Predictive factors for early discharge (≤24 hours) and re-admission following robotic-assisted laparoscopic pyeloplasty in children.

INTRODUCTION: Minimally invasive pyeloplasty (MIP) for correction of ureteropelvic junction obstruction in children has significantly improved the postoperative management of these patients. In this study, we sought to examine the factors associated with early discharge (≤24 hours) in children who underwent robotic-assisted laparoscopic pyeloplasty (RALP). METHODS: We performed a retrospective chart review of all children who underwent RALP from 2012-2018 in our center. Descriptive statistics and a non-adjusted risk analysis were performed to evaluate the factors associated with early discharge (≤24h), re-admission, and complications within the first 30 days after the procedure. RESULTS: Eighty-nine patients out of 124 total pyeloplasties (72%) stayed ≤24 hours post-surgery. Of the variables analyzed, later cases were statistically associated with length of stay (LOS); the first 55 patients had a lower probability of being hospitalized for ≤24 hours (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.09-0.64, p=0.004). CONCLUSIONS: RALP for children is associated with a high rate of early recovery, short hospital stay, and low re-admission and complication rates. Although not statistically significant, patients with shorter operative room time also had a shorter LOS. An increased LOS was observed in the initial patients of our series, and this is most likely explained by the initial learning curve of the team for the procedure itself and the more conservative postoperative management.

Prenatal renal parenchymal area as a predictor of early end-stage renal disease in children with vesicoamniotic shunting for lower urinary tract obstruction.

BACKGROUND: Vesicoamniotic shunting (VAS) and other bladder drainage techniques for fetal lower urinary tract obstruction (LUTO) have been proven to ameliorate pulmonary hypoplasia and increase survival in patients with an initial poor prognosis. Currently there are limited prognostic tools available during gestation to evaluate and predict postnatal renal function. OBJECTIVE: The aim was to describe the prenatal growth of the renal parenchymal area (RPA) in patients with LUTO and determine its application as a predictor of renal function at one year of life. STUDY DESIGN: The study population comprised a retrospective cohort of all infants who survived the fetal VAS to birth. Renal growth and size were measured using imageJ software to calculate the RPA in sequential prenatal ultrasounds. The parenchymal area was measured from the image of each kidney with the greatest longitudinal length. These measurements were further correlated and analyzed as a predictor of end-stage renal disease (ESRD) within the first year of life. RESULTS: Etiologies of LUTO in the 15 male fetuses included eight posterior urethral valves, four Eagle-Barrett/prune belly syndrome, two urethral atresia, and one megacystis microcolon intestinal hypoperistalsis syndrome. All patients had patent shunts, in place, at birth. Furthermore, ultrasonographic parameters such as oligohydramnios, keyhole sign, and bladder wall thickness showed no statistical difference between groups. Renal parenchymal growth correlated with postnatal renal function in both the ESRD (r = 0.409, p = 0.018) and the non-ESRD (r = 0.657, p < 0.001) groups. Most notably, RPA during the 3rd trimester predicted ESRD with the best cut-off point determined to be 8 cm2 (sensitivity, 0.714; specificity, 0.882; and positive likelihood ratio, 6.071) (Table). DISCUSSION: Despite definitive VAS for LUTO, postnatal morbidity and mortality remain high, emphasizing the role of renal dysplasia in postnatal renal failure, in spite of urinary diversion. Renal growth statistically differs between groups in the 3rd trimester of gestation; RPA development appears stagnant in patients that developed ESRD within the first year of life. In contrast, patients that did not develop ESRD continued to have renal parenchymal growth in a linear fashion. This suggests that prenatal RPA may be predictive of postnatal ESRD. CONCLUSIONS: RPA measurement during the prenatal period could play an important role as a non-invasive tool to predict postnatal renal function and to anticipate postnatal clinical interventions.

Staged Fowler-Stephens and Single-stage Laparoscopic Orchiopexy for Intra-abdominal Testes: Is There a Difference? A Single Institution Experience.

OBJECTIVE: To compare single-stage laparoscopic orchiopexy (SSLO) and staged Fowler-Stephens (SFS) procedures in the management of intra-abdominal undescended testes, and to analyze postoperative atrophy and malpositioning as end points. MATERIALS AND METHODS: A retrospective chart review identified laparoscopic orchiopexy patients with intra-abdominal testes between November 2006 and November 2014. Of 167 patients who had laparoscopic orchiopexy, 73 (85 testes) were identified as having laparoscopic orchiopexy. Baseline characteristics, as well as testicular scrotal position and size at follow-up, were recorded. Regression analysis was performed to compare outcomes between patients who underwent SFS and SSLO. RESULTS: Of the 85 laparoscopic orchiopexies, 35 underwent SFS and 50 had SSLO. Patient demographics were comparable in both groups. The median age at surgery was 12 months (5-151 months), and the average follow-up was 17.3 months. On follow-up, there were 0 recorded cases of SFS patients with abnormally positioned testes postoperatively, whereas there were 10 (20.0%) SSLO patients who had abnormally positioned testes (odds ratio: 0.05, 95% confidence interval: 0.01-0.44). Differences in atrophy rates were not significant. CONCLUSION: These results suggest that there may be no difference between the 2 approaches in terms of postoperative atrophy. However, the SFS appears to be more successful in securing a favorable scrotal position. Atrophy does not seem to be associated with other patient factors. Prospective, randomized studies are indicated to further explore outcome differences between the 2 approaches.

Case Report: Cystinuria and Polycystic Kidney Disease.

Cystinuria and polycystic kidney disease are 2 genetic disorders that affect the genitourinary tract but rarely together. This case report presents 2 pediatric patients diagnosed with polycystic kidney disease and cystinuria requiring surgical treatment. Both subjects presented acutely with stone disease. Imaging studies and stone analysis established the diagnoses. Although coexistence of these 2 conditions is rare, cystinuria should be considered in the differential diagnosis when evaluating patients with cystic disease who develop renal calculi.

Testicular asymmetry and adolescent varicoceles managed expectantly.

PURPOSE: Adolescent varicocele is often associated with testicular asymmetry. Depending on the degree of asymmetry, some physicians will recommend surgery. However, given the possibility that asynchronous growth may be transient, others advocate for a period of observation. We reviewed our outcomes in such patients who were initially treated expectantly. MATERIALS AND METHODS: We retrospectively reviewed our pediatric varicocele database. We analyzed the outcomes of patients presenting for evaluation of varicocele who were followed with serial testicular volume measurements using scrotal ultrasound or ring orchidometry and who had at least a 6-month interval between measurements. Fisher's exact test was used to compare groups based on initial and final testicular asymmetry. RESULTS: We identified 181 patients (median age 13.8 years) who were followed expectantly. Serial volume measurements had been obtained at a median interval of 12 months (interquartile range 8 to 21) between first and most recent visits. Mean percent asymmetry for the group did not change with time. Among patients who initially had less than 20% asymmetry 35% had 20% or greater asymmetry on followup, and among those with 20% or greater asymmetry initially 53% remained in that range (p = 0.007). CONCLUSIONS: Asymmetry can be a transient phenomenon. Patients with initial asymmetry can end up with significant asymmetry, and many with significant asymmetry can have catch-up growth. However, when patients have a peak retrograde flow of 38 cm per second or greater on duplex Doppler ultrasound in association with 20% or greater asymmetry spontaneous catch-up growth is unlikely to occur.

Skin to stone distance is an independent predictor of stone-free status following shockwave lithotripsy.

INTRODUCTION: In recent years several new parameters such as Hounsefield unit density and skin to stone distance (SSD) have been determined to correlate with successful extracorporeal shockwave lithotripsy (SWL). SSD has been shown to independently predict successful SWL for lower pole calculi. The objective of this study was to determine which stone characteristics on noncontrast computed tomography (NCCT), including SSD, independently predict for SWL success regardless of stone location within the kidney. MATERIALS AND METHODS: A retrospective review of all 1282 SWL procedures between 2004 and 2007 at a single institution revealed 83 patients meeting inclusion criteria for current study. All patients were treated using a single electromagnetic lithotriptor (DoLi 50; Dornier Medical Systems, Marrieta, GA) with a single technician. Stone-free (SF) status was determined by NCCT or abdominal plain film radiographs at 6 weeks post-SWL. Logistic regression analysis was computed to assess SF rates using SSD, stone size, location, and Hounsefield unit density as predictors. RESULT: Of the 83 patients, 51 were SF and 32 had residual stones at a mean follow-up of 2.3 months. The mean SSD in the SF group was 83.3 +/- 21.9 mm in comparison to those in the residual stone group who had a mean SSD of 107.7 +/- 28.9 mm (p < or = 0.05). Multivariate logistic regression analysis revealed that SSD was the only significant independent predictor of treatment outcome. CONCLUSION: SSD is an easily measured parameter on NCCT that independently correlates with SWL efficacy in treating stones in all locations.

Peak retrograde flow: a novel predictor of persistent, progressive and new onset asymmetry in adolescent varicocele.

PURPOSE: The major indication for adolescent left varicocelectomy is testicular asymmetry. However, a period of observation is often recommended preoperatively to determine if the asymmetry resolves, persists or progresses. We investigated whether varicocele grade or the duplex Doppler ultrasound measurements of peak retrograde flow and mean vein diameter could be used as predictors of persistent, progressive or new onset asymmetry. MATERIALS AND METHODS: Only patients with left varicoceles who had undergone at least 2 duplex Doppler ultrasounds without intervening surgery were included in the study. Grade of varicocele, peak retrograde flow and mean vein diameter were analyzed as possible determinants of catch-up growth, or persistent or new onset asymmetry. RESULTS: A total of 77 patients (mean age 14.3 years, range 9 to 20) were identified with a mean observation period of 13.2 months. Of the patients 50 (65%) had 10% or greater asymmetry at the first measurement. Of patients with initial 20% or greater asymmetry 71% had persistent or worsening asymmetry on followup evaluation. All 14 patients with the combination of an initial peak retrograde flow 38 cm per second or greater and 20% or greater asymmetry had progressive asymmetry on followup examination. Peak retrograde flow was the only significant parameter of predictive value for persistent or worsening asymmetry (p = 0.032). CONCLUSIONS: Peak retrograde flow can serve as a valuable tool in predicting persistent, progressive and new onset asymmetry. Varicoceles associated with a peak retrograde flow of 38 cm per second or greater and 20% or greater asymmetry should be considered for varicocelectomy at initial presentation. Patients with peak retrograde flow greater than 30 cm per second need to be monitored carefully. Those with peak retrograde flow less than 30 cm per second are less likely to require surgery.

Adolescent varicocelectomy: postoperative catch-up growth is not secondary to lymphatic ligation.

PURPOSE: The major indication for adolescent varicocelectomy is testicular asymmetry with the left testicle smaller than the right. Catch-up growth following surgery is one of the parameters used to assess efficacy of surgery. However, it is not clear whether this represents true tissue growth or increased interstitial fluid secondary to lymphatic obstruction. The purpose of this study was to compare catch-up growth in patients who underwent varicocelectomy with and without lymphatic preservation. MATERIALS AND METHODS: We retrospectively analyzed the outcomes of 136 boys (mean age 15.1years) who had 10% or greater preoperative testicular asymmetry and underwent varicocelectomy between 1997 and 2006. Surgery was either a laparoscopic nonlymphatic sparing or laparoscopic lymphatic sparing varicocelectomy. All patients had pre- and postoperative ultrasound volume measurements at least 6months following surgery. The groups were compared for incidence of postoperative catch-up growth, achieving less than 10% testicular asymmetry. RESULTS: After a mean follow up of 24.7months, catch-up growth was achieved in 62.8% of patients. There was no significant difference between the groups in regard to catch-up growth (51.7% vs 66.3%, P=0.193). CONCLUSIONS: Since no significant difference was found between the laparoscopic nonlymphatic sparing and laparoscopic lymphatic sparing varicocelectomies, we conclude that lymphatic obstruction is not the cause of catch-up growth.