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Background: H-type anorectovestibular fistula is a rare anorectal malformation (ARM) in females where the child passes stool through a vestibular opening in addition to the normal anus. The diagnosis is easy and largely clinical but controversies exist regarding the most suitable surgical approach and technique to minimize complications. Objectives: This study aims to discuss the different possible presentations of the anomaly and the most suitable surgical approach to it. Materials and Methods: We analyzed a total of ten patients with this condition treated over a period of 3 years from January 2017 to December 2019. All underwent definitive surgery by the anterior perineal approach without any protective colostomy. They were analyzed with respect to age, presentation, coanomalies, fistula location, internal opening to anus distance, wound related complications or recurrence, need for colostomy later, and presence of constipation over 8 months of follow-up. Results: Incidence was 8.77% (10/114) of all ARMs in females. Mean age at presentation was 47.1 days and 3 (30%) had coanomalies. Vestibular staining was the most common manifestation. Mean internal opening to anus distance was 2.04 cm. Two (20%) had wound breakdown postoperatively and one (10%) had recurrence in long-term follow-up. These patients underwent colostomy. Two had constipation but all allowed adequate dilatation during mean follow-up of 8 months. Conclusion: H-type ARM in females can be suitably managed with the anterior approach. However, a proximal colostomy appears to significantly decrease the complication rate of the definitive surgery.

IntroductionChildhood cancer is a leading cause of death. It is unclear whether the COVID-19 pandemic has impacted childhood cancer mortality. In this study, we aimed to establish all-cause mortality rates for childhood cancers during the COVID-19 pandemic and determine the factors associated with mortality.MethodsProspective cohort study in 109 institutions in 41 countries. Inclusion criteria: children ResultsAll-cause mortality was 3.4% (n=71/2084) at 30-day follow-up, 5.7% (n=113/1969) at 90-day follow-up and 13.0% (n=206/1581) at 12-month follow-up. The median time from diagnosis to multidisciplinary team (MDT) plan was longest in low-income countries (7 days, IQR 3–11). Multivariable analysis revealed several factors associated with 12-month mortality, including low-income (OR 6.99 (95% CI 2.49 to 19.68); pConclusionsChildren with cancer are more likely to die within 30 days if infected with SARS-CoV-2. However, timely treatment reduced odds of death. This report provides crucial information to balance the benefits of providing anticancer therapy against the risks of SARS-CoV-2 infection in children with cancer.

Background: Hirschsprung’s disease (HD) rarely co-occurs with anorectal malformation (ARM). If it occurs, the classical variety of HD is mostly associated. Total Colonic Aganglionosis (TCA) in a case with ARM is exceedingly rare. Case Presentation: A 3-day-old female neonate presented with neonatal intestinal obstruction. of such a rare association. Examination revealed a perineal fistula. A colostomy was formed for persistent abdominal distension, but it did not work properly. Re-exploration revealed TCA with a transition zone at the level of the terminal ileum. Conclusion: Though ARM is associated with several anomalies of various body systems, its association with TCA is exceedingly rare.

Transverse testicular ectopia (TTE) is a rare anomaly in which both the testes descend through a single inguinal canal and enter the same hemiscrotum. While TTE most commonly occurs in children, a few cases have been reported in adults as well. In this report, we present a case of TTE found accidentally during robotic exploration for right inguinal hernia with left cryptorchidism. Surgeons who frequently engage in the repair of inguinal hernia should be aware of the diagnostic and management options available to them when this condition is found unexpectedly during exploration.

Peritoneal cysts are not uncommon in children - mesenteric/omental cysts being the commoner entity. Peritoneal cysts in the falciform ligament are a very rare entity reported in the literature. We present a 5-year-old boy who presented with pain upper central abdomen and few episodes of non-bilious vomiting for 1 year. He was stable on examination, with abdominal examination revealing the fullness of the abdomen with palpable generalised cystic mass which was mobile transversely. Ultrasound and contrast-enhanced computed tomography of the abdomen revealed intra-peritoneal cystic lesion measuring 13 cm × 11.5 cm × 9 cm with septations seen in the abdominal cavity from the epigastric region to the infraumbilical region (D11-L5 level). Laparoscopy showed a large cyst of the abdomen arising from the anterior abdominal wall, along the falciform ligament. The dark yellow fluid was aspirated and the cyst was excised leaving a part which was adherent to the anterior wall. Histopathology revealed cuboidal epithelium lined by the fibrous wall. The patient is doing well at 6 months follow-up. Falciform ligament cysts are very rare and laparoscopy can confirm the diagnosis as well as help in excision of the cyst with good results.

Summary Introduction To assess the various anatomical patterns of the hypospadias penis, anatomical and histological study of the penile tissues, planes, and vascular patterns, and imagings such as ultrasound of penis, elastography, and Magnetic resonance imaging (MRI) of penis have been described in the literature. All these have been done to attempt the identification of anatomical variations that may influence surgical outcomes. There are very limited MRI studies of hypospadias penis to look for the pristine anatomy. Objective The objective was to identify anatomical variations in hypospadias penis such as the penile tissues and planes and the vascularity using MRI. Material and methods The total number of patients enrolled was 24 from January 2019 to July 2020. This included all the cases of hypospadias at any location aged ≥ 5 years. MRI penis was done using 3T (3 Tesla) MRI scanner (GE Healthcare signa 3T Scanner machine) with 3mm body coil slice thickness and the surface coil of 3 inches. Non-contrast images were taken using fast spin-echo sequences in sagittal, coronal, and transverse planes. The findings analyzed were: presence and distribution of penile tissue and fascial structures, urethral plate thickness, and penile vasculature. Results The mean age was 7.62 ± 2.14 years. The types of hypospadias included were Coronal 1/24 (4.2%), Subcoronal 14/24 (58.3%), Distal penile 3/24 (12.5%), Midpenile 5/24 (20.8%) and Penoscrotal 1/24 (4.2%). The mean urethral plate thickness was 1.33 ± 0.38 mm. The penile soft tissues were well visualized along with their fascial planes. The majority of patients (91.7%, 22/24) had Superficial Dartos vessels with both branches. Bulbourethral vessel was present in 18 (75.0%) cases but could not be visualized in the rest. Ventral and Lateral Dartos vessels were seen in 20 (83.3%) cases. Perforators distal to meatus were visualized in 21 (87.5%) cases (1 each in Penoscrotal, Midpenile, and Coronal hypospadias). Collaterals at corona sulcus were visualized in 23 (95.8%) cases, at paraurethral spongiosum in 15 (62.5%) cases, and at dorsum in 22 (91.7%) cases. Conclusion 3T MRI gives precise images in hypospadias with relation to the tissue and fascial planes of the penis. The vascular pattern visualization in these patients may be confirmed by the availability of a dedicated penile coil which will help to improve the resolution of the penile structures. Analyzing the penile vascular pattern and correlating it with surgical outcomes may aid the surgeon's knowledge of hypospadias, develop new surgical techniques and hence reduce complications.

Aims: To study the role of uroflowmetry in the preoperative and early postoperative period in children undergoing hypospadias repair. Materials and Methods: Twenty-six cases undergoing hypospadias repair over 1 year (tubularized incised plate [TIP] Snodgrass [17 patients], TIP with Snodgraft [5 patients], Duckett's onlay flap [2 patients], and Duckett's tube [2 patients] urethroplasty) were prospectively evaluated with preoperative ultrasound and uroflowmetry and postoperative uroflowmetry at 3 months after the surgery and at 6 and 9 months interval if these dates fell within the study period on follow-up. The parameters studied were maximum flow rate (Qmax), average flow rate (Qav), total voided volume, voiding time, and type of curve. Preoperative and postoperative uroflow data were compared. Results: Twenty-six cases comprised of anterior hypospadias (n = 8), mid penile (n = 11), and posterior hypospadias (n = 7). Fourteen patients had obstructed flow rates preoperatively. While 69% patients (18/26) had obstructed flow rates at 3 months postoperatively, it dropped to 43% at 9 months. Following TIP (Snodgrass) repair, 88% (15/17) had obstructed flow rates postoperatively. Best results were seen in patients undergoing circumferentially epithelialized urethral reconstruction (TIP with Snodgraft, Duckett's onlay flap, and Duckett's tube). Conclusions: Abnormal uroflow is an inherent aspect of hypospadias in 50% of the cases. Both preoperative and postoperative uroflow evaluation is necessary for meaningful conclusion. Patients with preoperative normal flow rates but obstructed postoperative flow rates need clinical evaluation. Obstructive flow rates are more common after TIP (Snodgrass) repair. The urinary flow rates improve with time.

Congenital megalourethra (CM) is an uncommon paediatric urogenital problem with less than 80 reported cases1 and may go ignored for years. It is defined as dilatation and elongation of the penile urethra associated with the deficiency of the corpora cavernosa and/or spongiosum. It may be of scaphoid or fusiform variety. However, surgery in most cases may be challenging. A 10-year-old boy presented with the complaint of a swelling appearing on the under-surface of the penis during voiding since birth. This persisted even after micturation and had to be milked out post voiding. His urinary stream was of good calibre and normal volume. There was no associated history of urinary tract infection or obstruction. External genital examination was normal with bilateral descended testes, stretched penile length=4.5 cm, normal prepuce and normally positioned urethral meatus. However, dilatation of the dorsal penile shaft was observed during micturation. A retrograde cum voiding cystourethrography revealed dilatation of the anterior urethra (maximum diameter=1.68 cm), normal posterior urethra, urinary bladder and no reflux (figure 1A, …

Aims: To Study the histology of the terminal end of distal rectal pouch and fistula region in cases of anorectal malformations (ARMs) and to get an insight on the usefulness of excising or preserving this region during its reconstruction. Materials and Methods: This was a prospective observational study of 20 consecutive cases of ARMs that underwent posterior sagittal anorectoplasty (PSARP) in our hospital over 6 months' period. The histopathological evaluation of the terminal end of the distal rectal pouch and fistula region in all cases with ARM was done. Complicated and redo cases were excluded from this study. Tissue specimen of about 0.5–1.0 cm from the most distal part of the rectal pouch and close to the fistula region was taken. Biopsy specimens were obtained from all patients undergoing a PSARP performed after a defunctioning colostomy or as a primary procedure without colostomy, and histopathological evaluation was done in all cases. Further, the internal sphincter and its morphology, hypoganglionosis or aganglionosis, anal glands and crypts, thickened nerve trunks, and other miscellaneous histopathological aberrations were studied. Based on these histological findings, conclusions were derived whether to preserve or excise this region during ARM reconstruction. Results: Out of the 20 ARM patients included, 12 patients (60%) were male and 8 (40%) were female. An internal sphincter was identified in all the patients. However, the smooth muscle bundles were disorganized in all the 20 patients (100%). While ganglion cells were absent in 90% cases, hypertrophic nerve bundles were a common histological finding (90% of patients). The abnormal mucosal finding was also noted in majority of the patients (75%). Conclusions: An atrophic or disorganized internal sphincter, absent ganglion cells, and abnormal anal mucosal findings in majority of these patients on histology would justify its excision during PSARP. However, further follow-up of these ARM patients in whom the terminal end of the distal rectal pouch and the fistula region is excised or retained is recommended.

We report a rare case of incomplete congenital duodenal obstruction (Type 1 duodenal atresia) in association with situs inversus totalis presenting with gastric perforation in a neonate. The infantogram was suggestive of perforation with air under diaphragm along with dextrocardia. On exploration, a pin point perforation at fundus near lesser curvature along with situs inversus was noted. Primary closure of gastric perforation was done. Patient was then discharged on full breast feeds but was readmitted with intolerance to feeds and recurrent bilious vomiting. Further, upper GI contrast study revealed partial duodenal obstruction. On re-exploration, duodenal web with central aperture was seen and duodeno-duodenostomy was done.

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) and anorectal malformations (ARM) in a newborn usually present with frothing of saliva and massive abdominal distension rendering it difficult to diagnose associated intrabdominal pathologies. We report a large gastric duplication (GD) cyst in a 2-day-old neonate with EA and TEF. GD cyst was detected in the early post-operative period as the abdominal distension persisted after repair of EA and TEF. The baby underwent excision of GD cyst with good outcome thereafter.