Laparoscopic nephrectomy for xanthogranulomatous pyelonephritis in childhood: the way forward

ObjectiveXanthogranulomatous pyelonephritis (XGP) is a severe, chronic renal parenchymal infection. Nephrectomy is curative. Open nephrectomy is a well-known operative challenge. We describe successful laparoscopic nephrectomy in three patients with XGP.Materials and methodsCase notes and radiology of three patients who underwent laparoscopic nephrectomy for XGP were reviewed. The preoperative presentation, operative details, postoperative recovery and complications were recorded.ResultsThe ages of the three children were 9, 5 and 1.3 years. Retroperitoneoscopy was performed via 3 × 5-mm ports. Creation of retroperitoneal space was easier than anticipated despite the perinephric inflammation. Excellent visualization of renal pedicle was obtained. The renal vessels were divided using the ultrasonic dissector (Sonosurg, Olympus). The kidney was then mobilized and dissected off adjacent structures. It was extracted via a small extension to one of the incisions on each occasion. None of them needed conversion. Average operating time was 3 h and 30 min. Histology of XGP was confirmed in all.ConclusionsLaparoscopic nephrectomy has replaced open nephrectomy for most conditions. Preoperatively, it was thought that laparoscopy might be unsuitable because of the involvement of perinephric tissues commonly seen in this condition; however, excellent visualization was achieved enhancing the ease of dissection. Dealing with the pedicle before handling the kidney also proved beneficial, allowing better visualization and safe dissection. Postoperative pain and morbidity were greatly reduced. The cosmetic result was excellent. We recommend the laparoscopic approach for nephrectomy in XGP when expertise is available.     

Laparoscopic heminephroureterectomy for duplex kidney anomalies in the pediatric population

ObjectiveDespite increasing acceptance of laparoscopy in pediatric urology, few published data are available on laparoscopic heminephroureterectomy in patients with duplex kidney anomalies. In the present study, we report our own experiences with this technique.Patients and methodsFrom August 2003 to January 2006, five laparoscopic heminephroureterectomies were performed in four girls with a mean age of 41 (9–67) months. In all cases, a non-functioning upper pole with an obstructive (n = 4) or refluxing (n = 1) megaureter was found. The upper pole was resected laparoscopically en bloc with the megaureter using three to four trocars.ResultsMean follow-up was 42.4 (±7.9) months. All procedures were performed successfully without conversion to open surgery with a mean operative time of 190 (170–210) min. Blood loss was minimal and no intraoperative complications occurred. Despite chronic inflammation in the resected specimens, the patients showed no clinical signs of infection postoperatively. The average length of hospital stay was 5.6 (4–7) days. All patients were followed using duplex sonography.ConclusionsThese data demonstrate that, even in infants, laparoscopic heminephroureterectomy is feasible and associated with minimal morbidity, a better cosmetic result and a shorter hospital stay compared to open surgery. The main disadvantage of the laparoscopic approach is a longer operative time. Laparoscopic heminephroureterectomy is a technically demanding procedure and should be performed only in specialized centers.     

Laparoscopic heminephrectomy in infants and children: first 54 cases

ObjectiveHeminephrectomy in the pediatric population remains a popular open surgical procedure. We describe our experience with laparoscopic heminephrectomy using a retroperitoneoscopic approach.Materials and methodsData were collected retrospectively and prospectively on all patients undergoing laparoscopic heminephrectomy by a single surgeon using a prone retroperitoneoscopic approach. Information relating to the age, sex, laterality, duration of surgery, analgesic requirements, duration of hospital stay, postoperative complications and outcome was recorded.ResultsBetween March 2001 and August 2005 54 laparoscopic heminephrectomies were performed in 48 children (34 girls and 14 boys). The median age at surgery was 14 months (range 2–112 months). Forty-four upper and 10 lower moieties were removed. The median operative time was 105 min (range 50–150 min). There were no intraoperative complications and no conversions. There were four minor complications, comprising haematuria (n = 1) and postoperative pyrexia (n = 3). The median length of follow up was 22 months (range 3–57 months). All patients remained asymptomatic at last follow up. Ultrasound findings included presence of a visible ureteric stump (n = 7) and cysts at the resection margin of the remaining remnant (n = 17); none of these patients manifested clinical symptoms (e.g. infection, pain).ConclusionsWith advanced laparoscopic skills, laparoscopic heminephrectomy is a feasible operation for the treatment of non-functioning duplex renal units in children and infants.     

The role of laparoscopic surgery for urinary tract reconstruction in infants weighing less than 10 kg: a comparison with open surgery

PurposeTo compare the outcome of laparoscopic urinary tract reconstruction (LUTR) in children weighing 10 kg or less with a weight-matched cohort undergoing open urinary tract reconstruction surgery (OUTR).Materials and methodsWe conducted a retrospective chart review of patients weighing 10 kg or less at the time of surgery who underwent open or laparoscopic pyeloplasty, transuretero-ureterostomy and ipsilateral uretero-ureterostomy between January 2000 and May 2007. The following information was recorded: body weight, age, sex, diagnosis, type of procedure, operative time, estimated blood loss, pre- and postoperative hemoglobin levels, length of hospitalization, length of follow up, use of drains and stents, intraoperative and postoperative analgesic requirement, need for readmission, subsequent procedures, costs, complications and reoperations.ResultsThere were 52 patients divided into two groups: LUTR (n = 23) and OUTR (n = 29). Median weight (range) and follow up was 6.2 kg (3.9–10) and 9 months and 6.5 kg (4.7–9.6) and 31 months for LUTR and OUTR, respectively. Mean operative time for LUTR (including cystoscopy and stent placement) was 237 min and for OUTR 128 min (P < 0.01). There were no differences in blood loss, intra- or postoperative analgesic requirement, results or complications. Mean hospitalization time was shorter for LUTR than OUTR (2 and 3 days, respectively). There were no differences in hospital costs between the two groups.ConclusionsLaparoscopic reconstructive surgery for congenital urological anomalies is safe and effective in small infants and can be performed with outcomes comparable to that of open surgery.     

Pneumovesicoscopic diverticulectomy in children and adolescents: Is open surgery still indicated?

ObjectivesSurgical treatment of a congenital bladder diverticulum is indicated in symptomatic children. Diverticulectomy can be performed by an open or a laparoscopic approach. We report our recent experience in using the pneumovesicoscopic approach for accomplishing vesical diverticulectomy.MethodsWe operated on three boys with a mean age of 11.6 years (10–14 years) during August 2006 to February 2007. In all children, a ureteric catheter was introduced first by cystoscopy followed by intravesical CO₂ insufflation at a pressure of 12–15 mmHg. Three trocars were inserted under visual control in the bladder. Diverticulectomy was performed. The defect was closed by interrupted sutures. Bladder drainage was achieved using a urethral catheter for 2 days.ResultsThe mean operative time was 133.3 min (100–180 min). Oral intake began after a mean of 5.3 h (4–6 h). Minimal blood loss was encountered. Non-steroidal analgesics were used only during the 1st day postoperatively with no need for morphia. All patients were discharged on the 2nd day postoperatively after removal of the urethral catheter and tube drain. The mean follow-up period was 5 months (3–6 months).ConclusionPneumovesicoscopic diverticulectomy is a feasible procedure. It does not require a long learning curve, and is associated with shorter hospital stay and rapid recovery with good cosmetic aspect. Pneumovesicoscopy has the potential to be used in the treatment of other conditions such as vesicoureteral reflux, and may replace open surgery.     

Tubeless percutaneous nephrolithotomy in children

ObjectiveTo assess the effectiveness of tubeless percutaneous nephrolithotomy (PCNL) as an alternative to extracorporeal shock-wave lithotripsy (ESWL) in the management of urolithiasis in children.Materials and methodsIn 2003–2005 we operated on 20 cases that met the inclusion criteria. Extensive follow-up tests were performed in all patients; stone clearance was defined as the absence of residual fragments on plain abdominal X-ray and renal ultrasound. Pain-scale ruler (0–10) was used to evaluate pain postoperatively. Comparison was made with a group of 10 patients with very similar criteria operated upon with PCN tube.ResultsMean follow-up period was 9 months (3–18 months) and mean age 7.5 years (4–15 years). Mean operative time was 115 min (45–180) with no significant bleeding intra- or postoperatively. Conversion to open surgery was necessary in one case. There were no major perioperative complications. In the tubeless group the pain score was 3–6 (mean 4.6), there was no need for IV analgesia, and median hospital stay was 1.7 days (1–4 days); urine leakage occurred in one patient. In the group with PCN tube the pain score was 5–8 (mean 5.5), IV analgesia was mandatory in four patients, and median hospital stay was 2.8 days (3–4 days); urine leakage occurred in five patients and a small residual stone was detected in one child.ConclusionTubeless PCNL in children has the advantages of being less painful, less troublesome and shortening the hospital stay of the child. The decision to use this procedure is best made intraoperatively and depends on the experience of the surgeon.     

Heminephroureterectomy for duplex kidney: Laparoscopy versus open surgery

ObjectiveTo report our experience of laparoscopic heminephroureterectomy (Hnu) in pediatric patients with duplex anomalies, in comparison to open surgery.Patients and methodsRetrospective review of data from patients who underwent Hnu from 2005 to 2008 was performed. The patients were divided into two groups: laparoscopic (LHnu) and open surgery (OHnu). Laparoscopic surgery was performed by transperitoneal approach in majority of cases. Open surgery was performed by retroperitoneal approach in all cases.ResultsGroup LHnu: nine patients (8 females, 1 male) with median age of 14 months (range 3–205). Transperitoneal approach was performed in eight patients. Mean operative time was 182 min (CI 95% 146–217). No conversion to open surgery was necessary and there were no complications. Mean hospital stay was 2.44 days (CI 95% 1.37–3.52). Group OHnu: eight patients (3 females, 5 males) underwent nine heminephrectomies at median age of 6.9 months (range 1–12). Mean operating time was 152 min (CI 95% 121–183). There were no complications and mean hospital stay was 4.38 (CI 95% 2.59–6.16) days. Statistical analysis showed no statistically significant difference (P > 0.05) in operating time between groups while mean hospital stay was significant (P = 0.021).ConclusionThe laparoscopic approach is feasible, safe, reduces hospital stay, does not increase operating time and has better cosmetic results. We believe this should be the first option for heminephrectomy.     

Laparoscopic Palomo varicocele surgery: Lessons learned after 10 years’ follow up of 156 consecutive pediatric patients

ObjectivesTo evaluate our experience using laparoscopic Palomo varicocele ligation in a population under 18 years, and confirm the factors involved in postoperative hydrocele formation.Patients and methodsBetween 1997 and 2007, 156 boys diagnosed as having varicocele were evaluated retrospectively. Outcome variables recorded for analysis were age at presentation, symptoms, varicocele grade (Dubin–Amelar classification), testicular atrophy, length of hospital stay, perioperative complications, recurrence and hydrocele formation after surgery. Mean follow up was 5.6 years (6 months– 9 years).ResultsAge at diagnosis ranged between 9 and 18 years. Mean age at operation was 14.1 ± 1.8 years. There were 153 left-side varicoceles (98%) and three cases were bilateral. All patients had grade II or III varicocele (38%/62%) and testicular atrophy was noted in 43.8%; 8.1% mentioned testicular pain at diagnosis. All boys underwent Palomo laparoscopic ligation of the spermatic vessels. Mean operative time was 38 min (25–82 min). The last 51 surgeries were performed on a two-trocar basis with Ligasure^® vascular sealing device and operative time decreased significantly to 22 min (16–32 min) (P < 0.05). Median hospital stay was 31 ± 8 h. Conversion rate was 1.28%. Twenty-one patients developed hydrocele (13.5%); 11 of these underwent Winkelman–Lord's hydrocelectomy at least 1 year after Palomo (9% of total). Of the remaining 10, two resolved spontaneously and eight were stable at mean 4-year follow up.ConclusionsLaparoscopic Palomo varicocele surgery for pediatric patients is a safe and effective procedure. Recurrence and complication rates are similar to those reported with open surgery.     

The effectiveness of aerosolized intraperitoneal bupivacaine in reducing postoperative pain in children undergoing robotic-assisted laparoscopic pyeloplasty

ObjectiveTo assess the effectiveness of aerosolized intraperitoneal bupivacaine in reducing postoperative pain in children. Laparoscopic surgery has decreased the severity of postoperative pain in children. However, children often experience abdominal and shoulder pain requiring significant amounts of opioids, potentially prolonging their hospitalization.MethodsForty-one consecutive patients undergoing unilateral robotic-assisted pyeloplasty between December 2005 and December 2007 were retrospectively reviewed to assess perioperative opioid requirements and length of hospitalization.ResultsIn addition to standard-of-care perioperative analgesia, five patients received intraperitoneal aerosolized bupivacaine just prior to trocar removal, 17 patients received aerosolized bupivacaine just prior to incising the perirenal fascia, and 19 patients received no intervention. There was a significant reduction in postoperative opioid utilization when bupivacaine was administered at the beginning of the surgery (0.1 mg/kg vs 0.4 mg/kg, P = 0.04), but not at the end (0.3 mg/kg, P = 0.25), as compared to controls. All patients receiving aerosolized bupivacaine had a significantly shorter time in hospital (2.4 vs 1.4 days, P = <0.01).ConclusionsThe administration of intraperitoneal aerosolized bupivacaine just prior to incising the perirenal fascia appears to be a simple, effective and low-cost method to reduce postoperative pain in children undergoing laparoscopic pyeloplasty.     

Retroperitoneoscopic adrenalectomy: an early institutional experience

ObjectiveTo review our initial experience with the retroperitoneoscopic approach, which is rapidly becoming the procedure of choice for paediatric adrenalectomy. Swift access to the vascular pedicle makes this approach ideal for adrenal surgery where haemodynamic instability is a common feature.MethodPatients were placed in a fully prone position and the locations of the 12th rib, iliac crest and paravertebral muscles were marked. A 10-mm incision was made lateral to the para-vertebral muscle, halfway between the iliac crest and costal margin. A retroperitoneal working space was created around the kidney using a homemade balloon. A 10-mm Hasson port was then inserted. A 5-mm working port was placed lateral to the tip of the 12th rib and, if necessary, a second was inserted medial to the camera port. Dissection was performed with diathermy and/or Harmonic Scalpel™ and the adrenal vessels were divided between clips. The specimen was retrieved in an endopouch through the 10-mm port.ResultsOver 16 months, six adrenalectomies were performed in five patients (three boys and two girls); two right, two left and one bilateral. Median age at surgery was 8 years. Presentation was with hypertension (n = 2), Cushing's syndrome (n = 2) and abdominal pain (n = 1). Median operative time was 154 min. A single-instrument port adrenalectomy was performed in three patients. Histopathological diagnosis included adrenal cyst (n = 1), cystic phaeochromocytoma (n = 1), adrenal cortical tumour (n = 2) and central Cushing's disease (n = 1). All were completely resected. All patients remain symptom free with a median follow up of 17 months.ConclusionThese cases represent our initial institutional experience with retroperitoneoscopic adrenalectomy. The senior reporting surgeons have already surmounted the general learning curve for laparoscopy, and this experience has proved vital to expand our repertoire with encouraging early results. This is our technique of choice as it provides a superior view of the adrenal gland and vessels, with good intraoperative haemodynamic stability.     

A long-term prospective analysis of pediatric unilateral inguinal hernias: Should laparoscopy or anything else influence the management of the contralateral side?

PurposeTo prospectively determine if children who present with a unilateral inguinal hernia can be identified as at risk for developing a metachronous inguinal hernia (MIH) based on risk factors and laparoscopic findings of the contralateral internal ring.Materials and methodsBetween April 2000 and October 2004, 299 patients with a unilateral inguinal hernia were followed prospectively. Laparoscopy was attempted in each child. Bilateral repair was only performed in those with contralateral swelling or crepitus during laparoscopic evaluation. All other children were followed regardless of laparoscopic findings. Risk factors to include premature delivery, family history and increased abdominal pressure were recorded. Clinical follow up and annual phone interviews were performed to determine the development of a MIH.ResultsThirteen patients underwent initial bilateral inguinal hernia repair. Of the remaining 286 patients (272 boys, 14 girls; ages 54 ± 50.8 months), laparoscopy revealed 127 closed, 48 cleft and 67 open (contralateral patent processus vaginalis) contralateral internal rings, and in 44 laparoscopy was not possible due to a small hernia. Of 222 patients followed for 53.2 months (30.1–82.5 months), 15 (6.8%) developed a MIH. When comparing age, gender, laterality, laparoscopic findings, family history, premature birth and intra-abdominal pressure, only family history exhibited a significant risk for MIH (33% vs 7.7%). However, 16/21 children with a family history never developed a MIH, and 47/53 children with a contralateral patent processus vaginalis have yet to develop one.ConclusionsRisk factors and laparoscopic findings failed to predict the few children who would develop a MIH. The contralateral side should not be routinely explored by any methodology.     

Functional outcome after laparoscopic dismembered pyeloplasty in children

ObjectiveLaparoscopic or retroperitoneoscopic pyeloplasty for ureteropelvic junction obstruction in children has become a routine procedure. The aim of this study was to evaluate functional outcome for patients who had undergone a laparoscopic dismembered pyeloplasty.Patients and methodsSeventy children underwent a laparoscopic dismembered pyeloplasty. Median follow up was 24 months (1–48). We reviewed differential renal function (DRF) and tracer clearance with diuretic renography before as well as 3 and 12 months after operation. Ultrasound was used to determine the grade of hydronephrosis pre- and postoperatively.ResultsMedian age at operation was 20 months (1–178). Median operating time was 140 min (95–220). Mean DRF could be preserved with no significant difference (P > 0.05). All patients showed a significant improvement in tracer clearance on diuretic renography postoperatively (P < 0.0001). Ultrasound examinations postoperatively showed a diminished grade of hydronephrosis without significance (P = 0.657).ConclusionIn terms of preservation of DRF the laparoscopic approach is as effective as open surgery. Tracer clearance is significantly improving. Operating times for laparoscopic pyeloplasty are competitive. We conclude that laparoscopic pyeloplasty requires extensive experience in laparoscopic pediatric urology but might replace the open surgical procedure as gold standard in the operative treatment of ureteropelvic junction obstruction.     

Durée d’hospitalisation en pédopsychiatrie : étude rétrospective des facteurs prédictifs sur deux ans en unité d’adolescents

BackgroundIn a context of increasing needs for child and adolescent psychiatry, psychiatric inpatient units are more and more solicited. We aim here to determine the factors predicting the length of stay (LOS) in an adolescent psychiatric unit.MethodsWe conducted a monocentric retrospective chart-review study based on all medical charts of adolescents who had been hospitalized in two full-time hospitalization units for adolescents in a university-based child psychiatry service (n = 191).ResultsThe mean LOS in this sample was 96 days (SD = 101, min = 1, max = 600, median 67). In multivariate analyses, the variables statistically associated with LOS were: a diagnosis of schizophrenia, an eating disorder, presence of suicidal ideation, a low score on the Children's Global Assessment of Functioning (C-GAF) scale at admission, having an educational measure, and being addressed at discharge to a part-time ambulatory care center. This model predicted around 40% of the LOS variance.ConclusionThe association between clinical and functional factors and the LOS are independent. The contribution of other factors (e.g., social factors and due to the health care system) raises questions about the objectives of inpatient treatment (i.e., crisis interventions, or developing the outpatient health care project via collaborative works with other professions).     

Ureteric stents in pyeloplasty: a help or a hindrance?

ObjectiveTo examine whether routine ureteric stenting influences outcome of pyeloplasty for pelvi-ureteric junction obstruction (PUJO).Patients and methodsA 10-year review was conducted of 105 consecutive open Anderson–Hynes dismembered pyeloplasties performed for PUJO, covering two periods: (1) pyeloplasties performed without ureteric stents (1994–1998) and (2) pyeloplasties performed with ureteric stents (1999–2003). Outcomes (expressed as means ± SEM) of unstented patients (UPs; n = 47) and stented patients (SPs; n = 58) were compared and results analysed using ANOVA and chi-square tests.ResultsFifty-five patients (53.9%) presented with antenatal hydronephrosis, whilst 47 (46.1%) presented postnatally (at mean age 88.4 ± 7.1 months) with one or more of the following: pain (n = 30, 63.8%), urinary tract infection (n = 16; 34.0%), haematuria (n = 3, 6.4%), abdominal mass (n = 3, 6.4%), acute renal failure (n = 2, 4.3%), incidental finding (n = 4, 8.5%). Pyeloplasty was performed (at mean age 58.9 ± 5.3 months) for one or more of the following: pain (n = 40, 38.1%), haematuria (n = 6, 5.7%), urinary tract infection (n = 18, 17.1%), poor initial or deteriorating function (n = 29, 27.6%), severe or deteriorating hydronephrosis (n = 41, 39.0%), calculus (n = 1, 0.95%). Recognised complications of surgery were significantly higher in UPs (5 of 47; 10.6%) than SPs (0 of 58); P = 0.016. These were leakage (n = 4, 8.5%) and obstruction by blood clot (n = 1, 2.1%). Nine SPs (15.5%) developed stent-related complications, including stent migration (n = 5, 8.6%), infection (n = 3, 5.2%) and calculus (n = 1, 1.7%). SPs had significantly shorter hospital stay (2.71 ± 0.25 days) than UPs (4.30 ± 0.38 days); P < 0.01. Preoperative renal pelvis antero-posterior diameter in SPs (3.24 ± 0.25 cm) and UPs (3.21 ± 0.28 cm) was comparable (P = 0.80). Following pyeloplasty, a significant improvement from these preoperative baselines occurred earlier in SPs (at 3.10 ± 0.46 months) than UPs (at 15.71 ± 3.05 months); P < 0.01.ConclusionStented pyeloplasty significantly reduces complications from surgery, particularly leakage, and results in shorter hospital stay and earlier resolution of hydronephrosis, but at the expense of stent-related complications which could be avoided in future by the use of external stents.     

Severe complications of circumcision: an analysis of 48 cases

ObjectiveCircumcision is still the most commonly performed surgery in Islamic and Jewish societies. We report the findings of 48 cases referred for serious complications after circumcision that needed secondary surgical interventions. The aim of this study is to emphasize the important problem of circumcision complications.Patients and methodsThe 48 cases (mean age 14 years, range 5 months-24 years) with complications of circumcision were reviewed retrospectively. Circumcisions were performed at various medical centers or during religious ceremonies in environments other than health facilities.ResultsThe most commonly observed complication was preputio-glandular fusion, seen in 25 cases (52%). The other complications were: meatal stenosis in 11 (23%), urethral fistula in five (10.4%), partial glandular amputation in four (8%) and opening distal urethra in three (6%). Adhesion freeing and revision were performed in all cases of preputio-glandular fusion, patients with meatal stenosis underwent meatotomy, urethral fistulae were repaired by simple closure, partial glans amputations were patched with buccal mucosa, and patients with complete open distal urethra were repaired by Mathieu (one patient) and tubularized incised plate urethroplasty techniques.ConclusionCircumcision may be associated with many serious complications. To prevent these complications, the operation should be performed by educated and experienced personnel.     

Laparoscopic transperitoneal pyeloplasty in children from age of 3 years: Our clinical outcomes compared with open surgery

ObjectiveTo report clinical outcomes for laparoscopic pyeloplasty (LP) in children compared with open pyeloplasty (OP) and literature findings.Patients and methodsIn a prospective study, the outcomes of 57 consecutive transperitoneal LP in children from the age of 3 years were analyzed and compared with a matched historic control group of OP and with series of LP in the literature. Successful result was defined as resolution of symptoms, no conversion or re-operation, improved hydronephrosis, and/or improved renographic drainage.ResultsMean operative time was 177 (SD 50.5) min in the LP group and 108 (SD 25.6) min in the OP group (p < 0.001). Mean hospital stay was 1.2 (SD 0.46) days in the LP and 6.7 (SD 1.2) days in the OP group. Improvement in renographic drainage was observed more often after LP than after OP (98% vs 83%; p = 0.010). A successful result was reported in 56 (98%) LP and 54 (95%) OP (p = 0.298) patients. Our LP series demonstrates a high success rate compared to literature data.ConclusionsOur LP has a similar success rate and more often improved renographic drainage in comparison to OP. Furthermore, our LP demonstrates a shorter hospital stay and favorable outcomes compared to the literature. We thus regard LP as standard treatment for repair of ureteropelvic junction obstruction in children from the age of 3 years.     

A prospective randomized trial of the effect of a soluble adhesive on the ease of dressing removal following hypospadias repair

AimTo determine whether the use of a novel dressing removal technique resulted in shorter removal times, reduced the child's experience of pain and/or reduced parental anxiety when compared to a standard approach.MethodsThis prospective unblinded randomized controlled trial of 53 consecutive boys undergoing primary hypospadias repair was powered using data from a prior feasibility study. Children were randomized to a standard control dressing (A) or standard dressing plus Cavilon™ (B) group. Removal was by (A) soaking the child and dressing in the bath or (B) application of an adhesive remover to the dressing. The primary outcome measure was dressing removal time. Secondary measures were: child pain scores on a visual analogue scale measured by the parent and nurse, and parental anxiety using the self-evaluative state anxiety measure. Data are expressed as median (range); P < 0.05 is significant.ResultsDressing B was significantly quicker to remove than A: B 30 min (5–86 min) vs A 40 min (17–105 min), P = 0.01, Mann–Whitney. No differences in parent/nurse pain scores between the two groups were seen. There was a strong correlation between parent and nurse reporting of pain scores at the time of dressing removal (Spearman 0.79, P < 0.000). No significant differences in pre- and post-dressing removal parental anxiety scores were seen (P = 0.159, Mann–Whitney). Several parents had high anxiety levels at both times.ConclusionThe novel dressing removal approach (B) was significantly shorter than the standard one (A). There were no significant differences in child's pain or parental anxiety score between the two approaches.     

Adolescent varicocelectomy: postoperative catch-up growth is not secondary to lymphatic ligation

PurposeThe major indication for adolescent varicocelectomy is testicular asymmetry with the left testicle smaller than the right. Catch-up growth following surgery is one of the parameters used to assess efficacy of surgery. However, it is not clear whether this represents true tissue growth or increased interstitial fluid secondary to lymphatic obstruction. The purpose of this study was to compare catch-up growth in patients who underwent varicocelectomy with and without lymphatic preservation.Materials and methodsWe retrospectively analyzed the outcomes of 136 boys (mean age 15.1 years) who had 10% or greater preoperative testicular asymmetry and underwent varicocelectomy between 1997 and 2006. Surgery was either a laparoscopic nonlymphatic sparing or laparoscopic lymphatic sparing varicocelectomy. All patients had pre- and postoperative ultrasound volume measurements at least 6 months following surgery. The groups were compared for incidence of postoperative catch-up growth, achieving less than 10% testicular asymmetry.ResultsAfter a mean follow up of 24.7 months, catch-up growth was achieved in 62.8% of patients. There was no significant difference between the groups in regard to catch-up growth (51.7% vs 66.3%, P = 0.193).ConclusionsSince no significant difference was found between the laparoscopic nonlymphatic sparing and laparoscopic lymphatic sparing varicocelectomies, we conclude that lymphatic obstruction is not the cause of catch-up growth.     

Manejo del reflujo gastroesofágico en niños. Funduplicatura de Nissen convencional y por laparoscopia en los últimos 15 años en un centro especializado

IntroductionNissen fundoplication (NF) is the most used and effective technique for the treatment of gastroesophageal reflux in children. The laparoscopic approach (LNF) is safe, with low morbidity and high success rate, although some cases require a conventional approach (CNF). The aim of the study is to compare the results between LNF and CNF in our centre.Material and methodsA retrospective review was performed on patients < 14 years after NF between 2000 and 2015. A comparison was made of the complications, hospital stay, and follow-up for both approaches.ResultsOf the total 75 NF performed, 49 (65.3%) were LNF, 23 (30.7%) CNF, and 3 (4.0%) reconversions. Concomitant laparoscopic gastrostomy was performed in 10.7%, and open gastrostomy in 5.3% of cases. Prior to NF, 10.7% had a gastrostomy. The mean age was 4 years and 68.7% were male. Of the diagnoses, 36% had encephalopathy, 14.7% hiatal hernia, 5.4% oesophageal atresia, and 5.4% an acute life-threatening event. No differences were found in operation time. More than two-thirds (36%) had complications, which were more frequent in the CNF (OR = 3.30, 95% CI: 1.1-9.6). The hospital-stay decreased by 9 days in the LNF (95% CI: 5.5-13.5). Mean follow-up was 26 months (95% CI: 20.9-31.6). Mortality during follow-up was of 5.3% (5 respiratory failure, 1 sudden cardiac death, and 2 due to complications of the encephalopathy), 4.2% required re-fundoplication, 15.8% had symptomatic improvement, and 64.0% had absence of symptoms.ConclusionsThe LNF is an effective technique for the treatment of gastroesophageal reflux, with lower morbidity and shorter hospital stay than CNF. It is recommended as the first surgical option.