Indirect signs of infravesical obstruction on voiding cystourethrography improve post-neonatal posterior urethral valves detection rate.

OBJECTIVES: To identify the diagnostic performance of clinical and radiological signs (on voiding cystourethrography [VCUG]) to detect posterior urethral valves (PUV) in the post-neonatal period. MATERIALS AND METHODS: One hundred eighteen males (median age = 0.8 years, range = 1 month-14 years, 48 toilet-trained) undergoing VCUG in a 2-year period were prospectively enrolled. Direct (dilated posterior urethra) and indirect (hypertrophied bladder neck, musculus interuretericus hypertrophy, and trabeculated appearance of the bladder wall) PUV signs on VCUG were assessed. Uroflowmetry was defined pathological by patterns suggesting infravesical obstruction. RESULTS: Twenty-two patients with direct, 28 with indirect PUV signs on VCUG, and one with normal VCUG but persisting micturition symptoms with pathological uroflowmetry underwent urethrocystoscopy and in 43/51 a PUV diagnosis was made (n = 22, 51.2%, with direct PUV signs). In 8/28 patients with indirect signs, PUV were not confirmed. Among non-toilet-trained patients, none of the clinical signs/symptoms was associated with PUV while among toilet-trained patients only pathological uroflowmetry (odds ratio, OR = 4.0 [95% confidence interval:1.2-13.2; p = 0.02]) and pathological uroflowmetry with history of urinary tract infection (OR = infinity) were significantly associated with PUV. Significant associations with PUV of direct and indirect signs on VCUG were found both in toilet-trained and non-toilet trained patients. Direct PUV sign had 100% specificity and sensitivity while indirect PUV signs showed sensitivity = 58.1% and specificity = 89.3%. The absence of any radiological sign had a negative predictive value = 98.5%. CONCLUSION: Only half of patients with endoscopy-confirmed PUV presents with direct sign of PUV on VCUG. Accounting for indirect PUV signs on VCUG and pathological uroflowmetry (in toilet-trained children) could improve the PUV detection rate. CLINICAL RELEVANCE STATEMENT: Indirect radiological PUV signs should be valorized when interpreting VCUG to improve the PUV detection rate. The absence of any radiological PUV (direct and indirect) sign on VCUG excludes PUV with a very high negative predictive value. KEY POINTS: • Worldwide agreement is that a non-dilated urethra on voiding cystourethrography excludes obstruction. • Half of patients with posterior urethral valves have non-dilated urethra on voiding cystourethrography. • Accounting for indirect signs of posterior urethral valves on voiding cystourethrography improves the diagnostic performance.

Twenty-year experience with laparoscopic inguinal hernia repair in infants and children: considerations and results on 1833 hernia repairs.

BACKGROUND: The role of laparoscopy in pediatric inguinal hernia (IH) is still controversial. The authors reported their twenty-year experience in laparoscopic IH repair in children. METHODS: In a twenty-year period (1995-2015), we operated 1300 infants and children (935 boys-365 girls) with IH using laparoscopy. The average age at surgery was 18 months (range 7 days-14 years). Body weight ranged between 1.9 and 50 kg (average 9.3). Preoperatively all patients presented a monolateral IH, right-sided in 781 cases (60.1 %) and left-sided in 519 (39.9 %). We excluded patients with bilateral IH and unstable patients in which laparoscopy was contraindicated. If the inguinal orifice diameter was ≥10 mm, we performed a modified purse string suture on peri-orificial peritoneum, in orifices ≤5 mm, we performed a N-shaped suture. RESULTS: No conversion to open surgery was reported. In 533 cases (41 %), we found a contralateral patency of internal inguinal ring that was always closed in laparoscopy. In 1273 cases (97.9 %), we found an oblique external hernia; in 21 cases (1.6 %), a direct hernia; and in 6 cases (0.5 %), a double hernia on the same side (hernia en pantaloon). We found an incarcerated hernia in 27 patients (2 %). Average operative time was 18 min (range 7-65). We recorded 5/1300 recurrences (0.3 %), but in the last 950 patients, we had no recurrence (0 %). We recorded 20 complications (1.5 %): 18 umbilical granulomas and two trocars scar infections, treated in outpatient setting. CONCLUSIONS: On the basis of our twenty-year experience, we prefer to perform IH repair in children using laparoscopy rather than inguinal approach. Laparoscopy is as fast as inguinal approach, and it has the advantage to treat during the same anesthesia a contralateral patency occured in about 40 % of our cases and to treat also rare hernias in about 3 % of cases.

Ultrasonography is unnecessary and misleading in evaluating boys with a nonpalpable testis and can be a cause of a legal process.

A 2-year-old boy came to our attention for a left non-palpable testis (NPT). The parents asked us to perform a laparoscopy to pull down a left intrabdominal testis (IAT), identified ultrasonographically before surgery. The ultrasonography (US) performed in another institution showed a right intrascrotal testis of normal size and a left IAT of 0.85 × 0.78 mm(2) located near the internal inguinal ring. We performed a laparoscopy that showed a blind-ending vas deferens and blind-ending inner spermatic vessels as in case of vanishing testis and a large lymphnode located near the internal inguinal ring that was closed. Parents were disappointed after laparoscopic diagnosis because the US performed before surgery showed them an IAT; for this reason they undertook a legal challenge against the pediatrician and the radiologist who had given them false information. In conclusion, we believe that in cases of NPT, laparoscopy is the gold standard for diagnosis and US is unnecessary and misleading.

Early-in-Life Serum Aldosterone Levels Could Predict Surgery in Patients with Obstructive Congenital Anomalies of the Kidney and Urinary Tract: A Pilot Study.

The aim of the study was to evaluate whether serum aldosterone levels or plasmatic renin activity (PRA) measured early in life (1-3 months) could predict a future surgical intervention for obstructive congenital anomalies of kidney and urinary tract (CAKUT). Twenty babies aged 1-3 months of life with suspected obstructive CAKUT were prospectively enrolled. The patients underwent a 2-year follow-up and were classified as patients needing or not needing surgery. In all of the enrolled patients, PRA and serum aldosterone levels were measured at 1-3 months of life and were evaluated as predictors of surgery by receiver-operating characteristic (ROC) curve analysis. Patients undergoing surgery during follow-up showed significantly higher levels of aldosterone at 1-3 months of life compared to those who did not require surgery (p = 0.006). The ROC curve analysis of the aldosterone for obstructive CAKUT needing surgery showed an area under the ROC curve of 0.88 (95%CI = 0.71-0.95; p = 0.001). The aldosterone cut-off of 100 ng/dL presented 100% sensitivity and 64.3% specificity and predicted surgery in 100% of cases. The PRA at 1-3 months of life was not a predictor of surgery. In conclusion, serum aldosterone levels at 1-3 months could predict the need for surgery during obstructive CAKUT follow-up.

Laparoscopic Trachelectomy for Cervix Yolk Sac Tumor in 11-Month-Old Girl: The Youngest Case.

BACKGROUND: Yolk sac tumor (YST) is a malignant entity that often occurs in girls less than 3 years of age and is the most frequent type of primary extragonadal germ cell tumor. CASE: We describe the case of an 11-month-old girl who was referred to our center for vaginal bleeding with evidence of a uterine mass on ultrasonography. Preoperative investigations confirmed YST of the uterine cervix without metastasis. After 4 cycles of systemic chemotherapy, the patient was treated with laparoscopic trachelectomy (fertility-sparing surgery) without perioperative complications. SUMMARY AND CONCLUSION: After 12 months of follow-up, no residual mass was seen. The laparoscopic technique for trachelectomy for uterine cervix YST seems to be feasible and safe in children under 1 year of age.

High-pressure balloon dilatation for the treatment of primary obstructive megaureter: is it the first line of treatment in children and infants?

AIMS OF THE STUDY: To evaluate the efficacy of high-pressure balloon dilatation (HPBD) as treatment of primary obstructive megaureter (POM) in paediatric patients, we analysed the data of our institute from June 2018 to September 2019. METHODS: 14 patients, aged 5 months to 5 years, with POM were treated with HPBD. All patients had a distal ureter dilatation greater than 7 mm associated with obstructive features on a mercaptoacetyl triglycine-3 diuretic renogram scan, and a voiding cystourethrogram without vesicoureteral reflux. HPBD was performed in 12 patients, whereas 2 patients (14%), aged 5 and 6 months, required open surgical treatment because of failure to pass the balloon catheter through the vesicoureteral junction. The procedure was performed with a 5 Fr balloon catheter for two cycles of 5 minutes each at 17 atm. A double-J stent and a urinary catheter were inserted at the end of procedure in all patients. RESULTS: No operative complications or symptoms or recurrence were recorded in our series. The patients were generally discharged 24 hours after surgery. All the patients showed an improvement on ultrasonography at the postoperative follow-up, with no evidence of obstruction. During the procedure a clear stenotic ring was identified in 10 of the 12 patients, which disappeared in all 10 cases after the HPBD technique. CONCLUSIONS: Based on our experience, HPBD may be considered the first-line surgical approach in the treatment of POM in children, avoiding bladder surgery in most cases.

Posterior Urethral Polyp Treated With Endoscopic Transurethral Resection: The Second Pediatric Case Managed With Holmium Laser.

Fibroepithelial urethral polyp is a rare benign tumor more common in children than adult that can cause bladder outlet obstruction. We describe a 3-year-old boy who presented with intermittent acute urinary retention affected by a fibroepithelial urethral polyp managed with endoscopic transurethral resection by HOLMIUM laser; no complications neither recurrence were observed. To our knowledge this is the second pediatric case of fibroepithelial urethral polyp treated by HOLMIUM laser.

Individualized robotic organ-sparing surgery in a paediatric case of renal perivascular epithelioid cell tumour.

BACKGROUND: Perivascular epithelioid cell tumours (PEComas) represent a rare group of mesenchymal tumours with an unpredictable outcome. They are usually observed in middle-aged women whilst they are very rare in children, with limited cases described. Due to the rare anatomical location in kidneys, a correct diagnosis and treatment is really challenging. METHODS: We observed and treated a case of kidney's PEComa in a 14-year-old boy. RESULTS: An individualized approach based on anatomical (3D CT-reconstructions) and histopathological (US-guided preliminary biopsy) features lead us to perform a successful robotic-sparing surgery enabling the preservation of two-thirds of the kidney involved. CONCLUSIONS: A meticulous preoperative planning in selected patients can lead to a minimally invasive approach even in some paediatric kidney's neoplasms.

Frequency of Antibiotic-Associated Diarrhea and Related Complications in Pediatric Patients Who Underwent Hypospadias Repair: a Comparative Study Using Probiotics vs Placebo.

This study aimed to evaluate the effectiveness of probiotics (Lactobacillus rhamnosus GG), as a preventive measure of antibiotic-associated diarrhea (AAD) in children who underwent hypospadias repair and its clinical consequences on postoperative outcome, comparing the group treated with probiotics + antibiotics with two control groups (only antibiotics and antibiotics + placebo). We performed a prospective, randomized, placebo-controlled study with three groups of patients (30 boys for each group) who underwent hypospadias repair in our unit from March 2016 to December 2016. G1 received antibiotics + probiotics (L. rhamnosus GG), while G2 and G3 respectively received only antibiotics or antibiotics + placebo (glucose solution at 5%) for the same period. The patients were evaluated in regard to the number of evacuations/day, stool consistency, and the number of dressings/day. The overall incidence of postoperative AAD was 33.3% (30/90), and it was statistically lower in G1 patients compared to G2 and G3 ones (p = 0.002). The duration of AAD was significantly longer in G2 and G3 compared to G1 (p = 0.001). In G1, the frequency of dressing change was significantly lower compared to G2 and G3 (p = 0.001).The incidence of postoperative complications (fistula and dehiscence) was significantly higher in G2 and G3 compared to G1 (p = 0.001). Our study confirmed that the use of probiotic L. rhamnosus GG associated with antibiotics significantly reduced the incidence and the duration of postoperative AAD. In addition, the use of probiotics LGG reduced the frequency of dressing changes and the incidence of postoperative complications, such as urethral fistula and foreskin dehiscence.

Surgical approaches for varicocele in pediatric patient.

BACKGROUND: Varicocele represents one of the most common surgically correctible urologic anomalies in adolescent males. The best procedure for the treatment of adolescent varicocele has not been established, but with recent advances in minimal access surgery, there have been many reports praising the safety and efficacy of laparoscopy and retroperitoneoscopy for the surgical correction of varicocele in adolescent. The aim of this review is to compare the results of Palomo's technique, with retroperitoneoscopic and transperitoneoscopic approaches in adolescent, analyzing recurrence, testicular growth and complications. METHODS: A literature search on PubMed and Cochrane Database was conducted with regard to management of varicocele in adolescent population. Twenty two English language studies that compared outcome of different minimally invasive treatments or outcome of minimally invasive and traditional surgical treatments for adolescent diagnosed with varicocele were included. RESULTS: Intraoperative complications of minimally invasive approaches occur in early cases, but in pediatric urology these procedures would become more efficient with experience and these approaches continue to increase in number. Postoperative hydrocele is the most postoperative compliance of Palom technique, and reports have shown a wide range of variability for his incidence, depending on the technique used for surgical treatment. Literature showed an increase of testicular volume for real growth of testis after surgery, and an intratesticular improvement in sperm quality after minimally invasive approach. In laparoscopic approach reports have showed very low recurrence because allows better vision of collateral veins, and a lymphatic sparing technique permit to identify lymphatic vessels in 100% of cases. CONCLUSIONS: The literature has shown that laparoscopic varicocelectomy is the surgical approach most commonly reported in adolescent patients, and that its use is increasing for better training for surgeons and the ability to avoid operational hydrocele that is a main complication after technical Palomo's technique.

Laparoscopic approach for gonadectomy in pediatric patients with intersex disorders.

The birth of a child with a disorder of sex development (DSD) prompts a long-term management strategy that involves a myriad of professionals working with the family. There has been progress in diagnosis, surgical techniques and in understanding psychosocial issues related to this condition. However, since these kinds of disorders are rare and have many anatomical variations, individual care is necessary, especially regarding surgical management. Gonadectomy is indicated in a number of intersex disorders with a Y chromosome to reduce the associated risk of cancer. Recently, laparoscopy has gained wide acceptance in pediatric urology. Laparoscopy is also reported to be a useful tool for diagnosing and treating DSD because of its minimal invasiveness and favorable cosmetic outcome. However, reports of evaluation and management using laparoscopy for large numbers of DSD patients are limited and debate is still open about indications and timing of gonadectomy. In this study, we reviewed the literature of the last 10 years about the role of laparoscopic gonadectomy in patients with DSD. In the analyzed papers, all the procedures were accomplished successfully using laparoscopy. No conversions to open surgery neither intra-operative complications were reported in all series. Post-operative complications were reported only in one series and included 1 umbilical port infection [2% (1/50)] and 1 pelvic abscess [2% (1/50)], both treated with antibiotic therapy (grade I Clavien-Dindo). Of the analyzed series, 7/10 reported postoperative diagnosis of gonadal tumors. The histopathologic examinations revealed 15 cases of gonadoblastoma, 7 cases of dysgerminoma and 2 cases of seminoma. Analyzing the single series, the incidence of these tumors varied between 10% and 33%. The results of our review confirmed the safety and efficacy of laparoscopic gonadectomy in DSD patients. In our mind, laparoscopic gonadectomy should be accepted as the treatment of choice in children and adolescents with these rare conditions. It thereby eliminates the risk of malignancies of gonadal origin with the advantages of a minimally invasive procedure, with lower morbidity, quicker postoperative recovery and excellent cosmetic results.

Retroperitoneal and laparoscopic heminephrectomy in duplex kidney in infants and children.

BACKGROUND: Two main techniques are adopted to perform partial nephrectomy in children: laparoscopy and retroperitoneoscopy. The aim of this paper is to review the larger multicentric experience recently published by our group to review indications, techniques and results of both approaches. METHODS: Data of 102 patients underwent partial nephrectomy in a 5-year period using minimally invasive surgery (MIS) procedures were analyzed. Fifty-two children underwent laparoscopic partial nephrectomy (LPN), and 50 children underwent retroperitoneoscopic partial nephrectomy (RPN). Median age at surgery was 4.2 years. Statistical analysis was performed using χ2 test and Student's t-test. RESULTS: The overall complications rate was significantly higher after RPN (15/50, 30%) than after LPN (10/52, 19%) (χ2 =0.05). In LPN group, complications [4 urinomas, 2 symptomatic refluxing distal ureteral stump (RDUS) and 4 urinary leakages] were conservatively managed. In RPN group, complications (6 urinomas, 8 RDUS, 1 opening of remaining calyxes) required a re-operation in 2 patients. In both groups no conversion to open surgery was reported. Operative time (LPN: 166.2 min vs. RPN: 255 min; P<0.001) and hospitalization (LPN: 3.5 days vs. RPN: 4.1 days; P<0.001) were significantly shorter in LPN group. No postoperative loss of renal function was reported in both groups. CONCLUSIONS: MIS now represents the gold standard technique to perform partial nephrectomy in children with duplex kidney. Our results demonstrate that RPN remains a technically demanding procedure with a significantly higher complications and re-operation rate compared to LPN. In addition, length of surgery and hospitalization were significantly shorter after LPN compared to RPN. LPN seems to be a faster, safer and technically easier procedure to perform in children compared to RPN due to a larger operative space and the possibility to perform a complete ureterectomy in refluxing systems.

Current concepts in the management of inguinal hernia and hydrocele in pediatric patients in laparoscopic era.

The surgical repair of inguinal hernia and hydrocele is one of the most common operations performed in pediatric surgery practice. This article reviews current concepts in the management of inguinal hernia and hydrocele based on the recent literature and the authors׳ experience. We describe the principles of clinical assessment and anesthetic management of children undergoing repair of inguinal hernia, underlining the differences between an inguinal approach and minimally invasive surgery (MIS). Other points discussed include the current management of particular aspects of these pathologies such as bilateral hernias; contralateral patency of the peritoneal processus vaginalis; hernias in premature infants; direct, femoral, and other rare hernias; and the management of incarcerated or recurrent hernias. In addition, the authors discuss the role of laparoscopy in the surgical treatment of an inguinal hernia and hydrocele, emphasizing that the current use of MIS in pediatric patients has completely changed the management of pediatric inguinal hernias.

Management of gastroesophageal reflux disease in pediatric patients: a literature review.

Gastroesophageal reflux (GER), defined as the passage of gastric contents into the esophagus, is a physiologic process that occurs throughout the day in healthy infants and children. Gastroesophageal reflux disease (GERD) occurs when gastric contents flow back into the esophagus and produce symptoms. The most common esophageal symptoms are vomiting and regurgitation. Lifestyle changes are the first-line therapy in both GER and GERD; medications are explicitly indicated only for patients with GERD. Surgical therapies are reserved for children with intractable symptoms or who are at risk for life-threatening complications of GERD. The laparoscopic Nissen antireflux procedure is the gold standard for the treatment of this pathology. A literature search on PubMed and Cochrane Database was conducted with regard to the management of GERD in children to provide a view of state-of-the-art treatment of GERD in pediatrics.

Preputioplasty associated with urethroplasty for correction of distal hypospadias: a prospective study and proposition of a new objective scoring system for evaluation of esthetic and functional outcome.

OBJECTIVE: Most surgical procedures for correction of hypospadias involve the removal of foreskin resulting in a circumcised penis. We report our experience and the medium-term results in the reconstruction of the foreskin during the correction of distal hypospadias. MATERIALS AND METHODS: Between January 2007 and December 2011, 445 patients aged between 8 and 120 months underwent surgical correction of hypospadias. In 354 out of 445 patients, we performed the reconstruction of the foreskin. Urethroplasty was performed according to either the TIPU (tubularized incised urethral plate urethroplasty; Snodgrass) technique (233/354, 66%) or MAGPI (meatal advancement glanduloplasty incorporated) procedure (121/354, 34%). In 91 out of 445 patients urethroplasty was performed using classic TIPU technique and they were circumcised. The cosmetic and functional results were evaluated using the Hypospadias Objective Penile Evaluation (HOPE) scoring system. RESULTS: At a 12 months follow-up, 300 patients (84.7%) had retractable foreskin while 54 patients (15.3%) required postoperative steroid application. We had a total complication rate of 8.7%. As for preputioplasty, 16 patients (4.5%) had partial or total dehiscence of the reconstructed foreskin, one patient was circumcised for persistent phimosis (0.2%). As for urethroplasty complications, we recorded 11 fistulas (3.1%) and three stenosis (0.9%). The complication rate of the control group of circumcised patients was of 3.3% (2 fistulas [2.1%] and 1 stenosis [1.2%]). CONCLUSIONS: Our experience shows that foreskin reconstruction can be performed successfully in selected patients with distal hypospadias. However, preputioplasty add an additional 4.7% complication rate. As for the complications of urethroplasty, it seems that preputioplasty does not increase the incidence of complications on the urethra reconstruction. We propose a new objective scoring system (modified HOPE score) for evaluation of esthetic and functional outcome.

Long-term results of laparoscopic treatment of esophageal achalasia in children: a multicentric survey.

BACKGROUND: This report describes three Italian centers' experience in the treatment of children with esophageal achalasia. PATIENTS AND METHODS: Between June 2000 and June 2012, 31 children (13 girls and 18 boys, with a median age of 8.4 years) affected by esophageal achalasia were treated in three different institutions with an esophagomyotomy according to Heller's procedure via laparoscopy associated with a Dor antireflux procedure. Between 2000 and 2005 (for 14 patients) we used mono- or bipolar coagulation to perform myotomy; after 2005 (for 17 patients) we used the new hemostatic devices to perform it. RESULTS: Median length of surgery was 120 minutes. Median hospital stay was 4 days. We recorded eight complications in our series: 3 patients (9.6%) had a mucosal perforation, and 5 children (16.1%) presented dysphagia after surgery. When comparing the data before and after 2005, it seems that the new hemostatic devices statistically shortened the length of surgery (P<.01, Student's t test). CONCLUSIONS: On the basis of our experience, laparoscopic Heller's myotomy associated with an antireflux procedure is a safe and effective method for the treatment of achalasia in the pediatric population. Intraoperative complications were <10%, and they occurred mostly at the beginning of our experience. Residual dysphagia occurred in about 16% of cases. The use of the new hemostatic devices seems to reduce the length of surgery and intraoperative bleeding. Considering the rarity of this pathology, we believe that patients with achalasia have to be treated only at centers with a strong experience in the treatment of this pathology.