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.

An atypical complication after hypospadias repair: A combined dorsal and lateral subcoronal urethrocutaneous fistulas.

Urethrocutaneous fistula (UCF) is one of the most common complications of hypospadias repair (HR). We present an unusual combined lateral and dorsal subcoronal (CLDSC) UCFs. Dorsal UCF has not been reported in children yet. A 10-year-old patient was admitted with the complaint of CLDSC UCFs following HR. A long fistula tract from the urethral meatus to the dorsal fistula orifice was excised together with urethroplasty. The patient did well postoperatively. Dorsal penile UCF is an unusual complication; but if it occurs, total excision of the fistula tract together with urethroplasty could be considered to prevent further complications.

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.

The evaluation of urinary incontinence in secondary school children and risk factors: An epidemiological study.

AIM: Urinary incontinence is an important problem that can arise due to neurogenic or functional reasons and negatively affect the psychological, social and personality development of children. This study was conducted on secondary school students to determine the prevalence and risk factors of urinary incontinence at night and/or in the daytime. METHODS: The study universe included all secondary school students attending public elementary schools in the city centre of Eskisehir (N = 34 000). Ethics Committee and Provincial Directorate of National Education approvals were obtained before conducting the study. A data collection form prepared by the researchers and a consent form were delivered in a sealed envelope to the parents via the students. The study data were collected over the period 09 May 2018-30 May 2018. A total of 6957 questionnaires that were fully completed among the 7370 surveys were taken into consideration. The statistical analysis was carried out using the SPSS software package. RESULTS: The number of children found to have urinary incontinence was 215 (3.1%). It was seen that 33 children had urinary incontinence only in the daytime, 61 children experienced it both at night and during the day and 121 children at night. It was observed that 56% of the children suffering from urinary incontinence had not applied to any health facility for treatment prior to the study. It was found that among the risk factors for urinary incontinence were young age, late start of toilet training and presence of a family history of urinary incontinence. CONCLUSIONS: Children with urinary incontinence and their families need medical information and support to reach the root of the problem and seek solutions. Accompanying pathologies in detected cases can be determined in the early period by means of school screenings, and medical evaluation and support can prevent adverse effects on children's psychosocial and personality development.

Application of Machine Learning Techniques for Enuresis Prediction in Children.

INTRODUCTION: As a subset of artificial intelligence, machine learning techniques (MLTs) may evaluate very large and raw datasets. In this study, the aim is to establish a model by MLT for the prediction of enuresis in children. MATERIALS AND METHODS: The study included 8,071 elementary school students. A total of 704 children had enuresis. For analysis of data with MLT, another group including 704 nonenuretic children was structured with stratified sampling. Out of 34 independent variables, 14 with high feature values significantly affecting enuresis were selected. A model of estimation was created by training the data. RESULTS: Fourteen independent variables in order of feature importance value were starting age of toilet training, having urinary urgency, holding maneuvers to prevent voiding, frequency of defecation, history of enuresis in mother and father, having child's own room, parent's education level, history of enuresis in siblings, consanguineous marriage, incomplete bladder emptying, frequent voiding, gender, history of urinary tract infection, and surgery in the past. The best MLT algorithm for the prediction of enuresis was determined as logistic regression algorithm. The total accuracy rate of the model in prediction was 81.3%. CONCLUSION: MLT might provide a faster and easier evaluation process for studies on enuresis with a large dataset. The model in this study may suggest that selected variables with high feature values could be preferred with priority in any screening studies for enuresis. MLT may prevent clinical errors due to human cognitive biases and may help the physicians to be proactive in diagnosis and treatment of enuresis.

The risk factors for recurrence of febrile urinary tract infection and renal scarring in children with functional urinary incontinence.

OBJECTIVES: Functional urinary incontinence is often associated with recurrent urinary tract infection (UTI), vesicoureteral reflux (VUR), and renal scarring. This study aims to evaluate the correlations between urodynamic findings and recurrence of UTI, VUR, and renal scarring in children with functional incontinence. METHODS: In this retrospective observational study, data on the presence of VUR, urodynamics and 99Tc-dimercaptosuccinic acid scintigraphy findings, and episodes of febrile UTI were obtained from patients' records. The patients had at least 3 years of follow-up. RESULTS: There were significant associations between recurrence of UTI and decreased bladder capacity (hazard ratio: 1.321, P = .028). The receiver operator characteristic curve analysis showed a cutoff value for compliance of 13.25 mL/cmH2 O for renal scarring (P = .000). There was a significant association between bladder wall thickening and VUR (odds ratio: 2.311, P = .008). The compliance had a cutoff value of 14.7 mL/cm H2 O (P = .023) for severe VUR. The frequency of renal scarring was higher in patients with severe VUR and dysfunctional voiding (P = .001 and P = .041, respectively). The independent risk factors for renal scarring were low compliance, severe VUR, and dysfunctional voiding in children with functional incontinence, but recurrence of febrile UTI was not a risk factor for renal scarring. Decreased bladder capacity was a risk factor for recurrence of febrile UTI. CONCLUSIONS: The present study suggests that low compliance, severe VUR, and dysfunctional voiding, but not the recurrence of febrile UTI, are the independent risk factors for renal scarring in children with functional incontinence, and decreased bladder capacity is the risk factor for the recurrence of febrile UTI.

Evaluation of renal oxygenization in laparoscopic pediatric surgery by near infrared spectroscopy.

PURPOSE: Increased intraabdominal pressure IAP may reduce renal blood flow (RBF). The study aims to evaluate the pneumoperitoneum effect on RBF by comparing renal regional oxygen saturation index (rSrO2) measured by near-infrared spectroscopy (NIRS) in pediatric patients having laparotomy and laparoscopy. METHODS: Of 58 patients having laparoscopy and laparotomy, 18 were excluded due to renal pathologies, combined open surgical procedures, and administration of inotropic drugs. Hemodynamic parameters and rSrO2 were recorded in laparoscopy (n = 20) and laparotomy (n = 20) groups before induction and with 5 min intervals up to 60 min and at post-extubation. RESULTS: Decrease in right renal rSrO2 at 45th and 60th min and 30th, 45th and 60th min in left were significant in the laparoscopy group compared to laparotomy group. In the laparoscopy group, reductions at T25, T30, T45, and T60 were significant in both renal rSrO2. Renal rSO2 increased to normal with desufflation. CONCLUSION: IAP with pneumoperitoneum may lead to renal hypoxia in children. Renal rSO2 returns to normal with desufflation. Renal NIRS monitorization might be needed in patients with renal parenchymal and vascular pathologies, solitary kidney, and multiorgan pathologies that may affect renal oxygenation.

Laparoscopic and robotic-assisted repair of retrocaval ureter in children: a multi-institutional comparative study with open repair.

PURPOSE: This retrospective study aimed to report a multi-institutional experience with laparoscopic and robotic-assisted repair of retrocaval ureter in children and to compare outcome of minimally invasive surgery (MIS) with open repair. METHODS: The records of all children, who underwent MIS and open repair of retrocaval ureters in six international pediatric urology units over a 5-year period, were retrospectively collected. Data were grouped according to the operative approach: a laparoscopic group (G1) included five patients, a robotic-assisted group (G2) included four patients, and an open group (G3) included three patients. The groups were compared in regard to operative and postoperative outcomes. RESULTS: At follow-up, all patients (one G1 patient after redo-surgery) reported complete resolution of symptoms and radiologic improvement of hydronephrosis and obstruction. In regard to postoperative complications, one G1 patient developed stenosis of anastomosis and needed re-operation with no further recurrence (IIIb Clavien). G2 reported the lowest average operative time (135 min) compared to G1 (178.3 min) and G3 (210 min). MIS (G1-G2) reported a significantly better postoperative outcome compared to open repair (G3) in terms of analgesic requirements, hospitalization, and cosmetic results. CONCLUSIONS: The study outcomes suggest that MIS should be the first choice for retrocaval ureter because of the minimal invasiveness and the better cosmetic outcome compared to open surgery. Furthermore, our results showed that robotic-assisted reconstruction was technically easier, safer, and quicker compared to laparoscopic repair, and for these reasons, it should be preferentially adopted, when available.

Gonadoblastoma and Papillary Tubal Hyperplasia in Ovotesticular Disorder of Sexual Development.

Ovotesticular disorder of sexual development (DSD), formerly known as true hermaphroditism, is a rare form of DSD in which both testicular and ovarian tissues are present in the same individual either in a single gonad (ovotestis) or in opposite gonads with a testis and an ovary on each side. The diagnosis of ovotesticular DSD is based solely on the presence of ovarian and testicular tissue in the gonad and not on the characteristics of the internal and external genitalia, even if ambiguous. Herein, we report two patients with ovotesticular DSD-one presenting with ambiguous genitalia on the third day after birth and the other with short stature and primary amenorrhea in adolescence. Clinical and histopathological investigation revealed a sex-determining region on the Y chromosome (SRY)-positive 46,XX karyotype and bilateral ovotestes in case 1 and a 46,XY karyotype with hypergonadotropic hypogonadism and a streak gonad in one ovotestis with dysgerminoma, gonadoblastoma, and papillary tubal hyperplasia in the contralateral ovotestis in case 2. Laparoscopic examination and gonadal biopsy for histopathological diagnosis remain the cornerstones for a diagnosis of ovotesticular DSD. Moreover, SRY positivity in a 46,XX patient, a 46,XY karyotype, an intra-abdominal gonad, and the age of patient at the time of diagnosis are predictive risk factors for the development of gonadoblastoma and/or dysgerminoma in ovotesticular DSD.

Elevated lactate level and shock index in nontraumatic hypotensive patients presenting to the emergency department.

BACKGROUND: The aim of our study was to evaluate the effect of lactate level (LL) and shock index (SI) on the outcome in nontraumatic hypotensive patients in the emergency department, and also to show the significance of the combined usage of these two parameters. METHODS: This is a prospective, observational study. Elevated and normal LL (ELL and NLL), elevated and normal SI (ESI and NSI), and a combination of these two parameters (lactate-SI group 1: ELL and ESI, lactate-SI group 2: ELL or ESI, and lactate-SI group 3: NLL and NSI) were evaluated for primary (mortality) and secondary outcome measures. RESULTS: A total of 131 patients who fulfilled the inclusion criteria were analysed. Of the patients with ELL, 34.78% were mechanically ventilated (P<0.001), 31.88% received vasoactive drugs (P<0.001), and 68.1% were hospitalized (P<0.01). The mortality rate among patients with ELL was 50.72% (P<0.001). Of the patients with ESI, 39.42% died (P<0.01). Use of mechanical ventilation in the emergency department was higher in lactate-SI group 1 [36.1%, P<0.0001, sensitivity: 100.0%, negative predictive value (NPV): 100.0%]. Vasoactive drug use was higher in lactate-SI group 1 (32.8%, P<0.0001, sensitivity: 100.0%, NPV: 100.0%). Lactate-SI group 1 showed a higher hospitalization rate (67.8%, P>0.05). In-hospital mortality in lactate-SI group 1 was higher (54.1%, P<0.0001, sensitivity: 100.0%, NPV: 100.0%). CONCLUSION: The combination of both parameters is effective in predicting these outcome measures with higher sensitivities and NPVs. Further studies on the subject are required.

Laparoscopic Approach to a Rare Cause of Ureteropelvic Junction Obstruction in a Child: Ureteral Polyp.

Fibroepithelial polyps are a rare underlying reason of ureteropelvic junction obstruction. In the past, open surgery was the only option. However, due to development of minimal invasive technics, treatment alternatives have been changed. Resection by laparoscopy or endoscopy, laser fulguration and/or percutaneous resection are recommended in children and adults. Here, we present a 10-year-old boy with severe left hydronephrosis due to fibroepithelial polyp close to the ureteropelvic junction and our laparoscopic approach.

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.

Anatomical variations of medial umbilical ligament: clinical significance in laparoscopic exploration of children.

BACKGROUND: The anatomy and clinical significance of obliterated umbilical artery called as medial umbilical ligament (MUL) have not been documented well in literature. In this study, we investigated anatomical variations of MUL determined by laparoscopic exploration of abdomen in children and anatomy dissection on cadaver. PATIENTS AND METHODS: The anatomy of MUL was investigated in a total of 126 patients including 41 retrospective cases. All 126 patients had laparoscopic exploration for a lower abdominal pathology. In retrospective group, videos demonstrating clearly both MULs and the region during laparoscopic exploration were selected. A dissection on an adult male cadaver was also performed. A preliminary grading scale of anatomical appearance of MUL was obtained. RESULTS: In grade 0, patients had no visible ligament (n = 14); in grade 1, MUL was a fibrous cord without a web formation (n = 63); in grade 2, MUL was a fibrous cord with a web (n = 49). MULs on both sides of the lower abdominal wall were symmetrical in all cases except one having a cloacal anomaly. This case had a solitary MUL on the right side. CONCLUSIONS: A MUL with a fibrous cord and significant web may cause technical difficulties and narrow the working space in laparoscopic exploration of children. It may also affect the surgeon's preference on trocar locations. In all grades of anatomical variation of MUL, formation of the ligament on both sides of the lower abdominal wall is similar. If there is a single umbilical artery, it becomes a solitary MUL after birth, and the possibility of associated malformations, especially urogenital abnormalities increases in such cases.

A comparison of analgesic efficacy of tramadol and pethidine for management of postoperative pain in children: a randomized, controlled study.

Prevention of postoperative pain in children is one of the most important objectives of the anesthesiologist. Opioids have been used as an analgesic for postoperative pain in children for many years. Tramadol has both opioid and monoaminergic agonist actions. The aim of the study was to determine if the analgesic potency and occurrence of adverse effects of tramadol differ from pethidine when administered to children. A total of 110 healthy children, aged 2-12 years, scheduled for elective lower abdominal surgery were randomized to receive either pethidine 1 mg/kg (Group I, n = 60) or tramadol 2 mg/kg (Group II, n = 50) for postoperative pain after anesthesia induction. Pain intensity, adverse effects, heart rate, and systolic and diastolic blood pressure were recorded at regular intervals. The mean pain scores on postoperative 24 h were significantly greater with tramadol than with pethidine. Sedation scores, heart rate and systolic and diastolic blood pressure showed no significant differences between the groups. We conclude that pethidine and tramadol are effective in providing analgesia in pediatric patients, but pethidine provided better postoperative analgesia than tramadol. Changes in blood pressure, heart rate and arterial oxygen saturation were minimal and were similar in both drugs.

Ingested gastrointestinal foreign bodies: predisposing factors for complications in children having surgical or endoscopic removal.

A retrospective study was performed to determine the predisposing factors associated with the complications of ingested gastrointestinal (GI) tract foreign bodies (FBs) in children who had surgical or endoscopic removal. The study was performed in 161 children who had endoscopic or surgical removal. The clinical data were evaluated in two groups. In groups I and II, respectively, 135 patients with no complications and 26 patients with complications were analyzed. The relative risk analysis was performed for the risk factors. The number of the patients with an accurate history and the radiopaque FBs was significantly higher in group I. Metal, especially sharp objects, and food plugs obstructing a diseased esophagus were the most common FBs found in group II. The majority of the FBs of both groups were entrapped in esophagus, the number of the FBs distal to esophagus was significantly higher and duration of lodgment was significantly longer in group II. Esophageal abrasion, laceration and bleeding, complete esophageal obstruction, caustic injury, severe esophageal stricture, laryngeal edema, recurrent aspiration pneumonia, loss of weight, intestinal perforation, constipation and intestinal obstruction were determined as complications. The relative risk was >1 for duration of lodgment more than 24 h, for sharp or pointed objects, button batteries, nonopaque objects, diseased esophagus and for the objects located below the upper third of esophagus. Type, radiopacity, location and duration of the ingested GI tract FB determine the outcome. A delayed diagnosis is the most significant factor increasing the risk of complications. Physician must maintain a high index of suspicion and a more extensive history; physical examination and radiodiagnostic investigation should be obtained in suspected cases.

Giant cyst of the rete ovarii in a child.

The ovarian cysts are mostly nonneoplastic in children and could be categorized as follicular, simple, and corpus luteum cysts. Follicle cysts are the most common type in both neonates and older children. The rete ovarii rarely gives rise to cysts and to benign and malignant tumors. The rete cysts are most often found in postmenopausal women and have not been reported in children yet. We describe herein a case of giant rete cyst of ovary in an 11-year-old girl and discuss the clinical and histopathologic features of such cysts.

Effects of the anti-ICAM-1 monoclonal antibody, allopurinol, and methylene blue on intestinal reperfusion injury.

PURPOSE: The aim of this study was to evaluate the effect of allopurinol, methylene blue, and a monoclonal antibody to the adhesion molecule ICAM-1 in intestinal ischemia and reperfusion injury. METHODS: The rats were divided into 5 groups. CG (n = 8) was untreated controls, SISG (n = 11) received sterile isotonic saline solution, ICAMG (n = 12) received a monoclonal antibody to rat ICAM-1, ALLOG (n = 12) received allopurinol, and MBG (n = 14) received methylene blue. Intestinal ischemia was performed for 60 minutes followed by 60 minutes of reperfusion. The agents were injected 10 minutes before the reperfusion to animals. After 60 minutes of reperfusion, the plasma samples for myeloperoxidase (MPO) activity, tumor necrosis factor alpha (TNF-alpha) and uric acid levels, and the intestinal biopsies of ileum and jejunum for histopathologic examination were taken. RESULTS: The mucosal damage was attenuated, and TNF-alpha level significantly decreased in ALLOG and ICAMG compared with SISG. The MPO activity was the lowest in ICAMG, and uric acid level was significantly decreased in ALLOG compared with the other groups. Methylene blue decreased TNF-alpha response to reperfusion injury but significantly increased the grade of the mucosal damage and the MPO activity. CONCLUSIONS: This study shows that prereperfusion application of allopurinol and monoclonal antibody to the adhesion molecule ICAM-1 may attenuate the damage caused by intestinal ischemia and reperfusion, but the different time-points for application, the effects observed in the different ischemia and reperfusion durations, and the long-term results also should be investigated in the same experimental model before the final conclusion. Methylene blue was not effective to prevent or attenuate the intestinal tissue injury, but because this was the first study examining the effect of methylene blue on intestinal reperfusion injury, further studies with the different doses, ischemic duration, and application times will be needed.

Neutropenic enterocolitis: is it possible to break vicious circle between neutropenia and the bowel wall inflammation by surgery?

BACKGROUND: Neutropenic enterocolitis is a devastating bowel wall inflammation in patients with protracted neutropenia. The approach for diagnosis and treatment is still controversial, and it is difficult and challenging to decide on what should be the next step in the management. CASE PRESENTATION: We report a 10-year-old boy who developed neutropenic enterocolitis in the course of the conservative treatment for aplastic anemia. Oral mucositis and the perianal fissure with an ulcer were important indicators for what was happening on the colonic mucosa. Colonoscopy and biopsy confirmed the diagnosis. A fast recovery was achieved with a right hemicolectomy and ileostomy. CONCLUSION: Retrospective analysis of the long-term follow-up of our patient suggests that defunctioning the colon by ileostomy breaks the vicious circle between neutropenia and bowel wall inflammation, and an early surgical intervention could be considered as an adjunctive approach to the conservative management of persistent cases.