Azad Mathur

Current practice in paediatric hypospadias surgery; A specialist survey

AIM To undertake an online survey of current hypospadias surgery practice among those specialists attending the IVth World Congress of the International Society for Hypospadias and Disorders of Sex Development (ISHID), 2011. MATERIALS AND METHODS An online survey covering 22 separate questions relating to proximal and distal hypospadias surgery was set up, and all delegates registered for the conference were invited to complete this questionnaire anonymously. The data was analysed by three of the authors. RESULTS A total of 162 delegates registered for the conference of whom 74% were paediatric surgeons, paediatric urologists, plastic surgeons and adult/adolescent urologists. 93 delegates completed the online survey, and most of them (57%) were from Europe. The majority of surgeons see over 20 new patients/year (90%) and perform primary hypospadias surgery in over 20 patients/year (76%). The tubularized incised plate (TIP) repair is the most frequent technique used for the management of distal hypospadias (59%); other techniques used included Mathieu, onlay and TIP with graft. A variety of techniques are used for proximal hypospadias, but nearly half of the respondents (49%) preferred a staged approach. Self reported complication rates for distal hypospadias surgery are favourable (less than 10%) for 78% of the respondents. However, proximal hypospadias complication rates are higher. CONCLUSIONS With a majority of paediatric urologists and European delegates responding to our survey, the results suggest that there are differences in the management of proximal and distal hypospadias between surgeons, yet no differences were observed according to the region of their practice. Variations in long-term outcomes appear to be in keeping with the current literature.

Pediatric advanced appendicitis: open versus laparoscopic approach.

Purpose Optimal surgical approach for advanced pediatric appendicectomy remains controversial. We compare the open versus the laparoscopic approach. Methods Retrospective case notes review of children operated on for advanced appendicitis between January 2005 and July 2006 was undertaken for length of hospital stay, operating time, wound complications, need for further surgery, and hospital readmission. Results Forty children were included, 17 were treated with open approach and 23 with laparoscopic approach. There was no conversion from laparoscopic to open approach. Overall complication rate, length of hospital stay, and need for further surgery were similar in both groups. The mean operative time was longer in the laparoscopic group. Wound complications occurred more in the open group. Readmission for gastrointestinal obstruction was noted in the laparoscopic group. Conclusions Laparoscopic approach is safe for advanced appendicitis in children. The outcomes are comparable in both study groups.

Home next day: early discharge of children following appendicectomy

Fifty-six children in two groups were discharged within 24 hours of an uncomplicated appendicectomy. While the children in the first group (N = 21) were visited by a nurse at home within 24 hours of discharge, the second group (N = 35) just received telephone calls. The cohort was evaluated by telephone interviews two weeks after discharge. All children fulfilling the discharge standards were discharged safely within 24 hours of surgery. Any physical complaints post-discharge were considered minor. The nurses were able to provide reassurance to the families, give advice and deal with minor problems. As a result the families felt safe and reassured, and in only one case did the fragility of parental confidence become obvious. This study has demonstrated the safety of discharging these children within 24 hours of surgery and the value to nursing contacts in enabling the families to care for their children at home.

Pyloromyotomy through circumbilical incision with fascial extension

Extending the fascial incision underlying the circumbilical approach to the shape of an ‘inverted T’ permits easy delivery of the pyloric tumour for Ramstedt’s pyloromyotomy. This modification was used in 51 consecutive infants (42 male, 9 female) with a mean age of 4.7 weeks. Extension of the skin incision or conversion to the right hypochondrium approach was not necessary in any patient and the mean operating time was 31.4 min. Mild wound infection occurred in two infants (3.9%) that resolved with antibiotic treatment. Follow-up at 3 months did not detect any incisional hernia. This modification allows delivery of small or large pyloric tumours, is associated with a low rate of wound infection and does not alter the excellent cosmetic finish.

Meconium per vagina: a rare presentation of meconium peritonitis

Meconium peritonitis results from antenatal perforation of the gastrointestinal tract; it presents as gastrointestinal obstruction, intraabdominal masses, or calcification. The presentation with passage of meconium per vagina secondary to meconium peritonitis is rare. We describe the radiologic and surgical findings in a neonate who had passage of meconium per vagina secondary to ileal atresia and meconium peritonitis. Initial clinical and radiologic examination suggested rectal atresia with an associated rectovaginal fistula, although subsequently, this was not the case. Possible explanations for the passage of meconium per vagina include decompression of a meconium cyst via the left fallopian tube or direct perforation of a collection into the vagina from the peritoneal cavity.

Bracka’s staged repair of proximal hypospadias - revisiting a versatile technique

OBJECTIVE Proximal hypospadias is associated with poorly defined urethral plate and often with chordee. A two-staged Brackas repair is reproducible and has been used routinely in our practice. We present the key steps of this technique on a 13-month-old boy. PATIENT AND METHOD This boy presented with proximal penile hypospadias, hooded foreskin and mild chordee. He underwent stage one Brackas repair. The steps included: 1) Artificial erection test to define extent of chordee; 2) inner preputial graft harvest and preparation; 3) glans and urethral plate incision down to corpora cavernosa; 4) partial release of chordee by division of aberrant corpus spongiosum, without degloving of penile skin; 5) laying of preputial graft; 6) dressing. RESULT The patient had catheter removed on second, and dressing removed on seventh, post-operative days, without complication. The patient is planned for second stage repair in 6 months. Our standard approach includes either removal of catheter on the second or seventh post-operative day, according to surgeon preference. The three senior surgeons have used this method in 54 patients without significant complication. The graft has taken in 100% of cases. CONCLUSION The Brackas staged repair of proximal hypospadias is a versatile technique that gives reproducible and sound results.

Varicocele Surgery: 10 Years of Experience in Two Pediatric Surgical Centers

AIM The study was designed to compare recurrence rates and complications after laparoscopic versus open varicocele surgery in children. SUBJECTS AND METHODS A retrospective case-note review of all varicocele surgery over a 10-year period (April 1999-March 2009) in two pediatric surgical centers was performed. Multivariate analysis using logistic regression was performed using SPSS Statistics version 18 (SPSS Inc., Chicago, IL). RESULTS Thirty-seven patients had varicocele surgery during the study period. The median age at surgery was 14 years (range, 11-16 years). Most children had left-sided Grade 2 varicocele. Twenty-five (68%) primary procedures were laparoscopic (17 artery-sparing), and 12 (32%) procedures were open (9 artery-sparing). Six (16%) children had recurrence, and 6 (16%) had postoperative hydrocele. Recurrence rates after laparoscopic (16%) and open (17%) surgery were similar. Increasing age significantly decreased recurrence (odds ratio, 0.373; 95% confidence interval 0.161-0.862; P = .021). Although laparoscopy was associated with higher rates of postoperative hydrocele (odds ratio, 2.817; 95% confidence interval, 0.035-3.595; P = .380) and artery-sparing ligation was associated with higher rates of recurrence (odds ratio, 2.667; 95% confidence interval, 0.022-4.235; P = .787), these associations were not statistically significant. CONCLUSIONS The best results of varicocele surgery in terms of recurrence and postoperative hydrocele were achieved by open mass ligation; however, larger prospective studies are warranted.

Video presentation of the second stage of a two-stage repair for proximal hypospadias: A safe and reproducible technique

OBJECTIVE The aims of proximal hypospadias repair are good cosmetic outcomes with low rates of complication, with a low number of operative exposures, before the age of genital difference realisation. Neo-urethral fistula and stenosis are well recognised complications; with international rates of 3.8-16% and 1.3-15.6% respectively. We present the key steps of the second of a two staged repair in video format. METHOD Video recording of the procedure performed on an 18-month-old with mid-penile hypospadias is presented. The steps are described; the importance of tension free tubularisation, layered urethral closure, suture technique, vascularised prepucal graft technique, optimal glanuloplasty, and penile shaft skin repair are highlighted. RESULT The child was brought back to the day ward for catheter removal at 7 days; follow-up in clinic showed good postoperative appearance. This technique has been performed on 31 boys with a fistula rate and stenosis rate favourable to the literature. CONCLUSION We demonstrate a two-stage technique by video format for proximal hypospadias which is reproducible and gives results comparable to the literature.

Preperitoneal approach for herniotomy in infants: a 9-year review.

Inguinal herniotomy is one of the most common operations performed in paediatric surgical practice. Isolation and high ligation of the indirect hernia sac is well recognised as an essential part of the operation and may be combined with narrowing of the deep ring and/or repair of the inguinal canal floor [1]. To gain access to the hernia sac at the deep ring, the transinguinal approach is commonly used; the superficial ring is opened and the hernia sac separated from the spermatic cord. In the preterm, neonate or young infant this step can be technically demanding and carries the risk of damaging the vas deferens, testicular vessels or creating a tear in the sac, which may lead to hernia recurrence. The preperitoneal approach is an alternative open technique for inguinal hernias that was introduced by Annandale in 1886. Access to the deep ring is achieved through the preperitoneal space with no dissection required in the inguinal canal. In early reports, the approach was not considered suitable for boys younger than 7 or 8, or for routine hernia repairs in infants and children [2, 3]. However, in later reports it was successfully used in infants with incarcerated hernias using a transverse suprainguinal muscle-splitting incision [4–6]. We have been using the preperitoneal approach on all infants with routine and incarcerated inguinal hernias for the past 9 years. The purpose of the current study was to evaluate our experience, in particular to examine efficacy, outcome and complications.