Mini Endoscopic Combined Intra-Renal Surgery (MiniECIRS) with endoview puncture in A 12 month boy. A safe but challenging procedure.

INTRODUCTION: Associating minipercutaneous nephrolithotomy and retrograde flexible ureteroscopy (fURS) is called Mini Endoscopic Combined Intra-Renal Surgery (miniECIRS). It's a safe and efficient technique, also in children. MATERIAL AND METHODS: The video describes miniECIRS in a 12 month-old boy with an infectious pelvic left stone (16 mm) and multiple caliceal stones. The UAS used was a 10FR and the percutaneous access was a 14Fr with Clear-Petra® sheath. RESULTS: The operative time was 180 min and blood losses were virtually absent. There were no intra- or post-operative complications and the patient was discharged at the 5th day. After 1 month, double J was removed having a stone free status. CONCLUSIONS: MiniECIRS with endoview puncture is a safe and efficient technique when performed by experienced hands. Therefore, it is an alternative to consider for the treatment of complex lithiasis in the pediatric population.

Retrorenal colon in pediatric patients with urolithiasis: Is the supine position for PCNL advantageous?

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is one of the main approaches for the treatment of large and complex stones in pediatric patients. The patient position for PCNL has been classically divided into prone or supine and the prone position is more commonly used. One of the most feared complications of this surgical technique is colon injury and the objective of this work is to evaluate the incidence of retrorenal colon (RRC) both supine and prone position, in pediatric patients, through radiological images. MATERIALS AND METHOD: A retrosepctive review was performed of all abdominal CT scans performed in one center, in patients under 18 years since 2017 to 2019. The ideal path for percutaneous puncture was traced in the upper, middle, and lower calyces of both kidneys in the prone and supine positions and contact with the kidney and adjacent organs was evaluated, with a uro-radiologist. Chi-square test and Student's t test were applied. RESULTS: 50 CT-scans were performed on 44 children. Patients had a mean age of 12.6 years and 71.4% were male. Twenty-five scans were performed in the prone and 25 in the supine position. The incidence of RRC for the left kidney (LK) was significantly higher in the lower calyx in prone position than in the supine position, 28% vs 4% (p = 0.049), and the right kidney (RK) presented RRC only in the prone position. The liver was the most frequent retrorenal organ (97.7%) for the RK, with a non-significant difference by position, while for the LK the spleen was the most frequent (61.1%). DISCUSSION: Colon injury is one of the most morbid complication in PCNL and one of the reasons to perform a CT scan before surgery, on which its incidence appears to be <1% in adults. The present study revealed RRC to be present in three (12%) patients in the supine position and seven (28%) patients in the prone position (p=0.15). These results were slightly higher from those reported in adults (supine: 1.7%-10%; prone: 6.8%-20%), but there are no reports in the literature on this issue to allow appropriate comparison. This is the first study to attempt to assess the incidence of RRC in children according to position. CONCLUSION: The incidence of RRC for an ideal puncture was significantly higher in the lower calyx of the left kidney in the prone position than in the supine position, and in the right kidney, the RRC only occurred in the prone position.

Robotic retroperitoneal lymphadenectomy in paratesticular rhabdomyosarcoma.

INTRODUCTION: Paratesticular sarcoma is an aggressive malignant tumor of mesenchymal origin. The rhabdomyosarcoma is the most common among children. Rhabdomyosarcoma treatment consists of surgery, chemotherapy and radiotherapy. Prognosic depends on local recurrence and distant metastasis. MATERIAL AND METHODS: We present the case of a 16-year-old male, who in April 2016 underwent right radical orchiectomy surgery by testicular mass rapidly evolving, with pathological results indicating a paratesticular rhabdomyosarcoma. The extension study showed a precaval adenopathy suggestive of lymph node metastasis, therefore it was a high-grade rhabdomyosarcoma. There was an appropriate response after chemotherapy (Protocol EpSSG RMS2005) and we decided to perform a robotic lymphadenectomy. RESULTS: We performed a transperitoneal approach with 8 mm trocar and 12 mm optica trocar. We accessed the retroperitoneal space through a latero-colic incision. Then we performed a craniocaudal lymph node dissection until the aortic bifurcation. The surgical time was 240 min with a blood loss of 200 ml. There were no complications. The patient was discharged on the fourth day after surgery. Pathology showed metastasis of rhabdomyosarcoma without capsular rupture. After two months, we placed the left testicle into inguinal canal prior to radiotherapy. CONCLUSIONS: Robotic lymph node metastasis lymphadenectomy from paratesticular sarcomas is a feasible treatment with the advantage of minimally invasive surgery and acceptable morbidity.

Ultra-mini Pcnl with clear Petra® suction-evacuation access sheath and warming irrigation fluid system (Rocamed®) for stone treatment in children.

INTRODUCTION: Inadvertent perioperative hypothermia (a drop in core temperature to below 36 °C) occurs because of interference with normal temperature regulation by anaesthetic drugs, skin exposure for prolonged periods and the introduction of large volumes of intravenous and irrigation fluids. If the temperature of these fluids is below core body temperature, they can cause significant heat loss. Warming irrigation fluids might prevent some of this heat loss and subsequent hypothermia and that is the role of warming irrigation fluid systems. MATERIAL AND METHODS: The video describes prone ultra mini PCNL with suction-evacuation access sheath under warming irrigation fluid system in a 15 month-old boy with a 2 cm-600HU staghorn calculi and one stone of 7 mm-500HU in proximal ureter. RESULTS: The surgery was performed without intraoperative complications and perioperative hypothermia was prevented. The patient started the surgery at 35.4 °C and the final temperature was 36.3 °C in 90 min of procedure, in addition to being free of stones. CONCLUSIONS: The warming irrigation fluid system can be helpful in preventing inadvertent perioperative hypothermia in children, improving the safety of ultra mini PCNL with suction-evacuation access sheath and shows promising results with high stone-free rates and low complications.

Autologous fat grafting with stem cell transplantation in an exstrophic patient. A case.

INTRODUCTION: Lipofilling has been used in plastic surgery for breast reconstruction and treatment of burns. Carrying out minimally invasive techniques would allow treatment of hypertrophic scars and depressed suprapubic area in exstrophic patients to improve their aesthetic appearance. MATERIAL AND METHODS: This video presents the case of a female 16 year old patient with bladder exstrophy, who initially had an urinary reconstruction with ureterosigmoidostomy and posteriorly bladder augmentation and Mitrofanoff, with hypertrophic scars and depressed abdominal wall in suprapubic area. We present this procedure for autologous fat grafting with stem cells in the abdominal area. RESULTS: The lipofilling procedure was carried out successfully, without intraoperative complications in 120 min. The liposuction was 250 cc and 80 cc was used for injection, achieving the improvement of the aesthetic appearance of the scars in a short time. The imaging control was follow up with abdominal wall ultrasound, three months later, increasing its thickness by 42%. CONCLUSION: The autologous fat grafting with stem cells is a safe and feasible procedure in the exstrophic population, with excellent aesthetic results, but we need long term follow ups to determine how long the effect of fat grafting remains.