Assessment of referral patterns for boys with suspected undescended testes and identification of risk factors to aid diagnosis.

INTRODUCTION: Undescended testis (UDT) is a clinical diagnosis and a common reason for referral to paediatric urology outpatients. Our aim was to assess current referral patterns at our unit and to identify predictive factors that may better aid primary care physicians (PCP) in diagnosing UDT based on history and physical exam. METHODS: A retrospective analysis of referrals to outpatients from 2014 to 2016 was performed to assess current referral patterns including referral source, age, reason for referral and outcome following assessment by a single consultant paediatric urologist.A prospective analysis of new referrals was performed to identify predictive factors which may aid in the diagnosis of UDT including gestational age, presence of scrotal asymmetry and previously obtained imaging. RESULTS: From 2014 to 2016, 259 boys were referred with suspected UDT. The majority of referrals were received from PCPs (62%) followed by Neonatology (29%), Paediatrics (8%) and general surgery (1%). Median age at time of assessment was 29 (5-180) months. One hundred and eight (41.7%) boys were diagnosed with UDT.There were 74 boys assessed prospectively. Median age at assessment was 24.5 (6-171) months. We identified 3 predictors of a diagnosis of UDT; history of prematurity (p = 0.001), UDT mentioned to the parents at birth (p = 0.027) and scrotal asymmetry on examination (p < 0.001). Greatest diagnostic inaccuracy was found in boys referred beyond one year of age (27.7%). In this cohort, the absence of all three risk factors was associated with a negative predictive value of 94.1%. CONCLUSION: The majority of boys with suspected UDT are referred beyond the age recommended for orchidopexy (6-12 months). The majority of boys referred for assessment did not have UDT. We have identified three predictive factors that may aid referring physicians when assessing boys, particularly those older than 1 year.

Umbilical hernia following gastroschisis closure: a common event?

PURPOSE: To assess incidence and natural history of umbilical hernia following sutured and sutureless gastroschisis closure. METHODS: With audit approval, we undertook a retrospective clinical record review of all gastroschisis closures in our institution (2007-2013). Patient demographics, gastroschisis closure method and umbilical hernia occurrence were recorded. Data, presented as median (range), underwent appropriate statistical analysis. RESULTS: Fifty-three patients were identified, gestation 36 weeks (31-38), birth weight 2.39 kg (1-3.52) and 23 (43 %) were male. Fourteen patients (26 %) underwent sutureless closure: 12 primary, 2 staged; and 39 (74 %) sutured closure: 19 primary, 20 staged. Sutured closure was interrupted sutures in 24 patients, 11 pursestring and 4 not specified. Fifty patients were followed-up over 53 months (10-101) and 22 (44 %) developed umbilical hernias. There was a significantly greater hernia incidence following sutureless closure (p = 0.0002). In sutured closure, pursestring technique had the highest hernia rate (64 %). Seven patients underwent operative hernia closure; three secondary to another procedure. Seven patients had their hernias resolve. One patient was lost to follow-up and seven remain under observation with no reported complications. CONCLUSIONS: There is a significant umbilical hernia incidence following sutureless and pursestring sutured gastroschisis closure. This has not led to complications and the majority have not undergone repair.

Re-evaluating the role of Doppler ultrasonography in patients presenting with scrotal pain.

AIM: To describe our experience of all patients presenting to a tertiary referral centre over a 5-year time period with acute scrotum and to investigate the role of Doppler ultrasonography (DUS) for investigating this group of patients. METHOD: A retrospective analysis was performed on all patients presenting to the emergency department (ED) of a level 1 trauma centre with acute scrotum from 2009 to 2014 inclusive. Inclusion criteria included all patients who underwent an investigatory DUS and/or emergency scrotal exploration. Recorded patient demographics included age, presenting symptoms, duration of symptoms and relevant examination findings. RESULT: Three-hundred and twelve patients were included with a mean age of 15 years (range 1 day-40 years). In total, 106 patients underwent immediate scrotal exploration, and testicular torsion (TT) was found in 30 % (n = 32/106). Two-hundred and twenty-two patients were initially investigated with DUS and 16 (7.2 %) proceeded to scrotal exploration. Of this sub-group, 2/16 presented with a history <24 h and exploration was negative for TT. In comparison, 14/16 presented with a history >24 h, and DUS findings were consistent with TT. No patients with a normal DUS represented to the ED after discharge. CONCLUSION: DUS may prevent unnecessary scrotal exploration in patients presenting with acute scrotal pain and is useful for diagnosing TT in patients presenting with symptoms >24 h.

Aetiology, epidemiology and management strategies for blunt scrotal trauma.

OBJECTIVES: To describe our experience of all patients presenting to a tertiary referral centre over a 3 year time period with blunt scrotal trauma and to describe a methodical approach for managing this group of patients. METHODS: A retrospective analysis was performed on all patients presenting to the Emergency Department (ED) of a level 1 trauma centre with blunt scrotal trauma from 2010 to 2013 inclusive. Inclusion criteria included a recent history of blunt scrotal trauma with associated pain and/or swelling of the affected testis on clinical examination. RESULTS: Twenty-seven male patients with a median age of 19 (range 8-65) years were included and all but 1 patient underwent scrotal ultrasonography upon presentation. Sixteen patients (59%) presented with scrotal trauma secondary to a sports related injury. Fifteen patients were managed conservatively and of the 12 who underwent urgent exploration 9 had a testicular rupture, including 1 who had an emergency orchidectomy due to a completely shattered testis. Four patients had >30% of the testis replaced by necrotic tissue/haematoma; of which 2 ultimately underwent orchidectomy and insertion of testicular prosthesis. CONCLUSION: Our findings demonstrate that the necessity for scrotal protection in sports that predispose to scrotal trauma should be reviewed. We also demonstrate the importance of scrotal ultrasonography for determining an appropriate management strategy (i.e., conservative versus surgical treatment) in this young patient cohort.

Esophageal atresia and malrotation: what association?

INTRODUCTION: Esophageal atresia/tracheo-esophageal fistula (EA/TEF) has an incidence of approximately 1:3,500. The incidence of malrotation is thought to be 1:200-500. We attempted to define the incidence of a combination and discuss the implications. METHODS: This was a retrospective review of all patients admitted to a single institution with a diagnosis of EA or EA/TEF or TEF between April 1981 and January 2013. Patients were included if the position of the duodeno-jejunal flexure (DJF) was determined by upper GI contrast study (UGIS), surgery or post-mortem. RESULTS: Case notes were reviewed for 235 patients. In the EA type A group, 3/28 (11 %; 95 % CI 3.7-27.2 %) had malrotation, significantly higher than the reported incidence of malrotation in the general population (p = 0.0008). All three patients in this group were symptomatic with one patient found to have a volvulus at emergency surgery. In the type C group, 6/196 (3 %, 95 % CI 1.4-6.5 %) had malrotation, significantly higher than the incidence reported for the general population (p = 0.0033) but not significantly different to that of the type A group (p = 0.0878). There were no patients with malrotation identified in any other EA/TEF type. In total, 9/235 (3.8 %; 95 % CI 2.0-7.2 %) patients with EA had malrotation, significantly higher than the 5/1,050 (0.48 %) reported for the general population (p = 0.0002). CONCLUSION: There is a high incidence of malrotation in patients with pure EA. In the type A group an attempt to identify the DJF position at gastrostomy siting and/or performance of UGIS in the neonatal period should be undertaken. There should also be a low threshold for UGIS in all EA/TEF patients.

Trends and attitudes towards paediatric circumcision in the South of Ireland.

BACKGROUND: Paediatric circumcision is one of the oldest surgical procedures performed worldwide. Traditionally performed by general surgeons, paediatric surgeons and urologists, there is a falling trend in the rate of paediatric circumcision being performed by adult and paediatric general surgeons. There is currently no corresponding contemporary data pertaining to trends and attitudes of general surgeons to paediatric circumcision in Ireland. AIM: The aim of this study was to assess the trends and attitudes of consultant general surgeons, and to assess its potential impact on the specialist delivery of paediatric urological care. METHODS: A questionnaire was mailed to all practicing general surgeons in whom we identified as having a potential role in the management of paediatric circumcision. Data pertaining to population demographics within the south of Ireland were accessed through the Central Statistics Office. RESULTS: There was an 89 % response rate to the questionnaire survey. Seventy-seven percent of those under 50 were trained in adult circumcision compared with 100 % of those respondents over 50 years. There was a significant difference in paediatric circumcision with only 24 % those under 50 performing this procedure compared with 68 % above 50 years. Eighty-six percent respondents under 45 years (35 % over 45 years) felt that this procedure should be carried out by urology. CONCLUSION: In a region with an expanding paediatric population, it is crucial to maintain paediatric urological services. Given present trends and attitudes of newer appointed general surgeons, it is essential that further specialist appointments are made, and funding directed towards demand in order to keep pace.

The impact of rolling theatre closures on core urology training.

Since 2008, government funding of the Health Service Executive (HSE) has decreased significantly. Our hospital, Cork University Hospital (CUH), implemented "cost saving" measures including scheduled operating theatre closures. We studied their affect on urological surgical activity at the hospital. A retrospective review was performed using theatre log books and theatre records to determine the number, type and training status of procedures performed for years 2009 and 2011. Scheduled theatre closures in 2011 resulted in 33 more theatre session cancelations compared to 2009. There was a reduction in the total number of procedures performed from 555 cases in 2009 to 443 in 2011 a 20.2(%) reduction. The number of "training" cases reduced from 325 (58.9%) in 2009 to 216 (48.7%) in 2011 a 10.2% reduction (Table 2). Eight out of the nine "core urology training" procedures reduced in number from 2009 to 2011 (Table 1). We have shown that scheduled theatre closures have reduced the number of procedures performed and have impacted on urology training. Scheduled theatre closures are expected to become more frequent in the future. Potential solutions to lessen the impact include providing simulation training using the Royal College of Surgeons in Ireland (RCSI) mobile skills unit during these theatre closures.

MAGPI hypospadias repair: factors that determine outcome.

BACKGROUND: This is a review of our experience with the meatal advancement and glanuloplasty incorporated (MAGPI) hypospadias repair, and we point to some of the factors that determine outcome. METHODS: We identified all patients who underwent MAGPI repair by a single surgeon over an 8-year period. We performed a retrospective chart review followed by telephone interview to assess parent satisfaction and also functional and cosmetic outcome. Decision to undergo this type of repair was intra-operative, depending on position and mobility of the meatus and the quality of peri-urethral tissue. RESULTS: We identified 48 patients, with a median age of 19 months (8 months-13 years). Position of meatus was glanular (40) or coronal (eight cases). Chordee required correction in 40 % (12/30). Urethral stenting was required in one case. There was no case of fistula, meatal regression, stenosis, or second procedure. A single case of mucosal prolapse was encountered. The majority (47/48) were performed as a day-case. Forty parents agreed to telephone interview. Cosmetic outcome was deemed satisfactory in 95 % (38/40). With regard to unsatisfactory cosmetic outcome, one had a megameatus and the other was aged 13 years and developed a mucosal prolapse. CONCLUSION: In selected cases, the MAGPI hypospadias repair provide excellent functional and cosmetic outcomes with minimal complications, and it can safely be performed as a day-case procedure.

The role of parenteral nutrition following surgery for duodenal atresia or stenosis.

PURPOSE: In our institution, some children routinely receive parenteral nutrition (PN) following surgery for duodenal atresia/stenosis, while others do not. Our aim was to compare growth and infection rate between these two treatment strategies. METHODS: This was a retrospective study of all children undergoing surgery for duodenal atresia/stenosis over 7 years. RESULTS: Of the 54 children, 19 commenced PN soon after surgery (the 'Initial PN' group). Of the remaining 35 children, 13 (37 %) subsequently required PN (the 'Delayed PN' group). The remaining 22 never received PN (the 'Never PN' group). The proportion of patients experiencing clinically suspected sepsis was higher in those receiving PN ('Initial' plus 'Delayed'; 41 %) compared with those who never received PN (14 %; p = 0.04). The 'Initial PN' and 'Never PN' groups did not show a significant change in weight Z score over time. However, the 'Delayed PN' group showed a significant decrease in weight Z scores from the time of operation to the time of achieving full enteral feeds, and failed to catch up by the time of last follow-up. CONCLUSION: Children with duodenal atresia/stenosis can be managed without PN. However, a third of these children subsequently require PN, lose weight centiles, and have a high rate of sepsis.

Advanced necrotizing enterocolitis part 1: mortality.

AIM OF THE STUDY: The aim of this study was to investigate the factors associated with mortality in infants referred for the surgical treatment of advanced necrotizing enterocolitis (NEC). METHODS: Retrospective review of all infants with confirmed (Bell stage II or III) NEC treated in our unit during the past 8 years (January 2002 to December 2010). Data for survivors and nonsurvivors were compared using Mann-Whitney test and Fisher's exact test and are reported as median (range). RESULTS: Of the 205 infants with NEC, 35 (17%) were medically managed; 170 (83%) had surgery; 66 (32%) infants died; all had received surgery. Survivors and nonsurvivors were comparable for gestational age, birth weight, and gender distribution. Overall mortality was 32%, the highest mortality was in infants with pan-intestinal disease (86%) but remained significant in those with less severe disease (multifocal 39%; focal disease 21%). The commonest cause of mortality was multiple organ dysfunction syndrome and nearly half of the nonsurvivors had care withdrawn. CONCLUSION: Despite improvement in neonatal care, overall mortality (32%) for advanced NEC has not changed in 10 years. Mortality is significant even with minimal bowel involvement.

Advanced necrotizing enterocolitis part 2: recurrence of necrotizing enterocolitis.

AIM OF THE STUDY: The aim of this study was to report incidence and clinical outcomes of recurrent necrotizing enterocolitis (NEC). METHODS: Review of infants treated for recurrent episode(s) of NEC at a tertiary Neonatal Surgical Intensive Care Unit over 8 years (January 2002 to February 2011). Demographic, clinical, radiological, and operative data were analyzed and compared using Mann-Whitney or Fisher's exact tests. Data are reported as median (range). RESULTS: A total of 212 consecutive infants were referred for surgical evaluation and treatment of NEC (Bell stage II or III). Of these patients, 22 (10%) had suspected recurrent NEC: in 11 of these the primary episode was Bell stage I successfully treated before coming to our institution (suspected recurrent NEC); in the remaining 11, the primary episode was confirmed (Bell stage II or III) NEC successfully treated in our hospital. Birth weight, gestational age at birth, corrected gestational age, weight on admission, gender, need for surgery, stricture, and mortality rates were similar between infants with recurrent NEC and those with a single episode. Long-term parenteral nutrition (PN) dependency (>28 days) was significantly more common following recurrent NEC compared with a single episode. Among the infants with recurrent NEC, medical therapy alone was not successful in the majority (82%) of cases during the first episode and all required surgery during the recurrent episode. CONCLUSION: Infants (10%) referred for surgical treatment of NEC develop recurrence of the disease. Surprisingly, these infants have similar mortality and stricture rates to those with a single episode. However, the incidence of long-term PN dependency was significantly increased in those with recurrent episodes of NEC.

Fundoplication in ventilator-dependent infants with gastro-oesophageal reflux.

AIM: In ventilator-dependent infants with complex comorbidities, severe gastro-oesophageal reflux (GOR) may contribute to prolonging the period of ventilation. It is often difficult to predict whether antireflux surgery will improve the respiratory status of an infant and assist with weaning off the ventilator. The aim of this study was to review the outcomes in a cohort of ventilator-dependent infants who underwent fundoplication to help wean them off ventilation. METHODS: Between January 2006 and December 2010, out of 596 infants who underwent fundoplication for symptoms of GOR, 26 were ventilator dependent before surgery; 13 patients had an emergency fundoplication following an acute life-threatening event (n = 5, 19%) or an acute deterioration of respiratory status (n = 8, 31%). Fundoplication was planned in the rest of the group (n = 13, 50%) with the aim of improving respiratory status and weaning from ventilation. The median age at surgery was 5.8 months (range: 0.8 to 19.4 months). The median weight at surgery was 6.3 kg (range: 4 to 15.1 kg). Data were collected for each infant on comorbidities, pre- and postoperative ventilation status, pre- and postoperative GOR symptoms, and survival. RESULTS: All infants underwent a Nissen fundoplication with no intraoperative morbidity or mortality. Of these, 12 infants had a laparoscopic fundoplication; 14 infants had an open fundoplication. Postoperatively, all infants received invasive positive pressure ventilation in the intensive care unit (ICU). All infants were successfully weaned from ventilation. The median time to extubation was 4 days (range: 2 to 18 days). The median postoperative ICU stay was 9 days (range: 3 to 52 days). Of the patients, 9 (34%) had a recurrence of symptoms following fundoplication; 5 (19%) subsequently underwent revision of fundoplication and 1 (3.8%) underwent oesophago-gastric dissociation; and 10 (38%) died within the study period. CONCLUSION: In infants with severe GOR, ventilator dependence, and complex comorbidities, fundoplication may be a useful procedure to assist weaning off ventilator dependence. Rates of symptom recurrence, of revision of fundoplication, and of mortality within this cohort were higher than expected. These data reflect the challenges of patient selection in high-risk groups.

Effectiveness of the antegrade colonic enema stopper at preventing stomal stenosis: long-term follow-up.

AIM OF THE STUDY: Stomal stenosis is the commonest complication of the antegrade colonic enema (ACE) procedure, reportedly occurring in 25-55% of patients. As such, a simple ACE stopper device (a small silicone plug sited in the ACE conduit between catheterisations) was designed to prevent stenosis. We performed a long-term follow-up study to determine the effectiveness of the stopper device. METHODS: A retrospective case note review was performed of all patients who successfully underwent a primary ACE procedure over an 8.5-year period (January 2002 to June 2010). The inclusion criteria were (i) a minimum of 6 months follow-up, (ii) simple appendicostomy, (iii) caecal/colonic flap. In all patients an ACE stopper was sited in the conduit for at least 4 months and removed only for catheterisation. Data are mean±SEM. MAIN RESULTS: 38 children were included in our study. Mean age at surgery was 9.6±0.5 years. Surgery was performed in 22 patients for incontinence and in 16 for chronic constipation. 31 underwent an appendicostomy and 7 had a caecal/colonic flap; all received an ACE stopper. The mean follow-up was 2.6±0.3 years. Only 3 patients (8%) developed stomal stenosis. The first occurred 6 months postoperatively, resulting from an ACE stopper which was too small and consequently persistently fell out. This conduit required dilatation. The second occurred at 27 months secondary to a stomal infection and required surgical revision. The third occurred 8 months postoperatively for no obvious cause, and was treated with dilation. 1 patient experienced stomal leakage. CONCLUSION: The ACE stopper is a simple yet highly effective method of preventing stomal stenosis. We recommend using the stopper in all ACE patients.

Malignant mesothelioma of the tunica vaginalis.

Malignant mesothelioma of the tunica vaginalis is a rare but potentially fatal disease. Lack of characteristic clinical features and tumour markers makes the pre-operative diagnosis very difficult. A 54 year-old man with no history of exposure to asbestos presented with a short history of scrotal swelling and pain. Ultrasound revealed a suspicious nodularity involving his tunica vaginalis, suggestive of mesothelioma. Excisional biopsy revealed a malignant mesothelioma; hence the patient was treated with radical inguinal orchidectomy and hemiscrotectomy. We present a case of this rare tumour, its management and a review of the literature.

Regional variations in testicular cancer rates in Ireland.

BACKGROUND: Traditionally, the incidence of testicular cancer (TCa) has shown a remarkable geographical variation. AIMS: To examine whether the rates of TCa varied within Ireland itself and to find possible explanations for any observations made. METHODS: We observed the incidence of TCa in counties in Ireland between January 1994 and December 2007. The rate of cryptorchidism over the same time was calculated. Incidence of TCa by socio-economic status was reviewed. The role of environmental pollutants was explored. We analysed teenage obesity data as a risk factor for the development of TCa in adulthood. RESULTS: Cork had a significantly higher rate of TCa than any other county in Ireland. Cork also had high rates of cryptorchidism, but interestingly not the highest nationwide. In Cork County specifically, least deprived areas had significantly higher rates of TCa. Organic pollutants previously linked to the development of TCa have been identified in large industries located only in Cork. Teenage obesity rates in Cork were not higher than elsewhere. CONCLUSIONS: There is a higher incidence rate of TCa in Cork than any other county. High rates of cryptorchidism alone cannot explain this. There appears to be a link with higher socio-economic status and possibly industrial pollutants. The association between sedentary lifestyle and the development of TCa is unproven.

Morbidity after ganglioneuroma excision: is surgery necessary?

INTRODUCTION: Ganglioneuroma (GN), the benign form of peripheral neuroblastic tumour, is often asymptomatic and the diagnosis can be incidental. Our aim was to evaluate the incidence of complications after surgical treatment following diagnosis of this tumour. MATERIAL AND METHODS: 24 consecutive children were diagnosed with GN in our centre between January 1989 and December 2009. All patients had negative urinary catecholamines and/or biopsy confirming the diagnosis of GN. Data are reported as mean ± SD. RESULTS: Age at diagnosis was 73 ± 43 months. The most common presentation was respiratory symptoms and/or abdominal pain; 9 (38%) patients were asymptomatic. Tumour location was in the chest (n=14), abdomen (n=7), or pelvis (n=3). 23 children (9 asymptomatic) were operated on; 1 child with a thoracic mass did not undergo surgery because of severe neurological impairments from birth unrelated to GN. 13 children (4 asymptomatic) had a thoracotomy, 8 children (4 asymptomatic) had laparotomy, and 2 (1 asymptomatic) underwent perineal resection. A macroscopically complete surgical excision was performed in 17 cases (74%) and a macroscopically near-complete excision in 6 (26%). At histological examination, resection margins contained tumour in 10 patients (43%) and were free of tumour in the remaining 13 (57%). 7 children (30%) had complications after surgery including 3 patients with Horner's syndrome (which persisted in 2), 1 with chylothorax, 1 with pneumothorax, 1 with pain in the arm, and 1 who developed adhesive intestinal obstruction. 2 children received adjuvant chemotherapy. We re-evaluated the histology specimens according to the International Neuroblastoma Pathology Classification and found that the diagnosis of GN was confirmed in 20 cases (83%), while intermixed ganglioneuroblastoma (iGNB) was diagnosed in 4 patients (17%). At 33.5 ± 40 months (range 1-137) follow-up, all 24 patients, including the child not operated on and the children with incomplete resection or iGNB, are alive with no tumour progression or recurrence. CONCLUSIONS: GN excision is associated with postoperative complications which can be persistent and may affect the quality of life of survivors. In our series we did not observe tumour progression in spite of incomplete excision. The rationale for GN excision should be revisited.

Surgical repair of incarcerated inguinal hernia in children: laparoscopic or open?

PURPOSE: The management of Incarcerated Inguinal Hernia (IIH) in children is challenging and may be associated with complications. We aimed to compare the outcomes of laparoscopic vs. open repair of IIH. METHODS: With institutional ethical approval (09SG13), we reviewed the notes of 63 consecutive children who were admitted to a single hospital with the diagnosis of IIH between 2000 and 2008. Data are reported as median (range). Groups were compared by chi-squared or t-tests as appropriate. RESULTS: · Open repair (n=35): There were 21 children with right and 14 with left IIH. 2 patients also had contralateral reducible inguinal hernia. Small bowel resection was required in 2 children. · Laparoscopic repair (n=28): All children had unilateral IIH (19 right sided, 9 left sided). 15 children (54%) with no clinical evidence of contralateral hernia, had contralateral patent processus vaginalis at laparoscopy, which was also repaired. The groups were similar with regard to gender, age at surgery, history of prematurity, interval between admission and surgery, and proportion of patients with successful preoperative manual reduction. However, the duration of operation was longer in the laparoscopy group (p=0.01). Time to full feeds and length of hospital stay were similar in both groups. Postoperative follow-up was 3.5 months (1-36), which was similar in both groups. 5 patients in the group undergoing open repair had serious complications: 1 vas transaction, 1 acquired undescended testis, 2 testicular atrophy and 1 recurrence. The laparoscopic group had a single recurrence. CONCLUSION: Open repair of incarcerated inguinal hernia is associated with serious complications. The laparoscopic technique appears safe, avoids the difficult dissection of an oedematous sac in the groin, allows inspection of the reduced hernia content and permits the repair of a contralateral patent processus vaginalis if present.

Patterns of referral and treatment of undescended testis: a 12-year experience in a single centre.

BACKGROUND: It is now recommended that orchidopexy be performed by 18 months. AIMS: To examine trends in the referral pattern and treatment of cryptorchidism in the south of Ireland. Secondly, to see how well EAU guidelines on orchidopexy management are being implemented in current practice. METHODS: A total of 145 orchidopexies performed over two periods, 1997-1998 (n = 31) and 2007-2008 (n = 114), were reviewed. RESULTS: There was a decrease in the mean age at referral, review in OPD and orchidopexy from 5.88, 6.26, and 6.98 years, respectively, in the first period, to 2.74, 3.45 and 4.1 years between 2007 and 2008. The proportion of boys having surgery before the age of 18 months was minimal and showed no improvement over time. CONCLUSIONS: Although there was a reduction in the age at orchidopexy, only a marginal number of boys underwent the surgery by 18 months of life.

Ovarian germ cell tumours: a 17-year study in a single unit.

BACKGROUND/PURPOSE: The aim of this study was to evaluate the clinical presentation, management and outcome in girls treated for ovarian germ cell tumours at a single unit. METHODS: The records of 40 girls (median age 10.5 years) with histologically proven ovarian germ cell tumours operated upon between 1990 and 2007 were reviewed. RESULTS: Twenty-nine patients had mature teratomas (MT), 5 patients had immature teratomas (IT) and 6 had malignant tumours: 4 malignant mixed germ cell tumours (MMGCT) and 2 germinomas (G). The median age at presentation was 11 years for the MT and IT groups and 8.5 years for the malignant group. The commonest symptoms and signs at presentation were pain (n=28), a palpable mass (n=15) and abdominal distension (n=9). Precocious puberty was noted at presentation in three patients with malignant tumours. Tumour markers were elevated at presentation in all patients with MMGCT. At operation, 14 patients with MT had ovarian torsion. Open unilateral oophorectomy was the procedure most frequently performed (n=30). Surgery alone was the treatment for all patients with MT and IT. Of the patients with malignant tumours, 1 had stage I, 2 had stage II, 1 had stage III and 1 had stage IV disease. All 40 patients are now between 8 months and 17 years post treatment with no contralateral tumours identified. There was one recurrence in a patient with IT, with raised tumour markers. CONCLUSIONS: Ovarian germ cell tumours are uncommon in childhood. Tumour markers are valuable both pre and post-operatively. Malignancy is a risk regardless of age. Surgery is curative in the majority of cases. The overall outlook is very good. However, a close collaboration between surgeons, histologists, radiologists and oncologists is essential to achieve good outcomes.