Are weight or age limits for pediatric laparoscopic pyeloplasty? Results of a multicentric study.

INTRODUCTION: Anderson-Hynes pyeloplasty is the technique of choice for the treatment of pyeloureteral junction obstruction (PUJO) with an excellent success rate. Minimally invasive surgery has become the standard of care for the management of PUJO in children. Although it has been comparable to the open approach at all levels, its diffusion or employment in younger children has not been widely adopted. Our aim is to evaluate laparoscopic pyeloplasty outcomes from international academic centers in children under 1 year of age, focusing on feasibility and outcomes including possible complications. MATERIALS AND METHODS: This is review of consecutive infants under 1 year of age who underwent laparoscopic pyeloplasty between 2009 and 2018 with more than 12 months of follow-up. Seven different training centers with different backgrounds participated in this study. Evaluation was carried out with ultrasound and renogram before and after surgery. Demographic data, perioperative characteristics, complications, and results are described and analyzed. RESULTS: Over 9 years, 124 transperitoneal laparoscopic Anderson-Hynes pyeloplasties were performed on 123 children under 1 year of age; 88 males and 35 females, with 1 case of bilateral PUJO. Of the 124 renal units, 86 were left-sided. Mean age at surgery was 6.6 months (1 week-12 months), with 56% (n = 70) done before 6 months of age. Mean weight at surgery was 6.8 kg (3-12 kg), with 59% (n = 73) weighing less than 8 kg. Mean operative time (skin-to-skin) was 150 min (75-330 min). After a mean follow-up of 46 months (12-84 months), 12 (9%) patients developed complications, with only 1 needing a redo pyeloplasty also done laparoscopically. One child, with deterioration in renal function, underwent nephrectomy. CONCLUSION: Laparoscopic pyeloplasty under 1 year of age and/or less than 12 kilos is feasible with lower complication rate. Furthermore, age younger than 6 months and weight less than 8 kg are no longer limiting factors for a successful pyeloplasty as shown by this multicentre study.

Laparoscopic and robotic-assisted repair of retrocaval ureter in children: a multi-institutional comparative study with open repair.

PURPOSE: This retrospective study aimed to report a multi-institutional experience with laparoscopic and robotic-assisted repair of retrocaval ureter in children and to compare outcome of minimally invasive surgery (MIS) with open repair. METHODS: The records of all children, who underwent MIS and open repair of retrocaval ureters in six international pediatric urology units over a 5-year period, were retrospectively collected. Data were grouped according to the operative approach: a laparoscopic group (G1) included five patients, a robotic-assisted group (G2) included four patients, and an open group (G3) included three patients. The groups were compared in regard to operative and postoperative outcomes. RESULTS: At follow-up, all patients (one G1 patient after redo-surgery) reported complete resolution of symptoms and radiologic improvement of hydronephrosis and obstruction. In regard to postoperative complications, one G1 patient developed stenosis of anastomosis and needed re-operation with no further recurrence (IIIb Clavien). G2 reported the lowest average operative time (135 min) compared to G1 (178.3 min) and G3 (210 min). MIS (G1-G2) reported a significantly better postoperative outcome compared to open repair (G3) in terms of analgesic requirements, hospitalization, and cosmetic results. CONCLUSIONS: The study outcomes suggest that MIS should be the first choice for retrocaval ureter because of the minimal invasiveness and the better cosmetic outcome compared to open surgery. Furthermore, our results showed that robotic-assisted reconstruction was technically easier, safer, and quicker compared to laparoscopic repair, and for these reasons, it should be preferentially adopted, when available.

[Neonatal circumcision with local anesthesia. Results of a standardized protocol]. / Circuncisión neonatal con anestesia local. Resultados de un protocolo estandarizado.

INTRODUCTION: Neonatal circumcision is a common procedure in the US and other countries, with low rates of complications in trained hands. However, it has recently been incorporated into the clinical environment in Chile. Our goal was to establish a local standardised protocol for neonatal circumcision under local anaesthesia, and evaluate the results and possible complications. PATIENTS AND METHOD: A standardised prospective protocol was used on patients who underwent neonatal circumcision. The inclusion criteria were: children <60days and <5kg. The surgical technique used was topical local anaesthesia and penile block, attrition of redundant prepuce and mucosa with Mogen® clamp, and section with scalpel. The protocol was used and evaluated from November 2005 to October 2014 by a paediatric surgeon and/or paediatric urologist trained in the technique. Complications and conditions until final discharge were analysed. RESULTS: The protocol was applied to 108 patients over a 9year period. The mean age at procedure was 9days (1-52). One patient (0.9%) had immediate bleeding, requiring further surgery. All patients were discharged from further medical checks at 1 month, without any other complications. The reason for the procedure was by parental request in 100% of the cases, and always for sociocultural reasons. CONCLUSION: Neonatal circumcision under local anaesthesia is a simple procedure, and has excellent results in selected patients, and with no major complications. With proper training, and adapting the initial protocol, it can be performed on an outpatient basis, without putting the neonates through the risks of general anaesthesia.

Vesicoureteral reflux: current management in children.

Vesicoureteral reflux (VUR) is a disorder that has been studied since the early days of pediatric urology. From 1893, when it was first documented in humans by Pozzi, the research and clinical management of VUR has been marked by pendulum swings through the decades. Initially, the vesicoureteral junction was the main subject of study, whereas current practice takes into account the bladder and bowel dynamics. The primary objective, however, is unchanged: preservation of the kidney and its function. Management of the condition has included open surgery, minimally invasive surgery, endoscopic treatment, antibiotic prophylaxis, and watchful waiting. In this article, we will attempt to cover every angle of this complex pathology and its current management in children.

Electropolishing Stainless Steel Optimization Using Surface Quality, Dimensional Accuracy, and Electrical Consumption Criteria.

Electropolishing (EP) processes require high electrical consumption that must be optimized to minimize production costs without sacrificing the objectives of surface quality and dimensional accuracy. The aim of the present paper was to analyze the effects of the interelectrode gap, initial surface roughness, electrolyte temperature, current density, and EP time on aspects of the EP process applied to AISI 316L stainless steel, which have not been examined in the literature, such as polishing rate, final surface roughness, dimensional accuracy, and electrical consumption cost. In addition, the paper aimed to obtain optimum individual and multi-objective considering criteria of surface quality, dimensional accuracy, and electrical consumption cost. The results showed that the electrode gap was not significant on the surface finish or current density, and the EP time was the parameter having the greatest effect on all criteria analyzed, with a temperature of 35 °C showing the best electrolyte performance. The initial surface texture with the lowest roughness Ra10 (0.5 ≤ Ra ≤ 0.8 µm) obtained the best results with a maximum polishing rate of ~90% and minimum final roughness (Ra) of ~0.035 µm. The response surface methodology showed the EP parameter effects and the optimum individual objective. The desirability function obtained the best global multi-objective optimum, while the overlapping contour plot provided optimum individual and simultaneous per polishing range.

Impact of inclusion of post-spermatic ejaculate fraction in boar seminal doses on sperm metabolism, quality, and interaction with uterine fluid.

Boar ejaculate is composed of sperm cells and seminal plasma (SP) and is emitted in different fractions (pre-sperm fraction; spermatic-rich fraction; intermediate fraction; post-spermatic fraction), with different composition of SP and volume, which could influence the sperm quality during seminal doses preparation, conservation, and interaction with the female reproductive tract. In artificial insemination (AI) centers, seminal doses are usually prepared with the spermatic-rich and intermediate fractions, but the inclusion of other ejaculate fractions, although controversial, is beginning to be applied. The objective was to evaluate the synergic effect of accumulative ejaculated fractions on sperm functionality during seminal doses preparation, throughout storage and after incubation with uterine fluid (UF). For this purpose, a total of 57 ejaculates were collected, and the following experimental groups were prepared (n = 19 per group): (F1) spermatic-rich fraction; (F2) F1 plus intermediate fraction; (F3) F2 plus post-spermatic fraction. Each group was stored for 5 days at ∼16 °C, and the following parameters were evaluated: sperm metabolism of pure and diluted semen (day 1), sperm quality parameters (days 1, 3, 5), thermal-resistance test (TRT) and incubation with uterine fluid (UF) (day 5). Sperm metabolic rates between accumulative ejaculate fractions from pure and diluted semen did not show differences. Also, sperm quality parameters were not affected by the ejaculate fraction during storage. However, sperm subjected to TRT showed similar results except for progressive motility, which was better in F2 and F3 than F1. When sperm were incubated with UF, the quality decreased in each group, but sperm from F2 and F3 were less affected than those from F1. In conclusion, the post-spermatic fraction can be included in seminal doses for their use in AI-centers, with functionality of sperm of different SP origins not being impaired throughout the storage, and responding better to thermal and UF stress. However, further research in AI-centers is necessary to test the sperm behaviour under presented conditions.

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.

Laparoscopic and robot-assisted ureterocalicostomy for treatment of primary and recurrent pelvi-ureteric junction obstruction in children: a multicenter comparative study with laparoscopic and robot-assisted Anderson-Hynes pyeloplasty.

PURPOSE: This multi-institutional study aimed to assess the outcomes of laparoscopic ureterocalicostomy (LUC) and robot-assisted laparoscopic ureterocalicostomy (RALUC) and compare them with laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) in children with pelvi-ureteric junction obstruction (PUJO). METHODS: The data of 130 patients (80 boys), with median age 7.6 years and median weight 33.8 kg, receiving minimally invasive treatment of PUJO over a 6-year period, were retrospectively analyzed. Patients were grouped according to the operative approach: G1 included 15 patients, receiving LUC (n = 9) and RALUC (n = 6), and G2 included 115 patients, receiving LP (n = 30) and RALP (n = 85). Patient characteristics and operative outcomes were compared in both groups. RESULTS: The median patient age and weight were significantly higher in G1 than in G2 [p = 0.001]. The median operative time was similar in both groups (157.6 vs 150.1 min) [p = 0.66] whereas the median anastomotic time was shorter in G1 than in G2 (59.5 vs 83.1 min) [p = 0.03]. The surgical success rate was similar in both groups (100% vs 97.4%) [p = 0.33]. Post-operative complications rate was higher in G1 than in G2 (20% vs 6.1%) but all G1 complications were Clavien 2 and did not require re-intervention. CONCLUSION: LUC/RALUC can be considered safe and effective alternative approaches to LP/RALP for PUJO repair and reported excellent outcomes as primary and salvage procedures. Robot-assisted technique was the preferred option to treat most patients with recurrent PUJO in both groups.

Should All Fractions of the Boar Ejaculate Be Prepared for Insemination Rather Than Using the Sperm Rich Only?

Boar ejaculate is released in several well-characterized fractions, differing in terms of sperm concentration, seminal plasma volume, and composition. However, the inclusion of the last part of the ejaculate for artificial insemination (AI) purposes is still under debate due to its controversial effects. Thus, there is a need to study the potential synergistic impact of the different ejaculate fractions. We aimed to evaluate the effect of accumulative ejaculate fractions on sperm conservation, AI performance, and offspring health. Ejaculates (n = 51) were collected and distributed as follows: F1: sperm-rich fraction; F2: sperm-rich + intermediate fractions; F3: sperm-rich + intermediate + poor fractions. Each group was diluted in a commercial extender, packaged in seminal doses (2000 × 106 sperm/60 mL), and stored at ~16 °C. On day 3 of conservation, sperm were analyzed and used for AI (n = 174). High sperm quality was observed after storage without a significant difference between the groups (p > 0.05). Moreover, no differences were obtained for AI performance (pregnancy and farrowing rates, and litter size; p > 0.05) and offspring health (growth and blood analysis; p > 0.05). Conclusively, the presence of all ejaculate fractions within the seminal doses does not impair the reproductive performance, reporting important economic savings according to the economic model included here.

[Perception of loneliness, happiness, and health, and quality of diet. The moderator role of weight status]. / Percepción de soledad, felicidad y salud, y calidad de la dieta. El rol moderador del estado ponderal.

INTRODUCTION: Aim: to determine the relationship between perceived loneliness, happiness, and health, and quality of diet, observing the moderator role of weight status in elementary school children during the state of alarm decreed for COVID-19. Methods: a descriptive, cross-sectional study in a sample of 116 Spanish schoolchildren. The perception of loneliness, happiness, and health was assessed using three items of the Health Behavior in School-aged Children questionnaire. The quality of their Mediterranean diet was assessed using the Mediterranean Diet Quality Index quetsionnaire for children and adolescents. Anthropometric variables were collected through a self-reported questionnaire, and for the calculation of body mass index the Quetelet index (kg/m2) was used. Results: the descriptive analysis showed no differences in the perception of loneliness, happiness, or health, quality of diet, or anthropometric variables (p > 0.005), except for weight (p < 0.005), according to sex. The inferential analysis showed that higher values in quality of diet are correlated with higher scores in perceived happiness and health (p < 0.005). In turn, the linear regression test showed an association between quality of diet and perception of happiness after the model was adjusted for normal weight (R2 = 0.382; p < 0.005). Likewise, it showed a significant association between quality of diet and perception of health after the model was adjusted for overweight schoolchildren (R2 = 0.455; p < 0.005). Conclusion: the association between perceived health and happiness with quality of diet seems to be moderated by weight status.

INTRODUCCIÓN: Objetivo: determinar la relación existente entre la percepción de soledad, felicidad y salud, y la calidad de la dieta, observando el rol moderador del estado ponderal en escolares de primaria durante el estado de alarma decretado por la COVID-19. Métodos: estudio descriptivo transversal de una muestra de 116 escolares españoles. Las percepciones de soledad, felicidad y salud se valoraron mediante tres ítems del cuestionario Health Behavior in School-aged Children. La calidad de la dieta mediterránea se valoró a través del cuestionario Índice de calidad de la dieta mediterránea en niños y adolescentes. Las variables antropométricas se recogieron a través de un cuestionario autoinformado y para el cálculo del índice de masa corporal se empleó el índice de Quetelet (kg/m2). Resultados: el análisis descriptivo no mostró diferencias en la percepción de soledad, felicidad y salud, la calidad de la dieta, y las variables antropométricas (p > 0,005), a excepción del peso (p < 0,005), según el sexo. El análisis inferencial mostró que los valores más elevados en la calidad de la dieta se correlacionan con valores más altos en la percepción de felicidad y de salud (p < 0,005). Por su parte, la prueba de la regresión lineal mostró asociación entre la calidad de la dieta y la percepción de felicidad tras ajustarse el modelo al normopeso (R2 = 0,382; p < 0,005). Asimismo, mostró una asociación significativa entre la calidad de la dieta y la percepción de salud tras ajustarse el modelo a los escolares con sobrepeso (R2 = 0,455; p < 0,005). Conclusión: la asociación entre la percepción de salud y de felicidad con la calidad de la dieta parece estar moderada por el estado del peso.

Relevance of the Ejaculate Fraction and Dilution Method on Boar Sperm Quality during Processing and Conservation of Seminal Doses.

During boar semen processing and distribution, maximizing the work protocols in the laboratories becomes essential for the conservation of seminal doses. One of the recent implementations in the boar studs to improve efficiency has been semi-automatic semen collection systems, which do not allow to discard fractions of the ejaculate. The objective of this work was to evaluate the dilution method and vibrations (simulating delivery transport) effect on sperm quality (motility, viability, morphology, thermo-resistance test) according to the fraction of ejaculate collected. Two different fractions of the ejaculate were obtained [rich fraction (RF); total fractions (TF)] from six boars, and two dilution methods applied [pouring the extender over the semen (control; ES); pouring the semen over the extender (reverse; SE)]. The seminal doses (2000 × 106 sperm/50 mL) were preserved for 5 days. The results showed that the fraction collected affects sperm quality (better total and progressive motility, and faster sperm in TF; p < 0.05) regardless of the dilution method applied. However, these differences diminished after submitting the semen to the thermo-resistance test, with only differences in sperm viability being observed (p < 0.05). When seminal doses were subjected to vibrations, the sperm viability was more affected in the TF than in the RF group (p < 0.05). In conclusion, using the TF ejaculate leads to comparable results to the RF in sperm quality during storage regardless of the dilution method applied. However, the vibrations of seminal doses are more affected in doses prepared with TF than with RF, although more factors should be included to approach the real conditions during transport.

Hydronephrosis Classifications: Has UTD Overtaken APD and SFU? A Worldwide Survey.

Objective: To collect baseline information on the ultrasonographic reporting preferences. Method: A 13-multiple choice questionnaire was designed and distributed worldwide among pediatric urologists, pediatric surgeons, and urologists. The statistical analysis of the survey data consisted of 3 steps: a univariate analysis, a bivariate and a multivariate analysis. Results: Three hundred eighty participants responded from all the continents. The bivariate analysis showed the significant differences in the geographical area, the years of experience and the volume of cases. Most of the physicians prefer the SFU and APD systems because of familiarity and simplicity (37 and 34%, respectively). Respondents noted that their imaging providers most often report findings utilizing the mild-moderate-severe system or the APD measurements (28 and 39%, respectively) except for North America (SFU in 50%). Multivariate analysis did not provide significant differences. Conclusion: Our study evaluates the opinions regarding the various pediatric hydronephrosis classification systems from a large number of specialists and demonstrates that there is no single preferred grading system. The greatest reported shortcoming of all the systems was the lack of universal utilization. The observations taken from this study may serve as basis for the construction of a common worldwide system. As APD and SFU are the preferred systems and the UTD a newer combination of both, it is possible that with time, UTD may become the universal language for reporting hydronephrosis. This time, based on the result of this survey, seems not arrived yet.

In vivo measurement of pH and CO2 levels in the uterus of sows through the estrous cycle and after insemination.

The pH-CO2-HCO3- system is a ubiquitous biological regulator with important functional implications for reproduction. Knowledge of the physiological values of its components is relevant for reproductive biology and the optimization of Assisted Reproductive Technologies (ARTs). However, in situ measurements of these parameters in the uterus are scarce or null. This study describes a non-invasive method for in situ time-lapse recording of pH and CO2 within the uterus of non-anesthetized sows. Animals were at three different reproductive conditions, estrous with no insemination and two hours after insemination, and diestrous. From pH and CO2 data, HCO3- concentration was estimated. The non-invasive approach to the porcine uterus with novel optical probes allowed the obtaining of in situ physiological values of pH, CO2, and HCO3-. Variable oscillatory patterns of pH, CO2 and HCO3- were found independently of the estrous condition. Insemination did not immediately change the levels of uterine pH, CO2 (%) and HCO3- concentration, but all the values were affected by the estrous cycle decreasing significantly at diestrous condition. This study contributes to a better understanding of the in vivo regulation of the pH-CO2-HCO3- system in the uterus and may help to optimize the protocols of sperm treatment for in vitro fertilization.

Unusual presentation of a Leydig Cell Tumor.

SUMMARY: Leydig Cell Tumors (LCT) in children are very rare, with an incidence of 1-3% for all testicular tumors in children. Clinical presentation is testicular mass, pain and hormone alteration such as precocious puberty and gynecomastia. We present one case of LCT and his conservative management after an incidental finding. Literature is reviewed.

Urethral diverticulum after laparoscopically-assisted anorectal pull-through (LAARP) for anorectal malformation: is resection of the diverticulum always necessary?

SUMMARY OBJECTIVES: With the increased use of minimally invasive surgery, the urethral diverticulum after anorectal surgery has become an issue. The few cases reported have been managed by surgical excision. We hereby report a case of urethral diverticulum after a laparoscopically-assisted anorectal pull-through (LAARP)procedure with a successful outcome after a period of active surveillance. METHODS: A full-term boy who displayed a high anorectal malformation (ARM) and a rectoprostatic fistula underwent colostomy on the first day. He also showed associated malformations: bilateral low-grade reflux, horseshoe kidney and thoracic hemivertebrae; however, there were no signs of spinal cord tethering. Antimicrobial prophylaxis was started. RESULTS: At the age of 3 months, he underwent a LAARP with a 3 abdominal-port approach. After complete dissection of the distal bowel, the recto-prostatic fistula was identified and tied with metallic clips. A 10 mm trocar was inserted through the centre of the sphincteric complex, which had been previously identified under laparoscopic view during perineal electrical stimulation. The anorectal pull-through was accomplished without tension. The bladder remained stented for 14 days. On the 18th postoperative day, a voiding cystourethrogram (VCUG) showed a 15 X 5 mm image of the diverticulum at the level of the membranous urethra. After 6 months, a new VCUG showed a normal urethra with neither signs of the diverticulum nor strictures; persistence of grade 2 reflux on the right side and resolution of the reflux on the left. When the boy was one year old his colostomy was closed uneventfully. Six months later he had not come into the emergency since the operation and voided with a normal flow. CONCLUSION: This report suggests that LAARP is a feasible approach for ARM, although urethral diverticulum is a major concern. It may evolve without complications, and eventually resolve spontaneously. Active surveillance might be an option in selected asymptomatic patients; however a longer follow-up is advised to constitute better evidence supporting that policy.

Clinical impact of Ga68-DOTATOC PET/CT on neuroendocrine tumors. A preliminary experience. / Impacto clínico del PET/TC Ga68-DOTATOC en tumores de origen neuroendocrino. Experiencia preliminar.

Ga-68-DOTATOC PET/CT is a recently introduced imaging technique for the diagnosis and follow-up of neuroendocrine tumors. A prospective observational study was conducted in seven patients who underwent a Ga-68-DOTATOC PET/CT study. They were suspected of active neuroendocrine tumor lesions, either on initial diagnosis or as a possible recurrence and/or progression of already known tumors. The results of prior imaging studies (MRI, thoracoabdominal CT scan, octreotide...), had been negative or inconclusive. All positive Ga-68-DOTATOC PETs were true positives, confirmed by pathological examination. There were no false positive results. Only one false negative result was found. Ga-68-DOTATOC PET/CC is more sensitive and specific for the detection of primary neuroendocrine tumor lesions, allows for a more complete extension study, and detects recurrences in earlier stages, conditioning changes in staging and surgical treatment. It provides additional information on somatostatin receptor overexpression, which is essential for the indication of PRRT (peptide receptor radionuclide therapy) with Lu177 dotatate.

[Feminizing genitoplasty in adrenal congenital hyperplasia: one or two surgical steps?]. / Genitoplastia feminizante en hiperplasia suprarrenal congénita; una o dos etapas quirúrgicas?

SUMMARY OBJECTIVES: The best time to perform a genitoplasty in a Congenital Adrenal Hyperplasia (CAH) girl is an issue that has been discussed extensively. The purpose of this study is to find criteria that may help in the decision. METHODS: Charts of all patients with diagnosis of CAH with 21 Hydroxylase deficit who underwent genitoplasty in our institution were reviewed (Jan 1996-Dec 2006). Demographic data, surgery performed and outcomes were analyzed. RESULTS: In the 10 year-period, 25 patients fit the inclusion criteria; 22 had complete data. All patients were classified based on Prader's criteria; Prader 2 (n=3), Pra der 3 (n=13) and Prader 4 (n=6). Mean age at first surgery was 13.5 months (range 2-89 m). In Prader 2 patients, a reduction clitoroplasty with a "cut back" vaginoplasty was performed with no complications. All patients in the Prader 3 group underwent a reduction clitoroplasty. A vaginoplasty was done in 9/13; 5/9 at the same surgery session (4 stenotic) and the other 4 in a 2nd stage with good results; vaginoplasty is still pending for the other 4 girls. In the Prader 4 group, a vaginoplasty pull-through was performed in 4/6 using the posterior sagital approach; one at the reduction clitoroplasty stage which ended stenotic and need dilatations, and the other 3 in a 2nd surgery with a good outcome. The other 2/6 girls are awaiting a vaginoplasty. 22/22 had acceptable results after a mean follow-up of 63 months (range 12-144). CONCLUSIONS: Congenital Adrenal Hyperplasia (CAH) shows different approaches may be used for different degrees of virilization. For less severe cases (Prader 3) a cut-back may be the surgery of choice for vaginoplasty, while in the more complex cases a flap with pull-through or a posterior sagital procedure could be useful. Based on this series, we recommend performing vaginoplasty in a 2nd stage surgery, avoiding complications and further procedures such as di lactations.

Pediatric Robotic Surgery in South America: Advantages and Difficulties in Program Implementation.

Robotic assisted laparoscopic surgery is gaining popularity around the world due to its vast benefits. Although it has been established mainly in developed countries, in South America the robotic programs have become more popular, but its growth is clearly slower. Information about robotic pediatric surgery program in Brazil, Chile, Uruguay, and Argentina was collected through e-mail surveys. Results were analyzed and compared to worldwide information about robotic surgery. Due to the wide social, economical, and technological gap between hospitals in South America, it is hard to develop a proper pediatric robotic surgery program. The main obstacles in those four countries appear to be a combination of high purchase costs and equipment maintenance, lack of financial coverage of the procedure by insurance companies and the absence of significant benefits proved in pediatrics in relation to laparoscopic surgery. The pediatric specialties are in the process of making and implementing robotic programs supported by the evident development in adult specialties. However, pediatric robotic surgery in Brazil, Chile, Uruguay and Argentina do not seems to share that growth.

Urology mythbusters: do we need to surgically correct vesicoureteral reflux in older girls to prevent problems in future pregnancy? (revision 1).

In this edition of Mythbusters we critically examine the premise that, because women with history of vesicoureteric reflux (VUR) are at higher risk of urinary tract infection (UTI) and other morbidity during pregnancy, persistent VUR in older girls should be considered an indication for surgical correction. The literature is very limited in that there are essentially no methodologically robust comparisons of pregnancy outcomes among women whose childhood VUR was or was not surgically repaired. Most of the case series and cohorts find relatively high incidence of UTI and pyelonephritis among pregnant women with a history of VUR, but there is very little to suggest that persistent VUR is itself a risk factor for infection during pregnancy. Indeed, some studies suggest that UTI risk is actually higher among women who previously underwent anti-reflux surgery compared to those who did not, although these data are compromised by significant selection bias. In contrast, there is relatively strong evidence that maternal and fetal morbidity is higher when the mother is known to have renal scarring; such women probably merit close surveillance during pregnancy for infection, hypertension and pre-eclampsia, and other problems. Overall, current evidence is insufficient to support routine anti-reflux surgery in girls with the sole purpose of decreasing complications during future pregnancy, particularly for girls with lower-grades of VUR and no renal scarring. The verdict for this urolegend: it contains a a "teeny, tiny nugget of truth."