Techniques of staged laparoscopic orchidopexy for high intra-abdominal testes in children: A systematic review and meta-analysis.

Background: Laparoscopic exploration is currently considered the gold standard for managing nonpalpable intraabdominal testes. The problem of short vascular pedicle is addressed in Fowler-Stephen (FS) technique by the division of testicular vessels and in Shehata technique (ST) by traction on testicular vessels. There is a lack of the consensus among pediatric surgeons on the choice of one technique over other. This analysis compares the reported outcomes of staged laparoscopic orchidopexy by ST with the time tested FS technique in managing high intraabdominal undescended testis. Materials and Methods: The present systematic review and meta-analysis was conducted as per the preferred reporting items for the systematic review and meta-analyses guidelines. Only randomized controlled trials and comparative studies were included. The primary outcomes compared were the incidence of testicular atrophy, testicular retraction/ascent rate, and operative time of Stage I and Stage II orchidopexy. Results: The present analysis was based on three randomized studies with a total of 119 undescended testes in 117 patients satisfying the inclusion criteria. The operative time was less in Stage I FS technique; however, there was no statistically significant difference in operative time of both procedures during the Stage II laparoscopic orchidopexy. Pooled analysis of postintervention testicular atrophy, testicular retraction rate, and duration of postoperative hospitalization showed no difference between both procedures. Conclusion: Both FS and STs are comparable in terms of postintervention testicular atrophy, testicular retraction/ascent; however, the mean operative time is significantly less with FS technique in Stage I laparoscopic orchidopexy.

The Management of Perineal Trauma in Children.

Aims: This study aimed to evaluate the outcome of perineal trauma in children and to a define protocol for their management. Methods: It is a retrospective study of children who presented with perineal injury between August 2012 and December 2020. The patients were classified into three groups: Group-1 included children with perineal and genitourinary injuries; Group-2 included patients with perineal and anorectal injuries; and Group-3 included patients with perineal, genitourinary, and anorectal injuries. All patients underwent primary repair. Those with full-thickness anorectal injury underwent an additional covering colostomy, while urethral disruption was initially managed by a diverting suprapubic cystostomy (SPC). Results: A total of 41 patients were studied. Impalement injury (n = 11; 27%) and sexual abuse (n = 11; 27%) were the most common mechanisms of injury. Twenty (49%) patients had anorectal injuries with 10 (24%) each of partial-thickness and full-thickness injury. There were 24 (59%) genital injuries and five (12%) urethral injuries. One patient each developed anal and vaginal stenosis, both were managed with dilatation. One patient developed a rectovaginal fistula repaired surgically at a later date. Conclusion: Perineal injuries with resultant anorectal or genital damage require a careful primary survey. Following stabilization, an examination under anesthesia as a set protocol will help determine the treatment strategy. A colostomy is essential in the acute management of severe anorectal injuries to reduce local complications and preserve continence. Urethral injuries may warrant an initial diverting SPC in selected cases.

Transureteroureterostomy in children: a retrospective study.

Transureteroureterostomy (TUU) is a urinary reconstructive procedure seldom used but has a role when conventional reconstructive techniques are not possible. However, the concern is whether it places the opposite, non-diseased ureter and kidney at risk. Hence a retrospective study was conducted to evaluate indications, methods, and outcomes of transureteroureterostomy in children. The study included seven children who underwent TUU between January 2011 and December 2015. The mean age of the study group was 4.5 ± 2.9 years. Six (86%) patients were males. Two patients had primary bladder diverticulum, two posterior urethral valves, two cases of vesico-ureteric reflux, and one had a persistent urogenital sinus. All patients presented with recurrent urinary tract infections. Three (43%) patients had bladder outlet obstruction. Four (57%) patients underwent left to right TUU with right ureteric reimplantation. Two (29%) patients underwent an additional procedure. No complications were found. The key to a good outcome in TUU is case selection. Surgical technique plays a very important role in ensuring good long-term outcome without compromising the normal moiety.

Outcome of restricted antibiotic policy in a tertiary-level paediatric surgical unit.

PURPOSE: The purpose was to evaluate the effect of a more restrictive antibiotic policy on infective complications, mainly surgical-site infection (SSI) in clean and clean contaminated surgeries in children. MATERIALS AND METHODS: The study included children who underwent clean or clean contaminated surgeries over a period of 18 months with a no-antibiotic or single dose of pre-operative antibiotic protocol, respectively. These were compared to historical controls in previous 18 months where the antibiotic policy was to continue the course for 3-5 days. The outcome looked for was presence of SSI or infection related to the operated organ. RESULTS: A total of 933 (study group) patients were compared to 676 historic controls (control group). In the study group, 661 of 933 were clean surgeries and 272 were clean contaminated surgeries. In the study group, 490 of the 676 were clean surgeries and 186 were clean contaminated surgeries. Clean contaminated surgeries included urological surgeries, gastrointestinal tract surgeries and neurosurgeries, whereas clean surgeries were typically day-care surgeries. Comparing the infective outcomes in each type of surgery, there was no statistical difference between cases or controls in either subgroup. CONCLUSION: Antibiotic prophylaxis (AP) is not required for clean surgeries. For clean contaminated surgeries, just one dose of pre-operative AP is effective in preventing SSI.

Pediatric Pancreatitis: Outcomes and Current Understanding.

AIM: The aim of this study was to analyze the clinical spectrum of pediatric pancreatitis and review current literature with regard to concepts of disease and management approaches. MATERIALS AND METHODS: This is a retrospective analysis of pancreatitis patients admitted to a tertiary referral pediatric surgical unit from March 2013 to September 2018. RESULTS: There were 106 patients from 1 year to 18 years with median age group between 11 and 15 years and equal gender distribution. Sixty-two children had acute pancreatitis (AP), with 13 of them having recurrent episodes. Forty-four patients had chronic pancreatitis (CP). Definite etiology was found in 11 AP patients. All patients had radiological changes. All AP patients were treated symptomatically except those with correctable underlying etiology. Sixteen with CP required intervention in the form of endoscopic retrograde cholangiopancreatography sphincterotomy/stenting or surgery. There were two mortalities. One with acute necrotizing pancreatitis and one CP girl due to the complication of diabetes mellitus, unrelated to episode of pancreatitis. All others are well at the last follow-up. CONCLUSION: Pediatric pancreatitis is a disease with a wide spectrum, but management can be standardized. Newer studies reveal that certain genetic mutations make children more susceptible to pancreatitis. Increasing incidence must prompt us to evaluate further so as to better equip ourselves to managing this disease entity in all its forms and evolve preventive strategies.

Tethered Cord Syndrome-Role of Early Surgery.

PURPOSE: 1. To evaluate the clinical course and effects of surgery on preexisting neurodeficits. 2. To address the issue of timing of intervention. MATERIALS: A prospective study at department of pediatric surgery, Bangalore Medical College and Research Institute and other hospitals from 2013 to 2017. RESULTS: There were 44 patients. Over 3/4 presented with a cutaneous marker while 9 had deficits and no markers. The commonest marker was a swelling on the back. 1/3 of infants had neurological sequelae while almost all midline older children presented with bowel/bladder/gait disturbances. All underwent detethering. Post-operative complications were minor and self-limiting. None of the children had associated Chiari malformation and 2 had a syrinx which at last follow up has been static and shown no clinical signs. Recovery was mostly seen in infants and only in one older child. CONCLUSION: Most of the patients with lipomeningomyelocele have early onset deficits and is recommended to operate at diagnosis. Children presenting with only deficits need to be evaluated for tethered cord syndrome but generally show poor or no recovery of deficits. Early prophylactic detethering is safe, feasible and advisable.

Complete laparoscopic removal of a gastric trichobezoar.

Trichobezoars are seen usually in adolescent girls and laparotomy is required to remove them, though recently laparoscopic assisted and laparoscopic removal have been reported in adults and older children. We report this 4-year-old boy who underwent complete laparoscopic removal of a gastric trichobezoar, both for its rarity in such young boys and also because he is the youngest reported patient to undergo complete laparoscopic removal of a gastric trichobezoar.

Modified koyanagi repair for severe hypospadias.

AIM: To report the results of an early series of patients who underwent modified Koyanagi repair for severe hypospadias. MATERIALS AND METHODS: A total of 24 boys (age: 9 months to 11 years) with proximal hypospadias, chordee, and poor urethral plate underwent modified Koyanagi repair between September 2008 and January 2012. Nine boys had associated penoscrotal transposition that was corrected simultaneously. Vascularized parameatal based foreskin flap was used to correct the hypospadias in a single stage. The follow-up ranged from 6 months to 3.5 years. RESULTS: A total of 13 of the 24 children had a good outcome and were voiding normally, while 11 boys developed complications, 3 of which were major and 8 minor. The major complications were complete breakdown (n = 1), meatal and distal neourethral stenosis requiring laying open of distal urethra (n = 1), and glans breakdown (n = 1). The minor complications included fistulae (n = 5), meatal stenosis amenable to dilatation (n = 1), and lateral chordee (n = 1). Majority of the complications were in the initial patients, with successful outcomes in the last 1 year. Most of these complications were successfully managed by minor second procedures. CONCLUSION: Modified Koyanagi repair not only corrects severe hypospadias with chordee but also corrects the associated penoscrotal transposition in a single stage. The results are good once the learning curve is crossed.

Embryogenesis and types of subcostal hernia--a rare entity.

BACKGROUND/PURPOSE: Four infants with congenital subcostal hernia are reported, as it is a rare entity with only two cases previously reported. Further, there are no reports concerning the complex multisystem subtype. Embryogenesis of the associated anomalies and subcostal hernia and their management are discussed. MATERIALS/METHODS: Clinical features, history, investigations, associated anomalies, and management data of four patients with subcostal hernia were collected and analyzed. RESULTS: The following associated anomalies were detected: renal agenesis (2), musculoskeletal abnormality (3), congenital heart disease (2), müllerian-renal-cervicothoracic somite abnormalities and vertebral-anorectal-cardiac-tracheoesophageal-renal-radial-limb anomalies (1). The subcostal hernias were treated by laparoscopic assisted (3) or laparoscopic herniorrhaphy (1). CONCLUSIONS: Subcostal hernia is a rare entity with varied clinical presentations and presents either as an isolated defect or as a complex multisystem defect. The exact etiology is still unknown. Phenotypic manifestation of the complex defect is probably due to developmental gene defect affecting the coordinated growth of mesoderm around 4th to 10th weeks of fetal life.

Bilateral spontaneous asymptomatic urinoma: report of an unusual case.

Urinoma, defined as a collection of chronically extravasated urine, is uncommon in children. The condition is usually secondary to obstructive uropathy, commonly posterior urethral valves. Non-obstructive causes include trauma to the kidney or collecting system. Urinoma in the absence of obstruction or trauma is rare. This report describes one such boy who had bilateral spontaneous asymptomatic urinoma.

Low anorectal malformation associated with 'ano-urethro-cutaneous' fistula.

Anorectal malformations are one of the common congenital anomalies encountered in the newborn period. The plethora of anomalies described makes it a complex subject for embryological explanations. Fistulous communications between the blind rectum and the urinary tract are common in boys with high/intermediate anomalies, but it is uncommon in children with low anorectal malformations, more so a double fistula. We are reporting a case of 'ano-uerthro-cutaneous fistula' associated with a low ano rectal malformation.

Vaginal endodermal sinus tumor.

Malignant germ cell tumors are rare tumors of childhood accounting less than 3% of pediatric malignancies, and endodermal sinus tumor (EST) is the most common histological subtype. The vagina is an extremely rare site for germ cell tumors (GCT). A one-year female was admitted with history of bleeding per vagina. She had pallor and a mass was palpable anteriorly on rectal examination. Magnetic Resonance Imaging (MRI) showed a tumor mass at the junction of cervix and vagina and biopsy was suggestive of a vaginal EST. The serum alpha fetoprotein (AFP) was elevated. She underwent vaginohysterectomy. The tumor was excised in toto and patient received four courses of cisplatin, etoposide and bleomycin. At one year of follow up, patient was symptom free and serum AFP remained at normal level. EST of the vagina is a rare, highly malignant GCT that exclusively involves children less than 3 years of age. It is both locally aggressive and capable of metastasis. Even though more conservative surgery is advised to maintain sexual and reproductive function, at times, radical surgery is mandatory depending on the infiltration of the tumor to the surrounding structures. Simple tumor excision is not sufficient, as residual cells induce recurrence and make chemotherapy ineffective. The serum AFP level is a useful marker for diagnosis and monitoring the recurrence of vaginal EST in infants.

Anovestibular fistula in adults: a rare presentation.

Adult presentation of anorectal malformations (ARM) is rare. Most of these anomalies are diagnosed and corrected at birth or shortly thereafter. We will present two cases of anovestibular fistula presenting in adulthood. One case is a woman with a history of passing stools through the vagina after marriage and the other case is a woman with a history of chronic constipation since childhood. Case 1 was treated with limited anterior sagittal anorectoplasty, and case 2 was treated with limited posterior sagittal anorectoplasty. Total correction was achieved both anatomically and physiologically after surgery. The reporting of this information should increase the awareness of this disease among surgeons treating adults.

Is gastropexy required for all cases of gastric volvulus in children?

Gastric volvulus (GV) is rare in the pediatric age group. The presentation is varied, and surgery in the form of gastropexy is recommended. We examine the place of gastric fixation in the management of these patients. The authors retrospectively reviewed five cases of gastric volvulus treated at their institute and noted presenting symptoms and signs, studies performed, associated anomalies, surgery done, and outcome. All patients had associated diaphragmatic abnormalities. Two patients had acute volvulus; three had a chronic presentation. Chest X-ray and barium meal were diagnostic. All patients underwent surgical correction of the diaphragmatic anomaly with detorsion of the stomach. Gastropexy was done in only one patient. All patients recovered without any complications and have been well. GV must be suspected in the appropriate clinical setting; chest X-rays and barium meals are the best studies in suspected cases. Gastropexy or gastrostomy is not necessary for a successful outcome in secondary volvulus.

A prospective comparison of two regimes of bowel preparation for pediatric colorectal procedures: normal saline with added potassium vs. polyethylene glycol.

We prospectively evaluated the safety and efficacy of total gut irrigation (TGI) using normal saline with added potassium (NS) and polyethylene glycol (PG) in patients undergoing a variety of colorectal procedures including single-stage pull-through for Hirschsprung's disease (HD). Fifty-four patients were randomly assigned into one of the two groups (NS or PG). Pre- and post-TGI weight, abdominal girth, and serum electrolytes were assessed. Patients were also evaluated for vomiting and abdominal discomfort. At surgery, bowel preparation was evaluated, and postoperative complications were recorded. Both NS and PG are safe and effective agents for TGI. No patient in either group had any clinical or statistically significant change in the evaluated parameters. The amount of NS required for TGI was significantly higher than PG, and PG was better tolerated than NS. All patients with HD completed TGI, although one patient with long segment HD had abdominal distension.

Lingual thyroid gland: clinical evaluation and management.

The authors present three illustrative cases of lingual thyroid gland in paediatric age group with a protocol for diagnosis and management of the condition. Elements in the diagnostic and therapeutic evaluation are outlined with attention to the clinical findings, laboratory tests and radiographic imaging studies employed in confirming the diagnosis and planning appropriate treatment. Presentations varied from swelling noticed on routine evaluation for upper respiratory tract infection in one, to dysphagia in the next and sore throat in the third patient. On examination they had swelling on the tongue just behind the circumvallate line. 99mTc thyroid scan confirmed the swelling as lingual thyroid with no thyroid tissue in the normal location. All three children had raised TSH levels and were put on suppressive L-thyroxine. At follow up patients are asymptomatic.