Coexisting pelviureteral and vesicoureteral junction obstruction in children.

OBJECTIVE: To address reasons for diagnostic failure in children with coexisting pelviureteral and vesicoureteral junction obstruction. PATIENTS AND METHODS: A total of 11 children with coexisting pelviureteral and vesicoureteral junction obstruction are reported. This anomaly was recognised at presentation in only 5 (45%) of cases. In the remainder, correct diagnosis was made after initial pyeloplasty and a significant delay occurred in 3 children. In all 11 patients treatment consisted of pyeloplasty and subsequent reimplantation. RESULTS: A satisfactory postoperative course with improvement of urinary tract dilatation was noted in all 11 patients, while 8 of 11 patients showed preserved renal function at late follow-up. CONCLUSION: According to the few available data, our data confirm the difficulty of diagnosing coexisting pelviureteral and vesicoureteral junction obstruction in children. However, prompt recognition and relief of urinary obstruction in these patients is mandatory in order to prevent deterioration of renal function.

Successful use of transureteroureterostomy in children: a clinical study.

The purpose of this review of patients was to look at the current role of transureteroureterostomy in children. In addition, this study should give an indication of the long-term safety of transureteroureterostomy in children with neurogenic bladder. From 1972 on, 70 subjects between the ages of 2 and 13 underwent transureteroureterostomy. In 68 patients (97 %), transureteroureterostomy was used as a salvage renal procedure after unsuccessful ureteroneocytostomy attempts at other institutions. In 2 patients (3 %), transureteroureterostomy was used as a diversion procedure. The postoperative course was uneventful except for 1 case of early anastomotic occlusion successfully treated by application of a double-J stent. No patient required surgical revision of the ureteral anastomosis. However, 4 patients with neurogenic bladder from myelomeningocele developed sequelae. Of these, 1 presented with stenosis at the end of the recipient ureter, 2 had occurrence of vesicoureteral reflux in nonreimplanted recipient ureter, 1 developed calculi in the donor pelvis. This study supports the view that transureteroureterostomy is highly useful for the management of children with a wide spectrum of urological anomalies. However, long-term monitoring of patients with neurogenic bladder who have undergone this procedure is essential to achieve a long-term good outcome.

Relevance of infection in children with urachal cysts.

OBJECTIVE: To assess the role of infection in the management of children with urachal cysts. METHODS: A retrospective study on 10 children with urachal cysts operated on over an 11-year period (from 1987 to 1998) was performed. Uncomplicated urachal cysts were found in 2 children who underwent primary cyst removal. The remaining 8 were admitted with severe sepsis due to the presence of a urachal abscess; they were managed by a staged approach including percutaneous drainage and delayed cyst removal. The diagnosis of urachal cyst was readily made by ultrasound in all the 10 patients (100%). In 1 patient with urachal abscess, computed tomography provided additional information. RESULTS: The postoperative course was uneventful in 9 of 10 children (90%). A 5-year-old female patient developed peritonitis following urachal abscess rupture into the peritoneal cavity, which resulted in additional surgery and prolonged hospitalization. CONCLUSIONS: (1) Ultrasound is an excellent diagnostic tool for patients with urachal cysts. (2) A renal screening ultrasound must be included in the preoperative work-up. (3) A thorough urological assessment is indicated in patients with abnormal renal ultrasound of recurrent urinary infections. (4) At present, a staged surgical procedure still remains the most effective surgical option in children with urachal cyst.

Fatal cardiac tamponade as a late complication of central venous catheterization: a case report.

Central venous catheterization is a reliable technique in neonatal surgery. Nevertheless, the rate of mechanical catheter-related complications remains high. We report a neonate with gastroschisis in which the successful placement of a central venous catheter was followed later by a cardiac tamponade with a fatal outcome. This complication occurred without perforation of the cardiac wall. A similar finding has been reported in only one other pediatric patient. Vigilant observation is required in any neonate with a central venous line in place to prevent the occurrence of this life-threatening event.

Endoscopic and minimal open surgical incision of ureteroceles.

Ureterocele decompression by endoscopic or open incision was the primary treatment in 59 children with 63 ureteroceles. Of these, 18 were intravesical and 45 were ectopic. The endoscopic or open incision adequately decompressed all intravesical ureteroceles and 37 of 45 ectopic ureteroceles (82%). After incision, the secondary operation rate was 17% for intravesical and 62% for ectopic ureteroceles. In our opinion, endoscopic or open incision must be considered a definitive treatment in the large majority of intravesical ureteroceles and is also valid in ectopic ureteroceles. In these cases, the early decompression obtained by this approach produced significant functional recovery, fewer urinary tract infections, and facilitated subsequent surgery in those patients requiring complete surgical reconstruction.

Blue venography in adolescent varicocelectomy: a modified surgical approach.

BACKGROUND/PURPOSE: Conventional varicocelectomy is often complicated by postoperative recurrences. When failure occurs, it is likely to be caused by incomplete interruption of the testicular vein, which is divided into multiple branches, or by the parallel collaterals, and to incompetence of the cremasteric vein(s). Occasionally it is caused by reversed flow in the deferential vein(s). METHODS: The author reports his experience with 172 consecutive corrections of varicocele in adolescents (mean age, 13.4 years) by means of a personally modified technique. This technique is characterized by ileoinguinal access to all venous areas such as the retroperitoneum and the inguinal canal; ligature and transection of the internal and external spermatic veins, the parallel collaterals, and the deferential vein(s), if dilated and tortuous, with spermatic artery preservation; control of the interruption of flow in these veins by injection of methylene-blue solution in a vein of the pampiniform plexus (blue venography). Optical magnification (4x) and papaverine solution were also used. The rationale for this surgical approach is twofold: interruption of all testicular veins incompetent and potentially incompetent; easy and effective intraoperative control of venous interruption. RESULTS: No varicocele recurrences or postoperative controlateral varicoceles were detected (follow-up, 6 to 24 months). The complications include a postoperative testicular atrophy by intraoperative methylene-blue extravasation with large hematoma of the cord and three postoperative hydroceles. CONCLUSION: The surgical approach reported here is a simple, safe, artery-sparing technique.

Labial skin-flap vaginoplasty using tissue expanders

In severe vaginal malformations, when the distance between the upper vaginal pouch and perineum is too long (6 cm or more), reconstruction of the vagina can be performed by colonic interposition or by long cutaneous flaps obtained by the tissue expansion technique. Two female adolescents were treated using expanded labial skin flaps. Dissection and anastomosis between the vaginal remnant and cutaneous tube was performed by the transtrigonal approach. Results were satisfactory at 2.5-year follow-up. In our opinion, expanded labial skin-flap vaginoplasty has three main advantages: (1) it permits the construction of a large, soft, well-vascularized neovagina using non-hair-bearing labial skin; (2) it obviates postoperative dilations and prevents delayed strictures; and (3) a transtrigonal approach permits an easy vaginal dissection and a careful, tension-free anastomosis.

Labial skin-flap vaginoplasty using tissue expanders.

In severe vaginal malformations, when the distance between the upper vaginal pouch and perineum is too long (6 cm or more), reconstruction of the vagina can be performed by colonic interposition or by long cutaneous flaps obtained by the tissue expansion technique. Two female adolescents were treated using expanded labial skin flaps. Dissection and anastomosis between the vaginal remnant and cutaneous tube was performed by the transtrigonal approach. Results were satisfactory at 2.5-year follow-up. In our opinion, expanded labial skin-flap vaginoplasty has three main advantages: (1) it permits the construction of a large, soft, well-vascularized neovagina using non-hair-bearing labial skin; (2) it obviates postoperative dilations and prevents delayed strictures; and (3) a transtrigonal approach permits an easy vaginal dissection and a careful, tension-free anastomosis.

[Non-palpable testis: modern diagnostic and therapeutic trends]. / II testicolo non palpabile: moderni orientamenti diagnostici e terapeutici.

Management of the nonpalpable testis is controversial and can be difficult as shown by the multiple modalities for evaluation and proposed treatment. In our opinion, laparoscopy is the ideal first step in the management of patients with a nonpalpable testis, having a great reliability in locating or confirming absence of an occult testis. Accurate preoperative assessment and localization will assist in selecting the appropriate surgical approach either laparoscopic, laparoscopic-assisted, or open procedure. Laparoscopy was performed on 74 patients with 86 nonpalpable testis. The technique has been demonstrated to be extremely safe and lead to diagnosis in 100% of cases. Surgical management of nonpalpable testis was directly performed by laparoscopy identifying intra-abdominal vanishing testis and locating an intra-abdominal or inguinal testis. The two-stage Fowler-Stephens orchiopexy was performed in 41 patients. The first stage consisted of laparoscopic clip ligation of the spermatic vessels. Of these, 32 underwent the second stage by vas-based orchiopexy; all testes, but one, showed a normal size and consistency. To conclude, we advocate the use of laparoscopy in all boys with nonpalpable testis.

[Severe chronic constipation: limitations of medical therapy and indications for surgical intervention. II]. / Stipsi cronica severa: limiti della terapia medica e indicazioni all'intervento chirurgico. Parte seconda.

Severe chronic constipation is a common problem in children. Most patients have functional constipation, only few (approximately 5%) have an underlying organic disease who requires surgical treatment. Anatomic problems with a painful defecation (anal rhagades, fistulas, hemorrhoids) or with difficult defecation (anal stenosis, tumor) require only a careful physical examination. Other organic problems due to neurogenic and myogenic colonic abnormalities require extensive investigations, including histological and histochemical study, for diagnosis. Ultrashort Hirschprung's disease, neuronal intestinal dysplasia type B and hypoganglionosis represent different levels of a developmental problem of the enteric nervous system. Surgical treatment is recommended in these cases. After surgery is recommended a long period of medical treatment to avoid a functional constipation.

[The non-palpable testis: modern diagnostic and therapeutic approaches]. / II testicolo non palpabile: moderni orientamenti diagnostici e terapeutici.

Management of the nonpalpable testis is controversial and can be difficult as shown by the multiple modalities for evaluation and proposed treatment. In our opinion, laparoscopy is the ideal first step in the management of patients with a nonpalpable testis, having a great reliability in locating or confirming absence of an occult testis. Accurate preoperative assessment and localization will assist in selecting the appropriate surgical approach either laparoscopic, laparoscopic-assisted, or open procedure. Laparoscopy was performed on 74 patients with 86 nonpalpable testis. The technique has been demonstrated to be extremely safe and lead to diagnosis in 100% of cases. Surgical management of nonpalpable testis was directly performed by laparoscopy identifying intra-abdominal vanishing testis and locating an intra-abdominal or inguinal testis. The two-stage Fowler-Stephens orchiopexy was performed in 41 patients. The first stage consisted of laparoscopic clip ligation of the spermatic vessels. Of these, 32 underwent the second stage by vas-based orchiopexy; all testes, but-one, showed a normal size and consistency. To conclude, we advocate the use of laparoscopy in all boys with nonpalpable testis.

Cowper's syringocele: an analysis of 15 consecutive cases.

Cystic dilatation of Cowper's gland ducts (Cowper's syringocele) is uncommon in children and is frequently asymptomatic, but it may cause urinary infection, haematuria, dysuria, and obstructive voiding symptoms. Fifteen consecutive children with syringocele aged 15 days to 15 years old are reported here. Only four patients with obstructive syringocele were successfully treated surgically; all the others were successfully treated conservatively. The true clinical significance of Cowper's syringocele lies in its potential to cause urethral obstruction. Careful clinical, radiological, endoscopic, and urodynamic evaluation is necessary in order to avoid unnecessary surgery.

Evolution of urodynamic patterns in posterior urethral valves.

A retrospective, long-term urodynamic study was performed in order to follow the evolution of the urodynamic patterns in 55 unselected patients previously affected by posterior urethral valves (PUV). The mean maximum cystometric capacity (MCC) values progressively increased over time and, on long-term follow-up, were just above 2 standard deviations (SD). The mean compliance values were clearly reduced in the first urodynamic studies after valve ablation, and only after a mean of 5 years follow-up did they approach the lower limits of normal. The small compliance and capacity (SCC) group showed two trends of evolution: a more numerous subgroup tended toward progressive normalization while a second subgroup (<20%) showed mean compliance values below normal limits, with reduced (-2 SD) MCC persisting at long-term follow-up. The number of patients in this group decreased over time. In contrast, we were able to show a significant increase in patients with myogenic failure. In this group scheduled voiding using the Valsava maneuver in conjunction with a regimen of double or triple micturition was usually succesful in modifying the course, normalizing MCC, reducing residual urine, and also eliminating incontinence. Finally, initial urodynamic investigations in the fulguration and vesicostomy groups showed a much higher percentage of SCC bladders in the latter group (83.5% vs. 35%). However, at long-term examinations the urodynamic parameters were nearly identical in both groups, showing that temporary bladder defunctionalization does bot adversely affect future detrusor activity. No direct relationship between urodynamic abnormalities and renal insufficiency could be shown, however, the majority of patients with reduced glomerular filtration rates still showed urodynamic dysfunction at long-term follow-up. In the authors' opinion, serial urodynamic investigations in association with serial evaluation of the evolution of upper urinary tract and renal function are mandatory for correct PUV management and provide useful guidelines for avoiding incorrect treatment and obtaining better long-term results.

Management of urethral strictures in children.

We report the results of a long-term follow-up study in 78 children with urethral strictures. The ages ranged from 1 month to 20 years and the follow-up from 8 months to 15 years (average 5.9 years). Balloon dilation was the primary treatment in 66 patients. Manipulative management (balloon dilation and endoscopic urethrotomy) was performed in 68 cases and was successful in 55. There were no complications. Balloon dilation alone provided an 80% success rate (53/66). Twenty-two patients were treated by one-stage urethroplasty, with an overall 95.5% success rate. The surgical repair was performed in 12 patients as a secondary procedure after failure of conservative treatment. Our data do not support the rather poor results usually reported in the pediatric literature associated with the balloon dilation technique.

[Idiopathic scrotal hemorrhage: a rare cause of acute scrotum in the newborn]. / L'emorragia scrotale idiopatica: una causa eccezionale di scroto acuto nel neonato.

Spontaneous hemorrhage of the scrotum in the newborn is an entity very rarely encountered in clinical practice and characterized by scrotal mass and slightly bluish discoloration. We present two cases of spontaneous idiopathic hemorrhage of the scrotum and review the literature. The difficulty in establishing the diagnosis and ruling out testicular torsion is outlined. The importance of ultrasounds in distinguishing between testicular and scrotal acute disease is stressed. Indications for surgery are: the important scrotal hematoma and the patent processus vaginalis.

Adolescent varicocele: operative anatomy and tricks for successful correction.

Conventional varicocelectomy is often complicated by high recurrence rate, ranging from 6 to 25% and the persistence usually is due to residual venous communications. We report our experience of 21 years in varicocele correction using 3 different operative techniques on 389 adolescents. In the first 12 years (120 patients) a typical ivanissevich operation was carried out with a recurrence rate of 18%. In the following 4 years (63 patients) a preoperative venography was always carried out and a surgical procedure via an inguinal approach was performed with high retroperitoneal and inguinal ligations of the internal spermatic vein(s) and cremasteric vein(s) as indicated by venography; the recurrence rate was still 8%. In the last 5 years we have been using a personally modified technique characterized by: 1) unique access to all venous areas both in the retroperitoneum and in the inguinal canal with a systematic ligation of the internal and external spermatic veins and the deferential vein when dilated; 2) intraoperative identification of the residual collaterals after venous ligations by injecting some milliliters of a blue-methylene solution. This procedure allowed a varicocele recurrence in only 2 out of 206 consecutive patients (1%). Our results suggest that it may be possible to lessen significantly the postoperative recurrence rate using some simple operative tricks.

[Cowper's syringocele in children: report on ten cases]. / Il siringocele delle ghiandole di Cowper in età pediatrica. A proposito di 10 osservazioni.

Cystic dilatation of Cowper's gland ducts (Cowper's syringocele) is uncommon in pediatric age. Cowper's syringocele frequently are asymptomatic, sometimes may cause dysuria, pollakiuria and obstructive voiding symptoms. We report ten children with syringocele. Five were observed for recurrent urinary infections, three for obstructive voiding symptoms and two for post-traumatic hematuria and for urinary incontinence. Only three patients with obstructive urethral symptoms were surgically treated. In our opinion careful clinical, radiologic and endoscopic evaluation is necessary in such cases so that unnecessary surgery can be avoided.

Value and limits of testicular scintigraphy in paediatric acute scrotum.

Abrupt onset of scrotal symptoms is a not uncommon condition, particularly in the paediatric age, which raises the problem of a rapid decision concerning proper therapeutic management (i.e. surgery or pharmacotherapy); the testicular radionuclide scan is generally considered to be helpful in making this choice, as it is theoretically able to distinguish between hypervascular (inflammation) and hypovascular conditions (testicular torsion). We report our experience in paediatric patients presenting acute scrotum. Thirty consecutive cases were examined, but three were discarded because of their non-routine features. Our records show that torsion of the appendix testis is far from uncommon (6 cases out of 27); however, the scintigraphic pattern of this pathological condition, which usually does not require urgent surgical treatment, does not seem to differ greatly from that of scrotal inflammation. Of the remaining 21 cases, 15 were correctly diagnosed, while 4 were to be considered non-diagnostic because of the presence of hypovascular scrotal conditions other than testicular torsion. We conclude that, while not always a very precise tool for the diagnosis of acute scrotum, nevertheless testicular scan results may be considered a useful parameter in choosing the proper type of treatment.

[Perineal ectopic testis. Report of seven cases]. / Il testicolo ectopico perineale. A proposito di sette osservazioni.

Between 1973 and 1993 7 perineal testis are observed and operated on in our surgical department. The perineal testis is a rare ectopic testis probably caused by some mechanical obstacles in the entrance of the testis in the scrotum. A diagnosis is easy if also the less frequent localizations of testicular ectopia are palpated. Surgery must be precociously performed or, in case of late discovery, upon diagnosis effected because the perineal testis is particularly subject to traumathisms. Orchiopexy is easy to perform, the results are good and, if promptly treated, this form of ectopia has an excellent prognosis of fertility.

[Diaphragmatic eventration in pediatric age: indications to surgery and results]. / L'eventratio diaframmatica in età pediatrica: indicazioni al trattamento chirurgico e risultati.

Indication for surgical treatment and its results are reported in 17 consecutive cases of diaphragmatic eventration in pediatric age. Fourteen of the patients are males and 3 are females. Eleven of them had a right eventration 6 had a left eventration. Three of the patients were new-born, 13 were aged from 6 months to 3 years and 1 was aged 6 years. Two patients had gastroesophageal reflux, 1 had right intralobar pulmonary sequestration, and another had inguinal hernia. In 2 of the new-born the eventration was caused by a phrenic nerve palsy (in 1 case resulting from birth trauma, while in the other one resulting from multiple thoracentesis). In this last patient surgical treatment wasn't performed, and restitutio ad integrum was observed in 4 weeks' time. The indication for surgical treatment in 2 new-born patients was persistent polypnoea and dyspnoea unresponsive to medical treatment, in 12 of the patients were relapsing bronchitis and bronchopneumonia. Moreover 1 patient with few symptoms but with important diaphragmatic eventration was operated. In all the patients a diaphragmatic plication with fixing of the diaphragmatic plica to the ribs was performed through a thoracic approach. Neither complication or deaths were noticed. There was an immediate remission of the symptomatology in all the cases examined. No relapse of eventration or restarting of the symptomatology was found during a follow-up for a period of 2 to 8 years.