Rectourethral Fistula after Posterior Urethral Valves Ablation in an Infant: A Rare Complication.

Acquired rectourethral fistula (RUF) is a rare but major complication of posterior urethral valve ablation. We present a case of a 1-year-old boy managed in a staged manner by completion of posterior urethral valves ablation, colostomy, RUF division through anterior sagittal transanorectal approach, and stoma closure. The child is continent for urine and feces.

Can Neonatal Pull-through Replace Staged Pull-through for the Management of Anorectal Malformation? A Systematic Review and Meta-analysis.

Anorectal malformations (ARMs) are managed classically in three stages - colostomy at birth, anorectal pull-through after 2-3 months, and stoma closure. Single-stage pull-through has been contemplated in neonatal age aimed to reduce the number of procedures, better long-term continence, the better psycho-social status of the child, and reduced cost of treatment, especially in resource-strained countries. We conducted a systematic review comparing neonatal single-stage pull-through with stage pull-through and did a meta-analysis for the outcome and complications. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. PubMed and Scopus databases were searched and RevMan 5.4.1 was used for the meta-analysis. Fourteen comparative studies including one randomized controlled trial were included in the systematic review for meta-analysis. The meta-analysis included 1845 patients including 866 neonates undergoing single-stage pull-through. There was no statistically significant difference for the occurrence of surgical site infection (odds ratio [OR] 0.82, 95% confidence interval [CI]: 0.24-2.83), urinary tract injury (OR 1.82, 95% CI: 0.85-3.89), rectal prolapse (OR 0.98, 95% CI: 0.21-5.04), anal stenosis/stricture, voluntary bowel movements (OR 0.97, 95% CI: 0.25-3.73), constipation (OR 1.01, 95% CI: 0.61-1.67), soiling (OR 0.89, 95% CI: 0.52-1.51), mortality (OR 1.19, 95% CI: 0.04-39.74), or other complications. However, continence was seen to be better among patients undergoing neonatal pull-through (OR 1.63, 95% CI: 1.12-2.38). Thus, we can recommend single-stage pull-through for managing patients with ARMs in the neonatal age.

To Compare Short-term Surgical Outcome among Patients given Continuous Postoperative Antibiotic Prophylaxis and those given no Postoperative Antibiotics after Urethroplasty for Hypospadias: A Pilot Study.

Introduction: There is no well-accepted guideline or uniform practice for the usage of prophylactic antibiotics along with urethroplasty for hypospadias. As antibiotic resistance is growing, it is imperative to rationalize the usage of antibiotics when a patient is operated for hypospadias. Aims and Objectives: The study is aimed at finding if there is any difference in outcome if prophylactic antibiotics are given after urethroplasty for hypospadias. Study Design: Prospective randomized controlled study. Material and Methods: Forty patients between 6 months and 12 years of age were included in the pilot study. All patients received a single preoperative antibiotic and surgery as per the discretion of the operating surgeon. The participants were randomly assigned to Group A or B, Group A not receiving any prophylactic antibiotic after surgery, and Group B receiving prophylactic antibiotics till indwelling urethral catheter was in situ as per the present antibiotic policy of the institute. The patients were followed up clinically at catheter removal, 1 week after surgery and 1 month after surgery. Urine was analyzed at the start of surgery and after catheter removal. Data were tabulated and analyzed using nonparametric Fischer's exact test with help of Epi Info™ v5.5.8. Results: Twenty-four patients were included in Group A and 16 in Group B. The clinical profile is presented in the detailed manuscript. Although pus cells could be demonstrated on urine examination in 82.5% of the study participants, only 10% grew organisms on culture media. No difference could be demonstrated among the two groups statistically. On following up with the patients for 1 month, the groups were comparable with respect to surgical site infections, and surgical complications such as urethrocutaneous fistula/dehiscence and thin stream. [Table: see text]. Discussion: There was a wide variability among practicing pediatric urologists in prescribing antibiotic prophylaxis for patients undergoing urethroplasty for hypospadias. In the Urologic Surgery Antimicrobial Prophylaxis Policy by the American Urology Association, no recommendation has been made with respect to urethroplasty. Our results are in concurrence with the available English literature which has not shown any benefit of prophylactic antibiotics after hypospadias repair. Conclusions: Antibiotics may not have a definite role in the prevention of surgical complications and it may be imperative to avoid unnecessary antibiotics to reduce antibiotic resistance.

Female with two perineal openings: Do not forget rectovaginal fistula.

Anorectal malformations (ARM) in females are identified by abnormal location of the anal opening. Management is guided by clinical examination to find the number of perineal openings. Two openings in the perineum of a female may be seen in cases of imperforate anus without fistula, vaginal agenesis with vestibular fistula or imperforate anus with recto-vaginal fistula (RVF). We present a case series of ARM with RVF and discuss their diagnosis and management.

Comparison of clinical outcome and anal manometry following laparoscopic-assisted anorectoplasty and posterior sagittal anorectoplasty in patients with high and intermediate anorectal malformation: A randomised controlled trial.

Introduction: High and intermediate types of anorectal malformations (ARMs) may be managed by either open posterior sagittal anorectoplasty (PSARP) or by laparoscopic-assisted anorectoplasty (LAARP). Most of the literature favours one approach over the other based on retrospective analysis. We performed this study with the aim to compare the short-term outcomes of both procedures. Materials and Methods: All paediatric patients with high and intermediate ARM were enrolled and randomised into two groups: open PSARP group and LAARP group. Outcome parameters such as faecal continence using Kelly's scoring system, anal manometric parameters and post-operative complications were compared between the groups. Results: A total of 16 patients were included with equal distribution in the open PSARP and LAARP group. Patient's variables were comparable in both the groups. Five patients developed immediate post-operative complications, three in the LAARP and two in the open group. The mean Kelly's score was 3.63 ± 1.6 versus 2.57 ± 1.9 (P = 0.132) for LAARP and PSARP group, respectively. The mean resting pressure was 34.71 ± 6.26 cm of H2O and 35 ± 6.16 cm of H2O (P = 0.384) in LAARP and open group, respectively. Rectoanal inhibitory reflex was demonstrated in 6/7 patients in LAARP group and 5/7 patients in open group. Conclusion: Faecal continence in patients undergoing either of the procedure is comparable. However, wound-related complications are lesser in LAARP procedure.

Correlation of Urethral Ratio and Bladder Wall Thickness with Cystoscopic Findings in Posterior Urethral Valve Patients to Assess Residual Valves.

Introduction: Posterior urethral valve (PUV) is life threatening congenital anomaly of urinary tract. Aim of the study was to correlate urethral ratio (UR) and bladder wall thickness (BWT) with cystoscopic findings in PUV patients to assess residual valves and to validate UR as a diagnostic tool for residual valves. It also aimed to assess the utility of bladder wall thickness in diagnosis of residual valves. Materials and Methods: A total of 31 patients were included in the prospective study done from 2017 to 2019. Calculation of UR was done in oblique VCUG films by dividing maximum posterior and anterior urethral diameter without the catheter insitu. Measurement of BWT was done at dome and bladder neck at full distension with feeding tube insitu and was done at same volume in follow up. The procedure was repeated at 3 months follow up. The findings were compared with cystoscopic findings for the status of residual valves as gold standard. Each patient served as control for self in the study. Results: Median age of presentation was 1 years with range of 1day to 10 years. The most common complains at the time of presentation in our study was straining (35.48%) followed by antenatally diagnosed patients (25.81%) and recurrent UTI (19.36%). Pre fulguration median UR was 2.45. Post Fulguration median UR was 1.20. It showed a statistically significant reduction (p < 0.001) after fulguration. Pre fulguration median BWT was 4 mm. Post fulguration median BWT was 2.5 mm. BWT showed a statistically significant reduction (p < 0.001) after fulguration as well. ROC curve was plotted for UR and BWT. BWT more than 1.95 mm (sensitivity-80%) and UR more than 1.2 (sensitivity-70%) indicates residual valves. Conclusion: A step ladder approach including BWT, UR and check cystoscopy can serve as a new diagnostic algorithm for the assessment of residual valves thereby avoiding extra radiation and general anesthesia exposure.

Hyponatremic-Hypertensive Syndrome in Ovarian Paraganglioma.

BACKGROUND: Hyponatremic-hypertensive syndrome (HHS) is characterized by combination of polyuria, polydipsia, hypertension, hyponatremia and hypokalemia in association with unilateral renal artery stenosis. CASE CHARACTERISTICS: A 10-year- old girl presented with polyuria, polydipsia, hypertension, hyponatremia, hypokalemia and proteinuria. Ultrasonography with doppler study revealed bilateral normal renal arteries. Completed tomography of abdomen detected a left adnexal mass, which was later confirmed as ovarian paraganglioma on histopathology. OUTCOME: After tumor excision, polyuria subsided and blood pressure normalized. MESSAGE: Hyponatremic-Hypertensive Syndrome does not always result from unilateral renal artery stenosis. High index of clinical suspicion with appropriate imaging technique may clinch rare endocrine causes of hypertension, like paraganglioma.

Mature cystic teratoma of liver.

A four-year-old boy presented with constipation and mild abdominal distention for one year. Radiologic investigations showed a multiloculated cystic lesion in the caudate lobe of liver with focal calcification in the wall. The child underwent laparotomy with marsupialization of the cystic lesion. Histopathologic examination showed mature teratoma of liver.

Spontaneous Biliary Perforations: An Uncommon yet Important Entity in Children.

Spontaneous or idiopathic biliary perforations are an infrequently encountered but an important cause of surgical jaundice in paediatric patients and one of the most common causes of surgical jaundice in infancy. A pre-operative diagnosis with a clinical history and physical findings may not be possible in most of the cases. The exact cause of the perforation remains unclear and the diagnosis is made at the time of laparotomy for an acute abdomen. An early, efficient and an effective surgical management is associated with a good prognosis; however, a delay in the correct diagnosis or an inappropriate management may result in bacterial contamination of the biliary ascites, with an unfavourable outcome. The relative rarity of this condition is reflected by the very few case reports, limited case studies and scarcity of published literature.

Urothelial polyps from anterior urethra in a prepubertal female child: a rare entity.

Urothelial polyps arising from the anterior urethra are rarely encountered in the pediatric age group and are even rarer in the females. Scarcely reported in English literature, their exact incidence is not known. They may be asymptomatic for years or present with features of urinary obstruction, mass or "vaginal" bleeding. They are important in the differential diagnosis of interlabial masses in female children. Anterior urethral polyps are benign fibroepithelial lesions. Surgery is indicated for relief of symptoms and differentiation from malignant lesions such as a sarcoma or a papilloma. No recurrences have been reported. We report a case of solitary anterior urethral polyp in an 8-year old girl managed successfully at our centre.

Imaging features of pediatric musculoskeletal tuberculosis.

Tuberculosis (TB) is widely prevalent in developing nations and has recently made a comeback in industrialized countries, with the rise in immunocompromized patients. Musculoskeletal TB in children presents a diagnostic challenge because it is difficult to recognize in the early stages of the disease, and imaging features mimic other entities. The clinical onset is insidious, with an indolent course and a resultant late presentation. It leads to significant morbidity; a delay in diagnosis can cause potentially serious neurological complications and bone and joint destruction. Conventional radiographs are the initial imaging modality and US, CT and MRI are used in conjunction to better delineate the disease extent and morphology. Radiologists should be familiar with the spectrum of imaging features of TB, including plain radiographs and MRI, and aid the clinician in making an early diagnosis. Aspiration or biopsy with examination for acid-fast bacillus and histological evaluation is required to confirm the diagnosis.

Prognostic factors determining mortality in surgical neonates.

BACKGROUND: To assess the prognosis of surgical neonates at admission and the factors responsible for mortality in neonates. MATERIAL AND METHODS: A prospective study was conducted in a tertiary level hospital over 15 months and various clinical and biochemical parameters were collected and analyzed using STATA(®) and SPSS(®). RESULTS: On multivariate analysis of 165 neonates, early gestational age, respiratory distress and shock at presentation were the factors of poor prognosis in neonates. The factors could be related to poor antenatal care and sepsis acquired before transfer of the baby to the nursery. CONCLUSION: The improvement in antenatal care and asepsis during transfer and handling the babies is of utmost importance to improve the prognosis of surgical neonates.

Intercostal variant of lumbar hernia in lumbocostovertebral syndrome: our experience with 6 cases.

Lumbocostovertebral syndrome (LCVS) is a rare type of congenital lumbar hernia. Its features include lumbar hernia associated with genitourinary, vertebral, and rib anomalies. Less than 25 cases have been reported to date. We describe the clinical manifestations and associated anomalies in 6 cases of LCVS managed by us. The patients with suspected LCVS syndrome should be evaluated by detailed clinical history, examination, conventional radiography, magnetic resonance imaging spine, ultrasound abdomen, and echocardiography. The defect can be repaired using local tissues in infancy. There is a need for long-term follow-up for possible late recurrence and scoliosis.

Evaluation of optimal acquisition duration or injected activity for pediatric 18F-FDG PET/CT.

UNLABELLED: Pediatric (18)F-FDG dosing and acquisition durations are generally based on coarse extrapolation from adult guidelines. This study sought to determine whether shorter acquisition durations or a lower (18)F-FDG injected activity could be used for pediatric (18)F-FDG PET/CT examinations while maintaining diagnostic utility. Reduction of overall scan time potentially reduces motion artifacts, improves patient comfort, and decreases length of sedation. Alternatively, decreased (18)F-FDG dose minimizes radiation risk. METHODS: Fourteen whole-body (18)F-FDG PET/CT examinations were performed on 13 patients (weight, 13-109 kg; age range, 1-23 y) with a weight-based injected activity (5.3 MBq/kg [0.144 mCi/kg]), fixed acquisition durations (3 min/field of view [FOV] if < 22 kg, 5 min/FOV if > 22 kg), and list-mode acquisition. For each examination, the list-mode data were truncated to form multiple datasets with shorter acquisition durations down to a minimum of 1 min/FOV (i.e., 1, 2, 3, 4, and 5 min/FOV data were formed from single 5 min/FOV acquisition). Fifty-six image volumes were generated, randomized, and reviewed in a masked manner with corresponding CT image volumes by 5 radiologists. Overall, subjective adequacy and objective lesion detection accuracy by body region were evaluated. RESULTS: All examinations with maximum acquisition duration were graded as adequate and were used as the reference standard for detection accuracy. For patients less than 22 kg, 1 of the 3 PET/CT examinations was graded as inadequate for clinical tasks when acquisition duration was reduced to 2 min/FOV, and all examinations were graded as inadequate when reduced to 1 min/FOV. For patients more than 22 kg, all 3-5 min/FOV studies were graded as adequate, and 2 of the 9 studies were graded as inadequate for 2 min/FOV studies. Lesion detection accuracy was perfect for acquisition times between 3 min/FOV and 5 min/FOV for all regions of the body. However, lesion detection became less accurate when imaging acquisition time was reduced more than 40%. CONCLUSION: Evaluation of image volumes generated from simulated shorter acquisition durations suggests that imaging times for larger patients (>22 kg) can be reduced from 5 min/FOV to 3 min/FOV without a loss of diagnostic utility. Using decreased acquisition times as a surrogate for (18)F-FDG dose, (18)F-FDG dose can be reduced by approximately 40% when all patients were scanned for 5 min/FOV.

Epidermoid cyst of clitoris mimicking clitoromegaly.

Clitoromegaly in pediatric and adolescent age group is usually indicative of a disorder of sexual differentiation. We report a girl child presenting with clitoral enlargement due to an epidermoid cyst. The cyst was excised with complete cosmetic recovery.

Neuroimaging in the clinical diagnosis of dementia: observations from a memory disorders clinic.

OBJECTIVES: To determine how often neuroimaging confirms, clarifies, or contradicts initial diagnoses of late-life cognitive disorders. DESIGN: Retrospective case review. SETTING: Outpatient clinic specializing in memory disorders. PARTICIPANTS: One hundred ninety-three consecutively referred cognitively impaired patients. MEASUREMENTS: Diagnoses using research criteria were developed for each patient at the first visit and ranged from cognitive impairment without dementia to dementias of single, complex, or indeterminate etiology. Structural (noncontrast magnetic resonance imaging) and perfusion (technetium-99m ethyl cysteine dimer single photon emission computed tomography) images were categorized together as normal, suggestive of specific diseases, or abnormal/not diagnostic. RESULTS: When a single neurodegenerative disease was suspected clinically (n=94), imaging confirmed the diagnosis in 50, contradicted the diagnosis in 32, and was abnormal/not diagnostic in 12. When more than one neurodegenerative etiology was clinically suspected (n=21), imaging assigned a single diagnosis in 13 and only cerebrovascular disease in one and was abnormal/not diagnostic in seven. In dementia not otherwise specified (NOS) (n=33), imaging suggested a specific etiology in 23 and was abnormal/not diagnostic in 10. Abnormal/not diagnostic images were more common in cognitive disorder NOS (n=25, 68%) than in other clinical groups (22%, chi-square=22.8 P<.001). Neuroimaging indicators of cerebrovascular disease were common (60% prevalence) but not predicted by the presence of vascular risk factors alone. CONCLUSION: Overall, neuroimaging confirmed, clarified, or contradicted the initial clinical diagnosis in more than 80% of patients, whereas fewer than 20% had abnormal/not diagnostic patterns. Imaging suggested a complex dementia etiology in 21% of cases clinically thought to be caused by a single process, whereas 46% of complex clinical differential diagnoses appeared to reflect a single causal pattern. Further work is needed to determine whether refinement of clinical diagnoses using specialized neuroimaging improves clinical decision-making and patient outcomes.