Evaluation of renal oxygenation by near-infrared spectroscopy during endoscopic injection of bulking agents in children with vesicoureteral reflux.

BACKGROUND: Near infrared spectroscopy (NIRS) is the measuring of regional tissue oxygenation (rSO2) by interpreting oxyhemoglobin and deoxyhemoglobin signals that come back by transmitting near infrared light to tissues. The effect of endourological interventions on renal perfusion in children is largely unknown. AIMS: To evaluate the effects of endoscopic injection of bulking agents (EIBA) for vesicoureteral reflux (VUR) on renal oxygenation (RO) using renal NIRS monitoring, which shows renal perfusion and oxygenation changes. STUDY DESIGN: Case-control study. METHODS: Group I had bilateral inguinal surgery, Group II cystoscopy, and Group III, EIBA for VUR with 30 patients in each group. During the operation, vital signs, peripheral oxygen saturation, end-tidal carbon dioxide, and renal regional oxygen saturation index (rSO2) values by bilateral renal NIRS monitoring were recorded. NIRS values before induction (T0) to postoperative (Tend) were determined. A 20% or more reduction in renal rSO2 (%20↓rSO2) was considered significant. Group III was also evaluated as subgroup III-A (not having "%20↓rSO2") and subgroup III-B ("%20↓rSO2"). RESULTS: The rSO2 decrease was observed in the first 5 min for both sides in group III. The most significant drop was at T30 for the right kidney and a significant decrease in rSO2, 20% or more, was observed in 6 renal units of 4 patients having higher SFU grading and renal scar in group III. CONCLUSION: EIBA may transitionally impair renal oxygenation. Higher SFU grading and renal scar may increase the risk of renal hypoxia during EIBA.

Monitoring renal oxygenation status by near-infrared spectroscopy during ureterorenoscopy in children.

BACKGROUND: : Near-infrared spectroscopy (NIRS) monitoring demonstrates renal blood flow, perfusion, and oxygenation changes. This study aimed to evaluate the effects of pediatric endourological interventions (PEI) on regional oxygen saturation value (rSO2) usingrenal NIRS monitoring. METHODS: Patients having bilateral inguinal surgery (group I), cystoscopy (group II), and ureterorenoscopy (group III), 20 patients in each group, were included in the study. NIRS values before induction (T0) and at 5 min (T5), 10 min (T10), 15 min (T15), 20 min (T20), 25 min (T25), 30 min (T30) of the surgical procedure, and at the postextubation (Tend) were determined. The amount of irrigation fluid was recorded in groups II and III. The ureterorenoscopy group was also evaluated as two subgroups, as group III-R with patients having a "20%↓rSO2" and as group III-NoR, not having a "20%↓rSO2". RESULTS: The mean total volume of irrigation was higher in group III, but the difference was not significant between the subgroups III-R and III-NoR. Renal rSO2 decreased significantly in T25, T30, and T-end values in group III. "20%↓rSO2" was seen in 1 patient in group II and 7 patients in group III. In the subgroups III-R, all patients had an obstructive pathology and significant preoperative hydronephrosis with a mean renal pelvis AP diameter of 21.1 ± 16.4 mm. DISCUSSION: Although rSO2 significantly improves postoperatively, our data may suggest that congenital and acquired obstructive pathologies with hydronephrosis, prolonged operative time with continuous irrigation, and instrument movement in a narrow lumen may increase intrarenal pressure and the risk of renal hypoxia in endourological interventions. Preoperative evaluation of kidney functions and a meticulously well-planned intervention can prevent possible complications.

Para-axillary subcutaneous endoscopic approach in torticollis: tips and tricks in the surgical technique.

AIM: An obvious scar on the neck may appear following the open surgery for congenital muscular torticollis (CMT). The cosmetic result may displease the patient and the family. In this study, we describe a minimally invasive technique, para-axillary subcutaneous endoscopic approach (PASEA) in CMT. PATIENTS AND METHODS: A total of 11 children (seven girls and four boys with the age range between 1 and 15 years) were operated for torticollis by PASEA. All patients had facial asymmetry and head and neck postural abnormality. Following an incision at the ipsilateral para-axillary region, a subcutaneous cavernous working space is formed toward sternocleidomastoid (SCM) muscle. The muscle and fascia are cut by cautery under endoscopic vision. The patients had postoperative 2nd-week and 3rd-month visits. The incision scar, inspection, and palpation findings of the region, head posture, and shoulder position of the affected side were considered in evaluation of the cosmetic outcome. Preoperative and postoperative range of motion of the head and neck were compared for functional outcome. RESULTS: We preferred single incision surgery in our last two patients; the rest had double para-axillary incision for port insertion. Incomplete transection of the muscle was not observed. There was no serious complication. Postoperatively, head posture and shoulder elevation were corrected significantly. Range of motion of the head was improved. Postoperatively, all the patients had rotation capacity with more than 30 degrees. The range of postoperative flexion and extension movements was between 45 and 60 degrees. CONCLUSIONS: The open surgery techniques of CMT causes visible lifelong incision scar on the neck. PASEA leaves a cosmetically hidden scar in the axillary region. A single incision surgery is also possible. A well-formed cavernous working space is needed. External manual palpation, delicate dissection, and cutting of SCM muscle with cautery are the important components of the procedure. Surgeons having experience in pediatric minimal invasive surgery may consider PASEA as an alternative to the open approach in CMT. The surgeon should be familiar with surgical anatomy of the neck and must be highly competent in management of possible complications in the region.