Tips and tricks for the extravesical robotic-assisted laparoscopic ureteral reimplantation for pediatric vesicoureteral reflux.

Over the past few years, robotic-assisted laparoscopic ureteral reimplantation (RALUR) has gained popularity as an acceptable alternative for the traditional open approach if surgery is elected for children with vesicoureteral reflux (VUR). We present our technique including the tips and tricks for both male and female patients, including a stepwise approach for ureteral identification in female patients depending on the level of technical difficulty. Our series include 30 patients who represent a spectrum in which we presented the different tips and tricks included in this video.

Double versus single diaper technique after hypospadias repair, does it really matter?

INTRODUCTION: Double-diaper technique with an open-drainage catheter is a common practice after hypospadias repair. However, double-diapering may increase the burden of postoperative care and has not been compared to single-diapering with an open-drainage catheter. OBJECTIVES: This study investigates whether the single-diaper technique is associated with inferior surgical outcomes compared to the double-diaper technique. MATERIALS AND METHODS: A single surgeon database was retrospectively reviewed for patients who underwent hypospadias repair between 2013 and 2021. Patients who were lost to follow-up and those in whom the type of diaper care (single- or double-diaper) was not documented were excluded. Patients in the single-diaper technique received the same type of dressing and discharge instructions, as those in the double-diaper group, except for leaving the catheter freely draining into a single-diaper. Short-term complications including surgical site infection (SSI), urinary tract infection (UTI) and wound dehiscence, were the primary outcome; whereas the long-term urethroplasty complications (urethrocutaneous fistula and meatal stenosis) were secondary outcomes. Outcomes were analyzed according to the type of diaper care. RESULTS: Among 323 patients reviewed, 219 patients met the inclusion criteria (72 patients in the double-diaper and 147 in the single-diaper group). Both study groups were similar regarding patient demographics, hypospadias characteristics and surgical technique. Looking at the primary outcomes, there was no statistically significant difference in SSI, UTI or wound dehiscence. For the secondary outcomes, the incidence of meatal stenosis (8.3 vs. 1.4%, p = 0.044), and fistula formation (15.3% vs 5.4%, p = 0.037) was significantly higher in the double-diaper than the single-diaper group, respectively (Table 2). CONCLUSION: Single-diaper technique following hypospadias repair is not associated with increased risk of complications compared to double-diaper technique.

Pediatric renal trauma at a level 1 trauma center in a rural state: A 10-year institutional review and protocol implementation.

INTRODUCTION: Unintentional injury is a leading cause of mortality and morbidity in children. There is no consensus on the ideal, discrete management of pediatric renal trauma (PRT). Therefore, management protocols tend to be institution-specific. OBJECTIVE: This study aimed to characterize PRT at a rural level-1 trauma center and subsequently develop a standardized protocol. STUDY DESIGN: A retrospective review of a prospectively maintained database of PRT at a rural level 1 trauma center between 2009 and 2019 was conducted. Injuries were characterized regarding renal trauma grade, associated multi-organ involvement and the need for intervention. The benefit of patient transfer from regional hospitals and length and cost of stay were evaluated. RESULTS: Of 250 patients admitted with renal trauma diagnosis 50 patients <18 years were analyzed. Of those, the majority (32/50, 64%) had low-grade (grade I-III) injuries. Conservative management was successful in all low-grade injuries. Of 18 high-grade PRT, 10 (55.6%) required intervention, one prior to transfer. Among patients with low-grade trauma, 23/32 (72%) were transferred from an outside facility. A total of 13 (26%) patients with isolated low-grade renal trauma were transferred from regional hospitals. All isolated, transferred low-grade renal trauma had diagnostic imaging before transfer and none required invasive intervention. Interventional management of renal injury was associated with a longer median LOS [7 (IQR = 4-16.5) vs 4 (IQR = 2-6) days for conservative management, p = 0.019)] and an increased median total cost of $57,986 vs. $18,042 for conservative management (p = 0.002). DISCUSSION: The majority of PRT, particularly low-grade, can be managed conservatively. A significant proportion of children with low-grade trauma are unnecessarily transferred to higher level centers. Review of pediatric renal trauma at our institution over a decade has allowed us to develop an institutional protocol which we believe allows for safe and effective patient monitoring. CONCLUSION: Isolated, low-grade PRT can be managed conservatively at regional hospitals without needing transfer to a level 1 trauma center. Children with high-grade injuries should be closely monitored and are more likely to need invasive intervention. Development of a PRT protocol will help to safely triage this population and identify those who may benefit from transfer to a tertiary care center.

Infantile Primary Hyperoxaluria Type 1 Treated With Lumasiran in Twin Males.

Primary hyperoxaluria type 1 (PH1) is a rare genetic disease that results in oxalate overproduction leading to nephrolithiasis (NL), nephrocalcinosis (NC), kidney failure, and systemic oxalosis. Infantile PH1 is its most severe form, and it may require intensive hemodialysis followed by a liver-kidney transplant. Lumasiran is an RNA interference (RNAi) therapeutic agent that reduces hepatic oxalate production, which has been recently approved for the treatment of PH1. In this report, we present a case of twin males with infantile PH1 and bilateral NL and NC who were treated with lumasiran at 12 months of age. Their symptoms abated after therapy was started without disease progression. To the best of our knowledge, this is the first report of PH1 occurring in twins and the first report on using lumasiran to treat infantile PH1 outside of a clinical trial. Lumasiran appears to be a successful therapeutic option for infantile PH1.

Dysfunctional Voiding- Presentation of a Rare Case of Pediatric Non Muscle Invasive Urothelial Bladder Carcinoma.

Bladder cancer is rare in children, with 86.8% of pediatric patients diagnosed not carrying any of the common risk factors commonly seen in adults. Here, a 16-year-old female presented to the ED with in urinary retention. A renal bladder ultrasound revealed an echogenic focus in the bladder wall. On diagnostic cystoscopy a small papillary bladder lesion was appreciated and resected. Final pathology of the bladder mass resulted as non-invasive low grade papillary urothelial carcinoma (pTa). This report demonstrates bladder cancer in the pediatric age group, and should be considered as a possible differential diagnosis in patients with dysfunctional voiding.

Bridging the Gap-Building Surgical Subspecialty Telemedicine Clinics in the Rural Setting.

INTRODUCTION: Pediatric urology is a much-needed subspecialty with a breadth of complex disorders that can often prove challenging to diagnose and manage. Exacerbating this need is the minimal exposure medical trainees receive to pediatric urology. Pediatric urology arrived in West Virginia in 1983 but the subspecialty has been inconsistently represented since then. Currently there are 2 fellowship-trained pediatric urologists in the state of West Virginia, which has an area of approximately 24,038 square miles. We review our experience with the use of telemedicine in providing outreach to the wider parts of our medically underserved state and ultimately evaluate its efficacy from a patient-centric cost analysis and diagnosis concordance perspective. We hypothesized that the use of telemedicine would be cost and time-effective for patients in our rural state. METHODS: We retrospectively reviewed our series of patients presenting from outside telemedicine "referral centers" in Martinsburg, Parkersburg and Wheeling for pediatric urological consultation. We evaluated reason for consultation, geographic driving distance, drive time and travel cost saved from telemedicine consultation. RESULTS: A total of 92 patients presented to outside designated telemedicine centers from August 2018 to April 2020. The mean driving time saved utilizing telemedicine consultation was 4 hours and 46 minutes, and mean driving distance saved was 299.8 miles. Travel costs saved in terms of fuel averaged $173.88 per patient. The most common reason for consultation was undescended testis, followed by recurrent urinary tract infection and nocturnal enuresis. Of the 23 patients who required surgery, only 2 (8.7%) had an initial diagnosis that was not concordant with their operating room examination. CONCLUSIONS: While modest, our data indicate a modern solution to a historical need in our state. Our high diagnosis concordance rate (91.3%) shows that a well-trained advanced practice provider can adequately perform an operative evaluation via telemedicine.

The Impact of Targeted Education of American Urological Association Cryptorchidism Guidelines in a Rural State: Improvement Still Needed.

BACKGROUND: The American Urological Association published guidelines in 2014 regarding management of undescended testicles (UDT). Despite these guidelines, prior studies have indicated discordance between guidelines and actual practice, especially in rural states. This study aims to identify if educating referring providers improves management of UDT. METHODS: Patients with UDT referred to our institution were divided into two groups: those referred prior to (Group 1) and after (Group 2) targeted education. A retrospective review was performed to compare the groups in terms of age at time of referral and surgery, laterality, specialty, and practice setting of referring provider, and whether or not ultrasound (US) was performed prior to referral. RESULTS: A total of 100 patients were identified in Group 1 and 168 in Group 2. No significant differences were noted between groups regarding age, variability of referring provider, or those receiving US prior to referral. Median age at referral was 20.7 months (range=0-194) and 33 months (range=0-205.1) in Groups 1 and 2, respectively (p=0.26). Sixty-two (37%) patients underwent surgical evaluation within 18 months of age or younger in Group 1 compared to 39 (39%) in Group 2 (p=0.73). Private practice pediatricians comprised the majority of referring providers in both cohorts. US was performed prior to referral in 41% of patients in Group 1 compared to 35.8% in Group 2 (p=0.51). The number of US ordered prior to referral significantly decreased from 10 (50%) to six (19%) following education among academic providers (p=0.02). No significant difference was found following education for private practice physicians (p=0.27). CONCLUSION: Targeted education did not improve age at referral in the short-term, which may reflect suboptimal healthcare access. Additionally, more research is needed to evaluate whether more diverse targeted education provided on a regular basis to both physician and mid-level providers would have a meaningful impact.

Surgical Correction of True Diphallia in a Newborn Male.

Diphallia is an exceedingly rare anomaly characterized by partial or complete duplication of the phallus. Approximately 100 cases have been reported worldwide since its initial documentation, and incidence is estimated at 1 in 5 to 6 million live births. Therapeutic management is dependent on the extent of the anomaly, ranging from phallic excision to complex reconstructive procedures in cases of broader systemic involvement. We present the case of congenital true diphallia with associated penoscrotal transposition, bifid scrotum, partial urethral duplication, ventral chordee, large scrotal lipoma and sacral dimple. We further present a review of available literature pertaining to diphallia.

Choosing the Right Catheter for Pediatric Procedures: Patient Considerations and Preference.

Determining the need for bladder decompression and urinary diversion in the perioperative pediatric surgical patient can cause a clinical conundrum for the surgical team. Add in the several different types of urinary diversion devices possible, and the various materials associated therein and the process can suddenly seem unnecessarily daunting given the lack of concise recommendations and broad consensus. The decision to divert urine, though seemingly trivial, is associated with inherent risks. Managing and mitigating certain risks are best approached through proper education, selection, and technique. We provide a broad overview of pediatric catheter selection, indications, and pitfalls to streamline the process so that energy and attention can best be focused on the planned intervention at hand.

Prenatally Diagnosed Testicular Torsion: A Rare Condition That Causes Dilemma in Management.

BACKGROUND: Prenatal testicular torsion (PTT) is exceedingly rare in intrauterine development, often diagnosed at the time of birth and very rarely diagnosed in utero during routine gestational ultrasound. As a result, incidence is unknown, and there exists no consensus regarding the pathophysiology of this phenomenon nor universally recognized algorithms and guidelines regarding its diagnosis and management. Case Presentation. We present the case of an antenatally diagnosed torsion and our subsequent management which included ipsilateral orchiectomy and prophylactic contralateral orchiopexy via a scrotal approach. CONCLUSION: While controversy regarding surgical intervention in patients with unilateral PTT exists due to poor salvage rates-estimated to be less than 1%-the risk of anorchia is higher in affected patients due to limitations in the accuracy of detecting bilateral testicular involvement. Risk of misdiagnosis of bilaterality may lead to lasting sequelae such as infertility and devastating psychological consequences for affected patients, supporting the need for surgical exploration, as was performed in our case.

True partial diphallia with associated penoscrotal transposition of two hemi-scrotums.

Diphallia or duplication of penis is extremely rare condition with a reported incidence of 1 in 5-6 million live births. Approximately around 100 cases of diphallia have been described in literature, each case have a unique presentation from associated anomalies. Clinically these patients can be classified into complete (true diphallia) or partial duplication. In true diphallia, each penis has 2 corpora cavernosa and 1 corpus spongiosum. If the duplicate penis is smaller or rudimentary with complete structure, it is described as true partial diphallia. The term bifid phallus is used if there is only one corpus cavernosum in each penis. Due to low incidence and varied presentation, not much is known about the underlying pathophysiology, management options, and outcomes. Here, we report a case of partial diphallia with associated penoscrotal transposition of 2 hemi-scrotums.

Rare late presentation of bilateral single system intravesical ureteroceles complicated with ureterolithiasis: Case report and literature review.

Bilateral intravesical ureteroceles is a rare condition where both ureters terminally end in cystic dilations in the urinary bladder. Herein, a 31-year-old male patient presented with severe right flank pain and gross hematuria. Upon computed tomography imaging, a right ureterocele with an entrapped stone was revealed. Direct visualization also showed a smaller ureterocele at the left ureterovesical junction. Both ureteroceles were unroofed using rigid resectoscope with cold knife resulting in rapid bilateral efflux. The treatment was well tolerated with no known complications. Albeit uncommon, this case highlights the need to consider ureteroceles in adult patients with urinary tract symptoms.

Evaluation of Preoperative Tamsulosin Role in Facilitating Ureteral Orifice Navigation for School-Age Pediatric Ureteroscopy.

PURPOSE: To address whether preoperative tamsulosin increases the rate of successful ureteral orifice navigation for ureteroscopy (URS) without prestenting in school-age pediatric patients. METHODS: We retrospectively reviewed all pediatric patients who had undergone ureteroscopy (URS) at our institution from 2013 to 2020. Patients were divided into two groups: those who had received tamsulosin 0.4 mg daily ≥48 hours preoperatively and those who had not. Statistical analysis was done using independent-sample t-tests and Mann-Whitney U tests for continuous variables, and χ2 and Fisher's exact tests were used for categorical variables. Multivariate analysis was done using binary logistic regression test. RESULTS: Overall, successful ureteral orifice navigation occurred in 44 of 50 patients (88%) who had received tamsulosin and 17 of 26 (65.4%) who had not (p=0.019). On further subanalysis based on stone location and instrumentation used, successful ureteral orifice navigation had occurred in 21 of 24 patients (87.5%) in the tamsulosin group and one of five (20%) in the no-tamsulosin group for semirigid ureteroscopy for mid-distal ureterolithiasis (p=0.007). For proximal ureteral and renal stones, successful ureteral orifice navigation with a flexible ureteroscope or ureteral access sheath had occurred in 23 of 26 patients (88.5%) in the tamsulosin group and 16 of 21 (76.2%) in the no-tamsulosin group (p=0.437). Multivariate analysis showed no significant difference between success rates in the two groups after controlling for patient weight, height, BMI, and stone location. We did not observe any adverse effects from tamsulosin. CONCLUSION: This is the first study to evaluate preoperative tamsulosin on successful ureteral orifice navigation in school-age pediatric patients. Although not reaching statistical significance, further evaluation should be done on larger cohorts. Patient height was found to be an independent predictor of successful ureteral orifice navigation.

Usability and safety of the new 5 French air-charged catheter for performing urodynamic studies on pediatric patients.

AIMS: To assess the performance and safety of the T-DOC® 5 French air-charged urodynamic catheters in pediatric patients and obtain feedback from providers related to usability performance. METHODS: Patients ages 12 years and younger undergoing urodynamics were prospectively recruited from two institutions. The T-DOC® 5 French air-charged catheters were used. Issues with catheter placement, adverse events (AEs), and pain scores were assessed. A follow-up telephone call was made to assess for post-urodynamic AEs. Providers completed a clinical user questionnaire. Likert scale was used (1 = most negative and 5 = most positive response) and reported in mean (range). RESULTS: A total of 28 patients completed the study. The mean age was 55 months (5-130) (10 females, 18 males). One problem was noted with the insertion of an abdominal catheter, secondary to stool impaction. Catheters stayed in place on all subjects, except for one related to patient hyperactivity. There were no AEs during the studies. In total four reported post-urodynamics AEs (one hematochezia, three dysuria). Among nine patients, pain level on the bladder and abdominal insertion was 3.6/10 (0-10) and 3.1/10 (0-10). Five providers completed the questionnaire. The overall ease of use was rated 4.3/5 (3-5). The ease of insertion was 4.1/5 (2-5) and set-up/clean-up time was 4.4/5 (3-5). Tracing stability, subtraction accuracy, and artifact sensitivity were all perceived favorably (respectively 4.8/5 [4-5], 4.6/5 [4-5], and 4.4/5 [4-5]). CONCLUSIONS: The T-DOC® 5 French air-charged catheter was considered safe and effective in pediatric patients. No AEs occurred during the studies. Providers, using the catheters, reported favorably on catheter usage.

Robot-Assisted Laparoscopic Management of Persistent Mullerian Duct Structures in a Male Infant: A Novel Technique.

Background: Persistent Mullerian duct syndrome (PMDS) is a rare disorder of sexual development that results in the presence of internal female reproductive structures in male children who are otherwise phenotypically normal. The removal of the Mullerian structures is suggested, as they pose a risk for future malignancy. Case Presentation: In this study, we present the case of a 14-month-old male infant who initially presented with bilateral nonpalpable undescended testes and was later diagnosed with PMDS. The effective removal of the Mullerian structures and bilateral orchiopexy was performed using robot-assisted laparoscopy, a novel approach for such a scenario. Conclusion: To our knowledge, this is the first report of using robotics for management of this syndrome.

Congenital Megaprepuce: Literature Review and Surgical Correction.

Congenital megaprepuce (CMP) is a type of buried penis characterized by extensive redundancy and ballooning of the inner prepuce as a result of preputial stenosis and phimosis. The malformation typically presents with difficulty voiding, often requiring manual expression of stagnant urine. Multiple techniques have been reported for the treatment of CMP with varying levels of positive outcomes. The authors provide a review of published literature, in addition to describing the procedure and results of our surgical technique in three children aged eleven months, two years, and twelve years. The literature review was conducted using PubMed with keywords "congenital megaprepuce," "megaprepuce," "buried penis," "CMP," and "correction." Results were then differentiated based on presence or absence of true congenital megaprepuce and the surgical correction thereof. Regarding our cases, all patients completed the procedure with excellent cosmesis and without complication. Our technique is shown to provide consistent, excellent esthetic outcome across a wide range of ages and may be replicated by others.

Pediatric testicular torsion: does patient transfer affect time to intervention or surgical outcomes at a rural tertiary care center?

BACKGROUND: Testicular torsion (TT) is a urologic emergency that requires prompt surgical intervention. In rural Appalachia, patients are often transferred from surrounding communities due to lack of urologic care. We hypothesized that those transferred would have delayed intervention and higher rates of orchiectomy when compared to those who presented directly to our hospital. METHODS: We performed a retrospective review of patient charts with an ICD-9 diagnosis of TT from 2008 to 2016. Patients met inclusion criteria if diagnosis was confirmed by operative exploration. We compared rate of testicular loss and time until surgical intervention between groups. RESULTS: Twenty-three patients met inclusion criteria (12 transferred, 11 direct). Patient demographics did not significantly differ between groups. Transferred patients had a higher orchiectomy rate (33% v 22%,p = 0.41) although this was not statistically significant. Time to surgery from symptom onset was significantly longer in those transferred (12.9 h) compared to those not transferred (6.9 h, p = 0.02). Distance of transfer was not correlated with time of delay (r2 = 0.063). CONCLUSIONS: Transferred patients with TT have numerically higher rates of orchiectomy which may reach significance in an appropriately powered study, and relative delays in surgical intervention. This study highlights the need for improved access to urologic care in rural areas.

Pedunculated and obstructive Wilms' tumor: A rare presentation in a 2 year-old male.

Wilms' tumor manifesting as an obstructing ureteral mass is extremely rare. Herein, we report an unusual case in which a child presented with a clinical picture concerning for and suggestive of ureteropelvic junction obstruction (UPJO), but was instead found to have an intrapelvic pedunculated Wilms' tumor with extension into the proximal ureter. We discuss the patient's diagnostic workup, radiographic, operative and pathologic findings, as well as important lessons learned from this unusual case.