Jason Au

Fetal lower urinary tract obstruction: proposal for standardized multidisciplinary prenatal management based on disease severity

To present a single center experience of a standardized prenatal multidisciplinary management protocol for fetal lower urinary tract obstruction (LUTO) and to propose a classification of fetal LUTO based on disease severity.

Defining and predicting ‘intrauterine fetal renal failure’ in congenital lower urinary tract obstruction

BackgroundThe aim of this study was to identify predictors of ‘intrauterine fetal renal failure’ in fetuses with severe congenital lower urinary tract obstruction (LUTO).MethodsWe undertook a retrospective study of 31 consecutive fetuses with a diagnosis of LUTO in a tertiary Fetal Center between April 2013 and April 2015. Predictors of ‘intrauterine fetal renal failure’ were evaluated in those infants with severe LUTO who had either a primary composite outcome measure of neonatal death in the first 24xa0h of life due to severe pulmonary hypoplasia or a need for renal replacement therapy within 7 days of life. The following variables were analyzed: fetal bladder re-expansion 48xa0h after vesicocentesis, fetal renal ultrasound characteristics, fetal urinary indices, and amniotic fluid volume.ResultsOf the 31 fetuses included in the study, eight met the criteria for ‘intrauterine fetal renal failure’. All of the latter had composite poor postnatal outcomes based on death within 24xa0h of life (nu2009=u20096) or need for dialysis within 1xa0week of life (nu2009=u20092). The percentage of fetal bladder refilling after vesicocentesis at time of initial evaluation was the only predictor of ‘intrauterine fetal renal failure’ (cut-off <27xa0%, area under the time–concentration curve 0.86, 95 % confidence interval 0.68–0.99; pu2009=u20090.009).ConclusionWe propose the concept of ‘intrauterine fetal renal failure’ in fetuses with the most severe forms of LUTO. Fetal bladder refilling can be used to reliably predict ‘intrauterine fetal renal failure’, which is associated with severe pulmonary hypoplasia or the need for dialysis within a few days of life.

Standardized process to improve patient flow from the Emergency Room to the Operating Room for pediatric patients with testicular torsion

BACKGROUNDnTesticular torsion (TT) remains one of the most common urological emergencies. The length of time from onset of symptoms to detorsion and degree of spermatic cord twisting are usually the most important factors for testicular damage. Therefore early presentation, accurate diagnosis, and prompt treatment are important factors for optimizing the testicular salvage rate. While delay in seeking medical attention is a common cause of testicular loss in pediatric patients with testicular torsion, delays in diagnosis and treatment can be preventable causes of testicular loss.nnnOBJECTIVEnIn this study, we aimed to develop a standardized process to improve the patient flow from the Emergency Room (ER) to Operating Room (OR) for TT patients in an academic childrens hospital.nnnSTUDY DESIGNnThirty consecutive pediatric patients with acute testicular torsion between November 2013 and July 2014 served as the control group. A scrotal pain checklist was implemented in July 2014, and 30 consecutive patients from July 2014 until April 2015 served as the study group. Perioperative parameters including times, ultrasound (US) findings, and surgical results were reviewed.nnnRESULTSnThe mean ages of the control group and the study group were similar (12.3xa0±xa04.9 years and 11.5xa0±xa05 years, respectively) (pxa0=xa00.575). ER arrival to OR time, triage completion to OR time, and scrotal US to OR time were significantly decreased in the study group (pxa0<xa00.001) (Table). Although triage time and ER arrival to scrotal US times were decreased in the study group, the differences were not significant (pxa0=xa00.071, pxa0=xa00.112, respectively).nnnDISCUSSIONnUtilizing scoring tools during the triage of patients with scrotal pain can help identify high-risk patients earlier and prevent unnecessary use of resources in an ER serving a large pediatric population. Limitations of this pilot study include the limited number of patients and the potential for the Hawthorne effect (staff awareness of the study). Additionally, we did not examine scrotal pain checklist scores for other acute scrotal diseases. This study focused on a quality improvement process for TT patients, in order to reduce ER to OR times.nnnCONCLUSIONnA standardized process with use of a scrotal pain checklist and prompt communication between the ER, Urology, and Radiology teams led to significantly reduced times from the ER to the OR. Standardized processes for pediatric patients with testicular torsion may help to improve testicular survival rates.

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

OBJECTIVEnWe 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.nnnMETHODSnWe 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.nnnRESULTSnPostoperatively, 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.nnnCONCLUSIONnRAL 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.

Influence of the neural microenvironment on prostate cancer

Nerves are key factors in prostate cancer (PCa), but the functional role of innervation in prostate cancer is poorly understood. PCa induced neurogenesis and perineural invasion (PNI), are associated with aggressive disease.

Urologic Outcomes of Children With Hemorrhagic Cystitis After Bone Marrow Transplant at a Single Institution

OBJECTIVEnTo analyze clinical outcomes and the risk factors associated with genitourinary (GU) morbidity and mortality in children who present with hemorrhagic cystitis (HC) after bone marrow transplant (BMT).nnnMETHODSnA retrospective chart review of patients with HC who had undergone BMT at a single pediatric hospital from 2008 to 2015 was conducted. Demographic data, severity of hematuria, HC management, and mortality were analyzed. Bivariate analysis and binary logistic regression were performed to identify risk factors.nnnRESULTSnOut of 43 patients who met inclusion criteria, 67.4% were male with a median age at BMT of 10.2 years (interquartile range 5.8-14.6). Percutaneous nephrostomy catheters were inserted in 5 patients for urinary diversion. All-cause mortality was 32.6% (Nu2009=u200914). Intravesical retroviral therapy (Pu2009<.001), HC grade (Pu2009<.001), total Foley time (Pu2009<.001), total gross hematuria time (Pu2009<.001), total days hospitalized (Pu2009=u2009.012), and days to most improved hematuria (Pu2009=u2009.032) were associated with significant GU morbidity on bivariate analysis. On multivariable analysis, days to most improved hematuria was associated with significant GU morbidity odds ratio of 1.177 (1.006-1.376) (Pu2009=u2009.042). Status of percutaneous nephrostomy was not associated with increased mortality (Pu2009=u2009.472); however, in the multivariate model, BK viremia (Pu2009=u2009.023), need for renal dialysis (Pu2009=u2009.003), and presence of Foley catheter (Pu2009=u2009.005) were associated with increased mortality.nnnCONCLUSIONnChildren with HC after BMT fall in a very high-risk category with high mortality and significant GU morbidity. The presence of a Foley catheter, need for dialysis, and BK viremia are associated with increased mortality.

Imaging characteristics associated with failure of nonoperative management in high-grade pediatric blunt renal trauma

INTRODUCTIONnSome children who sustain high-grade blunt renal injury may require operative intervention. In the present study, it was hypothesized that there are computed tomography (CT) characteristics that can identify which of these children are most likely to need operative intervention.nnnMATERIALS AND METHODSnA retrospective review was performed of all pediatric blunt renal trauma patients at a single level-I trauma center from 1990 to 2015. Inclusion criteria were: children with American Association for the Surgery of Trauma (AAST) Grade-IV or V renal injuries, aged ≤18 years, and having available CT images with delayed cuts. The CTs were regraded according to the revised AAST grading system proposed by Buckley and McAninch in 2011. Radiographic characteristics of renal injury were correlated with the primary outcome of any operative intervention: ureteral stent, angiography, nephrectomy/renorrhaphy, and percutaneous nephrostomy/drain.nnnRESULTSnOne patient had a Grade-V injury and 26 patients had Grade-IV injuries. Nine patients (33.3%) underwent operative interventions. Patients in the operative intervention cohort were more likely to manifest a collecting system filling defect (Pxa0=xa00.040) (Fig. A) and lacked ureteral opacification (Pxa0=xa00.010). The CT characteristics, including percentage of devascularized parenchyma, medial contrast extravasation, intravascular contrast extravasation, perirenal hematoma distance and laceration location, were not statistically significant. Of the 21 patients who had a collecting system injury, eight (38.1%) needed ureteral stents. Renorrhaphy was necessary for one patient. Although the first operative intervention occurred at a median of hospital day 1 (range 0.5-2.5), additional operative interventions occurred from day 4-16. Thus, it is prudent to closely follow-up these patients for the first month after injury. Two patients with complex renal injuries had an accessory renal artery resulting in well-perfused upper and lower pole fragments, and were managed nonoperatively without readmission (Fig. B).nnnCONCLUSIONSnCollecting system defects and lack of ureteral opacification were significantly associated with failure of nonoperative management. A multicenter trial is needed to confirm these findings and whether nonsignificant CT findings are associated with operative intervention. In the month after renal injury, these patients should be mindful of any changes in symptoms, and maintain a low index of suspicion for an emergency room visit. For the physician, close follow-up and appropriate counseling of these high-risk patients is advised.

MP52-07 DOES THE USE OF 5 MM INSTRUMENTS AFFECT THE OUTCOMES OF ROBOT-ASSISTED LAPAROSCOPIC PYELOPLASTY IN SMALLER WORKING SPACES? A COMPARATIVE ANALYSIS OF INFANTS AND OLDER CHILDREN

INTRODUCTION AND OBJECTIVES: Near-infrared fluorescence (NIRF) technology in robotic surgery allows visualization of tissue fluorescence after giving intravenous indocyanine green (ICG). While this technology has been available for five years and has been adopted for perfusion assessment, it has not been widely adopted for achieving differential fluorescence (DF) of normal kidney versus tumors during robotic partial nephrectomy (RPN). Normal kidney fluoresces with NIRF due to bilitranslocase transport of ICG into proximal tubule cells while most renal tumors, including most renal cell carcinomas (RCC), should not fluoresce. This differential fluorescence of normal kidney and RCC allows better visualization of tumor edges and visual assessment of margins during and after tumor resection with fluorescence confirming a grossly negative margin. Most surgeons have abandoned using NIRF for DF citing inability to reliably achieve fluorescence of the kidney and not the tumor. While the dose of ICG is not critical when used to assess perfusion, improper ICG dosing will cause the tumor to fluoresce and make it indistinguishable from normal kidney. We developed an ICG dosing regimen providing reliable DF in most cases and report our success with NIRF. METHODS: RPN was performed with NIRF imaging in 253 tumors, the largest reported experience to date. Intraoperative assessment of tumor fluorescence was prospectively recorded at the time of surgery by the surgeon before pathologic assessment of tumors. The ICG dosing regimen included test doses beginning as low as 0.25cc to avoid overdosing and panfluorescence. RESULTS: Mean age was 58yrs (26-89) with mean body mass index of 32kg/m2 (18-63). Mean tumor size on imaging was 3.4cm (0.79.7) with mean R.E.N.A.L. nephrometry score of 7.3 (4-11), including 32 hilar tumors and 164 tumors >50% endophytic. Mean operative time was 170min. Among all 253 tumors, DF was successfully achieved in 217 (86%). Among 36 tumors that undesirably fluoresced, 8 were oncocytomas and 4 were chromophobe RCC, which are both known to express bilitranslocase, with 4 angiomyolipomas. Among 25 oncocytomas, 8 fluoresced such that DF was only successful in 68% of oncocytomas. Among 209 RCCs, 186 did not fluoresce (89%). Only 1 positive margin occurred (0.4%). CONCLUSIONS: Robotic NIRF imaging was highly reliable (89%) in visualizing DF of RCC versus normal parenchyma but less so in oncocytomas as expected. Further study is needed to determine whether this contributed to the <1% positive margin rate.

A Case of Bilateral Cystic Partially Differentiated Nephroblastoma vs Cystic Wilms' Tumor: Highlighting a Diagnostic Dilemma.

Cystic partially differentiated nephroblastoma (CPDN) is a rare multicystic renal tumor along the spectrum of cystic nephroma and cystic Wilms tumor. There have only been two previously reported cases of bilateral CPDN in the literature. We present here a case of bilateral CPDN vs cystic Wilms tumor treated with neoadjuvant and adjuvant chemotherapy in addition to a bilateral partial nephrectomy. We also review the relevant literature regarding CPDN in an effort to aid in diagnosis and management of these rare cystic renal tumors.

Animal bite of genitalia in a child: A rare case of anterior urethral injury

Pediatric genital injuries are relatively uncommon. Urethral injuries occur in 3.4% of genitourinary injuries in children. The majority of urethral injuries in boys are to the anterior urethra. We review the diagnosis and management of anterior urethral injuries in the setting of a dog bite to the genitalia in child.