Surgical management of pediatric renal masses: surgeon subspecialty practice patterns.

INTRODUCTION: Management of pediatric renal masses has lagged behind adult paradigms adopting minimally invasive surgery (MIS) and nephron-sparing surgery (NSS). This study investigated national practice patterns between pediatric urologists (PU) and pediatric surgeons (PS) in pediatric renal malignancy. MATERIALS AND METHODS: The Pediatric National Surgical Quality Improvement Program database was queried for CPT codes for radical/partial nephrectomy from 2012-2017 performed for renal malignancy. Patients were grouped by specialty and operative approach. RESULTS: PU managed 175 (17%) patients while PS managed 811 (77%). PU were more likely to use MIS (14% versus 5%, p < 0.001) and NSS (33% versus 13%, p < 0.001) compared to PS. PS more commonly performed lymph node (LN) sampling/tumor thrombectomy, especially in MIS cases (67% versus 35%, p = 0.008). PS operated on younger patients with higher ASA class compared to PU, but had higher transfusion rates and longer length of stay. Central venous access surgery was more commonly performed on patients operated on by PS, while PU performed more cystoscopy/retrograde pyelography. Patients who underwent NSS compared to radical nephrectomy were less likely to undergo LN sampling, while LN sampling did not differ between open and MIS groups. CONCLUSIONS: PU were likely to perform MIS and NSS than PS for pediatric renal masses in this national database. This likely results from inherent training differences between PS and PU and reflects emerging data on safety and efficacy of these advanced surgical techniques. Further investigation into the impact on oncologic and clinical outcomes by surgical specialty and operative approach is necessary.

International Publication Patterns on Operative Management of Wilms Tumor: A Review by Surgeon Specialty and Surgical Modality.

OBJECTIVE: To review the temporal trends in the published literature of the surgical management of Wilms tumor (WT) relative to surgical modality and authorship by surgeon specialty (pediatric urology [PU] vs pediatric surgery [PS]). METHODS: The MEDLINE/PubMed database was queried for manuscripts published by PU or PS including operative management of WT from 1993-2017. After manuscript review, 187 of 2420 studies were included. Studies were compared by author specialty, country of origin, and represented patients. RESULTS: PU published 32% of included publications. The proportion of first author publications by PU increased over time (25% from 1993-2005 to 39% from 2006-2017, P = .029). While PU were first author on 44% of studies in North America, they were relatively underrepresented internationally. PU and PS were equally likely to be first author on cooperative group studies, which accounted for 19% of the overall publications. 14,958 patients underwent extirpative surgery for WT. There was a small increase in publications reporting the use of minimally-invasive surgery (MIS) and nephron-sparing surgery (NSS) over time (<1% and 4% from 1993-2005 to 2% and 7% from 2006-2017, respectively, P <.001). Compared to PS, PU were significantly more likely to publish on patients managed with MIS and NSS (P = .006 and P < 0.001 respectively). CONCLUSION: Publications by PU on the surgical management of WT are increasing over time, but are still fewer than PS. PU appeared to be the drivers of the temporal trend towards the increasing use of MIS and NSS in the published literature.

Technical refinements to improve outcomes following distal hypospadias repair.

INTRODUCTION: Hypospadias complications, most notably meatal stenosis, are commonly reported to occur after tubularized incised plate (TIP) hypospadias repair. We focus on a point of technique in TIP repair and its effect on outcome of this possible complication, as well as other commonly reported complications. Meatal stenosis after TIP can be avoided if the urethra and overlying glans are dissected and sutured separately with no attempt at cross suturing whether the urethra ends below, behind, or above the glans sutures. This hypothesis was evaluated by a prospective data collection before and after implementation to evaluate the effect of a technical refinement on rates of meatal stenosis in TIP hypospadias repair. MATERIALS AND METHODS: All cases of coronal to midpenile hypospadias repair during two periods were included in our study. Group 1 included 140 consecutive patients over a 30 month period. Group 2 included 122 consecutive patients over a 36 month period during which the above mentioned technical changes were implemented by all participating pediatric urologists. Rates of complications between the two groups were compared with special emphasis on meatal stenosis. RESULTS: Median follow up for both groups was > 1 year. Overall complication rate in Group 1 was 31.5% compared to 9.8% in Group 2. Meatal stenosis was significantly reduced from 13 patients (9.3%) in Group 1 to 2 patients (1.6%) in Group 2, p = 0.008. CONCLUSION: The technical refinements described resulted in reduction of complication rates and a decrease in incidence of meatal stenosis.

Pattern of clinical presentation of congenital anomalies of the kidney and urinary tract among infants and children.

AIM: Congenital anomalies of the kidneys and urinary tract (CAKUT) comprise various entities of structural malformations that result from defects in morphogenesis of the kidney and/or urinary tract. These anomalies are the most commonly diagnosed malformations in the prenatal period and constitute the leading cause of end-+stage renal disease (ESRD) in children, worldwide. This prospective study was performed to report the patterns of clinical presentation and diagnosis of infants and children with such malformations. METHODS: Patients with suggestive features of CAKUT, presenting to Cairo University Children Hospital over one year duration were investigated and categorized based on underlying renal structural/functional malformation and associated extra-renal anomalies. RESULTS: One hundred and seven CAKUT children were enrolled in the study. Familial clustering was identified in 14% of the cohort and syndromic CAKUT accounted for 31.8% of cases. Different anomaly entities have been identified; posterior urethral valves (PUV) being the commonest detected abnormality (36.4%). Of note, 9.3% of cohort patients had ESRD at presentation, of which 60% had PUV as their primary renal disease. Obstructive cases were noted to present significantly earlier and attain advanced CKD stages rather than non-obstructive ones. CONCLUSION: CAKUT is a clinically heterogeneous group of diseases with diverse clinical phenotypes. More efforts should be aimed at improving antenatal detection as well as classification with comprehensive reference to the clinical, genetic and molecular features of the diseases. The high frequency of familial and syndromic CAKUT among studied patients is seemingly a convincing reason to pursue the underlying genetic defect in future studies.

Distal hypospadias repair using only glans wing mobilization and approximation.

INTRODUCTION: Since its first description in 1994, tubularized incised plate (TIP) technique has become the most commonly performed hypospadias procedure and involves incision of the urethral plate with subsequent tubularization. Glans wings are then developed to cover the neourethra, thereby creating a cosmetically appealing repair. In some distal hypospadias cases, mobilization and approximation of glans wings is sufficient to create a normal appearing urethral meatus. MATERIALS AND METHODS: A retrospective chart review of all pediatric urology patients who underwent hypospadias repair by a single surgeon at the University of Kentucky between July 1, 2010 and April 1, 2013 was performed. Of the 46 patients who underwent one-stage distal hypospadias repair during that time, we performed the technique described above on 13 patients with amenable anatomy. Patients were evaluated for functional and cosmetic outcomes as well as complications at subsequent office visits and via telephone. RESULTS: Patients who underwent distal hypospadias repair with our technique had excellent functional and cosmetic outcomes analogous to those who underwent standard TIP repair. The only major complication in the study group was wound dehiscence in one patient that was required a second surgery. All other patients had excellent cosmetic and functional results without fistula formation, strictures or diverticuli, and with excellent parent satisfaction. CONCLUSIONS: Perceived benefits of this technique include simplicity and rapidity of technique, applicability to glanular, coronal and subcoronal hypospadias, and avoidance of sutures between urethra and glans with potential decrease in meatal stenosis.

Crossed testicular ectopia with preoperative ultrasound.

Crossed testicular ectopia/transverse testicular ectopia is a rare congenital anomaly. It is most commonly identified intraoperatively in the setting of inguinal hernia repair with contralateral cryptorchidism. We report a case of crossed testicular ectopia identified in a 3-month-old male who presented with right cryptorchidism. Preoperative ultrasound revealed no testicle on the right and two testicles on the left - one within the left hemiscrotum and one within the left inguinal canal. Laparoscopy at 7 months of age revealed a closed right external ring and right ectopic testicle at the left external ring. Bilateral orchiopexy was performed.

Assessment of recoverability of kidney function in children with obstructive calcular anuria: multicenter study.

OBJECTIVE: Urolithiasis in children can cause considerable morbidity. Our aim was to evaluate the impact of intervention on the recoverability of kidney functions. MATERIALS AND METHODS: This prospective study included 93 children (66 boys and 27 girls) with median age of 3 years (range 0-14). Inclusion criteria were presence of anuria, oliguria, serum creatinine >2 mg% and/or hyperkalemia ≥ 6 mmol/L. The mean duration of anuria or oliguria was (mean ± SE) 5.3 ± 0.4 days. On presentation, mean plasma creatinine was 6.5 ± 0.29 mg/dl with a mean estimated glomerular filtration rate (eGFR) of 14 ml/min and creatinine clearance (CC) of 8.24 ml/min. Dialysis was performed in 21 (22.6%) patients. When condition allowed, emergency surgery was performed. RESULTS: Mean follow up was 1.5 years with compliance of 82%. At the end of treatment, 83% of patients had complete clearance of calculi. Mean plasma creatinine after treatment was 3.3 ± 0.35 mg/dl with an average GFR of 24.5 ml/min. After treatment renal function returned to normal in 57%, improved in 27% and deteriorated in 16% of children. Renal function recoverability rate was 94.6%. Chronic renal failure developed in 3 (3.2%) patients and 2 (2.2%) patients died. When absolute plasma creatinine concentration [P(cr)] improved 20-50% the eGFR and CC were doubled, and when improved 50-70% eGFR and CC tripled. Beyond 70% improvement in [P(cr)], eGFR and CC improved 7-8 times. Using Spearman's correlation, the mode of presentation and the type of management had a significant correlation with renal function outcome (P = 0.019 and 0.013 respectively). CONCLUSION: Urgent management of calcular anuria both medically and surgically is the cornerstone for favorable outcome. The mode of presentation and the type of management are significant factors affecting final renal function outcome.

Extracorporeal shock wave lithotripsy monotherapy for renal stones >25 mm in children.

OBJECTIVES: To determine the safety and efficacy of extracorporeal shock wave lithotripsy (ESWL) as monotherapy for renal stones >25 mm in children. METHODS: Our prospective study included 24 children <14 years old with radiopaque renal stones >25 mm treated by ESWL as first-line treatment using the electromagnetic Dornier DoLi S device. Pretreatment kidney, ureter, and bladder plain films and intravenous urography and post-treatment ultrasonography and kidney, ureter, and bladder plain films were used to monitor the clearance of fragments. Stone clearance was assessed at 1 and 3 months. A stone-free state was defined as no radiologic evidence of stone. Asymptomatic noninfectious and nonobstructive fragments <3 mm were considered insignificant. RESULTS: The 24 children, aged 2-14 years (mean 7) underwent 53 ESWL sessions. Of the 24 children, 10 had stones located in the left kidney and 14 had stones located in the right kidney. The stone size was 25-35 mm (average 31). The average number of shock waves was 3489 per session. All children underwent lithotripsy with a gradual incremental energy increase from 14 to 20 kV. The overall stone-free rate was 83.3%. Four patients had clinically insignificant fragments and were followed up for the possibility of stone regrowth, microscopic hematuria, and urinary tract infection. Complications affected 25% of patients. CONCLUSIONS: ESWL is highly effective for treatment of large renal stones in children as a first-line treatment with minimal morbidity. The placement of a stent is not a prerequisite for success of treatment.

Metabolic stone composition in Egyptian children.

OBJECTIVE: The composition of urinary stones in children depends on socioeconomic conditions, geography and dietary habits. Pediatric urolithiasis remains endemic in developing countries. The aim of this study was to analyze stone composition in an Egyptian patient population. PATIENTS AND METHODS: We analyzed prospectively urinary stones from 100 consecutive children (73 males, 27 females), aged 14 months to 12 years. The stones were located in the upper urinary tract in 78%, lower urinary tract in 19% and both in 3%. Male patients had more lower urinary tract stones. On presentation 67% had flank pain and 37% had hematuria. Stones were treated by open surgery in 69% of patients, shockwave lithotripsy in 20% and endoscopic extraction in 13%. RESULTS: The components of the upper urinary tract calculi were calcium oxalate (47%), ammonium acid urate (26%) and calcium carbonate (21%), whereas the main components of the lower urinary tract calculi were ammonium acid urate (27.2%), struvite (27.2%) and calcium carbonate (22.7%). Urinary tract infection was involved in the development of one third of the stones. Endemic stones were present in 17% of patients, and stones of metabolic origin in 15%. The etiology of stone formation remained unknown in one third of patients. CONCLUSION: The epidemiological profile of urinary stones in Egyptian children can now be considered intermediate between developing countries where dietary deficiencies are the main causes and developed countries where infectious and metabolic calculi are observed.

Safety of ungated shockwave lithotripsy in pediatric patients.

OBJECTIVE: Ungated extracorporeal shockwave lithotripsy (ESWL) in adults is associated with cardiac arrhythmias. We report on the safety and efficacy of this method for treatment of renal calculi in children. PATIENTS AND METHODS: Children under 14 years with radio-opaque renal stones were treated by ungated ESWL. Pre-treatment plain radiographs and intravenous urography and post-treatment ultrasonography and plain films were used to follow up clearance of fragments. All children were monitored for arrhythmias. RESULTS: Thirty-seven children (28 males, nine females) with a median age of 5 years (range 2-14 years) underwent 69 ungated ESWL sessions for renal calculi. Nineteen children had stones located in the left kidney, 17 had stones located in the right kidney and one child had bilateral renal stones. The stone size ranged from 6 to 25 mm (mean 9.9 mm). Shockwave number ranged from 800 to 3650 (mean of 2500 shockwaves per session). All children underwent lithotripsy with a gradual incremental energy increase from 14 to 20 kV. No patient had cardiac arrhythmias or other intra-procedural complications. No patient required conversion to gated ESWL. The overall stone-free rate was 86%. CONCLUSION: The results suggest that ungated ESWL is safe in children under 14 years. The efficacy was comparable to that of gated ESWL from previously published series.

Tubularized incised plate (TIP) in previously operated (redo) hypospadias.

OBJECTIVE: We report our experience of using the tubularized incised plate (TIP) technique for repair of hypospadias in patients who had undergone one or more failed attempts at repair. METHODS: A total of 30 children (age range 2-10 years; mean 4.3 years) with hypospadias presented to our unit for redo hypospadias. The number of prior repairs was as follows: one in 17 patients, two in eight patients and three in five patients. The meatus was at the distal shaft in 19 cases, mid shaft in eight cases, and proximal shaft in three cases. Preoperatively 13 patients had fistulae, and none had residual chordee. The urethral plates were judged to be surgically altered in 11 patients and unaltered in 19 patients. The neourethra was then reconstructed using the Snodgrass TIP technique. Follow-up urethral calibration was performed to assess the results. All patients were discharged same day postoperatively. All patients were followed up at 1 week, 3 weeks, 6 weeks, 3 months, 6 months and 1 year. Patients were contacted in June/July 2005 and brought back for re-evaluation of the results. RESULTS: The cosmetic and functional results were satisfactory as judged by the parents. Overall complications were encountered in 7 patients (23%). Complications included six fistulae, five were associated with meatal stenosis and one with infection. Stand alone meatal stenosis occurred in three other cases of which only one required intervention. Fistula repair was successfully performed 6 months later in five patients with associated meatoplasty. One case had a revised repair. One case required meatotomy. CONCLUSION: The TIP procedure is a viable option with satisfactory cosmetic and functional results for the correction of a previously failed hypospadias repair.

Predictive factors of lower calyceal stone clearance after Extracorporeal Shockwave Lithotripsy (ESWL): a focus on the infundibulopelvic anatomy.

INTRODUCTION: Controversy exists as to whether ESWL is suitable for lower pole renal stones, given the dependent position of the lower calyces. This study aims to test the effect of lower pole anatomy, namely lower polar infundibulo-pelvic angle, infundibular length and width, on clearance of fragments after ESWL. PATIENTS AND METHODS: We conducted a retrospective study of 205 renal units with single lower pole stones of not more than 25 mm in their greatest diameter that were treated by ESWL alone. Exclusion criteria included multiple stones, patients requiring stenting or percutaneous drainage for various reasons. Pretreatment IVU was used to measure lower polar dimensions. Post treatment ultrasonography and KUB were used to assess clearance of fragments. RESULTS: The right kidney was involved in 68% and the left in 42% of cases. Average number of sessions was 1.6 with an average 3277 shockwaves per session. 134 patients (65.3%) required one session, 41 requiring 2 sessions (20%), 18 requiring 3 sessions (8.7%), 6 requiring 4 sessions (2.9%) and 8 requiring 5 sessions (3.9%). Complete clearance was attained in 141 cases, while 64 cases had residual fragments, 20 were asymptomatic and required no further management. The lower pole infundibulo-pelvic angle (LIP-A) was the most significant factor in clearance (p value 0.00001). Infundibular length (IL) was also statistically significant (p value 0.039). CONCLUSION: Lower pole anatomy has a significant impact on ESWL results. LIP-A not less than 70 degrees and an infundibular length of < 50 mm is preferable to achieve favorable outcome.