Tuğrul Tiryaki

Testis sparing surgery for steroid unresponsive testicular tumors of the congenital adrenal hyperplasia

The association between testicular tumors/nodules and congenital adrenal hyperplasia (CAH) has been recognized for many years. Tumors are considered to be an aberrant adrenal tissue that has descended with the testes and has become hyperplastic due to ACTH stimulation. The recommended treatment consists of increasing the glucocorticoid dose to suppress ACTH secretions. If the testicular size is not reduced after suppression therapy or a side effect of glucocorticoid dose is noted, surgical intervention should be considered. We diagnosed steroid unresponsive testicular tumors of the CAH in two patients who were treated by testicular sparing tumor enucleation. We believe that testis sparing surgery is the procedure of choice for all patients with testicular adrenal rest tumor, since it maximizes future fertility potential.

Anal canal duplication in children: a new technique

Anal canal duplication (ACD) is a very rare abnormality. Because of the high rate of malignant changes in anal canal duplications complete removal of the ACD is recommended. In the current study, simple mucosectomy for management of cases of ACD has been discussed. There was no complication and patients had good cosmetic results with a normal sphincter control. This technique is simple, safe, takes less time and achieves good anatomic appearance and functional results.

Ureteroscopy for Treatment of Ureteral Stones in Children: Factors Influencing the Outcome

OBJECTIVE To evaluate the factors that affect the success and complication rate of ureteroscopy for ureteral stone treatment in children. MATERIALS AND METHODS We retrospectively reviewed the records of children who were treated for ureteral stones at our institution from 2009 to 2011. The demographic data, stone size, stone location, number of stones, intraoperative complications, stone-free status, postoperative complications, and conversion to an open procedure were recorded. RESULTS A total of 54 ureteroscopic procedures were performed in 32 children. The mean age was 5.91 ± 4.98 years. Conversion to an open surgical procedure was required in 6 patients (18.75%). A significant relationship was found between conversion to an open procedure and patient age. Although the initial complete clearance rate was 57% after the first session, overall, the stone-free rate was 92.68%. A significant relationship was found between stone-free status and patient age and stone composition. Our overall complication rate was 9.7%. Only 1 major complication (2.4%) occurred. A significant relationship was found between the occurrence of complications and patient age. CONCLUSION Ureteroscopy is an effective method to treat ureteral stones in children. Cystine stones and lower patient age carry a risk of not achieving a stone-free status. The complication rate and conversion to an open procedure were greater in patients <5 years old. Parents should be informed before treatment that their children might require multiple treatment sessions.

Clinical Experience in Hypospadias: Results of Tubularized Incised Plate in 496 Patients

OBJECTIVES To review the tubularized incised plate, a recently popularized technique, and provide outcomes. METHODS From January 2000 to December 2006, 496 patients underwent the tubularized incised plate technique for hypospadias at our clinic. The patient age range was 6 months to 14 years. The postoperative follow-up time was 2 years (range 6 months to 3 years). The patients underwent the technique as described by Snodgrass, with some small technical modifications. The patients were hospitalized for 10 days postoperatively, with a urethral stent in place. RESULTS Of the 496 patients, 48 experienced 53 complications. The most frequent complication was meatal stenosis (n = 27, 5%), followed by urethrocutaneous fistula (n = 25, 5%). Dehiscence was noted in 1 patient (0% of 496 patients and 2% of the 48 patients with complications). Initially, the fistula occurrence rate was 11% and 4% for all 496 and the 48 patients with complications, respectively, which had decreased to 3% and 8% in the most recent 3 years. During the study period, some technical modifications have applied, with a resulting decrease in the complication rates. Complications occurred in 48 patients (9%), of whom 25 required surgical repair (5% of 496 patients). CONCLUSIONS The tubularized incised plate technique is a surgical method that can be applied to most hypospadias anomalies. Increasing clinical experience and minor additions to the technique have enhanced our success with this method.

Eventration of the diaphragm.

OBJECTIVE Eventration of the diaphragm (ED) is defined as the abnormal elevation of the diaphragm. Although asymptomatic ED may be amenable to conservative treatment, symptomatic ED in children, either congenital or acquired, may require surgical treatment. This study evaluated the results of diaphragmatic plication in children with unilateral ED. METHODS Fifteen patients who had undergone diaphragmatic plication for ED between 1997 and 2003 were evaluated retrospectively. The diagnosis of ED was established by routine chest radiographs and fluoroscopy. Patients who failed to respond to nonoperative treatment were referred for surgery. Nine patients underwent diaphragmatic fluoroscopy 1-5 years following plication to assess function. RESULTS Indications for diaphragmatic plication were respiratory symptoms such as tachypnoea, dyspnoea, recurrent pneumonia and failure to thrive. In 14 patients, the position of the diaphragm was normal after plication, but the diaphragm was elevated without symptoms in one patient during postoperative follow-up. The motion of the diaphragm was investigated in nine patients. Fluoroscopic studies showed that the operated hemidiaphragm was immobile and there was no paradoxical motion. No return of symptoms was found during follow-up. CONCLUSION ED is the abnormal elevation of the diaphragm as a result of paralysis or aplasia of the muscular fibres. The abnormally elevated diaphragm may compress the ipsilateral lung, and with respiratory effort the mediastinum may shift towards the normal side. Therefore, diaphragmatic plication is performed to restore normal pulmonary parenchymal volume by replacing the diaphragm in its normal location. After plication, there was immediate remission of symptoms in most patients and decreasing symptoms were observed for a year in others. During follow-up, the location of the diaphragm was normal and no paradoxical movement was observed. Relapse of symptoms was not noted in patients with immobile diaphragms.

Transverse Testicular Ectopia Associated with Persistent Müllerian Duct Syndrome

Transverse testicular ectopia (TTE) associated with persistent Müllerian duct syndrome (PMDS) is a rare genitourinary anomaly. The clinical and operative findings and treatment are discussed. It is very important to perform a careful exploration in TTE when the testes are undescended, in order to exclude the presence of PMDS. Transseptal orchidopexy is the surgical treatment of choice.

Conservative Approach to the Mediastinitis in Childhood Secondary to Esophageal Perforation

The aim of this study was to evaluate the safety and efficacy of nonoperative treatment of esophageal perforation (EP) in children. Between 1999 and 2004, 13 episodes in 12 patients were evaluated. The treatment program consisted of broad-spectrum antibiotics, nasopharyngeal aspiration, parenteral and/or enteral nutrition by gastrostomy, and pleural effusion or mediastinal abscess drainage when required. Mean age of the patients was 3.75 ± 1.13 (range 3-7 years). Two patients (16.7%) were girls and 10 patients (83.3%) were boys. Chest pain was found 76.9% of all EP episodes (10 of 13 perforations), followed by dyspnea in 69.2% (9 of 13), vomiting in 46.1% (6 of 13), fever in 46.1% (6 of 13), and epigastric pain in 7.6% (1 of 13). No deaths occurred. In children, in contrast with the adults, EP can be treated safely by nonoperative methods.

Combination of Tubularized Island Flap and Ventral Skin Flap Techniques in Single-Stage Correction of Severe Proximal Hypospadias

Objectives: To evaluate the success of the combined tubularized island flap (Duckett technique) and Thiersch-Duplay techniques in one-stage correction of proximal hypospadias. Methods: Thirty-four patients underwent surgical treatment for penoscrotal hypospadias in the last 9 years. Combined tubularized island flap (Duckett technique) and tubularized ventral skin (Thiersch-Duplay) procedures were performed in each case. The proximal urethra was repaired by the Thiersch-Duplay technique through the base of the phallus, and distal urethral repair was conducted via the tubularized island flap procedure. Results: The follow-up lasted from 5 months to 6 years (mean 4.1 years). The overall complication rate was 26%, but no recurrent chordee was detected. Recurrent fistulae were noted in 7 patients (20.5%). Anastomatic stricture was noted in 3 patients (8.8%). Conclusion: A combination of Duckett’s preputial tube and the Thiersch-Duplay procedure was employed to treat 34 cases of severe hypospadias, with a success rate of 74%. In our procedure, the island flap tube is relatively short. Oblique anastomoses of proximal and distal tubes were made, and the pedicule of the flap supported the neourethra following successful interventions. Because of the low complication and high success rates, this combination of two procedures is recommended for repair of severe proximal hypospadias.

Sertoliform cystadenoma: a case with overlapping features.

The 1st pediatric case of sertoliform cystadenoma with unique features is described herein. The patient is a 6-year-old boy who presented with gynecomastia and a left testicular cystic mass. Histopathologically the tumor was found to originate from the rete channels, filling and distending them with areas of mural Sertoli cell proliferations reminiscent of large cell Sertoli cell tumor (noncalcifying form) and showing widespread intratubular Sertoli cell proliferation islands in the vicinity. Histopathologic and immunohistochemical features are described in light of the relevant literature.

Importance of anorectal manometry after definitive surgery for Hirschsprung's disease in children

Objectives: The purpose of this investigation is to evaluate anorectal function after definitive surgery for Hirschsprung′s disease (HD) by anorectal manometry. Materials and Methods: We evaluated the anorectal manometric assessment of 18 children who were operated for HD. Functional outcomes were determined by a questionnaire. Rectoanal inhibitory reflex (RAIR) and maximum anal resting pressure (MARP) were monitored. The results were compared between obstructive patients and asymptomatic patients. Results: The median age at definitive operation was 19 months (range 12-72 months). Anorectal manometry was performed in 14 male and 4 female patients. All the cases underwent three staged procedure for HD and modified Duhamel procedure was performed as definitive procedure for all the patients. Mean age was 4.3 months (range 25 days to 5 years) at time of diagnosis. Post-operative enterocolitis or severe constipation was observed in seven patients (38.8%). There were no patients with incontinence. Eighteen patients underwent anorectal manometry meanly 2 years after definitive operation. RAIR was absent in 14 (77.7%) patients and abnormal in 4 (22.2%). There were no significant differences in the MARP values between symptomatic and asymptomatic patients. Conclusion: The results of our study showed that the majority of the patients have impaired anorectal motility. There were no significant differences in the results of the functional studies for the seven patients with symptoms of obstruction or constipation when compared with asymptomatic patients after surgery for HD.