ALESSANDRO CALISTI

Abstract: Endoscopic repair of recurrent tracheoesophageal fistula (RTF) in infants who underwent surgery at birth for esophageal atresia (EA) is under investigation as an alternative to open surgery, which is technically challenging and associated with high morbidity. The aims of this paper are to present the experience of a single institution in treating RTF using a novel submucosal bronchoscopic injection of biocompatible dextranomer/hyaluronic acid (Dx/HA) copolymer, and to discuss the indications and limitations of this technique.

Abstract: Access to pediatric surgical care in many sub-Saharan African countries is strongly limited by lack of medical facilities, adequate transport system, and trained medical and nursing manpower. The mortality rate for major congenital abnormalities remains extremely elevated in this area of the world. Strong efforts have been spent during the past decades to elevate the level of pediatric surgery standards in these countries through cooperation programs acting through periodical medical missions or supporting local medical teaching institutions. This is a report of a partnership between an Italian Medical Institution and the Eritrean Ministry of Health with the goal to improve pediatric surgical standard of care in the country.

Abstract: ABSTRACT: ABSTRACT BACKGROUND: Meconium abnormalities are characterized by a wide spectrum of severity, from the meconium plug syndrome to the complicated meconium ileus associated with cystic fibrosis. Meconium Related Ileus in absence of Cystic Fibrosis includes a combination of highly viscid meconium and poor intestinal motility, low grade obstruction, benign systemic and abdominal examination, distended loops without air fluid levels. Associated risk factors are severe prematurity and low birth weight, Caesarean delivery, Maternal MgSO4 therapy, maternal diabetes. In the last 20 yrs a new specific type of these meconium related obstructions has been described in premature neonates with low birth weight. Its incidence has shown to increase while its management continues to be challenging and controversial for the risk of complicated obstruction and perforation. Materials and Methods Among 55 newborns admitted between 1992-2008 with Meconium Related Ileus as final diagnosis, data about Low Birth Weight infants (LBW < 1500 g) were extracted and compared to those of patients [greater than or equal to] 1500 g. Hischsprung's Diseases and Cystic Fibrosis were excluded by rectal biopsy and genetic probe before discharge. A softening enema with Gastrografin was the first option whenever overt perforation was not present. Temporary stoma or trans appendiceal bowel irrigation were elected after unsuccessful enema while prompt surgical exploration was performed in perforated cases. NEC was excluded in all operated cases. Data collected were perinatal history and neonatal clinical data, radiological signs, clinical course and complications, management and outcome. Results 30 cases with BW [greater than or equal to] 1500 g had an M/F ratio16/14, Mean B.W. 3052 g, Mean G.A. 37 w Caesarean section rate 40%. There were 10 meconium plug syndrome, 4 small left colon syndromes, and 16 meconium ileus without Cystic Fibrosis. Five cases were born at our institution (inborn) versus 25 referred after a mean of 2, 4 Days (1-7) after birth in another Hospital (outborn). They were managed, after a Gastrografin enema with 90% success rate, by 1 temporary Ileostomy and 2 trans appendiceal irrigation. 25 cases with BW< 1500 g (LBW) had M/F ratio 11/14, Mean B.W. 818 g, Mean G.A. 27 w, Caesarean section rate 70%, assisted ventilation 16/25. There were 8 inborn and 17 outborn. Gastrografin enema was successful in 6 out 8 inborn infants only, all referred within one week from birth. There were 12 perforations mainly among late referred LBW outborn. Conclusions Meconium Related Ileus without Cystic Fibrosis responds to conservative management and softening enema in most of mature infants. In LBW clinical course is initially benign but as any long standing bowel obstruction management may present particular challenges. Clinical and plain radiographic criteria are reliable for making diagnosis and testing for Cystic Fibrosis may not be indicated. Enema may be resolutive when performed in a proper environment. . Perforated cases may be confused with NEC which is excluded by clinical history, no signs of sepsis, lab signs missing, abdominal signs missing, typical radiological signs missing. The higher complication rate is recorded among cases delivered and initially managed in Neonatal Units without co-located Surgical Facilities. Early diagnosis and aggressive medical therapy may lead to higher success rate and help avoiding surgical interventions. Surgical therapy in uncomplicated cases, unresponsive to medical management, should be minimally aggressive.

Abstract: Purpose. Totally endoscopic management (all-endo) of patients with a duplicated renal system (DS) associated with severe vesicoureteral reflux (VUR) or obstructive ureterocele (UC) is an attractive alternative to traditional open procedures. The authors discuss feasibility and results of an all-endo approach on a consecutive series of patients. Methods. From 1999 to 2009, all patients with a complete DS associated with UC and/or VUR were proposed for primary all-endo approach. UC puncture was performed using a 3�Fr Bugbee electrode. Deflux (dextranomer/hyaluronic acid copolymer) injection was administered for VUR. The need for secondary surgery was evaluated on followup. Results. Of the 62 patients recruited, 46 were treated using a primary all-endo approach and 16 patients received no treatment. Of the 46 treated patients with 56 affected renal units, 32 (97%) UCs collapsed following puncture and 29 (63%) VURs were resolved or downgraded. Secondary VUR occurred in 13 (39%) renal units. Secondary surgery was performed on 23 (41%) renal units. Conclusion. The all-endo approach for VUR in DS is an effective therapeutic option. UC collapse was achieved by puncture in most of the patients; secondary VUR was the main complication in a small group of extravesical UC.

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Abstract: Risk of vesicoureteral reflux (VUR) overtreatment was anticipated following introduction of endoscopic treatment (ET). New tool reduces hospitalization and patients discom-fort, with good results and parental preferences may prevail on questions about benefits of treatment. The authors analyzed two series of patients to evaluate impact of ET on management.

Abstract: Recurrent tracheoesophageal fistula (RTF) complicates 5-11% of cases of children treated at birth for esophageal atresia with inferior tracheoesophageal fistula (ITF), and it represents an important problem of respiratory morbility and mortality. Surgical correction of RTF is complex with high incidence of recurrence. The aim of this work is to demonstrate the usefulness of large vascularized pleural flap in the treatment of RTF and the prevention of recurrences.

Abstract: It was the aim of this study to determine if prenatal diagnosis of congenital duodenal obstruction (CDO) selects high-risk pregnancies and demands special perinatal attention.

Abstract: To compare predictive values of current morphologic parameters with congenital renal damage associated with severe megaureter.

Abstract: Voiding cystourethrogram (VCUG) and radionuclide scan is recommended for patients with solitary (secondary to aplasia or multicystic dysplasia), hypoplasic or single ectopic kidney, to detect associated anomalies (vesicoureteric reflux, obstructive uropathies). With the increase of occasional diagnosis, mainly by fetal ultrasound (US), the possibility of an unjustified extension of diagnostic work up must be prevented. Aim of this paper was to estimate the incidence of associated anomalies in asymptomatic cases without associated US signs of hydronephrosis.

Abstract: Tracheomalacia (TM) associated with esophageal atresia (OA) generally islocated in the thoracic segment of the trachea, and the close anatomical relationships it has with theaortic arch and the other mediastinal structures play a remarkable role in the dynamic obstruction ofthe airways. Only correct preoperative imaging studies permit a precise anatomic description of TM, reducingthe risk of incomplete treatment owing to the persistence of other undervalued problems. This reportdescribes the usefulness of preoperative imaging by dynamic fiberoptic bronchoscopy and spiral multilayercomputed tomography with 3-dimensional reconstruction in 7 symptomatic children with segmentary TM associatedwith esophageal atresia and treated surgically "case by case" based on dynamic fiberoptic bronchoscopyand computed tomography data.

Abstract: AIM: The aim of this study was to evaluate the role of different techniquesin the diagnostic workup of children with negative prenatal ultrasonogram, referred for urinary tractinfection (UTI) within the first 24 months. METHODS: One-hundred and forty-seven patients, 71 males/76females were studied. All patients were submitted to renal ultrasonogram (RUS) and to micturating cystourethrogram(MCU) independently from the results of RUS. In a small group (48 children) DMSA scan was performed independentlyfrom the results of RUS and MCU. Sensitivity and predictive value of RUS for vesicoureteric reflux (VUR)were estimated. Multiple regression analysis was performed on a selected number of signs to evaluatetheir predictive value. The group investigated by DMSA scan was analysed to evaluate how the presenceof VUR on MCU anticipated renal damage. RESULTS: Nineteen (21%) patients with normal RUS, had VUR. Predictivevalue of RUS (0.21) was influenced by the grade of the VUR but more than 30% of high grade refluxingrenal units appeared normal at initial ultrasonography. DMSA scan was abnormal in 27% of 48 patients;its result was independent from the presence of VUR of whatever grade. CONCLUSIONS: The increasing numberof renal abnormalities detected before birth reduces the possibility of late abnormal RUS findings. Itmakes RUS screening for abnormalities, after a first episode of UTI, scarcely useful. VUR may be easilymissed when RUS resulted normal and MCU is omitted. Negative MCU cannot exclude renal damage in presenceof UTI. Renal defects at DMSA scan may be unrelated to a demonstrable VUR and could have a differentpathogenesis.

Abstract: OBJECTIVE: A Tracheomalacia complicates 11-33% of cases of OesophagealAtresia with distal Tracheo-Oesophageal Fistula. The lesion generally involves only the thoracic segmentof the trachea, and it has close anatomical relationships with the mediastinal structures, speciallywith the aortic arch. We therefore tried to define the most important morphotypes of tracheobronchialmalacia by using dynamic fiberoptic bronchoscopy (DFB) and spiral multilayer computed tomography (CT).METHODS: Between 1999 and 2003 we studied 40 children from two different institutions who had been operatedon at birth for oesophageal atresia. All patients were been submitted to DFB, and the positive casesunderwent examination by CT with an iodinated contrast medium. CT angiographic images of great vesselsand multiplanar and three-dimensional images of the airways (virtual broncoscopy and broncography) wereobtained for morphological evaluation. RESULTS: Twenty-five patients (62%) tested positive for malaciausing DBF and all were also confirmed by CT study. In 11 cases (46%), the malacia was located at thethoracic section of the trachea, which was occluded by compression of the aorto-innominate complex. Asimple intrinsic tracheomalacia without any vascular compression was present in eight cases (33%), whilein five cases (21%), the malacia was complex. CONCLUSIONS: A correct morphological analysis of the malformedsegment permitted 'tailored surgery' for each individual patient, allowing us to take account of thetype of malacia, its length, and the compressive action exercised by the mediastinal great vessels.

Abstract: BACKGROUND: Long term follow-up of a prenatally diagnosed hydronephrosisusually extends no longer than the first two years of life. During this period spontaneous reductionoccurs in most of the dilatations, not sustained by obstruction or reflux. Late recurrence of hydronephrosisis considered to be unusual. The aim of the present work has been to verify the risk of recurrent hydronephrosislong time after reduction and to identify factors associated to recurrence. MATERIALS AND METHODS: Ina seven years period (1992-99) 276 patients with hydronephrosis unrelated to reflux, duplex kidney, megaureteror vesical obstruction have been observed. Among them, 231 were referred after prenatal diagnosis. Hydronephrosisof grade III or more was recorded in 73/231 with a pelvic diameter > or = 15 mms at ultrasonography (US)and a normal counter-lateral kidney. Surgical treatment was elected in 39 cases on the basis of a separatefunction < 40%, deterioration during follow-up, or occurrence of clinical symptoms. Thirthy four caseswere treated conservatively and four were lost at follow. Among the remaining 30 cases, 14 had a pelvicdiameter lager than 20 mms. They were followed for a mean of 16.6 months (range 7-26) and spontaneoussignificant reduction of pelvic dilatation was recorded in all of them. RESULTS: Patients were recalledafter a mean of 32.1 months from the last US. In 3 cases among 14 with a pelvic diameter larger than20 mms a recurrent severe hydronephrosis was found respectively at 39, 56, and 68 months. In two of them,isotopic scans documented a reduced separate function. The third case reported recurrent symtpoms. Apyeloplasty was performed in all cases. CONCLUSIONS: Spontaneous reduction in most of the prenatallydetected cases of neonatal hydronephrosis within the first two months of life make follow-up beyond thisterm controversial, whenever complete disappearance of pelvic dilatation has been documented. The Authorsreport three cases with severe hydronephrosis (pelvic diameter > 20 mms) among a group of patients treatedconservatively. Long time after spontaneous reduction, recurrent hydronephrosis was documented in allby US, associated to deterioration of separate function and symptoms. Long term follow-up is recommendablein severe cases of prenatally detected hydronephrosis cases, even after reduction, to warrant from recurrenceand renal damage.

Abstract: Hirschsprung's disease (HD) is a major cause of congenital bowel obstructionin children. Classical management includes stoma creation, a pull-through procedure, and restorationof bowel continuity. Colostomy may be also pulled through directly at second operation. Since the firstreport of a single stage (SS) primary pull-through without colostomy for HD, in 1980, several patientshave been treated according to this procedure, even in neonatal period. All of them had a favourableoutcome with better compliance of families and less hospital stay. The Authors reviewed the clinicalrecords of 22 patients selected among 36 treated for HD between 1992 and 2000; in all, disease extendedto rectum-sigma-descendent; all cases of "total aganglionosis" or "ultra short" cases were excluded.Fifteen patients underwent SS repair: 11 neonates were operated at mean age of 69 days (range 14-172).In four infants diagnosis was made later (mean age 15 +/- 9 months) and SS repair was performed 8 daysafter (range 4-14). Seven patients underwent multiple stage (MS) repairs for clinical reasons: pull-throughof the previous colostomy was performed at mean age of 171 days (range 47-330). A Duhamel procedure withan Endo-GIA linear stapler was performed in all No differences in gestational age or birth weight werefound in both groups. Complications were observed only in the MS group (2 related to colostomy, 1 topostoperative adhesions). The Authors conclude that primary SS treatment of HD is safe and effectiveeven in newborn patient, reduce familiar stress and hospital stay. The lower morbidity and complicationrates could be explained by the limited bowel manipulation. Accurate histological-hystochemical diagnosisand meticulous preoperative bowel management should be part of the management.

Abstract: Progress in perinatal and postoperative techniques has reduced the prognosticrole of traditional risk factors in esophageal atresia (EA). This paper reports on 75 cases of esophagealanomalies observed between 1992 and 2002 and followed after surgery from a minimum of six months to amaximum of ten years (mean five years). The impact on survival of birth weight, week of delivery, associatedanomalies and need of ventilatory support at birth are discussed. Twenty-four patients were born before37 weeks of gestation, 18 weighed less than 2000 g.; major anomalies affected 11 neonates, 23 cases requiredmechanical ventilation at birth. Seventy-four patients were operated on with a 90.6% survival rate; nodeaths were related to surgical treatment. Three cases required reoperation for postoperative complications.Birth weight and week of delivery did not seem to influence outcome; this is affected by severe associatedcardiovascular anomalies and the need of ventilation at birth. Follow up at 24 months on 51 patients,revealed respiratory problems in 12 cases and severe gastro-esophageal reflux in 16. This affected qualityof life of EA patients and required long term medical attention; improvement with growth was observed.No correlation between perinatal conditions and late sequelae could be demonstrated in our series.

Abstract: AIM: Primary gastrointestinal perforations have an incidence of between1% and 3% in NICU patients. The 3 Centers participating in this study cover nearly 40% of the NICU populationof the Lazio Region--Italy. The aim of this study is to discuss factors affecting survival in patientsaffected by a primary intestinal perforation. METHODS: From 1991 to 2001, 67 cases of 85 with a neonatalgastrointestinal perforation, were related to primary bowel lesions. Necrotizing enterocolitis (NEC)was not always the cause of perforation and in many patients an isolated bowel lesion without signs ofNEC was found. The aim of this study was to examine clinical and intraoperative findings of NEC and nonNEC perforations and their impact on survival. A relevant number of these patients were extremely low-birthweight (ELBW). Controversies about treatment of this category of neonates are discussed. RESULTS: Patientswere 37 males and 30 females (mean birth weight 1 274.8 g, mean gestational age 28.9 weeks, mean ageat perforation 10 days). Overall survival was 56.8%. Patients were divided by intraoperative findingsin 2 groups: NEC (n=48), or isolated intestinal perforation (IIP) without signs of NEC (n=19). Differencesbetween these 2 groups with regard to birth weight, maturity, associated cardiac anomalies (patent ductusarteriosus, PDA) were significant. NEC and IIP behaved as 2 distinct entities, each with peculiar clinical(age at perforation, oral feeding, need of ventilatory support) and radiological aspects. At surgery,multiple lesion on necrotic bowel were typical of NEC versus single, isolated perforations on healthybowel typical of IIP. Overall survival was almost identical in the 2 groups (59% vs 58%). ELBW patients(55% of the total neonatal intestinal perforations) were also studied. There were 21 patients with NECand 16 with IIP. The 2 groups were different in age at perforation, previous oral feeding and associatedcardiac anomalies (PDA). Overall survival was 62% for NEC and 50% for IIP. A laparotomy was always performed.Temporary peritoneal drainage was done in 4 cases only. Results were better when intestinal diversionwas performed rather than resection and primary anastomosis. Almost all NEC patients had multiple perforationsand extended bowel necrosis. CONCLUSION: NEC is the most frequent cause of neonatal intestinal perforation.This is a quite distinct entity from IIP, which must always be differentiated preoperatively and whichis most frequently found among low birth weight newborns. As far as surgical treatment of perforationamong ELBW neonates is concerned, peritoneal drainage might be reasonably performed when a single lesionon healthy bowel as in IIP is clearly diagnosed but it could be inadequate for NEC patients.

Abstract: Hypospadias surgery is one of the most difficult areas in pediatric urologyand has been characterized by constant evolution. Some of the surgical techniques proposed in the pastare now considered inadequate because of an unacceptable complication rate or poor functional and aestheticresults. The key for assessing a surgical technique (or a particular aspect of it) is continuous evaluationthrough long-term patient follow-up. We present the medical records of 693 patients over 10 years, alloperated on by the same surgeon (the first author), with a minimum of 12 months of follow-up. The overallcomplication rate was 6.49% (45 cases). The most frequent complication was urethral fistula, occurringin 28 patients (62%). Other complications were redo for penile deformity or meatal retraction (eightcases, 17%), megalourethra (five cases, 11%), meatal stenosis (two cases, 4%), and urethral stenosis(two cases, 4%). We have noticed an increased rate of complications in patients older than 12 months(18.7% vs. 3.4% in patients younger than 12 months) and in patients operated on at puberty or later (15%).We have seen no difference in the complication rate related to the type of hospitalisation (day surgeryvs. traditional hospitalisation). Regarding the relationship between the type of complication and thetype of defect, except for the constant presence of fistulae, a high incidence of megalourethra was seenin proximal defects treated with preputial graft. The sexual outcomes of 32 subjects are presented. Multiplefactors influence the final result, but the most important factor is the surgeon's own experience. Knowledgeof different techniques and delicate tissue handling are essential. Our experience shows that the idealage for surgery is 8-12 months. Owing to a minimal emotional impact on the child and to a reasonableuse of economical resources, we consider day surgery the ideal way to treat these patients whenever possible.Even in the absence of complications, follow-up must be continued at least until the end of puberty and,when possible, up to the patient's sexual debut. Adequate interviews with the patients (principally teenagersand young adults) are the best way to evaluate their need for psychological support.

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Abstract: Primary splenic cysts are a rare finding. Some are large and require surgicalremoval. The epidermoid type has an epidermal lining, and prevention of recurrence is dependent on completeresection of the cyst wall, preserving the splenic tissue. Several open, laparoscopic, or percutaneousprocedures have been proposed with or without splenic resection, but few give completely satisfactoryresults. Five consecutive splenic epithelial cysts in pediatric patients were treated by parenchyma-sparingcomplete removal of the cyst wall, which was gently peeled off the splenic tissue without major bleedingin all but one case. Long-term follow-up showed freedom from recurrence.

Abstract: PURPOSE: Varicocele is a common clinical condition that affects 15% ofthe male population and is an important cause of male infertility. Fluoroscopy-guided percutaneous treatmentwith retrograde sclerosis is a good alternative to surgery. We report our experience in calculating thetotal radiation dose to patient and the associated risk. MATERIALS AND METHODS: Our study was performedon 67 patients undergoing percutaneous treatment of varicocele with transbrachial approach and retrogradesclerosis. Thirteen dosimeters with two TLD detectors were positioned on the patients' skin. Calculationof the Entrance Surface Dose and application of appropriate transmission coefficients of the depth-doseallowed us to determine the Equivalent Doses for the single organs. Similar studies were conducted duringplain abdominal x-ray and urography for comparative purposes. RESULTS: The mean effective dose duringpercutaneous treatment of varicocele was 18 mSv, whereas the dose for abdominal x-ray was 1.31 mSv andthat for urography was 4.6 mSv. DISCUSSION AND CONCLUSIONS: Examinations involving the use of x-rayshave been estimated to contribute to half of all the radiation absorbed by the population, and the numberof both diagnostic examinations and interventional procedures is steadily rising. Radiation exposure,especially in children, requires special consideration. Percutaneous treatment of varicocele is a valuablealternative to surgery, not least because of reduced exposure. The use of specially-built lead coatsand the creation of regional referral centres employing specialised staff are two possible measures thatcould further reduce radiation doses and dispel concerns about this procedure.

Abstract: The authors reviewed two groups of patients with ureteropelvic junctionobstructión divided by age and mode of presentation: patients with neonatal asymptomatic hydronephrosisdiagnosed by prenatal ultrasonography and patients with symptomatic hydronephrosis. It was assumed thatin these patients we are observing a continuous spectrum of the same pathology; nevertheless, some relevantdifferences were found between the two groups. Diuretic renograms did not show any change in postoperativerenal function among prenatally detected cases while a significative improvement followed surgery amongmost of symptomatic cases. A possible explanation could be found in the obstructive mechanism which wasresponsible of obstruction in a significative proportion of these patients. Lower polar vessels producea progressive symptomatic hydronephrosis in an healthy kidney in respect to intrinsic obstruction whichare mainly found among prenatally detected cases and which are frequently associated to congenital renaldamage unresponsive to surgery.

Abstract: INTRODUCTION: Oesophageal surgery for reflux stricture is as challengingin adults as in the paediatric age group. Several management protocols, both medical and surgical, arecurrently proposed, such as bougienage, funduplication without dilatation, funduplication with pre- andpostoperative dilatation, resection and interposition, and pharmacological therapy. However, reportedresults are not univocal. The aim of this work is to demonstrate that preoperative treatment with H2-antagonistcombined with oesophageal dilatation and followed by anterior funduplication (Boix-Ochoa procedure withelongation of intraabdominal segment of the oesophagus) is a long-term, effective treatment for refluxstricture in children. It provides a tension free repair and an adequate protection to reflux, thus,preventing recurrences. MATERIALS AND METHODS: In the last five years we observed oesophageal stenosisin 10 out of 49 children, operated for gastroesophageal reflux (mean age 62.9 months, range 12-156 months).All children underwent treatment with H2-antagonist (Ranitidine) and prokinetic agent (Cisapride), followedby oesophageal dilatations (mean 2.8, range 2-4 cycles) with Savary-Gillard dilators. An open anti-refluxprocedure was performed (9 Boix-Ochoa and 1 Nissen) on children where a 9 mm endoscope passed easilythrough the oesophageal lumen. The pre and postoperative evaluation of all patients included symptomsassessment, esophagogram and endoscopy. RESULTS: Results were satisfactory in 9 patients. Only one patientwhere a Nissen wrap was performed, incomplete relaxation was documented radiologically. The patient requiredseveral dilatations for residual dysphagia before reaching a symptom free status. All other patientshad an average follow-up of 38 months (range, 5 months to 5 years) with relief from dysphagia and norecurrence of stricture. Radiological controls showed good oesophageal lumens, with normally positionedneocardias, opening regularly during barium passage with no sign of reflux. Multiple biopsies from endoscopiccontrols confirmed complete relief from oesophageal stricture but persistence of Barrett's mucosa. CONCLUSIONS:Our treatment of choice for reflux stricture is preoperative pharmacological therapy followed by seriesof dilatation with Savary-Gillard dilators till oesophagus is adequately dilated. Antireflux surgeryis mandatory when a stricture is observed. We prefer a Boix-Ochoa funduplication with extensive transhiatalmobilization of thoracic oesophagus. This results in a "tension free" fundoplication even when brachioesophagusis present. The procedure appears to be physiological for pediatric patients and in our hands was freefrom recurrences.

Abstract: Bronchogenic cyst a bronchopulmonary foregut malformation. An intramuralesophageal localization has rarely been reported in respect to more common esophageal duplications orleiomyoma. The authors describe a case of bronchogenic cyst of the esophageal wall in a 3 years old girl.It was an misdiagnosed cause of dysphagia and was revealed by endoscopy and CT scan after two uneffectiveantireflux procedures performed in different institutions, which caused a worsening of symptoms. Completeexcision of the lesion through a thoractomic approach and a redo of the antireflux procedure were followedby complete recovery.

Abstract: PURPOSE: Male varicocele affects children with the same incidence as itdoes adults. The association between asymptomatic idiopathic varicocele and male infertility and thepoor recovery of testicular function after varicocele repair in adulthood have called for noninvasiveclinical and instrumental diagnosis and increasingly early treatment. The department of Pediatric Surgeryat our Hospital has screened schoolchildren for the early diagnosis and treatment of childhood varicocele.Our Vascular and Interventional Radiology department has proposed percutaneous treatment for varicocelecorrection. We report our 10-year experience with percutaneous sclerotherapy of pediatric varicocelewith a retrograde transbranchial approach. MATERIALS AND METHODS: From a screening programme involvingschools 467 boys were selected who were positive for idiopathic varicocele at clinical examination andat Doppler CW, at rest and during Valsalva manoeuvre. Patients with grade III, or symptomatic grade IIvaricocele, testicular hypotrophy, or with a dilation of the testicular veins greater than 2.2 mm atbaseline were referred for percutaneous treatment. Percutaneous treatment was performed with a transbrachialapproach in the basilic vein. After searching for incontinence of the internal right spermatic vein,left renal phlebography was performed in order to identify any incontinence of the left spermatic vein.This vein was then selectively catheterised to perform sclerosis. Tungsten coil embolisation was alsoperformed over a number of years. Follow-up consisted of clinical examination, Doppler CW, Doppler US,or colour Doppler US performed at 3, 6, and 12 months. RESULTS: The radiological procedure was only diagnosticin 78 cases (16.7%). Basilic vein spasm and collaterally-supplied varicocele forced us to discontinuethe procedure. The use of materials with smaller diameters and the professional development of the radiologicalteam helped improve the catheterisation rate with time. Using the transbrachial approach alone a totalof 287 left-sided, 15 right-sided and 52 bilateral varicoceles were treated. Whereas in two cases ofbilateral varicocele a dissection at the origin of both spermatic veins prevented the use of sclerotherapy--thoughthe patients were found to be cured at follow-up with Doppler US--on the left the procedures were continuedwith a transfemoral approach due to difficulties with the transbrachial catheterisation. As for the left-sidedvaricoceles, sclerosis were performed in 230 procedures, whereas sclerosis and embolisation on 87 patients.The success rate was 92% for sclerosis, and 86% for sclerosis and embolisation. No major complicationswere observed. DISCUSSION: Percutaneous treatment is a minimally invasive and relatively non-traumaticinterventional radiology procedure, able to confirm the presence of varicocele, accurately map the venoussystem and allow selective therapy. Our experience with 467 patients over 10 years has allowed us tocompare two therapeutic options: sclerosis and sclerosis combined with embolisation. CONCLUSIONS: Percutaneoustreatment of varicocele with the transbrachial approach proved to be a safe, effective, inexpensive,and minimally invasive procedure. It can be suggested as the first therapeutic option for varicocelecorrection, especially for boys and for bilateral forms.

Abstract: OBJECT: Anterior sacral meningocele (ASM) is a rare congenital malformation.Often while still asymptomatic, ASM may achieve a considerably size, to the extent of exerting a masseffect on the pelvic structures. Spontaneous rupture with subsequent septic meningitis is the most frequentand dangerous complication. The meningocelic sac is usually isolated by a surgical procedure that requiresa sacral laminectomy or a transabdominal approach. Recently an alternative surgical technique, the posteriorsagittal approach, has been proposed. METHODS: We report on a 15-year-old girl with a long clinical historyof constipation and sporadic cystitis. Radiological examinations showed progressive enlargement of apresacral lipomeningocele, which grew to 12x14 cm. A posterior sagittal approach was performed; the stalkwas ligated, the sac totally excised and a small associated tumour removed. No intra-/post-operativecomplications were observed. CONCLUSION: The posterior sagittal approach is an easy and safe surgicaltechnique for the treatment of ASM, as it allows a complete isolation of the lesion and the removal ofassociated tumors without significant morbidity.

Abstract: OBJECTIVE: To compare functional outcome after pyeloplasty in two groupsof patients affected by hydronephrosis, which had different modalities of diagnosis. The first, asymptomatic,detected by prenatal ultrasonography and the second referred later because of clinical symptoms. PATIENTSAND METHODS: 84 patients (54 prenatally detected and 30 symptomatic) among 339 observed with hydronephrosis,operated in a single centre for ureteropelvic junction obstruction, have been retrospectively studied.Seventeen cases with prenatal diagnosis had an early treatment and thirty-seven were operated on afteran initial observation. Symptomatic cases were all operated on at diagnosis. Ultrasonographic and renographicassessment were made at diagnosis, before and after surgery. RESULTS: Renal function of prenatally detectedcases was not influenced by early or delayed surgery. Insignificant functional loss was recorded amongsome cases operated after conservative management. Improvement in differential renal function (p<0.05)was recorded in symptomatic patients after pyeloplasty. A high percentage of obstructions secondary tolower polar crossing vessel were found among symptomatic cases (12 out of 30). Intrinsic obstructionswere predominant among cases with in utero diagnosis (48 out of 54). Whenever the cause of obstructionis considered, postoperative functional improvement was limited to crossing vessels cases. CONCLUSIONS:Renal function among antenatally diagnosed obstructions is scarcely influenced by surgery; potentialrisk of further renal damage cannot be excluded when expectant management is decided. Later detected,symptomatic cases show a better functional response to surgery. This seems corresponding to distinctclinical entities based on different causes of hydronephrosis. A reversible renal damage seems to beassociated to extrinsic obstructions from polar vessel, which are predominant among symptomatic, laterdetected cases. A congenital, irreversible loss of function accompanies intrinsic obstructions, typicalof prenatally diagnosed cases.

Abstract: BACKGROUND: Management of Ureterocele (UC) associated to duplex kidneydepends from the type of UC (ectopic or intravesical), from the presence of symptoms and from associatedvesicoureteral reflux (VUR) in the lower pole of the duplex system. Individualized approach to UC mustconsider endoscopic puncture as a possible option to reduce hydronephrosis and preserve function. METHODS:The records of 68 patients with duplex system have been reviewed. UC was detected in 27 renal units:it was intravesical in 11 and ectopic in 16. VUR was present in the lower pole in 16 cases. Patientswere observed between 1991 and 2001 and mean follow up lasted 20 months (range 2-70). Endoscopic incisionwas performed in 21 patients. Upper pole nephrectomy, intravesical reconstruction or simple observationwere decided for six patients. RESULTS: Endoscopic incision was effective in the treatment of intravesicalUC and in some cases, without VUR in the lower pole, it was the unique procedure. Among ectopic UC, asecondary VUR developed following endoscopic incision in 43% of cases and required further treatment.Renogram did not show any significant functional improvement in the affected renal pole, secondary toendoscopic treatment. An open antireflux procedure was necessary in cases with associated VUR. CONCLUSIONS:Total or partial nephrectomy were performed among the first cases of the present series and in most ofthem it required a double step operation (abdominal and intravesical). In few cases of uncomplicatedUC with a non functioning upper pole, a conservative approach was followed by spontaneous reduction ofdilatation.

Abstract: INTRODUCTION: Ultrasonographic and radionuclide imaging of kidney in presenceof major vesicoureteric reflux, diagnosed in the first months of life, reflects a congenital anomalyof development of ureteric bud and metanephric blastema, more than a parenchymal damage secondary tosuperimposed infections. These lesions are mainly observed in male infants affected by reflux and referredon the basis of a prenatal diagnosis. The impact of therapy on these kidneys is still debated. PATIENTSAND METHODS: Among 273 pediatric patients with VUR observed between 1991 and 2000, 48 cases have beenselected where a reflux grade III or greater had been diagnosed within the first six months of life.Cause of admission was prenatal diagnosis in 29 cases and recurrent infection in 19. Reflux was bilateralin 30 patients. Cases of VUR associated to other urological or neurological anomalies were excluded.A complete ultrasonographic, cystographic and radionuclide study was performed in all patients includedin the present study within the fourth month of life. Mean Follow up lasted 17 months. Renal damage wasgraded by ultrasonography and DMSA renal scan on the basis or of a reduction in total kidney size anda poor radionuclide uptake either of an altered renal profile associated to focal defects of uptake.RESULTS: Resolution of reflux within the mean follow up period, was observed in 16 patients, even withhigh grade VUR, whenever major renal lesions were absent or focal. When severe renal damage was initiallydemonstrated the expectancy of reduction or resolution of VUR was significantly reduced and surgicaloption was considered. CONCLUSIONS: Among patients with major VUR diagnosed in the first months of life,early renal status affects prognosis more than the severity of reflux.

Abstract: INTRODUCTION: The aim of this study is to assess effectiveness of surgicaltreatment for hypospadia in the Regione Lazio (Italy). Hospital discharge data concerning surgical repairof hypospadia between 1996-1998 were analysed in order to: 1. estimate the trend of demand for hypospadiatreatment; 2. correlate clinical results with the type of Surgical Unit of admission (general pediatric,urological, plastic); 3. correlate surgical results with the workload of the Unit; 4. quantify the generalrisk of a secondary treatment. METHODS: The source of data was the Hospital Information System of theRegione Lazio. Cases have been grouped according to Health District, age at first operation, intervalto re-hospitalization after the first treatment for hypospadia. RESULTS: Age at first operation progressivelydeclined in the last years. The annual risk of readmission and reoperation after the first surgical treatment,calculated on a group of 521 cases in 1996, are respectively 6.6% and 5%. CONCLUSIONS: The demand forhypospadia surgery in children was, as expected, stable in the time. However, a tendency to an earliercorrection has been observed, mainly in the first and second year of life. Nearly all (99%) of the surgeryfor hypospadia in the Regione Lazio is performed in four hospitals; one of them accounts for three quartersof the workload. During the observed period a progressive reduction of hospital stay was seen. In thehospital with the best results in term of surgical efficiency, a significant number of patients is treatedon a Day Surgery basis. Institutions treating less than 50 cases per year show a significantly high rateof re-hospitalisation within 12 months.

Abstract: Torsion of the vascular pedicle in a wandering spleen is treated conservativelyin most of the cases whenever irreversible necrosis of the organ is not occurred. A case, in a 10 yearsold boy, is reported. The patient was admitted for acute abdominal pain and was investigated by ultrasounds,which showed an ectopic enlarged spleen at the left flank, without any sign of parenchymal necrosis.A spiral contrast enhanced angio-CT scan confirmed the diagnosis and demonstrated multiple ischemic lesionsof splenic pulp mainly at the lower pole. The child was treated with splenopexy followed by un uneventfulrecovery. CT scan study in cases of torsion of a wandering spleen is of great help in confirming clinicaland ultrasonographic diagnosis and in demonstrating the amount of ischemic lesion of the organ beforesurgical exploration.

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Abstract: OBJECTIVE: To assess the role of the renal resistive index ratio (RIR)in discriminating equivocal upper urinary tract dilatation in children, and thus in establishing theneed for surgery, in comparison with traditional diagnostic tools. PATIENTS AND METHODS: The study comprised40 children with unilateral hydronephrosis unrelated to vesico-ureteric reflux, posterior urethral valves,megaureter or a duplex system. In all patients one or more of the following 'indices of obstruction'were positive; an anteroposterior renal pelvic diameter of >20 mm, a half-time diuretic 'washout' (T/2)of > 20 min, a separate renal function of < 40%, and symptoms of obstruction (pain, sepsis). All thesevariables were measured on admission and after a mean (range) follow-up of 9 (2-24) months. After thisperiod, all patients who were symptomatic or with two or more of the variables above the normal rangewere considered as obstructed and underwent a dismembered pyeloplasty. The variables were then re-assessed6 months after surgery. The RIR was evaluated using duplex Doppler ultrasonography with a 3.5-5 MHz transducer,by the same operator. Differences between obstructive and unobstructive unilateral hydronephrosis wereestimated from the mean values of the variables assessed and Student's t-test used to determine significantdifferences. The correlation between the T/2 and RIR before and after surgery was also evaluated. RESULTS:During follow-up the RIR was abnormal in 27 of 30 patients with hydronephrosis who were considered tobe 'obstructed'. Twenty-three of these patients, selected for surgery, had a positive diuretic renogram;11 had loss of differential renal function and 16 had recurrent clinical symptoms. There were significantdifferences in the mean RIR and T/2 between obstructed and unobstructed patients. Six months after dismemberedpyeloplasty, the RIR returned to normal in all patients except three in whom it was previously > 1.1.The diuretic renogram, if initially showing pathology, always became normal. The RIR did not change inpatients with an unchanged and severe loss of differential renal function before and after surgery. CONCLUSIONS:In this study the RIR was a good index of obstruction in children with unilateral hydronephrosis andit correlated well with the results of diuretic renography. The specificity of the RIR was reduced wheneverthere was severe renal damage.

Abstract: Among 36 children, mostly less than 1 year of age, referred for a completeduplex-system anomaly, 18 were diagnosed before birth by obstetrical ultrasonography where a diagnosisof dilated upper urinary tract was the most frequent report; in the remaining cases urinary tract infectionwas the main presenting symptom. Five children had bilateral anomalies. Principal diagnoses associatedwith the complete duplex system were: 18 ureteroceles (UC) (11 extravesical [EUC] with bladder-neck orurethral extension, 7 intravesical [IUC]), 5 ectopic ureters without UC and 28 lower-polar vesicoureteralreflux (VUR) associated in 6 with upper polar VUR. The initial assessment was based on a voiding cystogramand radionuclide scan. Renal-polar function was severely impaired when major ureteral ectopia or severeprimary reflux was present. Primary surgery was performed in 8 patients, demolitive in 4 (3 upper-polarnephrectomies, 1 nephrectomy) and reconstructive in 4 (duplex en-bloc reimplantation); staged managementwith minimal endoscopic incision was undertaken in 15 UCs (9 EUCs and 6 IUCs). Expectant management waselected in all cases of mild primary, single, or double VUR not associated with UC and was followed byspontaneous reduction in one-half of the cases. Secondary VUR complicated endoscopic incision in 2 of6 IUCs and 5 of 9 EUCs; a certain degree of functional improvement after decompression could be observedin all IUCs versus only 2 EUCs. Twenty-one patients requested secondary surgery; 17 needed an open intravesicalprocedure for ureteral reimplantation, combined in 8 with UC excision and bladder-floor reconstructionand in 5 with upper-pole nephrectomy. A nephrectomy was required in 4 cases. All primary or secondarydemolitive procedures involved 9 of 11 EUCs extravesical and 2 of 5 ectopic ureters. EUCs and ureteralectopia were associated with severe renal-polar damage, and function was rarely affected by primary decompressiveprocedures even in prenatally detected, uninfected cases. Endoscopic incision of EUCs was frequentlyfollowed by secondary VUR, which made secondary intravesical operations more complex. For these reasons,primary elective resection of a dysplastic upper pole is preferable in most cases to temporary decompressivemeasures. Conservative surgery is always indicated in IUC, which may benefit from endoscopic decompression.Isolated VUR involving the lower pole of a completely duplicated system may respond to expectant managementin a significant number of cases.

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Abstract: PURPOSE: To minimize varicocele treatment in children and adolescents amultidisciplinary approach that includes surgery and operative radiology has been used at our institutionsince 1991. We present our results during this 7-year period. MATERIALS AND METHODS: From January 1991to December 1997 we examined 477 patients 4 years 5 months to 25 years 4 months old (mean age 13 years3 months) with varicocele, of whom 367 (396 varicoceles) required treatment. Percutaneous sclero-embolizationwas suggested as the primary treatment of choice in all cases, while surgery was reserved for selectcases. A total of 366 cases followed at least 6 months (mean 1 year) were entered into this study. RESULTS:Only 7.1% of the patients or families preferred surgery. In 47 patients sclero-embolization was not possibledue to technical problems or vascular anomalies. Sclero-embolization was successful in 79.4% of 277 patients,and retroperitoneal ligation was successful in 88.7% of 124. Since 1995 ligation of the whole spermaticbundle above the vas deferens has been preferred, and only 1 recurrence has been observed in 60 cases.CONCLUSIONS: Percutaneous sclero-embolization is a minimally invasive treatment of varicocele that isfeasible in children and adolescents. Most patients prefer this therapy, although it is not as safe assurgery. When open surgery is required, complete ligation of the whole vascular pedicle above the vasdeferens offers excellent success.

Abstract: With advances in obstetric ultrasound, prenatal observation of the pathogenesisand natural history of obstructive uropathy is possible. The Authors describe the ultrasonographic appearanceof a fetal monolateral urinoma associated with a severe hydronephrosis and the progressive reductionof the urinoma during the last weeks of the pregnancy until complete disappearance in the first monthof life. Urinoma detected antenatally, with onset very early in gestation, usually is associated withsevere urinary tract obstruction, like posterior urethral valves or ureteropelvic junction obstructionand is always associated with a severe impairment of ipsilateral renal function.

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Abstract: Scrotal hematoma is an uncommon presentation of neonatal adrenal hemorrhage.Nine previous cases of such an association have been reported in the literature, and unnecessary surgerywas carried out in five of these cases. The authors report three new cases observed during a 3-year periodand stress the critical role of scrotal and abdominal ultrasonography in order to avoid unnecessary surgicalexploration.

Abstract: A giant cavernous hemangioma of the left arm with severe thrombocytopeniaand consumptive coagulopathy was observed in a neonate. Initial treatment with prednisone, platelet transfusions,and clotting replacement failed to control the bleedings. The child was then treated with daily subcutaneousinfusions of interferon alpha-2a. Coagulopathy rapidly improved and transfusions were drastically reduced.The hemangioma regressed progressively and disappeared after 4 months of treatment.

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Abstract: Neonatal adrenal gland hemorrhage is not uncommon. Its etiology is stillquestionable, though hypoxia (antenatal, labor-induced, or neonatal) seems to be usually associated withthe event. Symptoms include acute shock associated with severe blood loss. Milder cases exhibit anemiaand jaundice associated with a suprarenal mass. Ultrasonography (US) has replaced urography in the diagnosisof this condition, demonstrating site and size of the lesion and allowing an accurate follow-up. Theauthors report on a series of 11 patients; US was performed on 9 of them. In 10 cases the lesion wasunilateral and in one case bilateral. Antenatal US diagnosis was possible in 2 cases and confirmed neonatally.The extant 9 infants developed a palpable abdominal mass or were diagnosed while examined for other conditions.All cases were evident by the 2nd week of life. Eight patients exhibited spontaneous hemorrhage resolution,as shown by repeated US and/or urographic exams. Three patients underwent surgery because the lesionseemed stable. In these 3 instances, CT scans were inconclusive. This paper is aimed at reporting onthe radiologic and US features we observed, with a special emphasis on the changes in size, shape andUS features in the cases which resolved spontaneously. The first US examination is not conclusive anddoes not allow an unquestionable differential diagnosis. Only lesion evolution with progressive decreasein its size (changes in US features are less useful) allows unquestionable US diagnosis and preventsunnecessary surgery.

Abstract: Meckel's diverticulum (MD) is a well-known cause of lower gastrointestinalhemorrhage, particularly in the pediatric age group. The radionuclide 99mTc-pertechnetate has been founduseful in visualizing MD which contain gastric mucosa. This test is predicated of the affinity of theisotope for the parietal cells of the gastric glands. In an attempt to evaluate the sensibility and specificityof pertechnetate, the clinical data and scintigrams of 27 patients with suspected MD were reviewed. Thescintigram correctly identified MD before operation in 6 of 7 patients. The false negative study occurredin a MD without gastric mucosa.

Abstract: Dumbbell neurogenic tumours are unusual neoplasms in the pediatric agegroup. Six cases all in children under 10 years of age, have been reviewed with respect to diagnosis,management and results. Neurologic deficits have been found in 4 patients only; in the other 2 casesthe tumours were occasionally discovered. Myelograms, sometimes associated with CT scan, allowed a correctdiagnosis in all the patients. Initial treatment consisted in all the cases in laminectomy or laminotomywith total excision of the extradural tumour. The primary paravertebral tumours have been removed inone patient during the same neurosurgical operation, and in other three patients at a second stage. Twopatients did not require the second operation: one recovered after chemotherapy and the other died fewdays after the first surgical procedure. Five patients are still alive: two, who had the tumour occasionallydiscovered, are free from disease; among the other 3 patients, presenting with neurological symptoms,1 is free from disease without neurological symptoms and 2 have still long lasting sequelae. The authorsemphasize the role of early diagnosis to prevent neurologic abnormalities and to achieve better results.

Abstract: Advantages of primary fascial closure of abdominal wall defects are mainlyin reducing the number of staged procedures with related complications and the need of multiple operation.Nevertheless correction of large defects still remains a challenge to pediatric surgeon. Postoperativeparalysis and mechanical ventilation after intraoperative milking of intestinal content and abdominalmuscles stretching have been reported to reduce the risks of "forced" primary closure. A series of 64Omphalocele and Gastroschisis has been reviewed. Associated anomalies are still the main cause of mortalityamong Omphalocele. Prematurity plays a secondary role on survival of Gastroschisis cases; deaths weremainly due to sepsis. Primary respiratory insufficiency affected a large number of Giant Omphalocelecases (larger than 5 cm with herniated liver) and was associated to a restricted chest structure. Allthese cases died in the first weeks of life. Primary closure with or without postoperative paralysisand mechanical ventilation showed to reduce in a significant way the postoperative complication ratecompared to staged procedures. Mortality and hospital stay were not significantly influenced by differentkinds of surgical treatment among Omphalocele. Associated anomalies are an unavoidable limiting factorto survival. Among Giant Omphalocele the use of aggressive primary fascial closure with ventilatory supportshowed in our hands to be a safe procedure provided that a preoperative selection of cases on the basisof chest X-ray and blood gases has been made.

Abstract: We discuss data on urinary tract dilatations diagnosed in utero from February1980 to May 1988. Over 8,900 pregnancies prenatally investigated with ultrasound during second and thirdtrimester in our center. We diagnosed 401 fetal defects (4.5%) with 121 urinary system anomalies (1.35%).In 90 cases (1.01%) urinary tract dilatation was present, representing the most frequent urinary pathologyin utero (74.3% of all urinary anomalies). We describe some diagnostic findings as particularly usefulin differential diagnosis of functional and obstructive conditions, stressing the possibility and thedifficulty of diagnostic accuracy for urinary tract anomalies. The perinatal outcome of each conditionis reported.

Abstract: Despite prenatal diagnosis, maternal transport and early perinatal treatmentin specialized hospitals, improvement in overall mortality has not been observed among newborns withabdominal wall defects (omphalocele and gastroschisis). A comparison has been made, for both anomalies,between 55 cases treated in the periods 1967-1979 and 30 treated in the periods 1980-1985. In this lastgroup 14 prenatally detected cases were separated from cases discovered at birth. Recent advances intreatment have reduced mortality rates for both of these anomalies. This was especially true for gastroschisis;in omphalocele cases, associated abnormalities appeared to be an unavoidable limiting factor in survival.With prenatal diagnosis a surprising increase in mortality rate was observed among omphalocele casesdetected before birth. A possible reason for this is the total number of antenatally diagnosed casesthat, with maternal transport, are concentrated in centers where surgical facilities are available. Beforeintroduction of antenatal diagnosis, most of these cases would never have been observed by the pediatricsurgeon because of death prior to referral or treatment. Gastroschisis cases may benefit more from antenatalrecognition and early treatment because multiple abnormalities or immaturity are not so important limitingfactors in survival as in omphalocele cases. Reduced trauma and contamination of exposed viscera, immediatetreatment and adequate supportive measures may significantly reduce mortality rate in gastroschisis cases.Operative delivery of fetuses with an abdominal wall defect is controversial. The risk of vaginal routedelivery has been over emphasized. Intrapartum rupture of an omphalocelic sac was an extremely rare eventbefore introduction of antenatal diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

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Abstract: Nine cases of fetal intrathoracic anomalies detected in utero and followedto birth are reviewed. There were 6 congenital diaphragmatic hernias (CDH), one congenital pleural effusionand two isolated cysts of the lung. All these conditions were potentially responsible for neonatal respiratorydistress and received early intensive treatment after maternal transport and delivery had been arrangedin a center with thoracic surgical facilities available. The risks of a delayed or missed diagnosis werethus avoided, especially for CDH. Despite intensive, traditional, respiratory support, started in thedelivery room, mortality among prenatally detected cases of CDH was paradoxically high (83%), comparedto mortality among 7 cases of CDH not detected in utero, referred in the same period to our Institution,and symptomatic within 6 h from birth (63%). With prenatal diagnosis the total number of CDH cases referredto a surgical center before birth increases. Many cases which would never have been treated in the pastbecause of death before referral and treatment for severe pulmonary hypoplasia not compatible with lifeare thus observed and sometimes treated. Nevertheless, lung development continues to be a determiningfactor for survival even when intensive treatment at birth is available. Responsiveness to therapy isunpredictable before birth and proposed antenatal treatment is still far from being a realistic option.For the other three newborns, where a pleural effusion and pulmonary cysts were found, prenatal diagnosishelped to start appropriate treatment and to prevent neonatal hypoxia in two of them. In the third case,with an incommunicant, isolated pulmonary cyst, the outcome would have been favourable even without aprenatal diagnosis.

Abstract: Appropriate management of fetal uropathies depends on accuracy in assessingthe severity of urinary tract obstruction and renal damage, and in predicting the potential for recoveryafter surgical correction. A review of 40 fetuses aged between 20 an 39 weeks referred to us for prenatalcounseling for a suspected anomaly of the urinary tract, has been made. Reliability of our diagnosticresources has been retrospectively evaluated on the basis of clinical, ultrasonographic and radiologicalpostnatal data. Conservative approach has been adopted in all our cases. None intrauterine surgery wasattempted; pre term delivery was advised only in two cases. Our results confirm poor prognosis of fetuseswith marked decrease of amniotic fluid within the 24th week of gestational age. After this date the amountof amniotic fluid alone may not be a completely reliable prognostic factor. Ultrasonographic aspect offetal kidneys and, in some occasions, chemical analysis of fetal urines may accomplish our prenatal studyand help to predict the degree of neonatal renal function and potential of survival.

Abstract: The authors report on clinical experience from 20 infants who were undersix months of age, and who had been referred during the last five years for pelvi-ureteric junction obstruction.Any over-eagerness to arrive at an early diagnosis, mostly on the basis of prenatal ultrasonographicsuspicion, must be tempered. Pyelocaliceal dilatation in newborn infants may not be related to obstruction,and overtreatment must be avoided by careful preoperative evaluation. Tc-DTPA diuretic computerised renographyproved extremely reliable, whereas IVP may be unsatisfactory and misleading. Whenever surgical correctionwas indicated for a documented pelvi-ureteric junction obstruction, Anderson-Hynes pyeloplasty was performed,except in one case, where severe dysplastic changes in the hydronephrotic kidney necessitated nephrectomy.Splinting of the anastomosis was adopted in newborn with thin ureters. An infant with left pelvi-uretericobstruction and right multicystic kidney died from renal failure a few days after right nephrectomy andleft pyeloureteroplasty. No operative failure was otherwise observed, except for a transient anastomoticobstruction in two cases. Treatment of pelvi-ureteric obstruction in the first 6 months is a seriousundertaking and should be restricted to experienced centres with facilities for intensive neonatal care,even for dialysis.

Abstract: Prenatal demonstration of congenital diaphragmatic hernia is described.Planned, early treatment is made possible with improvement of survival.

Abstract: The role of radionuclide investigation of urinary tract pathology in pediatricpatients (computerized radionuclide urography and radionuclide cystogram) is discussed. Advantages ofreliable morphological and functional study with a non invasive, low radiation procedure are emphasized.

Abstract: Results of US study in 30 children with various renal lesions are reported,and compared with clinical and surgical features. Different ultrasonographic aspects are discussed withspecial interest on cogenital abnormalities. US is proposed as first choice investigation in newbornswith antenatal ultrasonographic demonstration of renal lesions and in all patients where a mass of renalorigin is suspected. Renal function, nevertheless, must be investigated with radiologic and/or radioisotopictechniques. US have still a large indication in short term follow-up of renal lesions where surgicaltreatment is not indicated.

Abstract: A large series of malignant and benign conditions are generally collectedunder the term of abdominal masses. Their common aspect is the lack, in most of the cases, of peculiarclinical features which may help early differential diagnosis. In many cases the mass is detected lateafter a long period of vague, aspecific symptoms. 40% of these space occupying lesions of the abdomenare of malignant origin and delayed detection and investigation affect clinical course. Preoperativestudy of abdominal masses is a problem of primary importance in pediatric surgical practice. A changingattitude is registered towards many diagnostic procedures and the role of largely diffused techniqueslike angiography is controversial. The introduction of ultrasonography makes in many cases intensiveradiologic investigation unwarranted and academic. The Authors discuss the real role and targets of preoperativeinvestigations of abdominal masses and refer on their experience based on 52 cases, to underline someclinical aspects and analyse their diagnostic approach to this pathology.