Retrograde Intrarenal Surgery in Children: Evolution, Current Status, and Future Trends.

Introduction: Incidence of urolithiasis in children has increased in recent years and with technological advancements and miniaturization of surgical instruments, pediatric urologists have acquired an impressive arsenal for their treatment. Retrograde intrarenal surgery (RIRS) has gained widespread popularity as it is a natural extension of semirigid ureteroscopy and can be done through natural orifice minimizing the morbidity of percutaneous access. The aim of this narrative review is to describe how RIRS has evolved over the decades in children and if the age-related anatomical difference impacts reported outcomes especially stone-free rate (SFR) and complications. Materials and Methods: An electronic literature search from inception to October 15, 2021 was performed using Medical Subject Heading terms in several combinations on PubMed, EMBASE, and Web of Science without language restrictions. A total of 2022 articles were founded and 165 articles were full-text screening. Finally, 2 pediatric urologists included 51 articles that summarize the available literature regarding the development and use of RIRS in children. Results: RIRS as of today is well established as a superior modality for all stones in all locations compared with extracorporeal shockwave lithotripsy both in children and adults. The passive dilation has decreased the need of active ureteral dilation, but the need to perform prestenting is not defined yet. Regarding the use of the ureteral access sheath, the literature tends to lean toward its placement in most cases, but we do not know its long-term effects over the growth of children. Finally, the SFR has increased as the experience of pediatric urologists increases, as well as the number of complications has decreased. Conclusion: RIRS in pediatrics has crossed many milestones, yet many areas need further research and larger data are required to make RIRS the procedure of choice for renal stone management in children across all age groups.

Practical recommendations of the EAU-ESPU guidelines committee for monosymptomatic enuresis-Bedwetting.

BACKGROUND AND AIMS: The objective of this update of the EAU-ESPU guidelines recommendations for nocturnal enuresis was to review the recent published literature of studies, reviews, guidelines regarding the etiology, diagnosis and treatment options of nocturnal enuresis and transform the information into a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist and urologist. MATERIAL AND METHODS: Since 2012 a monthly literature search using Scopus® was performed and the relevant literature was reviewed and prospectively registered on the European Urology bedwetting enuresis resource center (http://bedwetting.europeanurology.com/). In addition, guideline papers and statements of the European Society for Paediatric Urology (ESPU), the European Association of Urology (EAU), the National Institute for Health and Care Excellence (NICE) and the International Children Continence Society (ICCS) were used to update the knowledge and evidence resulting in this practical recommendation strategy. Recommendations have been discussed and agreed within the working group of the EAU-ESPU guidelines committee members. RESULTS: The recommendations focus to place the child and his family in a control position. Pragmatic analysis is made of the bedwetting problem by collecting voiding and drinking habits during the day, measuring nighttime urine production and identification of possible risk factors such as high-volume evening drinking, nighttime overactive bladder, behavioral or psychological problems or sleep disordered breathing. A questionnaire will help to identify those risk factors. CONCLUSION: Motivation of the child is important for success. Continuous involvement of the child and the family in the treatment will improve treatment compliance, success and patient satisfaction.

Robot-assisted laparoscopic pyeloplasty (RALP) in children with horseshoe kidneys: results of a multicentric study.

PURPOSE: This multicentric study aimed to report our experience with robot-assisted laparoscopic pyeloplasty (RALP) in children with horseshoe kidney (HSK). METHODS: The records of 14 patients (11 boys and 3 girls with an average age of 9 years), who underwent RALP for repair of pelvi-ureteric junction obstruction (PUJO) in HSK in five international pediatric urology units over a 5-year period, were retrospectively reviewed. A dismembered pyeloplasty with no division of isthmus was performed in all the cases. RESULTS: The average operative time including docking was 143.5 min (range 100-205). No conversions to laparoscopy or open surgery or intra-operative complications occurred. Patients were discharged on postoperative day 2 following catheter and drain removal. The JJ stent was removed at mean 33 days postoperatively. Overall success rate was 92.8%. As for postoperative complications, we recorded a urinary tract infection (UTI) and stent-related irritative symptoms, managed with medical therapy, in two patients (II Clavien) and an anastomotic stricture in one patient needing surgical revision with no further recurrence (IIIb Clavien). At follow-up, all the patients (one after redo-surgery) reported complete resolution of symptoms, improvement of hydronephrosis on ultrasound and no residual obstruction on diuretic renogram. CONCLUSIONS: Our experience suggested that RALP in HSK is safe, feasible and with good medium-term outcomes in expert hands. An accurate pre-operative planning associated with a standardized technique is key points to achieve good surgical and functional outcomes in these challenging cases. The da Vinci robot technology offers the advantages of MIS procedures and overcomes the technical challenges of laparoscopic approach.

Validation of a Simulation-training Model for Robotic Intracorporeal Bowel Anastomosis Using a Step-by-step Technique.

OBJECTIVE: To develop and validate a training model for the robotic intracorporeal bowel anastomosis. METHODS: For simulation, surgeons with varying levels of experience were instructed about bowel anastomosis robotic surgical simulation in a short educational video. All participants performed the required steps for the intracorporeal bowel anastomosis under standardized conditions. The procedure consists of the following steps: division of the bowel with a stapler (1), incision and opening of the bowel limbs at the antimesenteric angle (2), insertion of the stapler into the 2 bowel limbs for the side-to-side anastomosis (3), and transverse closure of the anastomosis with the stapler (4). All simulations were performed using the daVinci SI robotic system. Face and content validity were assessed using a standardized questionnaire. Construct validity was evaluated using the Global Evaluative Assessment of Robotic Skills, a validated global performance rating scale. RESULTS: Twenty-two surgeons participated including 6 robotic experts and 16 trainees. The expert participants rated the bowel anastomosis model highly for face validity (median 4/5; 64% agree or strongly agree), and all participants rated the content as a training model very highly (median 4.5/5; 100% agree or strongly agree). Discrimination between experts and trainees using Global Evaluative Assessment of Robotic Skills demonstrated construct validity (novice 17.6 vs expert 24.7, P = .03). CONCLUSION: We demonstrate that the bowel anastomosis robotic surgical simulator is a reproducible and realistic simulation that allows for an objective skills assessment. We establish face, content, and construct validity for this model. This step-by-step technique may be utilized in training surgeons desiring to acquire skills in robotic intracorporeal urinary diversion.

Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines.

CONTEXT: Undescended testis is the most common endocrinological disease in the male newborn period. Incidence varies between 1.0% and 4.6% in full-term neonates, with rates as high as 45% in preterm neonates. Failure or delay of treatment can result in reduced fertility and/or increased testicular cancer risk in adulthood. OBJECTIVE: To provide recommendations for the diagnosis and treatment of boys with undescended testes which reduce the risk of impaired fertility and testicular cancer in adulthood. EVIDENCE ACQUISITION: Embase and Pubmed were searched for all relevant publications, from 1990 to 2015 limited to English language. Data were narratively synthesized in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed. EVIDENCE SYNTHESIS: There is consensus that early treatment, by 18 months at the latest, for undescended testes is mandatory to avoid possible sequelae regarding fertility potential and cancer risk. The current standard therapy is orchidopexy, while hormonal therapy is still under debate. However, in some individuals the successful scrotal placement of previously undescended testes may not prevent potential negative long-term outcomes regarding fertility and testicular malignancy. CONCLUSIONS: There is good evidence for early placement of undescended testes in the scrotal position to prevent potential impairment of fertility and reduce the risk of testicular malignancy. No consensus exists on the various forms of hormonal treatment, which are assessed on an individual basis.