Minimally invasive approaches advance in pediatrics

Across a spectrum of indications, minimally invasive procedures are having a major impact on the practice of pediatric urology, said Howard Snyder, MD, professor of surgery in urology, University of Pennsylvania School of Medicine and Children's Hospital of Philadelphia. This observation was evident in a number of papers presented at the AUA annual meeting.

Laparoscopic procedures, including nephrectomy, renal transplant, retroperitoneal lymph node dissection, and pyeloplasty are showing outcomes in children that approach those seen in adults.

"The pediatric urologists have been a little slower to get on the bandwagon in using these minimally invasive approaches, but as different groups have begun to report their experience, it is clear that these techniques are feasible in children and can produce the same excellent outcomes in our young patients as they do in adults," he said.

Children do well with any of three major treatments for stones: extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, and ureteroscopy.

Also in the realm of minimally invasive procedures, reports from various researchers support a role for endourology management of nephrolithiasis in children.

"Whether we are talking about ureteroscopy, percutaneous stone removal, or lithotripsy, there is no question that these techniques can be used successfully in our pediatric patients," Dr. Snyder said.

Injectable dextranomer/hyaluronic acid copolymer is effective for correcting moderate grades of vesicoureteral reflux, and new techniques have improved outcomes.

Various papers reporting on the use of dextranomer/hyaluronic acid copolymer (Deflux) emphasize the value of this minimally invasive approach to correcting VUR. With its efficacy and safety, the injectable gel has created a paradigm change for the management of patients with intermediate-grade VUR, Dr. Snyder said.

"Many parents prefer having their child undergo this endoscopic outpatient procedure, rather than waiting 4 to 5 years for the reflux to clear. Deflux is 80% to 90% effective in correcting moderate grades of reflux, and thereby enables children to discontinue antibiotic prophylaxis earlier and spares them the trauma of repeated, invasive VCUGs," he said.

Since the agent became available on the U.S. market, some new injection techniques have emerged that are proving useful for maximizing success rates. In particular, the hydrodistension implantation technique introduced by Andrew Kirsch, MD, represents a modification of the original subureteral transurethral injection (STING) procedure. This technique is easy to perform and has been associated with excellent safety and improved VUR resolution rates.

Patients with spina bifida and bladder cancer tend to be young, have variable tumor histology, and have a poor prognosis. Bladder cancer in these patients often has an atypical presentation.

The answer to the question of whether continent reconstructive procedures might be associated with an increased risk of tumor development is pending the availability of longer follow-up.

"Certainly, it does not appear in the near term that there are any malignant complications associated with continent reconstruction, but whether that will hold true 25 or 40 years after surgery remains to be seen, as we are just not there yet," Dr. Snyder said.

This report on spina bifida patients raises a cautionary reminder for urologists and underscores the importance of performing ongoing monitoring.

"I tell my patients and their families that they have bought a Lamborghini, not a Ford, and that they are going to need tuning for a long time," Dr. Snyder said.

The fact that bladder cancer may present atypically and appears to have a poor prognosis introduces questions about optimal methods for screening.