Are weight or age limits for pediatric laparoscopic pyeloplasty? Results of a multicentric study.

INTRODUCTION: Anderson-Hynes pyeloplasty is the technique of choice for the treatment of pyeloureteral junction obstruction (PUJO) with an excellent success rate. Minimally invasive surgery has become the standard of care for the management of PUJO in children. Although it has been comparable to the open approach at all levels, its diffusion or employment in younger children has not been widely adopted. Our aim is to evaluate laparoscopic pyeloplasty outcomes from international academic centers in children under 1 year of age, focusing on feasibility and outcomes including possible complications. MATERIALS AND METHODS: This is review of consecutive infants under 1 year of age who underwent laparoscopic pyeloplasty between 2009 and 2018 with more than 12 months of follow-up. Seven different training centers with different backgrounds participated in this study. Evaluation was carried out with ultrasound and renogram before and after surgery. Demographic data, perioperative characteristics, complications, and results are described and analyzed. RESULTS: Over 9 years, 124 transperitoneal laparoscopic Anderson-Hynes pyeloplasties were performed on 123 children under 1 year of age; 88 males and 35 females, with 1 case of bilateral PUJO. Of the 124 renal units, 86 were left-sided. Mean age at surgery was 6.6 months (1 week-12 months), with 56% (n = 70) done before 6 months of age. Mean weight at surgery was 6.8 kg (3-12 kg), with 59% (n = 73) weighing less than 8 kg. Mean operative time (skin-to-skin) was 150 min (75-330 min). After a mean follow-up of 46 months (12-84 months), 12 (9%) patients developed complications, with only 1 needing a redo pyeloplasty also done laparoscopically. One child, with deterioration in renal function, underwent nephrectomy. CONCLUSION: Laparoscopic pyeloplasty under 1 year of age and/or less than 12 kilos is feasible with lower complication rate. Furthermore, age younger than 6 months and weight less than 8 kg are no longer limiting factors for a successful pyeloplasty as shown by this multicentre study.

Optimization of Pediatric Bowel Management Using an Antegrade Enema Troubleshooting Algorithm.

BACKGROUND: A successful flush is the ability to flush through the appendicostomy or cecostomy channel, empty the flush through the colon, and achieve fecal cleanliness. We evaluated our experience with patients who were having flush difficulties based on a designed algorithm. METHODS: Eight patients with flush difficulties were initially evaluated. Based on the need for additional surgery versus changes in bowel management therapy (BMT), we developed an algorithm to guide future management. The algorithm divided flush issues into before, during, and after flushing. Children aged <20 y who presented with flush issues from September 2018 to August 2019 were evaluated to determine our algorithm's efficacy. Specific outcomes analyzed included changes in BMT versus need for additional surgery. RESULTS: After algorithm creation, 29 patients were evaluated for flush issues. The median age was 8.4 y (interquartile range: 6, 14); 66% (n = 19) were men. Underlying diagnoses included anorectal malformations (n = 17), functional constipation (n = 7), Hirschsprung's disease (n = 2), spina bifida (n = 2), and prune belly (n = 1). A total of 35 flush issues/complaints were noted: 29% before the flush, 9% during the flush, and 63% after the flush. Eighty percent of issues before the flush required surgical intervention, wherease 92% of issues during or after the flush were managed with changes in BMT. CONCLUSIONS: Most flush issues respond to changes in BMT. This algorithm can help delineate which types of flush issues would benefit from surgical intervention and what problems might be present if patients are not responding to changes in their flush regimen.

Laparoscopic vs Open Pyeloplasty in Children: Results of a Randomized, Prospective, Controlled Trial.

PURPOSE: Open dismembered pyeloplasty is the preferred repair for ureteropelvic junction obstruction. Minimally invasive techniques have been applied to the original open approach but no clear advantage has been demonstrated for these technological advances. We evaluate 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 laparoscopic or open pyeloplasty through a flank incision. RESULTS: A total of 50 patients in the laparoscopic group and 48 in the open group were enrolled from 2005 to 2014. Mean followup was similar between the groups (13.7 months in the laparoscopic group vs 12.3 months in the open group, p = 0.54). The only significantly different outcomes were for mean operative time, which was 139.5 minutes (range 94 to 213) in the laparoscopic group and 122.5 minutes (83 to 239) in the open group (p <0.01), and mean length of stay, which was 25.9 hours (18 to 143) in the laparoscopic group and 28.2 hours (16 to 73) in the open group (p = 0.02). Analgesic usage, success rate, total charges and all parameters in children older than 11 years were similar between the groups. CONCLUSIONS: Open and laparoscopic dismembered pyeloplasty are comparable and effective methods for repair of ureteropelvic junction obstruction. Although operative time was statistically shorter in the open group and length of stay was shorter in the laparoscopic group, the clinical significance of these variables is questionable. The approach to repair may best be based on family preference for incision aesthetics and surgeon comfort with either approach, rather than more classically objective outcome measures.

Surgical Approaches to Pediatric Ureteropelvic Junction Obstruction.

Approximately 10-30% of infants with hydronephrosis are found to have ureteropelvic junction (UPJ) obstruction. Technological advances in imaging have allowed physicians to better identify the location of the obstruction. The classic repair is the Anderson-Hynes repair which shows a 90-100% success rate and appears superior to many less complex techniques. Is it best to approach this repair through an open incision or laparoscopically with or without a surgical robot? That question remains to be answered and largely depends on how you define "best."

Latitudes and attitudes: A multinational study of laparoscopic pyeloplasty in children.

PURPOSE: The Anderson-Hynes technique has been the treatment of choice for primary ureteropelvic junction obstruction in children. Laparoscopic approach has shown similar outcomes to open, with advantages of shorter hospital stay and less pain. We reviewed the experience of 11 geographically diverse, tertiary pediatric urology institutions focusing on the outcomes and complications of laparoscopic pyeloplasty. MATERIALS AND METHODS: A descriptive, retrospective study was conducted evaluating patients undergoing Anderson-Hynes dismembered laparoscopic pyeloplasty. Centers from four different continents participated. Demographic data, perioperative management, results, and complications are described. RESULTS: Over a 9-year period, 744 laparoscopic pyeloplasties were performed in 743 patients. Mean follow-up was 31 months (6-120m). Mean age at surgery was 82 months (1 w-19 y). Median operative time was 177 min. An internal stent was placed in 648 patients (87%). A catheter was placed for bladder drainage in 702 patients (94%). Conversion to open pyeloplasty was necessary in seven patients. Average length of hospital stay was 2.8 days. Mean time of analgesic requirement was 3.2 days. Complications, according to Clavien-Dindo classification, were observed in 56 patients (7.5%); 10 (1%) were Clavien-Dindo IIIb. Treatment failure occurred in 35 cases with 30 requiring redo pyeloplasty (4%) and 5 cases requiring nephrectomy (0.6%). CONCLUSION: We have described the laparoscopic pyeloplasty experience of institutions with diverse cultural and economic backgrounds. They had very similar outcomes, in agreement with previously published data. Based on these findings, we conclude that laparoscopic pyeloplasty is safe and successful in diverse geographics areas of the world.

Antibiotic use for asymptomatic bacteriuria in children with neurogenic bladder.

PURPOSE: Patients with neurogenic bladder (NB) often perform clean intermittent catheterization (CIC) and are predisposed to bladder colonization. Antibiotics are not routinely indicated in those with asymptomatic bacteriuria (ASB). The original purpose of this study was to compare patients that received antibiotics for ASB and those that did not. However, because the non-antibiotic group was very small, the final analysis evaluated treatment patterns of ASB in children with NB. METHODS: A retrospective chart review was completed, including patients who presented with urinary tract infection (UTI) and NB managed by CIC. Patients with symptoms of UTI were excluded. Basic demographics, urinalysis, culture results, and antibiotic prescriptions were collected. RESULTS: The sample included 272 patient encounters for 109 unique patients. Of these, 50.7% were female, and the median age was 10.25 years. More than half the urine cultures (56.2%) grew gram-negative organisms, and 31.3% contained 2 or more organisms. Nearly all encounters received treatment with antibiotics. Twenty-three encounters with no culture performed or the culture resulted in no growth received antibiotic therapy. CONCLUSIONS: Antibiotic resistance and antibiotic stewardship are primary concerns in healthcare today. This organization's current practice pattern shows high antibiotic use for ASB in patients with NB. Future studies are required to identify outcomes associated with treatment versus non-treatment in these patients.

Single institution review of Mini-ACE® low-profile appendicostomy button for antegrade continence enema administration.

PURPOSE: Malone antegrade continence enemas (MACE) provide a conduit in which the patient can achieve improved continence, be clean of stool, and gain independence in maintaining bowel function. The Mini-ACE® is a low-profile balloon button that is used to facilitate the administration of antegrade enemas. We sought to describe our practice and short-term outcomes. METHODS: This work is a retrospective review of the Mini-ACE® appendicostomy button from April 2019 to March 2021, with follow-up concluding in October 2021. Patient demographics, colorectal diagnoses, and outcomes were examined. RESULTS: Forty-three patients underwent Mini-ACE® placement; 22 (51%) were male. The average age at Mini-ACE® insertion was 9.2 years (range 3-20 years). The most common diagnoses were functional constipation in 19 (44%), anorectal malformation in 15 (35%), and Hirschsprung disease in 3 (7%), spinal differences 3 (7%). There were no intra-operative complications, but 5 (12%) required prolapse resection. The median length of stay was two days (IQR 1, 4). Patients achieved self-catheterization at 4.5 [3,7] months from MACE creation, with 38 children (88%) reporting excellent success in remaining clean of stool. CONCLUSION: The Mini-ACE® appears to be a safe and low-profile option for antegrade continence enema access. Further research is needed directly comparing complications and patient satisfaction rates between different MACE devices and overall quality of life. LEVEL OF EVIDENCE: Level IV.

Adolescent Varicocelectomy: Success at What Cost? Clinical Outcome and Cost Comparison of Surgical Ligation and Percutaneous Embolization.

Objectives: Evaluate clinical outcome, recurrence, morbidity, and cost associated with laparoscopic surgical ligation versus percutaneous embolization of adolescent varicocele. We hypothesize that both approaches are similar in outcomes, complications, and cost. Materials and Methods: A retrospective review of 56 consecutive adolescent males, ≤18 years from 2006 to 2016 with clinical varicocele who underwent laparoscopic surgical ligation or percutaneous embolization. Patient demographics, operative time, postoperative complications, success, varicocele grade, recurrence, and hospital charges were abstracted. Results: Mean age was 14.2 ± 2.1 years; 48 (86%) patients having undergone laparoscopic surgical ligation and 8 (14%) percutaneous embolization. Intervention in 45 (80%) patients was for testicular hypotrophy (mean 27.4% ± 15.6%) and 11 (20%) for pain symptomology. Median follow-up was 17.5 months (range 1-65 months). After ligation, 2 (4%) patients developed hydroceles (1 with subsequent hydrocelectomy) and 6 (12%) varicocele recurrence. There were no cases of hydrocele or varicocele recurrence after percutaneous embolization. Twenty ligation patients had postoperative scrotal ultrasound demonstrating an increase in testicular volume by a reduction in difference in testicular volume from 27.3% ± 14.7% preoperatively to 11.2% ± 13.6% postoperatively (P < .001). There was significant difference in mean operative time between the groups (surgical ligation 41.3 minutes versus percutaneous embolization 117.9 minutes, P < .001) and hospital charges for the procedure (surgical ligation $3983 versus percutaneous embolization $18.165, P < .001). Conclusions: Contrary to our hypothesis, percutaneous embolization has seemingly lower rates of postoperative hydrocele and varicocele recurrence in comparison to surgical ligation but with three times the exposure to general anesthesia and at four times the price.

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.

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.

Variation in diethylenetriamine pentaacetic acid and mercaptoacetyltriglycine renal scans: clinical implications of interobserver and intraobserver differences.

PURPOSE: Diethylenetriamine pentaacetic acid and mercaptoacetyltriglycine renal scans are commonly used to evaluate infants and children with hydronephrosis to assess for changes in kidney function and drainage. We evaluate the certified nuclear medicine technologist intraobserver and interobserver variability of data processing in diuretic renal scan interpretation of the percent differential function of the right kidney so that true physiological changes can be understood by the clinician. MATERIALS AND METHODS: A total of 30 renal scans (diethylenetriamine pentaacetic acid in 20 patients and mercaptoacetyltriglycine in 10) were randomly selected for evaluation by 3 technologists who processed the scan data for each patient on 5 different occasions at least 1 week apart. Regions of interest were drawn and background areas were subtracted, and percent differential function of the right kidney was calculated. Technologists were blinded to patient identification and previous interpretation results. The data were then statistically analyzed. RESULTS: The data focused on percent differential function of the right kidney. Confidence limits for the single scan interpretation at the 95% level showed +/-5.8% differential function variation, although this scan was the same renal scan processed 1 week later. CONCLUSIONS: For differential function determined on diethylenetriamine pentaacetic acid or mercaptoacetyltriglycine diuretic renal scan the single scan 95% confidence limits were +/-5.8% differential function. From one renal scan to the next the differential percent of kidney function must change +/-11.6% differential function for a clinician to be 95% confident that a real change in kidney function has occurred. This uncertainty is substantial and is likely larger than is currently allowed for in clinical practice.

Current management of the acute scrotum.

Pediatric surgeons and urologists are often asked to evaluate boys with acute scrotal pain and inflammation. Although there are myriad etiologies for this syndrome, testicular torsion should be at the top of the list. It is the one diagnosis that must be made accurately and rapidly if there is any hope for testicular salvage. The purpose of this article is to update/review the appropriate evaluation and management of the acute scrotum and to guide the clinician in distinguishing testicular torsion from the other conditions that commonly mimic this surgical emergency.

Pediatric Testicular Torsion.

The pediatric patient presenting with acute scrotal pain requires prompt evaluation and management given the likelihood of testicular torsion as the underlying cause. Although other diagnoses can present with acute testicular pain, it is important to recognize the possibility of testicular torsion because the best chance of testicular preservation occurs with expeditious management. When testicular torsion is suspected, prompt surgical exploration is warranted. A delay in surgical management should not occur in an effort to obtain confirmatory imaging. When torsion is discovered, the contralateral testicle should undergo fixation to reduce the risk of asynchronous torsion.

Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction Following Open Pyeloplasty in Children.

OBJECTIVE: Few studies have evaluated the role of laparoscopic dismembered pyeloplasty in the setting of recurrent ureteropelvic junction (UPJ) obstruction following open dismembered pyeloplasty in the pediatric population. We present our experience at a single institution. PATIENTS AND METHODS: A retrospective analysis was performed of patients treated with laparoscopic pyeloplasty for secondary UPJ obstruction from March 2003 to August 2011 at a single institution. These patients were age and temporally matched with a control group of patients undergoing primary laparoscopic pyeloplasty. RESULTS: In total, 5 patients were identified as having undergone laparoscopic pyeloplasty for secondary UPJ obstruction following open dismembered pyeloplasty. Operative time was longer in the secondary repair group compared with the control group (190 versus 141 minutes; P = .24), although this was complicated by 1 patient in the secondary repair group undergoing multiple procedures. Morphine equivalent use and length of stay were similar (4.1 versus 6.6 mg [P = .21] and 1.4 versus 1.2 days [P = .67] in control patients versus secondary repair patients, respectively). All of the 5 (100%) patients undergoing secondary repair had successful outcomes with improved hydronephrosis on ultrasound, and 4 of 4 (100%) had improved or normal T½ times on postoperative mercaptoacetyltriglycine (MAG3) renal scan. One family in each group declined the renal scan for personal reasons. No complications were noted with a mean follow-up time of 13 months in both groups. CONCLUSIONS: Laparoscopic repair of secondary UPJ obstruction is a well-tolerated and effective option. When this technique is compared with primary laparoscopic pyeloplasty, results appear equivalent even after failed open repair, with comparable postoperative narcotic requirement and length of stay. Further studies are needed to better define the role of secondary laparoscopic pyeloplasty in the pediatric population, especially with regard to cost compared with other open and minimally invasive techniques.