Post-urethroplasty complications in hypospadias repair: a systematic review and meta-analysis comparing polydioxanone and polyglactin sutures.

Background: Polyglactin (PG) and polydioxanone (PDS) sutures are extensively used based on the surgeon's preference. The development of post-reconstruction urethrocutaneous fistula (UCF) is variably attributed to the choice of suture material for urethroplasty. This meta-analysis compares complications of hypospadias repair using PG and PDS sutures. Methods: The systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The authors conducted thorough searches in databases including MEDLINE, EMBASE, CENTRAL, Scopus, Google Scholar, and clinical trial registries. Outcome measures included UCF, meatal stenosis, wound infection, urethral stricture, glans dehiscence, and overall complications. Quantitative analysis was used with fixed or random-effect models to find the pooled risk ratio and I2 heterogeneity. Results: The criteria for inclusion were met by five comparative studies with the inclusion of 1244 children altogether. Pooled analysis failed to show a statistically significant difference in the incidence of meatal stenosis, urethral stricture, wound infection, and total complications using PG and PDS sutures. However, it showed a reduction in the incidence of UCF with PDS suture hypospadias repairs (risk ratio=0.66, 95% CI 0.48 to 0.92). Conclusions: PDS sutures are associated with decreased incidence of UCF than PG after hypospadias repair. The incidence of meatal stenosis, urethral stricture, wound infection, and total complications was not affected by the type of suture material used for repair. Clinical implications: This meta-analysis suggests decreased incidence of UCF when PDS sutures are used for hypospadias repair which may impact the choice of suture material for repair. PROSPERO registration number: CRD42023409710.

Tubularized incised plate urethroplasty and grafted tubularized incised plate urethroplasty: systematic review, meta-analysis and trial sequential analysis.

Background: Hypospadias is one of the most common genital birth defects. There are around 300 various techniques available for the repair of hypospadias. This study aims to compare the reported outcomes of Tubularized incised plate urethroplasty (TIP) and Grafted TIP (GTIP) repair in children undergoing primary hypospadias repair. Methods: This meta-analysisadhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and we framed our research question using the population, intervention, control and outcomes format. We conducted comprehensive electronic searches across various databases, employing a Boolean search strategy with predefined search terms. Only randomized controlled trials (RCTs) were included for quantitative analysis. Results: Totally, 10 RCTs met our inclusion criteria for quantitative analysis. The results indicated that urethrocutaneous fistula, glans dehiscence, and stricture rates were comparable between the two groups. The incidence of meatal stenosis was found to be significantly lower in the GTIP group with a relative risk (RR) of 0.32 (95% confidence interval (CI) 0.15 to 0.67). Conclusion: The coucomes UCF, glans dehiscence, and stricture rates were comparable between the two groups. Notably, the incidence of meatal stenosis was found to be significantly lower in the grafted TIP group. In terms of operative time, our quantitative synthesis demonstrated that the TIP group had a shorter operative time than the GTIP group with significant heterogeneity.

Techniques of staged laparoscopic orchidopexy for high intra-abdominal testes in children: A systematic review and meta-analysis.

Background: Laparoscopic exploration is currently considered the gold standard for managing nonpalpable intraabdominal testes. The problem of short vascular pedicle is addressed in Fowler-Stephen (FS) technique by the division of testicular vessels and in Shehata technique (ST) by traction on testicular vessels. There is a lack of the consensus among pediatric surgeons on the choice of one technique over other. This analysis compares the reported outcomes of staged laparoscopic orchidopexy by ST with the time tested FS technique in managing high intraabdominal undescended testis. Materials and Methods: The present systematic review and meta-analysis was conducted as per the preferred reporting items for the systematic review and meta-analyses guidelines. Only randomized controlled trials and comparative studies were included. The primary outcomes compared were the incidence of testicular atrophy, testicular retraction/ascent rate, and operative time of Stage I and Stage II orchidopexy. Results: The present analysis was based on three randomized studies with a total of 119 undescended testes in 117 patients satisfying the inclusion criteria. The operative time was less in Stage I FS technique; however, there was no statistically significant difference in operative time of both procedures during the Stage II laparoscopic orchidopexy. Pooled analysis of postintervention testicular atrophy, testicular retraction rate, and duration of postoperative hospitalization showed no difference between both procedures. Conclusion: Both FS and STs are comparable in terms of postintervention testicular atrophy, testicular retraction/ascent; however, the mean operative time is significantly less with FS technique in Stage I laparoscopic orchidopexy.

Single dartos flap versus double dartos flap in hypospadias repair: A systematic review and meta-analysis with trial sequential analysis and fragility index.

INTRODUCTION: Hypospadias is a common congenital urogenital anomaly. Despite advancements in surgical techniques, still it presents challenges in management. An important aspect of hypospadias repair is the use of protective layers to cover neourethra. This review focuses on comparing the Single Dartos Flap (SDF) and Double Dartos Flap (DDF) techniques, used to cover the neourethra. These techniques differ in terms of the number of dartos layers used to cover the neourethra. METHODS: This systematic review, follows PRISMA guidelines, included six RCTs from PubMed/MEDLINE, Cochrane Library, Scopus, Web of Science, and CINAHL. Patients with hypospadias repair with use of SDF or DDF were analyzed for outcome, Urethrocutaneous fistula, meatal stenosis, glans dehiscence, penile torsion and cosmetic outcomes. Statistical analysis was done using Review Manager, with TSA and FI ensuring result robustness. RESULTS: Six studies met inclusion criteria, and risk of bias assessment indicated low risk across all domains. Meta-analysis results favored DDF over SDF for reducing urethrocutaneous fistula (RR 0.37, 95% CI 0.20-0.68) but showed no significant difference in meatal stenosis and glans dehiscence. DDF also associated with lower risk of penile torsion (RR 0.05, 95% CI 0.01-0.35). CONCLUSION: The systematic review, based on randomized controlled trials (RCTs), provides evidence supporting the use of DDF over SDF in hypospadias repair, particularly in distal hypospadias using the TIP procedure. The article emphasizes the potential advantages of DDF in reducing UCF but further robust evidence is needed to confirm these results based on the findings of TSA and FI.

Solitary osteochondroma of the rib: An unusual chest wall tumor in the pediatric age group.

Pediatric chest wall tumors are unusual and can arise from bone structures or from adjacent soft tissues. Osteochondroma is a benign cartilaginous tumor arising from the metaphysis of bone; however, it is more common in extremity rather than in membranous bone. Although benign, osteochondroma of the rib may lead to fatal complications such as pneumothorax, hemothorax, fractures, and pleural or pericardial effusion. Therefore, some form of surgical management becomes necessary to treat these lesions. We present a case of 7-year-old female child with solitary osteochondroma of the rib. The tumor was surgically excised and the child is asymptomatic on follow-up.

Use of an Autologous Platelet-Rich Concentrate in Hypospadias Repair: A Systematic Review and Meta analysis.

Background: There is unanimous agreement amongst hypospadias surgeons to use an intermediate layer to cover the neourethra. Dartos fascia and tunica vaginalis (TV) flaps are the most preferred tissues to be used. Tissue glue, sealants and biomaterials are also useful where there is a paucity of local tissue to cover the neourethra. But these blood-derived products have associated infectious and allergic risks. The autologous human platelet concentrate (APC) contains biologically active factors and is safe for wound healing and soft tissue reconstruction. It has been used by few surgeons as an intermediate layer in hypospadias repair. This systematic review and meta-analysis aim to systematically compare the outcomes of hypospadias surgery in children with or without using APCs. Methods: This systematic review and meta-analysis was conducted as per the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Meta-analysis protocol was registered with INPLASY. A systematic, detailed search was carried out by the authors in the electronic databases, including Medline, Embase, CENTRAL, Scopus, Google Scholar and clinical trial registry. Studies were selected and compared based on primary outcome measures like urethra-cutaneous fistula, meatal stenosis, wound infection and operative time. Statistical analysis was performed using a fixed-effect model, pooled risk ratio and I2 heterogeneity. Results: Four randomized studies with a total of 355 patients were included. Pooled analysis for outcome of urethra-cutaneous fistula (UCF) showed no significant difference between the groups with APC and without APC. Pooled analysis for the other outcome like meatal stenosis, wound infection and total complications showed a decrease in incidence of these complications in groups with APC. Conclusion: This meta-analysis shows that there is a reduction in the incidence of wound infection, meatal stenosis and total complications in patients where APC was used to cover the neourethra, although no such difference was observed in UCF rates.

The comparison of interrupted and continuous suturing technique in Snodgrass urethroplasty in patients with primary hypospadias: A systematic review and meta-analysis.

Background: Hypospadias is among the common congenital anomalies in boys. Snodgrass urethroplasty is one of the most popular techniques for correcting distal and mid hypospadias. Although there is consensus among pediatric surgeons on using absorbable sutures for urethroplasty, there are no established guidelines about the suturing techniques (interrupted suturing [IS] or continuous suturing [CS]) for neourethra creation in Snodgrass urethroplasty. This analysis aims to compare the reported outcomes of both the urethroplasty suturing techniques. Materials and Methods: This systematic review and meta-analysis was conducted as per the preferred reporting items for systematic review and meta-analyses guidelines. A systematic, detailed search was carried out by the authors in the electronic databases - MEDLINE, PubMed Central, Scopus, Google Scholar, and Clinical Trial Registry. Studies were selected and compared based on primary outcomes - development of urethrocutaneous fistula (UCF), meatal stenosis, and secondary outcomes - wound infection, urethral stricture, and operative time. Statistical analysis was performed using a fixed-effect model, pooled risk ratio, and I2 heterogeneity. Results: Five randomized studies with a total of 521 patients met our inclusion criteria. Pooled analysis for total complications, UCF, meatal stenosis, and wound infection showed no significant difference between the CS and IS groups. Subgroup analysis of patients with the use of polyglactin sutures showed a decrease in total complications and UCF in the IS group. Conclusion: There is no difference in total complication rates among the CS and the IS group with the use of absorbable sutures in Snodgrass urethroplasty; however, there is a decrease in the incidence of total complications and UCF in the IS group when polyglactin was preferred over polydioxanone suture for urethroplasty.

Delayed presentation of duodenal atresia.

Background: The most common type of duodenal atresia (DA) (Type I), also known as duodenal web or membrane can present later in infancy or early childhood if the membrane or web is fenestrated. We describe six patients with delayed presentation of DA. Materials and Methods: Retrospective review of hospital records of six patients with delayed presentation of DA due to fenestrated web managed in Paediatric Surgery Department at a tertiary care institute over a period of 2 years (January 2019 to December 2020) was done. The data of these patients were analysed on the basis of age at presentation, clinical presentation, associated anomalies, radiological findings, intra-operative findings, management and postoperative course. Results: The median age at presentation was 6.5 months (range: 1 month to 10 years). There were four males and two females. The most common presentation was emesis seen in all six patients. Two patients had Down syndrome. Associated congenital anomalies were cardiac in one patient, anterior ectopic anus in one patient and malrotation of midgut in one patient. Upper gastrointestinal contrast suggested incomplete duodenal obstruction in all patients. At laparotomy, fenestrated duodenal membrane was observed in all patients - preampullary in three patients and postampullary in three patients. Lateral duodenotomy, web excision and transverse closure was done in all six patients. The postoperative period was uneventful in all patients and mean duration of hospital stay was 9 days. Conclusion: Fenestrated duodenal webs present a diagnostic challenge to the paediatric surgeons because of delayed and variable clinical presentation. A modification of the present classification of DA has been proposed in this study which would help in better reporting of epidemiology and aid in early diagnosis of this congenital anomaly.

Bilateral Congenital Diaphragmatic Hernia in a Neonate Managed Surgically.

Bilateral congenital diaphragmatic hernia (CDH) is a rare birth defect associated with poor prognosis associated with pulmonary hypoplasia, pulmonary hypertension, and other congenital anomalies. We describe a female neonate with bilateral CDH who was successfully managed surgically. A brief review of literature is also described.

Large Congenital Epulis: A Neonatal Tumour with Striking Appearance, but Simple Management.

Background Congenital epulis is a benign tumor of upper gingiva. Larger lesions interfere with mouth closing and normal feeding and may obstruct airways. We present a neonate with a large epulis. Case Report: A full term 3 kg 5 days female baby had a 20 cm × 15 cm gingival mass protruding from the oral cavity, connected by a pedicle attached to right upper gingiva (Figure 1). Multiple trophic ulcers had developed in the mass after birth. Mouth closing and normal feeding were hampered. The mass was excised surgically and baby improved. Conclusion: A large congenital epulis, though worrisome to parents, can be satisfactorily managed by surgical excision and has a good prognosis.

Efficacy of fibrin sealant as waterproof cover in improving outcome in hypospadias surgery.

BACKGROUND: This prospective comparative study aims to assess the efficacy of fibrin sealant to improve outcomes in paediatric patients operated for hypospadias. MATERIALS AND METHODS: Forty consecutive patients with hypospadias were randomised into two groups of twenty patients each. The first group underwent hypospadias repair, technique depending on the type of hypospadias, whereas in the second group, fibrin sealant was used to reinforce the urethroplasty. Assessment was done with respect to the type of hypospadias, type of repair done, operative time, immediate post-operative complications (early ooze and skin flap-related complications), intermediate complications (urethra-cutaneous fistula) and delayed post-operative complications (penile torsion and poor cosmetic outcome) at follow-up. We also compared the overall improvement in outcome among the two groups. RESULTS: First Group: The mean operative time was 1 h and 45 min. Complications were seen in nine patients: Early ooze (n = 2); skin flap-related complications (n = 3); fistula (n = 7); poor cosmetic outcome (n = 7) and penile torsion (n = 4). Second Group (Fibrin Sealant): The mean operative time was 1 h and 30 min. Post-operative complications were observed in five patients: Coronal fistula (n = 3) and poor cosmetic outcome (n = 3). On comparing, the differences in outcomes of ooze, skin flap-related complications and torsion were found to be statistically significant with P < 0.05. The differences in the urethra-cutaneous fistula and cosmetic appearance were not found to be statistically significant. The difference in overall improvement in complications was found to be statistically significant. CONCLUSION: Fibrin sealant, when applied over the urethroplasty suture line as a waterproof cover, may help to improve the outcome in patients with hypospadias.

Congenital H-type tracheo-oesophageal fistula: An institutional review of a 10-year period.

BACKGROUND: Congenital H-type tracheo-oesophageal fistula (H-TOF ) accounts for 4%-5% of all congenital tracheo-oesophageal malformations. We present our experience in managing 18 cases with congenital H-TOF at a tertiary institute over a 10-year period. METHODS: Records of all patients with congenital H-TOF managed from January 2009 to December 2018 in the Department of Paediatric Surgery at a tertiary institute were retrospectively analysed based on the age at presentation, gender, antenatal ultrasonography findings; birth history; details of previous hospitalisations, previous treatment details, presenting symptoms and associated anomalies; time to diagnosis; radiological investigations performed, bronchoscopy findings, intraoperative details, complications and postoperative follow-up. RESULTS: Totally 18 patients with congenital H-TOF were managed over a 10-year period. There were 12 females and six males. Six patients had associated anomalies. There was wide variation in age at the start of symptoms (3 days-4 years) and presentation/referral to us (15 days-12 years). Four patients were diagnosed to have H-TOF at first admission. The most common presenting symptom was recurrent pneumonias (n=18). Bronchoscopy was done in all patients, and fistula was diagnosed and cannulated before surgery. The fistula was present at C8-T1 in 14 patients. The median age at surgery was 12 months. In 17 patients, the fistula was repaired by the cervical approach. There were two deaths, and 16 patients are doing well on median follow-up of 8 years. CONCLUSION: Congenital H-TOF should be considered in differential diagnosis while managing patients with recurrent lower respiratory tract infection and 'coughing and choking episodes'; early diagnosis and management of the associated H-TOF is important for improved survival and outcome.

Evaluation of tunica vaginalis free graft as a better alternative to tunica vaginalis pedicled flap for providing waterproof cover in Stage II hypospadias repair.

BACKGROUND: Tunica vaginalis (TV) flap has been used by many surgeons as a waterproof layer to cover neourethra. We present our experience in using free TV graft as an alternative to TV flap for providing waterproof cover in second-stage hypospadias repair. MATERIALS AND METHODS: A retrospective review of ten patients with severe hypospadias who underwent Stage II hypospadias repair over a period of 15 months was carried out. Free TV graft was used to cover neourethra in all the patients. RESULTS: The median age of patients was 3.5 years. Six patients had proximal hypospadias with severe chordee and four patients had peno-scrotal hypospadias. Eight patients had undergone Byars procedure and two patients had undergone Bracka's procedure during the first stage repair in the same institute. The mean operative time for Stage II repair using free TV graft was 150 min (standard deviation ± 15 min). All patients passed urine in good stream following stent/feeding tube removal. The average duration of hospital stay was 11 days. None of our patients developed urethrocutaneous fistula. Only one patient had superficial surgical site infection. All patients are well on follow-up after 6 months. CONCLUSION: Free TV graft could be used in place of TV flap as an intermediate waterproof cover to reduce the incidence of urethrocutaneous fistula in staged II hypospadias repair; however, studies involving a larger number of patients would be required to draw conclusions.

Accelerated Clearance and Degradation of Cell-Free HIV by Neutralizing Antibodies Occurs via FcγRIIb on Liver Sinusoidal Endothelial Cells by Endocytosis.

Neutralizing Abs suppress HIV infection by accelerating viral clearance from blood circulation in addition to neutralization. The elimination mechanism is largely unknown. We determined that human liver sinusoidal endothelial cells (LSEC) express FcγRIIb as the lone Fcγ receptor, and using humanized FcγRIIb mouse, we found that Ab-opsonized HIV pseudoviruses were cleared considerably faster from circulation than HIV by LSEC FcγRIIb. Compared with humanized FcγRIIb-expressing mice, HIV clearance was significantly slower in FcγRIIb knockout mice. Interestingly, a pentamix of neutralizing Abs cleared HIV faster compared with hyperimmune anti-HIV Ig (HIVIG), although the HIV Ab/Ag ratio was higher in immune complexes made of HIVIG and HIV than pentamix and HIV. The effector mechanism of LSEC FcγRIIb was identified to be endocytosis. Once endocytosed, both Ab-opsonized HIV pseudoviruses and HIV localized to lysosomes. This suggests that clearance of HIV, endocytosis, and lysosomal trafficking within LSEC occur sequentially and that the clearance rate may influence downstream events. Most importantly, we have identified LSEC FcγRIIb-mediated endocytosis to be the Fc effector mechanism to eliminate cell-free HIV by Abs, which could inform development of HIV vaccine and Ab therapy.

Congenital Hepatic Arteriovenous Malformation Presenting as Isolated Massive Hepatomegaly in an Otherwise Healthy Neonate: A Case Report.

Congenital hepatic arteriovenous malformations (HAVMs), though rare, carry high morbidity and mortality rates if left undiagnosed. The usual clinical presentation is in infancy with congestive heart failure, anaemia and hepatomegaly. There are reports of presentation as persistent pulmonary hypertension in newborns and reports of their spontaneous regression as well. We describe a healthy full-term neonate with HAVM who was presented with isolated massive hepatomegaly and underwent surgical ligation.

Paediatric Intussusception: A Clinical Scoring System to Predict the Risk of Operative Intervention.

BACKGROUND: Intussusception is a common cause of obstruction in paediatric patients. Rapid clinical recognition and treatment is important to prevent potentially fatal complications. The present study aims to derive a clinical scoring system for prediction of risk of operative intervention in patients with intussusception. MATERIALS AND METHODS: Data of 100 patients with intussusception were analyzed retrospectively, and a score was calculated based on clinical parameters - age, presence/absence of symptoms and signs such as abdominal distention, vomiting, lump abdomen, red currant jelly stools and duration of abdominal pain. The maximum score was 12, and the minimum score was 6. This score was then applied to other 50 consecutive patients with intussusception. RESULTS: Of 100, 13 patients required operative intervention; 87 patients were managed by hydrostatic reduction. In all, four patients with a score of 12 and five patients with a score of 11 required operative intervention. Seven patients had a score of 10, out of which four (57.14%) required operative intervention. A total of 87 patients who had a score of 10 or less were successfully managed non-operatively by ultrasound-guided hydrostatic reduction. In the next 50 patients, two patients with a score of 9 and all patients with scores of 10 and 11 required operative intervention. Thus, age less than 3 months and more than 2 years, presence of symptoms such as abdominal lump, red currant jelly stools and duration of abdominal pain of 2 or more days were strong predictors of operative intervention. CONCLUSION: This clinical score helps to predict the risk of operative intervention required in a child with a diagnosis of intussusceptions - duration of abdominal pain of 48 h or more, presence of abdominal distention and lump and red currant jelly stools are strong predictors of need of operative intervention in patients with intussusception. Higher the score (8 or more, as concluded by this study), more the probability of requiring operative intervention in these patients. Though limited, this study could serve as a pilot work to develop a user-friendly score for early surgical decision making in the management of paediatric intussusception.

Stapled vs Conventional Hand-sewn Gastrointestinal Anastomosis during Infancy: A Prospective Comparative Study from Central India.

BACKGROUND: The creation of a joint between two bowel ends in newborns and infants is one of the core surgical procedures in pediatric surgery. For a proper and perfect gastrointestinal (GI) anastomosis, the factors to be considered are intraoperative duration, restoration of normal GI function, effective hemostasis, reduction of tissue damage, and prevention of postoperative mortality and morbidity. The safety and efficacy of stapled GI tract anastomosis in adults have been extensively documented; however, available literature on the same is limited for infants. MATERIALS AND METHODS: Fifty-six patients were divided into two groups-stapled group and hand-sewn group. Patients operated on both emergency and elective basis were included in the study. Hand-sewn anastomosis was done by either end-to-end single-layer or double-layer anastomosis. Suture material used for the anastomosis was Vicryl 3-0 or Vicryl 4-0. Stapled anastomosis was done by 55 mm linear cutting GI stapler with side-to-side anastomosis. RESULTS: The present study included a total of 56 patients; there were 28 neonates and 28 infants; 37 of them were males. The most common clinical presentations were vomiting, abdominal distention, refusal to feed, and lethargy. The intraoperative duration in stapled GI anastomosis was less when compared to hand-sewn anastomosis, so was the return of bowel activity and consequently early initiation of feeds and shorter hospital stay. CONCLUSION: The present study favors stapled over hand-sewn GI anastomosis in infancy in view of decreased intraoperative duration, reduced blood loss, early return of peristalsis, early initiation of feeds, and shorter duration of hospital stay. However, a small number of patients and lack of matching are the shortcomings of this study. HOW TO CITE THIS ARTICLE: Mitra AS, Chandak U, Kulkarni KK, et al. Stapled vs Conventional Hand-sewn Gastrointestinal Anastomosis during Infancy: A Prospective Comparative Study from Central India. Euroasian J Hepato-Gastroenterol 2020;10(1):11-15.