Evalynn Vasquez

Published surgical success rates in pediatric urology--fact or fiction?

PURPOSE Parents counseled for surgery are quoted operative risks based on published results in the literature. However, outcomes from single surgeon or single institution retrospective studies are not generalizable. We assessed whether published outcomes were perceived to be representative of personal practice by pediatric urologists. We also correlated patterns of perceptions with surgical volumes and demographic variables. MATERIALS AND METHODS A survey of 26 questions on 8 topics was e-mailed to 269 members of the American Academy of Pediatrics Section on Urology. Topics studied included distal and single stage proximal hypospadias, pyeloplasty, ureteral reimplantation with or without tapering, bladder neck reconstruction, and single and 2-stage bladder exstrophy repair. Participants were asked whether their rates of results were lower, the same or higher than specific published outcomes on a 5-point Likert scale. Study participants were also requested to provide demographic data and to estimate their annual case volume for each condition. RESULTS Of the 269 section members who were contacted 110 (40.9%) completed the survey. More than 80% of respondents practice pediatric urology exclusively with 50.9% reporting operative volumes of more than 400 cases per year. A greater proportion of participants reported worse outcomes than published reports for hypospadias fistula rates (distal p = 0.001, proximal p = 0.023), bladder neck repair (p = 0.018) and exstrophy repair continence rates (single and 2-stage p <0.001). Improved outcomes compared to published data were reported for ureteral reimplantation (p = 0.013) and pyeloplasty (p = 0.003). However, these findings did not correlate consistently with case volume or other demographic characteristics. CONCLUSIONS A significant proportion of pediatric urologists perceive their personal outcomes to be different than those in the published literature, regardless of practice setting, operative volume or time in practice. In an era of pay for performance and quality improvement, publication bias can have implications for patient care, reimbursement and malpractice.

V7-05 ROBOTIC ASSISTED LAPAROSCOPIC ADRENALECTOMY IN THE SETTING OF AN INCIDENTAL ADRENAL MASS

METHODS: A collaborative team was formed and consisted of a pediatric urologist trained in minimally invasive and oncologic surgery as primary surgeon with an adult minimally invasive oncologic urologist as proctor. Key aspects for translation to the pediatric setting included: port placement, lower insufflation pressure, choice and size of instruments and supplies, and minimization of potential hemorrhage and ischemia with selective clamping/early unclamping technique. This approach was applied to a 14 kilogram, 3 year old female with a right lower pole lesion with cystic and solid components, concerning for malignancy. RESULTS: The mass was resected with negative margins and demonstrated benign pathology. Clamp time was 14 minutes, and EBL was minimal. There were no intraor post-operative complications. The patient’s creatinine was unchanged, and a follow-up ultrasound demonstrated no residual mass in a normal appearing right kidney. CONCLUSIONS: Collaboration of experienced pediatric and robotic teams allows for successful adaptation of adult techniques to pediatric patients. Specific considerations must be made in order to achieve safety and feasibility of RPN with selective clamping for renal preservation in cases of pediatric renal masses.

V7-11 PEDIATRIC ROBOT-ASSISTED LAPAROSCOPIC EXCISION OF ECTOPIC DISTAL URETERAL STUMP

RESULTS: Surgery was uneventful. Identification of the distal ureter was somewhat challenging, but landmarks, such as the iliac bifurcation allowed for localization. The placement of both robotic ports along the midclavicular line provided maximum access to the distal and proximal segments of the ureter, aiding in our dissection. The ureter was transected proximally and distally to the stenotic segment. The retrocaval portion of the ureter was left in place though in discontinuity. The anastomosis was performed using a 5-0 PDS continuous suture. Operative time was 159 minutes, and EBL was 20mL. A 6x28 JJ internal ureteral stent was left in place for one month. The patient awaits further follow-up. CONCLUSIONS: A robotic-assisted approach to repair of a retrocaval ureter is a safe alternative to the conventional open approach. Identification of the distal ureter can be challenging, but the use of landmarks, such as the iliac bifurcation, as well as selective port placement can assist the dissection.

V7-04 MULTI-INSTITUTIONAL BLADDER EXSTROPHY CONSORTIUM: COMPLETE PRIMARY REPAIR OF EXSTROPHY

French catheter was used to inject methylene blue in a retrograde fashion to identify the os. The os was closed and the urothelial lining ablated with cautery. A perirenal drain and double-J ureteral stent were placed at the conclusion of the case. RESULTS: The patient was discharged home on the second post operative day. The drain was removed one week postoperatively with minimal output. At one month postoperatively the patient was recovering well. CONCLUSIONS: The robotic approach is an option in the treatment of renal calyceal diverticula, especially when more complex reconstruction is needed. Retrograde injection via ureteral catheter can aid in identifying the diverticular os. The robotic approach should be chosen carefully and the potential benefits must be balanced against the increased costs and potential for even less invasive options when endoscopic approaches are feasible.

Capillary hemangioma masquerading as a renal artery pseudoaneurysm.

THE CASE A62-year-old woman with history of type 1 diabetes mellitus presented to the emergency department with intractable nausea and vomiting. On further evaluation, the patient was noted to have a history of a remote fall from standing caused by loss of balance. She was otherwise asymptomatic and had no genitourinary complaints. She was hemodynamically stable, and her physical examination was within normal limits. Her laboratory evaluation was normal, including a serum creatinine of 1.1 mg/dL and a normal urinalysis. A computed tomography (CT) scan was performed and showed a 1-cm hyperdense lesion identified in the area of the left renal hilum with decreased attenuation centrally (Fig. 1). Urological and vascular surgical consultations were obtained. A decision was made between both services to survey the lesion with a repeat CT scan at 6 months; this showed interval growth of the mass to 1.5 cm. An arteriogram was performed by vascular surgery to further delineate the lesion, which showed evidence of a patent superior renal artery and what was felt to be a thrombosed renal aneurysm vs pseudoaneurysm. A decision was made to continue to manage the patient conservatively with interval imaging. The lesion continued to grow on follow-up imaging over the next 18 months (Fig. 2). A decision was made to perform covered stent grafting of the left superior renal artery with the objective to exclude the presumed pseudoaneurysm and prevent further expansion. The procedure was performed by the vascular surgery service without complication. However, follow-up CT angiogram demonstrated further growth to 2.5 2.2 cm and continued erfusion of the lesion (Fig. 3). Because the mass ontinued to grow and etiology was unclear, surgical xcision was advised.