Endoscopic placement of double-J ureteric stents in children as a treatment for primary hydronephrosis.

INTRODUCTION: The aim of this study was to determine the efficacy and potential complications of double-J ureteric stents in the treatment of primary hydronephrosis in pediatric patients. MATERIALS AND METHODS: A retrospective case-records review of 133 patients (45 girls and 88 boys) treated because of primary hydronephrosis with double-J ureteric stents, in Department of Pediatric Surgery, Split University Hospital, between December 1997 and December 2014, was performed. Success of treatment, results of follow up investigations and complications were recorded. Patients were followed up clinically and radiologically for a minimum of 2 years following stent insertion. RESULTS: In all, 133 endoscopic double-J ureteric stents insertions were performed. Of the total number of patients, left-sided hydronephrosis was found in 82 patients, right-sided in 38, and bilateral in 13 patients. The median age of children was 2 years (range 0-17 years). Mean hospital stay was 2 days (range 1-10 days). In primary hydronephrosis, double-J ureteric stenting alone was effective with resolution of hydronephrosis in 73% of cases (97/133 insertions). Regarding the age of the patients the highest success of 83.5% was achieved in age group 0-4 years. Success in groups 5-9 years; 10-14 years and 15-17 years were 47%; 33.5% and 0%, respectively. Several complications have been recorded: symptomatic infections, migration in the renal pelvis and bladder, progression of hydronephrosis, spontaneously prolapse of prosthesis, bleeding and perforation of the renal pelvis. A significant, decreasing trend in success rates by age of participants was observed (p < 0.001). CONCLUSIONS: Ureteric stenting is minimally invasive procedure that provides an alternative to open surgery in patients with primary hydronephrosis. Endoscopic placement of ureteric double-J stents should be considered as a first-line treatment in the management of primary hydronephrosis especially in children till 4 years of age, with success rate of 83.5% and without the need for conventional surgery. In a case of failure we are time-consuming to definitive surgery.

Modified Marcy repair for indirect inguinal hernia in children: a 24-year single-center experience of 6826 pediatric patients.

PURPOSE: To evaluate the management and outcomes of modified Marcy repair for inguinal hernia in a large series of children. METHODS: We analyzed the case records of 6826 pediatric patients who underwent surgery for inguinal hernia between January, 1991 and January, 2015 at Split University Hospital in Croatia. The following parameters were examined: sex, age, location of the hernia, intraoperative or postoperative complications, recurrence, and surgical method. RESULTS: The 6826 patients included 4751 boys and 2075 girls operated on for inguinal hernia. The mean age was 3.5 years, and mean followup was 14 years. Right-side predominance was noted with 59.50 % right hernia repairs, 33.72 % left hernia repairs, and 6.78 % bilateral hernia repairs. There were 6410 (93.90 %) elective procedures and 416 (6.10 %) emergency procedures for incarceration. The mean duration of surgery was 26 min (14-90 min), and the mean hospital stay was 1 day. Marcy repair was the most commonly performed operation (95.76 %), whereas Ferguson's technique was performed in only 3.98 % of the children. The overall recurrence rate was 0.43 %, with a recurrence rate of 0.36 % for Marcy repair and 1.83 % for Ferguson repair (p = 0.0003). CONCLUSION: Modified Marcy hernia repair is a safe and effective procedure for inguinal hernia in children with excellent outcomes and a low incidence of recurrence.

Endoscopic treatment of vesicoureteral reflux in children with subureteral dextranomer/hyaluronic acid injection: a single-centre, 7-year experience.

BACKGROUND: The goals of medical intervention in patients with vesicoureteral reflux are to allow normal renal growth, prevent infections and pyelonephritis, and prevent renal failure. We present our experience with endoscopic treatment of vesicoureteral reflux in children by subureteral dextranomer/hyaluronic acid copolymer injection. METHODS: Under cystoscopic guidance, dextranomer/hyaluronic acid copolymer underneath the intravesical portion of the ureter in a subureteral or submucosal location was injected in patients undergoing endoscopic correction of vesicoureteral reflux. RESULTS: A total of 282 patients (120 boys and 162 girls) underwent the procedure. There were 396 refluxed ureters altogether. The mean age of patients was 4.9 years. The mean overall follow-up period was 44 months. Among the 396 ureters treated, 76% were cured with a single injection. A second and third injection raised the cure rate to 93% and 94%, respectively. Twenty-two (6%) ureters failed all 3 injections, and were converted to open surgery. CONCLUSION: Endoscopic treatment of vesicoureteral reflux can be recommended as a first-line therapy for most cases of vesicoureteral reflux, because of the short hospital stay, absence of complications and the high success rate.

Acute appendicitis as a complication of varicella.

INTRODUCTION: Obstruction of the appendiceal lumen is the primary cause of appendicitis. The most common causes of luminal obstruction are fecaliths and lymphoid follicle hyperplasia. Additionally, bacterial infections or enteric and systemic viral diseases can cause a reaction of the lymphoid follicle. CASE PRESENTATION: An 11-year-old boy with active phase of chickenpox presented on our Pediatric surgery emergency department under the impression of acute appendicitis. An appendectomy was performed on the same day. An inflamed and edematous retrocecal appendix was removed during surgery. Histological investigation of the appendix revealed transmural acute inflammation, with diffuse proliferation of inflammatory cells, with characteristic intranuclear inclusion surrounded by a clear halo. The PCR analysis of peripheral blood and appendix tissue specimen revealed positive VZV DNA. CONCLUSION: We have shown that varicella-zoster virus infection of the appendix is associated with acute appendicitis and possibly also with severity of the disease.

Management of testicular rupture after blunt trauma in children.

PURPOSE: Testicular rupture is a very rare entity in children and adolescents. The aim of this study was to evaluate the outcomes of surgical repair after testicular rupture in children. METHODS: Between January 2000 and January 2010 seven patients were operated on because of testicular rupture. Mean age at the time of the accident was 15 years. In all patients, an emergency scrotal ultrasonography showed a rupture of the testicular capsule with a surrounding hematocele. Surgical exploration was performed to evacuate the hematocele and repair the ruptured testis. RESULTS: Mean follow-up was 4.9 years. Average hospital stay was 2 days. Mean time between surgery and the initial trauma was 35 h. There were no major complications. Control ultrasound imaging showed that the tunica was repaired and Doppler signal confirmed vascularity in all patients. There were no significant differences in size between the right and left testes. There were no recorded cases of testicular atrophy. Semen analysis showed normospermia 6 months after surgery and anti-sperm antibodies count was within normal limits in all patients. CONCLUSION: Prompt surgical intervention is crucial. Ruptured testis can be salvaged, with a high success rate, if surgical repair is performed within 72 h of testicular injury.

An unusual foreign body in the foot: traumatic implantation of a human tooth.

We report the case of a 29-year-old man who presented to the emergency department with persistent swelling and pain in his right foot, initially reported to be related to stepping on something while walking on the beach. When radiographs showed what appeared to be a human tooth embedded in the foot, the patient admitted to having been in a fight, during which he kicked his opponent in the jaw with his foot. The tooth was surgically removed and oral antibiotic therapy was administered for 1 week. The wound eventually healed by secondary intention without complications, and the patient returned to his regular activities 15 days after the operation.

Expression and prognostic value of the Ki-67 in Wilms' tumor: experience with 48 cases.

PURPOSE: Ki-67, tumor proliferation marker, is an important prognostic factor in a variety of cancers. In the present study, we investigated the expression and the prognostic value of Ki-67 in nephroblastoma. METHODS: Ki-67 expressions were investigated by immunohistochemistry on paraffin-embedded material in 48 children operated on because of nephroblastoma. Patients were treated according to SIOP protocol. The mean follow-up period was 5.4 years. A proliferation index was obtained by immunohistochemistry using anti-Ki-67 anti-body. RESULTS: The mean Ki-67 proliferation index in the blastemal type was 12.3%, and in the epithelial type, 21.4%. In the anaplastic type, Ki-67 proliferation index was: in the blastemal component 20%, in the stromal 21%, and in the epithelial 31%. In the mixed tumor type, Ki-67 proliferation index was assessed as: in the blastemal component 10%, in the epithelial 33% and in the stromal 31.5%. Proliferation index for the epithelium was significantly higher than those found for the blastema (P = 0.001). A correlation between Ki-67 and tumor stage found proliferation index significantly higher in stages I and II (P = 0.002). CONCLUSION: The results support the conclusion that Ki-67 is a relevant marker for assessing the proliferative activity and tumor cell dynamics of nephroblastoma, but it may not be a good clinical prognostic marker.

Injuries from Antitank mines in Southern Croatia.

OBJECTIVE: Antitank mines inflict devastating injuries that are usually fatal. The objective of this retrospective study was to analyze antitank mine casualties in South Croatia during the period from 1991 to 1995. METHODS: Mechanism, degree of injury according to Abbreviated Injury Scale and Injury Severity Score, as well as surgical treatment were analyzed. FINDINGS: Of 464 mine victims, 42 (9.0%) patients sustained antitank mine injuries, and 12 of these were fatal (29%). Abbreviated Injury Scale of the antitank mine injuries was 5.3 +/- 10.6. Military personnel were injured in 29 cases, and civilians were injured in 13 cases. CONCLUSION: Although injuries from antitank mines were ravaging, and frequently fatal, a significant number of patients survived.

Pediatric urolithiasis in Croatia.

A retrospective review was performed of the records of 148 Croatian children with urolithiasis treated between 1989 and 2003. The study evaluated age, gender, family history, clinical symptoms, location of stone, laboratory findings, stone composition, mode of treatment and compared our results with data from higher and lower socio-economic countries. The mean age of our patients was 9.38 years (10 months to 18 years). Thirty-seven children (25%) were less than 5 years (group 1), 44 (29.7%) were between 5 and 10 years (group 2) and 67 (45.3%) were older than 10 years of age (group 3). There were 60 girls and 88 boys with overall male to female ratio of 1.47. Abdominal pain (83%) and haematuria (59.5%) were the main symptoms in the groups 2 and 3. Urinary tract infection was predominant symptom in the group 1 (62.1%). Calculi were located in the kidney in 90 children (60.8%), in the ureter in 39 (26.4%), in the bladder in 8 (5.4%). Urinary tract anomalies with or without infection were associate with a greater frequency of urolithiasis in the youngest age group and hypercalciuria was predominant cause in children over 5. Stone analysis was performed in 80 children. Predominant constituent of stones was calcium oxalate (48.7%), followed by struvite (25%), calcium phosphate (13.7%), cystine (10%) and uric acid (1.2%). Calcium oxalate stones were most common in all age groups. Struvite stones were most prevalent in the children younger than 5 years of age. Most patients (33.1%) underwent surgery for removal of their calculi. In 31.8% of children stones were passed spontaneously and the highest spontaneous passage rate was in the group 3 (37.3%). Stone composition, location and etiology in Croatian children are similar to those in developed Western countries.

Influence of open testicular biopsy in prepubertal rats on rats' adulthood fertility with correlation to serum levels of inhibin B and follicle stimulating hormone.

OBJECTIVE: Open testicular biopsy (OTB) is one of the options to accurately assess fertility potential of the undescended testis. The aim of the study was to investigate consequences of OTB in prepubertal rats on their adulthood fertility. METHODS: Thirty-eight prepubertal male rats were divided into three groups depending on day 20 procedure. The first group was the control group, the second sham operated and the third has left OTB. Bilateral orchiectomy was performed on day 70 to all groups, with determination of serum inhibin B and follicle stimulating hormone (FSH). Removed testes were compared according to the weight, volume, spermatogenesis, histological and apoptotic changes in both testes with differences in serum levels of inhibin B and FSH. RESULTS: Ipsilateral testicular weight, volume, and spermatogenesis reduction with a reduction of tubular number, diameter and germinative epithelium was found in OTB group. Significant increase in apoptotic index was found in biopsied testis without compensatory hypertrophy of contralateral testis. Differences of inhibin B and FSH were not statistically significant among three groups. CONCLUSION: OTB in prepubertal rats has detrimental effects on fertility in adulthood. It does not cause compensatory hypertrophy of the contralateral testis nor does it disturb serum levels of inhibin B and FSH.

Testicular torsion in the inguinal canal in children.

OBJECTIVE: To evaluate the management and outcomes of pediatric patients presenting with torsion of an undescended testis in the inguinal canal. PATIENTS AND METHODS: The case records of 84 children operated on for testicular torsion were retrospectively reviewed. The medical records included initial medical history, physical examination, operative findings, and the results of follow-up. The diagnosis of torsion of undescended testis was made clinically and confirmed by a Doppler ultrasound and inguinal canal exploration. RESULTS: Eight children were operated following torsion of undescended testis. In four cases the testicle was preserved and orchidopexy was performed, while in four cases orchidectomy was performed due to testicular gangrene. Mean duration of symptoms, at time of surgery, in the orchidopexy group was 6 h and in the orchidectomy group was 50 h. At follow-up atrophy of the testis was found in only one patient. CONCLUSION: Torsion of an undescended testis is a relatively rare phenomenon that should be suspected, diagnosed and treated without delay. This study highlights the importance of examination of external genital organs. With improved recognition of this entity and earlier referrals of patients with undescended testes by primary care physicians, its occurrence might eventually be prevented.

Differentiation of inflammatory from non-inflammatory causes of acute scrotum using relatively simple laboratory tests: prospective study.

OBJECTIVE: The differential diagnosis of an acute scrotum is of great importance in clinical practice and may be difficult in some cases. The aim of this study was to differentiate inflammatory from non-inflammatory causes of acute scrotum using relatively simple laboratory tests which can be performed quickly and easily outside a hospital setting. PATIENTS AND METHODS: From 2007 to 2010, 85 boys with acute scrotum were included in this prospective study. There were 28 boys with inflammatory and 57 with non-inflammatory causes. We investigated the role of erythrocyte sedimentation rate, C-reactive protein, leukocyte, white blood cell differential count, alkaline phosphatase, creatine kinase and child's age in differential diagnosis of the acute scrotum, differentiating inflammatory from non-inflammatory causes of the disease. We used receiver operating characteristics (ROC) analysis and logistic regression analysis. RESULTS: Statistically significant parameters in accurate differentiation between inflammatory and non-inflammatory causes of the acute scrotum were C-reactive protein (p = 0.001) and child's age (p < 0.001). These two parameters yielded the probability of an inflammatory outcome in the etiology of acute scrotum with sensitivity of 75% and specificity of 69.1%. CONCLUSION: C-reactive protein and child's age are helpful in differentiating inflammatory from non-inflammatory causes of the acute scrotum.

Management of blunt pancreatic trauma in children.

PURPOSE: Blunt abdominal trauma is the major cause of abdominal injury in children. Because of the retroperitoneal location, insidious signs and symptoms and the lack of sensitivity with common imaging modalities often lead to difficulties in making an accurate diagnosis. The most common complication is the formation of a pancreatic fistula, pancreatitis and a pancreatic pseudocyst, which usually manifests within 3 or 4 weeks after injury. METHODS: The case records of seven children (4 male, 3 female) treated for blunt pancreatic injury in the department of pediatric surgery, University Hospital, Split were reviewed. RESULTS: The treatment modalities were selected according to the grade of the pancreatic injury, hemodynamic status and associated injuries. Because all of the patients were classified as grade I or II according to the American Association for the Surgery of Trauma (AAST) classification, a conservative treatment was selected for all seven patients. In four patients the conservative treatment resulted in the total regression of the clinical, biochemical and radiological signs within four weeks (AAST grade I). In the other three patients, pancreatic pseudocysts arose within 3 or 4 weeks after the injury (AAST grade II). CONCLUSIONS: The status of the main pancreatic duct and the location of the pancreatic injury constitute the basis of the AAST scoring system. This scale should be used as a guide to selecting a surgical or conservative strategy. Based on these data, two factors appear to be the most important determinants of the treatment strategy for children with pancreatic injury: the grade of the pancreatic injury, which is determined according to the status of the main pancreatic duct and the clinical status of the patient.