Caring for urologic transition patients: Current practice patterns and opinions.

INTRODUCTION: Congenitalism is an emerging field that recognizes the complex needs of adult patients with congenital urologic issues. Despite the onset of transitional care clinics, these patients remain difficult to care for due to resource availability, insurance coverage, and multi-disciplinary needs. OBJECTIVE: The current study sought to characterize practice patterns and opinions regarding care for urologic transition patients. DESIGN: An anonymous 20-question survey was sent to members of the Society of Pediatric Urology listserv. Questions pertained to physician background, practice demographics, clinic structure, and quality. Five-point Likert scales were used to assess quality markers (5 = most/best). Data were analyzed in R, and subgroup analyses were performed. Subgroups included presence of formal transition clinic, city size, and practice type. RESULTS: The response rate was 53%, with 124 respondents. A formal transition clinic was reported by 32%. Those with formal clinics reported higher enthusiasm (3.9 vs 3.4, P < 0.01) for care of these patients and believed they provided better care compared to other institutions (P < 0.001) Summart Table. There was no significant difference in perceived quality between respondents in academic vs other practices. There was a small trend towards higher-quality ratings in smaller cities (3.8 vs 3.5, P = 0.13). The majority (64%) felt that transition patients are best cared for by specialized adult providers; however, these formalized clinics found to be staffed primarily by pediatric providers (54%). DISCUSSION: This study supported the general consensus in the literature that transition clinics improve care for urologic transition patients, while underlining discordance between current practice patterns and recommendations for optimal care. CONCLUSION: The majority of practices appeared to lack a formal transition clinic, and there was variation in their structure. Those with formal clinics tended to rate themselves as providing higher-quality care. The majority of respondents believed that adult specialists in either reconstructive or neuro-urology are best suited to care for these complex patients.

Robotic-assisted laparoscopic MACE.

INTRODUCTION: The creation of a Malone antegrade continence enema (MACE) channel is an option to treat patients with neurologic conditions that result in fecal soiling or intractable constipation. It is typically performed in an open fashion through a midline incision or laparoscopically. The laparoscopic technique typically involves bringing the tip of the appendix to the skin whereas the open technique allows for imbrication of the cecum around the channel, which may improve continence and decrease the risk of perforation. Herein, we demonstrate a technique to create a MACE using both robotic-assisted and laparoscopic techniques that allows for imbrication of the channel without requiring an open incision. MATERIALS AND METHODS: Three robotic ports are placed in the midline and a fourth port is placed in the right lower quadrant at the location of the MACE stoma. Two mesenteric fenestrations are made along the appendix in order to imbricate the cecum around the channel. The tip of the appendix is then brought to through the laparoscopic port in the right lower quadrant, and matured to the skin. DISCUSSION: The MACE procedure can safely be performed using a robotic-assisted technique that allows for imbrication of the cecum around the channel and improved cosmesis.

Epispadias repair with tunica vaginalis flap.

INTRODUCTION: Primary epispadias is a rare congenital malformation that afflicts about 1 in 80,000 children. The surgical repair, originally described by Cantwell over 100 years ago, is fundamentally sound and incorporates several important steps to achieve an optimal result. METHODS: A 9-month-old male with penopubic epispadias presented for surgical repair. Pre-operative imaging included a normal renal ultrasound and voiding cystourethrogram that demonstrated a moderate-sized bladder, partially competent bladder neck, and no vesicoureteral reflux. A modified Cantwell-Ransley approach to the repair was performed without complete disassembly of the penis. Established surgical principles of identification of laterally placed neurovascular bundles, preservation of the ventral mesentery to the urethral plate, mobilization of the urethral plate off the corporal bodies with ventral relocation, and dorsal medial rotation of the corporal bodies are demonstrated in this video. RESULTS: This procedure was performed as an outpatient. The patient had an unremarkable postoperative course. The #6-French urethral stent was removed on postoperative day 10. CONCLUSIONS: This video demonstrates a modified Cantwell-Ransley technique for epispadias repair, which employs a tunica vaginalis flap to reinforce the urethral repair. The adherence to surgical principles described by Cantwell in the late 1800s for children with primary epispadias continues to lead optimal surgical outcomes.

Pediatric robotic-assisted laparoscopic ipsilateral ureteroureterostomy in a duplicated collecting system.

INTRODUCTION AND OBJECTIVE: Duplex renal collecting system is a common congenital anomaly in the pediatric population. The superior moiety ureter is often associated with an ectopic insertion. A common site of insertion is the urethra, which results in continuous incontinence. A novel repair for this abnormality is a robotic assisted laparoscopic ipsilateral ureteroureterostomy with end to side anastomosis. This teaching video will demonstrate positioning and operative technique for this procedure. PATIENT AND METHODS: This is the case of a 5-year-old girl who presented with lifelong continuous urinary incontinence. Workup revealed a duplicated collecting system with a functional superior moiety and ectopic ureter inserting into the urethra. A laparoscopic ipsilateral ureteroureterostomy was performed using a robotic surgical system. RESULTS: After docking the robotic surgical system, the duplicated collecting system was identified and an ipsilateral ureteroureterostomy was performed. The patient tolerated the procedure well and the ultrasound on follow up revealed no residual hydronephrosis. CONCLUSION: The accompanying teaching video shows appropriate positioning and operative technique for a robotic-assisted laparoscopic ureteroureterostomy. This innovative and minimally invasive technique is a safe and feasible approach to repair a duplex collecting system with an ectopic ureter in the pediatric population.

Experience with non-cycled artificial urinary sphincters.

OBJECTIVE: To report our experience in children and adolescents with a non-cycled artificial urinary sphincter. While some children with the AUS can void, others require clean intermittent catheterization (CIC) through the sphincter or an alternative site for catheterization; in some of the latter we have either not cycled (pumped) an activated AUS or the AUS has failed, and there is concern about ischaemia in some adults with a non-cycled AUS. PATIENTS AND METHODS: In all, 143 patients who had an AUS placed between 1980 and 2002 were reviewed retrospectively; 15 (10 boys and five girls) no longer cycled (pumped) their AUS. The mean age at AUS insertion was 11 years and the mean (range) follow-up after insertion was 10.4 (1.64-22.2) years. The diagnoses included myelomeningocele in 11, sacral agenesis in three and cloaca in one. Nine patients have an activated functioning AUS and in six the AUS does not function; in the first nine the sphincter has not routinely been cycled (pumped) for a mean (range) of 1.6 (0.6-2.9) years. In the other six with a nonfunctioning AUS the mean (range) observation period is 6.4 (1.5-10) years since the system has not functioned. RESULTS: All patients were completely continent, including the six with a nonfunctioning AUS. After inserting the AUS, two patients voided in combination with CIC (one each urethral and abdominal stoma) and 13 emptied by CIC (nine abdominal stoma, four urethral). There was a mechanical complication in eight patients; three had the AUS repaired and are dry, and five are dry with no repair. In one patient the AUS was never activated. To date there has been no erosion of the cuff in any of the 15 patients with a non-cycled AUS. CONCLUSION: The AUS remains an extremely reliable procedure to achieve continence in children and young adults. It is versatile and can be combined with other procedures that provide an alternative means for catheterization. While some have noted the need to routinely cycle the AUS to prevent erosion, this has not been our experience in these 15 patients.