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.

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.

Caudal anesthesia is not associated with post-operative complications following distal hypospadias repair.

INTRODUCTION: The use of caudal anesthesia at the time of hypospadias repair remains controversial as some prior studies have reported increased postoperative complication rates associated with caudal nerve block. However, these results have been called into question due to confounding factors and heterogeneous study groups. OBJECTIVE: Given the importance of identifying true risk factors associated with increased hypospadias complication rate, we examined our experience with caudal anesthesia limiting our analysis to distal repairs. We hypothesized that caudal anesthesia would not be associated with increased postoperative complications. STUDY DESIGN: We retrospectively reviewed our institutional hypospadias database from June 2007 to January 2021. All boys who underwent single-stage distal hypospadias repair with either caudal or penile block with minimum 1 month follow up were included. Records were reviewed to determine the type of local anesthesia, type of hypospadias repair, all complications, and time to complication. Association between any complication and local anesthesia type was evaluated by univariate and multivariate logistic regression analysis controlling for age at surgery and type of repair. A sub-analysis was performed for complications occurring ≤30 days. RESULTS: Overall, 1008 boys, 832 (82.5%) who received caudal and 176 (17.5%) penile block, were included. Median age at surgery was 8.1 months and median follow up was 13 months. Overall complication rate was 16.4% with 13.8% of patients requiring repeat operation. Median time to complication was 10.59 months and was significantly shorter in the caudal group (8.45 vs. 25.2 months). Caudal anesthesia was associated with higher likelihood of complication on univariate analysis; however, this was not true on multivariate analysis when controlling for age and type of repair. Caudal anesthesia was not associated with increased likelihood of complication within 30 days. DISCUSSION: Since the association between caudal anesthesia and hypospadias complications was first suggested, several studies have tried to answer this question with variable results. Our findings add to the evidence that there is no association between caudal anesthesia and increased hypospadias complications in either the short or long term. The major strengths of our study are a large, homogenous study population, robust follow up and inclusion of data from 14 surgeons over 14 years. Limitations include the study's retrospective nature as well as lack of standardized follow up protocol throughout the study period. CONCLUSIONS: After controlling for possible confounders, caudal nerve block was not associated with increased risk of postoperative complications following distal hypospadias 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.

Trends in opioid and nonsteroidal anti-inflammatory (NSAID) usage in children undergoing common urinary tract reconstruction: A large, single-institutional analysis.

INTRODUCTION AND OBJECTIVE: Opioid stewardship is recognized as a critical clinical priority. We previously reported marked reductions in narcotic administration after implementation of an opioid reduction protocol for pediatric ambulatory urologic surgery. We hypothesize that a decrease in post-operative and discharge opioid administration will not increase short-term adverse events. STUDY DESIGN: All pediatric patients undergoing open or robot-assisted laparoscopic pyeloplasty or ureteral reimplantation between 2015 and 2019 were included. Patients' demographics, opioid and NSAID administration, urology or pain-related emergency department (ED) visits, readmissions, and reoperations within 30 days of surgery, were aggregated. RESULTS: 438 patients, with a median age of 3.5 years (IQR 1.5-8.3) at the time of surgery, met the inclusion criteria. Annual rates of inpatient opioid administration and prescriptions decreased significantly over the study period, while rates of intra-operative, inpatient, and prescribed NSAIDs significantly increased. There was no significant difference in the occurrence of ED visits, readmissions, or reoperations within 30 days of surgery between patients who received an opioid prescription and those who did not. Multivariate regression showed that patients who did not receive an opioid prescription at discharge were found to be at a lower risk for unplanned encounters including ED visits, readmissions, or reoperations (OR:0.5, 95%CI: 0.2-0.9, p = 0.04). DISCUSSION: The present study shows the decreasing trend in inpatient opioid administration and opioid prescription after discharge, when accompanied by an increase NSAID administration, does not result in a significant change in rates of unplanned encounters and complications, similar to results from previous studies on non-urological and ambulatory urological surgeries. CONCLUSIONS: Non-opioid pain control after major pediatric urologic reconstruction is safe and effective. We found that a reduction in opioid administration can be associated with a reduced risk of unplanned ED visits, readmissions, or reoperations. Further investigations are required to corroborate this finding.

Incidence and resolution of de novo hydronephrosis after pediatric robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux.

INTRODUCTION: With the advent of robot-assisted laparoscopic ureteral reimplantation (RALUR) for primary vesicoureteral reflux (VUR), understanding and minimizing its complications continues to be critical. Incidence of de novo hydronephrosis after RALUR could be indicative of an outcome that needs further study or could be a benign transient finding. OBJECTIVE: In the present study, we hypothesized that the incidence of de novo hydronephrosis after RALUR is low and resolves spontaneously. METHODS: An IRB-approved prospective single-institutional registry was utilized to identify all patients undergoing RALUR via an extravesical approach from 2012 to 2020. Patients with primary VUR and minimal (Grade I SFU) or no hydronephrosis prior to surgery were included. Patients who had other associated pathology or underwent concomitant procedures were excluded. Preoperative characteristics including VUR and hydronephrosis grades as well as post-operative clinical details and hydronephrosis grades were aggregated and analyzed. RESULTS: 86/172 (50%) patients (133 ureters), with median reflux grade of 3 (IQR: G2, G3) met the inclusion criteria. Patients underwent RALUR at a median age of 5.7 years (IQR: 3.4, 8.7) with median 36.2 months (IQR: 19.6, 63.6) follow-up. Renal ultrasound at 4-6 weeks post-op showed de novo hydronephrosis in 18 (13.5%) ureters; the complete resolution was seen in 13 ureters (72%) at a median of 4.5 months from surgery. Among the 5 with non-resolved hydronephrosis (SFU G2:4, G3:1), 2 patients (3 ureters) underwent subsequent interventions. DISCUSSION: The present study evaluating the natural history of de novo hydronephrosis after RALUR-EV performed for primary VUR, is to our knowledge the largest cohort of patients undergoing RALUR that this has been studied in. In our cohort, the incidence of de novo hydronephrosis after RALUR was 13.5%, similar to rates reported in two OUR cohorts, and significantly lower than reported incidence rates of 22-26% in several OUR cohorts, and 30% in a RALUR cohort. In the present cohort, hydronephrosis resolved spontaneously in more than 72% of cases. The median time from surgery until resolution of hydronephrosis was 4.5 (1.6, 10.5) months, which is shorter in comparison to the average time to resolution of 7.6 months, reported by Kim et al. in an earlier study. CONCLUSIONS: De novo hydronephrosis after RALUR can be followed with serial renal ultrasounds. The majority of de novo hydronephrosis post-RALUR is transient and resolves spontaneously within a year of surgery with a very low re-intervention rate.

Office Based Pediatric Urologic Procedures: A Safe and Effective Alternative to Interventions Under Anesthesia.

OBJECTIVE: To report on our experience performing office-based pediatric urologic procedures. We hypothesize that office-based interventions are safe and effective for children, avoiding unnecessary risk and cost associated with general anesthesia. METHODS: We retrospectively identified patients undergoing office-based interventions from 2014 to 2019, including lysis of penile or labial adhesions, division of skin bridges, meatotomy and excision of benign lesion. Success was defined as a completed attempt in the office. Failure includes any unsuccessful office attempts. Complications include 30-day ED visits/readmissions and recurrent skin bridge post division of skin bridge. RESULTS: We identified 1326 interventions: 491 lyses of penile adhesions (37%), 320 division of skin bridges (24%), 128 lyses of labial adhesions (10%), 348 meatotomies (26%), and 39 excisions of benign lesions (3%) [Table 1]. There was a >95% success rate reported in every procedure with an overall complication rate of 0.6%. Excision of benign lesion had 100% success rate. ED visits within 30 days are rare (0.2%), and no patients required admission after their procedure [Table 2]. The rate of recurrence was highest following lysis of labial adhesions (13.3%). Of the 54 patients who underwent retreatment, very few required general anesthesia (n = 6). CONCLUSION: Office-based urologic interventions in children are well tolerated with excellent safety and efficacy. Complications and recurrence are universally low. Ultimately, 99.5% of this cohort was managed under local anesthetics, thereby avoiding the risks of anesthesia use in the pediatric population.

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.

Upper or lower tract approach for duplex anomalies? A bi-institutional comparative analysis of robot-assisted approaches.

Optimal management of duplication anomalies may include an upper or lower tract surgical approach. In the contemporary era, the robot-assisted laparoscopic heminephrectomy (RALHN) and robot-assisted laparoscopic ipsilateral ureteroureterostomy (RALIUU) are viable interventions predicated on clinical, institutional and surgeon preferences. We present a multi-institutional comparative analysis aiming to compare the outcomes of RALHN and RALIUU to see if either of the approaches confers an advantage over the other in treating duplex renal anomalies needing intervention. We completed a retrospective review of consecutive children undergoing RALIUU at Hospital A and RALHN at Hospital B from January 2009 to March 2017. The primary outcome was 'surgical success' defined by the resolution of clinical symptoms, improved radiological parameters, and no unplanned subsequent interventions till the time of study completion. Secondary outcomes included operative parameters, complications, and subsequent urinary infections. There were 39 RALIUU and 28 RALHN. Baseline demographic and clinical parameters across two cohorts were similar. The primary outcome of 'surgical success' was 100% across both cohorts. There were no major surgical complications, and the incidence of postoperative urinary tract infection was minimal and similar for both groups. Operative time favored RALHN; blood loss and analgesic requirements were minimal in both cohorts. Both RALIUU and RALHN are definitive surgical interventions in children with complex duplex moieties, delivering satisfactory surgical outcomes with a low complication profile and marginal differences in the postoperative patient outcomes. This pilot bi-institutional study provides the basis for a larger collaboration to further define optimal techniques, standardize surgical care pathways, and interrogate long-term outcomes.

Primary vs redo robotic pyeloplasty: A comparison of outcomes.

INTRODUCTION: Robot-assisted laparoscopic pyeloplasty (RALP) is a safe and efficacious option for repair of UPJO. We hypothesize that redo-RALP is technically more difficult but has comparable outcomes to primary RALP. METHODS: An IRB-approved single institutional registry was utilized to identify all patients undergoing primary or redo RALP from 2012 to 2019. Redo RALP consisted of pyeloplasty and ureterocalicostomy (RALUC). Peri-operative and post-operative details and outcomes were aggregated. Successful reconstruction was defined as resolution of symptoms, improved hydronephrosis and no need for additional procedures. RESULTS: From 399 patients who underwent UPJO repair at our center, a total of 306 with a median age of 4.9 years at surgery and a median follow-up of 18.5 months were included: 276 primary and 30 redo (21 RALP and 9 RALUC). Redo group had significantly longer procedure time and length of stay compared to the primary group. However, no significant difference was noted in the post-operative complications, need for additional endoscopic procedures or redo reconstruction, and success between the two groups. Multivariate analysis showed that when controlled for age, gender, 30-days post-operative complication and anatomy of obstruction, redo as compared to primary reconstruction did not have a significant effect on success. DISCUSSION: This study is the largest controlled cohort in the pediatric population comparing redo RALP with an established control group -primary RALP. This retrospective chart review possesses the biases innate to any retrospective study. The low number of re-operative cases as well as low rate of failure in redo RALP further complicates identification of statistically significant predictors of outcomes following redo RALP. CONCLUSION: Redo RALP is an efficient and safe approach for reconstruction of recurrent UPJO, with low complication rate and high success rate, comparable to primary RALP.

Pyeloplasty is a safe and effective surgical approach for low functioning kidneys with ureteropelvic junction obstruction.

INTRODUCTION: Indications for treatment of ureteropelvic junction obstruction (UPJO) include symptomatic obstruction, urinary tract infections, presence of an obstructive pattern on functional renal scan and/or worsening differential renal function (DRF). This paper aims to determine the relationship between preoperative DRF and surgical outcomes after pyeloplasty. We hypothesized that low preoperative DRF is not an independent predictor of pyeloplasty failure. METHODS: A retrospective chart review was performed to identify all patients undergoing pyeloplasty for UPJO between 2008 and 2019. Patients were included only if they had at least one preoperative functional scan and a minimum of one renal ultrasound post-operatively. Patients were divided into three groups based on DRF for analysis: Group 1- 0-10%, Group 2 - >10-≤20%, Group 3 - >20%. Baseline, intraoperative and postoperative characteristics, including success and complications were compared. Additional sensitivity analyses were performed comparing patients with ≤20%, and >20% function, ≤30%, and >30% function as well as an analysis of patients undergoing only minimally invasive reconstruction. RESULTS: Three hundred and sixty-four patients met inclusion criteria. We identified 8 patients in Group 1, 24 patients in Group 2 and 332 patients in Group 3. Mean procedure time was longest for the ≤10% function group (237.9 vs 206.4 vs 189.1; p = 0.01). We found no difference in 30-day post-operative complications, overall success rate or the need for additional procedures among the three groups. For patients in Group 1, we noted variation in the post-procedure DRF with a range of -2.8 to +47% change. In this group, none of patients with low DRF underwent nephrectomy. Multivariate logistic regression did not identify renal function as a predictor of operative success OR 1.00 (95% CI: 0.97-1.03) (p-value: 0.88). DISCUSSION: The results of the present study suggest that low DRF alone is not associated with worse outcomes and shows no difference in the failure rate. The incidence and type of complications were not increased for the lower functioning groups. The main limitation of this study would be its retrospective nature and single-institution experience. Furthermore, post-operative functional studies were not available for all patients, limiting the ability to draw conclusions on the change in DRF after surgery. CONCLUSIONS: In a large cohort, preoperative DRF was not predictive of pyeloplasty success rate. DRF ≤10% was not associated with higher incidence of complications or failure rate. The DRF alone should not dictate the management options available for patients with UPJO.

Robotics in Pediatric Urology: Evolution and the Future.

Almost 30 years have passed since the inception of minimally invasive surgery in urology and specifically in pediatric urology. Laparoscopy has now become an essential tool in the pediatric urologic armamentarium. The application of robot-assisted surgery in pediatrics has allowed for widespread utilization for common reconstructive procedures such as pyeloplasty and ureteral reimplantation. Understanding the implementation, technical considerations, and outcomes are critical for continued success and adoption. This has allowed for increased use in more complex urologic procedures such as redo pyeloplasty, dismembered ureteral reimplantation, catheterizable channel creation, and bladder augmentation.

Utilization of Robot-assisted Surgery for the Treatment of Primary Obstructed Megaureters in Children.

OBJECTIVE: To describe the technical aspects of robot assisted laparoscopic ureteral reimplantation (RALUR) for the management of primary obstructive megaureter (POM) and report initial outcomes, safety, and feasibility of the procedure. METHODS: Using an IRB- approved robotic surgery registry, we performed a retrospective chart review of patients undergoing RALUR for POM between April 2009 and May 2019. RESULTS: A total of 18 patients underwent RALUR using a modified Lich-Gregoir technique for management of POM and 7 (38.9%) of these underwent intracorporeal ureteral tapering at the time of surgery. At median follow up of 27.5 (IQR 11-50) months, no patient required reoperation for recurrent obstruction and all patients had improvement in hydronephrosis postoperatively. 30-day complications were low with 1 Grade I, 2 Grade II and 1 Grade III Clavien-Dindo complication. The most common issue postoperatively was febrile urinary tract infection, occurring in 6 patients (33.3%), at an average of 3.2 months after surgery. Increased operative time was the only significant difference between the tapered verses nontapered group. CONCLUSION: We present the largest series of RALUR for POM to date. Based upon our initial experience with this technique we believe it is technically feasible and reproducible with good outcomes and low complication rates. Future studies are needed to track long-term outcomes and better understand indications for and the utility of ureteral tapering as well as how to minimize febrile UTIs postoperatively. Additional follow up is needed to determine the efficacy of RALUR as compared to open ureteral reimplantation for POM.

Awareness, Knowledge, and Attitude of Saudi Students towards Basic Life Support: A Cross-Sectional Study

ABSTRACT Objective: To evaluate the knowledge and attitude in relation to basic life support (BLS) and cardiopulmonary resuscitation (CPR) skills among the dental undergraduates and interns in Sakaka, Saudi Arabia. Material and Methods: This cross-sectional study was undertaken between October 2019 and December 2019 in Sakaka, Saudi Arabia. One hundred and eighty randomly selected dental students aged over 18 years participated in the study. Their knowledge and attitude towards BLS were gathered through a questionnaire. Results: A total of 158 (out of 180) UG students and interns participated in this study, making the responses of 87.8%. The mean age of the participants was 24.6 years. The samples comprised 86 (54.4%) males and 72 (45.6%) females. The assessments showed that overall the participants had average knowledge towards BLS and CPR, with males responding significantly better than the females (p˂0.05). Furthermore, as students climb the academic ladder, their knowledge regarding BLS and CPR tends to rise. Also, their attitude was positive, and they were willing to receive CPR training. Conclusion: Attitude toward acquiring knowledge about CPR was very positive. However, their knowledge about the topic was average. Students should understand the importance of such skills and efficiently involve in these life-saving procedures.

Reducing post-operative opioids in children undergoing outpatient urologic surgery: A quality improvement initiative.

INTRODUCTION: Opioid prescriptions have been implicated as one of the proximate causes of the national opioid epidemic. Children and adolescents and their families are at risk for increased opioid exposure through prescriptions after surgery. In pediatric urologic surgery, indications for postoperative opioids can vary widely and a focus on opioid stewardship is important to reduce potential harms. OBJECTIVE: To measure the efficacy of a quality improvement initiative aimed to reduce post-operative opioids for pain management in a large pediatric surgical cohort. STUDY DESIGN: Patients undergoing ambulatory pediatric urologic surgery at a tertiary children's hospital between July 2016 to June 2019 were analyzed. Structured physician peer-to-peer comparisons, electronic health record redesign and a standardized pain management protocol were implemented. Rate of opioid prescriptions per month, utilization of non-opioid analgesia, unplanned encounters in the emergency department and/or office during implementation were aggregated. Opioid doses and prescribed opioid days before and after protocol implementation were analyzed. A subcohort, from October-December 2018 was administered a patient-reported outcome questionnaire focused on pain management and return to baseline activity. RESULTS: A total of 6684 consecutive outpatient urologic cases were included (median age = 3.3 years old (IQR 0.9-9.2) and 92.3% male). Comparing 6 months pre-intervention and the post-intervention latest 6 month intervals, opioid prescription rate decreased from 43.9% to 2.3% (p < 0.001). Additionally, non-opioid analgesia with ketorolac increased from 30.7% to 50.6% (p < 0.001). Concurrently, no differences in the rate of office visits within 5 days, overall ED visits, ED visits for pain or for bleeding within 30 days after implementation were identified. Between October to December 2018, 373 cases were performed and a Patient-Reported Outcome (PRO) questionnaire was completed for 128 of those patients (34%). Families reported a low patient pain score of 3.7 (SD 2.4) and a rapid postoperative recovery time of a median 2 (IQR 1-4) days to full resumption of pre-operative level of activity. High satisfaction with opioid reduction in post-operative pain management was reported (median score of 10 (IQR 8-10)). CONCLUSION: Opioid prescriptions and utilization may be minimized without increasing unplanned encounters or adversely affecting quality of life. The QI framework utilized in this process can be implemented to reduce opioid exposure in other surgical patient populations.

Calyceal diverticula in children: laparoscopic marsupialization is the optimal intervention.

BACKGROUND: Calyceal diverticula (CD) are abnormally dilated calyces caused by a narrowed infundibulum. Although rare, with incidence rates previously reported between 0.21% and 0.45%, CD pose diagnostic dilemmas in children as they mimic other cystic lesions of the kidney with different etiologies. Calyceal diverticula can become symptomatic if they become a locus for infections and stone formation, and the optimal treatment strategy is currently undefined. OBJECTIVE: The aim of the study is to present a large series of consecutive cases of pediatric CD and investigate the authors' hypothesis that CDs are more common than previously reported, size of the lesion drives intervention, and laparoscopic ablation is the most effective intervention. STUDY DESIGN: The authors conducted an observational case-control survey by reviewing all cases of pediatric CD through a prospectively maintained database of renal cystic lesions at their institution between 2012 and 2018. They analyzed the clinical and radiological presentation and description of symptoms with particular emphasis on the outcomes of ureteroscopic or laparoscopic surgical interventions. RESULTS: Of 757 renal cysts evaluated in the pediatric urology clinics at the authors' institution, there were 43 (5%) cases of CD confirmed by cross-sectional imaging or retrograde pyelogram. The median age was 12 years. There was a female preponderance (67%), and 14% were bilateral. Twenty-five of 43 children underwent surgery (58%). On multivariate analysis, the size/complexity of the cyst (odds ratio = 2.13, 1.02 to 4.4, P = 0.04) and the presence of pain (5.931, 1.36 to 25.87, P = 0.018) were found to correlate with the need for intervention. Ureteroscopic intervention (i.e., balloon dilatation, laser incision, or diathermy incision) was the most used index procedure (17/25), followed by laparoscopic ablation (6/25), with success rates of 40% and 100%, respectively (P = 0.01). Complications in either of the approaches were usually mild and similar (P = 0.63). The majority of ureteroscopic interventions required multiple sessions (11/17, 65%, median = 2 major procedures) to achieve resolution, whereas none in the laparoscopic group required a second procedure. There were a total of 30 ureteroscopic and 8 laparoscopic approaches. CONCLUSIONS: The authors demonstrate that CD comprise at least 5% of cystic lesions and that CD size and pain at presentation predict intervention in 60% of children diagnosed at their institution. Laparoscopic ablation is the optimal treatment and has significantly higher success rates than the ureteroscopic approach.

Robotic surgery in infants and children: an argument for smaller and fewer incisions.

PURPOSE: Robotic-assisted laparoscopic (RAL) surgery has gained momentum in pediatric urology. Technological adaptations such as the development of 5 mm instruments have led to robotic procedures being performed on younger children and those having smaller body habitus, with improved cosmesis. However, concerns have been raised regarding decreased intra-abdominal working space and the absence of monopolar curved scissors (hot endoshears®) when using 5 mm instruments. The aim of this study is to examine the overall experience at a single pediatric urology center using 5 mm instruments with no planned additional assistant ports during common robotic procedures. We hypothesized this approach is safe and feasible for a variety of pediatric urologic reconstructive procedures. METHODS: We retrospectively reviewed all major robotic procedures entered into an IRB approved data registry. The analysis was performed only for procedures in which 5 mm instruments were used exclusively with hook diathermy. Procedures that utilized 8 mm instrumentation were excluded from the study. Data were abstracted according to patient age, weight and robotic surgery performed. Outcomes included post-operative complications (Clavien-Dindo classification), operative time, operative blood loss, need for assistant port placement and conversion rates to open or pure laparoscopic surgery. RESULTS: From 2012 to 2016, 220 consecutive pediatric RAL urological surgical cases were performed on 201 patients. These comprised pyeloplasty (n = 102) 46.4%, ureteral reimplants (n = 84) 38.2% and ipsilateral ureteroureterostomy (n = 34) 15.5%. Median age at surgery was 4 years (3 months to 18 years). There were no conversions to open or laparoscopic surgery. Placement of an additional Assist port was documented in seven cases. Severe (Clavien grade 4) complications occurred in two patients requiring ICU admission: one for sepsis and one ventilator-dependent patient having increased work of breathing post-op. Intra-operative blood loss was minimal ( < 50 ml) in 97% of cases. Patients ≤ 1 year of age comprised 28.6% of the study population. Univariate analysis revealed no association between age and occurrence of complications (p = 0.957) CONCLUSIONS: This study represents one of the largest series of consecutive RAL surgery using 5 mm instruments in pediatric urology. Acceptable complication rates, OR times and blood loss were achieved using this technique. We conclude that the use of 5 mm instruments gives excellent operative outcomes in pediatric reconstructive procedures.

The Robot-Assisted Extravesical Anti-reflux Surgery: How We Overcame the Learning Curve.

Management of vesicoureteral reflux (VUR) has evolved over the past several decades, with a trend toward a decrease in surgical management. In spite of this, ureteral reimplantation remains a commonly performed procedure by pediatric urologists in selected cases. Although the basic tenets of the ureteral reimplant procedure remain the same, the extra- vs. intravesical approach, and the traditional open vs. minimally invasive approach remain the primary options to correct reflux. Considering the advantages conferred by the robotic surgery platform, many leading centers have preferentially adopted robot-assisted laparoscopic extravesical anti-reflux surgery, or in common surgical parlance, the robot-assisted laparoscopic ureteral reimplantation (RALUR), over pure laparoscopic or open approaches. Predicated on our experience of performing over 170 cases of RALUR, we have made technical modifications which we posit reduce the morbidity of the procedure while offering acceptable outcomes. This review highlights the evolution and establishment of RALUR as a standardization of care in the surgical management of VUR at our institution. In particular, we emphasize the technical nuances and specific challenges encountered through the learning curve in hopes of facilitating this process for others.