Teaching hypospadias repair by utilising a novel 3D-printed silicon model: An initial assessment using structured trainee and trainer feedback.

INTRODUCTION: Simulated paediatric surgical training is inherently advantageous and flourishing. Moreover, several working conditions resulted in reduced training hours, index and subspecialty cases encountered, and the COVID-19 pandemic affected elective surgery backlogs, hence training opportunities. Hypospadias repair is technically-demanding and requires a spectrum of dissective and reconstructive skills. We therefore aimed to test a 3D-printed silicon model for hypospadias repair, in the context of hands-on surgical training. MATERIAL AND METHODS: Twenty-Seven trainees, under the supervision of 15 instructors, completed the activity. They were given a seminar to show the relevant anatomy, and 8 key steps of the exercise: (1)-degloving; (2)-urethral plate marking; (3)-incision; (4)-tubularisation; (5)-glansplasty/glanuloplasty; (6)-dartos layer preparation; (7)-preputioplasty and (8)-skin closure. Each trainee completed a structured feedback assessment. An on-site trainer supervised and evaluated each exercise. Trainees and trainers rated the model through the above steps from unsatisfactory-(1/5) to excellent-(5/5), presented herein via cross-sectional analysis. RESULTS: Eleven-(40.7 %) trainees were in years:1-3 of specialist training, 10-(37 %) were in years:4-6, and 6-(22.2 %) were beyond year-6. Two-(7.4 %) trainees had nil-hypospadias experience, 16-(59.2 %) previously assisted in procedures or performed steps, 5-(18.5 %) performed whole procedures supervised and 4-(14.8 %) independently. Twenty-(74 %) trainees and 15-(100 %) instructors judged the model to resemble the anomaly. Seventeen-(63 %) trainees and 13-(86.6 %) instructors rated the material needle-penetrability ≥3/5, compared to human tissue. Sixteen-(59 %) trainees and 13-(86.6 %) instructors rated the material suture holding ≥3/5. Eleven-(73.3 %) trainees and 13-(86.6 %) instructors rated sutures' evenness and edge coaptability ≥3/5. DISCUSSION: Hypospadias is an index operation, which requires precision skills. Simulated training in Paediatric Surgery and Urology is gaining importance. 3D-printed models are gaining a key role in simulated training. The study presents a novel 3D-printed high-fidelity silicon-based hypospadias model designed for hands-on training. A structured pathway to divide a standard hypospadias repair into key steps is displayed to ensure skill acquisition and stabilisation. CONCLUSION: This 3D-printed silicon-based hypospadias model is proven useful for hands-on training. The fidelity can still improve, especially regarding suture holding of the material. LEVEL OF EVIDENCE: LEVEL III.

Modified versus Classical Tubularised Incised Plate Urethroplasty in Hypospadias: A Comparative Study.

BACKGROUND: Hypospadias is a wide-world congenital malformation that accounts for 1 of 300 live male births. Many procedures were considered for its management. As the tubularised incised plate (TIP) urethroplasty, the most prevalent technique, caused many complications, several modifications were applied to the original operation to improve the outcomes and alleviate complications. The aim of this study was to compare the outcome of the ordinary TIP urethroplasty with the technique modified without dissection of the glans penis. MATERIALS AND METHODS: A total of 82 patients with a mean age of 18.8 (±14.8) months, were randomly assigned to undergo TIP with either complete glans wings mobilisation (Group A, n = 42 patients) or without glans dissection (Group B, n = 40 patients). To evaluate the effect of modified TIP urethroplasty without glanular dissection for treatment of distal hypospadias in contrast to classical TIP repair. RESULTS: Both techniques showed similar outcomes regarding functional repair, with good to excellent results between 88% and 90% after 6 months of follow-up. Most confronted post-operative complications were wound infection, oedema, urethrocutaneous fistulas and meatal stenosis. Less frequently haematoma, post-operative bleeding and glans dehiscence were encountered. The differences in complication rates between the two studied groups were statistically insignificant except for oedema (P = 0.04), and need for urethral dilatation (P = 0.002) that were more prevalent among patients who were treated with classic TIP repair with complete glans wings mobilisation. CONCLUSION: From our point of view, it seems that TIP without glanular dissection technique does not outweigh TIP with complete glans wings mobilisation regarding functional outcomes and post-operative complications.

Comparative Study between Modified Millard and White Roll Vermilion Flap Techniques in Unilateral Lip Repair: A Randomised Controlled Study.

BACKGROUND: Cleft lip and palate, which affects 0.5-1.6 out of every 1000 live births, is the most prevalent congenital defect of the head and neck. Several approaches, including quadrangular flaps, triangular flaps and rotation-advancement procedures, White Roll Vermilion Turn Down Flap (WRV flap) from the lateral lip element were employed by Mishra to modify Millard's technique to create the vermilion and white roll on the medial lip segment. This study aimed to use the anthropometric measurements taken pre- and post-operation to evaluate quantitative assessment of modified Millard technique compared with WRV flap technique in unilateral cleft lip (UCL) repair. MATERIALS AND METHODS: Prospective, randomised controlled study recruited infants scheduled for UCL repair. Infants aged 3-6 months, either complete or incomplete deformity. A total of 42 patients were randomized in 1:1 ratio to undergo either WRV flap technique (group A) or modified Millard technique (group B) and another control included 21 age-matched healthy children. We compared WRV flap procedure to Modified Millard's procedure in terms of both qualitative (another surgeon's opinion) and quantitative (anthropometric) evaluation. RESULTS: Vertical lip length and philtral lip height significantly longer in Millard group (B) than WRV flap group (A) in immediate postoperative assessment and nasal width was significantly wider in WRV flap group (A) than Millard group (B) in 3-month post-operative assessment. The lip shape, the vermilion shape was better in Millard technique than WRV flap technique; however, this was statistically insignificant. However, no major difference in the overall results between the WRV flap and Millard rotation-advancement repairs. CONCLUSION: Anthropometric measurement of surgical outcome evaluates the surgical technique used and helps to compare between cleft and non-cleft side showing the degree of deformity and we used subjective assessment to analyse facial aesthetics. Overall results demonstrate no significant differences between modified Millard technique and WRV flap technique.

Management of Complete Persistent Rectal Prolapse in Children: A Comparative Study Between Mesh Repair Versus Suturing Rectopexy.

BACKGROUND: Rectal prolapse is a relatively common, usually self-limiting illness in children. Peak incidence is between 1 and 3 years. The primary treatment of rectal prolapse is non-operative. Surgical intervention is needed in long-standing intractable cases of rectal prolapse, rectal pain/bleeding/ulceration and prolapse that needs frequent manual or difficult reduction. The aim of this study was to compare the efficacy and outcome of laparoscopic ventral mesh rectopexy versus laparoscopic suture rectopexy in the management of persistent rectal prolapse in children not responding to conservative management and/or recurrent after sclerotherapy or anal encirclement. MATERIALS AND METHODS: Twenty-four cases were randomised into two groups at the ratio of 1:1, Group 1 patients were managed by laparoscopic ventral mesh rectopexy, whereas Group 2 cases were managed by laparoscopic suture rectopexy. Patients with primary surgical conditions such as anorectal malformations, Hirschsprung's disease, rectal polyps or masses and Ectopia Vesicae were excluded from the study. Inclusion criteria were complete rectal prolapse cases with failed medical treatment for at least 6 months and/or recurrent after injection sclerotherapy or anal encirclement. RESULTS: In the mesh rectopexy group, one case had recurrence in the form of partial prolapse 3 weeks postoperatively which improved 2 months postoperatively with conservative management, one case had bleeding per rectum 2 months postoperatively, stool analysis was done revealing parasitic infestation which was treated medically. In the suture rectopexy group, one case had one attack of bleeding per rectum on the 2nd day postoperatively which resolved spontaneously and one case was readmitted on the 5th day postoperatively for non-bilious vomiting which improved by medical treatment. No recurrent cases of complete rectal prolapse were reported in both groups. CONCLUSION: Laparoscopic rectopexy can be an effective modality for the treatment of refractory complete rectal prolapse in children. It is effective, safe and easy. Although the current study has shown that laparoscopic suture rectopexy and mesh rectopexy have nearly the same results, a larger number of patients are needed to compare more deeply between the two groups.

Patent processus vaginalis: role of ultrasound in pediatric population with unilateral inguinal hernia and other predictors.

INTRODUCTION: Inguinal hernia (IH) repair is a common procedure in the daily practice of pediatric surgeons. In a developing country with limited facilities, it is important to be able to predict and diagnose contralateral patent processus vaginalis (CPPV) to avoid the risk and cost of further surgery. OBJECTIVES: To assess the accuracy of ultrasound for the detection of CPPV, using laparoscopic evaluation as a confirmatory test. We also looked for various predictors of CPPV in our study population. METHODS: 141 patients were included in this 2-year, cross-sectional prospective study. Inclusion criteria were unilateral inguinal hernia elective patients with no major comorbidities and aged between 2 months and 8 years. Each patient was assessed in outpatient clinics and then a pre-operative ultrasound was conducted. This was followed by laparoscopic evaluation during repair of the hernia. RESULTS: Of the 141 patients included, 110 (78%) were males, 121 (85.9%) were born at full term, and 96 (68.1) had right-sided hernia. Mean age was 2.64 ± 1.9 years. Ultrasound was 85.7% sensitive in the detection of CPPV, 90.8% specific, and 90.1% accurate. In our analysis of patients younger than 1 year, right-sided hernia and defect size more than 10 mm were statistically significant predictors for a CPPV. CONCLUSIONS: Ultrasound has a high accuracy profile and is a useful alternative in limited resource settings with restricted access to minimally invasive surgery for the prediction of CPPV. Patients younger than 1 year with a right-sided hernia or a manifested hernia defect larger than 10 mm are at a higher risk of having a CPPV.

Glucose indices as inflammatory markers in children with acute surgical abdomen: a cross-sectional study.

BACKGROUND: Glycaemic dysregulation potentiates the pro-inflammatory response and increases oxidative injury; therefore, preoperative hyperglycaemia is linked to increased mortalities. In addition, inflammation is accompanied by higher glycated haemoglobin (HbA1c) levels, and the relationship between this and random blood sugar (RBS) could be non-linear. METHODS: This is a cross-sectional study. Non-diabetic paediatric patients with acute surgical abdomen, presenting to the emergency surgical services were enrolled, over a period of 6 months. They were all screened for their random blood sugar and HbA1c levels. RESULTS: Fifty-three cases were studied. The prevalence of glycaemic dysregulation in the enrolled children was high. Abnormal HbA1c was observed in 66% of the study group. Stress hyperglycaemia was observed in 60% of the enrolled children. There was a significant correlation (r = 0.770, p-value: < 0.001) between RBS and the total leucocytic count (TLC). The TLC cutoff value for predicting stress hyperglycaemia was 13,595 cells/mm3. The cutoff value of RBS for predicting leukocytosis was 111.5 mg/dl. Median RBS level was significantly higher in complicated appendicitis (169.5 mg/dl), compared to uncomplicated appendicitis (118.0 mg/dl). CONCLUSION: HbA1c and RBS could be used as inflammatory markers for surgical acute abdomen and its degree of severity, respectively. HbA1c rises in a considerable number of cases with surgical acute abdomen, irrespective of the disease stage. However, as the disease progresses, the random blood sugar rises due to stress hyperglycaemia, thus becoming a surrogate inflammatory marker.

What is already known on this topic? Preoperative stress hyperglycaemia is common in children, and it is linked to adverse postoperative outcomes. HbA1c could be a marker for inflammation and oxidative stress.What does this study add? HbA1c could be an inflammatory marker for surgical acute abdomen, irrespective of the disease stage, as it had a high prevalence in the enrolled children with an acute surgical abdomen. However, as the disease progresses, the random blood sugar rises due to stress hyperglycaemia, thus becoming a surrogate inflammatory marker, as there is a significant correlation between it and the TLC.How might this study affect research, practice, or policy? The novelty in this study centers around the role of glucose metabolism, as evaluated by random blood sugar and HBA1c, in the diagnostic evaluation and prognostication of inflammation, represented by the surgical acute abdomen. This may invite further research into understanding the underlining mechanisms. The outcome of the clinical management of conditions involving inflammation can be improved by using the proposed biomarkers, as peri/preoperative hyperglycaemia could lead to morbidity and mortality, consequently, as proven, the reliability of those biomarkers facilitates risk assessment and stratification. As both tests are cost-effective and universally available, they can be readily implemented in practice guidelines and departmental policies.

Evaluation of Clinical Outcomes in Children with Intrahepatic Cholestasis Postpartial External Biliary Diversion: A Single-Center Experience.

Background: Severe pruritus caused by progressive familial intrahepatic cholestasis (PFIC) and Alagille syndrome (AGS) is refractory to medical treatment. Surgical interruption of the enterohepatic circulation is considered the mainstay of alleviating distressing symptoms and delaying cirrhosis. Aim and Objectives: This study aims to evaluate the short-term effect of partial external biliary diversion (PEBD) on pruritus, liver disease progression, patient's growth, and quality of life. Material and Methods: This prospective cohort study enrolled children with PFIC and AGS from July 2019 to July 2021, whose guardians consented to the PEBD procedure. A standard surgical approach was performed by a single surgeon. Outcomes were measured subjectively and objectively pre- and post-procedure using the pruritus 5-D itching score, Paediatric Quality of Life Inventory scale (PedsQL), growth parameters, bile acids level, and liver function tests. Patients' follow-up period ranged from 6 to 12 months. Results: Seven patients had PEBD procedure; five with PFIC and two with AGS. A significant improvement was detected in the 5-D itching score (p-value < 0.001), PedsQL (p-value < 0.001), and bile acids level (p-value 0.013). The preexisting growth failure was ameliorated. The downward trend in the bilirubin level was not significant. No influential difference in the other liver function tests occurred. No intra-operative complications encountered. Only one case had a post-operative stoma prolapse which was managed surgically. Conclusion: PEBD procedure could be considered as an effective and safe treatment options for intractable pruritus in patients with PFIC or AGS, providing preserved synthetic liver functions.

Medium-Term Outcomes of Antegrade Continent Enema (ACE): Cairo University Specialized Pediatric Hospital (CUSPH) Experience.

AIM OF THE STUDY: To assess the medium-term outcomes of ACE in children with fecal incontinence (FI). METHOD: Eligible children were recruited from the colorectal clinic between December 2016 and January 2020 and were followed prospectively for 2-6 years. A series of questionnaires were used to assess QOL, patients and parent satisfaction, and to assess the outcomes of the ACE. RESULT: 24 children aged 6-12 years (mean age 8.17 ± 1.95), including 18 males (75%) and 6 females (25% were studied. Cases included anorectal malformations (45.83%)., Hirschsprung disease (25%), neural tube defects (16.66%), sacrococcygeal teratoma (4.16%), and intractable pseudoincontinence (8.33%). QOL improved from (3) [3 -3] to (16) [16-16],p < 0.05. Fecal incontinence index showed significant improvement: 20 [20-20] versus 3 [0-4],p < 0.05. Bowel symptoms demonstrated improvement in the ability to decide when to pass stools and a decrease in soiling. Stooling survey showed lower scores representing better outcome. ACE questionnaire showed that the range of irrigation volumes used by parents is wide, and that all families recommend the ACE for children with similar condition. Postoperative complications were stenosis (16.66%), stomal prolapse (12.5%), leakage (4.16%), and false passage (4.16%). Satisfaction questionnaire showed a median score of 9 (range, 5-10). CONCLUSION: ACE is an effective method to keep the child with FI clean, more socially active, and with a better QOL and FII in the medium-term. The reported complications were stenosis, false passage, and leakage. ACE mucosa prolapse is a novel complication picked up on medium-term follow up.

Congenital aflatoxicosis, mal-detoxification genomics & ontogeny trigger immune-mediated Kotb disease biliary atresia variant: SANRA compliant review.

Biliary atresia (BA) is the most common indication for pediatric liver transplantation. We describe The BA variant: Kotb disease. Liver tissue in the Kotb disease BA is massively damaged by congenital aflatoxicosis resulting in inflammation, adhesions, fibrosis, bile duct proliferation, scarring, cholestasis, focal syncytial giant cell transformation, and typical immune response involving infiltration by CD4+, CD8+, CD68+, CD14+, neutrophil infiltration, neutrophil elastase spill, heavy loads of aflatoxin B1, accelerated cirrhosis, disruption of p53 and GSTPi, and have null glutathione S transferase M1 (GSTM1). All their mothers are heterozygous for GSTM1. This inability to detoxify aflatoxicosis results in progressive inflammatory adhesions and obliterative cholangiopathy early in life. The typical disruption of both p53 and GSTPi causes loss of fidelity of hepatic regeneration. Hence, regeneration in Kotb disease BA typically promotes accelerated cirrhosis. The immune response in Kotb disease BA is for damage control and initiation of regeneration, yet, this friendly fire incurs massive structural collateral damage. The Kotb disease BA is about actual ongoing hepatic entrapment of aflatoxins with lack of ability of safe disposal due to child detoxification-genomics disarray. The Kotb disease BA is a product of the interaction of persistent congenital aflatoxicosis, genetic lack of GSTM1 detoxification, ontogenically impaired activity of other hepatic detoxification, massive neutrophil-elastase, immune-induced damage, and disturbed regeneration. Ante-natal and neonatal screening for aflatoxicosis, avoiding cord milking, and stringent control of aflatoxicosis content of human, poultry and live-stock feeds might prove effective for prevention, prompt diagnosis and management based on our recent understanding of its patho-genomics.

The dilemma after an unforeseen aortic arch anomalies at thoracoscopic repair of esophageal atresia: Is curtailing surgery still a necessity?

BACKGROUND AND OBJECTIVE: There are several forms of relevant epi-aortic branching anomalies, and perhaps that is why different views as to the best approach have been reported. To help resolve this dilemma, we examined the unforeseen arch anomalies found at thoracoscopic repair of esophageal atresia and the outcomes. METHODS: In a retrospective cohort, all consecutive patients who were thoracoscopically approached for esophageal atresia over a 5-year period with unforeseen aortic/epi-aortic branching were identified and grouped. Thoracoscopic views, operative interventions, and outcomes were studied. RESULTS: A total of 121 neonates were thoracoscopically approached for EA, of whom 18 cases with aberrant aortic architecture were selected. Four (3%) cases were diagnosed on a preoperative echocardiography as a right-sided aortic arch, whereas unforeseen anomalous anatomies were reported in 14 cases (11.6%): left aortic arch with an aberrant right subclavian artery (ARSA) (n = 10), right-sided aortic arch with an aberrant left subclavian artery (ALSA) (n = 3), and mirror-image right arch (n = 1). Single postoperative mortality was reported among the group with left arch and ARSA (10%), whereas all the cases with right arch and ALSA died. CONCLUSIONS: In all, 11.6% of the studied series exhibited unexpected aberrant aortic architecture, with higher complication rates in comparison to the typical thoracoscopic repairs. For EA with left aortic arch and ARSA, the primary esophageal surgery could safely be completed. Meanwhile, curtailing surgery-after ligating the TEF-to get advanced imaging is still advised for both groups with the right arch due to the significant existence of vascular rings.

Optimism for the Single-stage Transanal Swenson in Neonates.

BACKGROUND: Hirschsprung's disease (HD) has been traditionally treated from infancy onward and different techniques have been used including Swenson, Soave, and Duhamel procedures. The purpose of this study was to evaluate the transanal Swenson's procedure for classical rectosigmoid HD in neonates. PATIENT AND METHODS: This was a prospective study in which neonates diagnosed with HD were recruited from January 2017 to December 2018. Cases with a transition zone proximal to the midsigmoid were excluded. All patients underwent a transanal Swenson's procedure in the neonatal period using a unified protocol. Intraoperative course and postoperative outcomes such as leak, pelvic abscess, soiling, perianal excoriation, stricture, enterocolitis, and constipation were evaluated and all patients were followed for at least 6 months. RESULTS: Twenty-three patients (17 males and 6 females) underwent transanal Swenson's procedure. The mean age was 22 ± 5.7 days. Follow-up ranged from 6 to 30 months. No anastomotic leak, retraction, or prolapse was reported. Mild perianal excoriations occurred early in 9 (39%) cases and all responded to medical treatment and disappeared before 2 months postoperatively. Stricture occurred in 2 (8%) patients, enterocolitis in 3 (13%), and constipation in 3 (13%). CONCLUSION: Transanal Swenson's procedure is feasible and can be performed safely in neonates with rectosigmoid HD with good short-term outcomes. Proper patient selection and standard protocol following fine procedural hall-marks and details are keys for optimal results and patient satisfaction.

A report of two infant cases operated for jejunal duplication cyst associated with malrotation and volvulus.

INTRODUCTION: Both Enteric duplication and intestinal malrotation are concerning causes for intestinal obstruction in the pediatric age group and they very rarely coexist in the same patient. PRESENTATION OF CASES: We present 2 cases of previously healthy children, the first is a 4-month-old infant and the second is a 1.5-year-old boy, both presented with recurrent attacks of bilious vomiting that proved to be due to acute midgut volvulus caused by an enteric duplication cyst associated with intestinal malrotation. DISCUSSION: Enteric duplication and intestinal malrotation are two of the concerning causes of billious vomiting in the pediatric age group. They could be encountered at any level of the alimentary tract from the tongue to the anus. The term malrotation refers to all abnormalities of intestinal position. The coincidence of intestinal malrotation and an enteric duplication cyst (EDC) is very rare and has been described only in a few case reports. CONCLUSION: The concomitance of EDC and intestinal malrotation is extremely rare and should be kept in mind in a child presenting with bilious vomiting especially in a child preoperatively diagnosed with a duplication cyst.

Fetus in Fetu: Lessons Learned from a Large Multicenter Cohort Study.

INTRODUCTION: Fetus in fetu (FIF) is an extremely rare condition of abnormal twinning during embryogenesis. Most publications are single case reports. We describe the combined experience of four large tertiary referral centers with FIF which were not previously reported or published, and thereby draw conclusions to establish criteria for the workup, diagnosis, and management including intraoperative risk. MATERIALS AND METHODS: A survey was forwarded to a national pediatric surgery group which includes members from all pediatric surgery centers in the country enquiring about unpublished cases of FIF encountered over a 20-year interval. The cohort was analyzed for age of presentation, type of presentation, diagnostic workup, surgical management, and outcome. RESULTS: From 1998 to 2018, a total of 10 FIF cases were included in the study. Mean age of presentation was 4 months. Computed tomography and ultrasound were the main preoperative diagnostic modality in our cohort. Resection of the mass was curative in nine cases. Two cases in which the FIF was in direct topographic proximity to the biliary tree suffered severe intraoperative or lethal postoperative complications. CONCLUSION: Complete excision of FIF is the treatment of choice and generally results in excellent long-term quality of life. Mortality is rare and may be associated with biliary involvement and retroperitoneal right upper quadrant location of the FIF tends to be associated with increased risk in excision, and there is also a possible association with the presence of immature elements in the pathology report.

Laparoscopic Diamond Antroduodenostomy for Postcorrosive Pyloric Cicatrization: A Novel Approach.

BACKGROUND: Traditionally, Billroth I procedure or bypass gastrojejunostomy were the recommended approaches for management of postcorrosive complete gastric outlet obstruction (GOO), whereas Heineke Mickulicz pyloroplasty was recommended for moderate mucosal injury with partial cicatrization. In this study, laparoscopic diamond antroduodenostomy was carried out as an alternative minimally invasive approach for cases with pyloric cicatricial obstruction. PATIENTS AND METHODS: Between January and December 2017, children who were referred to Pediatric Surgery Department, Cairo University Hospital, with GOO as a consequence of caustic liquid ingestions were included in this study. Laparoscopic diamond antroduodenostomy was performed for the presented cases. RESULTS: Through the year 2017, 5 cases were approached with laparoscopic diamond antroduodenostomy. Isolated pyloric cicatrization was evident in 4 cases, whereas synchronous insult to thoracic esophagus and pylorus was manifest in the fifth case. Laparoscopic feeding jejunostomy completed the procedure for the case with esophageal stricture. Contrast study-24 hour postoperatively-assured no radiological leaks in the presented cases, where enteral feeding was gradually commenced, and patients discharged home a day later. After a mean follow-up of 13.5 months, neither recurrence of obstructive symptoms nor dumping was displayed. Cosmetic outlook inherent to the minimally invasive approach was appreciated by the parents. CONCLUSION: Laparoscopic diamond antroduodenostomy is a feasible approach for management of postcorrosive pyloric obstruction. It allowed early enteral feeding, with no dumping symptoms, in addition to the fundamental advantages of minimally invasive surgery. A bigger series and longer follow-up is recommended to verify the reported results.

Laparoscopically Assisted Vaginal Pull-Through in 7 Cases of Congenital Adrenal Hyperplasia with High Urogenital Sinus Confluence: Early Results.

INTRODUCTION: Surgical management of the high urogenital sinus (UGS) is challenging. Presence of a short urethra is a contraindication for UGS mobilization as this is likely to affect urinary continence. In addition, vaginal reconstruction of the high suprasphincteric confluence is complex and prone to complications and failure. METHODS: This study included 7 girls who underwent a laparoscopically assisted vaginal pull-through in the past 2 years. All cases included were diagnosed with congenital adrenal hyperplasia (CAH), with a high UGS, and a short urethra of ≤15 mm above the confluence. Patients were preoperatively assessed by genitography. Mobilization of the vagina was pursued until the confluence became visible and the vaginal caliber tapered off at its junction with the urethra. The connection was sutured or clipped and divided. Uterine round ligaments were divided to allow delivering the vagina to the perineum with minimum tension. The tract for the pull-through was created and the vagina was pulled outside and sutured to the perineal skin. Good vaginal mobilization allowed a direct perineal anastomosis without skin flap augmentation of the vaginal wall. Clitoroplasty and labiaplasty were deferred. RESULTS: Mobilization of the vagina was possible in all cases attempted, without injuries to the adjacent pelvic structures. Calibration and dilatation started 2 weeks postoperatively. At 12-month follow-up, all the patients had a patent vagina with good caliber, and were able to retain urine without dribbling. CONCLUSION: The laparoscopically assisted vaginal pull-through approach provides optimal exposure, facilitates vaginal dissection, separation from the urethra, and avoids injuries to the urinary structures. This allows vaginal reconstruction without tension.