Hidden Scars Robotic Ureteral Reimplantation for Vesicoureteral Reflux

Vesicoureteral reflux is when the urine goes back from the bladder into the kidneys due to defective “valves” at the junction of the ureter with the bladder.

Some children with vesicoureteral reflux suffer from recurrent febrile urinary tract infections, where the child has temperatures of more than 101.5 and urinary symptoms (if the child is old enough to be able to report them). Some of these infections can scar the kidney (15% of the times).

A child with vesicoureteral reflux and history of febrile UTI’s will have a roughly 40-50% chance of another febrile UTI if no treatment is given. If the child receives a daily dose of a preventative antibiotic, the chance of recurrent febrile UTI’s decreases by about 12% to somewhere around 28-38%. Surgery will decrease the chance of recurrence even more down to 10-20%.

Surgery for vesicoureteral reflux can be done different ways:

  • Endoscopic treatment: a paste is injected using a telescope inside the bladder. No incisions are made. Patient goes home the same day after a 30 minute procedure. You can find information about this procedure here: http://www.deflux.com/. Endoscopic treatment will cure reflux in 70-80% of children, although some centers have reported higher success rates (Atlanta). Complications after endoscopic treatment are rare.


  • Ureteral reimplantation: this surgery redirects the ureter inside the bladder in a way as to create a “new valve”. Success rates for this surgery are above 90%. Ureteral reimplantations can be done many different ways (from inside the bladder, outside the bladder). Although the surgery is more successful, complications can occur in around 5% of patients.

I usually do my reimplantations laparoscopically using the Da Vinci Robot following the principles of HIDES (Hidden Incision Endoscopic Surgery). What this means is that incisions are made where no one would usually see them (under the bikini line and inside the belly button).

Here is a picture of a girl that had a ureteral reimplantation with the Hidden scars technique.



The surgery takes anywhere from 2-4 hrs. Patients are discharged from the hospital in the first 24 hrs after the procedure most of the times.

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Labial Adhesions

Labial adhesions occur in up to 2% of girls usually in the first 2 years of life. These adhesions tend to start close to the side of the rectum and progress towards the clitoris.

Vaginal Adhesions


The cause of these adhesions has not been clearly identified. Some have postulated that they are due to low estrogen levels and others say they are due to irritation or trauma.

Most labial adhesions cause no symptoms. Occasionally they can cause urinary dribbling from some urine trapping behind the adhesions. Some girls may present with urinary tract infections, also from not been able to empty their bladders all the way.

The rate of spontaneous resolution has been reported to be as high as 80% within 1 year, reason why observation is recommended for most asymptomatic patients.

If the patient is having issues because of the adhesions treatment is recommended

Medical Treatments
Either an estrogen or steroid cream can be applied to the adhesions 2 times a day for 1 month with gentle retraction.
Surgical Treatments
When the adhesions are thin and the patient is cooperative, topical anesthesia can be applied to the adhesions in the office and then gentle retraction or scissors could be used to divide the adhesions. Alternatively, the same can be done under general anesthesia. Very thick adhesions are preferably done in the OR since stiches might be needed to control bleeding after dividing the adhesions (not very common).

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Pediatric Urinary Tract Infections

One of the most common problems I see in my practice is a child who has had one or more urinary tract infections.
The most important question to ask when someone is having urinary tract infections is whether the infections happen with fever. This is referred to as a febrile UTI. The workup and management of a febrile UTI is completely different than that of a non-febrile UTI. Failing to make this distinction usually results in unnecessary radiologic testing.
A child with a febrile UTI has a temperature of more than 101.5, looks like he has the flu, and often needs to be admitted to the hospital for IV fluids due to nausea and vomiting. He may also have burning and pain with urination, but not always.
A child with a non-febrile UTI feels well overall but hurts terribly when voiding. He may also void frequently in small amounts or instead hold his urine and then have accidents. Some children may have no symptoms, though parents report a strong smell in the child’s urine.
FEBRILE UTI (UTI with fever)
Febrile UTI’s are usually due to anatomic problems like urine going backwards from the bladder to the kidneys (vesicoureteral reflux), or a blockage in the kidney, ureter, or urethra.
The American Academy of Pediatrics (AAP) recommends obtaining a renal and bladder ultrasound after the first febrile UTI mainly to rule out blockage or obstruction in the urinary tract. A renal ultrasound is well tolerated by most children, is non-invasive, and there is no risk of radiation.
After the second febrile UTI, the AAP recommends a more invasive test, disliked equally by parents and children: the voiding cystourethrogram (VCUG). The VCUG is done mainly to detect vesicoureteral reflux, a condition associated with recurrent febrile UTI’s. Surgery for vesicoureteral reflux can decrease the chances of recurrent febrile UTI’s by more than half, however, it does not affect the risk of recurrent non-febrile UTI’s.

NON-FEBRILE UTI (UTI without fever)
Non-febrile UTI’s are usually due to infrequent voiding, incomplete voiding, bad hygiene, or constipation. Children with non-febrile UTI’s usually have normal anatomy. The treatment for recurrent non-febrile UTI’s is:
 voiding frequently (every 2 hours)
 double voiding (the child counts to 10 after voiding and then tries to void again)
 proper hygiene (sometimes using moist toilettes, wiping from front to back, etc.)
 treatment of constipation (which should be continued indefinitely, usually into adulthood)
A small subset of children with non-febrile UTI’s have what we call dysfunctional elimination syndrome, which is a failure to relax the urinary or anal sphincters when voiding or defecating. These patients usually don’t empty their bladders completely, which results in infections and/or incontinence. They also suffer from constipation and soiling. These patients might benefit from medications or pelvic muscle training (biofeedback) when simpler maneuvers like timed voiding, double voiding, and treatment of constipation fail to solve the problem.

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Antenatal hydronephrosis (kidney swelling)

With ultrasounds being done so commonly during pregnancy, one of the most common congenital abnormalities encountered is accumulation of urine inside the kidney, or in medical terms, hydronephrosis. This happens in 1-5% of pregnancies. Most cases of antenatal hydronephrosis (more than 50%) are inconsequential and transient, but on the other side of the spectrum there are cases of real urinary tract obstruction which, if untreated, could lead to infections, stones and loss of the kidney.

A well done study to determine which cases of antenatal hydronephrosis are transient versus potentially dangerous has not been done. Most of the studies to date are retrospective in nature and with substantial biases.


Measurement of the diameter of the renal pelvis (see picture) has been used to classify cases into mild, moderate, and severe.  Several researchers have come up with different thresholds, some categorizing greater than 15mm as severe, others categorizing greater than 10mm as severe.  Choosing a specific threshold to determine normal from abnormal has its consequences. We understand that the higher the measurement the more likely the kidney will have problems. So say you have 10 real cases: 5 are significant and their measurements are 8,9,14,16, and 18.  Five are not significant and their measurements are: 7,6,8,9, and 11.  If you chose 10mm as your threshold then 2 significant cases and 1 insignificant case would have been incorrectly diagnosed.  If you chose 15 as your threshold, 3 significant cases and no insignificant cases would have been incorrectly diagnosed.

So what are the most common causes of antenatal hydronephrosis?

1. Transient/Physiologic:This just means that the hydronephrosis is a normal anatomic variant with no clinical consequences. This accounts for roughly 40-88% of the cases.

2. Ureteropelvic Junction Obstruction. This refers to an obstructive process happening  between the renal pelvis and the ureter (see picture above). This accounts for 10-30% of the cases of antenatal hydronephrosis. Only 10-25% of children with ureteropelvic junction obstruction will eventually need an operation. The rest don’t develop an obstruction significant enough to damage the kidney, cause infections or symptoms.

3. Vesicoureteral Reflux: This means that urine will go back to the kidney from the bladder. It occurs in about 10-20% of antenatal hydronephrosis cases. The incidence of reflux is not different among children with or without antenatal hydronephrosis. In recent years, reflux has become one of the most controversial topics in pediatric urology. Some U.S. centers are aggressive at the diagnosis and management of reflux, whereas more and more centers are taking a very conservative approach at diagnosing and managing reflux. The main reason for the latter is that recent well conducted studies have failed to show much benefit in diagnosing and treating reflux, in terms of preventing renal damage, hypertension, or infections with either antibiotics or surgery.

4. There are other causes of antenatal hydronephrosis that are not common which I won’t cover in this post.

Which patients require further evaluations?

Most patients with antenatal hydronephrosis diagnosed during the second trimester will have their hydronephrosis resolved by the third trimester. If the hydronephrosis persists through the third trimester and especially if the diameter of the pelvis is greater than 10 mm, further postnatal evaluation with a renal bladder ultrasound is recommended.

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Bedwetting (Enuresis)

Bedwetting is a common problem seen by Pediatric Urologists. Some children who wet the bed also have accidents or urgency/frequency during the day. In this post, I want to focus on the patients that are okay during the day, but  wet the bed at night. So from now on, when I mention bedwetting, I refer to patients that only have problems at night.

Bedwetting occurs in around 15% of 6 year olds, but is  present in less than 1% of adults. This means that most children with bedwetting get better on their own. It is common for children with bedwetting to have 1 or 2 parents that wet the bed as children. Usually it is predicted that the child will stop wetting the bed around the same time their parents did (that is, of course, without treatment).

Bedwetting can be treated with medications, with non-pharmacologic interventions, or with both.

Medications do not cure bedwetting. Not only that, but medications are only temporarily effective in around 20-30% of patients taking them. Most people resume bedwetting when these medications are stopped. Medications can be useful for special occasions such as sleepovers, camp, etc.

Bedwetting alarms do cure bedwetting in up to 80% of children. Alarms are worn on the child’s pajamas and they have a humidity sensor that attaches to the child’s underwear. The alarm will go off as soon as the child starts voiding and initially will wake up at least the parents (most bedwetters are deep sleepers), who would then take the child to the bathroom to help him finish voiding, and then change the bed as needed. With time the child’s brain starts associating the sensation of a full bladder with the alarm and the child starts waking up on his own to go to the bathroom. Bedwetting alarms require cooperation from the parents and some maturity from the child, and thus might not be appropriate for all social situations or for children 5 years old or younger . It may take up to 3 months of daily use for the alarms to fully work.

Lastly, the following measures can be tried on all children regardless of the age to manage bedwetting:

  • Distribute fluid consumption evenly throughout the day (some kids don’t drink anything during the morning and then come back from school and drink all their fluids in the late afternoon and evening)
  • Have your child void before going to bed.
  • Take your child to the bathroom (either awake or asleep) before you go to bed.
  • Ensure that your child voids at least 4-7 times during the day.
  • Avoid caffeinated beverages and milk towards the end of the day.
  • Avoid punitive measures for times when your child wakes up wet. Bedwetting is not due to laziness or child misbehavior. Bedwetting is involuntary.

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Hidden Incision Endoscopic Surgery or “HIDES”

HIDES was developed by one of my mentors in Dallas, Dr. Gargollo. HIDES is just a different technique of placing the laparoscopic ports during laparoscopic surgery in order to ‘HIDE” all visible scars. During traditional laparoscopic surgery, some ports are placed above the belly button in areas that would be visible when wearing a swimming suit for example. With HIDES, one laparoscopic port is placed inside the belly button and the others are placed at or below the bikini line, thus hiding the incisions.

The patient below had a robotic pyeloplasty, using the traditional port placement. As can be seen, the most superior port scar would be visible when wearing a swimming suit.

NO hides

In contrast, the following picture shows a patient that had a robotic pyeloplasty using the HIDES technique, showing all the scars are hidden.

Gargollo Fellows Talk 2012

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