hosted by
publicationslist.org
    

Massimiliano Silveri


maxsilveri@tin.it
Pediatric Surgeon and Urologist
Bambino Gesu' Children's Research Hospital
Department of Pediatric Surgery

Journal articles

2006
M Silveri, L Salsano, M M Pierro, G Mosiello, M L Capitanucci, M De Gennaro (2006)  Pediatric spinal cord injury: Approach for urological rehabilitation and treatment.   J Pediatr Urol 2: 1. 10-15 Feb  
Abstract: PURPOSE: As proposed in this report, early urological rehabilitative management of patients with spinal cord injuries (SCIs) is mandatory, in order to prevent a poorly compliant bladder with related upper urinary tract complications and secondary renal failure. Moreover, the approach to treating this traumatic condition in children must be as much rapid as appropriate. MATERIALS AND METHODS: We evaluated our experience of the last 5 years with 17 patients (12 males and five females), with a mean age of 9.6 years at injury (range 6 months-18 years), all affected by an SCI and with direct trauma involved in more than 50%. Mechanism of injury, lesional level, the mean interval between injury and bladder management onset, and the mean interval between bladder management onset and our last control were evaluated. A standardized diagnostic approach was instituted, and all patients received at least a video-urodynamic evaluation before and after the start of urological management. A continence score was established and evaluated before and at least 6 months after the application of rehabilitation treatments (catheterization, medication). Follow-up ranged from 12 to 60 months (average 29.6 months). RESULTS: Sixteen of the 17 patients showed, at first urodynamic evaluation, a neurogenic overactive bladder. Mean bladder maximum capacity was 287.7ml+/-146.4SD. Mean reflex volume and end filling pressure were 119.7ml+/-76.4SD and 44.6cmH(2)O+/-25SD, respectively. Detrusor sphincter dyssynergia was present in 16 out of 17 of the cases. All patients but one began self-catheterization and medication (anticholinergics). Urinary continence improved in all patients but one. An adjunctive endoscopic procedure for continence was carried out in five out of 17 cases. The upper urinary tract was involved in two out of 17 cases. CONCLUSIONS: A prompt and standardized urological approach to pediatric SCIs is mandatory. The aims of this initial management are the prevention of further secondary damage to the upper tract and the achievement of a socially acceptable degree of urinary continence as soon as possible after the traumatic event.
Notes:
Emanuela Ceriati, Francesco De Peppo, Guido Ciprandi, Paola Marchetti, Massimiliano Silveri, Massimo Rivosecchi (2006)  Surgery in disabled children: general gastroenterological aspects.   Acta Paediatr Suppl 95: 452. 34-37 Jul  
Abstract: Cerebral palsy (CP) is a non-progressive but not unchanging disorder of movement and/or posture, due to an insult to or anomaly of the developing brain. Gastrointestinal surgery can play a role in the treatment of pathologies frequently associated with a condition of neurological impairment such as gastro-oesophageal reflux disease (antireflux procedure), feeding difficulties (percutaneous endoscopic gastrostomy/jejunostomy) and swallowing difficulties (ligation of salivary gland ducts). Gastro-oesophageal reflux occurs in up to 70-75% of children with cerebral palsy. Children with gastro-oesophageal reflux disease (GERD) may present with feeding difficulties, recurrent vomiting and recurrent chest infection associated with poor growth and nutrition, reactive airway disease particularly nocturnal asthma, choking attacks, anaemia, and wheezing. Nutritional deprivation in children with cerebral palsy is the summation of several factors which result in reduced intake. Percutaneous endoscopic gastrostomy (PEG) has radically changed the handling of children with nutritional problems who, before the introduction of this procedure, were force fed parenterally or enterally, by nasogastric tube, conventional surgical gastrostomy or central venous access. In children with CP, PEG is the preferred technique for long-term enteral feeding. Swallowing dysfunction is the main cause of drooling in cerebral palsy, and medical treatment is often inefficient. Surgical treatment involves neurectomy, translocation of the salivary duct, salivary gland resection or salivary duct (parotid and submandibular) ligation. CONCLUSION: This review focuses on the role of surgery in managing gastrointestinal aspects in children with CP and, in particular, surgical experience at our department with fundoplication, PEG placement and ligation of salivary ducts.
Notes:
2004
M De Gennaro, M L Capitanucci, P Mastracci, M Silveri, C Gatti, G Mosiello (2004)  Percutaneous tibial nerve neuromodulation is well tolerated in children and effective for treating refractory vesical dysfunction.   J Urol 171: 5. 1911-1913 May  
Abstract: PURPOSE: We evaluated pain tolerability and the preliminary results of percutaneous tibial nerve stimulation (PTNS) in children with unresponsive lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: A total of 23 children 4 to 17 years old with LUTS refractory to conventional treatment underwent PTNS at 12, 30-minute weekly sessions. Ten patients had idiopathic overactive bladder, 7 were in nonneurogenic urinary retention and 6 had neuropathic bladder. Ten children were carefully evaluated for pain during needle insertion and electrical stimulation using certain scoring systems, namely the faces pain rating scale, Children's Hospital of Eastern Ontario pain scale, visual analogue scale and Questionario Italiano del Dolore. Evaluation was done at the first, sixth and last sessions. An anxiety-depression test was administered. All 23 children underwent clinical and urodynamic evaluation before and after treatment. RESULTS: All except 1 patient completed treatment. An anxious-depressive trait was found in 7 of 10 children/parents on anxiety-depression testing. Regarding pain, the faces pain rating scale never showed the severe pain face, the Children's Hospital of Eastern Ontario scale showed signs of pain at the beginning of each stimulation but not at the end, and the visual analog scale generally showed a low score with a further decrease during the first (p = 0.05), sixth (p = 0.03) and twelfth (p = 0.02) sessions. The Questionario Italiano del Dolore score was significantly related to the affective component of pain (p = 0.002) and it decreased between the first and last sessions. The 10 children with overactive bladder had symptom improvement in 80%, incontinence was cured in 5 of 9 and urodynamics showed normalization of cystometric bladder capacity in 62.5% with no more unstable contractions in those who became continent. Symptoms improved in 71% of the children in urinary retention. One of 3 and 4 of 7 patients had incontinence and post-void residual urine cured, respectively. Urodynamics showed an improved detrusor pressure at maximum flow (p = 0.009) and flow rate (p = 0.005). Symptoms and urodynamics did not significantly change in the neuropathic bladder group. CONCLUSIONS: PTNS is safe, minimally painful and feasible in children. It seems helpful for treating refractive nonneurogenic LUTS.
Notes:
Emanuela Ceriati, Fiorella Deganello, Francesco De Peppo, Guido Ciprandi, Massimiliano Silveri, Paola Marchetti, Lucilla Ravà, Massimo Rivosecchi (2004)  Surgery for ulcerative colitis in pediatric patients: functional results of 10-year follow-up with straight endorectal pull-through.   Pediatr Surg Int 20: 8. 573-578 Aug  
Abstract: Children and adolescents affected by ulcerative colitis (UC) frequently require colectomy because of refractory or chronic symptoms. The aim of this paper is to present our experience and 10-year follow-up results of 28 patients who underwent endorectal pull-through (ERPT) as surgical treatment for UC, with special regard to surgical complications, stooling patterns (frequency of defecation, stool consistency, urgency period), fecal incontinence, and quality of life. A retrospective chart review of these patients was performed to evaluate age at colectomy, indication for surgical treatment, operative procedures, technical details, and early or late complications. Frequency of defecation was less than twice per day in two patients, between three and five times per day in nine patients, and more than six times per day in 10 patients. Stool consistency was normal in 14 patients, loose in five, and liquid in only two cases. Urgency period was normal (minutes) in 14 patients, short (seconds) in four, and absent in three. Ten patients (47%) have perfect or good fecal continence, whereas 11 (52%) patients present moderate to total incontinence. The self-reported emotional health was good in most of the patients. A large number are progressing well at school and are coping with their operations. Studies of quality of life in UC patients who underwent surgical treatment in childhood or adolescence, comparing as well the results according to the surgical technique adopted, must be encouraged.
Notes:
M Silveri, M De Gennaro, C Gatti, C Bizzarri, G Mosiello, M Cappa (2004)  Voiding dysfunction in x-linked adrenoleukodystrophy: symptom score and urodynamic findings.   J Urol 171: 6 Pt 2. 2651-2653 Jun  
Abstract: PURPOSE: Adrenoleukodystrophy is an x-linked genetic disorder characterized by the breakdown of the myelin sheath surrounding nerve cells in the brain and progressive dysfunction of the adrenal gland with 6 possible phenotypes. Lower urinary tract symptoms affect the quality of life of these patients but only sporadic cases have been previously studied by urodynamics. We report to our knowledge the first series in the literature looking at the prevalent pattern. MATERIALS AND METHODS: A total of 14 children and adults 8 to 53 years old (average age 30) with different phenotypes were referred for evaluation. Of the patients 6 had adrenomyeloneuropathy without cerebral involvement (C-) 3 had the adult cerebral form, 3 had the childhood cerebral form, 1 had cerebral involvement (C+) and 1 was asymptomatic. All patients were submitted to a screening protocol, consisting of the self-administered short form questionnaire International Conference on Incontinence Questionnaire-Short Form (ICIQ-SF) and a 3-day voiding diary. Patients were divided in group 1-no urinary symptoms, ICIQ-SF score 0 and no further investigation (3); group 2-frequency/urgency, ICIQ-SF score 1 to 5, uroflowmetry and post-voiding residual urine (4); and group 3-voiding symptoms and incontinence, ICIQ-SF score greater than 5, standard urodynamic examination (7). RESULTS: A neurogenic overactive bladder was the prevalent urodynamic finding (6 of 7 patients), while hypocontractility was found in 1 case. CONCLUSIONS: Vesicosphincteric dysfunction can be explained by spinal and/or cerebral involvement in the different neurological forms of adrenoleukodystrophy. Attempts at treatment with anticholinergics and neuromodulation in 4 of our patients provided temporary benefit with clear subjective amelioration of symptoms and improved quality of life.
Notes:
2003
M Silveri, O Adorisio, A Pane, M Colajacomo, M De Gennaro (2003)  Subinguinal microsurgical ligation--its effectiveness in pediatric and adolescent varicocele.   Scand J Urol Nephrol 37: 1. 53-54  
Abstract: OBJECTIVE: Treatment of varicocele using a microsurgical vein ligation approach is a successful procedure when applied to adult patients. We performed this procedure in prepubertal and pubertal patients in order to verify its feasibility and effectiveness in a younger population. MATERIAL AND METHODS: Between January 1998 and December 1999, 46 patients (average age 13 years) were operated on for a left varicocele using a microsurgical selective vein ligation procedure. All patients were evaluated clinically and using color Doppler ultrasound (CDUS): 34/46 patients were classified clinically as grade III and the remaining 12 as grade II. We used a magnification loupe (x3) in 34/46 patients and an operating microscope (x 10-16) in the remaining 12. RESULTS: The procedure was successful in all but one patient (2.1%) who showed recurrence of the disease at the time of the first postoperative follow-up CDUS scan and required a repeat procedure. The average operative times were 45 and 60 min for loupe and microscopic procedures, respectively. In three cases (6.5%), early postoperative complications (wound infection and transient hydrocele) occurred and quickly resolved. All the patients were discharged within 24 h, returned to normal daily life within 2 days and resumed physical and sporting activities within 1 week. CONCLUSION: Subinguinal "artery- and lymphatic-sparing" microsurgical varicocelectomy, considered the gold standard treatment in adults, also proved to be successful in this preliminary experience with pediatric patients. The minimally invasive approach ensures the prevention of recurrences and/or postoperative complications, and is associated with a very low morbidity rate.
Notes:
Giovanni Mosiello, Maria Luisa Capitanucci, Claudia Gatti, Ottavio Adorisio, Maria Chiara Lucchetti, Massimiliano Silveri, Paolo S Maria Schingo, Mario De Gennaro (2003)  How to investigate neurovesical dysfunction in children with anorectal malformations.   J Urol 170: 4 Pt 2. 1610-1613 Oct  
Abstract: PURPOSE: Neurovesical dysfunction (NVD) is common in children with anorectal malformation (ARM). NVD is mainly related to tethered cord or iatrogenic injury but how to investigate it is still debated. We evaluate the usefulness of routine magnetic resonance imaging (MRI) and urodynamics (UDS) for ARM. MATERIALS AND METHODS: A total of 89 children were screened for sacral, spinal or urological anomalies using sacrum x-ray, MRI, renal and spinal ultrasound, uroflowmetry and/or 4-hour voiding observation. UDS was performed in 60 patients with suspected NVD. Mean +/- SD followup was 9.8 +/- 5.2 years. RESULTS: Of the 89 patients 29 presented with urinary tract anomalies. The prevalence of sacral (53 cases) and spinal cord (54) anomalies was no different between patients with low, intermediate and high ARM. Spinal cord tethering was present in 13 patients with a normal sacrum x-ray. NVD was found in 31 of the 89 patients (hyperreflexia 21 and hypo-areflexia 10), and was associated with sacral and spinal anomalies in 23, occult spinal dysraphism without bone lesion in 3 and sacral anomalies in 5. The incidence of NVD was 40% of cases with low and 51% with high ARM. CONCLUSIONS: Because tethered cord occurs in children without sacral anomalies as well as in those with low ARM, we recommend evaluation of all patients using MRI. When MRI is positive UDS should be performed. We agree with a previous suggestion to evaluate all males with rectourethral fistula and females with cloaca malformations. Finally we recommend a noninvasive evaluation for all other children and UDS when neurogenic dysfunction is suspected.
Notes:
G Mosiello, C Gatti, M De Gennaro, M L Capitanucci, M Silveri, A Inserra, G M Milano, C De Laurentis, C Boglino (2003)  Neurovesical dysfunction in children after treating pelvic neoplasms.   BJU Int 92: 3. 289-292 Aug  
Abstract: OBJECTIVE: To evaluate 10 years of experience, and thus define the occurrence and causes, of neurogenic lower urinary tract dysfunction in children with pelvic neoplasms treated by surgery. PATIENTS AND METHODS: From 1991 to 2000, 33 children were operated by the same surgeons for pelvic neoplasms; 11 were analysed, comprising four each with sacrococcygeal teratoma (ST) and ganglioneuroma, and one each with yolk sac tumour (YST), neuroblastoma and myofibroblastic bladder sarcoma (MBS). The other patients were not assessed because eight had died or were in severe progression, three were treated by bladder substitution and the others were lost to follow-up or refused a urological evaluation. All 11 children were evaluated at >/= 6 months after surgery with a questionnaire about bowel and voiding habits, a neurological and orthopaedic assessment, a noninvasive urodynamic study, renal ultrasonography and spinal and pelvic magnetic resonance imaging (MRI). All patients with signs of bladder dysfunction were evaluated by a pressure-flow study. The results were analysed for surgical approach and anatomical involvement, i.e. group A, extensive surgery for complete tumour excision in the sacral area (ST and YST); group B, surgery for tumour resection in the paraspinal ganglia area (neuroblastoma and ganglioneuroma); and group C, bladder tumour with partial bladder resection (MBS). RESULTS: Eight patients had signs or symptoms related to bladder sphincter dysfunction. One child refused the invasive urodynamic evaluation, leaving seven for analysis (two each ST and ganglioneuroma, one each YST, neuroblastoma and MBS). The urodynamic findings were normal in three children. On spinal and pelvic MRI a presacral lipoma with syringomyelia was discovered in one child with ST. Eight children had bladder dysfunction and two had no neurogenic damage (which was only in sacral tumours); in one child it was related to an upper motor neurone lesion from spinal dysraphism and in the other to a lower motor neurone lesion from surgical injury to the splanchnic nerves. Patients operated for paraspinal tumours had more bladder dysfunction but no signs of neurogenic damage, as did the patient with partial bladder resection. However in Group B, there may have been a transient or incomplete nerve injury in one patient. CONCLUSIONS: Deficits of parasympathetic, sympathetic and somatic innervation of the bladder and the urethra may occur in children after surgery for pelvic neoplasms, related to minor or major surgical trauma. In ST, a tethered cord may be associated with mixed neurogenic damage. Knowledge of bladder dysfunction in anorectal malformations, spinal dysraphism, etc. and the clinical protocol used in these patients also seemed to be useful for understanding the development of voiding dysfunction in patients with neoplasm.
Notes:
2002
M Silveri, O Adorisio, A Pane, A Zaccara, E Bilancioni, C Giorlandino, M De Gennaro (2002)  Fetal monolateral urinoma and neonatal renal function outcome in posterior urethral valves obstruction: the pop-off mechanism.   Pediatr Med Chir 24: 5. 394-396 Sep/Oct  
Abstract: The "fetal urinoma" is a clinical and diagnostic entity due to urinary extravasation, early diagnosed in fetal and/or neonatal period. Both urinoma and urinary ascites, whose pathogenesis is not clear, are recognized associations of uterero-pelvic junction obstruction (UPJO) and neonatal posterior urethral valves (PUV) related with a protected fetal and neonatal renal function. Clinical and experimental studies have demonstrated that fetal urinary tract obstruction results in severe renal parenchymal injury. The so called "pop-off" valve mechanism has been advocated to justify the upper tract function preservation. Protective "pop-off" mechanisms, such as a unilateral reflux and dysplasia, urinary extravasation and congenital bladder diverticula are present in about 30% of patients with PUV. Their presence correlates with better overall long-term renal function. This mechanism has been justified as a sort of self derivation, to explain the renal function preservation in fetal and neonatal period. In the last two years we observed three cases of fetal monolateral urinoma, prenatally detected in fetuses with diagnosis of PUV. All three cases did well for that concerning renal function despite some current opinions suggesting the necessity of a bilateral urinary extravasation in order to preserve upper urinary tract function.
Notes:
2001
M De Gennaro, M L Capitanucci, M Silveri, F A Morini, G Mosiello (2001)  Detrusor hypocontractility evolution in boys with posterior urethral valves detected by pressure flow analysis.   J Urol 165: 6 Pt 2. 2248-2252 Jun  
Abstract: PURPOSE: We evaluated the natural evolution of detrusor voiding contractility in boys who underwent posterior urethral valve ablation using pressure flow analysis, which is a mathematical computerized analysis of pressure flow studies. MATERIALS AND METHODS: Among 30 boys with posterior urethral valves who were being prospectively followed, even if asymptomatic on serial pressure flow studies, 11 were included in our study. These 11 patients had had at least 2 evaluations performed between ages 5 and 15 years, a minimum interval of 4 years between the first and last examination, and all pressure flow studies records available for mathematical analysis of voiding contractility. The first examination had been done at ages 5 to 10 years (average 7 +/- 2.04) and the last one at ages 9 to 15 (12.5 +/- 2.5), including 6 evaluated after puberty. All but 1 patient underwent valve endoscopic resection as a newborn and none received urinary diversion. Voiding symptoms, post-void residual, cystometric bladder capacity and bladder instability were considered. Voiding phase maximal detrusor pressure and flow rate were evaluated and detrusor contractility was calculated by the pressure flow analysis parameters of contraction velocity, detrusor contractile power expressed as watt factor and Schafer's nomogram. Contraction velocity and contractile power factor were considered low if below 2 standard deviations of previously determined normal values. True hypocontractility was diagnosed when at least 2 pressure flow analysis parameters were low. RESULTS: True hypocontractility was detected in 3 of the 11 boys at the first examination and in 8 at the last pressure flow analysis. The remaining 8 and 3 cases of first and last examinations, respectively, were considered to have normal contractility even if 4 of the 8 and 1 of the 3 had 1 low pressure flow analysis parameter (covert hypocontractility). Detrusor contractility worsened in 6 patients, hypocontractility was detected at the first pressure flow analysis in 2, hypocontractility changed to normal in 1 and pressure flow analysis remained normal in 2. Of the 6 boys followed through puberty 5 had hypocontractility, including 3 with cystometric bladder capacity greater than 700 ml., high post-void residual and strained voiding. Of the 11 patients 8 had detrusor instability, including 7 with urge symptoms, at first evaluation which was not found at last examination. CONCLUSIONS: Pressure flow analysis extensively used in men has been confirmed as a useful tool to assess voiding contractility in children. The majority of boys with posterior urethral valves have progressive impairment of detrusor contractility at voiding many years after relief of obstruction. The pattern of hypocontractility, which is detected early on pressure flow analysis, follows a prolonged phase of instability in many cases and leads to an over distended bladder in most patients followed after puberty. Questions arise if this evolution may be prevented by early (pharmacological or rehabilitative) treatment and if it is partially determined by extensive use of drugs acting against unstable detrusor contractions.
Notes:
2000
M L Capitanucci, M Silveri, G Mosiello, A Zaccara, N Capozza, M de Gennaro (2000)  Prevalence of hypercontractility in male and female infants with vesico-ureteral reflux.   Eur J Pediatr Surg 10: 3. 172-176 Jun  
Abstract: PURPOSE: To establish whether infants with vesico-ureteral reflux (VUR) have bladder dysfunction, with difference in gender, age at presentation and severity. PATIENTS AND METHODS: 37 infants (24 male and 13 female) aged 2 to 24 months with II degrees to V degrees degree VUR underwent cystometry. Of those, 10 underwent natural filling cystometry. We considered: instability and maximal voiding detrusor pressure (VDP) to be "high" when it exceeded 90 cm H2O. We defined hypercontractility as high VDP and/or instability. RESULTS: The prevalence of hypercontractility was 75% (18/24) in male and 46% (6/13) in female infants (p<0.004). High VDP was found in 50% (12/24) of male and 7% (1/13) of female patients (p < 0.001); no significant difference was found between male (25%) and female ones (38%) with instability alone. The mean VDP was significantly higher in male than in female infants (p < 0.001), in patients < 1 year of age than in older ones (p<0.001) and in severe than in moderate reflux (p<0.006). The mean voiding detrusor pressure of male infants was higher in severe (108+/-46cm H2O) and bilateral (101.3+/-44cm H2O) than in moderate (76+/-24 cm H2O) and unilateral (73.7+/-24 cm H2O) and in infants < 1 year of age (101.7+/-42 cm H2O) than in older ones (70.2+/-21 cm H2O). Natural filling cystometry confirmed the results of standard urodynamic studies. CONCLUSIONS: Bladder dysfunction is confirmed also in infants with reflux, particularly in male younger patients, and it differs in gender. The pathogenesis of congenital reflux is not always a feature of malformation of the vesico-ureteral junction; therefore, patients with bladder dysfunction must be identified early.
Notes:
M De Gennaro, M L Capitanucci, G Mosiello, P Caione, M Silveri (2000)  The changing urodynamic pattern from infancy to adolescence in boys with posterior urethral valves.   BJU Int 85: 9. 1104-1108 Jun  
Abstract: OBJECTIVE: To determine whether bladder dysfunction in boys with posterior urethral valves (PUV) changes from a uniform pattern of hypercontractility during infancy to the hypocontractility found in adolescence, by reviewing serial urodynamic studies. PATIENTS AND METHODS: Thirty boys with PUV and no voiding symptoms underwent a total of 86 urodynamic tests (mean 2.8 each). The first urodynamic study was undertaken at 1-4 years of age in 15 boys and at 5-13 years in 15. They were re-evaluated at least 3 years later; 15 patients underwent the first and last urodynamic study, respectively, at a mean age of 2.8 and 7.7 years (group A), 10 boys at 6.2 and 8. 8 years (group B) and five at 9.4 and 15.2 years (group C). In 10 boys aged > 5 years the first and last pressure-flow studies (PFS) were analysed using an advanced analysis (PFA) to better identify hypocontractility. RESULTS: Bladder dysfunction was found in 21 of 30 (70%) boys at the first evaluation and in 18 (60%) at the last. In 25 boys the urodynamic pattern changed. Of the 15 boys in group A, 10 of 12 who had hypercontractility changed to normal (seven), low compliance (one) or hypocontractility (two), and two remained stable; two of the remaining three with normal urodynamic studies changed to hypocontractility, while one was unchanged. Among the 10 boys in group B, six with hypercontractility changed to normal (three) or hypocontractility (three); two with normal urodynamic findings and one with low compliance changed to hypocontractility. Of the five boys in group C who showed severe hypocontractility after puberty, three had a normal pattern, one low compliance and one hypercontractility before puberty. The PFA showed a 'weak' detrusor in four of the seven boys who were considered normal on standard PFS. At the urodynamic follow-up, the PFA pattern changed to a 'weak' detrusor in four boys who had a normal (two) or strong (two) detrusor at the first evaluation. CONCLUSIONS: Bladder dysfunction in boys with PUV changes during childhood and through adolescence. The urodynamic pattern of hypercontractility generally found soon after valve ablation gradually changes to hypocontractility in many boys and this pattern seems to be the rule after puberty. The evidence from this series supports the hypothesis that long-term detrusor hyperactivity in boys with PUV leads to detrusor failure, but a longitudinal 15-year follow-up from birth to puberty is needed to validate this concept.
Notes:
M De Gennaro, M Silveri, M L Capitanucci, A Silvano, F Colistro, A Villani, A Zaccara (2000)  N-acetyl-glucosaminidase (NAG) excretion in partially obstructed weanling rats.   Int Urol Nephrol 32: 2. 215-218  
Abstract: The understanding of pathophysiology of obstructed uropathy has been facilitated by animal models with partial ureteric obstruction. Some studies on partially obstructed adult rats have drawn attention to a biphasic pattern of obstructive uropathy: an initial 'destructive' phase and a 'steady' phase in which renal deterioration no longer occurs and in which relief of obstruction would be of no advantage. We aimed to verify if this pattern applies also to younger (weanling) rats with more immature kidneys, resembling those of the human fetus. We measured the NAG-values in the urine samples of partially obstructed animals at different intervals of obstruction and in those of controls. The biphasic pattern proved to be the same as in adult rats as was previously documented, but the turning point occurred earlier (between 10 and 15 days of obstruction). Furthermore, there is evidence of low level values of N-Acetyl-Glucosaminidase (NAG) in the early phase of obstruction (5 days), demonstrating that the increase of tubular enzyme is not due to the operation itself. There is evidence that, if the 'destructive' phase can be precisely identified by biochemical studies, this could help identifying those subjects who could benefit from relief of obstruction.
Notes:
1999
A Zaccara, C Gatti, M Silveri, M Rivosecchi, E Bilancioni, V Spina, C Giorlandino, M De Gennaro, P Bagolan (1999)  Persistent cloaca: are we ready for a correct prenatal diagnosis?   Urology 54: 2. Aug  
Abstract: Cloacal malformations are rare and can present in variable aspects. The importance of ultrasound in detecting these anomalies is well known. Sonographic features vary in accordance with the type of malformation and the gestational age. A positive diagnosis is not possible because of the lack of specific ultrasound findings, which can show similar aspects to other abnormalities. We present 3 cases of prenatal diagnosis of this malformation, emphasizing that in the presence of a plurilobed cystic pelvic fetal mass with associated malformations, such as cardiac, renal, and vertebral anomalies, a persistent cloaca can reasonably be suspected.
Notes:
1998
M De Gennaro, M L Capitanucci, N Capozza, P Caione, G Mosiello, M Silveri (1998)  Detrusor hypocontractility in children with posterior urethral valves arises before puberty.   Br J Urol 81 Suppl 3: 81-85 May  
Abstract: OBJECTIVES: To assess prepubertal boys with posterior urethral valves (PUV) using an analysis of pressure-flow studies to evaluate the voiding phase and thus determine if myogenic failure (hypocontractility) arises before puberty and if it can be detected early. PATIENTS AND METHODS: Eleven boys (8-13 years old) with PUV underwent urodynamics and the results were analysed using pressure-flow mathematical analysis (PFA) of the following variables of detrusor activity: contraction velocity (Vdet), detrusor contractile power expressed as power factor (WF) and Schafer's diagram, which differentiates a 'strong', 'normal' and 'weak' detrusor. Vdet and WF were compared with normal values previously determined in boys of similar age and considered 'low' if more than 2 SDs below the mean. The results of PFA were compared with standard pressure-flow studies and the three classical urodynamic patterns in boys with PUV, as determined by voiding symptoms. The subsequent PFA of seven of the 11 boys were also assessed as they had undergone previous urodynamics when < 8 years old. RESULTS: As assessed by the three patterns of dysfunction, two boys had bladder instability, two had low compliance and three had hypocontractility, with four boys being normal. From the PFA, the Vdet and WF were lower than normal, respectively, in seven and nine of the 11 boys; Schafer's nomogram showed a 'weak' detrusor in seven boys. The PFA suggested a pathology in four of five boys with symptoms and in three of six with no symptoms (two of the six showing a 'low' WF). Moreover, in older (11-13 years) boys, all five had a 'weak' detrusor, a 'low' WF and four a 'low' Vdet. Of the seven patients who underwent repeat PFA, three had a stable WF 3 years later, one (normal) worsened slightly and two were clearly worse, while one, who underwent late (at 3 years old) valve ablation, had an increased WF. CONCLUSIONS: The PFA showed hypocontractility in two-thirds of prepubertal boys with PUV, including asymptomatic patients. These findings confirm the hypothesis that bladder dysfunction in boys with PUV eventually causes detrusor myogenic failure and finally a postpubertal overdistended bladder.
Notes:
M Silveri, M L Capitanucci, G Mosiello, G Broggi, M De Gennaro (1998)  Endoscopic treatment for urinary incontinence in children with a congenital neuropathic bladder.   Br J Urol 82: 5. 694-697 Nov  
Abstract: OBJECTIVE: To verify, in a retrospective analysis, the effectiveness of endoscopic treatment (collagen injection) in children with neurogenic bladder and neurogenic urinary incontinence. PATIENTS AND METHODS: From January 1992 to March 1997, 36 endoscopic collagen injections were performed to treat neurogenic urinary incontinence in 23 patients (mean age 10.9 years, range 6-17 at the time of the first procedure) selected on the basis of clinical status and the patient's motivation. Nineteen patients were affected by myelomeningocele and four had an occult spinal dysraphism. All patients underwent a preoperative cystometric urodynamic evaluation (without urethral pressure measurement) which showed detrusor areflexia in 12, normal reflexia in one and hyper-reflexia in 10 patients. Bladder compliance was considered good (> or =20 cmH2O) in 13 patients and low (10-20 cmH2O) in 10, four of whom had detrusor areflexia. Twenty-one children emptied their bladder by intermittent clean catheterization. The mean (range) follow-up was 19.2 (6-54) months. Twenty (group A) and 16 (group B) procedures, performed early and late in the series, were analysed separately to determine any increase in effectiveness with surgical experience. The evaluation criteria were; the increase in the 'dry' interval (between catheterizations) before and after treatment/s (delta dry); the patient's and parent's satisfaction; the number of endoscopic procedures and quantity of injected materials. RESULTS: There was an improvement (dryness of at least 2 h: delta dry of 1 h) in 13 of 23 patients after 1-3 (mean 1.5) procedures; 10 patients had a 0.2 h increase in delta dry after 1-3 injections and none was satisfied. There was no difference in the delta dry (0.9 vs. 0.7 h) between groups A and B, and/or the patient's/parent's satisfaction. Success rates differed with urodynamic patterns; seven of 10 patients showing no improvement had hyper-reflexia and three of the remaining 12 with areflexia had hypocompliant bladders, while nine of the 13 showing improvement had an areflexic detrusor and low-pressure bladders. CONCLUSION: The efficacy of the treatment depends largely on the urodynamic selection of patients (mainly those with detrusor areflexia and good compliance). The outcome may be improved further by increasing the quantity of injected material and with a longer follow-up, performing the procedure again if advisable. A close postoperative clinical (pad test) and personal observation is necessary to evaluate the outcome and thus optimize the strategy of treatment.
Notes:
A Ponticelli, B D Iacobelli, M Silveri, G Broggi, M Rivosecchi, M De Gennaro (1998)  Colorectal dysfunction and faecal incontinence in children with spina bifida.   Br J Urol 81 Suppl 3: 117-119 May  
Abstract: OBJECTIVES: To quantify colorectal neurogenic dysfunction in children with spina bifida and to evaluate the clinical efficacy of appropriate rehabilitation performed by the coloproctologist in the spina bifida team. PATIENTS AND METHODS: The bowel function of 73 patients with congenital (67) and acquired (six) spinal lesions (age 7-25 years) was evaluated by one physician. Evacuation habit was classified as full bowel control, mild and severe constipation or incontinence. Fifty-two children had mild or severe incontinence or constipation, 22 of whom were treated by the coloproctologist using biofeedback or conventional therapy; 30 were not treated. The outcome was compared between the groups RESULTS: Bowel constipation remained stable in 90% and was complicated in 10% of the untreated patients, while it ameliorated in 59% of patients who received specialist treatment. CONCLUSION: Neurogenic bowel dysfunction needs specialist management to achieve better results, using the concept of controlled incontinence. There was no significant difference between conventional therapy and biofeedback methods.
Notes:
1997
M Silveri, M L Capitanucci, N Capozza, G Mosiello, A Silvano, M D Gennaro (1997)  Occult spinal dysraphism: neurogenic voiding dysfunction and long-term urologic follow-up.   Pediatr Surg Int 12: 2-3. 148-150 Feb  
Abstract: From 1976 to 1994, we followed 55 children with occult spinal dysraphism (OSD). The average age at diagnosis was 4.5 years (range: 24 days - 21 years). In 13 cases the OSD was associated with anorectal anomalies. Urologic symptoms were present at diagnosis in 24 children (43%), but urinary incontinence affected all patients in the evolution of the OSD. At diagnosis, all children underwent complete neurourologic and urodynamic evaluation. Nine required early neurosurgical correction, before 3 years of age. During follow-up, intermittent clean catheterization was started in all patients. Vesicoureteral reflux was present or developed in 17 patients: 15 underwent endoscopic procedures and 2 required bladder augmentation because of upper-tract and renal-function deterioration. Endoscopic treatment for urinary incontinence was performed in 3 children. At long-term follow-up (6 to 18 years), socially acceptable continence was achieved in 78% of the children; renal failure occurred in 8. The long-term results were analyzed in order to compare the evolution of urinary continence and renal function in children with OSD with or without neurosurgery.
Notes:
M L Capitanucci, M Silveri, S Nappo, G Mosiello, N Capozza, M De Gennaro (1997)  Total agenesis of the sacrum and neurogenic bladder dysfunction   Pediatr Med Chir 19: 2. 113-116 Mar/Apr  
Abstract: Total Sacral Agenesis (TSA) is a rare congenital anomaly of the lower vertebral column, frequently associated with bladder dysfunction. The diagnosis is often delayed until the evidence of neurological disorders addresses at neuro-radiological examination. In the last 9 years we observed 7 children, 3 males and 4 females, with TSA. The average age at diagnosis was 8 years (range: 1-15 years). Maternal diabetes was present only in one case. In 5 patients, urological ones have been the symptoms of presentation. In one case, TSA has been discovered because of the presence of a sacral mass (lipoma) and the subsequent development of club-foot. The neurological screening, performed in all patients with anorectal anomalies, led to the diagnosis of total sacral agenesis in a child with anteriorized anus. All patients have been evaluated by means of Magnetic Resonance Imaging, renal ultrasound, voiding cystography, renal nuclear scan and urodynamics. The functional evaluation of the lower urinary tract has shown a pattern of neurogenic bladder dysfunction in all children, while bilateral vesico-ureteral reflux has been detected in 2 cases. Intermittent clean catheterization (ICC) has been instituted at the diagnosis in all children. Surgery for continence and protection of upper urinary tract (bladder augmentation and bilateral ureteral reimplantation) has been performed in one patient. At a medium follow-up of 3 years (range: 1-5 years) 2 patients have been lost, normal renal function and urinary continence have been achieved in 4 and one child is continent but has renal failure. An early diagnosis and a correct neuro-urological evaluation and treatment are necessary to prevent urinary tract damage and achieve urinary continence in these patients. Symptoms, clinical findings and relationship with maternal diabetes are discussed. The diagnosis can be enough early if physicians pay attention to maternal diabetes, subtle neurological symptoms (voiding disturbance, constipation, club-foot) and careful physical examination of the back.
Notes:
Silveri, Capitanucci, Capozza, Mosiello, Silvano, Gennaro (1997)  Occult spinal dysraphism: neurogenic voiding dysfunction and long-term urologic follow-up   Pediatr Surg Int 12: 2/3. 148-150 Mar  
Abstract: From 1976 to 1994, we followed 55 children with occult spinal dysraphism (OSD). The average age at diagnosis was 4.5 years (range: 24 days - 21 years). In 13 cases the OSD was associated with anorectal anomalies. Urologic symptoms were present at diagnosis in 24 children (43%), but urinary incontinence affected all patients in the evolution of the OSD. At diagnosis, all children underwent complete neurourologic and urodynamic evaluation. Nine required early neurosurgical correction, before 3 years of age. During follow-up, intermittent clean catheterization was started in all patients. Vesicoureteral reflux was present or developed in 17 patients: 15 underwent endoscopic procedures and 2 required bladder augmentation because of upper-tract and renal-function deterioration. Endoscopic treatment for urinary incontinence was performed in 3 children. At long-term follow-up (6 to 18 years), socially acceptable continence was achieved in 78% of the children; renal failure occurred in 8. The long-term results were analyzed in order to compare the evolution of urinary continence and renal function in children with OSD with or without neurosurgery.
Notes:
M L Capitanucci, M Colaiacomo, M Silveri, A Silvano, G Mosiello, M De Gennaro (1997)  Vertebral schisis in enuretic children: preliminary results of a statistical analysis   Pediatr Med Chir 19: 6. 457-459 Nov/Dec  
Abstract: It is well known that vertebral schisis is frequent in enuretic children but the true incidence in the normal population is not clear, because all series published are referred to children with associated urinary anomalies, who were submitted to voiding cystography and or intravenous pyelography. This determine a statistical bias. The aim of our study was to compare the prevalence of vertebral schisis in enuretic children and in the general pediatric population. Therefore, we chose 142 enuretic children without associated urological or neurological anomalies and a control group of 152 children, assumed as general population, who were submitted to spinal X-rays during screening for scoliosis or congenital dysplasia of the hip. Vertebral schisis was found in 65% (93/142) of enuretics and in 18% (28/152) of control group children. Maximum association between enuresis and vertebral schisis was found in primary monosymptomatic nocturnal enuresis (82%), while minimum association was found in children with secondary enuresis (57%). The difference in percentage of association enuresis-schisis was statistically significant between enuretics and control group and between primary monosymptomatic and secondary enuresis (p < 0.001). The results of this paper are simply add knowledges on the prevalence of the sacral schisis in enuretic children. But, to speculate the different prevalence in different types of enuresis, the results should confirm that the phenomenon of enuresis is multifactorial and the primary monosymptomatic and secondary enuresis have different etiological factor.
Notes:
1996
M L Capitanucci, M Rivosecchi, M Silveri, M C Lucchetti, G Mosiello, M De Gennaro (1996)  Neurovesical dysfunction due to spinal dysraphism in anorectal anomalies.   Eur J Pediatr Surg 6: 3. 159-162 Jun  
Abstract: Spinal dysraphism (SD) has been found associated with functional abnormalities of anorectal anomalies (ARA). The incidence of SD in these children is probably underestimated and a complete neuroradiological investigation of the lower urinary tract function has not been carried out routinely. In a 2 years time frame we performed urodynamic (UDS) evaluations on 14 patients (8 males and 6 females) with ARA who showed SD at Magnetic Resonance Imaging (MRI) studies. We divided them into 2 groups by age: group A (5 to 18 months) and group B (3 to 12 years). The UDS findings were classified as upper (UMN) and lower motor neuron (LMN) lesion. Out of the 9 children included in group A, 5 showed normal urodynamic pattern, while 4 had pathological UDS findings suggesting UMN lesion. Among the older (group B) children only one had normal and 4 had pathological findings: 2 hyperreflexia suggesting UMN lesion and 2 external sphincter denervation suggesting LMN lesion. These data support the hypothesis that the neurovesical dysfunction found in children with anorectal anomalies results from a possible association with spinal dysraphism. An early morphological evaluation of the spinal cord is mandatory in all children with ARA prior to definitive surgical correction of the malformation. The low incidence of pathological UDS findings in small children if compared to older ones suggest that SD, although present, may be asymptomatic.
Notes:
M De Gennaro, G Mosiello, M L Capitanucci, M Silveri, N Capozza, P Caione (1996)  Early detection of bladder dysfunction following posterior urethral valves ablation.   Eur J Pediatr Surg 6: 3. 163-165 Jun  
Abstract: Urinary incontinence following Posterior Urethral Valves (PUV) ablation has been attributed in the past to sphincter injury, but it is nowadays accepted that bladder dysfunction (BD) plays a determinant role. In order to assess BD evolution, we have evaluated, from 1982 to 1994, 48 boys with PUV by urodynamics (UD) studies. Age of the patients ranged from 10 months to 15 years. A total of 65 examinations were performed. We considered four groups: 0-3 years; 4-7 years; 8-12 years and > 12 years. Uninhibited detrusor contractions (instability), end filling pressure (EFP), bladder capacity and voiding detrusor pressure were evaluated in order to assess the presence of BD distinguishing it in: hypercontractility, hypocontractility and low-compliant bladder. The results collected confirm a high percentage of BD in PUV boys (71%) and the evolution of hypercontractility versus hypocontractility in 60% of patients considered.
Notes:
M L Capitanucci, B D Iacobelli, M Silveri, G Mosiello, M De Gennaro (1996)  Long-term urological follow-up of occult spinal dysraphism in children.   Eur J Pediatr Surg 6 Suppl 1: 25-26 Dec  
Abstract: From 1980 to 1996 we followed up 65 children with occult spinal dysraphism (OSD) out of 85 observed in our urodynamic laboratory. The average age at diagnosis was 4.7 years (range: 1-21 years). In 19 cases (22%) the OSD was associated with anorectal anomalies (ARA). Urinary incontinence or voiding anomalies with urinary tract infection were the presenting symptom in 34 children (49%). At diagnosis all children underwent complete neuro-urological and urodynamic evaluation. Thirty-eight patients underwent neurosurgical correction. Vesicoureteral reflux (VUR) was present or developed in 17 patients: 15 underwent endoscopic procedures and 2 required surgery; 2 needed bladder augmentation because of upper tract and renal function deterioration. Urinary incontinence was treated mainly by intermittent catheterization and anticholinergic drugs, but endoscopic treatment was performed in 3 children. At long-term follow-up (2 to 14 years), socially acceptable continence was achieved in 78% of 57 children (8 could not be assessed because they were less than 4 years old). Upper urinary tract deterioration occurred in 15% and renal failure in 7.5%.
Notes:
M De Gennaro, M L Capitanucci, M Silveri, G Mosiello, M Broggi, F Pesce (1996)  Continuous (6 hour) urodynamic monitoring in children with neuropathic bladder.   Eur J Pediatr Surg 6 Suppl 1: 21-24 Dec  
Abstract: In adults the development of modern equipment for ambulatory monitoring permits long-term evaluation of the lower urinary tract which is more accurate than standard urodynamics (SUD). In children continuous urodynamic monitoring (CUM) has been used infrequently and therefore standardisation of the method has not been previously achieved, nor have the techniques and difficulties of performing 24-hour monitoring been solved. The aim of this study was to identify a technical method of CUM in children which was feasible and to verify its usefulness. For this purpose, we reviewed our preliminary experiences of CUM in children with neuropathic bladder. From March to November 1995 we made an outpatient study of the neuropathic bladders of 11 myelodysplastic children aged 1 to 18 years (average age 10.2 years). 7 of them were males and 4 females. All underwent SUD. With the children resting in bed, a 6-hour CUM (Lectromed MPR-2) was performed using a 4 Fr. microtip intravesical catheter (suprapubic in 3 infants and transurethral in 8 children) and an intrarectal catheter. The parents and/or a nurse monitored the fluid intake and micturition events and recorded the data in a diary. Based on the CUM experience in infants with non-neurogenic bladder dysfunction, the 3 suprapubic studies were done after 12 hours of urethral drainage in order to prevent leakage of urine. In all of the patients we were able to study 2 to 4 bladder fillings during a period of 6 to 8 hours (average 6.5 hours) observation. In 9 of the 11 children the CUM pattern was comparable to the SUD one but in the 2 remaining patients CUM showed uninhibited contractions. Higher uninhibited voiding contraction pressures were recorded in hyper-reflexic bladders. Our preliminary results show that it is feasible to perform CUM in children and that it has advantages over standard cystometry in the investigation of children with neuropathic bladder even if it is carried out for short term (6 hours).
Notes:
1995
P Caione, M Silveri, M L Capitanucci, N Capozza, M De Gennaro (1995)  Urinary continence in Müllerian duct anomalies.   Panminerva Med 37: 1. 14-17 Mar  
Abstract: Müllerian duct congenital anomalies such as Rokitansky-Mayer syndrome, Urogenital Sinus, Vaginal Atresia and Cloacal Malformation are relatively uncommon (1-5% of born female newborns). The complexity of these malformations has taken great interest regarding mainly the surgical procedure available for correction of genital abnormalities. However, the problem of urinary incontinence is still underestimated, and continence is often a goal difficult to achieve. Authors report 11 cases of congenital anomalies of Müllerian duct differentiation which have been observed in the last decade in pediatric age with special regard to preoperatory diagnostic procedures, urinary continence valuation after surgical correction, therapy chances for continence, considering the psychological implication of this unresolved abnormality in everyday-lifetime.
Notes:
1994
M De Gennaro, M Rivosecchi, M C Lucchetti, M Silveri, G Fariello, P Schingo (1994)  The incidence of occult spinal dysraphism and the onset of neurovesical dysfunction in children with anorectal anomalies.   Eur J Pediatr Surg 4 Suppl 1: 12-14 Dec  
Abstract: The urological malformations associated with anorectal anomalies (ARA) are not only anatomical, but also functional, the latter being related to congenital neurovesical dysfunction (NVD). The true incidence of spinal dysraphism (SD) in these children is still unclear and is probably underestimated. The concept of caudal regression could explain its association with the anorectal anomalies. Because of awareness of the late onset of neurovesical dysfunction and/or orthopaedic symptoms in some of our patients, in 1991 we started to screen with magnetic resonance imaging (MRI) the spinal cord of all patients with ARA. Eighteen (44%) out of 41 patients without neurological or orthopaedic symptoms and 7 (78%) of 9 children with neurological or orthopaedics symptoms screened by MRI showed pathological findings. The overall incidence of spinal dysraphism in ARA was 50%, without any great difference with respect to the type of the anomaly (high, low, cloacal). The pathological MRI findings encountered were: fibrolipoma (with or without a thickened filum terminale), tethering of the cord and syringomyelia, and sac anomalies. In order to check the onset of NVD in these children, we performed urodynamic studies with external sphincter electromyography in 24. Grouped by age: 14 were between 5 and 18 months and ten were 4 to 13 years old. Ten patients (71%) out of the first group and 3 (30%) out of the second had a normal urodynamic pattern. A total of 11 children had pathological findings; of these, 4 infants had a hyperreflexic bladder (one with detrusor-sphincter dyssynergia) suggesting upper motor neuron (UMN) lesion. Of the 7 older patients, two had UMN and 3 lower motor neuron (LMN) lesion.(ABSTRACT TRUNCATED AT 250 WORDS)
Notes:
1993
A Zaccara, A Spagnoli, M Broggi, M Silveri, G Broggi (1993)  Administration of 5% +EMLA cream for local anesthesia in ambulatory pediatric surgery   Minerva Pediatr 45: 12. 529-532 Dec  
Abstract: The use of local anaesthesia has been advocated by most pediatric surgeons in order to cut down hospitalization costs as well as to avoid general anaesthesia. In 1992, 26 patients aged 4 to 14 years (avg. 8 years) underwent small surgical procedures with local anesthesia, obtained by the application of EMLA cream 60 to 120 minutes prior to the procedure. EMLA cream is aneutectic mixture of lidocaine and prilocaine with a meeting point at a lesser temperature than the two compounds separately. In this way, concentration of anaesthetics increases up to 80% in the emulsion droplets. This preparation enables small operations to be performed under local anesthesia even in small children who can be safely treated as outpatients. Disadvantages due to the long time necessary for optimal action can be overcome by application of the cream at home by the parents themselves.
Notes:
Powered by publicationslist.org.