The surgical management of pediatric upper urinary tract calculi has evolved from open surgery to minimally invasive techniques. With advancement in instrumentation, endourological procedures are being performed more commonly in children. However, the endourological management of renal and ureteral stones in the pediatric population is considered challenging, owing to the smaller size of the urinary tract. Various minimally invasive techniques that are being applied in the management of pediatric urolithiasis, include shock wave lithitripsy (SWL), percutaneous nephrolithotomy (PCNL), ureterorenoscopy and a combination of these procedures. The role of SWL is well established and is considered the first line of treatment in the management of urinary calculi in pediatric patients. Recent reports have confirmed the safety of PCNL and ureteroscopy in children, although they are not as widely practiced in children as in adults. This article reviews literature published till October 2005, pertaining to the minimally invasive management of pediatric upper urinary tract calculi.

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BACKGROUND/PURPOSE: The purpose of this prospective study was to review the operative findings, treatment strategies, as well as the results of management of 46 consecutive cases of jejunoileal and colonic atresia, managed over a 2-year period. MATERIALS AND METHODS: There were 42 patients with jejunoileal atresia (JIA) and 4 with colonic atresia (CA). The 4 group types were: type I-membranous (n=20), type II- blind ends separated by a fibrous cord (n=6), type IIIa- blind ends with a V-shaped mesenteric defect (n=10), type IIIb- apple-peel atresia (n=4) and type IV- multiple atresias (n=6). Primary surgery for JIA consisted of resection with a single anastomosis (n=37), anastomosis after tapering jejunoplasty (n=3), multiple anastomosis (n=1) and a Bishop-Koop ileostomy (n=1). For CA, resection with primary anastomosis was performed. A single end-to-oblique anastomosis after adequate resection of dilated proximal bowel, was the preferred surgical procedure. In the absence of facilities for administering TPN, early oral/nasogastric (NG) tube feeding was encouraged. In patients with anastomotic dysfunction, conservative treatment of the obstruction followed after its resolution by gradually increased NG feeds, was the preferred treatment protocol. RESULTS: Late presentation or diagnosis with hypovolemia, electrolyte imbalance, unconjugated hyperbilirubinemia (n=25) and sepsis (n=6), were significant preoperative findings. After resection and anastomosis, significant shortening of bowel length was seen in 16 patients (34.7%). Postoperative complications included an anastomotic leak (n=3), a perforation proximal to the anastomosis in 1 and anastomotic dysfunction in 5 patients. Full oral or NG tube feeding was possible only by the 13th to 31st postoperative day (POD), after the primary surgery in patients with anastomotic dysfunction and those undergoing reoperation. Overall, 38 patients survived (82.6%). Mortality was highest in patients with type IIIb or type IV JIA. CONCLUSIONS: Despite lack of ideal facilities for neonatal intensive care and administration of TPN, good results were achieved in the management of JIA and CA by following these principles: (1) adequate preoperative resuscitation, (2) meticulous surgical technique and a standardized surgical protocol, (3) early recognition of postoperative complications and their management by a uniform protocol and (4) wherever possible, early institution of oral or NG feeds, preferably by breast milk.

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Epidermoid cyst is a rare and non-teratomatous, benign tumour of the testis. Testis-sparing surgery is recommended as surgical treatment. We present a 9-year-old-boy with testicular epidermoid cyst. The embryology, histogenesis and treatment of epidermoid cyst of testis, are discussed.

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Enteric duplication cysts occurring in tongue is rare. They present with feeding difficulty and rarely with respiratory distress. A one day old male baby presented with swelling in the oral cavity, interfering with feeding and inability to close the mouth. Under general anesthesia, subtotal excision was done and histopathology was gastric duplication cyst of fundic variety.

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OBJECTIVES: To evaluate the efficacy of fascia lata graft in hypospadias repair, especially in cases with paucity of subcutaneous dartos pedicle or tunica vaginalis flap, with the aim to avoid the potential complication of urethrocutaneous fistula and hence the resulting morbidity. MATERIALS AND METHODS: 10 patients aged 4-8 years, were included in this study. Six patients had posterior hypospadias and had undergone unilateral orchidopexy for associated undescended testis. Four patients had urethral fistula, following primary hypospadias repair. In all the cases, the reconstructed neourethra was reinforced with blanket wrap of fascia lata graft, harvested from lateral aspect of mid thigh. The follow up ranged from 12-18 months. RESULTS: There were no complications experienced in the present series and none of the cases developed urethro cutaneous fistula. The cosmetic results were satisfactory. CONCLUSION: We conclude that fascia lata blanket wrap can be successfully used as an interposition graft in hypospadias repair, with the aim to reduce the incidence of urethrocutaneous fistula.

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CONTEXT: The ultimate goal of reconstruction in anorectal malformations (ARM) in children, is to create a functional and anatomically aesthetic neoanus. AIMS: To document our experience with the technique of PSARP in ARM and the immediate anatomical and functional outcome SETTINGS AND DESIGN: A retrospective study 39 patients with high and intermediate ARM, managed by the posterior saggital approach, at the Obafemi Awolowo University Teaching Hospital in Ile Ife, Nigeria MATERIALS AND METHODS: Patient's bio-data were collected, as well as, the presentation, investigations, associated malformations, complications, average bowel opening per day and follow up. RESULTS: There were 17 males and 22 females (male: female ratio 1: 1.3). Twenty-three patients (59%) and 15 patients (38.5%), had intermediate and high malformations respectively, while 1(2.5%) had cloaca malformation. The mean age at presentation was 13.9±30.1 month (range 2 day to 15 years), while the mean age at PSARP was 21.6±29.9 months (range 2.5 days to 15 years). 3(7.6%) patients required laparotomy to mobilize the rectal pouch from the abdomen. Mucosal prolapse was the most common significant postoperative problem, occurring in 4(10.3%) patients. The average bowel motion was 3 times daily (range 1 to 8 times per day). CONCLUSIONS: The PSARP is a useful procedure for the correction of ARM, in children in developing countries, even in the absence of muscle stimulators. The immediate anatomical outcome is satisfactory, but functional results are difficult to access because of poor follow up.

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OBJECTIVES: To describe our experience with bowel vaginoplasty done in children. MATERIALS AND METHODS: This is a retrospective study of eight children aged 10 months to 8 years, who underwent bowel vaginoplasty over a period of 5 years (2000-2005). The indications of bowel vaginoplasty included anorectovestibular fistula (ARVF) associated with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome (n=6) and cloaca (n=2). The bowel segment used for vaginoplasty included colon (n=3), ileum (n=2) and duplicated rectum (n=1). In two patients of ARVF associated with uterovaginal agenesis, the distal- most part of ARVF was transected at the level of peritoneal reflection and left as neovagina, whereas the proximal bowel was pulled through at the proposed neo-anal site. All the patients were advised daily home dilatation of the neo vaginal orifice with Hegar's dilators, for a period of six weeks. RESULTS: Bowel vaginoplasty was done in eight patients. None had any significant per-operative complication. Two patients had abdominal wound dehiscence, requiring secondary suturing. Two patients had mucosal prolapse of the neovagina, which required trimming. One patient died two months after discharge, because of meningitis. Out of the eight patients, seven are in regular follow-up. Six patients have neovagina, cosmetically acceptable to the parents; all have been radiologically proven to have adequate length. One patient had unacceptable perineal appearance with nipple-like vaginal orifice and scarred perineal wound, that merits a revision. None of the patients had vaginal stenosis and excessive mucus discharge, during follow-up visits. Although post surgical results are acceptable to the parents cosmetically, the sexual and psychological outcome is yet to be assessed. Conclusions: Bowel vaginoplasty is a safe and acceptable procedure to treat the pediatric patients of uterovaginal agenesis and cloaca.

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A 10 months old girl child was admitted on June 05 2005, with a history of blunt injury of chest and respiratory distress for 2 days. Chest skiagram showed effusion on right side of chest, with shift of mediastinum to opposite side. Right intercostal chest drainage was done for pyopneumothorax. Rupture of esophagus was suspected, when the chest drain showed milk. Water-soluble contrast study confirmed rupture of thoracic esophagus. Conservative management was successful in the form of intercostal chest drainage, broad-spectrum antibiotics, nasogastric feeding, parenteral nutrition, etc. A repeat contrast study showed no stricture or leak. At a follow up of 3 months, she is doing well. To the best of our knowledge, this is the youngest patient with blunt injury of chest, leading to intrathoracic esophageal rupture.

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