Long term outcomes of Cohen's cross trigonal reimplantation for primary vesicoureteral reflux in poorly functioning kidney.

BACKGROUND: Open ureteric reimplantation by cross trigonal technique described by Cohen is considered a common surgical option for correction of vesicoureteral reflux (VUR). There is a lack of evidence in literature though for what happens to such kidneys, in the long run, particularly those which are poorly functioning. AIM: To assess the long-term outcomes of ureteric reimplantation in poorly functioning kidneys in children with unilateral primary VUR. METHODS: Children with unilateral primary VUR and a relative renal function of less than 35% who underwent open or laparoscopic ureteric reimplantation between January 2005 and January 2017 were included in the study. Patients who had a follow up of less than five years were excluded. Preoperative evaluation consisted of a voiding cystourethrogram and Dimercaptosuccinic acid (DMSA) scan. In the follow-up period, patients underwent a diuretic scan at 6 weeks and 6 months. Follow up ultrasound was done for change in grade of hydronephrosis and retrovesical ureteric diameter. Subsequent follow up was done at 6 monthly intervals with evaluation for proteinuria and hypertension and any recurrent urinary tract infection (UTI). For assessment of cortical function, DMSA was repeated annually for 5 years after surgery. A paired-samples t-test was used to test the mean difference of DMSA between pre-post observations. RESULTS: During this period, 36 children underwent ureteric reimplantation for unilateral primary VUR. After excluding those with insufficient follow-up, 31 were included in the analysis. Most of the patients were males (n = 26/31, 83.8%). Patient's age (mean ± SD, range) was 5.21 ± 3.71, 1-18 years. The grades of VUR were grade II (1 patient), grade III (8 patients), grade IV (10 patients), and grade V (12 patients). The pre and postoperative DMSA was 24.064 ± 12.02 and 24.06 ± 10.93, which was almost the same (statistically equal, paired-samples t-test: P = 0.873). The median (range) follow-up duration was 82 (60-120) mo. One patient had persistent reflux after surgery (preoperative: grade IV, postoperative: grade III), and the very same patient developed recurrent UTI. The difference in the preoperative and postoperative DRF was less than 10% in 29 patients. In one patient, the DRF decreased by 17% (22% to 05%) while in another patient, the DRF increased by 12% (25% to 37%) after surgery. None of the patients had an increase in scarring after surgery. 15% of patients were hypertensive before surgery and all of them continued to be hypertensive after surgery while none developed hypertension after surgery. None of the patients had significant proteinuria (> 150 mg/d) during the follow-up period. CONCLUSION: Children with unilateral primary VUR and poorly functioning kidney maintain the renal function over the long term in most cases. Hypertension and proteinuria do not progress over time in these patients.

"PTFE Sleeve Graft" Technique to Remove Neurovascular Conflict in Micro Vascular Decompression for Trigeminal Neuralgia.

Background: Microvascular decompression (MVD) of the trigeminal nerve is a well-accepted nondestructive procedure for trigeminal neuralgia. Usually, Teflon (PTFE) puff or felt graft techniques, which are most commonly used, are associated with arachnoiditis and recurrence among other complications. We use the "sleeve graft" technique using PTFE to separate the neurovascular conflict and here we describe our experience with the same in 376 cases. Objectives: To study the outcomes in 376 patients treated with sleeve graft technique for trigeminal neuralgia. Materials and Methods: For a period of 18 years, from 2002 to 2020, all cases of medically refractory trigeminal neuralgia were subjected to the "sleeve graft" technique for MVD. Pre- and post-operatively, pain score was given according to Barrow Neurological Institute pain intensity score. Cases were observed for any complications and pain relief in short and long-term follow-up. Results: In total, 376 cases of refractory primary trigeminal neuralgia cases, among which 198 patients underwent MVD with no prior intervention, 158 underwent MVD following percutaneous ablative procedure, 13 were "Revision MVD" previously done at other centers, and four were post gamma knife failure. There was no incidence of arachnoiditis or recurrence of symptoms. Further, 368 (97.8%) patients had complete recovery from symptoms while eight (2.2%) had partial recovery after 5 years of follow-up. Complications included hearing loss (n = 1), temporary hypoesthesia (n = 45), and permanent hypoesthesia (n = 7). Conclusion: "PTFE Sleeve Graft" technique to remove the neurovascular conflict in micro vascular decompression (MVD) for trigeminal neuralgia is a safe and effective technique that yields better results.

Unique Case of Spontaneous Basilar Artery Stroke in an Operated Child with Craniopharyngioma.

Craniopharyngiomas are the most commonly presented nonglial tumors in child patients. They cause significant morbidity and mortality, both before and after surgery. The most common immediate postsurgery complications are attributable to pituitary insufficiency. Neurovascular complications account for only 2.7 to 2.9% surgical cases, and usually involve the vessels of the Circle of Willis. Thrombosis or vasospasm of the vessels of posterior circulation is unheard of. Here, we are reporting a unique case of a child with craniopharyngioma who developed acute spontaneous basilar artery thrombosis and posterior circulation stroke 6 days after surgery.

Evaluation of polyuria and polydipsia along with other established prognostic factors in posterior urethral valves for progression to kidney failure: experience from a developing country.

BACKGROUND: Up to 50% of children with posterior urethral valves (PUV) progress to kidney failure. This study aimed to evaluate polyuria and polydipsia and other established variables with later development of kidney failure in children with PUV. METHODS: Retrospective analysis of 297 children with PUV who underwent ablation of valves between January 1992 and January 2015 at our tertiary care center. Patients were divided into two groups: those who developed kidney failure (group 1) and those who did not (group 2). Specific prognostic factors for progression to kidney failure were analyzed including age at presentation < 1 year, nadir serum creatinine > 1.0 mg/dl, bilateral grade 3 or higher VUR at diagnosis, recurrent febrile UTIs, severe bladder dysfunction, polyuria, and polydipsia. RESULTS: Thirty-eight (12.8%) patients progressed to kidney failure. Twenty-four and 64 patients were polyuric in group 1 and group 2 respectively (p < 0.001, Z-4.4666). Twenty-two and 61 patients were polydipsic in both groups respectively (p < 0.001). On univariate analysis, predicting variables were as follows: age at presentation < 1 year (p < 0.001), nadir serum creatinine > 1 mg/dl (p < 0.001), B/L high-grade VUR (p < 0.001), severe bladder dysfunction (p < 0.001), recurrent febrile UTIs (p = 0.002), polyuria (p < 0.001), and polydipsia (p < 0.001). On multivariate Cox regression analysis, severe bladder dysfunction, recurrent febrile UTIs, polyuria, and polydipsia were identified as significant prognostic factors predictive of ultimate progression to kidney failure. CONCLUSION: Polyuria and polydipsia along with recurrent febrile UTI and bladder dysfunction are major prognostic factors affecting long-term kidney outcome in cases of PUV. Graphical abstract.

A unique case of concomitant intra and extracranial Hansen's disease.

Leprosy is a debilitating disease that usually involves the peripheral branches of the cranial nerves leading to anesthetic/hypoesthetic skin lesions and thickened peripheral nerves. However, the involvement of the central nervous system (CNS) is extremely rare. To the best of the author's knowledge, the involvement of the cranial nerve nuclei by leprosy has not been reported in the literature and the present case is the first report of involvement of the facial nerve nuclei by leprosy.