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Purpose Non-operative treatment (NOT) for pediatric acute appendicitis complicated with intra-abdominal abscess (IAA) has been introduced in the last decade. The study aimed to report our experience with this approach and investigate potential predictors of success. Methods Medical records of patients affected by appendicitis complicated with IAA between January 2013 and December 2020 were reviewed. The interval before delayed appendectomy, rate of re-admission before delayed appendectomy and the rate of delayed appendectomy were the endpoints of NOT. The outcomes were compared between patients treated by NOT and patients who underwent urgent surgery for complicated appendicitis. Results In the study period, twenty-six patients (37%) underwent NOT, and 45 (63%) underwent urgent surgery for complicated appendicitis with IAA. A delayed appendectomy was performed in 24 children (92%). The median time before surgery was 32 days (IQR 20–58 days). Eight children (31%) were re-admitted before delayed appendectomy, and three cases presented a disease relapse. An appendicolith was detected in two of them. Even though the overall hospital stay was longer for NOT (p = 0.0009), all these patients underwent laparoscopic appendectomy, and no conversions were reported (p = 0.0001; p = 0.0006). In addition, no difference in the rate of post-operative complications was found between the two groups (p = 0.62). Conclusions NOT presented a high rate of success. The presence of appendicolith at diagnosis might be considered a negative predictor of success. NOT might increase the success of mini-invasive surgery when compared to urgent surgery.

Introduction Glans dehiscence (GD) is reportedly a common complication after proximal hypospadias repairs. However, the need for surgical correction is controversial. The aim of this study was to assess awareness, risk factors, and outcome of GD in post-pubertal patients. The agreement with surgeon assessment was also evaluated. Methods The design was retrospective. All consecutive patients treated for proximal hypospadias between 2000 and 2011 were included. The presence of GD was self-reported, and the participants could optionally upload a photograph for surgeon assessment. Cosmetic and functional outcomes were assessed by validated questionnaires (HOSE, PPPS, KINDL®, IIEF-5). Results were compared between patients with and without GD. Results Of 219 patients, 34 (16%) participated. Fourteen of them (41%) self-reported GD. Eighteen patients (8%) also uploaded a photograph and, in ten of them (56%), the surgeon noted the presence of GD with poor agreement [k = − 0.444 (95 CI − 0.856 to − 0.033)] with patient report. Patients self-reporting GD had had more frequently a penile curvature at diagnosis (12/14 = 86%, p = 0.01), and had undergone a single-staged repair (100% vs. 65%, p = 0.03). No difference was found in cosmetic and functional outcomes. Results were similar also comparing groups with and without GD as assessed by the surgeon. Conclusion GD was a common finding after severe hypospadias repair. It was more common in case of surgeon assessment with poor agreement between patients and surgeons. GD did not prove to have clear clinical implications. Therefore, in our opinion, surgical repair of GD should be recommended only on patients request.

The aim was to assess the success of a three-drug regimen, consisting of cefazoline, metronidazole and gentamicine, for the antimicrobial treatment of complicated appendicitis and to investigate predictors of failure.This retrospective study included patients who had undergone appendectomy for complicated appendicitis from 2013 to 2018. The shift to second-line antibiotics was considered a failure. The choice was based upon clinical deterioration. Patients were grouped into 2 groups: localized complicated appendicitis (LCA) and extensively complicated appendicitis (ECA) for the study purpose. Univariate and multivariate analysis were performed to identify predictors of failure.Ninety patients (65.2%) with LCA and 48 patients (35%) with ECA were included. Three-drug regimen failed in 50 patients (36%) with a higher rate in the ECA group (50%, p=0.017). In a multivariate analysis, this failure was found to be associated with ECA (adjusted OR 3.00 [1.2-7.4], p=0.041). Children with ECA experienced a longer hospital stay (median length 8 days, plt; 0.001) and antimicrobial therapy (median length 8 days, plt; 0.001). However, no difference in the rate of surgical site infections was found (p=0.514).The institutional antibiotic stewardship program highlighted a high failure rate for the old threedrug regimen. A new protocol should be recommended, especially for the patients affected by ECA.

The diagnosis of balanitis xerotica obliterans (BXO) in children may be challenging, since clinical examination only could lead to an underestimation of its incidence. The aim of this retrospective and single-centre study is to assess the diagnostic performance of clinical examination, together with clinical history, in identifying BXO. Ninety-seven children underwent circumcision for phimosis from 2015 to 2019. Histology was routinely performed. Cohen’s kappa coefficient, sensitivity, specificity, predictive values, likelihood ratios and accuracy of macroscopic appearance of the foreskin, steroid administration and past medical history were estimated. Forty-eight patients (50%) were affected by BXO; 31 of them (69%) presented with suggestive clinical signs. A strictured or whitish urethral meatus was detected during surgery in nine cases (19%); this was associated to allergic or immune diseases (p = 0.046). Foreskin appearance alone mildly correlated with histology (k = 0.494; p Conclusion: Foreskin appearance together with clinical history could predict BXO with certainty. However, since the absence of a positive medical history could not exclude the diagnosis, foreskin histology is still highly recommended. What is Known:• Occurrence of balanitis xerotica obliterans may be underestimated in children and it could lead to long-term complications.• The diagnostic accuracy of clinical examination is controversial. What is New:• Clinical signs together with patients’ medical history present high specificity and positive predictive values but low sensitivity.• When suggestive clinical aspects are present, patient should be referred to surgery avoiding prolonged conservative treatment; and preputial histology is highly recommended.

Purpose: To compare surgical scars assessed by a validated patient reported outcome questionnaire in children undergoing open (OP), laparoscopic (LP), or robotic-assisted (RALP) pyeloplasty. Secondary aim was to assess the influence on the outcomes of variables such as gender or body mass index (BMI). Materials and methods: Observational, cross-sectional, multicentric study of patients undergoing primary pyeloplasty between age 10- and 18-year at 5 tertiary Italian institutions in the period 01/2010 to 12/2019. Of 227 eligible patients, 114 (50%) participated. OP was performed in 37 (32%), LP in 30 (26%) and RALP in 47 (41%), After a median (IQR) follow-up of 5.2 (2.3-7.8) years, scars were measured and assessed by a validated Patient Scar Assessment Questionnaire (PSAQ). Scores were compared among techniques and in accordance to several variables. Results: The median length of the surgical scar at follow-up was significantly larger (p

Pediatric abdominal surgery is constantly evolving, alongside the advent of new surgical technologies. A combined use of new tools and traditional surgical approaches can be useful in the management of complex cases, allowing less invasive procedures and sometimes even avoiding multiple interventions. This combination of techniques has implications even from the anesthetic point of view, especially in post-operative pain control. Thereby, tertiary level centres, including highly-specialized professionals and advanced equipment, can maximize the effectiveness of treatments to improve the final outcomes. Our paper aims to present some possible combinations of techniques recently used at our institution to provide a one-session, minimally invasive treatment within different areas of abdominal surgery.

BACKGROUND Allograft venous thrombosis is a severe complication after kidney transplantation (KT). Early diagnosis and prompt treatment are crucial in preserving the survival of the allograft. In this study, we aimed to describe an emergent strategy for the management of acute allograft venous thrombosis. CASE PRESENTATION A 4-year-old girl, weighing 13.5 kg, was diagnosed with bilateral congenital renal hypodysplasia, urogenital sinus and anorectal malformation. The patient was referred to our department for living-donor KT. Her mother was eligible as a donor, presenting a body weight ratio of 1:4.5. Thrombosis of the inferior vena cava (ICV) was also identified, without any predisposing factor for thrombophilia. KT was performed by an extraperitoneal approach without complications. Venous anastomosis required a human vascular graft sutured to the ICV, and renal artery was anastomosed to the aorta. On postoperative day (POD) 8, acute abdominal pain and hematuria led to the diagnosis of an allograft venous thrombosis. An emergent laparotomy was required to explant the allograft, followed by bench surgery. The allograft was irrigated with thrombolytic agents and lactated Ringer's solution and then after removing the venous vascular graft, it was reimplanted through vascular anastomosis with the ICV and aorta. The recovery of perfusion and function was good with diuresis since day 4 after re-surgery. At 2-year follow-up, the child presented normal allograft function with an estimated GFR of 65 ml/min/1.73 m2 . CONCLUSION According to our experience, explantation of the kidney allograft, followed by irrigation with thrombolytics in bench surgery, and reimplantation resulted in unexpected optimal outcomes in the case of allograft venous thrombosis.

Background The use of transcutaneous near-infrared spectroscopy (NIRS) for monitoring the perfusion of kidney and liver allografts has been proposed in the last years. This device might detect an early decrease in allograft oxygenation allowing prompt detection of vascular complications. Methods A systematic review of the literature about the use of transcutaneous NIRS in monitoring allograft perfusion was performed according to the PRISMA guidelines. Results The authors screened 1313 papers. The search yielded five pertinent articles. Three of them reported the experience of NIRS in kidney transplantation and the other two dealt with its use in liver transplantation, for a total of 55 paediatric patients and 121 adults. In the studies concerning kidney transplantation, NIRS measurements were significantly related to serum creatinine, estimated glomerular filtration rate (eGFR), urinary neutrophil gelatinase-associated lipocalin (u-NGAL), serum lactate, resistive index assessed by Doppler-ultrasonography and systolic blood pressure. The two studies dealing with liver transplantation found a significant decrease in liver regional oxygenation, assessed by NIRS, before the occurrence of vascular complications. Conclusions Preliminary studies have related NIRS monitoring to kidney and liver allograft perfusion, both in adults and children. Further investigation is needed to establish the normal range of NIRS values and the factors influencing NIRS monitoring.

Extraperitoneal approach is sometimes recommended for kidney transplantation (KT) in children weighting15 kg. We hypothesized that this approach might be as successful as in patients with normal weight. Data of all consecutive KTs performed between 2013 and 2019 were retrospectively reviewed. Early outcomes and surgical complications were compared between children weighing ≤15 kg (low-weight (LW) group) and those weighing15 kg (Normal-weight (NW) group). All the 108 KTs were performed through an extraperitoneal approach. The LW group included 31 patients (mean age 3.5 ± 1.4 years), whose mean weight was 11.1 ± 2.0 kg. In the LW group,-a primary graft nonfunction (PNGF) occurred in one patient (3.2%), surgical complications occurred in nine (29%), with four venous thrombosis. In the NW group, PNGF occurred in one case (1.3%), delayed graft function (DGF) in eight (10%), surgical complications in 11 (14%) with only one case of venous thrombosis. In both groups, no need for patch during wound closure and no wound dehiscence were reported. The extraperitoneal approach can be effectively used in LW children. No differences were observed in the overall complication rate (P = 0.10), except for the occurrence of venous thrombosis (P = 0.02). This might be related to patients' characteristics of the LW group.

Midgut volvulus in infants may lead to extreme short bowel syndrome. Strategies to avoid post-ischemia bowel loss have been proposed, involving thrombolysis prior to a definitive surgical treatment. Haemorrhagic risks in these patients may withhold from this approach. Herein we describe the use of urokinase systemic infusion after an unsatisfactory second look laparotomy, performed in a term baby with midgut volvulus. Continuous infusion of urokinase was given for seventeen hours prior to a third laparotomy. A total of 25 cm of small bowel were finally kept in place. Twelve months after the 1st laparotomy the patient was on oral feeding 125 calories/Kg/day. This case showed the possible rescue role of a fibrinolytic agent against persistent ischemia after the second look laparotomy for neonatal volvulus.