Technical aspects of the Koff procedure (urethral mobilization) in anterior hypospadias.

INTRODUCTION: In our center the level of division of the corpus spongiosum as the determinant to classifying hypospadias. The hypospadias with a distal division is less severe and they present a little curvature. MATERIAL AND METHODS: We present a case of distal hypospadias corrected by Koff technique and we showed our tricks for avoiding curvature. RESULTS: In this selected case a Koff procedure are preferred because it has the main advantage of exicing the dysplastic tissues and avoiding a urethroplasty using nonurethral tissues. Late penile curvature is a source of concerns for some, but in our experience no significant curvature was found at follow up. DISCUSSION: We believe that some tricks, showed in our video, are necessary to avoid iatrogenic curvature and to obtain a good cosmetic result. CONCLUSIONS: Koff technique is a good technique for hypospadias with distal division of corpus spongiosum, without significant curvature at follow up.

[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.

[What is new about hypospadias?]. / Actualités sur l'hypospade.

Hypospadias surgery has considerably evolved during the last 15 years, thanks to a new anatomical approach of ventral penile anomalies and new techniques of repair. The description of the hypoplasia of the tissues forming the ventral aspect of the penis beyond the division of the corpus spongiosum and the concept of urethral plate are the two key-elements to select the most appropriate technique of reconstruction. These modern concepts and the various surgical techniques used in 2008 are reported here with their results.

A multicentre study of the management of disorders of defecation in patients with spina bifida.

Patients with spinal dysraphism may have severe constipation and faecal incontinence. The impact of antegrade colonic enema (ACE) in the management of patients with spina bifida (SB) is analysed. In a multicentre cross-sectional study, constipation, faecal incontinence and faecal management were described. Cases surgically treated were identified. Data were collected from 423 patients, of whom 230 did not use any manoeuvre or laxatives to assist evacuation. Conventional treatment was used in 193 patients, including digital extraction in 39%, retrograde enema in 21% and oral laxatives in 52%. For intractable constipation and overflow of faecal incontinence, 47 patients were treated with ACE, of whom 41 used the method at a mean time of interview of 4.1 +/- 1.9 years after ACE operation; six abandoned ACE for conventional management. With ACE, faecal continence was significantly improved compared with conventional management, and neither retrograde rectal enema nor digital extraction were required. The conduit was fashioned to the right colon in 32 cases and to the left colon in nine cases. This study provides information on a multicentre experience in bowel management in SB patients. Whatever the technique used, ACE has improved faecal status compared with conventional therapy.

[Evidence-based medicine and vesicoureteral reflux]. / Médecine factuelle et reflux vésico-urétéral.

Vesicoureteral reflux (VUR) remains one of the most controversial subjects in paediatric urology. Much literature has been published on VUR, making the understanding of this anomaly and its treatments quite opaque. Evidence-Based Medicine (EBM) should be helpful to clarify the various VUR approaches contained in the 6224 titles found on Medline using the keywords "vesicoureteral reflux" and "vesicoureteric reflux". These articles were critically reviewed and graded according to EBM scorings, with regard to their methodological designs. This review of VUR literature suggests that most of our knowledge is based on publications with a low level of evidence, and that EBM lacks arguments to support recommendations for VUR diagnostic and treatment. It appears yet that antenatal dilatation of the urinary tract and symptomatic urinary tract infections (UTI) justify VUR screening. Surgery should be discussed in recurrent UTIs or deterioration of renal function. There is no consensus in case of persistent asymptomatic VUR regarding indication and duration of antibio-prophylaxis, and selection of radical treatment.

[Ileocystoplasty, pregnancy and delivery]. / Iléocystoplastie, grossesse et accouchement.

INTRODUCTION: Bladder augmentation is commonly used in neurological and other congenital anomalies of the lower urinary tract. In pregnant women, this reconstructive surgery may affect pregnancy and delivery. The obstetrical consequences of these urological procedures are scarcely reported in literature. MATERIAL AND METHOD: Eight pregnancies in 6 pregnant women with ileocystoplasty were followed in our institution between 1998 and 2014. RESULTS: Urinary tract infections were the most frequent undesirable record event (5 patients, 7 pregnancies). Obstetrical complications were not more frequent compared to common pregnancies. Delivery was programmed at 37WA. Cesarean section was favoured in this group although natural delivery is possible. CONCLUSION: Urological complications were the major problem in this series. The type of delivery depends on the past surgical history and the obstetrical prognosis.

Spontaneous regression of suspected cystic dysplasia of the rete testis in three neonates.

INTRODUCTION: Cystic dysplasia of the rete testis (CDRT) is a rare cause of scrotal swelling during infancy. It is a benign lesion that is often associated with ipsilateral renal, ureteral or genital abnormalities. Leissring and Oppenheimer described it for the first time in 1973. CASE REPORTS: Since 2006, three neonates were referred to our pediatric surgery department because of a scrotal swelling related to intra-testicular cysts. Physical examination showed enlarged testicles without pain or inflammation. The ultrasound scan (USS) showed enlarged testicles related to multiple small cysts surrounded by normal parenchyma, and no other urinary abnormalities. As CDRT was suspected, a conservative strategy was proposed with repeated clinical examinations and USS. The cysts gradually regressed and disappeared in all cases, with a mean follow-up of 52 months. DISCUSSION: As reported by Jeyaratnam et al., mean age at presentation was around 6 years. The most frequently associated urinary abnormalities were renal agenesis and multicystic dysplasia of the kidney. Differential diagnosis of CDRT included single testicular cyst, epidermoid cyst, albugina cyst, teratoma, cystic lymphangioma, testicular juvenile granulosa cell tumor, cystic transformation after orchitis, or spermatic cord torsion. Ultrasonography was the method of choice for the diagnosis of CDRT and its follow-up. The USS showed multiple small cysts with normal, but compressed, surrounding testicular parenchyma. A high-frequency transducer was mandatory to exclude other causes of scrotal swelling. With the involution of the cysts, the aspect of the parenchyma could be slightly heterogeneous or confused with microlithiasis. Historically, orchidectomy was the proposed treatment. However, because of a more precise diagnosis with USS, a conservative approach has been proposed. Nonetheless, recurrence after sparing surgery was frequent, as reported by many authors. Non-surgical management was reported in selected cases, sometimes after a surgical biopsy to confirm a benign lesion. Spontaneous regression of CDRT without any sequelae has been reported in six cases (see Summary Table) but long-term follow-up in the adult population has never been published. Limitations of the present series were related to the small number of cases, the absence of follow-up beyond puberty, and the absence of biopsy to confirm the diagnosis of CDRT. CONCLUSION: Spontaneous regression of CDRT was possible, and conservative attitude was an option, as CDRT is a benign lesion. Careful and prolonged 'watch and wait' management was a safe alternative to surgery, but other causes of scrotal swelling must be excluded, possibly with a testicular biopsy.

Preputial plasty: a good alternative to circumcision.

Since 1991, boys needing surgery for tight nonretractile foreskin have been offered a choice of preputial plasty or circumcision, providing that there is no clinical evidence of preputial scarring. We compared two similar groups of 50 boys that underwent each procedure, through our routine audit and questionnaires sent to their parents. Of the boys with circumcisions, 20% required an overnight stay after the operation; 14% had anesthetic complications, and 6% required reoperation because of bleeding. Only 8% of patients with preputial plasty had an overnight stay, and no bleeding was observed. Parental assessment of both operations showed that morbidity was significantly less and of shorter duration for the preputial plasty group. Two patients in the preputial plasty group (4%) had recurrent narrowing of the foreskin caused by scarring and contraction of the incision. Parents were pleased with the long-term results of both procedures. This simple alternative to circumcision is easy to perform and allows full mobilization of the foreskin, preserving its function and providing an excellent cosmetic result.

Female hypospadias: a case report.

A case of proximal female hypospadias with urethral atresia is reported, and a nosological definition of this rare congenital anomaly is proposed. An attempt to clarify the difference between a urogenital sinus and a proximal or distal female hypospadias is made by examining the embryology of the urogenital tract.

Xanthogranulomatous pyelonephritis in childhood.

PURPOSE: Demographic data, clinical presentation, associated abnormalities, and radiologic findings were evaluated to outline diagnostic criteria that may lead to the diagnosis of xanthogranulomatous pyelonephritis in children. METHODS: Eleven boys and 8 girls with a mean age of 3.4 +/- 1.7 years were classified into obstructive xanthogranulomatous pyelonephritis (n = 13), which was associated with nephrolithiasis and nonobstructive (n = 6), which mimicked Wilms' tumor. RESULTS: Twelve children with obstructive diffuse involvement of the renal parenchyma, 1 with left-sided obstructive focal involvement in a horseshoe kidney (group 1), and 6 with nonobstructive diffuse xanthogranulomatous pyelonephritis (group 2) showed a male to female ratio of 1.2:1 and 2:1, respectively. Mean age was 4.1 +/- 1.2 years in group 1 versus 1.8 +/- 1.5 years in group 2; P =.001. The common features were renal mass, hematuria, and anemia (100%; P =.07) and leucocytosis (77% v 83%; P =.097). Main differences between the 2 groups were acute inflammatory syndrome (0 v 33%; P =.01), recurrent urinary infection (54% v 17%; P =.05), isolation of Proteus mirabilis as a pathogen (69% v 0; P =.001), and renal stones (100% v 0; P =.001). Preoperative diagnosis was accurate in all 13 (100%) children with obstructive xanthogranulomatous pyelonephritis. Radiologic features that were not consistent with Wilms' tumor in group 2 were absence of sharp definition and encapsulation of the mass, ill-defined margins with inflammatory infiltration of the perinephric fat and focal inflammatory tissue destruction. Nephrectomy was technically difficult because of extensive adhesions to the retroperitoneum, psoas muscle, and surrounding structures in both groups. CONCLUSIONS: Xanthogranulomatous pyelonephritis must be considered in the differential diagnosis of a child presenting with a renal mass, anemia, and elevated inflammatory markers. Treatment by nephrectomy is curative. J Pediatr Surg 36:598-601.

Meconium ileus due to extensive intestinal aganglionosis.

Seven full-term infants with aganglionosis extending into the small bowel presented with clinical, radiological, and operative features of meconium ileus. Misdiagnosis resulted in inappropriate treatment. The correct diagnosis was eventually established by rectal suction biopsy, mostly after either recurrent intestinal obstruction or stomal dysfunction, and after cystic fibrosis had been excluded. For two patients, the results of rectal suction biopsies were initially misleading. Two infants died. Extensive intestinal aganglionosis should be considered a rare possibility in all infants with meconium ileus. In such cases, histological examination of the appendix may avoid this potential pitfall.

High and intermediate imperforate anus: functional results and postoperative manometric assessment.

Between 1983 and 1989, 21 patients with high (12) and intermediate (9) imperforate anus were operated on according to the author's procedure. The anatomical results are satisfactory (20/21). The records of the clinical and paraclinical assessments of 13 of these patients with a follow-up of at least 5 years, is reported. The patient history demonstrates that 12 out of 13 are clean at night, with 1 to 3 bowel movements during the day. The intermediate forms have no accidental defecation and almost no soiling. Conversely, the high forms often soil but usually do not wear thick protections. Criteria of successful reconstruction as rectal examination, defecogram, CT scan or MRI, yield limited data but no formal conclusions. Manometric studies provide a better understanding of the bowel function after pull-through procedures, by studying the rectoanal inhibitory reflex threshold (RAIRT), the maximal anal resting closure (MARCP), the conscious rectal sensitivity threshold (CRST) and the maximal rectal compliance (MRC). Technical aspects of these recordings are detailed. Manometric recording from 13 of these 21 patients show that RAIRT is present in 3 out of 6 intermediate forms and 3 out of 7 high forms. CRST is normal in all the cases except 1. MARCP was normal in 5 out of 6 intermediate lesions and 5 out of 7 high lesions. MRC is good in 5 intermediate forms and 3 high forms.(ABSTRACT TRUNCATED AT 250 WORDS)

[Posterior urethral valve: determining factors of long-term results]. / Valves de l'urètre postérieur: facteurs déterminant les résultats à long terme.

Posterior urethral valves (PUV) is the most common congenital urine flow impairment in boys. Long-term prognosis involves: renal function impaired in 30 to 50% of PUV and leading to hyperdiuresis, low GFR and acidosis; bladder urodynamics impaired in 75% of PUV with abnormal urine storage, abnormal micturition and vesicoureteric reflux. Incontinence and recurrent urinary tract infections commonly reflect bladder and renal failures; abnormal bladder outlet leads to incontinence and abnormal ejaculation. The roles of antenatal treatments (vesico-amniotic shunts), neonatal treatments (resuscitation and endoscopic treatment of PUV) and long-term treatments (urinary diversions, bladder augmentation, alpha blockers, anticholinergic, dialysis and renal transplant) in the long-term outcomes of PUV are reviewed.

[Severe bladder dysfunction in the child abuse victim. Hinman syndrome]. / Dysfonctionnements vésicaux graves chez l'enfant victime de maltraitance. Le syndrome de Hinman.

Severe bladder dysfunction with possible consequence on the upper urinary tract caused by psychological trauma were recently identified. Hinman in 1973 was the first to report a series of 14 patients with severe abnormal bladder and bowels behaviour with organic cause. He described the most common symptoms met in this group of patients and their management using a non surgical approach based on bladder reeducation and hypnosis. Other authors such as Allen in 1977 reported a similar experience and found severe detrusor-sphincter dyssynergia. In 1995, Ellsworth reported a relation between these abnormal bladder behaviour and a medical history of sexual aggression. We report here in a series of 7 patients with Hinman syndrome associated with aggression. Diagnosis and management by a multidisciplinary team involving paediatricians, paediatric urologists, physiotherapists, paediatric psychologists are detailed [corrected].

[Early diagnosis of cancer of the prostate. Hypothetic role of transrectal echography]. / Diagnostic précoce du cancer de la prostate. Place hypothétique de l'échographie transrectale.

In order to clarify the value of transrectal ultrasonic examination of the prostate in the diagnosis of prostatic cancer at an early stage, 666 patients were screened in one year; 602 of them (TO) had a normal, firm or hypertrophic but non-nodular prostate at digital rectal palpation, 41 had a T1-T2 prostate and 23 a T3-T4 prostate. Among the 602 TO prostates, 162 showed a hypoechoic peripheral area which was biopsied, revealing an infiltrating carcinoma in 11 cases. The ability of transrectal ultrasound alone to detect TO cancer was estimated at 1.8 per cent (11/602). The positive predictive value of a hypoechoic image of the prostate was estimated at 7 per cent (11/162), which is much lower than the figures reported in the literature. Transrectal ultrasound can be considered an acceptable method for detecting TO tumours of the prostate with a yield comparable to that of digital rectal palpation in the T1-T2 tumours. The low performance (1.8 per cent) of transrectal ultrasound in detecting cancer at an early stage rules out any mass screening programme of the male population over 50 years of age. However, 45 per cent of localized tumours in this series were detected by transrectal ultrasound.

[Polycystic dysplasias of the kidney. Apropos of 55 cases]. / Les dysplasies multikystiques du rein. A propos de cinquante-cinq observations.

The authors define their diagnostic approach and current management of Polycystic Renal Dysplasia (PRD) on the basis of a retrospective study of 55 children. Antenatal and postnatal renal ultrasonography and I.V.P. ensure early diagnosis of this congenital malformation; these two investigations together with cystography demonstrate the high incidence (16/55) of associated contralateral uropathy (vesicoureteric reflux, megaureter, hydronephrosis). Three therapeutic possibilities are discussed: therapeutic abstention and ultrasound guided cyst aspiration may be justified, but the authors prefer surgery as it allows confirmation of the diagnosis, elimination of the symptoms related to the cysts and their complications, confirmation of the absence of an associated nephroblastoma and treatment of any associated contralateral uropathy. In any case, it is impossible to restore the function of the dysplastic kidney, hence the importance of identifying any associated contralateral uropathy which could determine the vital prognosis.

[Drainage of pyelo-ureteral junction surgery: personal technique and review of the literature]. / Drainage après chirurgie de la jonction pyélo-urétérale: technique personnelle et revue de la littérature.

OBJECTIVES: To compare the various Stenting techniques used in ureteropelvic junction (UPJ) surgery and to present a personal series of 54 cases in which the Multipurpose Blue Stent (BARD, ANGIOMED) was used. PATIENTS AND METHOD: Between 1994 and 1998, 54 patients were treated for UPJ obstruction (52 underwent a Anderson-Hynes pyeloplasty and 2 a ureterocalicostomy). The Multipurpose Blue Stent insertion technique is described. The stent is removed on postoperative day 10 in the ward without cystoscopy. RESULTS: Clinical, isotopic and ultrasound improvement was obtained in 98% cases. Seven complications were reported: 4 urinary tract infections and 2 stent displacements without noticeable detrimental consequences on the outcome; 1 anastomotic leakage following a ureterocalicostomy requiring a redo operation (which was successful). The average hospital stay was 3 days. DISCUSSION: This stenting method is compared to those reported in the literature and proves to be more satisfactory in terms of hospital stay and removal. CONCLUSION: Postoperative leakage in non-stented operated UPJs is an under-reported but significant complication. Trans-anastomotic stenting has proven to be much safer than non-stenting. The Multipurpose Blue Stent reduces hospital stay and does not require a second hospitalisation to be removed.

[The significance of the use of fibrin glue in complete cystectomy with urinary diversion]. / Intérêt de l'utilisation de la colle de fibrine dans la cystectomie totale avec dérivation urinaire.

Two groups of 15 patients were submitted to radical cystoprostatectomy with urinary diversion. Was used in one group. Fibrin glue appears to be a valuable progress to improve the immediate follow-up of these patients, in terms of morbidity and the duration of parenteral assistance.

Management of urinary incontinence in neurogenic bladder.

The treatment of children with urinary incontinence caused by a neurogenic bladder presents a challenge to the paediatric urologist. Between 1965 and 1989, 527 patients with neurogenic bladder were treated and followed-up in the Department of Paediatric Urology of Debrousse Hospital. Of these, 46 were submitted to continent cystostomy, 39 to urinary artificial sphincter and 177 to clean intermittent catheterization (CIC). This last treatment is of paramount importance in girls and can be associated with complementary procedures if cervico-urethral resistance and/or bladder compliance are poor. Urethral lengthening (Kropp's procedure) in combination with CIC represents a major means of providing dryness in girls. Our technique of urethral lengthening is detailed and the place of CIC among other incontinence treatment is discussed.