Postoperative hydronephrosis following ureteral reimplantation: Clinical significance and importance of surgical technique and experience.

BACKGROUND: Though common, postoperative hydronephrosis (POHN) following ureteroneocystostomy raises concern for an underlying obstruction. We aimed to determine the clinical significance of POHN following open (OUR) or robotic (RALUR) ureteral reimplantation. METHODS: We retrospectively reviewed pediatric patients who underwent ureteral reimplantation for vesicoureteral reflux (VUR) from 2008 to 2019 by a single surgeon. Baseline characteristics, operative outcomes, and trends in POHN were assessed. POHN was defined as new onset hydronephrosis or exacerbation of pre existing hydronephrosis. Renal ultrasounds were performed 1, 4, and 12 months postoperatively. Voiding cystourethrograms were performed 4 months postoperatively. Surgical experience for RALUR cases was defined as number of ureters operated over time. RESULTS: Altogether, 93 patients (127 ureters) underwent RALUR and 19 patients (26 ureters) underwent OUR. POHN was found in 27.6% and 30.8% of ureters after RALUR and OUR, respectively. Rate and time to POHN resolution for RALUR (91.4%, 112 days) and OUR (75%, 211 days) were statistically similar. Odds of POHN after RALUR were directly related with preoperative VUR grade (Range OR: 2.82[2.26-3.52]) and surgical experience (Range OR: 8.88[7.16-11.02]). Surgical experience was inversely related with odds of VUR recurrence (Range OR: 0.41[0.32-0.54]). Rates of VUR resolution were comparable for OUR and RALUR patients. No patient required additional intervention for POHN. CONCLUSIONS: Incidence and resolution rate of POHN after OUR and RALUR were similar. Higher VUR grades were associated with increased odds of POHN after RALUR. Increasing RALUR experience improved VUR resolution rate but increased odds of POHN. Surgical success rates were similar for RALUR and OUR. LEVEL OF EVIDENCE: II.

Blood Prostate-specific Antigen by Volume of Benign, Gleason Pattern 3 and 4 Prostate Tissue.

OBJECTIVE: To evaluate how blood levels of prostate-specific antigen (PSA) relate to prostate volume of benign tissue, Gleason pattern 3 (GP3) and Gleason pattern 4 (GP4) cancer. METHODS: The cohort included 2209 consecutive men undergoing radical prostatectomy at 2 academic institutions with pT2N0, Grade Group 1-4 prostate cancer and an undetectable postoperative PSA. Volume of benign, GP3, and GP4 were estimated. The primary analysis evaluated the association between PSA and volume of each type of tissue using multivariable linear regression. R2, a measure of explained variation, was calculated using a multivariable model. RESULTS: Estimated contribution to PSA was 0.04/0.06 ng/mL/cc for benign, 0.08/0.14 ng/mL/cc for GP3, and 0.62/0.80 ng/ml/cc for GP4 for the 2 independent cohorts, respectively. GP4 was associated with 6 to 8-fold more PSA per cc compared to GP3 and 15-fold higher compared to benign tissue. We did not observe a difference between PSA per cc for GP3 vs. benign tissue (P = 0.2). R2 decreased only slightly when removing age (0.006/0.018), volume of benign tissue (0.051/0.054) or GP3 (0.014/0.023) from the model. When GP4 was removed, R2 decreased 0.051/0.310. PSA density (PSA divided by prostate volume) was associated with volume of GP4 but not GP3, after adjustment for benign volume. CONCLUSION: Gleason pattern 4 cancer contributes considerably more to PSA and PSA density per unit volume compared to GP3 and benign tissue. Contributions from GP3 and benign are similar. Further research should examine the utility of determining clinical management recommendations by absolute volume of GP4 rather than the ratio of GP3 to GP4.

Robot-Assisted Laparoscopic Ureterocalicostomy in the Setting of Ureteropelvic Junction Obstruction: A Multi-Institutional Cohort.

PURPOSE: Recurrent ureteropelvic junction obstruction (UPJO) after failed pyeloplasty is a complex surgical dilemma. The robot-assisted laparoscopic ureterocalicostomy (RALUC) is a potential surgical approach, but widespread adoption is limited due to the perceived technical challenge of the procedure. We present a multi-institutional pediatric cohort undergoing RALUC for recurrent or complex UPJO, and hypothesize that the procedure is reproducible, safe and efficacious. MATERIALS AND METHODS: A 3-center multi-institutional collaboration was initiated and medical records of children undergoing RALUC between 2012 and 2020 were retrospectively reviewed. The details on baseline demographics, perioperative characteristics and postoperative outcomes were aggregated. RESULTS: During the study period 24 patients, 7 (29%) females and 17 (71%) males, were identified. Of the patients 21 (86%) had a history of previous pyeloplasty prior to RALUC, of whom 5 (24%) had 2 prior failed ipsilateral pyeloplasties. The reason for performing RALUC was short ureter in 3 (13%), intrarenal pelvis in 5 (21%) and extensive scarring at the ureteropelvic junction locus in 16 (67%) patients. The median age of patients at time of surgery was 5.1 years (IQR: 1.9, 14.7). Of the patients 9 (38%) had percutaneous nephrostomy prior to surgery; if percutaneous nephrostomy tubes were placed for relief of obstruction, an antegrade contrast study was done postoperatively to confirm resolution of obstruction. No 30-day Clavien-Dindo Grade III-V complications were noted. During the median followup of 16.1 months (IQR: 6, 47.5), 22 (92%) had improved symptoms and hydronephrosis with no further intervention; 2 (8%) patients underwent endoscopic interventions after RALUC and both ultimately underwent nephrectomy. CONCLUSIONS: This multi-institutional cohort demonstrates that RALUC is a safe and efficacious salvage option for failed pyeloplasty or complex anatomy with an acceptable success profile, especially in cases of extensive scarring at the UPJO or an intrarenal pelvis.

Systematic Review and Meta-Analysis of Pediatric Robot-Assisted Laparoscopic Pyeloplasty.

Introduction: To perform a systematic review (SR) and meta-analysis (MA) of outcomes of robot-assisted laparoscopic pyeloplasty (RALP) for ureteropelvic junction (UPJ) obstruction in children. Evidence Acquisition: A SR of the English-language literature on surgical techniques and perioperative outcomes of RALP for UPJ obstruction in children was performed without time filters using the MEDLINE (through PubMed), EMBASE, and Cochrane databases in July 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement recommendations. Evidence Synthesis: Overall, 58 studies were selected for qualitative analysis, 46 of which were included in the MA. Nearly all studies included were observational and retrospective, either cohort or case-control. The quality of evidence was assessed using Modified Newcastle-Ottawa Scoring, with the majority of studies scoring medium or high quality. The mean success rate was 95.4% (confidence interval 91.0%-99.3%), over a wide age range. There was a noticeable heterogeneity in reported follow-up length and definitions of success rate. The majority of studies reported length of stay of ∼1 day. The mean overall complication rate was 12%. For studies that reported complication rate by grade, the mean low Clavien grade (Grade 2 or less) complication rate was 9.3% and the mean high Clavien grade (Grade 3 or more) complication rate was 6.5%. Conclusions: Robot-assisted surgery is technically feasible and has been shown to achieve very favorable outcomes for pyeloplasty in children. The evidence, however, is mostly retrospective and from single sites, which introduces potential biases. Further research is needed to further elucidate RALP benefits compared with the open and laparoscopic approach. As a randomized control trial may not be practical in this space, perhaps a prospective multi-institutional design with a uniform reporting system of pediatric RALP is the next step to define its benefits and limits.

Antegrade Colonic Enema Channels in Pediatric Patients Using Appendix or Cecal Flap: A Comparative Robotic vs Open Series.

Introduction: We present perioperative outcomes of a single-center experience with robot-assisted antegrade colonic enema (ACE) channel creation for the treatment of chronic constipation refractory to medical therapy and compare it to the traditional open surgical approach. We also demonstrate a step-by-step video presentation of the robotic approach for cecal flap ACE performed as part of a dual continence procedure in patients with short length of appendix. Methods: A retrospective chart review of pediatric patients who underwent ACE channel creation between 2008 and 2020 was performed. We compared demographics and intraoperative and postoperative variables of the open vs robotic approach. Results: Among 28 patients, 15 were open and 13 robotic. To construct the ACE channel, a cecal flap was utilized in 36%, split appendix in 50%, full-length appendix in 11%, and sigmoid colon in 3% of patients. Both approaches showed equivalent estimated blood loss (50 mL [interquartile range; IQR = 20-100]), median length of hospital stay (7 days vs 8 days, p = 0.7), and median time to return to regular diet (4 days vs 5 days, p = 0.5) (Table 1). Patients in the open group were more likely to have a history of prior abdominal surgeries than those in the robotic group (80% vs 38.5%, p = 0.02). The risk of Clavien-Dindo grade 3 or more complications (40% vs 23.1%, p = 0.04) and the rate of ACE channel stenosis (46.7% vs 7.7%, p = 0.02) were significantly higher in the open approach. Channel stenosis was significantly higher in patients with an appendix ACE channel (87.5% vs 12.5%, p < 0.05) compared to those with cecal flap ACE. [Table: see text] Conclusion: Robot-assisted ACE channel creation is a safe and acceptable alternative with a significantly lower rate of channel stenosis and other clavien dindo grade 3 complications compared to the traditional open approach. Cecal flaps are also at a lower risk of stomal stenosis than appendix.

Ureteroneocystostomy without ureteral remodeling for grade III-V vesicoureteral reflux treatment.

BACKGROUND: Ureteral remodeling (tapering or tailoring) is often performed alongside ureteroneocystostomy (ureteric reimplantation) procedures despite limited evidence on its role in promoting reflux resolution. OBJECTIVES: To investigate the efficacy of ureteroneocystostomy in the absence of adjuvant ureteral remodeling for promoting reflux resolution in grade III-V vesicoureteral reflux. STUDY DESIGN: A retrospective analysis identified pediatric patients who underwent open or robotic assisted ureteroneocystostomy (OUN and RAUN, respectively) without ureteral remodeling (tailoring or tapering) at a single tertiary care center. The primary endpoint of reflux resolution was defined as no reflux on latest follow up postoperative voiding cystourethrogram (VCUG). Ureteral dilation was analyzed using the ureteral diameter ratio (UDR), which normalized for image characteristics. Inclusion criteria was as follows: grade III-V reflux, accessible postoperative VCUG scan, RAUN after June 2013 following technique optimization, and no other structural urologic abnormality or associated neurogenic bladder. RESULTS: A total of 68 ureters were analyzed (Grade III = 28, Grade IV = 27, Grade V = 13, OUN = 23, RAUN = 45). Complete reflux resolution was achieved postoperatively in 96% (27/28) of grade III, 100% (27/27) of grade IV and 100% (13/13) grade V cases, for a combined resolution rate of 99%. In the one failed case, the preoperative UDR was in the second quartile and postoperatively, reflux diminished from grade III to grade I. Notably, no cases with UDRs in the largest quartile required tapering/tailoring for complete reflux resolution. DISCUSSION: Ureteral tapering and tailoring were unnecessary to achieve reflux resolution in grade III-V VUR by both OUN and RAUN. Additionally, the unsuccessful case was classified as grade III with a UDR value in the second quartile, suggesting that high grade reflux (IV-V) can be repaired without tapering with equal success rates to that of grade III VUR repair, which is classically not tapered. Tapering was unnecessary for complete reflux resolution in the cases with the largest ureteral diameter ratios (UDR). These findings are limited by the single center retrospective nature of the study. CONCLUSIONS: This study demonstrates that vesicoureteral reimplantation for resolution of grade III-V reflux is successful in the absence of ureteral remodeling techniques.

Infant Robot-assisted Laparoscopic Pyeloplasty: Outcomes at a Single Institution, and Tips for Safety and Success.

BACKGROUND: Since its first description, multiple reports proved efficacy and safety of the robotic platform. Further progress has been made allowing for the application of robotic surgery to smaller patients, including infants. Despite the early favorable results, the use of robot surgery in infants is still controversial and more studies are needed to confirm its benefits. OBJECTIVE: To our knowledge, we present the largest single-institution case series of robot-assisted laparoscopic pyeloplasty (RAL-P) in infants, aiming to contribute to the current literature with a guide for key technical steps and safety tips for infant RAL-P. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective review of a prospectively maintained database. The study protocol was approved by the institutional review board. SURGICAL PROCEDURE: Only infants (≤12 mo of age) with a diagnosis of congenital ureteropelvic junction obstruction (UPJO) undergoing primary robotic dismembered pyeloplasty were included in the study. MEASUREMENTS: We critically reviewed the clinical outcomes, described the main steps of the operation, and shared tips for a safe approach. RESULTS AND LIMITATIONS: From January 2012 to August 2019, 44 infants underwent RAL-P for UPJO--33 (75%) males and 11 (25%) females. All robotic cases were completed successfully, with no laparotomic conversions. The median age and weight were 4 (1-12) mo and 6.8 (3.8-10.5) kg, respectively. The mean operative time was 142 (±25) min. The mean estimated blood loss was 7 (±3.6) ml, and no intraoperative complications occurred. The mean length of hospital stay (LOS) was 1.4 (±0.7) d. Seven (15.6%) patients had postoperative complications-one (2%) ileus (Clavien-Dindo grade [CDG] I), four (9%) urinary tract infections (CDG II), and two (4.5%) port-site hernias (CDG III). At a median follow-up of 19 mo, the success rate was 100%. CONCLUSIONS: Given the successful outcomes, benefits of decreased LOS, and improved cosmesis, RAL-P is an appealing management option for UPJO in infants. Market release of new systems, further miniaturization of instruments, and more affordable costs will hopefully be shedding light on more complex applications. PATIENT SUMMARY: Infants (≤12 mo of age) diagnosed with ureteropelvic junction obstruction undergoing primary robotic dismembered pyeloplasty were selected and included in this study. No intraoperative complications or conversion to an open approach occurred. Seven patients (16%) developed postoperative complications-one (2%) postoperative ileus, four (9%) urinary tract infections, and two (4.5%) port-site hernias. At a median follow-up of 19 (7-66) mo, the success rate was 100%.

Comparative Outcomes of Double-J and Cutaneous Pyeloureteral Stents in Pediatric Robot-Assisted Laparoscopic Pyeloplasty.

Background: Comparative outcome studies investigating internal Double-J (DJ) and externalized stents have primarily been performed for open and laparoscopic pyeloplasty, with a paucity of literature surrounding outcomes in robot-assisted laparoscopic pyeloplasty (RALP). Furthermore, outcomes of a modified external stent inserted into the renal pelvis, termed cutaneous pyeloureteral (CPU) stent, remain unexamined. This study investigates outcomes of DJ and CPU stents as methods of trans-anastomotic drainage. Materials and Methods: A retrospective analysis identified pediatric patients who underwent RALP between December 2007 and January 2020 at a single tertiary center, where CPU stents were introduced in June 2012. Operative success was defined as improved or stable hydronephrosis without subsequent redo pyeloplasty. Secondary outcomes included stent reinsertion, anesthesia requirements, opioid administration, urinary tract infection (UTI), and bladder spasms. Results: A total of 103 pediatric RALP procedures were analyzed (DJ = 70, CPU = 33). Operative success (DJ = 95.7%, CPU = 100%, p = 0.55), Society for Fetal Urology (SFU) grade improvement, and length of stay were comparable. Accidental stent expulsion was only seen with CPU stents (9%; p = 0.03). Intracorporeal stent migration also occurred more frequently in CPU stents (DJ = 3%, CPU = 15%, p = 0.03). Stent reinsertion, when needed, used a DJ stent with rates of 4% and 9% for DJ and CPU stents, respectively (p = 0.38). DJ stents were removed at a later postoperative day (DJ = 45.2 ± 25.0, CPU = 8.3 ± 4.2; p < 0.001) with increased general anesthesia (DJ = 99%, CPU = 3%; p < 0.001) and intravenous (IV) opioid (DJ = 27%, CPU = 9%; p = 0.04) requirements. Finally, DJ stents had nonsignificant increased rates of UTI (DJ = 17%, CPU = 3%, p = 0.06) and bladder spasms necessitating postoperative medication (DJ = 26%, CPU = 9%, p = 0.07). Conclusions: DJ and CPU stents display equivalent success rates in pediatric RALP and similar stent reinsertion rates. Appreciable differences can inform stent selection, including higher general anesthesia requirements and IV opioid administration among DJ stents and a higher incidence of accidental stent expulsion among CPU stents. In addition, DJ stents were associated with nonsignificant increased rates of UTI and bladder spasm necessitating medication.

Long term renal function following selective angioembolization for iatrogenic vascular lesions after partial nephrectomy: A matched case-control study.

PURPOSE: Partial nephrectomy is associated with a 1%-2% risk of renal iatrogenic vascular lesion (IVL) that are commonly treated with selective angioembolization (SAE). The theoretical advantage of SAE is preservation of renal parenchyma by targeting only the bleeding portion of the kidney. Our study aims to assess the long-term effect of SAE on renal function, especially that this intervention requires potentially nephrotoxic contrast load injection. MATERIALS AND METHODS: A retrospective review of patients undergoing partial nephrectomy between 2002 and 2018 was performed, and patients who developed IVL were identified. A 1:4 matched case-control analysis was performed. Paired t-test and χ² test were used for continuous and categorical variables, respectively. Multivariable logistic and Cox proportional hazards regression analyses were used to identify risk factors and confounders for SAE and postoperative renal function. RESULTS: Eighteen patients found to have an IVL after partial nephrectomy were matched with 72 control patients. IVL's were more common in patients after minimally invasive partial nephrectomy (89% vs. 70%, p=0.008) and in those with higher RENAL nephrometry scores (8.8±2.0 vs. 6.5±1.8, p<0.001). On multivariable analysis, lower RENAL scores proved to decrease the odds of requiring postoperative SAE. No significant difference in renal function outcomes was seen at 24 months of follow-up after surgery. CONCLUSIONS: SAE for the management of IVL following partial nephrectomy is a safe and efficient procedure with no significant impact on short or long-term renal function. Less complex renal tumors with lower RENAL scores are less likely to require postoperative SAE.

Pediatric urology amidst SARS-CoV-2 pandemic: Building the future with current knowledge.

INTRODUCTION: The COVID-19 pandemic has ripped around the globe, stolen family members and forced healthcare systems to operate under an unprecedented strain. As of December 2020, 74.7 million people have contracted COVID-19 worldwide and although vaccine distribution has commenced, a recent rise in cases suggest that the pandemic is far from over. METHODS: This piece explores how COVID-19 has explicitly impacted the field of pediatric urology and its patients with a focus on vulnerable subpopulations. RESULTS: Various medical and surgical associations have published guidelines in reaction to the initial onset of the pandemic in early 2020. DISCUSSION AND CONCLUSION: As the number of patients with COVID-19 increases, long-term recovery and future preparedness are imperative and should be cognizant of patient subpopulations that have been subject to disproportionate morbidity and mortality burden. Development of a dedicated response team would aid in achieving preparedness by drafting and implementing plans for resource allocation during scarcity, including logistic and ethical considerations of vaccine distribution. LEVEL OF EVIDENCE: III.

Continent Cutaneous Catheterizable Channels in Pediatric Patients: A Decade of Experience with Open and Robotic Approaches in a Single Center.

BACKGROUND: To allow patients with bladder and bowel dysfunctions to achieve social continence, continent catheterizable channels (CCCs) are effective alternatives to intermittent self-catheterization and enema. OBJECTIVE: We aimed to describe our progressive advancement from open to robotic construction of CCCs, reporting outcomes and comparing the two approaches. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed electronic medical records of pediatric patients who underwent construction of CCCs between 2008 and 2019. The inclusion criteria were age ≤18 yr, and CCCs with or without bladder augmentation or bladder neck surgery. We compared open versus robotic approaches for demographics, and intra- and postoperative outcomes; operative time was calculated as incision-to-closure time. SURGICAL PROCEDURE: Channels performed were appendicovesicostomy (APV), Monti with tapered ileum, and antegrade colonic enema (ACE). A Monti channel with tapered ileum was preferred to a spiral Monti or double Monti, as it has more robust blood supply and it was performed only with an open approach. MEASUREMENTS: The primary outcome was success rate, defined as postoperative stomal continence. Stomal incontinence was defined as the presence of urine leakage noted by caregivers or patients and confirmed by the surgeon. Secondary outcomes were stomal stenosis (supra- and subfascial), incontinence, need for surgical revision, and surgical site infection. RESULTS AND LIMITATIONS: A total of 69 patients were included in the study, with 35 open and 34 robotic procedures. The robotic approach showed a significant decrease in length of hospital stay (LOS) compared with the open approach. Six primary subfascial revisions were performed in five patients--three Monti, two ACE, and one APV. Continence rates were 91.4% and 91.2% for open and robotic approaches, respectively. CONCLUSIONS: Robotic surgery for CCCs showed acceptable postoperative functional outcomes and complication rates, which are comparable with those of the traditional open approach. Additionally, due to its minimally invasive nature, it offers advantages such as decreased postoperative pain, LOS, and time to full diet, and better cosmesis. PATIENT SUMMARY: Robotic surgery for continent catheterizable channels showed acceptable postoperative functional outcomes and complication rates, which are comparable with those of the traditional open approach.

The Surgical Management of Acute Gastric Volvulus: Clinical Outcomes and Quality of Life Assessment.

Background: Surgery is the mainstay of treatment for gastric volvulus. Despite its rarity, early experience from recent publications suggests that laparoscopy is a safe and effective approach for the treatment of acute gastric volvulus. Yet, more data focusing on patients' postoperative quality of life (QoL) is needed. The aim of this study is to report our institutional experience with the management of acute gastric volvulus, assessing surgical outcomes and postoperative QoL. Materials and Methods: We performed a retrospective review of a prospectively maintained database, looking for patients with gastric volvulus, requiring emergency laparotomic or laparoscopic surgery, between 2016 and 2018. Follow-up included clinical evaluation, barium swallow X-ray, and two QoL questionnaires-Gastroesophageal Reflux Disease-Health-Related Quality of Life and Gastrointestinal Symptom Rating Scale. Results: Over a 3-year period, 9 patients underwent emergency surgery for acute gastric volvulus, 5 (55%) of which were performed laparoscopically. In this group, the only postoperative complication was found in 1 (20%) patient who presented mild delayed gastric empty. In the laparotomic group, 3 patients (75%) had immediate (30-day) postoperative complications-1 pneumonia, 1 bowel obstruction, and 1 sepsis with multiorgan failure. At a median follow-up of 25 (15-48) months, hiatal hernia recurred in 1 (20%) patient after laparoscopic repair. No recurrence occurred in the open group. With a 100% response rate, QoL questionnaires revealed that 80% of the subjects treated laparoscopically were fully satisfied of the surgical approach, reporting slightly better QoL scores than the open surgery group. Conclusions: Improved postoperative clinical outcomes and QoL after laparoscopic repair of acute gastric volvulus provide encouraging evidence in support of this minimally invasive approach as an alternative to laparotomy.

Impact of Non-guideline-directed Care on Quality of Life in Testicular Cancer Survivors.

BACKGROUND: Non-guideline-directed care (NGDC) is seen in ∼30% of testicular cancer patients and has been identified as a significant predictor of relapse. However, the potential impact of mismanagement on patient quality of life (QoL) is yet to be established. OBJECTIVE: To explore the impact of NGDC on long-term QoL in testicular cancer survivors (TCSs). DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of TCSs, who completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) in person or via mail ≥6 mo after completion of treatment, was conducted. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The validated questionnaire evaluates global health status (GHS); cognitive, social, physical, emotional, and role functioning; financial burden; and treatment-specific side effects. RESULTS AND LIMITATIONS: A total of 120 men with a median age of 31.5 (interquartile range: 24-42) yr completed the questionnaire. Thirty-four (28%) men received NGDC: overtreatment (44%), improper imaging (32%), and undertreatment (29%). Men with NGDC presented with a more advanced clinical stage (≥IIA: 64% vs 32%, p = 0.007) and were less likely to undergo surveillance (19% vs 37%, p = 0.016). Patients receiving guideline-directed care reported higher GHS (84.1 vs 77.5, p = 0.015), higher physical function scores (98.5 vs 91.2, p = 0.013), and fewer financial difficulties (5.8 vs 18.6, p = 0.006) than those receiving NGDC. Multivariable linear regression showed a significant association between NGDC and poorer GHS (p = 0.002). Limitations of the study include its retrospective nature, modest sample size due to a 21% response rate, and quality-of-life assessment at a single time point rather than serially over time. CONCLUSIONS: In addition to treatment delay, avoidable morbidity, and higher rates of relapse, NGDC leads to inferior global QoL, worse physical functioning, and more financial stress. PATIENT SUMMARY: We have previously shown how mismanagement of testicular cancer results in a higher rate of disease relapse. In this study, we emphasize how the lack of adherence to standard treatment guidelines can lead to worse quality of life outcomes and financial stress in testicular cancer survivors.

The Urinary Microbiome and Bladder Cancer: Susceptibility and Immune Responsiveness.

Bladder cancer is a highly prevalent disease worldwide and is associated with a high mortality rate. Across all stages of bladder cancer, immunotherapy has now become the cornerstone of treatment. The commensal microbiome has become a major focus of research given its impact on numerous states of human health and disease. Many links between commensal microbes and immune function have been reported. Recently a commensal urinary microbiome has been identified and characterized in healthy individuals by several research groups. The urinary microbiome is now emerging as an important factor influencing bladder cancer development and therapeutic responsiveness. In this report, we identify findings from important clinical and mechanistic studies on the urinary microbiome and future opportunities to impact prevention and treatment of bladder cancer.

Paraesophageal Hernia Repair: How I Do It.

Although the results of a laparoscopic repair of a paraesophageal hernia are convincing and accepted, controversies still persist regarding indications for elective repair, the need for a concurrent fundoplication, the use of mesh, and the need for a Collis gastroplasty. This article is a description of our surgical approach to the patient with a paraesophageal hernia in need of a repair.

Live-case demonstrations in pediatric urology: Ethics, patient safety, and clinical outcomes from an 8-year institutional experience.

Purpose: Live case demonstrations have become a common occurrence at surgical meetings around the world. These demonstrations are meant to serve as an educational medium for teaching techniques, promote discussion, improve interventions and outcomes. Despite the valuable educational benefits, many authors still question the ethics of this approach. We present our 8-year experience in live surgery, discuss the ethical issues, and provide recommendations. Materials and Methods: We reviewed records of patients who underwent live robotic surgery during broadcasting events. Procedures performed were robot-assisted laparoscopic pyeloplasty (RAL-P), ureteral reimplantation (RALUR), and hemi-nephrectomy (RAL-HN). Peri- and post-operative outcomes were compared to our previously published case series. Results: From October 2011 to May 2019, the senior author (MSG) performed all live surgery demonstrations on 22 patients: 9 RAL-P, 9 RALUR, and 4 RAL-HN. Live RAL-Ps had a 100% success rate and lower 30-day Clavien-Dindo grade (CDG) III complications when compared to our previous case series (11.1% vs. 21.2%). RALURs performed during live demonstrations had a higher success rate than our previously published cohort (100% vs. 82%). RAL-HN operative time and length of stay were comparable to our non-live control group. Conclusions: Live surgery is a valuable didactic tool, but even experienced surgeons may be adversely affected by inappropriate case selection, technical difficulty, and anxiety associated with particular settings, such as operating at different institutions or working with unfamiliar surgical teams. We suggest consultation of an ethics review board and formulation of standard guidelines for patient selection, surgical equipment, and operative team.

Robot-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy in children: Step-by-step and modifications to UChicago technique.

Objective: To describe the step-by-step techniques and modifications for robot-assisted augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy in a pediatric population with updated institutional results. Introduction: Robot-assisted laparoscopic augmentation ileocystoplasty with Mitrofanoff appendicovesicostomy (RALIMA) protects the upper urinary tract and reestablishes continence in patients with refractory neurogenic bladder. Robotic assistance could provide the benefits of minimally invasive surgery without the challenges of pure laparoscopy. Here, we focus on the outcomes of RALIMA with salient tips and modifications of the technique. Methods: We performed a retrospective review of our robotic database and identified 24 patients who underwent attempted robot-assisted laparoscopic augmentation ileocystoplasty (RALI) between 2008 and 2017 by a single surgeon at an academic center. Outcomes of interest included operative time, hospitalization time, postoperative complications, and change in bladder capacity. RALI and all concomitant procedures were performed using the da Vinci® surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Results: Of 24 patients, 20 successfully underwent RALI. Eighty percent underwent concomitant appendicovesicostomy (APV), 40% underwent antegrade continence enema channel formation (ACE), and 30% underwent a bladder neck procedure. Mean operative time was 573 minutes and the most recent RALIMA was 360 minutes. The average return to regular diet was 3.9 days and length of stay was 6.9 days. Mean change in bladder capacity was 244% postoperatively. Thirty-day complications were noted in 35% of patients; one Clavian grade I (5%) complication, five grade II (25%) complications, and one grade IIIb (5%) complication. With a median follow-up of 83.1 months we note a 25% incidence of bladder stones, 15% upper tract stones, 5% incidence of bladder rupture, and 5% small bowel obstruction. No patients required re-augmentation in the follow-up period. Conclusions: RALI has similar functional outcomes and complications when compared with the open augmentation ileocystoplasty literature. RALI is desirable due to favorable pain control with decreased length of stay. Long-term outcomes after RALI are similar to the open approach. As the operative time is currently the largest point of criticism with the robotic approach, we discuss modifications to decrease the operative time.

Robot-assisted laparoscopic pyeloplasty in infants and children: is it superior to conventional laparoscopy?

INTRODUCTION: Open pyeloplasty (OP) has been the first-line treatment for ureteropelvic junction obstruction (UPJO) since it was first described by Anderson and Hynes. The use of minimally invasive surgery (MIS) to treat UPJO in the pediatric population has increased in recent years, due to decreased morbidity and shorter recovery times. Recently, robot-assisted laparoscopic pyeloplasty (RALP) has seen a steady expansion. Unlike laparoscopic pyeloplasty (LP), RALP comes with a more manageable learning curve aided by specialized technological advantages such as high-resolution three-dimensional view, tremor filtration with motion scaling, and highly dexterous wrist-like instruments. With this review, we aim to highlight the trend toward robotic pyeloplasty over laparoscopy and current available evidence on outcomes. METHODS: We systematically searched the PubMed and EMBASE databases, and we critically reviewed the available literature on the use of laparoscopy and robotic technology in pediatric patients with UPJO. RESULTS: Overall, we selected 19 original articles and 5 meta-analyses. The available literature showed that the robotic approach to the UPJO allowed for decreased operative times, shorter length of hospital stay, lower complication rates, with success rates comparable to LP. Conflicting results persist regarding robotic platform and equipment costs. CONCLUSION: While laparoscopy requires advanced skills for complex reconstructive procedures, such as pyeloplasty, robot-assisted surgery offers the valuable potential of making MIS more accessible to these types of procedure. Robotic technology has contributed to shortening the learning curve by acting as a bridge between open and endoscopic approach. There is still a strong need for higher quality evidence in the form of prospective observational studies and clinical trials, as well as further cost-effectiveness analyses. As robotic surgical technology spreads, future systems will be developed, offering smaller and more flexible tools, allowing enhanced applications on pediatric patients.

Impact and Outcomes of a Pediatric Robotic Urology Mini-Fellowship.

Introduction: In order to support practicing pediatric surgeons and urologists to safely and effectively incorporate robotic surgery into their practice, we established a 5-day mini-fellowship program with a mentor, preceptor and proctor at our institution. This study was designed to report our experience with the pediatric robotic mini-fellowship (PRM) and to evaluate the impact this course had on the participants' practice. Methods: The mini-fellowship training at our institution is provided in two modules, including upper and lower urinary tract surgery, over a 5-day period. The one to one teacher-to-attendee experience included tutorial sessions, hands-on inanimate, and animate skills training, clinical case observations and video discussions. Participants were asked to complete a detailed questionnaire on their practice patterns before and after the PRM. Results: Between 2012 and 2018, a total of 29 national and international pediatric surgeons and urologists underwent robotic renal and bladder surgery training. Twenty-six fellows (90%) completed the surveys, all of which were included for analysis. The median age at the time of fellowship was 43 years (32-63), and participants had practiced urology for a median of 76 months (3-372). All of them had a laparoscopic background, with a median experience of 120 months (12-372), and an average of 454 (± 703) laparoscopic procedures performed, including the years of training. The most common primary goals of participants were to understand the concept of robotic surgery and its applications (38.5%), and to practice in the wet lab to shorten their learning curve (38.5%). After PRM completion, 24 graduates (92%) felt likely to incorporate robotic surgery into their practice, of which 15 (58%) actually started a robotic program at their home institution. At 24 months after PRM completion, the overall number of surgeries performed with a robotic approach (RA) by these 15 participants was 478 with an average of 32 (± 44) procedures per fellow, of which 109 (23%) were extirpative (nephrectomy, partial nephrectomy, etc.), and 369 (77%) reconstructive procedures (pyeloplasty, ureteral reimplantation, etc.). Before PRM, the same 15 participants performed 844 procedures with a laparoscopic approach (LA), of which 527 (62.4%) were extirpative, and 317 (37.6%) were reconstructive surgeries. These data mark a significant switch in indications for minimally invasive surgery (MIS) in pediatric urology. The rise in the number of reconstructive procedures (37.6% LA vs. 77% RA) has shown that robotic surgery has undoubtedly facilitated the performance of more challenging procedures in a minimally invasive fashion. Conclusion: The success of a mini-fellowship program relies on the commitment of expert faculty to serve as tutorial instructors and proctors. In addition, a completely outfitted robotic laboratory with access to dry and wet lab is indispensable. A 5-day intensive PRM appears to enable postgraduate surgeons to successfully incorporate the robotic platform into their practice and to advance the complexity of minimally invasive procedures, allowing for more challenging surgeries, such as reconstructive urology.

Lessons learned from a single-surgeon series of paediatric robot-assisted laparoscopic urological procedures: predictors of high-grade postoperative complications.

OBJECTIVES: To describe postoperative complications after robot-assisted laparoscopic urological surgery in children, and identify potential predictors of these complications by analysing the outcomes of a large-volume single-surgeon experience. PATIENTS AND METHODS: We reviewed our institutional database to identify all robot-assisted laparoscopy (RAL) cases performed between December 2007 and December 2017. Patients were grouped into three cohorts based on the anatomical location of the procedure: upper urinary tract (kidney and renal pelvis); lower urinary tract (ureter); and lower urinary tract reconstruction with bowel (bladder reconstruction). A descriptive analysis of baseline characteristics, intra-operative variables and postoperative outcomes was carried out. All complications were graded using the Clavien-Dindo scale, and grouped based on type and time of occurrence (<30, 30-90, >90 days). Multivariable logistic regression analysis was performed to identify predictors of high-grade complications (Clavien-Dindo grade ≥ III). We also measured complication rates based on year of surgery and surgical caseload. RESULTS: Our database included a total of 326 patients, of whom 57% (n = 186) underwent upper urinary tract procedures, 30% (n = 97) ureteric procedures, and 13% bladder reconstruction. The median follow-up for each procedure was 13, 11 and 57 months, respectively. Of the total, 10 cases were converted to an open approach and excluded from further analysis. The most common types of complication in all groups were infections (urinary tract infections) and urinary complications (urine leaks and urolithiasis). Bladder reconstructive procedures, which require the use of bowel, presented the highest rate of high-grade complications (32%). Length of hospital stay (LOS; odds ratio [OR] 1.33, confidence interval [CI] 1.16-1.53), estimated blood loss (EBL) in surgery (OR 1.01, CI 1.002-1.019) and operating time (OR 1.004, CI 1.002-1.006) were all associated with increased odds of high-grade complications on multivariate analysis (P < 0.05). CONCLUSIONS: In this single-surgeon series, we have described the most commonly encountered complications after RAL in paediatric urology, finding rates similar to the complication rates reported in the current literature on other surgical approaches. In addition, LOS, operating time and EBL, which are probable surrogates of case complexity, were associated with increased odds of high-grade complications.