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El escritor búlgaro Tzvetan Todorov publicó en 1982, La conquista de América, la cuestión del otro, lo que despertó gran interés y muchos comentarios. Se sostiene que América le dio al mundo el concepto del «otro» y que quien supo descubrirlo a profundidad fue Vasco de Quiroga. Todorov, al analizar la actuación de Quiroga, afirma que en relación al otro fue un conquistador que obligó a los naturales a asimilar un ideal o proyecto no personal sino de otros, en especial de Tomás Moro. Al hacer uso de la misma metodología de Todorov, se intenta probar que Tata Vasco de Quiroga no sólo fue el descubridor del otro, sino que se hizo otro y contribuyó notablemente para lograr un mestizaje originario muy característico de la identidad mexicana. Abstract The Bulgarian writer Tzvetan Todorov published in 1982 The Conquest of America, the Question of the Other, which aroused great interest and many comments. We maintain that America gave the world the concept of the "other" and that Vasco de Quiroga was the one who knew how to discover it in depth. Todorov, in analyzing Quiroga's actions, affirms that in relation to the other, he was a conqueror who forced the natives to assimilate an ideal or project not of himself but of others, especially Thomas More. Making use of the same methodology of Todorov, we try to prove that Tata Vasco de Quiroga was not only the discoverer of the other, but that he became another and contributed notably to achieve an original mestizaje very characteristic of the Mexican identity. Keywords: Todorov, Vasco de Quiroga, conquest, discovery, the other, utopia, Thomas More.

Purpose: To review the current status of bladder neck procedures for incontinence in pediatric patients, focusing on the increasing role of robotic-assisted laparoscopic surgical techniques.Methods: A comprehensive review of the literature on open and robotic-assisted bladder neck procedures was conducted, with a focus on articles published in the last 20 years. This data was subsequently compared with published results from robotic-assisted bladder neck reconstruction series completed at our institution.Results: The principal bladder neck procedures for incontinence in pediatric patients include: Artificial Urinary Sphincter, Bladder Neck Sling, Bladder Neck Closure and Bladder Neck Reconstruction. Continence rates range from 60 to 100% with a lack of expert consensus on the preferred procedure (or combination of procedures). Robotic-assisted approaches are associated with longer operative times, especially early in the surgical experience, but demonstrate equivalent continence rates with potential benefits including: low intraoperative blood loss, improved cosmesis, and decreased intra-abdominal adhesion formation.Conclusions: Robotic-assisted procedures of the bladder neck are safe, feasible, follow the same steps and principles as those of open surgery and produce equivalent continence rates. Robotic-assisted techniques can be adapted to a variety of bladder neck procedures and safely expanded to selected patients with previous open abdominal surgery.

Presentamos el caso clínico de un paciente varón de 6 años de edad con antecedente de caída desde su propia altura un mes antes de su valoración en consulta, en donde se identifica una tumoración pulsátil en región hipotenar de mano derecha, no dolorosa y no fija a planos profundos. El ultrasonido doppler informa de una tumoración con pared definida, heterogénea, con flujo sanguíneo a través de la misma. En base a los antecedentes y a los resultados del ultrasonido se decide intervenir quirúrgicamente para evitar posibles complicaciones, encontrando un aneurisma de la arteria cubital de 3 x 3 cm de diámetro, no trombosado, que resecamos, practicando reconstrucción mediante injerto venoso término-terminal. El paciente evolucionó sin complicaciones.

Background and Purpose Horseshoe kidney is an uncommon renal anomaly often associated with ureteropelvic junction (UPJ) obstruction. Advanced minimally invasive surgical (MIS) reconstructive techniques including laparoscopic and robotic surgery are now being utilized in this population. However, fewer than 30 cases of MIS UPJ reconstruction in horseshoe kidneys have been reported. We herein report our experience with these techniques in the largest series to date. Materials and Methods We performed a retrospective chart review of nine patients with UPJ obstruction in horseshoe kidneys who underwent MIS repair at our institution between March 2000 and January 2012. Four underwent laparoscopic, two robotic, and one laparoendoscopic single-site (LESS) dismembered pyeloplasty. An additional two pediatric patients underwent robotic Hellstrom repair. Perioperative outcomes and treatment success were evaluated. Results Median patient age was 18 years (range 2.5-62 years). Median operative time was 136 minutes (range 109-230 min.) and there were no perioperative complications. After a median follow-up of 11 months, clinical (symptomatic) success was 100%, while radiographic success based on MAG-3 renogram was 78%. The two failures were defined by prolonged t1/2 drainage, but neither patient has required salvage therapy as they remain asymptomatic with stable differential renal function. Conclusions MIS repair of UPJ obstruction in horseshoe kidneys is feasible and safe. Although excellent short-term clinical success is achieved, radiographic success may be lower than MIS pyeloplasty in heterotopic kidneys, possibly due to inherent differences in anatomy. Larger studies are needed to evaluate MIS pyeloplasty in this population.

PURPOSE: To evaluate the efficacy of needle biopsy for diagnosing Wilmstumor (WT) before chemotherapy. MATERIALS AND METHODS:We reviewed our institutional experience with Tru-Cut biopsy of pediatric renal masses in patients who subsequently underwent nephrectomy. We compared biopsy pathology with nephrectomy specimens to determine if biopsy accurately predicted final pathology. RESULTS: Seven children underwent Tru-Cut renal mass biopsy followed by surgical resection. In 4 patients, the final biopsy pathology was definitively read as WT and in 3 subjects, the pathology was read as WT versus hyperplastic nephrogenic rest. In all 7 patients, the nephrectomy pathology confirmed a diagnosis of WT. There were no complications after biopsy, and no patients have had local or regional recurrence.CONCLUSION: In our experience, pre-therapy Tru-Cut biopsy safely provides an adequate specimen for pathologic review in diagnosing WT.

Los lipomas suponen el 16 % de los tumores de tejidos blandos que se originan en la mano. Tienen una presentación clínica particular debido a la complejidad anatomofuncional de la zona. Analizamos 14 pacientes con diagnóstico clínico de lipoma en mano, 64.3 % de ellos de sexo femenino, con edad promedio de 44.1 años. La localización fue: en la vaina flexora digital 33.3 %, medio palmar (musculatura tenar principalmente) 40 %, muñeca dorsal (incluido interóseo) 20 % y antebraquial 6.7 %. La disminución de la función de la mano y/o de la muñeca fue la principal sintomatología de los pacientes (66.7 %). Las alteraciones funcionales producidas incluyeron: dedo en gatillo, alteraciones de la flexión y de la pinza, seguidos de dolor en 26.7 % y alteraciones de la sensibilidad en 26.7 %. Síndrome de túnel del carpo en 20 %. En 26.7 % la queja fue cosmética. La escisión resolvió la sintomatología en todos los casos. El seguimiento promedio fue de 15.8 meses, sin ningún caso de recurrencia y solamente se presentó una complicación menor. El estudio por imagen solo fue necesario en 1 caso de esta serie; la certeza mediante diagnóstico clínico fue del 93 %.Lipomas account for the 16 % of all the soft tissue hand tumors. Their clinical presentation is particular, due to the anatomical and functional complexity of the hand. We analyze 14 patients with the clinical diagnosis of hand lipoma, 64.3 % female, with medium age 44.1 years old. The localization was: digital flexor sheath 33.3 %, midpalmar (thenar muscles mainly) 40 %, dorsal wrist (including interosseus muscle) 20 % and antebrachial 6.7 %. The decrease in hand or wrist function was the main symptom (66.7 %). The functional impairments include: trigger finger, flexion and grip impairment, followed by pain, sensitivity alterations and cosmesis in 26.7 %. The carpal tunnel syndrome presented in 20 %. The surgical excision solved the symptoms in all cases. The mean follow-up was 15.8 months. None recurrence was observed and only 1 minor complication presented. We used an image study to make the diagnosis in 1 case, having a clinical diagnosis accuracy of 93 %.

En la enfermedad de De Quervain, la cirugía es la indicación estándar como procedimiento terapéutico y consiste en la liberación de los tendones abductor pollicis longus (APL) y extensor pollicis brevis (EPB) del primer compartimento de la mano. Está documentada la presencia de un septum dentro del compartimento entre los tendones del extensor corto y del abductor largo del pulgar. La importancia que tiene describir y hallar este subcompartimento radica en que la falta de conocimiento del mismo provoca el fallo en su liberación completa en los pacientes con enfermedad de De Quervain, por lo que los síntomas pueden persistir en el postoperatorio inmediato y tardío. El objetivo de este trabajo es determinar la presencia de un subcompartimento en el primer compartimento extensor de la mano en la población mexicana. Realizamos en el Hospital General Dr. Manuel Gea González de México DF un total de 32 liberaciones del primer compartimento extensor en 30 pacientes, todas secundarias a enfermedad de De Quervain con seguimiento promedio postoperatorio de 7,5 meses. La presencia de este subcompartimento se encontró en 21 pacientes (65,6 % de los casos), conteniendo en el 100 % el tendón EPB. El APL presentó 3 fascículos en el 31,25 % de casos, 2 fascículos en el 53,12 % y 1 fascículo en el 15,6 %. El EPB presentó 2 fascículos en el 6,25 % de los casos y 1 fascículo en el 93,75 % del total. En el seguimiento, ningún paciente presentó recidiva de la enfermedad. Proponemos la falta de identificación de un subcompartimento en el primer compartimento extensor de la mano como la principal causa de recidiva de enfermedad de De Quervain en nuestro medio.Surgical release of the first compartment of the hand containing abductor pollicis longus tendon (APL) and extensor pollicis brevis (EPB) is the gold standard treatment for De Quervain's disease. It´s well known that a septum commonly exists between these two tendons. The importance of this septum has been addressed in current literature. Knowledge of this anatomy and its prevalence is important as failure to address first compartment as two subcompartments could lead to treatment failure and persistent symptoms. The aim of this study is to determine the prevalence of subcompartments in the first hand extensor compartment in mexicans. We performed 32 releases of the first extensor compartment in 30 patients at the Hospital General Dr. Manuel Gez González in México DF, all of them with De Quervain disease. Median follow up was 7,5 months. We found and released the described subcompartment in 21 patients (65,6 %), with EPB in the subcompartment in 100 % of the cases. The APL presented 3 bundles in 31,25 %, 2 bundles in 53,12 % and 1 bundle in 15,6 %. The EPB presented 2 bundles in 6,25 % and 1 bundle in 93,75 %. No patients experienced recurrence of De Quervain disease symptoms. We hypothesize that the rate of recurrence may be due to failure in identifying and releasing the subcompartments.

Los tumores glómicos fueron descritos en 1924; están formados por elementos vasculares, musculares y nerviosos por debajo de la uña y pueden afectar la regulación de la irrigación de la punta del dedo con el frío. Constituyen el 1-2% de los tumores de la mano. Aunque no se trata de una patología frecuente, el cirujano plástico debe estar familiarizado con ella para un diagnóstico y tratamiento adecuados. Presentamos la experiencia en tumores glómicos de la clínica de mano del Hospital Dr. Manuel Gea González; reportamos los hallazgos clínicos y el manejo en cada caso mediante resección quirúrgica y enfatizamos sobre la importancia de una exposición adecuada durante la cirugía para resecar el tumor completamente y evitar recidivas.Glomus tumors were described in 1924; they involve vascular, muscle and nerve elements under the nail and can affect vascular supply of the finger tip. It represents 1-2% of hand tumors. Although it is not a common pathology, plastic surgeons must be familiarized to be able to diagnose and treat it properly. We present the experience of glomus tumor in our hand clinic at Hospital Dr. Manuel Gea González, reporting the clinical presentation and the surgical excision. We emphasize the importance of a good exposition of the tumor in the surgery for a complete excision and to avoid recurrences.

An index was created for the spatial classification of oyster cultivation areas in terms of their potential productivity in Falsa Bay, San Quintín (Baja California, Mexico). The index included two main variables crucial for oyster development: food availability and depth. Food availability was based on the final distribution of particulate organic material; it is a passive variable that is transported by tidal currents. A balance was obtained between the volume incorporated into the bay by tidal inflow and its consumption by the organisms distributed in the cultivated areas, which are characterized by the percentage of cultivated areas within the bay. The distribution area of depth was obtained from a five-interval classification scale that allowed the identification of the highest and least exposure of the cultivation area to the proposed food availability. Both criteria were combined into one value in order to divide the bay region into zones in relative terms and determine which are the best suited for oyster cultivation. Given the characteristics of the area and production volume, food availability did not appear to be a limiting factor, and culture depth was the main factor controlling the zonal quality. A comparison of the index values and cultivated oyster growth rates showed that the higher index values corresponded to faster growth rates and vice versa.

The global prevalence of pediatric nephrolithiasis continues to rise amidst increased sodium and animal protein intake. Plant-based meat alternatives (PBMAs) have recently gained popularity due to health benefits, environmental sustainability, and increased retail availability. PBMAs have the potential to reduce the adverse metabolic impact of animal protein on kidney stone formation. We analyzed PBMAs targeted to children to characterize potential lithogenic risk vs animal protein. We performed a dietary assessment using a sample of PBMAs marketed to or commonly consumed by children and commercially available at national retailers. Nutrient profiles for PBMAs were compiled from US Department of Agriculture databases and compared to animal protein sources using standardized serving sizes. We also analyzed nutrient profiles for plant-based infant formulas against typical dairy protein-based formulas. Primary protein sources were identified using verified ingredient lists. Oxalate content was extrapolated from dietary data sources. A total of 41 PBMAs were analyzed: chicken (N = 18), hot dogs (N = 3), meatballs (N = 5), fish (N = 10), and infant formula (N = 5). Most products (76%) contained a high-oxalate ingredient as the primary protein source (soy, wheat, or almond). Average oxalate content per serving was substantially higher in these products (soy 11.6 mg, wheat 3.8 mg, almond 10.2 mg) vs animal protein (negligible oxalate). PBMAs containing pea protein (24%) had lower average oxalate (0.11 mg). Most PBMAs averaged up to six times more calcium and three times more sodium per serving compared to their respective animal proteins. Protein content was similar for most categories. Three-quarters of the examined plant-based meat products for children and infants contain high-oxalate protein sources. Coupled with higher per-serving sodium and calcium amounts, our findings raise questions about possible lithogenic risk in some PBMAs, and further studies are needed to assess the relationship between PBMAs and nephrolithiasis. [ABSTRACT FROM AUTHOR]

En la enfermedad de De Quervain, la cirugía es la indicación estándar como procedimiento terapéutico y consiste en la liberación de los tendones abductor pollicis longus (APL) y extensor pollicis brevis (EPB) del primer compartimento de la mano. Está documentada la presencia de un septum dentro del compartimento entre los tendones del extensor corto y del abductor largo del pulgar. La importancia que tiene describir y hallar este subcompartimento radica en que la falta de conocimiento del mismo provoca el fallo en su liberación completa en los pacientes con enfermedad de De Quervain, por lo que los síntomas pueden persistir en el postoperatorio inmediato y tardío. El objetivo de este trabajo es determinar la presencia de un subcompartimento en el primer compartimento extensor de la mano en la población mexicana. Realizamos en el Hospital General Dr. Manuel Gea González de México DF un total de 32 liberaciones del primer compartimento extensor en 30 pacientes, todas secundarias a enfermedad de De Quervain con seguimiento promedio postoperatorio de 7,5 meses. La presencia de este subcompartimento se encontró en 21 pacientes (65,6 % de los casos), conteniendo en el 100 % el tendón EPB. El APL presentó 3 fascículos en el 31,25 % de casos, 2 fascículos en el 53,12 % y 1 fascículo en el 15,6 %. El EPB presentó 2 fascículos en el 6,25 % de los casos y 1 fascículo en el 93,75 % del total. En el seguimiento, ningún paciente presentó recidiva de la enfermedad. Proponemos la falta de identificación de un subcompartimento en el primer compartimento extensor de la mano como la principal causa de recidiva de enfermedad de De Quervain en nuestro medio.

Summary Testicular torsion remains the most frequent cause of testicular ischemia, especially in adolescents and young adults. Timely diagnosis and intervention are keys to saving the affected testicle. This review presents current trends in the diagnosis and treatment of torsion, potential pitfalls and consequent outcomes. Additionally, other salient issues surrounding testicular torsion are also discussed, including: pathogenesis of injury, legal ramifications, fertility outcomes, novel management techniques, and recent advances in diagnostic technology. [ABSTRACT FROM AUTHOR]

In the past two decades, technology has advanced to augment an already minimally-invasive approach in laparoscopic surgery. Robotic-assisted laparoscopic platforms have now evolved to its 4th-generation product: a single-port system, first cleared through the FDA for urologic procedures last year. A single, 2.5 cm incision allows for placement of a port that admits a fully-wristed camera as well as three fully-wristed instruments, all controlled by the surgeon at the console. We sought to document the feasibility of the single-port (SP) robotic platform in the first clinical series of pediatric patients, reporting use of this system for dismembered pyeloplasty and Mitrofanoff. Secondary aims were to report intraoperative details and perioperative outcomes. Seven patients underwent surgery using the da Vinci SP Surgical System (Intuitive Surgical, Sunnyvale, CA). Six patients, two girls and 4 boys, were diagnosed with ureteropelvic junction obstruction and underwent SP robotic-assisted dismembered pyeloplasty while one male patient with neurogenic bladder underwent SP robotic-assisted Mitrofanoff procedure. Patient's ages ranged from 22 months to 14 years. A 2.5-cm incision was made within the Pfannenstiel line in HIdES fashion for the pyeloplasties, while the previous gastrostomy tube site was used for the Mitrofanoff. Through this incision a 25-mm multichannel port was placed. The 12 × 10-mm articulating robotic camera and two 6-mm articulating robotic instruments were utilized. All surgeries were completed successfully through the single port without intraoperative complications, need for separate ports, or conversion. Median operative time was 120 min, and all patients were dismissed in less than 24 h, taking only acetaminophen and ibuprofen for pain control. There was no issue with instrumentation in older patients; however, shorter working distance in the 22-month-old pyeloplasty limited wristing of the instruments. We report the first cases utilizing the SP robotic platform in children. Despite their smaller size and limited workspace, we had no issues with instrument clashing or triangulation in older patients, completing the procedures in a similar timeframe as multiport robotic platforms. Use of the SP platform is not recommended if working distance will be < 10 cm from the end of the port as instrument movement is prohibitive. The HIdES approach of placing the port in the Pfannenstiel line gave additional working distance and kept the incision below the swimsuit line for excellent cosmesis (Figure 1). Further study with additional cases will compare this approach with standard multiport robotics to analyze and compare operative data and outcomes. [ABSTRACT FROM AUTHOR]

Assessment and management of congenital penile curvature (PC) can be variable. Methods for correction of PC usually are dependent on degree of PC which is reliant on how degree is assessed. We sought to assess the confidence and accuracy of measuring PC and hence management using case-based examples. A survey was emailed to members of the Societies for Pediatric Urology. Demographic information, management strategies for PC, and self-reported confidence in measuring PC were assessed. A Likert scale measured self-confidence. Case scenarios were used to assess ability to measure PC and methods of correction. The cases consisted of three computer-generated penis model images with arc-type ventral curvature and one image of lateral curvature in an infant. The response rate was 30% (108/355). The mean confidence score was 3.6 ± 0.8 (3-fairly confident; 4-very confident). In clinic, 89% of urologists used eyeball estimates to assess PC; 5% used both eyeball and goniometer. In the operating room, 71% used eyeball estimates, 8% used goniometer, and 16% used both. If sole decision-maker, urologists recommend surgical correction of PC over observation at median 30° (IQR 21–30°). At a median of 45°, there was a shift in corrective surgical preference from dorsal plication (DP) (IQR 30–54°) to ventral lengthening (IQR 34–60°). Urologists underestimated PC degree for all cases (summary table). For all cases, there was no association between years in practice or confidence level on estimated PC degree. In case 1, only 24% of urologists would correct a mean estimate of 23° PC; those who would correct had a higher mean PC estimate vs those who would not (28° vs 21°, p < 0.001). Case 2 and 4 had similar estimations and correction methods. In case 2, those who chose VL had a higher mean PC estimate vs those who did not (43° vs 37°, p < 0.01), but no estimate difference was seen for DP (p = 0.52). In case 4 with lateral PC, those who chose DP had a higher mean PC estimate vs those who did not (41° vs 33°, p = 0.049). Yet in case 3, there was no difference in PC estimate in urologists who chose VL vs not (57° vs 53°, p = 0.16). A uniform underestimation of PC existed despite self-reported confidence in the ability to measure PC. An increasing willingness to perform surgical correction was demonstrated with a shift towards VL for ventral curvature and less so for lateral curvature as PC worsens. [Display omitted] [ABSTRACT FROM AUTHOR]

Purpose Care of children with spina bifida has significantly advanced in the last half century, resulting in gains in longevity and quality of life for affected children and caregivers. Bladder dysfunction is the norm in patients with spina bifida and may result in infection, renal scarring and chronic kidney disease. However, the optimal urological management for spina bifida related bladder dysfunction is unknown. Materials and Methods In 2012 the Centers for Disease Control and Prevention convened a working group composed of pediatric urologists, nephrologists, epidemiologists, methodologists, community advocates and Centers for Disease Control and Prevention personnel to develop a protocol to optimize urological care of children with spina bifida from the newborn period through age 5 years. Results An iterative quality improvement protocol was selected. In this model participating institutions agree to prospectively treat all newborns with spina bifida using a single consensus based protocol. During the 5-year study period outcomes will be routinely assessed and the protocol adjusted as needed to optimize patient and process outcomes. Primary study outcomes include urinary tract infections, renal scarring, renal function and bladder characteristics. The protocol specifies the timing and use of testing (eg ultrasonography, urodynamics) and interventions (eg intermittent catheterization, prophylactic antibiotics, antimuscarinic medications). Starting in 2014 the Centers for Disease Control and Prevention began funding 9 study sites to implement and evaluate the protocol. Conclusions The Centers for Disease Control and Prevention Urologic and Renal Protocol for the Newborn and Young Child with Spina Bifida began accruing patients in 2015. Assessment in the first 5 years will focus on urinary tract infections, renal function, renal scarring and clinical process improvements. [ABSTRACT FROM AUTHOR]

We sought to evaluate long-term surgical urinary and bowel management in cloacal exstrophy (CE) in a multi-institutional study. We performed a cross-sectional study of people with CE and covered variants managed at five participating institutions. Those with <1 year follow-up or born with variants without hindgut involvement were excluded. Primary outcomes were methods of urinary and bowel management. Urinary management included: voiding via urethra, clean intermittent catheterizations (CIC), incontinent diversion and incontinent in diaper. Bowel management included: intestinal diversion (colostomy/ileostomy) and pull-through (with/without MACE). We evaluated three age groups: children (<10 years), older children (10 to <18) and adults (≥18). We assessed if management varied by age, institution or time (born≤2000 vs. >2000). A total of 160 patients were included (40% male). Median follow-up was 15.2 years (36% children, 22% older children, 43% adults). While 42% of children were incontinent in diapers, 73% of older children and adults managed their bladder with CIC, followed by incontinent urinary diversion (21%) (p < 0.001, Table). CIC typically occurred after augmentation (88%) via a catheterizable channel (89%). Among older children and adults, 86% did not evacuate urine per urethra and 28% of adults had an incontinent urinary diversion. No child or adult voided per urethra. Age-adjusted odds of undergoing incontinent diversion was no different between institutions (p = 0.31) or based on birthyear (p = 0.08). Most patients (79%) had an intestinal diversion, irrespective of age (p = 0.99). Remaining patients had a pull-through, half with a MACE. The probability of undergoing bowel diversion varied significantly between institutions (range: 55–91%, p = 0.001), but not birth year (p = 0.85). We believe this large long-term data presents a sobering but realistic view of outcomes in CE. A limitation is our data does not assess comorbidities or patient-reported outcomes. Rarity of volitional urethral voiding in CE forces the question of whether is a potentially unachievable goal. We advocate thoughtful surgical decision making and thorough counseling about appropriate expectations, distinguishing between volitional voiding and urinary and fecal dryness. In this long-term, multi-institutional study of patients with CE, 94% of older children and adults manage their bladder with incontinent diversion or CIC. Nearly 80% of patients, regardless of age, have an intestinal diversion. Given that no patients were dry and voided via urethra and 86% of older patients do not evacuate urine per urethra, these data bring into question what functional goals are achievable when performing reconstructive surgery for these patients. Summary Table Urinary and bowel management stratified by age. Summary Table Younger children (0–9.9 years old, n = 57) Older children (10.0–17.9 years old, n = 35) Adults (≥18 years old, n = 68) p-value Overall (n = 160) Urinary management Clear intermittent catheterizations (CIC) 18 (32%) 29 (83%) 46 (68%) <0.001 93 (58%) Per channel 16 (89%) 28 (97%) 39 (85%) 83 (89%) Per urethra 2 (11%) 1 (3%) 7 (15%) 10 (11%) Augmentation 12 (67%) 25 (86%) 45 (98%) 82 (88%) Incontinent diversion 15 (26%) 3 (9%) 19 (28%) 37 (23%) Incontinent into diaper 24 (42%) 3 (9%) 2 (3%) 29 (18%) Empties per urethra with Valsalva maneuver 0 (0.0%) 0 (0%) 1 (1%) 1 (0.6%) Overall: empties urine via urethra (CIC, incontinent, Valsalva) 26 (46%) 4 (11%) 10 (15%) <0.001 40 (25%) Bowel management Intestinal diversion 45 (79%) 27 (77%) 54 (79%) 0.99 126 (79%) Pull-through without a MACE 7 (12%) 4 (11%) 7 (10%) 18 (11%) Pull-through with a MACE 5 (9%) 4 (11%) 7 (10%) 16 (10%) [ABSTRACT FROM AUTHOR]

The successful repair of Bladder Exstrophy remains one of the biggest challenges in Pediatric Urology. The primary focus has long been on the achievement of urinary continence. Historically there has been less focus on early penile outcomes. To this end we have incorporated penile perfusion testing using intraoperative laser angiography in to our operative approach. We hypothesize that assessment of penile perfusion at various points in the procedure is a feasible technique that may assist in decision making during the repair of this complex condition. This will reduce the risk of tissue compression and potential loss of penile tissue that has been reported to occur as a complication of the procedure. Consecutive patients presenting with bladder exstrophy were evaluated at four stages of their operation (i.e. following induction of anesthesia, after bladder mobilization, following internal rotation of the pubis and at the end of the procedure) by infusing indocyanine green (ICG) at a dose of 1 mg per 10 kg body weight. Measurements were taken at 80 s post infusion and the medial thigh served as the reference control. Postoperative penile viability was evaluated by visual inspection and palpation three months following the procedure. Eight consecutive patients were included in this study. Perfusion was easy to measure and posed no significant technical difficulties. Penile perfusion increased slightly following bladder dissection. Internal rotation of the hips with apposition of the symphysis pubis resulted in an average 50% reduction in penile blood flow. Patients undergoing CPRE experienced an additional mean 33% drop in blood flow. In all eight cases the penis was symmetric and healthy with no sign of tissue loss at three months follow up. This pilot study demonstrates that the measurement of penile perfusion utilizing intraoperative laser angiography is easy to employ and should be considered a reasonable adjunct to tissue assessment in this complex condition. Marked reduction in penile blood flow may occur without any outward clinical signs. Penile perfusion is markedly reduced by apposition of the symphysis pubis and, in the immediate postoperative period, there may be further reduction in penile blood flow with CPRE as opposed to a staged repair. Future correlation with measures of penile viability and function are needed to define the clinical utility of this modality. [Display omitted] [ABSTRACT FROM AUTHOR]

Spinal anesthesia (SA) has been safely utilized in infants. There are limited data regarding the safety and efficacy of SA in pediatric urologic surgery lasting ≥60 min. We outlined the perioperative course for infants undergoing single-injection 0.5% plain bupivacaine SA-only for urologic procedures lasting ≥60 min. To characterize the safety and efficacy of SA for urologic surgery in infants lasting ≥60 min. We reviewed our prospectively maintained database of infants undergoing SA for urologic procedures lasting ≥60 min from May 2018 to March 2021. Patients received preoperative intranasal dexmedetomidine, some received intranasal fentanyl, and all patients received lidocaine cream applied preoperatively over the lumbar spine. Oral sucrose on a pacifier was provided as needed, and the patient's arms were swaddled for the procedure. Success was defined as no conversion to general anesthesia. Time points for start/end of spinal injection, procedure duration, wheels in/out of operating room (OR), and discharge were collected. Of 245 cases conducted with SA during the study period, 76 (31%) infants underwent surgery lasting ≥60 min. Of these, 73 (96%) were successfully completed with SA alone. In the 3 cases converted to general anesthesia, 2 (67%) required mask anesthesia after 96 and 169 min (for the last <10 min of surgery), and one was converted to intubation before start of surgery. Median patient age was 6 (IQR 5–7) months, and median procedure length was 95 (IQR 75–120) minutes. Following initial preoperative intranasal dexmedetomidine ± fentanyl, at least one additional dose of IV sedative was given in 27 (36%) cases at a median time of 90 (IQR 60–120) minutes into surgery. Following closure, patients exited the OR after a median 10 (IQR 8–12) minutes and subsequently discharged after spending a median of 73 (IQR 61–96) minutes in recovery. We describe pediatric urologic surgical cases lasting ≥60 min that employed single-injection intrathecal bupivacaine alone without adjunct intrathecal agents. In this report, SA was safely utilized in infants undergoing urologic procedures lasting at least 60 min, with about 40% of patients receiving additional IV dexmedetomidine and fentanyl. Non-medication measures (swaddling, oral sucrose) were important for maximizing patient comfort. Communication between surgeon and anesthesia as cases progress is key to maintaining adequate anesthesia. A single-injection bupivacaine-only spinal anesthesia approach for urologic surgery lasting over an hour and up to 3 h is safe and effective in infants. Selecting appropriate candidates for SA should be a joint decision between the surgeon and the anesthesiologist. [Display omitted] [ABSTRACT FROM AUTHOR]

Purpose Complex urological reconstruction may be facilitated by the improved magnification and dexterity provided by a robotic approach. Minimally invasive surgery also has the potential advantages of decreased length of stay and improved convalescence. We reviewed perioperative and short-term outcomes between robot-assisted and open bladder neck sling/repair with catheterizable channel in patients with neurogenic bladder. Materials and Methods We performed an institutional review board approved retrospective chart review of all patients who underwent open or robotic bladder neck reconstruction without augmentation cystoplasty for refractory urinary incontinence between 2010 and 2014. Age at surgery, operative time, length of stay, complications within 30 days of surgery and future continence procedures (injection of bladder neck/catheterizable channel, additional bladder neck surgery, botulinum toxin A injection) were compared between the groups. Results A total of 45 patients underwent bladder neck reconstruction (open in 26, robotic in 19) with a mean follow up of 2.8 years. There was no difference in preoperative urodynamics, age at surgery or length of stay (median 4 days in each group, p >0.9). Operative time was significantly longer in the robotic group (8.2 vs 4.5 hours, p <0.001). Three patients (16%) undergoing robotic and 3 (12%) undergoing open surgery had a complication within 30 days (p >0.9). Of patients undergoing open repair 14 (56%) underwent 23 subsequent surgeries for incontinence. By comparison, 8 patients undergoing robotic repair (42%) underwent 12 additional procedures (p = 0.5). Conclusions Although a robotic approach may take longer to perform, it does not result in increased complications or length of stay, or worsened continence outcomes. [ABSTRACT FROM AUTHOR]

Purpose Bladder outlet procedures without augmentation cystoplasty remain controversial. We hypothesized that bladder outlet procedures without augmentation cystoplasty may lead to unfavorable bladder dynamics, upper tract changes and/or continued incontinence. We reviewed long-term urodynamic, upper tract and continence outcomes following bladder outlet procedures without augmentation cystoplasty. Materials and Methods We retrospectively reviewed all patients who underwent bladder neck reconstruction/closure/sling without augmentation cystoplasty between 2000 and 2014. Because of variation in length of followup, we calculated the cumulative incidence and proportion of cases of upper tract and urodynamic changes, augmentation cystoplasty and subsequent continence procedures. Preoperative factors were compared between patients with and without adverse outcomes. Results A total of 109 patients underwent bladder outlet procedures without augmentation cystoplasty at a mean age of 8.5 years. At a mean of 4.9 years of followup 59 patients (54%) had undergone additional continence surgery, 20 (18%) had undergone augmentation cystoplasty, 50 (46%) manifested vesicoureteral reflux or hydronephrosis and 23 (21%) had newly diagnosed or worsening renal scarring. At augmentation cystoplasty 13 of 18 patients (72%) had upper tract changes, 15 (83%) had continued incontinence and 11 (61%) had an end fill pressure of greater than 40 cm H 2 O. All patients had resolution of these changes after augmentation cystoplasty. Patients who had previously undergone vesicostomy or surgery for vesicoureteral reflux were significantly more likely to undergo a subsequent augmentation cystoplasty or to show upper tract changes. Conclusions Following bladder outlet procedures without augmentation cystoplasty the estimated 10-year cumulative incidence of augmentation cystoplasty is 30%, continence procedures 70%, upper tract changes greater than 50% and chronic kidney disease 20%. Because of these risks, careful patient selection and close followup are essential if considering a bladder outlet procedure without augmentation cystoplasty. [ABSTRACT FROM AUTHOR]

Purpose Robot-assisted laparoscopic appendicovesicostomy in children has become increasingly popular. However, the literature on this technique mainly consists of small case series with only 1 small comparison to an open cohort. We compared the number of complications and surgical revisions required with open and robotic surgery in children undergoing appendicovesicostomy at our institution. Materials and Methods We retrospectively reviewed the charts of all patients who underwent appendicovesicostomy by 3 surgeons between July 2002 and September 2013. Acute complications and surgical revisions were recorded and compared between groups with t-tests for continuous variables and Fisher exact test for categorical variables. Results A total of 28 open and 39 robotic appendicovesicostomies were included. At a mean followup of 2.7 years there was no difference in number of complications or reoperations (p = 0.788 and p = 0.791, respectively) between groups. Time to first reoperation was shorter in the robotic group. However, there was no significant difference between groups regarding number of patients who underwent reoperation within the first 12 months postoperatively (p = 0.346). Conclusions Comparison of robotic and open appendicovesicostomy revealed no significant difference in the number of acute complications or reoperations between groups. However, the nature and timing of complications differed between groups. [ABSTRACT FROM AUTHOR]

Purpose Proximal hypospadias repair using a staged approach is a complex reconstructive operation with the potential for significant complications requiring repeat surgery. We report outcomes of staged hypospadias repair using transposed preputial skin flaps and factors predictive of postoperative complications. Materials and Methods We retrospectively analyzed patients who underwent staged proximal hypospadias repair using transposed preputial skin flaps between 2002 and 2013. Patient demographics, operative details, complications, reoperations and factors predictive of complications were reviewed. Results A total of 56 patients were identified with a mean age of 14.1 months (median 14.3) at first stage. Mean followup was 38.6 months (median 34.1). Complications requiring additional unplanned operation(s) were observed in 38 patients (68%), including fistulas in 32 (57%), diverticula in 8 (14%), meatal stenosis in 5 (9%), urethral stricture in 8 (14%) and glans dehiscence in 3 (5%). In addition, redo first stage repair was performed in 4 patients (7%). Since some patients had more than 1 complication, the total number of complications is greater than the number of patients undergoing a redo operation. On univariate analyses the use of small intestinal submucosa was significantly associated with an increased risk of fistula (91% vs 49%, p = 0.02) and urethral diverticulum (64% vs 24%, p = 0.04). Incision of the tunica albuginea of the corpora was associated with an increased likelihood of fistula (77% vs 44%, p = 0.03). Finally, patients with glans dehiscence were significantly younger at first stage (5.8 vs 14.8 months, p = 0.01). Conclusions The reoperation rate for complications in children undergoing staged hypospadias repair using transposed preputial skin flaps is higher than previously reported. [ABSTRACT FROM AUTHOR]

Copyright of Cirugía Plástica Ibero-Latinoamericana is the property of Cirugia Plastica Ibero-Latinoamericana and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Pediatric surgery began with single-incision flank surgery and has evolved to multi-port laparoscopic and robotic approaches. Recent technological advances with the single-port (SP) robot have allowed for transition back to single-incision surgery. A 14-year-old paraplegic male with T2 spinal injury presented with neurogenic bladder and increasing difficulty performing clean intermittent catheterization thus the decision was made to perform the first SP robotic Mitrofanoff procedure in a pediatric patient. The SP platform has one 2.5 cm, 4-channel port, a 12 × 10 mm articulating camera, and 6 mm multi-wristed instruments. The SP robotic Mitrofanoff was completed successfully without issues with space, triangulation or articulation. There is, however, loss of insufflation with use of laparoscopic instruments as the seal on the port is difficult to maintain. The single-port robot has been successfully utilized in seven patients: six underwent dismembered pyeloplasty and one underwent Mitrofanoff with a median operative time of 120 min and estimated blood loss of <25 cc. Postoperatively, no patients required opioid pain medications, and all were discharged in <24 h without complications. Single-port robotic surgery is feasible in pediatric patients, but patient selection is key. Future development of the platform is needed to widen application to smaller patients. [ABSTRACT FROM AUTHOR]

Objective We report new hydronephrosis or VUR (vesicoureteral reflux) in patients with end filling pressures >40 cm for at least 1 year after bladder neck surgery without augmentation for neurogenic incontinence. Materials Consecutive children with neurogenic sphincteric incompetency had bladder neck surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually. Those with sustained end fill pressures >40 cm for ≥1 year were included as participants in the study. Results Of 79 patients, 17 (22%) had end fill pressures >40 cm for at least 1 year despite anticholinergics, with follow-up a mean of 39 months. New hydronephrosis or VUR developed in six (35%). All new hydronephrosis resolved with medical treatment, as did two out of three new VUR cases. The other patient with VUR had successful Dx/HA (dextranomer hyaluronic acid) injection. Conclusions Despite sustained pressures >40 cm, upper tract changes developed in only 35% of patients, and resolved with medical management or minimally invasive interventions. End pressures should not be used as an independent indication for augmentation. [ABSTRACT FROM AUTHOR]

Pediatric cystic renal lesions are challenging to manage as little is known about their natural course. A modified Bosniak (mBosniak) classification system has been proposed for risk stratification in pediatric patients that takes ultrasound (US) and/or computed tomogram (CT) characteristics into account. However, literature validating this system remains limited. To determine if the mBosniak classification system correlates with pathologic diagnoses. The hypothesis is that mBosniak classification can stratify the risk of malignancy in children with renal cysts. Patients treated for cystic renal masses with available imaging and pathology between 2000 and 2019 from five institutions were identified. Clinical characteristics and pathology were obtained retrospectively. Characteristics from the most recent US, CT, and/or magnetic resonance imaging (MRI) were recorded. Reviewers assigned a mBosniak classification to each scan. mBosniak scores 1/2 were considered low-risk and 3/4 high-risk. These groups were compared with pathology (classified as benign, intermediate, malignant). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were calculated to assess this categorization as a screening tool to guide surgical intervention. Agreement between imaging modalities was also explored. 99 patients were identified. High-risk imaging findings were correlated with malignant or intermediate pathology with a sensitivity of 88.3%, specificity of 84.6%, PPV of 89.8%, NPV of 82.5%, +LR of 5.7, and -LR of 0.14. The sensitivity for detecting malignant lesions only was 100%. There was substantial agreement between US/CT (n = 55; κ = 0.66) and moderate agreement between US/MRI (n = 20; κ = 0.52) and CT/MRI (n = 13; κ = 0.47). The mBos classification system is a useful tool in predicting the likelihood of benign vs. intermediate or malignant pathology. The relatively high sensitivity and specificity of the system for prediction of high-risk lesions makes this classification applicable to clinical decision making. In addition, all malignant lesions were accurately identified as mBosniak 4 on imaging. This study adds substantial data to the relatively small body of literature validating the mBosniak system for risk stratifying pediatric cystic renal lesions. Pediatric cystic renal lesions assigned mBosniak class 1/2 are mostly benign, whereas class 3/4 lesions are likely intermediate or malignant pathology. We observed that the mBosniak system correctly identified pathology appropriate for surgical management in 88% of cases and did not miss malignant pathologies. There is substantial agreement between CT and US scans concerning mBos classification. Summary Table Modified Bosniak class and pathologic correlation. Summary Table mBosniak class Benign Intermediate Malignant p-value 1 24 1 0 <0.001 2 9 6 0 3 4 11 0 4 2 5 37 1/2 33 7 0 <0.001 3/4 6 16 37 [ABSTRACT FROM AUTHOR]

Purpose: Anecdotal evidence suggests that complex congenital genitourinary anomalies are occurring less frequently. However, few epidemiological studies are available to confirm or refute this suggestion. Materials and Methods: The Kids' Inpatient Database (KID) is a national, all payer database of several million inpatient pediatric hospitalizations per year, including complicated and uncomplicated in-hospital births. We reviewed the 1997 to 2009 KID to determine the birth prevalence of spina bifida, posterior urethral valves, bladder exstrophy, epispadias, prune belly syndrome, ambiguous genitalia and imperforate anus. For posterior urethral valves and prune belly syndrome we limited our search to newborn males only. Results: During the study period, there was a diagnosis of spina bifida in 3,413 neonates, bladder exstrophy in 214, epispadias in 1,127, ambiguous genitalia in 726, prune belly syndrome in 180, posterior urethral valves in 578 and imperforate anus in 4,040. We identified no significant change in the birth prevalence of spina bifida (from 33.9 new spina bifida births of 100,000 uncomplicated births to 29.0/100,000, p = 0.08), posterior urethral valves (from 10.4/100,000 to 11.0/100,000, p = 0.51), prune belly syndrome (from 4.8/100,000 to 3.3/100,000, p = 0.44) or ambiguous genitalia (from 5.82/100,000 to 5.87/100,000, p = 0.38). There was a significant decrease in the birth prevalence of bladder exstrophy (from 2.4/100,000 to 1.6/100,000 uncomplicated births, p = 0.01) and a significant increase in epispadias (from 8.0/100,000 to 11.6/100,000) and imperforate anus (from 33.6/100,000 to 35.0/100,000, each p = 0.04) during the study period. Conclusions: The birth prevalence of spina bifida, posterior urethral valves and prune belly syndrome appears to have been stable in the last 12 years. Epispadias, ambiguous genitalia and imperforate anus diagnoses in newborns became more common in the same period, while bladder exstrophy diagnoses became less common. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To present our initial experience with “mini” percutaneous cystolithotomy performed as an outpatient procedure in patients with neurogenic bladders. Materials & methods: Over the last 6 years, patients with neurogenic bladders and bladder calculi were managed with outpatient percutaneous cystolithotomy. All but 1 had previously undergone appendicovesicostomy (APV) creation. The procedure was performed by first passing a pediatric cystoscope per APV. Once the calculi were visualized, and following bladder distention, additional bladder access was obtained by passage of either a 16F Peel-Away introducer using the Seldinger technique or a 5 mm laparoscopic trocar under direct vision. An ultrasonic lithotripter was then advanced through the percutaneous access site and stone fragmentation completed. Following procedure completion, a catheter was placed for 24 h for bladder decompression. All procedures were performed on an outpatient basis. Results: 12 patients underwent 18 successful operations. In 1 patient, percutaneous access was unsuccessful. Mean age at surgery was 12.3 years. Mean operative time was 72 min 8 patients had undergone previous ileocystoplasty. The remainder was rendered stone free at the completion of surgery. One patient had persistent bleeding from the intravesical trocar site necessitating fulguration and an overnight stay for observation. The remainder were sent home the same day. There were no cases of urine extravasation. Conclusions: “Mini” percutaneous cystolithotomy is a safe, effective technique for the outpatient management of bladder calculi. [Copyright &y& Elsevier]

Abstract: Purpose: We report outcomes after dextranomer/hyaluronic acid (Dx/HA) bladder neck injection for persistent outlet incompetency despite prior sling or Leadbetter/Mitchell bladder neck revision plus sling (LMS) in children with neurogenic urinary incontinence. Methods: Consecutive patients with outlet incompetency after sling (n = 17) or LMS (n = 9) underwent a maximum of 2 Dx/HA injections. Antegrade and/or retrograde endoscopy was used to access the bladder outlet, and injection done in quadrants to achieve visual mucosal coaptation. Outcomes were described as either “dry”, not requiring pads, or “wet”. Results: There were 24 children with follow-up after injection, of which 9 (38%) were initially dry and 15 (62%) remained wet. Of the 9 dry patients, 4 had recurrent incontinence at a mean of 16 months while 5 remained dry at a mean of 27 months. Second injections were done in a total of 14 children, with 1 dry at 39 months. Of all 24 children, up to 2 injections resulted in 6 (25%) dry patients, while the remainder was wet at last follow-up. Gender, initial outlet surgery, pre-injection pad use, injection technique, and volume injected did not predict outcomes. Conclusions: Dx/HA bladder neck injection resulted in dryness in 25% of patients in this series after failed sling or LMS. Second injections after either initial failure or success achieved dryness in only 7%, and are no longer recommended. [Copyright &y& Elsevier]

Purpose: Guidelines for staging Wilms tumor mandate regional lymph node sampling at nephrectomy. However, the usefulness of preoperative computerized tomography in staging lymph nodes has not been rigorously investigated. Thus, we correlated preoperative computerized tomography and pathological lymph node findings to establish a radiological criterion for pathological lymph node enlargement. Materials and Methods: We reviewed the medical records of children with Wilms tumor at our institution who underwent pre-chemotherapy surgery with lymph node sampling and had preoperative computerized tomography with contrast medium available for interpretation. Computerized tomography was independently reviewed by 2 radiologists blinded to the pathological findings. We collected data on the diameter of the largest regional lymph node identified and this measurement was correlated with the pathological results. Results: A total of 52 children (25 male, 27 female) with a median age of 3.1 years (range 0.4 to 9.6) were identified. The median largest regional lymph node diameter was 6 mm (range 2 to 15). Of the children 10 (19.2%) had metastatic involvement of sampled lymph nodes. A radiological cutoff of 7 mm for lymph node positivity corresponded to a negative predictive value of 89.0%, a sensitivity of 70.0% and a specificity of 57.1%. A ROC curve was constructed with these data describing the prognostic ability of the diameter of the largest regional lymph node on preoperative computerized tomography to determine lymph node positivity in Wilms tumor, which revealed an AUC of 0.67 (95% CI 0.48–0.87, p = 0.09). Conclusions: By defining a radiological size cutoff for suspicious lymph nodes, preoperative computerized tomography for staging lymph nodes in Wilms tumor demonstrates potential clinical usefulness through risk stratification for therapy and future study design. [Copyright &y& Elsevier]

Purpose: Nephron sparing surgery is accepted as standard of care for children with bilateral Wilms tumor or Wilms tumor in a solitary kidney and some study protocols allow nephron sparing surgery in select cases of unilateral Wilms tumor. With the increasing use of nephron sparing surgery in Wilms tumor, we reviewed pathological features from Wilms tumor radical nephrectomy specimens to determine the potential efficacy of a nephron sparing approach. Materials and Methods: Medical records of children undergoing pre-chemotherapy radical nephrectomy for unilateral Wilms tumor at our institution were reviewed. Ideal candidates for nephron sparing surgery were defined as those having a unifocal mass outside the renal hilum, sparing a third or more of the kidney, favorable histology, no signs of renal sinus or segmental vascular invasion, no metastatic lymph nodes or gross regional disease, and a distinct interface on pathological review between tumor and remaining parenchyma. Results: A total of 78 children at a median age of 3.2 years (range 0.3 to 16.2) underwent pre-chemotherapy radical nephrectomy for unilateral Wilms tumor. Median tumor diameter was 11 cm (range 2.5 to 22). Of these children 36 (46.2%) had tumors sparing a third or more of the kidney and 70 (89.7%) had unifocal tumors. There were 73 specimens (94.6%) that showed favorable histology, and 56 (71.8%) of the specimens had a distinct border between tumor and remaining parenchyma. In total, 19 (24.4%) of the patients reviewed met all of our strict pathological criteria as ideal partial nephrectomy candidates. Conclusions: In a post hoc analysis using strict pathological criteria and accepted surgical oncologic principles, as many as 1 in 4 children undergoing pre-chemotherapy surgery for nonmetastatic, unilateral Wilms tumor have post-resection pathological tumor characteristics favorable for nephron sparing surgery. [Copyright &y& Elsevier]

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Copyright of Cirugía Plástica Ibero-Latinoamericana is the property of Cirugia Plastica Ibero-Latinoamericana and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)