Shawn M. McGee

Sacral Neuromodulation in Children With Dysfunctional Elimination Syndrome: Description of Incisionless First Stage and Second Stage Without Fluoroscopy

OBJECTIVES To detail a percutaneous technique of sacral nerve neuromodulation (SN) that eliminates the first-stage incisions and the need for second-stage fluoroscopy. Our group has previously described the results of SN in children with medically refractory dysfunctional elimination syndrome. The drawbacks to SN include the use of fluoroscopy and the need to reopen recent skin incisions during the second stage. This results in increased radiation exposure, poor cosmesis, and possible wound infection. METHODS The incisionless first stage consisted of percutaneously tunneling the temporary external appliance to the contralateral axillary line at the buttock after localization of the S3 nerve root and placement of a quadripolar tined lead under fluoroscopic guidance. A subcutaneous bolus of methylene blue marked the lead connector site, obviating the need for later fluoroscopic localization to place the implantable pulse generator at the second stage. RESULTS A total of 27 children with refractory dysfunctional elimination syndrome underwent SN using the InterStim device. Of the 27 patients, 19 underwent our modified technique. The operative time for our modified tunneling and placement technique was < or = 2 minutes. The mean hospital stay was 0.6 day, with no patient requiring postoperative intravenous narcotics. At a mean follow-up of 35.9 months, no wound infections had occurred in the incisionless cohort compared with 1 postoperative wound infection requiring device explantation in the conventional lead placement group. CONCLUSIONS The incisionless technique of SN device implantation is technically simple, quick to perform, and results in decreased radiation exposure, excellent pain control, and improved cosmesis without compromising the outcomes.

Predicting Renal Outcomes in Children With Anterior Urethral Valves: A Systematic Review

PURPOSE Prognostic information is limited on children with congenital anterior urethral valves or a diverticulum. We reviewed the literature and examined our clinical database to identify clinical features predicting a poor renal outcome, defined as azotemia, renal failure or death. MATERIALS AND METHODS We reviewed 97 English language studies of patients 18 years old or younger. Seven patients from our institutions were also included in analysis. After data abstraction we used multivariate models to define factors associated with outcomes of interest. RESULTS We identified 239 male patients with anterior urethral valves, of whom 139 had adequate data available for study inclusion. Of these patients 108 (78%) had normal renal function after treatment. On bivariate analysis vesicoureteral reflux (OR 22.4, p <0.0001), pretreatment azotemia (OR 17.1, p <0.0001), urinary tract infection (OR 3.3, p = 0.006), hydronephrosis (OR 10.0, p = 0.0004) and bladder trabeculation (OR 7.3, p = 0.01) were associated with renal failure or death while treatment method (p = 0.9), obstruction type (valve vs diverticulum, p = 0.4) and valve location (p = 0.6) were not. After adjusting for other factors only pretreatment azotemia (p = 0.0005) and vesicoureteral reflux (p = 0.01) remained associated with renal failure and/or death with a trend toward significance for urinary tract infection (p = 0.06). When all 3 factors were present, the odds of a poor renal outcome increased 25-fold (p = 0.005). CONCLUSIONS Congenital anterior urethral obstruction in children has a generally good prognosis but may occasionally result in a poor renal outcome. The combination of pretreatment azotemia, vesicoureteral reflux and urinary tract infection is highly predictive of a poor renal outcome.

Minimal contamination of the human peritoneum after transvesical incision.

BACKGROUND AND PURPOSE The recent literature has questioned the infectious risk of natural orifice translumenal endoscopic surgery (NOTES). The need for a clean portal of entry may be important to minimize peritoneal contamination after NOTES. Our study examines the resultant microbial contamination of the human peritoneum after transvesical incision and exposure of the abdomen to bladder contents during robot-assisted laparoscopic prostatectomy (RALP) to better understand the potential for infection in transvesical NOTES. PATIENTS AND METHODS Sixty consecutive men undergoing RALP for clinically localized prostate adenocarcinoma from January to May 2008 were prospectively studied as part of a database approved by an Institutional Review Board. The patients preoperative urine microscopy values, complete blood cell count, and prostate-specific antigen (PSA) levels were recorded, along with the total length of time the cystotomy was open to the peritoneum. Intraoperative samplings of peritoneal fluid were collected before and after transvesical incision and sent for anaerobic, aerobic and fungal cultures. RESULTS Patients undergoing RALP had peritoneal exposure after transvesical incision for an average of 118 minutes. Five of 60 (8.3%) patients had evidence of novel aerobic bacterial contamination of the peritoneum after RALP. No patient had a positive anaerobic culture or fungal culture from the peritoneum. Preoperative serum leukocyte and PSA levels were elevated in patients with peritoneal contamination (P < 0.05). Remaining clinicopathologic features, total operative time, or open cystotomy time did not predict peritoneal contamination. CONCLUSION Prolonged peritoneal exposure to bladder contents demonstrates minimal contamination of the abdominal cavity and is without postoperative infectious significance. This study may overestimate bacterial contamination via the bladder during RALP, because the specific bacteria seen may have originated from the seminal or prostatic fluid during prostatectomy. Transvesical incision would effectively be a clean portal of entry for NOTES with its low rate of peritoneal contamination.

Carcinosarcoma of the Prostate Replacing the Entire Lower Genitourinary Tract

Less than 100 cases of prostate carcinosarcoma have been described in published studies. Most of these cases describe symptoms due to bladder outlet obstruction that typically results in transurethral resection of the prostate. Our patient presented with tenesmus and stranguria due to prostate carcinosarcoma that developed years after being treated with external radiation and androgen deprivation for prostate adenocarcinoma. Because of the patients escalating symptoms, a pelvic exenteration with creation of urinary and fecal diversions was performed. Despite the dismal survival associated with prostate carcinosarcoma, palliative surgical extirpation can be successful in patients with debilitating pain.

Acute Renal Infarction Due to Fungal Vascular Invasion in Disseminated Candidiasis

Disseminated candidiasis occurs almost exclusively in leukemic patients recovering from neutropenia. Although renal involvement can be a sequela of disseminated candidiasis, acute renal infarction secondary to Candida invading the renal vasculature has not previously been reported. Our patient, who was being treated for acute myelogenous leukemia, developed complete obstruction of the right renal vessels during the course of 36 hours as documented by serial renal ultrasound scans with Doppler investigation of the vasculature. Histopathologic examination of the nephrectomy specimen revealed complete infarction of the kidney secondary to Candida spp. infiltrating the parenchyma and occluding the hilar vessels.

Cystic Dysplasia of Testis Associated With Ectopic Ureter Causing Chronic Orchalgia

Cystic dysplasia of the testis (CDT) is a rare entity that typically does not present with orchalgia in affected patients. Most patients with CDT are asymptomatic and have ipsilateral renal malformations. Our patient with CDT was referred because of prolonged unilateral orchalgia. Computed tomography demonstrated an ipsilateral atrophic kidney and hydro-ureter traveling posterior to the bladder. Orchalgia resolved with resection of the dysplastic kidney and ectopic ureter, which drained to an enlarged seminal vesicle. Atypical symptoms associated with CDT, such as chronic orchalgia, should prompt additional investigation to rule out concomitant malformations. This is the first report of an ectopic ureter associated with CDT.

Robot-Assisted Laparoscopic Sacrocolpopexy

The gold standard for repair of symptomatic high-grade, posthysterectomy vaginal vault prolapse is the sacrocolpopexy. Surgical routes to perform the sacrocolpopexy have included the transabdominal, transvaginal, laparoscopic, and more recently the robot-assisted laparoscopic sacrocolpopexy (RALS). The Urology Department at our institution has recently described the long-term results from the RALS. This technique has demonstrated a greater than 90% durability in repair, as defined by no recurrent pelvic organ prolapse (Elliott DS, Krambeck AE, Chow GK, J Urol 176:655–659, 2006). In addition, it has been shown that the RALS is an excellent technique for posthysterectomy vaginal vault prolapse repair with decreased hospital stays, less postoperative pain control, and similar postoperative morbidity when compared to the open transabdominal route (Elliott DS, Siddiqui SA, Chow GK, J Robotic Surg 1:163–168, 2007; McGee SM, Chow GK, Elliott DS, World Congress of Endourology, Shanghai, China, 2008; Daneshgari F, Kefer JC, Moore C, Kaouk J, BJU Int 100:875–879, 2007). The success of the sacrocolpopexy is largely due to correctly identifying the appropriate patient for the RALS. The diagnosis of vaginal vault prolapse is broad and includes female patients with or without a uterus presenting with a cystocele, rectocele, enterocele, or a combination of these. The sacrocolpopexy has traditionally been used for patients with posthysterectomy apical vaginal vault prolapse which may include a concomitant posterior or anterior vaginal vault defect (Fig. 8.1). The female patient may be a candidate for sacrocolpopexy if she suffers from high-grade apical vaginal prolapse as classified by a standardized grading system such the Baden Walker scale or Pelvic Organ Prolapse Quantification system. This chapter focuses on RALS, a technique that has evolved since our first description in patients with posthysterectomy, high-grade vaginal vault prolapse (Elliott DS, Frank I, DiMarco DS, Chow GK, Am J Surg 188:52S–56S, 2004). Urologic surgeon familiarity is noted due to the set-up of the robotic system and surgical suite, which are similar when compared to the robotic-assisted laparoscopic prostatectomy described in other chapters. As the reader will see, specific steps of the RALS have evolved, but still simulate the open repair with respect to the female anatomy and sacral mesh fixation.

INCISIONLESS SACRAL NERVE STIMULATION IN CHILDREN: VIDEO DESCRIPTION OF TECHNIQUE AND INTERIM RESULTS

V888 INCISIONLESS SACRAL NERVE STIMULATION IN CHILDREN: VIDEO DESCRIPTION OF TECHNIQUE AND INTERIM RESULTS Shawn M McGee*, Jonathan C Routh, Timothy J Roth, Pam Hollatz, David R Vandersteen, Yuri Reinberg. Rochester, MN, and Minneapolis, MN. INTRODUCTION AND OBJECTIVE: We have previously described short-term results from 2-stage sacral nerve stimulation (SNS) in children with medically refractory dysfunctional elimination syndrome (DES) using the Interstim® device (Medtronic Inc., Minneapolis, USA).