Russian Journal of Pediatric Surgery

BACKGROUND: The effective evacuation of stone fragments is a critical stage which determines the success of extracorporeal shock wave lithotripsy in children with urolithiasis. However, optimal approaches to postoperative lithokinetic therapy in pediatric practice remain a subject of debate.

AIM: To perform a comparative analysis of the efficacy and safety profile of the combined lithokinetic therapy, including alpha-1-adrenergic blockers and polychromatic polarized light, for improving the elimination of stone fragments after extracorporeal shock wave lithotripsy in children with urolithiasis.

METHODS: This prospective randomized study included 250 children aged 2 to 18 years who underwent extracorporeal shock wave lithotripsy. All patients were randomized into three groups: a control group (n=150) receiving standard postoperative therapy, Group 2 (n=50) receiving a course of polychromatic polarized light exposure, and Group 3 (n=50) receiving a combination of alpha-1-adrenergic blockers (tamsulosin/silodosin) and a course of polychromatic polarized light exposure. To assess efficacy, the following parameters were analyzed: stone-free rate (SFR) criteria, time to stone expulsion, level of pain, and frequency of postoperative complications.

RESULTS: The combined lithokinetic therapy has resulted in the highest stone-free rate (88.0%), which was significantly higher than in the control group (60.0%; p <0.001). SFR criteria in the polychromatic polarized light group was 76.0%. Dynamics of SFR criteria differed; it was earlier in Groups 2 and 3. The lowest need for analgesia was noted in the combination therapy group (82.0% of patients required no pain relief). Dynamic ultrasound showed a significantly faster size reduction of residual fragments in the study groups. Postoperative complications were less frequent in Groups 2 and 3. No adverse effects of alpha-1-adrenergic blockers were noted.

CONCLUSION: The combined lithokinetic therapy with alpha-1-adrenergic blockers and polychromatic polarized lightis is associated with a higher rate of complete stone fragment passage after extracorporeal shock wave lithotripsy in children compared to standard therapy; it also reduces the need for analgesics.

In children older than one year of life, intussusception is more often associated with a pathological leading point, which reduces the success rate of exclusively conservative interventions and increases the importance of timely surgical treatment. However, maintained heterogeneity of approaches and diagnostic errors still affect outcomes.

A search and analytical summary of domestic and foreign publications was performed, with the priority given to clinical recommendations, systematic reviews/meta-analyses, multicenter studies, and large clinical series. The search was conducted in the eLibrary, PubMed, and Scopus databases for the period 01.01.2020–31.12.2025 using Russian and English keywords related to intussusception in children (diagnosis, pathological leading point, disinvagination, surgical tactics); the manual review of bibliographies on key publications was done as well. The analytical part of the review includes 27 sources, on the basis of which conclusions and tables were formed.

The clinical and instrumental signs of a probable pathological leading point and the ultrasound criteria for intestinal wall viability were summarized. It was shown that pneumatic/hydrostatic disinvagination under ultrasound or X-ray control is possible at an early stage; however, if it is ineffective, there are doubts about adequate perfusion, or there is a high probability of a pathological leading point, it is advisable to switch to diagnostic and therapeutic laparoscopy with mandatory removal of the pathological leading point, if present. The authors also outline situations requiring resection with the restoration of intestinal tube continuity. Organizational conditions reducing the proportion of emergency resections and complications (early availability of ultrasound, standardized routes, interdisciplinary interaction) as well as the role of machine learning algorithms and clinical predictive models as auxiliary decision support tools are highlighted as well. An age-oriented, practice-oriented management algorithm for children older than one year is presented: from recognizing the signs of pathological leading point and justifying the refusal of further attempts at disinvagination to the structure of laparoscopic intervention. Application of the presented scheme is intended to reduce the frequency of relapses and complications as well as to improve immediate and long-term treatment outcomes.

A new edition of clinical guidelines, developed by leading specialists of the Russian Association of Pediatric Surgeons, contains updated information on the treatment and diagnostics of the disease in compliance with the latest advances in emergency abdominal surgery. To diagnose such patients in a specialized surgical hospital, it is recommended to make ultrasound examination of the abdominal organs, as a basic mandatory noninvasive diagnostic technique, and to arrange dynamic follow-up for up to 12 hours in case of a doubtful diagnosis of acute appendicitis, which may be followed by diagnostic laparoscopy.

The presented edition discusses, in details, classification of acute appendicitis and peritonitis in children, highlights its basic complicated forms: appendicular infiltrate, appendicular peritonitis and periappendicular abscess.

For the first time, the authors present their material on accumulated global experience on the conservative treatment of acute appendicitis in children; they also discuss options on conducting such researches in large scientific centers in Russia after Russian Association of Pediatric Surgeons approval. The issues of preoperative preparation, postoperative management and rehabilitation of patients with severe appendicular peritonitis are discussed as well.

Robot-assisted surgery is a relatively new technology that enables a wide range of urological procedures to be performed using a minimally invasive approach. Various studies have shown that this technology is feasible and safe in most pediatric patients.

The authors of this study conducted a retrospective review of the medical history of a child with a doubling of the upper urinary tract, accompanied by obstructive damage to the upper segment of the ureter with loss of its excretory function. The data collection included the patient's medical history and demographic data, diagnosis, type of surgery, total time of surgery, outcome of surgery, and the anatomical and functional state of the kidney during follow-up.

A 12-year-old girl presented to the surgical department with complaints of recurrent urinary tract infections and right flank pain for the last year of her life. Robot-assisted laparoscopic heminephrectomy (RALHN) was performed using the Versius surgical robot. The upper segment ureter was transected at the lower pole of the kidney. The afunctional portion of the kidney was dissected from the normal kidney using a bipolar coagulation clamp. The lower segment incision edges were left open. The distal ureter was then isolated and sealed with a clip. The robot-assisted laparoscopic heminephrectomy procedure was successfully performed without intraoperative complications. The surgery duration was 225 minutes, including 20 minutes for robotic insertion. The total console time was 205 minutes. The drainage tube was removed after a follow-up ultrasound examination on the second day. The stent remained in the lower segment ureter until its removal six weeks after surgery. A repeat ultrasound examination performed postoperatively demonstrated no dilation of the lower segment pelvis or fluid collections in the area of the right kidney. Blood flow to the residual segment of the right kidney was not impaired.

The advantages of the robotic approach to treating upper urinary tract duplication, including improved instrument maneuverability and 3D visualization, make it a safe and effective alternative to open or laparoscopic surgery in children.

The problem of combined trauma to the thoracic and abdominal organs, including damage to the diaphragm and spleen, is currently becoming more urgent due to the growing number of road accidents. Combined injuries to the diaphragm and spleen in children are severe injuries accompanied by massive blood loss and traumatic shock. A successful management of such pathology can only be achieved with early diagnosis and timely surgical intervention.

Clinical case observation. Child K., 16 years old, was a passenger in a car that collided with another car. On November 20, 2024, the child was admitted to the Central District Hospital in Tuymazi (Republic of Bashkortostan) one hour 20 minutes after the traffic accident. She was in a serious condition with clinical features of traumatic shock. After clinical and ultrasound examination, a rupture of the spleen with massive intra-abdominal bleeding was suspected; the patient had grade III shock. She was taken to the operating room because of emergency indications. An upper midline laparotomy was performed under endotracheal anesthesia and blood transfusion and blood substitutes. 2500 ml of blood were removed from the abdominal cavity. Spleen rapture of grade III–IV was diagnosed. Splenectomy was performed with technical difficulties. Upon further revision, a rupture of the diaphragm was found as well; it was sutured with interrupted U-shaped sutures. Postoperative course was uneventful. In two weeks, the patient was discharged home in a satisfactory state. The repeated examination was made in 6 months, no complaints.

The presented case demonstrates a successful treatment of combined diaphragm and spleen injuries complicated by shock and massive intra-abdominal bleeding in a central district hospital. Only timely diagnostics, early anti-shock and resuscitation steps, as well as surgical intervention have helped to release the patient of a serious condition and to obtain satisfactory results.