Daryl J. McLeod

Robot-assisted laparoscopic management of duplex renal anomaly: Comparison of surgical outcomes to traditional pure laparoscopic and open surgery

INTRODUCTION Surgical management of duplex renal anomaly (DRA) is complex because of individual anatomic variation, competing priorities of vesicoureteral reflux (VUR) and ureteral obstruction present in the same child, the varied differential function of the different renal moieties, and the presence of voiding dysfunction and recurrent urinary tract infection (UTI). Robot-assisted laparoscopic (RAL) surgical management has been under-reported in this group of children but is becoming a viable alternative to traditional open surgery. OBJECTIVE The aim was to report the surgical outcomes of a series of children with DRA who had RAL surgery and compare these outcomes to historical cohorts of open and laparoscopic surgery. STUDY DESIGN This was a retrospective analysis of a prospective series of children who had RAL surgery for DRA over an 8-year period. Forty-five RAL surgeries were performed in 47 children. RAL heminephrectomy (RAL HN) was performed in 19 children for poorly or non-functional renal moiety. One had staged bilateral RAL HN. RAL ureteroureterostomy (RAL UU) was performed in 14 children for upper pole ureteral obstruction. Thirteen RAL common sheath ureteral reimplants (RAL csUN) with or without ureteral tapering were performed in 12 children with VUR and UTI. Diagnosis and demographics, results of preoperative imaging, intraoperative time stamps, perioperative complications, success rate, and renal outcomes were recorded. RESULTS Low-grade VUR present preoperatively in the RAL UU group all resolved within the follow-up period. Four (25%) children in the RAL HN group developed de novo VUR after surgery, which resolved in two (50%) and required surgery in two (50%). Grade I VUR after RAL csUR that occurred in two (14.3%) children was asymptomatic and observed when off preventative antibiotics. DISCUSSION Most children with DRA who need surgical treatment can be offered RAL surgery. We report good outcomes and improved operative times for RAL HN and UU that approach historical open and pure laparoscopic cohorts. However, RAL csUR, especially with ureteral tapering, is more complex and inherently susceptible to complications, and has not met the outcomes of the open gold standard. The limits of this study are that selection bias is present, and there is no study control cohort. CONCLUSIONS This report achieves its aim to report surgical outcomes of children who had RAL surgery for DRA.

Segmental arterial mapping during pediatric robot-assisted laparoscopic heminephrectomy: A descriptive series

INTRODUCTION The incidence of innocent moiety injury during heminephrectomy is estimated to be 4-5%. This complication can have long-term consequences for the child. Selective arterial mapping (SAM) with indocyanine green (ICG)-aided near infrared fluorescence (NIRF) imaging using the Firefly™ system on the da Vinci(®) surgical robotic console has proven to be valuable in robotic partial nephrectomy for adult renal tumors. However, there is nothing in the literature for using this technique in pediatric robot-assisted laparoscopic heminephrectomy (RALHN). OBJECTIVE To present a descriptive series of children who had SAM RALHN using ICG-aided NIRF imaging. To determine the feasibility of using ICG-aided NIRF SAM during RALHN, and to study if real-time delineation of the selective arterial anatomy of the upper and lower moieties would be helpful or change the immediate outcomes of the surgery. STUDY DESIGN A descriptive series of six children who received RALHN at the present institution. RESULTS Selective arterial mapping was performed safely without toxicity or vascular complications; it did not extend the operative time and did not change the complexity of the operation. As shown in the summary table below, SAM added value by increasing safety of the operation. The individual operation cost increase of using SAM was only related to the single-use vial of ICG. DISCUSSION Inadvertent injury to the innocent moiety in pediatric heminephrectomy is seldom noted intraoperatively, and many times only becomes evident postoperatively when there is acute ischemia or a chronic reduction in renal function. Although there is no replacement for good surgical technique and judgment, SAM during RALHN is a useful real-time way of alerting the surgeon to unexpected anatomy, and possible unintended or occult injury to the innocent moiety that could have devastating short-term and long-term consequences to the child, despite immediate recovery from surgery. CONCLUSIONS This report achieved its aim of reporting the feasibility of SAM on a small descriptive series of children who had RALHN.

Robot-assisted laparoscopic extravesical ureteral reimplant: A critical look at surgical outcomes

BACKGROUND Published reports of outcomes of robot assisted laparoscopic ureteral reimplantation (RALUR) show mixed results that, on average, are inferior to open ureteral reimplant. We present a retrospective analysis of a prospective series of children who had RALUR from 2013 to June 2015. We hypothesized that surgical outcomes are based on identifiable risk variables. We provide a critical analysis of the relationship between patient characteristics and several surgical and non-surgical outcomes. METHODS We reviewed the records of children who had Robot-Assisted Laparoscopic (RAL) Ureteral Reimplant (UR) at Nationwide Childrens Hospital. Patient age and gender, preoperative presentation, presence of preoperative bladder and bowel dysfunction (BBD), VUR grade and laterality, indication for operation, operative time, surgical outcome, surgical complications, post-operative prevalence of UTI, and pre- and post-operative status of BBD were recorded. We also recorded techniques for ureteral dissection, and closing the detrusorrhaphy. Surgical outcome was defined by post-operative VCUG. We define BBD based on publications by the standardization committee of International Childrens Continence Society (ICCS). All statistical calculations were performed with STATA version 11. RESULTS We performed extravesical RALUR on 54 children for a total of 72 ureters. Overall the study children were 74% female. The mean and median age was 5.2 and 4.9 years, respectively. Mean overall hospital length of stay (LOS) was 1.64 days. The mean LOS was 1.26 for unilateral (RALUUR) and 2.39 days for bilateral (RALBUR) surgeries and was significant (p < 0.05). Overall surgical success was 85.2% of ureters and 84.7% of children. Stratified by unilateral and bilateral surgeries, unilateral success was 91.7%, and bilateral success was 77.8% of ureters, and 72.2% of children. In the 3 failures in the RALUUR group the mean postoperative VUR grade was 1.3 from a pre-op mean grade of 3.3, whereas in the RALBUR group, the mean VUR grade among the failures was 3.0 from a mean pre-op VUR grade of 3.7. Urinary leak from ureteral injury, and urinary obstruction were more common in the RALBUR group. Post-operative urinary retention occurred in 4 children in the RALBUR and none in the RALUUR groups. Four with VUR after RALBUR and one child after RALUUR had open ureteral reimplant. Post-op UTI and non-surgical readmissions were higher in the RALBUR group. CONCLUSIONS Bilateral RALUR is associated with higher failure rates, higher complication rates, higher re-operation rates, and more postoperative UTIs and nonsurgical readmissions compared with unilaterasl RALUR.

Preoperative risk assessment in children undergoing major urologic surgery

BACKGROUND Preoperative risk assessment is standard in adult surgery, but often these risk assessments cannot be applied to children. Previous studies emphasize the differences between pediatric and adult populations and variability by surgical procedure types. OBJECTIVE We investigated preoperative risk factors for several outcomes in children undergoing major urologic surgery using the National Surgical Quality Improvement Program (NSQIP) Pediatric. STUDY DESIGN A cohort of 2-18-year-old children who underwent major urologic surgery was identified by Current Procedure Terminology (CPT) codes in the 2012-2013 NSQIP-Pediatric. The NSQIP-Pediatric prospectively collects standardized and validated data from 61 sites on preoperative, operative, and 30-day postoperative variables. Urologic surgeries involving dissection of the peritoneal or extraperitoneal space were included. Patients undergoing pure genitourinary surgery were analyzed separately from those with bowel involvement to improve homogeneity. Postoperative outcomes including hospital length of stay and 30-day infective complications, non-infective complications, unplanned reoperation and readmissions were evaluated by fitting multivariable logistic regression models. RESULTS A total of 2601 patients were identified, of whom 399 (15.3%) underwent bowel-involved surgery and 2202 (84.7%) underwent pure genitourinary surgery. Patients in the bowel-involved group were significantly older with more comorbidity. Postoperative complications, unplanned return to operating room, hospital length of stay and readmission rates were all significantly worse in the bowel-involved group. In the pure genitourinary group, older age and white race improved some outcomes, while American Society of Anesthesia (ASA) class ≥ 3, total operation time, obesity, pulmonary risk factors, preoperative renal disease, developmental delay, structural central nervous system abnormality, and supplemental nutrition independently predicted at least one negative outcome (Table). DISCUSSION Consistent with previous research on reconstructive surgery, we identified a significant difference in patient age, surgery details, comorbidity, and increased complications for patients undergoing urologic surgery with bowel involvement compared with pure genitourinary surgery. Focusing solely on pure genitourinary surgery, we identified predictors of outcomes. Identification of these factors in pediatric urology is novel and only recently possible with the availability of the NSQIP-Pediatric. CONCLUSION Using the NSQIP-Pediatric, we confirmed differences in complication rates for major urologic surgeries, with and without bowel involvement in a national sample. Preoperative risk characteristics were also identified for patients undergoing pure genitourinary surgery. Further investigation into these relationships is necessary to better elucidate their clinical significance with the goal of improving surgical planning, postoperative care, and family counseling.

Variation in Practice Patterns for the Management of Newborn Spina Bifida in the United States

OBJECTIVE To survey variations in recommended initial management of newborn spina bifida (SB). METHODS Members of an international pediatric urology ListServe and of the Pediatric Urology Nurse Specialists organization were surveyed on practice patterns for newborn SB. Pediatric urologists, nurse practitioners, and physician assistants practicing in the United States were included. RESULTS A total of 63 practitioners (48% pediatric urologists and 52% nurse practitioners or physician assistants) were included. Most practice at tertiary hospitals (94%) and about half use a protocol (56%). Recommended in-hospital screening tests include renal ultrasound (95%), voiding cystourethrogram (52%), catheterized bladder volumes (56%), and renal function tests (37%). Urodynamics are deferred until follow-up by 71%. Fifty percent of practitioners initiate clean intermittent catheterization (CIC) on all newborns, whereas 43% wait for symptoms. The majority of those who start CIC continue until residual volumes are below a threshold. Few recommend prophylactic antibiotics routinely (13%), or in patients on CIC (19%), but most recommend it for urinary reflux (62% grades 1-2, 79% grade 3, and 87% grades 4-5). Anticholinergics are deferred until after urodynamics (68%). Practicing at an institution with a pediatric urology fellowship program or an SB treatment protocol was associated with differing diagnostic work-up and urologic management. CONCLUSION There is variability in management of newborn SB among pediatric urology providers at tertiary care centers that may be influenced by institutional factors such as the presence of a pediatric urology fellowship or the presence of a protocol to care. This highlights the need for prospective multicenter projects to better understand how variations in management affect patient outcomes.

Reducing the Number of Anesthetic Exposures in the Early Years of Life: Circumcision and Myringotomy as an Example

Evidence suggests multiple anesthetics in early childhood may increase risk for neurodevelopmental injury. We evaluated proportions of children undergoing circumcision and myringotomy, concomitantly with or prior to circumcision, and compared costs between groups. The Pediatric Health Information System was queried for males aged 6 to 36 months who underwent circumcision in 2009-2014. Relative to circumcision, the proportion who underwent myringotomy previously, concomitantly, or both, was calculated. Of 29  789 patients who underwent circumcision, 822 also underwent myringotomy; 342 (41.6%) underwent myringotomy on a previous day, and 480 (58.4%) underwent myringotomy at time of circumcision. Total hospital costs were lower for concomitant procedures (median

Double-V scrotoplasty for repair of congenital penoscrotal webbing: a hidden scar technique.

2994 vs

Intraoperative Onabotulinumtoxin-A Reduces Postoperative Narcotic and Anticholinergic Requirements After Continent Bladder Reconstruction

4609, P < .001. In total, 58.4% of patients who underwent circumcision and myringotomy did so concomitantly. Combined procedures resulted in significantly reduced costs and potentially minimized neurocognitive risk. Ideally, both referring pediatricians and surgical specialists should inquire about other surgical needs to optimize the availability of concomitant procedures.

Is Delayed Phase Computed Tomography Imaging Necessary After Blunt Renal Trauma in Children

OBJECTIVE Penoscrotal webbing (PSW) is a common reason for deferral of neonatal circumcision. Reports of successful procedures and outcomes in the literature are sparse. We have performed double-V scrotoplasty (DVS), a modification of a V-Y technique, in 138 patients with excellent results. PATIENTS AND METHODS We retrospectively reviewed the charts of boys who had undergone DVS for PSW since January 2009 by a single surgeon (S.A.A.). The indications, intraoperative findings, concomitant procedures, outcomes, and complications were recorded. RESULTS A total of 138 DVSs were performed. Concomitant genital surgeries included 81 hidden penis repairs and 10 other (hernia, hypospadias, chordee, orchidopexy). The median age at the time of surgery was 9.6 months (6.1 months-9.8 years). Patients were evaluated about 1 month postoperatively. In seven cases (5%), minor skin separation occurred at the penoscrotal junction but all healed completely. Superficial skin infection occurred in one patient. None required reoperation and cosmetic results were subjectively excellent. CONCLUSIONS PSW has been corrected in 138 patients without significant complications and with excellent results. This is the largest known peer-reviewed series evaluating a surgical technique for congenital PSW repair. We believe our technique is simple, reproducible, and, with no diverging suture lines lateral to the median raphe, improves cosmesis.

Effect of bladder augmentation on VP shunt failure rates in spina bifida

OBJECTIVE To determine if intradetrusor injection of onabotulinumtoxin-A (BTX-A) would reduce postoperative narcotic and anticholinergic requirements in children undergoing open continent bladder reconstruction. MATERIALS AND METHODS After institutional review board approval, we retrospectively reviewed all bladder reconstructions performed. Bladder reconstruction was defined as the following procedures in any combination: bladder neck reconstruction and sling, bladder neck closure, Mitrofanoff, Monti, or bladder augmentation. We identified 15 children who underwent reconstruction with BTX-A injection and compared these with 15 children who did not receive BTX-A. Postoperative narcotic and anticholinergic requirements were recorded as well as length of stay, time to diet, time to return of bowel function, and complications. All medications were converted to morphine mEq/kg per day or mg/kg per day to standardize for patient size and length of stay. RESULTS Thirty patients who underwent open bladder reconstruction were included. Fifteen received BTX-A injection and 15 did not. The BTX-A group required significantly less narcotic medication postoperatively compared with the no-BTX-A group (0.32 vs 0.85 morphine mEq/kg per day; P = .0002). The BTX-A group also required significantly less anticholinergic medication compared with the no-BTX-A group (0.22 vs 0.88 mg/kg per day; P = .024). There was no significant difference between the groups with respect to length of stay (98.27 vs 9.287 days; P = .34) or return of bowel function (5.53 vs 4.93 days; P = .994). Complication rate between the groups was similar (P >.99). CONCLUSION Intraoperative injection of BTX-A significantly reduced postoperative narcotic and anticholinergic requirements in patients who underwent open continent bladder reconstruction. This is an encouraging alternative treatment to manage postoperative pain with no associated risk of significant complications.