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.
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.
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.
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.
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. Display omitted
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.
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.
Purpose Abnormal bladder function following posterior urethral valve ablation can lead to deleterious effects on renal function and urinary continence. We performed a pilot study to determine if ...bladder dysfunction could be ameliorated by the early administration of oxybutynin. Materials and Methods We enrolled infants who underwent primary posterior urethral valve ablation by the age of 12 months. On initial urodynamics patients demonstrating high voiding pressures (greater than 60 cm H2 O) and/or small bladder capacity (less than 70% expected) were started on oxybutynin. Urodynamics and ultrasound were performed every 6 months until completion of toilet training, at which time oxybutynin was discontinued. Results Oxybutynin was started in 18 patients at a mean age of 3.4 months and was continued for a mean of 2.2 years. Urodynamics revealed that initial high voiding pressures improved from a mean of 148.5 to 49.9 cm H2 O in 15 of 17 patients. All 8 patients with initially poor bladder compliance demonstrated improvement on oxybutynin. All 7 patients with initially low bladder capacity (mean 47.7% expected bladder capacity) demonstrated improvement while on oxybutynin (mean 216% expected bladder capacity). Conclusions This pilot study demonstrates that early use of anticholinergic therapy in infants with high voiding pressures and/or small bladder capacity after primary posterior urethral valve ablation has beneficial effects on bladder function.
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.
Abstract 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 (CO2 ) 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 CO2 laser is advantageous for detrusorotomy.
Abstract Objective We assessed whether increased BMI has a negative impact in children undergoing robot assisted laparoscopic pyeloplasty (RALP). Patients and methods 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. Results Of the 103 patients, there were 79 healthy weight and 24 overweight, with 10 of the 24 considered obese (BMI <85th, ≥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). Conclusions 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.
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.
