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More on Update: Pediatric Urology
More on Update: Pediatric Urology
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More on Update: Pediatric Urology
More on Update: Pediatric Urology
Update: Pediatric Urology
New York (May 15, 2009)
In recent years, considerable progress has been made in the treatment and management of pediatric urology diseases and conditions. At NewYork-Presbyterian Morgan Stanley Children's Hospital, the Division of Pediatric Urology is pioneering treatments in urinary tract reconstruction (including bladder, vaginal and genitalia reconstruction), vesicoureteral reflux (VUR), adolescent variocelectomies, as well as utilizing robotic surgery for the treatment of certain urological conditions in infants and children.
Advances in Urinary Tract Reconstruction
Bladder reconstruction is often necessary in children and young adults born with congenital abnormalities such as bladder exstrophy, posterior urethral valves, and neurogenic bladder secondary to a multitude of conditions, the most common being spina bifida. Recently, the Hospital's pediatric urologists have published findings on patients with bladder exstrophy, looking for the first time at the long-term effects on their life and lifestyle. The bladder exstrophy database has more than 300 patients, and the Hospital's physicians are actively looking into the 25-year follow-up of both primary closure and continent urinary diversion in this group of individuals.
Bladder reconstruction is also necessary on occasion in patients born with other congenital abnormalities in the lower urinary tract, including posterior urethral valves (PUVs) which can destroy the bladder and make continent urinary diversion and/or bladder augmentation necessary. In addition, patients born with neurogenic bladder secondary to spina bifida are often candidates for bladder reconstruction. NewYork-Presbyterian Morgan Stanley Children's Hospital physicians have experience not only with continent urinary diversion, but also with the use of the MACE (Malone Antegrade Continence Enema) procedure for management of neurogenic bowel dysfunction in patients with spina bifida.
A small number of females are born with an abnormality known as mullerian failure, or Mayer-Rokitansky syndrome. In these individuals, there is no normal development of the vaginal opening and that often leads to the necessity for vaginal replacement. "Dr. Terry Hensle, the prior Director of the Division, developed a technique for vaginal replacement which has been performed at NewYork-Presbyterian Morgan Stanley Children's Hospital for the last 25 years," said Kenneth I. Glassberg, MD, FAAP, FACS, Director, Division of Pediatric Urology. "We have a long-term database looking at sexual function and satisfaction with a group of 70 patients who have undergone vaginal replacement therapy." Dr. Glassberg, more recently made a neovagina out of the lining of the patient's mouth.
Children born with ambiguous genitalia often require genital reconstruction, including repair of hypospadias, as well as scrotal reconstruction. The repair or treatment of ambiguous genitalia requires a multidisciplinary effort that includes the collaboration of pediatric specialists in urology, endocrinology, and genetics. The physicians in the Division have always been at the forefront in the development for the repair of hypospadias, a condition in which the infant boy urinates from a site other than the tip of the penis.
The Wet Child
The division has an internationally recognized Center for Urinary Incontinence. In the Center a team of two nurse practitioners and a physician assistant, under the direction of Dr. Glassberg, investigate the cause of a particular child's wetting. This might involve only having the child sitting on a potty with two skin patches to detect muscle activity and evaluate the actual flow of urine and how the pelvic muscles relax, to more sophisticated studies involving a catheter to record pressures in the bladder. The team is among the leaders in the world helping to set the standards for the investigation of incontinence in children ranging from those with simple daytime wetting to those with spinal cord defects leading to poor bladder function. Doctors and nurses from all over the world visit our center to learn to use urodynamic equipment and develop biofeedback strategies to help children gain continence.
Managing Vesicoureteral Reflux (VUR)
Vesicoureteral reflux (VUR) is the retrograde flow of urine from bladder to the upper urinary tract and is a common anomaly affecting perhaps one percent of all children in the United States. A heterogenous disease, VUR is typically diagnosed after repeated urinary tract infections and approximately one-third of children with febrile urinary tract infection will eventually be diagnosed with VUR. In addition to UTI, patients with VUR may also present with voiding dysfunction, constipation, and/or fecal soiling.
VUR predisposes patients to pyelonephritis through the facilitation of bacteria transported from the bladder to the upper urinary tract. Immunological and inflammatory reactions resulting from the infections may potentially cause permanent renal injury and/or scarring. Renal scarring, if severe, may cause decreased renal function, end-stage renal disease and renin-mediated hypertension, as well as growth problems.
The primary goal of treatment for VUR is to prevent symptomatic pyelonephritis and long-term renal complications such as renal scarring and renal failure.
Therapy options include:
- Medical management with long-term antibiotic prophylaxis
- Curative surgical correction including both conventional open surgery and endoscopic treatment
- Combination of conventional surgery plus long-term antibiotics
Open surgical procedures, such as ureteral reimplantation, have been found to be highly effective, however, require an open surgical procedure. A less invasive procedure involving the endoscopic injection of material (Deflux) into the bladder has been increasingly popular and has gained FDA approval in the United States. Deflux is a substance that has been shown to be both safe and effective.
The incidence of varicocele – varicose veins of the testicle – is associated with a time dependent growth arrest of the affected testis in adolescent and adult males. Of males presenting with primary infertility, somewhere between 30 and 50 percent will have a varicocele. Varicoceles present almost always on the left side, and they usually appear early in puberty. Occasionally they can be found in preadolescent boys and, not infrequently, bilaterally. There is a clear association between varicocele, testicular growth retardation and infertility. Repair of a varicocele can reverse the growth arrest of the testis in adolescent boys.
Adolescents with growth retardation and a large varicocele are most often considered candidates for surgical intervention. There are a number of approaches that have been recommended, including open surgery, laparoscopic surgery and embolization.
Robotic Surgery in Pediatric Urology
Robotic surgery – pioneered in adult surgery – has been found to be well suited for certain procedures in children and include pyeloplasty for ureteropelvic junction (UPJ) obstruction, partial and total nephrectomy, nephroureterectomy, and ureteral reimplantation, among others.
The Division of Pediatric Urology at NewYork-Presbyterian Morgan Stanley Children's Hospital has expanded the use of robotic surgery and today routinely uses this approach to treat urological conditions in children, from infants to 18 years and older. While robotic surgery is not appropriate for every procedure, it is particularly helpful for operating on parts of the body that are difficult to access without making a large incision. During robotic surgery, the surgeon uses the assistance of a robot to operate on the patient through tiny ports in the body instead of a large open incision. Robotic technology consists of a surgeon's console that controls a tower with four working arms. One arm controls the three-dimensional camera's movements inside the body, while the remaining three arms hold specialized laparoscopic instruments. The robotic arms precisely replicate the surgeon's hand and finger movements from the console.
At the start of the robotic surgery, miniature instruments are introduced into the body by the surgeon via small tubes, eliminating the need for larger incisions. During robotic surgery, the surgeon sits at a console where he can manipulate the miniature instruments. The end of the instrument has three different hinges that allow the surgeon to rotate, spin, and move the instrument in any direction. The surgeon is able to control the instruments as nimbly as he or she would with their own fingers and wrists and in an intuitive fashion. Degrees of rotation of the instruments allow for meticulous surgical maneuvers.
The robot can only respond to the surgeon's movements and motions, and it is incapable of moving on its own, thereby ensuring safe outcomes.
"The advantage of robotic surgery, even over the standard laparoscopy, is that it really allows you to do things very precisely and with greater dexterity," said Richard N. Schlussel, MD, FAAP, FACS, Director, Pediatric Robotic Surgery, NewYork-Presbyterian Morgan Stanley Children's Hospital, and Assistant Professor of Urology, Columbia University College of Physicians and Surgeons.
"Another advantage is that the console's image is a three dimensional one resulting from the dual lenses in the robot's camera. The visualization is greater with greater magnification. Finally, the major advantage the robot offers, is the seven degrees of freedom that each instrument enjoys."
Robotic surgery benefits patients in a number of ways, including:
- Less pain
- Less blood loss
- Fewer complications
- Less scarring
- Shorter hospital stay
Faculty Contributing to this Article:
Kenneth I. Glassberg, MD, FAAP, FACS, Director, Division of Pediatric Urology, NewYork-Presbyterian Morgan Stanley Children's Hospital, and Professor of Urology, Columbia University College of Physicians and Surgeons
Richard N. Schlussel, MD, FAAP, FACS, Associate Director, Division of Pediatric Urology and Director, Robotic Surgery, NewYork-Presbyterian Morgan Stanley Children's Hospital, and Assistant Professor of Urology, Columbia University College of Physicians and Surgeons