Pigmentary complications after non-medical male circumcision

BACKGROUND

A wide spectrum of complications are reported after male circumcision (MC), the non-aesthetic complications are well known, but the pigmentary complications scale are not reported precisely.

METHODS

This is a prospective cohort study of 550 circumcised boys; aged from 6 months to 14 years (62% aged 5 years) who were examined and appropriately investigated for the incidence of pigmentary complications after circumcision. Most diagnoses were clinically, but dermoscopy was done for 17 case and a skin biopsy for 14 cases. Patients with personal or family history of vitiligo, or congenital nevi were excluded. Available hospital records details and parents' statements were revised. The main outcome measures are the incidence of different pigmentary complications and circumcision details; data were analyzed by a non-parametric tests including the Mann-Whitney U test.

RESULTS

69 cases had 72 confirmed pigmentary complications discovered at 2-36 months after commencement of circumcision (mean 18). 48 cases had pigmentary complications directly related to MC, 11 cases were probably related and 10 unrelated to MC. The most common lesion is the circular hyperpigmented scar (29 cases); liner hyperpigmented scar in 13, spotted exogenous melanosis in 18 cases, melanocytic nevi (7), hypopigmentation diagnosed in 3 cases, but kissing nevus is the rarest finding (2). Topical corticosteroid was tried in 15 cases, surgical excision of pigmented scar were done for 19 cases, local laser used for 4 resistant cases and reassurance with follow up for the rest.

CONCLUSION

Pigmentary complications after male circumcision are not rare and its management is challenging.

A spectrum of epididymis and vas deferens anomalies among children with cryptorchidism: a retrospective multi-center study

Background

Vasoepididymal anomalies are not rare among children with cryptorchidism. They may affect fertility following orchiopexy. Herein, we describe the cases of abnormalities of the vas deferens and epididymis in children undergoing orchidopexy for cryptorchidism. Data were collected retrospectively from six centers providing care for patients with undescended testicles from September 2017 to February 2019. All patients whose congenital anomalies of the epididymis or vas deferens were discovered incidentally during operative intervention for cryptorchidism and where photographs of the anomalies were taken were included.

Results

The total incidence of congenital anomalies on the 467 testicles which had operations was 13.2%. Congenital epididymal and vas deferens anomalies were more common on the left side than the right side in patients with cryptorchidism (P = 0.038). Attachment anomalies between the epididymis and testis were the most common epididymal anomaly (36.3%), while a vanished vas deferens was the most frequent vas deferens anomaly (18%). Three patients had absent vas deferens, two had curled vas deferens, two had vas deferens separated from the epididymis, and one had a duplicated vas deferens. Three patients had an epididymal cyst, one had an enlarged appendix of the epididymis, and one had epididymal agenesis.

Conclusion

Attention must be paid during any surgery on an undescended testicle as an anomaly of the vas deferens could lead to unexpected complications. Anomalies of the vas deferens or epididymis that present in cases of cryptorchidism occur mostly on the left side.

Efficacy of topical testosterone in management of scrotal hypoplasia and agenesis

BACKGROUND

Scrotal hypoplasia or agenesis may posses difficulty during orchidopexy or end with social anxiety around excessively small scrotal size when compared to peers, and where there may be concerns regarding the future sexual life.

OBJECTIVE

Any conservative modality applicable to ameliorate scrotal underdevelopment partially or completely will be useful either solely or before reconstructive surgery.

STUDY DESIGN

Seventeen child (3-8 years) were diagnosed with bilateral scrotal hypoplasia (SH) in 5 unilateral in 7, bilateral scrotal agenesis (SA) diagnosed in 4 cases, and unilateral in one. Testicles are either undescended, ectopic, or normal. All cases managed by Testogel 1% topical testosterone for 4 weeks. Clinical assessment by measurements of the scrotal skin surface area (scrotal length multiplied by width) and scrotal corrugations counting. Inguinal and renal ultrasound done for all cases and karyotyping for cases of agenesis and cases with bilateral undescended testicles. Total and free testosterone, LH, FSH and AMH hormones were assisted before treatment, weekly and one week after therapy. Data analyzed and evaluated, difference of means used to test for statistically significant differences between scores of scrotal development.

RESULTS

Free and total testosterone elevated in the 1st week of treatment, but restored to normal or higher levels in 60% of cases at the 2nd week. Satisfactory response (Increasing numbers of scrotal rugae or scrotal surface area by 30-50% above the pretreatment status) obtained in 85% and 60% of unilateral and bilateral SH, but only a partial response (10-20% increase) was gained in 40% of cases with agenesis. No major adverse effect was appreciated.

DISCUSSION

Response of some cases of SH to topical testosterone indicates presence of remnants of labioscrotal folds with testosterone receptors (Bell et al., 1971) [1]. Testosterone replacement therapy can improve the signs and well-being of a hypogonadal male by restoring serum testosterone concentrations to physiologic levels. In this study the mean average testosterone concentration one week after application of testogel was 13.47 ± 2.45 and 12.12 ± 2.5 within 2nd, 4th week, and after cessation of treatment. Anti-Mullerian hormone is significantly low in 12 cases; mainly in cases of SA (P-value <0.001).

CONCLUSION

Short term topical testosterone proved to be effective in a considerable percentage of cases of either bilateral or unilateral scrotal hypoplasia; with a subsequent increase in scrotal surface area and number of rugae, it may substitutes the indication for surgical reconstruction. Long term follow up is a limitation of this study.

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

BACKGROUND

End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection.

METHODS

This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model.

RESULTS

In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001).

CONCLUSION

Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone.

Autologous platelet-rich plasma covering urethroplasty versus dartos flap in distal hypospadias repair: A prospective randomized study

OBJECTIVE

To compare the outcome and complication rate of the platelet-rich plasma applied as a coverage layer and dartos flap layer during primary repair of distal hypospadias.

METHODS

A prospective randomized study was carried out comprising 180 boys (age range 12-65 months) from October 2011 to December 2016 at Al-Azhar University Hospitals, Cairo, Egypt. A single surgeon carried out all urethroplasty. Patients were randomly divided into two groups: group A (tubularized incised plate urethroplasty with platelet-rich plasma coverage layer) and group B (ventral dartos flap). Complication rates were compared between two groups.

RESULTS

There was a significant difference in the occurrence of complications between the two groups. A total of 36 (20%) complications were recorded in 26 patients, just 12 (13.3%) reported in group A, but 24 (26.7%) complications were reported in group B. Urethrocutaneous fistula was observed in nine patients (10%) in group A, and 12 (13.3%) in group B. Partial glans dehiscence occurred in one patient in group A, and four patients in group B. No patient in group A had a superficial wound infection, compared with six patients in group B. One case of meatal stenosis and urethral stricture was recorded in each group, all of which were managed conservatively. The resultant urinary stream was single and good in 154 patients of both groups.

CONCLUSIONS

Platelet-rich plasma sheet might be considered as an alternative coverage layer for distal hypospadias repair, especially in the absence of a healthy layer.

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

BACKGROUND

The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy.

METHODS

In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation.

RESULTS

Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89·6 per cent) compared with that in countries with a middle (753 of 1242, 60·6 per cent; odds ratio (OR) 0·17, 95 per cent c.i. 0·14 to 0·21, P < 0·001) or low (363 of 860, 42·2 per cent; OR 0·08, 0·07 to 0·10, P < 0·001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -9·4 (95 per cent c.i. -11·9 to -6·9) per cent; P < 0·001), but the relationship was reversed in low-HDI countries (+12·1 (+7·0 to +17·3) per cent; P < 0·001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0·60, 0·50 to 0·73; P < 0·001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries.

CONCLUSION

Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.

Penile Median Raphe Anomalies as an Indicator of Megameatus Intact Prepuce Anomaly in Children Undergoing Routine Circumcision

OBJECTIVE

To arouse the suspicious for early diagnosis and hence, proper management of megameatus with an intact prepuce (MIP), as there is no external clue for detection of such cases, which usually come to light for the first time in a boy who is about to retract his prepuce or during neonatal circumcision.

MATERIALS AND METHODS

Examination of neonates and infants coming to circumcision clinic to detect congenital genitourinary anomalies. Evaluation of 12,518 neonates and infants coming for ritual circumcision from 2006-2017, who were examined thoroughly to detect any incidental congenital genitourinary anomalies. Fifteen of them were diagnosed to have a MIP anomaly. They were investigated to perceive any associated median raphe (MR) anomalies. Sensitivity, positive predictive value, specificity, and negative predictive value of MR anomalies in cases of MIP were estimated and compared with other children who had a normally positioned meatus.

RESULTS

Overall incidence of MIP in this group of babies was 0.12%. Twelve of 15 cases (80%) with MIP had 19 forms of MR anomalies; mainly raphe deviation in 6 cases, hyperpigmented raphe in 6, prominent raphe in 4, and bifurcation in 3 cases. Three cases had a redundant long prepuce, and 1 had paraphimosis after preputial retraction, otherwise no other genitourinary anomalies could be detected in those cases.

CONCLUSION

MR anomalies, mainly deviation and hyperpigmented prominent raphe, are significant indictors for the presence of an invisible MIP anomaly. Abnormally redundant long prepuce may be seen in such cases, but this is not common.

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

BACKGROUND

Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI).

METHODS

This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression.

RESULTS

Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1·6 per cent at 24 h (high 1·1 per cent, middle 1·9 per cent, low 3·4 per cent; P < 0·001), increasing to 5·4 per cent by 30 days (high 4·5 per cent, middle 6·0 per cent, low 8·6 per cent; P < 0·001). Of the 578 patients who died, 404 (69·9 per cent) did so between 24 h and 30 days following surgery (high 74·2 per cent, middle 68·8 per cent, low 60·5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2·78, 95 per cent c.i. 1·84 to 4·20) and low-income (OR 2·97, 1·84 to 4·81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days.

CONCLUSION

Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role.

REGISTRATION NUMBER

NCT02179112 (http://www.clinicaltrials.gov).

Determinants of morbidity and mortality following emergency abdominal surgery in children in low-income and middle-income countries

BACKGROUND

Child health is a key priority on the global health agenda, yet the provision of essential and emergency surgery in children is patchy in resource-poor regions. This study was aimed to determine the mortality risk for emergency abdominal paediatric surgery in low-income countries globally.

METHODS

Multicentre, international, prospective, cohort study. Self-selected surgical units performing emergency abdominal surgery submitted prespecified data for consecutive children aged <16 years during a 2-week period between July and December 2014. The United Nation's Human Development Index (HDI) was used to stratify countries. The main outcome measure was 30-day postoperative mortality, analysed by multilevel logistic regression.

RESULTS

This study included 1409 patients from 253 centres in 43 countries; 282 children were under 2 years of age. Among them, 265 (18.8%) were from low-HDI, 450 (31.9%) from middle-HDI and 694 (49.3%) from high-HDI countries. The most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23), p<0.001) and middle-HDI (4.42 (1.44 to 13.56), p=0.009) countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed.

CONCLUSIONS

Adjusted mortality in children following emergency abdominal surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries. Effective provision of emergency essential surgery should be a key priority for global child health agendas.

TRIAL REGISTRATION NUMBER

NCT02179112; Pre-results.

Efficacy and safety of continent anal urinary diversion for complicated bladder exstrophy in children by using modified Duhamel's procedure

BACKGROUND

A high proportion of children with bladder exstrophy will continue to suffer from urinary incontinence and a miserable life even after a well-performed staged reconstruction in specialized centers. Most of those children usually have a normal anal sphincter allowing construction of a neobladder from the rectum, so they are continent without an abdominal stoma, and do not require frequent catheterization, which greatly contribute to a favorable body image.

OBJECTIVE

In this study a modified Duhamel's rectal pouch done for 19 children, with implication of suitable stapler adopted to construct a rectal bladder with a non-refluxing urterorectostomy, there is a theoretical advantage in our procedure of avoiding a mix of urine and feces. All patients were followed for up to 6 years (2-8 years) for efficacy, safety, subsequent renal complications, and surveillance for any rectal neoplastic changes in this new diversion.

STUDY DESIGN

Assessment of electrolytes, acid base balance, and renal function were carried out regularly and all data were analyzed using the SPSS 9.0.1 statistical package and compared using a paired t test; data were considered significant if p < 0.05. Proctoscopy was performed 6 monthly in the first year then annually thereafter, and at any time if there was any rectal bleeding.

RESULTS

In this group of patients, follow-up revealed no neoplastic changes in the rectal bladder, deterioration in renal function, or major electrolytes disturbance. They can hold up to 400 mL (350-550 mL) of urine and all are continent during the daytime with an emptying frequency of 3-5 h; three patients had infrequent (4 episodes/month) nocturnal enuresis; and four cases developed pyelonephritis controlled with medical treatment.

CONCLUSION

The continent rectal bladder created by using the principles of the Duhamel pull-through is feasible, easy to perform, successful in the immediate short term with low complications after 6 years of follow-up and appropriately accepted by the children and their families with marked improvement in quality of life regarding continence; longer-term follow-up is requested to rule out rectal neoplastic changes. A comparative review of the complications, patient's acceptance, and longer-term follow-up with other well-known procedures, such as Mainz II, is required.

A rare case of aphallia with right kidney hypoplasia and left kidney dysplasia

Aphallia or penile agenesis is an extremely rare congenital anomaly with an estimated incidence rate of 1 in 10 to 30 million births. We report a rare case of aphallia with right kidney hypoplasia and left kidney dysplasia in a 10-day old Iranian-Azeri male. The patient had creatinine rise and renal failure due to dysplastic left kidney and hypoplastic right kidney and expired on fifth day of admission. There were only six cases of renal malformation associated with aphallia in the literature review. Three of the cases were complicated by Potter sequence and one of them was accompanied by chronic renal failure. Our case had a unique presentation because of bilateral renal malformation and subsequent renal failure without the Potter sequence.

Versatility of tissue expansion in abdominal wall reconstruction after removal of vascular malformations in children

BACKGROUND

Children who have had extensive abdominal wall vascular anomalies (VAs) face 3 common reconstructive options: either tolerating the complications of these lesions, exposure to repeated laser therapy session with its sequelae, or excision followed by a color-matched skin graft. The use of serial tissue expansion and excision of the affected skin offers a potentially better option under the right circumstances. Tissue expanders (TEs) have broad applicability but are not without complications.

OBJECTIVE

To study the versatility of use of TEs in the management of children who had extensive VAs in their abdominal wall with special emphasis to the complications and children and parental satisfaction.

MATERIALS AND METHODS

Retrospective data collection of 12 patients' charts, operative data of 84 operative procedures, and follow-up visits. Statistical analysis done using Student t test significance and P<0.05 was considered statistically significant.

RESULTS

Using 35 different sizes of TEs and 84 operative procedures in 9 boys and 3 girls aged from 2 to 12 years with different types of abdominal wall VAs revealed an overall complications rate of 20%. Child and parental satisfaction was found to be good overall.

CONCLUSIONS

Tissue expander is a useful and feasible tool for reconstruction of the abdominal wall with extensive VAs in children; parents and children were satisfied and body image is acceptable.

Spectrum of penoscrotal positional anomalies in children

BACKGROUND

The normal relationship between the scrotum and penis during fetal development is controlled by several genetic and hormonal factors, and impairment of this positional relation results in a wide spectrum of positional congenital anomalies.

OBJECTIVE

This a cohort study analysing 63 cases of penoscrotal anomalies (PSAs) according to severity and other associated malformations to provide a simple classification for recognising, describing and categorizing cases that may require surgical correction.

DESIGN AND SETTING

Between 2005 and 2013, 63 diverse cases of penoscrotal positional anomaly were detected and analysed based on their hormonal profile and other associated anomaly.

RESULTS

A wide variety of PSAs were included in the study, 11 cases were of major PST with complete penoscrotal transposition in three, incomplete in eight, and minor degree in 45 cases, which are symmetrical (bilateral) in 29, sixteen are asymmetrical, 4 had midline scrotlisation, and 3 had wide penoscrotal distance. Associated genitourinary anomalies were detected in 29 babies. Sex hormonal assays showed no significant differences between the PSA patients and controls (P < .05), and no gross chromosomal anomalies were detected in any cases.

CONCLUSION

Penoscrotal positional anomalies include the previously described penoscrotal transposition, and the variants of a central penile scrotalisation, and wide penoscrotal distance. A simple classification for these anomalies adopted herein.

The spectrum of genital median raphe anomalies among infants undergoing ritual circumcision

OBJECTIVE

To evaluate the extent of genital median raphe (GMR) anomalies and their relation to other genitourinary anomalies, as well as the impact on performing ritual circumcision.

PATIENTS AND METHODS

This prospective study was designed to collect data from neonates coming for ritual circumcision in order to detect any associated congenital anomalies in their genitalia, particularly in the genital raphe. 2880 babies aged from 1 day to 7 weeks were examined, from 2006 to 2011. All doubtful cases were reevaluated and cases with GMR anomalies were investigated for detection of other congenital anomalies and enrolled in the study.

RESULTS

57 cases of GMR anomalies were detected with an overall incidence of 2%; 18 of them had hypospadias, 5 had renal anomalies and 3 had limb anomalies. Circumcision was postponed in 37 cases where further investigations were done, but routine circumcision was carried out in the remaining 20.

CONCLUSION

It is crucial to examine every baby coming for circumcision to detect obvious or hidden congenital genital anomalies. Congenital anomalies of GMR are not so rare as thought, and some of these anomalies may necessitate surgical correction, and are commonly accompanied by urinary tract anomalies.

The intra-abdominal testis: lessons from the past, and ideas for the future

The intra-abdominal testis (IAT) has been always an enigma for both diagnosis and treatment. Imaging techniques are known for low sensitivity for localizing the IAT. It has been universally accepted that the gold standard for localizing the IAT is diagnostic laparoscopy. Orchiopexy techniques for IAT are complicated and attended with a higher rate of failure and complication than those for the palpable testis. For the low-lying abdominal testis, a one-stage procedure without interruption of the vessels has a high success rate. The Prentiss maneuver bridges the borders of normal pathway to gain a straighter course to the scrotum. The interruption of the main vascular supply of the testis, depending on collateral circulation, has been used for many years but with questionable effects on the microscopic delicate structure of the testis. Microvascular autotransplantation was intended to avoid this effect, but it is technically demanding and requires special expertise. The principle of traction has been used in the past but was abandoned due to high rate of atrophy. Recently, traction has been revisited with a new approach with very encouraging results. The key to success in any technique for orchiopexy is the complete absence of tension.

The feasibility of tissue expanders in reconstruction of giant congenital melanocytic nevi in children

BACKGROUND

Children with giant congenital melanocytic nevi (GCMN) pose a great challenge to pediatric and reconstructive surgeons because they have to cover the widely exposed area after its excision. A variety of treatment options exist for the management of such cases. In this retrospective review of a selected group of children who had a GCMN of their abdominal walls managed with implantation of tissue expanders (TEs) for staged reconstruction, patients were evaluated with respect to complications and general and esthetic criteria for patient and parent satisfaction.

OBJECTIVE

The purpose was to study the feasibility of use of TEs in the management of children who had GCMN, with special emphasis on the complications and children's and parents' satisfaction.

MATERIAL AND METHODS

Retrospective data from the 12 patients' charts, operative data of 86 surgical procedures, and follow up visits were analyzed using the Student's t test, and P < .05 was considered statistically significant.

RESULTS

In a period of 4 years, from 2004 to 2008, the results of using 37 different sizes of TEs and 86 operative procedures in 12 children (9 boys and 3 girls) aged from 2 to 12 years with different types of abdominal wall GCMN are discussed.

CONCLUSION

The TE is a useful and feasible tool for reconstruction of the abdominal wall in cases of GCMN in children. Parents and children are satisfied in general and also with the body image.

Ureterorectostomy as a continent urinary diversion for complicated bladder exstrophy in children by using a modified Duhamel procedure: a case series

INTRODUCTION

Whatever the method and timing of surgery, a high proportion of children with bladder exstrophy will continue to suffer from urinary incontinence. They face the options of urinary diversion to an external stoma or construction of a neobladder from bowel. This study describes a modified Duhamel's rectal pouch with a ureterorectostomy was carried out on 11 children who had a failed repair of bladder exstrophy.

MATERIALS AND METHODS

Ten boys and one girl, aged from 4 to 7 years (mean 5.5), had several unsuccessful operations for bladder exstrophy. All selected to have good renal function and no other anomalies, but were incontinent of urine and had a small contracted or prolapsed bladder. They underwent urinary diversion to the rectum using the Duhamel pullthrough technique, where the sigmoid colon was opened into the back of the anal canal above the dentate line, creating a rectal bladder and making use of the anal sphincter to control urine and stool. All were followed up for 24 months (18-27 months).

RESULTS

In this selected group of patients there were no major operative or postoperative complications. Follow-up for 2 years revealed no deterioration in renal function, or electrolytes disturbance. They can hold up to 300 ml of urine and all patients are continent during the daytime with an emptying frequency of 3-5 times. Nocturnal wetting occur some 4-8 times per month with significant decrease with time. Two cases developed pyelonephritis but this was controlled with medical treatment.

CONCLUSION

Eleven children achieved effective urinary continence by ureteric diversion to the rectum using a modified Duhamel pullthrough technique. Two years follow up showed no complications, except bed wetting, but long term assessment is warranted.

Outcome of submucosal injection of different sclerosing materials for rectal prolapse in children

Parasitic infestations, mainly enterobiasis and amoebiasis, and poor toilet training practices are commonly associated with rectal prolapse in developing countries. Injection sclerotherapy is one of the commonly used modalities for treating partial rectal prolapse in children. Various materials are available for such injection, but each has its advantages and complications. Comparing different materials used in the treatment of such pathology form the basis of this study trying to define the best material with the least complications. Data records of 130 children with partial rectal prolapse referred to the Department of Pediatric Surgery at Al Galaa Teaching Hospital, Cairo, over a 3-year period were analyzed. Their ages ranged from 6 months to 12 years (mean 6.14 years +/-3.4). Forty-five patients (3 5%) responded to conservative treatment, and 85 patients (65%) required injection sclerotherapy and were divided into three groups: Group 1 (35 patients) was injected with 98% ethyl alcohol, group 2 (22 patients) was injected with phenol in almond oil 5%, and group 3 (28 patients) was injected with Deflux (Q-Med, Uppsala, Sweden). The follow-up period ranged from 2 months to 3 years; clinical data and all complications were recorded. Submucosal injection of the three sclerosing materials showed no mortality in this series, but in group 1, seven had recurrence on short-term follow-up that required reinjection, and long-term follow-up in this group showed a recurrence rate of 11% (four patients), plus two patients had mucosal sloughing and one girl developed a rectovaginal fistula. Group 2 showed abscess formation and mucosal sloughing in four patients (18%), and two developed perianal fistula. Group 3 showed immediate postoperative prolapse in two cases that ameliorated spontaneously. No patients had mucosal ulceration or abscess formation, and long-term follow-up showed no recurrence. Deflux had the lowest complication rate with no recurrence on long-term follow-up. Phenol in almond oil 5% injection should not be used for treating such conditions because of its high complication rate. Alcohol is commercially cheap and available and should be considered an alternative for Deflux.