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Among the surgical procedures to treat vesicoureteral reflux trigonoplasty is a conservative technique that preserves the integrity of the vesicoureteral junction. Since its introduction in 1984 by Gil Vernet it gained only little attention in small series. Between 1986 and 1989 we performed trigonoplasty in 51 children 4 months to 13 years old, of whom 47 had primary vesicoureteral reflux. Our study includes 44 patients who have sufficient followup and 69 refluxing units. Reflux was grade II in 25 units, grade III in 39 and grade IV in 5. Patients were arbitrarily divided into 2 age groups: less than (13) and greater than (31) 3 years old. All children underwent standard preoperative assessment. The operation, with technical modifications (absorbable sutures in all cases and muscular incision added in 12), was performed after failed conservative treatment in all patients except 5 who were operated on at diagnosis. Surgery was successful in 97.7% of the patients and in 92.3% of the children less than 3 years old. The only recurrence was noted on 1 side of a 2-year-old child who had had grade IV bilateral reflux. Considering that reimplantation threatens the integrity of the vesicoureteral junction and endoscopic injections still have unclear side effects, indications for trigonoplasty can be extended to higher grades of reflux if ureteral tapering is not required and a sufficient intramural length of ureter can be obtained.

Different techniques are available today for repairing distal (coronal and subcoronal) hypospadias but none is universally recommended. We developed the technique of a distal urethral advancement glanuloplasty operation that is specifically intended for distal hypospadias repair even with mild chordee. Mobilization of the distal urethra is performed for 1.0 to 1.5 cm. after subcoronal circumcision and a deep Y-shaped incision of the glans. The mobilized urethra is dorsally split and slid forward to the tip of the dart of the glans previously prepared. Glanuloplasty is performed using the 2 lateral flaps of glans tissue. From January 1987 to December 1989 we used this technique in 74 cases of distal hypospadias with mild or no chordee (patient age 18 months to 9 years, mean 3.5 years). A transurethral catheter was left indwelling for 3 to 4 days. Hospitalization time was 5 (plus or minus 1.5) days. Results after 4 to 40 months of followup are encouraging cosmetically and functionally. All patients were cured. In 3 cases (4%) meatal stenoses occurred requiring meatotomy and in 8 boys meatal dilations were performed on an outpatient basis. In 1 case (1.3%) a fistula developed, which was subsequently repaired without further complications. This operation may be successfully used in most cases of distal hypospadias, with a low complication rate and excellent cosmetic results. It also may be used if mild chordee is present, thus reducing the indications for flip-flap urethroplasty in those cases when meatal advancement procedures may not be effective.

Spinal dysraphism represents a very rare congenital anomaly of the spinal cord and cauda equina, often associated with cutaneous sacral lesions. This condition results in distorsion of neural tissue, possibly leading to vesical dysfunction and urinary incontinence. A series of 12 children with spinal dysraphism (4 lipomeningoceles with tethered cord, 3 tight filum terminale, 2 dermal sinuses, 2 arachnoid cysts, 1 anterior meningocele) observed during the last 6 years is presented. The patients are divided into two groups: group A includes 5 infants (age range 4 months-2 years) and group B 7 older children (4-12 years). All 7 patients of group B were referred for urinary incontinence as their chief complaint; only 1 had evidence of a skin lesion while 3 had a club foot. In group A, 4 had skin lesions (2 asymptomatic and 2 dermal sinuses referred after several episodes of meningitis) and the 5th child had a club foot. The diagnosis was made by myelo-CT scan in the earlier 4 and by magnetic resonance imaging in the more recent 8 cases. All 12 children were operated. In group B, the patients' urinary incontinence persisted but did not worsen (3 were stable and 4 had slightly improved); in group A, 2 were dry (follow-up greater than 2 years), 1 could not be accurately evaluated because he was less than 2 years of age, and the 2 who suffered from meningitis were incontinent. Early diagnosis and neurosurgical treatment of spinal dysraphism may prevent urinary incontinence. Accurate urodynamic, neurophysiologic, and neuroradiologic evaluation of children with severe voiding anomalies or club foot is recommended even if no lumbosacral cutaneous lesions are present.

To date, rigid operative ureterorenoscopy with ultrasound lithotripsy for the treatment of ureteral calculi has been performed only in adults or older children. The size of the instrument with the working channel for the ultrasound probe has been considered unsuitable for delicate anatomical structures, such as those of children younger than 4 years. We performed 8 ureterorenoscopic examinations in 7 patients (3 boys) 3 to 8 years old and have demonstrated that the 11.5F ureteroscope can be inserted without difficulty into the ureteral meatus of a 3-year-old boy. Introduction of the instrument is facilitated by the use of the Perez-Castro irrigation pump. This procedure does not lead to any urethral or ureteral damage, nor is vesicoureteral reflux shown on a postoperative cystogram. This technique allows extracorporeal shock wave lithotripsy to be extended also to small children, offering the possibility of easy and successful management of any residual steinstrasse.

The Authors describe the case of an acute brucellosis in a young veterinarian due to accidental injection of animal vaccine. The past history of the patient and the serological follow-up of the animals contacted by the professional did not evidence other risk contacts. The case evidence the real possibility that attenuated Brucella melitensis strains used in animal's vaccination can represent a source of occupational risk for this infection. In addition, it is important to notify similar cases to monitor the real extent of this phenomenon.

The authors report the results of a study on 20 children suffering from a particular type of enuresis, associated with bladder instability, characterized by uninhibited contractions of the detrusor muscle. The children selected showed symptoms of enuresis, frequency, urinary urgency and a positive urodynamic test. This test was performed on 11 patients before and after acupuncture. In 16 out of 20 children, the authors observed a net increase in the intensity and frequency of uninhibited bladder contractions 30 minutes after acupuncture. At 60 minutes the contractions decreased and at 24 hours they had practically disappeared. Clinically, a gradual elimination of enuresis has been observed in 11 cases and an improvement in the other 7. From these early observations, the efficiency of acupuncture in suppressing uninhibited bladder contractions seems to be proved, even though the therapeutic mechanism has yet to be clarified.

Urinary incontinence can only be considered a disease after a child has completely acquired spinal mechanisms of vesico-sphincteric nervous control. This normally happens for the majority of children between two and two-and-a-half years of age regarding voluntary daytime control, while complete night-time control is obtained in 90% of cases within the fourth year. By urinary incontinence we mean an involuntary leak of urine through the bladder neck. This can vary from an occasional leakage consisting of a few drops to a continuous and uncontrollable stream of urine. From 1981 to 1986 we evaluated, in the Pediatric Urological Service at Bambino Gesù Hospital, Rome, 426 children suffering from urinary incontinence. According to the etiology we divided the patients into two large groups: 1) patients with incontinence due to anatomic causes 56 (13%); 2) patients with incontinence due to dysfunctional causes 370 (87%).