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Baccarani A, Pappalardo M, Ceccarelli PL, Starnoni M, De Santis G. Combined Double-breasted Full-thickness Abdominal Flap Plication and Acellular Dermal Matrix in Prune-belly Syndrome Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5744. [PMID: 38645635 PMCID: PMC11029998 DOI: 10.1097/gox.0000000000005744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/20/2024] [Indexed: 04/23/2024]
Abstract
Background Reconstruction of the abdominal wall in patients with prune-belly syndrome (PBS) following previous intra-abdominal procedures is a challenging problem with a high incidence of revision due to persistent bulging or herniation. The abdominal wall flaccidity not only produces a severe psychological and aesthetic discomfort for the patient but often determines functional disabilities, including inability to cough properly, impaired bowel and bladder function, and delay in posture and balance. Methods The authors describe three cases of reconstruction of abdominal wall using a modified double-breasted abdominoplasty fascial plication with additional acellular dermal matrix interposition and review the literature for innovations in the use of abdominal repair for reconstruction of these difficult cases. Results Three children with PBS at a mean age of 7.3 years achieved successful reconstruction of the abdominal wall, using the modified double-breasted abdominoplasty fascial plication with acellular dermal matrix interposition. Patients underwent previous procedures, including orchiopexy in two patients and bilateral nephrectomy in one patient. No postoperative complications have been found, apart from superficial skin dehiscence along the abdominal incision treated conservatively in one child. At mean follow-up of 42 months (range 28-56 months), no patient presented incisional hernia, persistent or recurrent fascial laxity with abdominal bulging. All patients achieved significant aesthetic and functional improvements, including children's ability to cough, spontaneous gain of abdominal tonus, balance, and ambulation. Conclusion Modification of the original vertical, two-layer plications of the deficient abdominal interposing biological mesh has the purpose of improving strength, aesthetics, and function of the abdominal wall in pediatric patients with PBS.
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Affiliation(s)
- Alessio Baccarani
- From the Division of Plastic Surgery, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Marco Pappalardo
- From the Division of Plastic Surgery, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Pier Luca Ceccarelli
- From the Division of Plastic Surgery, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
- Division of Paediatric Surgery, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Marta Starnoni
- From the Division of Plastic Surgery, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Giorgio De Santis
- From the Division of Plastic Surgery, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
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Fernández-Bautista B, Angulo JM, Burgos L, Ortiz R, Parente A. Surgical approach to prune-belly syndrome: A review of our series and novel surgical technique. J Pediatr Urol 2021; 17:704.e1-704.e6. [PMID: 34376330 DOI: 10.1016/j.jpurol.2021.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/17/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Surgical management of children with Prune-belly syndrome (PBS) can be divided into three categories: urinary tract reconstruction, abdominal wall reconstruction, and orchidopexy. Adequate repair of the abdominal wall by abdominoplasty at an early age, allows an adequate aesthetic appearance, but also allows a correct development of walking, breathing, defecation and urination. OBJECTIVE To present a novel surgical technique for abdominal wall reconstruction, which combines plication with complete overlap of the fascia and neoumbilicoplasty with an island flap rotated on itself. STUDY DESIGN A retrospective review of the patients with PBS who underwent surgery in our center between 2009 and 2020. A new abdominoplasty technique was performed, which consists of plication with complete overlap of the fascia, as well as a neoumbilicoplasty with an island flap rotated on itself. The skin is then well freed from the rest of planes, and the plication is performed with complete overlapping of the muscle-aponeurotic plane from one side to the other. At this time, the interposition of some type of reinforcement material (mesh) may be required in the event of complete absence or insufficient presence of the fascia and muscle. RESULTS Abdominoplasty was performed in four patients. In all patients, bilateral orchidopexy was performed in the same surgical procedure for intra-abdominal testicles. The mean age of the patients at the time of surgery was 10,5 years and the average admission time was 4 days. There were no short-term or long-term complications. Average follow-up time was 7 years. All patients and their families are satisfied with the aesthetic result obtained. DISCUSSSION Abdominoplasty in patients with PBS in addition to aesthetic reconstruction, brings significant improvements to wandering, breathing, urination and defecation, improving the quality of life of the patient. Compared to the techniques described, the abdominoplasty we propose makes it possible to easily improve the abdominal wall support by means of meshes or synthetic devices if necessary and allows the evaluation and correction of cryptorchidism or other associated renal abnormalities in the same surgical act, as it allows full abdominal exposure. Likewise our modified abdominoplasty allows the creation of the new umbilicus in a more anatomical way, rectifying its natural position. CONCLUSION In our experience, this modified surgical technique for abdominal wall repair is a novel procedure in the PBS approach, easily reproducible, which provides good aesthetic results in our series of cases.
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Affiliation(s)
| | - Jose María Angulo
- Pediatric Surgeon, Gregorio Marañón University Hospital, St/ O´Donnell, 48. 28009, Madrid, Spain.
| | - Laura Burgos
- Pediatric Surgeon, Gregorio Marañón University Hospital, St/ O´Donnell, 48. 28009, Madrid, Spain.
| | - Rubén Ortiz
- Pediatric Surgeon, Gregorio Marañón University Hospital, St/ O´Donnell, 48. 28009, Madrid, Spain.
| | - Alberto Parente
- Pediatric Surgeon, Reina Sofia University Hospital, St/ Menendez Pidal, S/n, 14004, Córdoba, Spain.
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Lopes RI, Baker LA, Dénes FT. Modern management of and update on prune belly syndrome. J Pediatr Urol 2021; 17:548-554. [PMID: 34016542 PMCID: PMC8502198 DOI: 10.1016/j.jpurol.2021.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 01/22/2023]
Abstract
Prune belly syndrome (PBS) is characterized by the triad of abdominal flaccidity, a variable degree of urinary tract involvement and cryptorchidism. Most cases of PBS are sporadic and have a normal karyotype, with 95% patients being male. In the last decade, mutations in known genes that regulate embryonic genitourinary myogenesis have been identified and with increasing knowledge of these critical genes involved in bladder maldevelopment, advances can be made in genetic counseling. A multidisciplinary approach is necessary and individualization of care is recommended according to phenotypic severity. Some patients require abdominal and urinary tract reconstruction while others require as little as bilateral orchiopexies. Major treatment objectives are: preservation of renal function and upper urinary tract; polyuria management; adequate bladder emptying; improvement of corporal image and quality of life; preservation of fertility and adequate sexual function. Long-term surveillance of the urinary tract is essential up to adulthood, because functional dynamics can change over time.
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Affiliation(s)
- Roberto I Lopes
- Pediatric Urology Unit, Division of Urology, Hospital Das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Linda A Baker
- University of Texas Southwestern Medical Center at Dallas Children's Health, Dallas, USA
| | - Francisco T Dénes
- Pediatric Urology Unit, Division of Urology, Hospital Das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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Lopes RI, Tavares A, Dénes FT, Cocuzza M. Gonadal Function and Reproductive System Anatomy in Postpubertal Prune-Belly Syndrome Patients. Urology 2020; 145:292-296. [PMID: 32544553 DOI: 10.1016/j.urology.2020.04.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To gain insight into the causes of infertility in Prune Belly Syndrome (PBS) by evaluating reproductive system anatomy and gonadal function in a cohort of postpubertal PBS patients. METHODS We contacted all PBS patients 14 years old or older treated and followed at our institution. Age at orchiopexy, type of orchiopexy (with or without ligation of gonadal vessels), testicular volumes and positions were evaluated. Pelvic magnetic resonance imaging (to assess prostate size, seminal vesicles, and vas) and hormonal profile were ordered. Sperm analysis and analysis of urine after masturbation were performed after informed consent. RESULTS Fifteen patients were included in this study. Mean age was 19.2 years. Mean age at orchiopexy was 18 months. Fourteen patients (93.3%) had normal and orthotopic testes. Mean testicular volume was 6.9 cc. Eight patients collected semen, 5 of them (62.5%) had spermatozoa in the specimen and motile sperm was found in 4 (50%). Mean hormone levels were LH: 5.3 mg/dL, FSH: 6.9 mg/dL, testosterone 531 mg/dL. Magnetic resonance imaging revealed hypoplastic prostates in 66.6% and unilateral seminal vesicle absence in 66.6%. No vasal abnormality was noted. CONCLUSION Patients with PBS may have normal sexual hormonal levels. Motile spermatozoa were found in half of the patients. Our study highlights a high prevalence of prostate and seminal vesicle abnormalities that may represent an important cause for their infertility.
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Affiliation(s)
- Roberto Iglesias Lopes
- Uropediatric Unit and Division of Urology, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil.
| | - Alessandro Tavares
- Uropediatric Unit and Division of Urology, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Uropediatric Unit and Division of Urology, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Marcello Cocuzza
- Human Reproduction Unit, Division of Urology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Hamza F, Elbanoby T, Dahshan H, Elbatawy A. Infantile Asymmetrical Diffuse Infiltrative Lipomatosis of the Abdomen and Upper Thighs: A Case Report with Long-Term Follow-up. Aesthet Surg J Open Forum 2020; 2:ojaa026. [PMID: 33791649 PMCID: PMC7671237 DOI: 10.1093/asjof/ojaa026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2020] [Indexed: 11/14/2022] Open
Abstract
The authors present the case of an 11-year-old male patient with a diffuse infiltrative lipomatosis involving the abdomen, flanks, and upper thighs by applying body contouring principles at this early age. Abdominoplasty can be used in children for various purposes, including harvesting a full-thickness skin graft in burns or to treat congenital anomalies involving the pelviabdominal area. Level of Evidence: 5 ![]()
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Affiliation(s)
- Fawzy Hamza
- Plastic and Reconstructive Surgery Department, Al Azhar University, Cairo, Egypt
| | - Tarek Elbanoby
- Plastic and Reconstructive Surgery Department, Al Azhar University, Cairo, Egypt
| | - Hazem Dahshan
- Plastic and Reconstructive Surgery Department, Al Azhar University, Cairo, Egypt
| | - Amr Elbatawy
- Plastic and Reconstructive Surgery Department, Al Azhar University, Cairo, Egypt
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Smith EA, Srinivasan A, Scherz HC, Tracey AJ, Broecker B, Kirsch AJ. Abdominoplasty in prune belly syndrome: Modifications in Monfort technique to address variable patterns of abdominal wall weakness. J Pediatr Urol 2017; 13:502.e1-502.e6. [PMID: 28373000 DOI: 10.1016/j.jpurol.2017.02.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 02/16/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Abdominoplasty is an important component of the management of children with prune belly syndrome (PBS). While there are features of the abdominal defect in PBS which are common to all patients, there will be differences unique to each patient that should be taken into consideration in surgical planning. Specifically, we have come to realize that although the Monfort procedure assumes a symmetric pattern of abdominal wall laxity, this symmetry is rarely present. OBJECTIVE The aim of this report is to describe our modifications and review our outcomes for the Monfort procedure which more completely address correction of the abdominal wall laxity including both common and uncommon features while positioning the umbilicus to a more anatomically correct position (Figure). STUDY DESIGN Sixteen male patients with PBS and one female pseudoprune belly syndrome patient, aged 2-9 years, were treated at our institution between 2003 and 2014. Modifications incorporated into the abdominoplasty procedure for PBS applied to this study group included: 1) use of diagnostic laparoscopy to define the topography of the abdominal wall defect, 2) initial midline rather than elliptical skin incision to defer retailoring of the skin coverage until the final step of the procedure, 3) varying the width of the central plate to correct side to side asymmetry in redundancy, 4) plication of the central plate to reduce vertical redundancy and reposition the umbilicus, and 5) plication of focal areas of fascial weakness, most often in the flank region. RESULTS All patients have improved abdominal wall contour with a more uniform correction of areas of weakness at a mean follow-up of 5.5 years (range 18 months-11.5 years). All patients and parents indicate that they are very satisfied with the outcome of their procedures without any revisions being performed. This study is descriptive in nature and retrospective, with the patient population treated in a relatively uniform fashion that does not allow direct comparison with other techniques. CONCLUSIONS The modified Monfort procedure recognizes the pattern of abdominal muscular deficiency unique to each patient and incorporates this information into the surgical design.
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Affiliation(s)
- Edwin A Smith
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA.
| | - Arun Srinivasan
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA
| | - Hal C Scherz
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA
| | - Anthony J Tracey
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA
| | - Bruce Broecker
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA
| | - Andrew J Kirsch
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA
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Arlen AM, Kirsch SS, Seidel NE, Garcia-Roig M, Smith EA, Kirsch AJ. Health-related Quality of Life in Children With Prune-belly Syndrome and Their Caregivers. Urology 2016; 87:224-7. [DOI: 10.1016/j.urology.2015.09.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 09/22/2015] [Accepted: 09/24/2015] [Indexed: 10/22/2022]
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Dénes FT, Park R, Lopes RI, Moscardi PRM, Srougi M. Abdominoplasty in Prune Belly Syndrome. J Pediatr Urol 2015; 11:291-2. [PMID: 26227565 DOI: 10.1016/j.jpurol.2015.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 06/21/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Many patients with Prune Belly Syndrome (PBS) require abdominoplasty alone or in combination with correction of any urogenital abnormalities. This video presents a simplified technique with which to treat the abdominal flaccidity in PBS. METHODS A longitudinal xypho-pubic fusiform figure is drawn on the abdomen, based on the area of skin and subcutaneous tissue to be removed. This is performed with preservation of the musculo-fascial layer and the umbilicus. A lateral elliptical single xypho-pubic line is drawn in the most lax side of the fascia, which is incised along this line. After urinary tract reconstruction and orchidopexy, closure is initiated by suturing the medial edge of the wider fascial flap laterally to the peritoneal side of the contralateral flap. Next, the now outer fascial flap is laid over the inner flap, and a buttonhole is made to expose the umbilicus. The subcutaneous tissue of the inner flap is laterally undermined to gain extra distance for the suture of the outer flap over the inner flap. The subcutaneous tissue and skin are sutured in the midline, incorporating the umbilicus. RESULTS In a 30-year period, 43 PBS patients underwent this procedure with good cosmetic and long-term functional results. CONCLUSION This abdominoplasty technique is simple and presents good functional and cosmetic results in PBS patients.
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Affiliation(s)
- F T Dénes
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - R Park
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - R I Lopes
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil.
| | - P R M Moscardi
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - M Srougi
- Pediatric Urology Unit, Division of Urology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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27 years of experience with the comprehensive surgical treatment of prune belly syndrome. J Pediatr Urol 2015; 11:276.e1-7. [PMID: 26143487 DOI: 10.1016/j.jpurol.2015.05.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 05/06/2015] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Prune belly syndrome (PBS) presents with three main features: abdominal wall flaccidity, urological abnormalities and cryptorchidism. As a result, urologists must consider the eventual repair of the abdominal wall flaccidity and urinary tract abnormalities, and the mandatory correction of cryptorchidism, as well as decide whether to perform the procedures in a single comprehensive approach or in multiple steps. OBJECTIVES To report experiences with comprehensive surgical management of prune belly syndrome. MATERIAL AND METHODS From 1987 to 2014, 46 children with PBS were submitted for comprehensive surgical treatment. According to individual needs, treatment aimed to correct the abdominal flaccidity, reconstruct the urinary tract, and perform bilateral orchiopexy and circumcision, which were performed in one procedure. Urinary tract reconstruction was indicated whenever pyelo-ureteral dilatation with evidence of significant stasis and/or vesicoureteral reflux was associated with recurrent urinary tract infections (UTI). Treatment for this cohort included: 44 abdominoplasties, 40 upper urinary tract reconstructions, 44 cystoplasties associated with three appendico-vesicostomies, 46 bilateral orchiopexies and 36 circumcisions. The median age at surgery was 16 months and children were followed for a median of 143 months. RESULTS Abdominal appearance and tonus were improved in 90% of the children after the primary surgery and 100% after reoperation. Upper urinary tract reconstruction was performed in most children and long-term follow-up showed functional stabilization of the urinary tract in about 90% of the children, with progression to renal failure in 10%. Lower urinary tract reconstruction was performed in most children (95.6%); on late follow-up, continence was observed in 81% of them, while incontinence was present in 19% and usually associated with polyuria. Adequate bladder emptying was possible in most boys (82.6%), while the remaining required clean intermittent catheterization. Pre-operative UTI was present in 89.1% and urinary sepsis in 15.2%. Postoperatively, the incidence of laboratorial UTI was significantly reduced to 39.1%, while urinary sepsis was absent. Bilateral orchiopexy was performed in all children, with 85% of the testes becoming normal in size and well located in the scrotum. CONCLUSIONS Comprehensive surgical treatment is feasible and has good long-term results. A considerable incidence of reoperations due to complications or progression of the disease was observed. The long-term results for reno-ureteral anatomy and function, bladder function, infection, testicular size and location, as well as abdominal aspect and tonus, show that comprehensive surgery is an adequate method for managing children with PBS.
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Prune belly syndrome with overlapping presentation of partial urorectal septum malformation sequence in a female newborn with absent perineal openings. Case Rep Surg 2014; 2014:746323. [PMID: 25548711 PMCID: PMC4274712 DOI: 10.1155/2014/746323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 11/24/2014] [Indexed: 11/29/2022] Open
Abstract
Prune belly syndrome (PBS) is a rare congenital anomaly characterized in males by a triad of anomalous genitourinary tract, deficient development of abdominal wall muscles, and bilateral cryptorchidism. Although similar anomalies have been reported in females, by definition they do not full fill the classical triad. Urorectal septum malformation sequence (URSM) is a lethal condition characterized by presence of ambiguous genitalia, absent perineal openings (urogenital and anal), and lumbosacral abnormalities. In this original case report, the authors discuss the presentation and management of what would be analogous to a Woodhouse category 1 PBS in a female newborn associated with an overlapping presentation of URSM.
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