Intra-operative Urodynamics: Is the Test an Accurate Representation of the Lower Urinary Tract in Children?

OBJECTIVE: To compare intraoperative UDS results with UDS in the postoperative care unit (PACU) to assess the accuracy and efficacy of intraoperative UDS in children who cannot tolerate ambulatory urodynamic evaluation. METHODS: Pediatric patients undergoing intraoperative UDS at a single institution were enrolled over a 5-year time period (1/2013-8/2018). Urodynamics were performed in the operating room under general anesthesia, then in the PACU after recovery from anesthesia. Electromyographic (EMG) activity during filling, bladder compliance, cystometric bladder capacity (CBC), detrusor overactivity, presence of urinary leak, leak point pressure (LPP), and pressure specific volumes (PSV) at 10, 20, 30, and 40 cm water were compared between studies. RESULTS: Nineteen patients underwent urodynamic evaluation under general anesthesia and met inclusion criteria. Ten patients (52.6%) underwent 2 filling cycles while awake in PACU, resulting in a total of 48 urodynamic studies available for subsequent analysis. Intraoperative urodynamic studies were more likely to have decreased EMG activity during filling (P=<.01), normal compliance (P <.01), and a lower detrusor LPP (P = .03) compared to UDS performed after recovery from anesthesia. Detrusor overactivity was less frequently observed intraoperatively (P <.001) and involuntary detrusor contractions were lower in magnitude than those observed in the PACU. Twelve of the 19 (63%) children had detrusor overactivity that was present only on the UDS in PACU and not intra-operatively. CONCLUSIONS: The results of urodynamic testing performed under general anesthesia should be interpreted with caution, as pediatric patients appear to have improved bladder compliance, lower detrusor LPP and decreased detrusor overactivity when under anesthesia. For this reason, it is preferable to utilize ambulatory urodynamic evaluation to guide patient management and treatment.

Contemporary Management of Vesicoureteral Reflux.

The past 30 years have seen broad changes in the diagnosis and management of vesicoureteral reflux (VUR). Recently, a clinical debate has generated an open discussion in academic circles. New evidence has shifted treatment patterns away from widespread surgical management and recently brought into question some pharmacologic treatments. VUR is usually not hazardous by itself but is a significant risk factor for urinary tract infection (UTI) and less commonly, renal scarring and insufficiency. Given the costs and morbidity of UTI as well as the potential for significant renal injury, our approach remains conservative. Careful follow-up, parental education about pathophysiology and management of VUR and UTI, and management of bowel and bladder dysfunction (BBD) when present, are the foundation of treatment. Additionally, though we recognize the limitation of continuous antibiotic prophylaxis (CAP), we believe the benefits outweigh the risks and costs for many patients. Careful observation can be considered in patients with a single medical home, parental understanding of what UTI signs and symptoms are, low grade VUR, no history of complicated UTIs and close follow-up. Surgical management remains a relevant option for select patients who fail conservative measures with breakthrough UTIs or failure to resolve. Minimally invasive surgical options are available with acceptable outcomes though open ureteroneocystostomy still carries the highest success rate.

Robotic simple prostatectomy: a consideration for large prostate adenomas.

BACKGROUND: The management of benign prostatic hyperplasia (BPH) has changed considerably over the last several decades. First line treatment of BPH and lower urinary tract symptoms (LUTS) with medical therapy has created a population of men with much larger prostate glands, many of whom require surgical intervention. Patients with prostate glands greater than 80 to 100 grams may be better managed surgically with a retropubic prostatectomy. We explore our experience with robotic assisted simple prostatectomy and review the relevant literature. DATABASE: The database reviewed includes our experience with seven patients undergoing robotic simple prostatectomy, and a comprehensive review of the previously published series of this procedure. In addition, the literature pertaining to a pure laparoscopic approach to simple prostatectomy is reviewed. CONCLUSION: Robotic experience and training has become a standard in resident training programs; while classic transurethral resection is being performed less for large prostate glands. The robotic approach to simple prostatectomy provides an excellent option for surgical treatment of very large prostate glands, providing patients acceptable results in terms of operative time, estimated blood loss, hospital stay and duration of Foley catheter.