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.

[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.

Meckel's diverticulum and laparoscopy of children. What's new?

Laparoscopy has not changed the diagnostic approach in Meckel's diverticulum (MD). Preoperative echography and scintigraphy are still indicated in case of symptomatic diverticulum. During each submesocolic laparoscopy we must meticulously look for Meckel's diverticulum. There are two surgical procedures for MD resection: 1. Short intestinal resection after exteriorization (celio-assisted surgery) is advocated in young patients or in complicated MD. 2. Laparoscopic resection by the Endo GIA stapler is advocated in older patients and latent MD with a narrow base.

Retroperitoneal laparoscopic nephrectomy in children: preliminary report of six cases.

Laparoscopic nephrectomy is a new procedure that must be evaluated in adults and children. This technique allows a reduction in complications and sequelae. The majority of indications, such as renal dysplasia and destroyed kidneys due to obstructive or refluxing uropathy, are suitable for laparoscopic nephrectomy. Contraindications are Wilms' tumor and trauma, which represent only 20 percent of nephrectomies in our experience. As in open surgery, to perform nephroureterectomy for benign disease, a retroperitoneal approach seems more logical than transperitoneal approach, which is the usual approach for laparoscopic surgeons. We have attempted six retroperitoneal laparoscopic nephrectomies in children from 3 months to 14 years old. The patient is positioned in a lateral position after creation of a retropneumoperitoneum under visual control; three or four ports are needed and renal vessels are dissected then clipped, or coagulated if small. Destroyed kidneys are generally of small size, so they can be extracted via a 10- or 12-mm cannula site without morcellation. Operative time ranges from 35 to 210 mm (median 120 mm). We have had no complications or conversions. Retroperitoneal laparoscopic nephrectomy in children is a feasible and safe procedure in well-trained hands.

Post-traumatic pancreatic pseudocyst: non-operative conservative management--report on 3 cases.

The authors report on 3 cases of post-traumatic pancreatic pseudocysts in children. Complete healing occurred with non-operative conservative treatment and total parenteral nutrition. Daily follow-up with clinical evaluation, abdominal ultrasound and lab exams are detailed under definite criteria of selection and follow-up. This mode of treatment might be considered as an alternative to exploratory laparotomy and external drainage.

[Injuries of the testis in children]. / Les traumatismes du testicule chez l'enfant.

Thirty three blunt testicular injuries have been observed within the frame work of the French Society of Pediatric Surgery. Four histological stages are described. Stage 1: testis contusion: 17 cases. Stage 2: rupture and retraction of the albuginea: 10 cases. Stage 3: complete testis rupture: 4 cases. Stage 4: testis fragmentation: 2 cases. Diagnosis remains clinical in spite of the recent progress of ultrasonography. After surgical treatment results show: 9% castration, 25% testis atrophia, that is to say one testis out of three is lost after traumatism. The hormonal function was not affected. 2 Testis biopsies allowed us to study spermatogenesis. There is no proof of astheno or azo or teratospermia after childhood traumatism. Sterility by autoimmunization has been mentioned only in adults.

[Place of endoscopy in anorectal malformations]. / L'endoscopie dans les malformations ano-rectales.

Miniaturised cystoscope allows exploration in neonates, but in males, it may be difficult and dangerous. Recto-urinary fistulae are generally recto-prostatic, seldom recto-bulbar. Recto-vesical cases were not observed. The fistulous orifice is quite always small and its form is round or ovoid. An anfranctuous and large orifice may be of iatrogenic origin. Endoscopic examination is mandatory when recto-urinary fistula is clinically or radiologically suspected and is always necessary before surgery of cloaca or secondary operation for ano-rectal malformations.

[Genital tract anomalies in anorectal malformations]. / Anomalies de l'appareil génital dans la malformation ano-rectale.

Of 131 patients with imperforate anus, 16 girls (25%), 10 boys (15%) have an abnormality of the genital tract and real frequency seems under evaluate. In girls, vaginal septum, bicornuate and didelphys uterus are mostly diagnosed, associated with severe unilateral upper urinary tract malformations. Absent vagina and uterus (Rokitansky syndrome) must be seen at birth, to preserve perineal fistula used to fashion a vagina at the time of the abdomino-perineal pull through. In our 3 cases upper urinary tract was normal. In boys, uretero-vas deferens anastomosis must be documented by vesiculo-deferentography when orchi-epididymitis or unilateral renal agenesis is demonstrated.