Robotic Surgery

 

• Robotic technology has been an incredible advance in the field of surgery. Adult urologists were among the first users of this equipment. It wasn’t long before pediatric urologists recognized the benefits.

• The staff of Pediatric Urology Associates, of the Pediatric Urology Robotics Center, has the most extensive experience in the Tri State area in robotic surgery in children.

• The advantages of robotic surgery have made us so enthusiastic about its use. Surgery done robotically results in less pain, less scarring and quicker recovery than traditional open surgery. And the quicker children returned to their activities, the quicker parents can return to their activities.

• Robot instruments have many different joints that allow for the instruments to operate exactly like human fingers, wrists, and hands.

• These miniature instruments are introduced into the body through trocars (thin tubes). Large incisions are therefore not necessary. The dexterity of the instruments allow for us to do incredibly

• fine work with great precision

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Ureteropelvic Junction Obstruction

• Perhaps the most common usage of robotic surgery in pediatric urology is to repair a UreteroPelvic Junction (UPJ) obstruction. This procedure is called a pyeloplasty. In this condition, a small portion of the ureter needs to removed as it is obstructing the kidney. UPJ obstruction can be discovered with sonograms done during pregnancy, following a urinary tract infection, or in the course of an evaluation for abdominal pain. The segment that is causing the obstruction either is blocked due to a narrowing; or does not do its job of peristalsis (pushing the urine forward) due to a lack of muscle; or gets kinked as it lies over a blood vessel.

• After the abnormal section is removed, the healthy ureter is reattached to the renal pelvis. The ureter is only a little bigger than a piece of spaghetti and the sutures used are the size of a hair. The robotic instruments allow for far greater dexterity than standard laparoscopy. As opposed to open surgery, with its larger flank incision, the robotic procedure is done through several small incisions the size of a pen. The procedure is highly successful and patients are typically discharged home in 12 days.

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Partial Nephrectomy

• In certain conditions such as ectopic ureter or ureterocele, a diseased portion of the kidney may need to be removed. Robotic surgery allows for this removal with meticulous control of the blood vessels, ureter and kidney tissue. Robotic surgery for partial nephrectomy eliminates the need for open flank surgery and allows for quicker recuperation and better cosmetic outcome.

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Nephroureterectomy

• Occasionally an entire kidney and its ureter may need to be removed. This can occur with severe reflux or severe obstructions such as megaureter. Open surgery requires both a flank incision and a lower abdominal incision. Robotic surgery allows the procedure to be done with its small trocars and no large incisions.

 

Ureteral Reimplantation

• Urinary reflux is treated in a variety of ways depending on many factors, including the degree of reflux, the child’s age, the presence of infections etc. One of the options for treating reflux is surgery. Robotic surgery for reflux achieves the same goals as open surgery, namely to create a longer tunnel for the ureter in the bladder. Not only are the standard advantages of robotic surgery present, but because the robotic surgery is done by an extravesical approach (outside the bladder), there is less bleeding, bladder spasm and catheter time than when surgery is done via an open approach.

 

Mitrofanoff

• When a child is unable to empty their bladder (usually in conditions such as spina bifida), the bladder can be drained with intermittent catheterization of the urethra. However, if access to the urethra is difficult, a creative surgery called the Mitrofanoff procedure allows access to the bladder. In the Mitrofanoff procedure, one end of the appendix is connected to the bladder and one end is connected to the skin (often in the belly button). A catheter can then be easily inserted into the bladder by lifting or unbuttoning a few buttons of the shirt. Families feel this gives the child more independence for their bladder schedule. Robotic surgery has been used to perform this surgery with good results.

 

Mace Procedure

• Constipation can be a challenge for children with spina bifida and other neurological conditions. When rectal enemas are no longer an option, the MACE procedure (Malone Antegrade Continence Enema) offers predictable emptying of the colon. In this procedure the appendix is brought to the skin to allow passage of a catheter into the colon and irrigation of the colon. This procedure allows for quick, easy and predictable bowel emptying. Families are often quite happy with the improvement this offers over rectal enemas.

 

Adrenal Tumors

• Adrenal tumors can be benign or malignant. Removing them in the past required large flank or abdominal incisions. However, some of these tumors can be removed with robotic surgery, allowing for quicker recuperation.

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Laparoscopic Surgery

 

What is Laparoscopic Surgery?

• Laparoscopy is utilized to look in the abdomen and perform any procedures that may be indicated without having to make large incisions. It greatly reduces the pain and discomfort postoperatively in some cases, and in others it makes the procedure more successful. PUA has been involved in pediatric laparoscopic surgery for urologic disorders since its inception. Dr. Brock and his associates published one of the earliest papers in the English language literature on laparoscopy for nonpalpable undescended testes in 1984 and the first paper on the technique of transinguinal laparoscopy in 1994. They were the first to perform diagnostic laparoscopy for the non-palpable testis in the New York area in 1985 and taught the first courses for this form of laparoscopy in children in New York State. Since 1984, the physicians of PUA have built upon these earlier innovations and have become pioneers in the field of laparoscopic surgery, publishing numerous medical-journal articles describing our superior surgical results. Laparoscopic surgery is now widely applied to the treatment of urologic disorders in children. We have been the first to develop and describe additional laparoscopic procedures or techniques and among the first in the field of pediatric urology to perform robotic-assisted laparoscopic surgery. Dr. Franco has a special interest and expertise in this area, and he and the other members of the group are now recognized as pioneers and national experts in the field of laparoscopy. They are frequently asked by the editors of major peer-reviewed medical journals to review articles about pediatric urologic laparoscopy, and they are frequently invited to give presentations at national meetings. Members of the group are also actively involved in teaching laparoscopy at advanced national and international laparoscopy training courses for other urologists.

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What Procedures do we perform laparoscopically?

• Diagnostic laparoscopy

• Laparoscopic orchidopexy

• Laparoscopic pyeloplasty

• Laparoscopic lymphatic sparing Varicocelectomy

• Laparoscopic reimplantation of the Ureters

• Laparoscopic mitrofanoff catheterizable stoma

• Laparoscopic creation of catheterizable cecostomy/MACE

• Laparoscopic nephrectomy (removal of a kidney)

• Laparoscopic heminephrectomy (removal of half of a kidney)

• Laparoscopic ureterectomy (removal of ureteral stump)

• Laparoscopic orchiectomy (removal of an abdominal testis)

• Laparoscopic gonadectomy (removal of abnormal sex organs)

• Laparoscopic ureteroureterostomy (connect two ureters)

• Laparoscopic ureterocalicostomy

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Preoperative Preparation

• No preoperative preparation is necessary for laparoscopic orchidopexy other than that which would be performed for routine surgery.

 

Laparoscopic Orchidopexy

• Surgical intervention for the intra-abdominal testis is considered essential for the preservation of testicular function and for monitoring of testicular cancer later in adulthood. Laparoscopy for the evaluation of the nonpalpable testis has been long recognized as the ideal means of evaluating such testis. Management of the intra-abdominal testis has evolved over the years from large incisions with retroperitoneal and abdominal exploration to staged Fowler Stephens with laparoscopic clipping of the vessels to today’s one-stage laparoscopic orchidopexy. In the 1990s laparoscopic orchidopexy became a well-established technique for the management of the intra-abdominal testis. Once the testis is noted to be intra-abdominal on diagnostic laparoscopy or, in some cases, sitting at the level of the internal ring (the “peeping” testis), it is a perfect candidate to undergo laparoscopic treatment. The clear advantage of laparoscopic orchidopexy in these cases has been demonstrated in multiple studies in the literature in which success rates of 95% have been achieved (PUA authors’ series).

 

Inaccuracy of Other Tests to Locate a Testis

• Radiologic studies including CT scans and ultrasounds used to locate the nonpalpable testis are unreliable, with false positive and false negative rates as high as 20%. A definitive procedure such as laparoscopy is needed for positive identification of the presence or absence of the testis. Contrast augmented MRI studies have had a high success rate with false negatives in only one reported series to date.

• The fact that some form of testis will be found in 80% of patients who are designated initially as having impalpable testis is something we have found in our experience. (Brock et al, 1983). Of these 80%, some will be found in the groin and a simple inguinal orchidopexy can be performed. Others will have a peeping testis or a true intra-abdominal testis. The other 20% of the patients will not have a testis, and no further treatment or intervention is needed.

 

Two-Stage Orchidopexy (Fowler-Stephens Orchidopexy)

• There are cases where diagnostic laparoscopy shows that the blood vessels to the intra-abdominal testis are too short to allow the testis to be brought all the way to the scrotum without harm. It is possible to divide these vessels by laparoscopic surgery without injury to the testis. In this situation nearby blood vessels will then grow toward the testis, allowing it to be moved to the scrotum at a later date. It usually takes about six months for these blood vessels to get to the point that they provide enough blood flow to the high testis that allows it to be moved to the scrotum by a second laparoscopic procedure. This is called a two-stage Fowler-Stephens orchidopexy, and it is the procedure of choice in this situation.

 

Contraindications to Laparoscopy

• There are no real contraindications to laparoscopic orchidopexy other than extremely numerous and dense bowel adhesions that would make laparoscopy difficult. The experience of the surgeon in complex cases is the only other limiting factor.

 

Laparoscopic Pyeloplasty

• Pyeloplasty is an operation utilized to repair an obstruction at the ureteropelvic junction (UPJ). The UPJ is the point where the urine from the kidney starts to empty into the tube that will carry the urine to the bladder (the ureters). Open (non-laparoscopic) pyeloplasty typically requires a large and painful incision below the rib cage on the affected side. Laparoscopic pyeloplasty allows the surgeon to perform the procedure without a large incision. The use of a robot to perform this procedure allows the surgeon greater dexterity and vision to perform the procedure in a shorter time.

• We have performed numerous laparoscopic pyeloplasties with success rates that rival the open surgical technique. We have been able to perform the procedure in children as young as two years of age, utilizing the DaVinci robot.

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Laparoscopic Varicocelectomy

• The management of varicoceles in the adolescent male is controversial. While the indications for intervention can be debated, effective treatment options are available when intervention is deemed appropriate. The goal of the operation, regardless of which method is used, is to interrupt or obstruct the abnormal veins that are allowing blood to run backward to the testis. Once the blood vessel has been blocked or divided, the blood will stop at the point where the vein has been divided and will no longer back up into the scrotum. The veins can be divided just above the testis near the scrotum, higher up in the inguinal area (the groin) or in the lower abdomen. Minimally invasive laparoscopic techniques for the treatment of varicoceles in an adolescent were first described in 1992. The other available treatment options include open surgery (Palomo or Ivanisivich techniques) or percutaneous trans-venous embolization procedures.

• We have been able to perform lymphatic sparing varicocelectomy and obtain minimal recurrence rates and hydrocele rates that rival those of microscopic varicocele repair. Pain and recovery time have also been reduced using laparoscopic techniques.

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Radiology Testing

 

Ultrasound

• This test is done to outline the kidneys and bladder. It allows for kidney measurement and the detection of any “enlargement of the collecting systems of the kidney” termed hydronephrosis. This test is not invasive. It involves the placement of gel on the abdomen followed by placement of a probe to picture the kidneys and the bladder. The ureters are normally not imaged on ultrasound.

 

X-Rays

• Voiding Cystourethrogram
  This X-ray test gives important information regarding the structure of the bladder and the urethra (or the tube through which urine passes from the bladder during urination), and it allows for the detection of reflux (backflow of urine from the bladder to the kidneys through the tubes which connect the kidneys and the bladder). To perform the test, a small tube is passed through the urethra to the bladder. The bladder is filled through that tube and x-rays are taken as the bladder fills and then as the bladder empties. The test is not painful, but catheterization has some pain associated with it. Your child can read a book during the test. The result of the test is usually readily available for discussion with your urologist.

 

Nuclear Medicine

• Nuclear Cystogram: This test, like the voiding cystogram, is useful to detect ureteral reflux. However, it does not provide the urologist with a “picture of the bladder or urethra.” It involves passing a small tube into the urethra through which special fluid is used to fill the bladder and image the activity.

• Nuclear Renal Scan: This test is used to evaluate how well the kidneys function and how well they drain. It provides the urologist with a picture of the kidneys over a period of time; each of these pictures can be quantified by the computer and give a graph which is useful in determining if there is an obstruction in the kidney or in the ureter. The amount of radiation involved is much less than in a conventional IVP study.

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Biofeedback

 

What is Biofeedback?

• Biofeedback refers to the use of the mind to consciously change how the body unconsciously functions. When a parent uses a story book to calm a struggling, crying child, this is biofeedback. The mind starts to relax, and slowly the muscles also relax.

 

What is Biofeedback for Pelvic Floor Dysfunction and why does my child need Biofeedback?

• Research has shown that many children with urinary symptoms, such as incontinence or constipation, also have difficulty controlling the muscles used to void or have a bowel movement. For some reason, the muscles of the pelvic floor (the “bottom) seem to contract (or squeeze) when the child voids, instead of relaxing. For many of these children, the normal sensation of urge (or knowing when to “go”) is different.

 

How does Biofeedback help?

• Biofeedback therapy can help the child to learn how to use their muscles correctly, using the latest scientific understanding of how the muscles and mind interact.

 

What does Biofeedback involve?

• Biofeedback therapy involves muscles retraining. This takes place in the office, using a computer to help the child learn to contract and relax the muscles of the pelvic floor. It is non invasive and does not hurt. Many children look forward to their visits. Each session takes about one hour. Some children will achieve retraining in as little as three to five visits. Other children, especially those with more involved problems (such as recurrent infections, or urinary reflux), may need more visits. Successful retraining takes time. It also involves practice at home, or school. Some children may also need additional medication to help prevent accidents, or help with constipation.

 

Who provides Biofeedback?

• A parent may notice that the therapist (including many MD’s, NP’s, or  PT’s ) having the letters “BCB-PMD” on their title. These individuals have become certified by the Biofeedback International Alliance in Pelvic Floor Therapy, a rigorous training program which requires ongoing continuing education and research. Others have had special training in this area in order to utilize many of the biofeedback programs used in this therapy.  

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Does Biofeedback help with other urinary problems?

• Research has shown that improvement in bladder function can help with other urinary problems, such as urinary tract infections or other more serious problems. Talk to your doctor about how biofeedback can help with these problems.