Transurethral Resection of the Bladder Tumour as a Treatment Method in Children with Transitional Cell Carcinoma of the Bladder--Analysis of Our Material and Literature Review.

BACKGROUND: Bladder cancer occurs mainly in adults. In children, younger than 10 years in particular, it is very rare. OBJECTIVES: The aim of the study is to retrospectively evaluate the efficacy of transurethral resection of the bladder tumour (TUR-BT) of transitional cell carcinoma (TCC) of the bladder in children. MATERIAL AND METHODS: Transurethral resection of the bladder tumour was performed in 7 boys aged 4 to 17 years (median 12.1 years). In all cases laboratory tests, ultrasound, and cystoscopic tumour biopsy were carried out prior to the resection. Doxorubicin was additionally instilled intravesically as one dose in two patients. The Foley catheter was left in the bladder for 1 to 4 days (median 1.85 days). The follow-up period ranged from 10 months to 10 years (median 4 years). RESULTS: Papillary urothelial neoplasm of low malignant potential (PUNLMP) was diagnosed in 5 patients and urothelial papilloma in 2. Local recurrence was observed in one case two years after the resection. In all other cases complete remission was achieved. CONCLUSIONS: Transitional cell carcinoma of the bladder in children is usually benign and endoscopic treatment (TUR-BT) seems to be the treatment of choice. To determine a follow-up schedule a more substantial group of children with bladder cancer should be analysed.

An evaluation of the effectiveness of external urethral meatus incision in girls with an anterior deflected urinary stream and symptoms of detrusor overactivity.

BACKGROUND: Urethral stenosis or abnormalities in the external urethral meatus in girls may lead to serious functional bladder outlet obstruction and recurrent urinary tract infections. OBJECTIVES: The aim of the study was to analyze the efficacy of meatotomy in girls with an anterior deflected urinary stream (ADUS) and symptoms of detrusor overactivity. MATERIAL AND METHODS: A group of 67 girls between the ages of 5 and 16 (mean age: 8.6 years) with symptoms of detrusor overactivity participated in the study. The girls were treated with oxybutinin in the years 2010-2011. The group included 37 girls with ADUS (the ADUS group) while the remaining 30 girls (the OXY group) were found to have a normal urinary stream. In the ADUS group an external urethral meatus incision was performed. The follow-up period was three months. The presence of urinary tract infections (UTI) as well as nocturnal bedwetting and daytime incontinence were analyzed before and after treatment. RESULTS: After three months, in the ADUS group no UTI was found in 12 children (32%) (p < 0.05), including 11 patients with prior febrile UTI (p < 0.05). Recovery from daytime urinary incontinence was observed in 20 girls (54%) and recovery from nocturnal bedwetting in 8 girls (22%). In the OXY group no infections were found in three girls (10%); recovery from daytime urinary incontinence was noted in 21 girls (70%) and from nocturnal bedwetting in 10 girls (33%). CONCLUSIONS: Girls with symptoms of detrusor overactivity accompanied by an anterior deflected urinary stream experience UTIs and fever more often than girls with detrusor overactivity and a normal urinary stream. An incision in the external urethral meatus in girls with ADUS and detrusor overactivity seems to be effective treatment for recurrent urinary tract infections, especially febrile ones.

Acute appendicitis in children under 3 years of age. Diagnostic and therapeutic problems.

AIM: Analysis of diagnostic and therapeutic problems in acute appendicitis in children below 3 years of age. MATERIAL AND METHODS: The analysis was based on medical data of 53 children under 3 years of age, treated in our department for acute appendicitis in the years 1988-2008. Among 53 children, 29 (53.7%) were admitted directly to the surgical department and 24 (45.3%) were transferred from the regional pediatric department. In the period of 1 month before admission to the surgical department 13 patients (24.5%) were treated as outpatients due to acute respiratory or alimentary tract infection. On the basis of the data from the case histories, the most frequent symptoms and their duration were evaluated, as well as the clinical signs, intraoperative diagnosis and the postoperative course. RESULTS: The most frequent symptoms and clinical signs in this group of children were: abdominal pain, vomiting and fever, present in 83.0%, 75.5%, and 67.0% patients respectively. The mean time of the symptoms' duration was 3.6 days. The most frequently found physical signs on admission to the surgical ward were: abdominal pain on palpation, increased tonus of abdominal muscles and abdominal distension. On laparotomy gangrenous appendicitis was found in 49% of the children operated. In 24.5% of patients perforation of the appendix was confirmed. Further complications occurred in 9 children (16.9%). The average stay in hospital after the operation lasted 7.9 days. CONCLUSIONS: 1. Acute appendicitis in small children is a diagnostic problem not only for primary health care doctors but also for experienced pediatricians and pediatric surgeons. 2. Early surgical consultation should be a standard procedure in small children with acute symptoms of various locations when there is accompaning abdominal pain, not reacting to conservative treatment. Surgical consultation is also indicated in children under 3 years of age with relapses of abdominal pain. 3. Clinical signs of appendicitis in children aged less than 3 years, may differ from those in older children due to changes in their immunological reactivity. This problem should be included in under-graduate and post-graduate medical studies.

Thoracoscopic repair of tracheoesophageal fistula and esophageal atresia.

PURPOSE: To evaluate the safety and efficacy of the thoracoscopic repair of esophageal atresia and tracheoesophageal fistula (EA/TEF). METHODS: From August 2005 to March 2008, 23 consecutive patients (16 boys, 7 girls) weighing 1,070 to 3,390 g underwent thoracoscopic EA/TEF repair. Nine cases had associated malformations. Two 5-mm and one 2.5-mm trocars were placed. The 5-mm 25- to 30-degree telescope was preferred. A pneumothorax was maintained with 5 to 6 mm Hg. The azygos vein was never divided. The TEF was closed with 5-mm titanic clips mainly.The esophageal anastomosis was made over 6-French nasogastric tube by three to seven simple stitches of 5-0Vicryl. The 8-French chest tube was left without suction. The enteral feeding was usually started on postoperative day 3 or 4. Barium swallow was performed on postoperative day 5 or 6, then the chest tube was removed. RESULTS: All procedures were successfully completed without conversion. The average operative time was 131 minutes (range, 55-245 minutes) with significant improvement after gaining experience (mean, 171 minutes for first 10 cases and 98 minutes for last 13 cases). There were two cases of accidental tracheal opening. The anastomotic leak rate was 13% (three cases), and all were healed on conservative treatment. Four cases required one to three courses of anastomotic stricture dilatations. There were three deaths (13%) of causes not related with performed operation. CONCLUSIONS: The thoracoscopic repair of EA/TEF is effective method, and based on our experience, it is the procedure of choice if performed by an experienced endoscopic pediatric surgeon. The intraoperative complications observed if properly managed have a good prognosis.

Closure of large myelomeningocoele with Ramirez technique.

INTRODUCTION: The authors present their 7-year experience in operative closure of large open myelomeningocoele with a technique introduced by Ramirez et al. in 1986. It consists of medial advancement of bilateral bipedicled musculocutanous flap based on the latissimus dorsi and maximus gluteus without any relaxing incisions or skin grafting. RESULTS AND DISCUSSION: Thirty-five babies were operated on according to this technique on first day of life. In 16 cases, large thoracic or thoracolumbosacral defect was noted, while in further 19 newborns, lumbosacral or lumbar defect occurred. The dimensions of the entire defect ranged from 4.8x5 to 8x10.8 cm. In seven babies, the affected area had more than 50 cm(2). In all patients, three-layer tension-free closure of the dorsal wound was performed in one stage. The mean operative time was 115 min (90-195 min). All but two wounds healed uneventfully. In two babies with wide lumbosacral defects, minor skin necrosis with wound dehiscence was noted which subsequently required conservative treatment. Follow-up period ranges from 6 months to 7 years. In none of the 32 children was any late complication of the reconstructive procedure noted. CONCLUSION: Ramirez technique is a very reliable method of closure of myelomeningocoele regardless of the size of the defect and its topography. It may find a wide application in babies affected by neural tube defect.