Outcomes of complex robot-assisted extravesical ureteral reimplantation in the pediatric population.

INTRODUCTION AND OBJECTIVE: While open ureteral reimplantation remains the gold standard for surgical treatment of vesicoureteral reflux (VUR), minimally invasive approaches offer potential benefits. This study evaluated the outcomes of children undergoing complex robot-assisted laparoscopic ureteral reimplantation (RALUR) for failed previous anti-reflux surgery, complex anatomy, or ureterovesical junction obstruction (UVJO), and compared them with patients undergoing open extravesical repair. STUDY DESIGN: Children undergoing complex RALUR or open extravesical ureteral reimplantation (OUR) were identified. Reimplantation was classified as complex if ureters: 1) had previous anti-reflux surgery, 2) required tapering and/or dismembering, or 3) had associated duplication or diverticulum. RESULTS: Seventeen children underwent complex RALUR during a 24-month period, compared with 41 OUR. The mean follow-up was 16.6 ± 6.5 months. The RALUR children were significantly older (9.3 ± 3.7 years) than the OUR patients (3.1 ± 2.7 years; P < 0.001). All RALUR patients were discharged on postoperative day one, while 24.4% of children in the open group required longer hospitalization (mean 1.3 ± 0.7 days; P = 0.03). Adjusting for age, there was no significant difference in inpatient analgesic usage between the two cohorts. Three OUR patients (7.3%) developed postoperative febrile urinary tract infection compared with a single child (5.9%) undergoing RALUR (P = 1.00). There was no significant difference in complication rate between the two groups (12.2% OUR versus 11.8% RALUR; P = 1.00). A postoperative cystogram was performed in the majority of RALUR patients, with no persistent VUR detected, and one child (6.7%) was diagnosed with contralateral reflux. DISCUSSION: Reported VUR resolution rates following robot-assisted ureteral reimplantation are varied. In the present series, children undergoing RALUR following failed previous anti-reflux surgery, with complex anatomy, or UVJO experienced a shorter length of stay but had similar analgesic requirements to those undergoing open repair. Radiographic, clinical success rates and complication risk were comparable. This study had several limitations, aside from lack of randomization. Analgesic use was limited to an inpatient setting, and pain scores were not assessed. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. A larger patient cohort with longer follow-up is necessary to determine predictors of radiographic and clinical failure. CONCLUSION: Older children with a previous history of anti-reflux surgery were more likely to undergo RALUR. These children had success and complication rates comparable to younger patients following complex open extravesical reimplantation, which underscores the expanding role of robot-assisted lower urinary tract reconstructive surgery in the pediatric population.

Utility of urodynamics in the management of asymptomatic tethered cord in children.

BACKGROUND: We have noted a recent increase in neurosurgical requests at our institution for urodynamics (UDS) prior to release of asymptomatic tethered cord. Our aim was to determine how preoperative UDS results are used in the clinical management of asymptomatic tethered cord. METHODS: A retrospective review was performed of 120 patients diagnosed with primary tethered cord from 2007 to 2010. Inclusion criteria included MRI diagnosis of tethered cord and UDS performed by three pediatric urologists. Excluded were any neurologic or urologic dysfunction or associated syndromes, as well as other significant comorbidities. RESULTS: Thirty-eight patients (female 26; male 12), mean age of 3 years (0.2-16.3) were diagnosed with an asymptomatic tethered cord. The majority of the patients had normal preoperative renal ultrasounds. Thirty-one (82 %) of the children had normal baseline UDS, yet twenty-one (68 %) of these patients still underwent neurosurgical intervention. Of the 27 patients untethered, 15 patients (55 %) had follow-up UDS performed. Three patients had improved UDS parameters and one had worsening UDS parameters, including high PVR and DSD. Of the seven patients with abnormal baseline UDS, all had normal renal ultrasound findings and had no other significant differences in presentation from the patients with normal UDS. CONCLUSION: In children with asymptomatic tethered cord, abnormal preoperative UDS may prompt intervention, while normal UDS do not appear to prevent intervention. There is no significant correlation between abnormal preoperative UDS and abnormal preoperative imaging. Further study is needed to evaluate the utility of this procedure in the preoperative setting in this asymptomatic patient population.

Effective endoscopic diagnosis and treatment of pediatric occult vesicoureteral reflux with intermediate to long-term follow-up.

PURPOSE: Recurrent febrile urinary tract infections (fUTIs) in children with non-diagnostic voiding cystourethrogram (VCUG) are challenging, as misdiagnosis can lead to renal damage and increased morbidity. We compared fUTI rates before and after endoscopic treatment of patients with suspected occult VUR. METHODS: Between January 2009 and December 2012, children with history of fUTI and non-diagnostic VCUG(s) underwent endoscopic ureteral hydrodistention (HD) and injection of dextranomer hyaluronic acid co-polymer (Dx/HA). fUTI rates before and after intervention were evaluated. Demographics, imaging and endoscopic findings were assessed. RESULTS: Thirty-four children (mean age 5.4±2.8 years) underwent bilateral Dx/HA injection for occult VUR. Average follow-up was 28.8 months. Seventeen children had renal scarring. Mean ureteral HD grade was 2.2/3. HD grade for ureters associated with renal scarring was significantly (p<0.05) higher (2.6/3) than those without scarring (2.0/3). Mean injected volume was 1.2 mL. Ureters associated with renal scarring (n=21) required significantly (p<0.05) higher volumes (1.4 mL) than those without scarring (n=47; 1.1 mL). Prior to intervention, the fUTI rate was 0.15/patient/month compared to just 0.02 after treatment (p<0.0001). CONCLUSIONS: Incidence of fUTIs significantly decreased following treatment, supporting the use of Dx/HA injection in carefully selected children when the suspicion for occult VUR is high.

Temporal pattern of vesicoureteral reflux on voiding cystourethrogram correlates with dynamic endoscopic hydrodistention grade of ureteral orifice.

PURPOSE: The double hydrodistention implantation technique uses ureteral hydrodistention to visualize injection site(s) and determine required bulking agent volume. Along with grade, early vesicoureteral reflux on voiding cystourethrogram provides prognostic information regarding spontaneous resolution of reflux. We hypothesized that reflux timing is predictive of endoscopic hydrodistention grade. MATERIALS AND METHODS: We identified children undergoing the double hydrodistention implantation technique for primary vesicoureteral reflux between 2009 and 2012. Hydrodistention grade (0 to 3) was assigned prospectively, and compared to vesicoureteral reflux grade and timing on voiding cystourethrogram. RESULTS: A total of 196 children with a mean ± SD age of 3.94 ± 2.58 years underwent injection of 332 ureters. Mean ± SD vesicoureteral reflux grade was 2.8 ± 0.9. Of the ureters 52.4% demonstrated early to mid filling, 39.2% late filling and 8.4% voiding only reflux. Mean ± SD reflux grade was 3.1 ± 0.81 for early filling, 2.6 ± 0.81 for late filling and 2.1 ± 1.1 for voiding only (p <0.0001). Vesicoureteral reflux and hydrodistention grades correlated, with higher reflux grades associated with grade 3 hydrodistention (p <0.001). There was a significant relationship between reflux timing and hydrodistention grade (p <0.001), with a high percentage of ureters with grade 3 hydrodistention displaying early reflux compared to those with grade 1 disease. Significantly increased mean injected volume for ureters with grade 3 hydrodistention (1.6 ml) was observed compared to those with grade 1 or 2 disease (1.25 ml, p <0.001). CONCLUSIONS: Hydrodistention grade correlates with vesicoureteral reflux grade, timing of reflux and injected volume. Early to mid filling vesicoureteral reflux is associated with abnormal hydrodistention (grade 2 to 3). Temporal pattern of vesicoureteral reflux on voiding cystourethrogram may be used to predict ureteral orifice competency and thus aid in predicting resolution of reflux.

The current state of surgical practice for neonatal torsion: a survey of pediatric urologists.

OBJECTIVE: The evaluation and treatment of perinatal testicular torsion is controversial. We performed a survey to assess practice patterns among pediatric urologists regarding treatment of perinatal torsion. METHODS: An internet survey was administered to members of two pediatric urology societies. Cases of prenatal, postnatal and bilateral prenatal torsion were outlined. Respondents were asked about use of ultrasound, timing of surgery, incision, and management of the contralateral testicle. A case with a non-palpable testicle and blind ending vessels was also presented. RESULTS: We had 121 respondents. In a neonate with prenatal torsion, 34% percent would operate immediately, 26% urgently within 72 h, 28% electively and 12% would not explore; 93% would perform a contralateral orchiopexy. In a neonate with postnatal torsion, 93% would operate immediately, 5% urgently, 1% electively and 1% would not explore; 96% would perform a contralateral orchiopexy. In both cases, 75% would use a scrotal incision and 25% would use an inguinal incision. When presented with bilateral prenatal torsion, 90% would operate immediately, 1% urgently, 2% electively and 7% would not operate. In the case of a non-palpable testicle with blind ending vessels 28% would perform a contralateral orchiopexy, 12% would explore the ipsilateral canal for a "nubbin", 56% would perform no intervention and 4% would perform some other form of management. CONCLUSION: We documented variability of timing for intervention of prenatal torsion and confirmed that most view postnatal torsion as a surgical emergency. Most perform a contralateral orchiopexy for prenatal torsion despite the fact that most cases are extravaginal. The surgical approach via a scrotal incision appears to be preferred at this time.