Pediatric robotic surgery: issues in management-expert consensus from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP).

BACKGROUND: Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally. METHODS: A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place. RESULTS: During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management. CONCLUSION: Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program.

Paraovarian cystoadenofibroma: an unusual finding in two adolescent twin sisters.

BACKGROUND: The presence of a rare lesion for pediatric population, encountered in twins, as far as we know, is an exceptional event. The event made the management of a pathology, for which there are no guidelines in the pediatric field, even more delicate. CASE REPORT: Two twin sisters came to our attention, a short time after each other, due to the presence of a voluminous abdominal mass. After complete resection, the histological diagnosis was that of a paraovarian cystoadenofibroma. DISCUSSION: In pediatric surgery being minimally invasive is mandatory. However in selected cases the only objective, especially speaking of pediatric patients, ais to be radical and to protect the adnexal structures.

Dog bite injuries in a tertiary care children's hospital: A seven-year review.

BACKGROUND: Dog bites are a major cause of traumatic injury in children. The aim of this study was to determine the experience, management, and outcome of dog bite injuries in our department. METHODS: We retrospectively reviewed the clinical records for 127 patients (mean age 7.15 ± 4.24 years, range 1 to 17 years; 68 males) affected by dog-related injuries, from 2012 to 2018. Characteristics of patients and dogs, type and severity of injuries, circumstances of the accidents, treatment and outcome were analyzed. RESULTS: Of 141 wounds, 73 (51.8%) affected the head and neck, 62 (44%) the limbs, and six (4.2%) affected the trunk. According to the Mcheik classification, 107 lesions (75.9%) were stage 1, 26 (18.4%) stage 2, and eight (5.7%) stage 3. Seventy-eight percent of the cases involved known dogs. The breed of the dog was recorded in 62/127 cases (48.8%) and the most common were mongrels (23/62, 37.1%). Seventy-five percent of the attacks occurred during spring and summer. All patients underwent antibiotic prophylaxis and immediate surgical repair. Wound infection was observed in two patients. Three unsightly scars required rectification, with good cosmetic results in all cases. CONCLUSIONS: Our results are consistent with previous data showing that the typical dog-related injury occurs from a known dog, during spring and summer, and in younger boys, who are frequently exposed to head and neck wounds. Our experience showed the feasibility and safety of primary repair and antibiotic prophylaxis in all patients, with very low incidence of infection and good cosmetic results.

Clinical and radiological findings for early diagnosis of Herlyn-Werner-Wunderlich syndrome in pediatric age: experience of a single center.

OBJECTIVE: The authors present their experience in the management of pediatric patients with Herlyn-Werner-Wunderlich syndrome (HWWS) considering clinical classification and anatomical characteristics of the malformation. METHODS: All the data of the patient presented at our Pediatric Surgery Unit from February 2010 to August 2015 were collected. According to the type of malformations, patients were divided in 3 groups: A (completely obstructed hemivagina), B (incompletely obstructed hemivagina), and C (communication between the duplicated cervices). RESULTS: Six patients were treated in the study period. The mean age was 9 years (2 months-15 years). According to the characteristics of the HWWS, we had 5 patients in group A, 1 in group B, and none in group C. One-stage surgical treatment was performed in all cases of complete obstruction, but in one case a second look was necessary for a better resection of the septum. At a mean follow-up of 18 months all patients were symptoms free. CONCLUSIONS: Prognosis of this malformation is good in case of early diagnosis and treatment. We suggest that when a renal agenesia is diagnosed, the patient needs an ultrasonographic follow-up of the contralateral kidney but also of the genital tract to find each minimal abnormalities, furthermore, a MRI scanning before the onset of menstruation can be necessary.

Long-term outcomes following H-type tracheoesophageal fistula repair in infants.

PURPOSE: To evaluate outcomes following repair of H-type tracheoesophageal fistula (TEF). METHODS: Retrospective chart review of infants with H-type TEF treated at our institution between 2000 and 2014. Patient demographics, surgical management, and postoperative function were evaluated. RESULTS: Of the 268 patients with esophageal atresia/TEF treated at our center, 16 (6%) had an H-type TEF (10 males). Thirteen (81%) had associated anomalies. All patients were symptomatic: choking and sputtering were the most common presentation (n = 10, 63%). Diagnosis Age at diagnosis was 8 days (1 day-34 months). All patients were diagnosed based on a single esophagogram. Prior to surgery, 12 (75%) patients underwent bronchoscopy and 11 underwent cannulation of the TEF tract. Surgery All patients underwent open repair. One was started thoracoscopically but converted to open due to esophageal sero-muscular injury. Repair was achieved in all patients via a transcervical approach (right-sided incision in 15). One patient had an unsuccessful prior attempt at repair using tissue glue. Following TEF division, 11 patients had tissue interposition grafts placed (9 muscle, 2 fat). Postoperative course Eight (50%) patients had postoperative vocal cord paresis (6 right-sided, 2 bilateral). A patient developed recurrent TEF 78 days postoperatively that was subsequently repaired. Follow-up At 41 months (8-143), there were no mortalities, all patients with vocal cord paresis were asymptomatic despite the fact that only 3 of 8 (38%) regained function, and nine (56%) patients had gastro-esophageal reflux requiring treatment. CONCLUSIONS: This large, single-center series demonstrates that H-type TEF can be diagnosed with esophagogram at an early age. Postoperative recurrent laryngeal nerve paresis and gastro-esophageal reflux disease are common following repair. Although most patients with vocal cord paresis eventually become asymptomatic, two-thirds do not regain vocal cord function. This reinforces the importance of routine examination of vocal cord movement following H-type TEF repair.

Preservation of native esophagus in infants with pure esophageal atresia has good long-term outcomes despite significant postoperative morbidity.

PURPOSE: To evaluate long-term outcomes of pure esophageal atresia (EA) repair with preservation of native esophagus. METHODS: Infants with pure EA treated at our institution (2000-2010) and with minimum 5-year follow-up were reviewed (REB:1000046653). Data analysed included demographics, management and outcomes and are reported as mean ± SD/median (range). RESULTS: Of 185 infants with EA, 12 (7 %) had pure EA (gestational age: 36 ± 2.4 weeks, birth weight: 2353 ± 675 g). Ten had associated anomalies, including trisomy-21 (n = 2) and duodenal atresia (n = 1). SURGERY: 1 patient (short gap) underwent primary thoracoscopic anastomosis, 11 had gastrostomy (Stamm, n = 5; image-guided, n = 6) as initial procedure. At definitive repair (age: 128 ± 91 days; weight 5.5 ± 2.3 kg): ten had primary anastomosis and 1 had Collis gastroplasty. No patient had esophageal replacement surgery. OUTCOMES: three patients had gastrostomy dehiscence requiring re-operation. At post-operative esophagram, seven had anastomotic leak successfully treated conservatively. Seven patients developed strictures requiring balloon dilatations (median two dilatations, range 1-10), six received antireflux surgery. At 7-year follow-up (range 5-15 years), all patients had the gastrostomy closed and were on full oral feeds. CONCLUSIONS: The management of pure EA continues to be challenging. The preservation of native esophagus is possible with significant morbidity. The long-term outcomes are favourable.

Outcome of esophageal atresia/tracheoesophageal fistula in extremely low birth weight neonates (<1000 grams).

PURPOSE: To review the outcomes of extremely low birth weight (ELBW, <1000 g) infants with esophageal atresia/tracheoesophageal fistula (EA/TEF). METHODS: Health records of ELBW EA/TEF infants treated at our institution from 2000 to 2014 were reviewed (REB1000046653). Demographics, operative approach and postoperative complications were analyzed. Data are reported as median (range). RESULTS: Of 268 EA/TEF infants, 8 (3 %, five females) were ELBW (930 g, 540-995). Gestational age was 28 weeks (23-32). Seven had type-C EA/TEF and one type B. OUTCOMES: One trisomy 18 infant received no treatment and died; one initially diagnosed as type A had primary repair at 126 days of life (DOL); six underwent TEF ligation (three trans-pleural) with primary repair in one and delayed anastomosis in two (DOL 120 and 178). The remaining three died (gastrostomy dehiscence and peritonitis, liver hemorrhage during peritoneal drain insertion, severe chronic lung disease and brain hemorrhages). At a median follow-up of 3 years (range 15 months-5 years), all survivors are thriving. CONCLUSION: ELBW infants with EA/TEF are rare and result in high morbidity and mortality. Mortality is mainly related to complications not associated with EA/TEF repair. Fistula ligation followed by delayed anastomosis seems to achieve a better outcome in ELBW infants.

Are Infants with Bronchopulmonary Dysplasia Prone to Gastroesophageal Reflux? A Prospective Observational Study with Esophageal pH-Impedance Monitoring.

OBJECTIVE: To perform an observational cohort study with esophageal pH-multichannel intraluminal impedance (pH-MII) monitoring in symptomatic preterm infants with and without bronchopulmonary dysplasia (BPD). STUDY DESIGN: We prospectively studied 46 infants born ≤32 weeks gestational age: 12 infants with BPD and 34 infants without BPD. Each patient had symptoms consistent with gastroesophageal reflux and had 24-hour pH-MII, which were compared between BPD and non-BPD by univariate analysis and quantile regression analysis. RESULTS: Demographic and clinical characteristics were similar between infants with and without BPD, except for fluid administration (145 vs 163 mL/kg/d, P = .003), length of stay (92 vs 69 days, P = .019), and time to achieve complete oral feeding (76 vs 51 days, P = .013). The analysis of 1104 hours of pH-MII tracings demonstrated that infants with BPD compared with infants without BPD had increased numbers of pH-only events (median number 21 vs 9) and a higher symptom sensitivity index for pH-only events (9% vs 4.9%); the number and characteristics of acid, weakly acid, nonacid and gas gastroesophageal reflux events, acid exposure, esophageal clearance, and recorded symptoms did not significantly differ between the 2 groups. CONCLUSIONS: The increased number of (and sensitivity for) pH-only events among infants with BPD may be explained by several factors, including lower milk intake, impaired esophageal motility, and a peculiar autonomic nervous system response pattern.

A possible association between sports and isolated fallopian tube torsion in children and adolescent females.

Isolated fallopian tube torsion (IFTT) is a rare occurrence characterized by the rotation of the fallopian tube on its own axis, without twisting the ipsilateral ovary. Pre-operative diagnosis is difficult due to the lack of specific clinical symptoms and radiological signs. The etiology is to date unknown and only some pre-disposing factors have been reported. The history, clinical presentation, laboratory findings and surgical treatment of five patients aged 12-16 with IFTT were evaluated. All patients came to be examined for worsening abdominal pain, nausea or vomiting. 75% of them practiced sports involving sudden changes in body position. They all underwent blood tests, ultrasound and Magnetic Resonance and then laparoscopy for the persistence of acute symptoms. Laparoscopic salpingectomy was performed in three patients. Another two needed a conversion to open salpingectomy due to the presence of pelvic adhesions. During the follow-up period, every girl was fine. The cause of IFTT is undetermined. In this series, a close association between IFTT and sports causing rapid body movements was found. The possibility of IFTT should be considered in the differential diagnosis of acute abdominal pain in children or adolescent females, especially if they practice sports.

Combined Minimally Invasive Treatment of Pyeloureteral Junction Obstruction and Primary Obstructive Megaureter in Children: Case Report and Literature Review.

INTRODUCTION: In children, the association of ipsilateral pyeloureteral junction obstruction (PUJO) and ureterovesical junction obstruction (UVJO) is a rare malformation with a non-standardized treatment. We report a case of PUJO and UVJO treated by a combined minimally invasive surgical treatment to resolve the double urinary obstruction. The current literature was also reviewed. CASE REPORT AND REVIEW: A two-month-old boy, without antenatal and postnatal signs of urinary tract anomalies, was hospitalized presenting right hydronephrosis, perirenal fluid effusion, and ascites. An acute pelvic rupture was suspected, and a retrograde pyelogram was performed, showing a primary obstructive megaureter (POM) associated with a corkscrew pyeloureteral junction. The impossibility to place a double J catheter through the pyeloureteral junction led us to achieve percutaneous nephrostomy and an abdominal drain placement. Three months later, the patient underwent a combined high-pressure balloon ureterovesical junction dilation and retroperitoneoscopic Anderson Hynes one-trocar-assisted pyeloplasty (OTAP). The literature search identified 110 children experiencing double urinary tract obstruction. All authors agreed on the difficulty to diagnose both obstructions preoperatively, but there is still no consensus on which obstruction should be relieved earlier, because the alteration in urinary vascularity during a double surgery could damage the ureter. CONCLUSIONS: The simultaneous occurrence of UPJO and UVJO is rare, with a challenging diagnosis. Prompt identification and timely surgical intervention are crucial to mitigate the risk of renal function loss attributable to obstruction and infection. Drawing from our expertise and the analysis of the existing literature, we propose employing a simultaneous double minimally invasive strategy in order to optimize the preservation of ureteral vascularity. This approach entails performing a minimally invasive pyeloplasty for the PUJ and utilizing high-pressure balloon dilatation for the UVJ.

Pyeloplasty in Children with Ureteropelvic Junction Obstruction and Associated Kidney Anomalies: Can a Robotic Approach Make Surgery Easier?

BACKGROUND: Robot-assisted pyeloplasty is widely used in pediatric surgery because of its well-known advantages over open or laparoscopic surgery. The aim is to explore our experience and evaluate the achievements we have made. METHODS: We evaluated patients undergoing robotic pyeloplasty from January 2016 to November 2021, including those who presented with a ureteropelvic junction obstruction associated with other anomalies of the kidney. The parameters examined were: age, weight, associated renal malformations, conversion rate, operative time, and intra- and postoperative complications. RESULTS: Of 39 patients, 7 (20%) were included, of whom 5 (71%) were male and 2 (29%) were female. The mean age at surgery was 84 months (range 36-180 months), and the mean weight at surgery was 24.4 kg (range 11-40 kg). In five (71%) patients the ureteropelvic junction obstruction (UPJO) was left-sided and in two (29%) it was right-sided. In four (57%) cases, UPJO was associated with a horseshoe kidney, right-sided in one (25%) patient, and left-sided in the other three (75%). A 180° rotation of the kidney was present in one (14%) patient. Nephrolithiasis was present in two (29%) patients. The mean operative time was 160 min (range 140-240 min). The average bladder catheter dwell time was 1 day (range 2-3 days), while the average abdominal drainage dwell time was 2 days (range 2-4 days). The mean hospitalization time was 4 days (range 3-9 days). On average, after 45 days (range 30-65) the JJ ureteral stent was removed cystoscopically. No intraoperative complications were reported, while one case of persistent macrohematuria with anemia requiring blood transfusion occurred postoperatively. CONCLUSIONS: Ureteropelvic junction obstruction might be associated with other congenital urinary tract anomalies such as a duplicated collecting system, horseshoe kidney, or pelvic kidney. These kinds of malformations can complicate surgery and require more attention and accuracy from the surgeon. Our experience shows that, with regards to the robotic learning curve required for pyeloplasty, the treatment of the ureteropelvic junction in these situations does not present insurmountable difficulties nor is burdened by complications. The application of robot-assisted surgery in pediatric urology makes difficult pyeloplasties easier.

Hypertrophic Pyloric Stenosis in an Adolescent Girl: An Atypical Presentation of an Unexpected Disease.

Hypertrophic pyloric stenosis is a common cause of vomiting in the first few weeks of life, but in rare cases, it may occur in older subjects with a major risk of delayed diagnosis and complications. We describe the case of a 12-year-and-8-month-old girl who presented to our department for epigastric pain, coffee-ground emesis, and melena, which arose after taking ketoprofen. An abdomen ultrasound showed thickening (1 cm) of the gastric pyloric antrum, while upper-GI endoscopy documented esophagitis and antral gastritis with a non-bleeding pyloric ulcer. During her hospital stay, she had no further episodes of vomiting and was therefore discharged with a diagnosis of "NSAIDs-induced acute upper gastrointestinal tract bleeding". After 14 days, following recurrence of abdominal pain and vomiting, she was hospitalized again. At endoscopy, pyloric sub-stenosis was found, abdominal CT showed thickening of large gastric curvature and pyloric walls, and an Rx barium study documented delayed gastric emptying. On suspicion of idiopathic hypertrophic pyloric stenosis, she underwent Heineke-Mikulicz pyloroplasty with resolution of symptoms and restoration of a regular caliber of the pylorus. Hypertrophic pyloric stenosis, although occurring rarely in older children, should be taken into account in the differential diagnosis of recurrent vomiting at any age.

Pneumovesicoscopic management of bladder neoplasms in children: three case reports.

Urothelial bladder neoplasms (UBN) are uncommon in children and are poorly understood. Their management is contentious, and there are currently no pediatric guidelines available, making it difficult to envision a surgical approach that can be defined as the gold standard for the treatment of these diseases. Pneumovesicoscopy, which has already been used to treat other urological diseases, could be a promising treatment option for selected cases of this group of pathologies. We present our experience with three pediatric UBN cases in which pneumovesicoscopy was used for complete excision of a perimeatal papilloma in two cases and biopsy of a botryoid rhabdomyosarcoma in one. The pneumovesicoscopic approach, in our experience, provided a viable alternative technique for the management of selected cases of UBN.

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.

Antenatal Diagnosis and Management of Fetal Intestinal Volvulus: Case Series and Literature Review.

Fetal intestinal volvulus is a rare condition that can lead to hemorrhage, bowel necrosis, and urgent surgical treatment after birth. Thus, prompt diagnosis and treatment are essential to avoiding fetal or neonatal demise. Prenatal ultrasound is a keystone tool in the diagnostic course. However, sonographic findings tend to be non-specific, with limited understanding of the pathophysiology behind their atypical presentation. With a literature review and a case series, we aim to optimize the antenatal diagnosis and management of this rare but life-threatening condition. Six cases from our institution were retrospectively analyzed over 12 years. A literature review was conducted until December 2022. A total of 300 articles matched the keyword "Fetal volvulus", and 52 studies were eligible for the review. Our 6 cases are added to the 107 cases reported in the literature of fetal intestinal volvulus with antenatal ultrasound assessment and without associated gastroschisis or omphalocele. Several prenatal symptoms and ultrasound markers, even if not specific, were more frequently reported. Different experiences of management were described regarding follow-up, the timing of delivery, the mode of delivery, and surgery outcomes. This paper highlights the importance of suspecting and assessing fetal volvulus at routine ultrasound scans, describing the most frequent antenatal presentations and management in order to improve fetal and neonatal outcomes.

Transumbilical laparoscopic-assisted appendectomy versus laparoscopic appendectomy in children: a single center experience.

Laparoscopic Appendectomy (LPSA) is the first choice for appendectomy in pediatric surgery. Trans-Umbilical Laparoscopic Assisted Appendicectomy (TULAA) is another used technique. We compared both these procedures used for the treatment of acute appendicitis. The study was conducted between January 2019 to December 2020. Patients were divided into two groups: LPSA and TULAA groups. The collected data were: operative time, number of conversions, time of canalization and hospital stay. A total of 181 patients were included: 73 were kept in the LPSA and 108 in the TULAA group. Mean operative time was 70.9 minutes (range 45-130 min) for LPS and 56.4 (30-145 min) for TULAA group (p <0.0001). Complications rate showed no statistically significant difference between both the two groups. However, conversions showed a statistically significant difference (p=0.04). Both techniques showed similar results. TULAA technique takes a significantly shorter operating time. The selection between LPSA and TULAA techniques depends on the experience of the surgeon's work and the personal laparoscopic learning curve. In our experience LPSA was a useful technique to improve the laparoscopic skill of the pediatric surgery residents.

Robotic approach to the uretero-vesical junction in children: An international multicentric retrospective study.

BACKGROUND: Robot-assisted approach to UVJ is getting more and more used in pediatric patients. METHODS: In this retrospective study 26 patients affected by nephro-urological malformations, robotic-surgically treated from 2016 and 2021 at 3 Pediatric Surgery Department were included: 3 (11.5%) primary obstructive megaureter, 2 (7.7%) dysplastic kidneys, 3 (11.5%) duplex collecting system, 18 (69.2%) primary vescico-ureteral reflux (VUR). RESULTS: Mean age at surgery was 6 years old. 22 (84.6%) underwent Lich Gregoire extravesical ureteral reimplantation, 4 (15.4%) total nephroureterectomy. Mean operative time was 230 min. No conversions or intraoperative complications. Median hospital stay was 4 days. There were 4 (15.38%) postoperative complications: 3 (11.54%) persistent VUR and 1 (3.84%) refluxing megaureter. 2 (7.7%) redo-surgery. CONCLUSIONS: Robotic Surgery should be considered a safe and effective technique for treatment of UVJ anomalies in children, because it firstly allows surgeons to approach both upper and lower ureteral ends without modifying trocars' placement.

Preoperative anxiety management in children. Benefits of humanoid robots: an experimental study.

Objective: The purpose of this study was to determine whether the use of a humanoid robot (Estrabot) could reduce preoperative anxiety levels in children. Methods: An experimental study was conducted at Azienda Ospedaliero Universitaria delle Marche Hospital, involving the Pediatric Surgery ward and the Operating Room (OR). Patients aged between 2 and 14 years who underwent minor surgery were included. The Instruments used were the Children's Emotional Manifestation Scale to evaluate anxiety levels, and Estrabot, a humanoid robot that interacts with people. Medical records between April and May 2023 were analyzed and the data was anonymous. The level of anxiety is extrapolated in Pediatric Surgery during the administration of oral pre-medication, and in the Operating Room, during the induction of anesthesia. Patients were divided into an intervention group treated with Estrabot, and a control group without a robot. Results: The population consists of 60 patients (86.7% male) with a median (IQR) age of 6 (4-8) years. The median (IQR) anxiety score during premedication was 7 (5-11), while the median (IQR) anxiety score during anesthesia was 6 (5-10). A significantly lower level of anxiety was reported in the Estrabot group. Patients in the Estrabot group had significantly lower anxiety levels in different age groups. Conclusion: A humanoid robot can reduce preoperative anxiety levels in children during premedication and the induction of anesthesia.

Urology in Pediatrics.

Pediatric urology has been developed by many pediatric urologists and pediatric surgeons from all over the world [...].

Liver Resection Using Saline-Linked Radiofrequency Technology in an Infant with Congenital Hepatoblastoma.

We herein report a case of giant congenital hepatoblastoma in a 3-month-old male treated with neoadjuvant chemotherapy and hepatic resection. After considerable reduction of the tumor with chemotherapy, a right bloodless hemihepatectomy using saline-linked radiofrequency technology (SLRT) and without clamping of the hepatic pedicle was performed. Intraoperative blood loss was minimal, and consequently, no blood transfusions were required. The surgery lasted 140 min, and SLRT was used for a total of 60 min. No complications were observed during or after the surgery. In conclusion, congenital hepatoblastoma is a very rare cancer for which surgery is an essential therapeutic step, and in our presented case, we showed that SLRT allowed for a safe and effective bloodless liver resection.