Complication rates of proximal hypospadias: meta-analyses of four surgical repairs.

INTRODUCTION: Proximal hypospadias surgery is impacted by a high complication rate. The goal of this work was to assess the overall composite complication rate, fistula rate and stenosis rate following proximal hypospadias surgery realized according to onlay urethroplasty, Duckett, Koyanagi and Bracka techniques. METHODS: The databases MEDLINE, EMBASE, SCOPUS, Cochrane Library, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL) and Sciencedirect were searched. Studies had to report data about the mean age of population, the average duration of patient follow-up and the number of procedures required for surgical treatment of primary and proximal hypospadias. Two independent including one urologist reviewers screened all the articles and selected the articles to be included. RESULTS: Overall composite complication rates were 32%, 34%, 49%, and 43%, for Onlay urethroplasty, Duckett's tubularized flaps urethroplasty, Koyanagi repair and Bracka 2 stages repair, respectively. Fistula rates were 13%, 18%, 21% and 23% respectively. The heterogeneity of complication rates reported in the different studies was not moderated by age, country, or patient's continent origin. DISCUSSION: The classifications of complications used in articles were disparate and make comparisons between techniques difficult. The report of post-surgical complications in the literature is often poorly coded and follow-up times were often too short. CONCLUSION: This meta-analysis attempts to determine to the extent possible, given the serious weaknesses in the hypospadias literature, plausible estimates of complication rates after skin flap urethroplasty. The patched onlay skin flap, the Duckett's tubularized skin flap technique, the Koyanagi's technique, and the Bracka's two-stage urethroplasty procedure lead to very high complication rates. Reported complication rates are comparable across techniques.

Anti-reflux surgery in children with congenital diaphragmatic hernia: A prospective cohort study on a controversial practice.

INTRODUCTION: Gastro-esophageal reflux disease (GERD) is the most frequent long-term morbidity of congenital diaphragmatic hernia (CDH) survivors. Performing a preventive fundoplication during CDH repair remains controversial. This study aimed to: (1) Analyze the variability in practices regarding preventive fundoplication; (2) Identify predictive factors for fundoplication. (3) Evaluate the impact of preventive fundoplication on gastro-intestinal outcomes in children with a CDH patch repair; METHODS: This prospective multi-institutional cohort study (French CDH Registry) included CDH neonates born in France between January 1st, 2010-December 31st, 2018. Patch CDH was defined as need for synthetic patch or muscle flap repair. Main outcome measures included need for curative fundoplication, tube feed supplementation, failure to thrive, and oral aversion. RESULTS: Of 762 CDH neonates included, 81 underwent fundoplication (10.6%), either preventive or curative. Median follow-up was 3.0 years (IQR: 1.0-5.0). (1) Preventive fundoplication is considered in only 31% of centers. The rates of both curative fundoplication (9% vs 3%, p = 0.01) and overall fundoplication (20% vs 3%, p < 0.0001) are higher in centers that perform preventive fundoplication compared to those that do not. (2) Predictive factors for preventive fundoplication were: prenatal diagnosis (p = 0.006), intra-thoracic liver (p = 0.005), fetal tracheal occlusion (p = 0.002), CDH-grade C-D (p < 0.0001), patch repair (p < 0.0001). After CDH repair, 8% (n = 51) required curative fundoplication (median age: 101 days), for which a patch repair was the only independent predictive factors identified upon multivariate analysis. (3) In neonates with patch CDH, preventive fundoplication did not decrease the need for curative fundoplication (15% vs 11%, p = 0.53), and was associated with higher rates of failure to thrive (discharge: 81% vs 51%, p = 0.03; 6-months: 81% vs 45%, p = 0.008), tube feeds (6-months: 50% vs 21%, p = 0.02; 2-years: 65% vs 26%, p = 0.004), and oral aversion (6-months: 67% vs 37%, p = 0.02; 1-year: 71% vs 40%, p = 0.03). CONCLUSIONS: Children undergoing a CDH patch repair are at high risk of requiring a curative fundoplication. However, preventive fundoplication during a patch repair does not decrease the need for curative fundoplication and is associated with worse gastro-intestinal outcomes in children. LEVEL OF EVIDENCE: II - Prospective Study.

Professional practice assessment: establishment of an institutional procedure to treat blunt abdominal trauma in emergency pediatric department.

OBJECTIVE: The clinical process for the diagnosis of intra-abdominal lesion due to blunt abdominal trauma in children is not consistent. The goal of the present study was to assess the efficiency of our institutional procedure to manage hemodynamically stable pediatric patients with benign abdominal trauma and to select patients who need a radiological examination in an emergency pediatric department. MATERIAL AND METHODS: This was a prospective cohort study from June 2008 to June 2010 in a pediatric emergency department. Pediatric patients with benign abdominal trauma and with stable hemodynamic parameters were included in the study. We conducted first clinical examination and clinical laboratory assessment for blood count, platelet count, hematocrit, serum glutamo-oxalacétique transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), lipase and urine. A second clinical examination was performed 2 h later. Patients with biological abnormalities and/or with persistent pain underwent a computerized tomography (CT) of the abdomen. Our main criterion for judging was the presence of intra-abdominal lesion as revealed by the scan, which was considered as the gold standard. At the second clinical examination, patients without pain and with normal results for clinical laboratory assessment were sent home. A telephone call was made to the children 48 h after the visit to the hospital emergency department. The secondary criterion for judging was the absence of complication in children who did not undergo the scan. RESULTS: A total of 111 children were included. Seventy-five children underwent the complete procedure. Thirty-four scans were performed. The scan revealed that 22 patients had an intra-abdominal lesion. Multivariate analysis indicated that SGOT higher than 34 IU/L and the persistence of pain for more than 2 h from the initial evaluation of trauma favored the development of intra-abdominal lesion. On the basis of these two criteria, we developed a predictive diagnostic score for post-traumatic intra-abdominal injuries with a high negative predictive value. For children who were sent home without a radiological examination, no complications were observed at 48 h after the visit to the emergency department. CONCLUSION: The present protocol is a good approach to identify children at risk for intra-abdominal lesion who need a radiological examination and those who do not require any complementary examinations. The predictive diagnostic score could help young hospital doctors to assess blunt abdominal trauma.