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Corona LE, Lai A, Meyer T, Rosoklija I, Berkowitz R, Liu D, Maizels M, Cheng EY, Lindgren BW, Chu DI, Johnson EK, Gong EM. Response to commentary re retrograde incision from orifice (RIO) technique for endoscopic incision of ureterocele: 15 years of outcomes. J Pediatr Urol 2023; 19:670-671. [PMID: 37442689 DOI: 10.1016/j.jpurol.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 07/15/2023]
Affiliation(s)
- Lauren E Corona
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St., Chicago, Illinois, 60611, USA.
| | - Andrew Lai
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA; Department of Urology, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - Theresa Meyer
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Ilina Rosoklija
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Rachel Berkowitz
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Dennis Liu
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St., Chicago, Illinois, 60611, USA
| | - Max Maizels
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St., Chicago, Illinois, 60611, USA
| | - Earl Y Cheng
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St., Chicago, Illinois, 60611, USA
| | - Bruce W Lindgren
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St., Chicago, Illinois, 60611, USA
| | - David I Chu
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St., Chicago, Illinois, 60611, USA
| | - Emilie K Johnson
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St., Chicago, Illinois, 60611, USA
| | - Edward M Gong
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St., Chicago, Illinois, 60611, USA
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Lai A, Shannon R, Rosoklija I, Johnson EK, Gong EM, Chu DI, Lindgren BW. Robot-assisted Laparoscopic Pyeloplasty: Experience of a Single Pediatric Institution, Including Long-term and Safety Outcomes. Urology 2023; 176:167-170. [PMID: 37004846 PMCID: PMC10330237 DOI: 10.1016/j.urology.2022.12.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/11/2022] [Accepted: 12/27/2022] [Indexed: 04/03/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of robot-assisted laparoscopic pyeloplasty (RALP) and describe the short and long-term outcomes of pediatric RALP. METHODS We retrospectively reviewed all patients ..±21 years old who underwent primary RALP from 7/2007 through 12/2019. Patients were excluded from postoperative analysis if follow-up data after stent removal was not available. The primary outcome was surgical success, defined as radiographic improvement of hydronephrosis without need for reoperation. Secondary outcomes were time to reoperation and 90-day complication rate. RESULTS A total of 356 patients underwent primary repair of ureteropelvic junction obstruction during the study period; 29.ßpatients were limited to intraoperative data due to lack of follow-up imaging. Radiographic improvement at latest follow-up was seen in 308/327 (94.2%). Ten of 327 patients (3.1%) underwent reoperation: 7 were identified within 1 year of RALP and 3 were identified over 1 year after RALP. The median time to reoperation was 13.0 months (IQR 9.3-21.7). We defined long-term as>3 years after pyeloplasty. Over one-third (122/327, 37.3%) of the cohort had>3 years of follow-up, none of whom developed evidence of recurrent obstruction requiring reoperation beyond 3 years. Complications occurred within 90 days of surgery in 20/327 (6.1%). CONCLUSION This largest single-institution series confirms short- and long-term surgical effectiveness and safety of RALP. Our data also indicate that most patients who needed reoperation were identified within 1 year, and reoperation more than 3 years after RALP is rare.
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Affiliation(s)
- Andrew Lai
- University of Illinois at Chicago, Department of Urology, Chicago, IL
| | - Rachel Shannon
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Urology, Chicago, IL
| | - Ilina Rosoklija
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Urology, Chicago, IL
| | - Emilie K Johnson
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Urology, Chicago, IL; Northwestern University Feinberg School of Medicine, Department of Urology, Chicago, IL
| | - Edward M Gong
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Urology, Chicago, IL; Northwestern University Feinberg School of Medicine, Department of Urology, Chicago, IL
| | - David I Chu
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Urology, Chicago, IL; Northwestern University Feinberg School of Medicine, Department of Urology, Chicago, IL
| | - Bruce W Lindgren
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Urology, Chicago, IL; Northwestern University Feinberg School of Medicine, Department of Urology, Chicago, IL.
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Corona LE, Lai A, Meyer T, Rosoklija I, Berkowitz R, Liu D, Maizels M, Cheng EY, Lindgren BW, Chu DI, Johnson EK, Gong EM. Retrograde incision from orifice (RIO) technique for endoscopic incision of ureterocele: 15 years of outcomes. J Pediatr Urol 2023; 19:85.e1-85.e8. [PMID: 37590379 DOI: 10.1016/j.jpurol.2022.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/23/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Management of obstructing ureterocele often includes endoscopic transurethral incision (TUI) that can be challenging secondary to uncertainty in anatomic landmarks with risk of serious complications. To this end, we innovated a technique using predictable landmarks that begins endoscopic incision at the ureterocele orifice and extends retrograde proximal to the bladder neck (Figure). OBJECTIVE With over 15 years of experience in performing this retrograde incision from orifice (RIO) technique, we aimed to examine post-operative outcomes and risk of surgical failure after RIO compared to traditional TUI techniques for ureteroceles. We hypothesized that clinical outcomes after RIO would be superior to traditional endoscopic approaches to decompression of obstructing ureterocele in infants. STUDY DESIGN A retrospective study of patients ≤12 months old who underwent TUI ureterocele at our institution between 2007 and -2021 was conducted. Pre-, intra- and post-operative characteristics were compared between patients who underwent RIO vs non-RIO TUI. Primary outcome was post-incision febrile urinary tract infection (fUTI). Secondary outcome was a composite failure measure of fUTI, secondary surgery, de novo bladder outlet obstruction, or vesicoureteral reflux. Multivariable Cox proportional hazard models were fitted to compare the time-to-event risk of primary and secondary outcomes between groups. RESULTS Ninety patients with 92 ureteroceles were included (49 RIO, 43 non-RIO). Median follow-up from TUI was 33 months. RIO had a shorter median operative duration (27 vs 35 min, p = 0.021). Primary and secondary outcomes were similar between groups (fUTI: 29% RIO vs 19% non-RIO, p = 0.27; composite failure 54% RIO vs 69% non-RIO, p = 0.15). In multivariable Cox proportional hazard models, there was no significant difference in risk of fUTI (RIO aHR 0.98, 95% CI 0.38-2.54, p = 0.97) or composite failure (RIO aHR 0.80, 95% CI 0.45-1.44, p = 0.46) between TUI techniques. DISCUSSION RIO technique for TUI ureterocele is attractive in that it uses predictable anatomic landmarks making it simple to perform. In analyzing this 15-year institutional experience of TUI ureterocele, RIO showed similar success to non-RIO endoscopic incisions. This study is a retrospective, non-randomized, single-institutional study over 15 years and is therefore subject to change in surgeon practice over time and variable practices between providers. CONCLUSIONS Given comparable success and durability over time to other TUI ureterocele techniques, and with the advantage of operator ease using consistent anatomic landmarks, RIO is a worthy option for endoscopic ureterocele decompression.
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Affiliation(s)
- Lauren E Corona
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - Andrew Lai
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, University of Illinois at Chicago, Chicago, IL, 60612 USA.
| | - Theresa Meyer
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA.
| | - Ilina Rosoklija
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA.
| | - Rachel Berkowitz
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA.
| | - Dennis Liu
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - Max Maizels
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - Earl Y Cheng
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - Bruce W Lindgren
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - David I Chu
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - Emilie K Johnson
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - Edward M Gong
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
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Shaw A, Chan YY, Arora HC, Aguilar JB, Schechter J, Gong EM, Chu DI, Yerkes EB, Matoka DJ, Seager CM, Bowen DK, Lindgren BW, Liu DB, Maizels M, Cheng EY, Johnson EK. Streamlining surgical trays for common pediatric urology Procedures: A quality improvement initiative. J Pediatr Urol 2022; 18:412.e1-412.e7. [PMID: 35811279 DOI: 10.1016/j.jpurol.2022.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/16/2022] [Accepted: 06/22/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Procedures involving the external genitalia are the most common pediatric urologic operations. Our group identified excess instrumentation for these cases to be a potential cause of operating room (OR) inefficiency at our large, freestanding pediatric hospital. This quality improvement (QI) initiative aimed to streamline surgical instrumentation for the most-performed pediatric urologic procedures at our hospital. MATERIAL AND METHODS Six Sigma DMAIC methodology (Define, Measure, Analyze, Improve, Control) guided this multidisciplinary, iterative QI effort. A stakeholder team utilized data review, direct observations, and multiple in-person discussions to create a new "Groin-Penis Tray" (GPT) to replace a larger tray for the 90 most common pediatric urologic procedures. Suture preference cards and expectations about which sutures would be opened for each case were updated. The primary outcome was estimated yearly cost-avoidance due to reduced sterile processing. Additional outcomes included: instruments opened/case, % cases with complete trays, Mayo stand set-up time, and % cases with unused sutures. Balancing measures included: total median OR time and tray weights. Baseline and post-implementation measures were characterized and compared. RESULTS A QI professional, 10 pediatric urologists, 2 pediatric urology fellows, and multiple OR and sterile processing staff members participated. The Summary Figure compares baseline and post-implementation measurements. The number of instruments opened/case decreased from 146 to 65. Annual sterile reprocessing costs decreased by >$51,000. Median Mayo stand set-up time decreased from 7.3 to 3.5 min (p < 0.001). The number of cases with complete trays increased from 7/20 (35%) to 11/20 (55%, p = 0.34). The new GPT is 2.7 kg lighter than the prior tray. Median OR time remained stable (baseline: 91 min; post-implementation: 102 min, p = 0.44). The number of cases with suture waste decreased from 78% to 0% immediately post-implementation but increased to 40% one year later. DISCUSSION This systematic, iterative QI process spanned the course of ∼2 years, including planning, building, and updating new trays, then assessing longer-term success via the control phase. The new GPT is used for most pediatric urologic procedures at our hospital, and benefits include sterile reprocessing cost savings and ergonomics. Our team gained valuable experience related to assessing QI project scope, determining key stakeholders and roles, and strategies for sustainability that we will apply to future initiatives. CONCLUSIONS Streamlining surgical trays for common pediatric urologic procedures at a large freestanding children's hospital using established QI methodology reduced OR cost by >$51,000/year and Mayo stand set-up times without compromising balancing measures.
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Affiliation(s)
- Allison Shaw
- Center for Quality & Safety, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Chicago, IL 60611, USA.
| | - Yvonne Y Chan
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA.
| | - Hans C Arora
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA.
| | - Jazmina B Aguilar
- Procedural Services, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Chicago, IL 60611, USA.
| | - Jamie Schechter
- Procedural Services, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Chicago, IL 60611, USA.
| | - Edward M Gong
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA.
| | - David I Chu
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA.
| | - Elizabeth B Yerkes
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA.
| | - Derek J Matoka
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA.
| | - Catherine M Seager
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA.
| | - Diana K Bowen
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA.
| | - Bruce W Lindgren
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA.
| | - Dennis B Liu
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA.
| | - Max Maizels
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA.
| | - Earl Y Cheng
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA.
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 Clair St, Arkes 2300, Chicago, IL 60611, USA.
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Faasse MA, Farhat WA, Rosoklija I, Shannon R, Odeh RI, Yoshiba GM, Zu'bi F, Balmert LC, Liu DB, Alyami FA, Beaumont JL, Erickson DL, Gong EM, Johnson EK, Judd S, Kaplan WE, Kaushal G, Koyle MA, Lindgren BW, Maizels M, Marcus CR, McCarter KL, Meyer T, Qureshi T, Saunders M, Thompson T, Yerkes EB, Cheng EY. Randomized trial of prophylactic antibiotics vs. placebo after midshaft-to-distal hypospadias repair: the PROPHY Study. J Pediatr Urol 2022; 18:171-177. [PMID: 35144885 DOI: 10.1016/j.jpurol.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Use of prophylactic antibiotics after stented hypospadias repair is very common, but most research has not identified any clinical benefits of this practice. Only one study has found that postoperative prophylaxis reduces symptomatic urinary tract infections (UTIs). Data from the same trial suggested that prophylaxis may also reduce urethroplasty complications. No studies on this subject have been placebo-controlled. OBJECTIVE We performed a randomized, double-blind, placebo-controlled study to evaluate the effect of postoperative prophylactic antibiotics on the incidence of infection or urethroplasty complications after stented repair of midshaft-to-distal hypospadias. STUDY DESIGN Boys were eligible for this multicenter trial if they had a primary, single-stage repair of mid-to-distal hypospadias with placement of an open-drainage urethral stent for an intended duration of 5-10 days. Participants were randomized in a double-blind fashion to receive oral trimethoprim-sulfamethoxazole or placebo twice daily for 10 days postoperatively. The primary outcome was a composite of symptomatic UTI, surgical site infection (SSI), and urethroplasty complications, including urethrocutaneous fistula, meatal stenosis, and dehiscence. Secondary outcomes included each component of the primary outcome as well as acute adverse drug reactions (ADRs) and C. difficile colitis. RESULTS Infection or urethroplasty complications occurred in 10 of 45 boys (22%) assigned to receive antibiotic prophylaxis as compared with 5 of 48 (10%) who received placebo (relative risk [RR], 2.1; 95% confidence interval [CI], 0.8 to 5.8; p = 0.16). There were no significant differences between groups in symptomatic UTIs, SSIs, or any urethroplasty complications. Mild ADRs occurred in 3 of 45 boys (7%) assigned to antibiotics as compared with 5 of 48 (10%) given placebo (RR, 0.6; 95% CI, 0.2 to 2.5; p = 0.72). There were no moderate-to-severe ADRs, and no patients developed C. difficile colitis. CONCLUSIONS In this placebo-controlled trial of 93 patients, prophylactic antibiotics were not found to reduce infection or urethroplasty complications after stented mid-to-distal hypospadias repair. The study did not reach its desired sample size and was therefore underpowered to independently support a conclusion that prophylaxis is not beneficial. However, the result is consistent with most prior research on this subject. GOV IDENTIFIER NCT02096159.
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Affiliation(s)
- Mark A Faasse
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Advocate Children's Hospital, Chicago, IL, USA.
| | | | - Ilina Rosoklija
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Rachel Shannon
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Rakan I Odeh
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Grace M Yoshiba
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Fadi Zu'bi
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Lauren C Balmert
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dennis B Liu
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Fahad A Alyami
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Daniel L Erickson
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Edward M Gong
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emilie K Johnson
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sandra Judd
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - William E Kaplan
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Martin A Koyle
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Bruce W Lindgren
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Max Maizels
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Charles R Marcus
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Theresa Meyer
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Tarannum Qureshi
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Megan Saunders
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Theresa Thompson
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Elizabeth B Yerkes
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Earl Y Cheng
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Rague JT, Shannon R, Rosoklija I, Lindgren BW, Gong EM. Robot-assisted laparoscopic urologic surgery in infants weighing ≤10 kg: A weight stratified analysis. J Pediatr Urol 2021; 17:857.e1-857.e7. [PMID: 34635439 DOI: 10.1016/j.jpurol.2021.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Robot-assisted laparoscopic (RAL) urologic surgery is widely used in pediatric patients, though less commonly in infants. There are small series demonstrating safety and efficacy in infants, however, stratification by infant size has rarely been reported. Whether a cut-off weight, below which RAL surgery is not technically feasible, safe, or efficacious has not be determined. OBJECTIVE To assess safety and efficacy of RAL urologic procedures in infants <1 year of age, weighing ≤10 kg. STUDY DESIGN A single-institution retrospective cohort study of patients <1 year of age, and ≤10 kg undergoing RAL pyeloplasty (RALP) or RAL ipsilateral ureteroureterostomy (RALUU) between January 2011 and September 2020 was performed. Demographic, operative, and post-operative data were extracted from the medical record. Patients were stratified by post-hoc weight quartiles. Outcomes, including operative time, total OR time, estimated blood loss (EBL), post-operative length of stay (LOS), post-operative radiographic improvement, and 30-day complications were assessed by weight quartile for each procedure. The Kruskal-Wallis rank test was used to assess differences in continuous outcomes between weight quartiles and Pearson's Chi-squared test was used for categorical outcomes. RESULTS Of 696 RAL urologic surgeries performed, 101 met eligibility criteria. Median (IQR) age of patients was 7.2 (6.0-9.2) months with median weight of 8.0 (7.2-8.9) kg. The lowest weight was 5.5 kg. Procedures performed included 79 RALPs (78.2%), 22 RALUUs (21.8%). We identified 97 patients (94%) with post-operative imaging, with radiographic improvement in 92%. When stratified by weight quartile, there was no difference between groups in median operative time, total OR time, LOS, EBL, or post-operative radiographic improvement for both RALP and RALUU. Post-operative complications were assessed based on Clavien-Dindo classification with the majority of complications (9/12, 75%) in the >50th percentile weight groups. DISCUSSION To our knowledge, this is the largest published series of infant RAL urologic procedures, with similar rates of radiographic improvement and post-operative complications to prior published series. There are few prior series of RALP and RALUU in infants ≤10 kg, and we show comparable outcomes regardless of patient weight. Our study is limited by the inherent biases of retrospective studies. CONCLUSION RAL urologic surgery is technically feasible, safe, and efficacious in infants ≤10 kg, without worse outcomes as weight decrease. A cut-off weight, below which RAL surgery should not be performed has yet to be identified.
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Affiliation(s)
- James T Rague
- From the Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago (JR, RS, IR, BWL, EMG) and the Department of Urology, Northwestern University Feinberg School of Medicine (BLW, EMG), Chicago, IL, USA.
| | - Rachel Shannon
- From the Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago (JR, RS, IR, BWL, EMG) and the Department of Urology, Northwestern University Feinberg School of Medicine (BLW, EMG), Chicago, IL, USA.
| | - Ilina Rosoklija
- From the Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago (JR, RS, IR, BWL, EMG) and the Department of Urology, Northwestern University Feinberg School of Medicine (BLW, EMG), Chicago, IL, USA.
| | - Bruce W Lindgren
- From the Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago (JR, RS, IR, BWL, EMG) and the Department of Urology, Northwestern University Feinberg School of Medicine (BLW, EMG), Chicago, IL, USA.
| | - Edward M Gong
- From the Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago (JR, RS, IR, BWL, EMG) and the Department of Urology, Northwestern University Feinberg School of Medicine (BLW, EMG), Chicago, IL, USA.
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Chan YY, D'Oro A, Yerkes EB, Rosoklija I, Balmert LC, Lindgren BW, Gong EM, Liu DB, Johnson EK, Chu DI, Cheng EY. Challenging proximal hypospadias repairs: An evolution of technique for two stage repairs. J Pediatr Urol 2021; 17:225.e1-225.e8. [PMID: 33388263 DOI: 10.1016/j.jpurol.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/01/2020] [Accepted: 12/08/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Proximal hypospadias repair remains challenging. Our approach to the first stage of two-stage proximal hypospadias repairs has evolved from using Byars' flaps to preputial inlay grafts in anatomically suitable cases and pedicled preputial flaps in more complex repairs. We reviewed our outcomes, hypothesizing that inlay grafts and pedicled preputial flaps were associated with lower complication risks than Byars' flaps. STUDY DESIGN A single institution, retrospective, cohort study of consecutive two-stage, primary, proximal hypospadias repairs performed from 2007 to 2017 was conducted. Patients with <6 months follow-up and incomplete operative reports were excluded. Risk of complications (fistula, dehiscence, diverticulum, meatal stenosis, stricture) were evaluated following urethroplasty and stratified by first-stage repair technique. As technique refinements have been made since 2012, comparisons between two temporal subgroups (those who underwent repair in 2007-2012 and in 2013-2017) were made. RESULTS 78 of 127 patients met inclusion criteria. Overall complication rate was 47% (Summary Table). Median follow-up was 25.4 months (range 6.4-128.5 months) after urethroplasty. Pedicled preputial flaps (hazards ratio [HR] 0.30; 95% Confidence Interval [CI] 0.14-0.65) and inlay grafts (HR 0.32; 95% CI 0.11-0.95) were associated with lower complication risks compared to Byars' flaps (Summary Table). Median time to complication was significantly shorter for Byars' flaps (5.7 months) than for inlay grafts (40.6 months) and pedicled preputial flaps (79.2 months) by Kaplan Meier analysis. Temporal subgroup comparisons showed that overall complication rates decreased from 70% to 31% (p = 0.001), but differences in complication rates by first-stage technique were not statistically significant. DISCUSSION In our cohort, repairs with Byars' flaps had the highest complication rate, which is consistent with our observations that urethras tubularized from Byars' flaps lack appropriate backing and are hypermobile and irregular. To overcome these shortcomings, modifications were made to our approach to two-stage proximal hypospadias repairs with the use of inlay grafts and pedicled preputial flaps quilted to the underlying corporal bodies to optimize the stability of the urethral plate. Our preliminary results are promising. CONCLUSION Approach to the first stage of two-stage repairs affects outcomes. Pedicled preputial flaps and inlay grafts were associated with lower complication risks than Byars' flaps. Refinement of technique and patient selection may have resulted in fewer complications in the short term. However, long-term follow-up is needed.
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Affiliation(s)
- Yvonne Y Chan
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anthony D'Oro
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Elizabeth B Yerkes
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ilina Rosoklija
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Lauren C Balmert
- Department of Preventative Medicine/Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bruce W Lindgren
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Edward M Gong
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dennis B Liu
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emilie K Johnson
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David I Chu
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Earl Y Cheng
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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D'Oro A, Chan YY, Rosoklija I, Meyer T, Shannon R, Johnson EK, Liu DB, Gong EM, Maizels M, Matoka DJ, Yerkes EB, Lindgren BW, Cheng EY, Chu DI. Association between intra-operative meatal mismatch and urethrocutaneous fistula development in hypospadias repair. J Pediatr Urol 2021; 17:223.e1-223.e8. [PMID: 33339733 PMCID: PMC8068581 DOI: 10.1016/j.jpurol.2020.11.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/20/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The Glans-Meatus-Shaft (GMS) Score is a pre-operative phenotypic scoring system used to assess hypospadias severity and risk for post-operative complications. The 'M' component is based on pre-operative meatal location, but meatal location sometimes changes after penile degloving, resulting in 'meatal mismatch.' OBJECTIVE To identify: 1) the incidence and clinical predictors of meatal mismatch, and 2) the association of meatal mismatch with post-operative urethrocutaneous fistula development. STUDY DESIGN We performed a retrospective cohort study on patients who underwent primary hypospadias repair at a single center from 2011 to 2018. Meatal mismatch was defined as: upstaging (meatus moving more proximally after degloving), downstaging (moving more distally after degloving), or none. Covariates included: pre-degloving meatal location, chordee severity, penoscrotal anatomy, pre-operative testosterone, and number of stages for repair. To test the association between meatal mismatch and fistula development, we constructed two, nested, multivariable Cox proportional hazards regression models with and without meatal mismatch and compared them with the likelihood ratio test. A sensitivity analysis excluded patients with <6 months of follow-up. RESULTS Of 485 patients, 99 (20%) exhibited meatal mismatch, including 75 (15%) with upstaging and 24 (5%) patients with downstaging (Figure). Meatal mismatch was significantly associated with penoscrotal webbing, number of stages for repair, and pre-degloving meatal location, with downstaging being associated with more proximal meatal location. Over a median follow-up of 7.3 months (interquartile range 2.0-20.9), fistulae developed in 56 (12%) patients. On multivariable analysis, meatal upstaging was associated with a 3-fold increased risk of fistula development (Hazards Ratio [HR]: 3.04, 95% Confidence Interval [CI]: 1.44-6.45) compared to no mismatch. Meatal downstaging had similar risk of fistula development compared to no mismatch (HR: 0.99, 95% CI: 0.29-3.35). Multi-stage compared to single-stage repair was associated with reduced risk of fistula development (HR: 0.24, 95% CI: 0.09-0.66). The likelihood ratio test favored the model that included meatal mismatch. The sensitivity analysis showed similar findings. DISCUSSION Our short-term results suggest that meatal mismatch may be an important additional consideration to the GMS score as a tool to assess hypospadias severity, counsel families, and predict outcomes. Longer-term studies are needed to enhance the precision of risk stratification in hypospadias. CONCLUSIONS Meatal mismatch occurred in 20% of patients undergoing hypospadias repair. Among this cohort, meatal upstaging was associated with a 3-fold increased risk of post-operative urethrocutaneous fistula development.
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Affiliation(s)
- Anthony D'Oro
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA.
| | - Yvonne Y Chan
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA.
| | - Ilina Rosoklija
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine at Northwestern University, 633 N. St. Clair Street, Chicago, IL 60611, USA.
| | - Theresa Meyer
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA.
| | - Rachel Shannon
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA.
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine at Northwestern University, 633 N. St. Clair Street, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Dennis B Liu
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Edward M Gong
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Max Maizels
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Derek J Matoka
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Elizabeth B Yerkes
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Bruce W Lindgren
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - Earl Y Cheng
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
| | - David I Chu
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine at Northwestern University, 633 N. St. Clair Street, Chicago, IL 60611, USA; Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL 60611, USA.
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Roth JD, Gargollo PC, DaJusta DG, Lindgren BW, Noh PH, Rensing AJ, Krambeck AE, Whittam BM. Endoscopic-assisted robotic pyelolithotomy: a viable treatment option for complex pediatric nephrolithiasis. J Pediatr Urol 2020; 16:192.e1-192.e5. [PMID: 31932240 DOI: 10.1016/j.jpurol.2019.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 12/12/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION AND OBJECTIVE Endourological and percutaneous approaches are the standard of care for treatment of pediatric urolithiasis. However, in certain situations, an endoscopic-assisted robotic pyelolithotomy (EARP) can be an acceptable alternative. Limited data exist on pediatric EARP; thus, the authors describe their experience. METHODS Patient selection: The authors retrospectively analyzed the records of all robotic procedures performed at five institutions from 7/09-10/17 to identify patients who underwent EARP. The authors collected demographics data, indications, operative time, and postoperative complications. Stone composition was reported as the majority composition (≥50%), unless any uric acid or struvite was noted, and those stones were classified as such. TECHNIQUE Through a traditional or hidden incision endoscopic surgery (HIdES) robot pyeloplasty approach, the authors are able to easily pass a flexible endoscope through a robotic trocar and into the renal collecting system to perform pyeloscopy or ureteroscopy. Stones were primarily retrieved via the pyelolotomy and, if indicated, treated with laser lithotripsy. RESULTS The authors identified 26 patients who underwent EARP in 27 renal units. Median patient age was 12.2 years (interquartile range [IQR] 6.1-14.5 years), and body mass index was 17.5 kg/m2 (IQR 16.5-25.4 kg/m2). The median pre-operative dimension of the largest stone was 9.0 mm (IQR 5.8 mm-15.0 mm). Reasons for EARP: 21 (77.8%) concomitant pyeloplasty, four (14.8%) altered anatomy precluding other techniques, and two (7.4%) multiple large stones. Multiple stones were present in 20 renal units (74.1%). Stones were located in the renal pelvis in nine (33.3%), lower pole in 10 (37.0%), ureter in one (3.7%), and multiple locations in seven (25.9%). Hidden incision endoscopic surgery approach was used in 14 (51.9%), and the median operative time was 237.5 min (IQR 189.8-357.8 min) with a median length of stay 1.0 day (IQR 1.0-2.0 days). Stone composition included calcium oxalate in 14 (51.9%), calcium phosphate in five (18.5%), cysteine in two (7.4%), struvite in two (7.4%), and unknown in four (14.8%). Overall stone free status was 19 (70.4%); of the eight (29.6%) renal units with residual stones, four underwent ureteroscopy, two extracorporeal shockwave lithotripsy (ESWL), one spontaneously passed, and one underwent percutaneous nephrolithotomy (PCNL). After secondary treatment, final stone free rate was 96.3%. Complications included stent migration and admission for urosepsis. At a median follow-up of 12 months (IQR 6.2-19.2 months), five (18.5%) had stone recurrence. CONCLUSIONS Endoscopic-assisted robotic pyelolithotomy is a reasonable treatment option for select pediatric patients with concomitant ureteropelvic junction obstruction and nephrolithiasis or pediatric patients with stones inaccessible by standard methods.
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Affiliation(s)
- Joshua D Roth
- Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Suite 4230, Indianapolis, IN, 46202, USA.
| | | | - Daniel G DaJusta
- Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH, 43205, USA
| | - Bruce W Lindgren
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Paul H Noh
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave #2129, Cincinnati, OH, 45229, USA
| | - Adam J Rensing
- Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Suite 4230, Indianapolis, IN, 46202, USA
| | - Amy E Krambeck
- Indiana University Health Methodist Hospital, 1801 N Senate Street, Suite 220, Indianapolis, IN, 46202, USA
| | - Benjamin M Whittam
- Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Suite 4230, Indianapolis, IN, 46202, USA
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Jacobson DL, Shannon R, Johnson EK, Gong EM, Liu DB, Flink CC, Meyer T, Cheng EY, Lindgren BW. Robot-Assisted Laparoscopic Reoperative Repair for Failed Pyeloplasty in Children: An Updated Series. J Urol 2019; 201:1005-1011. [DOI: 10.1016/j.juro.2018.10.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Deborah L. Jacobson
- Department of Urology, Northwestern University, Chicago, Illinois
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Rachel Shannon
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Emilie K. Johnson
- Department of Urology, Northwestern University, Chicago, Illinois
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Edward M. Gong
- Department of Urology, Northwestern University, Chicago, Illinois
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Dennis B. Liu
- Department of Urology, Northwestern University, Chicago, Illinois
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Carl C. Flink
- Department of Radiology, University of Cincinnati, Cincinnati, Ohio
| | - Theresa Meyer
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Earl Y. Cheng
- Department of Urology, Northwestern University, Chicago, Illinois
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Bruce W. Lindgren
- Department of Urology, Northwestern University, Chicago, Illinois
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
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Jacobson DL, Flink CC, Johnson EK, Maizels M, Yerkes EB, Lindgren BW, Liu DB, Rosoklija I, Cheng EY, Gong EM. The Correlation between Serial Ultrasound and Diuretic Renography in Children with Severe Unilateral Hydronephrosis. J Urol 2018; 200:440-447. [PMID: 29630977 DOI: 10.1016/j.juro.2018.03.126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Deborah L. Jacobson
- Division of Pediatric Urology, Department of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Carl C. Flink
- Department of Radiology, University of Cincinnati, Cincinnati, Ohio
| | - Emilie K. Johnson
- Division of Pediatric Urology, Department of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Max Maizels
- Division of Pediatric Urology, Department of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Elizabeth B. Yerkes
- Division of Pediatric Urology, Department of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bruce W. Lindgren
- Division of Pediatric Urology, Department of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dennis B. Liu
- Division of Pediatric Urology, Department of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ilina Rosoklija
- Division of Pediatric Urology, Department of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Earl Y. Cheng
- Division of Pediatric Urology, Department of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Edward M. Gong
- Division of Pediatric Urology, Department of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Glaser AP, Bowen DK, Lindgren BW, Meeks JJ. Robot-assisted retroperitoneal lymph node dissection (RA-RPLND) in the adolescent population. J Pediatr Urol 2017; 13:223-224. [PMID: 28262537 DOI: 10.1016/j.jpurol.2017.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 01/21/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Robot-assisted retroperitoneal lymph node dissection (RA-RPLND) has built on success and techniques of laparoscopic RPLND, with the added benefits of robotic technology. This paper demonstrates use of the da Vinci Xi® system for RA-RPLND in two adolescent patients. METHODS Case #1: A 17-year-old male presented with a left testicular mass and elevated alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG). Pathology revealed a mixed non-seminomatous germ cell tumor (60% embryonal, 35% yolk sac, 5% choriocarcinoma, + lymphovascular invasion). Tumor marker normalized post-orchiectomy, and staging imaging was without evidence of metastatic disease. After discussion of options he opted to undergo RA-RPLND. Case #2: A 15-year-old male presented with a right para-testicular mass and negative tumor markers. He underwent inguinal exploration and excision of the paratesticular mass. Final pathology revealed an ectomesenchymoma with a spindle cell rhabdomyosarcoma component. Staging imaging was negative, and after discussion of options he underwent completion orchiectomy and RA-RPLND. RESULTS The patient in Case #1 underwent a left modified-template nerve-sparing RA-RPLND. Sixteen lymph nodes were negative for tumor. The patient in Case #2 underwent complete bilateral nerve-sparing RA-RPLND. Forty-two lymph nodes were negative for tumor. Estimated blood loss was <50 cc for both cases, and console time averaged 262 min. CONCLUSION This was a report of two cases of RA-RPLND in the adolescent population. RA-RPLND is technically feasible in this population, and further study of RA-RPLND is needed to determine long-term outcomes, as this technique is becoming more widely adopted.
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Affiliation(s)
- A P Glaser
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - D K Bowen
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - B W Lindgren
- Division of Pediatric Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - J J Meeks
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Li B, Maizels M, Liu D, Gong EML, Lindgren BW, Malhotra N, Bowen D, Corbett S. CEVL interactive - Promoting effective teamwork to perform robot assisted laparoscopic pyeloplasty in pediatric urology. J Pediatr Urol 2016; 12:430-433. [PMID: 27894745 DOI: 10.1016/j.jpurol.2016.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 11/06/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Belinda Li
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Max Maizels
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Dennis Liu
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Edward Ming-Luan Gong
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bruce W Lindgren
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Neha Malhotra
- Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Diana Bowen
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sean Corbett
- Division of Pediatric Urology, University of Virginia at Charlottesville, USA
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Faasse MA, Johnson EK, Bowen DK, Lindgren BW, Maizels M, Marcus CR, Jovanovic BD, Yerkes EB. Is glans penis width a risk factor for complications after hypospadias repair? J Pediatr Urol 2016; 12:202.e1-5. [PMID: 27321557 DOI: 10.1016/j.jpurol.2016.04.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 04/27/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Recent studies have suggested that a smaller glans penis size may be associated with a higher likelihood of complications after hypospadias repair. Accurate identification of risk factors other than the well-understood variable of meatal location would allow development of better prognostic models and individualized risk stratification. OBJECTIVE To test the hypothesis that a smaller width of the glans penis predicts adverse outcomes after hypospadias surgery. METHODS Prospectively recorded clinical data were reviewed from a single-institution registry of primary hypospadias repairs performed between 2011 and 2014. Follow-up records were examined for occurrence of complications. Urethroplasty complications were defined to include meatal stenosis, dehiscence, urethrocutaneous fistula, urethral stricture, and/or urethral diverticulum. The subset of meatal stenosis and dehiscence were regarded as glanular complications. Regression analyses were performed to determine association between glans width and occurrence of complications. Because pre-operative androgen stimulation is known to increase glans penis size, separate subgroup analyses were included of patients with and without pre-operative use of testosterone cream. RESULTS A total of 159 patients met criteria for inclusion in the study cohort: 140 patients underwent a single-stage repair, while 19 patients had a two-stage repair. The median glans penis width was 15 mm (range 10-22). Eighty-four patients (53%) received testosterone cream pre-operatively and had a significantly wider glans penis than the 75 patients who did not (median 15.5 vs 14 mm; P < 0.001). Median clinical follow-up was 7 months (IQR 1-12), with a minimum time elapsed since surgery of 10 months at the time of chart review. Twenty-four patients (15%) had one or more urethroplasty complications, including 11 (7%) with glanular complications. Overall, there was no statistically significant association between glans width and urethroplasty complications (P = 0.26) or glanular complications (P = 0.90) (Summary Table). Subgroup analyses of patients with and without pre-operative testosterone also revealed no significant associations between glans width and complications. CONCLUSIONS Glans penis width was not a risk factor for complications after hypospadias repair. This finding differs from the results of other recent studies and encourages further research into the value of measuring penile parameters in patients undergoing hypospadias repair.
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Affiliation(s)
- M A Faasse
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA; Advocate Children's Hospital, 4400 W. 95th St., Chicago, IL 60453, USA
| | - E K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - D K Bowen
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - B W Lindgren
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - M Maizels
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - C R Marcus
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA
| | - B D Jovanovic
- Department of Preventive Medicine-Biostatistics, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Dr., Chicago, IL 60611, USA
| | - E B Yerkes
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Chicago, IL 60611, USA.
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Bowen DK, Faasse MA, Liu DB, Gong EM, Lindgren BW, Johnson EK. Use of Pediatric Open, Laparoscopic and Robot-Assisted Laparoscopic Ureteral Reimplantation in the United States: 2000 to 2012. J Urol 2016; 196:207-12. [DOI: 10.1016/j.juro.2016.02.065] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Diana K. Bowen
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mark A. Faasse
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dennis B. Liu
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Edward M. Gong
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Bruce W. Lindgren
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Emilie K. Johnson
- Division of Pediatric Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Bowen DK, Lindgren BW, Cheng EY, Gong EM. Can proctoring affect the learning curve of robotic-assisted laparoscopic pyeloplasty? Experience at a high-volume pediatric robotic surgery center. J Robot Surg 2016; 11:63-67. [PMID: 27342871 DOI: 10.1007/s11701-016-0613-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 06/12/2016] [Indexed: 12/01/2022]
Abstract
We sought to determine if the learning curve in pediatric robotic-assisted laparoscopic pyeloplasty (RALP) for an experienced open surgeon (OS) converting to robotics would be affected by proctoring from an experienced robotic surgeon (RS), and/or the experience of training within the framework of an established robotics program. We reviewed pediatric RALP cases by three surgeons at our institution, including the OS, RS, and a new fellowship-trained surgeon (FTS). We compared the first eight independent RALPs for the OS with the most recent ten RALPs for the RS. As an ancillary analysis, to isolate the impact of proctoring and of a robotics program, we reviewed the first ten cases of the FTS as well the first and last eight cases of the RS at a prior institution. A total of 44 patient charts were reviewed, with a mean follow-up time of 16 months (range 6.7-45 months). Radiologic improvement was seen in all patients with the exception of one who required reoperative pyeloplasty. The FTS, RS, and OS had similar mean operative times; however; when comparing robotic cases at the beginning of each of their learning curves, shorter operative times were achieved by the proctored surgeon (OS). Finally, comparing two RALP cohorts by the RS at his prior institution revealed longer operative times with an inexperienced robotics team. We demonstrate that an experienced open surgeon and fellowship-trained surgeon can quickly attain levels of expertise with pediatric RALP within an established robotic surgical program.
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Affiliation(s)
- Diana K Bowen
- Department of Urology, Feinberg School of Medicine, Northwestern University, Tarry 16-703, 303 E. Chicago Ave, Chicago, IL, 60611, USA.
| | - Bruce W Lindgren
- Division of Pediatric Urology, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
- Department of Urology, Feinberg School of Medicine, Northwestern University, Tarry 16-703, 303 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Earl Y Cheng
- Division of Pediatric Urology, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
- Department of Urology, Feinberg School of Medicine, Northwestern University, Tarry 16-703, 303 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Edward M Gong
- Division of Pediatric Urology, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, 60611, USA
- Department of Urology, Feinberg School of Medicine, Northwestern University, Tarry 16-703, 303 E. Chicago Ave, Chicago, IL, 60611, USA
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Lindgren BW. Appendicovesicostomy--What is the Best Technique for a Good Operation? J Urol 2015; 194:617-8. [PMID: 26079331 DOI: 10.1016/j.juro.2015.06.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Bruce W Lindgren
- Ann and Robert H. Lurie Children's Hospital of Chicago, Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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18
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Diaz EC, Lindgren BW, Gong EM. Carbon dioxide laser for detrusor tunnel creation in robot-assisted laparoscopic extravesical ureteral reimplant. J Pediatr Urol 2014; 10:1283.e1-2. [PMID: 25168317 DOI: 10.1016/j.jpurol.2014.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 07/21/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Demonstrate and report initial results using a carbon dioxide (CO2) laser for detrusor tunnel creation in robot-assisted laparoscopic extravesical ureteral reimplant (RALUR). METHODS Retrospective chart review was performed for cases of RALUR from 2011 to 2014. Patients undergoing complex reconstruction (ureteral tailoring, dismembered reimplant, concomitant ureteroureterostomy), and those who had incomplete follow-up were excluded. Variables, including use of the CO2 laser, were collected and correlated with outcomes. RESULTS 23 patients representing 40 ureteral units were included for analysis. A CO2 laser was used in 9/23 (39%) patients and 16/40 (40%) ureteral units. Intraoperative mucosotomy was reported in 3/14 (21%) patients for the electrocautery group and 1/9 (11%) patients for the CO2 laser group. Resolution of VUR was observed in 11/14 (79%), and 9/9 (100%) of patients for the electrocautery group and the CO2 laser group, respectively. Two complications were identified in the electrocautery group of patients: ileus (Clavien 2), and transient bilateral ureteral obstruction requiring placement of ureteral stents (Clavien 3B). There were no complications in the CO2 laser group. CONCLUSIONS Creation of the detrusor tunnel with a CO2 laser is safe and effective, and is associated with a lower rate of failure and complication in this cohort.
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Affiliation(s)
- E C Diaz
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA.
| | - B W Lindgren
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA
| | - E M Gong
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA
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Faasse MA, Lindgren BW, Gong EM. Robot-assisted laparoscopic ureteral reimplantation with excisional tailoring for refluxing megaureter. J Pediatr Urol 2014; 10:773.e1-2. [PMID: 24613726 DOI: 10.1016/j.jpurol.2014.01.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 01/25/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To demonstrate a novel technique for robot-assisted laparoscopic excisional tailoring and reimplantation of a refluxing megaureter. METHODS A 9-year-old boy with dysfunctional elimination was found to have a refluxing megaureter and diminished ipsilateral renal function. Robotic ureteral reimplantation with excisional tailoring was performed using a three-port approach. Stay sutures were placed in the anterior aspect of the distal ureter and sequentially lifted to allow freehand excision of redundant ureter. The ureterovesical junction was left intact, and the ureter was repaired over a 6 Fr double-J stent. Detrusorotomy to create flaps for ureteral tunneling was performed with a carbon dioxide (CO2) laser. RESULTS The patient's vesicoureteral reflux was successfully corrected, and he is now asymptomatic. CONCLUSION Specific technical modifications can facilitate robotic megaureter repair with intracorporeal excisional tailoring. The CO2 laser is advantageous for detrusorotomy.
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Affiliation(s)
- Mark A Faasse
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA
| | - Bruce W Lindgren
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA
| | - Edward M Gong
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA.
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Ellimoottil C, Faasse MA, Lindgren BW. Endoscopic Management of Transurethrally Inserted Magnetic Beads. Urology 2013; 81:e13-4. [DOI: 10.1016/j.urology.2012.10.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Revised: 09/08/2012] [Accepted: 10/20/2012] [Indexed: 11/17/2022]
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Vasquez E, Kallen RJ, Shore RM, Lindgren BW. Pediatric Renal Lymphangiectasia: Importance of Recognition and Accurate Renal Imaging. Urology 2012; 80:434-6. [DOI: 10.1016/j.urology.2011.12.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 12/20/2011] [Accepted: 12/28/2011] [Indexed: 11/16/2022]
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22
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Moylan S, Armstrong J, Diaz-Saldano D, Saker M, Yerkes EB, Lindgren BW. Are abdominal x-rays a reliable way to assess for constipation? J Urol 2010; 184:1692-8. [PMID: 20728159 DOI: 10.1016/j.juro.2010.05.054] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Indexed: 11/19/2022]
Abstract
PURPOSE Currently to our knowledge no validated reliable tools are available to evaluate constipation in children. Abdominal x-rays are often done in clinical practice to evaluate patients with lower urinary tract symptoms. Although 3 previously published rating tools exist to score constipation based on x-ray, there is little information on their merits. We assessed these 3 tools for reliability among multiple practitioners. MATERIALS AND METHODS We retrospectively analyzed abdominal x-rays in a cohort of 80 patients between ages 4 and 12 years. X-rays were independently assessed by each of us using the previously published Barr, Leech and Blethyn scoring tools. Scores were analyzed for reliability using standard statistical methods. RESULTS The range of weighted κ score, indicating reliability, were 0.0491 to 0.4809 for the Barr, 0.1195 to 0.2730 for the Leech and 0.0454 to 0.4514 for the Blethyn method. Guidelines for κ scores are greater than 0.75-excellent, 0.4 to 0.75-good and 0 to 0.4-marginal reproducibility. ICC, another reliability measure, was 0.02577 for the Barr, 0.3313 for the Leech and 0.201 for the Blethyn method. ICC interpretations are greater than 0.75-excellent, 0.4 to 0.75-good and 0 to 0.4-poor. There was a trend toward good interrater reliability between more experienced urology practitioners with the Barr and Blethyn tools (0.48 and 0.45, respectively) but not between less experienced raters or with the Leech tool. CONCLUSIONS Currently available scoring tools to evaluate constipation by x-ray do not have good reliability among multiple examiners. Further research is needed to develop an alternate tool to increase the reliability of x-ray to assess constipation between multiple raters.
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Affiliation(s)
- Susan Moylan
- Division of Urology, Children's Memorial Hospital, Chicago, Illinois 60614, USA
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23
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Matoka DJ, Hagerty JA, Lindgren BW. PEDIATRIC ROBOT ASSISTED LAPAROSCOPIC URETEROCALYCOSTOMY. J Urol 2009. [DOI: 10.1016/s0022-5347(09)61087-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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24
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Meeks JJ, Hagerty JA, Lindgren BW. Pediatric Robotic-Assisted Laparoscopic Diverticulectomy. Urology 2009; 73:299-301; discussion 301. [DOI: 10.1016/j.urology.2008.06.068] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Revised: 06/09/2008] [Accepted: 06/11/2008] [Indexed: 11/25/2022]
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Abstract
PURPOSE Postoperative chylous ascites is a rare complication of retroperitoneal surgery that has considerable morbidity. We review the pathogenesis and management of chylous ascites following surgical treatment of Wilms tumor. MATERIALS AND METHODS We identified 9 children with chylous ascites after surgical treatment of Wilms tumor. Of these cases 3 were treated at a single institution during the last 20 years and 6 were identified during retrospective chart reviews of patients enrolled in National Wilms Tumor Studies 3 and 4 to identify surgical complications. Chylous ascites presented as increased abdominal girth and poor feeding. Paracentesis or laparotomy was diagnostic. RESULTS Patient age at presentation with Wilms tumor ranged from 6 to 95 months (median 15). Left nephrectomy was performed in 5 cases, right nephrectomy in 3, and left nephrectomy and partial right nephrectomy in 1 with bilateral disease. Lymphadenectomy including the hilar and periaortic lymph nodes was performed in 5 patients, 4 of whom also underwent some form of suprahilar lymph node dissection. Three patients underwent lymph node sampling of the hilar, periaortic and some suprahilar lymph nodes. All children received adjuvant chemotherapy and 4 were treated with adjuvant irradiation to the surgical bed before the diagnosis of chylous ascites. The interval between surgery and diagnosis of ascites ranged from 12 to 49 days (median 21). Of the patients 7 were successfully treated with conservative measures, total parenteral nutrition and/or a diet containing primarily medium chain triglycerides, and 2 required invasive procedures, including exploratory laparotomy and ligation of disrupted lymphatic vessels or placement of a peritoneovenous shunt. CONCLUSIONS Extensive lymph node dissection, particularly above the level of the renal hilum, appears to be associated with the development of postoperative chylous ascites. The National Wilms Tumor Study guidelines do not require formal lymph node dissection for staging and only lymph node sampling is recommended. Elimination of formal lymphadenectomy along with meticulous ligation of lymphatics should decrease the incidence of this complication. Fortunately, conservative treatment with total parenteral nutrition and/or medium chain triglycerides will remedy the problem in the majority of children.
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Affiliation(s)
- Adam C Weiser
- Division of Pediatric Urology, Schneider's Children's Hospital/Long Island Jewish Medical Center, New Hyde Park, New York, USA
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Affiliation(s)
- Leslie Minor
- Department of Urology, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois, USA
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Lindgren BW, Franco I, Blick S, Levitt SB, Brock WA, Palmer LS, Friedman SC, Reda EF. Laparoscopic Fowler-Stephens orchiopexy for the high abdominal testis. J Urol 1999; 162:990-3; discussion 994. [PMID: 10458418 DOI: 10.1016/s0022-5347(01)68042-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE Laparoscopic orchiopexy is extremely effective for treating patients with nonpalpable testis. However, despite the high dissection and wide mobilization it allows in some cases, vessel length prevents the testis from reaching the scrotum. There have been only incidental cases reported in which laparoscopy has been used for vessel transection and testicular mobilization orchiopexy. We reviewed our cases treated with the Fowler-Stephens orchiopexy performed laparoscopically in 1 or 2 stages. MATERIALS AND METHODS We reviewed the records of all boys who underwent laparoscopy for a nonpalpable testis at our institutions since 1992. Patients who underwent testicular vessel transection and orchiopexy performed laparoscopically in 1 or 2 stages were selected for evaluation. Office charts and operative reports were reviewed in detail. RESULTS Of the 126 nonpalpable testes in 108 patients 51 (40%) were intra-abdominal, including 18 (35%) in 14 patients in whom the Fowler-Stephens procedure was performed laparoscopically. Five testes were treated with a 2-stage procedure, while 11 were managed by laparoscopic mobilization followed by laparoscopic vessel clipping and orchiopexy in 1 stage. In 2 additional patients nearly all dissection was performed laparoscopically but due to extenuating circumstances inguinal incision was required as well. Thus, 13 testes were managed by 1-stage Fowler-Stephens orchiopexy, including all cases since August 1996 which required vessel transection. Two patients were hospitalized postoperatively for prolonged ileus after the second stage. All other 2-stage and all 1-stage cases were managed on an outpatient basis. There were no complications. At a mean followup of 6 months all cases without previous surgery that were managed by laparoscopic orchiopexy are without atrophy and the testes are in a scrotal position. Two testes in which previous surgery had been done atrophied postoperatively. CONCLUSIONS Laparoscopic transection of the testicular vessels is safe in boys with high abdominal testes that do not reach the scrotum after laparoscopic high retroperitoneal dissection. The magnification and wide mobilization of laparoscopy likely allow better preservation of the collateral vascular supply than open exploration. Previous surgery is a risk factor for atrophy. The success rate of 89% overall and 100% in patients who did not previously undergo testicular surgery equals or exceeds that of open orchiopexy in patients with abdominal testes. The 1-stage procedure avoids repeat anesthesia and the extensive, sometimes tedious, dissection that is occasionally required during reoperation.
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Affiliation(s)
- B W Lindgren
- Long Island Jewish Medical Center-Schneider Children's Hospital, New Hyde Park, Illinois, USA
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Abstract
PURPOSE Conventional techniques result in chordee correction in the majority of patients. However, some with extensive chordee require further treatment to correct persistent extraordinary penile curvature. Our practice has been to treat this condition with interpositional dermal grafting. We review our experience with this procedure. MATERIALS AND METHODS During a 5-year period dermal grafts harvested from the nonhair-bearing inguinal skin fold were placed in 51 patients with a mean age of 29 months. The primary diagnosis was penoscrotal or perineal hypospadias in 36 patients (hypospadias cripple in 4), the exstrophy-epispadias complex in 3, mid shaft or distal hypospadias with severe chordee in 10 and chordee without hypospadias in 2. A total of 49 patients (96%) underwent staged urethroplasty. RESULTS One graft was placed in 29 patients (57%), 9 (18%) received 1 graft and underwent a Nesbit plication, (14%) received 2 grafts, 5 (10%) received 2 grafts and underwent dorsal plication, and 1 (2%) received 3 grafts. Second stage urethral reconstruction was done using a Thiersch-Duplay tube in the majority of cases. In 5 patients mild residual chordee was easily corrected at the time of second stage repair. CONCLUSIONS In a staged repair the first priority of the initial stage is to achieve a straight phallus. While our experience indicates that a single dermal graft is sufficient in approximately 57% of cases, when it does not result in complete straightening, we have had success with placing additional graft(s) and/or performing dorsal plication. We believe that the additional penile length achieved with dermal grafting results in a dependent phallus and cosmesis preferable to that of plication only.
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Affiliation(s)
- B W Lindgren
- Long Island Jewish Medical Center, Schneider Children's Hospital, New Hyde Park, New York, USA
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30
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Abstract
PURPOSE Multiple approaches exist for the management of the nonpalpable testis. With the use of diagnostic laparoscopy widely accepted in the setting of the nonpalpable testis we have found laparoscopic orchiopexy to be an efficient and logical extension. To evaluate its use we report our experience with laparoscopic orchiopexy to treat 44 nonpalpable testes in 36 patients. MATERIALS AND METHODS We retrospectively reviewed the medical records of all patients who underwent laparoscopic orchiopexy for a 2 1/2-year period. Modifications of the surgical technique are described. RESULTS The left testis was affected in 18 boys, the right in 9 and both in 9. At laparoscopy 8 testes were at the internal ring or were peeping and the remainder were intra-abdominal. One patient underwent a unilateral 1-stage Fowler-Stephens orchiopexy, and 3 unilateral and 1 bilateral 2-stage Fowler-Stephens orchiopexy. Two patients underwent laparoscopically assisted orchiectomy. The remaining 31 patients underwent laparoscopic orchiopexy without division of the spermatic vessels. At followup (mean 6 months) all testes are without atrophy, and 39 of 42 (93%) are in an acceptable scrotal position. There are 3 testes (7%) high in the scrotum. CONCLUSIONS Laparoscopic orchiopexy is a logical extension of diagnostic laparoscopy for the evaluation and treatment of the nonpalpable testis. The low incidence of complications and 93% success rate underscore the feasibility of this procedure. It is our procedure of choice for the treatment of nonpalpable testis.
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Affiliation(s)
- B W Lindgren
- Division of Pediatric Urology, Long Island Jewish Medical Center, Schneider Children's Hospital, New Hyde Park, New York, USA
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Lindgren BW, Demos T, Marsan R, Posniak H, Kostro B, Calvert D, Hatch D, Flanigan R, Steinmuller D, Lewis R. Renal computed tomography with 3-dimensional angiography and simultaneous measurement of plasma contrast clearance reduce the invasiveness and cost of evaluating living renal donor candidates. Transplantation 1996; 61:219-23. [PMID: 8600627 DOI: 10.1097/00007890-199601270-00010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Renal computed tomography (CT), 3-dimensional CT angiography (3D-CTA), and simultaneous measurement of glomerular filtration rate (GFR) by x-ray fluorescence determination of plasma contrast clearance (PCC) are alternatives to intravenous urography (IVU), renal arteriography (RA), and 24-hr urine creatinine clearance (CrCl) for evaluation of renal structure and function in living renal donor (LRD) candidates. To determine if CT, 3D-CTA, and PCC provide data comparable to IVU, RA, and CrCl, both methods were used to evaluate 23 LRD candidates. Costs were also compared. Conventional RA identified 19 accessory arteries and one case of medial fibroplasia. Each of these anomalous vessels was recognized on 3D-CTA. Venous anatomy was more clearly delineated on 3D-CTA than the venous phase of conventional RA. CT demonstrated 3 benign cysts and a single, small intraparenchymal calcification in 3 renal units. GFRs measured by PCC and CrCl were 91 +/- 4 and 132 +/- 7 ml/min/1.73m2, respectively (r = 0.64, P < 0.05). Total cost for CT/3D-CTA/PCC was 46% less than that of IVU/RA/CrCl and 40% less than RA/CrCl. CT/3D-CTA/PCC provided reliable structural and functional data at substantially less cost, discomfort, and inconvenience to the living renal donor candidate. As such, CT/3D-CTA/PCC is superior to conventional methods for evaluation of the living renal donor candidate.
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Affiliation(s)
- B W Lindgren
- Department of Urology, Loyola University Medical Center, Maywood, Illinois 60153, USA
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