Prognostic values of shear wave elastography in adolescent boys with varicocele.

INTRODUCTION: Shear wave elastography is an ultrasound technique for non-invasive quantification of tissue stiffness. It was used in assessing testis elasticity in some scrotal abnormalities, such as undescended pediatric testes or adult varicocele testes. In this study, its usefulness in adolescent patients with varicocele was examined. OBJECTIVE: The aim of this study was to quantify elasticity of testes with the use of elastography and comparison of the results with typical threshold values used in varicocele management in adolescent patients with varicoceles. STUDY DESIGN: In 30 patients with clinically diagnosed left varicoceles, quantitative 2D shear wave imaging of varicocele testes and contralateral ones were performed. RESULTS: The relationships between the grade of varicocele and elastography were calculated. The stiffness was 2.5 ± 0.49 kPa in testes with grade I of varicocele, 2.59 ± 0.81 in grade II and 2.80 ± 0.72 kPa in grade III. In contralateral testes, it was respectively grade I 2.39 ± 0.49 kPa, grade II 2.41 ± 0.61 kPa, and grade III 2.42 ± 0.85 kPa. The statistical significance was close to importance in grade III (P = 0.153). There was a statistically significant difference between elastography results in patients with volume difference over 20%. In testes with varicocele, it was 2.77 ± 0.75 kPa and in contralateral testes, 2.37 ± 0.65 kPa (P < 0.05). In patients with testis volume difference between 0 and 20%, elastography results were comparable, and it was 2.45 ± 0.57 kPa in testes with varicocele and 2.44 ± 0.61 kPa in contralateral testes (Table). DISCUSSION: Ultrasound is currently the most widely used imaging technique for the assessment of varicocele, but its role in the diagnostic algorithm is still controversial. Therefore, many attempts are made to determine the manifestations of testicular damage that precede morphological deterioration, which could increase the importance of imaging techniques in treatment planning. CONCLUSION: The changes of tissue elasticity due to varicocele seem to confirm the need of surgery in patients with testis volume difference more than 20% and in grade III of varicocele (Table). In case of validation of diffuse testis changes, they could indicate the need for surgery also in other stages.

Kidney transplantation in children with bladder augmentation or ileal conduit diversion.

INTRODUCTION: Various congenital and acquired diseases of the lower urinary tract can lead to chronic renal failure requiring renal replacement therapy. AIM: The aim of the study was to assess problems and results of kidney transplantation in children with significant lower urinary tract dysfunction. MATERIALS AND METHODS: Between 1984 and 2007, there were 33 kidney transplantations in children with end-stage renal disease and severe lower tract dysfunction out of 539 kidney transplantations performed in our department. The patients were 23 males and 10 females. Thirty patients received a kidney from a deceased donor, the remaining 3 from a living related donor. The age at transplantation ranged from 2.25 years to 19 years. In 26 patients an ileal conduit modo Bricker was created (in 21 patients at transplant operation). Bladder augmentation was performed in 6 patients and a continent urinary reservoir was created in 1. RESULTS: Post-transplant follow-up ranged from 7 to 88 months (mean 32 months). Overall patient survival is 100% and graft survival is 97%. Creatinine concentrations ranged from 0.3 to 3.4 mg% (mean 0.92 mg%). Surgical complications were diagnosed in 16 patients. All surgical complications were treated successfully and none of them caused graft loss. Urinary tract infections (UTI) were the most commonly observed complication, occurring in 26/33 (78%) patients, but the majority of these UTI were asymptomatic and had no influence on graft function. CONCLUSIONS: Kidney transplantation in children with lower urinary tract dysfunction and end-stage renal failure offers excellent medium term results in our experience, despite the creation of non-standard urinary drainage. Recurrent urinary tract infections are the most common complications in these patients, but in the majority of cases this does not lead to impairment of graft function.

Vascular complications after pediatric liver transplantation from the living donors.

Early arterial or portal vein thrombosis is a complications that can lead to graft loss and patient death or need of immediate retransplantation. The aim of the study was to assess the incidence, causes, treatment, and outcome of vascular thrombosis after living related donor liver transplantation (LRdLTx). Between 1999 and 2004 71 LRdLTx were performed in children aged from 6 months to 10 years. Vascular thrombosis was found in 12 recipients. Hepatic artery thrombosis (HAT) occurred in 4 (5.6%), portal vein thrombosis (PVT) in 8 (11.2%) cases. HAT occurred 5 to 8 days, PVT 1 to 22 days after LTx. Diagnosis of vascular thrombosis was confirmed by routine Doppler ultrasound examination. Thrombectomy was successful in one patient with HAT and in three patients with PVT. Venous conduit was performed in one patient with PVT after second thrombosis. Two children developed biliary strictures as a late complication of HAT and required additional surgical interventions. Two children with PVT developed portal hypertension with esophageal bleeding, which required surgical intervention; one another underwent endoscopic variceal ligation for grade III varices. Follow-up ranged from 7 to 60 months. One patient died as a result of HAT after retransplantation due to multiple intrahepatic abscesses 2 months after first transplant. Any risk factors of vascular thrombosis that can be controlled should be avoided after transplantation. Routine posttransplant Doppler examination should be performed at least twice a day within 7 to 14 posttransplant days. Immediate thrombectomy should be always carried out to avoid late complications and even mortality.

Analysis of neurological complications in children transplanted due to fulminant liver failure.

Treatment of patients with fulminant liver failure is a challenge of contemporary medicine. Liver transplantation, in this group, is presently the only reasonable alternative, but in many patients the disastrous condition of the patient results in serious life-threatening complications, including neurological sequelae, which may influence the quality of life after transplantation, and in some cases even cause death. From 1990 to 2004, we performed 241 liver transplantations in children, including 20 transplanted due to fulminant liver failure (8.2%). Serious neurological complications followed liver transplantation in five cases (20%), three of which were fatal. The analysis revealed that the duration of pretransplant coma (grade III or IV) strongly correlated with the incidence of neurological complications (P < .05). Also a suboptimal quality of the donor liver and poor early graft function may contribute to these posttransplant complications.

Liver retransplantation in children in Poland.

An average of 15% of patients require retransplantation due to irreversible liver graft failure due to primary graft nonfunction, chronic rejection, vascular and biliary complications, or infections. The survival of patients and grafts after retransplantation is inferior to that after primary transplantation. The purpose of the present study was to examine the incidence, indications, and outcome of retransplantation in children. In our center 169 liver transplantations had been performed in 154 patients, and 14 patients (9%) required 15 retransplantations: nine in the early postoperative period, five late after primary transplantation, and one late after the second transplantation. One-year patient survival after primary transplantation was 82%, but after early retransplantation it was 55%.

Liver transplantation across ABO blood groups in children.

Late results after ABOI LTx are inferior to ABO compatible organs. We report seven patients who received LTx across ABO group for emergency indications. The blood type combinations were: A to O in three, B to O in two, and B to A in two. Episodes of acute and chronic rejection, immunosuppression, and biochemical and functional tests after transplantation as well as patient and graft survival were compared between ABOI group and patients with compatible ABO group transplanted due to FLF (group I) or in an elective setting (group II). Four children are alive. Two children died of sepsis and CNS damage or MOF, and one patient died during transplantation because of cardiac failure. All recipients of ABOI grafts received immunosuppression with cyclosporine or tacrolimus and steroids. MMF was added in two subjects, and induction with antilymphocyte globulins used in five patients. An acute rejection episode was diagnosed in two recipients between 7 and 11 days after LTx. All four living patients with ABOI grafts are doing well with follow-up time between 11 months and 5 years. In one patient PTLD occurred at 1 year after ABOI LTx but was cured by discontinuation of immunosuppression and administration of rituximab. Graft survival in the ABOI group was 57.1% versus 71% in group I and 73% in group II. Respective patients survival was 57.1% 71%, and 82.0% respectively. In conclusion, in urgent cases ABOI transplantation is justified in pediatric patients when compatible grafts are not available.

Switching cyclosporine blood concentration monitoring from C0 to C2 in children late after liver transplantation.

BACKGROUND: Measurement of cyclospoprine (CsA) blood levels at 2 hours after oral administration (C(2)) has been proposed as a better measurement of trough level (C(0)) due to reduced intrapatient variability, acute rejection rate and renal toxicity. The aim of the present study was to assess whether there was any advantage to conversion from C(0) to C(2) CsA blood level monitoring in children late after liver transplantation. We reviewed the data from 44 children more than 1 year after liver transplantation. We measured the daily dose of CsA and the C(0) level before switching versus the daily dose and C(2) level at 6 months after conversion, in addition to the alanine aminotransferase (ALT) activity, creatinine blood concentration, and episodes of acute rejection. RESULTS: Conversion from C(0) to C(2) monitoring was not associated with a significant change in mean daily dose of CsA, mean concentration of creatinine, ALT activity or occurrence of rejection episodes. CONCLUSION: Switching from C(0) to C(2) monitoring did not seem to proffer any benefits for children late after liver transplantation.

Acute coagulopathy after reperfusion of the liver graft in children correction with recombinant activated factor VII.

BACKGROUND: Several studies have proven that massive blood loss increases postoperative morbidity and mortality in liver graft recipients. Since we have successfully corrected coagulopathy preoperatively using an intravenous (IV) bolus of recombinant activated factor VII (rFVIIa) in 2 patients with fulminant liver failure, we observed that there was rapid reversal of preexisting advanced coagulopathy in another 40 patients with high risk for intraoperative bleeding by this treatment immediately before transplantation. Recently to control hemostasis we have administered rFVIIa also to patients presenting with acute coagulopathy and nonsurgical bleeding after graft reperfusion as described herein. MATERIALS AND METHODS: We have used rFVIIa in 7 children presenting with severe coagulopathy and nonsurgical bleeding after liver graft reperfusion. The dosage of rFVIIa ranged between 37 and 148 mcg/kg. An antifibrinolytic agent (aprotinin, tranexamic acid) was administered simultaneously. RESULTS: APTT before rFVIIa was 86.10 to 183 seconds, (mean, 132.1 +/- 39.88), after the bolus of rFVIIa 49.4 to 206.1 (mean, 112.7 +/- 58.53), and at the end of surgery 71.70 to 180 (mean, 110.3 +/- 40.98). INR after reperfusion was 1.82 to 3.91 (mean, 2.56 +/- 0.67), 1.03 to 1.92 (mean, 1.54 +/- 0.35) after rFVIIa, and 1.74 to 5.58 (mean, 2.64 +/- 1.35) at the end of surgery. Before rFVIIa administration intraoperative blood transfusions after graft reperfusion were 900 to 4200 mL of red blood cells (RBC) (0.82-5.4 total blood volume) and after reperfusion 0 to 1800 mL of RBC (0-2.5 TBV). No postoperative vascular complications were observed. CONCLUSIONS: A single dose of rFVIIa effectively reverses the severe coagulopathy developing after graft reperfusion, establishing effective hemostasis in liver transplant recipients without an increased risk of thrombotic complications.

Bladder autoaugmentation in myelodysplastic children.

OBJECTIVE: To present the long-term results of bladder autoaugmentation in myelodysplastic children with low compliance neurogenic bladders who failed attempts at medical management, including clean intermittent catheterization (CIC) and pharmacological bladder relaxation. PATIENTS AND METHODS: Twenty-one patients with a neurogenic bladder after myelomeningocele operations (mean age 9.5 years, range 3-16) underwent autoaugmentation; 12 children were paraplegic and hydrocephalic, and were treated by insertion of a ventriculoperitoneal valve. All patients had low-compliance neurogenic bladders confirmed urodynamically. Ten patients had vesico-ureteric reflux (VUR) and eight had dilated upper urinary tracts with no reflux. All patients had been treated pre-operatively using CIC and anticholinergic agents, with no success. RESULTS: Of 21 children treated surgically, 17 were assessed urodynamically and examined to determine the condition of the upper and lower urinary tract. The follow-up ranged from 3 months to 8 years (mean 6 years). In 13 patients the bladder capacity increased by approximately 60 mL and in 14 the intravesical pressure decreased by approximately 65 cmH2O. Fourteen children were continent using CIC (from 3- to 4-hourly); in the six patients with VUR the reflux resolved in two, decreased in two and remained unchanged in two. Of eight patients with dilated upper tracts but no reflux, seven improved. There was no improvement in bladder capacity in four patients and no reduction in intravesical pressure in three. Two patients underwent enterocystoplasty (one ileocystoplasty and one colocystoplasty) with good results. Two children needed anticholinergic agents after autoaugmentation. CONCLUSIONS: Autoaugmentation effectively reduces high intravesical pressure and provides a sufficient increase in bladder capacity with a concomitant improvement in urodynamic values. The present method allows the extent of the surgical procedure to be limited to the extraperitoneal space and thus maintains all of other options. Bladder autoaugmentation is a reasonable alternative to enterocystoplasty in selected patients.