Management strategies for idiopathic urethritis.

INTRODUCTION: Williams and Mikhael (1971) described idiopathic urethritis (IU) as a self-limiting condition that affects boys aged 5-15 years, with symptoms of urethrorrhagia, dysuria and haematuria. However, a proportion of boys will remain symptomatic for several years, and may develop urethral stricture (Poch et al., 2007; Palagiri et al., 2003). There is no universally effective treatment for IU, although various strategies have been employed. OBJECTIVE: To review the presentation and long-term outcomes of boys with IU, and present the efficacy of management strategies that have been utilised. STUDY DESIGN: A retrospective review was performed of all boys with IU. It was based on clinical and cystoscopic findings for presentation, medical history, management and clinical progress. RESULTS: Fifty-four boys were included, with a median age of 11 years (range 5-15 years) at presentation. The median duration of symptoms was 18 months (range 2-132 months). The median follow-up was 18.5 months (range 1-120 months). Seven (13.0%) boys had early urethral stricture at initial cystourethroscopy, and one (1.9%) developed stricture during follow-up. Thirty-six boys (66.7%) had previous circumcision and four (7.4%) had meatal stenosis. Eight (14.8%) had previous hypospadias repair. CONCLUSION: Whilst 50% of boys with IU do not require any specific treatment, those with severe/unremitting symptoms may benefit from a trial of urethral steroids or short-term urethral catheterisation. The mechanisms of benefit from these modalities are unclear and they require further evaluation.

Antenatal diagnosis of bladder/cloacal exstrophy: challenges and possible solutions.

OBJECTIVE: To identify the pitfalls in accurate antenatal diagnosis of bladder exstrophy (BE) and cloacal exstrophy (CE), and thus understand the challenges for antenatal counselling. METHODS: A prospectively maintained bladder exstrophy database of antenatal and live born referrals for BE/CE was used to identify patients. Data were collected about the antenatal scan findings and the outcome of pregnancy. RESULTS: Between 2003 and 2009, 40 new babies with BE/CE were referred and of them 10 had an antenatal diagnosis. Five patients did not have a diagnosis despite suspicious findings noted on antenatal scans and another three had a wrong diagnosis of BE/CE. Of the 16 referrals with antenatal suspicion of BE/CE, 5 opted for termination. At the 20-week scan, it was possible to identify the gender of the fetus in 3/16 cases only. CONCLUSIONS: Only a quarter of the babies born with BE/CE had received an antenatal diagnosis. Raising awareness about the condition amongst radiographers, and facilitating further scanning by a specialist fetal management unit if suspicious findings are noted, is crucial for improving the rate of detection. An antenatal diagnosis may not be reliable, and difficulty in identifying gender at the 20-week scan adds to the complexity of antenatal counselling. Magnetic resonance imaging and karyotyping may provide additional helpful information.

Knotting of a ureteric stent in a child.

Knotting of ureteric stents is an unusual complication of their use and has not previously been reported in a child. We present a case of a 4-year-old that developed symptomatic hydronephroureter following removal of a multilength stent, which had knotted at the proximal loop. The child made a full recovery but knotting must be considered if resistance is encountered during stent removal.

Elective delayed midgut reduction-No anesthesia for gastroschisis: Selection and conversion criteria.

BACKGROUND/PURPOSE: In 1998 Bianchi and Dickson published their proposal for elective delayed midgut reduction without anaesthesia (EDMR-No GA). The study has been prospectively extended to develop "selection and conversion criteria" to ensure safe application of the technique. METHODS: In a prospective study from 1993 to date, EDMR-No GA was considered as first-line postnatal management in 35 children. The protocol and technique were those described by Bianchi and Dickson in 1998. RESULTS: EDMR-No GA was completed successfully in 25 children, of whom, 23 are normal with an aesthetic, scarless abdomen. Two children had bowel necrosis and died of short bowel state. A trial EDMR-No GA was converted to a staged silo reduction in 2 children who are both alive and well. EDMR-No GA was considered contraindicated in 8. Five had an elective, staged silo reduction, 2 had EDMR under anesthesia, and one 27-week-gestation baby died of severe hypothermia and acidosis before any procedure. CONCLUSIONS: No single technique is applicable in all circumstances, and "selection and conversion criteria" are relevant to safe EDMR-No GA. These include poor general condition, significant vital organ anomaly, bowel-to-abdomen disproportion and "at risk" bowel circulation. The development of distress and progressive metabolic acidosis during and after EDMR-No GA, are indications for urgent conversion to avoid serious bowel injury. Experience with EDMR-No GA hones the surgeon's sensitivity in assessing abdominal.

The influence of delay in closure of the abdominal wall on outcome in gastroschisis.

To evaluate the effect of a delay in closure of the abdominal wall (AWC) on outcome in the management of gastroschisis, a retrospective analysis of 91 babies admitted over a 7-year period (1992-1998) to a single neonatal surgical unit with a diagnosis of gastroschisis was carried out. Antenatal diagnosis was made in 89 (98%) cases. Surgical intervention occurred in 90 babies at a median of 4 h (standard error 0.345, range 0.5-17) post-delivery. In 72 (80%) cases primary closure of the abdominal defect was achieved, with a silo fashioned in the remaining 18 (20%). One infant died prior to AWC. The median time to full oral feeding was 22 days (2.96, 5-160), and to discharge 28 days (4.03, 11-183). There was no correlation between time to AWC and any measured outcome parameter. There was no significant difference in mortality in those patients having closure before 6 h. Thus, no correlation between time to AWC and outcome was demonstrated. This would suggest that the time taken to optimally resuscitate a newborn infant prior to surgical closure does not have an adverse influence upon outcome and is to be recommended.

The contemporary outcome of gastroschisis.

BACKGROUND: The aim of this study was to evaluate the contemporary outcome in the management of gastroschisis. METHODS: A retrospective analysis was conducted of 91 babies admitted over a 7-year period to a single neonatal surgical unit with a diagnosis of gastroschisis. RESULTS: An antenatal diagnosis was made in 89 (98%) cases. Surgical intervention occurred in 90 babies, at a mean of 5 hours (range, 0.5 to 17) postdelivery. In 72 (80%) cases, primary closure of the abdominal defect was achieved, with a silo fashioned in the remaining 18 (20%). One child died before abdominal closure. The median time to full oral feeding was 30 days (range, 5 to 160 days), and to discharge was 42 days (range, 11 to 183 days). Those children who required a silo, took longer to feed (P =.008) and stayed longer in the hospital (P =.021). The 8 (8.8%) children with an intestinal atresia, required significantly more operative procedures (P =.0001) and took significantly longer to achieve full oral feeding (P =.04), but the presence of an atresia was not an independent risk factor for mortality. There were 7 deaths (7.7%), 3 within the first 7 days. Of the deaths, 5 (71%) were caused by overwhelming sepsis. CONCLUSIONS: The contemporary mortality rate from gastroschisis is less than 8%, and minimizing septic complications would contribute significantly to reducing this. Strategies designed to improve morbidity must focus on optimizing management of those factors associated with a prolonged recovery, namely intestinal atresia, prematurity, and the use of a silo.

Long-term outcome of Boix-Ochoa and Nissen fundoplication in normal and neurologically impaired children.

PURPOSE: The aim of this study was to compare the results of Boix-Ochoa and Nissen fundoplication performed in the authors' department in normal and neurologically impaired children. METHODS: The medical records of all children who underwent fundoplication in the span of 10 years from 1988 to 1997 were reviewed. Boix-Ochoa procedure was the preferred operation before 1993. Since 1993, the Nissen fundoplication has been used as the operation of choice for surgical antireflux treatment. RESULTS: A total of 109 fundoplications were performed during that period, of which 64.2% of the children involved were neurologically impaired. The Boix-Ochoa procedure and Nissen fundoplication were the 2 types of operations performed for antireflux surgical treatment. There were 22 recurrences of gastroesophageal reflux, 14 in the neurologically impaired group and 6 in the normal group. All except 2 recurrences were after the Boix-Ochoa procedure. Neurological impairment increased the morbidity rates after these procedures and dictated the effectiveness of the operation. Nissen fundoplication fared better in comparison with the Boix-Ochoa procedure in both the neurologically impaired and the normal group. CONCLUSIONS: Antireflux surgery is beneficial in children with significant gastroesophageal reflux, irrespective of their neurological status, although complications are more common in the neurologically impaired group. Nissen fundoplication is more effective and has fewer complications.

Antenatally detected pelvi-ureteric junction obstruction: concerns about conservative management.

OBJECTIVE: To review the conservative management of antenatally detected pelvi-ureteric junction (PUJ) obstruction in children. PATIENTS AND METHODS: The study included 121 children (142 kidneys) with antenatally diagnosed PUJ obstruction managed over an 8-year period, including 21 who were affected bilaterally; the main focus of the study was on the 100 children affected unilaterally. The intent was to manage these patients conservatively, with immediate surgery (early pyeloplasty) only if renal function was initially compromised (renographic function < 40%). The indications for surgery subsequently (delayed pyeloplasty) included either a deterioration in renal function, the onset of symptoms or increasing hydronephrosis. RESULTS: The anteroposterior diameter and renal function were weakly and negatively correlated. The kidneys in the delayed pyeloplasty group had a greater initial mean anteroposterior diameter than had those in the early or the conservative groups (P<0. 05). The improvement in renal function was the lower in the delayed pyeloplasty group than in the early pyeloplasty group; the improvement was inversely related to the anteroposterior diameter. CONCLUSIONS: The conservative management of some antenatally detected PUJ obstructions probably results in greater loss of function, which is not recovered after surgery.

Necrotizing enterocolitis in omphalopagus conjoined twins.

Female omphalopagus twins underwent laparotomy on the second day of life after an antenatally diagnosed high jejunal bowel obstruction. Bowel resection and choldocho-enterostomies were performed. Despite recovery from laparotomy, the development of severe necrotizing enterocolitis (NEC) in one twin led to rapid deterioration and the death of both infants on day 34. The elucidation of the combined biliary tree, the dilemma of NEC in conjoined twins, and the possibilities of emergency separation are discussed. Consideration should be given to emergency separation of conjoined twins in the event of potentially lethal complications.

Subcostal muscle-split incision in paediatric urology.

The subcostal muscle-split incision (SMSI) has been used in 108 consecutive operations for benign upper urinary tract disease. No wound-related complications have occurred. No conversion to other wounds has been required. The benefits of SMSI are described.

Elective delayed reduction and no anesthesia: 'minimal intervention management' for gastrochisis.

PURPOSE: In a pilot study of 14 children, born when the authors were on a 1:5 "on take" for neonatal referrals, a policy evolved of elective delayed midgut reduction without anaesthesia or sedation in the incubator on the neonatal surgical unit. There was no other form of selection, and it was fortunate that the authors did not encountered any adverse criteria in this small series. METHODS: Bowel reduction, which was pain free, was undertaken conventionally with the same attention and with no greater difficulty than under general anesthesia. Delaying midgut reduction for more than 4 hours led to more stable cardiovascular, respiratory, and renal parameters. Moderate lower limb congestion cleared rapidly. RESULTS: At the end of the procedure, all children were conscious, and 12 were alert and indistinguishable from normal babies. A mild periumbilical infection developed in two patients. Eleven of the 12 surviving children established enteral nutrition within 11 to 32 days, eight within 18 days. Another child with ileal atresia and bowel dilatation required bowel tailoring and lengthening (LILT) to allow enteral nutrition. All are physically and developmentally normal, and none has required umbilical herniorrhaphy or umbilicoplasty. All except one have a "scarless" abdomen and an aesthetically normal umbilicus. In marked comparison, two children immediately and obviously were unwell with abdominal pain, tachycardia, and metabolic acidosis. Abdominal wall cellulitis rapidly developed in both. At laparotomy one had a midgut volvulus and died at 22 months of short bowel syndrome (SBS) and the other with a perforated segmental ileal atresia died at 7 months of Enterobacter cloacae septicaemia. CONCLUSIONS: Our small study suggests that delayed midgut reduction without anaesthesia appears safe, carrying no additional morbidity or mortality. It helps avoid anaesthesia, muscle relaxants, and ventilation and has obvious resource benefits. The conscious child is a safety asset, and any postreduction deviation from a "normal, well-perfused, comfortable, and painfree" child is an indication for urgent laparotomy. This "minimal intervention management," when applicable, has become our preferred first option for children with gastroschisis. Further extension of this study will determine those not eligible for this technique and establish "exclusion criteria."

The Malone antegrade colonic enema procedure: outcome and lessons of 6 years' experience.

The successful management of faecal incontinence can dramatically improve the quality of life of affected children. The introduction of the non-refluxing, catheterisable appendico-caecostomy provides the opportunity to treat previously resistant patients. Over a 6-year period, 29 children had a Malone antegrade continent stoma for enema administration (MACE). Incontinence was related to spina bifida in 12 children, ano-rectal anomaly in 12, Hirschprung's disease in 2, followed excision of a pelvic tumour in 2, and was secondary to intractable chronic constipation in 1. The conduit was fashioned from the appendix (20), a caecal tube (8), or a gastric tube (1). Surgical complications were stomal stenosis (11), wound infection (1), anastomotic leak (1), MACE stoma prolapse (1), and a pressure sore (1). Colonic irrigation was achieved with washouts of saline (24), saline plus phosphate (4), and saline plus Picolax (1). Twenty-three patients have complete control of bowel function, but 4 still soil. Two remain incontinent, 1 of whom is still being instructed. One child subsequently had a colostomy, but still uses the MACE stoma. Successful bowel management requires motivation, dedication, commitment, and the input of a clinical nurse specialist. The MACE is a relatively straightforward operative procedure that provides an effective washout technique that is acceptable to both parents and children.

Advanced colonic carcinoma in children.

We report two cases of colorectal carcinoma in children with a delay in diagnosis due to the low index of suspicion of this pathology as the cause of presenting symptoms. We conclude that any child presenting with unexplained rectal bleeding and abdominal pain should be investigated with endoscopy and barium enema.

Malrotation and midgut volvulus presenting as malabsorption.

Volvulus of the midgut associated with intestinal malrotation classically presents in early life with complete, or intermittent, high intestinal obstruction. We describe the case of a boy presenting at 16 months of age with a history of malabsorption and failure to thrive. The importance of considering this rare diagnosis in such cases is discussed.

Histology and bacteriology of closed duodenal loop models of experimental acute pancreatitis in the rat.

Three variants of closed duodenal loop models of experimental acute pancreatitis in the rat have been analysed histologically and bacteriologically. Histological studies showed that the resulting pancreatitis was usually mild to moderate, being severe only in association with sepsis. Furthermore the duodenal wall became necrotic in most animals. Bacteriological studies revealed gross infection as a major complication. Peritoneal fluid and blood cultures taken at the time of animal sacrifice consistently demonstrated large numbers of bacteria. It is concluded that although these models undoubtedly cause acute pancreatitis, other more severe pathological events occur. Deductions regarding acute pancreatitis drawn from this type of model are therefore not relevant to the human disease.

BMX bicycle injuries in children.

The incidence and severity of injuries occurring on BMX bicycles coming to an Accident and Emergency department (A&E) of a children's hospital have been studied prospectively during a 4-month period in 1984 and compared with the same calendar period 1 year previously, before the increase in BMX sales had occurred. The majority of bicycle accidents in the 1984 period occurred on BMX models. There was a marked increase in the number of injuries seen in 1984 (288) in comparison with 1983 (188), reflecting the increased use of bicycles by children due to the current popularity of BMX models. Although there was an increase in minor injuries in 1984 (182) compared with 1983 (112), the number of severe injuries was less-56 in 1984 (20 per cent) and 68 in 1983 (37 per cent). BMX bicycles, although increasing the number of A&E attendances, have not caused a rise in the number of severe injuries related to bicycles in Edinburgh.