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.

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.

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 (...).

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. (...).

Point of view of the Italians pediatric scientific societies about the pediatric care during the COVID-19 lockdown: what has changed and future prospects for restarting

BACKGROUND

The coronavirus disease 2019 (COVID-19) is currently rare in children and they seem to have a milder disease course and better prognosis than adults. However, SARS-Cov-2 pandemic has indirectly caused problems in pediatric medical assistance. In view of this we wanted to draw a picture of what happened during health emergency and analyze future prospects for restarting.

METHODS

We involved the Italian pediatric scientific societies institutionally collected in the Italian Federation of Associations and Scientific Societies of the Pediatric Area (FIARPED); We sent a questionnaire to all scientific societies about the pediatric care activity during the COVID-19 emergency and future perspectives for the phase of post-containment.

RESULTS

The analysis of the questionnaires showed significant decrease of:admission, outpatient visits and specialist consultancy activities during the COVID-19 emergency, primarily linked to the fear of infection. Instead it was increased the serious degree of diseases admitted. Most of scientific societies maintained the relationship with chronic patients through some form of telemedicine, reporting a strong positive opinion about this modality. Finally showed the need to give life a new approach for hospitalizations and outpatient visits through a greater use of telemedicine, educational programs on families and a more decisive role of family pediatricians.

CONCLUSIONS

Our study highlighted many aspects that can be improved in pediatric care. We think that It will be necessary a new shared strategy to improve the management and continuity of care for pediatric patients, primarily developing a network of collaboration between families, family pediatrician and hospitals and by enhancing the use of new methods of telecommunications.

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.

Guidelines of the Italian Society of Videosurgery in Infancy for the minimally invasive treatment of the esophageal atresia

Esophageal Atresia (EA) is defined as an interruption in esophageal continuity that results in a proximal tract that ends in a blind pouch in 98% of cases, and a distal tract that in 87% of cases arises via a Fistula from the Trachea (TEF). (...).

Guidelines of the Italian Society of Videosurgery in Infancy for the minimally invasive treatment of the ureteropelvic-junction obstruction

The hydronephrosis, characterized by the dilation of the renal pelvicalyceal system with possible functional damage to the renal parenchyma, is the most common congenital abnormality of the urinary system detected in utero through the prenatal ultrasound screening. (...).

Guidelines of the Italian Society of Videosurgery in Infancy for the minimally invasive treatment of pediatric nephrectomy and partial nephrectomy

Throughout history, the pediatric laparoscopic nephrectomy was first described at the beginning of the Nineties by Erlich and colleagues in a child and by Koyle and colleagues in an unweaned patient. (...).

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.

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.

Glanular Venous Malformation in Pediatric Age: An Uncommon Vascular Disorder

Glanular venous malformations are uncommon in pediatric patients. The diagnosis can be easily achieved by observation, even if color Doppler ultrasound is useful for a better characterization. Abdomino-pelvic MRI is necessary to assess the extension of complex lesions and check for associated anomalies. Several therapeutic options are reported in literature. We report 3 paediatric cases successfully treated by surgery with no complications and functional sequelae. Cosmetic results were satisfactory, with minimal surgical scarring. In our opinion, surgery for small glanular venous malformations is indicated within puberty to prevent traumatic bleeding and psychological impact.

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.

Minimally Invasive Laser Treatment of Ureterocele

Introduction: Ureterocelemay cause severe pyelo-ureteral obstruction with afebrile urinary tract infections in infants and children. Early decompressive treatment is advocated to reduce the risk of related renal and urinary tract damage. Endoscopic techniques of incision have been offered utilizing diathermic electrode. We adopted laser energy to release the obstruction of the ureterocele and reduce the need of further surgery. Our technique is described and results are presented, compared with a group of matched patients treated by diathermic energy. Materials and methods: Decompression was performed by endoscopic multiple punctures at the basis of the ureterocele. Holmium YAG Laser was utilized with 0.5-0.8 joule energy, through 8-9.8F cystoscope under general anesthesia. The control group received ureterocele incision by diathermic energy through pediatric resettoscope. Foley indwelling catheter was removed after 18-24 h. Renal ultrasound was performed at 1, 3, 6, and 12 months follow-up. Voiding cysto-urethrogram and radionuclide renal scan were done at 6-18 months in selected cases. Statistical analysis was utilized for data evaluation. Results: From January 2012 to December 2017, 64 endoscopic procedures were performed: 49 were ectopic and 15 orthotopicureteroceles. Fifty-three were in duplex systems, mostly ectopic. Mean age at endoscopy was 6.3 months (1-168). Immediate decompression of the ureterocele was obtained, but in five cases (8%) a second endoscopic puncture was necessary at 6-18 months follow-up for recurrent dilatation. Urinary tract infections and de novo refluxes occurred in 23.4 and 29.7% in the study group, compared to 38.5 and 61.5% in the 26 controls (p < 0.05). Further surgery was required in 12 patients (18%) at 1-5 years follow-up (10 in ectopic ureteroceles with duplex systems): seven ureteral reimplantation for reflux, five laparoscopic hemy-nephro-ureterectomy. Orthotopic ureteroceceles had better outcome. Secondary surgery was necessary in 13 patients (50.0%) of control group (p < 0.05). Conclusions: Early endoscopic decompression should be considered first line treatment of obstructing ureterocele in infants and children. Multiple punctures at the basis of the ureterocele, performed by low laser energy, is resulted a really minimally invasive treatment, providing immediate decompression of the upper urinary tract, and reducing the risk of further aggressive surgery.

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.

Guidelines of the Italian Society of Videosurgery in Infancy for the minimally invasive treatment of pediatric nephrectomy and partial nephrectomy

Not available.

Guidelines of the Italian Society of Videosurgery in Infancy for the minimally invasive treatment of the ureteropelvic-junction obstruction

Not available.

Guidelines of the Italian Society of Videosurgery in Infancy for the minimally invasive treatment of the esophageal atresia

Not available.

Minimally Invasive Treatment of Pediatric Extrinsic Ureteropelvic Junction Obstruction by Crossing Polar Vessels: Is Vascular Hitching a Definitive Solution? Report of a Multicenter Survey

BACKGROUND

This article aimed to evaluate the outcome of laparoscopic vascular hitch (VH) as an effective alternative to dismembered pyeloplasty in the treatment of children with extrinsic ureteropelvic junction obstruction (UPJO) by crossing vessels (CVs), by reporting the experience of three Italian centers of Pediatric Surgery.

METHODS

From 2006 to 2014, 54 children (18 girls and 36 boys, average age 10.7 years) affected by suspected extrinsic UPJO by CV were treated in three different institutions: 51 patients underwent laparoscopic VH, while 3 patients, in which a coexisting intrinsic etiology of UPJO was doubtful, underwent laparoscopic dismembered pyeloplasty. Preoperative diagnostic workup included: ultrasound (US)/Doppler scan, mercaptoacetyltriglycine (MAG3)-renal scan, and functional-magnetic-resonance-urography (fMRU). Symptoms at presentation were recurrent abdominal/flank pain and hematuria. All patients presented intermittent hydronephrosis (range 18-100 mm) on US and an obstructive pattern on MAG3 renogram.

RESULTS

Average operative time was 108 minutes, and average hospital stay was 1.8 days. As for complications, we reported a small abdominal wall hematoma and a high UPJ distortion without obstruction in 2 patients, not requiring reintervention (grade I Clavien-Dindo). At follow-up (range 12-96 months), all patients reported resolution of symptoms, decrease in the hydronephrosis grade, and improved drainage on MAG3 renogram.

CONCLUSIONS

Our results demonstrated the safety and efficacy of laparoscopic VH for treatment of extrinsic UPJO by CV, registering excellent outcomes in a very selected patient population. The careful selection of patients through intraoperative assessment of anatomical and functional aspects is a crucial step to confirm indications for VH and maintain a high success rate with the procedure. We believe that any concerns regarding the coexistence of intrinsic stenosis should certainly lead to opening the collecting system and to performing a classic dismembered pyeloplasty.

Long-Term Follow-Up of Testicular Microlithiasis in Children and Adolescents: Multicenter Prospective Cohort Study of the Italian Society of Pediatric Urology

Introduction Testicular microlithiasis (TM), characterized by the presence of intratubular calcifications in a single or both the gonads, is an uncommon entity with unknown etiology and outcome in pediatric and adolescent age. In this study, the results of a multicenter long-term survey are presented. Materials and Methods From 11 units of pediatric urology/surgery, patients with TM were identified and yearly, followed up in a 7-year period, adopting a specific database. The recorded items were: age at diagnosis, presenting symptoms/associated abnormalities, ultrasonographic finding, surgery and histology at biopsy, if performed. Results Out of 85 patients, 81 were evaluated yearly (4 patients lost to follow-up). TM was bilateral in 66.6% of the patients. Associate genital abnormalities were present in 90%, more frequently undescended/retractile testis (23.4%) and varicocele (22.2%). TM remained unchanged at 4.7 years follow-up in 77 patients (93.8%) and was reduced in 4 patients after 1 to 5 years of inguinoscrotal surgery. Orchiectomy was performed in three patients (3.7%), one for severe testicular hypoplasia and two for seminoma (2.5%), respectively, concurrent and metachronous to diagnosis of TM. Tumorectomy with parenchymal sparing surgery was performed in a teratoma associated with TM. Conclusion TM is a controversial entity, often associated with several inguinogenital features, which rarely can recover. Testicular malignancy, although present in TM, has not proven definitively associated to microliths. Proper counseling, yearly ultrasound, and self-examination are long-term recommended.

Laparoscopic transposition of lower pole crossing vessels (vascular hitch) in children with pelviureteric junction obstruction

BACKGROUND

Congenital hydronephrosis due to intrinsic or extrinsic uretero-pelvic-junction (UPJ) obstruction (UPJO) is a common problem in childhood UPJO may be caused by intrinsic disorganization or by extrinsic compression from crossing vessels (CV); extrinsic causes usually present symptomatically in older children. This report the large Italian experience in the treatment of children with extrinsic-UPJO by CV.

METHODS

We analyzed the data of 51 children (17 girls and 34 boys, median age 10, 7 years) affected by extrinsic-UPJO were treated in three Italian institutions with laparoscopic transposition of CV (Hellström Vascular Hitch modified by Chapman).The intraoperative diuretic-test was performed in all patients before and after the vessels transpositions confirming the extrinsic-UPJO. We included in the study only patients with suspicion of vascular extrinsic obstruction of the UPJ. Symptoms at presentation were recurrent abdominal/flank pain and haematuria. All patients presented intermittent ultrasound (US) detection of hydronephrosis (range, 18-100 mm). Preoperative diagnostic studies included: US/doppler scan, MAG3-renogram, functional-magnetic-resonance-urography (fMRU).

RESULTS

Median operative time was 108 minutes; median hospital stay: 3, 4 days. Unique complications: a small abdominal wall hematoma and higher junction-translocation without obstruction. During follow-up (range, 12-96 months) all patients reported resolution of their symptoms, a decrease in the hydronephrosis grade and improved drainage on diuretic renogram.

CONCLUSIONS

We believe that Vascular Hitch is less technically demanding than laparoscopic pyeloplasty, resulting in a lower complication rate and a significantly reduced hospitalization. The results of our study allow us to conclude that laparoscopic VH may be a safe, feasible, and attractive alternative to treat obstructed hydronephrosis due to CV presenting a useful alternative to AHDP in the management of symptomatic children where CV are deemed the sole aetiology. We recommend careful patient selection based on preoperative clinical and radiologic findings that are diagnostic of extrinsic-UPJO, combined with intraoperative-DT to confirm the appropriate selection of corrective procedure.

Percutaneous endoscopic treatment for urinary stones in pediatric patients: where we are now

BACKGROUND

Percutaneous nephrolithotomy (PCNL) has been adopted for pyelo-calyceal stones treatment in pediatric patients, starting from the 90's. Very recently, miniaturization of endoscopic instruments allowed less invasive procedures with low complication rate. We reviewed our experience on upper tract stone treatment utilizing two different percutaneous accesses, focusing on the recent new miniaturized devices offered for pediatric renal stones.

METHODS

Patients presenting upper tract urinary stones observed from January 2011 to December 2015 and treated by percutaneous renal access were prospectively evaluated: age, sex, metabolic issues, associated abnormalities, treatment modalities, hospital stay and complication rate were recorded in a specific database. Two different endourological percutaneous modalities were adopted, depending to the stone size and position. PCNL was performed through a direct calyceal puncture under ultrasonographic and fluoroscopic guidance and Amplatz access dilatation till 24 Fr. Ballistic energy was used for fragmentation. Micropercutaneous (Microperc) procedure was recently offered utilizing a 4.85 Fr metallic needle and Holmium:YAG laser lithotripsy under direct vision through a 0.9 mm high resolution optic flexible wire connected with a telescope.

RESULTS

Thirty-eight percutaneous access to pyelo-calyceal renal stones were performed on a total of 108 children treated for upper tract stones, aged 4 to 18 years (mean age 7.5 years). The overall number of procedures was 144 (36 repeated procedures). Cystinuria was diagnosed in 5 patients. PCNL was adopted in 28 patients, Microperc was utilized in 8 patients. Hemoglobin dropdown was limited to 1.20±0.80 mg% in PCNL and was not significant in Microperc. No blood transfusion was needed. No significant complications were observed. Stone free rate or minimal not significant residuals were achieved in 82% of PCNL and in 87.5% of Microperc, after a single procedure.

CONCLUSIONS

Percutaneous endoscopic treatment of renal calculi is feasible in pediatric age, with high success rate in a single step. Advanced miniaturized endoscopic devices as Microperc guarantee high efficacy and reduced complication rate, but endo-urological experience and adequate learning curve are required, especially in small body weight children. Centralization of these patients in Pediatric Stone Centers is welcomed to optimize results and reduce risks.

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

Due to a technical error, Dr. Manuel Ferraro was omitted from the author list of this article. The correct author details appear above.

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.

Hypothesis on etiopathogenesis, congenital or acquired, of an imperforate distal ureter: a case report

INTRODUCTION

Ureteral atresia is a rare disease usually associated with a non-functioning kidney. Its association with other urinary anomalies is rare.

CASE PRESENTATION

In this study we discuss the possibility of congenital or acquired etiology of a right imperforate distal ureter. Here we report the case of 11-month-old white boy with a right ureteropelvic junction obstruction. He underwent a right pyeloplasty when he was 11-months old, and 3 weeks after surgery a cystoscopy was performed. Two months after the first operation, he underwent a right ureteral meatoplasty and a new pyeloplasty.

CONCLUSIONS

To the best of our knowledge, few cases of imperforate distal ureter have been described in the literature. The suspicion of a non-patent terminal ureter, occurring during upper urinary tract surgery, must be intraoperatively clarified to preserve the renal function and to avoid more complex surgical approaches.

Retroperitoneoscopic Heminephrectomy in Duplex Kidney in Infants and Children: Results of a Multicentric Survey

PURPOSE

Retroperitoneoscopic partial nephrectomy (RPN) in children is considered a complex technique with limited diffusion among pediatric surgeons and urologists. We aimed to report the outcome of this technique in infants and children with duplex kidney in a 5-year retrospective multicentric international survey.

MATERIALS AND METHODS

Data on 50 children who underwent RPN (41 upper-pole nephrectomies and 9 lower-pole nephrectomies) were retrospectively collected in this six-institution survey. Median age at surgery was 3.3 years. There were 35 girls and 15 boys. The left side was affected in 28 patients, versus the right side in 22 patients. We assessed intraoperative and postoperative morbidity. Follow-up (median, 2.5 years; range, 12 months-5 years) was based on clinical controls and echo color Doppler renal ultrasound scans.

RESULTS

Median duration of surgery was 255 minutes. Surgery was always performed with the patient in a lateral position. Special hemostatic devices were used for dissection and parenchymal section in all centers. Three patients from two centers (6%) required conversion to open surgery. We recorded seven complications (six peritoneal perforations, one opening of the remaining calyxes) in the 50 cases. Re-operation rate was 0%. Average length of hospital stay was 4.1 days.

CONCLUSIONS

Our survey shows that RPN remains a challenging procedure with a long learning curve, performed only in pediatric centers with huge experience in this field. In our survey operative time was longer than 4 hours. The complication rate remains high (7/50, or 14%), with complications classified as Grade II according to the Clavien-Dindo classification. They did not require further surgery, but they were associated with a prolonged hospital stay.

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.

Bladder urothelial neoplasms in pediatric age: experience at three tertiary centers

INTRODUCTION

Urothelial bladder neoplasms (UBN) typically occur in patients in their sixth or seventh decade of life while they are infrequent in children and young adults. They occur in 0.1-0.4% of the population in the first two decades of life. Their management is controversial and paediatric guidelines are currently unavailable.

OBJECTIVE

To further expound the available data on the outcome of patients younger than 18 year old diagnosed with UBN.

STUDY DESIGN

We retrospectively reviewed the files of all the consecutive paediatric patients with UBN treated in three tertiary paediatric urology units from January 1999 to July 2013. Lesions were classified according to the 2004 WHO/ISUP criteria as urothelial papillomas (UP), papillary urothelial neoplasm of low malignant potential (PUNLMP), low-grade urothelial carcinoma (LGUC), and high-grade urothelial carcinoma (HGUC).

RESULTS

The table shows the results. Management after TURB varied among centres. One centre recommended only follow-up US at increasing intervals whereas another follow-up US plus urine cytologies and endoscopies, every three months in the first year, and at increasing intervals thereafter. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed disease recurrence or progression.

DISCUSSION

UBN is an uncommon condition in children and adolescents and, unlike in adults, its incidence, follow-up and outcome still controversial. Paediatric guidelines are currently lacking and management varies among centres. Gross painless haematuria is the most common presenting symptom. Therefore, this symptom should never be underestimated. US is generally the first investigation and additional imaging seems unnecessary. TURB often allows for complete resection. Lesions are generally solitary, non-muscle invasive, and low-grade (mainly UP and PUNLMP). Ideal follow-up protocol is the most controversial point. Reportedly, recurrence or progression during follow-up is uncommon in patients under 20 years, recurrence rate 7% and a single case of progression reported so far. Accordingly, a follow-up mainly based on serial US might be considered in this age group compared to adults where also serial endoscopies and urine cytologies are recommended. In the selection of the follow-up investigations, it should also be taken into consideration that urine cytology has a low sensibility in the detection of low-grade lesions while cystoscopy in young patients requires a general anaesthesia and hospitalization, and carries an increased risk of urethral manipulation.

CONCLUSION

UBN is a rare condition in children. Ultrasound is generally accurate in order to visualize the lesion, and TURB can treat the condition. Lesions are generally low-grade and non-muscle invasive, but high-grade lesions can also be detected. In present series, after TURB, follow-up US monitoring at increasing intervals was used at all centres, follow-up cystoscopies were added in two centres, but with different schedules. Urine cytologies were considered only at one centre. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed recurrence or progression of the disease.

Microperc for pediatric nephrolithiasis: technique in valdivia-modified position

INTRODUCTION

Micropercutaneous nephrolithotomy (microperc) has been recently proposed in adult patients. We present our initial experience in children using a modified technical approach.

METHODS

After the retrograde positioning of a 5F catheter, a 4.85F metallic needle (1.9 mm) was used for direct percutaneous calyceal access under ultrasonographic and fluoroscopic guidance with the patient in supine Valdivia-modified position. Once a three-way connector was inserted to the needle, stone fragmentation was performed under direct vision using a 200 μm holmium:YAG laser fiber and a 0.9-mm high-resolution (10,000 pixels) optic flexible wire connected with the telescope, with intermittent saline infusion. The transureteral catheter was removed within 18 to 24 hours.

RESULTS

A total of five patients aged 18 months to 11 years (mean, 5.8 years) received microperc lithotripsy in a 6-month period. The mean stone size was 15.0 mm (± 2.5 mm). Conversion to retrograde intrarenal surgery was necessary in one case, due to stone migration and poor visibility. Moderate hydronephrosis was present in one kidney. The mean operative time was 56 minutes (± 23 minutes). The blood loss was insignificant (< 0.6 Hbg/dL) and postoperative discomfort was minimal. The mean hospital stay was 2.4 ± 0.6 days for four patients after the removal of ureteral catheter. The JJ stent was removed after 15 days in the last patient. The overall stone-free rate at 1 month was 100% and no ancillary procedures were required. Conclusions Microperc is a new cost-effective and time-saving technique that we demonstrated as safe and effective in minimally invasive procedure for lower pole and pelvic renal stones of small size. Indications and limits should be defined by multicenter randomized studies, comparing the former procedures.

Gait analysis in bladder exstrophy patients with and without pelvic osteotomy: a controlled experimental study

BACKGROUND

The role of bony pelvic anomalies in bladder exstrophy is long established and has generated many papers addressing walking problems. Biomechanical studies and kinematic gait analysis were performed on very young children.

AIM

A direct kinetic gait evaluation has never been performed, nor has the effect of pelvis dimorphism on the upper body been studied.

DESIGN

Controlled experimental study.

SETTING

Outpatients were studied at the time of periodic follow up.

POPULATION

Nineteen patients with bladder exstrophy, age 14±8 years, and twenty-five healthy control participants, age 15±8 years, were enrolled in the present gait analysis study.

METHODS

Clinical evaluation and standard gait analysis were performed.

RESULTS

Gait analysis deviations between exstrophy patients and controls and between patients that received pelvic osteotomy (OT--6 patients) and those that did not (no-OT--13 patients) were analyzed. Bladder exstrophy significantly affects kinematics and kinetics of trunk, spine, pelvis, knee and foot; in particular: in OT, trunk retroversion, pelvic retroversion and rotation, hip adduction angle and moment, knee flexion and its maximum power during loading response increased, whereas in no-OT, spine angle, pelvic posterior tilt, hip extension, and the external rotation of the foot progression angle increased. All the kinetics parameters analyzed in the study showed lower values in the patient group than in controls.

CONCLUSION

. Walking in patients with bladder exstrophy is accomplished by retroversion of the pelvis and deviations mainly in the spine angle in no-OT and in knee flexion in OT.

CLINICAL REHABILITATION IMPACT

Gait analysis was shown to be an effective tool for the detection of walking deviations that should be identified early, prompting rehabilitative treatment in order to prevent spine and knee diseases.

Conservative management of paediatric renal abscess

OBJECTIVE

Renal abscesses in the paediatric patient population are a rare entity. Patients are usually treated with percutaneous surgical drainage of the renal abscess as conservative treatment with broad-spectrum antibiotics is not considered as effective. We describe the conservative management of renal abscesses without percutaneous drainage in 6 children.

MATERIALS AND METHODS

Six patients with a median age of 31 months, admitted over a 6 year period at two medical centers, were retrospectively studied. All patients were treated conservatively.

RESULTS

In all patients, the abscesses were solitary, unilateral and located in the right kidney. The median abscess diameter was 38 mm. The diagnosis was made by ultrasonography. All 6 children were treated conservatively with a urinary catheter or suprapubic catheter and broad-spectrum antibiotics. None of the renal abscesses were surgically or percutaneously drained.

CONCLUSIONS

A series of 6 paediatric renal abscesses, all successfully treated without surgical intervention, is presented. We believe that, in carefully selected cases, renal abscesses can be managed without percutaneous drainage. Furthermore, all children had complete resolution of the abscess.

Diffuse ganglioneuromatosis and plexiform neurofibroma of the urinary bladder: an uncommon cause of severe urological disease in an infant

Neurofibromatosis of the urinary tract occurs infrequently: fewer than 70 cases with bladder involvement have been reported to date and of these, only 25 cases occurred in the pediatric population. We describe an unusual case of plexiform neurofibroma and diffuse ganglioneuromatosis of the bladder in a small infant, diagnosed with neurofibromatosis 1 (NF1) at 3 months of age. At the moment, there are no established criteria for the treatment of this rare lesion. Due to the high morbidity, although not very common, bladder involvement should be considered in infants with NF1.

Treatment of pediatric renal stones in a Western country: a changing pattern

BACKGROUND

Over the last 10years the miniaturization of endoscopic instruments made minimally invasive procedures for kidney stones feasible even in children. The evolution in management of kidney stones in a tertiary care center in Europe is reported.

METHODS

Patients treated in our hospital for kidney stones from 2002 to 2011 were reviewed and group A (2002 to 2006) was compared with group B (2007 to 2011). The therapeutic options offered were Extracorporeal Shock Waves Lithotripsy (ESWL), Retrograde Intrarenal Surgery (RIRS), Percutaneous Lithotripsy (PCNL) and open surgery. Outcome measures were: first treatment chosen, stone free rate after a single procedure, and retreatment. Results were compared by chi-square test, with p <0.05 considered statistically significant.

RESULTS

333 patients, mean age 9.7years, were treated, 161 in group A and 172 in group B. ESWL was the first option in both groups, but decreased by 34% in group B vs A. In contrast, RIRS and PCNL increased by 17% and 16%, respectively, in group B vs group A. Open surgery was never required in primary lithiasis cases without associated malformations.

CONCLUSION

The advent of PCNL and RIRS has significantly changed the pattern of renal stone treatment in the pediatric age group. A progressive increase of endourologic minimally invasive procedures was recorded. Open surgery should be a very rare option.

Selective arterial embolization of giant renal tuberous sclerosis

Different minimally invasive methods have been proposed to treat renal manifestation of tuberous sclerosis complex (TSC), in order to preserve kidney parenchyma and avoid nephrectomy. The case of a boy with bleeding giant angiomyolipoma treated by selective arterial embolization is discussed. The extensive renal lesions resulted significantly decreased, with resolution of arterial hypertension and abdominal symptoms. Differential renal function increased from 26.6% to 32.6%. Renal involvement in TSC requires careful parenchymal-sparing procedures. Selective embolization of the main renal lesions should be considered as first line therapy.

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.

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.

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.