How human health and well-being depends on healthy marine habitats in the Mediterranean: A review.

Human health and well-being, and how they are affected by terrestrial and freshwater ecosystems have been the subject of numerous studies. In contrast, there are very few such studies relating to marine ecosystems. Here, in the context of the Mediterranean Sea, we assess evidence of the broad interplay of relationships between marine habitats and human health and well-being. Our review shows that the major Mediterranean marine habitats provide various provisioning, cultural and regulating services that improve physical and mental health in a number of different ways. These include: (i) the provision of seafood rich in omega-3 fatty acids, which help to reduce the risk of developing certain types of illnesses; and also, species that produce bioactive compounds that are potential sources of new drugs; (ii) the provision of blue spaces - areas of water suitable for leisure and recreational activities able to inspire, educate, and appeal to the aesthetic senses - that not only increase physical and psychological health, but also foster an individual and collective sense of place and identity and contribute to improving social relations; and (iii) the regulation of climate change, and of water quality and pollution, for example via sequestration of carbon and heavy metals, thus reducing the associated health risks. Our results show that Mediterranean marine habitats are valuable for health and well-being, thus highlighting the need to conserve as much of these habitats as possible (particularly through marine protected areas) and to carry out new studies to determine the specific causal pathways by which certain characteristics of marine habitats - including biotic (e.g. marine biodiversity) and abiotic (e.g. water quality) factors - affect human health and well-being.

Blue prescription: A pilot study of health benefits for oncological patients of a short program of activities involving the sea.

Performing outdoor activities in blue spaces can help improve human health and mental well-being by reducing stress and promoting social relationships. The number of people surviving cancer has increased globally to experience this disease as a life-changing and chronic condition with physical and psychosocial symptoms that have negative impacts on their quality of life. While there has been a growth of programs in green spaces to meet the needs of cancer patients, such as follow-up post-treatment care, support groups and physical activity programs, very few studies have examined the effects of activities involving the sea for the health and well-being of oncology patients. This is the first study to evaluate whether different outdoor activities in blue spaces can benefit oncological patients' physical and mental health using smartwatches, sphygmomanometers and Profile of Mood States (POMS) questionnaires. We assessed changes in blood pressure, heart rate, sleep quality and mental health of 16 patients after twelve sessions of three different activities (walking, beach and snorkelling) and four sessions of a control activity. While no significant differences between activities were observed in terms of the data gathered by the smartwatches, a gradient of positive results for human mental health was observed towards exposure to a blue space, assessed through POMS questionnaires. Results show that exposure to blue spaces contributes to tension and anger reduction and improves the vigour mood state of oncology patients. No significant increases in patients' heart rate were recorded after the beach and snorkelling activities, with results similar to the control activity, suggesting that the contribution may be to participants' relaxation.

A study of trophic structure, physiological condition and mercury biomagnification in swordfish (Xiphias gladius): Evidence of unfavourable conditions for the swordfish population in the Western Mediterranean.

Studies integrating trophic ecology, physiological condition and accumulation of heavy metals in top predators, such as swordfish, are needed to better understand the links between them and the risk to humans associated with consumption of these fish. This research focuses on the swordfish of the Catalan Sea and follows a multi method approach that considers their diet, their liver lipid content, and mercury accumulation in their bodies as well as in their prey. The aim is to highlight the links between trophic ecology, physiology (fish condition), and eco-toxicology. Results indicate that poor condition of swordfish based on size and the levels of lipid in the liver, and the high Hg levels accumulated to the trophic web (particularly from cephalopods) may indicate potential unfavourable feeding and reproduction conditions for swordfish in the NW Mediterranean and this warrants further investigation.

Unravelling the ecological impacts of large-scale offshore wind farms in the Mediterranean Sea.

The need for alternative energy systems like offshore wind power to move towards the Green Deal objectives is undeniable. However, it is also increasingly clear that biodiversity loss and climate change are interconnected issues that must be tackled in unison. In this paper we highlight that offshore wind farms (OWF) in the Mediterranean Sea (MS) pose serious environmental risks to the seabed and the biodiversity of many areas due to the particular ecological and socioeconomic characteristics and vulnerability of this semi-enclosed sea. The MS hosts a high diversity of species and habitats, many of which are threatened. Furthermore, valuable species, habitats, and seascapes for citizens' health and well-being coexist with compounding effects of other economic activities (cruises, maritime transport, tourism activities, fisheries and aquaculture) in a busy space on a narrower continental shelf than in other European seas. We argue that simply importing the OWF models from the northern European seas, which are mostly based on large scale projects, to other seas like the Mediterranean is not straightforward. The risks of implementing these wind farms in the MS have not yet been well evaluated and, considering the Precautionary Principle incorporated into the Marine Strategy Framework Directive and the Maritime Spatial Planning Directive, they should not be ignored. We propose that OWF development in the MS should be excluded from high biodiversity areas containing sensitive and threatened species and habitats, particularly those situated inside or in the vicinity of Marine Protected Areas or areas with valuable seascapes. In the absence of a clearer and comprehensive EU planning of wind farms in the MS, the trade-off between the benefits (climate goals) and risks (environmental and socioeconomic impacts) of OWF could be unbalanced in favor of the risks.

Environmental and human health impacts of cruise tourism: A review.

The intensive growth of cruise tourism worldwide during recent decades is leading to growing concerns over the sector's global environmental and health impacts. This review combines for the first time various sources of information to estimate the magnitude of the cruise industry's environmental and public health footprints. This research shows that cruising, despite technical advances and some surveillance programmes, remains a major source of air, water (fresh and marine) and land pollution affecting fragile habitats, areas and species, and a potential source of physical and mental human health risks. Health risks impact both the people on board (crew and passengers) and on land (workers of shipyards where cruise ships are dismantled and citizens inhabiting cities with cruise ports and shipyards). In this context, we argue that the cruise industry should be held accountable with more monitoring and regulation to prevent or minimize the growing negative environmental and human health impacts.

The Bioactive Potential of Trawl Discard: Case Study from a Crinoid Bed Off Blanes (North-Western Mediterranean).

Although knowledge of the bioactive compounds produced by species inhabiting coastal waters is increasing, little is known about the bioactive potential produced by marine species occupying deeper habitats with high biodiversity and productivity. Here, we investigate about the bioactive potential of molecules produced by species that inhabit the crinoid beds, a poorly known essential fish habitat affected by trawling, wherein large amounts of commercial and noncommercial species are discarded. Based on a trawl survey conducted in 2019, 14% of the 64 species discarded on crinoid beds produce molecules with some type of bioactive potential, including; soft corals (Alcyonium palmatum); tunicates (Ascidia mentula); bony fish, such as horse mackerel (Trachurus trachurus); European hake (Merluccius merluccius); and chondrichthyans, such as small-spotted catshark (Scyliorhinus canicula). In addition, 16% of the discarded species had congeneric species that produce compounds with bioactive potential, indicating that such species might also possess similar types of bioactive molecules. Molecules with antioxidant, antitumour, antihypertensive, and antibacterial properties were the most frequent, which could provide the basis for future research aiming to discover new marine-based drugs and compounds for other human uses. Among all species or genera that produce compounds with bioactive potential, 68% presented medium or high vulnerability to trawling. Results show that the discarded catch contains many species, which produce different bioactive compounds that represent an added-value resource. These results highlight the importance of manage properly crinoid beds, to ensure that species that produce molecules with bioactive potential inhabiting these habitats are protected.

The poor health of deep-water species in the context of fishing activity and a warming climate: will populations of Molva species rebuild or collapse?

Many deep-water fish populations, being K-selected species, have little resilience to overexploitation and may be at serious risk of depletion as a consequence. Sea warming represents an additional threat. In this study, the condition, or health, of several populations of common ling (Molva molva), blue ling (Molva dypterygia) and Mediterranean or Spanish ling (Molva macrophthalma) inhabiting different areas in the North Atlantic and the Mediterranean was evaluated, to shed light on the challenges these deep-water species are facing in the context of fishing activity and a warming climate. The data on the condition of Molva populations which are analysed here have been complemented with data on abundance and, for the southernmost species (Mediterranean ling), with two other health indicators (parasitism and hepato-somatic index). Despite some exceptions (e.g., common ling in Icelandic waters), this study shows that the condition of many populations of Molva species in the northeastern Atlantic and the Mediterranean Sea has worsened, a trend which, in recent decades, has usually been found to be accompanied by a decline in their abundance. In addition, the poor health status of most populations of common ling, blue ling and Mediterranean ling considered in this analysis points to a lower sustainability of these populations in the future. Overall, the health status and abundance of Molva populations in the northeastern Atlantic and the Mediterranean suggest that only some populations located in the North Atlantic may be able to rebuild, whereas the populations in southern North Atlantic and the Mediterranean, which are probably most at risk from sea warming, are facing serious difficulties in doing so. In the context of fisheries and global warming, this study's results strongly indicate that management bodies need to consider the health status of many of the populations of Molva species, particularly in southern European waters, before implementing their decisions.

Benefits of Outdoor Sports in Blue Spaces. The Case of School Nautical Activities in Viana do Castelo.

Participating in outdoor sports in blue spaces is recognized to produce a range of significant social benefits. This case study empirically analyzes the social benefits associated with the School Nautical Activities project carried out in Viana do Castelo (Portugal) in school-age children and adolescents. It consisted of a 4 year program in which scholars took part in nautical activities (surfing, rowing, sailing, and canoeing) in blue spaces once a week during a semester as a part of their physical education course. The methods used for data collection were as follows: (1) a survey answered by 595 participants in the program and (2) five focus groups (FG): two FGs with participants (seven on each FG), two FGs with their parents (eight participants each), and one FG with the physical education teachers (five participants). Interviews were transcribed and qualitative analysis with NVivo software was developed. Results revealed clear evidence on the social benefits for school-age children and adolescents associated with participation in outdoor activities in blue spaces both in the overall health and in all the following analyzed categories: mental health and well-being, education, active citizenship, social behavior, and environmental awareness. More than 40% state that their overall health is much better now (13.4%) or somewhat better now (29.9%) due to their participation in the program. Thus, this article provides support for the anecdotal recognition of the benefits for school-age children and adolescents from participating in sports in the outdoors and especially in blue spaces.

The Beneficial Effects of Short-Term Exposure to Scuba Diving on Human Mental Health.

Exposure to outdoor blue spaces can help improve human health by reducing stress, promoting social relationships, and physical activity. While most studies have focused on the adverse health effects of scuba diving, very few have assessed its health benefits. Moreover, when scuba diving is done in large groups with no diving instructor or pre-dive briefing, negative environmental impacts are generated and negative impacts on human health may also occur due to overcrowding, which may create stress. This is the first study to evaluate the effects of scuba diving on divers' mental health using their diving practices to estimate the impacts on the ecosystem. In the marine-protected area of Cap de Creus and adjacent areas, we assessed the mental health of 176 divers and 70 beach users (control group) by employing a 29-item version of Profile of Mood State (POMS) questionnaires. According to the parameters associated with reduced environmental impacts, two scuba diving experiences were established. Poisson regression models were performed to assess both the contribution of the activity and diving experiences to POMS scores. Both groups (scuba divers and beach goers) reduced their POMS scores after carrying out the activities. Although no significant differences were found between beach and scuba diving activities, nor between the two different scuba diving experiences, our results showed that subjects with regular medication intake due to a chronic or psychiatric illness had a POMS reduction score significantly higher than other subjects. We conclude that both beach and scuba diving activities have positive effects for human mental health, particularly among subjects with regular medication intake.

The Roses Ocean and Human Health Chair: A New Way to Engage the Public in Oceans and Human Health Challenges.

Involving and engaging stakeholders is crucial for studying and managing the complex interactions between marine ecosystems and human health and wellbeing. The Oceans and Human Health Chair was founded in the town of Roses (Catalonia, Spain, NW Mediterranean) in 2018, the fruit of a regional partnership between various stakeholders, and for the purpose of leading the way to better health and wellbeing through ocean research and conservation. The Chair is located in an area of the Mediterranean with a notable fishing, tourist, and seafaring tradition and is close to a marine reserve, providing the opportunity to observe diverse environmental conditions and coastal and maritime activities. The Chair is a case study demonstrating that local, collaborative, transdisciplinary, trans-sector, and bottom-up approaches offer tremendous opportunities for engaging coastal communities to help support long-lasting solutions that benefit everyone, and especially those living by the sea or making their living from the goods and services provided by the sea. Furthermore, the Chair has successfully integrated most of its experts in oceans and human health from the most prestigious institutions in Catalonia. The Chair focuses on three main topics identified by local stakeholders: Fish and Health; Leisure, Health, and Wellbeing; and Medicines from the Sea. Led by stakeholder engagement, the Chair can serve as a novel approach within the oceans and human health field of study to tackle a variety of environmental and public health challenges related to both communicable and non-communicable diseases, within the context of sociocultural issues. Drawing on the example provided by the Chair, four principles are established to encourage improved participatory processes in the oceans and human health field: bottom-up, "think local", transdisciplinary and trans-sectorial, and "balance the many voices".

Twilight activity patterns and angling vulnerability of yellowmouth barracuda (Sphyraena viridensis Cuvier, 1829), a range-expanding thermophilic fish.

Among the thermophilic fishes that have become established in the north-western Mediterranean as a consequence of sea warming, the yellowmouth barracuda (Sphyraena viridensis Cuvier, 1829) appears to be one of the most successful and abundant in the coastal rocky environment, having increasingly become the object of recreational and commercial exploitation in the study area. Lure-fishing sessions were carried out from May 2016 to November 2018 in the Catalan Sea (NE Spain) at dawn and dusk, with the aim of providing new insight into the behavioural, spatial and feeding ecology and vulnerability to angling of this poorly known species. Generalized mixed-effects linear models showed that S. viridensis is a crepuscular inshore dweller, whose vulnerability to angling is significantly influenced by solar and lunar light intensities, being highest in the pre-spawn and spawning periods. Asymmetries between dawn and dusk activity patterns were detected, evidently related to a drop in aggressiveness at dusk following the spawning period. The simple study design adopted may be applied to other contexts, aiming to the recognition of several levels of fish vulnerability to angling.

Fatty acid composition and parasitism of European sardine (Sardina pilchardus) and anchovy (Engraulis encrasicolus) populations in the northern Catalan Sea in the context of changing environmental conditions.

The status of sardine and anchovy populations in the northern Mediterranean Sea has been declining in recent decades. In this study, fatty acids and parasitism at different reproductive and feeding stages in these two species were assessed using specimens caught along the northern Catalan coast, in order to assess the links between lipid dynamics, reproduction and feeding in these two species and to contribute towards an explanation of the potential causes of the current poor situation of the stocks. The results support the use of fatty acid levels as indicators of the body condition of sardine and anchovy at different reproductive and feeding stages, as well as that of the pelagic environmental conditions. In particular, the relatively low n-3 polyunsaturated fatty acid levels found in spawning sardines compared to spawning anchovies indicate a poorer reproductive health status of sardine. By comparing the current total lipid content values with those recorded in other Mediterranean and North Atlantic areas, and others from more than 10 years ago, in the adjacent area of the Gulf of Lion, our study reveals the persistent poor condition of sardine and anchovy in the northern Catalan Sea. Furthermore, the low levels of diatom fatty acid markers observed throughout the spawning and non-spawning seasons in both sardine and anchovy indicate a diet poor in diatoms. Moreover, the results indicate that it is very unlikely that parasitism is a significant factor in the decline in condition of sardine and anchovy in the northern Catalan Sea. In fact, the results, which we believe provide useful insights for the management of small pelagic fisheries in the Mediterranean, suggest that the current poor condition of sardine and anchovy in the northern Catalan Sea has probably been exacerbated by a decrease in plankton productivity and/or a shift in the taxonomic composition of phytoplankton communities, adding to the ongoing effects of overfishing.

New insights in oocyte dynamics shed light on the complexities associated with fish reproductive strategies.

Information on temporal variations in stock reproductive potential (SRP) is essential in fisheries management. Despite this relevance, fundamental understanding of egg production variability remains largely unclear due to difficulties in tracking the underlying complex fluctuations in early oocyte recruitment that determines fecundity. We applied advanced oocyte packing density theory to get in-depth, quantitative insights across oocyte stages and seasons, selecting the commercially valuable European hake (Merluccius merluccius) as a case study. Our work evidenced sophisticated seasonal oocyte recruitment dynamics and patterns, mostly driven by a low-cost predefinition of fecundity as a function of fish body size, likely influenced also by environmental cues. Fecundity seems to be defined at a much earlier stage of oocyte development than previously thought, implying a quasi-determinate - rather than indeterminate - fecundity type in hake. These results imply a major change in the conceptual approach to reproductive strategies in teleosts. These findings not only question the current binary classification of fecundity as either determinate or indeterminate, but also suggest that current practices regarding potential fecundity estimation in fishes should be complemented with studies on primary oocyte dynamics. Accordingly, the methodology and approach adopted in this study may be profitably applied for unravelling some of the complexities associated with oocyte recruitment and thereby SRP variability.

Trade-offs between life-history traits in a coldwater fish in the Mediterranean Sea: the case of blue whiting Micromesistius poutassou.

A combination of traditional and emerging methodologies was used to assess the trade-offs between several life-history traits (linked to reproduction and condition) and parasitism in a commercially-exploited cold-water species, blue whiting Micromesistius poutassou, in the Mediterranean Sea. The use of histological and gravimetric methods revealed conflicting evidence as to the fecundity type (indeterminate or determinate) of this species. Moreover, there seem to be condition-mediated compensations between egg quality and egg quantity. The effects of parasitism on reproduction and condition are species-specific and occur mainly at high intensities of infection; they include a lower batch fecundity (affecting reproductive potential), a higher hepatosomatic index and a higher spleen-somatic index. Considering the fact that larger fish spawn more eggs and that the minimum landing size is lower than the size at maturity, these results may have implications for the future management of M. poutassou stocks in the Mediterranean Sea. Local environmental conditions may account for geographical differences regarding infection in M. poutassou. Altogether, the results support the idea that the complex trade-offs between parasitism, reproduction and condition need to be considered in order to understand the status of cold-water species such as M. poutassou.

Management of neonates with right-sided aortic arch and esophageal atresia: International survey on IPEG AND ESPES members´ experience.

AIM: The optimum surgical approach of neonates with right-sided aortic arch (RAA) and esophageal atresia (EA)/tracheoesophageal fistula (TEF) is still an unsolved question. In order to propose an operative algorithm in the era of endoscopic surgery, we performed an international survey to know the current practice between pediatric endoscopic surgeons. Two of the most important societies in endoscopic pediatric surgery were queried: the International Pediatric Endosurgery Group (IPEG) and the European Society of Paediatric Endoscopic Surgeons (ESPES). MATERIALS AND METHODS: During December 2016, an anonymous online-based survey was sent to all IPEG and ESPES members, collecting data regarding perioperative management and surgical repair of EA/TEF with RAA. RESULTS: 144 surgeons from 23 countries completed the questionnaire. 69.2% of respondents were IPEG members, 30.8% were ESPES members. 71.5% of members who answered the survey had more than 10years of surgical experience. A preoperative echocardiography was almost uniformly performed (93.1%). 31.9% of the surveyed surgeons had never treated an EA/TEF with RAA. The remaining 98 surveyed surgeons had managed 279 cases of EA/TEF with RAA. Thoracotomy was considered the preferred approach for 54.2% of the surgeons, and 51.9% chose a right-sided approach. When RAA was an intraoperative finding, 76% would perform a contralateral thoracotomy if difficulties arose. Thoracoscopy was preferred by 45.8% of surgeons. If RAA was suspected preoperatively, 63.1% preferred to attempt a left-sided thoracoscopy and only 24.2% would change their approach to a thoracotomy. If RAA was an intraoperative finding and a safe surgical repair could not be achieved through right-sided thoracoscopy, 51.5% of them chose to perform a left sided thoracoscopy, rather than convert to thoracotomy. CONCLUSIONS: Preoperative echocardiography performed by experienced examiners helps in surgical planning. Preoperative diagnosis of RAA should not discourage thoracoscopic repair, which is increasingly becoming more popular for the correction of EA/TEF. In case of an unexpected intraoperative diagnosis of RAA or operative difficulties when approaching through the right side, thoracoscopy offers a less aggressive approach. LEVEL OF EVIDENCE: V.

Kidney transplantation in children weighing 15 kg or less is challenging but associated with good outcome.

OBJECTIVE: Pediatric kidney transplantation (KT) in small children is assumed to be related to potential surgical complications that may cause severe morbidity and graft loss. The aim of our study was to analyze the outcome of KT recipients weighing ≤15 kg, focusing on surgical complications, associated morbidity and mortality, as well as allograft loss. METHODS: We reviewed our retrospective institutional database for recipients of KT between January 2000 and December 2014 with body weight ≤15 kg. RESULTS: Forty-four children weighing ≤15 kg, out of a total of 164 children (26.8%), received a deceased donor KT at our center during the study period. Mean weight was 10.10 ± 2.9 kg (3-15 kg), and weight was ≤10 kg in 23 patients (52.3%). The allograft was implanted intraperitoneally in two cases (4.5%) and extraperitoneally in the remaining 42 (95.5%). Two patients received a simultaneous double liver-kidney transplant. Postoperative complications appeared in 10 patients (22.7%) and eight required reintervention. Five allografts (11.4%) were lost secondary to surgical complications. No statistically significant differences in surgical complications were observed when compared with patients weighing >15 kg. Actuarial graft survival was 81% and 73% at 1 and 5 years, respectively. No significant differences in graft survival were observed compared with patients >15 kg. Mean follow-up was 84.95 ± 50 months (1-190 months). CONCLUSIONS: Our results demonstrate that KT in children weighing ≤15 kg is challenging but not associated with increased risk of surgical complications or early graft loss.

Body reserves mediate trade-offs between life-history traits: new insights from small pelagic fish reproduction.

Limited resources in the environment prevent individuals from simultaneously maximizing all life-history traits, resulting in trade-offs. In particular, the cost of reproduction is well known to negatively affect energy investment in growth and maintenance. Here, we investigated these trade-offs during contrasting periods of high versus low fish size and body condition (before/after 2008) in the Gulf of Lions. Female reproductive allocation and performance in anchovy (Engraulis encrasicolus) and sardine (Sardina pilchardus) were examined based on morphometric historical data from the 1970s and from 2003 to 2015. Additionally, potential maternal effects on egg quantity and quality were examined in 2014/2015. After 2008, the gonadosomatic index increased for sardine and remained steady for anchovy, while a strong decline in mean length at first maturity indicated earlier maturation for both species. Regarding maternal effects, for both species egg quantity was positively linked to fish size but not to fish lipid reserves, while the egg quality was positively related to lipid reserves. Atresia prevalence and intensity were rather low regardless of fish condition and size. Finally, estimations of total annual numbers of eggs spawned indicated a sharp decrease for sardine since 2008 but a slight increase for anchovy during the last 5 years. This study revealed a biased allocation towards reproduction in small pelagic fish when confronted with a really low body condition. This highlights that fish can maintain high reproductive investment potentially at the cost of other traits which might explain the present disappearance of old and large individuals in the Gulf of Lions.

Links between parasitism, energy reserves and fecundity of European anchovy, Engraulis encrasicolus, in the northwestern Mediterranean Sea.

The European anchovy, Engraulis encrasicolus L. 1758, is one of the most sought-after target species in the northwestern Mediterranean Sea. However, this stock currently consists of small individuals, and landings are reported to have decreased considerably. The main purpose of this study was to assess, for the first time, the interrelationships between size, fecundity, energy reserves and parasitism in female anchovies, in order to analyse the potential implications for the health of northwestern Mediterranean anchovy stocks arising from the current shortage of large individuals. Results revealed that smaller individuals show lower fecundity, lower lipid content and a higher intensity of certain parasites. As it is known that smaller individuals now predominate in the population, the relationships found in this study indicate that the health of anchovies from the northwestern Mediterranean is currently impaired.

Evaluation of the Initial Treatment of Ureteroceles.

OBJECTIVE: To assess the results of the initial therapeutic approach to ureteroceles at our institution and the need for further interventions. PATIENTS AND METHODS: This is a retrospective study of all pediatric cases of ureterocele diagnosed at our center between January 2000 and December 2011. RESULTS: Forty-three patients were analyzed. Initial diagnoses were ureterohydronephrosis in 34 (33 prenatal), febrile urinary tract infection in 5, and prolapsed ureterocele in 3. Expectant management was decided upon in 6 patients (14%). Of these, 1 required surgery. The remaining 37 (86%) initially underwent surgery: transurethral puncture (18), heminephrectomy (14), nephrectomy (3), and reimplantation (2). Twelve (66.6%) of the 18 patients who underwent primary puncture progressed well and required no further intervention. New-onset vesicoureteral reflux to the upper pole appeared after puncture in 3 patients, but none required treatment. Only 6 patients (33.3%) underwent a second procedure. Mean follow-up was 8.5 years (standard deviation: 3.08). CONCLUSION: Early endoscopic puncture is useful for decompression and often the definitive treatment. Although new-onset vesicoureteral reflux into the punctured system is the most common complication, it often resolves spontaneously. Early heminephrectomy in patients with nonfunctioning upper moieties yields excellent results but may not be necessary. Some patients may not need transurethral puncture or any surgical intervention at all.