British Association of Paediatric Urologists consensus statement on the management of the primary obstructive megaureter

IntroductionIt is well-known that the majority of congenital megaureters may be managed conservatively, but the indications and surgical options in patients requiring intervention are less well defined. Hence this topic was selected for discussion at the 2012 consensus meeting of the British Association of Paediatric Urologists (BAPU). Our aim was to establish current UK practice and derive a consensus management strategy.MethodsAn evidence-based literature review on a predefined set of questions on the management of the primary congenital megaureter was presented to a panel of 56 Consultant Surgeon members of the British Association of Paediatric Urologists (BAPU), and current opinion and practice established. Each question was discussed, and a show of hands determined whether the panel reached a consensus (two-thirds majority).ResultsThe BAPU defined a ureteric diameter over 7 mm as abnormal. The recommendation was for newborns with prenatally diagnosed hydroureteronephrosis to receive antibiotic prophylaxis and be investigated with an ultrasound scan and micturating cystourethrogram, followed by a diuretic renogram once VUR and bladder outlet obstruction had been excluded. Initial management of primary megaureters is conservative. Indications for surgical intervention include symptoms such as febrile UTIs or pain, and in the asymptomatic patient, a DRF below 40% associated with massive or progressive hydronephrosis, or a drop in differential function on serial renograms. The BAPU recommended a ureteral reimplantation in patients over 1 year of age but recognized that the procedure may be challenging in infancy. Proposed alternatives were the insertion of a temporary JJ stent or a refluxing reimplantation.ConclusionA peer-reviewed consensus guideline for the management of the primary megaureter has been established. The guideline is based on current evidence and peer practice and the BAPU recognized that new techniques requiring further studies may have a role in future management.     

Long-term follow up of antenatally diagnosed megaureters

AimWe have retrospectively evaluated our 17 years of experience with antenatal diagnosis of hydronephrosis that led to postnatal diagnosis of megaureter, and tried to determine criteria for surgery.Patients and methodsSeventy-nine children (64 boys and 15 girls) with antenatal diagnosis of hydronephrosis that led to postnatal diagnosis of megaureter were followed conservatively over a period of 18 years (1988–2006). Right ureterohydronephrosis was seen in 23 children, left in 30 and 26 had bilateral ureterohydronephrosis comprising a total of 105 renal units (RU). According to SFU (Society for Fetal Urology) classification, 8 RU were grade 1, 57 grade 2, 29 grade 3 and 11 grade 4 postnatal hydronephrosis. Mean ureteral diameter was 1.2 cm. Relative renal function was in 82 RU more than 40%, in 18 RU 30–40% and in 5 RU less than 30%. Functional deterioration of the hydronephrotic kidney of more than 5%, worsening of hydronephrosis (SFU upgrade) and a persistent obstructive curve on radionuclide scans were the main indications for surgery.ResultsTwenty-five (31%) children required surgical correction. Mean age at surgery was 14.3 months (range 3–60). Univariate analysis revealed that gender and side of obstruction are not significant predictive factors for surgery SFU grade 3–4 of postnatal hydronephrosis, Relative renal function less than 30% and ureteral diameter more than 1.33 cm were significant independent risk factors leading to reimplantation.ConclusionsOnly 30% of children with antenatal diagnosis of megaureter required surgical correction. Renal function less than 30%, grades 3 and 4 hydronephrosis, and ureteric diameter more than 1.33 cm are statistically significant and independent predictive factors for surgery.     

Acute and delayed vesicoureteral obstruction after endoscopic treatment of primary vesicoureteral reflux with dextranomer/hyaluronic acid copolymer: Why and how to manage

ObjectiveTo present our cases of ureteral obstruction after endoscopic treatment of vesicoureteral reflux (VUR) with dextranomer/hyaluronic acid (Dx/HA).Patients and methodsWe collected data from patients who had suffered ureteral obstruction after endoscopic treatment of VUR with Dx/HA in our institution.ResultsFrom April 2002 to April 2011 we treated endoscopically 475 ureters with VUR, and detected 5 ureteral obstructions. Median age at reflux treatment was 39 months. Reflux grade before treatment was III in one patient and IV in four. Three ureterovesical junctions (UVJ) were blocked after a second endoscopic treatment. The median of Dx/HA injected was 1 ml (0.6–1.1). In two patients ureteral obstruction presented acutely and was treated with a ureteral stent. In the other three, the ureteral obstruction appeared gradually and was detected by ultrasound scans and MAG3 diuretic renogram; one underwent nephrectomy because of poor renal function, and the other two were treated with endoscopic dilatation of the UVJ. In all these patients both reflux and obstructions have resolved.ConclusionsOn preoperative cystography, three of the patients had a narrowed distal ureter, and probably had a refluxing and obstructive megaureter. Other causes are not clear, except for those patients with acute presentation in whom edema of the UVJ was found. Ureteral obstruction after endoscopic treatment of VUR is rare. Endoscopic intervention such as ureteral stent placement or high-pressure balloon dilatation of the UVJ has good results as a treatment of acute and delayed obstruction.     

Laparoscopic heminephroureterectomy for duplex kidney anomalies in the pediatric population

ObjectiveDespite increasing acceptance of laparoscopy in pediatric urology, few published data are available on laparoscopic heminephroureterectomy in patients with duplex kidney anomalies. In the present study, we report our own experiences with this technique.Patients and methodsFrom August 2003 to January 2006, five laparoscopic heminephroureterectomies were performed in four girls with a mean age of 41 (9–67) months. In all cases, a non-functioning upper pole with an obstructive (n = 4) or refluxing (n = 1) megaureter was found. The upper pole was resected laparoscopically en bloc with the megaureter using three to four trocars.ResultsMean follow-up was 42.4 (±7.9) months. All procedures were performed successfully without conversion to open surgery with a mean operative time of 190 (170–210) min. Blood loss was minimal and no intraoperative complications occurred. Despite chronic inflammation in the resected specimens, the patients showed no clinical signs of infection postoperatively. The average length of hospital stay was 5.6 (4–7) days. All patients were followed using duplex sonography.ConclusionsThese data demonstrate that, even in infants, laparoscopic heminephroureterectomy is feasible and associated with minimal morbidity, a better cosmetic result and a shorter hospital stay compared to open surgery. The main disadvantage of the laparoscopic approach is a longer operative time. Laparoscopic heminephroureterectomy is a technically demanding procedure and should be performed only in specialized centers.     

Refluxing ureteral reimplantation: A logical method for managing neonatal UVJ obstruction

ObjectiveAn obstructed megaureter can be managed using a number of techniques, with the primary goal being to minimize the potential for further injury to the affected kidney. Classically, these obstructed ureters have been treated using cutaneous ureterostomy. However, this technique has certain limitations including the potential for stenosis. We describe our experience with the refluxing ureteral reimplantation as a novel, yet technically simple, method for temporary internal diversion of the obstructed megaureter.MethodsTreatment consists of transecting the ureter proximal to the obstruction and performing an end-to-side anastomosis with the bladder in a freely refluxing fashion. Patients are placed on antibiotic suppression following surgery. Subsequent open definitive surgery is performed through the same incision site once the child is older than 1 year of age.ResultsSixteen patients identified with severe hydroureteronephrosis were found to have an obstructed megaureter(s) involving 19 ureteral moieties. Patients underwent internal diversion at an average age of 5 months. All patients demonstrated improved drainage of the affected kidney(s) following surgery. Three patients developed a febrile urinary tract infection. Definitive surgical treatment was undertaken in 18 of 19 ureters, and consisted of ureteral reimplantation with tapering or plication (13), ureteral reimplantation without tapering (3), and nephrectomy (2). One patient with multiple other congenital anomalies is not a candidate for further genitourinary reconstruction.ConclusionsRefluxing ureteral reimplantation is a safe and easy method of temporary internal urinary diversion. Simple in principle, the concept of creating a refluxing ureteral reimplantation is no different from that of incising an obstructing ureterocele. This technique allows time for the child to mature, while preserving renal function and awaiting definitive repair.     

Surgical management of nutcracker phenomenon presenting as left varicocele in adolescents: A novel approach

ObjectiveTo present a new approach using a shunt operation for the management of nutcracker phenomenon presenting as left varicocele in adolescent patients.Materials and methods12 adolescent patients with the nutcracker phenomenon presenting as left varicocele underwent a shunt operation consisting of anastomosis of the proximal part of the spermatic vein and inferior epigastric vein to lower the left renal vein (LRV) pressure. A simple ligation of the left spermatic vein was then used to repair the varicocele.Results12 patients underwent surgery, and symptoms of hematuria, proteinuria, scrotum discomfort, and flank pain disappeared post surgery in all patients. Patients were followed for 24–72 months (mean 48 months). The diameters of the proximal LRV and the peak velocities in the aortomesenteric portion of the LRV were significantly decreased after surgery (p < 0.001). Left testicular volume significantly increased after surgery. One patient had recurrence of the left varicocele and one adolescent had minimal hydrocele requiring no intervention. No major complications were observed during and after surgery.ConclusionAnastomosis of the proximal part of the spermatic vein and inferior epigastric vein is an efficacious and safe surgical approach for the management of nutcracker phenomenon presenting as left varicocele in adolescents.     

Impact of prenatal diagnosis on choledochal cysts and the benefits of early excision

Aim:   To evaluate the clinical outcomes of patients with prenatally diagnosed choledochal cysts compared with those diagnosed after birth and the optimal timing of definitive treatment.
Methods:   Retrospective review of all patients who underwent primary choledochal cyst excision and Roux-en-Y hepaticojejunostomy from 1996 to 2006 at a single institution.
Results:   A total of 45 patients were included. Ten (22.2%) of the patients had prior prenatal diagnosis. The mean age at operation for this group was 4.4 months and mean follow up was 55.9 months. There was no operative complication or late morbidity. For the post-natal diagnosis group, the mean age at operation was 5.7 years ( P  < 0.000) and mean follow up period was 69 months. The most common presentation in this group was abdominal pain (31.4%), followed by pancreatitis (28.6%) and symptoms of cholestasis (25.7%). Early post-operative morbidities occurred in two (5.7%) patients. On long-term follow up, two (5.7%) further patients in the post-natal group developed complications.
Conclusion:   Prenatal diagnosis of choledochal cysts results in earlier definitive surgery. More adverse complications were seen in those who had surgery at an older age. We therefore recommend early excision of choledochal cysts.     

Long-term complications following intestinal malrotation and the Ladd’s procedure: a 15 year review

Background: It is accepted that children with volvulus require urgent surgery. However the long term sequelae and late complications of its surgical therapy are less well understood. We hypothesised that the surgical corrected intestinal malrotation have significant long term impact on the patients quality of life. Methods: Forty-six children with intestinal malrotation were operated on at a tertiary referral centre over a fifteen year period. Their charts were retrospectively reviewed and the patients were contacted. Results: The study revealed two distinct groups, those without complications 25 (54%) and those without 21 (46%). In the acute post operative period four (9%) patients had on going feeding difficulties and one (2%) developed chronic abdominal pain. However 12 (26%) required readmission within the first six months after the initial operation. Eleven (24%) patients were readmitted with acute bowel obstruction. Six (13%) patients required multiple admissions due to small bowel obstruction and six (13%) patients underwent further surgery for adhesion related obstruction. There were four (9%) deaths in the study group, three due to other medical conditions and one following small bowel obstruction. There was zero mortality immediately after the primary operation. There was no significant difference in the initial presentation, age and operative findings in those requiring further surgery and those who did not. Conclusions: We demonstrated that there is a significant long-term morbidity associated with intestinal malrotation even after corrective surgery. Detailed education about the potential for small bowel obstruction must be given to the parents of these children.     

Management of primary non-refluxing upper urinary tract dilation: an analysis of 219 pediatric patients

Antenatal ultrasound (US) examinations have changed the diagnostic approach to and management of malformative uropathies. Primary non-refluxing upper urinary tract (UUT) dilation is one of the urinary malformations that has undergone significant evolution in recent years. From January 1972 to June 1991, 219 children with primary non-refluxing megaureter (caliber more than 10 mm on radiologic examination) were admitted to our pediatric surgical department; 37 (16.8%) had bilateral UUT dilatation, an overall 256 renal units. The patients were divided into two groups: from January 1972 to June 1985 and from July 1985 to June 1991. In the latter period there was a considerable and progressive increase in admissions of infants in whom a prenatal US diagnosis of UUT dilation was made. A total of 186 renal units in 166 patients were operated upon; the success rate was 92%. A total of 70 megaureters (17 bilateral) in 53 patients were managed conservatively. The percentage of conservatively managed cases has increased in recent years; in almost all these patients the diagnosis was made antenatally. Our criteria for conservative management have been absence of obstruction and normal renal function as assessed by dynamic diuretic DTPA renography. These patients were carefully followed by serial US examinations and diuretic DTPA renograms. The follow-up of these 53 patients ranged from 6 months to 16 years with an average of 3 years 6 months; 47 have had a minimum follow-up of 18 months. In all these patients there has been progressive, spontaneous reduction or normalization of the dilation and no deterioration of renal function. In the authors opinion less than 50% of infants with grossly dilated non-refluxing megaureter diagnosed prenatally should be considered candidates for surgery, while the majority can be successfully managed without surgery. Correspondence to: G. Belloli     

Modern staged repair of bladder exstrophy: a contemporary series

ObjectiveMany changes have occurred in the treatment of bladder exstrophy over the last few years and many repairs are now offered. The purpose of this study was to evaluate long-term outcomes in a select group of patients in whom modern staged repair (MSRE) was undertaken.Patients and methodsFrom an institutionally approved database were extracted 189 patients who had undergone primary closure between 1988 and 2004. The records of 131 patients (95 males) who underwent MSRE with a modified Cantwell-Ransley repair by a single surgeon in 1988–2004 were reviewed with a minimum 5-year follow up.ResultsSixty-seven patients with a mean age of 2 months (range 6 h to 4 months) underwent primary closure, and 18 underwent osteotomy at the same time. Mean age at epispadias repair was 18 months (8–24). Mean age at bladder neck reconstruction (BNR) was 4.8 years (40–60 months) with a mean capacity of 98 cc (75–185). Analysis of bladder capacity prior to BNR revealed that patients with a mean capacity greater than 85 cc median had better outcomes. Seventy percent (n = 47) are continent day and night and voiding per urethra without augmentation or intermittent catheterization. Social continence defined as dry for more than 3 h during the day was found in 10% (n = 7). Six patients required continent diversion after failed BNR. Seven patients are completely incontinent. The mean time to daytime continence was 14 months (4–23) and the mean time to night-time continence was 23 months (11–34). No correlation was found between age at BNR and continence.ConclusionsPatients with a good bladder template who develop sufficient bladder capacity after successful primary closure and epispadias repair can achieve acceptable continence without bladder augmentation and intermittent catheterization.     

Non-traumatic spinal cord ischaemia in childhood – Clinical manifestation,neuroimaging and outcome

BackgroundSpinal cord ischaemia is rare in childhood and information on clinical presentation and outcome is scarce.MethodsThis is a retrospective analysis of eight patients and 75 additional cases from the literature. Data search included: patient's age, primary manifestation, risk factors, neuroimaging and outcome.ResultsFive female and three male patients gave consent to participate. Mean age was 12.5 years (10–15 years). Six patients presented with paraplegia; this was preceded by pain in four. Brown Sequard syndrome and quadriparesis were the two others' presenting condition. Sensation levels were thoracolumbar in seven cases. Bladder dysfunction only or bladder and bowel dysfunction were reported in eight and five patients respectively. Time to maximal symptom manifestation was <12 h in 7/8. Risk factors included surgery, minor trauma, recent infection, and thrombophilia. Mean follow-up was 3.3 years (0.25–6.3 years). Three patients remained wheelchair-dependent and three patients were ambulatory without aid. Bladder function recovered fully in five children. Most affected aspects of quality of life were physical and mental well-being and self-perception.T2-weighted-MR images showed pencil-like hyperintensity (8/8) in sagittal and H-shaped or snake-eyes-like lesion (6/8) in axial views.Analyses of all 83 patients were in congruence with the above results of the study group.ConclusionSpinal cord ischaemia in childhood presenting with pain, paraplegia, and bladder dysfunction has high morbidity concerning motor problems and quality of life. Acute arterial ischaemic event in children seems similar to adult events with respect to clinical presentation and, surprisingly, also in outcome.     

Acute scrotum — Etiology and management

Objective: Acute scrotal pain is a common urological emergency. Urgent exploration is the standard means of management, since no investigation can confidently exclude torsion of testis from the differential diagnosis.Methods: A review of all boys presenting with acute scrotal pain who underwent emergency scrotal exploration between January 1983 and March 2003 was performed.Results: 195 boys were included in this study. They were divided into 3 groups: group 1–73 with epididymo-orchitis, group 2–63 with torsion of testicular appendages and group 3–57 with spermatic cord torsion. The patients in group 2 were older than group 1, also patients in group 1 were older than group 3. During neonatal period the most common pathology was spermatic cord torsion, whereas in prepubertal period torsion of appendages was more common. In all boys, mean duration of pain at presentation was 2.11 days. Epididymo-orchitis was diagnosed in 37% of patients, with torsion of the appendages being the next most common entity. Testicular torsion was diagnosed in 29% of patients. In the group with testicular torsion salvage rate of testis was 37% because of late admission. The perioperative morbidity and mortality was not seen in any of the groups.Conclusion: We believe that any boy with acute scrotal pain and any suspicion of testicular torsion in physical examination must be applied routine surgical exploration.     

Urologic Outcomes of Pediatric Pelvic Neuroblastoma Presenting in Acute Urinary Retention

Purpose: To evaluate long-term urologic outcomes of patients with pelvic neuroblastoma (NB) presenting with urinary retention. Methods: Five cases of pelvic NB presenting with urinary retention were identified between 1971 and 2011. Clinical presentation, treatment, survival and long-term voiding outcomes were analyzed. Results: All five patients presented with acute urinary retention and pelvic outlet dysfunction including bladder perforation (20%), constipation (40%), or fecal incontinence (20%). The presenting age ranged from 7 days to 4 years with female to male ratio of 3:2. Two patients presented with bilateral hydronephrosis and three patients were stage 4 at presentation. All required debulking surgery, four patients required combined anterior and posterior approaches for tumor resection, with two patients requiring concurrent laminectomy. Adjuvant or neoadjuvant chemoradiation was used in four of five cases. Follow-up ranged from 2 to 41 years. Although the long-term oncological outcome is favorable, urologic outcomes of these patients ranged from normal bladder function to the need significant reconstructive procedures. Conclusion: Urologic outcomes are related to pelvic nerve and organ preservation during resection more than the severity of urinary symptoms at presentation.     

The Kalicinski ureteral folding technique for megaureter in children. Experience in 23 cases.

We report our series of 16 children with 23 megaureters: 7 were refluxing, 11 were obstructive (7 primary and 4 secondary), 3 both refluxing and obstructive and 2 nonrefluxing nonobstructive. These patients had a Kalicinski folding-under remodeling of their megaureter and Cohen or Lead-better reimplantation. Success rate was 96% with only 2 failures: 1 recurrent low-grade reflux treated with subureteric Teflon injection and 1 stenosis that necessitated reoperation. Kalicinski's technique with Cohen type reimplantation is one of the best alternatives for megaureters, mainly because it does not present the disadvantages of the excisional procedure.     

Oophorectomy in children. Who and why: 13-year experience in a single centre

Aim: Oophorectomy performed in children is extremely uncommon. We aimed to investigate the disease pattern and the association between the underlying pathology and the clinical presentation among those patients who had their ovaries removed in their childhood. Methods: A retrospective study was performed on 41 consecutive children who underwent oophorectomy in a tertiary referral centre in the period between June 1995 and May 2008. Results: The median age was 11 years, ranged from 11 weeks to 15 years at the time of surgery. The primary presentations were acute lower abdominal pain (n= 20), progressive abdominal distension or abdominal mass (n= 13), chronic abdominal pain (n= 3), irregular menses (n= 1), antenatal diagnosis (n= 3) and incidental finding (n= 1). Ultrasound examination was performed in 31 patients and positive findings of ovarian pathology were found in all but one examination. Twenty cases of ovarian torsion were confirmed intra‐operatively. Patients presenting with acute abdominal pain were more likely to have torsion than other presentations (P < 0.01). Non‐neoplastic conditions and ovarian neoplasms were found in 11 and 30 patients, respectively. The most common neoplasm was mature teratoma (52%). Malignant neoplasms included immature teratoma (n= 3), dysgerminoma (n= 1), mixed dysgerminoma + yolk sac tumour (n= 2), yolk sac tumour (n= 2) and juvenile granulose cell tumour (n= 1). Malignant neoplasms were found to have more chronic presentation and less torsion than benign pathologies (P < 0.05). Conclusion: Although ovarian pathology is uncommon in children, a girl presenting with acute lower abdominal pain or progressive abdominal distension should raise the suspicion and prompt immediate investigation to rule out ovarian torsion or ovarian neoplasms.     

Urethral duplication in children: Our experience of eight cases

ObjectiveDuplication of urethra has varied presentations and multiple techniques have been described for its correction. We present our experience in the management of this anomaly.Material and methodWe retrospectively reviewed the records of eight patients treated for urethral duplication in 1998–2008. We managed four cases of Y-duplication, three of whom underwent buccal mucosal tube urethroplasty and one urethrourethrostomy. Two patients presented with double stream (type II A2); in one urethrourethrostomy was done and the other child underwent vesicostomy as initial treatment. Two cases were of type II B duplication (two urethra opening as single meatus); one required only dilatation of urethra and the other excision of accessory tract.ResultMean age at presentation was 56.9 months. Associated anomaly was present in only two patients. Single-stage procedure was done in four patients and multi-staged procedure in three patients. Overall mean number of procedures required was 2.8; more were required in the case of Y-duplication compared to the other types. On follow-up all patients were passing urine in single stream.ConclusionThorough work up to detect any associated anomaly and type of duplication is required for the management of urethral duplication. Single-stage repair with buccal mucosa as tube urethroplasty in cases of Y-duplication is feasible with good outcome.     

Ileal bladder augmentation and vitamin B12: levels decrease with time after surgery

ObjectiveWe investigated vitamin B12 deficiency following ileocystoplasty in children.MethodsPatients who underwent ileocystoplasty between December 1993 and September 2006 were included and B12 levels were retrospectively analysed. Patients with a serum B12 of less than 150 pg/ml were considered deficient. The distance of the ileal segment from the ileocaecal valve was recorded.ResultsThere were 105 patients in the series; 61 were male. Mean age at surgery was 7.7 years (SD = 3.9). The mean interval from surgery to most recent B12 level was 50 months (SD = 30). None of the patients were on B12 supplementation. Two patients were B12 deficient, both more than 7 years after surgery; 44% of patients with levels available 7 years after surgery had a B12 below 300 pg/ml. There was a significant negative correlation between B12 level and length of follow up (Spearman’s rank, P < 0.01). Twenty patients with an ileal segment sparing 60 cm from the ileocaecal valve had a higher mean B12 (524 vs 419, SEM 60 vs 28). This was not statistically significant.ConclusionWe demonstrate a reduction in serum B12 level with time following ileocystoplasty. These patients should have their B12 levels measured in the long term.     

Adolescent varicocelectomy: postoperative catch-up growth is not secondary to lymphatic ligation

PurposeThe major indication for adolescent varicocelectomy is testicular asymmetry with the left testicle smaller than the right. Catch-up growth following surgery is one of the parameters used to assess efficacy of surgery. However, it is not clear whether this represents true tissue growth or increased interstitial fluid secondary to lymphatic obstruction. The purpose of this study was to compare catch-up growth in patients who underwent varicocelectomy with and without lymphatic preservation.Materials and methodsWe retrospectively analyzed the outcomes of 136 boys (mean age 15.1 years) who had 10% or greater preoperative testicular asymmetry and underwent varicocelectomy between 1997 and 2006. Surgery was either a laparoscopic nonlymphatic sparing or laparoscopic lymphatic sparing varicocelectomy. All patients had pre- and postoperative ultrasound volume measurements at least 6 months following surgery. The groups were compared for incidence of postoperative catch-up growth, achieving less than 10% testicular asymmetry.ResultsAfter a mean follow up of 24.7 months, catch-up growth was achieved in 62.8% of patients. There was no significant difference between the groups in regard to catch-up growth (51.7% vs 66.3%, P = 0.193).ConclusionsSince no significant difference was found between the laparoscopic nonlymphatic sparing and laparoscopic lymphatic sparing varicocelectomies, we conclude that lymphatic obstruction is not the cause of catch-up growth.     

Outcome of bladder exstrophy repair based on age and technique. Single center experience

PurposeReconstruction of bladder exstrophy remains a challenge. We evaluated our experience with different techniques in different age groups.Material and MethodsA retrospective data review was conducted of bladder exstrophy patients presenting at our institution between May 2000 and September 2007. 61 patients (21 females and 40 males) with classic bladder exstrophy were included. Age of presentation ranged from 24 hours to 14 months. 51 patients underwent complete primary repair and 11 patients had staged repairs. Mean follow up was 3 years (1 month to 7 years). Mortality involved one male & one female (3.2%). 29 patients underwent anterior innominate osteotomy and 9 underwent posterior osteotomy. Patients were evaluated for continence, upper tract dilatation and cosmetic result.ResultsIn the primary repair group, 8 (15.6%) had failed closures and 5 (9.8%) had fistulas. In the staged repair group, 1 (0.9%) had a failed closure and 1 had an epispadic fistula. Evaluation of continence excluded 9 patients recently operated on and 17 patients not followed up at our center. The primary repair group had 15 of 25 dry patients (11 females and 4 males). In the staged repair group, 4 of 10 patients were continent. 4 of our staged cases became dry following augmentation cystoplasty. Upper tract changes were mild during our study (44% of complete repair group and 12.5% in the staged group) with all patients having normal serum creatinine.ConclusionsPatients may require more than one procedure for reconstruction. Continence was better in females than males with primary or staged repairs.     

Pediatric open partial nephrectomy: analysis of contemporary outcomes with a supracostal-12 approach

ObjectiveReports in the literature increasingly have demonstrated a shorter length of stay (LOS) with the laparoscopic approach to partial nephrectomy compared to historic open partial nephrectomy. We present data from the largest open series to date, to provide a more contemporary perspective.MethodsA retrospective review was performed on all pediatric patients who underwent upper pole partial nephrectomy from 1999 to 2011. Using univariate and multivariate linear regression, the associations between multiple explanatory covariates and outcomes such as pain and length of stay were analyzed.ResultsTwenty-five surgeries were performed via a supracostal-12 approach. The mean incision length and operative time was 3.7 cm and 137 min, respectively. The average pain score was 1.7/10 and 72% of patients did not require morphine. The mean LOS was 36 h and all patients with postoperative imaging had normal blood flow. Multivariate analysis demonstrated that a later date of surgery was the only covariate significantly associated with decreased operative time and LOS.ConclusionOpen partial nephrectomy can be performed in a minimally invasive manner via a small supracostal-12 incision with minimal pain and LOS. Surgeon experience is associated with decreased operative time and LOS. These contemporary open results should be considered when comparisons are made with laparoscopic surgery.