Can baseline serum creatinine and e-GFR predict renal function outcome after augmentation cystoplasty in children?

OBJECTIVE: To assess cut-off value of creatinine and glomerular filtration rate for augmentation cystoplasty (AC) in paediatric age-group. MATERIALS AND METHODS: Data of all paediatric-patients (<18 years) with small capacity bladder, in whom AC was advised between 2005-2015 were reviewed. All patients were divided in two-groups, AC-group and control-group (without AC). Creatinine and e-GFR were assessed at the time of surgery, at 6 months and at last follow-up. Renal function deterioration was defined as increase in creatinine by ≥25% from baseline value or new-onset stage-3 CKD or worsening of CKD stage with pre-operative-CKD stage-3. ROCs were plotted using creatinine and e-GFR for AC. RESULTS: A total of 94 patients with mean-age 8.9 years were included. The mean creatinine and e-GFR were 1.33mg/dL and 57.68mL/min respectively. Out of 94 patients, AC was performed in 45 patients and in the remaining 49 patients AC was not done (control-group), as they were not willing for the same. Baseline patient's characteristics were comparable in both Groups. 22 underwent gastro-cystoplasty (GC) and 25 underwent ileo-cystoplasty (IC). Decline in renal function was observed in 15 (33.3%) patients of AC-group and in 31 (63.3%) patients of control-group. Patients having creatinine ≥1.54mg/dL (P=0.004, sensitivity (S) 63.6% and specificity (s) 90.5%) at baseline and e-GFR ≤46mL/min (P=0.000, S=100% and s=85.7%) at the time of surgery had significantly increased probability of renal function deterioration on follow-up after AC. CONCLUSION: e-GFR ≤46mL/min and creatinine ≥1.54mg/dL at time of surgery could serve as a predictor of renal function deterioration in AC in paediatric patients.

Nephrectomy in children: Comparison of stress response to laparoscopic and open methods.

AIM: To evaluate and compare the extent of surgical stress following laparoscopic nephrectomy (LN) and open nephrectomy (ON) in children. MATERIALS AND METHODS: Twenty consecutive children undergoing nephrectomy were randomized to LN or ON groups. Acid-base balance, blood glucose, acute phase proteins (C-reactive protein [CRP]) and inflammatory markers (interleukin-6 [IL-6]) were measured pre-operatively, as well as 4 and 24 h after surgery. The differences between the two groups were analyzed statistically (significance value for P < 0.05). RESULTS: The overall acid base status was more stable in LN. The fall in pH 4 h after surgery was more in ON (P = 0.440) and the difference in pH in ON 4 h and 24 h post-operatively was statistically significant (P = 0.002). In LN, significant difference was found in the base excess mean pre-surgery (mean -3.280 mEq/L) and 4 h post-surgery (mean -7.480 mEq/L) (P = <0.05), as well as between 4 h and 24 h after surgery (mean -2.660 mEq/L) (P = 0.011). The acute rise in CRP 24 h post-operatively in the ON (88.972 mg/L) was significantly higher when compared to both the pre-operative and 4 h post-operative values (P < 0.05). This rise was however, not statistically significant when compared to the 24 h post-operative value in LN (46.399 mg/L) (P = 0.062). The rise in IL-6, 24 h post-procedure in LN (mean 44.444 pg/ml) was statistically lower than that in the open group (mean 343.333 pg/ml) (P = 0.041). CONCLUSIONS: The stable acid-base status and lesser rise of CRP and IL-6 in LN lead to the conclusion that surgical stress caused by LN is less than ON.

Nephroureterectomy with inferior vena-caval thrombectomy in post-chemotherapy Wilms' tumour in a child - From the eyes of the surgeon!

INTRODUCTION: Intracaval extension is present in 4-11% of all Wilms' tumour (WT). We present the open surgical nuances of inferior vena cava (IVC) thrombectomy with nephroureterectomy in post-chemotherapy WT. METHODS: A 10-year-old girl with right WT and intracaval tumour thrombus presented for surgical resection after six cycles of chemotherapy (vincristine, actinomycin D). A preoperative assessment plan of the vascular anatomy of the tumour was done. Meticulous intraoperative handling of the tumour mass, overcoming chemotherapy-induced fibrosis during inter-aortocaval groove dissection, optimal hemodynamic control during venotomy, en bloc resection of tumour with intracaval thrombus, and repair of the IVC are detailed. RESULTS: A 70 × 65 × 30 mm right renal mass with 20 × 10 × 4 mm level II IVC thrombus was excised en bloc. The intraoperative blood loss was 250 mL, operative time was 220 min, and total hospital stay was 7 days. The child completed post-surgical chemotherapy as per protocol. CONCLUSIONS: There is a paucity of literature regarding techniques for resection of WT with IVC extension in post-chemotherapy patients. With erudite preoperative planning and fine intraoperative dissection, complete resection of WT with intracaval thrombus is feasible with minimal blood loss and rapid postoperative recovery.

Bladder contractility index in posterior urethral valve: A new marker for early prediction of progression to renal failure.

INTRODUCTION: Posterior urethral valve (PUV) is the most common cause of pediatric end stage renal disease (ESRD), imposing a major health burden on medical community caregivers and adversely affecting the quality of life of patients. Chronic kidney disease (CKD) stage III or estimated GFR of <60 mL/min/1.73 m2 is known to be associated with more adverse renal, cardiovascular, and clinical outcomes. Thus, it is desirable to identify factors predicting the rapid and early progression of disease. In the present study, baseline characteristics and urodynamic study (UDS) parameters of boys with PUV are correlated with CKD progression to IIIB or more. AIMS AND OBJECTIVES: To study the correlation of bladder contractility index (BCI) with development of CKD stage IIIB (eGFR of <45 mL/min/1.73 m2) or more in boys with PUV. METHODOLOGY: Baseline characteristics and demographical variables of 270 boys with PUV who underwent valve fulguration at the hospital between 2000 and 2010 were recorded and certain UDS parameters in follow-up were noted such as bladder contractility index (BCI = PdetQmax + 5 Qmax), end filling pressure (EFP), compliance (ΔC), bladder outlet obstruction index (BOOI = Pdet Qmax - 2 Qmax), and bladder volume efficiency (BVE = Voided volume/total capacity). Fate of patients in follow-up was checked in December 2015. RESULTS: Mean follow-up period was 8.5 years (range 5-15) and median age of patients at the time of evaluation was 5.8 years. At the end of the study, 21.8% (59/270) of patients had progressed to CKD stage IIIB or more (primary end point). Cox regression analysis was applied to risk factors predicting development of CKD stage IIIB. In the multivariate model, bladder contractility index (BCI) (HR 0.8; p = 0.004), end filling pressure (EFP) (HR 2.1; p = 0.010), and compliance (ΔC) (p = 0.020) were significantly associated with the event (i.e. an eGFR of <45 mL/min/1.73 m2), whereas BOOI (p = 0.053) and bladder BVE (p = 0.267) were not. ROC cut-off level for BCI predicting the primary end point was 75 (AUC ± SE, 0.73 ± 0.03, sensitivity of 78.2%, and specificity of 62.5%). CONCLUSION: In a well performed UDS, BCI may be a useful tool for early detection of boys with PUV who are likely to progress to CKD stage IIIB or more.

Gunshot Injury of Pelvi-Ureteric Junction: Management by the Rendezvous Technique.

Background: Gunshot injury of ureter is common, but isolated injury of pelvi-ureteric junction (PUJ) has not been reported. Moreover, its management is evolving from the traditional urinary diversion, stenting followed later by definitive surgical repair to a more upfront minimally invasive endourologic approach. Case Presentation: An adolescent boy presented with gunshot laceration injury of left PUJ with associated small intestinal injury. Radiological investigations confirmed a contained urinary leak. Retrograde stenting was not effective. The same guidewire was retained into the urinoma and an antegrade percutaneous access was obtained. A snare was used to retrieve the guidewire and obtain a through and through access. A ureteropelvic drainage catheter was inserted over this guidewire and secured in the upper ureter, bypassing the region of injury. Three weeks later, the drainage tube was removed and the same tract was used for antegrade stenting. A retrograde pyelogram done 3 months later during stent removal demonstrated no leak. The patient is asymptomatic for urinary symptoms on 6 months of follow-up. Conclusion: Rendezvous technique is a feasible alternative to open repair of gunshot pelvi-ureteric junction injury. Long-term follow-up is awaited.

Exstrophy Bladder - Reconstruction or Diversion for the Underprivileged.

The surgical techniques for management of bladder exstrophy epispadias complex have evolved from staged reconstruction, complete primary repair to radical mobilization. Post-operative complications add to the multiplicity of surgical procedures at each step. The end results are variable with many achieving continence rates of 85-89% only after bladder augmentation and clean intermittent catheterization. The situation is further complicated in resource-poor settings, where illiteracy and poverty are the driving factors for choosing a single operative procedure for creation of low pressure reservoir aiming at upper tract preservation and good primary continence. Thus, primary urinary diversion should be offered as a surgical option to patients with limited access to health care facilities. Yogesh's cystorectostomy is a modification of Heitz-Boyer-Hovelacque procedure, wherein the bladder plate is directly anastomosed to the recto-sigmoid pouch, without mobilizing the ureters from their original location. The short-term follow-ups are encouraging with all achieving total urinary continence over the ensuing months. The upper tract functions are well preserved, along with huge parental and patient satisfaction and overall improvement in the quality of life.

Bilateral Transvesicoscopic Cross-trigonal Ureteric Reimplantation in Children: Surgical Subtleties and a Prospective Summary.

OBJECTIVE: To prospectively evaluate the surgical technique and results of bilateral transvesicoscopic cross-trigonal ureteric reimplantation (TVUR) in children with vesicoureteric reflux (VUR) and compare the results and surgical subtleties with the existing literature. MATERIALS AND METHODS: From January 2010 to December 2015, children between 2 and 14 years of age with bilateral primary VUR grades II-IV underwent bilateral TVUR at a tertiary referral center in Northern India. The grade of VUR was II in 12 patients, III in 19 patients, and IV in 3 patients. All surgeries were performed by a single surgeon. Success was defined as the absence of VUR on direct radionuclide cystogram at 8 weeks. RESULTS: Seventeen patients (34 refluxing ureters) underwent bilateral TVUR during the study period. They included 13 girls and 4 boys. The median age was 4.6 years (range: 2-14 years). Two patients required conversion to open surgery. Resolution of VUR was seen in 16 patients (32 out of 34 ureters). Hydronephrosis resolved on postoperative ultrasonography in all patients with low-grade reflux (lower than grade IV) and all except one patient with grade IV reflux. CONCLUSION: TVUR is a feasible method with success rate equal to that of open technique if patient selection is good. Success rate is low in high-grade reflux, and dilated and tortuous ureter. Subtle modifications in the surgical steps can make significant contribution toward learning this minimally invasive technique.

Radiographic gapometry score: A simple predictor for surgical approach in pediatric traumatic posterior urethral strictures.

BACKGROUND: Post-traumatic posterior urethral injuries in children are rare events. Their management algorithms are extrapolations from adult literature and they continue to pose a difficult challenge for pediatric urologists. Not much data for age-related feasibility of an end-to-end urethroplasty are available. OBJECTIVE: This study was designed to validate a simple preoperative radiographic score to predict the type of surgical repair for traumatic posterior urethral strictures in children. MATERIALS AND METHODS: This retrospective study was conducted in a tertiary care center in northern India between 2000 and 2015. All patients under 15 years with traumatic bulboprostatic stricture disease were included. Preoperative voiding cystourethrogam (VCUG) and retrograde urethrogram (RGU) films were used to calculate the gapometry index (G/U index), defined as the length of urethral gap divided by the bulbar urethral length. This index was then analyzed for two patient groups based on the anatomical approach employed for achieving an end-to-end urethroplasty: group 1, who underwent a simple perineal approach, and group 2, who needed a more elaborate procedure. Statistical analysis was performed with the two-tailed t-test with SPSS version 18. RESULTS: A total of 38 patients met the inclusion criteria. The age distribution and G/U index for both groups are detailed in the table. The difference in mean length of the urethral gap for both groups was statistically significant (2.1 cm in group 1 vs. 3.6 cm in group 2). There was a direct correlation between the complexity of surgical procedure required to bridge the urethral gap and the G/U index. The overall success for urethroplasty in either group was between 92.3% and 94.6%. DISCUSSION: Urethral extensibility is more suitable for younger children. This challenges the traditional viewpoint that the transpubic approach for urethroplasty is more favorable in children. No previous study has been cited in literature correlating the gapometry index with the surgical approach for posterior urethral defects. Our results reflect that a preoperative G/U index of 0.44 correlate with a simple perineal repair, whereas an index of above 0.87 indicates the likelihood of needing a more elaborate transpubic approach. CONCLUSIONS: Preoperative assessment of G/U index in children with traumatic posterior urethral injuries can successfully predict the operative approach and may therefore aid in better management of these patients.

Hepatic duct confluence injury in blunt abdominal trauma - a diagnostic dilemma.

Isolated hepatic duct confluence injury due to trauma is unusual. Two cases of isolated bile duct injury are presented, which were diagnosed and managed successfully at our institution.

Subcutaneoscopic excision of external angular dermoid cyst in children without conspicuous scarring.

INTRODUCTION: External angular dermoid cysts are benign lesions that are excised through an incision over the eyebrow. This leaves a visible scar that may not be cosmetically acceptable. Herein, we describe a minimally invasive subcutaneoscopic technique that involves placing incisions above the hairline to avoid scarring on the face. MATERIAL AND SURGICAL TECHNIQUE: This is a retrospective review of three consecutive cases of dermoid cysts. Each patient underwent subcutaneoscopic excision between March 2012 and September 2012. With the patient under general anesthesia, a 6-mm incision was made on the scalp above the hairline. After a wide subcutaneous tunnel was created, a 5-mm port with a 30° telescope was placed for an optical port. Insufflation was done with CO2 at pressure of 8 mmHg and flow rate of 1 L/min. Two para-optical stab incisions were used to insert a 3-mm Maryland dissector and a 3-mm hook for dissection. The cyst was excised and removed through one of the ports. DISCUSSION: All three cases underwent successful subcutaneoscopic excision without the need for conversion. The mean operative time was 42 min. There were no complications, and all patients had excellent cosmesis. Subcutaneoscopic excision of dermoid cyst is a technically feasible procedure in pediatric patients, as demonstrated by our three cases. It provides excellent cosmesis and avoids scarring on the face.

Can baseline serum creatinine and e-GFR predict renal function outcome after augmentation cystoplasty in children?

ABSTRACT Objective To assess cut-off value of creatinine and glomerular filtration rate for augmentation cystoplasty (AC) in paediatric age-group. Materials and Methods Data of all paediatric-patients (<18 years) with small capacity bladder, in whom AC was advised between 2005-2015 were reviewed. All patients were divided in two-groups, AC-group and control-group (without AC). Creatinine and e-GFR were assessed at the time of surgery, at 6 months and at last follow-up. Renal function deterioration was defined as increase in creatinine by ≥25% from baseline value or new-onset stage-3 CKD or worsening of CKD stage with pre-operative-CKD stage-3. ROCs were plotted using creatinine and e-GFR for AC. Results A total of 94 patients with mean-age 8.9 years were included. The mean creatinine and e-GFR were 1.33mg/dL and 57.68mL/min respectively. Out of 94 patients, AC was performed in 45 patients and in the remaining 49 patients AC was not done (control-group), as they were not willing for the same. Baseline patient's characteristics were comparable in both Groups. 22 underwent gastro-cystoplasty (GC) and 25 underwent ileo-cystoplasty (IC). Decline in renal function was observed in 15 (33.3%) patients of AC-group and in 31 (63.3%) patients of control-group. Patients having creatinine ≥1.54mg/dL (P=0.004, sensitivity (S) 63.6% and specificity (s) 90.5%) at baseline and e-GFR ≤46mL/min (P=0.000, S=100% and s=85.7%) at the time of surgery had significantly increased probability of renal function deterioration on follow-up after AC. Conclusion e-GFR ≤46mL/min and creatinine ≥1.54mg/dL at time of surgery could serve as a predictor of renal function deterioration in AC in paediatric patients.