Hazebroek, F.W.J.

Different surgical findings in congenital and acquired undescended testes (Article)

2012-02-01T00:00:00Z

Objective: To compare surgical findings in congenital and acquired undescended testes (UDT). Patients And Methods: A review of 139 boys with 158 congenital UDT and 69 boys with 84 acquired UDT was performed. The most caudal testicular position preoperatively, testis position at surgery, patency of the processus vaginalis and epididymal anomalies were prospectively recorded. RESULTS: In the congenital group, orchiopexy had been performed at median age (range) 4.9 (1.5-14.6) years, while the median age (range) in the acquired group was 11.9 (3.8-23.3) years. Preoperatively, only congenital UDT were found not palpable or emergent inguinal, while only acquired UDT could be manipulated in an unstable scrotal position. In comparison with congenital UDT, acquired UDT were significantly more often located at the scrotal entrance, 27/158 vs 32/84 respectively (P < 0.001). At surgery anorchia, vanished testis or testes lying intra-abdominally were only registered in the congenital UDT group. Also 37/158 congenital UDT were located in the superficial inguinal pouch vs 52/84 of the acquired UDT (P= 0.04). In congenital UDT the processus vaginalis was wide open in 74/158, while in acquired UDT the processus vaginalis was closed in 46/84 (P < 0.001) and small open in 26/84 (P= 0.04). Epididymal anomalies were more often seen in the congenital UDT group (37%) than in the acquired group (11%). CONCLUSION: The most caudal position of congenital UDT after manipulation before surgery was at the scrotal entrance. These testes were frequently associated with epididymal anomalies and wide open processus vaginalis. This was in contrast to acquired UDT, which can often be pushed down well below the scrotal entrance and are more likely to be situated in the superficial inguinal pouch, with a normal epididymis and closed processus vaginalis. © 2012 THE AUTHORS. BJU INTERNATIONAL

Surgical findings in acquired undescended testis: An explanation for pubertal descent or non-descent? (Article)

2011-08-31T00:00:00Z

Aim: Surgical findings were studied to find an explanation for the phenomenon that some acquired undescended testes (UDT) descend spontaneously whereas others need orchiopexy. Methods: In patients with acquired UDT spontaneous descent was awaited until at least Tanner stage P2G2. Orchiopexy was performed when a stable scrotal position had not been achieved by the end of follow-up. Results: Orchiopexy was needed in 57 of 132 cases (43%). In cases requiring orchiopexy, the difference in testis volume compared to the contralateral healthy testis was significantly larger than for spontaneously descended testes. 41 (72%) undescended testes were found in the superficial inguinal pouch; 16 (28%) at the external annulus. 26 of the 41 testes in the superficial inguinal pouch position (63%) could be manipulated preoperatively into a non-stable scrotal position; 15 could only reach the scrotal entrance prior to surgery. None of the 16 testes located at the external annulus could reach a scrotal position. Inguinal exploration in most cases revealed a fibrous string or a partially open processus vaginalis. Conclusion: The mobility of acquired UDT located within the external annulus is limited. It is mainly the fibrous string and the partially open processus vaginalis that prevent normal elongation of the spermatic cord with growth. These testes are unlikely to descend spontaneously. Acquired UDT lying in the superficial inguinal pouch can often be pushed down well below the scrotal entrance. We speculate that under normal hormonal stimulation at puberty, some of these growing testes may overcome the strength of the fibrous string in the spermatic cord and descend again spontaneously.

Interdisciplinary structural follow-up of surgical newborns: a prospective evaluation (Article)

2009-07-01T00:00:00Z

Background: Information on physical and developmental outcomes of children with anatomical congenital anomalies (CAs) may indicate the need for early intervention and reduce impact on the child's life and parental burden. Methods: From 1999 to 2003, 101 children with CA (76.5% of initial survivors) were seen 6-monthly in a tertiary children's hospital. Growth, neurologic outcome, mental and psychomotor development as determined with the Bayley Scales of Infant Development, and categorization of predictive sociodemographic and medical variables of the children were evaluated prospectively and longitudinally. Results: Congenital diaphragmatic hernia (CDH) and esophageal atresia patients showed impaired growth, that is, both height for age (-1.5 standard deviation score [SDS]) and weight for height (-1.0 SDS). Overall neurologic outcome was normal, however, suspect or abnormal for 40% of CDH patients. Overall mental development was normal, but psychomotor scores were significantly lower than the norm (95% confidence interval, 83.8-92.2 at 6 months and 87.9-98.5 at 24 months). Sex, maternal age, socioeconomic status, CA, severity-of-disease covariables, and need of medical appliances at home could predict negative outcome significantly (P < .05). Conclusions: The CA survivors show impaired growth and psychomotor developmental delay up to age 2 years. This warrants specific follow-up programs and infrastructure for these patients.

Cost-effectiveness of neonatal surgery: First greeted with scepticism, now increasingly accepted (Article)

2008-02-01T00:00:00Z

Mortality rates in neonatal surgery have dropped markedly, illustrating the enormous progress made. Yet, new questions have arisen. To mention one, health care budgets have tightened. It follows that the effects of medical interventions should be weighted against their costs. As evidence was particularly sparse, we set out to analyse cost-effectiveness of neonatal surgery. The purpose of this article is to summarise our findings and to review recent studies. Moreover, this article explains the relevance of cost-effectiveness analysis and explores how cost-effectiveness interacts with other determinants of health care priority setting. Our research revealed that treatments for two common diagnostic categories in neonatal surgery (congenital anorectal malformations and congenital diaphragmatic hernia) produce good cost-effectiveness. Other groups also published cost-effectiveness studies in the field of neonatal surgery, although their number is still small. Contemporaneously, the economic aspects of health care have captured the interest of policy makers. Importantly, this is not to say that there are no other factors playing a role in priority setting, foremost among which are ethical questions and arguments of equity. This article concludes that, according to present evidence, neonatal surgery yields good value for money and contributes to equity in health.

Influence of tumor site and histology on long-term survival in 193 children with extracranial germ cell tumors (Article)

2008-02-01T00:00:00Z

Aims: Although germ cell tumors (GCT) supposedly share the same cell type of origin, their clinical course differs considerably depending on tumor site and histology. The aim of this work was to study long-term survival stratified for tumor site and tumor histology. Materials and Methods: The medical records of 193 consecutive infants and children with extracranial GCT were studied. The GCT arose in the following anatomical sites: sacrococcygeal (n = 70), ovary (n = 66), testis (n = 20), retroperitoneum (n = 12), neck (n = 8), mediastinum (n = 7), and miscellaneous (n = 10). Histological analysis revealed 152 teratomas (mature: 115, immature: 37), 27 yolk sac tumors, 8 mixed tumors, 2 dysgerminomas, 2 gonadoblastomas, 1 choriocarcinoma and 1 embryonal carcinoma.

Further Evidence for Spontaneous Descent of Acquired Undescended Testes (Article)

2007-10-01T00:00:00Z

Purpose: It is still controversial whether acquired undescended testis can best be managed by orchiopexy or by the wait and see method. We prospectively evaluated spontaneous descent of acquired undescended testes and possible predictive factors in prepubertal boys. Materials and Methods: From 1982 to 2004 spontaneous descent was awaited until at least Tanner stage P2G2 in 109 boys with a total of 83 unilateral and 52 bilateral acquired undescended testes. Annually we established testis position and size. After Tanner stage P2G2 orchiopexy was done for all testes in an unstable scrotal position. Results: Two boys (3 acquired undescended testes) were excluded from analysis. Of 132 acquired undescended testes 75 descended spontaneously (57%, 95% CI 48-65), including 40 of 75 (57%) in early puberty or before puberty and 32 of 75 (43%) in mid puberty. Orchiopexy was performed in 57 of 132 acquired undescended testes (43%). Acquired undescended testes showed an increasing chance of descending spontaneously with increasing age (p trend = 0.002). In 63 of 82 unilateral undescended testes we were able to compare testis volume at the onset of puberty with that of the healthy contralateral side. Of 17 testes that needed orchiopexy 12 (71%) had a volume that was more than 1 ml smaller than the healthy testis. This was noted in only 18 of 46 spontaneously descended acquired undescended testes (39%, p = 0.053). Other factors, such as the most caudal testicular position at referral or the frequency of confirmed descended testicular position before referral, were not predictive of spontaneous descent. Conclusions: A conservative wait and see approach to acquired undescended testis until puberty could prevent more than half of the boys from undergoing orchiopexy and it does not seem detrimental in terms of testicular volume.

Nonpalpable testes: Is there a relationship between ultrasonographic and operative findings? (Article)

2007-04-01T00:00:00Z

Background: Ultrasonography (US) as a diagnostic tool in the work-up of boys with nonpalpable testes (NPT) is still controversial. Objective: To evaluate the relation between US and operative findings in boys with NPT. Materials and methods: During a 7-year period we saw 135 boys with 152 NPT. All were examined by the referring physician or a paediatric surgeon, underwent US examination, and were then re-examined afterwards by a specialist. Finally, all boys were surgically explored for testicular position. Results: US located 103 NPT (68%), 16 within the abdomen and 87 in the inguinal canal. With knowledge of the US result, 37 testes were palpable on re-examination. The sensitivity of US was 97% for inguinal and 48% for abdominal viable testes. Of the 49 testes (32%) missed by US, 16 were viable in either the abdominal (n=14) or the inguinal (n=2) position. Conclusion: All boys with presumed NPT should be referred to a specialist. US is useful to determine localization of NPT, which facilitates planning the surgical procedure. An inguinal exploration is called for when US identifies the testis in the inguinal canal. Because the sensitivity of US for viable abdominal testes is only 48%, we now always perform laparoscopic exploration when US is negative.

Van de Brug Af Gezien (Farewell Lecture)

2005-11-18T00:00:00Z

Glutamine supplementation of parenteral nutrition does not improve intestinal permeability, nitrogen balance, or outcome in newborns and infants undergoing digestive-tract surgery: results from a double-blind, randomized, controlled trial (Article)

2005-01-01T00:00:00Z

OBJECTIVE: To assess the effect of isocaloric isonitrogenous parenteral glutamine supplementation on intestinal permeability and nitrogen loss in newborns and infants after major digestive-tract surgery. SUMMARY BACKGROUND DATA: Glutamine supplementation in critically ill and surgical adults may normalize intestinal permeability, attenuate nitrogen loss, improve survival, and lower the incidence of nosocomial infections. Previous studies in critically ill children were limited to very-low-birthweight infants and had equivocal results. METHODS: Eighty newborns and infants were included in a double-blind, randomized trial comparing standard parenteral nutrition (sPN; n = 39) to glutamine-supplemented parenteral nutrition (GlnPN; glutamine target intake, 0.4 g kg day; n = 41), starting on day 2 after major digestive-tract surgery. Primary endpoints were intestinal permeability, as assessed by the urinary excretion ratio of lactulose and rhamnose (weeks 1 through 4); nitrogen balance (days 4 through 6), and urinary 3-methylhistidine excretion (day 5). Secondary endpoints were mortality, length of stay in the ICU and the hospital, number of septic episodes, and usage of antibiotics and ICU resources. RESULTS: Glutamine intake plateaued at 90% of the target on day 4. No differences were found between patients assigned sPN and patients assigned GlnPN regarding any of the endpoints. Glutamine supplementation was not associated with adverse effects. CONCLUSIONS: In newborns and infants after major digestive-tract surgery, we did not identify beneficial effects of isonitrogenous, isocaloric glutamine supplementation of parenteral nutrition. Glutamine supplementation in these patients therefore is not warranted until further research proves otherwise.

The impact of diagnostic delay on the course of acute appendicitis (Article)

2000-01-01T00:00:00Z

BACKGROUND: The diagnosis of acute appendicitis is often delayed, which may complicate the further course of the disease. AIMS: To review appendectomy cases in order to determine the incidence of diagnostic delay, the underlying factors, and impact on the course of the disease. METHODS: Records of all children who underwent appendectomy from 1994 to 1997 were reviewed. The 129 cases were divided into group A (diagnostic period within 48 hours) and group B (diagnostic period 48 hours or more). RESULTS: In the group with diagnostic delay, significantly more children had first been referred to a paediatrician rather than to a surgeon. In almost half of the cases in this group initial diagnosis was not appendicitis but gastroenteritis. The perforation rate in group A was 24%, and in group B, 71%. Children under 5 years of age all presented in the delayed group B and had a perforation rate of 82%. The delayed group showed a higher number of postoperative complications and a longer hospitalisation period. CONCLUSIONS: Appendicitis is hard to diagnose when, because of a progressing disease process, the classical clinical picture is absent. The major factor in diagnostic delay is suspected gastroenteritis. Early surgical consultation in a child with deteriorating gastroenteritis is advised. Ultrasonographs can be of major help if abdominal signs and symptoms are non-specific for appendicitis.

Brief report: parental burden and grief one year after the birth of a child with a congenital anomaly (Article)

1999-01-01T00:00:00Z

OBJECTIVE: To assess parental burden and grief one year after having a child with a congenital anomaly. METHOD: Twenty-five couples completed the Impact on Family Scale (IFS) and 22 couples answered the Perinatal Grief Scale (PGS). In addition, 27 mothers completed the Functional Health Status Scale (FSII-R). RESULTS: Mothers and fathers showed no significant differences in overall burden (IFS) and grief (PGS). Regarding the subscales, mothers reported significantly more personal strain. Foreknowledge from prenatal diagnosis about the anomaly, a low perceived functional health status of the child, and multiple congenital anomalies increased the burden and grief. CONCLUSIONS: A perinatal counseling team that provides clear and consistent information about the anomalies, the treatment, and the prognosis would help to reduce unnecessary stress and uncertainty, particularly for parents who received prenatal information and whose infant has multiple congenital anomalies.