Luke Harper

Conservative management of blunt pancreatic trauma in children: a single center experience.

INTRODUCTION Blunt trauma of the pancreas represents a significant part of abdomen trauma in children with an incidence estimated at around 10%. If the conservative management is widely accepted concerning the stages I and II, it remains controversial concerning stages III and IV. The aim of our study was to perform a descriptive analysis of the nonoperative management, with a focus on the occurrence of pseudocysts. MATERIALS AND METHODS The charts of the patients treated in our center for pancreatic trauma from 1990 to 2010 have been reviewed. It was defined by an initial lipase greater than three times the norm and an abnormal computed tomography scan. RESULTS A total of 36 patients were included, with 26 boys (72%) and 10 girls (28%) with an average age of 8.7 years. The trauma was isolated in 13 cases (36.1%) and in 23 cases, there were other associated lesions (mainly liver [n = 9] and spleen [n = 5]). Pancreatic injuries were graded as follows: I (n = 21), II (n = 2), III (n = 7), and IV (n = 6). Pseudocysts occurred in 11 patients (30.5%) mainly in grades III (n = 3) and IV (n = 7), with an average delay of 17 days. Initial management of pseudocysts was conservative in six patients (54.6%), whereas five patients required mini-invasive procedures. CONCLUSION Nonoperative management remains a safe way to treat pancreatic injuries despite an average 30% rate of pseudocyst (PC) appearance. It allows a reduction in the number of children who required procedures to less than half of the patients where PC occurred. Furthermore, these procedures were exclusively mini-invasive.

Inguinal hernia in premature boys: Should we systematically explore the contralateral side?☆ , ☆☆

OBJECTIVE Bilateral surgery has been largely advocated in premature boys with unilateral inguinal hernia owing to the high incidence of contralateral patent processus vaginalis. Recently, the potential morbidity of herniotomy in low birth-weight babies and the progress in pediatric anesthesia questioned this attitude. This study aims to evaluate the incidence of contralateral metachronous hernia in a large series of premature boys and to compare the morbidity of preventive versus elective surgery. METHODS This retrospective multicenter analysis of 964 premature boys presenting with unilateral inguinal hernia operated from 1998 to 2012 included 557 infants who benefited from a unilateral herniotomy and 407 from a bilateral herniotomy (median follow-up 12months). RESULTS Contralateral metachronous hernia after unilateral surgery occurred in 11% (n=60) without significant difference according to the initial symptomatic side (9.5% on right vs 13% on left, p>0.05). Postoperative morbidity on the contralateral side was higher after preventive surgery than elective surgery with metachronous hernia (2.45% versus 0.9%, p=0.05) especially for secondary cryptorchidism (1% vs 0%, p=0.03). Despite the risk of metachronous incarcerated hernia, elective surgery did not increase the rate of testicular hypotrophy on the opposite side (0.7%, vs 0.7%, p>0.05). CONCLUSION Systematic bilateral herniotomy is unnecessary in almost 90% of patients and has a significant morbidity. Secondary surgery for metachronous hernia does not increase the risk of testicular lesion and even reduces the risk of secondary cryptorchidism. These results, along with the risk of hypofertility reported after bilateral surgery, may justify treating only the symptomatic side in premature boys.

Choosing a technique for severe hypospadias

INTRODUCTION We participate in humanitarian missions in Madagascar during which we treat severe hypospadias. We report our experience and results with these patients, in these conditions, and discuss our choice of technique in this particular setting. MATERIALS AND METHODS We retrospectively reviewed the data of 27 patients operated for severe hypospadias during our humanitarian missions in Madagascar between November 2006 and September 2009. Twenty one patients underwent a modified Koyanagi procedure, three underwent a Duckett urethroplasty, two an onlay island flap, one an augmented Duckett and one a tubularised plate urethroplasty. Two patients who underwent a modified Koyanagi repair also had a Nesbitt dorsal plication. RESULTS Patient age at the time of surgery ranged from 22 to 198 months with a median age of 54.1 months. Mean follow-up was 16 months. Of the 21 patients who underwent a modified Koyanagi procedure, 16 presented at least one complication (76%): A fistula developed in 12 patients (57%), meatal regression developed in 7 (33%) and 2 showed complete wound dehiscence (9.5%). None developed stenosis or urethrocoele. CONCLUSION In this particular setting, the postoperative complication rate is high. Nevertheless, the Koyanagi technique is appropriate, because its complications are easy to treat and there is always sufficient ventral tissue for the secondary operation, if necessary.

The return of the solitary testis

PURPOSE To assess what is done and what is recommended concerning fixation of the solitary testis. MATERIAL AND METHOD We conducted an e-mail survey of current practices in 28 pediatric surgery departments in 28 university or general hospitals in France. We then reviewed what evidence could be found in the literature. RESULTS All surgeons fix the contralateral solitary testis following intravaginal torsion. Sixteen out of 28 fix the contralateral solitary testis following extravaginal torsion, 13/28 in cases of monorchia, and 8/28 following orchiectomy for trauma or tumour. Five surgeons have observed one case each of torsion of a solitary testis, and three have witnessed testicular necrosis following orchiopexy. CONCLUSION There is no consensus regarding fixation of the remaining testis in the literature. Scientific evidence does not show clearly whether fixation is necessary, regardless of the clinical situation. However, if fixation is performed it should be done using the dartos pouch sutureless technique.

Postoperative Cystography and Endoscopic Treatment of Low-Grade Vesicoureteral Reflux

INTRODUCTION The endoscopic subureteral injection of tissue-bulking agents has become an established alternative to long-term antibiotic prophylaxis and open surgery with a high success rate, especially for low-grade reflux (>90%). Though it is recognized that a routine postoperative voiding cystourethrography (VCUG) is unnecessary following a ureteroneocystostomy, most teams perform one after an endoscopic treatment. MATERIALS AND METHODS In this paper, we report on our experience with the endoscopic correction of vesicoureteral reflux in 72 ureteral units, for whom no routine postoperative cystography was performed. DISCUSSION Two children presented with postoperative recurrent febrile urinary tract infections (UTIs), which were not correlated with cystography findings. Postoperative VCUGs after a ureteroneocystostomy are invasive and expose the child to radiation, they are associated with a substantial cost, and most of all, they do not allow the identification of those patients at risk of recurrent febrile UTIs. Further, the endoscopic subureteral injection of tissue-bulking agents have been used for several years, and numerous studies, set in various clinical settings, have since been published, confirming excellent long-term results for low-grade reflux. CONCLUSIONS We feel that postoperative cystograms should be reserved for children who present with recurrent UTIs, new sonographic abnormalities, or who were treated for high-grade reflux.

Internal jugular venous line misplacement into the epidural space in a low birthweight premature child

function in two separate studies (7,8). Some anesthetic agents (halothane and enflurane) may cause much greater decrease of hepatic blood flow and oxygen supply than others (isoflurane and sevoflurane) (9). Isoflurane was preferred for this reason and titrated to hemodynamic parameters intraoperatively. Mivacurium was used as a muscle relaxant because its metabolism does not directly depend on the kidneys or liver (10). These patients may have a Vitamin K deficiency and liver dysfunction, resulting in prolonged PT and PTT. Splenomegaly and hypersplenism can result in thrombocytopenia. In this case, there was no clinical or laboratory evidence of bleeding abnormality. The anesthesia plan should be based on the careful preoperative assessment of the airway and neck mobility, attention to issues involving hepatobiliary, cardiac, neurodevelopmental, nutritional, hematological, ocular and facial abnormalities and adequate perioperative hydration. T U L A Y S. Y I L D I Z M D N U R C A N O. Y U M U K M D D U Y G U B A Y K A L M D M I N E S O L A K M D K A M I L T O K E R M D Department of Anaesthesiology, School of Medicine, University of Kocaeli, Kocaeli, Turkey (email: tulaysahin00@yahoo.com, tsyildiz@yahoo.com)

Intravesical instillation of ropivacaine reduces bladder spasms following paediatric ureteroneocystostomy

OBJECTIVE Bladder spasms are a common cause of pain after surgical procedures that call for postoperative catheter drainage. Several therapeutic methods have been used to lessen these spasms but none have received widespread success. PATIENTS AND METHODS Twenty-six children were included in a prospective randomized trial to evaluate the safety and efficacy of daily intravesical instillation of ropivacaine as prophylactic treatment for bladder spasms following ureteroneocystostomy. RESULTS Although six patients experienced mild transient pain during instillation, there was no systemic toxicity attributable to the ropivacaine. The average number of spasms per day fell by half in the instillation group (p<0.01). CONCLUSION Intravesical instillation of ropivacaine is a feasible alternative prophylactic treatment for postoperative bladder spasms.

Urethral duplication in girls: Three cases associating an accessory epispadiac urethra and a main hypospadiac urethra

INTRODUCTION Urethral duplication is extremely rare in girls, with less than 40 cases reported so far. Most of them present as a prepubic sinus. Literature is scare regarding aetiology, classification and management in other forms. This study presents three cases of sagittal urethral duplication in girls presenting a main hypospadiac urethra and an accessory epispadiac urethra. PATIENTS AND METHODS Medical records were retrospectively reviewed of three girls with urethral duplication managed over a 30-year period at a single institution. Circumstances of diagnosis, management and outcomes were analysed. RESULTS The oldest case presented as a neonatal retrovesical mass with an accessory clitoral stream, whereas the two more recent cases presented with antenatal hydrocolpos and bilateral ureterohydronephrosis. Cases 1 and 3 had an incomplete duplication, while Case 2 had a complete form. In Case 3, the duplication was associated with a urogenital sinus and an anteriorly placed anus. Management involved resection of the epispadiac accessory urethra to achieve continence, with dilatation and/or mobilisation of the hypospadiac one. All girls are now aged >5 years old and are continent, and one is old enough to have normal menstruation. Renal function is normal in all. The summary table presents the schematic anatomical description as shown on micturating cystourethrogram and endoscopy, as well as the management for each patient. DISCUSSION Step-by-step management is necessary in urethral duplication. The neonatal emergency is to release the urinary tract compression by evacuating urinary retention or hydrocolpos. Later in infancy, decision has to be taken regarding the urethras. If the resection of the epispadiac accessory urethra seems acceptable to achieve continence, the attitude towards the hypospadiac channel is more controversial and should be individualised. Embryologic and aetiopathogenic pathways are still missing to uniformly characterise the malformation. CONCLUSION Paediatric urologists should remember that there is a wide spectrum of urethral duplication in girls, and that various presentations exist beside the more classic prepubic sinus.

Commentary to ‘Native nephrectomy in pediatric transplantation-less is more!’

[4] Fujisawa M, Iijima, Ishimura T, Higuchi A, Isotani S, Yoshiya K, et al. Long-term outcome of focal segmental glomerulosclerosis after Japanese pediatric transplantation. Pediatr Nephrol 2002;17:165e8. [5] Cavallini M, Di Zazza GD, Giordano U, Pongiglione G, Strologo LD, Capozza N, et al. Long-term cardiovascular effects of pre-transplant native kidney nephrectomy in children. Pediatr Nephrol 2010;25:2523e9. [6] Gundeti M, Taghizaedh A, Mushtaq I. Bilateral synchronous posterior prone retroperitoneoscopic nephrectomy with simultaneous peritoneal dialysis: a new management for end-stage renal disease in children. BJU Int 2007;99:904e6. [7] Ubara Y, Tagami T, Sawa N, Katori H, Yokota M, Takemoto F, et al. Renal contraction therapy for enlarged polycystic kidneys by transcatheter arterial embolization in hemodialysis patients. Am J Kidney Dis 2002;39:571e9. [8] Nunes P, Mota A, Figueiredo A, Parada B, Rolo F. Simultaneous renal transplantation and native nephrectomy in patients with autosomal-dominant polycystic kidney disease. Transplant Proc 2007;39:2483e5. [9] Glassman DT, Nipkow L, Bartlett ST, Jacobs SC. Bilateral nephrectomy with concomitant renal graft transplantation for autosomal dominant polycystic kidney disease. J Urol 2000;164:661e4. [10] Darby CR, Cranston D, Raine AEG, Morris PJ. Bilateral nephrectomy before transplantation: indications, surgical morbidity and mortality. Br J Surg 1991;78:305e7. [11] Chaudhuri A, Salvatierra Jr O, Alexander SR, Sarwal MM. Option of pre-emptive nephrectomy and renal transplantation for Bartter’s syndrome. Pediatr Transplant 2006;10:266e70. [12] Odorico JS, Knechtle SJ, Rayhill SC, Pirsch JD, D’Alessandro AM, Belzer FO, et al. The influence of native

Combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy

Conventional and robotic-assisted laparoscopy is being used for more and more complex urological procedures in children. There have recently been reports of laparoscopic or laparoscopic-assisted appendicovesicostomies in children. We report a case of combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy in a 5-year-old boy with valve bladder syndrome.