Modified tubularized incised plate urethroplasty.

AIM: To share our experience of doing tubularized incised plate urethroplasty with modifications. MATERIALS AND METHODS: This is a single surgeon personal series from 2004 to 2009. One hundred patients of distal hypospadias were subjected for Snodgrass urethroplasty with preputioplasty. The age range was 1 to 5 year with mean age of 2.7 years. Selection criteria were good urethral plate, without chordee and torsion needing complete degloving. Main technical modification from original Snodgrass procedure was spongioplasty, preputioplasty, and dorsal slit when inability to retract prepuce during surgery. RESULTS: Average follow-up period is 23 months. Seven (7%) patients developed fistula and one patient had complete preputial dehiscence. Phimosis developed in three (3%) patients and required circumcision. Dorsal slit was required in seven patients. One patient developed meatal stenosis in postoperative period. All other patients are passing single urinary stream and have cosmesis that is acceptable. CONCLUSIONS: Modified tubularized incised plate urethroplasty with preputioplasty effectively gives cosmetically normal looking penis with low complications.

A retrospective analysis of early experience with modified complete primary repair of exstrophy bladder (CPRE) in neonates and children.

OBJECTIVE: To study the problems faced during the surgery and follow-up of modified complete primary repair of exstrophy (CPRE) technique. Initial experience with CPRE and its short- and long-term outcomes with respect to continence status and psychosocial impact are reported. MATERIALS AND METHODS: A retrospective review of the hospital case records from March 2008 to September 2012 was performed. Data of patients with bladder exstrophy managed by a single paediatric surgeon using modified CPRE technique were analysed. Quality of life and psychosocial impact of the surgery were assessed using Pediatric Quality of Life Inventory (PedsQL 4.0) and compared with those of typical peers. RESULTS: Eight children (age 4 days-12 years) underwent CPRE using modified Mitchell's technique. Two patients (25%) experienced early postoperative complications, with infection and fistula developing in one each. All the patients were doing well on follow-up, with variable continence rates and good cosmesis. Mean duration of follow-up was 18.5 months (range 6 months-4 years). Five out of seven (71%) children were continent or partially continent. One case was lost to follow-up. PedsQL scores were comparable with those of age-matched peers in all domains except the social functioning domain in 8-12 years age group (83.53 ± 9.70 vs. 77.86 ± 10.22, P < 0.05). CONCLUSION: Our preliminary results with modified CPRE in neonates and children have been encouraging. No major complications were observed. Continence rate was satisfactory and cosmetic results were good. Though the technique is being practiced at several Indian centres, there is a paucity of comprehensive Indian data on CPRE.

Choledochocele: An unusual presentation in a premature neonate.

Choledochocele in a premature neonate who presented with obstructive jaundice and was managed surgically is reported. At 1-year follow-up, the child is asymptomatic.

Mesentric cyst- an unusual presentation as inguinal hernia.

Mesenteric cyst is one of the uncommon childhood tumors. Mostly they are asymptomatic. Some of them present with non specific abdominal symptom like chronic abdominal pain very rarely they present as acute abdomen like torsion or intestinal obstruction. We are reporting a very rare presentation of Mesenteric cyst as an irreducible inguinal hernia.

Role of ultrasound-guided continuous brachial plexus block in the management of neonatal ischemia in upper limb.

Neonatal upper limb ischemia due to accidental arterial damage remains a major concern, which can lead to devastating complications if untreated. The primary objective of this case report is to emphasize the role of continuous infraclavicular brachial plexus block, the issues related with block performance in an ischemic hand, and the importance of ultrasound guidance in this particular case scenario. A 1.1 kg infant suffered from distal forearm ischemia due to accidental arterial damage, which was treated with brachial plexus block. An ultrasound-guided single shot block with 0.5 mL/kg of 0.25% bupivacaine was followed by ultrasound-guided catheter placement in the target area. A continuous infusion of 0.03% of bupivacaine at the rate of 0.5 mL/kg/hr (approx. 0.15 mg/kg/h of bupivacaine) was administered for 36 h. This treatment resulted in reversal of ischemia. Permanent ischemic damage was eventually confined to the tips of 4 fingers. We conclude that ultrasound-guided continuous infraclavicular block has a therapeutic role to play in the treatment of hand ischemia due to arterial damage and subsequent arterial spasm in neonates with added benefits.

Hypospadias with dorsal chordee: Case report of a novel approach for correction.

We report a novel surgical technique for correction of dorsal chordee with coronal hypospadias. The bulbar elongation and anastomotic meatoplasty procedure gave an excellent cosmetic and functional outcome.

Our 10-year experience of variable Müllerian anomalies and its management.

PURPOSE: Though the Müllerian duct anomalies are rare in incidence, their variable age, and mode of presentation makes their management difficult. METHODS: In the last 10 years authors managed 14 patients with different types of Müllerian anomalies. There were eight patients with complete Müllerian agenesis: three of partial Müllerian agenesis, one patient had uterine didelphys with vertical and transverse vaginal septum on left side, one patient had uterine didelphys with cervical agenesis on the right side, one patient had MRKH with anorectal malformation. RESULTS: Patients with complete Müllerian agenesis underwent bowel vaginoplasty, and patients with partial Müllerian agenesis with hydrocolpos underwent pull-through vaginoplasty. Patient of uterine didelphys one with septum underwent septum excision and in another with cervical agenesis, cervix opened and drain kept. In MRKH with vestibular fistula, fistulous opening was kept as vaginal opening and rectum brought down as a neoanus. CONCLUSION: Müllerian duct anomalies can present in any age group and with variable symptoms. Sigmoid colon vaginoplasty is an excellent procedure for complete or partial Müllerian agenesis. Correct evaluation of these patients and proper management is a challenge.

Our experience of ureteral substitution in pediatric age group.

OBJECTIVES: To find appropriate ureteric substitute in the pediatric age group. METHODS: Retrospective analysis was done from 2003 to 2008 of all patients operated in our hospital who had undergone ureteric replacement. All cases were followed up to find conduit patency, renal function, and any related complication. RESULTS: Ureteric replacement was performed in 5 cases. Age of the patients ranged from 6 months to 9 years. Three cases were of obstructive megaureter; 1 of redo-pyeloplasty and 1 of iatrogenic injury of the ureter. Three patients underwent partial ureteric substitution of the right ureter, and complete replacement of the left ureter with appendix was performed in 1 patient. In 1 case small bowel was used as Monti tube to substitute the ureter. At median follow-up of 23 months (14-66 months) all patients were well except 1 whose kidney function had deteriorated. CONCLUSIONS: We believe that our small series supports that either appendix or small bowel should be considered as Monti's tube for ureteric replacement when confronting with short ureter in pediatric age group.

Single-stage feminizing genitoplasty in aphallia through an anterior saggital approach.

PURPOSE: An ideal feminizing genitoplasty in aphallia should achieve good cosmesis and capacious vagina in a single-stage repair. Most of the techniques described in the literature are variations of the posterior sagittal approach with staged repair. We describe a single-stage anterior sagittal approach for feminizing genitoplasty in cases of aphallia. MATERIALS AND METHODS: A case of aphallia was operated through an anterior sagittal approach, and a spiral Monti tube of sigmoid colon was used to create a neovagina. Preservation of the skin tag around the urethra and its placement in the perineum gives it the appearance of the clitoris. RESULT: The patient has been observed for 7 months. She is continent and has a satisfactory cosmetic appearance and capacious vagina. CONCLUSION: A single-stage operation through an anterior sagittal approach is a good alternative technique for genital reconstruction in the case of aphallia.

Use of the processes vaginalis: A new technique for reinforcing the neourethra in hypospadias associated with undescended testis.

CONTEXT: The incidence of undescended testis (UDT) along with hypospadias varies from 6 to 31%. The simultaneous repair of UDT and hypospadias is rarely done. Herein, we present a novel technique to use processes vaginalis as a vascular cover for neourethra in a hypospadias patient with UDT. We have done urethroplasty and orchiopexy simultaneously. This is the first report concerning the use of processes vaginalis to reinforce the urethra. AIMS: Simultaneous repair of hypospadias and undescended testis. RESULTS: Both the patients withstood the procedure well. Postoperative period was uneventful. Patients passed urine in single stream without any fistula. CONCLUSIONS: In patients of undescended testis with hypospadias, simultaneous repair with the processes vaginalis flap is an ideal technique with good results. Processes vaginalis is good vascular cover for neourethra.

Use of the processus vaginalis: A new technique for reinforcing the neourethra in hypospadias associated with undescended testis.

Incidence of the undescended testis (UDT) along with hypospadias varies from 6 to 31%. The repair of UDT and hypospadias is rarely done simultaneously. Here we present a novel technique that uses processus vaginalis as vascular cover for neourethra in hyposapdias patients with UDT. We have done urethroplasty and orchiopexy simultaneously. This is the first report of processus vaginalis being used to reinforce the urethra.

Fetus in fetu: two case reports and review of literature.

Fetus in fetu is a rare disorder. Its embryopathogensis and differentiation from teratoma has not been well established. It is a parasitic twin of a diamniotic monozygotic twin. Here we report, two cases of fetus in fetu with review of literature. In case report 1, a 2-year-old boy was referred for asymptomatic lump in abdomen since birth. X-ray showed the mass in the abdomen with some calcification and fluid inside. CT scan reported a heterogenous mass in the retroperitoneum with bony malformation. CT showed presence of three vertebrae in it. After surgically excising the mass and opening the sac it showed presence of trunk and two limbs with one of the limbs having a nail. Histopathology showed presence of GI tract. In case report 2, 4 month female was found to have lump in the abdomen by housemaid while bathing. X-ray showed a soft tissue shadow while ultrasonography revealed cystic mass arising from right kidney. CT suggested cystic mass with calcification not arising from kidney. During exploration whole mass was excised and there was frank fetus inside it. Histopathology confirmed presence of four vertebral bodies with germ layers. Although fetus in fetu is rare condition, correct diagnosis using imaging can be made before surgery. Complete excision is curative.