Characterization and treatment of enuresis in overactive bladder patients

OBJECTIVE

To define the types of overactive bladder (OAB) patient enuresis and study daytime bladder treatment response.

MATERIALS AND METHODS

A prospective, multi-center study of OAB patients with enuresis treated with anticholinergics or neuromodulation over 3 months from 2019 to 2021 was carried out. Variables achieved from the voiding calendar and PLUTSS (Pediatric Lower Urinary Tract Score System), as well as enuresis-related variables, were collected. Two study groups were created -primary enuresis (PE) and secondary enuresis (SE). Partial enuretic response (PER) was defined as a >  50% reduction in baseline enuresis, and complete enuretic response (CER) as a 100% reduction. A multivariate analysis was eventually conducted to detect CER independent predictive factors.

RESULTS

152 OAB patients were included. 109 of them (71.7%) had enuresis -29 (26.7%) SE and 80 (73.3%) PE. PLUTSS score was higher in PE patients than in SE patients (20.8 vs. 17.2; p= 0.001). PER and CER were significantly higher in the SE group (55.2% vs. 15%; p= 0.000 in PER, and 48.3% vs. 5%; p= 0.000 in CER). In the multivariate analysis, SE patients demonstrated to have a 50-fold increased probability of responding to daytime bladder treatment than PE patients (OR: 49.79; 95%CI: 6.73-36.8).

CONCLUSIONS

Most OAB children have PE and not SE, which explains why enuresis does not typically respond to daytime bladder treatment. Characterizing the type of enuresis in OAB children is important to adequately approach treatment.

Pop-off mechanisms as protective factors against chronic renal disease in children with posterior urethral valves

OBJECTIVE

To identify whether pop-off mechanisms act as protective factors against chronic or end-stage renal disease in patients with posterior urethral valves.

MATERIALS AND METHODS

A retrospective cohort study of patients with posterior urethral valves treated at a tertiary care children's hospital was carried out. Demographic, clinical, analytical, and radiological variables were collected. Considered as pop-off mechanisms were: unilateral high-grade vesicoureteral reflux with ipsilateral renal dysplasia and without involvement of the contralateral kidney, urinoma, prenatal urinary ascites, large bladder diverticulum, and persistent urachus. Multiple logistic regression and multivariate Cox regression were used for statistical analysis.

RESULTS

70 patients undergoing posterior urethral valve surgery in our institution from 2010 to August 2020 were included. 14 (20%) had pop-off mechanisms and 56 (80%) did not. Pop-off mechanisms protected against developing chronic renal disease (0% vs. 27%; p = 0.03) and could protect against the need for renal replacement therapy (0% vs. 9%; p = 0.58). Nadir creatinine values (mg/dl) were predictors for the development of chronic renal disease (0.37 vs. 0.53; p < 0.0001) and the need for renal replacement therapy (0.38 vs. 1.21; p < 0.001).

CONCLUSIONS

Pop-off mechanisms act as a protective factor against chronic renal disease in patients with posterior urethral valves. Nadir creatinine is a predictor of chronic renal disease and the need for renal replacement therapy. A larger sample size is needed to determine whether pop-off mechanisms protect against the need for renal replacement therapy.

Advantages of endoscopic pilonidal sinus treatment

INTRODUCTION

Classic treatment of pilonidal sinus is associated with a high rate of complications and a long and painful postoperative period requiring daily wound care, with a decrease in patients' quality of life. The objective of our study was to evaluate the effectiveness and advantages of the endoscopic technique vs. conventional surgery of pilonidal sinus in the pediatric population.

METHODS

A quasi-experimental study was carried out in pediatric patients undergoing pilonidal sinus surgery at a single institution in 2019. Excision and healing by secondary intention (EHSI), excision and primary closure (EPC), and Pediatric Endoscopic Pilonidal Sinus Treatment (PEPSiT) were compared. The surgical technique chosen was surgeon-dependent.

RESULTS

49 patients were studied - 14 undergoing PEPSiT, 23 undergoing EHSI, and 12 undergoing EPC. Full healing process was faster in PEPSiT than in EHSI (11 weeks earlier; 95% CI: 6.2-15.9; p < 0.001). Pain on the Visual Analogue Scale (VAS) and need for analgesics were less in the PEPSiT group (p = 0.001). Mean time to return to normal life was shorter with PEPSiT - 78 days earlier than EHSI (95% CI: 42.2-114.9; p < 0.001) and 39 days earlier than EPC (95% CI: -2.5-81.4; p = 0.06). No complications were recorded with PEPSiT, whereas complication rate with EHSI was 69.6%, and complication rate with EPC was 58.3% (p = 0.001).

CONCLUSIONS

Endoscopic pilonidal sinus treatment is effective, with a short and painless postoperative period, and easy wound care. It allows for an early return to normal life without restrictions.

Our experience with laparoscopic Anderson-Hynes ureteropyeloplasty

OBJECTIVE

To analyze whether the application of laparoscopic surgery in the treatment of pyeloureteral junction obstruction (PUJO) has been beneficial for pediatric patients.

MATERIALS AND METHODS

Medical records of all patients undergoing PUJO surgery from January 1997 to December 2017 were retrospectively reviewed. Patients with <6-month follow-up and patients undergoing video-assisted surgery were excluded. Open surgery was compared with laparoscopic surgery. The following data were collected: surgical approach, need for and type of urinary diversion, operating time, mean hospital stay, complications, and restenosis rate. Ultrasound and diuretic renogram parameters were also retrieved.

RESULTS

328 Anderson-Hynes pyeloplasties were analyzed, 142 of which had been performed laparoscopically. Overall success rate was 96.6%, and complication rate was 11.9%. No significant differences were noted between open and laparoscopic surgery. In 97.5% of surgeries, urine was diverted using an external nephroureteral catheter, a double J stent, or a Salle stent, with significant differences between open and laparoscopic surgery. Mean operating time was significantly longer in laparoscopic surgery. Mean hospital stay was significantly shorter in the laparoscopic surgery group.

CONCLUSION

Surgical approach does not play a role in PUJO surgery success. Therefore, in our view, laparoscopic surgery should be the technique of choice in pediatric patients.

[Analysis of efficacy in diaphragmatic plication with minimally invasive surgery]

OBJECTIVE

Diaphragmatic paralysis may result difficulty for respiratory compromise and extubation. We study the effectiveness of diaphragmatic plication held in its two modalities: videothoracoscopy assisted surgery (VATS) and percutaneous with needle.

MATERIAL AND METHODS

Retrospective study of diaphragmatic plication performed in our center in the past three years. Review of clinical histories, analyzing the variables: sex and age, etiology and laterality, surgical indications, technique, ventilation support, complications and outcome. Data Analysis with SPSS 18.0.

RESULTS

From 2009-2012, 24 diaphragmatic plication were realized (7 left, 13 right, 2 bilateral) in 22 children (15 males). The mean age was 10.4 months (2 to 23.1). In 68.1% paralysis was secondary to thoracic surgery. In 12 patients was performed VATS and in 5 percutaneous with needle. Surgical indications were: respiratory distress (69.1%) with intercurrent processes (pneumonia, bronchiolitis, and atelectasis) and failure of extubation in 27.3%. After diaphragmatic plication in 90.9% respiratory symptoms remitted. Extubation was accomplished in all patients, requiring ventilator support for 12-96 hours. Mean hospital stay was 7.5 days (3 to 13.5). There were no complications derived from surgery. There were two recurrences (9.2%) and only one was reoperated (4.6%). The percutaneous technique decreased the required postoperative analgesia and improved cosmetic outcome in 90.9%.

CONCLUSIONS

The diaphragmatic plication by minimally invasive surgery reduces operative morbidity and facilitates extubation of ventilator-dependent patients with diaphragmatic paralysis. The percutaneous technique improves the cosmetic results and reduces pain after surgery, without finding differences with VATS.

[Comparative study of thoracoscopy versus thoracotomy in esophageal atresia]

INTRODUCTION

Thoracoscopic treatment of esophageal atresia type 3 has been previously reported to be feasible but no study clearly showed the benefits of thoracoscopy compared to open procedure. The aim of this study was to compare the outcome of esophageal atresia type III treated by thoracoscopic or open procedure.

MATERIAL AND METHOD

From january 2000 to december 2006, 31 children were operated, 17 by thoracotomy (weight range from 1750 to 4020 g) and 14 by thoracoscopy (weight range from 2110 to 4160 g). Neonatal deaths from an independent condition (3 cases in thoracotomy group) were excluded from the study and we analyzed 14 children in each group. Analyzed data included length of surgery, length of post operative assisted ventilation, length of pleural drainage, length of stay in ICU, delay before oral feeding, length of morphine analgesia, length of hospitalization and rate of complication.

RESULTS

Length of morphine analgesia was higher in thoracotomy group than in thoracoscopic group (mean 6.6 days versus 5.3 days, p = 0.16). Length of hospitalization was also higher in thoracotomy group (mean 22.6 days versus 19.1 days, p = 0.3). The rate of complication with thoracoscopy was not higher need of oesophageal dilatation (21% in thoracoscopic group versus 14% in thoracotomy group), need of Nissen fundoplication (21% in thoracoscopic group versus 28% in thoracotomy group).

CONCLUSION

Thoracoscopic treatment of esophageal atresia type III reduces the need of morphine analgesia and the length of stay without increasing the risk of postoperative complications.

[Applications of robotic surgery in pediatric urology. Description of the technical principles]

The incorporation of the robotic surgery to the pediatric urology permits less invasive and more precise therapeutic alternatives for the patient. It corrects some limitations of laparoscopic surgery, with its 3 dimensional vision, accurate movements without tremor, and more degrees of freedom, allows an ergonomic position to the surgeon and has a shorter learning curve. Different procedures were performed with da Vinci surgical system, in a secure and effective way, as pyeloplasty, total or partial nephrectomy, orchidopexy, intra or extravesical ureteral reimplant, enterocystoplasty, Mitrofanoff and others. These techniques and their outcomes will be reviewed, as well as some of the challenges still posed by this methodology.