[Our experience with sirolimus for the treatment of complicated vascular anomalies]

AIM OF THE STUDY

mTOR inhibitors are being used to treat complex vascular anomalies (VA) without response to conventional treatments. We report our results in pediatric patients treated with sirolimus.

METHODS

Retrospective review of patients treated with sirolimus between 2014 and 2017, analyzing vascular anomaly type, treatment response and complications. Treatment protocol included patients with complex vascular anomalies, after signing the informed consent. The initial dose was 0.8 mg/m2/12 h, verifying plasmatic levels. Favorable response was defined both in clinical and radiological terms.

MAIN RESULTS

Sirolimus was employed in nine patients, median age 14 months old (1 month-14 years), 66% girls. Five complex micro-cystic lymphatic malformations (LM), one multifocal lynphangioendotheliomatosis with thrombocytopenia, one kaposiform lymphangiomatosis, one lymphatic-venous malformation and one kaposiform hemangioendothelioma (KHE) were treated. Median treatment was 4 months (IQR 2-18 months). Resolution or improvement was objectified in four patients (44%). KHE patient presented complete resolution after two months of treatment. Two patients with micro-cystic LM and the one with lymphatic-venous malformation improved after a median treatment of three months. Two patients presented rebound effect after discontinuing treatment. Three patients had hypertransaminasemia and hypercholesterolemia without requiring medical treatment.

CONCLUSION

Sirolimus presented mild effects for treatment of complex VA in our study, but was highly resolutive at KHE.

Necrotic Lesions Following Elective Urological Surgery in an Infant

Case Report  An 11-month-old female infant presented on the first postoperative (PO) day following an elective pyeloplasty, a dark bluish erythema of her lumbotomy wound, plus a satellite lesion of the same characteristics. Fever and sepsis developed, and despite broad spectrum antibiotics (meropenem and vancomycin) were started, a diagnosis of necrotizing soft-tissue infection (NSTI or necrotizing fasciitis) was established. Surgical debridement of both lesions was performed on day 3 PO, and a surgical contamination (ring retractor blade) was suspected, due to the particular geography of the lesion. Urine and blood cultures yielded no bacteria, but tissue culture grew Pseudomonas aeruginosa . At PO 6th day, lesions still appeared exudative and poorly perfused, so vacuum-assisted therapy (VAT) treatment was started. Exudate control, perfusion, and granulation improved in consecutive days, which permitted direct closure (no graft needed) at PO day 12.

Discussion   P. aeruginosa can be a fatal cause of type I NSTI. It has been reported rarely in adult series, with a prevalence of 4%, but it can be a major pathogen in pediatric NSTI. Added to an early recognition, aggressive surgery and debridement are required, in combination with antibiotic therapy, to limit the spread of the infection. In our case, despite surgical debridement being performed on day 3 PO, both wounds maintained scarce perfusion, and debris and exudate were poorly controlled with usual silver foams and daily nursery cures. VAT pediatric device was then added, which rapidly improved surgical bed, enhancing tissue perfusion and granulation in the following days.

[Laparoscopic repair of inguinal hernia and communicating hydrocele in children. Our experience in the last years]

INTRODUCTION

Laparoscopic inguinal hernia and hydrocele repair has become an alternative to the more frequently used inguinal approach. We describe our experience with the laparoscopic technique.

MATERIAL AND METHODS

Retrospective study of laparoscopic inguinal hernia and hydrocele repair performed during the period between 2003-2016. We included patients < 14 years, with communicating hydrocele and/or indirect inguinal hernia diagnosis (N = 39). We have studied two cohorts; group A patients with indirect inguinal hernia (N = 31) and group B patients with communicating hydrocele (N = 8). We used intraperitoneal laparoscopic approach, performing herniorrhaphy of the internal inguinal orifice without resection of the hernial sac. The main outcome measurements were surgical indication and postoperative complications.

RESULTS

The indication for laparoscopic repair was bilateral defects (46.2%), unilateral defects (28.2%), defects associated with umbilical hernia (23.1%) and associated with another pathology (2.6%). In group A the rate of complications that required new admission was 3.2% and the recurrence rate was 9.7%. In group B, was 12.5% ​​and 12.5% respectively. We have not observed a significant relationship with respect to patient age, laterality or suture used and the rate of complications in any of the groups.

CONCLUSIONS

Despite the limitations of our study given the small sample size and retrospective nature, the complication rate (15%) is higher than that published in the literature. This makes us take a step back to reassess our indications and technique, and not forget that the laparoscopic approach is not a technique without risks and requires a learning curve.

[Functional and aesthetic evaluation of sacrococcygeal teratomas. Not everything ends with surgery]

INTRODUCTION

Sacrococcygeal teratoma is the most common solid neonatal tumour. The improvement in survival has meant that postoperative sequelae can be diagnosed and treated. The aim of this article is to evaluate the long-term outcomes of patients treated in our centre.

MATERIAL AND METHODS

Records of patients treated for a sacrococcygeal teratoma in our hospital from 1977 to 2014 were retrospectively reviewed. Personal data was collected and a telephone questionnaire was used to assess long-term bowel and urinary habits, as well as an aesthetic and functional self-assessment.

RESULTS

A total of 14 patients were treated during the study period, of whom 11 were females and 3 males, with a mean age at the time of the survey of 17 years (8 months-37 years). Eight patients completed the questionnaire (57.1%). The mean age of the 8 patients was 23 years (4-37 years), of whom 37.5% were operated on due to a sacrococcygeal teratoma type i, 25% type ii, 25% type iii, and 12.5% type iv. Two of them (25%) had constipation, and one (12.5%) had faecal incontinence. Two (25%) patients suffered from recurrent urinary tract infections, and 3 (37.5%) patients had urinary incontinence. Five patients (62.5%) had a perception of being physically impaired, with limitation of their social life.

CONCLUSIONS

The incidence of constipation does not differ from that found in the literature. Faecal incontinence is slightly improved compared to what has been published. However, urinary tract infections and incontinence are more prevalent in our series. Five patients out of the eight that responded suffered from psychosocial problems, according to DAS-59 questionnaire. Patients with SCT require urological, bowel, and psychological counselling, until they have a complete functional and emotional development.

[Long-term results of hypospadias surgery. Urinary and sexual function, and psychological impact]

OBJECTIVES

To determine the current status of the patients operated on for hypospadias in our region, in order to adapt the surgical technique to their real needs.

MATERIAL AND METHODS

A descriptive and observational study. Interviews were conducted with hypospadias surgery patients in our hospital between 1976 and 1996, focusing on their urinary and sexual function and psychological impact. We performed a descriptive statistical analysis and comparisons between types of hypospadias (SPSSv19).

RESULTS

566 patients were operated on for hypospadias during the study period, interviewing 100 aged between 18 and 40 years. The 73% were distal and 27% proximal. Of all patients, 30% do not have an orthotopic meatus, 10% have fistula, 18% have some degree of stenosis and 52% have penile curvature. The 13% feel to have had disadvantages in their life. They consider they have a different penis in: size (19%), glans shape (17%), curvature (14%), scars (10%) and lowest hole (7%). Sexual satisfaction was valued at 8.9 on a scale of 1 to 10, with no differences between the types of hypospadias. Proximal hypospadias patients have more ejaculation problems: 42% versus 11% in distal hypospadias. The 68% of the proximal ones would like to improve compared to 20% of the distal in: appearance (17%), size (11%) and way to urinate (11%).

CONCLUSIONS

Anatomic abnormalities are maintained but the aspects that values the adult patient differ from those persecuted by practiced surgeries. A significant percentage of patients would try to get another surgery. Keeping the size of the penis and natural appearance of the glans should be a priority in hypospadias surgery.

Pelvic cystic mass and ipsilateral renal agenesis detected by ultrasound in a young girl: early onset of Herlyn-Werner-Wunderlich Syndrome

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Radiation-free monitoring in the long-term follow-up of pyeloplasty: Are ultrasound new parameters good enough to evaluate a successful procedure?

INTRODUCTION

Long-term evolution of residual hydronephrosis after successful pyeloplasty is not common. In this report, we have studied new ultrasound parameters, and have investigated the frequency of residual hydronephrosis. We highlight alternative radiation-free monitoring of pediatric pyeloplasties with ultrasound alone.

PATIENTS AND METHODS

Children who had undergone successful open Anderson-Hynes pyeloplasties in the period 2001-2010 were followed up. Exclusion criteria included non-clearly obstructed renography scans (tracer clearance half-time < 20 min), crossing vessels, failed pyeloplasty, bilateral disease, other renal concomitant anomaly, absence of ultrasound measurements, and loss to follow up (<1 year). Postoperative (postoperative) ultrasound parameters were anteroposterior (AP) diameter, pelvis-cortex (P/C) ratio, a proportion that takes in account these two values, enhancing sensitivity to evaluate minimal evolutive changes), and percentage of improvement (PI) in AP diameter (which reflects in relative means the evolution of each AP diameter, being 0% no change, and 100% absence of hydronephrosis) (Figure). Echographic checks were made at 3 and 6 months postoperatively and then yearly afterwards. SPSS software (v. 17.0 IBM, College Station, TX, USA) was used.

RESULTS

Out of 80 pyeloplasties performed in the above-mentioned period, 44 patients (i.e., 44 renal units) fulfilled the inclusion criteria for the main study. The median age at time of operation was 15 months (range 2 months-10.3 years). The median follow-up was 4.5 years (range 1-12 years). The mean preoperative anteroposterior diameter was 26 mm (range 16-54 mm). At the third postoperative check, the mean the PI was 29%, and rose to 53% at 6 months (p=0.027). Posterior controls showed a stable yearly PI during follow-up, without statistically significant variations (40-59% in subsequent years, p>0.5). The P/C ratio had already downgraded significantly at the third postoperative check (4.6 preoperative vs. 1.8 postoperative; p=0.03). A subgroup analysis of failed pyeloplasty (4 renal units) showed all PI < 15% at the third postoperative month (sensitivity 100%, specificity 86%). Complete resolution of hydronephrosis occurred in nine patients (20%).

DISCUSSION

The P/C ratio and PI are new feasible ultrasound parameters in pyeloplasty follow-up. Early improvement in the P/C ratio can be expected and might avoid repeated ionizing scans. A PI>15% in subsequent postoperative checks might be enough for safe monitoring with ultrasound alone. Thus, renograms may be solicited only in these cases where ultrasound parameters do not improve in the first 6 postoperative months. Afterwards, ultrasound parameters often remain stable in the long term. Absence of hydronephrosis could only be documented in the long term in one out of every five patients.

HIV-infected children vaccination coverage and safety in a Western European cohort: a retrospective study

Since the implementation of highly active antiretroviral therapy in HIV-infected children, response to scheduled vaccines may determinate future morbidity and mortality. The aims of this study have been to describe the current vaccine coverage, vaccine safety and concordance with vaccine recommendations of the 68 HIV-infected children and adolescents followed up in our Unit. Forty-four percent of the children received at least one dose of the oral polio vaccine (OPV). Only 9.1% needed and received a second set of hepatitis B virus immunization because of low vaccine response. Only 14.7% were vaccinated against varicella. Coverages of 82.3% and 100% have been reached with the 23-valent and the 7-valent pneumococcal vaccines, respectively. Meningococcal conjugated vaccine uptake was moderate (80.8%). Influenza annual vaccination coverage was poor: only 22.7% had well-documented yearly vaccines. In our experience, vaccine coverage is lower in those vaccines administered in primary care centres compared with the immunizations given at the hospital. OPV administration did not cause any adverse effect in the children or in their families. Vaccine coverage in HIV-infected children was suboptimal.

Voiding urosonography with second-generation contrast as a main tool for examining the upper and lower urinary tract in children. Pilot Study

INTRODUCTION

In this series, we analyse the diagnostic efficacy of serial voiding urosonography (VUS) with second-generation contrast, combined harmoniously and specifically with contrast technology, in the examination of the urinary tract in children. This examination includes the diagnosis and follow-up for vesicoureteral reflux (VUR) and urethral disorders, mainly those of the posterior urethral valve (PUV).

PATIENTS AND METHODS

After obtaining informed consent, a prospective study was conducted using urosonography with second-generation contrast (sulphur hexafluoride microbubbles, SonoVue®) from November 2014 to October 2015 (1 year) in paediatric patients with suspected VUR or PUV impairment. For patients with a high suspicion of VUR and in cases of PUV, we also conducted simultaneous voiding cystourethrography (VCUG).

RESULTS

We studied 40 patients (80 renal units) between the ages of 2 months and 13 years (median age, 14 months). The indication for the test was a suspected VUR (36 patients, group A) and PUV follow-up (4 patients, group B). The test was correlated with VCUG in 16 patients (12 cases with high suspicion of VUR in group A and with 4 cases of PUV in group B). The visualisation of the urethra was appropriate in cases of dilation or urethral stricture. For 3 of these patients with bilateral VUR demonstrated in the serial VUS, the VCUG showed only unilateral VUR in 2 of the patients and no VUR in 1 of the patients (κ=.73).

DISCUSSION

We have shown that the visualisation of the urethra is no longer a limitation and that serial VUS can be superior to conventional VCUG in diagnosing VUR.

A modified device to facilitate flow measurements during voiding cystometry studies in infants

INTRODUCTION

Urodynamic studies (UDS) in infants are traditionally hampered by technique and flow collection; both are difficult and have not yet been standardized.

METHODS

A very simple device has been developed to collect urine during the voiding phase in UDS. It is based on a urine-collection adhesive bag, which is connected to a tube that conducts the urine to a flowmeter.

RESULTS

Eleven infants (4-23 months) were selected and a complete UDS was performed on all of them. A diagnosis was obtained for all of the infants.

DISCUSSION

This device is easily available in every pediatric clinic; it is also disposable and inexpensive. It enables UDS in infants to be complete and achievable.

[Vesicovaginal Reflux and Urocolpos]

OBJECTIVE

Vesico-vaginal reflux (VVR) is defined as the reflux of urine into the vaginal vault during voiding, occasionally seen in pre- adolescent girls. The typical history consists in post voiding leaks in the daytime, that correspond to the progressive urine discharge from the vagina, after it has been filled up during micturition. We intend to show two cases presenting with significant urocolpos.

METHODS

Description of two clinical cases observed in the pediatric urology office.

RESULTS

Clinical case 1.- A 10-year-old girl presented with the complaint of diurnal incontinence (in the immediate post-voiding minutes). The early voiding phase in the cystourethrogram (VCUG) demonstrated progressive gross distension of the vagina (urocolpos) due to retrograde filling as the bladder emptied. The girl was managed with behavioural modifications, and was dry afterwards. Clinical case 2.- A 9-year-old girl presented with history of incomplete voiding. In infancy, she had right-sided vesicoureteral reflux (VUR) and was endoscopically treated at the age of 2. VCUG showed VVR, and no VUR. She was then successfully treated with behavioural modifications. Clinical case 3.- A 10-year-old girl complained of diurnal urinary incontinence, described as post voiding leaks. Again, a VCUG showed VVR and a small urocolpos. After re-education of voiding habits, leaks disappeared, but recurred 6 months afterwards, when she acknowledged no adherence to the therapy.

DISCUSSION

Between 12 to 15% of girls referred to Urological clinics because of urine incontinence present VVR. In the absence of a clear anatomical obstruction, reflux happens as the urine flow encounters a natural obstacle in the labia majora usually in girls that close their legs as they void. Instructions on proper voiding form a key element in the management of VVR, and if not enough, the behavioural modification consists on a reverse position during voiding.

[Testicular and paratesticular tumors in prepubertal children]

OBJECTIVES

To describe our experience in testicular and paratesticular tumors during the prepubertal stage, focusing especially on its character of benignity/malignancy and surgical treatment used.

MATERIAL AND METHODS

Retrospective review of all testicular tumors in children under 12 years diagnosed and treated in our clinical setting from 1998-2015. Data on their presentation, study and management were collected.

RESULTS

17 children with prepubertal testicular tumors were identified. The clinical presentation as palpable testicular mass occurred in 12 cases (70.5%). Levels of tumor markers (alpha-fetoprotein and βhCG) were only increased alpha-fetoprotein in two cases. In the histopathological study, 64.7% of the tumors were benign (five mature teratomas, four Leydig cells tumors, one immature teratoma and one sexual cords-stromal tumor). Malignant tumors were three rhabdomyosarcoma (17.6%), two yolk-sac tumors (11.8%) and one Burkitt lymphoma (5.9%). The mean age of benign was 5.9 years old and malignant 2.9 years old (p=0.68). From neoplastic lesions nine were non-germline (53%) and eight germline (47%). In the management testis-sparing surgery was performed in six benign tumors, and orchiectomy in five benign tumors and in all malignant tumors except lymphoma which received chemotherapy.

CONCLUSIONS

Benign primary testicular and paratesticular tumors are more frequent in prepubertals and testis-sparing surgery is indicated by inguinal approach.

Birth defects in a cohort of infants born to HIV-infected women in Spain, 2000-2009

BACKGROUND

Antiretroviral therapy (ART) in pregnancy has resulted in a marked impact on reducing the risk of mother-to-child transmission (MCT) of HIV. However the safety of in utero ART exposure in newborns remains a concern.

METHODS

A multicenter prospective observational study of HIV-infected mother and their infants was performed in Madrid, Spain, from 2000 to 2009. Children had regular visits with clinical examination according to protocol until the age of 24 months. An abdominal ultrasound and an echocardiogram were scheduled during follow up. Birth defects (BDs) were registered according to European Surveillance of Congenital Anomalies (EUROCAT).

RESULTS

A total of 897 live births from 872 mothers were included. Overall the birth defects prevalence observed was 6.9% (95% CI 5.4-9.1).The most commonly reported birth defects types were in genital organs and urinary system (19 cases, 30.6%) and cardiovascular system (17 cases, 27.4%). There was no increased risk for infants exposed in the first trimester to ARVs compared with unexposed infants. No significant associations were observed between exposure to any individual antiretroviral agent during pregnancy and birth defects

CONCLUSION

A higher prevalence of BDs was observed, higher than previously reported. In utero exposure to ART was not proved to be a major risk factor of birth defects in infants. However the relatively small number of patients is a major limitation of this study.

Gestational diabetes mellitus in a cohort of HIV-1 infected women

OBJECTIVES

We undertook a prospective study to estimate the prevalence of gestational diabetes mellitus (GDM) and associated risk factors in a cohort of 669 HIV-1 infected women.

METHODS

The O'Sullivan and glucose tolerance tests were performed during regular visits of 609 mothers.

RESULTS

The median age of the cohort was 30.7 years (range 16-44), with most women having had heterosexual contact (67%). The majority were in Centers for Disease Control (CDC) category A (71%) and 53% exhibited hepatitis C co-infection. Median viral load and CD4 count at third trimester were 545 cells/microL (range 139-1690 cells/microL) and 1.9 log (range 1.7-5.4), respectively. Seventy-four per cent of the patients were treated with highly active antiretroviral therapy (HAART), of whom 41% received a protease inhibitor (PI). An above-average prevalence of 7% [95% confidence interval (CI) 5.2-9.5] for positive GDM diagnosis was found. Risk factors associated with GDM in univariate analysis included older age, hepatitis C co-infection, stavudine and PI exposure. However, only older age [adjusted odds ratio (AOR) 1.09, 95% CI 1-1.1] and PI exposure (AOR 2.4, 95% CI 1-5.3) remained as independent risk factors for GDM development in multivariate analysis.

CONCLUSIONS

In our cohort, the prevalence of GDM appears to be increased, with older age and PI exposure contributing as significant independent risk factors.

[Prevalence of antibodies against hepatitis A and B in HIV-1-infected children and adolescents]

INTRODUCTION

Patients coinfected with HIV and hepatitis B virus (HBV) have a higher risk of developing chronic HBV infection and a higher risk of hepatotoxicity. Hepatitis A virus (HAV) in HIV-infected patients may require antiretroviral treatment interruption, producing prolonged viremia. In this study, we assess the prevalence of protective antibodies in these patients.

METHODS

A cross-sectional study was conducted to determine the prevalence of IgG antibodies against HAV and antibody against HBs (anti-HBs) in a cohort of 121 HIV-infected children and adolescents (1-19 years), followed-up in 4 public hospitals in Madrid (Spain).

RESULTS

Among the total, 12.4% (95% CI: 7.1-19.6%) of children and adolescents had positive serology for HAV. Children of immigrant origin presented a higher percentage than children born in Spain: 50% vs. 6.2%, respectively (P<0.001). In addition, 16.5% (95% CI: 10.4-24.3) of the study population had protective anti-HBs. A higher percentage of children with anti-HBs antibodies was seen in CDC clinical category A: 20% vs. 16% of those in clinical category B vs. 9.4% of those in clinical category C (P=0.19). The percentage of positive-positive children progressively decreased according to the years elapsed since HBV vaccination.

DISCUSSION

Most HIV-infected children and adolescents have no protective antibodies against natural infection by HBV and HAV. More studies are needed to define the best vaccination strategy to achieve a higher percentage of patients protected against these infections.

[Why are HIV-infected infants still being born in Spain?]

INTRODUCTION

Despite the success of preventive measures against mother-to-child transmission (MTCT) of human immunodeficiency virus-1 and -2 (HIV-1 and -2) in developed countries, HIV-infected infants continue to be born. The aim of this study was to evaluate failures in the prevention of MTCT and the clinical characteristics of infected infants.

METHODS

The Foundation for the Investigation and Prevention of AIDS in Spain (FIPSE) Cohort in Madrid prospectively follows up children at risk of MTCT HIV born in eight public hospitals in Madrid. From May 2000 to December 2005, 632 children born to HIV-infected mothers were evaluated. Data from pregnancy follow-up, antiretroviral therapy (ART), and symptoms at diagnosis in infected infants were analyzed.

RESULTS

Nine infants were infected. The rate of vertical transmission was 1.42 (95% CI 0.7-2.68). Of the nine mothers, seven had not received ART during pregnancy (and five had not received ART at delivery). Of the mothers who received ART, one had only done so for the last month of pregnancy. Two infants were given three drugs as prevention of MTCT, one received bitherapy and six received monotherapy. The median age at diagnosis was 2.4 months (range 7 days-2 years). The mean plasma viral load at diagnosis was 276,000 copies/ml (range: 11,900-1,000,000). Five of the infants were symptomatic at diagnosis (P. jirovaci pneumonia in two, sepsis in one, recurrent bacterial infections in one, hepatosplenomegaly in one). Four of the nine infants had been admitted to hospital prior to HIV diagnosis.

DISCUSSION

Missed opportunities for the prevention of MTCT were identified in eight of the nine HIV-infected infants (89%). Administration of AZT during labor in HIV-infected mothers and triple therapy for the prevention of MTCT in high risk infants is not universal. Hospital admission in young infants at risk might lead to suspicion of infection in infants born to HIV-infected mothers. Improved implementation of all the preventive measures for MTCT should be encouraged.