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PURPOSE OF REVIEW: Endocrine disrupting chemicals (EDCs) potentially have a role in causing hypospadias malformation through modifiable in-utero exposure. Considering the emerging literature on the role of potential endocrine disrupting substances on the occurrence of hypospadias and the potential to inform public health efforts to prevent the occurrence of these malformations, we have summarized the current literature, identified areas of consensus, and highlighted areas that warrant further investigation. RECENT FINDINGS: Pharmaceuticals, such as diethylstilbestrol, progestin fertility treatments, corticosteroids, and valproic acid, have all been associated with hypospadias risk. Data on exposure to dichlorodiphenyltrichloroethane and hexachlorobenzene pesticides, as well as non-persistent pollutants, particularly phthalates, is less consistent but still compelling. SUMMARY: Improving exposure assessment, standardizing sample timing to relevant developmental windows, using clear case identification and classification schemes, and elucidating dose-response relationships with EDCs will help to provide clearer evidence. Promising directions for future research include identification of subgroups with genetic hypospadias risk factors, measurement of intermediate outcomes, and study of EDC mixtures that will more accurately represent the total fetal environment.

Ureteroneocystostomy is the standard mode of establishing urinary drainage in renal transplantation. However, donor-to-recipient ureteroureterostomy may be considered in the presence of a challenging bladder or an augmented bladder, or when the donor ureter might be compromised or is too short. This approach also preserves a nonrefluxing system with an orthotopic ureteral orifice.We retrospectively reviewed the records of all pediatric renal transplantations in which ureteroureterostomy was performed at a single tertiary care pediatric center over the 12-year period from 2004 to 2015. Ureteroureterostomy was performed in end-to-side fashion from donor-to-recipient ureter. Patients with a history of symptomatic vesicoureteral reflux were excluded from ureteroureterostomy. Parameters were reviewed, including age, gender, source of renal transplantation (deceased or living donor), indications for ureteroureterostomy and complications.Primary ureteroureterostomy was performed at 23 of the 213 renal transplantations (10.8%). At transplantation mean ± SD age was 11.7 ± 4.9 years and mean weight was 33.5 ± 18.9 kg. Two secondary ureteroureterostomies were done to salvage the ureter due to complications after ureteroneocystostomy. Of the patients 60% and 40% underwent ureteroureterostomy during deceased and living donor renal transplantation, respectively. The most common indications included a challenging small bladder due to anuria, a valve bladder and a neurogenic augmented bladder. Two urinary leaks (8%) occurred and no allografts were lost.Ureteroureterostomy is a safe alternative to standard ureteroneocystostomy in renal transplantation. Ureteroureterostomy should be considered a primary option in certain complex situations and secondarily as a salvage procedure when ureteral problems develop after ureteroneocystostomy in patients who undergo renal transplantation.

Summary Background Urothelial cell carcinoma (UCC) of the bladder is exceedingly rare in pediatric patients. Limited data are available to guide management in this population. Methods The authors systematically searched MEDLINE, Cochrane Library, and Google Scholar (through February 2019) for case reports and series to summarize data regarding presentation, evaluation, management, and follow-up for patients ≤ 18 years diagnosed with UCC of the bladder. Patient-level data were abstracted, and adjusted logistic regression was used to identify factors associated with a combined outcome of recurrence or death. Results One hundred two articles describing 243 patients from 26 countries met criteria. Average age was 12.5 years, 32.6% were female, 15.3% had medical comorbidities, and 13.2% had known risk factors for bladder cancer. Initial management was transurethral resection in 95.5% of patients, whereas 6.2% required secondary intervention. Tumor stage was TaN0M0 in 86.4% and low grade in 93.4%. Recurrence and death occurred in 8.6% and 3.7%, respectively. Mean time to recurrence or death was 8.6 months (standard deviation [SD] 7.6) for 10.7%. Mean disease free follow-up without recurrence or death was 56.9 months (SD 54.2) for 89.3%. Patients with comorbidities, risk factors, or family history (odds ratio [OR]: 2.4, 95% confidence interval [CI]: 1.02–5.6); ≥TaN0M0 disease (OR: 6.2, 95% CI: 2.5–15.6); and larger tumors at diagnosis (OR: 1.7, 95% CI: 1.2–2.4) had significantly greater adjusted odds of recurrence or death after initial treatment. Conclusion Based on pooled results, disease recurrence or death occurred in 10.7% of pediatric patients and within 9 months for most and within 32 months for all patients. This may suggest that low-grade and stage UCC of the bladder in pediatric patients can be systematically monitored for at least 3 years. However, prospective evaluation of this clinical strategy is warranted.

Since its development in 1989, the ACE procedure has become widely accepted as a valuable addition to the therapeutic regimens available for treating intractable faecal incontinence associated with conditions such as myelomeningocele and anorectal malformations. Thousands of patients around the world have undergone ACE procedures with success rates in excess of 80% reported.

Intra-operative arterial vasospasm during pediatric renal transplantation is an urgent clinical situation resulting in end-organ ischemia, associated changes in parenchymal turgor and color, diminished flow on ultrasound, and if left untreated, allograft loss. We hypothesized that intra-operative intra-arterial injection of nitroglycerin would reverse vasospasm and improve renal perfusion. A three-yr-old girl with end-stage renal disease due to autosomal recessive polycystic kidney disease on peritoneal dialysis underwent deceased donor renal transplantation. After optimal immediate reperfusion and hemodynamic parameters, the kidney lost turgor and became mottled in appearance despite adequate hilar arterial and venous Doppler waveforms. Two aliquots of 40 μg (0.4 mL of a 100 μg/mL) nitroglycerin solution were injected directly into the renal artery 10 min apart. Nitroglycerin resulted in dramatic change in the consistency and appearance of the allograft. An improvement in renal blood flow was demonstrated by ultrasound after the second intra-arterial nitroglycerin injection with only a transient decrease in systemic arterial blood pressure. The child experienced normal allograft perfusion on serial postoperative ultrasounds, with a prompt decrease in serum creatinine and excellent diuresis. Intra-arterial nitroglycerin is a promising option for intra-operative arterial vasospasm during pediatric renal transplantation with objective improvement in blood flow and perfusion.

OBJECTIVES:Elective newborn circumcision, one of the most common surgical procedures in the world, is often performed with either the Gomco clamp or the Mogen clamp. Our aims were to determine differential circumcision revision and complication rates due to surgical technique and differences in outcomes when residents versus attending physicians performed the procedure.METHODS:We conducted a retrospective chart review of newborns who underwent elective circumcision at our children’s hospital from January 2013 to June 2017 using Current Procedural Terminology codes for newborn circumcision and repair of an incomplete circumcision. We excluded patients who were initially circumcised by a physician other than a pediatrician and procedures that were performed after 31 days of age. The primary outcome was the rate of circumcision revisions. The secondary outcome was the incidence of minor and major complications. We used independent sample t tests, analysis of variance, Fisher’s exact test, and logistic regression models in the analysis.RESULTS:We analyzed 979 Gomco and 718 Mogen procedures. Both groups had similar complication (26 of 1697 or 1.53%) and revision rates (8 of 1697 or 0.47%). Attending physicians and residents had similar revision rates overall, but residents using the Gomco clamp had a higher rate of revision (2 of 249 or 0.80%) than attending physicians (2 of 730 or 0.27%; P = .003). Older age at primary procedure was significantly associated with revision (P = .03).CONCLUSIONS:Elective newborn circumcision is associated with similar complication and revision rates after the use of either Gomco or Mogen clamps. There were no differences in outcomes when the procedure was performed by pediatric residents or attending pediatricians.

Laparoscopic surgery is an evolving surgical modality in children, which has been applied to increasingly more complex surgeries and patients, including patients with renal insufficiency. These patients are particularly susceptible to the challenges that laparoscopy imposes on their altered physiology, leading to marked electrolyte disturbances, including metabolic acidosis and hyperkalemia. Hyperkalemia has the potential for marked impairment of cardiac conduction. We report 2 cases where significant, potentially lethal hyperkalemia developed during laparoscopic nephrectomy in adolescents with renal insufficiency. Awareness of this issue, as well as adequate preparation and intraoperative monitoring are essential to preventing this life-threatening complication.

Summary Introduction Ileocystoplasty is the standard technique used for bladder augmentation, and has been used widely for decades. However, it is known to be associated with complications such as stone formation, mucus production, metabolic acidosis, urinary tract infections, intestinal obstruction, and a long-term risk of bladder cancer. Seromuscular bladder augmentation (SMBA) is an alternative to the standard ileocystoplasty, and has been associated with a lower incidence of bladder stones. Few reports have been published on intermediate outcomes of SMBA. Herein, we report long-term outcomes of SMBA from a single institution compared with standard ileocystoplasty. Methods After Institutional Review Board approval, a retrospective chart review of all patients who underwent bladder augmentation at our institution over a 14-year period was performed. The status of patients after SMBA (10 patients) was compared according to age, sex, and diagnosis with patients who underwent traditional ileocystoplasty (30 patients). Parameters such as demographic information, pre- and postoperative bladder capacity as assessed by urodynamic studies, urinary tract infections (UTIs), bladder calculi, incontinence, need for secondary surgical procedures, and spontaneous bladder perforation were compared in the two groups. All the patients were on a clean intermittent catheterization (CIC) regimen. Results Over the study period, 10 patients underwent SMBA and 30 patients (according to age, sex, and diagnosis) underwent standard ileocystoplasty; the average age at surgery was 10.3 and 10 years respectively, with a mean follow up of 6.7 years in the SMBA group and 6 years in the ileocystoplasty group. There were no statistically significant differences in the rate of UTIs, urinary incontinence, subsequent surgery, or spontaneous bladder perforation. The mean bladder capacity increased significantly for both groups as assessed by pre- and postoperative urodynamic studies, although the difference in the rate of bladder calculi between the two groups (0 [0%] vs. 8 [27%], p = 0.06) did not reach statistical significance ( Table ). Conclusions SMBA is safe and efficacious and may result in a lower rate of stone formation than standard ileocystoscopy. SMBA should be considered as a viable alternative to standard ileocystoplasty Table . Outcome comparison: SMBA versus standard ileocystoplasty. SMBA (n = 10) Ileocystoplasty (n = 30) p Mean preoperative bladder capacity, mL (nA = 8, nB = 19) 121 ± 93 153 ± 130 0.26 Mean postoperative bladder capacity, mL (nA = 4, nB = 14) 400 ± 241 378 ± 153 0.42 Mean time of postoperative urodynamics 51 ± 44 50 ± 28 0.47 Urinary tract infections 3 (30%) 8 (27%) 0.8 Bladder calculi 0 (0%) 8 (27%) 0.06 Incontinence 2 (20%) 11 (37%) 0.3 Spontaneous bladder perforation 1 (10%) 0 (0%) 0.07 Secondary surgery 1 (10%) 7 (23%) 0.4 Re-do augmentation 0 (0%) 2 (7%) Stone surgery 0 (0%) 5 (17%) Bladder rupture repair 1 (10%) 0 (0%) .

Laparoscopic and robotic-assisted partial nephrectomy has become an increasingly viable approach for the resection of renal tumors. There are several technical limitations in performing laparoscopic partial nephrectomy, the most significant being the inability to easily obtain cold ischemia which allows for an extended operative time. In this study, we evaluated the feasibility and efficacy of cryoablation as an alternative to hilar clamping to maintain hemostasis during robotic-assisted laparoscopic partial nephrectomy in a porcine model. Twelve female swine underwent nine open and eight robotic-assisted laparoscopic partial nephrectomies using modified cryoablative methods to create hemostasis. Renal perfusion imaged with indocyanine green (ICG) and histological analysis was assessed immediately after the procedure and at 3 weeks post-operatively. With two freeze/thaw cycles, all nine open and eight robotic-assisted laparoscopic partial nephrectomies were successfully completed without the need for hilar clamping. The mean blood loss for the open and robotic-assisted groups was 230.6 and 99.4 ml, respectively. In all cases, maintenance of renal perfusion was confirmed by the presence of a renal pulse and intraoperative ICG imaging immediately and 3 weeks post-operatively. The histological anatomy was well preserved in the resected segment following cryo-resection. After 21 days following cryo-resection, histological analysis demonstrated normal viable tissue with minimal scarring in the remaining kidney. The use of cryoablation created a zone of hemostasis without compromising the vascularity of the remaining kidney, while preserving the renal cytoarchitecture of the segment remove for pathological analysis. Further studies will help to delineate its usefulness in laparoscopic partial nephrectomy.

Since its inception, robot assisted laparoscopic pyeloplasty has rapidly become the minimally invasive surgical intervention of choice for treating ureteropelvic junction obstruction at our institution. The large initial investment in robot assisted surgery is frequently justified by its association with improved optics and instrument articulation, decreased postoperative pain, shorter length of hospitalization and improved cosmesis. However, there are no data specifically showing patient satisfaction with robot assisted laparoscopic pyeloplasty compared to traditional open surgery.A previously validated satisfaction survey (Glasgow Children's Benefit Inventory) with 14 additional questions specifically addressing postoperative satisfaction was mailed to all parents (as patient proxy) of children who had undergone open or robot assisted laparoscopic pyeloplasty between January 2006 and December 2008.A total of 78 parents responded (response rate 70%). All responses achieving statistical significance favored robot assisted laparoscopic pyeloplasty. Parents of children who underwent robot assisted laparoscopic pyeloplasty reported significantly higher satisfaction with "overall life," confidence, self-esteem, burden of postoperative followup and size of incision scar.Parent satisfaction was greater with robot assisted laparoscopic pyeloplasty than with open surgery regarding amount of cosmesis and recovery. Interestingly the differences in satisfaction were not as large as anticipated, suggesting the impact of confounding factors such as age and preoperative parental expectations. Future large-scale prospective studies using validated surveys specific to pediatric surgery are needed to elucidate further the true benefits of minimally invasive surgical technology such as robot assistance.

A 76-year-old female with a history of high-grade transitional cell carcinoma (TCC) of the bladder presented with persistent nocturia and urge incontinence and was diagnosed with a necrotic bladder lesion. Cystoscopy revealed a 4 cm area of necrosis, ulceration, calcification, and fat. Transurethral biopsy confirmed the lesion to be benign, and two attempts to re-epithelialize the area of necrosis with cold scraping of exudate failed. Decision was then made to proceed with removal of necrotic lesion with bladder preservation. With the aid of concomitant cystoscopic visualization of the necrotic lesion, a robotic partial cystectomy with bladder reconstruction was performed. The patient tolerated the procedure, had an uneventful post-operative course, and remains asymptomatic and disease-free at last follow-up of 6 months. To our knowledge, this case represents the first report of a necrotic lesion as a complication of transurethral resection of a bladder tumor (TURBT) and the first description of a robotic partial cystectomy for the management of either benign or malignant bladder disease.

In children with congenital obstructive uropathy, including posterior urethral valves, lower urinary tract decompression is recommended pending definitive surgical intervention. Current options, which are limited to a feeding tube or Foley catheter, pose unappreciated constraints in luminal diameter and are associated with potential problems. We assess the impact of luminal diameter on the current draining options and present a novel alternative method, repurposing a widely available stent that optimizes drainage.We retrospectively reviewed patients diagnosed with posterior urethral valves between January 2013 and December 2014. In all patients a 6Fr 12 cm Double-J ureteral stent was advanced over a guidewire in a retrograde fashion into the bladder. Luminal flow and cross-sectional areas were also assessed for each of 3 tubes for urinary drainage, ie 6Fr Double-J stent, 5Fr feeding tube and 6Fr Foley catheter.A total of 30 patients underwent uneventful bedside Double-J stent placement. Mean ± SD age at valve ablation was 28.5 ± 16.6 days. Mean ± SD peak serum creatinine was 2.23 ± 0.97 mg/dl after birth and 0.56 ± 0.22 mg/dl at the procedure. Urine output after stent placement was excellent in all patients. The Foley catheter and feeding tube drained approximately 18 and 6 times more slowly, respectively, and exhibited half the calculated cross-sectional luminal area compared to the Double-J stent.Use of Double-J stents in neonates with posterior urethral valves is a safe and effective alternative method for lower urinary tract decompression that optimizes the flow/lumen relationship compared to conventional drainage options.

Summary Background The Emergency Department (ED) is being increasingly utilized as a pathway for management of acute conditions such as the urinary tract infections (UTIs). Objective We sought to assess the contemporary trends in pediatric UTI associated ED visits, subsequent hospitalization, and corresponding financial expenditure, using a large nationally representative pediatric cohort. Further, we describe the predictors of admission following a UTI associated ED visit. Methods The Nationwide Emergency Department Sample (NEDS; 2006–2011) was queried to assess temporal-trends in pediatric (age ≤17 years) ED visits for a primary diagnosis of UTI (ICD9 CM code 590.X, 595.0, and 599.0), subsequent hospital admission, and total charges. These trends were examined using the estimated annual percent change (EAPC) method. Multivariable regression models fitted with generalized estimating equations (GEE) identified the predictors of hospital admission. Results Of the 1,904,379 children presenting to the ED for management of UTI, 86 042 (4.7%) underwent hospital admission. Female ED visits accounted for almost 90% of visits and increased significantly (EAPC 3.28%; p = 0.003) from 709 visits per 100 000 in 2006 to 844 visits per 100 000 in 2011. Male UTI incidence remained unchanged over the study-period (p = 0.292). The overall UTI associated ED visits also increased significantly during the study-period (EAPC 3.14%; p = 0.006) because of the increase in female UTI associated ED visits. Overall hospital admissions declined significantly over the study-period (EAPC -5.59%; p = 0.021). Total associated charges increased significantly at an annual rate of 18.26%, increasing from 254 million USD in 2006 to 464 million USD in 2011 (p Figure ). This increase in expenditure was likely driven by increased utilization of diagnostic CT scanning in these patients (EAPC 22.86%; p In multivariable analysis, the independent predictors of admission included younger age (p Discussion We show that the incidence of ED visits for pediatric UTI is on the rise. This rise in incidence could be due to several factors, including increasing prevalence of metabolic conditions such as obesity, diabetes and metabolic syndrome in children predisposing them to infections, or could be secondary to increasing sexual activity amongst adolescents and changing patterns of contraceptive use (increased use of OCP in place of condoms), or more simply might just be a reflection of changing practice patterns. Second, we demonstrate that total charges for management of UTI in the ED setting are increasing rapidly; the increase is primarily driven by increasing utilization of diagnostic imaging in the ED setting, as has been demonstrated in other ED based studies as well. Conclusions In children presenting to the ED with a primary diagnosis of UTI, total ED charges are increasing at an alarming rate not commensurate with the increase in overall ED visits. While the preponderance of children presenting to the ED for UTI are treated and discharged, 4.7% of patients were admitted to the hospital for further management. The strongest predictors of inpatient admission were pyelonephritis, younger age, male gender, higher comorbidity status, and concurrent hydronephrosis, stone disease, or sepsis. Managing these at-risk patients more aggressively in the outpatient setting may prevent unnecessary ED visits and subsequent hospitalizations, and reduce associated healthcare costs. Download : Download high-res image (403KB) Download : Download full-size image Figure . (a) Temporal trends in pediatric urinary tract infection related ED-visits, stratified by gender; (b) Temporal trends in pediatric urinary tract infection associated total charges and CT scanning utilization; NEDS 2006–2011; EAPC = Estimated annual percent change; CI = Confidence Interval.

During the last decade, the annual volume of robot-assisted prostatectomies performed in the United States has risen steadily. Refinements in surgical technique, understanding of anatomy, and experience have led to more complex patients being offered surgery for management of organ-confined prostate cancer. Complication rates of robot-assisted prostatectomy have been reported in several articles; however, a paucity of data exists when evaluating ureteral injuries sustained during robot-assisted prostatectomy. No standardized universal criteria for reporting and grading of complications exists; therefore, the Martin-Donat criteria with Clavien-Dindo classification system were used to evaluate ureteral injuries in our series.From January 2001 to June 2013, 6442 consecutive patients were treated with robot-assisted prostatectomy at the same institution by one of five surgeons. All complications were documented through a prospectively maintained prostate cancer database with supplementation from electronic medical records, operative and nursing notes, claims data, discharge summaries, outpatient and emergency visits, institutional morbidity and mortality data, as well as National Surgical Quality Improvement Program data. The Martin-Donat criteria were used to facilitate the accurate and comprehensive reporting of surgical complications while complication severity was assigned following the Clavien-Dindo classification system.Three patients sustained ureteral injuries (ureteral transection) in our series. Both surgeons were beyond their learning curve (greater than 1000 cases) when the injuries occurred; one patient needed readmission, and all patients had risk factors predisposing them to ureteral injury. Each patient was managed with robot-assisted ureteroneocystostomy (1), open transureteroureterostomy (1) and robot-assisted ureteroureterostomy (1) respectively.Ureteral injuries are uncommon; however, thorough preoperative evaluation and surgical planning could identify patients at high risk for sustaining ureteral injury during prostatectomy. Measures can be taken preoperatively or intraoperatively to reduce the probability of ureteral injury, eliminating the necessity for additional procedures postoperatively.

UNLABELLED:Host-pathogen interactions can induce epigenetic changes in the host directly, as well as indirectly through secreted factors. Previously, uropathogenic Escherichia coli (UPEC) was shown to increase DNA methyltransferase activity and expression, which was associated with methylation-dependent alterations in the urothelial expression of CDKN2A. Here, we showed that paracrine factors from infected cells alter expression of another epigenetic writer, EZH2, coordinate with proliferation. Urothelial cells were inoculated with UPEC, UPEC derivatives, or vehicle (mock infection) at low moi, washed, then maintained in media with Gentamycin. Urothelial conditioned media (CM) and extracellular vesicles (EV) were isolated after the inoculations and used to treat naïve urothelial cells. EZH2 increased with UPEC infection, inoculation-induced CM, and inoculation-induced EV vs. parallel stimulation derived from mock-inoculated urothelial cells. We found that infection also increased proliferation at one day post-infection, which was blocked by the EZH2 inhibitor UNC1999. Inhibition of demethylation at H3K27me3 had the opposite effect and augmented proliferation. CONCLUSION:Uropathogen-induced paracrine factors act epigenetically by altering expression of EZH2, which plays a key role in early host cell proliferative responses to infection.

INTRODUCTION AND OBJECTIVES: In boys with an inguinal testis, the traditional approach is to perform an inguinal incision, open the inguinal canal, mobilize the testis and spermatic cord, repair the inguinal hernia if present, and place the testis in a dartos pouch in the scrotum. In boys, the inguinal canal is short and during inguinal hernia repair, it is often unnecessary to extend the dissection to the internal inguinal ring in order to mobilize enough length. The purpose of this study is to determine if performing a modified inguinal orchiopexy (without opening the inguinal canal) results in a successful orchiopexy. METHODS: Boys with an inguinal testis who underwent orchiopexy were reviewed retrospectively. Patient age and surgical approach (inguinal, with or without inguinal dissection, or prescrotal) were recorded. Only if the testis did not reach the dartos pouch was the inguinal canal opened and a standard orchiopexy performed with inguinal dissection. Presence of an inguinal hernia was also noted. All patients underwent clinical follow-up at 4-6 weeks. Boys with an ectopic, abdominal or absent testis and those undergoing previous inguinal surgery were excluded. RESULTS: A total of 254 boys with 323 undescended inguinal testes were reviewed. The results are shown in Table 1. Overall, 171 underwent a modified inguinal orchiopexy without opening the inguinal canal, 36 underwent inguinal orchiopexy with standard inguinal dissection, and 116 underwent prescrotal orchiopexy. A total of 123 (38.1%) testes were associated with an inguinal hernia that was repaired during orchiopexy. Of those with a hernia, 92 underwent a modified inguinal orchiopexy, 23 underwent a standard inguinal orchiopexy, and 9 were corrected via a prescrotal approach. There was one complication of testicular re-ascent in the modified inguinal orchiopexy group. CONCLUSIONS: In boys with an inguinal undescended testis, orchiopexy can be performed without opening the inguinal canal, even if there is an associated inguinal hernia, with the decision being dependent upon the ability to mobilize the testis and spermatic cord into the dartos pouch. Inguinal (M) Inguinal (S) Prescrotal Total No. testis 171 36 116 323 Mean age (yrs.) 5.1 5.9 4.9 5.1 Hernia 92 (54%) 23 (64%) 9 (8%) 123 (38%) No. side Lt 79 20 56 155 Rt 92 16 60 168 No. complications 1 (0.5%) 0 (0%) 0 (0%) 1 (0.3%) (M) modified, (S) standard

INTRODUCTION AND OBJECTIVES: Ipsilateral retroperitoneal lymph node dissection (RPLND) is indicated in cases of paratesticular rhabdomyosarcoma in the pediatric population greater than 10 years of age. Historically, RPLND has been performed in an open fashion. In the adult population, minimally invasive techniques are being more utilized due to shortened hospital stay and shorter convalescence period. METHODS: We performed a robotic-assisted laparoscopic left retroperitoneal lymph node dissection in a 10 year-old pediatric patient with left paratesticular embryonal rhabdomyosarcoma. The DaVinci SI was utilized. RESULTS: The procedure was performed safely with minimal blood loss. Thirty lymph nodes were collected. Patient was discharged on post-operative day one. CONCLUSIONS: Robotic RPLND can be performed safely with adequate tissue sampling in the pediatric population.

Vesicoureteral reflux is believed to be a largely asymptomatic condition. However, previous studies have failed to assess the precise impact of vesicoureteral reflux on quality of life. We created and validated a survey for assessment of quality of life in children with vesicoureteral reflux.Two surveys were created by a team of pediatric urologists and survey design specialists, 1 for general assessment and 1 for postoperative assessment in patients undergoing surgical treatment for vesicoureteral reflux. Cronbach alpha test was used to assess internal consistency reliability and the correlation coefficient for test-retest analysis. Surveys were distributed from November 2008 to January 2010 during routine office visits for vesicoureteral reflux. The postoperative survey was distributed 8 to 20 weeks following surgery.The general survey yielded a Cronbach alpha of 0.64 and a correlation coefficient of 0.78, while the postoperative survey results were 0.58 and 0.84, respectively, for the same parameters. Complete general surveys were obtained from 216 patients. All but 4 categories, related to repeat testing, office visits and medicine intake, reached greater than 80% positive quality of life responses. The postoperative survey was completed by 104 patients. Bladder spasm was the only category with less than 86% rate of positive quality of life response.Vesicoureteral reflux is shown to have little effect on quality of life in pediatric patients. These validated surveys should be applied to compare the effect of different management options on quality of life.

Purpose Significant research has been dedicated to the management of vesicoureteral reflux (VUR). However, few studies have been published to evaluate the impact of this disease on quality of life. The aim of this study was a prospective examination of the health-related quality of life (HRQoL) in children with VUR who have either been treated medically (antibiotics or surveillance) or by ureteral reimplant (UR) using a validated patient satisfaction survey. Materials and methods A prospective, longitudinal study was conducted using a validated HRQoL questionnaire, the Pediatric Quality of Life Inventory (PedsQL™ 4.0 Generic Core). 353 children or parents of children with VUR, age 2–18 years, completed the survey. Statistical analysis was performed with significance set at p-value ≤ 0.05. Results Children and parents of children with VUR did not score lower on total or subscale domains of HRQoL when compared to a historical healthy control. On univariate analysis, patients who underwent UR scored lower on total as well as physical, social, and school subscale HRQoL domains, compared to patients managed medically. When controlling for gender, ethnicity, age, reflux grade, and antibiotic use, there was no difference in total HRQoL between patients who underwent UR compared to those managed medically. Conclusions In terms of HRQoL, VUR is a benign clinical entity and neither antibiotic use nor UR is associated with lower HRQoL. Disease-specific quality of life surveys are needed to accurately evaluate patient and parent satisfaction in the management of VUR.

Approximately 35% of children with CKD who require renal replacement therapy have a significant urological abnormality, including posterior urethral valves, a neuropathic bladder, prune belly syndrome, Hinman syndrome, or severe vesicoureteral reflux. In such children, abnormal bladder function can have a significant deleterious effect on the renal function. In children with bladder outlet obstruction, bladder compliance and capacity often are abnormal, and a sustained intravesical pressure of >40 cm H(2)O impedes drainage from the upper urinary tract. Consequently, in these conditions, regular evaluation with renal sonography, urodynamics, urine culture, and serum chemistry needs to be performed. Pediatric urological care needs to be coordinated with pediatric nephrologists. Many boys with posterior urethral valves have severe polyuria, resulting in chronic bladder overdistension, which is termed as valve bladder. In addition to behavioral modification during the day, such patients may benefit from overnight continuous bladder drainage, which has been shown to reduce hydronephrosis and stabilize or improve renal function in most cases. In children with a neuropathic bladder, detrusor-sphincter-dyssynergia is the most likely cause for upper tract deterioration due to secondary vesicoureteral reflux, hydronephrosis, and recurrent urinary tract infection (UTI). Pharmacologic bladder management and frequent intermittent catheterization are necessary. In some cases, augmentation cystoplasty is recommended; however, this procedure has many long-term risks, including UTI, metabolic acidosis, bladder calculi, spontaneous perforation, and malignancy. Nearly half of children with prune belly syndrome require renal replacement therapy. Hinman syndrome is a rare condition with severe detrusor-sphincter discoordination that results in urinary incontinence, encopresis, poor bladder emptying, and UTI, often resulting in renal impairment. Children undergoing evaluation for renal transplantation need a thorough evaluation of the lower urinary tract, mostly including a voiding cystourethrogram and urodynamic studies.

Background There are numerous studies in the adult literature correlating comorbidities and pre- and intraoperative parameters with postoperative outcomes. However, there is a paucity of similar data in the pediatric population. Our goal was to elucidate which pre- and intraoperative patient characteristics in children undergoing surgery are associated with an increased risk of major complication within 30 days. Study Design We identified 108 children who underwent surgery at our institution between June 2005 and May 2007 and had major complication or death within 30 days of surgery. Forty-two preoperative patient characteristics and 22 intraoperative variables were evaluated. The severity of the complications was graded based on the Clavien classification system, with major complications grade III or greater. We randomly selected 723 controls who had undergone surgery within a 3-month date range of the original cohort, but did not develop complications. Statistical significance was assessed by univariate and multivariate analyses. Results Most complications were cardiovascular, occurred 1 to 3 days after surgery, and were classified as grade IIIB. We identified 5 independent risk factors on multivariate analysis: ≤36 weeks of gestation, American Society of Anesthesiologists score >3, undergoing a cardiovascular or neurosurgical procedure, and receiving an intraoperative albumin transfusion. Three scoring systems (overall, preoperative, and intraoperative complication score) were developed to provide objective risk stratification. Conclusions We found 5 patient-specific parameters that were independent risk factors for major complications or death after pediatric surgery. Future prospective studies will help to fully stratify risk and guide interventions to improve postoperative outcomes.

Radiological imaging is the mainstay of diagnosing ureteropelvic junction obstruction. Current established radiological modalities can potentially differentiate the varying degrees of obstruction but they are limited in functionality, applicability and/or comprehensiveness. Of particular concern is that some tests require radiation, which has long-term consequences, especially in children.We investigated the novel use of Genhance™ 680 dynamic fluorescence imaging to assess ureteropelvic junction obstruction in 20 mice that underwent partial or complete unilateral ureteral obstruction. Ultrasound, mercaptoacetyltriglycine renography, magnetic resonance imaging and fluorescence imaging were performed.Our model of partial and complete obstruction could be distinguished by ultrasound, mercaptoacetyltriglycine renography and magnetic resonance imaging, and was confirmed by histological analysis. Using fluorescence imaging distinct vascular and urinary parameters were identified in the partial and complete obstruction groups compared to controls.Fluorescence imaging is a feasible alternative radiological imaging modality to diagnose ureteropelvic junction obstruction. It provides continuous, detailed imaging without the risk of radiation exposure.

Approximately 50,000 children undergo voiding cystourethrography annually. There is a recent trend toward using sedation or delaying voiding cystourethrography due to the anticipated distress to the patient. We hypothesized that with adequate preparation and proper techniques to minimize anxiety, voiding cystourethrography can be performed without sedation. We assessed parental satisfaction associated with patient and parent experience of voiding cystourethrography without sedation.We used a 33-question survey to evaluate parental satisfaction with patient and parent experience of voiding cystourethrography without sedation. Children were divided into 3 groups according to toilet training status. Statistical analysis was performed using Stata®.A total of 200 surveys were completed. Of the children 54% were not toilet trained. Of the parents 90% reported adequate preparation. More than half of parents classified the experience of voiding cystourethrography as equivalent to or better than a physical examination, immunization, ultrasound and prior catheterization. Most parents were satisfied with the ability of the child to tolerate the procedure and considered the experience better than expected. Children in the process of toilet training had the most difficulty with the procedure, correlating with lower levels of parental satisfaction.Voiding cystourethrography performed with adequate preparation and support can be tolerated without sedation. Children in the process of toilet training and females tolerate the procedure least.

Objective To determine the frequency of concordance of testicular anatomical location between both undescended testes based on surgical findings. Background Cryptorchidism occurs in approximately 1% of boys over one year of age, and in 10–20% of these cases, the condition is bilateral. We report a series of 168 patients with a preoperative diagnosis of bilateral undescended testes who underwent surgical exploration and in whom two testes were surgically identified. Methods The testicular location of both testes was stratified according to six anatomic regions. For each patient the anatomic site of each testis, both palpable and impalpable, and the surgical procedure required for orchidopexy were recorded. Results The mean age was 59.3 months (2.5 months–21 years). In 90% of the cases the surgical technique was identical for both sides. Approximately two thirds of the patients were found to have both testes in concordant anatomical locations and in 88% the location of one testis was predictive within one anatomic “step” of the location of the contralateral gonad. Conclusion These findings may have significant implications for counseling families and anticipating the necessary surgical approach required when only one undescended testis has been localized preoperatively.

Background The most common laparoscopic complications are associated with trocar insertion. The purpose of this study was to develop an objective method of evaluating the safety profile of various access devices used in laparoscopic surgery. Study Design In 20 swine, 6 bladed and 2 needle access devices were evaluated. A force profile was determined by measuring the force required to drive the trocar or needle through the fascia and into the peritoneum, at 0 and 10 mmHg. The amount of tissue deformation, the length of blade exposed, and the duration of exposure were measured using a high-speed digital imaging system. Results The needle system without the sheath required the least driving force and had the most favorable force profile. In contrast, the bladed, nonretractable trocar system required a higher driving force and a rapid loss of resistance. Insertion under a pneumoperitoneum did not significantly alter the force profile of the various access devices except for the amount of tissue deformation. With the bladed system, the blade itself was exposed for an average of 0.5 to 1.0 seconds for a distance of 4.5 to 5.0 cm. In comparison, the needle system was exposed for 0.2 seconds for a distance of 1.8 cm. Conclusions We developed a reproducible method of measuring the forces required to place the access systems, their pattern of resistance loss, and the characteristics of the blade exposure. These parameters may provide an adjunctive and objective measurement of safety, allowing for more direct comparison between various trocar designs.

Continent urinary diversion has a central role in treating various urinary tract conditions and traditionally has been performed as an open procedure. We report on 10 patients who underwent a robotic assisted laparoscopic Mitrofanoff procedure using the da Vinci surgical system.Patients had bladder dysfunction of various etiologies, including posterior urethral valves and neurogenic bladder. Preoperatively all patients unsuccessfully attempted clean intermittent catheterization via the urethra.Mean operative time was 323 minutes (range 181 to 507). One case was converted to open surgery secondary to an inadequate appendix discovered intraoperatively. Mean estimated blood loss was 48.4 cc (range 5 to 200). Median hospitalization was 5 days. Median followup was 14.2 months. Urinary leakage developed postoperatively in 1 patient, requiring an open revision. Minor incontinence developed in 2 cases, of which 1 was corrected with dextranomer/hyaluronic acid injection and 1 resolved without intervention.The robotic assisted laparoscopic Mitrofanoff procedure is feasible to perform, is associated with satisfactory outcomes and minimal complications, and has the benefits of a minimally invasive approach.

INTRODUCTION AND OBJECTIVES: The Emergency Department (ED) is being increasingly utilized as a pathway for management of acute conditions such as UTIs. We sought to assess the contemporary national-trends in pediatric UTI associated ED visits, subsequent hospitalization, and corresponding financial expenditure. Further, we describe the predictors of hospitalization in these children. METHODS: Relying on the Nationwide Emergency Department Sample (2006-2011; age 17years) national trends in pediatric UTI ED visits, subsequent hospitalization, and total charges were examined using the estimated annual percent change (EAPC) methodology. Multivariable regression analyses were used to evaluate predictors of hospitalization following pediatric UTI ED visit. RESULTS: Of the 1,904,379 children presenting to the ED for management of UTI, 86,042 (4.7%) underwent admission. Female ED visits accounted for 90% of total visits and increased significantly (EAPC 3.28%; p1⁄40.003; fig. 1) over the study period. Male UTI incidence remained unchanged (p1⁄40.292). Overall hospital admission rates declined significantly (EAPC -5.59%; p1⁄40.021). Total charges increased significantly at an annual rate of 18.26%, increasing from 254 million USD in 2006 to 464 million USD in 2011 (p

Selenium supplementation in a population with low basal blood selenium levels has been reported to decrease the incidence of several cancers including prostate cancer. Based on the clinical findings, it is likely that the antioxidant function of one or more selenoproteins is responsible for the chemopreventive effect, although low molecular weight seleno-compounds have also been posited to selectively induce apoptosis in transformed cells. To address the effects of selenium supplementation on selenoprotein expression in prostate cells, we have undertaken an analysis of antioxidant selenoprotein expression as well as selenium toxicity in non-tumorigenic prostate epithelial cells (RWPE-1) and prostate cancer cells (LNCaP and PC-3). Our results show that two of the glutathione peroxidase family members (GPX1 and GPX4) are highly induced by supplemental selenium in prostate cancer cells but only slightly induced in RWPE-1 cells. In addition, GPX1 levels are dramatically lower in PC-3 cells as compared to RWPE-1 or LNCaP cells. GPX2 protein and mRNA, however, are only detectable in RWPE-1 cells. Of the three selenium compounds tested (sodium selenite, sodium selenate and selenomethionine), only sodium selenite shows toxicity in a physiological range of selenium concentrations. Notably and in contrast to previous studies, RWPE-1 cells were significantly more sensitive to selenite than either of the prostate cancer cell lines. These results demonstrate that selenoproteins and selenium metabolism are regulated at multiple levels in prostate cells.

In laparoscopic prostatectomies, vesicourethral anastomotic leaks may result in significant morbidity because of the chemical and metabolic derangements created by urine within the peritoneal cavity. To date, minimal data are available on this problem. Herein we present our experience with urine leaks after RALP. Over a period of 24 months, 135 men underwent RALP. Any drainage creatinine greater than two times the serum creatinine was considered as an anastomotic leak. According to our criteria, 20% of the first 110 patients developed an anastomotic leak. The patients were analyzed in two groups, those with and without leaks. In the two groups, there was no statistically significant difference in age, height, weight, prostate volume and pre-op hemoglobin. The patients with leaks did have higher rate of prior abdominal surgery (50 vs. 36%), higher average pre-operative PSA values (7.6 vs. 6.1), higher rates of multiple biopsies (27 vs. 17%) and a higher average BMI (29.6 vs. 27.8). Intraoperative differences included an average of 30 min longer operative time and 66 cm(3) higher average EBL in patients with leaks. The transfusion rate was higher in the leak group at 18 vs. 1% in the no leak group. Recovery tended to be longer in patients with leaks, with hospital stays of an average of 3.6 days longer. The most common indication for prolonged hospitalization was ileus, which 55% of patients with leaks developed. Management included placing the catheter on mild traction, continuous antibiotics and taking the drain-off suction with caution to monitor the signs of a worsening ileus. In the last 25 patients, we revised our anastomotic technique. We now include posterior tailoring of the bladder neck prior to the vesicourethral anastomosis when the bladder neck is enlarged. This facilitates a water-tight anastomosis. Using this technique, we have yet to see the anastomotic leak. In RALPs, anastomotic leaks can lead to ileus formation and longer hospital stays. These leaks are associated with a higher average blood loss and transfusion rate. Management should focus on prevention. Since we have incorporated posterior bladder neck tailoring with the anastomosis, the problem has been markedly reduced.