Tissue adhesive, adhesive tape, and sutures for skin closure of paediatric surgical wounds: prospective randomized clinical trial.

BACKGROUND: Tissue adhesive, adhesive tape, and sutures are used to close surgical incisions. However, it is unclear which produces the best results in children, and whether combination wound closure is better than sutures alone. METHODS: In this parallel randomised controlled trial (ANZCTR: ACTRN12617000158369), children (aged 18 years or less) undergoing elective general surgical or urological procedures were randomized to skin closure with sutures alone, sutures and adhesive tape, or sutures and tissue adhesive. Participants were assessed 2 weeks, 6 weeks, and more than 6 months after operation. Outcomes included wound cosmesis (clinician- and parent-rated) assessed using four validated scales, parental satisfaction, and wound complication rates. RESULTS: 295 patients (333 wounds) were recruited and 277 patients (314 wounds) were included in the analysis. Tissue adhesive wounds had poorer cosmesis at 6 weeks: median 10-point VAS score 7.7 with sutures alone, 7.5 with adhesive tape, and 7.0 with tissue adhesive (P = 0.014). Respective median scores on a 100-point VAS were 80.0, 77.2, and 73.8 (P = 0.010). This difference was not sustained at over 6 months. There was no difference in parent-rated wound cosmesis at 6 weeks (P = 0.690) and more than 6 months (P = 0.167): median score 9.0 with sutures alone, 10.0 with adhesive tape, and 10.0 with tissue adhesive at both stages. Parental satisfaction was similar at all points, with a median score of 5 (very satisfied) for all groups. There was one instance of wound dehiscence in the tissue adhesive group and no wound infections. CONCLUSION: Short-term wound cosmesis was poorer with tissue adhesive although it is unclear whether this difference is sustained in the long-term. There were no differences between techniques for the study outcomes. REGISTRATION NUMBER: ACTRN12617000158369 (ANZCTR) (https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372177&isReview=true).

Decade of the dangers of multiple magnet ingestion in children: A retrospective review.

AIM: Magnet ingestion has become more frequent in children as magnetic toys and jewellery have been popularised, with the potential to cause significant morbidity. Our aim was to describe our experience at a tertiary paediatric surgical centre. METHODS: Retrospective review of patients admitted with multiple magnet ingestion (January 2011-December 2020). Division into an intervention group and conservative group. Comparisons included demographics, number of magnets and clinical outcomes. Data analysis with a Student's t-test and ROC Curve, P value of <0.05 was significant. RESULTS: A total of 23 patients were identified with a total of 150 magnets ingested. The majority required an intervention for magnets retrieval (15/23, 65.2%), 11/15 (73.3%) surgical and 4/15 (26.7%) endoscopic. In the surgery group, 6/11 (54%) presented with an initial perforation and 1/11 (9.1%) an entero-enteric fistula. One patient (9.1%) had a multi-site anastomotic leak post-operatively. The conservative group had a significantly lower median number of ingested magnets (2 (2-6) vs. 7 (2-40), P = 0.03) and median length of stay (1 (1-4) vs. 7 (1-24), P = 0.03). ROC curve analysis revealed ingestion of >3 magnets had a sensitivity of 86.7% (95% CI: 62.1-97.6%) and specificity of 87.5% (95% CI: 53.0-99.4%) for requiring an intervention. CONCLUSION: This series highlights a significant morbidity in children with a higher incidence of intervention following ingestion of more than three magnets. There is a strong requirement for the creation and adherence to new legislature involving industry standards.

Repeated injections of intradetrusor onabotulinumtoxinA as adjunctive treatment of children with neurogenic bladder.

AIM: To evaluate the effects of repeated injections of onabotulinumtoxinA in children with neurogenic bladders refractory to conventional treatment. PATIENTS AND METHODS: A total of 26 children with neurogenic bladder were prospectively studied. Some patients received up to four repeat injections. Patients were reinjected if they showed improvement in voiding diary, score of urinary incontinence and/or urodynamic studies; otherwise, augmentation cystoplasty was indicated. RESULTS: Of the 26 patients, 12 were reinjected a second time, 6 patients were reinjected a third time and 2 patients received a repeat injection for the fourth time. Six months after the first, second and third injection, the urinary incontinence score 0 (dry) was 50, 77 and 75 %, respectively. After each injection, the mean bladder capacity in voiding diary and the mean maximum cystometric capacity increased. The mean detrusor pressure at the end of filling decreased. Only compliance after the first injection improved significantly. Detrusor overactivity (n: 4), improved during 3 months and reappeared in three children after the first injection, but at greater cystometric volumes. In the fourth case, it reappeared 11 months after the third injection. Five patients underwent cystoplasty. CONCLUSION: After treatment with onabotulinumtoxinA, urinary continence achieved was 50-77 %. There were favorable changes in urodynamic variables, but they were insufficient. Detrusor overactivity was attenuated, but did not disappear completely.

Latitudes and attitudes: A multinational study of laparoscopic pyeloplasty in children.

PURPOSE: The Anderson-Hynes technique has been the treatment of choice for primary ureteropelvic junction obstruction in children. Laparoscopic approach has shown similar outcomes to open, with advantages of shorter hospital stay and less pain. We reviewed the experience of 11 geographically diverse, tertiary pediatric urology institutions focusing on the outcomes and complications of laparoscopic pyeloplasty. MATERIALS AND METHODS: A descriptive, retrospective study was conducted evaluating patients undergoing Anderson-Hynes dismembered laparoscopic pyeloplasty. Centers from four different continents participated. Demographic data, perioperative management, results, and complications are described. RESULTS: Over a 9-year period, 744 laparoscopic pyeloplasties were performed in 743 patients. Mean follow-up was 31 months (6-120m). Mean age at surgery was 82 months (1 w-19 y). Median operative time was 177 min. An internal stent was placed in 648 patients (87%). A catheter was placed for bladder drainage in 702 patients (94%). Conversion to open pyeloplasty was necessary in seven patients. Average length of hospital stay was 2.8 days. Mean time of analgesic requirement was 3.2 days. Complications, according to Clavien-Dindo classification, were observed in 56 patients (7.5%); 10 (1%) were Clavien-Dindo IIIb. Treatment failure occurred in 35 cases with 30 requiring redo pyeloplasty (4%) and 5 cases requiring nephrectomy (0.6%). CONCLUSION: We have described the laparoscopic pyeloplasty experience of institutions with diverse cultural and economic backgrounds. They had very similar outcomes, in agreement with previously published data. Based on these findings, we conclude that laparoscopic pyeloplasty is safe and successful in diverse geographics areas of the world.

Ureteral replacement with appendix in pediatric renal transplantation.

Ureteral necrosis is an uncommon complication following RT which can adversely affect outcome. Even though authors agree that the native ureter ought to be preserved, there are cases in which graft function can only be salvaged by ureteral substitution. The scant references in the literature on the use of the appendix for left ureteral replacement in children prompted us to report the following two cases in whom the technique was employed and to assess the evolution of graft function in these patients.

Simplified surgical approach to congenital megaprepuce: fixing, unfurling and tailoring revisited.

PURPOSE: Megaprepuce is a congenital penile malformation that includes phimosis and severe ballooning of the internal prepuce. We combined the main technical details of 2 previously reported surgical techniques to simplify the surgical approach. We report the key points of this revisited surgical correction for megaprepuce and the long-term results. MATERIALS AND METHODS: Penile reconstruction was performed between March 2004 and March 2009 in 26 children 2 to 19 months old (median age 6) with congenital megaprepuce. Surgical repair consisted of limited preputial resection of the phimotic ring, wide dissection of the outer prepuce to the base of the penis, fixation of the proximal outer prepuce to Buck's fascia to create a new penoscrotal junction, and unfurling and wide tailoring of the inner prepuce in the ventral midline to resurface the whole elongated penile shaft. A bladder catheter was left in place for 5 or 6 days. Only patients with at least 6 months of followup were included in analysis. RESULTS: All patients underwent surgery on an outpatient basis. Operative time was between 50 and 85 minutes. Median followup was 17.6 months (range 6 to 59). Two patients had slight dehiscence of the ventral suture, which healed spontaneously without a scar. In 1 patient transient urethral meatal stenosis developed. The final cosmesis result was adequate in all patients. CONCLUSIONS: It is possible to correct megaprepuce and achieve an adequate genital aspect with a simple approach of resurfacing the penis with the unfurled, tailored inner prepuce.

Complication profile of augmentation cystoplasty in contemporary paediatric urology: a 20-year review.

BACKGROUND: The aim of this study was to describe the complication profile of augmentation cystoplasty in contemporary paediatric urology as well as its effect on bladder metrics. METHODS: Consecutive operative cases were retrospectively reviewed at a single institution over 20 years (1999-2019). Short- and long-term outcomes and complications following augmentation cystoplasty were defined. RESULTS: Of the 71 operative cases; the most common underlying diagnoses were neurogenic bladder (34%), exstrophy-epispadias complex (30%) and posterior urethral valves (23%). The most common tissue-type utilized was ileal (58%) and ureteric (30%). Peri-operative urine leak affected nine (13%) children but reservoir perforations were less common (4%). Mean end-of-study detrusor pressure improved significantly following bladder augmentation (38-17 cmH2 O, P < 0.001). Bladder capacity improved significantly (67-89%, P = 0.041). The median follow-up was 4.5 years (interquartile range: 1.9-10 years). Bladder urolithiasis affected 13 (18%) patients, and symptomatic urinary tract infections 36 (51%) patients. Formation of a continent catheterisable channel contributed a number of complications relating predominantly to stenosis (50%). Repeat augmentation cystoplasty was necessary in three (4%) cases. CONCLUSION: Augmentation cystoplasty is a surgical intervention that improves bladder metrics. Given the potential complications, careful patient selection and appropriate pre-operative counselling are essential. Furthermore, pro-active post-operative management and transitional care are vital in the surgical care of children following augmentation cystoplasty.

The use of polyacrylate-polyalcohol copolymer hydrogel in the endoscopic treatment of primary vesicoureteral reflux in children.

BACKGROUND/PURPOSE: It is still under discussion which is the best tissue augmenting substance for the endoscopic treatment of children with vesicoureteral reflux (VUR). We describe our preliminary experience (September 2009-November 2011) with polyacrylate-polyalcohol copolymer hydrogel (PPCH). METHODS: This is an observational, descriptive, prospective study which included 81 female and male patients (age 1-14 years) diagnosed with unilateral (n=45) and bilateral (n=36) primary VUR comprising a total of 117 refluxing renal units (RRU). Complex cases were excluded from the study. All patients were clinically and radiologically evaluated and those who met the inclusion criteria were treated endoscopically with a single subureteral injection of PPCH by a single surgeon. 11 patients (13.5%) had a pathological 99mTc-DMSA before treatment. The volume of injected product was measured in all cases. Results were considered successful if 6months postinjection, conventional voiding cystourethrogram (VCUG) revealed VUR was cured (Grade 0). Follow-up ranged from 7 to 32months. RESULTS: The overall resolution rate based on the number of RRUs studied was 92.3% (108/117). The mean injected volume of PPCH per patient was 0.6ml. One patient with obstructive anuria required vesicoureteral reimplantation. Other complications were persistent, self-limiting hematuria (n=2); lumbar pain (n=4) and urinary tract infection with normal VCUG (n=4). CONCLUSIONS: Our short term data show PPCH provides a high level of reflux resolution in selected patients. Long term follow-up is required.

Multicenter survey of endoscopic treatment of vesicoureteral reflux using polyacrylate-polyalcohol bulking copolymer (Vantris).

OBJECTIVE: To evaluate an outcome of endoscopic correction of vesicoureteral reflux (VUR) using Vantris (Promedon, Cordoba, Argentina) in terms of its effectiveness and morbidity in a multicenter study. MATERIALS AND METHODS: From 2009 to 2013, 611 patients (210 boys and 401 girls) with a mean age of 3.56 years (range, 1 month-18 years) were treated at 7 centers worldwide endoscopically with Vantris injection. VUR was unilateral in 413 and bilateral in 198 patients comprising 809 renal refluxing units (RRUs). Of these, primary VUR was present in 674 RRUs (83.3%) and 135 (16.7%) were complex cases. Reflux was grades I-V in 24 (2.96%), 123 (15.2%), 451 (55.8%), 158 (19.5%), and 53 (6.6%) RRUs respectively. The follow-up continued from 6 to 54 months. RESULTS: Reflux resolved in 759 RRUs (93.8%) after first Vantris injection, in 26 (3.1%) after second, and in 6 (0.7%) after third injection, respectively. VUR improved to grade I after 1 or 2 injections in 5 ureters (0.6%), which needed no further treatment. Thirteen ureters (1.6%) failed endoscopic correction and required ureteral reimplantation. Vesicoureteral junction obstruction requiring ureteral reimplantation developed in 6 ureters (0.7%) and in 4 (0.5%) required stent insertion. Twenty-three patients (3.8%) suffered afebrile urinary tract infection. Seven (1.2%) developed febrile urinary tract infection. None of the studied patients demonstrated VUR recurrence on voiding cystourethrography. CONCLUSION: The results of this multicenter survey confirm that endoscopic subureteral Vantris injection is a simple, safe, and effective outpatient procedure for treating all grades of VUR.

Laparoscopic Mitrofanoff procedure using single 'U-Stitch' anastomosis: a way to make it simple.

OBJECTIVE: to describe and incorporate a modification of the fully laparoscopic Mitrofanoff (LM) procedure with the aim of diminishing operative time and technical difficulties, and to reproduce functional results. PATIENTS AND METHODS: Retrospective review of six patients with voiding dysfunction with indication for clean intermittent catheterization who did not require bladder augmentation and who underwent a fully LM procedure between January and November 2011. RESULTS: The mean operative time was 183.3 min with a mean hospital stay of 6.15 days. No complications were recorded during the surgical procedure. Postoperative hematuria is the most frequent complication associated with this technique. One patient presented appendicovesical anastomotic leak that resolved spontaneously after 8 days with abdominal drainage. There were no other postoperative complications on an average 6.8-month follow up. CONCLUSION: We believe fully LM is a feasible and reproducible approach. The U-Stitch appendix implantation technique reduces total operative time and makes the procedure technically easier.