A prospective study to evaluate the contribution of the pediatric appendicitis score in the decision process.

BACKGROUND: The objective of this study was to assess the likelihood of acute appendicitis (AA) in children presenting with abdominal symptoms at the emergency department (ED), based on their prior primary care (PC) consultation history. METHODS: Between February and June 2021, we prospectively enrolled all children presenting at the ED with acute abdominal pain indicative of possible acute appendicitis (AA). Subsequently, they were categorized into three groups: those assessed by a PC physician (PG), those brought in by their family without a prior consultation (FG), and those admitted after a PC consultation without being assessed as such. The primary objective was to assess the probability of AA diagnosis using the Pediatric Appendicitis Score (PAS). Secondary objectives included analyzing PAS and C-reactive protein (CRP) levels based on the duration of pain and final diagnoses. RESULTS: 124 children were enrolled in the study (PG, n = 56; FG, n = 55; NG, n = 13). Among them, 29 patients (23.4%) were diagnosed with AA, with 13 cases (23.2%) from the PG and 14 cases (25.4%) from the FG. The mean PAS scores for AA cases from the PG and FG were 6.69 ± 1.75 and 7.57 ± 1.6, respectively, (p = 0.3340). Both PAS scores and CRP levels showed a significant correlation with AA severity. No cases of AA were observed with PAS scores < 4. CONCLUSIONS: There was no significant difference in PAS scores between patients addressed by PG and FG, even though PAS scores tended to be higher for patients with AA. We propose a new decision-making algorithm for PC practice, which incorporates inflammatory markers and pain duration. TRIAL REGISTRATION: Institutional Ethics Committee registration number: 447-2021-103 (10/01/2021). CLINICAL TRIALS REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT04885335 (Registered on 13/05/2021).

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.

Thoracoscopy for Pediatric Thoracic Neurogenic Tumors-A European Multi-Center Study.

OBJECTIVES: To assess the efficacy of thoracoscopy and the outcome for children with thoracic neurogenic tumors. METHODS: We performed a retrospective review of 15 European centers between 2000 and 2020 with patients who underwent thoracoscopy for a neurogenic mediastinal tumor. We assessed preoperative data, complications, and outcomes. Results were expressed with the median and range values. RESULTS: We identified 119 patients with a median age of 4 years old (3 months-17 years). The diameter was 5.7 cm (1.1-15). INRG stage was L1 n = 46, L2 n = 56, MS n = 5, M n = 12. Of 69 patients with image-defined risk factors (IDRF), 29 had only (T9-T12) locations. Twenty-three out of 34 patients with preoperative chemotherapy had an 18 mm (7-24) decrease in diameter. Seven out of 31 patients lost their IDRF after chemotherapy. Fourteen had a conversion to thoracotomy. The length of the hospital stay was 4 days (0-46). The main complications included chylothorax (n = 7) and pneumothorax (n = 5). Long-term complications included Horner's syndrome (n = 5), back pain, and scoliosis (n = 5). Pathology was 53 neuroblastomas, 36 ganglioneuromas, and 30 ganglioneuroblastomas. Fourteen had a postoperative residue. With a median follow-up of 21 months (4-195), 9 patients had a recurrence, and 5 died of disease. Relapses were associated with tumor biology, histology, and the need for chemotherapy (p = 0.034, <0.001, and 0.015, respectively). Residues were associated with preoperative IDRF (excluding T9-T12 only) and the need for preoperative chemotherapy (p = 0.04 and 0.020). CONCLUSION: Our results show that thoracoscopy is safe, with good outcomes for thoracic neurogenic tumors in selected cases. Surgical outcomes are related to the IDRFs, whereas oncologic outcomes are related to tumor histology and biology.

Efficiency of non-operative management for pectus deformities in children using an X-ray-free protocol.

OBJECTIVES: The aim of this study was to explore the correlation between the Haller index (HI), the external depth of protrusion and the external Haller index (EHI) for both pectus excavatum (PE) and pectus carinatum (PC) and to assess the variation in the HI during this first year of non-operative treatment for pectus deformities in children. METHODS: From January 2018 to December 2022, all children treated for PE by vacuum bell and for PC by compression therapy at our institution were evaluated by external gauge, 3D scanning (iPad with Structure Sensor and Captevia-Rodin4D) and magnetic resonance imaging (MRI). The main objectives were to assess the effectiveness of the treatment during the first year and to compare the HI determined by MRI to the EHI evaluated with 3D scanning and external measurements. The HI determined by MRI was compared to the EHI evaluated with 3D scanning and external measurements at M0 and M12. RESULTS: A total of 118 patients (80 PE and 38 PC) had been referred for pectus deformity. Of these, 79 met the inclusion criteria (median age 13.7 years, 8.6-17.8). There was a statistically significant difference in the external measurements of the depth for PE between M0 and M12: 23.0 ± 7.2 vs 13.8 ± 6.1 mm, respectively, P < 0.05, and for PC 31.1 ± 10.6 vs 16.7 ± 8.9 mm, respectively, P < 0.01. During this first year of treatment, the reduction in the external measurement increased more rapidly for PE compared with PC. We found a strong correlation between the HI by MRI and the EHI by 3D scanning for PE (Pearson coefficient = 0.910, P < 0.001) and for PC (Pearson coefficient = 0.934, P < 0.001). A correlation between the EHI by 3D scanning and the external measurements by profile gauge was found for PE (Pearson coefficient = 0.663, P < 0.001) but not for PC. CONCLUSIONS: Excellent results were observed as soon as the sixth month for both PE and PC. Measurement of protrusion is a reliable monitoring tool at clinical consultation but caution is required for PC as it does not appear to be correlated to the HI by MRI.

Evaluation of surgical outcomes of calcaneonavicular coalition and too-long anterior process in children: A prospective study.

INTRODUCTION: Calcaneonavicular coalitions (CC) affect approximately 1% of the general population. CC or Too-long anterior process (TLAP) result in "repeated sprains" that can be associated with foot and/or ankle chronic pain. The main objective of this study was to analyze the effectiveness of surgery using the AOFAS score. HYPOTHESIS: Functional results after surgical treatment of CC or TLAP are not as good as expected. MATERIALS AND METHODS: A single-center prospective study was carried out at our University Hospital from 01/01/2019 to 06/01/2021. The patients included were operated on in the pediatric surgery department for CC or TLAP resection by direct approach after MRI confirmation and failure of non-operative treatment. A survey evaluating the AOFAS score as well as the number of ankle sprains and the intensity of pain was undertaken at the preoperative consultation and then at three and twelve months postoperatively. RESULTS: A total of 17 feet in 16 patients (14 girls and 2 boys) comprising 12 TLAP and 5 CC were included. The AOFAS score was statistically significantly increased (58.6 vs. 82.9; p<0.001) postoperatively. No statistical difference was noted between the follow-up visits at three and twelve months. At the twelve-month follow-up, 9 out of 16 patients (56.2%) still reported activity restrictions; mainly linked to the persistence of chronic pain, and 10 out of 16 patients (62.5%) reported a feeling of instability. DISCUSSION: CC and TLAP surgery rapidly improves function but it does not dramatically reduce foot pain and activity restrictions. A dedicated score would be useful to identify patients who will benefit the most from surgery. LEVEL OF EVIDENCE: IV; prospective study.

Current trends in 2021 in surgical management of vesico-ureteral reflux in pediatric patients: results of a multicenter international survey on 552 patients.

BACKGROUND: The selection of best surgical approach for treatment of vesico-ureteral reflux (VUR) in the pediatric population remains debated. This study aimed to report the results of a multicenter survey about the current trends in surgical management of pediatric VUR. METHODS: An online questionnaire-based survey was performed, with participation of six international institutions. All children (age <18 years) affected by primary III-V grade VUR, who were operated over the last 5 years, were included. The incidence of each VUR intervention, patients' demographics and outcomes were analyzed. RESULTS: A total of 552 patients (331 girls), with a median age of 4.6 years (range 0.5-17.6), were included. Deflux® injection (STING) was the most common technique (70.1%). The multicenter success rate after single treatment was significantly lower after STING (74.4%) compared with the other treatments (P=0.001). Persistent VUR rate was significantly higher after STING (10.8%) compared with the other treatments (P=0.03). Choosing endoscopy over surgery mean reducing Clavien Dindo grade 2 complications by 5% but increasing redo procedure rate by 7%. STING was the most cost-effective option. CONCLUSIONS: This survey confirmed that the choice of the technique remains based on surgeon's preference. Deflux® injection currently represents the first line therapy for primary VUR in children and the role of surgical ureteral reimplantation is significantly reduced. STING reported acceptable success rate, less postoperative complications and lower costs but higher failure and re-operation rates and related costs compared with the other surgical approaches. The adoption of laparoscopy and robotics over open reimplantation remains still limited.

Pediatric robot-assisted extravesical ureteral reimplantation (revur) in simple and complex ureter anatomy: Report of a multicenter experience.

BACKGROUND: Robot-assisted extravesical ureteral reimplantation (REVUR) is a well established approach for surgical treatment of pediatric vesicoureteral reflux (VUR). However, further evidence is needed to confirm its efficacy even in case of complex anatomy. OBJECTIVE: This study aimed to further confirm the evidence that REVUR is safe and effective in both simple and complex ureter anatomy. STUDY DESIGN: The charts of all patients with VUR, who received REVUR in 6 different institutions over a 5-year period, were retrospectively reviewed. Patients with both simple and complex ureter anatomy were included. Patient demographics, surgical variables, and post-operative results were assessed. VUR resolution was defined as either being resolved VUR on voiding cystourethrogram (VCUG) or clinically without symptoms during the follow-up. RESULTS: Fifty-seven patients with median age of 6.9 years (range 4.5-12), receiving REVUR in the study period, were included. Eighteen (31.6%) patients had complex anatomy and included prior failed endoscopic injection (n = 13), complete ureteral duplication (n = 2), periureteral diverticulum (n = 2), ectopic megaureter requiring dismembering (n = 1). The median operative time was 155 min for unilateral and 211.5 min for bilateral repairs. The clinical + radiographic VUR resolution rate was 96.5%. Post-operative complications (Clavien 2) included urinary retention following bilateral repair (n = 5, 8.7%), febrile urinary tract infection (UTI) (n = 6, 10.5%) and gross hematuria (n = 3, 5.2%). Comparative analysis between simple and complex cases showed that REVUR was faster in simple cases in both unilateral [p = 0.002] and bilateral repair [p = 0.001] and post-operative urinary retention was more frequent in simple cases [p = 0.004] and in patients with pre-operative bowel and bladder dysfunction (BBD) [p = 0.001] (Table). DISCUSSION: This series confirmed that the robot-assisted technique was feasible even in cases with complex anatomy using some technical refinements, that justified the longer operative times in both unilateral and bilateral cases. An interesting finding of this study was the correlation emerged between BBD and risk of post-operative urinary retention and VUR persistence. Our results also excluded any significant correlation between complex cases and risk of post-operative urinary retention. The main study limitations included the retrospective and nonrandomized design, the small number of cases and the arbitrary definition of complex anatomy. CONCLUSION: REVUR was safe and effective for management of VUR in both simple and complex ureter anatomy. Complex REVUR required slightly longer operative times, without significant differences in post-operative mordidity and success rates. Aside from complex anatomy, BBD emerged as the main risk factor associated with surgical failure and post-operative morbidity.

Anti-reflux surgery in children with congenital diaphragmatic hernia: A prospective cohort study on a controversial practice.

INTRODUCTION: Gastro-esophageal reflux disease (GERD) is the most frequent long-term morbidity of congenital diaphragmatic hernia (CDH) survivors. Performing a preventive fundoplication during CDH repair remains controversial. This study aimed to: (1) Analyze the variability in practices regarding preventive fundoplication; (2) Identify predictive factors for fundoplication. (3) Evaluate the impact of preventive fundoplication on gastro-intestinal outcomes in children with a CDH patch repair; METHODS: This prospective multi-institutional cohort study (French CDH Registry) included CDH neonates born in France between January 1st, 2010-December 31st, 2018. Patch CDH was defined as need for synthetic patch or muscle flap repair. Main outcome measures included need for curative fundoplication, tube feed supplementation, failure to thrive, and oral aversion. RESULTS: Of 762 CDH neonates included, 81 underwent fundoplication (10.6%), either preventive or curative. Median follow-up was 3.0 years (IQR: 1.0-5.0). (1) Preventive fundoplication is considered in only 31% of centers. The rates of both curative fundoplication (9% vs 3%, p = 0.01) and overall fundoplication (20% vs 3%, p < 0.0001) are higher in centers that perform preventive fundoplication compared to those that do not. (2) Predictive factors for preventive fundoplication were: prenatal diagnosis (p = 0.006), intra-thoracic liver (p = 0.005), fetal tracheal occlusion (p = 0.002), CDH-grade C-D (p < 0.0001), patch repair (p < 0.0001). After CDH repair, 8% (n = 51) required curative fundoplication (median age: 101 days), for which a patch repair was the only independent predictive factors identified upon multivariate analysis. (3) In neonates with patch CDH, preventive fundoplication did not decrease the need for curative fundoplication (15% vs 11%, p = 0.53), and was associated with higher rates of failure to thrive (discharge: 81% vs 51%, p = 0.03; 6-months: 81% vs 45%, p = 0.008), tube feeds (6-months: 50% vs 21%, p = 0.02; 2-years: 65% vs 26%, p = 0.004), and oral aversion (6-months: 67% vs 37%, p = 0.02; 1-year: 71% vs 40%, p = 0.03). CONCLUSIONS: Children undergoing a CDH patch repair are at high risk of requiring a curative fundoplication. However, preventive fundoplication during a patch repair does not decrease the need for curative fundoplication and is associated with worse gastro-intestinal outcomes in children. LEVEL OF EVIDENCE: II - Prospective Study.

Lessons from a large nationwide cohort of 350 children with ovarian mature teratoma: A study in favor of ovarian-sparing surgery.

BACKGROUND: Ovarian mature teratoma (OMT) is a common ovarian tumor found in the pediatric population. In 10%-20% of cases, OMT occurs as multiple synchronous or metachronous lesions on ipsi- or contralateral ovaries. Ovarian-sparing surgery (OSS) is recommended to preserve fertility, but total oophorectomy (TO) is still performed. DESIGN: This study reviews the clinical data of patients with OMT, and analyzes risk factors for second events. A national retrospective review of girls under 18 years of age with OMTs was performed. Data on clinical features, imaging, laboratory studies, surgical reports, second events and their management were retrieved. RESULTS: Overall, 350 children were included. Eighteen patients (5%) presented with a synchronous bilateral form at diagnosis. Surgery was performed by laparotomy (85%) and laparoscopy (15%). OSS and TO were performed in 59% and 41% of cases, respectively. Perioperative tumor rupture occurred in 23 cases, independently of the surgical approach. Twenty-nine second events occurred (8.3%) in a median time of 30.5 months from diagnosis (ipsilateral: eight cases including one malignant tumor; contralateral: 18 cases; both ovaries: three cases). A large palpable mass, bilateral forms, at diagnosis and perioperative rupture had a statistical impact on the risk of second event, whereas the type of surgery or approach did not. CONCLUSION: This study is a plea in favor of OSS as the first-choice treatment of OMT when possible. Close follow-up during the first 5 years is mandatory considering the risk of 8.3% of second events, especially in cases with risk factors.

Robotic Surgery in Pediatric Oncology: Lessons Learned from the First 100 Tumors-A Nationwide Experience.

BACKGROUND: While robotics has become commonplace in adult oncology, it remains rare in pediatric oncology due to the rarity of childhood cancers. We present the results of a large nationwide experience with robotic oncology, with the aim of providing practical and feasible guidelines for child selection. METHODS: This was a prospective analysis performed over a period of 4 years. Treatment was delivered according to the Société Internationale d'Oncologie Pédiatrique/International Society of Paediatric Oncology Europe Neuroblastoma Group (SIOP/SIOPEN) protocols. Indications were approved by a certified tumor board. RESULTS: Overall, 100 tumors were resected during 93 procedures (abdomen, 67%; thorax, 17%; pelvis, 10%; retroperitoneum, 6%) in 89 children (56 girls). The median age at surgery was 8.2 years (range 3.6-13); 19 children (21%) harbored germinal genetic alterations predisposing to cancer. No intraoperative tumor ruptures occurred. Seven conversions (8%) to an open approach were performed. Neuroblastic tumors (n = 31) comprised the main group (18 neuroblastomas, 4 ganglioneuroblastomas, 9 ganglioneuromas) and renal tumors comprised the second largest group (n = 24, including 20 Wilms' tumors). The remaining 45 tumors included neuroendocrine (n = 12), adrenal (n = 9), germ-cell (n = 7), pancreatic (n = 4), thymic (n = 4), inflammatory myofibroblastic (n = 4), and different rare tumors (n = 5). Overall, 51 tumors were malignant, 2 were borderline, and 47 were benign. The median hospital stay was 3 days (2-4), and five postoperative complications occurred within the first 30 days. During a median follow-up of 2.4 years, one child (Wilms' tumor) presented with pleural recurrence. One girl with Wilms' tumor died of central nervous system metastasis. CONCLUSIONS: Robotic surgery for pediatric tumors is a safe option in highly selected cases. Indications should be discussed by tumor boards to avoid widespread and uncontrolled application.

The Potential and the Limitations of Esophageal Robotic Surgery in Children.

INTRODUCTION: There have been numerous reports of robotic pediatric surgery in the literature, particularly regarding urological procedures for school-aged children. Thoracic procedures appear to be less common, despite the fact that encouraging results were reported more than 10 years. Our aim was to report a national experience of esophageal robotic-assisted thoracoscopic surgery (ERATS) and to discuss the most appropriate indications. MATERIALS AND METHODS: A retrospective multicenter study was conducted to compile the ERATS performed at five French surgical centers that have been involved in spearheading robotic pediatric surgery over the past 15 years. The data were supplemented by a review of the literature. RESULTS: Over the study period, 68 cases of robotic thoracic surgery were performed at the five pediatric centers in question. ERATS was performed for 18 patients (mean age 7.1 years [ ± 5.6]) in four of the centers. These comprised seven esophageal duplications, four esophageal atresias, five Heller's myotomies, and two cases of esophagoplasty. A conversion was needed for two neonates (11%) due to exposure difficulties. Four other procedures for patients who weighed less than 15 kg were successfully completed without causing postoperative complications. In the past 12 years, 22 other cases of ERATS were published worldwide. The indications were the same, except for esophagoplasty, which was not found. CONCLUSION: Aside from accessibility issues with the robotic platform, the main limitation is still very much that the low body weight of children results in incompatibility between the size of the trocars and the size of the intercostal space. ERATS is clearly a feasible procedure with technical advantages for most pediatric cases with body weights more than 15 kg. A transdiaphragmatic abdominal approach should be considered for lower esophagus surgery.

Perineal ultrasound in infants with anteriorly displaced anus: A new decision-making tool for the surgeon?

BACKGROUND: Anteriorly displaced anus (ADA) is defined as anterior displacement of the anus toward the perineum. Early radiologic characterization is a crucial step in guiding the first-line management. OBJECTIVE: The objective of this study was to assess the urethra-to-anus distance (UAD) on perineal ultrasound in female infants under the age of 3 months with anteriorly displaced anus and to retrospectively determine a cut-off to guide the indications for surgery. MATERIALS AND METHODS: Perineal ultrasound was performed prospectively in female infants under the age of 3 months with determination of the UAD, during screening for congenital hip dislocation. Determinations of the UAD on perineal ultrasound and pelvic MRI were performed for anteriorly displaced anus in girls between 2011 and 2018. RESULTS: 230 patients were included, of whom 173 were in the control group, with 52 examinations performed for anteriorly displaced anus and 5 examinations performed for vestibular anus. The mean UAD for infants under the age of 3 months was: 22.9 mm (±1.7) in healthy infants, 21.4 mm (±2.4) in infants with non-operated ADA, 17.5 mm (±1.8) in infants with operated ADA, and 10.8 mm (±1.3) in infants with anorectal malformation (ARM). A statistically significant difference was observed between the control group and the ARM group (p = 0.0001) and between the control group and the operated ADA group (p = 0.0001). The mean UAD for infants over the age of 3 months was: 25.5 mm (±4.1) in infants with non-operated ADA and 26 mm (±3) in infants with operated ADA. CONCLUSION: A urethra-to-anus distance of less than 17 mm appears to be a cut-off for anteriorly displaced anus in anorectal malformations.

Hemolytic uremic syndrome following complicated appendicitis in a child: what is the missing link?

We herein describe an 18-month-old boy who underwent initially successful surgical and antibiotic treatment of complicated appendicitis with postoperative occurrence of hemolytic uremic syndrome (HUS). This complication was due to Shiga toxin-producing Escherichia coli (STEC) found secondarily in rectal swabs but not in the peritoneal cavity. The literature indicates that a causal link may exist between these two entities, and HUS could be considered an iatrogenic complication of appendicitis management due to a multimodal stress effect in non-symptomatic STEC carriers.

Comparison of the Learning Curve for Robot-Assisted Laparoscopic Pyeloplasty Between Senior and Junior Surgeons.

Introduction: The widespread use of robotic surgery has provided surgeons a high-quality and alternative method to perform pyeloplasty. Indeed, robot-assisted technology has made it a lot easier to obtain the advanced technical skills required to perform this procedure. The learning curve (LC) reflects the increase in learning as a function of experience. Robot-assisted laparoscopic pyeloplasty (RALP) represents a well-standardized and reproducible procedure with an LC that allows reliable results to readily be obtained. The aim of our study was to compare the RALP LC of senior versus junior surgeons. Materials and Methods: We reviewed all of the RALP procedures performed at three pediatric surgery centers between November 2007 and November 2018. Three senior surgeons and 4 junior surgeons performed the robotic procedures. Neither the senior nor the junior surgeons had previous experience with robotic surgery; they had experience with conventional laparoscopic procedures but not with laparoscopic pyeloplasty. The primary metric that we selected to evaluate competence acquisition was a composite outcome defined by a combination of operative time (OT), complications, and surgical success. The complications were rated according to the Clavien-Dindo classification expressed by a complication factor; surgical success was expressed as a success factor, and we used a cumulative sum (CUSUM) analysis to determine the LC. The CUSUM method, through its multioutcome approach, is a very effective way to evaluate LCs. Results: Between November 2007 and November 2018, 3 senior surgeons and 4 junior surgeons performed 88 RALP procedures. The included patients had a median age of 6.1 years (range 7 months-16 years). The median duration of follow-up was 6.4 years (range 14 months-12 years). The median OT was 198.86 minutes (range 106-335 minutes). By CUSUM analysis of the composite outcome, we found that despite the junior surgeons having performed fewer procedures than the senior surgeons, their LCs exhibited an earlier inflection point (Fig. 1) followed by a constant rate of improvement in proficiency, thus indicating a more rapid learning process. The median composite scores for the senior surgeons and the junior surgeons were 299 (range 210-370) and 193 (range 131-255), respectively, after seven procedures. Conclusion: Assuming proper exposure to robotics and an adequate case volume, we demonstrated that junior surgeons can readily achieve comparable levels of expertise compared with senior practitioners in the field of pediatric RALP. It can be assumed that the LC in robotic pyeloplasty is not only directly influenced by the individual surgical experience but also by the experience of the surgical team.

X-ray-free protocol for pectus deformities based on magnetic resonance imaging and a low-cost portable three-dimensional scanning device: a preliminary study.

OBJECTIVES: To compare a standard protocol using chest computed tomography (CT) to a non-irradiant protocol involving a low-cost portable 3D scanner and magnetic resonance imaging (MRI) for all pectus deformities based on the Haller index (HI). METHODS: From April 2019 to March 2020, all children treated for pectus excavatum or carinatum at our institution were evaluated by chest CT, 3D scanning (iPad with Structure Sensor and Captevia-Rodin4D) and MRI. The main objectives were to compare the HI determined by CT or MRI to a derived index evaluated with 3D scanning, the external Haller index (EHI). The secondary objectives were to assess the inter-rater variability and the concordance between CT and MRI for the HI and the correction index. RESULTS: Eleven patients were evaluated. We identified a strong correlation between the HI with MRI and the EHI (Pearson correlation coefficient = 0.900; P < 0.001), with a strong concordance between a radiologist and a non-radiologist using intra-class correlation for the HI with MRI (intra-class correlation coefficient = 0.995; [0.983; 0.999]) and the EHI (intra-class correlation coefficient = 0.978; [0.823; 0.995]). We also identified a marked correlation between the HI with CT and the EHI (Pearson coefficient = 0.855; P = 0.002), with a strong inter-rater concordance (intra-class correlation coefficient = 0.975; [0.901; 0.993]), a reliable concordance between CT and MRI for the HI and the correction index (Pearson coefficient = 0.886; P = 0.033). CONCLUSIONS: Non-irradiant pectus deformity assessment is possible in clinical practice, replacing CT with MRI and 3D scanning as a possible readily-accessible monitoring tool.

Robot-assisted laparoscopic pyeloplasty (RALP) in children with complex pelvi-ureteric junction obstruction (PUJO): results of a multicenter European report.

PURPOSE: This study aimed to report a multi-institutional retrospective case series of outcomes after robot-assisted laparoscopic pyeloplasty (RALP) in pediatric patients with complex pelvi-ureteric junction obstruction (PUJO). METHODS: All patients undergoing complex RALP over the last 5 years were included. RALP was defined complex in the following cases of PUJO: anatomic variations including ectopic, malrotated, horseshoe, or duplex kidney and recurrent PUJO after failed open pyeloplasty. RESULTS: Forty-eight patients underwent complex RALP in four European centers in the study period and included 18 girls and 30 boys with a median age of 8 years (range 5-12). The PUJO was associated with anatomic variations in 35/48 (72.9%), whereas a recurrent PUJO was present in 13/48 (27.1%). A dismembered Anderson-Hynes pyeloplasty was performed in all patients. The median operative time including docking was 178.5 min (range 117-255) and the median anastomotic time was 64.8 min (range 50-76). All patients were discharged on 2nd postoperative day (POD). The median follow-up was 18.2 months (range 14-43). The overall success rate was 95.8% (46/48). Early postoperative complications (< 30th POD) included urinary tract infections (UTIs) and stent-related irritative symptoms in 4/48 (8.3%) [II Clavien], whereas late complications (> 30th POD) included recurrence of PUJO in 2/48 (4.2%), who needed re-operation [IIIb Clavien]. CONCLUSIONS: RALP was safe, feasible, and with good mid-term outcome in complex PUJO. An accurate pre-operative planning, a standardized technique, and an experienced surgical robotic team represented key points to manage successfully such complex cases.

Management of lower urinary tract fibroepithelial polyps in children.

INTRODUCTION: Fibroepithelial polyps (FEP) of the lower urinary tract are relatively common in adults but rare in children, with fewer than 250 cases reported in the literature to date. OBJECTIVE: The aim of this study was to address the experience of FEP management in children. STUDY DESIGN: A retrospective multicenter review was undertaken in children with defined FEP of the lower urinary tract managed between 2008 and 2018. The data at 18 pediatric surgery centers were collected. Their demographic, radiological, surgical, and pathological information were reviewed. RESULTS: A total of 33 children (26 boys; 7 girls) were treated for FEP of the lower urinary tract at 13 centers. The most common presentation was urinary outflow as hematuria (41%), acute urinary retention (25%), dysuria (19%), or urinary infections (28%). A prenatal diagnosis was made for three patients with hydronephrosis. Almost all of the children (94%) underwent ultrasound imaging of the urinary tract as the first diagnostic examination, 23 (70%) of them also either had an MRI (15%), cystourethrography (25%), computerized tomography (6%), or cystoscopy (45%). Two of these children (6%) had a biopsy prior to the surgery. The median preoperative delay was 7.52 (range: 1-48) months. Most of the patients were treated endoscopically, although four (12.1%) had open surgery and two (6.1%) had an additional incision for specimen extraction. The median hospital stay was 1.5 (range: 1-10) days. There were no recurrences and no complications after a median follow-up of 13 (range: 1-34) months. DISCUSSION: The main limitation of our study is the retrospective design, although it is the largest one for this pathology. CONCLUSION: This series supports sonography as the most suitable diagnosis tool before endoscopy to confirm the diagnosis and to perform the resection for most FEP in children. This report confirms the recognized benign nature in the absence of recurrences. LEVEL OF EVIDENCE: Level V.

Transperineal ultrasound to assess anal positioning in female neonates.

AIMS: Anterior anal displacement is a condition that is difficult to define: is it merely an anatomical variation within the range of normality or is it a genuine malformation? In order to improve early diagnosis of anterior displacement of the anus, this study assessed the feasibility of transperineal ultrasound (US) in routine practice for use as first-line management. MATERIALS AND METHODS: Sagittal perineal US was performed on 187 female infants aged between 3 and 9 weeks. The ultrasound was performed randomly, either by a senior or a junior radiologist. The imaging by the senior radiologists defined the sagittal plane quality criteria. Scores to define image quality were established and then validated. The percentage of satisfactory images was then compared according to the planes and the seniority (junior vs. senior) of the radiologists. The junior radiologists were evaluated from the beginning to determine the learning curve for optimal image acquisition. RESULTS: The quality scores for the perineal ultrasounds revealed excellent intra-and inter-operator performances: 84.4% of the sagittal plane images were satisfactory. After the 20th examination, the success rate for the sagittal plane was independent of the seniority of the radiologist. CONCLUSIONS: This preliminary study demonstrates that transperineal sagittal plane US is easy to learn and readily yields reproducible results. The possibility of using this technique provides a solid basis for further studies to evaluate its relevance in regard to clinical data and MRI results, with the aim of providing a reliable early diagnostic tool for routine practice.

Long-Term Outcomes of Distal Hypospadias Repair: A Patients' Point Of View.

PURPOSE: To assess the long-term outcomes of patients treated for distal hypospadias. Assessment of long-term follow-up for a homogeneous population with hypospadias is difficult and there has consequently been a paucity of publications in this regard. MATERIALS AND METHODS: A retrospective review was carried out to compile cases of distal hypospadias operated at our center between 1990 and 1999 according to the MAGPI procedure. Four parameters were evaluated based on four validated questionnaires: Health-related quality of life (SF-36), Genital self-perception (PPS), Self-esteem (Rosenberg Self-Esteem Scale), and Erectile function (IIEF). RESULTS: A total of 77 patients who had undergone MAGPI surgery for hypospadias during the specified period were selected. Sufficient clinical data were available for 51 patients and only 15 of these patients were included, after a median follow-up of 22 years (20-26). Their outcomes were compared with those for a population of 15 matched circumcised men and 15 matched uncircumcised men. No significant difference was found between the patients and the control groups in terms of the score for quality of life (p = .29). There were, however, significant differences in the scores for self-perception of the penile cosmetic appearance (13.3 vs. 15.8; p < .01), self-esteem (30.6 vs. 35.8; p < .01), and erectile function (31.4 vs. 33.7; p = .04) between the patients and the controls. Lower self-esteem correlated with poor genital self-perception (r  = .92). CONCLUSION: This study confirms that adult patients operated for distal hypospadias have poor genital self-perception. This poor genital perception correlated with lower self-esteem.