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Papers by Andrew Kirsch

Research paper thumbnail of 2007 SPR Awards

Pediatric Radiology, 2007

Research paper thumbnail of A systematic review of outcomes of Deflux® treatment for vesicoureteral reflux following pediatric renal transplantation

Journal of Pediatric Urology

Research paper thumbnail of Urethral Multiplicity: When Two Are Better Than One

Research paper thumbnail of MP64-16 IMPACT of the 2011 American Academy of Pediatrics (Aap) Urinary Tract Infection (Uti) Guideline on Vesicoureteral Reflux Index (Vurx)

Journal of Urology

scan. Outcomes of interest were hypertension, proteinuria and kidney disease (CKD stages II-IV or... more scan. Outcomes of interest were hypertension, proteinuria and kidney disease (CKD stages II-IV or ESRD). These 3 outcomes were also considered as a composite outcome. Kaplan-Meier survival curves were constructed and association of initial RS with event-free survival was analyzed using Log-Rank test. RESULTS: Among 745 eligible patients, 393 (53%) had RS on DMSA scan and 352 (47%) did not. There was no significant difference in median age (4 vs 3 years) or follow up time (5.6 vs 5.5 years). The RS cohort had fewer females (68% vs 84%, p < 0.001) and a higher proportion of patients with VUR grades IV or V (28% vs 13%). RS patients were more likely to undergo surgical repair of VUR (59% vs 26%, p < 0.001) at a median of 83 days (IQR 35-370) after initial DMSA scan. Significantly more patients with RS developed proteinuria (5.1% vs 1.6%, p [ 0.005) and kidney disease (2% vs 0%, p [ 0.005; Table 1). Hypertension occurred in 2.8% of patients with RS and 1% of those without (p [ 0.09). Kaplan-Meier curves stratified by cohort demonstrate significantly increased probability of adverse renal outcomes for those with RS (6.2% vs 2.6%, p [ 0.02; Figure 1). CONCLUSIONS: In this cohort study, patients with RS were significantly more likely to develop proteinuria and kidney disease. Serial, longitudinal evaluation is essential for these at-risk children.

Research paper thumbnail of V09-11 Robot-Assisted Laparoscopic Ileovesicostomy

Research paper thumbnail of Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications

Journal of pediatric urology, 2018

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasi... more Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve. To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons. We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure. In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral...

Research paper thumbnail of Utility of magnetic resonance urography in pediatric urinary incontinence: Radiological considerations

Canadian Urological Association journal = Journal de l'Association des urologues du Canada, Jan 19, 2018

Research paper thumbnail of Faculty of 1000 evaluation for Multi-institutional review of outcomes of robot-assisted laparoscopic extravesical ureteral reimplantation

F1000 - Post-publication peer review of the biomedical literature

Research paper thumbnail of Faculty of 1000 evaluation for Previous antimicrobial exposure is associated with drug-resistant urinary tract infections in children

F1000 - Post-publication peer review of the biomedical literature

Research paper thumbnail of Faculty of 1000 evaluation for Outcomes of targeted treatment for vesicoureteral reflux in children with nonneurogenic lower urinary tract dysfunction

F1000 - Post-publication peer review of the biomedical literature

Research paper thumbnail of Faculty of 1000 evaluation for Efficacy of antibiotic prophylaxis in children with vesicoureteral reflux: systematic review and meta-analysis

F1000 - Post-publication peer review of the biomedical literature

Research paper thumbnail of V10-02 Complex Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation (Ralur) Following Endoscopic Injection of Dextronamer/Hyaluronic Acid for Vesicoureteral Reflux

Research paper thumbnail of High GMS score hypospadias: Outcomes after one- and two-stage operations

Journal of Pediatric Urology

Established criteria to assist surgeons in deciding between a one- or two-stage operation for sev... more Established criteria to assist surgeons in deciding between a one- or two-stage operation for severe hypospadias are lacking. While anatomical features may preclude some surgical options, the decision to approach severe hypospadias in a one- or two-stage fashion is generally based on individual surgeon preference. This decision has been described as a dilemma as outcomes range widely and there is lack of evidence supporting the superiority of one approach over the other. The aim of this study is to determine whether the GMS hypospadias score may provide some guidance in choosing the surgical approach used for correction of severe hypospadias. GMS scores were preoperatively assigned to patients having primary surgery for hypospadias. Those patients having surgery for the most severe hypospadias were selected and formed the study cohort. The records of these patients were reviewed and pertinent data collected. Complications requiring further surgery were assessed and correlated with the GMS score and the surgical technique used for repair (one-stage vs. two-stage). Eighty-seven boys were identified with a GMS score (range 3-12) of 10 or higher. At a mean follow-up of 22 months the overall complication rate for the cohort after final planned surgery was 39%. For intended one-stage procedures (n = 48) an acceptable result was achieved with one surgery for 28 patients (58%), with two surgeries for 14 (29%), and with three to five surgeries for six (13%). For intended two-stage procedures (n = 39) an acceptable result was achieved with two surgeries for 26 patients (67%), three surgeries for eight (21%), and four surgeries for three (8%). Two other patients having two-stage surgery required seven surgeries to achieve an acceptable result. Complication rates are summarized in the Table. The complication rates for GMS 10 patients were similar (27% and 33%, p = 0.28) for one- and two-stage repairs, respectively. GMS 11 patients having a one-stage repair had a significantly higher complication rate (69%) than those having a two-stage repair (29%) (p = 0.04). GMS 12 patients had the highest complication rate with a one-stage repair (80%) compared with a complication rate of 37% when a two-stage repair was used (p = 0.12). Guidelines to help standardize the surgical approach to severe hypospadias are needed. Staged surgery for GMS 11 and 12 patients may result in a lower complication rate but may not reduce the number of surgeries required for an acceptable result. Although further study is needed, the GMS score may be helpful for establishing such criteria.

Research paper thumbnail of Abdominoplasty in prune belly syndrome: Modifications in Monfort technique to address variable patterns of abdominal wall weakness

Journal of Pediatric Urology

Abdominoplasty is an important component of the management of children with prune belly syndrome ... more Abdominoplasty is an important component of the management of children with prune belly syndrome (PBS). While there are features of the abdominal defect in PBS which are common to all patients, there will be differences unique to each patient that should be taken into consideration in surgical planning. Specifically, we have come to realize that although the Monfort procedure assumes a symmetric pattern of abdominal wall laxity, this symmetry is rarely present. The aim of this report is to describe our modifications and review our outcomes for the Monfort procedure which more completely address correction of the abdominal wall laxity including both common and uncommon features while positioning the umbilicus to a more anatomically correct position (Figure). Sixteen male patients with PBS and one female pseudoprune belly syndrome patient, aged 2-9 years, were treated at our institution between 2003 and 2014. Modifications incorporated into the abdominoplasty procedure for PBS applied to this study group included: 1) use of diagnostic laparoscopy to define the topography of the abdominal wall defect, 2) initial midline rather than elliptical skin incision to defer retailoring of the skin coverage until the final step of the procedure, 3) varying the width of the central plate to correct side to side asymmetry in redundancy, 4) plication of the central plate to reduce vertical redundancy and reposition the umbilicus, and 5) plication of focal areas of fascial weakness, most often in the flank region. All patients have improved abdominal wall contour with a more uniform correction of areas of weakness at a mean follow-up of 5.5 years (range 18 months-11.5 years). All patients and parents indicate that they are very satisfied with the outcome of their procedures without any revisions being performed. This study is descriptive in nature and retrospective, with the patient population treated in a relatively uniform fashion that does not allow direct comparison with other techniques. The modified Monfort procedure recognizes the pattern of abdominal muscular deficiency unique to each patient and incorporates this information into the surgical design.

Research paper thumbnail of Multi-Institutional Review of Outcomes and Complications of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Primary Vesicoureteral Reflux in Children

The Journal of urology, Jan 24, 2017

Robot-assisted laparoscopic extravesical ureteral reimplantation has been proposed as a minimally... more Robot-assisted laparoscopic extravesical ureteral reimplantation has been proposed as a minimally invasive alternative to open ureteral reimplantation for correcting primary vesicoureteral reflux in children. However, in the current literature there are conflicting data regarding the safety and efficacy of this approach. Amid ongoing debate we analyzed outcomes and complications from this procedure in a large multi-institutional cohort. We reviewed the records of children who underwent robot-assisted laparoscopic extravesical ureteral reimplantation at 9 academic centers from 2005 to 2014. Radiographic failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram. Complications were graded using the Clavien-Dindo scale. A total of 260 patients (363 ureters) underwent robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux during the study period. The cohort included 90 patients w...

Research paper thumbnail of Validation of the ureteral diameter ratio for predicting early spontaneous resolution of primary vesicoureteral reflux

Journal of Pediatric Urology, 2017

Management of primary vesicoureteral reflux (VUR) remains controversial, and reflux grade current... more Management of primary vesicoureteral reflux (VUR) remains controversial, and reflux grade currently constitutes an important prognostic factor. Previous reports have demonstrated that distal ureteral diameter ratio (UDR) may be more predictive of outcome than vesicoureteral reflux (VUR) grade. We performed an external validation study in young children, evaluating early spontaneous resolution rates relative to reflux grade and UDR. Voiding cystourethrograms (VCUGs) were reviewed. UDR was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between the L1 and L3 vertebral bodies (Figure). VUR grade and UDR were tested in univariate and multivariable analyses. Primary outcome was status of VUR at last clinical follow-up (i.e. resolution, persistence, or surgical intervention). Demographics, VUR timing, laterality, and imaging indication were also assessed. One-hundred and forty-seven children (98 girls, 49 boys) were diagnosed with primary VUR at a mean age of 5.5 ± 4.7 months. Sixty-seven (45.6%) resolved spontaneously, 55 (37.4%) had persistent disease, and 25 (17%) were surgically corrected. Patients who spontaneously resolved had significantly lower VUR grade, refluxed later during bladder filling, and had significantly lower UDR. In a multivariable model, grade of VUR (p = 0.001), age &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;12 months (p = 0.008), ureteral diameter (p = 0.02), and UDR (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) achieved statistical significance. For every 0.1 unit increase in UDR, there was a 2.6 (95% CI 1.58-4.44) increased odds of persistent VUR, whereas a 1.6 (95% CI 0.9-3.0) increased odds was observed for every unit increase in grade. Both grade of reflux and UDR were statistically significant in a multivariable model; however, UDR had a higher likelihood ratio and was more predictive of early spontaneous resolution than grade alone. Furthermore, unlike traditional VUR grading where children with grade 1-5 may outgrow reflux depending on other factors, there appears to be a consistent UDR cutoff whereby patients are unlikely to resolve. In the present study, no child with a UDR greater than 0.43 experienced early spontaneous resolution, and only three (4.5%) of those with spontaneous resolution had a UDR above 0.35. UDR correlates with reflux grade, and is predictive of early resolution in children with primary VUR. UDR is an objective measurement of VUR, and provides valuable prognostic information about spontaneous resolution, facilitating more individualized patient care.

Research paper thumbnail of Establishing a standard protocol for the voiding cystourethrography

Journal of pediatric urology, 2016

The voiding cystourethrogram (VCUG) is a frequently performed test to diagnose a variety of urolo... more The voiding cystourethrogram (VCUG) is a frequently performed test to diagnose a variety of urologic conditions, such as vesicoureteral reflux (VUR). The test results determine whether continued observation or an interventional procedure is indicated. VCUGs are ordered by many specialists and primary care providers, including pediatricians, family practitioners, nephrologists, hospitalists, emergency room physicians, and urologists. Current protocols for performing and interpreting a VCUG are based on the International Reflux Study in 1985. However, more recent information provided by many national and international institutions suggests a need to refine those recommendations. The lead author of the 1985 study, R.L. Lebowitz, agreed to and participated in the current protocol. In addition, a recent survey directed to the chairpersons of pediatric radiology of 65 children's hospitals throughout the United States and Canada showed that VCUG protocols vary substantially. Recent gui...

Research paper thumbnail of Urinary tract infection in the setting of vesicoureteral reflux

F1000Research, 2016

Vesicoureteral reflux (VUR) is the most common underlying etiology responsible for febrile urinar... more Vesicoureteral reflux (VUR) is the most common underlying etiology responsible for febrile urinary tract infections (UTIs) or pyelonephritis in children. Along with the morbidity of pyelonephritis, long-term sequelae of recurrent renal infections include renal scarring, proteinuria, and hypertension. Treatment is directed toward the prevention of recurrent infection through use of continuous antibiotic prophylaxis during a period of observation for spontaneous resolution or by surgical correction. In children, bowel and bladder dysfunction (BBD) plays a significant role in the occurrence of UTI and the rate of VUR resolution. Effective treatment of BBD leads to higher rates of spontaneous resolution and decreased risk of UTI.

Research paper thumbnail of Ten-Year-Old Girl with Crossed-Fused Ectopic Kidney and Ectopic Ureter to Vagina

Urology, 2007

10-year-old girl presented with continuous urinary incontinence. At age 5, noncontrast magnetic r... more 10-year-old girl presented with continuous urinary incontinence. At age 5, noncontrast magnetic resonance imaging and cystoscopy had revealed a solitary malrotated left kidney. Repeat cystoscopy and retrograde pyelography at 10 years of age showed no change. Attempts to cannulate an orifice in the right lateral vaginal wall on vaginoscopy were unsuccessful. Flush vaginography revealed an ectopic ureteral insertion to the vagina crossing the midline to a moiety inferior to the left kidney (Fig. 1). A gadolinium magnetic resonance urogram confirmed the presence of a crossed-fused ectopic right kidney with relative function and an ectopic ureteral insertion to the vagina (Fig. 2). The patient subsequently underwent extravesical ureteral reimplantation and has remained completely continent. Crossed renal ectopia is nearly always associated with a normally placed ureteral orifice located within the contralateral trigone. 1-3 This is the first case of a crossed-fused ectopic kidney with an ectopic ureteral insertion to the vagina in an otherwise normal child. 4 We highlight flush vaginography as a convenient tool for the identification of an ectopic ureteral insertion to the vagina in incontinent girls. Furthermore, this report illustrates the superiority and utility of contrastenhanced magnetic resonance urography in the evaluation of ectopic ureters and functional renal moieties.

Research paper thumbnail of Endoscopic Treatment with Dextranomer/Hyaluronic Acid for Complex Cases of Vesicoureteral Reflux

The Journal of Urology, Oct 31, 2004

The surgical correction of primary vesicoureteral reflux (VUR) is highly successful. This success... more The surgical correction of primary vesicoureteral reflux (VUR) is highly successful. This success decreases in more complex cases and often involves reoperation and increased morbidity. We present our experience with the use of subureteral injection of dextranomer/hyaluronic acid (Dx/HA) in complex cases of vesicoureteral reflux in which open surgery would have been indicated. Between October 2001 and July 2003, 72 patients 9 months to 31 years old (mean age 5.6 years) underwent subureteral injection of Dx/HA for complex VUR at our institutions. Dx/HA was injected submucosally within the intramural ureter (modified STING) in most cases. A guidewire was used to manipulate the ureteral orifice and a retrograde ureterogram was used to delineate the anatomy in selected cases. The average volume of injected material was measured for each ureter. Renal sonography was performed to determine if hydronephrosis was present. At 3 months fluoroscopic voiding cystourethrograms were used to evaluate for the presence of VUR. A total of 93 ureters were treated in 55 girls and 17 boys. All cases were considered to be complex as 17 had persistent reflux after open surgery (7 megaureters repairs, 2 extravesical repairs, 7 intravesical reimplants and 1 blind ureter), 11 had persistent reflux and neurogenic bladder, 7 had ectopic ureters to bladder neck, 6 had bilateral Hutch diverticulum, 6 had persistent stump reflux, 5 had ureterocele after puncture or incision, 15 had duplications, 1 had the prune belly syndrome, 2 had posterior urethral valve following resection, 1 had epispadias and 1 had urogenital sinus. The average maximum reflux grade was IV. An average of 1.1 cc (range 0.4 to 2) was injected per ureter. Of the patients 69 had 3-month followup results. The overall success rate was 68% after 1 implantation (47 of 69). Submucosal intraureteral implantation with Dx/HA corrected complex vesicoureteral reflux in 68% of patients. In all of these patients open surgery would have potentially been difficult. The use of fluoroscopy and/or guidewires is a useful adjunct in these cases. We believe that this minimally invasive approach is warranted as an initial step in the management of complex cases of VUR before resorting to more difficult open surgical procedures.

Research paper thumbnail of 2007 SPR Awards

Pediatric Radiology, 2007

Research paper thumbnail of A systematic review of outcomes of Deflux® treatment for vesicoureteral reflux following pediatric renal transplantation

Journal of Pediatric Urology

Research paper thumbnail of Urethral Multiplicity: When Two Are Better Than One

Research paper thumbnail of MP64-16 IMPACT of the 2011 American Academy of Pediatrics (Aap) Urinary Tract Infection (Uti) Guideline on Vesicoureteral Reflux Index (Vurx)

Journal of Urology

scan. Outcomes of interest were hypertension, proteinuria and kidney disease (CKD stages II-IV or... more scan. Outcomes of interest were hypertension, proteinuria and kidney disease (CKD stages II-IV or ESRD). These 3 outcomes were also considered as a composite outcome. Kaplan-Meier survival curves were constructed and association of initial RS with event-free survival was analyzed using Log-Rank test. RESULTS: Among 745 eligible patients, 393 (53%) had RS on DMSA scan and 352 (47%) did not. There was no significant difference in median age (4 vs 3 years) or follow up time (5.6 vs 5.5 years). The RS cohort had fewer females (68% vs 84%, p < 0.001) and a higher proportion of patients with VUR grades IV or V (28% vs 13%). RS patients were more likely to undergo surgical repair of VUR (59% vs 26%, p < 0.001) at a median of 83 days (IQR 35-370) after initial DMSA scan. Significantly more patients with RS developed proteinuria (5.1% vs 1.6%, p [ 0.005) and kidney disease (2% vs 0%, p [ 0.005; Table 1). Hypertension occurred in 2.8% of patients with RS and 1% of those without (p [ 0.09). Kaplan-Meier curves stratified by cohort demonstrate significantly increased probability of adverse renal outcomes for those with RS (6.2% vs 2.6%, p [ 0.02; Figure 1). CONCLUSIONS: In this cohort study, patients with RS were significantly more likely to develop proteinuria and kidney disease. Serial, longitudinal evaluation is essential for these at-risk children.

Research paper thumbnail of V09-11 Robot-Assisted Laparoscopic Ileovesicostomy

Research paper thumbnail of Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications

Journal of pediatric urology, 2018

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasi... more Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve. To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons. We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure. In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral...

Research paper thumbnail of Utility of magnetic resonance urography in pediatric urinary incontinence: Radiological considerations

Canadian Urological Association journal = Journal de l'Association des urologues du Canada, Jan 19, 2018

Research paper thumbnail of Faculty of 1000 evaluation for Multi-institutional review of outcomes of robot-assisted laparoscopic extravesical ureteral reimplantation

F1000 - Post-publication peer review of the biomedical literature

Research paper thumbnail of Faculty of 1000 evaluation for Previous antimicrobial exposure is associated with drug-resistant urinary tract infections in children

F1000 - Post-publication peer review of the biomedical literature

Research paper thumbnail of Faculty of 1000 evaluation for Outcomes of targeted treatment for vesicoureteral reflux in children with nonneurogenic lower urinary tract dysfunction

F1000 - Post-publication peer review of the biomedical literature

Research paper thumbnail of Faculty of 1000 evaluation for Efficacy of antibiotic prophylaxis in children with vesicoureteral reflux: systematic review and meta-analysis

F1000 - Post-publication peer review of the biomedical literature

Research paper thumbnail of V10-02 Complex Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation (Ralur) Following Endoscopic Injection of Dextronamer/Hyaluronic Acid for Vesicoureteral Reflux

Research paper thumbnail of High GMS score hypospadias: Outcomes after one- and two-stage operations

Journal of Pediatric Urology

Established criteria to assist surgeons in deciding between a one- or two-stage operation for sev... more Established criteria to assist surgeons in deciding between a one- or two-stage operation for severe hypospadias are lacking. While anatomical features may preclude some surgical options, the decision to approach severe hypospadias in a one- or two-stage fashion is generally based on individual surgeon preference. This decision has been described as a dilemma as outcomes range widely and there is lack of evidence supporting the superiority of one approach over the other. The aim of this study is to determine whether the GMS hypospadias score may provide some guidance in choosing the surgical approach used for correction of severe hypospadias. GMS scores were preoperatively assigned to patients having primary surgery for hypospadias. Those patients having surgery for the most severe hypospadias were selected and formed the study cohort. The records of these patients were reviewed and pertinent data collected. Complications requiring further surgery were assessed and correlated with the GMS score and the surgical technique used for repair (one-stage vs. two-stage). Eighty-seven boys were identified with a GMS score (range 3-12) of 10 or higher. At a mean follow-up of 22 months the overall complication rate for the cohort after final planned surgery was 39%. For intended one-stage procedures (n = 48) an acceptable result was achieved with one surgery for 28 patients (58%), with two surgeries for 14 (29%), and with three to five surgeries for six (13%). For intended two-stage procedures (n = 39) an acceptable result was achieved with two surgeries for 26 patients (67%), three surgeries for eight (21%), and four surgeries for three (8%). Two other patients having two-stage surgery required seven surgeries to achieve an acceptable result. Complication rates are summarized in the Table. The complication rates for GMS 10 patients were similar (27% and 33%, p = 0.28) for one- and two-stage repairs, respectively. GMS 11 patients having a one-stage repair had a significantly higher complication rate (69%) than those having a two-stage repair (29%) (p = 0.04). GMS 12 patients had the highest complication rate with a one-stage repair (80%) compared with a complication rate of 37% when a two-stage repair was used (p = 0.12). Guidelines to help standardize the surgical approach to severe hypospadias are needed. Staged surgery for GMS 11 and 12 patients may result in a lower complication rate but may not reduce the number of surgeries required for an acceptable result. Although further study is needed, the GMS score may be helpful for establishing such criteria.

Research paper thumbnail of Abdominoplasty in prune belly syndrome: Modifications in Monfort technique to address variable patterns of abdominal wall weakness

Journal of Pediatric Urology

Abdominoplasty is an important component of the management of children with prune belly syndrome ... more Abdominoplasty is an important component of the management of children with prune belly syndrome (PBS). While there are features of the abdominal defect in PBS which are common to all patients, there will be differences unique to each patient that should be taken into consideration in surgical planning. Specifically, we have come to realize that although the Monfort procedure assumes a symmetric pattern of abdominal wall laxity, this symmetry is rarely present. The aim of this report is to describe our modifications and review our outcomes for the Monfort procedure which more completely address correction of the abdominal wall laxity including both common and uncommon features while positioning the umbilicus to a more anatomically correct position (Figure). Sixteen male patients with PBS and one female pseudoprune belly syndrome patient, aged 2-9 years, were treated at our institution between 2003 and 2014. Modifications incorporated into the abdominoplasty procedure for PBS applied to this study group included: 1) use of diagnostic laparoscopy to define the topography of the abdominal wall defect, 2) initial midline rather than elliptical skin incision to defer retailoring of the skin coverage until the final step of the procedure, 3) varying the width of the central plate to correct side to side asymmetry in redundancy, 4) plication of the central plate to reduce vertical redundancy and reposition the umbilicus, and 5) plication of focal areas of fascial weakness, most often in the flank region. All patients have improved abdominal wall contour with a more uniform correction of areas of weakness at a mean follow-up of 5.5 years (range 18 months-11.5 years). All patients and parents indicate that they are very satisfied with the outcome of their procedures without any revisions being performed. This study is descriptive in nature and retrospective, with the patient population treated in a relatively uniform fashion that does not allow direct comparison with other techniques. The modified Monfort procedure recognizes the pattern of abdominal muscular deficiency unique to each patient and incorporates this information into the surgical design.

Research paper thumbnail of Multi-Institutional Review of Outcomes and Complications of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Primary Vesicoureteral Reflux in Children

The Journal of urology, Jan 24, 2017

Robot-assisted laparoscopic extravesical ureteral reimplantation has been proposed as a minimally... more Robot-assisted laparoscopic extravesical ureteral reimplantation has been proposed as a minimally invasive alternative to open ureteral reimplantation for correcting primary vesicoureteral reflux in children. However, in the current literature there are conflicting data regarding the safety and efficacy of this approach. Amid ongoing debate we analyzed outcomes and complications from this procedure in a large multi-institutional cohort. We reviewed the records of children who underwent robot-assisted laparoscopic extravesical ureteral reimplantation at 9 academic centers from 2005 to 2014. Radiographic failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram. Complications were graded using the Clavien-Dindo scale. A total of 260 patients (363 ureters) underwent robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux during the study period. The cohort included 90 patients w...

Research paper thumbnail of Validation of the ureteral diameter ratio for predicting early spontaneous resolution of primary vesicoureteral reflux

Journal of Pediatric Urology, 2017

Management of primary vesicoureteral reflux (VUR) remains controversial, and reflux grade current... more Management of primary vesicoureteral reflux (VUR) remains controversial, and reflux grade currently constitutes an important prognostic factor. Previous reports have demonstrated that distal ureteral diameter ratio (UDR) may be more predictive of outcome than vesicoureteral reflux (VUR) grade. We performed an external validation study in young children, evaluating early spontaneous resolution rates relative to reflux grade and UDR. Voiding cystourethrograms (VCUGs) were reviewed. UDR was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between the L1 and L3 vertebral bodies (Figure). VUR grade and UDR were tested in univariate and multivariable analyses. Primary outcome was status of VUR at last clinical follow-up (i.e. resolution, persistence, or surgical intervention). Demographics, VUR timing, laterality, and imaging indication were also assessed. One-hundred and forty-seven children (98 girls, 49 boys) were diagnosed with primary VUR at a mean age of 5.5 ± 4.7 months. Sixty-seven (45.6%) resolved spontaneously, 55 (37.4%) had persistent disease, and 25 (17%) were surgically corrected. Patients who spontaneously resolved had significantly lower VUR grade, refluxed later during bladder filling, and had significantly lower UDR. In a multivariable model, grade of VUR (p = 0.001), age &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;12 months (p = 0.008), ureteral diameter (p = 0.02), and UDR (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001) achieved statistical significance. For every 0.1 unit increase in UDR, there was a 2.6 (95% CI 1.58-4.44) increased odds of persistent VUR, whereas a 1.6 (95% CI 0.9-3.0) increased odds was observed for every unit increase in grade. Both grade of reflux and UDR were statistically significant in a multivariable model; however, UDR had a higher likelihood ratio and was more predictive of early spontaneous resolution than grade alone. Furthermore, unlike traditional VUR grading where children with grade 1-5 may outgrow reflux depending on other factors, there appears to be a consistent UDR cutoff whereby patients are unlikely to resolve. In the present study, no child with a UDR greater than 0.43 experienced early spontaneous resolution, and only three (4.5%) of those with spontaneous resolution had a UDR above 0.35. UDR correlates with reflux grade, and is predictive of early resolution in children with primary VUR. UDR is an objective measurement of VUR, and provides valuable prognostic information about spontaneous resolution, facilitating more individualized patient care.

Research paper thumbnail of Establishing a standard protocol for the voiding cystourethrography

Journal of pediatric urology, 2016

The voiding cystourethrogram (VCUG) is a frequently performed test to diagnose a variety of urolo... more The voiding cystourethrogram (VCUG) is a frequently performed test to diagnose a variety of urologic conditions, such as vesicoureteral reflux (VUR). The test results determine whether continued observation or an interventional procedure is indicated. VCUGs are ordered by many specialists and primary care providers, including pediatricians, family practitioners, nephrologists, hospitalists, emergency room physicians, and urologists. Current protocols for performing and interpreting a VCUG are based on the International Reflux Study in 1985. However, more recent information provided by many national and international institutions suggests a need to refine those recommendations. The lead author of the 1985 study, R.L. Lebowitz, agreed to and participated in the current protocol. In addition, a recent survey directed to the chairpersons of pediatric radiology of 65 children's hospitals throughout the United States and Canada showed that VCUG protocols vary substantially. Recent gui...

Research paper thumbnail of Urinary tract infection in the setting of vesicoureteral reflux

F1000Research, 2016

Vesicoureteral reflux (VUR) is the most common underlying etiology responsible for febrile urinar... more Vesicoureteral reflux (VUR) is the most common underlying etiology responsible for febrile urinary tract infections (UTIs) or pyelonephritis in children. Along with the morbidity of pyelonephritis, long-term sequelae of recurrent renal infections include renal scarring, proteinuria, and hypertension. Treatment is directed toward the prevention of recurrent infection through use of continuous antibiotic prophylaxis during a period of observation for spontaneous resolution or by surgical correction. In children, bowel and bladder dysfunction (BBD) plays a significant role in the occurrence of UTI and the rate of VUR resolution. Effective treatment of BBD leads to higher rates of spontaneous resolution and decreased risk of UTI.

Research paper thumbnail of Ten-Year-Old Girl with Crossed-Fused Ectopic Kidney and Ectopic Ureter to Vagina

Urology, 2007

10-year-old girl presented with continuous urinary incontinence. At age 5, noncontrast magnetic r... more 10-year-old girl presented with continuous urinary incontinence. At age 5, noncontrast magnetic resonance imaging and cystoscopy had revealed a solitary malrotated left kidney. Repeat cystoscopy and retrograde pyelography at 10 years of age showed no change. Attempts to cannulate an orifice in the right lateral vaginal wall on vaginoscopy were unsuccessful. Flush vaginography revealed an ectopic ureteral insertion to the vagina crossing the midline to a moiety inferior to the left kidney (Fig. 1). A gadolinium magnetic resonance urogram confirmed the presence of a crossed-fused ectopic right kidney with relative function and an ectopic ureteral insertion to the vagina (Fig. 2). The patient subsequently underwent extravesical ureteral reimplantation and has remained completely continent. Crossed renal ectopia is nearly always associated with a normally placed ureteral orifice located within the contralateral trigone. 1-3 This is the first case of a crossed-fused ectopic kidney with an ectopic ureteral insertion to the vagina in an otherwise normal child. 4 We highlight flush vaginography as a convenient tool for the identification of an ectopic ureteral insertion to the vagina in incontinent girls. Furthermore, this report illustrates the superiority and utility of contrastenhanced magnetic resonance urography in the evaluation of ectopic ureters and functional renal moieties.

Research paper thumbnail of Endoscopic Treatment with Dextranomer/Hyaluronic Acid for Complex Cases of Vesicoureteral Reflux

The Journal of Urology, Oct 31, 2004

The surgical correction of primary vesicoureteral reflux (VUR) is highly successful. This success... more The surgical correction of primary vesicoureteral reflux (VUR) is highly successful. This success decreases in more complex cases and often involves reoperation and increased morbidity. We present our experience with the use of subureteral injection of dextranomer/hyaluronic acid (Dx/HA) in complex cases of vesicoureteral reflux in which open surgery would have been indicated. Between October 2001 and July 2003, 72 patients 9 months to 31 years old (mean age 5.6 years) underwent subureteral injection of Dx/HA for complex VUR at our institutions. Dx/HA was injected submucosally within the intramural ureter (modified STING) in most cases. A guidewire was used to manipulate the ureteral orifice and a retrograde ureterogram was used to delineate the anatomy in selected cases. The average volume of injected material was measured for each ureter. Renal sonography was performed to determine if hydronephrosis was present. At 3 months fluoroscopic voiding cystourethrograms were used to evaluate for the presence of VUR. A total of 93 ureters were treated in 55 girls and 17 boys. All cases were considered to be complex as 17 had persistent reflux after open surgery (7 megaureters repairs, 2 extravesical repairs, 7 intravesical reimplants and 1 blind ureter), 11 had persistent reflux and neurogenic bladder, 7 had ectopic ureters to bladder neck, 6 had bilateral Hutch diverticulum, 6 had persistent stump reflux, 5 had ureterocele after puncture or incision, 15 had duplications, 1 had the prune belly syndrome, 2 had posterior urethral valve following resection, 1 had epispadias and 1 had urogenital sinus. The average maximum reflux grade was IV. An average of 1.1 cc (range 0.4 to 2) was injected per ureter. Of the patients 69 had 3-month followup results. The overall success rate was 68% after 1 implantation (47 of 69). Submucosal intraureteral implantation with Dx/HA corrected complex vesicoureteral reflux in 68% of patients. In all of these patients open surgery would have potentially been difficult. The use of fluoroscopy and/or guidewires is a useful adjunct in these cases. We believe that this minimally invasive approach is warranted as an initial step in the management of complex cases of VUR before resorting to more difficult open surgical procedures.