The sensitivity of antenatal ultrasound for predicting renal tract surgery in early childhood.

OBJECTIVE: To establish the sensitivity of antenatal ultrasound for identifying the need for renal tract surgery in infancy and early childhood. METHODS: A retrospective analysis of the surgical records in children under 5 years of age undergoing renal tract surgery in a regional pediatric urological surgery referral unit was carried out. All records between May 1997 and July 2002 were examined to assess the relationship between prenatal ultrasound findings and postnatal surgical pathology. RESULTS: A total of 106 operations had been performed. The detection rate of multicystic renal dysplasia was 100% (17/17). The equivalent detection rates for pelviureteral junction obstruction, duplex renal system and vesicoureteral reflux were 82.8, 67 and 26.1%, respectively. None of the babies with renal tumors had abnormal antenatal ultrasound findings. The diagnosis of postnatal renal surgical pathology was made on the basis of prenatal scan findings in 59.6% of cases, while recurrent urinary tract infection led to the diagnosis in 26.0%. CONCLUSIONS: Approximately 40% of children requiring surgery for renal tract pathology will have a normal antenatal ultrasound examination. The prevalence of abnormal antenatal ultrasound findings varies depending on the type of renal tract pathology. Despite these findings, the commonest indicator for surgery remains abnormal prenatal scan findings, followed by recurrent urinary tract infections.

Improving hospital doctors' working lives: online questionnaire survey of all grades.

BACKGROUND: In 2001, the Department of Health produced the Improving Working Lives (IWL) for Doctors document. This is the first national survey which asks hospital doctors what changes are needed to improve their working lives. METHODS: An online questionnaire was run over a period of six weeks and was open to all doctors of all grades. Doctors were asked to choose their top five factors from a list of 35 diverse choices or to provide alternatives in free text. Demographic data were also collected. RESULTS: 1603 hospital doctors working in the UK completed the online questionnaire. Improved secretarial or managerial support was the first IWL choice for consultants, with different aspects of clinical and non-clinical support representing their top four choices. Junior hospital doctors and staff and associate specialist grades (staff grades, associate specialists, and clinical assistants) identified improved support for education and training as their first choice, while among the female specialist registrars, it was improved support for childcare. Greater opportunities to develop new skills was an important issue for doctors in the surgical specialties and improved access to mentoring was important for all junior doctors, staff and associate specialist grades, and doctors from black and ethnic minority groups. CONCLUSIONS: Hospital doctors in the UK need more support to improve their working lives. The principle needs are better secretarial and managerial support for consultants; education, training, and mentoring for junior doctors and staff and associate specialist grades; and improved opportunities to develop new skills for those in surgical specialties. Support with childcare is an important issue for female specialist registrars. The Department of Health, NHS trusts, deaneries, and Royal Colleges need to endorse policies that promote a training and working environment that will improve working lives for all hospital doctors, ensuring that appropriate and continuing support is available from the time doctors enter the new foundation programmes and proposed run-through grades, to their time spent as consultants in today's NHS.

Is spina bifida occulta associated with lower urinary tract dysfunction in children?

PURPOSE: Of congenital malformations of the central nervous system 46% are abnormalities of the spinal cord, which includes spina bifida occulta. The occurrence and significance of spina bifida occulta in children with lower urinary tract and bowel dysfunction were evaluated prospectively. MATERIALS AND METHODS: Between January 1999 and February 2001, 158 consecutive children presenting with lower urinary tract and bowel dysfunction were prospectively evaluated for associated spinal abnormalities. Plain abdominal x-ray showed either the presence or absence of fusion of the posterior elements of the lumbar and/or sacral spinous processes. Of the 158 patients 57 (36%) had spina bifida occulta (group 1) and 101 (64%) did not (group 2). RESULTS: There was no correlation between clinical outcome in group 1 with spina bifida occulta and lower urinary tract dysfunction and the pattern of spina bifida occulta. Significant correlation was present between lower urinary tract dysfunction and the presence of spina bifida occulta on plain abdominal x-ray. No significant correlation was found between the presence of spina bifida occulta and spinal cord abnormalities by magnetic resonance imaging scan. There was no direct causal relation between the radiological finding and lower urinary tract dysfunction. CONCLUSIONS: Children presenting with spina bifida occulta, and lower urinary tract and bowel dysfunction have normal genitourinary tracts and absent spinal cord abnormalities. Spina bifida occulta is probably a coincidental finding and its true significance in this cohort was not established.

Duodenal perforation: a diagnostic pitfall in non-accidental injury.

Duodenal perforation is a rare, life threatening injury associated with non-accidental blunt abdominal trauma. Diagnostic delay is common, as the true history is concealed and signs may be minimal. Double contrast computed tomography is the most sensitive investigation to confirm clinical suspicion. We report three cases, all with other features typical of non-accidental injury.

What happens to the bladder at night? Overnight urodynamic monitoring in children with neurogenic vesical dysfunction.

PURPOSE: We assess night and day function of the neuropathic bladder in children with neurogenic vesical dysfunction by overnight urodynamic monitoring and conventional static cystometrogram. Overnight urodynamics as a diagnostic tool was evaluated and its reproducibility analyzed. MATERIALS AND METHODS: In 18 months 3 boys and 3 girls 6 to 14 years old (mean age plus or minus standard deviation 10.3 +/- 3.3) were studied prospectively. Each child was evaluated on 4 separate occasions with 2-daytime cystometrograms at a standard fill rate of 10 ml. per minute and 2 overnight urodynamic studies for 8 hours using a Urolog Recorder. All 6 children were interviewed regarding the acceptability, repeatability and compliance to overnight urodynamics. RESULTS: Bladder capacity was not significantly different during each episode for either of the 2 tests. Mean bladder pressures in 2 children showed stable detrusor activity on cystometry (2 +/- 1.4 cm. H2O) and overnight urodynamics (0.4 +/- 0.5, r = 0.9). Detrusor compliance was not impaired in these 2 children. Four patients had frank detrusor instability with a mean bladder pressure of 50.6 +/- 17.4 cm. H2O on cystometry versus 35.9 +/- 5.2 on overnight urodynamics (r = 0.9). Bladder compliance was severely impaired in these 4 patients. Compliance at potential bladder capacity for patient age was 6.6 +/- 2.1 ml./cm. H2O for cystometry versus 9.2 +/- 3.4 for overnight urodynamics (p = 0.26, r = 0.9). Compliance at actual bladder capacity was 3.4 +/- 1.2 ml./cm. H2O for cystometry versus 3.8 +/- 0.8 for overnight urodynamics (p = 0.28, r = 0.9). There was good correlation between daytime cystometry and overnight urodynamics (p <0.001, Pearson's coefficient correlation 0.92, 95% confidence interval 0.90 to 0.94). A kappa statistical analysis showed good agreement between cystometry and overnight urodynamics for stable bladder and frank detrusor instability (kappa = 0.9). Replicated measurements of the same patient by the same observer had an error of variance of 1.7 cm. H2O with a narrow confidence interval, indicating the measurement error was small and that overnight urodynamics can be reproduced with relative accuracy within an individual. All 6 children preferred overnight urodynamics to cystometry. CONCLUSIONS: There was good correlation between bladder behavior day and night. Overnight urodynamics were accurate in predicting detrusor activity, and well tolerated and less embarrassing for a child with neurogenic vesical dysfunction.

Volvulus of the transverse and sigmoid colon.

A case of transverse and sigmoid-colon volvulus and a discussion of the probable mechanism of large-bowel volvulus (LBV) in children and its management is presented. A 5-year-old male with cerebral palsy presented with transverse-colon and subsequently sigmoid volvulus. The child underwent resection of the involved segments with primary colocolic and colorectal anastomosis, respectively. The recovery was uneventful. LBV in children is due to congenital anomalous or absent ligamentous fixation of the colon. Constipation is probably the result of the volvulus. Resection of the involved segment and primary anastomosis is the definitive treatment.

Large bowel volvulus in childhood.

BACKGROUND: Large bowel volvulus is extremely uncommon in children. The probable pathogenesis, predisposing factors and management of large bowel volvulus in children are debatable. METHODS: Seven consecutive cases of large bowel volvulus occurring over a 6-year period are reported. RESULTS: Two patients with caecal volvulus, one with transverse and subsequent sigmoid volvulus, one with transverse colon volvulus and three children with sigmoid volvulus are reported. Four girls and one boy with cerebral palsy, one female with Moya Moya disease and spastic paraplegia and an otherwise healthy boy presented at a mean age of 8.3 years (range: 3-15 years). The common presentation was abdominal distension (n = 6), tenderness (n = 6), constipation (n = 7) and bloody mucoid discharge per rectum (n = 6). Plain abdominal X-ray and barium enema were diagnostic. Resection with primary ileocolic, colocolic or colorectal anastomosis was performed in all cases. The mean follow-up was 3.4 years (range: 1-6 years) and there was no mortality. CONCLUSIONS: Large bowel volvulus in children may be due to congenital anomalous or absent ligamentous fixation of the large bowel, and abnormal mesocolon or a common ileocolo-mesentery. Large bowel obstruction due to volvulus must be considered in the differential diagnosis in a child presenting with constipation associated with bloody mucoid discharge per rectum. Resection of the involved segment and primary anastomosis is the definitive treatment for large bowel volvulus in children.

Efficacy and safety of OK-432 sclerotherapy for giant cystic hygroma in a newborn.

BACKGROUND: OK-432, a lyophilised incubation mixture of group A Streptococcus pyogenes of human origin, was used as a sclerosant for the involution of a giant cervical cystic hygroma in a newborn. RESULTS: There were no systemic side effects. Blood tests and double immune diffusion tests showed no systemic infection or generalised inflammatory response, or antibody production. Cellular and cytokine-induced localised inflammatory reaction within the cystic hygroma, was observed on analysis of the intracystic fluid. CONCLUSIONS: The leucocytosis induced and activated by OK-432 probably increases the endothelial permeability of the lymphatics. This probably accelerated lymph drainage leading to involution of the cystic hygroma. Intralesional injection of OK-432 was safe and effective therapy for cystic hygroma in this newborn as its inflammatory reaction was localised.

Mathieu and 'V' incision sutured (MAVIS) results in a natural glanular meatus.

BACKGROUND: The Mathieu hypospadias repair for distal hypospadias produces a horizontal bucket handle meatus, which is cosmetically unacceptable. A new surgical technique, the Mathieu and "V" Incision Sutured (MAVIS), is described. METHODS: In 52 children, with a mean age of 16.5 months, distal hypospadias was repaired using the vascularized parameatal-based flip flap repair. A "V" incision at the apex of the flap, and suturing of each side of the V to the glans flaps followed by glanuloplasty achieved a natural vertical slit meatus. RESULTS: The mean period of follow-up has been 19.7 months. Fistula occurred in 2 patients (3.9%) and was repaired successfully. CONCLUSIONS: This technique of MAVIS provides a cosmetically acceptable natural vertical slit glanular meatus. A generous vascular pedicle on the flap covers the lateral suture lines to prevent fistulas.

Is delayed surgery really better for congenital diaphragmatic hernia?: a prospective randomized clinical trial.

Delayed surgery has become widely accepted in the management of congenital diaphragmatic hernia after comparing outcomes only with historical retrospective controls. It was the aim of this study to compare early and delayed hernia repair in a randomized prospective clinical trial. Fifty-four infants were randomized to receive either early repair (within 4 hours of admission) or delayed repair (more than 24 hours after birth). The survival rate was higher for the delayed group (57% v 46%), but the difference was not significant (difference: -11; 95% confidence limits: -37.5, 15.5). There were no significant differences between the two groups with respect to length of hospital stay, ventilator dependency, or survival time. Recorded preoperative risk factors were similar for the two groups. Eight infants in the delayed repair group died without having undergone surgery. The optimum time for surgery still needs clarification.

Experience with the Fowler Stephens and microvascular procedures in the management of intraabdominal testes.

The Fowler Stephens operation and microvascular procedures were compared for the management of 23 intra-abdominal testes in 15 boys, 7 of whom had the prune belly syndrome. The Fowler Stephens operation was used for 15 testes (4 single-stage and 11 two-stage) and microvascular transfer was used for 8 testes. Eleven testes treated by the Fowler Stephens procedure (73%) and 7 treated by microvascular procedures (88%) were viable and intrascrotal after an average follow-up of 3.0 years, giving an overall success rate of 78%. Eight of 9 post-pubertal testes were biopsied. Severe maturational arrest was evident in all and carcinoma in situ was present in one.

Irrigation and acute ureteric dilatation--as for ureteroscopy.

The effects of irrigation with sterile and infected saline after acute ureteric dilatation by graded Teflon dilators were evaluated renographically and histologically in minipigs. The minipig ureter was dilated from its normal calibre of 4 F to 10 F, and 100 ml of sterile or infected saline were then introduced from a height of 60 cm under gravity. One week after irrigation and dilatation the ipsilateral kidney was either functioning less than 10% or there was an obstructive nephropathy. Histology at 3 months suggested that extravasation of infected irrigating fluid was the most likely cause of ureteric stricture formation.

Acute ureteric dilatation for ureteroscopy. An experimental study.

The effects of three methods of acute ureteric dilatation (by graded Teflon dilators, low and high pressure balloon dilators) were evaluated radiologically, renographically and histologically in minipigs. The minipig ureter was dilated from its normal calibre of 4 F to 10 F. All three methods caused upper urinary tract dilatation and an obstructive nephropathy which had not resolved 96 h after dilatation. Histology at 24 h showed destruction of the transitional epithelium, with inflammation throughout the ureteric wall. Four weeks after dilatation the ureter was still dilated and urothelial nests were seen in the lamina propria and in the muscle coats. There was no evidence of ischaemic necrosis or ureteric stricture formation. The implications of these findings for clinical practice are discussed.

Radionuclide evaluation pre- and postextracorporeal shock wave lithotripsy for renal calculi.

Forty-two patients were evaluated pre- and postextracorporeal shock wave lithotripsy (ESWL) using [99mTc]DTPA renography. A quantitative evaluation showed that the relative renal function decreased 2-3 days post-ESWL on the treated side, and the parenchymal transit time index (PTTI) increased 2-3 days post-ESWL (p less than 0.001) on the treated side and returned to the pretreatment level by 3 wk post-ESWL. The untreated side showed an increase in PTTI 2-3 days post-ESWL (p less than 0.01), which returned to normal by 3 wk post-ESWL. A significantly greater increase in PTTI was seen in patients who received greater than 1,000 shocks as compared with those who received less than 1,000 shocks. Five patients developed obstructing uropathy post-ESWL, when stone fragments caused ureteric obstruction.

Extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy in children.

The possibilities for treating children with renal stone disease by extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) have not been widely explored. We report ten children, aged between 5 and 16 years, treated by PCNL, and six children, aged between 6 and 15 years, treated by ESWL alone. A 16-year-old spina bifida child with a staghorn calculus was treated electively by a combination of the two methods. Hospital stay was 3 to 8 days for treatment by PCNL or ESWL, and was only 11 days for the combination treatment. Complete stone clearance was achieved in 12 children followed for 3 months. No significant complications occurred. ESWL and PCNL are suitable methods for the management of renal calculi in children.

Tissue effects of an ultrasonic scalpel for clinical surgical use.

The effects of a new ultrasonic scalpel were studied in laboratory animals. Tissue heat conduction from the tip of the ultrasonic blade was measured. Tissue damage was assessed by light microscopy of histochemically stained sections. The ultrasonic scalpel incised nonfibrous tissue effectively, with minimal heat conduction, and the incisions healed with no evidence of fibrosis nor of tissue destruction.