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Objectives: To evaluate the bladder preservation strategy in invasive bladder cancer particularly relapse, progression and complications., Materials and Methods: From January 2000 to May 2004 a total of 24 patients (mean age of 81 years; range 68-92) with muscle invasive bladder cancer who had refused or were not eligible for cystectomy were followed up for a period of up to four years., Results: 24 (21 M/3 F) patients were followed up for a mean time of 680 (182-1253) days. All patients complained of frequency, urgency and severe nocturia. The second most frequent complication was bleeding which required a salvage cystectomy in 7 cases. Other major complications were intestinal occlusion in three cases, an enterovesical fistula, brain metastasis requiring neurosurgical intervention and radiation therapy of the brain, bone metastasis in the cervical spinal column and chronic renal failure. The mean re-admission rate was 8 per patient and the mean time spent at the hospital was 109 (range 13-253) days., Conclusion: In our series the bladder preserving strategy does not confirm the optimistic results of other authors. The complications forced us to carry out a salvage cystectomy in nearly half of the cases. The other half of the patients complained of other severe complications reducing the quality of life of the remaining life span.

Objective: The purpose of this study was to evaluate the potential of MR urography in the assessment of children with a suspected "functional single kidney.", Subjects and Methods: Sixty patients (age range, 2.7 weeks to 15.7 years) who had been referred for assessment of a suspected functional single kidney underwent MR urography in addition to detailed sonography of the urinary tract and the currently indicated standard imaging. The results of the conventional imaging ((99m)Tc-dimer captosuccinic acid scintigraphy, voiding cystourethrography, and genitography) were compared with the results of sonography and MR urography; surgical findings served as the gold standard if available., Results: Twenty-six patients had a single kidney. The other diagnoses were six contralateral multicystic dysplastic kidneys, two normal ectopic kidneys, one crossfused double system, and 25 ectopic or dysplastic renal buds. Scintigraphy detected all normal kidneys, two ectopic kidneys, and two dysplastic renal buds. Detailed sonography missed two ectopic kidneys and two orthotopic dysplastic renal buds, but one additional renal bud that could not be confirmed on other imaging techniques (accuracy, 91.7%; sensitivity, 88.2%; specificity, 96.2%) was suspected. MR urography results were correct in all patients and verified in all 13 with surgical correlation., Conclusion: MR urography allows a reliable assessment of renal and ureteral anatomy and of dysplastic or ectopic renal buds, even in non- or poorly functioning systems. MR urography therefore has the potential to replace the currently used excretory urography and scintigraphy. In patients with a suspected functional single kidney a detailed sonographic study and MR urography should be considered the diagnostic algorithm of choice.

Purpose of Review: This is a review of the recent advances in the diagnosis and therapy of dysfunctional voiding. We aim to point out the fact that there are many modalities which are effective in the treatment of dysfunctional voiding but that the standard therapy is still not agreed upon., Recent Findings: Fifteen recent articles are reviewed. The two most interesting reviews are (1) the diagnosis of dysfunctional voiding and vesicoureteral reflux with contrast-enhanced ultrasonography and (2) the use of a scoring system to monitor the outcome of therapy and family compliance to the therapy., Summary: Periodic, critical, and objective reviews on this subject should help the attending physicians arrive at sound management plans.

Purpose: We evaluated the diagnostic potential of magnetic resonance urography (MRU) in pediatric patients with a solitary kidney and/or dysplastic orthotopic or ectopic renal buds. We present our evolving experience with this imaging procedure., Materials and Methods: A total of 30 patients with a mean age of 43.8 months with a known or suspected solitary kidney with or without clinical symptoms underwent ultrasound of the urinary tract as well as voiding cystourethrogram, renal static dimercapto-succinic acid (DMSA) scintigraphy and MRU. The results of these diagnostic imaging studies were then compared with each other and set against the results of the final diagnosis established at surgery and by histology, if available., Results: Dysplastic orthotopic or dystopic renal buds suspected on ultrasound in 11 of the 30 patients were confirmed in all 11 by MRU. While accompanying ectopic ureteral insertions were shown in only 3 patients by ultrasound, they were visualized in all 4 by MRU. The other 7 patients with dysplastic renal buds had orthotopic ureteral orifices. DMSA scintigraphy failed to detect 10 renal buds., Conclusions: The diagnostic value of MRU appears to be superior to that of other imaging tests, even to that of DMSA scintigraphy, which with voiding cystourethrography is currently considered the gold standard for evaluating sonographically suspected solitary kidneys with contralateral orthotopic or ectopic renal buds and ectopic ureteral insertion.

Objectives: To perform a biologic characterization of the urothelial neoplasms of patients in the intermediate-risk group using multicolor-fluorescence in situ hybridization (FISH). A general consensus has not been reached with regard to the optimal therapy and follow-up of patients with urothelial neoplasms at intermediate risk of progression. On the basis of the chromosomal pattern, we developed a new follow-up algorithm for this group and report our preliminary results., Methods: Voided urine samples of 51 consecutive patients (mean age 72.2 years, range 52 to 93) under follow-up after complete transurethral resection of intermediate-risk urothelial carcinoma were evaluated by liquid-based cytology (ThinPrep) and uCyt+. From the residual material, Multicolor-FISH (Urovysion) was performed. Any cystoscopically suspicious lesion was biopsied or removed transurethrally. The mean follow-up time was 14.2 months (range 6 to 30, SD 5.5)., Results: Two of the 51 patients were not evaluated because of the presence of intense granulocytosis and insufficient urothelial cells. Of the 49 remaining patients, the results of the Multicolor-FISH analysis were negative (diploid chromosomal pattern) in 14; 20 patients showed the loss of one or both alleles of p16 and/or an aneuploidy of chromosome 3, and 15 patients had aneuploidy of chromosome 7 and/or 17. Of the 14 FISH-negative patients, 2 (14.3%) had histologically verified recurrence, and 3 (15.0%) of the 20 p16/3-positive patients had recurrence and 9 (60.0%) of the 15 7/17-positive patients had either recurrence or progression., Conclusions: Using the Urovysion test, it is possible to predict the biologic behavior of urothelial cancer with a significant impact on the follow-up of patients. The intermediate-risk group of urothelial cancer can be eliminated in the routine workup by classifying these patients according to their chromosomal pattern and defining those patients who can follow the low-risk scheme and those who must be monitored according to the guidelines for high-risk superficial lesions.

Purpose: The efficacy and durability of botulinum-A toxin in the treatment of detrusor hyperreflexia in myelomeningocele (MMC) children was evaluated prospectively., Materials and Methods: A total of 15 children (10 male and 5 female, mean age 5.8 years), all on clean intermittent catheterisation (CIC) due to MMC, were "non responders" to orally and intravesically administered anticholinergic medication. Pretreatment assessment included a videourodynamic evaluation, incontinence scoring and a mercaptoacetyltriglycine-3 renal scan. We injected from 10 U/kg up to a maximum of 360 U botulinum-A toxin at 25-40 sites of the detrusor, sparing the trigone. Follow-up was 24 months. All children had a urodynamic reevaluation with assessment of bladder capacity and incontinence score at 3, 9 and 12 months., Results: Mean bladder reflex volume increased from 72.00 +/- 28.12 ml to 298 +/- 32.45 ml (p < 0.001). The maximal detrusor pressure decreased from 78.76 +/- 23.14 cm H(2)O to 42.76 +/- 24.34 cm H(2)O (p < 0.001). Maximal bladder capacity increased from 136.34 +/- 45.71 ml to 297.02 +/- 87.17 ml (p < 0.001). Detrusor compliance increased from 18.29 +/- 27.19 ml/cm H(2)O to 51.17 +/- 38.17 ml/mmH(2)O (p < 0.001). While 10 patients became completely dry between CIC, the remaining 2 patients improved from score 3 to 1. Results at 9 months were similar to the ones at 3 months. The mean efficacy and durability of the toxin was 10.5 months after the first intravesical injection., Conclusions: Botulinum-A toxin is a safe alternative in the management of detrusor hyperreflexia in MMC children. Preliminary results are promising concerning urodynamic parameters and continence.

Purpose: We prospectively evaluated the efficacy and durability of botulinum-A toxin in the treatment of detrusor hyperreflexia in children with myelomeningocele (MMC)., Materials and Methods: This study involved 15 patients with MMC (10 male and 5 female, mean age 5.8 years), all nonresponders to orally and intravesically administered anticholinergic medication and all on clean intermittent catheterization. Pretreatment assessment included a videourodynamic evaluation, an incontinence score and a mercaptoacetyltriglycine-3 renal scan. We injected 10 U/kg to a maximum of 360 U of botulinum-A toxin into the detrusor at 25 to 40 sites, sparing the trigone. Followup lasted between 12 and 30 months. All children underwent a urodynamic reevaluation, an assessment of the bladder capacity and an incontinence score at 3, 9 and 12 months after the first injection. A second intravesical injection was administered after 12 months and followup repeated as in the first year., Results: After the first injection treatment mean bladder reflex volume increased from 72.00 +/- 28.12 ml to 298 +/- 32.45 ml (mean +/- SD, p <0.001). Maximum detrusor pressure decreased from 78.76 +/- 23.14 cm H2O to 42.76 +/- 24.34 cm H2O (p <0.001). Maximum bladder capacity increased from 136.34 +/- 45.71 ml to 297.02 +/- 87.17 ml (p <0.001). Detrusor compliance increased from 18.29 +/- 27.19 ml/cm H2O to 51.17 +/- 38.17 ml/cm H2O (p <0.001). Of the 15 patients 13 became completely dry with CIC. The remaining 2 patients improved from score 3 to 1. Results after 9 months were similar to those obtained after 3 months. Mean durability of the effect of the drug was 10.5 months after the first as well as after the second intravesical injection., Conclusions: Botulinum-A toxin is a safe alternative in the management of detrusor hyperreflexia in children with MMC. The preliminary results regarding urodynamic parameters and continence have been promising.

Objectives: To evaluate the feasibility and safety of transurethral en bloc resection of bladder tumors using a flat loop. Transurethral en bloc resection of bladder tumors facilitates pathologic evaluation., Methods: A total of 37 patients with papillary transitional cell carcinoma of the bladder underwent transurethral en bloc resection with the use of a flat loop electrode., Results: In 37 patients, 62 lesions were removed using a flat loop to perform the en bloc technique. This method is safe to perform in the case of papillary tumors with a diameter of up to 25 mm and that are found in specific areas of the bladder., Conclusions: It is both safe and feasible to perform en bloc resection with a flat loop electrode but attention must be paid to the limitations of this technique. Excellent pathologic evaluation of the grade and stage of the removed specimen is possible.

Objective: We evaluated the potential of tubularised incised plate (TIP) urethroplasty in primary and secondary hypospadias repair focusing on the extended application of this procedure, the utility and handling of the urethral plate and operative results., Methods: In this retrospective study, we analysed the medical records of 228 children with different levels of the hypospadiac meatus who underwent a TIP procedure between February 1997 and December 2002. The children were followed a mean of 42 months. Our medical records provided us with details about the location of the hypospadiac meatus, the width of the urethral plate before and after midline incision, primary versus secondary surgery, complications as well as notes on the extended application of the TIP procedure., Results: The overall postoperative complication rate was 7.8%. The overall fistula rate was 5.7%, with 4.1% in primary distal, 9.6% in primary proximal and 7.5% in secondary repair respectively. We had one case of meatal stenosis (0.4%) and one of urethral stricture (0.4%) and 3 cases of glandular dehiscence (1.3%). Due to the encouraging results, the frequency of TIP procedure in hypospadias surgery increased from 33% in 1997 to 82% in 2002., Conclusion: In our study the TIP procedure has emerged as the first-choice technique in primary hypospadias repair--irrespective of the level of the hypospadiac meatus and the width of the original urethral plate. This procedure has also proved to be favourable for many cases at secondary surgery.

The aim of the study was to assess the value of liquid-based urinary cytology as a tool to perform uCyt+ and Multicolour-FISH in patients under follow-up after urothelial cancer. Therefore, standard cytology was compared to liquid-based cytology with the addition of the uCyt+ test, which traces the three monoclonal antibodies M344, LDQ10 and 19A211 in exfoliated urothelial cells; and Multicolour-FISH (including centromere-specific probes for chromosomes 3, 7, 17 and a locus-specific probe for 9p21/p16) performed on thin-layer specimens. UCyt+ showed an overall sensitivity of 86.2% and cytology of 45.0%. Overall sensitivity of both the tests combined was 90%. Sensitivity of Multicolour-FISH was 96.4%. All conventional cytology diagnoses were confirmed by liquid-based cytology. Liquid-based cytology is a valid tool for the performance of adjunctive analyses, such as uCyt+ and Multicolour-FISH, on residual cellular material.

Purpose: Retrospective evaluation of operative techniques and perioperative management as related to the primary anatomical and functional situation as well as analysis of the preliminary postoperative results regarding kidney function, continence and complications., Materials and Methods: From October 1992 to April 2003, 21 patients with bladder exstrophy-epispadias complex were treated, consisting of 12 children with untreated exstrophy and 9 who had undergone unsuccessful previous operations. Single-stage complete repair using the Erlangen concept was done during the first weeks of life in 8 infants and before school age in 3 children. One 13 year old girl had received a primary Mainz pouch II. The 9 unsuccessfully operated patients required a variety of different operations. The mean follow-up of 17 regularly controlled children was 62 months (range 3 to 129 months)., Results: In all children global kidney function remained stable, while reflux or obstruction was responsible for impaired unilateral split function ranging between 31 % and 45 % in 5. Four children were continent day and night after complete single-stage repair, 4 after ureterosigmoidostomy or Mainz pouch II and 5 after augmentation., Conclusions: In the newborn with previously untreated exstrophy-epispadias, we recommend single-stage complete functional reconstruction within the first weeks of life. Continence without loss of kidney function can be achieved in 50 % of these children. If adequate bladder capacity and continence cannot be achieved, an augmentation procedure or Mainz pouch II is our method of choice.

Objectives: To report on our 2-year experience in teaching transurethral resection (TUR) of bladder tumors to five trainees. We analyzed their problems, as well as those of the teachers, and present our solutions., Methods: Between April 2000 and March 2002, five residents and three members of the staff took part in a training program to teach TUR of the bladder. From a total of 692 patients with bladder tumors admitted for treatment to our department, 417 were selected for the study. These 417 had papillary tumors of small to medium size (maximum 25 mm in diameter). The mean patient age was 61 years (range 32 to 92) for men (n = 322; 77%) and 68.4 years (range 48 to 91) for women (n = 95; 33%)., Results: A total of 417 teaching TURs were performed during a 24-month period. A total of 65 complications (16%) occurred and were analyzed from the database. The most common complication was postoperative bleeding, occurring in 33 cases (8%), followed by extraperitoneal perforation, which occurred in 16 cases (4%)., Conclusions: Despite careful patient selection and the use of video-assisted equipment and permanent supervision by an experienced resectionist, a significant number of complications occurred. The question: "How to teach the teacher to teach TUR of the bladder?" remains open.

Purpose: We compared 4 techniques of varicocele ligation in boys and young adolescents to determine the optimal operative treatment that avoids varicocele recurrence and postoperative hydrocele formation., Materials and Methods: In 10 years a total of 128 varicocelectomies were performed sequentially in 121 boys and young adolescents with a mean age of 12 years using the laparoscopic, inguinal testicular artery sparing, standard Palomo (high mass retroperitoneal ligation) and modified Palomo approaches. The modified Palomo approach involved suprainguinal and retroperitoneal ligation of the veins and artery, and microsurgical sparing of the blue stained lymphatic pathway of the testis. Patients were followed a mean of 52 months., Results: In the 19 boys in the laparoscopy group varicocele persisted in 10% and hydrocele developed in 5%. In the 21 patients who underwent inguinal surgery with artery preservation recurrent varicoceles were identified in 14% and no hydroceles were observed. In the 32 patients who underwent the standard Palomo procedure there was no palpable varicocele persistence or recurrence, while hydroceles developed in 12%. Of the 56 patients in the modified Palomo group varicocele recurred in 1 (2%) and there were no hydroceles. No testicular atrophy developed in any patient., Conclusions: Comparison of all 4 groups revealed significant differences in varicocele recurrence (p = 0.038) and hydrocele formation (p = 0.023). Pairwise group comparison showed that the modified Palomo technique resulted in a significant decrease in the incidence of postoperative hydrocele formation compared with the standard Palomo method (p = 0.015). This procedure can be recommended as the optimal surgical technique for varicocele treatment in males of this young age.

Objectives: To test the clinical value and role of uCyt+ as a noninvasive tool for the detection and surveillance of urothelial carcinoma., Methods: Included in this prospective study were 235 patients (mean age 71.5 years, range 32 to 86). Of these, 98 patients had signs and symptoms suggestive of bladder cancer and 137 patients were being followed up after complete transurethral resection of superficial urothelial cancer (UC). All patients underwent urinary cytology and the uCyt+ test performed on ThinPrep (thin layer). All underwent subsequent cystoscopy and evaluation of any suspicious lesion by biopsy., Results: A total of 102 patients had histologically proven UC. In the group of patients with signs and symptoms suspicious of UC, the sensitivity of cytology increased from 5% for G1 to 84.6% for G3 tumors; for uCyt+, it was 85% for G1, 100% for G2, and 92.3% for G3 tumors. Combining cytology and uCyt+, the sensitivity was 85% for G1 and 100% for G2 and G3. In the group of follow-up patients, the sensitivity of cytology increased from 4.3% for G1 to 94.4% for G3 tumors; for uCyt+, it was 78.2% for G1, 70% for G2, and 94.4% for G3 tumors. Combining both tests, the sensitivity was 78.2% for G1, 90% for G2, and 100% for G3., Conclusions: The uCyt+ is a valid test in the detection of UC of all grades and stages. It improves the sensitivity of cytology in low-grade tumors. The two tests combined may be a highly sensitive method to detect UC early in detection and surveillance.

Purpose: We determined the advantages and disadvantages of different types of contrast medium injection into the bladder for imaging children during evaluation for urinary tract infection in regard to child behavior and distress during urethral catheterization or suprapubic puncture., Materials and Methods: From December 2000 to September 2001 we prospectively compared transurethral catheter and suprapubic voiding cystourethrography in children with a history of urinary tract infection. A total of 65 children with a mean age of 33.8 months were entered into the study, of whom 32 underwent transurethral catheterization and 33 underwent suprapubic puncture with topical anesthesia. Each child was evaluated, particularly in regard to discomfort and pain using an objective pain score that measures stress and pain during a medical procedure., Results: Objective pain score recording showed a mean pain score plus or minus SD of 4.25 +/- 1.3 in the transurethral catheterization and 3.03 +/- 1.21 in the suprapubic puncture groups. Correlation studies of age in the 2 groups also showed a significant impact of age on the objective pain score. In the transurethral group the score increased with age (p <0.001), whereas in the suprapubic group it decreased with age (p <0.001)., Conclusions: The current study shows that the suprapubic puncture technique with topical anesthesia was well tolerated and associated with a low pain score independent of patient age. Transurethral catheterization was also tolerated but it was associated with a low pain score only in the younger age group. Thus, we recommend that voiding cystourethrography in children older than 24 months should be done via the suprapubic route.

Objectives: To compare, in a prospective study, the efficacy of a single injection of polydimethylsiloxane (Macroplastique) or dextranomer/hyaluronic acid copolymer (Deflux), a new biodegradable substance, and to assess the short-term and 1-year clinical effects concerning reflux resolution and the safety of these two bulking agents. Subureteral injection of bulking agents has recently demonstrated good success rates for endoscopic treatment of vesicoureteral reflux. Macroplastique has been one of the most popular bulking agents during the past years. Nevertheless, considering the synthetic property, new biodegradable substances have become more relevant., Methods: From January 2000 to June 2001, 16 boys and 56 girls (total of 114 ureters) with a mean age of 34.5 months were treated endoscopically for vesicoureteral reflux. A single subureteral Macroplastique or Deflux injection was performed in 34 children (58 ureters) and 38 children (56 ureters), respectively. Both groups were comparable in terms of baseline parameters. Vesicoureteral reflux was grade II in 52, grade III in 57, and grade IV in 5 ureterorenal units. The procedure was performed on an outpatient basis, with the children under general anesthesia. In addition to the routine parameters, the follow-up evaluation consisted of renal ultrasonography and voiding cystourethrography at 3 and 12 months postoperatively., Results: Endoscopic treatment was performed without any complications in all cases. At the 3-month follow-up visit, reflux was corrected in 50 (86.2%) of 58 refluxing ureters in the Macroplastique group and in 40 (71.4%) of 56 refluxing ureters in the Deflux group. At 1 year of follow-up, reflux correction was maintained in 80.9% of ureters in the Macroplastique group and in 67.6% of ureters in the Deflux group. No postoperative complications were observed in either group., Conclusions: A single subureteral injection of either polydimethylsiloxane (Macroplastique) or dextranomer/hyaluronic acid copolymer (Deflux) is an effective treatment modality for children with vesicoureteral reflux. The procedure was well tolerated, safe, and associated with low morbidity. Deflux, a new biocompatible, biodegradable substance, seems to be an alternative modality to other bulking agents for treating vesicoureteral reflux in children, with acceptable short-term and 1-year results.

Objective: To report our 20-year experience with nephron-sparing surgery in the treatment of Fraley's syndrome., Materials and Methods: From September 1976 to July 1996, 6 women, 18-43 years old, underwent surgical treatment. All patients had been suffering debilitating right flank pain for at least 6 months before the operation. Diagnosis was in call cases made with the use of intravenous pyelography and renal arteriography, which showed a vascular impression on the superior infundibulum with secondary dilatation of the upper pole calyx. This was localized only on the right side in 5 cases, while in 1 it was bilateral though more severe on the right. Ipsilateral nephroptosis was observed in 2 of the patients. In 2 cases in whom the superior infundibulum was sufficiently long, an infundibulo-infundibulostomy with everted flaps was performed. In a case in whom a short infundibulum was compressed between a venous and an arterial branch, Fraley's infundibulopyelostomy was carried out. In 1 patient in whom the infundibulum was compressed by the anterior-superior segmental artery, a Heineke-Mikulicz-type infundibulorrhaphy was combined to vasopexy. In the remaining 2 cases, the infundibulum was not cut: in one case, a simple vasopexy of two vascular branches was carried out, while in the other, a minor arterial branch was ligated and divided. In 4 patients, nephropexy was also performed., Results: No significant intra- or postoperative complications were observed. Follow-up averaged 102.5 months. Pain relief was complete in 5 cases, in whom disappearance of the vascular impression was also radiologically demonstrated. Only 1 patient, who underwent infundibulorrhaphy and vasopexy, experienced occasional flank pain and urinary infection after the operation, with just a slight improvement in the excretory urogram., Conclusions: Surgical treatment of Fraley's syndrome is indicated only in symptomatic and/or complicated cases; in relation to the type of obstruction and the anatomy of the intrarenal structures, whether excretory or vascular, several effective nephron-sparing techniques can be selected.

Patients with transitional-cell carcinoma (TCC) require careful follow-up due to the high risk of recurrence. Cystoscopy and biopsy are reliable but invasive, while urine cytology is plagued by low sensitivity. It has recently been shown that allelic abnormalities detected by microsatellite analysis of DNA extracted from urine can be used to diagnose TCC with high reliability. As this analysis by classic techniques is unfeasible in a clinical setting, we performed a pilot study to determine the possibility of applying quick DNA extraction methods with laser detection and computer-based analysis of 15 fluorescently labeled PCR amplified microsatellites to detect molecular anomalies in urine sediment in 25 TCC follow-up patients. Of the eighteen cases with recurrent TCC, 14 (78%) were positive by the molecular test whereas only eight (44%) were detected by cytology. Of the seven patients with negative cystoscopy, one resulted positive by the molecular test and had recurrent TCC six-months later. Thus, this microsatellite analysis correctly predicted the clinical diagnosis in 84% (21/25) of cases, compared to 60% by cytology. The application of these semi-automated procedures allows the analysis of 18 samples with 15 markers in one day, encouraging a more expedient introduction into routine clinical use.