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Purpose: Gut microbiota has recently been recognized to be influenced by a broad range of pathologies. Alterations of gut microbiota are known as dysbiosis and have found to be related to chronic constipation, a condition which affects also pediatric patients with spina bifida (SB). Methods: In this study, gut microbiota richness and composition were investigated by 16S rRNA sequencing and bioinformatic analysis in 48 SB patients (mean age, 11.9 ± 4.8 years) with secondary neurogenic constipation and 32 healthy controls (mean age, 18.0 ± 9.6 years). The study also aimed at exploring eventual effects of laxatives and transanal irrigation (TAI) adopted by SB subjects to get relief from the symptoms of neurogenic constipation. Results: Collected data demonstrated that the microbiota richness of SB patients was significantly increased compared to healthy controls, with a higher number of dominant bacteria rather than rare species. The absence of SB condition was associated with taxa Coprococcus 2, with the species C. eutactus and Roseburia, Dialister, and the [Eubacterium] coprostanoligenes group. On the other hand, the SB patients displayed a different group of positively associated taxa, namely, Blautia, Collinsella, Intestinibacter, and Romboutsia genera, the [Clostridium] innocuum group, and Clostridium sensu stricto 1. Bifidobacterium and the [Eubacterium] hallii group were also found to be positively associated with SB gut microbiome. Conclusions: Among SB patients, the administration of laxatives and TAI did not negatively affect gut microbiota diversity and composition, even considering long-term use (up to 5 years) of TAI device.

At present, treatment of varicocele is still controversial in adolescents for at least three reasons. Firstly, the long-term outcome of treatment is not known in the absence of spermiogram support and in terms of long-term follow-up. Secondly, it is still uncertain which is the best type of operation for children/adolescents. Thirdly, the principle that if a technique is designed for adults, it can also be safely performed in adolescents cannot be applied. A recent systematic literature review and meta-analysis demonstrated that open and laparoscopic techniques appear to yield better results with a microsurgical approach compared with laparoscopy. However, laparoscopic techniques that preserve the lymphatic vessels appear to have a clear advantage by preventing postoperative hydrocele. At present, the evaluation and choice of treatment for adolescent varicocele patients are based not on objective fertility criteria (paternity) but on indirect evidence that testicular function or spermatogenesis and thus ultimately also fertility may be compromised. In the absence of sufficient data regarding the treatment of varicocele at a pediatric age, the choice of the technique appears to depend largely on the experience and preferences of the surgeon rather than on a shared option.

Imperforate hymen is a congenital anomaly in which the hymenal membrane has no opening with subsequent vaginal outlet obstruction. After maternal hormone stimulation there is an increased cervical mucous glands secretion, which gradually accumulates and expands forming a pelvic mass. Neonatal hydrometrocolpos is a dilatation of the vagina and uterus because of accumulation of secretions. A 39 + 4 weeks neonate was born by spontaneous vaginal delivery with normal antenatal scans. On day 2, she presented with irritability, poor feeding, abdominal tenderness and distention. Clinical examination revealed imperforate hymen with bulging of vaginal introitus. Subsequent abdominal ultrasound showed dilated vagina and uterus without urinary tract obstruction. The imperforate hymen was managed surgically with hymenal incision. Imperforate hymen is a rare but fearsome congenital disorder. Routine neonatal examination should include a careful inspection of the genitalia.

Constipation and fecal incontinence in pediatric patients are conditions due to either functional or organic bowel dysfunction and may represent a challenging situation both for parents, pediatricians, and pediatric surgeons. Different treatments have been proposed throughout the past decades with partial and alternant results and, among all proposed techniques, in the adult population the Transanal Irrigation (TAI) has become popular. However, little is known about its efficacy in children. Therefore, a group of Italian pediatric surgeons from different centers, all experts in bowel management, performed a literature review and discussed the best-practice for the use of TAI in the pediatric population. This article suggests some tips, such as the careful patients’ selection, a structured training with expert in pediatric colorectal diseases, and a continuous follow-up, that are considered crucial for the full success of treatment.

Men have most likely been affected by varicocele since the assumption of the upright position. In De Medicina, written during the first century AD, Celsus credits the Greeks with the first description of a varicocele, and he recorded his own acute observation: “The veins are swollen and twisted over the testicle, which becomes smaller”. Celsus himself is credited with the distinction between varicocele (dilation of surface veins) and “cirsocele” (dilation of deep veins). There has been a long history of treatment attempts and failures, some of which are remarkably strange, that have sometimes cul- minated in tragedy, as in the case of French professor Jacques-Mathieu Delpech (1772-1832). Although some questions regarding the etiopathology and treatment of varico- cele remain unanswered, a succession of more or less conservative attempts involving all medical cultures has been performed throughout history. The report by W.S. Tulloch in 1952 brought varicocele into the era of modern evidence-based medicine, and varicocele surgery finally progressed beyond the aim of merely relieving scrotal pain and swelling. From 1970 to 2000, varicocelectomies gained worldwide attention for the treatment of male infertility. Several innovative procedures to correct varicoceles began to appear in the world's literature as interventional radiology, microsurgery, laparoscopy, and robotics, while comprehensive review articles were also published on the subject of varicocelectomies. Microsurgery is nowadays used worldwide and it can be considered to be the gold standard for correcting infertility linked to varicocele.

We report our experience with a sutureless technique for laparoscopic inguinal hernia repair in children. Twenty-eight children, 12 girls and 16 boys, aged 3 months to 7 years, underwent sutureless laparoscopic inguinal hernia repair. In girls, we utilized simple cauterization of the internal inguinal ring with a single trocar technique. In boys denudation of the peritoneum was obtained utilizing a three-trocar technique. The peritoneum around the internal inguinal ring was peeled off and detached from the vas and the vessels, and then wrapped around the grasper, resulting in a large area of denudation. No perioperative complications were observed. No recurrences nor testicular damage were noted after a mean follow-up of 18 months (range 6-35 months). The mean operative time was 12 min (range 7-20 min) for girls and 19 min (range 15-30 min) for boys. A 6-year-old girl exhibited a lymphocele. The sutureless technique appears to be easy, safe, and effective, provided that the patients are carefully selected. In boys, special attention needs to be paid to preservation of the vas and the testicular vessels.

Simple renal cysts, although common in adults, are rare in children. They are usually discovered incidentally in the course of the study of other urinary tract symptoms, although they are not always asymptomatic. Renal cysts can be classified as being either simple or complex. The purpose of this review is to present our case series of simple symptomatic renal cysts treated with laparoscopy. Nineteen patients with symptomatic renal cysts (6 to 13.5 cm) were referred to our institution between January 2006 and January 2017. They comprised 12 (40.5%) females and seven (59.5%) males, aged 8 to 15, with a mean age of 12.2 years. Of these patients, nine had previously been treated unsuccessfully by ultrasound-guided aspiration/alcoholization with 95%-ethanol, between 9 and 13 months prior to the laparoscopy. Five patients had undergone one treatment and four had undergone two treatments. All of the patients were treated by laparoscopic threetrocar deroofing. The cysts were opened and the wall excised using scissors and a monopolar hook. In most cases, to better handle the edges of the cyst and obtain a better grip, a needle was used to aspirate a small amount of fluid (used for cytological examination). The wall of the cyst was excised, the cyst edges were sealed, and the perirenal fat was placed on the bottom of the cyst (wadding technique). The mean operating time was 95 minutes (range 50- 150). The postoperative course was uneventful for all of the patients. The hospital stay ranged from one to three days. All of the patients were asymptomatic following the treatment. At a mean follow-up time of 3.6 years, none of the patients had experienced a recurrence. Renal function, as assessed by a MAG3 renal scintigraphy scan, was well-preserved in all of the patients, and all of them undergo an annual ultrasound scan.

The prognosis for children with recurrent or refractory neuroblastoma remains a significant clinical challenge, and currently there are no known curative salvage regimens. In this paper we investigated the effect of imatinib with rapamycin and the chemotherapeutic agents temozolomide and irinotecan. We treated two children with recurrent neuroblastoma with this so called RIST protocol. Both patients, off therapy for 15 and 31 months, respectively are well, and developing normally, without any complications. These findings suggest that a combination regimen of RIST may provide a therapeutic benefit with a favorable toxicity profile to a unfortunate subset of patients with neuroblastoma.

Purpose We assessed short- and mid-long-term clinical efficacy of transanal irrigation (TAI) and its effect on the quality of life of children with spina bifida (SB) and anorectal malformations (ARM). Methods Seventy-four pediatric patients (age 6–17 years) with SB and ARM with neurogenic bowel dysfunction were enrolled for a prospective and multicentric study. Patients were evaluated before the beginning of TAI (T0), after 3 months (T1) and after at least 2 years (range 24–32 months) (T2) using a questionnaire assessing bowel function, the Bristol scale, and two validated questionnaires on quality of life: the CHQ-PF50 questionnaire for the parents of patients aged 6–11 years and the SF36 questionnaires for patients aged between 12 and 18 years. Results Seventy-two patients completed TAI program in T1, and 67 continued into T2. Bowel outcomes (constipation and fecal incontinence) improved in both the SB and the ARM groups in the short and mid-long term. In both groups at T1 and T2, parents and children reported an improvement in quality of life and there was a significant increase of stool form types 4 and 5 as described by the Bristol scale. Common adverse effects during the study were similar at T1 and T2 without serious complications. Conclusions We observed a sustained improvement in bowel management and quality of life in SB and ARM children during the study, more significant in the short term than in mid-long term. To maintain success rates in the mid-long term and to reduce the dropout rate, we propose patient training and careful follow-ups.

Aims OnabotulinumtoxinA (onaBNTa) for treating neurogenic detrusor overactivity (NDO) is widely used after its regulatory approval in adults. Although the administration of onaBNTa is still considered off-label in children, data have already been reported on its efficacy and safety. Nowadays, there is a lack of standardized protocols for treatment of NDO with onaBNTa in adolescent patients in their transition from the childhood to the adult age. With the aim to address this issue a consensus panel was obtained. Methods A panel of leading urologists and urogynaecologists skilled in functional urology, neuro-urology, urogynaecology, and pediatric urology participated in a consensus-forming project using a Delphi method to reach national consensus on NDO—onaBNTa treatment in adolescence transitional care. Results In total, 11 experts participated. All panelists participated in the four phases of the consensus process. Consensus was reached if ≥70% of the experts agreed on recommendations. To facilitate a common understanding among all experts, a face-to-face consensus meeting was held in Rome in march 2015 and then with a follow-up teleconference in march 2017. By the end of the Delphi process, formal consensus was achieved for 100% of the items and an algorithm was then developed. Conclusions This manuscript represents the first report on the onaBNTa in adolescents. Young adults should be treated as a distinct sub-population in policy, planning, programming, and research, as strongly sustained by national public health care. This consensus and the algorithm could support multidisciplinary communication, reduce the extent of variations in clinical practice and optimize clinical decision making.

Introduction The objective of this study was to report on the use of vesicoscopy in the treatment of symptomatic congenital bladder diverticula (CBD) in children. Material and Methods In this study, 16 males, aged 4 to 12 years (median age, 6.25 years), were treated for symptomatic CBD; 3 patients presented double diverticulum and 13 presented single diverticulum. The presenting symptoms were recurrent urinary tract infection, hematuria, lower abdominal pain, and voiding dysfunctions as urgency, frequency alone, or in association. A first midline 5-mm trocar was introduced for a 0-degree telescope at the dome of the bladder, and two left and right 3- or 5-mm trocars were inserted through the anterolateral wall. The bladder was then insufflated with carbon dioxide to 10 to 12 mm Hg pressure. The diverticula were inverted into the bladder and the mucosa around the neck was circumcised by using scissors and hook. The defect was sutured and the bladder was drained. Vesicoureteral reflux (VUR) of third grade or higher was treated endoscopically. Results Mean operative time was 90 minutes for procedures. At 6-month follow-up, ultrasound and voiding cystourethrogram (VCUG) showed the disappearance of the diverticulum in 15 out of the 16 patients. The patient, with huge double diverticulum and fourth grade right VUR, presented recurrence of a small left diverticulum. Patients with voiding disorders presented a gradual improvement of their urgency. VUR disappeared at VCUG in all patients. Conclusion Vesicoscopic diverticulectomy resulted a safe and effective procedure and can be considered a valid alternative to the open or laparoscopic procedures. In our opinion, routine use of vesicoscopy could become the gold standard for the treatment of CBD in children.

Aims.The closure of a cystic duct during cholecystectomy by means of radiofrequency is still controversial. We report our preliminary experimental results with the use of LigaSure on common bile duct in rats. MATERIALS AND METHODS: Thirty Wistar rats weighing 70 to 120gr were employed for this study. The animals were all anaesthetized with intraperitoneal Ketamine and then divided into three groups. The first group (10 rats, Group C) underwent only laparotomy and isolation of the common bile duct. The second (10 rats, Group M) underwent laparotomy and closure of the common bile duct (CBD) with monopolar coagulation. The third group (10 rats, Group L) underwent laparotomy and sealing of the common bile duct with two application of LigaSure. Thereafter, all rats were kept in comfortable cages and were administered Dibenzamine for five days. They were all sacrificed on day 20. Through a laparotomy, the liver and bile duct were removed for histological examination. Blood samples were obtained to dose bilirubin, amylase and transaminase levels. RESULTS: Mortality rate was 0 in the control group (C), 3/10 rats in group M and 0 in group L. In group L, the macroscopic examination showed a large choledochocele (3 - 3.5 cm x 1.5 cm) with few adhesions. At the histological examination there was optimal sealing of the common bile duct in 9/10 rats. In group M, 2/10 rats had liver abscesses, 3/10 rats had choledochocele and 5/10 rats, biliary peritonitis. There was intense tissue inflammation and the dissection was difficult. Analyses of blood samples showed an increase in total bilirubin, aspartate aminotransferase (AST) and alanine amitransferase (ALT) in groups M and L. CONCLUSIONS: The preliminary results of our study confirm that radiofrequency can be safely used for the closure of the common bile duct. The choledochocele obtained with this technique could represent a good experimental model. These results could be a further step for using the LigaSure in clipless cholecistectomy.

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.

Aims: Ergonomics and proper planning of surgical procedures are the basis of success for laparoscopy in children. The successful execution of a laparoscopic procedure requires a great familiarity with the equipment and the positioning of the operators. This is to avoid unnecessary surgical team fatigue that affects the duration and effectiveness of the intervention. We conducted a study on our laparoscopic procedures to determine the effectiveness and usefulness of the application of ergonomics and a regular use of a preoperative checklist. Materials and Methods: We studied the laparoscopic operations performed by a single operator between January 2008 and July 2011. These factors were considered: the position and orientation of equipment, crew and patient discomfort, and the problems encountered by the operators. We used as evaluation criteria the diagrams proposed by Lenoir and Steinbrecher and an appropriate preoperative checklist. Results: Of the 49 measures considered, only 22 procedures were useful and met the evaluation criteria. No correlation, referring to the physical measures, were detected in operations lasting

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 signifi cantly 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.Key words: Appendectomy, children, cholecystectomy, laparoscopy, pneumovesicoscopy

& 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 symptomfree, 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.

Aim: In this article, we report our experience with diverticulectomies of symptomatic congenital bladder diverticula in children, which was performed by utilizing pneumovesicoscopy. Materials and Methods: Six boys, 4–8 years of age (mean, 5.6) underwent pneumovesicoscopic diverticulectomy at our institution from June 2007 to June 2008. There were 4 right-single diverticula and 2 double-left diverticula. Under cystoscopic control, after the cystopexy to the abdominal wall, a midline 5-mm trocar for a 0-degree telescope and two lateral 3-mm reusable trocars through the anterolateral wall of the bladder in the midclavicular line were introduced, insufflating the bladder with carbondioxide to 10–12mmHg pressure. The diverticulum=a were inverted into the bladder and the mucosa around the neck was circumcized by using scissors and a monopolar hook. The defect was sutured with interrupted sutures and the bladder was drained with a Foley catheter, which was introduced at the site of the 5-mm port, and a urethral catheter. Results: Mean operative time was 110 minutes. No major peri- or postoperative complications were recorded, except that the displacement of one of the lateral trocars that resulted in gas leakage in 1 case. The trocar was replaced and the procedure was completed. An ultrasound and a voiding cystourethrogram, performed from 3 to 6 months after the operation, showed the disappearance of the diverticulum=a. Conclusions: In our experience, pneumovesicoscopic diverticulectomy is an easy, safe procedure and can be considered a valid alternative to the open or laparoscopic procedures. It also provides no postoperative discomfort and a good cosmetic result.

The laparoscopic herniorraphy in children is still associated to a high recurrence rate. The aim of this study was to assess whether the addition of the lateral incision of the sac to the sole suture of the inner inguinal ring could reduce the recurrence rate.A retrospective review was performed of the collected data of 248 laparoscopic inguinal hernia repairs in 224 children (175 males, 49 females) between 8 months and 11 years of age (mean age, 5 years; median, 4) in our institution from January 2004 to December 2007. The hernia was unilateral in 204 patients (133 on the right side, 71 on the left) and bilateral in 20 patients. A 5-mm umbilical camera port for a 0-degree laparoscopic optics and two operative 2- or 3-mm reusable trocars inserted in the lower right and left quadrants of the abdominal wall were utilized. In a group of 123 patients, the inner inguinal ring was closed, adopting a W-shaped suture (inguinal ring suture; IRS). In the other group of 101 patients, a lateral incision of the sac of 1-2 cm was carried out before the W-shaped suture of the inner inguinal ring (inguinal ring incision suture; IRIS).At a mean follow-up of 24 months (range, 6-36), 5 of 133 (3.76%) hernias recurred between 6 and 12 months after surgery in the IRS group. In the IRIS group, none of the patients presented with recurrence. The rate of recurrences in the two groups was compared and analyzed with the x2 test. The resulting difference was statistically significant (P0.05).In our experience, the incision of the peritoneum lateral to the internal inguinal ring and the W-shaped suture, compared to the sole W-shaped suture, is safe and effective in preventing hernia recurrence.

Aim In paediatric and adults patients with neurogenic bowel (NB), TransAnal Irrigation (TAI) of the colon has gained popularity due to the introduction of a specifically designed device. The aim of this pilot study was to present the results of TAI using Peristeen® Trans Anal Irrigation (PTAI) in a group of paediatric patients with anorectal malformations (ARM) and congenital or acquired spinal cord lesions (SCL). Method Eight Italian paediatric surgery and spina bifida centres participated in the study. The inclusion criteria were age between 6-17 years, weight above 20 kg, and unsatisfactory bowel management. Patients with chronic inflammatory bowel disease, mental disability and surgery within the previous three months were excluded. At the beginning of treatment (T0) and after three months (T1), the Bristol scale, a questionnaire assessing bowel function and two questionnaires on quality of life for patients aged 6-11 years (CHQ pf50) and 12-17 years (SF36) were administered. Results Eighty-three patients were enrolled, and seventy-eight completed the study (41 ARM, 37 SCL). At T1, constipation was reduced in ARM from 69% to 25,6% and in SCL from 92,7% to 41,5%, faecal incontinence in ARM from 50% to 18.6%, and in SCL from 39% to 9.8% and flatus incontinence in ARM from 20.9% to 9,8%, and in SCL from 31.7% to 10%. At T0, the Bristol Stool Scale types were 1-2 in 45% of ARM and 77.5% of SCL patients, whereas at T1 types 1-2 were recorded in only 2,5% of SCL patients. Quality of life (QoL) improved in both groups. In the younger group, a significant improvement in QoL was recorded in ARM patients for 8 of 9 variables and in SCL patients for 7 of 9 variables. Conclusion This study showed that PTAI resulted in a significant time reduction in colonic cleansing, increased independence from the carer, and improved QoL in paediatric patients with ARM and SCL.

Recurrent abdominal pains (RAPs) represent a common problem in children sometimes leading to unnecessary and invasive procedures. The rates of appendectomy were evaluated consecutively in 180 children with idiopathic hypercalciuria (HC) and/or hyperuricosuria (HU) and RAPs, and in 270 control subjects. Of the HC/HU patients 10% and of controls 1.5% underwent appendectomy (p0.0001). In 15 out of 18 HC/HU patients appendectomized, RAPs persisted with the same frequency and severity after the operation; 10 out of 18 had dysuria and/or gross hematuria 2 days-12 months after appendectomy. At our first visit, urinalysis was negative for hematuria in 13 out of 18 patients and in eight out of the 10 with a previous history of dysuria or gross hematuria. Pain recurrences resolved or improved in nine out of the 11 patients followed at least 1 year after general or specific therapy for HC/HU. The inconstant association of dysuria and hematuria with RAPs in children with HC/HU may lead to the urological origin of pain being overlooked, and may explain the high rate of appendectomy among these children. The possibility of HC/HU therefore should be taken into account in children with RAPs even when dysuria and hematuria are not present.

Background Surgeons are at risk for developing work-related musculoskeletal symptoms (WMS). The present study aims to examine the physical factors and their association with WMS among pediatric laparoscopic surgeons. Methods A questionnaire consisting of 21 questions was created and mailed to 25 pediatric laparoscopic surgeons (LG). 23/25 surgeons (92%) completed the survey. The questionnaire was analyzed and then split into 2 groups. Group 1 (LG1) included surgeons with greater laparoscopic experience, and group 2 (LG2) included surgeons with less important laparoscopic experience. In addition, we constructed and sent to the same surgeons a similar questionnaire focused on WMS after an open procedure (OG) with the aim to compare results of LG with OG. Results The prevalence rate of WMS with shoulder symptoms was 78.2% in surgeons that performed laparoscopy for more than 10years, with 60.8% also reporting other pain. In 66.6% this pain is evident only after a long-lasting procedure. Forty-four percent of these surgeons require painkillers at least twice a week. Fifty percent of these surgeons also suffer at home. Fifty-five and one half percent of surgeons indicate that this pain is related to their laparoscopic activity. Forty-three and a half percent think that laparoscopy is beneficial only for the patient but has a bad ergonomic effect for surgeons. Sixty-five and two-tenths percent think that robotic surgery can be helpful to improve ergonomics. Comparing the groups, WMS occur more frequently in LG (78.2%) than in OG (56.5%), but this difference was not statistically significant (χ 2 =0.05). In addition, WMS occur more frequently in LG1 (84.6%) than in LG2 (70%), but this difference was not statistically significant (χ 2 =0.05). Conclusions These results confirmed a strong association between WMS and the number of laparoscopic procedures performed. Skilled laparoscopic surgeons have more pain than less skilled laparoscopic surgeons. WMS in the same group of surgeons are more frequent after laparoscopy than after open procedures. The majority of surgeons refer to shoulder symptoms.

Background: Single-incision laparoscopic surgery (SILS) has gained great popularity in paediatric surgery due to its minimally invasive approach and improved cosmetic results. Notwithstanding, reports describing its adoption in children are still fragmentary and some perplexities have been raised by some surgeons. We reviewed our experience with the SILS Palomo varicocelectomy procedure (SIL-V) in children and adolescents, comparing this group with a similar series operated using conventional laparoscopic varicocelectomy (CL-V). Patients and Methods: A total of 69 Palomo laparoscopic varicocelectomies were performed in patients aged 11-17 years from January 2011 to January 2013. Indications for surgery included grades II-III varicocele or ipsilateral testicular hypotrophy. The SIL-V procedure was performed in 44 patients with roticulating and conventional 5 mm instruments. Testicular vessels were isolated “en bloc,” clipped and cut. Operating time, visual analogue scale and post-operative results were compared to a similar group of 25 patients operated with CL-V.Results: No patient of the SIL-V group required conversion to conventional laparoscopy, none to open surgery. Mean operative time was 22 min (range: 19-28) in the SIL-V group, not signifi cantly different compared with CL-V (mean 21 min, range: 18-25). All patients experienced a smooth recovery from surgery without any complications, and were discharged on day 1. No diffi culties were found in the SIL-V group. The post-operative pain score was signifi cantly better in SIL-V. Conclusion: The SIL-V procedure is safe and effective and allows a fast and effi cient isolation of the vascular bundle. The use of conventional instruments is technically feasible in SIL-V.Key words: Palomo, single-incision laparoscopic surgery, varicocele

The data from our follow-up confirm that the results of the laparoscopic IRIS technique, presents an acceptable low percentage of recurrences that is comparable to those of the open technique, with the advantage of reduced post operative pain, rapid return to everyday activities, and optimal cosmetic results. Although the results of our experience seems promising we think that the follow-up is too short and the number of the patients too small for drawing definitive conclusion.

Aims: Although the long-term outcomes of hypospadias surgery are considered important for psychosexual development, only a few attempts have been made to evaluate patient psico-pathology. Material and Methods: 20 out 40 patients who received under sealed cover two envelopes - the first containing the assessment tools, the other empty and prepaid for the answer – joined the study. The results came from the analysis of anamnestic interview specially created in order to gather information on how to access to surgery and the degree of information that the parents had from the surgeon, from the analysis of the CBCL (Child Behavior CheckList 2001:4-16 years) and TMA (Multidimensional self-esteem Test: the Italian version of the MSCS Multidimensional Self-Concept Scale). Of the 20 patients recruited, 15, aged from 9 to 18 years (mean age 12.5), age at operation between 2 and 5 years (mean age 3.3 yrs), have returned the questionnaires correctly compiled. Patient data were compared with those of a control group not suffering from genital pathology. Results: From the CBCL: the area of the identification of the problems showed no significant differences between the study group and the control. The area of competence, altered in both groups, did not show statistically significant differences. From the analysis of TMA: there were no statistically significant differences between the two groups in sub-domains: Social, Competence, Affect, Family and Physical. Within the subdomain school the two groups differed significantly for low self-esteem in the group of surgical patients. Conclusion: The MST test indicate that hypospadias surgery does not change the global self-esteem but, surprisingly, at least in this patient population, only a lower self-esteem in school performance in the age group considered . This study may indicate the importance of psychological support during the transition from adolescence to adulthood.

PURPOSE: Surgeons are at risk for developing work-related musculoskeletal symptoms (WMS). The present study aims to compare laparoscopy and SILS ergonomy among pediatric surgeons. METHODS: A questionnaire formed by 17 questions was mailed to 14 pediatric surgeons, seven with a large experience in laparoscopy and seven in SILS. All surgeons completed the survey. The questionnaires were focused on the type of laparoscopic or SILS activity, location and type of pain, need for drugs and its physical consequences. Results were analyzed using χ 2 test. RESULTS: Results indicated a similar incidence of WMS with shoulder symptoms (>75 %) in both groups. In laparoscopic group this pain is evident only after a long lasting procedure, while in SILS group the pain is present after each procedure performed. SILS surgeons used painkillers and other therapies statistically more frequently than laparoscopic group (χ 2 = 0.001). CONCLUSIONS: This study confirms there is a strong association between WMS and MIS surgery. The incidence of pain is similar in both groups. Pain was present only after long lasting procedures in laparoscopic group, while SILS surgeons have pain after each procedure performed. In addition SILS surgeons use more frequently painkillers and other therapies compared to laparoscopic surgeons. In conclusion, it seems that SILS has a worse ergonomy compared to laparoscopy.

Aims: The aim of this study is to describe vesicoscopic technique in the treatment of congenital bladder diverticula and vesicoureteral reflux (VUR) in children. Patients: With the vesicoscopic technique, 58 patients havebeen treated at our Institution from January 2007 to January 2013. There were 13 pts with congenital bladder diverticula and 45 pts with persistent grade ≥ 3 VUR. Under cystoscopic control, three trocars were placed (one at bladder dome, two laterally). The reimplantation was implemented using Cohen’s technique. In case of megaureter, the ureter was brought out the bladder and tailored. The diverticula were inserted into the bladder progressively and then removed. Results: Operating time ranged from 50 to 240 minutes. Three patients developed mild suprapubic emphysema after surgery. No patient was converted to open surgery or needed additional trocars. Renal scan with MAG3, VCUG and ultrasound performed in all patients 3 to 6 months after surgery showed the resolution of reflux in 31 out of 33 patients: an asymptomatic monolateral 1st grade reflux persisted in one girl who had been treated for monolateral 4th grade reflux, and in one boy with refluxing megaureter. All patients with diverticula presented full resolution. Conclusion: Our experience seems to show that the vesicoscopic treatment of bladder diverticula, vesicoureteral reflux and megaureter is safe andeffective and can represents a new viable alternative to the traditional procedures.

Mucosa-associated lymphoid tissue (MALT) lymphomas comprise a group of indolent B-cell non-Hodgkin lymphomas (NHL), which are rare in pediatric age. The clinical presentation of MALT lymphomas varies according to the location of the lymphoma. We report on a case of MALT lymphoma involving the appendix in a 6-year-old girl. A 6-year-old girl was referred to our institution in May 2005 with a diagnosis of appendicitis. The abdominal ultrasound showed slight effusion in the pelvic fossa. The patient underwent laparoscopic appendectomy using the three-trocar technique. The appendix appeared moderately hyperaemic with slight enlargement of the two-thirds of the distal portion. The postoperative course was uneventful and the girl was discharged on day 1 without any complication. The morphological and immunohistochemical examination showed typical findings of low-grade MALT lymphoma (positivity for CD20, no immunostaing for CD5 and CD10, positivity for anti-lambda light chain and low positivity for Ki-67). Further extensive examinations (abdominal MRI, gastroscopy, colonscopy and capsule endoscopy of the ileum) revealed that the lymphoma was limited to the distal two-third of the appendix (stage IA) and was not associated with any specific infection. At a recent follow-up the patients appeared to be doing well. Appendiceal MALToma is a rather uncommon pathology and, to our knowledge, there is only one report of appendiceal intussusception associated with appendiceal maltoma. According to our experience, low-grade MALToma can be managed by simple appendectomy. The histological examination should be the rule whenever an appendectomy is performed in children.

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. KEYWORDS: Gastrointestinal bleeding; Ileal duplication; Jejunal hemangioma; Laparoscopy; Meckel’s diverticulum; Minimal invasive surgery; One trocar surgery

Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm described in several tissues and organs including genitourinary system, lung, head, and neck. The etiology of IMT is contentious, and whether it is a postinflammatory process or a true neoplasm remains controversial. To our knowledge, we report the first reported case of IMT of urinary bladder in a pediatric patient with Wolf-Hirschhorn (WHS). We also review the literature about patients with associated neoplasia.

We verified the efficacy and safety of Botulinum-A toxin A (BT-A) in treating children with neuropathic bladder secondary to myelomeningocele. There were 47 patients out of 68 with neuropathic bladder, (22 females, 25 males, age range 5-17 years, mean age 10.7 years, with hypertonic/hyperactive neurogenic bladder detrusor hyperactivity, on clean intermittent catheterization, and resistant or non compliant to anticholinergics. 10 patients presented 2nd to 4thgrade concomitant monolateral/bilateral vesicoureteral reflux (VUR). All patients were incontinent despite catheterization. BT-A was administered by intradetrusoral injection of 200 IU of toxin in 20 sites. Follow-up including clinical, ultrasound, urodynamics was performed at 6, 12 and 24 weeks and annually thereafter.7 patients remained stable, 22 patients required a 2nd injection after 6-9 months and 18 a 3rd injection. VUR was corrected, when necessary, in the same session after Botox injection, by 1 to 3cc of subureteral dextranomer/hyaluronic acid copolymer (Deflux). Urodynamic parameters considered has been leak point pressure (LPP), leak point volume (LPV) and specific volume at 20 cmH2O pressure. The results were analyzed using the Wilcoxon test. All patients experienced a significant 66.45% average increase of LPV (Wilcoxon paired rank test=7,169 e-10) and a significant 118.57% average increase of SC 20 (Wilcoxon paired rank test=2.466 e-12). Difference between preoperative and postoperative LPP resulted not significant (Wilcoxon paired rank test=0.8858) The reflux was cured by one or two injection of Deflux. 38 out of 47 patients achieved dryness between CIC, 9 patients improved their incontinence but still need pads.

This retrospective study was performed to verify the efficacy and safety of Onabotulinumtoxin A (BTX-A) in treating children with neurogenic bladder (NB) secondary to myelomeningocele (MMC) with detrusor overactivity/low compliance. From January 2002 to June 2011, 47 patients out of 68 with neuropathic bladder were selected (22 females, 25 males, age range 5–17 years; mean age 10.7 years at first injection). They presented overactive/poor compliant neurogenic bladders on clean intermittent catheterization, and were resistant or non compliant to pharmacological therapy. Ten patients presented second to fourth grade concomitant monolateral/bilateral vesicoureteral reflux (VUR). All patients were incontinent despite catheterization. In the majority of patients Botulinum-A toxin was administered under general/local anesthesia by the injection of 200 IU of toxin, without exceeding the dosage of 12IU/kg body weight, diluted in 20 cc of saline solution in 20 sites, except in the periureteral areas. Follow-up included clinical and ultrasound examination, urodynamics performed at 6, 12 and 24 weeks, and annually thereafter. Seven patients remained stable, 21 patients required a second injection after 6–9 months and 19 a third injection. VUR was corrected, when necessary, in the same session after the BT-A injection, by 1–3 cc of subureteral Deflux®. Urodynamic parameters considered were leak point pressure (LPP), leak point volume (LPV) and specific volume at 20 cm H2O pressure. The results were analyzed using the Wilcoxon test. All patients experienced a significant 66.45% average increase of LPV (Wilcoxon paired rank test = 7169 × 10 −10) and a significant 118.57% average increase of SC 20 (Wilcoxon paired rank test = 2.466 × 10 −12). The difference between preoperative and postoperative LPP resulted not significant (Wilcoxon paired rank test = 0.8858) No patient presented severe systemic complications; 38/47 patients presented slight hematuria for 2–3 days. Twopatients had postoperative urinary tract infection. All patients were hospitalized for 24 h with catheterization. Thirty-eight out of 47 patients achieved dryness between CIC; nine patients improved their incontinence but still need pads. Ten patients have resumed anticholinergic agents. Our results suggest that the use of BTX-A is safe and effective in patients with MMC with a positive effect on their dryness and quality of life. Keywords: myelomeningocele; neurogenic bladder; vesicoureteral reflux; urodynamics

Aims: To assess the feasibility and safety of a laparoscopic approach to UPJ obstruction (UPJO) in ectopic pelvic kidneys. Material and Methods: In a retrospective analysis we selected 14 children, aged 6months to 17 years, 12 males, 2 females, who had been treated in our Department between January 2004 and June 2011. 9 patients presented ureteropelvic junction obstruction (in 3 cases pelvic stones coexisted) with normal/moderately reduced (≥25%) relative function at radionuclide scan (MAG3), 3 nonfunctioning kidneys associated or not to hypertension, 2 congenital hypo-dysplastic kidneys. The evaluation of each patient involved the medical history, ultrasound examination, VCUG, MAG3 diuresis renogram and MRI in some cases. Of the patients presenting UPJO, 5 underwent dismembered pyeloplasty with pyelolithotomy, if required, and 4 pelvic derotation with straightening of the uretero-pelvic junction. A previous cystoscopic placement of a Double J stent was utilized. This facilitated the identification and dissection around the pelvis. With the patient in Trendelenburg position we utilized an umbilical trocar and two trocar in the right and left iliac fossae; an additional trocar, when required, was inserted more cephalad on the midclavear line contralaterally to the lesion. The derotation of ureteropelvic junction was obtained by freeing the kidney’s lower pole and by placing intraperitoneally the junction protected with a Double J stent. This was obtained by suturing the peritoneum behind the ureteropelvic junction resulting in a forward rotation of the major axis of the kidney and a straightening of the junction. The 5 patients presenting nonfunctioning ectopic kidneys underwent laparoscopic nephrectomy. While the removal of congenital hypoplasic kidneys resulted easy, the removal of nonfunctioning kidneys was more difficult due to their complex vascular situation and for the embryonic disposition. Results: The operating time varied between 40 to 200 minutes. No patient required conversion to open surgery. The hypertension resolved after nephrectomy in all cases. 2 cases of dismembered pyeloplasty required a placement of Double J stent due the recurrence of symptoms and ! patient is waiting for redo operation. The pelvic derotation showed an improvement of diuretic MAG3 renogram and the function remained stable and patiens are symptoms-free. Conclusion: The UPJO in ectopic pelvic kidneys present a large spectrum of presentation. The laparoscopic approach provides good surgical exposure, and operative times are acceptable compared to those of laparoscopic procedure in anatomically normal kidneys. It has also proved a very useful tool in the non-functioning kidney nephrectomy thank to the help of magnification in the identification of numerous aberrant vessels that are quite often found in the pelvic kidneys. The derotation of the pelvis seems a useful procedure in moderate obstruction even if a longer follow-up is needed. Key words: ectopic, kidney, UPJ Obstruction

Lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) was first described by Isaacson et al. in 1983 (Isaacson & Wright, 1984). According to the WHO lymphoma classification, the indolent B cell lymphoma of MALT type is classified as a marginal zone lymphoma, thus called because it originates from the B lymphocytes normally present in a distinct anatomical location (marginal zone) of the secondary lymphoid follicles (Harris et al., 2001). MALT lymphomas comprise up to 40% of adult non-Hodgkin lymphomas (NHL); the median age at occurrence is 60 years, with a female predominance (Anonymous, 1997). In paediatric age MALT lymphomas are very rare. We report on a case of MALT lymphoma involving the appendix in a 6-year-old immunocompetent girl and its evolution toward an inflammatory bowel disease (IBD) at a middle-term follow-up.

Although pediatricians are frequently confronted with patients presenting urolithiasis symptoms without obvious stones, the syndrome of occult urolithiasis may be still viewed with some skepticism. We have compared the clinical and metabolic features of 197 children with obvious calculi, 189 with microcalculi (diameter a parts per thousand currency sign3 mm based on renal sonography), and 114 with symptoms of urolithiasis and normal renal sonography findings. Only microcalculi and normal sonography subjects with a urinary abnormality potentially leading to urolithiasis were included in the study. Age at presentation increased significantly (p = 0.0001) in the groups in the order normal sonography to microcalculi to calculi groups. There was no significant difference among the three groups in terms of family history of urolithiasis, gender distribution, and degree of hypercalciuria, hyperuricosuria, hyperoxaluria, or hypocitraturia. The average frequency of pain attacks of patients with recurrent abdominal pain (RAP) ranged from 3.6 to 4.6 days of pain per month among the three groups, which is four to ninefold lower than that reported for children with functional or organic gastrointestinal RAP. The consistency of many clinical and urinary metabolic characteristics indicates a common underlying disorder in overt and occult urolithiasis. The increase of age at presentation from the normal sonography to microcalculi and calculi groups may reflect progressive crystal accretion leading ultimately to overt stone formation.

La mancata conoscenza ed applicazione della ergonomia in laparoscopia e segnatamente in laparoscopia pediatrica , dove il campo operatorio e lo spazio di lavoro sono più ridotti che nell’adulto, può porre seri problemi di salute per il chirurgo e può condizionare l’ esecuzione ed i tempi dell’intervento.Nella chirurgia laparoscopica la situazione è molto diversa. L'occhio e l' azione si trasferiscono all' interno dell' addome (Endoblocco operatorio) ed il chirurgo deve rinunciare a parte della sua potenzialità tattile e palpatoria che sarà mediata dagli strumenti operativi. In questa condizione il chirurgo vede indirettamente il campo operatorio e può accedere alle strutture da manipolare in cavità (toracica, addominale , retroperitoneale etc.) attraverso lunghi strumenti che passano attraverso trocar che sono in posizione fissa. I nostri sensi, in questo caso, lavorano molto di più per ottenere lo stesso risultato. Il disegno appropriato degli strumenti e la disposizione della sala operatoria divengono allora critici per evitare stress ed errori. Possiamo esaminare l’ ergonomia in laparoscopia come l’insieme di problematiche che sono connesse • all’operatore • alla strumentazione (progettazione e modalità di utilizzazione) • alla sala operatoria

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.