Indocyanine green (ICG) fluorescence technology in pediatric robotic surgery.

This study aimed to report our experience in indocyanine green (ICG) fluorescence-guided surgery (FGS) in pediatric robotics. The data of 55 patients (35 boys and 20 girls), who underwent robotic surgery using ICG fluorescence in three institutions over the last 7 years, were retrospectively reviewed. The following robotic procedures were included: pyeloplasty (n = 21), complex Lich-Gregoir ureteral reimplantation (n = 8), varicocelectomy (n = 7), adnexal pathology resection (n = 8), partial nephrectomy (n = 4), nephrectomy (n = 4), renal cyst removal (n = 2), and excision of prostatic utricle (n = 1). The ICG was injected intravenously in all indications except for varicocele where intratesticular injection was done, and prostatic utricle or paraureteral diverticulum where trans-catheter injection was done. The ICG dosage was 0.2-0.3 mg/mL/kg. All the procedures were performed using da Vinci Xi platform. Firefly® allowed to switch form bright light to ICG-NIRF view and vice versa. All the procedures were accomplished in robotics without conversions to laparoscopy or open surgery. No episodes of allergy or anaphylaxis to ICG were recorded. An excellent ICG-NIRF view of target organs was obtained in all procedures. Based on our experience, we believe that application of ICG FGS in pediatric robotics enhances the identification of critical anatomical elements and pathological structures, thereby positively impacting both oncological and functional outcomes. This technique is safe, feasible, and versatile. We advocate the consideration of ICG as the standard of care in certain procedures such as partial nephrectomy, varicocele repair, tumor resection, and ovarian torsion. Nonetheless, further investigations are warranted to explore its potential broader applications in pediatric urology.

Robotic-assisted versus conventional laparoscopic ICG-fluorescence lymphatic-sparing palomo varicocelectomy: a comparative retrospective study of techniques and outcomes.

PURPOSE: This study aimed to compare techniques and outcomes of robotic-assisted varicocelectomy (RAV) and laparoscopic varicocelectomy (LV). METHODS: The medical records of 40 patients, who received RAV and LV over a 2-year period, were retrospectively analyzed. Palomo lymphatic-sparing varicocelectomy using ICG fluorescence was adopted in all cases. Three 5-mm trocars were placed in LV, whereas four ports, three 8-mm and one 5-mm, were placed in RAV. The spermatic vessels were ligated using clips in LV and ligatures in RAV. The two groups were compared regarding patient baseline and operative outcomes. RESULTS: All patients, with median age of 14 years (range 11-17), had left grade 3 varicocele according to Dubin-Amelar. All were symptomatic and 33/40 (82.5%) presented left testicular hypotrophy. All procedures were completed without conversion. The average operative time was significantly shorter in LV [20 min (range 11-30)] than in RAV [34.5 min (range 30-46)] (p = 0.001). No significant differences regarding analgesic requirement and hospitalization were observed (p = 0.55). At long-term follow-up (30 months), no complications occurred in both groups. The cosmetic outcome was significantly better in LV than RAV at 6-month and 12-month evaluations (p = 0.001). The total cost was significantly lower in LV (1.587,07 €) compared to RAV (5.650,31 €) (p = 0.001). CONCLUSION: RAV can be safely and effectively performed in pediatric patients, with the same excellent outcomes as conventional laparoscopic procedure. Laparoscopy has the advantages of faster surgery, smaller instruments, better cosmesis and lower cost than robotics. To date, laparoscopy remains preferable to robotics to treat pediatric varicocele.

The "V-I penoscrotal reconfiguration": A simple technique for the surgical treatment of congenital webbed penis.

OBJECTIVES: To describe a new penoscrotal reconfiguration technique, named "V-I penoscrotal reconfiguration" for the surgical reconstruction of a congenital webbed penis (CWP). METHODS: Twenty-one patients who underwent the "V-I penoscrotal reconfiguration technique" were included in this retrospective study. The CWP severity was assessed according to El-Koutby's classification. Demographic and clinical data, surgical data, and postoperative outcomes were scheduled and analyzed. Specifically, the postoperative follow-up included both physical and psychological assessments at 2 weeks, 1, 6, and 12 months after surgery. Parents' satisfaction degree was quantified by the Likert scale. RESULTS: CWP was grade 3 in 11 (52%) patients, 2 in five (24%), and 1 (24%) in five. Five (24%) CWP were isolated malformations, 11 (52%) were associated with phimosis, three (14%) with hypospadias, and two (10%) with hypospadias and phimosis. There were no postoperative complications and no cases of redo surgery. The cosmetic outcomes were excellent in all cases: the parents' satisfaction score was 4 in 17 (81%) cases and 3 (9%) in the other four cases. CONCLUSIONS: CWP may cause psychological distress and functional problems, especially during sexual intercourse. Its correction in childhood is advocated to prevent psychological and sexual issues. The "V-I reconfiguration technique" is simple, and easy with excellent cosmetic and functional outcomes.

Acute urinary retention in children: causes and the role of bladder catheterization and ultrasonogram.

BACKGROUND: Acute urinary retention in children is uncommon and can be related to several causes. The role of abdominal ultrasound and catheterization is controversial. We aimed to identify the most common causes of acute urinary retention in children, focusing, particularly on the role of bladder catheterization and the diagnostic value of acute ultrasound. METHODS: We retrospectively analyzed all consecutive children admitted to our emergency department with acute urinary retention from 2010 to 2020. Post-operative acute urinary retention, neonatal age, and known urological or neurological disorders were excluded. Diagnostic workup and management were adopted in each patient. Results were compared in patients with more and less than 5 years old. RESULTS: 193 patients were included. Median age was 3 (2-16) years; 53.4% were girls. Ultrasound evaluation was performed in (129/193; 66.8%) patients, more commonly <5-year-old (74% vs. 26%, P<0.01). A previously unknown urological condition was detected in (16/129; 12%). The majority of patients (124/193; 64%) were managed without bladder catheterization. These patients were significantly younger than the remainder (3- vs. 4-year-old, P<0.01) and the most common diagnosis was external genitalia inflammation (53%). Of the remaining patients, (34/69; 49%) restored spontaneous micturition after a single catheterization, whereas 35 required admission. The latter were more commonly males (32%, P=0.01), with higher incidence of abnormal ultrasound (33% vs. 7%, P<0.001). CONCLUSIONS: Acute urinary retention in commonly due to external genitalia inflammation, particularly in patients <5-year-old, and can be generally managed, without bladder catheterization. Abdominal ultrasound is an important diagnostic tool, that should be performed only in selected cases.

European Association of Urology/European Society for Paediatric Urology Guidelines on Paediatric Urology: Summary of the 2024 Updates.

BACKGROUND AND OBJECTIVE: We present an overview of the 2024 updates for the European Association of Urology (EAU)/European Society for Paediatric Urology (ESPU) guidelines on paediatric urology to offer evidence-based standards for perioperative management, minimally invasive surgery (MIS), hydrocele, congenital lower urinary tract obstruction (CLUTO), trauma/emergencies, and fertility preservation. METHODS: A broad literature search was performed for each condition. Recommendations were developed and rated as strong or weak on the basis of the quality of the evidence, the benefit/harm ratio, and potential patient preferences. KEY FINDINGS AND LIMITATIONS: Recommendations for perioperative management include points related to fasting, premedication, antibiotic prophylaxis, pain control, and thromboprophylaxis in patients requiring general anaesthesia. MIS use is increasing in paediatric urology, with no major differences observed among different MIS approaches. For hydrocele, observation is the initial approach recommended. For persistent cases, treatment varies according to the type of hydrocele. CLUTO cases should be managed in tertiary centres with multidisciplinary expertise in prenatal and postnatal management. Neonatal valve ablation remains the mainstay of treatment, but associated bladder dysfunction requires continuous treatment. Among urological traumas and emergencies, renal trauma is still an important cause of morbidity and mortality. Conservative management has become the standard approach in haemodynamically stable children. Ischaemic priapism is a medical emergency and requires stepwise management. Initial management of nonischaemic priapism is conservative. Fertility preservation in prepubertal children and adolescents has become an increasingly relevant issue owing to the ever-increasing number of cancer survivors receiving gonadotoxic therapies. A major limitation is the scarcity of relevant literature. CONCLUSIONS AND CLINICAL IMPLICATIONS: This summary of the 2024 EAU/ESPU guidelines provides updated guidance for evidence-based management of some paediatric urological conditions. PATIENT SUMMARY: We provide a summary of the updated European Association of Urology/European Society for Paediatric Urology guidelines on paediatric urology. There are recommendations on steps to take before and immediately after surgery, management of hydrocele, congenital lower urinary tract obstruction, and urological trauma/emergencies, as well as preservation of fertility. Recommendations are based on a comprehensive review of recent studies.

Voiding cystourethrography in patients undergoing endoscopic decompression of duplex system ureteroceles: to do or not to do?

OBJECTIVE: To assess the role of voiding cystourethrography (VCUG) in patients with duplex system ureterocele (DSU) undergoing endoscopic decompression (ED). MATERIALS AND METHODS: This is a retrospective study of 75 consecutive patients with DSU undergoing ED [median (range) age, 6 (1-148) months]. Patients were divided into 3 groups, 33 with a VCUG showing vesicoureteral reflux (VUR) before ED (VUR-group), 22 with a VCUG negative for VUR (No-VUR-group), and 20 who did not undergo a VCUG (No-VCUG-group). Secondary surgery (SS) rate was compared among groups. RESULTS: Groups were comparable for baseline characteristics. SS rate was 82% (27/33) in VUR-group vs. 32% (7/22) in the No-VUR-group (p = 0.0001), and 25% (5/20) in the No-VCUG-group (p = 0.001 vs. VUR-group, and 1 vs. No-VUR-group). In the VUR-group, 9 patients underwent preemptive endoscopic treatment of VUR during ED and SS rate was 44% (4/9) vs. 96% (23/24) in the remainder, p= 0.003. In the No-VCUG-group, a VCUG was performed during follow-up in 9/15 patients and showed reflux in all, although only 2 of these developed a (single) urinary tract infections. CONCLUSIONS: SS rate was significantly higher in patients with preoperative VUR. Instead, it was not significantly different between patients without VUR and those who did not undergo a VCUG before ED, despite all the latter who underwent a VCUG during follow-up had evidence of VUR generally in the absence of symptoms. In our opinion, a VCUG could be limited to patients developing symptoms after ED. If a VCUG is performed before ED, a preemptive treatment of VUR should be taken into consideration.

Risk Factors for Failure of Endoscopic Balloon Dilatation of Primary Obstructive Megaureter: Single-Center 12-Year Experience with 123 Cases.

Purpose: To review our experience with >100 patients with primary obstructive megaureter (POM) undergoing endoscopic balloon dilatation (EBD) and a follow-up of up to 12 years and determine potential risk factors for failure. Our hypothesis is that EBD allows for long-term treatment in >80% of patients, and its effectiveness decreases in more severe cases. Methods: This is a retrospective study of 123 consecutive patients (131 ureters) undergoing EBD from 2009 to 2021. Indications for EBD included symptoms, worsening dilatation, and/or renal function impairment. Clinical characteristics, complications, and outcomes, including those in the patients with >5-year follow-up, were described. Preoperative and intraoperative markers of severity chosen a priori were tested as risk factors for failure. Failure was defined as the need for ureteral reimplantation after EBD. Results: EBD was feasible in 121 of 123 (98%) patients, regardless of age. After a median follow-up of 38 (9-143) months, EBD was effective in 84.5% of cases. Failures generally occurred in the 1st year after EBD and were seldom associated with permanent loss of renal function. Of the 66 patients with follow-up >5 years, EBD was effective in 56 patients. No preoperative characteristic proved to be a risk factor for failure. The intraoperative absence of a ring was the only significant risk factor for failure, odd ratio 117.86 (95% confidence interval 6.27-2215.84). Conclusions: EBD was feasible and definitive treatment in 85% of our cases, regardless of age. Since this study did not identify preoperative factors to help the clinicians in patient selection, we consider EBD a viable initial procedure in all patients with POM who require surgical intervention, especially in infants.

Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children.

BACKGROUND AND OBJECTIVE: The prescriptive literature on vesicoureteral reflux (VUR) is still limited and thus the level of evidence is generally low. The aim of these guidelines is to provide a practical approach to the treatment of VUR that is based on risk analysis and selective indications for both diagnostic tests and interventions. We provide a 2023 update on the chapter on VUR in children from the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) guidelines. METHODS: A structured literature review was performed for all relevant publications published from the last update up to March 2022. KEY FINDINGS AND LIMITATIONS: The most important updates are as follows. Bladder and bowel dysfunction (BBD) is common in toilet-trained children presenting with urinary tract infection (UTI) with or without primary VUR and increases the risk of febrile UTI and focal uptake defects on a radionuclide scan. Continuous antibiotic prophylaxis (CAP) may not be required in every VUR patient. Although the literature does not provide any reliable information on CAP duration in VUR patients, a practical approach would be to consider CAP until there is no further BBD. Recommendations for children with febrile UTI and high-grade VUR include initial medical treatment, with surgical care reserved for CAP noncompliance, breakthrough febrile UTIs despite CAP, and symptomatic VUR that persists during long-term follow-up. Comparison of laparoscopic extravesical versus transvesicoscopic ureteral reimplantation demonstrated that both are good option in terms of resolution and complication rates. Extravesical surgery is the most common approach used for robotic reimplantation, with a wide range of variations and success rates. CONCLUSIONS AND CLINICAL IMPLICATIONS: This summary of the updated 2023 EAU/ESPU guidelines provides practical considerations for the management and diagnostic evaluation of VUR in children. ADVANCING PRACTICE: For children with VUR, it is important to treat BBD if present. A practical approach regarding the duration of CAP is to consider administration until BBD resolution. PATIENT SUMMARY: We provide a summary and update of guidelines on the diagnosis and management of urinary reflux (where urine flows back up through the urinary tract) in children. Treatment of bladder and bowel dysfunction is critical, as this is common in toilet-trained children presenting with urinary tract infection.

Vacuum-assisted Mini-percutaneous Nephrolithotomy for 2-3-cm Renal Stones: A Comparative Study with Retrograde Intra-renal Surgery.

PURPOSE: To compare vacuum-assisted percutaneous nephrolithotomy (VAmini-PCNL) with retrograde intra-renal surgery (RIRS) for the treatment of renal stones measuring 2-3 cm in diameter. MATERIAL AND METHODS: This retrospective study included children receiving treatment for pyelocalyceal stones of 2-3 cm in diameter from November 2018 to September 2022. Consecutive patients undergoing VAmini-PCNL after 2020 were compared with a historically matched group undergoing RIRS. VAmini-PCNL was performed using a 12-Ch nephroscope through a 16-Ch vacuum ClearPetra access sheet. RIRS was performed using a flexible ureteroscope through a ureteral sheath. The endpoints included the need for pre-stenting, duration of surgery, complications, stone-free rate (SFR), and need for secondary procedures. RESULTS: The patients were grouped into two with 15 patients for each group. VAmini-PCNL group was not different from the RIRS one for age at surgery [median (range) 6.6 (1-12)years vs. 7.7 (1.5-14)years], and stone diameter [median (range) 2.4 (2.0-2.9)cm vs. 2.3 (2.1-2.8)cm] and density [median (range) 577.5 (421-1068) vs. 541.5 (462-927) Hunsfield Units]. Pre-stenting was necessary in five RIRS patients (33 %). The median duration of surgery was 85.3 (76-112)min for VAmini-PCNL vs. 150.6 (132-167)min for RIRS, p = 0.00001. No major complications were observed. The SFR was 100 % after VAmini-PCNL and 60 % after RIRS, p = 0.02. All residual fragments were removed with a second RIRS. CONCLUSION: VAmini-PCNL was feasible and safe in children aged >1 year. It allowed for a significantly higher SFR despite a significantly shorter operative time than RIRS, which also requires pre-stenting in one-third of patients and a second RIRS in 40 % of cases. LEVEL OF EVIDENCE: III.

Endoscopic dilatation/incision of primary obstructive megaureter. A systematic review. On behalf of the EAU paediatric urology guidelines panel.

INTRODUCTION: Historically, ureteral reimplantation (UR) has been the gold standard for treatment of primary obstructive megaureter (POM) with declining renal function, worsening obstruction, or recurrent urinary tract infections. In infants, open surgery with reimplantation of a grossly dilated ureter into a small bladder, can be technically challenging with significant morbidity. Therefore, less invasive endoscopic management such as dilatation or incision of the ureter-vesical junction, has emerged as an alternative to reimplantation during the last decades. OBJECTIVE: To systematically evaluate the effectivity, safety, and potential benefits of endoscopic treatment (dilatation with or without balloon or incision) of POM in comparison to UR. STUDY DESIGN: A systematic review was conducted. Randomized controlled trials (RCTs), nonrandomized comparative studies (NRSs), and single-arm case series including a minimum of 20 participants and a mean follow-up more than 12 months were eligible for inclusion. RESULTS: Of 504 articles identified, 8 articles including 338 patients were eligible for inclusion (0 RCTs, 1 NRSs, and 7 case series). Age at time of surgery was minimum 15 days to a maximum of 192 months. Indications for endoscopic treatment (ET) included patients with loss of split renal function (>10%) and worsening of hydroureteronephrosis. The studies analysed reported a success rate ranging from 35% to 97%. Success was defined as stabilization of differential renal function without further procedures. A post-operative complication rate of 23-60% was reported (mostly transient haematuria, urinary tract infections and stent migration or intolerance). In 14% of the cases salvage UR following initial ET, was performed due to relapse of symptomatic POM. CONCLUSION: Endoscopic treatment for persistent or progressive POM in children is a minimally invasive alternative to UR with a long-term modest success rate. Additionally, it can be performed within a wide age span, with equal success rate and complication rates.

Where is the testis? The role of ultrasound and diagnostic laparoscopy for Crossed Testicular Ectopia (CTE): Case report and review of literature.

Crossed Testicular Ectopia (CTE) or transverse testicular ectopia is an anecdotic urogenital anomaly in which both testes are located on the same side, generally associated with a patent processus vaginalis (PPV). The condition can be detected by ultrasound. Nevertheless, the diagnosis is often missed preoperatively and CTE is recognized intraoperatively. Controversy exists regarding management and the role of diagnostic laparoscopy. The surgical technique depends on the anatomy of vas, vessels and testis found on surgical exploration. Diagnostic laparoscopy can be useful to rule out a vanishing testis and detect Müllerian remnants. We present the case of 8-months infant with no palpable testis on the right side and no signs of inguinal hernia, reporting the management and reviewing the scarce existing literature in this regarding. KEY WORDS: Crossed Testicular Ectopia, Laparoscopy, Ectopia, Testis, Transverse Testicular Ectopia, Urogenital Abnormalities.

Pyelo-ureteral junction obstruction in poorly functioning kidneys: Does conservative management play a role in pediatric patients?

Background: Management of Pyelo-ureteral Junction Obstruction (PUJO) in poorly functioning kidneys in pediatric patients is still controversial, particularly regarding the role of conservative treatment. Aim: To evaluate and present the outcomes of internal diversion and follow-up results of a small series of pediatric patients with UPJO in poorly functioning kidneys. Study design: Retrospective review of 17 consecutive patients with unilateral PUJO in kidneys with Differential Renal Function (DRF) <20% undergoing temporary internal urinary diversion between 2009 and 2021 at a single tertiary center. DRF was reassessed after 1-3 months of diversion and subsequent management was conservative or surgical (pyeloplasty or nephrectomy) based on surgeon's and family's preferences without randomization. Results: After a trial of internal urinary diversion, 4/17 patients (23%) showed a DRF increase ≥5% (9%-12%), up to a maximum DRF of 28%, 3 underwent pyeloplasty, while 1 was managed conservatively. The remaining 13 patients showed no differential renal function improvement after diversion, and 7 were managed expectantly while 6 surgically (4 pyeloplasty, 2 nephrectomy). Overall, nine patients (53%) were managed surgically and 8 (47%) expectantly After a median (range) follow-up of 3.1 (0.3-7.9) years, no significant difference was observed between groups regarding symptoms (p = 0.205), need for further surgery (p = 1.000), and renal function (p = 1.000). Discussion: Although fraught with the limitation of a small sample size, this is the first study reporting on the conservative management of this controversial group of patients. Conclusion: In present pediatric series of pyelo-ureteral Junction obstruction in poorly functioning kidneys with differential renal function <20%, function recovery after a trial of internal urinary diversion was quite exceptional, and no difference was observed in outcome between patients managed surgically and conservatively after stent removal.

Glans dehiscence after severe hypospadias repair. Is it a real complication? Clues from a study in post-pubertal patients.

INTRODUCTION: Glans dehiscence (GD) is reportedly a common complication after proximal hypospadias repairs. However, the need for surgical correction is controversial. The aim of this study was to assess awareness, risk factors, and outcome of GD in post-pubertal patients. The agreement with surgeon assessment was also evaluated. METHODS: The design was retrospective. All consecutive patients treated for proximal hypospadias between 2000 and 2011 were included. The presence of GD was self-reported, and the participants could optionally upload a photograph for surgeon assessment. Cosmetic and functional outcomes were assessed by validated questionnaires (HOSE, PPPS, KINDL®, IIEF-5). Results were compared between patients with and without GD. RESULTS: Of 219 patients, 34 (16%) participated. Fourteen of them (41%) self-reported GD. Eighteen patients (8%) also uploaded a photograph and, in ten of them (56%), the surgeon noted the presence of GD with poor agreement [k = - 0.444 (95 CI - 0.856 to - 0.033)] with patient report. Patients self-reporting GD had had more frequently a penile curvature at diagnosis (12/14 = 86%, p = 0.01), and had undergone a single-staged repair (100% vs. 65%, p = 0.03). No difference was found in cosmetic and functional outcomes. Results were similar also comparing groups with and without GD as assessed by the surgeon. CONCLUSION: GD was a common finding after severe hypospadias repair. It was more common in case of surgeon assessment with poor agreement between patients and surgeons. GD did not prove to have clear clinical implications. Therefore, in our opinion, surgical repair of GD should be recommended only on patients request.

Endoscopic injection of bulking agents in pediatric vesicoureteral reflux: a narrative review of the literature.

In the last 20 years, endoscopic injection (EI) has affirmed as a valid alternative to open surgery for management of pediatric vesicoureteral reflux (VUR). This study aimed to investigate and discuss some debated aspects such as indications, bulking agents and comparison, techniques of injection and comparison, predictive factors of success, use in specific situations. EI is minimally invasive, well accepted by patients and families, with short learning curve and low-morbidity profile. It provides reflux resolution rates approaching those of open reimplantation, ranging from 69 to 100%. Obviously, the success rate may be influenced by several factors. Recently, it is adopted as first-line therapy also in high grade reflux or complex anatomy such as duplex, bladder diverticula, ectopic ureters. The two most used materials for injection are Deflux and Vantris. The first is absorbable, easier to inject, has lower risk of obstruction, but can lose efficacy over time. The second is non-absorbable, more difficult to inject, has higher risk of obstruction, but it is potentially more durable. The two main techniques are STING and HIT. To date, the ideal material and technique of injection has not yet clearly established, but the choice remains dependent on surgeon's preference and experience.

Current trends in 2021 in surgical management of vesico-ureteral reflux in pediatric patients: results of a multicenter international survey on 552 patients.

BACKGROUND: The selection of best surgical approach for treatment of vesico-ureteral reflux (VUR) in the pediatric population remains debated. This study aimed to report the results of a multicenter survey about the current trends in surgical management of pediatric VUR. METHODS: An online questionnaire-based survey was performed, with participation of six international institutions. All children (age <18 years) affected by primary III-V grade VUR, who were operated over the last 5 years, were included. The incidence of each VUR intervention, patients' demographics and outcomes were analyzed. RESULTS: A total of 552 patients (331 girls), with a median age of 4.6 years (range 0.5-17.6), were included. Deflux® injection (STING) was the most common technique (70.1%). The multicenter success rate after single treatment was significantly lower after STING (74.4%) compared with the other treatments (P=0.001). Persistent VUR rate was significantly higher after STING (10.8%) compared with the other treatments (P=0.03). Choosing endoscopy over surgery mean reducing Clavien Dindo grade 2 complications by 5% but increasing redo procedure rate by 7%. STING was the most cost-effective option. CONCLUSIONS: This survey confirmed that the choice of the technique remains based on surgeon's preference. Deflux® injection currently represents the first line therapy for primary VUR in children and the role of surgical ureteral reimplantation is significantly reduced. STING reported acceptable success rate, less postoperative complications and lower costs but higher failure and re-operation rates and related costs compared with the other surgical approaches. The adoption of laparoscopy and robotics over open reimplantation remains still limited.

Current Status of Pediatric Robot-Assisted Surgery in Italy: Epidemiologic National Survey and Future Directions.

Background: Pediatric robot-assisted surgery (RAS) is gaining increasing acceptance. We aimed to assess the diffusion of pediatric RAS in Italy, the training period, indications, preliminary outcomes, and limitations. Materials and Methods: An online questionnaire-based survey was performed. The data about robotic activity of 9 Italian Pediatric Surgery units were collected and analyzed. Results: Most of the participating centers (7/9, 77.8%) started RAS less than 5 years ago with only 2 centers (22.2%) performing RAS since 2010. The training included dry-lab in 5/9 centers (55.5%), wet-lab in 5/9 centers (55.5%), and robot simulator in 7/9 centers (77.8%), followed by an exam to obtain a certificate. The average duration of training was 23.7 hours (range 5-50). A total of 209 robotic procedures was performed in all centers during the period 2010-2018 and included 119 urological (56.9%), 31 gynecological (14.8%), 41 gastrointestinal (19.6%), 12 oncological (5.7%), and 6 other (2.8%) procedures. The docking time significantly fell down after 18 robotic procedures (P = .001). Intraoperative complications were recorded in 4 cases (1.9%). Conversion to laparoscopy was needed in 4 cases (1.9%) whereas conversion to open was required in 6 cases (2.8%). Postoperative complications occurred in 17/209 cases (8.1%) and were graded Clavien I-II in 14 cases (6.7%) and Clavien IIIb in only 4 cases (1.9%). Conclusions: Our study confirmed that RAS has still a limited diffusion in Italy for pediatric patients. Before starting robotic activity, pediatric surgeons have to obtain a certificate after a virtual and experimental training period. A mentorship clinical period of 10 cases under supervision of a proctor is also needed. The main indications in children remain reconstructive urological procedures. RAS is safe in children but its applications are currently limited to patients older than 2 years and with a weight >15 kg, due to the size of robotic ports.

Complex Bench Surgery Does Not Increase the Risk of Vascular Complications after Pediatric Kidney Transplantation.

INTRODUCTION: Vascular complications are severe complications of pediatric kidney transplantation (KT). We aimed to investigate whether a complex bench surgery (BS) affects the outcomes. METHODS: All pediatric KT performed at the University Hospital of Padua from 2015 to 2019 were analyzed, comparing those in which a standard BS was possible to those that necessitated a complex BS. The rates of vascular complications, patients' outcome, and graft survival were compared in the two groups. RESULTS: Eighty KTs were performed in 78 patients with a median age of 11 years (interquartile range [IQR] 4.3-14) and a median body weight of 24 kg (IQR 13-37). Thirty-nine donor kidneys (49%) needed a complex BS due to anomalies of renal veins in 12 (31%) and renal arteries in 16 (41%). The remaining 11 grafts (28%) underwent an elongation of the vein. There was no difference in the rate of primary graft non function (p = 0.97), delayed graft function (p = 0.72), and overall survival (p = 0.27). The rates of vascular complications, bleedings, and venous graft thrombosis were similar (p = 0.51, p = 0.59, p = 0.78, respectively). No arterial thrombosis or stenosis was reported. CONCLUSION: Complex BS did not compromise survival of the graft and did not put the allograft at risk of vascular complications, such as bleedings or thrombosis.

Pediatric robot-assisted extravesical ureteral reimplantation (revur) in simple and complex ureter anatomy: Report of a multicenter experience.

BACKGROUND: Robot-assisted extravesical ureteral reimplantation (REVUR) is a well established approach for surgical treatment of pediatric vesicoureteral reflux (VUR). However, further evidence is needed to confirm its efficacy even in case of complex anatomy. OBJECTIVE: This study aimed to further confirm the evidence that REVUR is safe and effective in both simple and complex ureter anatomy. STUDY DESIGN: The charts of all patients with VUR, who received REVUR in 6 different institutions over a 5-year period, were retrospectively reviewed. Patients with both simple and complex ureter anatomy were included. Patient demographics, surgical variables, and post-operative results were assessed. VUR resolution was defined as either being resolved VUR on voiding cystourethrogram (VCUG) or clinically without symptoms during the follow-up. RESULTS: Fifty-seven patients with median age of 6.9 years (range 4.5-12), receiving REVUR in the study period, were included. Eighteen (31.6%) patients had complex anatomy and included prior failed endoscopic injection (n = 13), complete ureteral duplication (n = 2), periureteral diverticulum (n = 2), ectopic megaureter requiring dismembering (n = 1). The median operative time was 155 min for unilateral and 211.5 min for bilateral repairs. The clinical + radiographic VUR resolution rate was 96.5%. Post-operative complications (Clavien 2) included urinary retention following bilateral repair (n = 5, 8.7%), febrile urinary tract infection (UTI) (n = 6, 10.5%) and gross hematuria (n = 3, 5.2%). Comparative analysis between simple and complex cases showed that REVUR was faster in simple cases in both unilateral [p = 0.002] and bilateral repair [p = 0.001] and post-operative urinary retention was more frequent in simple cases [p = 0.004] and in patients with pre-operative bowel and bladder dysfunction (BBD) [p = 0.001] (Table). DISCUSSION: This series confirmed that the robot-assisted technique was feasible even in cases with complex anatomy using some technical refinements, that justified the longer operative times in both unilateral and bilateral cases. An interesting finding of this study was the correlation emerged between BBD and risk of post-operative urinary retention and VUR persistence. Our results also excluded any significant correlation between complex cases and risk of post-operative urinary retention. The main study limitations included the retrospective and nonrandomized design, the small number of cases and the arbitrary definition of complex anatomy. CONCLUSION: REVUR was safe and effective for management of VUR in both simple and complex ureter anatomy. Complex REVUR required slightly longer operative times, without significant differences in post-operative mordidity and success rates. Aside from complex anatomy, BBD emerged as the main risk factor associated with surgical failure and post-operative morbidity.

Endoscopic balloon dilatation for the treatment of primary obstructive megaureter <24 months of age: Does the size of the balloon influence results?

INTRODUCTION: Endoscopic balloon dilatation (EBD) can be performed with different catheters and its durability is still controversial. This study aimed to compare long-term results of EBD performed <24 months of age using balloons of 4 mm vs. 6 mm in diameter. MATERIALS AND METHODS: Retrospective study of consecutive patients with unilateral primary obstructive megaureter (POM) undergoing EBD <24 months of age by two surgeons from 01/2009 to 12/2020. The technique was consistent, but for balloon diameter, which was 4 mm in group A vs. 6 mm in group B. End-points included peri-operative complications, success rate (improving dilatation and non-obstructive drainage on 9-month scintigraphy), and long-term outcome (need for reimplantation and diameter of retrovesical ureter at last ultrasound). RESULTS: The procedure was completed in all planned patient. Group A included 15 patients and Group B 30 patients. Groups were not significantly different for age (p < 0.09), gender (p < 0.1), laterality (p < 0.7), and preoperative median ureteral diameter (p = 0.08). No perioperative complications occurred. Four group A patients required a cutting balloon to achieve a satisfactory dilatation of the vesicoureteral junction (p = 0.009). After a median (range) follow-up of 70 (19-155) months, success rate was 73.3% vs. 83.3% (p = 0.45), 4/15 group A and 5/30 group B patients required reimplantation within 2 years of EBD. In successful cases, median (range) ureteral diameter at last follow-up was 6 (0-17) mm vs. 5 (0-14) mm, which was significantly better than preoperative value (p = 0.003 and p < 0.001, respectively), but not significantly different (p = 0.8) between groups. DISCUSSION: EBD is an umbrella term that encompasses many technical variations, which can be key for success. Although limited by the small numbers and the comparison of patients treated over two subsequent periods, this is the first study focusing on the role of balloon size. CONCLUSIONS: The diameter of the balloon did not influence significantly long-term results, but the 6 mm balloon slightly increased the success rate of EBD to 83.3% and eliminated the need for cutting balloons to achieve a satisfactory dilatation.

The Discipline of Pediatric Urology: Prerogatives and Necessities.

To the Editor, The aim of this "position paper" is to describe the discipline of Pediatric Urology with its clinical and cultural competencies, represent the reasons for legitimizing its existence, and reinforce its importance in the "scenario" of the National Italian Healthcare System. The requisites and the educational requirements were defined by both the Italian Ministry of Health with the State-Regions Conference, and the European Union [...].