Voiding cystourethrography in patients undergoing endoscopic decompression of duplex system ureteroceles: to do or not to do?

OBJECTIVE: To assess the role of voiding cystourethrography (VCUG) in patients with duplex system ureterocele (DSU) undergoing endoscopic decompression (ED). MATERIALS AND METHODS: This is a retrospective study of 75 consecutive patients with DSU undergoing ED [median (range) age, 6 (1-148) months]. Patients were divided into 3 groups, 33 with a VCUG showing vesicoureteral reflux (VUR) before ED (VUR-group), 22 with a VCUG negative for VUR (No-VUR-group), and 20 who did not undergo a VCUG (No-VCUG-group). Secondary surgery (SS) rate was compared among groups. RESULTS: Groups were comparable for baseline characteristics. SS rate was 82% (27/33) in VUR-group vs. 32% (7/22) in the No-VUR-group (p = 0.0001), and 25% (5/20) in the No-VCUG-group (p = 0.001 vs. VUR-group, and 1 vs. No-VUR-group). In the VUR-group, 9 patients underwent preemptive endoscopic treatment of VUR during ED and SS rate was 44% (4/9) vs. 96% (23/24) in the remainder, p= 0.003. In the No-VCUG-group, a VCUG was performed during follow-up in 9/15 patients and showed reflux in all, although only 2 of these developed a (single) urinary tract infections. CONCLUSIONS: SS rate was significantly higher in patients with preoperative VUR. Instead, it was not significantly different between patients without VUR and those who did not undergo a VCUG before ED, despite all the latter who underwent a VCUG during follow-up had evidence of VUR generally in the absence of symptoms. In our opinion, a VCUG could be limited to patients developing symptoms after ED. If a VCUG is performed before ED, a preemptive treatment of VUR should be taken into consideration.

Risk Factors for Failure of Endoscopic Balloon Dilatation of Primary Obstructive Megaureter: Single-Center 12-Year Experience with 123 Cases.

Purpose: To review our experience with >100 patients with primary obstructive megaureter (POM) undergoing endoscopic balloon dilatation (EBD) and a follow-up of up to 12 years and determine potential risk factors for failure. Our hypothesis is that EBD allows for long-term treatment in >80% of patients, and its effectiveness decreases in more severe cases. Methods: This is a retrospective study of 123 consecutive patients (131 ureters) undergoing EBD from 2009 to 2021. Indications for EBD included symptoms, worsening dilatation, and/or renal function impairment. Clinical characteristics, complications, and outcomes, including those in the patients with >5-year follow-up, were described. Preoperative and intraoperative markers of severity chosen a priori were tested as risk factors for failure. Failure was defined as the need for ureteral reimplantation after EBD. Results: EBD was feasible in 121 of 123 (98%) patients, regardless of age. After a median follow-up of 38 (9-143) months, EBD was effective in 84.5% of cases. Failures generally occurred in the 1st year after EBD and were seldom associated with permanent loss of renal function. Of the 66 patients with follow-up >5 years, EBD was effective in 56 patients. No preoperative characteristic proved to be a risk factor for failure. The intraoperative absence of a ring was the only significant risk factor for failure, odd ratio 117.86 (95% confidence interval 6.27-2215.84). Conclusions: EBD was feasible and definitive treatment in 85% of our cases, regardless of age. Since this study did not identify preoperative factors to help the clinicians in patient selection, we consider EBD a viable initial procedure in all patients with POM who require surgical intervention, especially in infants.

Endoscopic balloon dilatation for the treatment of primary obstructive megaureter <24 months of age: Does the size of the balloon influence results?

INTRODUCTION: Endoscopic balloon dilatation (EBD) can be performed with different catheters and its durability is still controversial. This study aimed to compare long-term results of EBD performed <24 months of age using balloons of 4 mm vs. 6 mm in diameter. MATERIALS AND METHODS: Retrospective study of consecutive patients with unilateral primary obstructive megaureter (POM) undergoing EBD <24 months of age by two surgeons from 01/2009 to 12/2020. The technique was consistent, but for balloon diameter, which was 4 mm in group A vs. 6 mm in group B. End-points included peri-operative complications, success rate (improving dilatation and non-obstructive drainage on 9-month scintigraphy), and long-term outcome (need for reimplantation and diameter of retrovesical ureter at last ultrasound). RESULTS: The procedure was completed in all planned patient. Group A included 15 patients and Group B 30 patients. Groups were not significantly different for age (p < 0.09), gender (p < 0.1), laterality (p < 0.7), and preoperative median ureteral diameter (p = 0.08). No perioperative complications occurred. Four group A patients required a cutting balloon to achieve a satisfactory dilatation of the vesicoureteral junction (p = 0.009). After a median (range) follow-up of 70 (19-155) months, success rate was 73.3% vs. 83.3% (p = 0.45), 4/15 group A and 5/30 group B patients required reimplantation within 2 years of EBD. In successful cases, median (range) ureteral diameter at last follow-up was 6 (0-17) mm vs. 5 (0-14) mm, which was significantly better than preoperative value (p = 0.003 and p < 0.001, respectively), but not significantly different (p = 0.8) between groups. DISCUSSION: EBD is an umbrella term that encompasses many technical variations, which can be key for success. Although limited by the small numbers and the comparison of patients treated over two subsequent periods, this is the first study focusing on the role of balloon size. CONCLUSIONS: The diameter of the balloon did not influence significantly long-term results, but the 6 mm balloon slightly increased the success rate of EBD to 83.3% and eliminated the need for cutting balloons to achieve a satisfactory dilatation.

Cystic Dysplasia of the Rete Testis: Case Report and Systematic Review of the Literature.

Cystic dysplasia of the rete testis (CDRT) is a rare cause of testicular masses in children. The pathogenesis of this malformation remains unclear. It is often associated with other genitourinary anomalies, commonly presenting as agenesis or dysplasia of the ipsilateral kidney. A case involving a 9-year-old boy with a testicular lesion and ipsilateral renal agenesis, who was diagnosed with CDRT after histological examination, is reported. In addition, a systematic review of the literature was performed to better understand this pathology to design the most appropriate treatment and follow-up strategy for patients with CDRT.

Comparison of Cosmetic Results in Children >10 Years Old Undergoing Open, Laparoscopic or Robotic-Assisted Pyeloplasty: A Multicentric Study.

PURPOSE: Our goal was to compare surgical scars assessed by a validated patient reported outcome questionnaire in children undergoing open (OP), laparoscopic (LP), or robotic-assisted (RALP) pyeloplasty. Our secondary aim was to assess the influence on the outcomes of variables such as gender or body mass index (BMI). MATERIALS AND METHODS: We conducted an observational, cross-sectional, multicentric study of patients undergoing primary pyeloplasty between age 10 and 18 years at 5 tertiary Italian institutions during the period January 2010 to December 2019. Of 227 eligible patients 114 (50%) participated. OP was performed in 37 (32%), LP in 30 (26%) and RALP in 47 (41%), After a median (IQR) followup of 5.2 (2.3-7.8) years, scars were measured and assessed by a validated Patient Scar Assessment Questionnaire. Scores were compared among techniques and in accordance with several variables. RESULTS: The median length of the surgical scar at followup was significantly larger (p <0.0001) after OP (8.1 cm vs 1.8 cm for LP and 2.0 cm for RALP), where scar length correlated with BMI (p=0.04). Ninety patients (79%) had a Patient Scar Assessment Questionnaire score within the first quartile, the most favorable. During followup, 43 (38%) participants reported scar-related symptom. Symptoms were generally more common after OP (54% vs 30% for LP and 30% for RALP, p=0.06) and scar hyperesthesia was significantly more frequent after OP (p=0.01). CONCLUSIONS: Perception of the cosmetic outcomes in pre-adolescents and adolescents after pyeloplasty was generally good. LP achieved the best cosmetic results. OP was more commonly associated with scar-related symptoms and the size of the incision paralleled BMI.

Case Report: Massive Intestinal Pneumatosis and Pneumoretroperitoneum Following Hematopoietic Stem Cell Transplantation in a 2-Year-Old Child.

A 2-year-old boy with severe combined immunodeficiency (SCID) developed intestinal graft-versus-host disease (GVHD) after hematopoietic stem cell transplantation (HSCT), associated with massive intestinal pneumatosis (IP), pneumoretroperitoneum (PRP), and pneumomediastinum. His fair clinical conditions allowed conservative management, with progressive normalization of imaging findings. The patient did not require surgery and is alive and in good clinical conditions at follow-up. In children with GVHD-related IP but good clinical conditions and no signs of peritonitis, IP is not a mandatory indication for surgery, despite its potentially striking imaging features. Conservative management, with intestinal rest, decompression, and antibiotics, often allows regression of the clinical picture.

Incidence of Acute and Chronic Post-Thoracotomy Pain in Pediatric Patients.

We studied acute and chronic pain in pediatric patients who underwent thoracotomy for benign disease with a follow-up of at least three months. A telephone interview investigated about the presence of pain and the analgesic therapy in progress. The results were compared with the anesthetic technique, postoperative pain and the adequacy of pain therapy, both during the first week after surgery and at the time of interview. Fifty-six families consented to the study. The mean age of the children at surgery was 2.9 ± 4.5 years, while at the time of the interview was 6.5 ± 4.4 years. We performed different anesthetic strategies: Group A: general anesthesia (36 pts); Group B: general anesthesia and thoracic epidural (10 pts); Group C: general anesthesia and intercostal nerve block (10 pts). During the immediate postoperative period, 21 patients (37.5%) had at least one painful episode. At the time of interview, 3 children (5.3%) had moderate chronic neuropathic (burning) pain on surgical scar. There was no statistically significant difference between the type of anesthesia and the incidence and severity of acute post-operative pain. Despite its limitations, this study confirms the low incidence of chronic post-thoracotomy pain syndrome in children.

Predictive value of spinal bone anomalies for spinal cord abnormalities in patients with anorectal malformations.

AIM: To evaluate the correlation between sacral/vertebral anomalies and spinal cord anomalies (SCA) on MRI, in patients with anorectal malformation (ARM). METHODS: Patients with ARM consecutively treated between January 1999 and August 2019 were included. Radiological imaging of sacrum and spine were retrospectively analyzed and correlated to the presence of SCA at MRI. Fisher's exact test and X2 test were used as appropriate; p<0.05 was considered statistically significant. RESULTS: 348 patients with ARM were enrolled in the study, 147 presented SCA at MRI. 144 patients showed spinal bone anomalies, isolated vertebral and sacral anomalies were found in 17,6% and 35% respectively. Higher level of ARM was associated with a significant higher prevalence of sacral and vertebral anomalies. A significant correlation was found between the "level" of ARM and the presence of SCA (p<0.05). Sacral anomalies were significantly correlated with the presence of SCA at MRI (p<0.05). SCA were found in 70% of patients with vertebral anomalies (VA) and in 76% of patients with sacral anomalies. The presence of multiple malformations (vertebral and sacral anomalies) are strictly related to the presence of SCA. However, the absence of spinal bone anomalies does not exclude the presence of SCA. SD was the most represented type of SCA (n=94/147), of those 96% had fatty filum. Neurological or neurourological symptoms were detected in 11,5% patients (n=17) with SCA and required neurosurgical intervention. CONCLUSIONS: Our data confirm the strong relation between sacral or vertebral anomalies and SCA. However, in our series also patients without sacral/vertebral anomalies had SCA at MRI. Our results suggest that, despite the presence or absence of spinal anomalies, spinal cord MRI should be performed in all children with ARM, to allow a correct multidisciplinary follow-up and treatment. In fact, most patients with spinal bone and SCA are asymptomatic, but could develop clinical manifestations during their growth.

Modularising ontology and designing inference patterns to personalise health condition assessment: the case of obesity.

BACKGROUND: The public health initiatives for obesity prevention are increasingly exploiting the advantages of smart technologies that can register various kinds of data related to physical, physiological, and behavioural conditions. Since individual features and habits vary among people, the design of appropriate intervention strategies for motivating changes in behavioural patterns towards a healthy lifestyle requires the interpretation and integration of collected information, while considering individual profiles in a personalised manner. The ontology-based modelling is recognised as a promising approach in facing the interoperability and integration of heterogeneous information related to characterisation of personal profiles. RESULTS: The presented ontology captures individual profiles across several obesity-related knowledge-domains structured into dedicated modules in order to support inference about health condition, physical features, behavioural habits associated with a person, and relevant changes over time. The modularisation strategy is designed to facilitate ontology development, maintenance, and reuse. The domain-specific modules formalised in the Web Ontology Language (OWL) integrate the domain-specific sets of rules formalised in the Semantic Web Rule Language (SWRL). The inference rules follow a modelling pattern designed to support personalised assessment of health condition as age- and gender-specific. The test cases exemplify a personalised assessment of the obesity-related health conditions for the population of teenagers. CONCLUSION: The paper addresses several issues concerning the modelling of normative concepts related to obesity and depicts how the public health concern impacts classification of teenagers according to their phenotypes. The modelling choices regarding the ontology-structure are explained in the context of the modelling goal to integrate multiple knowledge-domains and support reasoning about the individual changes over time. The presented modularisation pattern enhances reusability of the domain-specific modules across various health care domains.