in girls the intermittent catheterization which respects continence and which can be associated to an ureteroneocystostomy or a pharmacologic therapy is at present the most appropriate method.

Of a total of 176 cases of spina bifida observed from a urological standpoint, we detected an infra-vesical obstruction in 27, the diagnosis being based upon urological findings alone: dysuria, residue and infection. The 11 boys had a disorder of the striated sphincter justifying sphincterotomy, the technique and results of which are discussed, in terms of symptoms and signs resulting from the obstruction, with respect to continence and the effects on the upper tract. 16 of our patients were female and the nature of the infra-vesical obstruction was far more uncertain. A disorder of the striated sphincter was present in the girl treated by a Y-V plasty of the anterior aspect of the bladder neck passing low down on the anterior aspect of the urethra. We also present results relating to residue, retention, dysuria, continence and the upper urinary tract. Overall, these results are too recent and difficult and no definite conclusions may be drawn.

Recent advances in the treatment of urinary incontinence of neurological origin in children are discussed. The etiology of the neurological changes is mainly congenital (myelomeningocele, sacral agenesis and hidden dysraphism) other causes such as myelitis, radiculitis or cord injuries being very rarely observed. Two fundamental elements can be evaluated by radiologic and urodynamic investigations of the lower urinary tract: the capacity for compliance of the detrusor muscle and the degree of cervico-urethral resistance. The presence of a cervico-urethral obstruction is no longer an indication for its removal but, on the contrary, a factor that can be retained to assist continence. Intermittent use of self-catheterization enables the obstruction to be used to obtain continence (dryness) and makes the obstruction innocuous, since it enables emptying of the bladder. Of 50 patients (26 girls and 24 boys) treated in this way, 11 were not seen again, but the other 39 are still being followed up after an average of 50 months. This method of bladder emptying maintains the integrity of the upper urinary tract when this was normal previously and improves uretero-pyelo-caliceal distension. Uretero-vesical reimplantation can prevent reflux. Of these 39 children, 23 are continent during the day and 13 among them during the night also. A colocystoplasty was performed in 3 cases to enlarge the bladder capacity. The use of a catheter is well accepted by the girls and young boys but less so by the male adolescents. In the absence of a cervico-urethral obstruction it is impossible to relieve incontinence by re-education, and only three solutions exist: high cutaneous diversion continent cystostomy and artificial sphincter. The high diversion operation should be used as a last resort only. The continent cystostomy uses an appendix isolated on its mesothelium an opening on the abdominal wall and into the bladder in a long anti-reflux tunnel. Catheterization is by a catheter which passes through the newly formed ureter and enables the bladder to be siphoned dry four times daily. This method was used in 25 patients but many complications developed, including febrile attacks with dilatation of the upper urinary tract due to too small a bladder under increased pressure (an enlarging colocystoplasty was required). Eight other children continued to have urine loss through the urethra and required repeated closure of the bladder neck, and one child developed a bladder stone.(ABSTRACT TRUNCATED AT 400 WORDS)

The authors study the management of the upper tract in 65 boys with posterior urethral valves from 1965 through 1978. Their behaviour has changed with time. At the beginning of their experience they used systematically urinary cutaneous diversion (18 cases : 9 good results -- 4 deaths -- 5 poor results). In a second period they used extensive surgical reconstruction at the same time as with destruction of the valves according to H.W. Hendren. Results were very bad : 5 cases: 1 good result, 3 poor results -- 1 death. During the later years of this study (1973 to 1978) 42 boys were managed by primary destruction of the valves. 22 required only valve ablation and recovered with a good upper tract. 6 severely ill infants who did not respond to valve ablation alone were nephrostomy (2) or ureterostomy (4) diverted (4 good results). In 14 additional patients a ureteral reimplantation was required : 8 successes -- 6 failures. Our experience supports the thesis that after primary resection alone the severely dilated and tortuous ureters usually improve strikingly with time. A period of watchful waiting before undertaking ureteral reimplantation is recommended. Measurements of ureteral pressure also are beneficial in determining the need for surgical intervention (Whitaker). Temporary ureteral diversion has a place in the severely ill patient who has not responded to valve resection.

Acute leukemia are now in progress with intensive and prolonged polychimiotherapy but such medicine is difficult to manage because veins are rapidly unserviceable. In order to simplify hematological treatment and psychological approach of this patients we have constructed arterio-venous fistula in children with malignancy. The operation of choice is a subcutaneous cephalic-vein to-radial-artery arterio-venous fistula on the fore arm at the distal part. 103 of this vascular access procedures are performed in 93 children and in infants weighing less than 10 kg: 57 are performed without magnification, 46 with the aid of operative microscope. The comparative study of this two procedures show that microsurgical technique is necessary to improve results, especially in the youngest patients. This vascular access are well accepted by the children and his families, and very useful for the medical staff.