Does Age Influence the Functional Recovery after Infant Pyeloplasty?

Purpose: The purpose was to study the correlation between age at surgery and functional recovery after infant pyeloplasty. Materials and Methods: All infants who underwent pyeloplasty were analyzed retrospectively in this multicenter study. Anteroposterior diameter (APD) >2 cm, split renal function (SRF) <40%, and Society of Fetal Urology (SFU) grade 3-4 were surgical indications. Based on the age at pyeloplasty, they were divided into Group 1 (1-3 months) and Group 2 (4-12 months). APD and SRF were compared before and after surgery in both groups. The fractional recoverable function (post-SRF-pre-SRF)/(50-pre-SRF) ×100 was correlated with age. Results: Fifty-one infants underwent pyeloplasty (mean age: 1.6 months - Group 1 and 7.2 months - Group 2). The mean APD decreased from 3 cm to 1.2 cm in Group 1 while 2.8 cm to 2 cm in Group 2 (P = 0.001). The mean SRF increased from 32.28% to 42.81% in Group 1 while 31%-34.18% in Group 2. SRF recovery was significantly higher in Group 1 compared to Group 2 (P = 0.001). Regression analysis showed a weak negative correlation (r = -0.2792) between age at surgery and renal function improvement. Conclusion: Functional recovery after pyeloplasty is better when done earlier (1-3 months), as this gives the growing kidney the best opportunity to recover.

Pathology and Surgical Management of Urinary Retention Manifesting After Anorectal Malformation Surgery.

Introduction: Associated congenital anomalies, operative structural injury, and postoperative neurovesical dysfunction combine to cause urinary retention in children with a history of surgery for anorectal malformation (ARM). Aim: To study the presentation and management of urinary retention in patients with a history of ARM surgery. Methodology: Retrospective study. Results and Discussion: Twenty-five children presented with urinary retention with a history of ARM surgery performed elsewhere. There were 17 males (high - 14, intermediate - 2, and low - 1) and 8 females (cloaca). Sixteen children had an abnormal spine. Eight children had urethral injury (total transection - 3) and three had a large residual rectal stump. 41/48 renal units were dilated and 27 refluxing. Seventeen children had abnormal estimated glomerular filtration rate and five had undergone urinary diversion. Management: Definitive surgical management was individualized, the most pertinent consideration being whether normal voiding would be feasible or whether a continent low pressure urinary reservoir with clean intermittent catheterization (CIC) would be a safer option. Operative management included excision of the rectal stump (3), urethral reconstruction (2), bladder augmentation (17), Mitrofanoff port (22), bladder neck closure (2), and antireflux surgery (13). Follow-up estimated glomerular filtration rate had improved/normalized in all but two patients. HUN resolved/improved in all and 25/27 refluxing units ceased refluxing. All are socially continent with ten voiding normally and the rest on CIC. Conclusion: Urinary retention after ARM surgery is multifactorial and requires prompt recognition and possibly urinary diversion. Final reconstruction aims at achieving continence with safe upper tracts. Urethral voiding is possible in the selected cases.

Pseudoaneurysm of Cavernosal Artery Presenting as Priapism in a 7-Year-Old Boy.

Priapism due to pseudoaneurysm of the cavernosal artery is very rare. Herein, we describe the magnetic resonance imaging and digital subtraction angiographic findings of pseudoaneurysm in the right corpus cavernosum in a 7-year-old boy who presented with pain in the penis and lower abdomen and priapism with an obscure history of trauma. This was managed by endovascular embolization of the aneurysm. One-year follow-up has shown him to be normal without any symptoms and normal erection.

A Rare Case of Pediatric Osteochondroma Presenting as Hemothorax.

Isolated osteochondroma presenting as hemothorax is a rare entity. A 7-year-old boy presented with respiratory distress and diagnosed with hemothorax, and computed tomography showed osteochondroma and removal with resection of the rib was curative.

Urinary Tract Infection in Pediatric Patients on Clean Intermittent Catheterization via a Mitrofanoff port with Reused Catheters - Any Association with Catheter Sterility?

OBJECTIVE: The objective of this study is to find out whether the reused catheters for clean intermittent catheterization (CIC) are colonized before insertion and its association with urinary tract infection (UTI). MATERIALS AND METHODS: This is a study conducted on 28 pediatric surgery patients who are on CIC via a Mitrofanoff port and who were reusing catheters, in a tertiary care private medical college hospital for 6-month period. Catheters to be used for the next catheterization were sent for culture along with urine culture. A questionnaire was utilized to assess CIC practice and UTI. RESULTS: Diseases of patients were: neurogenic bladder and exstrophy-epispadias and posterior urethral valve. Twenty-one of them had an augmented bladder. Hydronephrosis was present in ten and vesicoureteral reflux (VUR) in five. Their mean duration of CIC was 5.3 years. Of 28 catheter tip samples, 16 catheters were colonized with organism. Of the 28 urine culture samples, 17 cultures were positive and all were asymptomatic except one. Of the 16 positive catheter samples, only 9 had positive urine culture; four of them had grown different organisms and five of them had the same organism, and even in these five, single organism was seen only in three. Urine culture grew Gram-negative organism in 85%, but catheter grew Gram-positive organism in 46%. No difference was found in the variables between both groups such as hydronephrosis, VUR, and augmented bladder. CONCLUSION: Reused catheters were colonized in 57% of the study patients, but reused catheter may not be the cause of culture positivity or UTI in the study population.

Parental Satisfaction with Pediatric Day-Care Surgery and its Determinants in a Tertiary Care Hospital.

OBJECTIVE: The objective is to assess the level of parental satisfaction of pediatric day-care surgery and its different determinants. MATERIALS AND METHODS: This is a descriptive study performed in a tertiary care hospital in India among parents of pediatric day-care surgery patients from June 2013 to March 2015. The core questionnaire for the assessment of patient satisfaction for general day care (COPS-D) was used. Variables related to surgery, overall satisfaction, one open-ended question, and socio-demographic data were also collected. Calculated sample size was 121. RESULTS: The mean and standard deviation of parental satisfaction were estimated in eight domains of day care (COPS-D) using Likert scale 1-5. Preadmission visit had a mean of 4.63 (0.52), day of surgery 4.65 (0.58), operating room 4.76 (0.51), nursing care 4.46 (0.79), medical care 4.89 (0.48), information 4.51 (0.68), autonomy 4.64 (0.56), and discharge 4.50 (0.72). In elder children, there was less satisfaction on the information and discharge domains. Overall satisfaction was good in 88% of patients and was less than satisfactory when they had significant pain. CONCLUSION: Perception of quality of pediatric day-care surgery was assessed with a questionnaire and was found to be good. Variables related to surgery such as pain may be included in the questionnaire for assessing satisfaction in the day-care surgery.

Females with Externally Visible but Stenosed Fecal Orifice - Low or High Anorectal Malformation.

We report four female children with externally visible but stenosed fecal orifice which proved to be a high anorectal malformation (Type IV pouch colon). They were managed by an abdominoperineal approach with excellent results. We emphasize the correct recognition of this pathology.

Lumbar lipomeningomyelocele associated with multiple café au lait spots: a case report.

We report on a child with several café au lait spots in association with a lumbar lipomeningomyelocele as an apparently new association. Cutaneous markers, the identification of which plays a crucial role in the early diagnosis and management of spinal malformations, can accompany occult spinal dysraphism. Herein we report a case of lumbar lipomeningomyelocele associated with an overlying café au lait spot that served as a marker of occult spinal dysraphism. The patient also had segmental café au lait spots on the face, making the association unique.

Ex-utero intrapartum treatment in the Indian scenario: Anesthetic challenges and positioning.

Ex-utero intrapartum treatment (EXIT) is performed for fetuses diagnosed with large neck masses. A case report of a fetus diagnosed with a large cystic hygroma and cord around the neck who was delivered by EXIT is presented. The airway challenges and optimal positioning is discussed.

Ileo-caecal doughnut bladder augmentation in children with exstrophy- epispadias complex- a study of 100 cases.

AIM: The small bladder in failed exstrophy needs to be augmented and also accommodate bladder neck surgery, ureteric re-implantations and a catheterizable channel. We present a novel method of ileocecal bladder augmentation providing a non-implanted, un-detached appendicular channel, rendered non refluxing by an ileal "fundoplication". The colonic segment could receive ureteric reimplantation when bladder plate is unsuitable. MATERIALS AND METHODS: Operative technique: Bilateral cephalo-trigonal reimplantation and bladder neck surgery is done. The ileocecal segment is isolated and arranged as a ring (doughnut) around the un-detached appendix which is made to pass behind the terminal ileum, through the ileal mesentery and then in front of the ileum as it exits as a catheterizable channel. The bowel segment is opened on the antimesenteric aspect except for the retro appendiceal ileal segment. The opened ileo-caecum is reconfigured as a de-tubularised augmentation pouch while the retro appendiceal ileal segment is wrapped around the appendix like a fundoplication. The colon segment may receive the ureteric reimplantation if required. CASE MATERIAL: 100 children (mean age 6.3 years) with failed exstrophy underwent doughnut augmentation (3 neobladders) in 2006-2021. Ninety eight were incontinent, with 30 open/dehisced bladder plate, 48 units were hydronephrotic (HUN), 105 ureters were refluxing (VUR) and eGFR was subnormal in 20 children. 79 children underwent YDL bladder neck plasty and 23 underwent bladder neck closure (primarily in 18). Three infants with HUN did not undergo bladder neck surgery. 126 ureters were reimplanted into the bladder, 44 into the colon segment while 30 were not reimplanted. RESULTS: 95 children are continent on CIC, which was gradually introduced starting with once or twice daily change of indwelling Mitrofanoff catheter leading to regular 3-4 hourly CIC as the child became confident. The appendicular channel was easily catheterizable without any leak in 95, had minor issues in 4 while one necrosed and replaced by a gastric tube. HUN recovered (25/48) or stabilized with a significant reduction in the grade of hydronephrosis (p = 0.001). VUR resolved in 90% of bladder reimplants, 85% of colonic reimplants and 70% of non-reimplanted ureters. In the 20 children with compromised renal function eGFR improved (71-106 ml/m2/min) significantly (p = 0.036) at follow up (mean 5 years). Urodynamics study (N = 33) showed a mean capacity of 95% of expected bladder capacity (EBC) with end filling pressure less than 25 cm of water (Mean end filling cystometric pressure = 15 cm of water). Complications included adhesive intestinal obstruction (N = 16) and bladder calculi (N = 12). CONCLUSION: The doughnut ileocecal augmentation provides a easily catheterizable, non-refluxing, appendicular channel, not requiring isolation of the appendix nor its reimplantation into the bladder. The colonic segment can provide a bed for ureteric reimplantation. Dryness with a good capacity bladder and preserved upper tract is achieved.

Neonatal segmental enteritis due to cow's milk allergy.

Cow's milk protein allergy (CMPA) typically presents with persistent diarrhea or dysentery, vomiting and bleeding per rectum in young infants. CMPA is reported to mimic Hirschsprung's disease and malrotation. We report, a neonate who presented with recurrent attacks of segmental enteritis due to CMPA and the last episode presented with signs of peritonitis. He improved dramatically after elimination of cow's milk from his diet. CMPA should be considered in artificially fed babies with surgical abdomen and atypical clinical signs and symptoms.

A Case Series of Fetal-Neonatal Ovarian Cyst from a Tertiary Care Hospital.

The occurrence of ovarian cyst in the neonate is rare and antenatally diagnosed by ultrasonography. This study aims to increase awareness about its occurrence and histological features. We performed a retrospective review on 10 cases of neonatal ovarian cyst (NOC) during 4 years (2016-2020) in a tertiary care center in South India. The neonates were diagnosed with abdominal cysts by the antenatal ultrasonogram in the third trimester. They were operated from day 5 to 35 days of age. There was no side predilection, and most of them were unilateral (9 out of 10 cases). Histopathological examination showed simple cysts (50%), serous cystadenomas (20%), cyst with no viable lining (20%), and follicular cyst (10%) and 90% of the cysts had torsion-induced changes. The pathologist and the clinician should be aware of the occurrence of serous histology in NOC cases.

Urethral reconstruction in aphallia using transpubic exposure and colonic monti neo-urethra - An addition to the De Castro reconstruction.

INTRODUCTION: Fashioning a functioning neo urethra in a boy with aphallia is one of the unsolved problems in this condition. AIM: We present our technique and outcome of operative exposure and neo urethral construction in four aphallic boys. MATERIALS AND METHODS: Retrospective study of the records of four aphallic boys operated in the period 2015-2019 was undertaken. The demographics, presentation, operative procedure, current follow up and voiding outcome was noted. RESULTS: The neo phallus was constructed by the De Castro technique in four aphallic boys aged 1-8 years. Pre operative assessment revealed bladder outflow obstruction in two and urinary incontinence in one boy. The operative exposure afforded after reflection of the De Castro flap was utilized in doing a limited pubic symphysiectomy. This exposed the bladder neck, urethra and the urethral termination into the ano rectum. The healthy native urethra was isolated by disconnecting it from its ano rectal termination and a neo urethra constructed from a segment of proximal sigmoid colon by its reconfiguration into a Monti type tube. The neo urethra was then anastomosed to the native urethra and laid within the bed of the De Castro flap so as to reach the neo phallic termination. The De Castro flap was then tabularized over the neo urethra to form the new phallus. Appendicular or ileal Monti Mitrofanoff was also added to the reconstruction. Three boys are voiding well. One boy had a partial bladder outflow obstruction resulting from operative correction of incontinence and is dry on intermittent catheterization. Follow up was for 1-4 years and upper tracts are stable or improved. CONCLUSION: We describe the transpubic approach to the construction of a reliable neo urethra in the form of a Monti tube from the sigmoid colon in four boys with aphallia. We believe this to be a useful addition to the De Castro procedure for neo phallic construction.

Non-obstructive, non-refluxing uretero-colonic anastomosis by colonic sero-muscular excision and extra mural peri-ureteric wrap - A new technique in 17 children.

INTRODUCTION: Uretero-enteric anastomosis with concomitant neobladder/augmentation/conduit becomes necessary when the bladder is unavailable or unfit for reimplantation or the ureters are short after high diversion or resection of lower ureteric pathology. Aiming to prevent both obstruction and reflux, we report a novel technique of sero-muscle denuded extra mural uretero-colic anastomosis. OPERATIVE TECHNIQUE: (Fig 1) The ureter was brought through the colonic mesentery. An adjacent zone of colon "abcd" was chosen to receive the ureter and colonic sero-muscular layer was excised from this zone. The ureter was placed on the raw area and uretero-colic anastomosis was done (a-d).The edges of the sero-muscular layer (ab and cd) were sutured over the ureter to complete a submucosal tunnel. The augmentation/neo bladder was completed such that the implanted ureter lay within it between two regions of re-configured bowel, this adding to the anti-reflux mechanism created by the extra mural peri-ureteric wrap. AIM: Surgical audit of this technique. MATERIALS AND METHODS: 17 children (exstrophy - 8, ectopic ureter with bladder agenesis/hypoplasia - 3, prune belly - 2, neurogenic bladder -2, eosinophilic cystitis -1 and posterior urethral valve -1) underwent colonic implantation of 23 ureters while 6 ureters were drained via a trans uretero-ureterostomy into the reimplanted ureter. Nine augmentation, seven neo bladders and one sigmoid conduit was performed. The colon was available for ureteric re-implant in all patients. RESULTS: Pre-operatively 21 had hydroureteronephrosis. The bladder was agenetic/hypoplastic, small and fibrosed or poorly compliant. Eleven ureters had been diverted. Post operatively (mean follow up - 3.4 years) 16 of 30 renal units were normal, 11 had mild and three had moderate residual hydronephrosis, with no new hydronephrosis. Cystogram showed no reflux in 14 children and unilateral reflux in three (one re-diverted). Of 29 renal units drained directly or via trans uretero-ureterostomy by the uretero-colic reimplantation, none are obstructed, 26 have no vesico-ureteric reflux while three (10%) have reflux. DISCUSSION: We report results comparable to other extra mural techniques into the bowel, mainly from adult literature. Pediatric refluxing ureters are often large megaureters with or without preliminary diversions. The technique described avoids obstruction although having a slightly higher incidence of recurrent VUR. The ureters with recurrent reflux were massively dilated preoperatively and showed decrease in ureteric diameter postoperatively. The wrap, made for a larger ureter could have become too roomy and allowed reflux. CONCLUSION: This technique of non refluxing non obstructive uretero-colonic anastomosis has proven useful in selected situations.

Paediatric bladder neurofibroma on bilateral ureterostomy: rare case report-strategic management.

Urogenital involvement in neurofibromatosis is extremely rare and thus is less documented. Herein, we discuss a 11-year-old boy who was referred with a diagnosis of neurofibroma bladder on bilateral flank ureterostomy with mild renal failure. A diagnosis of neurofibroma of the bladder with ureterohydronephrosis had been made and partial excision had been attempted, followed by bilateral ureterostomy because of increasing ureterohydronephrosis. He was 13 years and wanted to be dry as he wanted to go to school. With the plan of attaining dryness with stable upper tracts, he was posted for surgery. Near-total excision followed by a sigmoid conduit was performed. The biopsy was reported as plexiform neurofibroma and is on regular follow-up, dry on a stoma bag with stable renal parameters.

Working classification and the quest for an effective, reconstructive management strategy in Y duplication of male urethra.

INTRODUCTION: Y-duplication is a rare subtype of urethral duplication whose surgical correction has traditionally yielded less than satisfactory results. Herein we report 18 patients, 17 of whom have completed successful urethral reconstruction. MATERIALS AND METHODS: A retrospective analysis was done on 18 children who have undergone repair of Y-duplication urethra in two tertiary care institutes from 2013 to 2020. The various subtypes encountered were classified in order to develop a rationale for reconstruction based on the underlying pathology. The various modalities used for reconstruction and the outcomes of the repair were studied. All but one boy voided mainly via the posterior (ventral) channel opening in the ano-rectum or perineum. These boys had the urethral reconstruction incorporating the healthy proximal ventral urethra at its origin. Further reconstruction up to the glans tip depended on the degree of dorsal (orthotropic) urethral patency, which forms the basis of our classification into Types I (completely stenotic), II (penile urethra patent), III (penile and bulbar urethra patent) and IV (fully patent dorsal urethra). RESULTS: Reconstruction resulting in voiding via a glanular or coronal meatus was completed in 17 boys. One boy is awaiting further surgery while being dependent on Mitrofanoff CIC. While urethral continuity could be achieved using patent segments of native urethra alone into two boys (Types II and III), all other children needed a neo-urethral segment to replace (Type I) or supplement (Type II) the dorsal urethra. Neo urethra was constructed from a tubularized preputial island flap (n = 11), Monti tube constructed from ileum (n = 3) or sigmoid colon (n = 4). A perineal operative exposure alone sufficed in 9, while the rest required an additional trans pubic approach. The only boy with Type IV anomaly underwent excision of the ventral urethral limb. Three boys with initially elevated serum creatinine have normal levels after reconstruction. CONCLUSION: Successful reconstruction of boys with Y- duplication of the urethra entailed elucidation of anatomical variations, adequate operative exposure (trans pubic and/or perineal) and innovative utilisation of local and/or distant tissues (preputial island flap, ileal/sigmoid Monti tubes).

Profile and Epidemiology of Intussusception in Children Under-Two Years of Age: A Prospective Surveillance.

OBJECTIVE: To report background intussusception epidemiology in children under-two years in Coimbatore district of Tamil Nadu state, India, prior to rotavirus vaccine (RVV) introduction. METHODS: Prospective sentinel surveillance was done at four hospitals in Coimbatore during April 2016 to September 2017. The children aged >1 mo and < 24 mo with diagnosed intussusception were recruited and data on clinical, treatment, diet, immunization, and sociodemography were collected. RESULTS: Sixty-eight children with intussusception were recruited. Among them 76.5% were infants with male predominance (57.4%) and 48.5% were 4-8 mo old. Vomiting (83.8%), pain in abdomen (including excessive crying) (72.1%), and bloody stools (45.6%) were the main symptoms. Reduction was tried in 92.6% cases with success in 83.8%. Surgery was needed by 16.2% children. No child died. Any RVV dose was received by 24.1% children and 2 children received RVV in 8-21 d and none within 1-7 d window. The incidence of intussusception requiring hospitalization was estimated to be 36.4 and 11.7 cases/100,000 children/y for the first and second years, respectively. CONCLUSION: Intussusception occurred in infants even without RVV exposure. Continued surveillance is needed to document the changes in intussusception epidemiology after RVV introduction.

An approach to giant neonatal hydrocolpos with normally sited anus - Diagnosis and management including a novel one stage operation.

INTRODUCTION: Giant non cloacal neonatal hydrocolpos is a rare entity where early recognition of the underlying cause and drainage of the distended vagina is paramount. Conventionally, immediate management has been by abdominal tube vaginostomy or, in urogenital sinus by vaginal clean intermittent catheterisation (CIC). Though effective in providing temporary relief, the abdominal tube vaginostomy is replete with complications, making it imperative to search for alternatives. Here we describe our method of emergent and definitive management of these children, where definitive repair, depending on the aetiology, has been made possible in a single stage. MATERIAL AND METHODS: Seven girls who presented primarily or with history of giant non cloacal neonatal hydrocolpos at two tertiary care centres from January 2013 to March 2021 were studied retrospectively. None had imperforate anus or a bulging hymenal membrane. Four had high vaginal atresia (VA) and three had Urogenital sinus (UGS), one with high confluence. Four girls (2 VA, 2 UGS) presented to us as neonates and were managed by emergency drainage procedures other than tube vaginostomy: CIC in one (low UGS) and a novel abdominoperineal U flap vaginoplasty in three (2 VA, 1 high confluence UGS) which was also the definitive procedure. This procedure involved fashioning an inferiorly based inverted U flap from the posterior wall of distended vagina which is tubularised and flipped down by an abdomino-perineal procedure. The girl with a low UGS later underwent a perineal procedure. Three presented elsewhere as neonates (2 VA, 1 UGS) and had abdominal tube vaginostomy as the emergency drainage procedure. This was complicated by tube dislodgement and pyocolpos till successful reconstruction was performed by us. Successful reconstructions included the abdominoperineal U flap vaginoplasty in one (VA) and a perineal procedure in another (low UGS). One girl with high VA had an inflamed vagina after tube vaginostomy, precluding the U flap vaginoplasty, and underwent abdominal vaginal mobilisation and pull through complicated by partial vaginal necrosis with septic complications. RESULTS: Reconstruction resulted in a patent and a good calibre neo-vagina in all at a mean follow up of 48 months. CONCLUSION: Immediate management of giant non cloacal neonatal hydrocolpos may either be vaginal CIC or a surgical procedure. The abdomino-perineal U flap vaginoplasty is a one stage neonatal procedure that provides effective drainage and forms a definitive neo-vagina. An abdominal tube vaginostomy can be avoided except where neonatal surgical expertise is unavailable.