Christina Kim

Laparoscopic nephrectomy in children: systematic review of transperitoneal and retroperitoneal approaches.

OBJECTIVES To perform a systematic review of the available medical data concerning laparoscopic nephrectomy in children. For many pediatric urologists, the laparoscopic approach to nephrectomy has become the standard of care. Access can be obtained using a retroperitoneal (RP) or transperitoneal (TP) approach. Previously, debates have argued the advantage of each technique relative to the other. METHODS We performed a data search through MEDLINE and PubMed to find reports of laparoscopic nephrectomy, nephroureterectomy, and partial nephrectomy in children. We analyzed the operative time, hospital stay, and rate of complication with each approach. Specifically, we assessed the rate of vascular, solid organ, and bowel injuries. RESULTS We found 51 articles that reported the outcomes of 689 pediatric nephrectomies. Of these, 401 were RP and 288 were TP laparoscopic renal surgeries in children. The mean patient age for RP and TP was 5.4 years and 4.8 years, respectively. The mean operative time was 129 minutes for RP and 154 minutes for TP. The hospital stay was 2.5 days for RP and 2.3 days for TP. The overall complication rate for RP was 4.3% and for TP was 3.5% (P = .58). The number of vascular injuries for RP was 2 and for TP was 0 (P = .12). The number of bowel injuries for RP was 2 and for TP was 1 (P = .68). CONCLUSIONS According to the available published data, no significant advantage is gained by a RP or TP approach for laparoscopic nephrectomy. Although the operative time for RP was slightly shorter than for TP, the types of cases performed were not directly matched and thus were more challenging to compare. The incidence of vascular and bowel injuries was rare for both approaches. Therefore, the choice of approach should be determined by surgeon preference, patient anatomy, or the procedure to be performed.

Robotic sigmoid vaginoplasty: a novel technique.

OBJECTIVES We describe an innovative approach to sigmoid vaginoplasty that uses robotic-assisted laparoscopy and 1 perineal incision. METHODS Our patient is a 17-year-old 46 XY adolescent. This patient had surgery performed in July 2007. The procedure was performed through 1 camera port and 3 working ports. RESULTS The intra-abdominal portion of surgery was performed entirely with a Davinci S robot (Intuitive Surgical, Sunnyvale, CA). The total time in the operating room was 9 hours and 45 minutes. The patient was discharged home on postoperative day 4. On follow-up at 10 months, the patient is dilating successfully with no complications. CONCLUSIONS The use of minimally invasive surgery continues to grow and evolve. This case represents the first reported robotically assisted laparoscopic sigmoid vaginoplasty. The favorable results support its use as another option for a challenging surgery in which cosmetic results are so important.

Nine Year Retrospective Review of Surgical Treatment of Vesicoureteral Reflux: Comparison of Three Approaches

Objective: To analyze our nine-year experience in the surgical management of vesicoureteral reflux (VUR) with open ureteral reimplantation, robotic reimplantation, and endoscopic correction with Deflux. Methods: We retrospectively reviewed all patients undergoing surgical intervention for primary VUR at our institution between 2001 and 2010. Treatment success was defined as complete resolution of VUR on postoperative voiding cystourethrography. Surgeries were performed by four pediatric urologists. All robotic reimplantations were performed by a single surgeon. Categorical comparisons were made using Pearson’s Chi-Square or Fisher’s Exact test, and continuous variables were compared using Mann-Whitney U. Results: One hundred eighty-three patients (287 ureters) were included. Fourteen patients underwent robotic surgery, while the open surgery and Deflux cohorts included 93 and 76 patients, respectively. Due to the significantly smaller sample size of the robotic cohort, statistical comparisons were made only between the open surgery and Deflux cohorts. Postoperative VUR resolution rate was 100% (open), 85% (robotic), and 78.4% (Deflux). Open reimplantation had a significantly higher VUR resolution rate than Deflux (p<0.001). Overall, 13.9% of patients developed contralateral reflux, with no significant differences between the open and Deflux cohorts. Conclusions: In this study, we found significantly higher success rates with open reimplantation versus Deflux. While robotic reimplantation had high success rates and short hospital stays, the smaller sample size limited statistical comparison of this modality to open surgery or Deflux. We continue to enroll patients into a prospective series of all VUR procedures at our institution, which will result in more robust comparisons.

A Case of High-grade Transitional Cell Carcinoma of the Bladder in a Pediatric Patient With Turner Syndrome

Transitional cell carcinoma is a rare entity in children, especially in the first decade of life. The majority of these tumors are of low grade and noninvasive. We report an interesting case of a high-grade superficial transitional cell carcinoma in a 3-year-old girl with Turner syndrome.

Pediatric robotic pyeloplasties: initial experience at a single center.

PURPOSE The purpose of this analysis was to review our initial experience of pediatric robotic-assisted pyeloplasties (RALPs). Our case series spanned a 7-year period (January 2004-February 2011). The initial 20 cases were reviewed retrospectively (RG group), and the later 20 cases were seen prospectively (PG group). We compared outcomes between these two groups. SUBJECTS AND METHODS After institutional review board approval, all charts were reviewed, and outcomes were based on postoperative imaging. For continuous variables t tests were performed, and for categorical variables Fishers exact tests were performed. Statistical analysis was performed with SPSS version 17.0 software (SPSS, Inc., Chicago, IL). RESULTS There was no significant difference in demographics between the two groups. Median age at time of surgery was 64 months (PG) and 36 months (RG). Narcotic use was statistically similar among the groups when comparing median morphine intravenous equivalent per kilgram. Mean follow-up was 15.6 months (PG) and 41.8 months (RG). Postoperative imaging was stable or improved in 95% (PG) and 100% (RG). RALP in 1 patient in the PG group failed and later required repeat surgery (5%). The only identified significant difference between the two groups was surgical time. Mean operative time was reduced by over an hour between the two time periods (230 minutes for PG, 297 minutes for RG [P<.01]). CONCLUSIONS The experience in pediatric RALP is growing at our institution. As this experience grows, the primary outcome that has changed is faster operative times. This increased efficiency does not correlate with compromised outcomes. We continue enrolling patients in our prospective database to strengthen the power of our outcomes analysis.

460 INCIDENCE OF REPEAT DEXTRANOMER/HYALURONIC ACID COPOLYMER INJECTION AMONG PEDIATRIC HEALTH INFORMATION SYSTEM HOSPITALS

During follow up, VUR disappeared spontaneously in 7, while antireflux surgery was performed in 7. Mean systolic blood pressure (BP) and mean diastolic BP at final visit were 108 mmHg (127 to 89) and 66mmHg (89 to 41). According to Guideline by Japanese Society of Hypertension, while none exceeded standard level of systolic BP, two patients slightly exceeded standard level of diastolic BP. No significant proteinuria was detected in all patients. Estimated GFR was evaluated in all of 10 patients over 10 years old at final visit and in 7 of 17 patients under 10 during follow up. CKD stage was 1 in all these 17 patients. CONCLUSIONS: Significant clinical findings related to UDRPL detected at less than 1 year old was rarely observed during a mean of 10 years follow up in this study. Accordingly, UDRPL seems to be a benign condition. No specific attention would be necessary during follow up in patients with UDRPL on one side and no or limited scar on the other on the initial nuclear renal scan.