Comparative study of open, laparoscopic and endoscopic treatments of intermediate grade vesicoureteral reflux in children.

BACKGROUND: Low-grade vesicoureteral-reflux (VUR) are rather treated by endoscopic injection, whereas open or laparoscopic procedures are mainly performed for high-grade VURs. Management of intermediate grades is controversial and no study focused on grade III to date. This study aims to compare the results of open, laparoscopic, and endoscopic approaches in children with grade III VUR. METHODS: A multicenter comparative retrospective study included children with grade III VUR operated for febrile urinary tract infections (UTIs) from 2007 to 2016. Children without UTI, with reflux of other grades, neurological bladder, duplex system, posterior urethral valves, and bladder exstrophy were excluded. Success was defined as no recurrence of febrile UTI and was presented as event-free survival curves. RESULTS: Out of 806 children operated of VUR, 171 met the inclusion criteria (114 females). Seventy-seven children (45%) underwent an open Cohen procedure, 35 (21%) a laparoscopic Lich-Gregoir and 59 (34%) a submucosal endoscopic injection according to the centers' preference. The mean follow-up was 64 months (24-132). Groups were not different for age, sex, and circumcision status. Compared to Cohen procedure, recurrences of febrile UTI were more frequent after laparoscopic treatment (p = 0,02, 8/35) and endoscopic treatment (p = 0.001, 16/59). Redosurgery was also more frequent after laparoscopy (n = 2) and endoscopic injection (n = 14) than after open surgery (n = 0, p < 0.001). CONCLUSION: Recurrent febrile UTIs and redosurgery are more frequent after endoscopic and laparoscopic procedures in grade III VUR than open reimplantation. Whether the lower morbidity of laparoscopic or endoscopic approaches balances the risk of recurrent febrile UTI remains to be determined for intermediate grade reflux.

[Laparoscopic extravesical ureteral reimplantation following Lich-Gregoire technique. Medium-term prospective study]. / Reimplante ureteral extravesical laparoscópico según técnica de Lich-Gregoir. Estudio prospectivo a medio plazo.

OBJECTIVES: To evaluate our results of Laparoscopic extravesical ureteral reimplantation according to Lich-Gregoire technique in the of vesicoureteral reflux treatment. MATERIAL AND METHODS: Between August 2007 and January 2013, 108 renal units in 80 patients were treated. There were 23 patients with double renal system; in 5 cases were associated with obstruction, and 3 with completely impaired function of the upper pole and ipsilateral ureterocele presence. RESULTS: Laparoscopic extravesical ureteral reimplantation was performed in all cases. The mean age was 52 months; The mean operative time was 70 minutes in unilateral and 144 minutes in bilateral. Three laparoscopic heminephroureterectomies were performed at the same time, with incision of ureterocele. The average hospital stay was 27 hours. Complete resolution was 96.5%. Mean follow-up was 27 months. CONCLUSION: Laparoscopic extravesical ureteral reimplantation following Lich-Gregoire technique is effective against the unilateral, bilateral and associated with double renal system vesicoureteral reflux. It's possible to perform others procedures in a securely and concomitantly way (eg., heminephroureterectomy). A shorter hospital stay, more comfort and quicker recovery are achieved, with similar succes rates to open surgery.

OBJETIVOS: Evaluar nuestros resultados del reimplante ureteral extravesical laparoscópico, según técnica de Lich-Gregoir, en el tratamiento del reflujo vésico-ureteral. MATERIAL Y METODOS: Entre Agosto de 2007 y Enero de 2013, fueron tratadas 108 unidades renales en 80 pacientes. De ellos, 23 pacientes presentaban doble sistema renal; en 5 casos estaban asociados a obstrucción, y 3 de ellos con completo deterioro de la función del polo superior y presencia de ureterocele homolateral. RESULTADOS: Se practicó en todos los casos un reimplante ureteral extravesical laparoscópico. La edad media fue de 52 meses; el tiempo medio quirúrgico fue de 70 minutos en los unilaterales y 144 minutos en los bilaterales. Se realizó en un mismo tiempo operatorio tres heminefroureterectomías laparoscópicas, con incisión del ureterocele. La estancia media hospitalaria fue de 27 horas. La resolución completa fue del 96,5%. El seguimiento medio fue de 27 meses. CONCLUSIONES: El reimplante ureteral extravesical laparoscópico según técnica de Lich-Gregoir es efectivo frente al reflujo vesicoureteral unilateral, bilateral y asociado a doble sistema renal. Es posible realizar otros procedimientos en forma concomitante de forma segura (por ejemplo, heminefroureterectomía). Se logra una menor estancia hospitalaria, mayor confort y rápida recuperación postoperatoria, con una tasa de éxito similar a la cirugía abierta.

Surgical management of thymic epithelial tumors in children: lessons from the French Society of Pediatric Oncology and review of the literature.

PURPOSE: We report the results of a French multicenter retrospective study based on a period of more than 30 years and a review of the literature in order to more clearly define the surgical approach and specific pediatric risk factors. METHODS: Clinical data of children comprising all histologic subtypes of thymic epithelial tumors (TET) treated between 1979 and 2009 in French pediatric oncology centers were retrospectively analyzed and discussed in the light of a review of all pediatric cases reported in the literature. RESULTS: Nine cases were identified, corresponding to five females and four males with a median age of 13 years (range: 7.5-17). Histologic subtypes were type AB (n = 1), type B (n = 5) and type C (n = 3). Treatment consisted of tumor resection (4 R0, 4 R1, 1 R2) via right anterior thoracotomy, posterolateral thoracotomy, left thoracoscopy, sternotomy and cervicosternotomy, and/or chemotherapy, mainly cyclophosphamide-doxorubicin-cisplatin (CAP; n = 5), and/or radiotherapy (n = 4). Two patients with TET type C died. All other patients are alive with a median follow-up of 4 years (range: 1.5-20). Review of a total of 93 pediatric cases reported in the literature showed statistically significant associations between less favorable histologic subtypes and male gender (P = 0.012), advanced Masaoka stage (P < 0.001) and quality of resection (P < 0.001) respectively. CONCLUSIONS: A review of the literature and our series identified several risk factors to take into account in the therapeutically decision. Complete resection through a sternotomy is highly recommended.

[Thoracoscopic treatment in pericardial tamponade]. / Tratamiento toracoscópico en taponamiento pericárdico.

Pericardial tamponade is a rare medical emergency in children. We describe a 16 years old patient, who presented with pneumonia localized in upper left lobe complicated with lung abscess and ipsilateral pleural effusion, associated with pericardial effusion. The initial treatment was: broad-spectrum antibiotics, left thoracic drenage and pericardiocentesis After 24 hours postoperative, developed circulatory collapse with significant increase in pericardial effusion. The preoperative studies were thoracic CT-scann and echocardiography, showing an increase of pericardial effusion with no major changes in lung pathology. We performed a pericardial window by right thoracoscopic. After this, quickly improved clinically and the echocardiography 24 hours postoperatively was normal. The thoracoscopic approach in cases of pericardial tamponade is an useful alternative, benefiting the patient of minimally invasive approaches.

[Congenital buried penis in children]. / La verge enfouie congénitale de l'enfant.

PURPOSE: Congenital buried penis in children is an uncommon and poorly known entity. The aims of this study were to report an original technique for correction of buried penis and to evaluate its results. PATIENTS AND METHODS: It is a retrospective study of buried penis operated between November 1998 and May 2009. The acquired concealed penis and hypospadias were excluded from this study. The procedure includes several stages: degloving of the penis through a ventral anchor-like incision; division of the adherent layers surrounding the corpora cavernosa; anchorage of the Buck's fascia to the corporeal albuginea at the base of the penis; and ventral cutaneous coverage. The long-term results were evaluated by the parents and the surgeon according to anatomical, functional and aesthetic criterion. RESULTS: Twenty-five boys were evaluated. The mean age at surgery was 27 months (seven days-120 months). Two children required an additional plasty. Results were satisfactory in 24 cases (96%). One child required a redo procedure for unsatisfactory outcome. Of seven children with redundant skin (28%), three underwent a complementary cutaneous excision. CONCLUSION: Congenital buried penis remains a controversial issue. Our technique was simple and easily reproducible. Voiding difficulties, urinary tract infection or strong parental request were the main indications of this surgery in our experience.

[Prenatal diagnosis and management of isolated bladder exstrophy]. / Diagnostic anténatal et prise en charge des extrophies vésicales isolées.

The isolated bladder extrophy is a major congenital malformation which prenatal diagnosis is essential. It is based on the non-visualization of the bladder during the first trimester ultrasound but in most cases, it is confirmed by the morphological ultrasound of the second trimester. For the baby, the prognosis of life quality depends on the accurate identification of the malformation, the foetal sex and the associated pathologies. Thus, a detailed ultrasound evaluation is necessary and requires an operator experienced in the search of malformations. As this abnormality has important aesthetic and functional consequences, a multidisciplinary management is required for a good information of the couple. The continuation of pregnancy is currently possible but the couple should be informed that after surgery, often a major one, more than 75% of children will have a urinary continence by reconstruction or bypass. Furthermore, their ability of reproduction will need to be medically improved.

[Early fetal megacystis at first trimester: a six-year retrospective study]. / Diagnostic anténatal de mégavessie au premier trimestre de la grossesse. Etude rétrospective sur six années.

OBJECTIVE: A fetal megacystis is defined by a longitudinal bladder diameter more than 7 mm. The purpose of this study is to describe the prenatal ultrasound findings of this early fetal pathology and to assess pronostic and aetiologycal criteria. PATIENTS AND METHODS: Between January 2003 and December 2008, 12 cases of early fetal megacystis were identified in our referral fetal medicine unit (Saint-Etienne hospital, France). RESULTS: There were two cases of spontaneous resolution and one case wasn't a fetal megacystis. Termination of pregnancy for medical indications was realised for another cases because of associated malformations and bad evolution (six cases) and three chromosomal abnormalities (two cases of trisomy 18 and one of trisomy 21). DISCUSSION AND CONCLUSION: Sonographic follow-up and fetal karyotyping are important to evaluate prognosis. However, our data suggest that fetal megacystis is a severe condition when diagnosed in early pregnancy.

[Water-electrolyte abnormalities during pregnancy: maternal and fetal complications (about a case)]. / Troubles hydroélectrolytiques pendant la grossesse: complications maternelles et foetales (à propos d'un cas).

Water-electrolyte abnormalities while pregnancy or for infant are very serious. We present a case of a woman at 26 weeks who had gestation pernicious vomiting that led to major extracellular dehydration, water intoxication and acute renal insufficiency. The etiology was a volvulus on common mesentery. Hyperemesis disappeared thanks to surgical treatment. The mother and her fetus would later present serious complications due to the water-electrolyte imbalance correction. The fetus suffered from cerebral hemorrhage and subdural hematoma subordinate to brain edema resorption. The mother presented centropontine myelinolysis. The treatment of electrolyte abnormalities during pregnancy could lead to serious complications for the mother and fatal for the foetus.

Laparoscopic pyeloplasty for repair of pelvi-ureteric junction obstruction in children.

PURPOSE: To report our initial experience with laparoscopic pyeloplasty (LP) in children with pelvi-ureteric junction (PUJ) obstruction, and to describe the evolution and evaluate the results for these patients. MATERIALS AND METHODS: Between May 2005 and April 2008, we retrospectively reviewed the records of 28 consecutive infants and children (20 males, eight females; mean age 63 months, range 2-180 months) with unilateral PUJ obstruction, some with deterioration of renal function on isotope renography. They all underwent LP (18 on the right, 10 on the left). The patient was placed in a (3/4) lateral position with three ports. The PUJ was resected and the anastomosis made using absorbable sutures. A JJ stent was inserted by laparoscopy in the majority of patients. Follow-up included clinical and ultrasound assessment, and isotope renography at 6 months. RESULTS: LP was feasible in 26 of 28 patients (93%). The procedure could not be completed by laparoscopy in two patients, the main reason being difficulty in completing the anastomosis. Stent insertion was successful in 25 of the remaining 26 cases. In the one unsuccessful case, a perianastomotic drain was placed without complication in the postoperative period. An aberrant crossing vessel was found in four patients. In two we held up the aberrant crossing vessel and PUJ by 2-3 non-absorbable sutures without tension, and without the need for pyeloplasty. In the other two cases we performed an LP-enabled ureteric transposition. There were three postoperative complications: pyelonephritis in two patients and one patient required operative intervention for PUJ leakage, and underwent a nephrostomy with a further uneventful course. The mean operative time was 145 min (range 70-270 min), and mean hospital stay was 4 (1-8) days. In one patient the JJ time of removal by cystoscopy, and ureteroscopy was used to retrieve it. Mean follow-up was 18 months (range 4-64 months). The 26 patients who underwent LP were asymptomatic after removal of the double JJ stent, showing reduction of the degree of hydronephrosis in all patients, and had also improved PUJ drainage on isotope renography or sonography. CONCLUSIONS: LP is effective and safe in children with minimal morbidity and gives excellent short-term results. The feasibility is also excellent in patients younger than 1 year. The transabdominal approach revealed good exposition without disadvantage to the patient. However, the LP is more difficult and the operative time remains longer than open pyeloplasty.

Antenatal isolated hydronephrosis associated with urinoma.

Two cases of prenatally identified urinoma associated with an isolated hydronephrosis are presented, and the pathophysiology and prognosis of this rare condition are discussed. The presence in utero of a peri-renal collection associated with an isolated hydronephrosis seems to be a sign of significant renal dysplasia. These urinomas disappear spontaneously, thus drainage is not necessary, except in the case of compression of surrounding structures. The functional prognosis of these kidneys seems to be most unfavourable.

[Management of blunt abdominal trauma in children]. / Prise en charge des traumatismes fermés de l'abdomen chez l'enfant.

UNLABELLED: The aim of this study was to evaluate the radiological and therapeutic management of blunt abdominal trauma (BAT) in children, with retrospective data. POPULATION AND METHODS: During 6 years (Nov 1995-Oct 2001), 92 children were hospitalised for BAT (mean age 9.5 years; 61.9% boys). Falls (45.6%) and motor vehicle accidents (43.5%) were the most frequent causes. The initial management included abdominal plain film X-ray and ultrasonography, and sometimes computed tomography (CT). The non-operative treatment was used, unless the patient was hemodynamically unstable or had hollow visceral injury, diaphragmatic rupture or renal artery rupture. RESULTS: Among 92 BAT, 52 were minor traumas and 40 were associated with one or several abdominal injuries. The sensitivity of ultrasonography to find hemoperitoneum and/or abdominal injuries was 80.3%, but the initial diagnosis of such lesions was accurate in 21 cases (52.5%) and delayed in 19 cases (47.5%), ranging from 1 to 7 days. In the delayed cases, the diagnosis was possible in nine cases with ultrasonography, in five cases with CT, but also with transaminase, amylase or lipase assays in two cases, and surgery in three cases. Twenty-nine children had a non-operative treatment and stayed in hospital about 12 days on average. Three children had surgery in emergency (two bowel perforations and one splenic rupture) and eight with delay (four renal ruptures, one associated splenic nodes, one pancreatic pseudocyst and one duodenal perforation). Only seven children (17.5%) required blood transfusion and no death occurred. CONCLUSION: In a trauma centre, the management of abdominal injuries is possible with ultrasonography and its sensitivity is correct without increasing of morbidity and mortality. But, if in doubt, a CT must be performed because its sensitivity is better. Most of the time, the children can benefit from non-operative treatment.

Role of laparoscopy in vaginal malformation.

BACKGROUND: The aim of this study was to assess the role of laparoscopy in the management of vaginal malformations in children, a subject not often discussed in the literature. METHODS: Between 1980 and 2002, we treated 22 children for vaginal malformations. Two main patient populations were distinguished: younger children with asymptomatic hymenal imperforation and hydrocolpos, and adolescents with hematocolpos. A third of the malformations were identified on systematic clinic examination, a third on the basis of abdominal pain, and a third due to various other symptoms. Nine of the girls had associated malformations of the uterus, external genital organs, or urinary tract. Eight patients underwent laparoscopy, either to look for endometriosis in cases of hematocolpos, to make an accurate determination of malformations in cases where clinical and paraclinical methods failed, or to manage an abnormality. RESULTS: Eleven laparoscopic procedures were performed in eight patients. Three diagnostic laparoscopies enabled us to determine the exact nature of the malformations. One newborn underwent two laparoscopic procedures to treat peritoneal fibrous bands that had caused repeated episodes of obstruction. Six patients underwent exploratory laparoscopy to look for endometriosis, but none was found. CONCLUSION: Laparoscopy is not applied systematically in the management of any malformation, but it can be useful when complementary exams fail to make an accurate diagnosis of the anomaly or for the management of the rare complication of adhesions and bands. When used to search for endometriosis, MRI detects ~50% of lesions, but laparoscopy is certainly still appropriate for that purpose. However, the optimal timing of the procedure still needs to be established.

[Priapism in the course of generalized atopic dermatitis]. / Priapisme au cours d'une dermatite atopique généralisée.

BACKGROUND: Priapism is a pathologically prolonged and painful penile erection, not resulting in ejaculation. Causes include certain oral medication, perineal trauma, thrombo-embolic process or primary priapism. We report a case of priapism secondary to diffuse general atopic dermatitis. CASE REPORT: An 11 year-old child, with atopic dermatitis, presented over the last 36 hours an irreduced painful penile erection. Other than priapism, he presented numerous scratched lesions on the body and the penis having developped over the last 2 months (treated by daily topical corticosteroid application) and consistent with atopic dermatitis exacerbation. Due to the urological emergency, a puncture of the corpora cavernosa was made, followed by an injection of etilephrine in the penis. Complete and definitive detumescence was obtained. Application of betamethasone healed the cutaneous lesions. The child was treated with ciclosporine for his atopic dermatitis with good results at 6 months. DISCUSSION: In our case, hypothesis of myeloid leukemia, sickle-cell disease and essential thrombocythemia were turned down. The young child did not exhibit any recent perineal trauma but the scratched lesions can be considered as microtraumas. The formation of an inflammatory oedema obstructed venous drainage of the penis and provoked priapism. We can not rule out the responsibility of topical corticosteroids in the formation of the priapism in this patient. Indeed, it was the only drug therapy prescribed, and since introduction of ciclosporine, there has been no relapse.

[Varicella complicated with necrotizing fasciitis caused by group A hemolytic Streptococcus]. / Varicelle compliquée d'une fasciite nécrosante à streptocoque hémolytique du groupe A.

UNLABELLED: Chickenpox has a high risk of invasive group A streptococcal disease and necroziting fasciitis. CASE REPORT: A five-year-old girl, during chickenpox treated with ibuprofen, developed sepsis and edematous and necrotic lesions of the pelvis and the abdominal wall. The child improved with surgical treatment and adjunction of clindamycin to the antibiotic therapy. CONCLUSION: We review the optimal medical and surgical treatment of necrotizing fasciitis and discuss the role of chickenpox and non steroidal antiinflammatory agents in this disease.

Laparoscopic treatment of varicoceles in children. Multicentric prospective study of 90 cases.

PURPOSE: The aim of this study was to assess the results of the laparoscopic treatment of varicoceles. MATERIAL AND METHODS: 92 observations were received, however 5 patients underwent a simultaneous associated open surgery; 90 varicoceles were evaluated (3 bilateral varicoceles). The dilated spermatic veins were treated by clips and partial resection in 74.7 %, by coagulation and partial resection in 21 %, and by clips in 4.3 %. The spermatic artery was ligated in 60 varicoceles and preserved in 28; in 2 cases it was not specified. The results were studied with a mean follow-up of 11.1 months (2 to 36 months). RESULTS: The varicocele disappeared in 76 cases (84.4 %) and diminished significantly in 12 cases (13.2 %) where it was large before treatment. Two middle-sized varicoceles were not modified by the treatment. Therefore, the results must be considered good or excellent in 97.6 % of cases. The spermatic artery was preserved in 28 cases and the size of the varicocele was not good in 9 (32.1 %); it was ligated in 60 cases and the size of the varicocele was not good in 5 cases (8.4 %) -- p < 0.01. In 42 cases the testicular size was noted before and after treatment, and likewise the conservation or not of the spermatic artery; the 30 artery ligations produced no testicular atrophy; only 3 hypotrophic testes were noted with a loss of size of between 8.4 and 59 % with regard to the contralateral testis. In 27 cases, the testicular size remained normal or increased if it was hypotrophic before treatment; there was a good result in 90 % of cases with no atrophy. When the spermatic artery was preserved (12 cases), 1 hypotrophy occurred with a loss of size of 16.7 % -- NS. CONCLUSION: The laparoscopic treatment of varicoceles is an efficient technique and the complete ligation of the whole vascular spermatic pedicle above the vas deferens offers excellent success, without atrophy.

[Intestinal volvulus in extremely premature infants]. / Volvulus du grêle et grande prématurité.

UNLABELLED: Volvulus with or without malrotation are infrequent in the extremely premature newborn. CASE REPORTS: Intestinal volvulus in seven premature newborns are reported with abdominal distention, bright and tense skin without visible bowel loops and spiraled bowel loops on the abdominal X-ray. Intestinal resection was avoided due to early diagnosis. We identified abdominal wall massages as a risk factor, because no new cases have occurred since interdiction of these practices. CONCLUSIONS: Symptoms and radiologic findings are relatively specific for excluding the diagnosis of necrotizing enterocolitis in premature newborns. Abdominal nursing could be the incriminating factor.

Epstein-Barr virus--positive undifferentiated thymic carcinoma in a 12-year-old white girl.

Thymic epithelial malignant diseases are extremely rare in children. The authors report a 12-year-old white girl admitted for a polymetastatic tumor of the anterior mediastinum. Tumor proliferation was typical of an undifferentiated thymic carcinoma. A close link between Epstein-Barr virus (EBV) and the tumor was established by a high titer of anti-VCA IgA and the presence of EBV RNA and DNA in the tumor. In addition, monoclonal viral episomes were present in tumor cells, indicating that EBV infection was an early event in the oncogenic process. The patient died despite resection, irradiation, and chemotherapy.

Tracheobronchial ruptures from blunt thoracic trauma in children.

BACKGROUND/PURPOSE: Tracheobronchial ruptures in blunt thoracic trauma in children are rare. The aim of this study was to suggest the means of an early diagnosis and a conservative management as often as possible. METHODS: Sixteen cases of tracheobronchial ruptures by blunt thoracic trauma were observed over 26 years in 9 regional pediatric centers. RESULTS: There were 12 boys and 4 girls, from ages 1 hour to 17 years. Nine children presented with associated lesions. Fibroscopy established the following diagnosis: 8 tracheal wounds and 8 bronchial wounds. Six children were operated on within 18 hours (on average) after installation of a thoracic drainage. Two lobectomies, 3 ideal tracheal sutures, and 1 bronchial suture were performed. Seven children were treated exclusively by thoracic drainage. Two of them were intubated through the lesion, leading to a transitory endoprothesis accompanied or not by an external thoracic drainage. One infant recovered spontaneously. There were no deaths in this series. Two recurrent postoperative nerve injuries were noted, one of which was a transitory spontaneously resolutive scar bud and one a granuloma treated by laser. Three times, a stenosis occurred after a conservative management. Two were operated on. CONCLUSIONS: Tracheobronchial ruptures in children are rare. An early fibroscopy holds an important place in the approach of this pathology. Treatment is variable, based on thoracic lesions, their tolerance by the child, and associated lesions. Surgery is not the only therapy because conservative treatment by simple thoracic drainage or lesion intubation has proved effective.

[Intra-thoracic costal sites of osteogenic exostoses in the child]. / Les localisations costales intra-thoraciques des exostoses osteogeniques de l'enfant.

PURPOSE OF THE STUDY: The authors report 2 cases of internal costal exostosis in children. OBSERVATIONS: Case 1: A 15-year-old boy with hereditary multiple exostosis presented for chest pain. Radiograph and CT scan showed an internal rib exostosis. It was removed by thoracotomy. Eighteen months later, the child was painfree. Case 2: An-11-year old boy presented with fever and a headache. A chest radiograph showed an image of pulmonary opacity interpreted as a pneumonia. The child was admitted for antibiotic therapy. Two months later, X-ray lesion persisted and a CT-scan was obtained. It showed a solitary costal internal exostosis which was removed by thoracotomy. At 12 months follow-up, he was asymptomatic. DISCUSSION: Internal costal exostosis can induce some complications such as hemothorax, diaphragmatic or pericardic wounds. In case of symptomatic exostosis, the authors recommend a surgical removal to avoid severe complications. If the exostosis is asymptomatic, abstention can be recommend. As a matter of fact, hemothorax, for instance, can occur even due to a round and smooth exostosis without any history of trauma.