Design and validation of a low-cost, high-fidelity model for robotic pyeloplasty simulation training.

INTRODUCTION/BACKGROUND: Owing to restrictions in operative experiences, urology residents can no longer solely rely on 'hands-on' operative time to master their surgical skills by the end of residency. Simulation training could help residents master basic surgical skills and steps of a procedure to maximize time in the operative room. However, simulators can be expensive or tedious to set up, limiting the availability to residents and training programs. OBJECTIVE: The authors sought to develop and validate an inexpensive, high-fidelity training model for robotic pyeloplasty. STUDY DESIGN: Pyeloplasty models were created using Dragon Skin® FX-Pro tissue-mimicking silicone cast over 3-dimensional molds. Urology faculty and trainees completed a demographic questionnaire. The participants viewed a brief instructional video and then independently performed robotic dismembered pyeloplasty on the model. Acceptability and content validity were evaluated via post-task evaluation of the model. Construct validity was evaluated by comparing procedure completion time, the Global Evaluative Assessment of Robotic Skills (GEARS) score, blinded subjective physical evaluation of repair quality (1-10 scale), and flow rate between experts and novices. RESULTS: In total, 5 urology faculty, 6 fellows, and 14 residents participated. The median robotic console experience among faculty, fellows, and residents was 8 years (interquartile range [IQR] = 6-11), 3.5 years (IQR = 2-4 years), and 0 years (IQR = 0-0.5 years), respectively. The median procedure completion time was 29 min (IQR = 26-40 min), and the median flow rate was 1.11 mL/s (IQR = 0-1.34 mL/s). All faculty had flow rates >1.25 mL/s and procedure times <30 min compared with 2 of 6 fellows and none of the residents (P < 0.001). All faculty, half of the fellows, and none of the residents achieved a GEARS score ≥20, with a median resident score of 12.5 (IQR = 8-13) (P < 0.001). For repair quality, all faculty scored ≥9 (out of 10), all fellows scored ≥8, and the median score among residents was 6 (IQR = 2-6) (P < 0.001). The material cost was $1.32/model, and the average production time was 0.12 person-hours/model. DISCUSSION AND CONCLUSION: This low-cost pyeloplasty model exhibits acceptability and content validity. Construct validity is supported by significant correlation between participant expertise and simulator performance across multiple assessment domains. The model has excellent potential to be used as a training tool in urology and allows for repetitive practice of pyeloplasty skills before live cases.

Design and Validation of a Low-Cost, High-Fidelity Model for Urethrovesical Anastomosis in Radical Prostatectomy.

OBJECTIVE: We sought to develop and validate a low-cost, high-fidelity robotic surgical model for the urethrovesical anastomosis component of the robot-assisted laparoscopic radical prostatectomy. MATERIALS AND METHODS: A novel simulation model was constructed using a 3D-printed model of the male bony pelvis from CT scan data and silicone molds to recreate the soft tissue aspects. Using a da Vinci Si surgical robot, urology faculty and trainees performed simulated urethrovesical anastomosis. Each participant was given 12 minutes to complete the simulation. A survey established face validity, content validity, and acceptability. Simulation runs were evaluated by three blinded reviewers. The anastomosis was graded by two reviewers for suture placement accuracy and anastomosis quality. These factors were compared with robotic experience to establish construct validity. RESULTS: Twenty participants took part in the initial validation of this model. Groups were defined as experts (surgical faculty), intermediate (fellows and chief residents), and novices (junior residents). Likert scores (1-5 scale, top score 5) examining face validity, content validity, and acceptability were 3.49 ± 0.43, 4.15 ± 0.23, and 4.02 ± 0.19, respectively. Construct validity was excellent based on the model's ability to stratify groups. All evaluated metrics were statistically different between the three levels of training. Total material cost was $2.50 per model. CONCLUSIONS: We developed a novel low-cost robotic simulation of the urethrovesical anastomosis for robot-assisted radical prostatectomy. The model discerns robotic skill level across all levels of training and was found favorable by participants showing excellent face, content, and construct validities.

Faculty Development for the Operating Room: An Examination of the Effectiveness of an Intraoperative Teaching Course for Surgeons.

OBJECTIVE: We describe a half-day faculty development course designed to equip surgical educators with evidence-based teaching frameworks shown to promote learning in the operating room (OR). We hypothesize that participating faculty will deliver improved instruction as perceived by residents. METHODS: Residents anonymously rated faculty teaching behaviors among whom they had recently worked in the OR (minimum 3 cases in preceding 6 months) using the Briefing - Intraoperative teaching - Debriefing Assessment Tool (BIDAT; 1 = never, 5 = always). Faculty then attended a half-day course. The curriculum was based on the "briefing-intraoperative teaching-debriefing" framework. Discussion and practice centered on goal setting, performance-enhancing instruction, dual task interference, and feedback. After the course, residents again evaluated the faculty. Paired-samples and independent-samples t tests were used to analyze pre and post course changes and differences between groups, respectively. RESULTS: Nineteen faculty completed the course. Associate professors (N = 4) demonstrated improved briefing (4.32 ±â€Š0.48 → 4.76 ±â€Š0.45, P < 0.01), debriefing (4.30 ±â€Š0.29 → 4.77 ±â€Š0.43, P < 0.01), and total teaching (4.38 ±â€Š0.78 → 4.79 ±â€Š0.39, P < 0.05). No significant changes were observed among assistant (N = 9) or full professors (N = 6). All 3 faculty members who served as course co-instructors, regardless of rank, improved significantly in briefing (4.42 ±â€Š0.22 → 4.98 ±â€Š0.29, P < 0.05), debriefing (4.27 ±â€Š0.23 → 4.98 ±â€Š0.29, P < 0.04), and total teaching (4.37 ±â€Š0.21 → 4.99 ±â€Š0.02, P < 0.05). Faculty with baseline teaching scores in the bottom quartile improved teaching behaviors in all phases of instruction (P < 0.05). Teaching scores over the same period did not change among faculty who did not attend. CONCLUSIONS: A half-day course aimed at enhancing intraoperative instruction can contribute to resident-perceived improvement in structured teaching behavior among participating faculty. Initiatives directed at intraoperative instruction might be best targeted towards midlevel faculty with established technical expertise who are motivated to expand teaching efforts and those who have low levels of baseline teaching scores.

Linking unfolded protein response to inflammation and depression: potential pathologic and therapeutic implications.

Depression is a devastating mental disorder that affects millions of people worldwide. Inflammation has been shown to be a key factor involved in the underlying pathophysiology of depression and has been shown in a substantial proportion of cases of depression. Changes attributed with morphological deformities and immunomodulation in susceptible regions of the depressed brain raised the possibility of altered cellular homeostasis transduced by the intracellular stress response. How emotional stressors can lead to an inflamed brain that directly affects physiology and activity is yet to be fully understood. The unfolded protein response (UPR) has been shown to be active in both models of depression as well as in postmortem brain of depressed individuals. The UPR is the cellular response to stress which results in misfolded proteins. Interestingly, UPR activation is directly linked to both inflammatory cytokine production and Toll-like receptor (TLR) expression. The TLRs are part of the innate immune response which typically reacts to "classic invasions" such as bacteria or viruses as well as trauma. TLRs have also been shown to be upregulated in depression, thus solidifying the connection between inflammation and depression. In this review, we aim to tie the UPR-TLR response and depression, and describe the implications of such an association. We also propose future directions for their role in treatment for depression.

Streamlining risk stratification in infants and young children with spinal dysraphism: Vesicoureteral reflux and/or bladder trabeculations outperforms other urodynamic findings for predicting adverse outcomes.

BACKGROUND: Baseline and interval dimercaptosuccinic acid (DMSA) scans and urodynamic (UD) studies are often obtained in infants and young children with spinal dysraphism (SD). OBJECTIVE: To identify practical UD parameters which accurately stratify urologic risk young children with SD. STUDY DESIGN: 130 expectantly managed infants/young children with SD and initial DMSA and UD before age 2 were reviewed. End fill pressure (EFP), bladder trabeculations, vesicoureteral reflux (VUR), initial volume (IV) drained at UD catheter placement, and detrusor pressure at initial volume (DPIV) were evaluated for association with subsequent febrile urinary tract infection (UTI), DMSA abnormalities, and early clean intermittent catheterization (CIC). A combination of factors to accurately stratify risk was sought. Groups were compared by log-rank test. The association of CIC and febrile UTI incidence was evaluated. RESULTS: 31/130 patients developed DMSA abnormalities, 52/130 started early CIC, and 61/130 developed a febrile UTI with median follow-up of 3.8 years. Trabeculations, VUR, EFP ≥40 cm H2O, IV ≥50% estimated bladder capacity (EBC), and DPIV >10 cm H2O were associated with subsequent abnormal DMSA scan (p < 0.001). The best predictor was combination of trabeculation and/or VUR (p < 0.001) (Figure). Among patients who maintained a non-trabeculated bladder without VUR during follow-up, 0/51 developed DMSA abnormalities compared with 31/79 who developed one or both (p < 0.001). Patients with trabeculations and/or VUR were more likely to start early CIC (8/51 vs. 44/79; p < 0.001) and have febrile UTI (11/51 vs. 50/79; p < 0.001). In those with trabeculations, CIC was associated with decreased incidence of febrile UTI (incidence rate ratio (IRR) 0.5, 95% CI 0.3-0.9); in those without trabeculations, CIC was associated with increased incidence of febrile UTI (IRR 1.8, 95% CI 1.1-3.1). CONCLUSIONS: VUR, bladder trabeculations, EFP ≥40 cm H20, IV ≥50% of EBC, and DPIV >10 cm H2O were associated with subsequent DMSA abnormalities in young children with SD managed expectantly. Many of these parameters were associated with febrile UTI and early CIC. The combination of trabeculations and/or VUR outperformed other UD parameters in identifying those high and low-risk for adverse urologic outcomes. Routine DMSA scan may have limited utility in patients with a non-trabeculated bladder without VUR, as none developed an abnormal DMSA. Most (71%) abnormal DMSAs were in patients with trabeculations and/or VUR following a febrile UTI. Given these findings and that incidence of febrile UTI may be lower in those with trabeculations while on CIC, patients with trabeculations and/or VUR should be managed aggressively to protect kidneys.

Examining the impact of surgical coaching on trainee physiologic response and basic skill acquisition.

BACKGROUND: We examined how problem-solving coaching impacts trainee skill acquisition and physiologic stress as well as how trainee sensitivity to feedback, known as self-monitoring ability, impacts coaching effectiveness. METHODS: Medical students completed a pre-training demographics questionnaire, a 12-item self-monitoring ability scale (1 = always false, 5 = always true), and baseline FLS Task 5 with physiologic sensors. After watching a laparoscopic suturing instructional video, students practiced the task for 30 min, either with a surgical coach, or alone, depending on condition. The coach logged frequency of coaching behaviors according to a task-specific coaching script. Trainees then completed FLS Task 5 with physiologic sensors, a post-training questionnaire, and a 12-item coaching quality evaluation (1 = poor, 5 = very good). RESULTS: Twenty-four students (age 24.5 ± 1.4; 54% men; 58% MS4) participated in the study. All were fairly high self-monitors (3.8 ± 0.76). No differences in baseline suturing skills between the groups emerged. Improvement in the coaching group's suturing (N = 12; 285.0 ± 79.9) was significantly higher than the control group (N = 12; 200.9 ± 110.3). One measure of physiologic stress (rMSSD) was significantly higher in the coaching group. Trainees who received more coaching demonstrated larger improvements (r = 0.7, p < 0.05). Overall ,perceived quality of the coaching relationship was high (4.4 ± 0.6). There was no correlation between trainee self-monitoring ability and skill improvement. CONCLUSIONS: This work suggests that coaching may increase heart rate variability of trainees, indicating coping well with training. Trainee disposition toward feedback did not play a role in this relationship.

Unfolded protein response and associated alterations in toll-like receptor expression and interaction in the hippocampus of restraint rats.

Recent evidence suggests that the cellular response to stress often elicits the unfolded protein response (UPR), which has an active role in major depression in emotionally relevant regions of the brain, such as the hippocampus. Much of the UPR activity has been found to be coalesced with the pro-inflammatory environment of the depressed brain. Specifically, downstream transcriptions of pro-inflammatory cytokines and increased regulation of candidate inflammatory mediators, such as toll-like receptors (TLRs), are promoted by the UPR. The present study examined the hippocampus associated expression profile of Tlr genes and their interaction with the UPR chaperone GRP94 in stress-induced rodent model of depression (restraint stress model). Also, the expression status of UPR related genes was evaluated in hippocampus using the same model. mRNA and protein levels of Tlr and UPR associated genes were examined by qRT-PCR and Western blot, respectively. Co-immunoprecipitation (Co-IP) method was used to determine the direct interaction between TLRs with GRP94 in depressed rat brain. The results showed that both UPR (Xbp-1, its spliced variant sXbp-1, Atf-6, Chop, and Grp94) and Tlr (2, 3, 4, 7 and 9) genes were significantly upregulated in the hippocampi of rats who were exposed to restraint stress. Similar upregulation was observed in the protein levels of the above-mentioned TLRs and the UPR chaperone protein GRP94 as well as total and phosphorylated forms of sensor proteins IRE1α and PERK. Further, a significantly increased interaction was observed between GRP94 and the activated TLR proteins. Since, increased inflammatory activity in vulnerable areas like hippocampus is coherently associated with depressed brain; our present data suggest that the UPR may be an integral part of increased activity of inflammatory regulations in depression.

Expectant use of CIC in newborns with spinal dysraphism: Report of clinical outcomes.

PURPOSE: Report urologic outcomes among newborns with spinal dysraphism managed within an expectant clean intermittent catheterization (CIC) program. METHODS: Newborns were followed clinically and with serial ultrasound (US). Urodynamics (UD) and dimercaptosuccinic acid (DMSA) renal scan were obtained at 3-6 months, 1 year, 3 years, then as needed. Patients with initial evaluation after 6 months were excluded. RESULTS: Median follow-up was 3.2 years. 11/102 began catheterization for continence (median 4.0 years) and 47/102 did not start CIC. Of these, 2/58 developed a DMSA abnormality. 44/102 began CIC early, often for elevated storage pressures and febrile urinary tract infection (UTI). Of these, 20/44 developed a DMSA abnormality including 9 who had abnormality detected prior to starting CIC. Being on CIC or starting immediately upon recognition of new hydronephrosis, reflux, elevated filling pressures, or febrile UTI was associated with lower chance of DMSA abnormalities (4/17, 24%) compared to delaying CIC (16/27, 60%) (p= 0.03). CONCLUSIONS: CIC can be deferred until continence in select infants with a low risk of significant DMSA abnormality. However, immediate initiation of CIC upon recognition of risk factors is recommended as this was associated with fewer DMSA abnormalities than delaying CIC. Recommendations for expectantly-managed patients include close follow-up, serial US and UD, and prompt initiation of CIC upon recognition of new hydronephrosis, reflux, elevated storage pressures, or febrile UTIs.

Simple visual review of pre- to post-operative renal ultrasound images predicts pyeloplasty success equally as well as geometric measurements: A blinded comparison with a gold standard.

BACKGROUND: MAG3 diuretic renal scan remains the gold standard for determination of improvement in renal drainage following pyeloplasty for ureteropelvic junction obstruction. We hypothesized that (i) a change in geometric measurements between pre-operative and post-operative renal ultrasound (RUS) images and (ii) blinded simple visual review of images both would predict pyeloplasty success. OBJECTIVE: To determine if simple visual review and/or novel geometric measurement of renal ultrasounds can detect pyeloplasty failure. STUDY DESIGN: This study was a retrospective, blinded comparison with a gold standard. Included were children aged ≤18 years undergoing pyeloplasty at our institution from 2009 to 2015. For each kidney, representative pre-operative and post-operative RUS images were chosen. Our standard for pyeloplasty success was improved drainage curve on MAG3 and lack of additional surgery. Measurements for collecting system circularity, roundness, and renal parenchymal to collecting system area ratio (RPCSR) were obtained by three raters (Figure), who were blinded to the outcome of the pyeloplasty. Changes in geometric measurements were analyzed as a diagnostic test for MAG3-defined pyeloplasty success using ROC curve analysis. In addition, six reviewers blinded to pyeloplasty success reviewed pre-operative and post-operative images visually for improved hydronephrosis and categorized pyeloplasty as success or failure based on simple visual review of RUS. RESULTS: Fifty-three repaired renal units were identified (50 children). There were five pyeloplasty failures, four of which underwent revision or nephrectomy. While all geometric measurements could discriminate pyeloplasty failure and success, the geometric measurements that discriminated best between pyeloplasty failure and success were change in collecting system roundness and change in RPCSR. Consensus opinion among six blinded reviewers using simple visual review had a sensitivity of 94% and PPV of 100% with respect to identifying pyeloplasty success (AUC 0.97 (95% CI 0.93-1.0)). This was not significantly different from AUC for change in roundness (p = 0.09) or change in RPCSR (p = 0.1). DISCUSSION: Change in collecting system roundness and change in RPCSR were the most accurate geometric measurements in predicting pyeloplasty success. Simple visual review of ultrasound images for pyeloplasty success performed as well or better than geometric measurements. However, geometric measurements remain useful as a research tool or to communicate findings between clinicians. CONCLUSIONS: Complex geometric measurements of hydronephrosis or post-operative MAG3 scans are not needed if hydronephrosis is visually significantly improved, as simple visual review is highly sensitive for detecting pyeloplasty failure.

The recent progress in animal models of depression.

Major depression disorder (MDD) is a debilitating mental illness with significant morbidity and mortality. Despite the growing number of studies that have emerged, the precise underlying mechanisms of MDD remain unknown. When studying MDD, tissue samples like peripheral blood or post-mortem brain samples are used to elucidate underlying mechanisms. Unfortunately, there are many uncontrollable factors with such samples such as medication history, age, time after death before post-mortem tissue was collected, age, sex, race, and living conditions. Although these factors are critical, they introduce confounding variables that can influence the outcome profoundly. In this regard, animal models provide a crucial approach to examine neural circuitry and molecular and cellular pathways in a controlled environment. Further, manipulations with pharmacological agents and gene editing are accepted methods of studying depression in animal models, which is impossible to employ in human patient studies. Here, we have reviewed the most widely used animal models of depression and delineated the salient features of each model in terms of behavioral and neurobiological outcomes. We have also illustrated the current challenges in using these models and have suggested strategies to delineate the underlying mechanism associated with vulnerability or resilience to developing depression.

What Do We Know About Intraoperative Teaching?: A Systematic Review.

BACKGROUND: There is increasing attention on enhancing surgical trainee performance and competency. The purpose of this review is to identify characteristics and themes related to intraoperative teaching that will better inform interventions and assessment endeavors. METHODS: A systematic search was carried out of the Ovid MEDLINE, Ovid MEDLINE InProcess, Ovid Embase, and the Cochrane Library databases to identify all studies that discussed teaching in the operating room for trainees at the resident and fellow level. Evidence for main outcome categories was evaluated with the Medical Education Research Study Quality Instrument (MERSQI). RESULTS: A total of 2101 records were identified. After screening by title, abstract, and full text, 34 studies were included. We categorized these articles into 3 groups on the basis of study methodology: perceptions, best practices, and interventions to enhance operative teaching. Overall strength of evidence for each type of study was as follows: perceptions (MERSQI: 7.5-10); best practices (6.5-11.5), and interventions (8-15). Although very few studies (n = 5) examined interventions for intraoperative teaching, these studies demonstrate the efficacy of techniques designed to enhance faculty teaching behaviors. CONCLUSIONS: Interventions have a positive impact on trainee ratings of their faculty intraoperative teaching performance. There is discordance between trainee perceptions of quantity and quality of teaching, compared with faculty perceptions of their own teaching behaviors. Frameworks and paradigms designed to provide best practices for intraoperative teaching agree that effective teaching spans 3 phases that take place before, during, and after cases.

Current status of robotic-assisted surgery for the treatment of vesicoureteral reflux in children.

PURPOSE OF REVIEW: Although open ureteral reimplantation remains the gold standard for surgical correction of vesicoureteral reflux (VUR), robotic-assisted laparoscopic ureteral reimplantation (RALUR) holds promise and is becoming more widely utilized. The present article outlines primary operative techniques for RALUR, summarizes the current literature with respect to surgical outcomes and costs, and discusses early applications of RALUR to complex and reoperative cases. RECENT FINDINGS: Intravesical and extravesical techniques for RALUR have been described. Published outcomes vary with respect to operational definitions of surgical success and reporting of complications. Several studies have directly compared RALUR and open reimplant, suggesting equivalent efficacy and safety. Recent noncomparative studies have reported lower VUR resolution rates and higher complication rates for RALUR, particularly in bilateral cases. The application of RALUR to reoperative surgery and cases requiring tapering and dismemberment is under very early investigation. RALUR is consistently associated with lower postoperative analgesic requirements and decreased hospital stay, but longer operative times and higher costs compared to open reimplant. SUMMARY: Published outcomes after RALUR show mixed results that, on average, may be inferior to open reimplant. Future investigations should seek to identify patient-related and intraoperative factors associated with successful and unsuccessful outcomes.

Species Differences in the Geometry of the Anterior Segment Differentially Affect Anterior Chamber Cell Scoring Systems in Laboratory Animals.

PURPOSE: To determine the impact of anterior segment geometry on ocular scoring systems quantifying anterior chamber (AC) cells in humans and 7 common laboratory species. METHODS: Using normative anterior segment dimensions and novel geometric formulae, ocular section volumes measured by 3 scoring systems; Standardization of Uveitis Nomenclature (SUN), Ocular Services On Demand (OSOD), and OSOD-modified SUN were calculated for each species, respectively. Calculated volumes were applied to each system's AC cell scoring scheme to determine comparative cell density (cells/mm(3)). Cell density values for all laboratory species were normalized to human values and conversion factors derived to create modified scoring schemes, facilitating interspecies comparison with each system, respectively. RESULTS: Differences in anterior segment geometry resulted in marked differences in optical section volume measured. Volumes were smaller in rodents than dogs and cats, but represented a comparatively larger percentage of AC volume. AC cell density (cells/mm(3)) varied between species. Using the SUN and OSOD-modified SUN systems, values in the pig, dog, and cat underestimated human values; values in rodents overestimated human values. Modified normalized scoring systems presented here account for species-related anterior segment geometry and facilitate both intra- and interspecies analysis, as well as translational comparison. CONCLUSIONS: Employment of modified AC cell scoring systems that account for species-specific differences in anterior segment anatomy would harmonize findings across species and may be more predictive for determining ocular toxicological consequences in ocular drug and device development programs.

Current applications of in utero intervention for lower urinary tract obstruction.

PURPOSE: Since the early 1980s with the inception of fetal intervention for obstructive uropathy, there have been creative attempts to improve both perinatal and long-term outcomes. Despite advances in technology and an improved understanding of lower urinary tract obstruction (LUTO) in the fetus, the results for these therapeutic interventions remain guarded and the long-term renal morbidity among survivors remains problematic. RECENT FINDINGS: Fetal LUTO represents a range of disorders but the most common of these is posterior urethral valves (PUVs). Selection criteria for candidates of possible intervention have improved with our understanding of fetal renal physiology. Serial urinalysis has marginally improved our ability to predict those that may ultimately respond to treatment [1,2], but the potential in the development of biomarkers for renal development or maldevelopment holds greater promise [3]. Advancements in fetal surgery may result in less fetal and maternal morbidity, but limited long-term improvement in outcomes highlights the controversial nature of the various interventions [4-10]. We must counsel families that fetal surgery offers hope but we cannot allow them to hold unrealistic expectations for cure. SUMMARY: In appropriately selected fetuses, intervention may improve perinatal survival but not without risk to mother and fetus. Long-term renal outcomes remain problematic amongst survivors. In the case of PUV, postnatal primary valve ablation remains the cornerstone of treatment for nephron preservation; however, our ability to mimic these results in the prenatal population remains poor [11]. Disease severity has likely predetermined those that will survive through the perinatal period with or without intervention. Nonetheless, our drive to assess and manage fetal obstructive uropathy perseveres so that we may ultimately relieve obstruction and preserve renal and lung function. We must maintain optimism that continued advances will ultimately improve outcomes, but also be realistic with our current expectations. This paper reviews the status of current in utero interventions and outcomes.

Laparoscopic percutaneous inguinal hernia repair in children: review of technique and comparison with open surgery.

INTRODUCTION: Minimally-invasive approaches for inguinal hernia repair have evolved from conventional laparoscopy requiring placement of three ports and intracorporeal suturing to simple, one and two port extraperitoneal closure techniques. We utilize a single port laparoscopic percutaneous repair (LPHR) technique for selected children requiring operative intervention for inguinal hernia. We suspect that compared to open surgery, LPHR offers shorter operative duration with comparable safety and efficacy. Our objectives are to (1) illustrate this technique and (2) compare operative times and surgical outcomes in patients undergoing LPHR versus traditional open repair. METHODS: We reviewed operative times, complications, and recurrence rates in 38 patients (49 hernias) who underwent LPHR at our institution between January 2010 and September 2013. These data were compared with an age-, gender-, weight-, and laterality-matched cohort undergoing open repair during the same 3 year period. All cases were performed by a pediatric urologist or pediatric surgeon. RESULTS: Thirty-eight patients with a median age of 21.5 months underwent LPHR, and 38 patients with a median age of 23 months underwent open repair. In both groups, 27/38 patients (71%) had unilateral repairs, and 11/38 patients (29%) had bilateral repairs. For unilateral procedures, average operative duration was 25 min for LPHR and 59 min for OHR (p < 0.001). For bilateral procedures, average operative duration was 31 min for LPHR and 79 min for OHR (p < 0.001). There were no intraabdominal injuries in either group. In the LPHR group, there were no vascular or cord structure injuries and no conversions to open technique. Median follow-up was 51 days for the LPHR group and 47 days for the OHR group (p = 0.346). No hernia recurrence was observed in either group. CONCLUSIONS: In select patients, LPHR is an efficient, safe, and effective minimally invasive alternative to OHR, with reduced operative times but without increased rates of complications or recurrences. The technique has a short learning curve and is a practical alternative to OHR for pediatric urologists who infrequently utilize pure laparoscopic technique.

Identification of adolescent and adult patients receiving pediatric urologic care and establishment of a dedicated transition clinic.

INTRODUCTION: Pediatric patients with chronic urologic conditions frequently require lifelong evaluation and treatment. Transition to adult urologic care is critically important as these patients mature and the goals of care shift to include sexual function, fertility, and reconstruction. OBJECTIVE: Our objectives are to (1) quantify and describe the population of young adult patients with congenital or childhood-acquired urologic problems who continue to be followed in pediatric urology clinic, to (2) discuss the numerous obstacles to successful care transition, and to (3) outline the design features of the dedicated transition clinic we established in response to the identification of a sizeable population in need. STUDY DESIGN: We (1) performed a retrospective review of our electronic health record to identify young adult patients 19-35 years of age seen in pediatric urology clinic over a five year period. Patients without a chronic urologic diagnosis were excluded. We identified each patient's primary diagnosis and status with respect to transition of care. We then (2) established a dedicated transition clinic to facilitate progression to adult care services at our institution. RESULTS: Among 480 young adult patients seen in the pediatric clinic during the five-year period, 99 patients with an average age of 22.4 years were identified as having a chronic congenital or childhood-acquired diagnoses requiring urologic care. At the end of the five-year period, 40 of 99 patients (40.4%) had successfully transitioned to adult care while 59 patients (59.6%) continued care with pediatric urology. Among patients yet to transition, spinal dysraphism (30%) was the most common primary diagnosis. In this same group, discussion regarding transfer to adult care was documented during at least one visit in only 8 of the 59 patients (13.6%). All patients in this cohort had healthcare needs that included sexual function, fertility, or reconstruction. DISCUSSION: The present data confirm the presence of sizeable population of young adult patients with chronic urologic problems and maturing care needs who 1) continue to receive exclusively pediatric care, and 2) are rarely engaged in preparatory discussions regarding care transition. Obstacles to successful transition of care are numerous and include limited staff training, lack of identified staff member responsible for transition, financial and psychosocial barriers, and discomfort on the part of physicians, patients and families. We describe the additional challenges that are unique to transition of care in urology. We share a blueprint of our recently-established transition with the hope of prompting additional discussion and facilitating transitional urologic care elsewhere. CONCLUSION: Many young adult patients with chronic urologic conditions continue to receive care from pediatric urologists well into adulthood. We hope that our clinic might serve as a model for augmentation of urologic transition services at other institutions. We anticipate a future report evaluating our clinic's impact on long-term follow up, clinical outcomes, and patient satisfaction.

Minimally invasive techniques for management of the ureterocele and ectopic ureter: upper tract versus lower tract approach.

The optimal management approach for children with ureterocele and complete pyeloureteral duplication, especially in the setting of high-grade ipsilateral vesicoureteral reflux, remains unclear. Trends in surgical management reflect a shift from single-stage open reconstruction toward conservative management and minimally invasive approaches. This article reviews lower tract approaches (endoscopic ureterocele incision and ipsilateral ureteroureterostomy), and upper tract approaches (ureterocele moiety heminephrectomy) in terms of selected operative techniques, patient selection, published outcomes, postoperative care, and follow-up. Current data support endoscopic puncture as a safe and effective treatment of symptomatic children with single-system intravesical ureteroceles.

Altered Expression of Endoplasmic Reticulum Stress Associated Genes in Hippocampus of Learned Helpless Rats: Relevance to Depression Pathophysiology.

The unfolded protein response (UPR) is an evolutionarily conserved defensive mechanism that is used by cells to correct misfolded proteins that accumulate in the endoplasmic reticulum. These proteins are misfolded as a result of physical stress on a cell and initiate a host of downstream effects that govern processes ranging from inflammation to apoptosis. To examine whether UPR system plays a role in depression, we examined the expression of genes that are part of the three different pathways for UPR activation, namely GRP78, GRP94, ATF6, XBP-1, ATF4, and CHOP using an animal model system that distinguishes vulnerability (learned helpless, LH) from resistance (non-learned helpless, NLH) to develop depression. Rats were exposed to inescapable shock on days 1 and 7 and were tested for escape latency on day 14. Rats not given shock but tested for escape latency were used as tested control (TC). Plasma corticosterone (CORT) levels were measured. Expression levels of various UPR associated genes were determined in hippocampus using qPCR. We found that the CORT level was higher in LH rats compared with TC and NLH rats. Expression of GRP78, GRP94, ATF6, and XBP-1 were significantly upregulated in LH rats compared with TC or NLH rats, whereas NLH rats did not show such changes. Expression levels of ATF4 and CHOP showed trends toward upregulation but were not significantly altered in LH or NLH group. Our data show strong evidence of altered UPR system in depressed rats, which could be associated with development of depressive behavior.

Mild to moderate postnatal hydronephrosis--grading systems and management.

No universal guidelines exist for the management of patients with mild to moderate antenatal hydronephrosis (ANH). Unsurprisingly, practice patterns vary considerably with respect to recommendations for postnatal evaluation and follow-up imaging schedule. Although some clinical tools are available to specifically grade ANH and postnatal hydronephrosis, these are commonly used interchangeably with varying degrees of success. A universal classification system and nomenclature are needed to best identify patients at risk of renal deterioration, UTI and need for surgical intervention. We present our own approach to postnatal risk stratification and management, including recommendations regarding serial ultrasonography schedule, prophylactic antibiotics, voiding cystourethrogram and renal scintigraphy.