Outpatient Robotic Unilateral Extravesical Ureteral Reimplantation in the Pediatric Population: Short-Term Assessment of Safety.

PURPOSE: Robotic extravesical ureteral reimplantation has been established as a viable option for surgical management of vesicoureteral reflux. Typically this procedure is associated with a hospital stay for routine postoperative care. We assessed the short-term safety of robotic unilateral extravesical ureteral reimplantation as a scheduled outpatient procedure in a pediatric population. MATERIALS AND METHODS: We retrospectively studied a cohort of patients who underwent robotic extravesical ureteral reimplantation between June 2012 and January 2018. No regional blocks were performed. Patients were discharged from the postanesthesia care unit as part of a scheduled outpatient procedure without an extended stay. Postoperative outcomes included 30-day emergency room visits, readmissions to the hospital and Clavien-Dindo grade I to V complications. RESULTS: Four male and 23 female patients were identified. Median age was 85 months (range 27 to 210) and median weight was 26 kg (13 to 97). Median robotic console time was 140 minutes (range 84 to 257). No patient required a hospital stay for management of pain. Two patients (9%) required unplanned antibiotic therapy postoperatively for bacterial cystitis and pneumonia (Clavien-Dindo grade II complications). The patient with pneumonia was diagnosed during a subsequent emergency room visit. One patient was rehospitalized on postoperative day 4 because of constipation. No Clavien-Dindo grade III or higher complication was observed in any patient. CONCLUSIONS: Robotic unilateral extravesical ureteral reimplantation is safe as an outpatient procedure in the pediatric population. Further evaluation is warranted to assess its short and long-term outcomes on a larger scale.

Calcium-to-Citrate Ratio Distinguishes Solitary and Recurrent Urinary Stone Forming Children.

PURPOSE: The prevalence of urinary stone disease is increasing in children. We previously reported a high rate of urinary metabolic abnormalities, including hypercalciuria and hypocitraturia, in stone forming children. In this study we determined whether calcium-to-citrate ratio could help predict those at risk for recurrent stone formation. MATERIALS AND METHODS: We conducted a retrospective cohort study to assess calcium-to-citrate ratios in children with urolithiasis. Two 24-hour urine collections were performed. Urinary excretions of calcium and citrate were analyzed, and calcium-to-citrate ratio was calculated. Patients were stratified into solitary and recurrent stone formers and compared to a control group of normal children. RESULTS: We identified 73 solitary and 92 recurrent stone formers. Mean patient age was 13 years for both groups. Gender was well matched. A total of 29 normal children served as controls. Mean calcium-to-citrate ratio was 0.41 in solitary stone formers and 0.64 in recurrent stone formers (p = 0.02). Mean value in normal children (0.33) was significantly less compared to recurrent stone formers (p = 0.002) and trended lower compared to solitary stone formers (p = 0.15). The ratio was abnormally high in recurrent stone formers (70%) compared to solitary stone formers (47%, p = 0.003). CONCLUSIONS: There are significant differences in urine calcium-to-citrate ratios between solitary and recurrent calcium stone forming children. Solitary stone formers trended higher compared to controls. These findings may allow more precise risk stratification and treatment to prevent recurrent stone episodes.

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.

A Case-Control Study on the Impact of Ventilator-Associated Tracheobronchitis in the PICU.

OBJECTIVES: Hospital-acquired infections increase morbidity, mortality, and charges in the PICU. We implemented a quality improvement bundle directed at ventilator-associated pneumonia in our PICU in 2005. We observed an increase in ventilator-associated tracheobronchitis coincident with the near-elimination of ventilator-associated pneumonia. The impact of ventilator-associated tracheobronchitis on critically ill children has not been previously described. Accordingly, we hypothesized that ventilator-associated tracheobronchitisis associated with increased length of stay, mortality, and hospital charge. DESIGN: Retrospective case-control study. PATIENTS: Critically ill children admitted to a quaternary PICU at a free-standing academic children's hospital in the United States. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We conducted a retrospective case control study, with institutional review board approval, of 77 consecutive cases of ventilator-associated tracheobronchitis admitted to our PICU from 2004-2010. We matched each case with a control based on the following criteria (in rank order): age range (< 30 d, 30 d to 24 mo, 24 mo to 12 yr, > 12 yr), admission Pediatric Risk of Mortality III score ± 10, number of ventilator days of control group (> 75% of days until development of ventilator-associated tracheobronchitis), primary diagnosis, underlying organ system dysfunction, surgical procedure, and gender. The primary outcome measured was PICU length of stay. Secondary outcomes included ventilator days, hospital length of stay, mortality, and PICU and hospital charges. Data was analyzed using chi square analysis and p less than 0.05 was considered significant. We successfully matched 45 of 77 ventilator-associated tracheobronchitis patients with controls. There were no significant differences in age, gender, diagnosis, or Pediatric Risk of Mortality III score between groups. Ventilator-associated tracheobronchitis patients had a longer PICU length of stay (median, 21.5 d, interquartile range, 24 d) compared to controls (median, 18 d; interquartile range, 17 d), although not statistically significant (p = 0.13). Ventilator days were also longer in the ventilator-associated tracheobronchitis patients (median, 17 d; IQR, 22 d) versus control (median, 10.5 d; interquartile range, 13 d) (p = 0.01). There was no significant difference in total hospital length of stay (54 d vs 36 d; p = 0.69). PICU mortality was higher in the ventilator-associated tracheobronchitis group (15% vs 5%; p = 0.14), although not statistically significant. There was an increase in both median PICU charges ($197,393 vs $172,344; p < 0.05) and hospital charges ($421,576 vs $350,649; p < 0.05) for ventilator-associated tracheobronchitis patients compared with controls. CONCLUSIONS: Ventilator-associated tracheobronchitis is a clinically significant hospital-acquired infection in the PICU and is associated with longer duration of mechanical ventilation and healthcare costs, possibly through causing a longer PICU length of stay. Quality improvement efforts should be directed at reducing the incidence of ventilator-associated tracheobronchitis in the PICU.

Tamsulosin and spontaneous passage of ureteral stones in children: a multi-institutional cohort study.

PURPOSE: Tamsulosin is associated with increased passage of ureteral stones in adults but its effectiveness in children is uncertain. We determined the association between tamsulosin and the spontaneous passage of ureteral stones in children. MATERIALS AND METHODS: We performed a multi-institutional retrospective cohort study of patients 18 years or younger who presented between 2007 and 2012 with ureteral stones up to 10 mm and who were treated with tamsulosin or oral analgesics alone. The outcome was spontaneous stone passage, defined as radiographic clearance and/or patient report of passage. Subjects prescribed tamsulosin were matched with subjects prescribed analgesics alone, using nearest neighbor propensity score matching to adjust for treatment selection. Conditional logistic regression models were used to estimate the association between tamsulosin and spontaneous passage of ureteral stones, adjusting for stone size and location. RESULTS: Of 449 children with ureteral stones 334 were eligible for inclusion, and complete data were available for 274 patients from 4 institutions (99 receiving tamsulosin, 175 receiving analgesics alone). Following case matching, there were no differences in age, gender, weight, height, stone size or stone location between the 99 subjects prescribed tamsulosin and the 99 propensity score matched subjects prescribed analgesics alone. In the tamsulosin cohort 55% of ureteral stones passed, compared to 44% in the analgesics alone cohort (p=0.03). In multivariate analysis adjusting for stone size and location tamsulosin was associated with spontaneous passage of ureteral stones (OR 3.31, 95% CI 1.49-7.34). CONCLUSIONS: The odds of spontaneous passage of ureteral stones were greater in children prescribed tamsulosin vs analgesics alone.

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.

Urinary NGAL levels correlate with differential renal function in patients with ureteropelvic junction obstruction undergoing pyeloplasty.

PURPOSE: Recent investigations described the use of NGAL, a sensitive biomarker for kidney injury, in the setting of ureteropelvic junction obstruction. We prospectively evaluated urinary NGAL levels in the affected renal pelvis and bladder of children with ureteropelvic junction obstruction undergoing unilateral dismembered pyeloplasty. Our hypothesis was that higher NGAL in the kidney and bladder would correlate with decreased ipsilateral differential function. MATERIALS AND METHODS: We performed a prospective cohort study in patients treated with unilateral dismembered pyeloplasty from 2010 to 2012. Urine was obtained intraoperatively from the bladder and obstructed renal pelvis. A control population of unaffected children was recruited to provide a voided bladder specimen. Bladder NGAL levels were compared between the study and control populations. We tested our study hypothesis by correlating bladder and renal pelvic NGAL levels with the differential renal function of the affected kidney. RESULTS: A total of 61 patients with a median age at surgery of 1.62 years (range 0.12 to 18.7) were enrolled in the study. Median bladder NGAL was 18.6 ng/mg (range 1.4-1,650.8) and median renal pelvic NGAL was 26.2 ng/mg (range 1.2-18,034.5, p = 0.004). Median bladder NGAL was significantly higher than in controls (p = 0.004). The correlation of bladder and renal pelvic NGAL with differential renal function was r = -0.359 (p = 0.004) and r = -0.383 (p = 0.002), respectively. CONCLUSIONS: Bladder NGAL is increased in children with ureteropelvic junction obstruction. Renal pelvic and bladder normalized urinary NGAL levels correlate inversely with the relative function of the affected kidney in cases of unilateral ureteropelvic junction obstruction.

Enteral nutrition and the risk of nephrolithiasis in complex pediatric patients.

PURPOSE: Medically complex, non-ambulatory children can often suffer from nephrolithiasis. The purpose of this study is to determine risk factors which are predictive for recurrent stone formation in this patient population. MATERIAL AND METHODS: A retrospective cohort study was performed on non-ambulatory patients with cerebral palsy and/or severe developmental delay presenting to a high-volume Pediatric Stone Center from 2015 to 2019. Two 24-hour urine collections were performed as a baseline prior to pharmacotherapeutic and/or dietary intervention. Healthy stone-forming children served as a control group. RESULTS: 28 non-ambulatory subjects and 38 healthy controls were evaluated. The study group had a higher rate of bilateral nephrolithiasis but a similar history of previous surgical procedures. 89% of the non-ambulatory children were fed via a gastrostomy. The median calcium excretion was the same in both groups (3.0 mg/kg/day). The median 24-hour excretion of oxalate was significantly increased in the study group (54 vs 31 mg/1.73 m2/day, p = 0.0001). Urinary citrate and phosphorus excretions, and the supersaturations of calcium oxalate and calcium phosphate were similar between study subjects and controls. Calcium oxalate stones were noted in 57% of those with known stone composition in the study group. Enteral feeding formulas were primarily based on soy protein, a known high oxalate food. CONCLUSIONS: Urinary oxalate excretion is significantly increased in a cohort of medically complex, non-ambulatory stone-forming children. Urinary calcium excretion was not elevated between study subjects and healthy controls. Further analysis is needed to assess if dietary intervention to limit oxalate excretion results in decreased stone formation.

Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: Business case for quality improvement.

OBJECTIVE: To determine whether catheter-associated bloodstream infections were associated with increased lengths of stay in pediatric intensive care units and hospitals and increased healthcare costs in critically ill children. Previous studies have shown that hospital-acquired bloodstream infections are associated with longer stays in pediatric intensive care units, increased hospital costs, and increased hospital mortality. Catheter-associated bloodstream infections comprise the vast majority of hospital-acquired bloodstream infections. DESIGN: Retrospective, case-matched, cohort study and financial analysis. SETTING: University-affiliated children's medical center. PATIENTS: Twenty-two critically ill children with catheter-associated bloodstream infections and their matched controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared the length of stay, mortality, and hospital costs in critically ill children with catheter-associated bloodstream infections and matched controls. The presence of catheter-associated bloodstream infections extended the entire hospital length of stay by 9 days (6.5 days while in the pediatric intensive care unit) and increased hospital costs by $33,039, primarily driven by the increase in length of stay days. Quality improvement efforts directed at reducing the prevalence of catheter-associated bloodstream infections during the period of study decreased total hospital days by 354, reduced total hospital costs by $1,298,271, and reduced total costs to payers by $1,415,676. CONCLUSION: The potential cost savings from reducing or eliminating catheter-associated bloodstream infections in the pediatric intensive care unit are significant. Elimination of catheter-associated bloodstream infections will directly reduce hospital costs, improve asset utilization, and most importantly, improve clinical care.

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.

Baseline Characteristics of Infants With Atypical Genital Development: Phenotypes, Diagnoses, and Sex of Rearing.

PURPOSE: Little is known about the phenotypes, diagnoses, and sex of rearing of infants with atypical genital development in the United States. As part of a multicenter study of these infants, we have provided a baseline report from US difference/disorder of sex development clinics describing the diagnoses, anatomic features, and sex of rearing. We also determined whether consensus guidelines are followed for sex designation in the United States. METHODS: Eligible participants had moderate-to-severe genital atypia, were aged <3 years, and had not undergone previous genitoplasty. Karyotype, genetic diagnosis, difference/disorder of sex development etiology, family history, and sex of rearing were collected. Standardized examinations were performed. RESULTS: Of 92 subjects, the karyotypes were 46,XX for 57%, 46,XY for 34%, and sex chromosome abnormality for 9%. The median age at the baseline evaluation was 8.8 months. Most 46,XX subjects (91%) had congenital adrenal hyperplasia (CAH) and most 46,XY subjects (65%) did not have a known diagnosis. Two individuals with CAH underwent a change in sex of rearing from male to female within 2 weeks of birth. The presence of a uterus and shorter phallic length were associated with female sex of rearing. The most common karyotype and diagnosis was 46,XX with CAH, followed by 46,XY with an unknown diagnosis. Phenotypically, atypical genitalia have been most commonly characterized by abnormal labioscrotal tissue, phallic length, and urethral meatus location. CONCLUSIONS: An increased phallic length was positively associated with rearing male. Among the US centers studied, sex designation followed the Consensus Statement recommendations. Further study is needed to determine whether this results in patient satisfaction.

Tubeless outpatient robotic upper urinary tract reconstruction in the pediatric population: short-term assessment of safety.

Robotic upper urinary tract reconstruction (UUTR) has been widely utilized for surgical management of congenital obstruction. To further reduce morbidity and simplify postoperative care, outpatient robotic pyeloplasty (RP) and robotic ureteroureterostomy (RUU) were performed without ureteral stents, drains, or urethral catheters. The aim of the study was to assess the safety of performing tubeless robotic UUTR as an outpatient procedure. A retrospective review was performed for patients who underwent outpatient tubeless RP and RUU between July 2015 and January 2017. All procedures were primary interventions. No ureteral stents, drains, or urethral catheters were utilized. No regional blocks were utilized. Patients were discharged from the post anesthesia care unit as a scheduled outpatient procedure without an extended stay. Primary outcomes included 30-day complications, emergency room (ER) visits, and readmissions. A total of 19 patients (14 male, 5 female) were identified (RP = 17, RUU = 3), including one patient who underwent staged bilateral RP. Median age was 21.5 months (range 3-220). Median weight was 11.5 kg (range 6-89). Median operative time was 167 min (range 108-249), defined as skin incision to closure. No 30-day complications, ER visits, or readmissions were observed for any patient. The study concludes that pediatric tubeless outpatient robotic UUTR is safe. Further evaluation is needed to assess this approach on a larger scale, as well as assessing the long-term outcomes of tubeless reconstruction.

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.

Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications.

BACKGROUND: Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve. OBJECTIVE: To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons. DESIGN AND METHODS: We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure. RESULTS: In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral, 56 bilateral; 199 ureters). The majority of ureters (73.4%) had grade III or higher VUR preoperatively. Radiographic resolution was present in 93.8% of ureters, as shown in the summary table. Ureteral complications occurred in five ureters (2.5%) with mean follow-up of 7.4 months (SD 4.0). Transient urinary retention occurred in four patients following bilateral procedure (7.1%) and in no patients after unilateral. On univariate analysis, there were no patient or technical factors associated with increased odds of radiographic failure. DISCUSSION: We report a radiographic success rate of 93.8% overall, and 94.1% among children with grades III-V VUR. In contemporary series, alternate management options such as endoscopic injection and open UR have reported radiographic success rates of 90% and 93.5% respectively. We were unable to identify specific patient or technical factors that influenced outcomes, although immeasurable factors such as tissue handling and intraoperative decision-making could not be assessed. Ureteral complications requiring operative intervention were rare and occurred with the same incidence reported in a large open series. Limitations include lack of long-term follow-up and absence of radiographic follow-up on a subset of patients. CONCLUSIONS: Radiographic resolution of VUR following RALUR is on par with contemporary open series, and the incidence of ureteral complications is low. RALUR should be considered as one of several viable options for management of VUR in children.

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.

Prospective evaluation of urinary metabolic indices in severely obese adolescents after weight loss surgery.

BACKGROUND: Observational studies in obese adults have found abnormal urinary metabolic indices that predispose to nephrolithiasis. Few studies have been performed in severely obese adolescents. OBJECTIVES: To assess urinary stone risk factors in severely obese adolescents and in those undergoing 2 types of weight loss surgery. SETTING: Children's hospital, United States. METHODS: A prospective cross-sectional study was performed to assess urinary metabolic profiles in severely obese adolescents who either have not undergone any gastrointestinal surgery or who have undergone Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (SG). Twenty-four-hour urine collections were performed at home and evaluated at a central laboratory. Established normal reference ranges for adults were used in the analysis. A linear regression analysis was performed assessing the relationship of the study group with each of the outcomes. RESULTS: A total of 55 samples were analyzed from 14 severely obese adolescents and from 17 severely obese adolescents after bariatric surgery (RYGB, 10; SG, 7). Median body mass index was similar between the RYGB and SG groups. The median 24-hour excretion of oxalate was significantly elevated in the RYGB group. Calcium and uric acid excretion and the median supersaturation of calcium oxalate, calcium phosphate, and uric acid were similar among all groups. CONCLUSIONS: Elevated excretion of oxalate in the urine of severely obese adolescents and in those who have undergone RYGB may portend increased risk for kidney stone formation. Larger longitudinal studies are needed to verify these findings and to determine the clinical risk of developing stone disease in these patient populations.

Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery.

OBJECTIVE: Our aim was to assess the outcomes of infant robot-assisted laparoscopic (RAL) upper urinary tract reconstruction. MATERIALS AND METHODS: The medical records of all infants who underwent RAL upper urinary tract reconstruction were reviewed. Patients less than 1 year of age at surgery were included. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed. RESULTS: Ten infants met the study criteria. There were five right and five left-sided procedures. Eight pyeloplasties (4 right, 4 left) and two ureteroureterostomies (1 right single system, 1 left duplex system) were performed. The median age was 8 months (range 3-12 months). Median weight was 7.7 kg (range 5.8-10.9 kg). Median operative time was 128 min (range 95-205 min). There was no significant blood loss or intraoperative complications. One (10%) patient received a regional block. Eight (80%) patients did not receive postoperative narcotics. Median hospital stay was 1 day (range 1-2). Median follow-up was 10 months (range 3-18 months). Complications included one urinary leak, one ileus, and one urinary tract infection. Hydronephrosis improved in all patients. CONCLUSIONS: Infant RAL upper urinary tract reconstruction is technically feasible, safe, and effective. It can be applied for duplication anomalies and single system obstructions in infants.