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Female hypospadias is a rare genito-urinary anomaly, often associated with other congenital malformations of the urinary tract. For female hypospadias it is meant a condition in which the external urethral meatus opens high up in the anterior vaginal wall proximal to the hymenal ring; the urethra is obviously shorter than usual. Embryologically, it is thought to be due to an abnormal development of the urogenital sinus or to a lack of differentiation of Wolff’s tissue. Etiology though still remains unknown. Even though commons symptoms related to female hypospadias include urinary incontinence, recurrent urinary tract infections and dyspareunia, patients are often diagnosed accidentally during catheterization for other reasons. Its detection is simple but often late in childhood or even in adulthood. Treatment can be difficult due to the lack of consistent literature on the topic and also because it requires management of the other associated anomalies. We describe the case of a 5-year-old girl presenting incontinence secondary to hypospadias, successfully treated with a 2-step surgical strategy.

Nel capitolo viene trattato l’addome acuto, condizione patologica caratterizzata da dolore addominale, irritazione peritoneale, turbe della motilità intestinale e schock. Vengono approfondite alcune cause frequenti di addome acuto in età pediatrica: appendicite acuta, peritonite, diverticolo di Meckel complicato, ernia inguinale complicata ed invaginazione intestinale, con particolare riferimento all’obbiettività clinica e alla diagnosi.

Robotic surgery has been introduced into clinical practice in the late 1990s to overcome well-recognized limitations of the conventional minimally invasive approach, including two-dimensional imaging, restricted range of motion of the instruments, hand tremors, and poor ergonomic positioning of the surgeon. Since then, robotic surgical systems have rapidly evolved and are used for an increasing number of complex minimally invasive surgical procedures [1–6]. Historically, new surgical techniques have had a more difficult and slower acceptance by the pediatric surgical community compared to the adults’ one. Indeed, small spaces and anesthesiological management have limited the use of these technologies. In the pediatric age, robotic surgery has been accepted and utilized by a small number of pediatric surgeons around the world. Since the first reported case in a child in April 2001, the use of robotic technology has rapidly expanded within pediatric surgery. During the last decade, it has successfully been applied to a large variety of gastrointestinal, genitourinary, and thoracic procedures in infants and children, thus demonstrating the safety and feasibility of this approach. The number of pediatric robotic procedures performed per year using this emerging method is growing rapidly, with no evidence that this will change in the future. The early functional outcomes of robotic procedures are promising; however at present, most of the comparative studies are from single institutions, and lack a high level of evidence. Although increasing numbers of larger pediatric robotic surgery case series have been published over the years, authors mainly focused on the comparison with open surgery. However, in order to identify potential advantages of a particular type of robotic procedure over the corresponding conventional laparoscopic or thoracoscopic approach, comparative studies providing evidence-based information are needed [6–10]. Performing robotic surgery in pediatric patients requires a complete new redesigned concept of the surgical techniques and modifications in the surgical operating room. The introduction of this innovative technology brings new advances in instrumental maneuverability, and better optics. However, robotic surgery also brings new challenges and limitations that will require improvement in the future. The successful transition from laparoscopy to robotic surgery requires some steps. These include developing a specific robotic team that should be well informed on setting up the robot and can deal with intraoperative problems. Another task of the team is to ensure that the surgeon has spent sufficient time on the robot to be familiar and proficient, and to help in the selection of patients, thus avoiding difficult cases in the beginning. During the first procedures it is important to have sufficient time so that no one is rushed or harassed by lack of time, and, of course, to make sure that a proctor is present. Finally, when the surgical session is over, a debriefing with the whole team will minimize problems, develop enthusiasm for this new technology, and allow checklists and protocols to be developed. With these simple steps, this transition can be performed relatively painlessly [11].

Background: To evaluate the feasibility and efficacy of endoscopic stricture index (SIEN) to define anastomotic strictures (ASs) and to predict the need of dilatations. Materials and methods: A retrospective longitudinal study was conducted on patients who underwent esophageal atresia repair from 1998-2020 (ethical committee approval CHPED- 05-20-AS). SIEN was calculated on the first endoscopy performed as follows: (D d )/D, where D is the maximum diameter of lumen of the upper esophagus close to the AS and d is the diameter of lumen of the stricture. Nonparametric variables were examined using Wilcoxon-Mann-Whitney test, and continuous variables were analyzed using Spearman’s test and regression analysis. A P value

Introduction: Surgical management of jejuno-ileal atresia/stenosis (JIA) is shifting to a minimally invasive approach. Our purpose is to evaluate the safety and feasibility of laparoscopy-assisted surgery (LAS) in JIA by comparing outcomes with a control group of open surgery (OS). Methods: A retrospective review of JIA cases was performed. Demographic, surgical, and outcomes data were extracted. LAS cases were compared with OS. Fisher's exact-test for qualitative and Mann-Whitney-test for quantitative values were used. p values

Introduction The uretero-pelvic junction (UPJ) is the most common site of obstruction in the pediatric upper urinary tract, causing hydronephrosis. In our institution, the gold standard approach for hydronephrosis in infants is the One-Trocar- Assisted Pyeloplasty (OTAP). The aim of this study is to evaluate the feasibility of OTAP in terms of efficacy and safety in the first 90 days of life. Methods We retrospectively reviewed all charts and long-term follow-up of 138 infants treated with OTAP; we selected and examined the ones with a defined diagnosis of severe UJPO and, thus, treated in the first 90 days of life: 28 patients. Indica- tions for early surgery were: antero-posterior pelvic diameter (APD) > 20 mm and an obstructive pattern on renography; impaired echotexture and/or relative renal function < 40% had to be associated. Results Out of 23 patients, we witnessed one conversion to open surgery (4.35%) and one recurrence (4.35%) of UPJO. The mean pre-surgery APD was 35.2 mm, while the mean post-surgery APD was 17.32 mm. The mean operative time was 133 min. The mean hospitalization time was 7.71 days. The mean average of follow-up was 46.41 months (minimum 1 year). Conclusions Our experience suggests that OTAP is a valid and feasible technique in terms of safety and efficacy for the early treatment of very young infants affected by UPJO.

Aim of the study: To assess the efficacy of a novel technique (echo-assisted intersphincteric autologous microfragmented adipose tissue injection, also called &ldquo, anal-lipofilling&rdquo, ) in the management of non-responsive fecal incontinence in children born with anorectal malformations (ARMs). Methods: Following ethical committee approval (CHPED-MAR-18-02), anal-lipofilling was proposed to patients with fecal incontinence not responsive to medications or bowel management (bowel enema and/or transanal irrigation automatic systems), then a prospective study was conducted. Anal-lipofilling consisted of three phases: lipoaspiration from the abdominal wall, processing of the lipoaspirate with a Lipogems system and intersphincteric injection of the processed fat tissue via endosonographic assistance. A questionnaire based on Krickenbeck&rsquo, s scale (KS) was administered to the patients to evaluate the clinical outcome. Main Results: Four male patients (three recto-urethral fistula, and one recto-perineal fistula) underwent the anal-lipofilling procedure at a mean age of 13.0 &plusmn, 4.2 yrs. There were no complications during or after the procedure. From an initial assessment of the patients there was an improvement in the bowel function at a median follow up of 6 months, with better scores at KS (100% Soiling grade three pre-treatment vs. 75% grade one post-treatment). Conclusions: Even if our Study is preliminary, echo-assisted anal-lipofilling could be considered as a feasible and safe alternative technique in the management of the fecal incontinence in non-responding ARMs patients. More studies are still necessary to support the validity of the implant of autologous adipose tissue in the anal sphincter as a therapy for fecal incontinence in children born with ARMs.

The aim of this study is to present our preliminary experience in robotics and a comparative analysis with conventional Minimally- Invasive Surgery (MIS). Cases operated by da Vinci Xi® System from February 2016 to October 2017 are reviewed retrospectively through demographics, diagnosis-procedure and short-term outcome parameters. A comparison with a matching conventional MIS population was also conducted. 40 robotic procedures were carried out and 112 (out of 3705) non-robotic procedures met inclusion criteria for comparison. Among robotic patients we observed: an average age of 143.5 months, weight of 42.9 Kg, operative and anaesthesia induction time respectively of 116.8 and 34.8 minutes. Furthermore, we observed a 6.1-day length of stay, 2.5% conversion rate and no complications. From the comparison between the groups, no statistical difference emerged in the length of stay, in conversion rates or in complications. A statistical significance was observed in terms of operative time in favour of non-Robotic- System. Our experience has meant to introduce the System in our surgical environment, comparing to the conventional MIS (an already established approach routinely performed at our center). Results have shown comparable safety and feasibility.

Persistent Müllerian duct syndrome is a disorder of sexual development, which features a failure of involution of Müllerian structures. An enlarged prostatic utricle is a kind of Müllerian duct remnant (MDR) with a tubular shaped structure communicating with the prostatic urethra. Treatment is aimed at relieving symptoms when present, preserve fertility and prevent neoplastic degeneration. We describe 3 cases of successful robot assisted-removal of symptomatic MDRs. The first case came to our attention for pseudo-incontinence; the other two for recurrent urinary tract infections. The patients have not presented such symptoms anymore on follow-up. We then reviewed existent literature on authors who have recently investigated the main issues concerning MDRs and have attempted a roboticassisted approach on them. Robot-assisted laparoscopy can be considered a valid, safe and effective minimally-invasive technique for the primary treatment of prostatic utricle.

We report the case of a neonate affected by prenatally diagnosed congenital diaphragmatic hernia (CDH), treated by thoracoscopy. During the procedure, we detected an associated extralobar pulmonary sequestration (EPS), which was preoperatively undiagnosed, and we removed it. EPS has been shown to be associated with CDH in up to 15 to 40% of cases. A possible explanation hypothesized is that pulmonary sequestration, which develops at 4 to 5 weeks of gestation, can disturb the fusion of the diaphragm and closure of the pleuroperitoneal canal. The thoracoscopic approach permitted us to identify the thoracic EPS that probably would have been otherwise missed.

Purpose The spectrum of male urethral duplication is heterogeneous and it includes the Y-duplication. The malformation is rare and there is only a few case series reported in the literature. The management of Y-forms remains challenging for the surgeon and the long-term follow-up is still scarcely investigated. We report our 40-year experience in the management of patients with Y-duplication. Materials and methods We conducted a restrospective analysis collecting information of patients with urethral Y-duplication treated at our department from April 1975 to April 2015. We investigated long-term effects of surgery by using a questionnaire. Results Ten male patients with Y-duplication came to our attention. One was treated conservatively, seven underwent surgery and two were lost. Surgery consisted of removal of the ectopic branch (via perineal or ASTRA/anterior sagittal trans-rectal approach approach) and reconstruction of the orthotopic urethra. Post-operative complications included stenosis and infections. Long-term results are influenced by associated anomalies and significant problems (incontinence, urinary tract infections and orchiepididimitis) have been reported. Conclusions Y-duplication (or λ-duplication, as we prefer calling it) is a particular form of urethral duplication. The management of patients should be based upon the identification of the functional channel. The removal of the ectopic channel with ASTRA approach is safe and feasible. On the other hand, the reconstruction of the anterior urethra (when steno-atresic) is more challenging and justifies the need for many procedures. The P.A.D.U.A. (progressive augmentation by dilating the anterior urethra) technique was not effective. Skin tube grafts were responsible for infections ("hairy urethra"). BMFG (bladder mucosa free graft) urethroplasty is a good alternative, although associated with well-known complications. Associated anomalies influence long-term outcomes. Clinical study with type IV level of evidence.

The persistence of cloacal and urogenital sinus remains one of the most challenging problems for pediatric urologist. In this chapter we will describe the characteristics of these malformations in terms of diagnosis, clinical presentation, surgical treatment, and complications.

The Anderson–Hynes pyeloplasty is still the gold standard for the surgical treatment of the ureteropelvic junction obstruction in children. Laparoscopic, retroperitoneoscopic, and robotic approaches have been proposed as alternatives in order to reduce postoperative hospitalization, pain, and scars. We describe a modification of the retroperitoneoscopic technique that combines the advantages of a minimally invasive technique with the high success rate of standard dismembered pyeloplasty. We called the procedure OTAP (one-trocar-assisted pyeloplasty).

Introduction Ureteropelvic junction obstruction (UPJO) is the most common pediatric obstructive uropathy. We report our 8-year experience with the use of a retroperitoneal laparoscopic-assisted pyeloplasty (one–trocar–assisted pyeloplasty [OTAP]). Materials and Methods This is a retrospective analysis of 88 patients treated in 8 years. Surgery was performed on the basis of standard indications and it consisted of 88 OTAP (the ureteropelvic junction is identified through a retroperitoneoscopic inspection and it is exteriorized to perform a traditional dismembered pyeloplasty). Operative time, hospital stay, complication, success of the technique, and aesthetical results are analyzed. Results In the 8-year period we performed 88 OTAP. Mean age was 19 months. Prenatal diagnosis was the most common presentation ( n = 73), followed by occasional identification ( n = 8), and symptomatic ( n = 7). Mean operating time was 139 minutes (range 60–225 minutes). Conversion was required in seven cases. The success rate was 87.5% (reduction of the severity of hydronephrosis on ultrasound) and 100% among symptomatic patients (symptoms resolution). Aesthetical results were excellent. Discussion and Conclusions OTAP is safe, feasible, and efficacious. Operative times are similar or even shorter than those of other minimally invasive techniques and complication rate agrees with the findings of literature. OTAP can be considered a reasonable alternative.