Laparoscopic selective clipping of upper moiety vasculature and ureter without partial nephrectomy: A novel technique for pediatric urinary incontinence due to ectopic ureter associated with poor functioning upper renal moiety.

OBJECTIVE: The aim of this study was to present a novel laparoscopic technique for persistent urinary incontinence in pediatrics due to ectopic ureter associated with poor functioning upper renal moiety. METHODS: This technique consisted of laparoscopic clipping of the upper moiety artery and vein. The ectopic ureter was also clipped afterwards without upper pole partial nephrectomy. RESULTS: The patient was a seven-year-old girl with persistent urinary incontinence and confirmation of duplex kidney with poor functioning upper moiety in pre-operative investigations. The upper moiety ureter was ectopically drained to the vaginal cavity. She was immediately dry after surgery and discharged on the second postoperative day. During the follow-up period of 14 months, she was continent and symptom-free. Hydronephrosis was not visualized in follow-up ultrasonography. CONCLUSIONS: This laparoscopic upper renal moiety vascular and ureteral clipping without partial nephrectomy could serve as a promising, safe and simple alternative in the treatment of patients with ectopic ureter associated with poor functioning renal moiety. Also, ipsilateral normal functioning moiety would not be associated with potential morbidity in this technique.

Lung tissue engineering and preservation of alveolar microstructure using a novel casting method.

We used a rat model to decellularize and seed alveolar cells on a three-dimensional lung scaffold to preserve alveolar microarchitecture. We verified the preservation of terminal respiratory structure by casting and by scanning electron microscopy (SEM) of the casts after decellularization. Whole lungs were obtained from 12 healthy Sprague-Dawley rats, cannulated through the trachea under sterile conditions, and decellularized using a detergent-based method. Casting of both natural and decellularized lungs was performed to verify preservation of the inner microstructure of scaffolds for further cell seeding. Alveolar cell seeding was performed using green fluorescent protein (GFP) lung cells and non-GFP lung cells, and a peristaltic pump. We assessed cell seeding using histological and immunohistochemical staining, and enzymatic evaluation. All cellular components were removed completely from the scaffolds, and histological staining and SEM of casts were used to verify the preservation of tissue structure. Tensile tests verified conservation of biomechanical properties. The hydroxyproline content of decellularized lungs was similar to native lung. Histological and immunohistochemical evaluations showed effective cell seeding on decellularized matrices. Enzymatic measurement of trypsin and alpha 1 antitrypsin suggested the potential functional properties of the regenerated lungs. Casts produced by our method have satisfactory geometrical properties for further cell seeding of lung scaffolds. Preservation of micro-architecture and terminal alveoli that was confirmed by SEM of lung casts increases the probability of an effective cell seeding process.

Diagnosis of testicular torsion using near infrared spectroscopy: A novel diagnostic approach.

We report a case of testicular torsion in a 14-month old boy. Testicular ischemia was suspected based on history and clinical presentations. The patient was referred following 24 hours of left acute scrotum. Erythema, swelling and tenderness associated with nausea and emesis were present, but the patient was not febrile. We used a spatially resolved near-infrared spectroscopy (SR-NIRS) device to study and compare the tissue saturation index (TSI) on both right and left spermatic cords. The TSI was significantly reduced in the left side. Both testicles were surgically explored and the left testis was found non-viable with a 1080-degree intra-vaginal torsion. NIRS monitoring of spermatic cord oxygen saturation appears feasible as a non-invasive bedside optical method to identify testicular torsion.

Aphallia associated with urethro-rectal fistula and stones in the bladder and urethra.

Aphallia is a rare urogenital anomaly. It usually coexists with other serious anomalies, which are incompatible with normal life. We present herewith a 18-month-old child who presented with aphallia and urethro-scrotal fistula along with stones in the bladder and urethra. The stones were removed and the fistula was surgically corrected.

Laparoscopic antegrade continent enema through VQ stoma skin flaps using two ports: Long-term follow-up.

PURPOSE: To introduce a simple technique for laparoscopic appendicostomy using two ports through "V" and quadrilateral "Q"-shaped skin flaps to create antegrade continent enemas in children with a neuropathic bowel incontinence or intractable constipation. PATIENTS AND METHODS: Laparoscopic appendicostomy was performed in 19 children through a V-shaped skin flap at McBurney's point. The first port was inserted into the peritoneal cavity under direct vision, and the second port was inserted after peritoneal insufflation. The appendix was brought to the abdominal surface, and its distal tip was resected and intubated. The spatulated appendix was used to create an anastomosis to the V-shaped skin flap. The appendix was then covered by a quadrilateral skin flap. RESULTS: All patients were discharged from the hospital within 3 days (range 1-3 days) after surgery with a catheter in place. An irrigation regimen was initiated 3 weeks after surgery. All but one patient became continent without constipation and diaper free. The duration of follow-up ranged from 15 to 54 months (mean 35.8 months). CONCLUSION: The laparoscopic antegrade continent enema through the VQ stoma skin flaps using two ports ensures rapid recovery, an excellent cosmetic appearance, and minimal complications in long-term follow-up. This is the first report of this technique, which shows promising results in stoma reconstruction.

Fetus in fetu.

Fetus in fetu (FIF) is a very rare condition, with a reported incidence of one in 500,000 live births. It most likely represents a monozygotic diamniotic twin that implants itself and grows within the body of its normal karyotypically identical sibling, which typically manifests as a fetiform abdominal mass in a newborn or infant. The mass is located in the retroperitoneum in most cases, including our example, and is commonly surrounded by encapsulated fluid. However, FIF has been reported to occur in other locations, such as within the cranium, the scrotum, and the oral cavity. Usually only one fetus is present but very rarely multiple fetuses may also be present. Five fetuses in the cranium of a 1-day-old female infant with hydrocephalus (although three of these fetuses were composed of extremities only) had been reported. The fetus itself is incomplete, containing a variable number of identifiable organs. The lung, the liver, the adrenal gland, the pancreas, and the genital organs may be seen in the more complex specimens. The presence of a head with eyes, hair, and teeth has been reported, but most of these fetuses are anencephalic. We are presenting a FIF mimicking a solid and cystic renal mass in a 6-month-old boy.

A novel technique for approximation of the symphysis pubis in bladder exstrophy without pelvic osteotomy.

PURPOSE: We evaluated the outcome of pubic bone approximation and internal fixation using a miniature metal plate and screws without osteotomy in children with bladder exstrophy. MATERIALS AND METHODS: A total of 17 children with bladder exstrophy underwent surgery. Mean patient age was 27 months. Of the patients 15 had a history of 1 or more failed bladder closures with or without osteotomy. All children underwent bladder closure and complete posterior and anterior urethroplasty with bladder neck wrap. Both ureteral orifices were brought together by the Gil-Vernet antireflux procedure. The pubes were brought together with 3 deeply placed 1 mm polyglactin sutures through the bone and fixed by placing a miniature metal plate with 6 to 7 screws. Patients remained in a frog leg bandage for 1 to 3 weeks. The plate was removed during additional surgery. Median followup was 61 months (range 14 to 71). RESULTS: All children had an uneventful postoperative period without any serious complications, except for skin erosion caused by a screw without bone infection in 1 patient, and miniature plate subluxation following cystoscopy for reinsertion of urethral catheter 3 days after initial surgery in 1. Operating time and hospital stay were significantly lower than in children undergoing osteotomy or Bryant's traction. Overall continence rate was 53.8%. CONCLUSIONS: Although the number of patients is low, these results are promising. Pubic bone adaptation with miniature plate fixation without any type of osteotomy or leg traction is safe and less invasive than bilateral osteotomy and postoperative leg traction or plaster.

Anterior urethral valve associated with posterior urethral valves.

The association of anterior urethral valve (AUV) with posterior urethral valve (PUV) is rare. A 7-month-old infant was presented at a district hospital with episodes of acute pyelonephritis. He was treated medically and a voiding cystourethrogram (VCUG) confirmed bilateral vesico-urethral reflux. The presence of concomitant AUV and PUV was not recognized. He underwent several surgical procedures, which failed. He had reflux recurrence following two antireflux procedures. He had urinary retention after each operation, which was managed by vesicostomy and perineal urethrostomy. At the age of 3.5 years, he was referred to our paediatric urology clinic. Noticing the AUV and PUV in the past VCUG, the valves were fulgurated. Urodynamic study before and 3 months after valve ablation showed a high voiding pressure. VCUG 6 months following ablation showed no reflux, but several uroflowmetric studies showed a staccato and interrupted pattern. Empirical treatment with an alpha-blocker was started. One year after treatment, a repeat VCUG showed no reflux. Uroflowmetry and urodynamic studies returned to normal. The perineal urethrostomy was closed. The child was asymptomatic after 9 months of follow up.

Simultaneous Malone antegrade continent enema and Mitrofanoff principle using the divided appendix: report of a new technique for prevention of stoma complications.

PURPOSE: We determine the results and complications of continent urinary diversion and simultaneous Malone antegrade continent enema (MACE) and the Mitrofanoff principle using the divided appendix, and report on the VQQ and VQ technique for prevention of complications at the stoma level. MATERIALS AND METHODS: Between June 1995 and June 1999, 40 patients 4 to 22 years old (mean age 9.5) underwent Mitrofanoff procedures in conjunction with the MACE and augmentation cystoplasty as primary (5) or salvage (35) therapy. Of the patients 35 had neuropathic bladder, and 5 had bladder and bowel dysfunction without detectable neurological abnormalities. All patients had an antireflux Mitrofanoff channel constructed using distal part of the appendix with its divided mesothelium. The proximal half of the appendix was preserved as a modified MACE. Average length of appendix was 10.3 cm. (range 9 to 15) and no correlation was found between the length of appendix and age of child. The stoma construction was performed as 2 different techniques. The 2 appendix stomas were initially anastomosed with 2 separate triangular posterior V shape skin flaps on the right lower abdominal wall. Both appendix mucosae were completely buried with a single or double quadrilateral skin flap (VQQ and VQ technique). RESULTS: All patients are continent day and night without diapers. Mean followup was 22 months (range 8 to 48) and the overall incidence of complications was 7.5%. Mitrofanoff stomal stenosis due to catheter false passage occurred postoperatively in 1 case, gas leakage from the MACE in 1 and partial mucosal prolapse in 1. CONCLUSIONS: The MACE and Mitrofanoff principle have proved invaluable for the treatment of children with urinary and fecal incontinence. The divided appendix with 2 separate mesotheliums is an ideal channel for simultaneous Mitrofanoff and MACE when the appendix length is 9 cm. or more with a suitable branching mesothelium. When the appendix is short we prefer to use it as the Mitrofanoff and create a pediculed tube flap from the cecum for the MACE. All patients with a short appendix or history of appendectomy operated on by different techniques, such as the Monti procedure, Casale technique, cecal flap or ureteral Mitrofanoff, were excluded from our study. Most of the minor complications are preventable by meticulous technique. The VQQ and VQ stomas have the lowest incidence of complications and produce the most satisfactory cosmetic appearance.

The role of ureter in the creation of Mitrofanoff channels in children.

PURPOSE: Since 1980 numerous variations of the Mitrofanoff principle have been described. We report on 22 children in whom a ureteral Mitrofanoff channel was created. MATERIALS AND METHODS: Between 1986 and 1995 a ureteral Mitrofanoff channel was constructed as a catheterizable conduit in 22 children 2 to 15 years old (average age 6.5) with various abnormalities of the lower urinary tract, mainly exstrophy and neurogenic bladder. Indications included unavailability or unsuitability of the appendix, preference for appendix as a catheterizable colonic stoma for antegrade washouts or concomitant removal of a nonfunctioning kidney, leaving the ureter available for use. Surgical technique was based on the principles of appendicovesicostomy and in 9 cases the ureteral Mitrofanoff channel was reimplanted. RESULTS: Followup ranged from 1 to 72 months (average 30.5). Complications included stenosis of the conduit that caused difficult catheterization in 3 patients, necessitating dilation or minor revision in 2 and complete replacement by appendix in 1. Urinary leakage from the Mitrofanoff channel in 5 patients was treated with polydimethylsiloxane injection or oxybutinin. In 1 patient the channel was reimplanted, since the catheter struck the bladder neck during catheterization and caused severe pain. CONCLUSIONS: Results of the ureteral Mitrofanoff channel seem somewhat less satisfactory than those of appendicovesicostomy but they remain acceptable and even comparable, strongly supporting its use in certain circumstances.

Arteriovenous fistula following nephrectomy.

UNLABELLED: Arteriovenous fistula (AVF) of the renal pedicle is a rare complication of nephrectomy. Since the 1st case report in the literature, 62 cases have been reported in the world literature. A continuous abdominal or lumbar bruit is diagnosed. They may also present with symptoms of congestive heart failure and/or hypertension. METHODS: 37 years following nephrectomy, a case of AVF of the right renal pedicle associated with gross proteinuria is described. RESULTS: The clinical diagnosis was confirmed by aortogram, and the proteinuria subsided after successful surgical management. CONCLUSION: The causes of proteinuria may be due to the hyperfiltration state. To our knowledge, there has been no previous report of this combination in the literature.

The evolution of penile reconstruction in epispadias repair: a report of 180 cases.

From 1978 to 1993, 180 boys with epispadias (85) and the exstrophy/epispadias complex (95) underwent epispadias reconstruction at our institution. The 180 patients were divided into 4 groups: group 1--2-stage epispadias reconstruction with dissection of the corporo (30 patients), group 2--pedicled preputial tube urethroplasty either alone or with a lyophilized human dural patch to the corpora for correction of penile deformity (35), group 3--pedicled preputial tube urethroplasty and corporeal rotation (40), and group 4--a modified Cantwell epispadias repair incorporating complete tubularized urethroplasty, cavernocavernostomy and corporeal rotation. In 46 patients from groups 1 to 3 the primary outcome was not considered satisfactory and they underwent radical penile revision with the modified Cantwell technique. Followup ranges from 1 to 15 years (mean 6 years). We conclude that a good cosmetic result can be achieved in almost all cases using the modified Cantwell technique as a primary procedure in experienced hands. This technique has a low complication rate and can be used as a salvage procedure following previous unsuccessful epispadias reconstruction using other techniques.

Radical single stage reconstruction in failed exstrophy.

Staged repair of exstrophy-epispadias complex cases with initial bladder closure followed by epispadias and bladder neck repair at a later date is well documented. However, the role of single stage repair as a primary and salvage procedure after failed closure is not well established. A total of 12 male patients with bladder exstrophy has undergone single stage repair at our facility (10 secondary and 2 primary procedures). Mean age of the 10 patients referred for secondary repair was 5.5 years (8 months to 13 years). In this group there had been 16 previously unsuccessful attempts at bladder closure and 15 operations for epispadias repair. The 2 primary repair patients were 15 months and 13 years old. Continence was achieved by bladder neck reconstruction combined with epispadias repair and all cases were augmented by enterocystoplasty in conjunction with a Mitrofanoff channel. Pelvic osteotomy was performed in 3 cases. After bladder neck revision in 2 children all are dry day and night on clean intermittent catheterization and have a satisfactory cosmetic appearance. Single stage reconstruction of the exstrophy complex is a satisfactory method with a low morbidity for treating children in whom previous repair has failed. Its more extended role in the primary case requires further evaluation.

Augmentation cystoplasty in boys with posterior urethral valves.

The role of augmentation cystoplasty in the neuropathic and exstrophy bladder has been well documented. However, its place and the timing of such surgery in the "valve bladder" are not well established. We report our experience with augmentation cystoplasty in 20 boys with previously treated posterior urethral valves. Urodynamic studies confirmed poorly compliant, unstable bladders with low functional capacities, which had failed to respond to anticholinergic treatment in all patients. The bladder was augmented with ileum in 9 cases, stomach in 7, colon in 2 and ureter in 2. A Mitrofanoff channel was fashioned in 6 cases. Upper tract dilatation improved in 17 patients and remained stable in 3. Of the patients 17 are dry day and night. Eleven patients void spontaneously without significant residual urine, 7 are on clean intermittent catheterization for residual urine of greater than 50 ml. and 2 are completely dependent on catheterization. Augmentation cystoplasty is a safe and effective method to achieve continence with a low capacity, poorly compliant bladder in children with posterior urethral valves who do not respond to medical management. In contrast to the neuropathic and exstrophy bladder, the augmented valve bladder allows spontaneous voiding without significant residual urine in the majority of cases. Early intervention in these patients may prevent deterioration in renal function.