Deepak Bagga

Predictive factors for successful vessel-intact laparoscopic orchiopexy for intra-abdominal testes

OBJECTIVE To identify the predictive factors for successful vessel-intact laparoscopic orchiopexy (VILO) for nonpalpable intra-abdominal testes (NPIT). MATERIALS AND METHODS 25 boys with 28 NPITs within 2 cm of the internal ring underwent VILO. They were divided into two groups based upon outcome, for statistical comparison. Group A (successful VILO): patients with testes pexed in scrotum during surgery, and maintained viability and scrotal position of testes at 3-month & 6-month postoperative follow up. Group B: failed VILO. RESULTS Intrascrotal fixation at VILO was achievable for 17/28 NPITs. Postoperative follow up and final outcome data were available for 25/28 NPITs, of which 14 were successful (A) while 11 had failed VILO (B). The mean age of patients in group A differed significantly from that of patients in group B (4.16 years versus 6.64 years; p = 0.035). The mean testis-to-internal ring distance was 0.50 cm for group A and 1.05 cm for group B, but this was not statistically significant (p = 0.141). There was statistically a highly significant difference (p = 0.002) with respect to the mean internal ring-to-midscrotum distances in groups A and B: 5.56 cm and 7.05 cm, respectively. A scatter-plot of age or height against internal ring-to-midscrotum distance showed a fairly linear relationship. CONCLUSIONS Age or height of the patient at surgery is an independent factor predicting the success of VILO for intra-abdominal testis. The internal ring-to-midscrotum distance increases with age/height, resulting in increased testis-to-midscrotum distance and higher failure rate of VILO in older children.

Primary presentation of Jeune's syndrome as gastric motility disorder in an infant: A case report

We report a case of a 4-week-old female neonate with Jeunes asphyxiating thoracic dystrophy (JATD) and coexistent situs anomaly, primarily presenting as gastric motility disorder. The child presented with abdominal distension and nonbilious vomiting since birth with failure to thrive. However, skeletal survey revealed JATD. Upper gastrointestinal contrast study showed situs inversus with delayed gastric emptying. Pyloric biopsy and intraoperative antro-duodenal manometry confirmed association of gastric motility disorder. Awareness of the unusual possibility of primary presentation of Jeune syndrome as gastric motility disorder will improve the management approach in such infants.

Approach to pediatric renal tumors: an imaging review

Renal tumors comprise 7% of all childhood cancers. A wide variety of renal tumors can affect the pediatric kidneys, which can be broadly classified as primary benign tumors, primary malignant tumors, and metastatic lesions. This article aims to enumerate usual benign and malignant renal tumors that can occur in childhood and emphasizes the characteristic imaging appearances which aid in their differential diagnosis. Additionally, the leading role of the Radiologist in primary diagnosis of renal infiltration by hematological malignancies and contiguous invasion by neuroblastoma is also introduced and unraveled. Imaging protocol comprises initial Ultrasound evaluation with subsequent computed tomography (CT) and/or Magnetic resonance imaging (MRI), all of which are invaluable in confirming the diagnosis, documenting the organ of origin, describing extent of local and distant spread. The complimentary role of nuclear medicine studies in delineating differential renal function, post-operative complications, and metastasis is also highlighted.

Characterizing renal abnormalities in children with high anorectal malformation with renal scintigraphy: A single-centre experience

Objective: The purpose of this study was to characterize the renal abnormalities with renal scintigraphy in patients with high anorectal malformation (HARM). Patients and Methods: We retrospectively reviewed 53 patients who had undergone corrective surgery for HARM from July 2011 to January 2017 and who were referred to this department for Technetium-99m dimercaptosuccinic acid (Tc99m-DMSA) scan for evaluation of renal cortical scarring. Scintigraphic evaluation of all 53 patients included both dynamic renography [Tc-99m diethylene triamine penta acetic acid (DTPA) and Tc-99m-L, L-ethylenedicysteine (L-EC) scan] and cortical scintigraphy. A total of 68 scans were done in these 53 patients in which there were 38 Tc-99m DMSA scans, 15 Tc-99m DTPA and 15 Tc-99m EC scans. Tc-99m DTPA scans were done in 15 patients (26 kidneys) to look for glomerular filtration rate and drainage pattern. Results: Mean age of presentation of these 53 patients (86 kidneys or renal units) with HARM was 28.9 months. Out of 53 patients, male comprised 62.26% of cases (n = 33) and female comprised 37.7% of cases (n = 20). Spectrum of urologic abnormalities noted in our patients with HARM included unilaterally non-visualized kidney in 37.7% cases, i.e., 20/53 patients; hydroureteronephrosis in 28.3% of cases, i.e., 15/53 patients; hydronephrosis in 16.98% cases, i.e., 9/53 patients. Scarring was noted in 28.3% cases, i.e., 15/53 patients. Small kidney was noted in 10 patients out of 53, i.e., 18.8% of cases. Ectopic kidney was seen in 5.6% cases, i.e., 3/53 patients, horseshoe kidney in 3.7% (2/53) and duplex kidney was found in 1 patient, i.e., 1.8% of cases. Conclusion: Children with HARM have a high incidence of renal anomalies and these are the most common cause of morbidity and mortality in these patients. It is important to document these renal anomalies early in life and initiate management as early as possible. Apart from routine investigations, such as ultrasound, renal scintigraphy performed with Tc-99m DTPA, Tc-99m EC and Tc-99m DMSA-III are non-invasive investigations that may provide important help in diagnosis, follow-up and management of renal anomalies in these patients.

Role of renal cortical scintigraphy with Tc99m-DMSA in diagnosing renal scarring in patients undergoing staged reconstruction of classical urinary bladder exstrophy

Objectives: The purpose of this study was to find out incidence of renal cortical scintigraphy done with Technetium-99m (Tc-99m) dimercaptosuccinic acid III (DMSA-III), scan to diagnose cortical scarring in patients undergoing staged reconstruction of exstrophy bladder. Patients and Methods: We retrospectively reviewed 29 post operative patients who were referred to our department for Tc99m-DMSA scan to look for renal cortical scarring from January 2012 to April 2016. Tc-99m DMSA(III) scan was done in all 29 patients (58 kidneys). Tc-99m DTPA and Tc-99m L, L-EC scans were done in 9 (18 kidneys) and 2 (4 kidneys) patients respectively. Results: Out of 29 patients male comprised 69% of cases (n = 20) and female comprised 31% of cases (n = 09).The mean age of the presentation of patients with exstrophy bladder was 7.8 years. Tc-99m DMSA(III) scan was done in 29 patients (58 kidneys).Scarring was noted in 28/58 kidneys (48.27%) on Tc-99m DMSA(III) scan. Tc-99m DTPA scan was done in 9 patients (18 kidneys). In Tc-99m DTPA scan mean GFR (standardized Gates gamma camera method) was 71.91ml/min. Micturating cystouretherography(MCU) was done in 10 patients which revealed vesicoureteric reflux(VUR) in all the patients. DRCG was done in 1 patient which showed unilateral high grade VUR. Ultrasonography (USG) was done in 29 patients. Eighteen patients were found to have normal USG findings. Four patients had bilateral hydroureteronephrosis (HDUN) and one had unilateral HDUN. Three had mild hydronephrosis (HDN) and 3 had gross HDN. Conclusion: Preservation of renal function is one of the major goals of staged reconstruction of bladder exstrophy. Renal cortical scintigraphy with Tc-99m DMSA-III has become the “the gold standard” for renal cortical scarring imaging. Hence Tc-99m DMSA scan offers a significant diagnostic advantage over other diagnostic modalities to diagnose and follow up renal cortical scarring in patients with exstrophy bladder thus help in management.

Transanal impalement of double J steel bar with colonic and jejunal injury: A unique pediatric case report.

Pediatric transanal impalement injuries are relatively uncommon and most are attributed to accidental fall on offending objects, sexual assault or blunt trauma. There may be difficulty in recognizing or properly treating such injuries because their severity may not be reflected externally. Evaluation of suspected rectal impalement injury involves careful history and physical examination and proper investigation. There are very few reports on pediatric perianal impalement with associated visceral injuries. We report a case of assault transanal impalement injury associated with mesenteric tear and jejunal perforation leading to devitalization of proximal jejunum in a 2 year male child and relevant literatures were reviewed. To the best of our knowledge, such dual proximal and distal gastrointestinal injury in such a small child has not been reported in any of the English literature so far.

Congenital epulis: A rare lesion

Congenital epulis, a rare benign soft tissue tumour from the alveolar crest is smooth-surfaced, pedunculated and lobulated. It is almost always located on the gingiva and is found predominantly on the maxilla. It can obstruct the oral passage by its size and induce airway obstruction and feeding problems. Spontaneous involution after birth is rare. Newborns with a diagnosis of congenital epulis should be immediately subjected to the simple conservative surgical excision to restore vital functions, improve quality-of-life and decrease parental anxiety. Wide radical excision is not recommended as no recurrences have been described even after incomplete excision. The parents of the newborn with congenital epulis should be assured of this benign pathology and the simple treatment. This report documents the presentation and management of a congenital epulis of the maxillary alveolar ridge found in a newborn female and treated with simple conservative surgical excision.

Management of female anterior perineal injuries with urethrovaginal disruption by anterior sagittal transanorectal approach

OBJECTIVE Urethrovaginal disruption injury poses a considerable challenge in surgical correction, mainly due to difficult access to the receded urethrovaginal unit deep in the scarred anterior perineum. We assessed the feasibility, safety and efficacy of the anterior sagittal transanorectal approach (ASTRA) in the repair of anterior perineal injury with urethrovaginal disruption in female children. MATERIALS AND METHODS Three girls with urethrovaginal disruption following perineal injury were operated by ASTRA between March 2008 and December 2010. All of them had severe scarring of the anterior perineum at the time of definitive repair by this approach. One underwent ASTRA repair without a covering colostomy. RESULTS Total urethrovaginal mobilization and anchorage of urethral and vaginal orifices at the vestibule were successfully achieved in all patients. One patient has developed vaginal stenosis at 1.5 years follow up. Despite the absence of a colostomy cover in one case, there were no wound complications in the early postoperative period. CONCLUSION The ASTRA is safe and efficacious in the repair of traumatic urethrovaginal disruption in children.