Medical clowns versus sedation for paediatric urinary catheter insertion-A randomised pilot study.

AIM: To investigate the potential benefits of medical clowns (MCs) in reducing anxiety and pain during paediatric urinary catheter insertion. METHODS: In this prospective pilot study, 51 children who required urinary catheter insertion were randomised into two groups; the first group (n = 29) underwent the procedure in the presence of a MCs, and the second control group (n = 22) underwent the procedure using sedation. Pain and anxiety levels as well as procedural duration were recorded. All procedures were filmed and evaluated for anxiety level by a paediatric psychiatrist. General satisfaction questionnaires were filled by the medical team and parents in the clown group. RESULTS: There were no differences in pain scores or anxiety levels between the two groups. Procedure duration and total hospital stay were significantly shorter in the MC group (p < 0.001). One hundred percent of the parents and the medical team were in favour of incorporating MCs during urinary catheter insertion. CONCLUSION: MCs are as good as sedation in lowering anxiety and pain levels in children undergoing urinary catheter insertion. In addition, MCs reduce the duration of the procedure and elicit a high degree of overall satisfaction from the parents and medical team.

Long term results of non-refluxing ureteral reimplantation in the pediatric population.

PURPOSE: To evaluate the long-term results of UR and to determine the difference between patients with VUR and OMU in terms of re-obstruction rate, complications associated with pregnancy, and de novo reflux. METHODS: Two-site retrospective study with 69 patients (36 females and 33 males) with a mean age of 5 ± 3.4 years. Fifty-nine (85.5%) underwent UR due to VUR and 10 (14.5%) due to OMU. Mean length of surgery and hospitalization was 90 ± 29.2 min and 9 ± 2.4 days, respectively. RESULTS: Eight (13.5%) patients with VUR suffered from febrile UTI with a mean of 2.1 ± 1.3 events. In the OMU group, 1 (10%) patient suffered from febrile UTI. None of the patients showed recurrence, obstruction or de novo VUR. Two patients (20%) with OMU suffered from CKD. In the VUR group, 3 (5.1%) patients suffered from CKD. Three women suffered from UTIs during pregnancy. Mean follow-up was 17.5 ± 4.6 years. CONCLUSIONS: Successful UR is associated with a decreased rate of febrile UTI in patients with VUR. Patients with OMU maintained and improved renal function in the long term. None demonstrated technical failures in the long term. Patients who presented with bilateral VUR are more prone to developing major complications.

Current management of the urachal anomalies (UA). Lessons learned from the clinical practice.

PURPOSE: It has been suggested that symptomatic UA requires surgical excision. However, the management of asymptomatic urachus is still controversial. We aimed to evaluate the clinical presentation, the efficacy of current modalities used, and postoperative pathology in patients with UA. MATERIALS AND METHODS: We have performed a retrospective review of all patients diagnosed with UA and treated surgically or conservatively over 18 years. Demographic data, clinical presentation, imaging modalities, pathology, treatment, and postoperative complications were analyzed. RESULTS: Twenty-five symptomatic patients (18 males and seven females) with a median age of 13 years (1 month to 37 years) were identified. 15 (60%) were diagnosed with a urachal cyst, 4 (16%) with sinus, 3 (12%) with urachal diverticulum, and the remaining 3 (12%) with patent urachus. Of those, 20 (80%) underwent surgical repair, and the remaining five (20%) patients were managed conservatively. 4 (20%) underwent laparotomy, 7 (35%) laparoscopic incision, and the remaining 9 (45%) laparoscopic robotic-assisted surgery. Nine patients required bladder cuff excision. The median operative time was 75 min (42-140 min). One patient developed Clavien-Dindo grade IIIA complication resulting in infected hematoma, which resolved after drainage. Another patient with a complication of grade IIIB needed reoperation as a result of recurrent events of an abscess. 13 (65%) demonstrated epithelium lining of the urachus on postoperative pathology. CONCLUSIONS: Our data show that most of the patients with UA presented with epithelial lining, which might lead to the later malignant transformation. It might cause a shift from the conservative management of asymptomatic patients to surgical intervention. Robotic-assisted surgery appears beneficial in these patients, especially when the bladder cuff excision is required.

Pediatric robotic-assisted laparoscopic pyeloplasty (RALP): does weight matter?

PURPOSE: RALP is rapidly becoming the new gold standard treatment for UPJO in children, who suffer from uretero-pelvic obstruction (UPJO). However, presently there is a lack of data regarding the outcomes of RALP in young infants and smaller children. This study aims to compare the outcomes of RALP in children weighing less than 10 kg and matched with an analogous cohort who underwent open pyeloplasty (OP). METHODS: We prospectively compared patients who underwent RALP to a matched cohort of patients who underwent OP from our retrospectively acquired data registry. Comparative outcomes included: Demographics, success rate, complications, and length of hospital stay, postoperative pain score and failure rate. Failure was defined as the need for a secondary intervention for UPJO, or worsening hydronephrosis during follow-up. RESULTS: A total of 15 patients with a median age of 8 months (range 5-11 months) and median weight 7 kg (range 5.6-9.8 kg) underwent RALP between 2016 and 2018, a matched cohort of 15 children who underwent OP similar in terms of age, weight, gender and affected side between 2014 and 2016. All children had prenatal diagnosis of hydronephrosis and underwent surgery utilizing combined general and regional (Caudal MO) anesthesia. Intrinsic obstruction was present in 13 of RALP group (86.7%) and in 14 in OP group (93.3%). Mean operative time was 67.8 + 13.4 min in RALP group, while 66.5 + 9.5 min in OP group. (p = 0.76) All but two patients in RALP group had stent inserted and required subsequent anesthesia for stent removal, while all OP children had a Salle Pyeloplasty stent inserted during the procedure and underwent removal in an ambulatory setting without the need for anesthesia. There were no failures recorded in the RALP group, while one patient in OP required a secondary intervention. Mean hospital stay was 1 day (1-2 days) for RALP and 2 days (2-3 days) for OP. There was no difference in FLACC Pain Scale in both groups. Clavien-Dindo grade I-II complications occurred in one patient from each group. Two patients from RALP underwent subsequent ureteral reimplantation due to accompanying uretero-vescical junction obstruction. CONCLUSIONS: Our data suggest that RALP can be performed safely in pediatric patients weighing less than 10 kg. with similar outcomes when compared to patients undergoing an open procedure for the same pathology.

Does endoscopic puncture of ureterocele provide not only an initial solution, but also a definitive treatment in all children? Over the 26 years of experience.

PURPOSE: We have retrospectively evaluated all patients who underwent endoscopic puncture (EP) of ureterocele over the last 26 years with special reference to the need in the second intervention and disease-free status. METHODS: 78 (69%) of the 112 patients following EP and completed follow-up were included. 51 (65%) were diagnosed prenatally and 27 (35%) postnatally. 46 patients (60%) had intravesical, while 32 (40%) had ectopic ureterocele. Median age at time of puncture was 4 months. Median time of the follow-up was 12 years (range 1-26 years), while 23 (30%) followed over 10 years and 15 (19%) completed adolescent period. RESULTS: Four children with ectopic ureterocele required secondary puncture. Ectopic ureterocele children had significantly more postoperative UTIs (13 (40%) ectopic vs 4 (19%) intravesical p = 0.047). 19 RRUs (44%) showed spontaneous resolution of VUR. 14 (18%) children required additional surgery: 7, endoscopic correction of VUR; 3, ureteral reimplantation and 4, partial nephrectomy. The need for additional surgery following puncture was higher in the group of children with ectopic ureterocele; however, this difference did not reach a statistical significance (p = 0.716). CONCLUSIONS: Our data show that EP of ureterocele is a durable and long-term effective procedure in vast majority of the children.

Medical clowns reduce pre-operative anxiety, post-operative pain and medical costs in children undergoing outpatient penile surgery: A randomised controlled trial.

AIM: The aim of this paper is to investigate prospectively the potential benefits of the participation of the medical clowns in the outpatient paediatric penile surgery programme. METHODS: Eighty children undergoing meatotomy, age 2 to 16 years, were randomised into two groups (40 each). In the first group, the medical clown was an integral part of the medical team, and in the second group, the treatment was given without participation of the medical clown. The following parameters were measured: the level of pre-operative anxiety, the level of the post-operative pain, the amount of pain medication use in the first 24 h after surgery and the time needed to return to normal activities. The operating room time and hospital costs were calculated. RESULTS: The patients from the first group demonstrated a lower pre-operative anxiety index upon (P = 0.0319) and after surgery (P = 0.0042), required less induction time for anaesthesia (P < 0.001), spent overall less time in the operating room (P < 0.0001) and required less time to recover from the surgery and to be discharged (P = 0.0172). The overall OR time and post-operative unit care savings of 20 and 155 min, respectively, led to the cost savings of $467. CONCLUSION: Our data demonstrated that the use of the medical clown functioning as an integral part of the operating team reduces children pre-operative anxiety and leads to a shortening of the overall time in the hospital thereby reducing the overall medical cost justifying the participation of medical clown as an integral part of the health team in a paediatric urology outpatient surgical unit.

One-Stage Laparoscopic Orchiopexy for the Treatment of Intraabdominal Testis.

BACKGROUND: Laparoscopy has gradually become the gold standard for the treatment of non-palpable testicles (NPT), with different success and complication rates. OBJECTIVES: To evaluate outcomes of the one-stage laparoscopic orchiopexy for NPT in our department. METHODS: We retrospectively evaluated the medical files of patients who underwent laparoscopic orchidopexy with the identical technique. Only patients with at least one year follow-up were included. At follow-up we assessed the age (at surgery), follow-up time, laterality of testes, postoperative complications, testicular size and testicular localization. RESULTS: Thirty-six consecutive patients, median age 16 months, underwent one-stage laparoscopic orchiopexy. Sixteen patients (44.4%) had peeping testis type, in 13 patients (36.1%) the testicle was located within 2 cm from the internal ring and in the remaining 7 patients (19.4%) it was detected > 2 cm from the internal ring. In six children (16.7%) dividing the spermatic vessels was performed in one stage with laparoscopic orchiopexy. In the remaining 30 patients (83.7%) a laparoscopic one-stage procedure was performed with preservation of the spermatic vessels. Testicular atrophy was observed in 2 cases (5.6%), and 6 patients (16%) had a relatively small testicle compared to the contralateral normal testicle at follow-up. Two patients (5.6%) presented with testicle positioning at the entrance area into the scrotum. None of the patients demonstrated hernia recurrence at follow-up. There was no difference in surgical outcome in children who had surgery with preservation of the spermatic vessels versus those who underwent orchiopexy with division of the spermatic vessels in one stage. CONCLUSIONS: Laparoscopic transection of the testicular vessels appeared to be safe in boys with high abdominal testes that did not reach the scrotum after laparoscopic high retroperitoneal dissection.

Endoscopic correction of complex cases of vesicoureteral reflux utilizing Vantris as a new non-biodegradable tissue-augmenting substance.

PURPOSE: We aimed to evaluate prospectively the efficacy of Vantris as a new non-biodegradable tissue-augmenting substance in children with complex cases of VUR. MATERIALS AND METHODS: Over the last 4 years, 37 children (28 female and 9 male) with a mean age of 5.8 ± 3.1 years (mean ± SD) underwent endoscopic correction of complex VUR. A total of 38 renal refluxing units (RRU) was treated as 5 had persistent reflux after open surgery, 16 had duplication, 4 had Hutch diverticulum, 6 had small poorly functioning kidneys (less than 20% of relative renal function) with grade V VUR, 2 had ureterocele after puncture, 3 had persistent stump reflux, 1 had prune belly syndrome, and 1 had urogenital sinus. VUR was Grade I in 2, Grade II in 9, Grade III in 11, Grade IV in 10, and Grade V in 6 RRU, respectively. RESULTS: The reflux was corrected in 34 (89.4%) RRU after a single injection, after second injection in 2 (5.3%) RRU. In 2 (5.3%) RRU, VUR downgraded to Grade I (1RRU) and Grade II (1RRU) and they were taken off antibiotic prophylaxis. VCUG was performed in 11 (73.3%) of 15 children who completed 1 year and in 3 (33.3%) of 9 who completed 3 years of follow up as a part of the routine protocol. None showed VUR recurrence. US demonstrated normal appearance of kidneys in all patients. CONCLUSION: Our data show that Vantris injection provides a high level of reflux resolution in complex cases of VUR.

Penoscrotal transposition: Long-term outcome in 29 patients.

OBJECTIVE: Penoscrotal transposition (PST) is a rare anomaly of the external genitalia characterized by malposition of the penis in relation to the scrotum. This transposition may be partial or complete and may be associated with hypospadias, chordee, and other anomalies. We have reviewed our experience with the surgical repair of PST utilizing a modified Glenn-Anderson technique. MATERIALS AND METHODS: Twenty-nine patients with a median age of 5.6 years (8 months -15 years) underwent surgical repair of PST at our institution between 2004-2022. Of those, 20 (69%) had complete PST, while 9 (31%) had partial PST. All children were divided into three groups. In the first group of 8 (28%) children, repair of PST was an integral part of one-stage male genitoplasty; in the second group of 18 (62%) children, repair of PST was an isolated last stage of the staged hypospadias repair and the remaining 3 (10%) children underwent PST repair without the presence of hypospadias. All patients underwent modification of the Glenn-Anderson technique involving utilization of bilateral rotational advancement scrotal flap, complete de-tethering of the testis from the internal part of the scrotum when indicated, and relocation of the scrotal compartment in a normal dependent position. The follow-up ranged from 6 months to 18 years. RESULTS: In the first group, five children (62%) underwent Onlay Prepucial Island Pedicle Flap (OIF) hypospadias repair, and three (38%) underwent Long Tubularized Incised Plate Repair (TIP). In the second group, 8 (44%) underwent OIF hypospadias repair, 2 (12%) had Long TIP repair, and the remaining 8 (44%) underwent staged hypospadias repair. Post-operative Clavien Dindo grade III presented among three patients in group I and only one patient in group II. In the third group, no postoperative complications were observed. CONCLUSION: Our data show that penoscrotal transposition correction utilizing the Glenn-Anderson technique is a reliable and durable surgery in the pediatric population. These children require careful monitoring till adolescence to ensure that no re-operation is needed.

Long-term outcome of gender assignment in individuals with 46, XY DSD assigned female sex in multicultural society.

BACKGROUND: The decision regarding sex rearing in patients with Disorders of Sex Development (DSD) is heavily connected to the shared decision-making model within multidisciplinary team. Some of these patients might develop gender dysphoria, when they become adults. We have aimed to evaluate the long-term outcomes of patients with XY DSD who underwent female gender assignment at our center. METHODS: We have conducted a retrospective study of all 46, XY DSD patients who underwent female assignment in our institution over the last 30 years. RESULTS: we have found 25 46, XY patients who were raised as a female after birth. After excluding the Androgen insensitivity syndrome (AIS) patients we have identified 15 patients who have matched study criteria. The decision on gender rearing was made by the parents in 11(74%) and by the surgical team 2(13%) during hernia repair/inguinal exploration. In 2(13%) cases, the patients opted to continue identifying as women after learning about the pathology during adolescence. Nine (60%) out of 15 patients (age17.9 ± 4.7 years (mean ± SD)) agreed to answer questionnaires regarding sexual function and satisfaction from gender assignment. Mean follow up was 11.1 ± 8.2 years (mean ± SD). only one participant consented to respond to a questionnaire regarding sexual intercourse (homosexual). The overall FSFI score was 24 which included the scores 4, 4, 3, 4, 3, 2 in the categories desire, arousal, lubrication, orgasm, satisfaction, and pain respectively. Two patients regretted the decision of female gender assignment. The first with 5α-reductase deficiency, he made the decision for assignment himself as an adult and the other (3ß-hydroxysteroid dehydrogenase) who underwent gonadectomy during inguinal exploration as a child. The rest of the patients were satisfied with the choice of gender, 2 need psychological support on the daily basis. In the study group, relationship and cohabitation were significantly later in life compared to the general population. CONCLUSIONS: Despite the sensitivity of the subject and cultural differences, most patients (78%) were satisfied with the decision to undergo female gender assignment. Over the years, patients require meticulous follow-up in order to consider additional interventions, and mental support if it is necessary. The two cases of later regret highlight the importance of proper education of patients, their families and medical providers upon decision on gender assignment.

Robotic-Assisted Laparoscopic Pyeloplasty in Challenging Cases of Ureteropelvic Junction Obstruction in the Pediatric Population: A Multicenter Review.

Purpose: To report a multi-institutional international experience in performing robotic pyeloplasty for complicated cases of ureteropelvic junction obstruction (UPJO) in the pediatric population and assess feasibility and outcomes. Materials and Methods: Retrospective chart review of all pediatric patients who underwent robotic-assisted laparoscopic pyeloplasty (RALP) for UPJO in challenging cases between 2013 and 2021 was included. Demographics, perioperative surgical data, complications, and results are described. Challenging cases were defined as bilateral UPJO, failure of previous open pyeloplasty (thus re-do cases), correction of UPJO in kidneys with anatomical variations, huge hydronephrosis, and low-weight infants (<6 kg). Results: Over an 8-year period, 36 children (62% males and 38% females) met the inclusion criteria for our study. Fifteen patients underwent RALP for recurrent UPJO; among them, 2 children required simultaneous surgery for renal stones, 3 cases of lower pole UPJO in double collecting system, 3 cases of pelvic and horseshoe kidneys, 10 cases of infants weighing <6 kg, 3 cases of huge hydronephrosis, and 2 cases of bilateral UPJO. The median age and weight were 36 months (interquartile range [IQR] 14-84) and 12 kg (IQR 10-20.5), respectively. All robotic cases were completed successfully with no conversion to an open procedure. The median operative time was 120 minutes (IQR 90-135). The mean length of hospital stay was 2.6 days. Four patients (17%) had postoperative complications-1 ileus (Clavien-Dindo grade [CDG] I) and 3 urinary tract infections (CDG II). No CDG III or higher complication was encountered. At a median follow-up of 36 months, the success rate was 95% with 1 patient requiring another re-do procedure due to recurrent obstruction. Conclusions: Our data suggest that RALP is safe and effective even for challenging cases of UPJO in children.

Laparoscopic and Robot-assisted Laparoscopic Reimplantation for Lower Ureter Pathology. A Multi-institutional Comparative Study in 1343 Patients.

OBJECTIVE: To evaluate the outcomes of children with vesicoureteral reflux (VUR) and obstructive megaureter (OM) utilizing various laparoscopic and robot-assisted approaches. MATERIALS AND METHODS: Retrospective review of all pediatric laparoscopic and robot-assisted cases for lower ureter pathology was performed between 2016-2022 in 13 academic centers worldwide. Five surgical approaches were assessed: LEUR, LVCUR, LDECUR, RALUR, and RADECUR. RESULTS: One thousand three hundred forty-three patients (490 boys and 853 girls) with a median age of 30 months (IQR 12-63) were treated at 13 centers. Nine hundred and eight patients (68%) underwent reimplantation due to VUR (unilateral in 818 and bilateral in 90 patients). Four hundred thirty-five (32%) had a surgery due to ureterovesical junction (UVJ) obstruction. Mean length of follow-up was 14 months (IQR 8-33). Median operative time was 202 minutes (IQR 142-220) in the robotic arm compared to 240 minutes (IQR 160-267) in the laparoscopic (P = .45). Intracorporeal excisional tapering was performed in 118 (8%) of the patients. Six patients in the OM group required additional surgery due to progressive obstruction. In the VUR group, 84% underwent voiding cystourethrography postoperatively. 5.6% showed residual reflux. Grade 1-2 Clavien-Dindo complications occurred in 10 patients (0.7%) and 6 (0.4%) in the laparoscopic and robotic arm, respectively. Grade 3 complications occurred in 17 (1.2%) and 8 (0.5%) in both arms, respectively. Surgical success was achieved in 96% of patients. CONCLUSION: Laparoscopic and robot-assisted laparoscopic approaches are simple, safe, and effective for treating all grades of VUR and OM. Robot-assisted approach is beneficial in terms of operative time, intracorporeal suturing, and lower complications rate.

Objective and subjective sexual outcomes in adult patients after hypospadias repair performed in childhood.

PURPOSE: We evaluated sexual function and psychosexual adjustment in adults who underwent hypospadias repair in childhood. MATERIALS AND METHODS: After receiving institutional review board approval, 119 of 449 adult patients (26.6%) who underwent hypospadias repair between 1978 and 1993 responded to questionnaires on penile appearance and sexual life. Patients were divided into 3 groups according to primary meatal location in childhood, including group 1-45 (37.8%) with glanular hypospadias, group 2-56 (48.2%) with distal hypospadias and group 3-18 (14%) with proximal hypospadias. RESULTS: All group 1 and 2 patients, and 11% in group 3 were satisfied with the penile appearance. Of group 1 patients 8.9% reported mild erectile dysfunction, as did 50% and 72.2% in groups 2 and 3, respectively. A total of 99 patients (83.2%) complained of premature ejaculation. All group 1 and 2 patients reported excellent self-esteem and relationship on the Self-Esteem and Relationship questionnaire. Most group 3 patients were satisfied with their relationship and only 1 (5.6%) was not satisfied. Two-thirds of the patients in groups 1 and 2 reported that sexual quality of life was excellent and the others described it as good. In group 3 sexual quality of life was somewhat decreased in all patients and 1 (5.6%) had poor sexual quality of life. Physical and mental component summaries were satisfactory in all patients reviewed. CONCLUSIONS: Our data show that the high incidence of mild erectile dysfunction and premature ejaculation should not be disregarded and requires appropriate counseling before surgery.

Surgical Treatment of Meatal Stenosis: Lessons Learned from the Pediatric Urology Practice.

OBJECTIVE: To evaluate the indications for surgery and outcome of meatotomy and meatoplasty in a big cohort of children. METHODS: We retrospectively evaluated 2211 children who underwent either meatotomy or meatoplasty between 2009 and 2020 utilizing the same operative setup. For continuous data, we performed t-test and Mann-Whitney U test. For categorical data, chi-squared test or Fisher's exact test was used. A binary logistic regression model was used to compare the indications for surgery between the groups. RESULTS: Of 2211 children, 1906 underwent meatotomy and 305 meatoplasty. The mean age was 5 years (range: 1m-15y) and there was no age difference between the groups. There was no difference between duration of surgery, recovery time, or complication rates between the groups. Deviated stream was the most frequent indication for treatment 1477 (67%). On Univariate logistic regression children with the following indications: dysuria, meatitis, and urinary retention had increased odds toward meatoplasty, while the indication of deviated stream had increased odds toward meatotomy. On Multivariate Logistic regression only deviated stream (Odd-ratios 1.47, P: .005) and urinary retention (Odds-ratio 4.5, P: .027) remained significant for meatotomy and meatoplasty respectively. Eleven (0.58%) children who underwent meatotomy developed recurrent Urethral Meatal Stenosis and underwent another surgery. Sixty-nine children (3.6%) after meatotomy required manual opening of the meatus on the first post-operative visit. None of the children, who underwent meatoplasty needed reoperation. CONCLUSION: Meatotomy had a higher reoperation rate and frequently required manual meatal spreading in early postoperative period. We believe meatoplasty is a preferable surgery for pediatric UMS.

Outcome of hypospadias repair in toilet-trained children and adolescents.

PURPOSE: To review a leading causes and surgical outcome of hypospadias repair in toilet-trained children and adolescents in our department. MATERIALS AND METHODS: Over the period from 1987 to 2010, 84 toilet-trained children and adolescents with a median age of 13 years (range 4-18) underwent hypospadias repair. Voiding symptoms were a cause for referral in 31(36%) patients, difficulties in self-appraisal or patient desire in 49(55.7%) and 4(4.8%) patients with DSD underwent male genitoplasty as a part of sex reassignment. Of those 43(51.2%) had glanular hypospadias, 36(42.9%) distal and 5(5.9%) had proximal type of hypospadias. Meatoplasty was performed in 18(21.4%) patients, MAGPI in 24(28.6%), Mathieu flip-flap in 20(23.8%), preputial pedicled flap as onlay in 2(2.4%) and as tubularized in 2(2.4%) patients, and TIP procedure was done in 16(19%). Two (2.4%) patients required two stage repair. RESULTS: Twenty-three (27.4%) developed surgery-related complications such as meatal stenosis in 3(15.5%), breakdown of primary repair in 7(8.3%), and urethral fistula in 13(15.5%) patients, respectively. CONCLUSIONS: There are clear differences in terms of complications rate and overall success compared with the repair in the earlier ages.

Is Ultrasound-Guided Single-Shot Quadratus Lumborum Block a Viable Alternative to a Caudal Block in Pediatric Urological Surgery?

OBJECTIVE: To review our experience with quadratus lumborum block (QLB) in pediatric urology. MATERIALS AND METHODS: This mixed prospective-retrospective study included 41 patients who received QLB following induction of general anesthesia. Data collected included: the duration of block induction, surgery, hospitalization, postoperative pain score, and the use of rescue analgesia. The results were compared with a matched cohort of patients who received caudal block (CB) during similar surgeries from our retrospectively acquired data registry. RESULTS: There was no difference between the type and length of surgery, weight, sex, and age of the patients between the two groups. The duration of block induction was significantly shorter in the CB group compared with the QLB group (35.6 ± 14.6 vs. 239 ± 33.4 seconds [p < 0.0001]). There was no difference between the groups in pain scores at 1, 4, and 24 hours postoperatively, in the time to first rescue analgesia, or in the postoperative opioid requirements. However, the QLB group required more rescue analgesia compared with CB group (p = 0.016). Finally, no differences were found in the use of rescue analgesics at home, pain record behavior, and overall satisfaction. CONCLUSION: Our data show that QLB might serve as a viable alternative to CB in pediatric urological surgery.

Laparoscopic single site surgery: initial experience and description of techniques in the pediatric population.

PURPOSE: Recently new approaches to laparoscopic surgery, named natural orifice transluminal endoscopy and laparoendoscopic single site surgery, have been proposed to improve the cosmesis and decrease the morbidity associated with multiple ports sites. Experience with laparoendoscopic single site surgery technique in pediatric urology is still limited. We present our initial results with this technique in children. MATERIALS AND METHODS: Since laparoendoscopic single site surgery received Food and Drug Administration approval, 11 patients have undergone a total of 14 procedures at our department, including nephrectomy due to nonfunctioning kidneys in 4, removal of bilateral intra-abdominal gonads in 2, unilateral varicocelectomy in 4 and bilateral varicocelectomy in 1. In all patients a multi-channel single laparoscopic port inserted through a 2 cm skin incision was used to achieve access to the abdominal cavity. RESULTS: All patients underwent laparoendoscopic single site surgery without complications within a reasonable operative time. None required conversion to open or conventional laparoscopic surgery. All except 1 patient were discharged home on the day of surgery or the day after surgery. CONCLUSIONS: Our initial data show that laparoendoscopic single site surgery is an effective technique for various pediatric and adolescent urology indications. Further application of this procedure in a large patient group will show whether there is a place for laparoendoscopic single site surgery in the pediatric urology surgical armamentarium.

Endoscopic Correction of Reflux Utilizing Polyacrylate Polyalcohol Bulking Copolymer (Vantris) as a Tissue Augmenting Substance: Lessons Learned Over the 10 Years of Experience.

Objectives: To prove the hypothesis that modifying the endoscopic correction of vesicoureteral reflux (VUR) technique (STING procedure) and sharpening its contraindications, lead to increased success rate and decline in the complication rate. Materials and Methods: All patients that underwent endoscopic correction of VUR utilizing Vantris were divided into two groups according to procedure date; before 2015 and 2015-2019. Indication for treatment included persistent high-grade VUR or breakthrough infections. Contraindications included voiding dysfunction, active infection and since 2015 suspicion for obstructive/refluxing ureterovesical junction (UVJ) presented by "beak" sign on voiding cystourethrography (VCUG). Follow-up regiment included ultrasound and VCUG at predetermined intervals. Results: The first group included 215 (158 girls and 57 boys) children with mean age of 4.8 ± 2.8 years who underwent endoscopic correction between 2009 and 2015 and the second group included 42 children (28 girls and 14 boys) with mean age of 3.9 ± 2.1 years who underwent surgery between 2015 and 2019. In the first group, VUR was unilateral in 74 patients and bilateral in 132 comprising 338 renal refluxing units. In the second group, VUR was unilateral in 14 patients and bilateral in 30 comprising 74 RRUs. In the first group reflux was corrected in 317 (94.9%) RRUs after a single injection, after the second in 7 (2.1%) RRUs. In seven (2.1%) RRUs, reflux downgraded to Grade I-II. Three RRUs (0.9%) failed endoscopic correction and required ureteral reimplantation. Nine (2.7%) RRUs developed UVJ obstruction. In the second group reflux was corrected in 61 (82.4%) RRUs after a single injection, after the second in 12 (16.2%) RRUs. In one (1.4%) RRU, endoscopic correction failed and required ureteral reimplantation. None of the patients developed UVJ obstruction. Reflux correction has led to the significant decrease of febrile urinary tract infection (UTI) in both groups. Conclusions: Our data indicate that endoscopic injection utilizing Vantris is safe and long durable procedure. Although utilizing the proper technique and contraindication criteria, the rates of post procedural VUJ obstruction is null.

Learning curve of robotic-assisted laparoscopic pyeloplasty (RALP) in children: how to reach a level of excellence?

It has been suggested that up to 40 cases of RALP are required to reach the operative results equal to open surgery. We have hypothesized that previous experience in open and laparoscopic surgeries might shorten the learning curve of robotic surgery. We have retrospectively evaluated the data of all children who underwent pyeloplasty in our institute by a single surgeon since 2003. The children were divided into three groups: open pyeloplasty (OP) of 72 children, laparoscopic pyeloplasty (LAP) of 22, and RALP of 33 patients subsequently. The data included: demographics, duration of surgery, length of stay, success of surgery, and complication rate according to the Clavien-Dindo score. The groups were ordered chronologically by the operation date and each group was divided into two different phases: early and late. A comparison was made between the data of the early and the late phase. There was no difference in the demographic data between the groups; however, the patients who underwent laparoscopic surgery were significantly older compared with the patients from the other groups. The median duration of surgery in the RALP group was significantly shorter than the OP group (65 min vs 72.5 min P < 0.01), while the first RALP case was already shorter than the median duration of surgery in OP group. There was no significant decrease in the duration of surgery of the RALP group over the study period, though there was a significant trend of decreasing operative time in the OP and LAP groups. There was no difference in the length of stay in the early vs late phases in the RALP group. There was no difference in the complication and success rate between the RALP and OP group, as well as the early and late phases of the RALP group. Our data show that previous experience in OP and LAP surgery may contribute to a shorter learning curve of robotic surgery required for the surgeon to achieve a similar outcome to that of OP.

Does Renal Function Remain Stable after Puberty in Children who underwent Ureteral Reimplantation due to Ureterovesical Junction Obstruction?

INTRODUCTION: Ureteric reimplantation due to ureterovesical junction (UVJ) obstruction enjoys high success in the short term. However, renal function after reimplantation must accommodate the numerous changes in the pediatric urinary tract that occur along with child development that may theoretically cause an occult loss of renal function. The purpose of this study was to evaluate whether improved renal function after ureter reimplantation for antenatal diagnosed UVJ obstruction remains stable after puberty. MATERIALS AND METHODS: Twenty-one children who underwent open reimplantation using Politano-Leadbetter technique were followed until they completed puberty. Mean age at surgery was 14.3 months (range: 3-60 months). Five (23.8%) of 21 children had right hydronephrosis, 13 (61.9%) had left hydronephrosis, and 3 (14.3%) had bilateral hydronephrosis. The Society for Fetal Urology (SFU) level of the hydronephrosis was 3 (47.6%) in 10 children and 4 (52.4%) in remaining 11. Fourteen (66.6%) patients had poor renal function upon surgery and the remaining seven (33.4%) patients had moderate renal function. The mean renal function upon operation was 28 ± 4.3 (mean ± standard deviation [SD]). RESULTS: Reimplantation led to the increase in the RRF in the short-term period from 28 ± 4.3% prior to the surgery to 36.4 ± 5% (p < 0.001) in all patients and remains stable 35 ± 5% after puberty in all the reviewed patients. CONCLUSION: Our data demonstrate for the first time that successful ureteral reimplantation following antenatal diagnosis of UVJ obstruction is associated with an improvement in renal function, not only during short- and midterm follow-up but also allows preserving the renal function throughout the puberty period.