Vertical plication: A penile curvature correction technique that reduces the need for urethral plate transection in penoscrotal hypospadias.

INTRODUCTION: Penile curvature (PC) is a frequent component associated with hypospadias. Medial corporal rotation by interrupted suturing without incising the corporal bodies is well described in patients with epispadias and we think that it is an alternative technique for the management of patients with ventral PC, with or without hypospadias. OBJECTIVE: We describe a PC correction technique which reduces the need for urethral plate transection in penoscrotal hypospadias. STUDY DESIGN: The main steps of "vertical plication" technique are following: The Buck's fascia at the maximum point of curvature was incised longitudinally at 12-o'clock position and then dissected from tunica albuginea from medial to lateral on each side. Minimal and precise dissection just enough to allow plication is essential to avoid injury to the neurovascular bundle. No incisions were made through the tunica albuginea. Corporal rotation was performed by approximating with polyester sutures which were placed 5 mm apart at and around the point of maximum curvature. Three to 5 sutures were enough for full straightening of PC in our cases. Follow-up range was 1.5-4.5 years (mean: 3 years). RESULTS: 17 patients underwent this technique. 16 of them had a penoscrotal hypospadias and one patient had congenital PC without hypospadias. Full PC correction was achieved in 15 patients and residual curvature below 10° was seen in two patients. We were able to perform single-stage repair in 13 (81,25%) of our penoscrotal hypospadias cases without transection of urethral plate. DISCUSSION: High recurrence rates were reported in dorsal plication technique when compared to ventral corporal lengthening in patients with PC > 30°. In the presence of high grade PC, a penile elongation technique is the preferred option for many authors. However, it requires incision of tunica albuginea. Although the variations of medial corporal rotation to correct ventral PC has been described in the past, they did not gain popularity. CONCLUSION: This technique allows the surgeon to proceed with single stage repair in patients with proximal hypospadias associated with high grade PC. Narrowing is the only disadvantages of our technique, which can easily be resolved by de-epithelialized flap coverage harvested from foreskin. No parents subjectively reported nor we detected narrowing, recurrence or shortening during follow-up.

Cystoscopy and mucosectomy: Essentials in the management of persistent müllerian duct syndrome with transverse testicular ectopia. / Cistoscopia y Mucosectomia: Manejo del síndrome de persistencia de los conductos mullerianos con ectopia testicular transversa.

OBJECTIVES: The concurrence of Persistent Müllerian Duct Syndrome and transverse testicular ectopia is rare. The risk of damage to the vas deferens and the deferential blood supply hinders some surgeons from complete excision of potentially malignant Müllerian duct remnants. METHODS: We present a unique surgical technique of Persistent Müllerian Duct Syndrome in a patient with right inguinal hernia accompanying transverse testicular ectopia. RESULTS: During exploration, both testes were detected in the right inguinal canal. When the hernia sac was opened, a primitive uterus and fallopian tubes without fimbria were identified confirming Persistent Müllerian Duct Syndrome. A 4 Fr catheter was placed into the os of the Müllerian duct remnants via the verumontanumorifice, and then a urethral catheter was placed. The full-thickness excision of proximal Müllerian duct remnant swere performed. The distal part of Müllerian duct remnants was layed open and only mucosa was excised for preserving vas deferens. Resection was completed just above its junction with the urethra with the aid of 4Fr catheter marked at centimeter intervals and the cuffwas oversewn. High ligation for right inguinal hernia and bilateral orchidopexy were performed. CONCLUSIONS: Removal of Müllerian duct remnantsis advised in order to reduce the jeopardy of malignancy, urinary tract infections, stones and hematuria. On the other hand, excision down to urethra which can compromise the integrity and vascularity of the vas deferens is diffucult, even in experienced surgical hands. Complete excision of these structures by mucosectomy of the distal part of remnant which lay closed to vas deferens is a safe and effective method. Cystoscopy assistance and placement of a catheter into MDRs were essential for the complete excision of this mucosa. To the best of our knowledge, cystoscopy assisted mucosectomy in Persistent Müllerian Duct Syndrome has not been reported previously.

OBJETIVOS: La presencia de síndromede persistencia de los conductos mullerianos y ectopia testicular transversa es raro. El riesgo de dañar el conducto deferente y la vascularización diversa hace que muchos cirujanos no realicen una extirpación completa de los conductos mullerianos remanentes con riesgo de malignización.MÉTODOS: Presentamos una técnica quirúrgica única para la resección completa de los conductos mullerianos remanentes en pacientes con hernia inguinal derecha acompañada de ectopia testicular transversa. RESULTADOS: Durante la exploración física se detectaron ambos testículos en el canal inguinal derecho. Cuando abrimos el saco herniario, se observó un útero primitivo con trompas de falopio sin fimbrias confirmando el síndrome de persistencia de los conductos mullerianos. Se colocó un catéter 4 Fr en la punta del remanente mulleriano a través del orificio del verumontanumy a posteriori se colocó una sonda uretral. CONCLUSIONES: La extirpación del remanente del conducto mulleriano esta indicada para evitar la malignización, infecciones urinarias, litiasis y hematuria. Por otro lado, la extirpación hasta la uretra puede comprometer la vascularización y integridad del conducto deferente, siendo dificultosa hasta en manos expertas. La extirpación completa de las estructuras con mucosectomia de la parte distal del remanente es segura y eficaz. La ayuda de la cistoscopia y colocación de un catéter en el remanente son muy importantes para la resección completa. Esta es la primera descripción de mucosectomia asistida por cistoscopia en un síndrome de persistencia del remanente mulleriano hasta la fecha.

The role of flexible bronchoscopy accomplished through a laryngeal mask airway in the treatment of tracheobronchial foreign bodies in children.

INTRODUCTION: We here present our experience with children who underwent flexible bronchoscopy for removal of inhaled tracheobronchial foreign bodies under general anesthesia via a laryngeal mask airway (LMA). MATERIALS AND METHODS: A total of 24 (16 male and 8 female, mean age: 30.75 ±â€¯29.68 months) patients who underwent flexible bronchoscopy under general anesthesia using a LMA for suspicion of tracheobronchial foreign bodies between July 2016 and April 2018 were retrospectively reviewed. RESULTS: The mean duration of admission to hospital was 162.56 ±â€¯309.56 h. Sixteen (66.7%) patients were found to have tracheobronchial foreign bodies. All procedures were successfully accomplished through a LMA by using basket forceps, a Fogarty catheter and a suction without any need for rigid bronchoscopy. 11 (68.7%) of tracheobronchial foreign body locations were right bronchial, 3 (18.8%) were left bronchial and 2 (12.5%) were tracheal. The types of extracted tracheobronchial foreign bodies were organic in 14 (87.5%) and non-organic in 2 (12.5%). There were no complications except laryngeal edema noted in 2 (8.3%) patients, relieved within 48 h. The mean time of postoperative hospitalisation was 2.42 ±â€¯0.97 days. CONCLUSION: Flexible bronchoscopy accomplished through a LMA is a safe, easy and effective technique, not only as a diagnostic procedure, but also as the initial therapeutic modality for retrieving tracheobronchial foreign bodies in children with high success and low complication rates. With further reports aforementioned, we hope that the flexible bronchoscopy will become a standard method in children.

Posterior sagittal anorectoplasty in vestibular fistula: with or without colostomy.

PURPOSE: The aim of this study is to compare the results and complications of one- and three-stage repairs in females with vestibular fistula (VF) and make contribution to the discussion of whether the disadvantages outweigh the protective effect of a colostomy from wound infection and wound dehiscence following posterior sagittal anorectoplasty (PSARP). METHODS: Patients with a diagnosis of VF who underwent PSARP between October 2009 and November 2015 were retrospectively reviewed. The patients were divided into two groups: Group 1-patients treated by one-stage procedure (n = 30); Group 2-patients treated by three-stage procedure (n = 16). RESULTS: There were no statistically significant differences between the groups with respect to wound infection, recurrence of fistula and rectal mucosal prolapse. Minor wound dehiscence occurred slightly more common in Group 1, even if p value is not significant. No wound dehiscence has been observed since we switched to the protocol of keeping the child nil per oral for 5 postoperative days and loperamide (0.1 mg/kg) administration for 7 postoperative days. The mean time before resuming oral intake was 2.87 ± 1.7 and 1.19 ± 0.4 days in Group 1 and Group 2, respectively (p = 0.001). None developed major wound disruption or anal stenosis in either group. There were no statistical differences between the groups in terms of voluntary bowel movements, soiling and constipation. CONCLUSIONS: PSARP performed without a protective colostomy in patients with VF has low morbidity, good continence rates and obvious advantages for both the patients and their parents.

The Place of Calprotectin, Lactoferrin, and High-Mobility Group Box 1 Protein on Diagnosis of Acute Appendicitis with Children.

The purpose of this study is to investigate the role of serum calprotectin (CP), lactoferrin (LF), and high-mobility group protein B1 (HMGB-1) levels and fecal CP and LF levels in differential diagnosis of acute uncomplicated appendicitis from other causes of abdominal pain and further from complicated appendicitis. Totally, 120 children were included grouped into 4 as: healthy controls, patients with right lower quadrant pain with other than surgical causes, patients with uncomplicated appendicitis, and patients with complicated appendicitis. Serum CP, LF, HMGB-1, C-reactive protein (CRP) levels, and white blood cell (WBC) count were studied as well as the fecal CP and LF levels. There was a statistically significant difference between control group and both uncomplicated and complicated acute appendicitis groups, regarding all parameters. In diagnosis of complicated acute appendicitis, area under curve (AUC) for fecal LF, serum CP, and serum HMGB-1 were determined as 1.00 and the cutoff level was determined as 25 µg/g feces, 670 ng/mL, and 30 ng/mL, respectively. In differential diagnosis of uncomplicated and complicated AA, the most accurate parameter was fecal LF with an AUC of 0.977. At a 60 µg/g cutoff value for this variable, sensitivity, specificity, and accuracy were 96.7, 93.3, and 95.0 %, respectively. In conclusion, HMGB-1, calprotectin, and lactoferrin constitute novel markers in diagnosis of AA. Moreover, their levels may be helpful for the clinicians to judge about the severity of the condition. Larger studies are warranted to determine the diagnostic potential of HMGB-1, LF, and CP in AA diagnosis.

Delayed diagnosis: An important prognostic factor for oesophageal atresia in developing countries.

AIM: The aim of this study is to analyse the effect of delayed diagnosis on mortality rates, and evaluate the role of delayed diagnosis as a new prognostic factor in patients with oesophageal atresia (OA), especially in developing countries. METHODS: The records of 80 consecutive patients with OA (2008-2013) were reviewed. Patients were divided into two groups according to the time of diagnosis. As we demonstrated the effect of delayed diagnosis on mortality, we decided to develop a new classification that will be utilised to predict the prognosis of OA. The discrimination ability of the new prognostic classification was compared with those of the Waterston, Montreal and Spitz classifications using the area under the curve. RESULTS: The parameters of the new prognostic classification were birth weight less than 2000 g, the presence of major cardiac/life-threatening anomalies and delay in diagnosis. Class I consisted of patients with none or one of these parameters. Class II consisted of patients with two or three of these parameters. The area under the curve of the new classification was better than those of the other classifications in determining the prognosis of patients with OA. CONCLUSIONS: Delayed diagnosis of OA significantly led to morbidity and mortality. Although delayed diagnosis is not a characteristic of newborn or a marker of severity for OA and is a health care system issue in developing countries, we here point out that it is a prognostic factor in its own right. Our new classification has a superior discriminatory ability compared to the above-mentioned classifications.

A giant choledochal cyst in infancy: a case report.

Choledochal cyst is a dilation that encloses the intrahepatic or both extra- and intrahepatic portions of the biliary ducts. Postnatally, ultrasonography is the initial diagnostic modality of choice, allowing for precise measurements of intra- or extrahepatic duct dilatation and identification of stones and sludge. Symptoms depend on the age at presentation. Common bile duct malformations should be considered as a differential diagnosis of a cystic mass regardless of the cyst's size or patient's age, especially in children presenting with abdominal pain, jaundice, and palpable mass. To the best of our knowledge, we report the largest choledochal cyst in infancy.

The comparison of dextranomer/hyaluronic acid and polyacrylate-polyalcohol copolymers in endoscopic treatment of vesicoureteral reflux.

BACKGROUND: Dextranomer/hyaluronic acid (Dx/Ha;Dexell®) and polyacrylate-polyalcohol copolymer (PPC;Vantris®) are the popular tissue-augmenting substances using for the endoscopic injections of vesicoureteral reflux (VUR). The aim of the study is to evaluate and compare Dx/Ha and PPC in terms of effectiveness, injection techniques and complications with special emphasis on vesicoureteral junction obstruction (VUJO). METHODS: A total of 95 patients who underwent endoscopic VUR treatment between 2009 and 2015 were retrospectively reviewed. The patients were divided into two groups: group 1: Patients underwent endoscopic treatment with PPC (n=50 patients, 70 renal refluxing units) group 2: Patients underwent endoscopic treatment with Dx/Ha (n=45 patients, 74 renal refluxing units). RESULTS: The overall resolution rates based on the number of renal refluxing units studied was 88.6% and 70.3% in group 1 and group 2, respectively. Resolution rates were significantly better in group 1 compared to group 2. VUJO requiring ureteral reimplantation or stent insertion developed in 7 patients in group 1. No VUJO was observed in group 2. VUJO in group 1 was markedly higher than that in group 2. CONCLUSIONS: Endoscopic treatment of VUR with PPC promises better resolution rates but higher VUJO rates compared to Dx/Ha.

Multiple Stones in a Single-System Ureterocele in a Child.

Presence of multiple calculi in ureterocele is rare in children. A 6-year-old boy presented with hematuria in whom on x-ray and ultrasound multiple calculi were noted in the urinary bladder. At surgery a ureterocele containing multiple calculi was found. The postoperative (99m) Tc-Dimercaptosuccinic acid scan (DMSA) reported normal renal function.

Rare causes of gastrointestinal hemorrhage in infancy.

Gastrointestinal hemorrhage in children is a critical condition that demands quick and effective management. The differential diagnosis of gastrointestinal hemorrhage is wide. Heterotopic pancreas is a rare congenital anomaly and usually discovered incidentally. It is generally asymptomatic, but symptoms may occur when complicated by inflammation, bleeding, obstruction or malign transformation. Heterotopic pancreas may present throughout the gastrointestinal tract, but it is most commonly found in the stomach, duodenum and proximal jejunum. Juvenile polyps are common during childhood and present most often with painless rectal hemorrhage. They remain the most common colonic polyps in children. Colonoscopic polypectomy is the most effective procedure in the treatment of juvenile polyps. In this study, we describe rare causes of gastrointestinal system hemorrhage in infancy and discuss some diagnostic and therapeutic approaches.

Modified Tubularized Incised Plate Urethroplasty Repair: Frenuloplasty and Long-Term Results in 155 Patients.

To describe a modification of tubularized incised plate (TIP) urethroplasty which we refer to as "frenuloplasty". We retrospectively reviewed 155 children who underwent TIP urethroplasty between June 2008 and August 2011 in our institution. In our technique, the circumcision incision went on through the mucocutaneous junction obliquely in order to form frenular wings instead of linear circumscribing incision joined the urethral plate vertically. The little triangle-shaped skin flaps between the oblique mucocutaneous incisions and urethral plate incisions were excised. The glans wings and frenular wings were re-approximated without tension after uretroplasty. The mean age of the patients was 4.63 ± 3.82 years. The mean follow-up was 15.94 ± 5.46 months. Location of hypospadias was distal penile in 126 patients (81.3 %) and mid-shaft in 29 (18.7 %). The following complications occurred in 21 patients (13.5 %): urethrocutaneous fistula formation in 7 (4.5 %), meatal stenosis in 14 (9 %) and no dehiscence. We suppose that there is no incompletely formed prepuce but a ventral fusion defect in the midline. Frenuloplasty reduces the necessity of ventral preputial flaps and provides satisfactory cosmetic outcomes with the appearence of normal circumcised penis.

Unusual Histopathological Findings in Childhood Appendectomy Specimens.

The purpose of this study was to find the unusual findings in the childhood appendectomy specimens and their incidence. The clinicopathological data of 1,306 patients whose ages ranged from 3 to 16 were retrospectively collected. Histopathological findings in appendectomy specimens taken from patients who had a prediagnosis of appendicitis were obtained. Incidental appendectomies were not included in the research. Unusual findings were reevaluated in the histopathological assessment of appendectomy specimens. The number of patients whose pathological findings are considered unusual is 25 (1.91 %). Nine of the patients were girls and 16 of them were boys. Their ages ranged from 6 to 15. Pathological results revealed that there were 16 (1.22 %) cases of parasitosis, 3 (0.23 %) cases of granulomatosis, 3 (0.23 %) cases of eosinophilic appendicitis, 2 (0.15 %) cases of carcinoid tumors, and 1 (0.08 %) case of appendiceal non-Hodgkin's lymphoma. All patients underwent a standard appendectomy. Uncommon histopathological findings in childhood appendectomy specimens are more common than those in adulthood. This kind of certain unexpected lesions of the appendix may require advanced diagnostics, careful clinical care, follow-up for years, and a multidisciplinary approach. Therefore, histopathological examinations of appendectomy specimens must be performed routinely.

A bladder stone within a congenital paraureteral diverticulum: a case report.

Paraureteral diverticula are rare in pediatric population. We here present a bladder stone in the congenital paraureteral diverticulum presenting with vesicoureteral reflux. To the best of our knowledge, stone formation in paraureteral diverticulum has not been reported previously. A 5-year-old boy was admitted with the complaint of dysuria. Abdominal ultrasonography revealed a bladder stone in a diverticulum arising from right posterolateral wall and a small right kidney. Voiding cystourethrogram confirmed large bladder diverticulum with vesicoureteral reflux. Cystoscopy revealed a giant stone in the paraureteral diverticulum. The stone was removed with open diverticulectomy and right Cohen ureteroneocystostomy was performed.

Diseases mimicking intussusception: diagnostic dilemma.

BACKGROUND: Intussusception is a common abdominal emergency in early childhood. The aim of this study was to describe the diseases mimicking intussusception and to discuss the causes and management of these conditions. METHODS: Seven patients who were initially diagnosed as having intussusception on abdominal ultrasonography but who had a final diagnosis of diseases other than intussusception were reviewed retrospectively. RESULTS: Two patients with ileocolic intussusception underwent ultrasonography-guided reduction with a hydrostatic method but the ultrasonographic findings persisted. At surgery, only edematous ileocecal valve and mesenteric lymphadenopathy were observed. In three patients with Henoch-Schönlein purpura, initial abdominal ultrasonography showed intussusception. The patients with no sign of obstructive symptoms were managed conservatively with a diagnosis of intramural hemorrhage and on follow up the ultrasonographic findings of intussusception was resolved. One patient with the target sign on computed tomography and ultrasonography of the abdomen underwent ileocolic resection and end-to-end anastomosis due to a tumor in the cecum. There was no evidence of intussusception. One patient with a cyst in the right lower quadrant accompanying intussusception on ultrasonography of the abdomen underwent ultrasonography-guided reduction but the ultrasonographic findings persisted. On exploration, only cecal duplication cyst without intussusception was detected. Cecal resection including the cyst and end-to-end ileocolic anastomosis were performed. CONCLUSIONS: Ultrasonography, color Doppler ultrasonography, barium or hydrostatic enema and computed tomography are helpful in diagnosing intussusception, but patients with radiologic findings of intussusception should be evaluated on symptoms and clinical findings before surgical intervention. Also, other diseases mimicking intussusception should be kept in mind in the differential diagnosis.

The effects of melatonin on intestinal adaptation in a rat model of short bowel syndrome.

INTRODUCTION: Short bowel syndrome (SBS) is a clinical condition resulting from the loss of absorptive surface area following resection of 50% or more small bowel. Morphological and functional changes called "intestinal adaptation" occur in the residual intestine. Melatonin exists in the gastrointestinal tract and has effect on mitotic activity. Therefore, we hypothesized that melatonin may have beneficial effects on intestinal adaptation. MATERIALS AND METHODS: A total of 32 male Wistar albino male rats were divided into four groups. In group I (sham-S), small bowel was transected and reanastomosed. In group II (SBS-control), 75% small bowel resection and anastomosis were performed. In group III (SBS-vehicle), after 75% small bowel resection and anastomosis, 2 mL of 5% ethanol in saline was given intraperitoneally once a day. In group IV (SBS-melatonin), after 75% small bowel resection and anastomosis, 300 µg/kg melatonin was given intraperitoneally once a day. After 15 days, small bowels were removed and divided into two segments as jejunum and ileum. Each segment was weight and measured. Histological examination was performed in all samples. Bowel and mucosal weights and DNA/protein ratio were calculated. Apoptotic cells were also identified. RESULTS: The bowel length measurements were statistically longer in group IV. Mucosal and bowel weights were the highest in group IV. The villus height, crypt depth, and the number of mitotic figures were the highest in the jejunum of group IV. Melatonin also gave rise to a significant increase in DNA/protein ratios in group IV. CONCLUSION: According to this study, melatonin significantly enhanced intestinal adaptation.

A simple method for percutaneous endoscopic gastrostomy tube removal: "tie and retrograde pull".

BACKGROUND/PURPOSE: Various techniques have been presented to remove the percutaneous endoscopically placed gastrostomy tube in children, but tubes with semi-rigid internal retaining discs are difficult or impossible to remove by external traction. We describe a simple and effective endoscopic removal technique that should be applicable to any type of percutaneous endoscopic gastrostomy tube. METHODS: Percutaneous endoscopic gastrostomy tube removal was performed with the "tie and retrograde pull" technique. After a polypropylene suture was placed and tied 1cm over the skin level, the percutaneous endoscopic gastrostomy tube was cut 0.5 cm over the knot. The suture was cut from the connection point between the needle and the suture. The distal end of the suture was pushed through the stoma into the stomach. Then a forceps was inserted through the gastroscope. The suture was caught, and the residual percutaneous endoscopic gastrostomy portion was retrieved via retrograde traction on the suture. RESULTS: The causes of exchange were determined to be planned tube replacement in 9, buried bumper syndrome in 1, and tube occlusion in 3 patients. The mean tube dwell time was 10.8 ± 3.9 months. Esophageal mucosal tear developed in 1 patient with epidermolysis bullosa during removal. No other complications occurred during PEG tube exchanges. CONCLUSION: This is a rapid and useful technique that does not require any complex endoscopic devices.

Is single port incisionless-intracorporeal conventional equipment-endoscopic surgery feasible in patients with retrocecal acute appendicitis?

PURPOSE: Since laparoscopic appendectomy was first described, various modifications, such as single port incisionless-intracorporeal conventional equipment-endoscopic surgery (SPICES), have been described for reducing pain and improving cosmetic results. In the retrocecal and retrocolic positions, attachments to the lateral peritoneum and cecum may lead to difficulties during SPICES, which is performed with only one port. Here, we present the effects of variations in the position of the vermiform appendix in treating acute appendicitis with SPICES. METHODS: We retrospectively reviewed 52 children who underwent SPICES for acute appendicitis between March 2010 and November 2011 in our institution. One group (group A) consisted of 30 patients (mean age, 10.5 ± 2.5 years) with retrocecal appendix, while the other group (group B) included 22 patients (mean age, 10.9 ± 2.3 years) with the appendix lying free in the peritoneal cavity. RESULTS: There were no significant differences between groups in terms of patient age, gender, success rate of SPICES, mean operating time, mean follow-up period, overall complication rates or mean postoperative hospitalization period. CONCLUSION: These results suggest that SPICES is a safe and feasible approach even in patients with retrocecal acute appendicitis.