[Current problems in training of minimally invasive surgery: vision of residents in pediatric surgery]. / Problemas actuales en la formación en cirugía mínimamente invasiva: visión de los residentes de Cirugía pediátrica.

INTRODUCTION: Minimally Invasive Surgery (MIS) is getting more and more important in our specialty. However, the formation of the residents on MIS is, in many cases, irregular. The purpose of this study is to assess the state of training in MIS among the residents of Pediatric Surgery and their potential weaknesses. MATERIAL AND METHODS: An electronic survey was distributed among 71 residents of Pediatric Surgery from 17 national hospitals. RESULTS: The response rate was 70.2%.100% of the residents are interested in a broadening of training activities in MIS. The main areas of interest are gastrointestinal (92%) and thoracic (47%) surgery. Only 57% have access to training facilities and less than half of them attend to courses and conferences. 80% believe that they are not given adequate attention from specialized associations. 52% think they should do rotations at referral centers, 86% that courses and seminars should be enhanced, and 44% that the responsibility of the resident in surgery should be increased. The main defects encountered in their training are scarce volume of patients, lack of financial support and overcoming the learning curve of surgeons in their services. CONCLUSIONS: Despite the advance of the MIS, resident's training in this discipline still has shortcomings, as expressed in their views. Knowledge of the current state of training should be the starting point for designing a training strategy that ensures adequate skills.

["Fast-track" in pediatric urologic surgery: pronenephrectomy]. / Fast-track en urología infantil: nefrectomía en prono ambulatoria.

UNLABELLED: INTRODUCTION AND OBJETIVES: Minimal invasive surgery trends to get prompt recovery in terms of inmediate deambulation and early discharge from hospital, without increasing patient's discomfort neither postoperative complications. This "fast-track" protocol is being progresively introduced in a crescent number of urological procedures. We are evaluating the viability of applying it in retroperitoneoscopic prone- position nephrectomy. METHODS AND MATERIALS: We have performed a retrospective review of the clinical reports of the patients submitted to prone nephrectomy with hospitalization between 2007 and 2011 and we present patients submitted to this procedure in an outpatient basis (less than 8 hours hospital stay) from 2011. We have recorded epidemiological factors, diagnosis, surgical time, first postoperative week analgesic requirements, parents cofort and postoperative complications. RESULTS: All the procedures were performed retroperitoneoscopically in prone position using two trocars. We included 34 nephrectomies with a mean surgical time of 107 minutes. Mean postoperative stay was under 24 hours in 23 patients, two of them were discharged in the first 8 hours after the procedure. Hospital stay over this time was due to concomitant pre-existent pathology in 6 patients and to non urological fever in the remaining 3. Analgesia was excellent in every patient with endovenous non-steroid drugs, registering no pain after administering them orally. There were no complications. CONCLUSIONS: We believe that "fast-track" requirements can be applied to prone-retroperitoneoscopic nephrectomy in pediatric population, as long as they have no associated pathology. In our experience this surgical procedure can be included in day-case surgery, increasing patient's confort and with a positive economical impact.

[Postoperative anal prolapse in patients with anorectal malformations: 16 years of experience]. / Prolapso anal postoperatorio en pacientes con malformaciones anorrectales: 16 años de experiencia.

INTRODUCTION: Anal prolapse is a common postoperative complication related to anorectal malformations (MAR) surgery, which is sometimes considered to be insignificant and/or not worthy of further intervention. We analysed the causes of this complication and our current surgical protocols. MATERIAL AND METHODS: Since 1995, 26 patients with anal prolapse have been operated secondary to surgical correction of an anorectal pathology. The most common MAR in girls (12) was cloaca (10), and in boys (14) was anorectal atresia with prostate fistula (8). The symptoms were anal pain and bleeding associated with alterations in bowel control alterations. The diagnosis in most patients was made in the first months after surgery, during the period of anal dilatations period. The surgical procedure involves prolapse resection of the prolapse and a new anoplasty. In 18 patients (69%) the prolapse was corrected before the colostomy closure on an outpatient basis. The other 8 patients (31%) underwent prolapse surgery after colostomy closure, requiring hospitalisation. RESULTS: There were no immediate postoperative complications, improving continence and aesthetic anus appearance. In 4 patients the prolapse recurred, requiring further surgical correction. CONCLUSIONS: Anal prolapse is a possible minor complication after anorectal correction. MAR type, the quality of the perineal musculature and defects in surgical technique are the main factors determining ia prolapse will appearance. The anal prolapse surgery indication has been recently increased (including small unilateral prolapses) as long as they are done before the colostomy closure, due to good aesthetic and functional results, requiring only outpatient surgery.

[Surgical wound infections in newborns: analysis of risk factors]. / Infección de la herida quirúrgica neonatal: análisis de factores de riesgo.

UNLABELLED: The incidence of surgical wound infections in neonates is high and it has an associated morbidity which extends hospital stay and gets a worse prognosis. The purpose of this study is to analyze the risk factors associated with the development of surgical wound infection and to identify susceptible patients with modifiable factors. MATERIAL AND METHODS: Case-control study of 90 surgical procedures underwent in newborns. We analyze pre-, intra- and postoperative risk factors. MAIN RESULTS: There are statically significant differences in terms of wound infection in dirty and contaminated surgery, reoperation, lavage of abdominal cavity, preoperative hospital stay longer than 8 days and wound closure with reabsorbable material. Furthermore, the surgical site infection is more likely in preterms patients, with a previous positive culture infection and the use of invasive devices as mechanical ventilation or central venous access. We found no relationship between wound infection and surgical time, bleeding during surgery and preoperative skin preparation with antiseptics. CONCLUSIONS: Reoperative patients, in which dirty and contaminated surgery is performed, absorbable material for skin is used and who have a preoperative hospital stay longer than 8 days, are in risk of developping wound infection and they will require an aggressive antibiotic treatment and special postsurgical care.

[Subcutaneously inserted central intravascular devices in the pediatric oncology patient: can we minimize their infection]. / Dispositivos intravasculares centrales de inserción subcutánea en el paciente oncológico pediátrico, ¿podemos minimizar su infección?

Long-term indwelling central venous access devices are frequently used in pediatric patients. Their main complication is infection, that can even mean their removal. We try to identify the risk factors really involved in this complication and in their removal. We have made a retrospective review of 120 oncologic pediatric patients who received a central venous device between 2003 and 2009. We searched for epidemiologic, clinic, microbiologic and surgical risk factors. We made a comparative data analysis among: GROUP A, children who suffered device infection, GROUP B the others. Group A was divided into early infection (first month after implantation)/late infection, removed/not removed. Data were analized with statistical program SPSS. 29 suffered from leukemia, 19 from lymphoma and the main part, 72, from solid tumour. 31% experienced infection (GROUP A), being early in the 36% of them. 16% had to be withdrawn. Data analysis revealed statistical association with the age (p=0.015) and with the reception of chemiotherapic treatment the week before the surgical insertion. The rest of the studied factors did not revealed a real association, but could be guess a relationship among infection and leukemia, subclavian catheters, those patients whose deviced was introduced using a guide over a previous catheter and also transplanted. Related to early infection the only associateon founded was with the subclavian access (p=0.018). In conclusion, in our serie long-term central venous access infection was more frequent in the younger patients and also in those who had received chemotherapy the week before the catheter implantation. The tendency towards infection in leukemia, transplanted and subclavian carriers has to be studied in a prospective way with a larger number of oncologic children.

[High-pressure balloon dilatation for treatment of orthotopic ureterocele]. / Dilatación con balón de alta presión como tratamiento del ureterocele ortotópico.

OBJECTIVE: Transurethral puncture or endoscopic unroofing is the best treatment currently used for both orthotopic and ectopic ureteroceles. However, they have a high incidence of secondary vesicoureteral reflux and subsequent procedures in both groups. We present a new technique for treatment of orthotopic ureterocele. MATERIAL AND METHODS: We have analyzed 4 patients with orthotopic ureterocele (9.7 ± 6.2 months old) treated by dilatation of the meatus of the ureterocele. No patient had vesicoureteral reflux or duplicate systems. The indication was pyonephrosis in 2 children and progressive worsening of hydronephrosis in 2. Dilatation was performed with 5 or 6mm high-pressure balloon after inserting a stent with guidewire of 0.014" to the ureterocele. RESULTS: There were no intraoperative or postoperative complications, surgical time being 24 ± 9minutes. All patients were discharged at 24 postoperative hours. Ureterohydronephrosis disappeared in all the children and they continue asymptomatic after 35 ± 22.5 months of follow-up. There were no cases of secondary vesicoureteral reflux and renal scan was unchanged after treatment. CONCLUSIONS: High pressure balloon dilatation of the meatus in cases of orthotopic ureterocele is a fast, safe and successful surgical technique. We did not find any cases of secondary vesicoureteral reflux or subsequent procedures in our series, so we believe this may offer significant benefits over the transurethral puncture in such patients.

[Botulinum toxin in the failure of high urinary diversion closure]. / Toxina botulínica en el fracaso del cierre de derivaciones urinarias altas.

INTRODUCTION: The closure of urinary diversions performed on newly born infants has a notable failure percentage in patients with bladder disease. We present the use of botulinum toxin as a useful and minimally invasive alternative to treat these patients. MATERIAL AND METHODS: We present two patients with a single kidney and with posterior urethral valves (PUV), in whom it was necessary to perform a ureterostomy due to chronic kidney disease. In both patients, the subsequent attempt to close the diversion failed. Aged 4 and 10 years respectively, they presented bladders commonly known as "dry bladders", with a low capacity (20 and 110 ml), bad adaptation (1.5 and 3.1 ml/ cm H(2)O) and high opening detrusor pressure. A 10 UI/Kg botulinum toxin A puncture was applied in the detrusor on one and two occasions respectively, prior to the closure of the diversion. RESULTS: Neither of the patients suffered clinical or ecographic worsening after the closure of the diversion and their kidney function continued without change with respect to the first diversion after one and four years of follow-up respectively. One year after the surgical procedure, video urodynamics showed a significant improvement in bladder capacity (451 and 250 ml), in adaptation (20.4 and 81.9 ml/ cmH(2)O) and in the opening detrusor pressure. CONCLUSIONS: The closure of high urinary diversions has a high failure percentage in infants with pathological high-pressure bladders. Botulinum toxin may be useful as bladder treatment prior to closure of the diversion, especially in patients with a single kidney.