Testicular-sparing surgery in the pediatric population: Multicenter review of practice with review of the literature

Purpose of review Pediatric testicular tumors have predominantly favorable histology, which may permit testicular sparing surgery (TSS). Limited guidance exists for TSS in adults and is absent in pediatric practice. The international survey and retrospective case series evaluated the current use of TSS in pediatric testicular tumors. Alongside the complementary literature review, the aim of this work was to provide evidence that could be used to produce a guideline document. Recent findings Published evidence advocates small mass size as an indicator for TSS, this was not supported in the pediatric literature. Frozen section examination at TSS was not always performed by surgeons and yet the literature reports close to 100% specificity. Tumor markers and ultrasound findings are also used as indicators for TSS, a finding reflected in our survey results. Summary Multiple case series are reported but no large data series exists, which will require international collaboration rather than a drive to publish the results of individual centers. Common indicators for TSS use; such as tumor markers and imaging are known but further work needs to evaluate the role of on-table histology and the risks of this not being available

Reflective Practice About Retroperitoneal Laparoscopy in Comparison to Open Surgery for Ureteropelvic Junction Obstruction Repair in Children Less Than 1 Year of Age

Introduction: The interest in laparoscopy in the treatment of ureteropelvic junction obstruction (UPJO) in children under 12 months of age remains controversial. The aim of this study is to evaluate feasibility and benefits of retroperitoneal laparoscopy (RL) compared to open surgery in this age group.Materials and Methods: Between January 2012 and May 2017, we performed 222 pyeloplasties: 144 by laparoscopy and 78 by open surgery. From 2012, the choice of operative technique was decided according to the laparoscopic experience of the surgeon; two surgeons operated laparoscopically on all children <12 months of age, while others operated using posterior lumbotomy (PL). The RL is standardized and performed by 3 trocars (5, 3, 3). Pre, per and postoperative parameters were analyzed retrospectively. Statistical tests: Pearson, Fisher, Student and Mann-Whitney.Results: During this 5-year period, 24 RL and 53 PL were included with a median follow-up of 27 months (5–63). In the LR group, postoperative drainage was performed by JJ (13 cases) and external stent (11 cases). No conversion has been listed in this group. In each group there was one failure that needed redo pyeloplasty. Duration of hospitalization and intravenous acetaminophen use were significantly lower in the RL group (2.8 vs. 2.3 days, p = 0.02, respectively) while operating time was significantly longer (163 vs. 85.8 min, p = 0.001). The postoperative complication rate was statistically identical in each group (urinary tract infection, wall hematoma, hematuria…).Conclusion: RL is feasible in children under 1 year of age in the hands of well-experienced surgeons with longer operative time but without added morbidity. Subject to the retrospective nature of our study, the RL seems to offer a benefit regarding duration of hospitalization and analgesics consumption

Management of lower urinary tract fibroepithelial polyps in children

Introduction Fibroepithelial polyps (FEP) of the lower urinary tract are relatively common in adults but rare in children, with fewer than 250 cases reported in the literature to date. Objective The aim of this study was to address the experience of FEP management in children. Study design A retrospective multicenter review was undertaken in children with defined FEP of the lower urinary tract managed between 2008 and 2018. The data at 18 pediatric surgery centers were collected. Their demographic, radiological, surgical, and pathological information were reviewed. Results A total of 33 children (26 boys; 7 girls) were treated for FEP of the lower urinary tract at 13 centers. The most common presentation was urinary outflow as hematuria (41%), acute urinary retention (25%), dysuria (19%), or urinary infections (28%). A prenatal diagnosis was made for three patients with hydronephrosis. Almost all of the children (94%) underwent ultrasound imaging of the urinary tract as the first diagnostic examination, 23 (70%) of them also either had an MRI (15%), cystourethrography (25%), computerized tomography (6%), or cystoscopy (45%). Two of these children (6%) had a biopsy prior to the surgery. The median preoperative delay was 7.52 (range: 1–48) months. Most of the patients were treated endoscopically, although four (12.1%) had open surgery and two (6.1%) had an additional incision for specimen extraction. The median hospital stay was 1.5 (range: 1–10) days. There were no recurrences and no complications after a median follow-up of 13 (range: 1–34) months. Discussion The main limitation of our study is the retrospective design, although it is the largest one for this pathology. Conclusion This series supports sonography as the most suitable diagnosis tool before endoscopy to confirm the diagnosis and to perform the resection for most FEP in children. This report confirms the recognized benign nature in the absence of recurrences

Financial and relational impact of having a boy with posterior urethral valves

IntroductionChildhood chronic diseases affect family functioning and well-being. The aim of this study was to measure the impact of caring for a child with PUV, and the factors that most impact the burden of care.Patients and methodWe gave a questionnaire on the familial impact of having a child with posterior urethral valves to all parents of a child included in the CIRCUP trial from 2015 onwards. The questionnaire included questions about the parents' demographics, health, professional, financial and marital status and how these evolved since the child's birth as well as the “impact on family scale” (IOFS), which gives a total score ranging from 15 (no impact) to 60 (maximum impact). We then analyzed both the results of the specific demographic questions as well as the factors which influenced the IOFS score.ResultsWe retrieved answers for 38/51 families (74.5% response rate). The average IOFS score was 23.7 (15–51). We observed that the child's creatinine level had an effect on the IOFS score (p = 0.02), as did the parent's gender (p = 0.008), health status (p = 0.015), being limited in activity since the birth of the child (p = 0.020), being penalized in one's job (p = 0.009), being supported in one's job (p = 0.002), and decreased income (p = 0.004). Out of 38 mother/father binomials, 8/33 (24.2%) declared that they were no longer in the same relationship afterwards.ConclusionIn conclusion, having a boy with PUV significantly impacts families. The risk of parental separation and decrease in revenue is significant. Strategies aiming to decrease these factors should be put in place as soon as possible

Pathogenic variants in the DEAH-box RNA helicase DHX37 are a frequent cause of 46,XY gonadal dysgenesis and 46,XY testicular regression syndrome

XY individuals with disorders/differences of sex development (DSD) are characterized by reduced androgenization caused, in some children, by gonadal dysgenesis or testis regression during fetal development. The genetic etiology for most patients with 46,XY gonadal dysgenesis and for all patients with testicular regression syndrome (TRS) is unknown

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Genetic Pathways Implicated in Male Genitalia Differentiation

Introduction. L’étiopathogénie de l’hypospadias reste largement discutée, faisant intervenir des facteurs endocriniens, génétiques, vasculaires et environnementaux. Objectifs. Étudier les mécanismes génétiques impliquées dans la différenciation sexuelle masculine. Matériels et méthodes. Une cohorte de 284 patients a été établie depuis 2011 pour séquençage de l’ADN lymphocytaire, préputial et urothélial de trois gènes candidats (NR5A1, MAMLD1, AR). Une analyse pangénomique (puce à ADN et Whole Exome Sequencing (WES)) a été réalisée. Le registre REMAPAR a été utilisé pour analyser l’association entre hormone chorionique gonadotrophique (hCGb) maternelle et hypospadias. Résultats. Des polymorphismes dans AR ont une fréquence allélique significativement plus élevée (p<0,01). Des variations non décrites des trois gènes ne semblent pas susceptibles d’altérer l’épissage. Une duplication hétérozygote intragénique de NR5A1 a été retrouvée chez un individu. Par ailleurs, 35 anomalies (15,7%) pouvant être en lien avec l’hypospadias ont été identifiées par puces à ADN englobant 25 gènes candidats. L’analyse WES a mise en évidence 22 nouveaux variants. Enfin, une association a été constatée pour l’hCGb surtout en cas de forme sévère et après ajustement pour dysfonction placentaire (p<0,03). Conclusion. L’étude des trois gènes candidats n’a pas vérifié l’hypothèse selon laquelle les séquences lymphocytaires et sur les tissus cibles seraient différentes. Cependant, l’analyse pangénomique a trouvé 15,7% anomalies et 47 gènes potentiellement candidats. L’utilisation des nouveaux outils d’analyse génétique semble essentielle à la compréhension des mécanismes conduisant à l’hypospadias.Background. Hypospadias is the most common malformation affecting the male genitalia. Although the causes remain often unknown, endocrine, vascular and environmental factors have been implicated. However, the genetic basis is probably underestimated. Objectives. To study the genetic factors implicated in sexual differentiation. Methods. A cohort of 284 children born with hypospadias has been established since 2011. DNA was extracted from blood lymphocytes and fibroblasts obtained after a foreskin biopsy. Sanger sequencing of AR, MAMLD1 and NR5A1, SNP-array analysis, and Whole Exome Sequencing (WES) were performed. A second cohort of 1,311 pregnant women was established to evaluate an association between maternal fhCGb and hypospadias. Results. No mutation in AR and MAMLD1 was found. Non-described variations of AR, MAMLD1 and NR5A1 were identified without any splicing activity. Some polymorphisms in AR gene had a MAF significantly higher (p<0.01). A heterozygous intragenic duplication of NR5A1 was found. Pangenomic analysis included 35 anomalies (15.7%) that could be a potential cause of isolated, distal, non-hereditary hypospadias encompassing 25 candidate genes. 22 variants was classified as pathogenic on WES. Finally, a significant difference of fhCGb for severe types was identified even after adjustment for placenta dysfunction (p<0.03). Conclusion. Our hypothesis about “somatic” mutations in 3 candidate genes was not ascertained. However, pangenomic analysis found 15.7% anomalies which could be likely linked to hypospadias. The use of WES could be an attractive method for exploring further these results as we identified 22 variants in 30 cases of familial hypospadias

Mécanismes physiopathologiques impliqués dans la différenciation du tractus génital masculin

Background. Hypospadias is the most common malformation affecting the male genitalia. Although the causes remain often unknown, endocrine, vascular and environmental factors have been implicated. However, the genetic basis is probably underestimated. Objectives. To study the genetic factors implicated in sexual differentiation. Methods. A cohort of 284 children born with hypospadias has been established since 2011. DNA was extracted from blood lymphocytes and fibroblasts obtained after a foreskin biopsy. Sanger sequencing of AR, MAMLD1 and NR5A1, SNP-array analysis, and Whole Exome Sequencing (WES) were performed. A second cohort of 1,311 pregnant women was established to evaluate an association between maternal fhCGb and hypospadias. Results. No mutation in AR and MAMLD1 was found. Non-described variations of AR, MAMLD1 and NR5A1 were identified without any splicing activity. Some polymorphisms in AR gene had a MAF significantly higher (p<0.01). A heterozygous intragenic duplication of NR5A1 was found. Pangenomic analysis included 35 anomalies (15.7%) that could be a potential cause of isolated, distal, non-hereditary hypospadias encompassing 25 candidate genes. 22 variants was classified as pathogenic on WES. Finally, a significant difference of fhCGb for severe types was identified even after adjustment for placenta dysfunction (p<0.03). Conclusion. Our hypothesis about “somatic” mutations in 3 candidate genes was not ascertained. However, pangenomic analysis found 15.7% anomalies which could be likely linked to hypospadias. The use of WES could be an attractive method for exploring further these results as we identified 22 variants in 30 cases of familial hypospadias.Introduction. L’étiopathogénie de l’hypospadias reste largement discutée, faisant intervenir des facteurs endocriniens, génétiques, vasculaires et environnementaux. Objectifs. Étudier les mécanismes génétiques impliquées dans la différenciation sexuelle masculine. Matériels et méthodes. Une cohorte de 284 patients a été établie depuis 2011 pour séquençage de l’ADN lymphocytaire, préputial et urothélial de trois gènes candidats (NR5A1, MAMLD1, AR). Une analyse pangénomique (puce à ADN et Whole Exome Sequencing (WES)) a été réalisée. Le registre REMAPAR a été utilisé pour analyser l’association entre hormone chorionique gonadotrophique (hCGb) maternelle et hypospadias. Résultats. Des polymorphismes dans AR ont une fréquence allélique significativement plus élevée (p<0,01). Des variations non décrites des trois gènes ne semblent pas susceptibles d’altérer l’épissage. Une duplication hétérozygote intragénique de NR5A1 a été retrouvée chez un individu. Par ailleurs, 35 anomalies (15,7%) pouvant être en lien avec l’hypospadias ont été identifiées par puces à ADN englobant 25 gènes candidats. L’analyse WES a mise en évidence 22 nouveaux variants. Enfin, une association a été constatée pour l’hCGb surtout en cas de forme sévère et après ajustement pour dysfonction placentaire (p<0,03). Conclusion. L’étude des trois gènes candidats n’a pas vérifié l’hypothèse selon laquelle les séquences lymphocytaires et sur les tissus cibles seraient différentes. Cependant, l’analyse pangénomique a trouvé 15,7% anomalies et 47 gènes potentiellement candidats. L’utilisation des nouveaux outils d’analyse génétique semble essentielle à la compréhension des mécanismes conduisant à l’hypospadias