The Vecchietti operation is suitable only for women without previous vaginal surgery. Similarly, a blind-ending sinus is found in many hypospadias patients and can be explained by the embryologic development. However, the creatinine clearance ratio can be used to monitor renal function in patients with renal failure. Retractile testes are typically normal in size and consistency, whereas undescended testes may be smaller and softer than normal. The logbook is an instrument for recording the voiding regimen, but it can also be used as a pedagogic instrument in which the therapist and the child together can see how the child has succeeded, and what changes are needed for even better results. The degrees of reflux are subjectively reported as "mild," "moderate," or "severe. Alkalosis is most frequently caused by hyperventilation, which is often the result of central nervous system disorders or psychological disease. Of children on continuous prophylaxis, 16% developed new scars or parenchymal thinning, and these children had breakthrough infection while on prophylaxis. Rehydrational fluids have a higher sodium concentration and are typically given in small doses (50 mL/kg) over 4 hours in mild dehydration. The overactivity can be seen either as a staccato flow pattern caused by periodic bursts of pelvic floor activity during the voiding, resulting in dips in flow rate and coinciding with high bladder pressure, or as fractionated voiding with complete interruption of the urinary stream. Of the 33 reclosures, 19 (57%) have progressed to bladder neck reconstruction and 12 of these 19 demonstrated at least social continence without the need for intermittent catheterization. D, A right antegrade nephrostogram with the patient in the prone position is shown. Because children generally have less fat than adults do, both within the renal sinus and around the kidney, the central echogenic renal sinus is less prominent early in life. However, the diastasis is minimal and rarely requires osteotomy for pelvic reconstruction. Regardless of the method of repair, the uterus must be anchored in such a way that it is solidly fixated in the pelvis and less prone to prolapse. Ingram and Hollman noted that 38% of normal boys aged 10 weeks to 13 years had no flow detectable with color Doppler ultrasound. It is conceivable that abnormal spatial and temporal progression of renal ascent and rotation combined with renovascular formation may lead to unfavorable ureterovascular configurations. The ureterocele may vary in size, from being so large that the inexperienced practitioner may mistake it for the bladder to being so collapsed that it is not recognizable even on a careful ultrasound examination. It is probably wise to ask for child psychiatric consultation or intervention in children and adolescents treated with psychotropic agents. A technique has been described to make a phallus from a skin flap, using the technique for female-to-male gender reassignment, and to "piggy-back" it onto the natural penis. These investigators found that only 9 of 48 contralateral kidneys showed subnormal compensatory growth; 4 of these patients had a renal abnormality in the solitary kidney. In fact, certain potassium channels ("inward rectifier" channels) are open in the resting cell, but little current flows through them because of this balance. New investigative tools and research have allowed us to study with much greater detail and precision the various components, including neurologic, muscular, urodynamic, and hormonal mechanisms, that may intricately interact to produce different patterns of bladder dysfunctions and their relentless changes. The cystoscope is passed, and the bladder wall, trigone, bladder neck, and both ureteric orifices are inspected. One possible explanation is prenatal environmental exposure to a growing group of compounds termed endocrine disruptors. Radiographic Evaluation B Bladder diverticula may be diagnosed by various radiologic methods.
In their pediatric genitourinary database of 5084 children, Blane and colleagues3 found a 1. Lastly, although excessive use of diuretics can impair renal function in all patients, the consequences are obviously more serious in patients with underlying renal disease. Children younger than 2 years of age have reflex micturitions that facilitate the postoperative period. Theophylline is metabolized by the liver, so usual doses may lead to toxic concentrations of the drug in patients with liver disease. This can stay in place for 6 weeks to 6 months, depending on the surgery, and it is taken out as an outpatient procedure via a cystoscopy. Alterations in renal differentiation are the result of disordered cell interactions in most cases. Unfortunately, omapatrilat causes a significant incidence of angioedema in addition to cough and dizziness and has not been approved for clinical use. The elements of bowel dysfunction, constipation, fecal impaction, and incontinence must be properly considered in the evaluation of children with myelodysplasia and neuropathic bladder dysfunction. As described in Chapter 10, some of these drugs have selectivity for cardiac 1 receptors, some have intrinsic sympathomimetic activity, some have marked direct membrane effects, and some prolong the cardiac action potential. Multiple etiologies in abnormal development have been proposed, including genetic, hormonal, and environmental influences. In the open ring variant, a patent processus vaginalis exits the internal inguinal ring, and the gubernaculum is present. Central nervous system excitatory agents that act on the chloride channel include picrotoxin and bicuculline. If there is no reflux driving surgery at the bladder level, and if upper pole function justifies salvage, a renal-level ureteroureterostomy or ureteral pyelostomy may be employed effectively. Regardless of the abdominal approach, a 8- to 10- cm segment of sigmoid colon is isolated on the left colic or superior hemorrhoidal artery. The effect is associated with the separation of the endothelial cells, which permits the transudation of fluid and molecules as large as small proteins into the perivascular tissue. However, numerous potential antagonists working together through several steroid-dependent signaling pathways could prove to be hazardous to normal sex differentiation. Immature detrusor-sphincter coordination with some degree of detrusor overactivity and interrupted voiding commonly occurs in the first 1 to 2 years of life. Of the two fetuses with patent urethras that survived the neonatal period, one had renal impairment and died at 4 months of age from bronchopneumonia, and the second died at 3 months from necrotizing enterocolitis. Highly intelligent people daily voluntarily donate one of their kidneys to another person. Diazoxide is partially metabolized; its metabolic pathways are not well characterized. Local antibiotic susceptibility patterns should be consulted and updated routinely. A large component of the pressor response is due to direct contraction of vascular-especially arteriolar-smooth muscle. Abscesses can be intraparenchymal or perirenal; they demonstrate an enhancing wall surrounding a central, low-density, nonenhancing cystic area. These anomalies can be broadly divided into three categories: (1) congenital abnormalities, (2) anomalies associated with other conditions, and (3) acquired or iatrogenic anomalies. Given that the ureter acts as an active peristaltic pump, as opposed to a passive fluid conduit, the pressure gradient between the renal pelvis and the bladder may not remain constant, as was presumed by Whitaker. With the long-term use of sedative-hypnotics, especially if doses are increased, a state of dependence can occur. The steep learning curve is attributed mainly to the requirement for intracorporeal suturing and knot tying. Although it is as yet incompletely determined whether these physiologically significant changes will ultimately lead to deterioration in renal function if the obstruction remains uncorrected, there are accumulating experimental and clinical data that such a correlation exists. C pressure in the ureters and renal pelvis, resulting in dilated ureters and hydronephrosis.
Because pressure-flow studies are performed only in hydronephrotic kidneys, there was a lack of normal controls for establishing what pressure-flow values might be encountered in nonhydronephrotic kidneys. The clinical course is that of stabilization of renal function, at normal or somewhat below normal levels, or progressive azotemia. Pneumoperitoneum is produced by Veress needle insertion while the umbilicus and abdominal wall are elevated with towel clips. Intraluminal anomalies are rare and are mainly described as valve-like processes and benign fibroepithelial polyps. Very high concentrations-well above those achieved even with maximal therapy-are required to inhibit the response of airway smooth muscle to nonmuscarinic stimulation. Impaired Arousal Mechanisms the idea that enuretic children are "deep sleepers" is not new. The hypothesis suggested by these studies-that asthmatic bronchospasm results from a combination of release of mediators and an exaggeration of responsiveness to their effects- predicts that asthma may be effectively treated by drugs with different modes of action. Allergic Reactions the thiazides are sulfonamides and share cross-reactivity with other members of this chemical group. Anticholinesterases block the degradation of acetylcholine and thereby prolong its action. Long-term results of open or laparoscopic autoaugmentation have not been consistent,128 and autoaugmentation has not achieved wide acceptance as a reconstructive technique in children. Presumably, like the very high 14 part I: Basics is reached somewhere between the first and the second birthdays. If upper tract dilatation is secondary to bladder distention, catheterization of the urinary bladder and complete decompression of the lower urinary tract-by aspiration of the bladder urine into a syringe, if necessary-can lead to rapid improvement in the appearance of the kidneys. The most specific V1 vasoconstrictor 2 3 8 agonist synthesized to date is [Phe, Ile, Orn]vasotocin. To achieve these functions, the ureter enters the bladder with an oblique intramural passage, which extends submucosally to open onto the trigone. If unilateral cryptorchidism was present, studies indicate that impaired germ cell production may be bilateral even though one testis was descended. Indications for surgery include difficulties with hygiene, phimosis, balanitis, and psychosocial stressors. Healthy newborn infants are growing at a faster rate than at any other stage of life. The degree of hypovolemia can often be gauged from the history, physical examination, and supplementary laboratory data. Multiple adverse effects associated with lithium therapy have been found and are discussed in Chapter 29. Because this is a form of bladder augmentation that does not involve the harvesting of gastrointestinal segments and requires very little suturing, it is adaptable to minimally invasive techniques. An excellent prognosis is more common than a good prognosis, which is more common than a poor prognosis, which is more common than a catastrophic prognosis. Urotherapy is based on behavioral therapy; the child has to modify his or her habits. A hydrocele may also develop acutely after testicular torsion, torsion of the appendix, testis epididymitis, or trauma. The pathogenesis of these abnormalities is discussed in the following sections, as are surgical methods of vaginal reconstruction or replacement. Splenogonadal Fusion Approximately 150 cases of splenogonadal fusion have been reported in the literature. Reduction in cardiac output, resulting from either left or right ventricular dysfunction, also eventually leads to renal dysfunction resulting from reduced perfusion pressures. Early adolescents begin to weave their anomaly or chronic illness into their developing perception of self, including body image, identity, self-esteem, sexual self-esteem, and mastery or autonomy. Laparoscopic autoaugmentation has been performed in animal models123 and in children,124-126 by both a transperitoneal and an extraperitoneal approach. Bladder-Sphincter Dysfunction during Bladder Emptying Dysfunctional Voiding Dysfunctional voiding is characterized by incomplete relaxation or overactivity of the pelvic floor muscles during micturition, and the term may be applied only in the presence of staccato voiding on repeat uroflowmetry measurements or during urodynamic investigations. A medially or caudally ectopic ureter inserts medial and distal to the normal position on the trigone.
Similarly, the exacerbations most prevented are the ones most important to prevent: Omalizumab treatment reduced exacerbations requiring hospitalization by 88%. Thus, caution must be exercised in starting a -receptor antagonist in patients with compensated heart failure even though long-term use of these drugs in these patients may prolong life. Although an undescended testis may function poorly for fertility, the usefulness in terms of androgen production must be considered, especially in cases of a solitary testis. These results indicate the potential for a molecular basis of the ureteral dysfunction, but also may suggest that the appearance of hydronephrosis may be the result of a growth disturbance not mediated by physical obstruction. The technique is to apply gentle pressure and to use the dilators regularly for 30 minutes two or three times a day. If the findings at the time of initial evaluation are equivocal, immediate exploration is indicated. The theory has been controversial and considered most plausible when applied to duplex systems. In our experience, if the glans is sewn to the pubis, it is often too high and too prominent. After the acute episode is healed, the scans may show (1) a normal pattern, (2) generally diminished uptake and small kidney volume, (3) diminished uptake in the medial kidney, or (4) polar defects with diminished uptake in the renal poles. Associated Abnormalities There is a high incidence of associated malformations, particularly if there is only one ureter. Voiding dysfunction has also been described, with staccato urinary flows, increased pelvic floor activity during voiding, and resulting incomplete bladder emptying. Differential diagnoses include multicystic renal dysplasia, obstruction from the lower urinary tract, renal cysts, and perinephric urinomas. Although the cystoscopes shown are the ones I prefer, a variety of excellent instruments with similar characteristics are available from various manufacturers. Renal scintigraphy provides functional assessment of the kidneys but supplies little anatomic information. Treatment is surgical, with removal of a poorly functioning upper pool moiety (heminephrectomy) or implantation of the ectopic ureter in the bladder if the function is good in the corresponding part of the kidney. After closure of the myelocystocele, long-term follow-up is mandatory to evaluate for subtle changes in neurologic examination findings that could herald cord tethering. Hyponatremia When used in patients with severe renal impairment, parenterally administered mannitol cannot be excreted and is retained intravenously. The most important indication is probably in patients in whom conventional treatment of daytime voiding disorders is unsuccessful. Approximately 60% of kidneys with significant degrees of reflux show an abnormal renogram within the first 4 weeks of life, before a urinary tract infection had occurred in the majority of cases. Hoxa10 mutant mice demonstrate cryptorchidism; the cause may be anterior homeotic transformation of L1 and L2 nerves with incorrect specification of genitofemoral nerve motoneurons or abnormal target tissue innervation or both. The sigmoid segment can be advanced to the perineum in an isoperistaltic fashion, or it may be rotated 180 degrees on its mesentery to obtain a tension-free anastomosis at the perineum. With this variation taken into consideration, formulas can be derived that estimate basic fluid requirements (Table 3-615). The technique teaches the child how to relax the pelvic floor muscles during micturition: the child sits on a toilet with a flow transducer, watching the flow curve and the electromyogram online on a computer monitor, trying to empty completely in one relaxed continuous portion. Balanitis refers to inflammation of the glans, and posthitis to the foreskin component of this common entity. Interventions for adults may include education about sexual functioning, sexual pleasure, satisfactory sexual intercourse, positions for intercourse, masturbation, verbal intimacy, sexual intimacy, and the importance of intimate activities other than intercourse-touching and sexual touching. The major drawback of robotic surgery is the lack of tactile sensation or feedback for the surgeon. Amar22 noted that, in girls, especially those with small diverticula, the associated reflux resolves spontaneously as the bladder matures; in boys, the diverticula tended to be larger, and the associated reflux was less likely to disappear. As the child grows into adolescence and adulthood, the sagittal and coronal renal axes gradually become more oblique as the psoas muscles enlarge and displace the lower poles anterolaterally. This protects the kidneys from vesicoureteral reflux, and undiversion can be performed at an older age. Neutrophils attracted by mucosal inflammation are an essential part of the bacterial clearance mechanism, but must migrate between the renal tubular cells to gain access to the bacteria within the tubular lumen. Female Reproductive System Studies with knockout mice have confirmed a role for prostaglandins in reproduction and parturition.
Voiding cystourethrogram in a 1-monthold girl with mild right antenatal hydronephrosis. The addition of bicarbonate can worsen hypokalemia, leading to neuromuscular complications. Drugs that inhibit renin have been available for many years but have been limited by low potency, poor bioavailability, and short duration of action. More rarely, an ectopic ureter can end at a higher site along the course of the Gartner duct with an opening at the level of the cervix or uterus (<5%). For small, ectopic, "invisible" kidneys or complex duplex excision with extensive ureterocelectomy and lower urinary tract reconstruction, a transperitoneal approach is recommended. This misconception is strengthened by the fact that most bed-wetting children keep their problem top secret even from their closest friends. This is the detrusor pressure (at any given volume during the filling phase) at which the first drops of urine pass the meatus. Because the neural ganglia controlling the facial muscles are situated very close to the pontine micturition center, it is tempting to speculate that a small neurologic lesion located in this area, which is probably congenital in origin and genetically predetermined, may be responsible for the peculiar facial expression and the bladder dysfunction. Psychoneuroendocrinologic implications of these conditions fall within the realm of both psychiatry and psychology. Biliary ascites secondary to spontaneous perforation of the bile ducts had accumulated within hydrocele sacs. Diabetic ketoacidosis is the result of anaerobic metabolism of glucose to -hydroxybutyrate and acetoacetate. This endoscopic technique has shown initial results comparable to those obtained with the open technique. Consequently, it has become desirable to identify tests capable of predicting renal functional outcome after birth in fetuses in whom a urinary tract anomaly has been detected. There is some contractile activity in the pelvis; it is not entirely a passive storage and confluence organ, although these contractile pressures are low. The robotic instruments are placed through 5- or 8-mm trocars allowing for 6 degrees of freedom. Cromolyn and nedocromil appear to have this effect (see Chapter 20) and have been used in the treatment of asthma, although the molecular mechanism underlying their action is not fully understood. Sustained-release metoprolol is effective in reducing mortality from heart failure and is particularly useful in patients with hypertension and heart failure. Neither drug has significant maternal cardiovascular toxicity in the recommended doses. Deflux is biodegradable, is nonimmunogenic, and has no potential for malignant transformation. Any productive examination of the external genitalia should begin by gaining the confidence of the parent and child. Whenever the "renal pelvis" appears to be mildly distended only on a single projection, it is important to consider the possibility that normal vessels in the renal hilum are being confused for a distended renal pelvis. A transperitoneal approach is occasionally necessary, and this has now been described using laparoscopic techniques. The upper pole system associated with the ureterocele typically involves only the parenchyma subserved by the upper pole infundibulum,24 however, which is usually less than one third of the renal function of the kidney. Of these causes of airway obstruction, contraction of smooth muscle is most easily reversed by current therapy; reversal of the edema and cellular infiltration requires sustained treatment with anti-inflammatory agents. Both ureteral catheterization and Fairley bladder washout localization techniques are invasive and impractical. Kessler and associates37 reported retrospectively on 14 of 23 (61%) patients with spontaneous regression at a mean of 10 months. Gastrointestinal tract smooth muscle-Histamine causes contraction of intestinal smooth muscle, and histamine-induced contraction of guinea pig ileum is a standard bioassay for this amine. Although there is general agreement as to the cosmetic benefit of abdominal wall reconstruction, it is controversial whether it improves bladder, bowel, and pulmonary function. When percutaneous pressure-flow studies are performed in patients with concomitant lower urinary tract anomalies, effective catheter drainage of the bladder during the study is critical.
Torsion within the tunica vaginalis is termed intravaginal torsion; it results from an abnormally high investment of tunica on the spermatic cord within the scrotum, termed the bell-clapper deformity. These are certainly poor results and should lead us again to question the role of early genital surgery. Given the complexity of factors contributing to normal sexual function, more prospective long-term studies are necessary to assess outcomes from contemporary techniques. Table 4-4 eyPointsforAssessment K Examine the whole renal tract Measure the kidneys Measure the amniotic fluid volume Search for extrarenal abnormalities Consider karyotyping Ascertain the family history Scan the parental kidneys ofHyperechogenicKidneys Further Prenatal Investigation of Dysplastic Kidneys Detection of dysplastic kidneys should stimulate a detailed examination of the fetus for other structural abnormalities, including heart, spine, extremities, face, and umbilical cord, because up to 35% of these fetuses have extrarenal anomalies. With ultrasound, it may be difficult to visualize the isthmus, as in this case where it was missed. After the clitoroplasty is completed, the child is rotated prone and placed on chest and pelvis rolls. The mechanics of urine transport in the upper urinary tract: the dynamics of the isolated bolus. In a contemporary Washington State report, 40% of infants hospitalized with a febrile urinary infection were not even evaluated for reflux, despite clear recommendations to do so by the American Academy of Pediatrics. In females, the tumors arise in the bladder or vagina or, rarely, from the uterine cervix. Excision of the redundant urethral tissues and treatment of the distal stenosis are required. The investigators also noted a thickened basement membrane in the primitive ducts in 64% of cases, which rendered it abnormally stretchable. We believe that the physician should declare his or her personal beliefs to the family. B, A catheter was placed to facilitate the surgical removal and adaptation of the mucosal edges. As important decisions are made on the relative renal function of each kidney, it is essential that its evaluation follow a rigorously standardized protocol. Endoscopic examination in these children is typically negative and is not indicated. Glutamate, which is released with substance P from these synapses, presumably plays an important role in transmitting pain stimuli. Their optimistic results did not prove, but certainly did suggest, that these children can be happy and well adjusted and can do relatively well. It is very clear now that definitive repair of all aspects of the cloaca should be addressed in the same sitting. A second 5-mm port is placed under direct vision in the midline just over the pubis, a position that ultimately will be hidden in the pubic hairline. Studies of asthmatic humans, however, have shown that treatment with atropine causes only a reduction in-not abolition of-the bronchospastic responses to antigens and to nonantigenic stimuli. We have seen two patients with duplicated vaginas side by side and duplicated bladders one on top of the other, demonstrating the complexity of the anatomy at times. Infants with abdominal wall defects such as omphalocele, gastroschisis, or umbilical hernia, as well as prune-belly syndrome or bladder or cloacal exstrophy, often have undescended testes. The umbrella cells have a long half-life; however, they are rapidly regenerated when the urothelium is damaged. At the time of surgery, it is easy to delineate this triangle by drawing two lines along the cutaneomucosal junction of the prepuce on each side. Retrograde femoral vein catheterization with embolization or sclerotherapy has found only limited appeal among pediatric urologists. Rarely, bladder diverticula are acquired iatrogenically, such as after antireflux surgery in which defects in the bladder muscular wall were not appropriately reapproximated. After the initial access to the peritoneal cavity at the umbilicus using the Hassan technique, in which a 10-mm trocar is placed, two additional trocars are placed: a 12-mm trocar along the lateral border of the left rectus muscle at the umbilical level and a 5-mm trocar along the lateral border of the right rectus muscle at the umbilical level. Recent data from Gearhart and associates80 described 14 patients who had undergone successful complete primary closure of exstrophy in infancy and were then referred for incontinence. The main key to success is the motivation of the patient, and retrospective success rates of 78% having "normal sexual function" have been reported. Children with a nephrotic or nephritic syndrome are more likely to show more severe histologic alterations on biopsy specimens and have a worse long-term prognosis.
Most pediatric genitourinary conditions affect child development, are affected by it, or both. Gait usually is not affected, although it may be delayed, and the children tend to roll to their side and use their arms to sit from a supine position. Ultrasound used to detect a dilated ureter behind the bladder may be particularly useful in this situation. A series of sutures is used to evert the detrusor ("keeling") until the bladder neck is reconstructed to a normal diameter. This diary provides indispensable information regarding bladder and bowel function. Treatment is primarily directed at reversal or control of atherosclerosis and requires measurement and control of hyperlipidemia (see Chapter 35), hypertension (see Chapter 11), and obesity; cessation of smoking; and control of diabetes, if present. The debate on how to best support this group continues, and the nurse has a responsibility to keep up to date with regard to new research and practice issues. Therefore, a hydronephrotic kidney that is found to have little or no reserve capacity for supraphysiologic flow rates may not require surgical intervention at the time the pressure-flow study was performed but should be closely monitored with a high index of suspicion for future deterioration. Regardless of the cause, such conditions may imperil sexual self-esteem, sexual function, or sexual relationships for many years. It increases total peripheral resistance when infused in doses less than those required to produce maximum urine concentration. However, we recommend a more complete classification, as proposed by Effmann and associates. Rarely, the urethra is hypoplastic, requiring urethral surgery in conjunction with skin rearrangement. In a recent series, buccal mucosal grafts had a 32% complication rate and a 14% reoperation rate at 5 years of follow-up. Note that the most superior visible calyx in each kidney is very far from the ipsilateral pedicle and the renal axes (hatched lines) are reversed bilaterally, suggesting that only the lower pole is opacified on each side. Standard urotherapy includes bladder retraining, pharmacologic bladder manipulation to target specific urodynamic abnormalities, and improvement of bowel function, especially the avoidance of severe constipation and fecal impaction; all have been shown to be effective. Nephrogenesis proceeds centrifugally: nephrons that eventually lie most deeply in the cortex (the juxtamedullary nephrons) are the first to be formed, and those in the most superficial (subcapsular) portion of the cortex are formed last. Physiologic phimosis can be simply observed; the age at resolution is an uncertainty, although the vast majority resolve. When it is connected to the nephrostomy access, the initial pressure reading represents the baseline renal pelvis pressure. The three circular muscles (external oblique, internal oblique, and transversus abdominis) are slid laterally to separate from each of three longitudinal muscles (erector spinae, quadratus lumborum, and psoas). Excretion the water-soluble metabolites of sedative-hypnotics, mostly formed via the conjugation of phase I metabolites, are excreted mainly via the kidney. Therefore, ultrasonography is primarily useful as a screening tool for hydronephrosis and for the follow-up evaluation of kidneys that are judged not to be in immediate need of surgical relief of obstruction. This is why anatomic evaluation of the kidney with ultrasound is an essential complement to the examination. Arguments in favor indicate that ligation of the artery includes the tiny periarterial veins that often result in persistence of the varicocele and leads to a significantly diminished recurrence rate. Ureteric abnormalities tend to predominate in the distal portion of the ureter; this becomes important when considering operative intervention. Kidney Stones Triamterene is only slightly soluble and may precipitate in the urine, causing kidney stones. The vaginal dose enters the maternal circulation, and a small amount is absorbed directly by the uterus via the cervix and the lymphatic system. At the same time, the ureteric bud divides sequentially to form the pelvicalyceal system. Scintigraphy may not be available at all times, limiting its common use today in the workup of acute scrotum. The greatest diagnostic difficulties arise in duplex renal units when there is a tiny upper pole unit draining into a minimally obstructed ectopic ureter with little dilation. It is in this group of patients that significant controversy regarding management exists. Surana and Puri found that the risk of a contralateral hernia was unrelated to age (in children younger than 2 years) or to gender but was significantly greater for those presenting with a left-sided inguinal hernia.
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