Safety and feasability of ureteroscopy for pediatric stone, in children under 5 Years (SFUPA 5): A French multicentric study

INTRODUCTION

Ureteroscopy (URS) can be proposed as first-line therapy for the management of pelvic stones from 10 to 20 mm and for lower ureteric stones in children. However, little is known about the success and the morbidity of URS in young children. Ureteroscopic treatment may present matters in young children because of the small size of the pediatric kidney and the small size of the collecting system.

OBJECTIVE

To assess safety and efficacy of URS for the treatment of urinary stones in children aged of 5 years or less.

STUDY DESIGN

After the institutional ethical board approval was obtained, we conducted a retrospective, analytic, multicentric study that included all URS performed between January 2016 and April 2022 in children aged of 5 years or less. In this non-comparative case series, anonymized pooled data were collected from 7 tertiary care centers of pediatric patients. Endpoints were the one-session SFR at 3 months and per and postoperatives complications. Descriptive statistics were applied to describe the cohort.

RESULTS

Eighty-three patients were included. For them, 96 procedures were performed at the median age of 3.5 years (IQR: 0.8-5) and median weight of 14 Kg (6.3-23). Median stone size was 13 mm (4-45). There were 65 (67 %) renal stones treated with flexible URS, most of which were in the renal pelvis (30 %) and in the lower calix (33 %). A ureteral access sheath was used in 91 % procedures. Preoperative ureteral stent was placed in 52 (54 %) of patients. None of patients had ureteral dilatation. The single-session SFR was 67.4 % (56.3 and 89.2 % for flexible URS and semi-rigid URS respectively) and children require 1.4 procedures to achieve complete stone clearance. The overall complication rate was 18.7 %, most of them were minor (Clavien I-II). Intraoperative perirenal extravasation (Clavien IIIb) due to forniceal rupture was documented in 6.2 % of cases, related to an increased intrapelvic pressure (IPP) performed in a closed pelvicalyceal system.

DISCUSSION

Pediatric urologists should be aware of forniceal rupture based on the presence of extravasation of contrast during endourological procedures especially when they have difficulties to reach lower caliceal stone in small patient.

CONCLUSION

URS in patients aged of 5 years or less, is a complex minimally invasive procedure with reasonable efficacy and low morbidity. Intrarenal stones treated by RIRS in young children carries the risk of additional procedures to complete stone clearance.

Mayer-Rokitansky-Küster-Hauser syndrome patients' interest, expectations and demands concerning uterus transplantation

OBJECTIVE

To better understand patients' conditions and expectations before starting a uterus transplantation (UTx) program for women suffering from Mayer-Rokitansky-Küster-Hauser syndrome (MRKH syndrome).

METHOD

A web-based survey was conducted among MRKH patients via the French national association network from March to August 2020. The questionnaire comprised twenty-eight questions about their desire for parenthood, their condition's characteristics and previous reconstructive procedures, opinions and knowledge about UTx.

RESULTS

Among the 148 participants, 88 % reported a desire for parenthood, and 61 % opted for UTx as their first choice to reach this aim. The possibility of bearing a child and having the same genetic heritage were the main motivations. Once informed about the usual course of an UTx protocol, only 13 % of the participants changed their mind and 3 out of 4 of them opted for UT.

CONCLUSION

Uterus transplantation seems to be the first option to reach motherhood in patients suffering from MRKH syndrome. The development of UTx programs could meet the demands of this already well-informed population.

[Management of urachal remnants in children: Is surgical excision mandatory?]

INTRODUCTION

The classical management of urachal remants consists in surgical resection, in order to prevent infections and long term malignancies. However, some reports have recently spread a wait and see management. The aim of our study was to report the results of the surgical management in our center.

MATERIAL AND METHODS

We conducted a retrospective, monocentric review of all patients managed for urachal remnants from January 2005 to December 2014.

RESULTS

Thirty-five patients have been operated during the study period (18 girls and 17 boys). Mean age at surgery was 4,9±4,4 years old. Twenty-seven patients were referred due to symptoms whereas 8 were discovered incidentally (4 by ultrasound scan and 4 during laparoscopy). Among them, 10 were urachal cysts, 15 were urachus sinusa and 10 were patent urachus. Thirty were operated using an open approach and 5 using a laparoscopic approach. Mean length of stay was 3,8±1,7days (1-10) with a mean duration of bladder drainage of 2,5±1 days. No major complications occurred. No abnormal tissue was discovered at the histological analysis.

CONCLUSION

Presentation of urachal remnants is variable but surgical outcomes remain excellent in our experience. When symptoms occur, the surgical decision is easy, but when the diagnosis is incidental, the decision is much more complicated. Official guidelines could ease the decision process and the management of urachal anomalies.

[Focusing of inguinal hernia in children]

Abnormal persistence of the processus vaginalis in children predisposes to a complication that is strangulated inguinal hernia. The inguinal hernia is a frequent pathology because global incidence varies from 0,8 to 4,4% for children of any age and reaches about 30% in premature children. Strangulated inguinal hernia is rare (from 1,5 to 8%) and constitutes a surgical emergency. More frequently, reduction following sedation is possible (from 25 to 33%), and normally leads to delayed surgery. Current practice is to operate early in these children, including preterm infants, before any complication arises. This early surgery requires use of regional anaesthetic techniques such as spinal anaesthesia, ileo-inguinal ileohypogastric nerve blocks and caudal anaesthesia. However, although this pathology may appear to be routine commonplace it requires a specialized surgical and anaesthetic approach and specialized environment.

Retroperitoneoscopic approach to the adrenal glands and retroperitoneal tumours in children: where do we stand?

Choosing the best way to approach adrenal gland and retroperitoneal tumours is still difficult. We reviewed our first 10 cases operated on by retroperitoneoscopy and compared this approach with other possible ways described in the literature. There were 2 intraoperative complications: 1 opening of the diaphragm and 1 bleeding. Tumour resection was always complete. There was no conversion. There were no postoperative complications. The retroperitoneoscopic approach for adrenalectomy and retroperitoneal tumour resection is increasingly being used. In children, operation is quite fast, without much blood loss and with spectacular postoperative recovery results. Even for the right side we advocate this approach, due to the particular anatomy (small tumour size, less fat, thinner muscle layers) in this age group. Trained surgeons are, of course, mandatory.

[Intermittent ureteropelvic junction obstruction and aberrant vessel to the lower pole of the kidney in children]

Intermittent ureteropelvic junction obstruction in children is a distinct clinical syndrome, it is often associated with an anteriorly crossing aberrant vessel to the lower pole of the kidney. The presence of these vessels increases the risk of complication and requires surgical management. CT scan is already the best exam to find these vessels in adults before treatment. It seems to be also efficient in children. This case report illustrates this indication.

Post-traumatic arterial priapism in the child: a study of four cases

The authors report four cases of arterial priapism in the child, a rare condition since only 13 cases are described in the literature. High-flow priapism follows perineal or penile injury with damage to a cavernosal artery and formation of an arteriosinusoidal fistula. The onset may be immediate but more often occurs after a few days. Arterial priapism is painless, as the corpora cavernosa are less tumescent in the anterior third of the penis. The clinical appearance and circumstances of onset suggest the diagnosis. Doppler ultrasound is the complementary investigation of choice, confirming and localising the fistula. Various methods of treatment have been proposed. Injections of alphastimulant seem ineffective in most cases and are not without danger. Surgery, which is potentially damaging, has been used only in the adult. Most authors propose embolising with resorbable material the artery which feeds the fistula. However, priapism may resolve spontaneously in less than three weeks, as occurred in our cases, without recurrence or subsequent erectile dysfunction. We thus consider the condition may initially be managed by observation alone, with recourse to embolisation if priapism does not resolve after a period of time which however remains to be defined.

[Management of ureteroceles with pyelo-ureteral duplication in children. Report of 64 cases]

Sixty four cases of ureteroceles in a context of pyeloureteric duplication were reviewed. They were detected antenatally in 69% of cases. Upper pole nephroureterectomy was performed as first-line procedure in 32 cases. In 37.5% of cases, this procedure was followed by lower tract reconstruction, essentially because of symptomatic reflux in the inferior renal pelvis. Complete renal and vesical reconstruction was performed as the first-line procedure in 6 cases. An ureteropelvic anastomosis allowed preservation of the superior renal pelvis in 4 cases, including one case with secondary lower tract reconstruction. Intravesical reimplantation of the two ureters was performed in 8 cases. Primary endoscopic opening of the ureterocele was performed in 10 cases and complementary surgery was required in 7 cases. Other procedures were used more rarely: temporary ureterostomy, nephrostomy, resection of the protruding dome of a cecoureterocele. Current management is usually neonatal. The first step consists of prevention of infection. The therapeutic approach depends on the quality of the superior renal pelvis assessed by DMSA renal scintigraphy. Immediate complete reconstruction of the kidney and bladder is now rarely indicated. When the superior renal pelvis is not functional, resection should be considered with aspiration of the ureterocele. A complementary bladder procedure is required in some cases (40% in our series) to treat symptomatic reflux in the inferior renal pelvis. When the superior renal pelvis is functional, ureteropelvic anastomosis is a good solution, especially when the superior ureter is very large and poorly functional, but endoscopic opening of the ureterocele can also be proposed, which may need to be followed be intravesical reconstruction.

Contribution to the study of the venous vasculature of the penis

The penile veins are thought to be responsible for some erectile disorders. The aim of this study was to describe the anatomy and function of these veins. The venous systems of 25 cadaveric penises were studied by various anatomic and histologic techniques. The superficial veins arising from the tegumentary layers drain into the superficial dorsal vein which in three-quarters of cases empties into the left great saphenous vein. The veins of the deep internal system, running below the deep fascia of the penis, emerge from the erectile bodies and can be divided into two systems, one anterosuperior and the other posteroinferior. The anterosuperior system comprises the veins of the glans which will form the deep dorsal vein; the latter receives blood from the medial portion of the corpus spongiosum and from the free portion of the corpora cavernosum mainly via the circumflex veins. It ends in the pre-prostatic plexus. The posteroinferior system, issuing from the posterior portion of the erectile bodies, is composed of the bulbar, cavernous and crural veins which drain towards the pre-prostatic plexus and the internal pudendal veins. Anastomoses link the two networks, superficial and deep. Study of the structure of the veins of the deep system reveals the presence of muscular cushions, which we have shown to have adrenergic innervation. These findings are compared with those of the literature, which show variations which are mainly of number. The place of veins in the mechanism of erection is discussed.

[Retro-iliac ureter. Report of a case lumbosacral agenesis]

The authors report a case of retro-iliac ureter associated with a lumbo-sacral agenesis. Retro-iliac ureter seems in relation with abnormal constitution of aortic division and/or ilio-cava confluence when the metanephros migrates. Lumbosacral agenesis is the most severe state of sacral agenesis and is a part of the syndrome of caudal regression. The association of the two malformations have never been described and could be fortuitous. Nevertheless, the vertebral malformation could induce a perturbation in the formation of vascular structures and so an abnormal migration of the metanephros.

Abdominal cystic lymphangioma in children: benign lesions that can have a proliferative course

Twenty-one pediatric cases of abdominal cystic lymphangioma (CL) treated in the past 20 years are reviewed. To date, this is the largest reported series. CL is a rare congenital malformation that presents either with chronic abdominal distension (and is detected by palpation of a cystic mass) or acutely with bowel obstruction or signs of peritonitis. It is more common among boys and most often occurs in children under 5 years of age. Abdominal ultrasonography is the procedure of choice for establishing the diagnosis. Acute cases with intracystic hemorrhage are more difficult to diagnose. Computed tomography and celioscopy may be useful. With these techniques, a correct diagnosis should be achieved in nearly every case. Enucleation (when feasible) or segmental intestinal resection (when the cyst is intimate to the bowel) is effective treatment. In a few cases the malformation is diffuse, and extensive bowel resection is necessary, with the risk of short bowel syndrome.

[Clinical course and treatment of pleural empyema in children]

BACKGROUND

Purulent pleurisy has become rare. It is often masked by previous antibiotic treatment so that functional prognosis may be poor.

PATIENTS AND METHODS

Twenty children with purulent pleurisy of the large cavity admitted from 1987 to 1993 were included in the study: there were nine infants (age 5 to 18 months) with pleuro-pulmonary staphylococcal infection (group I) and 11 children (4-13 years) (group II). Clinical, biological, bacteriological and radiologic findings were analysed retrospectively as was the outcome.

RESULTS

Patients of group I were admitted in poor general condition. X-ray showed moderate effusion and characteristic signs of staphylococcal infection. The bacteria identified in seven patients (77%) was S aureus. Recovery was rapid with antibiotics and simple local treatment. X-rays were normal two months after hospital discharge in seven patients (77%). One infant presented cicatricial bullous emphysema which required segmental resection. Patients of group II were admitted for moderate respiratory signs after a relatively long delay (14 days) since the onset of symptoms. X-rays showed considerable effusion in all and mediastinal shift in five patients (45%). Streptococcus pneumoniae was identified in one patient only. Local treatment of empyema was difficult; the effusion, already fibrinous, required repeated use of chest tubes in eight cases and surgical decortication in three. X-rays, performed 2 months after hospital discharge, were normal in only three patients. Long-term course was nevertheless favorable since chest X-rays at 5 months were normal in all children of both groups.

CONCLUSIONS

Early recognition of purulent pleurisy is important in children aged over 3 years to ensure effective drainage before the effusion becomes fibrinous. All patients in whom the first tube was inserted after more than 10 days had a difficult follow-up requiring repeated chest drainages or surgery. Ultrasonography was a useful aid for diagnosis and local treatment. Computed tomography was useful for adapting treatment after several days of course.

Morbidity using subcutaneous ports and efficacy of vancomycin flushing in cancer

An evaluation of totally implanted venous access systems inserted in 163 consecutive children with cancer is reported. From 1988 to 1994, 180 subcutaneous ports were inserted in children more than 1 year old. Initial diagnosis was acute leukaemia (n = 79), non-Hodgkin's lymphoma (n = 33), and solid tumour (n = 51). Median age was 85 months. All venous procedures were performed through the device. Chemotherapy was either moderate (n = 13) or intensive (n = 119) or very intensive (n = 48), including 16 patients undergoing marrow transplantation. Cumulative venous access totalled 55,770 patient days with a mean of 305 days/subcutaneous port. The cause of device removal was, end of treatment (n = 111), death due to malignancy (n = 20), catheter related infection (n = 7), and occlusion of the system (n = 4). Mechanical complications occurred in 19 ports; 16 were due to clots, of which 14 were cleared with instillation of urokinase. Documented infectious episodes occurred in 47 ports, recurred once in 14, and twice in five cases. Among these infections, 47 were septicaemic; 31 due to Staphylococcus epidermidis. Twenty seven of initial septic episodes were considered to be catheter related; the rate was 15%/subcutaneous port or 0.05/100 catheter days. Risk factors for the development of a first infection were age below 4 years and the time of use. Since February 1993, vancomycin (50 micrograms/ml) has been given and this has reduced the rate of S epidermidis infection from 26/83 subcutaneous port to 4/97. Life table analysis showed that the infection free interval for staphylococcus was significantly better after this technique ws initiated (log rank rest=0.02). Time saved was approximately 30minutes/patient/week compared with external catheters, or 45 hours/month for the cohort of children treated. Subcutaneous ports in paediatric cancer patients are reliable, safe, and durable and may offer an attractive alternative to external catheters for prolonged venous access and intensive treatment.

Laparoscopic appendicectomy: case reports of vascular injury in 2 children

The authors report 2 similar cases of serious vascular injury occurring during laparoscopic appendicectomy. These cases stress the potential risk of major accidents with laparoscopic surgery. There should be great care in the choice of indications and during the procedures.

Anatomic basis for use of a gracilis muscle flap

The aim of this study was to specify certain anatomic features of the gracilis m. with a view to the use of muscular or myocutaneous flaps. It was based on dissection of 84 gracilis muscles in 42 subjects as well as selective injection of the main pedicle of 20 muscles. This established the following points: 1) The arterial supply is abundant, consisting of several pedicles reaching the muscle on its deep aspect. The main neurovascular pedicle arises from the deep vessels of the thigh, via either the a. of the adductors (73%), the medial circumflex a. (19.2%) or as a double supply from both arteries (7.7%); 2) The cutaneous vascularisation over the gracilis m., derived from the solitary main pedicle, is inconstant. In 20 injections, it was satisfactory in 11 cases, poor in 5 and absent in 4; 3) The distal tendon of the gracilis m. is closely related to the posterior branch of the saphenous n. to the leg, which it crosses in an elongated X; 4) A simple method of calculation based on the distance between the upper border of the pubis and the medial femoral epicondyle allows quite precise determination of the point of entry of the main pedicle into the gracilis m. 5) Complete dissection of the main pedicle adds to the available length of the muscle flap.