Clinical features and treatment options for pediatric adrenal incidentalomas: a retrospective single center study.

BACKGROUND: The aim of this study was to investigate the clinical features and treatment options for pediatric adrenal incidentalomas(AIs) to guide the diagnosis and treatment of these tumors. METHODS: The clinical data of AI patients admitted to our hospital between December 2016 and December 2022 were collected and retrospectively analyzed. All patients were divided into neonatal and nonneonatal groups according to their age at the time of the initial consultation. RESULTS: In the neonatal group, 13 patients were observed and followed up, and the masses completely disappeared in 8 patients and were significantly reduced in size in 5 patients compared with the previous findings. Four patients ultimately underwent surgery, and the postoperative pathological diagnosis was neuroblastoma in three patients and teratoma in one patient. In the nonneonatal group, there were 18 cases of benign tumors, including 9 cases of ganglioneuroma, 2 cases of adrenocortical adenoma, 2 cases of adrenal cyst, 2 cases of teratoma, 1 case of pheochromocytoma, 1 case of nerve sheath tumor, and 1 case of adrenal hemorrhage; and 20 cases of malignant tumors, including 10 cases of neuroblastoma, 9 cases of ganglioneuroblastoma, and 1 case of adrenocortical carcinoma. CONCLUSIONS: Neuroblastoma is the most common type of nonneonatal AI, and detailed laboratory investigations and imaging studies are recommended for aggressive evaluation and treatment in this population. The rate of spontaneous regression of AI is high in neonates, and close observation is feasible if the tumor is small, confined to the adrenal gland and has no distant metastasis.

Modified onlay island flap versus tubularized incised plate urethroplasty for hypospadias reoperation.

This study aimed to assess the outcomes of modified onlay island flap (MOIF) urethroplasty for hypospadias reoperation. A retrospective analysis was conducted using clinical data on children reoperated with MOIF or tubularized incised plate (TIP) urethroplasty for hypospadias in the Children's Hospital of Nanjing Medical University (Nanjing, China) from December 2016 to September 2020. A total of 90 children with hypospadias who failed primary repair and were reoperated on with MOIF (MOIF group, n = 46) or TIP urethroplasty (TIP group, n = 44) were recruited. All children were postoperatively followed up for at least 6 months. Six patients with postoperative urinary fistula, 2 patients with glans dehiscence, and 1 patient with urethral diverticulum were reported in the MOIF group, while 7 patients with postoperative urinary fistula, 2 patients with urethral stricture, and 1 patient with glans dehiscence were reported in the TIP group. Postoperative infection, flap necrosis and other complications were not recorded. A total of 37 (80.4%) patients in the MOIF group and 34 (77.3%) patients in the TIP group were successfully reoperated. Although the success rates of MOIF and TIP urethroplasty are comparable, pediatricians should master different types of repair techniques for individualized hypospadias reoperation. MOIF urethroplasty can be recommended after failure of the primary repair.

[Staged urethroplasty by tubularization of reconstructed urethral plate using the preputial island flap for severe hypospadias].

OBJECTIVE: To explore the application value of staged urethroplasty by tubularization of the reconstructed urethral plate using the preputial island flap in the treatment of severe hypospadias. METHODS: From May 2014 to February 2019, 91 children with severe hypospadias received one- or two-stage urethroplasty by tubularization of the reconstructed urethral plate with the preputial island flap. We compared the patients' age, glans diameter, length of the straightened urethral defect, and incidence rates of postoperative urethral fistula, urethral diverticulum, glans dehiscence and urethral stricture between the two groups of patients. RESULTS: The 56 patients in the one-stage group were aged 7－144 (21.92 ± 13.37) months old, the urethral defect 3－5 (3.565 ± 0.528) cm in length and the glans 1.0－1.4 (1.195 ± 0.083) cm in diameter, and the 35 in the two-stage group aged 7 －153 (24.78 ± 13.59) months, the urethral defect 3－5 (3.857 ± 0.696) cm in length and the glans 0.8－2.5 (1.206 ± 0.389) cm in diameter. There were no statistically significant differences in age, glans diameter and the length of urethral defect between the two groups. In the one-stage group were found 18 cases of postoperative urinary fistula, 1 case of glans dehiscence, 1 case of urethral diverticulum, and 1 case of both urethral diverticulum and glans dehiscence, all cured by repeated urinary fistula repair/urethroplasty. No urinary fistula occurred in the two-stage group postoperatively except 4 cases of glans dehiscence, of which 2 were cured by repeated repair and the other 2 refused reoperation. The success rate was significantly higher in the two-stage than in the one-stage urethroplasty group (88.57% vs 62.50%, P < 0.05). CONCLUSIONS: Two-stage urethroplasty by tubularization of the reconstructed urethral plate with the preputial island flap can significantly reduce the incidence of urethral fistula in patients with severe hypospadias, but may increase the number of operations in those who do not need staged surgery. The necessity of two-stage urethroplasty can be determined according to the development of the glans, the degree of penile curvature, and the length of urethra defect.

Comparative study of one-stage and the novel two-stage urethroplasty using the transected urethral plate and transverse preputial island flap (TPIF) for severe hypospadias: a single-center experience.

BACKGROUND: To evaluate a novel two-stage method of urethroplasty using a transected urethral plate and transverse preputial island flap (TPIF) for proximal hypospadias with severe chordee. METHODS: We retrospectively analyzed 91 cases of proximal hypospadias, who had undergone either one-stage or two-stage urethroplasty. Comparisons between the two groups were made based on age, glans diameter, the length of the urethral defect, and the rate of complications. RESULTS: There was no significant difference in age at surgery, glans diameter, and the length of urethral defect between the two groups. In the one-stage group, 18 cases of urinary fistula and one case each of glans dehiscence, urethral diverticulum, and urethral diverticulum with concurrent glans dehiscence, were reported. All patients were treated using urinary fistula repair or urethroplasty. In the novel two-stage group, no cases of urinary fistula were reported after the secondary urethroplasty. However, 4 cases showed dehiscence at the glans, 2 were treated through reoperation but the 2 other 2 patients reoperation. The success rate was 62.50% and 88.57% in the one-stage and two-stage groups, respectively (P<0.05). CONCLUSIONS: Two-stage urethroplasty using a tubularized urethral plate and TPIF can significantly reduce the incidence of urethral fistula of the proximal hypospadias with severe chordee. However, it may increase the number of operations that need to be performed on children who do not need staged surgery. Although we could not prove it through this study, we believe that the necessity of two-stage urethroplasty should be determined based on the development of the glans, the severity of penile curvature, and the length of the urethra defect.

Patient transfer influences the prognosis of pediatric patients operated for testicular torsion: a single-center experience.

BACKGROUND: Testicular torsion (TT) remains an emerging issue for pediatric patients. This study's objective was to determine risk factors of TT outcomes in the Chinese pediatric cohort from a single center. METHODS: We performed a retrospective cohort study of patients who met the inclusion criteria in our center from 2013 to 2018. Clinical demographics, and TT-related data, including laterality, torsion degree, torsion direction, position to the cavity of tunica vaginalis, enorchia, and outcomes, were reviewed and extracted from medical charts and databases. Statistical analysis was conducted to compare and figure out the risk factors of TT outcomes. RESULTS: A total of 84 pediatric patients were enrolled in this study. Among these variables, age, duration of symptoms, and the patient transfer were significantly associated with the outcomes of TT (P<0.005). Patients transferred from other medical facilities underwent more orchiectomy than those without transfer (univariate analysis, P<0.0001; multivariate analysis, P=0.001). No difference was found in other variables between patients with or without transfer (P>0.05). Moreover, transferred patients tended to show worse testicular function. CONCLUSIONS: We have reported that age, duration of symptoms, and patient transfer were three significant risk factors in this cohort. Patients with transfer tended to suffer from more orchiectomy and worse prognosis of TT.

Lich-Gregoir vesico-ureteral reimplantation for duplex kidney anomalies in the pediatric population: a retrospective cohort study between laparoscopic and open surgery.

BACKGROUND: The aim of the study is to compare the Lich-Gregoir vesico-ureteral reimplantation in laparoscopy and open surgery. METHODS: In this case control study, we enrolled pediatric patients who were diagnosed with unilateral duplex kidney and had underwent surgical treatment. The surgical treatments were either conventional open surgery or laparoscopic surgery. We collected the basic demographic data and extracted the operative-related statistics such as operation time, blood loss, length of hospital stay, pain level, and post-operative complications. The two groups were compared using Student's t-test. RESULTS: A total of 90 subjects were enrolled. Of the enrolled subjects, 35 underwent open surgery and 55 underwent laparoscopic surgery. There were no observable difference in the basic demographics between two groups (P>0.05). The duration of operation in laparoscopic surgery group was significantly shorter than in the open surgery group (95.60±5.25 vs. 108.70±3.12 min, P=0.040). It was also noted that the amount of blood loss, length of hospital stay, drainage level, and the mean visual analog scale in laparoscopic group were significantly lower (P<0.05). The total incidence of complications in the laparoscopic and open surgery groups were 16.36% and 37.14%, respectively. CONCLUSIONS: Laparoscopic Lich-Gregoir vesico-ureteral reimplantation surgery management can be successful, clinically effective, and safe for pediatric population with functional duplex kidneys, and is better than the open surgery techniques.

[Application of the lateral preputial fascial island flap in hypospadias reoperation].

Objective: To evaluate the application and effect of the lateral preputial fascial island flap (LPFIF) in hypospadias reoperation. METHODS: We retrospectively analyzed the clinical data on the children patients undergoing hypospadias reoperation with LPFIF in our Department of Urology from December 2016 to June 2019. RESULTS: A total of 85 cases were included in this study, including 18 cases of LPFIF, 19 cases of Duplay technique, 25 cases of tubularized incised plate urethroplasty (TIP) and 23 cases of Mathieu urethroplasty. The patients were aged from 18 months to 12 years and 8 months, averaging 4.6 years. Postoperatively, all the children were followed up for ≥ 6 months, which found satisfactory appearance of the penis body and glans, the urethral orifice in the normal position of the glans, and the external orifice of the urethra fissured. Urethral fistula occurred in 2 cases and glans dehiscence in 1 after LPFIF; 5 of the patients presented urethral fistula after Duplay; 3 developed urethral fistula and 1 urethral stricture after TIP; 6 showed urethral fistula and 2 glans dehiscence after Mathieu urethroplasty. No postoperative urethral stricture, urethral diverticulum or flap necrosis occurred in any of the cases. Hypospadias reoperation succeeded in 83.3% (15/18) of the cases after LPFIF. The urine flow curve of the LPFIF cases was bell-shaped or high flat-shaped, with a maximum urinary flow rate of 8.56 ± 3.99 ml/s and an average urinary flow rate of 5.23 ± 2.32 ml/s, not significantly different from those of the TIP and Duplay cases. CONCLUSIONS: There is no statistically significant difference in the success rate of hypospadias reoperation between TIP and LPFIF. Urethroplasty with LPFIF can be used as one of the surgical options for hypospadias reoperation.

Use of double-J ureteric stents post-laparoscopic pyeloplasty to treat ureteropelvic junction obstruction in hydronephrosis for pediatric patients: a single-center experience.

OBJECTIVES: We aimed to investigate the safety concerns associated with placing double-J ureteric stents post-laparoscopic pyeloplasty surgery for congenital ureteropelvic junction obstruction (UPJO) and hydronephrosis. METHODS: A total of 1349 patients with postoperative double-J stent placement at our center were included. Clinical variables for enrolled patients were collected by two independent authors. We compared clinical variables and the efficacy of stenting post-laparoscopic pyeloplasty. RESULTS: The mean age of the patients was 4.23 ± 2.39 years. A total of 58.49% of patients were diagnosed with left UPJO with hydronephrosis and 33.95% were diagnosed with right UPJO. Furthermore, 7.56% of patients had bilateral UPJO. In all cases, 96.96% of indwelling double-J stents were successfully removed 4 weeks post-surgery. A total of 3.04% of the patients still required further management, including stent migration to the renal pelvis (0.37%), stent migration to the bladder (0.30%), prolapse of the stent through the ureter (0.15%), blockage of stents (1.85%), and fouling of stents (0.37%). CONCLUSIONS: Double-J ureteric stents used after laparoscopic pyeloplasty for treating UPJO in hydronephrosis for pediatric patients is a safe, feasible, and beneficial method, which can be recommended for routine procedures. However, caution should be practiced for follow-up and removal using this method.

Risk factors affecting the prognosis of urinary tract infection in Chinese pediatric patients: Single-center experience.

BACKGROUND: Urinary tract infection (UTI) is common in children. The purpose of this retrospective study was to determine the various risk factors that usually affect the prognosis of UTI in children diagnosed with the disease. METHODS: In the present retrospective study, we enrolled all pediatric patients diagnosed with UTI and hospitalized between 1 January 2013 and 31 July 2016 at Nanjing Children's Hospital. We then collected all the relevant patient clinical demographics and characteristics. RESULTS: The study involved 2,092 pediatric patients diagnosed with UTI. On logistic regression analysis, factors that could affect the prognosis of pediatric UTI were complications, hospitalization, intensive care unit (ICU) admission, type of UTI, urine culture results, blood lymphocytes, urine nitrites (NIT) and antibiotics (unstandardized coefficients, 0.06, <0.001, -0.28, 0.32, <0.001, 0.01, -0.11, 0.01, respectively, all P < 0.001). CONCLUSION: Complications, hospitalization, type of UTI, urine culture results, blood lymphocytes, and antibiotics had a significant, positive association with UTI prognosis. Meanwhile, ICU admission and urine NIT had a negative association with prognosis.

Nrf2 signaling attenuates epithelial-to-mesenchymal transition and renal interstitial fibrosis via PI3K/Akt signaling pathways.

BACKGROUND: Nrf2 constitutes a therapeutic reference point for renal fibrosis and chronic kidney diseases. Nrf2-related signaling pathways are recognized to temper endothelial-to-mesenchymal transition (EMT) in fibrotic tissue. Nevertheless, the mechanism by which Nrf2 mitigates renal interstitial fibrosis is imprecise. METHODS: The relationship between Nrf2 and renal interstitial fibrosis was investigated using the unilateral ureteral obstruction (UUO) model of Nrf2-/- mice. The mice were separated into four groups, based on the treatment and intervention: Nrf2-/- + UUO, Nrf2-/- + Sham, WT + UUO and WT + Sham. Histological examination of renal tissue following the hematoxylin-eosin and Masson staining was carried out, as well as immunohistochemical staining. Additionally, to confirm the in vivo discoveries, in vitro experiments with HK-2 cells were also performed. RESULTS: The Nrf2-/- + UUO group showed more severe renal interstitial fibrosis compared to the WT + UUO, Nrf2-/- + Sham and WT + Sham groups. Furthermore, the manifestations of α-SMA and Fibronectin significantly increased, and the manifestation of E-cadherin considerably decreased in kidney tissues from the group of Nrf2-/- + UUO, compared to the WT + UUO group. The Nrf2 protein level significantly decreased in HK-2 cells, in reaction to the TGF-ß1 concentration. In addition, the overexpression of Nrf2 presented contradictory results. What is more, the PI3K/Akt signaling pathway was discovered to be activated in the proteins extracted from cultured cells, and treated with Nrf2 siRNA and kidney tissues from the Nrf2-/- + UUO group. CONCLUSIONS: The results we obtained demonstrate that Nrf2 signaling pathway may perhaps offset the development of EMT, prompted by TGF-ß1 and renal interstitial fibrosis. Likewise, the anti-fibrotic effect of Nrf2 was imparted by the inactivation of PI3K/Akt signaling. From our discoveries, we deliver new insight related to the prevention and treatment of kidney fibrosis.

A successful pregnancy in a patient with secondary hypertension caused by adrenal adenoma: a case report.

BACKGROUND: Secondary hypertension is a rare complication in pregnancy that causes poor outcomes, such as preeclampsia, premature delivery, intrauterine growth retardation, stillbirths, spontaneous abortion or intrauterine death. Cushing's disease caused by an adrenal adenoma is rare during pregnancy and may be overlooked by obstetricians and physicians, but can lead to hypertension, diabetes mellitus and an increased risk of fetal and maternal morbidity. Approximately 200 cases have been reported in the literature. Here, we report the successful management of a pregnant patient with Cushing's syndrome due to an adrenal adenoma. CASE PRESENTATION: The 35-year-old Chinese female had no individual or family medical history of hypertension, and did not exhibit chronic kidney disease, diabetes mellitus, autoimmune and common endocrine diseases. Her blood pressure was elevated from the 16th week of gestation and was not controlled by 30 mg nifedipine twice a day. Examination in our department revealed her 24 h urinary free cortisol (24 h UFC) level was 1684.3 µg/24 h (normal range: 20.26-127.55 µg/24 h) and plasma adrenocorticotropic hormone was < 1.00 ng/L in three independent measurements (normal range: 5-78 ng/L). Ultrasonography demonstrated a mass (2.9 cm × 2.8 cm) in the right side of the adrenal gland. Magnetic resonance imaging without contrast showed a 3.2 cm diameter mass in the right-side of the adrenal gland. Other medical tests were normal. Laparoscopic adrenalectomy was performed at the 26th week of gestation by a urological surgeon in the West China Hospital. Histopathology revealed an adrenocortical adenoma. After surgery, the patient accepted glucocorticoid replacement therapy. The remaining trimester continued without complication and her blood pressure was normal at the 32nd week of gestation without antihypertensive therapy. The patient gave birth to a healthy boy at the 40th week of gestation. CONCLUSIONS: Cushing's syndrome caused by adrenal adenoma is rare during pregnancy. This unique case suggested that analysis of the UFC level and circadian rhythm of plasma cortisol provides a suitable strategy to diagnose Cushing's syndrome during pregnancy. Laparoscopic surgical resection in the second trimester provides a reasonable approach to treat pregnant patients exhibiting Cushing's syndrome caused by an adrenal adenoma.

Retroperitoneal malignant schwannoma in a child.

Retroperitoneal malignant schwannomas are extremely rare. Only a few cases have been reported, only one of which occurred in a child. We herein report a case of retroperitoneal malignant schwannoma in a 2-year-old boy who presented with a painless mass in the right lumbar region. The mass had gradually enlarged during a 1-year period, and it was about the size of the patient's fist at the time of consultation. Whole-abdomen computed tomography revealed a space-occupying lesion in the retroperitoneum infiltrating from the L1 to L4 spinal canal. A preoperative diagnosis of a retroperitoneal tumor was made, and complete tumorectomy was performed. Postoperative pathological examination showed a malignant schwannoma. The tumor recurred 1 month after the first operation, and a second complete excision was carried out; the postoperative pathologic examination findings were similar to the previous findings. The patient recovered well and continued to undergo close follow-up.

Etiology and antimicrobial resistance patterns in pediatric urinary tract infection.

BACKGROUND: Urinary tract infection (UTI) is one of most common pediatric infections. The aim of this study was to investigate the etiology and antimicrobial resistance patterns in children hospitalized at Children's Hospital of Nanjing Medical University. METHODS: We conducted a retrospective, descriptive study of all UTI from 1 January 2013 to 30 November 2016 in children discharged from Nanjing Children's Hospital. The isolated pathogens and their resistance patterns were examined using midstream urine culture. RESULTS: A total of 2,316 children with UTI were included in the study. The occurrence rates of isolated pathogens were as follows: Enterococcus spp., 35.15%; Escherichia coli, 22.32%; Staphylococcus aureus spp., 7.73%; Streptococcus spp., 7.51%; and Klebsiella spp., 6.95%. Uropathogens had a low susceptibility to linezolid (3.47%), vancomycin (0.92%), imipenem (5.74%), and amikacin (3.17%), but they had a high susceptibility to erythromycin (90.52%), penicillin G (74.01%), cefotaxime (71.41%), cefazolin (73.41%), cefuroxime (72.52%), and aztreonam (70.11%). CONCLUSIONS: There is high antibiotic resistance in hospitalized children with UTI. Susceptibility testing should be carried out on all clinical isolates, and the empirical antibiotic treatment should be altered accordingly.

Intermedin Ameliorates Atherosclerosis by Increasing Cholesterol Efflux Through the cAMP-PKA Pathway in Macrophage RAW264.7 Cell Line.

BACKGROUND The aim of this study was to explore the role of intermedin and its mechanism in cholesterol efflux of macrophage THP-1 and RAW264.7 cell lines in atherosclerosis (AS). MATERIAL AND METHODS ApoE-/- mice were fed with a high-fat diet, and the concentrations of total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) were measured. The lipidoses of the aortic sinus were analyzed by hematoxylin and eosin staining, and the cAMP level was detected by enzyme-linked immunosorbent assay (ELISA). The expressions of ATP-binding cassette transporter (ABCA1) were tested by real-time PCR and Western blot analysis. RESULTS IMD decreased serum TC and LDL-C, and increased serum HDL-C level in apoE-/- mice and attenuated AS plaque areas. In vitro, IMD increased intracellular cAMP concentration in a dose-dependent manner in THP-1 and RAW264.7 cell lines, which enhanced the expression of ABCA1 and increased cholesterol efflux rate. However, this effect was inhibited by PKAI in the RAW 264.7 cell line but not in the THP-1 cell line. CONCLUSIONS IMD can ameliorate the development of AS in ApoE-/- mice and regulate cholesterol balance in the RAW264.7 cell line through the cAMP-PKA pathway.

Retrospective analysis of individual risk factors for urethrocutaneous fistula after onlay hypospadias repair in pediatric patients.

BACKGROUND: To retrospectively identify the individual risk factors for the urethrocutaneous fistula (UCF) in pediatric patients after hypospadias repair (HR) with onlay island flap urethroplasty. METHODS: A total of 167 patients who underwent primary HR at Nanjing Medical University Affiliated Children Hospital from January 2009 to December 2012 were enrolled. Clinical data including the patient' age at HR, hypospadias type and urethral defect length were documented. RESULTS: Among 167 patients, 12.6% patients (n = 21) developed UCF after HR. Postoperative UCF occurred in 3.9% (3/76) cases at age of 0-2 years, 14.3% (9/63) at 2-4 years, 20.0% (2/10) at 4-6 years and 38.9% (7/18) at 6-12 years. The incidences of UCF were 12.0% (3/25), 11.4% (5/132) and 30.0% (3/10) for distal, middle and proximal types of hypospadias. As to the urethral defect length, the incidences of UCF were 8.2% (5/61) in patients with a length of ≤ 2 cm, 12.8% (9/70) in 2-3 cm, 22.6% (7/31) in 3-4 cm and 0% (0/5) in above 4 cm. Older age at HR was significantly associated with the high incidence of UCF formation (P = 0.004), while the hypospadias type and urethral defect length did not affect it (P = 0.264 and P = 0.312, respectively). CONCLUSIONS: The patient' age at HR was a risk factor for the UCF formation after HR, and treatment of HR within two years old might be with the least incidence of UCF.