Can we predict urethral length of boys? - An observational study.

INTRODUCTION: An additional knowledge about normal anatomy of urethra in boys can improve clinical outcome of any urological interventions. This will also reduce catheter related complications like intra vesical knotting and urethral injuries. At present there is no systematic data available which has studied the urethral length of boys. We have done this study to analyse the length of urethra in boys. AIM: The aim of the study is to measure the urethral length in Indian children from the age of 1 year till 15 years and plot a nomogram. Furthermore to analyse the influence of anthropometry on urethral length and derived a formula to predict the urethral length in boys. STUDY DESIGN: This is a single institution prospective observational study. After obtaining clearance from the institutional review board, a total of 180 children from the age of 1-15 were recruited for the study. The urethral length was measured during Foley's catheter removal. Other data like age, weight, and height of the patient are collected and the obtained values were analysed with SPSS software. The acquired figures were further used to derive formulae to predict urethral length. RESULTS: A nomogram of urethral length based on age was plotted. With collected figures, five separate formulae were derived to calculate the urethral length based on the age, height and weight. Furthermore for day-to-day use we have deduced a formulas to calculate urethral length which are simplified forms of original formulae. DISCUSSION: The length of urethra of a new-born male is 5 cm, which attains 8 cm by three years of age and to 17 cm by adulthood. There were attempts to measure the urethral length in adults using cystoscopy, Foley's catheter and different imaging techniques like Magnetic Resonance Imaging and dynamic retrograde urethrography. Simplified formulae which has been derived from this study for clinical use is Urethral length = 8.7 + Age (in year) × 0.55 CONCLUSION: Our results will complement the current anatomical understanding of the urethra. This evades some rare complications of catheterisation and facilitate reconstructive procedures.

Long-Term Outcomes and Prognostic Factors Affecting Survival after Pulmonary Metastasectomy in Solid Tumors of Childhood: A Single Center Experience.

Introduction: This study assessed the long-term survival and the prognostic variables affecting survival following pulmonary metastasectomy (PM) secondary to childhood solid tumors. Materials and Methods: A retrospective analysis was done on 22 children who underwent PM for solid tumors between January 2007 and February 2020. The overall survival (OS) and event-free survival (EFS) at the end of the study period were noted. Tumor histology, completeness of resection, disease-free interval, laterality, location, number, and size of lung nodules were assessed for their significance in contributing to survival. Results: High-grade osteosarcoma (54.5%), followed by Wilms' tumor (18.2%), was the most common histological types. Unilateral nodules (59.1%) situated in a peripheral, sub-pleural location (91%) were the most common presentation. Pleural extension was noted in 12 (54.5%) patients. Synchronous pulmonary metastases were noted in 12 (54.5%) patients. Two developed metastases while undergoing chemotherapy and eight after the completion of therapy. The EFS and OS were both 31.8% at a median follow-up of 15.5 months (range 3-129 months). The median time required for an event to occur was 4 months (95% confidence interval [CI]: 1.4, 6.6 months) and median post-PM survival interval was 17 months (95% CI: 6.6, 27.4 months). Significant association was noted between preoperative tumor response to chemotherapy (P = 0.002) and survival. Conclusion: PM can improve survival in a select group of children with metastatic solid tumors. Favorable tumor response to chemotherapy was found to be a significant prognostic factors influencing survival.

Surgical and anaesthetic outcomes of paediatric splenectomies at a tertiary care institution in South India: a retrospective cohort.

PURPOSE: Splenectomies though well-established in the successful management of several resistant haemoglobinopathies, have not been studied in detail in the paediatric population to assess the outcomes. We conducted this review to primarily assess the surgical and anaesthetic outcomes of paediatric splenectomies and secondarily highlight factors predictive for a high-risk splenectomy. METHODS: A 5 year retrospective chart review was made, and patient follow-up was done jointly using the hospital electronic medical records and telephonic calls. A p value of < 0.05 was considered significant. RESULTS: Among the 69 splenectomised children, 61% were male and the overall mean age was 10.2 years. The cohort consisted of patients with thalassemia (46%), ITP (30%), haemolytic anemia (19%) and 1 child each with lymphoma, splenic cyst and Kassabach Meritt syndrome. Most (96%) were electively operated and 23% were performed laparoscopically. 61% received intravenous analgesia and the mean volume of fluid administered intra-operatively was 21 ml/kg. There was no documented OPSI, and there was one mortality. The mean follow-up period was 43 months and the overall survival rate was 98.5%. CONCLUSIONS: Splenectomy was associated with a promising overall outcome. A greater pre-operative transfusion requirement, a larger sized spleen and increased fluid administration intra-operatively, were associated with a worse outcome.

Laparoscopic Cystogastrostomy in Children with Pancreatic Pseudocysts: A Preliminary Experience of Eight Cases.

Introduction: Pancreatic pseudocysts (PPCs) and walled-off necrosis (WON) in children following acute pancreatitis are uncommon. The various modalities of therapy possible are conservative treatment, external drainage, endoscopic stenting, and internal surgical drainage procedures. There are no existing guidelines for the management of PPC in children. We evaluate the outcomes of laparoscopic cystogastrostomy (LCG) performed at our center. Materials and Methods: Eight children (median age: 10 years) underwent LCG for large PPC (median size: 12.5 cm). There were seven patients with PPC and one with WON. Seven underwent LCG by a transgastric approach and one underwent LCG by a retrogastric approach. Results: Seven out of the eight patients had complete resolution of symptoms and the PPC. The median follow-up period was 32 months (interquartile range: 9.5-55.5 months). There were no conversions. There was one patient with a WON who developed a recurrence. Conclusion: LCG is a safe and effective treatment option for large PPC/WON in children. A posterior retrogastric approach, when indicated, is a safe approach with a comparable outcome.

Efficacy of Core Needle Biopsy in the Diagnosis of Pediatric Extracranial Solid Malignancies: A 10-Year Study.

Introduction: Core needle biopsies of solid masses in children are a minimally invasive technique. It guides to a definitive diagnosis and facilitates management. Aims and Objectives: To determine the accuracy, sensitivity, and specificity of core needle biopsies in diagnosing pediatric solid masses. Materials and Methods: A retrospective analysis of 430 children, who underwent core needle biopsy for solid masses between January 2007 and December 2016 at CMC Vellore, was done. Results: Retroperitoneal and intra-abdominal masses constituted 66% of cases. Real-time image guidance was used in 44% of cases. An accurate diagnosis was obtained in 93.6% of cases, while results did not correlate with the final diagnosis in 3.4%. Three percent had inadequate or necrotic tissue. None of the children had postprocedure complications. Conclusion: Core needle biopsies serve as good diagnostic modality, with minimal risks, in making a conclusive diagnosis and deciding on the line of management.

Surgical management of the acute paediatric scrotum: a three-year single centre experience.

BACKGROUND: Acute scrotal pain is a common emergency presentation in paediatric surgery. Torsion of the testicular appendage (TTA) is the most common cause for pain, with testicular torsion (TT) being the sinister pathology to exclude. Outcomes are time dependent, and a delayed scrotal exploration could result in testicular loss. METHODS: We performed a review on a large retrospective cohort of 449 surgical scrotal explorations at a large referral paediatric surgical centre over three years. RESULTS: Only about a quarter of children with testicular pain presented within 4 h. TT is commonly associated with nausea and an abnormal lie. Two children with a classical 'blue dot' sign were later found to have a testicular torsion. 19% of all children with a TTA were also seen to have Bell clapper anomaly (BCA). Recurrent testicular pain was associated with 84.7% (p < 0.001) of BCA. Intra-operative diagnosis of TTA correlated with histopathology in 84.6% (p=0.021). The sensitivity of intraoperative diagnosis was 90.9% with a specificity of 75.3%. CONCLUSION: Routine histopathology for a classic TTA may not be required especially in resource poor situations. All children presenting with recurrent episodes of testicular pain must be considered for surgical scrotal exploration. And in view of the incidence of BCA in this cohort, all scrotal explorations for acute scrotal pain should include an assessment for BCA.

Intussusception after Rotavirus Vaccine Introduction in India.

BACKGROUND: A three-dose, oral rotavirus vaccine (Rotavac) was introduced in the universal immunization program in India in 2016. A prelicensure trial involving 6799 infants was not large enough to detect a small increased risk of intussusception. Postmarketing surveillance data would be useful in assessing whether the risk of intussusception would be similar to the risk seen with different rotavirus vaccines used in other countries. METHODS: We conducted a multicenter, hospital-based, active surveillance study at 27 hospitals in India. Infants meeting the Brighton level 1 criteria of radiologic or surgical confirmation of intussusception were enrolled, and rotavirus vaccination was ascertained by means of vaccination records. The relative incidence (incidence during the risk window vs. all other times) of intussusception among infants 28 to 365 days of age within risk windows of 1 to 7 days, 8 to 21 days, and 1 to 21 days after vaccination was evaluated by means of a self-controlled case-series analysis. For a subgroup of patients, a matched case-control analysis was performed, with matching for age, sex, and location. RESULTS: From April 2016 through June 2019, a total of 970 infants with intussusception were enrolled, and 589 infants who were 28 to 365 days of age were included in the self-controlled case-series analysis. The relative incidence of intussusception after the first dose was 0.83 (95% confidence interval [CI], 0.00 to 3.00) in the 1-to-7-day risk window and 0.35 (95% CI, 0.00 to 1.09) in the 8-to-21-day risk window. Similar results were observed after the second dose (relative incidence, 0.86 [95% CI, 0.20 to 2.15] and 1.23 [95% CI, 0.60 to 2.10] in the respective risk windows) and after the third dose (relative incidence, 1.65 [95% CI, 0.82 to 2.64] and 1.08 [95% CI, 0.69 to 1.73], respectively). No increase in intussusception risk was found in the case-control analysis. CONCLUSIONS: The rotavirus vaccine produced in India that we evaluated was not associated with intussusception in Indian infants. (Funded by the Bill and Melinda Gates Foundation and others.).

Acceptability and outcomes of foreskin preservation for phimosis: An Indian perspective.

AIM: Understanding the Indian perspective, effectiveness, and acceptability of prepuce conservation in children with phimosis. Circumcision is performed and recommended far too often for nonphysiological phimosis. Will a less radical approach be acceptable in the subcontinent? METHOD: A two-arm study with the first arm as KAP (knowledge, attitude, and practice) study (n = 502). The second arm recruited deserving boys (n = 47) with symptomatic phimosis (see inclusion criteria). Betamethasone ointment was applied twice daily over the foreskin and gently massaged to stretch the phimotic band. Those who failed were offered lateral preputioplasty or circumcision. Religious beliefs influence attitude and practice and these were looked at with subgroup analysis. RESULTS: Most (85%) knew that circumcision was not the only treatment for phimosis. Though many parents (93%) knew the importance of foreskin cleanliness, few practiced it. The success of the steroid application was 81% (n = 38/47). Eight underwent preputioplasty. Minor discomfort as morbidity was noted. All parents were able to completely retract the foreskin of their children by the end of one month and were happy about the cosmetic result. CONCLUSIONS: KAP data on foreskin health is not available in the subcontinent, and this is a landmark study. Religious belief and community identity play a strong role in decisions related to foreskin preservation. Prepuce hygiene and knowledge about the usefulness of the foreskin is poor. The combination of medical and surgical methods of conserving the prepuce was effective. A high rate of success and the non-mutilating cosmetic result of prepuce preservation were acceptable to these parents.

Transureteroureterostomy as an adjunctive antireflux procedure in children undergoing bladder augmentation for neurogenic bladder with major reflux.

INTRODUCTION: Transureteroureterostomy (TUU) provides urinary drainage of both renal systems to the bladder via a single ureter and is useful in selected situations of complex urological reconstructions. Herein we discuss its use, advantages and complications in children with neurogenic bladders and high-grade (4/5) reflux who have undergone augmentation cystoplasty. PATIENTS AND METHODS: Children with neurogenic bladder complicated by unilateral or bilateral high-grade vesicoureteric reflux (VUR), who underwent TUU along with augmentation cystoplasty (BA), were selected from two institutions. Eighteen children with an average age of 5 years at presentation were identified from a retrospective chart review. RESULTS: All had bilateral hydroureteronephrosis (HUN) of which there were 30 refluxing megaureters. While BA reduced bladder pressure, VUR was managed by refluxing to non-refluxing TUU in six cases with unilateral VUR and unilateral reimplantation with TUU to the reimplanted ureter in 12 cases of bilateral VUR, thus minimizing reimplantation to 12 of 30 ureters. The average time of follow-up was 51 months. Follow-up cystograms showed complete resolution of VUR in all. HUN improved/stabilized in all but one child. Serum creatinine remained normal in all but two cases. Other advantages of TUU include the use of the distal ureter as a catheterizable channel and ease of undiversion when the ureter has been diverted as a ureterostomy. An unusual complication of a TUU site stricture is discussed and the innovative technique of using a cecal patch to salvage the anastomosis is detailed. CONCLUSION: We conclude that a TUU is a safe and useful adjunctive procedure in children undergoing BA for neurogenic bladder with high-grade VUR, minimizing the need for ureteric reimplant in an unhealthy bladder.

Paediatric mucormycosis: tailoring surgical strategies to compliment antifungal chemotherapy. Different strokes for different folks.

Children manifesting soft-tissue fungal infections are uncommonly seen, more so the subgroup of invasive soft-tissue mucormycosis. Invasive fungal infections in various organs respond differently and are often complicated by an immune-compromised host. Repeated and aggressive clearance of disease till an infection-clear margin is obtained is the mainstay of surgical therapy. This is coupled with appropriate antifungal therapy and the management of any underlying medical conditions. From our experience, we propose a surgical algorithm for therapy of soft-tissue mucormycosis in children.

Encouraging Results of Bowel and Bladder Management in Spina Bifida Aperta in South India with Quality of Life Scores in a Tertiary Care Institution in South India.

CONTEXT: It is often a challenge to counsel parents with children operated for spina bifida aperta in developing countries. Data regarding the efficacy of simple measures and preventive are scarce. AIMS: The aim of this study is to study such children for the incidence, prevalence of bowel bladder dysfunction, and the quality of life (QOL) in children who are involved with a multidisciplinary team in India. MATERIALS AND METHODS: All children with spina bifida occulta were followed - QOL questionnaires (PIN Q, modified Barthels activities of daily living , and the visual analog score [VAS]) were used. Interventions, such as clean intermittent catheterization (CIC), bowel enemas, and surgical procedures, were studied. RESULTS: A total of 68 children were assessed. Twenty-nine of these children over five were evaluated with QOL scores. The prevalence of incontinence of bowel and bladder was studied. The primary outcomes included the QOL scores, and the various surgical options help bowel and bladder management. Hydronephrosis in 17.95% of children <5 years and 65.5% of children over 5 years was noted. Nineteen children were socially independent for their bowel management. The Barthel index and PIN-Q showed a poor QOL in 27.6% and the VAS in 34.5% had the same. This translated to an acceptable QOL for over two-thirds of the children. CONCLUSIONS: Simple procedures and training for bowel management translate to a significant number of children being able to independently manage bowel care. About 30% of children develop hydronephrosis by 5 years; the decision to teach CIC must be made by then. We believe that positive counseling is given to the parents of children with spina bifida aperta as the children are capable of a reasonable QOL.

An unusual presentation of gall bladder papillomatosis in association with metachromatic leukodystrophy.

A 5-year-old boy with metachromatic leukodystrophy, debilitated by spastic quadriparesis presented to us with massive ascites and respiratory distress. A subtotal cholecystectomy was performed on him from another centre for a gall bladder mass a year before he came to us. Imaging revealed a polypoidal frond-like mass arising from the gall bladder fossa which was supplied by a hypertrophied branch of the right hepatic artery. A decision was made to offer surgical resection preceded by embolisation of the feeding vessel. At surgery, a polypoidal frond-like mass in communication with the peritoneal cavity was seen arising from the remnant gall bladder bed with over 4 L of mucoid ascites. The mass along with the remnant gall bladder was removed. Biopsy revealed villous papilloma of the gall bladder. The child is well and asymptomatic at 5-month follow-up.

Intestinal obstruction with a twist: a rare case of congenital portal vein aneurysm causing intestinal obstruction.

Bilious vomiting is often a presenting feature of upper intestinal obstruction in newborn. We present a case of intestinal obstruction in a newborn baby caused by abnormal vascular band arising from portal vein aneurysm in association with a midgut volvulus. Congenital anomalies of portovenous system are very rare, and it usually presents with portal hypertension in late infancy or childhood. In this particular child, the portal vein aneurysm contributed to intestinal obstruction due to both a failure of intestinal rotation and a mechanical band over the transverse colon.

Lateral Anal Sphincterotomy for Chronic Anal Fissures- A Comparison of Outcomes and Complications under Local Anaesthesia Versus Spinal Anaesthesia.

INTRODUCTION: Fissure-in-Ano is one of the common and most painful anorectal conditions encountered in surgical practice. Inspite of several conservative treatment options, surgical treatment in the form of Lateral Anal Spincterotomy (LAS) remains the gold standard of treatment for Chronic Anal Fissures (CAF). However, LAS is often done under spinal or general anaesthesia incurring huge treatment costs and hospital stay. AIM: To study if LAS can be treated with Local Anaesthesia (LA) thereby, reducing the costs and the anaesthetic risk to patients with no significant change in the surgical ease or clinical outcome. MATERIALS AND METHODS: A total of 79 patients with chronic fissure underwent randomized allocation to two treatment arms - The first to undergo LAS under LA and the second under Spinal Anaesthesia (SA). The primary outcome variables studied were complications like post-operative pain, infections, healing rate of fissure and incontinence rates. Secondary outcome variables studied were cost, hospital stay and need for additional anaesthetic. RESULTS: A total of 79 patients underwent LAS procedure. A total of 42 patients had LA and 39 patients had SA. There was no statistically significant difference in the healing rate, pain, infection and incontinence rates between the two groups. Moreover, the LA group incurred lower cost, reduced hospital stay and reduced risk of anaesthesia. CONCLUSIONS: LAS can be satisfactorily performed under local anaesthesia with no increased risk of pain or complications, and is best suited for resource-poor surgical settings.

Pneumonostomy in the Surgical Management of Hydatid Cyst of the Lung.

Background Pneumonostomy in the surgical treatment of bilateral hydatid cyst of the lung(HCL) was described by Anand et al. This study presents the comparative long-term results of pneumonostomy for simple and complicated HCL. Methods and Patients The pneumonostomy technique was applied to both open and minimally invasive operations. The cyst was opened, endocyst removed, and any bronchial openings closed. The pericyst was closed over a 20-French Malecot tube, which was exteriorized and connected to an underwater seal. The tube was removed after 3 weeks by which time a well-established tract had formed. Hospital records of 26 children with 30 HCL who underwent pneumonostomy between 2001 and 2014 were reviewed and followed up. Patients were analyzed in two groups:group1 comprised uncomplicated and group2 complicated HCL. There was a statistically significant difference in the age at presentation in the two groups. The groups were comparable with respect to presenting symptoms, sex ratio, and side or size of cyst. Results Six(20%) children with surgical complications were graded by Clavien-Dindo classification. Three(10%) children qualified as grade 1 and did not require pharmacologic or surgical therapy. Three(10%) children had grade 3 complications; two developed empyema and one pneumothorax. There were no prolonged air leaks. Children with complicated cysts did not require longer hospitalization. Follow-up was possible in 80.76% of the children. The mean duration of follow-up was 21.3 months (interquartile range, 5-63 months). There were no postoperative recurrences or disease-related mortality. Conclusion Pneumonostomy is a safe and effective technique for dealing with the residual cavity in large complicated cysts and bilateral HCL.

Idiopathic female pseudohermaphroditism with urethral duplication and female hypospadias.

Female hypospadias is a rare anomaly of the female urethra where it opens on the anterior vaginal wall anywhere between the introitus and the fornix. It is often associated with other genitourinary anomalies such as Cloacal malformation, female pseudohermaphroditism, nonneurogenic neurogenic bladder and urethral duplication. Idiopathic female pseudohermaphroditism is extremely rare, and most cases occur secondary to adrenogenital syndrome or maternal androgen exposure. We report a unique case of a 1-year and 4-month-old girl who presented with ambiguous genitalia and renal failure secondary to a non-neurogenic neurogenic bladder. On further evaluation, she was found to have urethral duplication with a hypospadiac female urethra. She initially underwent a vesicostomy and was further planned to undergo an appendicular Mitrofanoff at an older age. The mainstay of treatment in these cases includes relief of bladder outlet obstruction and recovery of renal function by adequate urinary drainage. Clitoral reduction, if cosmetically warranted, may be planned at puberty.

Enteric duplication in children: Experience from a tertiary center in South India.

BACKGROUND: Enteric duplications (EDs) are rare aberrations of the embryonic gut. This study was undertaken to define the clinical characteristics and management challenges of this unusual entity in the Indian population. MATERIALS AND METHODS: Hospital records of 35 children with 38 ED operated between 2003 and 2014 were analyzed and followed up. RESULTS: The median age at presentation was 285 days (range 1-day to 16 years) with male preponderance (71%). Small bowel duplications were the most common (44%), and thoracoabdominal duplications were seen in 8% children compared to 2% in the literature. The median duration of symptoms was 18 days (interquartile range [IQR] 3-210 days). Associated anomalies were seen in 49% children with vertebral and spinal anomalies being the most common. Ultrasonogram (US) was done in 83% children and had a sensitivity of 55%. In the presence of a gastrointestinal bleed, Technetium(99m) pertechnetate scintigraphy scan had a positive predictive value of 80%. Thirty-five lesions were completely removed. Mucosectomy was done in two children, and one total colonic duplication was left in situ after providing adequate internal drainage. There was no postoperative mortality. The follow-up was possible in 66% children. CONCLUSIONS: EDs are uncommon and have varied, nonspecific symptoms. Thoracoabdominal duplications are more common in the Indian population. The US is a good screening tool but requires a high index of suspicion where complete excision is not possible; the provision of adequate internal drainage is an acceptable alternative. The long-term prognosis of children with ED depends on the extent of physiological disturbance due to associated anomalies.

A low-cost banding device for oesophageal varices using Foley catheters.

Our institution has devised a low cost method of banding oesophageal varices by loading cut Foley catheters on to a banding apparatus.

Surgical intervention for anorectal fistula.

BACKGROUND: Surgery for anorectal fistula may result in recurrence, or impairment of continence. The ideal treatment for anorectal fistulae should be associated with low recurrence rates, minimal incontinence and good quality of life. OBJECTIVES: To assess the efficacy and morbidity of operative procedures for chronic anal fistula, primary outcomes being recurrence and incontinence. SEARCH STRATEGY: The following databases were searched: EMBASE (Webspirs 5.1, Silver Platter version 2.0, 1950-2009); Medline (Webspirs 5.1, Silver Platter version 2.0, 1950-2009); The Cochrane Central Register of Controlled Trials (2009 issue 4)and the IndMed ( Indian Medline, www.indmed.nic.in) database. We restricted our search to the English literature. The Indian Journal of Surgery was electronically searched (issues between 2003 and vol 71, Oct 2009). We also searched all primary trial registers (Indian, Australian, Chinese, WHO, ISRCTN and American). SELECTION CRITERIA: Randomised controlled trials comparing operative procedures for anorectal fistulae were considered. Non randomised trials and cohort studies were examined where data on recurrence and function were available. DATA COLLECTION AND ANALYSIS: Two reviewers (TJ and BP) independently selected the trials for inclusion in the review. Disagreements were solved by discussion. Where disagreement persisted and published results made data extraction difficult, we obtained clarification from the authors. REVMAN 5 was used for statistical analysis. Quality of the trials were assessed and allowances made for subgroup analysis and prevention of publication bias, using funnel plots if needed. MAIN RESULTS: Ten randomised controlled trials were available for analysis. The quality of included studies was adequate, though in some trials the numbers were small and they were inadequately powered for equivalence or to detect significant differences. Comparisons were made between various modalities of treatments. There were no significant difference in recurrence rates or incontinence rates in any of the studied comparisons except in the case of advancement flaps. There were more recurrences in the glue plus flap group, a significant difference that favoured the flap only technique. It was also noted that Fibrin glue and advancement flap procedures report low incontinence rates.In the review of literature of non-randomised trials, most trials on fibrin glue indicate good healing in simple fistulae with low incontinence rates. AUTHORS' CONCLUSIONS: There are very few randomized controlled trials comparing the various modalities of surgery for fistula in ano. While post operative pain, time to healing and discharge from hospital affect quality of life, recurrence and incontinence are the most important. As it turns out, there seems to be no major difference between the various techniques used as far as recurrence rates are concerned.The use of Fibrin glue and advancement flaps are associated with low incontinence rates.There is a crying need for well powered, well conducted randomised controlled trials comparing various modes of treatment of fistula in ano. Newer operations like the anal fistula plug and the LIFT procedure need to be evaluated by randomised clinical trials.