Andy Chang

Human capital gains associated with robotic assisted laparoscopic pyeloplasty in children compared to open pyeloplasty.

PURPOSE Robotic assisted laparoscopic pyeloplasty is an emerging, minimally invasive alternative to open pyeloplasty in children for ureteropelvic junction obstruction. The procedure is associated with smaller incisions and shorter hospital stays. To our knowledge previous outcome analyses have not included human capital calculations, especially regarding loss of parental workdays. We compared perioperative factors in patients who underwent robotic assisted laparoscopic and open pyeloplasty at a single institution, especially in regard to human capital changes, in an institutional cost analysis. MATERIALS AND METHODS A total of 44 patients 2 years old or older from a single institution underwent robotic assisted (37) or open (7) pyeloplasty from 2008 to 2010. We retrospectively reviewed the charts to collect demographic and perioperative data. The human capital approach was used to calculate parental productivity losses. RESULTS Patients who underwent robotic assisted laparoscopic pyeloplasty had a significantly shorter average hospital length of stay (1.6 vs 2.8 days, p <0.05). This correlated with an average savings of lost parental wages of

Testicular Compartment Syndrome: A New Approach to Conceptualizing and Managing Testicular Torsion

90.01 and hospitalization expenses of

Laparoendoscopic single-site nephrectomy in pediatric patients: initial clinical series of infants to adolescents.

612.80 per patient when excluding amortized robot costs. However, cost savings were not achieved by varying length of stay when amortized costs were included. CONCLUSIONS Robotic assisted laparoscopic pyeloplasty in children is associated with human capital gains, eg decreased lost parental wages, and lower hospitalization expenses. Future comparative outcome analyses in children should include financial factors such as human capital loss, which can be especially important for families with young children.

Cryptorchidism and testicular germ cell tumors: comprehensive meta-analysis reveals that association between these conditions diminished over time and is modified by clinical characteristics

OBJECTIVES Decompression of compartment syndrome is known to salvage tissues in numerous organ systems. To demonstrate evidence that testes exposed to prolonged ischemia exhibit compartment syndrome physiology and propose a novel technique in treating this phenomenon. METHODS Three boys, aged 11, 14, and 16 years, with prolonged testicular torsion lasting 6-7 hours were taken to the operating room. All testes appeared dusky and congested on manual detorsion. Testicular fasciotomy was performed by making a longitudinal incision in the tunica albuginea. The coloration of all testes improved dramatically. When the tunica albuginea was reapproximated, each testis returned to an ischemic appearance. The tunica albuginea was again opened. A harvested tunica vaginalis patch was placed over the exposed seminiferous tubules and secured in place. In the case of the 11-year-old boy, a handheld compartment monitor needle was used to measure the compartment pressure at all stages of the procedure. RESULTS All testes maintained a well-perfused coloration at completion of the procedure. The compartment pressures in the testis of the 11-year-old boy (diastolic pressure 52 mm Hg) were as follows: 34 mm Hg after detorsion, 5 mm Hg after testicular fasciotomy, 46 mm Hg after reapproximation of the tunica albuginea, 3 mm Hg on repeat fasciotomy, and 5 mm Hg after tunica vaginalis patch application. CONCLUSIONS Testicular compartment pressures appear elevated after prolonged torsion. Testicular fasciotomy, combined with a tunica vaginalis patch, relieved testicular compartment syndrome. Additional investigation is warranted to determine whether this technique affords improved preservation of testicular tissues.

Shorter Androgen Receptor CAG Repeat Lengths Associated with Cryptorchidism Risk among Hispanic White Boys

OBJECTIVES To present our initial clinical series of laparoendoscopic single-site (LESS) nephrectomy using an umbilical incision in children ranging from infants to adolescents. Laparoscopic surgery in pediatric urology is increasingly being performed for many intra-abdominal ablative procedures, such as nephrectomy for poorly functioning kidneys. We have previously reported our initial experience with LESS surgery in the adult population. METHODS A total of 11 pediatric patients (age range 0.1-16.2 years, mean 5.7) underwent LESS nephrectomy using an umbilical incision. The perioperative clinical parameters were reviewed retrospectively. RESULTS The 11 LESS pediatric nephrectomies were technically successful without conversion to conventional laparoscopy or open surgery. An accessory port was used in 5 of the cases early in the clinical series. Of the 11 patients, 2 were infants, aged 39 days and 3.5 months. The mean operative time was 139 minutes (range 85-205), and the mean hospital stay was 1.5 days (range 1.0-2.1). Complications included delayed hydrocele formation in 2 male patients. CONCLUSIONS The results of our study have shown that LESS nephrectomy using a single umbilical incision in pediatric patients is technically feasible with good outcomes. Additional studies are needed to evaluate the expected benefits of this novel technique. Also, miniaturization of currently available equipment is needed to adapt to the small working spaces available in the pediatric patient.

Early comparison of nephrectomy options in children (open, transperitoneal laparoscopic, laparo-endoscopic single site (LESS), and robotic surgery)

Introduction: Risk of testicular germ cell tumors (TGCT) is consistently associated with a history of cryptorchidism (CO) in epidemiologic studies. Factors modifying the association may provide insights regarding etiology of TGCT and suggest a basis for individualized care of CO. To identify modifiers of the CO-TGCT association, we conducted a comprehensive, quantitative evaluation of epidemiologic data. Materials and Methods: Human studies cited in PubMed or ISI Web of Science indices through December 2011 and selected unpublished epidemiologic data were reviewed to identify 35 articles and one unpublished dataset with high-quality data on the CO-TGCT association. Association data were extracted as point and 95% confidence interval estimates of odds ratio (OR) or standardized incidence ratio (SIR), or as tabulated data. Values were recorded for each study population, and for subgroups defined by features of study design, CO and TGCT. Extracted data were used to estimate summary risk ratios (sRR) and evaluate heterogeneity of the CO-TGCT association between subgroups. Results: The overall meta-analysis showed that history of CO is associated with four-fold increased TGCT risk [RR = 4.1(95% CI = 3.6–4.7)]. Subgroup analyses identified five determinants of stronger association: bilateral CO, unilateral CO ipsilateral to TGCT, delayed CO treatment, TGCT diagnosed before 1970, and seminoma histology. Conclusions: Modifying factors may provide insight into TGCT etiology and suggest improved approaches to managing CO. Based on available data, CO patients and their parents or caregivers should be made aware of elevated TGCT risk following orchidopexy, regardless of age at repair, unilateral vs. bilateral non-descent, or position of undescended testes.

Angiomyolipoma of the kidney: expanding disease spectrum demonstrated by 3 cases.

CONTEXT Cryptorchidism is the most frequent congenital malformation among males, the major established risk factor for testicular germ cell tumors, and a presumed infertility risk factor. Androgens are essential for testicular descent, and functional genetic polymorphisms in the androgen receptor gene (AR) are postulated to influence cryptorchidism risk. OBJECTIVE The aim of the study was to investigate whether the CAG repeat length polymorphism in exon 1 of the AR is associated with cryptorchidism risk. DESIGN AND SETTING We conducted a family-based genotype-risk association study employing the transmission disequilibrium test for genotypic variants transmitted on the X-chromosome at a university-affiliated regional childrens hospital. PARTICIPANTS We studied 127 Hispanic boys with persistent cryptorchidism and comorbidities described in detail and their biological mothers. INTERVENTION Genotypes defined by number of CAG repeats were measured for each member of participating son-mother pairs. MAIN OUTCOME MEASURE Associations between CAG tract length genotype and cryptorchidism risk were estimated using matched-pairs logistic regression. RESULTS Cryptorchidism risk was significantly associated with shorter CAG repeats [CAG≤19 vs. CAG≥20, odds ratio (OR)=0.44; 95% confidence interval (CI), 0.23-0.88]. This association was restricted to cryptorchidism with accompanying comorbidities, which was primarily hernia [CAG≤19 vs. CAG≥20, OR=0.35 (95% CI, 0.16-0.78)], and was strongest for bilateral cryptorchidism [CAG≤19 vs. CAG≥20, OR=0.09 (95% CI, 0.010-0.78)]. CONCLUSIONS Androgen receptor genotypes encoding moderate functional variation may influence cryptorchidism risk, particularly among boys with bilateral nondescent or congenital hernia, and may explain in part the elevated risk of testicular seminoma experienced by ex-cryptorchid boys. Mechanistic research is warranted to examine both classical and nonclassical mechanisms through which androgens may influence risk of cryptorchidism and related conditions.

Pediatric robot-assisted laparoscopic excision of urachal cyst and bladder cuff

Study Type – Therapy (case series)

Re: Prepubertal Orchiopexy for Cryptorchidism May be Associated With Lower Risk of Testicular Cancer: T. J. Walsh, M. A. Dall'Era, M. S. Croughan, P. R. Carroll and P. J. Turek J Urol 2007; 178: 1440–1446

We report 3 recent cases of angiomyolipoma of the kidney. Although generally regarded as a benign neoplasm, angiomyolipoma rarely behaves in an aggressive manner, producing complicated clinical courses leading to metastasis and death. The presence of epithelioid elements within the tumor can result in difficulty differentiating benign from malignant angiomyolipoma and differentiating this tumor from renal adenocarcinoma. The presence of lymph node involvement can cause difficulty in differentiating multicentric disease in lymph nodes from metastasis to lymph nodes. The presence of cytologic abnormalities in the primary tumor can result in difficulty in differentiating atypia in benign angiomyolipoma from malignant sarcomatous transformation of a benign lesion. The 3 cases reported show many of these problems. Criteria for predicting malignancy in epithelioid tumors and sarcomatous transformation are not well recognized because of the rarity of this entity. The typical immunophenotype of all types of angiomyolipoma (cytokeratin-negative and melanomarkers-positive) is very useful in diagnosis but does not help in the differentiation from renal adenocarcinoma at frozen section. We report the empiric use of Ki67 and p53 in these cases as adjuncts to clinical and histologic assessment in predicting behavior. High Ki67 expression was a feature of malignant epithelioid angiomyolipoma. Low levels of p53 expression were seen in the angiomyolipoma with sarcomatous transformation. Benign angiomyolipomas were consistently negative for both Ki67 and p53.

Aberrant activation of Notch signaling inhibits PROX1 activity to enhance the malignant behavior of thyroid cancer cells

Urachal cysts are the most common urachal anomaly in the pediatric population. There is an increasing body of literature documenting successful management of urachal cysts using laparoscopic techniques. There may be an advantage, however, with the use of robot-assisted laparoscopy for reconstructive cases. We describe the techniques used for robot-assisted laparoscopic excision of a urachal cyst and bladder cuff with bladder repair in a female child. This approach is a safe and effective option for the minimally invasive management of pediatric urachal cysts.