John M. Gatti

The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis

The evaluation and management of fetuses/children with antenatal hydronephrosis (ANH) poses a significant dilemma for the practitioner. Which patients require evaluation, intervention or observation? Though the literature is quite extensive, it is plagued with bias and conflicting data, creating much confusion as to the optimal care of patients with ANH. In this article, we summarized the literature and proposed recommendations for the evaluation and management of ANH.

Laparoscopic Versus Open Pyeloplasty in Children: Preliminary Report of a Prospective Randomized Trial

PURPOSE Pyeloplasty for ureteropelvic junction obstruction in children has traditionally been performed using an open technique. Although laparoscopic pyeloplasty has been shown to be comparable and possibly superior to open pyeloplasty in adult studies, such results in the pediatric population are limited. We evaluated outcomes between transperitoneal laparoscopic and open pyeloplasty in children. MATERIALS AND METHODS All children 1 to 18 years old with ureteropelvic junction obstruction requiring operative repair were offered enrollment in the study. Patients were prospectively randomized to either transperitoneal laparoscopic or open pyeloplasty through a flank incision. RESULTS We reviewed 20 patients (mean age 7.8 years) who underwent laparoscopy and 19 (7.2 years) who underwent open surgery (p = 0.48). Mean followup was similar between the groups (laparoscopic 8.1 months vs open 11.1 months, p = 0.38). Mean operative time was 151 minutes (range 94 to 213) for laparoscopy and 130 minutes (83 to 225) for open surgery (p = 0.09). Mean hospitalization was 29.3 hours (range 20.5 to 48) for laparoscopy and 36.2 hours (24 to 73) for open surgery (p = 0.06). Analgesic usage was similar between the groups. One failure in the open arm required a revision. Operative, hospital, anesthetic and total charges were similar between the groups. CONCLUSIONS Laparoscopic pyeloplasty appears to be a safe and effective alternative to open pyeloplasty in children. Although the cost is similar, there is a trend toward longer operative times in the laparoscopic group but a shorter overall hospitalization. As more patients are enrolled in the study, these differences may prove significant.

Extracorporeal shock wave lithotripsy for renal calculi.

PURPOSE To gain better understanding of ESWL efficacy in children with renal calculi we report our outcomes using this technique. MATERIALS AND METHODS We reviewed the records of children who underwent ESWL as monotherapy for renal calculi at our institution from 1988 to 2007. Data included clinical characteristics, stone-free rate and its relationship to stone size and location, lithotriptor and complications. RESULTS The 33 boys and 29 girls with an average age of 10 years underwent a total of 69 treatments. A 53% and 63% stone-free rate was achieved after 1 and 2 ESWL sessions, respectively. A trend toward a higher stone-free rate (61% to 70%) after 1 ESWL session was seen in children with stones less than 50 mm(2), renal pelvic stones and treatment with the Dornier HM3 lithotriptor. Children with stones greater than 100 mm(2), a caliceal location and those treated with the Dornier MFL 5000 lithotriptor had a higher failure rate (25% to 46%). Five patients (8%) required ureteroscopy after ESWL due to retained distal ureteral stone fragments. Five patients (8%) who were not stone-free after therapy required subsequent endoscopic treatment for the stone during followup. CONCLUSIONS Smaller renal stones, renal pelvic calculi and treatment with an older generation lithotriptor were independent variables associated with a higher stone-free rate in children. While ESWL is a simple method in children with renal calculi, those with large or caliceal stones may do best with a primary endoscopic approach.

Management of urethral diverticulum complicating hypospadias repair

BACKGROUND Urethral diverticula can occur after hypospadias repair, and may lead to stone formation, incomplete voiding, infection, postvoid dribbling, haematuria and other problems. We previously reviewed our experience with hypospadias complications. We separately analyzed those patients who developed urethral diverticula to attempt to identify predisposing factors and appropriate management strategies. PATIENTS AND METHODS We reviewed the available medical records and charts of 123 patients undergoing re-operation for hypospadias complications at The Childrens Mercy Hospital from 1 May 1984 until 1 January 2003. Hypospadias cripples, traumatic fistulae, complications after circumcision and true intersex patients were excluded. RESULTS Diverticula accounted for 11% of all complications (13 patients). The patients with diverticula were more likely to have perineal/proximal hypospadias. The initial repair was island tube urethroplasty in five, island onlay urethroplasty in seven and bladder mucosal graft in one child. The repair of the diverticulum in one stage was successful in 10 of the 13 patients. There was one recurrent diverticulum and two fistulas. A stricture was present in only one of the 13 patients but was detected overall in 14 of the 123 patients (11%). CONCLUSION Diverticula are uncommon after hypospadias repair, accounting for 11% of all complications in the present series. The stricture was not causative in 12 of 13 children. Repair of the diverticulum was successful after one attempt in 10 of 13 patients. The management of this complication is discussed.

Laparoscopic vs Open Pyeloplasty in Children: Results of a Randomized, Prospective, Controlled Trial

Purpose: Open dismembered pyeloplasty is the preferred repair for ureteropelvic junction obstruction. Minimally invasive techniques have been applied to the original open approach but no clear advantage has been demonstrated for these technological advances. We evaluate outcomes between transperitoneal laparoscopic and open pyeloplasty in children. Materials and Methods: All children 1 to 18 years old with ureteropelvic junction obstruction requiring operative repair were offered enrollment in the study. Patients were prospectively randomized to either laparoscopic or open pyeloplasty through a flank incision. Results: A total of 50 patients in the laparoscopic group and 48 in the open group were enrolled from 2005 to 2014. Mean followup was similar between the groups (13.7 months in the laparoscopic group vs 12.3 months in the open group, p = 0.54). The only significantly different outcomes were for mean operative time, which was 139.5 minutes (range 94 to 213) in the laparoscopic group and 122.5 minutes (83 to 239) in the open group (p <0.01), and mean length of stay, which was 25.9 hours (18 to 143) in the laparoscopic group and 28.2 hours (16 to 73) in the open group (p = 0.02). Analgesic usage, success rate, total charges and all parameters in children older than 11 years were similar between the groups. Conclusions: Open and laparoscopic dismembered pyeloplasty are comparable and effective methods for repair of ureteropelvic junction obstruction. Although operative time was statistically shorter in the open group and length of stay was shorter in the laparoscopic group, the clinical significance of these variables is questionable. The approach to repair may best be based on family preference for incision aesthetics and surgeon comfort with either approach, rather than more classically objective outcome measures.