Indocyanine green (ICG) fluorescence technology in pediatric robotic surgery.

This study aimed to report our experience in indocyanine green (ICG) fluorescence-guided surgery (FGS) in pediatric robotics. The data of 55 patients (35 boys and 20 girls), who underwent robotic surgery using ICG fluorescence in three institutions over the last 7 years, were retrospectively reviewed. The following robotic procedures were included: pyeloplasty (n = 21), complex Lich-Gregoir ureteral reimplantation (n = 8), varicocelectomy (n = 7), adnexal pathology resection (n = 8), partial nephrectomy (n = 4), nephrectomy (n = 4), renal cyst removal (n = 2), and excision of prostatic utricle (n = 1). The ICG was injected intravenously in all indications except for varicocele where intratesticular injection was done, and prostatic utricle or paraureteral diverticulum where trans-catheter injection was done. The ICG dosage was 0.2-0.3 mg/mL/kg. All the procedures were performed using da Vinci Xi platform. Firefly® allowed to switch form bright light to ICG-NIRF view and vice versa. All the procedures were accomplished in robotics without conversions to laparoscopy or open surgery. No episodes of allergy or anaphylaxis to ICG were recorded. An excellent ICG-NIRF view of target organs was obtained in all procedures. Based on our experience, we believe that application of ICG FGS in pediatric robotics enhances the identification of critical anatomical elements and pathological structures, thereby positively impacting both oncological and functional outcomes. This technique is safe, feasible, and versatile. We advocate the consideration of ICG as the standard of care in certain procedures such as partial nephrectomy, varicocele repair, tumor resection, and ovarian torsion. Nonetheless, further investigations are warranted to explore its potential broader applications in pediatric urology.

Robotic-assisted versus conventional laparoscopic ICG-fluorescence lymphatic-sparing palomo varicocelectomy: a comparative retrospective study of techniques and outcomes.

PURPOSE: This study aimed to compare techniques and outcomes of robotic-assisted varicocelectomy (RAV) and laparoscopic varicocelectomy (LV). METHODS: The medical records of 40 patients, who received RAV and LV over a 2-year period, were retrospectively analyzed. Palomo lymphatic-sparing varicocelectomy using ICG fluorescence was adopted in all cases. Three 5-mm trocars were placed in LV, whereas four ports, three 8-mm and one 5-mm, were placed in RAV. The spermatic vessels were ligated using clips in LV and ligatures in RAV. The two groups were compared regarding patient baseline and operative outcomes. RESULTS: All patients, with median age of 14 years (range 11-17), had left grade 3 varicocele according to Dubin-Amelar. All were symptomatic and 33/40 (82.5%) presented left testicular hypotrophy. All procedures were completed without conversion. The average operative time was significantly shorter in LV [20 min (range 11-30)] than in RAV [34.5 min (range 30-46)] (p = 0.001). No significant differences regarding analgesic requirement and hospitalization were observed (p = 0.55). At long-term follow-up (30 months), no complications occurred in both groups. The cosmetic outcome was significantly better in LV than RAV at 6-month and 12-month evaluations (p = 0.001). The total cost was significantly lower in LV (1.587,07 €) compared to RAV (5.650,31 €) (p = 0.001). CONCLUSION: RAV can be safely and effectively performed in pediatric patients, with the same excellent outcomes as conventional laparoscopic procedure. Laparoscopy has the advantages of faster surgery, smaller instruments, better cosmesis and lower cost than robotics. To date, laparoscopy remains preferable to robotics to treat pediatric varicocele.

Video-assisted anal fistula treatment (VAAFT) combined with ozonide oil dressing: standardization of technique in pediatric patients.

BACKGROUND: Anal fistula and perianal abscess are commonly acquired anorectal pathologies in children. Surgical treatment options commonly adopted are fistulotomy, fistulectomy, cutting seton placement, and more recently video-assisted anal fistula treatment (VAAFT). Optimal postoperative wound dressing remains debated. This study aimed to report our series of pediatric patients, who received VAAFT and postoperative wound dressing using ozonide oil. METHODS: All patients who underwent VAAFT between August 2018 and May 2023 were included in the study. Demographics, clinical features, pre-operative imaging, surgical details, outcome, and mid-term outcome data were retrospectively reviewed for each patient. All VAAFT procedures were performed under general anesthesia and using a 10-Ch fistuloscope. RESULTS: Thirty-three VAAFT procedures were performed in 30 patients over the study period. The median patient age was 5.7 years (range 1.75-14). Anal fistula was idiopathic in 26/30 (86.6%), iatrogenic in 2/30 (6.7%), and secondary to Crohn's disease in 2/30 (6.7%). The median duration of surgery was 23 min (range 18-40). All patients received ozonide oil dressing twice a day for 5 weeks postoperatively. The median hospital stay was 24 h (range 9-36). The median healing time was 28 days (range 17-39). With a median follow-up of 2 years (range 0.5-5), disease recurrence occurred in 3/30 (10%) patients with idiopathic fistula, who were re-operated using the same technique, with no further recurrence. No fecal incontinence or soiling was observed. CONCLUSION: Our series confirmed that VAAFT is a safe and effective technique to treat children with perianal fistula. The technique is versatile, allowing to treat fistulae of different etiologies. Postoperative course was painless and fast. Future comparative prospective studies are needed to better establish these conclusions.

Robotic-assisted surgery for gynecological indications in children and adolescents: European multicenter report.

Robotic-assisted surgery (RAS) is increasingly adopted in the pediatric population. This retrospective multicenter study aimed to report application of RAS for gynecological indications in pediatric patients. The medical records of all girls with gynecological pathology, operated in 4 different institutions over a 3-year period, were retrospectively collected. Robot docking time, total operative time, length of stay (LOS), requirement time of pain medication, complication rate, conversion rate, and pathology were analyzed. Twenty-three girls, with median age of 12.3 years (range 0.6-17.8) and median weight of 47.2 kg (range 9-73), received the following RAS procedures: ovarian cystectomy for ovarian cyst/mass (n = 10), salpingo-oophorectomy for ovarian complex mass (n = 6), bilateral gonadectomy for Turner syndrome SRY + (n = 1), salpingectomy for fallopian tube lesion (n = 1), paratubal cyst excision (n = 1), Gartner cyst excision (n = 1), paravaginal ganglioneuroma resection (n = 1), fistula closure in urogenital sinus (n = 1), and vaginoplasty using ileal flap in cloaca malformation (n = 1). Median operative time was 144.9 min (range 64-360), and median docking time was 17.3 min (range 7-50). Conversion to open or laparoscopy was not necessary in any case. Median LOS was 2.1 days (range 1-7), and median analgesic requirement was 2.2 days (range 1-6). One patient (4.3%) needed redo-surgery for recurrent Gartner cyst (Clavien 3b). This preliminary experience showed that RAS is safe and feasible for surgical treatment of gynecological pathology in pediatric patients, although no conclusive data are available to confirm its superiority over traditional laparoscopy. Randomized, prospective, comparative studies are needed to identify the gold standard approach for such indication.

Indocyanine green (ICG)-GUIDED lymphatic sparing laparoscopic varicocelectomy in children and adolescents. Is intratesticular injection of the dye safe? A mid-term follow-up study.

BACKGROUND: Laparoscopic Palomo varicocelectomy using indocyanine green (ICG) fluorescent lymphography (FL) is standardized technique to perform lymphatic sparing and avoid post-operative hydrocele. No data regarding the safety of intratesticular injection of ICG are currently available. OBJECTIVE: The study aimed to assess the safety and efficacy of this procedure at mid-term follow-up. STUDY DESIGN: Seventy-two patients (median age 14.5 years) undergoing laparoscopic Palomo varicocelectomy using ICG-FL from January 2019 to July 2022, were enrolled. Operative indication was high-grade varicocele in all patients, associated symptoms in 30/72 (41.7 %) and left testicular hypotrophy in 42/72 (58.3 %). Follow-up included clinical examination at 1, 6, 12 months and scrotal Doppler ultrasonography (US) at 12 months postoperatively to assess varicocele persistence, hydrocele, and injections-related complications. RESULTS: Lymphatic sparing was achieved using ICG-FL in all cases. No intra-operative complications or adverse reactions secondary to ICG occurred. The median follow-up was 22.8 months (range 11-49). Self-limited scrotal hematoma at the injection site occurred in 1/72 (1.4 %). Intratesticular hypoechoic millimetric area was detected at the injection site in 3/72 (4.2 %) on US. This finding disappeared after 1-year observation in 2/3 cases (66.7 %) (Figure). Persistent grade II varicocele was observed in 4/72 (5.5 %), not requiring re-intervention. No hydrocele occurred and 14/22 (63.6 %) with pre-operative hypotrophy showed catch-up growth. DISCUSSION: ICG-FL was clinically safe, with no allergy or systemic adverse reactions to the dye reported in this series. No injury directly related to the injection of the dye was clinically observed, except for self-limiting scrotal hematoma in one patient. A millimetric hypoechoic and avascular area in the body of the left testicle at the injection site was found on scrotal US at 1-year follow-up in 3 patients of our series. This finding does not seem to be clinically relevant as patients were asymptomatic and serum tumor markers were normal in all cases. Furthermore, the hypoechoic area with calcifications resolved 1 year later in 2/3 patients. The absence of evolution of this finding seems to exclude the heteroplastic nature. We hypothesized that this finding may be linked to elevated volume and/or pressure of intratesticular injection. Future prospective study with larger series and longer follow-up is needed to assess long-term testicular outcomes. CONCLUSION: Laparoscopic Palomo varicocelectomy using ICG-FL reported excellent outcomes with low incidence of varicocele persistence and no post-operative hydrocele. These preliminary data also confirmed safety of intratesticular injection of ICG at mid-term follow-up, without specific risks for both testis and patient.

Fantastic Needles and Where to Find Them During a Laparoscopic Nissen Fundoplication: Review of Safety Measures to Avoid Needle Loss During Minimally Invasive Surgery.

BACKGROUND: Losing a needle during laparoscopic surgery may be a dramatic moment for the surgeon and potentially have clinical and medico-legal consequences. This case report aims to describe an unusual case of needle loss that occurred during laparoscopic Nissen fundoplication and how to prevent its further occurrence. METHODS: The patient is an 11-year-old boy with a body mass index of 32.4 kg/m 2 . He suffered from severe gastroesophageal reflux disease not responding to medical therapy and hiatal hernia. A laparoscopic Nissen fundoplication was performed. RESULTS: At the closure of the Nissen wrap, CO 2 leakage through the umbilical trocar caused the needle lost during the introduction of the thread. We attempted to find the needle by exploring the entire abdominal cavity without success. Therefore, we decided to complete the surgical procedure. Another 2/0 nonresorbable thread was inserted in the same way as before. But this suture also disappeared. Hence, we manually straightened the needle and introduced it under vision. The operation was accomplished successfully. An intraoperative x-ray was obtained, showing the 2 needles at the level of the 12th rib, near the working port used for the liver retractor. A peritoneal window was created using a monopolar hook, allowing to finally extract the 2 hidden needles. CONCLUSION: The loss of needles, although a rare event, can occur during laparoscopic surgery. Based on our experience, we suggest that needle insertion during laparoscopic operations should be performed under direct vision, especially in obese patients, to reduce the likelihood of such complications.

Pediatric Testicular Cavernous Hemangioma With Acute Onset Mimicking Testicular Torsion: Case Report and Review of the Literature.

Testicular cavernous hemangioma is a rare benign vascular tumor that typically occurs in childhood and adolescence. The clinical presentation may be variable and lead to diagnostic difficulties. We report an atypical presentation of intratesticular cavernous hemangioma with acute onset mimicking testicular torsion in a teenager. Inadvertent minor scrotal injury may have probably triggered the rupture of the hemangioma, leading to hemorrhage and infarction of the testicle. Although ultrasonography findings and serum tumor markers may be helpful in differential diagnosis, surgical exploration, and pathology examination are essential for definitive diagnosis.

Indocyanine Green (ICG) Fluorescence-Assisted Open Surgery Using the Rubina® Lens System in the Pediatric Population: A Single-Center Prospective Case Series.

INTRODUCTION: There are scarce papers about the use of fluorescence-guided surgery (FGS) in the open surgical field. This study aimed to assess the usefulness of FGS in an open setting in the pediatric population and to report our preliminary experience using the Rubina® Lens system. METHODS: All patients undergoing ICG fluorescence-assisted open surgery over the period September 2022-September 2023 were enrolled. Each surgical procedure was performed using the Rubina® Lens for ICG fluorescence visualization. RESULTS: A total of 25 patients, 14 boys and 11 girls with a median age at surgery of 5.8 years-old (range 0-15), were enrolled. Surgical indications were dermoid/epidermoid cysts of the head (n = 7), lymphangiomas of the head/neck (n = 2), thyroglossal duct cysts (n = 7), gynecomastia (n = 3), preauricular fistula (n = 2), second branchial cleft fistula (n = 1), fibrolipoma of the shoulder (n = 1) and myofibroma of the gluteal/perineal region (n = 2). In all procedures, an intralesional injection of 2.5 mg/mL ICG solution using a 30-gauge needle was administered. No adverse reactions to ICG occurred. Median operative time was 68.6 min (range 35-189). The visualization of ICG-NIRF with the Rubina® Lens was achieved in all cases. No intraoperative complications were reported. Postoperative complications occurred in 3/25 patients (12%), with gynecomastia (n = 1), thyroglossal duct cyst (n = 1) and neck lymphangioma (n = 1), who developed a fluid collection in the surgical site, requiring needle aspiration in outpatient care (Clavien-Dindo 2). Complete mass excision was confirmed with pathology reports. CONCLUSIONS: Based on this initial experience, FGS using the Rubina® Lens was very helpful in open surgery, providing enhanced visualization of anatomy and identification of margins, real-time reliability and low complication rate. It was easy to use, time saving, feasible and clinically safe. Previous experience in MIS is necessary to adopt this technology. The accuracy of the injection phase is important to avoid diffusion of the ICG into the perilesional tissue.