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Background: Endoscopic treatment of vesicoureteral reflux (VUR) is an important minimally invasive surgical approach in patients undergoing surgical treatment of VUR. In our past experience, we observed that a bulking agent mound sagittal diameter of 10 mm is the main predictor of effectiveness of the procedure. Moreover we noticed that the use of intraoperative ultrasound, allows the surgeon to better identify the site, volume and shape of the bulking agent injected, finally reducing operative time., Objective: We aimed to evaluate if the intraoperative ultrasound assistance could definitively improve effectiveness of the endoscopic procedure., Methods: We retrospectively compared two series treated with endoscopic procedures for intermediate and high grade primary VUR, respectively without (series A) and with (series B) intraoperative ultrasound (IO-US). In all patients VCUG was performed to assess VUR grade and to verify resolution or VUR downgrading during the follow-up., Results: A total of 177 ureteric units were treated. Endoscopic procedures globally were effective in 68/96 ureters (70.8 %) in series A and in 68/81 ureters (83.9 %) in series B. No significant differences in effectiveness were observed comparing the series with regard to VUR grades, but a significant difference is shown (p < 0.05) when grouping grades III-V VUR. No significance in differences of volume injected were detected, but operative time was significantly lower in series B (27.5 min vs 19.6 min, p < 0.05). Mean sagittal mound diameter measured during cystoscopy in series B was 10.45 mm (range 8.5-14.2 mm)., Discussion: The intraoperative ultrasound assistance during endoscopic treatment of VUR could represent a valid tool for surgeons to better identify location, volume and shape of the bulking agent. Furthermore, the use of an objective parameter of evaluation of the implant can overcome the subjective intraoperative evaluation of the implant itself, improving results for experienced surgeons and reducing the learning-curve for inexperienced ones., Conclusions: Results of endoscopic injection of bulking-agent can be improved with intraoperative ultrasound, allowing at the same time a significant reduction of operative time., Competing Interests: Conflict of Interest None., (Copyright © 2023 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background/introduction: Vesicoureteral reflux (VUR) potentially leads to renal damage, scarring, and eventually end-stage renal disease. Endoscopic treatment is well tolerated in children, it has reduced costs, and it effectively prevents urinary tract infections (UTIs), while avoiding long term antibiotics use., Objective: With the aim to investigate the time needed to reach the stabilization of the dextranomer/hyaluronic acid (Dx/HA) implants and to identify cut-off heights to ensure the success of the procedure, the authors analyzed ultrasonographic (US) intra-operative appearance of the mounds following endoscopic treatment for VUR and repeated the measurements during serial postoperative evaluations. The final clinical goal would be to obtain an alternative parameter that might reduce the need for postoperative voiding cystourethrogram (VCUG)., Study Design: The authors selected all children treated for moderate-high grade VUR with renal scarring or repeated UTI under antibiotic prophylaxis and followed with regular time points for at least 1 year (time points 1, 3, 6, and 9 months). Endoscopic injection performed with double-HIT/STING technique was combined with US to determine the intra-operative mound height and to calculate reabsorption rate. Mound height was measured as the maximal vertical diameter of the mound visualized at the ureteral orifice. Based on postoperative VCUG findings, patients were divided in group A (success of the endoscopic treatment) and group B (persistence of reflux)., Results: Thirty patients aged 1-7 years, counting for 47 ureters, completed the protocol and were included in the analysis. Mounds height had a significant difference between A and B at all time points (P < 0.005). However, height did not differ between 6 and 9 months in both groups. Percentage of reduction in A was significant from 1 to 6 months (P < 0.005) but not onward, while in B, it was never significant. Ultimately, both groups had a comparable trend of reabsorption, with a complete stabilization achieved in 6 months and an overall reduction of approximately 22%., Discussion and Conclusion: Following the endoscopic injection of Dx/HA, US mounds height was found to strongly correlate with VCUG, both intra-operatively and for months following the procedure. Compared with the available literature, the authors first report a fixed reabsorption rate, consistent with the results in animal models and a timeframe to achieve stabilization. The possibility to measure those parameters with US renders this approach useful in the clinical setting, and it justifies the reduced use of VCUG in the follow-up of endoscopic injection for VUR., (Copyright © 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: Congenital pelvic skeletal anomalies (CPSA) may appear as isolated defects or in association with other anomalies like congenital malformations of the digestive system (CMDS). Minor CPSA in non-syndromic patients are often overlooked. We aimed to assess the frequency of CPSA in newborns with CMDS to review the diagnostic approaches., Study Design: A retrospective review of medical records of 201 newborns who underwent X-rays for different neonatal indications was conducted. In 122 patients CMDS were diagnosed and classified according to the ICD-10 classification; 79 non-CMDS patients acted as controls. Pelvic skeletal segments were examined by X-rays., Results: Patients with CMDS, showed a higher risk of CPSA (Odds ratio 2.89; 95% CI 1.34 6.23) and other associated malformations in comparison to non-CMDS patients. Newborns with malformations of the large intestine have the highest risk of adjacent CPSA (48%), as it is a developmental defect originating from the same somite. In addition to skeletal agenesis/hypoplasia, we reported dysmorphic and bifid vertebras, trident ileum, and elongated neural arches., Conclusions: The high incidence of CPSA in CMDS suggests performing a routine radiographic pelvic evaluation in cases of CMDS in order to identify complex phenotypes that could originate from the same developmental field., Competing Interests: Declaration of competing interest None., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: In principle, the prepuce can be reconstructed during hypospadias repair, but the procedure has not gained wide acceptance and preputial reconstruction (PR) is surrounded by several controversies., Material and Methods: A review is provided of the technique for PR, how PR combines with the other steps of hypospadias repair, the risks of complications related to the urethroplasty and specific to PR, and the results of PR with particular regard to the relevance for the patient and his family., Results: PR can be important for patients requiring hypospadias repair and their parents. It can be performed in almost all patients with distal hypospadias except perhaps those with the most asymmetrical prepuces or severe ventral skin deficiency. PR does not seem to increase urethroplasty complications, but combination of PR with tubularisation of the urethral plate urethroplasty seems to offer the best chance of success. Specific complications occur in around 8% of patients and include partial or complete dehiscence of the prepuce and secondary phimosis. To prevent the latter, the reconstructed prepuce should be easily retractile at the end of surgery. Technical modifications can help to achieve this goal. Cosmetically, reconstructed prepuces are not fully normal, but the abnormality could be less important for a patient and his parents that the complete absence of the prepuce., Conclusion: On the basis of the evidence summarised above, an algorithm for PR in patients with distal hypospadias is proposed. PR can be offered to the vast majority of distal hypospadias patients, although some modification of the technique for hypospadias repair can be required. Retractility of the reconstructed prepuce at the end of surgery seems paramount for final success., (Copyright © 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: To review the evolution in indications for treatment and treatment modalities for adolescent varicocele at our centre, and evaluate the impact of varicocelectomy on final outcome., Patients and Methods: Between 1995 and 2006, we treated 242 left varicoceles. Preoperative assessment included clinical evaluation, measurement of testicular volumes, and colour-Doppler ultrasound (CDUS). A subinguinal varicocelectomy was performed in 124 patients (group A), and a laparoscopic non-artery-sparing Palomo procedure in the remaining 118 (group B). In group B patients, CDUS was also used to investigate the functional anatomy of varicocele, and all the veins found to be refluxing were divided during surgery. The two groups were compared with regard to indications for surgery and outcome., Results: Over time the proportion of patients operated on because of testicular growth retardation increased. Persistence/recurrence rate was comparable between the two groups. In 13% of group B patients, the deferential vein was found to be refluxing on preoperative CDUS and was divided at surgery. Hydrocele rate was higher in group A, unless the vaginalis was excised and everted during varicocelectomy. About 75% of patients with preoperative left testicular growth failure experienced postoperative catch-up growth, irrespective of treatment., Conclusion: Indications for treatment are still evolving. Varicocele can successfully be treated in the majority of cases by either a laparoscopic or subinguinal approach. Both techniques require care, and CDUS can aid in the decision making. Most patients with preoperative testicular growth failure experience postoperative catch-up growth.

Gartner's duct cysts associated with renal dysgenesis are rare malformations and represent a diagnostic challenge. We report on one such case in which final diagnosis was achieved by laparoscopy and discuss the possible role of minimally invasive surgery in the management of this condition.

Aim: Testicular torsion (TT) requires prompt diagnosis and treatment to avoid testicular loss. Most studies have focused on the ideal work up to rule TT out in cases of acute scrotum. We attempted here to define objective criteria to select between orchidopexy and orchidectomy in patients undergoing surgery for TT., Patients and Methods: Fifteen boys with a median age at presentation of 7.8 (range 6.4-12) years undergoing surgical treatment for TT underwent color-Doppler ultrasound (CDU) preoperatively, and a bleeding test intraoperatively. Duration of preoperative history, degree of torsion, CDU findings and degree of bleeding were analyzed., Results: Salvageability was independent of the degree of torsion. In patients with a history longer than 10h, no flow on CDU and no bleeding, after orchidectomy all the testicles were necrotic on pathology. When all these variables were negative, all the testicles did well during follow up. In the group of patients with no agreement among the analyzed variables, the outcome was unpredictable. Five out of six underwent orchidopexy, but in two cases the testicle atrophied (in spite of flow on CDU in one)., Conclusions: No predictive parameters were found for testicular salvageability. Taken as a whole, the parameters studied can be of help in treatment choice. In patients with no agreement among the parameters, orchidopexy seems the appropriate option, but parents should be informed of the risk of testicular atrophy during follow up.