Upper or lower tract approach for duplex anomalies? A bi-institutional comparative analysis of robot-assisted approaches.

Optimal management of duplication anomalies may include an upper or lower tract surgical approach. In the contemporary era, the robot-assisted laparoscopic heminephrectomy (RALHN) and robot-assisted laparoscopic ipsilateral ureteroureterostomy (RALIUU) are viable interventions predicated on clinical, institutional and surgeon preferences. We present a multi-institutional comparative analysis aiming to compare the outcomes of RALHN and RALIUU to see if either of the approaches confers an advantage over the other in treating duplex renal anomalies needing intervention. We completed a retrospective review of consecutive children undergoing RALIUU at Hospital A and RALHN at Hospital B from January 2009 to March 2017. The primary outcome was 'surgical success' defined by the resolution of clinical symptoms, improved radiological parameters, and no unplanned subsequent interventions till the time of study completion. Secondary outcomes included operative parameters, complications, and subsequent urinary infections. There were 39 RALIUU and 28 RALHN. Baseline demographic and clinical parameters across two cohorts were similar. The primary outcome of 'surgical success' was 100% across both cohorts. There were no major surgical complications, and the incidence of postoperative urinary tract infection was minimal and similar for both groups. Operative time favored RALHN; blood loss and analgesic requirements were minimal in both cohorts. Both RALIUU and RALHN are definitive surgical interventions in children with complex duplex moieties, delivering satisfactory surgical outcomes with a low complication profile and marginal differences in the postoperative patient outcomes. This pilot bi-institutional study provides the basis for a larger collaboration to further define optimal techniques, standardize surgical care pathways, and interrogate long-term outcomes.

Robotic Bladder Neck Reconstruction With Mitrofanoff Appendicovesicostomy in a Neurogenic Bladder Patient.

OBJECTIVE: Robot-assisted laparoscopic (RAL) techniques for the management of neurogenic bladder involves complex procedures using lower urinary tract and bowel. When medical therapy fails, surgery aims to preserve upper tract function and social continence.1 Traditionally, the procedure was performed in an open approach, but newer minimally-invasive techniques offer improved cosmesis, reduced pain and length of stay.2 A series of 38 cases showed the feasibility and safety of this approach.3 Here, we describe a RAL bladder neck reconstruction with appendicovesicostomy in a 7-year-old with neurogenic bladder (Fig. 1). METHODS: The patient was placed in a lithotomy position followed by double-J and Foley catheter placement. With an open Hasson technique, a 12-mm, two 8-mm, and a 5-mm port were positioned. The bladder is prefilled with saline (80 mL) and a cystotomy is performed. The tubularization is completed in 2 layers achieving a 3-cm tunnel (Figs. 2-3). The appendix is implanted in the posterior wall of the bladder with a submucosal tunnel. Ultimately, 2 suprapubic tubes are placed and the bladder is closed in a single layer. RESULTS: No complications reported, operative time was 5 hours and estimated blood loss was 50 mL. At 1-month follow-up, double-J stents were removed and the patient reported catheterizing well with good continence and well-healed incisions. CONCLUSION: Robotic continence procedures have demonstrated to be a safe and effective alternative. Here, we presented a satisfactory outcome using RAL bladder neck reconstruction with appendicovesicostomy in a 7 years old with persistent incontinence, despite untethering and maximal anticholinergic therapy.

Postoperative course following complex major pediatric urologic surgery: A single surgeon experience.

BACKGROUND/PURPOSE: Payers have established unplanned returns as quality measures tied to reimbursement. We sought to identify patient characteristics and surgical factors associated with unplanned returns and postoperative complications following intraabdominal pediatric urologic procedures. Only one study has emergency room visits in pediatric urology, but included only limited case complexity. METHODS: We retrospectively reviewed electronic medical records of all pediatric patients who underwent urological surgery from 2007 to 2016 by a single surgeon. Univariate and multivariate regressions were used to determine factors associated with length of stay, unplanned ER visits and readmissions. RESULTS: A total of 372 cases were included, of which 251 were robotic and 121 were open. Overall, the rate of ER visits was 19%, rate of readmissions was 8.7%, and rate of reoperations was 4.3%. We found that the odds of a urologic ER visit and Clavien grade II (infectious) complications were comparatively lower for robotic surgery, but not readmission. Undergoing a lower tract procedure was significantly associated with a related ER visit; however, patient insurance status was not related to unplanned returns. CONCLUSIONS: Procedure characteristics, not patient demographics were associated with unplanned returns. Robotic approach was associated with fewer ER visits and infectious complications, indicating potential cost savings. LEVELS OF EVIDENCE: Level 3 Treatment Study.

Robot-assisted laparoscopic common sheath ureteral reimplantation in duplex ureters: LUAA technique tips for optimal outcomes.

OBJECTIVE: To describe surgical tips for robot-assisted laparoscopic (RAL) common sheath ureteral reimplantation using the previously reported LUAA technique in patients with duplex renal collecting systems, and to assess the efficacy of this technique by reviewing operative outcomes in a single-institution case series. METHODS: We retrospectively reviewed a consecutive series of patients with duplicated collecting systems and vesicoureteral reflux (VUR) who underwent RAL extravesical common sheath ureteral reimplantation at a single medical center from 2010 to 2017. We included all duplex ureters requiring antireflux surgery. A standardized technique (LUAA) was used in each case, with additional tips used as described herein: a) careful common sheath ureteral mobilization, b) wide detrusorotomy with adequate detrusor flap elevation from the mucosa, and c) appropriate tension during tunnel detrusorraphy. Patient demographics, perioperative data, and follow-up imaging were reviewed. Radiographic resolution was defined as absence of VUR on voiding cystourethrogram (VCUG) performed 4 months postoperatively. Only patients undergoing ureteral reimplantation for VUR were included. Those with ureterovesical junction obstruction were excluded. RESULTS: A total of 13 patients underwent RAL common sheath ureteral reimplantation, with three bilateral cases for a total of 16 duplicated ureters reimplanted. Mean age at surgery was 3.64 ± 1.04 years. Mean operative time was 125.1 ± 30.73 min in unilateral cases and 200 ± 51.18 in bilateral cases. Complete resolution of VUR was achieved in 14 of 16 ureters (87.50%). There were no high-grade complications (IIIV on the Clavien-Dindo scale). There were two grade II complications in our cohort, with a mean follow-up of 17.18 ± 18.41 months. CONCLUSIONS: We report a radiographic success rate of 87.50% for RAL common sheath ureteral reimplantation in children with duplicated ureters, using the LUAA technique with several additional technical considerations. In our experience, careful mobilization of the ureter to preserve vascularity, a wide detrusorotomy to adequately elevate the detrusor flaps, and appropriate tension during detrusorraphy are essential components to optimize outcomes and prevent complications.

Bladder Reconstruction with Bowel: Robot-Assisted Laparoscopic Ileocystoplasty with Mitrofanoff Appendicovesicostomy in Pediatric Patients.

Neurogenic bladder occur as a consequence of several conditions, most commonly posterior urethral valves syndrome, spina bifida, tethered cord, sacral agenesis, and Arnold-Chiari malformation. It is characterized by diminished bladder capacity and/or reduced compliance, associated with high-pressure voiding that can lead to deterioration of renal function if left untreated. When medical management fails, bladder reconstruction with bowel (aumentation ileocystoplasty) becomes the treatment of choice for these patients. In most cases, it is accompanied by the creation of a continent catheterizable channel, with the appendix being the most commonly used conduit (Mitrofanoff appendicovesicostomy). Conventional open surgery has proven to be an efficient and safe approach in these patients. However, robot-assisted surgery not only offers a cosmetic advantage, but also results in a shorter hospital stay, less postoperative pain, and even decreased number of adhesions (as shown in porcine models). Nevertheless, the complexity of this technique has limited the wide adoption of this approach. We seek to provide a technical guide to robot-assisted laparoscopic ileocystoplasty and Mitrofanoff appendicovesicostomy in pediatric patients, as well as a critical review of literature about the perioperative care of these patients.

Epidemiologia hospitalaria del Epoc en un Hospital Militar. Lima, Perú / Epidemiology of COPD in Military Hospital

Describir la dinámica epidemiológica de las hospitalizaciones por enfermedad obstructiva crónica (EPOC) en un hospital militar. Material y Métodos: Estudio observacional retrospectivo de las hospitalizaciones por EPOC en un Hospital Militar nivel III-1 de Lima-Perú. El periodo analizado fue desde enero de 1991 a diciembre de 2013. Para el análisis de los datos se utilizó el software de STATA V12.1 y ms Excel 2013. Resultados: Se registraron 1350 egresos con EPOC lo que representa el 1.14% del total de egresos IC95% (0.10% - 1.20%); el 58.15% de los pacientes pertenecían al sexo masculino (p=0.001), el promedio de edad fue de 74 años IC95% (73 - 75 años), (P=0.001), el promedio de estancia hospitalaria fue de 11.3 días IC95% (10.6 - 11.9 días), (P=0.001). En relación al tipo de pacientes según su condición en el hospital, el 31.41% fueron pacientes militares (424/1350) y representaron el 1.32% de todas las hospitalizaciones en esta población. La letalidad por EPOC fue 3.93% IC95% (2.95% - 5.10%) siendo superior a nuestra tasa de mortalidad hospitalaria por todas las causas (2.81%) siendo estadísticamente significativo (p=0.012) odds ratio (OR) 1.4 IC95% (1.05 - 1.87). Conclusión: El perfil epidemiológico de las hospitalizaciones por EPOC en nuestro hospital es la de un paciente del sexo varón con un promedio de edad superior a los 65 años, quién permanecerá en promedio 11 días hospitalizados y donde el 3.93% de los mismo fallecerá en dicha proceso de hospitalización. Observamos también que existe una laguna del conocimiento sobre la Epidemiologia hospitalaria del EPOC en nuestro país; nuestro estudio contribuirá a la generación de este conocimiento...

Objective: To describe the epidemiological dynamics of hospitalizations for chronic obstructive pulmonary disease (COPD) in a military hospital. Material and Methods: Retrospective observational study of hospitalizations for COPD in a level III-1 military Hospital of Lima-Peru. The analyzed period was from January 1991 to December 2013. The data analysis was performed using STATA V12.1 and ms EXCEL 2013. Results: 1350 medical discharged patients with COPD were registered representing 1.14% of all medical discharges IC95% (0.10% - 1.20%); 58.15% of the patients were males (p=0.001), the average age was 74 years IC95% (73 - 75 years old), (P=0.001), the average hospital stay was 11.3 days IC95% (10.6 - 11.9 days), (P=0.001). Regarding the patient type, according to their status in the hospital 31.41% (424/1350) were military servers and represented 1.32% of all hospitalizations in this population. The COPD mortality was 3.93% IC95% (2.95% - 5.10%) which was higher than our hospital mortality rate from all causes (2.81%). This was statistically significant (p=0.012) odds ratio (OR) 1.4 IC95 % (1.05 - 1.87). Conclusion: The epidemiological profile of the COPD patient hospitalization in our hospital is a male patient, with an average age of more than 65 years, with an average length stay of hospitalizated of 11 days, with a 3.93% rate of mortality in the same hospitalization process. We also note that there is a gap of knowledge on hospital epidemiology of COPD in our country; our study will contribute to the generation of this knowledge...

In vitro binding of Sorghum bicolor transcription factors ABI4 and ABI5 to a conserved region of a GA 2-OXIDASE promoter: possible role of this interaction in the expression of seed dormancy.

The precise adjustment of the timing of dormancy release according to final grain usage is still a challenge for many cereal crops. Grain sorghum [Sorghum bicolor (L.) Moench] shows wide intraspecific variability in dormancy level and susceptibility to pre-harvest sprouting (PHS). Both embryo sensitivity to abscisic acid (ABA) and gibberellin (GA) metabolism play an important role in the expression of dormancy of the developing sorghum grain. In previous works, it was shown that, simultaneously with a greater embryo sensitivity to ABA and higher expression of SbABA-INSENSITIVE 4 (SbABI4) and SbABA-INSENSITIVE 5 (SbABI5), dormant grains accumulate less active GA4 due to a more active GA catabolism. In this work, it is demonstrated that the ABA signalling components SbABI4 and SbABI5 interact in vitro with a fragment of the SbGA 2-OXIDASE 3 (SbGA2ox3) promoter containing an ABA-responsive complex (ABRC). Both transcription factors were able to bind the promoter, although not simultaneously, suggesting that they might compete for the same cis-acting regulatory sequences. A biological role for these interactions in the expression of dormancy of sorghum grains is proposed: either SbABI4 and/or SbABI5 activate transcription of the SbGA2ox3 gene in vivo and promote SbGA2ox3 protein accumulation; this would result in active degradation of GA4, thus preventing germination of dormant grains. A comparative analysis of the 5'-regulatory region of GA2oxs from both monocots and dicots is also presented; conservation of the ABRC in closely related GA2oxs from Brachypodium distachyon and rice suggest that these species might share the same regulatory mechanism as proposed for grain sorghum.

Expression of seed dormancy in grain sorghum lines with contrasting pre-harvest sprouting behavior involves differential regulation of gibberellin metabolism genes.

Grain sorghum [Sorghum bicolor (L) moench] exhibits intraspecific variability for the rate of dormancy release and pre-harvest sprouting behavior. Two inbred lines with contrasting sprouting response were compared: IS9530 (resistant) and RedlandB2 (susceptible). Precocious dormancy release in RedlandB2 is related to an early loss of embryo sensitivity to ABA and higher levels of gibberellins in imbibed grains as compared with IS9530. With the aim of identifying potential regulatory sites for gibberellin metabolism involved in the expression of dormancy in immature grains of both lines, we carried out a time course analysis of transcript levels of putative gibberellin metabolism genes and hormone content (GA(1), GA(4), GA(8) and GA(34)). A lower embryonic GA(4) level in dormant IS9530 was related to a sharp and transient induction of two SbGA2-oxidase (inactivation) genes. In contrast, these genes were not induced in less dormant RedlandB2, while expression of two SbGA20-oxidase (synthesis) genes increased together with active GA(4) levels before radicle protrusion. Embryonic levels of GA(4) and its catabolite GA(34) correlated negatively. Thus, in addition to the process of gibberellin synthesis, inactivation is also important in regulating GA(4) levels in immature grains. A negative regulation by gibberellins was observed for SbGA20ox2, SbGA2ox1 and SbGA2ox3 and also for SbGID1 encoding a gibberellin receptor. We propose that the coordinated regulation at the transcriptional level of several gibberellin metabolism genes identified in this work affects the balance between gibberellin synthesis and inactivation processes, controlling active GA(4) levels during the expression of dormancy in maturing sorghum grains.

Expression of ABA signalling genes and ABI5 protein levels in imbibed Sorghum bicolor caryopses with contrasting dormancy and at different developmental stages.

BACKGROUND AND AIMS: Pre-harvest sprouting susceptibility in grain sorghum (Sorghum bicolor) is related to low seed dormancy and reduced embryo sensitivity to inhibition of germination by abscisic acid (ABA). Intra-specific variability for pre-harvest sprouting might involve differential regulation of ABA signalling genes. METHODS: Sorghum genes encoding homologues for ABA signalling components from other species (ABI5, ABI4, VP1, ABI1 and PKABA1) were studied at the transcriptional and protein level (ABI5) during grain imbibition for two sorghum lines with contrasting sprouting phenotypes and in response to hormones. KEY RESULTS: Transcript levels of these genes and protein levels of ABI5 were higher in imbibed immature caryopses of the more dormant line. Dormancy loss was related to lower transcript levels of these genes and lower ABI5 protein levels in both genotypes. Exogenous ABA inhibited germination of isolated embryos but failed to prevent ABI5 rapid decrease supporting a role for the seed coat in regulating ABI5 levels. CONCLUSIONS: Several genes involved in ABA signalling are regulated differently in imbibed caryopses from two sorghum lines with contrasting pre-harvest sprouting response before - but not after - physiological maturity. A role for ABI5 in the expression of dormancy during grain development is discussed.