Transition effects from laparocscopic to robotic surgery skills in small cavities.

Conventional laparoscopic surgery (LS) is being challenged by the ever-increasing use of robotic surgery (RS) to perform reconstructive procedures. The purpose of this study was to assess the acquisition of skills in both techniques and the potential transfer of skills from one technique to the other when restricted spaces are involved. A preclinical randomized crossover study design was implemented. Twelve subjects performed two different reproducible drill procedures: "Thread the Ring" (TR) and "Transfer the Plot" (TP). To assess surgical proficiency in confined workspaces, these exercises were performed with LS and RS technology in a pediatric laparoscopic surgery (PLS) simulator. Each performance was recorded and evaluated by two reviewers using objective structured assessment of technical skills (OSATS). The times to complete the TP and the TR procedure were significantly shorter with RS compared to LS (64 s vs. 319 s; p < 0.0001 for both TP and TR). A significant transfer effect of skills between LS and RS was noted for the TP exercise (p = 0.006). The percentage improvement was greater overall with LS, meaning a higher number of trials were required to adequately master the procedure. This study demonstrated that RS performed significantly better compared to LS on pediatric simulation devices. A transfer effect was identified from LS to RS exclusively. The learning curves showed that progression was definitely longer with LS. These results, indicate that novice surgeons should be encouraged to persist with learning LS, and they support the use of a pediatric robotic simulation device.

Bertolotti's syndrome in children: From low-back pain to surgery. A case report.

Bertolotti's syndrome is a little-known and little-discussed pathology. We report the case of a 13-year-old child diagnosed with Bertolotti's syndrome after several years of functional complaints. Conventional radiography was used to diagnose the transverse mega-apophysis of L5, while sectional and functional imaging confirmed a lumbosacral-iliac impingement. In view of the transient efficacy of medical management, surgical resection of the transverse mega-apophysis was performed. The medium-term decline in symptoms was excellent and the patient resumed physical activities without limitation or pain.

Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a survey of 407 children.

INTRODUCTION: Pyloromyotomy is the standard care for hypertrophic pyloric stenosis. The traditional approach for this procedure is a right upper quadrant transverse incision, although other "open" approaches, such as circumumbilical or periumbilical incision have been described. The more recent approach used is laparoscopic pyloromyotomy (LP), but experience feedback is still debated and its benefits remain unproven. The aim of this study was to make a review of all our LP procedures with an objective evaluation according to the literature. METHODS: A retrospective analysis of all the LPs performed in one University Children's Hospital between 1 January 1996, and 30 December 2015 was realized. Information regarding the patient's status, intraoperative and postoperative data was analyzed. RESULTS: 407 patients were included in this study. The mean operative time of the overall procedure was 24 ± 13 min, which significantly increased with the length of the pyloric muscle (p = 0.004) and significantly impacted the full feeding time (p = 0.006). 3.4% required conversion to an open procedure during the LP. We observed a significant correlation between conversion for mucosal perforation and weight loss (p = 0.04) and between conversion for mucosal perforation and preoperative weight (p = 0.002). A redo procedure was indicated in 3.7%, for incomplete pyloromyotomy each time. The mean postoperative hospital length of stay for all procedures was 1.6 ± 0.8 days. There were no inflammatory scars. None had incisional hernias or wound dehiscence. DISCUSSION: LP procedure appeared to be as quick as the open procedure. Our results were similar to others series for intraoperative complications. According to operative time, this technique does not have an impact on operative room utilization. Vomiting duration at presentation in HPS does not seem to have a significant impact on postoperative outcomes. LP procedure causes little pain during the postoperative period. No wound complications were registered.

Robotic-assisted laparoscopic surgery for pediatric tumors: a bicenter experience.

Mini-invasive surgery is more and more integrated in pediatric surgery. The robotic-assisted surgery brought new advantages from which the patient and the surgeon could benefit compared to laparoscopy. Its use in oncological surgery is still controversial. 12 robotic-assisted tumor resections with the da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA) were attempted in 11 children (mean age 7.65 years; age range 0.75-16.75 years; mean weight 30.3 kg; weight range 8.6-62 kg) in two centers. Mean total operative time was 145 min (range 72-263 min). 1 procedure (8.3%) was converted. The pathology included renal tumors (n = 2; one nephroblastoma, one metanephric adenoma), adrenal tumors (n = 9; three neuroblastomas, two pheochromocytomas, two adrenocortical adenomas, one cystic lymphangioma, one paraganglioma) and a pancreatic tumor (n = 1; one pancreatic cyst). 4 tumors (33.3%) were malignant. Every patient underwent a R0 resection. 1 child (8.3%) developed a post operative complication. Mean length of hospitalization was 3.0 days (range 2-5 days). Followup averaged 3.3 years with no recurrence. All children are alive. Robot-assisted MIS seems to be safe and feasible in pediatric tumors. The oncological surgical principles were respected in our series with low morbi/mortality and good long-term results. Robotic surgery and its technical advantages bring potential benefits for children with cancer. It has a role to play in pediatric oncological surgery but its place and indications still need to be better defined.

[Pitfalls for renogram interpretation in pediatric urology]. / Biais d'interprétation de la scintigraphie rénale chez l'enfant.

Renograms are currently used for functional assessment by pediatric urologists. The aim of the present work was to focus on the potential pitfalls concerning renography. Potential confounding factors are described in reference to concrete cases. The main types of pitfalls concern venous or urinary catheters and background area definition. Protocols and renogram interpretation are critiqued in a bibliographic review. We propose a technical update and original data on the potential pitfalls in renography interpretation. Multidisciplinary discussion between nuclear medicine, pediatrics and pediatric surgery departments is required before drawing conclusions.

[Simulation training for urinary drainage improves skill retention]. / Simulation et rétention des acquisitions : application au drainage vésical.

INTRODUCTION: Urethral and suprapubic catheterizations are the two methods for urinary drainage. Systematic simulation training could improve the performance and reduce iatrogenic complications. The aim of the study was to evaluate the skills retention using simulation training. MATERIALS AND METHODS: It was an experimental study of the effect of urinary drainage simulation based skills on medical students in order to compare active and passive training methods. On the first session, randomization was proceeded. Then, the participant performed one of the two workshops (urethral or suprapubic catheterization) on a male mannequin. The maximal performance was 40 points on the assessment form. Both workshops were performed on the second (one month) and third sessions (six months). RESULTS: Eighteen participants were included. Main performance was 28.7/40 (23-34.2) at the first session. All the participants improved the performance on the second session with a significant difference (P<0.01) between passive 32.5 (26-36.5) and active participants 36.1/40 (34.5-39). On the third session, a similar difference was observed between passive and active participants (32.5 versus 30.4, P non significant). CONCLUSION: Simulation training seems to improve long-term skill retention of urinary drainage for inexperienced medical students. This preliminary study suggests to incorporate urinary drainage simulation training into all medical school curricula. LEVEL OF EVIDENCE: 4.

Benefits of primary surgical resection for symptomatic urethral prolapse in children.

OBJECTIVE: Urethral prolapse (UP) is a complete eversion of the distal urethral mucosa through the external meatus. UP must be distinguished by examination from trauma, prolapsed ureterocele, tumors or sexual abuse. Its management remains controversial. The aim of the study was to promote the benefits of primary surgical management for UP. METHODS: A retrospective multicenter review of children who received surgery for UP between 1991 and 2011 was carried out. Non-complicated UP was primarily treated conservatively. A total of 19 patients were referred for complicated UP and underwent resection of the prolapsed urethral mucosa. RESULTS: The mean delay in diagnosis was 2.2 days (range 1-6) and the most common symptoms were vaginal spotting and bleeding. No predisposing factor was found, but most patients had a mean weight, height and BMI greater than the 50th percentile. All patients underwent surgery successfully. One patient experienced a complication, i.e., dysuria. There was no case of recurrence after a mean 28 months of follow-up. CONCLUSION: Early detection is based on bedside examination. The first-line treatment strategy for uncomplicated UP should be conservative management. Surgical resection is safe and effective for patients with significant symptoms.

[Urogenital bleeding revealing urethral prolapse in a prepubertal girl]. / Hémorragie génitale de la petite fille: penser au prolapsus urétral.

Urethral prolapse is a complete eversion of the distal urethral mucosa through the external meatus. It occurs primarily in prepubertal, primarly Black girls. Its pathophysiology has not been clearly identified. We report a case of a 5-year-old girl who came to the Emergency Department with a 1-day history of genital pain and "vaginal bleeding". Early recognition makes differential diagnosis with sexual abuse and staging allows prompt management under general anesthesic like prolapse reduction or surgical excision.

[Primary obstructive megaureters: long-term follow-up]. / Méga-uretères primitifs : étude rétrospective sur dix ans.

INTRODUCTION: The objective of this study was to evaluate the clinical outcome of primary megaureters and to evaluate predictive factor for surgery need based on ultrasound values. METHODS: A total of 43 primary obstructive megaureters detected in 41 patients have been evaluated between January 2000 and may 2010. RESULTS: Mostly boys (73%) were concerned by megaureters, mainly on the left side (66%). Twenty patients were prenatally diagnosed. Surgical indications were: pyonephrosis (3), recurrent pyelonephritis (14), scintigraphic damage (3), ureteric diameter aggravation (7), disease occurring on unique kidney (2). Regarding the 30 patients who benefit surgery, the retrovesical ureter measured, before surgery 19.15 mm (± 7.17) on average and 3.18 mm, 44 months later. Over the 10 patients treated medically, the initial diameter was 9.91 mm and at the end of the study, five patients had megaureter completely regressed, three patients had a diameter greater than 10mm at the end of the study and two faced a worsening evolution with sudden and complete renal damage on scintigraphic nephrogram, after recurrent pyelonephritis despite antibioprophylaxis. CONCLUSION: We recommend a careful watch-fulling of primary megaureters; mainly for those with recurrent infections and whenever the retrovesical ureter diameter exceeds 14 mm at first ultrasound.

[Pediatric anterior urethral injuries: time to take stock]. / Mise au point sur la prise en charge des traumatismes de l'urètre antérieur de l'enfant.

INTRODUCTION: Anterior urethral injuries are a rare entity in the pediatric age group. Data of the literature are limited to the injuries of the posterior urethra. The aim of this study was to take stock of the initial management of this disease, from our experience and data of the literature. PATIENTS AND METHODS: A literature review and a retrospective study were conducted. We used our department database to find all the patients treated for anterior urethral injuries at the Children's Hospital of Toulouse between 2000 and 2011. Data on patients with trauma of the anterior urethra were analysed. RESULTS: Among the 13 patients treated for urethral injuries, seven patients had trauma to the anterior urethra. The initial symptom was an acute retention of urine in three cases (43%) and urethral bleeding in six cases (85%). All patients with acute retention of urine had emergency management consisting in endoscopic realignment and urinary diversion by suprapubic catheter. Patients with hematuria were treated with paracetamol and non-steroidal anti-inflammatory. After a mean follow-up of 507 days (332-893), none had dysuria and no posttraumatic stenosis has been demonstrated in uroflowmetry. CONCLUSION: In our experience, the trauma of the anterior urethra of the child had a satisfactory development through appropriate management. Clinical and uroflometry follow-up is necessary.

[Is there an outcome difference between posterior urethral valves diagnosed prenatally and postnatally at the time of antenatal screening?]. / Impact de l'âge au diagnostic sur le devenir à long terme des patients opérés de valves de l'urètre postérieur.

PURPOSE: Posterior urethral valves (PUV) diagnosed during childhood have classically been associated with a better outcome than antenatally diagnosed PUV. The aim of our study was to compare long-term outcome of these two patients' groups. MATERIAL AND METHODS: We retrospectively reviewed the medical records of boys with PUV managed between 1990 and 2010. Patient demographics, clinical background, radiographic data (including prenatal ultrasonography data when available), renal and bladder functional outcomes, surgical procedures and urinary tract infections (UTI) were abstracted. Impaired renal function (IRF) was defined as glomerular filtration rate less than 90 mL/min/1.73 m(2) at last follow-up. RESULTS: We identified 69 patients with confirmed PUV. Thirty-eight were diagnosed prenatally (group 1) at 30.5 weeks of gestation and 31 had a delayed diagnosis (group 2) at a median age of 6.31 years. At diagnosis, 20 patients in group 1 had renal insufficiency versus two in group 2 (P<0.05). At the end of mean follow-up of 7.2 ± 0.5 years, in group 1, 26.3% developed IRF versus 6.3% in group 2 (mean follow-up 2.3 years). Mean age at last follow-up was 7.3 years in group 1 versus 8.3 in group 2 (P>0.05). In group 1, 27% had voiding dysfunction versus 30% in group 2 (NS). In group 1, 35% had UTI during follow-up versus 10% (P=0.01). CONCLUSION: During the follow-up, the patients with delayed diagnosis VUP have developed fewer complications related to the initial obstruction than the population who was detected antenatally and managed from the early hours of life. However, the rate of IRF and voiding disorders in our study, associated with the data of the literature, highlights the potential persistence and worsening of these conditions. That is why, whatever the age at diagnosis, VUP patients require a close monitoring.

[Unusual fetal teratoma presenting as a posterior mediastinal cyst]. / Présentation atypique d'un tératome fœtal du médiastin postérieur.

Mediastinal cysts are uncommon prenatal findings. As isolated and non-compressing entities, they don't compromise the course of gestation. Massive lesions can compress vital structures, resulting in fetal demise. Thus, close follow-up with sonographic monitoring is recommended until birth. Non-hydroptic fetuses can be managed expectantly. Definitive etiology is known after surgical resection only. We present the first case of posterior mediastinal teratoma associated with severe vertebral abnormalities. After CT scan and fetal MRI, medical termination of pregnancy was decided. Histological examination revealed an immature teratoma. With this unique case report, we discuss the optimal prenatal management of mediastinal cysts.

Management of blunt tracheobronchial trauma in the pediatric age group.

INTRODUCTION: Tracheobronchial rupture (TBR) due to blunt chest trauma is a rare but life-threatening injury in the pediatric age group. The aim of this study was to propose a treatment strategy including bronchoscopy, surgery and extracorporeal membrane oxygenation (ECMO) to optimize the emergency management of these patients. METHODS: We reviewed a series of 27 patients with post-traumatic TBR treated since 1996 in our pediatric trauma center. RESULTS: Seven cases had persistent and large volume air leaks. Flexible bronchoscopy was performed in cases of persistent or large volume air leaks. It permitted accurate visualization of the rupture and its extent. It allowed for a clear-cut positioning of the endotracheal tube. Five were managed operatively. Four cases were considered to be life-threatening because of the combination of severe respiratory distress with hemodynamic instability. One of them had severe tracheal laceration and died. Another one had bilateral bronchi disconnection. Based on clinical and endoscopic findings, surgical repair was performed using extracorporeal membrane oxygenation as a ventilatory support. It provided quick relief from the injury, which was previously expected to result in a fatal issue. CONCLUSIONS: Prompt diagnosis and accurate management of surviving patients admitted to emergency rooms are necessary. Bronchoscopy remains a critical diagnosis step. Surgery is warranted for large tracheobronchial tears and ECMO could be beneficial as supportive therapy for selected cases.

[Asymptomatic neonatal neurocutaneous melanosis]. / Mélanose neurocutanée néonatale asymptomatique.

Giant congenital nevi in 1% of cases are associated with anomalies of the central nervous system, which are characteristic of neurocutaneous melanosis. When neurocutaneous melanosis becomes symptomatic, it is associated with a poor prognosis. With recommended neonatal screening, asymptomatic neonatal cases are being discovered more frequently. On the basis of this observation, we consider various aspects of this association.

[Prospective study of the results of ureterointestinal anastomosis in 100 patients after the Hautmann ileal neobladder with double chimney]. / Étude prospective chez 100 patients des résultats de la technique d'anastomose urétéro-iléale en double cheminée dans la néovessie de Hautmann.

PURPOSE: We attempted to determine the results of the ureterointestinal anastomosis in the Hautmann orthotopic ileal neobladder. This study was conducted prospectively and focused on ureteral stricture, which occurs mainly during the 2 years after surgery. PATIENTS AND METHODS: Between January1999 and June 2009, a total of 100 consecutive patients (five women and 95 men) with bladder cancer underwent cystectomy followed by construction of a Hautmann neobladder. The median age of the patients was 62 (36-78) years. The mean follow-up was 63 (±28) months and included physical examination, serum creatinine values, urine cytology, CT scans and renal ultrasonography. RESULTS: A total of 197 renal units (RU) were included. In eleven RU, hydronephrosis was present preoperatively and improved postoperatively. In ten others RU, hydronephrosis persisted postoperatively without symptoms. The anastomotic stricture rate was 4%, concerning eight RU by seven patients. Five inflammatory strictures (2.5%) occurred early on the 5th, 6th, 8th and 13th postoperative weeks and were revealed by pyelonephritis. Three strictures were tumors in nature and were revealed by urine cytology and radiology on the 6th, 7th and the 14th month respectively. The five inflammatory strictures were treated with percutaneous nephrostomy, balloon dilatation and ureteral stenting. For three of these four patients, surgical reimplantation was necessary on the 4th, 5th and 7th months, like in the case of the three tumoral strictures. CONCLUSION: With a minimal 2 years follow-up, ureterointestinal anastomosis with double chimney had, in this study, a 4% rate of anastomotic stenosis. The surgical modification avoiding tension seemed to preserve ureteral vascularization.

[Pulmonary sequestration and enteric cyst, 2 expressions of the same abnormality]. / Séquestration pulmonaire et kyste entérique, 2 expressions d'une même anomalie. Illustration par un cas.

We report the case of an 18-month-old boy operated on for a right lower lobe bronchopulmonary sequestration. At the immediate postoperative check-up, a septic right thoracic effusion appeared, connected to a cystic mediastinal retrocrural formation on CT. After a drainage attempt and medical therapy, the abdominal lesion was resected. Histological examination showed that the cyst cavity was lined with pseudostratified non-ciliated epithelium, without cartilage, consistent with an enteric cyst. Regardless of the embryological theory, a literature review confirmed that in presence of one of these two lesions, one should systematically look for the other.

[Functional damages after blunt renal trauma in children]. / Séquelles fonctionnelles après traumatisme rénal chez l'enfant.

PURPOSE: The purpose of this study was to determine the long-term functional outcome of renal injuries. METHODS: We retrospectively reviewed the charts of patients under 16 sustaining renal trauma and admitted to our department between 1990 et 2010. There were 66 renal lesions categorized as follows: grade I to III, 33, grade IV, 28 and grade V, 5. Whatever their initial status, all children were followed using ultrasonography or computed tomography. After complete healing, data of technetium-99m-dimercaptosuccinic acid nuclear were collected. RESULTS: There was no bilateral injury. Thirteen patients proceeded to laparotomy leading to nephrectomy in three cases, partial nephrectomy in two others cases. Four renovascular injuries required interventional radiologic management. Nine urinomas were managed with eight stentings and one percutaneous drainage. Percentage of renal function by technetium-99m-dimercaptosuccinic acid nuclear scanning concerning 26 patients was analysed. Split percentage of renal function was 43.4% (±6.2%), 35.7% (±5.3%) et 30.3% (±12.2%) (mean±SD); P=no significant, for grade I-III, IV and V, respectively. CONCLUSION: Functional outcome after blunt renal trauma appeared influenced by injury grade. Functional sequelae existed even with low-grade traumas. In keeping with literature, these results justified a close follow-up in which radionuclide study was the essential element.