Genitourinary injuries in the newborn.

BACKGROUND: Circumcisions and cesarian sections are common procedures. Although complications to the newborn child fortunately are rare, it is important to emphasize the potential significance of this problem and its frequent iatrogenic etiology. The authors present 7 cases of genitourinary trauma in newborns, including surgical management and follow-up. METHODS: The authors relate 7 recent cases of genitourinary trauma in newborns from a children's hospital in a major metropolitan area. RESULTS: Case 1 and 2: Two infants suffered degloving injuries to both the prepuce and penile shaft from a Gomco clamp. Successful full-thickness skin grafting using the previously excised foreskin was used in 1 child. Case 3, 4, and 5: A Mogen clamp caused glans injuries in 3 infants. In 2, hemorrhage from the severed glans was controlled with topical epinephrine; the glans healed with a flattened appearance. Another infant sustained a laceration ventrally, requiring a delayed modified meatal advancement glanoplasty to correct the injury. Case 6: A male infant suffered a ventral slit and division of the ventral urethra before placement of a Gomco clamp. Formal hypospadias repair was required. Case 7: An emergent cesarean section resulted in a grade 4-perineal laceration in a female infant. The vaginal tear caused by the surgeon's finger, extended up to the posterior insertion of the cervix and into the rectum. The infant successfully underwent an emergent multilayered repair. CONCLUSIONS: Genitourinary trauma in the newborn is rare but often necessitates significant surgical intervention. Circumcision often is the causative event. There has been only 1 prior report of a perineal injury similar to case 7, with a fatal outcome.

Long-term remission of Crohn's disease treated with thalidomide: a seminal case report.

A 31-year-old female with severe Crohn's disease for 15 years who had been treated with corticosteroids and 6-mercaptopurine, was treated with thalidomide initially for erythema nodosum. While on thalidomide all symptoms of Crohn's disease disappeared and she was able to discontinue all other drugs. At this writing she has been on thalidomide as sole therapy for over 4 years with the exception of a 5-week hiatus, during which time her symptoms recurred, but again disappeared after resumption of thalidomide therapy. This case suggests that thalidomide may be a useful therapy for Crohn's disease and provides impetus for a clinical trial of thalidomide for Crohn's disease.

Neonatal rectovaginal tear during cesarean section.

Intrauterine rectovaginal tears are an infrequent and life-threatening complication of breech presentation. One previous case has been presented in the literature with a fatal outcome. The authors report a second case of a severe rectovaginal intrauterine tear sustained during cesarean delivery. Prompt administration of antibiotics followed by debridement and primary repair was performed with a successful outcome.

Subsequent asynchronous torsion of normal adnexa in children.

Children who have suffered from ovarian torsion may be at increased risk for a repetitive event. Torsion in a normal adnexa may be due to excessive mobility resulting from congenitally long supportive ligaments. Oophoropexy or shortening of the ligamentous support of the remaining functional ovary after torsion is recommended in attempt to prevent a subsequent torsion. The evaluation of young females with abdominal pain should always include the consideration of ovarian torsion. Preoperative ultrasonography is not invasive and could lead to earlier operative intervention resulting in salvage of ovarian tissue. Observation in these same children may allow a torsed edematous ovary to convert to a nonviable necrotic tissue necessitating oophorectomy. Laparoscopy is useful in cases in which the diagnosis is unclear.

Pediatric lateral ventral (spigelian) hernias.

Lateral ventral (spigelian) hernias may not be recognized if the physician is unaware that they can occur in pediatric patients. Diagnosis depends on finding a protrusion in the spigelian fascia lateral to the rectus sheath at the junction of the arcuate and semilunar lines, below the umbilicus. We report nine such cases, to bring the total number of recorded pediatric cases to 18. Surgical repair involves a layered overlapping closure using interrupted nonabsorbable sutures. Since the rim of the defect is extremely difficult to outline once the child is asleep and relaxed, it must be outlined in indelible ink while the child is awake and straining.

Bladder duplication with one exstrophy and one cloaca.

Bladder duplication is a rare anomaly. Less than 100 cases of all types have been described in the literature. When duplication of the bladder occurs, it has previously been described as a mirror image or as a septate bladder. A newborn female presented with what appeared to be a complete bladder exstrophy, a large ruptured omphalocele with perforated large bowel, an imperforate anus, and a bifid clitoris. Urine was seen emanating from various sites: the bladder mucosa, the mucous fistula constructed at the time of the colostomy, and the left hemiclitoris. The anatomic puzzle was resolved when multiple studies disclosed the problem to be a bladder duplication. The bladder on the anterior abdominal wall was exstrophied, the intraabdominal bladder was a cloaca, and the left hemiclitoris contained a phallic urethra, which drained the intraabdominal bladder. Total correction with normal function was obtained. This patient demonstrates that bladder duplication may present in various ways.

To pex or not to pex.

There is little agreement as to the performance of an exploration and orchiopexy on the asymptomatic side when the neonate is found to have unilateral extravaginal torsion of the testis. If extravaginal torsion does not present bilaterally, many surgeons feel that the uninvolved testis is not at risk. Extravaginal torsion of the testis, fortunately, is a rare problem. Armed with the knowledge of this case report and one previous case report, however, it is clear that extravaginal torsion can present as separate and asynchronous events. Knowledge of this fact should stimulate surgeons to explore and pex the contralateral side upon finding extravaginal torsion of the testis.

A technique for radiographic cannulation and opacification of anatomical structures with small orifices--a new method.

A technique for the injection of contrast material into structures with small orifices which cannot be catheterized in the usual manner is described and illustrated. A small occlusion balloon catheter (Medi-Tech, Watertown, MA) allows for orifice cannulation and occlusion for retrograde contrast examination.

Persistent incompetence of the cervix in female infants with congenital abnormalities of the pelvic viscera and perineum.

Vaginal reflux during voiding cystourethrography (VCUG) is a common finding in young females. Reflux of urine into the uterus, fallopian tubes, and peritoneal cavity documented by contrast studies is rare and considered abnormal. Chronic retrograde flow of urine and its contaminants through an incompetent cervical os mechanism into the peritoneal cavity may lead to peritonitis, pelvic inflammatory disease, and sterility. Five females with congenital abnormalities of the pelvic viscera and perineum had reflux into the uterus, fallopian tubes, and/or peritoneal cavity during voiding studies done before or months to years after successful corrective surgery. The findings were compatible with a persistent incompetent cervical os. It appears that this group of patients is at risk for the development of chronic pelvic inflammatory disease and its consequences.

Ambulatory serial excision of giant nevi.

Nevi over the size of a dime at the time of birth should probably be removed. Nevi this size often cannot be differentiated histologically from the true giant nevus that may cover over 50% of the body. Giant nevi have a 2%-30% malignant potential. In order to avoid the morbidity of split-thickness skin grafts when removing the larger nevi, we have been successful in serially excising many nevi as ambulatory procedures. Most moderately large nevi, regardless of their location, can be managed with this method.

A new incision for penile surgery.

An original incision has been developed for surgery of the penis. The incision can be used as an alternative to the shaft skin retraction technique. The advantage of the new incision is that one can avoid suture lines on the penis and their accompanying complications.

A new surgical technique for lymphedema of the penis and scrotum.

All previous surgical procedures for correction of lymphedema of the penis and scrotum describe the formation of skin flaps or grafts which leave multiple suture lines on the penis. These suture lines are prone to serious problems. A safe and uncomplicated operation has been designed that avoids all suture lines on the penis and affords excellent cosmetic and functional results.

Multiple genitourinary abnormalities in females with unilateral renal agenesis: three cases.

We have the means to identify over 75% of infants and children with unilateral renal agenesis. It has been established that all patients with unilateral renal agenesis must be followed closely because of problems with the remaining kidney and other anomalies. It is apparent from embryologic studies and numerous reports that up to 89% of females with unilateral renal agenesis are likely to have significant accompanying genitourinary abnormalities. Most of these patients' genital problems occur at the time of puberty or pregnancy. Because of our experience with three teenage females who had unilateral renal agenesis and subsequent serious problems, we wish to advocate a prepubertal aggressive investigation.

Voiding cystourethrography in infants and children: a new technique.

A technique for voiding cystourethrography utilizing a small caliber (3.5 Fr.) catheter that is left in place during the entire examination is described and illustrated. Urethral pathology is not obscured. The contrast is infused under pressure applied with a blood administration set. Visualization of voiding can be achieved in all cases.

Surgical management of thirty-nine children with lymphedema.

Thirty-nine children underwent staged excisional surgery for lymphedema. The procedures are described in detail. All the children operated on have improved and have a more normal appearance. The decrease in attacks of cellulitis and lymphangitis is striking. The morbidity of this simple procedure is negligible. The operation is tedious, fatiguing, anatomically unexciting, and has a vague end-point. At this time, staged subcutaneous excision appears to be the procedure of choice in moderate to severe lymphedema in children regardless of etiology or classification. The procedure is not a cure.

Peroral removal of a sewing needle and attached thread from the esophagus in an infant.

The authors describe a simple Seldinger Catheter technique by which they removed a metallic sewing needle with attached thread from the esophagus of a 5 month old infant.

Chloride losing diarrhoea and metabolic alkalosis in an infant with cystic fibrosis.

A case of hypochloraemic metabolic alkalosis in an infant with chloride losing ileostomy drainage and cystic fibrosis is described. It is speculated that intestinal loss of chloride played a major role in the development of metabolic alkalosis.