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For more than 2 decades a major problem in pediatric urology has been the medical and surgical management of vesicoureteral reflux. Many effective surgical procedures have been advocated and used. A new surgical technique, particularly effective in patients with megatrigone, has been used in 38 children and adults with excellent results. The technique involves a single stitch that imbricates the trigone, effectively lengthening the intramural segment of terminal ureter.

A renal contact chassis that allows for the discovery of the smallest calculi and calcifications is described. The corrected images are far superior to commercially available plates and there is less radiation exposure to the patient and staff of the operating room. The bases have been established for intraoperative, 3-dimensional radiographic exploration of the kidney, which presently has not been achieved and is no doubt of great significance in operations for lithiasis. The technique represents a decisive aid for the intraoperative localization of residual calculi that allows for complete removal with a minimum of trauma to the kidney.

The urogenital diaphragm raising maneuver, a procedure to facilitate membranous urethral surgery, is described. The technique shortens operating time by permitting easy identification and exposure of the severed urethral ends, thus, allowing for precise re-establishment of urinary tract continuity. Selective membranous urethral surgery can be performed with ease, preserving external sphincter integrity. This maneuver represents an advance over any other technique by almost eliminating the risk of stenosis, urinary fistula and incontinence owing to failure of precise reapproximation of the membranous urethra.

A new operation is described, in which the right renal vein outlet is moved to a lower level on the vena cava, helping to decrease the distance between the kidney and the bladder. This procedure permits treatment of extensive obstructive wounds of the pyeloureteral junction or lumbar ureteral junction, caused by lithiasis and ureteral and renal operations, that cannot be treated with conventional operations. Renal circulation is not altered with this procedure. The operation is simple, does not cause complications and provides excellent results.

Although a commonly performed technique, heterotopic renal transplantation may be a cause of late graft failure owing to ureteral stenosis, urinary fistula and vesicoureteral reflux secondary to the immune response. The new retroperitoneal lumbar approach to the splenic vessels has allowed the orthotopic technique to be developed using the splenic artery or aorta, the renal vein and a pyelo-pyelic anastomosis. In this manner the renal graft is located in an anatomical position that is well protected, and with the recipient urinary tract the normal physiology is preserved with comparatively low complication and mortality rates. A third transplant attempt also is simplified. This method is the only alternative in some cases. Transplant ureter pathology symptoms are not observed. The results of 139 consecutive cases are presented.

Complex vesicovaginal fistulas still represent a management problem, since most of the cases have been operated on previously and because of the lack of a completely successful surgical technique. A new procedure for vesical autoplasty is presented. A flap is obtained from the posterosuperior bladder wall that slides down to cover large lesions, even in low capacity reservoirs. The technique has shown excellent long-term results in 42 consecutive complicated cases.

The procedures of bench surgery and autotransplantation have been extended to cases of complicated renal anomalies since conventional techniques do not always correct the multiple problems present. Complicated renal anomalies require techniques that will result in the simultaneous treatment of the renal pathological condition and of the urinary tract. In other words, the kidney must have normal anatomical orientation, allowing for ample resection of the dysplastic or dystrophic tract, good urinary drainage and no loss of renal parenchyma. A combination of nephrectomy, bench surgery and autotransplantation has been used successfully in 8 of 9 patients with various anomalies.

We present a technical modification of 3-dimensional intraoperative radiography of the kidney that reduces the cost of the material and makes preparation of the minichassis in the hospital laboratory possible. The radiogenic dose received by the kidney is 20 times less than when the system is used without screens.

The transperitoneal approach is used systematically for an arterial or a venous splenorenal anastomosis. However, this approach is associated with high morbidity and mortality rates. Because of our anatomical and surgical findings we have used the retroperitoneal approach to the splenic hilus by means of the lumbar region. The first splenorenal arterial anastomosis with this approach was done in 1972. The approach has proved to be less aggressive since it avoids the danger of damaging the pancreas, it is a more direct approach to the splenic vessels and it provides better exposure and facilitates the anastomosis. In addition, the loss or infection of ascitic fluid in cirrhotic patients is avoided with this approach, as well as intraoperative hemorrhaging caused by the great surplus circulation. There has been neither mortality nor complications in the 13 cases of arterial and venous splenorenal anastomoses that we have done with this method.

A simple technique of translumbar splenectomy during renal and pancreatic transplantation is described. This unique approach was used in 18 patients. Postoperative septic complications must be considered.