Circumcision and Risk of Febrile Urinary Tract Infection in Boys with Posterior Urethral Valves: Result of the CIRCUP Randomized Trial

BACKGROUND

Boys with posterior urethral valves (PUVs) have an increased risk of febrile urinary tract infections (fUTIs). Circumcision is believed to reduce the risk of fUTIs in boys, although there are no randomized trials demonstrating this.

OBJECTIVE

To determine the effect of circumcision on the risk of fUTIs in boys with PUVs.

DESIGN, SETTING, AND PARTICIPANTS

A clinical randomized trial that ran between August 2012 and July 2017 was conducted. The trial was multicentric, including 13 referral centers for pediatric urology. Male boys, aged 1-28 d, diagnosed with posterior urethral valves, confirmed by voiding cystogram, were included. The exclusion criteria included presence of a genital malformation contraindicating performing a circumcision.

INTERVENTION

Participants were randomized to neonatal circumcision + antibiotic prophylaxis (CATB) or antibiotic prophylaxis alone (ATB), and followed for 2 yr.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was a risk of presenting fUTIs in each group. An fUTI was defined as fever (>38.5 °C) with evidence of pyuria and culture-proven infection on urinalysis, obtained by urethral catheterization or suprapubic aspiration. A bivariate analysis of the primary outcome was performed using the Kaplan-Meier method.

RESULTS AND LIMITATIONS

In total, 91 patients were included: 49 in group CATB and 42 in group ATB. The probability of presenting an fUTI was 20% in group ATB versus 3% in group CATB. The hazard ratio of presenting an fUTI within 2 yr in the ATB group compared with that in the CATB group was 10.3 (95% confidence interval: 1.3-82.5). Sixty-four children (70.3%) had a complete follow-up at 2 yr of age.

CONCLUSIONS

Circumcision significantly decreases the risk of presenting an fUTI in boys with PUVs.

PATIENT SUMMARY

In this report, we compared, in a multicentric trial, the number of febrile urinary tract infections (UTIs) in boys with posterior urethral valves who had either antibiotic prophylaxis alone or antibiotic prophylaxis and circumcision. We found that those who had a circumcision had a significantly lower risk of febrile UTIs.

Endoscopic injection of bulking agent around the ejaculatory ducts at the verumontanum for recurrent paediatric epididymitis

INTRODUCTION

Paediatric recurrent epididymitis is frequently observed in several urogenital conditions, and may result in deterioration of long-term fertility. The management of recurrent epididymitis is still a therapeutic challenge for paediatric urologists, and as yet there is no consensus for treatment.

OBJECTIVE

To present a minimally invasive endoscopic approach for the treatment of recurrent epididymitis (more than three episodes).

PATIENTS AND METHODS

Eleven boys were referred with a history of recurrent epididymitis in a context of urogenital malformations. All children underwent endoscopic transurethral injection. Dextranomer/hyaluronic acid was injected around the ejaculatory ducts at the verumontanum (Summary Fig.). The medical records and outcomes of the patients were retrospectively reviewed.

RESULTS

Of the 11 boys, two (18%) had a history of bladder exstrophy, three (27%) anorectal malformation, two (18%) peno-scrotal hypospadias, two (18%) posterior urethral valves, one (9%) seminal vesicle cyst, and one (9%) urethral stricture. The median age at injection was 3.75 years (range 8 months-14.7 years). Endoscopic injection effectively prevented recurrence in eight patients (73%) with a mean follow-up of 3 years (range 6 months-8.8 years). The mean injected volume was 0.7 ml/session. No perioperative complications were recorded. Vas clipping was performed in three patients after unsuccessful injections.

DISCUSSION

The current discussion for management of recurrent epididymitis is mainly based on vas clipping. Endoscopic injection in the verumontanum could offer several potential advantages over vas clipping; moreover, it is easy to perform for an urologist who usually uses endourological approaches. It is believed that only Kajbafzadeh et al. have reported their experience with endoscopic injection in the verumontanum in seven patients with structural anomalies, and they had a 42% success rate. Similarly, the current study did not observe perioperative or postoperative complications.

CONCLUSION

In this series, endoscopic injection of the verumontanum was considered to be a safe and effective treatment in almost 73% of children with recurrent epididymitis. It did not result in perioperative complications and not contraindicate a subsequent surgical procedure such as vas clipping.

Postural therapy for renal stones in children: A Rolling Stones procedure

INTRODUCTION

Despite many advances, the management of renal stones - especially lower caliceal stones (LCS) - remains a challenge. The gravity-dependent location of the lower calices hinders the spontaneous clearance of fragments, which can be a nidus for future growth and symptomatic recurrence. Currently, there is no standard adjunctive therapy to facilitate fragment passage.

OBJECTIVES

To report the safety and effectiveness of mechanical percussion diuresis and inversion (PDI) therapy for eliminating renal stones in children.

PATIENTS AND METHODS

Since November 2013, children with residual fragments (after shock wave lithotripsy or flexible ureteroscopy) or native symptomatic renal stones were prospectively included in a protocol of four PDI sessions. After giving written consent, the children drank 10 ml/kg of water 30 min before therapy. They then laid in a prone Trendelenburg position on a couch angled at 45° and received continuous 10-min mechanical percussion applied over the affected flank by a physiotherapist (Figure summary). Tolerance stone burden reduction and stone clearance were documented with ultrasound 4 weeks after the last session.

RESULTS

Seventeen participants, with a median age of 10.8 years (range 18 months to 18 years), received 82 PDI sessions performed over 22 months. The median stone diameter was 5 mm (range 3-9). All children tolerated the PDI therapy well. Over a median follow-up of 11 months (range 3-18), no significant adverse effects were noted. The overall stone-free rate was 65%. Four of the six patients with residual fragment passed their fragments. The patients who did not become stone free by PDI experienced a decrease in fragment size of 57% (range 34-71). The observance rate was 100%.

DISCUSSION

Many studies have demonstrated that the gravity-dependent position of the lower calyces appears to be an important factor limiting the clearance of LCS. Positioning patients with a degree of inversion in order to put the collecting system beyond the horizontal plane affected the LCS through gravitational force. Complications were rare. PDI appeared to save costs and have similar success rates as shock wave lithotripsy for native small renal stones in children.

CONCLUSION

PDI is safe and effective for facilitating gravity-dependent drainage of renal stones and provides an opportunity to treat children in a quick, non-invasive, economic, painless, non-radiative and diverting fashion. This therapy is a valuable alternative in the pattern of stone management. In case of persistent fragments, it is recommend that the number of sessions be increased to six.

[Medium-term outcome, follow-up, and quality of life in children treated for type III esophageal atresia]

The aim of this study was to evaluate the medium-term outcome (health status, medical and surgical French National Health Authority-recommended follow-up, and quality of life) of children born with type III esophageal atresia (EA). Previous events (during the perinatal period, associated abnormalities, respiratory and digestive complications) of children treated for type III EA at the Marseille university hospitals between 1999 and 2009 were noted. Parents completed a standardized questionnaire concerning the health of their children during the previous year, and a quality-of-life questionnaire (PedsQL 4.0) was also completed by children aged more than 8 years. Among the 68 children treated, 44 responded to our solicitation (mean age, 7.6 years; range, 3-12.8 years). Previous important events were : pneumonia(s) (65%), asthma before the age of 3 years (66%), hospitalization for a respiratory event (45%), fundoplication (20%), and esophageal dilatation (45%). We noted current chronic cough (16%), asthma (30%), dysphagia (39%), and symptomatic gastroesophageal reflux (9%). National guidelines were not respected, except for the surgical indications in children aged less than 6 years. The quality-of-life scores (n=43 children) were similar to healthy controls but were negatively influenced by a gastrostomy procedure (P=0.020), pneumonia (P=0.013), and hospitalization due to a respiratory event (P=0.006) or a digestive event (P=0.010), and also by current asthma (P=0.004). In conclusion, despite recurrent respiratory or digestive symptoms and inadequate recommended follow-up, the quality of life of children treated for type III of EA is good.

[Paratesticular rhabdomyosarcoma in children: a scrotal emergency]

Paratesticular rhabdomyosarcoma is a rare and highly aggressive embryonal tumor in infancy and childhood. The tumor is intrascrotal, localized in the spermatic cord, the epididymis, or in the tunica vaginalis. Rhabdomyosarcoma represents 10% of testicular tumors of infancy. On physical examination, a painless scrotal tumefaction is observed. A surgical and pathological classification is used to group patients according to the extent of residual tumor after the initial surgical procedure: Intergroup Rhabdomyosarcoma Study classification (IRS). Multimodality therapy involving surgery, chemotherapy, and radiotherapy is necessary. Depending on the extent of disease and the staging group, the approach of treatment is different. The most important factors affecting treatment outcome are the stage, the pathological subtype of the tumor, and the age of the patient. Younger patients (<10 years) with a local tumor and with embryonal pathology have an excellent prognosis. We report the case of a 6-year-old boy admitted for a specialist consultation because of the recent appearance of a tumor in the right scrotum. On physical examination, a painless, solid, right scrotal mass was noted and the diagnosis of paratesticular rhabdomyosarcoma was made. This diagnosis can be suspected on physical and on ultrasound examinations, but only a pathological examination will confirm it. The authors discuss the therapeutic issues raised by this lesion and report one case of paratesticular rhabdomyosarcoma.

[Outcome of severe closed kidney injuries in children]

AIMS

To analyze the results of treatment of major renal injuries according imaging data in order to determine their function after follow-up.

PATIENTS AND METHODS

This is a retrospective study of 22 cases of fracture of the kidney (grade V) in two pediatric surgical services that were reviewed over a period of 16 years. After initial conservative treatment in 19 patients (86.5%), a scan and/or Uro-MRI were realized in all patients in monitoring evolving. Three children with vascular injury were treated by interventional radiology. The morphology and functional evolution of the injured kidney were determined.

RESULTS

A DMSA scan investigation was performed in 21 patients (95.5%) associated with Uro-MRI in two cases; one patient was only explored with Uro-MRI. A complete restitution of the renal parenchyma was confirmed in 10 children (45.5%), we noted an atrophy of the upper pole in 30%, a lower pole atrophy in 4.5%, two complete renal atrophy in 9%. An urinoma was present in six patients (27%) that required drainage in five cases and declined during the surveillance in one case. Normal function of the injured kidney was noticed in half of grade V (11 of 22 patients) with a mean follow-up of 19 months. None of our patients did present hypertension.

CONCLUSION

Non-operative conservative treatment in severe renal trauma was efficient, morphological and functional sequelae were present in 50% on scintigraphy and/or Uro-MRI.

[Diffuse xanthogranulomatous pyelonephritis in infant]

We report a case of a renal mass in a 4-month boy, which occured during the assessment of a pelvi-calyceal dilatation diagnosed at 23 weeks of gestational age. There was no history of urinary infection, fever or weight loss. Physical examination revealed a mass of the left flank with significant flank tenderness. Laboratory test showed a biological inflammatory syndrome and urine culture was negative. Investigations including ultrasound and computed tomography scan were suggestive of diffuse xanthogranulomatous pyelonephritis with a non-functioning left kidney. Left total nephrectomy was performed through a lumbar incision with an extraperitoneal approach. The kidney was enlarged with a dilated pelvis containing pus upstream of a proximal ureteral atretic segment. Pathological examination of the kidney confirmed the diagnosis of diffuse xanthogranulomatous pyelonephritis. The boy remains well at 1 year follow-up. Xanthogranulomatous pyelonephritis is very rare in infants. It is an uncommon severe progressive renal infection resulting in destruction of renal parenchyma, histologically replaced by xanthomatous cells and granulomatous reaction. Pathogenesis of xanthogranulomatous pyelonephritis remains unclear. But it is well known that urinary tract obstruction and renal lithiasis are determining factors. It can occur in variant clinical forms but its symptoms remain non-specific. Curative treatment consists in nephrectomy and definitive diagnosis is made on histological examination of the kidney. This diagnosis should be discussed when a renal mass occurs in a context of malformative uropathy and xanthogranulomatous pyelonephritis have to be included in the differential diagnosis of renal mass in infants and children.

Tonic inhibition of human small intestinal motility by nitric oxide in children but not in adults

BACKGROUND

Gastrointestinal motility is dependent on neural influences that largely involve the enteric nervous system (ENS). The main motor patterns that occur in the fasted and fed state are noticeably different in children compared with adults. Although the development of the ENS continues after birth, there is no data on the contractile activity of segments of small intestine from young children. This study was designed to provide data on the development of muscle control by the human ENS with particular attention to acetylcholine (ACh) and nitric oxide (NO) as the primary neurotransmitters of enteric motor neurons, respectively.

METHODS

Small intestinal specimens were obtained from 11 children and six adults undergoing surgery for various diseases. The mechanical activity of the circular muscle was recorded in vitro. The effects of N(ω)-nitro-L-arginine methyl ester hydrochloride, an inhibitor of NO synthesis, and of atropine, an antagonist of muscarinic receptors, were tested on the spontaneous motility and responses to nerve stimulation.

KEY RESULTS

Spontaneous motility was observed in all preparations. Responses to nerve stimulation were identical in child and adult. No tonic cholinergic excitation of small intestinal motility was observed either in child or in adult. Inhibition of NO synthesis induced a major disinhibition of motility in child but not in adult.

CONCLUSIONS & INFERENCES

Spontaneous intestinal motility and cholinergic and nitrergic neurotransmission are present from birth. NO provides a tonic inhibition of intestinal motility only in child. Our study indicates that NO may be a major player in shaping the ontogenic development of intestinal motility in human.

Traumatisme du testicule chez l’enfant

Introduction

Les traumatismes du testicule sont rares chez l’enfant, et la littérature est très pauvre sur ce sujet. Le but était de les analyser à partir d’une étude multicentrique rétrospective.

Matériel et méthodes

Un questionnaire sur les traumatismes du testicule survenus entre 2000 et 2009 a été envoyé dans les différents centres de chirurgie pédiatrique français. L’analyse a été effectuée à l’aide du questionnaire et du compte rendu opératoire, et n’ont été retenus que les dossiers de traumatisme vrai du testicule, excluant les plaies simples du scrotum, les traumatismes « révélateurs » d’une torsion de testicule ou d’hydatide, ou encore les dossiers incomplets.

Résultats

Quinze centres ont bien voulu nous transmettre leurs observations et parmi ceux-ci, deux ont répondu n’avoir opéré aucun cas; cette étude n’est pas exhaustive, car beaucoup d’équipes ont envoyé des dossiers d’enfants opérés et aucun cas de traumatisme bénin. Parmi les 60 observations reçues, 45 ont été retenues. L’âge moyen était de 12,3 ans (2 jours–18 ans). Les circonstances du traumatisme étaient 23 coups (pied, genou, poing), 13 chutes (vélo, banc, luge), quatre accidents de la voie publique, quatre traumatismes de nature inconnue et un traumatisme obstétrical. Le traumatisme était fermé 41 fois et ouvert quatre fois. L’échographie-doppler couleur a été réalisée dans 34 cas sur 45 (75,5 %); un diagnostic exact a été possible 30 fois, alors qu’il y a eu trois faux-positifs (deux fractures du testicule et un hématome intratesticulaire non confirmés à l’intervention) et un faux-négatif (contusion de l’épididyme non vue à l’échographie). Les lésions testiculaires étaient les suivantes: 15 fractures, huit hématomes intratesticulaires, six contusions testiculaires bénignes (dont une associée à une tumeur), six hématomes du cordon, six contusions de l’épididyme, trois hématocèles isolées et une avulsion. Le traitement a été chirurgical 33 fois et non opératoire 12 fois. Parmi les 15 fractures du testicule, 13 ont été opérées (huit sutures et cinq orchidectomies partielles) et deux ont été surveillées avec de bons résultats, sans atrophie secondaire. Pour les hématomes intratesticulaires, trois ont été surveillés et cinq opérés. Seuls 20 enfants ont été suivis au-delà de quatre mois, essentiellement les fractures testiculaires, et aucune atrophie secondaire n’a été constatée.

Conclusion

Les traumatismes du testicule chez l’enfant sont rares, mais leur pronostic est plutôt bon. L’échographie-doppler permet désormais de faire un diagnostic précis dans un grand nombre de cas, devant permettre d’éviter certaines explorations chirurgicales systématiques; mais l’intervention reste indispensable en cas de doute.

[Urinothorax: rare complication of neonatal sectioned posterior urethral valve]

We report a newborn aged 19 days, carrying a posterior urethral valve antenatal screening in which developed 7 days after the entire section of the valve, a compressive urinothorax in connection with a perirenal urinoma. Pleural and bladder drainage has a surrender of effusions and a healing of the renal parenchyma. The thoracic urine effusion is a very rare complication of a posterior urethral valve with perirenal urinoma. This probably results from a rupture of a fornix dysplastic by hypertension of the urinary tract. The authors emphasize the unusual discovery of this disease by breathing problems and his delayed character after resection of the obstruction in the neonatal period.

[Abdominoscrotal hydrocele with leg edema in a 4-month-old boy]

We present a case of a 4-month-old boy with a right abdominoscrotal hydrocele associated to a compression of the femoral triangle, causing an unilateral leg edema. Abdominoscrotal ultrasound revealed a fluid collection with abdominal and scrotal components, communicating through the deep inguinal ring. Sagittal views of magnetic resonance imaging (MRI) showed a dumbbell-shaped hydrocele and the angio-MRI venous sequences confirmed the compression of the right iliac vessels. Curative treatment was surgical through an inguinal approach and consisted in high ligation of the processus vaginalis and hydrocelectomy. Abdominoscrotal hydrocele is an uncommon pathology, which rarely occurs in pediatric population. This diagnosis should be discussed when a cystic abdominal mass is associated to an ipsilateral scrotal hydrocele. The abdominal component of the hydrocele can result in compression of adjacent structures (iliac vessels, ureter). Surgical treatment is recommended. Epididymal and testicular abnormalities are frequently described, as in our observation, and the effects on the future fertility are unknown.

[Non-operative management of a hepatic pseudoaneurysm and a biloma complicating a blunt abdominal trauma]

Hepatic artery pseudoaneurysm and bilioma are rare complications of blunt abdominal trauma in children. We report a case in an 11-year-old patient after a hepatic and splenic blunt trauma following a car accident. The initial evolution was simple with haemodynamic stability. On Day 12, a pseudoaneurysm was discovered on an abdominal magnetic resonance imaging whereas the patient presented a major pain syndrome and an icteric cholestase. Embolisation was realised a few hours later in emergency because of a haemorrhagic shock. On Day 26, an endoscopic retrograde cholangiopancreatography highlighted two bilary leaks: one extrahepatic, the other intrahepatic. The first one was treated with a stent and the second one needed three drains: two peritoneal and one in the biloma. The characteristic of this case relies on the association of two complications. It underlines the need of multidiscipline and non-operative management of pediatric blunt hepatic trauma.

Fetal magnetic resonance hydrography: evaluation of a single-shot thick-slab RARE (rapid acquisition with relaxation enhancement) sequence in fetal thoracoabdominal pathology

OBJECTIVES

To evaluate the potential of a single-shot thick-slab RARE (rapid acquisition with relaxation enhancement) sequence in fetal thoracoabdominal magnetic resonance (MR) examinations compared with multislice T2-weighted sequence and postnatal imaging.

METHODS

RARE sequence is rapid and provides very heavily T2-weighted images. Twenty-seven fetal thoracoabdominal MR imaging examinations were performed at 23-38 weeks using our conventional protocol. This included thin multislice T2-weighted half-Fourier acquired single-shot turbo spin-echo (HASTE) sequence and thin-slice GE (gradient echo) T1-weighted images with a 1.5-T MR unit. A single-shot thick-slab (60 mm) RARE sequence was added to all MR examinations. The acquisitions were obtained with the mother breath-holding. The thick-slab heavily T2-weighted images were compared with HASTE sequence images and with postnatal imaging in all cases.

RESULTS

The thick-slab RARE sequence did not show additional abnormalities compared with the conventional protocol but displayed an overall view of the urinary tract, tracheobronchial tract and small bowel. It gave information that was highly correlated with postnatal imaging, such as abdominal plain films, chest film or cystography. The quality of the thick-slab RARE images was considered as good in 13 cases (48%), moderate in 12 cases (45%) and poor in two cases (7%).

CONCLUSION

Although thick-slab RARE sequence does not show additional abnormalities compared with the conventional protocol, it illustrates very nicely static fluids such as those in urinary dilatation, the esophagus and small bowel (normal or dilated) and thoracic cystic masses. It is very rapid (5 s) to perform, allows fetal hydrography, and correlates well with postnatal imaging.

Duodenal duplications. Clinical characteristics, embryological hypotheses, histological findings, treatment

BACKGROUND

The aim of this study was to analyse different clinical aspects and embryologic hypotheses of duodenal duplications.

METHODS

Duodenal duplications occurring since 1995 were recorded. The age of the children at the time of diagnosis, the sex, location of the duplication, type of mucosa, clinical signs, associated lesions, and the type of surgical intervention were defined.

RESULTS

We identified 5 patients (3 girls and 2 boys) who presented with histological or intraoperative findings of duodenal duplication. Their ages ranged from 4 days to 9 years, with the exception of two prenatal diagnoses. Three children were symptomatic: high intestinal obstruction (1 case), digestive bleeding (2 cases). In 1 case we found a palpable abdominal mass and 1 case was completely asymptomatic (prenatal detection). The abnormality was located on the duodenal concavity, originating from the third part in 2 cases and from the second part in 3 cases. All cases were non communicating types, 4 of which were cystic duplications and 1 was a tube-like variety. The epithelial lining was duodenal mucosa in all patients, but gastric heterotopies were identified in 2 cases. We performed two complete resections and 3 intraduodenal derivations. The outcome was uneventful in 5 cases with an average follow-up of 2 years.

CONCLUSION

Duodenal duplications are rare malformations with several anatomical varieties. The preferred treatment for duodenal duplications is complete removal when the location allows it without endangering nearby anatomical structures.

[Prenatal MRI diagnosis of esophageal atresia]

The diagnosis of esophageal atresia may be suspected on prenatal ultrasonography in fetuses with absent or small stomach, upper esophageal dilatation and unexplained polyhydramnios. However, the diagnostic value of these findings is relatively poor. Two cases are reported where MRI appeared to be accurate for establishing the diagnosis of this congenital anomaly.

[Tracheal agenesis: CT diagnosis]

Tracheal agenesis is an exceptional congenital malformation of the airway with fatal consequences. A case of a newborn infant presenting with respiratory distress is reported. Laryngoscopy and helical CT of the airway confirmed the diagnosis of tracheal agenesis with tracheo-esophageal fistula and laryngeal agenesis.

Voiding cystourethrography in boys. Does the presence of the catheter during voiding alter the evaluation of the urethra?

PURPOSE

We determined whether the presence of the catheter during the voiding phase of voiding cystourethrography alters the evaluation of the urethra concerning the normal structures as well as pathological findings, especially posterior urethral valves.

MATERIALS AND METHODS

A total of 123 males 3 days to 16 years old (median age 2.6 months) underwent voiding cystourethrography. Urethral catheterization was performed in all cases. Four views were taken during the voiding phase with and without the catheter in place. Only 80 patients had available results. These examinations were studied with special attention to the normal structures and pathological findings.

RESULTS

A total of 36 examinations (45%) were normal. Pathological findings were observed in 44 patients (55%), with abnormal vesical findings and/or vesicoureteral reflux in 33 (41.25%). In 11 patients (13.75%) 12 urethral abnormalities were found (posterior urethral valves 3, hypospadias 4, prostatic utricle 1, verumontanum polyp 1, prune belly syndrome with urethral dilatation 1, imperforate anus with urethral fistula 1 and urethral duplication 1). In all cases excluding those involving hypospadias there was no difference between the views with and without the catheter. However, concerning the normal structures, the verumontanum and fossa navicularis were better delineated without the catheter in 27% and 33% of cases, respectively.

CONCLUSIONS

Our study shows that a urethral catheter does not alter the diagnosis of abnormalities of the posterior urethra but may hamper the observation of normal structures or abnormalities of the anterior urethra.

Congenital anterior urethrocutaneous fistula associated with urethral duplication

Congenital anterior penile urethral fistula is a rare anomaly; only seven cases have been reported to date. This report outlines the clinical presentation and the embryologic mechanism of a case associated with urethral duplication.

[Treatment of anterior hypospadias: comparison of modified Mathieu and Duplay techniques (report of 840 children)]

PURPOSE

The objective of this study is the comparison of 2 surgical procedures in the treatment of primary anterior hypospadias including the evaluation of short-term and long-term results.

PATIENTS AND METHODS

A retrospective study of the results of the modified Mathieu procedure performed in 392 patients presenting with previously untreated anterior hypospadias at one center by the same experienced surgeon is compared with the results of the modified Duplay procedure performed in 457 patients in a second center by a second experienced surgeon, both series spanning a period of 10 years.

RESULTS

Follow-up ranged from 21 months to 10 years. Overall, 7 of 392 patients (1.7%) treated by the Mathieu procedure had complications requiring surgery compared to 32 of 457 patients (7%) treated by the Duplay procedure, a difference that is statistically significant (P < 0.05). Patient satisfaction was excellent in both groups and cosmetic results were considered satisfactory by the parents in all 843 patients.

CONCLUSION

Both the modified Duplay and the Mathieu techniques are reliable procedures with reproducible results, a minimal risk of fistula formation as well as excellent cosmetic and functional results.

[Tumorlike form of bladder schistosomiasis in children]

Two tumorlike forms of urinary schistosomiasis are reported. Diagnosis was suspected as the patients exerted haematuria while they originated from a geographic area where schistosomiasis is endemic. Terminal urine samples were positive for Schistosoma haematobium. Cystoscopy revealed an hemorrhagic granulomatous polyp in one case and villous polyps in the other case, associated with suggestive lesions of schistosomiasis. Schistosoma haematobium infection in children is uncommon in Europe and rarely considered in the diagnosis of haematuria.

The cholecystocolic bypass with jejunal interposition graft for bile acid depletion in bile and portal blood in guinea pigs

Ileal bypass and cholecystostomy are used in children with selected cholestatic diseases to lower the bile acid (BA) levels in bile and blood and improve outcome. The efficacy of a cholecystocolic bypass in achieving the same goals was investigated in guinea pigs. In the study group (n=7), a cholecystocolic bypass was performed using a jejunal graft interposed between the gallbladder and the cecum. In the control group (n=5), a cholecystojejunal bypass was performed with a similar graft implanted in the proximal jejunum. Total BA concentration was measured in bile and portal blood at surgery (D0) and 30 days later (D30) by pooling the concentrations of 7 individual BA. D30/D0 BA ratios were compared. All animals developed normally without clinical symptoms. A 76% reduction in the bile T-BA levels was observed in both groups (p<0.05). A 80% decrease of T-BA levels was observed in portal vein in study group (p<0.05), suggesting that ileal bile flow and BA ileal reabsorption were highly impaired. No change in portal vein BA levels was observed in control group. Cholecystocolic bypass led to a significant loss of bile acids in guinea pigs and might be considered for bile diversion in pediatric patients with selected cholestatic diseases.

[Appendix-ureteroplasty in a child: report of a case]

The use of vermiform appendix as a tube to replace right ureteral segment has been reported, rarely in child. Herein is reported a case of right ischemic ureteral stenosis following a reimplantation of the ureter for high grade reflux secondary to posterior urethral valves with only one functioning kidney. A long ureteral defect was bridged successfully by appendix interposition and then reimplanted in the bladder at four years of age. The interest of ureteroappendiculoplasty provides temporary solution to repair long ureteral defect, in spite of uncertain future, especially in childhood.

[Prenatal screening of kidney pelvis ectasia, frequently caused by vesico-ureteral reflux detected after birth. Analysis of a series of 159 cases in 4 years at a maternal-child unit]

To describe the pre- and post-natal management of vesico-ureteric reflux in a prospective study of babies presenting with vesico-ureteric reflux suspected from pre-natal ultrasonography in a tertiary paediatric center.

PATIENTS AND METHODS

Between 1997 and 2001, 35 children (25 boys and 10 girls) with were vesico-ureteric reflux followed for 12 to 36 months after the pre-natal detection of urinary tract anomalies. Ultrasound examination was realized at the 5th of life, retrograde cystography at the 15th if the renal pelvic dilatation measured at least 10 mm of diameter. In 11 the reflux was bilateral and 46 refluxing units were reviewed.

RESULTS

According to the international classification of, 7% vesico-ureteric reflux were grade I, 20.5% were grade II, 32% were grade III, 18% were grade IV, 22.5% were grade V. Fourteen patients (17 refluxing units) underwent ureteric-reimplantation. Four total and two partial nephrectomics were carried out in patients < 2 years old; in 8 patients the VUR resolved spontaneously. Of the latter, 7 patients (ten refluxing grade III-IV units) are still being followed and awaiting a decision on treatment.

CONCLUSION

This study confirms the predominance of boys in those with antenatally suspected vesico-ureteric reflux. The spontaneous resolution or improvement during the first 3 years of life was apparent in most cases, even in those with severe reflux (grade III-V).

[Bilateral vas deferens agenesis and inguinal hernia in a child. A rare, early presentation of cystic fibrosis]

Epididymal and ductal anomalies can be discovered incidentally during inguinal herniorraphy in children. The congenital bilateral absence of vas deferens is frequently associated with cystic fibrosis.

CASE REPORT

This agenesia of vas deferens was detected in a 5-month-old boy who underwent an inguinal herniorraphy. Although the child did not present any symptoms, he actually presented cystic fibrosis: the sudoral test showed high levels of chloride (95 mmol/L) and an isolated homozygous delta F 508 deletion on the gene CFTR was evidenced on genetic investigations.

CONCLUSION

The congenital bilateral absence of vas deferens is the most frequent anomaly of the male genital tract discovered in adults investigated for azoospermia. Relations with cystic fibrosis are well established but congenital bilateral absence of vas deferens discovered during infancy is an exceptional situation that requires genetic investigations to show evidence of a likely underlying cystic fibrosis.

[Pre- and postnatal diagnosis of omphalo-xiphopagus conjoined twins]

We report a case with successful surgical separation of female omphalo-xiphopagus conjoined twins. Ultrasonographic examination at 20 weeks of gestation showed twins joined at the abdomen from the xiphoid process to the umbilicus. Conjoined structures included liver. Karyotype was normal. The parents refused interruption of the pregnancy. Plain films, US and MRI confirmed findings at prenatal ultrasound examination. There was no cross circulation into the livers and the gastrointestinal tract was not conjoined. In our observation, postnatal MRI did not offer additional information.

[Expression of sexual dimorphism in the fetal pelvic girdle]

The objective of this study was to analyse the development of the foetal pelvis in order to define normal anatomic reference values as a function of gender and gestational age. The study population included 500 stillborn foetuses between the gestational ages of 18 and 41 weeks. Those foetuses without known demographic histories were strictly excluded. For each case studied, an AP radiograph was performed with the following parameters measured by two independent observers: pelvic width, inter-iliac width, inter-sciatic nodes, inter-pubic width and bi-ischial width. The correlation between these radiographic measurements and the gestational age as well as the gender was analysed. The result indicated that the inter-ischiatic distance is significantly greater in the female foetus after the 26-27th week of gestation (P < 0.0062). Standard growth for the female and the male foetal pelvis is proposed with potential application in the study of normal and pathological development of the foetus.

Treatment of a case of congenital pseudarthrosis of the tibia-fibular osteosynthesis

We report the results of a case of congenital pseudarthrosis of the tibia treated by tibiofibular synthesis. A 1-year old girl was first treated by intramedullary fixation followed by an intertibiofibular bone graft. This method failed. She then underwent a new operation that was associated two simultaneous approaches, correction of the axis, tibiofibular synthesis and a new intertibiofibular bone graft. Union was achieved four months later. The child has now been followed up for 20 years. During this time, she has led a normal life as we have observed a "tibialisation" of the fibula. Intramedullary fixation has a success rate of 75% but requires repetitive insertion of intramedullary or telescopic rods. Transplantar intramedullary rods are responsible for significant ankle stiffness. Tibiofibular synthesis associated with an intertibiofibular bone graft after correction of the axis is the equivalent of vascularised graft of the fibula but with neither the difficulties of microsurgery nor valgus deformities of the ankle.

[Trauma of the renal pedicle in children. Report of 2 cases of late revascularization with endovascular prosthesis]

OBJECTIVE

The diagnosis of renal pedicle rupture in children is difficult and often delayed. Ultrasound alone is insufficient in the assessment of all cases of renal contusion. This often leads to nephrectomy, due to the uncertain results of a late surgical revascularization procedure. A minimally invasive endovascular approach is therefore sometimes useful.

CASE REPORTS

1st case: a 6-year-old boy was admitted to the emergency department with contusion of the right flank caused by a road accident. The immediate test for haematuria was negative. Twenty-four hours after trauma, renal duplex ultrasound was performed due to the appearance of microscopic haematuria and it demonstrated trunkal thrombosis of the right renal artery, while the initial ultrasound was normal. 2nd case: a 15-year-old girl who jumped out of a window. 48 hours after the trauma, IVU was performed because of persistent microscopic haematuria and revealed a silent kidney, while the initial ultrasound was normal. Renal arteriography showed complete dissection of the right renal artery in both cases. Stenting was performed. The postoperative course was uneventful. In the first case, follow-up duplex ultrasound revealed a modification of the echostructure of the superior pole (absence of blood supply) while the lower pole had a normal interlobular blood supply. CT scan at the 2nd month confirmed normal excretion from the lower pole. In the first case, revascularization was satisfactory on the follow-up duplex ultrasound. After 20 months of follow-up, the kidney presented a normal functional and morphological appearance.

CONCLUSION

The diagnosis of renal pedicle lesions remains difficult and is based on emergency CT angiography. Treatment by vascular stenting can be performed in children. In some cases of renal artery dissection, it can constitute an alternative to surgery. However, it raises the question of the medium- and long-term repercussions of renal artery stenosis on the child's growth.

[CT imaging of pelvic injuries in polytrauma patients]

CT has become a major tool in the management of multiple trauma. Concerning pelvic trauma, visceral and bone injuries can be detected. We review here the different pelvic injuries focusing on CT diagnostic approach.

[Exceptions to the rule concerning conservative treatment of polycystic renal dysplasia in children]

The authors report three cases of antenatally diagnosed polycystic renal dysplasia (PRD) associated with homolateral anomalies of the ureter and vas deferens requiring surgical exploration. The antenatal and postnatal diagnosis of polycystic renal dysplasia is based on ultrasound. It is recommended to look for associated vesicoureteric reflux by retrograde cystography. Conservative management is advised due to the natural involution of PRD. The authors emphasize the need for a more detailed ultrasound analysis of the lower genitourinary tract during the antenatal and postnatal period in order to identify an abnormal ureteric orifice, constituting the cause of the dysplasia. As dysplasia is predominant and the only anomaly detected on the antenatal examination, the associated lower tract anomalies will probably only be identified at birth. A better understanding and neonatal detection of associated lower urinary tract malformations probably justify a review of the current, systematic conservative approach, in a certain number of cases.

[Abdominal cystic lymphangiomas in children. Clinical, diagnostic and therapeutic aspects: apropos of 21 cases]

Twenty-one abdominal cystic lymphangiomas were observed in paediatric patients during a 15-year period, in 11 boys and 10 girls. Diagnosis was prenatal in 2 cases; the mean age of the other 19 children was 4.7 years (range: 3 months-8 years). Tumours were intraperitoneal in 16 cases and retroperitoneal in 5 cases. Symptoms were variable: abdominal pain in 15 cases, palpable tumour in 6 cases (excluding the two cases of prenatal diagnosis). Complications included obstruction in 7 cases (including 3 by volvulus), infection in 6 cases, and intracystic haemorrhage in 3 cases. Abdominal ultrasonography correctly established the diagnosis in all children. Surgical treatment included 20 complete resections and one incomplete resection, including 6 with bowel resections. With a follow-up ranging from 6 months to 10 years, one recurrence occurred and was successfully reoperated. Intraabdominal cystic lymphangioma in childhood is a rare tumour with a variable presentation. An accurate diagnosis can be established by abdominal ultrasound. Complete resection should be performed whenever possible.

Umbilical one-puncture laparoscopic-assisted appendectomy in children

To perform a laparoscopic appendectomy, three trocars are usually needed. In order to reduce abdominal wall trauma, we have adopted an umbilical one-puncture laparoscopic-assisted appendectomy (UOPLAA). We did a retrospective study of UOPLAA performed during last 2 years on 200 children aged from 5 to 18 years (median, 9 years). The patients were selected after clinical examination. No child with advanced generalized peritonitis or an abscess with a palpable mass was a candidate for this technique. UOPLAA was successful in 184 patients (92%). In 16 cases (8%), an additional trocar was required to manage perforated or retrocecal appendicitis. The mean operative time was 15 min, and the mean hospital stay was 2 days. There were no intraoperative complications. There were 10 (5%) postoperative complications (three parietal and seven intraabdominal). Four patients (2%) needed reoperation under general anesthesia. The UOPLAA is our preference in cases of acute nonperforated appendicitis because it is simple and fast, with good cosmetic results; but in 8% of our cases, an intraoperative difficulty (retrocecal location, abnormal adhesive band, peritonitis, etc.) arose that required the introduction of additional devices to ensure the safety of the laparoscopic procedure.

[Drug-resistant genito-urinary rhabdomyosarcoma in children with primary psoas abscess. Apropos of a case]

We report an unusually uncommon case of genitourinary rhabdomyosarcoma in a child which was chemoresistant and complicated by a primary psoas abscess which presented as a pelvic mass associated with an abscess of the right iliac fossa. Ultrasound and CT investigations suggested the diagnosis of a centropelvic tumor which was confirmed at puncture-aspiration. MRI was most contributive giving a precise description of the local extension. Intensive multi-drug chemotherapy would appear to have improved outcome in patients with poor-prognosis Maurer group III tumors. In exceptional cases when no tumor response is obtained, carcinological surgery with large dissection, possibly with adjuvant radiotherapy, is indicated. Percutaneous drainage of the deep psoas abscess is as effective as classical surgery and spares the abdominal wall, particularly important if a second operation should be needed. Multidisciplinary management is required for the treatment of this highly malignant tumor.

Anterior approach versus posterior approach to surgical treatment of children's supracondylar fractures: comparative study of thirty cases in each series

The purpose of this study was to consider the surgical treatment of severe supracondylar fractures of the elbow in children, and to compare the anterior approach with the posterior approach used in two homogeneous groups of 30 cases each by two experienced surgeons. Control procedures were maintained with the children of both groups when the plaster was removed, during the fourth month after surgery, and throughout the follow-up that continued for more than 1 year. A posterior approach to surgery is simpler than an anterior approach, but it creates supplementary anatomic damage that can cause circulatory disorders in the external condyle and a higher percentage of limitation in articulation mobility. Thus, although the anterior approach is more technically demanding, it gives better functional results. Because this approach concerns a zone already damaged by the trauma, it eliminates hematoma in the anterior brachial muscle and again places the fragments in the untouched shell of the periosteum.

Is diffuse xanthogranulomatous pyelonephritis a contraindication to retroperitoneoscopic nephroureterectomy? A case report

Diffuse xanthogranulomatous pyelonephritis (XGP) is a rare form of chronic infection of the child's kidney. The clinical presentation is nonspecific, and investigation often reveals a nonfunctional kidney. Preoperative diagnosis is very difficult even with ultrasonography and computed tomography. Total nephrectomy is the treatment of choice, but it is considered very difficult and is usually contraindicated for laparoscopic or retroperitoneoscopic techniques. Reported here is a case of retroperitoneal laparoscopic nephroureterectomy for XGP.