Pedobarographic outcome after subtalar screw arthroereisis in flexible juvenile flatfoot.

BACKGROUND: Flatfoot is a frequent skeletal deformity in childhood that can be minimally invasively treated by arthroereisis. QUESTION: Does the motion of juvenile flexible flatfoot normalize after arthroereisis? METHOD: Pedographic measurements were obtained from 39 patients preoperatively, six months postoperatively and compared to a healthy group. The footprints were divided into 8 areas. The selected parameters were: contact area and force-time-integral. RESULTS: After surgery, a load shift from the medial to the lateral areas was detected under the midfoot and forefoot. The force-time-integral under the hallux normalized. However, under the lateral midfoot, the postoperative force-time-integral was significantly higher than in the control group. SIGNIFICANCE: The study shows that arthroereisis is able to correct the medially displaced load distribution of juvenile flexible flatfoot. However, further investigations are required to find out if the higher punctual loading under the lateral midfoot may cause problems in the long term.

Epidural pressure changes following caudal blockade: a prospective, observational study.

PURPOSE: Recent case reports raise the question as to whether anesthetic agents injected into the epidural space could lead to a 'compartment syndrome' and neurovascular sequelae. Single-shot caudal epidural anesthesia has been established as a safe technique, but changes in pressure in the caudal epidural space have not been described. Our aim was to study pressure changes to provide preliminary information for future studies design. METHODS: We prospectively measured the pressure changes in the caudal epidural space in 31 pediatric patients. The pressures were measured at loss of resistance, immediately after the bolus dose of local anesthetic (1 ml/kg), and at 15-s intervals up to 3 min. RESULTS: The pressure at loss of resistance was 35.6 ± 27.8 mmHg. A pulsatile waveform was observed once the epidural space was accessed. The pressure after administration of the local anesthetic bolus (1 ml/kg 0.2 % ropivacaine/bupivacaine with 1:200,000 epinephrine) was 192.5 ± 93.3 mmHg. The pressure decreased to 51.5 ± 39.0 mmHg at 15 s, 26.9 ± 9.9 mmHg after 2 min, and 24.7 ± 11.7 after 3 min. The return to baseline occurred at approximately 45-60 s. CONCLUSIONS: Following the administration of the local anesthetic into the caudal epidural space, there was a marked, but transient, increase in the pressure within the epidural space. It appears unlikely that a slow epidural catheter infusion could lead to a sustained increase in epidural pressure.

Utilization and costs associated with robotic surgery in children.

BACKGROUND: To evaluate utilization and costs associated with robotic surgery in children. MATERIALS AND METHODS: We identified patients in the Pediatric Health Information System database who underwent robotic surgery between October 2008 and December 2013. After determining the six most frequently performed surgeries in this group, we identified patients who underwent equivalent nonrobotic surgeries at the same hospitals. Equivalent surgeries were defined as open procedures for urology and laparoscopic procedures for general surgery. We examined trends in the numbers of surgeries performed and compared hospitalization costs between patients undergoing elective robotic and nonrobotic surgery for each procedure. RESULTS: The number of robotic surgeries performed increased by 19.8% per year (P < 0.001). The most common robotic surgeries performed were pyeloplasty (n = 760), ureteral reimplantation (n = 351), nephrectomy (n = 145), partial nephrectomy (n = 56), gastrointestinal antireflux procedure (n = 61), and cholecystectomy (n = 46). Total increase over time was primarily driven by increases in urologic surgeries (17.4% per year, P < 0.001). Postoperative length of stay was shorter after robotic surgeries than equivalent open urologic surgeries but not equivalent laparoscopic general surgery procedures. Total hospitalization costs were higher for robotic surgeries than equivalent urologic or general surgery procedures. CONCLUSIONS: Use of robotic surgery in pediatrics is increasing especially in the management of urologic conditions. Costs of robotic surgery-associated hospitalizations were higher than nonrobotic surgery-associated hospitalizations.

Carbon dioxide monitoring during laparoscopic-assisted bariatric surgery in severely obese patients: transcutaneous versus end-tidal techniques.

Various factors including severe obesity or increases in intra-abdominal pressure during laparoscopy can lead to inaccuracies in end-tidal carbon dioxide (PETCO2) monitoring. The current study prospectively compares ET and transcutaneous (TC) CO2 monitoring in severely obese adolescents and young adults during laparoscopic-assisted bariatric surgery. Carbon dioxide was measured with both ET and TC devices during insufflation and laparoscopic bariatric surgery. The differences between each measure (PETCO2 and TC-CO2) and the PaCO2 were compared using a non-paired t test, Fisher's exact test, and a Bland-Altman analysis. The study cohort included 25 adolescents with a mean body mass index of 50.2 kg/m2 undergoing laparoscopic bariatric surgery. There was no difference in the absolute difference between the TC-CO2 and PaCO2 (3.2±3.0 mmHg) and the absolute difference between the PETCO2 and PaCO2 (3.7±2.5 mmHg). The bias and precision were 0.3 and 4.3 mmHg for TC monitoring versus PaCO2 and 3.2 and 3.2 mmHg for ET monitoring versus PaCO2. In the young severely obese population both TC and PETCO2 monitoring can be used to effectively estimate PaCO2. The correlation of PaCO2 to TC-CO2 is good, and similar to the correlation of PaCO2 to PETCO2. In this population, both of these non-invasive measures of PaCO2 can be used to monitor ventilation and minimize arterial blood gas sampling.

Effects of Different Types of Intermittent Fasting Interventions on Metabolic Health in Healthy Individuals (EDIF): A Randomised Trial with a Controlled-Run in Phase.

The effects of intermittent fasting (IF) on health promotion in the healthy population remain controversial. Therefore, our study aimed to analyse the efficacy and feasibility of different IF protocols and evaluated the effects within a cohort with a controlled-run in phase on the body mass index (BMI) as the primary outcome, the body composition, and metabolic and haematological markers in healthy participants. A total of 25 individuals were randomised into three fasting groups: 16/8 fasting (n = 11), 20/4 fasting (n = 6), and alternate-day fasting (ADF, n = 8). Assessments were conducted at baseline (visit 1), after a four-week controlled-run in phase (visit 2), and after eight weeks of fasting (visit 3). Both the BMI (p = 0.01) and bodyweight (p = 0.01) were significantly reduced in the ADF group, which was not seen in the 16/8 and 20/4 groups (p > 0.05). Adherence was different but not statistically among the groups (16/8: 84.5 ± 23.0%; 20/4: 92.7 ± 9.5%; and ADF: 78.1 ± 33.5%, p = 0.57). Based on our obtained results, the data suggest that some fasting interventions might be promising for metabolic health. However, adherence to the specific fasting protocols remains challenging even for the healthy population.

Efficacy of Fasting in Type 1 and Type 2 Diabetes Mellitus: A Narrative Review.

Over the last decade, studies suggested that dietary behavior modification, including fasting, can improve metabolic and cardiovascular markers as well as body composition. Given the increasing prevalence of people with type 1 (T1DM) and type 2 diabetes mellitus (T2DM) and the increasing obesity (also in combination with diabetes), nutritional therapies are gaining importance, besides pharmaceutical interventions. Fasting has demonstrated beneficial effects for both healthy individuals and those with metabolic diseases, leading to increased research interest in its impact on glycemia and associated short- and long-term complications. Therefore, this review aimed to investigate whether fasting can be used safely and effectively in addition to medications to support the therapy in T1DM and T2DM. A literature search on fasting and its interaction with diabetes was conducted via PubMed in September 2022. Fasting has the potential to minimize the risk of hypoglycemia in T1DM, lower glycaemic variability, and improve fat metabolism in T1DM and T2DM. It also increases insulin sensitivity, reduces endogenous glucose production in diabetes, lowers body weight, and improves body composition. To conclude, fasting is efficient for therapy management for both people with T1DM and T2DM and can be safely performed, when necessary, with the support of health care professionals.

Acute Fluid Intake Impacts Assessment of Body Composition via Bioelectrical Impedance Analysis. A Randomized, Controlled Crossover Pilot Trial.

Bioelectrical impedance analysis (BIA) has proven to be particularly useful due to its inexpensive and rapid assessment of total body water and body density. However, recent fluid intake may confound BIA results since equilibration of fluid between intra- and extracellular spaces may take several hours and furthermore, ingested fluids may not be fully absorbed. Therefore, we aimed to evaluate the impact of different fluid compositions on the BIA. A total of eighteen healthy individuals (10 females, mean ± SD age of 23.1 ± 1.8 years) performed a baseline measurement of body composition before they consumed isotonic 0.9% sodium-chloride (ISO), 5% glucose (GLU) or Ringer (RIN) solutions. During the visit of the control arm (CON), no fluid was consumed. Further impedance analyses were conducted every 10 min after the fluid consumption for 120 min. We found statistically significant interactions between the effects of solution ingestion and time for intra- (ICW, p < 0.01) and extracellular water (ECW, p < 0.0001), skeletal muscle mass (SMM, p < 0.001) and body fat mass (FM, p < 0.01), respectively. Simple main effects analysis showed that time had a statistically significant effect on changes in ICW (p < 0.01), ECW (p < 0.01), SMM (p < 0.01) and FM (p < 0.01), while fluid intake did not have a significant effect. Our results highlight the importance of a standardized pre-measurement nutrition, with particular attention to hydration status when using a BIA for the evaluation of body composition.

Effects of Different Fasting Interventions on Cardiac Autonomic Modulation in Healthy Individuals: A Secondary Outcome Analysis of the EDIF Trial.

The impact of a fasting intervention on electrocardiographic (ECG) time intervals and heart rate variability (HRV) is a focus that is scarcely analyzed. The main focus of these secondary outcome data was to describe the impact of a different fasting intervention on ECG and HRV analyses. Twenty-seven healthy individuals participated in this study (11 females, aged 26.3 ± 3.8 years, BMI 24.7 ± 3.4 kg/m2), including a pre-intervention controlled run-in period. Participants were randomized to one of the three fasting cohorts: (I) alternate day fasting (ADF, n = 8), (II) 16/8 fasting (16/8 h of fasting/feasting, n = 11) and (III) 20/4 fasting (20/4 h of fasting/feasting, n = 8). An analysis of baseline ECG parameters and HRV parameters following different fasting interventions demonstrated the safety of these interventions without impacting on heart rate variability parameters during Schellong-1 testing, and revealed comparable preserved autonomic cardiac modulation (ACM) independently of the fasting intervention. In conclusion, different short-term fasting interventions demonstrated no safety ECG-based concerns and showed comparable ACM based on ECG and HRV assessments. Finally, our research topic might strengthen the scientific knowledge of intermittent fasting strategies and indicate potential clinically preventive approaches with respect to occurring metabolic disease and obesity in healthy young subjects.

[A rare case of bilateral femoral neck fracture in a 5-year-old girl with autosomal dominant osteopetrosis type 2]. / Seltener Fall eines beidseitigen metaphysären Ermüdungsbruches des Schenkelhalses bei einem 5­jährigen Mädchen mit autosomal-dominant vererbter Osteopetrose Typ 2.

The rare case of a 5­year-old girl with autosomal dominant osteopetrosis type 2, who suffered metaphyseal fractures of the femoral neck on both sides within 6 months is described. On the right side, the diagnosis was made 3 months after the onset of symptoms, so that a coxa vara occurred. The treatment was surgically treated through a valgus osteotomy with fixation of the femoral head with K­wires. Three months after the operation, the girl complained of a painful restriction of movement on her left side. Radiologically, a metaphyseal femoral neck fracture without coxa vara was diagnosed and in situ fixated with 2 K wires. Two months after the second operation, there was a symmetrical free range of motion of the hips with no symptoms. The metaphyseal femoral neck fracture with verticalization of the growth plate is a serious disease in autosomal dominant osteopetrosis due to the development of a coxa vara, which, if diagnosed at an early stage, can be treated well with in situ fixation. If the coxa vara has already developed, a valgus osteotomy should be performed despite the risk of delayed bone healing.

Glucose and Fructose Supplementation and Their Acute Effects on Electrocardiographic Time Intervals during Anaerobic Cycling Exercise in Healthy Individuals: A Secondary Outcome Analysis of a Double-Blind Randomized Crossover-Controlled Trial.

The impact of glucose and fructose supplementation on acute cardiac effects during cardiopulmonary exercise testing (CPET) is a topic that is rarely investigated. The aim of the presented secondary outcome analysis of a double-blind, randomized crossover-controlled trial was to investigate the impact of glucose (Glu), fructose (Fru), glucose and fructose (GluFru), and sucralose on electrocardiogram (ECG), heart rate variability (HRV), premature ventricular complexes (PVCs), and heart rate turn points (HRTP) during CPET. Fourteen healthy individuals (age 25.4 ± 2.5 years, body mass index (BMI) 23.7 ± 1.7 kg/m2, body mass (BM) of 76.3 ± 12.3 kg) participated in this study, of which 12 were included for analysis. Participants received 1 g/kg BM of Glu, 1 g/kg BM of Fru, 0.5 g/kg BM of GluFru (each), and 0.2 g sucralose dissolved in 300 mL 30 min prior to each exercise session. No relevant clinical pathology or significant inter-individual differences between our participants could be revealed for baseline ECG parameters, such as heart rate (HR) (mean HR 70 ± 16 bpm), PQ interval (146 ± 20 ms), QRS interval (87 ± 16 ms) and the QT (405 ± 39 ms), and QTc interval (431 ± 15 ms). We found preserved cardiac autonomic function by analyzing the acute effects of different Glu, Fru, GluFru, or sucralose supplementation on cardiac autonomic function by Schellong-1 testing. SDNN and RMSSD revealed normal sympathetic and parasympathetic activities displaying a balanced system of cardiac autonomic regulation across our participating subjects with no impact on the metabolism. During CPET performance analyses, HRV values did not indicate significant changes between the ingested drinks within the different time points. Comparing the HRTP of the CPET with endurance testing by variable metabolic conditions, no significant differences were found between the HRTP of the CPET data (170 ± 12 bpm), Glu (171 ± 10 bpm), Fru (171 ± 9 bpm), GluFru (172 ± 9 bpm), and sucralose (170 ± 8 bpm) (p = 0.83). Additionally, the obtained time to reach HRTP did not significantly differ between Glu (202 ± 75 s), Fru (190 ± 88 s), GluFru (210 ± 89 s), and sucralose (190 ± 34 s) (p = 0.59). The significance of this study lies in evaluating the varying metabolic conditions on cardiac autonomic modulation in young healthy individuals. In contrast, our participants showed comparable cardiac autonomic responses determined by ECG and CPET.

Glucose and Fructose Supplementation and Their Acute Effects on Anaerobic Endurance and Resistance Exercise Performance in Healthy Individuals: A Double-Blind Randomized Placebo-Controlled Crossover Trial.

BACKGROUND: The effects of glucose, fructose and a combination of these on physical performance have been subject of investigation, resulting in diverse findings. OBJECTIVE: The aim of this study was to investigate how an individualized amount of glucose, fructose, and a combination of these compared to placebo (sucralose) alter endurance performance on a cycle ergometer, lower and upper body resistance exercise performance at individualized thresholds in healthy young individuals. METHODS: A total of 16 healthy adults (9 females) with an age of 23.8 ± 1.6 years and a BMI of 22.6 ± 1.8 kg/m2 (body mass (BM) 70.9 ± 10.8 kg, height 1.76 ± 0.08 m) participated in this study. During the screening visit, the lactate turn point 2 (LTP2) was defined and the weights for chest-press and leg-press were determined. Furthermore, 30 min prior to each exercise session, participants received either 1 g/kg BM of glucose (Glu), 1 g/kg BM of fructose (Fru), 0.5 g/kg BM of glucose/fructose (GluFru) (each), or 0.2 g sucralose (placebo), respectively, which were dissolved in 300 mL of water. All exercises were performed until volitional exhaustion. Time until exhaustion (TTE) and cardio-pulmonary variables were determined for all cycling visits; during resistance exercise, repetitions until muscular failure were counted and time was measured. During all visits, capillary blood glucose and blood lactate concentrations as well as venous insulin levels were measured. RESULTS: TTE in cycling was 449 ± 163 s (s) (Glu), 443 ± 156 s (Fru), 429 ± 160 s (GluFru) and 466 ± 162 s (Pla) (p = 0.48). TTE during chest-press sessions was 180 ± 95 s (Glu), 180 ± 92 s (Fru), 172 ± 78 s (GluFru) and 162 ± 66 s (Pla) (p = 0.25), respectively. CONCLUSIONS: Pre-exercise supplementation of Glu, Fru and a combination of these did not have an ergogenic effect on high-intensity anaerobic endurance performance and on upper and lower body moderate resistance exercise in comparison to placebo.

Variation in management of duplex system intravesical ureteroceles: a survey of pediatric urologists.

PURPOSE: Controversy exists in ureterocele management and the literature lacks clear management guidelines. We surveyed pediatric urologists to understand practice patterns and perceptions of managing duplicated system intravesical ureterocele. MATERIALS AND METHODS: The survey consisted of 3 case scenarios, including upper pole obstruction without reflux, ureterocele without hydronephrosis and reflux after incision. The survey evaluated management at patient age 3 months and used a Likert scale to evaluate management strategies later in life. RESULTS: We analyzed 233 responses. There was agreement in prophylactic antibiotic use and diagnostic evaluation. When managing a duplicated system intravesical ureterocele with poor upper pole function, 50.6% of respondents advocated puncture at age 3 months. However, when followed conservatively for 18 months, the preference changed to surgical management with partial nephrectomy preferred by 61.8% of respondents. When managing the condition without hydronephrosis, watchful waiting was preferred by 47.2% of respondents while 35.6% chose puncture and another 16.3% chose partial nephrectomy. Most respondents advocated ureteral reimplantation to manage reflux to the upper pole after puncture while some preferred endoscopic Deflux® injection. Continued nonoperative management while off prophylaxis was not preferred. Most respondents viewed the risks of surgery and anesthesia as important factors when weighing options in children younger than 3 months. Preventing symptoms and preserving function of the renal units were significant factors guiding surgical intervention. CONCLUSIONS: We found significant variation in management of duplicated system intravesical ureterocele. Most pediatric urologists see fewer than 10 cases per year, stressing the need for multi-institutional, randomized, controlled studies to evaluate management and long-term outcomes.

Variation among pediatric urologists and across 2 continents in antibiotic prophylaxis and evaluation for prenatally detected hydronephrosis: a survey of American and European pediatric urologists.

PURPOSE: No clear practice guidelines exist to evaluate prenatally diagnosed hydronephrosis or recommend antibiotic prophylaxis. We hypothesized that among pediatric urologists there is significant variability in prenatal hydronephrosis evaluation and management. MATERIALS AND METHODS: We created a survey questionnaire to answer certain questions, including 1) what prenatal parameters trigger postnatal evaluation, 2) how pediatric urologists manage prenatal hydronephrosis and 3) what are their recommendations for antibiotic prophylaxis. Survey questions included demographics and practice patterns, and influences concerning radiographic tests and prophylactic antibiotics. A Web based survey link was sent to members of the Urology Section, American Academy of Pediatrics and the European Society for Pediatric Urology. We received 156 responses. We also compared practices based in Europe in 60 respondents and in the United States in 70. RESULTS: There was significant response variability to all questions answered with no question achieving a consensus of more than 50%. European and American respondents were equally distributed in regard to years in practice and number of patients per month. Radiographic factors influenced the decision to perform further imaging or provide prophylactic antibiotics in around 50% of respondents. There was wide variability in parameters triggering intervention and in prophylactic antibiotics. Pediatric urologists in practice more than 15 years were less likely to prescribe antibiotic prophylaxis at birth than those in practice less than 15 years. Variation also existed by geographic region with American physicians more likely to prescribe antibiotics for any prenatal hydronephrosis compared to their European counterparts (77% vs 40%, p <0.005) and European physicians more likely to be influenced by prenatal pelvic diameter when obtaining postnatal imaging (unilateral 70% vs 47%, p = 0.009 and bilateral 55% vs 36%, p = 0.03, respectively). European pediatric urologists were also more likely to order renal scans than their American counterparts. These differences were less significant for high grade hydronephrosis. CONCLUSIONS: Even among pediatric urologists there is considerable variation in radiographic resource and prophylactic antibiotics use when managing prenatal hydronephrosis. Some variation may be explained by regional differences but it is most probably due to absent clear guidelines based on prospective, randomized, controlled trials.

5-year prospective results of dimercapto-succinic acid imaging in children with febrile urinary tract infection: proof that the top-down approach works.

PURPOSE: Evaluation in children after febrile urinary tract infection involves voiding cystourethrogram, which emphasizes urinary reflux rather than renal risk. We believe that early dimercapto-succinic acid renal scan after febrile urinary tract infection predicts clinically significant reflux and which children should undergo voiding cystourethrogram. The criticism of this approach is that some reflux and preventable renal damage would be missed. This study validates the use of initial dimercapto-succinic scan and presents 5-year renal outcomes. MATERIALS AND METHODS: We prospectively studied children with febrile urinary tract infection using initial dimercapto-succinic acid renal scan, voiding cystourethrogram and renal/bladder ultrasound. Children with anatomical or neurological genitourinary abnormality and protocol failures were excluded from analysis. Dimercapto-succinic acid scan was repeated at 6 months if initially abnormal. Followup was done every 6 months in all children for at least 5 years. RESULTS: A total of 121 children fit study inclusion criteria and completed the 5-year study. Overall 88 initial dimercapto-succinic acid scans (73%) were abnormal and 78 children (64%) had urinary reflux. The OR of having clinically significant reflux predicted by abnormal initial scan was 35.4. Abnormal followup scan did not predict clinically significant reflux. Overall subsequent urinary tract infection developed in 32 patients (26.5%) and 27 (85%) had an abnormal initial scan. No child with a normal initial scan had clinically significant reflux. CONCLUSIONS: Dimercapto-succinic acid scan can predict clinically significant reflux and children at greatest renal risk. Initial dimercapto-succinic acid scan should be done in all children after febrile urinary tract infection while voiding cystourethrogram should be reserved for those with an abnormal initial dimercapto-succinic acid scan.

Computer enhanced visual learning method to train urology residents in pediatric orchiopexy provided a consistent learning experience in a multi-institutional trial.

PURPOSE: Computer enhanced visual learning is a new method to train residents to perform surgery using components and provide them with access to a personalized surgical feedback archive using the Internet. At the parent institution in Chicago we have already noted that this method is effective to train residents to perform orchiopexy. To assess whether this new methodology to enhance resident surgical instruction is generalizable we performed a prospective, multi-institutional clinical trial. MATERIALS AND METHODS: We prospectively compared ratings of resident skills in performing pediatric orchiopexy at 4 institutions as novices to computer enhanced visual learning curriculum (study group) vs those at the single institution accustomed to that curriculum (control group). All urology residents and attending physicians accessed the computer enhanced visual learning curriculum. After each case was completed the attending urologist rated resident performance of each step and provided feedback on weaknesses for the resident to remediate at the next case. The learning score was calculated for each case as the sum of the ratings × case difficulty. Scores on the first case and the best case were compared between the study and control groups by resident and institution. RESULTS: The study group included 6 attending physicians and 36 residents (99 orchiopexies). The control group included 8 attending physicians and 21 residents (108 orchiopexies). Between the study and control groups we noted no significant differences in average resident postgraduate year (2.9 vs 2.7), number of procedures per resident (3.9 vs 4.9), frequency with which residents viewed computer enhanced visual learning preoperatively (63% vs 74%) or attending physician provision of feedback (63% vs 88%) (each p not significant). Similarly of residents who completed more than 1 surgery there was no significant difference in the percent who showed an improved learning score in the study vs the control group (86% vs 79%) or in the magnitude of average improvement (10.5 vs 13.4) (each p not significant). CONCLUSIONS: The institutional groups did not differ in training resident skills using computer enhanced visual learning for pediatric orchiopexy. Thus, the program provides a consistent learning experience and is generalizable across institutions. We believe that this tool will change the practice of how training programs educate residents by enhancing learning by a checklist approach and a computer platform to archive feedback and remediation.

Urinary tract infections in children: recommendations for antibiotic prophylaxis and evaluation. An evidence-based approach.

Urinary tract infections (UTIs) are common in children, but the routine work-up and treatment recommendations are still controversial. Long-term complications, including renal scarring, hypertension, and renal failure, have been the main concern and the reason for use of antibiotic prophylaxis and invasive imaging techniques. In the past several years, numerous studies have been published comparing different imaging protocols and questioning the use of antibiotic prophylaxis. The latest guidelines from the United Kingdom, published in 2007, recommend more selective approach based on evidence. In this review, we critically appraise the literature published in the past 5 years. The risk of developing long-term complications after a UTI is extremely low, and the evidence suggests selective imaging to a select group of children at risk. Finding those at risk for long-term complications is yet to be determined.

Intermittent torsion of the spermatic cord portends an increased risk of acute testicular infarction.

PURPOSE: Intermittent torsion of the spermatic cord is an episode of acute torsion of the spermatic cord that resolves spontaneously. We compared the outcomes in boys with intermittent spermatic cord torsion treated electively with testicular fixation with those in boys with a history of recurrent scrotal pain who required emergent operation for acute spermatic cord torsion without spontaneous resolution. MATERIALS AND METHODS: A retrospective review revealed 17 boys who required emergency operation for acute spermatic cord torsion and 30 who underwent elective surgery for intermittent spermatic cord torsion. The clinical presentation, number of recurrent painful episodes, lead time to operation, prior alternate diagnoses, intraoperative findings and clinical outcomes were recorded. RESULTS: There was a mean of 2 recurrent painful episodes in the elective group and 3 in the emergency group (p <0.005). In the elective group all boys were cured of pain after bilateral testicular fixation with 100% testicular preservation at a mean of 4 months of followup. In the emergency group at a mean of 10 months of followup the testicular preservation rate was 47% (p <0.01). Intraoperatively an ipsilateral bell clapper malformation was found in 100% of boys in each group. A contralateral bell clapper malformation was noted in 90% and 88% of boys in the elective and emergency groups, respectively. CONCLUSIONS: When diagnosed accurately, intermittent spermatic cord torsion can be treated with elective testicular fixation with an excellent outcome. Misdiagnosis may create a cohort of boys with intermittent spermatic cord torsion who are at risk for acute unresolved torsion and potential testicular loss. Urologists should be proactive in recommending elective scrotal exploration when intermittent spermatic cord torsion is a likely diagnosis.

Robot-assisted laparoscopic management of duplex renal anomaly: Comparison of surgical outcomes to traditional pure laparoscopic and open surgery.

INTRODUCTION: Surgical management of duplex renal anomaly (DRA) is complex because of individual anatomic variation, competing priorities of vesicoureteral reflux (VUR) and ureteral obstruction present in the same child, the varied differential function of the different renal moieties, and the presence of voiding dysfunction and recurrent urinary tract infection (UTI). Robot-assisted laparoscopic (RAL) surgical management has been under-reported in this group of children but is becoming a viable alternative to traditional open surgery. OBJECTIVE: The aim was to report the surgical outcomes of a series of children with DRA who had RAL surgery and compare these outcomes to historical cohorts of open and laparoscopic surgery. STUDY DESIGN: This was a retrospective analysis of a prospective series of children who had RAL surgery for DRA over an 8-year period. Forty-five RAL surgeries were performed in 47 children. RAL heminephrectomy (RAL HN) was performed in 19 children for poorly or non-functional renal moiety. One had staged bilateral RAL HN. RAL ureteroureterostomy (RAL UU) was performed in 14 children for upper pole ureteral obstruction. Thirteen RAL common sheath ureteral reimplants (RAL csUN) with or without ureteral tapering were performed in 12 children with VUR and UTI. Diagnosis and demographics, results of preoperative imaging, intraoperative time stamps, perioperative complications, success rate, and renal outcomes were recorded. RESULTS: Low-grade VUR present preoperatively in the RAL UU group all resolved within the follow-up period. Four (25%) children in the RAL HN group developed de novo VUR after surgery, which resolved in two (50%) and required surgery in two (50%). Grade I VUR after RAL csUR that occurred in two (14.3%) children was asymptomatic and observed when off preventative antibiotics. DISCUSSION: Most children with DRA who need surgical treatment can be offered RAL surgery. We report good outcomes and improved operative times for RAL HN and UU that approach historical open and pure laparoscopic cohorts. However, RAL csUR, especially with ureteral tapering, is more complex and inherently susceptible to complications, and has not met the outcomes of the open gold standard. The limits of this study are that selection bias is present, and there is no study control cohort. CONCLUSIONS: This report achieves its aim to report surgical outcomes of children who had RAL surgery for DRA.