Ureteroinguinal Herniation with Consecutive Ureteral Stricture in a 2-Month-Old Infant: Case Report.

Inguinal herniation of ureter is an uncommon finding among children, with scarce reported cases in the literature to date, that can potentially lead to obstructive uropathy. We report a case of ureteroinguinal herniation discovered during an inguinal hernia repair in a patient with antenatally ultrasound finding of hydronephrosis. A 2-month-old infant with antenatal left hydronephrosis presented with left inguinal mass. Preoperative ultrasound showed an anechoic tubular image producing a mass effect on the left testicle, with suspected bladder herniation and/or dilated ureter toward the inguinal canal. An open surgical inguinal exploration was performed, where the left inguinal canal revealed a peritoneal sac and sliding of the dilated left ureter behind the sac, with a significant change in diameter, corresponding to the paraperitoneal variant of ureteroinguinal herniation. Ligation of the sac and replacement of the ureter into the retroperitoneum were performed, with improvement in the hydronephrosis observed on the ultrasound 1 month after the intervention. However, 6 months later, hydronephrosis worsening as well as the obstructive pattern observed in the diuretic renogram required removal of the stenotic ureteral segment and reimplantation of the healthy proximal segment in the bladder by open approach (Cohen's reimplantation). Follow-up ultrasound of the renal tract showed no dilatation of the upper renal tract and the renal function tests were normal. Currently, the patient is 2 years old and he remains asymptomatic. In conclusion, s igns of ureteral obstruction such as hydronephrosis in patients with inguinal herniation may suggest the possibility of an ureteroinguinal hernia. Preoperative diagnostic suspicion is essential.

Sarcopenia as a Prognostic Factor in Patients with Hepatoblastoma: Does It Influence Surgical Outcomes and Survival? Preliminary Retrospective Study.

AIM: Sarcopenia is associated with poor prognosis in adult oncologic patients, with little evidence of this association in pediatric population, including hepatoblastoma. METHODS: Retrospective study in patients with hepatoblastoma, divided into those with or without sarcopenia. Sarcopenia was assessed by measuring psoas muscle area (PMA) at L4-L5 level on the CT/MR and defined as z-score values ≤ 2. Relapse and mortality were analyzed. RESULTS: Twenty-one patients (57.1% male) were included, with median age 35.7 months (IQR: 23.5-58.5). Seven (33.3%) had sarcopenia on initial studies compared to 14 (66.7%) who did not. No differences were found between groups in age, weight, PRETEXT, surgical treatment or. α-fetoprotein levels. Sarcopenia was associated with a higher rate of metastases at diagnosis (49.2% vs 0.0%; p = 0.026) and surgical complications (57.1% vs 21.4%, p = 0.047). After a median follow-up of 65.1 months (1.7-144.8), 2 patients (28.6%) had tumor relapse in sarcopenic group compared to 1 (7.1%) in non-sarcopenic group. Two patients died in sarcopenic group and 1 in non-sarcopenic group. Median event-free survival (EFS) was lower in sarcopenic group (100.38 ± 25.63 vs 118.91 ± 11.52 months) as well as overall survival (OS) (101.72 ± 24.86 vs 121.78 ± 8.75 months) with no statistical significance. Five-year EFS was also lower in sarcopenic group (71% vs 93%) as well as 5-year OS (71% vs 87%). CONCLUSIONS: Sarcopenia at diagnosis was associated with a higher rate of metastases and surgical complications in hepatoblastoma. Our data shows the first evidence of its role as a possible poor prognostic factor, influencing survival and risk of relapse. LEVEL OF EVIDENCE: II. TYPE OF STUDY: Original article. Retrospective study.

Neutrophil-to-lymphocyte ratio as a predictor of surgical site infection in acute appendicitis.

Background: Surgical site infection (SSI) is one of the most common complications after appendectomy, which carries high associated morbidity. Therefore, it is essential to determine SSI predictive factors in order to prevent its occurrence. The aim of this study is to explore the role of neutrophil-to-lymphocyte ratio (NLR) as a predictor of SSI after appendectomy in children. Methods: A single-center, retrospective cohort study was performed in children who underwent appendectomy between 2017-2020. Demographics, time since symptoms onset, laboratory tests at admission, ultrasound appendiceal diameter, rate of complicated appendicitis, surgical aproach, surgery time and SSI rate were analyzed. Follow-up was performed during hospitalization and at outpatient clinic at 2 weeks and 30 days postoperatively to assess the surgical wound aspect. Diagnostic cut-off values of these markers for SSI prediction were based on the significance in the univariate analysis. Variables with a P value <0.05 in the univariate analysis were then entered into the multivariate analysis. Results: A total of 1,136 patients (710 males; 426 females) were included. SSI was reported in 53 patients (4.7%) during the 30-day follow-up after appendectomy (SSI group), with no demographic differences with the control group. Time since symptoms onset was significantly higher in SSI group (24 vs. 18 hours; P=0.034), as well as ultrasound appendiceal diameter (10.5 vs. 8.5 mm; P=0.010). Complicated appendicitis was observed in about 60% of both groups, without differences in surgical approach between them. Surgery time was statistically higher in the SSI group (62.4 vs. 47.9 min; P<0.001). SSI group presented higher counts of leukocytes, neutrophils and NLR than control group (P<0.001). NLR was the parameter with the highest area under the curve (AUC) (AUC =0.808; P<0.001), with a cut-off point of 9.8 with maximum sensitivity (77.8%) and specificity (72.7%). NLR was an independent predictive factor for SSI in the multivariate analysis [odds ratio (OR) 1.82 (1.13-2.73); P<0.01]. Conclusions: NLR value at admission was the most promising predictive factor for the development of SSI in children undergoing appendectomy. It is an easy, simple, inexpensive, and rapid method to detect patients at high risk for SSI. However, further prospective studies are still needed to confirm these results.

Simultaneous bladder augmentation and artificial urinary sphincter placement in children with neuropathic urinary incontinence. Is it safe to perform? Long-term results.

INTRODUCTION: Simultaneous performance of artificial urinary sphincter (AUS) placement and bladder augmentation (BA) in patients with neuropathic bladder is currently controversial. OBJECTIVE: The aim of this study is to describe our very long-term results after a median follow-up of 17 years. STUDY DESIGN: A retrospective single-center case-control study was performed in patients with neuropathic bladder treated in our institution between 1994 and 2020, in whom AUS placement and BA were performed simultaneously (SIM group) or sequentially at different times (SEQ group). Demographic variables, hospital length of stay (LOS), long-term outcomes and postoperative complications were compared between both groups. RESULTS: A total of 39 patients (21 males, 18 females) were included, with a median age of 14.3 years. BA and AUS were performed simultaneously at the same intervention in 27 patients, and sequentially in different interventions in 12 cases, with a median of 18 months between both surgeries. No demographics differences were observed. SIM group had a shorter median LOS when compared to SEQ group, considering the two sequential procedures (10 vs. 15 days; p = 0.032). Median follow-up was 17.2 years (interquartile range 10.3-23.9). Four postoperative complications were reported, 3 patients in SIM group and 1 case in SEQ group, with no statistically significant differences between them (p = 0.758). Adequate urinary continence was achieved in more than 90% of patients in both groups. DISCUSSION: There are scarce recent studies comparing the combined performance of simultaneous or sequential AUS and BA in children with neuropathic bladder. The results of our study show a much lower postoperative infection rate than previously reported in the literature. It is a single-center analysis with a relatively small sample of patients although it is among the largest series published so far, and presents the longest long-term follow-up with more than 17 years of median follow-up time. CONCLUSION: Simultaneous BA and AUS placement appears safe and efficacious in children with neuropathic bladder, with shorter LOS and no differences in postoperative complications or long-term outcomes when compared to performing the two procedures sequentially at different times.

Utilidad del índice neutrófilo-linfocito en la detección de apendicectomías negativas / The role of the neutrophil-to-lymphocyte ratio in avoiding negative appendectomies

Introducción: El índice neutrófilo-linfocito (INL) es un biomarcador inflamatorio fácilmente calculable a partir del recuento diferencial de leucocitos. El objetivo de este estudio es analizar el papel del INL en la detección de apendicetomías negativas, y comparar su utilidad con otros factores clínicos, ecográficos y de laboratorio previamente descritos. Métodos: Estudio retrospectivo en pacientes menores de 16 años con sospecha de apendicitis aguda intervenidos en nuestra institución entre 2017-2020, que fueron divididos en 2 grupos según hallazgos histológicos apendiculares: Grupo AN: apendicitis negativa; ausencia de inflamación y grupo AP: apendicitis positiva; presencia de inflamación en la pared apendicular. Se analizaron las características demográficas, clínicas, ecográficas y de laboratorio. Resultados: Se incluyeron 1.269 pacientes (1.244 en el grupo AP; 25 en el grupo AN), sin diferencias demográficas entre ellos. Los pacientes del grupo AN presentaron un porcentaje significativamente menor de náuseas y vómitos en comparación con el grupo AP (p<0,001) y menor diámetro ecográfico apendicular (8,1±2,1 vs. 9,7±2,8mm; p<0,001). Los recuentos de leucocitos, neutrófilos e INL fueron significativamente superiores en el grupo AP (p<0,001), así como la proteína C reactiva (18,6 vs. 2,6; p=0,005). El análisis mediante curva ROC mostró que el INL fue el parámetro con mayor AUC (0,879) para el diagnóstico de apendicitis negativa, con un punto de corte de 2,65 con una sensibilidad del 84,2% y una especificidad del 83,8% máximas. Conclusiones: El INL es el parámetro preoperatorio que mejor distingue a los pacientes sin apendicitis aguda. Los valores inferiores a 2,65 deben hacernos sospechar otra causa diferente a la apendicitis. (AU)

Introduction: The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory biomarker that is easily calculated with data from the differential white blood cell count. The aim of our study was to analyse the role of the NLR in the detection of negative appendectomies and to compare its usefulness with other clinical, sonographic and laboratory factors previously described. Methods: We conducted a retrospective study in patients aged less than 16 years who underwent appendectomy in our hospital between 2017 and 2020. We divided patients into 2 groups based on appendiceal histological findings: NA group (negative appendicitis: absence of appendiceal inflammation) and PA group (positive appendicitis: presence of inflammation in any layer of the appendiceal wall). We analysed demographic, clinical, sonographic and laboratory characteristics. Results: We included a total of 1269 patients, 1244 in the PA group and 25 in the NA group, with no differences between groups in demographic characteristics. The proportion of patients that presented with nausea and vomiting was significantly smaller in the NA group compared to the PA group (P<.001), and there were no other differences in symptoms. The appendiceal diameter on ultrasound was significantly smaller in the NA group (8.1±2.1 vs. 9.7±2.8mm; P<.001). The white blood cell and neutrophil counts and the NLR were significantly higher in the PA group (P<.001), as was the level of C-reactive protein (18.6 vs. 2.6; P=.005). The ROC curve analysis revealed that the NLR was the parameter with the highest AUC (0.879) for the diagnosis of negative appendicitis, with a cut-off point of 2.65 for a maximum sensitivity of 84.2% and specificity of 83.8%. Conclusion: The NLR is the preoperative parameter that best discriminates patients without acute appendicitis. Values of less than 2.65 should make clinicians contemplate diagnoses other than appendicitis. (AU)

Intussusception Management in Children: A 15-Year Experience in a Referral Center.

OBJECTIVE: To report a 15-y, single-center experience in the management and outcomes of ileocolic intussusception (ICI) episodes. METHODS: A retrospective study was performed in patients with ICI episodes, who were treated at a single quaternary referral center from 2005 to 2019. Data evaluated included patient demographics, clinical presentation, treatment modalities, hospital stay, complications, and outcomes. RESULTS: A total of 546 ICI episodes (66.1% males) were included, with a median age at diagnosis of 15 mo. Enema reduction was performed in 478 patients (87.6%), with an overall success rate of 85.8%. Hydrostatic saline enema was the most effective method (89.3%) when compared to pneumatic (80.6%) or barium enema (79.8%), this difference being statistically significant (p = 0.031). No associated complications were observed during nonoperative reduction. Surgical treatment was performed in 101 patients, in whom 36 bowel resections were performed. Postoperative complications were reported in 6 patients (5.9%). Hospital stay was significantly longer in patients with operative management (median 5 d vs. 1 d; p < 0.001). CONCLUSIONS: Nonoperative management has a high overall success rate and low complication and recurrence rates. Saline enema reduction presents the highest effectiveness, and should be considered the first-line treatment.

The role of the neutrophil-to-lymphocyte ratio in avoiding negative appendectomies.

INTRODUCTION: The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory biomarker that is easily calculated with data from the differential white blood cell count. The aim of our study was to analyse the role of the NLR in the detection of negative appendectomies and to compare its usefulness with other clinical, sonographic and laboratory factors previously described. METHODS: We conducted a retrospective study in patients aged less than 16 years who underwent appendectomy in our hospital between 2017 and 2020. We divided patients into 2 groups based on appendiceal histological findings: NA group (negative appendicitis: absence of appendiceal inflammation) and PA group (positive appendicitis: presence of inflammation in any layer of the appendiceal wall). We analysed demographic, clinical, sonographic and laboratory characteristics. RESULTS: We included a total of 1269 patients, 1244 in the PA group and 25 in the NA group, with no differences between groups in demographic characteristics. The proportion of patients that presented with nausea and vomiting was significantly smaller in the NA group compared to the PA group (P < .001), and there were no other differences in symptoms. The appendiceal diameter on ultrasound was significantly smaller in the NA group (8.1 ±â€¯2.1 vs. 9.7 ±â€¯2.8 mm; P < .001). The white blood cell and neutrophil counts and the NLR were significantly higher in the PA group (P < .001), as was the level of C-reactive protein (18.6 vs. 2.6; P = .005). The ROC curve analysis revealed that the NLR was the parameter with the highest AUC (0.879) for the diagnosis of negative appendicitis, with a cut-off point of 2.65 for a maximum sensitivity of 84.2% and specificity of 83.8%. CONCLUSION: The NLR is the preoperative parameter that best discriminates patients without acute appendicitis. Values of less than 2.65 should make clinicians contemplate diagnoses other than appendicitis.

The effectiveness of matrix ablation with silver nitrate in the treatment of ingrown toenails. A single-center case-control study.

BACKGROUND: Partial onychectomy with chemical matrixectomy is considered the gold standard treatment for stage II-III ingrown toenails (IT). However, there are scarce reports describing the use of silver nitrate in IT management in adolescents. Our aim is to analyze the effectiveness of matrix ablation with silver nitrate and compare it with partial onychectomy by electrocautery. METHODS: A retrospective study of adolescent patients with stage II-III IT was performed. Those who underwent electrocautery matricectomy in a major outpatient surgical center (Group A) and those who were treated with silver nitrate at an outpatient clinic (Group B) were compared. Efficacy was determined by recurrence and postoperative infection rates. RESULTS: Two hundred and nine patients were included (86 group A; 123 group B), with a total of 382 partial onychectomies (151 group A; 231 group B). Group B patients exhibited a lower recurrence rate (4.7%) when compared to group A (11.2%, p = .02), and had a lower postoperative infection rate (4.0% group A vs. 1.7% group B; p = .18), although not statistically significant. CONCLUSION: Silver nitrate chemical matricectomy after partial onychectomy is an effective treatment for IT in adolescents, with few postoperative complications and low recurrence rate. Therefore, it should be considered as a possible alternative to electrocautery matricectomy.

Rhabdomyolysis following Nuss Procedure: A Prospective Study in Children.

INTRODUCTION: Postoperative rhabdomyolysis (RML) has been documented after several surgical procedures in adults. Musculoskeletal remodeling after Nuss procedure for pectus excavatum (PE) could cause RML. We evaluated the incidence of RML after Nuss procedure in children. METHODS: This study was a prospective study from 2018 to 2021. We enrolled all otherwise healthy patients who underwent PE correction with only one bar. Studied variables included demographic and clinical data, duration of surgery, complications, and length of hospitalization. The patients included underwent serial measurements of serum creatine kinase (CK), troponin I, N terminal pro B-type natriuretic peptide (NT-proBNP), serum creatinine, urea, and glomerular filtration rate at 6 and 48 hours postoperatively, and hospital discharge. RESULTS: Forty-six patients met criteria (40 males/6 females), with a mean age of 15.1 ± 1.4 years. Mean duration of surgery was 74 ± 28 minutes, and length of hospitalization was 4.6 ± 1.6 days. RML was diagnosed in 30.4% of patients at 6 hours, 91.3% at 48 hours, and 21.7% at hospital discharge. Mean preoperative CK value was 181.1 ± 141.6 IU/L, and postoperative values were 863.3 ± 302.6 IU/L at 6 hours, 1,675.2 ± 561 IU/L at 48 hours, and 850 ± 683.7 IU/L at hospital discharge, with statistically significant differences (p = 0.001). High-sensitivity troponin I and NT-proBNP levels increased significantly during the postoperative time (p = 0.001). Renal function remained stable (p = 0.55). CONCLUSION: Nuss technique produces RML without kidney injury in healthy patients. This knowledge should be considered for patients at increased risk of developing acute kidney injury and other complications.

Neutrophil-to-Lymphocyte Ratio as a Predictor of the Need for Surgical Treatment in Children's Intussusception.

OBJECTIVE: Neutrophil-to-lymphocyte ratio (NLR) is an emerging inflammatory marker in abdominal pathologies. Ileocolic intussusception (ICI) involves a progressive intestinal inflammation, and the effectiveness of nonsurgical treatment (enema) might be related to the inflammation degree, although no previous studies have investigated this relationship. Our aim is to identify predictors of the need for surgical treatment in ICI. MATERIALS AND METHODS: A single-center, retrospective, case-control study was performed in children with ICI, who were treated with initial nonsurgical management between 2005 and 2019. Patients were divided in two groups: A (effective enema) and B (need for surgery). Admission demographic and clinical and laboratory data were analyzed. Specificity and sensitivity of the different parameters as predictors of the need for surgical treatment were determined by receiver operating characteristic (ROC) curves. RESULTS: A total of 511 patients were included (410: group A; 101: group B), without statistically significant demographic differences. Group B presented significantly higher frequency of vomiting, bloody stools, and longer median time since symptoms onset (24 vs. 8 hours; p < 0.001). Group B presented higher median laboratory inflammatory markers than group A: NLR (6.8 vs. 1.8; p < 0.001), neutrophils (10,148 vs. 7,468; p < 0.001), and C-reactive protein (CRP; 28.2 vs. 4.7; p < 0.001). In ROC curve analysis, NLR had an area under the curve of 0.925, higher than neutrophil count (0.776; p = 0.001), CRP (0.670; p = 0.001), and time since symptoms onset (0.673; p = 0.001). It was estimated a cut-off point of NLR greater than 4.52 (sensitivity: 73.2%; specificity: 94.5%). CONCLUSION: High NLR values imply a high degree of bowel inflammation and might anticipate the need for surgical treatment in ICI in children. LEVEL OF EVIDENCE: III.

The role of neutrophil-to-lymphocyte ratio as a predictor of testicular torsion in children.

INTRODUCTION: Doppler ultrasound constitutes the gold standard for the diagnosis of testicular torsion (TT), although sometimes the spermatic cord twisting and absence of testicular flow are difficult to visualize. To date, no laboratory markers have been shown to be useful for preoperative TT diagnosis. OBJECTIVE: Our aim is to analyze the role of the neutrophil-to-lymphocyte ratio (NLR) as a predictor of pediatric TT. STUDY DESIGN: A retrospective single-center case-control study was performed in patients with ultrasound suspicion of TT, in whom surgical testicular examination was performed between 2016 and 2020. Patients were divided into two groups according to the intraoperative findings: TT group (testicular torsion), defined as spermatic cord twisting on itself around its longitudinal axis at least 360°, and non-TT group (no torsion). Demographics, clinical, ultrasound and laboratory features at admission were analyzed. Sensitivity and specificity were determined by the area under the curve (AUC) represented on the receiver operating characteristic (ROC) curves. RESULTS: A total of 159 patients were included (117 TT group; 42 non-TT group), with no demographic or clinical differences. TT group patients presented significantly shorter median time since symptoms onset (4 vs. 8 h; p < 0.012). Laboratory inflammatory test were significantly higher in TT group: Leukocytes (10,900 × 103/µl vs. 7,980 × 103/µl; p < 0.001), neutrophils (8,050 × 103/µl vs. 3,350 × 103/µl; p < 0.001) and NLR (4.6 vs. 1.1; p < 0.001). In ROC curve analysis, NLR presented the highest AUC (0.903), significantly higher than all other laboratory and ultrasound parameters. NLR of 2.3 was the cut-off point with maximum sensitivity (86.9%) and specificity (94.8%). DISCUSSION: This is, to the best of our knowledge, the first study to analyze the usefulness of NLR in predicting the diagnosis of TT in patients with clinical and ultrasound suspicion. The limitations are mainly derived from being a single-center retrospective study. For this reason, multicenter studies with a higher number of patients and prospective design may be useful to minimize these biases. The sample size of our study, although not large, has allowed us to identify significant differences between the distinct parameters analyzed as predictors of TT. However, the absence of other similar studies in pediatric patients has hindered the comparison of our results. CONCLUSION: NLR should be considered as a predictor of pediatric TT in cases with nuclear ultrasound suspicion that may help to anticipate the urgent surgical treatment in these patients.

The Use of Acellular Dermal Matrix (Integra Single Layer) for the Correction of Malformative Chest Wall Deformities: First Case Series Reported.

Introduction Autologous tissue transfers have been used in chest wall reconstruction for decades, with high morbidity. Recently, acellular dermal matrices (ADMs) have emerged as an alternative. The aim of this article is to report our initial experience in the reconstruction of malformative chest wall deformities with ADM. Methods A prospective observational study was performed in patients with malformative chest wall deformities, who were reconstructed with ADM at our institution between 2018 and 2020. We analyzed demographic variables, surgical features, postoperative complications, and cosmetic results at 12 months' follow- up. Results Four male patients were included (median age: 16 years). Two patients had bilateral costal anomalies, one patient had a unilateral chest deformity, and one patient had Poland syndrome. In all patients, blunt dissection of the subcutaneous cellular tissue overlying the defect was performed through 2.5 to 3 cm skin incisions, creating a pouch. Afterwards, several sheets of Integra Single Layer were placed in the pouch, to replace the volume defect. All patients were discharged same-day. No postoperative infections, hematomas, or seromas were observed. Only one patient presented with a partial surgical wound dehiscence. Revisions were performed at 1, 3, 6, and 12 months. All 4 patients were satisfied with the cosmetic outcome (Nuss Questionnaire: median score: 16 points; Q1-Q3: 22-26). Conclusion The use of ADM in malformative chest wall deformities reconstruction has not been previously described in children. This study demonstrates that the use of ADM is a safe and reliable technique. However, more studies with long-term follow-up are warranted.

Postoperative Pneumoperitoneum in Pediatric Patients: Residual Air or Surgical Complication? A Prospective Study.

Background: Residual postoperative pneumoperitoneum (RPP) can be confused with postoperative complications. Our aim was to study RPP characteristics in pediatric patients. Materials and Methods: Prospective study in children with noncomplicated appendicitis, from July to December 2019, divided into open appendectomy (OA) or laparoscopic appendectomy (LA). Abdominal ultrasounds were performed daily to assess RPP. Demographic, surgical data, and RPP characteristics were analyzed. Results: Forty-one patients (63% male) aged 9.8 ± 2.9 years were included: 19 had OA and 22 LA. RPP was present in 90.9% of LA patients versus 21.1% of OA (P < .001). RPP disappeared by the postoperative day (POD) 2, in all OA patients. RPP was present in 90.9% of LA patients in POD 1, 53.8% on POD 2, 25% on POD 3, and in no patient from POD 4. RPP prevalence was not associated with surgical duration, age, gender, or type of appendicitis. RPP was associated with pain radiating to the shoulders (PRS) (P = .018), with a sensitivity of 50.0% and specificity of 88.23% for diagnosis. Conclusions: Surgical approach was the main factor associated with RPP persistence. PRS in the physical examination may be helpful for diagnosis when RPP is suspected. The persistence of RPP beyond POD 4 is uncommon, and should be considered when making decisions.

Artificial urinary sphincter in congenital neuropathic bladder: Very long-term outcomes.

OBJECTIVE: Artificial urinary sphincter has been used to treat urinary incontinence in children with neuropathic bladder, although there are few studies reporting very long-term results. We assess our experience over the last 27 years in the management of artificial urinary sphincter. METHODS: A retrospective study was performed in patients with neuropathic bladder in whom an artificial urinary sphincter was placed in our institution between 1994 and 2020. Demographic variables, pre- and post-artificial urinary sphincter implantation urodynamic studies, long-term outcomes, and postoperative complications were collected. RESULTS: An artificial urinary sphincter was implanted in 71 patients (median age 14.5; interquartile range 12.8-15.9), with a median follow-up time of 17.2 years (interquartile range 9.8-23.9 years). Thirty-nine patients underwent enterocystoplasty combined with artificial urinary sphincter placement and 32 underwent artificial urinary sphincter implantation alone, of whom 12 patients (16.9%) eventually required an enterocystoplasty because of unexpected bladder behavior changes, usually within 3 years of artificial urinary sphincter implantation. Adequate urinary continence was reported in 90.1% of patients, nine void their bladders spontaneously, and 62 need clean intermittent catheterization. Eighteen mechanical malfunctions occurred in 15 patients (21.1%), with an average artificial urinary sphincter working life of 15.1 ± 1.3 years. In five patients artificial urinary sphincter was removed due to infection or erosion. In 12 patients (30.8%), a continent catheterizable stoma was made (before or during the follow-up) because of problems with clean intermittent catheterization through the urethra. CONCLUSION: The very long-term results of this study demonstrate that artificial urinary sphincter is an effective treatment for urinary incontinence in neuropathic bladder patients. Long-term follow-up is important to identify potential unexpected changes in bladder behavior in these patients.

Indocyanine Green (ICG)-Guided Identification of Hypermetabolic Pancreatic Nodules in Focal Congenital Hyperinsulinism: A Case Report in a 3-Month-Old Infant.

Indocyanine green (ICG)-guided near-infrared fluorescence has been recently adopted in pediatric surgery, although its use in the treatment of congenital hyperinsulinism has not been reported. We present a case of focal congenital hyperinsulinism in which ICG-navigation with ICG was used during surgical treatment. A 3-month-old infant was referred to our institution from a peripheral hospital for episodes of persistent hypoglycemia since birth, with no response to intravenous treatment with diazoxide, octreotide, or hydrochlorothiazide. An abdominal positron emission tomography-computed tomography scan showed a hypermetabolic nodule in the proximal portion of the body of the pancreas, compatible with focal congenital hyperinsulinism. A heterozygous mutation in the ABCC gene (Ala1516Glyfs*19) frameshift type inherited from the father was identified, which supported this diagnosis. Laparoscopy-assisted surgery was performed with ICG-guided near-infrared fluorescence, with intravenous injection of 16 mg ICG (2 mg/mg), which allowed localization of the focal lesion in the body of the pancreas. The lesion was resected with bipolar electrocautery and intraoperative histological study confirmed complete resection. Plasma glucose values normalized 6 hours after surgery and the patient was discharged 5 days later. In conclusion, the use of ICG in the treatment of congenital hyperinsulinism helps to identify hypermetabolic pancreatic nodules, decreasing the likelihood of incomplete resection.

Buried penis surgical treatment in children: Dorsal dartos flap VS. Fascia fixation. A retrospective cohort study.

INTRODUCTION: Several surgical techniques for buried penis (BP) treatment have been described, although there is not a reference pattern for it. In our institution, we have traditionally performed penis fixation to Buck's fascia at 3 points. In 2014 we introduced a dorsal dartos flap technique, fixed at both sides of the penis base. OBJETIVE: To compare both techniques and their long-term outcomes. METHODS: A retrospective cohort study was conducted on consecutive patients with BP who underwent surgery between 2010 and 2018. They were divided according to surgical technique performed: group A (fascia fixation) and B (dorsal dartos flap). Demographic variables, surgical time and postoperative complications were analyzed. Long-term cosmetic outcomes were evaluated through a telephone survey to patients parents. RESULTS: Thirty-five patients were included (16 group A; 19 group B). Median age at intervention was 9.7 years in group A, with no statistical differences with group B (7.3 years; p = 0.071). No statistically significant differences were observed in mean surgical time or postoperative complications between both groups. Cosmetic outcomes (Table 2) were significantly better in group B, which presented higher percentages of satisfaction with the outcomes (95% vs. 64%; p = 0.02) and age at intervention (89% vs. 59%; p = 0.032), higher perception of the procedure as "minimally invasive" (100% vs. 71%; p = 0.013) and higher recommendation rate of the intervention (95% vs. 57%; p = 0.029). CONCLUSIONS: Dorsal dartos flap is a reproducible, minimally invasive technique with minimal adverse effects and satisfactory long-term results. It has fewer postoperative complications and more satisfactory cosmetic results compared to fascia fixation.

Complicated Acute Appendicitis during COVID-19 Pandemic: The Hidden Epidemic in Children.

INTRODUCTION: Since home confinement for novel coronavirus disease 2019 (COVID-19) pandemic began, pediatric visits to the emergency department (ED) have decreased, including consultation for abdominal pain. Our aim is to investigate the incidence of complicated acute appendicitis (AA; peritonitis or appendicular mass) during confinement for COVID-19 pandemic and to compare it with the previous 5 years. MATERIALS AND METHODS: A retrospective study was performed in children with AA who underwent surgery between March 9 and April 13 from 2015 to 2020; patients were divided into six groups according to the year of surgery. We analyzed demographic variables, time from onset of symptoms, mean hospital stay, cumulative incidence, and incidence rate of complicated appendicitis. RESULTS: A total of 168 patients were included with no differences in the number of patients, gender, and age between groups. Patients in 2020 (COVID-19 group) presented longer symptom progression time (46.8 hours; p = 0.046), higher rate of complicated appendicitis (48.4%; p = 0.004), longer mean hospital stay (4.9 days; p < 0.001), increased cumulative incidence (8.27 cases per 100,000 children per 0.1 years; p < 0.001), and increased incidence rate of complicated appendicitis (83 cases per 100,000 children; p < 0.001) when compared with other groups. CONCLUSION: Delayed ED visit of children with AA during home confinement lead to an increased rate of complicated appendicitis. It is crucial to make parents aware of the importance of early diagnosis and treatment of abdominal pain.

Percutaneous Cryoanalgesia: A New Strategy for Pain Management in Pectus Excavatum Surgery.

INTRODUCTION: In recent years, pain protocols for pectus excavatum (PE) have incorporated cryoanalgesia through thoracoscopic approach. Since 2019, ultrasound-guided percutaneous cryoanalgesia (PCr) has been applied at our institution, either on the same day as the Nuss procedure or 48 hours before surgery. We carried out a preliminary retrospective review of patients with PE in whom PCr prior to surgery was performed at our institution between 2019 and 2021. MATERIALS AND METHODS: Two groups were evaluated: PCr on the same day (PCrSD) and PCr 48 hours before surgery (PCr48). Despite PCr, patients were treated with "patient-controlled analgesia" (PCA) with opioids for at least 24 hours, switching to conventional intravenous analgesia and oral analgesia in the following days. Demographic, clinical-radiological variables, PCA opioid use, pain grade according to the visual analog scale (VAS), and length of stay (LOS) were compared between the groups. A total of 20 patients were included (12 with PCrSD and 8 with PCr48), without significant differences in demographics or clinical-radiological variables. The overall median time of PCr was 65 minutes (55-127), with no differences between the groups. RESULTS: PCr48 group presented with significantly lower median number of hours of continuous PCA (24 vs. 32 hours; p = 0.031), lower median number of rescue boluses (11 vs. 18; p = 0.042), lower median VAS in the early postoperative hours (2 vs. 5.5; p = 0.043), and lower median LOS (3.5 vs. 5 days). CONCLUSION: PCr performed 48 hours prior to surgery is more effective in terms of PCA requirements, VAS, and LOS when compared with cryoanalgesia on the same day.