E. Durham Smith

CLASSIFICATION, IDENTIFICATION AND ASSESSMENT OF SURGICAL TREATMENT OF ANORECTAL ANOMALIES

In order to keep pace with new work in the field of anorectal anomalies, pediatric surgeons who had contributed recent publications on new aspects were invited to a workshop meeting, the objects of which included reviews of: (1) current classifications of anorectal anomalies; (2) criteria for assessment of results of treatment; and (3) methods of recording clinical features, diagnosis, and surgical procedures. The overall objective was standardization of terms and diagnostic features in order to facilitate intercommunication and comparison between surgeons engaged in the reconstruction of anorectogenital anomalies.

The history of hypospadias

The dictum, “There is nothing new in surgery not previously described”, is particularly true of hypospadias. The major significance of chordee was fully appreciated by Galen in the second century A. D. and then almost forgotten until Mettauer in 1842, all previous surgeons overstressing the position of the orifice. Mettauer recognised skin shortening as a cause of chordee, a fact not rediscovered until 1967. Urethroplasty from penile skin in situ was well described by Thiersch in 1869 and Duplay in 1874; additional covering skin flaps were developed in 1892 by Lauenstein. The modern enthusiasm for pedicle tubes from prepuce was first employed by Van Hook in 1896, Rochet in 1899, Hamilton Russell in 1900, and Mayo in 1901; the “buried skin” technique of Denis Browne was described by Duplay in 1880, although attributed by Browne to Hamilton Russell in 1915. Even scrotal tissues were incorporated in repairs in 1860 (Bouisson). Beck, in 1898, practised a repair for balanitic hypospadias very similar to the modern MAGPI repair, and free grafts, so popularised in the last 20 years, were performed by Nové-Josserand in 1897. We have certainly advanced from the era of the first millenium A. D., in which the treatment was amputation beyond the orifice, but almost all present-day techniques are well-founded in ideas developed by enterprising surgeons of the last century.

The bath water needs changing, but don't throw out the baby: An overview of anorectal anomalies*

Revue concernant les malformations anorectales. Diagnostic, exploration, traitement. Si les progres doivent etre pris en compte, les connaissances cliniques doivent etre preservees

Urinary anomalies and complications in imperforate anus and rectum

Abstract The high incidence of genitourinary anomalies associated in patients with imperforate anus and rectum has long been recognized. These anomalies and complications in the urinary tract after rectal surgery, contribute a significant degree of morbidity to the overall results. They may be serious in their own right or contribute to urinary infection, especially in the presence of a rectourinary communication, they may result in urinary incontinence. It is the purpose of this paper to discuss the effect of the urinary lesions on the management of the rectal or anal deformities.

A Study of the Sequelae of Posterior Urethral Valves

We discuss the drainage procedures prior to valve ablation and the long-term sequelae in the upper urinary tract of 135 boys with posterior urethral valves. Cutaneous ureterostomy in infants, which had been used previously, now has been replaced largely by lower tract drainage using stab cystotomy combined with irrigation. The former technique is reserved for those few patients who do not improve. Older patients require no preliminary drainage. The long-term sequelae were studied with respect to urinary control, the fate of ureteral reflux and the state of upper tract dilatation. Of our patients 14 per cent remain incontinent owing to too radical a transurethral resection, bladder neck surgery or a gross degree of urethral dilatation found in neonates. Only 32 per cent of the renal units were presented with ureteral reflux. After valve ablation moderate or gross reflux ceased spontaneously in 29 per cent of the patients, it persisted in 35 per cent and it required antireflux surgery or nephrectomy in 36 per cent. The upper urinary tracts were dilated in 90 per cent of the renal units and most had moderate or gross dilatation, especially in infants. Of 116 united with moderate or gross dilatation, or nonfunction 65 per cent remained unchanged after valve ablation but 35 per cent improved to normal or nearly normal. In 35 units with persistent dilatation in nonrefluxing systems the dilatation was associated with pelvioureteral or vesicoureteral obstruction in 10 units, although in 25 patients no obstruction could be identified. The dilatation was considered to be a manifestation of developmental dysplasia of the ureters.

Choledochal Cysts : Experience with Radical Excision

Abstract A choledochal cyst is still to some extent an enigma; the etiology is uncertain, the clinical history is episodic, appropriate investigations may yield negative results during remissions, and the operative procedures usually employed are not always entirely successful in relieving symptoms completely. The cystic dilatation of the bile ducts appears to be congenital, and causes symptoms during childhood although the progress of the pathologic changes does not appear to be necessarily related to age. At the Royal Childrens Hospital, Melbourne, a choledochal cyst has been successfully excised in five consecutive cases in the last 2 years, and these are the basis for this report.

Renal function and vesicoureteric reflux in children with ureteroceles

A total of 215 ureteroceles were present in 41 children with single-system and 154 children with double-system ureteroceles. Males were predominant in the single-system group while the reverse was true in patients with double-system ureteroceles. Single-system ureteroceles occurred more commonly on the left side. In double-system ureteroceles there was minimal renal function in 74% of the ureterocele-bearing moieties, 26% of the ipsilateral lower moieties, and 3% of the contralateral kidneys. Vesicoureteric reflux (VUR) was present in 17% of the ureterocele-bearing ureters, 54% of the ipsilateral second ureters, and 28% of the contralateral ureters. In the single-system ureteroceles, 20% of the ipsilateral kidneys had minimal renal function and 9% of both the ipsilateral and contralateral ureters had VUR. Differences in laterality, VUR, and function of the subservient renal tissue suggest that single-system ureteroceles are a different disease entity from the double-system type and should be considered separately in any discussion of the management of ureteroceles.

DIAGNOSIS AND MANAGEMENT OF THE CHILD WITH WETTING

In the majority of 192 children with wetting, no organic lesion could be identified and the cause was functional. In the minority with a variety of organic lesions, the diagnosis can usually be made by objective clinical signs and on the pattern of wetting. A few patients require extensive urological investigations and the indications are defined.

Multiple Atresia by Ileal and Colonic Septa: Case Report

A neonatal infant presented with jejunal atresia. A search in the course of the first laparotomy for other atretic areas failed to locate three separate complete bowel septa, which became revealed later by the clinical course, gastro-intestinal dye studies and threc further laparotomies. The patient illustrates the difficulties in locating these septa, and the importance of performing an opaque enema examination in the presence of any neonatal alimentary obstruction.

MANAGEMENT OF THE URINARY TRACT IN SPINAL MYELOMENINGOCELE: THE CASE FOR EARLY SURGICAL DIVERSION OF URINE

The policy of conservative bladder training by manual expression has almost universally failed to keep the incontinent child dry, and the incidence of urinary infection in such children over 2 years of age is so high, that conservative methods appear to have favoured the development of pyelonephritis, especially in the presence of unrelieved urethral obstruction.