Laparoscopic single site surgery: Experience in pediatric urology

Laparoendoscopic single-site surgery(LESS) has been developed to benefit patients by enabling surgeons to perform scarless surgery. In this review we aimed to summarize and critically analyze the available evidence on the current status and future prospects for LESS in pediatric urology, with special emphasis on our experience with LESS in children. The clinical data available clearly demonstrate that LESS can safely and effectively be performed in a variety of pediatric urology settings. As clinical experience increases, expanding indications are expected to be documented and the efficacy of the procedure to improve. So far, the quality of evidence of all available studies remains low; mostly being small case series or case-control studies from selected centers. Thus, the only objective benefit of LESS remains improved cosmetic outcome. Prospective randomized studies are awaited to determine which LESS procedures will be established and which are unlikely to stand the test of time. Technological advances hold promise to minimize the challenging technical nature of scarless surgery. In this respect, robotics may be a driving force in the development of LESS.

Robotic approach with neoadjuvant chemotherapy in adult Wilms’ tumor: A feasibility study report and a systematic review of the literature

Objective:The incidence of Wilms’tumor(WT)among adult individuals accounts for less than 1%of kidney cancer cases,with a prognosis usually less favorable when compared to younger individuals and an overall survival rate of 70%for the adult patients versus 90%for the pediatric cases.The diagnosis and treatment of WT are complex in the preoperative setting;neoadjuvant chemotherapy(NAC)or robotic surgery has rarely been described.This study aimed to review the literature of robotic surgery in WT and report the first adult WT management using both NAC and robotic strategy.Methods:We reported a case of WT managed in a multidisciplinary setting.Furthermore,according to Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations,a systematic review of the literature until August 2020 of WT treated with a robotic approach was carried out.Results:A 33-year-old female had a diagnosis of WT.She was scheduled to NAC,and according to the clinical and radiological response to a robotic radical nephrectomy with aortic lymph nodes dissection,she was managed with no intraoperative rupture,a favorable surgical outcome,and a follow-up of 25 months,which did not show any recurrence.The systematic review identified a total number of 230 cases of minimally invasive surgery reported in the literature for WT.Of these,approximately 15 patients were carried out using robotic surgery in adolescents while none in adults.Moreover,NAC has not been administered before minimally invasive surgery in adults up until now.Conclusion:WT is a rare condition in adults with only a few cases treated with either NAC or minimally invasive approach so far.The advantage of NAC followed by the robotic approach could lead to favorable outcomes in this complex scenario.Notwithstanding,additional cases of adult WT need to be identified and investigated to improve the oncological outcome.

Outcomes of Layered versus Mass Closure in Transverse Incision during Emergency Laparotomy in Children

Background: The value of laparotomy closure technique may be measured by the incidence of early and late wound complications. The best laparotomy closure technique should be less time consuming, easy and cost-effective, while preventing both early and late complications. Objective: To compare the outcomes of layered versus mass closure in transverse incision during emergency laparotomy in children. Methods: This prospective comparative study was conducted at Department of Pediatric Surgery, Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh from July 2016 to June 2018. A total of 60 pediatric age cases that underwent laparotomy were included in this study. Cases were randomly allocated into two groups;30 patients were in Group A (Layered closure) and 30 patients were in Group B (Mass closure). The outcome variables were time required for wound closure, wound infection, wound dehiscence and incisional hernia. Data were analyzed and compared by statistical tests. Results: The mean age of Group A and Group B patients were 31.08 ± 30.25 months and 34.70 ± 42.73 months respectively (p = 0.706). The ratio between male and female subject was 1.1:1 in Group A and 3.3:1 in Group B. The common diseases of the study patients who underwent laparotomy were intussusceptions, intestinal obstruction due to bands and adhesion, perforated appendix and perforation of small intestine due to blunt trauma respectively. Mean wound closure time was significantly less in mass closure group [28.20 ± 2.17 minutes in layered closure group and 18.80 ± 1.67 minutes in mass closure group, (p ≤ 0.001)]. Wound infection rate, incidence of superficial wound dehiscence, and incisional hernia were relatively less in mass closure group, however, the differences were not statistically significant (p = 0.053, p = 0.095 and p = 0.301 respectively). There was no complete wound dehiscence in Group A, but that was in 1 (3.3%) patient in Group B (p = 0.313). Conclusion: Mass closure technique is comparatively better than layered closure technique.

Multiplex gene editing reduces oxalate production in primary hyperoxaluria type 1

Targeting key enzymes that generate oxalate precursors or substrates is an alternative strategy to eliminate primary hyperoxaluria type I(PH1),the most common and lifethreatening type of primary hyperoxaluria.The compact Clustered Regularly Interspaced Short Palindromic Repeats(CRISPR)from the Prevotella and Francisella 1(Cpf1)protein simplifies multiplex gene editing and allows for all-in-one adeno-associated virus(AAV)delivery.We hypothesized that the multiplex capabilities of the Cpf1system could help minimize oxalate formation in PH1 by simultaneously targeting the hepatic hydroxyacid oxidase 1(Hao1)and lactate dehydrogenase A(Ldha)genes.Study cohorts included treated PH1 rats(Agxt Q84X rats injected with AAV-AsCpf1 at 7 days of age),phosphate-buffered saline(PBS)-injected PH1 rats,untreated PH1 rats,and age-matched wild-type(WT)rats.The most efficient and specific CRISPR RNA(crRNA)pairs targeting the rat Hao1and Ldha genes were initially screened ex vivo.In vivo experiments demonstrated efficient genome editing of the Hao1 and Ldha genes,primarily resulting in small deletions.This resulted in decreased transcription and translational expression of Hao1 and Ldha.Treatment significantly reduced urine oxalate levels,reduced kidney damage,and alleviated nephrocalcinosis in rats with PH1.No liver toxicity,ex-liver genome editing,or obvious offtarget effects were detected.We demonstrated the AAVAsCpf1 system can target multiple genes and rescue the pathogenic phenotype in PH1,serving as a proof-ofconcept for the development of multiplex genome editingbased gene therapy.

Prognostic Factors of Wilms＇ Tumor Complicated with Nephroblastomatosis

INTRODUCTION Nephrogenic rests (NRs) are abnormally persistent clusters of embryonal cells,representing microscopic dysplasias of the developing kidney.NRs are found in approximately 1％ of infant kidneys at autopsy.Nephroblastomatosis signifies the presence of multiple or diffuse NRs.Both NRs and nephroblastomatosis were known as precursor lesions of Wilms' tumor[1] Nephroblastomatosis can be classified into four categories:Perilobar (PLNR only);intralobar (ILNR only);combined (PLNR and ILNR);and universal.The diagnosis and treatment of Wilms' tumor have been improved constantly and achieved common sense.However,little information is available regarding Wilms' tumor associated with nephroblastomatosis for lower prevalence.This study aimed to investigate the prognostic factors of Wilms' tumor associated with nephroblastomatosis.

Application and efficacy of reconstructing forked corpus spongiosum in distal/midshaft hypospadias repair

We reviewed our experience in reconstructing forked corpus spongiosum(FCS)in distal/midshaft hypospadias repair and analyzed the efficacy of this surgical technique.From August 2013 to December 2018,137 consecutive cases of distal/midshaft hypospadias operated by the same surgeon in Urology Department,Children’s Hospital of Fudan University(Shanghai,China),were retrospectively analyzed.Sixty-four patients who underwent routine tubularized incised plate(TIP)or onlay island flap(ONLAY)surgery were included in the nonreconstructing group,and 73 patients who underwent reconstructing FCS during TIP or ONLAY surgery were included as the reconstructing group.Thirty-eight cases underwent TIP,and 26 underwent ONLAY in the nonreconstructing group,with a median follow-up of 44(range:30-70)months.Twenty-seven cases underwent TIP,and 46 underwent ONLAY in the reconstructing group,with a median follow-up of 15(range:6-27)months.In the nonreconstructing/reconstructing groups,the mean age at the time of surgery was 37.55(standard deviation[s.d.]:29.65)/35.23(s.d.:31.27)months,the mean operation duration was 91.95(s.d.:12.17)/93.84(s.d.:14.91)min,the mean neourethral length was 1.88(s.d.:0.53)/1.94(s.d.:0.53)cm,and the mean glans width was 11.83(s.d.:1.32)/11.56(s.d.:1.83)mm.Twelve(18.8%)/5(6.8%)postoperative complications occurred in the nonreconstructing/reconstructing groups.These included fistula(5/2),glans dehiscence(3/0),diverticulum(1/2),residual chordee(3/0),and meatus stenosis(0/1)in each group.There was a significant difference in the overall rate of complications(P=0.035).These results indicate that the technique of reconstructing FCS provides excellent outcomes with fewer complications in distal/midshaft hypospadias repair.

Analysis of trends in testicular atrophy index values with age in patients with unilateral palpable cryptorchidism

Cryptorchidism affects the growth of testicular volume.Testicular volume is associated with reproductive function.The testicular atrophy index evaluates the degree of damage caused by cryptorchidism,but it remains unclear whether changes in testicular atrophy index are related to age.We selected patients who underwent surgery for unilateral palpable cryptorchidism.Testicular volume was measured using ultrasonography.The testicular atrophy indices of the undescended testes were then reviewed,and their correlation with age was analyzed.We studied 228 cases(age range:6–53 months).Scatter plots were constructed,and Loess curves were fitted,revealing a turning point at 24 months of age.The patients were divided into age groups of 6–24 months and 25–53 months.The testicular volume of the cryptorchid side was smaller than that of the normal side in both groups(both P<0.001).In the 6–24-month group,the testicular atrophy index was positively correlated with age,testicular volume on the cryptorchid side was not correlated with age,and testicular volume was positively correlated with age on the normal side.In the 25–53-month group,testicular atrophy index and testicular volumes on either side were not correlated with age.A palpable unilateral cryptorchid testis is smaller than the contralateral testis.The testicular atrophy index increases with age between 6 months and 24 months,but not between 25 months and 53 months.Testicular volume increased with age on the normal side between 6 months and 24 months,but not on the cryptorchid side.Trends in testicular atrophy index with age contribute to the decision of operation time.

Long-term follow-up results of testicular torsion in children

December 2020 to investigate the long-term follow-up results after testicular torsion(TT)in children.Boys with TT were divided into the salvage orchiopexy group and the orchiectomy group,and the baseline characteristics,ultrasonographic indications,intraoperative findings,testicular volumes,and adverse events during follow-up were compared.A total of 145 cases were included in this study.Approximately 56.6%of patients who underwent salvage orchiopexy had testicular atrophy(TA),and the median testicular volume loss of the testes was 57.4%.Age less than 6 years,delayed surgery,and intraoperative poor blood supply were associated with TA in pediatric TT after orchiopexy.Most atrophied testes appeared within 3-6 months after surgery.Compared with the corresponding age-matched healthy controls,the contralateral testicular volumes were larger in the orchiopexy(P=0.o01 without TA,and P=0.042 with TA)and orchiectomy groups(P=0.033).The adverse events were comparable in patients with orchiectomy or orchiopexy.In summary,follow-up before 3 months after surgery may not offer sufficient clinical value,while that 3 months after surgery should be regarded as the first follow-up time for testicular monitoring.The contralateral testes of patients with TT showed compensatory hypertrophy.We suggest performing orchiectomy when torsed testes are surgically assessed as Arda gradeⅢor inviable.

Professor Chengru Huang:A great doctor who is sincere,kindhearted,and trustful

Chengru Huang(1926-)is one of the founders of pediatric urology in China.She graduated from the School of Medicine,Peking University in 1950.At that time,she worked as a resident doctor and assistant in the Department of Surgery,Dalian Medical College.Since 1956,she has worked in the Department of Surgery,Beijing Children’s Hospital Affiliated to Capital Medical University,and established the first pediatric urology team in 1972.Professor Huang was a visiting scholar at Monash University and Royal Children’s Hospital.

An Arc Incision Surgical Approach in Congenital Megaprepuce

INTRODUCTION Congenital megaprepuce (CMP) is considered as a congenital penile malformation,which includes phimosis and severe ballooning of the redundant inner prepuce,conferring the typical aspect of concealed penis,in which the whole attachment is hidden within subcutaneous tissue. Several approaches to concealed penis have been described in the literature,not all completely applicable to CMP,which is a condition that requires particular technique refinements to obtain the best functional and cosmetic results.Now,we provide an alternative and reproducible surgical procedure for correction,which has been used for more than 8 years by us with a satisfactory cosmetic appearance.

Cryptorchid testicular torsion in children characteristics and treatment outcomes

This study aimed to review and compare the characteristics and treatment outcomes of cryptorchid testicular torsion in pre-and postpubertal children.We reviewed the clinical data of 22 patients with testicular torsion complicated by cryptorchidism who were treated between January 2010 and December 2019.Patients were categorized into prepubertal(1 month to 9 years;n=12)and postpubertal groups(10-16 years;n=10).The age at presentation,clinical presentations,physical examination,and operation outcomes were assessed.The common clinical presentations in both groups were inguinal pain and a tender inguinal mass.Patients in the prepubertal group were significantly more likely to present with restlessness(33.3%)than those in the postpubertal group(0%;P-0.044).After detorsion,testicular blood flow recovered during surgery in 25.0%of the prepubertal and 80.0%of the postpubertal patients(P=0.010).Orchiectomy was required in 50.0%of the prepubertal and 20.0%of the postpubertal patients(P=0.145).Of the 22 patients with follow-up data,the rates of testicular salvage were significantly different,at 16.7%in the prepubertal patients and 60.0%in the postpubertal patients(P=0.035).Cryptorchid testicular torsion has various manifestations.Although an empty hemiscrotum and a painful groin mass were common in both groups,restlessness was more prevalent in the prepubertal patients during early testicular torsion onset than that in the postpubertal patients.Notably,the testicular salvage rate was significantly lower in the prepubertal patients than that in the postpubertal patients.