Gene O. Huang

Robot-assisted laparoscopic pyeloureterostomy in infants with duplex systems and upper pole hydronephrosis: Variations in double-J ureteral stenting techniques

OBJECTIVE We describe our experience with robot-assisted laparoscopic (RAL) pyeloureterostomy in infants with duplex systems and upper pole hydronephrosis with an emphasis on the various double J (DJ) ureteral stent placement techniques. METHODS We used our RAL pyeloureterostomy technique in two female infants with duplex systems and upper pole hydronephrosis. For case 1, we introduced the DJ stent and placed it in the recipient lower pole ureter during the robotic operation in an antegrade fashion. For case 2, we inserted the DJ stent during retrograde pyelography prior to the robotic procedure in a retrograde fashion, and the proximal portion of the stent was placed across the anastomosis into the upper pole renal pelvis. RESULTS Postoperatively, each of the patients were discharged on postoperative day 1 without complications. The postoperative renal ultrasound at 3 months demonstrated marked improvement of the right upper pole hydronephrosis in both patients. CONCLUSION RAL pyeloureterostomy represents a minimally invasive option for upper tract reconstruction of duplex systems with upper pole hydronephrosis in infants. The DJ stent can be placed at the beginning or during the procedure. The stent can be placed in the lower pole ureter or across the anastomosis into the upper pole renal pelvis.

Early postnatal bladder function in fetoscopic myelomeningocele repair patients

PURPOSE Prenatal repair of myelomeningocele (MMC) via hysterotomy has demonstrated neurosurgical and motor benefits, when compared to postnatal repairs. Urologic benefits, however, remain to be seen. The purpose of this study was to review early postnatal bladder function in patients undergoing a novel endoscopic approach for MMC repair using an exteriorized uterus. METHODS A prospective urologic assessment of patients undergoing fetoscopic MMC repair and receiving subsequent care at our facility, was performed. Patients were managed and urodynamic studies risk-stratified according to the Centers for Disease Control and Prevention Urologic and Renal Protocol for the Newborn and Young Child with Spina Bifida. RESULTS Fetoscopic MMC repair was performed in 14 patients. No patients had hydronephrosis or bladder thickening at birth. Detrusor overactivity was observed in nine (64.3%) patients. Impaired compliance was seen in eight (57.1%) patients. No patients had a detrusor leak point pressure of > 40 cm H2O or evidence of detrusor sphincter dyssynergia. Three (21.4%) patients had vesicoureteral reflux, seven (50.0%) had an open bladder neck, and none had trabeculated bladders. CONCLUSION In this early experience with fetoscopic MMC repair, postnatal bladder function does not appear to be any worse than that of previously reported prenatal or postnatal closures.

Complications in pediatric robotic urologic surgery

Robotic-assisted laparoscopic surgery, like other minimally invasive surgical modalities, in children with urologic conditions has proven to be a safe and effective alternative to open surgery and especially for reconstructive pediatric urologic procedures. However, potential complications can occur, especially with the learning curve that exists with all new procedures and techniques. The prevention of complications requires an integrated team approach that includes the surgeon, anesthesiologist, and operating room team members. Avoidance of preoperative complications usually involves adequate patient positioning and padding before surgery that prevents peripheral nerve injury. Intraoperative complications can occur during intra-abdominal access and port placement steps of the procedures with the potential for vessel injury or bowel injury. Postoperative complications have a wide variety of presentations that are dependent on the procedure, such as ureteral reimplantation, pyeloplasty, or complex reconstructive procedures. In general, surgeons early in their robotic surgery learning curve should gradually advance to complex reconstructive cases to help prevent both intra- and postoperative complications.

Surgical interventions and anesthesia in the 1st year of life for lower urinary tract obstruction

BACKGROUND Patients with a prenatal diagnosis of lower urinary tract obstruction (LUTO) may undergo prenatal interventions, such as vesicoamniotic shunt (VAS) placement, as a temporary solution for relieving urinary tract obstruction. A recent FDA communication has raised awareness of the potential neurocognitive adverse effects of anesthesia in children. We hypothesized as to whether a prenatal LUTO staging system was predictive of the number of anesthesia events for prenatally diagnosed LUTO patients. METHODS We retrospectively reviewed the prenatal and postnatal clinical records for patients with prenatally diagnosed LUTO from 2012 to 2015. Patients were stratified by prenatal VAS status and by LUTO disease severity according to Ruano et al. (Ultrasound Obstet Gynecol. 2016). RESULTS 31 patients were identified with a prenatal LUTO diagnosis, and postnatal records were available for 21 patients (seven patients in each stage). When combining prenatal and postnatal anesthesia, there was a significant difference in the number of anesthesia encounters by stage (1.6, 3.7, and 6.7 for Stage I, II, and III respectively, p = .034). Upon univariate analysis, higher gestational age (GA) at birth was associated with a decreased number of anesthesia events in the first year (p = .031). CONCLUSIONS The majority of infants with prenatally diagnosed LUTO will undergo postnatal procedures with general anesthesia exposure in the first year of life. Patients with higher prenatal LUTO severity experienced a higher number of both prenatal and postnatal anesthesia encounters. In addition, higher GA at birth was associated with fewer anesthesia encounters in the first year. LEVEL OF EVIDENCE This is a prognostic study with Level IV evidence.

Infant crossed renal ectopia with UPJ obstruction repaired via robot-assisted laparoscopic pyeloplasty

INTRODUCTION We present a robot-assisted approach to surgical treatment of UPJ obstruction associated with crossed renal ectopia in a male infant. METHODS A 31 year-old woman presented at 37 weeks gestation for prenatal hydronephrosis and delivered at 39 weeks. Renal ultrasound identified the bladder and right kidney in a crossed ectopic position in the left pelvis, and MRI showed the cystic lesion to be hydronephrosis associated with a ureteropelvic junction obstruction of the crossed ectopic right kidney. At three months of age, a robot-assisted laparoscopic dismembered pyeloplasty was performed. Post-operative renal ultrasounds at one, two, and 7 months showed persistent but decreasing hydronephrosis. He remains asymptomatic. DISCUSSION Crossed renal ectopia with associated ureteropelvic junction obstruction has been reported in the literature and managed using both open and minimally invasive approaches. To our knowledge, this is the first reported robot-assisted pyeloplasty performed for this condition in an infant. CONCLUSIONS With careful patient selection, the robot-assisted laparoscopic approach can be applied to infants that require pyeloplasty for kidneys with anomalous development that have evidence of ureteropelvic junction obstruction.

Pediatric medical device development by surgeons via capstone engineering design programs

BACKGROUND There is a need for pediatric medical devices that accommodate the unique physiology and anatomy of pediatric patients that is increasingly receiving more attention. However, there is limited literature on the programs within childrens hospitals and academia that can support pediatric device development. We describe our experience with pediatric device design utilizing collaborations between a childrens hospital and two engineering schools. METHODS Utilizing the academic year as a timeline, unmet pediatric device needs were identified by surgical faculty and matched with an engineering mentor and a team of students within the Capstone Engineering Design programs at two universities. The final prototypes were showcased at the end of the academic year and if appropriate, provisional patent applications were filed. RESULTS All twelve teams successfully developed device prototypes, and five teams obtained provisional patents. The prototypes that obtained provisional patents included a non-operative ureteral stent removal system, an evacuation device for small kidney stone fragments, a mechanical leech, an anchoring system of the chorio-amniotic membranes during fetal surgery, and a fetal oxygenation monitor during fetoscopic procedures. CONCLUSIONS Capstone Engineering Design programs in partnership with surgical faculty at childrens hospitals can play an effective role in the prototype development of novel pediatric medical devices. LEVELS OF EVIDENCE N/A - No clinical subjects or human testing was performed.