What urethrogram sees and a surgeon does not. / Lo que una uretrografía ve y un cirujano no.

INTRODUCTION: Urethrorrhagia is an infrequent sign in childhood. It should be distinguished from hematuria, since they have a different etiology. CLINICAL CASE: 11-year-old male patient with significant urethrorrhagia. Urinary sediment analysis: red blood cells++. Pelvic ultrasonography: fusiform anechoic image in the corpus spongiosum of the penile root. Retrograde urethrogram: normal anterior urethra, extraluminal contrast passage in the ventral aspect of the bulbar urethra. Cystoscopy: no pathological findings in the urethra or the bladder. Control retrograde urethrogram: cystic dilatation of Cowper's gland duct; Maizels' type 3 perforated syringocele. DISCUSSION: Cowper's syringocele is a rare pathology. It can occur at any stage of childhood in the form of urinary infection, obstructive voiding symptoms, or urethrorrhagia. Urethrogram is key for diagnostic purposes, since most Cowper's syringoceles are detected following urethrogram or cystoscopy. Cases with functional repercussions for the urinary system require surgical treatment. Otherwise, a wait-and-see approach is feasible.

INTRODUCCION: La uretrorragia es un signo infrecuente en la infancia que debe distinguirse de la hematuria dada la diferente etiología de las mismas. CASO CLINICO: Varón de 11 años con uretrorragia franca. Sedimento urinario: hematíes++. Ecografía pélvica: imagen anecoica fusiforme en cuerpo esponjoso de raíz peneana. Uretrografía retrógrada: uretra anterior normal, paso de contraste extraluminal ventral en uretra bulbar. Cistoscopia: sin hallazgos patológicos en uretra ni vejiga. Uretrografía retrógrada de control: dilatación quística del conducto de las glándulas de Cowper; siringocele perforado tipo 3 de Maizels. COMENTARIOS: El siringocele de Cowper es una patología infrecuente que puede debutar en cualquier momento de la infancia como infección urinaria, síntomas miccionales obstructivos o uretrorragia. La uretrografía es fundamental en su diagnóstico ya que la mayoría se objetivan por este medio o cistoscopia. Los casos con repercusión funcional del sistema urinario requieren tratamiento quirúrgico. En caso contrario podrá realizarse actitud expectante.

[An infant with intestinal pneumatosis and pneumoperitoneum: the difficult decision not to intervene]. / Un lactante con neumatosis intestinal y neumoperitoneo: la difícil decisión de no intervenir.

Pneumoperitoneum in children may be due to causes that do not require urgent surgery (cardiopulmonary resuscitation manoeuvres, severe respiratory pathology or mechanical ventilation). Surgery in these cases could even worsen the prognosis. We present the case of a male infant, ex-preterm, with a history of necrotizing enterocolitis and ileal perforation at birth, requiring laparotomy and intestinal resection on two occasions and developing a secondary microcolon, due to disuse. At six months, after transitioning to full oral feeding, he presented abdominal distension with extensive intestinal pneumatosis and pneumoperitoneum on radiographs. His general appearance was good with normal intestinal transit and no peritonitis. The patient remained fasting with intravenous antibiotics, nasogastric decompression and parenteral nutrition. The evolution was favourable with oral feeding restarting on the seventh day of admission. The existence of pneumoperitoneum does not always require a laparotomy and global assessment of the patient by an interdisciplinary health team may avoid unnecessary aggressive treatments.

[Early parenteral nutrition in complex post-operative periods]. / Nutrición parenteral precoz en postoperatorios complejos.

OBJECTIVE: The protein hypercatabolic state in critically ill pediatric patients can be minimized by an effective nutrition therapy. We conducted a study to evaluate the benefits of early parenteral nutrition (EPN) assessing its effect on nutritional parameters and clinical relevance after complex surgical procedures. METHODS: Prospective randomized study in patients undergoing abdominal surgery in which nothing by mouth is anticipated for a period ≥ 3 days, between 2012 and 2014. Blood tests were performed assessing nutritional parameters in the first 24 hours and the 5th postoperative day. Two groups were created, starting EPN in group A and standard fluid therapy in group B, after the extraction of the first sample. RESULTS: Forty-four patients were included, 18 in group A and 26 in group B. In the first analysis all had decreased levels of prealbumin and retinol-binding protein. On the 5th day, 55,6% of group A normalized prealbumin levels compared to 11,5% of B (p: 0.003, EF = 80%) whereas retinol-binding protein was normalized in 66,7% and 34.6%, respectively (p: 0,07, EF = 48,4%). Three patients in group A (16,7%) had postoperative infectious complications compared to 8 in B (30,8%), difference no statistically significant but clinically relevant (NNT=7,1), since the latter showed low prealbumin levels and longer hospital stay. No complications related to EPN were detected. CONCLUSION: Administration of EPN in the complex postoperative patients appears to be safe and beneficial for their recovery, being the prealbumin an early indicator of good nutritional response.

OBJETIVOS: El estado hipercatabólico proteico en el paciente pediátrico postoperado puede ser minimizado con un tratamiento nutricional eficaz. Realizamos un estudio para evaluar los beneficios de la nutrición parenteral precoz (NPp) valorando su efecto sobre los parámetros nutricionales y su relevancia clínica en postoperatorios quirúrgicos complejos. MATERIAL Y METODO: Estudio prospectivo aleatorizado en pacientes sometidos a cirugía abdominal donde se preveía dieta absoluta por un periodo ≥3 días, entre 2012 y 2016. Se realizaron analíticas valorando parámetros nutricionales en las primeras 24 horas y al 5º día postoperatorio. Se crearon 2 grupos, iniciando NPp en grupo A y fluidoterapia estándar en grupo B, tras la extracción de la primera muestra. RESULTADOS: Se incluyeron 44 pacientes, 18 en grupo A y 26 en grupo B. En la primera analítica todos presentaban niveles disminuidos de prealbúmina y proteína fijadora del retinol. Al 5º día, el 55,6% del grupo A normalizaron la prealbúmina frente al 11,5% del B (p: 0,003, FEE = 80%) mientras que la proteína fijadora del retinol se normalizó en el 66,7% y 34,6%, respectivamente (p: 0,07 FEE = 48,4%). Tres pacientes del grupo A (16,7%) presentaron complicaciones infecciosas en el postoperatorio frente a 8 del B (30,8%), diferencia no estadísticamente significativa pero relevante clínicamente (NNT = 7,1), ya que estos últimos mostraban niveles bajos de prealbúmina y mayor estancia hospitalaria. No se detectaron complicaciones relacionadas con la NPp. CONCLUSION: La administración de NPp en postoperatorios complejos parece ser segura y beneficiosa para la recuperación de los pacientes, siendo la prealbúmina un indicador precoz de buena respuesta nutricional.

[Peripherally inserted central catheters: Savings, comfort, many advantages]. / Catéteres centrales de inserción periférica: un ahorro, una comodidad, muchas ventajas.

INTRODUCTION: Peripherally inserted central catheters are indicated when an intravenous treatment is expected for more than 6 days or less if phlebotoxic medication is used. We report our recent experience. METHODS: Retrospective study from 2014 to 2015 including patients to whom a catheter was placed either, in the operating room after surgery and before awakening the patient, or in the Pediatric ICU by direct or ultrasound guidance venipuncture. We reviewed patient characteristics, underlying disease, line catheterization procedure, type and duration of venous line, intravenous treatment and complications. RESULTS: Sixty-nine catheters of 3, 4 and 5 Fr (1 or 2 lumens) were placed in 66 patients with a median age of 5.71 years (± 4.24). They were mainly Pediatric Surgery patients (n = 19) mostly complicated acute appendicitis (n = 12). Arm veins were catheterized without difficulties except for two accidental arterial punctures. There were no infectious complications but 7 patients presented extravasation (one chylothorax) that forced the removal of the catheters and 3 reported obstruction by parenteral nutrition resolved with heparin irrigation. Two patients died and one was referred to another center with the catheter in use. There were no clinical venous thromboses. The median line duration was 10.6 days (maximum of 62 days). CONCLUSIONS: Peripherally inserted central catheters facilitate the management of patients avoiding repeated peripheral venipunctures. Its placement in the operating room after surgery and before the patient awakes, facilitates line catheterization and reduces complications. That is why we have included it in the therapeutic protocol of selected patients, the use of this type of catheter.

INTRODUCCION: Los catéteres centrales de inserción periférica están indicados cuando se prevé un tratamiento endovenoso durante más de 6 días o menos si se utiliza medicación flebotóxica. Presentamos nuestra experiencia reciente. METODOS: Estudio descriptivo retrospectivo desde 2014 a 2015 incluyendo pacientes a los cuales se les colocó un catéter ya sea en quirófano, tras la cirugía y antes de despertar al enfermo, o en la UCI Pediátrica por venopunción directa o ecoguiada. Revisamos características del paciente, enfermedad de base, procedimiento de canalización, tipo y duración de la vía, tratamiento endovenoso y complicaciones. RESULTADOS: Colocamos 69 catéteres de 3, 4 y 5 Fr (1 o 2 luces) en 66 pacientes con edad media de 5,71 años (± 4,24). Eran mayoritariamente enfermos de Cirugía Pediátrica (n= 19) sobre todo apendicitis agudas complicadas (n=12). Se canalizaron venas del brazo sin dificultades salvo 2 punciones arteriales accidentales. No hubo complicaciones infecciosas, pero sí 7 extravasaciones (un quilotórax) que obligaron a retirar el catéter y 3 obstrucciones por nutrición parenteral resueltas con irrigación de heparina. Dos enfermos fallecieron y uno fue derivado a otro centro con el catéter en uso. No hubo trombosis venosas clínicas. La duración media del acceso fue de 10,6 días (máximo 62 días). CONCLUSIONES: Los catéteres centrales de inserción periférica facilitan el manejo de los pacientes evitando las punciones venosas periféricas repetidas y su colocación en quirófano, tras la cirugía y antes de despertar al enfermo, facilita la canalización y reduce las complicaciones. Es por eso que hemos incluido estos en el protocolo terapéutico de enfermos seleccionados.

[Effectiveness analysis of a therapeutic strategy for pediatric varicocele. Have we got what we expected?]. / Análisis de efectividad de una estrategia terapéutica en el varicocele pediátrico. ¿Hemos alcanzado nuestros objetivos?

OBJECTIVE: Optimal treatment ot vancocele in adolescents remains a topic of discussion. Strides in interventional radiology and laparoscopy have allowed us to implement a multidisciplinary therapeutic protocol that aims to get best of both. We evaluate our results. METHODS: . Retrospective study of pediatric patients treated for varicocele in our hospital under protocol between 2008 and 2013. Once the therapeutic indication is confirmed, through clinical and Doppler ultrasound examination, patients undergo percutaneous retrograde embolization (PRE). We perform laparoscopic varicocelectomy (LV) when the PRE fails, together with lymphatic preservation using blue patent lymphography prior to surgery. RESULTS: . Fifty-five patients with varicocele were treated at a mean age of 13 years old (range 11-16). PRE was performed in 50 patients (90.9%), with a proportion of remission of 80% by ultrasound study 6 months after PRE. Sixteen patients (29.1%) underwent LV five of whom without prior PRE. Lymphography with patent blue was performed in 13 (23.6%), and single-port surgery in 6 patients. The presence of coils of PRE did not hinder subsequent LV. The remission rate after LV was 100% at 6 months follow up. Two postoperative lymphoceles were recorded, none after patent blue lymphography. CONCLUSIONS: . We found in this therapeutic sequence a safe and efficient alternative, allowing a minimal surgical invasion and reducing the rate of postoperative lymphoceles.

[Single port video-assisted transumbilical appendectomy. What have we gained and what have we lost after 754 cases]. / Apendicectomía videoasistida transumbilical por puerto único. Qué hemos ganado y qué hemos perdido después de 754 casos.

INTRODUCTION: Single-port transumbilical laparoscopically assisted appendectomy (TULAA) has become the preferred method of treating appendicitis in our Department. At first, it was reserved for noncomplicated cases, and gradually for the rest of them. We have gained experience, and it is time to share it, evaluate the results and raise into new possibilities. MATERIAL AND METHODS: We performed a retrospective statistical analysis of undergone changes over the last years, referring to aspects such as surgical indications, andpostoperative complications, hospital stays and re-admissions. RESULTS: From September 2003 to January 2012, a total of 1,022 appendectomies were performed. Eight hundred and forty-one children underwent TULAA, 89.65% were completed with no problems. In 179 patients, open appendectomy was initially chosen. In those cases, the reasons were complicated appendicitis, obesity or surgeon's preference (43 in the first year and just 3 in the last one). Ninety seven patients had postoperative complications of any kind, fifteen were readmitted to the hospital and 3 were reoperated because of intestinal obstruction. Medical cost savings were estimated around 750.000 Euros. CONCLUSIONS: We think that TULAA is a simple and easy learning procedure, which does not result in any increase in complications, inexpensive and beneficial for patients. However, along these years, our surgical staff may have lost skills and training opportunities in conventional laparoscopic surgery. So although TULAA is still our preferred method in appendicectomy, selected cases will undergo laparoscopic appendectomy.

[Are we correctly treating pilonidal disease in children? therapeutic goals beyond preventing recurrence]. / Estamos tratando bien la enfermedad pilonidal en los niños? Objetivos terapéuticos más allá de prevenir la recidiva.

INTRODUCTION: We present a retrospective study of our paediatric patients affected by pilonidal disease over the last 5 years. PATIENTS AND METHOD: In all cases a broad excision of the pilonidal tissue was made, without colour signing the different incision sites and primary closure of the defect with no drainage. RESULTS: Using this technique we treated 20 adolescents (15 girls and 5 boys) of ages between 12 and 15 years (average age 13.3 years) and body mass index between 17 and 33 (mean BMI 26.4 kg/m2). Mean hospitalisation time was 1.45 days. Preoperative antibiotherapy with Amoxicillin-clavulanic was administered to 55% of patients and continued over the first postoperative week. We had four cases with recurrence of the disease (25%) (two of these with two recurrences), which we treated with three primary closures on the midline and three by flattening the cleft. In 2 cases with dehiscence of the wound we allowed treatment by secondary intention. No flaps or marsupialisation were attempted in any case. In all cases the result was aesthetically satisfactory, with maintenance of the intergluteal fold. CONCLUSIONS: In our series we have succeeded in undertaking primary closure of the defect after pilonidal resection without any excessive tension. This treatment enables a rapid return to a normal routine. We considered it important to undertake surgery that maintained the intergluteal fold, especially in patients with a short-term evolution of the disease, reserving flattening the cleft, closure by secondary intention, or primary closure by inserting flaps only for cases of recurrent disease; those with long-term evolution; or patients with complex lesions prior to surgery. Nutritional support to reduce overweight is very important in many patients.

[Scarring after Mustarde otoplasty: importance of cures and post-operative follow-up of the patients]. / Escaras tras otoplastia de Mustardé: importancia de las curas y seguimiento postoperatorio de los pacientes.

INTRODUCTION: In the treatment protocol for patients with Mustardé otoplasties we use tennis head sweatbands for 2 months (to be worn all the time in the first month and only at night in the second month) to protect the correction obtained and to avoid traumatisms. MATERIAL AND METHODS: We describe the cases of 3 patients who underwent Mustardé otoplasty and presented sloughs in the anterior edge of the antehelix that are secondary to the pressure of the compression bandage. RESULTS: One patient operated for unilateral malformation suffered bilateral scars (in the operated ear and in the healthy one). This prove that the scars are secondary to the dressings not to surgery. In two patients the sloughs evolved into the formation of nodular hypertrophic scars, which were slowly corrected with silicone dressings and externally applied corticosteroids and moisturising creams in one patient and had to be resected in the other. CONCLUSIONS: It is important to give a detailed explanation to the parents about the mission and characteristics of the sweatbands, and also about the need to frequently check their correct placing. This is to avoid a complication that, without spoiling the final result of the otoplasty, reduces patient satisfaction and extends the recovery period.

[Treatment of adolescent varicocele: is percutaneous embolization better?]. / Tratamiento del varicocele del adolescente. Es mejor la embolización percutánea?

UNLABELLED: There are still doubts as to the most suitable criteria when considering surgery as the indication and optimal treatment for adolescent varicocele. MATERIAL AND PATIENTS: We reviewed the hospital and primary health care histories of patients diagnosed by ultrasound for varicocele over the last 7 years. The data was taken from computerised clinical histories and hard copy back-up material stored and processed in computer format. RESULTS: We studied 135 cases (mean age 12.8 years). These patients (125) were referred for scrotal swelling or as a result of chance detection, except for 10 patients who reported pain or scrotal asymmetry. Seventy-three underwent surgery and 62 continued as controls over the study period. The surgical indication was significant progressive asymmetry in testicular volume (28 children), high grade varicocele (41) as well as other reasons (4). We undertook percutaneous embolization in 44 patients (with a 66% relapse rate) and laparoscopic section of the spermatic cord with no arterial preservation in 29 (no relapses but 7 post-surgery hydroceles). No testicles were lost. At the end of the study 10 children continued as controls, 34 were discharged after recovery, 56 were referred to urology due to their age group, and 35 were lost to the study. DISCUSSION: In the controversy over the treatment of varicocele our experience shows a high degree of relapses after embolization. Section of the spermatic vessels (including the artery) with no lymphatic preservation is highly effective but involves 27% post-op hydroceles, usually self-limiting (only one had later to undergo surgery), with no testicular atrophy or other complications. CONCLUSIONS: We prefer complete laparoscopic section of the spermatic pedicle to embolization but it would be advisable to introduce modifications to avoid post-surgical hydrocele. Embolization must be reserved for patients with one testicle or with bilateral disease. Efforts must be made to communicate more effectively, in order to reduce the high drop-out rate.

[Correction of recurrent pectus excavatum post-Ravitch with the Nuss technique]. / Corrección de la recidiva del pectus excavatum post-Ravitch con la técnica de Nuss.

INTRODUCTION: For one decade, the minimally invasive technique (MIRPE) of Nuss has been used in our Service as the elective technique for correction of Pectus Excavatum. If recurrences occur in patients that underwent open surgery, a new surgery of the same characteristics entails important technical problems, long surgical times and poor outcome. For this reason, we think that one specific indication for the MIRPE technique may be this type of patients. MATERIAL AND METHODS: Based on our experience with four patients with a recurrence of pectus excavatum after an open surgery "Ravitch type", we illustrate the fundamental aspects for the development of the Nuss technique, adapted to this type of patients. The factors to be consider are: Systematic bilateral thoracoscopy with a suitable position of the two towers to guarantee a good visualisation of the passage of the introducer clamp by the mediastino. Use of thoracoscope with work channel on the right side, that allows the releasing of adherences and with a 5 mm lens on the left side. Use of a large introducer clamp more length for adolescent patients, The rest of the material is the usual one in this protocol surgery. Our patients did not present any remarkable incidences, with very satisfactory results. COMMENTS AND CONCLUSIONS: We found of great importance for the good development of the technique to establish a correct strategy prior to surgery and to dispose a good organisation of the surgery room. The surgery must be carried out in a spacious surgical room, given the great amount of material that is used. It is important to be familiarized with the procedure, because even if performed in a regulated way, variations in the positioning and fixation of the bar are frequently needed.

[Scrotal hypospadias. Our experience with free oral mucosa grafts]. / Hipospadias escrotal. Nuestra experiencia con los injertos libres de mucosa oral.

Many surgical techniques, using different tissues, have been performed to repair the scrotal hypospadias in this century, but none of them has been completely effective. The use of autologous buccal mucosa as a free graft for urethral replacement was introduced in 1989. The reported results have been encouraged since then. Twenty three patients with scrotal hypospadias, have been treated from 1991 to 1998. These patients underwent a 2-stage surgical replacement. The first stage of the procedure included correction of the penile curvature and advancement of preputial flaps ventrally as described by Byras. The second stage of the procedure was the urethroplasty. The neourethra was made of a tubularized buccal mucosa graft. The mucosa was harvested from the inner surface of the lower lip. The first stage was performed at a mean age of 20 months old, and the second stage at a mean age of 32 months old. Micropenis was detected in 26% of patients. All of them were treated with topic testosterone before the second stage. The follow-up reflected that 7 out of 23 patients (30.4%) had not complications, while 16 patients (69.5%) developed urethro-cutaneous fistula. Six of them (26%) required only one surgical closure and the other 10 patients required more than one surgical procedure to correct several complications. One patient presented complications in both the recipient and the donor areas. Nowadays, cosmetic and functional results are good in 22 patients.