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Robot-assisted laparoscopic pyeloplasty (RALP) use in children has increased, though many centers still favor open pyeloplasty (OP) in infants. This study aims to compare safety and efficacy of RALP and OP in infants.A single-institution, retrospective cohort study of infants1 year of age who underwent primary RALP or OP between January 2009 and June 2020 was performed. Primary outcomes were intraoperative and 30-day complications, postoperative radiographic improvement at last clinic visit, and operative failure leading to redo pyeloplasty. Multivariable logistic regression was performed for 30-day complications to adjust for demographic variation between groups. Survival analysis was performed to compare time to diagnosis of operative failure leading to redo pyeloplasty.Among 204 patients, 121 underwent OP and 83 underwent RALP (74.5% male). RALP patients were older (median 7.2 vs 2.9 months, p0.001) and larger (median 8.2 vs 5.9 kg, p0.001) than OP patients. Radiographic improvement was seen in 91.1% of RALP patients and 88.8% of OP patients at last visit. Median (interquartile range) followup in months was 24.4 (10.8-50.3) for the full cohort. In adjusted analysis, the odds of a 30-day complication (OR 0.40, 95% CI 0.08-2.00) was lower for RALP compared to OP, though not statistically significantRALP is a safe and effective alternative to OP for infants, with comparable intraoperative and 30-day complications, radiographic improvement at last followup, and risk of pyeloplasty failure.

We identified the incidence of acquired cryptorchidism among patients with proximal and mid shaft hypospadias, predictors of acquired cryptorchidism, and the prevalence of testis-epididymis nonfusion with ascended testes. We hypothesized that proximal hypospadias would be associated with higher incidence of acquired cryptorchidism than mid shaft hypospadias, and that ascended testes would exhibit increased prevalence of testis-epididymis nonfusion similar to anatomical findings in an undescended testis.A retrospective cohort study of patients who underwent primary proximal and mid shaft hypospadias repair from 2010 to 2016 was conducted. Clinical and operative notes were reviewed. Patients with congenitally undescended testes or differences of sex development were excluded.A total of 175 patients were identified. Those with proximal hypospadias (14/104, 13%) were more likely than those with mid shaft hypospadias (1/71, 1%) to develop acquired cryptorchidism (p=0.04). Among proximal hypospadias patients, increased risk of acquired cryptorchidism was associated with pre-term birth (p0.01) and penoscrotal transposition (p=0.01) but not with testis position on initial examination (p0.99). In the 14 proximal hypospadias patients with acquired cryptorchidism, 21 ascended testes underwent orchiopexy. Operative notes adequately described testis-epididymis anatomy for 8/21 ascended testes. Testis-epididymis nonfusion was described in 6/8 ascended testes.Risk of acquired cryptorchidism is increased among patients with proximal hypospadias. Operative notes revealed a high rate of epididymal nonfusion with ascended testes, suggesting these testes morphologically resemble undescended testes. Close followup of testis position is needed in these patients, and the threshold to perform orchiopexy may need to be lower in select patients.

Purpose:Reoperative pyeloplasty is commonly used in children with recurrent obstruction after pyeloplasty. We previously reported on reoperative robot-assisted laparoscopic repair for failed pyelop...

Summary Introduction Proximal hypospadias repair remains challenging. Our approach to the first stage of two-stage proximal hypospadias repairs has evolved from using Byars' flaps to preputial inlay grafts in anatomically suitable cases and pedicled preputial flaps in more complex repairs. We reviewed our outcomes, hypothesizing that inlay grafts and pedicled preputial flaps were associated with lower complication risks than Byars’ flaps. Study design A single institution, retrospective, cohort study of consecutive two-stage, primary, proximal hypospadias repairs performed from 2007 to 2017 was conducted. Patients with Results 78 of 127 patients met inclusion criteria. Overall complication rate was 47% (Summary Table). Median follow-up was 25.4 months (range 6.4–128.5 months) after urethroplasty. Pedicled preputial flaps (hazards ratio [HR] 0.30; 95% Confidence Interval [CI] 0.14–0.65) and inlay grafts (HR 0.32; 95% CI 0.11–0.95) were associated with lower complication risks compared to Byars' flaps (Summary Table). Median time to complication was significantly shorter for Byars’ flaps (5.7 months) than for inlay grafts (40.6 months) and pedicled preputial flaps (79.2 months) by Kaplan Meier analysis. Temporal subgroup comparisons showed that overall complication rates decreased from 70% to 31% (p = 0.001), but differences in complication rates by first-stage technique were not statistically significant. Discussion In our cohort, repairs with Byars' flaps had the highest complication rate, which is consistent with our observations that urethras tubularized from Byars’ flaps lack appropriate backing and are hypermobile and irregular. To overcome these shortcomings, modifications were made to our approach to two-stage proximal hypospadias repairs with the use of inlay grafts and pedicled preputial flaps quilted to the underlying corporal bodies to optimize the stability of the urethral plate. Our preliminary results are promising. Conclusion Approach to the first stage of two-stage repairs affects outcomes. Pedicled preputial flaps and inlay grafts were associated with lower complication risks than Byars’ flaps. Refinement of technique and patient selection may have resulted in fewer complications in the short term. However, long-term follow-up is needed. Summary Table. Overall Complications and Unadjusted Cox Proportional Hazards Model Comparing Complications by First-stage Repair Technique Overall Complications All (N = 78) Inlay Graft (N = 13) Pedicled Preputial Flap (N = 33) Byars' Flaps (N = 21) Combined (N = 11) Complications a 37 (47%) 4 (31%) 11 (33%) 17 (81%) 4 (36%) Median Number of Complications Per Patient 0 (0–2) 0 (0–2) 0 (0–2) 1 (0–2) 0 (0–1) Type of Complications (n, % of cohort) b Fistula 18 (23%) 2 (15%) 6 (18%) 8 (38%) 2 (18%) Glans/Partial dehiscence 10 (13%) 1 (8%) 0 6 (29%) 3 (30%) Stricture 6 (8%) 2 (15%) 1 (3%) 3 (14%) 0 Diverticulum 3 (4%) 0 1 (3%) 2 (10%) 0 Meatal Stenosis 3 (4%) 0 3 (9%) 0 0 Dehiscence 2 (2.5%) 0 1 (3%) 1 (5%) 0 Unadjusted Cox Proportional Hazards Model Comparing Complications by First-stage Repair Technique Repair Hazard Ratio 95% Confidence Intervals Inlay Graft versus Byars' Flaps 0.32 0.11–0.95 Pedicled Preputial Flap versus Byars' Flaps 0.30 0.14–0.65 Combined versus Byars' Flaps 0.48 0.18–1.31 a This notes the number of patients who developed complications. If a patient developed two complications, they were only counted once for this variable. b This notes the number of patients with each type of complication.

While serial renal ultrasound is often used as an alternative to functional renal imaging in children followed for hydronephrosis, it is unclear whether a lack of hydronephrosis progression safeguards against loss of renal function. In this study we characterize the association between findings on serial renal ultrasound and diuretic renography in children with severe unilateral hydronephrosis.We retrospectively reviewed imaging among patients younger than 18 years old with a history of severe unilateral hydronephrosis, 2 renal ultrasounds and 2 diuretic renograms. Each pair of renal ultrasounds was interpreted by an independent blinded diagnostic radiologist and compared to a contemporaneous diuretic renogram. Change in hydronephrosis was considered as 1) a change in hydronephrosis grade or 2) any change by radiologist interpretation. A 5% or greater change in split differential function was considered significant. Chi-square and Spearman correlation analyses were performed.A total of 85 children were evaluated. Increased hydronephrosis was noted in 11.8% of children by grade and 32.9% by radiologist interpretation. Split differential renal function worsened by 5% or more in 17.6% of children. Overall, 13.3% of children with stable or decreased hydronephrosis demonstrated worsening split differential function at an average of 11.8 months. When renal ultrasound and diuretic renograms were directly compared, the Spearman correlation was poor (r = 0.24, 95% CI 0.03 to 0.43).The overall correlation between imaging modalities was poor, and 13.3% of children with stable or decreased hydronephrosis had worsening of split differential renal function. These findings are important to consider when counseling nonoperatively managed children followed without diuretic renography.

Robot-assisted laparoscopic (RAL) urologic surgery is widely used in pediatric patients, though less commonly in infants. There are small series demonstrating safety and efficacy in infants, however, stratification by infant size has rarely been reported. Whether a cut-off weight, below which RAL surgery is not technically feasible, safe, or efficacious has not be determined.To assess safety and efficacy of RAL urologic procedures in infants1 year of age, weighing ≤10 kg.A single-institution retrospective cohort study of patients1 year of age, and ≤10 kg undergoing RAL pyeloplasty (RALP) or RAL ipsilateral ureteroureterostomy (RALUU) between January 2011 and September 2020 was performed. Demographic, operative, and post-operative data were extracted from the medical record. Patients were stratified by post-hoc weight quartiles. Outcomes, including operative time, total OR time, estimated blood loss (EBL), post-operative length of stay (LOS), post-operative radiographic improvement, and 30-day complications were assessed by weight quartile for each procedure. The Kruskal-Wallis rank test was used to assess differences in continuous outcomes between weight quartiles and Pearson's Chi-squared test was used for categorical outcomes.Of 696 RAL urologic surgeries performed, 101 met eligibility criteria. Median (IQR) age of patients was 7.2 (6.0-9.2) months with median weight of 8.0 (7.2-8.9) kg. The lowest weight was 5.5 kg. Procedures performed included 79 RALPs (78.2%), 22 RALUUs (21.8%). We identified 97 patients (94%) with post-operative imaging, with radiographic improvement in 92%. When stratified by weight quartile, there was no difference between groups in median operative time, total OR time, LOS, EBL, or post-operative radiographic improvement for both RALP and RALUU. Post-operative complications were assessed based on Clavien-Dindo classification with the majority of complications (9/12, 75%) in the50th percentile weight groups.To our knowledge, this is the largest published series of infant RAL urologic procedures, with similar rates of radiographic improvement and post-operative complications to prior published series. There are few prior series of RALP and RALUU in infants ≤10 kg, and we show comparable outcomes regardless of patient weight. Our study is limited by the inherent biases of retrospective studies.RAL urologic surgery is technically feasible, safe, and efficacious in infants ≤10 kg, without worse outcomes as weight decrease. A cut-off weight, below which RAL surgery should not be performed has yet to be identified.

Summary Objective The objective is to describe our experience with robot-assisted laparoscopic diverticulectomy with extravesical ureteral reimplantation in a pediatric patient. Methods A 7-year-old male presented with a symptomatic urinary tract infection secondary to Staphylococcus epidermidis. The patient was found to have a large congenital paraureteral bladder diverticulum on work-up. His options were discussed and he proceeded with robotic diverticulectomy. Intraoperatively, the diverticulum was found to obscure the left ureteral orifice, which necessitated synchronous dismembered extravesical ureteral reimplantation. Results Robot-assisted laparoscopic diverticulectomy with extravesical ureteral reimplantation was performed. The procedure time was 283 min, and estimated blood loss was 3 mL. The patient was discharged home on post-operative day 1. He was last seen in clinic six months after surgery and was doing well without any recurrent urinary tract infections. Conclusion This video demonstrates a robotic approach for the treatment of complex congenital bladder diverticula. Robotic surgery offers the benefits of good visualization in the pelvis, minimal blood loss, and quick convalescence. Key portions of the diverticulectomy and ureteral reimplantation are clearly illustrated in this video, which can help other surgeons adopt this technique.

Summary Introduction and objective Endourological and percutaneous approaches are the standard of care for treatment of pediatric urolithiasis. However, in certain situations, an endoscopic-assisted robotic pyelolithotomy (EARP) can be an acceptable alternative. Limited data exist on pediatric EARP; thus, the authors describe their experience. Methods Patient selection: The authors retrospectively analyzed the records of all robotic procedures performed at five institutions from 7/09–10/17 to identify patients who underwent EARP. The authors collected demographics data, indications, operative time, and postoperative complications. Stone composition was reported as the majority composition (≥50%), unless any uric acid or struvite was noted, and those stones were classified as such. Technique Through a traditional or hidden incision endoscopic surgery (HIdES) robot pyeloplasty approach, the authors are able to easily pass a flexible endoscope through a robotic trocar and into the renal collecting system to perform pyeloscopy or ureteroscopy. Stones were primarily retrieved via the pyelolotomy and, if indicated, treated with laser lithotripsy. Results The authors identified 26 patients who underwent EARP in 27 renal units. Median patient age was 12.2 years (interquartile range [IQR] 6.1–14.5 years), and body mass index was 17.5 kg/m2 (IQR 16.5–25.4 kg/m2). The median pre-operative dimension of the largest stone was 9.0 mm (IQR 5.8 mm–15.0 mm). Reasons for EARP: 21 (77.8%) concomitant pyeloplasty, four (14.8%) altered anatomy precluding other techniques, and two (7.4%) multiple large stones. Multiple stones were present in 20 renal units (74.1%). Stones were located in the renal pelvis in nine (33.3%), lower pole in 10 (37.0%), ureter in one (3.7%), and multiple locations in seven (25.9%). Hidden incision endoscopic surgery approach was used in 14 (51.9%), and the median operative time was 237.5 min (IQR 189.8–357.8 min) with a median length of stay 1.0 day (IQR 1.0–2.0 days). Stone composition included calcium oxalate in 14 (51.9%), calcium phosphate in five (18.5%), cysteine in two (7.4%), struvite in two (7.4%), and unknown in four (14.8%). Overall stone free status was 19 (70.4%); of the eight (29.6%) renal units with residual stones, four underwent ureteroscopy, two extracorporeal shockwave lithotripsy (ESWL), one spontaneously passed, and one underwent percutaneous nephrolithotomy (PCNL). After secondary treatment, final stone free rate was 96.3%. Complications included stent migration and admission for urosepsis. At a median follow-up of 12 months (IQR 6.2–19.2 months), five (18.5%) had stone recurrence. Conclusions Endoscopic-assisted robotic pyelolithotomy is a reasonable treatment option for select pediatric patients with concomitant ureteropelvic junction obstruction and nephrolithiasis or pediatric patients with stones inaccessible by standard methods. Download : Download high-res image (478KB) Download : Download full-size image Summary Figure . Extrarenal view of the operative field from the laparoscopic camera depicting the flexible nephroscope in the renal pelvis performing nephroscopy.

Summary Introduction The Glans-Meatus-Shaft (GMS) Score is a pre-operative phenotypic scoring system used to assess hypospadias severity and risk for post-operative complications. The ‘M’ component is based on pre-operative meatal location, but meatal location sometimes changes after penile degloving, resulting in ‘meatal mismatch.‘ Objective To identify: 1) the incidence and clinical predictors of meatal mismatch, and 2) the association of meatal mismatch with post-operative urethrocutaneous fistula development. Study design We performed a retrospective cohort study on patients who underwent primary hypospadias repair at a single center from 2011 to 2018. Meatal mismatch was defined as: upstaging (meatus moving more proximally after degloving), downstaging (moving more distally after degloving), or none. Covariates included: pre-degloving meatal location, chordee severity, penoscrotal anatomy, pre-operative testosterone, and number of stages for repair. To test the association between meatal mismatch and fistula development, we constructed two, nested, multivariable Cox proportional hazards regression models with and without meatal mismatch and compared them with the likelihood ratio test. A sensitivity analysis excluded patients with Results Of 485 patients, 99 (20%) exhibited meatal mismatch, including 75 (15%) with upstaging and 24 (5%) patients with downstaging (Figure). Meatal mismatch was significantly associated with penoscrotal webbing, number of stages for repair, and pre-degloving meatal location, with downstaging being associated with more proximal meatal location. Over a median follow-up of 7.3 months (interquartile range 2.0–20.9), fistulae developed in 56 (12%) patients. On multivariable analysis, meatal upstaging was associated with a 3-fold increased risk of fistula development (Hazards Ratio [HR]: 3.04, 95% Confidence Interval [CI]: 1.44–6.45) compared to no mismatch. Meatal downstaging had similar risk of fistula development compared to no mismatch (HR: 0.99, 95% CI: 0.29–3.35). Multi-stage compared to single-stage repair was associated with reduced risk of fistula development (HR: 0.24, 95% CI: 0.09–0.66). The likelihood ratio test favored the model that included meatal mismatch. The sensitivity analysis showed similar findings. Discussion Our short-term results suggest that meatal mismatch may be an important additional consideration to the GMS score as a tool to assess hypospadias severity, counsel families, and predict outcomes. Longer-term studies are needed to enhance the precision of risk stratification in hypospadias. Conclusions Meatal mismatch occurred in 20% of patients undergoing hypospadias repair. Among this cohort, meatal upstaging was associated with a 3-fold increased risk of post-operative urethrocutaneous fistula development. Download : Download high-res image (274KB) Download : Download full-size image Summary Figure 1 . Flow diagram of cohort and major findings. Summary Table 1 . Sensitivity Analysis (restricted to patients with ≥6 months of follow-up, N=275) multivariable Cox regression models with and without meatal mismatch. Likelihood ratio test showed better fit with full model (p=0.04). Variable Base Model HR (95% CI), p-value Full Model HR (95% CI), p-value Pre-degloving Meatal Location Glanular Referent Referent Coronal 0.54 (0.09–3.24), p = 0.50 0.58 (0.10-3.53), p = 0.56 Distal/Midshaft 1.61 (0.38-6.91), p = 0.52 2.24 (0.50-10.03), p = 0.29 Proximal 3.33 (0.69-16.18), p = 0.14 7.18 (1.21-42.52), p = 0.001 Chordee Severity (n = 457) None (0°) Referent Referent Mild (1–29°) 3.41 (0.43-26.80), p = 0.24 3.90 (0.50-30.50), p = 0.20 Moderate (30–60°) 3.91 (0.48-31.66), p = 0.20 3.61 (0.45-29.01), p = 0.23 Severe (≥61°) 4.11 (0.50-34.02), p = 0.19 3.95 (0.48-32.51), p = 0.20 # of Stages of Repair Single-stage Referent Referent Multi-stage 1.97 (1.01-3.84), p = 0.047 1.76 (0.89-3.47), p = 0.11 Pre-operative Testosterone No Referent Referent Yes 1.65 (0.92–2.98), p = 0.10 1.43 (0.78–2.62), p = 0.25 Meatal Mismatch No mismatch – Referent Meatal downstaging – 0.88 (0.25-3.01), p = 0.84 Meatal upstaging – 3.04 (1.34-6.88), p = 0.007

Purpose: We characterize the use of pediatric open, laparoscopic and robot-assisted laparoscopic ureteral reimplantation in the United States from 2000 to 2012.Materials and Methods: We used the Kids’ Inpatient Database to identify patients who underwent ureteral reimplantation for primary vesicoureteral reflux. Before 2009 laparoscopic ureteral reimplantion and robot-assisted laparoscopic ureteral reimplantation were referred to together as minimally invasive ureteral reimplantation. A detailed analysis of open vs robot-assisted laparoscopic ureteral reimplantation was performed for 2009 and 2012.Results: A total of 14,581 ureteral reimplantations were performed. The number of ureteral reimplantations yearly decreased by 14.3%. However, the proportion of minimally invasive ureteral reimplantations increased from 0.3% to 6.3%. A total of 125 robot-assisted laparoscopic ureteral reimplantations were performed in 2012 (81.2% of minimally invasive ureteral reimplantations), representing 5.1% of all ureteral ...

We assessed whether increased BMI has a negative impact in children undergoing robot assisted laparoscopic pyeloplasty (RALP).Records of patients who underwent RALP were retrospectively reviewed and separated into healthy weight, overweight, and obese cohorts based on age-adjusted BMI percentile, and surgical and postsurgical outcomes were evaluated.Of the 103 patients, there were 79 healthy weight and 24 overweight, with 10 of the 24 considered obese (BMI85th, ≥85th, and ≥95th percentile for age, respectively). Cohorts were similar in respect to age, sex, laterality and symptoms. Operative time (234 min, 241 min, p=0.642; 254 min, p=0.324), EBL (7.1 ml, 10.5 ml, p=0.293; 6.8 ml, p=0.906), length of stay (1.2d, 1.2d p=0.545; 1.1d p=0.550), and narcotic administration (0.25 mg/kg, 0.25 mg/kg, p=0.545; 0.13 mg/kg, p=0.430) were similar between healthy weight, overweight, and obese cohorts, respectively. Complication rates were similar in regard to minor and major complications. There was no difference in decreased hydronephrosis (92.2%, 89.6%, p=0.440; 88.9%, p=0.730). Four patients (3.4%) required a reoperative procedure (three healthy weight, one overweight; p=NS).Despite the potential difficulties with surgery in overweight patients, our data indicate that robot-assisted laparoscopic pyeloplasty can be performed as safely and effectively in overweight or obese children as in healthy weight children.

Summary Background Robot-assisted retroperitoneal lymph node dissection (RA-RPLND) has built on success and techniques of laparoscopic RPLND, with the added benefits of robotic technology. This paper demonstrates use of the da Vinci Xi® system for RA-RPLND in two adolescent patients. Methods Case #1: A 17-year-old male presented with a left testicular mass and elevated alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG). Pathology revealed a mixed non-seminomatous germ cell tumor (60% embryonal, 35% yolk sac, 5% choriocarcinoma, + lymphovascular invasion). Tumor marker normalized post-orchiectomy, and staging imaging was without evidence of metastatic disease. After discussion of options he opted to undergo RA-RPLND. Case #2: A 15-year-old male presented with a right para-testicular mass and negative tumor markers. He underwent inguinal exploration and excision of the paratesticular mass. Final pathology revealed an ectomesenchymoma with a spindle cell rhabdomyosarcoma component. Staging imaging was negative, and after discussion of options he underwent completion orchiectomy and RA-RPLND. Results The patient in Case #1 underwent a left modified-template nerve-sparing RA-RPLND. Sixteen lymph nodes were negative for tumor. The patient in Case #2 underwent complete bilateral nerve-sparing RA-RPLND. Forty-two lymph nodes were negative for tumor. Estimated blood loss was Conclusion This was a report of two cases of RA-RPLND in the adolescent population. RA-RPLND is technically feasible in this population, and further study of RA-RPLND is needed to determine long-term outcomes, as this technique is becoming more widely adopted.

We sought to determine if the learning curve in pediatric robotic-assisted laparoscopic pyeloplasty (RALP) for an experienced open surgeon (OS) converting to robotics would be affected by proctoring from an experienced robotic surgeon (RS), and/or the experience of training within the framework of an established robotics program. We reviewed pediatric RALP cases by three surgeons at our institution, including the OS, RS, and a new fellowship-trained surgeon (FTS). We compared the first eight independent RALPs for the OS with the most recent ten RALPs for the RS. As an ancillary analysis, to isolate the impact of proctoring and of a robotics program, we reviewed the first ten cases of the FTS as well the first and last eight cases of the RS at a prior institution. A total of 44 patient charts were reviewed, with a mean follow-up time of 16 months (range 6.7-45 months). Radiologic improvement was seen in all patients with the exception of one who required reoperative pyeloplasty. The FTS, RS, and OS had similar mean operative times; however; when comparing robotic cases at the beginning of each of their learning curves, shorter operative times were achieved by the proctored surgeon (OS). Finally, comparing two RALP cohorts by the RS at his prior institution revealed longer operative times with an inexperienced robotics team. We demonstrate that an experienced open surgeon and fellowship-trained surgeon can quickly attain levels of expertise with pediatric RALP within an established robotic surgical program.

Failed pyeloplasty represents a management dilemma, with treatment options including balloon dilation, endopyelotomy and reoperative pyeloplasty. We review our experience with robot-assisted laparoscopic reoperative repair of recurrent/persistent ureteropelvic junction obstruction in children and compare this method to other approaches.We reviewed in detail all cases of failed prior ureteropelvic junction procedures, either open or laparoscopic, managed by robot-assisted laparoscopic reoperative repair between 2006 and July 2011.Robot-assisted laparoscopic repair was performed in 16 cases for persistent or recurrent ureteropelvic junction obstruction following a prior procedure involving the ureteropelvic junction (12 open pyeloplasties, 4 robot-assisted laparoscopic repairs). Additional interventions had been performed in 12 patients. Reoperative robot-assisted laparoscopic pyeloplasty was performed in 13 patients and reoperative robot-assisted laparoscopic ureterocalycostomy in 3. Patient age ranged from 12 months to 15.3 years (mean 6.1 years). Mean operative time and length of stay were 303 minutes and 1.6 days, respectively. Mean followup was 14.9 months. All symptomatic patients had resolution of symptoms postoperatively. A total of 14 patients (88%) had improved radiological findings. One patient underwent transfusion and conversion to an open procedure due to bleeding.Robot-assisted laparoscopic reoperative repair of persistent/recurrent ureteropelvic junction obstruction is a safe, highly effective procedure even in the setting of multiple prior procedures. In our series all patients improved symptomatically, 88% improved radiographically and none have required further surgical intervention. Success is greater than with endopyelotomy and comparable to open reoperative repair for this challenging condition during short-term and intermediate followup.

Summary Objective The aim was to demonstrate surgical techniques used in pediatric robot-assisted laparoscopic megaureter tapering (RALMT) with ureteral reimplantation. We report on our preliminary experience. Methods We reviewed video of patients who underwent RALMT with ureteral reimplantation between August 2012 and November 2015. MT was performed extravesically and ureteral reimplantation was performed by extravesical detrusorrhaphy with ureteral anchoring. All patients had an intraoperatively placed ureteral stent. Results Between August 2012 and November 2015, 14 patients underwent RALMT with ureteral reimplantation. Highlighted techniques include variations in ureteral stent insertion, method of excisional tapering, and approach to reimplantation. All (10/10) patients with postoperative ultrasounds following ureteral stent removal demonstrated radiographic improvement at a mean follow-up of 9 months. No patients had postoperative febrile urinary tract infections. The only complication was one patient with postoperative ileus. Conclusions We demonstrate variations in surgical techniques which may facilitate the surgical steps of RALMT with ureteral reimplantation. Our preliminary experience suggests the procedure is safe and feasible for pediatric patients with symptomatic megaureter.

We report 4 pediatric cases of ureteropelvic junction obstruction involving delayed progression of initially mild postnatal hydronephrosis. All 4 children became symptomatic; however, 3 already had a substantial decrement of ipsilateral kidney function by the time of diagnosis. Two of these 3 patients had previous renal scintigraphy demonstrating normal differential function. We caution that counseling regarding hydronephrosis should emphasize the importance of prompt re-evaluation for any symptoms potentially referable to delayed presentation of ureteropelvic junction obstruction, irrespective of initial hydronephrosis grade. Future studies are needed to determine the optimal follow-up regimen for conservative management of hydronephrosis.

Renal lymphangiectasia is a rare diagnosis. It is also referred to as renal lymphangioma, renal lymphangiomatosis, peripelvic lymphangiectasia, renal peripelvic multicystic lymphangiectasia, and hygroma renale. The presentation varies, and the diagnosis depends on accurate radiologic interpretation. We present the radiologic images of a pediatric patient who was diagnosed with renal lymphangiectasia after being evaluated for suspected nonaccidental trauma to emphasize the importance of identifying this entity by the characteristic radiologic findings.

Objective Demonstrate and report initial results using a carbon dioxide (CO 2 ) laser for detrusor tunnel creation in robot-assisted laparoscopic extravesical ureteral reimplant (RALUR). Methods Retrospective chart review was performed for cases of RALUR from 2011 to 2014. Patients undergoing complex reconstruction (ureteral tailoring, dismembered reimplant, concomitant ureteroureterostomy), and those who had incomplete follow-up were excluded. Variables, including use of the CO 2 laser, were collected and correlated with outcomes. Results 23 patients representing 40 ureteral units were included for analysis. A CO 2 laser was used in 9/23 (39%) patients and 16/40 (40%) ureteral units. Intraoperative mucosotomy was reported in 3/14 (21%) patients for the electrocautery group and 1/9 (11%) patients for the CO 2 laser group. Resolution of VUR was observed in 11/14 (79%), and 9/9 (100%) of patients for the electrocautery group and the CO 2 laser group, respectively. Two complications were identified in the electrocautery group of patients: ileus (Clavien 2), and transient bilateral ureteral obstruction requiring placement of ureteral stents (Clavien 3B). There were no complications in the CO 2 laser group. Conclusions Creation of the detrusor tunnel with a CO 2 laser is safe and effective, and is associated with a lower rate of failure and complication in this cohort.

Regional anesthesia is often used in combination with general anesthesia for pediatric surgery, however, it is unknown if adjunctive regional blocks are beneficial to children undergoing urologic laparoscopic or robot-assisted laparoscopic (RAL) procedures.To compare perioperative outcomes in children with adjunctive caudal blocks, transversus abdominis plane (TAP) blocks, or no regional anesthesia for common RAL surgical procedures in pediatric urology.Inclusion in this retrospective study was limited to children who underwent RAL renal or ureteral/bladder procedures and received a standardized regimen of scheduled intravenous ketorolac and oral acetaminophen for acute postoperative pain control, with opioids as needed (PRN). Perioperative outcomes were compared between patients with an adjunctive caudal block (n = 25), bilateral TAP blocks (n = 44), or no regional anesthesia (n = 51).Children with a preoperative caudal block received less intraoperative opioids than children with TAP blocks or no regional anesthesia (p0.001). This difference was observed both for renal procedures (p0.01) and ureteral/bladder procedures (p = 0.01). Patients with caudal blocks were also the least likely to require postoperative antiemetics (p = 0.03). There were no significant differences between groups in postoperative opioid use, maximum pain scores within 6 and 24 hours postoperatively, or length of hospital stay (LOS). No complications attributable to regional blocks were identified by chart review.Use of adjunctive caudal blocks for pediatric RAL renal or ureteral/bladder surgical procedures may reduce need for alternate analgesic and/or anesthetic agents intraoperatively, as well as decrease postoperative nausea and vomiting. These findings may be related, since nausea and vomiting are common side effects of opioids and inhalational anesthetics. Consideration of the potential impact of caudal blocks on general anesthetic requirements is timely in light of concerns regarding the risk of anesthetic neurotoxicity in young patients. There was no evidence of improved postoperative pain control or shorter LOS for children who received regional anesthesia. It is unknown if regional blocks would have a greater impact in the absence of scheduled pain medications, which all patients in our study received. Limitations of this study include its retrospective nature and moderate sample size. Future randomized controlled trials are necessary to provide a more definitive understanding of regional anesthesia's role in minimizing pediatric surgical and anesthetic morbidity.Administration of caudal blocks should be considered for children of suitable age undergoing RAL surgery involving either the upper or lower urinary tract.

Objective To demonstrate a novel technique for robot-assisted laparoscopic excisional tailoring and reimplantation of a refluxing megaureter. Methods A 9-year-old boy with dysfunctional elimination was found to have a refluxing megaureter and diminished ipsilateral renal function. Robotic ureteral reimplantation with excisional tailoring was performed using a three-port approach. Stay sutures were placed in the anterior aspect of the distal ureter and sequentially lifted to allow freehand excision of redundant ureter. The ureterovesical junction was left intact, and the ureter was repaired over a 6 Fr double-J stent. Detrusorotomy to create flaps for ureteral tunneling was performed with a carbon dioxide (CO 2 ) laser. Results The patient's vesicoureteral reflux was successfully corrected, and he is now asymptomatic. Conclusion Specific technical modifications can facilitate robotic megaureter repair with intracorporeal excisional tailoring. The CO 2 laser is advantageous for detrusorotomy.

Congenital bladder diverticula are rare anomalies of the bladder. Patients present with infection, hematuria, and/or urinary obstruction. We report on the case of a 12-year-old boy who developed gross hematuria and recurrent infection owing to a 12-cm bladder diverticulum. Robotic-assisted laparoscopic diverticulectomy was performed. We describe the first reported robotic-assisted laparoscopic diverticulectomy in a pediatric patient.

Purpose: Laparoscopic orchiopexy is extremely effective for treating patients with nonpalpable testis. However, despite the high dissection and wide mobilization it allows in some cases, vessel length prevents the testis from reaching the scrotum. There have been only incidental cases reported in which laparoscopy has been used for vessel transection and testicular mobilization orchiopexy. We reviewed our cases treated with the Fowler-Stephens orchiopexy performed laparoscopically in 1 or 2 stages.Materials and Methods: We reviewed the records of all boys who underwent laparoscopy for a nonpalpable testis at our institutions since 1992. Patients who underwent testicular vessel transection and orchiopexy performed laparoscopically in 1 or 2 stages were selected for evaluation. Office charts and operative reports were reviewed in detail.Results: Of the 126 nonpalpable testes in 108 patients 51 (40%) were intra-abdominal, including 18 (35%) in 14 patients in whom the Fowler-Stephens procedure was per...

Renal computed tomography (CT), 3-dimensional CT angiography (3D-CTA), and simultaneous measurement of glomerular filtration rate (GFR) by x-ray fluorescence determination of plasma contrast clearance (PCC) are alternatives to intravenous urography (IVU), renal arteriography (RA), and 24-hr urine creatinine clearance (CrCl) for evaluation of renal structure and function in living renal donor (LRD) candidates. To determine if CT, 3D-CTA, and PCC provide data comparable to IVU, RA, and CrCl, both methods were used to evaluate 23 LRD candidates. Costs were also compared. Conventional RA identified 19 accessory arteries and one case of medial fibroplasia. Each of these anomalous vessels was recognized on 3D-CTA. Venous anatomy was more clearly delineated on 3D-CTA than the venous phase of conventional RA. CT demonstrated 3 benign cysts and a single, small intra-parenchymal calcification in 3 renal units. GFRs measured by PCC and CrCl were 91±4 and 132±7 ml/min/1.73m 2 , respectively (r=0.64, P

Summary Introduction Recent studies have suggested that a smaller glans penis size may be associated with a higher likelihood of complications after hypospadias repair. Accurate identification of risk factors other than the well-understood variable of meatal location would allow development of better prognostic models and individualized risk stratification. Objective To test the hypothesis that a smaller width of the glans penis predicts adverse outcomes after hypospadias surgery. Methods Prospectively recorded clinical data were reviewed from a single-institution registry of primary hypospadias repairs performed between 2011 and 2014. Follow-up records were examined for occurrence of complications. Urethroplasty complications were defined to include meatal stenosis, dehiscence, urethrocutaneous fistula, urethral stricture, and/or urethral diverticulum. The subset of meatal stenosis and dehiscence were regarded as glanular complications. Regression analyses were performed to determine association between glans width and occurrence of complications. Because pre-operative androgen stimulation is known to increase glans penis size, separate subgroup analyses were included of patients with and without pre-operative use of testosterone cream. Results A total of 159 patients met criteria for inclusion in the study cohort: 140 patients underwent a single-stage repair, while 19 patients had a two-stage repair. The median glans penis width was 15 mm (range 10–22). Eighty-four patients (53%) received testosterone cream pre-operatively and had a significantly wider glans penis than the 75 patients who did not (median 15.5 vs 14 mm; P Twenty-four patients (15%) had one or more urethroplasty complications, including 11 (7%) with glanular complications. Overall, there was no statistically significant association between glans width and urethroplasty complications ( P = 0.26) or glanular complications ( P = 0.90) (Summary Table). Subgroup analyses of patients with and without pre-operative testosterone also revealed no significant associations between glans width and complications. Conclusions Glans penis width was not a risk factor for complications after hypospadias repair. This finding differs from the results of other recent studies and encourages further research into the value of measuring penile parameters in patients undergoing hypospadias repair. Summary Table . Association of glans width (mm) and complications after hypospadias repair, overall and stratified by pre-operative testosterone use. Odds ratio (95% CI) for all urethroplasty complications Odds ratio (95% CI) for glanular complications Overall ( n = 159) 1.12 (0.92–1.35) P = 0.26 1.02 (0.78–1.33) P = 0.90 With pre-operative testosterone ( n = 84) 1.03 (0.79–1.33) P = 0.84 1.03 (0.72–1.51) P = 0.84 Without pre-operative testosterone ( n = 75) 1.14 (0.83–1.57) P = 0.41 0.88 (0.54–1.45) P = 0.63

Treating constipation in children with voiding dysfunction may improve or resolve urinary symptoms. A clinical diagnosis of constipation may not identify all patients. Abdominal radiographs (plain x-ray of the kidneys, ureters and bladder) are often used to assess constipation but no objective definition of constipation based on abdominal radiographs exists. Most abdominal radiograph rating scales use subjective criteria and our previous series showed that these scales have poor reliability. We identified reliable, objective parameters on abdominal radiograph to predict constipation.The abdominal radiographs of 80 children 4 to 12 years old, including 40 with constipation and 40 successfully treated for constipation, were assessed for several measurable parameters. Logistic regression was used to construct a model to predict constipation status based on these abdominal radiograph parameters. Model accuracy was assessed using AUC analysis of ROC curves.The most predictive model included cecal diameter, total length of stool measured, stool length in the rectum, and patient age and gender. As measured by the area under the ROC curve, accuracy was excellent at 0.87. We calculated cutoffs for individual parameters on abdominal radiograph, including total stool length greater than 33.4 cm, cecal diameter greater than 3.7 cm and stool length in the rectum greater than 5.9 cm.We identified accurate, reliable criteria based on objective measurements on abdominal radiograph to differentiate patients with and without constipation. These criteria may be applied to objectively assess constipation status in children with urinary symptoms without a history of constipation. Further study will determine whether these criteria predict the response to treatment.

Currently to our knowledge no validated reliable tools are available to evaluate constipation in children. Abdominal x-rays are often done in clinical practice to evaluate patients with lower urinary tract symptoms. Although 3 previously published rating tools exist to score constipation based on x-ray, there is little information on their merits. We assessed these 3 tools for reliability among multiple practitioners.We retrospectively analyzed abdominal x-rays in a cohort of 80 patients between ages 4 and 12 years. X-rays were independently assessed by each of us using the previously published Barr, Leech and Blethyn scoring tools. Scores were analyzed for reliability using standard statistical methods.The range of weighted κ score, indicating reliability, were 0.0491 to 0.4809 for the Barr, 0.1195 to 0.2730 for the Leech and 0.0454 to 0.4514 for the Blethyn method. Guidelines for κ scores are greater than 0.75-excellent, 0.4 to 0.75-good and 0 to 0.4-marginal reproducibility. ICC, another reliability measure, was 0.02577 for the Barr, 0.3313 for the Leech and 0.201 for the Blethyn method. ICC interpretations are greater than 0.75-excellent, 0.4 to 0.75-good and 0 to 0.4-poor. There was a trend toward good interrater reliability between more experienced urology practitioners with the Barr and Blethyn tools (0.48 and 0.45, respectively) but not between less experienced raters or with the Leech tool.Currently available scoring tools to evaluate constipation by x-ray do not have good reliability among multiple examiners. Further research is needed to develop an alternate tool to increase the reliability of x-ray to assess constipation between multiple raters.

Transurethral insertion of foreign bodies into the urinary bladder is uncommon in children. We report an 11-year-old boy who presented with hematuria and difficulty voiding secondary to numerous magnetic beads lodged in the urinary bladder and posterior urethra.

Postoperative chylous ascites is a rare complication of retroperitoneal surgery that has considerable morbidity. We review the pathogenesis and management of chylous ascites following surgical treatment of Wilms tumor.We identified 9 children with chylous ascites after surgical treatment of Wilms tumor. Of these cases 3 were treated at a single institution during the last 20 years and 6 were identified during retrospective chart reviews of patients enrolled in National Wilms Tumor Studies 3 and 4 to identify surgical complications. Chylous ascites presented as increased abdominal girth and poor feeding. Paracentesis or laparotomy was diagnostic.Patient age at presentation with Wilms tumor ranged from 6 to 95 months (median 15). Left nephrectomy was performed in 5 cases, right nephrectomy in 3, and left nephrectomy and partial right nephrectomy in 1 with bilateral disease. Lymphadenectomy including the hilar and periaortic lymph nodes was performed in 5 patients, 4 of whom also underwent some form of suprahilar lymph node dissection. Three patients underwent lymph node sampling of the hilar, periaortic and some suprahilar lymph nodes. All children received adjuvant chemotherapy and 4 were treated with adjuvant irradiation to the surgical bed before the diagnosis of chylous ascites. The interval between surgery and diagnosis of ascites ranged from 12 to 49 days (median 21). Of the patients 7 were successfully treated with conservative measures, total parenteral nutrition and/or a diet containing primarily medium chain triglycerides, and 2 required invasive procedures, including exploratory laparotomy and ligation of disrupted lymphatic vessels or placement of a peritoneovenous shunt.Extensive lymph node dissection, particularly above the level of the renal hilum, appears to be associated with the development of postoperative chylous ascites. The National Wilms Tumor Study guidelines do not require formal lymph node dissection for staging and only lymph node sampling is recommended. Elimination of formal lymphadenectomy along with meticulous ligation of lymphatics should decrease the incidence of this complication. Fortunately, conservative treatment with total parenteral nutrition and/or medium chain triglycerides will remedy the problem in the majority of children.

Multiple approaches exist for the management of the nonpalpable testis. With the use of diagnostic laparoscopy widely accepted in the setting of the nonpalpable testis we have found laparoscopic orchiopexy to be an efficient and logical extension. To evaluate its use we report our experience with laparoscopic orchiopexy to treat 44 nonpalpable testes in 36 patients.We retrospectively reviewed the medical records of all patients who underwent laparoscopic orchiopexy for a 2 1/2-year period. Modifications of the surgical technique are described.The left testis was affected in 18 boys, the right in 9 and both in 9. At laparoscopy 8 testes were at the internal ring or were peeping and the remainder were intra-abdominal. One patient underwent a unilateral 1-stage Fowler-Stephens orchiopexy, and 3 unilateral and 1 bilateral 2-stage Fowler-Stephens orchiopexy. Two patients underwent laparoscopically assisted orchiectomy. The remaining 31 patients underwent laparoscopic orchiopexy without division of the spermatic vessels. At followup (mean 6 months) all testes are without atrophy, and 39 of 42 (93%) are in an acceptable scrotal position. There are 3 testes (7%) high in the scrotum.Laparoscopic orchiopexy is a logical extension of diagnostic laparoscopy for the evaluation and treatment of the nonpalpable testis. The low incidence of complications and 93% success rate underscore the feasibility of this procedure. It is our procedure of choice for the treatment of nonpalpable testis.

Malacoplakia is a rare disease of the urinary tract, especially in children, with only 15 reported pediatric cases in the English literature. We report on a 16-year-old girl who presented with renal insufficiency and multiple bladder masses. CASE REPORT A 16-year-old girl was admitted to the hospital for a possible seizure. Evaluation revealed a creatinine of 3.0 mg/dl (normal 0.7 to 1.5) and an Escherichia coli urinary tract infection. The patient had developmental delay and was unable to give a reliable symptom history but the family denied any history of flank pain, urinary tract infection, dysuria, hematuria, frequency or incontinence. She was on no medications at home. Renal ultrasonography demonstrated echogenic kidneys bilaterally with caliceal dilatation and multiple polypoid solid bladder masses with blood flow by color Doppler (fig. 1). Diuretic renography showed minimal function of the left kidney but no obstruction. Voiding cystourethrography revealed multiple filling defects in the bladder and grade I vesicoureteral reflux bilaterally. Retrograde pyelograms demonstrated dilatation of the calices bilaterally, normal ureters and no filling defects in the upper tracts. Cystoscopy showed multiple yellow-tan polypoid smooth masses, which were biopsied. Histological changes were consistent with malacoplakia. The patient was never febrile while in the hospital and the seizure evaluation was negative. She was discharged home on oral fluoroquinolone and bethanechol therapy for 3 months. She remained asymptomatic. Followup ultrasonography revealed resolution of the bladder polyps and no change in the kidneys. Repeat bladder biopsy was negative for malacoplakia. Urine culture was negative off of antibiotic prophylaxis. DISCUSSION