Sundeep Kisku

Bowel vaginoplasty in children and young women: an institutional experience with 55 patients

Introduction and hypothesisAbsence of a vagina owing to congenital Mullerian defects or other acquired causes requires reconstruction of the female genital passage. We present our experience using various bowel segments.MethodsBowel vaginoplasty was performed in 55 patients from January 2004 through May 2014 for cervicovaginal atresia (20), Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome (20), distal vaginal atresia (8), cloaca (2), cervical atresia (1), complex urogenital sinus (1), transverse vaginal septum (1), rhabdomyosarcoma of the vagina (1), and traumatic stricture of the vagina (1). The bowel segments used were sigmoid (50), ileum (2), anorectovestibular fistula ( 2), and loop rectovaginoplasty (1).ResultsThirty-nine patients who had the proximal vagina or uterus anastomosed to the bowel segment reported regular menstrual flows. Three patients are sexually active with satisfactory coital function. None of our patients developed pyometra. Five patients had neovaginal mucosal prolapse. Two patients had severe stenosis requiring excision of the neovagina. Seven patients had mild stenosis requiring dilatations in 6 patients and V-Y meatoplasty for 1 patient. One patient had a descending colon anastomotic leak requiring a diversion ileostomy.ConclusionsGenital reconstruction with bowel vaginoplasty is a highly skilled operation that provides a durable and lubricated replacement of the vagina with good outcomes. Utero-coloneovaginoplasty is a safe procedure preserving the menstrual flow in patients with a functional uterine fundus.

Bladder calculi in the augmented bladder: A follow-up study of 160 children and adolescents

INTRODUCTION Bladder augmentation (BA) has been used for various congenital and acquired conditions to create a low pressure, continent catheterizable reservoir. The prevalence of calculi within the BA have been reported to be from 3 to 52.5%. The present study reports the prevalence and risk factors of bladder calculi in patients with BA. MATERIAL AND METHODS A retrospective review of 160 patients was performed from January 1997 through December 2012. The various risk factors for the formation of bladder calculi such as the nature of the anatomical defect, presence of preoperative urinary calculi, type of bowel augmentation, addition of a mitrofanoff and/or bladder neck procedure, prevalence of post-operative urinary tract infections (UTIs), need for mitrofanoff revision due to stenosis/difficulty catheterization, postoperative significant hydronephrosis and bladder calculi were recorded for analysis. The children underwent open removal or endoscopic cystolithotripsy. One hundred and eight males and 52 females (average age 6.3 years) were followed up for a median of 70.5 months. All patients performed daily bladder irrigation with tap or drinking water. RESULTS Post-operative bladder calculi were noted in 14 (8.8%) of 160 patients following BA. Median time to stone formation was 37.5 months (11-120 months). Recurrent febrile UTIs were noted in 16 of the 160 patients following BA. The various risk factors and their outcomes are summarized in table. Eight patients underwent open cystolithotomy and four patients were treated by cystolithotripsy. Post-operative recurrent bladder calculi were noted in 2 patients. Multivariate analysis revealed that exstrophy/epispadias (OR 17.2) and recurrent UTI (OR 55.4) were independent risk factors for developing postoperative calculi in bladder augmentations. All other risk factors did not achieve statistical significance. DISCUSSION There seemed to be no difference in the prevalence of calculi in the ileal or colonic augmentations. Mucus secreted by the bowel segment blocks catheters leading to incomplete drainage, stagnation and UTIs. Our protocol consists of daily bladder irrigation till the effluents are clear of mucus. This is probably the key to the low prevalence of postoperative calculi (8.8%) in our patients. CONCLUSION Bladder exstrophy/epispadias and UTIs are independent statistically significant risk factors for the formation of bladder calculi in BA patients. Other risk factors such as preoperative calculi, bladder neck procedures and the use of mitrofanoff though not statistically significant, may contribute to the overall risk. The performance of daily bladder irrigation is an important part of our management of mucus.

Cervicovaginal atresia with hematometra: restoring menstrual and sexual function by utero-coloneovaginoplasty

BackgroundCervicovaginal atresia is a rare Mullerian anomaly. The management of cervicovaginal atresia has evolved from historical recommendations of hysterectomy to various reconstructive procedures more recently. The latter carries a risk of significant morbidity and unknown fertility. We present our experience in the management of this complex anomaly.MethodsTwenty patients with cervicovaginal atresia were operated in our hospital from January 2004 through December 2013. The details of their anatomical variations and functional outcomes were analyzed.ResultsEighteen out of twenty patients had cervical agenesis. Two patients had cervical hypoplasia. All patients underwent utero-coloneovaginoplasty. Post operatively, all patients have regular menstrual cycles. One patient is married, sexually active and has satisfactory coital function. One patient had a bowel anastomotic leak that required a diversion ileostomy. Two patients developed mild stenosis. One patient has mild neovaginal mucosal prolapse. No patient has developed pyometra.ConclusionPatients with cervicovaginal atresia need to be counselled about the various reconstructive options available and the potential risks. Social and economic factor play a significant role in determining the plan of management. For patients from conservative societies, utero-coloneovaginoplasty provides a safe conduit for the passage of menstrual flow and coitus, at the cost of permanent infertility.

Rectovestibular fistula with vaginal atresia: our experience and a proposed course of management

AbstractBackground Rectovestibular fistula with coexisting vaginal atresia poses a surgical dilemma with regard to the timing and type of reconstruction. We present our experience and suggest an appropriate course of management.MethodsSeven patients with rectovestibular fistula and coexisting vestibular atresia were operated in our hospital during January 2004 through December 2013. The details of their bowel, menstrual and sexual functions were recorded.ResultsFive of the seven patients who underwent anoplasty in childhood presented to us in their teens with primary amenorrhea and cyclical abdominal pain. All five had sigmoid colon neovaginoplasty. Four of these had the uterus or its remnants anastomosed to the neovagina. All four have regular menstrual cycles. One patient is sexually active and has satisfactory sexual function. The bowel function in all the five patients is good. The remaining two patients presented in their infancy and had the anorectovestibular fistula left as the neovagina. The recto-sigmoid was pulled down to form the neoanus. Both these patients have bowel incontinence.ConclusionWe recommend the rectovestibular fistula be used as the neoanus and not as the neovagina. Delayed bowel vaginal replacement has excellent results and allows for optimal assessment of functioning uterine body or remnants.

A retroperitoneal enteric duplication cyst communicating with the right upper ureter in an infant.

We report an extremely rare case of isolated retroperitoneal enteric duplication cyst with gastric mucosa causing haematuria and dysuria by communicating with the urinary system. A 9-month-old male child was admitted to our hospital with persistent haematuria, dysuria and anaemia. Investigations revealed a retroperitoneal cyst abutting the hydronephrotic non-functioning right kidney. At surgery an isolated retroperitoneal cyst communicating with the right pelviureteric junction was found. The kidney and associated cyst were excised. Histology of the cystic lesion revealed an enteric duplication cyst lined by ectopic gastric mucosa. Isolated retroperitoneal enteric duplication cyst communicating with the urinary tract has not been previously reported in the English literature. We propose that acid secretion into the right renal system was the cause of the haematuria–dysuria syndrome which promptly resolved postoperatively.

An Uncommon Twist: Isolated Fallopian Tube Torsion in an Adolescent

We report a 13-year-old girl with bilateral paratubal cysts and left isolated fallopian tube torsion (IFTT). Paratubal cysts are uncommon in children, and IFTT is a rare complication. Awareness of this entity and prompt surgical intervention could potentially salvage the fallopian tube preserving fertility.

A helping clamp for thoracoscopic plication of eventration of the diaphragm.

Background and Aim: It is difficult to suture an extremely thin and billowed up congenital eventration of the diaphragm thoracoscopically, without insufflation. Materials and Methods: The authors describe their technique using an intestinal clamp to control the redundant tissue and a feeding tube as a flexible knot pusher, to perform the thoracoscopic plication without risking hypercapnia. Results: A satisfactory result was obtained in all the four children. Conclusion: This is a useful adjunctive for thoracoscopic plication of diaphragmatic eventration.

Novel use of tendon tunneler to create space with minimal dissection in endoscopic head and neck operations

Sir, Endoscopic surgery for benign head and neck lesion is effective and has cosmetically superior results. This technique, however, carries the risk of inadvertent injury to neural and vascular structures due to the extensive sub-cutaneous working space that is required to be created along the port tract in order to afford access to the lesion. We present an improvization that creates the working space around the lesion using an inexpensive tendon tunneler thus minimizing dissection and consequent tissue damage.