A BURST-BAUS consensus document for best practice in the conduct of scrotal exploration for suspected testicular torsion: the Finding consensus for orchIdopeXy In Torsion (FIX-IT) study.

OBJECTIVES: To produce a best practice consensus guideline for the conduct of scrotal exploration for suspected testicular torsion using formal consensus methodology. MATERIALS AND METHODS: A panel of 16 expert urologists, representing adult, paediatric, general, and andrological urology used the RAND/UCLA Appropriateness Consensus Methodology to score a 184 statement pre-meeting questionnaire on the conduct of scrotal exploration for suspected testicular torsion. The collated responses were presented at a face-to-face online meeting and each item was rescored anonymously after a group discussion, facilitated by an independent chair with expertise in consensus methodology. Items were scored for agreement and consensus and the items scored with consensus were used to derive a set of best practice guidelines. RESULTS: Statements scored as with consensus increased from Round 1 (122/184, 66.3%) to Round 2 (149/200, 74.5%). Recommendations were generated in ten categories: consent, assessment under anaesthetic, initial incision, intraoperative decision making, fixation, medical photography, closure, operation note, logistics and follow-up after scrotal exploration. Our statements assume that the decision to operate has already been made. Key recommendations in the consent process included the discussion of the possibility of orchidectomy and the possibility of subsequent infection of the affected testis or wound requiring antibiotic therapy. If after the examination under anaesthesia, the index of suspicion of testicular torsion is lower than previously thought, then the surgeon should still proceed to scrotal exploration as planned. A flow chart guiding decision making dependent on intraoperative findings has been designed. If no torsion is present on exploration and the bell clapper deformity is absent, the testis should not be fixed. When fixing a testis using sutures, 3 or 4-point is acceptable and non-absorbable sutures are preferred. CONCLUSIONS: We have produced consensus recommendations to inform best practice in the conduct of scrotal exploration for suspected testicular torsion.

Bladder urothelial cell carcinoma as a rare cause of haematuria in children: Our experience and review of current literature.

OBJECTIVES: To report our experience of bladder urothelial cell carcinoma (UCC) in children and review contemporary management and follow-up of paediatric UCC. PATIENTS AND METHODS: Between 2004 and 2020, five patients (4 boys and 1 girl) were managed at our centre for urothelial cell carcinoma of the bladder. Data was collected by note review for age at presentation, symptoms, clinical findings, investigations, treatment and follow-up. RESULTS: All five patients presented with visible haematuria, two had dysuria and one had suprapubic pain. Bladder ultrasound scan (USS) showed exophytic bladder lesions in only 4 patients. Definitive diagnosis and treatment were achieved by cystoscopic excision. Four patients had PUNLMP while one had Grade 3 pTa UCC of the bladder which required further cystoscopic excision and intravesical Mitomycin C (MMC) instillation. All patients were followed up clinically, with renal USS and cystoscopy. We have observed recurrence of the carcinoma in two patients requiring further cystoscopic excision and intravesical MMC. CONCLUSION: Bladder urothelial cell carcinoma in children should be suspected in children presenting with haematuria. If renal USS is normal, cystoscopy should be considered for diagnosis and treatment. Compared to adults, children with bladder UCC often have favourable histopathology and prognosis. Close follow-up is necessary with renal USS and cystoscopy to detect recurrence even in PUNLMP.

Does decentralisation of surgical management improve outcomes for paediatric testicular torsion?

INTRODUCTION: In testicular torsion (TT), delayed emergency scrotal exploration (ESE) increases the risk of orchidectomy. Transfer of a patient with suspected TT from a district general hospital (DGH) to a paediatric surgical centre (PSC) delays ESE and potentially puts them at increased risk of testicular loss. Prior to 1st January 2017, all boys under aged <16 years presenting to a DGH within the East Midlands Clinical Network (EMCN) would be referred to the PSC. From this date, it was agreed within the EMCN that boys aged ≥5 years with suspected TT presenting to a network DGH would be managed locally, barring exceptional circumstances. Boys aged <5 years would be referred to the PSC for management. AIM: This study aimed to assess the impact of decentralisation of ESE for suspected TT on orchidectomy rates in the EMCN. METHODS: All patients who underwent ESE under the care of paediatric surgery in the PSC, and all patients <16 years old who underwent ESE in 4 EMCN DGHs between January 2017 and December 2019 were identified. Neonatal cases and inpatient referrals were excluded. Comparison was made with published data on ESE performed in the PSC over the 9 years 2008-2016 prior to decentralisation. RESULTS: In the 9 years prior to decentralisation, there were 110 cases of TT in the PSC. In the subsequent 3 years, there were 40 in the PSC and 37 in the DGHs. The orchidectomy rate of boys with TT presenting to DGHs and undergoing exploration locally (16%, 6/37) contrasts with the rate in those transferred from DGHs to the PSC for exploration (58%, 15/26). The difference is highly significant (p = 0.00059, RR 0.28 [95% CI 0.13-0.63]) and indicates that in the EMCN, avoiding hospital transfer and performing ESE at the presenting DGH reduces the risk of orchidectomy by 72%. CONCLUSION: Decentralisation of the provision of ESE in boys with TT has resulted in a significantly lower orchidectomy rate in boys undergoing ESE in the presenting hospital than when transferred to the PSC. This study reinforces existing literature that demonstrates the effect of delayed ESE on orchidectomy rate, and supports the recommendations of national guidelines in the UK that transfer of boys to a PSC for ESE should only occur in exceptional circumstances.

Outcomes following emergency fixation of torted and non-torted testes.

INTRODUCTION: Scrotal exploration is a frequently performed emergency procedure in children. It is a subject of debate as to whether and how a non-torted testis should be fixed, with a wide variation in practice across the UK. This study aims to ascertain whether the method of testicular fixation (if any) impacts on patient outcomes. METHODS: A review of all emergency scrotal explorations performed in children under the age of 18 between 2008 and 2018 in a tertiary Paediatric Surgery unit was undertaken. Patients were categorised by initial fixation method, chi squared analysis was used to compare complication and reoperation rates. RESULTS: 522 boys were taken to theatre, 424 had a unilateral procedure and 98 had bilateral; after 35 orchidectomies, 585 testes were left in situ. The most frequent diagnosis at operation was torted testicular appendage (n = 278, 53%), followed by testicular torsion (n = 79, 15%). The number of testes by category of fixation were: 72 no documented fixation, 130 dartos pouch only, 34 absorbable sutures, 346 non-absorbable sutures and 3 unspecified sutures. There was no difference in the reattendance rate between groups after outliers were removed (p = 0.72). Thirty-seven patients experienced complications, most commonly ongoing pain. Nine patients required an ipsilateral reoperation, 25 underwent a contralateral operation at a later date. The complication rate appeared to be higher in the no fixation group compared to the dartos (p = 0.02) and sutured groups (p = 0.048). Testes in the no fixation group had a higher reoperation rate compared to the sutured group (p = 0.002). CONCLUSIONS: The present study is a detailed analysis of a wide variety of emergency testicular fixation methods in a large cohort, including the routine fixation of non-torted testes. Whilst there appears to be a benefit to using sutured or dartos fixation, this merits cautious interpretation. It is likely that influences on complications and reoperations are multifactorial and cannot be attributed solely to the method of testicular fixation. Adoption of a standardised approach to emergency fixation of testes within or across institutions may be a potential avenue for future studies.

Effect of Surgical Specialty on Management of Adnexal Masses in Children and Adolescents: An 8-Year Single-Center Review.

STUDY OBJECTIVE: Children with adnexal masses might be managed by pediatric surgeons, urologists or gynecologists, with the potential for different management strategies between specialties. In this study we compared ovarian conservation rates and surgical approach for adnexal masses in children and adolescents managed either by pediatric surgeons/urologists or gynecologists at a tertiary care institution. DESIGN: Retrospective cohort review. SETTING: Tertiary pediatric and adult university hospital. PARTICIPANTS: Patients younger than 18 years of age with an adnexal mass managed surgically with removal of histologically confirmed ovarian or fallopian tube tissue from 2008 to 2015. INTERVENTIONS: Laparoscopic or open procedure for adnexal mass. MAIN OUTCOME MEASURES: The primary outcome was rate of ovarian conservation relative to surgical specialty. The secondary outcome was surgical approach relative to surgical specialty. RESULTS: Forty-eight patients underwent surgery for adnexal masses; 26 (54%) under pediatric surgery/urology and 22 (46%) under gynecology care. Laparoscopy was performed in 5 (19%) pediatric and 19 (86%) gynecology cases (P = .000006). Of 24 patients older than 12 years of age with a benign tumor, 10 (42%) underwent procedures resulting in loss of an ovary with or without fallopian tube; 8 of these (80%) were under pediatric care. Of the remaining 14 (58%) who underwent ovarian conserving surgery, 12 (80%) were under gynecology care (P = .0027). CONCLUSION: Patients with a benign tumor were significantly more likely to undergo ovary-preserving surgery under gynecology care than under pediatric surgery/urology care. A multidisciplinary team approach involving gynecology and pediatric surgical specialties would be valuable in assessing the merits of ablative or conservative surgery in each case.

Intradetrusor injection of botulinum toxin A in children: a 10-year single centre experience.

PURPOSE: We evaluated the efficacy and safety outcomes of endoscopic intradetrusor botulinum toxin A (BTA) injections for the treatment of children with neuropathic bladder (NB) and non-neuropathic bladder (NNB) with or without detrusor overactivity in a single centre with a retrospective analysis. METHODS: For the period 2006-2015, children who received BTA in our hospital were analysed. They were divided into group 1, those with underlying NB and group 2, those without a clear neuropathic cause of symptoms (NNB). Data are given as percentages or medians (interquartile range). RESULTS: Over the study period, 52 children (28 boys, 54%) received BTA, 28 in group 1 (54%; 17 (61%) boys) and 24 in group 2 (46%; 11 (46%) boys). Age at first injection was 11.8 (9.5-14.4) years. After initial injection, 40 (77%) reported symptomatic improvement, 17 (43%) becoming dry. There was no significant difference in response to initial injection between groups (p = 0.11). Duration of improvement after first injection was 7 (5.8-14) months. Twenty-five (48%) had further injections, of whom 3 (12%) were initial non-responders. Ongoing improvement was reported in 20 (80%), 11 (44%) of whom were dry. There was no significant difference in overall response to injections between groups (p = 0.11). Of the 11 non-responders, none (0/3) improved after subsequent injection and 3 (27%) subsequently underwent major urological surgery. Of the 40 who responded, 2 (5%) underwent major surgery. CONCLUSION: BTA injection produced symptomatic improvement in 77% of our study population, with no significant differences in response between NB and NNB groups. In 95% of those who improved, major urinary tract procedures were avoided during the period studied. None of the initial non-responders improved after subsequent BTA injection. BTA injection is effective and reliable in the management of children with NB and NNB refractory to medical therapy.

Chronic peritoneal dialysis in children.

The incidence of end-stage renal disease in children is increasing. Peritoneal dialysis (PD) is the modality of choice in many European countries and is increasingly applied worldwide. PD enables children of all ages to be successfully treated while awaiting the ultimate goal of renal transplantation. The advantages of PD over other forms of renal replacement therapy are numerous, in particular the potential for the child to lead a relatively normal life. Indications for commencing PD, the rationale, preparation of family, technical aspects, and management of complications are discussed.

Native nephrectomy in pediatric transplantation--less is more!

OBJECTIVE: Indications for pre-transplantation native nephrectomy (PTNN) include chronic renal parenchymal infection, proteinuria, intractable hypertension, polycystic kidneys and malignancy. Our aim was to establish the frequency and reasons for PTNN in children undergoing renal transplant at our center. MATERIALS AND METHODS: Children listed for renal transplant between 1998 and 2010 who underwent PTNN were analyzed. Etiology of established renal failure, indication for nephrectomy, stage of chronic kidney disease, laterality, complications, and timing of subsequent transplant were determined. Outcome of children, and that of preserved native kidneys following transplant, was reviewed. RESULTS: 21/203 children listed for transplant (10.3%) underwent PTNN (32 nephrectomies). Indications were drug-resistant proteinuria (6 children), recurrent upper tract urosepsis (6), refractory hypertension (4), malignancy/malignant predisposition (4), concomitant procedure during ureterocystoplasty (1). Median age at nephrectomy was 3.3 years; 86% had impaired renal function at time of (first) nephrectomy. Median time until transplantation following bilateral nephrectomy was 1.7 years. 19/21 children have been transplanted; 17 reached stable graft function. Only 2 children who did not undergo PTNN required nephrectomy post-transplant. CONCLUSION: When malignancies were excluded, PTNN was performed in a minority (8.4%) of children, mainly for proteinuria. This adds great advantage by reducing morbidity. Resulting graft function seems favorable.

The challenge of maintaining dialysis lines in the under twos.

INTRODUCTION: Hemodialysis (HD) and peritoneal dialysis (PD) are essential adjuncts in the management of children with established renal failure (ERF), but complications are common, particularly in the younger age groups. We reviewed catheter life and catheter-related complications in children who began chronic dialysis before the age of 2 years. METHOD: From the case notes of the children, born between 1990 and 2008, the data gathered included etiology of ERF, age at first dialysis catheter, complications, catheter life, and number of PD and HD. RESULTS: Ninety lines were inserted (40 PD and 50 HD) in 22 children with ERF. Eleven children were aged <6 months when commencing dialysis, six of whom were neonates. PD, the preferred modality, was offered to all but two children. Four children were managed with PD alone. One child died of overwhelming sepsis secondary to PD peritonitis. Average catheter life for HD was 3 months and PD 9.1 months. Luminal blockage and infection were the commonest reasons for change of HD catheters. Peritonitis was the commonest factor leading to PD removal. CONCLUSIONS: Children younger than 2 years can be dialyzed successfully by HD or PD but complications are frequent, leading to >2 catheters in the majority. Chronic dialysis in the very young is achievable and useful, but a high incidence of catheter changes must be anticipated.

Dysplastic kidneys in children - do they grow?

OBJECTIVES: Dysplastic kidneys (DK) are a common cause of chronic kidney disease (CKD). Little is known about their growth or how their sonographic appearance changes. This study aimed to test the hypothesis that DK gain little length, and to identify radiologic trends predictive of CKD. METHODS: Ultrasound scans of children with DK born in 1980-2005 and referred to a single tertiary centre were analysed by a pediatric radiologist. Renal lengths were plotted on standard nomograms and the degree of dysplastic appearance noted. Factors related to DK - bladder outlet obstruction, vesico-ureteric reflux and renal impairment - were noted. RESULTS: Fifty-three children were studied (83 kidneys), of whom 41 were boys; 289 scans were analysed. In 33 children there was associated bladder outlet obstruction or vesico-ureteric reflux. Forty-four DK were noted to fall off their renal length 'centile'. This correlated well with the development of CKD and is statistically significant. Deterioration occurred in 53% of DK; primarily progressive reduction in corticomedullary differentiation. This also correlated well with development of CKD. CONCLUSION: More than half of the DK showed poor growth velocity. This, together with the degree of sonographic abnormality, carries a high predictive value for development of CKD. We recommend diligent serial sonography to follow renal growth and dysplastic appearance in children with DK.

Oblique anastomosis in Soave endoanal pullthrough for Hirschsprung's disease--a way of reducing strictures?

The Soave endorectal pullthrough is a commonly performed procedure for the definitive management of children with Hirschsprung's disease (HD). Anastomotic stricture is a recognised complication of this procedure. There are multiple causes for these strictures, circular anastomosis being one of them. There are techniques described which alter the shape of the anastomosis of the pulled through bowel to decrease the incidence of strictures. These are oblique and heart-shaped anastomoses. We describe a new technique of oblique anastomosis where the pulled through bowel is anastomosed posteriorly 0.5 cm from the dentate line, and anteriorly 1.5 cm above this point. This oblique anastomosis is designed to lower the stricture rate. If a stricture does occur, an anastomosis near the anocutaneous junction on the posterior aspect also faciltates Y-V anoplasty. We present our experience using this technique. Seventeen consecutive children underwent the procedure at our institution between 2003 and 2006. Only one child developed an anastomotic stricture requiring anal dilatation.

Neonatal omphalitis: a review of its serious complications.

UNLABELLED: Until the advent of aseptic deliveries and aseptic umbilical cord care, many deaths occurred from umbilical infections. Omphalitis is a localized infection of the umbilical cord stump, most commonly caused by a single organism, which usually responds well to appropriate antibiotics. Umbilical sepsis is relatively uncommon in the developed world but is endemic in less-developed regions. Complications of omphalitis are exceedingly rare, but potentially catastrophic. Many of these babies will require surgical intervention. This paper aims to review the serious complications of omphalitis and how these should be managed. CONCLUSION: It is important to be aware of the rare but potentially lethal complications of omphalitis. Prompt recognition of serious sequelae is crucial for survival.

Tracheal agenesis with unique anatomy.

A premature infant with a unique form of tracheal agenesis is described. The combination of difficulty in intubation, abnormal course of the nasogastric tube on plain x-ray, and gastric perforation raised the suspicion of an upper airway malformation. Tracheal agenesis is an extremely rare, typically fatal, congenital anomaly with scattered case reports of its successful management. On many occasions, the diagnosis is a retrospective one at postmortem examination. The possibility of surgical correction rests on early diagnosis, anatomy, birth weight, and associated anomalies. Early recognition is mandatory, but in our case, the low birth weight precluded consideration for reconstructive surgery.

An unusual left-sided abdominal-wall defect.

Gastroschisis is a congenital abdominal-wall defect (AWD) that typically occurs to the right of the umbilicus. Rarely, a mirror variation of the above may occur with a defect to the left of the umbilical cord. This report concerns a neonate born with an unusual AWD in the left upper quadrant, distant from an intact umbilicus.

A prospective study of neonatal inguinal herniotomy: the problem of the postoperative hydrocele.

Previous studies have reported an increased incidence of complications following neonatal inguinal herniotomy (IH) in boys. The incidence and natural history of postoperative hydrocele in such cases has not been described. A prospective follow-up study of a consecutive series of male infants weighing less than 3 kg at the time of IH was undertaken. Regular follow-up examinations were scheduled for at least 1 year. Thirty-eight boys weighing less than 3 kg underwent IH during an 18-month period. One subsequently died from complications of prematurity. Complete follow-up data were available for 29/37 (78%) patients, yielding a total of 46 IHs. There were 2 recurrent hernias (4%), 2 unequivocally atrophic testes (4%), and 1 iatrogenic testicular ascent (2%). Five ipsilateral hydroceles complicated the postoperative course of 4 boys (14% of patients, 11% of herniotomies). Two of these were explored, but in neither case was a recurrent/residual patent processus vaginalis found. One hydrocele was aspirated without recurrence, and the remaining 2 resolved spontaneously. The complication rate in small infants undergoing neonatal IH is significantly higher than in older boys. The presence of a hydrocele after neonatal IH may simply reflect the accumulation of fluid in the distal hernia sac and, provided there is no evidence of a recurrent inguinal hernia, an expectant approach is recommended.