Time to therapy and safety of testicular tissue cryopreservation in children undergoing gonadotoxic treatment or hematopoietic stem cell transplant.

BACKGROUND: With the use of multimodal treatments and hematopoietic stem cell transplant, the majority of children diagnosed with malignancies and hematologic diseases are now surviving into adulthood. Due to the gonadotoxic effects and potential for future infertility associated with many of these treatments, fertility counseling with sperm cryopreservation prior to starting therapy is the standard of care for post-pubertal males. Unfortunately, the options are limited for pre-pubertal patients or those unable to provide a specimen. Testicular tissue cryopreservation (TTC) is an investigational method to surgically obtain germ cells from testicular tissue and potentially restore future spermatogenesis. While TTC has been shown to be safe, little is reported on the time to treatment following the procedure to ensure adequate wound healing and avoid delays in definitive therapy. OBJECTIVES: The primary outcome was the time to initiation of treatment following TTC. Secondary outcomes were complication rates, delays in treatment due to TTC, and presence of germ cells. METHODS: We conducted a single-institution retrospective cohort study of patients undergoing TTC between 2017 and 2023. Patients at significant risk for treatment related infertility based on established criteria were eligible for TTC. Patients were excluded if they received their oncology or hematology care elsewhere. All patients were enrolled in an IRB approved research protocol with 75% of the tissue submitted for cryopreservation and 25% for research purposes. Time to therapy was defined as the first receipt of gonadotoxic treatment following TTC. RESULTS: A total of 122 patients (53 = malignant, 69 = non-malignant) underwent TTC with a median age of 5.9 years (IQR 2.3-9.35). Germ cells were identified in 115 (94%) specimens. A total of 109 (89%) patients underwent concomitant procedures. The median time to initiation of therapy was 5 (IQR 1.0-7.0) and 7 days (IQR 6.0-13.0) for malignant and non-malignant disease, respectively. The 30-day surgical complication rate was 2.5% and was similar between malignant vs non-malignant diagnoses (p = 0.58). All surgical complications were managed non-operatively. No patients had a delay in definitive treatment due to concern for wound healing or complications. DISCUSSION: Our surgical complication rates are similar to previous studies and are not affected by the time to treatment following TTC. Limitations of the study are its retrospective design, single institution, and short-term follow up. CONCLUSION: TTC can be performed safely, efficiently, and in conjunction with other necessary procedures without resulting in delays of definitive treatment. TTC affords the opportunity for fertility preservation in children who have no other options.

Reoperative Anorectal Procedures in Patients with Anorectal Malformations - Is Bladder Function Affected?

BACKGROUND: Anorectal malformations (ARM) are associated with neurogenic bladder. The traditional surgical ARM repair is a posterior sagittal anorectoplasty (PSARP), which is believed to have a minimal effect on bladder dynamics. However, little is known about the effects of reoperative PSARP (rPSARP) on bladder function. We hypothesized that a high rate of bladder dysfunction existed in this cohort. METHODS: We performed a retrospective review of ARM patients undergoing rPSARP at a single institution from 2008 to 2015. Only patients with Urology follow-up were included in our analysis. Data was collected regarding original level of ARM, coexisting spinal anomalies and indications for reoperation. We assessed urodynamic variables and bladder management (voiding, CIC or diverted) before and after rPSARP. RESULTS: A total of 172 patients were identified, of which 85 met inclusion criteria with a median follow-up of 23.9 months (IQR, 5.9-43.8 months). Thirty-six patients had spinal cord anomalies. Indications for rPSARP included mislocation (n = 42), posterior urethral diverticulum (PUD; n = 16), stricture (n = 19) and rectal prolapse (n = 8). Within 1 year following rPSARP, 11 patients (12.9%) had a negative change in bladder management, defined as need for beginning intermittent catheterization or undergoing urinary diversion, which increased to 16 patients (18.8%) at last follow-up. Postoperative bladder management changed in rPSARP patients with mislocation (p < 0.0001) and stricture (p 0.005) but not for rectal prolapse (p 0.143). CONCLUSIONS: Patients who undergo rPSARP warrant especially close attention for bladder dysfunction as we observed a negative postoperative change in bladder management in 18.8% of our series. LEVEL OF EVIDENCE: Level IV.

Outpatient Robotic Surgery in Pediatric Urology: Assessment of Feasibility and Short-Term Safety.

PURPOSE: Robotic reconstructive and extirpative procedures have been widely utilized for surgical management of various conditions in pediatric urology. Outpatient laparoscopic surgery has become the standard in cases of orchidopexy, inguinal hernia repair and varicocelectomy. There is a growing body of evidence that robotic surgery for more complex conditions can also be performed in an outpatient setting. The aim of the study was to assess the short-term safety and feasibility of robotic reconstructive and extirpative procedures for various pediatric urological conditions as scheduled outpatient procedures. MATERIALS AND METHODS: Demographic information and perioperative data were prospectively collected in an institutional database for all pediatric patients undergoing outpatient robotic surgery from June 2012 to December 2019. Primary outcomes included rates of 30-day complications, emergency room visits and readmissions. RESULTS: A total of 135 pediatric patients underwent robotic procedures in an outpatient setting. The majority underwent pyeloplasty (62) or extravesical ureteral reimplantation (55). Ten patients underwent ureteroureterostomy and 8 patients underwent extirpative procedures (nephrectomy, hemi-nephrectomy). Median age at surgery was 62 months (IQR, 27-99), median weight was 20 kg (IQR, 12-30) and median body mass index was 17 (IQR, 15-18). During the 30-day followup period there were 9 complications (6.7%), of which only 1 (0.7%) was high grade (Clavien-Dindo 3). There were 9 emergency room visits (6.7%) including 5 cases of readmission (3.7%). CONCLUSIONS: Robotic reconstructive and extirpative procedures in pediatric urology can be safely performed as scheduled outpatient procedures in the majority of patients, obviating the need for routine inpatient care.

Diagnosis, management and recurrence rates of Mitrofanoff polyps.

BACKGROUND: Intraluminal polyps are a known complication following creation of a urinary continent catheterizable channel (Mitrofanoff). These polyps can lead to difficult catheterizations in addition to symptomatic bleeding. However, there is limited data available regarding management and outcomes of these polyps. We aim to describe clinical presentation and management of a large series of polyps occurring in a Mitrofanoff channel. METHODS: We performed a retrospective review of all patients that were treated for polyps in a Mitrofanoff at our institution. Information was collected regarding presenting symptoms, management and recurrence rates of the polyps. RESULTS: A total of 24 patients were identified that fulfilled inclusion criteria. The majority of these polyps developed in channels composed of appendix (87%), while only 3 patients (13%) had polyps develop in an ileal composed channel. Thirteen (54%) of these polyps were incidentally diagnosed while 11 patients presented with a variety of symptoms such as difficulty in catheterization, bleeding with catheterization or both difficulty catheterizing and bleeding. For management of the polyps, a cystoscopy was performed and snaring the polyp with stone basket was performed in 37%, energy was applied to base to remove polyps in 33%, 16% were fulgurated and only 13% were left in situ. All procedures were performed under general anesthesia and all of the pathology was benign showing chronic inflammatory tissue. Eight polyps (33%) recurred after initial treatment. DISCUSSION: We did not observe an asymptomatic channel polyp convert to a symptomatic during our follow up period. Our experience has led us to not intervene on all asymptomatic Mitrofanoff polyps encountered during cystoscopy under assumption they will inevitably become symptomatic. Although we admit our follow up period may not be long enough to make this a universal declaration of best practice when any Mitrofanoff polyp is diagnosed. Endoscopic treatment was effective minimally invasive method to address the symptomatic polyp rather than excision and construction of new channel. CONCLUSIONS: This is the largest series to date of polyps developing in urinary continent catheterizable channels. The majority of these polyps were encountered incidentally however symptomatic polyps presented with difficulty with catheterizations. Symptomatic polyps can be managed endoscopically but recurrence of the polyp can occur.

Outcomes according to channel type for continent catheterizable channels in patients undergoing simultaneous urinary and fecal reconstruction.

INTRODUCTION: When creating a continent catheterizable channel (CCC) the choice of bowel segment used as the conduit should be tempered with the morbidity associated with it. The split-appendix technique allows the creation of both a urinary and fecal CCC without the need for a bowel anastomosis. However, there is concern that by splitting the appendix there is compromise to its blood supply and may affect outcomes. We aim to compare what affect the bowel segment used for urinary and fecal CCCs has on perioperative and long-term outcomes in patients undergoing simultaneous urinary and fecal reconstruction. METHODS: A retrospective review was performed analyzing all patients that underwent simultaneous continent catheterizable urinary and fecal CCC between the years 2010-2016. Patient demographics, channel characteristics, perioperative complications and clinical success rate were analyzed. RESULTS: A total of 106 patients were identified that had simultaneous fecal and urinary CCC created at time of reconstruction. For urinary CCC, there were 64 patients (60.4%) that underwent a split-appendix technique, 27 patients (25.4%) underwent a Monti, and 15 patients (14.2%) had the appendix used only for the urinary channel. Those patients undergoing a split-appendix technique had median operative time of 447 min compared to 619 min when a Monti channel was created. The median length of hospital stay was 9 days for the split-appendix technique compared to 12 and 13 day median hospital stay when the appendix was used only for the urinary channel or a Monti was created, respectively. There was no difference seen in revision free survival of the channel following surgery of any of the channels with median follow-up of 44.5 months. However, there were more subfascial revisions of urinary CCC in those that underwent a Monti (5 patients, 18.5%) compared to other bowel segments (0 patients). CONCLUSIONS: Utilizing a split-appendix approach for creation of urinary and fecal CCCs does not affect 30-day complications or long-term revision rates compared to other established techniques. This technique minimizes the potential surgical morbidity of a bowel anastomosis and provide shorter operative times, when feasible, at time of simultaneous creation of fecal and urinary CCC.

Clinical urologic and urodynamic outcomes in patients with anorectal malformation and absent vagina after vaginal replacement.

INTRODUCTION AND OBJECTIVES: Anorectal malformations (ARMs) represent a complex spectrum of anorectal and genitourinary anomalies and a paucity of evidence is available on long-term urologic outcomes in all ARM subtypes. It was our subjective bias from being a referral center for ARM patients that the subtype of rectovestibular fistula and absent vagina had higher risk of renal and bladder abnormalities than typical rectovestibular fistula patients. Therefore, to confirm or refute our clinical suspicions, the purpose of this study was to review this specific cohort of ARM patients and describe both the clinical urological and urodynamic outcomes. METHODS: A retrospective cohort study was performed for 120 patients who were treated for ARM and vaginal replacement at our institution between 1991 and 2017. Fifteen patients with rectovestibular fistula and absent vagina were included in our review. Demographic and clinical data were abstracted from their medical records, including urodynamic findings, need for clean intermittent catheterization (CIC), urinary continence, and renal function. RESULTS: Vaginal replacement surgery was undertaken concomitantly with ARM repair in 10 of the 15 patients (67%). One patient was lost to follow up, and mean follow up postoperatively was 39 months. In all but one patient, rectum or colon was used as the substrate for vaginal replacement. Of the 15 patients, 13 had continence data available. A total of 10 patients (77%) were able to achieve social continence. Overall six patients used CIC to manage their bladder and 40% of continent patients used CIC. Urinary continence outcomes in patients who had partial vaginal replacement compared to those with total vaginal replacement did not reveal a clinically significant difference. Continence was achieved in 3/4 patients (75%) with a history of tethered cord compared to 7/9 patients (78%) without a history of tethered cord release. Urodynamics were performed postoperatively in 7 of the 157 patients (47%). Uninhibited detrusor contractions (UDCs) were present in 3 out of 7 patients, and a cystometric capacity greater than expected was noted in 4 patients. Additionally, 2 patients had end filling detrusor pressure greater than 40 cm H2O. GFR data were available for 13 of the 15 patients and (85%) were classified as chronic kidney disease (CKD) stage I or not having any significant loss of renal function. CONCLUSIONS: In this cohort of rectovestibular fistula and absent vagina, 77% reported achieving urinary continence. However CIC was employed in 40% of the patients which is higher than prior published noncloaca female ARM patient population. Urodynamic abnormalities were noted when performed and led to change in bladder management. Renal function measured with GFR was normal in 85%. Patients with rectovestibular fistula and absent vagina benefit from urologic screening given higher rates of lower urinary tract dysfunction that can require CIC to protect the upper urinary tract and achieve urinary continence. TYPE OF STUDY: Case series. LEVEL OF EVIDENCE: Level IV.

Long-Term Follow-Up of Laparoendoscopic Single-Site Partial Nephrectomy for Nonfunctioning Moieties of Renal Duplication and Fusion Anomalies in Infants and Children.

Objectives: To report on long-term follow-up and outcomes of infants and small children who have undergone laparoendoscopic single-site (LESS) partial nephrectomy to manage upper urinary tract duplication and fusion anomalies. Materials and Methods: A retrospective review was performed evaluating outcomes of pediatric patients who underwent LESS partial nephrectomy for upper urinary tract duplication and fusion anomalies from January 2012 to July 2015, by a single surgeon at a tertiary pediatric referral center. Demographic and perioperative data were reviewed as well as follow-up imaging. Descriptive statistics were used for analysis. Results: A total of 18 patients were identified. Additional access was used for two patients to complete the procedure. Median follow-up was 39 months. No short-term complications were encountered. Three patients were noted to have abnormal postoperative ultrasounds: two perinephric fluid collections and one atrophy of the remaining ipsilateral moiety. One fluid collection resolved completely, and the other decreased in size. Complete atrophy of the ipsilateral moiety occurred. No secondary procedures were required. Conclusions: LESS partial nephrectomy is safe for renal duplication and fusion anomalies with good long-term outcomes. Although it can be safely performed, it is a technically demanding procedure and has been discontinued in favor of robotic partial nephrectomy.

Does a Multidisciplinary Pediatric Stone Center Improve Outcomes?

INTRODUCTION: Urolithiasis is becoming more prevalent in children in the United States. A multidisciplinary pediatric stone center was initiated in 2014 to address this growing public health issue. The purpose of this manuscript is to assess the development of the stone center and its clinical outcomes. METHODS: A retrospective cohort study was performed to assess clinical outcomes. Inclusion criteria included patients younger than 21 years of age with more than 6 months of followup. Data abstracted from the medical record included patient demographics, medications, imaging, metabolic evaluations, surgical procedures, and emergency department visits. The number of surgical procedures, emergency department visits, and computerized tomography scans were compared before and after the first visit to the stone center. RESULTS: A total of 353 patients were evaluated in the stone center during the study period, 264 (98 male, 166 female) of whom met inclusion criteria. The mean age was 14.5 years, and the mean followup was 1.1 years. Of all patients 60% had a metabolic abnormality. Prior to the first visit 104 patients underwent surgery. Surgical procedures decreased from 39% to 17% during the year before and at any time after the first visit (p <0.0001). Emergency department visits per year decreased from 1.4 to 0.6 before and after the first visit (p <0.0001). Computerized tomography scan use decreased from 32% to 24% (p=0.3). CONCLUSIONS: A multidisciplinary stone center can be a feasible option to coordinate care and improve clinical outcomes. In our series the number of surgical procedures and emergency department visits decreased after enrollment.

Risk of Reaugmentation after Enterocystoplasty Using a Reconfigured Bowel Segment in Patients with Spina Bifida: A Bi-Institutional Cohort Study.

PURPOSE: Reaugmentation cystoplasty rates vary in the literature but have been reported as high as 15%. It is likely that bladders augmented with detubularized and reconfigured bowel are less likely to require reaugmentation. We assessed the incidence of reaugmentation among patients with spina bifida at 2 high volume reconstruction centers. MATERIALS AND METHODS: We retrospectively reviewed medical records of patients with spina bifida who underwent enterocystoplasty before age 21 years (1987 to 2017). Those who did not undergo augmentation with a detubularized and reconfigured bowel segment were excluded from analysis. Data on demographic and surgical variables were collected. Reaugmentation was the main outcome. One analysis was performed using the entire cohort and another analysis was restricted to patients with ileocystoplasty performed in the last 15 years (2002 to 2017). Survival analysis was used. RESULTS: A total of 289 patients were identified. Enterocystoplasty was performed in patients at a median age of 8.1 years (median followup 11.3, IQR 5.2-14.9). Most initial augmentations were performed using ileum (93.4%), followed by sigmoid (6.2%). Seven patients underwent reaugmentation, including 6 with initial augmentation using ileum and 1 with initial augmentation using sigmoid. On survival analysis risk of reaugmentation was 1.1% at 5 years and 3.3% at 10 years after the original surgery. All reaugmentations occurred within the first 9 years of followup. In the more contemporary cohort (162, median followup 7.0 years) only 1 patient underwent reaugmentation at 2.0 years. CONCLUSIONS: The risk of reaugmentation after enterocystoplasty with a detubularized and reconfigured bowel in the spina bifida population is lower than that reported in initial series.

Hidden incision endoscopic surgery (HIdES) trocar placement for pediatric robotic pyeloplasty: comparison to traditional port placement.

Robotic assisted laparoscopy pyeloplasty (RALP) has been associated with shorter recovery, less pain and improved cosmesis. To minimize visible scars, the hidden incision endoscopic surgery (HIdES) trocar placement has been previously developed. Our aim was to compare outcomes between the HIdES and traditional port placement (TPP) for pediatric RALP. A retrospective study was performed on patients under 15 years of age who underwent RALP at a single institution between August 2011 and November 2013. Patient demographics, intraoperative details, narcotic administration, and complications were reviewed. A total of 49 patients were identified (29 in HIdES, 20 in TPP). There was no difference in median age (p = 0.77) or median height (p = 0.88) between the two groups. Median operative time was 180 min for HIdES and 194 min for TPP (p = 0.27). Eleven patients (11/29, 37.9%) in the HIdES group and fourteen patients (14/20, 70%) in the TPP group received postoperative narcotics (p < 0.05). Median follow-up was 42 months for HIdES and 41 months for TPP (p = 0.96). There were two complications (2/29, 6.9%) with HIdES, and one complication (1/20, 5.0%) with TPP (p = 1.00). The success rates were 96.6% (28/29) for HIdES and 100% (20/20) for TPP (p = 1.00). HIdES trocar placement for pediatric robotic pyeloplasty is a safe and viable alternative to TPP. HIdES is comparable to TPP regarding operative time, narcotic administration, hospital stay, and complication rate, without compromising success.

A Non-Narcotic Pathway for the Management of Postoperative Pain Following Pediatric Robotic Pyeloplasty.

PURPOSE: The purpose of this study is twofold: first, to describe the non-narcotic pathway (NNP) for the management of postoperative pain after robotic pyeloplasty (RP); second, to compare perioperative outcomes for children undergoing RP whose postoperative pain was managed with and without the NNP. PATIENTS AND METHODS: A retrospective review was performed on 96 consecutive patients from October 2011 to December 2015 who underwent RP by three primary surgeons at a single pediatric institution. Children managed with an NNP received alternating doses of scheduled intravenous acetaminophen and ketorolac every 3 hours throughout the postoperative course. Perioperative outcomes were compared after grouping patients according to the type of postoperative pain management pathway. Continuous variables were compared using the Mann-Whitney U test, and categorical variables were compared using the two-tailed chi-squared test. RESULTS: A total of 49 (51.0%) patients were managed with the NNP, and 47 (49.0%) patients were managed without the NNP. A larger proportion of patients in the NNP did not receive postoperative narcotic medications (71.4% vs 25.5%; p < 0.001). Patients in the NNP were administered less narcotics (median 0.000 mg vs 0.041 mg morphine equivalents/kg/day; p < 0.001) and had a shorter length of stay (median 1.0 day vs 2.0 days; p < 0.001). There was no significant difference in the proportion of patients with postoperative complications (p = 0.958) or surgical success (p = 0.958). CONCLUSIONS: An NNP following pediatric RP is a viable and effective analgesic regimen that is associated with less narcotic use. It may also facilitate a shorter hospital stay. The majority of patients managed with this pathway had adequate pain control without being subject to the potential adverse effects of narcotic medications.

Use of cone-beam CT and live 3-D needle guidance to facilitate percutaneous nephrostomy and nephrolithotripsy access in children and adolescents.

BACKGROUND: Gaining access into non-dilated renal collecting systems for percutaneous nephrolithotripsy, particularly in patients with prohibitive body habitus and/or scoliosis, is often challenging using conventional techniques. OBJECTIVE: To evaluate the feasibility of cone-beam CT for percutaneous nephrostomy placement for subsequent percutaneous nephrolithotripsy in children and adolescents. MATERIALS AND METHODS: A retrospective review of percutaneous nephrostomy revealed use of cone-beam CT and 3-D guidance in 12 percutaneous nephrostomy procedures for 9 patients between 2006 and 2015. All cone-beam CT-guided percutaneous nephrostomies were for pre-lithotripsy access and all 12 were placed in non-dilated collecting systems. RESULTS: Technical success was 100%. There were no complications. CONCLUSION: Cone-beam CT with 3-D guidance is a technically feasible technique for percutaneous nephrostomy in children and adolescents, specifically for nephrolithotripsy access in non-dilated collecting systems.

Chronic Kidney Disease Stage Progression in Patients Undergoing Repair of Persistent Cloaca.

PURPOSE: Children born with persistent cloaca undergo complex pelvic reconstruction early in life. Long-term risks of bladder dysfunction and chronic kidney disease are well described. We report upper urinary tract outcomes and the risk of chronic kidney disease stage progression in this patient population. MATERIALS AND METHODS: We retrospectively studied a cohort of patients undergoing posterior sagittal anorecto-vagino-urethroplasty at a single institution from 2006 to 2013. Inclusion criteria consisted of complete urological care at our institution. Chronic kidney disease stage was calculated from cystatin C or nuclear medicine glomerular filtration rate. RESULTS: A total of 44 patients met inclusion criteria. Of the patients 12 had undergone vesicostomy or ureterostomy. A total of 19 patients had hydronephrosis, 19 had vesicoureteral reflux and 15 had a tethered spinal cord. Median length of the common channel was 3.5 cm. Median age at posterior sagittal anorecto-vagino-urethroplasty was 7.3 months. Median followup was 5.3 years. A total of 30 patients had neurogenic bladder, of whom 27 required clean intermittent catheterization and 3 had undergone vesicostomy. Of the patients 38 had stage I or II, 5 had stage III and 1 had stage IV chronic kidney disease. During followup no patient with initial stage I to III chronic kidney disease had stage progression. The patient with stage IV chronic kidney disease had a renal allograft placed at age 34 months before needing dialysis. CONCLUSIONS: Early outcomes in patients with stage I to III chronic kidney disease demonstrate that renal function can be maintained despite a high rate of lower urinary tract dysfunction. Aggressive bladder management may help prevent progressive renal injury in this population.

Prechemotherapy robotic-assisted laparoscopic radical nephrectomy for an adolescent with Wilms tumor.

Although Wilms tumor (WT) is the most common pediatric renal tumor, adolescent and adult WT is rare. Nevertheless, adolescent renal tumors as a group are sufficiently uncommon that WT must be included in the differential diagnosis for such patients, and in doing so affects the oncologic considerations of the surgery. Herein, we describe a 14-year-old female presenting with a 1-month history of right flank pain. Subsequent work-up revealed a localized, centrally located, enhancing right renal mass. The patient underwent robotic-assisted laparoscopic radical nephrectomy and pathology demonstrated stage II, favorable histology WT. Herein, we will discuss the pertinent details regarding adolescents with renal tumors and the risks and benefits of using a minimally invasive surgical approach.

Endoscopic treatment with dextranomer/hyaluronic acid for persistent incontinence after continent urinary reconstruction.

PURPOSE: To determine the applicability and long-term outcome of endoscopic injection of dextranomer/hyaluronic acid (Dx/HA) to correct incontinence in patients who had previously undergone continent urinary reconstruction. PATIENTS AND METHODS: A retrospective cohort study was performed of all patients who underwent Dx/HA injection at our institution from January 2001 to June 2011. All patients had adequate bladder capacity and compliance on maximized medical therapy before injection. "Success" was defined as either "continence" (daytime dry interval >3 hours) or "improvement" (daytime dry interval >2 hours). RESULTS: A total of 22 children (16 females and 6 males) had Dx/HA injections for persistent incontinence from either bladder neck (7), Mitrofanoff (10), or both (5). Median age at injection was 13 years (range 4-21). Children underwent an average of 1.6 injection sessions per patient with an average of 2.6 mL of Dx/HA per session. At a median follow-up of 72 months (range 4-104), 19 (86.4%) patients had successful results (16 continent, 3 improved). For those incontinent from bladder neck, 42% became continent after 1, 75% after 2, and 83% after 3 injections, with a success rate of 91% (10 continent, 1 improved). For those incontinent from Mitrofanoff, 20% became continent after 1, and 73% after 2 injections, with a success rate of 86% (11 continent, 2 improved). CONCLUSIONS: Endoscopic injection of Dx/HA to correct residual incontinence in selected children after urinary reconstruction appears to be safe and effective, achieving a dry interval in more than two-thirds of patients.

Pediatric urological laparoendoscopic single site surgery: single surgeon experience.

OBJECTIVE: The aim was to assess the feasibility and outcomes of pediatric urological laparoendoscopic single site (LESS) surgery. MATERIALS AND METHODS: A retrospective review was performed of all children who underwent LESS surgery at a single pediatric institution from September 2010 to July 2013. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed. The umbilicus was used as the surgical site in all cases. All procedures were performed with a flexible tip laparoscope, a multichannel port, standard 3- or 5-mm laparoscopic instrumentation, and articulating instruments. RESULTS: Sixty-one patients (50 male, 11 female) were identified. Procedures included 18 orchidopexies, 15 nephrectomies, 11 varicocelectomies, nine nephroureterectomies, four partial nephrectomies, one ureterectomy, one ureterolithotomy, one orchiectomy, and one utricle excision. The ureterolithotomy was converted to open surgery for failure to progress. The utricle excision was converted to conventional laparoscopy by adding one accessory port and one skin puncture because of the close proximity of the vas deferens to the utricle. Intraoperative complications included one vas deferens injury during orchidopexy in a postpubertal male. Postoperative complications occurred in six patients: five grade II and one grade IIIb. CONCLUSIONS: Pediatric urological LESS procedures are technically feasible, safe, and effective. Further evaluation is warranted to better define its role in pediatric urological surgery.

Pediatric varicocelectomy: a comparative study of conventional laparoscopic and laparoendoscopic single-site approaches.

BACKGROUND AND PURPOSE: Laparoscopy is a common approach to manage varicoceles in both the adult and pediatric population. The purpose of this study is to report our experience and compare outcomes between conventional laparoscopy and laparoendoscopic single-site (LESS) surgery for varicocelectomy in the pediatric population. PATIENTS AND METHODS: A retrospective cohort study was performed of all patients who underwent conventional laparoscopic varicocelectomy (LV) and laparoendoscopic single-site varicocelectomy (LESSV) at a single pediatric institution from December 2007 to March 2012. Patient demographics, intraoperative details, narcotic use, and complications were reviewed. RESULTS: LV was performed in 32 patients and LESSV in 11 patients. None had conversion to open surgery. Median age was 16 years for LV (range 12-23) and 15 years for LESSV (range 12-20), P=0.061. Median operative time was 55 minutes for LV (range 28-90) and 46 minutes for LESSV (range 33-59), P=0.037. Nine (81.8%) patients in the LESSV group and 10 (31.2%) patients in the LV group were administered narcotics in the recovery room, P=0.005. One (3.1%) patient in the LV group was administered ketorolac in the recovery room, P=1. Five patients in each group, LESSV (45.5%) and LV (15.6%), received acetaminophen in the recovery room, P=0.092. All procedures were performed on an outpatient basis except for one because of a concomitant procedure. Median follow-up was 22 months in LV and 15 months in LESSV, P=0.015. One (3.1%) postoperative hydrocele was noted after LV and 1 (9.1%) after LESSV, P=0.451. All varicoceles were clinically resolved in both groups. CONCLUSIONS: LESSV is comparable to LV in the pediatric population. Our initial experience indicates that the LESS approach may be more painful in the immediate postoperative period than conventional laparoscopy. The LESS technique warrants further evaluation to determine if one approach is clearly more advantageous.

Comparison of pediatric robotic-assisted laparoscopic nephroureterectomy and laparoendoscopic single-site nephroureterectomy.

OBJECTIVE: To compare outcomes between pediatric robotic-assisted laparoscopic nephroureterectomy (RALNU) and laparoendoscopic single-site nephroureterectomy (LESSNU). METHODS: A retrospective cohort study was performed of all patients who underwent RALNU and LESSNU at a single pediatric institution from April 2009 to April 2013. Patient demographics, perioperative details, and outcomes were reviewed. RESULTS: Thirty-two patients (20 men, 12 women) were identified. Twenty-four patients underwent RALNU and 8 patients underwent LESSNU. There was no significant blood loss, intraoperative complication, or conversion to open or standard laparoscopy for either procedure. Median age was 55.1 months (range 4.5-171.8 months) for RALNU and 51.6 months (range 16.3-144.9 months) for LESSNU (P = .695). Median weight was 19.1 kg (range 7-55 kg) for RALNU and 16.9 kg (range 11-41 kg) for LESSNU (P = .727). Median operative time was 227 minutes (range 112-362 minutes) for RALNU and 174 minutes (range 74-288 minutes) for LESSNU (P = .028). Median length of hospital stay was 2 days (range 1-4 days) for RALNU and 1 day (range 0-6 days) for LESSNU (P = .134). Median in-patient postoperative narcotic use of morphine-equivalent was 0.03 mg/kg/day (range 0-0.2) for RALNU and <0.01 mg/kg/day (range 0-0.2) for LESSNU (P = .134). Median in-patient postoperative Ketorolac use was <0.01 mg/kg/day (range 0-0.8) for RALNU and <0.01 mg/kg/day (range 0-0.5) for LESSNU (P = .784). Median follow-up was 22 months (range 0.8-48.4 months) for RALNU and 18.8 months (range 0.3-29.4 months) for LESSNU (P = .361). We observed 2 complications (8.3%) in RALNU and 1 in LESSNU (P = 1). CONCLUSION: LESSNU has a significantly shorter operative time with comparable in-patient postoperative narcotics use as compared to RALNU.

High-grade transitional cell carcinoma of the bladder in a 5-year-old boy successfully treated with partial cystectomy and intravesical bacillus Calmette-Guerin.

Pediatric transitional cell carcinomas of the bladder are typically characterized by low-grade histology, adolescent and young adult age, and cure with surgical resection. Here, we report a high-grade transitional cell carcinoma of the bladder in a 5-year-old boy treated with a partial cystectomy and adjuvant intravesical Bacillus Calmette-Guerin.

Complications of robotic surgery in pediatric urology: a single institution experience.

OBJECTIVE: To report our analysis of complications on pediatric robotic urologic procedures. METHODS: A retrospective review was performed for all robotic surgeries by pediatric urologists at a single pediatric institution, from the start of the robotic surgery program in February 2009 through February 2013. Data included patient demographics, intraoperative details, outcomes, and complications (Clavien system). RESULTS: The analysis included 136 patients. There were 10 different types of procedures performed by 3 pediatric urologists. There were no intraoperative complications, robotic malfunctions, conversions to open or laparoscopic surgery, or mortalities. There were 11 total complications (8.1%): 2 grade I (1.5%), 7 grade II (5.1%), and 2 grade IIIb (1.5%). Complications included ileus in 2 patients (1.5%), port site infection in 2 (1.5%), urinary leak in 2 (1.5%), urinary retention in 2 (1.5%), urinary tract infection in 2 (1.5%), and stent migration in 1 (0.7%). The complication rate was in 3 of 10 infants (30%) and 8 of 126 noninfants (6.3%), P = .035. However, grade I, II, and IIIb complication rates were not significantly higher in infants vs noninfants, P = 1, .084, and .142, respectively. There was no difference in complication rates between the 3 surgeons. CONCLUSION: Pediatric robotic urologic procedures are safely performed with a relatively low complication rate and a low incidence of additional interventions owing to complications. Ongoing use of robotic technology in the pediatric population can be supported. Further reports are needed to validate our findings.