Effectiveness of primary endoscopic incision of ureteroceles

Endoscopic incision of a ureterocele (EIU) is simple when compared to an open procedure such as ureterocele excision with or without an upper-pole nephrectomy. It has, however, the potential to induce vesicoureteric reflux (VUR), which traditionally requires further surgical intervention. The natural history of the VUR that develops following EIU is not known. We have treated asymptomatic VUR that developed following EIU conservatively and have surgically intervened only in cases with recurrent urinary tract infections (UTI). This is a review from a single surgeon's practice involving 29 consecutive cases of ureterocele spread over a period of 4 years. The range of follow up was 4–54 months (median 32). Of the 24 children who underwent primary EIU, 6 required a second procedure, 3 a reincision and 3 an open procedure. Of the 3 who had a reincision, 2 required a further open procedure. The indication for reincision was failure of decompression of the upper tract and the indication for an open procedure was recurrent UTI following EIU. Thus, overall success was achieved in 19 of 24 cases of primary EIU (79.2%). VUR following EIU appeared in 10 cases (41%); UTI developed in only 5 (50%) of these 10 cases. Overall, UTI developed in 6 of the 24 (25%) cases of primary EIU. Eight children had an open procedure (3 as a primary procedure and 5 after EIU); 2 (25%) from this group had UTI following the procedure, and interestingly, neither had VUR. Ureterocele incision is thus a good alternative to upper-pole nephrectomy or excision of the ureterocele, especially in infancy. There is an inherent risk of producing VUR in the postincision period, however, the majority of cases can be managed conservatively. All patients need to be monitored for hypertension and UTI following EIU. Accepted: 17 October 2000     

Management of duplex ureteroceles detected by prenatal ultrasound

During the last 13 years 110 children with duplex ureteroceles were treated. There was a 3 to 1 female-to-male predominance. The authors report their experience with a group of 25 patients with duplex ureteroceles diagnosed in utero. Endoscopic incision of the ureterocele was performed as the initial treatment in 18 (72%) of these patients; decompression of the upper pole of the ureterocele was achieved in 100% of cases. Preservation of the upper pole was possible in 8 patients (44%); vesicoureteral reflux was created at the level of the upper pole in 8 (44%). Reconstruction of the lower urinary tract was accomplished in 15 (83.3%) patients who had had endoscopic treatment. Our experience has led us to believe that endoscopic incision of the ureterocele deserves reconsideration and re-evaluation because, as our series has shown, this intervention offers the great advantage of allowing good functional recuperation of the obstructed moiety with a high rate of success in a totally asymptomatic group of patients diagnosed in utero.     

Renal function and vesicoureteric reflux in children with ureteroceles

A total of 215 ureteroceles were present in 41 children with single-system and 154 children with double-system ureteroceles. Males were predominant in the single-system group while the reverse was true in patients with double-system ureteroceles. Single-system ureteroceles occurred more commonly on the left side. In double-system ureteroceles there was minimal renal function in 74% of the ureterocele-bearing moieties, 26% of the ipsilateral lower moieties, and 3% of the contralateral kidneys. Vesicoureteric reflux (VUR) was present in 17% of the ureterocele-bearing ureters, 54% of the ipsilateral second ureters, and 28% of the contralateral ureters. In the single-system ureteroceles, 20% of the ipsilateral kidneys had minimal renal function and 9% of both the ipsilateral and contralateral ureters had VUR. Differences in laterality, VUR, and function of the subservient renal tissue suggest that single-system ureteroceles are a different disease entity from the double-system type and should be considered separately in any discussion of the management of ureteroceles.     

右腋下小切口入路手术治疗先天性心脏病患儿的临床疗效

目的分析右腋下小切口入路手术在先天性心脏病(CHD)患儿中的应用价值。方法选取2015年1月至2017年9月河南省儿童医院收治的86例CHD患儿,按简单随机法分为对照组和观察组,每组各43例。对照组实施胸骨正中切口手术,观察组实施右腋下小切口入路手术,比较2组总有效率、切口满意度、手术一般情况(体外循环时间、手术时间、主动脉阻断时间、术中失血量)、术后相关情况(胸腔引流量、术后监护时间、术后辅助通气时间、住院时间、住院费用)、Wong-Baker面部表情量表(FPS-R)评分、麻醉后(T1)、术毕(T2)、入监护病房(T3)、拔管前(T4)呼吸功能指标,即呼吸道峰压(PIP)及肺泡气-动脉血氧分压差[p(A-a)(O2)]水平及并发症发生率。结果1.观察组切口满意度[90.70%(39/43例)]高于对照组[62.79%(27/43例)],2组比较差异有统计学意义(χ2=9.382,P=0.002)。2.观察组体外循环时间、手术时间、主动脉阻断时间分别为(68.94±8.26)min、(2.33±0.21)h、(28.79±7.32)min,与对照组[(67.11±9.11)min、(2.25±0.31)h、(30.02±6.88)min]比较差异均无统计学意义(均P>0.05)。3.观察组术中失血量[(89.87±11.25)mL]少于对照组[(105.91±31.01)mL],差异有统计学意义(t=3.189,P=0.002)。4.观察组术后监护时间[(30.55±10.39)h]、术后辅助通气时间[(9.68±2.19)h]、住院时间[(9.61±2.17)d]、胸腔引流量[(90.36±26.14)mL]、住院费用[(36956.15±1097.84)元]均低于对照组[(41.39±9.93)h、(12.72±3.81)h、(12.33±3.15)d、(163.24±29.36)mL、(45271.97±1134.55)元],差异均有统计学意义(t=4.946、4.536、4.663、12.157、34.540,均P<0.01)。5.观察组术后1 d、2 d、3 d、4 d FPS-R评分分别为(4.02±0.41)分、(3.41±0.15)分、(2.55±0.20)分、(1.16±0.27)分,低于对照组[(5.21±0.89)分、(5.02±0.63)分、(4.12±0.67)分、(3.05±0.39)分],差异均有统计学意义(t=7.963、16.302、14.724、26.128,均P<0.01)。6.观察组T1、T2、T3、T4时刻p(A-a)(O2)及PIP与对照组比较差异均无统计学意义(均P>0.05);观察组并发症发生率[6.98%(3/43例)]与对照组[4.65%(2/43例)]比较差异无统计学意义(χ2=0.000,P>0.05)。结论右腋下小切口入路手术不影响CHD患儿呼吸功能,可提高切口满意度,减少失血量,加快患儿术后恢复,改善术后疼痛程度,减轻家长经济负担,术中熟练准确操作可减少或避免相关并发症的发生,保证手术安全性。     

The role of minimal surgery with renal preservation in abnormal complete duplex systems

Among 36 children, mostly less than 1 year of age, referred for a complete duplex-system anomaly, 18 were diagnosed before birth by obstetrical ultrasonography where a diagnosis of dilated upper urinary tract was the most frequent report; in the remaining cases urinary tract infection was the main presenting symptom. Five children had bilateral anomalies. Principal diagnoses associated with the complete duplex system were: 18 ureteroceles (UC) (11 extravesical [EUC] with bladder-neck or urethral extension, 7 intravesical [IUC]), 5 ectopic ureters without UC and 28 lower-polar vesicoureteral reflux (VUR) associated in 6 with upper polar VUR. The initial assessment was based on a voiding cystogram and radionuclide scan. Renal-polar function was severely impaired when major ureteral ectopia or severe primary reflux was present. Primary surgery was performed in 8 patients, demolitive in 4 (3 upper-polar nephrectomies, 1 nephrectomy) and reconstructive in 4 (duplex en-bloc reimplantation); staged management with minimal endoscopic incision was undertaken in 15 UCs (9 EUCs and 6 IUCs). Expectant management was elected in all cases of mild primary, single, or double VUR not associated with UC and was followed by spontaneous reduction in one-half of the cases. Secondary VUR complicated endoscopic incision in 2 of 6 IUCs and 5 of 9 EUCs; a certain degree of functional improvement after decompression could be observed in all IUCs versus only 2 EUCs. Twenty-one patients requested secondary surgery; 17 needed an open intravesical procedure for ureteral reimplantation, combined in 8 with UC excision and bladder-floor reconstruction and in 5 with upper-pole nephrectomy. A nephrectomy was required in 4 cases. All primary or secondary demolitive procedures involved 9 of 11 EUCs extravesical and 2 of 5 ectopic ureters. EUCs and ureteral ectopia were associated with severe renal-polar damage, and function was rarely affected by primary decompressive procedures even in prenatally detected, uninfected cases. Endoscopic incision of EUCs was frequently followed by secondary VUR, which made secondary intravesical operations more complex. For these reasons, primary elective resection of a dysplastic upper pole is preferable in most cases to temporary decompressive measures. Conservative surgery is always indicated in IUC, which may benefit from endoscopic decompression. Isolated VUR involving the lower pole of a completely duplicated system may respond to expectant management in a significant number of cases. Accepted: 5 January 1999     

Endoscopic cystogastrostomy

Endoscopic cystoenterostomy for drainage of pancreatic pseudocyst is a new emerging modality which has rarely been reported in pediatric patients. Only ten successfully performed cases of pediatric endoscopic cystoenterostomy have been reported previously. We report a case of 9 year old male child with post traumatic pseudocyst of pancreas, successfully managed by endoscopic cystogastrostomy. To best of our knowledge, this is the first pediatric case report in Indian literature.     

Endoscopic treatment of vesicoureteral reflux with collagen

Submucosal injection of bovine collagen (Zyplast) was performed in 1 boy, 41 girls, and 9 women with 79 refluxing ureters. Five ureters had grade IV reflux, while the others had grades I–III. All patients suffered from recurrent urinary tract infections. In 25 ureters a second injection was given. As a result of this treatment, reflux is absent in 86% of the ureters. Only 15 patients had urinary tract infections during the follow-up period (6–30 months). Collagen injections could gain great importance in the management of vesicoureteral reflux.     

Ureteroceles in infancy and childhood: in search of the correct surgical approach

Between 1967 and 1986, 61 patients with 63 ureteroceles were treated; 53 ureteroceles were associated with duplex, 10 with single collecting systems. Antenatal and postnatal presentation and the means and limits of the possible investigations (intravenous urography, ultrasound, cystoscopy, micturition cystogram, isotope renography) are discussed. Thirty-nine ureteroceles were enucleated either with or without ureteric reimplantation. In patients with duplex systems this procedure was followed by heminephroureterectomy. The operative technique of the enucleation is discussed and the pros and cons of urinary diversion are mentioned. Eight ureteroceles were treated by primary heminephroureterectomy only, however in 75% secondary enucleation or ureteric reimplantation to stop reflux and infection became necessary; 12.5% developed a diverticulum. The remaining 16 ureteroceles were mainly treated unroofing or incision. The overall long-term results regarding reflux, urinary-tract infectios, and continence were excellent; in the majority of cases this was only after full reconstruction of the lower urinary tract. The function of the renal units involved remained constant or improved in 82% of the cases. We are aware that the enucleation procedure is a technically very demanding and time-consuming operation, nevertheless we highly recommend it, as it follows the principle and philosophy of surgical correction, achieving results as near normality as possible.     

Subcostal muscle-split incision in paediatric urology

The subcostal muscle-split incision (SMSI) has been used in 108 consecutive operations for benign upper urinary tract disease. No wound-related complications have occurred. No conversion to other wounds has been required. The benefits of SMSI are described. Accepted: 14 June 1998     

Orchiopexy through a single high transverse scrotal incision

Background:

Palpable Undescended Testis (PUT) represents a common paediatric problem in many premature and some mature infants. There are several surgical techniques to correct PUT either through combined inguinal and scrotal incision or single transverse scrotal incision. This study assessed single high transverse scrotal incision for the management of PUT as regards to feasibility, postoperative success and final cosmetic results.

Materials and Methods:

One hundred twenty patients were managed at the Paediatric Surgery Department of Tanta University Hospital with PUT during the period from March 2010 to March 2014. They were all operated at the age of 6-12 months. We excluded recurrent cases, and cases older than 12 months. Through high transverse scrotal incision, the layers were divided, and the canal entered through the external ring, dissecting the PUT and bringing it through the incision. Hernia sac, if present, was ligated at the neck. Creation of the dartos pouch was then made through the same incision. All infants were followed-up at 1 month, 2 months and 6 months to detect any re-ascended cases, testicular atrophy and the final cosmetic appearance.

Results:

A total of 140 PUTs were operated upon in 120 patients. PUT was bilateral in 20 patients, right-sided in 65 cases and left-sided in 35 cases. Thirty testes were located at the external ring; the others were located within the inguinal canal. No cases needed a redo operation, and there was no case of postoperative testicular atrophy.

Conclusion:

Single high transverse incision was sufficient to deal with PUT especially, in young infants (age 6 months) with no need for conversion in most cases to the traditional two incisions technique, and good long term follow-up and a better cosmetic results.     

Endoscopic correction of severe laryngomalacia

Tracheostomy for management of severe laryngomalacia is associated with significant morbidity and mortality. Two cases are reported wherein the laryngeal abnormality was corrected by ary-epiglottic fold incision and CO₂ laser supraglottoplasty. Stridor and respiratory obstruction were relieved and a long term tracheostomy avoided. Endoscopic correction of laryngomalacia offers significant benefits over conventional treatment with tracheostomy in terms of decreased morbidity and improved quality of life.