Twenty-year experience with laparoscopic and retroperitoneoscopic nephrectomy in children: considerations and details of technique.

BACKGROUND: Nephrectomy is probably the most common urological indication for minimally invasive surgery (MIS) in children. The authors reported their experience in laparoscopic and retroperitoneoscopic nephrectomy analyzing their 20 years of experience in this procedure. METHODS: In a 20-year period (1995-2015), the authors performed 149 nephrectomies in children using MIS (87 left, 62 right). One hundred and one nephrectomies were performed using laparoscopy (LN) and 48 using retroperitoneoscopy (RN). Patients included 90 girls and 59 boys (average age 5.7 years). All the removed kidneys were nonfunctioning because of benign diseases: VUR (84), UPJO (38), MKDK (20), xanthogranulomatosis pyelonephritis (4), nephropathy causing uncontrollable hypertension (2) and nephrolithiasis (1). RESULTS: We had no conversion in laparoscopy. As for RN, we had 2 conversions to laparoscopy at the beginning of experience due to peritoneal opening. Operative time varied from 30 to 130 min in laparoscopy (average 47 min) and from 60 to 150 min (average 78 min) in retroperitoneoscopy. We recorded 8 complications (5.3 %): 3 small bleedings (2 RN, 1 LN) during dissection, 2 peritoneal perforations during RN requiring conversion in LN, 1 abdominal abscess in case of xanthogranulomatosis pyelonephritis after LN requiring a redo surgery to drain the abscess, 1 instrumentation failure (LN) and 1 refluxing ureteral stump after RN requiring a redo surgery to remove it. CONCLUSIONS: LN is easier and faster to perform compared to RN. Complication rate was higher after RN compared to LN. In case of xanthogranulomatous pyelonephritis or other kidney infections or in case of previous renal surgery, retroperitoneoscopy is contraindicated. In case of VUR, LN is preferable to RN because it is fundamental to remove all the ureter. On the basis of our 20-year experience, we clearly prefer to perform nephrectomy using laparoscopy rather than retroperitoneoscopy leaving the indication to adopt RN only for the rare cases of MKDK.

The immunoprofile of interstitial Cajal cells within adenomyosis/endometriosis lesions.

Adenomyosis and endometriosis are lesions which have aroused the interest for the investigation of antibodies specific to the structures from the composition, but also for the cause behind the appearance of these lesions in completely different structures. The impact they have on fertility is not known entirely, for they are difficult to diagnose. Endometriosis causes infertility and it is a hard to treat lesion. The research performed in the last years has been focused on the so-called linkage analysis, or reverse genetics. It refers to identifying the genes which are prone to developing this affection. We investigated clinically 40 female inpatients (n=40) who had underwent genital surgery and received a variegate diagnosis in the "Sf. Ioan" Emergency Hospital, Bucharest, Romania, between January-September 2014 and also their histopathology and immunohistochemistry. We proceeded with the histopathology examination in order to establish a diagnosis in respect to the admission diagnosis and then, using the ABC (Avidin-Biotin complex) method, we analyzed the immunohistochemistry of the following markers: S100 protein (for detection of ganglia and nerve cells), CD117÷c-kit (selective detection of interstitial Cajal cells - ICC), desmin and vimentin (intermediary filaments for detecting ICC-like cells, which cohabit with uterine myocytes and are not contractile cells) and CD10 (a sensitive and useful immunomarker in the diagnosis of endometrial stroma and, in some cases, of neoplasia). Our study, regarding the immunoprofile of some markers of adenomyosis÷endometriosis lesions, supports the hypothesis that the interstitial Cajal cells are non-reactive, they are not in relationship with investigated lesions, but CD10 is a very useful marker to highlight the endometrial stroma in query cases.

European Society of Pediatric Endoscopic Surgeons (ESPES) guidelines for training program in pediatric minimally invasive surgery.

PURPOSE: The aim of this paper was to propose structured guidelines for a European pediatric MIS training program created by ESPES. METHODS: A questionnaire, focused on how the pediatric training program in MIS has to be structured, was proposed to all participants at the ESPES Congress in Marseille in 2013. RESULTS: We received 178 questionnaires but only 139 questionnaires were fully completed and analyzed. All respondents agree that the training program has to be divided into 4 steps: (1) theoretical part: 2 theoretical courses in laparoscopy (101/139 respondents, 72.7 %), 1 theoretical course in retroperitoneoscopy (99/139 respondents, 71.2 %) and 1 in thoracoscopy (91/139 respondents, 65.5 %); (2) experimental part: 10-20 h of training on pelvic trainer (103/139 respondents, 74.1 %) and 10 h of training on animal models (91/139 respondents, 65.5 %); (3) stages in European centers of reference for MIS: a 1-3 months stage (96/139 respondents, 69.1 %); (4) personal experience: 30 procedures as cameraman (98/139 respondents, 70.5 %) and >50 basic MIS procedures as main surgeon under supervision (114/139 respondents, 82 %). CONCLUSIONS: On the basis of our survey ESPES MIS training curriculum for pediatric surgeons must contain the following educational components: (1) theoretical knowledge; (2) practice-based learning and improvement in experimental setting; (3) stages in European centers of reference for MIS; (4) personal operative experience. At the end of the training program, ESPES will analyze the candidate training booklet and release for each applicant an ESPES certification after an exam.

Laparoscopic partial nephrectomy in duplex kidneys in infants and children: results of an European multicentric survey.

BACKGROUND: We aim to report a 5-year retrospective multicentric European survey about the outcome of laparoscopic partial nephrectomy in infants and children with duplex kidneys. METHODS: The data of fifty-two children underwent laparoscopic partial nephrectomy (42 upper-pole nephrectomies and 10 lower-pole nephrectomies) in six European centers of Pediatric Surgery, were collected and analyzed. Median age at surgery was 5.1 years (range 6 months-9.7 years). There were 32 girls and 20 boys. In 37 patients, the left side was affected and in 15 patients the right side. For the right side, 4 trocars were used and for the left side 3/4 trocars. Special hemostatic devices were used for dissection and parenchymal section in all centers. We assessed intraoperative and postoperative morbidity. RESULTS: Median length of surgery was 166.2 min (70-215 min). No conversion to open surgery nor intraoperative bleeding was reported. Mean hospitalization was 3.5 days. We recorded 10/52 complications (4 urinomas, 2 recurrent UTIs, 4 prolonged urinary leakage), all managed conservatively. Reoperation rate was 0%. No loss of renal function on the residual kidney moiety was recorded in all operated patients. CONCLUSIONS: Laparoscopic partial nephrectomy remains a technically challenging procedure performed only in pediatric centers with high experience in minimally invasive surgery. Although the median operative time was higher than 2 h, we recorded no conversions in our series. The complication rate remains high (10/52-19.2%). All were II grade complications according to Clavien-Dindo classification and were treated conservatively without the need of other surgical procedures.

Technological update of the video-endoscopic approach of the diagnosis and staging of tumors in children.

The pediatric patient is often difficult to diagnose, especially since the surgical pathology is tumoral. Establishing the histopathological diagnosis of a tumor, staging of a disease and certifying the existence of rare pediatric affections are three of the motives for which the specialists frequently appeal to an exploratory laparoscopy, accompanied by biopsy procedures. The paper presents the laparoscopic biopsy experience of the team from the Department of Pediatric Surgery, "Maria Sklodowska Curie" Emergency Clinical Hospital for Children, Bucharest, Romania. From 2000 to 2013, 95 such procedures were performed (7.76% of a total of 1224 laparoscopic interventions). In many cases, the laparoscopy had an exclusive diagnostic purpose, of whose success has been primarily responsible the targeted biopsy. Current issues are discussed, centered on the most advanced technologies used in minimally invasive approach of pediatric malignancies, referring to the effect of minimizing the possible complications that can arise from this type of intervention. The authors concluded that laparoscopic technique is the method of choice in comparison to other ways of biopsy (classical surgery, ultrasound guidance, tomography, etc.), and it is characterized by a high diagnostic value.

The impact of melanocytic cell destruction in pediatric facial burns and plastic surgery therapeutic management.

The main role of the melanin production belongs to the keratinocyte-Langerhans-melanocyte complex that within a burn injury might be destroyed. A particular aspect has the pediatric patient with burns due to a deficit in pigment synthesis and particularities involving the growth process of facial structures. This article presents four eloquent cases of pediatric patients with sequelae, consequence of facial burns that varied in depth and etiology. The age of patients at time of admission was between four and 18 years, and the interval between production of the primary lesion and admission was variable (0-17 years). Conservative treatments prove to be insufficient, requiring the destroyed structures to be replaced with compatible tissue by surgical intervention. The therapeutic success of skin grafts and dermal substituents acknowledges the main role of plastic surgery. New technologies as well as new cell focused studies support the clinical proven results as well as they enlarge the spectrum of potential available therapeutic methods in order to obtain the best therapeutic results.

Fibroepithelial polyps - a rare pathology of the upper urinary tract.

Ureteral fibroepithelial polyps are a rather uncommon pathological entity. However, an increase of their incidence was recorded during the recent period, probably due to better access to the investigative methods. The aim of this study was to assess the diagnosis and endoscopic treatment particularities of these cases. Our experience was based on 11 cases evaluated in the last 12 years. The mean patients' age was 43 years (between 26 and 54). Hematuria, flank pain, suprapubic discomfort and urinary frequency were the main symptoms. Diagnosis was based on ultrasonography, IVP (intravenous pyelography), cystoscopy and ureteroscopy and confirmed by histopathology. In four cases, smooth polypoid masses covered by apparently normal urothelium and protruding through the ureteral orifice were discovered. In six cases, the fibroepithelial polyps appeared as a large filling defect in the ureter. In another case, a large, organized, blood clot protruding from the left orifice imposed ureteroscopy with the identification of a mid-ureteral polyp. Ten cases were treated by ureteroscopic laser ablation, while transureteral resection was applied in one case. After complete excision of the polypoid base, a double-J stent was indwelled for six weeks. Histology described the lesions as fibroepithelial polyps: hyperplastic urothelium overlying an intact basement membrane with extensive submucosal edema, dilated blood vessels, chronic inflammatory cells and fibrous stroma. No recurrences were found during a follow-up period of 56 months (between 6 and 72 months). Ureteral fibroepithelial polyps represent a rare pathology, ureteroscopy being the gold standard diagnostic method. The appearance and location of the lesions are pathognomonic, and complete excision may be performed by ureteroscopic approach. Recurrences seem to be rare in these tumors.