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The indications for "ex vivo" surgery and autotransplantation have been broadened o complicated renal anomalies; particularly in the cases of the horseshoe kikney and kidney malrotation. This position is justified as conventional techniques do not correct the multiple causes that are responsible for these complications. These complications requiere a surgical strategy that simultaneously deals with the pathology of the renal anomaly itself and that of its excretory tract. The aforementioned means that the abnormal kidney orientation and position must be retified to permit a large resectioning of the dysplasic or dystrophic excretory conduct in order to achieve normal urinary drainage while conserving all the renal parenchyma. It has been achieved in thirteen out of the 14 cases operated on that correspond to distinct types of complicated anomalies. The excellent results demonstrate that this new and innovative surgery has resolved the complex and difficult issue of kidney malformations. The surgical method and long-therm results in the adult and child, the first in the literature, are presented here.

Background: A renal transplant is the treatment of choice for patients with end-stage renal disease due to its superior short- and long-term survival benefits compared with dialysis treatment. A common trend for kidney transplantation in developed countries is an increasing acceptance of older patients, patients with comorbidities, and patients with vascular problems (eg, atheromatosis, venous thrombosis). For those patients, an orthotopic kidney transplant (OKT) is an option., Objective: Our aim was to analyze the results of the largest OKT series in the world (surgical technique, complications, and outcomes) and to compare indications, surgical techniques, and long-term results from two different periods (before and after February 1987)., Design, Settings, and Participants: Between April 1978 and September 2009, 223 OKT were performed. We compared the results of transplants performed in two different periods: from April 1978 to January 1987 with 139 patients and from February 1987 to September 2009 with 84 patients., Intervention: OKT were performed in all cases as described in the first report published in 1989 by Gil-Vernet et al., Measurements: The clinical data, surgical reports, and complications rate of all patients were reviewed retrospectively. From a database maintained prospectively, two different periods were described, and the long-term results of the OKT were compared. Graft and patient survival in orthotopic versus heterotopic transplants from the same period were also compared., Results and Limitations: During the second period an important decrease in the number of OKT was observed due to the change in indication for this specific technique. No important differences between periods were noted in terms of surgical technique. The rate of urinary complications rate was similar in both periods. No differences in graft survival between series have been observed (p=0.22), but a higher mortality rate was seen in the second period mostly due to an older unfit population (p=0.031). No differences were observed in overall graft and patient survival between orthotopic and heterotopic kidney transplants performed during the same period., Conclusions: OKT is a good alternative with acceptable rates of urologic and vascular complications for those patients for whom heterotopic transplant is considered unsuitable., (Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: Esophageal stenosis, due to its important implications on the patients' quality of life, poses a serious problem, often difficult to resolve, that requires therapeutical solutions that could irreversibly affect vital conditions and quality of life of those affected. For this reason our group has tried over the last thirty years to employ conservative solutions in the damaged aesophagus, showing that a complete cure is possible in most cases although the way to achieve this can be dramatically long., Material and Methods: We present our experience employing topical Mitomicyn C over the last year and a half in eight patients, six of them affected with caustic stenosis and two with secuelae of esophageal atresia, highlighting the three cases that received at least five applications of the product. We describe the method employed that consists in the spraying of the correct dose using a flexible fibroscope on the dilated area, loading the dose in the container of the cleaning water of the fibroscope, employing a system that permits only to apply the exact quantity necessary of the product. The application time is five minutes and the dose is 0.4 mg/ml applying 5ml or 10 ml according to the patient's weight ( under 12 kg = 2.5 ml and over 25 kg=5 ml). Upon completion of the application, a washing of the product is performed using the same fibroscope., Results: From the eight cases in which it was applied, we analysed the three that received at least five doses. These were two boys of seven and eight years and a 25 year-old woman. In the children the dilatations interval has passed from 4-5 weeks to 8-11 respectively. The woman has passed from 12 to15 weeks. The children have been in the dilatation program more than 3 years and the woman more than 18., Conclusions: Although the time period that we have been applying Mitomicyn C is still short, the symptom-free interval after dilatations is proving to be highly promising. This fact is highlighted in those patients included in the dilatation program recently. We have not seen any adverse side effect from the application of the product.

The suspicion of Hirschsprung's disease (HD) or Neurointestinal Dysplasia (NID) arises with the appearance of a common symtomatology : delay in meconium evacuation, abdominal distention, vomiting, intestinal occlusion and ultimately, chronic constipation. The need to perform a correct differential diagnosis between both pathologies is essential, given that the treatment of HD is surgical while NID is expectant. The objective of this paper is to define the necessity of using or not all the diagnostic tests simultaneously to obtain a precise diagnosis. The authors performed a complete clinical review of a series of 42 HD and 18 NID analysing the results of diagnostic procedures (Radiology / transition zone, anorrectal manometry / absence of anal inhibitory reflex, and suction biopsy / AcHE study). The authors concluded that is necessary to perform all the three diagnostic procedures simultaneously in all patients with symtomatology given that not one test has the capacity to provide a diagnosis alone. Anorectal manometry has proven to be the most reliable test to diagnose HD. The authors agree with the guidelines published by Meier Ruge in 2004 to diagnose NID.

Since 1975, our experience in the treatment of biliary atresia with Kasai's technique has improved little by little, achieving 65% favourable outcome in the last five years. We define "good results" as the complete restoration of biliary flow and normalization of bilirrubin levels. The long-term evolution of these good results can be diverse. The objective of the present work is to analyze the outcome of patients in our series in whom a favourable initial response was achieved, as well as evaluating their present situation and future perspectives. The authors present a total of 17 patients operated by Kasai's technique since 1985, that constitutes the group with good results in our series. The controls were based on general analysis, liver function and periodic ultrasound explorations. All received a standardized medical treatment consisting of vitamin supplements (A, D3, E, K) minerals (zinc, calcium, phosphate, iron) ursodexoxicolic acid, luminal,as well as close control of calorie intake. In two patients the levels of bilirrubine were progressively increased with time, stabilizing at between 5/6 mgs/100 ml, with progressive hepatic hardening, appearance of splenomegalia, indirect signs of portal hypertension and a slight deterioration of hepatic function. One received a transplant at age 12 with Quick levels below 50%. The other, aged 16, continues with an acceptable hepatic function and good quality of life under recommendation of transplant. Eleven patients with ages ranging from fourteen months to seventeen years presented slight and firm hepatomegalia, moderate portal hypertension, GOT 71 +/- 8 mg/100 ml, GPT 97 +/- 11 mg/100 ml and normal bilirrubine levels. From this group, 3 patients, all under five years of age, experienced bleeding from esophageal varices which were controlled by sclerosis and medical treatment (propanolol and isosorbide dinitrate). Recently, one three year-old patient developed a hepatocarcinoma of rapid, mortal evolution. Since then, the determination of alfa-feto protein in follow-up controls has been introduced. Four other patients of 5, 6, 14, 16, years of age are completely assymptomatic with an excellent clinical evolution. In our experience,the patients that overcome the third year after surgery without serious complications seem destined to reach puberty with a good quality of life. However, some cases show signs of hepatic fibrosis and portal hypertension, 77% in our series. Only 23% of patients with a favorable initial evolution appear to present a complete normalization of their hepatic lesion in the long term.

Unlabelled: Posterior sagittal anorectoplasty (PSARP) is considered today the best surgical technique for the treatment of the anorectal malformations. With the aim of evaluating the results of the PSARP in our patients, the charts of 39 children (27 male, 12 female) were reviewed. Mean age was 11 years (3 to 20 years) and the mean follow-up period from the closure of the colostomy was 9.4 years (1 to 18 years). Patients with any alteration of the extrinsic innervation or those with rare malformations were excluded of the study. According to the Wingspread classification, 14 patients had a high defect, 13 had an intermediate type and 12 had a low one. One patient had a PSARP in the newborn period whereas the rest of them had a descending loop colostomy. Definitive repair consisted in PSARP in low and intermediate forms and in six of the high type patients. The rest (8) of the high type patients had a Rehbein abdominoperineal pull-through (DA) plus a PSARP. Evaluation for the surgical results was made by means of an anorectal manometry (existence or not of anal inhibitory reflex [RIA], the symmetry and pressure of the canal anal, and the existence of extrinsic innervation) and a clinical questionnaire. Patients or parents were asked for fecal continence, age at which the continence was achieved and the existence of severe constipation., Results: Low defects: Eleven patients were continent between 3 and 5 years old. Seven patients had RIA. Intermediate defects: Seven patients were continent. Five (all with RIA) achieved continence between 2 and 8 years old; the other 2 were continent at the age of 10. The six incontinent patients had absence of RIA and/or low-pressure anal canal. High defects: Five patients were continent, between 11 and 16 years old. All had an DA plus PSARP. None of them had RIA. All the incontinent patients had an anomalous anal canal., Conclusions: The lowest the type of an anorectal malformation, the better the prognoses. In these patients, there is a relationship between the achievement of continence, the presence of RIA and the symmetry and high pressures at the anal canal. Among the patients with high defects, the results are better when they had an abdominoperineal pull-through plus PSARP.

Study Design: A case report of urethral destruction in a spinal cord injured (SCI) patient., Objectives: To report the reconstruction of the whole anterior urethra in one-stage using an epilated scrotal flap., Setting: Institut Guttmann, Hospital de Neurorehabilitació, Barcelona, Spain., Methods: A one-stage tubular substitution urethroplasty based on a bi-axial epilated scrotal flap design ('BAES flap') was performed successfully., Results: Long-term follow-up of 6 years has confirmed the excellent adaptation of the flap to its urethral function., Conclusion: The bipedicle epilated scrotal flap can effectively resolve this challenging urethral pathology.

Caustic stenosis is a serious problem in children due to its complicated resolution and implications in important areas like nutrition, as well as the child's tolerance to the measures taken to correct them. After dealing extensively with this problem over the last twenty five years, always from a conservative approach using traditional methods like dilatations, we believe we have found a technique that brings together all the necessary conditions to achieve a favorable and definitive solution. Our ideal goal to achieve a device that provides a well-tolerated permanent esophageal expansion during the scarring process, also permitting normal swallowing, seems to have been reached through the use of the new generation of silicone stents. The authors present their experience in the first seven cases of caustic stenosis treatment through the placement of silicone stents, describing a precise placement technique while establishing a standard protocol for the use of these devices.

Unlabelled: Biliary atresia continues to be a serious and relatively rare disease (1/50,000 newborns) and whose long-term prognosis has changed drastically since the appearance of liver transplant (LT) as a therapeutic weapon. The combination of two factors, early diagnosis and correct application of Kasai's surgical technique, is essential to obtain acceptable results and sufficient biliary drainage allowing the children to overcome the critical 7 kg barrier and place them in the lesser morbi-mortality range in relation to a possible LT. But we must keep in mind that despite its critics, Kasai's technique can guarantee, both in our own experience and in the literature, ten years survival percentages over 50% with correct hepatic function, as well as clinical normality and a quality of life clearly superior to first years post-LT. We present the evolution of a group of 20 patients affected with biliary atresia, diagnosed in our center since 1985, the year when pediatric LT began to be used as a therapeutic procedure in this country. We valued the age of intervention, technique, immediate and long-term results and the evolution and necessity of LT. All 20 patients were analyzed individually, and they currently have an age range from 2-14 years and were all operated by Kasai's technique. We classified the patients as having good, regular or poor results with regards to biliary flow, normalization of billirubin levels and clinical evolution. Sixteen patients presented biliary flow of such an extent that 14 of them, classified as good, completely normalized the billirubin levels. Two others, presently aged 14 and 8 years respectively, present average levels of 2.5-5.5 mg/100 ml and are classified as regular in a situation of advisable transplant, although with an acceptable hepatic function. Only one case, the first in the poor group, did not initially present biliary elimination and died at age six months while on the waiting list. Three other cases in the same group presented insufficient biliary elimination and were transplanted with 7, 11 and 12.5 kg, respectively. The second died in the first year post-transplant., Conclusions: In our opinion, action in biliary atresia must be early and based on the correct application of Kasai's technique, seeking to achieve a biliar flow that eliminates or distances the patient as far as possible from the necessity of a future LT. Three lines come together to obtain this target: an early diagnosis, a correct application of Kasai's technique, and an implication in the follow-up and treatment of these children by the hepatic transplant groups. All this advises us, as is done in other countries, to create reference centers for the study of neonatal cholestasis where an accumulated experience of a relatively rare pathology can be taken advantage of.

Objective: To improve the results of corrective surgery for severe urinary incontinence in the female (sphincteric lesion) utilizing a new prosthesis that allows adjusting the degree of tension of the band or urethrocervical sling., Methods: We have added the use of a subcutaneous hydraulic device to the classical pubovaginal sling procedure. The device can be gradually filled by percutaneous punction to adjust the urethral closure pressure., Results: All patients had previously undergone different procedures and had grade III stress urinary incontinence. With the hydraulic device, the success rate (complete continence) was 95.5% (21/22 patients) and the complication rate was 9% (2 cases; one developed infection and the other chronic urinary retention)., Conclusions: The hydraulic device described herein is easy to place, low-cost and carries a minimum morbidity. Its use is indicated in patients who have previously undergone surgery, with a sphincteric lesion and who require precise adjustment of the urethrocervical sling. The degree of tautness can be adjusted repeatedly according to the clinical course of a patient without requiring reoperation.

Esophageal stenosis is a frequent consequence of lye ingestion, and their treatment is of longstanding and complex matter. The search of new solutions for this problem is challenging and always attractive if its associated with less aggressiveness to the patient. The use of intraesophageal stents is not new in the treatment of stenosis, but it was anecdotal, until histocompatible material came out in the market. The stent is designed in the OR, having the same length as the stenosis, previously observed by endoscopy, its made out of a silicone tube 30 or 36 French, mounted over an ng tube 16, all this is fixed in the ends of the silicone tube, that way won't slip over the ng tube. It is placed with a laryngoscope assistant, the proximal end of the ng tube comes out the nasal nares. Once the location of the tube is checked, the stent is left in place for six weeks. Our experience, with seven patients, has shown excellent tolerance to the stent; at the third post procedure day the patients were eating soft diet by mouth, we believe that the esophageal spasm had resolved by this day. Once the stent was withdraw, five cases were free of esophageal lesions, in the other two small areas of bleeding were visualized. In the follow-up the five cases that were free of lesions, had a normal esophageal diameter, in the other two, one had a moderate restenosis and the other case was severe.

Achalasia is an uncommon esophageal motor disorder. It has been associated with other diseases such as Parkinson's disease and depressive disorders, but coincidence of achalasia and Down's syndrome is rare. We report five cases of achalasia in Down's syndrome patients seen in our institution. Two of the five cases were diagnosed at pediatric age. Respiratory symptoms and growth retardation were the main clinical manifestations in pediatric patients, whereas adult patients mainly complained of dysphagia. Taking into account the prevalence rate of both disorders, the association seems higher than that expected by chance. The possible etiopathogenic implications of this association, as well as its clinical relevance, are discussed.

Video-assisted endoscopic techniques have decreased the surgical aggression in abdominal and thoracic surgery. In our country, pediatric laparoscopy has been developing slowly, but this is not the case for thoracoscopy. The aim of this paper is to present the techniques and results of thoracoscopy pulmonary biopsy in our first patients. Pulmonary biopsies with this approach had been done in 9 patients (5 males, 3 females). Their age ranged between 30 months and 16 years. In all cases this was the last resort for the diagnosis of pulmonary condensation of unknown etiology. The biopsies were done with the pretied knot in 5 cases, stappler in 1 case and with biopsy forceps in 2 cases. Thoracotomy was necessary in one patient, due to intraoperative haemorrhage. Enough tissue for bacterial and pathological diagnosis was obtained. There was not mortality nor important morbidity related with the technique. Postoperative recovery is better when compared with conventional thoracotomy. Thoracoscopy is an adequate approach to perform pulmonary biopsies in children. The advantages if we compare with open thoracotomy are: 1. The possibility to choose the are to perform a minimally invasive biopsy. 2. To take samples of different pulmonary lobes. 3. Less postoperative pain and shorter hospital stay (36-48 hours).

The authors show their experience in the use of the laparoscopic approach in 18 cases of unilateral exploratory anorchia. They highlight the advantages that this method offers in efficiency, speed, security and minimal aggression compared with conventional exploration of the inguinal channel in the search of the undetectable testis. In the 18 cases studied through the insertion of 5 mm lense in the umbilical area, it was established that a testicular hypoplasia was present in 8 cases. In another 5 cases testicular agenesia was diagnosed, and in the remaining 5, intraabdominal testis were found. In four of these testicles, a laparoscopic approach helped in their correct placement and also in the removal of the fifth in a patient with recurrent leukemia.

The appearance of the new lecture systems for the manometry studies by computer, like the Polygram by Synectics (vector volume), offer the possibility to see the circumferential pressure forces, that even in rest conditions as in voluntary contraction, they keep coaptation of the anal canal, and this will act as a continent closure system in the most distal part of the G.I. tract. The study is with the normal parameters obtained in 14 individuals, considered as normal, getting the mean +/- sd pressure of the anal canal convey in mm Hg, from de anal canal profile in rest as in voluntary contraction, and the maximum variability that could exist between the six profile waves, that are obtained in the same individual to develop an image of the anal canal. This valves will allow the author's to get to the bottom of fecal incontinence derivative from anorectal malformations, defining the pressure valves of muscular hypoplasia or surgical outcomes of the malformations.

Background: The regulated ability of sphincters to relax allows adequate control of digestive transit. Relaxation of the lower esophageal sphincter (LES) is essential for esophageal emptying and, similarly, pyloric relaxation permits gastric emptying. When the relaxatory response of these sphincters is impaired, luminal transit is altered, as occurs in achalasia and hypertrophic pyloric stenosis. Nitric oxide (NO) has been identified as the main inhibitory neurotransmitter in both sphincteric regions. Moreover, the absence of NO synthase in the LES and the pylorus has been implicated in the pathogenesis of infantile hypertrophic pyloric stenosis (IHPS) and achalasia, respectively., Case Report: We present the case of a 12-year-old boy diagnosed with these two different conditions attributed to NO absence: IHPS and achalasia., Conclusion: To our knowledge this is the first time that such an association has been reported. Whether IHPS and achalasia have been associated in this patient by chance or because they share common pathophysiological mechanisms remains speculative, but is a tantalizing dilemma.

The authors present 14 patients affected with portal cavernoma, diagnosed and controlled over the last 12 years. The splenomegaly (60%) and the digestive hemorrhages (40%) were the initial study causes. The cavernoma appeared idiopathic in 10 patients or secondary either to a catheterization of umbilical vein (3 cases) or onfalitis (1 case). The first clinical manifestation oscillated between the ages of 3 months to nine years. The diagnosis was performed in the initial cases (4 cases) using splenoportography (3 cases) and superior mesenteric arteriography (SMA) in the other. In the remaining cases the ultrasonography together with the endoscopic evidence of the varies backed up the diagnosis. Before the intervention, a SMA was performed in all cases. The surgical decision was taken with regards to the persistence of the digestive bleeding after the start of medical treatment with propranolol, cimetidine, and sucralfate, along with the existence of dangerous varices. Eight patients were operated on, two by the Warren technique, four by mesocaval jugular graft interposition (MJI) and two by azigo portal disconnection (APD). The shunts initially controlled the bleeding in all cases. There was one rebleeding instance at eleven months in a patient operated on by MJI, and in another by APD. Four patients continue medical treatment without problems, and two are free of treatment. Our experience with varies sclerosis is limited to two cases, although since the beginning of the treatment, one year ago, neither of them has bled.

The transjugular portosystemic bypass is a new technique for treating portal hypertension of an intrahepatic nature by inserting a multipurpose catheter through the jugular vein and vena cava as far as the suprahepatic vein, with the aid of a puncture device it is fed via the hepatic parenchyma into a portal branch. The passageway thus created is distended with a balloon to permit the insertion of an extensible metal mesh prosthesis or "stent" to maintain a permeable connection. Our experiment was conducted on a paediatric patient suffering from mucoviscidosis with severe pulmonary and hepatic involvement and recurrent bleeding in an uncontrollable position. After inserting the bypass, portal pressure dropped sharply and the bleeding stopped, the patient being discharged on the sixth day. Two months after the bypass, the coronary vein of the stomach, the seat of the gastric varicose veins, was selectively occluded through the stent via the femoral vein. Six months after follow-up, the digestive bleeding has not recurred.

Unlabelled: Hirschsprung's disease may be due to impaired nonadrenergic-noncholinergic inhibitory input in the aganglionic segment of the colon. It has been suggested that nitric oxide (NO) might be the lacking neurotransmitter. Thus, our specific aims were to determine in ganglionic and aganglionic segments: 1. The activity of the NO synthetase (NO-S); 2. The location of this enzyme; and 3. The "in vitro" basal motor activity of the muscle strips and their responses to an NO donor and to an NO antagonist., Methods: NO synthetase activity was quantified in samples of tissue from both aganglionic and ganglionic segments obtained during surgery in 6 patients with Hirschsprung's disease by the transformation of 14C-L-arginine into 14C-L-citrulline in tissue homogenates. Immunohistochemical staining of the tissues was performed using a polyclonal antibody raised against a peptide sequence of rat brain NO synthetase. Furthermore, in 2 patients we measured "in vitro" the tonic response of muscle strips to an exogenous NO donor (sodium nitroprusside) and to an NO antagonist (L-NAME)., Results: NOS activity was undetectable in every aganglionic segment whereas it was present in all ganglionic segments (0.49 +/- 0.09 pmol citrulina/mg.min; mean +/- SE). Immunohistochemically, NO-S was absent in the myenteric plexus of aganglionic segments and it was present in ganglionic segments. "In vitro" basal motor activity of ganglionic segments was normal, with presence of low-frequency contractions (LFC) and summation contraction (SC); in aganglionic segments SC were absent. Sodium nitroprusside induced a marked relaxation (90% from basal) in muscle strips, both aganglionic and ganglionic, precontracted with bethanocol.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To study the ejaculatory mechanisms in men using a dynamic endorectal ultrasonographical approach., Subjects and Methods: Seven recordings were made of a young healthy volunteer during ejaculation, scanning the longitudinal plane from the bladder neck to the bulbous urethra., Results: The study demonstrated the existence of a pre-ejaculatory phase characterized by a notable decrease in echogenicity of the inner prostate gland, due to the contraction of the pre-prostatic sphincter 13-25 s before ejaculation. Several stages were recorded including an ejaculatory stage with an initial prostatic emission phase lasting 2-20 s and a posterior emission phase through the ejaculatory ducts lasting 3-14 s, with a seminal stoppage of 3-8 s, and finally a urethro-vesical reflux of a minimal fraction of the ejaculate over 5-9 s. The bladder neck and inner gland returned to their resting configuration between 10 and 90 s after ejaculation., Conclusions: Endorectal ultrasonographical imaging during ejaculation, a recently developed diagnostic procedure, may provide a new approach to ejaculation-related problems.

Hyperganglionosis or neuronal intestinal dysplasias (NID) and hypoganglionosis (HO) are intestinal diseases of difficult diagnosis and treatment and diverse evolution, despite identical histologic findings. The aim of this study was to discuss the therapeutic problems derived from the patients differing clinical course. Retrospective review of 14 patients with regard to diagnosis, manometry and histology (hematoxylin-eosin, acetylcholinesterase activity, immunohistochemistry and Smith's silver stain) was done. Six patients presented intestinal occlusion or sub-occlusion from the first months of life with impeded oral feeding. Ileostomy was performed in 5 and total colectomy with anastomosis in 1. All patients required parenteral nutrition; cisapride was added in 2. Three died from sepsis (3 NID). Of the 3 survivors, 2 have ileostomies (2 NID) and the other ileo-rectal anastomosis (NID). Of the remaining patients, two presented aganglionism and the finding of proximal hyperganglionism occurred post-surgery. Surgery was repeated in one patient. The remaining 6 (1 HO, 5 NID) were diagnosed between 3 and 10 years of age because of constipation. Four are under treatment with cisapride and 2 required partial colic resection. No relationship can be established between histologic findings and clinical manifestations. In chronic clinical courses, treatment with cisapride and cleaning enemas should be tried first. Acute clinical pictures (occlusion-sub occlusion) should be treated by decompressive ileostomy. Partial colic resection may lead to new intestinal failure.

With the discovery during the 1960s of an access to the renal sinus and intra-operative radiological monitoring, the lithiasis surgery reached its summit of technical perfection. A comparative study on the various therapeutical options is presented: NLP, URN, ESWL and open surgery, as the single or combined treatment in complex renal lithiasis. Also, intrasinusal and transparenquimatous accesses to the intrarenal tract are compared, evaluating the morbidity, surgical time and economical interpretation of both techniques. Establishment of each treatments' indications and contraindications as well as likely short- and long-term adverse effects of the new technologies.

A 18 month-old boy with asplenic syndrome was admitted to our hospital with a twelve hours history of mucous vomiting, abdominal pain and a round epigastric mass. It was diagnosed as having a gastric volvulus and an emergency laparotomy was performed. The stomach was situated at the right side and a mesenterioaxial volvulus was found, with cyanosis of the antrum. The gastrophrenic and gastrosplenic ligaments were absent. The clinical and radiological characteristics of asplenic syndrome are reviewed. The pediatric surgeons must be aware of the digestive malformations of the asplenic syndrome, because some of that like malfixation of the stomach could be the cause of an acute abdomen.

A total of 84 radical cystectomies were performed for invasive bladder cancer in 67 men (79.8%) and 17 women (20.2%). The present study investigated the possible sex-dependent differences in the pattern of invasive bladder cancer. More than 40% of the women presented lower urinary tract syndrome alone or with haematuria, giving a clinical picture similar to acute cystitis. This caused an average time-lag in diagnosis of 18.5 months in the women and 8 months in the men. There was a higher frequency of non-transitional cell carcinoma in the women (17.6%) than in the men (2.9%). We found statistically significant differences (p < 0.005) in tumor grade: 35.2% of the women had low grade tumors, compared to 7.4% of the men. However, no significant differences in staging or survival rate were found when comparing the two sexes. This leads us to believe that bladder cancer is less aggressive in women.

To show the absence of inhibitory reflex of the anus (R.I.A.) by ano-rectal manometry is an important sign in the diagnosis of Hirschsprung's disease. Between 1989 and 1991, a series of 199 patients was studied. The patients were divided into two groups: 0-1 month and 1 month to 50 years. Both groups were subdivided into cases with or without clinical and radiological suspicion of aganglionism. In this series, R.I.A. was absent in 88 patients and present in 111. Histologic study and follow-up confirmed the existence of aganglionism in 86 patients, hyperganglionism in 1, anal stenosis in 8, cystic fibrosis in 4 and 1 coeliac disease; the rest were megarecta to a greater or lesser degree. There was 1 false negative, signifying a percentage of error of 0.5%.

Chronic intestinal pseudo-obstruction is defined as a syndrome related to any process which affects intestinal regulation and propulsion. Its origin may be muscular, neurogenic or hormonal, excluding Hirschsprung's disease or any known mechanical obstruction. Between 1989 and 1991, 11 patients with intestinal pseudo-obstruction were studied at our centre, and included nine hyperganglionisms B, and two hypoganglionisms) and two visceral myopathies (Berdon's syndrome). Diagnosis was established in all cases by histologic study. The techniques of haematoxylin-eosin, acetylcholinesterase, enolase, protein S-100 and Smith were used in neuropathies and haematoxylin-eosin and Masson's trichromic in myopathies. Intestinal motility was studied by ano-rectal and gastrointestinal manometry in seven and three cases respectively. Gastrointestinal manometry and radiology permitted differentiation of localized and diffuse forms of involvement. Medical treatment consisted of total parenteral nutrition when oral feeding was impossible, and in five cases, cisapride was given, with good results in four. Derivative surgery was performed in cases of diffuse involvement, and resection with anastomosis in those of localized forms. We conclude that: 1. Diagnosis is established according to histologic criteria. 2. Complementary examinations should be directed towards distinguishing localized from diffuse involvement. 3. Cisapride was effective in the treatment of neuropathies in the majority of cases.

We present the results obtained in a study of the pharmacological action (phase II) of alpha-interferon and oral fluorouracyl administered in our 2-year study (Feb. 1988-Feb. 1990) in 10 patients suffering from surgically unremovable or metastatic renal cancer. Our results were: 1 patient with complete regression of lung metastasis; 5 with progressive disease within 3-4 months from beginning of treatment and 2 deaths with stable disease after 4-5 months. Two patients abandoned treatment and their disease progressed within 4-5 months.

Nonatretic cholestatic disorders exhibit differential features in the pediatric age group, at times not too obvious but always discernible. These characteristic differences, with the aid of increasingly more precise exploratory techniques, make a rapid and sound diagnosis possible. At present, echography, transparietohepatic cholangiography and endoscopic retrograde cholangiography allow us, within a short time, to reach a diagnosis of disorders that not long ago were only roughly profiled and on occasion were left undiagnosed. At the Children's Hospital Valle de Hebrón, treatment has been afforded, in the last seven years, to seven patients with a choledochal cyst, four with a long common biliopancreatic duct, one with a choleperitoneum due to spontaneous perforation of a choledochal cyst and one patient with congenital stenosis of the common hepatic duct. In all cases where echography was performed, an intra- or extrahepatic bile duct dilatation could be demonstrated, or otherwise the diagnosis of a choledochal cyst was established. Furthermore, four transhepatic and three retrograde cholangiographic examinations were carried out, via a fiber duodenoscopy, in those cases that failed to show, on echography, the existence of a choledochal cyst.

A case of testicular malacoplakia and epididymis in a 62 year old man is presented. A literature review is made (only 6 cases describing epididymal malacoplakia have been reported), commenting on the clinical, diagnostic, anatomopathological, pathogenic and therapeutic aspects of malacoplakia.

Posterior sagittal anorectoplasty (ARPSP) was described at first of the 80-90 decade like a new surgical technique for the anorectal malformation treatment and derived fecal incontinence. We have evaluated 35 of 67 ARPSP using biofeedback techniques (BFB) before surgery as restore system to striate muscle. Manometric values of the canal anal profile (PCA), postoperative external sphincter pressure and postoperative, first and last BFB voluntary contraction pressure shows clearly the differences between surgical intervention and BFB outcome. The author's opinion is that BFB is the indispensable therapy in the ARPSP postoperative to lend the patients get optimal fecal continence.

In 1987, ninety-six surgical patients, of whom 44 were premature or newborn babies and 52 were infants or older children, received total parenteral nutrition (T.P.N.) at our hospital. A peripheral venous line was utilized on forty patients in the first group and only on 9 in the second group. The excellent results yielded by T.P.N. are self-evident from the low mortality showed by these patients. Thirty-three out of the 44 neonates and premature infants with serious surgical problems survived, being noteworthy the occurrence of just 3 deaths within a series of 13 necrotizing enterocolitis. In the series of 52 infants and older children, composed of 13 digestive patients (with 5 liver transplants), 6 tumoral, 9 neurologic, 4 renal (2 transplantations), 18 cardiac, 1 thoracic and 1 burnt, only 9 patients died. The average duration of T.P.N. was 10 days in the group of premature and newborn infants and 6 days for the nursing infants and older children, save for the 8 patients in whom the treatment had to be prolonged for a few months. We conclude that T.P.N., when applied in time and of short duration should entail no risk at all. In neonate and premature infant a peripheral vein shall be the route of choice. In the nursing infant and older child a central venous line is preferable, if possible the superior vena cava or its major tributary veins.

The oncocytoma constitutes 3-6% of the kidney neoplasiae. The authors report one case of calcified kidney tumor, Its presentation as a calcified kidney mass is exceptional and is not present in the largest series of calcified kidney tumors. The calcification prognosis is much debated, even more in the case of oncocytoma due to the very limited series available. For calcified kidney tumor, the oncocytoma should be included as one of the differential diagnosis, even if it is not very frequent.

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.