Octreotide and enterocutaneous fistula closure in neonates and children.

UNLABELLED: Enterocutaneous fistula and its conservative management still pose a challenge for the surgeon. The use of octreotide and somatostatin in neonates and children as adjunctive therapy in the conservative management of this condition, leads to major controversy regarding its efficacy. Therefore, we conducted an extensive literature review of published articles regarding the use of somatostatin and its analogues in the treatment of enterocutaneous fistula in neonates and children. Our review is then presented together with a case vignette and discusses the different practical aspects of the treatment with these drugs. CONCLUSION: The major diversity in treatment regimens among published studies makes outcomes difficult to compare. However, given the results of the different cases reported in the literature and of our own experience, we suggest a possible beneficial effect of octreotide and somatostatin on closure of enterocutaneous fistula in these patients.

[Severe bilateral vesicoureteral reflux and nephropathy in male newborns: valve-like syndrome or uncoordinated voiding in the male fetus]. / Reflujo vesicoureteral bilateral grave y nefropatía renal en pacientes varones recién nacidos: síndrome de válvulas-like o Micción no coordinada en el feto varón.

OBJECTIVES: Various papers differentiating neonatal vesicoureteral reflux (VUR) with severe renal damage from other predominant group of newborns with neonatal VUR without renal lesions and those diagnosed in older ages, generally in relation with urinary tract infection (UTI), have been published over the last decade. From the standpoint that VUR is part of a broad spectrum both in clinical expression as in pathogenesis, with different theories described to explain the existence of this type of congenital VUR in males. The existence of a fetal vesicourethral dysfunction, presenting after birth as a high risk bladder, which is defined by urodynamic tests in the first trimester, explains the appearance of severe fetal VUR with functional deterioration of one or both renal units at the time of birth; this entity must be diagnosed to establish the adequate therapeutic management. This clinical picture is named Valve like syndrome or male uncoordinated fetal voiding.

[Evaluation of the lower urinary tract function in pediatric patients with primary vesicoureteral reflux]. / Valoración de la función del tracto urinario inferior en el paciente pediátrico portador de reflujo vesicoureteral primario.

OBJECTIVES: To present a methodology of perioperative evaluation of lower urinary tract function in patients with primary VUR. To describe the most frequent urodynamic patterns in patients with primary VUR and their treatment. To show the results of a lower urinary tract evaluation in a prospective study in a pediatric population of 63 patients, with persistent primary VUR, with the aim to help to a better understanding of the natural history of VUR. METHODS: The study includes a pediatric population of 63 patients with primary grade II-V VUR, 28 girls and 35 boys, with ages between six months and 15 years (mean age 5.9 yr.). In the study protocol for the systematic study of primary vesicoureteral reflux we perform a non invasive screening for lower urinary tract dysfunction, which select patients that will benefit from a complete cystomanometry. STUDY VARIABLES: age, gender, VUR side and grade, and renal function, in relation with the lower urinary tract function at the time of recruitment. The results of urodynamics have been evaluated in relation to urinary symptoms and history of lower urinary tract infection. RESULTS: Differential characteristics of the study population: high mean age (overall 5.9 yr.; 7.7 in girls), high percentage of high grade VUR (59%), renal damage (52%) and lower urinary tract dysfunction (86%) without significant differences between boys and girls. Statistically significant associations between: VUR grade and renal damage; presence of lower urinary tract dysfunction and bilateral VUR; female gender and lower urinary tract dysfunction; and normal lower urinary tract function and absence of renal damage. The voiding dysfunction pattern was predominant in females and bladder hyperactivity in males. Urinary symptoms did not differ between the various patterns of urodynamic abnormalities. The incidence of UTI shows significant differences between the various urodynamic patterns, being more frequent in girls with type 4 urodynamic pattern (dysfunctional voiding). CONCLUSIONS: The performance of a non invasive screening of lower urinary tract function by medical history, urine analysis, ultrasound and post void residual ultrasound evaluation enabled the selection of patients who would benefit from a complete urodynamic study. If there are symptoms or signs of lower urinary tract dysfunction it is recommended to perform a complete urodynamic study. Pediatric cystomanometry provides precise data about bladder filling and voiding phases, facilitating the specific treatment of the lower urinary tract dysfunction. The urodynamic study has a special significance in the prognosis of the urological malformation associated in children with VUR. With this systematic study of the lower urinary tract function early diagnosis and treatment of patients in risk may be achieved, as well as adequate selection of patients that will benefit from pharmacotherapy and/or urotherapy, with the aim to prevent renal damage progression and to potentiate definitive cure of VUR.

Reflujo vesicoureteral bilateral grave y nefropatía renal en pacientes varones recién nacidos: síndrome de válvulas-like o micción no coordinada en el feto varón / Severe bilateral vesicoureteral reflux and nephropathy in male newborns: valve-like syndrome or uncoordinated voiding in the male fetus

Diversos trabajos se han publicado en la última década, que diferencian el reflujo vesico ureteral (RVU) neonatal con afectación grave renal, de otro grupo mayoritario de neonatos con RVU neonatal sin lesión renal y los diagnosticados en edades más tardías generalmente relacionados con infección urinaria (ITU). Conviniendo en que el RVU forma parte de un amplio espectro tanto en la expresión clínica como por lo tanto de su patogénesis, se han descrito diversas teorías para explicar la existencia de este tipo de RVU congénito en varones. La existencia de una malfunción vesico uretral fetal, expresada postnatalmente con una vejiga de alto riesgo, definida ésta mediante estudio urodinámico en el 1º trimestre de vida extrauterina, explica la aparición de RVU grave fetal con afectación funcional de una o ambas unidades renales ya en el recién nacido y que precisa de su reconocimiento para un adecuado planteamiento terapéutico, éste cuadro lo hemos caracterizado como Síndrome de Válvulas-Like o Micción no coordinada fetal en el varón (AU)

Objectives: Various papers differentiating neonatal vesicoureteral reflux (VUR) with severe renal damage from other predominant group of newborns with neonatal VUR without renal lesions and those diagnosed in older ages, generally in relation with urinary tract infection (UTI), have been published over the last decade. From the standpoint that VUR is part of a broad spectrum both in clinical expression as in pathogenesis, with different theories described to explain the existence of this type of congenital VUR in males. The existence of a fetal vesicourethral dysfunction, presenting after birth as a high risk bladder, which is defined by urodynamic tests in the first trimester, explains the appearance of severe fetal VUR with functional deterioration of one or both renal units at the time of birth; this entity must be diagnosed to establish the adequate therapeutic management. This clinical picture is named Valve like syndrome or male uncoordinated fetal voiding (AU)

Valoración de la función del tracto urinario inferior en el paciente pediátrico portador de reflujo vesicoureteral primario / Evaluation of the lower urinary tract function in pediatric patients with primary vesicoureteral reflux

Objetivos: Los objetivos del trabajo son: Presentar una metodología de valoración perioperatoria de la función del tracto urinario inferior en el paciente con Reflujo Vésico Ureteral (RVU) Primario; Describir los patrones urodinámicos más frecuentes en los pacientes con RVU primario y su tratamiento en base al patrón urodinámico. Exponer los resultados de la valoración del tracto urinario inferior de un estudio prospectivo de una población pediátrica de 63 pacientes, portadores de RVU primario persistente, con el fin de ayudar a la mejor comprensión de la historia natural del RVU. Métodos: El estudio comprende una población pediátrica de 63 pacientes portadores de RVU primario grado II-V, 28 niñas y 35 varones, de edades comprendidas entre 6 meses y 15 años de edad, con una edad media global de 5,9 años. Dentro del protocolo de estudio sistemático RVU primario, se realiza un despistaje no invasivo de la presencia de malfunción del tracto urinario inferior (MTUI), del cual se seleccionan los pacientes que se beneficiarán de un estudio cistométrico completo. Variables estudiadas: edad, sexo, lateralidad y grado de RVU, y función renal, en relación con la función del tracto urinario inferior (TUI) al reclutamiento. Los resultados del estudio urodinámico se han valorado en relación a las variables: sintomatología urinaria y antecedente de infección del tracto urinario inferior (ITU). Resultados: Características diferenciales de la población estudiada: Edad media elevada (global de 5,9 años; 7,7 años en las niñas), porcentaje elevado de RVU de alto grado (59%), de daño renal (52%) y de MTUI (86%), sin diferencias significativas entre varones y niñas. Asociación estadísticamente significativa entre: Grado de RVU y daño renal; presencia de MTUI y bilateralidad del RVU; sexo femenino y MTUI; y normalidad de la función del TUI y ausencia de daño renal. Predominio del patrón urodinámico tipo disfunción miccional en la niña y de la hiperactividad del detrusor en el varón. La sintomatología urinaria no difiere en los distintos patrones de alteración urodinámica. Solo la incidencia de ITU muestra diferencias significativas entre los distintos patrones urodinámicos, siendo mayor en las niñas con patrón urodinámico tipo disfunción miccional (micción no coordinada). Conclusiones: La realización de un despistaje no invasivo de la función del TUI mediante la historia miccional y fecal, el análisis urinario, la ecografía y la medida ecográfica del residuo postmiccional, permite la selección de los pacientes que se beneficiarán de un estudio urodinámico completo. La cistometría pediátrica aporta datos precisos sobre las fases de llenado y vaciado vesical, que facilitan el tratamiento específico de la MTUI. El estudio urodinámico cobra un especial significado en el pronóstico de la malformación urológica asociada en los niños portadores del RVU. Con esta sistemática de estudio de la función del TUI puede lograrse un diagnóstico y tratamiento precoz de los pacientes en riesgo y una adecuada selección de los pacientes que se beneficiarán de la farmacoterapia y/o uroterapia, con el fin de prevenir la progresión del daño renal y potenciar la curación definitiva del RVU (AU)

Objectives: To present a methodology of perioperative evaluation of lower urinary tract function in patients with primary VUR. To describe the most frequent urodynamic patterns in patients with primary VUR and their treatment. To show the results of a lower urinary tract evaluation in a prospective study in a pediatric population of 63 patients, with persistent primary VUR, with the aim to help to a better understanding of the natural history of VUR. Methods: The study includes a pediatric population of 63 patients with primary grade II-V VUR, 28 girls and 35 boys, with ages between six months and 15 years (mean age 5.9 yr.). In the study protocol for the systematic study of primary vesicoureteral reflux we perform a non invasive screening for lower urinary tract dysfunction, which select patients that will benefit from a complete cystomanometry. Study variables: age, gender, VUR side and grade, and renal function, in relation with the lower urinary tract function at the time of recruitment. The results of urodynamics have been evaluated in relation to urinary symptoms and history of lower urinary tract infection. Results: Differential characteristics of the study population: high mean age (overall 5.9 yr.; 7.7 in girls), high percentage of high grade VUR (59%), renal damage (52%) and lower urinary tract dysfunction (86%) without significant differences between boys and girls. Statistically significant associations between: VUR grade and renal damage; presence of lower urinary tract dysfunction and bilateral VUR; female gender and lower urinary tract dysfunction; and normal lower urinary tract function and absence of renal damage. The voiding dysfunction pattern was predominant in females and bladder hyperactivity in males. Urinary symptoms did not differ between the various patterns of urodynamic abnormalities. The incidence of UTI shows significant differences between the various urodynamic patterns, being more frequent in girls with type 4 urodynamic pattern (dysfunctional voiding). Conclusions: The performance of a non invasive screening of lower urinary tract function by medical history, urine analysis, ultrasound and post void residual ultrasound evaluation enabled the selection of patients who would benefit from a complete urodynamic study. If there are symptoms or signs of lower urinary tract dysfunction it is recommended to perform a complete urodynamic study. Pediatric cystomanometry provides precise data about bladder filling and voiding phases, facilitating the specific treatment of the lower urinary tract dysfunction. The urodynamic study has a special significance in the prognosis of the urological malformation associated in children with VUR. With this systematic study of the lower urinary tract function early diagnosis and treatment of patients in risk may be achieved, as well as adequate selection of patients that will benefit from pharmacotherapy and/or urotherapy, with the aim to prevent renal damage progression and to potentiate definitive cure of VUR (AU)

Estado actual del abordaje retroperitoneoscopico en Urología Pediátrica / Current status of the retroperitoneoscopic surgical approach in pediatric urology

La retroperitoneoscopia urológica pediátrica presenta tres etapas diferenciadas que han condicionado su desarrollo, aunque no impedido: 1) limitadas indicaciones en la edad pediátrica, debido a que la cirugía pediátrica convencional se caracteriza por ser poco invasiva; 2) adecuación del desarrollo tecnológico realizado en el adulto a la edad pediátrica; 3) superar las controversias entre cirujanos pediátricos y no laparoscopistas. Tras superar ésta etapa, la retroperitoneoscopiase ha impuesto como herramienta imprescindible para el tratamiento de las diversas patologías de la celda renal, siendo de las indicaciones ablativos la nefrectomía su «gold estándar», y de las reconstructivas la pieloplastia, por abordaje retroperitoneoscopico completo o asistido (AU)

Urologic pediatric retroperitoneoscopy has had three different stages that have conditioned, although not hindered, its development: 1) limited number of indications in the pediatric age, because pediatric surgery itself is not much invasive; 2) adaptation of the technological development from adult to children; 3) overcoming the controversies between laparoscopic and non laparoscopic pediatric surgeons. After overcoming these stages, retroperitoneoscopy has become an indispensable tool for the treatment of various diseases of the kidney, being nephrectomy the gold standard among the indications for ablation, and pyeloplasty among reconstructive, through a complete or assisted retroperitoneoscopic approach (AU)

[Renal biopsy through a retroperitoneoscopic approach: our experience in 53 pediatric patients]. / Biopsia renal por abordaje retroperitoneoscópico: nuestra experiencia en 53 pacientes pediátricos.

OBJECTIVES: The retroperitoneoscopic approach enables adequate vision of the renal fossa and retroperitoneal structures. Our objective is to support the performance of renal biopsies through a retroperitoneoscopic approach in those pediatric surgery departments still doing open biopsies. METHODS: We performed 53 renal biopsies through a retroperitoneoscopic approach. Twenty-eight patients were males and 25 females, with ages between 13 months and 19 years (mean age range 4 years). The biopsies were indicated after the following diagnosis: nephrotic syndrome (n = 20), hemolytic-uremic syndrome (n = 3), hematuria (n = 15), idiopathic purpura (n = 2), proteinuria (n = 13). Ten patients were in renal failure. We performed our technique of retroperitoneoscopic approach in all cases. RESULTS: Adequate exposure of the kidney was achieved in all cases, and the biopsy sample gave a pathologic diagnosis after immunohistochemical and morphologic studies. One case was converted to open surgery due to bleeding from the kidney. In 51 cases the estimated blood loss was lower than 20 cc. No drainage was necessary after surgery. Mean hospital stay was 48 hours for the first 20 cases and between 24-36 hours for the remainder. CONCLUSIONS: The Retroperitoneoscopic renal biopsy is an adequate procedure for the pediatric patients and represents a real alternative to open biopsy, and in cases of contraindication for ultrasound guided percutaneous biopsy, because: 1. It offers an excellent exposure of the kidney. 2. It obtains a kidney sample enough for the study. 3. The morbidity associated with the procedure is minimal. 4. Diminishes the hospital stay and shortens the time to return back to normal life.

Biopsia renal por abordaje retroperitoneoscópico: nuestra experiencia en 53 pacientes pediátricos / No disponible

OBJETIVO: El abordaje retroperitoneoscó- pico posibilita una adecuada visualización de la fosa renal y de las estructuras retroperitoneales. Planteamos como objetivo la realización de biopsia renal por retroperitoneoscopia en aquellos Servicios de Cirugía Pediátrica en los que se realiza por cirugía convencional. MÉTODOS: Hemos realizado 53 biopsias renales por abordaje retroperitoneoscopico Se realizaron en 28 varones y 25 mujeres, de edades entre los 13 meses y 19 años ( rango medio de edad de 4 años). Los diagnósticos por los que sé biopsió fueron: Síndrome nefrótico (n=20); Síndrome hemolítico-urémico(n=3); Hematuria (n=15); Purpura idiopàtica (2 ); proteinuría (n=13), de estos pacientes, 10 estaban en insuficiencia renal. En todos los casos el abordaje retroperitoneoscópico se realizó según nuestra técnica. RESULTADOS: En todos los casos la exposición del riñón fue adecuada y la toma de biopsia concluyente con un diagnóstico anatomopatológico, realizándose pruebas de immunohistoquímica y estudio morfológico de la muestra. Se reconvirtió 1 caso por sangrado del lecho renal. En 51 casos el sangrado del procedimiento no alcanzó los 20 cc. No se precisó drenaje postoperatorio. La estancia media fue en los primeras 20 casos de 48 horas y en el resto de 24 a 36 horas. CONCLUSIONES: La biopsia renal retroperitoneoscópica es adecuada para la edad pediátrica siendo una alternativa real de la cirugía abierta y en las situaciones de contraindicación de la biopsia percutánea ecodirigida por: 1. Excelente exposición del riñón. 2. Adecuada cantidad de tejido renal para estudio. 3. Mínima morbilidad intra y postoperatoria. 4. Disminución de estancias hospitalarias con incorporación precoz a la vida cotidiana (AU)

OBJECTIVES: The retroperitoneoscopic approach enables adequate vision of the renal fossa and retroperitoneal structures. Our objective is to support the performance of renal biopsies through a retroperito- neoscopic approach in those pediatric surgery departments still doing open biopsies. METHODS: We performed 53 renal biopsies through a retroperitoneoscopic approach. Twenty-eight patients were males and 25 females, with ages between 13 months and 19 years (mean age range 4 years). The biopsies were indicated after the following diagnosis: nephrotic syndrome (n = 20), hemolytic-uremic syndrome (n = 3), hematuria (n = 15), idiopathic purpura (n = 2), proteinuria (n = 13). Ten patients were in renal failure. We performed our technique of retroperitoneoscopic approach in all cases. RESULTS: Adequate exposure of the kidney was achieved in all cases, and the biopsy sample gave a pathologic diagnosis after immunohistochemical and morphologic studies. One case was converted to open surgery due to bleeding from the kidney. In 51 cases the estimated blood loss was lower than 20 cc. No drainage was necessary after surgery. Mean hospital stay was 48 hours for the first 20 cases and between 24-36 hours for the remainder. CONCLUSIONS: The Retroperitoneoscopic renal biopsy is an adequate procedure for the pediatric patients and represents a real alternative to open biopsy, and in cases of contraindication for ultrasound guided percutaneous biopsy, because: 1. It offers an excellent exposure of the kidney. 2. It obtains a kidney sample enough for the study. 3. The morbidity associated with the procedure is minimal. 4. Diminishes the hospital stay and shortens the time to return back to normal life (AU)

[Laparoscopy in pediatric urology]. / Laparoscopia en urología pediátrica.

OBJECTIVES: To establish urological pathologies in which video-assisted laparoscopy would be indicated as an alternative to conventional surgery. METHODS: From 1995 to December 2000 we performed 106 urological laparoscopic procedures in 99 children six months to 16 years old (mean age of 7 years). The indications for laparoscopy were: a) Diagnostic indications in 60 patients (n)/65 procedures (p) including intrabdominal testis (n = 28, p = 33) and renal biopsy (n = 32, p = 32); b) Therapeutical indications in 33 patients (n)/34 procedures (p) consisted of varicocelectomy (n = 5, p = 7), orchiectomy (n = 1, p = 1), closure of patent processus vaginalis (n = 2, p = 4), retroperitoneoscopic nephrectomy (n = 16, p = 18), renal cyst excision (n = 2, p = 2), marsupialization of symptomatic giant lymphocele after renal transplantation (n = 2, p = 4), and c) Retroperitoneoscopic approach before open access in 6 patients/7 procedures. RESULTS: The laparoscopic approach was effective in 100% and 94.2% of diagnostic and therapeutic procedures, respectively. Conversion to an open approach was required in two procedures because of peritoneal perforation during retroperitoneoscopic nephrectomy in one case and bleeding after retroperineoscopic renal biopsy in the other. Previous retroperitoneal surgery is not a contraindication for retroperitoneoscopy. There were no postoperative complications with intraoperative morbidity of 2.8%. Overall average hospital stay was 1.4 days. CONCLUSIONS: Minimally invasive surgery plays an important role in management of pediatric urology patients. Nowadays, there are procedures in pediatric urology that can be considered established indications for laparoscopic or retroperitoneoscopic approaches.

Laparoscopia en urología pediátrica / Laparoscopy in Pediatric Urology

Objetivos: Definir las patologías urológicas en las que el abordaje videolaparoscópico sería el indicado como alternativa de la cirugía convencional. Métodos: Desde 1995 hasta Diciembre 2000, hemostratado 99 pacientes realizando 106 procedimientos laparoscópicos. La edad media fue de 7 años, con rango entre 6 meses y 16 años. La indicación laparoscópica fue: a) Diagnóstica en 60 pacientes (n)/ 65 procedimientos (p) : teste intrabdominal (n=28,p=33) y biopsia renal (n=32,p=32) ; b) Terapeútica en 33 pacientes (n)/34 procedimientos (p): varicocelectomía (n=5,p=7), orquiectomía(n=1,p=1),cierredelconductoperitoneo-vaginal permeable (n=2,p=4), nefrectomía retroperitoneal (n=16,p=18), quistectomía renal simple (n=2,p=2), marsupilización y omentoplastia en un linfocele gigante postrasplante renal (n=1,p=2); y c) Abordaje retroperitoneoscópico previo a la cirugía convencional (ARPCC) en 6 pacientes / 7 procedimientos. Resultados: El abordaje laparoscópico fue eficaz en el 100 por ciento de los procedimientos diagnósticos y en el 93,4 por ciento en los terapéuticos. Se realizó reconversión en 2 casos de abordaje retroperitoneal (2,4 por ciento), siendo sus causas: perforación del peritoneo (n=1) en un nefrectomía retroperitoneal, y sangrado activo al finalizar una biopsia renal (n=1). El antecedente de cirugía renal previa no contraindica el abordaje retroperitoneoscópico. Destacamos la ausencia de complicaciones postoperatorias siendo la tasa de morbilidad intraoperatoria del 2,8 por ciento. La estancia media general fue de 1,4 días. Conclusiones: Creemos que existen unas claras indicaciones clínicamente establecidas del abordaje laparoscópico y retroperitoneoscópico, diagnóstico y terapéutico, en la cirugía urológica pediátrica. Existen otras indicaciones que están consideradas como anecdóticas en el momento actual pero que en un futuro inmediato puede que sean consideradas como válidas OBJETIVOS: Definir las patologías urológicas en las que el abordaje videolaparoscópico sería el indicado como alternativa de la cirugía convencional (AU)