Aseem R. Shukla

Paediatric testicular cancer: an updated review of incidence and conditional survival from the Surveillance, Epidemiology and End Results database.

To determine, using the Surveillance, Epidemiology, and End Results (SEER) population‐based database, the epidemiological variables and update the understanding of testicular tumours in children, as knowledge of their incidence and survival is predicated upon multi‐institutional cooperation.

Robot-assisted laparoscopic ureteral reimplantation: A single surgeon comparison to open surgery

OBJECTIVE The aim was to report a single surgeons experience comparing open and robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR) to treat vesicoureteral reflux (VUR). SUBJECTS AND METHODS We retrospectively reviewed the outcomes of RALUR and open extravesical ureteral reimplantations consecutively performed by a single surgeon between January 2008 and December 2010 using the da Vinci(®) Surgical System. Both groups of patients were subjected to identical pre- and postoperative care protocols. RESULTS During the defined study interval, 20 open and 20 RALUR procedures were completed by a single surgeon at our institution. Gender and VUR grade were similar in both cohorts. Operative times were longer in the RALUR group, but postoperative opioid use (morphine equivalents) was significantly lower in the RALUR group (RALUR: 0.14 mg/kg, open: 0.25 mg/kg, p = 0.021). There was no significant difference in estimated blood loss (EBL) or length of hospitalization (LOH). The overall rate of surgical complications was similar; however, the complications in the open group tended to be less severe than those occurring in the RALUR group. On follow-up, after a median of 52 months for open surgery and 39 months for RALUR, two children had developed a febrile urinary tract infection in both groups, of which one in the open group had persistent VUR. CONCLUSION This single-surgeon experience of open and initial experience with RALUR performed with the same surgical technique on consecutive cohorts with identical post-surgical care protocol allows a comparative analysis of outcomes for a surgeon transitioning to RALUR. The RALUR reduces postoperative analgesic requirements while yielding similar clinical outcomes as the open technique.

Bladder malignancies in children aged <18 years: results from the Surveillance, Epidemiology and End Results database.

Study Type – Prognosis (inception cohort)
Level of Evidence 1b

Robot-assisted laparoscopic ureteroureterostomy for proximal ureteral obstructions in children

OBJECTIVE Ureteropelvic junction obstruction is a common presentation in the pediatric population, but proximal ureteral obstructions are rare. In this setting, robot-assisted laparoscopy (RAL) offers a minimally invasive option to open or traditional laparoscopic repair. The present study demonstrates successful RAL in two children with proximal ureteral obstructions: one with a right retrocaval ureter and one with a left ureter entrapped between two lower-pole crossing vessels. METHOD After retrograde placement of a double-J ureteral stent, the child was secured in a lateral decubitus position exposing the affected side. A three-port RAL system was used to dissect free the obstructed ureter. A spatulated watertight ureteroureterostomy was then fashioned after transposition of the ureter into an anatomic position. Sutures and free instruments were passed into the peritoneal cavity via the 5-mm instrument ports, thus obviating the need for a separate assistant port. RESULTS RAL provided for crisp visualization, meticulous dissection, and precise approximation of the reconstructed ureter. In both patients, blood loss was negligible, narcotic use was minimal, and length of stay was roughly 30h. Follow-up imaging at 1 month showed excellent hydronephrosis resolution for both reconstructions. CONCLUSION These two cases demonstrate the feasibility of RAL for proximal ureteral anomalies in the pediatric population.

Risk Factors and Treatment Success for Ureteral Obstruction After Pediatric Renal Transplantation

PURPOSE Risk factors and treatment efficacy for ureteral obstruction following pediatric renal transplantation are poorly understood. We describe a single center experience with pediatric transplant recipients in an effort to discern risk factors and treatment efficacy. MATERIALS AND METHODS We retrospectively reviewed the pediatric renal transplant database at our institution from January 1984 to March 2008. Donor and recipient demographics, treatment indications, graft characteristics, surgical techniques, treatment course, complications and graft outcomes were abstracted from clinical records. RESULTS A total of 449 children (mean age 8.6 years) who underwent 526 renal transplants were included in the study. Ureteral obstruction requiring intervention developed in 42 cases (8%). Recipient age and gender, recipient and donor race, donor harvest technique, ureterovesical anastomosis with or without stenting, number of donor arteries, number of human leukocyte antigen mismatches, prior renal transplant and ischemia time were not significantly associated with increased incidence of ureteral obstruction. Renal failure secondary to posterior urethral valves was the only parameter significantly associated with increased incidence of ureteral obstruction (univariate OR 4.93, p = <0.0001; multivariate point estimate 7.59, p <0.0001). Of patients with ureteral obstruction 48% presented within 100 days after transplant. Kaplan-Meier analysis showed significantly decreased ureteral obstruction-free survival in patients with vs without posterior urethral valves (log rank test, p <0.0001). Ureteral obstruction, stenting and dilation were not significantly associated with increased graft loss or patient death. CONCLUSIONS Ureteral obstruction after renal transplantation in children is a challenging complication that demands clinical vigilance. Posterior urethral valves appear to be a significant risk factor for post-transplant ureteral obstruction likely due to local factors such as ischemia, thick bladder wall and collagen remodeling.

Robot-Assisted Laparoscopic Ipsilateral Ureteroureterostomy for Ectopic Ureters in Children: Description of Technique

PURPOSE We report our experience and present our technique with the robot-assisted laparoscopic ipsilateral ureteroureterostomy (IUU) in the management of ureteral duplication with ectopia in children. PATIENTS AND METHODS We reviewed our institutional experience for all patients who underwent a robot-assisted laparoscopic IUU at the University of Minnesota Amplatz Childrens Hospital between December 2010 and October 2011. An intraoperative, three-port technique was used after a ureteral stent was placed into the ipsilateral lower pole. Demographic information, diagnosis, operative time, hospital course, complications, and follow-up were all evaluated. RESULTS Our series included four female patients and one male patient with a mean age of 61 months (6 to 182 mos). All five had a diagnosis of upper pole ectopic ureters, one of which was associated with an ureterocele. Mean total operative time was 225 minutes (181 to 253 min), and mean hospital stay was 1.2 days (1-2 days). There were no intraoperative complications. In follow-up, at the time of ureteral stent removal, pyelonephritis developed in one patient, but all patients had resolution of their presenting symptoms including urinary tract infections and incontinence. A significant reduction in upper pole hydronephrosis was seen in all patients. CONCLUSIONS Our experience indicates that robot-assisted laparoscopic IUU is safe and effective in the management of ureteral duplication anomalies in children.

Preoperative Stone Attenuation Value Predicts Success After Shock Wave Lithotripsy in Children

PURPOSE We determined whether stone attenuation can predict stone fragmentation after shock wave lithotripsy in the pediatric population. Previous studies show that preoperative attenuation in HU on noncontrast computerized tomography predicts shock wave lithotripsy success. To our knowledge study of this parameter in the pediatric population has been lacking to date. MATERIALS AND METHODS We performed a multi-institutional review of the records of 53 pediatric patients 1 to 18 years old who underwent shock wave lithotripsy for 3.8 to 36.0 mm renal calculi. Stone size, average skin-to-stone distance and attenuation value were determined by bone windows on preoperative noncontrast computerized tomography. Success was defined as radiographically stone-free status at 2 to 12-week followup after a single lithotripsy session without the need for further sessions or ancillary procedures. RESULTS After lithotripsy 33 patients (62%) were stone-free and 20 had incomplete fragmentation or required additional procedures. Mean ± SD stone attenuation in successfully treated patients vs those with incomplete fragmentation was 710 ± 294 vs 994 ± 379 HU (p = 0.007). Logistical regression analysis revealed that only attenuation in HU was a significant predictor of success. When patients were stratified into 2 groups (less than 1,000 and 1,000 HU or greater), the shock wave lithotripsy success rate was 77% and 33%, respectively (p <0.003). CONCLUSIONS Stone attenuation less than 1,000 HU is a significant predictor of shock wave lithotripsy success in the pediatric population. This finding suggests that attenuation values have a similar predictive value in the pediatric population as that previously reported in the adult population.

Ninety-day perioperative complications of pediatric robotic urological surgery: A multi-institutional study.

BACKGROUND Robotic technology is the newest tool in the armamentarium for minimally invasive surgery. Individual centers have reported on both the outcomes and complications associated with this technology, but the numbers in these studies remain small, and it has been difficult to extrapolate meaningful information. OBJECTIVES The intention was to evaluate a large cohort of pediatric robotic patients through a multi-center database in order to determine the frequency and types of complications associated with robotic surgery for pediatric reconstructive and ablative procedures in the United States. STUDY DESIGN After institutional review board approvals at the participating centers, data were retrospectively collected (2007-2011) by each institute and entered into a RedCap(®) database. Available demographic and complication data that were assigned Clavien grading scores were analyzed. RESULTS From a cohort of 858 patients (880 RAL procedures), Grade IIIa and Grade IIIb complications were seen in 41 (4.8%); and one patient (0.1%) had a grade IVa complication. Intraoperative visceral injuries secondary to robotic instrument exchange and traction injury were seen in four (0.5%) patients, with subsequent conversion to an open procedure. Grade I and II complications were seen in 59 (6.9%) and 70 (8.2%) patients, respectively; they were all managed conservatively. A total of 14 (1.6%) were converted to an open or pure laparoscopic procedure, of which, 12 (86%) were secondary to mechanical challenges. DISCUSSION It is believed that this study represents the largest and most comprehensive description of pediatric RAL urological complications to date. The results demonstrate a 4.7% rate of Clavien Grade IIIa and Grade IIIb complications in a total of 880 cases. While small numbers make it difficult to draw conclusions regarding the most complex reconstructive cases (bladder diverticulectomy, bladder neck revision, etc.), the data on the more commonly performed procedures, such as the RAL pyeloplasty and ureteral reimplantation, are robust and more likely represent the true complication rate for these procedures when performed by highly experienced robotic surgeons. CONCLUSION Pediatric robotic urologic procedures are technically feasible and safe. The overall 90-day complication rate is similar to reports of laparoscopic and open surgical procedures. COMPLICATIONS n (%) Life threatening (IVa): 1 (0.1%) Requiring radiologic and or surgical intervention (IIIa and IIIb): 41 (4.8%) Secondary to robotic system: 4 (0.5%) Mechanical failure leading to conversion: 14 (1.6%).

Modified tubularized transverse preputial island flap repair for severe proximal hypospadias

The best surgical approach for repairing proximal hypospadias with chordee remains controversial among urologists. Based on various considerations, from age and anatomy to surgeon preference, techniques have been described that might be broadly classified as singleor multiple-stage procedures. Numerous alternatives have been described for single-stage neourethral reconstruction for proximal hypospadias, including prepuce-based flaps, incised-plate urethroplasty, and free grafts, with varying results [1–4]. Surgical innovation has enabled most variants of hypospadias to be repaired with preservation of the urethral plate, but proximal hypospadias with severe chordee might still require transection of the urethral plate. Since Duckett [5] first described the transverse preputial island flap (TPIF) repair in 1980, we have continued to prefer to incorporate vascularized preputial flaps for these difficult cases.

Intermediate-Term Followup of Proximal Hypospadias Repair Reveals High Complication Rate

Purpose: Results following distal hypospadias repair are favorable. Grouping proximal and distal hypospadias repair artificially increases the perceived success rate of proximal hypospadias. We identified our complication rate of proximal hypospadias repair and hypothesized a higher complication rate for 1‐stage repair. Materials and Methods: We retrospectively reviewed the records of consecutive boys who underwent proximal hypospadias from 2007 to 2014. Proximal hypospadias was defined as a urethral meatus location at or more proximal than the penoscrotal junction after penile degloving. We further stratified boys into those with planned 1‐stage vs 2‐stage repair. Univariate and Cox regression analyses were performed to assess associations with covariates and compare time to the first complication, respectively. Results: A total of 167 boys met study inclusion criteria. Median followup was 31.7 months for 1‐stage repair in 86 patients and staged repair in 81. The overall complication rate was 56%. Complications developed in 53 of 86 1‐stage (62%) vs 40 of 81 staged (49%) repairs (p = 0.11). The number of unplanned procedures per patient was higher in the 1‐stage than in the staged group (0.99 vs 0.69, p = 0.06), as was the number of patients who had at least 2 complications (29 of 86 or 33% vs 13 of 81 or 16%, p = 0.03). Cox regression showed no difference in time to the first complication for staged compared to 1‐stage repair (HR 0.77, 95% CI 0.43–1.39). Conclusions: Our 56% complication rate of proximal hypospadias warrants further long‐term patient followup. More patients in the 1‐stage group experienced at least 2 complications. However, when complications developed, they developed no differently in the 2 groups.