[Laparoscopic ureterovesical repair for megaureter treatment]. / Plastia ureterovesical laparoscópica para el tratamiento del megauréter.

BACKGROUND: An alternative treatment for obstructive and refluxing obstructive megaureter with ureterovesical junction maintenance through laparoscopy is proposed. MATERIAL AND METHODS: The series consists of 8 cases, all of them studied because of prenatal hydronephrosis or febrile urinary tract infection. Seven were diagnosed with obstructive megaureter and one with obstructive refluxing megaureter. The procedure consisted in incising the stenotic portion of the ureter longitudinally and maintaining its posterior wall attached to the bladder, the anterior wall of the ureter was anastomosed transversally to the bladder mucosa in order to liberate the obstruction. RESULTS: Two of the 8 cases were women and 6 were male. They were aged between 5 months and 11 years (average age of 2.9 years). The surgical time varied between 90 and 120min, with a 48h hospital stay. The permanence of the vesical catheter and the double J stent was of 48h and 6 weeks, respectively. A female patient developed febrile urinary tract infection one week after the surgical procedure. The rest of the patients remained asymptomatic, with normal urinalysis and quarterly urine culture results. Six months after the procedure, the ultrasound showed improvement of the ureteral diameter and of the pyelocaliceal ectasia. The average follow-up was of 2 years. DISCUSSION: The handling of stenosis with longitudinal incision of the ureter and transverse anastomosis to the bladder mucosa, seems promising. The laparoscopic approach allows to identify clearly the longitude of the stenotic segment and join with relative precision such opening with the one of the vesical mucosa.

[Pineal region tumors in children: is gross-total resection necessary? A single-center experience]. / Tumores de región pineal en niños: ¿es la resección total necesaria? Experiencia en un centro de referencia.

BACKGROUND: Survival of children with pineal region tumors has increased significantly in the last decade; these tumors have an insidious outcome associated with endocrine disorders with high morbidity and mortality, especially after gross resection. The objective was to report the survival, outcome, morbidity and mortality according to type of surgery, histology and treatment in children with pineal region tumors. METHODS: This retrospective study included all patients of 17 years or less with diagnosis of pineal region tumor, who went over a period of 10 years to a children's hospital. A histopathological review was made, and the extent of resection was determined. The survival was also estimated. RESULTS: Forty-six patients were included, out of which 36 had complete medical records and adequate pathologic material. Gross resection was performed in 24 (66.6 %), and biopsy in 12 (33.3 %); 23 (88 %) patients died; hydroelectrolytic imbalance was the cause of 14 deaths (60 %) and the other nine (39.1 %) were secondary to tumor progression. Ten-years survivals among patients treated with gross resection and biopsy were 52 and 75 %, respectively (p = 0.7). Endocrine alterations were observed in 13 patients (36.1 %); in 10 of these (76.9 %) the total resection was performed. CONCLUSIONS: Pineal region tumors in children can be treated with diagnostic biopsy, followed by adjuvant treatment consisting of chemotherapy and radiotherapy.

Introducción: la supervivencia de los niños con tumores de la región pineal se ha incrementado en la última década; estos tienen una evolución insidiosa asociada con los desórdenes endocrinológicos y una alta morbilidad y mortalidad, sobre todo después de la resección. El objetivo es reportar la supervivencia, la morbilidad y mortalidad según el tipo de cirugía, la histología y el tratamiento en un grupo de niños con tumores de la región pineal. Métodos: estudio retrospectivo que incluyó a todos los pacientes con diagnóstico de tumor de la región pineal menores de 17 años de edad que acudieron en un periodo de 10 años a un hospital de pediatría. Se realizó una revisión histopatológica, se determinó la extensión de la resección y se estimó la supervivencia. Resultados: se incluyeron 46 pacientes, 36 de los cuales tenían expediente completo y material de patología adecuado. La resección total se realizó en 24 (66.6 %) y biopsia en 12 (33.3 %); fallecieron 23 pacientes (88 %) y fue el desequilibrio hidroelectrolítico la causa de 14 defunciones (60 %) y la progresión tumoral la causa de las 9 defunciones restantes (39.1 %). La sobrevida a 10 años de los pacientes tratados con resección total y biopsia fue del 52 y 75 %, respectivamente, con una p = 0.7; se presentaron alteraciones endocrinológicas en 13 (36.1%) pacientes de los cuales a 10 (76.9 %) se les realizó la resección de la tumoración. Conclusión: los tumores de la región pineal en niños se pueden tratar con biopsia diagnóstica seguida de tratamiento adyuvante con quimioterapia y radioterapia.

[Laparoscopic vs opened appendicovesicostomy in pediatric patients]. / Apendicovesicostomia laparoscópica vs abierta en pacientes pediátricos.

BACKGROUND: Appendicovesicostomy is commonly employed to facilitate drainage of urine through the catheter. Due to the tendency to less invasive procedures for the treatment of patients with neurogenic bladder, laparoscopy has been used as an alternative to open surgery, with the immediate advantages of postoperative recovery, shorter postoperative ileus, better cosmetic results, lower postoperative pain and early reintegration into everyday life. PURPOSE: Compare the results of laparoscopic procedure with open appendicovesicostomy. METHODS: We conducted an observational, analytical, longitudinal, ambispective cohort study, which included patients from 6-16 years of age diagnosed with neurogenic bladder, operated through laparoscopic and open appendicovesicostomy from January 2009 to June 2013. Information was obtained from clinical records. Six patients were operated laparoscopically and 14 by open approach. RESULTS: Surgical time was longer and statistically significant in the laparoscopic group with a median of 330 min (300-360 min) compared to open procedure of 255 min (180-360 min). Seven patients had complications in the open group and only one in the laparoscopic group. The difference in the dose of analgesics and time of use was statistically significant in favor of the laparoscopic group. The degree of urinary continence through the stoma was higher for laparoscopic (100%) compared to the open procedure (64%). CONCLUSIONS: In neurogenic bladder with urodynamic bladder capacity and leak point pressure bladder within acceptable values, laparoscopic appendicovesicostomy was a better alternative.

Antecedentes: la apendicovesicostomía suele practicarse para facilitar el drenaje de orina por medio del cateterismo. La tendencia a ofrecer procedimientos menos invasivos a pacientes con vejiga neurogénica ha hecho de la laparoscopia una alternativa a la cirugía abierta, por sus ventajas de recuperación, menor tiempo de íleo postoperatorio, mejor cosmética, menor dolor postquirúrgico y reintegración temprana a la vida cotidiana. Objetivo: comparar los resultados de la apendicovesicostomía laparoscópica con la abierta. Material y métodos: estudio de cohorte, observacional, analítico, longitudinal, ambispectivo, que incluyó pacientes de 6 a 16 años, con diagnóstico de vejiga neurogénica, intervenidos mediante laparoscopia y cirugía abierta entre enero de 2009 y junio 2013, recuperándose la información de los expedientes clínicos. Resultados: seis pacientes se operaron mediante laparoscopia y 14 con cirugía abierta. El tiempo quirúrgico fue mayor en el grupo intervenido mediante laparoscopia, con una mediana de 330 minutos (300-360), en comparación con el abierto de 255 minutos (180-360), diferencia estadísticamente significativa. Siete pacientes del grupo abierto tuvieron complicaciones y solo 1 del grupo laparoscópico. La diferencia en la dosis de analgésicos y en el tiempo de su consumo fue estadísticamente significativa a favor del grupo intervenido mediante laparoscopia. El grado de continencia urinaria por la derivación fue mayor para el procedimiento laparoscópico (100%) que para el abierto (64%). Conclusiones: la apendicovesicostomía laparoscópica resultó una mejor alternativa para pacientes con vejiga neurogénica con parámetros urodinámicos de capacidad vesical y presión de punto de fuga dentro de valores aceptables.

Laparoscopic ureterocystoplasty with Mitrofanoff system.

PURPOSE: To describe a laparoscopic surgical technique for ureterocystoplasty in pediatric patients with the Mitrofanoff procedure. PATIENTS AND METHODS: The procedure was performed in 4 patients (2 females and 2 males), 8-11 years old (average, 9.5 years), with a history of myelomeningocele and secondary neurogenic bladder. The patients were evaluated before the surgery with renal ultrasound, voiding cystourethrography, and renal scintigraphy. All subjects reported left hydronephrosis with severe dilatation of ureter and the collector system, left megaureter with grade V vesicoureteral reflux, and left functional exclusion, with right renal normal function. The urodynamic investigations revealed low bladder size and bladder leak point pressure (BLPP) above 40 cm H2O. The laparoscopic ureterocystoplasty augmentation procedure and the Mitrofanoff procedure with the proximal ureter were performed in these patients. Complications and outcomes were recorded and compared with those of the postoperative urodynamic test. RESULTS: The 2-4 years of follow-up of the patients and its urodynamic postoperative evaluation reported at least 75% of the capacity according to their age, compliance that varied between 15 to 20 mL/cm H2O, and a BLPP of less than 40 cm H2O. This last parameter is considered of low risk to damage the upper urinary tract. There was no leaking of urine by the stoma over the 4 hours of catheterization. CONCLUSIONS: Even though enterocystoplasty is the gold standard to increase the capacity of the neurogenic bladder, it has an elevated morbidity. So the use of a dilative ureter to increase bladder size and create a Mitrofanoff stoma in patients with neurogenic bladder, pop-off phenomenon, and renal ipsilateral atrophy could be considered by the laparoscopic approach.

[Survival of patients with malignant astrocytomas according to the expression of Ki67 antigen in a pediatric hospital]. / Sobrevida de los pacientes con astrocitoma de alto grado que expresan el antígeno Ki67, atendidos en un hospital de pediatría.

BACKGROUND: Pediatric patients with malignant gliomas and same histological diagnosis respond distinctly to treatment. It is thus necessary to determine other factors that may influence the response to treatment and survival. Over expression of the Ki67 protein has been associated with poor treatment response. The aim of this study was to determine if the expression of this antigen influences survival of patients treated for malignant gliomas in the CMN SXXI Pediatrics Hospital. METHODS: We included patients with anaplasic astrocitoma or glioblastoma multiforme seen at our hospital between 1995 and 2005. We determined the expression of Ki67 by immunohistochemistry and correlated the findings with tumor histology and patient survival. RESULTS: Of the 21 patients studied, 12 overexpressed antigen Ki67. There was no significant association between over expression of Ki67 and survival, although we observed a clinical association. Over expression of Ki67 correlated with more aggressive histology. Being under the age of 11 was a poor prognostic factor. Overall survival was 49% at 120 months. CONCLUSIONS: Being young (under 11 years) is a marker of poor prognosis among pediatric patients with anaplasic astrocytoma or glioblastoma multiforme. Overexpression expression of antigen Ki67 is associated with histology and may be associated with poor survival among patients treated in our hospital.

Sobrevida de los pacientes con astrocitoma de alto grado que expresan el antígeno Ki67, atendidos en un hospital de pediatría / Survival of patients with malignant astrocytomas according to the expression of Ki67 antigen in a pediatric hospital

Antecedentes: Los pacientes pediátricos con astrocitomas de alto grado con mismas histologías presentan respuestas diferentes a idéntico tratamiento. Es necesario identificar los factores que influyen en el pronóstico y respuesta al mismo. La sobreexpresión de la proteína Ki67 se ha asociado con respuestas poco favorables. El objetivo fue determinar si la expresión de este antígeno influye en la sobrevida de los pacientes con astrocitoma de alto grado del Hospital de Pediatría del Centro Médico Nacional Siglo XXI. Métodos: Se incluyeron pacientes con astrocitoma anaplásico o glioblastoma multiforme atendidos entre 1995 y 2005. Por inmunohistoquímica se determinó la expresión del antígeno Ki67 en las muestras de tejido tumoral y se correlacionó con la histología tumoral y la sobrevida de los pacientes. Resultados: De 21 pacientes, 12 sobreexpresaron el antígeno Ki67. No se encontró asociación estadísticamente significativa entre la sobreexpresión del antígeno Ki67 y la sobrevida, aunque sí clínica. Se encontró asociación estadísticamente significativa entre la sobreexpresión del Ag Ki67 y el grado de malignidad del tumor. La edad menor de 11 años resultó un factor de mal pronóstico. La sobrevida global fue de 49 % a 120 meses. Conclusiones: La edad menor de 11 años fue un factor de mal pronóstico en los pacientes estudiados con astrocitoma o glioblastoma multiforme. La sobreexpresión del antígeno Ki67 está asociada con la histología y pareciera tener relación con la sobrevida de los pacientes pediátricos con astrocitoma.

BACKGROUND: Pediatric patients with malignant gliomas and same histological diagnosis respond distinctly to treatment. It is thus necessary to determine other factors that may influence the response to treatment and survival. Over expression of the Ki67 protein has been associated with poor treatment response. The aim of this study was to determine if the expression of this antigen influences survival of patients treated for malignant gliomas in the CMN SXXI Pediatrics Hospital. METHODS: We included patients with anaplasic astrocitoma or glioblastoma multiforme seen at our hospital between 1995 and 2005. We determined the expression of Ki67 by immunohistochemistry and correlated the findings with tumor histology and patient survival. RESULTS: Of the 21 patients studied, 12 overexpressed antigen Ki67. There was no significant association between over expression of Ki67 and survival, although we observed a clinical association. Over expression of Ki67 correlated with more aggressive histology. Being under the age of 11 was a poor prognostic factor. Overall survival was 49% at 120 months. CONCLUSIONS: Being young (under 11 years) is a marker of poor prognosis among pediatric patients with anaplasic astrocytoma or glioblastoma multiforme. Overexpression expression of antigen Ki67 is associated with histology and may be associated with poor survival among patients treated in our hospital.

[Prognostic and survival factors among pediatric patients with ependymomas]. / Factores pronósticos y sobrevida de pacientes pediátricos con ependimomas.

BACKGROUND: Ependymomas constitute the third most common intracranial tumors in children. Risk factors include age, location, extent of surgical excision, and radiation therapy. Recently, chromosomal imbalances have been described. OBJECTIVE: Determine global survival of patients with ependymomas according to different prognostic factors. METHODS: We reviewed the medical charts of every pediatric patient with ependymoma from 1996 to 2005. Genomic imbalances were determined using comparative genomic hybridization (CGH). Survival was calculated using the Kaplan and Meier method. We used the Log Rank test for each risk factor. Death risk was calculated by odds ratio (OR). RESULTS: We included 24 patients. Global survival was 58.04%. The presence of chromosomal imbalances, particularly in chromosome 21, significantly affected survival Being under 5 years of age, anaplastic histology, chemotherapy other than ICE (ifosfamida-carboplatin-etoposide) and partial resection increased the risk of death. CONCLUSIONS: Known risk factors were confirmed in our study, including chromosomal imbalances. We describe a new chromosomal imbalance in chromosome 21 among 30% of study participants.

Factores pronósticos y sobrevida de pacientes pediátricos con ependimomas / Prognostic and survival factors among pediatric patients with ependymomas

Antecedentes: El ependimoma es el tercer tumor intracraneano más frecuente en pediatría. Los factores que influyen en el pronóstico son la localización, la edad del paciente, la resección quirúrgica y el tratamiento con radioterapia. Recientemente se ha descrito la presencia de alteraciones cromosómicas en el tumor como factor de mal pronóstico. El objetivo de esta investigación fue determinar la sobrevida de pacientes pediátricos con ependimoma de acuerdo con los diferentes factores pronósticos. Métodos: Se revisaron los expedientes de pacientes pediátricos con ependimoma de 1996 a 2005. Se determinaron las alteraciones cromosómicas mediante hibridación genómica comparativa. Se calculó la sobrevida de acuerdo con el método Kaplan-Meier y prueba de log rank de acuerdo a cada factor pronóstico. Se calculó el riesgo de morir para cada factor de acuerdo con la razón de momios. Resultados: Se incluyeron 24 pacientes. La sobrevida global fue de 58.04%. La presencia de alteraciones cromosómicas, particularmente en el cromosoma 21, afectó significativamente la sobrevida. La edad menor a cinco años, la histología anaplásica, la quimioterapia diferente a ifosfamida-carboplatino-etopósido y la resección parcial aumentaron el riesgo de morir. Conclusiones: Se confirman los factores descritos anteriormente en la literatura, incluyendo alteraciones cromosómicas. Se describe un nuevo desbalance en el cromosoma 21 en 30% de los pacientes.

BACKGROUND: Ependymomas constitute the third most common intracranial tumors in children. Risk factors include age, location, extent of surgical excision, and radiation therapy. Recently, chromosomal imbalances have been described. OBJECTIVE: Determine global survival of patients with ependymomas according to different prognostic factors. METHODS: We reviewed the medical charts of every pediatric patient with ependymoma from 1996 to 2005. Genomic imbalances were determined using comparative genomic hybridization (CGH). Survival was calculated using the Kaplan and Meier method. We used the Log Rank test for each risk factor. Death risk was calculated by odds ratio (OR). RESULTS: We included 24 patients. Global survival was 58.04%. The presence of chromosomal imbalances, particularly in chromosome 21, significantly affected survival Being under 5 years of age, anaplastic histology, chemotherapy other than ICE (ifosfamida-carboplatin-etoposide) and partial resection increased the risk of death. CONCLUSIONS: Known risk factors were confirmed in our study, including chromosomal imbalances. We describe a new chromosomal imbalance in chromosome 21 among 30% of study participants.

Phase II study of metronomic chemotherapy with thalidomide, carboplatin-vincristine-fluvastatin in the treatment of brain stem tumors in children.

BACKGROUND: Brain stem tumors (BST) constitute 20% of all intracranial tumors. Survival for these patients has been very poor worldwide. Four different treatment schemes have been evaluated at our institution, with only a discrete increment in survival when treated with carboplatin-vincristine and fluvastatin (CVF). Low-dose, continuous antiangiogenic treatment has been recently introduced in the treatment of cancer. Our objective was to determine tumor response to metronomic chemotherapy combined with an antiangiogenic drug and fluvastatin and to calculate the survival of pediatric patients with brain stem tumors. METHODS: This was a phase II study. A magnetic resonance (MRI) study was made at inclusion and after the fourth course. Routine laboratory analyses were performed prior to each treatment scheme. Patients received four courses of chemotherapy every 28 days consisting of thalidomide alternating with fluvastatin every 14 days and combined with carboplatin and vincristine every 14 days followed by radiotherapy (56 cGy) and four more courses of the same chemotherapy. Toxicity was evaluated according to Miller criteria. RESULTS: Nine recently diagnosed BST patients were included. Five patients had low-grade astrocytomas, three patients had glioblastoma multiforme, and one patient presented high-grade astrocytoma. There was a significant reduction in tumor volume and a significant increase in survival at 24 months. Two patients died. Toxicity included carboplatin allergy in one patient, grades 1 and 3 neutropenia in two patients, and grade 4 thrombocytopenia in two patients. CONCLUSIONS: Metronomic treatment with carboplatin and vincristine associated with fluvastatin and thalidomide significantly increased survival of pediatric brain stem tumor patients. Tumor volume showed a significant reduction. Quality of life was also increased. Sample size must be increased in order to make final conclusions.

Efecto de una plastia circular en el cuello de la vejiga paralítica experimental / Effect of circular plasty in the experimental paralitic bladder neck

Introducción. La incontinencia urinaria es un problema grave que demanda medidas terapéuticas de acuerdo a su grado y etiología. En la llamada vejiga neurógena por ser consecutiva a lesiones nerviosas, se han utilizado diversos métodos para su control, tales como: medicamentos, cateterismo uretral, colectores, esfínteres artificiales e intervenciones quirúrgicas en cuello, pared vesical y derivación permanente de vías urinarias. Material y métodos. En este trabajo se presenta un modelo experimental de plastia circular en 55 conejos machos, en los cuales se produjo una vejiga paralítica por sección medular en la que se realizó una plastia, no descrita, por plegamiento del cuello con suturas de pespunte vertical y transversal en todo su rededor, respetando la desembocadura de ureteros y conductos espermáticos. Resultados. Evaluada por cistometría en la etapa previa al procedimiento, la vejiga tuvo una capacidad media de 37 mL, con presión de salida de 28 cm; en la fase paralítica la capacidad fue de 200 mL y la presión de 28 cm; después de la plastia tuvo 61 mL de capacidad y 27 cm de presión de salida. Conclusión. El resultado de la plastia fue satisfactorio porque la incontinencia presente en la fase paralítica no existió después de la plastia