Pediatric Robot-Assisted Laparoscopic Pyeloplasty: Where Are We Now?

PURPOSE OF REVIEW: This review aims to provide an in-depth exploration of the recent advancements in robot-assisted laparoscopic pyeloplasty (RALP) and its evolving landscape in the context of infant pyeloplasty, complex genitourinary (GU) anatomy, recurrent ureteropelvic junction (UPJ) obstruction, cost considerations, and the learning curve. RECENT FINDINGS: Recent literature highlights the safety and efficacy of RALP in treating the infant population, patients with complex GU anomalies, and recurrent UPJO which were all traditionally managed using the open approach. Cost considerations are evolving, with the potential for RALP to have a lesser financial burden. In addition, the learning curve for RALP is diminishing due to robust training programs and advances in research. RALP has become the gold standard in the treatment of UPJO in pediatric urology at many children's hospitals. Surgeon comfort and research in this space allow safe and successful reconstruction in the most challenging of cases.

Does Preoperative Testosterone Administration Decrease Complications in Distal Hypospadias Repair With Urethroplasty?

PURPOSE: Testosterone administration prior to hypospadias repair is common practice among pediatric urologists; however, its impact on surgical outcomes remains controversial. We hypothesize that testosterone administration prior to distal hypospadias repair with urethroplasty significantly decreases postoperative complications. MATERIALS AND METHODS: We queried our hypospadias database for primary distal hypospadias repairs with urethroplasty from 2015 to 2021. Patients undergoing repair without urethroplasty were excluded. We collected information on patient age, procedure type, testosterone administration status, initial visit and intraoperative glans width, urethroplasty length, and postoperative complications. To determine the role of testosterone administration on incidence of complications, a logistic regression adjusting for initial visit glans width, urethroplasty length, and age was performed. RESULTS: A total of 368 patients underwent distal hypospadias repair with urethroplasty. One hundred thirty-three patients received testosterone and 235 did not. Initial visit glans width was significantly larger in the no-testosterone vs testosterone group (14.5 mm vs 13.1 mm, P = .001). Testosterone patients had significantly larger glans width at the time of surgery (17.1 mm vs 14.6 mm [no-testosterone group], P = .001). On multivariable logistic regression analysis after controlling for age at surgery, preoperative glans width, testosterone status, and urethroplasty length, testosterone administration did show significant association with reduced odds of postoperative complications (OR 0.4, P = .039). CONCLUSIONS: This retrospective review of patients shows that on multivariable analysis there is significant association between testosterone administration and decreased incidence of complications in patients undergoing distal hypospadias repair with urethroplasty. Future studies on testosterone administration should focus on specific cohorts of patients with hypospadias as benefits of testosterone may be more evident in some subgroups than others.

Quantifying Glans Width Changes in Response to Preoperative Androgen Stimulation in Patients Undergoing Hypospadias Repair.

PURPOSE: Testosterone (T) administration prior to hypospadias surgery to increase glans size remains controversial. Understanding T's effect on glans width (GW) is essential to understanding its potential impact on surgical outcomes. We hypothesized that preoperative T in prepubertal boys significantly increases GW at the time of hypospadias surgery. MATERIALS AND METHODS: Our single institutional database was queried to identify patients who underwent hypospadias surgery from 2016 to 2020, in which data for T administration and GW were available. Descriptive, nonparametric and categorical statistics were performed as indicated. RESULTS: A total of 579 patients were eligible for analysis. Median age at surgery was 0.9 years (IQR 0.6-1.6). A total of 247/579 patients (42.7%) received T. The median GW at surgery was 15 mm (IQR 13-17). When comparing patients who had T administered to those who did not, we found a significant difference in GW at surgery (16 mm vs 14 mm, p <0.001). The median change in GW from the office to surgery was 4 mm for those receiving T vs 0 mm for those not receiving T (p <0.001). We identified a greater change in GW from preoperative to intraoperative measurements in patients who received 2 doses of T vs 1 dose (4 mm vs 2 mm, p <0.001). A histogram plot revealed the distribution of GW change at surgery. CONCLUSIONS: In our prospectively collected cohort of patients undergoing hypospadias surgery, we were able to quantitate the change in GW from preoperative T. Two doses of T resulted in a significant increase in GW vs 1 dose.

Robot-Assisted Laparoscopic Ureterocalicostomy in the Setting of Ureteropelvic Junction Obstruction: A Multi-Institutional Cohort.

PURPOSE: Recurrent ureteropelvic junction obstruction (UPJO) after failed pyeloplasty is a complex surgical dilemma. The robot-assisted laparoscopic ureterocalicostomy (RALUC) is a potential surgical approach, but widespread adoption is limited due to the perceived technical challenge of the procedure. We present a multi-institutional pediatric cohort undergoing RALUC for recurrent or complex UPJO, and hypothesize that the procedure is reproducible, safe and efficacious. MATERIALS AND METHODS: A 3-center multi-institutional collaboration was initiated and medical records of children undergoing RALUC between 2012 and 2020 were retrospectively reviewed. The details on baseline demographics, perioperative characteristics and postoperative outcomes were aggregated. RESULTS: During the study period 24 patients, 7 (29%) females and 17 (71%) males, were identified. Of the patients 21 (86%) had a history of previous pyeloplasty prior to RALUC, of whom 5 (24%) had 2 prior failed ipsilateral pyeloplasties. The reason for performing RALUC was short ureter in 3 (13%), intrarenal pelvis in 5 (21%) and extensive scarring at the ureteropelvic junction locus in 16 (67%) patients. The median age of patients at time of surgery was 5.1 years (IQR: 1.9, 14.7). Of the patients 9 (38%) had percutaneous nephrostomy prior to surgery; if percutaneous nephrostomy tubes were placed for relief of obstruction, an antegrade contrast study was done postoperatively to confirm resolution of obstruction. No 30-day Clavien-Dindo Grade III-V complications were noted. During the median followup of 16.1 months (IQR: 6, 47.5), 22 (92%) had improved symptoms and hydronephrosis with no further intervention; 2 (8%) patients underwent endoscopic interventions after RALUC and both ultimately underwent nephrectomy. CONCLUSIONS: This multi-institutional cohort demonstrates that RALUC is a safe and efficacious salvage option for failed pyeloplasty or complex anatomy with an acceptable success profile, especially in cases of extensive scarring at the UPJO or an intrarenal pelvis.

Expanding the Use of Nephron-Sparing Surgery for Wilms Tumor.

Radical nephrectomy combined with contemporary chemotherapeutic and radiation therapy protocols has drastically improved outcomes for children with Wilms tumor. Patients with bilateral disease and a syndrome predisposing to tumor development have necessitated the use of nephron-sparing surgery in select cases. Success in managing these patients has increased the indication for partial nephrectomy, although current guidelines for unilateral Wilms tumor are limited. Given that children are being cured with increasing success, recent focus has shifted to long-term health outcomes in addition to tumor treatment. Specifically, renal function has an impact on long-term cardiovascular health and events. Adult outcomes with partial nephrectomy provide a guideline for a paradigm shift in the management of children with Wilms tumor, particularly with advances in imaging and adjuvant therapy. The data are limited for children undergoing partial nephrectomy for unilateral Wilms tumor and outcomes for larger tumors will need to be studied closely in future trials. Increased utilization of neoadjuvant chemotherapy could further expand the number of patients eligible for partial nephrectomy.

New approach to second metacarpophalangeal joint dislocation management: the SKY needling technique.

Second metacarpophalangeal dislocation is a rare entity, wherein correct diagnosis can be achieved by careful and experienced clinical examination that must be followed by radiological examination. This mostly requires open reduction either by dorsal or volar approach. Open reduction by volar approach is being used most widely but has more incidence of postoperative loss of sensation at volar aspect of finger due to neurovascular injury (digital nerve and vessel) and also required more extensive dissection. Dorsal approach is a rather safe alternative to volar approach as it provides better exposure to volar plate. We present a new technique wherein the chances of neurovascular injury are very rare and make it an effective and less complicated surgery.

Use of Digital Rectal Examination as an Adjunct to Prostate Specific Antigen in the Detection of Clinically Significant Prostate Cancer.

PURPOSE: Guidelines from the NCCN® (National Comprehensive Cancer Network®) advocate digital rectal examination screening only in men with elevated prostate specific antigen. We investigated the effect of prostate specific antigen on the association of digital rectal examination and clinically significant prostate cancer in a large American cohort. MATERIALS AND METHODS: We evaluated the records of the 35,350 men who underwent digital rectal examination in the screening arm of the Prostate, Lung, Colorectal and Ovarian Cancer Screening trial for the development of clinically significant prostate cancer (Gleason 7 or greater). Followup was 343,273 person-years. The primary outcome was the rate of clinically significant prostate cancer among men with vs without suspicious digital rectal examination. We performed competing risks regression to evaluate the interaction between time varying suspicious digital rectal examination and prostate specific antigen. RESULTS: A total of 1,713 clinically significant prostate cancers were detected with a 10-year cumulative incidence of 5.9% (95% CI 5.6-6.2). Higher risk was seen for suspicious vs nonsuspicious digital rectal examination. Increases in absolute risk were small and clinically irrelevant for normal (less than 2 ng/ml) prostate specific antigen (1.5% vs 0.7% risk of clinically significant prostate cancer at 10 years), clinically relevant for elevated (3 ng/ml or greater) prostate specific antigen (23.0% vs 13.7%) and modestly clinically relevant for equivocal (2 to 3 ng/ml) prostate specific antigen (6.5% vs 3.5%). CONCLUSIONS: Digital rectal examination demonstrated prognostic usefulness when prostate specific antigen was greater than 3 ng/ml, limited usefulness for less than 2 ng/ml and marginal usefulness for 2 to 3 ng/ml. These findings support the restriction of digital rectal examination to men with higher prostate specific antigen as a reflex test to improve specificity. It should not be used as a primary screening modality to improve sensitivity.

Prognostic Significance of Digital Rectal Examination and Prostate Specific Antigen in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Arm.

PURPOSE: The absence of definitive data or explicit guidelines regarding the use of digital rectal examination for prostate cancer screening may lead to confusion for physicians and patients alike. We evaluated the prognostic value of abnormal digital rectal examination and prostate specific antigen following the widespread dissemination of prostate specific antigen testing in the U.S. MATERIALS AND METHODS: Collectively, men comprising the screening arm of the PLCO cancer screening trial who underwent digital rectal examination screening (35,350) were followed for 314,033 person-years. Adjusted analyses with competing risks regression were performed to assess the association of suspicious (nodularity, induration, asymmetry) digital rectal examination and abnormal prostate specific antigen (4 ng/ml or greater) with the detection of clinically significant prostate cancer, prostate cancer specific mortality and overall mortality. RESULTS: Among all screening encounters with a suspicious digital rectal examination only 15.4% had a concurrently abnormal prostate specific antigen (McNemar's test p <0.001). During followup there were 1,612 clinically significant prostate cancers detected, 64 prostate cancer specific deaths and 4,600 deaths. On multivariable analysis suspicious digital rectal examination and abnormal prostate specific antigen were associated with a greater risk of clinically significant prostate cancer (HR 2.21, 95% CI 1.99-2.44 vs HR 5.48, 95% CI 5.05-5.96, p <0.001 and p <0.001) and prostate cancer specific mortality (HR 2.54, 95% CI 1.41-4.58 vs HR 5.23, 95% CI 3.08-8.88, p=0.002 and p <0.001), respectively. CONCLUSIONS: In a secondary analysis of a contemporary U.S. cohort, suspicious digital rectal examination and abnormal prostate specific antigen on routine screening were independently associated with clinically significant prostate cancer and prostate cancer specific mortality. However, additional research is needed to optimize screening protocols.

Prostate size, nocturia and the digital rectal examination: a cohort study of 30 500 men.

OBJECTIVES: To evaluate the utility of the digital rectal examination (DRE) in estimating prostate size and the association of DRE with nocturia in a population-based cohort. SUBJECTS AND METHODS: We identified all men randomized to the screening arm of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) trial for whom DRE results were available. Men were excluded if they had a history of prostate surgery or incident prostate cancer. Prostate posterior surface area was derived from DRE sagittal and transverse estimates. Relationships between prostate posterior surface area, transrectal ultrasonography (TRUS), prostate-specific antigen (PSA) and nocturia were analysed using intraclass correlation coefficients (ICCs), Spearman's rank correlation and multivariable logistic regression. RESULTS: A total of 30 500 men met the inclusion criteria, with 103 275 screening visits containing paired DRE and PSA data. Digital rectal examination posterior surface area estimates had an ICC of 0.547 (95% CI 0.541-0.554) and were significantly yet modestly correlated with elevated PSA level (rs = 0.18, P < 0.001) and TRUS prostate volume (rs = 0.32, P < 0.001). Prostate posterior surface area was significantly associated with nocturia on multivariable analysis, but was not significant in stratified analysis of men with cardiovascular risk factors (hypertension, diabetes, high body mass index, stroke). In men without these risk factors, the highest quintile of DRE posterior surface area had 22% greater odds of nocturia than the lowest quintile (odds ratio 1.216, 95% CI 1.036-1.427). CONCLUSIONS: Digital rectal examination is a modestly accurate tool for measuring prostate volume. While DRE posterior surface area represents a statistically significant predictor of nocturia, the magnitude of effect suggests it has limited clinical utility for assessing this condition, particularly in the presence of cardiovascular risk factors.

Decline in Prostate Cancer Screening by Primary Care Physicians: An Analysis of Trends in the Use of Digital Rectal Examination and Prostate Specific Antigen Testing.

PURPOSE: Prostate cancer screening by digital rectal examination and prostate specific antigen testing has been routine clinical practice in the United States for the last 25 years. Recent studies have shown a national decline in prostate specific antigen testing following the USPSTF (United States Preventive Services Task Force) recommendation against routine prostate specific antigen screening. However, to our knowledge the effect of this recommendation on digital rectal examination utilization remains unknown. MATERIALS AND METHODS: We used NAMCS (National Ambulatory Medical Care Survey) to characterize trends in the rate of digital rectal examination and prostate specific antigen testing by primary care physicians in men older than 40 years presenting for preventive care. From 2005 to 2012 NAMCS contained 3,368 such visits (unweighted) for the study of digital rectal examination trends and 4,035 unweighted visits from 2002 to 2012 for the study of prostate specific antigen trends. RESULTS: Following the USPSTF recommendation the proportion of visits where digital rectal examination was performed decreased from 16.0% (95% CI 13.1-19.5) to 5.8% (95% CI 4.0-8.3, p <0.001). Similarly, the proportion of visits where prostate specific antigen testing was performed decreased from 27.3% (95% CI 24.5-30.3) to 16.7% (95% CI 12.9-21.2, p <0.001). This represents a relative 64% decrease in digital rectal examination and a 39% decrease in prostate specific antigen testing. Among men 55 to 69 years old the number of visits where digital rectal examination and prostate specific antigen testing were performed decreased 65% and 39%, respectively (p <0.001). CONCLUSIONS: Utilization of digital rectal examination and prostate specific antigen has declined significantly following the release of the USPSTF recommendation against prostate specific antigen screening. This suggests that prostate cancer screening is rapidly disappearing from primary care practice.

Combating the Health Risks of Sedentary Behavior in the Contemporary Radiology Reading Room.

OBJECTIVE: We detail the association of sedentary behavior with a variety of health problems and provide the radiologist with a number of simple activities and techniques that can improve overall health while still meeting the productivity demands of a high-volume practice. Although these techniques are well known and recognized in the fitness and nutrition literature, they are not widely used in the radiology reading room. The computer- and workstation-based work routinely performed by diagnostic radiologists typically occurs in the seated position, leading to more than 8 hours per day of sitting. Studies have found that even for those who exercise regularly, spending increased time sitting can negate the healthful effects of exercise. Time spent in a seated or sedentary position leads to slowing of one's metabolism, with negative resultant effects. CONCLUSION: The concept of nonexercise activity thermogenesis (NEAT) will be described, with examples given of how to burn more calories while at work and, therefore, improve the health of the diagnostic radiologist. NEAT refers to the energy expended during activities of daily living, excluding sportlike or intentional exercise. The concept of NEAT must be understood by radiologists, because it allows the development of multiple strategies to combat the ill effects of sitting while working. Adding intermittent movement and stretching exercises throughout the day can stimulate metabolism. An understanding of the association of sedentary work behavior with a number of health risks is crucial for radiologists so that they can implement basic changes into their work routine, allowing them to increase activity to address and avoid these potential health hazards.

Unmasking Ureteral Polyps: Insights From a Case Series.

Fibroepithelial polyps in the urinary tract are a rare cause of obstructive uropathy with fewer than 130 cases reported in the literature. In our series, we describe polyps that were missed on preoperative imaging and later found in the operating room during pyeloplasty. It is critical for urologists to be aware of polyps as a potential source of obstruction as they can increase the complexity of a reconstruction and, if missed, may result in a failed repair and persistent obstruction. We hypothesize that performing a retrograde pyelogram prior to ureteric reconstruction will facilitate diagnosis prior to surgical repair.

Deferring gonadectomy in patients with turner syndrome with a genetic Y component is not a safe practice.

INTRODUCTION: Patients with Turner syndrome who harbor Y chromosome material are known to be at increased risk of developing germ cell neoplasms. The optimal timing to perform gonadectomy to reduce the risk of cancer development in these patients is not well defined. We present outcomes of Turner with a Y component (TSY) patients who underwent gonadectomy at our institution. HYPOTHESIS/OBJECTIVE: We hypothesized that tumors could occur in a significant portion of TSY patients at any age and gonadectomy can be safely performed at diagnosis rather than deferred. STUDY DESIGN: We performed an IRB-approved retrospective single center study in which we queried our institutions electronic health record to identify all patients with TSY who underwent gonadectomy at our institution from 2012 to 2021. RESULTS: In our series of 18 consecutive TSY patients, a tumor was identified in 6 patients (33.3%): 4 (22.2%) with dysgerminoma (DG) [Fig. 1] and 2 (11.1%) with gonadoblastoma (GB). DISCUSSION: Our cohort of 18 consecutive TSY who underwent gonadectomy over a 9-year period is the largest published single site cohort to date. Additionally, our patient who was found to have GB at 40 days is to our knowledge the youngest TSY patient to be diagnosed with GB in the literature. This patient's remarkably early incidence of tumor occurrence illustrates the urgency of protective gonadectomy. Given the high incidence of tumor formation in this population and the minimal morbidity associated with gonadectomy, we do not recommend delaying gonadectomy in this population for any reason. Our study is vulnerable to selection bias and confounding innate to any retrospective study. There was variation with respect to the frequency and timing of pre-operative imaging as a strict preoperative imaging protocol with sequential studies was not in place at our institution. Additionally, we do not have a comparison cohort of patients who are being followed without operative intervention as all TSY patients at our institution have undergone gonadectomy. CONCLUSION: TSY patients cannot be safely observed for tumor formation based on clinical factors such as imaging or age. Gonadectomy is safe with a low complication rate and without tumor recurrence during three-year follow-up. We continue to recommend bilateral gonadectomy in this patient population at the time of diagnosis.

Does ketorolac administration at the time of hypospadias surgery increase unplanned encounters in the immediate postoperative period?

INTRODUCTION & OBJECTIVE: The opioid crisis has raised concerns for long-term sequela of routine administration of opioids to patients, particularly in the pediatric population. Nonsteroidal anti-inflammatory drug use is limited in hypospadias surgery due to concerns for post-operative bleeding, particularly with ketorolac. We hypothesize that ketorolac administration at the time of hypospadias repair is not associated with increased bleeding or immediate adverse events. METHODS: A retrospective single institution study included all patients undergoing hypospadias surgery from 2018 to 2021. Outcomes measured include peri-operative ketorolac administration, opioid prescriptions, and unplanned encounters (i.e., emergency department or office visits). Comparative statistics using non-parametric and binary/categorical tests and a logistic regression were performed. RESULTS: 1044 patients were included, among whom there were 562 distal, 278 proximal and 204 hypospadias complication repairs. Ketorolac was administered to 396 (37.9%) patients and its utilization increased during the study period [Summary Figure]. Patients receiving ketorolac were older (p = 0.002) and were prescribed opioids less often after surgery (2.0% vs 5.2%, p = 0.009). There was no difference in unplanned encounters across repair types (p = 0.1). Multivariate logistic regression showed ketorolac use was not associated with an increased likelihood of an unplanned encounter. DISCUSSION: The use of NSAIDs post-operatively has traditionally been limited due to concerns about bleeding risks, however the present study displayed no significant increases in unplanned patient encounters either in the ED or outpatient clinic after ketorolac administration. Our study has several limitations including its retrospective and single-institutional design, difficulties of pain assessment in pediatric population, and possibility of under estimation of unplanned encounters due to limited access to patients' records outside of our institution. CONCLUSIONS: The use of ketorolac is not associated with an increase in unplanned encounters in children undergoing hypospadias repair. It should be considered a safe agent for perioperative analgesia to decrease opioid utilization. Further studies will evaluate long-term surgical outcomes in children receiving ketorolac after hypospadias repair.

Utilizing RENAL nephrometry in pediatric patients undergoing nephron-sparing surgery for renal tumors: A single-institutional cohort.

INTRODUCTION: RENAL Nephrometry is a complexity score validated in adults with renal tumors and describes the likelihood of complication after partial nephrectomy (PN). Utilization in pediatrics has been limited. Thus, our goal is to quantify inter-rater agreement as well as determine how scores correlate with outcomes. We hypothesize that the RENAL Nephrometry Score is reproducible in children with renal tumors and is related to perioperative and post-operative complications. METHODS: All pediatric patients who underwent PN for a renal mass from 2006 to 2019 were identified. Patient data, operative details, and outcomes were aggregated. Pre-operative CT/MR imaging was anonymized and scored by 2 pediatric radiologists and 2 pediatric urologists using RENAL Nephrometry metrics. Statistical analysis utilized Fleiss' kappa and the intraclass correlation coefficient (ICC). Comparative analyses were performed based on Nephrometry Score <9 and ≥ 9. RESULTS: 28 patients undergoing 33 PN were identified. Median age at surgery was 3.2 years (IQR 1.8-4.0). There is moderate-good agreement across scorers on the domains of RENAL Nephrometry Score, with the lowest agreement noted for anterior vs posterior tumors. Comparing patients with scores <9 and ≥ 9, there was increased operative time (357 vs 267 min, p = 0.003) and LOS for those with a higher score, but no difference in the incidence of 30-day complications. CONCLUSION: RENAL Nephrometry Score is an easily reproducible complexity score for renal tumors in pediatric patients. Higher scores are associated with increased length of stay and estimated blood loss but not complications. Reporting of nephrometry scores in future publications on pediatric renal tumors should become standard in the literature.