Hydronephrosis and Hydroureter Improvement Rates in Robotic-Assisted Laparoscopic Uretero-Ureterostomies: Does Anastomotic Site Matter?

OBJECTIVE: To compare improvement/change of hydronephrosis and hydroureter in patients with complete ureteral duplications that underwent upper and lower robotic-assisted laparoscopic uretero-ureterostomies. The hypothesis being that improvement of hydronephrosis and hydroureter between the two groups was similar. METHODS: 35 subjects met inclusion criteria and were reviewed retrospectively. 'Upper' anastomoses were defined as those being done below the lower pole of the kidney (Group 1), while 'lower' anastomoses were those done below the iliac vessels (Group 2). Primary variables analyzed were antero-posterior and diameter measurements of the renal pelvis and ureter, respectively, before and after surgery. Secondary variables included operative time, length of hospital stay, and complication rates. RESULTS: Group 1 consisted of 20 subjects while Group 2 consisted of 15 subjects. Presenting diagnoses were hydronephrosis in 31 subjects and incontinence in 4 subjects. Group 1 mean AP renal diameters decreased by 62.9% (P<.05), while Group 2 decreased by 65.4% (P<.05). Group 1 mean hydroureter diameter measurements decreased by 80.3% (P<.05), while Group 2 decreased by 83% (P<.05). The improvement in hydronephrosis and hydroureter between the two groups was not statistically different. Group 1 median operative time (271 minutes) was longer than Group 2 (201 minutes) (P<.05). There was no significant difference in hospital stay between the groups and there were no significant complications within the cohort. CONCLUSION: The improvement rate of hydronephrosis and hydroureter is similar in upper versus lower RAL UU. Operative time was significantly shorter in the lower anastomosis group.

2-octyl cyanoacrylate hypospadias repair dressing: a retrospective, controlled comparison.

INTRODUCTION: 2-octyl cyanoacrylate (OC) has been shown to be a viable option for usage following standard circumcision but data on its utilization following hypospadias repair is limited. Both OC and a standard waterproof transparent dressing (WD) are used following hypospadias repair at our children's hospital. Our hypothesis is that patients with distal hypospadias repair using OC for surgical dressing have similar outcomes as compared to patients with WD. MATERIALS AND METHODS: A retrospective study was performed evaluating all patients with distal hypospadias repair during a 2 year period. OC was primarily used by one of the three physicians in the practice with the other two primarily used WD for surgical dressing. The primary endpoints evaluated include hematoma requiring surgical drainage, infection, meatal stenosis, urethrocutaneous fistula, dehiscence, and diverticulum. Standard follow up after hypospadias repair includes a 1 week follow up for patients requiring urethral stent removal and reevaluation for all patients 3-4 months after surgery. REDCap was used in order to compile the database used in this study. RESULTS: A total of 280 patients underwent distal hypospadias repair during this interval. One hundred twenty-two patients had OC used with 3 (2.4%) having complications: 2 fistulas and 1 with both meatal stenosis and fistula. One hundred fifty-eight patients were dressed with WD with 5 (3.2%) complications: 4 fistulas and 1 meatal stenosis. No patients had hematoma, wound dehiscence, diverticulum, or infection. CONCLUSION: A low rate of complication was observed following distal hypospadias repair using both 2-octyl cyanoacrylate and a standard waterproof transparent dressing. 2-octyl cyanoacrylate is a safe option for surgical dressing following distal hypospadias repair but its utilization in this setting is surgeon dependent.

Association of O-Antigen Serotype with the Magnitude of Initial Systemic Cytokine Responses and Persistence in the Urinary Tract.

UNLABELLED: Urinary tract infection (UTI) is one of the most common ailments requiring both short-term and prophylactic antibiotic therapies. Progression of infection from the bladder to the kidney is associated with more severe clinical symptoms (e.g., fever and vomiting) as well as with dangerous disease sequelae (e.g., renal scaring and sepsis). Host-pathogen interactions that promote bacterial ascent to the kidney are not completely understood. Prior studies indicate that the magnitude of proinflammatory cytokine elicitation in vitro by clinical isolates of uropathogenic Escherichia coli (UPEC) inversely correlates with the severity of clinical disease. Therefore, we hypothesize that the magnitude of initial proinflammatory responses during infection defines the course and severity of disease. Clinical UPEC isolates obtained from patients with a nonfebrile UTI elicited high systemic proinflammatory responses early during experimental UTI in a murine model and were attenuated in bladder and kidney persistence. Conversely, UPEC isolates obtained from patients with febrile UTI elicited low systemic proinflammatory responses early during experimental UTI and exhibited prolonged persistence in the bladder and kidney. Soluble factors in the supernatant from saturated cultures as well as the lipopolysaccharide (LPS) serotype correlated with the magnitude of proinflammatory responses in vitro. Our data suggest that the structure of the O-antigen sugar moiety of the LPS may determine the strength of cytokine induction by epithelial cells. Moreover, the course and severity of disease appear to be the consequence of the magnitude of initial cytokines produced by the bladder epithelium during infection. IMPORTANCE: The specific host-pathogen interactions that determine the extent and course of disease are not completely understood. Our studies demonstrate that modest changes in the magnitude of cytokine production observed using in vitro models of infection translate into significant ramifications for bacterial persistence and disease severity. While many studies have demonstrated that modifications of the LPS lipid A moiety modulate the extent of Toll-like receptor 4 (TLR4) activation, our studies implicate the O-antigen sugar moiety as another potential rheostat for the modulation of proinflammatory cytokine production.

Relationship among bacterial virulence, bladder dysfunction, vesicoureteral reflux and patterns of urinary tract infection in children.

PURPOSE: We hypothesized that virulence levels of Escherichia coli isolates causing pediatric urinary tract infections differ according to severity of infection and also among various uropathies known to contribute to pediatric urinary tract infections. We evaluated these relationships using in vitro cytokine interleukin-6 elicitation. MATERIALS AND METHODS: E. coli isolates were cultured from children presenting with urinary tract infections. In vitro cytokine (interleukin-6) elicitation was quantified for each isolate and the bacteria were grouped according to type of infection and underlying uropathy (neurogenic bladder, nonneurogenic bowel and bladder dysfunction, primary vesicoureteral reflux, no underlying etiology). RESULTS: A total of 40 E. coli isolates were collected from children with a mean age of 61.5 months (range 1 to 204). Mean level of in vitro cytokine elicitation from febrile urinary tract infection producing E. coli was significantly lower than for nonfebrile strains (p = 0.01). The interleukin-6 response to E. coli in the neurogenic bladder group was also significantly higher than in the vesicoureteral reflux (p = 0.01) and no underlying etiology groups (p = 0.02). CONCLUSIONS: In vitro interleukin-6 elicitation, an established marker to determine bacterial virulence, correlates inversely with clinical urinary tract infection severity. Less virulent, high cytokine producing E. coli were more likely to cause cystitis and were more commonly found in patients with neurogenic bladder and nonneurogenic bowel and bladder dysfunction, whereas higher virulence isolates were more likely to produce febrile urinary tract infections and to affect children with primary vesicoureteral reflux and no underlying etiology. These findings suggest that bacteria of different virulence levels may be responsible for differences in severity of pediatric urinary tract infections and may vary among different underlying uropathies.

Novel management of urinary tract infections.

PURPOSE OF REVIEW: To highlight observations that have suggested the need for changing the conventional approach to the evaluation and management of urinary tract infections (UTIs) and vesicoureteral reflux in children and examine new alternative approaches to prevention of UTI and renal scarring based on research into host-pathogen interaction. RECENT FINDINGS: Recent studies have questioned the traditional approach of using prophylactic antibiotics to prevent recurrence of UTI and development of renal scarring in children with vesicoureteral reflux. Ongoing research on host-pathogen interactions reveals a promising capability to analyze virulence factors in bacteria causing UTIs in children, identify highly virulent bacteria capable of causing pyelonephritis and renal injury, and to selectively target the gastrointestinal reservoirs of these bacteria for elimination using probiotics. SUMMARY: Promising experimental studies correlating bacterial virulence with pattern of UTI and identification and characterization of a newly available probiotic capable of eradicating uropathogenic bacteria make targeted probiotic prevention of renal injury-inducing UTIs a potential therapeutic reality.

Ultrasonography underestimates the volume of normal parenchyma in benign testicular masses.

PURPOSE: In children with testicular masses characteristic ultrasonographic features may occasionally allow the preoperative determination of a benign process and permit a testis sparing procedure to be performed. Often the amount of normal parenchyma surrounding the mass may be seemingly negligible, which may prompt some investigators to wonder what a testis sparing procedure might realistically spare. MATERIALS AND METHODS: We retrospectively reviewed 7 consecutive patients with intratesticular lesions who underwent surgical exploration. Several of these children seemingly had complete replacement of the testis with the pathological process with little to no discernible normal parenchyma. The surgical technique involved delivery of the testis and control of the vessels. The capsule was incised and the normal parenchyma was bluntly separated to the level of the tumor. The mass was then mobilized circumferentially and enucleated intact. The residual parenchyma was reapproximated, the capsule was closed and the testicle was replaced in the scrotum. All patients were followed postoperatively by physical examination and ultrasonography. RESULTS: The series consists of 7 children 10 to 188 months old (mean age 68). The final diagnosis was cystic teratoma in 4 cases, epidermoid tumor in 2 and a simple cyst in 1. Postoperative physical examinations revealed symmetrical testes. Postoperative ultrasonography demonstrated normal echo texture and testicular volumes. Furthermore, no tumor recurrence was detected. CONCLUSIONS: Classic ultrasonographic patterns of testicular masses may permit preoperative identification of a benign process, permitting a testis sparing procedure to be planned. However, ultrasonography underestimates the amount of normal residual parenchyma because this tissue is compressed against the capsule into a thin rim. The amount of normal residual parenchyma identified on preoperative ultrasound should not be used as a factor when deciding whether a testis sparing procedure might be appropriate.

Vesicoscopic cross-trigonal ureteral reimplantation: a minimally invasive option for repair of vesicoureteral reflux.

PURPOSE: Cross-trigonal ureteral reimplantation is a commonly performed procedure for the correction of vesicoureteral reflux. Most previously described laparoscopic techniques have used an extravesical approach. A "vesicoscopic" technique is analogous to standard open cross-trigonal repair in principle, except that 3 ports with insufflation of the bladder are used to perform the ureteral reimplantation. MATERIALS AND METHODS: A retrospective review was performed of patients treated for primary vesicoureteral reflux with either vesicoscopic or open ureteral reimplantation. For patients with vesicoscopic reimplantation a 5 mm port is placed in the dome of the bladder and 2, 3 mm ports are placed laterally. The ureters are mobilized transvesically, cross-trigonal submucosal tunnels are made and the ureters are sutured in place with intracorporeal suturing. The bladder ports are closed and a urethral catheter is left indwelling for 36 hours. Among the open reimplantation group 38 patients underwent cross-trigonal ureteral reimplantation, 2 underwent extravesical ureteral reimplantation and 2 were excluded due to insufficient records. Followup imaging for both groups included ultrasonography at 1 month and voiding cystography at 3 months postoperatively. RESULTS: A total of 52 consecutive children underwent vesicoscopic ureteral reimplantation with 1 patient converted to open intravesical reimplantation, and 40 consecutive controls underwent open ureteral reimplantation. Postoperative vesicoureteral reflux resolution rates for the vesicoscopic and open groups were 91% (42 of 46 patients) and 97% (31 of 32 patients), respectively. Mean patient age and mean maximal grade of vesicoureteral reflux in the vesicoscopic and open groups were 5.7 and 4.0 years (p=0.001), and 2.8 and 3.2 (p=0.036), respectively. Mean operative times for vesicoscopic and open procedures were 199 and 92 minutes, respectively (p=0.001). While the average length of hospital stay of 2 days was similar between the groups (p=0.122), less oral and intravenous analgesia was needed postoperatively in the vesicoscopic group (p=0.001 and p=0.005, respectively). Complications of vesicoscopic ureteral reimplantation included urinary leakage in 1 child, bladder stones in 1 and bilateral ureteral obstruction in 1. There were no complications in the open group. CONCLUSIONS: There is an ever increasing trend toward minimally invasive surgery. Our preliminary results indicate that vesicoscopic ureteral reimplantation is an effective procedure with minimal morbidity. Although success rates for vesicoureteral reflux resolution were slightly lower in the vesicoscopic group in this study, the favorable results of other series and the improvement in postoperative discomfort observed here suggest that this technique may be a reasonable option in the management of vesicoureteral reflux. Further refinement of the technique and critical analysis of the long-term outcomes are needed to understand fully its place in the treatment of vesicoureteral reflux.