[Cryptorchidism in children: Predictive factors of orchidopexy failure and postoperative testicular atrophy]. / La cryptorchidie chez l'enfant : facteurs prédictifs d'atrophie et de réascension testiculaires postopératoires.

INTRODUCTION: Outcomes of orchidopexy for undescended testes may be disappointing. The aim of our study was to identify predictive factors of testicular atrophy and orchidopexy failure. METHODS: It was a prospective monocentric study including all boys operated for undescended testes between January 2009 and December 2014. We have recorded for all boys: age at surgery, testes volume and position, epididymo-testicular fusion and spermatic vessels abnormalities, surgical technique, need for extensive cord dissection and tension-free orchidopexy. RESULTS: We have included 688 boys operated for undescended testes. The whole number of undescended testes was 816. Predictive factors for postoperative testicular atrophy in univariate analysis were: testicular position in deep inguinal orifice, intra-abdominal testes, hypotrophic preoperative testes, epididymo-testicular fusion and spermatic vessels abnormalities, laparoscopic orchidopexy, complete testicular vessels skeletonization and under-tension orchidopexy. In multivariate analysis, peroperative testicular hypotrophy and testicular position in deep inguinal orifice have been identified as independent factors of postoperative atrophy. Predictive factors for testicular reascension in univariate analysis were: intra-abdominal testis position, scrotal orchidopexy and under-tension orchidopexy. In multivariate analysis, no independent factor was identified. CONCLUSION: Peroperative testicular hypotrophy and testicular position in deep inguinal orifice have been identified as independent factors of postoperative atrophy. There was no independent predictive factor for postoperative testicular reascension. LEVEL OF PROOF: 2.

Quality of life of children operated for bladder exstrophy.

INTRODUCTION: Bladder exstrophy is a rare malformation with functional and psychological issues affecting children's quality of life. This study aims to evaluate the urinary continence and the quality of life of patients operated for bladder exstrophy in our institution. METHODS: This is a retrospective study including fifteen patients operated for bladder exstrophy between 1995 and 2015. All patients underwent a physical examination and an interview with a psychiatrist. Urinary continence was evaluated by dryness periods. Quality of life was evaluated by the QoL SF-36 scale. RESULTS: All patients underwent primary early bladder closure. Posterior osteotomy was performed initially in 6 cases, and during the redo surgery in 7 cases. Leakage was recorded in 4 cases, fistula in 9 patients. Twelve patients had one or more redo surgery. Final bladder closure success rate was of 80%. Additional continence surgical procedures were performed by a Young Dees technique in 8 cases and with bladder enlargement associated with Mitrofanoff continent derivation in 5 cases. Only two patients over fifteen did not use diapers. All the items of QoL score according SF-36 were under the normal value (75%) except physical functioning and physical limitation. These scores go worst with age. Scores were better for continent boys in both physical and psychological items, but the difference was not significant However, significant difference was observed between boys having less than 3 surgeries and those having more than three procedures. Psychological and social scores were better for girls than for boys and differences were significant. CONCLUSIONS: The risk of urinary incontinence is high in children managed for bladder exstrophy. Boys are more affected than girls with subsequent psychological and social repercussions. In our study, quality of life depends more on number of surgery than continence results. Psychological problems should be screened early for accurate treatment. LEVEL OF EVIDENCE: 3.

Ovarian masses in pediatric patients: a multicenter study of 98 surgical cases in Tunisia.

Ovarian masses requiring surgical intervention are uncommon in the pediatric population. Our aim is to report results of a multicentric Tunisian study concerning the clinical practice and the management of pediatric ovarian masses and to identify the factors that are associated with ovarian preservation. Between January 2000 and December 2015, 98 pediatric patients (<14 years) were surgically treated for ovarian masses at the five pediatric surgery departments in Tunisia. Ninety-eight patients were included in this study. The mean age of the patients at time of surgery was 8.46 ± 4.87 years. Sixty-three ovarian masses (64.3%) were non-neoplastic lesions, 24 (24.5%) were benign tumors, and 11 (11.2%) were malignant neoplasms. Conservative surgery (ovarian-preserving surgery) was successfully performed in 72.4% of the benign lesions, whereas only three patients (27.3%) with malignant tumors underwent ovary-sparing tumor resection (p < .001). The mean diameter of the tumors in the patients who underwent oophorectomy was significantly larger than that in the patients who underwent conservative surgery (7.8 ± 3.9 cm vs. 5.7 ± 2.9 cm, respectively, p = .001). In our study, the risk factors for oophorectomy were a malignant pathology and large tumor size. In accordance with the Gynecologic Cancer Intergroup consensus, we recommend that surgical management of ovarian masses in children should be based on ovarian-preserving surgery.

Combination of partial situs inversus, polysplenia and annular pancreas with duodenal obstruction and intestinal malrotation.

Situs inversus is a challenge to the physician, both for the diagnostic and for the therapeutic. A combination of partial situs inversus, annular pancreas and polysplenia with bowel malrotation has been reported in a newborn who presented as duodenal obstruction. Situs inversus is rare especially without heart malformation. All the abnormalities in this combination can be explained on the basis of multiple organ malrotation. It also demonstrates the necessity of meticulous investigation and precise description of the anomaly as far as the management of this case is concerned.

Surgical management of recto-sigmoid Hirschsprung's disease.

INTRODUCTION: Over the years, the surgical management of recto-sigmoid Hirschsprung's disease (HD) has evolved radically and at present a single stage transanal pull-through can be done in suitable cases, which obviates the need for multiple surgeries. AIM: The aim of this paper was to evaluate the role of transanal pull-through in the management of recto-sigmoid HD in our institution. MATERIAL AND METHODS: A retrospective analysis (between January 2003 and December 2009) was carried out on all cases of Hirschsprung's reporting to unity of pediatric surgery of Tunis Children's Hospital that were managed by transanal pull-through as a definitive treatment. All selected patients including neonates had an aganglionic segment confined to the rectosigmoid area, confirmed by preoperative barium enema and postoperative histology. Twenty-six children (86%) had their operation done without construction of prior colostomy. RESULTS: Transanal pull-through was performed in 31 children. Mean operating time was 150 minutes (range 64 to 300 minutes). No patients required laparotomy because all patients including neonates had an aganglionic segment confined to the rectosigmoid area. Blood loss ranged between 20 to 56 ml without blood replacement. Since all children were given an epidural caudal block, the requirement of analgesia in these cases was minimal. Postoperative complications included perianal excoriation in 7 out of 31 patients lasting from 3 weeks to 6 months. Complete anorectal continence was noted in 21 of 31 (67%) children in follow up of 3-5 years. CONCLUSIONS: Transanal endorectal pull-through procedure for the management of rectosigmoid HD is now a well-established and preferred approach. Parental satisfaction is immense due to the lack of scars on the abdomen. As regards the continence, a long-term follow-up is necessary to appreciate better the functional results of this surgery.

Small bowel obstruction by an anomalous congenital band.

We report a case of a 3-year-old boy who presented with symptoms and signs of intestinal obstruction. The patient reported no previous history of abdominal surgery or trauma while clinical and radiographic examinations were not diagnostic. An open laparotomy was subsequently performed and the intraoperative findings were consistent with a congenital band extending from the antimesenteric wall of the jejunum to the root of mesentery. The band was ligated and divided with an uneventful postoperative course. Congenital bands are extremely rare. Their exact incidence is still unknown. This case, therefore, represents an unusual surgical problem in a child in which the diagnosis was clinically unexpected.

Small bowel obstruction caused by congenital transmesenteric defect.

Transmesenteric hernias are extremely rare. A strangulated hernia through a mesenteric opening is a rare operative finding. Preoperative diagnosis still is difficult in spite of the imaging techniques currently available. The authors describe two cases of paediatric patients presenting with bowel obstruction resulting from a congenital mesenteric hernia. The first patient had a 3-cm wide congenital defect in the ileal mesentery through which the sigmoid colon had herniated. The second patient is a newborn infant who presented with symptoms and radiographic evidence of neonatal occlusion. At surgical exploration, a long segment of the small bowel had herniated in a defect in the ileal mesentery. A brief review of epidemiology and anatomy of transmesenteric hernias is included, along with a discussion of the difficulties in diagnosis and treatment of this condition.

Primary pelvic hydatid cyst with sciatic compression.

Hydatid cysts are endemic in certain regions of the world and particulary in North Africa. They are usually located in the liver, lung, and spleen, though many uncommon locations have been reported. This is the first report of a child with primary pelvic hydatid disease causing a sciatic compression.