Update of the Spanish clinical practice guideline for urinary tract infection in infants and children. Summary of recommendations for diagnosis, treatment and follow-up.

The management of urinary tract infection (UTI) in infants and children has changed significantly over the past few decades based on scientific evidence that questioned the efficacy of strategies used to prevent kidney injury and subsequent progression to chronic kidney disease, which is very unlikely in most paediatric cases. However, there is still substantial heterogeneity in its management and uncertainty regarding the diagnosis, indication of imaging tests, treatment or follow-up in these patients. The Spanish clinical practice guideline has been updated through the review of the literature published since 2009 and a rigorous evaluation of current clinical practice aspects, taking into account the evidence on the benefits of each intervention in addition to its risks and drawbacks to attempt to provide more precise recommendations.

Prevalence, pain trajectories, and presurgical predictors for chronic postsurgical pain in a pediatric sample in Spain with a 24-month follow-up.

ABSTRACT: Pediatric chronic pain, particularly chronic postsurgical pain (CPSP), poses a significant public health challenge, impacting 20% of pediatric populations. While several presurgical predictors have been identified, there is a scarcity of data on long-term outcomes, especially beyond 1 to 2 years postsurgery. Previous research primarily focuses on North American children, creating gaps in understanding CPSP outcomes in diverse health systems, such as in Spain. This study, registered as NCT04735211, investigates CPSP in 159 children and adolescents (mean age = 12.4 years, 37.1% girls, retention rate = 65%) undergoing various surgeries in Spain. The objectives include examining CPSP prevalence (Numerical Rating Scale ≥ 4) at 3, 6, 12, and 24 months, exploring postsurgical pain trajectories through group-based trajectory modeling, and identifying potential presurgical predictors for CPSP (pain intensity, pain catastrophizing, pain anxiety, fear of pain, kinesiophobia, health-related quality of life, pain interference, and physical activity), using multiple logistic regressions. Results show a CPSP prevalence of 41% at 3 months, decreasing to 14% at 24 months. Presurgical factors including pain intensity (adjusted odds ratio [aOR] = 1.25, 95% confidence interval [CI] = 1.02-1.53), pain catastrophizing (aOR = 1.06, 95% CI = 1.00-1.13), and pain anxiety (aOR = 1.06, 95% CI = 1.02-1.11) were associated with CPSP at 3 months. Group-based trajectory modeling revealed 3 postsurgical pain trajectories: Low Pain with Rapid Recovery Group (30.2%), Moderate Pain with Recovery Group (53.5%), and High Pain with Slow Recovery Group (16.3%), with group differences in presurgical predictors, excluding physical activity. This study contributes valuable insights into CPSP, emphasizing the need for long-term follow-up. The findings could inform the implementation of preventive programs for CPSP into diverse health systems.

Validation of the Spanish version of the Pain Catastrophizing Scale for Children (PCS-C).

INTRODUCTION: Pain catastrophizing is a powerful factor that can affect health care outcomes as well as emotional and physical well-being. The Pain Catastrophizing Scale for Children (PCS-C) is widely used, but it is not validated in Spanish. The aim of the study was to translate the PCS-C to Spanish and assess the validity and reliability of the translated version. PATIENTS AND METHODS: This study was carried out in two phases: (a) instrument translation (via a translation-back-translation process) and (b) psychometric analysis (construct validity: exploratory and confirmatory factor analysis, internal consistency, floor and ceiling effects and convergent validity). It had a cross-sectional design and was conducted on a sample of children aged 8-18 years was selected by convenience in a paediatric hospital. The study followed the STARD checklist. RESULTS: The sample included 150 children and adolescents (mean age, 12.45 years; 63.8% male) and their parents. The exploratory and the confirmatory analysis showed a good adjustment of the model to the original 3-model structure with 13 items. The internal consistency of the scale was excellent (Cronbach α, 0.904), and no floor or ceiling effects were detected. In the convergent validity analysis, the Spanish version of the PCS-C showed a moderate correlation with pain interference (r=0.400) and with health-related quality of life (r=0.217-0.303). CONCLUSIONS: These results show that the Spanish version of the PCS-C is a valid and reliable scale to assess pain catastrophizing in children and adolescents.

Cross-cultural adaptation and psychometric properties of Spanish Child Pain Anxiety Symptoms Scale.

INTRODUCTION: Pain anxiety is a psychological component that can regulate and modulate the experience of pain in children and adolescents. It can also have an impact on the outcomes of surgical procedures, chronic pain management and psychological interventions. The aim of our study was to translate the Child Pain Anxiety Symptoms Scale (CPASS) into Spanish and assess the psychometric properties of the Spanish version. PATIENTS AND METHODS: First, the CPASS was translated according to international guidelines. Secondly, to assess the psychometric properties of the translated version, we conducted an analysis in a paediatric sample. A total of 160 children, 49.37% female, with a mean age of 14.5 years (SD, 2.3; range, 8-18 years) completed pain catastrophising, health-related quality of life, pain interference and pain intensity scales. We assessed the following psychometric properties: construct validity (exploratory and confirmatory factor analysis), internal consistency, floor and ceiling effects and convergent validity (correlation of CPASS to the other completed questionnaires completed and with objective aspects of the health history). RESULTS: In the exploratory factor analysis, the final 18-item version (having excluded items 18 and 19) of the CPASS was the best fit, with all items included in the hypothetical construct and exhibiting optimal factor loadings. The confirmatory factor analysis showed that the final 18-item, 4-factor model was adequate for the scale structure. We did not detect any floor or ceiling effects in the final version. Lastly, the results confirmed that the Spanish version has good internal consistency (Cronbach  α, 0.88) and an adequate convergent validity. CONCLUSION: The Spanish CPASS exhibits good psychometric proprieties and it can be used to assess pain anxiety in the paediatric population.

Utilidad del Renograma Diurético tras la Pieloplastia en la Población Pediátrica. ¿Es Necesario de Rutina?

PURPOSE: The diuretic renal scan (MAG3) continues being the gold standard to test the improvement of the urinary drainage after pyeloplasty. Recent researches suggest that there are certain parameters of ultrasound (US) that may indicate an adequate urinary drainage during the follow-up. Our aim is to prove if the measurement of the anteroposterior diameter (APD) of renal pelvis by USS after the pyeloplasty may be a valid screening method to select those patients who also require a MAG3. METHODS: We retrospectively study the patients who underwent pyeloplasty between 2010 and 2019. The sample was divided in two groups depending of the increase or non-increase in the pelvic APD on postoperative US. The results of the MAG3 and the US of both groups were compared in relation to the presence or absence of obstruction and the need for repyeloplasty. RESULTS: We included a total of 124 pyeloplasty, with a median age of 6 months (IQR 4-36); 12 patients showed an increase in pelvic APD, of those 5 had an obstructive MAG3 and renal function >10%, requiring reoperation. Of the 112 patients in whom the pelvic APD did not increase, only one patient needed reoperation due to obstruction in the MAG3, showing the same pre and postoperative pelvic APD. The sensitivity (S) of the US was 83.33% and the specificity (E) was 94.07%. CONCLUSION: A decrease of the renal pelvic APD between US before and after surgery appears to be enough to exclude those patients who will not to develop a recurrence of ureteropelvic junction obstruction (UPJO). In the rest of the patients, it would be necessary study the urinary drainage using MAG3, avoiding its inherent drawbacks in all patients undergoing pyeloplasty.

The effect of the Covid-19 pandemic on pediatric urology

ABSTRACT Medical and surgical priorities have changed dramatically at the time of this pandemic. Scientific societies around the World have provided rapid guidance, underpinned by the best knowledge available, on the adaptation of their guidelines recommendations to the current situation. There are very limited scientific evidence especially in our subspecialty of pediatric urology. We carry out a review of the little scientific evidence based mainly on the few publications available to date and on the recommendations of the main scientific societies regarding which patients should undergo surgery, when surgery should be performed and how patient visits should be organize.

The effect of the Covid-19 Pandemic on pediatric urology.

Medical and surgical priorities have changed dramatically at the time of this pandemic. Scientific societies around the World have provided rapid guidance, underpinned by the best knowledge available, on the adaptation of their guidelines recommendations to the current situation. There are very limited scientific evidence especially in our subspecialty of pediatric urology. We carry out a review of the little scientific evidence based mainly on the few publications available to date and on the recommendations of the main scientific societies regarding which patients should undergo surgery, when surgery should be performed and how patient visits should be organize.

[Impact of COVID-19 during de-escalation in pediatric urology.] / El impacto del COVID-19 en la epoca de transición o "desescalada" en la urología pediátrica.

Medical and surgical priorities have changed dramatically following the COVID-19 pandemic declaration. The rapid spread of the virus and the high number of cases has saturated the health system in our country and has forced many hospitals to redistribute resources to care for infected patients. This has led to asignificant reduction in surgical activity, in some cases reaching the point of delaying all elective interventions by performing only urgent interventions. The decrease in the number of infections with the progressive desaturation of hospitals has currently allowed us to enter a new phase of "de-escalation" or transition in order to recover our surgical activity in pediatric urology, which was practically canceled. It is proposed how surgical care activities such as outpatient care should be deal twith, in addition to the different circuits that patients must maintain and, above all, their and professional safety.

Las prioridades médicas y quirúrgicas han cambiado drásticamente tras la declaración de pandemia de COVID-19. La rápida propagación del virus y el elevado número de casos ha saturado el sistema sanitario de nuestro país y obligado a muchos hospitales a redistribuir sus recursos para atender a los pacientes infectados. Esto ha llevado a una reducción significativa de la actividad quirúrgica llegando al extremo de demorar todas las intervenciones electivas, realizándose únicamente las intervenciones urgentes. La disminución del número de contagios con la progresiva desaturación de los hospitales nos ha permitido en la actualidad entrar en una nueva fase de "desescalada" o de transición para poder recuperar nuestra actividad quirúrgica dentro de la urología pediátrica que fue prácticamente cancelada. Se propone cómo se debe afrontar la actividad asistencial quirúrgica así como la actividad de consultas externas, además de establecer los distintos circuitos que deben mantener los pacientes para su seguridad y la de los profesionales que los atienden.

[Pyeloplasty and vascular crossing detection: Surgical approach influence on pieloureteral junction stricture.] / Pieloplastia y detección de cruces vasculares: análisis de la influencia del abordaje quirúrgico en la evolución de la estenosis de la unión pieloureteral.

OBJECTIVE: Polar vessels are related with pyelo-ureteral stenosis (PUE) in 5-10% of the patients. In the 24% of these cases an intrinsic cause of stenosis can also be found. An increased incidence of polar vessels is found in laparoscopic surgery, compare to open procedures. Our study analyses this difference in our hospital, studying its influence in the aetiology of the disease.MATERIAL AND METHODS: Descriptive and retrospective study of patients operated in our hospital of pyeloplasty, because of PUE between 2009 and 2017. Patients have been divided in two groups: operated by laparoscopy (PL), or operated by conventional surgery (PA). All cases in which polar vessels were seen in TC where excluded. Each group included 47 patients. RESULTS: We found no statistical differences in the age of surgery of the two groups (36,1±41,3 months PL/31,8±37,2 months PA; p=0.527). Overall, 18 polar vessels were found, 15 in PL and 3 in PA. 6 patients of the PA group presented recurrence of the obstruction, and in 2 of them, polar vessels were found in the second surgery. All the 18th cases presented anomalies in the histological study related with inflammation or fibrosis. CONCLUSIONS: The laparoscopic approach allows a better vision of crossing vessels in the cases of extrinsic PUE. Dismembered pyeloplasty might be the best treatment, as an intrinsic cause of obstruction cannot be ruled out according to the observed histological alterations.

OBJETIVO: La incidencia de vasos polares como causa de estenosis pielo-ureteral (EPU) es del 5-10%. En un 24% de los casos asocia, además, una estenosis intrínseca. La aplicación de la laparoscopia para la realización de la pieloplastia ha aumentado significativamente la detección de cruces vasculares respecto a la cirugía abierta. El objetivo del estudio es analizar esta diferencia en nuestro centro, valorando su repercusión en el cuadro de obstrucción.MATERIAL Y MÉTODOS: Estudio descriptivo y retrospectivo de pacientes intervenidos mediante pieloplastia por EPU entre 2009 y 2017. Los pacientes se han dividido en dos grupos: intervenidos por vía laparoscópica (PL) o por cirugía abierta (PA), excluyéndose los casos diagnosticados previamente de vaso polar. La muestra incluyó un total de 94 pacientes, 47 en cada grupo. RESULTADOS: No se han encontrado diferencias estadísticamente significativas en la edad de intervención de ambos grupos (36,1±41,3 meses PL/31,8±37,2 meses PA; p=0,527). Se detectaron 18 vasos polares en total, 15 en PL y 3 en PA. 6 pacientes del grupo PA presentaron recidiva de la obstrucción y 2 de ellos presentaron cruces vasculares no detectados en la primera cirugía. En los 18 casos se encontraron alteraciones histológicas de tipo inflamatorio/fibrosis. CONCLUSIONES: La laparoscopia ofrece una visión mas detallada de la vascularización del riñón, permitiendo una mayor detección de vasos polares frente a la PA. La pieloplastia desmembrada constituye el tratamiento con mejores tasas de éxito, pues no se puede descartar un componente intrínseco obstructivo, además de la compresión vascular.

Thoracoscopic esophagoesophagostomy for a refractory stricture in a patient with esophageal atresia.

Anastomosis stricture is a well-known complication after esophageal atresia repair. Endoscopic dilatation is the gold standard treatment for esophageal stenosis. However, surgical interventions are indicated for refractory cases. We present a 2-year-old girl with esophageal stricture refractory to regular endoscopic dilatation after esophageal atresia repair that underwent thoracoscopic stricture resection and reanastomosis. Although thoracoscopic approach is widely used for esophageal atresia repair, this approach has not been used before for the treatment of anastomosis stricture.

[How do renal function and dilation change after pieloplasty surgery in children?] / ¿Cómo varía la función y dilatación renal después de la cirugía de pieloplastia en edad pediátrica?

OBJECTIVE: The effects of pyeloplasty on renal function are not fully well defined. Our objective is to determine if renal function and renal dilation change after pyeloplasty and the risk factors that may influence in both parameters. METHODS: Retrospective study of patients who underwent pyeloplasty. The parameters analyzed included: age, differential renal function, renal dilation, infection and complications. We compared ultrasound findings with measurement of the anterior-posterior diameter of the renal pelvis (mm) and the time/activity upload curve of the 99mTc- Mercaptoacetyltriglycine renography before and after surgery. Patients were divided in groups by renal function: bad (<20%), diminished (20-40%), normal (40-55%) and supranormal (>55%). RESULTS: A total of 129 patients were included in the study. The normal renal function group was the one undergoing surgery most frequently. Comparison of function before and after surgery showed a statistically significant improvement when preoperative function was bad (<20%) (mean 9.2+/-8.9) or supranormal (>55%) (mean -8.7+/-8.5). In the subgroup of patients under 12 months, it was notable there were significant results only when renal function was diminished (20-40%) (mean 5.6+/-2.2). Renal dilation presented significant changes after surgery in all groups (mean 5.6+/-2.2) (p<0.0001), except in cases presenting complications. CONCLUSIONS: Previous renal function has prognostic value on pieloplasty results. Supranormal renal function should be considered pathologic, but recoverable and it may improve after pieloplasty. In the absence of intra or postoperative complications, pyelocalycial dilation diminished after pieloplasty.

OBJETIVO: Los efectos de la pieloplastia sobre la función renal no están totalmente definidos. Nuestro objetivo es determinar si cambia la función renal y la dilatación renal después de la cirugía de pieloplastia y los factores que pueden influir en ambos parámetros.MÉTODOS: Estudio retrospectivo de pacientes intervenidos de pieloplastia. Se analizaron los parámetros: edad, función renal diferencial, dilatación renal, infección y complicaciones. Se compararon los hallazgos en la ecografía con la medición del diámetro anteroposterior de la pelvis (mm) y la curva de captación tiempo/ actividad en el renograma 99m Tc- Mercaptoacetiltriglicina antes y después de la cirugía. Dividimos a los pacientes en función mala (<20%), regular (20-40%), normal (40-55%) y supranormal (>55%). RESULTADOS: Se incluyeron un total de 129 pacientes, el grupo de pacientes intervenidos más frecuentemente fueron aquéllos que presentaban una función renal normal (40-55%). Al comparar la función antes y después de la cirugía, se observó una mejoría estadísticamente significativa cuando la función preoperatoria es mala <20% (media 9,2 +/-8,9) o cuando es supranormal >55% (media -8,7+/-8,5). En el subgrupo de pacientes menores de 12 meses destacó que sólo hubo resultados significativos cuando la función era regular 20-40% (media 5,6+/-2,2). La dilatación renal presentó cambios significativos (p<0,0001) tras la cirugía en todos los grupos de pacientes (media -12,4 +/-1,2), excepto cuando se habían producido complicaciones. CONCLUSIONES: La función renal previa tuvo valor pronóstico en cuanto a resultados de la pieloplastia. La función supranormal debe considerarse patológica, pero recuperable y puede mejorar tras pieloplastia. En ausencia de incidencias intra o postoperatorias, la dilatación pielocalicial disminuyó tras la pieloplastia.

Wilkie's syndrome in monozygotic twins treated by 3-D laparoscopic duodenojejunostomy.

Superior mesenteric artery syndrome, also known as Wilkie's syndrome, is a rare cause of proximal duodenum obstruction in children. Here, we describe the first pediatric case of superior mesenteric artery syndrome in monozygotic twin brothers. Both patients underwent 3-D laparoscopic duodenojejunostomy at the same age with an uneventful recovery.

[Endoscopically treated vesicoureteral reflux: Evolution of the recurrences.] / Evolución de los casos de recidiva del reflujo vesico ureteral resuelto endoscópicamente.

OBJECTIVES: In recent years, different studies have mentioned the recurrence of vesicoureteral reflux (VUR) endoscopically resolved, an exceptional event after open surgery. The aim of this study is to describe the evolution of the cases of recurrence identified in our center to assess the importance of this event. METHOD: We have identified the cases of VUR that recurred after successful endoscopic treatment in our anesdepartment. We have analyzed diagnostic tests, management and final outcome. RESULTS: In our series, we have a 19.5% incidence of VUR recurrence after endoscopic correction. Out of these patients, 66.2% were asymptomatic. Ultrasound (US) showed modifications only in two of the cases. Five of them had worsen differential renal function in the Tc- 99 dimercapto succinyl choline acid scan (DMSA). We performed a new endoscopic procedure in 49 ureteral units with a success rate of 75.5%. CONCLUSIONS: Most patients with VUR recurrence were asymptomatic, with no alterations in US or DMSA scan. Both endoscopic treatment or surveillance might be appropriate in this setting. These data lead us to reckon that the systematic search for VUR relapse in the asymptomatic patient might not be necessary. Similarly, ultrasound or DMSA monitoring should be aimed to the assessment of established reflux nephropathy, regardless of the possibility of recurrence.

Is the laparoscopic approach appropriate for pediatric subhepatic appendicitis?

INTRODUCTION: Subhepatic appendicitis in children is an unusual condition that can be challenging for the pediatric surgeons to treat. The aim of our study was to compare the outcomes of laparoscopic appendectomies based on the position of the appendix. METHODS: The data of 1736 patients who had undergone laparoscopic appendectomy in our tertiary center were retrospectively reviewed. We compared two groups: subhepatic location (n = 56) and non-subhepatic location (n = 1680). A P-value of less than 0.05 was considered statistically significant. RESULTS: There was no statistically significant difference between the demographic variables of the groups. More than half of the subhepatic appendicitises were gangrenous (44.6%) or perforated (16.1%), whereas most of the non-subhepatic appendicitises were phlegmonous (56.9%). Extracorporeal ligation of the appendix was the preferred technique in both the subhepatic and non-subhepatic groups (69.6% and 89.8%, respectively). The subhepatic group had a statistically significant higher incidence of technical difficulties (1.6%) and abdominal drain (18.6%) than the non-subhepatic group, as well as a longer operative time and hospital stay. However, intraoperative and postoperative complications were similar in both groups. CONCLUSION: Laparoscopic subhepatic appendectomy is safe and does not lead to increased complications. However, the technique is made difficult by the fact that the appendix is an atypical location, and the rate of complicated appendicitis is higher.

Laparoendoscopic single-site nephrectomy in children: Is it a good alternative to conventional laparoscopic approach?

BACKGROUND: Minimally invasive surgery is considered to be the gold standard treatment for nephrectomy in children. In recent decades it has been proposed that laparoendoscopic single-site (LESS) surgery is a feasible alternative to perform laparoscopic nephrectomies. OBJECTIVE: The aim of our study was to compare the safety and efficacy of LESS against conventional laparoscopic (CL) nephrectomy. STUDY DESIGN: From March 2010 to November 2012 charts of pediatric patients who underwent laparoscopic nephrectomy at our tertiary center were revised. The data from 23 nephrectomies performed by either LESS or conventional laparoscopic approach were analyzed retrospectively. A transperitoneal approach was selected for both modalities. Indications for surgery included multicystic dysplastic kidneys (MCDK), hydronephrosis, vesicoureteral reflux (VUR), and renal dysplasia. Malignancy and previous abdominal interventions were exclusion criteria. Differences with a p value less than 0.05 were considered to be statistically significant. RESULTS: Twenty-three laparoscopic nephrectomies were performed, 13 by CL (53.5%) and 10 by LESS (46.5%). The mean age of patients was 3.29 ± 3.5 years. There were no significant differences in age, gender, laterality of pathology, size of the kidneys, and surgical indications between the groups (p = 0.067, 0.431, 0.94, 0.644, and 0.078, respectively). The mean operative times were 120 min for LESS and 132.7 min for CL (p = 0.334). No procedures required conversion to open surgery or to standard laparoscopy. There was one intraoperative complication in each group (p = 0.845). The mean length of stay (LOS), narcotic usages, and postoperative complications were similar in both groups. DISCUSSION: To overcome technical difficulties of the LESS approach, articulated tools have been developed. However, they may be not suitable for use with younger children. Although we performed LESS nephrectomies with conventional laparoscopic instruments, in our study, LESS and CL approach were comparable in terms of operative time, analgesic therapy, LOS, and complications. CONCLUSIONS: LESS nephrectomy for benign kidney diseases performed by skilled laparoscopic surgeons is safe and comparable with CL technique in pediatric patients. However, although minimally invasive development pushes towards "a scar-free surgery" (see Figure), these approaches have been performed in only a few centers in the world. Prospective studies comparing both approaches are necessary to verify the advantages of LESS nephrectomy in children.

Pediatric femoral hernia in the laparoscopic era.

INTRODUCTION: Femoral hernia is a rare and often misdiagnosed condition in childhood. The aim of our study was to demonstrate that the laparoscopic approach improves diagnostic accuracy and offers a safe and effective treatment. METHODS: A retrospective study of 687 pediatric patients who underwent laparoscopic inguinal hernia repair from January 2000 to December 2015 was performed. RESULTS: Femoral hernias were identified in 16 patients (2.3%). The right side was affected in 10 cases (62.5%), the left side in 5 (31.2%), and 1 case was bilateral (6.2%). The mean age of patients was 8.00 ± 3.81 years, and there was a male predominance. Preoperative diagnosis was femoral hernia in eight cases (50%) and indirect inguinal hernia in the remaining eight (50%). Seven children (43.8%) presented with hernia recurrence after having undergone an open ipsilateral indirect hernia repair. A modified laparoscopic McVay technique was performed in 12 cases (70.6%). An epigastric artery injury by trocar occurred in one patient. All operations were completed laparoscopically. The mean surgical time was 45.6 ± 22.9 min for unilateral cases and 110 ± 10.0 min for bilateral cases. No immediate postoperative complications were noted. The mean postoperative hospital stay was 0.6 ± 0.4 days. No recurrence was observed after a median follow-up of 11 years (range, 4-16 years). CONCLUSION: Femoral hernia is a rare pathology in pediatric patients that is often difficult to diagnose. The laparoscopic approach is effective in the diagnosing and treating these hernias, and it allows for the simultaneous repair of multiple groin defects.

Endoscopic Treatment of Vesicoureteral Reflux in Infants. Can We Do It and Should We Do It?

OBJECTIVE: To evaluate the outcomes of endoscopic treatment of vesicoureteral reflux (VUR) performed on infants, and to discuss the possible role of this approach in selected cases. MATERIAL AND METHODS: A retrospective analysis was conducted on the patients who underwent endoscopic injection of a bulking substance for VUR in our institution, and a comparison was made with patients treated during infancy and those treated later in life. RESULTS: A total of 463 ureteral units were included (296 children), of whom 47 were patients less than 1 year of age (infants, INF group); the remaining 416 were included in a second group (children, CHL). In this study, the percentage of high-grade VUR and presence of reflux nephropathy were significantly higher in younger patients. Both early failure and recurrence rate were significantly higher in the INF group when compared with the CHL group. No complications were observed in the INF group. CONCLUSION: Endoscopic treatment of VUR is feasible in patients less than 1 year of age. The effectiveness is lower than when patients are treated at a later age but was still over 80% in our series. There were no complications reported related to the procedure itself or to the general anesthesia. Once it is known that endoscopic treatment of VUR can be performed, controversy arises about the indication of treating patients with VUR. Careful selection of VUR cases that are less likely to spontaneously resolve, presence of breakthrough infections, and parental preference, all play a role in the decision-making process.

Laparoscopic approach for Wilms tumor.

INTRODUCTION: Traditionally, radical nephrectomy for Wilms tumor has been performed through an open approach. Advances in minimally invasive surgery have led to the application of these techniques to malignant lesions, including Wilms tumor. We aim to present our experience with laparoscopic nephrectomy (LN) for Wilms tumor. PATIENTS AND METHODS: Four patients with Wilms tumor were treated preoperatively with chemotherapy and afterwards underwent an LN and lymph node sampling. Four ports were placed and the tumors were removed without morcellation in an endoscopic bag through an incision by extending the umbilical or the suprapubic port site. RESULTS: The average age at the time of surgery was 3 years and 7 months (range, 23 mo to 6 y). There were no intraoperative complications and the blood loss was minimal in all cases. The mean operative time was 125 minutes (range, 90 to 160 min). Among our patients, we had 2 stage IV and 2 stage I cases. The mean time of hospitalization was 3 days (range, 2 to 4 d). There were no long-term complications at the mean follow-up of 3 years and 6 months. CONCLUSIONS: LN for Wilms tumor may be considered as an option in selected patients. Minimally invasive surgery allows the surgeon to follow all the oncologic principles required for surgical treatment of this neoplasm and provides the advantages of these techniques for cancer patients. Preoperative chemotherapy is essential to decrease tumor size and facilitate the dissection avoiding tumor rupture.