Clasificación, diagnóstico y tratamiento de los trastornos miccionales en la infancia / Classification, diagnosis and treatment of urinary disorders in childhood

La disfunción vesical o disfunción del tracto urinario inferior(DTUI), traducción literal del inglés de Lower urinary Tract Disfunction (LUTD) puede ser causa del 40% de las consultas en pediatría. Estos trastornos suponen una alteración en cualquiera de las fases del ciclo miccional y pueden responder a causas neurológicas, anatómicas o funcionales. Es muy importante realizar una adecuada historia clínica que nos permita conocer al paciente de manera global de manera que podamos lograr un correcto diagnóstico de la causa de la disfunción y así poder realizar un tratamiento dirigido. La evaluación de la mayoría de los niños con disfunción vesical puede limitarse a una anamnesis exhaustiva, un examen físico y pruebas no invasivas, como un análisis de orina y un urocultivo. En niños seleccionados, una evaluación más extensa incluye estudios de imagen urológicos, mediciones del flujo urinario y determinación del residuo postmiccional. En cuanto a las herramientas terapéuticas, partiremos de pautas higiénico-dietéticas básicas y de aplicación global a las que podremos asociar terapia conductual, farmacológica, fisioterápica o quirúrgica, siempre de manera individualizada.(AU)

Vesical disfunction or Lower urinary Tract Dysfunction (LUTD), can be the cause of 40% of pediatric consultations. Dysfunctions of the lower urinary tract involve an alteration in any of the phases of the voiding cycle and may respond to neurological, anatomical or functional causes. It is very important to take an adequate clinical history that allows us to know the patient globally so that we can achieve a correct diagnosis of the cause of the lower urinary tract dysfunction and thus be able to carry out targeted treatments. The evaluation for most children with bladder dysfunction can be limited to a thorough history, physical examination, and noninvasive testing, such as a urinalysis and urine culture. In selected children, more extensive evaluation includes urologic imaging studies, measurements of urinary flow, and post-void residual determination. As for therapeutic tools, we will start from basic hygienic-dietary guidelines of global application to which we can associate behavioral, pharmacological, physiotherapy or surgical therapy, always in an individualized manner.(AU)

Tratamiento quirúrgico del reflujo vesicoureteral en la infancia. Actualización / Surgical treatment of vesicoureteral reflux in childhood. Updat

El tratamiento endoscópico (ET) y quirúrgico, es una de las opciones fundamentales para alcanzar la curación del Reflujo vesicoureteral (RVU) en el paciente pediátrico. La tasa de éxito del tratamiento quirúrgico del RVU, es superior al 90%. Existe controversia a la hora de elegir la modalidad de tratamiento óptimo, e individualizada por cada paciente. El objetivo de esta revisión es actualizar conocimientos, conocer las nuevas modalidades diagnósticas y terapéuticas, y obtener un algoritmo de manejo individualizado según las características propias de cada paciente. El tratamiento quirúrgico es el pilar fundamental y el más efectivo, para un tratamiento exitoso del RVU en pacientes pediátricos

Endoscopic and surgical treatment is one of the fundamental options to achieve cure of Vesicoureteral Reflux (VUR) in the pediatric patient. The success rate of surgical treatment of RVU is greater than 90%. There is controversy when choosing the optimal treatment modality, and individualized by each patient. The objective of this review is to update knowledge, learn about new diagnostic and therapeutic modalities, and obtain an individualized management algorithm according to the characteristics of each patient. Surgical treatment is the fundamental and most effective pillar for successful treatment of RVU in pediatric patients

Importancia del reflujo vesicoureteral en Pediatría. Seguimiento conjunto del paciente entre Nefrología y Cirugía Pediátrica / Importance of vesicoureteral reflux in Pediatrics. Joint patient follow-up between Pediatric Nephrology and Pediatric Surgery

El reflujo vesicoureteral (RVU) es la malformación nefrourológica más frecuente del recién nacido, pudiendo aparecer de forma secundaria en otras patologías malformativas, como en el caso de las valvas de uretra posterior, o ser secundario a una disfunción de la unión ureterovesical. De esta manera se distinguen dos fenotipos de pacientes, por un lado los diagnosticados en época prenatal o neonatal, generalmente varones, con afección anatómica y/o funcional de la unión ureterovesical, lo que se conoce con el nombre de "RVU primario", frente a formas postnatales en el escolar mayor, generalmente mujeres con disfunción vesical y de la unión ureterovesical, conocidas como "RVU secundario". Estas formas clínicas presentan distinta evo-lución clínica y pronóstico, con desarrollo de enfermedad renal crónica (ERC) debida a un mal desarrollo nefrourológico asociado o no a infecciones urinarias recurrentes. La técnica gold standard para diagnosticar daño renal es la gammagrafía renal DMSA Tc99 mientras que la prueba diagnóstica de RVU es la cistouretrografía miccional seriada (CUMS). El tratamiento inicial debe ser conservador optimizando medidas higiénicas, dada la posibilidad de resolución espontánea del mismo con el tiempo, principalmente de las formas leves de RVU, reservando el tratamiento quirúrgico correctivo en las formas severas y con mala evolución clínica, por el probable desarrollo de ERC que puede conducir al paciente a una enfermedad renal terminal con necesidad de técnicas de depuración extrarrenal o incluso trasplante renal. Dicho tratamiento quirúrgico será preferentemente endoscópico. Aún existe controversia en el uso de profilaxis antibiótica, recomendándose en casos concretos. Un manejo integral multidisciplinar del paciente mejorará su pronóstico renal y vital, así como su calidad de vida y la de su familia

Vesicoureteral reflux (VUR) is the most frequent nephrourological malformation of the newborn, and may appear secondary in other malformative pathologies, such as in the case of the posterior urethral leaflets, or be secondary to a dysfunction of the ureterovesical junction. In this way, two phenotypes of patients are distinguished, on the one hand those diagnosed in the prenatal or neonatal period, generally males, with anatomical and/or functional affection of the ureterovesical junction, which is known as the "primary VUR", compared to postnatal forms in the older schoolchild, generally women with bladder and ureterovesical junction dysfunction, known as "secondary VUR". These clinical forms present different clinical and prognostic evolution, with development of chronic kidney disease (CKD) due to poor nephrourological development frequently associated with recurrent urinary infections. The gold standard technique for diagnosing kidney damage is nuclear renal scanning with dimercaptosuccinic acid (DMSA), while the diagnostic test for VUR is voiding cystourethrography (VCUG). Initial treatment should be conservative, optimizing hygienic measures, given the possibility of spontaneous resolution of it over time, mainly in mild forms of VUR, reserving corrective surgical treatment in severe forms and with poor clinical evolution, due to the probable development of CKD that can lead the patient to end-stage kidney disease with the need for extrarenal clearance techniques or even kidney transplantation. Surgical treatment will preferably be endoscopic. There is still controversy in the use of antibiotic prophylaxis, being recommended in specificcases. A comprehensive multidisciplinary management of the patient will improve their renal and vital prognosis, as well as their quality of life and that of their family

[Laparoscopic assisted percutaneous treatment of inguinal hernia in infants]. / Tratamiento percutáneo asistido por laparoscopia de la hernia inguinal infantil.

INTRODUCTION: Thanks to the generalization of minimally invasive surgery in pediatric patients some classic techniques are being replaced. Inguinal hernia repair may be an example. MATERIAL AND METHODS: We present the technique and our first results in 10 patients treated by percutaneous laparoscopic assisted herniotomy. For this purpose we used an umbilical port, for a 5 mm camera and an optional 2 mm grasper. By laparoscopic guidance we make two inguinal punctures with a 20G needle that introduces a non absorbable suture that crosses the whole inguinal defect and allows it closure by extracorporeal knot tying. RESULTS: The ages ranged between 1 month and 8 years with a median age of 10 months. 50% of the patients were boys. 50% of the patients had previous diagnosis of inguinal bilateral hernia. 30% of patients presented a postoperatory diagnosis different from the previous one. The average time of intervention was 32 minutes in bilateral hernias, and 19 in the unilateral ones. Follow-up time was 6 months without complications. The aesthetic result was ideal. CONCLUSION: Percutaneous laparoscopic assisted herniotomy is an effective, simple and feasible option for inguinal hernia in chidren without a high rate of complications.

Tratamiento percutáneo asistido por laparoscopia de la hernia inguinal infantil / Laparoscopic assisted percutaneous treatment of inguinal hernia in infants

Introducción. Gracias a la generalización de la cirugía mínimamente invasiva en pacientes pediátricos se están sustituyendo algunas técnicas clásicas, como el tratamiento de la hernia inguinal, por nuevos abordajes asistidos por laparoscopia. Material y métodos. Presentamos nuestra técnica y nuestros primeros resultados de 10 pacientes tratados mediante herniotomía inguinal percutánea asistida por laparoscopia. Para ello utilizamos un puerto umbilical, por el que introducimos una óptica de 5 mm y una pinza opcional de 2 mm. Mediante dos punciones a nivel inguinal con una aguja de epidural de 20 G se introduce un hilo de sutura de 3/0 irreabsorbible que recorre todo el trayecto del orifico y permite que, al traccionar de este es de la piel, se cierre el orifico inguinal, quedando el nudo de sutura bajo una incisión subcutánea de 2 mm. Resultados. Las edades de los pacientes varían entre 1 mes y 8 años con una mediana de 10 meses. El 50% de los pacientes fueron niños. El 50% de los pacientes tenían diagnóstico previo de hernia inguinalbilateral y el resto, unilateral, 3 de los 10 pacientes presentaron un diagnóstico postoperatorio distinto al previo. El tiempo de intervención medio fue de 32 minutos en hernias bilaterales, mayor en varones, y 19 (..) (AU)

Introduction. Thanks to the generalization of minimally invasivesurgery in pediatric patients some classic techniques are being replaced. Inguinal hernia repair may be an example. Material and methods. We present the technique and our first results in 10 patients treated by percutaneous laparoscopic assisted herniotomy. For this purpose we used an umbilical port, for a 5 mm camera and an optional2 mm grasper. By laparoscopic guidance we make two inguinal punctures with a 20G needle that introduces a non absorbable suture that crosses the whole inguinal defect and allows it closure by extracorporeal knot tying. Results. The ages ranged between 1 month and 8 years with a median age of 10 months. 50% of the patients were boys. 50% of the patients had previous diagnosis of inguinal bilateral hernia. 30% of patients presented a postoperatory diagnosis different from the previous one. The average time of intervention was 32 minutes in bilateral hernias, and 19 in the unilateral ones. Follow-up time was 6 months without complications. The aesthetic result was ideal. Conclusion. Percutaneous laparoscopic assisted herniotomy isan effective, simple and feasible option for inguinal hernia in chidren without a high rate of complications (..) (AU)

Hidronefrosis: manejo prenatal y postnatal / Hydronephrosis: perinatal and postnatal management

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Patología quirúrgica en pediatría. Diagnóstico. Edad de derivación. Tratamiento actualizado / Pediatric surgical pathology. Diagnosis. Referral age. Up-dated treatment

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[When is it best to perform enterostomy closure in premature infants with necrotizing enterocolitis?]. / ¿Cuándo es mejor cerrar la enterostomía en prematuros con enterocolitis necrosante?

UNLABELLED: INTRODUCION AND AIM: The enterostomy used in the treatment of Necrotizing Enterocolitis (NEC) causes many complications before and after its closure. The aim of this study was to examine the complications of closure aiming at determining the best timing for this operation. PATIENTS AND METHOD: Retrospective review patients (p) below 1500 g with NEC in whom the enterostomy was closed in the last seven years. P were divided into two groups: PC (planned closure after uncomplicated postoperative period) and CC (advanced closure due to stomal--excessive looses--or to parenteral nutrition complications--septicemia, liver dysfunction-). We compared the age at closure, time of enterostomy, weight gain and complications. RESULTS: Out of a total of 25 p requiring surgical treatment for NEC, 16 from the PC group and 9 from the CC group were included. The mean age at the moment of the closure were, respectively, 129 + 65 vs. 204 +/- 121 days (p < 0.05). Weight at closure was 2665 +/- 841 vs. 4665 +/- 2076 g (p < 0.05); the mean time with the enterostomy was 105 +/- 64 vs. 187 +/- 116 d (p < 0.05), and the weight gain was 1779 +/- 859 vs. 3693 +/- 2155 g (p < 0.05). After stomal closure, 7/16 p of the CC group (43%) and 2/9 of the PC group (22%) required reoperation due to severe complications (ns). In 4 of them, three of the CC group and one of the PC group, a new enterostomy was performed. CONCLUSIONS: In p with enterostomy-related complications, closure has often to be advanced and it is performed in deficient nutritional conditions. Severe complications after enterostomy closure required reoperation in 43% of the CC group and in 22% of the PC group. Although there was no statistically significant difference, the trend indicates an augmented risk in CC group. The timing for enterostomy closure should be chosen individually. At the time of indicating the closure, the high risk of complications, should be taken into account particularly in preterms with enterostomy-related problems.

Nefroureterectomía laparoscópica en el tumor de Wilms / Laparoscopic nephroureterectomy in wilms tumor

Introducción. La cirugía mínimamente invasiva (CMI) en el tratamiento de tumores malignos en la infancia comienza a tener un importante papel con resultados similares a la cirugía abierta en casos seleccionados. Presentamos nuestros dos primeros casos de tumor de Wilms tratados por laparoscopia. Material y métodos. Caso 1: niña de tres años de edad que acude or hematuria macroscópica. En el diagnóstico por imagen se identifi ca masa de 8 cm en riñón izquierdo en probable relación con tumor de Wilms. Tras 4 semanas de quimioterapia se realiza nefroureterectomía laparoscópica. El resultado anatomopatológico es tumor de Wilms estadio I de alto riesgo anaplásico. Se completa el tratamiento quimioterápico7 meses más. Caso 2: paciente de 5 años, diagnosticada de tumoración renal derecha de 6,5 cm en una ecografía realizada por abdominalgia en probable relación con tumor de Wilms. Después de 4semanas de quimioterapia se realiza nefroureterectomía laparoscópica. El resultado anatomopatológico es tumor de Wilms estadio II de alto riesgo (blastematoso). Se completa el tratamiento con quimioterapia ostoperatoria. Resultados. Después de 1 año de seguimiento ambas pacientes se encuentran libres de enfermedad. Conclusión. La CMI en casos seleccionados de tumor de Wilms cumple con éxito los objetivos del tratamiento quirúrgico (AU)

Introduction. Minimally invasive surgery (CMI) for the treatment of malignant tumors in children begins to have a role for selected cases and reaches similar results than open surgery. We show our first two cases of Wilms tumor treated by laparoscopy describing patients and technique. Material and methods. Three-year-old girl with macroscopic hematuriais diagnosed of 8 cm mass in the left kidney suggesting Wilms tumor. After 4 weeks of chemotherapy she went under laparoscopic nephroureterectomy. The histological result was Wilms tumor. Chemotherapy was completed seven more months. Five-year-old patient with abdominal pain is diagnosed of renal right mass suggesting Wilms tumor. After 4 weeks of chemotherapy the laparoscopic nephroureterectomy was performed. The histological result was Wilms tumor. Treatment was completes with postoperatory chemotherapy .Results. After 1 year follow-up both patients have clinical and radiological absence of disease. Conclusion. The CMI in selected cases of Wilms tumor fulfi llssuccessfully the aims of the surgical treatment (AU)

¿Cuándo es mejor cerrar la enterostomíaen prematuros con enterocolitis necrosante? / When is it best to perform enterostomy closure in premature infants with necrotizing enterocolitis?

Introducción y objetivos. Revisar las complicaciones del cierre de enterostomía usada en el tratamiento de la enterocolitis necrosante(ECN) con el fin de precisar el momento más oportuno para esta operación. Pacientes y métodos. Estudio retrospectivo de los pacientes (p)< 1.500 g con ECN y en quienes se cerró la ostomía en los últimos 7años. Dividimos a los pacientes en dos grupos: CP (cierre programado por evolución sin incidentes) y CC (cierre adelantado por complicaciones del estoma o de la nutrición parenteral). Comparamos edad en el momento del cierre, tiempo de enterostomía, ganancia ponderal y complicaciones. Resultados. De un total de 37 p, 16 (64%) se incluyeron en el grupoCC y 9 (36%) en el CP. La edad al cierre fue respectivamente de 129± 65 vs. 204 ± 121 días (p < 0,05). El peso en el momento del cierre fuede 2.665 ± 841 vs. 4.665 ± 2.076 g (p < 0,05), el tiempo medio con el (..) (AU)

Introduction and aim. The enterostomy used in the treatment of Necrotizing Enterocolitis (NEC) causes many complications before and after its closure. The aim of this study was to examine the complications of closure aiming at determining the best timing for this operation. Patients and method. Retrospective review patients (p) below1,500 g with NEC in whom the enterostomy was closed in the last seven years. P were divided into two groups: PC (planned closure after uncomplicated postoperative period) and CC (advanced closure dueto stomal –excessive looses– or to parenteral nutrition complications–septicemia, liver dysfunction–). We compared the age at closure, time (..) (AU)

[Laparoscopic nephroureterectomy in Wilms tumor]. / Nefroureterectomía laparoscópica en el tumor de Wilms.

INTRODUCTION: Minimally invasive surgery (CMI) for the treatment of malignant tumors in children begins to have a role for selected cases and reaches similar results than open surgery. We show our first two cases of Wilms tumor treated by laparoscopy describing patients and technique. MATERIAL AND METHODS: Three-year-old girl with macroscopic hematuria is diagnosed of 8 cm mass in the left kidney suggesting Wilms tumor. After 4 weeks of chemotherapy she went under laparoscopic nephroureterectomy. The histological result was Wilms tumor. Chemotherapy was completed seven more months. Five-year-old patient with abdominal pain is diagnosed of renal right mass suggesting Wilms tumor. After 4 weeks of chemotherapy the laparoscopic nephroureterectomy was performed. The histological result was Wilms tumor. Treatment was completes with postoperatory chemotherapy. RESULTS: After 1 year follow-up both patients have clinical and radiological absence of disease. CONCLUSION: The CMI in selected cases of Wilms tumor fulfills successfully the aims of the surgical treatment.