Laparoscopy or retroperitoneoscopy for pediatric patients with adrenal masses?

Minimally invasive approach to the adrenal gland was first reported in 1992. Since then, the experience with the laparoscopic technique for adrenal disease in children has been limited. We report our experience with minimally invasive adrenal surgery in children. Two young girls (2 and 4 years old) with a left adrenal mass were operated using minimally invasive surgery (MIS) in our Unit. Ultrasonography and MRI showed in the oldest a 2 x 3 cm adrenal mass, while in the youngest a 5.5 x 5 cm adrenal tumor was found. According to the pre-existing literature, we approached the smallest lesion via retroperitoneoscopy, and the largest one laparoscopically. The operating time was 110 minutes for retroperitoneoscopy and 75 minutes for laparoscopy. No major intra or postoperative complications occurred. There were no conversions to open surgery. Postoperative hospital stay was 5 days for both patients. In both cases, the anatomo-pathological result was an adenoma. Minimally invasive adrenalectomy is a safe and feasible procedure in children with good results. For lesions smaller than 3-4 cm retroperitonescopy is feasible, while for tumors larger than 5 cm, due to malignancy risk, the laparoscopic approach is indicated. To keep oncologic criteria it is important to avoid tumor rupture and to extract the specimen in an endobag.

Is retroperitoneoscopic renal ablative surgery easier and safer using a new hemostatic device compared with clips and monopolar coagulation? A comparative study.

AIM: The aim of study was to retrospectively analyze our series of total and partial retroperiotoneoscopic nephrectomies performed in the last 5 years. METHODS: Twenty-two procedures were performed, 20 patients underwent nephrectomy and 2 patients underwent partial nephrectomy. The 20 patients who underwent nephrectomy were divided in 2 groups: group 1 (G1) patients-1-10, for whom we performed the procedure using monopolar coagulation, and group 2 (G2) patients 11-20 for whom we used a new hemostatic device to perform dissection and hemostasis. The results were analyzed using χ2 test. The results of partial nephrectomies were analyzed separately. RESULTS: No conversion were reported. We analyzed 6 parameters to compare the results: operative time (OT), estimated blood loss (EBL), need for transfusion (NT), complications, time to oral intake (TOI), hospital stay (HS). OT in G1 was in median 85 minutes, in G2 65 minutes (P=0.004); EBL was 15 mL for G1 and 5 mL for G2 (P=0.000.), NT was not necessary in both, in G1 we had 2 complications and 1 complication in G2; TOI was day 1 for both groups; median HS was 3 days for both. As for heminephrectomy, OT was 120 and 140 min, EBL 30 mL in both, NT not necessary, TOI was 1 day and HS 4 and 5 days respectively. CONCLUSION: Our study shows that the use of a new hemostatic devices reduce significantly OT and EBL in children underwent renal ablative surgery for benign pathologies compared with the use of monopolar coagulation.

Meckel's diverticulum causing severe hemorrhage.

Meckel's diverticulum has varied presentations in children and often becomes a diagnostic challenge. The authors present a 10-year-old boy with abdominal pain and one episode of melena. His symptoms were undervalued during two previous hospitalizations in pediatric units until his hemoglobin level dropped from 8.2 to 3.5 g/dL. The laparoscopic intervention performed in emergency identified a bleeding Meckel's diverticulum that was resected after being exteriorized from the umbilicus. Our observation shows that severe hemorrhage due to a Meckel's diverticulum is possible albeit exceptional.

Long-term outcome of laparoscopic Fowler-Stephens orchiopexy in boys with intra-abdominal testis.

PURPOSE: We reviewed the records of 36 pediatric patients operated on between 1990 and 1997 for high intra-abdominal testes, using the 2-step Fowler-Stephens procedure via laparoscopy. MATERIALS AND METHODS: Patients were followed for 10 to 17 years. Three patients who had undergone the second stage by open procedure were excluded from study. The 33 remaining patients were contacted by telephone, and 12 (7 with right and 5 with left intra-abdominal testes) agreed to undergo clinical and instrumental examination. Patient age ranged from 13 to 26 years (average 14.7). All patients underwent clinical examination and volumetric measurement of both testes using color Doppler ultrasound. RESULTS: Two of the 12 patients (16.7%) had an atrophic testis in the scrotum and 10 (83.3%) had a viable testis in the scrotum. The operated testis was always smaller than the normal testis, despite the good vascularization detected on echo color Doppler ultrasound. One patient had ultrasound evidence of bilateral microcalcifications with normal vascularization. Mann-Whitney test showed there was a statistically significant difference between the volume of the operated testis and the normal testis. CONCLUSIONS: It is extremely difficult to perform studies on the long-term outcome of surgical procedures. We describe the outcome at more than 10 years postoperatively, and demonstrate that greater than 83% of patients who underwent a 2-step Fowler-Stephens procedure using laparoscopy had satisfactory results. The operated testis was always significantly smaller compared to the normal testis but was well vascularized.

[Current trend in the diagnosis and treatment of primary non refluxing megaureter]. / Orientamenti attuali nella diagnosi e nel trattamento del megauretere primitivo non refluente.

BACKGROUND: The terms megaureter or hydroureteronephrosis are non-specific because indicate various pathologic entities recognise different causes (obstruction, reflux, obstruction-reflux, primary and secondary). An undeveloped renal function in neonatal period makes more difficult the therapeutic approach. Actually the problem is to find the indicators that consent us the individualization of patients more suitable for nonoperative management. METHODS: From 1996 to 2002, we observed 60 patients with 74 megaureters. In 24 cases the diagnosis was antenatal, 6 cases were diagnosed immediately after birth, 13 in the first year of life and 17 after the first year (2y-10y). Patients were classified in two groups based on age; 43 cases diagnosed in the first year of life and 17 after. Both of them were classified in two further groups based on ureteral size and renal function, scintigraphically evaluated. RESULTS: In the first group (A) ureters with 10 mm of dilatation improved in 38.9% of the cases. Were stationary 50% and impaired 11,1% of them. Ureters with dilatation between 7 and 10 mm improved in 24%, were stationary in 72% and impaired in in 4% of the cases. Ureters with less than 7mm dilatation improved in 35.2% and were stationary in 64.8%. In the group A renal scintigraphy MAG3 demonstrated, in the patients with acceptable renal function and washout, an improvement in 65% of the cases. Was stationary in 30% and impaired in 10%. CONCLUSIONS: The grade of dilatation evaluated with ultrasonographic exam and the study of renal function with diuresis renal scintigraphy using Tc-99m MAG3 and washout grade with diuresis renal scintigraphy are remarkable markers for the treatment choice.

Reconstruction of hypospadias with a vertical preputial island flap. A follow-up study of 127 patients.

The preputial island flap technique presented here was described by Scuderi for a one-stage repair of hypospadias. The operation utilizes a subcutaneous pedunculated preputial flap, designed dorsally along the vertical axis of the penis and transposed ventrally to reconstruct the new urethra. This surgical procedure is useful in distal and proximal hypospadias or in cases with short or absent prepuce, when the dorsal coating of the penis can be used. The technique permits a complete release of the chordee and a meatus placed at the apex of the glans. One hundred and twenty-seven patients treated during the period 1982 to 1987 were analysed. All patients had a urodynamic check and some also had a urethroscopic evaluation of the new urethra. The incidence of complications (8.65%) was very low compared with other techniques.

[Vesico-ureteral reflux and vesico-sphincteral dysfunction in children]. / Reflusso vescico-ureterale e disfunzioni vescico-sfinteriche in età pediatrica.

The neurologically normal children affected by v.u. reflux frequently have miction disorders. The bladder-sphincter dysfunction can determine high intravesical pressures causing distortion of the vesico-ureteral junction in the same way of anastomotic obstruction. The urodynamic study allows the diagnosis of bladder-sphincter dysfunction and the careful therapeutic management. The medical treatment of the dysfunctional voiding may improve the evaluation of the reflux and reduce postoperatively complications and urinary tract infections. The Authors analyse their experience in the medical treatment of 40 children with vesico-ureteral reflux associated with miction disorders. The reflux resolved after medical treatment in 25% of cases and miction disorders in 50% of cases. The Authors stress the importance of careful diagnosis and treatment to improve results in this group of patients.

Annular pancreas combined with distal stenosis. A report of four cases and review of the literature.

BACKGROUND: Congenital duodenal obstruction (CDO) in combination with more distal duodenal obstructions is a rare anomaly occurring in 4% of neonates with duodenal atresia. The experience of two European Pediatric Centers in treatment of congenital double duodenal obstruction (CDDO) is reported and the pertinent literature is reviewed. MATERIALS AND METHODS: During the last 15 years a total of 86 neonates were operated upon for CDO at the department of pediatric surgery of "St. Sophia" Children's Hospital of Athens in Greece and the department of pediatric surgery of "Federico II" Children's University Hospital of Naples in Italy; four of them had a CDDO. These ones presented with nonbilious vomiting and the plain film of the abdomen showed the typical "double bubble". Our cases with CDDO presented annular pancreas causing complete obstruction of the second part of the duodenum and dilatation of the duodenum distal to this obstruction due to an additional congenital stenosis (two cases) or a membranous web (two cases). A diamond shaped duodeno-duodenal (DDD) anastomosis was carried out to relieve the proximal obstruction and a Heinecke-Mikulicz plasty was used to relieve the distal stenosis. RESULTS: All patients with double obstruction underwent successful surgery with no complications. The postoperative course was uneventfuL An upper gastrointestinal barium study at one month postoperatively showed no blind loop, megaduodenum, anastomotic stenosis or malfunction. CONCLUSIONS: a) The combination of duodenal atresia with annular pancreas and distal duodenal stenosis or web is extremely rare. b) Patency of the duodenum distal to the usual obstruction should always be checked in order to avoid misdiagnosis of this combination.

[Unusual course of a case of urethral rhabdomyosarcoma in a 10-year-old boy]. / Singolare evoluzione di un caso di rabdomiosarcoma uretrale in un bambino di 10 anni.

The authors report a case of rhabdomyosarcoma of posterior urethra they observed in a 10 year-old boy who was referred for an acute urinary retention. The story of the patient included other urinary tract troubles: macroscopic haematuria and stranguria had been observed when the boy was four year old and at that time cystography and cystoscopy grave normal results. In the following years the patient presented repeatedly episodes of haematuria, stranguria, dysuria and urinary tract infections. The authors stress the slow evolution of the tumor and the difficulties for diagnosing the disease in its early phase.

A modified approach for feminizing genitoplasty.

PURPOSE: We reported the use of the mucosal layer of preputial skin to give extra length to penile flaps on vaginal introitus and labia minora reconstruction in children with congenital adrenal hyperplasia. MATERIALS AND METHODS: Since November 1999, 14 patients (average age 16 months, range 6 months-4 years) have undergone early one-stage reconstruction of external genitalia. All patients were classified according to Prader's classification (from III to V degree) with clitoral size of 3 +/- 1.5 cm. The perineal sagittal approach is followed by careful dissection and partial mobilisation of the urogenital sinus. Subcutaneous reduction clitoroplasty has been performed. The mucosal layer of the prepuce, developed as an extended flap on the end of the phallic shaft skin used for labia minora, is ideally placed for reconstruction of the vestibulae and distal vagina. RESULTS: The vagina was calibrated, the main vaginal calibre was 10 Hegar (range 6-14). With one exception, the urethral meatus was situated in the vestibulae and easily accessible. One distal vaginal stenosis was observed in a case with high confluence. No urinary incontinence was noted. The appearance of external genitalia was very satisfactory. CONCLUSIONS: The described genitoplasty provides a good cosmetic appearance. As most of our patients have not yet reached the age of sexual activity and child bearing, the functional results of this operation will need longer-term evaluation.

Bochdaleck diaphragmatic hernia, complicated by an antenatal gastric perforation, presenting as a pneumothorax and a perforative peritonitis.

The presentation of congenital diaphragmatic hernia (CDH) at birth may fall outside the typical features (cyanosis, tachypnea and respiratory failure), manifesting, instead, also with others pictures that make the diagnosis difficult or even impossible. We report a case of CDH presenting as a pneumothorax and a perforative peritonitis due to an antenatal gastric perforation.