EAU Pediatrics 2021 Rapid Flashcards
Treatment for phimosis usually starts: ___
After two years of age or according to caregivers’ preference
Primary phimosis: conservative 1st line treatment with 80% success rate:
3rd generation corticoid ointment or cream
Offer ___ or ___ to treat primary symptomatic PHIMOSIS.
Corticoid ointment or cream
OR Circumcision
Treat primary phimosis in patients with ____.
recurrent urinary tract infection and/or with urinary tract abnormalities.
Circumcise phimotic patients in case of ___.
lichen sclerosus or scarred phimosis.
Treat paraphimosis by ___.
manual reposition and proceed to surgery if it fails.
Phimosis: Avoid retraction of ___.
asymptomatic preputial adhesions.
Classification of Undescended Testis
Palpable
- Inguinal
- Ectopic
- Retractile
Non-palpable
- Inguinal
- Ectopic
- Intraabdominal
- Absent: (1) agenesis (2) vanishing
Unilateral NON-palpable testis –> EUA (always) –> PALPABLE
Standard orchidopexy
Unilateral NON-palpable testis –> EUA (always) –> NON-PALPABLE
Inguinal Exploration with possible lap
OR
Diagnostic Lap
- Testis close to internal ring –> LAP or inguinal orchidopexy
- Testis too high for orchidopexy –> Staged Fowler-Stephens procedure
- Blind-ending spermatic vessels –> vanishing testis no further steps
- Spermatic vessels enter inguinal ring –> inguinal exploration
An undescended testis justifies treatment early in life to ____.
A failed or delayed orchidopexy may increase ___.
The earlier the treatment, the ___.
avoid loss of spermatogenic potential.
the risk of testicular malignancy later in life.
lower the risk of impaired fertility and testicular cancer.
In unilateral undescended testis, fertility rate is ___ whereas paternity rate is ___.
fertility - reduced
paternity - NOT reduced
In bilateral undescended testes, fertility and paternity rates are ___
BOTH impaired.
The treatment of choice for undescended testis is ___.
There is no consensus on the use of ___.
surgical replacement in the scrotum.
hormonal treatment.
The palpable testis is usually treated surgically using ___.
an inguinal approach.
Do not offer ___ for retractile testes instead ___.
medical or surgical treatment
undertake close follow-up on a yearly basis until puberty.
Perform surgical orchidolysis and orchidopexy before the age of ___.
TWELVE months, and by EIGHTEEN months at the latest.
Evaluate male neonates with ___ for possible ____.
bilateral non-palpable testes
disorders of sex development.
Perform a ____ to locate an intra-abdominal testicle.
diagnostic laparoscopy
Hormonal therapy in unilateral undescended testes is ___ for future paternity.
of NO BENEFIT
Offer ___ treatment in case of bilateral undescended testes.
Endocrine treatment
Inform the patient/caregivers about the ___with an undescended testis in a post-pubertal boy or older and discuss ___.
increased risk of a later malignancy
removal in case of a contralateral normal testis in a scrotal position.
Testicular tumours in prepubertal boys have a ___.
lower incidence and a different histologic distribution 2a compared to the adolescent and adult patients.
In prepubertal boys up to 60-75% of testicular tumours are ___.
benign.
Testicular Tumors
___ should be performed to confirm the diagnosis.
High-resolution ultrasound (7.5 – 12.5 MHz), preferably a doppler ultrasound,
Testicular Tumors
___ should be determined in prepubertal boys with a testicular tumour before surgery.
Alpha-fetoprotein
Testicular Tumors
____, but not as an emergency operation.
Surgical exploration should be done with the option for frozen section
Testicular Tumors
Organ-preserving surgery should be performed in ___.
all benign tumours.
Testicular Tumors:
___ should only be performed in patients with a malignant tumour to exclude metastases.
Staging (MRI abdomen/CT chest)
Testicular Tumors:
___ should only be performed in patients with the potential malignant Leydig or Sertoli-cell-tumours to rule out lymph node enlargement.
Magnetic resonance imaging
Testicular Tumors:
Patients with a non-organ confined tumour should be ___.
Referred to paediatric oncologists post-operatively.
HYDROCELE
In the majority of infants, ___ is not indicated within the first twelve months due to the tendency for ___. Little risk is taken by initial observation as progression to hernia is rare.
surgical treatment of hydrocele
spontaneous resolution.
HYDROCELE
In the paediatric age group, an operation would generally involve ___
ligation of the patent processus vaginalis via inguinal incision.
HYDROCELE
In the majority of infants, ___ prior to considering surgical treatment.
observe hydrocele for twelve months
HYDROCELE
Perform early surgery if ___
there is suspicion of a concomitant inguinal hernia or underlying testicular pathology.
HYDROCELE
Perform a scrotal ultrasound in case of ___
doubt about the character of an intrascrotal mass.
HYDROCELE
Do not use ___ because of the risk for chemical peritonitis.
sclerosing agents
Child ≥ 5 years nocturnal enuresis
Detailed questions for day-time symptoms Physical exam and urinanalysis 2 days day-time voiding and drinking diary 2 weeks night-time urine production recording (= weight night-time diapers + morning first voided volume) Upon indication • Urine microscopy • Uroflow- metry • Ultrasound • ENT referral • Psychologist referral
Supportive measures (not a treatment) (max 4 weeks) • Normaland regular drinking habits • Regular voiding and bowel habits • Monitor night-time production (weight diapers)
Child + caregivers seek a treatment --Nocturnal enuresis wetting alarm treatment with regular follow-up --desmopressin +/- anticholinergics
If no improvement (< 4 weeks) OR Lack of compliance +
Re-evaluate
Do not treat children ___ in whom spontaneous cure is likely.
less than five years of age
** inform the family about the involuntary nature, the high incidence of spontaneous resolution and the fact that punishment will not help to improve the condition.
Use___ to exclude day-time symptoms.
Perform a ___ to exclude the presence of infection or potential causes such as diabetes insipidus.
voiding diaries or questionnaires
urine test
Offer desmopressin +/- cholinergics in ___.
Offer ___ in motivated and compliant families
proven night-time polyuria: success rates of 70% can be obtained with desmopressin (DDAVP), either as tablets (200-400 μg), or as sublingual DDAVP oral lyophilisate
ALARM treatment: device that is activated by getting wet –> method of action is to repeat the awakening and therefore change the high arousal to a low arousal threshold when a status of full bladder is reached
Myelodysplasia
includes a group of developmental anomalies that result from defects in neural tube closure. Lesions include spina bifida aperta and occulta, meningocele, lipomyelomeningocele, or myelomeningocele. Myelomeningocele is by far the most common defect seen and the most detrimental.
MYELODYSPLASIA + NB: Neurogenic detrusor-sphincter dysfunction (NDSD) may result in ___
different forms of LUTD and 2a ultimately result in incontinence, UTIs, VUR, and renal scarring.
MYELODYSPLASIA + NB: In children, the most common cause of NDSD is ___
myelodysplasia (a group of developmental anomalies 2 that result from defects in neural tube closure).
MYELODYSPLASIA + NB: Bladder sphincter dysfunction correlates poorly with ___
the type and level of the spinal cord lesion. 2a Therefore, urodynamic and functional classifications are more practical in defining the extent of the pathology and in guiding treatment planning.
MYELODYSPLASIA + NB: Children with neurogenic bladder can have disturbances of ___
The main goals of treatment are ___
bowel function as well as urinary function 2a which require monitoring and, if needed, management.
prevention of urinary tract deterioration and achievement of 2a continence at an appropriate age.
MYELODYSPLASIA + NB: Injection of ____ in children who are refractory to anticholinergics, has been shown to have beneficial effects on clinical and urodynamic variables.
botulinum toxin into the detrusor muscle
MYELODYSPLASIA + NB: Urodynamic studies should be performed in ___ to estimate the risk for the upper urinary tract and to evaluate the function of the detrusor and the sphincter.
every patient with spina bifida as well as in every child with high suspicion of a neurogenic bladder
MYELODYSPLASIA + NB: In all newborns with myelodysplasia, intermittent catheterisation (IC) should be started ___
soon after birth.
*** In those with a clear underactive sphincter and no overactivity starting IC may be delayed. If IC is delayed, closely monitor babies for urinary tract infections, upper tract changes (US) and the lower tract (UD).
MYELODYSPLASIA + NB: Start early anticholinergic medication in the newborns with ___
suspicion of an overactive detrusor.
MYELODYSPLASIA + NB: The use of ____ is an alternative and a less invasive option in children who are refractory to anticholinergics in contrast to bladder augmentation.
suburothelial or intradetrusoral injection of onabotulinum toxin A
MYELODYSPLASIA + NB: Treatment of faecal incontinence is important ___. Treatment should be started with ___. If not sufficient transanal irrigation is recommended, if not practicable or feasible, a ___
to gain confidence and independence.
mild laxatives, rectal suppositories as well as digital stimulation
Malone antegrade colonic enema (MACE)/Antegrade continence enema (ACE) stoma should be discussed.
MYELODYSPLASIA + NB: Ileal or colonic bladder augmentation is recommended in patients with___.
therapy resistant overactivity of the detrusor, small capacity and poor compliance, which may cause upper tract damage and incontinence
** The risk of surgical and non- surgical complications and consequences outweigh the risk of permanent damage of the upper urinary tract +/- incontinence due to the detrusor.
MYELODYSPLASIA + NB: In patients with a neurogenic bladder and a weak sphincter, ____should be offered.
a bladder outlet procedure
** It should be done in most patients together with a bladder augmentation.
MYELODYSPLASIA + NB: ___ should be offered to patients who have difficulties in performing an IC through the urethra.
Creation of a continent cutaneous catheterisable channel
MYELODYSPLASIA + NB: A life-long follow-up of ___should be available and offered to every patient. Addressing sexuality and fertility starting before/during puberty should be offered.
renal and reservoir function
MYELODYSPLASIA + NB:
Urinary tract infections are common in children with neurogenic bladders, however, only ___ should be treated.
symptomatic UTIs
UPJO/UVJO:
In children diagnosed with antenatal hydronephrosis, ____ were shown to
be at higher risk of developing UTI.
non-circumcised infants (LE: 1a), children diagnosed with high-grade hydronephrosis (LE: 2) and hydroureteronephrosis (LE: 1b)
UPJO/UVJO: Include ___ in post-natal investigations.
serial ultrasound (US) and subsequent diuretic renogram and sometimes voiding cystourethrography
UPJO/UVJO: Offer ___ to the subgroup of children with antenatal hydronephrosis who are at high risk of developing urinary tract infection like ____, respectively.
continuous antibiotic prophylaxis
uncircumcised infants, children diagnosed with hydroureteronephrosis and high- grade hydronephrosis
UPJO/UVJO: Decide on surgical intervention based on the ___
time course of the hydronephrosis and the impairment of renal function.
UPJO/UVJO: Offer surgical intervention in case of a ___
n impaired split renal function due to obstruction or a decrease of split renal function in subsequent studies and increased anteroposterior diameter on the US, and grade IV dilatation as defined by the Society for Fetal Urology.
UPJO/UVJO: Offer pyeloplasty when ureteropelvic junction obstruction has been ___
confirmed clinically or with serial imaging studies proving a substantially impaired or decrease in function.
UPJO/UVJO: Do not offer surgery as a standard for ___ since the spontaneous remission rates are as high as 85%.
primary megaureters
**Ureterovesical junction (UVJ) obstruction is an obstructive condition of the distal ureter as it enters the bladder, commonly called a primary obstructive megaureter. Megaureters are the second most likely cause of pathological neonatal hydronephrosis.
Ureteropelvic junction (UPJ) obstruction is defined as
impaired urine flow from the pelvis into the proximal ureter with subsequent dilatation of the collecting system and the potential to damage the kidney.
It is the MOST COMMON pathological cause of neonatal hydronephrosis
VUR: Inform parents of children with vesicoureteric reflux (VUR) that ___
Do not screen ___ since there is no added value in screening for VUR.
siblings and offspring have a high prevalence of VUR.
older toilet-trained children
- Use renal ultrasound (US) for screening of sibling(s).
- Use voiding cystourethrography if there is evidence of renal scarring on US or a history of urinary tract infection.
VUR: There is no evidence that correction of ___ offers a significant benefit.
persistent low-grade reflux (grades I-III) without symptoms and normal kidneys
VUR: Surgical correction should be considered in ___.
There is no consensus about the timing and type of surgical correction.
The outcome of open surgical correction is better than endoscopic correction for ___
whereas satisfactory results can be achieved by endoscopic injection for ___.
patients with persistent high-grade reflux (grades IV/V)
higher grades of reflux
lower grades
VUR: Initially treat all patients diagnosed within the first year of life with ___
Offer immediate, parenteral antibiotic treatment for ___
continuous antibiotic prophylaxis, regardless of the grade of reflux or presence of renal scars.
febrile breakthrough infections.
VUR: Offer ___ to patients with frequent breakthrough infections.
definitive surgical or endoscopic correction
VUR: Offer___ to patients with persistent high-grade reflux and ___for lower grades of reflux.
open surgical correction
endoscopic correction
VUR: Initially manage all children presenting at ___ conservatively.
Offer surgical repair to children above the age of one presenting with ___
age one to five years
high-grade reflux and abnormal renal parenchyma.
VUR: Offer close surveillance without antibiotic prophylaxis to ___
children presenting with lower grades of reflux and without symptoms.
VUR: Ensure that a detailed investigation for the presence of___is done in all and especially in children after toilet-training.
lower urinary tract dysfunction (LUTD)
** If LUTD is found, the initial treatment should always be for LUTD.
STONES:
MAP stones on analysis
Urine CS - if urease producing bacteria – surgery/SWL, antibiotics
STONES:
Uric acid stones
Check urine pH, uric acid levels
Acidic urine
Hyperuricosuria
Hyperuricemia
TX: Alkali replacement - K citrate
Allopurinol (10 mg/kg)
Low purine diet
STONES:
Cystine
Urine pH
Urine cystine level
- If with cystinuria
High fluid intake
K citrate (3-4 mEq/kg/d)
Mercaptopropiyonilglycine 10-15 mg/k/d
Penicillamin 30 mg/kg/d
STONES:
CaOx-CaPO
CHECK:
Urine and blood: pH, Ca, uric acid, PO, CaOxCitrateMgUricAPhos
pH>5.5: investigate for RTA
pH <5.5
- -Hypercalciuria: K citrate, normal Ca, low sodium, HCTZ
- -Hyperoxaluria: Regular Ca diet, low oxalate diet; K citrate, pyrodixine
- -Hyperuricosuria: K citrate, allopurinol
- -Hypocitraturia: K citrate
IF Elevate serum PTH + hypercalcemia = hyperparathyroidism surgical treatment
STONES:
Most common complications from SWL in children
- renal colic;
- transient hydronephrosis;
- dermal ecchymosis;
- UTI;
- formation of Steinstrasse;
- sepsis;
- rarely, haemoptysis.
STONES:
In children with ___, antibiotic prophylaxis to decrease infectious complications is not recommended
sterile pre-operative urine cultures
STONES:
Staghorn stones
Pelvis > 20 mm
PCNL
Open/SWL
PCNL
MicroPerc/Open
STONES:
Pelvis < 10 mm
Pelvis 10-20 mm
SWL
RIRS/PCNL/MicroPerc
SWL
PCNL/RIRS
STONES:
Lower pole calyx
PCNL
SWL/Open
STONES:
Kidney < 10 mm
SWL
RIRS/PCNL/MicroPerc
STONES
Kidney > 10 mm
PCNL
RIRS PCNL Microperc
STONES
Upper ureteral stones
Lower ureteral stones
SWL
SWL/Microperc
URS
PCNL/URS/Open
STONES
Bladder
Endoscopic
SWL/Open
**Open is easier and with less operative time with large stones
DSU
Asymptomatic
No VUR or VUR low grade
Observation
DSU
Asymptomatic
High grade VUR or multiple infections
Bladder surgery or endoscopic
DSU
Symptomatic with NO VUR
No/poor function
Intravesical endoscopic decompression
OR
Ectopic upper pole partial nephrectomy
DSU
Symptomatic or severe hydroureteroneprhsosi or obstruction
VUR or no VUR with good function
Ectopic – upper to lower tract anastomosis
OR Intravesical endoscopic decompression
DSU
___ are associated with complete renal duplication, but they also occur in a 1 single system.
Ureterocele and ectopic ureter
DSU
Management includes a conservative approach, endoscopic decompression, partial nephroureterectomy, or complete primary reconstruction. Choice of treatment will depend on:
- clinical status of the patient (e.g., urosepsis);
- patient age;
- function of the upper pole;
- presence of reflux or obstruction of the ipsilateral or contralateral ureter;
- presence of bladder neck obstruction caused by ureterocele;
- intravesical or ectopic ureterocele;
DSU
Ureterocele: DIAGNOSIS
Use ultrasound (US), radionuclide studies (mercaptoacetyltriglycine (MAG3)/dimercaptosuccinic acid (DMSA)), voiding cystourethrography (VCUG), magnetic resonance urography, high-resolution magnetic resonance imaging (MRI), and cystoscopy to assess function, to detect reflux and rule out ipsilateral compression of the lower pole and urethral obstruction.
DSU
Ureterocele: Treatment
Select treatment based on symptoms, function and reflux as well on surgical and parenteral choices: observation, endoscopic decompression, ureteral re-implantation, partial nephroureteretomy, complete primary reconstruction. Offer, early endoscopic decompression to patients with an obstructing ureterocele.
DSU
Ectopic ureter: Diagnosis
Use US, DMSA scan, VCUG or MRI for a definitive diagnosis.
DSU
Ectopic ureter: Treatment
Treatment In non-functioning moieties with
recurrent infections, heminephro-ureterectomy
is a definitive solution. Ureteral reconstruction (ureteral re-implantation/ureteroureterostomy/ ureteropyelostomy and upperpole ureterectomy) are other therapeutic option especially in cases in which the upper pole has function worth preserving.
Findings in a newborn suggesting the possibility of DSD
APPARENT MALE
Severe hypospadias associated with bifid scrotum Undescended testis/testes with hypospadias
Bilateral non-palpable testes in a full-term apparently male infant
APPARENT FEMALE Clitoral hypertrophy of any degree, non-palpable gonads Vulva with single opening Indeterminate Ambiguous genitalia
DSD
Investigations
Blood analysis: 17-hydroxyprogesterone, electrolytes, LH, FSH, TST, cortisol, ACTH Urine: adrenal steroids
Karyotype
Ultrasound
Genitogram
hCG stimulation test to confirm presence of testicular tissue Androgen-binding studies
Endoscopy
DSD
Do not delay diagnosis and treatment of any neonate presenting with ___
ambiguous genitalia since salt-loss in a 46XX CAH girl can be fatal.
PUV/UUT + renal insufficiency
Diagnose posterior urethral valves (PUV) initially by
ultrasound but a voiding cystourethrogram (VCUG) is required to confirm the diagnosis.
PUV/UUT + renal insufficiency
Assess split renal function by ___
dimercaptosuccinic acid scan or mercaptoacetyltriglycine (MAG3) clearance. Use serum creatinine as a prognostic marker.
PUV/UUT + renal insufficiency: Vesico-amniotic shunt antenatally is :___
NOT recommended to improve renal outcome.
PUV/UUT + renal insufficiency: Offer ___after bladder drainage and stabilisation of the child.
endoscopic valve ablation
PUV/UUT + renal insufficiency: Offer suprapubic diversion for bladder drainage if : ___
the child is too small for valve ablation.
PUV/UUT + renal insufficiency: Offer a ____ if bladder drainage is insufficient to drain the upper urinary tract and the child remains unstable.
high urinary diversion
PUV/UUT + renal insufficiency: Monitor ___ life-long, in all patients.
bladder and renal function
Urachal remnants originate from failure of the obliteration of the ALLANTOIS, resulting in a urachal anomaly such as: ____ (4)
(1) urachal sinus, (2) urachal cyst, (3) vesico-urachal diverticulum, and (4) patent urachus
URACHAL REMNANTS
Urachal remnants with no epithelial tissue : __
carry little risk of malignant transformation.
URACHAL REMNANTS
___ urachal remnants can safely be managed non- operatively.
Asymptomatic and non-specific atretic
URACHAL REMNANTS Urachal remnants (URs) \_\_\_ should also be observed non-operatively since they tend to resolve spontaneously.
incidentally identified during diagnostic imaging for non-specific symptoms
URACHAL REMNANTS
A ____, may be viewed as physiological.
small urachal remnant, especially at birth
URACHAL REMNANTS
Urachal remnants in patients younger than ___ are likely to resolve with non-operative management.
Follow-up is necessary only when symptomatic for___
6 months
6 to 12 months.
URACHAL REMNANTS
Surgical excision of urachal remnants solely as a preventive measure against later malignancy appears to have ___
minimal support in the literature.
URACHAL REMNANTS
Only ___ should be safely removed by open or laparoscopic approach.
symptomatic URs
URACHAL REMNANTS
A __ is only recommended when presenting with febrile UTIs.
VCUG
PENILE RARE CONDITIONS
Epidermal inclusion cysts Mucoid cyst of the penis Median raphe cysts Smegmal cysts or smegmal pearls Dermoid cyst
PENILE VASCULAR LESIONS
Haemangiomas
pyogenic granulomas: benign outgrowths of cutaneous capillary vessels formed usually from chronic irritation
develop rapidly at birth and involute slowly
Propranolol is currently first line treatment for infantile haemangiomas, the exact mechanism of action is unknown but can include inhibition of angiogenesis, vasoconstriction among others
The dose is in the range of 1.5-2.5 mg/kg, which needs to be continued for 12 to 18 months and then tapered through active or passive weaning to reduce risk of rebound growth
PENILE VASCULAR LESIONS
Glomus tumors
primarily congenital arteriovenous shunts that develop from thermo-regulatory glomus bodies (fast- flow vascular malformations).
symptomatic at presentation or may have symptoms such as priapism, palpitation and perineal pain.
benign and treated either with laser, sclerotherapy or surgical excision.
Penile neurofibroma
extremely rare lesion arising from perineural and Schwann cells, and occurs usually with evidence of systemic neurofibromatosis or von Recklinghausen syndrome
reated successfully with complete excision
Penile malignant schwanomas
secondary to malignant transformation of benign neurofibromas have been reported in boys with a strong family history of neurofibromatosis
require long-term follow-up due to risk of recurrence, new tumour formation and malignant transformation.
Fibrosarcoma of the penis
rare and those occurring on the penis are even rarer in the paediatric age-group.
Surgical intervention has a favourable prognosis
___ are the commonest paediatric penile lesions followed by vascular malformations and neurogenic lesions.
Cystic penile lesions
___ patients require long-term follow-up due to risk of recurrence, new tumour formation 3 and malignant transformation.
Neurofibroma
___ are rare and require excision in order to differentiate between benign and malignant neoplasms.
Mesenchymal tumours
Treatment of penile cystic lesions is by ___
total surgical excision, it is mainly indicated for cosmetic or symptomatic (e.g. infection) reasons.
___ is currently the first-line treatment for infantile haemangiomas.
Propranolol
___ is the first-line treatment for penile lymphedema.
Conservative management
In symptomatic cases or in patients with functional impairment, ___ may become necessary for penile lymphedema.
surgical intervention
TRAUMA: Offer surgical intervention in case of ___
haemodynamic instability and a Grade V renal injury.
TRAUMA: Diagnose suspected ureteral injuries by ___
retrograde pyelogram.
TRAUMA: Manage ureteral injuries ___, using internal stenting or drainage of an urinoma, either percutaneously or via a nephrostomy tube.
endoscopically
TRAUMA: Use ___to diagnose suspected bladder injuries.
retrograde cystography
TRAUMA: Manage extra-peritoneal bladder ruptures conservatively with ___
a transurethral catheter left in place for seven to ten days.
TRAUMA: Do not delay treatment of intra-peritoneal bladder ruptures by ___
surgical exploration and repair as well as post-operative drainage for seven to ten days.
** Post-operative drainage with a suprapubic tube is mandatory.
Urethral trauma:
A transurethral catheter should only be inserted if ___.
there is a history of voiding after the traumatic event, and if a rectal and pelvic examination, as described above, has not suggested a urethral rupture.
Urethral trauma:
Perform ____ to determine the position of the prostate.
A rectal examination
Manage posterior urethral disruption by either: ___
- primary reconstruction;
- primary drainage with a suprapubic catheter alone and delayed repair;
- primary re-alignment with a transurethral catheter.
Pediatric pre-operative fasting times
Minimum fasting hours for ingested material
Clear liquids 1 hour
Breast milk 4 hours
Light meal 6 hours
Pedia PREOP:
Use ___ solutions in hospitalised children because they are at high risk of developing hyponatraemia.
isotonic
Assess the baseline and daily levels of ___ in every child who receives intravenous fluids, especially in ___ regardless of the type of solution chosen since there is an increased risk of electrolyte abnormalities in children undergoing such surgery.
serum electrolytes, glucose, urea and/or creatinine
intestinal surgery (e.g. ileal augmentation),
PEDIA LAP
Use lower intra-abdominal pressure: ___ during laparoscopic surgery in infants and smaller children.
6-8 mmHg
