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.

Bilateral methachronous testicular germ cell tumor and testicular microlithiasis in a child: Genetic analysis and insights. A case report

OBJECTIVES

To report our experience with a case of a child with bilateral testicular micro-lithiasis (TML) who developed bilateral metachronous testicular germ cell tumor (TGCT) and determine the most appropriate follow-up and care management in children with testicular micro calcifications in regards to the theoretical risk of testicular cancer.

CASE REPORT

A 12 year-old boy was diagnosed with TGCT and TML. Ten years after complete remission, he presented with a recurrence on the contralateral testis. Genetic screening was performed on both resected and the patient's karyotype was analyzed.

RESULTS

Blood karyotype was normal. Aberrations were found in the tumor karyotype. CGH array showed alterations in chromosome arm 12p.

DISCUSSION

TML is frequently associated with testicular malignancy in adults: in 16.9% of cases the normal contralateral testicle develops TML in TGCT. Recent works of literature find no relationship between TML and cancer in general, but in patients with additional risks, the relationship becomes stronger. Some authors suggest that environmental components and genetics are determinant factors. This is highly suspected in our reported case. It would seem that TML is not a precancerous lesion per se, but rather a marker of an at-risk situation. Long term evolution is uncertain and regular self-palpation that starts before puberty is the only way to ensure proper screening and monitoring.

CONCLUSION

TML have been suspected to be a sign of testicular dysgenesis syndrome, which yields a risk of developing TGCT in case of noxious associations. In patients with a history of TGCT contralateral TML is alarming and aggressive surgical management should be discussed. Therapeutic education of these patients on self-palpation is the best way to ensure proper follow-up.

New in vivo model to analyse the expression of angiogenic genes in the borders of a cleft lip

Defects in the fusion of facial buds can result from an anomaly in tissue development or apoptosis, or both. Our working hypothesis was that anomalies in the development of tissues could be caused by a genetic angiogenic defect. Our main objective was to design a reproducible experimental model to study the expression of angiogenic genes in the borders of cleft lips with or without cleft palate. We therefore prospectively studied seven non-syndromic patients, three with a cleft lip (2 right, 1 left), and four with a cleft lip and palate (1 bilateral, 2 right, 1 left), with no CGH (comparative genomic hybridisation) array, who had primary operations to repair their clefts. We also used four controls (cultured fibroblasts from healthy skin samples). The mean (range) age at operation was 44 (13-77) days. We studied the lateral and medial borders histologically and did qPCR (quantitative real-time polymerase chain reaction) analysis for gene expression with 22 genes of interest (and two housekeeping genes) involved in cleft lip and angiogenesis. The qPCR analysis found significant (p<0.05) overexpression of eight genes in the medial border and seven in the lateral border, and underexpression of nine genes in the medial, and ten in the lateral border. The difference in expression between the two borders was not significant. This preliminary study has enabled us to develop a new method to analyse the expression of angiogenic genes in the borders of cleft lips.

[Umbilicus in children]

The umbilicus is our first scar. It is the last remain of our life in utero. Besides the umbilical hernia, a common pathology during the first three years of life that rarely requires surgery, there are some rare congenital abnormalities such as gastroschisis and omphalocele, which occur in about 1-5/10,000 births. Gastroschisis is a birth defect of the anterior abdominal wall, through which the fetal intestines freely protrude and are not covered by any membranes. During the 13th week prenatal ultrasound, the umbilical cord can be seen to be properly attached while the intestines float freely in the amniotic fluid. This defect is most common in young women who smoke and/or use cocaine and is not typically associated with genetic disorders. Omphalocele is an average coelosomy, in which a visceral hernia protrudes into the base of the umbilical cord. Omphalocele is typically diagnosed during the prenatal phase, and occurs most commonly in older mothers. It is frequently associated with genetic and morphologic abnormalities, therefore a karyotype should automatically be performed. For these two pathologies, the surgical problem lies in managing, during the reintegration, the conflict container/content responsible to lower vena cava syndrome and disorders ventilatory. Deciding on the technique will depend on the clinical form, and on the tolerance to reinsertion. The success of the surgery is directly linked to the postoperative emergence care for the pre-, per- and postnatal phases. The umbilical cord is preserved in the case of a gastroschisis. A primary or secondary umbilicoplasty will be performed for an omphalocele closure. The umbilicoplasty aims to create an umbilicus in a good position by giving it a shape, ideally oval, but also and especially an umbilication. The primary or secondary umbilicoplasty remains a challenge in a growing abdomen (change in position, deformation, loss of intussusception with growth). Many techniques are described: cutaneous flaps randomly placed, excision and skin plasty, resection and controlled wound healing. The choice of technique is a matter of practice but must be done in a rational way, depending on the scar condition when secondary reconstruction, and with minimal scarring, for primary reconstruction. To avoid morphological changes associated with growth, secondary umbilicoplasty should be proposed after the age of five.

Should we question early feminizing genitoplasty for patients with congenital adrenal hyperplasia and XX karyotype?

BACKGROUND

There is a wide difference of opinion between the medical-surgical community and advocacy group regarding Disorders of Sexual Development (DSD) secondary to congenital adrenal hyperplasia (CAH) being ranked in the intersex category. This rupture is even more evident when the issue of genitoplasty is brought up. For physicians it is obvious and unequivocal that a person with CAH and an XX karyotype has a female gender identity, whereas associations tend to rank persons with CAH in the intersex category and advocate holding-off on surgical management.

MATERIAL/METHODS

A retrospective case study vs. control group, spanning over 40years, included 21 patients who were treated in 3 different centers. Each patient and their parents were contacted independently and interviewed regarding interpersonal relationships, psychological impact of genitoplasty, gender identity and opinion on optimal care management for this disorder. Three couples controls (parent-child) per CAH patients were used and matched according to age, sex assigned at birth and ethnic origin.

RESULTS

Sex assigned at birth seemed to concord with the gender identity perceived by the patients in 85.7% of cases. In fact, 89.7% of patients and 100% of parents felt that feminizing genitoplasty should be performed within the first year of life. There is however a significant difference compared to controls who felt that surgical management should occur later on in life. No difference was highlighted during childhood regarding parents-child relationships or social integration. However, during adolescence, the parents-child relationship tended to be significantly more painful for the CAH group. Integrating their parenting role was significantly harder for patients in the CAH-DSD group. In the population of CAH-DSD patients who had genitoplasty the level of sexual fulfillment was not lower to the one reported by the control group.

CONCLUSION

Female sex assignment seems legitimate according to this study and the development of gender identity in these patients matches the sex assigned at birth. Resolving early on the adequacy of the genital anatomy with the sex assigned is promoted by patients as well as their parents. Proper psychomotor development and sexual satisfaction underline the absence of complications related to the surgical technique and the relevance of early surgical management.

[Recurrence of pregnancies with gastroschisis: a case report]

Gastroschisis, a parietal anomaly belonging to median celosomia, is characterized by right lateral-umbilical evisceration. Its frequency, estimated at 1 birth in 2700, shows an excellent final prognosis conditioned by the digestive ischemic damage found at birth whose therapeutic management is often limited. No genetic cause is currently incriminated in the genesis of gastroschisis, except syndromic group associations. In this original observation, we report the case of a couple with a normal history whose obstetric management of the first pregnancy showed a fetus with gastroschisis at 12 WG, with primary closure at birth. The same couple began a second pregnancy in post-partum with on the first-quarter echography showing gastroschisis. A boy was delivered vaginally with extraction, who died of a multivisceral failure at 48h of life. Although no genetic factor is currently identified in gastroschisis onset and although only environmental factors such as illicit substance consumption, young maternal age, and socio-economic precariousness explain the genesis of this parietal anomaly, our observation is original because of the recurrence of this anomaly in the same woman during two successive pregnancies. The early characteristic of the second pregnancy, starting as soon as menstruation returned, can explain the organogenesis of this second gestation in a similar environmental context.

[Primary surgery for cleft palate and short hospital stay (48 h): Are they compatible?]

The aim of this study was to evaluate our practices by studying the duration of hospitalization and the parental real-life experience after a primary surgery of a cleft palate.

MATERIALS AND METHODS

Monocentric retrospective study by analysis of the patients files and phone interview of the parents whose children were operated for a primary surgery of a cleft palate isolated, or associated with a labial cleft, or included in a syndromic form.

RESULTS

Forty-nine patients (25 B-24 G) were performed by 44 Wardill and five Furlow procedures (average age: 11 months ½) between 2010 and 2012. The average duration of the post-operative stay was 1.5 days. Thirty-three parents were contacted (67%). The return was "very well" or "well done" in 82% of the cases. The pain at home was estimated by the parents as "worthless" or "little intense" in 73% of the cases. For 16% of the parents, the child seemed "uncomfortable". The prescription of analgesic was followed only in 70% of the cases. The duration of hospitalization was considered by the families as "good one" in 70% of the cases, "too long" for 12% and "too short" for 18% in particular because of difficulty in eating or parental anxiety.

CONCLUSION

Even if palatine surgery is considered to be painful, anaesthetic techniques and current analgesic protocols allow to envisage very simple and fast consequences, authorizing an early return of the children at home.

[Recurrent distal ileal obstruction by a trichobezoar in a 5-year-old child]

The diagnosis of trichobezoar can be difficult, due to its low prevalence in the pediatric population, limited knowledge of behavioral disorders in children and their prevention, and the difficulty of the clinical diagnosis. We report a case of intestinal occlusion in a 5-year-old child, whose diagnosis was delayed and the trichobezoar, revealed intraoperatively, confined 15cm from the ileocecal valve. Diverging management strategies are proposed in the literature concerning the indication of CT for diagnostic and prognostic purposes, and fibroscopy, still considered as the diagnostic reference. Surgical exploration can lead to the final diagnosis. Bowel obstruction requires emergency surgery to avoid intestinal complications and must be followed by psychological therapy to limit recurrence.

[Cleft lip and palate: Health-related quality of life (French VSP-A scale) for patients and their family. About 51 families]

PURPOSE, OBJECTIVE

The aim of our study was to investigate the quality of life of patients undergoing cleft lip or cleft lip and palate as well as the perception of quality of life of patients perceived by their parents slot.

PATIENTS AND METHODS

Fifty-one adolescents and young adults (29 boys and 22 girls) who underwent cleft lip (FL 22) or lip and palate (CLP 29) and their parents have received psychological and surgical joint consultation. The minimum age for inclusion was 10 years (mean age 15.5 years). A quality of life questionnaire (VSP-A) "children" was given between 10 and 11 years and a questionnaire "adolescents" beyond. Parents have them answered a questionnaire of perceived quality of life of their children. The results were analyzed and compared to a control population (Statistics Student test). Perceived parents lived in relation to their children was obtained through the study of linear regression curves.

RESULTS

The response rate to the questionnaires was 66.7% for parents, 85.7% for children and 63.6% for teenagers. The quality of life of the patients was assessed by the patients to 65.1/100 on average. The index of overall quality of life was superimposed on the control population (p=0.66). Perceived quality of life of patients by their parents was fairly close to the quality of life described by patients (66.5). On the areas of family, education, recreation, quality index was proportionately less than for other areas. For each of these areas, parents overestimated the quality of life of their child. Compared to the control group the fields of education, leisure, vitality quality index were significantly lower in the/FL population P.

Use of cutaneous flap for continent cystostomy (daoud technique)

PURPOSE

We present the results of a new technique using a pedicled cutaneous flap for continent cystostomy.

MATERIALS AND METHODS

A total of 15 boys and 8 girls (mean +/- SD age 13.4 +/- 6.4 years) underwent continent cystostomy for neurogenic bladder (20), bladder exstrophy (2) and sequelae of hypospadias (1) between 1999 and 2008. In this procedure a rectangular pedicled flap is surgically elevated from a hairless area on the abdomen. The flap is tubularized and passed through the anterior abdominal wall directly into the bladder. A submucosal detrusor incision is made to expose the bladder mucosa, and the distal part of the flap is anastomosed to the bladder mucosa in a circular manner. The tube is positioned along the incised detrusor, which is closed over. Viability of the flap, self-catheterization management and continence status are then evaluated.

RESULTS

Mean +/- SD followup was 4.5 +/- 3.1 years. There was 1 case of distal necrosis of the flap, which required a secondary surgery using the Mitrofanoff technique. The 22 remaining flaps were initially viable, although 2 patients were eventually lost to followup and 3 subsequently presented with false-passage incidents requiring a few days of calibration using a balloon catheter. Dryness was achieved immediately in 73% of the cases. After adding a complementary bulking agent the dryness rate reached 77%.

CONCLUSIONS

We present a novel approach to continent cystostomy that is safe and easy to perform. This technique is a less invasive and more efficient alternative to other commonly used approaches.

Tracheobronchial injury by blunt trauma in children: is emergency tracheobronchoscopy always necessary?

PURPOSE

To discuss the usefulness of CT scan in initial management of well tolerated tracheobronchial injuries and the place of tracheoscopy.

METHODS

We report our experience of three cases treated for tracheobronchial rupture resulting from three different mechanisms and review the literature. Three boys, aged 4 to 10 years, were referred to our institution for tracheobronchial rupture. Two of them presented with subcutaneous emphysema after a minor trauma, the third was a polytrauma referred after a severe car crash and was already intubated. We emphasise the importance of an initial CT scan, as this allowed us twice to confirm the tracheal wound prior to tracheoscopy. We discuss the necessity of performing a tracheoscopy in the case of a well tolerated lesion, as this procedure clearly worsened the ventilatory state in one of our cases. Moreover, one of our cases illustrates the fact that even a minor trauma can lead to life-threatening respiratory distress. All the lesions observed in our study were linear and were managed by thoracic drainage; they were then closely monitored and required no further surgical procedure.

CONCLUSION

Tracheobronchial rupture in children can result from minor cervical traumas and in such cases special attention must be paid to mild discomfort or subcutaneous emphysema on admission. Initial CT scan can be very helpful in visualising the level of the rupture and its consequences with respect to the pulmonary parenchyma. One can question the necessity for tracheoscopy in well tolerated lesion, as its results do not always improve the therapeutic outcome.

Is ilioinguinal/iliohypogastric nerve block always totally safe in children?

We report a case of accidental puncture of the small bowel during an ilioinguinal/iliohypogastric nerve block procedure for hernia repair. The diagnosis was made a few days later during a laparoscopic exploration owing to the progressive onset of clinical and radiological intestinal obstruction. A large, obstructing subserosal haematoma was found without any apparent perforation of the mucosa, and the damaged loop was resected. Such a complication has already been reported once in the literature after use of a long bevel needle for the puncture. This case is the first reported using an atraumatic short bevel needle. We discuss the technical aspects of the procedure and underline the fact that regional anaesthesia in children is never totally risk free.

Interest of direct radionuclide cystography in repeated urinary tract infection exploration in childhood

108 children with repeated urinary tract infection were examined both with direct contrast cystography and radionuclide cystography. There was a good correlation between the two procedures in the majority of the cases (79), but in 21 cases, direct radionuclide cystography alone was positive and for 8 other children, direct contrast cystography showed a low-grade vesico-ureteric reflux even though radionuclide cystography was negative. When comparing the two procedures and taking into consideration the age of the patients we find that radionuclide cystography is more sensitive to detect vesico-ureteric reflux in the younger population (p < 0.02). This advantage is less clear for older children who more often present a low-grade reflux. Low radiation exposure is also a great advantage of radionuclide cystography, but anatomic definition is better with contrast cystography. It seems thus that the two procedures complement rather than rival each other. Their respective interest for evaluation of repeated urinary tract infection in children therefore depends on age, attain-ability of the procedure, and the possibility of a bladder or ureteral abnormality. Quite a few authors consider radionuclide cystography as at least as valid as contrast cystography, and even more sensitive. We have attempted to compare both procedures and to determine their respective role in repeated urinary tract infection exploration.

[Vitamin-resistant rickets cured by removal of a bone tumor. Review of the literature]

PURPOSE OF THE STUDY

Rickets secondary to bone or soft tissue tumors are rare in children. Majority of the reported cases occurred in adults older than thirty. This entity can be cured after tumor removal. The authors present a case in a ten year boy and literature review.

MATERIAL

A ten year boy complained of diffuse bone and muscle weakness for two years. A diagnosis of arthritis was made but the patient continued to complain. Serum calcium level was normal (2.33 mmol/l), phosphorus was very low (0.43 mmol/l), serum alkaline phosphatase was high, parathyroid hormone and vitamin D level were normal. Urinalysis showed abnormal phosphate excretion.

METHODS

The absence of malabsorption, no family history of rickets or hypophosphatermy presence of a marked excess of urinary phosphate, very low serum phosphate and normal serum calcium, vitamin D and parathyroid hormone levels led us to consider a diagnosis of tumor induced osteomalacia. Radiographs showed a large round radiolucent lesion in the left superior pubic ramus and generalized demineralisation.

RESULTS

We performed a complete tumor resection and the space was filled with bone graft. On histopathologic examination it was a benign mesenchymal tumor. Rapid reversal of biochemical anomalies, radiographs anomalies and clinical manifestation were observed after complete tumor resection.

DISCUSSION

The authors have described the tumor, the osteomalacia and the pathogenesis of tumor rickets. Histologically the most common causative tumors were vascular tumors, mesenchymal tumors and non ossifying tumors. The tumor were of bone or soft tissue origin. Clinical symptoms were muscular weakness, bone and muscle pain. Biochemically there is a very low phosphate level, a normal serum calcium level as well as a normal vitamin D and PTH level. There is a significant high level of urinal phosphate. The mechanism proposed to explain oncogenic osteomalacia includes tumor secretion of phosphaturic substance other than PTH and calcitonin. Another hypothesis is a substance interfering with normal vitamin D metabolism. The pathogenesis is not clearly defined.

CONCLUSION

Regardless to the mechanism of osteomalacia, complete removal of the tumor will cure the patient. A diligent search for tumors should be done in patients with vitamin D resistant rickets.

Interest of umbilical fold incision for pyloromyotomy

We report the results of a study concerning 80 infants undergoing a pyloromyotomy over a 3-and-a-half-year period. 40 infants had a right upper quadrant transverse rectus incision and 40 infants had an umbilical fold incision. Morbidity and cosmetic aspect of the two techniques were compared. We insist on the umbilical fold incision which presents the same advantages as the classic one and a better cosmetic result.