Evaluation of a video telescopic operating microscope (VITOM) for pediatric surgery and urology: a preliminary report.

INTRODUCTION: Optical magnification is an essential tool in the practice of pediatric surgery. Magnifying loupes are the most frequently used instrument, although their use often comes at the expense of neck pain experienced by the operating surgeon. Recent advances have led to the development of a compact video microscope (VITOM(®); Karl Storz Endoscopy GmbH, Tuttlingen, Germany) that displays high-definition magnified images on a flat screen. This study was designed to evaluate VITOM as a potential substitute for loupes in complex open pediatric procedures and to explore VITOM as an effective intraoperative teaching modality for open surgery. SUBJECTS AND METHODS: Three surgeons used the VITOM II exoscope in 20 operations: 14 hypospadias repairs, 2 inguinal hernia repairs, 1 sacrococcygeal teratoma resection, 1 recurrent tracheoesophageal fistula repair, and 2 additional procedures. Surgeons, trainees, and surgical technicians subjectively evaluated image quality; surgeons evaluated handling of VITOM, degree of neck strain, and fatigue. Three midlevel surgical trainees assessed the VITOM potential for teaching value. Overall impressions of each group and consensus opinions were generated. RESULTS: All procedures were completed without complication. The consensus opinion of the entire group was that image quality was excellent. The surgeons found VITOM easy to use, and all agreed that neck strain and fatigue were reduced. Surgical trainees felt that VITOM imaging aided in their understanding of procedures and anatomy. Surgical technicians perceived improved operation flow through better visualization of the procedure. CONCLUSIONS: VITOM provides excellent visualization of pediatric operations with improved surgeon comfort and may serve as a substitute for loupes. Secondarily, we found enhanced trainee learning and potential improvement in the flow of surgical procedures. Further study of VITOM with a larger sample size and validated tools is needed.

Omental herniation through a 3-mm umbilical trocar site.

Omentum herniated through a 3-mm umbilical port site 6 days after laparoscopic exploration for a nonpalpable testicle in an 18-month-old boy. Fascial closure of even these small sites may be advisable.

Initial comparison of robotic-assisted laparoscopic versus open pyeloplasty in children.

OBJECTIVES: To compare the initial results of robotic-assisted laparoscopic versus open pyeloplasty in children with ureteropelvic junction obstruction. METHODS: From June 2002 to July 2004, 8 pediatric patients underwent robotic-assisted laparoscopic pyeloplasty and were matched by age group with patients undergoing conventional open pyeloplasty. The mean age was 11.5 years (range 6.4 to 16.5) in the robotic-assisted group and 9.8 years (range 6.0 to 15.6) in the open group. A four-port transperitoneal technique was used to perform the Anderson-Hynes pyeloplasty with the da Vinci Surgical System. RESULTS: The mean operative time and estimated blood loss was 363 minutes (range 255 to 522) and 13.1 mL (range 5 to 25) in the robotic-assisted group versus 248 minutes (range 144 to 375) and 53.8 mL (range 5 to 200) in the open group, respectively. The mean length of hospitalization and pain medication use was 2.4 days (range 1 to 5) and 7.4 mg morphine (range 0 to 23) in the robotic-assisted group compared with 3.3 days (range 1 to 8) and 22.0 mg morphine (range 0 to 100) in the open group, respectively. At a mean follow-up of 14.7 months (range 2 to 24), all robotic procedures were successful as determined by subjective data using pain scales and radiologic data. CONCLUSIONS: Robotic-assisted laparoscopic pyeloplasty appears to decrease the length of hospitalization and use of pain medication, but has a longer operative time. Additional clinical experience is required to determine the long-term efficacy of this method.

A noninvasive ultrasonographic method to evaluate bladder function recovery in spinal cord injured rats.

Suprasacral spinal cord injury induces changes in the mechanical and neuronal properties of the bladder resulting in bladder areflexia followed by bladder-sphincter dyssynergia and detrusor muscle hypertrophy, which lead to urinary retention and increased bladder size. These changes are most often quantified using highly skilled urodynamic techniques that involve catheterization. We investigated whether a hand-held digital ultrasound imaging system could monitor urinary retention in the bladder following spinal cord injury in adult rats. Our findings indicate that contusive spinal cord injury resulted in high residual bladder volumes that decreased and stabilized by 2 weeks post-injury but remained significantly higher than control bladder volumes up to 46 days post-injury (the longest time point examined). Post hoc analysis indicated that the degree of bladder function recovery recorded at the end of the study correlated with the degree of bladder function recovery recorded at 6 days post-injury, indicating that bladder function recovery can be predicted by analyzing bladder volume as early as 6 days post-injury. Bladder function recovery correlated with locomotor recovery as assessed using the BBB locomotor rating scale. While providing a noninvasive assessment of bladder function with no detrimental impact on locomotor function or assessment, this protocol provides researchers with a clinically relevant outcome measure for quantifying bladder function recovery after spinal cord injury or after experimental treatments for spinal cord injury.

A survey of voiding dysfunction in children with attention deficit-hyperactivity disorder.

PURPOSE: Physicians treating attention deficit-hyperactivity disorder (ADHD) have long had the clinical impression that these children suffer disproportionately from voiding dysfunction and incontinence. However, no data exist to confirm this suspicion. In an attempt to investigate this clinical finding, we administered a survey asking about any functional bladder symptoms to a group of children with ADHD and a control group without ADHD. MATERIALS AND METHODS: The Dysfunctional Voiding Symptom Survey (DVSS) was administered to a group of children being treated for rigorously diagnosed ADHD and a control group without ADHD. The DVSS consists of 10 questions that assess daytime incontinence, nocturnal enuresis, constipation, urgency, voiding frequency and dysuria, each scored from 0 to 4 (0-never, 1-almost never, 2-less than half the time, 3-about half the time, 4-almost every time) for a maximum total score of 40 (severest symptoms). Scores for patients and controls were compared for each question and in aggregate. Boys and girls underwent separate statistical analysis. An additional eleventh question assesses recent stressful events within the family. RESULTS: The patient group included 23 boys and 5 girls, and the control group 10 boys and 12 girls. Children with ADHD of both sexes had statistically significant higher overall DVSS scores. Boys had significant differences on several questions. Due to the small number of girls, there were no statistically significant differences on individual questions. CONCLUSIONS: Children with ADHD have significantly higher rates of incontinence, constipation, urgency, infrequent voiding, nocturnal enuresis and dysuria than those without ADHD. Further study is needed to discern the cause of this difference and develop appropriate treatment strategies.

Biofeedback therapy and dysfunctional voiding in children.

Dysfunctional voiding, a condition in which a neurologically intact child fails to relax the urinary sphincter during micturition, was first described in the 1970s. Clinically, these children have urinary incontinence and recurrent urinary tract infections. Biofeedback, through which the child is taught to relax the pelvic floor during voiding, has become an increasingly popular method of treatment. Many series, most retrospective, have shown biofeedback to be very effective in the treatment of this disorder.