Ricardo Zubieta

¿Divertículo uretral tras descenso anorectal asistido por laparoscopia (DARAL) en malformación anorectal: es siempre necesario resecar el diverticulo?

Resumen es: Objetivo: Con el uso cada vez mayor de la cirugia minimamente invasiva, el diverticulo uretral tras la cirugia anorectal se ha convertido en un problema....

Vesicoureteral Reflux: Current Management in Children

Vesicoureteral reflux (VUR) is a disorder that has been studied since the early days of pediatric urology. From 1893, when it was first documented in humans by Pozzi, the research and clinical management of VUR has been marked by pendulum swings through the decades. Initially, the vesicoureteral junction was the main subject of study, whereas current practice takes into account the bladder and bowel dynamics. The primary objective, however, is unchanged: preservation of the kidney and its function. Management of the condition has included open surgery, minimally invasive surgery, endoscopic treatment, antibiotic prophylaxis, and watchful waiting. In this article, we will attempt to cover every angle of this complex pathology and its current management in children.

Genitoplastia feminizante en hiperplasia suprarrenal congénita; ¿una o dos etapas quirúrgicas?

Resumen es: Objetivo: El mejor momento para realizar una genitoplastia en una nina con Hiperplasia Suprarrenal Congenita (HSRC) es un tema que ha sido debatido ampli...

Cirugía de neoimplante vesico ureteral por vía extravesical: modificaciones técnicas y consejos basados en más 30 años de experiencia

OBJECTIVES: The uneven relationship between length and diameter of the intramural ureter is essential for the development of vesicoureteral reflux (VUR). Surgical treatment should reconstruct that relationship. Several surgical techniques have been described to achieve this objective. After more than 30 years of experience, in our hands the Lich-Gregoir extra vesicoureteral reimplantation technique shows excellent results. We describe the technique step-by-step, emphasizing the modifications introduced, also in its laparoscopic version. METHODS: The Lich-Gregoir extravesical ureteral reimplantation technique is completely described, reinforcing those technical details allowing the achievement of better results. We comment on the technical variations in the laparoscopic version. We also perform a retrospective review of the clinical records and imaging tests in patients who underwent vesicoureteral reimplantation in the period between 1974-2006 in the Hospital de Ninos Dr. Exequiel Gonzalez Cortes. INCLUSION CRITERIA: patients with primary VUR in which Lich-Gregoir extravesical ureteral reimplantation technique was performed. Secondary de VUR was excluded. We registered age, gender, radiological grade, bilateralism, surgical time, and development of complications such as persistent reflux, contralateral reflux, postoperative urinary tract infection, urinary retention, postoperative obstruction, reoperation, the degree of renal insufficiency, and long-term followup. RESULTS: Over the 33 years of the study period there were 267 patients with primary VUR who required surgery. 379 ureters were reimplanted in an extravesical fashion, 112 (42%) corresponded to bilateral VUR. Mean age at the time of surgery was 4 years (from three months to 16 years); 156 patients (58%) were girls and 111 boys (42%). All patients presented primary VUR, and 63% of them were high grade (grades IV-V). All ureters were reimplanted without modelling in a mean surgical time of 62 minutes for the open technique. After a mean follow-up of two years (2 months-5.5 yr.) 7% of the patients have presented complications. Our reoperation rate is 1.3%. There was not any postoperative urinary retention. Our success rate for VUR resolution with this technique is 98.5%. CONCLUSIONS: Based on the results the the authors think that extravesical ureteral reimplantation following the Lich-Gregoir technique is safe, simple, technically reproducible, efficient, and with a low morbidity to resolve primary unilateral and bilateral primary VUR.

Varicocele adolescente: ¿Cuál es la mejor opción quirúrgica?

Resumen es: Objetivo: Comparar tres diferentes abordajes para la realizacion de varicocelectomia en la poblacion pediatrica, analizando su efectividad y complicacion...

Circuncisión neonatal con anestesia local: Resultados de un protocolo estandarizado

INTRODUCTION Neonatal circumcision is a common procedure in the US and other countries, with low rates of complications in trained hands. However, it has recently been incorporated into the clinical environment in Chile. Our goal was to establish a local standardised protocol for neonatal circumcision under local anaesthesia, and evaluate the results and possible complications. PATIENTS AND METHOD A standardised prospective protocol was used on patients who underwent neonatal circumcision. The inclusion criteria were: children <60days and <5kg. The surgical technique used was topical local anaesthesia and penile block, attrition of redundant prepuce and mucosa with Mogen® clamp, and section with scalpel. The protocol was used and evaluated from November 2005 to October 2014 by a paediatric surgeon and/or paediatric urologist trained in the technique. Complications and conditions until final discharge were analysed. RESULTS The protocol was applied to 108 patients over a 9year period. The mean age at procedure was 9days (1-52). One patient (0.9%) had immediate bleeding, requiring further surgery. All patients were discharged from further medical checks at 1 month, without any other complications. The reason for the procedure was by parental request in 100% of the cases, and always for sociocultural reasons. CONCLUSION Neonatal circumcision under local anaesthesia is a simple procedure, and has excellent results in selected patients, and with no major complications. With proper training, and adapting the initial protocol, it can be performed on an outpatient basis, without putting the neonates through the risks of general anaesthesia.

Unusual presentation of a Leydig cell tumor: Presentacion inusual

SUMMARY Leydig Cell Tumors (LCT) in children are very rare, with an incidence of 1-3% for all testicular tumors in children. Clinical presentation is testicular mass, pain and hormone alteration such as precocious puberty and gynecomastia. We present one case of LCT and his conservative management after an incidental finding. Literature is reviewed.

Ureter ectópico en pediatría: un cambio en su forma de presentación

Clasicamente el diagnostico de ureter ectopico se hacia en ninas mayores por incontinencia urinaria, hoy los diagnosticos son mas precoces, lo que ha cambiado parcialmente su tratamiento. El objetivo del presente trabajo es realizar una revision de nuestra experiencia en los ultimos anos y correlacionar con la forma de presentacion en la actualidad. METODOS Se estudiaron todos los pacientes con diagnostico de ureter ectopico en un periodo de 10 anos, entre enero de 1997 y diciembre de 2006. Se analizaron las caracteristicas demograficas, la forma de presentacion, estudios realizados, edad al diagnostico y tratamiento, junto a las distintas tecnicas empleadas para solucionar su patologia. RESULTADOS Se encontraron 19 pacientes con esta patologia, 15 de sexo femenino. La forma de presentacion estuvo dada en 13 pacientes con infeccion urinaria febril, 2 con incontinencia urinaria y en 4 el diagnostico fue prenatal por hidronefrosis. Doble sistema pielo ureteral tenian 16 ninos y solo 3 tenian sistema unico. El diagnostico en todos los casos se realizo con ecografia renal y vesical, uretrocistografia y estudios endoscopicos. Estudios adicionales como pielografia de eliminacion se realizo en 8 al comienzo de la serie, y estudios de medicina nuclear en 17. La mediana de edad al momento del diagnostico fue de 8 meses. El tratamiento fue quirurgico en todos. En los dobles sistemas se realizo heminefroureterectomia superior en 8 pacientes, reimplante vesicoureteral en 3 y pielo-pieloanastomosis en 3 casos con funcion remanente del polo renal superior. En otros 2 casos se realizo nefroureterectomia por presencia de reflujo al sistema inferior y compromiso renal severo. En los sistemas unicos se realizo reimplante en los 3 casos. CONCLUSIONES La sospecha prenatal y el estudio adecuado de las infecciones del tracto urinario permite confirmar el diagnostico de ureter ectopico. Pocos ninos debutan con incontinencia urinaria en la actualidad, debido a lo precoz del diagnostico. El tratamiento es siempre quirurgico, y depende basicamente de la funcion renal, y la presencia o no de relujo vesico ureteral. De preferencia en los pacientes con ureter ectopico en sistema unico se realiza un reimplante vesicoureteral y en los con doble sistema una heminefrectomia superior, abandonando el ureter distal en una primera instancia.