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Obstructed megaureter in the newborn – Repair by temporary refluxing megaureter reimplantation
Journal of Pediatric Urology (2015) 11, 110e112
CEVL Editorial
Obstructed megaureter in the newborn e Repair by temporary refluxing megaureter reimplantation Introduction The advent of fetal diagnosis and followed up newborn assessment has confronted Pediatric Urologists with the new challenge of performing surgical reconstruction in newborns. For example, maternalefetal ultrasonography may show bilateral obstructed megaureters in the fetus. Because such cases may be associated with small bladder size and reduced amniotic fluid volume, there is urgency to remedy the obstruction in the newborn, particularly if there is azotemia. Traditional approaches to resolve such newborn obstructions may not suffice. This is because upper tract diversion (e.g., vesicostomy or bilateral loop ureterostomy) may adversely impact bladder growth; or success of primary repair by tapered ureter reimplantation may be reduced because it is done in a small sized bladder. Kaefer has proposed a novel approach for such megaureter repairs by promoting repair in two stages [1]. The 1st stage remedies the obstruction without the concern of creating an anti-reflux mechanism, by performing a refluxing reimplantation; then, as the bladder size increases during infancy, perform the 2nd stage, a standard tapered ureteral reimplantation with creation of an anti-reflux valve mechanism. This approach is effective in the author’s (MK) personal experience [2]. However, we note the newborn repair demands attention to various details which may not be self-evident. In order to promote a better understanding of how to perform the 1st stage newborn surgery, we have re-formatted the surgery plan utilizing a CEVL (Computer Enhanced Visual Learning) context (MM) [3,4]. CEVL provides on-line access to the surgical plan as a series of discrete procedural components each of which contains the steps to complete the surgery. Herein, we present CEVL for “Repair of Obstructed Megaureter in
1
the Newborn by Temporary Refluxing Megaureter Reimplantation”1.
Methods The original clinical content presented is derived from a single case, except for that displayed under the supplemental “extras” tab which presents a bilateral case. This content was co-created during cyber meetings which provided real time audio and video feeds. In this manner the authors could collaborate while stationed in their native institution. Then, the content was formatted and edited (Adobe) and imported to be interactive (Articulate Storyline).
Results CEVL presents the main body of training as a procedure sequence comprising several broad components, each of which contains specific “steps.” Supplementing the main content are a number of expectations which the OR staff is required to fulfill (Surgery tab >> Procedure Plan >> click interactive icon for Room Staff). This interactivity also presents the Surgeon staff with “tips” to perform the procedure efficiently. Similarly, “cautions” in performing the procedure are accessed as clickable interactives. In addition, a “your feedback” utility promotes dialog between authors and JPU readership. Highlights of the CEV-ule are presented in the Figures. “Overview” tab accesses diverse background information pertinent to perform the surgery. This includes an understanding of fetal ultrasound imaging (Fig. 1). The click sequence (“Surgery” tab >> surgery components >> Asses Prox. Obstruction) details strategy for assessing tandem proximal ureter obstruction and the procedure for such assessment (Fig. 2). At surgery, the component “expose ureter”
http://cevlforhealthcare.org/cevl/Products/Urology/JournalOfPediatricUrology/Menu/
http://dx.doi.org/10.1016/j.jpurol.2015.05.001 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
CEVL Editorial
111
Figure 1 Fetal ultrasound image is deconstructed using color overlays. Screen capture from CEV-ule. Legend: thorax (gray), enlarged kidneys (pink), dilated ureters (yellow), small bladder (white). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
Figure 2 Assessing for tandem proximal ureter obstruction and the procedure for such assessment. Screen capture shows appearance of potential proximal obstructions.
Figure 3 Exposure of obstructed megaureter. At surgery the component “expose ureter” presents the steps for such exposure textually and with the companion video. Screen capture shows ready to divide the ureter at the bladder hiatus.
112
CEVL Editorial
Figure 4 Anastomosis of end of ureter to cystostomy. Steps for anastomosis are shown. The anastomosis begins with the back wall. Screen capture shows anastomosis back wall is done (as highlighted by colored overlays marking interrupted sutures placed). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
presents the steps for such exposure textually and with companion video (Fig. 3). The component anastomosis shows end of ureter to cystostomy (Fig. 4).
context promotes a standardized surgical plan for repair which includes the entire operating room staff.
Discussion
References
Our Pediatric Urology Surgical subspecialty has yet to develop and agree on methods to utilize which promote surgical training and/or procedure performance. The authors have collaborated to create stylized e-learning which strives to suffice a variety of needs: a standardized method for resident training, provision of a surgical plan for the OR room staff, and utilization of a layout to perform surgery which is performed infrequently for Attending Surgeons. Specifically, the authors have found that training works best by providing the material to trainees and OR staff for study prior to the case. In addition, the electronic content is ready for display on OR room monitors such that it may be accessed while the procedure is being performed. Such utilization helps ground the entire OR room staff in the procedure and needs to suffice in real time. While the procedure sequence represents the current experience of the authors, it may be customized to represent the surgical practices of other individual surgeons. As this procedure is uncommonly performed, archiving the plan online provides opportunity for the operating room team to prepare for an upcoming case. To date, we have received positive feedback on the content use as accessed by Pediatric Urology Attending Surgeon, Resident, and Fellow.
[1] Lee SD, Akbal C, Kaefer M. Refluxing ureteral reimplant as temporary treatment of obstructive megaureter in neonate and infant. J Urol 2005 Apr;173(4):1357e60 [discussion 1360]. [2] Kaefer M, Misseri R, Frank E, Rhee A, Lee SD. Refluxing ureteral reimplantation: a logical method for managing neonatal UVJ obstruction. J Pediatr Urol 2014 Oct;10(5):824e30. [3] Maizels M, Yerkes EB, Macejko A, Hagerty J, Chaviano AH, Cheng EY, et al. Kaplan: a new computer enhanced visual learning method to train urology residents in pediatric orchiopexy: a prototype for Accreditation Council for Graduate Medical Education documentation 2008 Oct;180(Suppl. 4): 1814e8. [4] Maizels M, Mickelson J, Yerkes E, Maizels E, Stork R, Young C, et al. Computer-enhanced visual learning method: a paradigm to teach and document surgical skills. J Grad Med Educ 2009 Sep;1(1):109e13.
Conclusion In the newborn, temporary refluxing reimplantation of obstructed megaureter is a practical approach. CEVL
Martin Kaefer, MD Department of Urology, Indiana University, USA Max Maizels, MD* Department of Urology, Lurie Children’s Hospital, Northwestern University, USA *Correspondence to: M. Maizels E-mail address: [email protected] (M. Maizels) 8 May 2015
CEVL Editorial
Obstructed megaureter in the newborn e Repair by temporary refluxing megaureter reimplantation Introduction The advent of fetal diagnosis and followed up newborn assessment has confronted Pediatric Urologists with the new challenge of performing surgical reconstruction in newborns. For example, maternalefetal ultrasonography may show bilateral obstructed megaureters in the fetus. Because such cases may be associated with small bladder size and reduced amniotic fluid volume, there is urgency to remedy the obstruction in the newborn, particularly if there is azotemia. Traditional approaches to resolve such newborn obstructions may not suffice. This is because upper tract diversion (e.g., vesicostomy or bilateral loop ureterostomy) may adversely impact bladder growth; or success of primary repair by tapered ureter reimplantation may be reduced because it is done in a small sized bladder. Kaefer has proposed a novel approach for such megaureter repairs by promoting repair in two stages [1]. The 1st stage remedies the obstruction without the concern of creating an anti-reflux mechanism, by performing a refluxing reimplantation; then, as the bladder size increases during infancy, perform the 2nd stage, a standard tapered ureteral reimplantation with creation of an anti-reflux valve mechanism. This approach is effective in the author’s (MK) personal experience [2]. However, we note the newborn repair demands attention to various details which may not be self-evident. In order to promote a better understanding of how to perform the 1st stage newborn surgery, we have re-formatted the surgery plan utilizing a CEVL (Computer Enhanced Visual Learning) context (MM) [3,4]. CEVL provides on-line access to the surgical plan as a series of discrete procedural components each of which contains the steps to complete the surgery. Herein, we present CEVL for “Repair of Obstructed Megaureter in
1
the Newborn by Temporary Refluxing Megaureter Reimplantation”1.
Methods The original clinical content presented is derived from a single case, except for that displayed under the supplemental “extras” tab which presents a bilateral case. This content was co-created during cyber meetings which provided real time audio and video feeds. In this manner the authors could collaborate while stationed in their native institution. Then, the content was formatted and edited (Adobe) and imported to be interactive (Articulate Storyline).
Results CEVL presents the main body of training as a procedure sequence comprising several broad components, each of which contains specific “steps.” Supplementing the main content are a number of expectations which the OR staff is required to fulfill (Surgery tab >> Procedure Plan >> click interactive icon for Room Staff). This interactivity also presents the Surgeon staff with “tips” to perform the procedure efficiently. Similarly, “cautions” in performing the procedure are accessed as clickable interactives. In addition, a “your feedback” utility promotes dialog between authors and JPU readership. Highlights of the CEV-ule are presented in the Figures. “Overview” tab accesses diverse background information pertinent to perform the surgery. This includes an understanding of fetal ultrasound imaging (Fig. 1). The click sequence (“Surgery” tab >> surgery components >> Asses Prox. Obstruction) details strategy for assessing tandem proximal ureter obstruction and the procedure for such assessment (Fig. 2). At surgery, the component “expose ureter”
http://cevlforhealthcare.org/cevl/Products/Urology/JournalOfPediatricUrology/Menu/
http://dx.doi.org/10.1016/j.jpurol.2015.05.001 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
CEVL Editorial
111
Figure 1 Fetal ultrasound image is deconstructed using color overlays. Screen capture from CEV-ule. Legend: thorax (gray), enlarged kidneys (pink), dilated ureters (yellow), small bladder (white). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
Figure 2 Assessing for tandem proximal ureter obstruction and the procedure for such assessment. Screen capture shows appearance of potential proximal obstructions.
Figure 3 Exposure of obstructed megaureter. At surgery the component “expose ureter” presents the steps for such exposure textually and with the companion video. Screen capture shows ready to divide the ureter at the bladder hiatus.
112
CEVL Editorial
Figure 4 Anastomosis of end of ureter to cystostomy. Steps for anastomosis are shown. The anastomosis begins with the back wall. Screen capture shows anastomosis back wall is done (as highlighted by colored overlays marking interrupted sutures placed). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
presents the steps for such exposure textually and with companion video (Fig. 3). The component anastomosis shows end of ureter to cystostomy (Fig. 4).
context promotes a standardized surgical plan for repair which includes the entire operating room staff.
Discussion
References
Our Pediatric Urology Surgical subspecialty has yet to develop and agree on methods to utilize which promote surgical training and/or procedure performance. The authors have collaborated to create stylized e-learning which strives to suffice a variety of needs: a standardized method for resident training, provision of a surgical plan for the OR room staff, and utilization of a layout to perform surgery which is performed infrequently for Attending Surgeons. Specifically, the authors have found that training works best by providing the material to trainees and OR staff for study prior to the case. In addition, the electronic content is ready for display on OR room monitors such that it may be accessed while the procedure is being performed. Such utilization helps ground the entire OR room staff in the procedure and needs to suffice in real time. While the procedure sequence represents the current experience of the authors, it may be customized to represent the surgical practices of other individual surgeons. As this procedure is uncommonly performed, archiving the plan online provides opportunity for the operating room team to prepare for an upcoming case. To date, we have received positive feedback on the content use as accessed by Pediatric Urology Attending Surgeon, Resident, and Fellow.
[1] Lee SD, Akbal C, Kaefer M. Refluxing ureteral reimplant as temporary treatment of obstructive megaureter in neonate and infant. J Urol 2005 Apr;173(4):1357e60 [discussion 1360]. [2] Kaefer M, Misseri R, Frank E, Rhee A, Lee SD. Refluxing ureteral reimplantation: a logical method for managing neonatal UVJ obstruction. J Pediatr Urol 2014 Oct;10(5):824e30. [3] Maizels M, Yerkes EB, Macejko A, Hagerty J, Chaviano AH, Cheng EY, et al. Kaplan: a new computer enhanced visual learning method to train urology residents in pediatric orchiopexy: a prototype for Accreditation Council for Graduate Medical Education documentation 2008 Oct;180(Suppl. 4): 1814e8. [4] Maizels M, Mickelson J, Yerkes E, Maizels E, Stork R, Young C, et al. Computer-enhanced visual learning method: a paradigm to teach and document surgical skills. J Grad Med Educ 2009 Sep;1(1):109e13.
Conclusion In the newborn, temporary refluxing reimplantation of obstructed megaureter is a practical approach. CEVL
Martin Kaefer, MD Department of Urology, Indiana University, USA Max Maizels, MD* Department of Urology, Lurie Children’s Hospital, Northwestern University, USA *Correspondence to: M. Maizels E-mail address: [email protected] (M. Maizels) 8 May 2015