Long-term bladder function after ureterocele decompression in children.

PURPOSE: There is limited knowledge of long-term bladder function after ureterocele decompression. We studied bladder function in patients who underwent surgery in childhood for duplex system ureteroceles. MATERIALS AND METHODS: Toilet trained children treated for duplex system ureteroceles between 1990 and 2010 were included in study. We evaluated voiding dysfunction by the valid DVSS questionnaire and noninvasive studies, including uroflowmetry, electromyogram and post-void residual urine measurement. Urodynamics were done only in patients with abnormal DVSS or abnormal noninvasive studies. Patients were divided into group 1-ureterocele decompression (endoscopic incision), upper pole partial nephrectomy and ureteropelvic anastomosis, and group 2-primary or secondary bladder surgery (ureterocelectomy, ureterovesical reimplantation and bladder floor reconstruction). RESULTS: Of 62 operated patients 17 were lost to followup and 45 were fully studied at a mean followup of 9.5 years (range 3 to 20). Initial surgery was done at mean age of 5.1 months (range 6 days to 48 months). In the 33 group 1 patients, of whom 70% underwent endoscopic incision, the mean DVSS score was 1.5 (range 0 to 6), 7 patients (22%) had abnormal uroflowmetry or significant post-void residual urine and none had abnormal DVSS results. In the 12 patients in group 2 the mean DVSS score was 4 (range 0 to 11), 8 patients (66%) had abnormal uroflowmetry and significant post-void residual urine, and 3 had abnormal DVSS findings (p = 0.036). All group 2 patients underwent bladder surgery after decompression, including endoscopic incision in 2 and upper pole partial nephrectomy in 1. Only 1 child needed clean intermittent catheterization at age 3 years for hypocontractile megacystis and repeat febrile urinary tract infections. CONCLUSIONS: Ureterocele decompression alone in early childhood does not lead to major bladder dysfunction at long-term evaluation. Even if secondary bladder surgery is needed, significant bladder dysfunction is rare.

Reflective Practice About Retroperitoneal Laparoscopy in Comparison to Open Surgery for Ureteropelvic Junction Obstruction Repair in Children Less Than 1 Year of Age.

Introduction: The interest in laparoscopy in the treatment of ureteropelvic junction obstruction (UPJO) in children under 12 months of age remains controversial. The aim of this study is to evaluate feasibility and benefits of retroperitoneal laparoscopy (RL) compared to open surgery in this age group. Materials and Methods: Between January 2012 and May 2017, we performed 222 pyeloplasties: 144 by laparoscopy and 78 by open surgery. From 2012, the choice of operative technique was decided according to the laparoscopic experience of the surgeon; two surgeons operated laparoscopically on all children <12 months of age, while others operated using posterior lumbotomy (PL). The RL is standardized and performed by 3 trocars (5, 3, 3). Pre, per and postoperative parameters were analyzed retrospectively. Statistical tests: Pearson, Fisher, Student and Mann-Whitney. Results: During this 5-year period, 24 RL and 53 PL were included with a median follow-up of 27 months (5-63). In the LR group, postoperative drainage was performed by JJ (13 cases) and external stent (11 cases). No conversion has been listed in this group. In each group there was one failure that needed redo pyeloplasty. Duration of hospitalization and intravenous acetaminophen use were significantly lower in the RL group (2.8 vs. 2.3 days, p = 0.02, respectively) while operating time was significantly longer (163 vs. 85.8 min, p = 0.001). The postoperative complication rate was statistically identical in each group (urinary tract infection, wall hematoma, hematuria…). Conclusion: RL is feasible in children under 1 year of age in the hands of well-experienced surgeons with longer operative time but without added morbidity. Subject to the retrospective nature of our study, the RL seems to offer a benefit regarding duration of hospitalization and analgesics consumption.

Duhamel operation vs neonatal transanal endorectal pull-through procedure for Hirschsprung disease: which are the changes for pathologists?

BACKGROUND: The aim of this study was to evaluate whether performing definitive surgery for Hirschsprung disease (HD) in neonatal period with a transanal endorectal pull-through (TEPT) procedure had modified our diagnostic relevance, particularly during intraoperative frozen sections (IOFS), compared to classic Duhamel (DH) surgery performed in older children. METHODS: We collected pathologic data for 47 children who underwent surgery for neonatal nontotal HD over a 5-year period. RESULTS: Twenty-nine patients underwent TEPT and 18 the DH operation. Mean age at operation was 19 days for TEPT and 4 months for DH operation. The mean number of IOFS was 2.6 for TEPT and 2.4 for DH operation. Gross examination could be fully completed in all TEPT cases, but was incomplete in 5 DH cases. The average total lengths of bowel, and aganglionic, transitional, and ganglionic segments were 12.3, 7.3, 3, and 2 cm for TEPT, and 17.6, 9.3, 3.5, and 4.8 cm for DH operation, respectively. Discordance between IOFS and paraffin-section analysis occurred in 5 cases (3 TEPT and 2 DH operation). CONCLUSION: When TEPT was used, the gross examination and sampling was more accurate, leading to a clearer pathology report. The TEPT procedure facilitates the work of the pathologist without modifying the results of IOFS, if some precautions are taken.

The management of long gap esophageal atresia.

BACKGROUND: Present management of esophageal atresia has enabled the survival rate to approach 95%. Controversy remains concerning the many options for the surgical management of long gap esophageal atresia without tracheoesophageal fistula and represents the difficulty of this pathology. In the last couple of years, we have had a nonexplained outbreak of cases of long gap esophageal atresia without tracheoesophageal fistula. This article reports our experience in the management of these children. MATERIAL AND METHODS: It is a retrospective study of all cases of long gap esophageal atresia without tracheoesophageal fistula managed in our institution since 1992, focusing on the antenatal period, delivery with weight and term, the associated malformations, the initial management, and the definitive surgery. Mann-Whitney U test was used for statistical analysis. RESULTS: Ten cases (8.7%) of long gap esophageal atresia according to Ladd's classification, 6 during the past 2 years, were taken in charge at Robert Debré Hospital between 1992 and 2002. There were 4 girls and 6 boys. Ten had a prenatal diagnosis of esophageal atresia. The average birth weight was 2496 g (range, 1400-3400 g) with an average term of 36.6-week gestation (range, 31.5-39.6). Delayed reconstruction was done in all children between 41 and 147 days of life (average of 102 days). Six had a direct anastomosis and 4 had a colonic esophagoplasty (3 with an esogastric disconnection during the same procedure). The average follow-up was 60 months (range, 27-133). There was 1 death owing to adenovirus infection at 5 years of age. Four children required a Nissen fundoplication for severe gastroesophageal reflux. At least, 2 children presented an anastomotic stricture which required pneumatic dilatations. CONCLUSION: Treatment options for long gap esophageal atresia generally require several stages over several months. We propose, for their management, a direct anastomosis at 4 months of age whenever it is possible. If not, we use a colonic esophagoplasty with an esogastric disconnection to control the gastroesophageal reflux which is responsible for strictures and respiratory impairment and does not obstruct the aperistaltic tube.