A novel therapy for idiopathic urethritis in children: Local steroid injection.

Idiopathic urethritis (IU) is difficult to manage and there is no standarized therapy. The technique of local steroid injection (LSI) for the treatment of IU in children and the results of the patients undergoing LSI from 2020 to 2021 in a single center are presented. Seven patients with IU underwent LSI. An internal urethrotomy was also performed in two patients with stricture. Complete resolution of symptoms and signs occurred in six patients. The remaining patient did not achieve total remission but did substantially improve symptoms. LSI seems to be an effective alternative for treatment of IU in children.

Long-term outcome of randomized clinical trial between polyacrylate-polyalcohol copolymer (PPC) and dextranomer-hyaluronic acid copolymer (Dx/HA) as bulking agents for endoscopic treatment of primary vesicoureteral reflux (VUR).

OBJECTIVE: The aim of our study is to compare long-term outcome of endoscopic treatment of VUR using PPC or Dx/HA. PATIENTS AND METHODS: From October 2014 to April 2017 patients with VUR grades from 3 to 5 that needed endoscopic treatment were eligible for this RCT. Patients were randomized in two groups: PPC and Dx/HA. A VCUG was performed at 6 months; if VUR > 3 was still present a second ET was performed. We included for this long-term follow-up study those patients that were successfully treated at short-term follow-up. At 36 months postoperative VCUG was performed to assess outcome. Success was considered if postoperative VUR grade was 0 at 36 months, and there was no ureteral obstruction. RESULTS: In the previous study, 60/73 ureters were successfully treated in 36/44 patients, and then we have analyzed 60 ureters in 36 patients. Three patients were lost in long-term follow-up, and then we analyzed 57 ureters in 33 patients divided. PPC group 18 patients (28 ureters); and Dx/HA group 15 patients (29 ureters). After 3 years of follow-up the VCUG showed a success rate of 26/28 of RU in PPC and 26/29 of DX/HA. Two RU in PPC group had ureteral obstruction, and then the successful rate for PPC group dropped to 24/28. The overall successful rate at long-term was 72.7% of the RU in PPC group and 70.3% in Dx/HA group. CONCLUSION: PPC and Dx/HA has similar long-term outcome in VUR resolution, but ureteral obstruction could be present at long-term follow-up in PPC group.

Is Being Overweight a Risk Factor for Torsion of the Appendix Testis in Children?: A Paired Case-Control Study.

OBJECTIVE: This study aimed to determine whether being overweight during childhood is a risk factor for torsion of the appendix testis (TAT). METHODS: We conducted a paired case-control study with all boys surgically treated for TAT, paired by age and sex with patients who were seen in the emergency department for a reason other than acute scrotum. Age and weight were registered, and weight percentile (WP) by age was calculated and compared between groups. Weight percentile was classified into 4 groups (<25, 25-50, 50-75, >75), and a conditional logistic regression analysis was performed to establish the risk of TAT related to the WP. RESULTS: A total of 980 patients were diagnosed as having TAT in our institution, of which 118 patients (12%) were surgically treated and randomly paired with 118 controls. Mean age was the same in both groups (11.2 years, P = 0.908). Patients with TAT had a higher median of WP (79; interquartile range, 49-94) than the control group (49; interquartile range, 20-79; P < 0.0001). For each WP point increase, risk of TAT raised by 2.2% (odds ratio [OR], 1.022; 95% confidence interval [CI], 1.011-1.032; P < 0.001). Weight percentile >75 increased the risk of TAT: 6-fold compared with WP <25 (OR, 5.9; 95% CI, 2.5-14; P < 0.001), 4-fold compared with WP of 25 to 50 (OR, 4.3; 95% CI, 1.8-10.5; P = 0.001), and 3-fold compared with WP of 50 to 75 (OR, 3.3; 95% CI, 1.5-7.6; P = 0.004). CONCLUSIONS: Overweight increases the risk of being operated on because of TAT. Because obesity is a rising problem, a greater incidence of TAT remains to be proved.

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.

Expression of Protein SOX9 in Biliary Atresia.

OBJECTIVES: Biliary atresia (BA) is still an enigmatic disease. Deeper knowledge of its pathophysiology could help develop better treatments. SOX9 regulates bile duct development, liver regeneration and fibrosis; therefore, it could be determinant in characterizing BA liver damage. Aim: To study if there is a SOX9 expression pattern in liver biopsies from BA patients. METHODS: Liver biopsies from BA patients (group BA), from age-matched infants without primary hepatic disease (group Control), and from patients with other liver conditions (group OLC) were compared. Expression of SOX9 was checked for: amount, intensity of immunoreaction, localization within ductular structures, perifibrotic epithelial cells, and lobular cells. The scores were added to create a scale from 0 to 11 that allowed group comparison. SOX9 Scale and liver survival were also looked for a correlation. RESULTS: All BA cases had a score >4, while all controls scored <4. OLC livers scored 1 to 8 (3.5 ±â€Š2.0) (P < 0.001 between all groups). A cut-off at 4 had 100% sensitivity and 88.24% specificity to differentiate BA from Controls and from OLC (area under receiver operating characteristic curve: 0.9989 (95% confidence interval: 0.9964-1.000). Strong expression of SOX9 was observed mainly in the nuclei of proliferated ductules of portal spaces and fibrotic bridges. SOX9 Scale score could not be related to liver survival in this study. CONCLUSION: In BA livers, SOX9 is mainly expressed in reactive ductular epithelium, following a pattern significantly different from that seen in non-BA patients; thus, SOX9 Scale may have a role in the diagnosis of BA.

Distinguishing outcomes of neonatal intestinal volvulus: Review of our experience over the last 20 years.

AIM: There are two types of intestinal volvulus: midgut (MGV) and segmental (SV). Patients with different types of intestinal volvulus are often included in the same case series, which may affect the perception of how severe "intestinal volvuli" are. We aimed to compare both types of intestinal volvulus. METHODS: This is a retrospective observational study including all patients with MGV and SV up to 28 days of life admitted to a tertiary hospital in Spain over a 20-year-period (1999-2019). A comparison between groups and a logistic regression model for mortality were done. RESULTS: We identified 32 patients: 23 MGV and 9 SV. Malrotation was exclusive of MGV. Prenatal diagnosis, cystic fibrosis, and intestinal resection were significantly more frequent in SV. Surgery was performed at a significantly lower age in SV. The mortality observed in acute MGV with intestinal compromise (41.7%) is four times higher than the mortality of SV (11.1%). The overall mortality of all MGV patients (21.7%) is almost twice that of SV. Mortality was best predicted by the presence of hemodynamic instability (OR 27.5 95% CI 2.50-302.17; p = 0.007). CONCLUSION: SV and MGV have a different clinical presentation. Hemodynamic instability is the major risk factor for death.

Cuerpo extraño intravesical / Intravesical foreign body

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Imposibilidad para el sondaje vesical: siringocele de Cowper / Impossibility for bladder catheterization: Cowper's syringocele

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Comparison between mini-laparoscopy, conventional laparoscopy and open approach for ureteropelvic junction obstruction treatment in children.

INTRODUCTION: The aim of the study was to compare 3 mm mini-laparoscopy (mini LP), standard 5 mm laparoscopy (LP) and open surgery for pediatric pyeloplasty in a single center. METHODS: Patients who underwent pyeloplasty from 1997 to 2017 at Hospital Sant Joan de Déu were prospectively collected. Demographic data, clinical, surgical and radiological variables were assessed. A multivariate logistic regression analysis was performed in order to identify risks for surgical complications, urinary leak and need for redo-surgery. RESULTS: 340 pyeloplasties were performed in this period: 197 open, 30 LP and 113 mini LP. Independent risk factors for surgical complications in a multivariate logistic regression model were: LP (vs mini LP, OR = 3.95; 95% CI: 1.13-13.8), higher differential renal function (each point more increases the risk 6%; 95% CI: 1-11%), older children (every year increases the risk 1.11 times; 95% CI: 1.002-1.225). Open surgery, pelvis diameter or the use of different stents were not risk factors. This model had an 80% PPV and a 92% NPV. LP (OR = 4.65; 95% CI: 1.08-19.96) and longer surgical time (OR = 1.014; 95% CI: 1.003-1.025) were independent risk factors for urinary leak. Higher pelvis diameter (OR = 0.93; 95% CI: 0.87-0.99) and the use of external stents were independent protective risk factors for urinary leak (OR = 0.09; 95% CI: 0.01-0.72). We have not found independent risk factors for redo-surgery in a multivariate logistic regression model. CONCLUSION: mini LP can be safely and effectively used to perform pyeloplasty in pediatric patients of all ages.

Incidence and risk factors for calcification after dextranomer/hyaluronic acid (Dx/HA) copolymer injection for vesicoureteral reflux.

INTRODUCTION: Since the first case of dextranomer/hyaluronic acid (Dx/HA) implant calcification in 2008, concern about the long-term sequelae of Dx/HA injection has been growing. According to previous reports, the incidence of Dx/HA calcification 4 years after injection would be around 2%. AIM: The primary aim was to estimate the incidence of Dx/HA implant calcification after endoscopic treatment of vesicoureteral reflux in pediatric patients. Secondary objectives were to establish risk factors and to perform a survival analysis after Dx/HA injection. STUDY DESIGN: Patients undergoing Dx/HA endoscopic injection from 2007 to 2014 were prospectively registered. The database included clinical, surgical and radiological outcomes. Patients that showed Dx/HA implant calcification during follow-up were compared to those who did not. Univariable and survival statistical analyses were performed. RESULTS: 30 implants calcified over 355 ureters endoscopically treated. Age at first treatment was lower in patients with implant calcification (2.4 ± 1.3 years vs 3.6 ± 2.5 years; p < 0.005). The risk of implant calcification was 8.45% (95% CI: 5.96-11.85%). Median follow-up was 7.6 years (IQR: 5.2-9.5). The incidence rate was 12.06 cases per 1000 ureters-year. The period of highest hazard of implant calcification was between 3 and 5 years after injection. The only risk factor related to implant calcification was the age at first injection: relative risk of implant calcification was 4.4 (95% CI: 1.6 to 12.4; p = 0.002) for patients first treated before the age of 3.5 years. DISCUSSION: The risk and the incidence rate of Dx/HA implant calcification were higher than previous data. The period of highest hazard and detection of implant calcification were consistent with previous reports. Patients first treated before the age of 3.5 had shorter survival time without implant calcification. These are the first data about risk factors and survival function of Dx/HA implant calcification. However, our conclusions about the clinical significance of Dx/HA implant calcification were limited because the patients with implant calcification were asymptomatic. Further studies with larger sample and longer follow-up should confirm the clinical significance and life-long tendency of Dx/HA implant calcification. CONCLUSIONS: The risk and the incidence rate of Dx/HA implant calcification were higher than expected. The hazard of calcification was higher between 3 and 5 years after injection. The risk was especially higher in patients treated before the age of 3.5. Caution should be taken not to confuse implant calcifications with ureteric stones. A 5-year follow-up would set a better understanding of the actual incidence and clinical significance of implant calcification.

Porcine dermal patches as a risk factor for recurrence after congenital diaphragmatic hernia repair.

PURPOSE: Recurrence of congenital diaphragmatic hernia (CDH) is a treatment-related morbidity which can be preventable. There is no consensus about the ideal material for diaphragmatic substitution. The aim of our study is to identify if the use of porcine dermis patches increases the risk of CDH recurrence. METHODS: Retrospective review of medical records of CDH patients treated between 2013 and 2017 in our center was carried out. Demographic, clinical and surgical variables were collected. Regression analysis was performed to identify which factors increase the risk of recurrence. RESULTS: 50 patients entered the study. 94% of the patients had a left CDH, mean observed/expected lung-to-head ratio was 46%. 17 patients underwent a primary closure, the rest a patch closure: 25 Gore-Tex® and 8 porcine dermis patches were used. Seven patients presented recurrence (14%). Median follow-up time was 3.5 years (1.2-6.2). Univariate analysis revealed that the use of a porcine dermis patch (75%) increased the risk of recurrence compared with Gore-Tex® patch (4%) and primary closure (0%) p < 0.001 (HR 58.7; IC 95%: 6.9-501.2; p < 0.001). CONCLUSION: The main risk factor for CDH recurrence is the use of a porcine dermis patch. We do not recommend the use of these patches for CDH repair.

Value of supranormal function on 99m Tc-mercaptoacetyltriglycine renal scan in paediatric patients with obstructive hydronephrosis.

OBJECTIVES: To study related factors and clinical significance of supranormal function in paediatric patients with pelvi-ureteric junction obstruction, and to predict which factors cause renal function overestimation. PATIENTS AND METHODS: Patients who underwent pyeloplasty from 2012 to 2017 were prospectively collected. Variables were compared between patients with and without supranormal function on 99m Tc-mercaptoacetyltriglycine renal scan (supranormal defined as differential renal function [DRF] ≥55%). Univariate, multivariate logistic and linear regressions analyses were performed. RESULTS: Of 100 patients, 18 were excluded because of comorbidities. Nine patients (11.5%) showed preoperative supranormal function. The preoperative anteroposterior pelvic diameter (APD; 24 mm vs 35 mm, P = 0.026) and the ratio between preoperative pelvic and kidney volumes (0.2 vs 0.6, P = 0.003) were higher in supranormal kidneys. For each unit increase in the preoperative ratio between pelvic and kidney volumes, the risk of supranormal function rose 3.23-times (95% confidence interval [CI] 1.051-9.955). A preoperative APD ≥30 mm was a reliable predictor of supranormal function (area under the curve 0.804, 95% CI 0.707-0.902), with 88.9% sensitivity. Patients with either preoperative supranormal function or preoperative APD ≥30 mm had a greater reduction in renal function after pyeloplasty. CONCLUSION: Supranormal function is related to large hydronephrosis where geometrical features are modified. A preoperative APD ≥30 mm is a reliable predictive factor of supranormal function. Preoperative renal function is overestimated either in supranormal patients or severe hydronephrotic kidneys. DRF should be interpreted with caution in kidneys with large hydronephrosis with or without supranormal function. Surgical indication should not entirely rely upon DRF.

Bilateral hydrosalpinx in patients with Hirschsprung's disease.

PURPOSE: Hirschsprung's disease (HD) is uncommon in females. There are very few reports on the patients' obstetric and gynecological outcome. Hydrosalpinx causes pain and infertility. It is rare in nonsexually active teenagers. It may be because of an intrinsic disease of the fallopian tubes or secondary to surgery. AIM: to describe the relationship between hydrosalpinx and HD or its surgical approach; to report the impact of bilateral hydrosalpinx on fertility in HD. METHODS: The records of all females with HD since 1980 were reviewed. Only patients who reached menarche were included. Prevalence of hydrosalpinx and hydrosalpinx-free survival were compared after abdominoperineal (A) or transanal (T) surgery. Treatment for hydrosalpinx was reviewed. RESULTS: Seventeen out of 27 patients had reached menarche (Group A: 13 patients; Group T: 4 patients). Five patients in group A and none in group T presented bilateral hydrosalpinx (p=0.261). There were no statistical differences in hydrosalpinx-free survival between groups (p=0.344). Hydrosalpinx treatment: two bilateral and one unilateral salpingectomy, one pyosalpinx evacuation and one untreated. Three patients had conception desire: one has children; two are on IVF program. CONCLUSION: An association between hydrosalpinx and HD was observed. The development of hydrosalpinx was not associated with surgical approach in our study. Females with HD should have a gynecological follow-up for the development of hydrosalpinx, which can impair fertility. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Effects of Platelet-Rich Plasma (PRP) on a Model of Renal Ischemia-Reperfusion in Rats.

Renal ischemia-reperfusion injury is a major cause of acute renal failure, causing renal cell death, a permanent decrease of renal blood flow, organ dysfunction and chronic kidney disease. Platelet-rich plasma (PRP) is an autologous product rich in growth factors, and therefore able to promote tissue regeneration and angiogenesis. This product has proven its efficacy in multiple studies, but has not yet been tested on kidney tissue. The aim of this work is to evaluate whether the application of PRP to rat kidneys undergoing ischemia-reperfusion reduces mid-term kidney damage. A total of 30 monorrenal Sprague-Dawley male rats underwent renal ischemia-reperfusion for 45 minutes. During ischemia, PRP (PRP Group, n = 15) or saline solution (SALINE Group, n = 15) was administered by subcapsular renal injection. Control kidneys were the contralateral organs removed immediately before the start of ischemia in the remaining kidneys. Survival, body weight, renal blood flow on Doppler ultrasound, kidney weight, kidney volume, blood biochemistry and histopathology were determined for all subjects and kidneys, as applicable. Correlations between these variables were searched for. The PRP Group showed significantly worse kidney blood flow (p = 0.045) and more histopathological damage (p<0.0001). Correlations were found between body weight, kidney volume, kidney weight, renal blood flow, histology, and serum levels of creatinine and urea. Our study provides the first evidence that treatment with PRP results in the deterioration of the kidney's response to ischemia-reperfusion injury.