Single port (SP) robotic pyeloplasty in a pediatric patient.

We began using the da Vinci single port (SP) robot for pediatric urologic surgeries at our institution due to limited access to the multiport robot. Availability of this technology has allowed us to schedule cases in a timelier fashion and increase access to minimally invasive urologic surgery for children in our area. Here, we report our technique for transperitoneal SP robotic pyeloplasty in the case of a 7 year-old boy with left ureteropelvic junction obstruction. Our technique was refined over a series of 10 patients under the age of 18. Highlights of the SP RALP technique include one 3 cm, concealed incision over the pubic tubercle, gentle frog leg positioning and burping of the boom to create optimal angle for robotic docking, and use of a "floating dock" to obtain 10 cm distance from target anatomy which is essential in smaller pediatric patients. SP pyeloplasty is safe and feasible in children and offers a concealed single incision alternative to the multiport approach.

Bilateral proximal ureteral and ureterovesical junction obstruction in a child.

The most common sites of ureteral obstruction in children are at the level of the ureteropelvic junction (UPJ) and ureterovesical junction (UVJ). Bilateral hydronephrosis or hydroureteronephrosis due to varying degrees of obstruction at the UPJ or UVJ is common in children and typically improves with time. Clinically significant obstruction at both locations in an ipsilateral ureter occurs less commonly and rarely requires both dismembered pyeloplasty and ureteral reimplantation. We believe this case report is the first description of bilateral proximal and distal ureteral obstruction requiring both dismembered pyeloplasty and ureteral reimplantation.

Ovotesticular Disorder Mimicking Acute Spermatic Cord Torsion.

Ovotesticular disorder is a rare form of sexual development in which a patient may have one ovary and one testis, or more commonly a gonad or gonads containing both ovarian and testicular tissue. Patients with this condition typically present in infancy with ambiguous genitalia. Delayed presentations of clinically symptomatic, older patients with normal external genitalia are extremely rare. We present a case of a 14-year-old male with normal external genitalia who presented with symptoms and signs consistent with spermatic cord torsion but found to have ovotesticular disorder on evaluation.

A narrative review of the history and evidence-base for the timing of orchidopexy for cryptorchidism.

INTRODUCTION: Consensus recommendations for surgical management of cryptorchidism recommend orchidopexy between 6 and 18 months of age. The COVID-19 pandemic has impacted elective surgical scheduling. OBJECTIVE: In response to the COVID-19 pandemic, we sought to review the available data regarding the natural history, surgical management, and infertility- and cancer-related risks associated with cryptorchid testes. The purpose of this review is to provide parents, referring providers, and surgeons with information to inform their decisions to proceed with or delay orchidopexy. METHODS: A retrospective review and analysis of all available articles relevant to the natural history, surgical management, and infertility- and cancer-related risks of cryptorchidism present on PubMed, SCOPUS, and Cochrane Library was conducted. RESULTS: The quality of historic literature pertaining to the effect of cryptorchidism on fertility and malignancy differ, with poorer data available on fertility. Cryptorchid testes may show histologic differences as early as birth, and some of these changes may have prognostic value in future fertility. Formerly unilateral cryptorchid men have slightly but not significantly reduced paternity rates compared to the general population. Cryptorchid testes have an increased risk of germ cell carcinogenesis, and robust data suggest the risk for malignancy in cryptorchid testes increases substantially after puberty. CONCLUSION: The current body of evidence regarding the risks for future infertility and testicular cancer support the consensus recommendations for surgical correction of cryptorchidism between 6 and 18 months of age. During the uncertain time of the COVID-19 pandemic, decision for orchidopexy is a shared-decision between physician and parent. For an infant or young boy with a unilateral undescended testes, delaying orchidopexy several months until a time of decreased exposure risk is unlikely to result in substantial or sustained fertility or malignant risks.

Bilateral Calculi in a Child With Bilateral Single System Ureteroceles.

Ureteroceles in children are detected with prenatal sonography and less commonly during the evaluation following a urinary tract infection. Rarely do ureteroceles in the pediatric population present with stones, particularly in a bilateral fashion. We present a case of a 5-year-old boy found to have bilateral intravesical single system ureteroceles harboring multiple large calculi treated successfully with a staged endoscopic approach.

Impact of hospital transfer on testicular torsion outcomes: A systematic review and meta-analysis.

INTRODUCTION: Testicular torsion is an emergent condition requiring prompt treatment. Previous studies have suggested transfer of pediatric testicular torsion cases may be detrimental to patient outcomes. Findings have not reached statistical significance. No study has quantitatively analyzed all literature reporting outcomes for transferred torsion patients. The aim of this study was to elucidate the impact of hospital transfer on pediatric testicular torsion outcomes through a systematic review and meta-analysis. METHODS: A predefined study protocol registered with PROSPERO was developed according to PRISMA. A comprehensive literature review of articles investigating outcomes for pediatric testicular torsion for transferred and non-transferred (treated "directly" at presentation institution) patients with orchiectomy as the primary outcome was conducted by systematically searching PubMed and Embase. Potential studies were screened against a predefined study protocol. Meta-analysis using a random effects model with transferred status as the "intervention" was performed using Review Manager 5.3. RESULTS: Of 18 eligible studies, 9 retrospective studies comprised of 2564 patients (532 transferred and 2032 direct) were suitable for quantitative analysis. Main analysis showed transfer status does not have a significant effect on torsion outcomes (RR 0.96 [95% CI 0.78-1.17]; I2 = 44%). Subgroup analysis for torsion patients presenting within 24 h of symptom onset shows patients who are transferred to another facility for management are more likely to undergo orchiectomy than those treated at their presenting institution (RR 0.35 [95% CI 0.24-0.51]; I2 = 4%). CONCLUSIONS: In this meta-analysis, hospital transfer does not affect orchiectomy rate in pediatric patients with testicular torsion when pooling data from all presentation timeframes. Subgroup analysis of patients presenting with testicular torsion in an acute setting (<24 h of symptom onset) suggests the delay associated with hospital transfer has a deleterious effect on testicular viability.

Laparoscopic versus open pyeloplasty in children: preliminary report of a prospective randomized trial.

PURPOSE: Pyeloplasty for ureteropelvic junction obstruction in children has traditionally been performed using an open technique. Although laparoscopic pyeloplasty has been shown to be comparable and possibly superior to open pyeloplasty in adult studies, such results in the pediatric population are limited. We evaluated outcomes between transperitoneal laparoscopic and open pyeloplasty in children. MATERIALS AND METHODS: All children 1 to 18 years old with ureteropelvic junction obstruction requiring operative repair were offered enrollment in the study. Patients were prospectively randomized to either transperitoneal laparoscopic or open pyeloplasty through a flank incision. RESULTS: We reviewed 20 patients (mean age 7.8 years) who underwent laparoscopy and 19 (7.2 years) who underwent open surgery (p = 0.48). Mean followup was similar between the groups (laparoscopic 8.1 months vs open 11.1 months, p = 0.38). Mean operative time was 151 minutes (range 94 to 213) for laparoscopy and 130 minutes (83 to 225) for open surgery (p = 0.09). Mean hospitalization was 29.3 hours (range 20.5 to 48) for laparoscopy and 36.2 hours (24 to 73) for open surgery (p = 0.06). Analgesic usage was similar between the groups. One failure in the open arm required a revision. Operative, hospital, anesthetic and total charges were similar between the groups. CONCLUSIONS: Laparoscopic pyeloplasty appears to be a safe and effective alternative to open pyeloplasty in children. Although the cost is similar, there is a trend toward longer operative times in the laparoscopic group but a shorter overall hospitalization. As more patients are enrolled in the study, these differences may prove significant.

Endodermal origin of bladder trigone inferred from mesenchymal-epithelial interaction.

PURPOSE: In the classic view of bladder development the trigone originates from the mesoderm derived wolffian ducts while the remainder of the bladder originates from the endoderm derived urogenital sinus. Recent molecular developmental studies have questioned the veracity of this received wisdom, suggesting an endodermal origin for the trigone. To shed further light on this issue we observed mesenchymal-epithelial interactions between trigone epithelium and fetal urogenital sinus mesenchyma to infer the trigonal germ layer of origin. MATERIALS AND METHODS: Mouse trigone epithelium was recombined with fetal rat urogenital sinus mesenchyma in tissue recombinant grafts that were placed beneath the renal capsule of athymic mouse hosts. Grafts were harvested at 4 weeks. Control grafts with bladder dome and ureteral epithelium were also examined. Tissues were evaluated with hematoxylin and eosin, and Hoechst dye 33258 to confirm cell species origin. Immunohistochemistry was done with androgen receptor, broad spectrum uroplakin, dorsolateral prostate secretions and seminal vesicle secretions to differentiate prostatic and seminal vesicle differentiation. RESULTS: Grafts of mouse trigone epithelium with fetal rat urogenital sinus mesenchyma yielded epithelial tissue that stained for dorsolateral prostate secretions but not for seminal vesicle secretions. Control grafts of bladder dome epithelium yielded the expected endodermal prostate differentiation. Control grafts of ureteral epithelium yielded the expected mesodermal seminal vesicle differentiation. CONCLUSIONS: The consistent finding of prostatic epithelium in tissue recombinants of trigone epithelium and fetal urogenital sinus mesenchyma reinforces the hypothesis that the trigone is derived from the endoderm and not from the mesoderm, as commonly accepted.

Robot-assisted laparoscopic unroofing and fulguration of sequestered caliceal diverticula cluster.

INTRODUCTION: We report a rare case of four sequestered caliceal diverticula that failed previous percutaneous sclerotherapy and were subsequently managed with robot-assisted laparoscopic unroofing and fulguration of the sequestered diverticula cluster. METHODS: A 6 year-old female was admitted for urosepsis and flank pain. At age 2, a previous institution diagnosed a caliceal diverticulum. Prolonged-delayed magnetic resonance urography confirmed four sequestered caliceal diverticula. Intraoperative ultrasonography identified the diverticula cluster and ensured decompression. The defects were closed after ablating the blood supply, unroofing and decompressing the diverticula, and fulgurating the caliceal lining. RESULTS: Console time was 4 h with an estimated blood loss of 30-50 cc. The patient was discharged post-op day 3. Follow-up renal ultrasound at 6 weeks and 5 months demonstrated progressive atrophy of the left upper pole with preservation of the lower pole size and perfusion. At 9 months, the patient is free of symptoms and urinary tract infections. CONCLUSION: Closure of unroofed and fulgurated diverticula may be considered when diverticula are anatomically sequestered from the renal collecting system. Robotic-assisted laparoscopic unroofing and fulguration is a technically feasible approach for treatment of sequestered caliceal diverticula in pediatric patients. Additional studies and monitoring of long-term renal function are required.

Robot-Assisted Laparoscopic Resection of the Mesonephric Duct Remnant in a Patient with Zinner Syndrome.

Introduction: A 17-year-old male with Zinner syndrome, a right seminal vesicle cyst, and a solitary left kidney presented with chronic pelvic pain. Previous surgeons had attempted robot-assisted laparoscopic seminal vesicle cyst aspiration and transurethral resection of the ejaculatory duct. Neither surgery provided sustained symptom relief. Abdominal and pelvic MRI showed a cystic structure lodged between the prostate and bladder. The right seminal vesicle, kidney, and ureter were not observed. Materials and Methods: A robot-assisted laparoscopic seminal vesiculectomy was planned. Dissection distal to the right vas deferens and between the bladder neck and prostate revealed a cystic seminal vesicle-like structure. Attached to this was a tubular structure coursing deep to the vas deferens from the right renal fossa. This was presumed to be a dysplastic ureter. The dysplastic ureter was transected from the seminal vesicle and the seminal vesicle was marsupialized to the deep pelvis. Proximally, the dysplastic ureter was transected and left open. Results: Histologic assessment of the specimen revealed an ∼12.1 cm tubular mesonephric remnant. The postoperative course was uncomplicated. At 6 months follow-up, the patient remains free of symptoms with preserved ejaculatory volume. Conclusions: Mesonephric duct abnormalities and symptoms present on a spectrum. We present a safe and effective resection of a mesonephric duct remnant from a 17-year-old male with Zinner syndrome. A robotic approach localized to the right allowed for excellent observation without compromising left-sided genitourinary anatomy. In males presenting with renal agenesis and pelvic symptoms, clinicians should be suspicious of Zinner syndrome and other mesonephric abnormalities.

Pediatric Robot-Assisted Laparoscopic and Ureteroscopic Ureterolithotomy and Ureteroplasty.

Background: Pediatric urolithiasis may coexist with congenital urinary tract abnormalities, complicating conventional methods of stone treatment. Here, we present an effective case of robot-assisted laparoscopy and simultaneous ureteropyeloscopy for the definitive management of pediatric urolithiasis complicated by a congenital ureteral stricture. Case Presentation: A 3-year-old girl presented to clinic with an outside noncontrast CT scan showing two 6-7 mm nonobstructing calculi in a mildly distended upper pole moiety of a duplex left kidney. Ureteral duplication status was unclear. The patient had suffered multiple febrile urinary tract infections throughout her life. Retrograde ureteropyelogram showed a stenotic waist in the upper pole ureter just proximal to the duplex ureteral convergence, and flexible ureteroscopy confirmed a congenital ureteral stricture. Simultaneous robot-assisted laparoscopic and ureteroscopic ureterolithotomy and ureteroplasty were offered and performed using a 3-armed robotic approach. The precise location of the stricture was identified robotically with simultaneous left ureteroscopy. A medial 1.5 cm longitudinal ureterotomy was made through the ureteral stricture to facilitate upper moiety ureterorenoscopy. The calculi were visualized in the upper moiety and retrieved in whole using a stone basket. The calculi were passed via the ureterotomy to the robotic instruments intraperitoneally. The longitudinal ureterotomy was closed transversely. A ureteral stent was placed, and indocyanine green was administered intravenously to confirm good perfusion of the ureteroplasty segment via fluorescence imaging. The stent was removed at 4 weeks. Retrograde ureterography and flexible ureteroscopy revealed complete patency of the anastomosis. At 11 months, the upper pole moiety remained decompressed on ultrasonography. The patient has remained off antibiotic prophylaxis without further infection. Conclusion: Robot-assisted approaches can be primary or adjunct tools in the definitive treatment of pediatric urolithiasis with concomitant urinary tract abnormalities.

Long-term followup of dextranomer/hyaluronic acid injection for vesicoureteral reflux: late failure warrants continued followup.

PURPOSE: Dextranomer/hyaluronic acid injection of ureteral orifices is a popular option in the treatment of vesicoureteral reflux, with success rates ranging from 69% to 89%. We found only 1 study that followed patients beyond the initial postoperative voiding cystourethrogram, which describes a 96% success rate at 2 to 5 years but defines success as "nondilating" reflux. We examined our dextranomer/hyaluronic acid series to evaluate the long-term (1-year) outcome in children who had resolution of reflux on initial postoperative voiding cystourethrography. MATERIALS AND METHODS: We retrospectively reviewed our dextranomer/hyaluronic acid experience from February of 2002 to December of 2005. We determined initial success on early (6 to 12-week) postoperative voiding cystourethrogram. We then evaluated long-term success by obtaining a voiding cystourethrogram at 1 year postoperatively in patients who were initially cured of reflux. In addition, success rates between the first and second halves of our experience were evaluated to account for surgeon experience and modification of technique. RESULTS: Our total success rate at initial voiding cystourethrogram was 73% (246 of 337 total ureters). The success rate in the first half of our experience was 65.9% (112 of 170 ureters) and in the second half was 80.2% (134 of 167). A total of 150 ureteral units with initial successful dextranomer/hyaluronic acid treatment were evaluated at 1 year by voiding cystourethrogram. Of these ureters 111 had continued resolution of vesicoureteral reflux, for a long-term success rate of 74%. Including initial postoperative failures, the complete 1-year total success rate was 46.1% (111 of 241 ureters). CONCLUSIONS: Although the reflux resolution rates at initial postoperative voiding cystourethrogram approach those of open surgery, there is a significant failure rate at 1 year, which warrants long-term followup.

Extracorporeal shock wave lithotripsy for renal calculi.

PURPOSE: To gain better understanding of ESWL efficacy in children with renal calculi we report our outcomes using this technique. MATERIALS AND METHODS: We reviewed the records of children who underwent ESWL as monotherapy for renal calculi at our institution from 1988 to 2007. Data included clinical characteristics, stone-free rate and its relationship to stone size and location, lithotriptor and complications. RESULTS: The 33 boys and 29 girls with an average age of 10 years underwent a total of 69 treatments. A 53% and 63% stone-free rate was achieved after 1 and 2 ESWL sessions, respectively. A trend toward a higher stone-free rate (61% to 70%) after 1 ESWL session was seen in children with stones less than 50 mm(2), renal pelvic stones and treatment with the Dornier HM3 lithotriptor. Children with stones greater than 100 mm(2), a caliceal location and those treated with the Dornier MFL 5000 lithotriptor had a higher failure rate (25% to 46%). Five patients (8%) required ureteroscopy after ESWL due to retained distal ureteral stone fragments. Five patients (8%) who were not stone-free after therapy required subsequent endoscopic treatment for the stone during followup. CONCLUSIONS: Smaller renal stones, renal pelvic calculi and treatment with an older generation lithotriptor were independent variables associated with a higher stone-free rate in children. While ESWL is a simple method in children with renal calculi, those with large or caliceal stones may do best with a primary endoscopic approach.

Genital Neurofibromatosis Presenting as Painful Clitoromegaly.

Neurofibromatosis type 1 (NF1) is a neurocutaneous disorder caused by a mutation on chromosome 17 of the gene for neurofibromin. Patients with this condition are prone to develop benign and malignant tumors of the central and peripheral nervous systems. Genitourinary involvement in children with NF1 is uncommon and primarily affects the bladder. External genital manifestations of NF1 are rare with sporadic reports of children presenting with enlargement of their penis, clitoris, or labia due to a neurofibroma. We present a case of painful clitoromegaly due to a plexiform neurofibroma in a child.

Community associated methicillin resistant staphylococcal infections in a pediatric urology practice.

PURPOSE: Methicillin resistant Staphylococcus aureus is a virulent organism that has seen a rapid increase in prevalence. Community associated methicillin resistant S. aureus is discussed frequently in the infectious disease community. However, there has been little mention of this entity in the urological literature. MATERIALS AND METHODS: We reviewed the records of patients presenting with skin/soft tissue infections or documented methicillin resistant S. aureus infection treated at an academic pediatric urology practice between October 2004 and August 2006. RESULTS: A total of 12 patients were included (33% female, 67% male). Mean patient age was 49 months (range 8 to 202). Of the patients 11 (92%) presented with spontaneous infection and 1 (8%) presented with a wound infection. Abscess location was inguinal in 4 patients (33%), scrotal in 3 (25%), perineal in 2 (17%), perinephric in 2 (17%) and labial in 1 (8%). The most common presenting sign at referral was fluctuance (30%). While all patients eventually required surgical drainage, initial treatment by the primary care physician consisted of observation on oral antibiotics in 7 patients (58%). A total of 10 cultures (83%) revealed methicillin resistant S. aureus and 2 cultures (17%) were negative. Mean hospital stay was 5 days (range 0 to 16). Postoperatively, most patients (58%) were discharged home on oral trimethoprim-sulfamethoxazole. Mean followup was 4 months (range 0 to 15). Recurrence was seen in 3 patients at 1 to 15 months postoperatively (mean 6.3). CONCLUSIONS: Methicillin resistant S. aureus is increasing in the community and will likely be seen more often in pediatric and adult urological practices. The regional differences among bacterial strains make a standardized approach to these cases difficult. However, increased awareness of this virulent organism is necessary to deliver prompt and successful treatment.