Ectopic Ureter Accompanied by Duplicated Ureter: Three Cases.

We report cases of ectopic ureter accompanied by three types of ureteral duplication that had been diagnosed previously and treated for enuresis. Data from three female patients ranging in age from 1 to 10 years were evaluated. The ectopic ureter was observed on the left in one case, on the right in another and bilateral in the third case. Complete duplication was found in two cases, while the third had incomplete duplication. Ureteroneocystostomy was performed in one case and subtotal nephrectomy was carried out in the other two cases. Ureteroneocystostomy was performed for the ectopic ureter found in the opposite urinary system in one of the cases. Ectopic duplicated ureter should be considered in treatment-resistant enuresis and urinary tract infections and after a careful physical examination, imaging as well as function tests should be performed.

Effect of ketamine versus alfentanil following midazolam in preventing emergence agitation in children after sevoflurane anaesthesia: a prospective randomized clinical trial.

OBJECTIVE: To investigate the effect of intranasal ketamine versus alfentanil in addition to oral midazolam for the prevention of emergence agitation in children. METHODS: Children undergoing urological surgery with sevoflurane anaesthesia received oral midazolam 40 min before induction and were then randomly assigned to receive 2 mg/kg ketamine, 10 µg/kg alfentanil or 1 ml isotonic saline intranasally. Parental separation status and mask acceptance were assessed preoperatively. Emergence agitation was evaluated using a paediatric anaesthesia emergence delirium (PAED) score. RESULTS: Data from 78 children were evaluated in the study. There were no significant differences between the groups in demographic characteristics, recovery times or parental separation scores. Mask acceptance was significantly better in the ketamine group than in the saline group. The mean PAED score in the ketamine group was significantly better than in the other two groups, but was similar in the saline and alfentanil groups. The incidence of emergence agitation was 3.8%, 36.0% and 40.7% in the ketamine, alfentanil and saline groups, respectively. CONCLUSIONS: The addition of intranasal ketamine to oral midazolam significantly improved the quality of induction and reduced sevoflurane-induced emergence agitation, in children undergoing urological surgery.

A rare complication of an ingested foreign body: gallbladder perforation.

We present a 13-year-old child who admitted with a dull right upper quadrant pain that started 3 weeks before her referral. Several medications were given but they did not change the intensity and the frequency of the pain. Her physical examination was nonspecific except for slight right upper quadrant tenderness. The imaging studies revealed a sewing pin perforating the stomach and gallbladder. The patient was treated with a successful operation, and no postoperative complications were observed. To our knowledge, this is the first case of a sharp foreign body gallbladder perforation in a child.

A comparison of two different doses of bupivacaine in caudal anesthesia for neonatal circumcision. A randomized clinical trial.

BACKGROUND: We aimed to compare the analgesia quality of caudal block of low volume, high concentration bupivacaine to the conventionally used volumes and concentrations of the drug in neonates undergoing circumcision with sole caudal anesthesia. METHODS: Fifty neonates, undergoing circumcision were randomly assigned to low volume high concentration (group LVHC, n=25) and control groups (group C, n=25). Both groups received a caudal injection: Group LVHC 0.5 ml/kg bupivacaine 0.375% (1.875 mg/kg) and group C 1 ml/ kg bupivacaine 0.25% (2.5 mg/kg). Hemodynamic parameters, block onsets and analgesia periods were compared among the groups. Pain scores were evaluated hourly for 3 hours postoperatively with NIPS (neonatal infant pain score). Statistical analyses were performed with Student's t-test for continuous variables. X(2) and Mann-Whitney U-tests were used for nominal and/or categorical variables. RESULTS: Demographic, hemodynamic data, block onset time (group LVHC and C values were 4.9 +/- 1 vs 5.2 +/- 2 mins, respectively; p=0.53) was similar and postoperative median NIPS (a median value of 0 at postoperative 1, 2, and 3. hours) were identical among the groups (p=0.7, p=0.9, p=1). None of the neonates required additional analgesic for the first 24 hours following the surgery; therefore postoperative analgesic requirement was similar among the groups (p>0.1). CONCLUSIONS: Low volume high concentration caudal bupivacaine provided a similar perioperative analgesia quality, time and safety profile compared to conventional bupivacaine doses in awake neonates undergoing circumcision. Low volume, high concentration bupivacaine may be used to reduce the risk of local anesthetic toxicity in outpatient neonates.

Subsequent alterations in the contractile property of the vas deferens according to duration of spermatic cord torsion.

OBJECTIVE: To determine whether twisting of the ipsilateral vas deferens results in alteration of its contractility. DESIGN: Experimental study. SETTING: University animal lab. ANIMAL(S): 24 male Wistar rats. INTERVENTION(S): All the rats in the experimental groups underwent spermatic cord torsion. Durations of torsion were 45 minutes, 3 hours, and 24 hours in groups 2, 3, and 4, respectively. In groups 2 and 3, subgroups b were created to evaluate late effects using in vitro pharmacological techniques. MAIN OUTCOME MEASURE(S): The contractility of the vas deferens was evaluated in groups 1, 2a, 3a, and 4 right after and in groups 2b and 3b 48 hours after the initial operation. RESULT(S): Group 4 and subgroups 2b and 3a had significantly diminished responses compared with the control group, whereas in subgroups 2a and 3b, the responses to noradrenaline and to single-pulse field stimulation were not significantly different. CONCLUSION(S): The impairment of contractility with the twisting of the vas deferens might be another factor responsible for subfertility, particularly that related to sperm transport. The unfavorable late change in short duration of torsion may be the result of either ischemia and reperfusion injury or sympathetic overactivation in the acute period of torsion.

Effects of hydroxyzine-midazolam premedication on sevoflurane-induced paediatric emergence agitation: a prospective randomised clinical trial.

BACKGROUND AND AIM: Anaesthesia with sevoflurane leads to a high prevalence of emergence agitation in paediatric patients. This study investigates the effects of combining hydroxyzine and midazolam on sevoflurane-induced emergence agitation in paediatric patients undergoing infraumbilical surgery with a caudal block. PATIENTS AND METHODS: Eighty-four children 1-7 years of age undergoing general anaesthesia with sevoflurane and caudal block were assigned to two groups. Children in group M (n = 42) were premedicated with 0.5 mg kg oral midazolam and children in group MH (n = 42) were premedicated with 0.5 mg kg oral midazolam and 1 mg kg hydroxyzine given 30 min before anaesthesia induction. A caudal epidural block was performed following anaesthesia induction. Induction quality, parental separation scores and emergence agitation were evaluated. Emergence agitation was evaluated with the PAED score (Paediatric Anesthesia Emergence Delirium) every 5 min during the first 30 min after admission to recovery room. Induction quality and parental separation were assessed with 4-point scores. Postoperative pain was evaluated with the 10-point Children's and Infants' Postoperative Pain Scale. RESULTS: Median parental separation (3 vs. 2; P = 0.01), induction quality (2 vs. 2; P = 0.03) and sedation scores (3 vs. 2; P = 0.003) were significantly better in the MH group compared to the M group. Median PAED score of group M (15) was higher than that of group MH (11; P < 0.001) and the number of children with PAED scores more than 16 was also higher in group M (n = 16) compared to group MH (n = 2; P < 0.001). None of the children had a pain score more than 3 throughout the study period. CONCLUSION: The incidence of sevoflurane-induced emergence agitation was significantly lower in children premedicated with a midazolam and hydroxyzine combination compared to those premedicated with midazolam only. Furthermore, the midazolam and hydroxyzine combination provided better premedication quality than midazolam alone.

Loss of Insl3: a potential predisposing factor for testicular torsion.

PURPOSE: The testicular hormone Insl3 is critical for mouse gubernacular development. Knockout mice exhibit bilateral intra-abdominal cryptorchidism with absent gubernaculum. Prior studies described torsion of the vas deferens in Insl3 mutant mice. We performed a detailed anatomical analysis of the vas deferens and testis in Insl3 mutant mice to characterize associated anomalies further. MATERIALS AND METHODS: Insl3 wild-type (Insl3(+/+)), heterozygous (Insl3(+/-)) and knockout (Insl3(-/-)) male mice were examined either prepubertally (postnatal day 23) or in adulthood (postnatal day 90 or later). The macroscopic appearance, characteristics, and mobility of the testes and spermatic cord were recorded. RESULTS: We examined 56 prepubertal and 33 adult mice (175 testes, 28 [20:8] Insl3(+/+), 97 [60:37] Insl3(+/-), 50 [32:18] Insl3(-/-)). Unlike normal Insl3(+/+) testes, 94% of Insl3(-/-) testes were located intra-abdominally at all ages. Delayed descent occurred in Insl3((+/-)) testes, since 37% of postnatal day 23 and 8% of P90 or later testes were intra-abdominal. Vas elongation/convolution and spermatic cord twisting were noted in 65% of Insl3(-/-), 27% of Insl3((+/-)) and 0% of Insl3(+/+) testes. While all Insl3(+/+) testes were normal, 5% of Insl3((+/-)) and 32% of Insl3(-/-) testes showed significant testicular pathology, including torsion, atrophy and vanished testis, which statistically increased with age. CONCLUSIONS: Poorly formed gubernacula and increased testicular mobility in Insl3 mutant mice result in spermatic cord anomalies, delayed/absent testicular descent and subsequent testicular torsion in a gene dose dependent manner. Prepubertal testicular torsion in the mutant mice predisposes to testicular atrophy and vanishing testes in adulthood. Thus, Insl3 is a candidate signaling molecule in human delayed testicular descent and torsion.

Comparison of the effect of sevoflurane and halothane anesthesia on the fall in heart rate as a predictor of successful single shot caudal epidural in children.

OBJECTIVE: To investigate the effect of sevoflurane anesthesia on heart rate HR fall with the injection of the initial drug in caudal space to confirm the correct needle placement. METHODS: After the ethical approval was obtained from the hospital's ethics committee, a prospective, randomized, clinical study was designed in Yeditepe University Hospital, in 2007. Children aged 1-12 years, scheduled for infraumbilical surgery under general anesthesia, and caudal block were included in the study. Anesthesia was induced, and maintained by sevoflurane in group S (n=85), and by halothane in group H (n=82). Baseline HR was recorded before the caudal block was performed. The HR changes during the initial dose, and total drug injection were recorded followed by 2 more HR recordings taken 5, and 10 minutes after caudal injection. The success of the block was recorded by a blind observer. RESULTS: There were 167 children included in the study. Caudal block success was 96.5% in group S, and 97.6% in group H. Basal HR was 110.9 +/- 10.9 in group S, and 105.9 +/- 10.1 in group H. Following the initial drug injection, mean HR was 109.8 +/- 10.9 in group S, and 102.9 +/- 9.9 in group H. It was significantly lower than the baseline in group H. The only significant decrease in the HR of the patients in group S was at the tenth minute following caudal injection. CONCLUSION: The decrease in HR with drug injection has no value to predict the success of caudal block under sevoflurane anesthesia.

An old technique for surgery of 'high' undescended testis revisited.

INTRODUCTION: Most undescended testes resolve spontaneously in the first year of life. If the testis remains undescended by the second year, the most probable means of scrotal placement is orchiopexy. After the first successful operation for orchiopexy, many surgical modifications were described. This study presents our limited experience with Prentiss' maneuver in six boys with high undescended testes. PATIENTS AND METHODS: Two left, two right and two bilateral testes, in six patients, were operated. Five patients were admitted with the complaint of unilaterally or bilaterally 'empty scrotum'. The sixth patient previously had a right high undescended testis which had been placed in a high scrotal position. Following the standard steps of inguinal orchiopexy Prentiss' maneuver were performed and yielded adequate distance to place the testes mid scrotum. RESULTS: On follow-up, Doppler ultrasound examination revealed normal sized testes with normal blood flow in all patients with dimensions correlated with age. CONCLUSION: Although perhaps only useful in orchiopexy for high undescended testis, incision of the transversalis fascia preserves testicular blood flow by relieving tension on the testicular vessels.

Internal jugular vein diameter in pediatric patients: are the J-shaped guidewire diameters bigger than internal jugular vein? An evaluation with ultrasound.

AIM: This study investigates whether the diameters of right internal jugular vein (RIJV) are suitable for the use of 'big radius curved J-tip' Seldinger wires in pediatric patients. METHODS: One-hundred and thirty-five children, 1 month to 15 years of age, scheduled for pediatric surgery were divided into four subgroups according to their age (0-12 months, 1-2 years, 2-6 years old, and >6 years). Patients in the 0-12 months group were further divided into two groups as 0-6 months and 7-12 months of age to evaluate RIJV characteristics in detail. Following anesthesia induction, depth, diameter, and area of RIJV were measured with ultrasound at the level of cricoid cartilage and sterno-clavicular junction in supine and Trendelenburg position. RESULTS: Infants in the 0-6 months of age group had the least mean diameter of RIJV at both the cricoid cartilage and the sternoclavicular junction level (0.484 +/- 0.132 and 0.499 +/- 0.136 cm). The aforementioned diameter was significantly lower than the values of other age groups (P < 0.05). Trendelenburg position did not increase RIJV diameter in children below 6 and cross-sectional area below 2 years old. Correlations between age, height, weight, head circumference and RIJV diameter, cross-sectional area, depth from the skin were weak. CONCLUSION: The diameter of the IJV in pediatric patients, especially infants, is often smaller than the diameter of the J-tip guidewire curve. We speculate that this may lead to impeded guidewires and failed cannulation. It must also be kept in mind that the Trendelenberg position might not facilitate IJV cannulation in children <2 years of age.

Preoperative sonography of nonreducible inguinal masses in girls.

PURPOSE: Inguinal hernia is one of the most common surgical pathologies in childhood. Any of the abdominal organs can slide into the hernial sac and become incarcerated there. In girls, the fallopian tubes, ovaries, uterus, and-rarely-ovarian cysts can form the sliding component of an inguinal hernia. The aim of this study was to investigate the diagnostic value of preoperative sonographic examination in girls with nonreducible inguinal masses. METHODS: Nine girls ranging in age from 2 months to 8 years who were admitted to our clinic with nonreducible inguinal masses were included in the study. All patients underwent sonographic examination followed by surgery on the day of admission. RESULTS: A definitive diagnosis was obtained in 6 patients on preoperative sonographic evaluation, whereas 3 patients were misdiagnosed. One patient was diagnosed sonographically as having lymphadenopathy, but surgery revealed an ovarian cyst sliding into the hernial sac. A second patient was found to have an infected lymph node at surgery instead of a strangulated bowel loop as diagnosed on sonographic examination. In the third patient, the preoperative sonographic diagnosis was an ovarian cyst in the hernia sac, but surgery revealed a cyst of the canal of Nuck. CONCLUSION: Inguinal masses in young girls must be carefully evaluated, because the sonographic preoperative diagnosis may be misleading.

The effect of 2 different concentrations of rectal ketamine on its premedicant features in children.

OBJECTIVE: To investigate whether changing concentration and volume of ketamine for rectal premedication would change the premedication and recovery characteristics. METHODS: A prospective, randomized, clinical study was designed in Yeditepe University Hospital, Istanbul, Turkey in 2006-2007. The study group included children weighing 10-20 kg, American Society of Anesthesiologists grade I, scheduled for inguinal hernia repair or circumcision under general anesthesia with orotracheal intubation and caudal blockade. Children were rectally premedicated with 10 mg.kg-1 ketamine 5% in group K, and 2.5% in the Group K1/2, 45 minutes before anesthesia. Anesthesia was induced and maintained by inhalation. Sedation scores at 15 minutes intervals in the preinduction area, parental separation scores, induction and recovery characteristics, time to discharge and a questionnaire at 24th postoperative hour were recorded. RESULTS: One hundred children were randomized into 2 groups of 50. Thirty minutes 1.2 versus 0.48, p=0.018 and 45 minutes 2.24 versus 1.8, p=0.027 following premedication group K1/2 had significantly lower mean sedation scores than group K. Separation, induction quality scores, induction duration, secretion scores either during induction or postoperative period, and recovery characteristics were all comparable in both groups. CONCLUSION: Although adequate sedation was obtained for most of the children in both groups, rectal premedication with 5% ketamine resulted in higher levels of sedation appearing earlier than that of 2.5% ketamine, while change of volume and concentration had no effect on recovery characteristics.

Incomplete duodenal obstruction in a newborn.

A case of newborn with incomplete duodenal obstruction caused by superior mesenteric artery syndrome has been presented with this report. A full term, 1-day-old baby girl was referred to our hospital because of recurrent bilious vomiting since birth and upper gastrointestinal barium study revealed the incomplete obstruction at the 3rd part of the duodenum with a vertical abrupt cutoff. The diagnosis of superior mesenteric artery syndrome was made with ultrasonography and duodenojejunostomy was carried out. Although it is extremely rare, superior mesenteric artery syndrome should also be considered as one of the rare cause of incomplete duodenal obstruction in newborn period.

A continuous debate on contralateral processus vaginalis: evaluation technique and approach to patency.

We present our experience with the transinguinal diagnostic laparoscopy and discuss its efficacy in evaluating the contralateral side in unilateral inguinal hernias. The possible influence of the initial side of hernia, age and gender on recognized bilateralism were also evaluated in two study groups (diagnostic laparoscopy vs clinical diagnosis). In this retrospective study, we evaluated 36 bilateral, 158 left-sided and 303 right-sided consecutive inguinal hernia cases. A total of 211 out of 461 unilateral cases underwent hernia repair and transinguinal laparoscopic evaluation of the contralateral side. Complications and difficulties of the technique, the mean duration of laparoscopy and operative times were additionally analyzed from operation charts. In this study, bilateralism was determined by transinguinal laparoscopy in Group 1 (children with a contralateral patent processus vaginalis) and clinically in Group 2 those who had a metachronous hernia. The patients were also analyzed according to the side of the inguinal hernia, age and gender in both groups. We found an overall positive contralateral patency in 41 cases (19.4%). We failed to perform a successful diagnostic laparoscopy in six cases (2.7%). No anesthetic or surgical complications were noted. Transinguinal laparoscopy did not add any considerable time to the mean operation time. The incidence of bilateralism in Group 1 was higher in girls than boys. Clinically detected bilateralism was significantly higher in 0-6 month age group and contralateral patency detected via laparoscopy was high in all other age groups. We may conclude that transinguinal diagnostic laparoscopy is a feasible technique in children. We advocate its use as a tool with minimal complication risk even in the hands of novice.

Familial ureteroceles: an evidence for genetic background?

In the pediatric population, ureteroceles may present with different clinical pictures, and the severity of the renal damage is greater than in adults. Ureterocele, an anomaly of ureteric budding, is likely a component of a spectrum of anomalies including vesicoureteral reflux and ureteral duplications. Both have been confirmed to have a genetic and familial basis. We document the largest series of familial cases of ureteroceles, giving evidence for genetic background. We retrospectively reviewed the charts of patients with familial ureteroceles seen between 1992 and 2002. Coexisting ureteral anomalies and features of the cases were documented and compared to sporadic cases and all familial cases within the literature. This is the largest series of familial ureterocele patients in the literature. The review of the literature revealed seven publications with seven ureterocele families (15 affected patients) between 1936 and 2002. Comparing sex, ureterocele location, and single versus duplex systems, familial series are similar to other sporadic cases. Three of the families have twin siblings with ureteroceles. Familial cases, despite their rarity, raise the issue of the genetic origin of uretereoceles. Family members of ureterocele cases should be informed and followed carefully, especially twins. Increased reporting and genetic analysis of familial ureteroceles may prove to link the genetic mouse models of abnormal ureteric budding to the human conditions.

Consistency of urodynamic parameters in children with detrusor instability: how many times should the bladder be filled?

INTRODUCTION: It is recommended that the bladder be filled at least twice to perform a standard urodynamic study. However, the procedure is time-consuming and distressing for both the patient and the professional. The impact of the number of fillings on urodynamic parameters in children with normal urodynamic results and those with detrusor instability is presented in this study. PATIENTS AND METHODS: Urodynamic data from 70 children with detrusor instability and 42 with normal urodynamic parameters who had undergone 3 consecutive fillings in a single session during a 2-year period were reviewed retrospectively. The variable parameters that were compared between the 2 groups were the mean bladder capacity ratio, maximum filling pressure and the number of contractions during the filling phase. RESULTS: In the normal group, no difference was found in bladder capacities between the 3 fillings, but there was a significant decrease in the maximum bladder filling pressures in the subsequent fillings. In children with detrusor instability, the number of contractions in the 1st filling was significantly higher than those in the subsequent fillings. Also in this group, a significant difference in the mean bladder capacities between fillings was noted as well as a decrease in the maximum bladder filling pressures in contrast to normal bladders. CONCLUSION: In patients with suspected detrusor instability the bladder should be filled at least twice for a reliable urodynamic assessment. Two normal fillings without contractions, with normal capacity and normal maximum bladder filling pressure are highly suggestive of a normal 3rd filling.

Advantages of video-assisted approach in detecting epididymal anomalies and treatment of nonpalpable testis.

In children with a nonpalpable abdominal testis, preoperative localization is very helpful prior to surgical investigation both to reduce the time required and to plan the correct surgical procedure. It is no doubt that laparoscopy is useful in both diagnosis and management of nonpalpable testis. In this study, 15 patients with 17 nonpalpable testes admitted to our clinic in 2 years period were evaluated retrospectively. Ultrasound study was performed in all patients after detailed physical examination. Testicular location, size, and configuration of epididymis were determined by laparoscopy and compared with ultrasound findings. Laparoscopy, in conjunction with ultrasound, permits not only a better localization and anatomy of the testis but is also superior in planning the best choice of management. We believe that the video-assisted inguinal approach is a feasible method in the treatment of nonpalpable testis when compared to pure open surgery.