Outcome of redo orchidopexy after previous laparoscopic orchidopexy.

PURPOSE: Testicular reascent is a recognised complication of orchidopexy, and redo surgery may be required. In this report, we present our experience of redo orchidopexy after initial laparoscopic surgery. METHODS: Patients who had undergone redo orchidopexy following an initial vessel-sparing (VS) or non-vessel sparing (NVS) laparoscopic orchidopexy between 2005 and 2019 were identified. Outcome data, including complications and testicular size, were recorded. RESULTS: The series comprised 23 patients (5: initial bilateral surgery with reascent on one side only; 18: unilateral surgery) with a mean age at original surgery of 3.5 years (range 8 months-6 years) and at redo surgery, 4 years (range 1.5-7 years). VS surgery had been undertaken in 15 and NVS in 8. A tension-free scrotal position was achieved in all cases. There were no complications and no patient required orchidectomy. At a minimum of 6-month follow-up after redo surgery, there were no cases of reascent and there was no change in testicular size/volume (based on clinical examination). CONCLUSION: Redo orchidopexy is an effective treatment following failed laparoscopic orchidopexy and a scrotal testis can be achieved in all cases. Complete testicular atrophy did not occur, but the risk of partial atrophy could not be accurately quantified.

Accessory scrotum with perineal lipoma/hamartoma mimicking penoscrotal pseudoduplication.

Congenital anomalies of the scrotum are thought to be caused by an abnormal migration of the labioscrotal swelling during the embryological process. We report the case of an infant in whom suspected penoscrotal pseudoduplication was apparent at delivery. Imaging using ultrasound scan and magnetic resonance imaging allowed anatomical delineation of the abnormality and the appropriate surgical intervention to be determined. Full surgical correction was done at 4 weeks of age with good outcome. We discuss the differential diagnosis and the management of congenital scrotal abnormalities.

Anterior deflected urinary stream.

We present a case of anterior deflected urinary stream (ADUS) secondary to meatal shelf with no dysfunctional voiding symptoms (DV). The video illustrates the presentation, operative management and literature review. Meatal deformity in girls has been described in association with DV. Hoebeke et al. highlighted the strong correlation between meatal abnormality and non-neurogenic bladder dysfunction in girls. They demonstrated that girls with ADUS had more severe dysfunction on urodynamics. Klijn et al. prospectively evaluated the effect of surgical meatal correction in girls with ADUS. They found that 39% of female patients with DV had ADUS, 50% of them were free of symptoms following surgical correction. This is the first reported case of an isolated ADUS without DV. Early correction of the anomaly is advocated to limit social distress, and potentially prevent development of DV.

How dangerous a toy can be? The magnetic effect.

During the last decade, there has been a significant increase in the number of magnetic toys available for children. Two or more magnets separate from each other along the gastrointestinal course can attract each other across bowel walls, resulting in pressure necrosis, bowel perforations and fistulas formation. This has led to an increasing number of case reports describing serious complications from ingesting more than one magnet. We report the ingestion of a large number of magnets from one toy (>60 pieces). Our patient presented with generalised peritonitis and shock. During emergency laparotomy, she was found to have gross abdominal contamination with multiple bowel perforations and fistulae. This report emphasises the danger of such toys and how important that parents, physicians and manufacturers are aware of such fatal hazards that can arise from 'unsupervised' ingestion of these 'nice-looking' toys.

Assessment of the introduction of an adolescent transition urology clinic using a validated questionnaire.

BACKGROUND: Adolescents with complex urological conditions are at risk of bladder dysfunction, metabolic disturbances, neoplastic changes and deterioration in renal function. Hence they require appropriate transition to the adult service to ensure lifelong urological care is adequately provided. OBJECTIVE: Barriers and difficulties to the transition process have been identified in the literature. To overcome these difficulties an Adolescent Transition Urology Clinic (ATUC) was established in 2009 where the patients are seen by a paediatric and an adult urologist, a urology nurse and if needed an adolescent gynaecologist. Our aim was to assess the ATUC and present the patient's perspective to this new service using a validated questionnaire. MATERIALS AND METHODS: Data of all patients seen at the ATUC over the study period were prospectively recorded. Patients who completed the transition were contacted and asked to complete two online urological transition questionnaires: 1) The Care Transition Measure 15 (CTM-15) which is a validated questionnaire to assess the quality of care during transition from the patients' perspective. 2) The Transition Care Experience (TCE) which was created for the purpose of this study. RESULTS: Thirty patients attended the ATUC over 4.5 years, with 26 (87%) completing the transition to the adult urological care. Of the 26 patients there were 14 (54%) males with a mean age of 18 years. The most common underlying urological condition was neurogenic bladder (85%). Nineteen (73%) patients completed the questionnaires. Only 1 (5%) patient thought that attending the ATUC was not beneficial, 17 (89%) would recommend the ATUC to other adolescents and 9 (47%) patients considered 18 as the appropriate transition age. Overall, 74% thought that written information would have been useful and 21% considered the adult hospital as an inappropriate environment for young adults. After attending the ATUC, 2 (11%) patients thought their preferences were not met and 3 (16%) patients were not confident that they can take care of their health. DISCUSSION: Transition of patients with complex urological conditions should aim to facilitate transferring the care from the parent to the patient and preparing the adolescent to adult life by addressing their sexual and reproductive functions. Inadequate transition can have serious health consequences. On-going communication between the paediatric and the adult urologist facilitates the transition process even after the transfer of care has occurred. The CTM-15 has been considered as "the only available measure of quality of care during transition from the patients' perspective". Our study suggests that the large majority of adolescent attending the clinic are confident in looking after their complex urological condition. In addition one patient in 5 found the adult hospital environment an inappropriate place for adolescents and they would have preferred longer follow up in a children's hospital. The value of written information after clinic consultation seems to be a useful adjunct that might facilitate the complex transition process. CONCLUSION: This is the first report evaluating the transition of adolescents with complex urological conditions using a validated transition questionnaire. The combined paediatric/adult urology clinic is beneficial in addressing the patients' needs and allowing smooth transition of these complex patients to the adult service.

The long-term outcome of patients diagnosed with sacrococcygeal teratoma in childhood. A study of a national cohort.

BACKGROUND/PURPOSE: The improved survival of sacrococcygeal teratoma (SCT) has led to increased awareness of its long-term sequelae. Our aim was to assess the long-term outcome of a national cohort using detailed questionnaires. METHODS: The three paediatric surgery centres in Scotland were contacted to identify all SCT patients ≥5 years of age. Case notes were reviewed. Detailed separate questionnaires were used to assess long-term bowel, urinary and obstetric outcomes and were completed during an arranged interview. Groups were statistically compared using Z-tests or Fisher's exact test. RESULTS: Overall, 48 patients were identified but only 31 were available for follow-up. Age ranged from 5-35 years (median 12 years and 8 months). There were 25 (81%) females and 5 (16%) patients had malignant disease. Abnormal bowel function was noted in 42% of patients, with constipation being the commonest complaint (39%) with no obvious predictive features at presentation. Urinary symptoms were reported in 55% of the patients. A total of nine (29%) patients suffered from urgency and/or wetting. Confirmed urinary tract infections (UTIs) were reported by nine patients. Successful pregnancies were reported by two females and neither of their children had SCT. CONCLUSIONS: This is one of the largest national studies assessing the long-term outcome of patients with SCT. It highlights the significant gastrointestinal and urological long-term morbidities of SCT patients, which is useful for counselling families.

The long-term psychosocial outcomes following excision of sacrococcygeal teratoma: a national study.

OBJECTIVE: The overall effect of the reported long-term sequelae following sacrococcygeal teratoma (SCT) excision on the psychosocial and sexual development has not been addressed appropriately in the literature. The aim of this study was to evaluate the psychosocial adjustment of a national cohort of SCT patients using a validated psychosocial questionnaire. METHODS: Three paediatric surgery centres in Scotland were contacted to identify those SCT patients who were now 5 years or older. The main outcome measure was the Derriford Appearance Scale 59 (DAS-59) which assesses concerns of everyday living, personal relationships, self-esteem and emotional distress. Following ethical approval, age appropriate invitation letters and information sheets for both parents and patients were sent to prospective participants. Parents/patients were contacted after 2 weeks to arrange an interview to complete the questionnaire. RESULTS: 31/48 (65%) of patients identified with SCT completed the DAS-59. Participant ages ranged from 5 to 35 years (median 12 years). 5/31 (16%) were malignant cases. There were 25 (81%) female participants and 12 (39%) patients older than 16 years. 9/31 (29%) participants indicated concern over their appearance. However, we found low levels of appearance-related distress and overall participants showed positive adjustment to personal relationships and everyday living on the DAS-59. CONCLUSIONS: This is the first study looking at the psychosocial adjustment of patients with SCT using a validated psychosocial questionnaire. Encouragingly, we found low levels of appearance-related distress. Future research could identify those factors associated with increased risk of poorer outcomes and highlight those in need of psychological intervention.

Feasibility and safety of monopolar diathermy as an alternative to clip ligation in laparoscopic Fowler-Stephens orchiopexy.

PURPOSE: The aims of the study were to study the effect of Fowler-Stephens orchiopexy (FSO) on testicular histology and to assess the feasibility of using monopolar diathermy as an alternative to clip ligation during laparoscopic FSO. PATIENTS AND METHODS: The study included 20 patients with 20 intraabdominal testes and short vessels managed by laparoscopic-staged FSO. Biopsies were taken from intraabdominal testes during the first and second stages of the procedure for histologic comparison. The patients in the study were divided into 2 groups according to the method of dividing the testicular vessels in stage 1. The first 13 patients (group A) were managed by clip ligation of the vessels, whereas monopolar diathermy was used in the following 7 patients (group B). RESULTS: Biopsy findings at stage 2 revealed an overall reduction in both the total number of germ cells per tubule and mean diameter of seminiferous tubules, whereas there was no statistically significant difference between the results in groups A and B. CONCLUSION: The seminiferous cells can withstand (survive) dividing the main blood supply of the testis during FSO. The monopolar diathermy can be used as an alternative to clipping during laparoscopic procedures, having the advantages of lower expenses and using smaller instruments.

Urogenital anomalies in girls with sacrococcygeal teratoma: a commonly missed association.

BACKGROUND: The association of urogenital (UG) anomalies and sacrococcygeal teratoma (SCT) has not been widely reported. Our aim was to look at the national incidence and presentation of this anomaly in patients with SCT and to provide the first report of a clear anatomical description of this commonly missed association. METHODS: Sacrococcygeal teratoma cases in Scotland during the last 30 years were identified. Patients with associated UG anomalies were reviewed in detail to identify their presentation, anatomy, and management. RESULTS: Fifty-three patients with SCT were identified, including 41 girls. Five girls (12%) subsequently had a UG anomaly diagnosed, which was not apparent at the initial surgery. Two patients presented with retention, and their anomaly was diagnosed at 6 weeks and 7 months of age. The other 3 presented with incontinence, and despite thorough assessment, including cystoscopy, their UG anomalies were not recognized until the ages of 7, 9, and 13 years. CONCLUSIONS: Urogenital anomalies are surprisingly common in girls with SCT. The reason for this association is unclear. None of these cases were diagnosed initially, which means that it was either missed or acquired. Urogenital anomalies should be suspected in girls with SCT and actively excluded in those with voiding difficulties.

Thoracoscopic excision of the sympathetic chain: an easy and effective treatment for hyperhidrosis in children.

BACKGROUND: Thoracoscopic sympathectomy (TS) is an effective treatment for hyperhidrosis. Various surgical approaches are described in the literature. We describe the technique of thoracoscopic excision of the sympathetic chain done exclusively in children younger than 13 years. METHODS: All patients younger than 13 years who underwent TS from 2006 at a single institution were prospectively identified and fully evaluated with emphasis on demographic data, age, surgical management, complications and follow-up. All patients were contacted again at the end of 2009 to complete a follow-up questionnaire. RESULTS: Twelve patients underwent TS between 2006 and 2009. Age ranged from 6 to 13 years. This involved T2-T3 excision for nine patients with isolated palmar hyperhidrosis, and T2-T3-T4 excision for three with additional axillary hyperhidrosis. Six underwent bilateral TS at the same session and six underwent unilateral TS for the dominant side. Four of them had their contralateral operation performed 2-3 months later. Dry limbs were immediately achieved in all patients. Compensatory sweating (CS) was noted in eight patients. Complications included transient ptosis in two and mild recurrence in one. CONCLUSIONS: Thoracoscopic excision of the sympathetic chain is a simple and safe procedure that relieves hyperhidrosis in all cases and significantly improves the quality of life.