Molly Fuchs

Robot-assisted laparoscopic extravesical ureteral reimplant: A critical look at surgical outcomes

BACKGROUND Published reports of outcomes of robot assisted laparoscopic ureteral reimplantation (RALUR) show mixed results that, on average, are inferior to open ureteral reimplant. We present a retrospective analysis of a prospective series of children who had RALUR from 2013 to June 2015. We hypothesized that surgical outcomes are based on identifiable risk variables. We provide a critical analysis of the relationship between patient characteristics and several surgical and non-surgical outcomes. METHODS We reviewed the records of children who had Robot-Assisted Laparoscopic (RAL) Ureteral Reimplant (UR) at Nationwide Childrens Hospital. Patient age and gender, preoperative presentation, presence of preoperative bladder and bowel dysfunction (BBD), VUR grade and laterality, indication for operation, operative time, surgical outcome, surgical complications, post-operative prevalence of UTI, and pre- and post-operative status of BBD were recorded. We also recorded techniques for ureteral dissection, and closing the detrusorrhaphy. Surgical outcome was defined by post-operative VCUG. We define BBD based on publications by the standardization committee of International Childrens Continence Society (ICCS). All statistical calculations were performed with STATA version 11. RESULTS We performed extravesical RALUR on 54 children for a total of 72 ureters. Overall the study children were 74% female. The mean and median age was 5.2 and 4.9 years, respectively. Mean overall hospital length of stay (LOS) was 1.64 days. The mean LOS was 1.26 for unilateral (RALUUR) and 2.39 days for bilateral (RALBUR) surgeries and was significant (p < 0.05). Overall surgical success was 85.2% of ureters and 84.7% of children. Stratified by unilateral and bilateral surgeries, unilateral success was 91.7%, and bilateral success was 77.8% of ureters, and 72.2% of children. In the 3 failures in the RALUUR group the mean postoperative VUR grade was 1.3 from a pre-op mean grade of 3.3, whereas in the RALBUR group, the mean VUR grade among the failures was 3.0 from a mean pre-op VUR grade of 3.7. Urinary leak from ureteral injury, and urinary obstruction were more common in the RALBUR group. Post-operative urinary retention occurred in 4 children in the RALBUR and none in the RALUUR groups. Four with VUR after RALBUR and one child after RALUUR had open ureteral reimplant. Post-op UTI and non-surgical readmissions were higher in the RALBUR group. CONCLUSIONS Bilateral RALUR is associated with higher failure rates, higher complication rates, higher re-operation rates, and more postoperative UTIs and nonsurgical readmissions compared with unilaterasl RALUR.

The incidence of long-term hypertension in children after high-grade renal trauma.

INTRODUCTION It is generally accepted that there is a risk of hypertension after renal trauma, particularly in high-grade and devascularizing injuries. Hypertension following renal trauma is estimated to occur in five percent of adults, however, the incidence is unknown in the pediatric population. MATERIALS AND METHODS We performed a retrospective review of all pediatric trauma patients at Primary Childrens Hospital in Salt Lake City, Utah between 2002 and 2012. We included all children age ≤17years old with American Association for Surgery of Trauma (AAST) grade 3-5 renal injury. Hypertension was defined as persistent hypertension that required anti-hypertensive medications. Our primary outcomes were incidence of hypertension during the acute trauma and in long-term follow. RESULTS A total of 62 children were identified with AAST grade 3-5 renal injuries during our study period. Follow up blood pressures were recorded in 36 (58%) of these children with a median follow of 4.1years (IQR 2.1-5.1years) after trauma. Four children (6.5%) were identified to have some degree of hypertension while hospitalized after trauma and started on anti-hypertensive medication. Two out of these four children remained on hypertensive medication at follow up, while the remaining two childrens hypertension resolved. No children who were normotensive in the immediate post-trauma period, developed delayed hypertension during long-term follow up. CONCLUSIONS There is a low risk of developing hypertension following severe renal trauma in the pediatric population. Patients who develop long-term problems with hypertension after renal trauma manifest it during the initial hospitalization, rather than subsequently during the long-term.

Factors Predicting Complications After Sacral Neuromodulation in Children

OBJECTIVE To identify if any preoperative variables are associated with postoperative complications after pediatric sacral neuromodulation (SNM). MATERIALS AND METHODS A review of all patients undergoing SNM with an implantable pulse generator at our institution was performed. Postoperative infection, lead migration, lead breakage, and need for reoperation were recorded in a prospective database. We collected demographic information and indication for the procedure. We defined indication for procedure as either primarily bowel or primarily bladder symptoms. Multivariate analysis was used to determine any associations between preoperative factors and postoperative complications. RESULTS Sixty-three children (34 females, 29 males) underwent SNM from 2012 to 2015. Mean age was 11.5 years, and body mass index (BMI) was 51st percentile for age. SNM was placed for primarily bowel symptoms in 49% and for primarily bladder symptoms in 51%. Follow-up was 1.9 years (0.19-4.3). Reoperation was required in 25%, with mean time to reoperation of 10.9 months (0.9-31.5). Lead migration occurred in 17.4%, and wound infection in 8%. There were no significant associations between patient age, gender, or BMI, and need for reoperation, wound infection, or lead migration. Low BMI had no increased risk of lead complications (P = .115). There was a significant increase in lead migration in the children who underwent SNM for primarily bladder symptoms (P = .0034). CONCLUSION There is no association between age, gender, or BMI and postoperative complications in this large cohort of pediatric SNM. Children with primarily bladder symptoms may have higher rate of lead complications for unclear reasons.

Cloaca reconstruction: a new algorithm which considers the role of urethral length in determining surgical planning

BACKGROUND Cloacal malformations represent a uniquely complex challenge for surgeons. The surgical approach to date has been based on the common channel (CC) length with two patient groups considered: less than or greater than 3cm, which we believe is an oversimplification. We reviewed 19 patients, referred after surgery done elsewhere. Eight had postoperative urinary complications, 3 had constant urinary leakage and had been left after surgery with a urethra <1cm, .5 with an original 3 to 5cm common channel, who had undergone total urogenital mobilization (TUM), experienced peri-operative urethral loss needing a vesicostomy, and later, a Mitrofanoff. These patients together with a review of the cloacal and urological literature led us to design a new algorithm where urethral length is a key determinant for care. METHODS We prospectively collected data on 31 consecutive cloaca patients referred to our team (2014 to 2016) and managed according to this new protocol. The CC length, urethral length, surgical technique employed, and initial outcomes were recorded. RESULTS Of 31 primary cases, CC length was 1 to 3cm in 20, 3 to 5cm in 9, and greater than 5cm in 2. In the 1 to 3cm and the 3 to 5cm groups, a urethra less than 1.5cm led us to perform an urogenital separation. We only performed a TUM if the urethra was greater than 1.5cm. Using this protocol, we performed a urogenital separation in 1 of 20 in the 1 to 3cm CC group, 6 of 9 in the 3 to 5cm CC group, and 2 of 2 in the greater than 5cm CC group. Seven patients underwent separation, who with the previous approach, would have had a TUM. Thus far, no urinary leakage or urethral loss has occurred in any patient, but follow-up is less than 3years. CONCLUSION Urethral length appears to be a vitally important component in cloacal reconstruction. A short urethra left after repair can lead to urinary leakage. A TUM done under the wrong circumstances can lead to urethral loss. We describe a new technical approach to cloacal repair which considers urethral length but recognize that long term urological outcomes will need to be carefully documented. TYPE OF STUDY Clinical cohort study with no comparative group. LEVEL OF EVIDENCE Level 4.

Intraoperative Onabotulinumtoxin-A Reduces Postoperative Narcotic and Anticholinergic Requirements After Continent Bladder Reconstruction

OBJECTIVE To determine if intradetrusor injection of onabotulinumtoxin-A (BTX-A) would reduce postoperative narcotic and anticholinergic requirements in children undergoing open continent bladder reconstruction. MATERIALS AND METHODS After institutional review board approval, we retrospectively reviewed all bladder reconstructions performed. Bladder reconstruction was defined as the following procedures in any combination: bladder neck reconstruction and sling, bladder neck closure, Mitrofanoff, Monti, or bladder augmentation. We identified 15 children who underwent reconstruction with BTX-A injection and compared these with 15 children who did not receive BTX-A. Postoperative narcotic and anticholinergic requirements were recorded as well as length of stay, time to diet, time to return of bowel function, and complications. All medications were converted to morphine mEq/kg per day or mg/kg per day to standardize for patient size and length of stay. RESULTS Thirty patients who underwent open bladder reconstruction were included. Fifteen received BTX-A injection and 15 did not. The BTX-A group required significantly less narcotic medication postoperatively compared with the no-BTX-A group (0.32 vs 0.85 morphine mEq/kg per day; P = .0002). The BTX-A group also required significantly less anticholinergic medication compared with the no-BTX-A group (0.22 vs 0.88 mg/kg per day; P = .024). There was no significant difference between the groups with respect to length of stay (98.27 vs 9.287 days; P = .34) or return of bowel function (5.53 vs 4.93 days; P = .994). Complication rate between the groups was similar (P >.99). CONCLUSION Intraoperative injection of BTX-A significantly reduced postoperative narcotic and anticholinergic requirements in patients who underwent open continent bladder reconstruction. This is an encouraging alternative treatment to manage postoperative pain with no associated risk of significant complications.

A descriptive model for a multidisciplinary unit for colorectal and pelvic malformations

INTRODUCTION Patients with anorectal malformations (ARM), Hirschsprung disease (HD), and colonic motility disorders often require care from specialists across a variety of fields, including colorectal surgery, urology, gynecology, and GI motility. We sought to describe the process of creating a collaborative process for the care of these complex patients. METHODS We developed a model of a devoted center for these conditions that includes physicians, psychologists, social workers, nurses, and advanced practice nurses. Our weekly planning strategy includes a meeting with representatives of all specialties to review all patients prior to evaluation in our multidisciplinary clinic, followed by combined exams under anesthesia or surgical intervention as needed. RESULTS There are 31 people working directly in the Center at present. From the Centers start in 2014 until 2017, 1258 patients were cared for from all 50 United States and 62 countries. 360 patients had an ARM (110 had a cloacal malformation, 11 had cloacal exstrophy), 223 presented with HD, 71 had a spinal malformation or injury causing neurogenic bowel, 321 had severe functional constipation or colonic dysmotility, and 162 had other diagnoses including familial polyposis, Crohns disease, or ulcerative colitis. We have had 170 multidisciplinary meetings, 170 multispecialty outpatient, and 52 nurse practitioner clinics. In our bowel management program we have seen a total of 514 patients in 36 sessions. CONCLUSION This is the first report describing the design of a multidisciplinary team approach for patients with colorectal and complex pelvic malformations. We found that approaching these patients in a collaborative way allows for combined medical and surgical decisions with many providers simultaneously, facilitates therapy, and can potentially improve patient outcomes. We hope that this model will help establish new-devoted centers in other locations to encourage centralized care for these rare malformations. LEVEL OF EVIDENCE IV.

Can sacral development as a marker for caudal regression help identify associated urologic anomalies in patients with anorectal malformation

BACKGROUND AND AIM The sacral ratio (SR) is a well-established tool to quantify sacral development in patients with anorectal malformations (ARM) and can be used as a predictor of fecal continence. We hypothesized that a lower SR correlated with the presence of urologic and renal malformations. METHODS We retrospectively reviewed the medical records of patients with ARM treated at our center from 2014 to 2016. We measured the lateral SR as a marker for sacral development and assessed the spine for the presence of tethered cord (TC). Urological and renal anomalies, including single kidney, hydronephrosis, hypospadias, vesicoureteral reflux (VUR), ectopic ureter, and penoscrotal transposition were assessed. Analysis of variance (ANOVA), t-tests, and multivariable linear regression were used to test for differences in SR with consideration of associated urologic malformations and tethered cord. RESULTS 283 patients with ARM were included for analysis (156 females). The median age was 39months (10-90). Among these, 178 (55.6%) had 1 or more urologic malformations, and 81 (25.3%) had a TC. Hydronephrosis, high-grade VUR (3-5), solitary kidney, and tethered cord were significantly associated with lower SR (p<0.01). In multivariable regression models, the presence of urologic abnormalities remained significantly associated with lower a SR despite the presence or absence of TC (p<0.001). CONCLUSION SR is a potentially useful indicator of certain urologic anomalies including hydronephrosis, high grade VUR, and solitary kidney in patients with ARM. This association is independent of the presence of TC. A sacral ratio as a part of the VACTERL screening can help the surgeon identify which patients need closer urologic follow up. LEVEL OF EVIDENCE IV.

Simultaneous Robotic-Assisted Laparoscopy for Bladder and Bowel Reconstruction

INTRODUCTION Patients with neurogenic bladder frequently also have bowel dysfunction and a simultaneous urologic and colorectal reconstruction is possible. We present our experience with combined reconstructive procedures using robot-assisted laparoscopy, and demonstrate the utility of a minimally invasive approach that considers both the bowel and bladder management of these patients. METHODS We retrospectively reviewed all patients who underwent combined bowel and urologic reconstruction at our institution since the start of our multidisciplinary robotic program. RESULTS Seven patients were identified in our cohort with a mean age of 6.4 years (3.8-10.1 years). Six patients had myelomeningocele and 1 had caudal regression. Malone appendicostomies were placed in all 7 patients. A split appendix technique was used as a conduit in 5 patients, in situ appendix in 1, and neoappendicostomy with cecal flap in 1. Six patients had a Mitrofanoff appendiceal conduit created, while 1 patient had a sigmoid colovesicostomy for urinary diversion. Five patients required bladder neck repair. One patient had stenosis of the Mitrofanoff and one patient had an anastomotic leak of the sigmoid anastomosis. The average operating time was 526 minutes (313-724 minutes). The median length of stay (LOS) was 5 days (4-7 days), excluding one outlier who suffered an anastomotic leak and had an extended LOS (50 days). All patients who underwent continent bladder reconstruction are dry on their current catheterizing regimen, 6/7 are clean with antegrade flushes. CONCLUSION Patients with neurogenic bladder often have coexisting bowel dysfunction, which provides an opportunity to reconstruct both organ systems simultaneously and achieve social urinary and bowel continence. Before committing to any intervention, the surgeon should consider both the urologic and gastrointestinal needs of the patient, and perform the needed procedures simultaneously. We describe a number of combined operations aimed at bowel and bladder management that can be performed safely using robot-assisted laparoscopy.

Urinary Outcomes in Patients with Down's Syndrome and Hirschsprung's Disease

INTRODUCTION  Previous research in children with Hirschsprungs disease (HD) and Downs syndrome (DS) has focused on colorectal outcomes. We set out to review urinary outcomes in this patient group. METHODS  The medical records of all patients aged five years and older with HD were reviewed, and patients and caregivers filled out the Vancouver Symptom Score at intake, which is designed and validated to diagnose dysfunctional elimination syndrome. RESULTS  A total of 104 patients with HD were included in this study. Of these, 16 (15%) patients had DS. There were no significant differences in the prevalence of enterocolitis or colorectal symptoms between patients with or without DS. Five of 88 (6%) patients without DS and 7 of 16 (44%) (p = 0.00001) with DS reported having urinary accidents. Patients with HD and DS scored higher on the Vancouver score (9 vs. 17.5; p = 0.007), indicating more severe urinary symptoms. Patients who also reported fecal accidents scored significantly higher on the Vancouver (12 vs. 9; n = 61; p = 0.016), indicating more problems. CONCLUSION  Patients with DS appear to be a unique subset of HD patients who have a higher prevalence of urinary symptoms after surgery. In the postoperative care of patients with HD and DS, a strong focus should be placed on postoperative urinary care in addition to their bowel care. This could significantly ease care and contribute to the quality of life of the parents and the patient.

Cystic Dysplasia of the Testis in an Intraabdominal Undescended Testicle

Cystic dysplasia of the testis is a rare, benign pathologic finding. We present two recent cases of cystic dysplasia of the testis to our practice. The first case involves an 11 month old male presenting with a non-palpable, intra-abdominal left testis. The second case involves a 7 year old male with left scrotal swelling and a history of left renal agenesis. After review of the literature, the first case represents the first report of cystic dysplasia of the testis in an undescended, intra-abdominal testicle.