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Institute for Pediatric Urology Advances Minimally Invasive Surgical Approaches for Urological Disorders in Children

New York (Dec 17, 2010)

stethoscope
Dix Poppas, MD

Minimally invasive surgery and laparoscopy have rapidly come to the forefront as options for children with certain urological diseases. As these procedures have been performed successfully on adults, their application to the pediatric population has been investigated with good results, even in very young patients. The advantages are many, including decreased post-operative pain, short hospital stays, the possibility of performing such procedures on an outpatient basis in select patients, quicker healing, and improved cosmetic results.

"Developing procedures to treat urological conditions that minimize the physical impact on children while still achieving optimal outcomes is a key mission of the Institute for Pediatric Urology," says Dix Poppas, MD, Chief of the Institute for Pediatric Urology at NewYork-Presbyterian Phyllis and David Komansky Center for Children's Health. Dr. Poppas oversees a comprehensive program in the management of complex genital and urinary problems that occur in children, from birth to 18 years of age, and continues to guide the development of clinical applications for new techniques and instruments used in minimally invasive procedures.

The Institute also includes the Linda and Carl Seaman Pediatric Urodynamics Unit, a Pediatric Stone Unit, and a program for fetal urology in collaboration with the Division of Newborn Medicine and the Department of Obstetrics and Gynecology.

Laparoscopic Approaches for Kidney Disorders and Ambiguous Genitalia

Laparoscopic nephrectomy is performed to remove a kidney in a child who has a large painful, abnormal kidney, poorly controlled renovascular hypertension, or a non-functioning kidney secondary to severe vesicoureteral reflux (abnormal flow of urine) or chronic obstruction. A laparoscopic camera is inserted through a small umbilical opening near the naval and instruments are placed through tiny openings along the abdominal wall. The kidney is removed through the umbilical opening, avoiding a large visible incision.

"Laparoscopic nephro-ureterectomies have been performed to remove the kidney and the entire ureter in children with severe vesicoureteral reflux," notes Dr. Poppas. "Reflux allows the passage of infected urine into the kidney through the ureter and can result in chronic infection and scarring of the kidney, necessitating its removal. We also perform partial nephrectomies with ureterectomy, when indicated, to preserve the normally functioning portion of the kidney and future kidney function.

Ambiguous genitalia occur early in fetal development when the tissue that will become the ovaries or testes is undifferentiated. "If a physical examination is unable to determine the presence or absence of internal genital structures, laparoscopy can be used to visualize the gonads and internal reproductive structures and confirm disorders associated with ambiguous genitalia," notes Dr. Poppas.

Advances in Robotic Surgery

The application of robotic technology to the field of pediatric urology has made great strides in the past several years, enabling pediatric urologists to perform robotic surgery or assisted robotic surgery to treat an increasing number of urologic disorders in children. In 2001, Dr. Poppas was the first in New York City to perform a robotic pyeloplasty to repair a uretero-pelvic junction obstruction (UPJ) in a 7-year-old boy. "Ureteropelvic junction obstruction is a narrowing of the kidney where it connects to the ureter and, if untreated, can endanger kidney function," says Dr. Poppas. "Robotically assisted pyeloplasty offers young patients with UPJ several advantages. Unlike 'open' pyeloplasty, the robotic procedure will not leave a large, disfiguring scar, and unlike laparoscopic pyeloplasty, another surgical option, suturing of the ureter is easier, making the procedure safer."

Adopting Microsurgery Procedures for Children

Microsurgery for managing varicoceles, which is an enlargement of the veins in the scrotum, began to be used in the adult population some 25 years ago. Its success led Dr. Poppas to adopt the procedure for children, training under Marc Goldstein, MD, Director of the Center for Male Reproductive Medicine and Microsurgery at NewYork-Presbyterian/Weill Cornell. Dr. Goldstein is internationally known for his pioneering work in the microsurgical repair of varicoceles and blockages.

In 2005, Dr. Poppas, Dr. Goldstein and their colleagues published their experience of elective varicocelectomy using microsurgical techniques in a large series of children. They found the procedure to be safe and effective, with a much lower complication rate than the published rate using other approaches. There were no infections, hematomas or intraoperative injuries to the vas deferens or testicular arteries, and all patients were discharged home on the day of surgery. The Institute for Pediatric Urology continues to report the highest success rate and lowest recurrence rate for microsurgical management of varicocelectomies in children.

Extravesical Correction of Urinary Reflux

Vesicoureteral reflux is a fairly common problem usually diagnosed in infancy and childhood after the child has had a urinary tract infection. "At the Institute for Pediatric Urology, vesicoureteral reflux that requires surgical correction is frequently treated with the extravesical approach," says Dr. Poppas. "This nerve-sparing technique was pioneered here and is the least invasive surgical procedure available to correct vesicoureteral reflux proven to be effective over 95 percent of the time. Our surgeons can correct the reflux condition without having to open the bladder, without the need to use postoperative stents or drains, and with 100 percent of patients going home the same day as the surgery."

For More Information

For more information on the Institute for Pediatric Urology, please contact Dr. Poppas at (212) 746-5337.

Faculty Contributing to this Article:

Dix Poppas, MD, Chief of the Institute for Pediatric Urology at NewYork-Presbyterian Phyllis and David Komansky Center for Children's Health, and Richard Rodgers Professor of Pediatric Urology, Weill Cornell Medical College

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