Dennis B. Liu

Contemporary national comparison of open, laparoscopic, and robotic-assisted laparoscopic pediatric pyeloplasty.

OBJECTIVE We sought to determine current and longitudinal trends in the usage of open (OP), laparoscopic (LP), and robotic pyeloplasties. (RALP) Furthermore, we aimed to describe patient and hospital level characteristics associated with the use of minimally invasive pyeloplasties (MIP) and to compare basic utilization metrics for each approach. MATERIALS/METHODS The 2000, 2003, 2006, and 2009 Kids Inpatient Databases (KID) were used to determine current and longitudinal trends. As a result of a specific billing code for robotic surgery introduced in 2008, the 2009 KID database was used for analysis of RALP. Patient and hospital characteristics examined included: age, gender, race, insurance status, hospital location, and academic status. Utilization metrics of length of stay (LOS) and cost were determined from each modality. RESULTS In 2009, there were 3354 pediatric pyeloplasties performed in the USA (85% OP, 3% LP, 12% RP). Compared with 2000, this represents an 11.7% decrease in the overall number of pyeloplasties but a progressive increase in MIP from 0.34% in 2000 to 11.7%. Mean patient age was 3.7 years for OP, 9.3 years for LP and 9.9 years for RALP. MIP was more commonly performed in females, Caucasians, patients with private insurance, at urban hospitals and at teaching hospitals. Although length of stay (LOS) in days was statistically lower for MIP (3.46 OP, 2.86 LP, 1.96 RP, p < 0.001), total cost between the groups was not statistically different. On multivariable logistic regression analysis, age (OR 1.17, p < 0.001) increased the odds of MIP whereas lack of private insurance decreased the odds of MIP (OR 0.62, p = 0.002). CONCLUSION Although utilization of MIP is increasing in the USA, especially in older children, OP remains predominant. MIP was associated with a decrease in LOS. The odds of MIP were higher in older children, whereas the lack of private insurance decreased the odds of MIP.

A new computer enhanced visual learning method to train urology residents in pediatric orchiopexy: a prototype for Accreditation Council for Graduate Medical Education documentation.

PURPOSE Residency programs must continue to restructure teaching and assessment of surgical skills to improve the documentation of Accreditation Council for Graduate Medical Education competencies. To improve teaching and documenting resident performance we developed a computer enhanced visual learning method that includes a curriculum and administrative reports. The curriculum consists of 1) study of a step-by-step surgical tutorial of computer enhanced visuals that show specific surgical skills, 2) a checklist tool to objectively assess resident performance and 3) a log of postoperative feedback that is used to structure deliberate practice. All elements of the method are repeated with each case performed. We used the Accreditation Council for Graduate Medical Education index case of orchiopexy to pilot this project. MATERIALS AND METHODS All urology residents who trained at our institution from January 2006 to October 2007 performed orchiopexy using the computer enhanced visual learning method. The computer enhanced visual learning tutorial for orchiopexy consisted of customized computer visuals that demonstrate 11 steps or skills involved in routine inguinal orchiopexy, eg ligate hernia. The attending urologist rated resident competence with each skill using a 5-point Likert scale and provided specific feedback to the resident suggesting ways to improve performance. These ratings were weighted by case difficulty. The computer enhanced visual learning weighted score at entry into the clinical rotation was compared to the best performance during the rotation in each resident. RESULTS Seven attending surgeons and 24 urology residents (resident training postgraduate years 1 to 8) performed a total of 166 orchiopexies. Overall the residents at each postgraduate year performed an average of 7 cases each with complexity ratings that were not significantly different among postgraduate year groups (average 2.4, 1-way ANOVA p not significant). The 7 attending surgeons did not differ significantly in assessment of skill performance or case difficulty (1-way ANOVA p not significant). Of the 24 residents 23 (96%) showed improvement in computer enhanced visual learning score/skill performance. In the entire group the average computer enhanced visual learning weighted score increased more than 50% from entry to best performance (137 to 234 orchiopexy units, paired t test p <0.0001). CONCLUSIONS Computer enhanced visual learning is a novel method that enhances resident learning by breaking a core procedure into discrete steps and providing a platform for constructive feedback. Computer enhanced visual learning, which is a checklist tool, complies with Accreditation Council for Graduate Medical Education documentation requirements. Computer enhanced visual learning has wide applicability among surgical specialties.

Survey of pediatric urologists on the preoperative use of testosterone in the surgical correction of hypospadias

OBJECTIVE To better characterize the current state of testosterone use in the surgical correction of hypospadias among pediatric urologists. METHODS An email was sent via the pedsurology research listserv through the American Academy of Pediatrics, inviting members to participate in an anonymous survey regarding their use of preoperative testosterone in hypospadias correction. RESULTS Twenty-seven responses were obtained for a response rate of 53%. Almost all responders practiced in North America, had exclusively pediatric patients in their practice, and had been in practice for 30 years or less. 55% were classified as high-volume surgeons, completing >50 cases yearly, 87% of whom use preoperative androgen therapy currently, compared with 67% of low-volume surgeons. Testosterone was prescribed primarily for a small appearing penis, reduced glans circumference, reduced urethral plate width, and/or proximal hypospadias. The effect of testosterone was determined primarily by evaluating penile appearance (59%). However, the majority (56%) of physicians stopped giving testosterone when they completed a predetermined regimen. CONCLUSIONS While many pediatric urologists use testosterone prior to hypospadias repair, the practice patterns are variable. It appears that the use of testosterone is primarily limited to patients with proximal hypospadias, small appearing penis, reduced glans circumference or reduced urethral plate.

Hydronephrosis: Prenatal and Postnatal Evaluation and Management

Antenatal hydronephrosis (ANH) is one of the most frequently detected abnormalities found on routine prenatal ultrasounds, affecting 1% to 4.5% of all pregnancies. Despite its prevalence, there continues to be uncertainty regarding the clinical impact after birth. Prognosis depends on the severity of the dilation. Expectant prenatal management is the rule with fetal intervention rarely needed in a few select cases. Ureteropelvic junction obstruction and vesicoureteral reflux are the most common postnatal diagnoses. A renal and bladder ultrasound is essential in the follow-up of patients with ANH and helps dictate further investigation with voiding cystourethrography and/or diuretic renography.

Magnetic Resonance Arteriography/Venography is Not Accurate to Structure Management of the Impalpable Testis

PURPOSE Recent studies have shown that magnetic resonance arteriography/venography is a highly sensitive tool to identify impalpable testes in young boys. Due to this and the low risk of cancer in testicular nubbins observation has been proposed after the identification of nubbins by magnetic resonance arteriography/venography. We prospectively examined the accuracy of magnetic resonance imaging and magnetic resonance imaging with magnetic resonance arteriography/venography for identifying impalpable testes in a younger cohort of patients typically seen at a pediatric institution in the United States. MATERIALS AND METHODS We prospectively studied 26 infants and boys with impalpable testes. Conventional magnetic resonance imaging or magnetic resonance imaging with magnetic resonance arteriography/venography was performed in all patients. All patients subsequently underwent surgical exploration. Surgical and radiological findings were then evaluated for concordance. RESULTS A total of 26 boys (29 impalpable testes) with a median age of 13 months were evaluated. A subset of 14 boys (14 impalpable testes) also underwent magnetic resonance arteriography/venography. Standard magnetic resonance imaging correctly identified 10 of 12 intra-abdominal testes, 4 of 6 intracanalicular testes, 4 of 10 testicular nubbins and 0 of 1 scrotal testis. Magnetic resonance arteriography/venography correctly identified 4 of 5 intra-abdominal testes, 2 of 3 intracanalicular testes, 2 of 5 testicular nubbins and 0 of 1 scrotal testis. The overall accuracy of magnetic resonance imaging alone and magnetic resonance arteriography/venography for identifying a viable testis or testicular nubbin was 62% and 57%, respectively. The accuracy of magnetic resonance imaging and magnetic resonance arteriography/venography for identifying a viable testis was 74% and 67%, respectively. CONCLUSIONS Preoperative magnetic resonance imaging or magnetic resonance arteriography/venography does not accurately identify or localize impalpable testes in the age group typically presenting to pediatric urologists. Accuracy at our institution is discrepant with that in previous studies. We do not recommend using magnetic resonance imaging or magnetic resonance arteriography/venography for the possible observation of vanishing testes or nubbins and we recommend surgical exploration in all individuals.

Computer Enhanced Visual Learning Method to Train Urology Residents in Pediatric Orchiopexy Provided a Consistent Learning Experience in a Multi-Institutional Trial

PURPOSE Computer enhanced visual learning is a new method to train residents to perform surgery using components and provide them with access to a personalized surgical feedback archive using the Internet. At the parent institution in Chicago we have already noted that this method is effective to train residents to perform orchiopexy. To assess whether this new methodology to enhance resident surgical instruction is generalizable we performed a prospective, multi-institutional clinical trial. MATERIALS AND METHODS We prospectively compared ratings of resident skills in performing pediatric orchiopexy at 4 institutions as novices to computer enhanced visual learning curriculum (study group) vs those at the single institution accustomed to that curriculum (control group). All urology residents and attending physicians accessed the computer enhanced visual learning curriculum. After each case was completed the attending urologist rated resident performance of each step and provided feedback on weaknesses for the resident to remediate at the next case. The learning score was calculated for each case as the sum of the ratings × case difficulty. Scores on the first case and the best case were compared between the study and control groups by resident and institution. RESULTS The study group included 6 attending physicians and 36 residents (99 orchiopexies). The control group included 8 attending physicians and 21 residents (108 orchiopexies). Between the study and control groups we noted no significant differences in average resident postgraduate year (2.9 vs 2.7), number of procedures per resident (3.9 vs 4.9), frequency with which residents viewed computer enhanced visual learning preoperatively (63% vs 74%) or attending physician provision of feedback (63% vs 88%) (each p not significant). Similarly of residents who completed more than 1 surgery there was no significant difference in the percent who showed an improved learning score in the study vs the control group (86% vs 79%) or in the magnitude of average improvement (10.5 vs 13.4) (each p not significant). CONCLUSIONS The institutional groups did not differ in training resident skills using computer enhanced visual learning for pediatric orchiopexy. Thus, the program provides a consistent learning experience and is generalizable across institutions. We believe that this tool will change the practice of how training programs educate residents by enhancing learning by a checklist approach and a computer platform to archive feedback and remediation.

Complete Excision or Marsupialization of Ureteroceles: Does Choice of Surgical Approach Affect Outcome?

PURPOSE Two accepted open surgical techniques exist for lower urinary tract reconstruction for ureteroceles, that is complete excision/enucleation and marsupialization/partial excision. To our knowledge it is currently unknown whether 1 method offers better clinical outcomes. We sought to answer this question. MATERIALS AND METHODS We retrospectively reviewed the records of patients who underwent open surgical repair for ureterocele at 3 academic institutions. The 2 groups (complete excision vs marsupialization) were compared for each clinical outcome, including ongoing vesicoureteral reflux, new bladder diverticulum, hydronephrosis, continence, urinary tract infection and voiding dysfunction. Each clinical outcome was analyzed for independence from the surgical method. RESULTS A total of 33 cases of complete excision and 24 of marsupialization were collected. The excision and marsupialization groups were similar with respect to patient age at surgery, gender and average followup (55 and 38 months, respectively). Most ureteroceles were unilateral and part of a duplicated system. Approximately half were intravesical and vesicoureteral reflux was the primary indication for surgery. In the excision group 82% of ureteroceles were previously punctured but only 50% were punctured in the marsupialization group (p = 0.09). Postoperatively the groups did not differ significantly in terms of ongoing vesicoureteral reflux (13% and 14%), bladder diverticulum (3% and 9%), continence (100% and 95%), urinary tract infection (43% and 46%) or voiding dysfunction (24% and 25%, respectively). They varied significantly in terms of improved or stable hydronephrosis (70% vs 91%, p = 0.05). CONCLUSIONS When performing lower urinary tract reconstruction for ureterocele, this study demonstrates that the choice of complete excision vs marsupialization/partial excision does not appear to differentially affect clinical outcomes.

Treatment of Occult Reflux Lowers the Incidence Rate of Pediatric Febrile Urinary Tract Infection

OBJECTIVES To examine whether vesicourethral reflux diagnosed by positioned instillation of contrast (PIC-VUR) shows clinical importance by comparing the incidence rates of febrile urinary tract infection (FUTI) before and after treatment of PIC-VUR. METHODS Beginning in 2001 we used a multi-institutional registry to prospectively enroll consecutive pediatric patients with a history of FUTI without VUR according to voiding cystourethrogram (VCUG) and yet who show PIC-VUR. Treatment of PIC-VUR was with prophylactic antimicrobials or antireflux surgery. The post-treatment occurrence of FUTI was tracked. RESULTS A total of 14 centers enrolled 118 patients (mean age, 7.2 years; range, 0.5 to 20 years). Parents self-selected the treatment of PIC-VUR as endoscopic injection (104), ureteral reimplantation (3), or antimicrobial prophylaxis (11). Study intervals surveying for FUTI before PIC (mean, 12 months; range, 1 to 17 years) and after PIC treatment (mean, 11 months; range, 0 to 3 years) were not significantly different. Overall the incidence rate for FUTI decreased significantly from 0.16 per patient per month before PIC-VUR treatment to 0.008 per patient per month after treatment (rate ratio 20; 95% confidence interval 11 to 36). The post-treatment rate of FUTI in patients treated with antibiotics versus surgery was not significantly different (rate ratio 2.5; 95% confidence interval 0.33 to 27). CONCLUSIONS The diagnosis of PIC-VUR is clinically important because children treated for PIC-VUR with either antimicrobial prophylaxis or surgery show a significant reduction in the incidence rate of FUTI. This is the basis for a current prospective study randomizing patients with PIC-VUR to treatment or observation.

The Correlation between Serial Ultrasound and Diuretic Renography in Children with Severe Unilateral Hydronephrosis

Purpose: While serial renal ultrasound is often used as an alternative to functional renal imaging in children followed for hydronephrosis, it is unclear whether a lack of hydronephrosis progression safeguards against loss of renal function. In this study we characterize the association between findings on serial renal ultrasound and diuretic renography in children with severe unilateral hydronephrosis. Materials and Methods: We retrospectively reviewed imaging among patients younger than 18 years old with a history of severe unilateral hydronephrosis, 2 renal ultrasounds and 2 diuretic renograms. Each pair of renal ultrasounds was interpreted by an independent blinded diagnostic radiologist and compared to a contemporaneous diuretic renogram. Change in hydronephrosis was considered as 1) a change in hydronephrosis grade or 2) any change by radiologist interpretation. A 5% or greater change in split differential function was considered significant. Chi‐square and Spearman correlation analyses were performed. Results: A total of 85 children were evaluated. Increased hydronephrosis was noted in 11.8% of children by grade and 32.9% by radiologist interpretation. Split differential renal function worsened by 5% or more in 17.6% of children. Overall, 13.3% of children with stable or decreased hydronephrosis demonstrated worsening split differential function at an average of 11.8 months. When renal ultrasound and diuretic renograms were directly compared, the Spearman correlation was poor (r = 0.24, 95% CI 0.03 to 0.43). Conclusions: The overall correlation between imaging modalities was poor, and 13.3% of children with stable or decreased hydronephrosis had worsening of split differential renal function. These findings are important to consider when counseling nonoperatively managed children followed without diuretic renography.

CEVL interactive – Promoting effective teamwork to perform robot assisted laparoscopic pyeloplasty in pediatric urology☆

Performing pediatric robotic surgeries effectively and efficiently requires the pediatric urologist to “team” with the entire operating room staff. Yet members of this team often achieve competency through different training paths. Attending surgeons often train in a structured, hands-on skills course and then gradually advance to be observed by a mentor. Circulating nurses and surgical technicians typically train together at their home institutions with instructors or by immersion in the operating room. Urology trainees may have opportunity to prepare with review of video clips and a robotic simulator if available, but often do the majority of their learning through immersion in the operating room. Finally, training of anesthesiologists and radiology technicians typically is provided only as an afterthought. To address this situation, the authors created this “CEV-ule” based on their belief that improving the effectiveness of the entire surgical team performance could be achieved by providing the OR staff with a shared online interactive learning for all to use prior to and concurrent with the surgical case. Because pediatric robot-assisted laparoscopic pyeloplasty (RALP) is the most commonly performed pediatric robotic procedure, we chose it as the index case to test this hypothesis. Herein, we present a paradigm approach to RALP. We identified critical points of the procedure in which effective teamwork is essential (e.g., suture passing, instrument exchange). In this manner the surgical workflow may include troubleshooting these points.