[Outcome of severe closed kidney injuries in children]. / Devenir des traumatismes fermés sévères du rein de l'enfant.

AIMS: To analyze the results of treatment of major renal injuries according imaging data in order to determine their function after follow-up. PATIENTS AND METHODS: This is a retrospective study of 22 cases of fracture of the kidney (grade V) in two pediatric surgical services that were reviewed over a period of 16 years. After initial conservative treatment in 19 patients (86.5%), a scan and/or Uro-MRI were realized in all patients in monitoring evolving. Three children with vascular injury were treated by interventional radiology. The morphology and functional evolution of the injured kidney were determined. RESULTS: A DMSA scan investigation was performed in 21 patients (95.5%) associated with Uro-MRI in two cases; one patient was only explored with Uro-MRI. A complete restitution of the renal parenchyma was confirmed in 10 children (45.5%), we noted an atrophy of the upper pole in 30%, a lower pole atrophy in 4.5%, two complete renal atrophy in 9%. An urinoma was present in six patients (27%) that required drainage in five cases and declined during the surveillance in one case. Normal function of the injured kidney was noticed in half of grade V (11 of 22 patients) with a mean follow-up of 19 months. None of our patients did present hypertension. CONCLUSION: Non-operative conservative treatment in severe renal trauma was efficient, morphological and functional sequelae were present in 50% on scintigraphy and/or Uro-MRI.

Circumcision and Risk of Febrile Urinary Tract Infection in Boys with Posterior Urethral Valves: Result of the CIRCUP Randomized Trial.

BACKGROUND: Boys with posterior urethral valves (PUVs) have an increased risk of febrile urinary tract infections (fUTIs). Circumcision is believed to reduce the risk of fUTIs in boys, although there are no randomized trials demonstrating this. OBJECTIVE: To determine the effect of circumcision on the risk of fUTIs in boys with PUVs. DESIGN, SETTING, AND PARTICIPANTS: A clinical randomized trial that ran between August 2012 and July 2017 was conducted. The trial was multicentric, including 13 referral centers for pediatric urology. Male boys, aged 1-28 d, diagnosed with posterior urethral valves, confirmed by voiding cystogram, were included. The exclusion criteria included presence of a genital malformation contraindicating performing a circumcision. INTERVENTION: Participants were randomized to neonatal circumcision + antibiotic prophylaxis (CATB) or antibiotic prophylaxis alone (ATB), and followed for 2 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was a risk of presenting fUTIs in each group. An fUTI was defined as fever (>38.5 °C) with evidence of pyuria and culture-proven infection on urinalysis, obtained by urethral catheterization or suprapubic aspiration. A bivariate analysis of the primary outcome was performed using the Kaplan-Meier method. RESULTS AND LIMITATIONS: In total, 91 patients were included: 49 in group CATB and 42 in group ATB. The probability of presenting an fUTI was 20% in group ATB versus 3% in group CATB. The hazard ratio of presenting an fUTI within 2 yr in the ATB group compared with that in the CATB group was 10.3 (95% confidence interval: 1.3-82.5). Sixty-four children (70.3%) had a complete follow-up at 2 yr of age. CONCLUSIONS: Circumcision significantly decreases the risk of presenting an fUTI in boys with PUVs. PATIENT SUMMARY: In this report, we compared, in a multicentric trial, the number of febrile urinary tract infections (UTIs) in boys with posterior urethral valves who had either antibiotic prophylaxis alone or antibiotic prophylaxis and circumcision. We found that those who had a circumcision had a significantly lower risk of febrile UTIs.

[Urinothorax: rare complication of neonatal sectioned posterior urethral valve]. / Urothorax: complication rare d'une valve de l'urètre postérieur sectionnée en période néonatale.

We report a newborn aged 19 days, carrying a posterior urethral valve antenatal screening in which developed 7 days after the entire section of the valve, a compressive urinothorax in connection with a perirenal urinoma. Pleural and bladder drainage has a surrender of effusions and a healing of the renal parenchyma. The thoracic urine effusion is a very rare complication of a posterior urethral valve with perirenal urinoma. This probably results from a rupture of a fornix dysplastic by hypertension of the urinary tract. The authors emphasize the unusual discovery of this disease by breathing problems and his delayed character after resection of the obstruction in the neonatal period.

[Diffuse xanthogranulomatous pyelonephritis in infant]. / Pyélonéphrite xanthogranulomateuse diffuse du nourrisson.

We report a case of a renal mass in a 4-month boy, which occured during the assessment of a pelvi-calyceal dilatation diagnosed at 23 weeks of gestational age. There was no history of urinary infection, fever or weight loss. Physical examination revealed a mass of the left flank with significant flank tenderness. Laboratory test showed a biological inflammatory syndrome and urine culture was negative. Investigations including ultrasound and computed tomography scan were suggestive of diffuse xanthogranulomatous pyelonephritis with a non-functioning left kidney. Left total nephrectomy was performed through a lumbar incision with an extraperitoneal approach. The kidney was enlarged with a dilated pelvis containing pus upstream of a proximal ureteral atretic segment. Pathological examination of the kidney confirmed the diagnosis of diffuse xanthogranulomatous pyelonephritis. The boy remains well at 1 year follow-up. Xanthogranulomatous pyelonephritis is very rare in infants. It is an uncommon severe progressive renal infection resulting in destruction of renal parenchyma, histologically replaced by xanthomatous cells and granulomatous reaction. Pathogenesis of xanthogranulomatous pyelonephritis remains unclear. But it is well known that urinary tract obstruction and renal lithiasis are determining factors. It can occur in variant clinical forms but its symptoms remain non-specific. Curative treatment consists in nephrectomy and definitive diagnosis is made on histological examination of the kidney. This diagnosis should be discussed when a renal mass occurs in a context of malformative uropathy and xanthogranulomatous pyelonephritis have to be included in the differential diagnosis of renal mass in infants and children.

[Vascular ischemic lesions of the kidney in multiple trauma patients: incidence and management, a report of 7 cases]. / Lésions vasculaires ischémiques rénales chez le polytraumatisé: incidence et prise en charge à propos de 7 cas.

AIMS: Study the incidence, type and outcome of traumatic ischemic arterial lesions of the kidney in multiple trauma patients. MATERIALS AND METHODS: Retrospective study of 500 multiple trauma patients who underwent whole body 64 slice CT Scan (mean age 34 years old, sex ratio 4M/1W, mean ISS 29). RESULTS: There were seven cases of vascular lesions of the left kidney 1.4% of patients (men, median age 25 years old, mean ISS43.9). These were closed traumas with sudden deceleration and dissection of the renal artery trunk in three cases and injury to its branches in four cases with preserved excretion. Three patients died of associated injuries, including one patient who received a stent on D0. One patient underwent a nephrectomy and the three other patients were not treated which did not affect renal function or pressure (follow-up 19 months). CONCLUSION: We found a high incidence of traumatic renal dissection in multiple trauma patients. Multidetector scan appears to provide the best results for the diagnosis of these lesions as well as the many associated lesions resulting in a very poor prognosis for these patients. Treatment is not well defined and management of these lesions is often of secondary importance because of the severity of associated injuries.

[Intestinal obstruction in children due to isolated intestinal malrotation. Report of 11 cases]. / Occlusion intestinale de l'enfant par malrotation intestinale isolée. A propos de 11 cas.

UNLABELLED: The purpose of this study was to determine the clinical significance of children presenting with malrotation to develop treatment recommendations. METHODS: Records of children undergoing a Ladd procedure were identified in the pediatric patient database from 1 June 1996 to 31 March 2007. Patients with intestinal obstruction caused by isolated intestinal malrotation were included. The exclusion criteria were the association of predisposing factors (omphalocele, gastroschisis, diaphragmatic hernia). Patient characteristics, imaging investigations, operations performed, and morbidity were evaluated. RESULTS: Eleven children (7 boys and 4 girls) underwent a Ladd procedure at the median age of 14 days. Seven patients presented bilious vomiting, alimentary vomiting associated with weight loss (2 cases), and melena (1 patient) at admission. The upper gastrointestinal radiological investigations established the diagnosis of intestinal malrotation in 6 cases confirmed by ultrasonography in 3 cases. Isolated Doppler ultrasound investigation was sufficient in 4 cases before abdominal surgery. In 1 case, preoperative diagnosis of intestinal malrotation was not made. Intraoperative anomalies were midgut volvulus in 7 cases, Ladd bands in 3 patients, and malrotation with intestinal ischemia in 2 cases with spontaneous resolution of midgut volvulus. Incomplete intestinal malrotation (180 degrees) was found in 10 cases and a mobile cecum in 1. CONCLUSION: These findings provide support for performing early diagnosis of intestinal malrotation to prevent the rare but potentially devastating complications of this anomaly.

[Ultrasonography of acute scrotum in children]. / La bourse aiguë de l'enfant : corrélations radiocliniques.

Paediatric surgeons and urologists are often asked to evaluate boys with acute scrotal pain and inflammation. Although, there is much aetiology for this syndrome: testicular torsion, appendicular testicular torsion, epididymo-orchitis, hernia, hydrocele, trauma, Henoch-Schonlein purpura, idiopathic scrotal edema. However, testicular torsion should be at the top of the list because of the medico legal aspects. It is the one diagnosis that must be made accurately and rapidly, if there is any hope for testicular salvage. Color Doppler ultrasound scan can reliably identify those children, who required exploration and spare medical causes. The purpose of this article is to update/review the appropriate evaluation and management of the acute scrotum and to guide the clinician in distinguishing testicular torsion from the other conditions that commonly mimic this surgical emergency.

[Abdominoscrotal hydrocele with leg edema in a 4-month-old boy]. / Hydrocèle abdomino-scrotale compliquée d'un lymphoedème de jambe chez un nourrisson.

We present a case of a 4-month-old boy with a right abdominoscrotal hydrocele associated to a compression of the femoral triangle, causing an unilateral leg edema. Abdominoscrotal ultrasound revealed a fluid collection with abdominal and scrotal components, communicating through the deep inguinal ring. Sagittal views of magnetic resonance imaging (MRI) showed a dumbbell-shaped hydrocele and the angio-MRI venous sequences confirmed the compression of the right iliac vessels. Curative treatment was surgical through an inguinal approach and consisted in high ligation of the processus vaginalis and hydrocelectomy. Abdominoscrotal hydrocele is an uncommon pathology, which rarely occurs in pediatric population. This diagnosis should be discussed when a cystic abdominal mass is associated to an ipsilateral scrotal hydrocele. The abdominal component of the hydrocele can result in compression of adjacent structures (iliac vessels, ureter). Surgical treatment is recommended. Epididymal and testicular abnormalities are frequently described, as in our observation, and the effects on the future fertility are unknown.

[Thoracic and abdominal trauma in children]. / Particularités des traumatismes thoraciques et abdominaux chez l'enfant.

Knowledge of the characteristics of thoraco-abdominal trauma in children is important to optimize the imaging work up while keeping radiation exposure to a minimum. Because of the plasticity of the pediatric rib cage, rib fractures are infrequent, and severe parenchymal injuries may be present in the absence of rib fracture. Mediastinal injuries are unusual. The increased mobility of solid intraabdominal organs combined with a weaker abdominal wall are specific to pediatric patients. First-line imaging typically includes chest radiograph and abdominal US with Doppler imaging. Contrast-material enhanced CT is used as a second-line technique, with delayed imaging in patients with urinary tract lesions. Dedicated pediatric acquisition protocols are mandatory. Follow-up is obtained mainly with US.

Endoscopic injection of bulking agent around the ejaculatory ducts at the verumontanum for recurrent paediatric epididymitis.

INTRODUCTION: Paediatric recurrent epididymitis is frequently observed in several urogenital conditions, and may result in deterioration of long-term fertility. The management of recurrent epididymitis is still a therapeutic challenge for paediatric urologists, and as yet there is no consensus for treatment. OBJECTIVE: To present a minimally invasive endoscopic approach for the treatment of recurrent epididymitis (more than three episodes). PATIENTS AND METHODS: Eleven boys were referred with a history of recurrent epididymitis in a context of urogenital malformations. All children underwent endoscopic transurethral injection. Dextranomer/hyaluronic acid was injected around the ejaculatory ducts at the verumontanum (Summary Fig.). The medical records and outcomes of the patients were retrospectively reviewed. RESULTS: Of the 11 boys, two (18%) had a history of bladder exstrophy, three (27%) anorectal malformation, two (18%) peno-scrotal hypospadias, two (18%) posterior urethral valves, one (9%) seminal vesicle cyst, and one (9%) urethral stricture. The median age at injection was 3.75 years (range 8 months-14.7 years). Endoscopic injection effectively prevented recurrence in eight patients (73%) with a mean follow-up of 3 years (range 6 months-8.8 years). The mean injected volume was 0.7 ml/session. No perioperative complications were recorded. Vas clipping was performed in three patients after unsuccessful injections. DISCUSSION: The current discussion for management of recurrent epididymitis is mainly based on vas clipping. Endoscopic injection in the verumontanum could offer several potential advantages over vas clipping; moreover, it is easy to perform for an urologist who usually uses endourological approaches. It is believed that only Kajbafzadeh et al. have reported their experience with endoscopic injection in the verumontanum in seven patients with structural anomalies, and they had a 42% success rate. Similarly, the current study did not observe perioperative or postoperative complications. CONCLUSION: In this series, endoscopic injection of the verumontanum was considered to be a safe and effective treatment in almost 73% of children with recurrent epididymitis. It did not result in perioperative complications and not contraindicate a subsequent surgical procedure such as vas clipping.

Duodenal duplications. Clinical characteristics, embryological hypotheses, histological findings, treatment.

BACKGROUND: The aim of this study was to analyse different clinical aspects and embryologic hypotheses of duodenal duplications. METHODS: Duodenal duplications occurring since 1995 were recorded. The age of the children at the time of diagnosis, the sex, location of the duplication, type of mucosa, clinical signs, associated lesions, and the type of surgical intervention were defined. RESULTS: We identified 5 patients (3 girls and 2 boys) who presented with histological or intraoperative findings of duodenal duplication. Their ages ranged from 4 days to 9 years, with the exception of two prenatal diagnoses. Three children were symptomatic: high intestinal obstruction (1 case), digestive bleeding (2 cases). In 1 case we found a palpable abdominal mass and 1 case was completely asymptomatic (prenatal detection). The abnormality was located on the duodenal concavity, originating from the third part in 2 cases and from the second part in 3 cases. All cases were non communicating types, 4 of which were cystic duplications and 1 was a tube-like variety. The epithelial lining was duodenal mucosa in all patients, but gastric heterotopies were identified in 2 cases. We performed two complete resections and 3 intraduodenal derivations. The outcome was uneventful in 5 cases with an average follow-up of 2 years. CONCLUSION: Duodenal duplications are rare malformations with several anatomical varieties. The preferred treatment for duodenal duplications is complete removal when the location allows it without endangering nearby anatomical structures.

Postural therapy for renal stones in children: A Rolling Stones procedure.

INTRODUCTION: Despite many advances, the management of renal stones - especially lower caliceal stones (LCS) - remains a challenge. The gravity-dependent location of the lower calices hinders the spontaneous clearance of fragments, which can be a nidus for future growth and symptomatic recurrence. Currently, there is no standard adjunctive therapy to facilitate fragment passage. OBJECTIVES: To report the safety and effectiveness of mechanical percussion diuresis and inversion (PDI) therapy for eliminating renal stones in children. PATIENTS AND METHODS: Since November 2013, children with residual fragments (after shock wave lithotripsy or flexible ureteroscopy) or native symptomatic renal stones were prospectively included in a protocol of four PDI sessions. After giving written consent, the children drank 10 ml/kg of water 30 min before therapy. They then laid in a prone Trendelenburg position on a couch angled at 45° and received continuous 10-min mechanical percussion applied over the affected flank by a physiotherapist (Figure summary). Tolerance stone burden reduction and stone clearance were documented with ultrasound 4 weeks after the last session. RESULTS: Seventeen participants, with a median age of 10.8 years (range 18 months to 18 years), received 82 PDI sessions performed over 22 months. The median stone diameter was 5 mm (range 3-9). All children tolerated the PDI therapy well. Over a median follow-up of 11 months (range 3-18), no significant adverse effects were noted. The overall stone-free rate was 65%. Four of the six patients with residual fragment passed their fragments. The patients who did not become stone free by PDI experienced a decrease in fragment size of 57% (range 34-71). The observance rate was 100%. DISCUSSION: Many studies have demonstrated that the gravity-dependent position of the lower calyces appears to be an important factor limiting the clearance of LCS. Positioning patients with a degree of inversion in order to put the collecting system beyond the horizontal plane affected the LCS through gravitational force. Complications were rare. PDI appeared to save costs and have similar success rates as shock wave lithotripsy for native small renal stones in children. CONCLUSION: PDI is safe and effective for facilitating gravity-dependent drainage of renal stones and provides an opportunity to treat children in a quick, non-invasive, economic, painless, non-radiative and diverting fashion. This therapy is a valuable alternative in the pattern of stone management. In case of persistent fragments, it is recommend that the number of sessions be increased to six.

[Sports-related concussions in youths]. / Commotions cérébrales chez le jeune sportif.

Mild head trauma can be associated with concussion, defined as transient brain function impairment without radiological findings. Sports-related concussion is also reported in pediatrics (rugby, ice hockey, football, boxing, etc.). Misdiagnosis can lead to persistent neurocognitive signs with athletic and academic problems. Consensual tools are available, but they are not well-known by first-line doctors, coaches, and patients or parents. Concussed players should not be allowed to return to the field on the same day. Return to play should be gradual over 3weeks or more. School activities may need to be modified to favor cognitive rest. Prevention is based on risk information and knowledge transfer, rule changes, and protective helmets, whose effectiveness is not always proven.

[Does prenatal diagnosis modify neonatal management and early outcome of children with esophageal atresia type III?]. / Le diagnostic anténatal modifie-t-il la prise en charge néonatale et le devenir à 1 an des enfants suivis pour atrésie de l'œsophage de type III ?

OBJECTIVE: Evaluate neonatal management and outcome of neonates with either a prenatal or a post-natal diagnosis of EA type III. STUDY DESIGN: Population-based study using data from the French National Register for EA from 2008 to 2010. We compared children with prenatal versus post-natal diagnosis in regards to prenatal, maternal and neonatal characteristics. We define a composite variable of morbidity (anastomotic esophageal leaks, recurrent fistula, stenosis) and mortality at 1 year. RESULTS: Four hundred and eight live births with EA type III were recorded with a prenatal diagnosis rate of 18.1%. Transfer after birth was lower in prenatal subset (32.4% versus 81.5%, P<0.001). Delay between birth and first intervention was not significantly different. Defect size (2cm vs 1.4cm, P<0.001), gastrostomy (21.6% versus 8.7%, P<0.001) and length in neonatal unit care were higher in prenatal subset (47.9 days versus 33.6 days, P<0.001). The composite variables were higher in prenatal diagnosis subset (38.7% vs 26.1%, P=0.044). CONCLUSION: Despite the excellent survival rate of EA, cases with antenatal detection have a higher morbidity related to the EA type (longer gap). Even if it does not modify neonatal management and 1-year outcome, prenatal diagnosis allows antenatal parental counseling and avoids post-natal transfer.

Treatment of a case of congenital pseudarthrosis of the tibia-fibular osteosynthesis.

We report the results of a case of congenital pseudarthrosis of the tibia treated by tibiofibular synthesis. A 1-year old girl was first treated by intramedullary fixation followed by an intertibiofibular bone graft. This method failed. She then underwent a new operation that was associated two simultaneous approaches, correction of the axis, tibiofibular synthesis and a new intertibiofibular bone graft. Union was achieved four months later. The child has now been followed up for 20 years. During this time, she has led a normal life as we have observed a "tibialisation" of the fibula. Intramedullary fixation has a success rate of 75% but requires repetitive insertion of intramedullary or telescopic rods. Transplantar intramedullary rods are responsible for significant ankle stiffness. Tibiofibular synthesis associated with an intertibiofibular bone graft after correction of the axis is the equivalent of vascularised graft of the fibula but with neither the difficulties of microsurgery nor valgus deformities of the ankle.

X-ray transparency interpositions after reduction of traumatic dislocations of the hip in children.

Traumatic dislocations of the hip are much less frequent in children than in adults. If some complications are well known (avascular necrosis of the femoral head, recurrent dislocation), the lateralization of the head by x-ray transparency interposition is less appreciated. We report 4 cases of x-ray transparency interposition in 15 reductions of incomplete traumatic dislocation of the hip. These 4 dislocations were posterior in non-pathological hips, three on the left side and one on the right. Our reductions have been easy and the hips remained stable. However, the post-reduction roentgenogram shows the same unusual enlarged joint space corresponding to the lateralization of the femoral head. Four arthrotomies were performed, tracing a cartilaginous fragment free or fixed to the articular capsule into the femoral joint. We have found a concentric reduction of the hip in 4 cases and enlargement from 1 to 3 mm of the joint space of the hip. After several years, articular function of the four hips is normal, nevertheless, they have shown a coxa valga with a femoral elongation to 10 mm, a coxa magna with an articular space wider than 1 mm, 2 very good concentric reductions of the hip. The lateralization of the head after reduction had to be detected as soon as the first radiographic control because it can cause immediate instability or arthrosis of the hip. Because of the cartilaginous or capsular composition and the size of the interposition, an arthrotomy is performed in front of a radiological enlarging of the space joint, or a loss of parallelism of osteochondral acetabulum bone. Computerized tomography and MRI can reveal the nature, the place of the included fragment, as well as the surgical approach. An arthrogram is not absolutely indispensible. Surgical exploration should avoid degenerative arthrosis after a lateralisation left untreated.

The choice of treatment for simple bone cysts of the upper third of the femur in children.

A retrospective study of a series is presented of 19 simple cysts of the upper third of the femur in children of a mean age of 7 years. The patients included 4 adolescents and 15 children under the age of 10. Mean recurrence was 6 years. Different treatment methods were utilized: - surgical treatment: curettage-bone grafting with or without osteosynthesis, - intra-cystic corticoid injection, - orthopedic treatment. Cysts may be small with a low lytic potential, in this case intra-cystic corticoid injections are very effective; or bigger in size with a risk of fracture or have already caused a fracture, the treatment is then surgical but should always be combined with osteosynthesis.

Anterior approach versus posterior approach to surgical treatment of children's supracondylar fractures: comparative study of thirty cases in each series.

The purpose of this study was to consider the surgical treatment of severe supracondylar fractures of the elbow in children, and to compare the anterior approach with the posterior approach used in two homogeneous groups of 30 cases each by two experienced surgeons. Control procedures were maintained with the children of both groups when the plaster was removed, during the fourth month after surgery, and throughout the follow-up that continued for more than 1 year. A posterior approach to surgery is simpler than an anterior approach, but it creates supplementary anatomic damage that can cause circulatory disorders in the external condyle and a higher percentage of limitation in articulation mobility. Thus, although the anterior approach is more technically demanding, it gives better functional results. Because this approach concerns a zone already damaged by the trauma, it eliminates hematoma in the anterior brachial muscle and again places the fragments in the untouched shell of the periosteum.

[Abdominal cystic lymphangiomas in children. Clinical, diagnostic and therapeutic aspects: apropos of 21 cases]. / Les lymphangiomes kystiques abdominaux de l'enfant. Aspects cliniques, diagnostiques et thérapeutiques: à propos de 21 observations.

Twenty-one abdominal cystic lymphangiomas were observed in paediatric patients during a 15-year period, in 11 boys and 10 girls. Diagnosis was prenatal in 2 cases; the mean age of the other 19 children was 4.7 years (range: 3 months-8 years). Tumours were intraperitoneal in 16 cases and retroperitoneal in 5 cases. Symptoms were variable: abdominal pain in 15 cases, palpable tumour in 6 cases (excluding the two cases of prenatal diagnosis). Complications included obstruction in 7 cases (including 3 by volvulus), infection in 6 cases, and intracystic haemorrhage in 3 cases. Abdominal ultrasonography correctly established the diagnosis in all children. Surgical treatment included 20 complete resections and one incomplete resection, including 6 with bowel resections. With a follow-up ranging from 6 months to 10 years, one recurrence occurred and was successfully reoperated. Intraabdominal cystic lymphangioma in childhood is a rare tumour with a variable presentation. An accurate diagnosis can be established by abdominal ultrasound. Complete resection should be performed whenever possible.