Long-term outcome of severe hypospadias.

OBJECTIVE: To evaluate, from the patient's point of view, long-term urinary and sexual outcome of surgery for severe hypospadias. PATIENTS AND METHOD: Patients treated for severe posterior hypospadias during childhood and now aged 20-35 years were included. Outcome was evaluated using the Hypospadias Objective Scoring Evaluation and our own quality of life questionnaire. RESULTS: Of 48 patients, 13 were lost to follow up. The questionnaire was thus sent to 35 patients of whom 27 agreed to answer (77% response rate). Fifteen presented proximal and 12 scrotal hypospadias. Average age at surgery was 3.3 years and the children underwent an average of 3.7 procedures. There were 40% early complications, and 59% late complications, including 33% fistulae and 26% stenosis. At present, 70% of patients have an apical meatus, 82% have a straight penis, 37% present difficulty initiating voiding, and one patient has a persistent fistula; 74% say their penis looks abnormal, either because of the absence of foreskin, penis size or scarring. Sexual and global satisfaction rates, determined using a visual analogue scale, are respectively 68% and 63%. Satisfaction is statistically correlated to the presence of early complications or stenosis, but not fistula. It decreases if the patient thinks his penis is not normal, even if the anatomical result is good. CONCLUSION: Urinary and sexual outcome is good for most patients though the results are variable. Satisfaction seems more affected by subjective feelings than the anatomical result.

Complications occurring during conservative management of splenic trauma in children.

AIM: Conservative management of splenic rupture in haemodynamically stable children is now generally accepted. However, during follow-up, many complications can occur. The aim of this study was to describe the complications we observed and to propose a standardised follow-up adapted to them. METHODS: Between March 1992 and December 2002 we managed 65 children (aged between 3 and 15 years old) with accidental splenic rupture. Follow-up and treatment consisted of a 10-day bed rest with sonogram and Doppler controls on the 5th and 10th day and subsequently every month until complete healing. Complications included secondary haemorrhage in 3 cases, cystic evolution in 5 cases, and pseudo-aneurysm in 2 cases. All were treated by renewed bed rest. Three of the cysts resolved spontaneously, the other two underwent cystic resection and epiploplasty by laparotomy (n = 1) or laparoscopy (n = 1) and both pseudo-aneurysms were selectively embolised. There were no splenectomies. CONCLUSIONS: Complications essentially occurred in older children and were not related to gender, type of fracture, or extent of bleeding. Cystic evolution of the sub-capsular haematomas can appear up to 1 month after trauma. Peripheral pseudo-aneurysms which could be responsible for secondary haemorrhages were selectively embolised. We favour the use of the Doppler sonogram for follow-up until total recovery of these patients, even in low-grade traumas. Considering the number of complications encountered we do not believe the American evidence-based guidelines are suitable for our population.

The parapelvic renal cyst. A rare aetiology of blood hypertension in children.

Parapelvic renal cysts are uncommon in children. We report a case occurring in a 2-year-old girl, diagnosed during follow-up for blood hypertension. The cyst measured 8 cm in length. There was associated hydronephrosis, due to obstruction of the renal pelvis. Surgical resection was performed. Normotension returned within 3 months, and the obstruction disappeared. A renovascular mechanism can be evoked to explain hypertension.

Treatment of post-appendectomy intra-abdominal deep abscesses.

The treatment of acute appendicitis in children is sometimes followed by complications including intra-abdominal abscess, for which the traditional treatment is surgical drainage. We evaluated the efficacy of antibiotic management compared to classic surgical treatment. This retrospective study investigated 22 children from 5 to 13 years of age with one or many abscesses after appendectomy, treated between 1992 and 2002. Eleven received surgery and the other 11 were treated with triple antibiotherapy. The two groups were comparable. Surgery was efficient in 36% of cases and complications occurred in 64% of cases (digestive fistula, intraperitoneal abscess, gaseous gangrene and septic shock). Average hospital stay in this group was 16.7 days. In the other group, medication was efficient in 91% of cases; a recurrent abscess was operated and a residual stercolith, which was maintaining the infection, was removed. The average hospital stay in this group was 10.4 days. Medical treatment of intraperitoneal abscess seems to be effective. Hospitalisation is shorter with medical management and complications are rare. Therefore, medication may be proposed in most cases, except when there are residual foreign bodies or stercoliths. Poor patient status and septic shock are the two other contraindications, because antibiotherapy is not immediately efficient.

Laparoscopic treatment of ovarian cyst in the newborn.

BACKGROUND: Nine cases of persistent or complicated cyst were analyzed in an attempt to answer two questions: whether laparoscopic treatment of ovarian cyst in the newborn is justified and whether a pneumoperitoneum can be used in such infants. METHODS: Laparoscopic treatment was used for nine newborn babies. The children were 4 days to 2.5 months old. Cyst size ranged from 36 to 72 mm in length. RESULTS: The treatment was exclusively laparoscopic in six cases, and the other three cases required conversion. A maximal insufflation of 4 mmHg was used in five cases. Adnexectomy was necessary in three cases. The duration of the laparoscopic procedure was 20 to 75 min, and that of the postoperative stay was 1 to 5 days. There were no intraoperative or postoperative complications. CONCLUSIONS: Laparoscopy in the newborn is justified, but only in the hands of well-trained teams. The use of a pneumoperitoneum is possible, but should be reserved for difficulties with abdominal wall suspension.

[Early repair for infants with cleft lip. Retrospective study of 263 cleft lip repairs]. / Réparation chirurgicale précoce des fentes labiales. Revue de 218 enfants (263 fentes labiales) opérés.

This study attempts to define the effect of early repair on the surgical procedure and immediate outcome of cleft lip surgery. The first part deals with 263 consecutive cleft lip repairs (218 infants) categorized retrospectively by age at operation. 123 patients (150 cleft lips) were operated on during the first 4 weeks of life; a subgroup of 40 infants was operated on at a week or less of age; 95 patients (113 cleft lips) were operated at an older age (1 to 12 months). There were no significant difference in immediate surgical result between the groups and there was no apparent difference in the operative results as defined by whether or not the child needed subsequent revision. We are currently encouraging early repair in the full-term baby as the optimum method of management of newborns with cleft lip.

Phagocytic reaction in contact with macroplastic: application in pediatric surgery.

BACKGROUND/PURPOSE: With regard to the problems of using polytetrafluoroethylene (PTFE) in the treatment of vesicoureteric reflux in children, the authors have tested polydimethylsiloxane (PDMS), which is conveyed by polyvinylpyrrolidone (PVP), a hydrogel. METHODS: The phagocytic reaction was tested with both PDMS and PVP. The phagocytic reaction of PDMS and PVP was tested in vitro, then the outcome of PVP was tested in vivo in the mouse. RESULTS: In vitro PVP was phagocytosed by mouse peritoneal macrophages. However, PDMS particles were not phagocytosed because of their large size. In vivo, PVP migrated to other organs but did not induce clear histologic lesions. CONCLUSIONS: Silicone (PDMS) has been used in the treatment of vesicoureteric reflux in children. It is now necessary to do tests on heavier animals with a long incubation period to know whether these particles migrate and what the histologic and clinical consequences might be.

[Cleft lip and palate. Epidemiologic analysis: report of 60 cases]. / Fentes labiopalatines. Analyse épidémiologique: à propos de 60 cas.

The authors reviewed 60 cases of cleft lip and palate between November 1996 and May 1998. Any family history of cleft lip and palate and associated syndromes was noted, to detect a possible mode of transmission. A family history of cleft lip and palate was reported in 14 cases (23%). Possible autosomal dominant transmission was observed in this series. A syndromic form was observed in eight cases (13%), with one case of Van der Woude's Syndrome (VWS), and another of velo-cardiofacial Syndrome (VCFS). Molecular and chromosomal studies are indicated in both cases. A Pierre Robin sequence (PRS) was found in six cases.

Treatment of facial dog bite injuries in children: a retrospective study.

PURPOSE: The authors assess their approach to immediate surgical repair with general anesthesia of facial dog bites in children over a 10-year period in their pediatric department. METHODS: The authors reviewed a series of 100 children (59 boys, 41 girls) who required immediate surgical intervention during the first hours after admission between 1985 and 1995. Strict disinfection was always used to preclude the risk of rabies, and parenteral antibiotherapy was used to avoid aero-anaerobic infections. RESULTS: A total of 68% of children were below 5 years of age. The most frequent injury was to the midface. Associated injuries or death were not observed. One case of postoperative wound infection was noted. Four surgical revisions were performed because of unsightly scars, but in most children the scar had attenuated 1 year after injury. CONCLUSIONS: The aim of immediate surgical repair is to obtain a satisfactory cosmetic result and to avoid infections. Better cosmetic results (4 cases of scar revisions) with a minimal risk of wound infections (1 cheek wound infection) are obtained.

Portal vein thrombosis after splenectomy for hereditary stomatocytosis in childhood.

UNLABELLED: Portal vein thrombosis is a rare but potentially lethal complication in children requiring splenectomy. We report on a 15-year-old boy with a dehydrated hereditary stomatocytosis, who underwent splenectomy and presented a postoperative partial portal vein thrombosis. With prompt heparin therapy, neither propagation of the thrombus nor further cavernous transformation in the following occurred 6 years. CONCLUSION: Recent data suggest that hereditary stomatocytosis carries a high risk of thrombotic complications, especially after splenectomy. This procedure, the benefit of which is limited in this condition, should therefore be strongly avoided.

Artificial urinary sphincter implantation for neurogenic bladder: a multi-institutional study in 107 children.

OBJECTIVES: To evaluate the outcome of implantation of the AMS 800 artificial urinary sphincter in children with neurogenic bladder. PATIENTS AND METHODS: The records of 107 children (74 boys and 33 girls) treated for neurogenic urinary incontinence by implantation of the AMS 800 artificial sphincter between 1983 and 1993 were reviewed retrospectively. The underlying cause of incontinence in 92 patients was spina bifida, the mean age at implantation was 13.7 years and 30 patients had undergone previous bladder neck surgery. Implantation was carried out in combination with another surgical procedure in 24.3% of patients. The mean follow-up was 61 months (minimum 12). RESULTS: The mean operational life of the sphincter was 56 months. No deaths occurred but removal of the artificial sphincter was necessary in 20 patients (19%). Surgical revision was not required in 44 patients (41%) but at least one revision was performed in 63 and more than one in 42. There were 21 mechanical failures, 40 surgical complications and 39 cases involving changes in the dynamics of bladder function. Of the 87 children (81%) in whom the device is still in place, 72 are completely continent (83%), 10 are slightly wet, and five are incontinent. The overall success rate was 77%. CONCLUSIONS: The results emphasize that for successful implantation of an artificial urinary sphincter in children, the pre-operative bladder capacity must be sufficient and previous surgery should not have been performed on the bladder neck, the site of choice for implantation in children. Sphincterotomy is not always necessary in paediatric patients. Children and parents should be informed of the high complication rate and the need for long-term follow-up.

[Duckett's+ simple surface or double surface? Comparison of 2 urethroplasty procedures. Report of 91 hypospadias]. / Duckett "simple face" ou "double face"? Comparaison des 2 procédés d'uréthroplastie. A propos de 91 hypospadias.

The results and complications of the treatment of hypospadias were studied in relation to the two pedicle foreskin mucosal flap techniques described successively by Duckett, "single surface" and "double surface". 91 urethroplasties were performed: 58 "single surface" and 33 "double surface" Duckett urethroplasties. The children were operated between the ages of 18 months and 16 years with a mean age of 4 years. 75% of children had a good result on long-term follow-up. In the case of major complications, essentially fistula, distal necrosis àf the urethra or stricture, a single reoperation increased the percentage of good results to almost 98% for the entire series. However, when the two procedures were compared, a good result was obtained immediately in 81% of cases for the "single surface" operation versus 66% for the "double surface" operation. The fistula rate was 27.2% with the "double surface" flap versus 13.7% with the "single surface" flap and the distal stricture rate was 15.1% with the "double surface" flap versus 3.4% with the "single surface" flap. In the light of these results, Duckett's "double surface" procedure has been abandoned in favour of the "single surface" flap.

[Apple-peel jejunal atresia. Nutritional management]. / Atrésie du grêle avec intestin en colimaçon. Prise en charge nutritionnelle.

Apple-peel jejunal atresia is a rare digestive tract congenital defect often accompanied with a short gut. Two cases managed by a three-stage medical and surgical approach are reported. A protein hydrolysate-jejunal secretion mixture was drip-fed through the distal ileostomy to stimulate trophicity of the distal gut.

Repeated skin expansion for excision of congenital giant nevi in infancy and childhood.

Three children with giant pigmented nevi were treated by repeated tissue expansion. Five flaps were expanded twice, and one flap was expanded three times. The delay between expansions was 4 to 15 months (mean 9 months). With full inflation, vascularization of the flap remained good. However, every new expansion decreased flap length by 50 percent. Overall results with this technique, especially in two infants with giant pigmented nevi involving respectively 20 and 40 percent of the body surface, have been most impressive. Only one major complication has occurred: erosion of the skin caused by a fold of the expander envelope resulting in exposure of the expander. This technique improves the early surgical management of giant pigmented nevi and may provide better long-term functional and cosmetic results.

[Cleft palate and inflammatory diseases of the middle ear]. / Division palatine et pathologie inflammatoire de l'oreille moyenne.

Based on a series of 57 children who were operated for velar clefts, the authors studied the different associated aspects of middle ear inflammatory pathology: physiopathology, occurrence, evolution, complications. Seromucous otitis was initially found in 87% of the cases. Three years after surgery, it persisted in 70% of the cases. These children should be monitored on a long-term basis for timely detection of any and all evolution towards chronic otitis or even cholesteatomas.

[Multicystic renal dysplasia with ectopic implantation of the ureter in boys. Apropos of 6 cases]. / La dysplasie rénale multikystique avec abouchement ectopique de l'uretère chez le garçon. A propos de six observations.

The prevalence of multicystic dysplastic kidney has increased since the development of antenatal ultrasound diagnosis. Even though, the rarity of symptomatic forms and case reports of spontaneous regressions antenatally or after postnatal ultrasound follow-up have reduced indications of nephrectomy which is less and less appropriate. However, discovery of ectopic ureteric implantation in boys makes certain additional investigations as intravenous pyelography, cystography and ultrasound, essential before making any therapeutic decision. Nevertheless, some cases remain undescriptible. In these cases, operative opacification of any patent ureter can provide more precise information about ureteric implantation. Lastly, only a dissection and resection as complete as possible of any patent ureter and pelvic cystic dilatation can prevent subsequent complications.

[Accessory thymus in cervical ectopy: apropos of a case]. / Thymus accessoire en ectopie cervicale: à propos d'un cas.

Cervical tumors of thymic origin are considered to be uncommon lesions in the differential diagnosis of neck masses. They can be either cystic or solid. The authors present one case of solid cervical thymic tumor in a 2 month-old baby. The embryogenesis of the thymus explains the cervical location of these tumors. Theories of physiopathology are presented. The clinical presentation is variable and their nature is often recognized only upon surgery and preoperative pathologic examination. Some cases of thymoma and respiratory complications resulting from ectopic thymus have been described in the literature, so that total excision of the mass must be performed. This lesion may be more common than suggested in the literature.

[Antibiotic therapy of perforated appendicitis in children: comparison between the amoxicillin-clavulanic acid and the benzylpenicillin-netilmicin-metronidazole combinations]. / Antibiothérapie de l'appendicite perforée chez l'enfant: comparaison de l'amoxicilline-acide clavulanique et de l'association benzylpénicilline-nétilmicine-métronidazole.

In a multicentre trial we compared the clinical efficacy of amoxicillin/clavulanate used as a single-agent therapy with that of the three-agent combination usually prescribed in the post-operative period for appendicular peritonitis in children. Only bacteriologically documented peritoneal infections were included. Sixty-four patients were randomly distributed between two groups: Group A (29 cases) treated with amoxicillin/clavulanate, first administered iv (100 mg/kg/d), followed by conversion to the oral route (50 mg/kg/d) once the patient had been afebrile for 48 hours; Group B (35 cases) first treated by the iv route with benzylpenicillin (100,000 IU/kg/d) plus netilmicin (5 mg/kg/d) plus metronidazole (30 mg/kg/d), followed by conversion to the oral route for metronidazole (30 mg/kg/d). In both groups, the total duration of parenteral and oral treatment was not less than 5 days. One hundred and seventy nine bacterial strains were recovered from peritoneal fluid samples obtained during surgery; 86% of these were sensitive to amoxicillin/clavulanate. Clinical efficacy, assessed on the basis of time until return to normal temperature and gut transit and duration of hospitalization, was identical in both groups, with follow-up monitoring on day 30 showing recovery in all cases. Cure was obtained without any problems of infection in 25/29 patients in group A and in 34/35 patients in group B (non significant difference). Tolerance was excellent and identical in the two groups with the exception of three cases of thrombophlebitis which occurred in group B. The results of this study suggest that amoxicillin/clavulanate may be useful as single-agent therapy as a first-line curative treatment for appendicular peritonitis in children.

[Fetus in fetu and acardiac monster: can the similar patterns of these 2 malformations be explained by a common morphogenic mechanism?]. / Foetus in fetu et monstre acardiaque: un mécanisme morphogénique commun explique-t-il les similitudes de ces deux malformations?

Fetus in fetu and acardiac monster are two unusual malformations (estimated incidences: 1 in 500,000 and 1 in 34,600 deliveries respectively) which present very similar morphological patterns. The authors report two cases of acardiac monster and a case of fetus in fetu which emphasize this fact. These findings suggest that a single morphogenic mechanism leads to the defects observed in these two groups of malformations.

[Sacrococcygeal teratomas in antenatal diagnosis]. / Tératomes sacro-coccygiens de diagnostic anténatal.

The authors report eight cases of antenatal diagnosis of sacro-coccygeal teratoma (SCT) in five girls and three boys in whom the diagnosis was made between the 19th and 34th week of amenorrhea (mean = 27 weeks). The ultrasound pictures taken antenatally of the SCT assist in the discovery of a mass that is usually heterogenous, attached to the distal end of the sacrum, and the discovery is usually made fortuitously or because the height of the uterus is too great. A different series of antenatal diagnoses for SCT have made it possible to work out certain criteria of seriousness to be able to predict intra-uterine death: the presence of anasarca or of hydramnios, the discovery of the lesion before the 30th week of amenorrhoea, the relative weight of the teratoma as against the weight of the fetus being above 50%. We think from our experience that it is important to add the scale of the antenatal growth of the teratoma. A rapid growth of the SCT will lead to a tumour mass which is great as compared to the size of the fetus. Similarly in certain cases the vascular bed will increase in size, and intratumour haemorrhages can occur and give rise to fetal heart failure and also to fetal anaemia, hypoproteinaemia and the appearance of anasarca or of hydramnios. The child dies in utero or immediately after birth because of prematurity from the haemorrhagic state or from cardiac insufficiency. Furthermore accelerated growth of the tumour is nearly always in the immature tumour cells and that means that the child, if it is born alive, should be followed up for a long time because there is a risk of it becoming locally malignant. In practice the monitoring of SCT and the antenatal discovery of the condition should be carried out very seriously in order, in some cases, if it is viable to produce a living child in conditions where the rapid growth of tumour would make it likely that the child would die in utero.