Urethral Plate Substitution in Two-Stage Hypospadias Repair: Grafts Versus Flaps

BACKGROUND

Choosing between flaps or grafts to substitute the urethral plate in 2-stage hypospadias repair has been a matter of debate with no consensus in the literature. Flaps have reliable blood supply that maybe theoretically less liable for strictures or contractures. Grafts are more versatile, which can be used in primary and recurrent cases when healthy local skin is deficient.In this report, our aim was to compare outcomes of grafts and flaps when used to substitute the urethral plate in two-stage repair of primary proximal hypospadias with ventral curvature.

METHODS

This retrospective study included primary cases of hypospadias with significant curvature who underwent two-stage repair using either grafts or flaps to substitute the urethral plate in the first stage. Cases included in the study were divided into two groups according to the technique of substituting the urethral plate at the first stage of repair. During first part of the study period (2015 through 2018), we mostly used grafts to substitute the urethral plate (group A); later, we shifted to skin flaps (Group B) during the period 2019 through 2021.

RESULTS

The study included 37 boys with primary proximal hypospadias who underwent two-stage hypospadias repair. The meatus position was penoscrotal in 18, scrotal in 16, and perineal in three. Inner preputial graft was used to substitute the urethral plate in 18 cases (group A), while dorsal skin flaps were used in 19 (group B). Out of the 37 cases, 27 were available at follow-up after second stage (group A = 14; group B = 13). Follow up period ranged between 6 and 42 months (mean 19.7; median 18.5). Overall, 14 cases required reoperations for different indications: partial disruptions of distal part of the repair in six, closure of urethro-cutaneous fistula in six, and urethral strictures in two. The rate of complications was higher in group A (10 cases: 71%) compared to group B (4 cases: 31%) (Fisher exact test, p-value = 0.057).

CONCLUSION

Grafts were associated with higher complication rate than flaps when used to substitute the urethral plate in two-stage repair of proximal hypospadias with chordee.

TYPE OF STUDY AND LEVEL OF EVIDENCE

This is non-randomized comparative study (level III evidence).

Postnatal imaging of conjoined twins: a customized multimodality approach

Medical imaging plays a crucial role in the management of conjoined twins. The role of imaging is to explore the anatomy, outline the shared organs and determine whether surgery is feasible. It also serves as a roadmap for successful separation. Additionally, imaging helps with counseling parents about prognosis. This review aims to illustrate recent advances in different imaging modalities and their role in the management of the various types of conjoined twins with an emphasis on relevant tips for optimal imaging.

Management strategy and outcomes of sacrococcygeal teratoma - an Egyptian multicenter experience

OBJECTIVES

Nationwide criteria regarding patients with sacrococcygeal teratoma (SCT) are still lacking in Egypt. We aimed to present a multicenter study regarding the management and outcomes of this tumor to evaluate our national treatment strategy.

METHODS

A retrospective analysis including all patients with SCT who were managed at four major Egyptian centers between 2013 and 2023. Clinical data, surgical approaches, and short- and long-term outcomes were discussed.

RESULTS

The study included 95 patients (74 were females). Antenatal diagnosis was reported in 25% of patients. Seventy-one patients (74.7%) were classified as Altman type I/II. Surgery was performed via a perineal approach in 75 patients, whereas the remaining 20 underwent a combined abdominoperineal approach. Vertical elliptical incision with midline closure was conducted in 51.5% of patients, followed by classic or modified chevron incisions. Benign mature teratoma was detected in 82% of patients. At a median follow-up of 57 months, eight patients (8.5%) had relapsed. The 5-year overall survival (OS) and event-free survival (EFS) of all patients were 94% and 91%, respectively. In the after-care monitoring, 19 patients (20%) had urinary or bowel dysfunctions. Nine of them were managed using medications. Clean intermittent catheterization was practiced in another five patients. The remaining five underwent further surgical interventions.

CONCLUSION

Favorable outcomes were achieved in our country during the last decade. Diverse perineal incisions were performed for resection, and vertical elliptical with midline closure was the commonest. During follow-up, 20% of patients developed urological or bowel dysfunctions that required medical and surgical treatment modalities to improve their quality of life.

De-epithelialized overlap flap to secure urethroplasty in second stage hypospadias repair: revisiting the Smith technique

BACKGROUND

The application of a second layer between the neourethra and skin was a major contribution, which has improved the outcome of hypospadias repair. Here, we report our experience of revisiting the original Smith technique using a de-epithelialized overlap flap to support the urethroplasty in staged hypospadias repair.

METHODS

The study included primary cases of proximal hypospadias with significant chordee who underwent two-stage repair during the period 2016 through 2021. The ventral curvature was corrected at first stage by excision of the urethral plate, followed by covering the ventral shaft by skin flaps or inner preputial graft. The second stage (Thiersch -Duplay urethroplasty) was performed six months later. The de-epithelialized overlap flap (double breasting) technique was used to cover the neo-urethra in all cases, which was combined with a dartos scrotal flap to cover the proximal neourethra when indicated.

RESULTS

The study included 17 boys with proximal hypospadias who underwent two-stage repair. Follow up period after the second stage ranged between 6 and 30 months (mean 19.7; median 18.5). Post-operative complications were detected in 7 cases (41%). Most complications were related to distal/glanular disruptions whether partial or complete (5 cases). One case developed a penoscrotal fistula that was closed surgically. Another case (belonging to the group which used preputial graft in the 1st stage) presented 21 months after the second stage with urethral stricture (penoscrotal).

CONCLUSION

Applying the de-epithelialized double-breasting skin closure can offer alternative second layer coverage for the neourethra along the penile shaft in staged repair of proximal hypospadias.

Vertical wound closure following sacrococcygeal teratoma excision: an approachable aesthetic solution

Background

Sacrococcygeal teratoma is a rare tumour, usually presenting in the neonatal period. The benign nature of most tumours and the high survival rates would emphasise on the importance of both cosmetic and functional outcomes.

We report on our extended experience with more cases concentrating on the aesthetic outcome of vertical wound closure following excision of large irregular sacrococcygeal tumours.

The study included primary cases of sacrococcygeal teratoma who were referred to our surgical team for excision. Cases of presacral tumours associated with anorectal anomalies and sacral bony defects (Currarino triad) were excluded. In all cases, we planned for a vertical midline wound closure after tumour excision. The aesthetic outcomes are evaluated concerning the vertical midline scar, buttock’s contour, and position of the anus.

Results

In addition to twelve previously reported cases (during the period 2011 through 2016), we included another ten new consecutive cases operated during the period 2017 through 2021. Collectively, the study included 22 cases of sacrococcygeal teratoma that underwent vertical perineal wound closure after excision of the tumour. In 13 cases (those with relatively small or medium-sized tumours), the perineal wound was perfectly closed in the midline (well-hidden vertical scar in the natal cleft). For the rest of the cases (9 cases with large and/or irregular sacrococcygeal tumours), some modification was applied on the vertical linear mid-line skin closure to accommodate for skin redundancy and irregularity at the lower end of the wound, usually ending with an ‘inverted-Y’ skin closure

Conclusion

Vertical wound closure was always feasible after excision of sacrococcygeal teratomas. Even with large and irregular tumours, the vertical scar was perfectly or partially hidden within the natal cleft. Usually, there was adequate buttock development with minimal disturbance to the normal anal location within the perineum.

Autologous platelet gel improves outcomes in tubularized incised plate repair of hypospadias

BACKGROUND

hypospadias is one of the most widespread male congenital anomalies, occurring in 1:250 to 1:300 live births. Several repair techniques have been developing to improve the outcomes.

PURPOSE

a randomized prospective controlled study was adopted to evaluate effectiveness of autologous platelet gel in healing promotion and improving the outcomes of hypospadias repair.

METHODS

thirty children who aged between 6 months and 12 years were recruited and subdivided into two groups; group A had tubularized incised plate (TIP) repair with autologous platelet gel application and group B had TIP repair without autologous platelet gel.

RESULTS

there was no significant difference in duration of operation between both groups. All patients in groups A and B had slit-like meatus shape in the distal glans. While all those of group A had one urine stream, yet only 11 of group B had one. There were complications that happened exclusively in group B such as spray stream (27%) and fistula (20%). Whereas other complications occurred insignificantly more in group B than in A including meatal stenosis (53 versus 27%), glans dehiscence, (20 versus 7%), bleeding (33 versus 13%), infection (33 versus 27%), edema (27% versus13), respectively. The incidence of skin necrosis was equal in both groups.

CONCLUSION

autologous platelet gel usage in TIP hypospadias repair can be a reliable technique to promote wound healing, and to limit of postoperative surgical complications.

Imaging of urinary tract in children in different clinical scenarios: a guide for general radiologists

Background

Children are frequently referred to the pediatric radiology department due to complaints related to the urinary tract.

Main body

We aimed to describe common clinical scenarios in paediatric urology practice and their recommended imaging diagnostic algorithms. Practical imaging approach to following common clinical scenarios and the common radiological findings are discussed: (A) perinatal urinary tract dilatation and other congenital anomalies; (B) recurrent urinary tract infection; (C) enuresis and daytime urinary incontinence; (D) abdominal masses; (E) flank pain; (F) hematuria; (G) trauma; (H) nonpalpable testis, ambiguous genitalia and common urogenital sinus anomalies; and I) renovascular hypertension

Conclusions

Imaging investigations should be tailored according to the clinical presentation in a stepwise approach aiming for optimum patients’ care.

Vascular anatomical considerations in preparing colonic flaps to replace the oesophagus

Background

The colon is among the best options to substitute the oesophagus; it is well known for its durability and good function that makes it most suitable for paediatric patients. The steps of the procedure, postoperative complications, and outcome assessment were thoroughly discussed in previous reports. However, in this report, we have tried to focus on one basic and essential step of the operation, which is fashioning of the colonic flap used to substitute the oesophagus.

Results

The study included 50 consecutive paediatric cases who underwent colonic replacement of the oesophagus during the period 2010 through 2020. The indication for oesophageal replacement was either oesophageal atresia (27 cases) or corrosive strictures (23 cases). Our standard technique was using a middle segment of the colon (transverse colon) based on the left colic vessels (vascular pedicle) after ligation of middle colic vessels. Variations of the middle colic vessels were encountered that included single, double, or absent vessels. In a single case (2%), the middle colic vessels were multiple, short, and non-branching with interrupted continuity of marginal vessels at that point. In the latter situation, we had to use a different technique by fashioning a right colonic flap based on the middle colic vessels.

Conclusion

In colonic replacement of the oesophagus, preparing a pedicled flap from the transverse colon based on the left colic vessels was almost always feasible owing to the stable collateral marginal vessels. On a rare occasion, the marginal vessels were interrupted by disturbed anatomy of the middle colic vessels when we had to shift to another technique using a right colonic flap.

Anorectal anomalies in the female: Highlights on surgical management

BACKGROUND

Anorectal anomalies (ARA) are characterized by different clinical presentations in both sexes with consequently different management protocols. There exist several controversies and different strategies to manage ARA in the female.

PURPOSE

To present our experience in managing girls with ARA highlighting the rationale behind the chosen protocol.

PATIENTS AND METHODS

The study included 121 girls with ARA who underwent sagittal anorectoplasty during the period 2009 through 2019. Their age ranged from 3 to 57 months (median = 7 months). There were 68 cases with rectoperineal fistula, 51 with rectovestibular fistula, 1 case with rectovaginal fistula and another case without fistula. Preoperative colostomy was performed in only 5 cases (3 rectovestibular; 1 rectovaginal; 1 without fistula). The rest of cases underwent delayed primary sagittal anorectoplasty (beyond the neonatal period).

RESULTS

Postoperative wound complications were detected in 14 cases (11.7%). In general, wound complications were more common among the rectoperineal group. Delayed healing problems in the form of mucosal prolapse/ectropion were detected in 10 cases. Thirty-four cases were available for delayed functional assessment. Voluntary bowel control was present in 91% of cases. Constipation was detected in 7 cases (20%) at follow up. Fecal soiling was present in 6 cases (17.6%); 3 of them were associated with constipation.

CONCLUSION

Delayed primary repair of rectoperineal and rectovestibular fistula is feasible with low complications. By adopting this protocol of management, we could achieve comparable results while avoiding unnecessary operations during the neonatal period.

LEVEL OF EVIDENCE

This is a case series (Level IV Evidence).

Anatomical derangements after failed PSARP: correlating MRI and operative findings

Background

Redo surgery for anorectal anomalies (ARA) may be considered a special category of reconstructive surgery with less predictable outcomes. In this report, we studied anatomical derangements in a group of boys following a previously complicated PSARP procedure, in addition to the effect of reoperation on rectifying this distorted anatomy.

Results

The study included 27 boys who were re-operated after a previous complicated PSARP. Included cases were divided into two groups: group A (14 cases) was referred before colostomy closure with an obviously complicated primary operation, and group B (13 cases) was referred with delayed complications after colostomy closure.

Pelvic MRI examinations were performed before reoperation in 19 cases. In nine of these cases, a repeat MRI examination was performed at follow-up after reoperation to study the effect of redo surgery on rectifying the distorted anatomy.

Abnormal wide anorectal angle and wide pelvic hiatus were common anatomical derangements after a previously complicated PSARP. An important goal of reoperation was reconstruction of the levator ani behind the anorectum trying to create a more acute anorectal angle and a narrower pelvic hiatus. The success of this corrective step was evaluated by MRI comparing pre- and postoperative measurements that showed a favourable decrease in the values of anorectal angle and hiatal/PC ratio. Improvement of faecal continence was documented after reoperation in 8 out of 10 cases in group B.

Conclusion

A wide pelvic hiatus was a frequently encountered postsurgical complication after failed PSARP that has most probably resulted from poor reconstruction of the pelvic floor at time of the primary repair. Re-approximation of the split halves of levator ani in the midline behind the anorectum at reoperation can help to correct the distorted internal anatomy and improve bowel control in these cases.

Posterior cloaca: A urogenital rather than anorectal anomaly

BACKGROUND

'Persistent Cloaca' refers to one of the major groups of anorectal anomalies in the female when a single perineal orifice is located at the normal site of the urethra draining both urogenital and alimentary tracts. However, 'posterior cloaca' is a new term developed by Pena to describe a unique defect in females in which a common urogenital sinus is deviated posteriorly to open into normally located anorectum (type A) or in the perineum slightly anterior to the anus (type B).

METHODS

The study included seven girls diagnosed as posterior cloaca. Their age at presentation ranged from 1 to 108 months (median 12 months). The main presentation was abnormal external genitalia, while two cases underwent colostomy (±vaginostomy) at birth. Surgical reconstruction varied according to the degree of deviation from normal anatomy. Partial urogenital sinus mobilization (PUM) was used to correct minor forms; while at the other end of the spectrum (absent urinary bladder), continent urinary diversion was performed. Due to the high incidence of renal and urological anomalies, regular follow up at paediatric nephrology/urology clinics was advised for affected cases.

RESULTS

All seven cases had a common urogenital confluence characteristically deviated posteriorly. The degree of backward deviation of the common urogenital orifice was variable ranging from mild to severe posterior displacement. In six cases (85%), the common urogenital orifice was shifted backwards in the perineum approaching the anal verge (type B). In one case, the common urogenital orifice opened internally into the anorectum (type A). Major urinary tract anomalies were quite common (5 of 7 cases; 71%): absent urinary bladder (2 cases); single kidney (2 cases); crossed ectopic kidney (1 case); hydroureteronephrosis (2 cases).

CONCLUSION

Posterior cloaca is a rare anomaly in the female essentially affecting the lower urogenital tract with a high incidence of associated renal anomalies. Management should be tailored according to the degree of developmental defect.

Infantile haemangioma: 5-year experience at the vascular anomaly clinic

Background

Infantile haemangiomas (IH) represent a common benign vascular tumour affecting the paediatric population. Infantile haemangiomas are characterised by a natural history differentiating it from other vascular anomalies. After a transient proliferative phase in early infancy, the tumour passes through a plateau phase before going into spontaneous involution. In this report, we tried to share our experience over the last 5 years in managing cases presenting with IH at a specialised vascular anomaly clinic.

Main body of abstract

This report included cases of IH who were attending the vascular anomaly clinic during the period 2015 through 2019. Data of all patients attending the clinic were retrospectively examined. Files of 103 cases with IH were available for review. The diagnosis of IH was usually straight forward owing to the typical history and characteristic findings at clinical examination. A significant female predominance was noticed. Generally, IH were more common in the head and neck region (70%). Active intervention was necessary in specific situations (eye occlusion, airway involvement, large lesions with skin ulcerations). Whenever intervention proved to be necessary, propranolol was chosen as the first line of treatment with a favourable response detected in about 90% of cases. Surgery was still a valid option (6%) for lesions amenable to resection; however, we must put in consideration that most lesions will spontaneously regress.

Conclusion

Infantile haemangiomas are common benign vascular tumours of infancy with relatively few complications. Cosmesis is a major concern especially for lesions affecting the face. Propranolol can induce tumour regression in most cases, and generally, a favourable outcome can be anticipated.

Anorectal anomalies in the male: revisiting the radiological classification

Background

Classifying anorectal anomalies (ARA) has always been a matter of debate among pediatric surgeons. A new classification does not necessarily imply discarding older ones. Several concepts have been introduced in the past and stood the test of time being still valid up till now

In this report, we present our experience in managing a group of boys with ARA by PSARP. We have tried to enhance the current classification to include information about the level of the rectum in relation to sacrum, not just the location of the fistula.

Results

The study included 62 consecutive male patients with anorectal anomalies who underwent PSARP between 2009 and 2019. Included cases were either recto-bulbar fistula (21 cases), recto-prostatic fistula (30 cases), or imperforate anus without fistula (11 cases). Their age at operation ranged from 3 to 36 months (mean 7.8 months).

Cases with recto-prostatic fistula were further subclassified according to the level of distal rectum into two subgroups: (type 1) those with the rectum ending opposite the level of S4/S5, and (type 2) those with the rectum ending at a higher level opposite S3.

The PSARP procedure proved to be a successful surgical approach to reach, separate, and mobilize the rectum in all cases of recto-bulbar fistula, imperforate anus without fistula, and recto-prostatic fistula type (1). In cases of recto-prostatic fistula type (2), the perineal approach (PSARP) failed to reach and mobilize the rectum in two out of the eleven cases.

Conclusion

In management of anorectal anomalies, the sacrum can provide two important indicators: a prognostic value for continence, and anatomical landmark to stratify the level of distal rectum in the pelvis which is crucial for planning the best surgical approach.

Preoperative topical testosterone for penile hypospadias repair `a comparative study`

Background

Although the outcome of hypospadias repair has much improved, repair of a small-sized phallus is still challenging. Whether preoperative hormonal therapy is beneficial remains controversial.

In this report, we prospectively conducted a clinical trial comparing two groups of patients regarding the effect of preoperative topical testosterone application on the outcome of primary hypospadias repair.

Results

The study included 40 cases of primary hypospadias with a small glans. Their age ranged from 6 months to 3 years. Patients were divided into two equal groups. Group A were treated by local application of testosterone topical gel 1% for 30–40 days and stopped one month before operation, while cases in group B did not receive preoperative hormonal treatment. Genital skin biopsies were taken for histopathological examination. For group A, penile measurements were documented before and after hormonal therapy.

There was a significant increase in all penile parameters after hormonal stimulation in group A. Interestingly, the ventral penile length proximal to the meatus showed more growth in response to hormonal stimulation compared to ventral penile length distal to meatus.

We did not find significant difference between both groups regarding the rate of postoperative complications. Also, the cosmesis and parent satisfaction were ‘more or less’ similar. On the histopathological level, we could not detect a difference between both groups regarding micro-vessel density using CD31, which is a vascular marker indicating neovascularization supposed to play a fundamental role in the healing process.

Conclusion

The use of preoperative topical testosterone significantly increases the size of the hypospadiac phallus. However, this increase in size appears to be disproportionate on the ventral penile surface and has not been reflected on improving the surgical outcome.

Level of evidence

This is a case control study (level III evidence).

Role of sagittal anorectoplasty in treating constipation in patients with recto-perineal fistula

Background

Recto-perineal fistula is a common anorectal anomaly, affecting both males and females. The anus is abnormally anteriorly located and is usually stenotic. Management of recto-perineal fistula is a dialectic problem. The most common presenting complaint is constipation; also, long-term follow-up of these patients revealed high incidence of postoperative constipation.

Results

The study included 30 patients (19 female and 11 male). Their age at time of repair ranged from 3 to 78 months. We compared the pre- and postoperative constipation rate after limited posterior sagittal anorectoplasty (PSARP) using Krickenbeck score. Overall, the rate of constipation has dropped from 77 (23/30) to 30% (9/30) after surgery. Fourteen patients out of 23 patients with preoperative constipation were cured. Another patient with preoperative constipation improved regarding the grade of constipation. The remaining 8 patients with preoperative constipation did not show improvement after operation. These results were statistically significant (McNemar test). Out of the 9 patients who were still constipated after surgery, 7 had associated fecal soiling that showed good response with bowel management of constipation.

Conclusion

Limited posterior sagittal anorectoplasty can have a role in treating constipation among cases of recto-perineal fistula.

Feminizing genitoplasty in childhood: aiming for achievable outcomes

Background

Early genital reconstruction may be recommended in cases of congenital adrenal hyperplasia to avoid the stigma that can affect these individuals with variable degrees through different cultures. However, the separation and mobilization of a high vagina has remained challenging with less satisfactory surgical outcomes. Therefore, the value of early vaginal reconstruction has been questioned in favour of delaying the whole repair after puberty. In this report, the author has adopted the third option in-between, which comprises early reconstruction of the external genitalia and delaying the more challenging vaginal reconstruction (if needed) to be performed after puberty.

Results

The study included ten consecutive cases of CAH who underwent feminizing genitoplasty during the period 2016 through 2019. Their age at operation ranged from 8 to 84 months (mean 31; median 15).

In five cases (50%), the technique of limited urogenital sinus mobilization adopted in this report succeeded in bringing the vaginal introitus down to the perineum. Those cases had originally a low vagina. In the rest of cases, labial retraction showed a common but wide urogenital introitus perfectly lined by urogenital mucosa. The outcomes have been considered satisfactory to a great extent for both parents and doctors regarding cosmesis and lack of functional complications (voiding problems). Longer follow up is still needed to assess the sexual function when these girls become sexually active.

Conclusion

In cases of congenital adrenal hyperplasia, reduction clitoroplasty combined with partial urogenital sinus mobilization can achieve predictable and satisfactory outcomes. In about 50% of cases, this approach is sufficient to bring the vagina down to the perineum. In the other half of cases with higher vagina, the possibility of satisfactory sinus intercourse can be studied when these girls grow and become sexually active; otherwise, a delayed vaginal reconstruction may turn to be necessary.

Histopathological perspective of the pulled-through colon in Hirschsprung disease: Impact on clinical outcome

BACKGROUND

The outcome in HD has not been always satisfactory even after a technically sound operation.

PURPOSE

To define the characteristic histopathological features of the pulled-through colon in patients with HD, and it is impact on clinical outcome.

PATIENTS AND METHODS

The study included patients with HD who underwent surgical repair between 2010 through 2016. The proximal margin of resected bowel segments (which corresponds to the pulled through colon) was subjected to detailed histopathological examination by two experienced pathologists. Based on the frequency of postoperative attacks of HAEC (fever, vomiting, abdominal distention, fluid offensive stools), cases included in the study were divided into two groups: Group A, those with less frequent attacks of HAEC; and Group B, those with recurrent attacks of HAEC (more than 3).

RESULTS

The study included 35 patients (25 in group A; and 10 in group B). Their age ranged from 0.2 to 144 months (median 6 months). Comparing the histopathological findings in the two clinical groups, we have found that Group B (recurrent attacks of HAEC) had significantly more frequent focal disarray of nerve bundles and thicker nerve bundle diameter. Also, histopathological features of acute inflammation were more prevalent in examined specimens from group B.

CONCLUSION

Several histopathological features of the examined bowel specimens in HD, other than presence or absence of ganglion cells, are indicative of postoperative functional outcome. These include the thickness and maturity of nerve bundles, in addition to the presence of histopathological features of acute inflammation.

LEVEL OF EVIDENCE

This is a case control study (level III evidence).

Transformation of the female genitalia in congenital adrenal hyperplasia: MRI study

PURPOSE

In this report, we aim to define the different degrees of structural abnormality affecting the female genitalia in cases of CAH by using the multiplanar capabilities and high soft tissue resolution of MRI.

PATIENTS AND METHODS

The study included cases of CAH who were referred to our pediatric surgical facility for genital reconstruction during the period 2016 through 2019. We studied the pelvic MRI anatomy in cases of CAH while referring to clinical and operative findings. To set up a grading scale for the degree of virilization in cases of CAH, we included another two control groups of normal boys and girls representing the two ends of the spectrum.

RESULTS

The study included 23 cases of CAH who underwent preoperative pelvic MRI examination. All cases had normal chromosomal analysis (46 XX). Their age ranged from 1 to 156 months at time of MRI examination (mean 42.4; median 25). The level of the lower end of the vagina was identified in midsagittal T2WI and confirmed in sequential axial cuts. Based on the level of the lower end of the vagina in relation to the pubic symphysis, we classified cases of CAH into either low or high types. Moreover, we could observe a correlation between the degree of vaginal descent and structural transformation of erectile tissue between both genders.

CONCLUSION

MRI can have an important role in the evaluation of cases of CAH by displaying the severity of internal anomaly which is crucial for proper preoperative counseling.

TYPE OF STUDY

Case control study.

LEVEL OF EVIDENCE

Level III.

Persistent cloaca: persistence of the challenge

Background

Persistent cloaca or cloacal anomalies represent a special category of anorectal anomalies affecting the female sex with a reported incidence of about one in 25,000 live birth.

The study included 34 cases of cloaca that were managed at our unit between 2003 through 2017. We retrospectively reviewed patients’ records that included clinical presentation, investigations, operative data, and follow-up notes.

Anatomically, we stratified cloaca into three types according to the level of urogenital confluence. A low confluence (type 1) was defined by being at or below the level of the lower border of pubic symphysis with a short common channel (11 cases). A high confluence (type 3) was defined by being at or above the level of the upper border of pubic symphysis (9 cases). Between the low and high types, we defined an intermediate type (type 2) where the urogenital confluence was behind the mid-portion of pubic symphysis (14 cases).

Results

Renal anomalies were common association: solitary kidney in seven, pelvic kidney in two, and urinary tract dilatation (hydroureteronephrosis) in 12 cases. At follow-up, chronic renal insufficiency was detected in seven cases

The prognosis for urinary continence was excellent in low confluence (type 1) cloaca. On the other hand, urinary incontinence was common among type 3 (high confluence) cloaca (62.5%).

Conclusion

Renal anomalies represent a common association with cloaca and a major cause of morbidity. Efforts should be directed to preserve renal function during the initial management, and to preserve the continence potential following the definitive repair.

Level of evidence

This is a case series with no comparison group (level IV).

Anatomical alterations following the 'PSARP' procedure: Correlating MRI findings with continence scores

PURPOSE

To identify anatomical aberrations following PSARP procedure by using MRI, while correlating MRI findings to clinical outcome.

PATIENTS AND METHODS

Between January 2014 and December 2017, we conducted our study on male patients with rectourethral fistula who underwent PSARP. Postoperative pelvic MRI studies were performed and correlated to their clinical continence scores (Rintala, and Krickenbeck classification).

RESULTS

The study included 31 patients. Fourteen patients were retrieved from the hospital records and accepted to participate in the study; while the remaining 17 were collected from the fecal incontinence clinic. Their age ranged from 40 to 156 months (mean 83) We divided patients in the study into two groups according to their Rintala continence scores: (Group A) 15 patients with low scores (10 or less); and (Group B) 16 patients with higher scores (more than 10). We detected wider pelvic hiatus (hiatus/PC ratio) and more obtuse anorectal angle in group A than B.

CONCLUSION

Several anatomical alterations can be detected by MRI following the PSARP procedure that include abnormalities in the striated muscle sphincter (attenuation/deficiency), deviated neorectum, and presence of excessive perirectal fat. A widened pelvic hiatus and/or obtuse anorectal angle may correlate with poor fecal continence in these patients.

LEVEL OF EVIDENCE

This is a case control study (level III evidence).

The Currarino triad: What pediatric surgeons need to know

PURPOSE

We report our experience in managing a group of patients with Currarino syndrome, highlighting diagnostic challenges, surgical techniques, in addition to a review of current neurosurgical options.

PATIENTS AND METHODS

The study included patients with Currarino syndrome who presented to our pediatric surgery department during the period 2010 through 2016. The 'sacral scimitar' in plain X-ray provided the clue for the diagnosis; while MRI examination was essential to define the nature of the presacral mass and associated spinal anomalies.

RESULTS

The study included 17 patients (13 girls and 4 boys). Their age at presentation ranged from 7months to 10years. We used posterior sagittal approach to correct anorectal anomalies, and excise presacral cysts that were subjected to histopathological examination. Two cases presented with a pelvic abscess (infected presacral dermoid cyst), which were initially drained followed by excision. The presacral mass consisted of either lipomyelocele (6), lipomyelomeningocele (3), or a developmental (dermoid) cyst (8). Tethering of the spinal cord was a common association (70%) CONCLUSION: Apart from diagnostic challenges, the management of Currarino syndrome is similar to the usual management of ARM regarding the surgical approach and probably the prognosis that mainly depends on degree of associated sacral dysplasia.

LEVEL OF EVIDENCE

This is a case series with no comparison group (level IV).

Low-type anorectal malformations in the male: Extent of deviation from the norm

PURPOSE

To define the degree of deviation from the norm among boys with minor forms of anorectal malformations (ARM).

PATIENTS AND METHODS

Between March 2015 and January 2016, we studied the preoperative MRI of nine boys with low-type ARM. For comparison, we included another nine boys (control group) who underwent MRI pelvis for causes other than ARM (e.g. impalpable testes).

RESULTS

In boys with low-type ARM, the rectum descends forwards to touch the back of the prostate (as in the norm), but then goes downwards (with little or no backward deflection) keeping intimately attached to the bulb of the corpus spongiosum and displacing it downwards and forwards. The striated sphincter muscles do not follow the anterior displacement of the bowel termination, but remain orthotopically compacted at the normal predestined site of the anal canal.

CONCLUSION

Among boys with low ARM, the minor abnormalities at the external anal orifice are associated with deeper anatomical aberrations in the form of anterior misplacement of the anorectum. These findings may help in understanding the disturbed act of defecation among these patients, and provide guidance to the best way of surgical correction.

Surgical Management of Hair-coil Penile Injury: Anatomical Insights and Grading System

OBJECTIVE

To report our experience in the surgical management of a group of patients with varying degrees of hair-coil penile injury, while applying a more detailed grading scale for the severity of injury.

PATIENTS AND METHODS

The study included 16 boys with hair-coil penile injury who were managed during the period 2010 through 2016. In the acute state, the constricting hair coil was removed under general anesthesia. The repair was planned 6 months later after the acute injury. In 1 case presenting with severe form (near total glanular amputation), the glans was resutured to the penile shaft immediately after removal of the hair coil; the urethroplasty was performed six months later.

RESULTS

The patients' age ranged from 2 to 17 years (mean 4.8 years). The urethroplasty was always covered by a protective layer, which was derived from the ventral dartos fascia in all but 1 case. In the latter, we used a tunica vaginalis flap for covering the urethroplasty. A successful outcome (regarding both urethral reconstruction and cosmesis) was achieved in all cases.

CONCLUSION

Hair-coil penile injury is an uncommon condition with insidious course. Unawareness of such condition can lead to progression to serious complications. Delayed and staged surgical repair is associated with successful outcome.

The radiological assessment of colonic replacement of the esophagus in children: A review of 43 cases

PURPOSE

To define the characteristic radiological features following colonic replacement of the esophagus in children.

MATERIALS AND METHODS

The upper gastro-intestinal contrast studies of 43 patients who underwent colonic replacement of the esophagus at our pediatric surgery unit were available for analysis. UGI contrast studies were performed routinely in the post-surgical period in 17 cases (first asymptomatic group), while the rest of contrast studies (26) belonged to a second group of out-patients complaining of dysphagia (18) or dyspepsia (8) following colonic replacement of the esophagus. Based on our observations, we proposed a grading system to describe the degree of colonic redundancy in the thorax.

RESULTS

Redundancy of the colonic conduit in the thoracic cavity was a common radiological finding (62.8%). The redundancy was mild (grade 1) in 18 patients, moderate (grade 2) in eight, and severe (grade 3) in only one patient. In 88.9%, the redundancy was in the right hemi-thorax. Patients presenting with postoperative dysphagia had a stricture at the site of the esophago-colic anastomosis in the neck, which should be differentiated from other sites of anatomical narrowing at the inlet and outlet of the thoracic cavity. Gastro-colic reflux was common among patients who underwent colonic replacement of the esophagus without an anti-reflux procedure.

CONCLUSION

Colonic replacement of the esophagus in children results in considerable anatomical alterations. Knowledge about the normal post-surgical changes and imaging features of the commonly encountered complications can increase the diagnostic confidence among radiologists and clinicians when dealing with these cases.

Intra-abdominal testis: histological alterations and significance of biopsy

PURPOSE

Intra-abdominal testes represent only 5% of undescended testes. Review of the literature reveals that few data exist on the histological analysis of intra-abdominal testes. We studied histological alterations in intra-abdominal testes in relation to patient age at orchiopexy.

MATERIALS AND METHODS

A total of 57 boys underwent laparoscopy for impalpable undescended testes between October 2002 and June 2005. Testicular biopsies were taken from intra-abdominal testes, fixed in 3% glutaraldehyde, embedded in Epon, sectioned at 1 micron thickness and stained with toluidine blue. Histomorphometric analysis was performed by light microscopy. Effect of age at operation on histological evaluation of abdominal testes was also studied.

RESULTS

Testicular biopsies from 29 patients with intra-abdominal testes showed the histological alterations of decreased mean diameter of seminiferous tubules, germinal cell depletion (55%) and presence of microliths (6.9%).

CONCLUSIONS

As age at orchiopexy increases, deviation from the norm is more evident and absence of germ cells on biopsy becomes more pronounced, reaching a rate of 93% after age 3 years. Further studies on orchiopexy with or without biopsy in the first few months of life would likely improve our understanding and treatment of cryptorchidism.