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.

Risk Factors for Complications and Disease Recurrence after Ileocecal Resection for Crohn's Disease in Children and Adults.

This study reports the complication and disease recurrence rates for ileocecal resection for pediatric and adult Crohn's disease (CD) and identifies perioperative risk factors for these adverse outcomes in the two groups. Patients who underwent ileocecal resection for CD in a tertiary hospital in Italy (2010-2021) were included. Risk factors for postoperative complications and clinical and surgical disease recurrences were investigated with multivariate models. A total of 96 patients were included (children, 25%). There were no intraoperative complications. Thirty-one (32.3%) patients experienced 35 (36.5%) postoperative complications, and five (5.2%) were severe (Clavien-Dindo III-IV-V), with no intergroup difference for either overall postoperative complication rate (p = 0.257) or severe postoperative complication rate (p = 0.097). Most of these (77.1%) occurred within 30 days after surgery, especially in adults (p = 0.013). The multivariate analysis did not show risk factors for postoperative complications. Clinical and surgical recurrence rates after 5 years were 46.8% and 14.6%, respectively, with no intergroup rate differences. Clinical disease recurrence was positively correlated with previous abdominal surgery (p = 0.047) and negatively correlated with preoperative Hb levels (p = 0.046). A positive correlation was found between perianal disease and both clinical (p = 0.045) and surgical disease recurrences (p = 0.045). Urgent surgery was positively associated with surgical disease recurrence (p = 0.045). Notably, no children underwent urgent surgery in this study. In conclusion, the risk of postoperative complications among CD patients receiving ileocecal resection remains high, but most of them are nonserious. Some factors, such as urgent surgery, may increase the risk of disease recurrences.

Immunohistological Analysis of Lichen Sclerosus of the Foreskin in Pediatric Age: Could It Be Considered a Premalignant Lesion?

BACKGROUND: A major worry of juvenile penile LS is potential malignant degeneration to spinocellular carcinoma (SCC) in adulthood. LS is characterized by increased CD8+ and CD57+ cells, dermal sclerosis, epidermal atrophy, and hyperkeratosis. p53 and Ki67 are reliable premalignant markers. Our aim was to define the LS immunohistochemical profile of foreskin in children, focusing on tissue immune response and cell proliferation. METHODS: Thirty specimens of foreskins removed from pediatric patients during circumcision were included: six from ritual operation (A), twelve from phimosis (B), and twelve from phimosis with LS (C). Formalin-fixed paraffin-embedded sections were stained for histomorphology and immunohistochemistry. A quantitative evaluation for CD8, CD57, p53, and Ki-67 and a statistical analysis were performed. RESULTS: As compared to groups A and B, the samples from group C patients showed an acanthotic epidermis, a dermal band of lymphoid infiltrate with a significant enhancement of CD8+ CD57+ lymphocytes, and a keratinocytic hyperplasia with an overexpression of Ki67+ and p53+ cells. CONCLUSIONS: Immunohistological findings confirmed an immune reaction and proliferative behavior in juvenile LS of foreskin. We believe that radical circumcision should be the first treatment of choice in pediatric patients with clinical suspicious of LS for the potential risk of transformation to SCC in adulthood.

Early and Long-term Complications of Robotic Assisted Laparoscopy in Infants and Children.

BACKGROUND: Robotic-assisted laparoscopy still lacks wide acceptance in infants and children. We developed the service and report the largest single institution experience of complications over a period of 11 years. METHODS: Between March 2006 and May 2017, consecutive infants and children who underwent robotic assisted laparoscopy under the care of two laparoscopic surgeons were studied. Data for patients, surgeons, year of surgery, operation, and timing, nature, grades of complications were assessed. RESULTS: A total of 601 robotic procedures (45 different types) were carried out in 539 patients. Of these 31 (5.8%) were converted, none for operative complications. These and another 4 with complicated co-morbidity were excluded, leaving 504 patients for further analysis. There were 60 (11.9%) complications in 57 (11.3%) patients. Mean (SD) age was 7.7 years -/+5.1 with the youngest being 4 weeks. Concomitant or bilateral robotic and non-robotic procedures took place in 8.1% and 13.3% of patients respectively. Significant medical co-morbidity and abdominal scarring were present in 29% and 14.9% of patients respectively. Complications occurred in theatre 1.6%, hospital 5.6%, 28 days 1.2%, and late 3.6%. Mean follow up was 7.6 years -/+ 3.1 SD. Over-all postoperative complication rate was 10.3%: CD grade I 6.5% (33), II 0.6% (3), and IIIa/b 3.2% (16) which included 1.4% (7) re-do surgery. Most (11/16) grade III occurred late. There were no bleeding, grade IV or V complications, surgical mortality, or technology related complications. CONCLUSIONS: Complications are low even during the learning phase and while developing the new technique. Most complications occurred early and were minor. Most high-grade complications presented late. LEVELS OF EVIDENCE: 2B.

Corrigendum to "Spontaneous round ligament hematoma as an unusual cause of pelvic pain in a young female patient: MRI demonstration" [Radiology Case Reports 17 (2022) 1765-1769].

[This corrects the article DOI: 10.1016/j.radcr.2022.02.079.].

CO2 pneumoperitoneum effects on proliferation and apoptosis in two different neuroblastoma cell lines.

PURPOSE: The proto-oncogene MYCN is considered a transcription factor involved in the regulation of neuroblastoma (NB) cell biology. Since minimally invasive-surgery represents a debated treatment of NB, we investigated CO2 effects on proliferative activity and apoptotic pathway in two NB cell lines, SH-SY5Y (MYCN-non-amplified) and IMR-32 (MYCN-amplified). METHODS: SH-SY5Y and IMR-32 were exposed to CO2 (100%) at a pressure of 15 mmHg for 4 h and then moved to normal condition for 24 h. Cell proliferation, caspase 3 activity and transcript levels of BAX, BCL-2, cyclin B, cyclin D and MMP-2 were evaluated. RESULTS: CO2 exposure caused a decrease in cell proliferation associated to increases in BAX/BCL-2 ratio and caspase 3 activity in SH-SY5Y, while opposite effects have been found in IMR-32. CO2 exposure induced a decrease of cyclin B1 in SH-SY5Y, while an increase in cyclin B1 and D1 was observed in IMR-32. A slight up-regulation of MMP-2 expression in SH-SY5Y and a significant increase of 2.2 folds in IMR-32 was observed (p < 0.05). CONCLUSIONS: Our results suggest that CO2 exposure may cause different effects on various NB cell lines, likely due to MYCN amplification status. Further in vitro and in vivo studies are needed to highlight the role of laparoscopy on NB behaviour.

Pathogenesis of Congenital Malformations: Possible Role of Oxidative Stress.

OBJECTIVE: Congenital anomalies are important causes of morbidity and mortality in children. Oxidative stress (OS) is involved in the physiopathology of pregnancy-related congenital malformations. This review summarizes the role of OS in the pathogenesis of congenital malformations; in particular, its purpose is to describe how OS influences the development of heart congenital malformations, oesophageal atresia, biliary atresia, diaphragmatic hernia, and autosomal dominant polycystic kidney disease. STUDY DESIGN: Systematic review of previous studies about the role of OS in pregnancy and its possible effects in developing of congenital malformations. One electronic database (PubMed) was searched and reference lists were checked. RESULTS: An imbalance between the production of reactive oxygen species (ROS) and antioxidant defense can occur early in pregnancy and continue in the postnatal life, producing OS. It may destroy the signaling pathways needed for a correct embryogenesis leading to birth defects. In fact, cell functions, especially during embryogenesis, needs specific signaling pathways to regulate the development. These pathways are sensitive to both endogenous and exogenous factors; therefore, they can produce structural alterations of the developing fetus. CONCLUSION: Because OS plays a significant role in pathogenesis of congenital malformations, studies should be developed in order to better define their OS mechanisms and the beneficial effects of supplemental therapeutic strategies. KEY POINTS: · Oxidative stress is involved in the pathogenesis of congenital malformations.. · Heart malformations, oesophageal atresia, biliary atresia, diaphragmatic hernia, and autosomal dominant polycystic kidney are analyzed.. · A knowledge of pathomechanism of OS-related congenital malformations could be useful to prevent them..

Enhanced Recovery After Gastrointestinal Surgery (ERAS) in Pediatric Patients: a Systematic Review and Meta-analysis.

AIM: To systematically review literature and to assess the status of the ERAS protocol in pediatric populations undergoing gastrointestinal surgery. METHODS: Literature research was carried out for papers comparing ERAS and traditional protocol in children undergoing gastrointestinal surgery. Data on complications, hospital readmission, length of hospital stay, intraoperative fluid volume, post-operative opioid usage, time to defecation, regular diet, intravenous fluid stop, and costs were collected and analyzed. Analyses were performed using OR and CI 95%. A p value <0.05 was considered significant. RESULTS: A total of 8 papers met the inclusion criteria, with 943 included patients. There was no significant difference in complication occurrence and 30-day readmission. Differently, length of stay, intraoperative fluid volume, post-operative opioid use, time to first defecation, time to regular diet, time to intravenous fluid stop, and costs were significantly lower in the ERAS groups. CONCLUSIONS: ERAS protocol is safe and feasible for children undergoing gastrointestinal surgery. Without any significant complications and hospital readmission, it decreases length of stay, ameliorates the recovery of gastrointestinal function, and reduces the needs of perioperative infusion, post-operative opioid administration, and costs.

Giammusso corporoplasty for the treatment of isolated congenital ventral penile curvature: Results and long-term follow-up.

The aim was to retrospectively evaluate our experience in a large series of patients affected by isolated congenital ventral penile curvature, surgically treated using a previously described modified incisional corporoplasty. Two hundred and six patients with isolated congenital ventral penile curvature underwent a modified incisional corporoplasty. Mean age at surgery was 20.7 ± 5.5 years, and degree of ventral curvature was 60 ± 23°. After the point of maximum convexity identification, Buck's fascia was vertically opened along the deep dorsal vein, which was partially ligated, resected and removed. Tunica albuginea was then longitudinally incised and transversally closed. Post-operative follow-up examination was performed at 2 weeks, 6, 12 and 24 months and then annually. Surgical time was 79 ± 12 min. At follow-up, 189 out of 198 patients (95%) were completely satisfied, four patients (2%) complained a recurrence of penile curvature, and 6 (3%) complained about shortening of the penis. None of the patients had any interference with sexual activity. One patient (0.5%) showed erectile dysfunction 5 years after surgery, but there was no organic dysfunction during examination. The proposed technique allows correction of ventral congenital penile curvature without dorsal neurovascular bundle manipulation, resulting in minimum trauma of the erectile tissue, without injury to nerve fibres.

Conversion Rate in Pediatric Robotic-Assisted Surgery: Looking for the Culprit.

Introduction: Robotic-assisted surgery (RAS) is increasingly used in adulthood but its application in pediatric population is limited. We report our initial experience in pediatric RAS, focusing on conversions to analyze their causes. Methods: All pediatric patients who underwent RAS between June 2015 and April 2019 were included, analyzing demographics, comorbidities, previous surgery, and intraoperative surgical and anesthetic parameters. A three-arms robotic technique was used in all cases. Additional laparoscopic ports were added, when needed. The surgical team did not change during the program, whereas the anesthesiology team varied. Results: Thirty-nine patients (23 females, 16 males; mean age ± SD = 9.33 ± 4.73 years [range = 1-16]; mean weight ± SD = 35.2 ± 20.0 kg [range = 9-85]) underwent 40 different procedures (18 gastrointestinal, 15 urogynecological, 5 oncological, and 2 miscellaneous). Three procedures (7.5%) were converted to open surgery for inadequate working space (two marked bowel distension and one insufficient hepatic retraction). Converted patients were of significant lower age (mean ± standard error of mean [SEM] = 2.97 ± 1.03 versus 9.83 ± 0.77 years, P = .01) and lower weight (mean ± SEM = 11.83 ± 1.74 versus 35.47 ± 3.16 kg, P = .03). The two groups did not differ statistically for duration of facial mask ventilation before intubation (mean ± SEM = converted 10.67 ± 2.33 versus completed 10.31 ± 0.91 minutes), neuromuscular block dosage (rocuronium; mean ± SEM = converted 0.46 ± 0.06 mg/kg versus completed 0.62 ± 0.03 mg/kg) and in the type of bowel preparation (mechanical and/or pharmacological). Discussion: Conversion rate in initial pediatric RAS program is acceptable. In children, the need for conversion is mainly because of inadequate working space, particularly in smaller children, but it seems not to be influenced by measurable anesthetic factors or different regimen for bowel preparation.