The effects of intrathecal levobupivacaine and bupivacaine in the elderly

The objective of this study was to compare the block durations and haemodynamic effects associated with intrathecal levobupivacaine or bupivacaine in elderly patients undergoing transurethral prostate surgery. Eighty patients were prospectively randomised to receive plain 1.5 ml levobupivacaine 0.5% (group levobupivacaine) or 1.5 ml plain bupivacaine 0.5% (group bupivacaine) in combination with fentanyl 0.3 ml (15 microg) for spinal anaesthesia. The time to reach T10 and peak sensory block level, and to maximum motor block were significantly shorter in group bupivacaine compared to group levobupivacaine (p < 0.05). Peak sensory block level was also significantly higher in group bupivacaine. In group bupivacaine, mean arterial pressure was significantly lower than group levobupivacaine, starting from 10 min until 30 min after injection (p < 0.05). Hypotension and nausea were less common in group levobupivacaine than group bupivacaine (p < 0.05). Because of the better haemodynamic stability and fewer side-effects associated with levobupivacaine, it may be preferred for spinal anaesthesia in elderly patients.

The Effects of Dexmedetomidine and Fentanyl on Emergence Characteristics after Adenoidectomy in Children

This randomised controlled study evaluated the effects of fentanyl and dexmedetomidine on emergence characteristics of children having adenoidectomy and anaesthetised with sevoflurane.

Ninety children, two to seven years of age and ASA physical status I, were studied. Children were randomly assigned to one of three groups of 30 children, with the study intervention injection given intravenously after intubation. Children in Group F received fentanyl 2.5 μg.kg−1 children in Group D received dexmedetomidine 0.5 μg.kg−1 and children in Group C received saline solution. Anaesthesia was induced with 50% N2O and 8% sevoflurane in O2 by mask and atracurium 0.6 mg.kg−1 was administered for tracheal intubation. All children received paracetamol 40 mg/kg rectally one hour preoperatively and dexamethasone 0.5 mg.kg−1 intravenously.

The time to extubation was shorter in Group D than Group F. The eye-opening time was longer in Group F (16.1∓5.3 minutes) than in Groups C (12.0∓4.2 minutes) and D (12.7∓3.2 minutes). The proportion of pain-free children in early recovery was significantly higher in Groups D (47%) and F (43%) than Group C (13%) (P <0.05). The proportion of children with agitation scores >3 was lower in Groups D 17% (5/30) and F 13% (4130) than in Group C 47% (14/30) (P <0.05). Fentanyl 2.5 μg.kg−1 and dexmedetomidine 0.5 μg.kg−1 had similar haemodynamic effects and emergence characteristics. Fentanyl has been safely used in children for many years. Further studies of dexmedetomidine safety and its interaction with other anaesthetic agents are required before recommending its routine use during general anaesthesia in children.

Ketamine or alfentanil administration prior to propofol anaesthesia: the effects on ProSeal laryngeal mask airway insertion conditions and haemodynamic changes in children

This study was designed to compare the effects of ketamine and alfentanil administered prior to induction of anaesthesia with propofol, on the haemodynamic changes and ProSeal laryngeal mask airway (PLMA) insertion conditions in children. Eighty children, aged between 3-132 months, were randomly allocated to receive either alfentanil 20 microg.kg(-1) (alfentanil group) or ketamine 0.5 mg.kg(-1) (ketamine group) before induction of anaesthesia. Ninety seconds following the administration of propofol 4 mg.kg(-1), a PLMA was inserted. In the ketamine group, heart rate and mean arterial pressure were higher during the study period compared with the alfentanil group (p < 0.05). The time for the return of spontaneous ventilation was prolonged in the alfentanil group (p = 0.004). In conclusion, we found that the administration of ketamine 0.5 mg.kg(-1) with propofol 4 mg.kg(-1) preserved haemodynamic stability, and reduced the time to the return of spontaneous ventilation, compared with alfentanil 20 microg.kg(-1) during PLMA placement. In addition, the conditions for insertion of the PLMA with ketamine were similar to those found with alfentanil.

Dexmedetomidine blunts acute hyperdynamic responses to electroconvulsive therapy without altering seizure duration

BACKGROUND

This study was designed to evaluate the effect of dexmedetomidine on the acute hyperdynamic response, duration of seizure activity and recovery times in patients undergoing electroconvulsive therapy (ECT).

METHODS

Fourteen patients underwent a total of 84 ECT sessions as a crossover design. Patients were randomly allocated to receive either dexmedetomidine (1 mug/kg IV over a period of 10 min) or saline (control). Anaesthesia was induced with propofol 1 mg/kg, and then succinylcholine 0.5 mg/kg IV was administered. Arterial blood pressure and heart rate (HR) were recorded during the study period.

RESULTS

HR in the dexmedetomidine group was lower than that in the control group at 5 and 10 min after the start of study drug infusion, and at 1, 3 and 10 min after the seizure ended (P<0.05). Peak HR was lower in the dexmedetomidine group compared with that in the control group (P<0.05). The mean arterial pressure (MAP) values in the dexmedetomidine group were lower at 0, 1, 3 and 10 min after the seizure ended compared with the control group (P<0.05). Both motor and electroencephalography (EEG) seizure duration in the control group (35.65 +/- 14.89 and 49.07 +/- 9.94 s, respectively) were similar to that in the dexmedetomidine group (33.30 +/- 12.01 and 45.15 +/- 17.79 s, respectively) (P>0.05). Time to spontaneous breathing, eye opening and obeying commands were not different between the groups.

CONCLUSION

A dexmedetomidine dose of 1 mug/kg IV administered over 10 min before the induction of anaesthesia with propofol may be useful in preventing the acute hyperdynamic responses to ECT without altering the duration of seizure activity and recovery time.

The Effects of Methylene Blue on Lung Injury in Septic Rats

PURPOSE

We aimed to investigate the effects of methylene blue (MB) on NO production, myeloperoxidase (MPO) activity, antioxidant status and lipid peroxidation in lung injury during different stages of sepsis in rats.

MATERIAL AND METHODS

Rats were randomly divided into 4 groups (n = 20): group C, sham operated; group CMB, sham operated and receiving MB (25 mg/kg, i.p.); group S, sepsis; group SMB, sepsis and receiving MB (25 mg/kg, i.p.). Sepsis was induced by cecal ligation and puncture (CLP). The MB dose was administered after CLP. Each group was subdivided into two subgroups (n = 10) which were sacrificed at 9 or 18 h after the surgical procedure. The levels of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSH-PX) and MPO activity, total nitrite/nitrate and malondialdehyde (MDA) in the lung tissue were measured. Lung injury was graded from 1 (injury to 25% of the field) to 4 (diffuse injury) by the pathologist.

RESULTS

In group SMB, while SOD and CAT increased in both early and late sepsis periods, GSH-PX increased significantly only in the early sepsis period when compared with group S. Increase in lung MPO activity after CLP-induced sepsis was prevented by MB administration. MB significantly decreased to nitrite/nitrate and MDA levels both in early and late sepsis periods when compared with group S (p < 0.05). Group S showed a marked increase in neutrophil infiltration into the interstitial space and thickening of the alveolar septa, whereas the alveolar damage score was lower in the SMB group (p < 0.05).

CONCLUSION

MB reduced the MPO activity and lipid peroxidation by both decreasing oxidative stress and NO overproduction in the lungs, which resulted in the attenuation of lung injury after CLP-induced sepsis in rats.

Comparison of propofol-alfentanil and propofol-remifentanil anaesthesia in percutaneous nephrolithotripsy

BACKGROUND AND OBJECTIVE

Percutaneous nephrolithotripsy (PCNL) is used for the fragmentation and removal of stones from the renal pelvis and renal calyceal systems. We compared the effects of propofol-alfentanil or propofol-remifentanil anaesthesia on haemodynamics, recovery characteristics and postoperative analgesic requirements during percutaneous nephrolithotripsy.

METHODS

Thirty non-premedicated patients were randomly allocated to receive either propofol-alfentanil (Group A) or propofol-remifentanil (Group R). The loading dose of the study drug was administered over 60 s (alfentanil 10 microg kg(-1) or remifentanil 1 microg kg(-1)) followed by a continuous infusion (alfentanil 15 microg kg(-1) h(-1) or remifentanil 0.15 microg kg(-1) min(-1)). Propofol was administered until loss of consciousness and maintained with a continuous infusion of 75 microg kg(-1) min(-1) in both groups. Atracurium was given for endotracheal intubation at a dose of 0.5 mg kg(-1) and maintained with a continuous infusion of 0.4 mg kg(-1) h(-1). Mean arterial pressure heart rate, the total amount of propofol, time of recovery of spontaneous ventilation, extubation and eye opening in response to verbal stimulus and analgesic requirement were recorded.

RESULTS

In Group A, mean arterial pressure was higher at the first minute in the prone position, and during skin incision and lithotripsy, and heart rate was higher during skin incision and lithotripsy when compared with Group R (P < 0.05). The total amount of propofol did not differ between groups. Time of recovery of spontaneous ventilation, extubation and eye opening were significantly shorter in Group R than Group A (P < 0.05).

CONCLUSIONS

Both propofol-remifentanil and propofol-alfentanil anaesthesia provided stable haemodynamics during percutaneous nephrolithotripsy, whereas propofol-remifentanil allowed earlier extubation.

Sedative, haemodynamic and respiratory effects of dexmedetomidine in children undergoing magnetic resonance imaging examination: preliminary results

BACKGROUND

We evaluated the sedative, haemodynamic and respiratory effects of dexmedetomidine and compared them with those of midazolam in children undergoing magnetic resonance imaging (MRI) procedures.

METHODS

Eighty children aged between 1 and 7 yr were randomly allocated to receive sedation with either dexmedetomidine (group D, n=40) or midazolam (group M, n=40). The loading dose of the study drugs was administered for 10 min (dexmedetomidine 1 microg kg(-1) or midazolam 0.2 mg kg(-1)) followed by continuous infusion (dexmedetomidine 0.5 microg kg(-1) h(-1) or midazolam 6 microg kg(-1) min(-1)). Inadequate sedation was defined as difficulty in completing the procedure because of the child's movement during MRI. The children who were inadequately sedated were given a single dose of rescue midazolam and/or propofol intravenously. Mean arterial pressure (MAP), heart rate (HR), peripheral oxygen saturation (SpO2) and ventilatory frequency (VF) were monitored and recorded during the study.

RESULTS

The quality of MRI was significantly better and the rate of adequate sedation was higher in group D than in group M (P<0.001). In group D, the requirement for rescue drugs was lower and the onset of sedation time was shorter than in group M (P<0.001). MAP, HR and VF decreased from baseline during sedation in both groups (P<0.001).

CONCLUSIONS

Dexmedetomidine provided adequate sedation in most of the children aged 1-7 yr without haemodynamic or respiratory effects during MRI procedures.

Effects of fentanyl on the incidence of emergence agitation in children receiving desflurane or sevoflurane anaesthesia

BACKGROUND AND OBJECTIVE

In children, emergence agitation frequently complicates sevoflurane and desflurane anaesthesia. The effect of intravenous fentanyl 2.5 microg kg(-1) was examined on the incidence of emergence agitation in children who received desflurane or sevoflurane after midazolam premedication and intravenous thiopental induction.

METHODS

One hundred and twenty children (2-7 yr) undergoing adenoidectomy or tonsillectomy, or both, were studied. All children were premedicated orally with midazolam 0.5 mg kg(-1). After intravenous induction with thiopental and atracurium to facilitate endotracheal intubation, patients were randomly assigned to one of four groups: Patients in Groups 1 and 3 received physiological saline solution, whereas patients in Groups 2 and 4 received intravenous fentanyl 2.5 microg kg(-1) during induction. Anaesthesia was maintained with sevoflurane in Groups 1 and 2 and with desflurane in Groups 3 and 4. After discontinuation of the volatile anaesthetic, the times to tracheal extubation and response to verbal stimuli (emergence time), and emergence behaviours were recorded.

RESULTS

The time to tracheal extubation was significantly shorter in Groups 3 (5.2+/-1.7 min) and (6.4+/-2.1 min) than in Groups 1 (8.1+/-2.1 min) (P = 0.0001 and 0.006, respectively) and 2 (8.8+/-1.9 min) (P = 0.0001). The emergence time was significantly shorter in Group 3 (10.0+/-3.9 min) than in Groups 1 (13.8+/-4.9 min) (P = 0.017) and 2 (14.9+/-4.1 min) (P = 0.003). The incidence rate of severe agitation was 13% in Groups 1 and 3, and 7 and 10% in Groups 2 and 4, respectively (P > 0.05).

CONCLUSIONS

After midazolam premedication and intravenous induction of anaesthesia with thiopental administration of intravenous fentanyl 2.5 microg kg(-1) did not provide any clinically significant benefit on emer gence agitation in children who receive sevoflurane or desflurane anaesthesia.

Effects of S(+) ketamine added to bupivacaine for spinal anaesthesia for prostate surgery in elderly patients

BACKGROUND AND OBJECTIVE

Intrathecal ketamine as the sole anaesthetic agent has demonstrated a lack of cardiovascular depression that should be of advantage in an elderly population. S(+) ketamine has three-times the analgesic potency of R(-) ketamine and its antinociceptive effects after intrathecal administration in rats are known. We decided to evaluate the effects of intrathecal S(+) ketamine added to a small dose of spinal bupivacaine in elderly patients undergoing transurethral prostate surgery.

METHODS

Forty males over 60 yr old, scheduled for transurethral prostate resection under spinal anaesthesia, were studied in a prospective, double-blinded, randomized way. Patients were allocated to receive either bupivacaine 10 mg or bupivacaine 7.5 mg combined with S(+) ketamine 0.1 mg kg(-1). Spinal block onset time, maximum sensory level, duration of blockade, haemodynamic variables, postoperative analgesic requirements and adverse events were recorded.

RESULTS

Onset times of motor and sensory block were shorter in the bupivacaine plus S(+) ketamine group. Incomplete motor block of the lower extremities was seen in 80% of the patients in bupivacaine plus S(+) ketamine group. Duration of complete motor block and spinal analgesia was shorter in the bupivacaine plus S(+) ketamine group. There was no significant difference in arterial pressure. Heart rate decreased after spinal anaesthesia in the bupivacaine plus S(+) ketamine group and was significantly lower until the end of anaesthesia. The incidence of adverse effects was not different between groups.

CONCLUSIONS

Intrathecal S(+) ketamine administered with a low dose of bupivacaine provides shorter motor and sensory block onset time, shorter duration of action and less motor blockade in elderly males.

Polyunsaturated phosphatidylcholine lowers collagen deposition in a rat model of corrosive esophageal burn

Esophageal strictures are characterized by excess deposition of collagen in the esophageal wall. Polyunsaturated phosphatidyl-choline (PPC) stimulates collagen breakdown in experimental models of liver cirrhosis and colitis. This study was done in order to investigate the therapeutical effect of PPC in preventing esophageal strictures due to alkali-induced esophageal burns in rats. Fifty-five albino rats were divided into four groups as follows: control group (Group A, 10 rats), rats with sham operation and treated with saline (Group B, 15 rats), rats with esophageal burns only (Group C, 15 rats), and PPC-fed rats with esophageal burns (Group D, 15 rats). A standard esophageal burn was produced as described by Gehanno. PPC was administered orally to Group D rats in doses of 100 mg/day for four weeks. All animals were sacrificed on the 28th day of the experiment. Hydroxyproline levels in esophageal tissue was determined in each rat, and histopathologic evaluation was performed for each group. Hydroxyproline levels were significantly lower in the PPC-fed rats than in the rats with pure esophageal burns (p < 0.001). Histopathologically, collagen deposition in the submucosa and tunica muscularis was lower in Group D rats (PPC-fed rats with esophageal burn) than Group C rats (pure esophageal burn) (p < 0.05). As a result of our study, we concluded that PPC has an ameliorating effect on stricture formation after alkali-induced corrosive esophageal burns in rats.

Outcomes of one-stage techniques for proximal hypospadias repair

OBJECTIVES

To evaluate the success of three preputial flap techniques in the one-stage correction of proximal hypospadias.

METHODS

From 1993 to 1999, 43 children underwent one-stage proximal hypospadias repair using preputial flaps, which were performed by a single surgeon. Of the 43 patients, 21 (48.8%), 10 (23.2%), and 12 (27.9%) underwent tubularized island flap urethroplasty, double-faced tubularized island flap urethroplasty, and onlay island flap urethroplasty, respectively. The age range of the patients at surgery was 18 months to 14 years (mean 3.4). Dorsal plication was required for chordee repair in 12 patients (3 in tubularized island flaps, 3 in double-faced tubularized island flaps, and 6 in onlay island flaps). In addition to the dorsal plication, posterior dissection of the urethral plate without division was performed on 3 of the 6 patients with mild to severe chordee in the onlay island flap group. The incidence of complications requiring repeated surgery was evaluated for each group.

RESULTS

The follow-up was 8 months to 7 years (mean 4.1 years). The overall complication rate was 90% for the double-faced tubularized island flap repair, 38% for the tubularized island flap repair, and 33% for the onlay island flap repair. Recurrent chordee was observed in 2 (66.6%) of the 3 patients who underwent onlay island flap repair with urethral plate dissection.

CONCLUSIONS

The use of a tubularized island flap is suggested for one-stage repair of proximal hypospadias, especially in the patients with severe chordee. Because of the high complication rates, the double-faced tubularized island flap technique is not advocated. The onlay island flap may also be used for proximal hypospadias repair if mild chordee is present. Because of the high recurrent chordee rate, dissection of the urethral plate without division is not suggested in the onlay island flap technique.

Hydatid disease of the liver in childhood: the success of medical therapy and surgical alternatives

Hydatid liver disease in children is a serious problem where the parasite is endemic. Although surgery is considered the treatment of choice, medical therapy is an alternative, but its curative efficacy is controversial. The aims of this study were to evaluate the curative efficacy of medical treatment and compare the results of surgical techniques with respect to postoperative complications in 102 consecutive children (64 male and 38 female, aged 4 to 15 years, mean 8.15 years) treated in two children's hospitals between 1988 and 1997. In 67, medication with albendazole was used as the initial therapy; 17 had multiple hepatic cysts and 8 had coexisting cysts in the lung. Success was defined as progressive shrinkage and solidification of the cyst. The overall success of medical therapy was approximately 27%: 18 of the 67 patients were cured with albendazole (15 had a single cyst, 3 multiple cysts) and 1 recurrence (6%) was observed. Age, sex, and the size, location, and number of cysts did not show any relationship to the response to medical therapy. After 12 to 14 weeks of medical treatment, a viable cyst on ultrasonography and/or computed tomography was accepted as a sign of treatment failure and these patients were scheduled for surgery. A total of 84 patients (35 primarily, 49 after unsuccessful medical therapy) were treated surgically. Procedures included cystectomy and tube drainage in 11 patients, cystectomy in 17, cystectomy and capitonnage in 24, and cystectomy and omentoplasty in 32. The incidence of early postoperative complications was 55% for tube drainage, 18% for cystectomy, 13% for capitonnage, and 0% for omentoplasty. During the follow-up period, 2 surgical patients (2%) developed recurrent disease. Medical treatment with albendazole resulted in fewer curative successes than expected. A longer period of medical treatment may increase the success rate; this question requires further study. Omentoplasty decreased the rate of early postoperative complications, especially cavity abscess and biliary fistula, after surgical treatment and should be recommended in this setting.

Mast-cells distribution and colonic mucin composition in Hirschsprung's disease and intestinal neuronal dysplasia

Intestinal neuronal dysplasia (IND) is a malformation of the enteric plexus that clinically resembles Hirschsprung's disease (HD). In HD, the aganglionic bowel is characterized by the presence of hypertrophic nerve trunks and increased numbers of adrenergic and cholinergic nerve fibers, whereas IND type B (IND-B) is characterized by dysplasia of parasympathetic nerves, hyperganglionosis, and giant ganglia. The aims of this study were to investigate the relationship between the distribution of mast cells (MC) and abnormal neuronal innervation and the impact of abnormal neuronal innervation on colonic epithelial differentiation in relation to the typical innervation abnormalities seen in HD and IND. Full-thickness rectal-biopsy or resected surgical specimens from 15 patients (7 HD, 4 IND, 4 control) were examined by conventional hematoxylin-eosin, periodic acid-Schiff Alcian blue (PAS-AB), toluidine blue staining. The aganglionic and IND-B segments had larger numbers of MC in all layers than the ganglionic and control segments. There was a close relationship between the hypertrophic nerve fibers and the distribution of the MC. In contrast to the aganglionic segments, the mucin composition of the IND-B segments was normal. This finding suggests that innervation anomalies do not reflect epithelial differentiation to the same extent.

Chemically induced intestinal de-epithelialization using silver nitrate for bladder augmentation

The use of bowel segments for bladder augmentation has been associated with metabolic complications, infections, stones, and cancer at the vesicoenteric anastomosis. The establishment of a transitional epithelium over the de-epithelialized surface of a segment of intestine might alleviate these complications. In this study, chemical de-epithelialization and urothelial re-epithelialization were attempted using silver nitrate (AgNO3) solutions at different concentrations. Augmentation cystoplasty was performed in 55 female Swiss-Albino rats using a 1.5-cm detubularized segment of sigmoid. Forty-one rats survived and were killed 12 weeks postoperatively. There were four groups, including one group of eight rats that underwent augmentation alone (group 1, control), while the other three groups were treated with 1 g/100 ml (11 rats), 5 g/100 ml (10 rats), and 10 g/100 ml (12 rats) AgNO3 solutions, respectively, before augmentation. Histopathological analysis demonstrated almost complete de-epithelialization and urothelialization of the sigmoid segment treated with 10 g/100 ml AgNO3 solution, which did not occur in the other groups. Postoperative bladder capacities were increased in all groups. There was no obvious histological difference in the level of collagen deposition and/or fibrosis in the augmented tissues in any of the experimental groups. We conclude that 10 g/100 ml AgNO3 solution can be successfully used for chemical de-epithelialization and urothelial re-epithelialization of augmented intestinal segments, and are worthy of further investigation.

Primary pleural lymphoma: an unusual presentation of childhood non-Hodgkin lymphoma

A case of primary pleural non-Hodgkin lymphoma in a 2.5-year-old girl is reported. The patient had pleural involvement as the initial and only manifestation of the disease. Histopathologic examination showed lymphoblastic lymphoma of T-cell origin. The child received the modified LSA2-L2 protocol. During the maintenance treatment, she had an isolated central nervous system relapse and died of neutropenic sepsis. To the authors' knowledge this represents the first case report of primary pleural lymphoma in the childhood period.

Surgical complications of bladder augmentation: comparison between various enterocystoplasties in 133 patients

OBJECTIVES

Ileal and sigmoid augmentation are equally effective at increasing bladder capacity and compliance. Therefore, knowledge of the incidence of major complications, including perforation, small bowel obstruction (SBO), anastomotic complications, calculus formation, and indications for revision may be useful in choosing the ideal segment. We compared the complications of ileocystoplasty and two types of sigmoidocystoplasty that required reoperative surgery.

METHODS

Between 1981 and 1997, 158 patients with a mean age of 11 years (range 2 to 25) underwent augmentation cystoplasty. Ileum or sigmoid colon was used in 133 patients, who were the subjects of this study. The mean follow-up was 64 months (range 6 to 185). Indications included neurogenic bladder (n = 100), bladder exstrophy (n = 12), cloacal exstrophy (n = 6), posterior urethral valves (n = 3), and miscellaneous (n = 12). Ileum was used in 65 patients and sigmoid colon in 68. Of these, 48 underwent conventional colocystoplasty and 20 seromuscular colocystoplasty lined with urothelium (SCLU). Seventy-nine percent required additional procedures to achieve continence or facilitate catheterization, which included bladder neck procedures in 56% or continent stomas alone in 23%.

RESULTS

There were no deaths or complications of bowel anastomosis. Overall, continence was achieved in 95%. Spontaneous bladder perforation was highest in patients with neurogenic bladder. Calculi developed more frequently in patients with continent stomas (P = 0.04) and in patients with bladder/cloacal exstrophy (32%) than in patients with neurogenic bladder (P = 0.01). Additional procedures and route of catheterization did not increase the risk of perforation. One patient with SCLU with known hypercalciuria developed bladder calculi.

CONCLUSIONS

Sigmoid colon showed a trend of a lower rate of SBO with no difference in perforation or stone formation compared with ileum. Primary diagnoses of bladder or cloacal exstrophy and continent stomas are risk factors for the development of calculi. SCLU has a low rate of surgical complications and no incidence of perforation or SBO thus far; therefore, we advocate the use of SCLU when feasible, and sigmoid as the preferred bowel segment for augmentation cystoplasty.

A modification for bladder neck reconstruction in the treatment of patients with exstrophy and incontinence

PURPOSE

We present a modification of bladder neck reconstruction which resulted in improved continence and voiding compared to other techniques of bladder neck repairs in patients with exstrophy and complete incontinence.

MATERIALS AND METHODS

The series consisted of 10 patients with the exstrophy-epispadias complex and complete incontinence who previously had undergone multiple operations for bladder closure, bladder neck reconstruction and epispadias repair. This modification combines bladder neck lengthening and narrowing of the distal half of the urethra, and submucosal embedding of the proximal half of the neourethra in the trigonal area. All patients also underwent bladder augmentation with detubularized sigmoid colon concurrent with bladder neck reconstruction. Additionally the appendical Mitrofanoff principle was applied to 5 cases.

RESULTS

Of the 10 patients who underwent bladder neck reconstruction with sigmoid cystoplasty 8 are voiding voluntarily without catheterization and are dry for longer than 4 hours day and night. Only 2 patients are partially dry with stress nocturia incontinence and in both we performed a Mitrofanoff procedure as an adjunct to catheterization and to ensure voiding and continence.

CONCLUSIONS

Our modified bladder neck reconstruction provides better overall voiding and continence rates than the other bladder neck/urethral reconstruction procedures in patients with exstrophy and complete incontinence.

Congenital muscular torticollis and sternomastoid tumor: results of nonoperative treatment

BACKGROUND

Congenital muscular torticollis (CMT) and sternocleidomastoid tumor of infancy remains to be one of the mysteries of pediatric surgery. Its cause is still debated and its management is controversial.

METHODS

Fifty-seven infants and children treated consecutively for sternomastoid tumors and CMT over a 5-year period (1992 to 1997) at the Pediatric Surgery Clinic of Social Security Council Ankara Children's Hospital are reviewed. The obstetric history was recorded in 48 patients. A lump in the neck, head tilt, plagiocephaly, and facial asymmetry were reasons for refferal correlating with the age of admission. Under 18 months of age passive and active stretching exercises (PSE and ASE) were initiated in all of the cases.

RESULTS

In 28 children under the age of 3 months the outcome was excellent with none needing surgery. Successively 25% of the 3- to 6-month-old infants, 70% of the 6- to 18-month-old children, and 100% of all the older children required surgery. Spontaneous normal vaginal delivery was recorded in 23 of 48 (48%) cases, whereas vaginal vacuum extraction in four cases, vaginal forceps in six, vaginal as breech in two, and caesarean section in 11 was noted.

CONCLUSIONS

It was concluded that PSE and ASE are highly effective for the treatment of congenital muscular torticollis. The success rate of conservative treatment is primarily dependent on the patients' age at the initiation of exercises. The hypothesis of injury through the birth canal and intrauterine malposition are valid only in 12 (25%) and 13 (27%) of cases, respectively. Therefore, it is difficult to attribute as an etiologic factor.

Anal transposition without colostomy: functional results and complications

Rectovestibular fistula (RVF) is the most common form of anorectal anomaly in female infants. In the surgical repair of these malformations, most pediatric surgeons use cutback, fistula transposition with or without colostomy, and lately, posterior anorectoplasty with colostomy. This is a retrospective evaluation of the functional results and complications in 47 patients who underwent fistula transposition without colostomy for the treatment of a RVF. We prefer to perform the operation when the rectovaginal septum is amenable to dissection (width >2 mm). All patients had voluntary bowel movements; 28 (60%) had completely normal bowel habits, 45 (96%) good and only 2 (4%) fair. We did not encounter serious surgical complications such as infection dehiscence, and fistula recurrence. We thus prefer anal transposition without colostomy to other modes of surgical therapy for RVF.

One-stage hypospadias repair with stent or suprapubic diversion: which is better?

PURPOSE

The authors report on 105 consecutive patients who underwent one-stage hypospadias repair based on use of suprapubic diversion or transurethral drainage with stenting.

METHODS

The surgical procedures included 52 metal-based flap urethroplasty (Mathieu) for coronal, subcoronal, and distal shaft hypospadias; 32 transverse island pedicle graft (Duckett) for mid and proximal shaft hypospadias; 21 transverse island pedicle (Duckett) plus rolled midline tube (Thierchs) for penoscrotal and scrotal hypospadias. To accomplish urinary drainage, suprapubic diversion (cystofix) was used in 28 of 52 Mathieu operations, in 17 of 32 Duckett operations, and in 11 of 21 transverse island pedicle graft plus rolled midline tube operations. In the rest of the cases, transurethral drainage with stenting was used.

RESULTS

All children had excellent cosmetic and functional outcomes. But the rates of complications such as fistula and meatal stenosis were significantly different between the groups in which suprapubic tube or urethral stent was used. In 56 of the 105 patients in whom suprapubic diversion was used, four (7.14%) had fistulas and three (5.35%) had meatal stenosis, in contrast to a fistula rate of 14.28% and meatal stenosis rate of 12.24% in patients that urethral stent is used for urinary drainage.

CONCLUSION

The authors believe that the use of suprapubic diversion is advantageous for the outcome of one-stage hypospadias repair in relation to fistula occurrence and meatal stenosis.

Seromuscular gastrocystoplasty in rats

Long-term results of seromuscular gastrocystoplasty have not been reported in the literature. In the presented study, a seromuscular gastrocystoplasty technique in rats and related biochemical, physiological, and histopathologic results are discussed. Fifty rats were grouped as follows: control and sham (group A), animals with gastrocystoplasty (group B), and animals with seromuscular gastrocystoplasty (group C). Urine pH, blood pH, and bicarbonate levels, bladder capacity, and end filling pressures were evaluated in all groups. After gastrocystoplasty and seromuscular gastrocystoplasty both group B and C showed a statistically significant increase in bladder capacity. Aciduria developed in 22% of rats in group B. In group A and C aciduria was not noted. No statistically significant difference was observed in blood pH, bicarbonate levels, and end-filling pressure measurements in each group of rats. Significant histopathologic changes of bladder occurred in the gastrocystoplasty group. In the 13 bladders examined histologically in group B, 2 had a papilloma on the mucosal surface of the transplanted gastric patch. The bladder mucosa adjacent to the transplanted gastric patch had pronounced hyperplastic and squamous metaplastic changes. In the 15 bladders examined histologically in group C none had a papilloma on the gastric segments. Squamous metaplasia in the bladder mucosa adjacent to the transplanted gastric patch was noted only in 2 rats of this group. Two rats also had bladder calculi in the lumen. Possible etiologies and differences of gastrocystoplasty and seromuscular gastrocystoplasty related pathological changes between two groups are discussed.

Bladder mucosa in posterior urethral repair

The case of a 10-year-old male child with posterior urethral stricture due to infections caused by indwelling urethral catheters treated by patch urethroplasty using free bladder mucosal graft is described.

Does treatment with human chorionic gonadotropin induce reversible changes in undescended testes in boys?

Between May 1993 and November 1995, 71 cryptorchid boys were treated with human chorionic gonadotropin (hCG); 42 were operated upon following unsuccessful hCG treatment. A routine orchiopexy was performed in each case. In 10 cases a testicular biopsy was made during orchipexy within 3 days following hCG treatment; in another 10 biopsies were taken 6 to 9 months after treatment. Testicular biopsies were taken at the time of orchiopexy in 5 cryptorchid boys who were not treated with hCG as a control group. A mild, inflammation-like reaction was found in the cryptorchid testes in the period immediately following the last hCG injections, but those studied 6 to 9 months after the last injection there were no apparent such reactions. In contrast to the inflammation-like reaction, the volume density of blood vessels, interstitial bleeding, and diameter of the seminiferous tubules had not regressed. The numbers of spermatogonia per tubular transverse section and the percentage of tubular transverse sections containing spermatogonia (the fertility index) were increased.

A case of a mediastinal neurenteric cyst demonstrated by prenatal ultrasound

We report the case of a posterior large mediastinal neurenteric cyst demonstrated by prenatal ultrasound (US). Postnatal chest radiography and CT studies demonstrated a posterior, large cystic mediastinal mass associated with vertebral abnormalities including scoliosis, hemivertebrae and anterior spina bifida. Because postnatally respiratory distress developed and rapidly progressed, an emergency operation was performed 12 hours after delivery. The cyst was excised via right posterolateral thoracotomy. Postoperatively, respiratory distress regressed. This is the third reported case of a neurenteric cyst demonstrated by prenatal ultrasound.

Effects of estradiol and progesterone on the synthesis of collagen in corrosive esophageal burns in rats

The effects of sex hormones on the synthesis of collagen were investigated in rats with alkali-induced corrosive esophageal burns. In 75 rats, a standard esophageal burn was produced as described by Gehanno. The animals were then grouped as follows: controls (group A), animals with pure esophageal burns (group B), and animals with esophageal burns treated with estradiol and progesterone (group C). All animals were killed on the 28th day of the experiment. Hydroxyproline levels were determined, and histopathologic evaluation was performed for each group. The hydroxyproline levels were significantly lower in the rats treated with estradiol and progesterone. Histopathologically, collagen deposition in the submucosa and tunica muscularis was lower in the estradiol/progesterone group than in the group with pure esophageal burns. Based on the results, the authors believe that estradiol and progesterone inhibited new collagen synthesis, and therefore, alkali-induced esophageal stricture formation.

"H-type" urethrorectal communication and complete urethral stenosis with unilateral renal agenesis

Congenital "H-type" urethrorectal communication with complete urethral stenosis is extremely rare in the pediatric population. The evaluation and surgical treatment of a "H-type" urethrorectal communication with complete urethral stenosis presenting in a 4-month-old infant is described. Additionally, he had a left renal agenesis and anal stenosis.