Are mechanical and chemical trauma the reason of meatal stenosis after newborn circumcision?

Mechanical and chemical trauma are a widely accepted theories to explain the pathogenesis of meatalstenosis after newborn circumcision. The aim of the present study was to explore the theory that an exposed glans is prone to meatal stenosis. This was done by a novel investigation of boys who were born with "hooded prepuce", a condition in which the glans is completely exposed. Physical examination, lower urinary tract symptoms, urethral meatus configuration, and surgical procedures of 18 children admitted for routine circumcision, who had congenital hooded prepuce with normally located urethral meatus, were analyzed. The study period was 2013 and 2018. All the cases have been seen because of neonatal circumcision request, but was postponed due to hooded prepuce. The only presenting complaint in children was a cosmetically unattractive appearance. There were no symptoms associated with meatal stenosis, they circumcised in an average of 6 years and non of them required any additional procedure.Conclusion: Meatal stenosis did not occur in cases whose glans penis are naked with hooded prepuce. These findings do not support the default chemical and mechanical trauma theories. Hooded prepuce without any penile anomalies is only a cosmetically unattractive appearance and circumcision can correct this. What is known: • The common theory of meatal stenosis etiology is that the meatus undergoes irritation with chemical/mechanical trauma in the absence of a prepuce after newborn circumcision. • Circumcision is usually postponed in newborns with hooded prepuce. What is new: • We did not notice meatal stenosis in cases whose urethral meatus were not covered with a prepuce congenitally. Ammoniacal dermatitis or mechanical trauma theories may not explain the cause of meatal stenosis. • Hooded prepuce is not a handicap to newborn circumcision. It is just a cosmetic problem and circumcision can solve it.

Determining the Risk Factors for Anastomotic Stricture Development after Esophageal Atresia Repair: Results from the Turkish Esophageal Atresia Registry.

INTRODUCTION: Anastomotic stricture (AS) is the second most common complication after esophageal atresia (EA) repair. We aimed to evaluate the data in the Turkish Esophageal Atresia Registry to determine the risk factors for AS development after EA repair in a large national cohort of patients. METHODS: The data between 2015 and 2021 were evaluated. Patients were enrolled into two groups according to the occurrence of AS. Patients with AS (AS group) and without AS (non-AS group) were compared according to demographic and operative features, postoperative intubation status, and postoperative complications, such as anastomotic leaks, fistula recanalization, and the presence of gastroesophageal reflux (GER). A multivariable logistic regression analysis was performed to define the risk factors for the development of AS after EA repair. RESULTS: Among the 713 cases, 144 patients (20.19%) were enrolled into the AS group and 569 (79.81%) in the non-AS group. The multivariable logistic regression showed that, being a term baby (odds ratio [OR]: 1.706; p = 0.006), having a birth weight over 2,500 g (OR: 1.72; p = 0.006), presence of GER (OR: 5.267; p < 0.001), or having a recurrent tracheoesophageal fistula (TEF, OR: 4.363; p = 0.006) were the risk factors for the development of AS. CONCLUSIONS: The results of our national registry demonstrate that 20% of EA patients developed AS within their first year of life. In patients with early primary anastomosis, birth weight greater than 2,500 g and presence of GER were risk factors for developing AS. When patients with delayed anastomosis were included, in addition to the previous risk factors, being a term baby, and having recurrent TEF also became risk factors. LEVEL OF EVIDENCE: III.

The effect of postoperative ventilation strategies on postoperative complications and outcomes in patients with esophageal atresia: Results from the Turkish Esophageal Atresia Registry.

OBJECTIVES: Postoperative ventilatory strategies in patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) may have an impact on early postoperative complications. Our national Esophageal Atresia Registry was evaluated to define a possible relationship between the type and duration of respiratory support on postoperative complications and outcome. STUDY DESIGN: Among the data registered by 31 centers between 2015 and 2021, patients with esophago-esophageal anastomosis (EEA)/tracheoesophageal fistula (TEF) were divided into two groups; invasive ventilatory support (IV) and noninvasive ventilatory support and/or oxygen support (NIV-OS). The demographic findings, gestational age, type of atresia, associated anomalies, and genetic malformations were evaluated. We compared the type of repair, gap length, chest tube insertion, follow-up times, tensioned anastomosis, postoperative complications, esophageal dilatations, respiratory problems requiring treatment after the operation, and mortality rates. RESULTS: Among 650 registered patients, 502 patients with EEA/TEF repair included the study. Four hundred and seventy of patients require IV and 32 of them had NIV-OS treatment. The IV group had lower mean birth weights and higher incidence of respiratory problems when compared to NIV-OS group. Also, NIV-OS group had significantly higher incidence of associated anomalies than IV groups. The rates of postoperative complications and mortality were not different between the IV and NIV-OS groups. CONCLUSION: We demonstrated that patients who required invasive ventilation had a higher incidence of low birth weight and respiratory morbidity. We found no relation between mode of postoperative ventilation and surgical complications. Randomized controlled trials and clinical guidelines are needed to define the best type of ventilation strategy in children with EA/TEF.

Symptomatic omphalomesenteric duct remnants in children.

BACKGROUND: The present study gathers a single institutional experience of symptomatic omphalomesenteric duct (OMD) remnants in children with an emphasis on the age and modes of presentation, the surgical intervention and the histopathological findings. METHODS: The data on children who underwent surgical treatment for symptomatic OMD remnants during a 17-year period were reviewed retrospectively, excluding incidental diverticulectomies. RESULTS: A total of 59 children with a median age of 36 months underwent operations for symptomatic OMD remnants. There were 48 boys and 11 girls. The presenting signs were gastrointestinal tract (GIT) obstruction in 21 (36%) patients, acute abdomen in 18 (31%), umbilical abnormalities in 17 (29%), and rectal bleeding in three (5%). Patients presenting with umbilical anomalies were significantly younger than others. At surgery, a wedge resection of the remnant was carried out in 32 cases and an ileal resection was carried out in 27. Children presenting with GIT obstruction underwent segmentary ileal resection more often than other groups. Histopathology revealed inflammation in 26 (44%) specimens, ectopic tissue in 18 (31%) and necrosis in four (7%). Ectopic gastric mucosa was detected in 15 specimens, pancreatic tissue in two and both gastric and pancreatic tissue in one. CONCLUSIONS: Symptomatic OMD remnants in children most commonly presented with GIT obstruction, acute abdomen and umbilical anomalies. Rectal bleeding was not a predominant finding in the present series. Surgery is curative and can safely be done either by way of wedge resection or ileal segmentary resection. Ectopic tissue is detected in approximately one third of symptomatic remnants.

Two-year old girl with glial choristoma presented in a thyroglossal duct cyst.

BACKGROUND: Neuroglial choristomas are rare entities that are composed of differentiated neuroectodermal cells presenting where they do not belong. CASE: Here in this paper, we represent a two-year old patient with a very rare presentation of neuroglial choristoma which manifested itself within a thyroglossal duct cyst. In this paper we will also discuss pathogenesis, clinical manifestation, differential diagnosis and management of the neuroglial choristomas. CONCLUSION: In conclusion we believe this unique case may aid in understanding the pathophysiology, differential diagnosis, and management of this rare congenital anomaly.

Does Voiding Cystourethrogram Exclude Posterior Urethral Valves in Late Presenting Cases?

INTRODUCTION: Delayed presentation of posterior urethral valves (PUVs) is a rare condition. Presentation and diagnosis of the patients with late PUVs are challenging. Voiding cystourethrogram (VCUG) is mainly practiced. In this study, we aimed to evaluate the children with late-presented PUVs, and the reliability of VCUG in this group. MATERIALS AND METHODS: Between January 2003 and December 2017 records of patients who were diagnosed with late-presented PUVs were analyzed. Delayed presentation of PUV was defined as patients who were diagnosed and treated after infancy. Cases were examined in terms of age at diagnosis, presenting symptoms, urinalysis, urinary ultrasound, urodynamic studies, VCUG, and dimercaptosuccinic acid scintigraphy findings. Postoperative follow-up conditions were also assessed. RESULTS: Seventeen boys were diagnosed with late-presented PUVs (mean age was 7.35 years). The most common symptoms at presentation were frequency (58.8%), day and nighttime incontinence (47%), and febrile urinary infection (41%). PUV was noted by VCUG in 10 patients alone. The classical sign of dilated posterior urethra was detected in 9 patients. The 10th patient had posterior urethral irregularity. Urethra could not be evaluated due to unsuccessful voiding in one patient. Six patients had normally appearing urethra on VCUG. Reflux was detected in nine (52.9%) patients. CONCLUSION: Late-presented PUVs may be missed on VCUG. Whether a PUV might be present is crucial in boys with a history of recurrent urinary infection, persistent reflux, and repetitive daytime incontinence. Based on our results, we conclude that cystoscopic examination should be preferred for those cases to diagnose PUVs regardless of VCUG results.

Complication of newborn circumcision: Meatal stenosis or meatal web?

INTRODUCTION: Meatal stenosis (MS) is a known complication of newborn circumcision. Symptoms are usually masked in young kids with a diaper. Deflation of urinary stream, dysuria, urinary frequency, and incontinence are the most common reported symptoms. Diagnosis of MS is still controversial. A narrow pinpoint urethral meatus is the current accepted diagnostic criteria. OBJECTIVE: In our practice, we observed that our cases do not overlap to the classic definition and presentation of MS. In this study, we presented our cases and aimed to share our observations. MATERIALS AND METHODS: Records of children who had meatoplasty between 2014 with 2016 were analyzed retrospectively. Only children with MS who had had newborn circumcision performed in our clinic were included in the study. Over 500 newborn circumcisions are performed per year in our clinic using the Gomco Clamp technique. Age at diagnosis, presenting complaints, penile anomalies including urethral meatus configuration, urinary symptoms, operation methods, and postoperative follow-up were gathered. RESULTS: A total of 13 boys who were circumcised in the newborn period had undergone meatoplasty with the diagnosis of MS. The mean age at the time of meatoplasty was 52.5 ± 17.9 (range 37-93 months). All children were examined before and during the circumcision. There were no associated penile anomalies, including MS. The only presenting complaint was upward deflation of urinary stream instead of other lower urinary tract symptoms. Although the appearance of the meatus was pinpoint in all cases (Figure); it was easy to calibrate with an 8-10 Fr feeding tube. There was no stenosis, but a ventral web was detected. Meatoplasty with removal of this web was performed under general anesthesia. Two sutures were applied at 5 and 7 o'clock with 7/0 PDS. Mean postoperative follow-up time was 16.9 ± 7.5 months. Children were pleased with direction of urinary stream. DISCUSSION: Both the diagnosis and morphological definition of MS have some controversies. To our knowledge, there is no similar reported study with pinpoint appearance and normal calibration of the meatus. There was no stenosis in any of them. Unlike classical MS presentations, upward deflation of urinary stream resulting from ventral web was a single presenting complaint. CONCLUSIONS: Upward deflation of urinary stream can develop after neonatal circumcision because of a meatal web without stenosis, and can be cured easily with meatoplasty. Instead of 'meatal stenosis', 'meatal web' may be a more appropriate term to explain the pathology in these patients.