Laparoscopy-assisted hydrostatic in situ reduction of intussusception: A reasonable alternative?

AIM: To evaluate an alternative way of reducing intussusceptions under laparoscopic guidance. MATERIALS AND METHODS: This is a retrospective observational study of children who underwent laparoscopy-assisted hydrostatic in situ reduction of intussusceptions (LAHIRI). Under general anesthesia with laparoscopic vision, warm saline was infused into the rectum with a 16-18 F Foley catheter and a drip set till the intussusception was reduced. RESULTS: Eleven patients [age 7.8 (±2.8) months] were operated over a period of 1 year. Ten (90.9%) patients had ileocolic intussusception, which got completely reduced, but one (9%) had ileo-ileocolic intusussception, in whom manual reduction by extending the subumbilical incision was required to reduce the ileoileal part. The mean duration of surgery was 38.5 (±6.6) min. No patient had bowel ischemia and there were no intra- or postoperative complications. CONCLUSIONS: LAHIRI appears to be an effective and safe technique in children. Specific advantages are that it is performed in a controlled environment in the operating room, avoids patient apprehension and discomfort, avoids bowel handling, provides a safe opportunity to create higher intraluminal pressure, ensures visual assessment of bowel vascularity and completeness of reduction.

Lower urinary tract obstruction secondary to congenital bladder diverticula in infants.

PURPOSE: Congenital primary bladder diverticulum is a rare condition and may present with urinary infection; other forms of presentation are rare. We present a series of infants who presented with urinary retention secondary to large primary bladder diverticulum. METHODS: Seven infants were evaluated for symptoms of lower urinary tract obstruction. All seven were infant boys; three were neonates. Investigations included ultrasonogram, voiding cystourethrogram (VCUG) and cystoscopy. RESULTS: Six infants had single large diverticulum while one had bilateral diverticula. VCUG was diagnostic in all cases demonstrating the mechanism of obstruction clearly except one where bilateral diverticula was diagnosed only on cystoscopy prior to definitive surgery. Five children (including one neonate) underwent successful definitive repair consisting of diverticulectomy and ureteral re-implant while two neonates were planned for a staged correction. One neonate later in the series underwent definitive primary repair as bladder was good sized. All five children have done well after definitive repair at a follow-up of 6-72 months. CONCLUSION: Primary bladder diverticulum in infants may present with lower urinary obstructive symptoms indistinguishable from posterior urethral valves. A carefully done VCUG can help in diagnosis. Primary definitive repair can be undertaken even in first few months of life with good results.

Is retrograde stenting more reliable than antegrade stenting for pyeloplasty in infants and children?

OBJECTIVES: To compare antegrade and retrograde internal double-J stenting for pyeloplasty drainage in children. The success of placing the stent in position and the complications were compared in both groups. METHODS: Between October 2001 and December 2004, 42 children with unilateral pelviureteral junction obstruction underwent pyeloplasty by a single surgeon. Antegrade and retrograde double-J stenting was attempted in 17 children (mean age 1.3 years) and 25 children (mean age 1.5 years), respectively. Antegrade stenting was attempted during the pelviureteral anastomosis, and the retrograde stent was placed just before the operation by cystoscopy. Fluoroscopy was not routinely used to confirm stent placement in either group. The stents were removed 4 weeks later at cystoscopy. RESULTS: Successful stent placement without malpositioning was achieved in 14 (82%) of 17 and 24 (96%) of 25 children, respectively, in the antegrade and retrograde groups. The cause of unsuccessful stenting in both groups was the inability to cross the ureterovesical junction. The mean time taken for retrograde stenting was 9 minutes (range 6 to 15). All children with successful stent placement by either technique were discharged within 72 hours after the operation. The hospital stay for children with unsuccessful double-J stent placement varied from 7 to 10 days. No stent malpositioning occurred with retrograde stenting; 1 child in the antegrade stent group had a malpositioned stent in the distal ureter, which was retrieved at ureteroscopy. CONCLUSIONS: In our experience, retrograde double-J stenting seems more reliable than antegrade stenting for pediatric pyeloplasty, with greater success and lower complication rates.

Laparoscopy vs inguinal exploration for nonpalpable undescended testis.

OBJECTIVE: The optimal initial surgical approach for nonpalpable undescended testis (UDT) is debated. The aim of the present study is to compare the results of initial laparoscopy and inguinal exploration in the management of unilateral nonpalpable undescended testes. METHODS: The results of 20 children with unilateral nonpalpable UDT managed by initial laparoscopy (group I) were compared with 20 age-matched children managed by inguinal exploration (group II). The location of testes and results of orchiopexy were compared in both groups. A single surgeon performed all the operative procedures. RESULTS: The majority of testes (16/20 group I, 17/20 group II) in both groups were canalicular or low abdominal. Vanishing testes accounted for one-third (13/40) of the testes, the majority (85%) of which were located in the inguinal canal. All children were discharged within 24 hours of the operation. The success of orchiopexy at 4-6 weeks post-operatively was 85% and 86% in the two groups respectively. Retrospectively, only 7/40 (18%) of the testes would benefit from laparoscopy. CONCLUSIONS: Initial laparoscopic and inguinal approaches to nonpalpable UDT give comparable results. This report failed to demonstrate any specific advantage of initial laparoscopy in the majority of children with unilateral nonpalpable UDT.

Prepubertal human chorionic gonadotropin injection affects postpubertal germ cell maturation and androgen production in rat testis.

OBJECTIVES: To examine the effects of varying doses of prepubertal human chorionic gonadotropin (hCG) administration on postpubertal germ cell status and androgen status in rats. The long-term effects of prepubertal hCG administration on postpubertal testicular function are still debated. METHODS: Forty male prepubertal Wistar rats, aged 20 days, were divided into four equal groups. Group 1 served as the controls. Each rat in groups 2, 3, and 4 received subcutaneous hCG injections of 5 IU, 10 IU, and 50 IU, respectively, on days 20 and 30 of life. Serum testosterone levels were estimated on days 33 and 70. On day 70, the left testis of each rat was harvested for DNA flow cytometric analysis. RESULTS: The testosterone levels on day 33 progressively increased from groups 1 through 4, and the difference between any two groups was statistically significant. In contrast, the testosterone levels on day 70 were greatest in group 1 and progressively decreased in groups 2 through 4, with the lowest value in group 4. On day 70, only group 4 rats had a significantly reduced haploid cell population compared with all other groups. CONCLUSIONS: Prepubertal hCG administration adversely affects testosterone levels, and a high dose of hCG has adverse effects on the germ cell haploid cell population. A critical reevaluation of the use of hCG is required in prepubertal boys, especially with respect to the dosage.

Urinary-tract infection affects somatic growth in unilateral symptomatic hydronephrosis.

To assess whether symptomatic unilateral ureteropelvic junction obstruction (SUUPJO) affects somatic growth and, if so, the parameters associated with it, 61 children (54 boys and 7 girls) who underwent pyeloplasty for SUUPJO without any other associated urological abnormalities were retrospectively studied. Height was compared with standard growth charts and was considered to be affected if it was below 2.00 Z-score. Such children were considered group B and the rest group A. Mean (+/-SD) age at presentation and mean (+/-SD) split renal function (SRF) (%) of the affected kidney were 6.0 +/- 4.0 years and 27.3 +/- 13.2, respectively, for the entire group. Somatic growth was affected in 16 (12 boys, 4 girls) children (26.2%). Urinary tract infection (UTI) was the presenting symptom in 11 (69%) and 5 (11%) children in groups B and A, respectively. Impaired somatic growth had no association with age at presentation or SRF, but a significant association (P < 0.001) was found with UTI. The mean post-surgery height percentile (2.92 +/- 4.85) over a mean follow-up of 3.37 +/- 1.86 years was significantly (P < 0.005) better compared with pre-surgery height percentile (0.67 +/- 0.96) in group B, indicating catch-up growth after surgery. In SUUPJO, somatic growth is affected. Presentation with UTI has a significant association, and height significantly improves after surgery in these patients.

A clinicopathological study of acute necrotising jejunoileitis.

We describe a variety of acute necrotizing enteritis that is endemic to the Indian subcontinent. During the period 1992-1998, 18 cases of acute jejunoileitis (AJI) were managed. Only those in whom the diagnosis was confirmed at laparotomy have been included in this study. The most common symptoms were abdominal pain (100%), fever (77%), and blood in the stool (100%). A stricture following conservative treatment was present in 1 case. The mean age at presentation was 6.5 years (range 6 months-12 years); the male:female ratio was 1.2:1. All cases were seen during May-October. Routine investigations and X-ray films were nonspecific. Stool cultures did not show any clostridia, shigella, or salmonella. The jejunum was involved most commonly; 28% of patients did not require a bowel resection. Only 1 child presented with shock; the mortality was less than 5%. Short-bowel syndrome resulted in 1 patient due to extensive disease. The histopathologic features that were characteristic of the disease were patchy transmural mucosal necrosis extending centrifugally with submucosal edema, interstitial hemorrhage, type III hypersensitivity reaction, and extensive neovascularization. This type of AJI seen in South/Southeast Asia does not seem to be due a to bacterial infective etiology; immune mediation is suggested. The milder forms can be confused with dysentery. Mild forms of the disease can be managed conservatively, but carry the risk of developing strictures. This disease should be suspected in cases of prolonged dysentery during the summer and autumn months.

Effects of unilateral grade I testicular injury in rat.

OBJECTIVES: The effect of unilateral blunt testicular trauma on subsequent testicular function is still debated. None of the experimental studies had the exact grading of testicular injury and evaluation of hormone status and hence this study was designed. METHODS: Twenty male prepubertal (20 days old) Wistar rats were divided into two groups: group 1 (n = 10) underwent sham surgery; group 2 (n = 10) underwent blunt trauma to the right testis by a 5-g sterile weight dropped three times on the testis from a height of 10 cm. T(1)-weighted and T(2)-weighted magnetic resonance images were taken within 6 hours to confirm grade I injury. At 60 days of age, blood samples were obtained from each rat for follicle-stimulating hormone, luteinizing hormone, testosterone, and estradiol levels, and both testes of each rat were harvested separately for DNA flow cytometric analysis. RESULTS: Group 2 rats had significantly reduced (P <0.001) haploid cell populations in both right and left testis compared with the corresponding testis of the group 1 rats. Within group 2, the right testis was significantly (P <0.001) more affected. Serum levels of testosterone were significantly lower (P <0.05) and follicle-stimulating hormone (P <0.01) and estradiol (P <0.05) levels were significantly higher in group 2 rats than in group 1 rats. However, the luteinizing hormone levels were not significantly different. CONCLUSIONS: Grade I unilateral blunt testicular trauma in prepubertal rats significantly affected germ cell maturation in both ipsilateral and contralateral testis and altered the sex hormone profile.

Potential of MRI and 31P MRS in the evaluation of experimental testicular trauma.

OBJECTIVES: To prognosticate and assess the metabolic status of germ cells of the testis after unilateral blunt testicular trauma using both magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS). MRI is a noninvasive technique suitable for evaluating testicular trauma, and MRS is useful in assessing the metabolic status of the testis. METHODS: The right testis of 35 male prepubertal Wistar rats, aged 30 days, was explored through an inguinal incision. The rats were randomized into control (group 1, sham surgery, n = 10) and study (n = 25) groups. The study group received unilateral blunt testicular trauma to the right testis. T(1)- and T(2)-weighted proton MRI of the ipsilateral testis were taken 6 hours after sham surgery or injury, and the rats were stratified on the basis of the absence or presence of intratesticular hemorrhage on MRI into groups 2 (n = 14) and 3 (n = 11), respectively. At 60 days of age, the contralateral testis of each rat was evaluated by 31P MRS and histologic examination. Quantification of phosphomonoesters, phosphodiesters, phosphocreatine, and adenosine triphosphate (gamma, alpha, and beta) was done. RESULTS: A statistically significant difference (P <0.05) in the phosphomonoester/adenosine triphosphate ratio, seminiferous tubular diameter, and Johnsen score of the contralateral testis was observed, indicating decreased testicular maturation of the contralateral testis in group 3 rats compared with groups 1 and 2. CONCLUSIONS: MRI after testicular trauma helped to stratify the extent of injury as determined by the presence or absence of intratesticular hemorrhage with prognostic value; 31P MRS and histologic examination revealed that testicular trauma significantly affects the maturation of the contralateral testis.

Angiographic and immunologic studies in acute necrotizing jejunoileitis.

Eighteen cases of laparotomy-proven acute necrotizing jejunoileitis were treated during the period 1992-1998. Routine laboratory investigations and bacteriological studies were non-contributory towards establishing an etiological basis for the diagnosis. Superior mesenteric artery digital subtraction angiography, carried out in five patients, demonstrated extensive neovascularization. IgG, IgM and IgA were normal in all eight children in whom it was measured; IgE levels were grossly elevated (mean 900 IU/ml; normal range 0-100 IU/ml). Four cases had evidence of hypersensitivity reactions (type I in one patient and type III in three patients) on histopathological examination of the resected small bowel. In addition, histopathological examination also showed the neovascularization observed on angiography. The evidence suggests an immunologically mediated insult resulting in intense vasculitis, which in turn causes ischemic damage to the bowel wall.

Nonoperative management of neonatal moderate to severe bilateral hydronephrosis.

PURPOSE: The natural history of prenatally diagnosed bilateral ureteropelvic junction hydronephrosis is unknown. No definite recommendations exist regarding management, and many authors recommend unilateral or bilateral pyeloplasty. We present the results of nonoperative management of bilateral hydronephrosis. MATERIALS AND METHODS: A total of 16 patients (32 kidneys) with prenatally diagnosed moderate to severe bilateral hydronephrosis were followed nonoperatively. Pyeloplasty was performed only for evidence of deterioration of function and only unilateral surgery was performed when necessary. RESULTS: Of the 32 kidneys 31 had moderate or severe hydronephrosis and 4 (12.5%) required pyeloplasty during a mean followup of 36 months. Hydronephrosis spontaneously resolved or improved in 78% of those observed nonoperatively. Of the 25 kidneys followed nonoperatively for at least 2 years 80% demonstrated improvement. While initial drainage half-time was more than 20 minutes in 55% of kidneys, 78% of unoperated kidneys had a final half-time of less than 20 minutes. Of the 10 kidneys with bilateral severe hydronephrosis 3 (30%) required pyeloplasty. All children had normal glomerular filtration rate for age at the latest followup. Only 1 child has persistent bilateral severe hydronephrosis at age 1 year. CONCLUSIONS: Initial nonoperative observation appears to be safe in all cases of moderate to severe bilateral neonatal hydronephrosis. Spontaneous improvement can be expected in most kidneys by 2 years. Only a few children require unilateral pyeloplasty and bilateral operation can be avoided in most cases.