Pathogenesis and prognosis of intrarenal reflux.

Scar development in the children's renal cortex with vesicoureteral reflux (VUR) is one of the most important parameters of prognosis. It can develop regardless of the chosen treatment, even after the regression of VUR. The shape of the renal papillae, the ascending urinary tract infection, the greater than third-degree VUR, and finally the increased intra-calyceal pressure, induce the formation of renal scarring in the renal parenchyma. Renal scarring may complicate VUR independently of the therapeutic strategy (conservative or operative) and its regression. For restitution of this entity, many scientific terms have been used and the most common of them is intrarenal reflux (IRR). The effects of VUR on future renal function result from the limited ability of the affected kidney to grow (failure of renal growth) due to the existence of scars in the renal cortex, the worsening of these scars, or finally the creation of new scars. With the present study, we intend to clarify the etiology and the pathophysiology of IRR and the relation of VUR prognosis to newer biomarkers such as N-acetyl-beta-glycosaminidase, beta-2 microglobulin, Pen- traxin- 3 and Liver-type fatty-acid-binding protein.

Symptomatic Intraparenchymal Epididymal Cysts: Description of 11 cases.

Epididymal cysts are benign cystic formations of the epididymis that usually appear in adolescence or early adulthood. Their frequency doubles after the age of 14-15. Obstruction in the epididymal efferent ductules with subsequent prostenotic dilatation of them, as well as dysgenesis due to hormonal disorders during fetal or postnatal life, are possible. At the 1st Department of Pediatric Surgery of A.U.Th. we treated 11 cases of boys at the age of 11-16 who presented with acute scrotum because of an epididymal cyst. The diagnosis was confirmed by ultrasound scanning . Due to persistent symptomatology, patients underwent surgical exploration and removal of the cyst. The postoperative care of the patients was uncomplicated with immediate remission of symptoms. In one case, ipsilateral acute epididymitis occurred after 10 days, which was successfully treated with antibiotic therapy. It is reported that approximately 50% of epididymal cysts involute within an average of 17 months. In conclusion, using the data obtained from the review, of the small in number of international bibliography studies, it is proposed conservative treatment of asymptomatic cysts with diameter smaller than 1 cm and surgical excision [1] of large asymptomatic cysts with diameter greater than 1 cm, which do not regress after a follow-up of 24-48 months, cysts, regardless of their diameter, responsible for persistent symptoms and in the manifestation of acute scrotal symptoms due to inflammation, intravesical bleeding or secondarily torsion of the epididymis.

Urachal remnants: from embryology to clinical practice.

The urachus is a tubular structure that is apparent on the third week and connects the ventral cloaca to the yolk sac, as a progression from the allantois. Following the normal regression procedure, the urachus remains as the median umbilical ligament. Urachal remnants are present in 1.03% of paediatric patients while in 92.5% of cases represent incidental findings. Urachal anomalies are classified in four types as patent urachus (50-52%), urachal sinus (15%), urachal cyst (30%) and urachal diverticulum (3-5%). Ultrasound scan is the most commonly performed diagnostic imaging study. In case of symptomatic urachal remnants, surgical excision is indicated. Asymptomatic urachal remnants that are diagnosed at the neonatal period or early infancy should be watched up to 6 months of age, as they are likely to resolve. In persistent or symptomatic urachal remnants there is a risk of inflammation or even malignancy development, therefore we believe that there is indication for preventive surgical excision that may be performed either open or laparoscopically or by robot-assisted laparoscopy.

The challenging diagnosis of acute scrotum: remaining difficulties and further insights.

The main target during management of a male pediatric patient with clinical signs of acute scrotum is the timely diagnosis, in order not to jeopardize the viability of the affected testicle. Thorough evaluation of the patient's medical history, symptomatology, clinical and ultrasonographic findings, constitutes the basis of the diagnostic procedure. After comprehensive research of the relevant literature, we highlight the remaining difficulties in the evaluation of the clinical and ultrasonographic findings for the accurate diagnosis of the acute scrotum. In conclusion, it is worth emphasizing on the following: a. the most common diseases that come under the diagnosis of the acute scrotum may present with similar symptoms, b. in neglected cases the diagnostic approach becomes more difficult, constituting the evaluation of the pathognomonic clinical signs challenging, and c. inability to exclude the diagnosis of spermatic cord torsion should be an indication for the surgical exploration of the affected hemiscrotum.

A Remarkably Rare Position of a Cutaneous Ciliated Cyst in a 16 Month-old Female: A Case Report.

OBJECTIVE: The aim of the work was to show a Cutaneous Ciliated Cyst (CCC) in an unusual location in a 16-month-old girl. CASE REPORT: We present the case of a 16-month otherwise healthy girl presented to our hospital, with a report of a palpable mass in the left suprascapular region. Physical examination revealed a soft-textured, fluctuating, mobile and painless entity, with no further indications of local inflammation. The mass was totally excised, under general anesthesia, for both diagnostic and therapeutic purposes. According to the histopathological findings, the cystic lesion was covered by a pseudostratified ciliary epithelium, resembling the epithelium of a normal fallopian tube, surrounded by a smooth muscle layer. Immunohistochemical studies identified the cyst epithelium as having cytokeratin (CKAE1/AE3) expression, despite the negative immunostaining findings on Estrogen and Progesterone Receptors. CONCLUSION: Our case report concerns a CCC in an unusual position, in the suprascapular area. After a thorough review of the international literature, we concluded that this is the second published case regarding this specific location. To our knowledge our patient is the youngest ever diagnosed with CCC.

Hutch diverticulum: from embryology to clinical practice.

Hutch Diverticulum (HD) is defined as the protrusion of the mucosal and submucosal layer through the muscle bundles of the underlying detrusor muscle. HD is located at the vesicoureteral junction with a backward direction from the homolateral ureteral orifice. As far as its etiology is concerned, HD is caused either by a congenital muscle wall defect at the level where the Waldeyer's fascia occupies the clefts between the vesical part of the homolateral ureter and the detrusor, or is associated with abortive ureteral duplication or defective incorporation of mesonephric duct into the bladder at the site of ureteral hiatus or finally is associated with the development of transient urethral obstruction. HD is usually unilateral and more common in male patients. It may be associated with the Ehlers-Danlos, Williams-Elfin and Menkes syndromes. HD usually occurs in childhood and rarely during adulthood. It is found in 0.2-13% of all children presenting with urinary tract infection. Through this short review article, we attempt to present in detail the most recent bibliographic data concerning this entity, focusing on pathophysiology, diagnostic approach, and treatment strategy.

Dysfunctional elimination syndrome: a short review of the literature.

The combination of the functional disorders of urination and defecation constitutes the Dysfunctional Elimination Syndrome (DES). DES refers to an abnormal pattern of elimination of unknown etiology characterized by bowel and bladder incontinence and withholding, with no underlying anatomic or neurologic abnormalities. Essential precondition for a child to be subsumed under this entity is the exclusion of either anatomical or neurological causative factors. In the present review study the individual entities of dysfunctional filling, such as the unstable or lazy bladder, or dysfunctional urination, such as the detrusor sphincter dyssynergia and the functional constipation are being described comprehensively. Subsequently, the analysis of the pathophysiological effects of the dysfunctional elimination syndrome such as incontinence, urinary tract infections and the conservation or the deterioration of vesicoureteric reflux, is being accentuated. With the documentation of DES, the therapeutic strategy should aim at treating both the functional disorder of the vesicourethral unit and the functional constipation. The first part does not specify depending on the type of this disorder. Rarely, surgical treatment of functional urinary disorders may be required.

Balanitis Xerotica Obliterans:an underestimated cause of secondary phimosis.

Balanitis Xerotica Obliterans is a chronic, progressive, sclerosing inflammation of unclear etiology. It involves the external genitalia of males and more specifically the prepuce and its frenulum, the glans, and the external urethral meatus while it may extend to the peripheral part of the urethra. Recent studies have noted an increasing incidence in the paediatric population. It is the most common cause of secondary (pathologic) phimosis. Even more, in boys with physiologic phimosis that does not respond to conservative treatment, Balanitis Xerotica Obliterans should be considered as the underlying condition. In this study, we present all the latest data and attempt to create a diagnostic and curative algorithm regarding this condition.

Femoral artery thrombosis in an 11-year old boy due to a blunt trauma.

An 11-year old boy presented with a blunt trauma in the right inguinal area after a bicycle accident. Initial clinical picture was indicative of decreased arterial blood supply to the right lower extremity and the diagnostic confirmation was made with a colour flow Doppler ultrasonography. During operative investigation, a thrombosis of the common femoral artery, 3.5 cm in length, was found. The thrombotic part of the femoral artery was removed and replaced with a venous graft taken from the major saphenous vein, before the saphenofemoral junction. Postoperative course was uneventful. Traumatic thrombosis of the common femoral artery as a result of a blunt trauma is very rare, as only 4 relevant cases have been described previously.

Hydrocele in Pediatric Population.

Hydrocele is a collection of fluid within the tunica vaginalis. Based upon the etiology and the pathophysiology, it is divided into, the primary and secondary. The primary hydrocele includes the neonatal or the congenital, the communicating and the non-communicating or the closed or the adult type. The secondary hydrocele can develop in the substrate of a pre-existing disease. After systematic and thorough systematic and thorough research of the relevant literature, we aim at describing all the aspects of this entity, with specific emphasis on the issues that remain unanswered from the scientific community.

Clinical image. Chylolymphatic mesenteric cyst in a 3-month old infant.

Chylolymphatic mesenteric cysts are extremely rare among children. Herein we report a case of a 3-month old infant that was admitted to the Emergency Department due to repeated vomiting. Preoperative ultrasonography demonstrated the presence of a thin-walled multiloculated cystic lesion in the right abdomen. Patient underwent then elective surgical excision. Histopathological examination documented the diagnosis of cystic lymphangioma type III, according to Lozanoff classification.

Intramuscular hemangioma in the anterior scalene muscle in an infant boy: a case report.

The extremely rare localization of an intramuscular hemangioma (IMH) into the anterior scalene muscle was the motive for the present case report, aiming to highlight major, atypical characteristics. An 11-month-old boy with free medical history presented with a painless and progressively growing lesion 4.5 × 4 cm in diameter, located in the left supraclavicular region over the last 4 months. During physical examination, the presence of a painless, non-pulsating, non-adhesive to the overlying skin lesion was documented. Color Doppler flow ultrasonographic examination demonstrated the increased blood supply to the aforementioned lesion. Thus, we planned an elective surgical excision of the lesion in healthy limits. The postoperative course was uneventful, and the patient was discharged on the second postoperative day in good general condition. Histopathologic examination revealed the presence of hemangioma surrounded by connective tissue bundles and striated muscle fibers. IMHs do not follow the general rule of regression, beyond the age of 6-12 months, with no trend to increase over time. Accurate preoperative diagnosis is challenging. Color Doppler flow ultrasonographic examination is the imaging modality of choice during the preoperative assessment. Surgical excision of the IMH in healthy limits is the most appropriate treatment option.

Fusiform Cervical Mass in a 6-Year Old Boy; Do not Forget the Thymic Cyst.

Cervical thymic cyst is a rare clinical entity, with approximately one hundred cases reported in the literature so far. The purpose of this case report is to highlight some certain features, along with an extensive research of the relevant literature. A 6-year-old boy was admitted to the Otorhinolaryngology Department due to the presence of a left-sided, painless, latero-cervical swelling, first observed by his parents 2 weeks ago. Physical examination revealed a painless, well-delineated mass, with no signs of inflammation. No enlarged cervical nodes were present. The mass extended from the mandibular angle, under the sternocleidomastoid muscle, in proximity with the ipsilateral neurovascular bundle. Ultrasound transverse gray-scale panoramic view detected a wellcircumscribed lesion, with fine echogenic foci, appearing in close proximity with the upper pole of the left thyroid lobe and the ipsilateral common carotid artery. Elective surgical intervention with complete mass excision was performed. Histopathological examination confirmed the diagnosis of a cervical thymic cyst. Cervical thymic remnants represent a group of neck masses that pediatricians and pediatric surgeons should consider in differential diagnosis of both cystic and solid neck masses. Most cystic cervical thymic masses are found in the lower third of the anterior neck, extending deep to the sternocleidomastoid muscle, featuring close anatomic relationship with the composites of the ipsilateral carotid sheath. Elective surgery is kept as the treatment of choice, after ruling out the possibility of subject immunologic disturbance.

Early diagnosis and surgical intervention untie the Gordian knot in newborns with colonic atresia: report of two cases and review of the literature.

Incidence of colonic atresia in living infants ranges from 1:5,000 to 1:60,000 (average 1:20,000). It constitutes 1.8 to 15% of all cases of atresia of the gastrointestinal tract. In 58.56-75% of all cases is right-sided. We aim, through the presentation of two cases of colonic atresia which we encountered and after systematic research of the current literature, at addressing three major issues: diagnostic approach, operative strategy and management of the prognostic parameters of the colonic atresia. The common parameter in these two cases was the early diagnosis, which played a significant role in the uncomplicated postoperative course. The first case was a type I sigmoid atresia. Contrast's escape during contrast enema examination due to accidental rupture of the distal part of the colon led to diagnosis. Side-to-side anastomosis, restoration of the rupture and a central loop sigmoidostomy were urgently performed. The second case was a type III atresia at the level of the ascending colon, which was early diagnosed via pregenital ultrasonography, in which colonic dilation was depicted. Restoration of the intestinal continuity early after birth was performed at a time. In conclusion, we believe that early diagnosis, selection of the appropriate operative strategy and prompt recognition of potential post-operative complications, especially rupture of the anastomosis, contribute to the optimization of the prognosis in patients with colonic atresia.

Congenital Spigelian hernia and ipsilateral cryptorchidism: a new syndrome?

Spigelian hernia (SH) is a rare ventral interstitial hernia occurring through a defect in the transversus abdominis aponeurosis (Spigelian fascia). Spigelian fascia is found between the lateral border of the rectus abdominis muscle and the semilunar line, which extends from the costal cartilage to the pubic tubercle. In other words, Spigelian line is where the transversus abdominis muscle ends in an aponeurosis characterized by a congenital or acquired defect in the Spigelian aponeurosis. Pediatric cases of SH are either congenital or acquired due to trauma, previous surgery or increased intra-abdominal pressure. SH in combination with ipsilateral cryptorchidism may constitute a new syndrome, as such cases are extremely rare in the literature is new syndrome is characterized by the following congenital, ipsilateral disturbances: SH, absence of inguinal canal and gubernaculum and the homolateral testis found within the Spigelian hernia sac (a hernia sac containing undescended testis). The aim of this study is to emphasize some typical findings of this specific entity, and, hence, the necessity for a thorough investigation of the origin of the SH.

Covered perforation of Meckel's diverticulum ulcer to transverse colon: highlighting the urgent intervention and the avoidance of a dramatic evolution (case report and literature review).

Meckel's diverticulum represents a remnant of the proximal end of the omphalomesenteric duct, which constitutes a connection between the middle intestine and the vitelline vesicle. It is the most common congenital anomaly of the gastrointestinal tract and is found in approximately 0.3-2% of the general population. Complications such as hemorrhage, bowel obstruction, inflammation, perforation, intussusception, volvulus and malignant transformation develop in only 4-4.8% of all patients, with most cases presenting in childhood, while relative risk decreases during life. The aim of the present study is to present our experience in managing a 15-year old male patient with Meckel's diverticulum covered perforation. It was a case of disguised perforation of the Meckel's diverticulum, with development of adhesions to the anterior surface of the right third of the transverse colon, which was successfully treated on the basis of emergency. Diagnosis was made intraoperatively and was documented by histological examination of the excised diverticulum.