Number of robotic surgeries done

Sometimes patients ask me how many robotic surgeries I have done.

Since I started practice in July of 2013, I have kept a log of all my surgeries (robotic or otherwise).

I was recently asked by an administrator about the number of robotic surgeries that I have done so I put the numbers together.

In total since July of 2013 I have done 161 robotic procedures. The 2 most common robotic procedures have been:

  1. Robotic assisted laparoscopic ureteral reimplantation: total 83
  2. Robotic assisted laparoscopic pyeloplasty: total 56

The other procedures include uretero-ureterostomies, nephrectomies, ureteral stump removal, removal of prostatic utricle, diverticulectomy, transuretero-ureterostomy.

These numbers do not include approximately 200 robotic cases I participated in during residency and fellowship.






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Infant robotic pyeloplasty with hidden incisions: comparison of outcomes with conventional port placement

Conventional port placement for robotic pyeloplasty leaves visible scars: NO hides

HIDES robotic pyeloplasty is a technique of port placement that “hides” the incisions inside the belly button and along the bikini line:


Robotic pyeloplasty was initially advocated for older children but as surgeons have become more comfortable with the technique more younger children and infants are undergoing the procedure.

Avery et al in 2015 published a multi-center study on infant (under 12 months of age) robotic pyeloplasty that included 60 patients*.

Since 2013 we have done 15 robotic pyeloplasties in Infants using the HIDES technique.

We compared our outcomes to the ones published by Avery et al . All outcomes were calculated as described on Avery et al manuscript and using the same units and descriptors:Capture

One HIDES patient had worse postoperative hydronephrosis and continued to be obstructed on the nuclear medicine renal scan. He underwent successful reoperative HIDES pyeloplasty while still under 12 months of age  with much improved hydronephrosis postoperatively. Both techniques had one failed pyeloplasty but the difference was not significant (p=0.3).

On average, HIDES pyeloplasty took 89 minutes less than pyeloplasty done using conventional PP (p=0.0001). This difference was statistically significant. We had 3 postoperative febrile urinary tract infections, 2 of them in infants that were left with a dangler coming out the urethra attached to the stent. After those 2 infections we don’t leave danglers anymore and we have not seen any more urine infections.

In conclusion, HIDES pyeloplasty does not appear to be inferior to conventional port placement with regards to hospital stay and resolution of hydronephrosis.

Operative times appear to be shorter with HIDES PP which could be due to the greater operating space provided by the technique, although further studies will be needed to validate this statement.


  • Avery D, Herbst K, Lendvay T, Noh P, Dangle P, Gundeti M, Steele M, Corbett S, Peters C, Kim C. Robot-assisted laparoscopic pyeloplasty: Multi-institutional experience in infants.  Journal of Pediatric Urology (2015) 11, 139.e1e139.e5

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Clinic Meatotomy

Meatal stenosis after newborn circumcision is common and usually presents after potty training with a deflected stream. 

Although reports of any serious consequences (bladder or kidney problems) from meatal stenosis after circumcision are not evident in the literature (as opposed to meatal stenosis secondary to surgery to correct penile congenital anomalies), treatment is commonly offered to families when urinary deflection prevents normal voiding or when the child presents with recurrent crusting of the meatus accompanied by pain at the start of urination.

In 1996, Cartwright et al. (1) published the results of a series of 58 boys who underwent clinic meatotomy (CM) using only topical anesthesia. During the period of the study, only one operation was performed in the operating room, related to behavioral concerns about the patient. Two other patients had midazolam (medicine to calm the nerves) by parent request. Three out of fifty-eight (5%) had some discomfort during the procedure, and at a minimum follow-up of 3 months, 57 out of 58 (98%) did not have a recurrence.  

Despite the findings of Cartwright et al., which robustly make a case in favor of CM and the abandonment of meatotomy under general anesthesia (GA), it appears that at the present time,  50% of meatotomies are still done under GA (2). Even those performed in the clinic are often augmented with sedation, either with nitrous oxide or midazolam (3), despite Cartwright’s (1) reporting that just 5% of patients have discomfort.

Meatotomy done at the first consultation in the office saves time for the parents and decreases costs by about 10 Fold. At our institution the cost of an office meatotomy is in between 300-500 dollars versus the cost in the OR is around 6000 dollars (cost might be lower in outpatient surgery centers). When a meatotomy is done at the first visit, the patient is only charged for the meatotomy. When the meatotomy is done under general anesthesia, the first visit is charged as a consultation and then more charges are incurred the day of the actual surgery of which the meatotomy is actually just a minor part of the bill.


Clinic Meatotomy same day of visit Meatotomy under general anesthesia
Charge for meatotomy Yes Yes
Charge for initial consultation No Yes
Anesthesia charges No Yes
Hospital Charges/Facility fees No Yes
Time away from work for family 1 hr on one day 15 min on one day

3-6 hrs on a separate day


In the past 3 years we have offered CM to all our patients presenting with meatal stenosis.

90% of our patients have seen either complete resolution or improvement in their symptoms.

The meatotomy in the clinic is done by first applying EMLA cream to the penis and covering the penis with a tegaderm (transparent plastic dressing) for 20-60 minutes. The tegaderm is then partially or fully removed to allow the performance of the meatotomy.

Over the past 3 years we have documented the presence or absence of pain during the CM and defined it as any sound, grimace, or movement during the procedure. If the patient laid still during the procedure without any of the above, this was classified as “no pain.” Pain during the removal of the tegaderm was not taken into consideration. We do have observed that that nearly all of the boys complained mildly during the removal of the tegaderm.

About 80% of our patients have had no pain as defined above. In the other 20% the pain was mild enough that we were still able to complete the procedure and no procedure had to be stopped and done in the operating room under general anesthesia so far.

Our results augment the body of evidence now documenting the safety and efficacy of CM. We now make parents aware of these results, and since we started doing that no one has requested a meatotomy under GA. We believe the literature does not support a role for GA in the management of meatal stenosis.,

Assuming a birth rate in the US of 2 million boys per year, with 60% who will be circumcised, and 7.3% of whom will develop meatal stenosis (5), that would account for 87,600 meatotomies a year in the US. Assuming a cost of $500 dollars for the office meatotomy and $5000 dollars for an  meatotomy under GA, as well as 10% recurrence rate requiring meatoplasty under GA, avoiding GA for the initial meatotomies would save $350 million dollars a year in the US, not including other financial losses such as lost work time and the like.

For the patients clinic meatotomy is safer since GA is not used.

(1) Cartwright PC, Snow BW, McNees DC. Urethral meatotomy in the office using topical EMLA cream for anesthesia. J Urol 1996 Aug;156(2 Pt 2):857-8; discussion 858-9.

(2) Godley SP, Sturm RM, Durbin-Johnson B, Kurzrock EA. Meatal stenosis: a retrospective analysis of over 4000 patients. J Pediatr Urol 2015 Feb;11(1):38.e1-38.e6.

(3) Ben-Meir D, Livne PM, Feigin E, Djerassi R, Efrat R. Meatotomy using local anesthesia and sedation or general anesthesia with or without penile block in children: a prospective randomized study. J Urol 2011 Feb;185(2):654-657.

(4) Priyadarshi V, Puri A, Singh JP, Mishra S, Pal DK, Kundu AK. Meatotomy using topical anesthesia: A painless option. Urol Ann 2015 Jan-Mar;7(1):67-70.

(5) Van Howe RS. Incidence of meatal stenosis following neonatal circumcision in a primary care setting. Clin Pediatr (Phila) 2006 Jan-Feb;45(1):49-54.

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New study recommends against the use of scrotal ultrasound for undescended testicles

A study published in the September 2015 issue of Pediatrics, is echoing what current guidelines and the AMA already recommends: to avoid scrotal US in cases of undescended testicles.

This Canadian study found that despite current recommendations against the use of ultrasound, it was still been used in 33.5% of provincial referrals and 50% of institutional referrals. Children who underwent ultrasound experienced an approximate 3-month delay in definitive surgical management. Ultrasound correctly predicted physical examination findings in only 54% of patients

The American Urological Association released for the first time guidelines on the management of cryptorchidism in April of 2014. In the guidelines, they recommend that “Providers should not perform ultrasound (US) or other imaging modalities in the evaluation of boys with cryptorchidism prior to referral as these studies rarely assist in decision making”

In 2013 also the AUA recommended as part of the Choosing Wisely Campaign to not perform ultrasound on boys with cryptorchidism. From the Choosing Wisely Website;

“Ultrasound has been found to have poor diagnostic performance in the localization of testes that cannot be felt through physical examination. Studies have shown that the probability of locating testes was small when using ultrasound, and there was still a significant chance that testes were present even after a negative ultrasound result. Additionally, ultrasound results are complicated by the presence of surrounding tissue and bowel gas present in the abdomen”.

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Cutaneous Ureterostomy versus Definitive Reimplant for Obstructed Ureter

Although rarely indicated, patients presenting before the age of 6-12 months with distal ureteral obstruction with associated ipsilateral renal function loss / severe hydroureteronephrosis and/or febrile UTI have been traditionally managed with an end cutaneous ureterostomy. If I was asked in my boards how to deal with such a problem I would answer “cutaneous ureterostomy”. Its a big dogma in pediatric urology.

Once these patients are older than 1 year of age, a ureteral reimplantation with or without ureteral tapering is usually performed.

The outcomes of cutaneous ureterostomy were published by Kitchens et al (2007, Kitchens, J Urology). These are the outcomes for only the patients with primary distal obstruction (obstructed megaureter) in the series:

  • There was an incidence of 40% (6/15) of febrile UTI while awaiting undiversion
  • 4/13 (31%) required ureteral tapering at undiversion.
  • 5/13 (38%) renal units developed postoperative reflux. 4 of these patients had successful Deflux and 1 had spontaneous resolution at 12 months.
  • For the 13 megaureter units that had undiversion, there was a 100% reoperation rate (undiversion) plus a 31% re-reoperation rate (Deflux).
  • No information was provided regarding skin problems (rashes) associated with the cutaneous ureterostomy and parent stress related to having the ureterostomy in place.

An alternative to a cutaneous ureterostomy for these infants is immediate reconstruction (reimplant with or without tapering) at the time of presentation. The outcomes of such an approach for obstructed megaureters were published by Peters et al (1989, Peters, J Urol):

  • 42 megaureter repairs in infants younger than 8 months (mean age 1.8 months for prenatally diagnosed, 3.8 months for postnatal diagnosis).
  • 40/42 had ureteral tailoring, all intravesical reimplants.
  • 6 complications all in babies younger than 6 weeks: transient apnea in 3, UTI in 1, hyponatremia in 1 and meningitis in 1.
  • 3 (7%) patient developed postoperative obstruction treated with ureteral meatotomy (1) and redo repair (2).
  • Reflux occurred in 8 patients (20%). Reflux resolved spontaneously in 3 patients, was observed in 2 more and 3 patients underwent reoperation (redo reimplant)
  • Overall, 14% patients had a reoperation with 86% patients having successful outcome (no reflux, no obstruction) with a single surgery.

The Following table compares the outcomes of both of these approaches:

Cutaneous Ureterostomy Primary repair at time of presentation
Reoperation Rate 100% 14%
Re- reoperation rate 31% 0%
Success of ureteral reimplant 62% 88%
Febrile UTI after first surgery 40% 2%

After comparing these 2 approaches, one would wonder why surgeons are still doing cutaneous ureterostomies. Greenfield et al (Greenfield, 1983, J Urol) showed even better results than Peters et al for infant (8 weeks to 6 months of age) ureteral reimplants with 97% success rates for tapered reimplants and 100% for non-tapered reimplants.  Similar outcomes were published in infants less than 3 months of age by Liu et al (Liu, 1998, Journal Of Pediatric Surgery).

Some surgeons are concerned about postoperative voiding dysfunction if one does a ureteral reimplant in infancy. Laetitia et al (Laetitia, 2002, J Urol) compared pre and post-operative urodynamics in 2 groups of 25 children who had reimplantation before and after 12 months of age. There was no difference in urodynamic parameters between the groups.  Ooi et al (Ooi, 2014, J Ped Urol) found to evidence of lower urinary tract dysfunction in children undergoing intravesical Cohen reimplants under one year of age.

If several series show good outcomes for infant ureteral reimplants with rare postoperative obstruction, why is the cutaneous ureterostomy still been done?  The medical literature does not give any insights as to why so we are left to deliberate. One reason could be that an intravesical ureteral reimplant in a baby is technically difficult.

A refluxing extravesical reimplant as an alternative to cutaneous ureterostomy has been promoted by the group in Indiana (Kaefer, 2014, J Pediatric Urology). Although devoid of the skin complications caused by having a cutaneous ureterostomy, the refluxing reimplant suffers from similar reoperation rates and recurrent UTI’s as the cutaneous ureterostomy.

A formal Extravesical non refluxing ureteral reimplant in infancy has not been published to our knowledge.  Over the past 18 months, we performed extravesical ureteral reimplants in infants with distally obstructed ureters with severe hydro (SFU 3 and 4) and evidence of decreased function and obstruction on nuclear scan (infinite curve in 3, one got DMSA so no curve, DIFFERENTIAL FUNCTION of 18, 25, 32 and 36%) in 4 consecutive patients (1 presented with urosepsis and 3 prenatally diagnosed).  Ureters were not tapered and intravesical tunnels were around 3 cm in length. All were done at age 2 months. All patients underwent surgery with no postoperative complications. A stent sutured to the Foley was left for 1 week and removed in clinic. No patient has developed a postoperative UTI. Hydronephrosis was completely resolved in all the patients. 2 patients had normal postoperative VCUG and 2 had postoperative reflux which is being observed since the patients are asymptomatic 3 and 9 months after surgery.

Extravesical ureteral reimplantation might be technically easier than intravesical ureteral reimplantation in infants. Our experience indicates that is probably a much better alternative to cutaneous ureterostomy.  Surgeons might be less concerned about postoperative voiding dysfunction with extravesical unilateral reimplant compared to intravesical reimplant. A multicenter prospective observation study of extravesical reimplants could help establish the reproducibility of our results and hopefully steer surgeons away from the current standard of care (cutaneous ureterostomy) which is a procedure not supported by the medical literature.

We are currently working in such a prospective study.

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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: 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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