Characterization and treatment of enuresis in overactive bladder patients. / Caracterización y tratamiento de la enuresis en pacientes con vejiga hiperactiva.

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.

OBJETIVOS: Definir los tipos de enuresis de los pacientes con vejiga hiperactiva (VH) y estudiar su respuesta al tratamiento vesical diurno. MATERIAL Y METODOS: Estudio prospectivo y multicéntrico: pacientes con VH y enuresis, tratados con anticolinérgicos o neuromodulación durante 3 meses (2019-2021). Recogimos variables obtenidas del calendario miccional, cuestionario PLUTSS (Pediatric Lower Urinary Tract Score System), y relacionadas con la enuresis. Generamos 2 grupos de estudio: enuresis primaria (EP) y enuresis secundaria (ES). Consideramos respuesta parcial enurética (RPE) a la reducción del valor de enuresis inicial en más de un 50% y respuesta completa (RCE) el 100%. Finalmente realizamos un análisis multivariante para detectar factores predictivos independientes de RCE. RESULTADOS: Incluimos 152 pacientes con VH, 109 de los cuales presentaban enuresis (71,7%): 29 ES (26,7%) y 80 EP (73,3%). El valor PLUTSS fue mayor en pacientes con EP que en ES (20,8 vs. 17,2, p= 0,001.) La RPE y la RCE fueron significativamente mayores en el grupo de ES (55,2% vs. 15%, p= 0,000 en RPE y 48,3% vs. 5%, p= 0,000 en RCE). En el análisis multivariante se identificó que los pacientes con ES tienen una probabilidad de responder al tratamiento vesical diurno 50 veces superior que los pacientes con EP (OR 49,79, IC95% 6,73-36,8). CONCLUSIONES: La mayoría de niños con VH tienen una EP y no secundaria, por lo que generalmente la enuresis de estos pacientes no responde al tratamiento vesical diurno. Es importante caracterizar el tipo de enuresis de los niños con VH para plantear su tratamiento de forma adecuada.

Can double J stent complications be reduced in pediatric patients? / ¿Podemos reducir las complicaciones de doble J en el paciente pediátrico?

OBJECTIVE: The use of double J (DJ) stents is frequent in urological pediatrics, but it is not exempt from morbidity. The objective of this study was to describe the risk factors (RF) of DJ complications in pediatric patients, and to analyze the quality of the information provided to the families with respect to the stent. MATERIALS AND METHODS: A retrospective study of patients undergoing surgery with DJ placement in the urology department from 2017 to 2022 was carried out. Study patients were divided into two groups -complicated (C) and non-complicated (NC). A multivariate analysis was performed to identify complication-related RFs, and a quality analysis as perceived by the families was conducted by means of a satisfaction survey (0 = total dissatisfaction; 10 = maximum satisfaction). RESULTS: 180 patients were included (236 DJs). The main diagnoses included renal transplantation (29.8%), ureteropelvic stenosis (26%), and urolithiasis (20.7%). Complication rate was 21.9%, with a mean comprehensive complication index (CCI) of 26.8. Prophylactic antibiotic therapy was not associated with fewer complications (97.3% vs. 98.1%; p= 0.727). Complication RFs included more than one stent (p< 0.001; OR= 6.628) and bilateral placement (p< 0.05; OR= 4.871). Poor registration in the medical records was associated with greater complications (p= 0.025). In the information quality survey, 20% reported a score lower than 7/10. CONCLUSIONS: DJ-associated morbidity has a direct relationship with DJ duration, bilaterality, and carrying more than one stent in a lifetime. Adequate registration in the medical records is associated with shorter DJ duration, and therefore, fewer complications. Antibiotic prophylaxis did not reduce complications, which means its routine use should be reconsidered.

OBJETIVOS: El uso de catéteres doble J (DJ) es un proceso frecuente en uropediatría, pero no exento de morbilidad. El objetivo de nuestro estudio es describir factores de riesgo (FR) de complicación de los DJ en pacientes pediátricos y comprobar la calidad de la información transmitida a las familias en relación al catéter. MATERIAL Y METODOS: Estudio retrospectivo de pacientes intervenidos en urología con colocación de DJ (2017­2022). Grupos a estudio: complicados (CC) y no complicados (SC). Realizamos un análisis multivariante para identificar FR relacionados con complicaciones y un análisis de calidad percibida por las familias mediante encuesta de satisfacción (0 no satisfacción, 10 máxima satisfacción). RESULTADOS: Incluimos 180 pacientes, (236 DJ). Diagnósticos principales: trasplante renal 29,8%, estenosis pieloureteral 26%, y urolitiasis 20,7%. La tasa de complicaciones fue del 21,9%, con un Comprehensive Complication Index (CCI) medio de 26,8. La antibioterapia profiláctica no se relaciona con menos complicaciones (97,3% vs 98,1% p= 0,727). FR de complicación: acumular más de un catéter (p< 0,001, OR 6,628) o la colocación bilateral (p< 0,05; OR 4,871). Un mal registro en la historia clínica se relacionó con más complicaciones (p= 0,025). En la encuesta de calidad de información recibida, el 20% reflejaron una puntuación inferior a 7/10. CONCLUSIONES: La morbilidad asociada al DJ se relaciona con su duración, la bilateralidad o acumular más de un catéter. Su adecuado registro en la historia clínica se relaciona con menor duración del mismo y, por tanto, menos complicaciones. La profilaxis antibiótica no ha demostrado disminuir las complicaciones, su uso rutinario debe ser revalorado.

Efficacy of sacral transcutaneous electrical nerve stimulation in patients with overactive bladder refractory to anticholinergic treatment: a prospective multi-center study. / Eficacia de la electroestimulación transcutánea sacra en pacientes con vejiga hiperactiva refractarios a fármacos anticolinérgicos. Estudio prospectivo y multicéntrico.

OBJECTIVE: To determine whether sacral transcutaneous electrical nerve stimulation (S-TENS) is an effective treatment in patients refractory to anticholinergic drugs (Achs). MATERIALS AND METHODS: A prospective multi-center study of patients with overactive bladder (OB) refractory to Achs treated with S-TENS from 2018 to 2021 was carried out. S-TENS was applied over 3 months. Symptom progression was assessed using the voiding calendar and the Pediatric Lower Urinary Tract Symptoms Score (PLUTSS), excluding questions 3 and 4 -referring to enuresis- so that progression of daytime symptoms only (LUTS variable) was analyzed. RESULTS: 66 patients -50% of whom were female- were included, with a mean age of 9.5 years (range: 5-15). S-TENS significantly lowered PLUTSS (19.1 baseline vs. 9.5 final, p< 0.001) and LUTS (13.1 baseline vs. 4.8 final, p< 0.001). It also reduced the number of mictions (8.5 baseline vs. 6.4 final, p< 0.001), while increasing urine volume in the voiding records (214 ml baseline vs. 258 ml final, p< 0.001). Enuresis was the only variable refractory to S-TENS. Complication rate was 3% (2 patients with dermatitis in the S-TENS application area). CONCLUSIONS: S-TENS is effective and safe in the short-term in patients with OB refractory to Achs. Further studies assessing long-term efficacy and potential relapses are required.

OBJETIVOS: Determinar si la electroterapia nerviosa transcutánea a nivel sacro (TENS-S) es un tratamiento efectivo en pacientes refractarios a fármacos anticolinérgicos (Ach). MATERIAL Y METODOS: Estudio prospectivo y multicéntrico: pacientes con VH refractaria a Ach tratados con TENS-S entre 2018-2021. El TENS-S se aplicó durante 3 meses. La evolución sintomática fue evaluada utilizando el calendario miccional y el cuestionario PLUTSS (Pediatric Lower Urinary Tract Symptoms Score), pero excluyendo sus preguntas 3 y 4 (referidas a la enuresis) para analizar solamente la evolución de la sintomatología diurna (variable LUTS). RESULTADOS: Fueron incluidos 66 pacientes (50% niñas), con una edad media de 9,5 años (rango: 5-15). El TENS-S disminuyó significativamente el PLUTSS (19,1 inicial vs 9,5 final, p< 0,001) y el LUTS (13,1 inicial vs 4,8 final, p< 0,001). Además, redujo el número de micciones (8,5 inicial vs 6,4 final, p< 0,001) y aumentó el volumen de orina en los registros miccionales (214 ml inicial vs 258 ml final, p< 0,001). La enuresis fue la única variable refractaria al TENS-S. La tasa de complicaciones fue del 3% (2 pacientes, dermatitis en el área de aplicación del TENS-S). CONCLUSIONES: El TENS-S es efectivo y seguro a corto plazo en pacientes con VH refractarios a los Ach. Deben realizarse estudios para evaluar la eficacia a largo plazo y posibles recaídas.

[Neonatal pyloroduodenal duplication cyst. A case report].

Intestinal duplications located in the duodenum are rare conditions that generally affect the first or second duodenal portion. It is extremely unusual for this condition to be located in the pyloroduodenal area, accounting for less than ten documented cases. This research presents a case of a female newborn who showed on the second day of life signs of upper intestinal obstruction which required exploratory laparotomy. The surgery revealed a pyloroduodenal cyst that was successfully excised. This is an extremely rare congenital anomaly that encompasses challenging symptoms and signs, and the purpose of the surgery should be the complete resection of the lesion. If the complete excision endangers the surrounding organs, partial resection through mucosectomy is a valid alternative to prevent the complications of more invasive surgery.

[Update on vesical electrostimulation and neuropatic bladder in pediatrics: A sistematic review]. / Puesta al día en electroestimulación vesical y vejiga neurógena en pediatría: una revisión sistemática.

INTRODUCTION AND OBJECTIVE: Bladder neuromodulation has emerged as a new alternative in the management of adults with bladder dysfunctions from a neuropathic origin. Despite the fact that, numerous studies have proven the efficacy and safety of this therapy in adults' patients, there are however, still few studies that demonstrate its success in paediatric neuropathic bladder. MATERIALS AND METHODS: We perform a systematic review of the studies which analysed the impact of bladder electrostimulation in paediatric patients (0 to 18 years) with a neurogenic origin. The search identified 9716 potentially articles. Finally, 11 papers published between 1992 and 2019 fulfilled the necessary criteria to be part of our study and were selected for the systematic review. RESULTS: We did not find a common trend among the results obtained from the studies included in the present review. Most of the studies demonstrated an optimal efficacy rate and high safety, but however the superiority of this therapy over anticholinergic drugs could not be established due the presented results. For this fact, these results continue to be controversial. Furthermore, the methodology between the different studies was very huge, which made it difficult to compare the results obtained from each one of them. CONCLUSIONS: Given the potential risk of renal failure presented by paediatric patients with neurogenic bladder, the therapeutic alternatives used in the management of this disease must have a proven efficacy. For this reason, and after the review, due the absence of evidence regarding bladder electrotherapy in this group of patients, its use should be limited and exceptional. Bladder neuromodulation has emerged as a new alternative in the management of adult patients with bladder dysfunctions of neuropathic origin. Despite the fact that numerous studies have proven the efficacy and safety of this therapy in this age group, there are still few studies that show its success in paediatric neuropathic bladder.

TITLE: Puesta al día en electroestimulación vesical y vejiga neurógena en pediatría: una revisión sistemática.Introducción y objetivo. La electroestimulación vesical ha surgido como nueva alternativa en el manejo de pacientes adultos con disfunciones vesicales de origen neuropático. A pesar de que numerosos trabajos han probado la eficacia y la seguridad de esta terapia en este grupo de edad, todavía son escasos los estudios que demuestran su éxito en la vejiga neuropática pediátrica. Material y métodos. Realizamos una revisión sistemática de los estudios que evalúan el impacto de la electroestimulación vesical en pacientes pediátricos (0-18 años) con vejiga de origen neurógeno. La búsqueda identificó 9.716 artículos potencialmente elegibles. Finalmente, 11 trabajos publicados entre 1992 y 2019 cumplieron los criterios necesarios para formar parte del estudio y fueron seleccionados para la presente revisión sistemática. Resultados. No encontramos una tendencia común entre los resultados obtenidos de los estudios incluidos en la presente revisión. A pesar de que la mayoría de ellos demostró individualmente una tasa de eficacia óptima y una alta seguridad, la superioridad de esta terapia frente a los fármacos anticolinérgicos no pudo establecerse. Por tanto, hasta la fecha, sus resultados continúan siendo controvertidos. Además, la metodología entre los diferentes estudios fue muy diversa, lo que dificultó la comparación entre los resultados obtenidos de cada uno de ellos. Conclusiones. Dado el potencial riesgo de insuficiencia renal que presentan los pacientes pediátricos con vejiga neurógena, las alternativas terapéuticas utilizadas en su manejo deben tener una eficacia demostrada. Así, ante la ausencia de evidencia con respecto a la electroestimulación vesical en este grupo de pacientes, por el momento su utilización debería ser limitada y excepcional.

[Sacral electrical neurostimulation in the refractory pediatric overactive bladder].

Urinary incontinence is one of the principal reasons for visiting the urologist amongst paediatric patients, and an overactive bladder is the vesical dysfunction that most frequently provokes this. Currently the only medicine approved for managing an overactive bladder is oxybutynin; however, many patients respond partially to this therapy or are refractory to it. Vesical electrotherapy has emerged as a new alternative in the algorithm for managing patients with an overactive bladder refractory to anticholinergic medicines, but the evidence on this issue has to date been scant. We present the case of a 12-year-old patient with an overactive bladder refractory to oxybutynin and solifenacin who presented a good response to treatment with sacral vesical electrotherapy, with complete disappearance of the symptoms (diurnal incontinence and urgency of micturition) without adverse effects.

At-home transcutaneous electrical nerve stimulation: a therapeutic alternative in the management of pediatric overactive bladder syndrome. / Influencia del sobrepeso y obesidad infantil en la apendicitis aguda en niños. Estudio de cohortes.

INTRODUCTION: In recent years, bladder electroneurostimulation or TENS (Transcutaneous Electrical Nerve Stimulation) has emerged as a new alternative in the management of lower urinary tract dysfunctions. Our objective was to evaluate the efficacy and safety of this therapy in children with overactive bladder. MATERIAL AND METHODS: Prospective study of patients diagnosed with overactive bladder and treated with electroneurostimulation. The system was maintained for 6 months. The severity of urinary symptoms was assessed using the PLUTSS (Pediatric Lower Urinary Tract Scoring System) questionnaire. RESULTS: A total of 21 patients were included in the study, with an average age of 10 years (range: 6-16). The most frequent symptoms were incontinence (89%) and urgency (100%). Statistically significant differences (p<0.05) in mean PLUTSS scores between treatment initiation and treatment completion were found: PLUTSS was 17.8 (range: 10-29) at baseline, 7.21 (range: 2-16) at month 3, and 5.6 (range: 3-12) at month 6. The maximum voiding volume of all patients increased after 6 months of treatment. All patients had their quality of life improved at the end of the study. CONCLUSIONS: Home TENS therapy is a safe and effective option in the management of overactive bladder in the pediatric population. However, further randomized studies should be carried out to protocolize and clarify the effectiveness of this therapeutic approach.

INTRODUCCION: La electroneuroestimulación vesical o TENS (transcutaneous electrical nerve stimulation) ha surgido como nueva alternativa en el manejo de las disfunciones del tracto urinario inferior. Nuestro objetivo fue evaluar la eficacia y seguridad de esta terapia en niños con diagnóstico de vejiga hiperactiva. MATERIAL Y METODOS: Estudio prospectivo de pacientes con diagnóstico de vejiga hiperactiva tratados con electroneuroestimulación. La terapia con TENS domiciliario se mantuvo durante 6 meses. Evaluamos la severidad de la sintomatología urinaria utilizando el cuestionario PLUTSS (Pediatric Lower Urinary Tract Symptoms Score). RESULTADOS: Un total de 21 pacientes (13 niñas) fueron incluidos en el estudio, con una edad media de 10 años (Rango: 6-16). Los síntomas más frecuentes fueron: incontinencia (89%) y urgencia (100%). Encontramos diferencias estadísticamente significativas (p<0,05) en los valores medios del PLUTSS antes de iniciar tratamiento y al finalizar el mismo: PLUTSS inicial 17,8 (Rango: 10-29), a los 3 meses: 7,21 (Rango: 2-16), a los 6 meses: 5,6 (Rango: 3-12). El volumen miccional máximo de todos los pacientes aumentó a los 6 meses de tratamiento. Todos los pacientes sintieron una mejora en su calidad de vida al finalizar el estudio. CONCLUSIONES: La terapia con TENS domiciliario parece una opción segura y eficaz en el manejo de la vejiga hiperactiva, sin embargo, deben ser realizados más estudios randomizados para demostrar su efectividad y protocolizar su aplicación en los pacientes en edad pediátrica.

[Varicoceles in adolescents and relationship with bmi: are varicoceles more frequent in tall thin men?] / Varicoceles en adolescentes y su relación con el índice de masa corporal: ¿son más frecuentes en varones altos y delgados?

OBJECTIVES: Varicocele is a dilatation of the venous pampiniform plexus considered the leading cause of correctible male infertility. Varicocele ethology remains controversial and there have been several studies which inform that varicoceles are found less frequently in obese adolescents but relationship between varicocele and body mass index (BMI) remains controversial yet. SUBJECTS AND METHODS: To study the relationship between varicocele and body mass index in children population we review the patients treated for varicocele in our institution. We analyzed patients with varicocele surgical correction in our centre in the last 10 years. At our institution all patients were treated by Palomo technique. We analyzed: age, location and degree of varicocele, weight and height, surgical technique, appearance of reactive hydrocele or others complications, varicocele recurrence and reoperation. Our objective is to study the relationship between BMI and varicocele in adolescent boys. RESULTS: We observed that varicocele in our series was found more frequently in taller patients and less frequently in obese patients (higher BMI). CONCLUSIONS: Future studies will be needed to confirm that theory and to understand varicocele ethology but we consider that this fact is very useful because we are talking about a pathology with repercussion in fertility so we must be alert about it in adolescent population to correct it.

OBJETIVOS: El varicocele constituye la principal causa de infertilidad masculina tratable. Su fisiopatología no es todavía bien conocida y existen varios estudios que sugieren que esta patología se desarrolla con menos frecuencia en pacientes obesos. Sin embargo, la relación entre el varicocele y el índice de masa corporal (IMC) continúa siendo controvertida. Nuestro objetivo es estudiar los pacientes pediátricos con varicocele y establecer una relación entre el IMC de estos pacientes y esta patología. MATERIAL Y METODOS: Para estudiar la relación entre el varicocele y el índice de masa corporal en la población infantil, revisamos a los pacientes intervenidos de varicocele en nuestro centro. Se estudiaron 79 pacientes en los últimos 10 años. Todos los pacientes fueron tratados con técnica de Palomo. Analizamos: edad, localización y grado de varicocele, peso y talla, técnica quirúrgica, aparición de hidrocele reactivo u otras complicaciones, recurrencia de varicocele y reintervención. RESULTADOS: Observamos en nuestra serie una mayor frecuencia de varicocele en pacientes más altos y delgados (menor IMC) comparándolos con los pacientes con mayor masa corporal en relación a la altura. CONCLUSIONES: Concluimos que según nuestra serie y en concordancia con literatura, el varicocele podría darse con más frecuencia en pacientes altos y delgados. Son necesarios más estudios para confirmar este hecho y aclarar la fisiopatología de esta entidad, pero dado que se trata de una patología que podría tener repercusión en la fertilidad creemos que debemos estar alerta en este grupo de pacientes para detectar esta patología y valorar la necesidad de corrección.

[Urinary incontinence and lower urinary tract dysfunction prevalence in schoolchildren: risk factors]. / Prevalencia de incontinencia urinaria diurna (IUD), disfunción del tracto urinario inferior en edad escolar y análisis de factores de riesgo.

Recently, many papers report an increase of pediatric lower urinary tract dysfunction (LUTD), which affects 10-15% of schoolchildren. Recent life style and dietary changes have been postulated as the cause of that high prevalence. There is a lack in epidemiological investigations about bowel and bladder dysfunctions and the risk factors. We aim to know the LUTD prevalence and the main risk factors. We carry out an observational and transversal investigation with a representative sample of our pediatric schoolchildren (N=1,069). We used a questionnaire about toilet training habits, social, familiar, and dietary data. We also used the PLUTSS (Pediatric Lower Urinary Tract Symptoms Score) questionnaire after validation of the Spanish version. The logistic regression analysis determined the main risk factors of DTUI. Results showed that boys get toilet trained later than girls (2.41 vs. 2.25) and the rate of incontinence is greater than girls when they start on the school. 31.9% of children remove their diapers to get into school. The prevalence was 15% for diurnal urinary incontinence and 12.2% nocturnal, DTUI 8.3%, constipation 20%, faecal incontinence 2.8%, ITUs 12.4%, retention habits 39.8%. 28.7% of children with DTUI refer psychological affectation. The main independent predictors were: male sex (OR 1.87), younger children (OR 0.78), forced toilet training (OR 2.14), constipation (OR 1.61) and holding habits (OR=3.87). This study showed a high prevalence of bladder in our pediatric population. Male gender, voiding postposition, early schooling or constipation were the main risk factors. The knowledge of the bladder and bowel dysfunction prevalence and the toilet training habits in our Community lets us to conclude school, family and primary care recommendations. This will let to prevent this so much prevalent disease.

En los últimos años se ha incrementado la prevalencia de disfunciones del tracto urinario inferior (DTUI), afectando al 10-15% de escolares. Este incremento se ha relacionado con cambios en el estilo de vida y dietéticos. Pocos estudios analizan los factores de riesgo. Nuestro objetivo es conocer la prevalencia de DTUI y sus principales factores. Realizamos un estudio observacional transversal de prevalencia sobre una muestra representativa de escolares de nuestra comunidad (N=1.069). Utilizamos un cuestionario sobre hábitos de aprendizaje miccional, hábito intestinal y datos dietéticos. Asociamos el cuestionario PLUTSS (Pediatric Lower Urinary Tract Symptoms Score) de screening de DTUI, tras traducirlo y validarlo en español. Análisis de regresión logística evaluaron los principales factores de riesgo. Los varones retiran el pañal más tarde (2,41 vs. 2,25) comenzando el colegio con mayor porcentaje de incontinencia. El 31,9% retiraron el pañal para poder escolarizarse. La prevalencia de incontinencia urinaria fue 15% diurna y 12,2% nocturna, la de DTUI 8,3%, estreñimiento 20%, incontinencia fecal 2,8%, ITUs 12,4%, hábito posponedor 39,8%. El 28,7% de las DTUI referían repercusión psicológica. Los principales factores de riesgo fueron: varón (OR 1,87), menor edad (OR 0,78), retirada de pañal forzada por escolarización (OR 2,14), estreñimiento (OR 1,61) y hábito retencionista (OR 3,87). Nuestro estudio mostró una elevada prevalencia de disfunción vesical en nuestra población pediátrica. El sexo masculino, el hábito posponedor, la escolarización precoz y el estreñimiento fueron los principales factores de riesgo. Conocer su epidemiología, nos ha permitido emitir recomendaciones escolares, familiares y en atención primaria, con el fin de prevenir esta patología tan prevalente.

[DRESS syndrome, a differencial diagnosis in late postoperative complications]. / Síndrome de DRESS en el diagnóstico diferencial de las complicaciones postquirúrgicas.

The DRESS syndrome (drug rash with eosinophilia and systemic symptoms) is a serious pharmacodermia which must be taken into account when establishing an optimal early treatment to prevent a systemic and potentially lethal evolution. Pharmacodermias are the third most frequent cause of adverse effects during surgical hospitalization, after nosocomial infections and intraoperative complications. In most cases, they pose a challenge to the surgeon, since their onset is nonspecific and, therefore, can be easily mistaken for a surgery complication. We present the case of a 54-year-old man, healthy and without relevant background, who was operated on two times due to spontaneous abdominal bleeding. Three weeks after the last surgery, and coinciding with the administration of oral metamizole, the patient developed a DRESS syndrome. The initial unspecific deterioration, characteristic of this syndrome, is the main cause of the delay in diagnosis and correct treatment, causing the resulting evolution to systemic affectation.

[Parent controled analgesia system in postoperative pain management in patients undergoing lip and cleft palate surgery]. / Analgesia mediante bomba de infusión continua controlada por el paciente para el manejo postoperatorio del dolor en pacientes intervenidos de fisura palatina y labio fisurado.

OBJECTIVES: Craniofacial clefts surgery associates a painful postoperative pain whose management is complicated with conventional analgesia. PATIENTS AND METHODS: A parent controlled analgesia system was implanted with a continuous perfusion of tramadol, ondansetron and metamizole adjusted by weight. Parents are allowed to administer additional boluses if they observe irritability. We compared the variables of the cleft patients operated before and after the implantation of the system in our center. RESULTS: During 2016, 16 craniofacial clefts were operated (4 cheilorhinoplasties and 12 palatal clefts). No PCA (parent controlled analgesia) system was used. The average time of stay in PICU was 1.5 days. It took an average of 2.5 days to initiate tolerance. The mean of VAS (Visual Analogic Scale) was 3. 53% required major opioids (morphine, fentanyl) not being sufficient analgesia every 3 hours. During 2017, 7 palatal fissures and 4 cheilorhinoplasties were operated (11). Both of them were controlled by PCA. Patients with palatal cleft were admitted to the PICU with a total mean of 0.5 days. The beginning of tolerance was advanced to the first postoperative day. The VAS diminished to 0.5. Only one patient required opioids. 72% did not need to associate any type of analgesia. CONCLUSIONS: The PCA system is a safe and risk-free insurance for analgesia of fissured patients with benefits such as: decrease in pain, stay in PICU, the need for analgesia and initiation of early tolerance.

OBJETIVOS: La cirugía de las fisuras craneofaciales asocia un intenso dolor postoperatorio cuyo manejo resulta complicado con la analgesia convencional. MATERIAL Y METODOS: Utilizamos una bomba de analgesia controlada por los padres que contiene una perfusión continua de tramadol, ondansetrón y metamizol ajustada por peso. Se permite a los padres administrar bolos adicionales si observan irritabilidad. Comparamos variables de los pacientes fisurados intervenidos antes y después de la implantación del sistema en nuestro centro. RESULTADOS: Durante 2016 fueron intervenidos 16 fisurados (4 queilorrinoplastias y 12 fisuras palatinas). En ninguno se empleó bomba de analgesia. El tiempo medio de estancia en UCIP fue 1,5 días. Tardaron de media 2,5 días en iniciar tolerancia. La media de EVA (Escala Analógica Visual) fue de 3. El 53% precisaron opiáceos mayores (morfina, fentanilo), no siendo suficiente la analgesia c/3 horas. Durante 2017 se operaron 7 fisuras palatinas y 4 queilorrinoplastias (11). En todos empleamos bomba. Únicamente ingresaron en UCIP las fisuras palatinas (debido al manejo de la vía aérea) con una media total de 0,5 días. Se adelantó el inicio de tolerancia al primer día postoperatorio. La EVA disminuyo a 0,5. Solo un paciente precisó opiáceos. El 72% no precisó asociar ningún tipo de analgesia. CONCLUSIONES: La bomba de PCA (analgesia controlada por el paciente/por los padres) es un método seguro y exento de riesgo para la analgesia de los pacientes fisurados con beneficios como: disminución del dolor, de la estancia en UCIP, de la necesidad de analgesia e inicio de tolerancia precoz.

[Appendicitis, an unusual cause of acute abdomen in neonatal patients. A case report]. / Apendicitis como causa de abdomen agudo en etapa neonatal. A propósito de un caso.

Appendicitis is the most frequent surgical disease in childhood, but it is very uncommon in the neonatal period. In this period of life, a delay in diagnosis (frequently due to the rareness of this pathology and lack of clinical suspicion) and consequently in therapeutic approach, frequently results in appendicular perforation and a subsequently poor evolution of this pathology. We present the case of a neonate with a history of Down's syndrome and Fallot's tetralogy. Due to her basal cardiopathy, she required surgical intervention to create a systemic-pulmonary fistula, as a temporary bridge until definitive cardiac surgery could be performed. In the postoperative period of this surgery she presented fever, acute abdomen and abdominal radiography compatible with pneumoperitoneum. An emergency laparotomy was performed, which revealed peritonitis secondary to a cecal gangrenous appendix with perforation in its middle third. Neonatal appendicitis is usually associated with diseases such as cystic fibrosis, necrotizing enterocolitis, or Hirschsprung's disease, as in the case of our patient. In neonates with acute abdomen and presence of pneumoperitoneum, appendicitis must be part of the differential diagnosis and requires urgent surgical intervention. Despite this, it presents a high rate of morbidity and mortality. Once the definitive diagnosis is made, any basal pathology that justifies its presence should be discarded.

Endoscopic balloon dilatation in primary obstructive megaureter: Long-term results.

BACKGROUND: Open neoureterocystostomy is the traditional surgical treatment for primary obstructive megaureter (POM). Endoscopic balloon dilation is a new minimally invasive alternative. It has been shown to be a safe and effective endoscopic procedure over short-term follow-up; however, few studies have shown its long-term efficacy. OBJECTIVE: The aim of this study was to evaluate the long-term results and complications of balloon dilation for the treatment of primary obstructive megaureter in infants. MATERIALS AND METHOD: A retrospective review was performed of patients with primary obstructive megaureter treated with balloon dilation. The diagnosis was made through ultrasonography, diuretic isotopic renogram, and voiding cystourethrogram (VCUG). The indications for surgery were: worsening hydronephrosis, renal function impairment, and recurrent urinary tract infections (UTI). All patients were followed 3 months after the endoscopic procedure with ultrasonography and MAG-3 renogram, and 6 months after surgery with VCUG and ultrasonography. Annual ultrasound and clinical follow-up were performed until present time. RESULTS: Seven boys and six girls were treated (median age 9 months, range 2-24). Ten patients had a prenatal diagnosis of hydronephrosis, and the diagnoses was made after UTI in three patients. No intraoperative complications were observed. One double-J stent was replaced after endoscopic procedure for malpositioning, and four patients developed UTIs after surgery. All patients had non-obstructive MAG-3 diuretic renogram 6 months after surgery. The mean washout on the renogram and the ultrasound pelvic diameter showed pre-operative and postoperative statistical differences (Summary Table). All patients maintained their results without recurrence or any other complications in the long-term follow-up. The median follow-up was 10.3 years (range 4.7-12.2). DISCUSION: In 2014, Aparicio et al. first described balloon dilation being used as a definitive treatment for primary obstructive megaureter in infants. Bujons et al. also presented 20 cases with a mean follow-up of 6.9 years. The current study is the largest to date, with a median follow-up of 10.2 years. It demonstrated the value of balloon dilation as a definitive treatment for POM. Despite these results, it was difficult to establish endoscopic balloon dilation as a definitive treatment for POM, due to the absence of long-term studies like the current one. CONCLUSION: Balloon dilation can be a safe and effective endoscopic procedure for the treatment of primary obstructive megaureter in infants, and has shown good outcomes in long-term follow-up. More studies are needed to demonstrate these results.

[Management of recurrent urethrocutaneous fistula after hypospadias surgery in pediatric patients: initial experience with dermal regeneration sheet Integra]. / Manejo de la fístula uretrocutánea recurrente tras cirugía de hipospadias: experiencia inicial con lámina de regeneración dérmica.

OBJECTIVE: To present our initial experience using a dermal regeneration sheet as an urethral cover in the repair of recurrent urethrocutaneous fistulae in pediatric patients. METHODS: Since May 2016 to March a total of 8 fistulaes were repaired using this new technique. We performed the ddissection of the fistulous tract and posterior closure of the urethral defect. A dermal regeneration sheet was used to cover the urethral suture. Finally a rotational flap was performed to avoid overlap sutures. RESULTS: During the follow-up (average 6 months), one patient presented in the immediate postoperative period infection of the surgical wound. This patient presented recurrence of the fistula. 88% of the patients included presented a good evolution with no other complications. CONCLUSIONS: In our initial experience the new technique seems easy, safe and effective in the management of the recurrent urethrocutaneous fistulae in pediatric patients. More studies are needed to prove these results.

OBJETIVO: Describir nuestra experiencia inicial en la reparación de la fístula uretrocutánea recurrente en la población pediátrica, mediante el uso de una lámina de regeneración dérmica como cobertura uretral. MATERIAL Y METODOS: Desde mayo del 2016 hasta marzo del 2017 se repararon 8 fístulas uretrocutáneas mediante esta técnica. Se realizó la disección del trayecto fistuloso, la sección del mismo y el posterior cierre del defecto uretral. Una lámina de regeneración dérmica monocapa se utilizó como cobertura sobre la sutura uretral. Finalmente se realizó un colgajo cutáneo de rotación evitando la superposición de las suturas. Los pacientes fueron seguidos mensualmente en consulta mediante exploración física. RESULTADOS: Durante un seguimiento medio de 6 meses (R: 2-10), únicamente 1 paciente (12%), que sufrió una infección de la herida quirúrgica durante el postoperatorio inmediato, sufrió una recidiva de la fístula uretrocutánea. El resto de los pacientes (88%) no desarrollaron ninguna complicación durante su evolución. CONCLUSION: En nuestra experiencia inicial, la técnica descrita parece sencilla, segura y eficaz en el manejo de los pacientes con fístulas uretrocutáneas recurrentes. No obstante, estudios a largo plazo son necesarios para corroborar estos resultados.