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Renal function recovery after nephrectomy or nephron-sparing surgery in children with unilateral renal tumor
No full textIntroduction Children with unilateral renal tumor (URT) and preoperative renal
dysfunction (PRD) may benefit from nephron-sparing surgery (NSS). To test this
hypothesis, we studied the outcome of baseline renal function after nephrectomy or
NSS among children with URT.
Materials and Methods Retrospective records review of children with URT who
underwent nephrectomy (25 children) or NSS (11 children) at our institution. We
analyzed the estimated glomerular filtration rate (eGFR) changes over time among
patients, stratified by both preoperative renal function (with or without PRD) and
surgical extent (NSS vs. nephrectomy). The primary end point was evaluation of
compensatory recovery of preoperative eGFR after surgery. Only children older than
2 years at surgery were included in the study. Renal dysfunction was defined as an
eGFR < 90 mL/min/1.73 m2.
Results After nephrectomy or NSS, patients with PRD presented, on average during
adolescence, a significant increase in eGFR, whereas patients without PRD presented, on
average during adolescence, a stable eGFR. However, after nephrectomy, 5 of 17 (29%)
and 7 of 8 (87%) adolescent patients with baseline eGFR or > 100 mL/min/1.73 m2,
respectively, achieved or maintained two-kidney eGFR values (T-KEV) (p 1⁄4 0.01). After
NSS, four adolescent patients with PRD and seven without PRD achieved or maintained
T-KEV.
Conclusion The majority of children with URT and low baseline eGFR present with an
impaired renal function recovery after nephrectomy and may benefit from NSS.
Collaborative studies are needed to support present findings
Re: Lopes et al.: “Zero-Ischemia” Laparoscopic-assisted Partial Nephrectomy for the Management of Selected Children With Wilms Tumors Following Neoadjuvant Chemotherapy. (Urology 2017;100:103-110)
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Wilms Tumor
No full textWilms tumor, or nephroblastoma, is the most frequent primary renal tumor in the pediatric age group,
accounting for 5% of all childhood cancers and affecting one in about 10,000 children. Clinical onset tends
to occur between ages 1 and 5 years, with 90% of new cases diagnosed before age 7 years. Despite its
malignant nature, long term survival rate after treatment is excellent, being greater than 90% for localized
disease and 75% for metastatic disease. Most of the dramatic improvements in survival of these children
have been achieved by results from randomized clinical studies conducted by the two largest collaborative
groups from both sides of the Atlantic, namely the Children’s Oncology Group (COG—formerly the
National Wilms Tumor Study [NWTS]) and the Société Internationale d’Oncologie Pédiatrique (SIOP).
Surgery still plays a pivotal role in the multimodal treatment strategy of Wilms tumor, which also includes
chemotherapy, and, in certain circumstances, radiation therapy according to patient stratification into welldefined risk groups. Future goals will focus on further reduction in frequency and intensity of acute and
late toxicity while maintaining current high rate of cure. Additionally, the use of biomarkers for patient risk
stratification and the introduction of newer molecular targeted therapies will hopefully improve prognosis and treatment of the high risk patients
Early surgery versus watchful waiting strategy for infantile abdominoscrotal hydrocele
Full text linkBackground: Infantile abdominoscrotal hydrocele is generally managed with early surgery. However, whether these patients actually benefit from an initial watchful waiting strategy is yet to be determined. Methods: This single-center, comparative observational analysis included 36 consecutive patients (9 bilateral cases) diagnosed between January 1998 and December 2019. Initial 16 patients (21 lesions) underwent surgical repair shortly after diagnosis (Group A) at a mean (SD) age of 8 (4) months. Remaining 20 patients (24 lesions) underwent initial nonoperative management (Group B). Overall follow-up was 82.74 (63.84) months. Results: Six lesions of Group B spontaneously regressed at a mean age of 23.8 (7.8) months. Remaining 18 hydroceles underwent surgical management at a mean age of 18.7 (12.6) months. Early postoperative morbidity was high (43%) in both groups (Clavien-Dindo grade I-II). During follow-up, there were 1 recurrent hydrocele and 1 testicular atrophy, both events occurring in Group A patients. Group B patients required a higher need for concomitant ipsilateral orchidopexy (61% versus 14%; p = 0.001), and developed a higher rate of ipsilateral inguinal hernia (39% versus 5%; p = 0.01), occurring within 8.3 (3.53) months of surgery. On multivariable analysis, nonoperative management was associated with unplanned second surgery (odds ratio 5.5, 95% CI 1.25-24.17, p = 0.02), regardless of the type of hydrocelectomy performed. Conclusions: Nonoperative management provides effective spontaneous resolution in about 25% of infantile abdominoscrotal hydrocele. Clinicians must balance the potential benefits of such strategy against the impact of pressure induced detrimental effects on the success of future surgery when dealing with longstanding lesions. Level of evidence: III
Feasibility, safety and outcome of inguinal hernia repair under spinal versus general anesthesia in preterm and term infants
Full text linkBackground: Inguinal hernia repair (IHR) is a common operation in preterm and term infants. Recently, spinal anesthesia (SA) has been proposed as an alternative to avoid exposure to general anesthesia (GA) during early life. The aim of this study was to compare surgical outcomes of open IHR performed under SA versus GA in neonates and infants, and to detect criteria to predict the success or failure of SA. Materials and methods: This is a 6-year, single center, nonrandomized interventional study (2013–2019). SA was performed with 0.5% bupivacaine. GA was given using propofol, fentanyl, sevoflurane, and laryngeal mask. Patient demographics, operative time, intraoperative events related to surgery or anesthesia, and complications were analyzed at short and long-term follow-up. Results: 68 infants (78 IHR) and 37 infants (44 IHR) received SA and GA at the discretion of the anesthesiologist, respectively. SA failure rate was 9%, and positively correlated with weight at surgery (p = 0.001; rp = 0.38). Conversion from SA to GA occurred in 4 (6%) patients owing to prolonged operative time (43.75 ± 4.8 vs 23.02 ± 11.3 min; p = 0.0006). There were no differences regarding operative time and intra- and postoperative complications among the two groups at mean follow-up of 18.53 ± 21.9 months. Conclusions: This pilot study confirms that SA is safe, effective and not detrimental to surgical outcome of neonates and infants undergoing IHR. Additionally, it may help further define what patients may have a successful SA. Our experience suggests that SA is especially suitable in infants weighing < 4000 g, and conversion to GA correlates with prolonged operative time. Level of evidence: Level II
Reduction of 50% of renal mass in children: consequences of hyperfiltration up to the fifth decade of life
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