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ABSTRACT: PURPOSE: We report our experience and compare the outcomes between standard and robot-assisted laparoscopic pyeloplasty to treat ureteropelvic junction obstruction in children. MATERIALS AND METHODS: A retrospective cohort study was performed of all children who underwent standard or robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction at a single institution from October 2007 to January 2012. Indications for surgery included symptomatic obstruction and abnormal diuretic renal scan. A successful outcome was defined as resolution of clinical symptoms, improvement of hydronephrosis on ultrasound, stable ultrasound with resolution of symptoms or improvement of the drainage curve on diuretic renal scan. RESULTS: We reviewed 18 patients (median age 8.1 years) who underwent standard and 46 (8.8 years) who underwent robot-assisted laparoscopic pyeloplasty (p = 0.194). Median operative time was 298 minutes (range 145 to 387) for standard and 209 minutes (106 to 540) for robot-assisted laparoscopic pyeloplasty (p = 0.008). Mean hospitalization was similar between the groups (1 day for standard vs 2 days for robot-assisted laparoscopic pyeloplasty, p = 0.246). Narcotic use was similar between the groups. Median followup was 43 months for standard and 22 months for robot-assisted laparoscopic pyeloplasty (p <0.01). Renal ultrasound showed postoperative improvement of hydronephrosis in 85% and stable disease in 15% of patients following robot-assisted laparoscopic pyeloplasty, and improvement in 89.5% and stable disease in 10.5% after standard laparoscopic pyeloplasty. Symptoms resolved in 100% of patients (38 of 38) after robot-assisted laparoscopic pyeloplasty and 87.5% of patients (7 of 8) after standard laparoscopic pyeloplasty. CONCLUSIONS: Robot-assisted laparoscopic pyeloplasty and standard laparoscopic pyeloplasty are effective techniques to correct ureteropelvic junction obstruction, with similar outcomes. Robot-assisted laparoscopic pyeloplasty had a shorter operative time, and its success and complication rates are comparable to standard laparoscopic pyeloplasty.
The Journal of urology 11/2012; · 4.02 Impact Factor
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ABSTRACT: Robot-assisted laparoscopic pyeloplasty has become more widely used. Intraoperative placement and confirmation of ureteral stent position can be cumbersome with the robotic arms in place. We present a technique of percutaneous antegrade stent placement that is reliable with minimal morbidity.
A retrospective cohort study was performed. Patient demographics, radiographic imaging, intraoperative details, and surgical outcomes were abstracted from the medical record. A 14-gauge angiocatheter was placed through the abdominal wall. A ureteral stent was guided over a wire down the dismembered ureter. Stent position was confirmed by retrograde reflux of methylene blue. A urethral catheter was left in place for 12 to 36 hours.
Twenty-nine patients (15 male, 14 female) were identified. Average age was 10 years. Average follow-up was 14 months. Fifteen left- and 14 right-sided procedures were performed. Two patients needed retrograde stent placement. Mean time to correctly position the stent was less than 5 minutes. Postoperatively, one patient had a urine leak managed by an indwelling urethral catheter and did not need percutaneous drainage. All stents were removed approximately 4 to 6 weeks postoperatively. One patient had retrograde migration of the stent managed by ureteroscopy at the time of stent retrieval.
Antegrade ureteral stent placement through a percutaneous angiocatheter, during robot-assisted laparoscopic pyeloplasty, is a rapid and effective technique. Intraoperative confirmation of stent position can be obtained, using methylene blue bladder distention, without repositioning the patient or undocking the surgical robot.
Journal of endourology / Endourological Society 10/2011; 25(12):1847-51. · 1.75 Impact Factor
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ABSTRACT: One of the main ergonomic challenges during surgical procedures is surgeon posture. There have been reports of a high number of work related injuries in laparoscopic surgeons. The Alexander technique is a process of psychophysical reeducation of the body to improve postural balance and coordination, permitting movement with minimal strain and maximum ease. We evaluated the efficacy of the Alexander technique in improving posture and surgical ergonomics during minimally invasive surgery.
We performed a prospective cohort study in which subjects served as their own controls. Informed consent was obtained. Before Alexander technique instruction/intervention subjects underwent assessment of postural coordination and basic laparoscopic skills. All subjects were educated about the Alexander technique and underwent post-instruction/intervention assessment of posture and laparoscopic skills. Subjective and objective data obtained before and after instruction/intervention were tabulated and analyzed for statistical significance.
All 7 subjects completed the study. Subjects showed improved ergonomics and improved ability to complete FLS™ as well as subjective improvement in overall posture.
The Alexander technique training program resulted in a significant improvement in posture. Improved surgical ergonomics, endurance and posture decrease surgical fatigue and the incidence of repetitive stress injuries to laparoscopic surgeons. Further studies of the influence of the Alexander technique on surgical posture, minimally invasive surgery ergonomics and open surgical techniques are warranted to explore and validate the benefits for surgeons.
The Journal of urology 08/2011; 186(4 Suppl):1658-62. · 4.02 Impact Factor
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ABSTRACT: The ideal approach to the radiological evaluation of children with urinary tract infection (UTI) is in a state of confusion. The conventional bottom-up approach, with its focus on the detection of upper and lower urinary tract abnormalities, including vesicoureteral reflux, has been challenged by the top-down approach, which focuses on confirming the diagnosis of acute pyelonephritis before more invasive imaging is considered. Controversies abound regarding which approach may best assess the ultimate risk for reflux-related renal scarring. Evolving practices motivated by the emerging evidence, the desire to minimize unnecessary interventions, as well as improve compliance with recommended testing, have added to the current controversies. Recent guideline updates and ongoing clinical trials hopefully will help in addressing some of these concerns.
Pediatric Surgery International 02/2011; 27(4):337-46. · 1.25 Impact Factor
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ABSTRACT: Advances in technology and the continued evolution in the design of ureteroscopes now permit a primary endoscopic approach to the upper urinary tract of pediatric patients on a routine basis to treat a diverse group of conditions that include urolithiasis, hematuria and strictures. The purpose of this review article is to demonstrate that ureteroscopic lithotripsy is now to be considered the standard of care in the management of upper tract urolithiasis in the pediatric patient, replacing shockwave lithotripsy (ESWL) as the first line of therapy. Additionally, the article will discuss the available endoscopic equipment and the lessons learned over the years to optimize the success of these procedures in children.
A systematic review of articles written about ureteroscopy (URS) in the contemporary urological literature (1990-2009) on PubMed was undertaken. The success rates and complications of pediatric ureteroscopic procedures were abstracted from the identified publications and the results were tabulated and compared with the success rates of shockwave lithotripsy.
In over 832 URS cases, there was a 5.9% complication rate and a stone-free rate of 93.4%. The stone-free rates of URS are superior to those obtained with the published success rates with ESWL of 80.3% in 1,839 cases.
The safety and outcomes of ureteroscopic lithotripsy in the management of pediatric urolithiasis now justify that this treatment modality be considered the standard of care and first line of therapy in the management of children who present with upper tract stones.
Indian Journal of Urology 10/2010; 26(4):555-63.
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ABSTRACT: We evaluated long-term (> or =12 months) efficacy and safety of tolterodine in children with neurogenic detrusor overactivity.
Subjects successfully completed one of three 12-week, open-label studies and had stable neurologic disease and urodynamic evidence of neurogenic detrusor overactivity requiring intermittent catheterization. Drug formulation and dosing were based on age (4 months-4 years, tolterodine oral solution 0.2-2mg twice daily; 5-10 years, tolterodine oral solution 0.5-4 mg twice daily; 11-16 years, tolterodine extended-release capsules 2, 4, or 6 mg once daily). Daily doses were individualized for each subject. Efficacy was evaluated urodynamically and using parent-completed 3-day bladder diaries.
Thirty subjects were enrolled. Functional bladder capacity (volume at first leakage, first sensation of bladder fullness or 40 cm H(2)O pressure) increased by month 12 in the younger age groups but not in the oldest subjects. Volume to first detrusor contraction >10 cm H(2)O pressure and detrusor leak point pressure did not change in any age group. The number of incontinence episodes per 24h decreased in all subjects, as did the number of catheterizations per 24h. Mean volume per catheterization increased in all subjects. Seven treatment-related adverse events were reported.
Both tolterodine formulations were effective and well tolerated in children with neurogenic detrusor overactivity.
Journal of pediatric urology 12/2008; 4(6):428-33. · 1.38 Impact Factor
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Pramod P Reddy
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ABSTRACT: Pediatric Urology is a surgical subspecialty that is very dependent upon radiographic imaging as the majority of the genitourinary (GU) tract is internally located. Technological advances in various imaging modalities (e.g. ultrasonography, nuclear medicine, CT and MRI) have aided in our ability to visualize and evaluate the functionality of the GU tract, enabling the diagnosis of various disease processes that affect the genitourinary system. Collectively the advances in uro-radiology have improved our understanding of the natural history of many conditions that involve the GU tract. As a result of these newer imaging modalities, some of the more traditional techniques have assumed a limited role in the diagnostic evaluation of the pediatric GU patient (e.g. intravenous urography).The purpose of this article is to review the advances in radiographic imaging, in particular the cross-sectional imaging modalities and discuss their utility (appropriate indications and application) in Pediatric Urology, so that the reader can maximize the diagnostic yield of these studies. For a thorough review of any of the imaging modalities discussed in this article and their utility in the practice of pediatric urology, I would direct the readers to articles in the radiological literature that are specific to that technology. Besides the obvious technological advances in imaging modalities, this review also discusses the attention to radiation safety for the pediatric patient that every physician who orders a diagnostic imaging study in a child should be aware of.
Indian Journal of Urology 11/2007; 23(4):390-402.
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ABSTRACT: Little has been reported concerning the efficacy of endoscopic injection of dextranomer/hyaluronic acid for the treatment of residual incontinence following bladder neck reconstruction. We present the experience of 2 institutions using endoscopic submucosal injection of dextranomer/hyaluronic acid to correct incontinence in patients who had previously undergone bladder neck reconstruction with or without concomitant enterocystoplasty.
A retrospective chart review was performed with patient demographics, indications for treatment and outcomes recorded. All patients had adequate bladder capacity and compliance on maximized medical therapy before injection. Continence was defined as at least a 3-hour daytime dry interval, while improvement was defined as an increase in the daytime dry interval to at least 2 hours.
A total of 14 patients (10 females and 4 males) underwent 21 injections. At a median followup of 17 months 10 patients had successful results (6 continent, 4 improved).
Endoscopic injection of dextranomer/hyaluronic acid to correct incontinence following bladder neck reconstruction appears safe and can increase the daytime dry interval in more than 70% of carefully selected patients. Continued followup is necessary to evaluate the long-term effectiveness of this treatment.
The Journal of Urology 02/2007; 177(1):302-5; discussion 305-6. · 3.75 Impact Factor
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ABSTRACT: Three exploratory studies were conducted to investigate the pharmacokinetics (PK) and safety of tolterodine in children 1 month to 15 years old with neurogenic detrusor overactivity. We urodynamically evaluated the dose and concentration effects of tolterodine to establish safe and effective dosing regimens.
Three open-label, dose escalating studies were conducted in children with stable neurological disease and detrusor overactivity. In studies 1 (patient aged 1 month to 4 years) and 2 (5 to 10 years) patients received 0.03, 0.06 and 0.12 mg/kg tolterodine solution day twice daily for 4 weeks each. In study 3 (patient age 11 to 15 years) patients received 2, 4 and 6 mg tolterodine extended-release capsules once daily for 4 weeks each. PK was assessed after 8 weeks, urodynamic assessments were conducted after each 4-week dosing period and 3-day micturition diaries were completed.
Patients in studies 1 (19) and 2 (15) showed some dose related increases in volume to first detrusor contraction and cystometric bladder capacity. In study 3 (11 patients) there were no obvious dose-response relationships. PK results from studies 1 and 2 suggest that there was no apparent effect of age (< or =10 y) on these parameters. In study 3 time of maximum observed serum concentration and apparent terminal half-life were delayed, which is consistent with the extended-release formulation. Tolterodine was well tolerated, and there was no apparent relationship between tolterodine dose and adverse events in any study.
These results support the safety of age and body weight adjusted dosing regimens for further clinical evaluation of tolterodine in children with neurogenic detrusor overactivity.
The Journal of Urology 11/2005; 174(4 Pt 2):1647-51; discussion 1651. · 3.75 Impact Factor
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Pramod P Reddy
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ABSTRACT: Endoscopic evaluation and management of the diverse conditions involving the upper urinary tract of children is now feasible and has been shown to be safe and efficacious. This modality should be considered an essential part of the armamentarium of any urologist involved in the care of children. Continued technological advances will allow the indications for pediatric ureteroscopy to evolve. The benefits of minimally invasive surgery that have been proved in adult patients can now be offered to pediatric patients. A thorough knowledge of available equipment and the anatomic and physiologic differences of pediatric patients will ensure a successful outcome with minimal morbidity.
Urologic Clinics of North America 03/2004; 31(1):145-56. · 1.82 Impact Factor
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ABSTRACT: Wetting disorders in children can be frustrating for the patient, his parents and the physician caring for him. Although in most children the urinary incontinence will resolve with maturation, it is the persistent wetter that is brought in for management. There are two main categories of wetting disorders: those associated with neurological dysfunction of the lower urinary tract (neurogenic bladder) and those with normal neurological function (voiding dysfunction). This communication will be limited to the features, evaluation and management of voiding dysfunction.
The Journal of the Arkansas Medical Society 04/2003; 99(9):295-8.
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ABSTRACT: Urinary tract infections can result in significant morbidity and represent one of the most common urological conditions that the pediatrician and family practitioner encounter in the pediatric patient population. The prevalence of UTI in girls may be as high as 8.1%. UTIs also represent the most commonly identified serious bacterial infection in infants presenting with a febrile illness. Of febrile infants aged 2-3 months, 3-10% have a documented UTI. While the majority of the UTIs are not associated with any significant underlying conditions, the mere presence of a UTI is worrisome to most parents. An appropriate evaluation will determine which of these patients need referral. A brief summary is therefore presented to assist the primary care physician in the evaluation and management of childhood UTIs.
The Journal of the Arkansas Medical Society 12/2002; 99(5):156-8.
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The Journal of the Arkansas Medical Society 11/2002; 99(4):123-4.
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ABSTRACT: Primary care physicians, including family practitioners and pediatricians, frequently are consulted about children and adolescents with disorders of the inguinal canal and scrotum and are asked about the proper course of management, even if only to confirm an opinion of the surgical specialist. The purpose of this communication is to review the management of these conditions, including undescended testis, hydrocele and hernia, varicocele, testicular torsion, testicular trauma, epididymo-orchitis and scrotal edema.
The Journal of the Arkansas Medical Society 10/2002; 99(3):89-91.
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ABSTRACT: Bilateral single ureteral ectopia is exceedingly rare, with fewer than 80 cases reported. Fewer than 20 cases have been reported in males. We describe a recent patient with bilateral single ureteral ectopia with bilateral megaureter and ureteral orifices opening into the prostatic urethra.
Urology 10/2002; 60(3):514. · 2.43 Impact Factor
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ABSTRACT: We describe our experience with reconstruction of the ureter in 2 patients who sustained extensive upper and mid ureteral loss as newborns.
Two male patients, a 1-month-old and a neonate, sustained extensive ureteral loss due to candidal infection involving the retroperitoneum and ureter. The 1-month-old sustained a loss of the middle third of the ureter, and the neonate sustained a 3 cm. loss of the upper ureter. The first case was managed with a combination of renal mobilization and an extensive Boari flap, while the second was managed with renal mobilization and nephropexy with primary ureteropyelostomy.
Both patients had a successful outcome with no evidence of anastomotic stenosis or obstruction.
Extensive upper and middle third ureteral defects may be primarily bridged successfully in pediatric patients using the standard technique of renal mobilization combined with ureteropyelostomy and a Boari flap, respectively.
The Journal of Urology 09/2002; 168(2):691-3. · 3.75 Impact Factor
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ABSTRACT: To report a recent consecutive series of children undergoing open renal and upper ureteral surgery that was analyzed for outcomes, particularly morbidity and length of stay.
A total of 64 children underwent open renal or upper ureteral surgery using an upper abdominal retroperitoneal approach.
The mean operation time was 206 minutes, with a mean estimated blood loss of 20 mL. The mean analgesic dosage during the in-house postoperative period was 2.9 doses. The mean length of stay was 21.3 hours. A single complication occurred. One patient had a postoperative temperature of 38.6 degrees C, which was attributed to a pulmonary causation.
For now, open surgery remains the standard approach for pediatric renal and upper ureteral anomalies and diseases with an expected postoperative result and course similar to that of laparoscopically performed procedures.
Urology 05/2002; 59(4):588-90; discussion 590. · 2.43 Impact Factor
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ABSTRACT: Purpose:Three exploratory studies were conducted to investigate the pharmacokinetics (PK) and safety of tolterodine in children 1 month to 15 years old with neurogenic detrusor overactivity. We urodynamically evaluated the dose and concentration effects of tolterodine to establish safe and effective dosing regimens.Materials and Methods:Three open-label, dose escalating studies were conducted in children with stable neurological disease and detrusor overactivity. In studies 1 (patient aged 1 month to 4 years) and 2 (5 to 10 years) patients received 0.03, 0.06 and 0.12 mg/kg tolterodine solution day twice daily for 4 weeks each. In study 3 (patient age 11 to 15 years) patients received 2, 4 and 6 mg tolterodine extended-release capsules once daily for 4 weeks each. PK was assessed after 8 weeks, urodynamic assessments were conducted after each 4-week dosing period and 3-day micturition diaries were completed.Results:Patients in studies 1 (19) and 2 (15) showed some dose related increases in volume to first detrusor contraction and cystometric bladder capacity. In study 3 (11 patients) there were no obvious dose-response relationships. PK results from studies 1 and 2 suggest that there was no apparent effect of age (≤10 y) on these parameters. In study 3 time of maximum observed serum concentration and apparent terminal half-life were delayed, which is consistent with the extended-release formulation. Tolterodine was well tolerated, and there was no apparent relationship between tolterodine dose and adverse events in any study.Conclusions:These results support the safety of age and body weight adjusted dosing regimens for further clinical evaluation of tolterodine in children with neurogenic detrusor overactivity.
The Journal of Urology.
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ABSTRACT: ObjectiveWe evaluated long-term (≥12 months) efficacy and safety of tolterodine in children with neurogenic detrusor overactivity.Subjects and methodsSubjects successfully completed one of three 12-week, open-label studies and had stable neurologic disease and urodynamic evidence of neurogenic detrusor overactivity requiring intermittent catheterization. Drug formulation and dosing were based on age (4 months–4 years, tolterodine oral solution 0.2–2 mg twice daily; 5–10 years, tolterodine oral solution 0.5–4 mg twice daily; 11–16 years, tolterodine extended-release capsules 2, 4, or 6 mg once daily). Daily doses were individualized for each subject. Efficacy was evaluated urodynamically and using parent-completed 3-day bladder diaries.ResultsThirty subjects were enrolled. Functional bladder capacity (volume at first leakage, first sensation of bladder fullness or 40 cm H2O pressure) increased by month 12 in the younger age groups but not in the oldest subjects. Volume to first detrusor contraction >10 cm H2O pressure and detrusor leak point pressure did not change in any age group. The number of incontinence episodes per 24 h decreased in all subjects, as did the number of catheterizations per 24 h. Mean volume per catheterization increased in all subjects. Seven treatment-related adverse events were reported.ConclusionsBoth tolterodine formulations were effective and well tolerated in children with neurogenic detrusor overactivity.
Journal of Pediatric Urology.
