Andjelka Slavkovic

Extracorporeal shock wave lithotripsy for cystine urolithiasis in children: outcome and complications.

The Siemens Lithostar Litotriptor was used to treat 6 children withcystine nephrolithiasis, previously treated by open surgery. Fivechildren had renal calculi (3 multiple caliceal, 2 pelvis) and one hadureteral calculus. Stone size ranged from 0.2–2.5 cm in diameter,and stone burden was from 0.24 to 10.81 cm3 per kidney. Fromone to 4 ESWL sessions per unit were applied, with a total of 1,800 to12,000 shock waves. The stone free rate at 3 months was 50%. Acomplete elimination was obtained with cystine stones in renal pelvisand ureter, however, up to 4 ESWL treatments failed in caliceal stones.Rather location of cystine calculi than previous surgery was associatedwith ESWL success rate. Two patients with positive urine cultures weresuccessfully treated with appropriate antibiotics before ESWL wasattempted. Perirenal hematoma was major complication demonstrated byradionuclide scintigraphy in one patient, and resolved spontaneously by3 months. In the combined treatment of cystine urolithiasis in childrenESWL, as auxillary procedure, was safe and effective in pelvis stone butfailed in caliceal stones. Medical dissolution for retained fragmentswas found effective.

Multicenter Survey of Endoscopic Treatment of Vesicoureteral Reflux Using Polyacrylate-Polyalcohol Bulking Copolymer (Vantris)

OBJECTIVE To evaluate an outcome of endoscopic correction of vesicoureteral reflux (VUR) using Vantris (Promedon, Cordoba, Argentina) in terms of its effectiveness and morbidity in a multicenter study. MATERIALS AND METHODS From 2009 to 2013, 611 patients (210 boys and 401 girls) with a mean age of 3.56 years (range, 1 month-18 years) were treated at 7 centers worldwide endoscopically with Vantris injection. VUR was unilateral in 413 and bilateral in 198 patients comprising 809 renal refluxing units (RRUs). Of these, primary VUR was present in 674 RRUs (83.3%) and 135 (16.7%) were complex cases. Reflux was grades I-V in 24 (2.96%), 123 (15.2%), 451 (55.8%), 158 (19.5%), and 53 (6.6%) RRUs respectively. The follow-up continued from 6 to 54 months. RESULTS Reflux resolved in 759 RRUs (93.8%) after first Vantris injection, in 26 (3.1%) after second, and in 6 (0.7%) after third injection, respectively. VUR improved to grade I after 1 or 2 injections in 5 ureters (0.6%), which needed no further treatment. Thirteen ureters (1.6%) failed endoscopic correction and required ureteral reimplantation. Vesicoureteral junction obstruction requiring ureteral reimplantation developed in 6 ureters (0.7%) and in 4 (0.5%) required stent insertion. Twenty-three patients (3.8%) suffered afebrile urinary tract infection. Seven (1.2%) developed febrile urinary tract infection. None of the studied patients demonstrated VUR recurrence on voiding cystourethrography. CONCLUSION The results of this multicenter survey confirm that endoscopic subureteral Vantris injection is a simple, safe, and effective outpatient procedure for treating all grades of VUR.

[Evaluation of using Alvarado score and C-reactive protein in diagnosing acute appendicitis in children].

BACKGROUND/AIMS Acute appendicitis (AA) remains a diagnostic challenge in children, despite ongoing researches. With an aim to facilitate making diagnosis of AA many scoring systems have been created; among them Alvarado score is the most popular. C-reactive protein (CRP) has proven significance for diagnosing AA in adults, but not in children. The aim of this study was to evaluate significance of Alvarado score, as well as CRP values, in making diagnosis of AA in children. METHODS This prospective six-month study was performed on 257 patients under the age of 15, admitted for acute abdominal pain in the Clinic of Pediatric Surgery and Orthopedics in the Clinical Centre of Nis. Alvarado score and CRP values were determined on admission and compared with final diagnosis on discharge. The patients were divided into two groups: group I--non operated patients with abdominal pain (n=184) and group II--operated on patients for appendectomy (n=73). RESULTS Values of Alvardo score were statistically significantly different between groups (group I: 4.9 +/- 1.21, group II: 8.55 +/- 1.32). Also, our results showed significantly high values of CRP measured in operated children (group I: 8.17 +/- 4.7 mg/L, group II: 38 +/- 26 mg/L). Values of validity parameters for Alvarado score were: sensitivity 90%, specifity 80%, positive predictive values 87%; for CRP 95%, 70% and 80%, respectively. CONCLUSION Alvarado score and CRP are very useful adjuvant diagnostic tool for AA to a less experienced surgeon. High values of Alvarado score and CRP cannot be ignored neither at the same time, used as the sole diagnostic method for discriminating children with AA.

Transverse testicular ectopia with and without persistent Müllerian duct syndrome

Transverse testicular ectopia (TTE) in an extremely rare entity in which both testes migrate along the same inguinal canal towards the same hemiscrotum, while the opposite inguinal canal and hemiscrotum are empty [1–3]. The clinical findings are usually symptomatic inguinal hernia on one side to which the ectopic gonad has migrated, and an impalpable testis on the other side. TTE is usually associated with abnormalities such as persistent Müllerian duct syndrome (PMDS). PMDS is a rare form of male pseudohermafroditism characterized by the persistence of Müllerian duct structures (uterus, fallopian tubes) in phenotypically normal boys [4–6]. Majority of patients were of a very young age, around 1–2 years old. In 65% cases the exact diagnosis is not determined prior to surgical intervention [3]. Patient often undergoes unsuccessful inguinal exploration and the ectopic testis is usually discovered during the repair of an inguinal hernia [7, 8]. In this paper, with an aim to raise awareness of this uncommon condition, we report two cases of TTE, one of which is associated with PMDS.

Ectopic Adrenocortical Tissue: An Incidental Finding During Inguinal Surgery in Children

Adrenal rests are usually unrecognized during operation, and the incidence of ectopic adrenal cortical tissue in pediatric patients during inguinal surgery procedures is unknown. We performed 3028 groin surgical explorations in 2680 patients aged 1 month to 17 years. Ectopic adrenal tissue was found in 69 inguinal operations (2.2%): 37 during 1.524 orchiopexy (2.4%), 23 during 1.115 herniectomy (2.0%), and 9 during 389 hydrocoela operation (2.3%). Statistically there were no significant differences among those three groups. No adrenal rests were detected in females. Although a few reported cases with hormonal activity of ectopic adrenocortical tissue (EACT), the recommendation is to remove them if found.

A rare case of intestinal obstruction due to ascariasis in Niš, south Serbia

Ascariasis is a helminthic infection of global distribution, and intestinal obstruction is its most common gastrointestinal complication. This is a case of a 7-year-old boy admitted to Pediatric Surgery because of intestinal obstruction caused by ascariasis. On admission, the patient presented with colicky abdominal pain, bile-stained vomiting and meteorism. On physical examination, the patient was thin, pale, and dehydrated. An abdominal examination showed distention and diffuse tenderness. After admission, the patient had fecal vomiting and expulsion of worms through the mouth. Laboratory-test results showed leucocytosis, eosinophilia, hypoalbuminaemia, and hypochloremia. Abdominal radiographs and ultrasound studies were indicative of small-bowel obstruction due to roundworms, which led to the performance of an exploratory laparotomy. On bowel exploration, an intraluminal mass, 10 by 6 cm in diameter, consisting of roundworms in the middle third of the ileum was found. A longitudinal enterotomy was performed, and the worms were meticulously extracted manually. Postoperatively, broad-spectrum antibiotics and antihelminthic drugs were administered. Our case of intestinal obstruction caused by ascariasis is the first to be reported in Serbia, according to the Serbian literature.

Surgical treatment of gastrointestinal autonomic nerve tumors (GANT) in children-2 case reports

Gastrointestinal autonomic nerve tumors form an uncommon subcategory of stromal tumors of the intestinal tract although their histologic appearance is similar to other gastrointestinal stromal tumors. Our aim was to evaluate our experience in the diagnosis and therapy of these kinds of tumors. Two patients were admitted to the Pediatric Surgery Clinic in Niš with abdominal pain and a palpable mass in the abdomen. After excision, the tumor tissue was sampled, sent for histopathological diagnosis, and examined by light microscopy, immunohistochemistry, and electron microscopy. Postoperatively, both patients recovered without complications. The patient with the tumor bulk in the mesentery of the small bowel had no evidence of tumor progression 6 years after surgery. In the second case, a giant tumor was present along the greater curvature of gaster. Even with a tumor of this size, there were no signs of progression 10 years after surgery. Radical surgical resection of gastrointestinal autonomic nerve tumors seems to be the curative approach to date, and long-term survival is possible even with large tumors.

Evaluation of autosomal dominant polycystic kidney disease by DTPA renal scintigraphy

Sixty patients with previously documented autosomal dominant polycystic kidney disease (ADPKD) were investigated using dynamic kidney scintigraphy with99mTc-diethylenetriaminepentaacetic acid (DTPA). Patients were subdivided in respect of glomerular filtration rate (GFR) as follows: PKD I group (normal GFR), PKD II group (moderately reduced GFR), and PKD III (severely reduced GFR). Seintigraphic features, time activity curves, excretion parameters, global and individual kidney functions were analyzed. Because of GFR dependent sensitivity, in advanced renal failure being only 0.1, and low reproducibility (11% intraobserver, 22% interobserver),99mTc-DTPA dynamic kidney scintigraphy cannot be generally recommended for the diagnosis of ADPKD, but has to become a routine method for functional evaluation of both global and individual renal functions, as well as degree of excretion disturbances in ADPKD patients.

Are Interferential Electrical Stimulation and Diaphragmatic Breathing Exercises Beneficial in Children With Bladder and Bowel Dysfunction

OBJECTIVE To evaluate the effects of interferential current (IC) stimulation and diaphragmatic breathing exercises (DBEs) in children with bladder and bowel dysfunction. PATIENTS AND METHODS Seventy-nine children with dysfunctional voiding and chronic constipation who were failures of primary care interventions were included in the prospective clinical study. All the children were checked for their medical history regarding lower urinary tract symptoms and bowel habits. Physical examination, including abdominal and anorectal digital examination, was performed. Children kept a bladder and bowel diary, and underwent urinalyses and urine culture, ultrasound examination of bladder and kidneys, and uroflowmetry with pelvic floor electromyography. Eligible children were divided into 3 groups (A, B, and C). All groups were assigned education and behavioral modifications. Additionally, group A underwent DBEs and IC stimulation, whereas group B received only DBEs. The treatment was conducted for 2 weeks in the clinic in all 3 groups,. The behavioral modifications and DBEs were continued at home for 1 month. Clinical manifestations, uroflowmetry parameters, and postvoided residual urine were analyzed before and after 6 weeks of therapy. RESULTS After the treatment, significant improvement in defecation frequency and fecal incontinence was noticed only in group A (P < .001 and P < .05, respectively). These children demonstrated significant improvement in lower urinary tract symptoms and postvoided residual urine (P < .001 and P < .05, respectively). Bell-shaped uroflowmetry curve was observed in 73.3% of group A patients (P < .001). CONCLUSION IC stimulation and DBEs are beneficial in chronically constipated dysfunctional voiders. Further trials are needed to define the long-term effects of this program.

Scintigraphy evaluation of the types of functional constipation in children with bowel bladder dysfunction

PURPOSE To evaluate the types of constipation according to colonic transit time in chronically constipated children with dysfunctional voiding (bowel bladder dysfunction, BBD group) and to compare the results with transit type in children with chronic functional constipation without urinary symptoms (constipation group) and children with normal bowel habits, but with lower urinary tract symptoms (control group). PATIENTS AND METHODS One-hundred and one children were included and their medical histories were obtained. The BBD group kept a voiding diary, and underwent urinalyses and urine culture, ultrasound examination of bladder and kidneys and uroflowmetry with pelvic floor electromyography. Radionuclear transit scintigraphy was performed in all children according to a standardized protocol. Patients were categorized as having either slow-transit (ST), functional fecal retention (FFR) or normal transit. RESULTS FFR was diagnosed in 31 out of 38 children with BBD, and 34 out of 43 children in the constipation group. ST was found in seven children with BBD, compared with nine children in the constipation group. The control group children demonstrated normal colonic transit. Urgency, daily urinary incontinence and nocturnal enuresis were noted only in children with FFR. Both children with ST constipation and FFR complained of difficulties during voiding, voiding postponement and urinary tract infections. CONCLUSIONS FFR is the most common form of constipation in children with dysfunctional voiding. However, some children might suffer from ST constipation. Differentiation between these two types of constipation is clinically significant because they require different treatment. Future studies with larger numbers of patients are needed to confirm the noted differences in urological symptoms in these two groups of constipated children..