Outcomes following 'mini' percutaneous nephrolithotomy for renal calculi in children. A single-centre study.

INTRODUCTION: This retrospective review was undertaken to identify the postoperative outcomes of children undergoing 'mini' percutaneous nephrolithotomy (MPCNL) at a single institution. OBJECTIVE: Outcomes measured included: percentage of stone clearance, postoperative analgesia requirements, the need for intraoperative or postoperative blood transfusion, length of stay and morbidity. STUDY DESIGN: A total of 46 patients were reviewed over a two-and-a-half-year period; the mean age was 7.3 years (range: 1-16 years). The MPCNL was performed with a radiological-guided peripheral puncture, followed by dilatation of the nephrostomy tract to a maximum Amplatz sheath size of 16-French; an 11-French nephroscope was used. Stone disintegration was achieved either with pneumatic or laser lithotripsy. RESULTS: Complete stone clearance was achieved in 35/46 children (76%). The remaining 11 children had a stone clearance rate of over 80%. No patients required intraoperative/postoperative blood transfusion. A total of 39% of patients were managed on simple/non-opiate based analgesia, with 54% requiring opioid analgesia postoperatively for less than 24 h. There were no procedure-related complications and no mortalities. The mean length of stay was 2.24 days. DISCUSSION: The management of urolithiasis can be challenging in children. The use of percutaneous nephrolithotomy, is becoming increasingly popular in the treatment of paediatric urolithiasis. The stone clearance rate in children undergoing standard PCNL, has been reported to be 50-98% in the literature [1,2,3,4]. Samad et al. [2] in 2006, reported their experience in 188 consecutive PCNLs, using a 17Fr or 26Fr nephroscope. Their largest sub group included children aged >5-16 yrs. Within this group, 57% were treated with a 17Fr nephroscope and 43% with the 26Fr nephroscope, achieving stone clearance of only 47% with PCNL monotherapy. In this group the transfusion rate was 3% [2]. Badawy et al., reported their experience of 60 children in 1999, using a 26 or 28Fr Amplatz sheath. They reported an 83.3% stone clearance with single session PCNL, with only one procedure being abandoned due to intraoperative bleeding requiring blood transfusion [3]. In 2007, Bilen et al. reported their experience and compared the use of 26Fr, 20Fr and 14Fr (mini) PCNL. Stone size, previous surgery and the mean haemoglobin drop postoperatively did not change between the groups, however the blood transfusion rate was higher in the 26Fr and 20Fr Amplatz sheath groups. The stone clearance was highest in the 'mini PCNL' group at 90%, compared to 69.5% in the 26Fr and 80% in the 20Fr group [4]. MPCNL has become increasingly popular over recent years, with stone clearance reported as 80-85% [5-7] following a single session of MPCNL as monotherapy. In 2012, Yan et al. reported 85.2% stone clearance with mini PCNL monotherapy (tract size 14-16Fr), with no children requiring blood transfusion [6]. Zeng et al. reported their experience of 331 renal units in children, with stone clearance rates reaching 80.4% and a blood transfusion rate of 3.1% [8]. In our centre, we do not perform postoperative haemoglobin levels as a matter of routine and any investigations are performed on an intention to treat principle. Bilen et al. reported no blood transfusions being required in their cohort of patients undergoing MPCNL [4] and this is supported by Yan et al. [6]. CONCLUSION: Mini PCNL is an effective and safe procedure for the treatment of paediatric renal stones. In the present series, all children achieved greater than 80% stone clearance, none received a blood transfusion (intra/postoperatively) and there were no mortalities. Postoperative pain was managed with simple analgesia in 39%; however, the majority required opiate analgesia for less than 24 hours.

Foreskin preputioplasty and intralesional triamcinolone: a valid alternative to circumcision for balanitis xerotica obliterans.

BACKGROUND: We previously reported our short-term experience of foreskin preputioplasty as an alternative to circumcision for the treatment of foreskin balanitis xerotica obliterans (BXO). In this study, we aimed to compare this technique with circumcision over a longer period. METHODS: Between 2002 and 2007, boys requiring surgery for BXO were offered either foreskin preputioplasty or primary circumcision. The preputioplasty technique involved triradiate preputial incisions and injection of triamcinolone intralesionally. Retrospective case-note analysis was performed to identify patient demographics, symptoms, and outcomes. RESULTS: One hundred thirty-six boys underwent primary surgery for histologically confirmed BXO. One hundred four boys opted for foreskin preputioplasty, and 32, for circumcision. At a median follow-up of 14 months (interquartile range, 2.5-17.8), 84 (81%) of 104 in the preputioplasty group had a fully retractile and no macroscopic evidence of BXO. Of 104, 14 (13%) developed recurrent symptoms/BXO requiring circumcision or repeat foreskin preputioplasty. In the circumcision group, 23 (72%) of 32 had no macroscopic evidence of BXO. The incidence of meatal stenosis was significantly less in the foreskin preputioplasty group, 6 (6%) of 104 vs 6 (19%) of 32 (P = .034). CONCLUSION: Our results show a good outcome for most boys undergoing foreskin preputioplasty and intralesional triamcinolone for BXO. There is a small risk of recurrent BXO, but rates of meatal stenosis may be reduced.

Outcomes and fate of the remnant moiety following laparoscopic heminephrectomy for duplex kidney: a multicenter review.

PURPOSE: To evaluate outcomes following laparoscopic heminephrectomy (LHN) in duplex kidneys in the pediatric population, focusing on the fate of the remnant moiety. METHODS: 142 patients underwent laparoscopic heminephrectomy for duplex kidney across 4 different institutions in the U.S. and Europe. Median age at surgery was 11.4 months. A retroperitoneoscopic approach was used in all patients, with 82 (57.7%) patients placed in posterior prone position (PPR), and 60 (42.3%) in lateral retroperitoneal (LRP). Follow up included routine ultrasound, and DMSA was performed in the event of abnormalities in ultrasound or postoperative course. RESULTS: Median operative time was 120 min. 11 patients (7.7%) required open conversion, the majority of which (8/11) occurred prior to 2000. Median hospital stay was 2 days and no major complications were observed. 7 patients (4.9%) developed a postoperative urinoma, and 1 patient required ureterectomy for urinary tract infection. With a median follow-up of 4.5 years, 7 children (4.9%) experienced significant loss of function in the remaining moiety, with 3 patients requiring completion nephrectomy. Of patients losing their remaining moiety, median age at surgery was 9 months [4 - 42], and all except 1 (6/7) had an upper pole heminephrectomy. Three patients in this group (42%) experienced an immediate postoperative complication (hematoma, UTI, urinoma). No consistent preoperative or technical factors were consistent in the renal loss group. CONCLUSIONS: LHN for duplex kidney produces satisfactory outcomes in the pediatric population. With a median follow up of 4.5 years, we demonstrate a non-functioning renal moiety rate of 5%. We did not identify any clinical predictors of this outcome in our series, although upper pole heminephrectomy, patient age, and postoperative complications may be contributing factors.

Subtle Radiological Features of Splenic Avulsion following Abdominal Trauma.

Splenic trauma in children following blunt abdominal injury is usually treated by nonoperative management (NOM). Splenectomy following abdominal trauma is rare in children. NOM is successful as in the majority of instances the injury to the spleen is contained within its capsule or a localised haematoma. Rarely, the spleen may suffer from an avulsion injury that causes severe uncontrollable bleeding and necessitates an emergency laparotomy and splenectomy. We report two cases of children requiring splenectomy following severe blunt abdominal injury. In both instances emergency laparotomy was undertaken for uncontrollable bleeding despite resuscitation. The operating team was unaware of the precise source of bleeding preoperatively. Retrospective review of the computed tomography (CT) scans revealed subtle radiological features that indicate splenic avulsion. We wish to highlight these radiological features of splenic avulsion as they can help to focus management decisions regarding the need/timing for a laparotomy following blunt abdominal trauma in children.

Investigating febrile UTI in infants: is a cystogram necessary?

OBJECTIVE: Current imaging recommendations for investigating any infantile febrile urinary tract infection (UTI) are ultrasound scan (US), micturating cystourethrogram (MCUG) and dimercaptosuccinic acid (DMSA) scan. The aim of this retrospective cohort study was to determine the need and indications for MCUG in the investigation of a first febrile infantile UTI, as doubts have been raised over its benefit. PATIENTS AND METHODS: Information on 427 infants who had undergone US, MCUG and DMSA following a first febrile UTI was prospectively recorded. The infants were divided into two groups: A (354) with normal renal US and B (73) with abnormal US. DMSA findings were correlated with findings on MCUG. Main outcome measures were incidence of recurrent UTIs, change in management or intervention as a result of MCUG, and outcome at discharge. RESULTS: Only 21/354 (6%) infants in Group A had both scarring on DMSA and vesicoureteric reflux (VUR), predominantly low-grade on MCUG. In Group B (abnormal US), 23/73 (32%) had scarring on DMSA and vesicoureteric reflux, predominantly high grade on MCUG. Of the infants with non-scarred kidneys, 73% had dilating reflux. Successful conservative treatment was performed in 423 infants, and 4 infants in Group B required surgery. CONCLUSION: We recommend US and DMSA in all infantile febrile UTI cases. Where US is normal, MCUG should be reserved for those cases with abnormal DMSA. Where US is abnormal, MCUG should be performed irrespective of findings on DMSA scan. A randomized prospective study is necessary to evaluate this further.

Vesicostomy vs primary ablation for posterior urethral valves: always a difference in outcome?

OBJECTIVE: A vesicostomy is believed to have a detrimental effect in boys with posterior urethral valves compared to primary valve ablation. We compared the outcomes of boys managed by initial vesicostomy with those undergoing primary fulguration. MATERIALS AND METHODS: The outcomes of 54 boys (23 vesicostomy, 31 primary valve fulguration) over 1 year of age who had not undergone renal transplant were considered. Outcome parameters identified were ultrasound findings, continence status, glomerular filtration rate (GFR) and 1-year creatinine. Dryness was defined as completely dry both day and night with no need to wear pads. Results are presented with 95% confidence intervals. RESULTS: Ultrasound examinations were normal in 9/19 (47.4%) of the vesicostomy group and 11/24 (45.8%) of the fulguration group. Graded ultrasound results were not significantly different (p=0.24). The vesicostomy patients were more often dry (79% vs 64%, p=0.43). The vesicostomy group had on average higher GFR (95.26 vs 85.79) and lower 1-year creatinine (49.58 vs 52.46) values. After accounting for age differences between groups, there was no significant difference in the GFR and 1-year creatinine values (p=0.16 and p=0.87, respectively). CONCLUSIONS: There was a tendency for the major outcomes to be more favourable in the vesicostomy group. Although trends were non-significant, confidence intervals were wide and potential differences of clinical importance could not be discounted.

Myogenin and desmin immunohistochemistry in the assessment of post-chemotherapy genitourinary embryonal rhabdomyosarcoma: prognostic and management implications.

PURPOSE: Posttreatment genitourinary embryonal rhabdomyosarcoma often shows well differentiated rhabdomyoblasts, which are detectable on routine histological staining. Definite areas of residual undifferentiated rhabdomyosarcoma indicate residual/recurrent disease. However, the recent use of immunohistochemical staining with desmin and myogenin in resected specimens and surveillance biopsies following adjuvant therapy may demonstrate scant positive staining cells that appear undifferentiated on light microscopy. To our knowledge the clinical significance of this finding is currently unknown. Therefore, we reviewed our retrospective experience with genitourinary embryonal rhabdomyosarcoma to examine the relationship between immunostain positive undifferentiated cells and subsequent clinical outcome. MATERIALS AND METHODS: A total of 14 children with a median age of 2.75 years (range 8 months to 7 years) with genitourinary embryonal rhabdomyosarcoma were identified in the histopathology database. All had biopsy confirmation of the diagnosis, followed by multi-agent chemotherapy. Two children in whom there was obvious residual active tumor at the resection margins were excluded from further analysis. Histopathological findings in all patients on the resection/posttreatment biopsy were reviewed. All specimens were immunostained with desmin and myogenin to detect residual undifferentiated rhabdomyoblasts. The relation between histopathological findings and outcome was determined. RESULTS: There were 14 cases of genitourinary embryonal rhabdomyosarcoma. In 2 cases (14%) residual embryonal tumor was pathologically confirmed following initial treatment. In 12 cases no obvious residual tumor was present following initial therapy. Rhabdomyosarcoma affected the bladder in 10 cases and the vagina in 2. There were no distant metastases in any child. Ten patients underwent local resection following chemotherapy and 2 underwent followup biopsies only without resection. A total of 11 cases showed well differentiated, posttreatment rhabdomyoblasts that was identifiable on routine hematoxylin and eosin staining with margins apparently free of tumor and 1 showed no morphological evidence of residual rhabdomyosarcoma. However, all cases demonstrated at least scant abnormal desmin and myogenin positive cells in the specimens. Four patients had no further treatment and none had clinical recurrence. All were well 10 years (range 8 to 13) after treatment. Eight patients received further treatment (chemotherapy and/or radiotherapy) based on clinical and pathological findings, followed by further resection in 3. One patient died of disease but 7 were well a median of 7.2 years (range 8 months to 13 years) after treatment. CONCLUSIONS: The significance of undifferentiated myogenin/desmin positive cells in genitourinary embryonal rhabdomyosarcoma in the absence of morphological residual/recurrent embryonal rhabdomyosarcoma remains unclear since such cells can be detected in all cases of posttreatment embryonal rhabdomyosarcoma. In some cases findings are associated with clinical disease recurrence, while others with identical histopathological findings following initial treatment have no clinical sequelae even in the absence of further treatment. In genitourinary embryonal rhabdomyosarcoma close and regular clinical surveillance is essential. Desmin/myogenin immunohistochemistry to detect scattered undifferentiated cells does not appear to provide useful prognostic information.

Laparoscopic transposition of lower pole vessels--the 'vascular hitch': an alternative to dismembered pyeloplasty for pelvi-ureteric junction obstruction in children.

OBJECTIVE: Dismembered pyeloplasty is the traditional technique in the management of ureterovascular pelvi-ureteric junction obstruction (PUJO) in children. Controversy remains regarding the role of lower pole vessels as the sole aetiology for PUJO. Endopyelotomy and concomitant laparoscopic transposition of lower pole vessels for PUJO has been described in adults. We describe our technique of laparoscopic transposition of lower pole vessels in children with PUJO, leaving the PUJ intact. PATIENTS AND METHODS: Thirteen patients (seven boys and six girls) with a mean age of 10.2 years (range 7-16 years) underwent laparoscopic transposition of lower pole vessels. Surgery was indicated on the basis of intermittent pain and ultrasound/MAG3 appearance of obstruction with or without reduced function. The technique involved laparoscopic transperitoneal mobilization of the lower pole vessels from the region of the PUJ thereby freeing the junction and transposing them superiorly onto the anterior wall of the pelvis. The main outcome measures were relief of pain and improvement in ultrasound appearance or drainage parameters on a postoperative MAG3 renogram performed within 4-6 weeks of surgery. RESULTS: Median operating time was 92 min. All patients were discharged within 36 h of surgery. All patients remain pain free at a median of 6 months (range 3-18 months). Twelve patients showed good drainage on the postoperative MAG3 renogram and improvement in ultrasound appearance. One patient had recurrent symptoms requiring insertion of a JJ stent. She has undergone further laparoscopic exploration. The vessels were in their transposed position and there was a kink at the PUJ which was released. She had a vertical pyelotomy and transverse closure over the JJ stent with good results. CONCLUSION: This technique is simple and requires less operating time. No anastomosis or temporary JJ stent is required. Our early results are very encouraging with no serious complications.

Routine urine microscopy and culture in paediatric surgical outpatients: is it necessary?

Midstream urine culture has been the gold standard for diagnosing a urinary tract infection. But sample collection in children can be time-consuming and frustrating. In our department, a urine sample is routinely collected by the nursing staff prior to the outpatient consultation. We therefore reviewed our practice with respect to correlation with symptoms, change in management occurring as a result of the culture, and financial implications. Case notes of 109 children attending paediatric nephrourology clinics over a three-month period were retrospectively reviewed. Data collected included underlying diagnosis, symptomatology, urine culture results at current and previous outpatient visits, and change in management that occurred as a direct result of the culture. A pure growth of >10(5 )colony-forming units/ml was considered to be a positive result. Of 783 urine samples, only 23 were positive in 15 patients, nine of which required change in management. All of these nine patients were symptomatic at or just preceding the clinic visit. None of the remaining patients in the group had symptoms of a urinary tract infection at the time of the outpatient visit. Change in management therefore occurred in 8.3% of patients, all symptomatic, based on the results of 1.1% of urine samples. At a cost of pound 3.00 per sample during working hours, the cost of processing 783 samples was pound 2349.00. We conclude that urine samples from paediatric surgical outpatients should not be sent routinely unless the patients are symptomatic or a change in management is anticipated. Other techniques to screen for urine samples needing culture may be considered.

Expanded PTFE bladder neck slings for incontinence in children: the long-term outcome.

OBJECTIVE: To assess the long-term outcome of circumferential expanded PTFE (Gore-tex, WL Gore Associates, Scotland) bladder neck slings for achieving urethral continence in children with a neuropathic bladder. PATIENTS AND METHODS: The records were reviewed of 19 children undergoing bladder reconstruction (most with a neuropathic bladder) who had a Gore-tex sling placed circumferentially at the bladder neck, over a 5-year period. Of these, seven had spina bifida; two each spinal dysraphism, surgery for anorectal anomalies and an idiopathic neuropathic bladder; five who developed a neuropathic bladder from other causes, and one born with bladder exstrophy. All children had an uncompliant bladder with a low urethral leak-point pressure on preoperative urodynamics. In all children conventional clean intermittent catheterization and pharmacotherapy had failed. Four had had previous augmentation surgery while 15 had concomitant bladder augmentation and formation of a Mitrofanoff stoma. The main outcome measure was achieving dryness. The original intention of the procedure was also to maintain urethral catheterization. RESULTS: Full details of the follow-up were available in 17 patients. Despite initial good short-term results, at a median follow up of 7 years, in 14 patients the sling had to be removed because of erosion, often with transient urethral leakage before the bladder neck subsequently closed. A bladder calculus was associated with each case of erosion except one. CONCLUSION: Although in the short term this technique had favourable results, it was not a useful technique in the long term.

Endourethral injection of bulking agents for urinary incontinence in children.

OBJECTIVE: To assess the early and late outcome of endourethral injection with bulking agents in children with urinary incontinence (a neuropathic bladder or exstrophy-epispadias complex), by reviewing our experience over a 5-year period. PATIENTS AND METHODS: The records of 15 children (10 boys) were reviewed retrospectively; 10 had spina bifida and a neurogenic bladder, four had a neurogenic bladder from other causes and one had epispadias. All children had a stable low-pressure detrusor and a compliant bladder with sphincteric weakness on preoperative urodynamic testing. Four children had undergone previous enterocystoplasty with a Mitrofanoff stoma, with concomitant urethral lengthening in two and a Goretex trade mark bladder neck sling in two. Three children voided spontaneously while 12 depended on intermittent catheterization. The agent was injected under general anaesthesia in all patients but one, with an endourethral submucosal injection of the bulking agent into four or more points at the junction of the bladder neck and proximal urethra, aiming to obtain visual occlusion of the urethra. The median (range) number of injections was 2 (1-3); five children had one injection, seven had two and three had three. There were no procedure-related complications and most were day-case procedures. Initially PTFE paste was used as the bulking agent, being replaced by bovine collagen or polydimethylsiloxane in the latter half of the series. RESULTS: At a median (range) follow-up of 28 (11-65) months three children were completely dry after a single injection; there was no change in four and a short-term improvement (median 25 months, range 4 days to 37 months) in eight. After this period all children deteriorated to their original incontinence grade; hence the overall cure rate was three of 15. CONCLUSION: This experience with a long-term follow-up differs from previously reported high success rates for the endourethral injection of bulking agents for urinary incontinence in children. Despite a short-term benefit, in the long-term this technique was unreliable and often ineffective. Patients and their carers should be given a realistic and guarded prognosis.

Splenectomy after paediatric trauma: could more spleens be saved?

AIMS: Guidelines for the emergency management of paediatric splenic trauma became widely available in 1993. A regional survey was undertaken to assess the application of Advanced Paediatric Life Support guidelines to children who had undergone splenectomy after trauma. PATIENTS AND METHODS: All children who had undergone splenectomy for a ruptured spleen at 8 district hospitals and 2 teaching hospitals in our region between January 1994 and January 1999 were identified from histopathology departmental records. With appropriate permission their case notes were reviewed. RESULTS: Eleven children (9 males) were identified, all from district hospitals, with a median age at presentation of 11.8 years (range, 6.6-16.8 years). All presented within 6 h of blunt abdominal trauma. Median systolic blood pressure, pulse rate, haemoglobin concentration and injury severity score (ISS) on admission were 115 mmHg (range, 80-140 mmHg), 108 bpm (range, 84-150 bpm), 12.1 g/dl (range, 10.7-12.8 g/dl) and 17 (range, 17-29), respectively. Three children had additional relatively minor injuries. On admission, 3 children received an intravenous fluid bolus of 20 ml/kg and the remainder received only maintenance fluid requirements or less. Five children were investigated by ultrasound imaging, one by double contrast CT scan, and three by laparoscopy. Two children had no imaging studies prior to laparotomy. Laparotomy was performed by a consultant surgeon in 7 cases and by a specialist registrar in 4 cases. Ten children underwent total splenectomy and one child had a partial splenectomy. Median hospital stay was 7 days (range, 5-10 days). The child with an ISS of 29 developed a persistent pancreatic fistula and subsequently required a distal pancreatectomy. All children received Pneumovax and penicillin prophylaxis. CONCLUSIONS: All children made a full recovery without surgical morbidity. However, none of these cases fulfilled the recommended criteria for laparotomy in children with blunt abdominal trauma and splenectomy may have been avoidable.

Limitations and uses of gastrojejunal feeding tubes.

BACKGROUND: Gastrostomy feeding is a well established alternative method to long term nasogastric tube feeding. Many such patients have gastro-oesophageal reflux (GOR) and require a fundoplication. A transgastric jejunal tube is an alternative when antireflux surgery fails, or is hazardous or inappropriate. AIMS: To review experience of gastrojejunal (G-J) feeding over six years in two regional centres in the UK. METHODS: Retrospective review of all children who underwent insertion of a G-J feeding tube. RESULTS: There were 18 children, 12 of whom were neurologically impaired. G-J tubes were inserted at a median age of 3.1 years (range 0.6-14.7) because of persistent symptoms after Nissen fundoplication (n = 8) or symptomatic GOR where fundoplication was inappropriate. Four underwent primary endoscopic insertion of the G-J tube; the remainder had the tube inserted via a previous gastrostomy track. Seventeen showed good weight gain. There was one insertion related complication. During a median follow up of 10 months (range 1-60), four experienced recurrent aspiration, bilious aspirates, and/or diarrhoea. There were 65 tube related complications in 14 patients, necessitating change of the tube at a median of 74 days. Jejunal tube migration was the commonest problem. Five died from complications of their underlying disease. CONCLUSIONS: Although G-J feeding tubes were inserted safely and improved nutritional status, their use was associated with a high rate of morbidity. Surgical alternatives such as an Roux-en-Y jejunostomy may be preferable.

A family study and the natural history of prenatally detected unilateral multicystic dysplastic kidney.

PURPOSE: We document the inheritance pattern of multicystic dysplastic kidney in 3 affected families and screen first-degree relatives of a cohort of children with prenatally detected multicystic dysplastic kidney for renal anomalies. The study also afforded an opportunity to document the natural history of prenatally detected multicystic dysplastic kidney. MATERIALS AND METHODS: We identified 3 families during clinical treatment of children with prenatally detected multicystic dysplastic kidneys. Other members of these families were evaluated with renal ultrasonography. For the family screening study index cases were identified from a fetal uropathy database. A total of 94 first-degree relatives (52 parents, 35 full siblings and 7 half siblings) of 29 children with prenatally detected multicystic dysplastic kidneys were studied with urinary tract ultrasonography, blood pressure measurement, urinalysis and plasma biochemistry. RESULTS: Two families had affected sibling pairs, 1 of which also had a half sibling with vesicoureteral reflux. The third family included 3 individuals with multicystic dysplastic kidney and 1 with renal agenesis thought to have resulted from involution of multicystic dysplastic kidney. This family is consistent with autosomal dominant inheritance with variable expressivity and reduced penetrance. In the screening study ultrasonography did not demonstrate significant renal anomalies in any of the 94 first-degree relatives of the multicystic dysplastic kidney index cases. Followup assessment of prenatally detected multicystic dysplastic kidneys in index cases demonstrated total involution in 52% at a median age of 6.5 years with no multicystic dysplastic kidney related morbidity. CONCLUSIONS: Multicystic dysplastic kidney can be familial but is most commonly a sporadic anomaly. Formal screening of relatives is not recommended. Followup data on a cohort of children with prenatally detected multicystic dysplastic kidney add further support to conservative management.

Laparoscopic orchidopexy in children.

BACKGROUND: Cryptorchidism is a common condition in boys. Approximately 20% of undescended testes are nonpalpable and may be located within the abdominal cavity. Given the potential of these gonads for malignant transformation and infertility, it is essential to determine the presence or absence of a nonpalpable testis. METHODS: Radiologic imaging and open surgical exploration have proved to be unreliable. In the hands of experienced surgeons, laparoscopy has become the method of choice for evaluating the nonpalpable testis. RESULTS AND CONCLUSION: An increasing number of surgeons are applying laparoscopy in the treatment of nonpalpable testes, and early results are encouraging. Both diagnostic and therapeutic laparoscopy necessitate operative skills. The exact advantages of laparoscopy over conventional surgery in orchidectomy and single- or two-stage orchidopexy need to be determined.

Idiopathic megarectum in children.

There is scant information about the management of idiopathic megarectum in childhood. Children with idiopathic megarectum referred to a single institution between 1994 and 1998 were identified prospectively. Those with Hirschsprung's disease or an anorectal malformation were excluded. The remaining patient group, 22 boys and 7 girls, had a median age of 8.0 years (range 3.5-14.0 y). Median duration of symptoms prior to referral was 2.0 years (range 0.4-11 y). Chronic soiling was the dominant complaint in 28/29 (97%) cases. 23 children had received regular stimulant laxatives for periods ranging from 1 month to 11 years, and 9 children had been treated with regular enemas. The degree of megarectum assessed by both abdominal palpation and plain radiography was: grade 1 (below umbilical level) n=6; grade 2 (at umbilical level) n=15; and grade 3 (above umbilical level) n=8. Hirschsprung's disease was specifically excluded by rectal biopsy in all cases and no patient had evidence of spinal dysraphism. Three boys with massive megarectums and intractable symptoms were treated by a staged Duhamel sigmoid pull-through with excellent functional results. Fifteen patients (52%) were treated by a single manual evacuation under general anaesthesia followed by a daily Bisacodyl 5-10 mg suppository. After a median follow-up of 16 months, 13 continue to respond well with a daily bowel action and no soiling (4 of the 13 have discontinued treatment and remain well). The remaining 11 patients (38%) have continued conventional treatment with oral laxatives but with limited success. Idiopathic megarectum is poorly described in children. It is more common in boys and is often resistant to laxative therapy alone. After appropriate preparation, treatment with stimulant suppositories can be effective. Surgery has a valuable role in selected patients with a massive megarectum.

Solitary rectal ulcer syndrome in children.

Solitary rectal ulcer syndrome (SRUS) is rare in children. Few reported cases have undergone detailed investigations, treatments have been extremely varied and outcome poorly documented. We report two cases of SRUS in children, each with a different macroscopic pathology. The diagnosis was delayed in both cases. The importance of appropriate investigation and the need to tailor treatment to the type of lesion are emphasised. One case of SRUS was associated with a complete, full thickness rectal prolapse and symptoms improved after an abdominal sutured rectopexy. The other patient responded well to endoanal excision of polypoid lesions. The diagnosis and management of this condition in children deserves wider recognition.