Long-term fate of the bladder after isolated bladder neck procedure

ObjectiveRecent and historical studies suggest that bladder neck procedures (BNPs) without augmentation are safe and effective. In select patients we have performed BNPs without concomitant augmentation. We sought to determine long-term outcomes of this approach and attempt to identify risk factors for bladder deterioration.Patients and methodsA retrospective chart review was conducted to identify patients who underwent a BNP without bladder augmentation and followed for at least 4 years. BNPs were only performed in patients with favorable preoperative urodynamics (UDS). The charts were analyzed for long-term outcomes with the primary endpoint of bladder augmentation.ResultsTwenty-nine patients (21 females) with poor bladder outlet resistance underwent a BNP without augmentation (mean follow-up 8 years). Thirteen patients (45%) were augmented at an average of 2.6 years. No predictive UDS parameters were identified; however, exploratory analysis suggested detrusor pressure at 100 mL bladder volume prior to BNP (p = 0.009) was predictive of delayed augmentation.ConclusionWe report a 45% augmentation rate after isolated BNP in patients with favorable preoperative UDS parameters. We recommend close observation of this patient population with serial UDS, routine ultrasounds, and appropriate preoperative counseling prior to undertaking this approach, as this represents a life-long risk to the upper tracts.     

Stapled intestinal anastomosis is a simple and reliable method for management of intestinal caliber discrepancy in children

Purpose

Popularity of minimally invasive surgeries has led to the development of stapled intestinal anastomosis for adults. The advanced instruments used in this technique are getting suitable with the small intestinal lumens of neonates and infants. We reviewed and compared the intraoperative and postoperative results of stapled and hand-sewn anastomoses in children.

Methods

The operative data of children who underwent stapled and hand-sewn anastomoses between March 2005 and December 2011 were collected and analyzed retrospectively. Furthermore, we compared patients who underwent anastomoses for colostomy closure of anorectal malformation (4 stapled, 9 hand-sewn) and those who underwent anastomoses for treatment of ileal atresia (3 stapled, 11 hand-sewn).

Results

In the 47 patients who underwent stapled anastomosis, no intraoperative complications were observed and postoperative complications included wound infection (n?=?3), delayed gastric emptying (n?=?1), and ileus (n?=?1). No complications suggesting anastomotic dilatation were identified. It was observed that patients who underwent stapled anastomosis for colostomy takedown with caliber discrepancy had significantly shorter surgery time than those who underwent hand-sewn anastomosis.

Conclusion

Our results suggest that stapled anastomosis is safe and effective for various surgical diseases in neonates, infants, and children.     

Upper tract changes in patients with neurogenic bladder and sustained pressures >40 cm following bladder neck surgery without augmentation

ObjectiveWe report new hydronephrosis or VUR (vesicoureteral reflux) in patients with end filling pressures >40 cm for at least 1 year after bladder neck surgery without augmentation for neurogenic incontinence.MaterialsConsecutive children with neurogenic sphincteric incompetency had bladder neck surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually. Those with sustained end fill pressures >40 cm for ≥1 year were included as participants in the study.ResultsOf 79 patients, 17 (22%) had end fill pressures >40 cm for at least 1 year despite anticholinergics, with follow-up a mean of 39 months. New hydronephrosis or VUR developed in six (35%). All new hydronephrosis resolved with medical treatment, as did two out of three new VUR cases. The other patient with VUR had successful Dx/HA (dextranomer hyaluronic acid) injection.ConclusionsDespite sustained pressures >40 cm, upper tract changes developed in only 35% of patients, and resolved with medical management or minimally invasive interventions. End pressures should not be used as an independent indication for augmentation.     

Augmentation colocystoplasty in bladder exstrophy

A good bladder capacity and adequate outlet resistance determine success after staged reconstruction of bladder exstrophy (BE). Augmentation cystoplasty (AC) is an established salvage procedure to treat the small, noncompliant bladders of some of these children. In a series of 89 patients with BE treated over the last 12 years, 19 underwent detubularized augmentation colocystoplasty (ACC) as an adjunctive procedure. Nine underwent ACC at the time of bladder-neck reconstruction (BNR) for small bladder capacity and poor compliance; 10 underwent ACC as a secondary procedure after BNR for persistent urinary incontinence or poor bladder compliance and upper-tract deterioration. The follow-up period ranged between 6 months and 12 years (mean 41 months). Complications included symptomatic urinary-tract infection in 4 patients, recurrent epididymo-orchitis in 2, calculi in 3, colonic anastomotic dehiscence in 1, bladder-patch fistula in 2, and secondary coloureteric-junction obstruction in 1. There was no postoperative reservoir perforation or mortality. The upper tract remained normal or stable in all patients. Nine of the 19 patients are dry both day and night; 4 others are dry during the day but have occasional nocturnal wetting. Three patients have nocturnal wetting with stress incontinence and 2 remain incontinent. Seven patients can void effectively using abdominal contractions and 12 require clean intermittent catherization to ensure complete voiding. The indications and results of AC in BE from other series are reviewed. AC is an important and safe adjunctive procedure in a subset of BE patients with small and poorly compliant bladders. Despite the known complications, more liberal use of AC in BE is warranted. Accepted: 21 March 2001     

Does bladder augmentation negatively affect renal transplant outcome in posterior urethral valve patients?

ObjectiveAlthough renal transplant (RT) is a safe and effective treatment for end-stage renal disease, the outcome of RT has been mixed for posterior urethral valve (PUV) patients. In addition, some PUV patients need an augmentation cystoplasty (AC), which may negatively affect their RT outcome. The aim of this study is to compare RT outcome between PUV children with and without AC.Materials and methodsBetween 1985 and 2012 a total of 309 children received 369 RTs at our institution. Among these patients, 36 were had classified as having PUV. Of these, 12 underwent an AC before RT (AC group) and 24 did not (controls). Data, including age at transplant, allograft source, urological complications, urinary tract infection (UTI) incidence, the presence of vesicoureteral reflux (VUR), and patient and graft survival, were compared between groups.ResultsMean age at RT and mean follow-up were 7.6 versus 7.9 years and 8.9 versus 7.9 years in the AC group and in the control group, respectively (not significant [NS]). Allografts were from living donors in 50% of the AC group and in 41.6% of the controls (NS). The rate of UTI was 0.02 UTI/patient/year and 0.004 UTI/patient/year in the AC and control group, respectively (p = 0.001). Of the nine patients with UTI in the augmented group, five (55.5%) had VUR, while 5/8 (62.5%) patients in the control group with UTI had VUR. All patients with VUR in either group had UTIs previously. Of the five AC patients with more than three UTIs, two (40%) were non-compliant with clean intermittent catheterization (CIC), and UTI incidence was not associated with either a Mitrofanoff conduit or the urethra being used for CIC. Graft function at the end of study was 87.8 ± 40.5 ml/min/m² in the AC group and 88.17 ± 28.20 ml/min/m² in the control group (NS). The 10-year graft survival rate was 100% in AC group and 84.8% in controls. Two patients in the AC group lost their grafts (mean follow-up 13.3 ± 0.8 years) and five in the control group (mean follow-up 7.1 ± 4.7 years).ConclusionsBladder augmentation does not negatively affect renal outcome in PUV patients undergoing transplantation. However, recurrent UTIs are more frequent in transplanted PUV patients with an AC than in those without AC, and they are generally related to non-compliance with CIC or the presence of VUR but, mostly, they will not result in impaired graft function.     

Severe bladder dysfunction revealed prenatally or during infancy

ObjectiveAlthough thought to be an acquired condition, non-neurogenic neurogenic bladder may sometimes be a congenital dysfunction, revealed before toilet training. We report our experience with the condition diagnosed prenatally or during early infancy.Patients and methodWe retrospectively reviewed cases of severe bladder dysfunction with upper-tract impairment, without neurological or obstructive pathology, in children diagnosed before toilet training: five with prenatal diagnosis of severe hydro-ureteronephrosis (group 1) and six with signs of bladder dysfunction during infancy (group 2).ResultsFollow up of group 1 showed decompensation toward severe bladder dysfunction, diagnosed after either toilet training or ureteral reimplantation (n = 3). After a median follow up of 14 years (0.5–20), four were on clean intermittent catheterization with bladder augmentation and one required sphincteric re-education with good result. Two of the five had chronic renal failure. In group 2, six children (two females) presented at median age of 20 months (2–30) with indirect signs of bladder dysfunction, including vesicoureteral reflux (n = 4) and/or hydro-ureteronephrosis (n = 4). After a median follow up of 11 years (5–20), three were on clean intermittent catheterization (two Mitrofanoff channels), and three underwent bladder augmentation. Three children had chronic renal failure of whom one underwent renal transplant.ConclusionThese cases of severe bladder dysfunction were initially misdiagnosed. In both groups, follow up revealed severe dilatation of the upper tract and secondary renal impairment. Antenatal diagnosis of bilateral pyeloureteral dilatation may be the first sign of early bladder dysfunction.     

New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder

ObjectiveWe report new upper tract changes in children after bladder neck (BN) surgery without augmentation for neurogenic incontinence.Materials and methodsConsecutive children with neurogenic sphincteric incompetency had BN surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually.ResultsThere were 75 patients with mean follow-up of 48 months. Of these, 17 (23%) developed new hydronephrosis (HN) or vesicoureteral reflux (VUR). All HN resolved with medical management, as did 25% of VUR cases. Persistent VUR was treated by dextranomer/hyaluronic acid injection, or re-implantation in two patients undergoing re-operative BN surgery. There was no association between these upper tract changes and end filling pressures (<40 cm vs. >40 cm) or continence status (dry vs. wet).ConclusionsUpper tract changes developed in 25% of patients with neurogenic bladders after BN surgery without augmentation during a follow-up of 48 months. All new HN and most new VUR resolved with medical management or minimally invasive intervention. No patient developed upper tract changes requiring augmentation.     

Comparison of traditional enterocystoplasty and seromuscular colocystoplasty lined with urothelium

ObjectiveTo evaluate long-term outcomes between various methods of augmentation cystoplasty.MethodsA retrospective analysis was performed of patients undergoing seromuscular colocystoplasty lined with urothelium (SCLU, n = 26), and their outcomes compared to a similar population of patients in the same institution who had received traditional forms of bladder augmentation (colocystoplasty and ileocystoplasty, n = 32). Measurements included efficacy of the procedure in increasing bladder capacity and achieving urinary continence, and the need of subsequent surgery for complications.ResultsThere was no statistically significant difference in achieved bladder capacity, subjective urinary continence and the rates of subsequent surgery for stones, vesicoureteral reflux, augment failure, bladder neck continence and catheterizable channel. None of the patients in the SCLU group had spontaneous perforation or small bowel obstruction.ConclusionPatients with SCLU are at decreased risk for bowel obstruction and spontaneous perforation, but are not devoid of other long-term complications including bladder stones, vesicoureteral reflux and augment failure. Most of the risks and benefits of augmentation cystoplasty performed using ileum, colon, or SCLU appear similar.     

The search for continence in bladder exstrophy: Bladder neck transection and Macedo catheterizable reservoir to augment the nativebladder

IntroductionBladder exstrophy remains one of the most challenging abnormalities in pediatric urology. We propose bladder neck transection and bladder augmentation with a catheterizeable reservoir technique to achieve continence after previous anatomic reconstruction in stages.MethodsAt the age of 5–6 years, we offer the transection of bladder neck and enterocystoplasty to achieve continence. We report on a 6-year-old boy that underwent this procedure. We perform the reservoir from ileum according to Macedo-technique that constructs a catheterizeable channel from the same bowel segment. The continence mechanism of the efferent tube is based on angulation and a serous lined tunnel created with 3.0 prolene sutures. The stoma is placed in the midline.ResultsPatient had an uneventful evolution and is continent performing CIC every 4 h with 9 months of follow up.DiscussionIn spite of continuous development of bladder exstrophy surgery, the urethral continence and voluntary micturition is still not possible in the majority of patients. We discuss with our patients honestly and offer this method as a viable alternative to achieve continence.ConclusionIn our experience, most patients accept urethral transection and suprapubic CIC when educated about results with other alternatives of bladder neck plasty.     

Influence of type of conduit and site of implantation on the outcome of continent catheterizable channels

ObjectiveContinent catheterizable channels (CCC) using the Mitrofanoff principle are essential for pediatric urinary tract reconstruction. There is controversy over the influence of type of CCC (appendix vs. Yang–Monti) and site of implantation (augmentation vs. native bladder) on outcome.Patients and methodsA retrospective record review was conducted of all patients undergoing CCC since 1999, excluding patients who underwent seromuscular colocystoplasty. We analyzed the type of channel, site of implantation, complications requiring re-operation, and the revision rate according to type of CCC, type of stoma, site of implantation (bladder vs. augmentation) and segment used for augmentation (ileum vs. sigmoid colon).ResultsThere were 41 patients with a mean age of 11.2 years and a mean follow-up of 33.3 months. Of these, 33 CCC were constructed with appendix and eight with a Yang–Monti technique (4 ileal, 4 sigmoid); 31 patients also had an enterocystoplasty (19 sigmoid, 9 ileal and 3 others). Overall revision rate was 27%; revision was required in 8/33 (24%) appendiceal and 3/8 (38%) Yang–Monti CCC (P = 0.7). Revisions were required in 4/21 CCC implanted in the native bladder and 7/20 implanted in augmented bladder (P = 0.3). The majority of revisions were at skin level.ConclusionsAlthough there was no statistical difference in revision rate according to type of CCC, type of stoma or site of implantation, complications appeared to be more common in patients requiring a more complex reconstruction.     

Delayed exstrophy repair (DER) does not compromise initial bladder development

ObjectiveDelayed exstrophy repair (DER) represents an alternative to early neonatal bladder closure. This study aims to define the consequence of DER on bladder growth in bladder exstrophy patients who underwent routine DER, compared with those who underwent immediate postnatal reconstruction.MethodsBetween 2000 and 2005, classic bladder exstrophy patients referred to the authors' institution underwent early neonatal bladder closure (group 1). Subsequently, classic bladder exstrophy patients referred to the authors' institution were treated with an elective DER (group 2). Bladder capacity was assessed between the age of 1 and 4 years with an unconscious cystogram. When dilating VUR was present, the volume of the contrast migrated into the ureter was calculated and subtracted.ResultsSixty patients were treated between 2000 and 2012. Complete follow-up data were available for 45 patients and they were included in the study: 21 in group 1 (11 males) and 24 in group 2 (14 males). The mean (SD) bladder volumes were 72.85 (28.5) ml in group 1 and 72.87 (34.9) in group 2 (p = 0.99).ConclusionIn the authors' experience, DER does not reduce the subsequent bladder capacities compared with neonatal exstrophy closure.     

Urologic complications of major genitourinary reconstruction in the exstrophy–epispadias complex

ObjectiveTo present the authors' experiences with urologic complications associated with various techniques used to create a continent stoma (CS), augmentation cystoplasty (AC), and neobladder in the exstrophy–epispadias complex (EEC) population.MethodsRetrospective review of medical records of patients who underwent CS with or without bladder augmentation were identified from an institutional review board-approved database of 1208 EEC patients. Surgical indications, tissue type, length of hospital stay, age, preoperative bladder capacity, prior genitourinary surgeries, postoperative urological complications, and continence status were reviewed.ResultsAmong the EEC patients reviewed, 133 underwent CS (80 male, 53 female). Mean follow-up time after initial continent stoma was 5.31 years (range: 6 months to 20 years). Appendix and tapered ileum were the primary bowel segments used for the continent channel and stoma in the EEC population. The most common stomal complications in this population were stenosis, incontinence, and prolapse. Seventy-nine percent of EEC CS patients underwent AC primarily done with sigmoid colon or ileum. Eleven patients (8%) underwent neobladder creation with either colon or a combination of colon and ileum. Bladder calculi, vesicocutaneous fistula, and pyelonephritis were the most common non-stomal complications. Stomal ischemia was significantly increased in Monti ileovesicostomy compared to Mitrofanoff appendicovesicostomy in classic bladder exstrophy patients (p = 0.036). Furthermore, pyelonephritis was more than twice as likely in colonic neobladder than all other reservoir tissue types in the same cohort (OR = 2.53, 95% CI: 1.762–3.301, p < 0.001).ConclusionsTo the best of the authors' knowledge, this is the largest study examining catheterizable stomas in the exstrophy population. While Mitrofanoff appendicovesicostomy is preferred to Monti ileovesicostomy because it is technically less challenging, it may also confer a lower rate of stomal ischemia. Furthermore, even though ileum or colon can be used in AC with equally low complication rates, practitioners must be wary of potential urologic complications that should be primarily managed by an experienced reconstructive surgeon.     

Renal transplantation with and without bladder augmentation in children posterior urethral valve is there a difference in the long term?

PurposePosterior urethral valve (PUV) is a common etiology of end-stage renal disease(ESRD) in children. We compared children who underwent bladder augmentation prior to renal transplantation with those who underwent transplantation in the native bladder in regards to occurrence of UTI and long term renal function.Material and MethodsWe identified 40 patients with PUV from 1992 and 2006 who underwent renal transplantation in our institution. These patients were divided into two groups, Group 1: 20 patients who underwent bladder augmentation and Group 2 20 patients who did not undergo bladder augmentation. Graft dysfunction was defined as an increase of >20% in creatinine levels.ResultsForty-four transplantations were performed, 21 in G1 and 23 in G2, 35 from deceased donors(16 in G1 and 19 in G2). Medium age at transplantation was 11 years (5 to 17). Bladder drainage was done using clean intermittent catheterization by external continent ostomy in 95% of patients. Average renal graft survival at one year was 88% for both groups, after 5 years values were maintained of 90% in G1 and 87% in G2. Acute rejection occurred in 15% of grafts in G1 and 26% in G2. Urinary tract infection (UTI) was found in 85% of G1 and 25% of G2. An increase in creatinine of 20% above the nadir was found in 33% of G1 patients and 10% in G2.ConclusionsPatients who underwent bladder augmentation had a higher incidence of infection and increase of creatinine levels, however these events did not affect renal graft survival when compared to non-augmented patients.     

Augmentation cystoplasty in children without preoperative mechanical bowel preparation

ObjectiveTo retrospectively assess early postoperative complications in augmentation cystoplasty without preoperative mechanical bowel preparation (MBP).Material and MethodsBetween May 1987 and May 2006, 162 cystoplasties were performed in 158 children. The segments used were: sigmoid colon (81.5%), ileum (13%), and ileocecum (5.5%). The mean age was 8.65 years (range 2.1–22.7 years). No preoperative MBP of any kind was used in any of the patients and all of them received antibiotics preoperatively and postoperatively.ResultsNo intraoperative complications related to the procedure were reported. The mean hospital stay was 9.48 days (range 4–30 days). The mean time to intake of oral fluids was 94.77 h (range 48–288 h). Postoperative complications occurred in 9.87%: urinary fistula was the most common (2.4%); only 3 patients presented wound infection (1.85%); 5 patients required reoperative surgery (hemoperitoneum, patch necrosis and 3 cases of urinary peritonitis); 1 patient presented an intra-abdominal abscess that resolved with antibiotic treatment.ConclusionsPreoperative MBP can be omitted in children that require augmentation cystoplasty without an increased risk of infectious or anastomotic complications. Further prospective, randomized clinical trials should be carried out in order to validate our findings in the pediatric population.     

Transanal irrigation for the treatment of neuropathic bowel dysfunction

IntroductionChildren with spinal cord lesions very often experience bowel dysfunction, with a significant impact on their social activities and quality of life. Our aim was to evaluate the efficacy of the Peristeen transanal irrigation (TI) system in patients with neuropathic bowel dysfunction (NBD).Material and methodsWe prospectively reviewed 40 children with spina bifida and NBD who did not respond satisfactorily to conventional bowel management and were treated with the Peristeen TI system. Dysfunctional bowel symptoms, patient opinion and level of satisfaction were analysed before and during TI treatment using a specific questionnaire.ResultsThirty-five children completed the study. Mean patient age and follow up were 12.5 years (6–25) and 12 months (4–18), respectively. Average irrigation frequency and instillation volume were once every 3 days and 616 ml (200–1000), respectively. Bowel dysfunction symptoms including faecal incontinence improved significantly in all children. Patient opinion of intestinal functionality improved from 2.3 ± 1.4 to 8.2 ± 1.5 (P < 0.0001) and mean grade of satisfaction with the Peristeen system was 7.3. Patient independence also improved from 28 to 46% and no adverse events were recorded.ConclusionsTI should be used as a first therapeutic approach in those children with NBD who do not respond to conservative or medical bowel management before other more invasive treatment modalities are considered. The Peristeen system is as effective as other TI methods, but it is easy to learn, safe and increases the patient's independence.     

Translation and cross-cultural adaptation of the Childhood Bladder and Bowel Dysfunction Questionnaire (CBBDQ)

ObjectiveTo translate and cross-culturally adapt the Childhood Bladder and Bowel Dysfunction Questionnaire (CBBDQ) for use in Brazilian Portuguese. The CBBDQ is an 18-item tool covering 10 bladder and 8 bowel symptoms that was developed for use with children of 5 to 12 years of age with bowel and bladder dysfunction (BBD). The instrument has already been validated for use in Dutch and English.MethodIn the process of translation and cultural adaptation from English to Portuguese, the CBBDQ was submitted to undergo the required steps as established by the international methodological criteria: forward translation, synthesis, back-translation, expert panel review and pre-testing.ResultsNinety-three parents of children with lower urinary tract dysfunction answered the questionnaire. The mean age of the children was 7.6 ± 2.1 years and 54 were female. Internal consistency was excellent, with a Cronbach’s alpha of 0.91 to 0.96. Additionally, reliability was high, with an intraclass correlation coefficient of 0.94 (95%CI: 0.85-0.93; p < 0.0001).ConclusionThe translation and cultural adaptation of the CBBDQ enabled a quantitative evaluation of bladder and bowel symptoms to be performed in Brazilian children. The scores achieved allow the severity of BBD to be evaluated, as well as the patient’s progress during treatment. The use of this questionnaire in clinical practice and research will allow more consistent data on BBD to be obtained.     

Effective endoscopic diagnosis and treatment of pediatric occult vesicoureteral reflux with intermediate to long-term follow-up

PurposeRecurrent febrile urinary tract infections (fUTIs) in children with non-diagnostic voiding cystourethrogram (VCUG) are challenging, as misdiagnosis can lead to renal damage and increased morbidity. We compared fUTI rates before and after endoscopic treatment of patients with suspected occult VUR.MethodsBetween January 2009 and December 2012, children with history of fUTI and non-diagnostic VCUG(s) underwent endoscopic ureteral hydrodistention (HD) and injection of dextranomer hyaluronic acid co-polymer (Dx/HA). fUTI rates before and after intervention were evaluated. Demographics, imaging and endoscopic findings were assessed.ResultsThirty-four children (mean age 5.4 ± 2.8 years) underwent bilateral Dx/HA injection for occult VUR. Average follow-up was 28.8 months. Seventeen children had renal scarring. Mean ureteral HD grade was 2.2/3. HD grade for ureters associated with renal scarring was significantly (p < 0.05) higher (2.6/3) than those without scarring (2.0/3). Mean injected volume was 1.2 mL. Ureters associated with renal scarring (n = 21) required significantly (p < 0.05) higher volumes (1.4 mL) than those without scarring (n = 47; 1.1 mL). Prior to intervention, the fUTI rate was 0.15/patient/month compared to just 0.02 after treatment (p < 0.0001).ConclusionsIncidence of fUTIs significantly decreased following treatment, supporting the use of Dx/HA injection in carefully selected children when the suspicion for occult VUR is high.     

Wide hilar hepatico-jejunostomy: the optimum method of reconstruction after choledochal cyst excision

Standard reconstruction after choledochal cyst excision is by Roux-en-Y hepaticojejunostomy to the common hepatic duct. Long-term follow up studies have shown a 10% incidence of late complications, including anastomotic stricture. By extending the bilio-enteric anastomosis along the left hepatic duct, a wide hilar bilio-enteric anastomosis is created which may help to minimize late anastomotic complications. Forty-one consecutive patients (24 girls, 18 infants) with a median age of 2.3 years (range 44 days to 15.6 years) and median weight 11.5 kg (range 2.1–59 kg) underwent radical choledochal cyst excision with a wide hilar hepticojejunostomy. Thirty-eight were followed-up both clinically and by ultrasound scan and biochemical liver function tests for a median of 2.7 years (range 0.1–12.5 years). The median width of the hilar hepaticojejunostomy was 8 mm (range 6–25 mm) in 18 infants, and 15 mm (range 10–25 mm) in 22 older children. In one patient it was not measured. Only one surgical complication occurred—a self-limiting bile leak which settled spontaneously. Median postoperative stay was 6 days (range 5–21 days). No patient has had an episode of cholangitis or adhesive small bowel obstruction to date. Postoperative biochemical liver function tests have remained normal in all but one child (with pre-existing biliary cirrhosis). After radical resection of a choledochal cyst, a wide hilar hepaticojejunostomy is a, safe, effective and durable reconstructive technique that can be performed at any age and may help to minimize the long-term risk of complications.     

Evaluation of the BladderScan® in estimating bladder volume in paediatric patients

ObjectiveTo evaluate the reliability of estimates of bladder volume (BV) in children with the BladderScan BVI 9400 (BS) compared with the volume obtained at catheterization (CV).Materials and methodsBV was measured using the BS in 50 children (age range 6 weeks–14 years) who required urinary catheter placement during surgery or urodynamic studies. BS measurements were taken prior to catheter insertion. BV was compared with CV.ResultsBS volumes ranged from 0 to 513 mL (mean = 79 mL, median = 34 mL) and CV from 0 to 500 mL (mean = 81 mL, median = 31 mL). There was high correlation between the BS and CV measures (rho = 0.96). The mean difference between BS and CV volumes was −2.1 mL (SD 21). Where the CV ≤ 100 mL the BS volumes ranged from 0 to 84 mL (mean = 74 mL, median = 30 mL) and the CV from 0 to 88 mL (mean = 76 mL, median = 25 mL) (rho = 0.89). The mean difference = 0.5 mL (95% limits of agreement ± 23 mL). In a small sample of 12 children <36 months, correlation between BS and CV volumes was not as strong with rho = 0.82.ConclusionsOverall the BladderScan showed a high correlation with catheter volume and there was good clinical agreement between the measures.     

Modified method of primary esophageal anastomosis with improved outcome in cases of esophageal atresia with tracheoesophageal fistula

Survival rates for infants who have esophageal atresia (EA) with or without fistula (TEF) have improved dramatically in the past 50 years. Despite excellent long-term survival for patients with esophageal atresia with tracheoesophageal fistula (EA-TEF), many significant complications can occur. Anastomotic leak at the esophagoesophagostomy site is one such problem resulting in considerable morbidity and mortality in these patients. The methods of esophageal anastomosis for long period has remained the simple end to end anastomosis of esophageal ends with various modifications described from time to time. The present study aims to study the effect on the early postoperative complications, following horizontal mattress suture technique on the primary esophageal anastomosis in cases of EA-TEF. A total of 32 patients with EA-TEF, were operated by our technique during a period of 1 year (2007–2008). The results were compared with the patients (n = 66), who were operated by the traditional simple technique during the same period. Among those patients in whom the esophageal anastomosis was done by horizontal mattress suture, only one had major anastomotic leak, while two had minor anastomotic leaks, as compared to six and nine cases correspondingly in other patients in whom anastomosis was done by simple technique. There was single mortality. We propose that, the utilization of our technique of horizontal mattress suture in primary anastomosis of esophagus in cases of EA-TEF significantly reduces the risk of anastomotic leaks and subsequent morbidity and mortality.