Pasquale Casale

Laparoscopic Pyeloplasty in the Infant Younger Than 6 Months—Is it Technically Possible?

PURPOSE Laparoscopic dismembered pyeloplasty is an acceptable option for UPJ obstruction in the pediatric population. We report our initial experience with this approach in infants. MATERIALS AND METHODS Eight infants 3 to 5 months old (mean 4.5) underwent transperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction. All patients underwent dismembered pyeloplasty with renal pelvis tapering. Two patients underwent concomitant pyelolithotomy and 1 underwent contralateral nephrectomy. Outcome measures included operative time, length of hospital stay, and resolution of obstruction by ultrasonography and DRI. RESULTS Mean operative time was 1.8 hours for the pyeloplasty portion. Mean hospital stay was 1.2 days. The stent was removed 6 weeks postoperatively in all patients except 1. This patient, 1 of the 2 patients who underwent concomitant pyelolithotomy, had development of a new stone while the stent was still indwelling. Laparoscopic pyeloplasty resulted in 100% resolution of UPJ obstruction in this series. CONCLUSIONS We believe that laparoscopic dismembered pyeloplasty is technically possible in infants younger than 6 months.

Pediatric Flexible Ureteroscopic Lithotripsy: The Children's Hospital of Philadelphia Experience

PURPOSE Therapeutic options currently available for urinary stones include shock wave lithotripsy, percutaneous nephrolithotomy and ureteroscopic treatment. While these treatment options have become the standard of care in the adult population, the same has not necessarily been applied to the pediatric population, despite an increasing prevalence of stone disease in children. We report our flexible ureteroscopic experience with urinary stones in children. MATERIALS AND METHODS A total of 170 ureteroscopic treatments were performed. Demographic information was collected. Stone burden was measured in millimeters. Operative access, operative times, intraoperative complications, stone-free status and postoperative complications were evaluated. RESULTS A total of 167 children (89 boys and 78 girls) underwent 170 ureteroscopic procedures for urinary calculi. Mean patient age was 62.4 months at the time of the procedure (range 3 to 218). Mean followup was 19.7 months (range 6 to 39). Mean stone burden was 6.12 mm (range 3 to 24), with an average of 1.3 stones per patient. Retrograde access could not be obtained in 95 of the children (57%). No ureters were actively dilated. Flexible ureteroscopy was performed in all cases regardless of stone location. Stone clearance was 100% for stone burdens 10 mm or less and 97% for burdens greater than 10 mm after 1 ureteroscopy. CONCLUSIONS Pediatric ureteroscopy is a safe and efficacious modality in the treatment of all upper urinary tract calculi, including lower pole calculi.

Prospective long-term analysis of nerve-sparing extravesical robotic-assisted laparoscopic ureteral reimplantation.

OBJECTIVE To prospectively review our experience with extravesical robotic-assisted laparoscopic ureteral reimplantation to determine whether postoperative voiding dysfunction can be avoided with pelvic plexus visualization and to assess the efficacy of this approach for the treatment of vesicoureteral reflux (VUR). METHODS We prospectively followed 150 patients who underwent bilateral extravesical robotic-assisted laparoscopic ureteral reimplantation by a single surgeon at an academic institution. Each patient was followed for a 2-year period. All 150 patients had primary VUR of grade 3 or greater bilaterally, with 127 having parenchymal defects found on renal scans. All patients were toilet trained before surgical intervention. The operation was performed with an extravesical transperitoneal approach with robotic assistance using the daVinci Surgical System. All patients underwent voiding cystourethrography at 3 months postoperatively to document the resolution of VUR. Voiding dysfunction was assessed in each patient by uroflow, postvoid residual urine volume, and a validated questionnaire. RESULTS The operative success rate was 99.3% for VUR resolution on voiding cystourethrography. One patient with bilateral grade 5 VUR that was downgraded to unilateral grade 2 VUR was considered to have treatment failure. This patient ultimately underwent subsequent subureteral injection therapy after an episode of pyelonephritis. No patient experienced de novo voiding dysfunction. CONCLUSION Bilateral nerve-sparing robotic-assisted extravesical reimplantation has the same success rate as the traditional open approaches, with minimal morbidity and no voiding complications in our series.

Robotic pediatric urology

The number of current advances in robotic surgery for the pediatric population is growing every day: the different procedures range from extirpative to reconstructive, including pyeloplasty, reimplantation, catheterizable channels and augmentation. Despite its early success, robotic surgery still poses many challenges in pediatric patients. Robotics also allows the seasoned laparoscopist to become more proficient and refined, providing a greater armamentarium to expand minimally invasive surgery to more complex reconstructive procedures. The procedure most performed with the da Vinci® Surgical System in pediatric urology is pyeloplasty for ureteropelvic junction obstruction. There are many other procedures that can be performed with the robot, such as ureteral reimplantation, and nephrectomy, both total and partial. The reconstructive aspect has been taken to the next level where more difficult procedures, such as appendicovesicostomy and bladder augmentation, can be performed in children.

Robotic Ureterocalicostomy in the Pediatric Population

PURPOSE Ureterocalicostomy is a potential option in patients with ureteropelvic junction obstruction and significant lower pole calicectasis. It is often reserved for patients with a failed pyeloplasty and a minimal pelvis, or patients with an exaggerated intrarenal pelvis. We present our technique of robotic ureterocalicostomy in the pediatric population as a primary modality for an exaggerated intrarenal collecting system not amenable to standard dismembered pyeloplasty, and for secondary ureteropelvic junction obstruction. MATERIALS AND METHODS Nine patients 3 to 15 years old (mean age 6.5) underwent transperitoneal robotic ureterocalicostomy for ureteropelvic junction obstruction. Six of the patients had recurrent ureteropelvic junction obstruction after primary pyeloplasty performed elsewhere. The remaining 3 patients had an exaggerated intrarenal collecting system with minimal or no appreciable renal pelvis for reconstruction. Outcome measures included operative time, length of hospital stay and postoperative ultrasound at 3 months, as well as resolution of obstruction by diuretic radionuclide imaging at 6 and 12 months of followup. RESULTS Mean operative time was 168 minutes (range 102 to 204) for the ureterocalicostomy portion. Two patients underwent concomitant pyelolithotomy, with 14 and 21 minutes added to the operative time. Mean hospital stay was 21 hours (range 17 to 26). Diuretic radionuclide imaging, which was performed in all patients at 6 and 12 months postoperatively, revealed no evidence of obstruction in any patient. CONCLUSIONS Robotic ureterocalicostomy is a viable and technically feasible treatment option for patients with recurrent ureteropelvic junction obstruction, or patients with difficult intrarenal ureteropelvic junctions.

Testicular Compartment Syndrome: A New Approach to Conceptualizing and Managing Testicular Torsion

OBJECTIVES Decompression of compartment syndrome is known to salvage tissues in numerous organ systems. To demonstrate evidence that testes exposed to prolonged ischemia exhibit compartment syndrome physiology and propose a novel technique in treating this phenomenon. METHODS Three boys, aged 11, 14, and 16 years, with prolonged testicular torsion lasting 6-7 hours were taken to the operating room. All testes appeared dusky and congested on manual detorsion. Testicular fasciotomy was performed by making a longitudinal incision in the tunica albuginea. The coloration of all testes improved dramatically. When the tunica albuginea was reapproximated, each testis returned to an ischemic appearance. The tunica albuginea was again opened. A harvested tunica vaginalis patch was placed over the exposed seminiferous tubules and secured in place. In the case of the 11-year-old boy, a handheld compartment monitor needle was used to measure the compartment pressure at all stages of the procedure. RESULTS All testes maintained a well-perfused coloration at completion of the procedure. The compartment pressures in the testis of the 11-year-old boy (diastolic pressure 52 mm Hg) were as follows: 34 mm Hg after detorsion, 5 mm Hg after testicular fasciotomy, 46 mm Hg after reapproximation of the tunica albuginea, 3 mm Hg on repeat fasciotomy, and 5 mm Hg after tunica vaginalis patch application. CONCLUSIONS Testicular compartment pressures appear elevated after prolonged torsion. Testicular fasciotomy, combined with a tunica vaginalis patch, relieved testicular compartment syndrome. Additional investigation is warranted to determine whether this technique affords improved preservation of testicular tissues.

Learning Curve of Robotic Assisted Pyeloplasty for Pediatric Urology Fellows

PURPOSE Little is known about the learning curve of robotic surgery for surgeons in training. We hypothesized that pediatric urology fellows could attain proficiency in robotic pyeloplasty, defined as operative time equivalent to that of an experienced robotic surgeon, within the 2-year time frame of fellowship. MATERIALS AND METHODS From 2006 to 2010 we performed a prospective cohort study of pediatric robotic pyeloplasty done by 4 pediatric urology fellows and 1 pediatric urology attending surgeon. We recorded operative times and surgical outcomes of the total of 20 consecutive robotic pyeloplasties performed by the 4 pediatric urology fellows (80 cases) and a random sample of 20 performed by the attending surgeon. Multivariate linear regression was used to determine the change in operative time for each case done by fellows and estimate the number of cases needed for fellows to achieve the median operative time of the attending pediatric urologist. RESULTS Fellow operative time decreased at a constant average rate of 3.7 minutes per case (95% CI 3.0-4.3). Fellows were projected to achieve the median operative time of the attending surgeon after 37 cases. No operative complications or failed pyeloplasties occurred. CONCLUSIONS The operative time for robotic pyeloplasty performed by fellows consistently decreased with cumulative surgical experience. These data can be used to help establish benchmarks of robotic pyeloplasty for pediatric urology, assuming appropriate exposure to robotics and adequate case volume.

Endoscopic Management and the Role of Double Stenting for Primary Obstructive Megaureters

PURPOSE We determined the efficacy and potential complications of endoscopic incision and balloon dilation with double stenting for the treatment of primary obstructive megaureter in children. MATERIALS AND METHODS We prospectively reviewed cases of primary obstructive megaureter requiring repair due to pyelonephritis, renal calculi and/or loss of renal function. A total of 17 patients were identified as candidates for endoscopy. Infants were excluded from study. All patients underwent cystoscopy and retrograde ureteropyelography to start the procedure. In segments less than 2 cm balloon dilation was performed, and for those 2 to 3 cm laser incision was added. Two ureteral stents were placed within the ureter simultaneously and left indwelling for 8 weeks. Imaging was performed 3 months after stent removal and repeated 2 years following intervention. RESULTS Mean patient age was 7.0 years (range 3 to 12). Of the patients 12 had marked improvement of hydroureteronephrosis on renal and bladder ultrasound. The remaining 5 patients had some improvement on renal and bladder ultrasound, and underwent magnetic resonance urography revealing no evidence of obstruction. All patients were followed for at least 2 years postoperatively and were noted to be symptom-free with stable imaging during the observation period. CONCLUSIONS Endoscopic management appears to be an alternative to reimplantation for primary obstructive megaureter with a narrowed segment shorter than 3 cm. Double stenting seems to be effective in maintaining patency of the neo-orifice. Followup into adolescence is needed.

Lower pole pelvi-ureteric junction obstruction in duplicated collecting systems

Authors from Philadelphia revisit their extensive experience in lower‐pole PUJ obstruction in duplicated collecting systems, finding that this occurred in 2.05% of duplicated systems. They found an apparent increase in the incidence of this anomaly in boys, and in those with complete duplications. In the second paper in this section, authors from Belgrade describe calibration and dilatation with topical steroids in the treatment of stenosis of the neourethral meatus after hypospadias repair.

Pediatric Laparoscopic and Robot-Assisted Laparoscopic Surgery: Technical Considerations

Laparoscopy has become an effective modality for the treatment of many pediatric urologic conditions that need both extirpative and reconstructive techniques. Laparoscopic procedures for urologic diseases in children, such as pyeloplasty, orchiopexy, nephrectomy, and bladder augmentation, have proven to be safe and effective with outcomes comparable to those of open techniques. Given the steep learning curve and technical difficulty of laparoscopic surgery, robot-assisted laparoscopic surgery (RAS) is increasingly being adopted in pediatric patients worldwide. Anything that can be performed laparoscopically in adults can be extended into pediatric practice with minor technical refinements. We review the role of laparoscopic and RAS in pediatric urology and provide technical considerations necessary to perform minimally invasive surgery successfully.