Bladder Management and Continence in Girls With Cloacal Malformation After 3 Years of Age.

BACKGROUND: Multiple factors impact ability to achieve urinary continence in cloacal malformation including common channel (CC) and urethral length and presence of spinal cord abnormalities. Few publications describe continence rates and bladder management in this population. We evaluated our cohort of patients with cloacal malformation to describe the bladder management and continence outcomes. METHODS: We reviewed a prospectively collected database of patients with cloacal malformation managed at our institution. We included girls ≥3 years (y) of age and evaluated their bladder management methods and continence. Dryness was defined as <1 daytime accident per week. Incontinent diversions with both vesicostomy and enterovesicostomy were considered wet. RESULTS: A total of 152 patients were included. Overall, 93 (61.2%) are dry. Nearly half (47%) voided via urethra, 65% of whom were dry. Twenty patients (13.1%) had incontinent diversions. Over 40% of the cohort performed clean intermittent catheterization (CIC), approximately half via urethra and half via abdominal channel. Over 80% of those performing CIC were dry. In total, 12.5% (n = 19) required bladder augmentation (BA). CC length was not associated with dryness (p = 0.076), need for CIC (p = 0.253), or need for abdominal channel (p = 0.497). The presence of a spinal cord abnormality was associated with need for CIC (p = 0.0117) and normal spine associated with ability to void and be dry (p = 0.004) CONCLUSIONS: In girls ≥ 3 y of age with cloacal malformation, 61.2% are dry, 65% by voiding via urethra and 82% with CIC. 12.5% require BA. Further investigation is needed to determine anatomic findings associated with urinary outcomes. LEVEL OF EVIDENCE: IV.

Robotic-Assisted Surgery in Patients Less than 15 kg: A Single Center Review.

Introduction: Robotic-assisted surgery (RAS) is an increasingly utilized tool in children. However, utilization of RAS among infants and small children has not been well established. The purpose of this study was to review and characterize RAS procedures for children ≤15 kg. Methods: We performed a single institution retrospective descriptive analysis including all patients ≤15 kg undergoing RAS between January 2013 and July 2021. Data collection included procedure type, age, weight, gender, and surgical complications. Cases were further categorized according to surgical specialty: pediatric urology (PU), pediatric surgery (PS), and multiple specialties (MS). t-Tests were used for statistical analyses. Results: Since 2013, a total of 976 RAS were identified: 492 (50.4%) were performed by PU, 466 (47.8%) by PS, and 18 (1.8%) by MS. One hundred eighteen (12.1%) were performed on children ≤15 kg, consisting of 110 (93.2%) PU cases, 6 (5.1%) PS cases, and 2 (1.7%) MS cases. Procedures were significantly more common in the PU subgroup, mean of 12 cases/year, compared to PS subgroup, mean of 0.63 cases/year, (P < .01). The mean weight of PU patients (10.5 kg) was significantly less than PS patients (13.9 kg) (P < .01). Mean age was also significantly lower among PU patients (18.6 months) compared to PS (34.2 months) (P < .01). Conclusion: RAS among patients ≤15 kg is safe and feasible across pediatric surgical subspecialties. RAS was performed significantly more frequently by pediatric urologists in younger and smaller patients compared to pediatric surgeons. Further refinement of robotic technology and instrumentation should enhance the applicability of these procedures in this young group.

Robotic retroperitoneal lymph node dissection for paratesticular rhabdomyosarcoma in adolescents: a case series.

Robotic assisted (RA) retroperitoneal lymph node dissection (RPLND) has grown in popularity as it offers decreased morbidity and faster recovery compared to the open technique. Proponents of open surgery raised concerns about the oncological fidelity of the RA approach for testicular tumors where complete resection is needed. In boys > 10 years with paratesticular rhabdomyosarcoma (RMS), RPLND is indicated for staging purposes only. In this population, the RA technique should provide its benefits without concerns for oncological compromise. We present an analysis of RA-RPLND for boys with paratesticular RMS. We queried our institution's prospectively collected database of pediatric robotic cases for patients undergoing RA-RPLND post-radical orchiectomy for paratesticular mass, confirmed by pathology as RMS. Demographic, surgical, follow-up, and oncological outcomes were evaluated between 2017 and 2023. Five patients underwent RA-RPLND for paratesticular RMS. The median age was 16.1 years (15-17), with median OR time of 456 min (357-508). No conversions to open occurred. Inpatient median total opioid use was 1.8 (0.4-2.7) morphine equivalent/kg. The median lymph node yield was 27 (8-44) and post-op length of stay was 3 days (2-5). The median time to initiating adjuvant chemotherapy was 10.5 days (7-13). One patient had complications: pneumothorax attributed to central line placement and chyle leak that resolved in 1 week with dietary restriction. Our series demonstrates the feasibility, safety, and efficacy of the RA approach for RPLND in pediatric patients with paratesticular RMS. This is the most extensive case series currently in the literature and the only one exclusively done for paratesticular RMS.

Tunica Vaginalis Graft Use for Repair of Traumatic Testicular Rupture: A Case Report.

Testicular rupture is a rare but serious condition which requires immediate and emergent surgical intervention in order to preserve fertility and maintain gonadal hormone function. We present here a case of a 16-year-old male who suffered a shattered right testicle following gunshot wound. Additionally, the left cord structures were also hit with possible compromise of the left testicle. He underwent scrotal exploration with reconstruction of the right tunica albuginea with a tunica vaginalis graft. The right testicle was found to be viable within 2months postoperatively with normal arterial and venous flow seen on Doppler scrotal ultrasound. We propose that tunica vaginalis can be used successfully as a graft to manage testicular rupture.

Urinary and bowel management in cloacal exstrophy: A long-term multi-institutional cross-sectional study.

BACKGROUND: We sought to evaluate long-term surgical urinary and bowel management in cloacal exstrophy (CE) in a multi-institutional study. METHODS: We performed a cross-sectional study of people with CE and covered variants managed at five participating institutions. Those with <1 year follow-up or born with variants without hindgut involvement were excluded. Primary outcomes were methods of urinary and bowel management. Urinary management included: voiding via urethra, clean intermittent catheterizations (CIC), incontinent diversion and incontinent in diaper. Bowel management included: intestinal diversion (colostomy/ileostomy) and pull-through (with/without MACE). We evaluated three age groups: children (<10 years), older children (10 to <18) and adults (≥18). We assessed if management varied by age, institution or time (born≤2000 vs. >2000). RESULTS: A total of 160 patients were included (40% male). Median follow-up was 15.2 years (36% children, 22% older children, 43% adults). While 42% of children were incontinent in diapers, 73% of older children and adults managed their bladder with CIC, followed by incontinent urinary diversion (21%) (p < 0.001, Table). CIC typically occurred after augmentation (88%) via a catheterizable channel (89%). Among older children and adults, 86% did not evacuate urine per urethra and 28% of adults had an incontinent urinary diversion. No child or adult voided per urethra. Age-adjusted odds of undergoing incontinent diversion was no different between institutions (p = 0.31) or based on birthyear (p = 0.08). Most patients (79%) had an intestinal diversion, irrespective of age (p = 0.99). Remaining patients had a pull-through, half with a MACE. The probability of undergoing bowel diversion varied significantly between institutions (range: 55-91%, p = 0.001), but not birth year (p = 0.85). SUMMARY: We believe this large long-term data presents a sobering but realistic view of outcomes in CE. A limitation is our data does not assess comorbidities or patient-reported outcomes. Rarity of volitional urethral voiding in CE forces the question of whether is a potentially unachievable goal. We advocate thoughtful surgical decision making and thorough counseling about appropriate expectations, distinguishing between volitional voiding and urinary and fecal dryness. CONCLUSIONS: In this long-term, multi-institutional study of patients with CE, 94% of older children and adults manage their bladder with incontinent diversion or CIC. Nearly 80% of patients, regardless of age, have an intestinal diversion. Given that no patients were dry and voided via urethra and 86% of older patients do not evacuate urine per urethra, these data bring into question what functional goals are achievable when performing reconstructive surgery for these patients.

Improvement in bladder function in children with functional constipation after a bowel management program.

PURPOSE: We sought to determine if children with functional constipation (FC) would have an improvement in bladder function with treatment of constipation with a bowel management program (BMP). METHODS: A single-institution review was performed in children aged 3-18 with FC who underwent a BMP from 2014 to 2020. Clinical characteristics, bowel management details, and the Vancouver Symptom Score for Dysfunctional Elimination Syndrome (VSS), Baylor Continence Scale (BCS), and Cleveland Clinic Constipation Score (CCCS) were collected. Data were analyzed using linear mixed effect modeling with random intercept. RESULTS: 241 patients were included with a median age of 9 years. Most were White 81 and 47% were female. Univariate tests showed improvement in VSS (- 3.6, P < 0.0001), BCS (- 11.96, P < 0.0001), and CCCS (- 1.9, P < 0.0001) among patients having undergone one BMP. Improvement was noted in VSS and CCCS among those with more than one BMP (VSS: - 1.66, P = 0.023; CCCS: - 2.69, P < 0.0001). Multivariate tests indicated undergoing a BMP does result in significant improvement in VSS, BCS, and CCCS (P < 0.0001). CONCLUSIONS: There is significant improvement in bladder function in children with FC who undergo a BMP. For patients with bowel and bladder dysfunction and FC, a BMP is a reasonable treatment strategy for lower urinary tract symptoms.

Effectiveness of a Practical, At-Home Regimen of Parasacral Transcutaneous Electrical Nerve Stimulation in Pediatric Overactive Bladder.

OBJECTIVE: To describe and evaluate efficacy of a more practical, at-home regimen of parasacral transcutaneous electrical nerve stimulation (TENS) for pediatric overactive bladder (OAB). METHODS: We prospectively enrolled patients with OAB. INCLUSION CRITERIA: age 5-13 years and willingness to try TENS. EXCLUSION CRITERIA: urinary tract anatomic abnormalities, current use of OAB medications, neurologic condition, and elevated post-void residual. Patients were instructed to complete 20-minute sessions 2x/day for 1 month. Patients completed the Vancouver Symptom Score (VSS) and 48-hour frequency-volume chart before/after treatment. Compliance was assessed with a daily log. We recorded patient-reported improvement. Primary outcome was difference in VSS before/after treatment; secondary outcomes included: differences in frequency of voids/24 hours, max voided volume in 48 hours (%EBC), mean voided volume (%EBC), and mean number incontinence episodes/24 hours. RESULTS: We enrolled 21 patients (3 male, 18 female; median age 9.9 years). We had complete VSS data on 17 patients and frequency-volume chart data on 12 patients. Median % of TENS sessions completed was 98%. 8/17 patients reported subjective improvement. There was a significant difference between pre- and post-TENS VSS (median score: 23 pre-TENS and 21 post-TENS, P = .009). There were no differences in secondary outcomes before/after treatment. CONCLUSION: In our cohort of medically-refractory OAB pediatric patients, nearly half reported subjective improvement with our regimen, despite modest objective improvement. Our compliance rates suggest this regimen is practical but may be best used as an adjunct to other therapies.

Robotic upper tract surgery in infants 6 months or less: is there enough space?

Robot-assisted laparoscopic surgery (RALS) has recently been described in children < 1 year old. However, little data exist on robotic utilization in infants ≤ 6 months old, likely due to concerns for limited intraabdominal space and decreased distance between ports in this cohort. We hypothesized that the robotic approach can be successfully used for infants ≤ 6 months old. A prospectively collected database of patients undergoing urologic robotic surgery at our institution was reviewed. Patients ≤ 6 months and ≥ 4 kg were included. Patient demographics, intraoperative details, hospital length of stay, and complications were reviewed. Descriptive statistics were performed. Twelve patients ≤ 6 months old underwent urologic robotic surgery by three surgeons at our institution (2013-2019): pyeloplasty (6), ureteroureterostomy (4), heminephrectomy (1), and nephrectomy (1). Median age at surgery was 4.75 months (IQR 4, 6). Median weight was 7.09 kg (IQR 6.33, 7.78). Median console time was 105 min (IQR 86, 123). For all procedures, 8-mm robotic arm ports were used. No procedures were converted to open. Median post-operative hospital stay was 24 h (IQR). Febrile UTI was the only complication occurring within 30 days of surgery (n = 4, 33%; 7-20 days, Clavien grade 2). For those undergoing pyeloplasty or ureteroureterostomy (n = 10), postoperative ultrasound showed improved (n = 9) or stable hydronephrosis (n = 1). At a median follow-up of 19.73 months (IQR 4.27, 38.32), no patient required an unplanned secondary intervention. Robotic upper urinary tract surgery is feasible and safe in patients ≤ 6 months of age and can be performed successfully with the same technique as for older children.

Correlation of anorectal malformation complexity and associated urologic abnormalities.

BACKGROUND: Patients with anorectal malformations (ARM) commonly have associated urologic anomalies. Few large studies exist to accurately characterize the incidence or associations between severity of malformation and urologic diagnosis. The purpose of our study was to determine the incidence of urologic diagnoses in a large cohort of children with ARM and evaluate for any correlation between severity of ARM and the incidence and number of associated urologic diagnoses. METHODS: A retrospective review was performed of patients with ARM treated at our pediatric colorectal center. All patients underwent protocolized urologic screening. ARM subtypes were ordered with increasing severity as follows in males: perineal, bulbar, prostatic and bladder neck fistulae. Females were similarly categorized as perineal, vestibular and vaginal fistulae followed by cloaca with <3 cm common channel and cloaca with >3 cm common channel. The following urologic diagnoses were assessed to determine whether a correlation existed with the severity of the ARM subtype: hydronephrosis, vesicoureteral reflux (VUR), solitary kidney, renal ascent anomalies (ectopic or pelvic), renal fusion anomalies (horseshoe or cross fused kidney), duplex kidney, hypospadias and undescended testicle. ARM subtypes were defined by distal rectal anatomy. RESULTS: A total of 712 patients were included in our study with a mean age of 4 years and of whom 45% were male. The overall rate of urologic anomalies was greater in males than females (65% vs 56% p < 0.026). In both sexes, the rate of urologic anomalies increased with increasing severity of ARM subtype (p<0.00010) finding that males with bladder neck fistula and females with cloacal malformations, particularly with long common channels, being the highest incidence. In males and females, the rate of hydronephrosis increased as the complexity of ARM increased and this correlated significantly (p < 0.0001 vs p < 0.0003 respectively). Similarly, the incidence of VUR also increased as complexity of ARM increased in both males and females (p = 0.01 and p<0.0001 respectively). The remaining urologic diagnoses were not significantly correlated with severity of ARM. CONCLUSIONS: Urologic anomalies occur at a high rate in children with ARM and appear to increase in frequency with increasing complexity of ARM subtype. These findings stress the importance of proper ARM screening and proactive collaboration with a clinician with expertise in pediatric urology early in the management of such children to improve early recognition of urologic diagnoses. LEVEL OF EVIDENCE: Level III.

Does a standardized operative approach in cloacal reconstruction allow for preservation of a patent urethra?

BACKGROUND: Cloacal malformations are recognized as a particularly challenging congenital condition to manage and they present with a wide spectrum of anatomical configurations making surgical repair very complicated. Urethral necrosis or urethral loss is a known and devastating complication of cloacal repair. The surgical repair of these malformations has evolved over time and historically only common channel (CC) length was measured. More recently, it has been advocated that the urethral length and the CC are both important in determining surgical repair. The purpose of our study is to evaluate if this surgical approach allows for preservation of a patent urethra. METHODS: A prospective database of all cloaca patients maintained with IRB approval (IRB# STUDY00000721) was retrospectively reviewed. We included any girl with cloacal malformation who underwent primary repair at our institution between May 2014 and December 2019. Standardized preop evaluation with endoscopy and 3-dimentional imaging to assess urethral length and CC length. These measurements were used to determine operative approach. Girls with CC < 1 cm undergo posterior sagittal anorectoplasty and introitoplasty (PSARP + I), those with CC measuring 1-3 cm and urethra > 1.5 cm undergo total urogenital mobilization (TUM) and those with CC > 3 cm or urethra < 1.5 cm undergo urogenital separation (UGS). Postoperative urethral patency was determined at the time of cystoscopy and exam under anesthesia (EUA) 4-6 weeks postoperatively by visualizing a viable and healthy urethra that is catheterizable. RESULTS: A total of 59 patients met inclusion criteria with a median age of 11.6 months. Four girls underwent PSARP + I, 19 girls had a TUM and 36 girls underwent a UGS. All of the girls who had PSARP +I (n = 4) or TUM (n = 19) had a viable and patent urethra that was catheterizable at the cystoscopy and EUA 4-6 weeks postoperatively. Of the 36 girls who had UGS, all but 2 (5.6%) had a viable and patent urethra that catheterized without problems. Overall, 97% of girls in this cohort had a patent urethra after cloacal repair using this surgical protocol. CONCLUSIONS: The use of a standard protocol that considers urethral and common channel length for cloacal repairs results in a viable and patent urethra in 97% of patients. LEVEL OF EVIDENCE: Level II.

Long-term urologic and gynecologic follow-up and the importance of collaboration for patients with anorectal malformations.

Anorectal malformations (ARM) are well recognized to be associated with anomalies in other organ systems. The introduction of screening protocols has increased the diagnosis of these anomalies and greater collaboration with other specialties has influenced the treatment and follow-up of patients with ARMs. Much of the medical literature regarding the treatment of anorectal malformations has focused on technical details of operations and early post-surgical outcomes. Recently, an increase in published data regarding the long-term sequelae of an ARM diagnosis has resulted in an emphasis extended follow up in this population. Patient support groups have highlighted complex issues in ARM patients persist into adulthood have advocated for improved transitional care. This article describes the benefits of long-term follow-up and identifies key issues in ARM patients with respect to urologic and gynecologic health. A collaborative model of care is outlined and suggested timings of screening for potential problems is described.

Surgical outcomes are equivalent after pure laparoscopic and robotic-assisted pyeloplasty for ureteropelvic junction obstruction.

INTRODUCTION: Minimally invasive (robotic and pure laparoscopic) pyeloplasty has been increasingly used for treatment of ureteropelvic junction obstruction (UPJO). However, few large-scale studies have compared these two modalities directly. METHODS: We performed a retrospective single-center review of all patients who underwent pure laparoscopic (LP) or robotic pyeloplasty (RALP) between 2007 and 2018. Patients were excluded if the initial surgery at our institution was a redo pyeloplasty or if they lacked follow-up information. Outcomes of interest included operative time, length of stay, and complication rates, including rates of secondary procedures. We compared these outcomes between groups using Student's t test for continuous variables and a Chi-square for categorical variables. RESULTS: A total of 282 patients were identified. Forty-eight were excluded based on study criteria; therefore, our total study cohort was 234 patients: 119 RALP and 115 LP cases. Overall mean postoperative follow-up time was 20.8 months, with no significant differences between groups. Mean operative time was shorter in the LP group when compared the RALP group (3 h 7 min vs. 3 h 41 min, p < 0.001). There were no significant differences between groups in length of stay (1.22 days vs 1.50 days, p = 0.095). Complications occurred in 52 patients (22.2% of overall cohort) with no difference in incidence between groups. Twenty-five patients (14 in the RALP group and 11 in the LP group) underwent unplanned secondary procedures; 19 of these patients (9 in the RALP group and 10 in the LP group) needed a procedure to address secondary obstruction. CONCLUSION: We demonstrated no significant differences between RALP and LP in regards to complication rates. Surgeons performing RALP and LP have the potential to offer the same level of care for the surgical management of UPJO, especially in countries where robotic technology may not be readily available.

Anatomic factors predict urinary continence in patient with anorectal malformation.

It has been described that patients with more complex anorectal malformations (ARM), lower sacral ratios and spinal anomalies have poorer rates of fecal and urinary continence. While the ARM subtype has been shown to be an independent predictor of fecal continence, it is not well understood how each of these anatomic factors impact urinary continence. The purpose of this study was to identify anatomic factors associated with urinary continence in children born with ARM. We performed a retrospective review of a large prospectively collected database of children with ARM. Inclusion criteria included diagnosis of ARM, age >4 years, available lateral sacral ratio measurement and presence of spinal MRI. Any child with incomplete or absent continence data was excluded. Continence was defined as voiding per urethra volitionally, dry between voids and ≤1 urinary accident per week. Bivariable tests of association and log-binomial regression models were used to examine association between anatomic factors and urinary continence. A total of 434 patients were included in the study. 57.8% (n = 251) were male. Median age was 8.4 years (IQR 6.0-12.3). With regards to severity of ARM, 20.3% (n = 88) were complex, 23.3% (n = 101) were moderate and 56.5% (n = 245) were simple. Lateral sacral ratio included 11.1% (n = 48) that were <0.4, 36.2% (n = 157) 0.4-0.7 and 52.8% (n = 229) > 0.7. Spine status was found to be myelomeningocele in 4.4% (n = 19), low conus or tethered cord in 34.8% (n = 151) and normal or fatty filum in 60.8% (n = 264). Overall 62.2% were continent. ARM severity, lateral sacral ratio and spine status were each independent predictors of urinary continence on univariate and multivariable analysis. We conclude that in children born with ARM, the severity of ARM, lateral sacral ratio and spine status each independently predict urinary continence. These results allow us to better understand these complex patients and their ability to develop urinary continence. This is crucial in enabling proper patient and family counseling and thus, setting appropriate expectations.

Robotics in Pediatric Urology

ABSTRACT Robotic surgery has been slow to be fully accepted in the world of pediatric urology largely because of its initial application directed towards adult use and because of the inherent high cost associated with it. However, as previously shown, it has now become the gold standard for adolescent pyeloplasty in The United States. As the adoption of robotic surgery in children has become more widespread, its use has been applied to a broader spectrum of procedures with similar success rates to standard laparoscopy. These procedures include nephrectomy, heminephrectomy, ureteral reimplantation, and ureteroureterostomy. However, it has also shown feasibility and comparable success when compared to open surgery in procedures that were previously deemed too complex to be done by standard laparoscopy. For example, bladder neck reconstruction with Mitrofanoff and Malone procedure as well as bladder augmentation. This review objective is to provide an overview of robotic surgery in pediatric urology, with a focus on the more common cases such as pyeloplasty and reimplantation as well as more complex bladder reconstruction procedures.

Robotics in Pediatric Urology.

Robotic surgery has been slow to be fully accepted in the world of pediatric urology largely because of its initial application directed towards adult use and because of the inherent high cost associated with it. However, as previously shown, it has now become the gold standard for adolescent pyeloplasty in The United States. As the adoption of robotic surgery in children has become more widespread, its use has been applied to a broader spectrum of procedures with similar success rates to standard laparoscopy. These procedures include nephrectomy, heminephrectomy, ureteral reimplantation, and ureteroureterostomy. However, it has also shown feasibility and comparable success when compared to open surgery in procedures that were previously deemed too complex to be done by standard laparoscopy. For example, bladder neck reconstruction with Mitrofanoff and Malone procedure as well as bladder augmentation. This review objective is to provide an overview of robotic surgery in pediatric urology, with a focus on the more common cases such as pyeloplasty and reimplantation as well as more complex bladder reconstruction procedures.

Endoscopic-assisted robotic pyelolithotomy: a viable treatment option for complex pediatric nephrolithiasis.

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.

Combination treatment for cicatrix after neonatal circumcision: An office-based solution to a challenging problem.

Cicatrix formation, which can form after neonatal circumcision to entrap the glans penis, presents a therapeutic challenge. Previous studies in the literature have described either using a topical steroid cream or stretching of the scar tissue with an instrument but not a combination of both modalities. In our experience, monotherapy has resulted in significant recurrence and/or need for further treatment. We present our successful experience that combines cicatrix stretching with a hemostat using local anesthesia in the office followed by several weeks of topical steroids with a minority of patients needing any additional therapy.