Congenital anterior urethral valves and diverticulum: A case series and association with posterior urethral valves.

INTRODUCTION: There is limited data regarding long-term results and associated complications in patients with anterior urethral valve (AUV) and diverticulum (AUD). We retrospectively reviewed AUV/AUD cases managed by us between the year 2002-2020. MATERIAL AND METHODS: Presentation, investigations, management, concomitant posterior urethral valves (PUV) and pre-operative characteristics predisposing to long-term poor renal outcome were assessed. RESULTS: There were 27 patients [AUV (n = 11); AUD (n = 16)] with 5 having concomitant PUV. All presented with poor urinary stream and dribbling at a median age of 1-year (5 days-12 years). More patients with AUD (9 of 16, 56.3%) especially with concomitant PUV presented at ≤1-year-age as compared to those with AUV (4 of 11, 36.4%). Concomitant PUV and AUD cases (n = 3) had characteristic micturating cystourethrography (MCUG) features. (Fig. 1A) Retrograde urethrography delineated the valve and distal urethra dimensions better (Fig. 1B, C). Urethral hypoplasia distal to the valve (n = 4) urethral duplication (n = 1) were associated (Fig. 1D). Syringocele was ruled out in proximal AUD by absence of filling defect on MCUG and appearance of urethral walls on urethrocystoscopy. Serum creatinine > 1 mg/dL (n = 5), trabeculated bladder (n = 12), and vesicoureteral reflux (VUR) (n = 12) was noted at presentation. Diverticulum/valve excision (n = 13, 48.2%), fulguration alone (n = 12, 44.4%) and primary urinary diversion (n = 2, 7.4%) were performed. Follow up (range:3 mo-19 years), showed deranged renal function tests (n = 6), VUR (n = 4), impaired renal function on scans (n = 8), and lower urinary tract dysfunction (n = 7). Outcome with and without associated PUV was similar. Long term results were better in AUV compared to AUD. Pre-operative raised serum creatinine (>1 mg/dL), trabeculated bladder, non-dilated posterior urethra on MCUG and bilateral impaired renal function on scans had significant association with follow up eGFR less than 60 ml/kg/min. CONCLUSIONS: Co-existing PUV and AUD present earlier and have specific imaging findings. In proximal AUD, possibility of syringocele should be kept in mind, as they have similar presentation and imaging. Concomitant PUV did not alter prognosis. Secondary effects on bladder and renal function were more with AUD. Follow up eGFR less than 60 ml/kg/min was associated with pre-operative elevated serum creatinine, trabeculated bladder, non-dilated posterior urethra, and bilateral impaired renal function on scans.

External and internal parasitic conjoined twinning: Diverse presentation and different surgical challenges.

Background: Parasitic conjoined twin is a rare but well-known entity with unclear embryopathogenesis. Abnormal conjoined twinning can result in an externally attached parasitic twin (PT), an enclosed foetus in foetu, or a mature teratoma. The treatment requires complete excision and reconstruction of local anatomy which is not always straightforward. Materials and Methods: PT cases presenting over 12 years were analysed. Patients with complete data, histopathological diagnosis and follow-up were included in the study. During follow-up, specific complications and related investigations were considered. Results: A total of five patients at four different sites were identified: two retroperitoneal foetus in foetu and three externally attached PTs which were located in the lumbar region, sacrococcygeal area and on the lower anterior abdominal wall. All patients underwent complete surgical excision. In foetus in foetu cases, the blood supply was directly from the aorta with a short stump while the three externally located ones required meticulous and careful dissection with the reconstruction of local anatomy. Conclusion: Parasitic conjoined twinning can present at different sites and surgical challenges vary accordingly. For surface lesions, reconstruction may be as complicated as excision. Prognosis can be affected by the excellence of anatomical restoration. Long-term follow-up is essential to address problems specific to the site of lesion and method of surgical reconstruction.

Outcome of pediatric germ cell tumor with comparison of carboplatin and cisplatin based regimens: A 10-year analysis.

Carboplatin is being advocated more frequently for treatment of childhood germ cell tumors (GCT), due to less long-term toxicity, and demonstrable equivalence in outcome as compared to cisplatin. This analysis presents the survival of GCT in a low middle-income country and compares two different chemotherapeutic regimens. A retrospective analysis of patient case records was carried out over 10-years (January 2007-December 2016). Chemotherapy regimen used was bleomycin, etoposide, and cisplatin (PEb) for initial 6-½ years and carboplatin, etoposide, and bleomycin (CEb) subsequently. Ninety patients with GCT were treated over 10-years. Malignant GCT was diagnosed in 69 (77%) patients, with 21(23%) having teratoma. The chemotherapy protocol was PEb in 38 (42%), CEb in 28 (31%) patients, while 24 patients were treated with surgery only. Stage 4 tumor was observed in 19 (21%) patients. Relapse or disease progression was seen in 11(12%). Overall and event-free survival at 5-years for the entire cohort was 77% and 73%, being similar with PEb (OS:77%; EFS:72.5%) vs. CEb (OS:69%; EFS: 69%). Significantly better overall survival was noted for patients with gonadal GCT) and non-stage 4 disease, while event-free survival was significantly better in patients with non-stage 4 disease. The chemotherapeutic regimen (PEb vs. CEb), very high AFP (value ≥10,000 IU/L), and risk stratification (low, intermediate, or high-risk disease) did not affect survival significantly. Carboplatin-based strategy was equivalent in our cohort to cisplatin-based strategy, and could be used safely in the LMIC set-up. The overall survival is suboptimal, with delayed presentation, abandonment, and relapse being barriers to survival.

Modified Duhamel's Two-Staged Procedure for Hirschsprung's Disease: Further Modifications for Improved Outcomes.

AIMS AND OBJECTIVES: We studied the short- and long-term outcomes and quality of life (QOL) in patients undergoing a two-staged modified Duhamel's procedure for Hirschsprung's disease. MATERIALS AND METHODS: Patients who had undergone this modified procedure, with initial Hartmann's procedure based on contrast enema, followed by bowel preparation and low colo-anal anastomosis below the dentate line were included. The patient who underwent this procedure over 10 years with a minimum 2-year follow-up were analysed based on an interview-based questionnaire. RESULTS: Of the 152 patients, 69 responded. Mean age at the time of interview was 7.72 ± 3.04 years with mean follow-up of 4.9 years (2-11 years). Perineal excoriation and soiling was present in 60.9% and 36.2% of patients initially which reduced to 0 and 4.3% by the end of 2 years. In the first 6 months, postoperative period, 15.9% of patients had constipation and 78.2% had altered stool consistency. Good fecal continence score was present in 97.1% of patients in the long term. About 95.4% had good QOL scores. There was no mortality in this series. CONCLUSIONS: Although short-term outcomes showed altered bowel function, soiling, and perineal excoriation, this improved significantly in the long term, with good QOL scores in the majority.

Pediatric Trauma: Management and Lessons Learned.

AIM: The aim is to prospectively study 125 trauma patients admitted in the pediatric surgery ward in our institute. MATERIALS AND METHODS: Pediatric patients admitted in the ward after initial resuscitation in the triage room were included. Isolated neurosurgical and orthopedic injuries were excluded. X-ray cervical spine, hip, and chest and a focused assessment with sonography in trauma ultrasound were done for all patients. Computed tomography of the abdomen or chest was done where relevant. Injury profile and surgical intervention when needed were analyzed. RESULTS: Road traffic accidents and fall from height caused 73.6% of the injuries. School-going children were most commonly affected (60.8%). Distinctive injuries were noted such as abdominal wall hernias and delayed bladder perforation. All solid organ injury irrespective of grade treated conservatively. Forty percent of the children required surgical intervention. Five patients after laparotomy were found to have surgical conditions unrelated to trauma, whereas another 14 required delayed surgery. Five patients had injuries secondary to sexual abuse. All except two patients were discharged in a satisfactory condition and are doing well in the follow-up. CONCLUSION: In spite of extensive injuries and the need for multiple surgeries, children with trauma have a good prognosis. Close observation during admission and also in follow-up are essential, as many patients may require delayed surgery ≥1 week from injury.

Challenges in the management of localized Ewing sarcoma in a developing country.

Survival in pediatric Ewing sarcoma (ES) lags in low- and middle-income countries (LMICs). This study analyzed factors contributing to a lower outcome in an LMIC center. A retrospective case review of children with localized ES treated from January 2011 till December 2017 was performed. Neoadjuvant chemotherapy with alternating cycles of vincristine, doxorubicin, cyclophosphamide; and ifosfamide, etoposide was administered 3-weekly for 48 weeks. Reassessment was planned for week 12, followed by local therapy (surgery/radiotherapy or both) tailed by adjuvant chemotherapy. Forty-eight patients with mean age 8 years (range: 0.7-14) were evaluated. Extremity and central axis tumors were seen in 25 (52%) and 23 (48%) patients. Three patients died of neutropenic sepsis and five abandoned therapy. Local therapy included primary surgery, radiotherapy and a combination of surgery and radiotherapy in 7 (16%), 20 (45%) and 17 (39%) patients. The 3-year event-free survival (EFS) and disease-free survival (DFS) for the cohort were 47.7 ± 11% and 57.6 ± 11.2%. Time to local therapy >16 weeks was associated with inferior DFS vs. local therapy administered within 16 weeks [46.6 ± 12.4 vs. 63.9 ± 19.4, p=.046]. Older age, axial site, large size and incomplete surgical resection did not predict relapse/progression. Patients who received wide local excision, as local therapy, had 100% DFS. Coordinated efforts to ensure timely therapy can improve outcome in pediatric ES. Abandonment and treatment-related mortality (TRM) are additional challenges that need to be tackled in LMICs.

Clinical Presentation and Surgical Management of Neonatal Tumors: Retrospective Analysis.

AIMS: Neonatal tumors (NTs) include a group of diverse neoplasms. In this study, we reviewed our data for clinical presentations, management options, and outcome. MATERIALS AND METHODS: All patients from 0- to 1-month age presenting with solid tumors, from 2006 to 2018 were studied. The gender, presentation, location, type of tumor, and management were analyzed. The final diagnosis was made with histopathology in all cases. Hemangiomas and lymphangiomas were excluded from the study. RESULTS: A total of 32 neonates were studied. The most common tumor was sacrococcygeal teratoma (SCT,16) followed by teratoma at other sites including two cases of fetus-in-fetu, soft-tissue sarcoma (STS, 4), mesenchymal hamartoma (2), hemangioendothelioma (2), and other rare tumors. Three tumors were diagnosed antenatally; of whom, two were neither visible externally nor palpable. Complete surgical excision was done for all except in a case of ovarian cyst where near-total cystectomy was done. No patient received chemotherapy or radiotherapy. Six patients had postoperative complications, including two who had local recurrence requiring excision. There was one mortality. All the other patients are doing well during follow-up. CONCLUSION: NTs have varied presentations. SCT and STS were the most common benign and malignant tumor, respectively. Early diagnosis and complete surgical excision are often curative for all, regardless of the pathology with the minimal role of chemotherapy or radiotherapy.

Type IV Congenital Pouch Colon in Male Children: Anatomical Variations and a Proposed New Subclassification.

BACKGROUND: Congenital pouch colon (CPC) is a rare variant of anorectal malformation. In male patients, CPC communicates distally with the urogenital tract by a large fistula. The CPC cases which do not fulfill the criteria as mentioned in the classical description are reported along with the pertinent literature review. MATERIALS AND METHODS: This was a retrospective study from January 2004 to December 2017 of male children with Type IV CPC. We evaluated clinical presentation, primary management, anatomical relationship, previous surgical intervention, definitive management, result, and outcome in terms of continence status on Templeton score. RESULTS: Fifty-one children were included in the study among whom 36 children (Group 1) had a colovesical fistula and 15 children (Group 2) had no communication of the pouch with the genitourinary tract. In Group 2 children, the clinical presentations and management were varied: 4 underwent primary pull-through procedure, whereas 11 underwent staged procedure. Group 2 included three children in whom a narrow and thin-walled anal canal or anal canal with lower rectum was present, which was incorporated during the pull-through procedure. On continence assessment, only one child in Group 1 had "good" continence score compared to four children (three having anal canal) in Group 2. CONCLUSION: CPC Type IV can present without genitourinary tract communication (fistula), contrary to its emblematic description. Awareness about anatomical variations and adaptation of surgical technique accordingly is vital. The identification of the anal canal with or without the lower part of the rectum (even though apparently narrow and thin walled) and incorporation of this in bowel continuity lead to better outcomes in terms of continence.

Outcome Analysis of Patients of Congenital Hydrocephalus with Ventriculoperitoneal Shunt at a Tertiary Care Hospital in North India.

INTRODUCTION: Ventriculoperitoneal (VP) shunt is a commonly performed neurosurgical procedure in pediatric surgical practice. This study is aimed at determining the outcome of congenital hydrocephalus patients who underwent shunt surgery at our center. MATERIALS AND METHODS: A total of 278 operated cases of congenital hydrocephalus with a minimum follow-up of 6 months were analyzed in terms of complications. Hydrocephalus associated with intracranial hemorrhage, neural tube defects, and ventriculitis were excluded from the study. RESULTS: Complications were observed in 32.0% (89/278) of cases. Shunt block and chamber migration were the most common complications (29.21%). Abdominal wound complications were seen in 4.49% of cases. Shunt exposure due to erosion of overlying skin was noted in 6 patients. Shunt infection was diagnosed in only 9 patients (4.4%). New-onset seizures were seen in 4 cases. Overall, 21% of patients required redo shunt and there were 2 mortalities. CONCLUSION: VP shunt continues to have high complication rates. Shunt migration and new-onset seizure disorders are important late complications. In spite of inherent problems, shunt surgery is the procedure of choice until a safer effective alternative is available.

Consensus on the Management of Posterior Urethral Valves from Antenatal Period to Puberty.

The need for successful management of posterior urethral valves always captivates the minds of pediatric surgeons. Its success, however, depends on several factors ranging from prenatal preservation of upper tracts to postoperative pharmacological compliance. Regardless of measures available, some cases do not respond and progress to end stage. The management depends on several issues ranging from age and severity at presentation to long-term follow-up and prevention of secondary renal damage and managing valve bladder syndrome. This article is based on a consensus to the set of questionnaires, prepared by research section of Indian Association of Paediatric Surgeons and discussed by experienced pediatric surgeons based in different institutions in the country. Standard operating procedures for conducting a voiding cystourethrogram and cystoscopy were formulated. Age-wise contrast dosage was calculated for ready reference. Current evidence from literature was also reviewed and included to complete the topic.

Effectiveness of hand hygiene promotional program based on the WHO multimodal hand hygiene improvement strategy, in terms of compliance and decontamination efficacy in an indian tertiary level neonatal surgical intensive care unit.

Background: The WHO Multimodal Hand Hygiene Improvement Strategy (MHHIS) has been proposed to improve the Hand Hygiene (HH) compliance of the WHO recommendations on HH.Therefore, the current study was planned in our neonatal unit with the objective of evaluating the effectiveness of a Hand Hygiene Promotional Program (HHPP) based on the WHO MHHIS, in terms of compliance and decontamination efficacy among the health-care workers (HCWs) in the unit. Objective: The objective of the study was to evaluate the effectiveness of the WHO MHHIS on HH compliance and decontamination efficacy. Methods: The HHPP was carried out in our neonatal surgical intensive care unit from July to August 2013. A pre-intervention phase consisted of assessment of ward infrastructure, HH knowledge and perception, determination of HH compliance and collection of hand rinse samples from the HCWs before and after handwashing. Intervention phase consisted of changing traditional to elbow-operated taps, display of posters and reminders, placement of soaps in water draining trays, autoclaved single-use paper towels for hand drying, availability of hand rubs and training sessions for health-care providers. In the post-intervention phase, all the assessments and observations of pre-intervention phase were repeated. Results: HHPP resulted in a significant increase in overall HH compliance from 26.6% (95% confidence interval [CI] 23.9-29.3) to 65.3% (95% CI 62.4-68.2) (P < 0.001) and reduction in load of microorganisms (P = 0.013). There was a significant improvement in HH knowledge (P < 0.001), and perception surveys revealed high appreciation of each strategy component by the participants. Conclusion: To the best of our knowledge, this is the first study about the effect of implementation of the WHO MHHIS from an Indian hospital. HHPP was found to be effective in terms of HH compliance and decontamination efficacy. Its implementation is highly recommended to promote HH in a developing country like India.

Concurrent Congenital Fibrolipomatous Hamartoma and Congenital Nevus of Infancy: A Syndromic or Chance Association.

Congenital nevi and fibrolipomatous hamartoma are benign tumors of childhood, the latter being very uncommon. Fibrous hamartoma of infancy typically occurs in <2 years of life. The concurrence of these two lesions is extremely rare. We report a case of congenital fibrolipomatous hamartoma and congenital nevus of infancy in a 6-month-old male infant. Clinically, a suspicion of benign versus malignant lesion beneath the giant congenital nevus prompted its surgical removal. The histopathology confirmed it to be a compound lesion with benign melanocytic nevi and fascicles of spindle cells with eosinophilic cytoplasm representing hamartoma. Several types of melanocytic combined lesions have been noted with neuroectodermal and mesenchymal components. Sometimes, malignant soft-tissue neoplasm such as liposarcoma, rhabdomyosarcoma, and ganglioneuroblastoma do occur. This case report highlights the role of prompt surgical excision and histopathological examination.

Splenic Hemangiomatosis: An Uncommon Vascular Lesion in an Infant.

BACKGROUND: Vascular tumors of spleen represent a wide spectrum of lesions, ranging from benign to highly aggressive neoplasms. Among the benign tumors, localized hemangiomas are the most frequently encountered. Splenic hemangiomatosis is seldom seen especially in the pediatric population with anecdotal cases described in the literature. CASE REPORT: We present of 6-month-old child presenting with abdominal distention. The resected spleen was totally replaced with a hemangiomatous lesion. There were no other hemangiomatous foci outside the spleen. CONCLUSIONS: Hemangiomatosis limited to the spleen can occur in a child, and the present case demonstrates its characteristic histological features.

Erb's palsy complicating a case of annular pancreas.

We report an unusual presentation of annular pancreas with pneumoperitoneum in a newborn with an associated left sided Erb's palsy. The neurological deficit caused considerable confusion in the diagnosis and unexpected complications after surgery. We highlight the importance of clinical examination and the complications that an Erb's palsy can cause. This unusual triad of Erb's palsy, eventration of diaphragm and annular pancreas has hitherto not been described in literature.

Abdominoperineal Pull-through with Simultaneous Extravesical Detrussoraphy: An Alternative Surgical Technique for Congenital Pouch Colon with High-grade Vesicoureteric Reflux.

Congenital pouch colon (CPC) is frequently associated with vesicoureteric reflux (VUR). These patients require long-term antibiotic prophylaxis and/or an additional surgical intervention for the management of the refluxing system. We propose a single-stage alternative approach in these patients. Two patients diagnosed to have CPC underwent pouch excision and an end colostomy at birth. Further evaluation revealed high-grade reflux in both the patients. At 6 months of age, definitive abdominoperineal pull-through (APPT) surgery along with extravesical detrusorrhaphy was performed. In the follow-up at 1 year, they are thriving well with no urinary complaints. Micturating cystourethrogram revealed complete resolution of VUR. This approach takes the advantage of the anesthesia for APPT and offers a relatively simple and quick solution for the refluxing system, thus, enabling the stoppage of antibiotic prophylaxis and obviating the need for a future endoscopy/surgery.

Health-related Quality of Life in Children with Congenital Hydrocephalus and the Parental Concern: An Analysis in a Developing Nation.

PURPOSE: To analyze quality of life of children operated for congenital hydrocephalus and the concern of parents in taking care of these children. METHODS: Thirty patients who underwent ventriculo-peritoneal shunt were randomly selected with minimum gap of 1 year between surgery and study. Canadian validated questionnaire was used. Overall health score (OHS) and parental concern score (PCS) were correlated with gender, family type and number of surgeries. RESULTS: Mean OHS was 159.43 which was summation of physical health (mean 45.76), social-emotional (mean 80.03) and cognitive health scores (mean 33.66). Mean OHS was 151.57 for males and 177.77 for females (p-value 0.233). Nuclear and joint families had mean OHS of 160.36 and 158.89 respectively (p-value 0.944). Those who underwent one surgery had mean OHS of 167.48 and PCS of 23.10 whereas mean OHS was 140.66 and PCS was 27.78 for those with multiple procedures. Mean PCS for males was 26.71 and for females was 19.33 (p-value 0.036 statistically significant). This was not statistically significant between nuclear (24.73) and joint families (24.26). CONCLUSIONS: Quality of life of survivors of hydrocephalus is reasonably good even in developing countries due to keen parental involvement irrespective of gender, family type and number of surgeries.

Dedicated donor unit transfusions reduces donor exposure in pediatric surgery patients.

BACKGROUND: Many strategies have been explored to reduce multiple donor exposures in neonates such as use of restrictive transfusion protocols, limiting iatrogenic blood loss, use of recombinant erythropoietin and single donor programs. METHOD: In our study we assessed the feasibility of dedicating single donor units with reserving all the components from the same donor for the specified neonates/infants undergoing surgery and estimating reduction of donor exposure. Fifty neonates undergoing surgery were included in the prospective study group and the transfusion details were compared with 50 retrospective cases with same inclusion criteria. RESULTS: An intra-operative blood loss of >13 ml/Kg was significantly associated with transfusion (P <0.05) which was most frequently administered in the intra-operative period. Donor exposure rate of overall transfusion was 1.15 in the study group as compared to 4.03 in the retrospective control group. In study group Donor Exposure Rate (DER): Transfusion Rate (TR) ratio was 1:1.5 and Transfusion per Donor Unit (TPDU) of 1.5, means that one donor unit contributed to 1.5 transfusions in each patient and contributed to 50% reduction in donor exposure in each patient as compared to retrospective control group. CONCLUSION: Our study showed that by practicing dedicated donor unit transfusion policy, for neonates undergoing surgery we could significantly reduce the donor exposure.

Is urodynamic evaluation a must in all operated cases of open neural tube defects.

BACKGROUND: Spina bifida is a common cause of pediatric neurogenic bladder. It causes renal failure in almost 100% of patients if the associated detrusor sphincter dyssynergia (DSD) is inadequately managed. Detrusor instability and high detrusor pressures (Figure) have been implicated as the major factors predictive of renal damage in these patients. Urodynamic studies provide early identification of "at risk" kidneys so that appropriate intervention can be made. However, the role in post-operative patients of spina bifida who have no clinical manifestations remains unclear. OBJECTIVE: To study the bladder dynamics in asymptomatic post-operative patients of spina bifida and to determine whether routine urodynamic study is justifiable. MATERIAL AND METHODS: Urodynamics was performed on 15 operated patients of spina bifida who did not have any neurological deficit and were asymptomatic. RESULTS: The mean age of the patients was 4.97 years. None of the patients had any urological complaints with their ultrasonography being normal. None had scars on nuclear scan. Of the 15 patients, 12 (80%) had abnormal findings on urodynamic assessment. Three patients (20%) had detrusor pressures greater than 40 cm of H2O. One patient had significant residual urine and detrusor instability. DISCUSSION: The use of urodynamic studies in asymptomatic patients of spina bifida remains controversial, with one school of thought advocating early invasive urodynamic testing. In contrast, some favor noninvasive sonological monitoring, reserving invasive tests only for patients with renal tract dilatation. In our subset of patients none had renal tract dilatation but three patients (20%) had "at risk" bladders. These patients would benefit from early intervention aimed at renal preservation. The study is limited by a small sample size because of the relative rarity of the patient profile included. A further multicenter study with a case-control design could conclusively indicate the role of urodynamic testing in these patients. CONCLUSION: Patients of spina bifida, even when asymptomatic, have a high incidence of unsafe bladders. Early identification and appropriate measures can protect kidneys from long-term damage, hence urodynamic profiling is mandatory for identification of potentially high-risk bladders.

Outcome of urethroplasty after parenteral testosterone in children with distal hypospadias.

INTRODUCTION: Pre-operative testosterone use in hypospadias surgery is known to increase penile dimensions and vascularity, which should facilitate tension-less formation of the urethral tube and tissue healing. However, androgens can have a negative effect on wound healing. There are very few randomized studies on postoperative results after androgen use, and this study attempted to understand the utility of pre-operative testosterone in distal hypospadias. OBJECTIVE: To study the effect of parenteral testosterone in children undergoing single stage urethroplasty for distal hypospadias, especially the occurrence of urethrocutaneous fistula and wound dehiscence. DESIGN: Patients were prospectively enrolled and randomized into two groups: Group 1 (control group) and Group 2 (receiving three injections of pre-operative intramuscular testosterone enanthate (2 mg/kg) at 1 monthly intervals; they were further subdivided into those operated 1 month (Group 2A) or 3 months (Group 2B) later. Patients with micropenis, previous testosterone use or any surgical intervention were excluded. Preputial skin was studied with hematoxylin and eosin (H&E) staining and CD31 immunohistochemistry. Patients were followed up for at least 18 months. RESULTS: Ninety four patients underwent urethroplasty over a 3.5-year period. Penile dimensions increased significantly after testosterone use (Summary table). On H&E staining, proliferating blood vessels and increased lymphocytic infiltrates were significantly increased in Group 2B. Group 2 patients tended to have more postoperative edema and inflammation. Although urethrocutaneous fistula rates were similar in Group 1 (n = 7) and Group 2 (n = 5) (P = 0.438), wound dehiscence occurred only in Group 2 (P = 0.01). DISCUSSION: The total number of patients in this study was small and this was a drawback. Although, several factors played a role in wound healing, the overall higher complication rate, especially wound dehiscence in Group 2, pointed to a higher incidence of inflammatory reaction and healing complication rates with testosterone use. CONCLUSION: Testosterone should be used judiciously in distal hypospadias. While tissue availability significantly increased, there was an increase in inflammatory reaction and edema, which increased the risk of wound dehiscence in cases of precocious surgery.

Role of glycopyrrolate in healing of anastomotic dehiscence after primary repair of esophageal atresia in a low resource setting-A randomized controlled study.

AIMS: To investigate the role of glycopyrrolate in decreasing oral secretions in patients of esophageal atresia (EA) with anastomotic leak and evaluate its effect on healing of anastomotic dehiscence. METHODS: The study comprised consecutive neonates of esophageal atresia, who had undergone primary surgery and developed anastomotic leak. The patients were randomized into two groups with the observer blinded to the group. The patients in the treatment group were administered glycopyrrolate in the dose of 8 µg/kg 8 hourly, whereas placebo group patients were injected normal saline only. Neonates, in both the groups, were managed conservatively based on the clinical and radiological parameters. The end points of the study were either resolution or progression of the leak. The study was approved by the institute ethics committee. RESULTS: There were 21 patients each in two groups with comparable preoperative characteristics. All the cases had anastomotic leaks clinically detectable in the chest tube. Saliva alone constituted the leak material in 18 cases in the treatment group and 10 in the placebo group. Cumulative total of mean chest tube output per patient for all patients in the treatment group was 124.15ml as compared to 370.27ml in the placebo group (p=0.001). Anastomotic leak stopped in 16 cases (76%) in the treatment group, as compared to 6 cases (29%) in the placebo group (p=0.004). The postoperative ventilation was required in 8 cases (8/21, 38%) in the treatment group and 17 cases (17/21, 81%) in the placebo group (p=0.010). In the treatment group, the diversion procedures were carried out in 2 out of 21 cases (10%), whereas in the placebo group, 52% of the patients (11/21) required such an intervention (p=0.003). At the time of discharge, the oral feeds could be started in 15 cases (15/21, 71%) in the treatment group, as compared to 3 (3/21, 14%) in the placebo group (p=0.0004). CONCLUSIONS: Administration of glycopyrrolate in patients of anastomotic leak after primary repair of esophageal atresia resulted in reduced oral secretions, which helped in healing of the anastomotic dehiscence in a significant number of patients.