Single port (SP) robotic pyeloplasty in a pediatric patient.

We began using the da Vinci single port (SP) robot for pediatric urologic surgeries at our institution due to limited access to the multiport robot. Availability of this technology has allowed us to schedule cases in a timelier fashion and increase access to minimally invasive urologic surgery for children in our area. Here, we report our technique for transperitoneal SP robotic pyeloplasty in the case of a 7 year-old boy with left ureteropelvic junction obstruction. Our technique was refined over a series of 10 patients under the age of 18. Highlights of the SP RALP technique include one 3 cm, concealed incision over the pubic tubercle, gentle frog leg positioning and burping of the boom to create optimal angle for robotic docking, and use of a "floating dock" to obtain 10 cm distance from target anatomy which is essential in smaller pediatric patients. SP pyeloplasty is safe and feasible in children and offers a concealed single incision alternative to the multiport approach.

Beluga whale and bottlenose dolphin ACE2 proteins allow cell entry mediated by spike protein from three variants of SARS-CoV-2.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viruses infect numerous non-human species. Spillover of SARS-CoV-2 into novel animal reservoirs may present a danger to host individuals of these species, particularly worrisome in populations already endangered or threatened by extinction. In addition, emergence in new reservoirs could pose spillback threats to humans, especially in the form of virus variants that further mutate when infecting other animal hosts. Previous work suggests beluga whales (Delphinapterus leucas) and bottlenose dolphins (Tursiops truncatus) may be at risk owing to their formation of social groups, contact with humans, exposure to contaminated wastewater, and structure of their angiotensin-converting enzyme 2 (ACE2) proteins, which SARS-CoV-2 uses as a cellular receptor. We examined marine-mammal susceptibility to virus infection by challenging 293T cells expressing beluga or dolphin ACE2 with pseudovirions bearing the SARS-CoV-2 spike protein. Beluga and dolphin ACE2 were sufficient to allow cell entry by an early pandemic isolate (Wuhan-Hu-1) and two evolved variants (Delta B.1.617.2 and Omicron BA.1 strains). We conclude that SARS-CoV-2 poses a potential threat to marine mammal reservoirs that should be considered in surveillance efforts.

Bilateral proximal ureteral and ureterovesical junction obstruction in a child.

The most common sites of ureteral obstruction in children are at the level of the ureteropelvic junction (UPJ) and ureterovesical junction (UVJ). Bilateral hydronephrosis or hydroureteronephrosis due to varying degrees of obstruction at the UPJ or UVJ is common in children and typically improves with time. Clinically significant obstruction at both locations in an ipsilateral ureter occurs less commonly and rarely requires both dismembered pyeloplasty and ureteral reimplantation. We believe this case report is the first description of bilateral proximal and distal ureteral obstruction requiring both dismembered pyeloplasty and ureteral reimplantation.

Ovotesticular Disorder Mimicking Acute Spermatic Cord Torsion.

Ovotesticular disorder is a rare form of sexual development in which a patient may have one ovary and one testis, or more commonly a gonad or gonads containing both ovarian and testicular tissue. Patients with this condition typically present in infancy with ambiguous genitalia. Delayed presentations of clinically symptomatic, older patients with normal external genitalia are extremely rare. We present a case of a 14-year-old male with normal external genitalia who presented with symptoms and signs consistent with spermatic cord torsion but found to have ovotesticular disorder on evaluation.

Influence of season, age, sex, and time of day on the endocrine profile of the common bottlenose dolphin (Tursiops truncatus).

Understanding baseline hormone levels, the magnitude of intra-individual variability, and their variation as a function of life history is difficult in toothed whales (e.g. dolphins and porpoises) because of the effects of capture stress. To determine the endocrine profile of the common bottlenose dolphin (Tursiops truncatus) as a function of season, time of day (TOD), age, sex, and reproductive status, blood corticosteroids, thyroid hormones, and catecholamines were repeatedly measured in a managed-care population exposed to ambient light and water temperatures of San Diego Bay. Additionally, fecal hormone metabolites were assessed for cortisol, aldosterone, and triiodothyronine. Samples were collected at two to four-week intervals over a period of two years, and multiple times within a day at monthly intervals over a year. Samples were collected through the voluntary participation of the dolphins in the blood draws and fecal collections in order to avoid the effects of handling stress. All serum hormones except aldosterone significantly varied with season and all serum hormones except total thyroxine significantly varied as a function of TOD. Fecal glucocorticoid metabolites significantly correlated with circulating cortisol levels, and there was a significant seasonal effect on triiodothyronine fecal metabolites. Strong seasonal effects demonstrated complex interactions with age and sex suggesting that contextual information is critical to interpreting differences in endocrine profiles. Strong circadian patterns further suggest that sampling design is important to the interpretation of blood or fecal collections, particularly since diurnal changes in some serum hormone levels are similar to the magnitude of seasonal differences. Despite potential impacts of feeding schedules on diurnal patterns, managed care populations can provide important insights into seasonal and age-related endocrine changes in toothed whales.

A narrative review of the history and evidence-base for the timing of orchidopexy for cryptorchidism.

INTRODUCTION: Consensus recommendations for surgical management of cryptorchidism recommend orchidopexy between 6 and 18 months of age. The COVID-19 pandemic has impacted elective surgical scheduling. OBJECTIVE: In response to the COVID-19 pandemic, we sought to review the available data regarding the natural history, surgical management, and infertility- and cancer-related risks associated with cryptorchid testes. The purpose of this review is to provide parents, referring providers, and surgeons with information to inform their decisions to proceed with or delay orchidopexy. METHODS: A retrospective review and analysis of all available articles relevant to the natural history, surgical management, and infertility- and cancer-related risks of cryptorchidism present on PubMed, SCOPUS, and Cochrane Library was conducted. RESULTS: The quality of historic literature pertaining to the effect of cryptorchidism on fertility and malignancy differ, with poorer data available on fertility. Cryptorchid testes may show histologic differences as early as birth, and some of these changes may have prognostic value in future fertility. Formerly unilateral cryptorchid men have slightly but not significantly reduced paternity rates compared to the general population. Cryptorchid testes have an increased risk of germ cell carcinogenesis, and robust data suggest the risk for malignancy in cryptorchid testes increases substantially after puberty. CONCLUSION: The current body of evidence regarding the risks for future infertility and testicular cancer support the consensus recommendations for surgical correction of cryptorchidism between 6 and 18 months of age. During the uncertain time of the COVID-19 pandemic, decision for orchidopexy is a shared-decision between physician and parent. For an infant or young boy with a unilateral undescended testes, delaying orchidopexy several months until a time of decreased exposure risk is unlikely to result in substantial or sustained fertility or malignant risks.

Impact of hospital transfer on testicular torsion outcomes: A systematic review and meta-analysis.

INTRODUCTION: Testicular torsion is an emergent condition requiring prompt treatment. Previous studies have suggested transfer of pediatric testicular torsion cases may be detrimental to patient outcomes. Findings have not reached statistical significance. No study has quantitatively analyzed all literature reporting outcomes for transferred torsion patients. The aim of this study was to elucidate the impact of hospital transfer on pediatric testicular torsion outcomes through a systematic review and meta-analysis. METHODS: A predefined study protocol registered with PROSPERO was developed according to PRISMA. A comprehensive literature review of articles investigating outcomes for pediatric testicular torsion for transferred and non-transferred (treated "directly" at presentation institution) patients with orchiectomy as the primary outcome was conducted by systematically searching PubMed and Embase. Potential studies were screened against a predefined study protocol. Meta-analysis using a random effects model with transferred status as the "intervention" was performed using Review Manager 5.3. RESULTS: Of 18 eligible studies, 9 retrospective studies comprised of 2564 patients (532 transferred and 2032 direct) were suitable for quantitative analysis. Main analysis showed transfer status does not have a significant effect on torsion outcomes (RR 0.96 [95% CI 0.78-1.17]; I2 = 44%). Subgroup analysis for torsion patients presenting within 24 h of symptom onset shows patients who are transferred to another facility for management are more likely to undergo orchiectomy than those treated at their presenting institution (RR 0.35 [95% CI 0.24-0.51]; I2 = 4%). CONCLUSIONS: In this meta-analysis, hospital transfer does not affect orchiectomy rate in pediatric patients with testicular torsion when pooling data from all presentation timeframes. Subgroup analysis of patients presenting with testicular torsion in an acute setting (<24 h of symptom onset) suggests the delay associated with hospital transfer has a deleterious effect on testicular viability.

Bilateral Calculi in a Child With Bilateral Single System Ureteroceles.

Ureteroceles in children are detected with prenatal sonography and less commonly during the evaluation following a urinary tract infection. Rarely do ureteroceles in the pediatric population present with stones, particularly in a bilateral fashion. We present a case of a 5-year-old boy found to have bilateral intravesical single system ureteroceles harboring multiple large calculi treated successfully with a staged endoscopic approach.

Robot-Assisted Laparoscopic Resection of the Mesonephric Duct Remnant in a Patient with Zinner Syndrome.

Introduction: A 17-year-old male with Zinner syndrome, a right seminal vesicle cyst, and a solitary left kidney presented with chronic pelvic pain. Previous surgeons had attempted robot-assisted laparoscopic seminal vesicle cyst aspiration and transurethral resection of the ejaculatory duct. Neither surgery provided sustained symptom relief. Abdominal and pelvic MRI showed a cystic structure lodged between the prostate and bladder. The right seminal vesicle, kidney, and ureter were not observed. Materials and Methods: A robot-assisted laparoscopic seminal vesiculectomy was planned. Dissection distal to the right vas deferens and between the bladder neck and prostate revealed a cystic seminal vesicle-like structure. Attached to this was a tubular structure coursing deep to the vas deferens from the right renal fossa. This was presumed to be a dysplastic ureter. The dysplastic ureter was transected from the seminal vesicle and the seminal vesicle was marsupialized to the deep pelvis. Proximally, the dysplastic ureter was transected and left open. Results: Histologic assessment of the specimen revealed an ∼12.1 cm tubular mesonephric remnant. The postoperative course was uncomplicated. At 6 months follow-up, the patient remains free of symptoms with preserved ejaculatory volume. Conclusions: Mesonephric duct abnormalities and symptoms present on a spectrum. We present a safe and effective resection of a mesonephric duct remnant from a 17-year-old male with Zinner syndrome. A robotic approach localized to the right allowed for excellent observation without compromising left-sided genitourinary anatomy. In males presenting with renal agenesis and pelvic symptoms, clinicians should be suspicious of Zinner syndrome and other mesonephric abnormalities.

Robot-assisted laparoscopic unroofing and fulguration of sequestered caliceal diverticula cluster.

INTRODUCTION: We report a rare case of four sequestered caliceal diverticula that failed previous percutaneous sclerotherapy and were subsequently managed with robot-assisted laparoscopic unroofing and fulguration of the sequestered diverticula cluster. METHODS: A 6 year-old female was admitted for urosepsis and flank pain. At age 2, a previous institution diagnosed a caliceal diverticulum. Prolonged-delayed magnetic resonance urography confirmed four sequestered caliceal diverticula. Intraoperative ultrasonography identified the diverticula cluster and ensured decompression. The defects were closed after ablating the blood supply, unroofing and decompressing the diverticula, and fulgurating the caliceal lining. RESULTS: Console time was 4 h with an estimated blood loss of 30-50 cc. The patient was discharged post-op day 3. Follow-up renal ultrasound at 6 weeks and 5 months demonstrated progressive atrophy of the left upper pole with preservation of the lower pole size and perfusion. At 9 months, the patient is free of symptoms and urinary tract infections. CONCLUSION: Closure of unroofed and fulgurated diverticula may be considered when diverticula are anatomically sequestered from the renal collecting system. Robotic-assisted laparoscopic unroofing and fulguration is a technically feasible approach for treatment of sequestered caliceal diverticula in pediatric patients. Additional studies and monitoring of long-term renal function are required.

Pediatric Robot-Assisted Laparoscopic and Ureteroscopic Ureterolithotomy and Ureteroplasty.

Background: Pediatric urolithiasis may coexist with congenital urinary tract abnormalities, complicating conventional methods of stone treatment. Here, we present an effective case of robot-assisted laparoscopy and simultaneous ureteropyeloscopy for the definitive management of pediatric urolithiasis complicated by a congenital ureteral stricture. Case Presentation: A 3-year-old girl presented to clinic with an outside noncontrast CT scan showing two 6-7 mm nonobstructing calculi in a mildly distended upper pole moiety of a duplex left kidney. Ureteral duplication status was unclear. The patient had suffered multiple febrile urinary tract infections throughout her life. Retrograde ureteropyelogram showed a stenotic waist in the upper pole ureter just proximal to the duplex ureteral convergence, and flexible ureteroscopy confirmed a congenital ureteral stricture. Simultaneous robot-assisted laparoscopic and ureteroscopic ureterolithotomy and ureteroplasty were offered and performed using a 3-armed robotic approach. The precise location of the stricture was identified robotically with simultaneous left ureteroscopy. A medial 1.5 cm longitudinal ureterotomy was made through the ureteral stricture to facilitate upper moiety ureterorenoscopy. The calculi were visualized in the upper moiety and retrieved in whole using a stone basket. The calculi were passed via the ureterotomy to the robotic instruments intraperitoneally. The longitudinal ureterotomy was closed transversely. A ureteral stent was placed, and indocyanine green was administered intravenously to confirm good perfusion of the ureteroplasty segment via fluorescence imaging. The stent was removed at 4 weeks. Retrograde ureterography and flexible ureteroscopy revealed complete patency of the anastomosis. At 11 months, the upper pole moiety remained decompressed on ultrasonography. The patient has remained off antibiotic prophylaxis without further infection. Conclusion: Robot-assisted approaches can be primary or adjunct tools in the definitive treatment of pediatric urolithiasis with concomitant urinary tract abnormalities.

Genital Neurofibromatosis Presenting as Painful Clitoromegaly.

Neurofibromatosis type 1 (NF1) is a neurocutaneous disorder caused by a mutation on chromosome 17 of the gene for neurofibromin. Patients with this condition are prone to develop benign and malignant tumors of the central and peripheral nervous systems. Genitourinary involvement in children with NF1 is uncommon and primarily affects the bladder. External genital manifestations of NF1 are rare with sporadic reports of children presenting with enlargement of their penis, clitoris, or labia due to a neurofibroma. We present a case of painful clitoromegaly due to a plexiform neurofibroma in a child.

Effects of health status on pressure-induced changes in phocid immune function and implications for dive ability.

The ability of marine mammals to cope with environmental challenges is a key determining factor in strandings and successful release of rehabilitated animals. Dive behavior is related to foraging and thus survival. While dive adaptations have been well studied, it is unknown how the immune system responds to diving and whether health status impacts immune function during diving. This study investigated the functional response of ex situ immune cells from stranded phocids to in vitro increased pressure, over the course of rehabilitation. Blood samples were drawn from stranded harbor seals (Phoca vitulina), gray seals (Halichoerus grypus) and harp seals (Phoca groenlandica) at the time of admit to the Mystic Aquarium, Mystic, CT and again after rehabilitation (pre-release). Phagocytosis, lymphocyte proliferation and immune cell activation were measured in vitro, with and without exposure to 2000 psi (simulated dive depth of 1360 m). Plasma epinephrine and norepinephrine, and serum cortisol were measured in vivo. All hormone values decreased between admit and release conditions. Under admit or release conditions, pressure exposures resulted in significant changes in granulocyte and monocyte phagocytosis, granulocyte expression of CD11b and lymphocyte expression of the IL2 receptor (IL2R). Overall, pressure exposures resulted in decreased phagocytosis for admit conditions, but increased phagocytosis in release samples. Expression of leukocyte activation markers, CD11b and IL2R, increased and the response did not differ between admit and release samples. Specific hematological and serum chemistry values also changed significantly between admit and release and were significantly correlated with pressure-induced changes in immune function. Results suggest (1) dive duration affects the response of immune cells, (2) different white blood cell types respond differently to pressure and (3) response varies with animal health. This is the first study describing the relationship between diving, immune function and health status in phocids.

The transgenerational effect of maternal and paternal F1 low birth weight on bone health of second and third generation offspring.

Low birth weight programs diseases in adulthood, including adverse bone health. These diseases can have intergenerational and transgenerational origins, whereby transmission to subsequent generations occurs via both parental lines. Uteroplacental insufficiency surgery (Restricted) or sham surgery (Control) was performed on gestational day 18, in F0 Wistar-Kyoto rats. F1 Restricted males and females mated with breeders in order to generate F2 offspring of maternal and paternal lineages. F2 males and females were randomly selected for breeding to generate F3 offspring. F2 and F3 offspring did not have differences in birth weight irrespective of F1 low birth weight and parental line. Maternal line females had minor alterations to trabecular content and density at 6 months, these differences were not sustained at 12 months. Maternal line males had changes to trabecular content at 6 and 12 months; however, differences were no longer present at 16 months. Despite altered bone geometry at 12 and 16 months, bending strength remained unaffected at both ages. Bone health of paternal line females was not affected at 6 and 12 months. Paternal line males at 6 months had changes to trabecular and cortical content; cortical thickness, periosteal circumference and bending strength; however, these differences were no longer sustained at 12 and 16 months. Our data demonstrate that there is no transgenerational transmission of adverse bone health in F2 and F3 offspring, derived from low F1 birth weight females and males. Our results are novel, as bone health across generations and both parental lines has not been investigated in a model of low birth weight due to uteroplacental insufficiency.

Uteroplacental insufficiency in rats induces renal apoptosis and delays nephrogenesis completion.

AIM: Uteroplacental insufficiency in rats reduces nephron endowment, leptin concentrations and programmes cardiorenal disease in offspring. Cross-fostering growth-restricted (Restricted) offspring onto a mother with normal lactation restores leptin concentrations and nephron endowment. This study aimed to determine whether the reduced nephron endowment in Restricted offspring is due to delayed glomerular formation and dysregulation of renal genes regulating branching morphogenesis, apoptosis or leptin signalling. Furthermore, we aimed to investigate whether cross-fostering Restricted offspring onto Control mothers could improve glomerular maturation and restore renal gene abundance. METHODS: Uteroplacental insufficiency was induced by bilateral uterine vessel ligation (Restricted) or sham (Control) surgery on gestation day 18 (E18). Kidneys were collected at E20, postnatal day 1 (PN1) and PN7. An additional cohort was cross-fostered onto separate mothers at birth and kidneys collected at PN7. RESULTS: Kidneys were lighter in the Restricted group, but weight was restored with cross-fostering. At E20, abundance of Bax, Flt1 and Vegfa was increased in Restricted offspring, while Ret and Bcl2 transcripts were increased only in Restricted females. At PN7, abundance of Gdnf and Ret was higher in Restricted offspring, as was Casp3. Restricted offspring had a wider nephrogenic zone with more immature glomeruli suggesting a delayed or extended nephrogenic period. Cross-fostering had subtle effects on gene abundance and glomerular maturity. CONCLUSION: Uteroplacental insufficiency induced apoptosis in the developing kidney and delayed and extended nephrogenesis. Cross-fostering Restricted offspring onto Control mothers had beneficial effects on kidney growth and renal maturity, which may contribute to the restoration of nephron endowment.