Diagnosis, management and recurrence rates of Mitrofanoff polyps.

BACKGROUND: Intraluminal polyps are a known complication following creation of a urinary continent catheterizable channel (Mitrofanoff). These polyps can lead to difficult catheterizations in addition to symptomatic bleeding. However, there is limited data available regarding management and outcomes of these polyps. We aim to describe clinical presentation and management of a large series of polyps occurring in a Mitrofanoff channel. METHODS: We performed a retrospective review of all patients that were treated for polyps in a Mitrofanoff at our institution. Information was collected regarding presenting symptoms, management and recurrence rates of the polyps. RESULTS: A total of 24 patients were identified that fulfilled inclusion criteria. The majority of these polyps developed in channels composed of appendix (87%), while only 3 patients (13%) had polyps develop in an ileal composed channel. Thirteen (54%) of these polyps were incidentally diagnosed while 11 patients presented with a variety of symptoms such as difficulty in catheterization, bleeding with catheterization or both difficulty catheterizing and bleeding. For management of the polyps, a cystoscopy was performed and snaring the polyp with stone basket was performed in 37%, energy was applied to base to remove polyps in 33%, 16% were fulgurated and only 13% were left in situ. All procedures were performed under general anesthesia and all of the pathology was benign showing chronic inflammatory tissue. Eight polyps (33%) recurred after initial treatment. DISCUSSION: We did not observe an asymptomatic channel polyp convert to a symptomatic during our follow up period. Our experience has led us to not intervene on all asymptomatic Mitrofanoff polyps encountered during cystoscopy under assumption they will inevitably become symptomatic. Although we admit our follow up period may not be long enough to make this a universal declaration of best practice when any Mitrofanoff polyp is diagnosed. Endoscopic treatment was effective minimally invasive method to address the symptomatic polyp rather than excision and construction of new channel. CONCLUSIONS: This is the largest series to date of polyps developing in urinary continent catheterizable channels. The majority of these polyps were encountered incidentally however symptomatic polyps presented with difficulty with catheterizations. Symptomatic polyps can be managed endoscopically but recurrence of the polyp can occur.

Comparison of risk of anticholinergic utilization for treatment of neurogenic bladder between in utero or postnatal myelomeningocele repair.

INTRODUCTION: In utero myelomeningocele (MMC) repair has resulted in significant decrease in need for shunt-dependent hydrocephalus, however its impact on bladder function remains less clear. Neurogenic detrusor overactivity (NDO) due to MMC can be addressed with combination of clean intermittent catheterization (CIC) and anticholinergic (AC) therapy to minimize its effect on bladder function and upper urinary tract. The aim of this study was to compare the risk of postnatal AC utilization for in patients that underwent either postnatal or in utero MMC repair related to neurogenic bladder (NGB) management. We hypothesized that postnatal MMC repair would be associated with increased risk of postnatal AC utilization compared to in utero MMC repair. MATERIAL AND METHODS: All newborns with MMC in our hospital undergo prospective surveillance radiographic and urodynamic testing as part of institutional MMC protocol. Those MMC patients born between 2013 and 2018 at our institution, who underwent in utero or postnatal MMC repair were retrospectively analyzed. We identified postnatal AC utilization from electronic medical records and recorded indications for AC therapy according to the urodynamic, radiographic and clinical findings related to NGB management. RESULTS: 97 patients fulfilled the inclusion criteria. 56 patients underwent a postnatal and 41 an in utero repair. Median follow-up for the in utero and postnatal MMC repair groups was the same at 37 months (p = 0.53). More newborns from the postnatal group were discharged from birth hospital performing CIC (91.1% vs. 58.5%, p < 0.0001), however upon last follow up no difference existed between the groups on use of CIC (83.9% postnatal group % vs. 82.9% in utero group, p = 0.78). At last follow up, postnatal AC utilization was observed in 75% of postnatal MMC group compared to 78.1% of the in utero MMC repair group, p = 0.81 (Figure). The median time to AC utilization was 6.9 months and 8.8 months in the in utero and postnatal groups, respectively (p = 0.28). DISCUSSION: We observed no reduction in risk of AC utilization with in utero repair which refuted the hypothesis of our study. Indications for AC utilization were urodynamic abnormalities such as NDO (81.3% in utero vs. 81% postnatal) or impaired bladder compliance (53.1% in utero vs. 64.3% postnatal). CONCLUSIONS: We found no difference in risk of postnatal AC utilization between in utero or postnatal MMC repair. CIC rates were higher at birth hospital discharge in the postnatal repair group, however at last follow up CIC rates did not differ between groups.

Need for botulinum toxin injection and bladder augmentation after isolated bladder outlet procedure in pediatric patients with myelomeningocele.

INTRODUCTION: In patients with neurogenic bladder outlet incompetence, a bladder outlet procedure (BOP) may be required to achieve urinary continence. However, when performed in isolation, a BOP can be associated with bladder deterioration and upper-tract injury. In the event of bladder deterioration, additional procedures such as bladder augmentation (BA) or botulinum toxin injection (BTI) may be pursued. OBJECTIVE: The aim of this study was to assess long-term outcomes after isolated BOP in a pediatric myelomeningocele (MMC) population, including the need for additional surgical intervention in the form of BTI or BA. MATERIALS AND METHODS: A retrospective cohort study was performed for patients with MMC who underwent an isolated BOP between 2004 and 2017. Primary outcomes included the need for postoperative BTI or BA. Secondary outcomes included the association between preoperative urodynamic parameters and need for BTI or BA. RESULTS: BTI or BA was performed in 18 of 36 (50%) patients at a median of 17.8 months (IQR 11.2-29.3) after an isolated BOP. A median of 1 (IQR 1-3) BTI was performed in 11 (30.6%) patients. BA was performed in 9 (25%) patients, including 2 patients who previously underwent BTI. Patients who did not undergo BTI or BA after BOP had a slightly increased percentage estimated bladder capacity at the end of follow-up (107% versus 95%, p=0.42). By contrast, patients who underwent BTI or BA had a post-BOP percentage estimated bladder capacity that decreased from 112 to 70% (p < 0.001), increased maximum detrusor leak point pressure from 43 to 67 cm H2O (p = 0.01), and higher rate of de novo upper-tract changes. Unfortunately, no preoperative clinical, radiographic, or urodynamic factors predicted the need for BTI or BA. DISCUSSION: On time-to-event analysis, the risk of BTI or BA was 53% at 5 years in our cohort. Risk of these procedures was highest in the first two years after BOP. 9 of 11 (82%) patients who underwent BTI had improvement in bladder dynamics and BA was not pursued. These findings suggest that BTI provides a less-morbid alternative to BA in patients with MMC and de novo adverse bladder storage changes after an isolated BOP. CONCLUSION: The need for BTI or BA after an isolated BOP is significant in patients with MMC. BTI offers a less-invasive alternative to BA in this population.

Risk of Reaugmentation after Enterocystoplasty Using a Reconfigured Bowel Segment in Patients with Spina Bifida: A Bi-Institutional Cohort Study.

PURPOSE: Reaugmentation cystoplasty rates vary in the literature but have been reported as high as 15%. It is likely that bladders augmented with detubularized and reconfigured bowel are less likely to require reaugmentation. We assessed the incidence of reaugmentation among patients with spina bifida at 2 high volume reconstruction centers. MATERIALS AND METHODS: We retrospectively reviewed medical records of patients with spina bifida who underwent enterocystoplasty before age 21 years (1987 to 2017). Those who did not undergo augmentation with a detubularized and reconfigured bowel segment were excluded from analysis. Data on demographic and surgical variables were collected. Reaugmentation was the main outcome. One analysis was performed using the entire cohort and another analysis was restricted to patients with ileocystoplasty performed in the last 15 years (2002 to 2017). Survival analysis was used. RESULTS: A total of 289 patients were identified. Enterocystoplasty was performed in patients at a median age of 8.1 years (median followup 11.3, IQR 5.2-14.9). Most initial augmentations were performed using ileum (93.4%), followed by sigmoid (6.2%). Seven patients underwent reaugmentation, including 6 with initial augmentation using ileum and 1 with initial augmentation using sigmoid. On survival analysis risk of reaugmentation was 1.1% at 5 years and 3.3% at 10 years after the original surgery. All reaugmentations occurred within the first 9 years of followup. In the more contemporary cohort (162, median followup 7.0 years) only 1 patient underwent reaugmentation at 2.0 years. CONCLUSIONS: The risk of reaugmentation after enterocystoplasty with a detubularized and reconfigured bowel in the spina bifida population is lower than that reported in initial series.

Is anuria prior to pediatric renal transplantation associated with poor allograft outcomes?

INTRODUCTION: Anuria from end-stage renal disease leads to a defunctionalized bladder and may pose technical challenges at the time of renal transplantation. Anuria's effect on bladder function after renal transplantation is considered to be minimal in adults, although a paucity of evidence is available in children. The purpose of this study was to examine the effects of anuria prior to pediatric renal transplantation for ESRD due to medical renal disease on allograft outcome. METHODS: We performed a retrospective review of pediatric patients who underwent renal transplantation for medical renal disease at our institution between 2005 and 2016. Demographics and clinical data were assessed. We also compared GFR at 1 year post-transplant for medical renal patients with history of anuria and those without. RESULTS: Twenty-one patients fulfilled our inclusion criteria with median duration of anuria was 10 months. Preoperative VCUG was available in five patients and their bladder capacity was 29% of expected bladder capacity for age (range 8%-41%). Anticholinergic therapy was prescribed in six patients (28%) for a mean duration of 5 months (range 1-16 months). Comparison of GFR at 1 year post-transplant in anuria group and those without anuria showed no difference (69 vs 75 mL/min, P = 0.37). No correlation was observed between duration of anuria and post-transplant GFR. CONCLUSION: The majority of children in our pretransplant anuria cohort did not develop bladder dysfunction after renal transplantation. No difference was observed between GFR at 1 year when comparing anuric to non-anuric transplant recipients of medical renal disease etiology.

Hidden incision endoscopic surgery (HIdES) trocar placement for pediatric robotic pyeloplasty: comparison to traditional port placement.

Robotic assisted laparoscopy pyeloplasty (RALP) has been associated with shorter recovery, less pain and improved cosmesis. To minimize visible scars, the hidden incision endoscopic surgery (HIdES) trocar placement has been previously developed. Our aim was to compare outcomes between the HIdES and traditional port placement (TPP) for pediatric RALP. A retrospective study was performed on patients under 15 years of age who underwent RALP at a single institution between August 2011 and November 2013. Patient demographics, intraoperative details, narcotic administration, and complications were reviewed. A total of 49 patients were identified (29 in HIdES, 20 in TPP). There was no difference in median age (p = 0.77) or median height (p = 0.88) between the two groups. Median operative time was 180 min for HIdES and 194 min for TPP (p = 0.27). Eleven patients (11/29, 37.9%) in the HIdES group and fourteen patients (14/20, 70%) in the TPP group received postoperative narcotics (p < 0.05). Median follow-up was 42 months for HIdES and 41 months for TPP (p = 0.96). There were two complications (2/29, 6.9%) with HIdES, and one complication (1/20, 5.0%) with TPP (p = 1.00). The success rates were 96.6% (28/29) for HIdES and 100% (20/20) for TPP (p = 1.00). HIdES trocar placement for pediatric robotic pyeloplasty is a safe and viable alternative to TPP. HIdES is comparable to TPP regarding operative time, narcotic administration, hospital stay, and complication rate, without compromising success.

Prospective evaluation of urinary incontinence in severely obese adolescents presenting for weight loss surgery.

BACKGROUND: Obesity has been associated with daytime urinary incontinence (UI), likely due to increased intra-abdominal pressure. OBJECTIVES: To assess incontinence symptoms in severely obese adolescents before and 3 years after bariatric surgery. SETTING: Tertiary care pediatric hospitals in the United States. METHODS: The Teen-Longitudinal Assessment of Bariatric Surgery is a prospective, multicenter study designed to evaluate efficacy and safety of bariatric surgery in adolescents. Patients<19 years of age undergoing bariatric surgery at 5 centers between 2007 and 2012 were enrolled. Trained study staff collected baseline and postoperative anthropometric and clinical data. Presence and severity of UI were determined by standardized interview. RESULTS: A total of 242 patients (76% female) were evaluated at baseline. The mean age was 17.1 years at baseline, and 72% were of white race. The preoperative median body mass index was 50.5 kg/m2. At baseline, 18% of females and 7% of males reported UI. Prediction analysis at baseline indicated that females, white race, and increasing body mass index had greater odds for UI. UI prevalence in females and males decreased to 7% and 0%, respectively, at 6 months after surgery (P<.01) and remained stable out to 36 months postoperatively. Furthermore, older patients were less likely to achieve 3-year UI remission or improvement. CONCLUSIONS: In adolescents undergoing bariatric surgery, UI was more common in females than in males. Incontinence status significantly improved by 6 months and was durable to 3 years after surgery, suggesting that bariatric surgery favorably affects anatomic or physiologic mechanisms of bladder control in both males and females.

A Non-Narcotic Pathway for the Management of Postoperative Pain Following Pediatric Robotic Pyeloplasty.

PURPOSE: The purpose of this study is twofold: first, to describe the non-narcotic pathway (NNP) for the management of postoperative pain after robotic pyeloplasty (RP); second, to compare perioperative outcomes for children undergoing RP whose postoperative pain was managed with and without the NNP. PATIENTS AND METHODS: A retrospective review was performed on 96 consecutive patients from October 2011 to December 2015 who underwent RP by three primary surgeons at a single pediatric institution. Children managed with an NNP received alternating doses of scheduled intravenous acetaminophen and ketorolac every 3 hours throughout the postoperative course. Perioperative outcomes were compared after grouping patients according to the type of postoperative pain management pathway. Continuous variables were compared using the Mann-Whitney U test, and categorical variables were compared using the two-tailed chi-squared test. RESULTS: A total of 49 (51.0%) patients were managed with the NNP, and 47 (49.0%) patients were managed without the NNP. A larger proportion of patients in the NNP did not receive postoperative narcotic medications (71.4% vs 25.5%; p < 0.001). Patients in the NNP were administered less narcotics (median 0.000 mg vs 0.041 mg morphine equivalents/kg/day; p < 0.001) and had a shorter length of stay (median 1.0 day vs 2.0 days; p < 0.001). There was no significant difference in the proportion of patients with postoperative complications (p = 0.958) or surgical success (p = 0.958). CONCLUSIONS: An NNP following pediatric RP is a viable and effective analgesic regimen that is associated with less narcotic use. It may also facilitate a shorter hospital stay. The majority of patients managed with this pathway had adequate pain control without being subject to the potential adverse effects of narcotic medications.

Prospective evaluation of urinary metabolic indices in severely obese adolescents after weight loss surgery.

BACKGROUND: Observational studies in obese adults have found abnormal urinary metabolic indices that predispose to nephrolithiasis. Few studies have been performed in severely obese adolescents. OBJECTIVES: To assess urinary stone risk factors in severely obese adolescents and in those undergoing 2 types of weight loss surgery. SETTING: Children's hospital, United States. METHODS: A prospective cross-sectional study was performed to assess urinary metabolic profiles in severely obese adolescents who either have not undergone any gastrointestinal surgery or who have undergone Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (SG). Twenty-four-hour urine collections were performed at home and evaluated at a central laboratory. Established normal reference ranges for adults were used in the analysis. A linear regression analysis was performed assessing the relationship of the study group with each of the outcomes. RESULTS: A total of 55 samples were analyzed from 14 severely obese adolescents and from 17 severely obese adolescents after bariatric surgery (RYGB, 10; SG, 7). Median body mass index was similar between the RYGB and SG groups. The median 24-hour excretion of oxalate was significantly elevated in the RYGB group. Calcium and uric acid excretion and the median supersaturation of calcium oxalate, calcium phosphate, and uric acid were similar among all groups. CONCLUSIONS: Elevated excretion of oxalate in the urine of severely obese adolescents and in those who have undergone RYGB may portend increased risk for kidney stone formation. Larger longitudinal studies are needed to verify these findings and to determine the clinical risk of developing stone disease in these patient populations.

Chronic Kidney Disease Stage Progression in Patients Undergoing Repair of Persistent Cloaca.

PURPOSE: Children born with persistent cloaca undergo complex pelvic reconstruction early in life. Long-term risks of bladder dysfunction and chronic kidney disease are well described. We report upper urinary tract outcomes and the risk of chronic kidney disease stage progression in this patient population. MATERIALS AND METHODS: We retrospectively studied a cohort of patients undergoing posterior sagittal anorecto-vagino-urethroplasty at a single institution from 2006 to 2013. Inclusion criteria consisted of complete urological care at our institution. Chronic kidney disease stage was calculated from cystatin C or nuclear medicine glomerular filtration rate. RESULTS: A total of 44 patients met inclusion criteria. Of the patients 12 had undergone vesicostomy or ureterostomy. A total of 19 patients had hydronephrosis, 19 had vesicoureteral reflux and 15 had a tethered spinal cord. Median length of the common channel was 3.5 cm. Median age at posterior sagittal anorecto-vagino-urethroplasty was 7.3 months. Median followup was 5.3 years. A total of 30 patients had neurogenic bladder, of whom 27 required clean intermittent catheterization and 3 had undergone vesicostomy. Of the patients 38 had stage I or II, 5 had stage III and 1 had stage IV chronic kidney disease. During followup no patient with initial stage I to III chronic kidney disease had stage progression. The patient with stage IV chronic kidney disease had a renal allograft placed at age 34 months before needing dialysis. CONCLUSIONS: Early outcomes in patients with stage I to III chronic kidney disease demonstrate that renal function can be maintained despite a high rate of lower urinary tract dysfunction. Aggressive bladder management may help prevent progressive renal injury in this population.

A comparison of renal function outcomes after nephron-sparing surgery and radical nephrectomy for nonsyndromic unilateral Wilms tumor.

OBJECTIVE: To better understand the impact of nephron-sparing surgery (NSS) on renal function in patients with nonsyndromic unilateral Wilms tumor (uWT), a group of such patients treated with NSS were compared with a stage-matched cohort managed with radical nephrectomy (RN). The recommended management of nonsyndromic uWT is RN. However, NSS may decrease the risk of long-term renal disease and associated comorbidities. MATERIALS AND METHODS: An international, multi-institutional review was conducted of nonsyndromic uWT cases managed with NSS and compared with a stage-matched RN cohort. Data were collected on demographics, oncologic characteristics and outcomes, serum creatinine, and estimated glomerular filtration rate (eGFR) calculated via Schwartz formula. RESULTS: Fifteen patients who underwent NSS (6 females and 9 males) met study criteria and were diagnosed at a median age of 2.5 years (range, 0.2-8.2 years) and followed for a median of 8.4 years (range, 0.5-31.8 years). The stage-matched RN cohort consisted of 15 patients (8 females and 7 males) diagnosed at a median age of 3.7 years (0.3-7.4) and followed for a median of 2.1 years (0.6-10.5 years). The median preoperative eGFR was 91.7 (39.4-237.7) and 149.9 (93.8-215.9) for NSS and RN, respectively, P=.026. The median eGFR at last follow-up was 135.3 (57.5-185.8) and 131.0 (98.6-161.2) for NSS and RN, respectively, P=.95. The median change in eGFR during the study period was a gain of 28.6 (-51.9 to 83.0) for the NSS cohort vs a loss of 19.1 (-54.7 to 25.2) for the RN cohort, P=.007. CONCLUSION: In a highly selected patient population with nonsyndromic uWT, NSS provides excellent renal function preservation when compared with RN. These data require validation via prospective investigation on a larger scale.

Creation of an appendicovesicostomy Mitrofanoff from a preexisting appendicocecostomy utilizing the spilt appendix technique.

Continent catheterizable channels have revolutionized reconstructive surgery to achieve both urinary and fecal continence. The Mitrofanoff and Malone antegrade continent catheterizable channels offer improved quality of life relative to permanent incontinent stomas. A frequently employed surgical option for creating a Mitrofanoff when an existing appendicocecostomy exists involves harvesting a separate piece of intestine. If however the Malone has preceded the creation of a Mitrofanoff, we describe a surgical technique that may avoid the need for a bowel harvest and resultant anastomosis. We report our series of patients utilizing a novel alternative strategy in the select clinical circumstance of an existing appendicocecostomy to expand the armamentarium of the urologic reconstructive surgeon.

The initial experience with RENAL Nephrometry in children, adolescents, and young adults with renal tumors.

BACKGROUND: No standardized manner exits to objectively compare renal tumor complexity in children and adolescents. However, the RENAL Nephrometry scoring system has been recently developed in adults and shown to predict tumor complexity and correlate with clinical outcomes. Thus, the study objective was to evaluate RENAL Nephrometry tumor score in a population of children, adolescents, and young adults and correlate it with tumor features and pathology. METHODS: Patients at the study institution who underwent attempted renal tumor resection from 2002 to 2012, and had pre-operative imaging available for scoring were retrospectively reviewed. A Nephrometry score for each affected kidney was calculated separately by two blinded reviewers and the final score was based on consensus review. Tumor characteristics and oncologic outcomes were compared between the low-, moderate-, and high-complexity masses. RESULTS: Sixty-five patients and 67 kidneys met study criteria. This included: 5 (7.5%) low-complexity, 11 (16.4%) moderate-complexity, and 51 (76.1%) high-complexity lesions. In comparing the clinical and pathologic features between groups, it was observed that less complex masses were observed in older patients, were more commonly managed with nephron-sparing surgery, and more often represented renal cell carcinoma (RCC) and other non-Wilms tumor pathology. No statistically significant correlation was observed between tumor complexity score and blood loss, operative time, transfusion requirement, positive margins or tumor rupture. CONCLUSION: In general, renal lesions in this population are highly complex. In its current form, RENAL Nephrometry appears most useful in evaluating tumor complexity in RCC and masses in older children and adolescents.

Adolescent urologic oncology: current issues and future directions.

Recent Surveillance Epidemiology and End Results (SEER) data indicate that the annual cancer incidence in adolescents is higher than in children, and is on the rise. However, the amount of attention, research funding, and therapeutic progress made in the adolescent oncology population pales in comparison with that of pediatric oncology. Issues of adolescent oncology have only recently been acknowledged by leaders in the field, and current efforts now focus on raising awareness of this unique patient group. In urology, there have been many gains made in pediatric urologic oncology, most notably in Wilms tumor and genitourinary rhabdomyosarcoma (genitourinary [GU] rhabdomyosarcoma [RMS]); however, there has been little to no progress in the adolescent population. In general, adolescent cancer represents the interface between pediatric and adult oncology. Similarly, adolescent urologic oncology must be approached as a distinct entity because of the unique disease processes, treatment-related comorbidities, and psychosocial issues. This article will serve to review the most pertinent adolescent urologic oncologic diagnoses (testicular germ call malignancy, the second peak of the bimodal age distribution of GU-RMS, and adolescent renal malignancies). Also, we focus on such issues as the therapeutic impact on fertility, radiation exposure during therapy, and surveillance, risk of secondary malignancy, the long-term impact of chemotherapy, and the psychosocial burden of cancer in this population. Lastly, we highlight future directions and the foreseeable obstacles towards achieving the same research and therapeutic success enjoyed in pediatric urologic oncology.

Comparison of pediatric robotic-assisted laparoscopic nephroureterectomy and laparoendoscopic single-site nephroureterectomy.

OBJECTIVE: To compare outcomes between pediatric robotic-assisted laparoscopic nephroureterectomy (RALNU) and laparoendoscopic single-site nephroureterectomy (LESSNU). METHODS: A retrospective cohort study was performed of all patients who underwent RALNU and LESSNU at a single pediatric institution from April 2009 to April 2013. Patient demographics, perioperative details, and outcomes were reviewed. RESULTS: Thirty-two patients (20 men, 12 women) were identified. Twenty-four patients underwent RALNU and 8 patients underwent LESSNU. There was no significant blood loss, intraoperative complication, or conversion to open or standard laparoscopy for either procedure. Median age was 55.1 months (range 4.5-171.8 months) for RALNU and 51.6 months (range 16.3-144.9 months) for LESSNU (P = .695). Median weight was 19.1 kg (range 7-55 kg) for RALNU and 16.9 kg (range 11-41 kg) for LESSNU (P = .727). Median operative time was 227 minutes (range 112-362 minutes) for RALNU and 174 minutes (range 74-288 minutes) for LESSNU (P = .028). Median length of hospital stay was 2 days (range 1-4 days) for RALNU and 1 day (range 0-6 days) for LESSNU (P = .134). Median in-patient postoperative narcotic use of morphine-equivalent was 0.03 mg/kg/day (range 0-0.2) for RALNU and <0.01 mg/kg/day (range 0-0.2) for LESSNU (P = .134). Median in-patient postoperative Ketorolac use was <0.01 mg/kg/day (range 0-0.8) for RALNU and <0.01 mg/kg/day (range 0-0.5) for LESSNU (P = .784). Median follow-up was 22 months (range 0.8-48.4 months) for RALNU and 18.8 months (range 0.3-29.4 months) for LESSNU (P = .361). We observed 2 complications (8.3%) in RALNU and 1 in LESSNU (P = 1). CONCLUSION: LESSNU has a significantly shorter operative time with comparable in-patient postoperative narcotics use as compared to RALNU.

Pediatric varicocelectomy: a comparative study of conventional laparoscopic and laparoendoscopic single-site approaches.

BACKGROUND AND PURPOSE: Laparoscopy is a common approach to manage varicoceles in both the adult and pediatric population. The purpose of this study is to report our experience and compare outcomes between conventional laparoscopy and laparoendoscopic single-site (LESS) surgery for varicocelectomy in the pediatric population. PATIENTS AND METHODS: A retrospective cohort study was performed of all patients who underwent conventional laparoscopic varicocelectomy (LV) and laparoendoscopic single-site varicocelectomy (LESSV) at a single pediatric institution from December 2007 to March 2012. Patient demographics, intraoperative details, narcotic use, and complications were reviewed. RESULTS: LV was performed in 32 patients and LESSV in 11 patients. None had conversion to open surgery. Median age was 16 years for LV (range 12-23) and 15 years for LESSV (range 12-20), P=0.061. Median operative time was 55 minutes for LV (range 28-90) and 46 minutes for LESSV (range 33-59), P=0.037. Nine (81.8%) patients in the LESSV group and 10 (31.2%) patients in the LV group were administered narcotics in the recovery room, P=0.005. One (3.1%) patient in the LV group was administered ketorolac in the recovery room, P=1. Five patients in each group, LESSV (45.5%) and LV (15.6%), received acetaminophen in the recovery room, P=0.092. All procedures were performed on an outpatient basis except for one because of a concomitant procedure. Median follow-up was 22 months in LV and 15 months in LESSV, P=0.015. One (3.1%) postoperative hydrocele was noted after LV and 1 (9.1%) after LESSV, P=0.451. All varicoceles were clinically resolved in both groups. CONCLUSIONS: LESSV is comparable to LV in the pediatric population. Our initial experience indicates that the LESS approach may be more painful in the immediate postoperative period than conventional laparoscopy. The LESS technique warrants further evaluation to determine if one approach is clearly more advantageous.

Pediatric robotic assisted laparoscopic nephropexy: case study.

We describe pediatric robotic assisted laparoscopic left nephropexy in a 12-year-old female for symptomatic nephroptosis after partial nephroureterectomy.

Complications of robotic surgery in pediatric urology: a single institution experience.

OBJECTIVE: To report our analysis of complications on pediatric robotic urologic procedures. METHODS: A retrospective review was performed for all robotic surgeries by pediatric urologists at a single pediatric institution, from the start of the robotic surgery program in February 2009 through February 2013. Data included patient demographics, intraoperative details, outcomes, and complications (Clavien system). RESULTS: The analysis included 136 patients. There were 10 different types of procedures performed by 3 pediatric urologists. There were no intraoperative complications, robotic malfunctions, conversions to open or laparoscopic surgery, or mortalities. There were 11 total complications (8.1%): 2 grade I (1.5%), 7 grade II (5.1%), and 2 grade IIIb (1.5%). Complications included ileus in 2 patients (1.5%), port site infection in 2 (1.5%), urinary leak in 2 (1.5%), urinary retention in 2 (1.5%), urinary tract infection in 2 (1.5%), and stent migration in 1 (0.7%). The complication rate was in 3 of 10 infants (30%) and 8 of 126 noninfants (6.3%), P = .035. However, grade I, II, and IIIb complication rates were not significantly higher in infants vs noninfants, P = 1, .084, and .142, respectively. There was no difference in complication rates between the 3 surgeons. CONCLUSION: Pediatric robotic urologic procedures are safely performed with a relatively low complication rate and a low incidence of additional interventions owing to complications. Ongoing use of robotic technology in the pediatric population can be supported. Further reports are needed to validate our findings.