A Randomized Control Trial Comparing Outcome after Stented and Nonstented Anderson-Hynes Dismembered Pyeloplasty.

AIM: The aim of the study was to compare the efficacy and postoperative complications of stented and nonstented open pediatric dismembered pyeloplasty for ureteropelvic junction (UPJ) obstruction. SETTINGS AND DESIGN: A balanced, parallel group, prospective randomized controlled trial comparing stented and nonstented Anderson-Hynes Dismembered Pyeloplasty. SUBJECTS AND METHODS: It included 42 children who required Anderson-Hynes dismembered pyeloplasty for UPJ obstruction (UPJO). Patients were randomized into stented (double "J" [DJ] stent) and nonstented pyeloplasty groups. The intraoperative and postoperative course was compared. Both groups were analyzed for problems such as dysuria, frequency, pain, hematuria and urinary tract infection, and postoperative renal status. STATISTICAL ANALYSIS: Mann-Whitney U-test, Fisher's exact test, Student's t-tests, and Chi-squared test were used. RESULTS: Surgical duration was significantly shorter for the nonstented group as compared to the stented group (60.4 ± 6.49 min vs. 78.9 ± 8.17 min). The intraoperative negotiation of DJ stent was troublesome in 21.7% patients belonging to the stented group. The hospital stay was comparable in both groups (4.67 ± 1.9 vs. 4.28 ± 0.67 days). Patients in stented group had experienced dysuria, loin pain, lower abdominal spasmodic pain, and frequency significantly higher than nonstented group. However, the other problems such as fever, hematuria, and urinary tract infections were more common in stented group, but the difference was not statistically significant. There was no difference in resolution of hydronephrosis in both groups. CONCLUSIONS: There is no statistically significant difference in resolution of hydronephrosis following nonstented or stented dismembered pyeloplasty in children with UPJO. However, the patient is more symptomatic due to stent in the postoperative period.

A Case of Recto-Vesico-Cutaneous Fistula Following Perineal Injury by Wild Boar.

It is very uncommon for a boar to become aggressive in nature against human unless they are cornered. A wild boar attacked a 24-year-old male from behind in perineal region. At presentation, he had continuous dribbling of urine and fecal matter from perineal wound. On CT-scan, a well defined tract delineated by contrast was seen between postero-lateral aspect of bladder and anterior wall of rectum, and there was contrast extravasation through perineal wound. After resuscitation, fistula was repaired through abdominal approach, and perineal wound was debrided. Emergency physician should be aware of such cases as increasing deforestation and shifting of humans to sub-urban area, have resulted in increased incidences of wild boar attack. Prompt stabilization of patient, treatment of infection with proper antibiotics, prevention of tetanus and rabies infection and emergency surgical interventions are necessary to reduce morbidity and mortality from such trauma.

Parental evaluation of postoperative outcome of circumcision with Plastibell or conventional dissection by dorsal slit technique: a randomized controlled trial.

AIM: To evaluate and compare parental satisfaction after Plastibell and conventional dissection circumcision. METHODS: 198 children were randomly and equally allocated to two groups (PD: Plastibell and CDS: dissection) for circumcision. Follow-up was done at 7th, 15th and 90th day after surgery. Written questionnaires were given to parents at the time of discharge to complete and return at the 15th and 90th day follow-up visits. RESULTS: Both groups were balanced with respect to various demographic factors, indications for surgery and Kayaba's classification of the prepuce. Surgical duration was significantly shorter for the PD as compared to the CDS group (5.91 ± 1.74 min vs. 23.52 ± 5.94 min; p < 0.0001 H.S.). Swelling, dysuria and infection were the prominent problems reported in both groups in the first 7 days. The Plastibell separated earlier in younger children (p < 0.0001). Postoperatively, children in the PD group required 2.79 fold more analgesic than those in the CDS group. 97.9% of parents in the PD group and 80.2% of parents in the CDS group claimed satisfactory aesthetic results. The PD group parents were statistically significantly more concerned about swelling. CONCLUSIONS: Plastibell use has comparable outcomes to the conventional dissection technique for paediatric circumcision and has an obvious advantage of shorter surgical duration. However, it is less comfortable in the postoperative period due to swelling, and requires greater use of analgesics.

Malrotation beyond infancy.

OBJECTIVE: The aim of this work was to study the various presentations of malrotation and management in patients older than 1 year. MATERIALS AND METHODS: Medical records of patients operated on over the last 6 years who were older than 1 year with a diagnosis of intestinal malrotation were evaluated retrospectively. Data about age at presentation, sex, presenting symptoms, time to diagnosis, radiographic imaging performed, surgical intervention, complications, and postoperative follow-up were collected and evaluated. RESULTS: The study population included 35 children and 3 adults. About three-fourths of pediatric patients were younger than 5 years, and about half of these presented in the second year of life. All patients who presented in the second year of life had a classical presentation of malrotation. Older patients presented more commonly with atypical symptoms. Of these, 5 older children were previously treated for suspected diagnosis of abdominal tuberculosis. Two patients were referred for acute pancreatitis and 1 for severe gastroesophageal reflux disease. Three adults presented with acute small intestinal obstruction and were diagnosed to have malrotation intraoperatively. Upper gastrointestinal contrast study was diagnostic of malrotation in all pediatric patients. Ultrasound and color Doppler study of the abdomen revealed abnormal relationship of the superior mesenteric artery and vein in about one-third of the patients. All patients underwent a standard Ladd procedure. Midgut volvulus was present in about one-fourth of patients. Forty percent of patients with atypical presentation had persistence of preoperative symptoms postoperatively. Two adults developed complications postoperatively. There was no mortality in the present study. CONCLUSION: Malrotation should be suspected in all patients with varied acute or chronic abdominal symptoms, and the upper gastrointestinal contrast study should be conducted. If the existence of typical malrotation is confirmed, surgical correction is mandatory to avoid volvulus and intestinal obstruction independently of the patient's age.

Neonatal posterior sagittal anorectoplasty for a subset of males with high anorectal malformations.

AIM: To assess the results of primary posterior sagittal anorectoplasty (PSARP) in male neonates with high anorectal malformations (ARM) who on invertogram showed well descended rectum. MATERIALS AND METHODS: Twelve full-term male neonates with high ARM over a period of one and half years were selected for primary PSARP based on the findings of invertogram. Primary PSARP was performed in all neonates with lower limit of rectal gas bubble at or below the ossified fifth sacral vertebra. The patients were followed-up for a period between three to four and half years. The clinical evaluation of fecal continence was performed using Pena's criteria for assessment of continence. RESULTS: All neonates underwent PSARP on second to fourth postnatal day. The fistula with urinary tract was found in 11 patients (seven had fistula to bulbar urethra and four to prostatic urethra). Rectal tapering was not required in any neonate. No patient had urinary problems after removal of catheter. Most of the neonates were discharged by ninth day. Postoperatively, two patients had superficial wound infection of anoplasty without any disruption or bowel retraction. Two patients had severe perianal excoriation. No patient had anorectal stenosis. Nine of twelve patients on follow-up had good voluntary bowel movements. Of the three patients who had grade I soiling two had recto-prostatic urethral fistula. No patient had constipation. All patients had good urinary stream. CONCLUSIONS: Repair of high ARM in male neonates with a well descended rectum is feasible without significant morbidity and good continence.