Awake Combined Spinal Caudal Anesthesia for Longer-Duration Urologic Surgery in Infants: A Case Series.

Awake combined spinal caudal anesthesia has been used as an anesthetic technique for longer-duration infraumbilical surgeries in infants. Literature on the safety and feasibility of this technique is limited. We share our experience with 27 infants undergoing longer-duration urologic surgery using awake combined spinal and caudal anesthesia without the use of systemic sedatives or inhalational agents. We describe our technique, safety considerations, and details surrounding the optimal timing of caudal catheter activation for prolongation of surgical anesthesia.

Emergence of the natural history of Myhre syndrome: 47 patients evaluated in the Massachusetts General Hospital Myhre Syndrome Clinic (2016-2023).

Myhre syndrome is an increasingly diagnosed ultrarare condition caused by recurrent germline autosomal dominant de novo variants in SMAD4. Detailed multispecialty evaluations performed at the Massachusetts General Hospital (MGH) Myhre Syndrome Clinic (2016-2023) and by collaborating specialists have facilitated deep phenotyping, genotyping and natural history analysis. Of 47 patients (four previously reported), most (81%) patients returned to MGH at least once. For patients followed for at least 5 years, symptom progression was observed in all. 55% were female and 9% were older than 18 years at diagnosis. Pathogenic variants in SMAD4 involved protein residues p.Ile500Val (49%), p.Ile500Thr (11%), p.Ile500Leu (2%), and p.Arg496Cys (38%). Individuals with the SMAD4 variant p.Arg496Cys were less likely to have hearing loss, growth restriction, and aortic hypoplasia than the other variant groups. Those with the p.Ile500Thr variant had moderate/severe aortic hypoplasia in three patients (60%), however, the small number (n = 5) prevented statistical comparison with the other variants. Two deaths reported in this cohort involved complex cardiovascular disease and airway stenosis, respectively. We provide a foundation for ongoing natural history studies and emphasize the need for evidence-based guidelines in anticipation of disease-specific therapies.

Dietl crisis: Presentation and imaging findings in a 7-year-old boy.

Intermittent ureteropelvic junction obstruction, or Dietl crisis, is a rare entity with sparse reports in published literature. Establishing the diagnosis is challenging given its intermittent nature. We report a case of Dietl crisis, focusing on ultrasound (US) and magnetic resonance urography (MRU) findings in a 7-year-old boy with recurrent episodes of colicky abdominal pain prompting multiple visits to the emergency department. Severe left hydronephrosis was visualized on US during one episode with complete resolution on follow-up US. MRU demonstrated severe left hydronephrosis with delayed calyceal transit time, time-to-peak enhancement, and excretion. There was no aberrant blood vessel. Surgical pyeloplasty provided complete symptomatic resolution. MRU can be a valuable tool in eliciting and dynamically confirming the diagnosis of Dietl crisis.

Differences in early career operative experiences among pediatric urologists.

INTRODUCTION: Previous research suggests that pediatric urologists feel well trained by their fellowship for cases encountered early in their career. We questioned the complexity and diversity of cases new pediatric urologists were actually performing. OBJECTIVE: The aim was to identify the frequency with which newly trained pediatric urologists are performing various procedures, investigate which factors are associated with case complexity and diversity, and evaluate for differences between male and female surgeons. STUDY DESIGN: Case logs of urologists from July 30, 2007, to June 30, 2013, initially applying for the certifying examination who self-identified as pediatric urologists were reviewed. Data points included cases/dates, and surgeon demographics. An in-depth analysis was performed on 51 index cases from the 71 included pediatric urologists, for which a level of complexity was assigned. RESULTS: Compared with the bottom volume quartile, surgeons in the top quartile performed more cases of minimal (115.9 ± 8.7 vs. 51.7 ± 8.7, p < 0.001), moderate (31.1 ± 2.7 vs. 10.1 ± 1.0, p < 0.001) and significant (10.8 ± 1.9 vs. 2.0 ± 0.4, p < 0.001) complexity. More than 90% logged circumcisions, orchiopexies, and inguinal hernia repairs, while less than 1.5% logged open nephroureterectomies or complete male epispadias repair. Surgeons submitted at least one of 17.2 ± 0.5 (range 5-28) unique codes. The figure presents the percentage of current procedural terminology (CPT) codes performed by each urologist. Surgeons with the least case diversity performed a higher percentage of low-complexity cases, and lower percentages of moderate and complex cases (p < 0.001). Males, comprising 60.6% of urologists, performed more cases than females (342.9 ± 30.9 vs. 229.1 ± 18.1, p = 0.007), averaging more cases of minimal (95.0 ± 6.6 vs. 73.3 ± 4.6, p = 0.018) and significant (6.7 ± 1.0 vs. 2.8 ± 0.5, p = 0.005) complexity. There was no difference in cases of moderate complexity (22.0 ± 1.9 vs. 18.1 ± 2.1, p = 0.201). DISCUSSION: In general, pediatric urologists should expect to perform many minor cases when they enter practice. Women are entering urology in increasing numbers. In our study, female urologists performed fewer cases. This could have implications for the workforce, which in urology in general is expected to decrease. CONCLUSIONS: Case diversity and degree of complexity vary among newly trained pediatric urologists. The urologist with the greatest case diversity never performed 45% of the 51 analyzed CPT codes, while the one with the least case diversity never performed 90% of the codes. Male surgeons performed more operations, particularly those of minimal and significant complexity. The variability in operative experience reinforces the importance of continuing education and mentorship after completion of fellowship.

Prolonged urinary retention can and does occur after any type of ureteral reimplantantion.

OBJECTIVE: Transient urinary retention has been recognized as a complication of bilateral ureteroneocystostomy (UNC), when performed extravesically. The objective of this study was to review a collective surgeons' experiences of unilateral extra- and unilateral and/or bilateral intra-vesical ureteral reimplanation, where urinary retention greater than 6 weeks, or what we have termed, "prolonged urinary retention" (PUR), occurred. MATERIALS AND METHODS: We retrospectively reviewed charts to identify PUR after any open or robotic reimplant, other than bilateral extravesical, between 1998 and 2015 as reported by five surgeons. RESULTS: During the review period, ten cases were documented where PUR was encountered. Bilateral Cohen reimplants (5), unilateral extravesical open reimplant with ureteral tapering (3), unilateral Cohen reimplant (1) and unilateral extravesical robotic reimplant with tapering (1) were associated with PUR. Younger males predominated (70%). The mean age at operation of the patients was 3.1 years. Eventually 7/10 patients were able to void normally, with periods ranging from 6 weeks to 8 years. The remaining three patients are still unable to void more than 5 years after UNC. A majority of the samples (6/10) were suspected to have bowel and bladder dysfunction (BBD), but neurologically all were normal. CONCLUSION: PUR can occur as a potential complication following any type of UNC and is associated with the risk of significant morbidity, including permanent urinary retention. Patients and caregivers should be counseled accordingly.

Zero-fragment Nephrolithotomy: A Multi-center Evaluation of Robotic Pyelolithotomy and Nephrolithotomy for Treating Renal Stones.

BACKGROUND: Robotic pyelolithotomy (RPL) and robotic nephrolithotomy (RNL) may be utilized for treating kidney stones as an alternative to percutaneous nephrolithotomy or flexible ureteroscopy. OBJECTIVE: To describe the techniques of RPL and RNL, and present multi-center outcome data for patients undergoing these procedures. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective analysis of 27 patients undergoing RPL and RNL at five tertiary academic institutions between 2008 and 2014. SURGICAL PROCEDURE: RPL and RNL without use of renal ischemia. MEASUREMENTS: We assessed stone clearance by visual assessment and postoperative imaging. We also examined other factors, including complications (Clavien grade), estimated blood loss, operative time, and length of stay. RESULTS AND LIMITATIONS: Twenty-seven patients underwent 28 procedures for a mean renal stone size of 2.74cm (standard deviation: 1.4, range: 0.8-5.8). The mean stone volume was 10.2cm3. RPL accounted for 26 of these procedures. RNL was performed in one patient, while another underwent combined RPL-RNL. Indications included failed previous endourological management (13), staghorn calculi (five), gas containing stone (one), calyceal diverticulum (one), complex urinary tract reconstruction (two), and patient preference (four). The mean patient age was 35.6 yr and mean body mass index was 25.5kg/m2. Mean operative time/console times were 182min and 128min, respectively. The mean estimated blood loss was 38ml. The mean length of stay was 1.7 d. There was no significant change in preoperative and postoperative serum creatinine levels. The overall complication rate was 18.5% (Clavien 1=3.7%; 2=7.4%; 3b=7.4%). The complete stone-free rate was 96%. CONCLUSIONS: RPL and RNL are safe and reasonable options for removing renal stones in select patients. In particular, RPL allows the removal of stones without transgressing the parenchyma, reducing potential bleeding and nephron loss. PATIENT SUMMARY: The robotic approach allows for complete removal of the renal stone without fragmentation, thereby maximizing chances for complete stone clearance in one procedure.

Surgical Management of the Undescended Testis: Recent Advances and Controversies.

Undescended testis (UDT) is the most common disorder of sexual development in boys and affects 3.5% of male newborns. Although approximately half of newborn UDTs descend spontaneously, some boys develop an ascending testis later in childhood. Recent guideline recommendations advocate orchiopexy by 18 months of age to maximize potential for fertility and perhaps reduce the risk for testicular carcinoma in the future. For palpable testes, a standard inguinal approach is appropriate. However, the prescrotal approach is often effective for low inguinal testes and reduces surgical time and patient discomfort with an equivalent success rate in boys with an ascending testis. Some advocate monitoring until adolescence to determine whether the testis will spontaneously descend into the scrotum, but data do not support this approach. Instead, prompt orchiopexy is recommended. In boys with a nonpalpable testis, approximately 50% are abdominal or high in the inguinal canal and 50% are atrophic, typically in the scrotum. Routine inguinal/scrotal ultrasound is not recommended, although in an older boy who is overweight, it is appropriate. If the patient has contralateral testicular hypertrophy, scrotal exploration is appropriate, and removal of the testicular remnant and contralateral scrotal orchiopexy to prevent future contralateral testicular torsion is recommended. In most cases, diagnostic laparoscopy is advised to determine whether the testis is abdominal. For the abdominal testis, there are numerous treatment options. If the testis is mobile or a peeping testis just distal to the internal inguinal ring, standard one-stage laparoscopic or open orchiopexy should be attempted using the Prentiss maneuver. If the testicular vessels are short or the testis is not mobile, a two-stage Fowler-Stephens orchiopexy is appropriate. The second stage can be performed laparoscopically or open. Another option is microvascular testicular autotransplantation, which is a technically demanding procedure. Surgical results of abdominal orchiopexy are highly variable, short term, and highly subjective. Prospective clinical trials with follow-up into adolescence and adulthood are necessary to assess the success of various surgical approaches.

Checklist assessment tool to evaluate suitability and success of neonatal clamp circumcision: A prospective study.

BACKGROUND: The American Academy of Pediatrics (AAP) Task Force on Circumcision has called for the development of standards of trainee proficiency in regards to evaluation and technique for neonatal clamp circumcision (NCC). At the present time, there is no standardized or general consensus on patient selection for NCC. An improved method to evaluate newborns for NCC is an important first step in this process. Therefore, the authors collaborated to identify criteria useful in the evaluation of newborns for suitability for NCC, and for assessment of success after NCC and have named it "Checklist Assessment for Neonatal Clamp Circumcision Suitability." METHODS: A national multi-institutional collaboration was created to obtain consensus on objective criteria for use in determining patient suitability for NCC, and for assessing post-circumcision success outcomes. Criteria included elements from detailed medical history, bedside physical examination, and post-circumcision follow-up. Patients desiring NCC were enrolled consecutively and prospectively. The Checklist was followed to determine which newborns were suited to NCC, and NCC was done in those cases. The patients' caretakers were given post-circumcision care instructions and a follow-up appointment. Post circumcision, the Checklist was followed to determine if the procedure resulted in a successful circumcision or if there were complications. RESULTS: A total of 193 cases were enrolled prospectively and consecutively from January 2014 through October 2014. The mean age was 15 days (1-30 days). Of those 193 patients, 129 (67%) were deemed suitable for circumcision and underwent NCC. Post-circumcision assessment showed a 100% success rate with no complications. A total of 64 (23%) cases were deemed unsuitable for NCC because at least one checklist criterion was not satisfied, most commonly: penile torsion (n = 25), chordee (n = 19), and penoscrotal webbing (n = 19). DISCUSSION: Use of the Checklist in the present study has demonstrated a method of patient screening resulting in a 100% success rate with no complications. A high proportion of patients (33%) was identified as unsuited for NCC; however, the patient population consisted of newborn males referred to pediatric urology, and thus does not represent the general population, which is expected to have a lower proportion of unsuited patients. Regardless, the Checklist has the potential to enhance the decision-making process for both urologic and non-urologic care providers. CONCLUSIONS: The use of the "Checklist Assessment for Neonatal Clamp Circumcision Suitability" assessment tool improves identification of patients unsuited for NCC and thereby potentially decreases the likelihood of circumcision-related complications.

Treatment patterns, testicular loss and disparities in inpatient surgical management of testicular torsion in boys: a population-based study 1998-2010.

OBJECTIVES: To examine temporal trends in inpatient testicular torsion (TT) treatment and testicular loss (TL), and to identify risk factors for TL using a large nationally representative paediatric cohort, stratified to established high prevalence TT cohorts (neonatal TT [NTT]; age <1 years) and adolescent TT (ATT; age 12-17 years). METHODS: Boys (age ≤17 years, n = 17 478) undergoing surgical exploration for TT were identified within the Nationwide Inpatient Sample (1998-2010). Temporal trends in inpatient TT management (salvage surgery vs orchiectomy) and TL were examined using estimated annual percent change methodology. Multivariable logistic regression models were used to identify risk factors for TL. RESULTS: Teaching hospitals treated 90% of boys with NTT, compared with 55% with ATT (P < 0.001). Of boys with NTT, 85% lost their testis, compared with 35% with ATT (P < 0.001). Inpatient management of NTT declined during the study period, from 7.5/100 000 children in 1998 to 3/100 000 in 2010 (estimated annual percent change -4.95%; P < 0.001). The decrease was similar but less dramatic in ATT. TL patterns did not improve. In adjusted analyses, for NTT, orchiectomy was more likely at teaching hospitals. For ATT, orchiectomy was more likely in children with comorbidities (odds ratio 5.42; P = 0.045), Medicaid coverage or self-pay (P < 0.05) and weekday presentation (P = 0.001). Regional or racial disposition was not associated with TL. CONCLUSIONS: There has been a gradual decrease in inpatient surgical treatment for both NTT and ATT, presumably as a result of increased outpatient and/or non-operative management of these children. Concerningly, TL patterns have not improved; targeted interventions such as parental and adolescent male health education may lead to timely recognition/intervention in children at-risk for ATT. We noted no regional/racial disparities in contrast to earlier studies.

Simultaneous bilateral robotic-assisted laparoscopic procedures in children.

Our main objective is to report the feasibility of performing simultaneous robotic-assisted laparoscopic (RAL) heminephrectomy with contralateral ureteroureterostomy in children with bilateral duplicated systems. Three female children with bilateral congenital renal/ureteral anomalies underwent concurrent RAL simultaneous unilateral partial nephrectomy with ureterectomy and contralateral ureteroureterostomy with redundant ureterectomy using a four/five-port approach. Mean age at repair was 32.9 months (range 7-46 months) and mean weight was 13.7 kg (range 10.4-13.6 kg). The RAL heminephroureterectomy and contralateral ureteroureterostomy were performed via a four-port approach (five ports in one patient), and the patients were repositioned and draped when moving to the other side. Mean operative time was 446 min (range 356-503 min). Mean estimated blood loss was 23.3 cc (range 10-50 cc). Postoperative length of stay for two patients was 2 days and 1 day for one patient (mean = 1.7 days). Mean length of follow-up was 18.3 months (range 7-36 months). No significant intraoperative or postoperative complications occurred for any of the three patients. Two children had no hydronephrosis on postoperative imaging in follow-up, and one child had a small stable, residual pararenal fluid collection on the side of heminephrectomy. Two patients underwent postoperative ureteral stent removal under general anesthesia. In children with bilateral duplicated urinary tract with ureterocele, ectopic ureter, and/or vesicoureteral reflux, laparoscopic repair with robotic assistance can be accomplished safely in a single operative procedure with a short hospital stay.

Corrigendum: Inpatient hypospadias care: Trends and outcomes from the American nationwide inpatient sample.

[This corrects the article on p. 594 in vol. 56, PMID: 26279829.].

Inpatients hypospadias care: trends and outcomes from the American nationwide inpatient sample.

PURPOSE: Hypospadias is the most common congenital penile anomaly. Information about current utilization patterns of inpatient hypospadias repair as well as complication rates remain poorly evaluated. MATERIALS AND METHODS: The Nationwide Inpatient Sample was used to identify all patients undergoing inpatient hypospadias repair between 1998 and 2010. Patient and hospital characteristics were attained and outcomes of interest included intra- and immediate postoperative complications. Utilization was evaluated temporally and also according to patient and hospital characteristics. Predictors of complications and excess length of stay were evaluated by logistic regression models. RESULTS: A weighted 10,201 patients underwent inpatient hypospadias repair between 1998 and 2010. Half were infants (52.2%), and were operated in urban and teaching hospitals. Trend analyses demonstrated a decline in incidence of inpatient hypospadias repair (estimated annual percentage change, -6.80%; range, -0.51% to -12.69%; p=0.037). Postoperative complication rate was 4.9% and most commonly wound-related. Hospital volume was inversely related to complication rates. Specifically, higher hospital volume (>31 cases annually) was the only variable associated with decreased postoperative complications. CONCLUSIONS: Inpatient hypospadias repair have substantially decreased since the late 1990's. Older age groups and presumably more complex procedures constitute most of the inpatient procedures nowadays.

Practice patterns and outcomes of pediatric partial nephrectomy in the United States: Comparison between pediatric urology and general pediatric surgery.

BACKGROUND: In the United States, both pediatric urologists (PUROs) and general pediatric surgeons (GPSs) perform nephrectomies in children, with PUROs performing more nephrectomies overall, most commonly for benign causes. GPSs perform more nephrectomies for malignant causes. We questioned whether the same trends persisted for partial nephrectomy. OBJECTIVE: We hypothesized that PUROs performed more partial nephrectomies for all causes, including malignancy. Our primary aim was to characterize the number of partial nephrectomies performed by PUROs and GPSs. We also compared short-term outcomes between subspecialties. STUDY DESIGN: We analyzed the Pediatric Health Information System (PHIS), a database encompassing data from 44 children's hospitals. Patients were ≤18 years old and had a partial nephrectomy (ICD-9 procedure code 554) carried out by PUROs or GPSs between 1 January, 2004 and June 30, 2013. Queried data points included surgeon subspecialty, age, gender, 3M™ All Patient Refined Diagnosis Related Groups (3M™ APR DRG) code, severity level, mortality risk, length of stay (LOS), and medical/surgical complication flags. Data points were compared in patients on whom PUROs and GPSs had operated. Statistical analysis included the Student t test, chi-square test, analysis of covariance, and logistic regression. RESULTS: Results are presented in the table. While PUROs performed the majority of partial nephrectomies, GPSs operated more commonly for malignancy. For surgeries performed for non-malignant indications, PURO patients had a shorter LOS and lower complication rate after controlling for statistically identified covariates. There was no difference in LOS or complication rate for patients with malignancy. DISCUSSION: A Pediatric Health Information System study of pediatric nephrectomy demonstrated PUROs performed more nephrectomies overall, but GPSs performed more surgeries for malignancy. The difference was less dramatic for partial nephrectomies (63% GPS, 37% PURO) than for radical nephrectomies (90% GPS, 10% PURO). PUROs performed more partial nephrectomies for benign indications (94% PURO, 6% GPS) at an even greater rate than nephrectomies (88% PURO, 12% GPS). As a national database study, there are a number of inherent limitations: applicability of results to non-participating hospitals, possibility of inaccurate data entry/coding, and lack of data points that would be relevant to the study. CONCLUSIONS: While most partial nephrectomies in the United States are performed by PUROs, GPSs perform the majority of surgeries for malignancy. There is no difference in LOS or complication rate undergoing nephron-sparing surgery for malignant disease; however, PUROs had a shorter LOS and lower complication rate when operating for benign diseases.

Incidence, admission rates, and economic burden of pediatric emergency department visits for urinary tract infection: data from the nationwide emergency department sample, 2006 to 2011.

BACKGROUND: The Emergency Department (ED) is being increasingly utilized as a pathway for management of acute conditions such as the urinary tract infections (UTIs). OBJECTIVE: We sought to assess the contemporary trends in pediatric UTI associated ED visits, subsequent hospitalization, and corresponding financial expenditure, using a large nationally representative pediatric cohort. Further, we describe the predictors of admission following a UTI associated ED visit. METHODS: The Nationwide Emergency Department Sample (NEDS; 2006-2011) was queried to assess temporal-trends in pediatric (age ≤17 years) ED visits for a primary diagnosis of UTI (ICD9 CM code 590.X, 595.0, and 599.0), subsequent hospital admission, and total charges. These trends were examined using the estimated annual percent change (EAPC) method. Multivariable regression models fitted with generalized estimating equations (GEE) identified the predictors of hospital admission. RESULTS: Of the 1,904,379 children presenting to the ED for management of UTI, 86 042 (4.7%) underwent hospital admission. Female ED visits accounted for almost 90% of visits and increased significantly (EAPC 3.28%; p = 0.003) from 709 visits per 100 000 in 2006 to 844 visits per 100 000 in 2011. Male UTI incidence remained unchanged over the study-period (p = 0.292). The overall UTI associated ED visits also increased significantly during the study-period (EAPC 3.14%; p = 0.006) because of the increase in female UTI associated ED visits. Overall hospital admissions declined significantly over the study-period (EAPC -5.59%; p = 0.021). Total associated charges increased significantly at an annual rate of 18.26%, increasing from 254 million USD in 2006 to 464 million USD in 2011 (p < 0.001; Figure). This increase in expenditure was likely driven by increased utilization of diagnostic CT scanning in these patients (EAPC 22.86%; p < 0.001). Ultrasonography (p = 0.805), X-ray (p = 0.196), and urine analysis/culture use (p = 0.121) did not change over the study-period. In multivariable analysis, the independent predictors of admission included younger age (p < 0.001), male gender (OR = 2.05, p < 0.001), higher comorbidity status (OR = 14.81, p < 0.001), pyelonephritis (OR = 4.45, p < 0.001) and concurrent hydronephrosis (OR = 49.42, p < 0.001), stone disease (OR = 6.44, p < 0.001), or sepsis (OR = 18.83, p < 0.001). DISCUSSION: We show that the incidence of ED visits for pediatric UTI is on the rise. This rise in incidence could be due to several factors, including increasing prevalence of metabolic conditions such as obesity, diabetes and metabolic syndrome in children predisposing them to infections, or could be secondary to increasing sexual activity amongst adolescents and changing patterns of contraceptive use (increased use of OCP in place of condoms), or more simply might just be a reflection of changing practice patterns. Second, we demonstrate that total charges for management of UTI in the ED setting are increasing rapidly; the increase is primarily driven by increasing utilization of diagnostic imaging in the ED setting, as has been demonstrated in other ED based studies as well. CONCLUSIONS: In children presenting to the ED with a primary diagnosis of UTI, total ED charges are increasing at an alarming rate not commensurate with the increase in overall ED visits. While the preponderance of children presenting to the ED for UTI are treated and discharged, 4.7% of patients were admitted to the hospital for further management. The strongest predictors of inpatient admission were pyelonephritis, younger age, male gender, higher comorbidity status, and concurrent hydronephrosis, stone disease, or sepsis. Managing these at-risk patients more aggressively in the outpatient setting may prevent unnecessary ED visits and subsequent hospitalizations, and reduce associated healthcare costs.

National practice patterns and outcomes of pediatric nephrectomy: comparison between urology and general surgery.

PURPOSE: In adults nephrectomy is under the purview of urologists, but pediatric urologists and pediatric general surgeons perform extirpative renal surgery in children. We compared the contemporary performance and outcome of all-cause nephrectomy at pediatric hospitals as performed by pediatric urologists and pediatric general surgeons. MATERIALS AND METHODS: We queried the Pediatric Health Information System to identify patients 0 to 18 years old who were treated with nephrectomy between 2004 and 2013 by pediatric urologists and pediatric general surgeons. Data points included age, gender, severity level, mortality risk, complications and length of stay. Patients were compared by APR DRG codes 442 (kidney and urinary tract procedures for malignancy) and 443 (kidney and urinary tract procedures for nonmalignancy). RESULTS: Pediatric urologists performed more all-cause nephrectomies. While pediatric urologists were more likely to operate on patients with benign renal disease, pediatric general surgeons were more likely to operate on children with malignancy. Patients on whom pediatric general surgeons operated had a higher average severity level and were at greater risk for mortality. After controlling for differences patients without malignancy operated on by pediatric urologists had a shorter length of stay, and fewer medical and surgical complications. There was no difference in length of stay, or medical or surgical complications in patients with malignancy. CONCLUSIONS: Overall compared to pediatric general surgeons more nephrectomies are performed by pediatric urologists. Short-term outcomes, including length of stay and complication rates, appear better in this data set in patients without malignancy who undergo nephrectomy by pediatric urologists but there is no difference in outcomes when nephrectomy is performed for malignancy.

Role of insulin resistance in uric acid nephrolithiasis.

Metabolic syndrome has been implicated in the pathogenesis of uric acid stones. Although not completely understood, its role is supported by many studies demonstrating increased prevalence of uric acid stones in patients with metabolic syndrome and in particular insulin resistance, a major component of metabolic syndrome. This review presents epidemiologic studies demonstrating the association between metabolic syndrome and nephrolithiasis in general as well as the relationship between insulin resistance and uric acid stone formation, in particular. We also review studies that explore the pathophysiologic relationship between insulin resistance and uric acid nephrolithiasis.

Robotic nephrolithotomy and pyelolithotomy with utilization of the robotic ultrasound probe.

INTRODUCTION: The treatment of large renal stones in children can be challenging often requiring combination therapy and multiple procedures. The purpose of this video is to describe our technique of robotic nephrolithotomy and pyelolithotomy for complex renal stone disease in children, and to demonstrate the utility of the robotic ultrasound probe to aid with stone localization. MATERIALS AND METHODS: Robotic nephrolithotomy/pyelolithotomy was carried out in four consecutive patients. A robotic ultrasound probe (Hitachi-Aloka, Tokyo, Japan) under console surgeon control was used in all cases. RESULTS: Two patients underwent robotic pyelolithotomy, one patient underwent robotic nephrolithotomy, whilst the fourth patient underwent robotic pyelolithotomy and nephrolithotomy along with Y-V pyeloplasty for concurrent ureteropelvic junction obstruction. Mean operative time, blood loss and hospital stay was 216 minutes, 37.5 mL and 2 days, respectively. The robotic ultrasound probe aided identification of calculi within the kidney in all cases. For nephroli¬thotomy it was helpful in planning the incision for nephrotomy. After nephrotomy or pyelotomy, stones were removed using a combination of robotic Maryland forceps, fenestrated grasper or Prograsp. Antegrade nephroscopy introduced through a laparoscopic port was used in all patients for confirmation of residual stone status. Two patients did not require a ureteral stent in the post-operative period. One patient had a minor complication (Clavien Grade 2 - dislodged malecot catheter). All patients were stone free at last follow-up. CONCLUSIONS: Robotic nephrolithotomy and pyelolithotomy with utilization of the robotic ultrasound probe offers a one-stop solution for complex renal stones with excellent stone-free rates.

Pediatric nephrectomy: incidence, indications and use of minimally invasive techniques.

PURPOSE: There is a paucity of knowledge regarding nephrectomy in contemporary United States pediatric populations. Usage patterns, indications and demographics of children undergoing nephrectomy are unknown. Given the significant increases in the use of minimally invasive nephrectomy in adults, we hypothesized similar trends may be seen in the pediatric population. MATERIALS AND METHODS: An estimated total of 27,615 children undergoing nephrectomy between 1998 and 2010 was extracted from the Nationwide Inpatient Sample. Trends in use were analyzed with the estimated annual percent change methodology using linear regression and proportions by chi-square. Determinants of minimally invasive nephrectomy were evaluated using generalized linear models adjusted for clustering with generalized estimating equations. RESULTS: The annual incidence of pediatric nephrectomy was 2.90 per 100,000 patient-years and remained stable. Nephrectomy was most common in children 0 to 1 year old (36%) and least common in children 6 to 9 years old (14%). However, nephrectomy for malignancy was most common in children 3 to 4 years old. Minimally invasive nephrectomy usage increased from 1.1% to 11.6% during the study period (estimated annual percent change 72.82%, p = 0.007). On multivariable analysis patients with malignancy (OR 0.07, p <0.001) had a lower rate of minimally invasive nephrectomy. Increased use was associated with increasing age (OR 1.07, p <0.001), treatment at a teaching institution (OR 1.95, p = 0.008) and increasing hospital volume (OR 1.01, p = 0.001). CONCLUSIONS: While the annual incidence of nephrectomy is stable, the use of minimally invasive nephrectomy is expanding in the pediatric population. Benign pathology and increasing age as well as nephrectomy at high volume teaching institutions are independently associated with minimally invasive nephrectomy use.