Can paediatric surgical registrars safely perform supervised hypospadias surgery?

INTRODUCTION: Hypospadias repair is regarded as a technically demanding, complex procedure, with variable outcomes. Therefore, it tends to be performed by consultants, with limited trainee involvement. We aimed to study the clinical outcomes of supervised registrars performing proximal and distal hypospadias repairs, compared to their consultant mentors. METHODS: We undertook a retrospective review of all primary hypospadias repairs performed between April 2013-April 2022 at our tertiary paediatric urology centre. Redo repairs and patients lost to follow-up were excluded. Pre-operative anatomy, theatre time, grade of primary surgeon (registrar (trainees and non-training middle grades) or consultant), operative technique, follow-up duration, complications, and reoperation rates were recorded. The procedures were assessed in two groups according to the primary operator: registrar or consultant. The Zwisch scale is used to describe level of consultant support. Registrars as primary operators received "passive help" or "supervision" (Zwisch levels 3/4). Consultants as primary operators provided registrars with "show-and-tell" or "active help" (Zwisch levels 1/2). RESULTS: 270 procedures performed on 228 patients met the inclusion criteria. 109 were performed by registrars and 161 by consultants. In both groups, median age was two years (p = 0.23). Median theatre time was similar (registrars 2.8 h vs. consultants 2.7 h, p = 0.88), as was median follow-up (registrars 25months, vs. consultants 21months, p = 0.99). Operations performed by registrars were 76% distal and 24% proximal; and by consultants were 62% distal and 38% proximal. The overall urethroplasty complication rate was similar, at 24% for registrars and 23% for consultants (p = 0.89). The summary table shows the distribution of different complications. Re-operation rate was 16% in both groups (p = 0.99). Complications were further assessed according to operation type (TIP vs. two-stage repair). DISCUSSION: Contrary to popular belief amongst hypospadiologists, we found complication rates were similar for registrar and consultant surgeons. We question that involvement of registrars increases complications. The literature demonstrates safety of trainee performance of limited steps of the procedure. However our institution permits registrars to perform up to the whole hypospadias repair under direct supervision, with no predefined limit to their involvement. CONCLUSION: Paediatric surgical registrars can be safely supervised to have substantial involvement in proximal and distal hypospadias repair, without compromising the duration or outcomes of surgery. We hope that allowing more registrar involvement can lead to faster acquisition of surgical skills, whilst remaining under the safety of senior supervision. Increasing opportunities for those with an aptitude for hypospadias repair can equip them with skills and confidence for entering fellowship training.

Correction of curvature in single stage hypospadias repair with foreskin reconstruction.

INTRODUCTION: Many surgeons offer foreskin reconstruction (FR) as a routine part of hypospadias repair. We present a step-by-step video of the procedure of Tubularised Incised Plate (TIP) repair, FR and dorsal plication through a ventral skin incision. MATERIALS AND METHODS: A ventral incision is made between the inner preputial mucosa and the outer skin extending below the meatus. Ventral degloving is carried out. The dissection is extended laterally around the corporal bodies. The point of maximal curvature (PMC) is marked on the dorsal midline. A vertical incision is made and closed transversely with 5-0 prolene suture in a Heineke- Mikulicz fashion. Urethroplasty is performed in 2 layers using 7-0 polydioxanone (PDS). Spongioplasty and ventral dartos are used as barrier layers. Glansplasty is performed in 2 layers.FR is carried out in 3 layers. DISCUSSION: Curvature correction is key to good outcome. Dorsal degloving can be achieved through a ventral incision allowing exposure of the dorsal midline for plication sutures. RESULTS: The patient had good cosmetic and functional outcome at 1 month follow up. CONCLUSION: FR can be safely performed during TIP repair for distal hypospadias repair. Curvature of less than 30° can be corrected through a ventral incision only.

Fifteen-Year Single-Center Experience of Biliary Complications in Liver Trauma Patients: Changes in the Management of Posttraumatic Bile Leak.

INTRODUCTION: Management of posttraumatic bile leak has evolved over time in our unit, from endoscopic retrograde cholangiopancreatography (ERCP) stenting to intraperitoneal drainage (IPD) alone as first-line treatment for intraperitoneal bile leak. MATERIALS AND METHODS: Retrospective review of liver trauma patients from 2002 to 2017. Demographics, time and mode of diagnosis of bile leak, management, and outcome were analyzed of the box plot. RESULTS: In 118 patients, there were 28 traumatic bile leaks. Eighteen were free intraperitoneal and 10 were localized bilomas. The median time of diagnosis was 6 days following injury. The modes of diagnosis were preemptive hepatobiliary scintigraphy (18), computed tomography (CT) or ultrasound (7), and laparotomy (3). Free intraperitoneal biliary leak management included 11 IPD alone, 3 IPD plus ERCP, 2 IPD plus transcystic biliary stent (TBS), 1 operative cholangiogram, and 1 no intervention. Median time of IPD duration was 7 days (4-95) in IPD alone versus 14 days (6-40) in IPD + ERCP/TBS (p = 0.3). Median inpatient length of stay was 13 days (8-44) in IPD alone versus 12 days (8-22) in IPD + ERCP/TBS (p = 0.4). CONCLUSION: Placement of IPD alone, as first-line treatment, is safe and effective in the management of intraperitoneal bile leaks, avoiding the costs and potential complications of ERCP.

Utility of a routine bench cholangiogram for ex situ split liver procedure.

BACKGROUND: Biliary complications can result in a significant morbidity for split liver graft recipients. Biliary drainage for segment 1 and 4 is highly variable and could be the source of bile leaks. Use of a bench cholangiogram (BCH) can accurately define the segmental biliary system and identify any significant biliary radicles that need retention or repair during bench preparation of split grafts. This study evaluates the clinical relevance of routine BCH in split liver transplantation (SLT). METHODS: Retrospective review of 100 BCH images performed during ex situ deceased donor SLT between January 2009 and January 2015. The radiographs were reviewed by two surgeons and the biliary anatomy was compared using Huang and Reichert classification. RESULTS: 100 BCH images were reviewed. Variant anatomy was frequently identified in the intrahepatic bile duct system, the number and drainage patterns of segment 1&4 duct was diverse. BCH results guided the line of parenchymal transection to obtain a single segment 2&3 duct in 15 cases. A surgical intervention in the form of suture ligation of significant segment 1 or 4 duct at bench preparation was performed in 6 cases. BCH images guided surgical control of post-operative bile leak in 3 patients. CONCLUSION: Bench cholangiogram is a useful tool to guide liver parenchymal transection and potentially reduce the incidence of biliary complications.

Outcomes and Long-Term Follow-Up with the Use of Ureteral Access Sheath for Pediatric Ureteroscopy and Stone Treatment: Results from a Tertiary Endourology Center.

PURPOSE: The aim of this study was to retrospectively analyze outcomes of flexible ureteroscopy and laser fragmentation (FURSL) of renal stones with the use of ureteral access sheath (UAS) in the pediatric population. MATERIALS AND METHODS: We retrospectively collected data between January 2011 and January 2018 for patient demographics, stone characteristics, and outcomes in 21 children who underwent FURSL with the use of UAS. RESULTS: Twenty-one patients (10 boys and 11 girls) with a mean age of 11.8 years (range: 2-16 years) underwent FURSL using an access sheath. The stone location was in the lower pole in 13 patients (62%) with 12 patients (57%) having multiple stones. A 9.5F (35 cm) Cook Flexor UAS was used in all cases. The mean and overall stone size was 12 mm (range: 5-30 mm) and 15.4 mm (range: 5-35 mm), respectively. Preoperative stent was present in 8(38%) patients, and a postoperative stent or overnight ureteric catheter was inserted in 14 patients (67%). Thirty-one procedures (average: 1.5/patient) were needed to achieve a stone-free rate of 95%. There were no procedural or long-term complications noted over a mean follow-up of 26 months (4-37 months). CONCLUSION: The use of UAS in the treatment of pediatric renal stones is safe and feasible with good outcomes and without any long-term sequelae.

The Excised Appendix Tip-To Send or not to Send, That is the Question.

A 9-year-old boy, with previous anorectal malformation and neuropathic bladder and bowel, underwent ileocystoplasty, Monti-Mitrofanoff and appendix antegrade colonic enema procedure. The tip of the macroscopically normal appendix was sent for routine histopathology. Microscopy demonstrated a 5-mm well-differentiated neuroendocrine tumor extending into muscularis propria. K i -67 index was <2%. Due to margin involvement, the appendix conduit and surrounding skin were re-excised and a tube cecostomy was created through a separate incision. Microscopy revealed no residual neuroendocrine tumor, and no further treatment was required.

Intention to Split Policy: A Successful Strategy in a Combined Pediatric and Adult Liver Transplant Center.

OBJECTIVE: The primary aim of this study is to evaluate the role of split liver transplantation (SLT) in a combined pediatric and adult liver transplant center. The secondary aim is to reflect on our clinical practice and discuss strategies to build a successful split program using an "intention to split policy." BACKGROUND: SLT is an established procedure to expand the organ pool and reduce wait list mortality; however, technical and logistic issues are limiting factors. METHODS: Prospectively collected data and outcomes of SLT procedures performed between November 1992 and March 2014 were analyzed retrospectively. To assess the effect of standardization and learning curve, the experience was divided into 2 time periods. RESULTS: Out of 3449 liver transplant procedures performed, 516(15%) were SLT. The recipients included 266 children (290 grafts; 56%) and 212 adults (226 grafts; 44%). The median donor age was 25(7-63 years) and the median weight was 70(22-111 kg). The cold and warm ischemic times improved significantly during the second period (SP) (2001-2014). With experience, there was a significant reduction in the biliary complications for both grafts. The introduction of "intention to split policy" resulted in a significantly increased usage of SLT. There was no mortality on the pediatric wait list for last 4 years. Over the last decade 65% of our pediatric transplants were SLT. The overall 1-, 5-, 10-year patient and graft survival of left graft recipients was 91%, 90%, and 89% and 90%, 87%, and 86%. For right grafts it was 87%, 82%, and 81% and 82%, 81%, and 79%, respectively. CONCLUSIONS: SLT is an effective surgical strategy to meet the demands in a combined adult and pediatric transplant center. Good outcomes can be achieved with a standardized technique.

Management of large primary spontaneous pneumothorax in children: radiological guidance, surgical intervention and proposed guideline.

PURPOSE: Primary spontaneous pneumothorax (PSP) is managed in accordance with the adult British Thoracic Society (BTS) guidelines due to lack of paediatric evidence and consensus. We aim to highlight the differences and provide a best practice surgical management strategy for PSP based on experience of two major paediatric surgical centres. METHODS: Retrospective review of PSP management and outcomes from two UK Tertiary Paediatric hospitals between 2004 and 2015. RESULTS: Fifty children with 55 PSP (5 bilateral) were referred to our Thoracic Surgical Services after initial management: 53% of the needle aspirations failed. Nine children (20%) were associated with visible bullae on the initial chest X-ray. Forty-nine children were assessed with computed tomography scan (CT). Apical emphysematous-like changes (ELC) were identified in 37 children (75%). Ten children had also bullae in the asymptomatic contralateral lungs (20%). In two children (4%), CT demonstrated other lung lesions: a tumour of the left main bronchus in one child; a multi-cystic lesion of the right middle lobe in keeping with a congenital lung malformation in another child. Contralateral asymptomatic ELC were detected in 20% of the children: of those 40% developed pneumothorax within 6 months. Best surgical management was thoracoscopic staple bullectomy and pleurectomy with 11% risk of recurrence. Histology confirmed ELC in 100% of the apical lung wedge resections even in those apexes apparently normal at the time of thoracoscopy. CONCLUSION: Our experience suggests that adult BTS guidelines are not applicable to children with large PSP. Needle aspiration is ineffective. We advocate early referral to a Paediatric Thoracic Service. We suggest early chest CT scan to identify ELC, for counselling regarding contralateral asymptomatic ELC and to rule out secondary pathological conditions causing pneumothorax. In rare instance if bulla is visible on presenting chest X-ray, thoracoscopy could be offered as primary option.