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We performed an urodynamic study in enuretic children to evaluate the relationship between urodinamic findings and symptoms. We studied 175 patients, with age from 5 to 12 years, who presented with nocturnal enuresis: 45 monosymptomatic and 130 polysymptomatic (in association with urinary urgency, urge incontinence, etc.). Despite differences in symptoms, in 151 patients (86%) abnormal urodynamic findings were identified. Bladder instability was the most common disorder. However, mild abnormalities were found in the monosymptomatic patients. In treated patients urodinamic findings and clinical improvement were correlated. This study confirmed that most patients with nocturnal enuresis have cystometric abnormalities. Although possible etiologies of nocturnal enuresis are various, bladder dysfunction may be an underlying cause.

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BACKGROUND: With today's improved surgical techniques, complications in hypospadias surgery are seen less often, especially in distal form (1-5%). However, in proximal or complex hypospadias complications rate varied between 15 and 57%. Corrective surgery is mandatory in maior complications (urethrocutaneous fistulas, persistent chorde, urethral strictures, superficial skin separation). The search for the innovative surgical procedures and the optimal urethral substitute continues because each tissue has its particular shortcomings and disadvantages. METHODS: At our hospital complications occurred in 25 ( 15%) of 177 patients who underwent primary hypospadias repair between 1994 and 1998. 9 patients required further surgery to repair the complications of previous hypospadias operations performed at other institutions. When local epithelial tissue was not available, different surgical procedures were performed, using bladder or buccal mucosa graft and free or vascularized tunica vaginalis flaps. RESULTS: Follow up ranged from 3 to 6 years: the cosmetic and functional results were excellent. Small fistulas occurred in 3 patients and were corrected successfully in a subsequent surgical procedure using a tunica vaginalis wrap. CONCLUSIONS: The concept of using tunica vaginalis in urethral reconstruction represent a recent innovation. This tissue is a valid alternative in cases of multiple failed repairs.

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BACKGROUND: Despite the large number of children with reflux, management among urologists is still controversial. One of the most debated aspects is the choice between observation treatment or surgical treatment. METHODS: We assessed the natural course of children with vesico-ureteral reflux in the period 1990-1995, to correlate factors and identify patients with high risk of renal damage. We retrospectively reviewed the clinical course of 80 children with vesicoureteral reflux. Thirty-two were diagnosed during prenatal ultrasound scan. In the other cases urologic evaluation was requested because of urinary tract infections. The following data were analyzed: medical records, diagnostic and follow-up cystogram, renal imaging, medical therapy or surgical treatment carried out according to the reflux grade, diagnostic age, congenital reflux nephropathy or postnatal acquired scarring, voiding patterns, spontaneous resolution during medical management. Follow up ranged from 5 to 10 years. RESULTS: Vesicoureteral reflux resolved spontaneously in 29 patients: 25 were affected from moderate reflux, 4 from IV grade reflux. Surgical correction was carried out in 32 patients. Endoscopic treatment was performed in 25. Twenty-two children are still receiving prophylaxis and 12 were lost to follow-up. Congenital renal pathology correlate with poor outcome. CONCLUSIONS: The conclusion is drawn that there is a wide clinical variability in children with vescicoureteral reflux. The most important is host's susceptibility to urinary tract infection, but the severity of reflux, age of patients and congenital reflux nephropathy influence prognosis and long-term outcome.

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BACKGROUND: Elevated urinary levels of microproteinuria or renal enzyme have shown to be associated with renal injury. Data collected in children with vesico-ureteral reflux (VUR) or hydronephrosis have been evaluated to identify a means of predicting renal damage. METHODS: Levels of urinary microproteinuria (N-acetyl-beta-glucosaminidase, aminoalanina peptidase, lisozyme, beta(2)-microglobulin) were evaluated with immunoassay in catheterized or voided urine. The levels of urinary creatinine were also determined. Of the 85 children enrolled in this study 22 were affected from reflux, 16 had hydronephrosis. Urine was obtained from the bladder in all children and also from renal pelvis in 9 patients at surgery for ureteropelvic junction obstruction. In addition, urine was obtained from 27 patients with a variety of pathophysiological conditions (neoplasia, ematuria, parenteral nutrition, ecc.). Normal healthy controls were performed in 20 children who volunteered for the study. RESULTS: In the group of children affected from reflux urinary microprotein elevated levels were in 18. In children with hydronephrosis pathological findings were observed in 2 cases. Abnormal pattern was found in 27 patients as response to various agents. Data obtained in healthy children were normal. Sensitivity in reflecting renal damage makes urinary enzymes measurement attractive as an indicator of renal dysfunction. CONCLUSIONS: Urinary microproteinuria evaluation may be a useful marker of progression of renal injury in children with reflux. However, excretion level of these microproteins is not helpful in identifying upper tract obstruction in small children, but values arise in those left untreated.

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Distal penile curvature associated with anterior hypospadias can be corrected by urethral plate mobilization. The authors present 11 cases, in which this procedure was performed modifying the classic Mathieu's technique in the surgical treatment of coronal and distal shaft hypospadias associated with chordee. Performing this modified-Mathieu's technique, excellent results, both functional and cosmetic, are obtained without any complication.

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BACKGROUND: Recent developments regarding the conservative management of multicystic dysplastic kidney disease (MDKD) have shown a reduction in the well-established practice of elective surgical treatment. It has been seen that in the majority of cases the evolution of MDKD is either partial or complete atrophy. The incidence of complications due to MDKD is very low. The aim was to study the ultrasound changes of MDKD in a group of patients from 1990, since this date the elective surgical procedure had been eliminated. MATERIALS AND METHODS: This group consisted of 16 patients. The diagnosis in each patient was confirmed by ultrasound and isotopic examinations. Other investigations were performed where there was a suspect of associated contralateral renal abnormalities or when a urinary tract infection occurred. RESULTS: Ultrasound follow-up revealed: no enlargement whatsoever in the kidney size in any patient; in 10 patients a reduction in the size of the MDK; in 3 patients a complete atrophy of MDK; in 3 patients there was no change at all. Five patients were found to have contralateral renal abnormalities. Compensatory hypertrophy of the contralateral kidney was present in all patients. No complications occurred. A nephrectomy was performed only in one patient aged 6 due to the express wishes of his parents. CONCLUSIONS: The results agree with recently published literature that routine surgical removal of the MDK is unnecessary.

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OBJECTIVE: Different etiopathological mechanisms of enuresis are today under study, and different therapies and drugs have been proposed. The Italian Multicentric Trial was undertaken in twelve pediatric and urological centers in order to assess the efficacy of two of the most popular drugs, desmopressin (DDAVP) and oxybutynin. METHODS: 114 enuretic patients were enrolled in the study. After a 2-week observation period, 66 patients with primary monosymptomatic enuresis were treated with DDAVP, 30 micrograms/day intranasally, for 6 weeks, 48 patients with enuresis and voiding dysfunction were randomly assigned to a protocol with oxybutynin alone or oxybutynin plus DDAVP. The efficacy of the two drugs was measured in terms of reduction of wet nights per week during the 6-week treatment period and a 2-week follow-up period. Children with 0-3 dry nights/week were considered as nonresponders. RESULTS: Patients with monosymptomatic enuresis treated with DDAVP reported a significantly lower number of wet night during treatment than during the baseline period, with 79% showing a 'good' (6-7 dry nights/week) or 'intermediate' response (4-5 dry nights/week). Of the patients with diurnal voiding disturbances and enuresis, those treated with oxybutynin alone had a 54% success rate. The patients treated with both oxybutynin and DDAVP showed a better response, with a 71% rate of success. CONCLUSIONS: The efficacy of the two drugs is confirmed in patients carefully selected on the clinical basis of voiding disturbances. In patients with enuresis and voiding dysfunction, the reduced urinary output and the lower bladder filling rate due to DDAVP can reduce uninhibited bladder contractions, thus enhancing the oxybutynin action.

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Many theories on the etiology of enuresis have been suggested, including psychogenic, structural abnormalities, dysfunctional aspects. The study consisted of 95 children with primary enuresis (35 girls, 60 boys). 58% of patients presented with enuresis plus evidence of voiding dysfunction. Patients with pure nocturnal enuresis were 17%. 42% of children have normal bladder on urodynamic testing. Anticholinergic medication was effective in children with voiding dysfunction. The base line treatment program, in children with normal urodynamic studies, included psychotherapy, medications, bladder training. Authors present their experience and results of treatment. The usefulness of urodynamic assessment in children with only nocturnal enuresis is discussed.

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Infertility in subjects affected by undesceded testis occurs in from 25 to 100% of the cases according to the various Authors. This depends on whether one or both gonads are concerned and on the age when medical and/or surgical treatment of the condition was begun. Our study was made in two successive periods: first we studied the secretory causes of infertility by examining some histological parameters, (MTD, IFT), and endocrinological ones, (basal testosterone and then after HCG, basal gonadotropin and then after GnRH) in 43 subjects of ages ranging between 2 and 13 years who are affected by uni- or bilateral maldescension. We then analysed the excretory causes of infertility and classified and interpreted 108 epididymo-testicular malformations out of a total of 144 undescended testis observed during our last year of work. We conclude that from a histological point of view, from the third year after birth there is a steady progressive reduction in the tubular fertility index in undescended testis compared to scrotal testis. There is no significant reduction, however, in the mean tubular diameter up to the prepubertal phase. From the endocrinological point of view, we found a normal LH secretion and hypertonia in the pituitary secretion of FSH in bilateral maldescension, not found, however, in unilateral maldescension. Finally, anomalies concerning the epididymo-testicular relationship are found in 75% of undescended testis and of these 36% have a definite effect on infertility of the excretory type.

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