Tips and tricks for the extravesical robotic-assisted laparoscopic ureteral reimplantation for pediatric vesicoureteral reflux

Over the past few years, robotic-assisted laparoscopic ureteral reimplantation (RALUR) has gained popularity as an acceptable alternative for the traditional open approach if surgery is elected for children with vesicoureteral reflux (VUR). We present our technique including the tips and tricks for both male and female patients, including a stepwise approach for ureteral identification in female patients depending on the level of technical difficulty. Our series include 30 patients who represent a spectrum in which we presented the different tips and tricks included in this video.

Double versus single diaper technique after hypospadias repair, does it really matter?

INTRODUCTION

Double-diaper technique with an open-drainage catheter is a common practice after hypospadias repair. However, double-diapering may increase the burden of postoperative care and has not been compared to single-diapering with an open-drainage catheter.

OBJECTIVES

This study investigates whether the single-diaper technique is associated with inferior surgical outcomes compared to the double-diaper technique.

MATERIALS AND METHODS

A single surgeon database was retrospectively reviewed for patients who underwent hypospadias repair between 2013 and 2021. Patients who were lost to follow-up and those in whom the type of diaper care (single- or double-diaper) was not documented were excluded. Patients in the single-diaper technique received the same type of dressing and discharge instructions, as those in the double-diaper group, except for leaving the catheter freely draining into a single-diaper. Short-term complications including surgical site infection (SSI), urinary tract infection (UTI) and wound dehiscence, were the primary outcome; whereas the long-term urethroplasty complications (urethrocutaneous fistula and meatal stenosis) were secondary outcomes. Outcomes were analyzed according to the type of diaper care.

RESULTS

Among 323 patients reviewed, 219 patients met the inclusion criteria (72 patients in the double-diaper and 147 in the single-diaper group). Both study groups were similar regarding patient demographics, hypospadias characteristics and surgical technique. Looking at the primary outcomes, there was no statistically significant difference in SSI, UTI or wound dehiscence. For the secondary outcomes, the incidence of meatal stenosis (8.3 vs. 1.4%, p = 0.044), and fistula formation (15.3% vs 5.4%, p = 0.037) was significantly higher in the double-diaper than the single-diaper group, respectively (Table 2).

CONCLUSION

Single-diaper technique following hypospadias repair is not associated with increased risk of complications compared to double-diaper technique.

Pediatric renal trauma at a level 1 trauma center in a rural state: A 10-year institutional review and protocol implementation

INTRODUCTION

Unintentional injury is a leading cause of mortality and morbidity in children. There is no consensus on the ideal, discrete management of pediatric renal trauma (PRT). Therefore, management protocols tend to be institution-specific.

OBJECTIVE

This study aimed to characterize PRT at a rural level-1 trauma center and subsequently develop a standardized protocol.

STUDY DESIGN

A retrospective review of a prospectively maintained database of PRT at a rural level 1 trauma center between 2009 and 2019 was conducted. Injuries were characterized regarding renal trauma grade, associated multi-organ involvement and the need for intervention. The benefit of patient transfer from regional hospitals and length and cost of stay were evaluated.

RESULTS

Of 250 patients admitted with renal trauma diagnosis 50 patients <18 years were analyzed. Of those, the majority (32/50, 64%) had low-grade (grade I-III) injuries. Conservative management was successful in all low-grade injuries. Of 18 high-grade PRT, 10 (55.6%) required intervention, one prior to transfer. Among patients with low-grade trauma, 23/32 (72%) were transferred from an outside facility. A total of 13 (26%) patients with isolated low-grade renal trauma were transferred from regional hospitals. All isolated, transferred low-grade renal trauma had diagnostic imaging before transfer and none required invasive intervention. Interventional management of renal injury was associated with a longer median LOS [7 (IQR = 4-16.5) vs 4 (IQR = 2-6) days for conservative management, p = 0.019)] and an increased median total cost of $57,986 vs. $18,042 for conservative management (p = 0.002).

DISCUSSION

The majority of PRT, particularly low-grade, can be managed conservatively. A significant proportion of children with low-grade trauma are unnecessarily transferred to higher level centers. Review of pediatric renal trauma at our institution over a decade has allowed us to develop an institutional protocol which we believe allows for safe and effective patient monitoring.

CONCLUSION

Isolated, low-grade PRT can be managed conservatively at regional hospitals without needing transfer to a level 1 trauma center. Children with high-grade injuries should be closely monitored and are more likely to need invasive intervention. Development of a PRT protocol will help to safely triage this population and identify those who may benefit from transfer to a tertiary care center.

Bridging the Gap-Building Surgical Subspecialty Telemedicine Clinics in the Rural Setting

INTRODUCTION

Pediatric urology is a much-needed subspecialty with a breadth of complex disorders that can often prove challenging to diagnose and manage. Exacerbating this need is the minimal exposure medical trainees receive to pediatric urology. Pediatric urology arrived in West Virginia in 1983 but the subspecialty has been inconsistently represented since then. Currently there are 2 fellowship-trained pediatric urologists in the state of West Virginia, which has an area of approximately 24,038 square miles. We review our experience with the use of telemedicine in providing outreach to the wider parts of our medically underserved state and ultimately evaluate its efficacy from a patient-centric cost analysis and diagnosis concordance perspective. We hypothesized that the use of telemedicine would be cost and time-effective for patients in our rural state.

METHODS

We retrospectively reviewed our series of patients presenting from outside telemedicine "referral centers" in Martinsburg, Parkersburg and Wheeling for pediatric urological consultation. We evaluated reason for consultation, geographic driving distance, drive time and travel cost saved from telemedicine consultation.

RESULTS

A total of 92 patients presented to outside designated telemedicine centers from August 2018 to April 2020. The mean driving time saved utilizing telemedicine consultation was 4 hours and 46 minutes, and mean driving distance saved was 299.8 miles. Travel costs saved in terms of fuel averaged $173.88 per patient. The most common reason for consultation was undescended testis, followed by recurrent urinary tract infection and nocturnal enuresis. Of the 23 patients who required surgery, only 2 (8.7%) had an initial diagnosis that was not concordant with their operating room examination.

CONCLUSIONS

While modest, our data indicate a modern solution to a historical need in our state. Our high diagnosis concordance rate (91.3%) shows that a well-trained advanced practice provider can adequately perform an operative evaluation via telemedicine.

Infantile Primary Hyperoxaluria Type 1 Treated With Lumasiran in Twin Males

Primary hyperoxaluria type 1 (PH1) is a rare genetic disease that results in oxalate overproduction leading to nephrolithiasis (NL), nephrocalcinosis (NC), kidney failure, and systemic oxalosis. Infantile PH1 is its most severe form, and it may require intensive hemodialysis followed by a liver-kidney transplant. Lumasiran is an RNA interference (RNAi) therapeutic agent that reduces hepatic oxalate production, which has been recently approved for the treatment of PH1. In this report, we present a case of twin males with infantile PH1 and bilateral NL and NC who were treated with lumasiran at 12 months of age. Their symptoms abated after therapy was started without disease progression. To the best of our knowledge, this is the first report of PH1 occurring in twins and the first report on using lumasiran to treat infantile PH1 outside of a clinical trial. Lumasiran appears to be a successful therapeutic option for infantile PH1.

Surgical Correction of True Diphallia in a Newborn Male

Diphallia is an exceedingly rare anomaly characterized by partial or complete duplication of the phallus. Approximately 100 cases have been reported worldwide since its initial documentation, and incidence is estimated at 1 in 5 to 6 million live births. Therapeutic management is dependent on the extent of the anomaly, ranging from phallic excision to complex reconstructive procedures in cases of broader systemic involvement. We present the case of congenital true diphallia with associated penoscrotal transposition, bifid scrotum, partial urethral duplication, ventral chordee, large scrotal lipoma and sacral dimple. We further present a review of available literature pertaining to diphallia.

The Impact of Targeted Education of American Urological Association Cryptorchidism Guidelines in a Rural State: Improvement Still Needed

Background

The American Urological Association published guidelines in 2014 regarding management of undescended testicles (UDT). Despite these guidelines, prior studies have indicated discordance between guidelines and actual practice, especially in rural states. This study aims to identify if educating referring providers improves management of UDT.

Methods

Patients with UDT referred to our institution were divided into two groups: those referred prior to (Group 1) and after (Group 2) targeted education. A retrospective review was performed to compare the groups in terms of age at time of referral and surgery, laterality, specialty, and practice setting of referring provider, and whether or not ultrasound (US) was performed prior to referral.

Results

A total of 100 patients were identified in Group 1 and 168 in Group 2. No significant differences were noted between groups regarding age, variability of referring provider, or those receiving US prior to referral. Median age at referral was 20.7 months (range=0-194) and 33 months (range=0-205.1) in Groups 1 and 2, respectively (p=0.26). Sixty-two (37%) patients underwent surgical evaluation within 18 months of age or younger in Group 1 compared to 39 (39%) in Group 2 (p=0.73). Private practice pediatricians comprised the majority of referring providers in both cohorts. US was performed prior to referral in 41% of patients in Group 1 compared to 35.8% in Group 2 (p=0.51). The number of US ordered prior to referral significantly decreased from 10 (50%) to six (19%) following education among academic providers (p=0.02). No significant difference was found following education for private practice physicians (p=0.27).

Conclusion

Targeted education did not improve age at referral in the short-term, which may reflect suboptimal healthcare access. Additionally, more research is needed to evaluate whether more diverse targeted education provided on a regular basis to both physician and mid-level providers would have a meaningful impact.

Choosing the Right Catheter for Pediatric Procedures: Patient Considerations and Preference

Determining the need for bladder decompression and urinary diversion in the perioperative pediatric surgical patient can cause a clinical conundrum for the surgical team. Add in the several different types of urinary diversion devices possible, and the various materials associated therein and the process can suddenly seem unnecessarily daunting given the lack of concise recommendations and broad consensus. The decision to divert urine, though seemingly trivial, is associated with inherent risks. Managing and mitigating certain risks are best approached through proper education, selection, and technique. We provide a broad overview of pediatric catheter selection, indications, and pitfalls to streamline the process so that energy and attention can best be focused on the planned intervention at hand.

Rare late presentation of bilateral single system intravesical ureteroceles complicated with ureterolithiasis: Case report and literature review

Bilateral intravesical ureteroceles is a rare condition where both ureters terminally end in cystic dilations in the urinary bladder. Herein, a 31-year-old male patient presented with severe right flank pain and gross hematuria. Upon computed tomography imaging, a right ureterocele with an entrapped stone was revealed. Direct visualization also showed a smaller ureterocele at the left ureterovesical junction. Both ureteroceles were unroofed using rigid resectoscope with cold knife resulting in rapid bilateral efflux. The treatment was well tolerated with no known complications. Albeit uncommon, this case highlights the need to consider ureteroceles in adult patients with urinary tract symptoms.

True partial diphallia with associated penoscrotal transposition of two hemi-scrotums

Diphallia or duplication of penis is extremely rare condition with a reported incidence of 1 in 5-6 million live births. Approximately around 100 cases of diphallia have been described in literature, each case have a unique presentation from associated anomalies. Clinically these patients can be classified into complete (true diphallia) or partial duplication. In true diphallia, each penis has 2 corpora cavernosa and 1 corpus spongiosum. If the duplicate penis is smaller or rudimentary with complete structure, it is described as true partial diphallia. The term bifid phallus is used if there is only one corpus cavernosum in each penis. Due to low incidence and varied presentation, not much is known about the underlying pathophysiology, management options, and outcomes. Here, we report a case of partial diphallia with associated penoscrotal transposition of 2 hemi-scrotums.

Evaluation of Preoperative Tamsulosin Role in Facilitating Ureteral Orifice Navigation for School-Age Pediatric Ureteroscopy

Purpose

To address whether preoperative tamsulosin increases the rate of successful ureteral orifice navigation for ureteroscopy (URS) without prestenting in school-age pediatric patients.

Methods

We retrospectively reviewed all pediatric patients who had undergone ureteroscopy (URS) at our institution from 2013 to 2020. Patients were divided into two groups: those who had received tamsulosin 0.4 mg daily ≥48 hours preoperatively and those who had not. Statistical analysis was done using independent-sample t-tests and Mann–Whitney U tests for continuous variables, and χ² and Fisher’s exact tests were used for categorical variables. Multivariate analysis was done using binary logistic regression test.

Results

Overall, successful ureteral orifice navigation occurred in 44 of 50 patients (88%) who had received tamsulosin and 17 of 26 (65.4%) who had not (p=0.019). On further subanalysis based on stone location and instrumentation used, successful ureteral orifice navigation had occurred in 21 of 24 patients (87.5%) in the tamsulosin group and one of five (20%) in the no-tamsulosin group for semirigid ureteroscopy for mid–distal ureterolithiasis (p=0.007). For proximal ureteral and renal stones, successful ureteral orifice navigation with a flexible ureteroscope or ureteral access sheath had occurred in 23 of 26 patients (88.5%) in the tamsulosin group and 16 of 21 (76.2%) in the no-tamsulosin group (p=0.437). Multivariate analysis showed no significant difference between success rates in the two groups after controlling for patient weight, height, BMI, and stone location. We did not observe any adverse effects from tamsulosin.

Conclusion

This is the first study to evaluate preoperative tamsulosin on successful ureteral orifice navigation in school-age pediatric patients. Although not reaching statistical significance, further evaluation should be done on larger cohorts. Patient height was found to be an independent predictor of successful ureteral orifice navigation.

Usability and safety of the new 5 French air-charged catheter for performing urodynamic studies on pediatric patients

AIMS

To assess the performance and safety of the T-DOC® 5 French air-charged urodynamic catheters in pediatric patients and obtain feedback from providers related to usability performance.

METHODS

Patients ages 12 years and younger undergoing urodynamics were prospectively recruited from two institutions. The T-DOC® 5 French air-charged catheters were used. Issues with catheter placement, adverse events (AEs), and pain scores were assessed. A follow-up telephone call was made to assess for post-urodynamic AEs. Providers completed a clinical user questionnaire. Likert scale was used (1 = most negative and 5 = most positive response) and reported in mean (range).

RESULTS

A total of 28 patients completed the study. The mean age was 55 months (5-130) (10 females, 18 males). One problem was noted with the insertion of an abdominal catheter, secondary to stool impaction. Catheters stayed in place on all subjects, except for one related to patient hyperactivity. There were no AEs during the studies. In total four reported post-urodynamics AEs (one hematochezia, three dysuria). Among nine patients, pain level on the bladder and abdominal insertion was 3.6/10 (0-10) and 3.1/10 (0-10). Five providers completed the questionnaire. The overall ease of use was rated 4.3/5 (3-5). The ease of insertion was 4.1/5 (2-5) and set-up/clean-up time was 4.4/5 (3-5). Tracing stability, subtraction accuracy, and artifact sensitivity were all perceived favorably (respectively 4.8/5 [4-5], 4.6/5 [4-5], and 4.4/5 [4-5]).

CONCLUSIONS

The T-DOC® 5 French air-charged catheter was considered safe and effective in pediatric patients. No AEs occurred during the studies. Providers, using the catheters, reported favorably on catheter usage.

Robot-Assisted Laparoscopic Management of Persistent Mullerian Duct Structures in a Male Infant: A Novel Technique

Background: Persistent Mullerian duct syndrome (PMDS) is a rare disorder of sexual development that results in the presence of internal female reproductive structures in male children who are otherwise phenotypically normal. The removal of the Mullerian structures is suggested, as they pose a risk for future malignancy. Case Presentation: In this study, we present the case of a 14-month-old male infant who initially presented with bilateral nonpalpable undescended testes and was later diagnosed with PMDS. The effective removal of the Mullerian structures and bilateral orchiopexy was performed using robot-assisted laparoscopy, a novel approach for such a scenario. Conclusion: To our knowledge, this is the first report of using robotics for management of this syndrome.

Pedunculated and obstructive Wilms' tumor: A rare presentation in a 2 year-old male

Wilms' tumor manifesting as an obstructing ureteral mass is extremely rare. Herein, we report an unusual case in which a child presented with a clinical picture concerning for and suggestive of ureteropelvic junction obstruction (UPJO), but was instead found to have an intrapelvic pedunculated Wilms' tumor with extension into the proximal ureter. We discuss the patient's diagnostic workup, radiographic, operative and pathologic findings, as well as important lessons learned from this unusual case.

The Undescended Testicles of West Virginia: A Single Center Experience

OBJECTIVE

To determine the age of pediatric patients who underwent surgical intervention for undescended testicles (UDT) at our institution.

METHODS

We retrospectively reviewed all pediatric patients who underwent orchiopexy and/or diagnostic laparoscopy for undescended or non-palpable testicles with our pediatric urologist from January 2013-March 2014. Patients were separated into those undergoing surgical intervention at 6-12 months, 13-24 months, 25-48 months, and >48 months of age.

RESULTS

70 patients underwent surgical intervention. Only 15 patients (21.4%) underwent surgical intervention within the recommended time period of 6-12 months. Orchiopexy was performed on 21 patients (30.0%) from 13-24 months, 12 patients (17.1%) from 25-48 months, and 22 patients (31.5%) after 48 months of age.

CONCLUSIONS

Current American Urologic Association (AUA) recommendations advocate orchiopexy between 6-12 months of age. Improved parent and primary care education and access to pediatric urological evaluation of UDT will hopefully improve the timeliness of intervention within our state.

Femoral hernias in the pediatric patient: a case report and review of the literature

We report a case of a femoral hernia in a 9-year-old male. Femoral hernias in children are rare and a diagnostic challenge. Definitive treatment is with surgical repair.

Nocturnal enuresis: A topic review and institution experience

The objective is to provide a review of nocturnal enuresis (NE), including its epidemiology, etiology, pathophysiology, evaluation, and current management. We also set to provide further insight on the treatment of this condition from the experience derived from patients cared for at our tertiary-care institution. NE affects approximately 15% of all children at 5-year-old, affecting boys more frequently than girls. At our large university tertiary pediatric urology center, NE and incontinence, in general, is one the most common chief complaints prompting urologic care. In this review, we examine the condition in detail, highlighting specific goals of the initial evaluation and treatment. We contrast the commonly implemented treatment recommendations, available from the literature with strategies we have found valuable from our extensive experience in treating patients with this disorder. Using current urologic reference textbooks, book chapters, Medline, journal articles and reviews describing the many aspects of NE were reviewed in order to describe NE and the current practices at our institution. Although, this is not a systematic literature review, it includes relevant available research, institutional experience and urological expert opinion and current practices at a tertiary state health facility. The treatment of NE remains a challenge for many pediatricians and pediatric urologists. This likely stems from the multiple possible etiologies of the disorder. We have established a treatment algorithm at our institution, which we have found successful in the majority of our patients. This consists of starting patients on urotherapy, then offering both the enuresis alarm device and medication therapy as first line treatments, and finally adding anticholingerics for combination therapy. Our hope is with further research the treatment of NE will continue to improve.

Cold knife valvulotomy for posterior urethral valves using novel optical urethrotome

OBJECTIVES

To present our results after valve ablation using a novel cold knife urethrotome.

METHODS

Eleven consecutive male patients with posterior urethral valves underwent cold knife valvulotomy using a modified optical pediatric urethrotome. Patients were assessed both pre- and postoperatively using serum creatinine, voiding cystourethrography, and renal/bladder ultrasonography.

RESULTS

From August 2003 to August 2005, 11 patients underwent cold knife valvulotomy, of whom 7 returned for postoperative follow-up (mean follow-up 17.4 months). At surgery, the patients ranged in age from 5 days to 9 years. At presentation, 5 of the 7 patients had an elevated serum creatinine (mean 2.5 mg/dL, range 0.3-6.5), all had bilateral hydronephrosis of at least grade 3, and 6 of 7 had at least grade 3 reflux on 1 side. Intraoperatively, 1 complication (minor urethral laceration) occurred. Postoperatively, all 6 patients with serum creatinine levels measured showed improvement in renal function (mean creatinine 0.47 mg/dL, range 0.2-0.9). For the 6 patients who underwent postoperative ultrasonography, 4 had either complete resolution or significant improvement in their hydronephrosis, and none showed worsening. Six patients underwent postoperative voiding cystourethrography, with 5 showing either marked improvement or complete resolution of their reflux and 1 showing stable, unilateral reflux.

CONCLUSIONS

Valvulotomy using our modified urethrotome is a safe and effective technique for valve ablation.

Comparison of traditional enterocystoplasty and seromuscular colocystoplasty lined with urothelium

OBJECTIVE

To evaluate long-term outcomes between various methods of augmentation cystoplasty.

METHODS

A retrospective analysis was performed of patients undergoing seromuscular colocystoplasty lined with urothelium (SCLU, n=26), and their outcomes compared to a similar population of patients in the same institution who had received traditional forms of bladder augmentation (colocystoplasty and ileocystoplasty, n=32). Measurements included efficacy of the procedure in increasing bladder capacity and achieving urinary continence, and the need of subsequent surgery for complications.

RESULTS

There was no statistically significant difference in achieved bladder capacity, subjective urinary continence and the rates of subsequent surgery for stones, vesicoureteral reflux, augment failure, bladder neck continence and catheterizable channel. None of the patients in the SCLU group had spontaneous perforation or small bowel obstruction.

CONCLUSION

Patients with SCLU are at decreased risk for bowel obstruction and spontaneous perforation, but are not devoid of other long-term complications including bladder stones, vesicoureteral reflux and augment failure. Most of the risks and benefits of augmentation cystoplasty performed using ileum, colon, or SCLU appear similar.

Testicular infarction in a 12-year-old boy with Wegener's granulomatosis

We present the case of a 12-year-old boy with testicular infarction secondary to Wegener's granulomatosis. Scrotal exploration revealed no evidence of testicular torsion. The testis was left in place, and, after systemic therapy, partial reperfusion was present.

Continent urinary diversion with a urachal remnant

The Mitrofanoff procedure, first described in 1980, has been widely adopted for pediatric continent urinary diversion to increase patient independence and continence, decrease morbidity and infections, and preserve renal function. Although this principle employs the appendix primarily, numerous other tissue conduits have been described. We report a unique use of a urachal remnant as a continent conduit resulting in less morbidity by maintaining the integrity of the native urinary bladder, while maintaining patient continence and allowing easy and successful catheterization.

FATE OF THE RETAINED RESERVOIR AFTER REPLACEMENT OF 3-PIECE PENILE PROSTHESIS

PURPOSE

We evaluated patients who underwent surgery for implant malfunction to determine whether retaining the reservoir was associated with an increased risk of erosion or infection. We also reviewed the literature to study possible risk factors for reservoir erosion.

MATERIALS AND METHODS

We reviewed the records of 85 patients who underwent 98 procedures for replacement of a malfunctioning 3-piece penile implant. Of these patients 13 underwent 2 replacement procedures. At the time of primary surgery the reservoir was placed in either the retropubic space or extraperitoneally in the lower lateral abdomen if the patient had undergone prior pelvic surgery. During surgery for replacement of the malfunctioning implant the cylinders and pump were removed, and the reservoir of the original 3-piece device was retained. During followup patients were assessed for implant function and the development of any complication such as infection and/or reservoir erosion into the bladder or bowel.

RESULTS

Infection developed in 1 patient and implant malfunction occurred in 13 but no patient had erosion of the retained reservoir. All 85 patients had a functioning implant at a mean followup of 50 months (range 12 to 148). Review of the literature suggests that prior pelvic surgery and infection are major risk factors for reservoir erosion.

CONCLUSIONS

Retaining the reservoir during replacement of malfunctioning 3-piece implants is not associated with a significant risk of erosion and routine removal is not necessary. Prior pelvic surgery and infection appear to be risk factors for reservoir erosion.