Pharmacologic and Environmental Endocrine Disruptors in the Pathogenesis of Hypospadias: a Review.

PURPOSE OF REVIEW: Endocrine disrupting chemicals (EDCs) potentially have a role in causing hypospadias malformation through modifiable in-utero exposure. Considering the emerging literature on the role of potential endocrine disrupting substances on the occurrence of hypospadias and the potential to inform public health efforts to prevent the occurrence of these malformations, we have summarized the current literature, identified areas of consensus, and highlighted areas that warrant further investigation. RECENT FINDINGS: Pharmaceuticals, such as diethylstilbestrol, progestin fertility treatments, corticosteroids, and valproic acid, have all been associated with hypospadias risk. Data on exposure to dichlorodiphenyltrichloroethane and hexachlorobenzene pesticides, as well as non-persistent pollutants, particularly phthalates, is less consistent but still compelling. Improving exposure assessment, standardizing sample timing to relevant developmental windows, using clear case identification and classification schemes, and elucidating dose-response relationships with EDCs will help to provide clearer evidence. Promising directions for future research include identification of subgroups with genetic hypospadias risk factors, measurement of intermediate outcomes, and study of EDC mixtures that will more accurately represent the total fetal environment.

Gomco Versus Mogen? No Effect on Circumcision Revision Rates.

OBJECTIVES: Elective newborn circumcision, one of the most common surgical procedures in the world, is often performed with either the Gomco clamp or the Mogen clamp. Our aims were to determine differential circumcision revision and complication rates due to surgical technique and differences in outcomes when residents versus attending physicians performed the procedure. METHODS: We conducted a retrospective chart review of newborns who underwent elective circumcision at our children's hospital from January 2013 to June 2017 using Current Procedural Terminology codes for newborn circumcision and repair of an incomplete circumcision. We excluded patients who were initially circumcised by a physician other than a pediatrician and procedures that were performed after 31 days of age. The primary outcome was the rate of circumcision revisions. The secondary outcome was the incidence of minor and major complications. We used independent sample t tests, analysis of variance, Fisher's exact test, and logistic regression models in the analysis. RESULTS: We analyzed 979 Gomco and 718 Mogen procedures. Both groups had similar complication (26 of 1697 or 1.53%) and revision rates (8 of 1697 or 0.47%). Attending physicians and residents had similar revision rates overall, but residents using the Gomco clamp had a higher rate of revision (2 of 249 or 0.80%) than attending physicians (2 of 730 or 0.27%; P = .003). Older age at primary procedure was significantly associated with revision (P = .03). CONCLUSIONS: Elective newborn circumcision is associated with similar complication and revision rates after the use of either Gomco or Mogen clamps. There were no differences in outcomes when the procedure was performed by pediatric residents or attending pediatricians.

Hyperkalemia After Laparoscopic Nephrectomy in Patients With Renal Insufficiency: A Case Report.

Laparoscopic surgery is an evolving surgical modality in children, which has been applied to increasingly more complex surgeries and patients, including patients with renal insufficiency. These patients are particularly susceptible to the challenges that laparoscopy imposes on their altered physiology, leading to marked electrolyte disturbances, including metabolic acidosis and hyperkalemia. Hyperkalemia has the potential for marked impairment of cardiac conduction. We report 2 cases where significant, potentially lethal hyperkalemia developed during laparoscopic nephrectomy in adolescents with renal insufficiency. Awareness of this issue, as well as adequate preparation and intraoperative monitoring are essential to preventing this life-threatening complication.

Outcomes of seromuscular bladder augmentation versus standard ileocystoplasty: A single institution experience over 14 years.

INTRODUCTION: Ileocystoplasty is the standard technique used for bladder augmentation, and has been used widely for decades. However, it is known to be associated with complications such as stone formation, mucus production, metabolic acidosis, urinary tract infections, intestinal obstruction, and a long-term risk of bladder cancer. Seromuscular bladder augmentation (SMBA) is an alternative to the standard ileocystoplasty, and has been associated with a lower incidence of bladder stones. Few reports have been published on intermediate outcomes of SMBA. Herein, we report long-term outcomes of SMBA from a single institution compared with standard ileocystoplasty. METHODS: After Institutional Review Board approval, a retrospective chart review of all patients who underwent bladder augmentation at our institution over a 14-year period was performed. The status of patients after SMBA (10 patients) was compared according to age, sex, and diagnosis with patients who underwent traditional ileocystoplasty (30 patients). Parameters such as demographic information, pre- and postoperative bladder capacity as assessed by urodynamic studies, urinary tract infections (UTIs), bladder calculi, incontinence, need for secondary surgical procedures, and spontaneous bladder perforation were compared in the two groups. All the patients were on a clean intermittent catheterization (CIC) regimen. RESULTS: Over the study period, 10 patients underwent SMBA and 30 patients (according to age, sex, and diagnosis) underwent standard ileocystoplasty; the average age at surgery was 10.3 and 10 years respectively, with a mean follow up of 6.7 years in the SMBA group and 6 years in the ileocystoplasty group. There were no statistically significant differences in the rate of UTIs, urinary incontinence, subsequent surgery, or spontaneous bladder perforation. The mean bladder capacity increased significantly for both groups as assessed by pre- and postoperative urodynamic studies, although the difference in the rate of bladder calculi between the two groups (0 [0%] vs. 8 [27%], p = 0.06) did not reach statistical significance (Table). CONCLUSIONS: SMBA is safe and efficacious and may result in a lower rate of stone formation than standard ileocystoscopy. SMBA should be considered as a viable alternative to standard ileocystoplasty.

Ureteroureterostomy: An Alternative to Ureteroneocystostomy in Select Cases of Pediatric Renal Transplantation.

PURPOSE: Ureteroneocystostomy is the standard mode of establishing urinary drainage in renal transplantation. However, donor-to-recipient ureteroureterostomy may be considered in the presence of a challenging bladder or an augmented bladder, or when the donor ureter might be compromised or is too short. This approach also preserves a nonrefluxing system with an orthotopic ureteral orifice. MATERIALS AND METHODS: We retrospectively reviewed the records of all pediatric renal transplantations in which ureteroureterostomy was performed at a single tertiary care pediatric center over the 12-year period from 2004 to 2015. Ureteroureterostomy was performed in end-to-side fashion from donor-to-recipient ureter. Patients with a history of symptomatic vesicoureteral reflux were excluded from ureteroureterostomy. Parameters were reviewed, including age, gender, source of renal transplantation (deceased or living donor), indications for ureteroureterostomy and complications. RESULTS: Primary ureteroureterostomy was performed at 23 of the 213 renal transplantations (10.8%). At transplantation mean ± SD age was 11.7 ± 4.9 years and mean weight was 33.5 ± 18.9 kg. Two secondary ureteroureterostomies were done to salvage the ureter due to complications after ureteroneocystostomy. Of the patients 60% and 40% underwent ureteroureterostomy during deceased and living donor renal transplantation, respectively. The most common indications included a challenging small bladder due to anuria, a valve bladder and a neurogenic augmented bladder. Two urinary leaks (8%) occurred and no allografts were lost. CONCLUSIONS: Ureteroureterostomy is a safe alternative to standard ureteroneocystostomy in renal transplantation. Ureteroureterostomy should be considered a primary option in certain complex situations and secondarily as a salvage procedure when ureteral problems develop after ureteroneocystostomy in patients who undergo renal transplantation.

Intra-arterial nitroglycerin for intra-operative arterial vasospasm during pediatric renal transplantation.

Intra-operative arterial vasospasm during pediatric renal transplantation is an urgent clinical situation resulting in end-organ ischemia, associated changes in parenchymal turgor and color, diminished flow on ultrasound, and if left untreated, allograft loss. We hypothesized that intra-operative intra-arterial injection of nitroglycerin would reverse vasospasm and improve renal perfusion. A three-yr-old girl with end-stage renal disease due to autosomal recessive polycystic kidney disease on peritoneal dialysis underwent deceased donor renal transplantation. After optimal immediate reperfusion and hemodynamic parameters, the kidney lost turgor and became mottled in appearance despite adequate hilar arterial and venous Doppler waveforms. Two aliquots of 40 µg (0.4 mL of a 100 µg/mL) nitroglycerin solution were injected directly into the renal artery 10 min apart. Nitroglycerin resulted in dramatic change in the consistency and appearance of the allograft. An improvement in renal blood flow was demonstrated by ultrasound after the second intra-arterial nitroglycerin injection with only a transient decrease in systemic arterial blood pressure. The child experienced normal allograft perfusion on serial postoperative ultrasounds, with a prompt decrease in serum creatinine and excellent diuresis. Intra-arterial nitroglycerin is a promising option for intra-operative arterial vasospasm during pediatric renal transplantation with objective improvement in blood flow and perfusion.

Novel Strategy for Temporary Decompression of the Lower Urinary Tract in Neonates Using a Ureteral Stent.

PURPOSE: In children with congenital obstructive uropathy, including posterior urethral valves, lower urinary tract decompression is recommended pending definitive surgical intervention. Current options, which are limited to a feeding tube or Foley catheter, pose unappreciated constraints in luminal diameter and are associated with potential problems. We assess the impact of luminal diameter on the current draining options and present a novel alternative method, repurposing a widely available stent that optimizes drainage. MATERIALS AND METHODS: We retrospectively reviewed patients diagnosed with posterior urethral valves between January 2013 and December 2014. In all patients a 6Fr 12 cm Double-J ureteral stent was advanced over a guidewire in a retrograde fashion into the bladder. Luminal flow and cross-sectional areas were also assessed for each of 3 tubes for urinary drainage, ie 6Fr Double-J stent, 5Fr feeding tube and 6Fr Foley catheter. RESULTS: A total of 30 patients underwent uneventful bedside Double-J stent placement. Mean ± SD age at valve ablation was 28.5 ± 16.6 days. Mean ± SD peak serum creatinine was 2.23 ± 0.97 mg/dl after birth and 0.56 ± 0.22 mg/dl at the procedure. Urine output after stent placement was excellent in all patients. The Foley catheter and feeding tube drained approximately 18 and 6 times more slowly, respectively, and exhibited half the calculated cross-sectional luminal area compared to the Double-J stent. CONCLUSIONS: Use of Double-J stents in neonates with posterior urethral valves is a safe and effective alternative method for lower urinary tract decompression that optimizes the flow/lumen relationship compared to conventional drainage options.

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.

Ureteral injuries sustained during robot-assisted radical prostatectomy.

BACKGROUND AND PURPOSE: During the last decade, the annual volume of robot-assisted prostatectomies performed in the United States has risen steadily. Refinements in surgical technique, understanding of anatomy, and experience have led to more complex patients being offered surgery for management of organ-confined prostate cancer. Complication rates of robot-assisted prostatectomy have been reported in several articles; however, a paucity of data exists when evaluating ureteral injuries sustained during robot-assisted prostatectomy. No standardized universal criteria for reporting and grading of complications exists; therefore, the Martin-Donat criteria with Clavien-Dindo classification system were used to evaluate ureteral injuries in our series. PATIENTS AND METHODS: From January 2001 to June 2013, 6442 consecutive patients were treated with robot-assisted prostatectomy at the same institution by one of five surgeons. All complications were documented through a prospectively maintained prostate cancer database with supplementation from electronic medical records, operative and nursing notes, claims data, discharge summaries, outpatient and emergency visits, institutional morbidity and mortality data, as well as National Surgical Quality Improvement Program data. The Martin-Donat criteria were used to facilitate the accurate and comprehensive reporting of surgical complications while complication severity was assigned following the Clavien-Dindo classification system. RESULTS: Three patients sustained ureteral injuries (ureteral transection) in our series. Both surgeons were beyond their learning curve (greater than 1000 cases) when the injuries occurred; one patient needed readmission, and all patients had risk factors predisposing them to ureteral injury. Each patient was managed with robot-assisted ureteroneocystostomy (1), open transureteroureterostomy (1) and robot-assisted ureteroureterostomy (1) respectively. CONCLUSIONS: Ureteral injuries are uncommon; however, thorough preoperative evaluation and surgical planning could identify patients at high risk for sustaining ureteral injury during prostatectomy. Measures can be taken preoperatively or intraoperatively to reduce the probability of ureteral injury, eliminating the necessity for additional procedures postoperatively.

Development and initial validation of a disease specific quality of life survey for children with vesicoureteral reflux.

PURPOSE: Vesicoureteral reflux is believed to be a largely asymptomatic condition. However, previous studies have failed to assess the precise impact of vesicoureteral reflux on quality of life. We created and validated a survey for assessment of quality of life in children with vesicoureteral reflux. MATERIALS AND METHODS: Two surveys were created by a team of pediatric urologists and survey design specialists, 1 for general assessment and 1 for postoperative assessment in patients undergoing surgical treatment for vesicoureteral reflux. Cronbach alpha test was used to assess internal consistency reliability and the correlation coefficient for test-retest analysis. Surveys were distributed from November 2008 to January 2010 during routine office visits for vesicoureteral reflux. The postoperative survey was distributed 8 to 20 weeks following surgery. RESULTS: The general survey yielded a Cronbach alpha of 0.64 and a correlation coefficient of 0.78, while the postoperative survey results were 0.58 and 0.84, respectively, for the same parameters. Complete general surveys were obtained from 216 patients. All but 4 categories, related to repeat testing, office visits and medicine intake, reached greater than 80% positive quality of life responses. The postoperative survey was completed by 104 patients. Bladder spasm was the only category with less than 86% rate of positive quality of life response. CONCLUSIONS: Vesicoureteral reflux is shown to have little effect on quality of life in pediatric patients. These validated surveys should be applied to compare the effect of different management options on quality of life.

CKD and bladder problems in children.

Approximately 35% of children with CKD who require renal replacement therapy have a significant urological abnormality, including posterior urethral valves, a neuropathic bladder, prune belly syndrome, Hinman syndrome, or severe vesicoureteral reflux. In such children, abnormal bladder function can have a significant deleterious effect on the renal function. In children with bladder outlet obstruction, bladder compliance and capacity often are abnormal, and a sustained intravesical pressure of >40 cm H(2)O impedes drainage from the upper urinary tract. Consequently, in these conditions, regular evaluation with renal sonography, urodynamics, urine culture, and serum chemistry needs to be performed. Pediatric urological care needs to be coordinated with pediatric nephrologists. Many boys with posterior urethral valves have severe polyuria, resulting in chronic bladder overdistension, which is termed as valve bladder. In addition to behavioral modification during the day, such patients may benefit from overnight continuous bladder drainage, which has been shown to reduce hydronephrosis and stabilize or improve renal function in most cases. In children with a neuropathic bladder, detrusor-sphincter-dyssynergia is the most likely cause for upper tract deterioration due to secondary vesicoureteral reflux, hydronephrosis, and recurrent urinary tract infection (UTI). Pharmacologic bladder management and frequent intermittent catheterization are necessary. In some cases, augmentation cystoplasty is recommended; however, this procedure has many long-term risks, including UTI, metabolic acidosis, bladder calculi, spontaneous perforation, and malignancy. Nearly half of children with prune belly syndrome require renal replacement therapy. Hinman syndrome is a rare condition with severe detrusor-sphincter discoordination that results in urinary incontinence, encopresis, poor bladder emptying, and UTI, often resulting in renal impairment. Children undergoing evaluation for renal transplantation need a thorough evaluation of the lower urinary tract, mostly including a voiding cystourethrogram and urodynamic studies.

Improving lymph node yield in retroperitoneal lymph node dissection using fluorescent molecular imaging: a novel method of localizing lymph nodes in Guinea pig model.

OBJECTIVES: To propose that fluorescent molecular imaging has utility in specifically identifying the lymph nodes, thereby enabling more definitive lymph node visualization and dissection. Retroperitoneal lymph node dissection (RPLND) is an invasive procedure with significant morbidity. A minimally invasive approach would be of great clinical benefit but has been limited by the extensive perivascular dissection required to remove all lymphatic tissue. Directed lymph node visualization would allow a limited dissection, making a laparoscopic approach more feasible. METHODS: Ten male Hartley guinea pigs underwent nonsurvival RPLND, 5 with the protease activatable in vivo fluorescent molecular imaging agent, ProSense and 5 without image guidance (control). ProSense was administered 24 hours before surgery and detected 24 hours later using a photodynamic detector. In group 1, RPLND was first performed without molecular imaging followed by image-guided lymph node dissection for residual nodes. In group 2, the near infrared detector was used initially for lymph node excision followed by traditionally unassisted extraction of the residual lymph nodes. The lymph nodes were extracted, counted, and sent for histopathologic analysis. RESULTS: With the assistance of molecular imaging, no additional lymph nodes were identified after complete dissection, and all tissue identified by ProSense was confirmed by histopathologic analysis to be lymph nodes. Without molecular imaging, all lymph nodes were not identified, and in 2 instances, the tissue was incorrectly thought to be lymphatic tissue. CONCLUSIONS: Molecular image-guided RPLND is a promising technique to improve in vivo, live visualization and dissection of lymph nodes and has the potential for application in improving the diagnosis and treatment of other urologic malignancies.

Quality of life in children with vesicoureteral reflux as perceived by children and parents.

PURPOSE: Significant research has been dedicated to the management of vesicoureteral reflux (VUR). However, few studies have been published to evaluate the impact of this disease on quality of life. The aim of this study was a prospective examination of the health-related quality of life (HRQoL) in children with VUR who have either been treated medically (antibiotics or surveillance) or by ureteral reimplant (UR) using a validated patient satisfaction survey. MATERIALS AND METHODS: A prospective, longitudinal study was conducted using a validated HRQoL questionnaire, the Pediatric Quality of Life Inventory (PedsQL™ 4.0 Generic Core). 353 children or parents of children with VUR, age 2-18 years, completed the survey. Statistical analysis was performed with significance set at p-value ≤ 0.05. RESULTS: Children and parents of children with VUR did not score lower on total or subscale domains of HRQoL when compared to a historical healthy control. On univariate analysis, patients who underwent UR scored lower on total as well as physical, social, and school subscale HRQoL domains, compared to patients managed medically. When controlling for gender, ethnicity, age, reflux grade, and antibiotic use, there was no difference in total HRQoL between patients who underwent UR compared to those managed medically. CONCLUSIONS: In terms of HRQoL, VUR is a benign clinical entity and neither antibiotic use nor UR is associated with lower HRQoL. Disease-specific quality of life surveys are needed to accurately evaluate patient and parent satisfaction in the management of VUR.

Identifying ureteropelvic junction obstruction by fluorescence imaging: a comparative study of imaging modalities to assess renal function and degree of obstruction in a mouse model.

PURPOSE: Radiological imaging is the mainstay of diagnosing ureteropelvic junction obstruction. Current established radiological modalities can potentially differentiate the varying degrees of obstruction but they are limited in functionality, applicability and/or comprehensiveness. Of particular concern is that some tests require radiation, which has long-term consequences, especially in children. MATERIALS AND METHODS: We investigated the novel use of Genhance™ 680 dynamic fluorescence imaging to assess ureteropelvic junction obstruction in 20 mice that underwent partial or complete unilateral ureteral obstruction. Ultrasound, mercaptoacetyltriglycine renography, magnetic resonance imaging and fluorescence imaging were performed. RESULTS: Our model of partial and complete obstruction could be distinguished by ultrasound, mercaptoacetyltriglycine renography and magnetic resonance imaging, and was confirmed by histological analysis. Using fluorescence imaging distinct vascular and urinary parameters were identified in the partial and complete obstruction groups compared to controls. CONCLUSIONS: Fluorescence imaging is a feasible alternative radiological imaging modality to diagnose ureteropelvic junction obstruction. It provides continuous, detailed imaging without the risk of radiation exposure.

Perioperative risk factors for major complications in pediatric surgery: a study in surgical risk assessment for children.

BACKGROUND: There are numerous studies in the adult literature correlating comorbidities and pre- and intraoperative parameters with postoperative outcomes. However, there is a paucity of similar data in the pediatric population. Our goal was to elucidate which pre- and intraoperative patient characteristics in children undergoing surgery are associated with an increased risk of major complication within 30 days. STUDY DESIGN: We identified 108 children who underwent surgery at our institution between June 2005 and May 2007 and had major complication or death within 30 days of surgery. Forty-two preoperative patient characteristics and 22 intraoperative variables were evaluated. The severity of the complications was graded based on the Clavien classification system, with major complications grade III or greater. We randomly selected 723 controls who had undergone surgery within a 3-month date range of the original cohort, but did not develop complications. Statistical significance was assessed by univariate and multivariate analyses. RESULTS: Most complications were cardiovascular, occurred 1 to 3 days after surgery, and were classified as grade IIIB. We identified 5 independent risk factors on multivariate analysis: ≤36 weeks of gestation, American Society of Anesthesiologists score >3, undergoing a cardiovascular or neurosurgical procedure, and receiving an intraoperative albumin transfusion. Three scoring systems (overall, preoperative, and intraoperative complication score) were developed to provide objective risk stratification. CONCLUSIONS: We found 5 patient-specific parameters that were independent risk factors for major complications or death after pediatric surgery. Future prospective studies will help to fully stratify risk and guide interventions to improve postoperative outcomes.

The concordance of testicular anatomic location in bilateral cryptorchidism.

OBJECTIVE: To determine the frequency of concordance of testicular anatomical location between both undescended testes based on surgical findings. BACKGROUND: Cryptorchidism occurs in approximately 1% of boys over one year of age, and in 10-20% of these cases, the condition is bilateral. We report a series of 168 patients with a preoperative diagnosis of bilateral undescended testes who underwent surgical exploration and in whom two testes were surgically identified. METHODS: The testicular location of both testes was stratified according to six anatomic regions. For each patient the anatomic site of each testis, both palpable and impalpable, and the surgical procedure required for orchidopexy were recorded. RESULTS: The mean age was 59.3 months (2.5 months-21 years). In 90% of the cases the surgical technique was identical for both sides. Approximately two thirds of the patients were found to have both testes in concordant anatomical locations and in 88% the location of one testis was predictive within one anatomic "step" of the location of the contralateral gonad. CONCLUSION: These findings may have significant implications for counseling families and anticipating the necessary surgical approach required when only one undescended testis has been localized preoperatively.

Assessment of parental satisfaction in children undergoing voiding cystourethrography without sedation.

PURPOSE: Approximately 50,000 children undergo voiding cystourethrography annually. There is a recent trend toward using sedation or delaying voiding cystourethrography due to the anticipated distress to the patient. We hypothesized that with adequate preparation and proper techniques to minimize anxiety, voiding cystourethrography can be performed without sedation. We assessed parental satisfaction associated with patient and parent experience of voiding cystourethrography without sedation. MATERIALS AND METHODS: We used a 33-question survey to evaluate parental satisfaction with patient and parent experience of voiding cystourethrography without sedation. Children were divided into 3 groups according to toilet training status. Statistical analysis was performed using Stata®. RESULTS: A total of 200 surveys were completed. Of the children 54% were not toilet trained. Of the parents 90% reported adequate preparation. More than half of parents classified the experience of voiding cystourethrography as equivalent to or better than a physical examination, immunization, ultrasound and prior catheterization. Most parents were satisfied with the ability of the child to tolerate the procedure and considered the experience better than expected. Children in the process of toilet training had the most difficulty with the procedure, correlating with lower levels of parental satisfaction. CONCLUSIONS: Voiding cystourethrography performed with adequate preparation and support can be tolerated without sedation. Children in the process of toilet training and females tolerate the procedure least.

Robotic-assisted laparoscopic cryo-partial nephrectomy: a novel technique using cryoablation in lieu of hilar clamping in a porcine model.

Laparoscopic and robotic-assisted partial nephrectomy has become an increasingly viable approach for the resection of renal tumors. There are several technical limitations in performing laparoscopic partial nephrectomy, the most significant being the inability to easily obtain cold ischemia which allows for an extended operative time. In this study, we evaluated the feasibility and efficacy of cryoablation as an alternative to hilar clamping to maintain hemostasis during robotic-assisted laparoscopic partial nephrectomy in a porcine model. Twelve female swine underwent nine open and eight robotic-assisted laparoscopic partial nephrectomies using modified cryoablative methods to create hemostasis. Renal perfusion imaged with indocyanine green (ICG) and histological analysis was assessed immediately after the procedure and at 3 weeks post-operatively. With two freeze/thaw cycles, all nine open and eight robotic-assisted laparoscopic partial nephrectomies were successfully completed without the need for hilar clamping. The mean blood loss for the open and robotic-assisted groups was 230.6 and 99.4 ml, respectively. In all cases, maintenance of renal perfusion was confirmed by the presence of a renal pulse and intraoperative ICG imaging immediately and 3 weeks post-operatively. The histological anatomy was well preserved in the resected segment following cryo-resection. After 21 days following cryo-resection, histological analysis demonstrated normal viable tissue with minimal scarring in the remaining kidney. The use of cryoablation created a zone of hemostasis without compromising the vascularity of the remaining kidney, while preserving the renal cytoarchitecture of the segment remove for pathological analysis. Further studies will help to delineate its usefulness in laparoscopic partial nephrectomy.

Parental satisfaction after open versus robot assisted laparoscopic pyeloplasty: results from modified Glasgow Children's Benefit Inventory Survey.

PURPOSE: Since its inception, robot assisted laparoscopic pyeloplasty has rapidly become the minimally invasive surgical intervention of choice for treating ureteropelvic junction obstruction at our institution. The large initial investment in robot assisted surgery is frequently justified by its association with improved optics and instrument articulation, decreased postoperative pain, shorter length of hospitalization and improved cosmesis. However, there are no data specifically showing patient satisfaction with robot assisted laparoscopic pyeloplasty compared to traditional open surgery. MATERIALS AND METHODS: A previously validated satisfaction survey (Glasgow Children's Benefit Inventory) with 14 additional questions specifically addressing postoperative satisfaction was mailed to all parents (as patient proxy) of children who had undergone open or robot assisted laparoscopic pyeloplasty between January 2006 and December 2008. RESULTS: A total of 78 parents responded (response rate 70%). All responses achieving statistical significance favored robot assisted laparoscopic pyeloplasty. Parents of children who underwent robot assisted laparoscopic pyeloplasty reported significantly higher satisfaction with "overall life," confidence, self-esteem, burden of postoperative followup and size of incision scar. CONCLUSIONS: Parent satisfaction was greater with robot assisted laparoscopic pyeloplasty than with open surgery regarding amount of cosmesis and recovery. Interestingly the differences in satisfaction were not as large as anticipated, suggesting the impact of confounding factors such as age and preoperative parental expectations. Future large-scale prospective studies using validated surveys specific to pediatric surgery are needed to elucidate further the true benefits of minimally invasive surgical technology such as robot assistance.