Non-absorbable sutures are associated with lower recurrence rates in laparoscopic percutaneous inguinal hernia ligation.

INTRODUCTION: Laparoscopic hernia repair with percutaneous ligation of the patent processes vaginalis is a minimally invasive alternative to open inguinal herniorrhaphy in children. With the camera port concealed at the umbilicus, this technique offers an excellent cosmetic result. It is also faster than the traditional laparoscopic repair with no differences in complication rates or hospital stay. The goal of this study was to describe a series of consecutive patients, emphasizing the impact of suture materials (absorbable vs. non-absorbable) on hernia recurrences. METHODS: A retrospective review was performed of consecutive transperitoneal laparoscopic subcutaneous ligations of a symptomatic hernia and/or communicating hydrocele by 4 surgeons. Patients > Tanner 2 or with prior hernia repair were excluded. The success of the procedure and number of sutures used was compared between cases performed with absorbable vs. non-absorbable suture. Risk factors for surgical failure (age, weight, number of sutures used, suture type) were assessed with logistic regression. RESULTS: 94 patients underwent laparoscopic percutaneous hernia ligation at a mean age of 4.9 years. Outcomes in 85 (90%) patients with 97 hernia repairs at a mean of 8 months after surgery revealed 26% polyglactin vs 4% polyester recurrences (p = 0.004) which occurred at mean of 3.6 months after surgery, Table 1. Repairs performed with non-absorbable suture required only 1 suture more often than those performed with absorbable suture (76% vs 60%, p = 0.163). Logistic regression revealed suture type was an independent predictor for failure (p = 0.017). Weight (p = 0.249), age (p = 0.055), and number of sutures (p = 0.469) were not significantly associated with recurrent hernia. DISCUSSION: Our review of consecutive hernia repairs using the single port percutaneous ligation revealed a significantly higher recurrent hernia rate with absorbable (26%) versus non-absorbable (4%) suture. This finding remained significant in a logistic regression model irregardless of number of sutures placed, age, and weight. Though the authors acknowledge the drawback of the potential for learning curve to confound our data, we still feel these findings are clinically important as this analysis of outcomes has changed our surgical practice as now all providers involved perform this procedure with exclusively non-absorbable suture. We thus suggest that surgeons who perform this technique, especially those newly adopting it, use non-absorbable suture for optimal patient outcomes. CONCLUSIONS: Recurrent hernia after laparoscopic percutaneous hernia ligation was significantly lower in repairs performed with non-absorbable suture. Based on this data, we recommend the use of non-absorbable suture during laparoscopic ligation of inguinal hernias in children.

Renal damage detected by DMSA, despite normal renal ultrasound, in children with febrile UTI.

OBJECTIVES: 2011 American Academy of Pediatrics guidelines recommended renal-bladder ultrasound (RBUS) as the only evaluation after febrile urinary tract infection (FUTI) in infants aged 2-24 months. We determined the sensitivity, specificity, and false negative rate of RBUS to identify DMSA-detected renal damage in this age group as well as in older children. METHODS: Consecutive patients referred to pediatric urology with a history of FUTI underwent DMSA ≥ 3 months after FUTI. Abnormal RBUS was defined as: Society of Fetal Urology hydronephrosis grades I-IV; hydroureter ≥ 7 mm; renal scar defined as focal parenchymal thinning; and/or size discrepancy ≥ 1 cm between kidneys. Abnormal DMSA was presence of any focal uptake defects and/or split renal function < 44%. We calculated sensitivity, specificity, positive and negative predictive values, and false negative rates of RBUS compared to DMSA. RESULTS: 618 patients (79% female), median age 3.4 years, were referred for FUTIs. Of the 512 (83%) with normal RBUS, 99 (19%) had abnormal DMSA. Children with normal RBUS after their first FUTI had abnormal DMSA in 15/151 (10%) aged ≤ 24 months and 23/119 (19%) aged > 24 months. RBUS had poor sensitivity (34%) and low positive predictive value (47%) to identify patients with renal damage. 99/149 (66%) children with renal damage on DMSA had normal RBUS. CONCLUSION: After FUTI, 66% of children with reduced renal function and/or renal cortical defects found by DMSA scintigraphy had a normal RBUS. Since abnormal DMSA may correlate with increased risk for VUR, recurrent FUTI and renal damage, our data suggest RBUS alone will fail to detect a significant proportion of patients at risk. The data suggest that imaging after FUTI should include acute RBUS and delayed DMSA, reserving VCUG for patients with abnormal DMSA and/or recurrent FUTI.

Ureterocystoplasty: indications for a successful augmentation.

PURPOSE: We evaluate the outcome of ureterocystoplasty based on preoperative evaluations. MATERIALS AND METHODS: We reviewed preoperative ultrasound, voiding cystourethrography and preoperative/postoperative urodynamic studies (UDS) in 64 patients undergoing ureterocystoplasty. RESULTS: Augmentation was performed with the distal 5 to 8 cm of a single megaureter in 8 patients without and 16 with grade 4 to 5/5 reflux. Median gain or loss in capacity and compliance was +0.14-fold and -0.11-fold, respectively. Re-augmentation has occurred or is pending in 23 cases (92%). Augmentation was performed in 40 patients with either a complete single or double collecting system. In 9 patients without reflux the diameter of the augmenting system was directly related to success. None of 6 with a ureteral diameter of greater than 1.5 cm required re-augmentation (median increase in bladder capacity and compliance 6 and 50-fold, respectively). Ureterocystoplasty was inadequate in 3 patients with a ureteral diameter of less than 1.5 cm and re-augmentation was required. In 31 patients with reflux, preoperative UDS of the entire system was beneficial. If the system had either normal or mild noncompliance (greater than 20 ml/cm H2O) ureterocystoplasty improved compliance 1-fold (6 cases) and re-augmentation not required. If UDS showed moderately or severely noncompliant system (less than 20 ml/cm H2O, 26 cases) ureterocystoplasty increased capacity and compliance by 0.4-fold (40%) and 0.25-fold (25%), respectively. Re-augmentation has occurred or is pending in 21 of 26 cases (81%). CONCLUSIONS: Ureterocystoplasty with any single or double collecting system is warranted in patients without reflux and a ureteral width greater than 1.5 cm, and in patients with reflux and mild noncompliance (greater than 20 ml/cm H2O) on UDS.

Tubularized incised-plate urethroplasty for proximal hypospadias.

OBJECTIVE: To report the experience of one surgeon using tubularized incised-plate (TIP) urethroplasty to repair proximal hypospadias in a consecutive series of boys. PATIENTS AND METHODS: The records of 33 consecutive patients with midshaft to scrotal hypospadias undergoing TIP repair by one surgeon were reviewed. Dorsal plication was used as necessary for penile straightening, to preserve the urethral plate. Standard TIP urethroplasty was undertaken, and the follow-up included the selective use of neourethral calibration and urethroscopy. RESULTS: Plication was necessary in 18 (55%) patients. The incised plate had a supple appearance in all but two boys. The mean (range) follow-up was 9 (1-48) months and included calibration in 16 (48%) and urethroscopy in 13 (39%) patients. Complications were noted in 11 (33%) boys, of whom seven (21%) developed small fistulae. The two patients in whom the incised plate appeared unhealthy had dehiscence of the repair and contracture of the neourethra with recurrent penile curvature, respectively. There was one meatal stenosis and one short neourethral stricture. CONCLUSIONS: TIP urethroplasty can be used to repair proximal hypospadias in the absence of severe penile curvature, and if the incised urethral plate has a supple appearance. As with distal hypospadias repair, the procedure creates a normal-appearing penis with a slit-like meatus.

Regular dilatation is unnecessary after tubularized incised-plate hypospadias repair.

OBJECTIVE: To determine if patients who undergo tubularized incised-plate (TIP) urethroplasty need regular dilatation to prevent neourethral strictures or meatal stenosis. PATIENTS AND METHODS: The follow-up of two consecutive series of patients who underwent primary TIP hypospadias repair by one surgeon was reviewed. The first 72 patients (group 1) had periodic neourethral calibrations for 1 year after repair, while the next 62 patients (group 2) had no routine dilatation, except for six patients (10%) in whom the meatus appeared to be small. Urethroscopy was performed in both groups at the time of fistula repair, skin revisions or during anaesthesia for unrelated procedures. RESULTS: There was no evidence of scarring in group 1; one case of meatal stenosis and one neourethral stricture were detected in group 2. The difference in outcome was not statistically significant (P = 0.4). Overall, the incidence of meatal stenosis was low (0.7%) and comparable with most recent series in which postoperative calibration was not used routinely. CONCLUSION: Dilatation of the neourethra is unnecessary after TIP urethroplasty. Calibration or uroflowmetry 6 months after surgery may be useful to detect subclinical obstruction.

Tubularized incised-plate urethroplasty for hypospadias reoperation.

OBJECTIVE: To review our preliminary results of tubularized incised-plate (TIP) urethroplasty for reoperative hypospadias repair. PATIENTS AND METHODS: The study comprised 15 patients, of whom eight had undergone a previous repair by techniques that included incision into the midline of the urethral plate, while in the remaining seven the midline of the plate had been left undisturbed. The meatus at reoperation was subcoronal or on the distal shaft in all but one boy, who had a midshaft hypospadias. All had previously undergone one attempt at hypospadias repair, except for one patient presenting after two failed 'meatal advancement and glanuloplasty incorporated' procedures. The TIP repair was undertaken as described for primary surgery, except that the dorsal dartos flaps for interposition between the neourethra and skin closure were available less often. RESULTS: TIP resulted in a functional neourethra and a cosmetically normal meatus in 13 of the 15 patients. One boy healed with a slightly rounded meatus and the other had wound dehiscence; fistulae developed in another two boys, giving three patients with complications. The fistulae occurred in boys whose original surgery did not include urethral plate incision, while the dehiscence was in a patient with partial excision of the plate during previous tubularized preputial flap repair. CONCLUSIONS: TIP urethroplasty can potentially be used for hypospadias reoperation. Previous incision of the urethral plate was not a contraindication in these selected cases in which the plate appeared supple. However, TIP repair should be avoided in repeat hypospadias surgery if the plate has been resected or is obviously scarred.

Long-term followup of the hematuria-dysuria syndrome.

PURPOSE: The hematuria-dysuria syndrome is the most common reported complication of gastrocystoplasty. We reviewed our cases of gastrocystoplasty to determine the long-term incidence and significance of the syndrome. MATERIALS AND METHODS: We performed a retrospective study of 78 patients who underwent gastrocystoplasty at our institution between July 1989 and October 1994. A total of 72 of the 78 cases were evaluated within the last year to elicit symptoms of the hematuria-dysuria syndrome. RESULTS: Spina bifida and bladder exstrophy were the most common diagnoses of patients undergoing gastrocystoplasty. There were 3 (4%) patients who required medications on a continuous basis to control symptoms of the hematuria-dysuria syndrome. However, using broad criteria 17 (24%) patients would be categorized as having the syndrome. Of these patients 9 did not require any medications and 4 occasionally took medications to control symptoms. A significant increase in the incidence of the hematuria-dysuria syndrome was detected in those cases with a sensate compared to those with an insensate urethra. CONCLUSIONS: The hematuria-dysuria syndrome is a clinically significant problem at long-term followup in a small percentage of patients treated with gastrocystoplasty. The lowest incidence is in those children with an insensate urethra who are continent. When symptoms occur they are easily treated in the majority of cases. We believe that gastrocystoplasty remains a viable option in the armamentarium of bladder augmentation.

Hypertension associated with multicystic dysplastic kidney in children.

PURPOSE: The results of nephrectomy for hypertension in 4 children with unilateral multicystic dysplastic kidney are presented. MATERIALS AND METHODS: The records of 3 boys and 1 girl 4 months to 4 years old with multicystic kidney and documented systolic hypertension leading to nephrectomy were reviewed. RESULTS: Blood pressure normalized after surgery in 2 patients and remained persistently elevated in the other 2. CONCLUSIONS: Children with multicystic dysplastic kidney should be screened for hypertension. Nephrectomy resolves hypertension in some patients with multicystic kidney.

Systemic zygomycosis caused by Apophysomyces elegans.

A case of systemic zygomycosis caused by Apophysomyces elegans in a 56-year-old man is described. The left kidney and the bladder showed presence of broad, nonseptate-to-infrequently septate hyphae in both the bladder lesion and in the septic kidney. Surgical debridement and treatment with amphotericin B cured the infection. No underlying immune defect was ever demonstrated, and the patient was not hyperglycemic or acidotic at any time. This zygomycetous fungus closely resembles Absidia corymbifera, but is distinguished by its distinctive morphological features.