Nicolás Fernández

Association between maternal prenatal vitamin use and congenital abnormalities of the genitourinary tract in a developing country

OBJECTIVE To determine the association between prenatal multivitamin supplementation and congenital genitourinary tract anomalies in a group of Colombian newborn babies included in the Latin-American surveillance program (ECLAMC). STUDY DESIGN We included all neonates born between January 2004 and August 2007 registered in the ECLAMC database. Maternal prenatal multivitamin use was assessed for 122 newborns with congenital genitourinary tract anomalies and then compared to 271 non-malformed controls. RESULTS 46,850 births were registered and 122 (26/10,000) of them were identified to have a genitourinary tract anomaly. Prenatal multivitamin supplementation during the first, second, and third trimesters of pregnancy was associated with a reduction in the risk of these anomalies: OR 0.16 (0.08-0.31), OR 0.31 (0.19-0.52), and OR 0.38 (0.23-0.63) respectively. CONCLUSIONS Maternal prenatal multivitamins may reduce the risk of congenital genitourinary tract anomalies, not only during the first 8 weeks of gestation but also later in pregnancy, in developing countries.

Neurostimulation Therapy for Non-neurogenic Overactive Bladder in Children: A Meta-analysis

OBJECTIVE To assess the efficacy and safety of neurostimulation for non-neurogenic overactive bladder in children, we conducted a meta-analysis of randomized controlled trials (RCTs). MATERIALS AND METHODS A systematic literature search was performed on August 2016. RCTs were evaluated according to the Cochrane Collaboration risk of bias assessment. Number of patients with post-treatment partial response (PR) (50%-89%), complete response (CR) (≥90%), and full response (FR) (100%) were extracted for relative risk (RR) and 95% confidence interval (CI). Effect estimates were pooled using the Mantel-Haenszel method with random effect model if significant inter-study heterogeneity (P <.1) was noted. Subgroup analysis was performed according to each treatment setting (PROSPERO CRD42016043502). RESULTS Five eligible studies (245 patients) were included. Overall effect estimates showed that compared with standard urotherapy, neurostimulation demonstrated significantly better ≥50% (PR + CR + FR) response (RR = 2.8, 95% CI 1.1-7.2), but not ≥90% (CR + FR) response (RR = 8.28, 95% CI 0.65-105.92). Clinic-based neurostimulation had significantly better treatment outcomes for both ≥50% (PR + CR + FR) and ≥90% (CR + FR) responses (RR = 3.24, 95% CI 1.89-5.57; RR = 20.81, 95% CI 2.97-145.59, respectively), whereas a self-administered regimen showed no differences for both ≥50% (PR + CR + FR) and ≥90% (CR + FR) response rates between treatment groups (RR = 2.61, 95% CI 0.48-14.15; RR = 3.55, 95% CI 0.19-67.82, respectively). No serious adverse events were reported. CONCLUSION Neurostimulation therapy may lead to better partial improvement of non-neurogenic overactive bladder; however, it may not render a definitive complete response. Office-based neurostimulation seems more efficacious than self-administered neurostimulation. Further RCTs are needed to compare outcomes of the 2 regimens.

Clinical implication of renal allograft volume to recipient body surface area ratio in pediatric renal transplant

Our study aims to assess the clinical implication of RAV/rBSA ratio in PRT as a predictor for attained renal function at 1 year post‐transplantation and its association with surgical complications. A retrospective cohort was performed for PRT cases from January 2000 to December 2015 in our institution. Extracted clinical information includes the recipients demographics, donor type, renal allograft characteristics, arterial, venous and ureteral anastomoses, vascular anastomosis time while kidney off ice, overall operative time, and estimated blood loss. The RAV/rBSA was extrapolated and assessed for its association with renal graft function attained in 1 year post‐transplantation and surgical complications within 30‐day post‐transplantation. A total of 324 PRTs cases were analyzed. The cohort consisted of 187 (52.4%) male and 137 (42.3%) female recipients, with 152 (46.9%) living donor and 172 (53.1%) deceased donor renal transplants, and an overall median age of 155.26 months (IQR 76.70‐186.98) at time of renal transplantation. The receiver operating characteristic identified that a RAV/rBSA ratio of 135 was the optimal cutoff in determining the renal graft function outcome. Univariate and multivariate analyses revealed the relative OR for RAV/rBSA ≥ 135 ratio in predicting an eGFR ≥ 90 attained within 1 year post‐transplant was highest among younger pediatric recipients (<142.5 months) of deceased kidney donors (OR = 11.143, 95% CI = 3.156‐39.34). Conversely, Kaplan‐Meier analysis revealed that RAV/rBSA ratio ≥ 135 is associated with lower odds of having eGFR <60 (OR = 0.417, 95% CI = 0.203‐0.856). The RAV/rBSA ratio was not associated nor predictive of transplant‐related surgical complications. Our study determined that the RAV/rBSA ratio is predictive of renal graft function at 1‐year PRT, but not associated with any increased surgical complications.

Modified staged repair of bladder exstrophy: a strategy to prevent penile ischemia while maintaining advantage of the complete primary repair of bladder exstrophy

INTRODUCTION Penile ischemic injury is a reported catastrophic complication after complete primary repair of exstrophy (CPRE). Aiming to improve the bladder exstrophy-epispadias repair outcomes, the study institution adopted a modified staged exstrophy repair to incorporate the advantages of CPRE by avoiding concurrent epispadias repair and adding bilateral ureteral re-implantation and bladder neck tailoring (staged repair of bladder exstrophy with bilateral ureteral re-implantation [SRBE-BUR]) at the initial repair. It was hypothesized that such modifications minimize penile complications and prevent upper tract deterioration while enhancing bladder resistance and consequent capacity. Here, a comparative series of outcomes between CPRE and SRBE-BUR is reported. METHODS A retrospective cohort study including all exstrophy-epispadias male neonates managed in the study institution from January 2000 to December 2014 was performed. Patients were divided into those who underwent CPRE-BUR (group 1) and SRBE-BUR (group 2) (Figure). Baseline characteristics, peri-operative data, and long-term surgical outcomes were collected and analyzed for between-group comparison. Fisher exact and Mann-Whitney U tests were performed for statistical analysis. RESULTS A total of 21 eligible patients were included: 10 in group 1 and 11 in group 2. Baseline characteristics were comparable. Two patients in group 1 had intra-operative penile ischemic injury (one with subsequent penile tissue loss), whereas none of the group 2 patients had intra-operative complications. No significant difference between the groups was noted for operative time; however, significantly lesser blood loss was noted in group 2. Comparable long-term surgical outcomes such as additional surgical intervention, urinary continence, bladder capacity, vesicoureteral reflux, hydronephrosis and recurrent urinary tract infections (UTIs) were noted. In addition, although subjective, better penile length and cosmesis were achieved by staging the repair (Figure). CONCLUSION The SRBE with bilateral ureteral re-implantation is a safe alternative for the repair of the exstrophy-epispadias repair as it prevents the catastrophic complication of penile tissue loss, while having comparable long-term outcomes with the CPRE. Delaying epispadias repair avoids penile injury besides possible improvement of its overall cosmesis.

Neurostimulation Therapy for Pediatric Primary Enuresis : a Meta-Analysis

OBJECTIVE To assess the efficacy and safety of neurostimulation compared with control groups in the treatment of pediatric primary enuresis by performing meta-analysis of randomized controlled trials (RCTs). METHODS A systematic literature search with no language restriction was performed in August 2016. RCTs were identified and evaluated according to the Cochrane Collaboration risk of bias assessment recommendations. The number of patients with post-treatment responses such as partial response (PR) (50%-89%), complete response (CR) (≥90%), and full response (FR) (100%) were extracted for relative risk (RR) and 95% confidence interval (CI). Effect estimates were pooled using the Mantel-Haenszel method. The review protocol was registered in the PROSPERO registry (CRD42016043502). RESULTS A total of 292 subjects from 7 nonheterogeneous RCTs were included for meta-analysis. Pooled effect estimate of subjects with ≥50% post-treatment wet-night reduction (PR, CR, and FR) showed a significantly better outcome after neurostimulation compared with controls (RR = 2.20, 95% CI 1.66, 2.90), whereas patients with ≥90% post-treatment wet-night reduction (CR and FR) showed a significantly better outcome in the neurostimulation groups (RR = 2.79, 95% CI 1.54, 5.06). Furthermore, a significant mean difference in wet-night reduction per week was noted between treatment groups in favor of neurostimulation treatment (mean difference -1.95, 95% CI -2.84, -1.07). No serious adverse effects were noted related to neurostimulation therapy. CONCLUSION Current evidence suggests that neurostimulation therapy is efficacious and safe for the treatment of PPE. Head-to-head randomized clinical trials are needed to further assess relative efficacy among variable treatment protocols.

Craniofacial anomalies associated with hypospadias. Description of a hospital based population in South America

ABSTRACT Introduction: Hypospadias is a congenital abnormality of the penis, in which there is incomplete development of the distal urethra. There are numerous reports showing an increase of prevalence of hypospadias. Association of craniofacial malformations in patients diagnosed with hypospadias is rare. The aim of this study is to describe the association between hypospadias and craniofacial congenital anomalies. Materials and Methods: A retrospective review of the Latin-American collaborative study of congenital malformations (ECLAMC) data was performed between January 1982 and December 2011. We included children diagnosed with associated hypospadias and among them we selected those that were associated with any craniofacial congenital anomaly. Results: Global prevalence was 11.3 per 10.000 newborns. In this population a total of 809 patients with 1117 associated anomalies were identified. On average there were 1.7 anomalies per patient. Facial anomalies were present in 13.2%. The most commonly major facial anomaly associated to hypospadias was cleft lip/palate with 52 cases. We identified that 18% have an association with other anomalies, and found an association between craniofacial anomalies and hypospadias in 0.59 cases/10.000 newborns. Discussion: Hypospadias is the most common congenital anomaly affecting the genitals. Its association with other anomalies is rare. It has been reported that other malformations occur in 29.3% of the cases with hypospadias. The more proximal the meatus, the higher the risk for having another associated anomaly. Conclusion: Associated hypospadias are rare, and it is important to identify the concurrent occurrence of craniofacial anomalies to better treat patients that might need a multidisciplinary approach.

Estado actual de la urología pediátrica en Colombia

Resumen Introduccion y objetivos La urologia pediatrica (UP) es reconocida como subespecialidad de la urologia general. En nuestro pais, no existe un programa de educacion formal que capacite a los urologos como subespecialistas en esta area. Bogota parece concentrar el mayor numero de especialistas que atienden UP; la atencion en el resto del pais se hace con urologos generales o cirujanos pediatras dedicados durante varios anos a este ejercicio, logrando abrir un espacio para esta subespecialidad, hoy plenamente identificada por los demas colegas y por el sistema de salud. Con este estudio, queremos hacer un diagnostico de la situacion de la UP en Colombia, para identificar su estado actual y las necesidades que existen en las diferentes regiones geograficas del pais. De esta forma, hacer recomendaciones a los entes educativos y sociedades cientificas en cuanto a la formacion, educacion y distribucion de estos subespecialistas en el territorio colombiano. Materiales y Metodos Se envio un correo electronico con 21 preguntas a las bases de datos de la Sociedad Colombiana de Urologia y Sociedad Colombiana de Cirugia Pediatrica. Resultados Aproximadamente, fueron enviadas 550 encuestas, 127 fueron contestadas por 111 urologos y 16 cirujanos pediatras. El 50% de los que contestaron desarrollan su practica profesional en Bogota, un 30% en ciudades intermedias como Cali, Barranquilla y Medellin, y el otro 20% en el resto del pais. Los resultados se dividieron en 2 grupos, los que dedican menos del 10% a la atencion de la UP que fueron el 55% de los encuestados, y aquellos con mayor dedicacion. De este segundo grupo, solo una cuarta parte dedica mas del 60% de su tiempo a esta practica, un 32% reporta tener educacion formal en UP. A pesar de esto, el 60% atienden menos de 50 ninos por semana en consulta externa, y la mitad realiza menos de 10 cirugias al mes. Conclusiones En Colombia, la UP se ejerce principalmente en grandes ciudades, predominando Bogota. Existen muchas zonas del pais con deficiencia en esta atencion. Los especialistas que reportan tener una practica clinica significativa en pacientes pediatricos no hacen un numero importante de consultas o cirugias. Solo un pequeno numero ejerce la UP como unica especialidad.

Tendencia del PSA en pacientes con carcinoma de próstata metastásico manejados con orquiectomía vs. bloqueo hormonal con análogos de la hormona liberadora de gonadotrofinas

Resumen Introduccion El manejo estandar del carcinoma de prostata metastasico (CaPM) actualmente es el bloqueo hormonal. El uso de bloqueo con analogos y la orquiectomia bilateral (OQ) son reconocidos como manejos efectivos y comparables en resultados y pronostico. En nuestro medio no contamos con estudios descriptivos en el comportamiento de los niveles de PSA en este grupo de pacientes al igual que la historia natural de la enfermedad en nuestro entorno. Metodo logia: Se realizo un estudio de cohorte retrospectivo de pacientes con CaPM llevados a orquiectomia vs. bloqueo hormonal con analogos de la GnRH (BA). Se reviso el historial del seguimiento en el tiempo de los niveles de PSA y se tuvieron en cuenta variables asociadas como edad del paciente, Gleason, iPSA y TNM. Se realizo un analisis de t de Student y Chi cuadrado para las variables descritas. Resultados Se revisaron 124 historias clinicas en un periodo de 2 meses. Se dividio el analisis en dos grupos, OQ y BA. Se analizaron las tendencias en el tiempo del PSA encontrando que en cuanto a los niveles del PSA, los dos grupos tienen una tendencia similar. La progresion fue mas temprana en el grupo de OQ siendo a los 27 vs. 32 meses del grupo de BA. Conclusiones Las dos terapias logran un control similar de los niveles de PSA. En nuestra poblacion aparentemente no se identificaron impactos administrativos y de administracion de medicamentos por parte de las aseguradoras sobre los resultados de las terapias.

Acute labio-scrotal pain in a patient with ovotesticular syndrome. Case report

Ovotesticular syndrome (OTS) belongs to the group of disorders of sex development (DSD). We present a case of a patient with OTS presenting with acute labioscrotal pain. A surgical exploration was indicated, and hemorrhage was identified. A gonadectomy was performed and the final pathology report revealed an ovotestis with a bleeding follicle, normal ovarian parenchyma and atrophic testicular parenchyma. After reviewing the literature there is scarce information on this complex topic, but conservative management could be an option if the risk of a gonadal malignancy is low.