Does intraoperative success predict outcome in the treatment of urethral sphincter insufficiency with bulking agent?

Introduction Sphincter insufficiency is mostly associated with neurogenic and some structural abnormalities in the pediatric population. As a mini-invasive treatment, urethral bulking agents have been used to treat this problem. Objective The aim was to evaluate if technical success, defined as intraoperative increase in abdominal leak point pressure (ALPP), predicts the outcome of the treatment of sphincter insufficiency with urethral bulking agent. Study design We reviewed all children treated first time with dextranomer/hyaluronicacid (Dx/HA) copolymer (Deflux) for urethral sphincter insufficiency and who intraoperatively had ALPPs measured during 2004-2014. Patient characteristics, change in urinary continence and the duration of the possible response were evaluated in neurogenic and non-neurogenic cases. Results The median age of the patients was 7.8 years (range 4.1-14.5) at initial treatment and median volume of Dx/HA instilled was 3.5 mL (IQR 2-5). Twelve patients had neurogenic disease and 15 had nonneurogenic disease. Median ALPPs before and after the injections were 19 cmH(2)O (IQR 14-28) and 70 cmH(2)O (IQR 48-80), p <0.001. Increases in ALPPs were similar in both patient groups (p = 0.661) and in 17 patients with any response and 10 patients with no response (p = 0.267). In patients with any response the median duration of the response was only 0.8 years (IQR 0.09-2.0). During a median follow-up of 4.9 years (range 1.7-11.8), 15 patients received one to three repeat injections and eight patients went through sling or bladder neck operation (Summary table). During repeat injections, the preoperative ALPPs had returned injections, the preoperative ALPPs had returned to the original levels. Currently, 20% are continent or almost continent with one or more Dx/HA injections. In half of the patients with neurogenic bladder, compliance or volume deteriorated slightly in follow-up. Five out of 15 patients who reached puberty become continent spontaneously after failed bladder neck injection. Discussion Intraoperative ALPPs increased significantly in most patients during the procedure. However, only 52% of the patients experienced more than 1 month of success after the procedure, and even in those the effect lasted mostly under a year. With one to four injections one-fifth seem to have had a good longterm result. Although the long-term success rate is limited, bulking agent injection allowed the patients with spontaneous voiding to continue it and the injection did not prevent future treatments. Conclusion Intraoperative increased ALPP does not predict a good long-term outcome after Dx/HA injection. At the end, only a fifth of our patients had good result with one or more Dx/HA injections. A change in bladder behavior is possible after treatment.Peer reviewe

Introduction of Pediatric Robot-Assisted Pyeloplasty in A Low-Volume Centre

(1) Background: This study investigated the introduction of pediatric robot-assisted pyeloplasty in a low-volume centre with reference to open pyeloplasty with regards to operative times, length of stay (LOS) and outcomes and cost analysis. (2) Methods: Data from 10 consecutive robot-assisted pyeloplasties was compared retrospectively to an age and weight matched cohort of open pyeloplasties operated on during two previous years. Operative times were analyzed in conjunction with LOS, outcomes and cost-analysis from patient records. (3) Results: Operative times remain longer in robot-assisted pyeloplasties (168 (IQR 68) vs. 141 (IQR 51) min), but patients are discharged from the hospital earlier and may return to daily activities earlier. In our hospital, the difference in LOS levels to some degree the cost difference between operations. (4) Conclusions: Robot-assisted pyeloplasty can be safely and economically introduced and maintained in a low-volume centre.Peer reviewe

Retrovesical cysts in boys-case series and literature review

Background: Retrovesical cysts present with varying etiologies. We initiated this study to provide insights into retrovesical cysts in boys through a case series and systematic literature review and to aid in treatment alternatives. Materials and methods: Case series of seven patients from the in-hospital register with a systematic literature review on retrovesical cysts in children. Results: We identified seven patients from the in-hospital register during 2005-2020 and eighty-two patients from the literature review. The literature review showed that children's retrovesical cysts are mainly asymptomatic before puberty. Those detected earlier in childhood present mostly with renal abnormalities. In our series, retrovesical cysts derived from three distinct etiologies with different treatment modalities. Asymptomatic cysts do not need excision and are to be followed up through puberty, but in the case of an ectopic ureter, nephroureterectomy is optional. Symptomatic retrovesical cysts may demand surgical excision. Ultrasonography is usually sufficient for diagnosis, but MRI provides better anatomical delineation and aids in surgical planning. Conclusions: Retrovesical cysts in boys are benign conditions associated with abnormal development of the ureter and kidney. Ultrasonography is sufficient for diagnosis, with MRI giving further detail for surgical planning. Treatment consists of cyst excision, heminephrectomy/nephrectomy, transurethral canalization, or excision of prostatic utricle, depending on etiology. Asymptomatic cases are to be followed up through puberty, but in cases of an ectopic ureter, nephroureterectomy is preferred.Peer reviewe

Mean Platelet Volume in the Diagnosis of Acute Appendicitis in the Pediatric Population: A Systematic Review and Meta-Analysis

Background: Mean Platelet Volume (MPV) has been suggested as a biomarker for acute appendicitis (AA) in the adult population. The utility of MPV in pediatric AA remains vague. This systematic review and meta-analysis aimed to systematically summarize and compare all relevant data on MPV as a diagnostic biomarker for AA in children.Methods: Databases were systematically searched using keywords ((mean platelet volume) OR mpv) AND (appendicitis). The inclusion criteria were all comparative studies of MPV in children aged less than 18 years and diagnosed with AA. Two authors independently assessed the methodological quality using the Downs and Black scale.Results: We included fourteen studies in the final meta-analysis; most were retrospective. Eight studies compared the MPV values between AA and non-AA; four studies compared the same between AA and healthy controls; two studies compared the MPV values among all three groups. The estimated heterogeneity among the studies for all outcomes was high and statistically significant. The pooling the data showed no statistically significant difference in MPV (weighted mean difference (WMD) = -0.42, 95% CI = (-1.04, 0.20), p = 0.19) between AA and healthy controls or AA and non-AA cases (WMD = 0.01, 95% CI = (-0.15, 0.17), p = 0.90).Conclusion: While MPV levels seem to have some utility in adult AA diagnosis, MPV levels should not dictate treatment options in pediatric AA.</p

Outcomes at a Mean of 13 Years After Proximal Humeral Fracture During Adolescence

Background:The long-term outcomes of a proximal humeral fracture during adolescence are not well known. We investigated the course of primary treatment for these injuries and the long-term outcomes in adulthood, comparing the outcomes with those from age-matched controls. We also compared outcomes after operative and nonoperative treatment via propensity score matching.Methods:We included children who sustained a proximal humeral fracture between the ages of 10.0 and 16.0 years and underwent treatment between 1995 and 2005. Data from primary treatment episodes were extracted from patient files. The patients were invited to a follow-up visit with outcome assessment and radiographs or to a telephone interview if unable to attend. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The secondary outcomes were the Simple Shoulder Test (SST), pain at rest and with strenuous use, shoulder range of motion, strength measurements, health-related quality of life (15D), and harms. Participant results were compared with the normal values of an age-matched population. The effect of operative treatment was assessed using propensity score matching and the average treatment effect was calculated.Results:This study included 209 patients (210 fractures). The mean follow-up (and standard deviation) was 13.1 +/- 3.2 years. Outcome data were obtained from 152 participants (153 fractures); 78 participants attended the follow-up visit. The primary treatment episodes were uneventful. The mean scores were 2.5 (95% confidence interval [CI], 1.8 to 3.3 [range, 0 to 13]) for the DASH and 11.7 (95% CI, 11.5 to 11.8 [range, 8 to 12]) for the SST. Other outcomes were similarly good. There were no differences in function compared with the normal population values. Propensity matching showed no treatment effect for operative treatment compared with nonoperative treatment.Conclusions:Proximal humeral fractures of adolescents heal well and rarely result in impairments whether treated operatively or nonoperatively.Peer reviewe