Management strategy and outcomes of sacrococcygeal teratoma - an Egyptian multicenter experience.

OBJECTIVES: Nationwide criteria regarding patients with sacrococcygeal teratoma (SCT) are still lacking in Egypt. We aimed to present a multicenter study regarding the management and outcomes of this tumor to evaluate our national treatment strategy. METHODS: A retrospective analysis including all patients with SCT who were managed at four major Egyptian centers between 2013 and 2023. Clinical data, surgical approaches, and short- and long-term outcomes were discussed. RESULTS: The study included 95 patients (74 were females). Antenatal diagnosis was reported in 25% of patients. Seventy-one patients (74.7%) were classified as Altman type I/II. Surgery was performed via a perineal approach in 75 patients, whereas the remaining 20 underwent a combined abdominoperineal approach. Vertical elliptical incision with midline closure was conducted in 51.5% of patients, followed by classic or modified chevron incisions. Benign mature teratoma was detected in 82% of patients. At a median follow-up of 57 months, eight patients (8.5%) had relapsed. The 5-year overall survival (OS) and event-free survival (EFS) of all patients were 94% and 91%, respectively. In the after-care monitoring, 19 patients (20%) had urinary or bowel dysfunctions. Nine of them were managed using medications. Clean intermittent catheterization was practiced in another five patients. The remaining five underwent further surgical interventions. CONCLUSION: Favorable outcomes were achieved in our country during the last decade. Diverse perineal incisions were performed for resection, and vertical elliptical with midline closure was the commonest. During follow-up, 20% of patients developed urological or bowel dysfunctions that required medical and surgical treatment modalities to improve their quality of life.

Ectopic opening of vasa deferentia into a prostatic utricle cyst.

Prostatic utricle cysts result from incomplete regression of the Müllerian duct remnant or decreased androgenic stimulation of the urogenital sinus. Children usually present with urinary tract infections (UTIs), irritative symptoms and urine retention, although some cases are asymptomatic. These cysts sometimes can cause a palpable abdominal mass, urethral discharge, terminal hematuria and recurrent epididymitis. A high incidence of such cysts is seen in boys with hypospadias, especially the more proximal types.

Evaluation of the safety of using harmonic scalpel during laparoscopic cholecystectomy in children: A preliminary report.

Background and objective: In spite of being one of the most common surgical procedures performed in adults, laparoscopic cholecystectomy (LC) is relatively uncommon in the pediatric age group. Most surgeons prefer to dissect the cystic duct using a monopolar electrosurgical hook and occlude it with simple metal clips. Although the safety of using the ultrasonically-activated shears, e.g., harmonic scalpel for dissection of the gallbladder is confirmed in many studies, its efficacy in the closure of the cystic artery and duct in adults is still debatable. Furthermore, very few reports studied its safety in children during LC. The aim of our work is to study the safety and efficacy of ultrasonic shears in controlling the cystic duct and artery during LC in children. Materials and methods: A prospective study was conducted from May 2017 to April 2020, where all children having symptomatic gallbladder stone disease were included in the study. HS was used as a sole instrument in gallbladder dissection as well as in controlling cystic duct and artery. No metal clips or sutures were used throughout the procedure. Results: A total of forty-two children having symptomatic gallstone disease were included in the study. The main indication for LC was hemolytic anemia. Their age ranged from 3 to 13 years with a mean of 8.4 ± 3.25 years. All operations were completed laparoscopically, i.e., no conversion to open surgery was needed. The mean operative time was 40 ± 10.42 min. There were no intraoperative complications apart from gall bladder perforation in two cases during dissection from the liver bed while the postoperative recovery was smooth in all patients. Patients started oral feeding after 11.30 ± 3.01 h. The mean time for discharge was 25.47 ± 7.49 h, ranging from 14 to 48 h. Postoperative ultrasound for all cases showed no evidence of minor or major bile leaks or CBD injuries. Conclusion: This is the first report to evaluate the use of HS as a sole instrument during LC in the pediatric age group. HS is a safe and efficient instrument that can be used alone in gallbladder dissection as well as in controlling cystic duct and artery during LC in children.

Sigmoid volvulus; a rare complicated presentation of Hirschsprung's disease: A case report.

INTRODUCTION: Sigmoid volvulus (SV) is a rare complication of Hirschsprung's disease (HD) with only 31 cases have been reported in the English literature. Although its diagnosis is challenging, unrecognized SV is a life-threatening condition requiring early recognition to decrease morbidity and mortality. PRESENTATION OF CASE: A 14-year-old male presented to our emergency department with massive abdominal distention. Plain erect abdominal X-ray showed massive colonic distention with multiple fluid levels. Colonoscopy failed to pass beyond 15 cm after entering dilated sigmoid loop. Open surgical exploration was done through a lower midline incision and revealed SV with massive distention of the entire colon. After detorsion, we found a markedly dilated sigmoid colon with an evident discrepancy at the lower sigmoid. Due to massive colonic dilatation, the decision was made for terminal ileostomy. Histopathological examination of biopsy from the narrow segment demonstrated aganglionosis and hypertrophic submucosal neural fibers confirming the diagnosis of HD. DISCUSSION: SV is a rare serious complication of HD. Unrecognized SV is a serious life-threatening condition, so it should be considered in children with acute or recurrent abdominal pain, distension, constipation and vomiting as early recognition and management of volvulus is essential to decrease morbidity. CONCLUSION: The presented case highlights the possibility of SV as a rare complication of HD should be considered especially in children with a history of chronic constipation and abdominal distension who present with acute colonic distension and failure to decompress despite rectal washes.

Delayed Presentation of Congenital Jejunal Web beyond the Neonatal Period.

Congenital web of the gastrointestinal tract is a rare anomaly which may present at any site of the gastrointestinal tract. In cases with an intact membrane, the presenting symptoms may take the form of complete intestinal obstruction while in other cases with a fenestrated membrane, it may present with partial intestinal obstruction such as failure to thrive, volume depletion, or poor body-weight gain, representing a chronic condition. It is very rare for a jejunal web to present with retention of accidently ingested foreign body. In this report, we document a case of 14-month boy with retention of accidently ingested button battery who was found to have a jejunal web on surgical exploration. This case report stresses on the importance of prevention of ingestion of inanimate foreign bodies especially in young infants and that the absence of symptoms does not preclude presence of foreign body in children. Also, surgeons should be prepared to deal with other unsuspected findings intraoperatively. After a review of the literature, jejunal web should be considered in the differential diagnosis of chronic partial intestinal obstruction even in adults.

Congenital Lumbar Hernia in an 8-Month-Old Boy.

Congenital lumbar hernias are uncommonly seen in the pediatric age group, with only about 60 cases reported in the literature. It is usually accompanied by a multitude of congenital anomalies involving different organ systems of the body. For instance, it may involve the ribs, spine, muscles, and the kidneys. Herein, we report a case of congenital lumbar hernia in an 8-month-old boy who underwent an operative repair using a mesh with an uneventful outcome.

Role of Wrap-Crural Fixation and Minimal Dissection in Prevention of Transmigration After Laparoscopic Nissen Fundoplication in Children.

Background: Laparoscopic Nissen fundoplication is the gold standard antireflux procedure in pediatric age group. Intrathoracic migration of the fundic wrap is a common cause failure, leading to recurrence of gastroesophageal reflux disease (GERD) symptoms. Objectives: To investigate the impact of wrap-crural fixation and minimal esophageal dissection in prevention of wrap transmigration after laparoscopic Nissen fundoplication in children. Methods: Prospective randomized study of 46 pediatric patients with refractory GERD who underwent laparoscopic Nissen fundoplication divided into two equal groups. In Group A, wrap crural fixation was done, whereas in group B no fixation was done. Minimal esophageal dissection with preservation of the phrenoesophageal ligament was done in both groups. Approval of the Ethics Committee of our Faculty was obtained. Results: There was no difference between both groups regarding operative time, intraoperative complications, or length of hospital stay. Two patients in group B without wrap fixation suffered recurrence of GERD symptoms. On contrast study, they both showed intrathoracic wrap migration. One of them was reoperated. Whereas in group A, no recurrence of symptoms and no wrap transmigration were noticed in follow-up. Conclusion: In laparoscopic Nissen fundoplication, with minimal esophageal dissection and preservation of the phrenoesophageal ligament, there is no additional benefit from wrap-crural fixation in prevention of wrap transmigration.

Transverse testicular ectopia with Müllerian duct remnant in an incarcerated congenital inguinal hernia - a case report.

BACKGROUND: Transverse testicular ectopia (TTE) is a rare anomaly characterized by both testes descending through a single inguinal canal. In this report, the diagnosis of TTE was discovered in the event of an incarcerated congenital inguinal hernia in a neonate. CASE PRESENTATION: We present a case of TTE accompanied by persistent Müllerian duct structures (PMDS) that had been discovered incidentally during inguinal exploration of a 26-day-old boy who presented with an incarcerated congenital inguinal hernia on the right side and left cryptochidism on the left side. The pathogenesis, approach and proposed management of TTE are discussed. CONCLUSION: TTE is an extremely rare anomaly, especially in neonates, and should be suspected in patients presenting with inguinal hernia on one side and cryptorchidism on the other side.

Acute intrathoracic gastric volvulus: A rare delayed presentation of congenital diaphragmatic hernia: A case report.

INTRODUCTION: Acute intrathoracic gastric volvulus occurs when the stomach undergoes organoaxial rotation in the chest due presence of a diaphragmatic defect. Gastric volvulus associated with congenital diaphragmatic hernia is extremely rare and can be explained as 2 of the 4 ligaments supporting the stomach (gastrophrenic and gastrosplenic) which are connected to the left diaphragm may become elongated or absent. According to the current literature, only 27 pediatric cases have been reported so far. PRESENTATION OF CASE: We describe an 8 years old boy who presented to our emergency department with acute epigastric pain and vomiting. The chest radiograph obtained in the emergency department demonstrated an elevated gastric air-fluid level in the left hemithorax. A computed tomography scan demonstrated a sizable left diaphragmatic defect admitting stomach, small bowel loops and transverse colon with organoaxial gastric volvulus. Emergent laparotomy was done for reduction of the viscera to the abdominal cavity and repair of the diaphragmatic defect. The patient showed an uneventful recovery without experience any pain or difficulty with eating. DISCUSSION: Acute gastric volvulus is a rare pathology defined as an abnormal rotation of the stomach for more than 180° leading to a closed-loop obstruction which may progress to ischemia and strangulation. A plain standing abdominal X-ray and an upper gastrointestinal contrast study are useful for diagnosis, but some authors recommend performing CT or MRI to confirm the diagnosis. The standard treatment for volvulus is open laparotomy with detorsion and anterior gastropexy. CONCLUSION: The presented case highlights congenital diaphragmatic hernia associated with gastric volvulus is a serious condition with very high morbidity and mortality. It should be considered in the differential diagnosis of children with epigastric pain and uncontrolled non bilious vomiting. An upper gastrointestinal contrast study is useful for early diagnosis and surgical treatment should not be delayed awaiting further complementary imaging tests.

Early Clinical Outcome of Staged Laparoscopic Traction Orchidopexy for Abdominal Testes.

AIMS OF THE STUDY: To assess the short-term clinical outcome of the novel Shehata technique of laparoscopic traction-lengthening for abdominal testes in a single center over a 12-month period (January-December 2014). An ethics approval of the study and appropriate consents were obtained for all patients before inclusion in our study. MATERIALS AND METHODS: A total of 47 consecutive boys presented with impalpable testes in the ipsilateral hemiscrota, 3 of them were bilateral summing up to a total of 50 U of impalpable testes to a single center over 12 months (January-December 2014). Those boys underwent a preoperative ultrasound (US) Doppler scan for the ipsilateral and contralateral testes. They then proceeded to a first-stage laparoscopic exploration for the testes in which the cranial testicular artery and the caudal vas deferens were traced to their meeting point to locate the abdominal testes that were either found (peeping at the internal inguinal ring [IIR] or more cranially) or otherwise vanishing (intraabdominally blind-ending vas and vessels or extra-abdominally passing through the IIR). All 50 testes failed to stay at the contralateral IIR when brought there mandating a preliminary lengthening of the testicular vessels by lateral dissection, traction, and fixation to a point 1-2 cm superolateral to the contralateral anterior superior iliac spine (ASIS), essentially a mobile traction point. After 12 weeks, all underwent a second-stage laparoscopic-assisted ipsilateral subdartos orchidopexy for the testes under traction. Occasional slippage of the testis under traction mandated an otherwise second-stage retraction and a third-stage orchidopexy. All underwent US Doppler scan 3 and 6 months after orchidopexy. RESULTS: The 47 cryptorchid boys presented at a mean age of 3 years 2 months (range: 6 months-8 years). Out of the 50 impalpable testes, 9 were nonvisualized on preoperative US Doppler scan and 16 were vanishing on laparoscopic exploration: 5 abdominally (in utero vascular accident) and 11 scrotally (perinatal torsion). The remaining 34 testes were fixed loosely near the contralateral ASIS in the first-stage laparoscopic exploration. Out of which, 3 had slipped traction at the second stage. The 12-week traction interval went uneventfully and a predefinitive US Doppler scan confirmed viability of all testes under traction. All 34 elongated testes were mobilized and fixed in the ipsilateral hemiscrota inside a created subdartos pouch (of de Netto). All 34 fixed testes were confirmed viable on US Doppler scan 1, 3, and 6 months after orchidopexy. CONCLUSION: The novel Shehata technique of staged laparoscopic traction-lengthening for abdominal testes is safe, easy, and convenient as evidenced by our limited early experience. Neither internal herniation complicated the traction period nor testicular atrophy (by undue tension) complicated the traction or follow-up periods. We believe it is a good alternative to the Fowler-Stephens staged orchidopexy that entails risky division of the testicular vessels.

Pediatric inguinal hernias, are they all the same? A proposed pediatric hernia classification and tailored treatment.

PURPOSE: To propose a new clinical classification for pediatric inguinal hernias modified from a similar classification system for adult inguinal hernia and to propose a tailored repair for each type. The impact of this approach on hernia recurrence will be assessed. METHODS: This prospective and retrospective cross-sectional study was conducted in two tertiary teaching university hospitals in Egypt (Alexandria and Tanta University Children's Hospitals) from January 2013 to December 2014 on children below 12 years of age with indirect inguinal hernias who were divided into two groups: (a) prospective group I, classified according to our proposed pediatric hernia classification and tailored treatment (PHCTT) into types: pediatric Nyhus 1 (PNI) assigned for herniotomy alone, pediatric Nyhus II (PNII) assigned for herniotomy plus deep ring narrowing, and type pediatric Nyhus III (PNIII) assigned for herniotomy plus posterior wall repair. (b) Retrospective unclassified group II where all cases were assigned to herniotomy alone (open). Data about patient characteristics, assigned hernia type, operative findings, procedures done, and postoperative complications were documented and analyzed by comparing the outcomes of the two groups. RESULTS: A total of 371 patients were included in this study with 401 hernias (30 bilateral); group I included of 217 patients, while group II included 154 patients. There was a male preponderance in group I (173/217 = 80%) and in group II (130/154 = 85%); the majority in both groups were less than 12 months of age, in group I (132/217 = 66%) and in group II (120/154 = 85%). The median age was 4 months and the median duration of symptoms was 2 months. For group I, PNII hernias formed the predominant cluster making 40% (94/235) followed by PNI hernias making 34.8% (82/235), while PNIII hernias were the least group being 25% (59/235) only. The mean follow-up period was 9.2 months ± 4.8 SD (and 9.1 months ± 2 SD in group II). The pooled recurrence rate was 1.9% (8/401) of the whole series, a weighted mean of the individual recurrence rates of 0% (0/235) of group I and 4.8% (8/166) of group II patients, all males. This difference in the recurrence rates between the two groups was statistically significant (P = 0.004). CONCLUSIONS: Pediatric inguinal hernias are not the same and there is extreme variation in the presentation regarding the size of the defect. We proposed a nouvelle pediatric hernia classification modified from the original Nyhus classification for adult inguinal hernia with tailored surgical approach to each type (PHCTT). Applying this (PHCTT), it has the benefit of a significant reduction of recurrence rate.

Staged laparoscopic traction-orchiopexy for intraabdominal testis (Shehata technique): Stretching the limits for preservation of testicular vasculature.

BACKGROUND: We present the midterm results of the novel technique of two-stage laparoscopic traction orchiopexy (SLTO) for the high intraabdominal testis (IAT) for elongation of the testicular vessels without division. PATIENTS AND METHODS: Boys with IAT proven by laparoscopy were selected for the technique between September 2009 and April 2013 in 2 Egyptian pediatric surgery units. Boys <6months or >9years were excluded. The technique entails fixation of the testis to a point one inch above and medial to the contralateral anterior superior iliac spine for 12weeks. Subdartos orchiopexy is then done at the second stage. Both stages are laparoscopically assisted. RESULTS: SLTO was used in 124 boys (140 testis units) with IAT. Mean follow-up period was 16 (range 6-36) months. Scrotal testes were achieved in 105 (84%) of 125 followed cases. Success was correlated with patient age at operation and with distance of IAT from the internal inguinal ring with higher success in younger patients and in testes nearer to internal inguinal ring. CONCLUSION: The novel technique of two-stage laparoscopic traction-orchiopexy is useful in IAT not amenable to one-stage laparoscopic-assisted orchiopexy; it resulted in significant elongation of testicular vessels without atrophy. It is a safe and valid alternative to two-stage laparoscopic Fowler-Stephens technique, which entails division of the main testicular vessels.

Hypoplastic gonadal vessels exiting the deep ring during laparoscopy for impalpable testes: when is inguinal exploration necessary?

BACKGROUND/PURPOSE: During laparoscopy for impalpable testes (IT), if the vas and vessels are found exiting the deep ring, many surgeons proceed to inguinal exploration as a routine, regardless of the adequacy of the vessels or the presence or absence of the processus vaginalis (PV). We tried to find out whether this was necessary in cases with hypoplastic vessels. PATIENTS AND METHODS: This was a retrospective study of cases of IT where during laparoscopy, the vas deferens and the gonadal vessels were seen passing through the deep inguinal ring. Cases were divided into four groups, according to the condition of the PV: present (whether patent or closed) or absent and the adequacy of the vessels. Findings at inguinal exploration and histopathologic examination were compared. RESULTS: Over a period of 4 years, 27 children had laparoscopy for 36 IT. Twenty-three cases (64%) had the vas and vessels passing through the deep ring. Eleven cases (48%) had hypoplastic vessels: 5 (22%) with PV, and on inguinal exploration, 3 (60%) had atrophic testes, and 2 small "nubbins," and 6 (26%) with no PV; 3 with blind ended vas and vessels and 3 with small "nubbins." No case in the last group showed testicular tissue on histopathology. CONCLUSIONS: In cases with hypoplastic vessels exiting the deep inguinal ring, it is the presence or absence of PV that should determine the next step. If it is present, inguinal exploration should follow. If it is absent, exploration is unnecessary.

Cavernous nerve regeneration using acellular nerve grafts.

INTRODUCTION: The restoration of erectile function following complete transection of nerve tissue during surgery remains challenging. Recently, graft procedures using sural nerve grafts during radical prostatectomy have had favorable outcomes, and this has rekindled interest in the applications of neural repair in a urologic setting. Although nerve repair using autologous donor graft is the gold standard of treatment currently, donor nerve availability and the associated donor site morbidity remain a problem. In this study, we investigated whether an "off-the-shelf" acellular nerve graft would serve as a viable substitute. We examined the capacity of acellular nerve scaffolds to facilitate the regeneration of cavernous nerve in a rodent model. MATERIALS AND METHODS: Acellular nerve matrices, processed from donor rat corporal nerves, were interposed across nerve gaps. A total of 80 adult male Sprague-Dawley rats were divided into four groups. A 0.5-cm segment of cavernosal nerve was excised bilaterally in three of the four groups. In the first group, acellular nerve segments were inserted bilaterally at the defect site. The second group underwent autologous genitofemoral nerve grafts at the same site, and the third group had no repair. The fourth group underwent a sham procedure. Serial cavernosal nerve function assessment was performed using electromyography (EMG) at 1 and 3 months following initial surgery. Histological and immunocytochemical analyses were performed to identify the extent of nerve regeneration. RESULTS: Animals implanted with acellular nerve grafts demonstrated a significant recovery in erectile function when compared with the group that received no repair, both at 1 and 3 months. EMG of the acellular nerve grafts demonstrated adequate intracavernosal pressures by 3 months (87.6% of the normal non-injured nerves). Histologically, the retrieved regenerated nerve grafts demonstrated the presence of host cell infiltration within the nerve sheaths. Immunohistochemically, antibodies specific to axons and Schwann cells demonstrated an increase in nerve regeneration across the grafts over time. No organized nerve regeneration was observed when the cavernous nerve was not repaired. CONCLUSION: These findings show that the use of nerve guidance channel systems allow for accelerated and precise cavernosal nerve regeneration. Acellular nerve grafts represent a viable alternative to fresh autologous grafts in a rodent model of erectile dysfunction.