Short and Long-Term Outcomes of PSARP versus LAARP and Single versus Staged Repair for Infants with High-Type Anorectal Malformations: A Systematic Review and Meta-Analysis.

BACKGROUND: We aimed to compare among patients with high-type anorectal malformations (ARM): (i) short- and long-term outcomes of laparoscopic-assisted anorectoplasty (LAARP) compared to classic posterior sagittal anorectoplasty (PSARP) and (ii) the results of single-stage versus staged PSARP. METHODS: Using a defined search strategy, two independent investigators systematically reviewed the English literature. PRISMA guidelines were followed, and meta-analysis was performed using RevMan5.3. RESULTS: Of 567 abstracts screened, 7 papers have been included (254 pts; 121 PSARP, 133 LAARP) in the first systematic review and meta-analysis. The length of hospitalization was shortened in LAARP versus PSARP (10.9 versus 14.4 days; p < 0.0001). PSARP and LAARP were comparable in terms of early postoperative complications (28.9% versus 24.7%; p = ns) and rectal prolapse (21.6% versus 17.5%; p = ns). At long-term follow-up, the presence of voluntary bowel movements (74.0% versus 83.5%; p = ns) and the incidence of soiling (45.5% versus 47.6%; p = ns) were similar in both PSARP and LAARP. Six papers (297 pts) were included in the second systematic review, with three comparative studies included in the meta-analysis (247 pts; 117 one-stage, 130 staged procedures). No significant difference in terms of presence of voluntary bowel movements after single-stage versus staged procedures (72.6% versus 67.3%; p = ns) has been detected. CONCLUSIONS: LAARP seems to be a safe and effective procedure, showing short- and long-term outcomes similar to PSARP. One-stage PSARP could be a safe alternative to the classic three-stage procedure, even for those infants with high-type ARM. Further and larger comparative studies would be needed to corroborate these partial existing data.

Management and outcomes of acute appendicitis in children during the COVID-19 pandemic: a systematic review and meta-analysis.

The COVID-19 pandemic has changed the way to manage the emergencies, as people faced fear of the hospitals, with possible delay in the diagnosis. Moreover, clinicians had to rearrange protocols for diagnosis and treatment. We aimed to assess whether COVID-19 pandemic influenced severity of inflammation, management, and outcomes of acute appendicitis (AA), when compared to the pre-COVID era. Using defined search strategy, two independent investigators identified those studies comparing pediatric AA during COVID-19 pandemic versus the pre-COVID-19 period. Meta-analysis was performed using RevMan 5.3. Data are mean ± SD. Of 528 abstracts, 36 comparative studies were included (32,704pts). Time from symptoms onset to surgery was longer during the pandemics compared to the pre-COVID-19 (1.6 ± 0.9 versus 1.4 ± 0.9 days; p < 0.00001). Minimally Invasive Surgery was similar during COVID-19 (70.4 ± 30.2%) versus control period (69.6 ± 25.3%; p = ns). Complicated appendicitis was increased during the pandemics (35.9 ± 14.8%) compared to control period (33.4 ± 17.2%; p < 0.0001). Post-operative complications were comparable between these two groups (7.7 ± 6.5% versus 9.1 ± 5.3%; p = ns). It seems that the COVID-19 pandemic influenced the time of diagnosis, severity of inflammation, and type of surgery. However, the number of post-operative complications was not different between the two groups, leading to the conclusion that the patients were correctly managed. LEVEL OF EVIDENCE: Level 3 Meta-analysis on Level 3 studies.

Rare Single Nucleotide and Copy Number Variants and the Etiology of Congenital Obstructive Uropathy: Implications for Genetic Diagnosis.

SIGNIFICANCE STATEMENT: Congenital obstructive uropathy (COU) is a prevalent human developmental defect with highly heterogeneous clinical presentations and outcomes. Genetics may refine diagnosis, prognosis, and treatment, but the genomic architecture of COU is largely unknown. Comprehensive genomic screening study of 733 cases with three distinct COU subphenotypes revealed disease etiology in 10.0% of them. We detected no significant differences in the overall diagnostic yield among COU subphenotypes, with characteristic variable expressivity of several mutant genes. Our findings therefore may legitimize a genetic first diagnostic approach for COU, especially when burdening clinical and imaging characterization is not complete or available. BACKGROUND: Congenital obstructive uropathy (COU) is a common cause of developmental defects of the urinary tract, with heterogeneous clinical presentation and outcome. Genetic analysis has the potential to elucidate the underlying diagnosis and help risk stratification. METHODS: We performed a comprehensive genomic screen of 733 independent COU cases, which consisted of individuals with ureteropelvic junction obstruction ( n =321), ureterovesical junction obstruction/congenital megaureter ( n =178), and COU not otherwise specified (COU-NOS; n =234). RESULTS: We identified pathogenic single nucleotide variants (SNVs) in 53 (7.2%) cases and genomic disorders (GDs) in 23 (3.1%) cases. We detected no significant differences in the overall diagnostic yield between COU sub-phenotypes, and pathogenic SNVs in several genes were associated to any of the three categories. Hence, although COU may appear phenotypically heterogeneous, COU phenotypes are likely to share common molecular bases. On the other hand, mutations in TNXB were more often identified in COU-NOS cases, demonstrating the diagnostic challenge in discriminating COU from hydronephrosis secondary to vesicoureteral reflux, particularly when diagnostic imaging is incomplete. Pathogenic SNVs in only six genes were found in more than one individual, supporting high genetic heterogeneity. Finally, convergence between data on SNVs and GDs suggest MYH11 as a dosage-sensitive gene possibly correlating with severity of COU. CONCLUSIONS: We established a genomic diagnosis in 10.0% of COU individuals. The findings underscore the urgent need to identify novel genetic susceptibility factors to COU to better define the natural history of the remaining 90% of cases without a molecular diagnosis.

Ureteropelvic junction obstruction in infants: Open or minimally invasive surgery? A systematic review and meta-analysis.

Introduction: The historical gold standard treatment for ureteropelvic junction obstruction (UPJO) was the open Anderson-Hynes dismembered pyeloplasty (OP). Minimally invasive surgery (MIS) procedures, including laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP), have been reported to achieve better outcomes (i.e., decreased morbidity, reduced postoperative pain, superior esthetic results, and shortened length of hospital stay, LOS), with a success rate similar to OP. The main limitation of the MIS approach is the age and weight of patients, limiting these procedures to children >1 year. This study aims to evaluate the feasibility and benefits of MIS pyeloplasty compared to OP to surgically treat UPJO in children <1 year of age. Materials and methods: A systematic review was independently performed by two authors. Papers comparing both techniques (MIS pyeloplasty vs. OP) in infants were included in the meta-analysis. Data (mean ± DS or percentage) were analyzed using Rev.Man 5.4 A p < 0.05 was considered significant. Results: Nine studies (eight retrospective and one prospective) meet the inclusion criteria. A total of 3,145 pyeloplasties have been included, with 2,859 (90.9%) OP and 286 (9.1%) MIS. Age at operation was 4.9 ± 1.4 months in OP vs. 5.8 ± 2.2 months in MIS, p = ns. Weight at surgery was 6.4 ± 1.4 kg in OP vs. 6.9 ± 1.4 kg in MIS, p = ns. Operative time was 129.4 ± 24.1 min for OP vs. 144.0 ± 32.3 min for MIS, p < 0.001. LOS was 3.2 ± 1.9 days for OP vs. 2.2 ± 0.9 days for MIS, p < 0.01. Postoperative complications were present in 10.0 ± 12.9% of OP vs. 10.9 ± 11.6% in MIS, p = ns. Failure of surgery was 5.2 ± 3.5% for OP vs. 4.2 ± 3.3% for MIS, p = ns. Conclusion: The development of miniaturized instruments and technical modifications has made MIS feasible and safe in infants and small children. MIS presented a longer operative time than OP. However, MIS seemed effective for treating UPJO in infants, showing shortened LOS compared to OP. No differences have been reported with regard to the incidence of postoperative complications and failure of pyeloplasty. Given the low quality of evidence of the meta-analysis according to the GRADE methodology, we would suggest limiting MIS procedures in infants to only those high-volume centers with experienced surgeons.

Minimally invasive vascular hitch to treat pediatric extrinsic ureteropelvic junction obstruction by crossing polar vessels: A systematic review and meta-analysis.

INTRODUCTION: Vascular hitch (VH) gained an increasing success in treating ureteropelvic junction obstruction (UPJO) by crossing vessels (CV) in pediatrics. AIMS OF THE STUDY: We aimed: (i) to compare laparoscopic VH versus laparoscopic dismembered pyeloplasty (DP) to treat UPJO by CV; (ii) to review possible amelioration given by a robot-assisted procedure. METHODS: Using defined search strategy, three investigators identified all studies on laparoscopic VH. Those studies comparing VH versus DP or versus robot-assisted VH were included in the meta-analysis. The meta-analysis was conducted using RevMan 5.3. Data are mean ± SD. RESULTS: Systematic review - Of 2783 titles/abstracts screened, 43 full-text articles were analyzed. Twelve studies on laparoscopic VH (298 pts) reported 98.3% success rate, with 1.3% intra-operative complications. Meta-Analysis - Five studies compared laparoscopic VH versus laparoscopic DP (277 pts). Operative time was reduced in VH (102.5 ± 47.5min) compared to DP (165.7 ± 53.7min; p < 0.00001). Complications were similar (VH 4/119 pts, 3.4 ± 1.2% versus DP 15/158 pts, 9.5 ± 6.8%; p = ns). Hospital stay was shortened in VH (1.1 ± 0.9dd) versus DP (3.3 ± 3.2dd; p < 0.0001; Summary Figure). The success rate was comparable (VH 115/118 pts, 97.5 ± 1.6% versus DP 157/158 pts, 99.4 ± 0.5%; p = ns). Two prospective studies compared robot-assisted VH to laparoscopic VH (53 pts). No differences were found among complications (robot-assisted VH 0/13 pts, 0% versus laparoscopic VH 1/40 pts, 2.5%; p = ns) and success rate (robot-assisted VH 13/13 pts, 100% versus laparoscopic VH 39/40 pts, 97.5%; p = ns). DISCUSSION: Several studies have been reported long-term results of laparoscopic VH in children. However, few papers demonstrated its superiority over laparoscopic DP to treat extrinsic UPJO. In the present study, we found similar incidence of complications and success rates when comparing VH versus DP. Nonetheless, the operative time and the length of hospital stay were significantly reduced in VH compared to DP. An increasing number of surgeons performed robotic-assisted VH, reporting promising outcomes. However, only a couple of studies compared robot-assisted VH to laparoscopic VH, with a similar incidence of complications and success rate in both procedures. The main limitations of the study were related to the slight number of papers included and to their quality, since all of them were retrospective studies or prospectively followed-up cohort of patients. CONCLUSIONS: Laparoscopic VH seems to be a safe and reliable procedure to treat UPJO by CV. The procedure appeared quicker than laparoscopic DP, with shortened hospital stay. Further studies are needed to corroborate these results and to establish amelioration given by a robot-assisted procedure.

Spontaneous regression of cystic dysplasia of the rete testis in an 18-month-old boy: the key role of ultrasonography.

Cystic dysplasia of the rete testis (CDT) is a rare cause of scrotal swelling in children. It is a congenital disorder and it can be associated with other genitourinary abnormalities. At present, there is no clear consensus on treatment. Surgical approach has traditionally been the treatment of choice, while, more recently, conservative approach has been applied, justified by the benign nature of the lesion and after few cases of spontaneous regression have been documented. Ultrasonography, supported by negative tumor markers, plays a key role in the diagnostic work up and during observational follow-up. We report a further case of spontaneous regression of suspected CDT in an 18-month-old boy, who has been followed with clinic and ultrasonographic checks.

Esophageal Atresia and Associated Duodenal Atresia: A Cohort Study and Review of the Literature.

INTRODUCTION: Esophageal atresia (EA) is associated with duodenal atresia (DA) in 3 to 6% of cases. The management of this association is controversial and literature is scarce on the topic. MATERIALS AND METHODS: We aimed to (1) review the patients with EA + DA treated at our institution and (2) systematically review the English literature, including case series of three or more patients. RESULTS: Cohort study: Five of seventy-four patients with EA had an associated DA (6.8%). Four of five cases (80%) underwent primary repair of both atresia, one of them with gastrostomy placement (25%). One of five cases (20%) had a delayed diagnosis of DA. No mortality has occurred. Systematic Review: Six of six-hundred forty-five abstract screened were included (78 patients). Twenty-four of sixty-eight (35.3%) underwent primary correction of EA + DA, and 36/68 (52.9%) underwent staged correction. Nine of thirty-six (25%) had a missed diagnosis of DA. Thirty-six of sixty-eight underwent gastrostomy placement. Complications were observed in 14/36 patients (38.9 ± 8.2%). Overall mortality reported was 41.0 ± 30.1% (32/78 patients), in particular its incidence was 41.7 ± 27.0% after a primary treatment and 37.0 ± 44.1% following a staged approach. CONCLUSION: The management of associated EA and DA remains controversial. It seems that the staged or primary correction does not affect the mortality. Surgeons should not overlook DA when correcting an EA.

A Rare Case of Giant Mesenteric Lipoblastoma in a 6-Year-Old Child and Review of the Literature.

Giant mesenteric lipoblastoma is a rare benign tumor arising from the adipocytes. It can mimic malignant tumors, and its diagnosis is difficult before surgery. Imaging studies could lead the diagnosis but not confirm it. Those tumors arising in the abdomen are usually larger and can cause symptoms of compression. Surgical excision is the treatment of choice, and a long-term follow-up is necessary to detect local recurrences. Only a few cases of lipoblastomas arising from the mesentery are reported in literature. We present a case of a rare giant lipoblastoma arising from the mesentery of a 6-year-old girl, with a history of postprandial abdominal pain.

Holmium: Yttrium-aluminum-garnet laser for endoscopic decompression of ureterocele in the first months of life: A comparison with electrosurgery.

INTRODUCTION: Few case series report the use of holmium: yttrium-aluminum-garnet (Ho:YAG) laser to decompress ureterocele (UC) in pediatric population, and only two studies compared its outcomes with electrosurgery. This study aims to compare outcomes of Ho:YAG laser transurethral endoscopic puncture (TUP) versus electrosurgery TUP of UC in the 1st month of life, analyzing incidence of secondary surgery, redo TUP, and iatrogenic vesicoureteral reflux (VUR). PATIENTS AND METHODS: A retrospective study of patients treated by TUP of UC from 2008 to 2017 was performed. Those undergoing Ho:YAG laser TUP were included in Group A, those undergoing electrocautery TUP were included in Group B. Data were compared using Fisher's exact test. RESULTS: Group A included seven patients (mean follow-up 4 years). Two required a redo TUP. Two had preoperative VUR, which resolved after TUP. Two developed VUR after TUP, which resolved spontaneously. No secondary surgery was required. Group B included nine patients (mean follow-up: 9.5 years). One required a redo TUP. Preoperative VUR was detected in 4/9 and persisted after TUP in 2. Three developed post-TUP VUR, which persisted. Five required further surgery because of persistent and symptomatic VUR. Secondary surgery was significantly lower after Ho:YAG laser compared to electrocautery TUP (P < 0.05). The incidences of both redo TUP and postoperative VUR were not significantly different between the two groups (P = ns). CONCLUSION: Ho:YAG laser TUP seems to be safe and effective in the decompression of obstructive UCs and maybe advantageous over electrocautery puncture. However, further studies with larger cohort are needed to corroborate our preliminary results.

Conversion Rate in Pediatric Robotic-Assisted Surgery: Looking for the Culprit.

Introduction: Robotic-assisted surgery (RAS) is increasingly used in adulthood but its application in pediatric population is limited. We report our initial experience in pediatric RAS, focusing on conversions to analyze their causes. Methods: All pediatric patients who underwent RAS between June 2015 and April 2019 were included, analyzing demographics, comorbidities, previous surgery, and intraoperative surgical and anesthetic parameters. A three-arms robotic technique was used in all cases. Additional laparoscopic ports were added, when needed. The surgical team did not change during the program, whereas the anesthesiology team varied. Results: Thirty-nine patients (23 females, 16 males; mean age ± SD = 9.33 ± 4.73 years [range = 1-16]; mean weight ± SD = 35.2 ± 20.0 kg [range = 9-85]) underwent 40 different procedures (18 gastrointestinal, 15 urogynecological, 5 oncological, and 2 miscellaneous). Three procedures (7.5%) were converted to open surgery for inadequate working space (two marked bowel distension and one insufficient hepatic retraction). Converted patients were of significant lower age (mean ± standard error of mean [SEM] = 2.97 ± 1.03 versus 9.83 ± 0.77 years, P = .01) and lower weight (mean ± SEM = 11.83 ± 1.74 versus 35.47 ± 3.16 kg, P = .03). The two groups did not differ statistically for duration of facial mask ventilation before intubation (mean ± SEM = converted 10.67 ± 2.33 versus completed 10.31 ± 0.91 minutes), neuromuscular block dosage (rocuronium; mean ± SEM = converted 0.46 ± 0.06 mg/kg versus completed 0.62 ± 0.03 mg/kg) and in the type of bowel preparation (mechanical and/or pharmacological). Discussion: Conversion rate in initial pediatric RAS program is acceptable. In children, the need for conversion is mainly because of inadequate working space, particularly in smaller children, but it seems not to be influenced by measurable anesthetic factors or different regimen for bowel preparation.

Contrast-enhanced ultrasonography (CEUS) in the follow-up of pediatric abdominal injuries: value and timing.

AIMS: Primary aim was to investigate the value and safety of contrast-enhanced ultrasonography (CEUS) during follow-up (FU) of splenic, hepatic and renal post-traumatic injuries in a pediatric population. Secondary aim was to extrapolate appropriate timing of FU-CEUS. METHODS: In a retrospective study, post-traumatic parenchymal injuries diagnosed with CT or CEUS, were subjected to non-operative management and followed with CEUS. RESULTS: Forty-six patients were enrolled, with isolated or combined injuries, for a total of 30 splenic, 15 hepatic and 12 renal injuries. At admission 42/46 patients underwent CT and 4/46 underwent CEUS. During FU a total of 65 CEUS were performed: 16 within 72 h to check delayed active bleeding or parenchymal rupture; 24 between 5 and 10 days post admission, to pose indication to active mobilization or to discharge; 21 between 20 and 60 days post admission to document complete healing of the lesion or pose indication to discharge in most severe injuries. No complications related to CEUS were encountered. CONCLUSIONS: CEUS is valuable and safe to follow patients with post-traumatic abdominal injuries, even if further data are needed for renal injuries. We propose a tailored approach based on injury grade and clinical course: in the first 3 days only in case of delayed bleeding or rupture suspect; between 5 and 10 days post trauma to ensure a safe active mobilization and/or pose indication to discharge, and over 20-30 days post trauma to pose indication to discharge in most severe injuries or document complete healing and permit return to sport activities.

Zinner Syndrome in Pediatric Age: Issues in the Diagnosis and Treatment of a Rare Malformation Complex.

Zinner syndrome (ZS) is the association of congenital seminal vesicle cysts and ipsilateral upper urinary tract anomalies, such as multicystic displastic kidney (MCDK). This condition is rare in pediatric age and both diagnosis and treatment are challenging. The aim of this study was to analyze the issues in diagnosis, management, and treatment of ZS in pediatric age. The medical records of two patients with ZS were examined. Furthermore, a review of the literature on this topic in pediatric age was performed. In our experience the diagnosis of ZS was incidentally achieved in the first months of life, as a consequence of studies performed for a prenatal diagnosis of MCDK. The first patient presented unspecific and transient symptoms, the second infant was completely asymptomatic. They were conservatively treated, with a long-term follow-up planned at least until adolescence. Fifty cases of ZS in pediatric age have been reported in the literature up to now. Only 12/50 were diagnosed in the first year of life. The diagnosis was demanding, as the clinical presentation was unspecific and the results at imaging studies needed a differential diagnosis with other retrovesical masses. More than 80% of these cases were asymptomatic at long-term follow-up. Therefore, a conservative management of ZS has been accepted for asymptomatic or poorly symptomatic patients, with occasional, transient, and unspecific symptoms, such as urinary tract infections or orchyepididimytis. As the surgical management is challenging, it is proposed only in those symptomatic patients. In conclusion, ZS is rare in pediatric age. However, it should be considered in the differential diagnosis of cystic masses within the pelvis in males with ipsilateral renal anomalies. A conservative treatment with a long-term follow-up is a safe option in the management of asymptomatic or poorly symptomatic patients, thus reserving the surgical approach only in those cases with symptoms.

One-stage repair of anorectal malformations in females with vestibular fistula: a systematic review and meta-analysis.

PURPOSE: Females with recto-vestibular fistula (RVF) can be managed either by one-stage sagittal anorectoplasty (SARP) or by conventional multi-stage approach with colostomy followed by SARP. Our aim was to define which approach, one-stage or multi-stage, is safer and more beneficial. METHODS: Using a defined search strategy, two investigators identified all comparative studies on the mentioned procedures. The study was conducted under PRISMA guidelines. The meta-analysis was performed using RevMan 5.3. Data are mean ± SD. RESULTS: Of 649 titles/abstracts screened, 13 full-text articles were analyzed. Three studies were included (156 females). One-stage SARP was associated with increased risk of wound infection (24.3 ± 8.7%) compared to multi-stage approach (10.9 ± 2.5%; p < 0.01) and increased risk of wound dehiscence (16.2 ± 4.8% vs. 2.4 ± 1.1%, respectively; p < 0.01). The incidence of anorectal stenosis was higher following one-stage repair (33.3%) vs. multi-stage approach (10.7%; p < 0.05). No differences were found with regards to redo SARP in both groups (12.9 ± 7.3% vs. 4.8 ± 0.8%; p = ns). At follow-up, the prevalence of soiling and constipation were similar after one-stage (19.7 ± 10.3% and 29.5 ± 5.4%) and multi-stage repair (13.7 ± 8.9% and 28.7 ± 4.4%; p = ns). CONCLUSIONS: In females with RVF, the SARP performed without protective colostomy increases the risk of postoperative complications. However, this one-stage approach seems not to be associated with reduced fecal continence.

Robot-assisted resection of gastric duplication cysts in a child: a detailed case report.

Gastric duplication cysts (GDCs) represent 4-9% of alimentary tract duplications. Early diagnosis and surgical excision are essential to avoid morbidity or neoplastic degeneration. Roboticassisted excision of GDCs has never been described in childhood. We report an asymptomatic male patient with 2 gastric cystic masses at ultrasonography (US)-study (diameter 25mm and 8mm), increasing in size at follow-up. At 20 months of age, magnetic- resonance-imaging-scan confirmed 2 round gastric masses (44×35mm and 16×12mm, respectively). Two months later, an elective robotic-assisted excision of GDCs was completed without complications. The patient was discharged at day 6 after procedure. Histology confirmed the diagnosis of GDCs. At a 2-year follow- up, US-study did not evidence any issue. In this first reported case of robotic-assisted cystectomy for CGD in childhood, the procedure seems safe, effective, and feasible. This approach improves the movements of the surgical instruments with better 3- D visualization in comparison with the laparoscopic approach.

Unilateral Papillary Cystadenoma of the Epididymis as a First Presentation of Von Hippel-Lindau Disease.

Association between papillary cystadenoma of the epididymis (PCE) and Von Hippel-Lindau Disease (VHLD) is well known and stronger for bilateral tumors. Unilateral PCE occurs either as a sporadic tumor without evidence of VHLD or in the context of a known diagnosis of VHLD, indeed it has never been reported as the first manifestation of VHLD. In contrast, we report the case of a boy with an apparently isolated, unilateral PCE that resulted to be the first manifestation of an unknown VHLD. Thus, we recommend screening for VHLD in patients with a new diagnosis of unilateral PCE, especially if the patients are young.

Testicular teratoma, mimicking a simple testicular cyst, in an infant.

Prepubertal testicular tumors are rare, and teratoma is the second most frequent histologic type. Its typical features are those of a hard and painless scrotal mass at clinical examination, and nonhomogeneous, echoic, often with calcifications at ultrasonography. Rare but reported is the atypical presentation as a transilluminating scrotal mass, due to the presence of some internal cystic areas, detectable at ultrasonography. We report the case of an infant with a transilluminating scrotal mass, mimicking at ultrasonography and surgery a simple, fully liquid cyst, which the pathologic examination revealed to be mature cystic testicular teratoma.

Long-term followup of primary nonrefluxing megaureter.

PURPOSE: We evaluated outcomes of nonoperative management of primary nonrefluxing megaureter at long-term followup to identify clinical predictors of spontaneous resolution. MATERIALS AND METHODS: A total of 75 patients (88 primary megaureters) were diagnosed between 1990 and 2005 and followed for more than 6 months. Of the patients 63 (74 primary megaureters) were included in the main study population. Indications for surgery were obstructive hydroureteronephrosis, functional impairment and persistent symptoms. RESULTS: Of the 74 primary megaureters 20 (27%) required surgery up to 7 years after diagnosis. Surgery was not indicated in 82% of primary megaureters with grade I or II hydronephrosis vs 62.9% of those with grade III or higher hydronephrosis (difference not significant), nor in 76.5% of types I and II primary megaureters vs 33.3% of type III primary megaureters (p = 0.040), 78.7% of renal units with differential function 40% or greater vs 0% with differential function less than 40% (p = 0.027), 80% of primary megaureters with a nonobstructive washout pattern vs 44.4% with an intermediate/obstructive pattern (p = 0.032), 67.9% of patients with perinatal presentation vs 25% with postneonatal presentation (p = 0.008) or 63.2% of patients presenting with symptoms vs 76.4% of those who were asymptomatic (difference not significant). On multivariate analysis age at presentation and washout pattern were significant predictors of spontaneous resolution. CONCLUSIONS: Most cases of primary megaureter resolve spontaneously or improve without loss of function or development of symptoms. Careful observation allows surgery to be delayed beyond the neonatal period in most patients. Long-term followup is recommended because symptoms can develop years later. Washout pattern and age at presentation are statistically significant predictors of spontaneous resolution.

Irreducible indirect inguinal hernia containing uterus and bilateral adnexa in a premature female infant: report of an exceptional case and review of the literature.

Indirect inguinal hernia is the most common congenital anomaly in the pediatric age group. About 15-20% of hernias in infant girls contain ovary, sometimes with a Fallopian tube. The presence of the uterus incarcerated with the adnexa is a very unusual occurrence in female infants with normal kariotype and phenotype, being commonly associated with several disorders of sex development. The surgical repair of this form of hernia is more difficult than a common herniorrhaphy because of the adhesions between the organs and the wall of the sac and the risk of damage during their freeing. We present a rare case of irreducible indirect inguinal hernia containing uterus and bilateral adnexa (fallopian tubes and ovaries) in a premature female infant, discussing the etiopathogenesis and the surgical features of this disorder.

Transurethral puncture for ureterocele-which factors dictate outcomes?

PURPOSE: We evaluated which clinical factors influence the outcome of primary transurethral puncture for ureterocele. MATERIALS AND METHODS: A total of 45 patients (47 ureteroceles) underwent primary transurethral incision between 1994 and 2008 at 2 institutions. Age at and mode of presentation, upper tract status, ureterocele site, preoperative vesicoureteral reflux and the corresponding upper pole or kidney function were analyzed to identify which factors influenced the need for secondary surgery. RESULTS: Transurethral puncture was the only treatment in 24 of 45 patients (53%) while 21 (47%) required further surgery. After transurethral puncture secondary surgery was required in 56% of patients who presented prenatally vs 27% of those who presented postnatally (p = 0.165), in 18% with a single system vs 58% with a duplex system (p = 0.036), in 30% with intravesical vs 63% with ectopic ureterocele (p = 0.039) and in 61% vs 37% with ureterocele units with vs without preoperative vesicoureteral reflux (p = 0.148). Fisher's 2-tailed exact test revealed an inconsistent distribution of negative prognostic factors, including duplex systems, ectopic ureterocele and vesicoureteral reflux at presentation, in prenatally vs postnatally and in asymptomatically vs symptomatically presenting subgroups. CONCLUSIONS: Upper tract status and ureterocele site influence the outcome of primary transurethral puncture as a definitive procedure. After puncture secondary surgery is least likely in patients with a single system and intravesical ureterocele.

Bilateral scrotal abscesses caused by Klebsiella pneumoniae in a newborn.

The management of acute scrotal swelling can be challenging in neonatal age, with scrotal infections being great mimickers of testicular torsion. Only a few unilateral cases of scrotal abscess have been previously reported, mostly caused by Staphylococcus and Salmonella. We describe the case of a newborn who developed bilateral scrotal abscesses caused by Klebsiella pneumoniae and discuss the rarity of the case, regarding both the bilaterality and the pathogen, never reported before.