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.

Prospective quality of life in men choosing open vs. robotic radical prostatectomy: long-term results from a racially diverse multi-institutional database.

PURPOSE: To compare 5-year health-related quality of life (HRQoL) outcomes between prostate cancer (CaP) patients who underwent robotic-assisted laparoscopic radical prostatectomy (RALP) versus open radical retropubic prostatectomy (RRP) and assess for racial disparities between Caucasian American (CA) and African American (AA) men undergoing surgery. METHODS: A prospective cohort study of HRQoL data was conducted on patients diagnosed with CaP from 2007 to 2017 and enrolled in the Center for Prostate Disease Research (CPDR) Multicenter National Database. Using the EPIC and SF-36 instruments, changes in urinary, sexual, bowel, and hormonal domains, as well as physical and mental component summary scores were compared across surgery type (RALP versus RRP) at pre-treatment ("baseline"), and annually for 5 years. We further compared HRQoL outcomes in CA and AA men undergoing surgery. Longitudinal HRQoL patterns were modeled using generalized estimating equations (GEE), adjusting for baseline HRQoL and other characteristics. RESULTS: 448 CaP patients (22% AA) met study inclusion criteria, 66% underwent RALP and 34% underwent RRP. At baseline, HRQoL domains were comparable across treatment group (RALP vs. RRP). In the adjusted low-risk cohort, there were only three time points that met a statistically significant HRQoL difference in EPIC scores between RALP and RRP. Urinary function score during year 4 of follow-up showed a 7.5 (95% CI 3.1-11.9, P = 0.01) points difference in favor of RRP. Bowel bother scores favored RRP in year 1 with a difference of 3.1 (95% CI 0.7-5.4, P = 0.04) points, and in year 5 with a difference of 3.8 (95% CI 1.1-6.4, P = 0.03) points. In the intermediate/high-risk cohort, there were no statistically significant differences in any of the domain scores between RALP and RRP during follow-up. CONCLUSIONS: The robotic and open approach to radical prostatectomy led to comparable HRQoL outcomes at a follow-up length of 60 months. No HRQoL racial disparities were found between AA and CA men during long-term follow-up.

Standardized single-stage laparoscopic Fowler-Stephens orchiopexy regardless of testis position: Modification of technique eliminates the need for intra-operative decision-making.

Background / Purpose: It is generally perceived that a primary laparoscopic orchiopexy has superior outcomes due to preservation of the testicular artery, and thus should be the choice when achievable. The two-stage laparoscopic Fowler-Stephens orchiopexy (LFSO) is considered superior regarding success rate compared to the one-stage procedure when the artery must be transected. Outcomes can be jeopardized when a primary orchiopexy is ultimately realized to be the incorrect procedure due to insufficient testicular artery length. It is preferable to decide the approach before initiating dissection, however, in reality, this does not always occur. A single uniform approach to all intraabdominal testes (IAT) that takes into consideration the main challenges encountered when performing laparoscopic orchiopexy can simplify the approach and potentially achieve good outcomes. We present our experience with a standardized approach for IAT regardless of testicular position and describe the surgical modification needed to achieve good results with the one-stage LFSO. Materials and Methods: Key surgical maneuvers implicated in the modified one-stage LFSO (M-LFSO) include preservation of a wide peritoneal flap between the vessels and the vas deferens, dissecting the vessels as proximal as possible and avoiding manipulation of the epididymis and vessels between the vas and epididymis when transferring the testis to the scrotum. Results: Our cohort included 55 boys (59 testes). Median age and weight at surgery were 13.3 months (interquartile range [IQR] 9.2-32.4) and 10.4 kg (IQR 9.2-12.6). The mean operative time was 70 min (IQR 60-85). The median follow-up was 11 months (IQR 7-12). There was one case of testicular atrophy (2%) and two cases of suboptimal testicular position in the scrotum at 6 months. Conclusions: M-LFSO is a standardized approach for all cases of IAT regardless of testicular position. Preservation of a wide peritoneal flap and proximal dissection of the vessels may contribute to the adequate testicular blood supply. The proposed approach eliminates the need for intra-operative decision-making and for ancillary procedures.

Minimally Invasive Approach for Treatment of Seminal Vesicle Cyst Associated with Ipsilateral Renal Agenesis.

OBJECTIVES: We reviewed the clinical presentation and approach for the treatment of symptomatic seminal vesicle cyst associated with ipsilateral renal agenesis while presenting our experience with a series of 5 patients treated with minimally invasive surgery for Zinner syndrome. MATERIALS AND METHODS: Between the years 2008 and 2016, we operated on 5 patients who presented with symptomatic seminal vesicle cyst and ipsilateral renal agenesis. Patients' charts and medical records were reviewed and compared with past published minimally invasive series. RESULTS: Four patients were treated in a laparoscopic approach and one was treated with robotic-assisted seminal vesicle cyst excision. In all cases, the cystic complex was drained and excised with marsupialization of the remaining cyst walls to prevent cystic recurrence. The mean operating time was 3:47 h and mean hospitalization time was 7 days (4-14). The mean follow-up period was 3.2 years (range 1.7-4.8 years). All patients reported a resolution of symptoms during postoperative follow-up. CONCLUSIONS: Seminal vesicle cyst with ipsilateral renal agenesis should be suspected in young male patients presenting with pelvic cystic masses. Treatment is reserved for symptomatic patients and the preferred approach is minimally invasive surgery. This approach is feasible and effective while providing advantages both for the patient and the surgeon.

The effect of ureteropelvic junction obstruction and pyeloplasty on somatic growth during infancy.

Background: Evidence regarding the impact of perinatal ureteropelvic junction obstruction (UPJO) and surgical correction during infancy, on somatic growth are scarce. Understanding these impacts could help advise parents and aid in treatment decision making. Objectives: To assess the impact of unilateral UPJO and surgical correction on somatic growth in infants diagnosed antenatally and treated during infancy. Design: A retrospective bi-institutional analysis of somatic growth in patients under 2 years who underwent dismembered pyeloplasty for the treatment of UPJO was conducted. Methods: We evaluated patients who were diagnosed with unilateral hydronephrosis during pre-natal ultrasound screening for detection of fetal anomalies between May 2015 and October 2020. The height and weight of patients who were diagnosed with UPJO were recorded at the age of 1 month, time of surgery, and 6 months after surgery. Standard deviation scores (SDSs) for height and weight were calculated and compared. Results: Forty-eight patients under the age of 2 years were included in the analysis. Median age and weight at pyeloplasty were 6.9 months and 7.5 kg. At 1 month, the median SDS for weight in the entire cohort was -0.30 [interquartile range (IQR): -1.0 to 0.63] and the median SDS for height was -0.26 (IQR: -1.08 to 0.52). In 22.9% of patients (11/48), weight and height were below -1 age-appropriate standard deviations, and 6.3% (3/48) were below -2 standard deviations, suggesting growth restriction. When comparing SDS for the entire cohort, there was no significant difference corelated to measurement time or effect of surgery. In the growth restricted cohort, we found a significant improvement in linear growth for height, which was demonstrated between birth and surgery as well as after surgery. Conclusion: Infants with unilateral UPJO diagnosed antenatally as a single anomaly may be at an increased risk of somatic growth restriction in comparison with the general population. In children with growth restriction at time of birth, height seems to improve regardless of surgical treatment. Pyeloplasty during infancy does not seem to negatively affect somatic growth. These findings can be used to counsel parents regarding the potential effects of UPJO and pyeloplasty.

Ureteral Stent Colonization and Urinary Tract Infection in Children Undergoing Minimally Invasive Pyeloplasty.

INTRODUCTION: Minimally invasive pyeloplasty (MIP), namely, laparoscopic and robot-assisted interventions, has gained popularity in recent years. Double-J ureteral stents are frequently inserted during surgery. Foreign bodies in the urinary tract are considered as risk factor for developing urinary tract infection (UTI). This study aimed to specify the bacteria cultured from urine and stents responsible for UTI in children with indwelling ureteral stents undergoing MIP. PATIENTS AND METHODS: We retrospectively reviewed medical records of 30 children (22 boys and 8 girls) who had undergone MIP between 2014 and 2017. Median age at surgery was 2.7 years (interquartile range [IQR]: 0.5-7.9). Urine cultures were obtained before surgery, before stent removal, 1 month after stent removal, and if UTI was suspected. Stents were removed 4 to 8 weeks after surgery and cultured. Patients' demographics, types of stents, and surgical details were recorded. RESULTS: Median stent indwelling time was 5.09 weeks (IQR: 4-6). Postoperative febrile UTI developed in 4/30 (13%) patients. Afebrile UTI occurred in another 4/30 (13%) patients. Stent cultures were positive in 19/30 (63%) patients. Stent and urinary cultures were identical in only one patient. Three of four patients with preoperative asymptomatic bacteriuria developed postoperative UTI. There was no association between UTI, gender, stent diameter, and duration of indwelling catheter. CONCLUSION: After MIP, febrile UTI and afebrile UTI occurred in about one quarter of patients. Pathogens isolated postsurgically from urinary cultures were unrelated to those colonizing the stents. Therefore, routine stent culturing is of low clinical significance. Moreover, small-caliber stents and longer indwelling periods were not risk factors for UTI. Optimizing antibiotic treatment for children with preoperative UTI may potentially prevent morbidity after surgery.

Laparoscopic Ureteral Reimplantation after Failed Open Surgery: Incorporating the Psoas Hitch Maneuver for Sufficient Tunnel Length.

BACKGROUND: Failure after open ureteral reimplantation has been reported to occur in 2 to 7% of cases. While a second open reconstructive surgery is appropriate in most cases, there are data suggesting similar outcomes utilizing the laparoscopic approach. The objective of this study is to describe a modification and report our experience with laparoscopic ureteral reimplantation after failed open reimplantation reinforced with a psoas hitch. MATERIALS AND METHODS: A retrospective review of pediatric patients who underwent laparoscopic ureteral reimplantation after failed open surgery between September 2012 and April 2018 at three different academic centers was performed. Patient demographics, surgical indications, complications, and outcomes were reviewed. Either ipsilateral ureteral reimplantation with a combined intravesical and extravesical approaches or a cross-trigonal extravesical approach was utilized, depending on the length of the ureter. In all cases, a psoas hitch was performed to gain a longer submucosal tunnel and relieve tension, thus facilitating an efficient antireflux mechanism. RESULTS: Seventeen patients underwent a laparoscopic ureteral reimplantation after failed open surgery. Median age at second surgery was 106 months (interquartile range [IQR]: 53-122.5). Ipsilateral ureteral reimplantation with a combined intravesical and extravesical approaches was performed in 11 cases and cross-trigonal extravesical approach in 6 cases. Median ureteral diameter before the redo surgery was 16 mm (IQR: 14.5-18.5) and after surgery was 6 mm (IQR: 3.5-8.5) (p < 0.001). Postoperative mercaptoacetyltriglycine renal scan showed a nonobstructive pattern and stable renal function in all cases. CONCLUSION: Laparoscopic ureteral reimplantation with incorporation of a psoas hitch after failed open reimplantation is safe and effective.

Are high-risk prostate cancer patients being treated equally? The impact of PSA.

BACKGROUND: Patients with high-risk (HR) prostate cancer (PCa) represent a heterogeneous group, however, current treatment guidelines do not consider their specific features. The objective of this study was to evaluate treatment trends and outcomes in HR patients defined by PSA alone and otherwise low-risk features. METHODS: Using the National Cancer Database, we identified patients diagnosed with HR PCa between 2010 and 2016. A study group of patients defined by PSA >20 ng/ml alone and otherwise low-risk features, was compared to a group of HR patients defined by Gleason score or stage. We compared treatment rates over time, the use of concomitant androgen deprivation therapy (ADT), and overall survival (OS). Examination of treatment trends was done using a Z-test analysis. A Kaplan-Meier survival analysis was used to determine 5-year OS with the Log-rank test for comparison. Statistical analyses were completed using R Version 3.5.2. RESULTS: We identified 5,652 patients in the study group and 71,922 in the comparison group. Only 6.8% of the study group had disease ≥cT2, compared to 43.7% in the comparison group. In the study group, 12.5% (709), underwent active surveillance (AS), 36.4% (2,055) radiation therapy (EBRT) and 51.1% (2,888) radical prostatectomy (RP), while the rate of AS, EBRT, and RP in the comparison group were 0.3% (191), 43.0% (30,928), and 56.7% (40,803), respectively. Over the study period, adoption of AS increased from 6.2% in 2010 to 25.0% in 2016 in the study group (P< 0.001), but not in the comparison group. In patients undergoing EBRT, ADT treatment increased from 2010 to 2016 in both groups, though by 2016 only 45.3% of patients in the study group and 86.3% in the comparison group received ADT. The 5-year OS was 93.7% (95% CI 92.8-94.6) in the study group and 89.7% (95% CI 89.2-90.1) in the comparison group (P< 0.001). CONCLUSIONS: Men with HR PCa defined by PSA with otherwise low risk features present at an earlier stage and receive less aggressive therapy than other HR patients. Despite increased rates of AS and decreased use of ADT, these patients appear to have improved survival when compared to other HR patients. These findings suggest that not all HR patients will benefit from aggressive definitive treatment.

Prospective Long-term Health-related Quality of Life Outcomes After Surgery, Radiotherapy, or Active Surveillance for Localized Prostate Cancer.

Background: Localized prostate cancer (PCa) treatment is associated with reduced health-related quality of life (HRQoL). Current literature is limited by short-term follow-up. Objective: To prospectively evaluate the 5-yr HRQoL outcomes in men undergoing radical prostatectomy (RP), external beam radiotherapy (EBRT), or active surveillance (AS). Design setting and participants: We prospectively evaluated HRQoL in patients with low-risk/favorable intermediate-risk PCa enrolled in the Center for Prostate Disease Research multicenter database between 2007 and 2017. Intervention: Of 1012 patients included in the study, 252 (24.9%) underwent AS, 557 (55.0%) RP, and 203 (20.0%) EBRT. Patients complete the Expanded Prostate Cancer Index Composite and the 36-item Medical Outcomes Study Short Form at baseline and thereafter each year up to 5 yr after treatment. Outcome measurements and statistical analysis: Temporal changes in HRQoL were compared between treatments and were modeled using linear regression models adjusted for baseline HRQoL, demographic, and clinical characteristics. Results and limitations: RP showed the least irritative symptoms and worse incontinence in comparison with AS (p < 0.001 for both subdomains) or EBRT (p < 0.001 for both subdomains) at all time points. RP sexual domain score was worse than the scores of AS (mean difference 22.3 points, 95% confidence interval [CI] 10.5-27.8, p < 0.001) and EBRT (mean difference 16.9 points, 95% CI 12.5-20.3, p < 0.001) during years 1-3 and not different from that of EBRT (mean difference 2.9 points, 95% CI -4.8 to 8.3, p = 0.3) at years 4 and 5. Bowel function and bother were worse for EBRT than for AS (p < 0.001 for both subdomains) and RP (p < 0.001 for both subdomains) at all time points. During the 3-5-yr period, AS demonstrated the worst decline in all mental health domains (p < 0.001 in comparison with both EBRT and RP). Conclusions: RP results in worse long-term urinary function and incontinence, but in less irritative and obstructive symptoms than EBRT and AS. Sexual domain scores were least affected by AS, while RP shows similar scores to EBRT at long term. Long-term HRQoL changes are critical for advising patients. Patient summary: We evaluated long-term health-related quality of life (HRQoL) in a large US population treated for localized prostate cancer. HRQoL outcomes varied according to treatment modality and time. These changes should inform patients about their expected outcomes following treatment.

The Effects of Surgical Approaches and Enhanced Recovery Protocols on the Cost Effectiveness of Radical Cystectomy.

Enhanced recovery protocols and robotic approaches to radical cystectomy are known to reduce perioperative complications; however, the most cost-effective strategy is unknown. We aim to assess the cost effectiveness of radical cystectomy with different surgical techniques and perioperative treatment protocols. We performed a meta-analysis of studies comparing open radical cystectomy (ORC), robotic assisted radical cystectomy (RARC) using extracorporeal (ECUD) or intracorporeal urinary diversion (ICUD) and enhanced recovery after surgery (ERAS) protocols. Operative time, transfusion, complication, Ileus, length of stay and re-admission rates were extracted. US costs for surgery, treatment, hospitalization and complications were obtained from the literature. Israeli costs were obtained from hospital administrative data. Two cost effectiveness models (US and Israel) were developed. The two most cost-effective strategies in both models were ORC with ERAS and RARC with ICUD and ERAS. RARC with ERAS produced the two most effective strategies with ICUD being dominant over ECUD. All strategies implementing the ERAS protocol were more effective than their parallel non-ERAS strategies. RARC with ICUD and ERAS is cost effective compared to ORC. ERAS protocol improves treatment effectiveness and lowers overall costs. ICUD was shown to be more effective and less costly in comparison to ECUD.

Patient reported outcomes and health related quality of life in localized prostate cancer: A review of current evidence.

BACKGROUND: Oncological outcomes after localized prostate cancer (CaP) treatment are excellent and generally considered equivalent across treatment modalities. Thus, short, and long-term patient health related quality of life (HRQoL) is an important factor in treatment discussions. The purpose of this review was to assess the impact of treatment modality for localized CaP on HRQoL as reflected by recent published trials. METHODS: We conducted a literature review using the PubMed database for studies published between January 2010 and January 2021. We included randomized control trials and observational cohort studies examining HRQoL in patients with localized CaP treated with active surveillance, radical prostatectomy, external beam radiotherapy or brachytherapy. RESULTS: Four randomized control trials and 15 prospective cohort studies were reviewed. Current evidence suggests that surgery has the largest short and long-term negative effect on sexual function and incontinence but advantages with regards to bowel function and irritative-obstructive urinary symptoms. Radiation therapy mainly impacts urinary irritative symptoms and bowel bother. Short-term HRQoL outcomes for active surveillance are most favorable, however, during long-term follow up, there is no significant difference in comparison to radiation. Long-term global quality of life impact regarding anxiety, mental, emotional well-being, and fatigue seem to be equivalent between treatment modalities. CONCLUSIONS: The choice of primary treatment modality for localized CaP results in a unique impact profile on cancer specific HRQoL in both the short and long-term periods. Understanding the different adverse events profiles can provide a basis for informing patients and clinicians regarding the impact of disease and treatments on quality of life and allow for a better patient centered discussion.

Impact of COVID-19 on Society of Urologic Oncology fellowship operative volumes.

PURPOSE: The COVID-19 pandemic impacted all aspects of healthcare including surgical training. Our objective was to assess the impact of the pandemic on surgical case volumes of graduating Society of Urologic Oncology (SUO) fellows during the academic years 2019 to 2020 and 2020 to 2021. MATERIALS AND METHODS: Deidentified case logs for graduating SUO fellows from 2017 to 2021 were obtained from the SUO Education Committee. Cases are stratified by category and minimally invasive surgery (MIS) or open approach. Graduates of 2017, 2018, and 2019 were combined into a pre-COVID cohort and compared to COVID-affected 2020 and 2021 cohorts. Total case volumes, case category volumes, and surgical approach type were compared with Kruskal-Wallis test. RESULTS: A total of 173 graduating SUO fellow case logs were analyzed with 100, 38, and 35 in the pre-COVID and COVID-affected 2020 and 2021 cohorts, respectively. All fellow logs were obtained for 2017 to 2020 graduates while 5 of 40 were missing for the 2021 cohort. There was no statistical difference in median total cases across cohorts (P = 0.52). For the first COVID-affected cohort of 2020, they reported significantly fewer total MIS cases in 2020 compared to pre-COVID fellows (median 92.5 vs. 135 pre-COVID, P = 0.002). However, there were no significant differences among the tracked oncologic MIS categories except a statistically significant increase in MIS retroperitoneal lymph node dissection between 2020 and 2021 COVID-affected cohorts (0 vs. 2, P = 0.033) CONCLUSIONS: The oncologic case volumes of the initial SUO fellows graduating during COVID pandemic were minimally affected. This national deidentified data is reassuring that oncologic training has not been impacted by widespread decreases in case volume. However, impacts on individuals, programs or geographic regions may have varied.

Minimally Invasive Dismembered Extravesical Cross-Trigonal Ureteral Reimplantation for Obstructed Megaureter: A Multi-Institutional Study Comparing Robotic and Laparoscopic Approaches.

OBJECTIVE: To compare 2 minimally invasive surgical options for the treatment of obstructed megaureter: robot assisted dismembered extravesical cross-trigonal ureteral reimplantation (RADECUR) and laparoscopic dismembered extravesical cross-trigonal ureteral reimplantation (LDECUR). METHODS: A 2 arm retrospective comparative study, including all pediatric patients who underwent ureteral reimplantation of unilateral obstructed megaureter, either by RADECUR or LDECUR. Patient demographics, perioperative surgical data, complications, and results are described. The surgical technique in both arms was similar: dismembering of the ureter, performing an extravesical cross-trigonal detrusorotomy, and intracorporeal tailoring of the ureter when indicated, were the pivotal maneuvers utilized. RESULTS: The study included 95 patients (48 and 47 in the RADECUR and LDECUR arms, respectively) operated between the years 2016 and 2019. Overall, median age at surgery was 24 months (IQR 12-48) and median weight was 14 kg (IQR 11-21). Median operative time was 93 minutes (IQR 90-120) for RADECUR and 130 minutes (IQR 105-160) for LDECUR (P< 0.001). Intracorporeal excisional tapering was performed in 11 of the RADECUR patients and 19 LDECUR patients. Grade 1-2 Clavien-Dindo complications occurred in 7 patients, and grade 3 complication in 1 patient in the RADECUR arm. In the LDECUR arm, grade 1-2 complications occurred in 2 patients, and 2 had a grade 3 complications. Surgical success was achieved in 97% and 94% in the RADECUR and LDECUR groups, respectively. CONCLUSION: Unilateral robotic extravesical cross-trigonal ureteral re-implantation for treatment of obstructed megaureter in the pediatric population is safe and effective both for RADECUR and LDECUR. Operative time is significantly shorter for RADECUR.

A Novel Surgical Technique for Obstructed Megaureter: Robot-Assisted Laparoscopic Dismembered Extravesical Cross-Trigonal Ureteral Reimplantation-Short-Term Assessment.

Purpose: To describe our experience with robot-assisted laparoscopic dismembered extravesical cross-trigonal ureteral reimplantation (RADECUR)-a novel minimally invasive surgical technique for treatment of obstructed megaureter. Materials and Methods: A retrospective review of our prospectively collected data, of all pediatric patients who underwent unilateral RADECUR for the treatment of primary or secondary obstructed megaureter at two medical centers during a 3-year period. Patient demographics, perioperative data, surgical technique, complications, and results are described. Results: Thirty-five pediatric patients underwent RADECUR between January 2016 and May 2019. Median age and weight at surgery were 28 months (interquartile range [IQR]: 20-58) and 20 kg (IQR: 13-27), respectively. There were no conversions to an open procedure. Median console time was 100 minutes (IQR: 90-125). Ten patients underwent intracorporeal excisional tapering of the obstructed ureter. Mean pre- and postoperative ureteral diameters were 14.5 mm (IQR: 12-18) and 7 mm (IQR: 0-10), respectively (p < 0.0001). All but one patient demonstrated a reduction in hydronephrosis and ureteral diameter on follow-up ultrasonography. Grade 1-2 Clavien-Dindo complications occurred in five patients (14%) and another patient developed a grade 3 complication. Three patients developed postoperative febrile urinary tract infection, one of them was found to have high-grade reflux and subsequently underwent open ureteral reimplantation. Conclusions: Unilateral robotic extravesical cross-trigonal ureteral reimplantation for treatment of obstructed megaureter in the pediatric population is safe and effective. Further larger scale comparative studies with other surgical techniques are needed to determine the role of RADECUR in the armamentarium of treatment for distal ureteral obstruction.

Interobserver Agreement of the Estimated Contact Surface Area System for Renal Masses.

BACKGROUND: Nephrometry scores have been designed to assist in standardization of renal masses before nephron-sparing surgery. Estimated contact surface area (eCSA) has been recently described. However, its reproducibility between raters has not been rigorously explored. Our aim was to examine the reproducibility of eCSA and Radius, Exophytic, Nearness, Anterior, Line (RENAL) score (RS) nephrometry systems for renal masses by studying the interobserver agreement between 4 raters. MATERIALS AND METHODS: We reviewed the cross-sectional images (computed tomography, magnetic resonance imaging) of patients who underwent nephron-sparing surgery (open, laparoscopic, and robotic). Four urologists independently scored the renal tumors according to the eCSA and RS systems. Scoring was done separately for each nephrometry system. Interobserver agreement was assessed for total scores and separate components of each system by calculating the intraclass correlation coefficient (ICC). RESULTS: Ninety patients were scored to achieve power of 83% with α = 0.05. eCSA and RS demonstrated excellent interobserver agreement (ICC = 0.89 for both). The radius component of eCSA and RS had the highest ICC (0.97 and 0.9, respectively) compared with the other components. Location and anterior/posterior components of RS showed poor interobserver correlation (ICC = 0.69 and 0.50, respectively). Maximal difference in RS complexity group assignment was 1 of 43 (47.8%) of cases. CONCLUSION: eCSA has excellent interobserver agreement, similar to RS. Directly measurable anatomic variables have better interobserver correlation compared with qualitative variables. These results strengthen the applicability of eCSA as a surgical complexity metric for renal surgery.

Robot-assisted Laparoscopic Extravesical Cross-trigonal Ureteral Reimplantation With Tailoring for Primary Obstructive Megaureter.

OBJECTIVE: To describe a novel, minimally invasive surgical technique, robotic-assisted laparoscopic dismembered extravesical cross-trigonal ureteral reimplantation for primary obstructive megaureter and to report a case series of 13 patients. METHODS: Thirteen patients between the ages of 10 and 96 months who were diagnosed with primary obstructive megaureter underwent robotic-assisted laparoscopic dismembered extravesical cross-trigonal ureteral reimplantation between April 2017 and May 2019. The principle of this technique is performing an extravesical cross-trigonal ureteral reimplantation with intracorporeal tailoring of the ureter. This provides the advantage of achieving a long tunnel mimicking the Cohen cross-trigonal ureteral reimplantation, without performing the open surgical technique and offers the potential benefits of minimally invasive surgery. Surgical technique is described, demographic data and intra- and/or postoperative parameters are reported. RESULTS: Median age was 26 months (IQR 16-60). Median weight was 15 kg (IQR 10.1-31). Median console time was 113 minutes (IQR 90.5-140). Median postoperative stay was 2.5 days (IQR 1.3-3). Median ureteral diameter decreased from 17 mm (IQR 12.5-18.5) to 3 mm (IQR 0-6.5, P = .001). Median renal pelvis diameter decreased from 28 mm (IQR 20.5-37.8) to 4 mm (IQR 1.5-5, P = .005). Median renal function before surgery was 46% (IQR 24.5-48.5) and following surgery was 42% (IQR 36-42, P = .700). Median T1/2 decreased from 28 minutes (IQR 19.3-30) to 4.5 minutes (IQR 3-5, P = .009). Postoperative complications graded by the Clavien-Dindo classification were apparent in 3 patients (21%). One had grade I complication (fever, resolved spontaneously) and 2 had a Grade II complication (urinary tract infection). CONCLUSION: Robot-assisted cross-trigonal ureteral reimplantation with intracorporeal tailoring is safe, feasible, and reproducible in short-term follow-up.

Pediatric Partial Nephrectomy for Upper Urinary Tract Duplication Anomalies: A Comparison Between Different Surgical Approaches and Techniques.

OBJECTIVE: To review and compare 4 different surgical approaches for partial nephrectomy of a nonfunctioning moiety in children with upper urinary tract duplication anomalies. MATERIALS AND METHODS: A retrospective review of all pediatric patients who underwent open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), robotic partial nephrectomy (RPN), or laparoendoscopic single site partial nephrectomy (LESS-PN) for the treatment of a nonfunctioning moiety in a duplicated collecting system at 2 medical centers between 2007 and 2017. Patient demographics, perioperative data, surgical techniques, complications, and results were compared. RESULTS: A total of 59 pediatric patients underwent partial nephrectomy for an upper urinary tract duplication anomaly during a 10-year period: 24 OPN, 7 LPN, 18 RPN, and 10 LESS-PN. Median age was 16 months (interquartile range 9-49.7). Median weight was 10.7 Kg (interquartile range 8.8-16.4). Median estimated blood loss was comparable between all minimally invasive approaches, but significantly increased in the open approach. OPN required more narcotics (0.554 mg Morphine equivalent/Kg/day, range 0.03-6.13) and Acetaminophen (72.12 mg/Kg/day, range 0-209.06) than all other groups in the study. Median operating time in OPN (154.5 minutes, range 108-413) and LESS-PN (140 minutes, range 65-245) were found to be significantly shorter in comparison to LPN (190 minutes, range 159-355), and RPN (256 minutes, range 163-458); (P = .03, .005, .02, and .005). CONCLUSION: Minimally invasive approaches (LPN, RPN, and LESS-PN) for partial nephrectomy in upper urinary tract duplication anomalies may be associated with decreased postoperative analgesia requirements, shorter hospital stay, less blood loss, and less use of drains in comparison to the open approach, while demonstrating efficacy and safety.

Laparoscopic excision of complete bladder duplication in a 1-year-old male.

OBJECTIVE: Complete bladder duplication is a male predominant rare congenital malformation usually diagnosed at birth. Owing to the rarity of this anomaly, only few reports have discussed the surgical approach for this condition, with the open approach for excision being the most common. We hereby present a video of a laparoscopic resection of complete bladder and urethral duplication in a 1-year-old male. METHODS: The patient presented to our clinic with a red mucosal tissue protruding from a cutaneous opening at the dorsal base of the penis that has been present from birth. A normally located and functioning bladder and urethra were present. During work-up, a cystic mass located above the bladder was discovered in imaging examinations. No other anomalies were found. After a shared decision process, we performed a laparoscopic transperitoneal bladder duplication excision during which the accessory urethra and duplicated bladder were removed with preservation of the adjacent normal urethra. The patient had an uneventful recovery with excellent cosmetic results. CONCLUSION: The minimally invasive approach can be utilized for treatment of complex urinary anomalies in young children.

Comparison of Robotic Pyeloplasty and Standard Laparoscopic Pyeloplasty in Infants: A Bi-Institutional Study.

PURPOSE: To compare outcomes between robotic pyeloplasty (RP) and standard laparoscopic pyeloplasty (LP) in the infant population for the treatment of ureteropelvic junction (UPJ) obstruction. MATERIALS AND METHODS: We performed a retrospective cohort study of all children under 1 year of age who underwent RP or LP at two different medical centers between October 2009 and February 2016. Patient demographics, perioperative data, complications, and results were reviewed. RESULTS: Thirteen patients underwent standard LP, and 21 patients underwent RP during the study period. Median age and median weight at time of operation for the whole cohort were 6.1 months and 7.9 kg. Surgery success rates were similar with 95% and 92% in RP and LP, respectively. There was no statistically significant difference in operating time between the 2 groups, with a median time of 156 minutes in RP (range 125-249) and 192 minutes (range 98-229) in standard LP (P = .35). Median length of hospital stay was significantly shorter in the robotic group with a median stay of 1 day (range 1-3) and 7 days (range 7-12) in the standard LP group.(P < .0001) Drains or nephrostomy tubes were used more often in the laparoscopic group (100%, 13/13) as opposed to RP (9.5%, 2/21, P < .0001) There was a comparable complication rate between the 2 groups, 30.8% for LP and 23.8% for RP (P = .65). CONCLUSIONS: The minimally invasive dismembered pyeloplasty is safe and effective in the infant population and produces high success rates. The results, complication rates, and operative time were comparable between the two surgical methods while the standard LP demonstrated longer hospital stay. Both the robotic approach and the LP can be successfully utilized for the benefit of infants with UPJ obstruction.

Salivary Neutrophil Gelatinase-Associated Lipocalin Sampling Feasibility in Acute Renal Colic.

PURPOSE: Neutrophil gelatinase-associated lipocalin (NGAL) levels in the serum and urine are predictive biomarkers of acute kidney injury with correlation to complication and survival in major surgery. Salivary levels of NGAL during acute renal colic may reflect the degree of renal injury as it appears in different compartments encompassing body response in time perspective. Our aim is to evaluate and examine the feasibility and correlation of salivary NGAL with serum and urine levels in acute renal colic event. MATERIALS AND METHODS: A prospective controlled study of all patients presenting to the emergency room with acute renal colic event diagnosed with single ureteral stone obstruction by noncontrast CT. Saliva, urine, and blood samples were collected in patients and a control group during the first morning of admission. RESULTS: The study groups consisted of 44 patients and 13 controls, mean age 47 ± 15 years, body mass index 29 ± 6, mean stone size 6 ± 4 mm, mean creatinine levels 1.3 ± 0.7 mg/dL, mean white blood count 10,900 ± 3100 counts per field, and C-reactive protein 29 ± 55. Serum (190 ± 120 ng/mL vs 81 ± 24; p < 0.001) and predominantly salivary (474 ± 185 vs 328 ± 134 ng/mL; p < 0.05) NGAL levels were significantly elevated in patients compared with controls. CONCLUSIONS: Salivary NGAL sampling is feasible during the acute phase of renal colic. High levels of salivary NGAL are observed in a single sampling during acute ureteral stone obstruction and may advance clinical decision-making.