Abdominal Compartment Syndrome in a Pediatric Patient With Cloacal Exstrophy.

We present a rare complication of abdominal compartment syndrome (ACS) in a child undergoing complex urologic reconstruction. A 10-year-old female born with the abdominal wall defect cloacal exstrophy who had previously undergone multiple abdominal procedures then developed findings consistent with ACS following a complex Mitrofanoff procedure. Although intravesical pressures were not documented because of the nature of her reconstruction, her ACS-type findings were (1) abdominal pain, (2) melena, (3) pulmonary hypoinflation, (4) renal insufficiency, (5) tachycardia, and (6) segmental ischemic small bowel. Management consisted of abdominal decompression, segmental bowel resections, and wound vacuum-assisted-closure management. Patient was eventually discharged home.

Performance of open renal and bladder surgery at a freestanding pediatric surgery center.

PURPOSE: More ambulatory urological surgeries are being performed in children due to innovations in techniques and trends in medical care. Pediatric ambulatory surgery centers are seeing more complex procedures that were traditionally hospital based. MATERIALS AND METHODS: A total of 343 open renal and bladder procedures were performed by a single pediatric urologist at a freestanding pediatric surgery center (12 miles from a pediatric hospital) between July 2003 and October 2009. Charts were analyzed to determine the demographics and complications necessitating hospitalization within 48 hours of discharge home. RESULTS: During the study period 28 children (mean age 1.62 years, range 4 months to 6 years) underwent nephrectomy, 50 (2.92 years, 3 months to 12 years) underwent pyeloplasty, 216 (4.01 years, 8 months to 21 years) underwent simple ureteral reimplantation and 49 underwent complex ureteral reimplantation (2.79 years, 5 months to 12 years). Two children were acutely transferred to the hospital, 1 for pain management and 1 for respiratory distress. Two additional children were hospitalized within 48 hours, 1 due to partial ureteral obstruction, and 1 due to dehydration and urinary tract infection. All 4 of these patients underwent simple reimplantation surgery. CONCLUSIONS: Carefully selected children undergoing open renal and bladder procedures can be expected to be discharged home on the same day. Older children, those with significant comorbidities and those undergoing procedures later in the day may not be ideal outpatient candidates. Nephrectomy, pyeloplasty and ureteral reimplantation are excellent outpatient procedures for most children.

The efficacy of LMX versus EMLA for pain relief in boys undergoing office meatotomy.

PURPOSE: We determined if a difference in pain management occurred when topical anesthetics LMX (formerly ELA-Max, lidocaine 4%) and EMLA (lidocaine 2.5% and prilocaine 2.5%) were compared in boys undergoing office meatotomy for symptomatic meatal stenosis. MATERIALS AND METHODS: A prospective randomized study was performed on 52 boys who underwent office meatotomy by a single pediatric urologist. Of the boys 26, 2 to 9 years old (mean age 4.4) underwent meatotomy 45 minutes after topical anesthetic application (LMX 13, EMLA 13) between February and December 2001, 26, ages 1 to 10 years old (4.6) underwent meatotomy 30 minutes after topical anesthetic application (LMX 13, EMLA 13) between April 2002 and January 2003. A single pediatric urological nurse performed pain assessment using the Wong-Baker Faces scale before applying the anesthetic ointment and immediately following the procedure. Each child had either LMX or EMLA applied and covered with an occlusive dressing for either 45 or 30 minutes before the procedure. Oral acetaminophen (10 mg/kg) was given at the time of anesthetic application. A meatotomy was then performed using a straight crushing hemostat for 1 to 2 minutes followed by incision. Mann-Whitney rank sum test was implemented to determine statistical significance. RESULTS: Excellent procedure outcomes were experienced by all patients without recurrent meatal stenosis. CONCLUSIONS: There was no significant difference between LMX and EMLA when applied 45 minutes before meatotomy. When applied 30 minutes before meatotomy LMX provided significantly superior pain management than EMLA.

Snodgrass hypospadias repair with vascularized dartos flap: the perfect repair for virgin cases of hypospadias?

PURPOSE: Since its introduction, the Snodgrass hypospadias repair has been applied to virtually all forms of hypospadias repair. However, fistula rates have still been reported to be as high as 5% from large center, multiple surgeon studies and 16% from smaller center studies. We report on the use of the Snodgrass repair in conjunction with routine use of a vascularized dartos flap and 2-layer closure of the neourethra from multiple institutions. MATERIALS AND METHODS: Records of patients who underwent a primary 1-stage hypospadias repair with the Snodgrass technique in conjunction with vascularized dartos flap coverage were reviewed. Nearly identical surgical technique was used by all 6 surgeons in each case, which included a 2-layer closure of the neourethra, preservation of the well vascularized periurethral tissue and routine use of vascularized dartos flap coverage. A total of 514 cases were identified, including 414 with distal and 100 with midshaft or proximal hypospadias. Stents were used in 292 of the 514 repairs. RESULTS: Of the 414 distal cases there were no fistulas and 1 case of meatal stenosis. Of the 100 proximal cases there were 3 fistulas and 1 case of meatal stenosis. The overall complication rate was less than 1% for all cases combined. CONCLUSIONS: This series represents the largest reported multi-institutional experience with the Snodgrass technique. When used in conjunction with vascularized dartos flap coverage, 2-layer closure of the neourethra and special attention to preservation of the periurethral vascular supply, this repair can be performed with a near 0 complication rate. We believe that this is the optimal repair for routine cases of hypospadias.