Since the approval of dextranomer/hyaluronic acid copolymer (Deflux) for the endoscopic treatment of vesicoureteral reflux (VUR) in 2001, endoscopic treatment of VUR has gained widespread acceptance at many centers in the United States and abroad. Many have advocated its use as primary therapy, replacing the traditional mainstay of prophylactic antibiotics. Nelson et al (page 1152), representing the Urologic Diseases in America Project, investigated patterns of care for VUR from 2002 through the first quarter of 2007 using a large medical insurance claims database containing data for more than 39 million lives. Patients were included in the study if they were 18 years old or younger, had an ICD-9 diagnosis code for VUR and CPT codes for voiding or nuclear cystogram and had at least 1 year of followup after the diagnosis of VUR. Rates of surgical intervention were based on CPT codes for open (OARS) and endoscopic (EARS) antireflux surgery. Only initial surgical procedures were included and surgery performed within 1 year of diagnosis was selected as the proxy to indicate use of surgery as initial therapy.
A total of 9,496 pediatric patients were available for analysis. Overall antireflux surgery was performed in 1,988 (21%) patients during the study period, consisting of OARS in 1,037 (52%) and EARS in 961 (48%). Surgery was performed within 12 months of diagnosis of VUR in 1,234 patients (62%). The overall proportion of newly diagnosed reflux in the early surgery group increased from 12% in 2002 to 17.3% in 2006 (p <0.0001). The increase was primarily due to a doubling of the proportion of patients undergoing EARS from 4.2% in 2002 to 9.7% in 2006 (p <0.0001). In contrast, the proportion of newly diagnosed patients undergoing OARS did not change significantly. The authors conclude that, despite the lack of evidence of benefit, EARS is increasingly viewed by some as first line therapy for VUR.
Open Ureteral Reimplantation Without Morphine
Surgical treatment options for VUR include open ureteral reimplantation and endoscopic implantation of dextranomer/hyalouronic acid polymer (Deflux). Preference for Deflux is based on it being considered a minimally invasive procedure associated with less pain, decreased convalescence and improved aesthetics. Chamie et al (page 1147) from Sacramento, California describe their contemporary experience with open minimally invasive ureteral reimplantation, examining the relationship of analgesic use, patient age, gender, laterality and intravesical vs extravesical reimplant with postoperative pain and length of stay. The records of 100 consecutive patients who underwent open ureteral reimplantation between 2001 and 2007 were reviewed. Intravesical and extravesical reimplantations were performed through a 4 cm transverse incision without caudal or epidural anesthesia. Postoperatively all patients received 0.5 mg/kg ketoralac every 6 hours and 0.2 to 0.4 ml/kg acetaminophen with codeine as needed. Postoperative pain was assessed by the nursing staff in the recovery room and every 4 hours on the ward using standardized pain scales for children, with mild pain defined by a score of 0 to 3, moderate 4 to 7 and severe 8 to 10.
Of 60 bilateral repairs 97% were performed through an intravesical approach, whereas an extravesical approach was used in 78% of 40 unilateral repairs. Foley catheter drainage was discontinued after overnight use. Only 7 patients received morphine, including 6 operated on early in the series before 2003. Pain scores were low with a mean of 1.2, median 0.9 and maximum 3.4. Mean length of stay was 24.4 hours. Three patients were rehospitalized for nausea and vomiting (1), urinary retention (1) and pain (1). A urinary tract infection developed in 24 patients postoperatively. The authors conclude that open ureteroneocystostomy can be performed in a minimally invasive manner, and that the success rates, lower morbidity and shorter length of stay for contemporary open ureteral reimplantation series should be used when comparing endoscopic and open surgical treatment of VUR.
Cryptorchidism With Short Spermatic Vessels
Nonpalpable undescended testes are usually intra-abdominal and associated with short spermatic vessels which may have to be divided to place the testis in a satisfactory scrotal position. In some cases atrophy of the testis occurs, even if the orchiopexy is done in stages. Dessanti et al (page 1163) from Brescia, Italy report their initial experience with a novel technique for a staged orchiopexy which preserves the spermatic vessels. The technique is performed through an oblique inguinal incision and begins in a standard fashion with identification of the processus vaginalis and testis, ligation of the processus, and retroperitoneal mobilization of the spermatic vessels as much as possible. When the spermatic vessels are too short to allow the testis to be placed in the scrotum, the spermatic cord is wrapped along its entire length with an “anti-adhesion” Gore Preclude® pericardial membrane expanded polytetrafluoroethylene sheet. The testis itself is fixed to the bottom of the scrotum which is invaginated up into the inguinal incision using 5-zero polydioxanone monofilament sutures. A small synthetic pledget on the outside of the scrotal skin typically falls off after 30 days. Stage 2 is performed after 9 to 12 months by which time the testis has usually migrated into the scrotum as a result of the scrotal fixation and traction. In those cases all that is required is to remove the membrane. If the testis is not in a satisfactory scrotal location, it can be repositioned in the scrotum after the membrane is removed and the testis is isolated again.
This procedure was performed in 38 patients with 45 nonpalpable testes, including 34 intra-abdominal and 11 “peeping” through the internal inguinal ring. Patients ranged in age from 1 to 5 years (mean 35 months). There were no intraoperative or postoperative complications, and 37 of the 45 testes were in a satisfactory scrotal position at the time of stage 2. The remaining 8 testes were in a high scrotal position but were successfully repositioned into the scrotum. At followup, ranging from 1 to 8 years (mean 3 years) after stage 2, all 45 testes were located in a satisfactory scrotal position with stable or increased volume as measured by ultrasound. The authors conclude that this technique is an alternative to the Fowler-Stephens approach with less risk of ischemic atrophy of the undescended testis.
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