Emergent robot-to-open conversion - Multidisciplinary simulation training in crisis management.

Anticipating and addressing unexpected intraoperative events and anatomies are some of the most challenging aspects of pediatric urologic practice; uncontrolled hemorrhage is one of the most anxiety provoking and precarious. The increasing application of the robotic platform in pediatric urology adds another layer of complexity as surgeons are not immediately at the patient's bedside. Should hemorrhage occur in robotic cases, clear communication and seamless coordination between members of the operating room team are paramount to optimize patient safety and minimize errors. This is especially important in pediatric cases for which the margin of error is narrow. Non-technical skills, including leadership, decision-making, situational awareness, stress management, and team-communication, become increasingly critical. While many programs have focused on robotic training, few prepare the operating room team and surgical trainees to manage these unforeseen, emergent intraoperative scenarios. This review discusses the role of a multidisciplinary, in situ robot-to-open conversion simulation program in addressing this educational gap, ways to approach establishing these programs, and potential barriers.

Causes of death among people with myelomeningocele: A multi-institutional 47-year retrospective study.

PURPOSE: This study aimed to analyze organ system-based causes and non-organ system-based mechanisms of death (COD, MOD) in people with myelomeningocele (MMC), comparing urological to other COD. METHODS: A retrospective review was performed of 16 institutions in Canada/United States of non-random convenience sample of people with MMC (born > = 1972) using non-parametric statistics. RESULTS: Of 293 deaths (89% shunted hydrocephalus), 12% occurred in infancy, 35% in childhood, and 53% in adulthood (documented COD: 74%). For 261 shunted individuals, leading COD were neurological (21%) and pulmonary (17%), and leading MOD were infections (34%, including shunt infections: 4%) and non-infectious shunt malfunctions (14%). For 32 unshunted individuals, leading COD were pulmonary (34%) and cardiovascular (13%), and leading MOD were infections (38%) and non-infectious pulmonary (16%). COD and MOD varied by shunt status and age (p < = 0.04), not ambulation or birthyear (p > = 0.16). Urology-related deaths (urosepsis, renal failure, hematuria, bladder perforation/cancer: 10%) were more likely in females (p = 0.01), independent of age, shunt, or ambulatory status (p > = 0.40). COD/MOD were independent of bladder augmentation (p = >0.11). Unexplained deaths while asleep (4%) were independent of age, shunt status, and epilepsy (p >= 0.47). CONCLUSION: COD varied by shunt status. Leading MOD were infectious. Urology-related deaths (10%) were independent of shunt status; 26% of COD were unknown. Life-long multidisciplinary care and accurate mortality documentation are needed.

Ureteral stent extraction strings in children: Stratifying the risk of post operative urinary tract infection.

INTRODUCTION: Ureteral stents facilitate recovery and avoid external drains in pediatric ureteral reconstruction. Extraction strings avoid the need for a secondary cystoscopy and anesthetic. Due to concerns regarding febrile UTIs in children with extraction strings, we retrospectively assessed the relative risk of UTI in children with extraction strings. OBJECTIVE: Our hypothesis was that stents with extraction strings do not increase the risk of UTI after pediatric ureteral reconstruction. METHODS: Records of all children undergoing pyeloplasty and ureteroureterostomy (UU) from 2014 to 2021 were reviewed. The incidences of UTI, fever, and hospitalization were recorded. RESULTS: 245 patients mean age 6.4 years (163M:82F) underwent pyeloplasty (n = 221) or UU (n = 24). 42% (n = 103) received prophylaxis. Of these, 15% developed UTI versus 5% of those not receiving prophylaxis (p < 0.05). 42 females had prior history of UTI, compared to 20 males (p < 0.05). 49 patients had an extraction string. Stents with extraction strings were removed on average 0.6 months post-op while others underwent cystoscopic removal on average 1.26 months post-op (p < 0.05). 9 (18.4%) required hospitalization for febrile UTI while the stent with extraction string was in place, while only 13 (6.6%) of those without extraction string did (p < 0.02). Of the 9 children with a febrile UTI in the extraction string group, 6 had history of prior UTI (46.1%), compared to only 3 (8.3%) without a prior UTI (p < 0.05). With no prior UTI, there was no difference in UTI risk between those with (3, 8.3%) and without (8, 6.4%) extraction string (p = 0.71). Females with prior UTI and extraction string were more likely to develop UTI than those with prior UTI and no extraction string (p = 0.01). There were not enough males with history of UTI to analyze alone. There were 5 (10%) stent dislodgements in the extraction string group, 2 required further intervention with cystoscopy or percutaneous drainage. DISCUSSION: Extraction strings provide the assurance of drainage while avoiding the need for a second general anesthetic procedure. There is not an increased risk of UTI with extraction string in those without prior history of UTI, but we no longer routinely leave extraction strings if there is history of UTI. CONCLUSION: Children, particularly females, with prior history of UTI have a significantly increased risk of febrile UTIs associated with the use of extraction strings. Prophylaxis does not seem to reduce this risk. Patients with no prior UTI had no higher risk of UTI with extraction string use for pyeloplasty or UU.

Clinical utility and interrater reliability of video urodynamics in children with isolated fibrolipoma of filum terminale.

INTRODUCTION: Children with an isolated fibrolipoma of filum terminale (IFFT) but otherwise normal spinal cord are often evaluated with video urodynamics (VUDS). VUDS interpretation is subjective and can be difficult in young children. These patients may undergo detethering surgery if there is concern for current or future symptomatic tethered cord. OBJECTIVE: We hypothesized that VUDS in children with IFFT would have limited clinical utility regarding decision for or against detethering surgery and VUDS interpretation would have poor interrater reliability. METHODS: Patients with IFFT who underwent VUDS for from 2009 to 2021 were retrospectively reviewed to evaluate clinical utility of VUDS. 6 pediatric urologists who were blinded to patient clinical characteristics reviewed the VUDS. Gwet's first order agreement coefficient (AC1) with 95% CI was used to assess interrater reliability. RESULTS: 47 patients (24F:23M) were identified. Median age at initial evaluation was 2.8yrs (IQR:1.5-6.8). 24 (51%) patients underwent detethering surgery (Table). VUDS at initial evaluation were interpreted by treating urologist as normal in 4 (8%), reassuring for normal in 39 (81%), or concerning for abnormal in 4 (9%). Based on neurosurgery clinic and operative notes for the 47 patients, VUDS made no change in management in 37 patients (79%), prompted detethering in 3 (6%), was given as reason for observation in 7 (15%), and was normal or reassuring for normal but not documented as a reason for observation in 16 (34%) (Table). Interrater reliability for VUDS interpretation had fair agreement (AC1 = 0.27) for overall categorization of VUDS and EMG interpretation (AC1 = 0.34). Moderate agreement was seen for detrusor overactivity interpretation (AC1 = 0.54) and bladder neck appearance (AC1 = 0.46). DISCUSSION: In our cohort, 90% of patients had a normal or reassuring for normal interpretation of VUDS. VUDS interpretation affected clinical course in a minority of patients. There was fair interrater reliability for overall VUDS interpretation and therefore clinical course regarding detethering surgery could vary depending upon interpreting urologist. This fair interrater variability appeared to be related to variability in EMG, bladder neck appearance, and detrusor overactivity interpretation. CONCLUSION: VUDS affected clinical management in about 20% of our cohort and supported the choice for observation in around 50% of patients. This suggests VUDS does have clinical utility in pediatric patients with IFFT. The overall VUDS interpretation had fair interrater reliability. This suggest VUDS interpretation has limitations in determining normal versus abnormal bladder function in children with IFFT. Neurosurgeons and urologists should be aware of VUDS limitations in this patient population.

Proximal isolated congenital anterior urethrocutaneous fistula resulting in a urethral "skip" lesion.

Urethrocutaneous fistula is an unfortunate but well recognized complication of hypospadias repair surgery and traumatic injury to the penis. Congenital anterior urethrocutaneous fistula of the male urethra is an exceedingly rare phenomenon, with approximately 50 cases being reported in the literature. We report a case of proximal isolated congenital anterior urethrocutaneous fistula at the penoscrotal junction.

Splenogonadal fusion: A rare finding during routine orchiopexy.

Splenogonadal fusion remains a rare congenital anomaly, with limited reports in the literature. It is important to be aware of this benign condition as orchiectomy can result from confusion with malignant processes. We present a case of splenogonadal fusion in a 12-month-old healthy male with history of cryptorchidism found at the time of surgery.

Prospective Evaluation of Predictors of Testis Atrophy After Surgery for Testis Torsion in Children.

OBJECTIVE: To prospectively correlate pain duration, red scrotal skin, ultrasound appearance of testis, and intraoperative testis color to future testis atrophy after acute testicular torsion. METHODS: Patients 2 months-18 years old with unilateral acute scrotum were consecutively enrolled in a National Institutes of Health transcutaneous near-infrared spectroscopy study, with a subgroup analysis of the true torsion group. Presence or absence of red scrotal skin, pain duration, testicular heterogeneity on preoperative ultrasound, and intraoperative testis color based on a novel visual chart 5 minutes after detorsion were recorded. All testes underwent orchiopexy regardless of appearance. Percent volume difference between normal and torsed testicles on follow-up ultrasound was compared between patients with and without risk factors. RESULTS: Thirty of 56 patients who had surgical detorsion underwent scrotal ultrasound at a mean of 117 days after surgery. A color of black or hemorrhagic 5 minutes after detorsion, pain duration >12 hours, and heterogeneous parenchyma on preoperative ultrasound were associated with significant testis volume loss in follow-up compared with normal testis. All patients with a black or hemorrhagic testis had >80% volume loss. Erythematous scrotal skin was not significantly associated with smaller affected testis volume in follow-up. CONCLUSION: Based on the high atrophy rate, orchiectomy can be considered for testes that are black or hemorrhagic 5 minutes after detorsion. Pain duration >12 hours and parenchymal heterogeneity on preoperative ultrasound were also associated with testis atrophy. Red scrotal skin was not a reliable predictor of atrophy and should not delay exploration.

Bowel preparation prior to reconstructive urologic surgery in pediatric myelomeningocele patients.

INTRODUCTION: Mechanical bowel preparation (MBP) has historically been the standard of care for patients undergoing reconstructive urologic surgery, including urinary diversion. To date, several studies have examined the role of mechanical bowel preparation in postoperative outcomes in pediatric patients undergoing augmentation cystoplasty. However, these patient populations have been heterogeneous in nature, with no studies dedicated to examining the role of MBP prior to reconstructive urologic surgery in pediatric patients with myelomenginoceles. Thus, our objective was to retrospectively assess perioperative measures and postoperative complications after reconstructive urologic surgery with or without mechanical bowel preparation in pediatric myelomeningocele patients. MATERIALS AND METHODS: From 2008 to 2013, 80 patients with myelomeningocele underwent reconstructive urologic surgery involving the use of bowel. Seventy patients underwent a preoperative MBP while 10 did not. Perioperative measures and postoperative complications for these two cohorts were assessed. RESULTS: Eighty patients with myelomeningocele were identified; 70 patients underwent MBP while 10 patients did not. There were no statistically significant differences in demographics or operative time. There were no statistically significant differences in postoperative outcomes including time to first bowel movement and time to tolerating diet. There was also no significant difference in overall complication rate; patients with MBP had 31/70 (44%) complications while 2/10 (20%) of those without MBP had complications (p = 0.18). CONCLUSION: There was no significant difference in perioperative measures and postoperative complications for patients who did not receive a mechanical bowel preparation. Our findings indicate that it is safe and warranted to perform a prospective, randomized study to better characterize the risks and benefits of preoperative bowel preparation for patients with myelomeningocele.

Simple visual review of pre- to post-operative renal ultrasound images predicts pyeloplasty success equally as well as geometric measurements: A blinded comparison with a gold standard.

BACKGROUND: MAG3 diuretic renal scan remains the gold standard for determination of improvement in renal drainage following pyeloplasty for ureteropelvic junction obstruction. We hypothesized that (i) a change in geometric measurements between pre-operative and post-operative renal ultrasound (RUS) images and (ii) blinded simple visual review of images both would predict pyeloplasty success. OBJECTIVE: To determine if simple visual review and/or novel geometric measurement of renal ultrasounds can detect pyeloplasty failure. STUDY DESIGN: This study was a retrospective, blinded comparison with a gold standard. Included were children aged ≤18 years undergoing pyeloplasty at our institution from 2009 to 2015. For each kidney, representative pre-operative and post-operative RUS images were chosen. Our standard for pyeloplasty success was improved drainage curve on MAG3 and lack of additional surgery. Measurements for collecting system circularity, roundness, and renal parenchymal to collecting system area ratio (RPCSR) were obtained by three raters (Figure), who were blinded to the outcome of the pyeloplasty. Changes in geometric measurements were analyzed as a diagnostic test for MAG3-defined pyeloplasty success using ROC curve analysis. In addition, six reviewers blinded to pyeloplasty success reviewed pre-operative and post-operative images visually for improved hydronephrosis and categorized pyeloplasty as success or failure based on simple visual review of RUS. RESULTS: Fifty-three repaired renal units were identified (50 children). There were five pyeloplasty failures, four of which underwent revision or nephrectomy. While all geometric measurements could discriminate pyeloplasty failure and success, the geometric measurements that discriminated best between pyeloplasty failure and success were change in collecting system roundness and change in RPCSR. Consensus opinion among six blinded reviewers using simple visual review had a sensitivity of 94% and PPV of 100% with respect to identifying pyeloplasty success (AUC 0.97 (95% CI 0.93-1.0)). This was not significantly different from AUC for change in roundness (p = 0.09) or change in RPCSR (p = 0.1). DISCUSSION: Change in collecting system roundness and change in RPCSR were the most accurate geometric measurements in predicting pyeloplasty success. Simple visual review of ultrasound images for pyeloplasty success performed as well or better than geometric measurements. However, geometric measurements remain useful as a research tool or to communicate findings between clinicians. CONCLUSIONS: Complex geometric measurements of hydronephrosis or post-operative MAG3 scans are not needed if hydronephrosis is visually significantly improved, as simple visual review is highly sensitive for detecting pyeloplasty failure.

Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score.

PURPOSE: The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score uses urological history and physical examination to assess risk of testis torsion. Parameters include testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1) and high riding testis (1). While TWIST has been validated when scored by urologists, its diagnostic accuracy among nonurological providers is unknown. We assessed the usefulness of the TWIST score when determined by nonurological nonphysician providers, mirroring emergency room evaluation of acute scrotal pain. MATERIALS AND METHODS: Children with unilateral acute scrotum were prospectively enrolled in a National Institutes of Health clinical trial. After undergoing basic history and physical examination training, emergency medical technicians calculated TWIST score and determined Tanner stage per pictorial diagram. Clinical torsion was confirmed by surgical exploration. All data were captured into REDCap™ and ROC curves were used to evaluate the diagnostic usefulness of TWIST. RESULTS: Of 128 patients (mean age 11.3 years) 44 (13.0 years) had torsion. TWIST score cutoff values of 0 and 6 derived from ROC analysis identified 31 high, 57 intermediate and 40 low risk cases (positive predictive value 93.5%, negative predictive value 100%). CONCLUSIONS: TWIST score assessed by nonurologists, such as emergency medical technicians, is accurate. Low risk patients do not require ultrasound to rule out torsion. High risk patients can proceed directly to surgery, with more than 50% avoiding ultrasound. In the future emergency medical technicians and/or emergency room triage personnel may be able to calculate TWIST score to guide radiological evaluation and immediate surgical intervention at initial assessment long before urological consultation.

Perioperative and Short-Term Outcomes of Robotic vs Open Bladder Neck Procedures for Neurogenic Incontinence.

PURPOSE: Complex urological reconstruction may be facilitated by the improved magnification and dexterity provided by a robotic approach. Minimally invasive surgery also has the potential advantages of decreased length of stay and improved convalescence. We reviewed perioperative and short-term outcomes between robot-assisted and open bladder neck sling/repair with catheterizable channel in patients with neurogenic bladder. MATERIALS AND METHODS: We performed an institutional review board approved retrospective chart review of all patients who underwent open or robotic bladder neck reconstruction without augmentation cystoplasty for refractory urinary incontinence between 2010 and 2014. Age at surgery, operative time, length of stay, complications within 30 days of surgery and future continence procedures (injection of bladder neck/catheterizable channel, additional bladder neck surgery, botulinum toxin A injection) were compared between the groups. RESULTS: A total of 45 patients underwent bladder neck reconstruction (open in 26, robotic in 19) with a mean follow up of 2.8 years. There was no difference in preoperative urodynamics, age at surgery or length of stay (median 4 days in each group, p >0.9). Operative time was significantly longer in the robotic group (8.2 vs 4.5 hours, p <0.001). Three patients (16%) undergoing robotic and 3 (12%) undergoing open surgery had a complication within 30 days (p >0.9). Of patients undergoing open repair 14 (56%) underwent 23 subsequent surgeries for incontinence. By comparison, 8 patients undergoing robotic repair (42%) underwent 12 additional procedures (p = 0.5). CONCLUSIONS: Although a robotic approach may take longer to perform, it does not result in increased complications or length of stay, or worsened continence outcomes.

Long-Term Outcomes of Bladder Neck Reconstruction without Augmentation Cystoplasty in Children.

PURPOSE: Bladder outlet procedures without augmentation cystoplasty remain controversial. We hypothesized that bladder outlet procedures without augmentation cystoplasty may lead to unfavorable bladder dynamics, upper tract changes and/or continued incontinence. We reviewed long-term urodynamic, upper tract and continence outcomes following bladder outlet procedures without augmentation cystoplasty. MATERIALS AND METHODS: We retrospectively reviewed all patients who underwent bladder neck reconstruction/closure/sling without augmentation cystoplasty between 2000 and 2014. Because of variation in length of followup, we calculated the cumulative incidence and proportion of cases of upper tract and urodynamic changes, augmentation cystoplasty and subsequent continence procedures. Preoperative factors were compared between patients with and without adverse outcomes. RESULTS: A total of 109 patients underwent bladder outlet procedures without augmentation cystoplasty at a mean age of 8.5 years. At a mean of 4.9 years of followup 59 patients (54%) had undergone additional continence surgery, 20 (18%) had undergone augmentation cystoplasty, 50 (46%) manifested vesicoureteral reflux or hydronephrosis and 23 (21%) had newly diagnosed or worsening renal scarring. At augmentation cystoplasty 13 of 18 patients (72%) had upper tract changes, 15 (83%) had continued incontinence and 11 (61%) had an end fill pressure of greater than 40 cm H2O. All patients had resolution of these changes after augmentation cystoplasty. Patients who had previously undergone vesicostomy or surgery for vesicoureteral reflux were significantly more likely to undergo a subsequent augmentation cystoplasty or to show upper tract changes. CONCLUSIONS: Following bladder outlet procedures without augmentation cystoplasty the estimated 10-year cumulative incidence of augmentation cystoplasty is 30%, continence procedures 70%, upper tract changes greater than 50% and chronic kidney disease 20%. Because of these risks, careful patient selection and close followup are essential if considering a bladder outlet procedure without augmentation cystoplasty.

Success of Laparoscopic Robot-Assisted Approaches to Ureteropelvic Junction Obstruction Based on Preoperative Renal Function.

BACKGROUND AND PURPOSE: No literature exists examining the risk factors for failure after robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction (UPJO) in children. The goal of this study was to compare the success of robot-assisted pyeloplasty between UPJO kidneys with preoperative renal function <30% versus >30%. METHODS: We performed a retrospective review of all patients who underwent a robot-assisted laparoscopic pyeloplasty for UPJO at a single institution from June 2009 to September 2013 by four surgeons. A failed procedure was defined as necessitating a second surgery for the UPJO, nonresolution of symptoms with no improvement of washout on postoperative mercaptoacetyltriglycine (MAG)-3 scan, and/or a reduction in renal function of the obstructed kidney to <10%. Success was compared between patients with <30% and >30% preoperative differential renal function via the Fisher exact test. RESULTS: There were 116 patients who were included. At a mean follow-up of 507 days after the surgical procedure, there were eight (8%) failures. The majority of the failures (5/8) were in kidneys whose preoperative function was <30%. There was a significant difference in the success of procedures performed on kidneys with >30% (86/89, 97%) versus <30% (7/12, 58%) preoperative renal function (P=0.0005). CONCLUSIONS: In this large cohort of patients, kidneys with preoperative function >30%, robot-assisted pyeloplasty had a 97% success rate. This was significantly different than the success of robot-assisted pyeloplasty (58%) in kidneys with preoperative function <30%. This information is useful for patient counseling as these patients may be at higher risk for a secondary procedure such as a subsequent nephrectomy or may benefit from a preoperative trial of nephrostomy tube drainage.

Comparison of Complications of Robot-Assisted Laparoscopic and Open Appendicovesicostomy in Children.

PURPOSE: Robot-assisted laparoscopic appendicovesicostomy in children has become increasingly popular. However, the literature on this technique mainly consists of small case series with only 1 small comparison to an open cohort. We compared the number of complications and surgical revisions required with open and robotic surgery in children undergoing appendicovesicostomy at our institution. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients who underwent appendicovesicostomy by 3 surgeons between July 2002 and September 2013. Acute complications and surgical revisions were recorded and compared between groups with t-tests for continuous variables and Fisher exact test for categorical variables. RESULTS: A total of 28 open and 39 robotic appendicovesicostomies were included. At a mean followup of 2.7 years there was no difference in number of complications or reoperations (p = 0.788 and p = 0.791, respectively) between groups. Time to first reoperation was shorter in the robotic group. However, there was no significant difference between groups regarding number of patients who underwent reoperation within the first 12 months postoperatively (p = 0.346). CONCLUSIONS: Comparison of robotic and open appendicovesicostomy revealed no significant difference in the number of acute complications or reoperations between groups. However, the nature and timing of complications differed between groups.

Multi-institutional review of outcomes of robot-assisted laparoscopic extravesical ureteral reimplantation.

PURPOSE: We performed a multi-institutional assessment of the outcomes and complications of robot-assisted laparoscopic extravesical ureteral reimplantation for vesicoureteral reflux in children. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent robot-assisted laparoscopic extravesical ureteral reimplantation as done by 1 of 5 surgeons at Children's Medical Center, Dallas, Texas, or Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, from 2010 to 2013. Procedure failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram and/or the need for reoperation. Multivariate logistic regression was done to identify possible risk factors for failure using STATA®, version 11. RESULTS: A total of 61 patients (93 ureters) with a mean age of 6.7 years (range 0.6 to 18.0) underwent a procedure, of which 32 (52%) were bilateral. Ten patients (16%) underwent previous subureteral injection for vesicoureteral reflux. At a mean followup of 11.7 months the procedure was successful in 44 of 61 patients (72%). There were 14 cases of persistent vesicoureteral reflux (23%), 6 complications (10%) and 9 reoperations (11%). Multivariate logistic regression identified no factor that increased the risk of failure (p = 0.737). CONCLUSIONS: Compared to the literature we found a notably lower success rate for robot-assisted laparoscopic extravesical ureteral reimplantation in the hands of 5 fellowship trained, robotically experienced pediatric urologists. More than 10% of patients required at least 1 reoperation for persistent vesicoureteral reflux or a surgical complication. Our experience suggests a higher complication rate and a lower success rate for robot-assisted laparoscopic ureteral reimplantation compared to the gold standard of open reimplantation.

Laparoscopic-assisted ureteroureterostomy for duplication anomalies in children.

PURPOSE: To describe a novel laparoscopic-assisted technique for ureteroureterostomy for the surgical management of a completely duplicated collecting system with an obstructed and/or ectopic ureter. PATIENTS AND METHODS: A camera is placed through a 5-mm infraumbilical port and the duplicated ureters identified and delivered through a small inguinal incision with a laparoscopic Babcock clamp. The ureteroureterostomy is performed in an open fashion. The mean operative time, length of stay, success, and complications of nine patients who underwent this technique were reviewed and compared with a cohort of patients who underwent open ureteroureterostomy at a single institution. In addition, the existing literature on laparoscopic and robot-assisted ureteroureterostomy is reviewed. RESULTS: There were no statistically significant differences in operative time (134 vs 133 min, P=0.950), length of stay (0.32 vs 0.33 days, P=0.929), complications (2 and 2, P=0.574), or rates of success (95% vs 100%, P=1.00) between the open and laparoscopic-assisted ureteroureterostomy groups. In addition, the operative times and length of stay in our laparoscopic cohort were shorter than a majority of the laparoscopic and robotic cases reported in the literature. CONCLUSIONS: Laparoscopic-assisted ureteroureterostomy is a successful technique for the management of an ectopic and/or obstructed ureter in a completely duplicated collecting system. This technique combines the speed and ease of the open technique with the improved cosmesis and visualization of a laparoscopic approach and is thus a useful approach for the pediatric urologist.

Demographics of pediatric renal trauma.

PURPOSE: There is a lack of national data describing the demographics and nature of pediatric renal trauma. We used the National Trauma Data Bank to analyze mechanisms and grades of injury, demographics and treatment characteristics of pediatric renal trauma cases. MATERIALS AND METHODS: Renal injuries were identified by Abbreviated Injury Scale codes and converted to American Association for the Surgery of Trauma renal injury grades. Patients were stratified by age (0 to 1, 2 to 4, 5 to 14 and 15 to 18 years) for more specific analyses of mechanisms and grades of injury. Data reviewed included mechanisms and grades of renal injury, demographics, and setting and type of treatment. RESULTS: A total of 2,213 pediatric renal injuries were converted to American Association for the Surgery of Trauma grade. Mean ± SD age at injury was 13.7 ± 4.4 years, with 2,089 patients (94%) being 5 to 18 years old. Of the injuries 79% were grade I, II or III. Penetrating injury accounted for less than 10% of all pediatric renal injuries. A majority of patients (57%) were admitted to university hospitals with a dedicated trauma service (73%) and only 12% of patients were admitted to a pediatric hospital. A total of 122 nephrectomies (5.5%) were performed. CONCLUSIONS: Most renal trauma in children is low grade, is blunt in nature and occurs after age 5 years. The majority of these cases are managed at adult hospitals. Although most patients are treated conservatively, the rate of nephrectomy is 3 times higher at adult hospitals than at pediatric centers.

Reinnervating the penis in spina bifida patients in the United States: ilioinguinal-to-dorsal-penile neurorrhaphy in two cases.

INTRODUCTION: Penile sensation is absent in some patients with myelomeningocele owing to the dysfunction of the pudendal nerve. Here, we describe the introduction of penile sensation via ilioinguinal-to-dorsal-penile neurorrhaphy in two patients with penile anesthesia due to neural tube defects. AIM: To establish penile sensation via ilioinguinal-to-dorsal-penile-nerve neurorrhaphy. METHODS: A 20-year-old and a 35-year-old male with L5/S1 myelomeningocele were both highly functioning and ambulatory, with intact ilioinguinal nerve distribution sensation but anesthesia of the penis and glans. They were sexually active and able to ejaculate antegrade. Both had high International Index of Erectile Function scores for confidence to achieve erection sufficient for intercourse. An incision was made from anterior superior iliac crest to the glans penis to expose the inguinal canal and ilioinguinal nerve. The ilioinguinal and dorsal penile nerve were transected and anastomosed. The anastomotic site was then wrapped in a hemostatic agent and a drain was left in place. For penile rehabilitation, both patients were instructed to stimulate the penis while looking at the genitalia to encourage redistribution of perceived sensation. MAIN OUTCOME MEASURES: Presence of erogenous penile sensation was tested by neurologic examination and patient feedback, and patients completed sexual health questionnaires. RESULTS: Both patients reported paresthesias of the groin with penile stimulation 1 month after surgery. Both patients are now 24 months postoperative and have erogenous sensation on the ipsilateral glans and shaft during intercourse. Neither patient has difficulty achieving or maintaining erections. CONCLUSIONS: We present two patients with dorsal penile reinnervation via the ilioinguinal nerve. Although nerve reinnervation has been used in urological procedures, this is the first description of an attempt to resupply penile sensation via the dorsal penile nerve in the United States with a minimum of 18 months follow-up. Early follow-up suggests successful neuronal remapping and regained sensation of the penis.

Practice variation and clinical confusion regarding undescended testes and retractile testes among primary care respondents: a multi-regional survey study in the United States.

PURPOSE: Although previous studies have looked at referral patterns and indications for orchiopexy, this is the first attempt at quantifying the primary care provider knowledge base of cryptorchidism and its implications in a large multi-state setting in the United States. METHODS: Primary care providers (PCPs) (n = 3,000) were invited to complete a web-based survey regarding cryptorchidism. We evaluated: practice setting; training; knowledge of cryptorchidism; relationship to pediatric urologists and surgeons; understanding of the relationship between cryptorchidism, infertility and testis cancer. RESULTS: Seventeen percent (n = 453) of PCPs responded to the survey. Fifty-three percent indicated that they had minimal to no exposure to pediatric urology during training. Two-thirds refer patients with retractile testes to surgical specialists. Practice setting was associated with the type of information families received about the impact of UDT on fertility and malignancy with rural practices being more likely to counsel that unilateral UDT imparted a high risk of malignancy (RR 1.5; 95 % CI 1.2, 1.9) and bilateral UDT resulted in likely infertility (RR 2.1; 95 % CI 1.5, 2.8). CONCLUSIONS: This study underscores the need for increased evidence-based recommendations, as well as improved training and education of PCPs in the US who deal with disorders of testicular descent.

Conservative management vs early surgery for high grade pediatric renal trauma--do nephrectomy rates differ?

PURPOSE: Guidelines for management of pediatric high grade renal injuries are currently based on limited pediatric data and algorithms from adults, for whom initial nonoperative management is associated with decreased nephrectomy risk. Using a national database, we compared nephrectomy rates between children with high grade renal injury managed conservatively and those undergoing early surgical intervention. MATERIALS AND METHODS: All children with high grade renal injuries were identified in the National Trauma Data Bank®. High grade renal injuries were defined as American Association for the Surgery of Trauma grade IV or V renal injuries. After excluding fatalities within 24 hours of hospitalization, 419 pediatric patients comprised our study cohort. A total of 81 patients underwent early (within 24 hours of hospitalization) surgical intervention, while 338 were initially treated conservatively. Using stratified analysis with adjustment for relevant covariates, we compared nephrectomy rates between these groups. RESULTS: Nephrectomy was performed less often in patients treated conservatively (RR 0.24, 95% CI 0.16 to 0.36, adjusted for age, renal injury grade and injury mechanism). The decreased risk of nephrectomy was more marked among children with grade IV vs grade V renal injuries (adjusted RR 0.16, 95% CI 0.08 to 0.23). Multiple procedures were more common in patients initially observed. Of pediatric patients with grade IV and V renal injuries 11% still underwent nephrectomy. CONCLUSIONS: Conservative management of high grade renal injuries is common in children. Although mechanism of injury and renal injury grade impact initial clinical management decisions, the risk of nephrectomy was consistently decreased in children with high grade renal trauma managed conservatively regardless of injury characteristics.