Transperitoneal Versus Retroperitoneal Robotic-assisted Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Children. A Multicentre, Prospective Study.

Background: Robotic-assisted laparoscopic pyeloplasty (RALP) has been gaining acceptance among paediatric urologists. Objective: To compare surgical variables and clinical outcomes, including complications and success rate, with RALP using the transperitoneal (T-RALP) and retroperitoneal (R-RALP) approaches. Design setting and participants: We performed a multicentre, prospective, cohort study (NCT03274050) between November 2016 and October 2021 in three paediatric urology teaching centres (transperitoneal approach, n = 2; retroperitoneal approach, n = 1). The diagnosis of ureteropelvic junction obstruction (UPJO) was confirmed by renal ultrasound and mercaptoacetyltriglycine-3 renal scan or uro-magnetic resonance imaging with functional evaluation. The exclusion criteria were children <2 yr old, persistent UPJO after failed pyeloplasty, and horseshoe and ectopic kidney. Intervention: We performed dismembered pyeloplasty using running monofilament 6-0 absorbable suture. Outcome measurements and statistical analysis: We assessed intra- and postoperative morbidity (primary outcome) and success (secondary outcome). Data were expressed as medians and interquartile range (25th and 75th percentiles) for quantitative variables, and analysed comparatively. Results and limitations: We operated on 106 children (T-RALP, n = 53; R-RALP, n = 53). Preoperative data were comparable between groups (median age 9.1 [6.2-11.2] yr; median weight 26.8 [21-40] kg). Set-up time (10 vs 31 min), anastomotic time (49 vs 73 min), and console time (97 vs 153 min) were significantly shorter with T-RALP than with R-RALP (p < 0.001). No intraoperative complications occurred. No conversion to open surgery was necessary. The median hospital stay was longer after T-RALP (2 d) than after R-RALP (1 d; p < 0.001). Overall, postoperative complication rates were similar. No failure had occurred at the mean follow-up of 25.4 (15.1-34.7) mo. Conclusions: In selected children, RALP is safe and effective using either the transperitoneal or the retroperitoneal approach, with a shorter hospital stay after R-RALP. Patient summary: In our multicentre, prospective study, we compared the results and complications of robotic-assisted laparoscopic pyeloplasty (RALP) using the transperitoneal and retroperitoneal approaches. We found that RALP is safe and effective using either approach, with a shorter hospital stay after R-RALP.

Laparoscopic Vascular Hitch for Polar Vessels in Pyeloureteric Junction Obstruction: Medium-Term Follow-up of a Monocentric Experience.

INTRODUCTION: To evaluate medium-term results of the management of patients with pyeloureteric junction obstruction (PUJO) secondary to lower pole vessels managed by a laparoscopic vascular hitch technique. MATERIALS AND METHODS: We performed a retrospective monocentric study of all patients who were operated using this technique, transperitoneal laparoscopy (TL) or robotic surgery (RS), from 2011 to 2018. Description of the initial population, pre- and postoperative data was collected and analyzed. RESULTS: During the study period, 25 patients (11 males and 14 females) with a mean age of 11.1 years were managed. Initial symptoms leading to the diagnosis were present in 21 children (lumbar pain 17, high blood pressure 1, and infection 3). Four patients were diagnosed incidentally (three) or following a prenatal screening (one). The diagnostic has been confirmed in all patients by ultrasound scan completed by computed tomography or magnetic resonance imaging scans. Twenty-one patients were operated by TL and four by RS. Mean operating time was 90.2 minutes. Three immediate postoperative complications were noticed including one urinary tract infection, one urinary tract rupture, and one postoperative massive dilatation. After a mean follow-up of 3 1.5 years, 17 patients remain asymptomatic. Mean pelvic diameter was preoperatively 35 mm and postoperatively 10.5 mm (p < 0.005). Of the eight remaining patients, six required reoperation (pyeloplasty) and two remained symptomatic with recurrent flank pain. CONCLUSION: In our experience, PUJO managed by the vascular hitch technique is associated with a 68% success rate after a 3-year follow-up. These results are different from the current literature which reported success rate of 96% after 52 months. It leads us to question the efficiency of this technique in the long term in our hands both concerning the indications and the surgical procedure itself. Further studies are required to collect data concerning the evolution of our patients during adulthood to compare their evolution to classic pyeloplasty.

Heterotopic pancreas without Meckel's diverticulum in children as unique cause of gastrointestinal bleeding: think about it!

Ectopic pancreas also known as heterotopic pancreas (HP) is a rare congenital anomaly, mainly found as incidental finding during autopsy or abdominal exploration for an other condition. Incidence rate is probably underestimated as patients are mostly asymptomatic; otherwise, it is capable of producing symptoms depending on its location, size, often appearing in the 4th-to-6th decades. Complications such as inflammation, obstruction, bleeding, and malignancy degeneration must be considered. Pediatrics cases are very rare, generally concerning HP within Meckel's diverticulum, manifesting by gastrointestinal bleeding and intussusception. We report a rare case of jejunum bleeding, due to an isolated HP in a 15-year-old adolescent. Endoscopic and computed tomographic scan were normal, in particular did not found Meckel's diverticulum. Diagnosis and treatment have been apprehended performing a laparoscopic exploration. It is a singular location for HP, predominantly found in upper gastrointestinal tractus. So far, there have been no case reports of jejunal bleeding from ectopic pancreas without Meckel's diverticulum in children.

Pancreatic fracture: a rare complication following scoliosis surgery.

STUDY DESIGN: Grand Round case report. OBJECTIVE: We report a pancreatic fracture associated with Wirsung duct disruption, following a scoliosis surgery in a cerebral palsy adolescent. Spinal fusion surgery is the standard treatment for severe neuromuscular scoliosis. Many complications such as digestive ones account for its complexity. Postoperative acute pancreatitis is well described, although its pathophysiology remains unclear. To our knowledge, pancreatic fracture following scoliosis correction has never been described to date. Clinical presentation is not specific, and management is not consensual. CASE REPORT: A 14-year-old adolescent had posterior spinal fusion for neuromuscular scoliosis due to cerebral palsy. During the postoperative course, she developed progressive nonspecific abdominal symptoms. The abdominal CT scan demonstrated a pancreatic fracture and a surgical exploration was decided as perforations of the bowel were highly suspected. Drains were placed around the pancreatic area as the retrogastric region was out of reach due to local inflammation. Conservative management led to the occurrence of a pseudocyst in the following weeks as the pancreatic leakage progressively dropped. DISCUSSION: Two hypotheses have been proposed: direct iatrogenic trauma from lumbar pedicle screws and pancreatic rupture related to the correction of the spinal deformity. As the latter seems the most likely, spinal surgeons should be aware of this occurrence following severe scoliosis correction. CONCLUSION: Spinal fusion for severe neuromuscular scoliosis is a difficult procedure, with a high rate of complications. Among them, pancreatic fracture should be considered when abdominal pain persists in the postoperative period. Conservative management is advocated especially in case of a poor general condition.

Prenatal diagnosis of right-sided diaphragmatic hernia and ipsilateral intrathoracic kidney in a female fetus: a rare observation.

Congenital diaphragmatic hernia is a rare congenital malformation, as well as kidney ectopia. Among kidney ectopias, the intrathoracic one is the rarest. Those malformations concern more frequently boys, and affected more the left than the right side. Their association is poorly reported in the literature. We report the rare case of an early sonographic prenatal diagnosis of intrathoracic kidney at 22 weeks of gestation in a female fetus, completed on the follow-up by the diagnosis of an associated diaphragmatic hernia at 33 weeks of gestation. If chest mass is diagnosed prenatally or in neonate, ITK should be considered in a differential diagnosis, all the more if the ipsilateral renal fossa is empty. An associated DH should be searched if ITK is confirmed. Isolated ITK usually requires no specific treatment, in contrast with ITK associated with DH.