UroToday - Video sessions began the day. Dr Richard Grady from Seattle Children's Hospital discussed the proper way to perform a complete primary exstrophy repair (CPER). The belief of CPER is the ability to allow tissue to return to an anatomically normal position. Key components seem to be at the bladder neck and not to include any nonurethral tissue. Osteotomies are required in newborns whose symphyseal diastasis is wide (greater than 4-4.5cms). Osteotomies are used in any baby over 48 hours old. He advocates a SPICA cast immobilization for 4 weeks. In girls, the urethra, vagina, and bladder are mobilized as one unit. Dr. Warren Snodgrass demonstrated techniques for the Tubularized Incised Plate (TIP) hypospadias repair. Key aspects are correction of the chordee and minimizing overlying suture lines. Urinary diversion in the form of urethral catheters seems beneficial. Long term data on voiding patterns is currently undergoing scrutiny. Dr. Joseph G Borer from Boston Children's discussed Mitrofanoff Procedures emphasizing that patient education is the most important aspect in regards to safety and success. The characteristics of the tube itself should be short, smooth, and straight. The appendix should be placed in a submucosal tunnel of the bladder either in an intravesicle or extravesicle approach. Dr. Israel Franco demonstrated laparoscopic orchiopexy delineating the advantages of a laparoscopic approach, namely the outstanding visualization.

The day continued with a panel discussion of the "Proper Evaluation of Urinary Tract Infection". Douglas Coplen, MD emphasized that many children with urinary tract infections do not have an anatomic abnormality that contributes to the development of infection. Ron Keren, MD from The Children's Hospital of Philadelphia discussed the ongoing Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) study, emphasizing that DMSA renal scan might be the best predictor of those who would need surgical intervention. Hans Pohl, MD from Children's National discussed the "top down" approach showing that DMSA can help predict which children are at more risk regarding VUR.

The Meredith Campbell Lecture was given by Col. John B. Holcomb, MD on advances in trauma care during the war on terrorism. The bottom line of this talk was that whole blood is the best for resuscitation in regards to being the most physiologic. The current accepted dogma of resuscitation is based on hypothesis more than outcomes. The bottom line was that we must always question what we do in order to advance and learn.

The debate on adolescent varicoceles continues with a panel discussion involving Thomas Kolon, MD from the Children's Hospital of Philadelphia, David Diamond, MD from Boston Children's, and Kenneth Glassberg, MD from Columbia moderated by Evan Kass, MD. The debate continues despite excellent arguments from both sides. It appears that semen analysis should play a role in the decision to perform varicocelectomy since our endpoint is fertility. Dr. Glassberg made an argument that testicular vein velocity can be correlated to patients who are at a high risk of infertitlity and can help decide who might benefit from early intervention.

A luncheon discussion was held on pay for performance issues that might arise in our near future based on the healthcare crisis in this country. Epidemiology and outcomes will have an important role in the overall economics of medicine.

The afternoon session began with redo surgery. Mark Cain, MD moderated the session. Michael Keating discussed the hypospadias cripple. One key aspect was not to be afraid to stage the cripple redo patients. Skin coverage seemed to be the biggest challenge. Dr. Howard M. Snyder III from The Children's hospital of Philadelphia discussed redo pyeloplasty. He felt a transperitoneal approach was the best and in children older than one year of age, a laparoscopic or robotic approach was favored in his practice. John Gearhart, MD from Johns Hopkins illustrated the difficulties encountered with redo exstrophy surgery. This appears to be quite a tedious task that the take home message was to get it right the first time: don't be afraid of osteotomies when needed; immobilization of the pelvis is key; postoperative hypospadias is more than acceptable in order to attempt to achieve continence; and parent education and counseling are imperative.

Robert Lebowitz, MD from Boston Children's highlighted the advances in pediatric urology over the past 35 years. It was an interesting perspective from a pediatric uroradiologist. Dr. Lebowitz discussed advances in imaging techniques that helped fine tune our practices. Steve Skoog, MD moderated a discussion on VUR. Barry Belman, MD focused on where we were in regards to VUR. He emphasized that in 1937, Campbell's urology at that time stated that the bladder drives relux. For many years to follow, only a simple paragraph was devoted to reflux disease. In 1963, Douglas Stephens postulated that the abnormality in VUR was in the distal ureter. The most important contribution was in the 1980s where the International Reflux Study concluded that there is no difference in renal function between surgical and nonsurgical management of Grade 3 to 4 VUR. However, there was a lower incidence of pyelonephritis in the surgical group. Barry Kogan, MD continued the discussion with where we are in regards to VUR. Surgery has improved with less morbidity. Antibiotic use has decreased as parental concerns increased. Deflux is now available. Most importantly, DMSA scans seem to be most beneficial in regards to determining which children need a VCUG. Saul Greenfield, MD concluded the discussion with where we are going with VUR. His message was that our ultimate goal is to be able to segregate the majority of children with VUR who do not need treatment from those who need it. The RIVUR study is aiding to answer this question especially in regard to the need of antibiotic prophylaxis.

The day concluded with a video forum on less common ureteral reimplantation surgery. Techniques in open extravesical, combined extravesical-intravesical modified Politano-Leadbetter, laparoscopic extravesical, and a robotic transvesical Cohen approach were shown. It appeared that all the approaches had a comparable success rate with minimal morbidity on the patients. The technical difficulty of the laparoscopic and robotic approaches limits there use and the overall acceptance of the procedure. These minimally invasive approaches are currently under development. The future of MIS in VUR surgery will most likely be based on the advances in laparoscopic instrumentation and robotic platforms.

Presented at the Annual Meeting of the American Urological Association (AUA) - May 17 - 22, 2008. Orange County Convention Center - Orlando, Florida, USA.

Reported by UroToday Medical Editor Pasquale Casale, MD

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