Endoscopic injection of bulking agents in pediatric vesicoureteral reflux: a narrative review of the literature.

In the last 20 years, endoscopic injection (EI) has affirmed as a valid alternative to open surgery for management of pediatric vesicoureteral reflux (VUR). This study aimed to investigate and discuss some debated aspects such as indications, bulking agents and comparison, techniques of injection and comparison, predictive factors of success, use in specific situations. EI is minimally invasive, well accepted by patients and families, with short learning curve and low-morbidity profile. It provides reflux resolution rates approaching those of open reimplantation, ranging from 69 to 100%. Obviously, the success rate may be influenced by several factors. Recently, it is adopted as first-line therapy also in high grade reflux or complex anatomy such as duplex, bladder diverticula, ectopic ureters. The two most used materials for injection are Deflux and Vantris. The first is absorbable, easier to inject, has lower risk of obstruction, but can lose efficacy over time. The second is non-absorbable, more difficult to inject, has higher risk of obstruction, but it is potentially more durable. The two main techniques are STING and HIT. To date, the ideal material and technique of injection has not yet clearly established, but the choice remains dependent on surgeon's preference and experience.

Retroperitoneoscopic partial nephrectomy in children: a multicentric international comparative study between lateral versus prone approach.

BACKGROUND: Very limited informations are currently available about the best approach to perform retroperitoneoscopic surgery. This multicentric international study aimed to compare the outcome of lateral versus prone approach for retroperitoneoscopic partial nephrectomy (RPN) in children. METHODS: The records of 164 patients underwent RPN in 7 international centers of pediatric surgery over the last 5 years were retrospectively reviewed. Sixty-one patients (42 girls and 19 boys, average age 3.8 years) were operated using lateral approach (G1), whereas 103 patients (66 girls and 37 boys, average age 3.0 years) underwent prone RPN (G2). The two groups were compared in regard to operative time, postoperative outcome, postoperative complications, and re-operations. RESULTS: The average operative time was significantly shorter in G2 (99 min) compared to G1 (160 min) (p = 0.001). Only 2 lateral RPN required conversion to open surgery. There was no significant difference between the two groups as for intraoperative complications (G1:2/61, 3.3%; G2:6/103, 5.8%; p = 0.48), postoperative complications (G1:9/61, 14.7%; G2:17/103, 16.5%; p = 0.80), and re-operations (G1:2/61, 3.3%; G2:4/103, 3.8%; p = 0.85). Regarding postoperative complications, the incidence of symptomatic residual distal ureteric stumps (RDUS) was significantly higher in G2 (7/103, 6.8%) compared to G1 (1/61, 1.6%) (p = 0.001). Most re-operations (4/6, 66.6%) were performed to remove a RDUS . CONCLUSIONS: Both lateral and prone approach are feasible and reasonably safe to perform RPN in children but the superiority of one approach over another is not still confirmed. Although prone technique resulted faster compared to lateral approach, the choice of the technique remains dependent on the surgeon's personal preference and experience. Our results would suggest that the lateral approach should be preferred to the prone technique when a longer ureterectomy is required, for example in cases of vesico-ureteral reflux into the affected kidney moiety, in order to avoid to leave a long ureteric stump that could become symptomatic and require a re-intervention.

Minimally invasive resection of adrenal masses in infants and children: results of a European multi-center survey.

BACKGROUND: Minimal access adrenal surgery (MAAS) for adrenal pathologies is the standard for many pediatric surgical centers. However, the literature offers few reports and minimal evidence from small case series. The aim of this study was to evaluate the outcomes of pediatric MAAS through a multi-center data analysis. METHOD: Pediatric patients who underwent MAAS between January 2002 and December 2013 were retrospectively included. Data analysis was conducted using Spss software (Welch's t-test, X-square, Fisher tests, multiple regression model). RESULTS: Six European centers participated, 68 patients were included with mean age of 5.2 years (2 months-16 years). Lesion volume was of 18.1 cc (0.78-145.6), with a mean diameter of 2.8 cm (1.1-6.5). Localization was 50% left-sided masses, 45.6% right-side masses, and 4.4% bilateral. Histological examination revealed 36 neuroblastomas, 15 adenomas, nine pheochromocytomas, three ganglioneuromas, two ganglioneuroblastomas, one bilateral hyperplasia, one adrenocortical carcinoma, an alveolar sarcoma, and a calcification. Surgical access was transperitoneal in 63 (92.6%) and retroperitoneal in 5 (7.4%). Mean operative time was 170 ± 87 min (285 ± 30 min for bilateral lesions). Mean hospital stay was 4.2 ± 2.5 days. Complications included blood loss requiring transfusion in five patients (7.4%) and a diaphragmatic tear. Infiltration of surrounding structures correlated with intraoperative complication rate (p = 0.027) and operative time (p < 0.01). No mass rupture, conversion, or post-operative complications were observed. Median follow-up was 52 months (1-161). Two recurrences occurred in patients with pheochromocytoma. Age, weight, symptoms, characteristics at imaging, chemistry, volume, or histology, did not influence operative time, hospital stays, or complication rate. CONCLUSIONS: Pediatric MAAS was safe adopted for masses up to 145.6 cc, with a very low rate of complication. Conversion to open is not necessary even in the presence of infiltrations. MAAS should represent the first-line treatment for selected cases in centers experienced in laparoscopy.

A comparison between laparoscopic and retroperitoneoscopic approach for partial nephrectomy in children with duplex kidney: a multicentric survey.

PURPOSE: To compare the outcome of laparoscopic and retroperitoneoscopic approach for partial nephrectomy in infants and children with duplex kidneys. METHODS: Data of 102 patients underwent partial nephrectomy in a 5-year period using MIS procedures were analyzed. Fifty-two children underwent laparoscopic partial nephrectomy (LPN), and 50 children underwent retroperitoneoscopic partial nephrectomy (RPN). Median age at surgery was 4.2 years. Statistical analysis was performed using χ (2) test and Student's t test. RESULTS: The overall complications rate was significantly higher after RPN (15/50, 30 %) than after LPN (10/52, 19 %) [χ (2) = 0.05]. In LPN group, complications [4 urinomas, 2 symptomatic refluxing distal ureteral stumps (RDUS) and 4 urinary leakages] were conservatively managed. In RPN group, complications (6 urinomas, 8 RDUS, 1 opening of remaining calyxes) required a re-operation in 2 patients. In both groups no conversion to open surgery was reported. Operative time (LPN:166.2 min vs RPN: 255 min; p < 0.001) and hospitalization (LPN: 3.5 days vs RPN: 4.1 days; p < 0.001) were significantly shorter in LPN group. No postoperative loss of renal function was reported in both groups. CONCLUSIONS: Our results demonstrate that RPN remains a technically demanding procedure with a significantly higher complications and re-operation rate compared to LPN. In addition, length of surgery and hospitalization were significantly shorter after LPN compared to RPN. LPN seems to be a faster, safer and technically easier procedure to perform in children compared to RPN due to a larger operative space and the possibility to perform a complete ureterectomy in refluxing systems.

Dietary treatment of urinary risk factors for renal stone formation. A review of CLU Working Group.

OBJECTIVE: Diet interventions may reduce the risk of urinary stone formation and its recurrence, but there is no conclusive consensus in the literature regarding the effectiveness of dietary interventions and recommendations about specific diets for patients with urinary calculi. The aim of this study was to review the studies reporting the effects of different dietary interventions for the modification of urinary risk factors in patients with urinary stone disease. MATERIALS AND METHODS: A systematic search of the Pubmed database literature up to July 1, 2014 for studies on dietary treatment of urinary risk factors for urinary stone formation was conducted according to a methodology developed a priori. Studies were screened by titles and abstracts for eligibility. Data were extracted using a standardized form and the quality of evidence was assessed. RESULTS: Evidence from the selected studies were used to form evidence-based guideline statements. In the absence of sufficient evidence, additional statements were developed as expert opinions. CONCLUSIONS: General measures: Each patient with nephrolithiasis should undertake appropriate evaluation according to the knowledge of the calculus composition. Regardless of the underlying cause of the stone disease, a mainstay of conservative management is the forced increase in fluid intake to achieve a daily urine output of 2 liters. HYPERCALCIURIA: Dietary calcium restriction is not recommended for stone formers with nephrolithiasis. Diets with a calcium content ≥ 1 g/day (and low protein-low sodium) could be protective against the risk of stone formation in hypercalciuric stone forming adults. Moderate dietary salt restriction is useful in limiting urinary calcium excretion and thus may be helpful for primary and secondary prevention of nephrolithiasis. A low-normal protein intake decrease calciuria and could be useful in stone prevention and preservation of bone mass. Omega-3 fatty acids and bran of different origin decreases calciuria, but their impact on the urinary stone risk profile is uncertain. Sports beverage do not affect the urinary stone risk profile. HYPEROXALURIA: A diet low in oxalate and/or a calcium intake normal to high (800-1200 mg/day for adults) reduce the urinary excretion of oxalate, conversely a diet rich in oxalates and/or a diet low in calcium increase urinary oxalate. A restriction in protein intake may reduce the urinary excretion of oxalate although a vegetarian diet may lead to an increase in urinary oxalate. Adding bran to a diet low in oxalate cancels its effect of reducing urinary oxalate. Conversely, the addition of supplements of fruit and vegetables to a mixed diet does not involve an increased excretion of oxalate in the urine. The intake of pyridoxine reduces the excretion of oxalate. HYPERURICOSURIA: In patients with renal calcium stones the decrease of the urinary excretion of uric acid after restriction of dietary protein and purine is suggested although not clearly demonstrated. HYPOCITRATURIA: The administration of alkaline-citrates salts is recommended for the medical treatment of renal stone-formers with hypocitraturia, although compliance to this treatment is limited by gastrointestinal side effects and costs. Increased intake of fruit and vegetables (excluding those with high oxalate content) increases citrate excretion and involves a significant protection against the risk of stone formation. Citrus (lemons, oranges, grapefruit, and lime) and non citrus fruits (melon) are natural sources of dietary citrate, and several studies have shown the potential of these fruits and/or their juices in raising urine citrate levels. CHILDREN: There are enought basis to advice an adequate fluid intake also in children. Moderate dietary salt restriction and implementation of potassium intake are useful in limiting urinary calcium excretion whereas dietary calcium restriction is not recommended for children with nephrolithiasis. It seems reasonable to advice a balanced consumption of fruit and vegetables and a low consumption of chocolate and cola according to general nutritional guidelines, although no studies have assessed in pediatric stone formers the effect of fruit and vegetables supplementation on urinary citrate and the effects of chocolate and cola restriction on urinary oxalate in pediatric stone formers. Despite the low level of scientific evidence, a low-protein (< 20 g/day) low-salt (< 2 g/day) diet with high hydration (> 3 liters/day) is strongly advised in children with cystinuria. ELDERLY: In older patients dietary counseling for renal stone prevention has to consider some particular aspects of aging. A restriction of sodium intake in association with a higher intake of potassium, magnesium and citrate is advisable in order to reduce urinary risk factors for stone formation but also to prevent the loss of bone mass and the incidence of hypertension, although more hemodynamic sensitivity to sodium intake and decreased renal function of the elderly have to be considered. A diet rich in calcium (1200 mg/day) is useful to maintain skeletal wellness and to prevent kidney stones although an higher supplementation could involve an increase of risk for both the formation of kidney stones and cardiovascular diseases. A lower content of animal protein in association to an higher intake of plant products decrease the acid load and the excretion of uric acid has no particular contraindications in the elderly patients, although overall nutritional status has to be preserved.

Penile repair in patients with epispadias-exstrophy complex-can we prevent resultant hypospadias?

PURPOSE: Male genitalia reconstruction in patients with exstrophy-epispadias complex often leads to secondary hypospadias, thus requiring additional surgery and resulting in possible complications. We describe a technique of male epispadias repair to prevent resultant hypospadias. MATERIALS AND METHODS: The complete penile disassembly technique is modified by multiple Z-plasties, which enable creation of a funnel-like bladder neck and urethral plate lengthening. A total of 29 patients 2 months to 12 years old presenting with pure epispadias and bladder exstrophy were treated with this technique between 2004 and 2011. These patients were compared to 19 patients 1 day to 11 years old with exstrophy-epispadias treated with the standard penile disassembly technique between 2000 and 2004. RESULTS: Outcome measures were urethral orifice position, penile length and complications. There was no statistically significant difference between the 2 groups regarding penile length or complications. In the study group the urethra reached the tip of the glans in all patients, whereas the creation of intentional hypospadias was necessary in 6 patients (31.5%) in the control group (p <0.05). CONCLUSIONS: The modified technique was effective in obtaining appropriate meatal location without decreasing the penile length. The complication rate was not changed. Creation of resultant hypospadias at genitalia reconstruction in male epispadias should strongly be prevented.

Bladder augmentation using acellular collagen biomatrix: a pilot experience in exstrophic patients.

PURPOSE: A preliminary experience on in vivo bladder wall regeneration in a subset of patients born with exstrophy-epispadias complex is reported. The objective was to improve bladder capacity and compliance without bowel augmentation. METHODS: Five patients (3 males, 2 females), mean age 10.4 years, presenting poor bladder capacity and compliance after complete exstrophy repair, underwent bladder augmentation using small intestinal submucosa (SIS) scaffold. Ultrasonography, cystoscopy with cystogram, assessment of bladder volume and compliance and bladder biopsy were performed before surgery (T0), at 6 (T1) and 18 months (T2) follow-up. Histology was compared with normal bladder specimens. Wilcoxon test was adopted for statistics. RESULTS: Bladder capacity and compliance resulted increased (+30%) at T1 (p < 0.05) and remained stable at T2, despite dry intervals did not changed significantly. Bladder biopsy at T1 showed no evidence of SIS, but normal transitional mucosa and sero-muscular layer containing smooth muscle fascicles, small nerve trunks and vessels within abundant type-3 collagen. Muscle/collagen ratio was decreased compared with controls at T1 and T2 (p < 0.05). No kidney damage, bladder diverticula, or stones were observed at 3 years follow-up. CONCLUSIONS: Bladder regeneration was feasible in these patients, but bladder capacity and compliance was poorly increased to obtain significant clinical benefit. Histology showed poor muscle components. The acellular matrix grafting failed to provide long-term effective results in terms of continence achievement.

Phytotherapy as ancillary treatment after urinary stone lithotripsy in pediatric age.

AIM: Small stone fragments (NSRF) may be observed after mini-invasive lithotripsy. A 3-components herbal extract drug was tested in young patients presenting NSRF to assess efficacy, safety and tolerability. MATERIAL AND METHODS: Patients aged 6-18 years, treated by endo-urological procedures in 5-year period, were randomly divided in 2 groups. Group A received a 3-components phytotherapic composed of Herniaria hirsuta and Peumus boldus plus water oral intake for 12 days/month in 3 months. Group B had no adjuvant phytotherapy. Group A and B were divided in 2 subgroups, according to persistence of NSRF. Patients were evaluated after the endo-urological procedure (Time 0), at 3-months therapy (Time 1) and after 3-months follow-up (Time 2). Persistence or development of new micro-lithiasis, adverse effects and urological check were registered. RESULTS: Thirty-four patients were enrolled (Group A=15, Group B=19). Two patients were excluded. In Group A, 6 patients were stone free at Time 0 and had no recurrence, while 7 patients (53.8%) had NSRF at Time 0, reduced to 3 (23.0%) and to 2 (15.4%) at Time 1 and 2 respectively. In Group B, 11 patients (57.9%) presented NSRF at Time 0, reduced to 8 (42.1%) and 7 (36.8%) at Time 1 and 2. The difference was significant (Time 1 p=0.006, Time 2 p=0.009). No adverse effects were reported. DISCUSSION AND CONCLUSIONS: The drug was effective in preventing new stones development and reducing significantly stone fragments persisting after endo-urological lithotripsy in children, with optimal tolerability and no adverse effects. KEY WORDS: Arbutin, Boldine, Phytotherapy, Pediatrics, Umbelliferone, Urinary tract stones.

Posterior urethral valves: long-term outcome.

Posterior urethral valves represent the most common cause of bladder outlet obstruction in infancy that impairs renal and bladder function. Long-term outcome of patients with previous PUV is evaluated. Patients over 18 years of age, treated from 1982 to 1995 before the age of 3 years were considered. Previous surgery, renal function, bladder activity, urinary incontinence, and fertility/sexual activity were evaluated. Clinical interview, creatinine clearance, uroflowmetry with ultrasound post-void urine residue, and self-administered questionnaire were recorded. Out of 45 identified records, 24 patients (53.3%) accepted to be enrolled (age 18-34 years, mean 23 years). The mean follow-up was 19.5 years (16-30 years). Out of the 21 excluded patients, 20 did not reply to the clinical interview and 1 died at age of 6 years. All the 24 patients had early endoscopic section of PUV; nine also received transient ureterocutaneostomy or vesicostomy. Ureteroneocystostomy was performed in five patients and ureterocystoplasty with unilateral nephrectomy in two. At follow-up chronic renal failure was detected in 13 patients (54.1%) and 9 (37.5%) had arterial hypertension. End-stage renal disease developed in five patients (20.8%): three had successful renal transplantation and two were in dialysis. Lower urinary tract symptoms were present in seven patients (29.1%). No significant fertility deficit and sexual dysfunction were observed in 23 patients, while 1 patient was azoospermic. No paternity was reported so far. Long-term outcome of patients with previously treated PUV is mandatory. Kidney, bladder, and sexual functions should be monitored till adulthood to verify any modified behaviour.

Urodynamics investigation on children with vesicoureteral reflux identifies overactive bladder and poor compliance in those with voiding dysfunction.

BACKGROUND: Up to 50% of children with vesicoureteral reflux (VUR) may have associated voiding dysfunction. It is thought to be an important determinate of the severity and resolution of VUR; however, to date there has been no objective measurement defining the impact of voiding dysfunction in children with VUR. The purpose of this study is to compare the urodynamic parameters of children with VUR who have and do not have symptomatic voiding dysfunction. METHODS: We performed a retrospective study of 138 children with a diagnosis of primary VUR who underwent urodynamic investigations. Information regarding patient demographics, grade and laterality of VUR and clinical history of bladder dysfunction were assessed. Urodynamic parameters recorded included detrusor overactivity, early and late compliance, voiding pressure, post-void residual volume and functional bladder capacity. Statistical analysis was performed using t Student analysis, Pearson's χ(2) test or Fischer's exact test, with a p < 0.05 as being significant. RESULTS: The mean age of the patients at the time of urodynamic evaluation was 5.8 years (SD 4.4). 30% had symptomatic voiding dysfunction based on the clinical history. Children without a history of voiding dysfunction had higher grades of VUR as compared to those with it (p = 0.002). Bladder hypertone, detrusor overactivity, detrusor hypereflexia and poor late bladder compliance presented a statistically significant higher incidence the incidence of bladder overactivity and poor late bladder compliance was higher in children with bladder dysfunction than those without it. CONCLUSION: Our findings suggest that voiding dysfunction does have objective and quantifiable effects on bladder dynamics. Urodynamic evaluation may play a role in the management of children with VUR by identifying those with bladder dysfunction secondary to abnormal voiding habits.

The concealed penis: the "two-corner" surgical technique.

BACKGROUND: Concealed penis is an uncommon genital abnormality that requires surgical repair. Several techniques are offered but not fully accepted. We present a novel standardized approach that is suitable for concealed penis and penoscrotal webbing. METHODS: From January 2005 to December 2013, patients presenting concealed penis were treated utilizing the "two corners" technique: through a midline penoscrotal incision, the superficial ventral chordee is removed, freeing the corpus spongiosum till the peno-scrotal angle. Circumferential degloving of the shaft is performed and the scrotal septum is separated from the urethra, allowing the penile shaft to pull out. The new peno-scrotal junction is rebuilt downwards, anchoring the peno-scrotal dartos corners to the peripubic tissue bilaterally and stabilizing the penile lengthening. Tension-free skin coverage is allowed by a series of Z-plasty at the penoscrotal angle avoiding circumcision if not needed. RESULTS: Forty-nine patients aged 3-14 years (mean age 4.7 years) underwent correction of the concealed penis according to our technique. Of them, 26 were primary and 23 after previous to hypospadias repair or other genital surgery. Penile lengthening varied from 1 to 2.5 cm (median 1.8 cm). Hospital stay varied from 1 to 4 days (mean 1.6 days). Follow-up ranged from 4 to 14 years (median 7.3 years). Forty-five parents were satisfied with the results (92%), while the defect was judged imperfectly repaired in four patients. CONCLUSIONS: The "two-corners" technique allows easy and effective correction of the concealed penis in both congenital and acquired conditions. It can be performed as outpatient procedure and results are stable at long-term follow-up.

One-port retroperitoneoscopic assisted pyeloplasty versus open dismembered pyeloplasty in young children: preliminary experience.

PURPOSE: We propose 1-port retroperitoneoscopic assisted pyeloplasty as a minimally invasive approach and compare the results to open dismembered pyeloplasty. MATERIALS AND METHODS: All patients 6 months to 5 years old presenting with ureteropelvic junction obstruction between January 2008 and June 2009 were offered 1-port retroperitoneoscopic assisted pyeloplasty. Age matched patients who underwent open dismembered pyeloplasty during 2007 served as controls. The ureteropelvic junction was isolated retroperitoneoscopically and exteriorized through a single operative trocar. Pyeloplasty was performed in an open fashion with Double-J® stenting. Operative time, postoperative pain, surgical complications, hospital stay, ultrasound and mercaptoacetyltriglycine nuclear scan results at 6-month followup were evaluated and compared. Chi-square test and Student's t test were adopted for statistical analysis, with p <0.05 considered statistically significant. RESULTS: A total of 28 children (17 males) with a mean age of 18 months were treated with 1-port retroperitoneoscopic assisted pyeloplasty (18 left side). The control group consisted of 25 patients (11 males) with a mean age of 19 months who underwent open dismembered pyeloplasty (10 left side). Median operative time was 95 minutes (range 70 to 130) in 1-port retroperitoneoscopic assisted pyeloplasty and 72 minutes (58 to 102) in open dismembered pyeloplasty (p <0.05). Median postoperative hospital stay was 2.4 days with the 1-port approach and 6.1 days with the open procedure (p <0.05). Postoperative pain was significantly less in the 1-port group. Skin scar length was 1.4 to 2.9 cm (median 1.7) with 1-port retroperitoneoscopic assisted pyeloplasty and 3.5 to 6.0 cm (4.3) in the open group (p <0.05). CONCLUSIONS: The 1-port retroperitoneoscopic assisted pyeloplasty represents a safe and effective minimally invasive technique to treat hydronephrosis and could be the treatment of choice in young children. The procedure does not require laparoscopic suturing skills, and combines the advantages of open and laparoscopic pyeloplasty.

Bladder injuries following inguinal canal surgery in infants.

PURPOSE: Surgery of the inguinal canal is very common in infancy. Occasionally, injury of the bladder may occur with severe consequences. The aim of this paper was to warn young surgeons of this serious complication. METHODS: During the last 2 years, we observed four cases of bladder injury following surgery on inguinal canal. All were males. The indication for surgery was inguinal hernia in three patients and cryptorchidism in one patient. RESULTS: Two cases presented with urinary peritonitis. One child was referred later for a retracted bladder with reflux. In one child, the lesion was promptly recognized and repaired. Of the four cases, two ruptures of the bladder caused transient sequaele, i.e. persisting catheter drainage, and voiding disorders later. In two cases, there were serious consequences: the bladder had to be partially removed in one child, ending up in temporary ureterostomy and subsequent reconstruction with bladder augmentation. The fourth child developed a small, water clock-shaped bladder with a thick wedge of scarred tissue, and bilateral ureteral reimplantation with bladder augmentation was necessary. CONCLUSIONS: Surgery of the inguinal canal is very common in children and infants, and is often performed by trainees. Awareness of this serious event should be emphasized in training programs.

Stone treatment in children: where we are today?

OBJECTIVE: Stone disease in children differs in pathogenesis, presentation and in treatment from adults. In recent years, big changes on its management have occurred. We reviewed our experience on upper tract urinary calculi in paediatric age. MATERIAL AND METHODS: Patients observed for upper tract urinary stones from June 2002 to June 2008 were reviewed. Bladder-urethral calculi were excluded. Presenting symptoms had a wide range: macro- or micro-hematuria, recurrent abdominal or flank pain, or non-specific symptoms such as irritability and failure to thrive. Renal and urinary tract ultrasonography, plain abdomen X-ray were performed in case of suggestive symptoms. Spiral CT without contrast was recommended to better define the stone disease. Metabolic evaluation is mandatory for any child presenting history of urinary calculi or nephrocalcinosis. Idiopathic hypercalciuria has been recognized as predominant ethiological factor of paediatric nephrolithiasis, excluding stones correlated with urinary tract malformations (up to 45%). RESULTS: In a 6-year period, 232 patients, aged 19 months to 18 years, were treated: 195 children (60.8%), mean age 8.3 years, underwent ESWL. Re-do treatments were 233 (2.3 ESWL/patient), with 77% stone free rate. Percutaneous nephrolithotomy (PCNL) was adopted in 33 patients, mean age 13.4 years, with 2 re-treatments. Stone clearance was 74% after single treatment, increased to 88% by secondary ESWL. Blood transfusion was needed in 7 cases (16%). Retrograde ureterolithotripsy (ULT) was performed in 96 patients presenting ureteral stones, for a total of 99 procedures. Stone free rate was 99%, as 1 pushed up stone required subsequent ESWL. No ureteral perforation or other significant complications occurred. Medical treatment was offered as ancillary therapy or to prevent recurrences, according to the metabolic results and the stone biochemistry. CONCLUSIONS: Stone treatment in children is changing dramatically, thanks to progressive transfer of procedures from adult patients and recent advances in miniaturized new technologies. Surgical approach to renal and urinary tract stones in childhood was recently moving from open surgical procedures (nephrolithotomy, ureterolithotomy, cystolithotomy), to less invasive procedures, such as ESWL and endoscopic approaches, as ULT and PCNL. Mini-invasive procedures present high efficacy and safety, also in young children, but require appropriate instrumentation and specific experience.

Laparoscopic Dismembered Repair in Two Patients with Retrocaval Ureter.

Retrocaval ureter (RCU) or circumcaval ureter is a rare cause of congenital hydronephrosis. The surgical correction of RCU should be performed in all patients with obstruction and hydronephrosis symptoms, lumbar pain, urinary tract infections, hematuria, or urolithiasis. Traditionally, an open surgical approach was used for the treatment of RCU. Nowadays, surgical correction of these anomalies is performed using minimally invasive techniques. We report on two cases treated with our standardized laparoscopic technique using only three 5-mm trocars. The proposed approach could be considered as the first-line treatment for RCU.

Urethral duplication in male epispadias: a very uncommon association.

BACKGROUND: Urethral duplication associated with epispadias is a rare malformation. Few cases are described in Literature. We report the experience of two centers to add to the literature. METHODS: A retrospective study was conducted in two Italian Centers. All patients with urethral duplication associated with epispadias, treated from 1997 to 2017 were included. The preoperative work-up included renal-urinary ultrasonography and voiding cystourethrogram. All patients underwent surgery according to the Mitchell-Caione technique. Cosmetic result, urinary continence and satisfaction degree of patients at the last follow-up were evaluated as outcomes. Six male patients with urethral duplication in epispadias were included. Two patients presented penile epispadias and four penopubic epispadias. Only one patient had urinary incontinence as presenting symptomatology. The diagnosis of urethral duplication was accidental during preoperative evaluation in the remaining five patients. RESULTS: At last follow-up (mean 8.3 years) all patients but one presented good cosmetic result, one patient presented mild stress urinary incontinence, one presented nocturnal enuresis. The physical genital appearance was improved in all patients. Urethral duplication in association with epispadias is a rare urogenital abnormality. No classification is universally accepted. CONCLUSIONS: Based on our experience, we believe that the presence of any duplication should be carefully searched during surgery for male epispadias.

Guidelines of the Italian Society of Videosurgery in Infancy (SIVI) for the minimally invasive treatment of fetal and neonatal ovarian cysts.

In the last three decades, fetal ovarian cysts were diagnosed more frequently, due to technological improvement and the increasing use of prenatal screening ultrasound. Nonetheless, treatment uncertainties are still present, either prenatally or postnatally. Recently, significant innovations on diagnosis and treatment have been proposed and a more conservative, minimally invasive approach may be offered to the Pediatrician or the Surgeon who face with this condition during prenatal or neonatal age. (...).

Guidelines of the Italian Society of Videosurgery (SIVI) in Infancy for the minimally invasive treatment of Hypertrophic Pyloric Stenosis in neonates and infants.

The most appropriate treatment for the infantile Hypertrophic Pyloric Stenosis (HPS) is still debated. The non-surgical conservative treatment with oral or intravenous administration of atropine does not enjoy a widespread appreciation for several factors (...).