Posterior urethral injuries associated with motorcycle accidents and pelvic trauma in adolescents: analysis of urethral lesions occurring prior to a bony fracture using a computerized finite-element model.

UNLABELLED: Adolescent males involved in motorcycle accidents are particularly at risk for pelvic injury, which may provoke a posterior urethral injury. The aim of this study was to develop a model to analyze the association between injuries and fractures of the pelvic ring and the risk of posterior urethral injury. METHOD: Based on experience with traffic accident modeling, a computerized finite-element model was extrapolated from a computerized tomography scan of a 15-year-old boy. The anatomic structures concerned in urethral and pelvic ring trauma were isolated, rendered in 3D and given biomechanical properties. The model was verified according to available experiments on pelvic ring trauma. RESULTS: To apply the model, we recreated three impact mechanisms on the pelvic ring: lateral impact, antero-posterior impact and a real car‒motorcycle accident situation (postero-lateral impact). In all three situations, stretching of the posterior urethra was identified prior to bony fracture visualization. CONCLUSION: Application of this model allowed us to analyze precisely the link between trauma of the pelvic ring and lesions of the posterior urethra. The results should help to establish guidelines for urethral catheterization in male adolescents in cases of pelvic trauma, even when no bony fracture is present, in order to prevent iatrogenic worsening of a misdiagnosed posterior urethral trauma.

Polymorphisms of MAMLD1 gene in hypospadias.

PURPOSE: Mastermind-like domain containing 1 (MAMLD1) is a causative gene for the fetal development of male external genitalia. Almost 10% of patients with both severe and non-severe hypospadias exhibit mutations of MAMLD1. The aim of this work was to determine whether polymorphisms of MAMLD1 are a genetic risk factor for hypospadias. MATERIAL AND METHODS: This study included 150 hypospadias with a range of severities and 150 controls. Direct sequencing of the MAMLD1 coding exons and their flanking splice sites was performed. In silico secondary and tertiary structure prediction and accessibility of changed amino acids were evaluated using JPred, Netsurf and PHYRE software. Functional studies of the transactivation of haplotypes on Hes3 promoter were performed in vitro using cDNAs of missense variants of MAMLD1. RESULTS: The p.P286S polymorphism was identified in 17/150 patients and 12/150 controls (11.3% vs. 8.0%, p = 0.32). The p.N589S polymorphism was identified in 22/150 patients and 12/150 controls (14.6% vs. 8.0%, p = 0.068). The double polymorphism (S-S haplotype) was present in 16/150 patients and 6/150 controls (10.6% vs. 4.0%, p = 0.044, OR = 2.87, CI from 1.09 to 7.55). The association of polymorphisms consistently revealed a modification in the structure prediction or amino acid accessibility in all three in silico models. The P286S, N589S and P286S + N589S proteins did not exhibit reduced transactivating activity on Hes3 promoter. CONCLUSION: Polymorphisms of MAMLD1 gene are frequent in patients with hypospadias. Although no change in transactivation was noted on Hes3 promoter, the in silico studies and the significantly increased incidence of the S-S haplotype in hypospadiac patients raise the hypothesis of a particular susceptibility conferred by these variants.

Transvesicoscopic Cohen ureteric reimplantation for vesicoureteral reflux in children: a single-centre 5-year experience.

PURPOSE: To evaluate our results with a new method of intravesical ureteric reimplantation using laparoscopic pneumovesicum in children. MATERIALS AND METHODS: Seventy-two patients (mean age 4.2 years, range 0.5-20 years) with primary vesicoureteral reflux (VUR) underwent a laparoscopic transtrigonal ureteric reimplantation with CO(2) pneumovesicum. Ports were inserted suprapubically - 5mm for the camera and two 3-5-mm working ports. Having mobilized the ureter(s) intravesically, a submucosal tunnel is created and ureteric reimplantation performed with 5/0 and 6/0 absorbable sutures. Bladder drainage was maintained for 2-3 days postoperatively. Patients were followed up with clinical assessment and renal ultrasonography+/-voiding cystourethrogram. RESULTS: Ninety percent had VUR grade > or =3. A total of 113 ureters were reimplanted. The mean operative time was 82min for unilateral and 130min for bilateral reimplantation. Four cases (6%) were converted. Three patients presented with temporary ureteric dilatation without symptoms on follow-up renal ultrasound. Seven patients had postoperative urinary tract infection without persistent reflux on cystography. Follow-up cystogram was performed in 50 patients (81 ureters). Reflux persisted in four patients (8%). CONCLUSIONS: Laparoscopic ureteric reimplantation with CO(2) pneumovesicum is technically feasible with a high success rate (92%). The role of this new technique in the treatment of VUR remains to be determined.

Retroperitoneoscopic vs open dismembered pyeloplasty for ureteropelvic junction obstruction in children.

PURPOSE: To compare the effectiveness, potential advantages and complications of classical open pyeloplasty with retroperitoneoscopic pyeloplasty in children. MATERIALS AND METHODS: Two patient cohorts with confirmed ureteropelvic junction obstruction (UPJO) undergoing open or retroperitoneoscopic pyeloplasty over a 7-year period were analysed comparatively. RESULTS: Operative time was significantly longer in the retroperitoneoscopic group (mean 155 min) compared to the open pyeloplasty group (mean 98 min, P<0.05). Mean hospital stay was shorter in the retroperitoneoscopic group (mean 4.1 days, compared to 5.1 days, open). Complication rates were similar (open, 27% vs retroperitoneoscopic, 29%). These included anastomotic urinary leakage, stenosis and infection. Anastomotic leakage was more common in the retroperitoneoscopic group. There was a 6.6% conversion rate in the retroperitoneoscopic group. Success, defined as improved ultrasonic or renographic parameters, with resolution of symptoms where discernable, was noted in 96% of the open group and 97% of the retroperitoneoscopic group with a mean follow up of 38 and 25 months, respectively. CONCLUSIONS: Retroperitoneoscopic pyeloplasty is as safe and effective as open pyeloplasty. This technique is now our procedure of choice for children>4 months old. The advantages are more obvious in children over 4 years than in infants. This technique remains difficult to perform and teach.

Minimally invasive urologic surgery in children: an overview of what can be done.

PURPOSE: Laparoscopy has emerged as a feasible and effective alternative for abdominal pathologies in children. Urological minimally invasive surgery is now commonly used for basic operations in most centres and is just beginning to expand its use in more complex operations in several selected centres around the world. We present the current state of the art of minimally invasive surgery in children. MATERIAL AND METHODS: We first reviewed all the urological pathologies treated with minimally invasive surgery in our institution. Secondly we reviewed the literature in order to highlight and discuss certain relevant articles and compare them with our own experience. RESULTS: Since beginning to use minimally invasive surgery at our institution we have operated more than 550 cases with urological pathologies. We used three approaches: the transperitoneal, the retroperitoneal and the transvesical approach. Our preferred indications for each approach are discussed. DISCUSSION: Non palpable testis, varicocele surgery, nephrectomy and adrenalectomy are, in our opinion, established minimally invasive procedures. Hemi-nephrectomy, pyeloplasty and Cohen antireflux surgery are probably excellent indications when minimally invasive surgery is carried out by expert hands. Stone management should not be forgotten in cases of contraindication or failure of ESWL. Even the most complex urological operations may be safely carried out using a minimally invasive approach, although most of the cases described are case reports. CONCLUSION: More papers are published on ablative or reconstructive urological minimally invasive surgery. Transperitoneal and retroperitoneal approaches are used with the same results. Transvesicoscopic surgery should rapidly grow to become a standard approach for Cohen reimplantation. It is anticipated that technical progress will provide the opportunity for more paediatric urologists to develop a minimally invasive approach.

Current indications for laparoscopy and retroperitoneoscopy in pediatric urology.

Laparoscopy has raised great interest in the past few years in the field of pediatric urology. It has evolved from a simple diagnostic maneuver to complex operative procedures. The aim of this study was to review urologic laparoscopy literature and provide a critical review of this field to establish current indications for videosurgery in pediatric urology. In general, from an anatomic point of view, retroperitoneoscopy seems to be more suitable than the transperitoneal laparoscopic approach for reaching the upper urinary tract. It also is less invasive and complies with the criteria for open renal surgery. With respect to current indications for videosurgery in pediatric urology, the authors have identified several well-established clinical procedures, although no large series have been published for any of the procedures, except for the treatment of varicocele, nonpalpable testis, and nephrectomy. In conclusion, the data reviewed suggest that videosurgery is a safe and feasible technique in pediatric urology if performed by expert surgeons, and that it certainly will develop further in the next few years.

[Conservative treatment of traumatic rupture of the biliary ducts: a case report]. / Traitement conservateur des ruptures traumatiques des voies biliaires: à propos d'un cas.

The diagnosis of a biliary duct transection after blunt trauma is difficult in children. Surgery is often performed late and therefore complicated. We present a case of mini-invasive approach for biliary duct transection in a 12-year-old child and review the literature. Transhepatic cholangiography is at the moment the most used technique to make the diagnosis but necessitates general anaesthesia. Stent placement is possible by the way. Endoscopic retrograde cholangiogram (ERCP) has been proposed even in children. Stent placement may be easier by this technique. For the diagnosis, Technetium 99m dimethylminodiacetic acid (HIDA) scanning seems interesting in terms of both sensitivity and specificity. Another promising diagnostic technique is MRI with 3D reconstruction.

Retroperitoneoscopic approach to the adrenal glands and retroperitoneal tumours in children: where do we stand?

Choosing the best way to approach adrenal gland and retroperitoneal tumours is still difficult. We reviewed our first 10 cases operated on by retroperitoneoscopy and compared this approach with other possible ways described in the literature. There were 2 intraoperative complications: 1 opening of the diaphragm and 1 bleeding. Tumour resection was always complete. There was no conversion. There were no postoperative complications. The retroperitoneoscopic approach for adrenalectomy and retroperitoneal tumour resection is increasingly being used. In children, operation is quite fast, without much blood loss and with spectacular postoperative recovery results. Even for the right side we advocate this approach, due to the particular anatomy (small tumour size, less fat, thinner muscle layers) in this age group. Trained surgeons are, of course, mandatory.

Long-term outcome of laparoscopic Nissen and Toupet fundoplication in normal and neurologically impaired children.

BACKGROUND: Laparoscopic fundoplication is a commonly performed procedure in children. This report describes the incidence of long-term recurrence and complications after laparoscopic Nissen or Toupet fundoplication in neurologically impaired and normal children. METHODS: Fifty-three children operated on before 1999 were reviewed. All children were evaluated clinically and with a barium meal study thereafter. Symptomatic children and those with abnormal barium meal underwent 24 h pH monitoring. RESULTS: A total of 45 patients were included in the study. The mean follow-up was 4.5 years. All, except one asymptomatic child that declined, had a barium meal. Four were abnormal (2 parahiatal hernias and 2 slight episodes of reflux). Four patients had symptoms related to the operation and 2 to clinical recurrence. Only 1 asymptomatic child with slight reflux at barium meal revealed abnormal 24 h pH monitoring. Finally, 6.6% patients were found to have late recurrence (2 clinical and 1 pHmetry). There was an obvious increase in children's weight, especially in neurologically impaired patients. CONCLUSION: Laparoscopic antireflux surgery is of value in children with gastroesophageal reflux disease. The long-term results are comparable with open surgery, and there was no difference in term of wrap failure between neurologically impaired and normal children.

Diaphragmatic duodenal atresia: laparoscopic repair.

Stenosis due to a diaphragm is a type of intrinsic duodenal obstruction in newborns and even in childhood, when obstruction is partial. We present a case of a 13-month-old girl with diaphragmatic stenosis associated with a dilated first and second duodenum. Surgical management consisted of a partial excision of the diaphragm after vertical incision of the anterior part of the second duodenum followed by a transverse suture. This diamond-shaped anastomosis was successfully carried out laparoscopically. No tapering of the duodenum was performed as some authors suggest in cases of megaduodenum. The rapid resumption of peristalsis and fewer adherences than expected after such a minimally invasive approach could make a more invasive procedure unnecessary. Only long-term follow-up and greater experience will show which procedure is most suitable.

[Two rare case reports of ureteral triplication]. / A propos de deux cas rares de triplication urétérale.

Triplication of the upper urinary tract is rare. It is classified according to its extent and four types have been documented. Since the first description of ureteral triplication by Wrany only about a hundred cases have been reported in the literature. Paediatric cases are very few and female patients seem more concerned. The embryological event resulting in ureteral triplication derives from multiple ureteral buds arising from the Wolffian duct with fissuring of one or more of them. We report on two cases of ureteral triplication. The first one associated with an extravesical ectopic ureter and a dysplasic kidney. Diagnosis was particularly difficult and treatment consisted of total nephrectomy. The second case was associated with an upper pole hydronephrosis and a partial nephrectomy was realized.

Is the appendix graft suitable for routine biliary surgery in children?

BACKGROUND/PURPOSE: The appendix graft (AG) is used widely for urinary tract replacement in children. Biliary tract replacement is less common. The purpose of this retrospective multicentric study was to evaluate the safety of appendix grafting for biliary reconstruction. METHODS: The files of 33 patients treated at 7 European pediatric centers were reviewed. Indications included choledochal cyst (CC) in 5 cases, biliary trauma (BT) in 1, and biliary atresia (BA) in 27. In CC and BT patients, the graft was inserted isoperistaltically between the proximal biliary duct and second duodenum. In all but one of the BA patients, the graft was placed antiperistaltically by patching its cecal end onto the porta hepatis. RESULTS: Postoperatively, all CC and BT patients initially became asymptomatic but developed laboratory evidence of anicteric cholestasis within 1 year. The most common manifestation was increased gamma-glutamyl-transpeptidase level (GGT), whereas histologic findings showed liver damage (mainly fibrosis). Reoperation has been carried out in 4 CC and 1 BT patients within a mean period of 19 months after appendix grafting. The graft procedure was converted to hepaticojejunostomy (HJ) in 4 and to choledocoduodenostomy in 1. Surgical exploration showed kinking in 1 patient and stenosis in 1. In the remaining 3 cases, there was no discernible cause of cholestasis, and appendix histology findings were normal. In all 5 reoperated patients, liver function findings returned to normal within 1 month. Reoperation is scheduled for the remaining CC patient who currently requires ursodesoxycholic medication to maintain normal liver function and presents histologic evidence of "de novo" sclerosing cholangitis. Results of appendix grafting also were poor in the 27 BA patients. Procedure-related perioperative complications occurred in 4 (15%) including 1 early death from graft necrosis. Another early death resulted from intestinal hemorrhage. Jaundice cleared in only 8 (28%). CONCLUSIONS: The findings of this study suggest that the AG is unsuitable for routine biliary repair in children. It should be used only as a salvage technique when conventional HJ repair is contraindicated. Because of the high risk of graft dysfunction, we recommend screening tests to detect biochemical or histologic cholestasis in any patient previously treated with appendix grafting.

[Solid and pseudopapillary tumor of the pancreas: immunohistochemical and ultrastructural study of 2 pediatric cases]. / Tumeur solide et pseudo-papillaire du pancréas : étude immunohistochimique et ultrastructurale de 2 observations pédiatriques.

We report 2 cases of solid and pseudopapillary tumors of the pancreas occurring in female children. Lesions were made of uniform small cells arranged in solid areas associated with pseudopapillary and cystic patterns. Immunohistochemistry study was positive for neuron-specific enolase, alpha-1 anti-trypsin and vimentin. Ultrastructural study showed an abundant cytoplasm, rich in mitochondria, containing a lot of granules of variable sizes, often disintegrated, and some lipid droplets. The differential diagnosis of this lesion included endocrine tumor, pancreatoblastoma and acinar cell carcinoma. It is a rare tumor of the pancreas with a favorable prognosis after complete resection.

[Urinary lithotripsy in children. Multicenter study of the Pediatric Urology Study Group]. / Lithotritie urinaire de l'enfant. Etude multicentrique du Groupe d'Etudes en Urologie Pédiatrique (GEUP).

The authors present the results of a survey conducted among French paediatric urologists belonging to the Groupe d'Etudes en Urologie Pédiatrique (GEUP) (Paediatric Urology Study Group). This study, based on 122 cases observed in 13 centres, is not exhaustive, but is nevertheless statistically significant. The preoperative assessment confirms the usual findings of urinary stones in children: pyelonephritis, haematuria and abdominal pain, the usual presenting complaint, concomitant malformative uropathy (10% of cases) and a predominance of calcium stones. More than 200 stones were treated, larger than 10 millimeters in diameter in one-third of cases. Renal stones, mainly caliceal (more than 50%), included 11 staghorn calculi. This study also included 22 ureteric stones, mainly in the pelvic ureter, and 2 bladder stones. Lithotripsy was ultrasound-guided in 2/3 of cases and required general anaesthesia in about 3/4 of cases. Ureteric catheterization was required in 19 infants preoperatively, but in only 2 infants (stein strasse) postoperatively. One or two lithotripsy sessions were sufficient in most cases, but 4 sessions were necessary in 5 patients, to the same kidney in 1 case. The mean hospital stay was 2 to 3 days, but the procedure was performed on an outpatient basis in 15 cases. The immediate postoperative course was uneventful and asymptomatic. This survey revealed about 10% of complete failures, corresponding to solitary caliceal stones in 2/3 of cases; 29 partial failures were essentially due to lower caliceal stones and staghorn calculi; 84 successes (stone-free), mainly pelvic or simple caliceal stones. Scintigraphy did not reveal any immediate postoperative impairment of renal function. This study reported a success rate of about 70%, regardless of the type of apparatus used. Assessment of the results of ESWL requires sufficient follow-up both concerning the outcome of fragmented stones and evaluation of possible functional repercussions. This survey defines the main indications: although ESWL can be applied to most stones, some stones constitute poor indications (cystine stones, stenotic malformative uropathy) or dubious indications: small lower caliceal stones, densely calcified staghorn calculi in older children. This study confirmed the efficacy and low morbidity of ESWL in children. A prospective study needs to be conducted according to a rigorous protocol in order to refine the technique and indications while reducing the possible long-term risks.

[Mini-invasive surgery of the retroperitoneal space in children]. / Chirurgie mini-invasive de l'espace rétropéritonéal chez l'enfant.

UNLABELLED: Although laparoscopic surgery now represents today an essential surgical technique, its use remains limited in urology and especially in pediatric urology for many reasons, main because of the lack of indications. After a large experience acquired in abdominal laparoscopic surgery, and because we were convinced of the advantages offered by this new mini-invasive approach, we have tried to develop it for the retroperitoneal space. METHODS: Over a five-year period we performed 88 retroperitoneal procedures in children:--50 nephrectomies (44 total, 10 partial) for the following indications: 15 polycystic dysplastic kidney, 13 kidney destroyed by reflux, 18 by obstruction, hypertensive uropathy 3, pyonephrosis 1.--5 renal cystectomies, 3 pyelolithotomies, 2 pyeloureteral obstructions, 2 adrenalectomies, 1 retrocaval ureter, 25 varicoceles. The age range was 2 months to 16 years (mean: 3.7 years, 25 children under 1 year). The patients were placed in the lateral debubitus. The retroperitoneal space was created by dissection under direct vision, then insufflation was performed directly in the retroperitoneal space without balloon. Three or four ports were used except for varicocelectomy which was performed with only one port and an operating channel telescope. RESULTS: Follow-up range was 6 months to 5 years. The mean operating time was 96 minutes (35 to 210 min.). Average postoperative stay was 2 days. Conversion was needed in 7 cases (8%). Operative incidents consisted of one duodenal perforation, one ureteral burn, 21 peritoneal perforations (24%). There were 5 postoperative complications (2 urinomas after partial nephrectomy, 1 hydrocele, 1 varicocele recurrence, 1 recurrent stones) not related to the technique. 3 cases needed reoperation (ureteral injury, varicocele recurrence, recurrence of cystine stones) with good result. CONCLUSION: Like other laparoscopic techniques, retroperitoneoscopy requires a training: it remains delicate in children because of the reduced working space and the fragility of the peritoneum. However the advantages seem sufficiently obvious for us to recommend and promote this procedure.

[Benign testicular tumors in children. Value of simple tumorectomy]. / Tumeurs bénignes du testis chez l'enfant. Intérêt de la tumorectomie simple.

From 1984 to 1999, the authors observed 18 intratesticular tumours, 13 of which corresponded to benign lesions. The objective of this study is to define preoperative and intraoperative criteria of benign lesions in order to allow conservative management (simple excision or enucleation) and to analyse the results of this treatment. The 13 boys of this series were between the ages of 5 months and 14 years (mean: 7.1 years). The lesion presented as scrotal swelling in 12 cases and gynaecomastia in 1 case. Tumour markers (alphafoetoprotein, beta HCG) were at the limit of normal for age. Ultrasonography was performed in every case. In each case, treatment consisted of primary exposure of the pediclc with clamping then exteriorization and macroscopic examination of the lesion. Frozen section examination was performed in 11 cases. Treatment consisted of 9 enucleations and 4 orchidectomies. The final histology concluded on epidermoid cyst or simplified teratoma with exclusively ectodermal development in 4 cases, multi-differentiated teratoma in 2 cases, sex cord tumour in 2 cases, simple cyst in 2 cases, rete testis dysplasia in 1 case, cavernous haemangioma in 1 case, and vestigial cyst in 1 case. There was no discordance between the final histological examination and the frozen section examination. The mean follow-up is 4.4 years. No secondary atrophy and no local or distant recurrence was observed in the 9 cases of enucleation. In conclusion, testicular tumours are often benign in children. Selection based on a body of clinical, laboratory, radiological and frozen section histological evidence should allow carcinologically safe conservative surgery with an aesthetic, psychological and functional benefit for the child.

Laparoscopic appendectomy in children: sense or nonsense?

The authors present a retrospective analysis of their first 1.500 paediatric laparoscopic appendectomies. Three types of techniques (OUT, MIXED, IN) are described. The average age of the patients was 8 years (range: 2 to 16 years). In case of acute appendicitis the postoperative complication rate was 0.6%. In case of peritonitis the postoperative complication rate raised to 13.3%. Conversion rate was 3.3%. There were no death. Mean hospital stay was 1.8 days for acute appendicitis and 6.5 days for peritonitis. Laparoscopic appendectomy in children has an unquestionable diagnostic interest, decreases the parietal complications and has a better cosmetic result in case of peritonitis or ectopic appendicitis. Benefits are highest in case of peritonitis by decreasing postoperative pain and length of hospital stay. The teaching value for learning laparoscopic surgeons is obvious. Increase of intraperitoneal residual abscesses, as well as increasing cost, remain controversial. This series is a plea for laparoscopic appendectomy in children.