[Long-term renal function in Wilms tumor survivors]

OBJETIVE

To evaluate long-term renal function and morbimortality in non-syndromic Wilms tumor (WT) survivors.

METHODS

Retrospective study about WT patients treated in 1993-2017, according to SIOP protocols. Mortality, glomerular filtration rate (GFR), prevalence of hypertension and requirement of dialysis and renal transplant were evaluated. Chronic kidney disease (CKD) was defined as GFR <90 ml/min/1.73 m2.

RESULTS

Thirty-nine children were treated in the 25 analyzed years. Median time of follow-up was 6 years (0.5-21 years). 48% (19 patients) debuted with stage I or II. Four cases had high-grade histo-logy. Mortality rate was 10%. GFR data were found in 37 patients. Chronic kidney disease (grade I-II) turned up in 6 patients (16%). No patient required renal replacement therapy or renal transplant. 16% of patients developed CKD in both unilateral and bilateral WT, (p>0.05); OR 1.04 (IC 95% 0.09-10.9). Identical results were obtained comparing patients treated with or without radiotherapy (16%). Children with stage I-III had CKD in 11% vs. 40% of patients with stage IV (p=0.12); OR 5.3 (IC 95% 0.61-45). None of them presented hypertension in addition.

CONCLUSIONS

In the current study the prevalence of CKD was low but not negligible, although no patients required renal replacement therapy or renal transplant. Bilateral renal involvement and radiotherapy were not associated with CKD development. Metastatic disease determines a higher risk of CKD.

[Long-term results of hypospadias surgery. Urinary and sexual function, and psychological impact]

OBJECTIVES

To determine the current status of the patients operated on for hypospadias in our region, in order to adapt the surgical technique to their real needs.

MATERIAL AND METHODS

A descriptive and observational study. Interviews were conducted with hypospadias surgery patients in our hospital between 1976 and 1996, focusing on their urinary and sexual function and psychological impact. We performed a descriptive statistical analysis and comparisons between types of hypospadias (SPSSv19).

RESULTS

566 patients were operated on for hypospadias during the study period, interviewing 100 aged between 18 and 40 years. The 73% were distal and 27% proximal. Of all patients, 30% do not have an orthotopic meatus, 10% have fistula, 18% have some degree of stenosis and 52% have penile curvature. The 13% feel to have had disadvantages in their life. They consider they have a different penis in: size (19%), glans shape (17%), curvature (14%), scars (10%) and lowest hole (7%). Sexual satisfaction was valued at 8.9 on a scale of 1 to 10, with no differences between the types of hypospadias. Proximal hypospadias patients have more ejaculation problems: 42% versus 11% in distal hypospadias. The 68% of the proximal ones would like to improve compared to 20% of the distal in: appearance (17%), size (11%) and way to urinate (11%).

CONCLUSIONS

Anatomic abnormalities are maintained but the aspects that values the adult patient differ from those persecuted by practiced surgeries. A significant percentage of patients would try to get another surgery. Keeping the size of the penis and natural appearance of the glans should be a priority in hypospadias surgery.

[Animated biofeedback for the dysfunctional voiding syndrome]

OBJECTIVES

To analyze clinical and electromyographic treatment outcome of dysfunctional voiding (DV) with animated Biofeedback (Bfb). Clinical or electromyographic variables associated with higher success rate were checked.

PATIENTS AND METHODS

Cross-sectional study of patients with DV, that in 2010- 2015 followed animated Bfb program. Efficacy was measured with Uroflowmetry, Electromyography (EMG) and validated clinical questionnaire. Inclusion criteria: no myelodysplasia, no anatomical malformations and a minumin of 3 Bfb sessions. Clinical variables: age, number of sessions, daytime leaks, nocturnal enuresis, constipation, UTI, VUR. Flow measurement variables: morphology of curves, electromyogram, flows, and elevated post void residual (PVR).

RESULTS

Of 37 patients who received Bfb, 27 girls who met inclusion criteria were selected. Mean age: 7.8 years (2.5). Twelve (44%) had detrusor overactivity on urodynamics concomitantly. Globally, all clinical and flowmetry parameters improved. Clinically 33.5% had complete resolution of symptoms, 37% improved (> 50% of symptoms according to criteria ICCS) and 29% had no improvement. In EMG, 74% achieved normal perineal relaxation. Constipation at baseline is associated with lower rates of success (cure: 13 vs. 58%, p = 0.019; cure + improvement: 60% vs. 83% p> 0.05). The absence of RPM at the end of the study was associated with clinical improvement (cure: 66.7% vs. 0%, p = 0.012; cure + improvement: 89% vs. 60%, p> 0.05).

CONCLUSIONS

Bfb in DV provides cure or improvement and electromyographic resolution are 69 and 74% respectively. The absence of constipation is associated with higher success rates. The High RPM correlates with persistence of clinics.

[Neonatal surgical site infection: multicentric survey on prophylactic measures]

OBJECTIVES

Surgical site infection (SSI) has a considerable impact on neonatal morbidity. There are known risk factors such type of surgery (clean/contaminated), prematurity, surgical length, hypoalbuminemia, previous infection, prolonged mechanical ventilation, and so on. Many perioperative factors have not been studied, opposite to adults. We have developed a survey on intraoperative attitudes and measures, as surgical wound management in Neonates among pediatric surgeons, to seek for a wider consense.

METHODS

Multi-response survey with 22 items, based on the Surgical Infection Society NIH 2008 clinical guideline. Each item poses a question on perioperative attitudes, surgical aspects and wound management. Each question is subdivided in two categories, depending on urgency and type of surgery (clean/contaminated).

RESULTS

159 surveys were sent. Among those, we received back 51 (32%). 69% of the interviewed surgeons use clorhexidin to prepare surgical field, 25% use Iodine solutions. 69% never use diathermy to incise skin. There was no agreement on the use of sterile plastic adhesive drapes, intra-cavity lavage, changing surgical gloves/material, or wound irrigation during closure. 82% never use cyanocrilate dressing. Intracuticular skin suture and simple stitches were used indistinctly. Wound management and dressings were not uniform and depended on each pediatric unit.

CONCLUSIONS

The survey reflects the lack of consensus regarding prophylactic measures and wound management among pediatric surgeons who care after surgical neonates.

[Ultrasound markers in the follow up of pyeloplasty]

INTRODUCTION

There are few studies on the long term follow up of pyeloplasty. Is there a residual pelvis dilatation in all successful procedures? How is the long term evolution of the ecographic parameters and measures postoperatively (PO)?

PATIENTS AND METHODS

We reviewed all successful Anderson-Hynes pyeloplasties performed on obstructed renal pelvis with an anterio-posterior diameter >15 mm during 2001-2010. Ultrasound controls were made at 3 and 6 months postoperatively and then yearly afterwards. We aimed to describe time course of hydronephrotic changes following unilateral pyeloplasties, using three parameters: pelvic anterior-posterior diameter (APD), pelvis/córtex ratio (P/C R) and the percentage of improvement in APD (PI-APD).

RESULTS

41 patientswereincluded. Age at intervention ranged from 2 months to 10.3 years (mean 13 months, 83% were operated in the first year of life). Median of follow up was 4 years (range 1-12 years). Mean APD preoperatively was 25 mm (range 16-54). At the third month PO, PI-APD was 28%. At the sixth month control, it was 51%, and remained stable during the next consecutive yearly controls, without statistically significant variations (50%, 57%, 60%, 51%, 39%, 46%, 38%, 42%). P/C R diminished significantly already in the third month control (4.6 vs. 1.8, p=0.03). We observed complete disappearance of hidronephrosis in 8 patients (19.5%).

DISCUSSION

Although early postoperative ultrasound changes occur, the ultrasound parameters remain often stable during long term follow up. We documented the complete normalization of renal pelvis (no hydronephrosis) in one of every five patients.

[Mesenteric cysts in children]

OBJECTIVES

Mesenteric cysts (MC) are benign cystic tumors that grow within mesentery or omentum tissue. We have reviewed the cases of MC reported and operated on in our centre.

MATERIAL AND METHODS

Retrospective review of clinical records of MC cases during the period 2002-2012 RESULTS: A total of 7 patients were found. Mean age was 5.3 years (range 3-11). Abdominal ultrasound was the diagnostic tool in all cases, except for one, which was diagnosed during laparotomy. All presented abdominal pain, 5 (71.4%) vomiting, 4 (57%) gross abdominal distension, 3 (42.8%) fever, and none presented complete abdominal obstruction, although 2 patients (28.6%) had slight sub-occlusion symptoms. All MC were pedicled or sesil, except for our last case, which extended into the retroperitoneum. All specimens were reported as Limphatic Malformation. None recurred.

CONCLUSIONS

MC in children are mostly Lymphatic Malformations of mesentery or omentum origin, and clinical presentation varies from chronic abdominal pain to sudden-onset peritonitis or volvulus. About 50-60% require intestinal resection and anastomosis.

[Uroflowmetry values among asymptomatic children who underwent tubularized incised plate urethroplasty]

PURPOSE

Tubularized incised plate uretroplasty (TIPU) technique for hypospadias repair or Snodgrass procedure has become increasingly popular since its description in 1994. The elasticity of the neouretra is reduced and several studies have pointed out that flow parameters of the patients operated on this procedure show some grade of asymptomatic functional obstruction, although there are reports on the improvement of these parameters on the mid term. We evaluated the functional outcome in the form of urinary flow in asymptomatic children following uncomplicated TIPU.

PATIENTS AND METHODS

We reviewed the urine flow rate of asymptomatic toilet trained children who underwent TIPU at our institution between 2005 and 2012. Uroflowmetries were performed in a serial fashion, during the follow up visits at the first months after the repair and yearly afterwards. Unfavourable values were plateau or interrupted curves and peak flow below the 5th percentile of a validated Nomogram for children (Gutiérrez-Segura). Statistical work up: SPSS 15.0.

RESULTS

85 patients were eligible. The mean age at surgery was 2.7 years. Median follow up was 29 months (6-82 months). Hypospadias was distal penile in 76 (89.5%) and mid penile in 9 (10.6%). We obtained 131 uroflowmetries (1.54 per patient) at a mean age of 5.1 years (2.5-8). 66.7% of the peak flow values and 55% of the average flow values were below the 5th percentile of the Nomogram. Flow curve was normal (bell- shaped) in 35 charts (26.5%), irregular in 38 (28.8%) and plateau in 56 (42.4%). Peak flow values improved in the second year after surgery (compared to the first year values): 7 ml/sgvs 8.09 ml/sg (p=0.07). The difference was significative in low volumes (<100 ml) (6.3 vs 7.8 ml/sg, p=0.04). Bell-shaped curve rate also grew: 21% (6/29) vs 28% (29/74), p> 0.05. We constructed a specific Nomogram for this population.

CONCLUSIONS

Our data confirm that many asymptomatic patients who undergo TIPU repair present altered flow patterns. Spontaneous partial improvement is the norm after the first year of surgery.

[Evaluation of the effect of hospital clown's performance about anxiety in children subjected to surgical intervention]

OBJECTIVE

To be hospitalized is a highly distressing event for children. At present, a resort used in Spain and other countries to reduce children's anxiety in the health context are hospital's clown. We studied the effect of the hospital's clowns about the anxiety in children that going to be operated.

METHODS

We recruited 60 children aged 6 to 10 years scheduled to undergo elective surgery. 30 children would have clowns before the surgery (case group) and 30 would not have them (control group). In the case group, two clowns performed for children. We measured the anxiety with several scales (STAIC, CCPH, faces scale), after the performance and until 7 days after the surgery.

RESULTS

The outcomes show both groups a tendency to increase anxiety but the children of the case group showed less increase at the anxiety's score. In the control group is showed that the children are more alterated at seven days from the discharge.

CONCLUSIONS

Children that receive the clown's care, have tendency to be less distressing and with less fear that another ones, measurement by STAIC and faces scale, and these results are maintained seven days after the discharge.

[Endoscopic treatment of primary vesicoureteral reflux in childhood. Review of 989 cases in a 9 years period]

PURPOSE

The primary vesicoureteral reflux (PVUR) is the most common urologic pathology during childhood and affects from 1 to 3% of newborn. It causes acute pyelonephritis (APN) and renal damage in addition to hospital visits with high economic and social costs. Nowadays the endoscopic treatment (ETR) seems to be the most suitable one for the reflux, due to its lower biological cost and its good results. We report our experience in the endoscopic treatment of the primary vesicoureteral reflux (ETR) in Murcia Pediatric Hospital from 1998 to 2007.

PATIENTS AND METHODS

We present a retrospective study describing 989 patients (1498 ureters) treated by means of ETR. All patients were treated with chemoprophylaxis since the moment of the diagnosis. ETR was fulfilled by the surgeon in an ambulatory way and with Sevofluorano. Deflux, Macroplastique and Coaptite were used. Age, stade, number of ETR, material, chemoprophylaxis, ureterocistoneostomy and ETR costs were evaluated.

RESULTS

One-thousand four-hundred and ninty-eight ureteral units, corresponding to 989 patients, (51,2% males), at ages from 4 months to 21-years-old, have been treated by means of ETR. The average age was 4-years-old. Grade III reflux was the most common of all, with 801 ureters affected. Deflux was used in 777 patients, Macroplastique in 203 and Coaptite in 9. No problems in early post-operation happened and the average length was shorter than 2 hours. Forty-eight hours after, 7 patients had to be treated due to APN. Four patients showed late litiasis related to ETR. Two suffered litotomy. The 89.9% of the patients were cured at first ETR. The 11.2% needed a second ETR, with 2.12% of failure (21 patients). Six cured with the third injection and 2 needed a fourth ETR. Thirteen children were treated with ureterocistoneostomy. Radiological correction have not relation with PVUR level and does not show significant differences. Failure regarding the used material was around 9% for Deflux, 11.8% for Macroplastique and 66.6% for Coaptite. The cost of ETR was 1.400 euros, the cost of ureterocistoneostomy 4.822 euros and of the chemoprophylaxis 4.158,7 euros per year.

CONCLUSIONS

From our experience, ETR is a method as safe as surgery and with less morbility. It is, furthermore, much more predictable than chemoprophylaxis and implies lower economical, biological and social costs than those other methods. In case of failure, ETR does not prevent any other kind of treatment. We regard ETR as a first order therapeutic gesture when dealing with PVUR.

[Adherence formation following different forms of treatment of peritoneal lesions]

The authors analyse the adhesion forming capacity of various forms of treating a peritoneal lesion. There were four groups each of 10 rats, all receiving the same peritoneal lesion. The control group did not receive any treatment for this injury; in the remaining three, the peritoneal lesion was treated with electrocoagulation, mechanical suture or manual suture. The animals were killed after 30 days, and adhesions quantified using an original method of the authors, which evaluates number, thickness, tenacity, vascularisation and site. Electrocoagulation significantly generated the smallest number of adhesions. The application of suture stimulated the formation of adhesions to a larger extent, manual suture more so than the mechanical method.

[Neoformation of intestinal mucosa on dura mater patches. Application in the surgical treatment of short bowel syndrome. Experimental study in rats]

The creation of intestinal neomucosa on grafts or materials implanted in the intestinal wall is one of the therapeutic procedures that has been tested in the short bowel syndrome. This paper presents the results obtained after intestinal implanting lyophilised dural patches in an experimental model of massive intestinal resection in rats. Data were contrasted with those of a control group subjected to massive resection without patches. The findings reveal: 1) high mortality related to the surgical technique; 2) slight improvement in the ponderal curve; 3) slowing down of intestinal transit; 4) neomucosa on the patch, with histological characteristic similar to normal. We conclude that although the creation of neomucosa on dural patches is feasible and conditions a slight improvement in the animal's nutritive status, application of the procedure is not practical in treatment for the short bowel syndrome due to the high mortality rate.