Indupur R. Ravish

Robot-assisted laparoscopic ureteroureterostomy for proximal ureteral obstructions in children

OBJECTIVE Ureteropelvic junction obstruction is a common presentation in the pediatric population, but proximal ureteral obstructions are rare. In this setting, robot-assisted laparoscopy (RAL) offers a minimally invasive option to open or traditional laparoscopic repair. The present study demonstrates successful RAL in two children with proximal ureteral obstructions: one with a right retrocaval ureter and one with a left ureter entrapped between two lower-pole crossing vessels. METHOD After retrograde placement of a double-J ureteral stent, the child was secured in a lateral decubitus position exposing the affected side. A three-port RAL system was used to dissect free the obstructed ureter. A spatulated watertight ureteroureterostomy was then fashioned after transposition of the ureter into an anatomic position. Sutures and free instruments were passed into the peritoneal cavity via the 5-mm instrument ports, thus obviating the need for a separate assistant port. RESULTS RAL provided for crisp visualization, meticulous dissection, and precise approximation of the reconstructed ureter. In both patients, blood loss was negligible, narcotic use was minimal, and length of stay was roughly 30h. Follow-up imaging at 1 month showed excellent hydronephrosis resolution for both reconstructions. CONCLUSION These two cases demonstrate the feasibility of RAL for proximal ureteral anomalies in the pediatric population.

Cystoscopy-Assisted Laparoscopic Partial Cystectomy

BACKGROUND AND PURPOSE Laparoscopic partial cystectomy is performed in selected patients with isolated diseases, such as bladder endometriosis, pheochromocytoma, leiomyoma, and malignant bladder tumors. Laparoscopic partial cystectomy is indicated for a solitary bladder tumor that is distant from the bladder neck, the ureteral orifices, and the trigone, to allow a resection margin of 1 to 2 cm. We report our experience with cystoscopy-assisted laparoscopic partial cystectomy. MATERIALS AND METHODS The bladder was mobilized adequately by laparoscopy. Intraoperative cystoscopy was performed Cystoscopic guidance was used for the initial cystotomy. Further excision of the bladder tumor with a safety margin of 1.5 to 2 cm was performed under laparoscopic vision. RESULTS Three patients underwent cystoscopy-assisted laparoscopic partial cystectomy. Cystoscopy aided in planning a proper and adequate safety margin around the tumor as well as helped in marking the initial cystotomy. CONCLUSIONS Cystoscopic assistance during laparoscopic partial cystectomy helps to properly place the initial cystotomy as well aids in planning the safety margin around the tumor. It is safe, easy, and does not add to increased operative time or morbidity.

Preoperative Stone Attenuation Value Predicts Success After Shock Wave Lithotripsy in Children

PURPOSE We determined whether stone attenuation can predict stone fragmentation after shock wave lithotripsy in the pediatric population. Previous studies show that preoperative attenuation in HU on noncontrast computerized tomography predicts shock wave lithotripsy success. To our knowledge study of this parameter in the pediatric population has been lacking to date. MATERIALS AND METHODS We performed a multi-institutional review of the records of 53 pediatric patients 1 to 18 years old who underwent shock wave lithotripsy for 3.8 to 36.0 mm renal calculi. Stone size, average skin-to-stone distance and attenuation value were determined by bone windows on preoperative noncontrast computerized tomography. Success was defined as radiographically stone-free status at 2 to 12-week followup after a single lithotripsy session without the need for further sessions or ancillary procedures. RESULTS After lithotripsy 33 patients (62%) were stone-free and 20 had incomplete fragmentation or required additional procedures. Mean ± SD stone attenuation in successfully treated patients vs those with incomplete fragmentation was 710 ± 294 vs 994 ± 379 HU (p = 0.007). Logistical regression analysis revealed that only attenuation in HU was a significant predictor of success. When patients were stratified into 2 groups (less than 1,000 and 1,000 HU or greater), the shock wave lithotripsy success rate was 77% and 33%, respectively (p <0.003). CONCLUSIONS Stone attenuation less than 1,000 HU is a significant predictor of shock wave lithotripsy success in the pediatric population. This finding suggests that attenuation values have a similar predictive value in the pediatric population as that previously reported in the adult population.

Posterior urethral injury in male children: Long-term follow up

OBJECTIVE Owing to the immature pelvis and the relative intra-abdominal position of the childs bladder, children with a posterior urethral injury differ from adults. We report our experience in the management of such injuries in male children. PATIENTS AND METHODS Children with suspected urethral injury underwent retrograde urethrography once their clinical condition was stable. Children with complete urethral injury underwent primary urethral realignment either endoscopically or by open surgical technique. Suprapubic cystostomy was performed in other children who were unfit to undergo primary realignment or in whom the management of other injuries took precedence over that of urethral injury. Children referred from elsewhere for further management of urethral injury and those with initial suprapubic cystostomy underwent delayed urethroplasty. RESULTS Twenty-two children with mean age of 11.3 years were treated at our centre for urethral injury. Seven children underwent primary endoscopic urethral realignment, five open surgical realignment and 10 initial suprapubic cystostomy followed by delayed urethroplasty. Six of the 12 children undergoing primary urethral realignment required additional endoscopic urethrotomy for managing the stricture, and three of these six children eventually underwent urethroplasty. Of the 10 children undergoing delayed urethroplasty, three required additional sessions of endoscopic urethrotomy and two of these required further correction graft urethroplasty. CONCLUSION Most male children with posterior urethral injuries need immediate realignment to prevent long-term complications.

Stone Size is Only Independent Predictor of Shock Wave Lithotripsy Success in Children: A Community Experience

PURPOSE We determined whether age, gender, body mass index, number of stones, stone location or total stone diameter could independently predict stone-free rates after extracorporeal shock wave lithotripsy in children. MATERIALS AND METHODS We reviewed 149 patients 3 to 17 years old undergoing shock wave lithotripsy between 2001 and 2008. Cases were retrieved from a regional shock wave lithotripsy database. Variables analyzed included age, gender, body mass index, number of shocks delivered, stone location, number of stones and total stone diameter. Stone-free status on followup imaging at 2 weeks to 3 months was considered a successful outcome. RESULTS Of 149 patients 32 had multiple stones. After shock wave lithotripsy 106 patients (71%) were stone-free, 12 (8%) required a repeat procedure and 31 (21%) had residual fragments. Number of stones per patient ranged from 1 to 18 (mean +/- SD 2.14 +/- 2.60). Mean +/- SD number of stones was 1.87 +/- 2.42 in successfully treated patients and 2.81 +/- 2.92 in those with treatment failure (p = 0.065). Total stone diameter ranged from 2 to 90 mm (mean +/- SD 14.03 +/- 16.68). Mean total stone diameter was 11.1 +/- 13.4 mm in successfully treated patients and 21.3 +/- 21.4 mm in those with treatment failure (p <0.005). CONCLUSIONS To our knowledge we present the first multi-institutional cohort study in children demonstrating no significant relationship between successful outcome and patient age, gender, body mass index, stone location or number of stones. Only total stone diameter independently predicted shock wave lithotripsy success.

Genital self-mutilation in nonpsychotic heterosexual males: Case report of two cases

Genital self-mutilation is a rare event that is commonly associated with psychotic disorders. However such injuries have also been reported from nonpsychotic patients as a result either from bizarre autoerotic acts, attempts at crude sex change operation by transsexuals or secondary to complex religious beliefs and delusions regarding sexual guilt. We report two cases of genital self-mutilation in nonpsychotic married heterosexual males as a result of conflict and frustration.

Complex Cloacal Anomaly in Discordant Monozygotic Twins

Urorectal septum malformation sequences are rare congenital malformations. We report a case of persistent cloaca prenatally diagnosed at 26 weeks of gestation in 1 of a set of discordant monozygotic twins. The affected fetus at birth had a phallus-like structure, bladder outlet obstruction, an imperforate anus, and uterine distension. Diverting colostomy, vesicostomy, and percutaneous colpostomy tube were initially placed before definitive posterior sagittal anorectovaginoplasty was completed. A cloacal anomaly occurring in only 1 of a set of monozygotic twins is an exceedingly rare event.