Walid Farhat

Laparoscopic dismembered pyeloplasty by a retroperitoneal approach in children

To report our experience with dismembered laparoscopic pyeloplasty by a retroperitoneal approach in children with pelvi‐ureteric junction (PUJ) obstruction.

Retroperitoneal laparoscopic vs open partial nephroureterectomy in children.

To compare the results of retroperitoneal laparoscopic with open partial nephroureterectomy.

Pediatric Renal Cell Carcinoma: Single Institution 25-Year Case Series and Initial Experience With Partial Nephrectomy

PURPOSE RCC represents less than 2% to 6% of pediatric renal tumors. Few reports of long-term outcomes exist. We sought to determine the presentation, treatment and outcome of patients at our institution. MATERIALS AND METHODS We retrospectively reviewed the age, mode of presentation, mode of treatment, histological subtype, tumor grade, stage and survival of all patients with RCC from 1980 to 2005. RESULTS A total of 15 patients were identified. Mean age at presentation was 7.9 years. Symptomatic presentations in nearly 75% of patients included gross hematuria, abdominal pain and polycythemia. The remaining 25% of cases were asymptomatic, and were identified by physical examination or incidentally on imaging. Surgical resection consisted of radical nephrectomy in 10 patients and partial nephrectomy in 5. Pathological analysis revealed papillary RCC in 8 patients and clear cell RCC in 7. Six patients had high stage disease. One patient with stage IV disease died 8 months postoperatively. The remaining 14 patients were alive at a mean followup of 4.9 years. All but 1 patient remain recurrence-free, including all of those who underwent nephron sparing surgery. CONCLUSIONS To our knowledge this single institution series is the first to include children treated with partial nephrectomy. Pediatric patients with RCC tend to be older and more likely to present symptomatically compared to the typical patient with Wilms tumor. Hematuria and abdominal pain were the most common presentations, and papillary RCC was proportionately more common in this series. Our initial experience suggests that equivalent cure rates can be expected from a nephron sparing approach in appropriately selected cases.

IMPACT OF PRENATAL DIAGNOSIS ON THE MORBIDITY ASSOCIATED WITH URETEROCELE MANAGEMENT

PURPOSE We postulated that prenatal detection of ureteroceles has a positive impact on the natural history and clinical outcome of ureteroceles in duplex system. MATERIALS AND METHODS Between 1992 and 2000, 95 children underwent surgery for a ureterocele in a duplex system. We evaluated the impact of prenatal diagnosis in 40 cases versus postnatal diagnosis in 55 on morbidity, as measured by postoperative urinary tract infection and secondary procedures, while controlling for ureterocele type and the initial surgical approach. RESULTS Mean followup in the 2 groups was 3.9 years. Preoperatively the reflux rate was 51% in the prenatal and 66% in the postnatal groups. Preoperatively urinary tract infections were less common in the prenatal group (12% versus 84%). Mean age at initial intervention in prenatally and postnatally diagnosed patients was 6 and 31 months, respectively. Postoperatively the urinary tract infection rate was double in postnatally diagnosed patients. Overall postoperatively reflux was similar in the 2 groups and grades III to V reflux with urinary tract infection accounted for 14 of the 21 secondary bladder procedures (67%). After initial endoscopic decompression none of the prenatally diagnosed patients with intravesical ureteroceles required reoperation, whereas 6 (50%) with extravesical ureteroceles required reoperation. All 10 prenatally diagnosed extravesical ureteroceles treated with partial nephrectomy were cured. Overall the secondary procedure rate in the postnatal group was higher than in the prenatal group (46% versus 20%, p = 0.02). Also, there was a difference in the reoperation rate in the endoscopic decompression group according to mode of presentation (p = 0.03) and a difference when comparing endoscopic treatment with partial nephrectomy in all patients (p = 0.02). CONCLUSIONS Prenatal diagnosis decreases morbidity and potential adverse outcomes related to infection. Overall prenatal diagnosis is associated with a decreased rate of secondary procedures independent of the type of ureterocele. Prenatally diagnosed intravesical ureteroceles may be cured by endoscopic incision alone but for extravesical ureteroceles partial nephrectomy appears to be more definitive.

Renal pseudoaneurysm after blunt renal trauma in a pediatric patient: management by angiographic embolization

Renal pseudoaneurysm is a rare complication after blunt renal trauma. Only 18 cases have been reported in English-language published reports. We present a case of blunt renal trauma in an 11-year-old boy, complicated by delayed bleeding from a renal artery pseudoaneurysm. The patient was initially treated with conservative measures and was later treated with selective embolization of the pseudoaneurysm. The clinical presentation, management options, and clinical decisions are discussed.

The use of tolterodine in children after oxybutynin failure

To assess the safety and efficacy of tolterodine tartrate prescribed to children who previously failed to tolerate oxybutynin chloride.

Mentored retroperitoneal laparoscopic renal surgery in children: a safe approach to learning

Minimally invasive surgery is not exclusive to the treatment of adult conditions. It has also been used in paediatric urology, and the authors from Toronto and Paris describe a mentorship‐training model for laparoscopic retroperitoneal surgery. They confirmed that a mentored approach is the way to develop this procedure. They also found that ablative procedures are learned relatively early, but that reconstructive procedures require a high degree of skill in laparoscopic techniques, requiring formal training focusing mainly on suturing techniques.

Histology Of Upper Pole Is Unaffected By Prenatal Diagnosis In Duplex System Ureteroceles

PURPOSE We determined whether the histology of upper pole nephrectomy specimens vary with prenatal detection or ureterocele position. MATERIALS AND METHODS Between 1992 and 2000, 95 patients with ureteroceles associated with a duplex system underwent surgical interventions, including upper pole nephrectomy in 60. A total of 55 specimens, of which 25 and 30 involved a prenatal and postnatal diagnosis, and 18 and 37 involved an intravesical and extravesical location, respectively, were available for independent review by a single pathologist. Histological lesions were classified into the 5 categories of chronic interstitial inflammation, fibrosis, tubular atrophy, glomerulosclerosis and dysplasia. Each category was divided into moderate/severe histological lesions (greater than 25% involvement) and minimal/mild lesions (25% or less involvement). RESULTS A moderate/severe histological lesion was identified in 38 patients (69%) and a minimal/mild lesion was detected in 17 (31%), while dysplasia was present in 35 (64%). There was no significant difference in histological lesions and mode of presentation. In contrast to intravesical ureteroceles, extravesical ureteroceles were associated with severe fibrosis and tubular atrophy (p <0.05). Chronic interstitial inflammation, fibrosis, tubular atrophy and glomerulosclerosis in each specimen were graded moderate/severe (greater than 25% involved) in 55%, 67%, 66% and 53%, respectively. CONCLUSIONS Prenatally diagnosed ureteroceles were not associated with less severe upper pole histological lesions. We noted pathological differences when comparing specimens according to ureterocele position, but chronic inflammation and dysplasia were similar in intravesical and extravesical ureterocele cases. It appears that the histological lesions observed are not progressive or reversible. Therefore, the goals of clinical management should focus on providing adequate drainage, antibiotic prophylaxis coverage and followup of reflux rather than the preservation or enhancement of upper pole function.

Open Versus Laparoscopic Staged Fowler-Stephens Orchiopexy: Impact of Long Loop Vas

PURPOSE There is a paucity of literature on factors associated with testicular atrophy following second stage laparoscopic Fowler-Stephens orchiopexy. We hypothesized that dissection of a long looping vas during this procedure could compromise testicular blood supply, leading to testicular atrophy. MATERIALS AND METHODS Following an initial laparoscopic testicular vessel ligation, a second stage Fowler-Stephens orchiopexy was performed in 73 testes (laparoscopic in 61, open in 12). The presence of a long looping vas was noted from the first stage operative notes. Doppler ultrasound was performed postoperatively to confirm testicular atrophy. RESULTS Atrophy rate at a mean followup of 13.5 months was 20.5% (15 of 61 in laparoscopic and 0 of 12 in open orchiopexy). None of the 5 long looping vas testes atrophied following open orchiopexy, compared to 5 of 6 (83%) following laparoscopic orchiopexy (p = 0.03). Analyzing the laparoscopic group alone, a long looping vas was significantly associated with risk of atrophy (p <0.01). CONCLUSIONS The presence of a long looping vas was associated with a higher atrophy rate following laparoscopic second stage Fowler-Stephens orchiopexy. Laparoscopic management of the long looping vas may be more challenging and, therefore, in such cases open Fowler-Stephens orchiopexy may result in better success rates by preserving the integrity of the collateral vessels.

The predictive value of diagnostic imaging for histological lesions of the upper poles in duplex systems with ureteroceles

To compare the diagnostic imaging findings with the histological lesions in upper pole nephrectomy (UPN) specimens of duplex system ureteroceles, using renal ultrasonography (US) and nuclear renal scintigraphy.