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Duodenal perforation is a rare, life threatening injury associated with non-accidental blunt abdominal trauma. Diagnostic delay is common, as the true history is concealed and signs may be minimal. Double contrast computed tomography is the most sensitive investigation to confirm clinical suspicion. We report three cases, all with other features typical of non-accidental injury. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the adrenoceptor agonist, ephedrine hydrochloride, is an effective treatment for resistant non-neurogenic daytime urinary incontinence in children., Methods: From 2000 to 2010, eighteen children with resistant non-neurogenic daytime urinary incontinence were treated with oral ephedrine hydrochloride at our institution. Sixteen were female and two were male. Median age at treatment was 12 years (range 5-15 years). Two children had spina bifida occulta. There were no other co-morbidities. Multiple anticholinergics were prescribed and dose maximized to support a bladder and bowel training programme, without achieving continence in this resistant group of children. Pre-treatment urodynamics were normal in 10, but revealed an open bladder neck in 8 patients. None showed detrusor over-activity. Oral ephedrine hydrochloride was started at 7.5 mg or 15 mg twice daily and titrated up to a maximum of 30 mg four times daily according to response., Results: Median follow-up was 7 years (range 6-8 years). Seventeen children (94%) reported improvement in symptoms and six (33%) achieved complete urinary continence. All patients maintained compliant bladders on post-treatment urodynamics. Seven of the 8 previously open bladder necks were closed. No patients reported any significant side effects. Patients with open bladder necks on pre-treatment urodynamics were more likely to show a full response to ephedrine (odds ratio 15; 95% CI 1.2-185.2)., Conclusions: Oral ephedrine hydrochloride is an effective treatment for carefully selected children with resistant non-neurogenic daytime urinary incontinence., (Copyright © 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: To determine our single centre experience of long term renal function and mortality rates of our cohort of spina bifida patients born since 1970., Materials and Methods: We collected a prospective database and included all patients born with spina bifida between 1970 and 2011 managed by our centre. Data we collected included the glomerular filtration rates, results of renal tract imaging, management strategies and mortalities., Results: Of 160 patients identified, 120 were included for analysis with a mean age of 20 years. In our cohort 48% (58/120) had normal renal function and only 1.6% (2/120) had severe renal impairment or end stage renal failure. There was a mortality rate of 4.4% and there were no deaths from renal failure., Conclusion: Spina bifida patients have been reported to have high mortality rates and high morbidity secondary to renal failure. Historical data does not appear to reflect current advancements and we would therefore be more optimistic when counselling families about long term survival into adulthood., (Copyright © 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

The American Academy of Pediatrics recently released its new Technical Report and Policy Statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the 8 task force members reflect what these individual physicians perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious, and the report's conclusions are different from those reached by physicians in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a different view is presented by non-US-based physicians and representatives of general medical associations and societies for pediatrics, pediatric surgery, and pediatric urology in Northern Europe. To these authors, only 1 of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.

Background: The indications for partial or total nephrectomy for urological reasons are not clearly documented in the paediatric surgical literature and there are only a limited number of publications on this subject., Purpose: In order to clarify the situation in our centre, we reviewed our own indications for nephrectomy over a 20-year period., Methods: Medical records of patients who underwent nephrectomy for urological and oncological causes between May 1990 and October 2010 at our centre were retrospectively reviewed. Indications for nephrectomy were noted. Renal function was noted for urological cases., Results: A total of 357 nephrectomies were undertaken; out of these, 241 cases were for urological causes and 116 for oncological reasons. The majority of total nephrectomies were performed for multicystic dysplastic kidneys, reflux nephropathy, pelvi-ureteric junction obstruction and dysplasia. Eighty-seven patients exhibited no function at the time of nephrectomy. Of the remainder, 17 had <5% function, 18 had 5-10% function, 5 had 10-15% function and 2 patients had 15-20% function., Conclusions: This is the largest series of nephrectomies in the paediatric surgery literature to date. The majority of nephrectomies were undertaken for urological conditions with relative renal function of <10% and could not have been usefully preserved in situ. We suggest that kidneys with >10% function should not be routinely removed.

Objective: The aim of our study was to review the management of stomal stenosis after the Malone antegrade continence enema (MACE) procedure at our center, and to describe and assess the early outcomes of 2 novel procedures used in the management of conduit stenosis: Maceoscopy and the rendez-vous., Subjects/patients and Methods: We retrospectively reviewed 45 consecutive MACE cases performed by 1 surgeon at St George's hospital over a 13-year period., Results: Until April 2002, 5 cases presented with difficulty catheterizing their MACE. This was attributed to stenosis without further investigation, and the MACE revised surgically. Of 13 cases presenting with suspected stenosis since May 2002, 8 channels turned out to be patent when assessed and catheterized endoscopically via Maceoscopy. Two truly stenotic MACEs were revised; patency of the other 3 was reestablished by means of a new double-endoscopic procedure we have termed the rendez-vous.

Objective: To establish the sensitivity of antenatal ultrasound for identifying the need for renal tract surgery in infancy and early childhood., Methods: A retrospective analysis of the surgical records in children under 5 years of age undergoing renal tract surgery in a regional pediatric urological surgery referral unit was carried out. All records between May 1997 and July 2002 were examined to assess the relationship between prenatal ultrasound findings and postnatal surgical pathology., Results: A total of 106 operations had been performed. The detection rate of multicystic renal dysplasia was 100% (17/17). The equivalent detection rates for pelviureteral junction obstruction, duplex renal system and vesicoureteral reflux were 82.8, 67 and 26.1%, respectively. None of the babies with renal tumors had abnormal antenatal ultrasound findings. The diagnosis of postnatal renal surgical pathology was made on the basis of prenatal scan findings in 59.6% of cases, while recurrent urinary tract infection led to the diagnosis in 26.0%., Conclusions: Approximately 40% of children requiring surgery for renal tract pathology will have a normal antenatal ultrasound examination. The prevalence of abnormal antenatal ultrasound findings varies depending on the type of renal tract pathology. Despite these findings, the commonest indicator for surgery remains abnormal prenatal scan findings, followed by recurrent urinary tract infections.

Background/purpose: Clean intermittent catheterization has been an established practice for more than 3 decades. The validity of antibiotic prophylaxis has been questioned although not tested., Methods: Eighty-five patients were recruited into a randomized controlled trial. The randomization involved the placement into 1 of 2 groups: (A) continuing antibiotics or (B) discontinuing antibiotics. The trial would last 4 months with the outcome being a confirmed urinary tract infection. All groups were matched for age, sex, and pathology., Results: The incidence of urinary tract infections was significantly increased in the group who continued to use antibiotics (n = 20) when compared with the group who discontinued prophylaxis (n = 3). The common infecting organism was Escherichia coli., Conclusions: The use of prophylactic antibiotics for children who intermittently catheterize may not be necessary. The use of prophylactic antibiotics may result in increased rates of infection because of the development of resistant organisms.

Background: In 2001, the Department of Health produced the Improving Working Lives (IWL) for Doctors document. This is the first national survey which asks hospital doctors what changes are needed to improve their working lives., Methods: An online questionnaire was run over a period of six weeks and was open to all doctors of all grades. Doctors were asked to choose their top five factors from a list of 35 diverse choices or to provide alternatives in free text. Demographic data were also collected., Results: 1603 hospital doctors working in the UK completed the online questionnaire. Improved secretarial or managerial support was the first IWL choice for consultants, with different aspects of clinical and non-clinical support representing their top four choices. Junior hospital doctors and staff and associate specialist grades (staff grades, associate specialists, and clinical assistants) identified improved support for education and training as their first choice, while among the female specialist registrars, it was improved support for childcare. Greater opportunities to develop new skills was an important issue for doctors in the surgical specialties and improved access to mentoring was important for all junior doctors, staff and associate specialist grades, and doctors from black and ethnic minority groups., Conclusions: Hospital doctors in the UK need more support to improve their working lives. The principle needs are better secretarial and managerial support for consultants; education, training, and mentoring for junior doctors and staff and associate specialist grades; and improved opportunities to develop new skills for those in surgical specialties. Support with childcare is an important issue for female specialist registrars. The Department of Health, NHS trusts, deaneries, and Royal Colleges need to endorse policies that promote a training and working environment that will improve working lives for all hospital doctors, ensuring that appropriate and continuing support is available from the time doctors enter the new foundation programmes and proposed run-through grades, to their time spent as consultants in today's NHS.

Purpose: Of congenital malformations of the central nervous system 46% are abnormalities of the spinal cord, which includes spina bifida occulta. The occurrence and significance of spina bifida occulta in children with lower urinary tract and bowel dysfunction were evaluated prospectively., Materials and Methods: Between January 1999 and February 2001, 158 consecutive children presenting with lower urinary tract and bowel dysfunction were prospectively evaluated for associated spinal abnormalities. Plain abdominal x-ray showed either the presence or absence of fusion of the posterior elements of the lumbar and/or sacral spinous processes. Of the 158 patients 57 (36%) had spina bifida occulta (group 1) and 101 (64%) did not (group 2)., Results: There was no correlation between clinical outcome in group 1 with spina bifida occulta and lower urinary tract dysfunction and the pattern of spina bifida occulta. Significant correlation was present between lower urinary tract dysfunction and the presence of spina bifida occulta on plain abdominal x-ray. No significant correlation was found between the presence of spina bifida occulta and spinal cord abnormalities by magnetic resonance imaging scan. There was no direct causal relation between the radiological finding and lower urinary tract dysfunction., Conclusions: Children presenting with spina bifida occulta, and lower urinary tract and bowel dysfunction have normal genitourinary tracts and absent spinal cord abnormalities. Spina bifida occulta is probably a coincidental finding and its true significance in this cohort was not established.

Purpose: We assess night and day function of the neuropathic bladder in children with neurogenic vesical dysfunction by overnight urodynamic monitoring and conventional static cystometrogram. Overnight urodynamics as a diagnostic tool was evaluated and its reproducibility analyzed., Materials and Methods: In 18 months 3 boys and 3 girls 6 to 14 years old (mean age plus or minus standard deviation 10.3 +/- 3.3) were studied prospectively. Each child was evaluated on 4 separate occasions with 2-daytime cystometrograms at a standard fill rate of 10 ml. per minute and 2 overnight urodynamic studies for 8 hours using a Urolog Recorder. All 6 children were interviewed regarding the acceptability, repeatability and compliance to overnight urodynamics., Results: Bladder capacity was not significantly different during each episode for either of the 2 tests. Mean bladder pressures in 2 children showed stable detrusor activity on cystometry (2 +/- 1.4 cm. H2O) and overnight urodynamics (0.4 +/- 0.5, r = 0.9). Detrusor compliance was not impaired in these 2 children. Four patients had frank detrusor instability with a mean bladder pressure of 50.6 +/- 17.4 cm. H2O on cystometry versus 35.9 +/- 5.2 on overnight urodynamics (r = 0.9). Bladder compliance was severely impaired in these 4 patients. Compliance at potential bladder capacity for patient age was 6.6 +/- 2.1 ml./cm. H2O for cystometry versus 9.2 +/- 3.4 for overnight urodynamics (p = 0.26, r = 0.9). Compliance at actual bladder capacity was 3.4 +/- 1.2 ml./cm. H2O for cystometry versus 3.8 +/- 0.8 for overnight urodynamics (p = 0.28, r = 0.9). There was good correlation between daytime cystometry and overnight urodynamics (p <0.001, Pearson's coefficient correlation 0.92, 95% confidence interval 0.90 to 0.94). A kappa statistical analysis showed good agreement between cystometry and overnight urodynamics for stable bladder and frank detrusor instability (kappa = 0.9). Replicated measurements of the same patient by the same observer had an error of variance of 1.7 cm. H2O with a narrow confidence interval, indicating the measurement error was small and that overnight urodynamics can be reproduced with relative accuracy within an individual. All 6 children preferred overnight urodynamics to cystometry., Conclusions: There was good correlation between bladder behavior day and night. Overnight urodynamics were accurate in predicting detrusor activity, and well tolerated and less embarrassing for a child with neurogenic vesical dysfunction.

Background: Large bowel volvulus is extremely uncommon in children. The probable pathogenesis, predisposing factors and management of large bowel volvulus in children are debatable., Methods: Seven consecutive cases of large bowel volvulus occurring over a 6-year period are reported., Results: Two patients with caecal volvulus, one with transverse and subsequent sigmoid volvulus, one with transverse colon volvulus and three children with sigmoid volvulus are reported. Four girls and one boy with cerebral palsy, one female with Moya Moya disease and spastic paraplegia and an otherwise healthy boy presented at a mean age of 8.3 years (range: 3-15 years). The common presentation was abdominal distension (n = 6), tenderness (n = 6), constipation (n = 7) and bloody mucoid discharge per rectum (n = 6). Plain abdominal X-ray and barium enema were diagnostic. Resection with primary ileocolic, colocolic or colorectal anastomosis was performed in all cases. The mean follow-up was 3.4 years (range: 1-6 years) and there was no mortality., Conclusions: Large bowel volvulus in children may be due to congenital anomalous or absent ligamentous fixation of the large bowel, and abnormal mesocolon or a common ileocolo-mesentery. Large bowel obstruction due to volvulus must be considered in the differential diagnosis in a child presenting with constipation associated with bloody mucoid discharge per rectum. Resection of the involved segment and primary anastomosis is the definitive treatment for large bowel volvulus in children.

Background: OK-432, a lyophilised incubation mixture of group A Streptococcus pyogenes of human origin, was used as a sclerosant for the involution of a giant cervical cystic hygroma in a newborn., Results: There were no systemic side effects. Blood tests and double immune diffusion tests showed no systemic infection or generalised inflammatory response, or antibody production. Cellular and cytokine-induced localised inflammatory reaction within the cystic hygroma, was observed on analysis of the intracystic fluid., Conclusions: The leucocytosis induced and activated by OK-432 probably increases the endothelial permeability of the lymphatics. This probably accelerated lymph drainage leading to involution of the cystic hygroma. Intralesional injection of OK-432 was safe and effective therapy for cystic hygroma in this newborn as its inflammatory reaction was localised., (Copyright 2000 S. Karger AG, Basel.)

A case of transverse and sigmoid-colon volvulus and a discussion of the probable mechanism of large-bowel volvulus (LBV) in children and its management is presented. A 5-year-old male with cerebral palsy presented with transverse-colon and subsequently sigmoid volvulus. The child underwent resection of the involved segments with primary colocolic and colorectal anastomosis, respectively. The recovery was uneventful. LBV in children is due to congenital anomalous or absent ligamentous fixation of the colon. Constipation is probably the result of the volvulus. Resection of the involved segment and primary anastomosis is the definitive treatment.

Delayed surgery has become widely accepted in the management of congenital diaphragmatic hernia after comparing outcomes only with historical retrospective controls. It was the aim of this study to compare early and delayed hernia repair in a randomized prospective clinical trial. Fifty-four infants were randomized to receive either early repair (within 4 hours of admission) or delayed repair (more than 24 hours after birth). The survival rate was higher for the delayed group (57% v 46%), but the difference was not significant (difference: -11; 95% confidence limits: -37.5, 15.5). There were no significant differences between the two groups with respect to length of hospital stay, ventilator dependency, or survival time. Recorded preoperative risk factors were similar for the two groups. Eight infants in the delayed repair group died without having undergone surgery. The optimum time for surgery still needs clarification.

The Fowler Stephens operation and microvascular procedures were compared for the management of 23 intra-abdominal testes in 15 boys, 7 of whom had the prune belly syndrome. The Fowler Stephens operation was used for 15 testes (4 single-stage and 11 two-stage) and microvascular transfer was used for 8 testes. Eleven testes treated by the Fowler Stephens procedure (73%) and 7 treated by microvascular procedures (88%) were viable and intrascrotal after an average follow-up of 3.0 years, giving an overall success rate of 78%. Eight of 9 post-pubertal testes were biopsied. Severe maturational arrest was evident in all and carcinoma in situ was present in one.

In a four-year period 46 boys have been laparoscoped in the search for 55 impalpable testes. Thirty-three per cent of the testes were located intrabdominally. Another 53 per cent were absent. This could be diagnosed by laparoscopy alone in 35 per cent. Laparotomy was needed in only 3 boys to locate the testes.

The effects of irrigation with sterile and infected saline after acute ureteric dilatation by graded Teflon dilators were evaluated renographically and histologically in minipigs. The minipig ureter was dilated from its normal calibre of 4 F to 10 F, and 100 ml of sterile or infected saline were then introduced from a height of 60 cm under gravity. One week after irrigation and dilatation the ipsilateral kidney was either functioning less than 10% or there was an obstructive nephropathy. Histology at 3 months suggested that extravasation of infected irrigating fluid was the most likely cause of ureteric stricture formation.

The effects of three methods of acute ureteric dilatation (by graded Teflon dilators, low and high pressure balloon dilators) were evaluated radiologically, renographically and histologically in minipigs. The minipig ureter was dilated from its normal calibre of 4 F to 10 F. All three methods caused upper urinary tract dilatation and an obstructive nephropathy which had not resolved 96 h after dilatation. Histology at 24 h showed destruction of the transitional epithelium, with inflammation throughout the ureteric wall. Four weeks after dilatation the ureter was still dilated and urothelial nests were seen in the lamina propria and in the muscle coats. There was no evidence of ischaemic necrosis or ureteric stricture formation. The implications of these findings for clinical practice are discussed.

A case of torsion of gall bladder, embedded in an accessory lobe of liver in a neonate with Beckwith syndrome is described. This case has not been previously reported.

The possibilities for treating children with renal stone disease by extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) have not been widely explored. We report ten children, aged between 5 and 16 years, treated by PCNL, and six children, aged between 6 and 15 years, treated by ESWL alone. A 16-year-old spina bifida child with a staghorn calculus was treated electively by a combination of the two methods. Hospital stay was 3 to 8 days for treatment by PCNL or ESWL, and was only 11 days for the combination treatment. Complete stone clearance was achieved in 12 children followed for 3 months. No significant complications occurred. ESWL and PCNL are suitable methods for the management of renal calculi in children.

Forty-two patients were evaluated pre- and postextracorporeal shock wave lithotripsy (ESWL) using [99mTc]DTPA renography. A quantitative evaluation showed that the relative renal function decreased 2-3 days post-ESWL on the treated side, and the parenchymal transit time index (PTTI) increased 2-3 days post-ESWL (p less than 0.001) on the treated side and returned to the pretreatment level by 3 wk post-ESWL. The untreated side showed an increase in PTTI 2-3 days post-ESWL (p less than 0.01), which returned to normal by 3 wk post-ESWL. A significantly greater increase in PTTI was seen in patients who received greater than 1,000 shocks as compared with those who received less than 1,000 shocks. Five patients developed obstructing uropathy post-ESWL, when stone fragments caused ureteric obstruction.

The effects of a new ultrasonic scalpel were studied in laboratory animals. Tissue heat conduction from the tip of the ultrasonic blade was measured. Tissue damage was assessed by light microscopy of histochemically stained sections. The ultrasonic scalpel incised nonfibrous tissue effectively, with minimal heat conduction, and the incisions healed with no evidence of fibrosis nor of tissue destruction.