Does the contralateral testicular volume decide the need for diagnostic laparoscopy in cases of unilateral impalpable undescended testis?

BACKGROUND: This study aimed the evaluation of the value of the calculated volume of a normal testis to predict the status of its contralateral impalpable side and hence decide the importance of laparoscopic exploration. METHODS: Patients with unilateral impalpable undescended testis - as confirmed by clinical and sonographic examination- were enrolled in our prospective interventional study between November 2018 and August 2022 at Elshatby University Hospital, Faculty of Medicine, Alexandria University. The volume and three-dimensional diameter of the normal contralateral testis were measured by the pre-operative US using the formula: Volume = L x W x H x π/6, where L is the length, W is the width, H is the height, and was correlated with the intra-operative laparoscopic findings. RESULTS: Seventy-six patients were included in our study. The age of the studied patients ranged between 6 months and 4 years with a mean of 2.17 ± 1.30 years; most of them were between one and three years old. Forty-six patients (60.5%) have left-sided impalpable testis and 30 patients (39.5%) have right-sided impalpable testis. The calculated volume of the contralateral normal testis was significantly larger in those patients who had both blind ending vas and vessels (0.89 ± 0.16) and in those who had an atrophic testis passing through the deep inguinal ring (DIR) -which was excised through the inguinal region- (0.83 ± 0.20) than in those patients who had their testes intra-abdominal (0.53 ± 0.18) or passing through the DIR to the inguinal region (0.80 ± 0.19). (Kruskal Wallis test; p < 0.001*). CONCLUSIONS: The calculated sonographic volume of a normal testis can predict the status of its contralateral impalpable side significantly with sensitivity & specificity of 75.0% & 88.89% respectively and a cut-off point of ≤ 0.674; hence, helps in parent counselling preoperatively. TRIAL REGISTRATION: Name of the registry: Clinicaltrials.gov PRS. TRIAL REGISTRATION NUMBER: NCT05933811. Date of registration: 10-7-2023 (retrospectively registered). URL of trial registry record: https://clinicaltrials.gov .

Evaluation of Z-plasty versus Heineke-Mikulicz scrotoplasty in the management of penoscrotal web in pediatric age group.

BACKGROUND: The penoscrotal web may be congenital or acquired following excessive ventral skin removal during circumcision. Several surgical techniques were described for the treatment of congenital webbed penis without a clear comparison between their outcomes. This prospective study aimed at comparing the surgical results of Z-scrotoplasty and Heineke-Mikulicz scrotoplasty in the treatment of congenital webbed penis in uncircumcised pediatric patients. METHODS: Our study included 40 uncircumcised patients who were divided randomly into two groups; Group A included 20 patients who were treated by Z-scrotoplasty and Group B included the other 20 patients who were treated by Heineke-Mikulicz scrotoplasty. All patients were circumcised at the end of the procedure. RESULTS: The surgical outcome was good without a significant difference between the two groups in 36 patients. Recurrent webbing developed in one patient of Group A and in three patients of Group B (FE p = 0.605) The only significant difference between the two groups was the operative duration which was shorter in Group B than in Group A (P < 0.001*). CONCLUSIONS: Treatment of congenital penoscrotal web in the pediatric age group could be done with either Z-scrotoplasty or Heineke-Mikulicz scrotoplasty with satisfactory results, however, without significant difference in the surgical outcomes. TRIAL REGISTRATION: • Registration Number: ClinicalTrials.gov ID: NCT05817760. • Registration release date: April 5, 2023.

Concealed penis in pediatric age group: a comparison between three surgical techniques.

BACKGROUND: Comparison between three different surgical techniques in the management of concealed penis. METHODS: This prospective interventional non-randomized study included 150 pediatric patients with a concealed penis. They were distributed equally into three groups; group A; patients treated by anchoring the penile skin dermis to Buck's fascia at the penile base at 3 and 9 o'clock points using PDS 5/0 (phallopexy), group B; patients treated by complete dissection and excision of dartos fascia and group C; patients treated by phallopexy as in group A after complete dissection and excision of dartos fascia. Follow-up at the end of the 1st post-operative week and then monthly for 6 months as regards penile skin congestion and/or necrosis, wound infection, edema, and/or re-retraction was carried out. RESULTS: Penile edema and re-retraction have a statistically significant difference among the studied groups (p < 0.001 and p = 0.002 respectively). Penile re-retraction was noticed to be lowest in patients of group C, however penile edema was observed to be highest in patients of group B. CONCLUSIONS: Phallopexy after complete dissection and excision of dartos fascia have better results than doing either phallopexy or dartos excision alone in the treatment of concealed penis. CLINICAL TRIAL REGISTRATION: The manuscript was registered in ClinicalTrials.gov Protocol Registration and Results System. CLINICALTRIALS: gov Identifier: NCT05565040. Our manuscript was registered on 4/10/2022.

Two levels vs. one level of phallopexy in the treatment of concealed penis in patients in pediatric age group.

Introduction: Concealed penis, which is the congenital type of buried penis, is a condition in which a normal-sized penis is totally or partially hidden by pubic, scrotal, or thigh skin. Several procedures had been described for its correction including phallopexy, that is, fixation of penile Buck's fascia to the sub-dermis. Aim of the work: Our work aims to study the difference in outcome between performing phallopexy at one level and at two levels. Material and methods: Our study included 180 uncircumcised patients who had a concealed penis while having an average length of an outstretched penis. These patients were divided into two groups: the first one was treated with one level of phallopexy at the 3 and 9 o'clock points, while the second group was treated with the same procedure in addition to another level of stitches at the mid-penile level. The follow-up was carried out for one post-operative year regarding penile skin edema, infection, congestion, necrosis, and/or re-retraction. Results: The overall success rate was 96.1% for a normally-looking penis without post-operative re-retraction. Re-retraction developed in two patients (2.2%) of those who had one-level phallopexy and in five patients (5.6%) of those who had two-level phallopexy without statistical significance (FE p = .444). Penile skin edema developed in 76 patients (42.2%) being significantly lower in patients with lower body weight (p = .030*). Conclusion: Phallopexy could be performed safely in the case of the concealed penis with satisfactory results. Two levels of phallopexy did not add any advantage to the post-operative results besides the fact that this may be demanding, time-consuming, and may require higher resources, so we recommend the easier one-level phallopexy in the treatment of such conditions with satisfactory results.

Intussusception in preterm neonates: A systematic review of a rare condition.

BACKGROUND: While necrotizing enterocolitis (NEC) is a prevalent condition in preterm neonates admitted to neonatal intensive care unit (NICU), intussusception is exceedingly uncommon and often overlooked. This is due to the fact that they share many clinical characteristics. The initial misdiagnosis of intussusception in preterm neonates (IPN) especially has led to a delay in their management, which increases the risk of developing compromised bowel. Additionally, it is difficult to reach a diagnosis as neonatal intussusception does not have any classical radiological signs even when contrast enema is used. This systematic review is based on the published literature including case reports and case series to review the clinical features of IPN and how to differentiate it from NEC in order to shed the light on this rare disease and how having a high index of suspicion would help practitioners to make an early and accurate diagnosis METHODS: A systematic literature search to report all cases of relevant articles that reported IPN till date. All cases that were born before 37 weeks gestational age, presented within the neonatal period and having well established documentation were included in the study. Any case that did not have these criteria was excluded from our study. RESULTS: Only 52 cases met these criteria during the period from 1963 till date. An average of 10 days had elapsed before the cases were confirmed to have IPN either clinically or intraoperatively. The most frequent manifestations were abdominal distension and bilious gastric residuals, occurring in 85% and 77% of the cases respectively, followed by bloody stools in 43% of cases. However, this triad was present only in approximately one-third of the cases. Only 13 cases were diagnosed as having intussusception preoperatively. About two thirds of the intussusception were located in the ileum. Pathological lead point was present in 7 cases only; 4 of them were due to Meckel's diverticulum. Nine cases only out of the 52 cases with IPN died. CONCLUSION: It is crucial to detect the clues for diagnosis of intussusception because in contrast to NEC, it is unresponsive to conservative management, affects the viability of the bowel and surgery is essential.

Management of pediatric benign ovarian tumors in England and Egypt: A comparative study.

AIM OF THE STUDY: We aimed to compare the management of pediatric benign ovarian tumors between an English center and three Egyptian institutions. MATERIALS AND METHODS: This was a retrospective review of all children presenting with benign ovarian tumors between January 2014 and January 2019. A standardized dataset was used to compare between both sides. RESULTS: Eighty-nine patients were included (54 English and 35 Egyptians). Median age at diagnosis in England was 13 years (2-16y), while in Egypt it was 7 years (9m-16y) with P =0.001. Mature teratomas or dermoid cysts were the most common findings in England and Egypt; 75.9% and 82.8% of cases, respectively. The presentation with an acute abdomen represented 27.8% of English and 28.6% of Egyptian patients. Incidentally diagnosed lesions constituted 15% of English patients, whereas none of the Egyptian cases were discovered incidentally. There were variations in diagnostic imaging; England: Ultrasound (USS) (54), magnetic resonance imaging (MRI) (37), and computed tomography (CT) (only one)-Egypt: USS (35), CT (17), and MRI (only one). Minimally invasive surgery (MIS) was performed in 15% of English and 23% of Egyptian patients (P = 0.334). Ovarian-sparing surgery (OSS) was performed in: England 35%, Egypt 37%; P = 0.851. OSS was performed using MIS in 87.5% (7/8) of English patients and 100% (8/8) of Egyptians. Patients presented as emergencies generally had open oophorectomies: England; 86.7% open and 80% oophorectomy-Egypt; 100% open and 90% oophorectomy. Recurrences or metachronous disease occurred in 5.6% of English and 5.7% of Egyptian patients. CONCLUSIONS: There were no significant differences regarding surgical management, tumor pathology, and recurrence or metachronous disease. However, age, incidental diagnosis, and imaging modalities showed notable differences. MIS was correlated with ovarian preservation, whereas emergency surgery generally resulted in open oophorectomy.

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.

Fatal Course of a Male Newborn with Double Duodenal Atresia.

Multiple point duodenal atresia is an extremely rare condition with atretic segments in either two or three sites of the duodenum. We report a newborn male patient who presented to our institution with bilious vomiting, nonpassage of meconium, mild abdominal distension, and a palpable epigastric abdominal mass ∼1 × 1 cm. A faint double bubble was found on abdominal X-ray. On exploratory laparotomy, a duodenal cyst due to double duodenal atresia was found and a typical diamond-shaped duodeno-duodenostomy was created. A postoperative contrast study revealed passage of the contrast media into distal intestine. However, the patient died 2 weeks later due to uncontrolled sepsis and pneumonia. Despite the fact that multiple-point duodenal atresia is a rare condition, it should be considered as a differential diagnosis to avoid missed pathology.

Anterior sagittal anorectoplasty as a technique for the repair of female anorectal malformations: A twenty two-years-single-center experience.

BACKGROUND: Anorectal malformations (ARMs) are major congenital malformations occurring in female children in approximately 1 out of every 4000-5000 births. Posterior sagittal anorectoplasty (PSARP) was introduced for their treatment in early 1980s by Pena and Devries. However, anterior sagittal anorectoplasty (ASARP) was first introduced by Okada as a modification of the previous technique. PURPOSE: The aim of this study was to report our experience and the long-term follow-up results of 594 female patients with anorectal malformations treated by anterior sagittal anorectoplasty (ASARP) in a single center over 22 years. We chose this approach as the incision is smaller, with minimal cutting of the external sphincter and easier dissection of the vagina and rectum. The type of our study was retrospective study. RESULTS: The study included 594 patients; 342 of them were less than 1 year old. About 526 patients had rectovestibular fistula, anterior perineal anus in 55 patients, anocutaneous fistula in 6 patients and rectovaginal fistula in 7 patients. All of these patients had been subjected to ASARP technique which had been done in one stage without proceeding colostomy in about 470 cases and in staged fashion with a protective colostomy in 124 patients. Postoperative follow up revealed that four patients (0.7%) developed anal retraction, 30 patients (5%) developed anal stricture, 20 patients (3.4%) had rectal prolapse and 40 patients (6.7%) developed anterior anal migration. Constipation was observed in 161 patients (27%) by the end of 1st postoperative year reduced to 41 patients (7%) after one year. 474 patients were assessed for continence by Kelly's continence score and 453 patients showed good result, 16 patients showed fair result and about 5 patients had poor continence outcome. CONCLUSION: Anterior sagittal anorectoplasty is a procedure with optimal functional outcome especially at if done at an early age in one stage without preliminary colostomy.

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.