Lap procedures increasing in pediatric urology

May 15, 2008

In the office and the operating room, urologists are finding an array of more palatable approaches to managing pediatric cases.

Key Points

Urology is, by its very nature, an invasive branch of medicine. From surgery to cystoscopy to even routine exams, urologists must often take patients far beyond their comfort zones as they diagnose and treat disease. Because they work with children, pediatric urologists are always receptive to new and less-traumatic ways to work with their young patients.

Perhaps that explains why the growth of minimally invasive therapies continues to be one of the hottest topics in pediatric urology. In the office and the operating room, urologists are finding an array of more palatable approaches to managing pediatric cases.

A 4-year review of dextranomer/hyaluronic acid injections for VUR showed that while success rates were relatively high at initial postoperative voiding cystourethrogram, the failure rate at 1 year was still considered significant and long-term follow-up is warranted.

Interestingly, dextranomer/hyaluronic acid injections sometimes lead to the formation of blebs that may be mistaken for ureteral stones on CT scan. Knowing a patient's history of endoscopic injection and the location of the calcified material outside the ureteral lumen, along with the absence of hydronephrosis, should help urologists and radiologists reading these scans avoid a misdiagnosis.

On the surgical side, laparoscopic pyeloplasty is technically challenging but yields decreased operating and length-of-stay times, according to new data.

However, at least one study finds that the rate of re-operative intervention for laparoscopic pyeloplasty in children is three times higher than that of open surgery. The authors recommend the use of diuretic renography to justify surgical intervention and in the evaluation of its outcome.

Increasingly, urologic researchers are finding links between exposure to synthetic substances and a higher incidence of male genitourinary conditions. For example, one group will soon tie the prevalence of such conditions as hypospadias and cryptorchidism to exposure to polybrominated biphenyls (also known as PCBs), a suspected endocrine-disrupting chemical.

"As long as the incidence of these genital abnormalities rises, we'll be hearing about it," said Dr. Snyder.

It has been suggested that younger children are less likely than older children to pass urinary calculi spontaneously, and that stone formers under age 10 years are more likely to have some sort of metabolic abnormality with a higher risk for recurrence.

A team of researchers will soon report that identifiable metabolic risk factors may be found in three-quarters of pediatric stone formers.

Other emerging findings include:

Conforming to the trend of less-invasive treatments, young patients with grade IV renal injuries were found to benefit from nonoperative treatment protocols. Open exploration was necessary in only a small percentage in one cohort.

"Indications for open intervention in renal trauma are decreasing," Dr. Snyder said.

Children with renal trauma also do not necessarily require CT scan re-evaluation after their initial scans unless certain abnormalities are found on serial ultrasound, thus minimizing these patients' exposure to radiation.

Another center is reporting that pediatric iatrogenic ureteral injuries can be repaired using standard techniques that are employed in adult populations with an expectation of favorable long-term results.

Urologists who treat children will also want to monitor results from studies discussing the following: cranberry powder extract as prophylaxis for VUR, and renal cell carcinoma found to be more aggressive in children than in adults.