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

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

Port Site Local Anesthetic Infiltration Vs Single-dose Intrathecal Opioid Injection to Control Perioperative Pain in Children Undergoing Minimal Invasive Surgery: A Comparative Analysis.

OBJECTIVE: To compare the efficacy of the intrathecal opiate vs wound site local anesthetic infiltration for perioperative pain control during and after surgery in patients undergoing minimally invasive pediatric urologic procedures. METHODS: Using an Institutional Review Board-approved registry database, we identified patients who underwent minimally invasive urologic procedures at our institution between 2009 and 2013. We collected all relevant preoperative variables and postoperative outcomes. Patients in intrathecal injection of opioids (ITO) group were matched with patients who received local anesthetic infiltration (LAI) based on age, diagnosis, and procedure. Perioperative analgesic requirements were converted to morphine equivalents standardized to body weight. Statistical analysis was performed using SPSS, and parametric comparisons were completed to determine difference in morphine equivalents between the 2 groups. RESULTS: One hundred thirty children (78 girls and 52 boys) were included in our study. Sixty-six patients underwent ITO and 66 received LAI. Sixty-six patients underwent ureteral reimplantation, 60 underwent pyeloplasty, and 4 underwent nephrectomy. Ages ranged from 0.5 to 19.9 years. There was no significant difference in cumulative morphine equivalents or weight administered between the ITO and LAI groups for the total period of hospitalization (0.76 units vs 0.79 units, P > .05). Multivariate regression analysis predicted that older age corresponds to higher analgesic requirements. CONCLUSION: ITO does not impact total analgesic requirements during the hospital stay compared to LAI following minimally invasive surgery. Considering the potential complications of ITO, LAI may be the preferred modality for pain management for minimally invasive surgery in children.

Multi-institutional Experience in Laparoendoscopic Single-site Surgery (LESS): For Major Extirpative and Reconstructive Procedures in Pediatric Urology.

OBJECTIVE: To review peri-procedural outcomes from a large, multi-institutional series of pediatric urology patients treated with laparaendoscopic single-site surgery (LESS) for major extirpative and reconstructive procedures. MATERIALS AND METHODS: Consecutive LESS cases between January 2011 and May 2014 from three free-standing pediatric referral centers were reviewed. Data include age, sex, operative time, blood loss, length of stay, and complications according to the modified Clavien-Dindo classification. Hasson technique was used for peritoneal entry, GelPOINT advanced access platform was inserted, and standard 5mm laparoscopic instruments were used. RESULTS: Fifty-nine patients (median age 5 years, 4 months-17 years) met inclusion criteria: 29 nephrectomies, 9 nephroureterectomies, 3 bilateral nephrectomies, 5 heminephrectomies, 5 renal cyst decortications, 3 bilateral gonadectomies, 2 Malone antegrade continence enema, 2 calyceal diverticulectomy, and 1 ovarian detorsion with cystectomy. Median operative times for each case type were comparable to published experiences with traditional laparoscopy. Overall mean and median length of stay was 36.2 hours and 1 day, respectively. There were two complications: port site hernia requiring surgical repair (Clavien IIIb) and a superficial port site infection that resolved with antibiotics (Clavien II). Cosmetic outcomes were subjectively well received by patients and their parents. Operative time was significantly shorter between the first half of the experience and the second half (102 vs 70 minutes, P < .05). CONCLUSION: LESS approach can be broadly applied across many major extirpative and reconstructive procedures within pediatric urology. Our series advances our field's utilization of this technique and its safety.