Intussusception in a 7-week-old baby.

A 7-week-old baby presented to a district general hospital with a history of pallor, lethargy, vomiting and high pitched cry. She had vomited three times at home. It was reported that the last vomitus had a greenish tinge to it. In hospital, she had a non-bilious vomit. There was no history of fever, constipation or diarrhoea. Her birth history and medical history were unremarkable. She was noted to be pale, lethargic and quiet on examination. Her vital signs were unremarkable. She had a soft scaphoid abdomen on examination. No masses were palpable. Investigations for sepsis were done and antibiotics started. Results of all the investigations were normal apart from mildly raised blood glucose and neutrophilia. Later on she passed a small amount of blood per rectum. Examination revealed a palpable mass in the epigastrium. An abdominal x-ray was suggestive of intestinal obstruction. Intussusception was confirmed on ultrasound. The intussusception was successfully reduced following surgery.

Dynamic pelvic floor ultrasound for lower urinary tract symptoms in children--initial report on normative values.

PURPOSE: Lower urinary tract symptoms (LUTS) are common in children. The aim of this study was to determine normal values for pelvic floor movement in asymptomatic controls to allow comparison with symptomatic children with dysfunctional voiding (DV) in the next phase of the study. MATERIAL AND METHODS: One hundred children between the ages of 5-17 years were recruited prospectively as controls. All were asked to perform a voluntary pelvic floor contraction manoeuvre with a full bladder. All scans were performed on a Vivid I GE ultrasound machine with a 4-9 MHz curvilinear probe. M Mode was used to determine the direction of pelvic floor (levator plate-LP) movement, the distance in cms and the endurance in seconds. Each measurement was taken 3 times. RESULTS: Six children were unable to understand and perform the manoeuvre and were excluded. The median age was 10 years (range 4-17). The median LP movement was 0.3 cm (range 0.1-1.6) and cranial in 86/94 (91%). The median endurance time was 5.8 s (range 2.3-15.5). For the (n = 59) younger children aged 4-11, the 95% normal reference range for LP movement was 0.1 cm-1.4 cm and for endurance was 2.5-13.5 s. For the (n = 33) older children aged 12-17, the 95% normal reference range for LP movement was 0.2 cm-1.2 cm and for endurance was 2.3-15.5 s. There was a significant correlation (Pearson r = 0.39, P = 0.001) between average LP movement and endurance. CONCLUSIONS: This study gives the normal reference ranges for the variables measured. A further study is currently underway examining the same variables in children with dysfunctional voiding (DV) and comparing these with the reference range.

Cystoscopy assisted transvesical biopsy of prostatic rhabdomyosarcoma.

The treatment of prostatic rhabdomyosarcoma (RMS) depends on tumour stratification based on site and histology. An increasing range of cytogenetic, molecular, and immunohistochemistry studies are required. This is difficult to achieve using standard cystoscopic biopsies alone. We present a 5-year-old male, diagnosed with a prostatic RMS. He underwent cystoscopy to confirm the diagnosis and at the same time tissue was obtained for histology using laparoscopic graspers via a STEP Port inserted percutaneously into the apex of his bladder. Histology and cytogenetics confirmed an embryonal botryoid RMS for which he received chemotherapy followed by a radical prostatectomy for residual disease.

Infantile urinary tract infection and timing of micturating cystourethrogram.

OBJECTIVE: The investigation of infantile febrile urinary tract infection (UTI) is still a subject of debate and controversy. To evaluate for vesicoureteric reflux (VUR) most authorities recommend a micturating cystourethrogram (MCUG) to be performed at least 4 weeks after UTI to avoid false positive. PATIENTS AND METHODS: At a tertiary centre for paediatric specialities, information on 427 infants who had undergone MCUG following a first febrile UTI was prospectively recorded and their case notes reviewed. The infants were divided into two groups: Group A (117) with MCUG performed less than 4 weeks from UTI diagnosis and Group B (310) with MCUG after at least 8 weeks from diagnosis. RESULTS: Of the 427 children, VUR was detected in 33% of those for whom MCUG was performed less than 4 weeks after UTI diagnosis and in 24% of those for whom it was performed at least 8 weeks after diagnosis. CONCLUSION: Neither the prevalence nor the grade of VUR in infants with a first episode of UTI is influenced by the timing of the MCUG following diagnosis. We therefore suggest that it is better to perform an MCUG as soon as possible, provided inflammation has subsided.

Laparoscopic excision of abdominoscrotal hydrocele.

Abdominoscrotal hydrocele (ASH) is reported with increasing frequency and is recognized to be responsible for complications not only related to the pressure effect on the contiguous structures, but a wide a variety of conditions, including hemorrhage and malignant transformation. Although there are only two reports in the literature of spontaneous resolution, the actual accepted consensus for treatment is complete excision. The surgical approaches are abdominal, scrotal or combined. There is no report in the literature of a laparoscopic excision of ASH. In this paper, we report on the first case to be treated with this approach and highlight the new advantages and simplicity in using this recommended technique.

Is bowel preparation required before cystoplasty in children?

PURPOSE: We evaluated whether bowel preparation is required before augmentation cystoplasty in children. MATERIALS AND METHODS: A total of 46 consecutive children underwent cystoplasty using detubularized ileum between 1998 and 2004. Group 1 (24 patients) underwent standard mechanical bowel preparation with sodium picosulfate, a bowel enema (sodium phosphate) if required and clear fluids for 24 hours preoperatively. Group 2 (22 patients) received no bowel preparation and was on a normal diet preoperatively. One dose of parenteral triple antibiotics was administered at induction of anesthesia in both groups. The surgical technique was similar in both groups. Postoperatively, group 1 had a nasogastric tube in situ, while group 2 had no nasogastric tube. The main outcome measures were hospital stay (days), time to commencing fluids postoperatively (hours), incidence of urinary tract infection during hospitalization and incidence of wound infection. RESULTS: Median postoperative stay was 5 days (range 4 to 7) in group 1 and 4 days (3 to 6) in group 2. Median time to intake of oral fluids was 48 hours (range 24 to 72) in group 1 and 24 hours (12 to 48) in group 2. Three patients in group 1 and 2 in group 2 had a symptomatic urinary tract infection during the postoperative course. One patient in each group had a superficial wound infection. CONCLUSIONS: There were no significant differences in hospital stay or postoperative complications between the 2 groups. This series suggests that bowel preparation is unnecessary for children undergoing cystoplasty.

Neonatal paratesticular abscess mimicking perinatal torsion.

Management of perinatal torsion varies between centers from urgent surgical exploration and contralateral fixation to conservative nonoperative management. We present a case of paratesticular abscess in a neonate mimicking a perinatal torsion which may influence management of this condition in some cases.

Follow-up after unilateral nephrectomy in children: is an estimate of glomerular filtration rate necessary?

OBJECTIVE: To determine the need for an estimate of glomerular filtration rate (GFR) in the follow-up of children undergoing unilateral nephrectomy for benign renal disease. PATIENTS AND METHODS: Forty-four children (21 girls and 23 boys) undergoing unilateral nephrectomy for benign renal disease over a 3-year period were reviewed for the underlying diagnosis and indication for nephrectomy, imaging before and after surgery, postoperative GFR and final outcome. The follow-up included ultrasonography (US) of the contralateral kidney at 3 and 12 months and an estimate of GFR before discharge at > or = 1 year. All children were aged > 2 years when the GFR was measured. The criteria for discharge were normal imaging of the contralateral kidney before and after surgery and a normal GFR afterward. Spearman's correlation coefficient was used to determine the relationship between age, GFR and contralateral renal length after surgery. RESULTS: The median (range) age at surgery was 2.5 (0.67-16) years. The indications for nephrectomy included reflux nephropathy in 18, multicystic dysplastic kidney in 12, a congenital obstructive uropathy in eight, congenital renal dysplasia in four and miscellaneous in two. All patients had a normal contralateral kidney before surgery on US and functional imaging, and normal US at the follow-up, with evidence of compensatory hypertrophy in all. The median (range) corrected GFR for the 44 children was 109 (81-140) mL/min/1.73 m2, with no correlation between age and GFR, or between renal length and GFR. CONCLUSION: After unilateral nephrectomy for benign renal disease, provided there is a structurally and functionally normal contralateral kidney before surgery, with no abnormality on US, a routine estimate of GFR is unnecessary before discharge from follow-up. There was no correlation between GFR and age or renal length.

Bilious vomiting in the newborn: How often is it pathologic?

BACKGROUND/PURPOSE: Intestinal obstruction is one of the most common reasons for admission to a neonatal surgical unit and frequently is manifest by bilious vomiting. Not all cases of neonatal bilious vomiting are caused by intestinal obstruction. This study aimed to investigate the outcome of neonates with bilious vomiting. METHODS: A prospective audit was undertaken of all neonates with a history of bilious vomiting referred to a regional pediatric surgical unit during a 2-year period (1998 to 2000). Infants with bilious nasogastric aspirates but no vomiting were not included. Demographic details, symptomatology, investigations, and final diagnoses were recorded. Subsequent clinical progress was ascertained by out-patient review or telephone interview. RESULTS: Sixty-three consecutive neonates (35 boys, 28 girls) were identified with a median gestational age of 40 (range 31 to 42) weeks and median birth weight of 3.5 kg (range 1.67 to 4.64). Median age at presentation was 26 hours (range, 9 hr to 28 days). A surgical cause of bilious vomiting was identified in 24 (38%): Hirschsprung's disease (n = 9), small bowel atresia (n = 5), intestinal malrotation (n = 4), meconium ileus (n = 3), meconium plug (n = 1), colonic atresia (n = 1), and milk inspissation (n = 1). Nineteen of these had both abdominal signs and an abnormal plain abdominal radiograph, and 4 had an abnormal abdominal radiograph only. In one infant with intestinal malrotation, clinical examination and plain radiography were unremarkable. After definitive surgery, all 24 infants were well at a median age of 14 (7 to 28) months. No surgical cause for bilious vomiting was found in 39 (62%) neonates whose symptoms resolved with conservative management. CONCLUSIONS: These data emphasize the maxim that bilious vomiting in the newborn should be attributed to intestinal obstruction until proved otherwise. However, in this prospective audit, bilious vomiting was not caused by intestinal obstruction in 62% of cases, and most of these infants suffered no further sequelae.