Transanal Endoscopic-Assisted Pull-Through Colectomy for Children with High Intestinal Aganglionosis.

Intestinal aganglionosis in children is a common cause of neonatal and infantile obstruction or ileus. Diagnosis is based on a histologically proven absence of enteric ganglion cells in deep biopsies of the gut wall. Therapeutic goal is a one-stage repair with a resection of the affected segment. The endorectal pull-through (ERP) can be performed entirely transanally in a lot of the cases. In patients with difficult preparation or a high aganglionosis ERP often needs to be assisted by laparoscopy or laparotomy. We present two cases with a technical modification performing a totally transanal pull-through colectomy without any trocars other than an umbilical camera trocar. The procedure starts with a classical endorectal technique. Usually, the transanal preparation is limited by reaching the colon descendens. A camera trocar is inserted and under laparoscopic vision the preparation is completed placing the instruments directly via the opened anus. After reaching the healthy colon segment, the pull-through is completed transanally. One of the main advantages of ERP is the sparing dissection. Our modification combines advantages of laparoscopy and ERP. The umbilical camera allows an excellent view while the instruments for dissection are used like with ERP without any further trocar or traction of the anal sphincter. The dispensation of any transanal trocar allows a higher grade of freedom in preparation and possibly a smaller trauma on the distal anal channel.

Establishment of a Pediatric Surgical Unit at a University Hospital in Eastern Africa.

INTRODUCTION: Ethiopia is a rapidly developing country in Eastern Africa. In total, 43.2% of the population are younger than 15. In contrast, until a few years ago, pediatric surgery was only available in Addis Ababa. Now, Ethiopia is making great efforts to improve the care of children who require surgery. JimmaChild was established to set up a pediatric surgery in Jimma. MATERIAL AND METHODS: JimmaChild developed from a scientific collaboration between Jimma University (JU) and Ludwig-Maximilians-University. The project was developed and realized by Ethiopian and German colleagues. A curriculum was written for this purpose. The pediatric surgical training of the fellows was carried out on-site by German pediatric surgeons. RESULTS: A new pediatric surgery was established at JU with its own operating room, ward, and staff. After two and a half years, two fellows completed their final examinations as pediatric surgeons. Among others, 850 elective surgeries were performed, 82% assisted by the German colleagues. The German colleagues rated the preparation for the trip, the on-site support, and the professional progress of the fellows mostly as good to very good. Reported problems in the program flow were also recognized and solved in part. CONCLUSIONS: The best possible integration of the project into existing structures was achieved by close cooperation of Ethiopian and German colleagues during the project development. Problems were identified and addressed early on by external monitoring. As the project responsibility was mainly with the Ethiopian colleagues, a department was created that now exists independently of external funding and trains its own fellows.

Cowper's syringocele: A rare differential diagnosis of infravesical obstruction in boys and young adults.

OBJECTIVE AND INTRODUCTION: Cowper's syringocele is a cystic dilation of the bulbourethral gland duct, initially defined by Maizels et al. in 1983. Although obstructive and non-obstructive types of this rare anomaly are described, clinical symptoms are highly unspecific. Therefore, we report 12 cases of children and young adults diagnosed with Cowper's syringocele to further clarify clinical course, comorbidity and treatment strategies. STUDY DESIGN: We retrospectively collected clinical data of 12 children and young adults from birth to 18.5 years (median 7.2 years) who had been treated in four different institutes during a period of 16 years. The primary specific diagnostic work-up consisted of ultrasound, cystourethrography, and cystoscopy. RESULTS: 3Older patients with a median age of 11.8 years clinically presented with obstructive voiding pattern or gross hematuria; infants with a median age of 0.6 years presented with febrile urinary tract infections (UTIs). After cystoscopic confirmation in all patients, endoscopic treatment was possible in nine; open surgical resection was necessary in three patients. Because of intrauterine megacystis and chronic renal failure, one boy underwent suprapubic diversion with a cystostomy soon after birth. Owing to urological comorbidity or later complications, additional procedures were necessary, for example, resection of minor urethral valves, prophylactic circumcision for UTI, endoscopic or open antireflux procedures, and occasionally complex bladder reconstructions in the long term. DISCUSSION: According to our data, the initial clinical symptoms of Cowper's syringocele were related to presenting age rather than the previously described type of syringocele according to Maizels et al. Infants presented with febrile UTIs; however, older boys and young adults had mainly voiding problems or nocturnal enuresis. Therefore, the clinical significance of the described syringocele types must be questioned. Eighty-three percent of our patients showed additional urological pathology such as vesicoureterorenal reflux, ureteropelvic junction obstruction, megaureter, or minor urethral valves. Thus, Cowper's syringocele hardly seems to be an isolated pathology. CONCLUSION: Although rare, Cowper's syringoceles should be considered in differential diagnosis of infravesical obstruction in boys and young adults. Diagnostics are usually justified by presenting symptoms such as UTI or urinary flow impairment, which seem to be age dependent. Despite modern diagnostic tools, diagnosis is usually made by cystourethrography and sometimes accidentally by cystoscopy. Considerable urological comorbidities and consecutive bladder dysfunction need long-term follow-up.

Reduced bacterial colonisation of the glans penis after male circumcision in children--a prospective study.

OBJECTIVE: The aim of this prospective study was to evaluate the effect of male circumcision on the bacterial colonisation of the glans penis in children. PATIENTS AND METHODS: 244 males were included in this study. The study group consisted of 143 boys admitted for circumcision between August 2009 and July 2010. Periurethral swabs were taken preoperatively and one week postoperatively. The control group included 101 boys without phimosis, in which only one swab was taken. Patients were subgrouped according to age below and above five years. Bacterial cultures were analysed, results were categorized by non-uropathogenic and uropathogenic bacteria, and compared within and between groups. RESULTS: Patients in both control group and study group before circumcision showed significant bacterial colonisation (>98%), involving known uropathogenic bacteria in over 86%. After circumcision, bacterial colonisation dropped from 100% to 86.3% (p < 0.005) in boys younger than five years and from 98.57% to 77.14% (p < 0.001) in those aged five or above, respectively. Moreover, the fraction of uropathogenic bacteria decreased significantly. CONCLUSION: Male circumcision significantly reduces the bacterial colonisation of the glans penis with regard to both non-uropathogenic and uropathogenic bacteria.

Improvement of continence with reoperation in selected patients after surgery for anorectal malformation.

PURPOSE: Fecal incontinence is a serious complication after repair of anorectal malformations. We investigated whether reoperation can improve fecal continence. METHODS: Medical records of 41 patients (40 children and one adult; 26 male and 15 female) who underwent reoperation after previous reconstruction of an anorectal malformation were reviewed for outcomes of bowel function. Type of primary corrective surgery performed, therapeutic measures, results of physical examination and barium enema, and reoperation procedures were evaluated. A questionnaire was administered to assess stool behaviour and level of continence at follow-up three or more years after secondary operation. RESULTS: Secondary operations in males comprised posterior sagittal anorectoplasty (PSARP) in 16 patients, PSARP with antegrade continent enema in one patient, antegrade continent enema alone in 6, anoplasty in one, rectosigmoid resection in 1, and definitive colostomy in 1 patient. Secondary operations in females included PSARP alone in 4 patients, PSARP with total urogenital mobilization in 4, PSARP with vaginoplasty in 2, PSARP with vaginoplasty and antegrade continent enema in 2, and PSARP with vaginourethroplasty in 3. Of 41 patients 18 (44 percent) were continent at follow-up, 21 (51 percent) were clean with use of enemas, diet, or drug therapy. One patient had a definitive colostomy. One died after kidney transplantation. CONCLUSIONS: Surgery is a good option for improving incontinence in selected patients previously operated for anorectal malformations. Posterior sagittal anorectoplasty is advocated to improve bowel control. Antegrade continent enema is a reliable therapeutic option to maintain clean patients with fecal incontinence.

Rotundum psoas hitch: a new method for colpohysteropexy in girls with bladder exstrophy.

Female patients with bladder exstrophy frequently suffer from uterine prolapse, which is due to a defective pelvic floor anatomy. Different techniques for the correction of procidentia in this patient population have been described; however, since the numbers of patients are very small and no series with long-term follow-up exists, it is unclear which technique yields superior results. We describe here a new technique for uteropexy in girls and women with bladder exstrophy. In the rotundum psoas hitch procedure (RPH), the round ligaments are detached from the inner inguinal ring and fixed to the psoas muscle on both sides, thereby fixing the uterus in a more cranial and dorsal position. This procedure has been applied successfully in nine patients with a mean follow-up of 23.8 months. In six cases RPH was done prophylactically and in three cases therapeutically to correct an existing uterine prolapse. The mean age at operation was 9.6 years. In all but one case, RPH was combined with continent urinary reconstruction. No postoperative morbidity due to this technique has been described. RPH is an effective means of preventing or correcting procidentia in patients with bladder exstrophy; we emphasize that it should be combined with other abdominal operations, such as continent reconstruction, in girls or women with this condition.