Utilizing the Ex-Vivo Bovine Model in Retrograde Intrarenal Surgery Training.

OBJECTIVE: To present an ex-vivo bovine model for retrograde intrarenal surgery (RIRS) training. MATERIALS AND METHODS: The model was specifically developed for a pre-congress course organized as part of the National Pediatric Urology Congress. The course involved a 2-day online theoretical segment followed by hands-on training. Bovine kidneys were chosen for their anatomical resemblance to human kidneys. The kidneys were sourced from a local slaughterhouse, ensuring the intactness of the pelvis, ureters, and perirenal fat. A Modified Larssen solution was used for tissue preservation. The tissue was positioned within a cardboard box, with specific preparation techniques to ensure realism. During the hands-on training, participants utilized a flexible ureterorenoscope for practice. After the course, participants completed an 18-question survey assessing the model and training experience. RESULTS: Twenty-four participants completed the training and survey. Four out of 8 procured kidneys were suitable. The model's cost was 18 euros. Around 87.5% of participants reported increased RIRS confidence. Those with prior course experience rated the model's anatomical resemblance higher (P = .016). No significant difference was observed in feedback on the model's durability or tactile feedback based on prior experience (P >.05). CONCLUSION: The ex-vivo bovine model provides a promising alternative for RIRS training. While further studies are needed to validate its widespread application, initial feedback suggests it offers a balance between cost-effectiveness and realistic training experience.

Effectiveness of extracorporeal shock wave lithotripsy in urolithiasis patients under 2 years of age.

OBJECTIVE: In this study, we present our extracorporeal shock wave lithotripsy (ESWL) outcomes in urolithiasis patients under the age of two. MATERIALS AND METHODS: The procedure was performed with patients < 2 years of age sedated, under anesthesia using ketamine and Dormicum (midazolam), in the supine position. Fragmentation was evaluated by fluoroscopy after the procedure. RESULTS: A total of 74 procedures were performed on 65 kidneys. One patient with bilateral stones had two sessions of ESWL on the right side; three sessions of ESWL were performed in one patient with a unilateral stone, and two sessions were performed in seven patients with unilateral stones. All other patients underwent one session of ESWL. As post-procedural complications, hematuria was observed in 14 patients (12 mild and 2 significant), and vomiting occurred in 1 patient. Ureterorenoscopy was performed in 5 patients, and percutaneous nephrolithotomy in 6 patients due to a failed procedure. CONCLUSION: As a result, ESWL treatment is effective and has advantages such as a short hospitalization time, good reproducibility, cost-effectiveness, and a low rate of complications. Therefore, we recommend ESWL as the first-line treatment for renal and proximal ureteral stones in infants < 2 years of age.

OBIETIVO: En este estudio, presentamos nuestros resultados de ESWL en pacientes con urolitiasis menores de dos años. MATERIALES Y MÉTODOS: El procedimiento se realizó con pacientes menores de dos años sedados, bajo anestesia con ketamina y Dormicum (midazolam), en posición supina. La fragmentación se evaluó mediante fluoroscopia después del procedimiento. RESULTADOS: Se realizaron total de 74 procedimientos en 65 riñones. Un paciente con cálculos bilaterales tuvo dos sesiones de ESWL en el lado derecho; se realizaron tres sesiones de LEOC en un paciente con litiasis unilateral y dos sesiones en siete pacientes con litiasis unilateral. Todos los demás pacientes se sometieron a una sesión de ESWL. Como complicaciones post-procedimiento se observó hematuria en 14 pacientes (12 leves y 2 significativas) y vómitos en 1 paciente. Se realizó URS en 5 pacientes y NLP en 6 pacientes debido a un procedimiento fallido. CONCLUSIONES: Como resultado, el tratamiento de la ESWL es efectivo y tiene ventajas como un tiempo de hospitalización corto, buena reproducibilidad, costo-efectividad y baja tasa de complicaciones. Por tanto, recomendamos la ESWL como tratamiento de primera línea para cálculos renales y ureterales proximales en bebés < 2 años de edad.

Grading of Hydronephrosis: An Ongoing Challenge.

The crucial point for prompt diagnostics, ideal therapeutic approach, and follow-up of hydronephrosis associated with UPJ anomalies in children is the severity of hydronephrosis. Such many hydronephrosis grading systems as AP diameter, SFU, radiology, UTD, and Onen have been developed to evaluate hydronephrosis severity in infants. Unfortunately, it is still an ongoing challenge and there is no consensus between different disciplines. AP diameter is a very dynamic parameter and is affected by many factors (hydration, bladder filling, position, respiration). More importantly, its measurement is very variable and misleading due to different renal pelvic configurations. The radiology grading system has the same grades 1, 2, and 3 as the SFU grading system with addition of the AP diameter for the first 3 grades. This grading system divides parenchymal loss into two different grades. Grade 4 represents mild parenchymal loss while grade 5 suggests severe parenchymal loss. However, it is operator dependent, is not decisive, and does not differentiate grades 4 and 5 clearly. All grades of SFU are very variable between operators and clinicians. UTD classification aims to put all significant abnormal urinary findings together including the kidney, ureter, and bladder and thus determines the risk level for infants with any urinary disease. Different renal deterioration risks occur depending on the mechanism of hydronephrosis. Therefore, SFU and UTD classification may result in significant confusion and misleading in determining the severity of hydronephrosis. SFU-4 and UTD-P3 represent a considerable range of severity of hydronephrosis. Both represent minimal thinning of the medullary parenchyma and severe thinning of the cortical parenchyma (cyst-like hydronephrotic kidneys) at the same grade. The wide definition of SFU-4 and UTD-P3 fails to indicate accurately the severity of hydronephrosis and thus significantly misleads from a prompt treatment. They do not suggest who need surgical treatment and who can safely be followed non-operatively. The anatomy and physiology of the 4 suborgans of the kidney (renal pelvis, calices, medulla, and cortex) are completely different from each other. Therefore, each part of the kidney affect and behave differently as a response to UPJ-type hydronephrosis (UPJHN) depending on the severity of hydronephrosis. The upgraded Onen hydronephrosis grading system has been developed based on this basic evidence both for prenatal and post-natal periods. The Onen grading system determines specific detailed findings of significant renal damage, which clearly show and suggest who can safely be followed conservatively from who will need surgical intervention for UPJHN. Neither AP diameter nor radiology, SFU, or UTD classification is the gold standard in determining the severity of hydronephrosis. All these grading systems are based on subjective parameters and are affected by many factors. They do not determine the exact severity of UPJHN and thus cause permanent renal damage due to a delay in surgical decision in some infants while they may cause an unnecessary surgery in others. The Onen grading system has resolved all disadvantages of other grading systems and promises a safer follow-up and a prompt treatment for UPJHN. It is an accurate and easily reproducible grading that has high sensitivity and specificity.

Predicting pseudocyst formation following pancreatic trauma in pediatric patients.

BACKGROUND: There are insufficient data on pre-screening for pancreatic pseudocysts (PC) following pancreatic trauma. This study investigated the use of radiological and laboratory testing for predicting the development of pancreatic pseudocysts after trauma. MATERIALS AND METHODS: The clinical records of all pediatric patients presenting with pancreatic trauma between January 2003 and December 2014 were reviewed retrospectively. Patients with American Association for the Surgery of Trauma (AAST) scores of Grade 3-5 were enrolled. The patients were divided into groups that developed [Group 1 (n = 20)] and did not develop [Group 2 (n = 18)] PC. The patients were evaluated in terms of their baseline characteristics, additional injuries, Injury Severity Score (ISS), pancreatic injury site, blood amylase levels 2 h and 10-15 days after the trauma, clinical presentation, and duration of intensive care unit (ICU) stay. FINDINGS: We followed 38 patients. Of the patients in Group 1, 70 % had an injury to the tail of the pancreas. The ISS trauma scores and durations of hospitalization and ICU stay were significantly greater in Group 2 (p < 0.05). The mean blood amylase level on Day 1 was 607 U/L (range 183-801 U/L) in Group 1 and 314 U/L (range 25-631 U/L) in Group 2; the respective levels on Day 10 were 838 U/L (range 123-2951 U/L) and 83.2 U/L (range 35-164 U/L). The serum amylase levels were significantly higher (p < 0.001) in Group 1 than in Group 2 on Days 1 and 10. Four patients developed complications and two patients died. CONCLUSION: Pancreatic pseudocyst formation is more likely in patients with AAST Grade 3 pancreatic injury, also serum amylase levels ten times greater than normal 2 h after the trauma, and persistently elevated serum amylase levels 10-15 days following the trauma.

Traumatic diaphragmatic rupture in children.

BACKGROUND: The purpose of this study was to describe our experience with traumatic diaphragmatic rupture (TDR). Very little has been written about this condition in the pediatric age group. METHODS: Between January 2000 and December 2011, data on twenty-two patients with TDR were analyzed, and clinical data were recorded. The patients were divided into subgroups based on injury type and ISS values. RESULTS: Four patients were female, and eighteen were male. Mean age was 9.4 years (range 2-15 years). TDR was left-sided in twenty (91%) patients and right-sided in two (9%). The mean ISS (Injury Severity Score) was 19 (range 11-29). No significant difference in morbidity was noted between firearm and other injuries (p=0.565) or between ISS values below and above 16 (p=0.565). Seven patients (32%) had isolated diaphragmatic injury, while the other fifteen cases had additional associated injuries. Diagnoses were determined via a chest radiograph alone in the majority of cases, while suspected cases were confirmed by multidetector computed tomography if the patients were hemodynamically stable. Herniation was observed in twenty patients. Primary suture of the diaphragm and tube thoracostomy were performed in all patients. Postoperative complications included ileus (two cases), intussusception (one case), empyema (one case), and one patient succumbed during the operation. CONCLUSIONS: TDR, while uncommon, should be considered in cases of thoracoabdominal injury. All patients should undergo meticulous examination preoperatively. When the chest radiograph does not provide a definitive diagnosis, multidetector computed tomography, including multiplanar reconstruction or volume rendering, may be beneficial for confirming suspicion of diaphragmatic rupture.

Nonoperative management of pancreatic injuries in pediatric patients.

PURPOSE: Nonoperative management of minor pancreatic injury is the generally accepted approach. However, the management of major pancreatic injury remains controversial in pediatric patients. The aim of the present study was to determine the safety and efficacy of nonoperative management of pancreatic injury in pediatric patients. METHODS: Between 2003 and 2009, 31 patients, 28 male and 3 female, with pancreatic injury due to blunt abdominal trauma were treated in our clinic. All patients were evaluated by ultrasonography, computed tomography (CT), and evaluation of serum amylase levels. Patients with ongoing hemodynamic instability after resuscitation or signs of bowel perforation underwent immediate laparotomy, and the remaining patients were conservatively treated. Conservative treatment consisted of nasogastric tube replacement, total parenteral nutrition, monitoring of amylase levels, and serial clinical examination. RESULTS: The most common mechanism of injury was a fall (35.4%). Ten patients (32.2%) had associated extra-abdominal injuries, and 18 patients (58.1%) had associated abdominal injuries. The spleen was the most common site of intra-abdominal injury that was associated with pancreatic trauma. Initial amylase levels were normal in 5 patients, whose CT scans revealed pancreatic injury. Twenty-five patients (80.6%) were conservatively treated. Six patients (19.4%) required surgical intervention because of a hollow viscus or diaphragmatic injury and hemodynamic instability. A pseudocyst developed in 11 of the 25 patients who were nonoperatively treated; 6 patients required intervention for the pseudocyst (percutaneous drainage and cystogastrostomy). No patient succumbed to injury. CONCLUSIONS: The majority of the pancreatic injuries in pediatric patients can be successfully treated conservatively, unless there is hemodynamic instability and a hollow viscus injury. The most common complication is a pseudocyst.

Is there a role for antioxidants in prevention of pulmonary hypoplasia in nitrofen-induced rat model of congenital diaphragmatic hernia?

BACKGROUND/PURPOSE: Many studies suggest a role for antioxidants in the prevention of lung hypoplasia in nitrofen-induced rat models with congenital diaphragmatic hernia (CDH). This study investigates the oxidative status and the histological outcome of prenatal administration of vitamins E and C with synergistic effect, and effect of N-acetylcysteine (NAC) to improve lung maturation of nitrofen-induced rats. METHODS: CDH was induced by maternal administration of a single oral dose of nitrofen on day 9.5 of gestation, and the Sprague-Dawley rats were randomly divided into five groups: nitrofen (N), nitrofen + vitamin C (NC), nitrofen + vitamin E (NE), nitrofen + vitamin C + vitamin E (NCE) and nitrofen + NAC (NNAC). A control group in which only vehicle was administered was included. Cesarean section was performed on day 21. Body weight (BW) and total lung weight (LW) of all fetuses with CDH were recorded; lung histological evaluation was performed, and protein content of lungs, determination of thiobarbituric acid reactive substances, and the protein carbonyls in tissue samples were determined. RESULTS: A total of 133 rat fetuses with CDH were investigated. The body weight and the lung weight of fetuses of all groups that were exposed to nitrofen were significantly decreased than of the control group (P < 0.05). The animals exposed to nitrofen with different antioxidants showed increased protein levels in lung tissue. However, in the NCE and the NNAC groups, protein levels were significantly increased than in the others. Malondialdehyde levels significantly decreased in the NCE and the NNAC groups when compared with the NC and the NE groups. In addition, the NCE and NNAC groups decreased protein oxidation to control levels, and no significant difference was observed between control and these two antioxidants groups. The N, NC, NE and NNAC groups showed minimal improvement in lung histology; the NCE groups showed the most improvement in lung histology when compared with the other nitrofen plus antioxidant groups. CONCLUSION: Prenatal administration of NAC and vitamin E in combination with vitamin C represented the best effects to avoid oxidative damage and protein content of the lungs in rat pups with CDH at birth.

Selective nonoperative management of penetrating abdominal injuries in children.

BACKGROUND: Nonoperative management of solid organ injuries caused by blunt abdominal trauma has been the standard care for many years. However, operative management is considered the standard care for penetrating abdominal trauma by most surgeons. The aim of this study was to assess the feasibility of selective nonoperative management of penetrating abdominal trauma in children. METHODS: A total of 90 children suffering from penetrating abdominal trauma between 2003 and 2008 were evaluated. Patients who had hemodynamic instability or signs of bowel perforation underwent an immediate laparotomy. The remaining patients were observed with serial clinical examinations, radiologic evaluation, and hemoglobin level. RESULTS: There were 76 boys and 14 girls. The mean age was 9.9 years (range, 1-16 years). The mechanism of injury was stab wound in 60 patients (67%) and gunshot in 30 (33%). The most commonly injured organ was bowel (51.7%). Omentum or bowel was eviscerated through wound in seven patients; none of these patients had organ injury. Although 51 (56.6%) were treated nonoperatively, 39 patients (43.4%) required surgical treatment (19 of 60 stab wound, 20 of 30 gunshot). Of the 39 patients who underwent surgery, 6 (15.3%) were found to have no significant organ injury during surgery. Of the all, 51 patients who were initially followed nonoperatively, two patients required surgery. There were two complications. CONCLUSION: The majority of abdominal stab wound and many gunshot wounds can initially be managed nonoperatively in children, when there is no hemodynamic instability or signs of hollow viscus perforation.

Associated malformations in Morgagni hernia.

Morgagni hernia (MH) is a congenital herniation of the abdominal organs through the subcostosternal portion of the diaphragm. It is a rare type of diaphragmatic hernia that has been associated with other congenital anomalies. The purpose of this clinical review was to determine the incidence of associated anomalies in patients with MH at a major pediatric referral center. The medical records of all patients with the diagnosis of MH were reviewed retrospectively between 1983 and 2006. The age, sex, side of herniation, presenting symptoms and signs, associated anomalies, radiologic features, intraoperative findings, postoperative course, complications, and mortality were recorded. There were 11 males and 5 females. The average age of the patients was 34.5 months (range 2 months-14 years). Twelve patients (75%) had at least one associated congenital malformation and eight (66.6%) of them had multiple anomalies. Six (37.5%) patients had a chromosomal anomaly, Down's syndrome in five and Turner syndrome in one. MH has a high incidence of associated congenital malformations.

A comprehensive analysis of 51 neonates with congenital intestinal atresia.

OBJECTIVE: To determine contemporary patterns of presentation and trends in the management and outcome of 51 newborn infants with intestinal atresia. METHODS: We retrospectively reviewed 51 cases of intestinal atresia between January 1983 and February 2003. Clinical data included antenatal history, age, gender, weight, presenting symptoms and signs, diagnostic procedures, location and type of atresia, associated abnormalities, surgical treatment, associated problems, morbidity, mortality and plans of treatment. RESULTS: Twenty children had duodenal obstruction, 24 had jejunoileal atresia, and 7 had colonic atresia. Approximately one-fourth of patients associated with duodenal atresia had preterm delivery and all patients with jejunoileal and colonic atresia were full term. Clinical features such as vomiting, abdominal distention, delayed meconium passage and jaundice were more frequent in jejunoileal atresia patients. Other associated organ anomalies particularly Down's syndrome were more frequent in duodenal atresia patients. A duodeno-duodenostomy was preferred in most of the patients with duodenal atresia and annular pancreas; duodenotomy and web excision for those with duodenal webs; and resection with end-to-end anastomosis for those with jejunoileal atresia. In all patients with colonic atresia, colostomy procedure was performed as the first step of surgery. CONCLUSION: Experienced neonatal care and prompt total parenteral nutrition by placing central line during surgery may improve the outcome of such patients.

Late presentation of bochdalek-type congenital diaphragmatic hernia in children: a 23-year experience at a single center.

PURPOSE: The purpose of this article is to report on our 23-year experience of treating children with late-presenting congenital diaphragmatic hernia (CDH), focusing on diagnostic difficulties, associated anomalies, and morbidity. METHOD: We reviewed 19 children in whom Bochdalek-type CDH was diagnosed after the neonatal period, between 1983 and 2005. RESULTS: There were 14 boys and 5 girls, with a mean age of 18.3 months (range, 5 weeks-14 years). Ten (52.6%) of the patients presented with respiratory symptoms and five (26.3%) with gastrointestinal symptoms. The diagnosis of CDH was based on the findings of chest X-rays, gastrointestinal tract contrast radiographs, and computerized tomography findings. The CDH was on the left side in 16 patients and on the right side in three patients. A hernia sac was present in seven (36.8%) patients. The only postoperative complications were intestinal obstruction caused by adhesions, incisional hernia, and eventration of the diaphragm in one patient each. None of the patients died within this study period. CONCLUSION: The possibility of a delayed presentation of CDH should be considered in the differential diagnosis of recurrent non-specific respiratory or gastrointestinal tract symptoms in a child. A plain roentgenogram with a swallowed nasogastric tube might assist in the diagnosis. Early surgical correction of the diaphragmatic defect is crucial for preventing life-threatening complications.

An alternative grading system to refine the criteria for severity of hydronephrosis and optimal treatment guidelines in neonates with primary UPJ-type hydronephrosis.

OBJECTIVE: We present our alternative hydronephrosis grading system (AGS) in an attempt to establish optimal treatment guidelines, and clarify and refine the criteria for severity of hydronephrosis in neonates. PATIENTS AND METHODS: A total of 162 newborns (228 affected kidneys) with antenatally diagnosed primary ureteropelvic junction-type hydronephrosis were prospectively followed and treated by the same surgeon for a mean of 46 (6-65) months. Ultrasonography and diuretic renogram were used for diagnosis and follow up. Society for Fetal Urology (SFU) grading system, anteroposterior diameter of renal pelvis (APDRP) and our AGS were used to determine the degree of hydronephrosis. AGS: 0, no hydronephrosis; 1, dilatation of renal pelvis alone; 2, plus caliceal dilatation; 3, plus <1/2 (mild-to-moderate) renal parenchymal loss; 4, plus >1/2 (severe) renal parenchymal loss (cyst-like kidney with no visually significant renal parenchyma). RESULTS: On the first postnatal ultrasound, the severity of hydronephrosis was SFU< or =2 in 152 kidneys (surgery, 0%), SFU-3 in 41 kidneys (surgery, 19.5%) and SFU-4 in 35 kidneys (surgery, 68.6%). The follow up, treatment and outcome of SFU-1 and SFU-2 patients were similar; all resolved spontaneously without renal deterioration (renal function >40%). Renal function ranged between 7% and 39% in SFU-4 patients. Intrarenal pelvis was found in one patient with an APDRP of <15 mm, seven patients of 16-30 mm, and five patients of >30 mm. Overall, 201 hydronephrotic kidneys (88.2%) resolved spontaneously while 27 (11.8%) required pyeloplasty. CONCLUSION: Neither an SFU grading system nor measurement of APDRP is the gold standard in determining the severity of hydronephrosis. Both methods may fail, particularly in children with intrarenal pelvis configuration or SFU-4 hydronephrosis. Our AGS promises easier follow up and more timely treatment.

Treatment and outcome of prenatally detected newborn hydronephrosis.

OBJECTIVE: For neonates with antenatally diagnosed primary ureteropelvic junction (UPJ)-type hydronephrosis, to attempt to clarify and refine criteria for establishing optimal follow-up and treatment guidelines. PATIENTS AND METHODS: A total of 162 newborns (228 hydronephrotic kidneys) with this condition were prospectively followed and treated by the same surgeon in 2001-2005 for a mean of 53 (13-72) months. Ultrasonography and diuretic renogram were used for diagnosis and follow up, and Onen's grading system to determine degree of hydronephrosis. RESULTS: On first postnatal ultrasound, the severity of hydronephrosis was grade 1 in 152 kidneys (surgery, 0%), 2 in 41 (surgery, 19.5%), 3 in 19 (surgery, 42.1%), and 4 in 16 kidneys (surgery, 93.8%). All the grade 1 cases resolved spontaneously without renal deterioration (renal function >40%). Renal function ranged between 7% and 34% in grade 4 patients. Overall, 201 hydronephrotic kidneys (88.2%) resolved spontaneously, while 27 (11.8%) required pyeloplasty because of evidence of obstructive injury, including increased hydronephrosis in 14/27 (6/27 had less than 10% decrease in renal function), greater than 10% decrease of renal function in 9/27, and greater than 10% decrease of renal function as well as increased hydronephrosis in 4/27 patients (15%). CONCLUSION: In most cases, neonatal hydronephrosis is a relatively benign condition that can be followed safely by an initial non-operative approach unless there is evidence of obstructive injury. A follow-up protocol that permits early identification of a limited number of kidneys that may develop signs of obstruction and require pyeloplasty is crucial for a favorable outcome in patients with primary UPJ-type hydronephrosis. Onen's hydronephrosis grading system promises an easier and more appropriate follow up and timely treatment for children with this condition. A sufficient follow-up interval, especially during the first 3 years of life, is essential to help prevent permanent loss of renal function in kidneys that do develop signs of obstruction.

The mechanical complications of colostomy in infants and children: analysis of 473 cases of a single center.

The purpose of this study was to determine the morbidity, mortality and possible risk factors in children who underwent colostomy. A total of 473 children who underwent colostomy in our clinic between 1983 and 2005 were retrospectively reviewed. Of these patients, 278 were boys and 195 were girls. The major indications for colostomy were anorectal malformation (252 patients), Hirschsprung's disease (117), and trauma (66). The patients' age ranged from 1 day to 15 years. Of the 473 patients, 254 (53.6%) were < 1 month of age, 97 (20.5%) were 1-12 months of age, and 122 (25.7%) were > 12 months of age. The side of colostomy was transverse in 341 (72%) patients and sigmoid in 132 (28%). The type of colostomy was loop in 364 (77%) patients and diverting in 109 (23%). Postoperative complication was observed in 80.5% of patients; excoriation (46.5%), prolapse (20.5%), stomal obstruction/stenosis (6.1%), and stomal bleeding (2.1%). A stomal revision was required for 26 (5.5%) patients. Overall, 50 (10.5%) patients died; 37 were related directly to major congenital anomalies, while 13 (2.7%) patients had a colostomy complication. The age of patients who died was < 1 month in 46 (92%) patients. The incidence of morbidity and mortality in children with colostomy is significantly high, particularly in neonates. Prompt colostomy procedure by an experienced hand, prompt stomal care under the supervision of a trained and experienced stomal care giver and early closure of the colostomy may increase the survival of these patients.

Postoperative abdominal evisceration in children: possible risk factors.

Postoperative abdominal evisceration may lead to high morbidity and mortality. The purpose of the present study was to determine possible risk factors, morbidity and mortality associated with abdominal evisceration in children. A total of 3,591 children underwent abdominal exploration in our clinic between 1983 and 2005. In this study, we retrospectively reviewed 29 patients who developed abdominal evisceration after abdominal exploration. The incidence for abdominal evisceration was found to be 0.8%. The mean age was 16 months (range 1 day-13 years), while 48.2% of the patients were younger than 1 month. The incidence of abdominal evisceration was significantly higher in patients younger than 1 month (2.5%) compared to older ones (0.4%) (P < 0.0001). The mean time interval between primary abdominal exploration and development of abdominal evisceration was 7 days (2-21 days). The risk for development of evisceration was significantly higher in patients who underwent colonic or small bowel surgery compared to those underwent laparotomy alone (P < 0.0001, P < 0.01, respectively). Absorbable suture was used in 15 patients for closure of abdominal fascia, while a silk suture material was used in 14 patients (P > 0.05). The age-weight percentile was lower than 3% in 41.3% of patients. At the follow-up period, 19 patients recovered completely whereas 10 (34.5%) died. As a result, the age (neonates), primary surgery (colo-rectal), type of incision (median), and emergency surgery were significant risk factors for development of abdominal evisceration in children.

The value of open surgical approaches for aspirated pen caps.

PURPOSE: The aim of this study was to present the therapeutic approach of aspirated pen cap foreign bodies, with emphasis on the importance of open surgical intervention. METHODS: The records of patients who underwent bronchoscopy and bronchoscopy and surgical therapy for pen cap foreign bodies between January 1997 and June 2003 were reviewed retrospectively. Diagnosis was made based on history, physical examination, radiological methods, and bronchoscopy. Age, sex, symptoms, radiological methods, surgical procedure, complications, and outcomes were recorded. RESULTS: A total of 24 bronchoscopies were performed on 19 patients (10 boys, 9 girls) with a median age of 11 years (range, 8-15 years). Pen caps were localized in the right bronchial tree in 14 cases (74%). Pen caps were extracted successfully by forceps during bronchoscopy in 9 patients. Of the remaining 10 patients, 5 underwent bronchoscopy and tracheostomy and 5 patients underwent thoracotomy and bronchotomy. Significant complications were observed in 2 patients (10.53%) (severe bronchospasm in one and pneumothorax and subglottic edema in another). CONCLUSIONS: Pen caps aspiration is a challenging problem because of the difficulties during extraction and higher morbidity compared with other foreign body aspirations. In such cases in which classic bronchoscopy failed and/or pen caps could not be removed via vocal cords, open surgical approaches, either bronchoscopy and tracheostomy or thoracotomy and bronchotomy, may be an alternative procedure of choice.

Long-term outcome of posterior urethral rupture in boys: a comparison of different surgical modalities.

OBJECTIVES: To evaluate the long-term outcome of posterior urethral rupture due to pelvic trauma. METHODS: We retrospectively reviewed the records of 49 children with posterior urethral rupture from 1986 to 2000. The urologic evaluation at the last follow-up visit was made by the same surgeon and included physical examination, ultrasonography, simultaneous retrograde urethrography, and voiding cystourethrography, as well as cystourethroscopy in some cases. The long-term urologic results were determined by voiding function, continence and erectile function, and semen analysis. RESULTS: The mean follow-up was 12 years (range 4 to 17). The average age was 8 years at the time of trauma and 20 years at the last follow-up visit. Primary realignment (22 patients), immediate repair (8), and delayed repair (16) were performed for posterior urethral rupture. Urethral continuity was achieved in 97.9% of patients, and 30 (61.2%) were free of symptoms. The overall rate of long-term complications was significantly greater in patients with a prostatic urethra location injury, and it was similar for the three surgical procedures. CONCLUSIONS: The results of our study have shown that, apart from partial injury, all types of surgical treatment are equally problematic, with similar complication rates and long-term morbidity. The procedure of choice should be individualized, depending on the anatomy and the extent of the urethral injury, stability of the patient, and presence of additional injuries.

The outcome of one-stage hypospadias repairs.

OBJECTIVE: Hypospadias is an increasingly common condition, and many procedures have been described for operative correction. We reviewed our experience of different techniques of one-stage hypospadias repair. MATERIALS AND METHODS: We retrospectively reviewed 107 hypospadic boys who were younger than 15 years between January 1986 and June 2003. We included all patients who underwent one-stage hypospadias repair. All patients were evaluated for age, type of hypospadias, associated anomalies, surgical technique, and morbidity rate. The functional and cosmetic results were evaluated at 1 month, 6 months and 1 year postoperatively. Univariate analysis was done to identify those variables that might serve as interdependent predictors of postoperative complications. RESULTS: The median age was 7 years (6 months to 13 years). Severe chordee was observed in 15 patients. The majority of cases were anterior hypospadias (53%), while the majority of complications were observed in the middle group (62%). Cosmetic and functional results were satisfactory in the majority of the patients. Complications included 16 fistulae (15%) and 11 meatal stenoses (10%). Some prognostic factors such as age, insertion of a suprapubic cystostomy tube, suture structure, and time of catheter removal did not significantly affect the risk of complication, whereas some other factors such as associated anomalies, severe chordee, middle and posterior hypospadias, and use of a pedicle island flap were significant in their relation to the complication rate. CONCLUSION: Such possible risk factors as severe chordee, middle and posterior localized hypospadias, and use of a pedicle island flap may increase the postoperative complication rate. There is no gold-standard technique for hypospadias repair; the procedure of choice should depend on the individual anatomy of the penis. The long-term outcome after puberty has to be awaited.

Intrapleural fibrinolytic treatment of multiloculated pediatric empyemas.

Our objective was to compare the efficacy of adjunctive intrapleural fibrinolytic agents (IPFA) (streptokinase, urokinase) on fibrinopurulent stage empyema and chronic stage empyema in children. IPFA were used in 78 pediatric patients with empyema (36 fibrinopurulent stage empyemas, 42 chronic stage empyemas) between December 1994 and September 2002. Pleural biopsy was done for staging in all cases. Streptokinase 250,000 units in 100 ml normal saline (62 patients) or 100,000 units urokinase in 100 ml normal saline (16 patients) was instilled daily into the patient's chest tube, and the tube was clamped for 4 h, followed by suction. This treatment was continued daily for 2-8 days until resolution was demonstrated by chest radiographs and/or computed chest tomography. Success of treatment was 97.2% (complete response 24/36, partial response 11/36) in the fibrinopurulent stage and 9.4% (complete response 2/42, partial response 2/42) in chronic empyema cases. In one patient with fibrinopurulent empyema, the treatment was stopped due to allergic reaction and pleural hemorrhage; this patient died 1 day later in a septic condition. Although an invasive method, the pleural biopsy technique may be an alternative way of more properly staging thoracic empyema in selected children in whom staging based on radiographic and biochemical findings is doubtful. Intrapleural fibrinolytic treatment is an effective and safe therapy of choice and may have significant benefit in most children with fibrinopurulent phase empyema, except for those with bronchopleural fistula. IPFA do not seem to be effective in children with chronic phase empyema.

The effects of nitric oxide on the expression of cell adhesion molecules (ICAM-1, UEA-1, and tenascin) in rats with unilateral testicular torsion.

BACKGROUND/PURPOSE: The aim of this study was to determine the effects of nitric oxide (NO) on the expression of adhesion molecules in the early course of testicular I-R injury in rats. METHODS: Forty male Sprague-Dawley rats were separated into 4 groups, each containing 10 rats. A sham operation was performed in group 1 (control). In group 2 (I-R), after 6 hours of unilateral testicular torsion, 1-hour detorsion of the testis was performed. In group 3 (I-R/L-NAME), after performing the same surgical procedures as in group II, L-NAME was given for 30 minutes. In group 4 (I-R/Mol), after performing the same surgical procedure (torsion and detorsion) as in group II, molsidomine, an NO donor, was infused for 30 minutes. Then, ipsilateral orchiectomies were performed to measure the tissue levels of malondialdehyde (MDA) and NO and to make histologic examination. RESULTS: MDA values and the testicular injury score decreased and NO values increased in the I-R/Mol-treated group compared with other experimental groups. The tenascin expression in the interstitial space and basement membrane of the tubuli seminiferi were milder in the I-R/Mol group compared with that of the I-R and the I-R/L-NAME. The acrosomes of the spermatids in I-R and I-R/L-NAME groups were stained mildly by lectin. In the I-R and I-R/L-NAME groups, the interstitial spaces, basement membrane of the tubuli seminiferi, and sertoli and germinal cells in testicular tissue were stained intensely by ICAM-1. CONCLUSIONS: The expression of adhesion molecules such as tenascin, lectin, and ICAM-1 in the torted testicular tissue may be a pathophysiologic sign of inflammation. NO regulates adhesion molecules expression.