This Month in Pediatric Urology

Article Outline

• Reoperative Laparoscopic Pyeloplasty in Children
• Laparoscopic Treatment of Urachal Remnants in Children
• Management of Repeatedly Failed Phallus Reconstruction Using Tissue Expanders
• Urinary Tract Infections and Bladder Dysfunction After Renal Transplantation
• Percutaneous Nephrolithotomy in Children
• Copyright

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Reoperative Laparoscopic Pyeloplasty in Children 

Laparoscopic pyeloplasty is being performed commonly in children, although there are few reports of this treatment for persistent or recurrent ureteropelvic junction obstruction. Piaggio et al (page 1878) from Wilmington, Delaware retrospectively reviewed their experience with 10 children who underwent 11 redo pyeloplasties from 2003 to 2006. Of the patients 4 underwent open pyeloplasty and 6 were treated with transperitoneal laparoscopic pyeloplasty. The total number of previous procedures was 9 and 11 in the 6 and 4 patients, respectively. An indwelling stent was left postoperatively in all patients. Operative time was approximately 90 minutes longer in the laparoscopic group but there was a shorter hospital stay and decreased narcotics usage. The complication and success rates were similar in both groups. Further experience with laparoscopic pyeloplasty for recurrent ureteropelvic junction obstruction is warranted.

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Laparoscopic Treatment of Urachal Remnants in Children 

Urachal remnants can be associated with infection and possibly malignant degeneration. Turial et al (page 1864) from Mainz, Germany retrospectively reviewed their experience with 27 children 4 weeks to 10 years old, who underwent laparoscopic removal of a symptomatic urachal remnant. No incidental remnants were included. Pathological evaluation confirmed 15 urachal fistulas, 8 urachal cysts, 4 urachal sinuses and 4 urachal abscesses. Two different approaches were used. In the first 9 children the laparoscope was inserted at the umbilicus and the working ports were placed in the left and right upper abdominal walls. In the latter children the laparoscope was inserted at the left lower abdominal wall and working ports were placed in the left lower and upper abdomen. Mean operative time was 35 minutes and no complications occurred. A urethral catheter was left indwelling for 1 to 3 days postoperatively. The authors also describe laparoscopic removal of urachal adenocarcinoma in 3 patients, of whom 2 are disease-free. The authors thought that the lateral approach provided better anatomical exposure. Whether this approach is superior to an infraumbilical approach remains to be determined.

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Management of Repeatedly Failed Phallus Reconstruction Using Tissue Expanders 

Often there is insufficient penile skin after failed phallic reconstruction. Kajbafzadeh et al (page 1872) from Tehran, Iran retrospectively reviewed their experience with 16 patients 5 to 22 years old (mean age 9.9 years) who underwent penile tissue expansion for treatment of failed phallic reconstruction. Most were born with proximal hypospadias. The injection port was placed in the suprapubic area lateral to the penile base with a small incision between the anticipated expander pouch and reservoir. Penile tissue expanders were inflated by injections 1 to 2 weeks postoperatively. The definitive reconstructive surgery was planned 2 to 11 months after implantation. One tissue expander was removed due to erosion. However, sufficient expanded skin was available for penile skin coverage and urethral reconstruction in all patients. In 2 a urethral fistula developed and meatal stenosis occurred in 2. With a mean followup of 6.5 years acceptable cosmetic and functional results were obtained in 81% of patients. The authors recommend the use of tissue expansion in men with limited penile skin for reconstruction.

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Urinary Tract Infections and Bladder Dysfunction After Renal Transplantation 

Urinary tract infections (UTIs) can adversely affect graft function following renal transplantation. Herthelius and Oborn (page 1883) from Stockholm, Sweden evaluated bladder function in 68 children who had undergone renal transplantation to assess the impact of bladder dysfunction on the incidence of UTI after transplantation and the impact of recurrent UTIs on graft function. The patients underwent extravesical ureteroneocystostomy. Bladder dysfunction was defined as abnormal urinary flow (eg staccato, fractionated or plateau flow pattern), an abnormal bladder capacity (less than 60% or greater than 150% expected for age) and/or greater than 20 ml residual urine on repeated occasions. The incidence of bladder dysfunction was similar among children with and without recurrent UTIs, and the authors concluded that it had no effect on the risk of UTI. Graft function gradually deteriorated in all patients. However, graft function deteriorated faster in patients with than those without recurrent UTI.

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Percutaneous Nephrolithotomy in Children 

Percutaneous nephrostolithotomy is often performed in children with a renal pelvic calculus. Bilen et al (page 1867) from Samsun, Turkey retrospectively reviewed the records of 46 children who underwent this procedure. Indications included stones resistant to shock wave lithotripsy, stones requiring repeated sessions of shock wave lithotripsy, staghorn calculi, stones in a caliceal diverticulum, faint or radiolucent stones, and dilated and obstructed kidneys. The authors compared the outcomes using adult devices via a 26Fr tract (mean patient age 13.2 years), instrumentation via a 20Fr tract (mean age 5.9 years) and a miniperc (14Fr) (mean age 6.3 years). They used 26Fr or 20Fr instruments for semi-complete or complete staghorn calculi. The miniperc was reserved for residual calculi following shock wave lithotripsy for large stones, stones in a caliceal diverticulum, low volume stones and cases with additional access needs. The stone-free rate was 90% in the miniperc group, 80% in the 20Fr group and 70% in the 26Fr group. The transfusion rate was lowest in the miniperc group.