Paweł Nachulewicz

Two-dimensional (2D), three-dimensional static (3D) and real-time (4D) contrast enhanced voiding urosonography (ceVUS) versus voiding cystourethrography (VCUG) in children with vesicoureteral reflux.

BACKGROUND Two-dimensional (2DUS) contrast enhanced voiding urosonography has been used in the diagnosis and treatment monitoring of the vesicoureteral reflux in children for over 15 years. The opportunity of performing this examination with the use of three-dimensional static (3DUS) and real-time (4DUS) techniques opens up new diagnostic horizons. OBJECTIVE To analyze if 3DUS/4DUS bring additional information leading to an increased detection rate or change in the grading of reflux compared to 2DUS and voiding cystouretrography. MATERIAL AND METHODS We evaluated 69 patients (mean 4.1 years) who underwent 2DUS/3DUS/4DUS contrast enhanced voiding urosonography (ceVUS) and voiding cystourethrography (VCUG) for the diagnosis and grading of vesicoureteral reflux. RESULTS 2DUS and 3DUS/4DUS urosonography diagnosed 10 more refluxes (7.25%) than cystourethrography and in 3 refluxes (2.17%) detected a higher grade. In 9 refluxes (6.52%) 3DUS/4DUS urosonography and cystourethrography diagnosed a higher grade than 2DUS. There was a statistically significant difference between cystourethrography and 3DUS/4DUS urosonography when the number of detected refluxes and differences in grading were compared. 4DUS enabled a better visualization of reflux than 3DUS. CONCLUSIONS 3DUS/4DUS techniques bring additional information leading to a change in reflux grading compared to 2DUS and a detect higher number of refluxes compared to cystourethrography.

A new CO2 laser technique for the treatment of pediatric hypertrophic burn scars: An observational study

AbstractTreatment of hypertrophic scars arising as a result of thermal burns in children is still a big problem. The results of the treatment are not satisfactory for patients and parents, and new methods of treatment are still investigated.We present the use of one of the most modern carbon dioxide (CO2) lasers (Lumenis Encore laser equipped with a Synergistic Coagulation and Ablation for Advanced Resurfacing module) in the treatment of hypertrophic scars in children after burns.From March to April of 2013, a group of 47 patients aged 6 to 16 years underwent 57 laser surgery treatments. The average time from accident was 7.5 years. The results of treatment were investigated in 114 areas. The assessed areas were divided into 2 groups: 9-cm2 area 1, where the thickness of the scar measured by physician was the lowest and 9-cm2 area 2, where the thickness of the scar was the biggest. The results were considered on the Vancouver Scar Scale (VSS) independently by the surgeon and by parents 1, 4, and 8 months after the procedure. In addition, ultrasound evaluation of the scar thickness before and after laser procedure was made.VSS total score improved in all areas assessed by both the physician and parents. The biggest change in total VSS score in area 1 in the evaluation of the investigator was obtained at follow-up after the 1st month of treatment (average 7.23 points before and 5.18 points after the 1st month after surgery—a difference of 2.05 points). Scar ratings by parents and the physician did not differ statistically (P < 0.05). In the ultrasound assessment, the improvement was statistically significant, more frequently for both minimum and maximum thickness of the scars (B-mode measures) (P < 0.05).The use of a CO2 laser in the treatment of hypertrophic scars in children is an effective and safe method. The use of a CO2 laser improves the appearance and morphology of scarring assessed using the VSS by both the parents and the physician. The treatment also reduced the thickness of scars evaluated by ultrasound.

Sonocystografia mikcyjna 2D/3D/4D w diagnostyce i monitorowaniu leczenia odpływów pęcherzowo-moczowodowych u dzieci – czy może zastąpić rentgenowską cystouretrografię mikcyjną?

Introduction Vesicoureteral reflux appears in 20–50% of pediatric patients with recurrent urinary tract infections. The most common method of diagnosing this disease is voiding cystourethrography. However, contemporary pediatric radiology does not favor this method due to exposure to X-radiation. Aim The aim of this study was to assess the usefulness of 2D/3D/4D contrast-enhanced voiding urosonography in the diagnosis and treatment monitoring of vesicoureteral reflux in children and the possibility of using contrast-enhanced voiding urosonography to replace voiding cystourethrography. Material and methods Voiding cystourethrography and contrast-enhanced voiding urosonography were conducted in 80 pediatric patients in order to assess sensitivity, specificity, positive and negative predictive values as well as the number of vesicoureteral refluxes detected by each of the two methods. The second stage of the study involved performing voiding urosonography in an extended protocol in 58 children in order to determine the usefulness of three-dimensional (3D/4D) examinations in the assessment of vesicoureteral reflux and the ability to assess the urethra. Results The concordance between the two methods was 86.95%. The sensitivity of voiding urosonography was 84.51%, specificity – 90.99%, positive predictive value – 85.71% and negative predictive value – 90.17%. A 3D/4D assessment of the urinary bladder and transperineal 2D morphological assessment of the urethra were possible in all patients (100%). Assessment of the urethra during micturition with the use of 2D/3D/4D techniques was possible in all patients in whom voiding was elicited (95.83%), and 3D/4D assessment of vesicoureteral reflux was possible in all patients with reflux (100%). Although the application of 3D/4D techniques allowed accurate specification of the grade of reflux in all cases (100%), it appeared particularly useful in differentiating between grades II and III (70.97%). Conclusions Contrast-enhanced voiding urosonography allows the diagnosis and monitoring of treatment of vesicoureteral reflux in pediatric patients as well as assessment of the urethra in both girls and boys. The method is characterized by high sensitivity and specificity. Moreover, it is safe, relatively inexpensive and can replace voiding cystourethrography.

Esophageal Duplication Cyst Treated Thoracoscopically During the Neonatal Period: Clinical Case Report.

AbstractEsophageal duplication cysts (EDCs) are rare developmental anomalies. They may occur anywhere along the esophagus with the predominant location in the thoracic segment. Presently, most are diagnosed prenatally or in early childhood. The prevalence of EDCs is estimated at 1 in 8200 live births. Usually, cysts are asymptomatic in the neonatal period, but they may cause respiratory distress or feeding difficulties depending on the size and location of the lesion.This report presents a female neonate with a cyst located in the right pleural cavity recognized prenatally. Computed tomography confirmed the diagnosis and revealed a round cystic mass in proximity to the left lung base. Thoracoscopic cyst excision was undertaken on day 15 after delivery. The postoperative period was uneventful. Histological cyst examination confirmed the diagnosis of foregut duplication.This case underlines the importance of early diagnosis and treatment of EDC, before symptoms and complications arise, and confirms that surgery in the neonatal period is safe and effective.

Color Doppler dynamic tissue perfusion measurement: a novel tool in the assessment of renal parenchymal perfusion in children with vesicoureteral reflux.

Introduction Vesicoureteral reflux (VUR) occurs in 20–50% of children suffering from recurrent urinary tract infections (UTIs) and is associated with an increased risk of renal scarring and impaired renal function. Early detection of renal perfusion deterioration would allow for the implementation of more aggressive treatment and potentially prevent further damage to the renal parenchyma. The aim of the study was to assess renal parenchymal perfusions in children with recurrent UTIs with and without coexisting VUR, and compare the findings with the results of healthy patients. Material and methods Color Doppler sonographic dynamic renal parenchymal perfusion measurements were performed with PixelFlux (Chameleon-Software, Germany) software in 77 children with recurrent UTIs and coexisting VUR and in 30 children with UTIs without VUR. The findings were compared with the results of 53 healthy children. Results Cortical parenchymal perfusion of children suffering from UTIs and VUR was significantly reduced when compared to the control group. Statistically significant differences (p < 0.05) were found in all perfusion parameters (i.e. mean velocity (vmix), mean perfused area (Amix), mean perfusion intensity (Imix), tissue pulsatility index (TPI), and tissue resistance index (TRI)) between the control group and children suffering from UTIs and VUR, particularly VUR grades III and IV. There were no significant differences between the UTI group and the control group. No differences were found between the controls and VUR grade II. Conclusions Renal parenchymal perfusion decreases significantly with higher grades of VUR.

Treatment of impalpable testis – one clinic’s experience

Introduction Undescended testes are recognised in 1% to 2% of boys during the first year of life, and about 20% of them are impalpable. Ultrasonography (US) may establish the localisation of the testis but the final diagnosis is usually determined laparoscopically. Aim To evaluate long-term results of laparoscopic treatment of boys with impalpable testes and sensitivity of preoperative ultrasound. Material and methods Between 2011 and 2015, we operated on 545 boys with undescended testes. Sixty-two of them with 65 impalpable testes were treated laparoscopically – the study group. Mean age was 3.5 years. The study group was divided into 5 groups according to type of treatment. The volume and position of the operated gonad were assessed manually and by ultrasound. Results In group 1 testicular agenesis was observed in 19 patients. In group 2 revision of the inguinal canal revealed testicular agenesis in 7 and atrophy in 4 patients. In group 3 conversion to classic orchiopexy was performed in 10 patients. In group 4 one-stage orchiopexy was performed in 9 patients on 12 testes. In group 5 a two-stage F-S procedure was performed in 13 patients. Ten testes in group 4 had a volume in the normal range (84%) and also 10 testes in group 5 (77%). Conclusions Laparoscopy in impalpable testes is the procedure of choice and allows definitive management, even when conversion to open procedure is necessary. Sensitivity of preoperative ultrasound is generally about 60% for true intra-abdominal testes, so diagnostic laparoscopy is necessary.

Closure of the thoracic duct from the left-side access: A case report.

Background:We report a 16-year-old patient with a massive left-sided chylothorax after chemotherapy due to mixed germinal tumor of the testis with massive metastases located in the retroperitoneal space and posterior mediastinum. Chemotherapy resolved the metastases in the mediastinum but evoked a huge pleural effusion in the left pleural cavity, requiring surgical intervention.Left-sided access was used. The 5-mm camera and 3 5-mm working ports were inserted. The parietal pleura was incised and the esophagus located and protected. Behind the esophagus, the thoracic duct and concomitant tissue were clipped with titanium clips, and additionally, thrombin glue was used. Stopping of the lymph leakage was observed during surgery. A local argon pleurodesis was used to finish the procedure. The thoracic tube was removed on the third postoperative day. Conclusion:Left-side access may be a good alternative in the left-sided chylothorax, but the crucial points are location and protection of the esophagus during the procedure, which is also the landmark that allows for locating the thoracic duct.

The role of ultrasound in the management of undescended testes before and after orchidopexy – an update

AbstractThe aim of this study was to evaluate the testicular volume and structure using ultrasound (US) before and up to 3 years after orchidopexy in children with different age.A total of 128 patients underwent orchidopexy for undescended testes. Afterwards, patients were invited for annual follow-up and control scrotal US. The total number of analyzed testes after orchidopexy was 184. Patients were divided according to age at the time of surgery: group I (2–4 years old), group II (5–7), and group III (8–10). In all patients, the testicular volume ratio was calculated as the operated testes volume versus the control testes mean volume.There was an increase in the median ratio in all age groups, from 0.86 to 0.95 in group I, 0.82 to 0.92 in group II and 0.78 to 0.90 in group III. In group of the patients 2 to 4 years old the growth of the ratio 3 years after surgery was statistically significant.Abnormalities in the structure of the testes, which may indicate severe damage to the testis, were seen in approximately 20% of patients on initial exams. On follow-up exams, this type of structure remained in 7% of patients. Testes with an initial ratio <0.25 and inhomogeneous structure did not show any significant growth.Scrotal US can be used for an accurate comparative assessment of the structure and growth of the testes before and after orchidopexy.Abnormalities in the structure of the testes may identify testes requiring more advanced methods of evaluation.