Results of uretero-ureteral anastomosis in pathological duplex kidney.

INTRODUCTION: Duplex renal collecting system or duplex kidney (DK) commonly is associated with uropathy, with upper pole obstruction or lower pole vesicoureteral reflux (VUR). Its management is variable, ranging from therapeutic abstention to total nephrectomy. In case of damage to a single renal pole, uretero-ureteral anastomosis (UUA) is one of the surgical techniques for preserving the pathological pole. It can be performed by laparotomy, laparoscopy, or both. The aims of this study are to report the results of UUA in pathological DK, and compare outcomes depending on the surgical approach. METHODS: This is a retrospective analysis study over 20 years, from April 2002 to July 2022, including all children from 0 to 15 years old who underwent UUA for a DK. Outcome measure included per- and post-operative complications, the occurrence of urinary tract infections and ultrasound measurements during follow-up. RESULTS: Thirty-three children underwent an UUA over 20 years. The median age at diagnosis was 25 days (range: 1 day-12 years). The median age at surgery was 13 months (range: 2 months - 13 years). The sex ratio was 0.22. Prenatal diagnosis was made in 87.9 % of cases (n = 29). The left kidney was affected in 72.7 % of cases. Twenty-seven children (81.8 %) had an ectopic ureteral opening of the upper pole ureter; four children (12.1 %) had ureterocele of the upper pole and 2 children (6.1 %) had vesicoureteral reflux of the inferior pole. UUA was performed by inguinal approach (laparotomy) in 17 children (51.5 %), by laparoscopy in 9 cases (27.3 %), and by laparoscopy combined with laparotomy in 7 cases (21.2 %). The complication rate was 12.1 % (n = 4), including recurrent pyelonephritis with superior polar hydronephrosis (n = 2); iatrogenic injury of the lower pole ureter (n = 1) and a urinoma (n = 1), that all required surgical management with a polar nephrectomy. Between each surgical approach, there were no significant differences in operative time, hospital stay, complications. CONCLUSION: UUA is an effective therapeutic option in duplex kidneys as it allows the preservation of the pathological pole with low complication rates, regardless of the surgical approach.

The National Pediatric Surgery Simulation Program in France: A tool to develop resident training in pediatric surgery.

BACKGROUND/PURPOSE: To implement resident curriculum in France based on theoretical teaching and bed side training, the national council known as the "Collège Hospitalier et Universitaire de Chirurgie Pédiatrique" examined the relevance and feasibility of systematically introducing simulation program in the pediatric surgery resident training. MATERIAL AND METHODS: A national simulation training program was developed and took place in a 2-day session organized in 7 simulation centers in France. The program included technical (laparoscopic/suturing technique on low-fidelity models) and nontechnical (6 scenarios for standardized consultation, and a team work scenario based on errors prevention in the operative room) skills. Evaluation of the program (Likert scale from 1 (bad) to 5 (excellent) and notation on 20 points) concerned trainees and trainers. RESULTS: 40 residents (95% of all pediatric surgery French residents) attended with a ratio of trainees/trainer of ½. The training objectives earned a score of 4.46/5. The pedagogical value of the seminar scored 4.7/5, teaching quality 17.95/20, and the overall seminar score was 17.35/20. CONCLUSION: This program, unique nationally, was assessed very favorably by the participating residents and by the involved trainers. To our knowledge, it represents the first mandatory national simulation training program included within a surgical training model. LEVEL OF EVIDENCE: Level IV.

Evaluation of the Bladder Stimulation Technique to Collect Midstream Urine in Infants in a Pediatric Emergency Department.

OBJECTIVE: Midstream clean-catch urine is an accepted method to diagnose urinary tract infection but is impracticable in infants before potty training. We tested the bladder stimulation technique to obtain a clean-catch urine sample in infants. MATERIALS AND METHODS: We included 142 infants under walking age who required a urine sample in a cross-sectional study carried out during a 3-months period, from September to November 2014, in the emergency department of the University Children's Hospital of Nice (France). A technique based on bladder stimulation and lumbar stimulation maneuvers, with at least two attempts, was tested by four trained physicians. The success rate and time to obtain urine sample within 3 minutes were evaluated. Discomfort (EVENDOL score ≥4/15) was measured. We estimated the risk factors in the failure of the technique. Chi-square test or Fisher's exact test were used to compare frequencies. T-test and Wilcoxon test were used to compare quantitative data according to the normality of the distribution. Risk factors for failure of the technique were evaluated using a multivariate logistic regression model. RESULTS: We obtained midstream clean-catch urine in 55.6% of infants with a median time of 52.0 s (10.0; 110.0). The success rate decreased with age from 88.9% (newborn) to 28.6% (>1 y) (p = 0.0001) and with weight, from 85.7% (<4 kg) to 28.6% (>10 kg) (p = 0.0004). The success rate was 60.8% for infants without discomfort (p<0.0001). Heavy weight and discomfort were associated with failure, with adjusted ORs of 1.47 [1.04-2.31] and 6.65 [2.85-15.54], respectively. CONCLUSION: Bladder stimulation seems to be efficient in obtaining midstream urine with a moderate success rate in our study sample. This could be an alternative technique for infants before potty training but further randomized multicenter studies are needed to validate this procedure.