D.C.S. Gough

An objective assessment of the results of hypospadias surgery

To compare the cosmetic result of tubularized incised‐plate urethroplasty (Snodgrass method) with that of two established techniques, the meatal‐based flap and onlay island flap repair.

The Malone antegrade colonic enema procedure : outcome and lessons of 6 years' experience

Abstract The successful management of faecal incontinence can dramatically improve the quality of life of affected children. The introduction of the non-refluxing, catheterisable appendico-caecostomy provides the opportunity to treat previously resistant patients. Over a 6-year period, 29 children had a Malone antegrade continent stoma for enema administration (MACE). Incontinence was related to spina bifida in 12 children, ano-rectal anomaly in 12, Hirschprungs disease in 2, followed excision of a pelvic tumour in 2, and was secondary to intractable chronic constipation in 1. The conduit was fashioned from the appendix (20), a caecal tube (8), or a gastric tube (1). Surgical complications were stomal stenosis (11), wound infection (1), anastomotic leak (1), MACE stoma prolapse (1), and a pressure sore (1). Colonic irrigation was achieved with washouts of saline (24), saline plus phosphate (4), and saline plus Picolax (1). Twenty-three patients have complete control of bowel function, but 4 still soil. Two remain incontinent, 1 of whom is still being instructed. One child subsequently had a colostomy, but still uses the MACE stoma. Successful bowel management requires motivation, dedication, commitment, and the input of a clinical nurse specialist. The MACE is a relatively straightforward operative procedure that provides an effective washout technique that is acceptable to both parents and children.

Ileocystoplasty in children : assessing safety and success

From 1987 to 1992, bladder augmentation using clam ileocystoplasty was performed in 39 children 1.5-17.5 years old (mean age 9.7 years). Indications for augmentation included neuropathic bladder, epispadias-exstrophy complex and posterior urethral valves. A satisfactory bladder capacity at safe storage pressures of < 20 cm saline was achieved in all patients. Hydroureteronephrosis resolved or improved in 33 of the 36 moieties (91.7%). No patient showed biochemical or radiological deterioration of the upper tracts. The incidence of symptomatic urinary tract infection fell significantly postoperatively. Seven patients (17.9%) developed a total of 10 complications, with rupture of the augmented bladder occurring in 4 patients (10.3%).

The use of renal scintigraphy in assessing the potential for recovery in the obstructed renal tract in children.

Objective To assess the value of renal scintigraphy with 99mTc‐dimercaptosuccinic acid (DMSA) in predicting functional recovery after the surgical relief of obstructed kidneys in children.

Bladder washout and stone formation in paediatric enterocystoplasty

Objective: To review the incidence of stone formation in our patients with enterocystoplasty to determine the effect of regular bladder washout. Methods: From 1988 to 1995, a prospective cohort of 30 children underwent enteroplasty with continent diversion. Over the same period, a consecutive group of 30 children had an augmentation alone. All were instructed to wash out their bladder on a weekly basis with sterile water. The frequency of the washouts increased if there were problems with increasing mucus production. Their incidence of stone formation has been compared to a similar group of 30 children performing clean intermittent self catheterisation (CISC) on their native bladders. Results: Five (17%) children with continent diversions formed bladder stones (mean time to formation 35 months, range 13–59 months) were compared with 2 (7%) of children with augmentation. No child performing CISC alone formed stones. Conclusions: A regime of regular bladder washout in children with enterocystoplasty did not significantly reduce the incidence of stone formation when compared to previously published data.

Reflux nephropathy in the 1st year of life―the role of infection

The importance of infection and vesico-ureteric reflux in the development of reflux nephropathy is generally accepted. Widespread use of antenatal ultrasound scanning has identified dilated fetal urinary tracts, allowing prompt investigation and treatment in the early post-natal period; some of these children have vesico-ureteric reflux. This study compares renal parenchymal damage, demonstrated by uptake of technetium 99m dimercaptosuccinic acid (DMSA) in two groups. The first included babies less than 6 months old who had presented with their first urinary tract infection and had vesico-ureteric reflux. The second included those in whom a dilated urinary tract had been identified at antenatal ultrasound and post-natal investigation revealed vesico-ureteric reflux, but who had no evidence of urinary tract infection. Renal damage was present in 68% of group 1 and 29% of group 2 when DMSA scanning was used to detect scarring (P = <0.05). Our results support the proposal that infection is a major factor in development of renal damage in patients with vesico-ureteric reflux. Identification by antenatal ultrasound scanning allows early therapeutic intervention before renal damage occurs.

Paediatric anatrophic nephrolithotomy; stone clearance — at what price?

Objective To evaluate the functional outcome of anatrophic nephrolithotomy in children.

The Mitrofanoff procedure: does it last?

Objective To examine the long‐term effectiveness of the Mitrofanoff principle and establish if the catheterizing channel is sufficiently robust for long‐term use.

Ramstedt's pyloromyotomy: circumumbilical versus transverse approach

Three hundred twenty infants underwent a Ramstedt pyloromyotomy for hypertrophic pyloric stenosis, 182 via a transverse right hypochondrial incision and 138 via a circumumbilical incision. The overall rate of wound infections was 16% for operations performed via the umbilical approach compared with 5.5% for operations via a transverse approach despite a higher use of antibiotic prophylaxis (64% vs 13%). The rate of serious infections was similar (5.8% vs 4.9%) and there was no difference in average duration of hospital stay (4.1 vs 4.4 days). The incidence of post-operative incisional hernia was less when performed via the umbilical approach (0.7% vs 2.7%) and all umbilical incisions healed well, resulting in an apparently unscarred abdomen.

Management of benign sacrococcygeal teratoma: reducing mortality and mornidity

Between 1954 and 1987, 43 children with sacrococcygeal teratoma have been seen in our institution. There was 1 stillbirth, 4 neonates (9%) died during transfer, and there were 2 operative deaths (4.5%). Median age at operation was 4 days (range 1 day to 3 years). The survivors have been followed up for a median of 5.5 years (range 5 months to 32 years). Four patients have faecal and/or urinary incontinence. One developed a malignant teratoma subsequent to excision of a benign tumour. Since 1982, 4 patients have been diagnosed by antenatal ultrasound scanning, there have been no deaths related to sacrococcygeal teratomas either during transit or at operation, and morbidity has been minimal. Increasing use of antenatal ultrasound and improved neonatal anaesthetic and surgical care are the main contributory factors.