Open vs robotic infant ureteroureterostomy.

INTRODUCTION: A ureteroureterostomy (UU) is often used to manage some duplication anomalies. The operation is commonly performed through a Pfannenstiel incision, but other minimally invasive approaches have been described. The objective of this study is to compare open vs robotic infant UU with regards to operative time, complications, and operative success. METHODS AND MATERIALS: This is a retrospective institutional review board approved study of all infant UUs performed from July 2013 to January 2019. Before the DaVinci Xi became available (November 2017), UUs were primarily done open. All UUs after November 2017 were robotic. Surgery was recommended electively at 6 months in suspected cases of ectopic ureters or earlier for history of febrile UTI's or worsening hydronephrosis. Both open and robotic cases were started with cystoscopy and lower pole ureteral stent placement. A 5-0 polypropylene suture was tied in between in the stent and the Foley catheter. Foley and stent were removed 3-7 days after surgery in the clinic or at home by the parents. For both open and robotic approaches, patients were discharged on postoperative day (POD) 1 with the Foley draining into a double diaper on antibiotic prophylaxis. RESULTS: From July 2013 to January 2019, 12 open and eight robotic infant UUs were performed. One patient in each group had a ureterocele, and the rest had ectopic ureters. Median age was 7 months for both the open and robotic groups. All patients except one had a 3.7 Fr by 10-12 cm stent placed attached to an 8-10 Fr silicone Foley catheter. The exception was the first robotic case who had a 3 Fr stent with no dangler placed after failed attempts with a 4.7 Fr stent (there were no 3.7 Fr stents that day). Median surgery time was 129 min (range 100-188, mean 133 min) for open and 130 min (range 79-226 min, mean 137 min) for robotic (P-value 0.8). In addition to the robotic case who had a 3 Fr stent placed with no dangler, an additional robotic case had to have her stent removed under anesthesia because the dangler broke or the knot got undone when the Foley was removed. One patient in the robotic arm who had the surgery done for a ureterocele had two postoperative febrile UTI's. Evaluation with VCUG and renal ultrasound (US) did not reveal hydronephrosis or reflux. She was managed conservatively. Other than the two cystoscopy and stent removals, no patient required a reoperation. DISCUSSION: These data indicate that the laparoscopic robotic-assisted UU can be safely performed in infants with similar operative time compared with the traditional open Pfannenstiel approach. The two complications in the robotic arm were not related to the approach itself but to issues with the stents, which would have not been prevented by an open approach. There were no complications specific to the robotic approach. CONCLUSIONS: Laparoscopic robotic-assisted infant UUs are safe, effective, and can be done in a similar time compared with the traditional open Pfannenstiel approach.

'Mini' extravesical reimplant with 'mini' tapering for infants younger than 6 months.

INTRODUCTION: Some infants with obstructed megaureters or ectopic ureters requiring surgery undergo a cutaneous ureterostomy followed by definitive repair after 12 months of age. Since 2013, a 'mini' extravesical reimplant with or without 'mini' tapering (MER) was performed instead of cutaneous ureterostomy in such infants. OBJECTIVE: To describe the technique and outcomes for MER. STUDY DESIGN: This is a retrospective review of infants younger than 6 months who underwent MER. MER consists of a 2- to 3-cm extravesical tunnel, regardless of the ureter diameter. 'Mini' tapering consisted of an adventitial sparing technique involving only the distal 2-3 cm of the ureter. Details of the technique are included in the video. The main outcomes were postoperative symptomatic urinary tract infections (UTI's) and reoperations. Voiding function was assessed at the last contact with the family. RESULTS: Nine consecutive infants underwent MER from July 2013 to March 2018. Four patients had ectopic ureters and five had primary obstructed megaureters. The median ureteral diameter was 1.5 cm. Indications for surgery were as per the British Association of Pediatric Urologists guidelines on megaureters. All patients had 3-month postoperative renal ultrasound, and seven of the nine patients had postoperative voiding cystourethrogram (VCUG). One patient with a normal postoperative VCUG and MAG 3, as well as resolved hydroureteronephrosis had a few postoperative febrile UTIs but no more for >1 year at the last follow-up. At a median time from surgery of 44 months, there have been no reoperations (except cystoscopy with stent removal). With regard to voiding function, six patients were successfully potty trained, one has bowel and bladder incontinence at the age of 4 years - with stable renal ulstraound -, and two are younger than 2 years. DISCUSSION: MER has been the only surgery needed for the cohort of nine infants younger than 6 months with distal ureteral obstruction at a median time from surgery of 44 months. Voiding function does not appear to be affected by the operation. CONCLUSIONS: For babies younger than 6 months of age in need of surgery for obstructed distal ureter, MER appears to be a feasible and effective option, associated with reduced morbidity and reoperation rate compared to the alternatives.

Ureteral tunnel length versus ureteral orifice configuration in the determination of ureterovesical junction competence: A computer simulation model.

INTRODUCTION: The long-held belief that a ureteral re-implant tunnel should be five times the diameter of the ureter, as proposed by Paquin in 1959, ignores the effect of the orifice on the occurrence of reflux. In 1969, Lyon proposed that the shape of the ureteral orifice (UO) is more important than the intravesical tunnel. However, both theories missed quantitative evidence from principles of physics. The goal of the current study was to test Lyon's theory through numerical models (i.e. to quantify the sensitivity of ureterovesical junction (UVJ) competence to intravesical tunnel length and to the UO). MATERIALS AND METHODS: The closure of a three-dimensional spatial configuration of ureter, constrained within a bladder, was simulated. Two common UO shapes (i.e. golf type vs 2-mm volcano type (Summary Fig.)), and two different intravesical ureteral tunnel length/diameter ratios (3:1 and 5:1) were examined. The required closure pressures were then compared. RESULTS: The UO was a significant factor in determining closure pressure. Given the same intravesical ureteral tunnel length/diameter ratio, the required closure pressure for the volcanic orifice was 78% less than that for the golf orifice. On the other hand, the intravesical ureteral tunnel length/diameter ratio had minimal effect on the required closure pressure. As the intravesical ureteral tunnel length/diameter ratio changed from 3:1 to 5:1, the required closure pressure was reduced by less than 7%, regardless of the orifice shape. CONCLUSIONS: The simulation results showed that UVJ competence was more sensitive to a 2-mm protrusion of the UO compared to an increase in the intravesical tunnel length from 3:1 to 5:1. This agrees with Lyon's theory, and at the same time challenges Paquin's 5:1 rule. Researchers could use this information to consider the UO configuration in further animal, human, computer or material models.

Clinic meatotomy under topical anesthesia.

OBJECTIVES: Almost 20 years after Cartwright et al. (1996) demonstrated the feasibility and effectiveness of clinic meatotomy (CM) under topical lidocaine and prilocaine (EMLA) anesthesia, 50% of meatotomies are still performed under general anesthesia (GA) (Godley et al., 2015). The cost of a meatotomy under GA is approximately 10 times the cost of CM in the present practice. This study presented the outcomes for CM under topical anesthesia, in consecutive patients who presented with meatal stenosis secondary to circumcision. MATERIALS AND METHODS: This was a retrospective descriptive study of data, which were collected prospectively for quality improvement purposes from July 2013 to September 2015, of 55 consecutive boys who underwent CM for meatal stenosis (occlusion of urethral meatus by a crust; deflected stream). Meatotomy was performed after applying EMLA and covering it with a Tegaderm® dressing, and then waiting 20-60 min. The recorded outcomes were pain and success rate. Pain was defined at the beginning of data collection as any sound, grimace or movement during the procedure. Success rate was recorded during follow-up in the clinic or over the phone, when the family was asked if symptoms were the same, improved or completely resolved. RESULTS: Forty-three boys (78%) had no pain and 12 (22%) had pain as defined above (Figure), but no CM had to be stopped due to pain. At a median follow-up of 1.6 months (IQR 1.3-2.7 months) 41 (75%) patients had resolution of their symptoms and a normal urinary stream, nine (16%) had improved symptoms, and three (5%) had unchanged symptoms. CONCLUSIONS: More patients reported pain than those in the Cartwright study; this was perhaps because a full hour was not waited after EMLA application with most of the present patients. The present success rate was also lower than that reported by Cartwright, and for that there is no explanation. However, all CM could be completed and >90% of patients saw resolution or improvement of their symptoms. At a cost ten times lower than a meatotomy performed under GA, and with no evidence of inferiority evident in the literature, it is believed that CM should be the standard of care when meatal stenosis is treated by a meatotomy.

Bullous hemorrhagic dermatosis at distant sites: a report of 2 new cases due to enoxaparin injection and a review of the literature.

Enoxaparin is a low-molecular-weight heparin used in the prevention and treatment of pulmonary thromboembolism and other thrombotic disorders. The most common adverse reactions to enoxaparin are ecchymosis, skin necrosis, urticaria, angioedema, and eczema. The first 2 cases of bullous hemorrhagic dermatosis in areas distant from heparin injection sites were described in 2006. We present the cases of 2 men, aged 68 and 78 years, with progressive, advanced-stage lung cancer, who consulted with bullous hemorrhagic lesions without associated symptoms. Both patients reported that the lesions had appeared after initiation of heparin therapy at therapeutic doses. In our review of the literature, we found just 7 cases of heparin-induced bullous hemorrhagic dermatosis. We report a further 2 cases, caused by enoxaparin, in which treatment was continued and in which the lesions resolved in 2 to 3 weeks.