Comparative, Prospective, Case-Control Study of Open versus Laparoscopic Pyeloplasty in Children with Ureteropelvic Junction Obstruction: Long-term Results.

INTRODUCTION: We compare open pyeloplasty (OP) versus laparoscopic pyeloplasty (LP) in children in a multicenter, prospective, case-control study. MATERIALS AND METHODS: From May 2007 to March 2009, a program was established at Hospital Garrahan, the reference center, to perform LP with a mentoring surgeon that would attend the institution once a month. Every new case of ureteropelvic junction obstruction (UPJO) diagnosed in the reference institution was offered to participate in the study. If the patient was enrolled, it was scheduled for LP. The following patient diagnosed with UPJO was operated on with open technique and served as a case-control. In three other facilities, patients were only offered LP and had a matched control open case at the reference institution. The first end point of the study was patient recovery: analgesia requirement and length of hospitalization (LOH). The second end point of the study was resolution of UPJO in long-term follow-up for the two techniques. Demographic data, surgical time, perioperative complications, analgesia requirement, analgesia score during hospitalization, LOH, and outcome were recorded. Both groups received the same postoperative indications for pain control. Parents were asked to assess pain in their children every 4 h postoperatively and to complete a pain scale chart to which the nurses were blinded. RESULTS: Fifteen OP and 15 LP were compared. Groups were similar with regard to sex, age, weight, and laterality. Mean surgical time was longer in LP than in OP group (mean 188 versus 65 min) (p < 0.01). Hospitalization was shorter for LP group with a mean of 1.9 versus 2.5 days for OP group (p < 0.05). Postoperative analgesia requirement was significantly higher in the OP group with a mean use of morphine of 1.7 versus 0.06 mg/kg in the LP group (p < 0.05). Pain scores were similar in both the groups. At a mean follow-up of 58 months there were no failures. CONCLUSION: In this prospective comparative cohort, LP was a longer procedure than OP. Both procedures had the same efficacy and complication rates, but patients undergoing LP needed fewer narcotics for pain control and had a shorter hospitalization.

Pediatric laparoscopic pyeloplasty: lessons learned from the first 52 cases.

BACKGROUND AND PURPOSE: The use of laparoscopy for pediatric pyeloplasty is increasing. We review our experience with our first 50 cases and describe the main technical points learned during this experience. PATIENTS AND METHODS: We retrospectively reviewed the charts of all patients who underwent laparoscopic pyeloplasties (LP) over a 4-year period (January 2004 to January 2008) at our institution. Patient demographics, operative details, hospital stay, outcomes, and complications were examined. RESULTS: Fifty-two patients underwent LP from for primary repair of ureteropelvic junction obstruction (UPJO). Thirty-six male and 16 female were operated on at an average age and weight (range) of 51.8 months (3 weeks to 216 months) and 20 kg (3.9-74.2 kg), respectively. Intraoperatively, 47/52 (90%) underwent retrograde ureteropyelography (RUPG), and 51/52 (98%) had a ureteral stent placed during surgery. Nine crossing vessels (17%) were identified at the time of surgery. The anastomoses were performed with a running absorbable suture. Operative time was 248 min (range 120-693 min). The average hospital stay was 3 days (range 1-7). A bladder catheter usually remained indwelling for 2 days and a perirenal drain for 3 days; they were removed before hospital discharge. The stent remained in place on average 39 days (range 11-127 d) and was removed with the patient under a brief general anesthetic. Anastomotic patency was seen in 51/52 (98%) patients determined by improvement on postoperative renal ultrasonography and/or resolution of symptoms. Mean follow-up was 20 months (range 3-50 mos). Complications included recurrence of UPJO necessitating redo LP (1), dislodgement of a nephrostomy (1), stent replacement (1), ileus (2), and vascular injuries treated laparoscopically (2). No patients needed conversion to open surgery. CONCLUSION: LP has supplanted open pyeloplasty at our institution. We have noted improved success by performing RUPG to define the anatomy and stent placement at the beginning of the case, using purple 5-0 or 6-0 poliglecaprone suture for the anastomosis and a 5-mm wide-angle lens for visualization. We found no disadvantages for the transperitoneal approach, although we find it necessary to leave a drain. With the increased use of LP in pediatric urology, we hope these observations from our experience will help improve the learning curve for others making this transition.

Could prophylactic antibiotics be stopped in patients with history of vesicoureteral reflux?

OBJECTIVE: To compare the incidence and type of urinary tract infection (UTI) in patients with primary vesicoureteral reflux (VUR) diagnosed after a febrile UTI while they were on prophylactic antibiotics (PA) and after stopping PA. MATERIALS AND METHODS: Criteria to discontinue PA were: no UTI during 12+ or more months on PA, old enough to communicate UTI symptoms, potty trained and absence of risk factors for UTI. Patients with at least 1 year of follow up without PA were included (n=77). We recorded: age at which PA was indicated and stopped, time on and off PA, incidence and type of UTI (cystitis vs acute pyelonephritis (APN)), and renal scan results. RESULTS: PA was started and stopped at a mean age of 18.5 and 61 months, respectively. Mean time on PA was 39 months (range 12-95): 25 patients had 44 UTI episodes (0.17 episodes/patient/year), and 31 (70%) of them were APN. Mean time of antibiotics was 44.5 months (range 12-162): 13 patients had 24 UTI episodes (0.08 episodes/patient/year), eight (33%) of which were APN (P<0.05). A renal scan was performed in 71 patients after the index infection and repeated in 12. Two patients lost renal function while still on PA. CONCLUSION: Discontinuing PA in patients with history of VUR is a safe practice and should be considered as a management option.

Transperitoneal laparoscopic pyeloplasty for primary repair of ureteropelvic junction obstruction in infants and children: comparison with open surgery.

PURPOSE: Pediatric laparoscopic pyeloplasty to treat ureteropelvic junction obstruction has been reported to decrease hospitalization stay and the analgesic requirement compared to open pyeloplasty. It is not clear if all age groups benefit from this procedure. We compared primary laparoscopic and open pyeloplasty in infants and children. MATERIALS AND METHODS: We retrospectively reviewed the records of consecutive primary pyeloplasties at a single institution during a 4.5-year period. Demographic data, body measurements, presentation, indications for surgery, operation type, surgical time, complications, analgesia requirement, hospital stay and outcome were recorded. RESULTS: Patients were divided in the open pyeloplasty group of 41 and the laparoscopic pyeloplasty group of 37. The groups were similar with regard to sex and laterality. There were more patients 14 months or younger in the open pyeloplasty group. Mean surgical time was longer in laparoscopic pyeloplasty but it decreased significantly after the first 15 cases (each p <0.001). Hospitalization and postoperative analgesia requirements were similar in the 2 groups. There was a higher success rate for laparoscopic pyeloplasty in patients older than 14 months (p <0.05). In the open pyeloplasty group there were more re-interventions as well as a trend toward more complications and readmissions. CONCLUSIONS: Transperitoneal laparoscopic pyeloplasty was performed safely in all pediatric age groups with minimal morbidity and excellent short-term results. In our experience laparoscopic pyeloplasty in infants and children is more difficult and time-consuming surgery than open pyeloplasty. However, it may provide a better outcome with fewer complications and better cosmesis. Prospective studies are needed to confirm these results.

Laparoscopic transureteroureterostomy: a novel approach.

PURPOSE: We describe the feasibility and short-term results of laparoscopic transureteroureterostomy in children. MATERIALS AND METHODS: We performed transperitoneal laparoscopic transureteroureterostomy with a 4-trocar technique in 3 children with a mean age of 63 months (range 18 to 105). Diagnoses were unilateral ureteral obstruction after cross-trigonal reimplantation for vesicoureteral reflux (1 patient), unilateral refluxing megaureter (1) and ureteral injury after bladder diverticulectomy (1). Cystoscopy, retrograde pyelogram and stent placement in the recipient ureter were performed at the beginning of each case. The anastomoses were carried out with running 6-zero reabsorbable sutures at the level of the pelvic bream. An abdominal drain and Foley catheter were left indwelling for 1 to 3 days. RESULTS: All cases were performed successfully. Postoperative course was uneventful except for a transient urinary leak, and patients were discharged home on postoperative day 2 to 4. At a mean followup of 6 months all patients were clinically well, with normal kidney function and blood pressure, and no significant hydronephrosis. CONCLUSIONS: Based on our initial experience, laparoscopic transureteroureterostomy is safe and effective, and is associated with little blood loss, minimal analgesia requirements, fast recovery and excellent cosmetic results. We believe that in selected cases in which transureteroureterostomy is the chosen technique a laparoscopic approach is advantageous.

Reoperative laparoscopic pyeloplasty in children: comparison with open surgery.

PURPOSE: We assessed the feasibility of pediatric redo laparoscopic pyeloplasty in comparison to redo open pyeloplasty for safety, efficacy, operative time, blood loss, postoperative analgesic requirements, length of hospitalization, complications, need for readmission and subsequent procedures. MATERIALS AND METHODS: We performed a retrospective chart review of consecutive patients undergoing reoperative pyeloplasty between June 2003 and July 2006. RESULTS: A total of 10 patients (11 redo pyeloplasties) were divided into 2 groups, ie those undergoing redo open (4) and laparoscopic (6) pyeloplasty. Groups were similar in age, sex, weight, laterality, and number and type of prior interventions to repair ureteropelvic junction obstruction. Surgical time for redo laparoscopic pyeloplasty was longer than for redo open pyeloplasty (290 vs 203 minutes, p<0.05). Success rate was the same in both groups (80%). The redo laparoscopic pyeloplasty group had a shorter hospital stay (mean 2.5 vs 4.6 days, p<0.05), decreased use of parenteral narcotics (0.2 vs 5 mg/kg, p<0.01), and a trend toward decreased oral narcotics (0.2 vs 2.1 mg/kg, p=0.09) and fewer complications (0 vs 4, p<0.05). CONCLUSIONS: We confirm the feasibility of redo laparoscopic pyeloplasty in the pediatric population. In experienced hands pediatric redo laparoscopic pyeloplasty can be performed safely with a success rate similar to that of open surgery, and it may provide a faster recovery with decreased narcotic requirements and morbidity. Further studies are needed to better define the role of laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction in the pediatric population.

Ambiguous genitalia.

PURPOSE OF REVIEW: To review the relevant publications since 2004 on surgery for female pseudohermaphroditism. Current controversies exist regarding the timing and technical aspects of female genital reconstruction and indeed the wisdom of performing these procedures in childhood. RECENT FINDINGS: Nine articles, published between 2004 and the present time, were found worthy of being included in this review. The topics include surgical technique, short-term and long-term results, voiding function after feminizing genitoplasty, and the timing of surgery. SUMMARY: Although results for surgery for congenital adrenal hyperplasia have been less than satisfactory when adults who had surgery in childhood are evaluated, all present reports include patients operated on using a variety of techniques many years ago. Rather than abandoning the efforts to repair this malformation early, we favor the continued development of more refined surgical techniques that may yield better results in the future.