Bruce W. Lindgren

LAPAROSCOPIC ORCHIOPEXY: PROCEDURE OF CHOICE FOR THE NONPALPABLE TESTIS?

PURPOSE Multiple approaches exist for the management of the nonpalpable testis. With the use of diagnostic laparoscopy widely accepted in the setting of the nonpalpable testis we have found laparoscopic orchiopexy to be an efficient and logical extension. To evaluate its use we report our experience with laparoscopic orchiopexy to treat 44 nonpalpable testes in 36 patients. MATERIALS AND METHODS We retrospectively reviewed the medical records of all patients who underwent laparoscopic orchiopexy for a 2 1/2-year period. Modifications of the surgical technique are described. RESULTS The left testis was affected in 18 boys, the right in 9 and both in 9. At laparoscopy 8 testes were at the internal ring or were peeping and the remainder were intra-abdominal. One patient underwent a unilateral 1-stage Fowler-Stephens orchiopexy, and 3 unilateral and 1 bilateral 2-stage Fowler-Stephens orchiopexy. Two patients underwent laparoscopically assisted orchiectomy. The remaining 31 patients underwent laparoscopic orchiopexy without division of the spermatic vessels. At followup (mean 6 months) all testes are without atrophy, and 39 of 42 (93%) are in an acceptable scrotal position. There are 3 testes (7%) high in the scrotum. CONCLUSIONS Laparoscopic orchiopexy is a logical extension of diagnostic laparoscopy for the evaluation and treatment of the nonpalpable testis. The low incidence of complications and 93% success rate underscore the feasibility of this procedure. It is our procedure of choice for the treatment of nonpalpable testis.

LAPAROSCOPIC FOWLER-STEPHENS ORCHIOPEXY FOR THE HIGH ABDOMINAL TESTIS

PURPOSE Laparoscopic orchiopexy is extremely effective for treating patients with nonpalpable testis. However, despite the high dissection and wide mobilization it allows in some cases, vessel length prevents the testis from reaching the scrotum. There have been only incidental cases reported in which laparoscopy has been used for vessel transection and testicular mobilization orchiopexy. We reviewed our cases treated with the Fowler-Stephens orchiopexy performed laparoscopically in 1 or 2 stages. MATERIALS AND METHODS We reviewed the records of all boys who underwent laparoscopy for a nonpalpable testis at our institutions since 1992. Patients who underwent testicular vessel transection and orchiopexy performed laparoscopically in 1 or 2 stages were selected for evaluation. Office charts and operative reports were reviewed in detail. RESULTS Of the 126 nonpalpable testes in 108 patients 51 (40%) were intra-abdominal, including 18 (35%) in 14 patients in whom the Fowler-Stephens procedure was performed laparoscopically. Five testes were treated with a 2-stage procedure, while 11 were managed by laparoscopic mobilization followed by laparoscopic vessel clipping and orchiopexy in 1 stage. In 2 additional patients nearly all dissection was performed laparoscopically but due to extenuating circumstances inguinal incision was required as well. Thus, 13 testes were managed by 1-stage Fowler-Stephens orchiopexy, including all cases since August 1996 which required vessel transection. Two patients were hospitalized postoperatively for prolonged ileus after the second stage. All other 2-stage and all 1-stage cases were managed on an outpatient basis. There were no complications. At a mean followup of 6 months all cases without previous surgery that were managed by laparoscopic orchiopexy are without atrophy and the testes are in a scrotal position. Two testes in which previous surgery had been done atrophied postoperatively. CONCLUSIONS Laparoscopic transection of the testicular vessels is safe in boys with high abdominal testes that do not reach the scrotum after laparoscopic high retroperitoneal dissection. The magnification and wide mobilization of laparoscopy likely allow better preservation of the collateral vascular supply than open exploration. Previous surgery is a risk factor for atrophy. The success rate of 89% overall and 100% in patients who did not previously undergo testicular surgery equals or exceeds that of open orchiopexy in patients with abdominal testes. The 1-stage procedure avoids repeat anesthesia and the extensive, sometimes tedious, dissection that is occasionally required during reoperation.

SINGLE AND MULTIPLE DERMAL GRAFTS FOR THE MANAGEMENT OF SEVERE PENILE CURVATURE

PURPOSE Conventional techniques result in chordee correction in the majority of patients. However, some with extensive chordee require further treatment to correct persistent extraordinary penile curvature. Our practice has been to treat this condition with interpositional dermal grafting. We review our experience with this procedure. MATERIALS AND METHODS During a 5-year period dermal grafts harvested from the nonhair-bearing inguinal skin fold were placed in 51 patients with a mean age of 29 months. The primary diagnosis was penoscrotal or perineal hypospadias in 36 patients (hypospadias cripple in 4), the exstrophy-epispadias complex in 3, mid shaft or distal hypospadias with severe chordee in 10 and chordee without hypospadias in 2. A total of 49 patients (96%) underwent staged urethroplasty. RESULTS One graft was placed in 29 patients (57%), 9 (18%) received 1 graft and underwent a Nesbit plication, (14%) received 2 grafts, 5 (10%) received 2 grafts and underwent dorsal plication, and 1 (2%) received 3 grafts. Second stage urethral reconstruction was done using a Thiersch-Duplay tube in the majority of cases. In 5 patients mild residual chordee was easily corrected at the time of second stage repair. CONCLUSIONS In a staged repair the first priority of the initial stage is to achieve a straight phallus. While our experience indicates that a single dermal graft is sufficient in approximately 57% of cases, when it does not result in complete straightening, we have had success with placing additional graft(s) and/or performing dorsal plication. We believe that the additional penile length achieved with dermal grafting results in a dependent phallus and cosmesis preferable to that of plication only.

Are abdominal x-rays a reliable way to assess for constipation?

PURPOSE Currently to our knowledge no validated reliable tools are available to evaluate constipation in children. Abdominal x-rays are often done in clinical practice to evaluate patients with lower urinary tract symptoms. Although 3 previously published rating tools exist to score constipation based on x-ray, there is little information on their merits. We assessed these 3 tools for reliability among multiple practitioners. MATERIALS AND METHODS We retrospectively analyzed abdominal x-rays in a cohort of 80 patients between ages 4 and 12 years. X-rays were independently assessed by each of us using the previously published Barr, Leech and Blethyn scoring tools. Scores were analyzed for reliability using standard statistical methods. RESULTS The range of weighted κ score, indicating reliability, were 0.0491 to 0.4809 for the Barr, 0.1195 to 0.2730 for the Leech and 0.0454 to 0.4514 for the Blethyn method. Guidelines for κ scores are greater than 0.75-excellent, 0.4 to 0.75-good and 0 to 0.4-marginal reproducibility. ICC, another reliability measure, was 0.02577 for the Barr, 0.3313 for the Leech and 0.201 for the Blethyn method. ICC interpretations are greater than 0.75-excellent, 0.4 to 0.75-good and 0 to 0.4-poor. There was a trend toward good interrater reliability between more experienced urology practitioners with the Barr and Blethyn tools (0.48 and 0.45, respectively) but not between less experienced raters or with the Leech tool. CONCLUSIONS Currently available scoring tools to evaluate constipation by x-ray do not have good reliability among multiple examiners. Further research is needed to develop an alternate tool to increase the reliability of x-ray to assess constipation between multiple raters.

Robot-Assisted Laparoscopic Reoperative Repair for Failed Pyeloplasty in Children: A Safe and Highly Effective Treatment Option

PURPOSE Failed pyeloplasty represents a management dilemma, with treatment options including balloon dilation, endopyelotomy and reoperative pyeloplasty. We review our experience with robot-assisted laparoscopic reoperative repair of recurrent/persistent ureteropelvic junction obstruction in children and compare this method to other approaches. MATERIALS AND METHODS We reviewed in detail all cases of failed prior ureteropelvic junction procedures, either open or laparoscopic, managed by robot-assisted laparoscopic reoperative repair between 2006 and July 2011. RESULTS Robot-assisted laparoscopic repair was performed in 16 cases for persistent or recurrent ureteropelvic junction obstruction following a prior procedure involving the ureteropelvic junction (12 open pyeloplasties, 4 robot-assisted laparoscopic repairs). Additional interventions had been performed in 12 patients. Reoperative robot-assisted laparoscopic pyeloplasty was performed in 13 patients and reoperative robot-assisted laparoscopic ureterocalycostomy in 3. Patient age ranged from 12 months to 15.3 years (mean 6.1 years). Mean operative time and length of stay were 303 minutes and 1.6 days, respectively. Mean followup was 14.9 months. All symptomatic patients had resolution of symptoms postoperatively. A total of 14 patients (88%) had improved radiological findings. One patient underwent transfusion and conversion to an open procedure due to bleeding. CONCLUSIONS Robot-assisted laparoscopic reoperative repair of persistent/recurrent ureteropelvic junction obstruction is a safe, highly effective procedure even in the setting of multiple prior procedures. In our series all patients improved symptomatically, 88% improved radiographically and none have required further surgical intervention. Success is greater than with endopyelotomy and comparable to open reoperative repair for this challenging condition during short-term and intermediate followup.

Pediatric Robotic-Assisted Laparoscopic Diverticulectomy

Congenital bladder diverticula are rare anomalies of the bladder. Patients present with infection, hematuria, and/or urinary obstruction. We report on the case of a 12-year-old boy who developed gross hematuria and recurrent infection owing to a 12-cm bladder diverticulum. Robotic-assisted laparoscopic diverticulectomy was performed. We describe the first reported robotic-assisted laparoscopic diverticulectomy in a pediatric patient.

Renal computed tomography with 3-dimensional angiography and simultaneous measurement of plasma contrast clearance reduce the invasiveness and cost of evaluating living renal donor candidates

Renal computed tomography (CT), 3-dimensional CT angiography (3D-CTA), and simultaneous measurement of glomerular filtration rate (GFR) by x-ray fluorescence determination of plasma contrast clearance (PCC) are alternatives to intravenous urography (IVU), renal arteriography (RA), and 24-hr urine creatinine clearance (CrCl) for evaluation of renal structure and function in living renal donor (LRD) candidates. To determine if CT, 3D-CTA, and PCC provide data comparable to IVU, RA, and CrCl, both methods were used to evaluate 23 LRD candidates. Costs were also compared. Conventional RA identified 19 accessory arteries and one case of medial fibroplasia. Each of these anomalous vessels was recognized on 3D-CTA. Venous anatomy was more clearly delineated on 3D-CTA than the venous phase of conventional RA. CT demonstrated 3 benign cysts and a single, small intraparenchymal calcification in 3 renal units. GFRs measured by PCC and CrCl were 91 +/- 4 and 132 +/- 7 ml/min/1.73m2, respectively (r = 0.64, P < 0.05). Total cost for CT/3D-CTA/PCC was 46% less than that of IVU/RA/CrCl and 40% less than RA/CrCl. CT/3D-CTA/PCC provided reliable structural and functional data at substantially less cost, discomfort, and inconvenience to the living renal donor candidate. As such, CT/3D-CTA/PCC is superior to conventional methods for evaluation of the living renal donor candidate.

Endoscopic Management of Transurethrally Inserted Magnetic Beads

Transurethral insertion of foreign bodies into the urinary bladder is uncommon in children. We report an 11-year-old boy who presented with hematuria and difficulty voiding secondary to numerous magnetic beads lodged in the urinary bladder and posterior urethra.

Early administration of oxybutynin improves bladder function and clinical outcomes in newborns with posterior urethral valves.

PURPOSE Abnormal bladder function following posterior urethral valve ablation can lead to deleterious effects on renal function and urinary continence. We performed a pilot study to determine if bladder dysfunction could be ameliorated by the early administration of oxybutynin. MATERIALS AND METHODS We enrolled infants who underwent primary posterior urethral valve ablation by the age of 12 months. On initial urodynamics patients demonstrating high voiding pressures (greater than 60 cm H(2)O) and/or small bladder capacity (less than 70% expected) were started on oxybutynin. Urodynamics and ultrasound were performed every 6 months until completion of toilet training, at which time oxybutynin was discontinued. RESULTS Oxybutynin was started in 18 patients at a mean age of 3.4 months and was continued for a mean of 2.2 years. Urodynamics revealed that initial high voiding pressures improved from a mean of 148.5 to 49.9 cm H(2)O in 15 of 17 patients. All 8 patients with initially poor bladder compliance demonstrated improvement on oxybutynin. All 7 patients with initially low bladder capacity (mean 47.7% expected bladder capacity) demonstrated improvement while on oxybutynin (mean 216% expected bladder capacity). CONCLUSIONS This pilot study demonstrates that early use of anticholinergic therapy in infants with high voiding pressures and/or small bladder capacity after primary posterior urethral valve ablation has beneficial effects on bladder function.

Perioperative effects of caudal and transversus abdominis plane (TAP) blocks for children undergoing urologic robot-assisted laparoscopic surgery

INTRODUCTION Regional anesthesia is often used in combination with general anesthesia for pediatric surgery, however, it is unknown if adjunctive regional blocks are beneficial to children undergoing urologic laparoscopic or robot-assisted laparoscopic (RAL) procedures. OBJECTIVE To compare perioperative outcomes in children with adjunctive caudal blocks, transversus abdominis plane (TAP) blocks, or no regional anesthesia for common RAL surgical procedures in pediatric urology. STUDY DESIGN Inclusion in this retrospective study was limited to children who underwent RAL renal or ureteral/bladder procedures and received a standardized regimen of scheduled intravenous ketorolac and oral acetaminophen for acute postoperative pain control, with opioids as needed (PRN). Perioperative outcomes were compared between patients with an adjunctive caudal block (n = 25), bilateral TAP blocks (n = 44), or no regional anesthesia (n = 51). RESULTS Children with a preoperative caudal block received less intraoperative opioids than children with TAP blocks or no regional anesthesia (p < 0.001). This difference was observed both for renal procedures (p < 0.01) and ureteral/bladder procedures (p = 0.01). Patients with caudal blocks were also the least likely to require postoperative antiemetics (p = 0.03). There were no significant differences between groups in postoperative opioid use, maximum pain scores within 6 and 24 hours postoperatively, or length of hospital stay (LOS). No complications attributable to regional blocks were identified by chart review. DISCUSSION Use of adjunctive caudal blocks for pediatric RAL renal or ureteral/bladder surgical procedures may reduce need for alternate analgesic and/or anesthetic agents intraoperatively, as well as decrease postoperative nausea and vomiting. These findings may be related, since nausea and vomiting are common side effects of opioids and inhalational anesthetics. Consideration of the potential impact of caudal blocks on general anesthetic requirements is timely in light of concerns regarding the risk of anesthetic neurotoxicity in young patients. There was no evidence of improved postoperative pain control or shorter LOS for children who received regional anesthesia. It is unknown if regional blocks would have a greater impact in the absence of scheduled pain medications, which all patients in our study received. Limitations of this study include its retrospective nature and moderate sample size. Future randomized controlled trials are necessary to provide a more definitive understanding of regional anesthesias role in minimizing pediatric surgical and anesthetic morbidity. CONCLUSION Administration of caudal blocks should be considered for children of suitable age undergoing RAL surgery involving either the upper or lower urinary tract.