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619 MODIFICATIONS IN TECHNIQUE LEADING TO IMPROVED SUCCESS OF ROBOTIC EXTRAVESICAL URETERAL REIMPLANATION
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THE JOURNAL OF UROLOGY姞
Vol. 187, No. 4S, Supplement, Sunday, May 20, 2012
619
620
MODIFICATIONS IN TECHNIQUE LEADING TO IMPROVED SUCCESS OF ROBOTIC EXTRAVESICAL URETERAL REIMPLANATION
PREDICTING FACTORS OF BREAKTHROUGH INFECTION IN CHILDREN WITH PRIMARY VESICOURETERAL REFLUX
Kyle Kiriluk*, Alexandre Rosen, Marcelo Orvieto, Mohan Gundeti, Chicago, IL
INTRODUCTION AND OBJECTIVES: Many pediatric urologists still favor using of prophylactic antibiotics to treat children with vesicoureteral reflux. But, breakthrough infection sometimes occurs and causes significant morbidity resulting renal scarring. So, we tested whether abnormal renal scan and other factors are predictive of breakthrough infection using univariate analyses. METHODS: We retrospectively reviewed the medical records of 163 consecutive children who were diagnosed with vesicoureteral reflux between 1997 and 2010. Clinical parameters for the statistical analysis included form of presentation, gender, age, VUR grade, laterality, presence of intrarenal reflux, class of antibiotic drug, and presence of abnormal renal scan by Dimercapto-succinic acid (DMSA). Clinical parameters used for prognostic factors were established by univariate analyses. Fisher’s exact test and unpaired t test were done using SPSS (SPSS ver. 12.0 (SPSS Inc., Chicago,IL, USA)). RESULTS: Breakthrough infection developed in 61 children (48.0%). A total of 58 children (45.7%) had abnormal renal scans. Time to development of breakthrough infection was significantly longer in girls (9.0 ⫾ 8.2 months) than in boys (5.8 ⫾ 4.8 months, p⬍0.05). On univariate analysis, the most predicting factor for breakthrough infection was abnormal renal scan (p⫽0.062). The second predicting factor was higher reflux grades (p⫽0.071). In patients with abnormal renal scans, there was significant difference between patients younger than 1 year and those 1 year old or older. Mean ⫾ SD age at diagnosis of VUR with breakthrough infection (1.14 ⫾ 3.14) was significantly less than without breakthrough infection (5.05 ⫾ 3.31, p⬍0.01). There was also significant difference between patients with bilateral and unilateral reflux. CONCLUSIONS: Our data showed that abnormal renal scan is the most predicting factor for breakthrough infection. Parents and physicians should aware that these patients are at risk for breakthrough urinary tract infection, potentially leading to renal damage.
INTRODUCTION AND OBJECTIVES: While initial series have reported high failure rates, success of robotic assisted laparoscopic extravesical ureteral reimplantation (RALUR) has now approached that of open surgery. Improved success is often accredited to increased experience without indicating any improvement to technique. We review the outcomes of our first patients to have RALUR and analyze success based on changes in our technique that have occurred over time. METHODS: Between November 2008 and June 2011, a single surgeon, MSG, performed RALUR on a total of 22 patients (35 ureters) with vesicoureteral reflux (VUR). Retrospective analysis of our prospectively maintained database was performed. Only patients with successful completion of RALUR and postoperative voiding cystourethrogram (VCUG) were included in analysis. Success was defined as complete resolution of VUR on VCUG. The surgical technique for RALUR and subsequent modifications were placed into the following categories: Use of simple interrupted stitches and detrussoraphy length (DL) of 3 cm (1), Running stitch with DL of 4 cm (2), Running stitch, incorporation of ureteral adventitia with detrussoraphy closure, and DL of 5 cm (3) (Figure1). RESULTS: 20 patients (8 unilateral and 12 bilateral ureters) fit inclusion criteria. On preoperative VCUG, 12 ureters had grade 3 and 18 ureters grade 4 VUR. In patients with bilateral VUR, one had unilateral grade 1 and one had unilateral grade 2 VUR. Average age at surgery was 5.2 years (range 2.8 – 7.9 years). Mean operative time was 193 minutes for unilateral and 216 minutes for bilateral surgery. Average length of stay was 2.2 days (range 1 to 4 days). One patient was discharged with a catheter for transient urinary retention. No patient required readmission after discharge. Overall, resolution of VUR was seen in 25 of 32 ureters (78%). Resolution of VUR based on surgical technique was 8 of 13 ureters (62%), 6 of 8 ureters (75%), and 11 of 11 ureters (100%) for techniques 1, 2, and 3 respectively. Average follow up was 337 days (range 98 to 889 days). De novo postoperative hydronephrosis was seen in 9 ureters (28%) and resolved in all cases. CONCLUSIONS: Improvement in surgical technique including use of a running stitch, incorporation of ureteral adventitia into closure of detrussoraphy and increasing DL have helped in improving our success of RALUR.
jae shin park*, daegu, Korea, Republic of
Univariate analyses of factors predicting breakthrough infection Univariate Analysis (p-value) Abnormal vs normal renal scan 0.062 Reflux grade l/ll vs. lV/V
0.071
Laterality(unilat. vs bilat.)
0.192
Febrile vs. afebrile presentation
0.131
Age younger than 1yr vs 1yr or older
0.189
Male vs femal Gender
0.984
Present vs. absent intrarenal reflux
0.218
Source of Funding: none
621 INCIDENCE OF UTI AND REFLUX IN A NICU SETTING Douglas Coplen*, Akshaya Vachharajani, Tasnim Najaf, Erica Traxel, Paul Austin, Saint Louis, MO
Source of Funding: None
INTRODUCTION AND OBJECTIVES: Urinary tract infections (UTI) are a cause of bacterial infection in up to 7% of febrile infants and children. Hydronephrosis and vesicoureteral reflux(VUR) are risk factors for febrile UTI. Ultrasound (US) identifies obstruction but is not sensitive or specific in the detection of VUR. The AAP guidelines (2011) for infants 2-24 months of age recommend a VCUG only if the US is abnormal. We evaluated US findings and the incidence of reflux in premature neonates with a history of UTI identified during hospitalization in a NICU. METHODS: We retrospectively reviewed the records of all NICU admissions during a 5 year period (2006-2010) at a tertiary care children’s hospital. UTI was defined as ⬎ 10000 bacteria on a catheterized urine sample. Concomitant blood culture results were tabulated
THE JOURNAL OF UROLOGY姞
Vol. 187, No. 4S, Supplement, Sunday, May 20, 2012
619
620
MODIFICATIONS IN TECHNIQUE LEADING TO IMPROVED SUCCESS OF ROBOTIC EXTRAVESICAL URETERAL REIMPLANATION
PREDICTING FACTORS OF BREAKTHROUGH INFECTION IN CHILDREN WITH PRIMARY VESICOURETERAL REFLUX
Kyle Kiriluk*, Alexandre Rosen, Marcelo Orvieto, Mohan Gundeti, Chicago, IL
INTRODUCTION AND OBJECTIVES: Many pediatric urologists still favor using of prophylactic antibiotics to treat children with vesicoureteral reflux. But, breakthrough infection sometimes occurs and causes significant morbidity resulting renal scarring. So, we tested whether abnormal renal scan and other factors are predictive of breakthrough infection using univariate analyses. METHODS: We retrospectively reviewed the medical records of 163 consecutive children who were diagnosed with vesicoureteral reflux between 1997 and 2010. Clinical parameters for the statistical analysis included form of presentation, gender, age, VUR grade, laterality, presence of intrarenal reflux, class of antibiotic drug, and presence of abnormal renal scan by Dimercapto-succinic acid (DMSA). Clinical parameters used for prognostic factors were established by univariate analyses. Fisher’s exact test and unpaired t test were done using SPSS (SPSS ver. 12.0 (SPSS Inc., Chicago,IL, USA)). RESULTS: Breakthrough infection developed in 61 children (48.0%). A total of 58 children (45.7%) had abnormal renal scans. Time to development of breakthrough infection was significantly longer in girls (9.0 ⫾ 8.2 months) than in boys (5.8 ⫾ 4.8 months, p⬍0.05). On univariate analysis, the most predicting factor for breakthrough infection was abnormal renal scan (p⫽0.062). The second predicting factor was higher reflux grades (p⫽0.071). In patients with abnormal renal scans, there was significant difference between patients younger than 1 year and those 1 year old or older. Mean ⫾ SD age at diagnosis of VUR with breakthrough infection (1.14 ⫾ 3.14) was significantly less than without breakthrough infection (5.05 ⫾ 3.31, p⬍0.01). There was also significant difference between patients with bilateral and unilateral reflux. CONCLUSIONS: Our data showed that abnormal renal scan is the most predicting factor for breakthrough infection. Parents and physicians should aware that these patients are at risk for breakthrough urinary tract infection, potentially leading to renal damage.
INTRODUCTION AND OBJECTIVES: While initial series have reported high failure rates, success of robotic assisted laparoscopic extravesical ureteral reimplantation (RALUR) has now approached that of open surgery. Improved success is often accredited to increased experience without indicating any improvement to technique. We review the outcomes of our first patients to have RALUR and analyze success based on changes in our technique that have occurred over time. METHODS: Between November 2008 and June 2011, a single surgeon, MSG, performed RALUR on a total of 22 patients (35 ureters) with vesicoureteral reflux (VUR). Retrospective analysis of our prospectively maintained database was performed. Only patients with successful completion of RALUR and postoperative voiding cystourethrogram (VCUG) were included in analysis. Success was defined as complete resolution of VUR on VCUG. The surgical technique for RALUR and subsequent modifications were placed into the following categories: Use of simple interrupted stitches and detrussoraphy length (DL) of 3 cm (1), Running stitch with DL of 4 cm (2), Running stitch, incorporation of ureteral adventitia with detrussoraphy closure, and DL of 5 cm (3) (Figure1). RESULTS: 20 patients (8 unilateral and 12 bilateral ureters) fit inclusion criteria. On preoperative VCUG, 12 ureters had grade 3 and 18 ureters grade 4 VUR. In patients with bilateral VUR, one had unilateral grade 1 and one had unilateral grade 2 VUR. Average age at surgery was 5.2 years (range 2.8 – 7.9 years). Mean operative time was 193 minutes for unilateral and 216 minutes for bilateral surgery. Average length of stay was 2.2 days (range 1 to 4 days). One patient was discharged with a catheter for transient urinary retention. No patient required readmission after discharge. Overall, resolution of VUR was seen in 25 of 32 ureters (78%). Resolution of VUR based on surgical technique was 8 of 13 ureters (62%), 6 of 8 ureters (75%), and 11 of 11 ureters (100%) for techniques 1, 2, and 3 respectively. Average follow up was 337 days (range 98 to 889 days). De novo postoperative hydronephrosis was seen in 9 ureters (28%) and resolved in all cases. CONCLUSIONS: Improvement in surgical technique including use of a running stitch, incorporation of ureteral adventitia into closure of detrussoraphy and increasing DL have helped in improving our success of RALUR.
jae shin park*, daegu, Korea, Republic of
Univariate analyses of factors predicting breakthrough infection Univariate Analysis (p-value) Abnormal vs normal renal scan 0.062 Reflux grade l/ll vs. lV/V
0.071
Laterality(unilat. vs bilat.)
0.192
Febrile vs. afebrile presentation
0.131
Age younger than 1yr vs 1yr or older
0.189
Male vs femal Gender
0.984
Present vs. absent intrarenal reflux
0.218
Source of Funding: none
621 INCIDENCE OF UTI AND REFLUX IN A NICU SETTING Douglas Coplen*, Akshaya Vachharajani, Tasnim Najaf, Erica Traxel, Paul Austin, Saint Louis, MO
Source of Funding: None
INTRODUCTION AND OBJECTIVES: Urinary tract infections (UTI) are a cause of bacterial infection in up to 7% of febrile infants and children. Hydronephrosis and vesicoureteral reflux(VUR) are risk factors for febrile UTI. Ultrasound (US) identifies obstruction but is not sensitive or specific in the detection of VUR. The AAP guidelines (2011) for infants 2-24 months of age recommend a VCUG only if the US is abnormal. We evaluated US findings and the incidence of reflux in premature neonates with a history of UTI identified during hospitalization in a NICU. METHODS: We retrospectively reviewed the records of all NICU admissions during a 5 year period (2006-2010) at a tertiary care children’s hospital. UTI was defined as ⬎ 10000 bacteria on a catheterized urine sample. Concomitant blood culture results were tabulated