Safety and Effectiveness of Triclosan-Coated Polydioxanone (PDS Plus) versus Uncoated Polydioxanone (PDS II) Sutures for Prevention of Surgical Site Infection after Hypospadias Repair in Children: A 10-Year Single Center Experience with 550 Hypospadias.

AIM: Triclosan is an antiseptic substance that has been shown in preclinical studies to reduce bacterial load in the wound and slow bacterial growth by inhibiting fatty acid synthesis. It is claimed that the coating protects against colonization of the tissue around the suture. This study aimed to compare the safety and efficacy of triclosan-coated polydioxanone versus uncoated polydioxanone sutures for the prevention of surgical site infections (SSIs) following hypospadias repair in children. METHODS: The medical records of 550 children who underwent hypospadias repair between 1 January 2014 and 31 December 2023 were retrospectively analyzed. The patients included in the study were divided into two groups. The first group consisted of the patients in whom polydioxanone (PDS II) was used (n = 262), while in the patients of the second group (n = 288), triclosan-coated polydioxanone (PDS Plus) was used for hypospadias repair. Secondary outcomes were defined as the occurrence of early and late complications, the number of readmissions within 30 days after surgery (ReAd), unplanned return to the operating room (uROR), and repeat operations. RESULTS: The median age of all children enrolled in the study was 16 (IQR 14, 20) months. The patients in whom PDS Plus was used for hypospadias repair had a significantly lower number of SSIs than the patients in whom PDS II was used (n = 18 (6.9%) vs. n = 4 (1.4%), p < 0.001). Wound infection led to wound dehiscence in 10 of 18 patients from the PDS II group, while all four wound infections from the PDS Plus group led to wound dehiscence (p = 0.07). The number of postoperative urethrocutaneous fistulas was significantly lower in the patients in whom PDS Plus was used (13.7% vs. 8.3%, p = 0.042). The incidence of late complications did not differ between the study groups: meatal stenosis (p = 0.944), residual chordee (p = 0.107), urethral stricture (p = 0.196), scarring (p = 0.351) and urinary discomfort (p = 0.713). There were no cases of uROR in either group. The ReAd rate was low in both groups (n = 5 (1.9%) vs. n = 2 (0.6%), p = 0.266). The frequency of reoperations was lower in the group of patients treated with PDS Plus than in the group of patients treated with PDS II (11.1% vs. 20.6%; p = 0.03). CONCLUSION: The use of PDS Plus in hypospadias surgery significantly reduces the incidence of SSI, postoperative fistulas, and reoperation rates compared to PDS II.

Same-Day Discharge after Laparoscopic Appendectomy for Simple Appendicitis in Pediatric Patients-Is It Possible?

(1) Background: One-day surgery has been widely adopted for many elective laparoscopic procedures in pediatric patients. Recently, the same protocol has been investigated for some emergency procedures, such as laparoscopic appendectomy. This study aimed to evaluate the safety and effectiveness of discharge from hospital within 24 h in pediatric patients who received laparoscopic appendectomy for uncomplicated acute appendicitis. (2) Methods: From 1 March 2021 to 1 May 2022, a total of 180 pediatric patients who were discharged from hospital within 24 h after laparoscopic appendectomy for uncomplicated appendicitis were included in this prospective single-center study. The primary outcome of this study was the safety of discharge from hospital within 24 h after laparoscopic appendectomy for uncomplicated appendicitis, as well as the parental satisfaction with this protocol. Secondary outcomes included the rate of readmission or unplanned return to the operating room, the complication rate and a cost-effectiveness analysis. For each patient, demographic data, preoperative evaluation (physical examination, laboratory data, imaging), duration of surgery, intraoperative and postoperative complications, length of hospital stay and pain levels, as well as parental satisfaction with this protocol, were recorded. (3) Results: The median age was 11 years (interquartile range (IQR) 10, 14). The majority of the patients (63.8%) were males. The median length of hospital stay after surgery was 15 h (IQR 12, 19). The highest level of satisfaction, at discharge, was recorded in most of the respondents (n = 155, 86.1%), while the remaining 25 (13.9%) expressed moderate levels of satisfaction. The median pain levels according to a visual analogue scale for all postoperative days were low (range 0-4). In four patients (2.2%), unplanned readmission before the seventh postoperative day because of postoperative intraabdominal abscess was recorded. All patients with abscess formation were treated conservatively. The majority of the parents (n = 175; 97.2%) expressed the highest level of satisfaction during the outpatient follow-up examination on the seventh postoperative day. (4) Conclusions: Same-day discharge after laparoscopic appendectomy for simple appendicitis in pediatric patients was safe and feasible. Parental satisfaction with this protocol was very high. With the right protocol and parent education, pediatric patients who underwent laparoscopic appendectomy because of non-complicated acute appendicitis may be successfully treated in this way.

Laser-puncture of the ureterocele in neonatal patients significantly decreases an incidence of de novo vesico-ureteral reflux than electrosurgical incision.

INTRODUCTION: Endoscopic laser-puncture or electrosurgical incision are the most commonly used minimaly invasive approaches for the treatment of the ureterocele. Both techniques are mainly successful in decompressing of ureteroceles, but the consequence of such treatment may be formation of de novo vesicoureteral reflux and febrile urinary tract infection which could impact the final results. OBJECTIVE: To compare outcomes of treatment of two endoscopic techniques used in management of neonatal patients with intravesical ureterocele. STUDY DESIGN: A case records of 64 neonates who underwent endoscopic procedures for intravesical ureterocele, performed at our institution from January 2005 to January 2021, were retrospectively reviewed. The patients were divided in two groups depending on used endoscopic procedure. The first group (n = 41) consisted of patients who underwent electrosurgical incision of the ureterocele, while the second group (n = 23) consisted of patients in whom 6 to 8 laser-punctures of the ureterocele were performed. The groups were compared in regards to outcomes of treatment, with special emphasis on de novo vesicoureteral reflux and the need for further treatment and surgery. RESULTS: Median follow-up was 7.5 (IQR 3, 11.5) and 3.5 (IQR 1.5, 5) years in the electroincision and laser-puncture groups, respectively (P = 0.017). No significant differences between the groups in regards to medians of duration of surgery (12 min vs. 11 min, P = 0.670), length of hospital stay (2 days in both groups, P = 0.988) or postoperative obstruction (n = 1 vs. n = 0, P > 0.999) were recorded. Ureterocele decompression was achieved after endoscopic treatment in 87.9% and 100% of the patients in electrosurgery and laser-puncture groups, respectively (P = 0.150). Five patients (12.1%) from electrosurgery group required endoscopic retreatment. The laser-puncture group had a significantly decreased rate of de novo vesicoureteral reflux (8.7% vs. 58.5%; P = 0.0001) and lower incidence of subsequent surgery due to de novo vesicoureteral reflux (50% vs. 62.5%; P = 0.727). CONCLUSION: Both electrosurgical incision and laser-puncture endoscopic techniques are safe and effective in relieving the obstruction. Laser-puncture technique is associated with significantly lower incidence of de novo vesicoureteral reflux and accordingly fewer invasive procedures for neonatal patients.

Laparoscopic Versus Open High Ligation for Adolescent Varicocele: A 6-year Single Center Study.

OBJECTIVE: The aim of this study was to compare the outcomes of high ligation in adolescents with varicocele between open and laparoscopic surgical approaches. DESIGN: Retrospective study. SETTING: The study was conducted from January 2012 to January 2018, with median follow-up of 36 months, in the division of pediatric surgery at tertiary-care hospital. PATIENTS: Data of 537 adolescents who underwent varicocelectomy were classified into two groups, depending on surgical approach. INTERVENTION: Open or laparoscopic varicocelectomy. MAIN OUTCOME MEASURES: Indications for surgery, complications, duration of surgery, hospital stay, and recurrences rate. RESULTS: The median age of the patients was 15 years. The median (IQR) duration of surgery was 12 (11,15.3) min in laparoscopic and 25 (10,30) min in open group (P<0.001). The most common complication was hydrocele (n=29), which was more common in open group (6.8% vs 1.4%; P=0.01). A total of 16 recurrences were recorded, all in open group (P=0.049). In both groups, sperm concentration (P<0.001), morphology (P<0.001) and motility (laparoscopy, P=0.001; P=0.02; open varicocelectomy, P=0.001; P=0.04) improved six months after surgery in patients with varicocele stage I and II. In stage III there was an improvement in sperm concentration (P=0.002; P=0.001) and morphology (P=0.03; P=0.06), while sperm motility (P=0.15; P=0.2) did not significantly recover in either of the groups. CONCLUSION: Laparoscopic and open varicocelectomy are equally effective and result in significant improvement of testicular volume, disappearance of pain, and sperm parameters in adolescents. Based on our findings laparoscopic varicocelectomy is associated with shorter operating time, shorter hospitalization, faster recovery, and fewer complications and recurrences.

Endoscopic placement of double-J ureteric stents in children as a treatment for primary hydronephrosis.

INTRODUCTION: The aim of this study was to determine the efficacy and potential complications of double-J ureteric stents in the treatment of primary hydronephrosis in pediatric patients. MATERIALS AND METHODS: A retrospective case-records review of 133 patients (45 girls and 88 boys) treated because of primary hydronephrosis with double-J ureteric stents, in Department of Pediatric Surgery, Split University Hospital, between December 1997 and December 2014, was performed. Success of treatment, results of follow up investigations and complications were recorded. Patients were followed up clinically and radiologically for a minimum of 2 years following stent insertion. RESULTS: In all, 133 endoscopic double-J ureteric stents insertions were performed. Of the total number of patients, left-sided hydronephrosis was found in 82 patients, right-sided in 38, and bilateral in 13 patients. The median age of children was 2 years (range 0-17 years). Mean hospital stay was 2 days (range 1-10 days). In primary hydronephrosis, double-J ureteric stenting alone was effective with resolution of hydronephrosis in 73% of cases (97/133 insertions). Regarding the age of the patients the highest success of 83.5% was achieved in age group 0-4 years. Success in groups 5-9 years; 10-14 years and 15-17 years were 47%; 33.5% and 0%, respectively. Several complications have been recorded: symptomatic infections, migration in the renal pelvis and bladder, progression of hydronephrosis, spontaneously prolapse of prosthesis, bleeding and perforation of the renal pelvis. A significant, decreasing trend in success rates by age of participants was observed (p < 0.001). CONCLUSIONS: Ureteric stenting is minimally invasive procedure that provides an alternative to open surgery in patients with primary hydronephrosis. Endoscopic placement of ureteric double-J stents should be considered as a first-line treatment in the management of primary hydronephrosis especially in children till 4 years of age, with success rate of 83.5% and without the need for conventional surgery. In a case of failure we are time-consuming to definitive surgery.

Management of acute scrotum in children: a 25-year single center experience on 558 pediatric patients.

INTRODUCTION: The aim of this study was to analyze management and outcomes of treatment in patients with acute scrotum. MATERIAL AND METHODS: From January 1990 until January 2015 case records of 558 patients who underwent surgery for acute scrotum were retrospectively reviewed. Mean age was 12 years old. Each patient was analyzed for following parameters: history data, localization of pain, physical examination, operating results and the results of follow up, age, etiology, and the time from initial symptoms to surgery. RESULTS: Scrotal explorations revealed 142 cases (25%) of spermatic cord torsion, 344 (62%) torsion of the testicular appendage, 54 (10%) epididymitis, 10 (2%) testicular trauma and 8 cases (1%) of other conditions. Two peaks of incidence of spermatic cord torsion were found, the first during first year of life and the second between 13 and 15 years of life. In patients with spermatic cord torsion, median duration of symptoms in the group of salvaged testes was 6 hours; while in the group of patients who underwent orchiectomy was 46 hours. Of the total number of patients with spermatic cord torsion 40 patients (28%) underwent orchiectomy while 102 testicles (72%) were saved. There were no major complications. Acute scrotum is significantly more common in the winter. Torsion of the testis has the highest incidence in January and August. CONCLUSION: Early scrotal exploration based on careful physical examination decreases the risk of misdiagnosis of spermatic cord torsion. It is of great importance that the patient seeks immediate medical attention. If the patient arrived within 6 hours the testicle can be saved.

Comparison of dextranomer/hyaluronic acid based bulking agents in the treatment of vesicoureteral reflux in children: Deflux versus Vurdex.

INTRODUCTION: The objective of this study was to compare the clinical efficacy of two similar tissue bulking agents, Deflux and Vurdex, used for a treatment of vesicoureteral reflux (VUR) in our institution. MATERIAL AND METHODS: The case records of 104 children, treated endoscopically for primary VUR from January 2010 to January 2015, were retrospectively reviewed. Most of the patients were treated with Deflux until 2012, when use of Vurdex was started. Exclusion criteria were patients with secondary reflux due to neurogenic bladder, duplicated refluxing ureters, primarily operated patients and patients operated after first or second injection. RESULTS: Endoscopic treatment of vesicoureteral reflux using Deflux was performed in 65 children (106 ureters). There were 24 patients with unilateral and 41 patients with bilateral VUR. After first injection of Deflux success was achieved in 74 ureters (69.8%), after second injection in 91 ureters (85.8%) and after third injection in 99 ureters (93.3%). The same procedure using Vurdex was performed in 39 children (58 ureters). There were 20 patients with unilateral and 19 patients with bilateral reflux. After first injection of Vurdex success was achieved in 43 ureters (74.1%), after second injection in 52 ureters (89.6%) and after third injection in 55 ureters (94.8%). CONCLUSIONS: Overall success rate for patients treated with Deflux was 93.3% and for patients treated with Vurdex 94.8%. No significant difference in success rates between two groups was found (p = 0.714). However, Vurdex has an advantage because of the significantly lower price, but with same treatment results as Deflux.

Endoscopic treatment of vesicoureteral reflux in children with subureteral dextranomer/hyaluronic acid injection: a single-centre, 7-year experience.

BACKGROUND: The goals of medical intervention in patients with vesicoureteral reflux are to allow normal renal growth, prevent infections and pyelonephritis, and prevent renal failure. We present our experience with endoscopic treatment of vesicoureteral reflux in children by subureteral dextranomer/hyaluronic acid copolymer injection. METHODS: Under cystoscopic guidance, dextranomer/hyaluronic acid copolymer underneath the intravesical portion of the ureter in a subureteral or submucosal location was injected in patients undergoing endoscopic correction of vesicoureteral reflux. RESULTS: A total of 282 patients (120 boys and 162 girls) underwent the procedure. There were 396 refluxed ureters altogether. The mean age of patients was 4.9 years. The mean overall follow-up period was 44 months. Among the 396 ureters treated, 76% were cured with a single injection. A second and third injection raised the cure rate to 93% and 94%, respectively. Twenty-two (6%) ureters failed all 3 injections, and were converted to open surgery. CONCLUSION: Endoscopic treatment of vesicoureteral reflux can be recommended as a first-line therapy for most cases of vesicoureteral reflux, because of the short hospital stay, absence of complications and the high success rate.

Management of testicular rupture after blunt trauma in children.

PURPOSE: Testicular rupture is a very rare entity in children and adolescents. The aim of this study was to evaluate the outcomes of surgical repair after testicular rupture in children. METHODS: Between January 2000 and January 2010 seven patients were operated on because of testicular rupture. Mean age at the time of the accident was 15 years. In all patients, an emergency scrotal ultrasonography showed a rupture of the testicular capsule with a surrounding hematocele. Surgical exploration was performed to evacuate the hematocele and repair the ruptured testis. RESULTS: Mean follow-up was 4.9 years. Average hospital stay was 2 days. Mean time between surgery and the initial trauma was 35 h. There were no major complications. Control ultrasound imaging showed that the tunica was repaired and Doppler signal confirmed vascularity in all patients. There were no significant differences in size between the right and left testes. There were no recorded cases of testicular atrophy. Semen analysis showed normospermia 6 months after surgery and anti-sperm antibodies count was within normal limits in all patients. CONCLUSION: Prompt surgical intervention is crucial. Ruptured testis can be salvaged, with a high success rate, if surgical repair is performed within 72 h of testicular injury.

Pediatric urolithiasis in Croatia.

A retrospective review was performed of the records of 148 Croatian children with urolithiasis treated between 1989 and 2003. The study evaluated age, gender, family history, clinical symptoms, location of stone, laboratory findings, stone composition, mode of treatment and compared our results with data from higher and lower socio-economic countries. The mean age of our patients was 9.38 years (10 months to 18 years). Thirty-seven children (25%) were less than 5 years (group 1), 44 (29.7%) were between 5 and 10 years (group 2) and 67 (45.3%) were older than 10 years of age (group 3). There were 60 girls and 88 boys with overall male to female ratio of 1.47. Abdominal pain (83%) and haematuria (59.5%) were the main symptoms in the groups 2 and 3. Urinary tract infection was predominant symptom in the group 1 (62.1%). Calculi were located in the kidney in 90 children (60.8%), in the ureter in 39 (26.4%), in the bladder in 8 (5.4%). Urinary tract anomalies with or without infection were associate with a greater frequency of urolithiasis in the youngest age group and hypercalciuria was predominant cause in children over 5. Stone analysis was performed in 80 children. Predominant constituent of stones was calcium oxalate (48.7%), followed by struvite (25%), calcium phosphate (13.7%), cystine (10%) and uric acid (1.2%). Calcium oxalate stones were most common in all age groups. Struvite stones were most prevalent in the children younger than 5 years of age. Most patients (33.1%) underwent surgery for removal of their calculi. In 31.8% of children stones were passed spontaneously and the highest spontaneous passage rate was in the group 3 (37.3%). Stone composition, location and etiology in Croatian children are similar to those in developed Western countries.