Combined Minimally Invasive Treatment of Pyeloureteral Junction Obstruction and Primary Obstructive Megaureter in Children: Case Report and Literature Review

INTRODUCTION

In children, the association of ipsilateral pyeloureteral junction obstruction (PUJO) and ureterovesical junction obstruction (UVJO) is a rare malformation with a non-standardized treatment. We report a case of PUJO and UVJO treated by a combined minimally invasive surgical treatment to resolve the double urinary obstruction. The current literature was also reviewed.

CASE REPORT AND REVIEW

A two-month-old boy, without antenatal and postnatal signs of urinary tract anomalies, was hospitalized presenting right hydronephrosis, perirenal fluid effusion, and ascites. An acute pelvic rupture was suspected, and a retrograde pyelogram was performed, showing a primary obstructive megaureter (POM) associated with a corkscrew pyeloureteral junction. The impossibility to place a double J catheter through the pyeloureteral junction led us to achieve percutaneous nephrostomy and an abdominal drain placement. Three months later, the patient underwent a combined high-pressure balloon ureterovesical junction dilation and retroperitoneoscopic Anderson Hynes one-trocar-assisted pyeloplasty (OTAP). The literature search identified 110 children experiencing double urinary tract obstruction. All authors agreed on the difficulty to diagnose both obstructions preoperatively, but there is still no consensus on which obstruction should be relieved earlier, because the alteration in urinary vascularity during a double surgery could damage the ureter.

CONCLUSIONS

The simultaneous occurrence of UPJO and UVJO is rare, with a challenging diagnosis. Prompt identification and timely surgical intervention are crucial to mitigate the risk of renal function loss attributable to obstruction and infection. Drawing from our expertise and the analysis of the existing literature, we propose employing a simultaneous double minimally invasive strategy in order to optimize the preservation of ureteral vascularity. This approach entails performing a minimally invasive pyeloplasty for the PUJ and utilizing high-pressure balloon dilatation for the UVJ.

Transumbilical laparoscopic-assisted appendectomy <em>versus</em> laparoscopic appendectomy in children: a single center experience

Laparoscopic Appendectomy (LPSA) is the first choice for appendectomy in pediatric surgery. Trans-Umbilical Laparoscopic Assisted Appendicectomy (TULAA) is another used technique. We compared both these procedures used for the treatment of acute appendicitis. The study was conducted between January 2019 to December 2020. Patients were divided into two groups: LPSA and TULAA groups. The collected data were: operative time, number of conversions, time of canalization and hospital stay. A total of 181 patients were included: 73 were kept in the LPSA and 108 in the TULAA group. Mean operative time was 70.9 minutes (range 45-130 min) for LPS and 56.4 (30-145 min) for TULAA group (p <0.0001). Complications rate showed no statistically significant difference between both the two groups. However, conversions showed a statistically significant difference (p=0.04). Both techniques showed similar results. TULAA technique takes a significantly shorter operating time. The selection between LPSA and TULAA techniques depends on the experience of the surgeon's work and the personal laparoscopic learning curve. In our experience LPSA was a useful technique to improve the laparoscopic skill of the pediatric surgery residents.

Robotic Surgery: Is There a Possibility of Increasing Its Application in Pediatric Settings? A Single-Center Experience

Introduction: Robotic surgery has shown explicit benefits and advantages in adults, but it is not yet strongly established in the pediatric population, even though its popularity is increasing, especially in the urologic field. Materials and methods: In this article we present our experience with the Da Vinci System (SI first and XI nowadays) at our pediatric institution in order to analyze our progress over the years. We considered all patients from the start of the robotic surgery program in 2016 until the end of 2021, dividing them into general abdominal surgery and genitourinary surgery. Analyzed data were the patient’s demographic, details of surgery, and intra and post-operative complications. Results: The total number of patients (pts) included in this study was 76, of whom 40 (52%) were male and 36 (48%) were female. The mean age at surgery was 90.9 months (range 10–207 months), and the mean weight at surgery was 29.3 kg (range 9.5–68 kg). There were 18 general abdominal robotic surgeries and 58 genitourinary robotic surgeries performed. The most performed surgeries in these two categories were fundoplication for gastro-oesophageal reflux disease (11%) and Anderson–Hynes pyeloureteroplasty. The mean operative time was 224.2 min (range 72–530 min): the mean times in the two groups (general abdominal surgery and genitourinary surgery) were 165 min (range 84–204 min) and 194 min (range 95–360 min), respectively. A total of four (5%) minor complications were reported. The total conversions were two (2.6%) and the mortality rate was 0%. Conclusions: Pediatric robotic surgery is a field of considerable interest and it is rapidly expanding. In our experience, it is evident how the learning curve has increased gradually, but steadily, allowing us to advance from standardized surgery, such as fundoplication and pieloplasty, towards a more technically complex one, achieving the same good results. We believe that robotic surgery is very respectful of tissues and feasible, especially for reconstructive surgery. For these reasons, it could become of common use also in the pediatric population, overcoming impediments such as excessive cost and the lack of pediatric instruments, in order to be able to treat children with a progressively lower age and weight.

Dog bite injuries in a tertiary care children's hospital: A seven-year review

BACKGROUND

Dog bites are a major cause of traumatic injury in children. The aim of this study was to determine the experience, management, and outcome of dog bite injuries in our department.

METHODS

We retrospectively reviewed the clinical records for 127 patients (mean age 7.15 ± 4.24 years, range 1 to 17 years; 68 males) affected by dog-related injuries, from 2012 to 2018. Characteristics of patients and dogs, type and severity of injuries, circumstances of the accidents, treatment and outcome were analyzed.

RESULTS

Of 141 wounds, 73 (51.8%) affected the head and neck, 62 (44%) the limbs, and six (4.2%) affected the trunk. According to the Mcheik classification, 107 lesions (75.9%) were stage 1, 26 (18.4%) stage 2, and eight (5.7%) stage 3. Seventy-eight percent of the cases involved known dogs. The breed of the dog was recorded in 62/127 cases (48.8%) and the most common were mongrels (23/62, 37.1%). Seventy-five percent of the attacks occurred during spring and summer. All patients underwent antibiotic prophylaxis and immediate surgical repair. Wound infection was observed in two patients. Three unsightly scars required rectification, with good cosmetic results in all cases.

CONCLUSIONS

Our results are consistent with previous data showing that the typical dog-related injury occurs from a known dog, during spring and summer, and in younger boys, who are frequently exposed to head and neck wounds. Our experience showed the feasibility and safety of primary repair and antibiotic prophylaxis in all patients, with very low incidence of infection and good cosmetic results.

Clinical and radiological findings for early diagnosis of Herlyn-Werner-Wunderlich syndrome in pediatric age: experience of a single center

OBJECTIVE

The authors present their experience in the management of pediatric patients with Herlyn-Werner-Wunderlich syndrome (HWWS) considering clinical classification and anatomical characteristics of the malformation.

METHODS

All the data of the patient presented at our Pediatric Surgery Unit from February 2010 to August 2015 were collected. According to the type of malformations, patients were divided in 3 groups: A (completely obstructed hemivagina), B (incompletely obstructed hemivagina), and C (communication between the duplicated cervices).

RESULTS

Six patients were treated in the study period. The mean age was 9 years (2 months-15 years). According to the characteristics of the HWWS, we had 5 patients in group A, 1 in group B, and none in group C. One-stage surgical treatment was performed in all cases of complete obstruction, but in one case a second look was necessary for a better resection of the septum. At a mean follow-up of 18 months all patients were symptoms free.

CONCLUSIONS

Prognosis of this malformation is good in case of early diagnosis and treatment. We suggest that when a renal agenesia is diagnosed, the patient needs an ultrasonographic follow-up of the contralateral kidney but also of the genital tract to find each minimal abnormalities, furthermore, a MRI scanning before the onset of menstruation can be necessary.

Genetics of Vesicoureteral Reflux

Vesicoureteral reflux (VUR) is the retrograde passage of urine from the bladder to the upper urinary tract. It is the most common congenital urological anomaly affecting 1-2% of children and 30-40% of patients with urinary tract infections. VUR is a major risk factor for pyelonephritic scarring and chronic renal failure in children. It is the result of a shortened intravesical ureter with an enlarged or malpositioned ureteric orifice. An ectopic embryonal ureteric budding development is implicated in the pathogenesis of VUR, which is a complex genetic developmental disorder. Many genes are involved in the ureteric budding formation and subsequently in the urinary tract and kidney development. Previous studies demonstrate an heterogeneous genetic pattern of VUR. In fact no single major locus or gene for primary VUR has been identified. It is likely that different forms of VUR with different genetic determinantes are present. Moreover genetic studies of syndromes with associated VUR have revealed several possible candidate genes involved in the pathogenesis of VUR and related urinary tract malformations. Mutations in genes essential for urinary tract morphogenesis are linked to numerous congenital syndromes, and in most of those VUR is a feature. The Authors provide an overview of the developmental processes leading to the VUR. The different genes and signaling pathways controlling the embryonal urinary tract development are analyzed. A better understanding of VUR genetic bases could improve the management of this condition in children.

Peritoneal morphological changes due to pneumoperitoneum: the effect of intra-abdominal pressure

INTRODUCTION

Carbon dioxide (CO2) used in laparoscopy evokes local and systemic effects. This study was designed to evaluate the histopathologic morphologic changes due to CO2 and air insufflation, at different pressure levels, on visceral and parietal peritoneum in rats.

MATERIALS AND METHODS

A total of 56 rats were object of the study, randomly divided into five groups. Pneumoperitoneum (PN) was maintained for 30 minutes, at a flow rate of 0.5 L/min and at a pressure of 10 and 6 mm Hg with CO2 (group S1-S2, n = 32) and filtered air (group A1-A2, n = 16). Only anesthesia was performed in the fifth group (group C, n = 8). Peritoneal samples were obtained 24 hours later for blinded histological evaluation. A grading system was adopted to evaluate histological peritoneal changes (0, no change; 1, mild; 2, moderate; and 3, severe) such as mesothelial aspect, inflammatory response, edema, and hemorrhage. The score reflected the severity of damage and was calculated by the sum of the degree evaluated separately. Values were compared with the analysis of variance analysis.

RESULTS

CO2 and air insufflation caused reactive mesothelial cells and peritoneal inflammation of different degrees depending on the level of intra-abdominal pressure (IAP) and type of gas. These modifications were absent in group C and were less evident in low pressure S2 group with respect to S1 and A1-A2 groups. The average values of histopathologic peritoneal score showed significant differences between S2 (11.5) versus S1 groups (16.83) with respect to A groups (A1 = 27.83; A2 = 20.5) and compared with the controls (C = 2.5).

CONCLUSIONS

Our data confirm that PN affects the peritoneal integrity. The grades of morphological peritoneal changes are related to the level of IAP. Low CO2 pressure causes minor peritoneal changes with respect to high pressure and air insufflation.

Laparoscopic approach to Meckel's diverticulum

AIM: To retrospective review the laparoscopic management of Meckel Diverticulum (MD) in two Italian Pediatric Surgery Centers.

METHODS: Between January 2002 and December 2012, 19 trans-umbilical laparoscopic-assisted (TULA) procedures were performed for suspected MD. The children were hospitalized for gastrointestinal bleeding and/or recurrent abdominal pain. Median age at diagnosis was 5.4 years (range 6 mo-15 years). The study included 15 boys and 4 girls. All patients underwent clinical examination, routine laboratory tests, abdominal ultrasound and technetium-99m pertechnetate scan, and patients with bleeding underwent gastrointestinal endoscopy. The abdominal exploration was performed with a 10 mm operative laparoscope. Pneumoperitoneum was established based on the body weight. Systematic overview of the peritoneal cavity allowed the ileum to be grasped with an atraumatic instrument. The complete exploration and surgical treatment of MD were performed extracorporeally, after intestinal exteriorization through the umbilicus. All patients’ demographics, main clinical features, diagnostic investigations, operative time, histopathology reports, conversion rate, hospital stay and complications were registered and analyzed.

RESULTS: MD was identified in 17 patients, while 1 had an ileal duplication and 1 a jejunal hemangioma. Fifteen patients had painless intestinal bleeding, while 4 had recurrent abdominal pain and exhibited cyst like structures in an ultrasound study. Eleven patients had a positive technetium-99m pertechnetate scan. In the patients with bleeding, gastrointestinal endoscopy did not name the source of hemorrhage. All patients were subjected to a TULA surgical procedure. An intestinal resection/anastomosis was performed in 14 patients, while 4 had a wedge resection of the diverticulum and 1 underwent stapling diverticulectomy. All surgical procedures were performed without conversion to open laparotomy. Mean operative time was 75 min (range 40-115 min). No major surgical complications were recorded. The median hospital stay was 5-7 d (range 4-13 d). All patients are asymptomatic at a median follow up of 4, 5 years (range 10 mo-10 years).

CONCLUSION: Trans-umbilical laparoscopic-assisted Meckel’s diverticulectomy is safe and effective in the treatment of MD, with excellent results.

Spermatogenesis and cryptorchidism

Cryptorchidism represents the most common endocrine disease in boys, with infertility more frequently observed in bilateral forms. It is also known that undescended testes, if untreated, lead to an increased risk of testicular tumors, usually seminomas, arising from mutant germ cells. In normal testes, germ cell development is an active process starting in the first months of life when the neonatal gonocytes transform into adult dark (AD) spermatogonia. These cells are now thought to be the stem cells useful to support spermatogenesis. Several researches suggest that AD spermatogonia form between 3 and 9 months of age. Not all the neonatal gonocytes transform into AD spermatogonia; indeed, the residual gonocytes undergo involution by apoptosis. In the undescended testes, these transformations are inhibited leading to a deficient pool of stem cells for post pubertal spermatogenesis. Early surgical intervention in infancy may allow the normal development of stem cells for spermatogenesis. Moreover, it is very interesting to note that intra-tubular carcinoma in situ in the second and third decades have enzymatic markers similar to neonatal gonocytes suggesting that these cells fail transformation into AD spermatogonia and likely generate testicular cancer (TC) in cryptorchid men. Orchidopexy between 6 and 12 months of age is recommended to maximize the future fertility potential and decrease the TC risk in adulthood.

[Epidemiology and treatment of cryptorchidism and retractile testis: retrospective study in the area of Naples]

AIM

The authors report the results of a retrospective study carried out with family pediatricians (PDF) in the area of Naples to verify the epidemiology of cryptorchidism and retractile testis, the therapeutic strategy adopted and to assess whether they were in agreement with the data of the scientific literature.

METHODS

The study enrolled 6880 children, aged between 0-14 years, till March 2007; among those were recruited the patients with a diagnosis of cryptorchid and/or retractile testis. A patient schedule was completed with the affected side or bilaterality, age at diagnosis, type of treatment and the number of ascent retractile testis.

RESULTS

A purely descriptive analysis of the data was carried out: 81 patients were diagnosed with cryptorchid patients (1.18%) and 116 with retractile testis (1.68%). In 11 cases an ascent testicle was detected (9.48%). Forty-nine of the 81 cryptorchid patients (60.49%) were diagnosed in the age group of 0-2 years, 25 (30.86%) between 2-4 years and 7 (8.64 %) between 4-8 years. The hormonal therapy associated with surgery was mainly adopted in cryptorchid patients (35 patients).

CONCLUSION

The incidence of cryptorchidism in the area of Naples (1.18%) has not changed significantly. Only 60.49% of patients have been treated in an appropriate age group (0-2 years). The survey confirms the need to follow up the retractile testes for the possibility of definitive ascent in the inguinal canal. The study highlights the need for early diagnosis and treatment of this disease.

An unusual case of intra-abdominal testicular torsion: role of laparoscopy

The authors report a case of intra-abdominal testicular torsion, where laparoscopy has been useful for diagnosis and surgical management. A boy was presented with a left impalpable testis. Laparoscopy revealed a twisted spermatic cord at the inlet pelvis, which ended in a testicular remnant located in the sub-umbilical area. After orchiectomy, the pathologist confirmed testicular atrophy. Diagnosis of intra-abdominal testicular torsion should be considered in patients with impalpable testis and abdominal pain, but could not be excluded in those with no symptoms.

"Spaghetti maneuver": a useful tool in pediatric laparoscopy - our experience

AIMS

The laparoscopic "Spaghetti Maneuver" consists in holding an organ by its extremity with a grasper and rolling it up around the tool to keep the organ stable and facilitate its traction within a small space. We describe our experience with the "Spaghetti Maneuver" in some minimally invasive procedures.

MATERIALS AND METHODS

We successfully adopted this technique in 13 patients (5F : 8M) aged between 6 and 14 years (average age, 10) on whom we performed 7 appendectomies, 2 ureteral reimplantation and 4 cholecystectomies. In all cases, after the first steps, the appendix, the gallbladder and the ureter were rolled around the grasper and easily isolated; hemostasis was thus induced and the organ was mobilized until removal during cholecystectomy and appendectomy, and before the reimplantation in case of ureteral reimplantation.

RESULTS

We found that this technique facilitated significantly the acts of holding, isolating and removing, when necessary, the structures involved, which remained constantly within the visual field of the operator. This allowed a very ergonomic work setting, overcoming the problem of the "blind" zone, which represents a dangerous and invisible area out of the operator's control during laparoscopy. Moreover the isolation maneuvers resulted easier and reduced operating time.

CONCLUSION

We think that this technique is easy to perform and very useful, because it facilitates the dissection of these organs, by harmonizing and stabilizing the force of traction exercised.

The value of laparoscopy in the management of non-palpable testis

OBJECT

To retrospectively review the value of laparoscopy in the management of impalpable testis.

MATERIALS AND METHODS

In 1993-2006, 182 laparoscopies for impalpable testis were performed for a total of 194 testicular units. Five laparoscopic findings were considered: testicular ectopia, intra-abdominal testis, and cord structures that are blind ending, completely absent (agenesis) or entering the internal inguinal ring.

RESULTS

In 62 cases an intra-abdominal testis was found; 18 were classified as high and managed by a laparoscopic Fowler-Stephens procedure. Cord structures entering the inguinal ring were observed in 77 patients and 45 underwent an inguinal exploration: a testis was found in 12 cases and in 33 a remnant was excised. In 35 cases, intra-abdominal blind ending vas and vessels were observed and eight showed testicular agenesis. No major surgical complications were recorded. Follow up ranged from 1 to 3 years.

CONCLUSIONS

Our study confirms the value of laparoscopy in the management of non-palpable testis, providing a definitive diagnosis by the direct view of spermatic bundle and testis. Ninety-three patients were managed by laparoscopy only, and in 44 it was essential for the subsequent surgical approach. When the internal inguinal ring is patent and/or normal spermatic vessels are present an inguinal exploration is mandatory.

Pneumovesicoscopic correction of primary vesicoureteral reflux (VUR) in children. Our experience

AIM

We report our experience with pneumovesicoscopic cross-trigonal ureteral reimplantation to correct primary vesicoureteral reflux (VUR) in children.

MATERIAL AND METHODS

14 children (10 girls, 4 boys, aged 4 to 12 years) with persistent VUR ≥ grade III (5 bilateral, 19 refluxing ureters) underwent pneumovesicoscopic Cohen's cross-trigonal reimplantation. Under cystoscopic control, a first midline 5-mm trocar was introduced for a 0°\30° telescope at the dome of the bladder, and 2 left and right 3- or 5-mm trocars were inserted through the anterolateral wall. The ureter was freed by creating a sharp plane between the detrusor muscle and the ureteral wall. If necessary, the ureter was tailored outside the bladder. Submucosal tunnel(s) were prepared with the help of scissors and graspers. The detrusor at the site of the ureter mobilization was repaired and ureteroneocystomy was performed using 4-5 interrupted absorbable sutures. A 12-Ch Foley catheter was introduced at the site of the dome port. The urethral and suprapubic catheters were removed 2-3 days after the procedure and the patients were discharged on day 3.

RESULTS

One boy developed mild suprapubic emphysema postoperatively. Mean operating time was 136 min (range 80-230 min). No patient required conversion to the open technique. Renal US, VCUG, and MAG3 radionuclide scans were obtained in all patients between 3-6 months postoperatively, and provided evidence of reflux resolution in 13 out of 14 patients.

CONCLUSION

Our experience seems to confirm that pneumovesicoscopic cross-trigonal ureteral reimplantation can be performed safely and effectively.

Effectiveness of botulinum-A toxin for the treatment of refractory overactive bladder in children

AIMS

We describe our experience with botulinum-A toxin (BTX-A) in children presenting idiopathic overactive bladder (OAB) refractory to anticholinergic drugs.

MATERIAL AND METHODS

21 patients, aged 8-12 years, were treated over a 3-year period. BTX-A was administered at a dosage of 12.5 UI /kg body weight, without exceeding 200 UI, at 20 detrusor sites. To ensure a stable solution, each 100 UI of botulinum toxin was diluted with 5 cc saline solution just prior to performing the cystoscopy.

RESULTS

No patient presented with severe systemic complications or urinary retention after injection therapy; 6 patients presented with slight hematuria for 2-3 days. The clinical results were as follows. At 6 months, 8/21 patients (38%) showed full response, 12/21 (57%) had a partial response after a 2 (nd) injection, and 1/21 (4.7%) showed no response after a 2 (nd) injection. At 12 months, 16 patients (76%) had a full response, 4 (19%) showed a partial response after a 3 (rd) injection, and 1 patient (4.7%) still had no response. At 18 months, 18 patients (85%) showed a full response, 2 patients (9.5%) had a partial response, 1 patient (4.7%) had no response. At the end of this study, 8/21 patients (38%) were symptom-free, after only one botulinum detrusor injection, 13/21 patients (61.9%) received a second botulinum injection because of recurrence of urinary incontinence 6-7 months after the initial treatment, and 4/21 patients (19%) received a third injection 12-14 months after the initial treatment, of whom 2 had a full response and 2 had a partial response. Patient no. 20 refused any further botulinum treatment after the 2 (nd) unsuccessful injection series.

CONCLUSION

Intravesical BTX-A injection appears to be safe and useful in children presenting with idiopathic overactive drug-resistant bladder.

[Syringocele in children: an unusual presentation as scrotal mass]

Syringocele is a cystic dilation of the excretory bulbourethral Cowper gland duct, and is a rather uncommon finding in pediatric age. It is frequently asymptomatic but sometimes may cause voiding symptoms and urinary tract infection (UTI). This case report describes an unusual manifestation of syringocele presenting with hydrocele. The case concerns a 2-year-old boy who was referred to our Clinic with a diagnosis of hydrocele. The patient underwent hydrocelectomy through a bilateral inguinal incision, but no clear communication with the patent peritoneal vaginal ducts could be demonstrated. The histology evidenced an epidermoid cyst. One year later the scrotal mass relapsed. Sonography, voiding cistography (VCG), computed tomography (CT) scan and magnetic resonance imaging (MRI) were performed. VCG, CT scan and MRI demonstrated the communication between the urethra and the scrotal mass. A surgical excision of the syringocele with endoscopic resection of the collar were performed. Syringocele is a rare entity in pediatrics. To this authors' knowledge there are no reports in the literature describing cases presenting with scrotal mass.

Design and validation of a practical index for trauma assessment

In the past 20 years a variety of indices have been suggested for measuring the severity of trauma, however none of them meets the requirement of being a simple and objective instrument that can be utilized efficiently by lay persons and providers of health services without previous experience in triaging. A new system has been proposed which meets this requirement and which has been validated with 197 injured persons at the emergency ward of the Valle University Hospital in Call, Colombia. The instrument showed a high level of concordance with the conventional triaging method and classifies victims into four categories: critical with recovery unlikely, critical but recoverable, moderately serious, and ambulatory. There is discussion on the reliability of this instrument and it is recommended that it be validated with victims from larger disasters. Regardless, it has the advantage of being specific and free of the subjectivity that characterizes other indices.