Multicenter comparative study of open, laparoscopic, and robotic pyeloplasty in the pediatric population for the treatment of ureteropelvic junction obstruction (UPJO).

INTRODUCTION: Dismembered open pyeloplasty described by Anderson and Hynes is the "gold standard" for the treatment of ureteropelvic junction obstruction. The aim of our study was to compare the results of open (OP) vs laparoscopic (LP) vs robotic (RALP) pyeloplasty. MATERIAL AND METHODS: A multicenter prospective review was conducted of pyeloplasty surgeries performed at five high-volume centers between 2014 and 2018. Demographic data, history of prenatal hydronephrosis, access type, MAG3 renogram and differential renal function, surgery time, length of hospital stay, and complication rate (Clavien-Dindo) were recorded. Access type was compared using the Kruskal-Wallis, Chi-square, or Fisher's exact tests. RESULTS: A total of 322 patients were included: 62 OP, 86 LP, and 174 RALP. The mean age was 8.13 (r: 1-16) years, with a statistically significant lower age (mean 5 years) in OP (p < 0.001). There were no significant differences in the distribution of the side affected. Operative time was 110.5 min for OP, 140 min for LP, and 179 min for RALP (p < 0.0001). Hospital stay was significantly shorter in the RALP group than in the other groups (p < 0.0001). There were no differences in postoperative complications and reoperations between the three groups. CONCLUSIONS: Minimally invasive surgery for the management of UPJO in children is gaining more acceptance, even in patients younger than 1-year-old. Operative time continues to be significantly shorter in OP than in LP and RALP. Hospital stay was shorter in RALP compared to the other techniques. No differences were found in complication rates, type of complications, and reoperation rate.

"Epstein-Barr virus associated smooth muscle tumour as an unusual cause of ureteric graft obstruction in a child".

BACKGROUND: Epstein-Barr virus (EBV) is a DNA virus with oncogenic potential, especially in immunocompromised patients. EBV can promote smooth muscle proliferation, resulting in EBV-associated smooth muscle tumors (EBV-SMT). METHODS: We report a case of a 10-year-old child with end-stage renal disease secondary to hypoplastic crossed and fused kidneys who underwent kidney transplantation. EBV serology was unknown for the donor and negative for the recipient; three months after he had a primary EBV infection. Two years after the transplantation, percutaneous nephrostomy was performed because of a drop in the estimated glomerular filtration rate and severe dilatation of the graft. Nephrography showed contrast enhancement of the pelvis of the graft kidney and proximal ureter, with a clear blockage at the level of the mid ureter and no passage towards the bladder. A 1.5-cm tumor was found causing intraluminal compression of the mid ureter. RESULTS: Complete resection of the tumor and distal ureter was performed leaving a short proximal ureter. A tension-free uretero-ureteroanastomoses was achieved using the native ureter. There were no surgical complications. Histologic evaluation showed spindle-shaped muscle cells, moderate pleomorphism, and inflammatory infiltration. Immunohistochemical staining was positive for muscle-specific actin. Epstein-Barr encoding region (EBER) in situ hybridization was positive, confirming the diagnosis of EBV-associated SMT. CONCLUSIONS: EBV-SMT is an exceedingly rare oncological entity that may develop in either the graft or any other organ. The clinical findings are location related. EBV seroconversion following transplantation might be a risk factor for the development of SMT in solid organ recipients.

The effect of the Covid-19 Pandemic on pediatric urology.

Medical and surgical priorities have changed dramatically at the time of this pandemic. Scientific societies around the World have provided rapid guidance, underpinned by the best knowledge available, on the adaptation of their guidelines recommendations to the current situation. There are very limited scientific evidence especially in our subspecialty of pediatric urology. We carry out a review of the little scientific evidence based mainly on the few publications available to date and on the recommendations of the main scientific societies regarding which patients should undergo surgery, when surgery should be performed and how patient visits should be organize.

Repeated injections of intradetrusor onabotulinumtoxinA as adjunctive treatment of children with neurogenic bladder.

AIM: To evaluate the effects of repeated injections of onabotulinumtoxinA in children with neurogenic bladders refractory to conventional treatment. PATIENTS AND METHODS: A total of 26 children with neurogenic bladder were prospectively studied. Some patients received up to four repeat injections. Patients were reinjected if they showed improvement in voiding diary, score of urinary incontinence and/or urodynamic studies; otherwise, augmentation cystoplasty was indicated. RESULTS: Of the 26 patients, 12 were reinjected a second time, 6 patients were reinjected a third time and 2 patients received a repeat injection for the fourth time. Six months after the first, second and third injection, the urinary incontinence score 0 (dry) was 50, 77 and 75 %, respectively. After each injection, the mean bladder capacity in voiding diary and the mean maximum cystometric capacity increased. The mean detrusor pressure at the end of filling decreased. Only compliance after the first injection improved significantly. Detrusor overactivity (n: 4), improved during 3 months and reappeared in three children after the first injection, but at greater cystometric volumes. In the fourth case, it reappeared 11 months after the third injection. Five patients underwent cystoplasty. CONCLUSION: After treatment with onabotulinumtoxinA, urinary continence achieved was 50-77 %. There were favorable changes in urodynamic variables, but they were insufficient. Detrusor overactivity was attenuated, but did not disappear completely.

Urological outcome with the use of salvage continent vesicostomy in pediatric reconstructive surgery. A single tertiary center experience.

PURPOSE: To report our experience and results in terms of complications, reoperation rate and urinary continence with the Salvage Continent Vesicostomy (SCV) technique in pediatric patients with history or need of enterocystoplasty and absent appendix. METHODS: Retrospective review of all patients with a history of a continent catheterizable channel surgery performed in our institution between June 2016 and January 2022. Only patients with a SCV surgery with a minimum 6-month post operative follow up were included in this cohort and divided in group 1 (history of previous bladder augmentation) and group 2 (simultaneous bladder augmentation and SCV). Primary outcome of the study was to assess both continence and postoperative complication rates. Early complications were assessed using the Clavien-Dindo classification (I-V). Late complications were focused on the need of further subfascial revision. RESULTS: 84 patients with a history of a continent stoma creation surgery were identified. In 20 of them (12 males) a SCV was performed. The mean age at surgery was 10.38 (range 4.87-15.6) years and the median postoperative follow-up time was 32 (range 6-64) months. Eleven patients were included in Group 1, while 9 patients in Group 2. Early complications occurred in 4 patients (20%), two of them required a re-intervention (Clavien-Dindo IIIb). Stoma subfascial revision was further required in 2 patient (10%). Continence rate at last follow up was 95%. CONCLUSIONS: In our early experience, the salvage continent vesicostomy has proven to be a simple continent stoma technique with acceptable both continence and complication rates that can be used in selected patients with a history or need of bladder augmentation and absent appendix.

Latitudes and attitudes: A multinational study of laparoscopic pyeloplasty in children.

PURPOSE: The Anderson-Hynes technique has been the treatment of choice for primary ureteropelvic junction obstruction in children. Laparoscopic approach has shown similar outcomes to open, with advantages of shorter hospital stay and less pain. We reviewed the experience of 11 geographically diverse, tertiary pediatric urology institutions focusing on the outcomes and complications of laparoscopic pyeloplasty. MATERIALS AND METHODS: A descriptive, retrospective study was conducted evaluating patients undergoing Anderson-Hynes dismembered laparoscopic pyeloplasty. Centers from four different continents participated. Demographic data, perioperative management, results, and complications are described. RESULTS: Over a 9-year period, 744 laparoscopic pyeloplasties were performed in 743 patients. Mean follow-up was 31 months (6-120m). Mean age at surgery was 82 months (1 w-19 y). Median operative time was 177 min. An internal stent was placed in 648 patients (87%). A catheter was placed for bladder drainage in 702 patients (94%). Conversion to open pyeloplasty was necessary in seven patients. Average length of hospital stay was 2.8 days. Mean time of analgesic requirement was 3.2 days. Complications, according to Clavien-Dindo classification, were observed in 56 patients (7.5%); 10 (1%) were Clavien-Dindo IIIb. Treatment failure occurred in 35 cases with 30 requiring redo pyeloplasty (4%) and 5 cases requiring nephrectomy (0.6%). CONCLUSION: We have described the laparoscopic pyeloplasty experience of institutions with diverse cultural and economic backgrounds. They had very similar outcomes, in agreement with previously published data. Based on these findings, we conclude that laparoscopic pyeloplasty is safe and successful in diverse geographics areas of the world.

Nephro-urological outcomes of a proactive management of children with spina bifida in their first 5 Years of life.

INTRODUCTION: The proactive management of spina bifida (SB), especially of its severe form, myelomeningocele (MMC), has contributed to decreasing chronic kidney disease (CKD). The objective of this study is to present the evolution of 5-year-old patient with MMC followed from birth with a proactive approach. MATERIAL AND METHODS: This retrospective study included 55 cases with MMC of up to 5 years of age. All of them were admitted at birth and followed by a multidisciplinary group, with a proactive approach: CIC and anticholinergics. In the same group, the variables were compared within the first year and the within the fifth year of life. Chronic kidney disease (CKD) was defined by: alterations on renal DMSA scintigraphy; alterations in microalbuminuria/creatininuria ratio, proteinuria 24 hs and decrease in glomerular filtration rate (GFR) calculated with Schwartz bedside equation. RESULTS: Although overactivity, UTI and VUR decreased throughout the first 5 years (49, 9 and 12%), reduced cystometric capacity, DLPP >40 cm of water and end-filling pressure (Pdet) >20 cm of water increased (41, 27 and 61%). All patients at 5 years of age required CIC. Reduced cystometric capacity and VUR were more significant with abnormal DMSA (36%) at 5 years old ( p: 0.03). Proteinuria and CKD increased to 25% and 49%. Similarly, the need for enalapril increased from 10% to 27%. The microalbuminuria/creatininuria ratio was pathological in 27.3%. 48 patients (87%) remained unchanged on DMSA scan and the other 7 underwent modifications (4 new cases with altered DMSA) over time. Of the 32 normal DMSA cases without changes, 81% did not present proteinuria and 88% continued to respond favorably to oxybutynin. GFR <90 ml/min/1.72m 2 was found in only 3 cases with abnormal DMSA. There was a RR 1.91 (IC95% 1.15-3.16) greater of renal compromise in cases that were anticholinergic-resistant compared to non-refractory cases. DISCUSSION: Over time, some patients suffered loss of bladder wall compliance, despite the proactive approach. There is an association between abnormal renal DMSA, reduced bladder capacity, and VUR at 5 years of age. Although proteinuria, CKD and enalapril requirement increased over 5 years, almost 90% did not show changes in renal DMSA status. CONCLUSIONS: Over time, some patients suffered loss of bladder wall compliance. Hence, even if a proactive approach is followed since birth, it is essential to continue with the ongoing monitoring of the renal status and thus avoid greater renal deterioration.

High flow priapism: diagnosis and treatment in pediatric population.

PURPOSE: To present three cases of arterial high flow priapism (HFP) and propose a management algorithm for this condition. MATERIALS AND METHODS: We studied three children with post-traumatic arterial HFP (two patients with perineal trauma and one with penis trauma). RESULTS: Spontaneous resolution was observed in all the patients. The time of resolution by a return to a completely flaccid penis was different: 14, 27 and 36 days in each case. CONCLUSIONS: Absence of long-term damaging effects of arterial HFP on erectile tissue combined with the possibility of spontaneous resolution associated with blunt perineal trauma are suggestive signs for the introduction of an observation period in the management algorithm of HFP. Such a period may help to avoid unnecessary surgical intervention. Thus, these cases reinforce the decision to manage these patients conservatively and avoid angiographic embolization as a first therapeutic choice.

Outcome of renal transplant in patients with abnormal urinary tract.

PURPOSE: To determine whether surgical procedures of the lower urinary tract in patients with uropathies affect evolution of the graft in renal transplantation. METHODS: 156 kidney transplantations were performed in 150 patients with end-stage renal failure due to urologic disorders. The patients were classified into three groups: A, patients who did not require surgery in the lower urinary tract; B, required surgery and preserved adequate bladder function, and C, required surgery due to vesical dysfunction. RESULTS: Graft survival rates at 1 year were 93.38% in group A, 95.45% in group B and 93% in group C. Rates at 5 years post-transplantation were 82.45, 79.85 and 86.58% for each group, respectively (not significant). Complications were vesicoureteral stenosis: 2 in group A, 3 in B and 1 in C; vesicoureteral reflux: 1 in group A, 1 in B and 10 in C; distal ureteral necrosis: 2 cases in group A, 2 in B and 1 in C; upper urinary tract infection: 12, 23.1 and 42.2% in each group, respectively. CONCLUSION: Children with reconstructed urinary tract may be good candidates for kidney transplantation despite the higher frequency of urinary infections. Thus, careful and strict post-surgical urologic follow-up is mandatory.

The Impact of Adjuvant Sirolimus Therapy in the Surgical Management of Scrotal Slow-Flow Vascular Malformations.

OBJECTIVE: To describe the effects of oral sirolimus administered before and after surgical resection of slow-flow vascular malformations of the scrotum in pediatric patients. METHODS: Retrospective review of 3 patients presenting with complex lymphatic-venous malformations of the scrotum who received adjuvant oral sirolimus 3 months before and 3 months after surgical resection. Demographic data, clinical course, imaging findings, and management strategies were reviewed for each patient. RESULTS: In each of the 3 patients, there was a significant volume reduction of the lesion within the 3 months after initial dose of sirolimus. Scarce lymphatic leakage during and after surgery was reported, associated with an adequate wound healing. Two years after the last postsurgical dose of sirolimus, all patients remain asymptomatic without any lymphatic leakage or lesion recurrence. CONCLUSION: Combined lymphatic-venous vascular malformations of the male genitalia are rare but associated with high morbidity and challenging treatment options. Pre- and postsurgical adjuvant treatment with oral sirolimus seems to be a promising therapeutic option that provides reduction of the lesion size before surgery and improvement of postsurgical recovery and wound healing.

Outcomes of event-free survival in patients with Wilms tumor undergoing preoperative chemotherapy. Analysis of lymph-node yield in a single-center cohort.

INTRODUCTION: The clinical value of lymph node sampling in Wilms tumor (WT) lies in its ability to accurately determine lymph node (LN) involvement. LN yield (LNY) is used as a valuable tool to measure LN retrieval, and a minimum of 6 LNs is one of the current recommendations. In patients who are managed with the SIOP strategy, preoperative chemotherapy decreases the retrieval of LN during surgery resulting in lower LNY values. PURPOSE: To determine the mean LNY and to analyze survival outcomes in patients with WT who underwent preoperative chemotherapy at a single center. METHODS: We performed a retrospective chart review of all patients between 6 months and 12 years of age with unilateral WT who underwent preoperative chemotherapy between 2010 and 2018. Patients with bilateral WT or without preoperative chemotherapy were excluded. Collected data included: demographics, tumor volume, tumor histopathology, number of LNs collected (LNY), presence or absence of tumor in the retrieved LNs, and disease stage according to these results. Kaplan Meier curves were calculated to estimate 5-year event-free survival (EFS) and overall survival (OS). RESULTS: 95 patients with a median follow-up of 25 months were included in the study. A total of 19 patients underwent laparoscopic surgery. Mean LNY for the entire cohort was 3.26 (95% CI, 2.4-3.6; SD, 3.62). Six patients (6.3%) had at least one positive LN. The estimated 5-year OS was 89.3% (95% CI, 82.1%-96.5%). EFS was 79.8 (95% CI, 74.8%-84.8%). Recurrence rate was 20% (n: 19). Four patients (4.2%) developed local recurrence and 15 patients (15.7%) developed pulmonary recurrence. The initial mean LNY in patients that relapsed was 4.16 (95% CI, 2.2-5.8; SD: 4.18), which was higher than in patients who did not relapse (LNY: 3; 95% CI, 2.33-3.67; SD, 3.39). No recurrences or deaths occurred in the laparoscopic group. DISCUSSION: The identification of a minimum LNY (i.e. threshold) to minimize the risk of harboring occult metastatic disease has been proposed to standardize the surgical procedure. Preliminary results in this study suggest that a limited LNY with acceptable survival outcomes is a possible scenario in patients treated according to the SIOP protocol. Systematic LN sampling to reduce the rate of false negatives is still strongly recommended. CONCLUSION: Our cohort presented with a relatively low LNY compared to standard recommendations. Our EFS, however, remained acceptable. Multivariate analysis would be necessary to determine the actual role of LN sampling as an isolated prognostic factor in unilateral WT.

Bladder Volume Assessment in Pediatric Patients With Neurogenic Bladder: Is Ultrasound an Accurate Method?

OBJECTIVE: To define the accuracy of ultrasound to determine bladder volume in pediatric patients with neurogenic bladder (NB). METHODS: Retrospective analysis of children with NB in treatment with urethral clean intermittent catheterization. EXCLUSION CRITERIA: bladder surgeries, and catheterization through a channel different than urethra. Bladder volume was measured with ultrasound using the formula: anteroposterior bladder diameter by side to side diameter by distance from dome to outlet tract by 0.523 (cm3). In the same act, the patient was performed urethral catheterization and the drained volume was measured in millimeters. Finally, postvoid residual volume (PVR) was assessed with ultrasound. RESULTS: We performed 318 measurements in 299 patients, mean age was 9.95 years (standard deviation: 4.6), 59% were female. Most frequent etiologies of NB were myelomeningocele and lipomyelomeningocele. Mean ultrasound-determined bladder volume was 213.9cm3 (range: 20-899 cm3) and mean bladder volume drain through catheterization was 336.4 mL (range: 30-1480 mL; P : .0001). In 67.3% of the patients (n: 214) PVR was not significant, and their mean ultrasound volume was 212.7 mL and the volume evacuated by catheterization was 339.9 mL (P : .0001). In all age groups ultrasound-determined bladder volume was statistically lower than catheterized bladder volume (P : .0001). The mean percentage error of the ultrasound-determined bladder volume was 15.58% ± 44.09. Linear regression analysis and Bland-Altman plot showed low agreement between both measurement techniques. CONCLUSION: In children with NB, ultrasound-determined bladder volume was statistically lower than catheterized bladder volume measured at the same moment, and this relation persisted regardless of sex, age, and the presence of PVR.

Laparoscopic Upper-pole Heminephrectomy for the Management of Duplex Kidney: Outcomes of a Multicenter Cohort.

OBJECTIVE: To analyze the outcomes of patients undergoing upper-pole heminephrectomy surgery and to assess the different variables that may have an impact on outcome, specifically regarding morbidity and the need for further surgeries. MATERIALS AND METHODS: A retrospective study of patients who underwent laparoscopic upper-pole heminephrectomy for a nonfunctional moiety between August 2007 and December 2019 was conducted at 3 centers. A total of 130 patients met the inclusion criteria. A transperitoneal approach was used. The following variables were evaluated: (1) preoperative: presentation, presence of ureterocele and history of ureterocele incision, hydronephrosis grade, presence of vesicoureteral reflux (VUR), and differential renal function (DRF) on renal scintigraphy; and (2) postoperative outcomes: Doppler ultrasound, renal scintigraphy, complications, febrile urinary tract infection, lower urinary tract symptoms, and need for further surgery. Findings were considered statistically significant at P <.05. RESULTS: Postoperative complications were observed in 5 patients (3.8%). Six patients (4.6%) needed further surgeries after heminephrectomy. The presence of ureterocele and VUR was related with the need for further surgeries odds ratio (OR) 4.91, P = .0415) and the occurrence of postoperative febrile urinary tract infection (OR 2.81, P = .0376). A 13.9% incidence of lower urinary tract symptoms was found with no difference between patients with ureterocele and those with an ectopic ureter. Renal scintigraphy showed a median decrease in DRF of 2.7%. No patient had complete loss of function. CONCLUSION: Laparoscopic upper-pole heminephrectomy showed to be a feasible and safe procedure. In most patients this surgery will be the definitive procedure. Patients with both VUR and ureterocele will need special consideration. No significant loss of function in the remaining lower moiety was found.

Simultaneous bilateral endoscopic surgery in a pediatric patient: Description of a NOVEL technique.

INTRODUCTION: Simultaneous bilateral endoscopic surgery (SBES) is the performance of a percutaneous nephrolithotomy (PCNL) on one side and a retrograde intrarenal surgery (RIRS) on the other kidney simultaneously. OBJECTIVE: Our aim is to report through a video the surgical technique and the step-by-step details of a SBES performed in a pediatric patient. PATIENTS AND METHODS: A 12-year-old male patient with bilateral upper tract urolithiasis. RESULTS: Supine PCNL is performed in Galdakao-modified Valdivia position. Ureteroscopic surgeon performs retrograde pyelography on PCNL kidney. Percutaneous access under fluoroscopic guidance trough the lower calyx and dilated with Amplatz dilators to 17.5 Fr. Storz® 17.5 MIP Nephroscope is introduced and fragmentation with pneumatic lithotripter starts. On the other kidney, after introduction of ureteral sheet 12/14 Fr and digital flexible ureteroscope Flex Xc ® 9.5Fr, pulverization of the stone starts with Laser Holmium YAG (Oddysey®). Surgeons work simultaneously and share fluoro-scopic c-arm. CONCLUSION: SBES can be reproduced in children. Proper planification and preparation of the involved team and OR set up are essential. Further prospective randomized studies are needed to establish safety and efficacy of SBES in pediatric patients.

Burnout syndrome in pediatric urology: A perspective during the COVID-19 pandemic - Ibero-American survey.

INTRODUCTION: Burnout syndrome is a major cause of decreased life quality, mental health, and productivity for physicians. It is strongly related to work overload and has been a scarcely studied topic in pediatric urology. During the COVID-19 pandemic, authorities' recommendations have led to big changes in pediatric urology practice worldwide. This study aimed to evaluate the level of burnout in Ibero-American pediatric urologists (IPUs) during this pandemic. MATERIAL AND METHODS: A cross-sectional study was conducted by applying an electronic survey during the COVID-19 pandemic peak to members of the two major associations of pediatric urology in Ibero-America (the Ibero-American Society of Pediatric Urology [SIUP] and the Brazilian School of Pediatric Urology [BSPU]) to evaluate demographic, pre-pandemic, and pandemic data. Burnout levels were assessed using the Copenhagen Burnout Inventory (CBI) questionnaire. RESULTS: A response rate of 40% was obtained (182 out of 455 IPU respondents). Participants were from 14 different countries in Ibero-America and 75.4% were male. Data showed that during the pandemic there was a significant decrease in weekly workload, that is: > 40 h per week (h/w) (91.4%-44.6%, p < 0.001); and >6 h/w (94.9%-45.1%%, p < 0.001) in operating room time (ORT). Personal (Pe-BO), work-related (W-BO), and patient-related (Pa-BO) burnout levels among IPUs were 26.3%, 22.3%, and 7.4%, respectively (Summary table). An important difference by gender was seen, with women suffering more from the syndrome (odds ratio of 2.67 [95% confidence interval, 1.285.58; p = 0.013] for Pe-BO and OR of 3.26 [95% CI, 1.52-7.01; p = 0.004] for W-BO). CONCLUSION: A significant decrease in workload for IPU during the pandemic was observed, as well as a low level of burnout syndrome during this time. However, the predominance of burnout in women found in this study is notable.

Garrahan U-Stitch laparoscopic appendicovesicostomy - Making surgery easier.

Appendicovesicostomy is an established continent urinary conduit. The development of minimally invasive techniques and the reduction of operative time instigated the search for new techniques. In this video we show the laparoscopic transabdominal technique for appendicovesicostomy using U-stitch technique as proposed by Santiago Weller et al. We present a case of a teenager with neurogenic bladder and intolerance for urethral catheterization. The procedure was performed using a transperitoneal approach. The appendix was detached from the colon preserving its pedicle. The proximal appendix was spatulated and pulled through a hiatus created in the distal vesical mucosa into the bladder using a U-stitch, on a Shanfield fashion anastomosis in the anterior wall of the bladder. Detrusor was approximated over the appendix creating an antireflux mechanism. The tip of the appendix was brought out to the right iliac fossa and ostomy was fashioned. The operative time was 180 min. A Foley catheter was placed through the conduit. The case was done without any intraoperative or postoperative complications. Laparoscopic appendicovesicostomy with U-stitch technique is feasible and can be easily done in a short operative time in centers with expertise in laparoscopic surgeries with low complexity and high reproducibility.

Laparoscopic Nephro-Sparing Surgery of a Reninoma Tumor in a Pediatric Patient.

OBJETIVE: Reninoma, or juxtaglomerular cell tumor, is a benign neoplasm which causes severe hypertension with elevated plasma renin activity.1-3 Usually, it is well localized on computed tomography scan or magnetic resonance images, and complete resection of the tumor with renal function preservation is the optimal treatment.2-4 To describe the technique of a transperitoneal nephron-sparing laparoscopic surgery in a pediatric patient. MATERIAL AND METHODS: Describe the technique of a minimally invasive nephron-sparing surgery for resection of a reninoma tumor in a child. RESULTS: In a 14-year-old girl with history of severe high blood pressure, ultrasound detected a hypoechoic lesion in right kidney. Angio computed tomography scan confirmed a 20-mm diameter lesion in the anterior surface of the lower pole of right kidney and also informed a lower pole renal artery. Transperitoneal laparoscopic approach was performed using 4 ports. After mobilization of the colon, Gerota's fascia was opened and the tumor identified. Both polar and principal renal arteries were dissected and secured with vessel loops. The tumor was resected using an ultrasonic energy device. Selective clamping of the lower pole renal artery was performed during 8 minutes. The transected renal surface was closed with two continuous barbed sutures and the tumor was removed using a handmade endobag. Perirenal drainage was left for 4 days, there were no perioperative complications and the patient was discharged 2 days after surgery. Pathology confirmed typical reninoma immunohistochemical features. Blood pressure and plasma renin levels returned to normal. Postsurgical scintigraphy informed 40% differential function of the right kidney. CONCLUSION: Reninoma is a benign renal tumor and because of its nature and localization, minimally invasive nephron-sparing surgery should be considered. Strategic planning of the surgery based on preoperative images is essential. If vessel clamping is imperative, minimizing ischemia time and/or selective clamping, when possible, help preserve renal function.

Pediatric Urodynamic Study Without a Preprocedural Urine Culture, Is It Safe in Clinical Practice?

OBJECTIVE: To prove that incidence of UTI after a pediatric urodynamic study (UDS) is low, and that patients without urine culture (UC) analysis prior to a UDS will not have a significant increase in the incidence of UTI (post-UDS UTI). METHODS: Prospective cohort study including consecutive pediatric patients undergoing UDS in a single center for 1 year. Patients were divided in 2 groups: (G1) UDS with a previous negative UC and (G2) UDS without a previous UC analysis. A clean UC was obtained in all patients at the moment of the UDS (UDS-UC). Primary outcome was post-UDS UTI. Secondary outcome was to compare UC cost per patient and cancellation rates in each group. All patients were followed 15 days after the UDS to detect onset of UTI symptoms. RESULTS: Four hundred two patients were included, 198 patients in G1 and 204 patients in G2. Median age was 9 years old. Both groups were similar in terms of demographic and clinical records data except for a proportion of patients on CIC which was larger in G2 (P <.008). Overall incidence of post-UDS UTI was 0.7% (3/402), G2 incidence (0.98%) being slightly higher than G1 (0.50%; P <.58). UDS-UC was positive in 32% of G1 vs 55% in G2 (P <.001). About 98% of patients with positive UDS-UC did not progress to symptomatic UTI. G1 cost was 140% higher than G2. CONCLUSION: Overall incidence of post-UDS UTI is low (0.7%). Patients without UC prior to UDS did not have a significant increase in post-UDS UTI.

Efficacy and safety of Mirabegron as adjuvant treatment in children with refractory neurogenic bladder dysfunction.

INTRODUCTION: When patients with neurogenic bladder become refractory, there are different alternatives, such as the use of ß3-adreceptor agonists. The aim of the present study is to evaluate efficacy and safety of Mirabegron as adjuvant treatment. MATERIAL AND METHODS: 37 patients under 18 years of age who underwent Mirabegron were retrospectively studied. The inclusion criteria were: cases with neurogenic bladder who were under clean intermittent catheterization (CIC) programs and refractory to oral oxybutynin (Group A) and/or onabotulinumtoxinA (Group B). Once refractory neurogenic bladder was confirmed by clinical and/or urodynamic studies, Mirabegron 25 mg/day was indicated and evaluation was performed in the third month without stopping therapy. Systolic/diastolic blood pressure and transaminases were monitored. Paired t test and Pearson's chi - squared test were used. RESULTS: Maximum cystometric capacity increased significantly by 125 mL, from 322 to 446 ml (p < 0.0001). End-filling detrusor pressure decreased significantly by 12 cm H2O, from 44 to 31 cm H2O (p < 0.0001). The variation in both parameters was significant in Groups A and B. The presence of detrusor overactivity increased globally from 21 to 32% after starting Mirabegron, but the intensity of contractions was reduced in 20 cm H2O. Of the 18 patients who were incontinent before, 13 cases (72%) remained dry after initiating therapy with Mirabegron. None of the patients stated having suffered any adverse effects. Blood pressure and transaminases showed no significant difference. None of the patients discontinued treatment due to intolerance to Mirabegron (Summary Table). DISCUSSION: In our study the treatment with Mirabegron improved significantly the clinical and urodynamic parameters. A significant increase in bladder capacity and a significant decrease in end-filling detrusor pressure were observed in both groups. The intensity of overactivity was attenuated. According to the records of the voiding diary, over 70% of the incontinent patients became dry after the administration of Mirabegron. We did not observe any adverse effects. The most important limitations of the present study are its retrospective design, the small size of the sample population and of each group, and the use of only one dose of Mirabegron. CONCLUSIONS: Mirabegron as adjuvant treatment in children with refractory neurogenic bladder increased bladder capacity, reduced intravesical pressure and helped achieve continence in more than two thirds of the sample population. Mirabegron was safe and well tolerated by children.

Laparoscopic total nephrectomy for Wilms tumor: Towards new standards of care.

INTRODUCTION: Laparoscopic total nephrectomy (LN) in malignant pediatric tumors remains controversial. For selected patients undergoing pre-operative chemotherapy in referral centers, LN has so far shown comparable results to the standard open technique. PURPOSE: To describe the inclusion criteria and preliminary results of laparoscopic nephrectomies (LN) for the treatment of unilateral Wilms tumors (WT). MATERIAL AND METHODS: Between November 2010 and January 2016, a retrospective study of patients with WT and undergoing pre-operative chemotherapy was performed. Inclusion criteria for candidates for LN were: unilateral tumors without venous invasion and central kidney localization. Tumor size and vascular thrombus were estimated with pre-operative computed tomography (CT) scan. Overall survival and recurrence rates were evaluated. RESULTS: Among 105 patients with WT, 14 underwent LN. Tumor bleeding or the lack of response to chemotherapy were not exclusion criteria. Median tumor volume for the patients undergoing LN was 71.5 cc (range 7-169). Patients with small tumors localized near the renal pole and candidates for nephron sparing surgery (NSS) were excluded. Estimated 5-year overall survival for all patients with WT during this period was 88.7% (88.1-103.1). Two patients underwent conversion. No recurrence or related death was found at a mean 32- month follow-up period. DISCUSSION: Reproducing the steps of the open nephrectomy when performing LN for malignant tumors allowed comparable oncologic results to the conventional procedure. However, upstaging of the tumor was not admissible and has become the main goal when approaching these patients laparoscopically. Preliminary results showed that the incidence of intraoperative rupture and incomplete node sampling were not an issue when comparing LN to open nephrectomy. On the other hand, LN for malignant tumors requires experience in advanced laparoscopy and oncologic surgery. Pre-operative chemotherapy changes the tumor's consistency and this is the key point as to why these patients are amenable to be approached laparoscopically. Lifting the tumor along with the fat to avoid capsule fraction, as well as changing the lens to the lateral port to achieve a correct view for lymph node sampling are some of the considerations when performing LN. CONCLUSIONS: Preliminary data suggest that LN for WT is feasible and has promising results in terms of event-free and overall survival. In patients undergoing pre-operative chemotherapy the correct selection for LN is crucial. Following the basic oncological precepts and in experienced centers, LN represents a plausible modality in the care of these patients.