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Overall, the incidence of paediatric urolithiasis is increasing; 50-90% of cases are due to metabolic alterations, 3-30% are associated with urinary tract infections and the remaining cases are idio-pathic. About 20-30% of children, especially boys who are younger than 2 years of age, present an anatomic urinary tract anomaly. The main symptom is abdominal pain; however, young children tend to have subtle manifestations. Abdominal ultrasound is the first-line imaging technique. Conservative treatment with fluid intake, pain relievers and alpha-adrenergic blockers are used during the acute episode, whereas a surgical treatment is indicated in selected cases. Since there is an increased rate of recurrence in comparison to adulthood, abundant hydration and changes in dietary habits have a central role in the prevention of paediatric urolithiasis. It is very important to perform a metabolic evaluation when the acute episode is resolved, as 50% of the cases present an underlying metabolic disorder. If a metabolic abnormality is diagnosed, specific preventive interventions should be undertaken. The paper presents the clinical case of an infant who during a Proteus mirabilis urinary tract infection has developed obstructive acute kidney injury due to a stone in the distal urethra. The incidence of urinary stones caused by urinary tract infection is decreasing, however this eventuality should be considered.

Introduction: Antegrade sclerotherapy (Tauber) effectively treats varicocele. However, fluoroscopy exposes young males to ionizing radiation. We aimed to evaluate radiation exposure and surgical outcomes after the Tauber procedure. Materials and methods: We retrospectively analysed data from 251 patients. Dose area product (DAP) and fluoroscopy time were recorded. The effective dose was calculated with the PCXMC software. Descriptive statistics and linear regression tested the association between clinical predictors and radiation exposure. Results: Median (IQR) age and body mass index (BMI) were 14 (13–16) years and 20.1 (17.9–21.6) kg/m². Five (2.1%) patients developed clinical recurrence and two (0.81%) developed complications. Median fluoroscopy time and DAP were 38.5 (27.7–54.0) s and 89.6 (62.5–143.9) cGy*cm2. The effective dose was 0.19 (0.14–0.31) mSv. Fluoroscopy time was higher in patients with collateral veins (41 (26–49) s vs. 36 (31–61) s, p = 0.02). The median amount of sclerosing agent (SA) used was 3 (3–4) ml. DAP was higher when SA > 3 mL was used (101.4 (65–183) cGy*cm2 vs. 80.5 (59–119) cGy*cm2; p < 0.01). At univariable linear regression, age, BMI, operative time and SA > 3 mL were associated with higher DAP (all p < 0.01). At multivariable linear regression, only BMI (beta 12.9, p < 0.001) and operative time (beta 1.9, p < 0.01) emerged as predictors of higher DAP, after accounting for age and SA > 3 mL. Conclusions: The Tauber procedure is safe and associated with low effective doses. Operative time and the patient’s BMI independently predict a higher radiation dose.

Fluorescence-guided surgery (FGS), three-dimensional (3D) imaging technologies, and other innovative devices are rapidly revolutionizing the field of urology, providing surgeons with powerful tools for a more complete understanding of patient-specific anatomy. Today, several new intraoperative imaging technologies and cutting-edge devices are available in adult urology to assist surgeons in delivering personalized interventions. Their applications are also gradually growing in general pediatric surgery, where the detailed visualization of normal and pathological structures has the potential to significantly minimize perioperative complications and improve surgical outcomes. In the field of pediatric urology, FGS, 3D reconstructions and printing technologies, augmented reality (AR) devices, contrast-enhanced ultrasound (CEUS), and intraoperative magnetic resonance imaging (iMRI) have been increasingly adopted for a more realistic understanding of the normal and abnormal anatomy, providing a valuable insight to deliver customized treatments in real time. This narrative review aims to illustrate the main applications of these new technologies and imaging devices in the clinical setting of pediatric urology by selecting, with a strict methodology, the most promising articles published in the international scientific literature on this topic. The purpose is to favor early adoption and stimulate more research on this topic for the benefit of children.

Purpose: To compare surgical scars assessed by a validated patient reported outcome questionnaire in children undergoing open (OP), laparoscopic (LP), or robotic-assisted (RALP) pyeloplasty. Secondary aim was to assess the influence on the outcomes of variables such as gender or body mass index (BMI). Materials and methods: Observational, cross-sectional, multicentric study of patients undergoing primary pyeloplasty between age 10- and 18-year at 5 tertiary Italian institutions in the period 01/2010 to 12/2019. Of 227 eligible patients, 114 (50%) participated. OP was performed in 37 (32%), LP in 30 (26%) and RALP in 47 (41%), After a median (IQR) follow-up of 5.2 (2.3-7.8) years, scars were measured and assessed by a validated Patient Scar Assessment Questionnaire (PSAQ). Scores were compared among techniques and in accordance to several variables. Results: The median length of the surgical scar at follow-up was significantly larger (p

Our study aims to assess the clinical implication of RAV/rBSA ratio in PRT as a predictor for attained renal function at 1 year post-transplantation and its association with surgical complications. A retrospective cohort was performed for PRT cases from January 2000 to December 2015 in our institution. Extracted clinical information includes the recipient's demographics, donor type, renal allograft characteristics, arterial, venous and ureteral anastomoses, vascular anastomosis time while kidney off ice, overall operative time, and estimated blood loss. The RAV/rBSA was extrapolated and assessed for its association with renal graft function attained in 1 year post-transplantation and surgical complications within 30-day post-transplantation. A total of 324 PRTs cases were analyzed. The cohort consisted of 187 (52.4%) male and 137 (42.3%) female recipients, with 152 (46.9%) living donor and 172 (53.1%) deceased donor renal transplants, and an overall median age of 155.26 months (IQR 76.70-186.98) at time of renal transplantation. The receiver operating characteristic identified that a RAV/rBSA ratio of 135 was the optimal cutoff in determining the renal graft function outcome. Univariate and multivariate analyses revealed the relative OR for RAV/rBSA ≥ 135 ratio in predicting an eGFR ≥ 90 attained within 1 year post-transplant was highest among younger pediatric recipients (

Summary Introduction Studies have shown that non-stented distal hypospadias repair eliminates stent-related bladder spasm and stent removal discomfort without increasing complications; however, results are inconsistent. We performed a systematic review to assess the complication rates of non-stented compared to the stented distal hypospadias repair. Methods The literature search included randomized control trials (RCTs) and cohort studies published prior to October 2016 in all languages (PROSPERO CRD42016047563). All included studies were assessed according to Cochrane Collaborative recommendations and included for meta-analysis. Surgical outcomes from each treatment group were classified according to early complications and later final outcomes. Outcomes were expressed as relative risk (RR) and 95% confidence intervals (CI). Interstudy heterogeneity was assessed using chi-square and I2. Effect estimates were pooled using the inverse variant method with random effect model. Subgroup analysis was performed according to surgical technique (Mathieu versus tubularized incised plate) and study design. Results A total of 20 studies (14 cohorts, 6 RCTs) with 2466 hypospadias repairs (1290 non-stented, 1176 stented) were included for the meta-analysis. Serious risk of bias was noted among the cohort studies with publication bias likely present, while the included RCTs were of moderate methodological quality. The overall pooled effect estimates comparing non-stented versus stented distal hypospadias repair showed no between-group difference for outcomes of early and late complications (RR 0.83, 95% CI 0.46–1.50; RR 0.96, 95% CI 0.92, 1.48; respectively) Conclusions Current evidence of low to moderate quality suggests that there is likely no outcome difference between non-stented and stented distal hypospadias repair.

Summary Introduction Preoperative hormonal stimulation (PHS) is commonly administered to improve hypospadias outcomes. However, current literature provides no clear evidence to support its use, and controversies exist regarding its effect on postoperative complications. Herein we systematically evaluate the effect of PHS on postoperative complications rates following hypospadias repair. Materials and methods Comprehensive literature search performed on April 2016 including OVID MEDLINE, EMBASE, Web of Science, Cochrane Library, Clinicaltrials.gov , World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and ProQuest. Study quality assessment followed the Cochrane collaboration recommendation using risk of bias assessment, ROBINS-I and NOQAS. Effect estimates were extracted as relative risk (RR) with 95% confidence interval (CI) and pooled using Mantel-Haenzel method. Evidence quality was assessed using GRADE approach. Protocol Registration: PROSPERO CRD42016037881. Results Twenty-one publications from 16 trials examining the effect of androgenic PHS on postoperative outcome were included. Subgroup analysis based on study design (including nine cohort studies with moderate to high risk of bias for patient selection) showed no significant difference on postoperative outcomes (RR 1.31, 95% CI 0.95–1.81) (table). Pooled effect estimates with moderate quality of evidence from three randomized controlled trials suggest that significant lesser postoperative complications occur among patients exposed to PHS (RR 0.36, 95% CI 0.20–0.65). Uniformly, the reported adverse effects related to PHS were mild and transient, with good overall tolerance. Conclusions Effect estimates generated from the better quality of evidence showed that PHS may decrease postoperative complications following hypospadias repair. Future studies should aim at identifying indicated subgroup of patients that will benefit from it and standardizing the dose and mode of delivery for best clinical result. Table . Summary of relative risk and corresponding 95% CI according to study design. No. of studies Relative risk for postoperative complication 95% CI Randomized controlled trials 3 0.36 0.20–0.65 Cohorts 9 1.31 0.95–1.81 Total 12 0.99 0.63–1.55

PURPOSE RT remains the best available strategy for addressing stage 5 chronic kidney disease in children and adolescents. Technical aspects of the procedure can have a clear impact on complications and health of the allograft, including DGF. Immediate optimal perfusion is paramount, thus choosing a target vessel has to take into account the flow demands imposed by an adult-size kidney in a proportionally smaller recipient. Herein, we explore the hypothesis that vascular anastomosis location can impact DGF adjusting for patient age and body size. METHODS Retrospective review of a single institution referral center transplant database, including information on 156 patients. We collected data on patient characteristics (age, height, BSA, gender, preoperative need for dialysis), donor source (deceased vs living), WIT/CIT, hemodynamics during the procedure, use of inotropes or diuretics, and location of the arterial and venous anastomoses. The primary outcome, DGF, was assessed by measuring the ttNC (in days), adjusting for age and BSA. RESULTS Location of the arterial anastomosis was clearly impacted by age and donor size (Figure 1A). On univariate analyses, longer ttNC was associated with deceased vs living donor (11.8 ± 11.5 and 4.3 ± 5.0; P

Robotic technology is the natural evolution and simplification of traditional laparoscopy. Robotic surgery has the same benefits of traditional laparoscopic surgery in terms of cosmetic results, pain control and short in-hospital stay. However, magnified three-dimensional vision and the use of fully articulated wristed-instruments allow to increase the precision control. Recently, robotic surgery has been even more used in urology. In fact, robot-assisted radical prostatectomy (RARP) is currently the most common treatment used for localized prostate cancer in the United States. Perioperative and functional outcomes resulted significantly better after RARP. As a consequence of the diffusion of RARP, other urological procedures were performed using the robotic approach. Particular attention has been paid to the use of robotic surgery for the treatment of benign and malignant renal diseases. In 2002 the first robot-assisted pyeloplasty was performed followed by the first robot-assisted partial nephrectomy. This last procedure had widespread a lot in the last years and it can currently be considered as the main alternative to the traditional open partial nephrectomy. Finally, the evolution of technology and surgeon skills allowed us to consider the less invasive approaches also for renal transplantation surgery and vena cava tumor thrombectomy. The objective of this review was to analyze current indications and outcomes of robot-assisted procedures for the treatment of benign and malignant renal diseases.

BACKGROUND The optimal management of high-risk prostate cancer remains uncertain. In this study we assessed the safety and efficacy of a novel multimodal treatment paradigm for high-risk prostate cancer. METHODS This was a prospective phase II trial including 35 patients with newly diagnosed high-risk localized or locally advanced prostate cancer treated with high-dose intensity-modulated radiation therapy preceded or not by radical prostatectomy, concurrent intensified-dose docetaxel-based chemotherapy and long-term androgen deprivation therapy. Primary endpoint was acute and late toxicity evaluated with the Common Terminology Criteria for Adverse Events version 3.0. Secondary endpoint was biochemical and clinical recurrence-free survival explored with the Kaplan-Meier method. RESULTS Acute gastro-intestinal and genito-urinary toxicity was grade 2 in 23% and 20% of patients, and grade 3 in 9% and 3% of patients, respectively. Acute blood/bone marrow toxicity was grade 2 in 20% of patients. No acute grade ≥ 4 toxicity was observed. Late gastro-intestinal and genito-urinary toxicity was grade 2 in 9% of patients each. No late grade ≥ 3 toxicity was observed. Median follow-up was 63 months (interquartile range 31-79). Actuarial 5-year biochemical and clinical recurrence-free survival rate was 55% (95% confidence interval, 35-75%) and 70% (95% confidence interval, 52-88%), respectively. CONCLUSIONS In our phase II trial testing a novel multimodal treatment paradigm for high-risk prostate cancer, toxicity was acceptably low and mid-term oncological outcome was good. This treatment paradigm, thus, may warrant further evaluation in phase III randomized trials.

We tried to verify retrospectively, the clinical importance of a single microfocal prostate cancer at biopsy (as microscopic aspect of a group of 12 neoplastic glands 40x) in patients subsequently treated with radical prostatectomy (RP).from January 2008 to November 2010 we carried out 760 eight-core prostate biopsies for increased PSA in patients with a prostatic volume of dor =40 cc. A total of 252 patients (33.15%) had a prostate cancer and out of them 17 (6.7%) had a microscopic prostate cancer--16 a single microscopic focus and a case 2 microscopic foci in two different specimens. PSA ranged 5 to 7.4 ng/ml (mean 6.2 ng/ml), age ranged 61 to 75 (mean 68.29), Gleason score was G6 in all cases; in 4 cases a microscopic focus of PIN3 was associated.All patients had a RP and the pathologic stage was T2a in 4, T2b in 1, T2c in 9 (3 of these had microscopic PIN3 at biopsy) and T3a in 3 (including the one with 2 microscopic foci of prostate cancer on 2 different bioptic samples). Gleason was G6 in 12 cases and G7 in 5.The single microscopic focus of prostate cancer has always raised diagnostic problems, in fact some authors report these patients have 30 to 90% of probability to have a significant prostatic cancer (volume0.5 mi) whereas other authors found an insignificant prostatic cancer in 30% of the patients with a single microscopic focus of prostate cancer. It is really very difficult to predict the extent of the tumor in these cases because the different parameters employed are not reliable. Our series, although very small, support the hypothesis that significant cancers are more frequently associated with a single microscopic focus of prostate cancer at biopsy (in fact 17 out of 17 patients had a significant cancer) and consequently we feel that it is more oncologically correct to choose an aggressive therapy in these cases (RP, radiotherapy or androgen deprivation according to the individual case) rather then a "wait and see" which could be less cautious.