Robotic-assisted surgery for gynecological indications in children and adolescents: European multicenter report.

Robotic-assisted surgery (RAS) is increasingly adopted in the pediatric population. This retrospective multicenter study aimed to report application of RAS for gynecological indications in pediatric patients. The medical records of all girls with gynecological pathology, operated in 4 different institutions over a 3-year period, were retrospectively collected. Robot docking time, total operative time, length of stay (LOS), requirement time of pain medication, complication rate, conversion rate, and pathology were analyzed. Twenty-three girls, with median age of 12.3 years (range 0.6-17.8) and median weight of 47.2 kg (range 9-73), received the following RAS procedures: ovarian cystectomy for ovarian cyst/mass (n = 10), salpingo-oophorectomy for ovarian complex mass (n = 6), bilateral gonadectomy for Turner syndrome SRY + (n = 1), salpingectomy for fallopian tube lesion (n = 1), paratubal cyst excision (n = 1), Gartner cyst excision (n = 1), paravaginal ganglioneuroma resection (n = 1), fistula closure in urogenital sinus (n = 1), and vaginoplasty using ileal flap in cloaca malformation (n = 1). Median operative time was 144.9 min (range 64-360), and median docking time was 17.3 min (range 7-50). Conversion to open or laparoscopy was not necessary in any case. Median LOS was 2.1 days (range 1-7), and median analgesic requirement was 2.2 days (range 1-6). One patient (4.3%) needed redo-surgery for recurrent Gartner cyst (Clavien 3b). This preliminary experience showed that RAS is safe and feasible for surgical treatment of gynecological pathology in pediatric patients, although no conclusive data are available to confirm its superiority over traditional laparoscopy. Randomized, prospective, comparative studies are needed to identify the gold standard approach for such indication.

Quality of life of pediatric patients operated for pilonidal sinus disease.

Quality of life (QOL) outcome is an ideal method for determining the efficacy of a surgical treatment. In children operated for pilonidal sinus disease (PSD), open procedures imply prolonged wound care, significant morbidity, and high recurrence rates. Endoscopic treatment (PEPSIT) overcomes these limitations. We report our experience in the management of PSD to evaluate the QOL of patients undergoing open and endoscopic treatment. The records of 177 patients undergoing surgery for PSD from 2008 to 2021 were retrospectively reviewed. Twenty patients were operated with open surgery (G1) and 157 with PEPSIT (G2). We analyzed QOL through the following criteria: hospital stay (HS), healing time (HT), return to sport (RTSp), return to school (RTSc), resumption of social life (RSL), and recurrence rate and reoperation (RRR). Moreover, we used Pediatric Quality of Life Enjoyment and Satisfaction Questionnaire (PQ-LES-Q) for a more subjective evaluation of life satisfaction. We found significant differences in all the analyzed criteria: HS varied from 3 to 7 days in G1 and from 1 to 2 days in G2; HT from 40 to 75 days in G1 while from 20 to 41 days in G2; RTSp from 50 to 80 days in G1 while from 7 to 21 days in G2; RTSc from 9 to 15 days in G1 while from 2 to 4 days in G2; RSL from 13 to 20 days in G1 while from 2 to 5 days in G2; RRR was 25% in G1 and 4.4% in G2. CONCLUSION: Endoscopic treatment (PEPSIT) significantly improves the quality of life of patients operated for PSD. Compared to open surgery, PEPSIT presents shorter hospital stay, faster healing time, return to sport activities, return to school and resumption of a normal social life, and lower rates of recurrence and reoperation. In addition, PQ-LES-Q demonstrated a good overall quality of life and life satisfaction. Further prospective studies should be obtained to consider PEPSIT as the gold standard for the treatment of PSD in pediatric patients. WHAT IS KNOWN: • Many techniques have been proposed in the last 20 years for the surgical treatment of PSD. • PEPSIT is showing promising results in terms of safety and long-term efficacy. WHAT IS NEW: • The main impact in QOL of patients operated with PEPSIT is on their daily activity, including a shorter hospital stay, faster healing time, return to sport activities, return to school and resumption of a normal social life, lower rates of recurrence and reoperation. • After PEPSIT, children maintain a satisfactory quality of life according to the analysis of PQ-LES-Q.

Effectiveness of a Laparoscopic Training Model for Pediatric Surgeons During COVID-19 Pandemic: A Single-Center Experience.

Background: During COVID-19 pandemic, many restrictions were applied in the field of health care. For this reason, we decided to adopt the laparoscopic simulator Laparo® Analytic to allow the trainees of our pediatric surgery training program to continue their training activity, and we determined its impact on their surgical education. Methods: We used Laparo Analytic Simulator for laparoscopic surgery training among the residents of our center. Fifteen residents from different years of the pediatric surgery program participated in this study. Each participant performed a 2-hour training session per week, consisting of three different exercises: Rubber Bands, Knotting, and Suturing. For each training session, the following parameters were analyzed: training time, economy of movement, smoothness, instrument activity (IA), instrument visibility (IV), and instrument symmetry. Results: Results were collected after the first training session (T0), at 3 months after the beginning of the study (T1) and at 6 months after the beginning of the study (T2). At T2 of training with Laparo Analytic Simulator, residents were able to complete their tasks significantly faster (P = .001) and had a significant improvement in smoothness of movements, IA, IV, and instrument symmetric movements during the tasks analyzed. Conclusion: On the basis of our results, we believe that Laparo analytic is an excellent system to adopt in minimally invasive surgery (MIS) training programs, in particular, during periods of surgical restrictions, as COVID-19 pandemic, or in centers with a limited MIS activity.

Laparoscopic Partial Nephrectomy for Duplex Kidneys in Infants and Children: How We Do It.

Duplication anomalies of the kidney represent common congenital malformations of the urinary tract. A duplex kidney has often one pole that is poorly or nonfunctioning. In this last case, surgery may be indicated to remove the nonfunctioning pole. The most common indications for partial nephrectomy in pediatrics include symptomatic vesicoureteral reflux to the nonfunctioning pole and/or ectopic ureter or ureterocele causing urinary incontinence. In this article, we describe the technique of laparoscopic partial nephrectomy in infants and children with duplex kidney. A surgical procedure properly executed following critical technical steps is the key factor for the success of surgery.

Robotics and future technical developments in pediatric urology.

Minimally invasive surgery (MIS) has represented the main innovation in the field of pediatric surgery and urology over the last 30 years. Pediatric MIS is a wide field, ranging from the standard laparoscopic surgery using 3-mm ports to robotics mainly adopted for pediatric urology indications. The aim of this paper was to summarize the current status of robotic surgery in pediatric urology and to evaluate possible future technical developments for this technique. In pediatric urology, many procedures are challenged by the narrow working space available in smaller children, the difficulty to perform complex and long suture lines to repair complex urinary malformations, and the challenge to remove renal or adrenal tumors. The main characteristic of robotic surgery is that the robotic instruments inserted into the abdominal cavity are remotely controlled by the surgeon, who is sitting at a console next to the patient or even far away, avoiding human tremor during complex suturing. Due to the magnification of the operative field view and the six degrees of freedom of the robotic instruments compared to conventional laparoscopic instruments, providing enhanced 3D vision and improved surgeon ergonomics, robot-assisted surgery appears to be beneficial over conventional MIS, especially in complex reconstructive procedures. Currently, there are two robotic systems available on the market and certified for robotic surgery in children: the DaVinci (Intuitive Surgical, since 2001) and Senhance (Transenterix, since 2020). However, almost the totality of papers published in the international literature are focused on robotic procedures using the DaVinci platform. Analyzing the current literature, there is no evidence about the indications where robotics are preferable to conventional MIS approaches. Currently, the main indications of robotic surgery in pediatric urology are: pyeloplasty for ureteropelvic junction obstruction (UPJO), ureteral reimplantation according to Lich Gregoire technique, Mitrofanoff procedure, nephrectomy or partial nephrectomy for oncological indications, removal of renal cysts, bladder neck reconstruction or removal of urinary tract stones. The future developments in this field are certainly represented by intraoperative use of indocyanine green (ICG) fluorescence imaging that permits to have a better vision of vascular anatomy or clearly identify nodes in case of tumors, and by development of 5G technology. The main limitation of robotic surgery today remains the excessive cost of the machine itself and the limited lifespan of robotic instruments. We believe that robotic surgery will surely represent the new field of development in pediatric surgery, but its widespread application will depend on the introduction of new robotic platforms in the market, that will certainly low the costs, and also to the development of smaller size instruments more suitable for pediatric use.

Technical standardization of ICG near-infrared fluorescence (NIRF) laparoscopic partial nephrectomy for duplex kidney in pediatric patients.

PURPOSE: This study aimed to standardize the operative technique of indocyanine green (ICG) near-infrared fluorescence (NIRF) laparoscopic partial nephrectomy (LPN) and compare it with the standard technique. METHODS: In the last 4 years, we performed 22 LPN (14 right-sided, 8 left-sided) in children with non-functioning moiety of duplex kidney. Patients included 12 girls and 10 boys with a median age of 3.9 years (range 1-10). Patients were grouped according to the use of ICG-NIRF: G1 included 12 patients operated using ICG-NIRF and G2 included 10 patients receiving the standard technique. We standardized the technique of injection of ICG in three different steps. RESULTS: The median operative time was significantly lower in G1 [87 min (range 68-110)] compared with G2 [140 min (range 70-220)] (p = 0.001). One intra-operative complication occurred in G2. At post-operative ultrasound (US), the residual moiety was normal in all patients. An asymptomatic renal cyst related to the site of surgery was visualized at US in 8/22 (36%), with a significantly higher incidence in G2 (6/10, 60%) compared with G1 (2/12, 16.6%) (p = 0.001). Renogram demonstrated no loss of function of residual moiety. No allergic reactions to ICG occurred. CONCLUSION: ICG-NIRF LPN is technically easier, quicker, and safer compared with the standard technique. The main advantages of using ICG-NIRF during LPN are the clear identification of normal ureter, vasculature of non-functioning pole, and demarcation line between the avascular and the perfused pole. The main limitation of ICG technology remains the need for specific laparoscopic equipment that is not always available.

Video-Based Coaching: An Efficient Learning and Teaching Modality for Pediatric Surgery and Pediatric Urology Training Program.

Objective: The development of integrated multimedia operating rooms has made possible to record surgical procedures mainly in minimally invasive surgery (MIS) and robotic surgery. This modality of video storage allows the trainees to study surgical procedures based on video analysis. The aim of this study is to compare two learning methods of surgical procedures, operative textbooks and video-based coaching, in a group of 10 pediatric surgery trainees. Patients and Methods: We selected five surgical procedures to study: three MIS procedures, Nissen fundoplication, partial nephrectomy, and cholecystectomy; and two robotic procedures, Lich-Gregoir reimplantation for vesicoureteral reflux and Henderson-Hynes pyleoplasty for ureteropelvic junction obstruction. Ten trainees were divided into two groups of 5 each, Group 1 (G1) and Group 2 (G2). G1 studied the procedures analyzing videos, G2 studied the same procedure classically reading textbooks. Tutors prepared a questionnaire of 100 multianswered questions that was submitted to both groups, divided into 20 questions for each surgical technique. The questionnaire focused on the different steps of surgical techniques. Results: Analyzing the 10 questionnaires, G1 (video group) obtained a median result of 82 exact answers (74-97), whereas G2 (textbook group) obtained a median result of 64.2 correct answers (53-79). Analyzing statistically the results of two groups, using unpaired t-Student's test with a level of statistical significance >95%, the results of G1 were statistically significantly better that G2 with a P = .0265 for the average scores. Conclusion: Video-based coaching to learn surgical techniques is a novel, feasible, and excellent modality for supplementing surgical techniques learning for pediatric surgery trainees. Objective evaluation using a multianswered questionnaire demonstrates that video-based coaching in pediatric surgery is statistically better than textbook classic education. We suggest to adopt this teaching modality in every surgical training program above all to teach MIS and robotic surgery.