Robotic-assisted surgery in pediatrics: what is evidence-based?-a literature review

BACKGROUND AND OBJECTIVE

The use of robotic-assisted surgery (RAS) has increased more slowly in pediatrics than in the adult population. Despite the many advantages of robotic instruments, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) still presents some limitations for use in pediatric surgery. This study aims to examine evidence-based indications for RAS in the different fields of pediatric surgery according to the published literature.

METHODS

A database search (MEDLINE, Scopus, Web of Science) was performed to identify articles covering any aspect of RAS in the pediatric population. Using Boolean operators AND/OR, all possible combinations of the following search terms were used: robotic surgery, pediatrics, neonatal surgery, thoracic surgery, abdominal surgery, urologic surgery, hepatobiliary surgery, and surgical oncology. The selection criteria were limited to the English language, pediatric patients (under 18 years of age), and articles published after 2010.

KEY CONTENT AND FINDINGS

A total of 239 abstracts were reviewed. Of these, 10 published articles met the purposes of our study with the highest level of evidence and therefore were analyzed. Notably, most of the articles included in this review reported evidence-based indications in urological surgery.

CONCLUSIONS

According to this study, the exclusive indications for RAS in the pediatric population are pyeloplasty for ureteropelvic junction obstruction in older children and ureteral reimplantation according to the Lich-Gregoire technique in selected cases for the need to access the pelvis with a narrow anatomical and working space. All other indications for RAS in pediatric surgery are still under discussion to date, and cannot be supported by papers with a high level of evidence. However, RAS is certainly a promising technology. Further evidence is strongly encouraged in the future.

Management of Primary Spontaneous Pneumothorax in a Third-Level Pediatric Surgical Center: A Retrospective Study

INTRODUCTION

The management of primary spontaneous pneumothorax (PSP) in pediatrics remains controversial. The aim of this study was to investigate the risk of recurrence after non-surgical treatment vs. surgery, the difference in the length of stay (LOS) between various treatment options, and the role of computed tomography (CT) in the management of PSP.

MATERIALS AND METHODS

We retrospectively reviewed patients admitted to our Pediatric Surgery Unit for an episode of PSP between June 2009 and July 2020. Medical records including clinical presentation at admission, diagnostics, treatments, complications, and LOS were collected.

RESULTS

Twenty-three patients (22 males and 1 female) were included in this study. Median age was 15.65 (range 9-18). Chest X-rays were performed in all patients and showed 5 small (22%) and 18 large (78%) PSP. Chest drain was used for large PSP (≥2 cm) if the patient was clinically unstable. Eleven patients (48%) were managed non-operatively with observation alone and a recurrence rate of 18%, chest drain was used in 11 patients with a recurrence rate of 36%, and surgery was deemed necessary as a first treatment choice in one case. Six patients (27%) had an episode of relapse after non-operative management or chest drain placement. Following surgery, a relapse occurred in 2 of the 6 patients. Chest drain insertion was associated with a longer LOS than observation alone (6.36 vs. 2.4 days), and surgery resulted in a longer LOS than other types of treatment (P = 0.001).

CONCLUSION

According to our experience, small PSP or clinically stable larger PSP can be treated conservatively with observation alone. Operative management should be taken into consideration in children with large symptomatic PSP, persistent air leak, and/or relapse after chest drain insertion.

Medium-term outcome after stented and un-stented distal urethroplasty: A retrospective analysis on redo-urethroplasty need and cosmetic results

INTRODUCTION

Long-term complication rates after distal hypospadias repair can be close to 20%. There are no available guidelines regarding the need for a catheter in distal urethroplasty. We report a retrospective analysis on medium-term redo-urethroplasty rate and cosmetic results after a two-years pilot study on stented/un-stented distal urethroplasties.

MATERIALS AND METHODS

A total of 11 stented (Group A) and 17 un-stented (Group B) Snodgrass-procedures were performed by the same pediatric surgeon at our Institution (2011-2013). The median age at surgery was 2.1 years (range 1-8.5). Inclusion criteria were primitive distal defect, same surgeon in both interventions, catheter-free discharge. The median follow-up was 6.4 years (range 1.5-8.1). All patients received at least one post-operative clinical-cosmetic examination (HOSE). The aim of our study was to compare medium-term complications and redo-urethroplasty rates before starting a randomized study. A retrospective analysis was performed. We used Fisher's exact-test (P < 0.05) for statistical analysis.

RESULTS

Of 28 complications, 5 required redo-surgery: 2/11 stented-cases, 3/17 un-stented. Cosmetic results were satisfactory in both groups. These results were not statistically significant (P = 1.000).

CONCLUSION

Long-term follow-up is mandatory to know redo-urethroplasty rate and cosmetic outcome after distal stented/un-stented repair. Further studies are needed to evaluate the role of catheter placement and the definitive outcome in distal urethroplasty.

Neo-phalloplasty in children and adolescents for acquired penile loss

INTRODUCTION

From 2000 to 2019, the De Castro's neo-phalloplasty was used in 47 patients with congenital and acquired penile loss.

PURPOSE

Herein, the technical aspects of penile reconstruction and the outcomes in 17 children and adolescents treated for total or sub-total acquired penile loss are reported.

MATERIAL AND METHODS

The median age at the time of injury was 3 months (range: 2 days-15 years). Twelve patients were born with normal penis but suffered injuries (11) or underwent surgical resection of the penis (1). The remaining 5, affected by bladder exstrophy (2) or cloacal exstrophy (3), had penile loss due to surgical complications.

RESULTS

The median age at the time of surgery was 5 years (range: 2-20 years). The median length of the procedure was 5 h (range 4-8 h). Skin expander were inserted in preparation of phalloplasty in 9 patients. Corpora-cavernosa remnants were found and incorporated in the neophallus in 12 patients. In 7 patients, urethral remnants were also incorporated into the repair, placing the meatus at the tip of the neophallus. In the remaining patients the urethra was left in the acquired position after penile loss creating a perineal (2), scrotal (3), peno-scrotal (3), or posterior penile (1) urethrostomy. The first patient of this series was the only patient to receive simultaneously phalloplasty and total urethroplasty, with failure of urethral reconstruction. The median follow-up was 2 years (range 1-11 years). The overall complication rate was about 47%. All of the complications were late and required surgical revision. The results were assessed regarding overall functionality (voiding, erection/erogenous areas, masturbation/sexual intercourse) and aesthetic outcome using subjective and objective parameters. Psychological evaluation for both patient and parents was performed in 4 cases.

DISCUSSION

There are no specific guidelines for treating significant penile injuries in the pediatric population. We do not think secondary severe penile impairments should wait until adult age for repair. In this specific subgroup of patients technical aspects differ from phalloplasty done for congenital aphallia, due to the possible presence of corpora-cavernosa/urethral remnants and the feasibility to perform a "functional phalloplasty" with very encouraging results.

CONCLUSION

The De Castro's neo-phalloplasty remains one of the few techniques available for total penile reconstruction in pediatric age group. Data demonstrate that this technique for acquired aphallia is feasible and reproducible, however, it is a challenging procedure with a high complication rate and likelihood of revisions.

Medium-term outcome after stented and un-stented distal urethroplasty: A retrospective analysis on redo-urethroplasty need and cosmetic results

INTRODUCTION

Long-term complication rates after distal hypospadias repair can be close to 20%. There are no available guidelines regarding the need of a catheter in distal urethroplasty. We report a retrospective analysis on medium-term redo-urethroplasty rate and cosmetic results after a two-year pilot study on stented/un-stented distal urethroplasties.

MATERIALS AND METHODS

A total of 11 stented (Group A) and 17 un-stented (Group B) Snodgrass-procedures were performed by one pediatric surgeon at our Institution (2011-2013). The median age at surgery was 2.1 years (range 1-8.5). Inclusion criteria were primitive distal defect, same surgeon in both interventions, catheter-free discharge. The median follow-up was 6.4 years (range 1.5-8.1). All patients received at least one post-operative clinical-cosmetic examination (HOSE). The aim of our study was to compare medium-term complications and redo-urethroplasty rates before starting a randomized study. A retrospective analysis was performed. We used Fisher's exact-test (P<0.05) for statistical analysis.

RESULTS

Of 28 complications, 5 required redo-surgery: 2/11 stented-cases, 3/17 un-stented. Cosmetic results were satisfactory in both groups. These results were not statistically significant (P=1.000).

CONCLUSION

Long-term follow-up is mandatory to know redo-urethroplasty rate and cosmetic outcome after distal stented/un-stented repair. Further studies are needed to evaluate the role of catheter placement and the definitive outcome in distal urethroplasty.

Glans ischemia after circumcision in children: Two case reports

BACKGROUND

Circumcision refers to the removal of the skin covering the tip of the penis and is one of the most common surgical procedures performed in childhood. Even though circumcision is a well-standardized operation, several minor and major complications may be experienced by paediatric surgeons. Glans ischemia (GI) has been widely reported in the paediatric literature as a complication following circumcision. Nonetheless, etiopathogenesis of GI is not well defined and management guidelines are lacking.

CASE SUMMARY

We describe our experience with this rare and scary complication using subcutaneous enoxaparin alone or in association with a topical vasodilator.

CONCLUSION

Hypothetical causes and different management strategies are discussed.

Bilateral sactosalphinx and congenital adrenal hyperplasia: case report on two rare conditions in two virgin girls

BACKGROUND

Sactosalpinx means a collection of fluid (serum, blood or pus) in the fallopian tube. CAH (Congenital Adrenal Hyperplasia) is a typical 46XX DSD (Disorder of Sex Development) due to a steroidogenic enzymatic defect. Both conditions are rare and can lead to reduced fertility rate.

CASE PRESENTATION

We describe two post-menarche virgin girls with CAH who were hospitalized for acute abdomen due to laparoscopically confirmed sactosalpinx. Case 1 recovered after conservative management, case 2 after a second-look and bilateral salpingectomy. The first case consisted of right sactosalpinx and previous peritonitis reported; the second one of bilateral symptomatic pyosalpinx and previous vaginal stenosis. Recurrent abdominal pain persisted at follow-up in Case 1: post-operative MRI (Magnetic Resonance Imaging) showed bilateral hydrosapinx that disappeared at a following ultrasound scan control. Follow-up was uneventful 36 months after surgery in Case 2, except for the surgical revision of the vaginal introitus.

CONCLUSIONS

CAH-sactosalpinx association is a very rare but not negligible event. We suggest a conservative approach for sactosalpinx if tubal and/or ovary torsion can be excluded. Pyosalpinx is more challenging to treat, but during pediatric age we suggest starting with a conservative approach, especially in patients with CAH who have a potential low fertility rate. Careful gynecological follow-up after menarche is recommended to rule out any further causes of infertility.

A young girl with right ovarian torsion and left ovarian ectopy

Background

Mayer-Rokitansky-Küster-Hauser (MRKHS) syndrome refers to congenital hypoplasia/aplasia of the uterus, the cervix and the upper 2/3 of the vagina, in females with normal ovaries and fallopian tubes, secondary sexual characteristics and 46 XX karyotype. This condition originates from abnormal development of Müller’s paramesonephric ducts in the early stages of embryonic development. Kidney agenesis or malformations are the most commonly associated with unilateral kidney agenesis. Ovaries may be ectopic in 16–19% of MRKHS patients. Primary amenorrhoea, due to the absence of the uterus, is the most common presentation. Female karyotype confirmation is mandatory to differentiate it from complete androgen insensitivity syndrome and 17-alpha-hydroxylase deficiency. The management of MRKHS is multidisciplinary in order to encompass psychological, medical and surgical issues.

Case presentation

A four-year-old girl, presented to the emergency department complaining of left groin swelling noted 2 days earlier. The patient had recently been evaluated for an episode of acute abdominal pain and vomiting, with a final diagnosis of right ovarian torsion. At that time, the ultrasound imaging was not able to identify the left kidney, the left ovary and uterus. Surgical abdominal exploration confirmed the right ovarian torsion and was not able to identify the left kidney and the left ovary. Only a remnant of the uterus was present. Therefore, the right ovary was removed, and a diagnosis of MRKHS was made. Ultrasound imaging showed a left inguinal hernia. The hernial sac consisted of a solid oval vascularized formation suggestive of an annexe. The patient underwent a surgical procedure to correct the left inguinal hernia. In the operating setting, the presence of a vascularized, ectopic ovary carrying the tuba inside the hernial sac was observed.

Conclusions

In front of a patient with ovarian torsion and anatomical features suggestive of MRKHS, both the ovaries should always be searched for, with a high suspicion threshold for extrapelvic ovary. Identifying the ectopic ovary, in this case, helped to preserve patient fertility, avoiding a possible torsion.

Laparoscopy or retroperitoneoscopy for pediatric patients with adrenal masses?

Minimally invasive approach to the adrenal gland was first reported in 1992. Since then, the experience with the laparoscopic technique for adrenal disease in children has been limited. We report our experience with minimally invasive adrenal surgery in children. Two young girls (2 and 4 years old) with a left adrenal mass were operated using minimally invasive surgery (MIS) in our Unit. Ultrasonography and MRI showed in the oldest a 2 x 3 cm adrenal mass, while in the youngest a 5.5 x 5 cm adrenal tumor was found. According to the pre-existing literature, we approached the smallest lesion via retroperitoneoscopy, and the largest one laparoscopically. The operating time was 110 minutes for retroperitoneoscopy and 75 minutes for laparoscopy. No major intra or postoperative complications occurred. There were no conversions to open surgery. Postoperative hospital stay was 5 days for both patients. In both cases, the anatomo-pathological result was an adenoma. Minimally invasive adrenalectomy is a safe and feasible procedure in children with good results. For lesions smaller than 3-4 cm retroperitonescopy is feasible, while for tumors larger than 5 cm, due to malignancy risk, the laparoscopic approach is indicated. To keep oncologic criteria it is important to avoid tumor rupture and to extract the specimen in an endobag.

Is retroperitoneoscopic renal ablative surgery easier and safer using a new hemostatic device compared with clips and monopolar coagulation? A comparative study

AIM

The aim of study was to retrospectively analyze our series of total and partial retroperiotoneoscopic nephrectomies performed in the last 5 years.

METHODS

Twenty-two procedures were performed, 20 patients underwent nephrectomy and 2 patients underwent partial nephrectomy. The 20 patients who underwent nephrectomy were divided in 2 groups: group 1 (G1) patients-1-10, for whom we performed the procedure using monopolar coagulation, and group 2 (G2) patients 11-20 for whom we used a new hemostatic device to perform dissection and hemostasis. The results were analyzed using χ2 test. The results of partial nephrectomies were analyzed separately.

RESULTS

No conversion were reported. We analyzed 6 parameters to compare the results: operative time (OT), estimated blood loss (EBL), need for transfusion (NT), complications, time to oral intake (TOI), hospital stay (HS). OT in G1 was in median 85 minutes, in G2 65 minutes (P=0.004); EBL was 15 mL for G1 and 5 mL for G2 (P=0.000.), NT was not necessary in both, in G1 we had 2 complications and 1 complication in G2; TOI was day 1 for both groups; median HS was 3 days for both. As for heminephrectomy, OT was 120 and 140 min, EBL 30 mL in both, NT not necessary, TOI was 1 day and HS 4 and 5 days respectively.

CONCLUSION

Our study shows that the use of a new hemostatic devices reduce significantly OT and EBL in children underwent renal ablative surgery for benign pathologies compared with the use of monopolar coagulation.

Work-related upper limb musculoskeletal disorders in pediatric minimally invasive surgery: a multicentric survey comparing laparoscopic and sils ergonomy

PURPOSE

Surgeons are at risk for developing work-related musculoskeletal symptoms (WMS). The present study aims to compare laparoscopy and SILS ergonomy among pediatric surgeons.

METHODS

A questionnaire formed by 17 questions was mailed to 14 pediatric surgeons, seven with a large experience in laparoscopy and seven in SILS. All surgeons completed the survey. The questionnaires were focused on the type of laparoscopic or SILS activity, location and type of pain, need for drugs and its physical consequences. Results were analyzed using χ(2) test.

RESULTS

Results indicated a similar incidence of WMS with shoulder symptoms (>75%) in both groups. In laparoscopic group this pain is evident only after a long lasting procedure, while in SILS group the pain is present after each procedure performed. SILS surgeons used painkillers and other therapies statistically more frequently than laparoscopic group (χ(2) = 0.001).

CONCLUSIONS

This study confirms there is a strong association between WMS and MIS surgery. The incidence of pain is similar in both groups. Pain was present only after long lasting procedures in laparoscopic group, while SILS surgeons have pain after each procedure performed. In addition SILS surgeons use more frequently painkillers and other therapies compared to laparoscopic surgeons. In conclusion, it seems that SILS has a worse ergonomy compared to laparoscopy.

Technical standardization of laparoscopic lymphatic sparing varicocelectomy in children using isosulfan blue

PURPOSE

The lymphatic preservation to prevent hydrocele formation after laparoscopic varicocelectomy is essential. Lymphatic sparing procedures using scrotal injection give a rate of mapping failures of 20%-30%. The aim of the present study is to standardize the technique of injection to perform a lymphatic sparing procedure in case of laparoscopic varicocelectomy.

METHODS

We retrospectively evaluated 50 patients who underwent laparoscopic varicocelectomy from July 2010 to July 2013. Patients were divided into two groups: G1 (25 patients) those who underwent a classical isosulfan blue scrotal intra-dartos injection and G2 (25 patients) those who underwent the new standardized isosulfan blue scrotal intra-dartos/intra-testicular injection.

RESULTS

In G1 lymphatic vessels were identified as blue coloured in 19/25 of cases (76%), in G2 in 25/25 of cases (100%). The results were analyzed using test χ(2) with Yates' correction and there was a statistically significant difference (χ(2)=0.05,1) between G2 and G1. Postoperative hydrocele was noted in 2/6 patients of G1 in whom the lymphatic vessels were not identified.

CONCLUSIONS

Laparoscopic lymphatic sparing varicocelectomy is an effective procedure to adopt in children with varicocele. The intra-dartos/intra-testicular injection of isosulfan blue is significantly better than the previously described intra-dartos injection, permitting to identify lymphatic vessels in 100% of cases in our series. No allergy to isosulfan blue was reported in both groups.

Laparoscopic management of a newborn with a right Amyand's hernia and a left incarcerated inguinal hernia

A one month old boy presented with left incarcerated inguinal hernia. After unsuccessful manual reduction, we decided to perform laparoscopic herniorrhaphy. Laparoscopic examination showed a left hernia with intestinal loops that entered into the internal inguinal ring, on the right side there was an unknown patency of the peritoneal vaginal duct with the appendix completely incarcerated within the sac. On the left side, the loops were reduced with a combined technique of external manual pressure and internal pulling by forceps; the bowel was inspected, and the hernia was repaired. On the right side, the appendix was strongly adherent with the peritoneal vaginal duct, and the reduction was not possible. The appendix was dissected from the sac using a 3-mm monopolar hook and than reduced into the abdomen, then right herniorrhaphy was performed. Two days after surgery, the baby had fever and abdominal distension. He was re-operated through mini-Pfannenstiel incision and an ischemic appendix was identified and removed. Postoperative period was uneventful. In our case, laparoscopy allowed for simultaneous reduction under direct visual control, inspection of the incarcerated organ, definitive repair and incidentally discovery and treatment of the contralateral incarcerated Amyand's hernia. In case of incarcerated appendix, appendectomy is preferable during the same procedure to reduce the incidence of postoperative complications.

Unilateral inguinal hernia: laparoscopic or inguinal approach. Decision making strategy: a prospective study

The management of the contralateral region in a child with a known unilateral inguinal hernia is a debated issue among paediatric surgeons. The available literature indicates that the perspective of the child's parents is seldom. This study was performed to evaluate parents' views on this topic. After the Ethical Committee's approval, 100 consecutive patients under 12 years of age with a unilateral inguinal hernia were studied prospectively from March 2010 to September 2010. After an oral interview, a study form was given to the parents about the nature of an inguinal hernia, the incidence of 20 to 90% of a contralateral patency of the peritoneal-vaginal duct and the possible surgical options (inguinal repair or laparoscopic repair). The parents' decision and surgical results were analyzed. Eighty-nine parents chose laparoscopic approach, and 11 parents preferred inguinal exploration. Regarding their motives, all 89 parents requesting laparoscopic approach indicated that the convenience and risk to have a second anaesthesia was the primary reason of their decision. The 11 parents who preferred inguinal approach indicated that the fear of a new surgical technology was their primary reason. Conclusion There is no consensus about the management of paediatric patients with a unilateral inguinal hernia. We believe that a correct decision-making strategy for parents' choice is to propose them the both procedures. Our study shows that parents prefer laparoscopic inspection and repair in the vast majority of cases.

Meckel's diverticulum causing severe hemorrhage

Meckel's diverticulum has varied presentations in children and often becomes a diagnostic challenge. The authors present a 10-year-old boy with abdominal pain and one episode of melena. His symptoms were undervalued during two previous hospitalizations in pediatric units until his hemoglobin level dropped from 8.2 to 3.5 g/dL. The laparoscopic intervention performed in emergency identified a bleeding Meckel's diverticulum that was resected after being exteriorized from the umbilicus. Our observation shows that severe hemorrhage due to a Meckel's diverticulum is possible albeit exceptional.