This Month in Pediatric Urology

Article Outline

• Safety and Efficacy of Supracostal Percutaneous Nephrolithotomy
• Pre-Scrotal Approach for the Palapable Undescended Testis
• Patterns and Predictors of Laparoscopic Complications in Pediatric Urology
• Parental Decision Making for Surgical Correction of Vesicoureteral Reflux
• Copyright

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Safety and Efficacy of Supracostal Percutaneous Nephrolithotomy 

Management of complex renal stones in children is challenging and not always amenable to shock wave lithotripsy or flexible ureteroscopy due to the location of the stone and stone burden. Percutaneous nephrolithotomy (PCNL) provides a suitable alternative for management. EL-Nahas et al (page 676) from Mansoura Egypt explore the safety and efficacy of subcostal vs supracostal PCNL in 50 children with a mean age of 7 years. A total of 60 PCNL procedures were performed using a subcostal puncture to access 40 units and a supracostal puncture above the 12th rib to access 20 units. The percutaneous tract was dilated to a 22Fr in 33 procedures, which allowed use of an 18Fr pediatric nephroscope. In older children the tract was dilated to 30Fr which allowed use of adult instruments. The stones were removed with combination therapy of holmium:YAG laser lithotripsy and forceps extraction. At the end of the procedure either a 16Fr or 22Fr nephrostomy tube was placed.

Postoperative complications included fever in 3 patients, urine leakage in 3 and hematuria requiring blood transfusion in 2. The distribution of postoperative complications between the subcostal and supracostal groups was comparable. Overall 46 (77%) patients were stone-free at the time of hospital discharge, 9 (15%) required a course of shock wave lithotripsy and 5 (8%) had insignificant residual stones. There was no significant difference in hospital stay, auxiliary procedures, subsequent ureteroscopy, need for Double-J® stent or shock wave lithotripsy with either approach. Stones recurred in 36% of the subcostal group and 33% of the supracostal group.

Technical points of importance include 1) limiting the supracostal access to the 12th rib, 2) making the supracostal skin puncture lateral to the rib during breath holding at expiration, 3) identifying the inferior plural margin using lateral fluoroscopy, 4) entering the calix during full inspiration and 5) placing the dilating sheath well into the collecting system to reduce the risk of symptomatic hydrothorax. The authors conclude that PCNL in children provides a high degree of safety and efficacy when performed by an experienced endourologist.

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Pre-Scrotal Approach for the Palapable Undescended Testis 

Urologists have always respected the importance of cosmesis and morbidity when performing operations. One of the most common procedures performed by a pediatric urologist is an orchiopexy. The traditional inguinal approach is well tolerated but requires a second scrotal incision for placement of the testicle into a dartos pouch. In an attempt to improve upon this common procedure, a single incision using a pre-scrotal approach for dissection and placement of the testicle in the scrotum was evaluated.

Al-Mandil et al (page 686) from Toronto, Canada compare the traditional inguinal and scrotal incision in 47 boys with a single pre-scrotal incision in 56 boys for a dartos pouch orchiopexy. The preoperative location of the testicle in both groups was similar. Surgical time for the pre-scrotal group was 34 minutes vs 64 minutes for the traditional group. None of the boys in the pre-scrotal incision group required conversion to an inguinal approach to achieve a tension-free orchiopexy. One boy in each group had subsequent ascent of the testicle requiring redo orchiopexy. An inguinal hernia requiring subsequent surgery developed in 2 boys (3%) in the pre-scrotal group.

Primary operative steps for the pre-scrotal orchiopexy include an incision at the skin crease between the scrotum and perineum with creation of a subcutaneous dartos pouch followed by division of the gubernacular attachments. Cremasteric fibers are then divided, and the hernia sac is mobilized and ligated under a little tension allowing withdrawal of the sac to the internal ring without opening the external oblique fascia. The testis is ultimately delivered into the pouch and secured to the dartos.

The authors indicate that locating the testis within the canal is the most important predictor of success. They conclude that a pre-scrotal approach is an appropriate alternative to the traditional inguinal and scrotal incision used in a dartos pouch orchiopexy. They believe a single incision provides better cosmesis and less operative time, and may translate into less postoperative discomfort.

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Patterns and Predictors of Laparoscopic Complications in Pediatric Urology 

The popularization of pediatric laparoscopic surgery in children has increased from an initial diagnostic modality for the nonpalpable testicle to major therapeutic intervention. The importance of identifying risk factors for laparoscopy compared to conventional open surgery is obvious. Passerotti et al (page 681) from Boston, Massachusetts retrospectively reviewed a 10-year experience of conventional and robotic assisted laparoscopic procedures performed by 10 surgeons, and provide an unbiased, blinded assessment. They identified 806 cases meeting their study criteria, of which 45% were diagnostic and 54% were therapeutic. The 366 diagnostic procedures were equally divided between Veress needle access and an open Hasson technique for creating the pneumoperitoneum. Intraoperative complications were graded by Clavien's Classification System. Factors assessed when evaluating complications included the type of case, surgical approach, use of an access system, duration of the procedure, patient age and weight, and number of cases performed by each surgeon.

Overall complications occurred in 16 (2%) cases, including preperitoneal insufflation resulting in conversion to an open procedure in 6 (0.7%), vessel injury in 3 (0.4%), small bowel puncture in 3 (0.4%) requiring conversion to an open repair in 1, bleeding requiring conversion to open repair in 1 (0.1%), bladder perforation in 1 (0.1%) and vas deferens injury in 2 (0.2%). There were 9 (2.3%) complications with the Veress needle placement vs 3 (0.8%) with the open Hasson technique, which was not statistically significant. Significant complications of Clavien's scale greater than 3 were identical for both techniques at 3 each. Complications were associated more often with the technique of access than the operative procedure itself. The type of procedure performed, patient age and weight, duration of the procedure and conventional or robotic assisted procedures did not affect the risk of a complication.

The total complication rate was significantly different when surgeons performed fewer vs more than 12 laparoscopic cases a year regardless of the complexity of the procedure. Surgical experience did not reduce the overall complication risk, although this may be due to the fact that the most experienced surgeons performed the most challenging procedures with an inherent higher complication risk. It did appear that a higher laparoscopic volume lowered the complication rate. With the majority of complications due to access, the authors stress the importance of surgical education directed toward access technique. They also note that Clavien's Classification System for laparoscopic complications may be more suited to the adult population since it is focused on postoperative complications which were found to be rare in this series of children. The authors conclude that surgical volume appears to be the best predictor of complications and that avoidance of complications is possible in most cases. Constant review, objective assessment and training are required.

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Parental Decision Making for Surgical Correction of Vesicoureteral Reflux 

Callaghan et al (page 701) from Rhode Island and Massachusetts explore parental factors used in the decision making process regarding their selection of treatment for vesicoureteral reflux. In a retrospective review 74 children 1.5 to 18 years old were identified who had undergone 52 open and 25 endoscopic ureteral reimplantations. In a telephone survey conducted by an individual not involved with the operative team parents were asked 6 questions related to why they selected a particular therapy and 7 questions regarding why they did not select the alternative treatment.

Preoperatively the families were primed with similar statistics reporting success rates of 98% to 100% for an open reimplantation with a hospital stay of 2 to 3 days and 85% for a single system and 65% to 70% for duplex systems approached endoscopically. A voiding cystourethrogram (VCUG) was not required in children undergoing an open procedure but all children undergoing endoscopic treatment were scheduled for a VCUG. The indications for surgery included breakthrough urinary infections in 29 children, persistent reflux for less than 4 years in 32, persistent reflux for more than 4 years in 13 and failure of prior endoscopic correction in 3.

Of the 52 children undergoing an open procedure the first or second reason for choosing this approach was the success of the procedure in 47 (90.4%). The invasiveness of the procedure was rated as least important in 18 (35%) cases. Interestingly the lack of a need for a postoperative VCUG was most important in only 15 (29%) cases and least important in 30 (58%). Of the 25 endoscopy cases initial success of the procedure was rated as most important in only 13 (52%). Lack of invasiveness and minimal morbidity were of prime importance in 21 (84%) cases and concern about a followup VCUG was rated least important in 16 (64%). Of the parents who selected an open approach 52 (96%) said they would take the same option and 2 would not, both of whom had older children (ages 15 and 18 years). Of the parents of the children undergoing endoscopic surgery 3 (13%) would not choose the same procedure. Not surprising, the initial attempt failed all 3 children. Interestingly, physician recommendation and recommendations by other family members did not have a role in the decision making process. The authors conclude that parents select open surgery because of its success rate and are satisfied with their decision. Parents select an endoscopic approach because it is minimally invasive but ultimately outcome may affect overall satisfaction.