Ureteroinguinal Herniation with Consecutive Ureteral Stricture in a 2-Month-Old Infant: Case Report.

Inguinal herniation of ureter is an uncommon finding among children, with scarce reported cases in the literature to date, that can potentially lead to obstructive uropathy. We report a case of ureteroinguinal herniation discovered during an inguinal hernia repair in a patient with antenatally ultrasound finding of hydronephrosis. A 2-month-old infant with antenatal left hydronephrosis presented with left inguinal mass. Preoperative ultrasound showed an anechoic tubular image producing a mass effect on the left testicle, with suspected bladder herniation and/or dilated ureter toward the inguinal canal. An open surgical inguinal exploration was performed, where the left inguinal canal revealed a peritoneal sac and sliding of the dilated left ureter behind the sac, with a significant change in diameter, corresponding to the paraperitoneal variant of ureteroinguinal herniation. Ligation of the sac and replacement of the ureter into the retroperitoneum were performed, with improvement in the hydronephrosis observed on the ultrasound 1 month after the intervention. However, 6 months later, hydronephrosis worsening as well as the obstructive pattern observed in the diuretic renogram required removal of the stenotic ureteral segment and reimplantation of the healthy proximal segment in the bladder by open approach (Cohen's reimplantation). Follow-up ultrasound of the renal tract showed no dilatation of the upper renal tract and the renal function tests were normal. Currently, the patient is 2 years old and he remains asymptomatic. In conclusion, s igns of ureteral obstruction such as hydronephrosis in patients with inguinal herniation may suggest the possibility of an ureteroinguinal hernia. Preoperative diagnostic suspicion is essential.

Neonatal Paratesticular Abscess as the Greatest Mimicker of Testicular Torsion.

INTRODUCTION: The management of acute scrotal swelling can be challenging in neonatal age, with scrotal abscess being great mimickers of testicular torsion. CASE PRESENTATION: We report a 12-day-old previously healthy male infant who presented with 72 h of increasing right-sided scrotal swelling, without fever or irritable behavior. The left testicle was palpable, but the right side was too swollen to palpate a testicle, with absent cremasteric reflex. Biochemical analysis was normal and Doppler sonography demonstrated a hypoechogenic avascular lesion compressing the right testis, without intratesticular flow. Due to these findings, surgical exploration was undertaken on suspicion of potential testicular torsion. Purulent material was encountered and cultured. The testis and epididymis were covered by thick necrotic fibrinous exudate, with no spermatic cord torsion. Gentamicin and vancomycin were begun immediately. The patient remained afebrile and the scrotal induration gradually subsided. Urine and blood cultures were sterile. On the second postoperative day, cultures yielded Escherichia coli sensitive to gentamicin. One-month follow-up testicular ultrasound demonstrated complete inflammation resolution. CONCLUSION: Paratesticular abscess may be considered as the greatest mimicker of testicular neonatal torsion, due to the frequent absence of classical signs of inflammation. Early surgical exploration can be diagnostic and therapeutic and should be performed in these cases.

Neutrophil-to-lymphocyte ratio as a predictor of primary vesicoureteral reflux evolution in children with associated acute pyelonephritis.

Background: Neutrophil-to-lymphocyte ratio (NLR) has been recently postulated as an inflammatory biomarker for the diagnosis of vesicoureteral reflux (VUR). The aim of this study is to determine the role of NLR as a predictor of evolution of primary VUR in patients with associated acute pyelonephritis (APN). Methods: A retrospective observational cohort study was performed in patients with APN episodes with associated primary VUR diagnosed between 2013-2020. Patients were divided into two groups according to VUR evolution after APN: group A [spontaneous resolution (SR)] and group B [VUR complications development (CD) during follow-up: new APN or renal function worsening]. Demographic, prenatal, laboratory, microbiological and radiological data were analysed. Sensitivity and specificity for CD of VUR was determined by receiver operating characteristic (ROC) curves. Results: A total of 1,146 episodes of APN were analysed of which 273 patients with APN and associated primary VUR were finally included (median age of 11 months at APN diagnosis). SR of VUR occurred in 169 patients (SR group), while CD were observed in the remaining 104 patients (CD group). No differences in demographic, prenatal, microbiological and radiological features were observed. CD patients had significantly higher levels of leukocytes, neutrophils, NLR, C-reactive protein and creatinine. NLR was the parameter with the highest area under the curve (AUC =0.966) for predicting the development of VUR complications (cut-off point =3.41) with a maximum sensitivity of 92.7% and specificity of 91.1% (P<0.001). Conclusions: NLR may be considered as a simple and cost-effective predictor of clinical outcome of VUR, which may correlate with the increased risk of developing complications of primary VUR after an episode of APN. Therefore, it should be included in the management algorithm for these patients, although future prospective studies are still required to confirm these results.

Management of Recurrent Sigmoid Volvulus in the Pediatric Population.

Sigmoid volvulus is a rare etiology of bowel obstruction in the pediatric population that can be easily misdiagnosed, leading to delayed treatment and potential complications. Given that sigmoid volvulus is a common cause of bowel obstruction in the adult population and the significant lack of literature on its management in children, treatment strategies for pediatric patients often follow standardized protocols for adults. We report the case of a 15-year-old boy who presented with recurrent episodes of sigmoid volvulus over a 1-month period. Computed tomography demonstrated a sigmoid volvulus without evidence of ischemia or bowel infarction. Colonoscopy demonstrated a descending megacolon, and bowel transit studies demonstrated normal transit time. Acute episodes were managed conservatively with colonoscopic decompression. After a complete study, laparoscopic sigmoidectomy was performed. This work demonstrates the importance of early recognition and treatment of sigmoid volvulus in the pediatric population to limit recurrent episodes.

Intraoperative high-field resonance: How to optimize its use in our healthcare system.

BACKGROUND AND AIMS: Intraoperative MRI (ioMRI) consists of performing a MRI during brain or spinal surgery. Although it is a safe and useful technique, it is available in a few hospitals. This means some aspects are not perfectly defined or standardized, forcing each center to develop its own solutions. Our goal is to describe the technique, evaluate the changes made to optimize its use and thus be able to facilitate the intraoperative resonance implementation in other neurosurgery departments. METHODS: A prospective analysis of patients consecutively operated using high-field ioMRI guidance was carried out, describing the type of tumor, clinical data, time and sequences of ioMR, use of intraoperative neurophysiology, preoperative tumor volume, after ioMR, and postoperative, as well as complications. RESULTS: ioMR was performed in 38 patients selected from among 425 brain tumors (9%) operated on in this interval. The tumor types were: 11 glioblastomas, 8 anaplastic astrocytomas, 5 diffuse astrocytomas, 4 meningiomas, 3 oligodendrogliomas, 2 metastases, 2 epidermoid cysts, 1 astroblastoma, 1 arachnoid cyst and 1 pituitary adenoma. The mean age was 45 years. The mean preoperative tumor volume was 45.22cc, after the ioMR 5.08cc and postoperative 1.28cc. Resection was extended after ioMR in 76%. Gross total resection was achieved in 15 patients and residual tumor of less than 1cc was observed in 8. An intentional tumor tissue was left in an eloquent brain region (mean volume 7cc) in 13 patients. Bleeding and ischemia complications were detected early on ioMR in 5%. MRI length was 47 min on average. CONCLUSIONS: Intraoperative MRI was a useful and safe technique, and no associated complications were registered.

Use of hem-o-lok clips for laparoscopic appendectomy in children: retrospective analysis and comparison to ligature loop and endoscopic surgical stapler.

BACKGROUND: There are multiple techniques used for laparoscopic appendectomy (LA): ligature loop (LL), surgical stapler (SS) (Endopath Ets-Flex-Endoscopic Articulating Linear Cutter 33 mm Standard Ref Atb 35. Ethicon, Somerville, New Jersey, US), and hem-o-lok clips (HOL) (Weck Closure System. Triangle Park, NC, USA). The application of the LL usually demands dexterity and training, whilst using HOL may be more advantageous due to its simplicity in terms of application and its low cost in contrast with the SS. The objective of this study is to determine safety and efficacy of the different devices that can be used in the surgical procedure. METHODS: From June 2016 to December 2019, 253 consecutive children aged to 1 to 18 years were retrospectively reviewed. They were divided into three groups depending on the device used to secure the appendix: (I) in the first group, the base of the appendix was secured by double LL, (II) in the second group the base of the appendix was secured with SS, and (III) in the third group the base of the appendix was secured with two non-absorbable HOL. The data collected includes age, gender, operative time, device used to ligate the base of the appendix, previous tests (blood analysis, imaging), antibiotic prophylaxis administered, length of hospital stay, intraoperative and postoperative complications, shoulder pain and histological study of the specimen. RESULTS: There were 253 patients that underwent laparoscopic appendectomy during the study time, with a mean age of 10.3±4.1 in the LL group, 9.4±2.7 in the SS group and 10.4±3.3 in the HOL group, P=0.165. Distribution by gender was 77.8% for males in the LL group, 65.2% in the SS group and 61.3% in the HOL group, P=0.559. The mean surgical time with IQR in brackets was 60.0 (10.0) minutes (min), in the first group in which the base of the appendix was secured with LL, in the second group in which the base of the appendix was secured with SS 60.0 (15.0) min and finally in the third in which the base of the appendix was secured with HOL 40.0 (30.0) min, P<0.001. HOL clips have a significantly lower cost than their analogues. Specifically, 5 HOL clips have a cost of EUR 26.75, while three LL have a cost of EUR 53.70 and a single SS has a cost of EUR 276.58. Postoperative complications were found in 14.3% of the LL group, 9.8% in the SS group and 4.6% in the HOL group, P=0.137. Efficacy and safety in controlling the base of appendix were the same in all groups. CONCLUSIONS: The HOL are safe and reduce surgical costs during laparoscopic appendectomy in children.

Transverse testicular ectopia discovered following reduction of an inguinal hernia.

Transverse testicular ectopia is a rare condition in which both testicles occupy a single hemiscrotum. The aberrant positioning may lead to vascular compromise or impaired temperature regulation, which elevate the risks for torsion, infertility and testicular cancer. Definitive therapy consists of orchiectomy or orchiopexy. We report a case of a 10-month-old boy with an incarcerated inguinal hernia who was discovered to have transverse testicular ectopia following hernia reduction. The patient was treated with herniorrhaphy and open transseptal orchiopexy.