A combined approach of robot-assisted laparoscopic pyeloplasty and flexible endoscopy to treat concomitant ureteropelvic junction obstruction and calyceal stones in children: Technical considerations and review of the literature.

The management of children with concomitant ureteropelvic junction (UPJ) obstruction and calyceal stones remains challenging. The various treatment options available for pediatric nephrolithiasis may require multiple sessions, and the techniques by themselves are not designed for simultaneous correction of UPJ obstruction. Recently, success in combining robot-assisted laparoscopic pyeloplasty (RALP) and flexible endoscopy has been reported by multi-institutional studies to treat children with concomitant UPJ obstruction and renal stones. Given the paucity of technical details of this novel approach in the existing literature, we herein report our techniques to treat two girls aged 6 and 10 years who had concomitant UPJ obstruction and multiple stones in mid- and lower poles calyces. Three robotic ports were used without any assistant ports. A flexible endoscope, either a cystoscope or a single-use ureteroscope, was introduced via the undocked epigastric port to perform nephroscopy and stones removal after the renal pelvis was opened. The rest of the RALP was completed in the usual manner. Technical modifications were employed to facilitate the flexible endoscope to examine the entire calyceal system. Both patients underwent successful surgical procedures by the combined approach without any intra- or post-operative complications. Three and 14 stones were removed from each of the patients respectively. Postoperative investigations demonstrated successful correction of UPJ obstruction and complete stone clearance in both patients. A combined approach of RALP and flexible endoscopy is a safe and effective technique to treat concurrent UPJ obstruction and calyceal stones in children.

Surgery in Chinese children affected by 45,X/46,XY disorders of sex development: A 20-year experience in a single center.

BACKGROUND: Children affected by 45,X/46,XY mosaicism have a wide spectrum in their phenotypes. Although surgery has a role in management, there is no universally agreed strategy. METHODS: We conducted a retrospective review in a tertiary center on the surgical management and its long-term outcomes in children with the karyotype 45,X/46,XY or its variants over a 20-year study period. Patients were divided into 4 groups based on their phenotypes. RESULTS: 22 children(female=13, male=9) were included in the study, and were grouped as I)female phenotype(n = 11), II)ambiguous external genitalia(n = 2), III)undervirilized male with hypospadias(n = 6), and IV)normal male phenotype(n = 3). 19/22(86%) underwent gonadal surgeries(bilateral gonadectomy=15; unilateral gonadectomy=1; testicular biopsy=3) and  8/22(36%) underwent genitalia reconstructive surgeries(hypospadias repair=6; feminizing surgery=2). Gonadal germ cell tumors were detected in 55%, 50% and 50% of Group I, II and III respectively. 3/6 patients required reoperations for complications after hypospadias repairs. None of the patients had recurrence of germ cell tumors after gonadectomy. All the patients who had reached late adolescence or adulthood maintained their genders as their sex of rearing. CONCLUSIONS: Majority of 45,X/46,XY children benefit from timely gonadal surgery while genitalia reconstructive surgery can be considered in selected patients. Surgical management can be strategized by patients' phenotypes.

Tubular Dysfunction and Ruptured Ureter in a Child with Menkes Syndrome.

Children with Menkes disease may develop various urological and renal problems that evolve as the disease progresses. A 4-year-old boy with Menkes disease had multiple bladder diverticula and a history of recurrent urinary tract infection caused by urea-splitting organisms. The child developed urosepsis and right pyelonephritis. Subsequent investigations revealed multiple right renal stones and a ruptured right ureter. The child also developed hypokalemia, hypophosphatemia, and normal anion gap metabolic acidosis that required electrolyte and potassium citrate supplement. Further assessment revealed renal tubular dysfunction. Our case suggests that regular imaging surveillance, monitoring of renal function and electrolyte profile, and tubular function assessment should be considered in children with Menkes disease.

Comparing Robot-Assisted Laparoscopic Pyeloplasty vs. Laparoscopic Pyeloplasty in Infants Aged 12 Months or Less.

Objective: To investigate the outcomes of minimally invasive approach to infants with ureteropelvic junction (UPJ) obstruction by comparing the two surgical modalities of robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP). Methods: We conducted a retrospective review of all consecutive infants aged ≤12 months who underwent either LP or RALP in a single institution over the period of 2008-Jul 2020. We included primary pyeloplasty cases that were performed by or under the supervision of the same surgeon. Results: Forty-six infants (LP = 22; RALP = 24) were included with medians of age and body weight at 6 months (2-12months) and 8.0 kg (5.4-10 kg), respectively. There was no difference between the two groups in the patients' demographics and pre-operative characteristics. All infants underwent LP or RALP successfully without conversion to open surgery. None had intraoperative complications. Operative time (OT) was 242 min (SD = 59) in LP, compared with 225 min (SD = 39) of RALP (p = 0.25). Linear regression analysis showed a significant trend of decrease in OT with increasing case experience of RALP(p = 0.005). No difference was noted in the post-operative analgesic requirement. RALP was associated with a shorter hospital length of stay than LP (3 vs. 3.8 days; p = 0.009). 4/22(18%) LP and 3/24(13%) RALP developed post-operative complications (p = 0.59), mostly minor and stent-related. The success rates were 20/22 (91%) in LP and 23/24 (96%) in RALP (p = 0.49). Conclusions: Pyeloplasty by minimally invasive approach is safe and effective in the infant population. RALP may have superiority over LP in infants with its faster recovery and a more manageable learning curve to acquire the skills.

A standardized technique of laparoscopic placement of peritoneal dialysis catheter with omentectomy and closure of patent processus vaginalis: A 3-in-1 minimally invasive surgical approach in children.

BACKGROUND: Omental wrapping is a common cause for catheter failure in children on peritoneal dialysis (PD). Previous studies are conflicting in the benefits of omentectomy. METHODS: We conducted a retrospective study comparing children who underwent PD catheter placement by a standardized laparoscopic three-in-one technique (lap3-in-1) from 2013 to 2018 versus a historical control cohort by open surgery without omentectomy. Lap3-in-1technique combined catheter placement with well-defined indication and extent of omentectomy, and closure of any patent processus vaginalis (PPV). RESULTS: There were 33 and 32 children in the lap3-in-1 and control cohorts respectively. 4/33(12.1%) in lap3-in-1 had reoperations for catheter failures which equated 1 reoperation per 144 catheter months. No reoperations were performed in lap3-in-1 cohort for omental wrapping or inguinal hernia, compared with 13/32 (41%; p < 0.001) and 5/32 (16%; p = 0.02) in the control cohort. Kaplan Meier survival curves showed significantly longer catheter life in the lap3-in-1 cohort (p < 0.001). In multivariate analysis by the COX proportional hazards model, the lap3-in-1 approach had significantly reduced risk of reoperation for catheter failure (HR 0.11; 95% CI: 0.04-0.31; p < 0.001). CONCLUSIONS: The lap3-in-1 technique is effective in selecting those children who would benefit from omentectomy, and avoiding a second operation for inguinal hernia which develops after PD. LEVEL OF EVIDENCE: Treatment study, level III.

The Hypospadias Phenotype With A Distal Meatus In The Presence Of Distal Penile Penoscrotal Angle Fixation.

OBJECTIVE: Hypospadias patients may present with the phenotype that features the migration of scrotum to distal penile shaft below a coronal/subcoronal meatus. Patients with this phenotype differ widely in the severity of the hypospadias and the complexity of the surgical repair. We aimed to investigate the operative findings and the outcomes of consecutive patients who presented with this phenotype. METHODS: We retrospectively reviewed the medical charts of 31 consecutive patients who underwent hypospadias repairs from January 2014 to May 2017, and the hypospadias was characterized by i) the external urethral meatus at coronal/subcoronal region, ii) scrotal skin encroaching distally resulting in fixation of penoscrotal angle at distal penile shaft, and iii) urethral plate below the glans on penile shaft invisible or barely visible. RESULTS: The median age at the time of surgery was 15.5 months (10-63). The division of corpus spongiosum was noted at distal penile shaft (n=2; 6.5%), mid-shaft (n=5; 16.1%) and proximal location (n=24; 77.4%). The median ventral curvature before degloving was 45 degrees (10-90). Twenty-eight and 3 patients underwent tubularized incised plate and 2-stage preputial flap repairs, respectively. Twenty-nine of 31 patients required cutback of the hypoplastic urethra. At the time of urethroplasty, 2 (6.5%), 7 (22.6%) and 22(70.9%) patients underwent distal, mid-shaft and proximal repairs, respectively. At a median follow-up of 30 months (14-50), 6 (19.4%) patients developed one or more complications (fistula=3; meatal stenosis=5). CONCLUSION: Patients affected by this particular phenotype likely require non-distal hypospadias repair with possibly higher complication rate and should be treated by surgeons with expertise in complex hypospadias repair.

Magnetic Foreign Body Ingestion in Children: The Attractive Hazards.

Foreign body ingestions are frequent in the childhood population. Most foreign bodies are passed spontaneously through the gastrointestinal tract. However, on occasion, they can also be a rare cause of morbidity and even mortality, such as in the case of multiple magnetic foreign body ingestion, which can cause injury via magnetic attraction through bowel walls. We present two cases of multiple magnetic foreign body ingestion, which to our knowledge are the first ones reported in Hong Kong. One patient presented with shock and intestinal necrosis requiring extensive intestinal resection, whereas the other patient had no gastrointestinal injury but surgical removal was deemed necessary.

Incidence and diagnoses of disorders of sex development in proximal hypospadias.

BACKGROUND: Evidence-based guidelines on evaluation of boys with proximal hypospadias for the possibility of a disorder of sex development (DSD) have yet to be developed. We aimed to investigate the incidence and diagnoses of DSD in patients with proximal hypospadias. METHODS: We retrospectively reviewed the records of consecutive boys who underwent proximal hypospadias repairs from 2006 to Sept 2017. Data collected included scrotal anomaly, testes position/palpability, micropenis, DSD investigations, and surgical techniques. RESULTS: 165 patients were eligible for the study. 14 (8.5%) were diagnosed to have DSD. The diagnoses were 46,XX testicular DSD [n = 1], 46,XY DSD [n = 7; partial gonadal dysgenesis (PGD) = 3; 5α-reductase type 2 deficiency = 3; 17α-hydroxylase deficiency = 1], Sex Chromosome DSD [n = 6; 45,X/46,XY PGD = 4; Klinefelter = 2]. 3/7 (43%) patients with PGD had gonadal germ cell neoplasms. Of the DSD patients, 6/14 (43%), 11/14 (79%) and 11/14 (79%) had undescended/impalpable testes, micropenis and penoscrotal transposition/bifid scrotum, respectively, significantly higher prevalence rates than those without DSD diagnosis (p-values <0.05). 10/14 (71.4%) DSD patients underwent 2-stage repair compared with 57/151 (37.7%) of others without DSD diagnosis (p = 0.01). CONCLUSIONS: Patients presenting with proximal hypospadias and one or more of the coexisting anomalies of micropenis, undescended/impalpable testes, and penoscrotal transposition/bifid scrotum should warrant DSD evaluation. Presence of bilaterally descended testes in scrotum does not preclude the possibility of DSD. LEVEL OF EVIDENCE: IV.

From Laparoscopic Pyeloplasty to Robot-Assisted Laparoscopic Pyeloplasty in Primary and Reoperative Repairs for Ureteropelvic Junction Obstruction in Children.

PURPOSE: Robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP) are both minimally invasive surgical options to correct ureteropelvic junction obstruction in children. There are limited data reporting surgeons' experience of switching from LP to RALP and comparing the outcomes of the two procedures. METHODS: We conducted a retrospective study on 63 consecutive children who underwent either LP or RALP by the same surgeon in a tertiary center from January 2008 to November 2016. LP had been the standard practice until January 2014 when it was replaced by RALP in short transition. RESULTS: Thirty-seven LP and 26 RALP were successfully performed in children aged 2 months to 16 years. There was no difference between the two groups in age, body weight, laterality, clinical presentations, preoperative imagings, primary/reoperative repairs. The overall success rates were 34/37 (91.9%) and 25/26 (96.2%) for LP and RALP, respectively (P > .05). RALP was associated with shorter length of stay (3.1 days versus 4.0 days; P = .03). Surgeon-in-training participation was greater in RALP group (P < .001). There was no difference in operative time, complication rates, and analgesic requirement between the two groups. CONCLUSIONS: Surgeons proficient in LP can adapt quickly to RALP, achieving comparable outcomes. Robotic technology may facilitate training on minimally invasive pyeloplasty.

Early Reoperations after Primary Repair of Jejunoileal Atresia in Newborns.

Aim: To review nine-year experience in managing jejuno-ileal atresia (JIA) by primary resection and anastomosis and identify factors associated with reoperations. Methods: From April 2006 to May 2015, all consecutive neonates who underwent bowel resection and primary anastomosis for JIA were analyzed retrospectively. Patients with temporary enterostomy were excluded. Patient demographics, types of atresia, surgical techniques, need for reoperations, and long-term outcomes were investigated. Results: A total of forty-three neonates were included, in which nineteen (44.2%) of them were preterm and fourteen (32.6%) were of low birth weight. Thirteen patients (30.2%) had jejunal atresia whereas thirty patients (69.8%) had ileal atresia. Volvulus, intussusception and meconium peritonitis were noted in 12, 8, and13 patients, respectively. Eight patients (18.6%) had short bowel syndrome after operation. Ten patients (23.3%) required reoperations from 18 days to 4 months after the initial surgery due to anastomotic stricture (n=1), adhesive intestinal obstruction (n=1), small bowel perforation (n=2) and functional obstruction (n=6). Prematurity and low birth weight were associated with functional obstruction leading to reoperation (p=0.04 and 0.01 respectively). The overall long-term survival was 97.7%. All surviving patients achieved enteral autonomy and catch-up growth at a median follow-up of 4.7 years. Conclusion: Long-term survival of JIA after primary resection and anastomosis are excellent. However, patients have substantial risk of early reoperations to tackle intraabdominal complications.

Improved outcomes after technical modifications in tubularized incised plate urethroplasty for mid-shaft and proximal hypospadias.

PURPOSE: To investigate and compare the outcomes after tubularized incised plate (TIP) urethroplasty in mid-shaft and proximal hypospadias using a standard and a modified technique. METHODS: We conducted a retrospective study in 104 consecutive children who underwent mid-shaft or proximal TIP repairs from Jan 2007 to Sept 2015. Patients in Cohort One had dorsal dartos (DD) neourethral coverage while patients in Cohort Two had either de-epithelialized split preputial (DESP) or tunica vaginalis (TV) flap coverage. TV flap was used only when DESP flap was not sufficient to cover the neourethra. RESULTS: There were 52 patients each in Cohort One (DD, n = 52) and Cohort Two (DESP, n = 38; TV, n = 14) with no difference in ratio of mid-shaft/proximal between the two cohorts. At a median follow-up of 28 months, 36 patients (34.6 %) developed 47 complications including fistula (n = 19; 18.3 %) and neourethral dehiscence (n = 4; 3.8 %). Cohort One patients had significantly more fistula (28.8 vs 7.7 %; p = 0.005) and neourethral dehiscence (7.7 vs 0 %; p = 0.04) than Cohort Two. There was no difference between the two cohorts in the complication rates of meatal stenosis, recurrent ventral curvature and neourethral stricture. CONCLUSIONS: Both DESP and TV flap appear to be superior to DD in preventing fistula and neourethral dehiscence in non-distal TIP repairs.

Tumor risk of children with 45,X/46,XY gonadal dysgenesis in relation to their clinical presentations: Further insights into the gonadal management.

OBJECTIVE: To investigate the risk of gonadal germ cell neoplasms (GCN) in children with 45,X/46,XY gonadal dysgenesis and its relation to the clinical presentations. METHODS: We conducted a retrospective study reviewing the clinical and gonadal features of all consecutive children with 45,X/46,XY gonadal dysgenesis who received gonadal management in a tertiary center from 1985 to 2015. Study subjects were divided into Group I(significant genitalia anomaly), Group II(female phenotype) and Group III(male phenotype). RESULTS: 21 children were studied (Group I=8; Group II=11; Group III=2). All 19 children of Group I and II eventually underwent bilateral gonadectomy. One patient of Group III underwent gonadal biopsy which showed increase in fibrous tissue in the testes without any GCN. 3/8(37.5%) and 6/11(54.5%) of patients in Group I and II respectively had either gonadoblastoma (GB) or carcinoma-in-situ (CIS) or both affecting one or both gonads. Among Group I patients, the 4 dysgenetic testes affected by CIS in 3 patients were intraabdominal (n=1), inguinal (n=1) and scrotal (n=2) in positions. Among Group II patients, 6/20 streak gonads had GB and 2/2 dysgenetic testes had GB or CIS. CONCLUSIONS: 45,X/46,XY children with significant genitalia anomaly or female phenotype are both at high risk of gonadal GCN.

A case report of laparoscopic ipsilateral ureteroureterostomy in children with renal duplex.

We report on two children aged 2 and 6 years, who underwent laparoscopic ipsilateral ureteroureterostomy for their renal duplex anomalies. Both patients had complete duplex and were investigated by ultrasound, micturating cystourethrogram, magnetic resonance urography, and radioisotope scan. One patient had high-grade vesicoureteral reflux to lower moiety complicated with recurrent urinary tract infections, while the other had obstruction to upper moiety due to ectopic ureter. The pathological moieties of both patients were functional. Both patients underwent laparoscopic ipsilateral ureteroureterostomy uneventfully without any intraoperative complications. Postoperative imagings confirmed successful outcomes after surgery.

One-stop clinic for ketamine-associated uropathy: report on service delivery model, patients' characteristics and non-invasive investigations at baseline by a cross-sectional study in a prospective cohort of 318 teenagers and young adults.

OBJECTIVE: To describe a service delivery model and report the baseline characteristics of patients investigated by a non-invasive approach for ketamine-associated uropathy. PATIENTS AND METHODS: This was a cross-sectional study in a prospective cohort of patients who attended their first visit and underwent non-invasive investigations at a dedicated centre to treat ketamine-associated uropathy in Hong Kong from December 2011 to July 2013. Data on demographics, illicit ketamine use, symptoms scores and voiding function parameters at baseline were prospectively collected. Differences between active abusers and ex-abusers, and risk factors for the most symptomatic group were investigated by univariate and multivariate analysis. RESULTS: In all, 318 patients completed the non-invasive assessment at their first visit and were eligible for inclusion. In all, 174 were female and the mean (sd) age of the entire cohort was 24.4 (3.1) years. Patients had used ketamine for a mean (sd) period of 81 (36) months. The mean (sd) ketamine use per week was 18.5 (15.8) g. In all, 214 patients were active abusers while 104 were ex-abusers but had persistent lower urinary tract symptoms. The mean (sd) voided volume, bladder capacity, and bladder emptying efficiency were 111.5 (110) mL, 152.5 (126) mL and 73.3 (26.9)%, respectively. The ex-abusers had a lower symptom score (19.3 vs 24.1; P < 0.001), a larger voided volume (126 vs 85 mL; P < 0.001), and a larger bladder capacity (204.8 vs 126.7 mL; P < 0.001) compared with active abusers. Multivariate analysis found female gender was associated with a higher symptom score (odds ratio [OR] 2.39; 95% confidence interval [CI] 1.35-4.23; P = 0.003) and a smaller voided volume (OR 1.9; 95% CI 1.1-3.3; P = 0.02). Ketamine taken (g/week) was another risk factor for a higher symptom score (OR 1.03; 95% CI 1.01-1.05; P = 0.002). Status of ex-abuser was the only protective factor associated with fewer symptoms, larger voided volume and bladder capacity. CONCLUSIONS: An effective service model for recruiting patients with ketamine-associated uropathy is possible. With such a service model as a platform, further prospective studies are warranted to investigate the appropriate choice of treatment for this new clinical entity.

Single-incision laparoscopic surgery in diagnosis and treatment for gastrointestinal bleeding of obscure origin in children.

In this multimedia manuscript with video presentation, we reported our experience of performing single-incision laparoscopic surgery (SILS) on 3 children who presented with gastrointestinal bleeding from congenital small bowel lesions. Preoperative investigations including endoscopy and technetium scintigraphy were all negative in the 3 patients aged 4, 7, and 10 years, respectively. SILS was performed using reusable 3- and 5-mm ports and standard straight instruments. The small bowel lesions were located by SILS and the bowel segment with the pathology was exteriorized through the umbilical wound for extracorporeal resection. The diagnoses of the 3 children were Meckel's diverticulum, ileal duplication cyst, and multiple small bowel vascular malformations. All the 3 children recovered uneventfully from surgery without any complications and required minimal postoperative analgesia. Our experience suggested that SILS is an effective alternative to conventional laparoscopy in both diagnostic and therapeutic functions for children with gastrointestinal bleeding of obscure origin.

Laparoendoscopic single-site nephrectomy and heminephroureterectomy in children using standard laparoscopic setup versus conventional laparoscopy.

OBJECTIVE: To investigate the safety and effectiveness of laparoendoscopic single-site surgery (LESS) using standard laparoscopic setup in pediatric nephrectomy/heminephroureterectomy (HN) by comparing with conventional laparoscopy (CL). METHODS: Twelve consecutive children who underwent LESS (nephrectomy = 8, HN = 4) from 2009 to 2012 were compared with a matched cohort of 18 children who underwent CL (nephrectomy = 12, HN = 6) at the same institution. Data were reviewed retrospectively. RESULTS: There was no difference between the 2 groups in the age of patients, body weight, gender distribution, laterality of pathology, postoperative analgesic requirement, and hospital stay. Eleven of the 12 children in the LESS group underwent the procedure successfully without additional trocar placement. The only open conversion happened in the case of LESS of the lower moiety HN. LESS nephrectomy took longer operative time than CL (mean 156 +/- 45 vs 99 +/- 35 minutes, median 155 vs 90 minutes, P <.01). Wound infection occurred in 1 patient after CL nephrectomy. No postoperative complication or access site hernia was noted in the children in the LESS group at follow-up. CONCLUSION: LESS nephrectomy and HN in the pediatric population is safe and effective with a minimally invasive nature comparable to CL. Learning curve factors may contribute to the reported longer operative time in LESS. Further studies are required to investigate the implication of patient selection and the cosmetic benefits of LESS, which may potentially require longer operative time.

Simple maneuvers to reduce the incidence of false-negative findings for contralateral patent processus vaginalis during laparoscopic hernia repair in children: a comparative study between 2 cohorts.

BACKGROUND: Transumbilical or transinguinal laparoscopic evaluation for contralateral patent processus vaginalis (CPPV) is commonly performed during laparoscopic or open hernia repair in children but may occasionally give false-negative findings. METHODS: A retrospective study was conducted to compare 2 cohorts of children who underwent laparoscopic repair for clinically demonstrated unilateral inguinal hernia and evaluation for CPPV by transumbilical laparoscopy during the study periods of 2004 to 2007 (cohort 1) and 2008 to 2011 (cohort 2). Cohort 1 was a known historical cohort with CPPV being evaluated by laparoscopic inspection alone, whereas additional maneuvers were adopted in cohort 2. RESULTS: There were 395 and 564 patients in cohorts 1 and 2, respectively. There was no difference between the 2 cohorts in age of patients, sex distribution, laterality of clinically demonstrated inguinal hernia, and follow-up period at the time of data collection. More CPPV were diagnosed in cohort 2 than cohort 1(36.2% vs 25.8%; P < .01). 4 children (1.4%) developed metachronous inguinal hernia following negative laparoscopic evaluation for CPPV in cohort 1 compared with none from cohort 2 at a similar median follow-up period (P < .05). CONCLUSIONS: The additional maneuvers appear to be superior to laparoscopic inspection alone to evaluate CPPV during laparoscopic hernia repair in children.

Unexpected metachronous hernia development in children following laparoscopic unilateral hernia repair with negative evaluation for contralateral patent processus vaginalis.

BACKGROUND: Metachronous hernia has been reported to develop unexpectedly in children after negative evaluation for contralateral patent processus vaginalis (CPPV) by transinguinal laparoscopy. Scarce data exist regarding such phenomena following laparoscopic unilateral hernia repair and negative findings for CPPV in transumbilical laparoscopy. PATIENTS AND METHODS: A retrospective study was performed to investigate metachronous hernia development in a cohort of consecutive children who had undergone laparoscopic unilateral hernia repair with negative findings of CPPV by transumbilical laparoscopy 5 or more years ago. RESULTS: Study subjects included 293 children 1 month to 15 years old at the time of laparoscopic unilateral hernia repair (left, n=116; right, n=177). There were 246 boys and 47 girls. Nine children (3.1%), all boys, developed metachronous hernia at a median of 24 months (range, 6-42 months) from the time of negative laparoscopic evaluation for CPPV. There was no statistical difference between the genders and laterality of the initial hernia in the development of metachronous hernia. CONCLUSIONS: False-negative CPPV evaluation by transumbilical laparoscopy during laparoscopic unilateral hernia repair can occur and result in unexpected metachronous hernia development. Further prospective studies are warranted to develop effective maneuvers in addition to inspection alone to reduce false-negative laparoscopic assessment.

Oophorectomy in children. Who and why: 13-year experience in a single centre.

AIM: Oophorectomy performed in children is extremely uncommon. We aimed to investigate the disease pattern and the association between the underlying pathology and the clinical presentation among those patients who had their ovaries removed in their childhood. METHODS: A retrospective study was performed on 41 consecutive children who underwent oophorectomy in a tertiary referral centre in the period between June 1995 and May 2008. RESULTS: The median age was 11 years, ranged from 11 weeks to 15 years at the time of surgery. The primary presentations were acute lower abdominal pain (n= 20), progressive abdominal distension or abdominal mass (n= 13), chronic abdominal pain (n= 3), irregular menses (n= 1), antenatal diagnosis (n= 3) and incidental finding (n= 1). Ultrasound examination was performed in 31 patients and positive findings of ovarian pathology were found in all but one examination. Twenty cases of ovarian torsion were confirmed intra-operatively. Patients presenting with acute abdominal pain were more likely to have torsion than other presentations (P < 0.01). Non-neoplastic conditions and ovarian neoplasms were found in 11 and 30 patients, respectively. The most common neoplasm was mature teratoma (52%). Malignant neoplasms included immature teratoma (n= 3), dysgerminoma (n= 1), mixed dysgerminoma + yolk sac tumour (n= 2), yolk sac tumour (n= 2) and juvenile granulose cell tumour (n= 1). Malignant neoplasms were found to have more chronic presentation and less torsion than benign pathologies (P < 0.05). CONCLUSION: Although ovarian pathology is uncommon in children, a girl presenting with acute lower abdominal pain or progressive abdominal distension should raise the suspicion and prompt immediate investigation to rule out ovarian torsion or ovarian neoplasms.