With footage from his team’s minimally invasive surgeries, Laurence S. Baskin, MD, UCSF’s chief of pediatric urology, describes the latest approaches to conditions ranging from undescended testicles to blocked ureters and ureteral polyps. With a better understanding of these procedures and their advantages (such as less scarring and recovery time), referring pediatricians can answer parents’ questions and help them know what to expect. Bonus: Find out whether imaging is worthwhile for an undescended testicle.
I wanted to give a little bit of um, kind of feeling of of, you know what we do in the operating room and you know, show some videos and kind of related. So you can better, you know, counsel your patients when you send them our way of like what exactly is going to happen there and over the last 15 years or so. We've been super interested in kind of minimally invasive procedures. Honestly, when it comes down to it, I think families and patients just really want to kind of take care of business and get, you know, the kidney fixed. But if we can do that in a way where they're back at school quickly where the parents don't need to be home for a month. Um, you know, then all the better. So initially we started with laproscopic surgery and now we're doing a fair amount of robotic surgery and I think this was a good chance just to kind of review um, what's happening. So this is one of our robots. Uh this is the da Vinci X I robot and it'd be great if we could just press the button and get a cup of coffee and say take care of business. But it's a little more complicated than that as I think you all know, this is our room setup and you're not even seeing really the patient bed, which is off to the right here. These are the councils that we work with the robot is next to the patient and there's a lot of tactical equipment involved, which means that we have a big staff to make all this happen seamlessly. These are the councils that we sit at. So we're kind of looking through these two sites, We have them side by side. So we can work with fellow residents or um other surgeons kind of together where one council will be active and the other one you basically can look in and you can use like a pointer and say, what's this, what that um etcetera. Our fingers are in these little holes here on each hand and we basically move uh these arms here and they directly move laproscopic robotic equipment that's inside the patient. Thanks. Um here's our fellow at the bedside. Um this is an older patient and you can see these are the ports, cites the patients on the side because we're operating on the kidney up here. Um if we were operating on the bladder, the ports sites would be up here and we be aimed kind of in this direction. So the concept is, is that uh you place the ports sites and then you hook up the robotic arms to these ports as we're doing here and then you can exchange instruments through the ports site where a camera would be here and dissecting equipment, etcetera. So, and equipment would be here and you're doing the surgery, not remotely because we're in the same room, but theoretically you couldn't be doing it in a in a different place, um problematically, people have tried to do this halfway around the world and it turns out that there's a couple of seconds delay in the room. There's zero delay, which is obviously critical because you want to have, you know, real time, uh, you know, movement. The dream was to be able to adapt this for example, to unfortunately in the news a lot, you know, wartime situations where you'd have uh, an operator offsite who could, you know, guide somebody who could put the ports in to do complex surgery. We're not quite there yet. So this is a time lapse of what's actually happening so that there's a little baby under here and you can see the red area is the light from the laparoscopic camera. And then I'm sitting over at the council moving uh, my fingers and in coordination. The robots doing exactly what I'm doing. Ultimately we would like to teach the robot to do it with me not having to do it. But um, that will be a little while off. Uh, here is Hillary cop. I think we all know my partner and we've done a number of these together and kind of, uh, you know, credit Hillary with helping getting this program going and being quite successful. So occasionally with complex stuff. She will be on the council and all the, uh, next to the patient or vice versa. So what are we using the robot and minimally invasive surgery for. And I've got a kind of by font size and color. So I think the most common operation we've been performing is for block kidneys or your internal pelvic junction obstruction. And we'll show examples. We also have been doing this for block your auditors typically and duplex systems where you have, you're going to the wrong spot either topically or from your readers. Still. We've also been using this more recently for very complex disorders of sex development. I think the most common thing is when you have what's called a common Euro general sinus where the vagina is not a separate opening on the perineum but inserts behind the bladder robotically. We've we've been able to dissect this off the bladder and I think it much better results. And when we did the surgery kind of through the perineum and then we also can have your ocular anomalies like retained you're a caucus, um, which also was done very nicely with these techniques. So here's the schematic of a bloc kidney, which I think we're all familiar with. Uh, there's a normal ureter. The kidney itself is in good shape, but the blockage here is causing pressure on the kidney and that can cause either loss of kidney function, uh, pain or stones classically. We would make flank incision that would be, you know, 78 centimeters here and then um, we would undo the blockage and reach. So it Back together over the last 10 years, Um, and then earlier on, about 20 years ago we had a little break in our robotic uh experience because of the robot moved to our cancer hospital which which we couldn't do kids. But since we've been in michigan bay, we're basically back in business for the last seven years. So we put in three ports sites. Excise the new robot S. I. Is the older robot now the portside and the belly button and these two ports sites quite low here are pretty much hidden. And so you end up with one little scratch. As I mentioned, we've done a number of studies and families actually don't particularly care about the scar that they just want their kidney fixed or their child's kidney fixed. But so this is an example on the inside and we're looking at the portside that's up high near this avoid process. And then this is an example of basically looking at the dilated pelvis and I'll show you a little more higher power. But we can see the big dilated pelvis and you can see the ureter on the pelvis and right here that there's kind of a kink or an obstructed irritable pelvic junction obstruction. So this is also a bloc kidney. And you can see I'm looking straight at the U. P. J. Or the blocked ureter as enters the pelvis. And I've got the robotic instruments where I'm dissecting out the tethering tissue uh in preparation basically to cut this out and reattach it normally in a normal kidney, you wouldn't see the big highlighted pelvis. This is a patient's left side. So we do what's called a transmission Terek operation, basically, we're operating in the area about the size of a quarter, so it's truly minimally invasive. And these kids could essentially go home the same day, although we haven't been bold enough to do that, we keep them just overnight for 23 hours stay. Here's another example. Um, you can see the bow and we're going right through a little mess enteric window. Here's the blockage right here, The dilated pelvis, you can see the very narrow ureter and the idea is we take off all the tethering tissue and then we're going to just cut this out and sew it back together. Not, for example, here, where we can see the pelvis and the dilated ureter, but in this case, if I'm not mistaken, this is due to an extra blood vessel. So this is what's called a crossing vessel. Here's a blood vessel here, here's the normal ureter, it goes underneath the blood vessel into the pelvis. What happens in this case is the classic kato who comes in a little bit older with severe flank pain and they have an intermittent blockage due to this accessory vessel. So, for us, what we do is we cut this, drop the vessel below, bring the your editor back in, put it back to the pelvis and then that obstruction can occur again because the accessory vessel, lower polar kidney is now out of the way. Finally, on the rarest of occasions, we'll have an intermittent blockage, and we don't see a crossing vessel or an intrinsic obstruction. And we cut in the ureter. What we're seeing uh is not an alien or the matrix. This is a irritable polyp that's causing an intermittent blockage. And here's the same patient after really, you can see we've opened up the ureter, so from here to the kidneys normal, but this big Paul of growing inside was causing intermittent blockage. So we cut that out and still that back together. This occurs in about 1% of kids we see with the most common the ideology of your initial public junction obstruction uh in kids being an intrinsic obstruction. And then less commonly, more common in adults that crossing vessels that I just previously showed you after we sew everything back together. And here's the kidney here, here's the open pelvis. Here's half of the anastomosis. We put a little stenton robotically, that's called a double J stent looks like. So that goes in through a little angelo calf and wire and then the distal end of the stent. The distal double J ends up curling inside the bladder, the proximal part. You can see we're gonna lift up and we're gonna put it inside the pelvis and we're going to finish the anastomosis. Um This double J stent stays for about six weeks and then they come back for a fast track five minute and aesthetic mask and aesthetic where we induced test Oscar p then pull the stent out through the urethra. So it's not another incision. And I think this is really um allowed our results to be, you know, super here. So placement of the double J stent and then we finished the anastomosis. I had mentioned that ironically, I didn't think families really cared about their scars but we wanted to kind of prove that. So Katie wang, one of our previous fellows, did a nice study where we brought back patients after robotic pile plasticky, we measured the tiny little incisions, you know, which were a centimeter or so and basically would disappear over time into just a little thin scratch and compared it to kids who had an open pile of plastic, who as a baby, I might make a 34 centimeter incision. And then when I saw them as teenagers, just like, well, I guess scars grow. But the bottom line is nobody really cared about their scars. They really just cared whether they're kidney was fine and that they were in good health saying that um we've been super pleased with the robotic approach to you PJ obstruction and I think the huge advantage here is you've got magnification, you know 30 to 50 times as opposed to 2.5 times from open surgery. And from a patient perspective the scars. Not really the issue, but um The deal is that especially the teenagers are basically home the next day. They're in school a few days later and they're back to athletics, you know, a week after the operation. And of course parents are back at work. So changing kind of a 4-6 week recovery into a couple of recoveries is pretty cool. So we've also been adapting this to patients who have congenital anomalies of the kidney. And I think the most common that we're seeing is the ectopic ureter. So a duplex kidney duplex kidding itself as we know, it's not typically abnormal or a problem, but a duplex kidney where the upper pole ureter goes past its normal insertion in the bladder. And in girls this can present after potty training with persistent and continents because the ureter inserts past the sphincter eric mechanism. And boys typically they would present with infection. The other similar but different scenario is a duplex kidney where the upper pole basically sub tends or gets blocked by your readers cell and there's lots of ways to deal with this. But they're all surgical. And if this part of the kidney, uh, in this schematic, it doesn't represent that. But if this part of the kidney is nonfunctional, then we simply remove all of this, uh, minimally invasively. If this part of the kidney's functional, then we take this Ureter and we would re implant it to the lower pole ureter that's called the Eureka Eureka rasta, me and we would do the same thing here uh depending on whether there's reflux into the lower pole the kidney, which happens more commonly in the ureter still. So, if you think it's a little bit confusing on exactly what to do, I would agree with you because there's so many variables. But we kind of order things up to find how well the kidneys working and then plan either reconstructive surgery of bringing this to this with a minimally invasive technique or basically, if it's non functional, which is more common, we remove the non functional segment. So here's an X ray of that upper pole ureter going to a non functional segment, uh an ectopic ureter. And if you were to look at this in a minimally invasive approach, we basically go in using the same technique, the same ports sites and we find that huge big ureter that's going to go to the upper pole. This is the right side. So the kidney is going to be over here. This is the liver for orientation. And what I'm going to show you is that we find the big, your editor, the normal, your daughter will be below here and then we will see the blood vessels to the kidney. These aren't an accessory vessels. These in this case this is more normal where most people, not all, but most people typically have one big renal artery, One big renal vein. And the idea here is you got to dissect this figure later. Um underneath that renal renal artery and renal vein. Okay, so, same patient liver here, here's the kidney here. Here's that big curator and these are the blood vessels here. And you can see them carefully putting my robotic instrument underneath the blood vessels. So, here's the renal vein, you can see some blood kind of flowing through there, the renal arteries going to be below it. And I'm making a window. And the idea here is I make a window leaving all of this alone. So we don't injure the kidney, and I'm gonna pull this big ureter through the window and then use the ureter to grasp onto it to remove that upper part. Nonfunctional kidney. What's what I think is great about this operation is that you get a complete closure. In other words, once you do this, you're done and the kids never going to have any problem again. And that upper pole of kidneys usually only about 10% of function. So, they're not really at risk for renal issues. Okay, so now we've made the window, we've dissected the urine office abnormal origin way down near the bladder. And now I'm going to basically pop the ureter through the window and then I don't have a grasshopper in my hand, having the scissors here, but I'm going to use the scissors to kind of tease it off and then I'll pull my grasshopper out and we'll be able to pull on that ureter and um bring it up in the air and then you'll see, I think in the next of and yet that we're going to basically cut off the upper pole abnormal segment. And now we've got it away from the vessels and we're not going to mess with a normal kidney. So, here's that big, your murder. I'm using a ligature now, basically a Kateri to basically come across that non functional upper pole. And then I've got my nephew throw your directory specimen, basically that whole nonfunctional upper segment here. And you can see the smoke from the ligature and a literature, make sure obviously that we don't have any bleeding issues. Here's that same patient where I'm showing you the distal ureter. So now we're looking down into the pelvis. Here is the vast deference here, is that you're going deep. And I'm gonna pull this up and make sure that we don't uh injure any of the important structures and take that off at its at its abnormal insertion. And I think you just saw it kind of fly off there and we'll get that out through one another ports. So, upper pole, non functional systems, minimally, minimally invasive approach is super helpful. Okay, what about something a little bit more mundane, but obviously very important for families and that's undescended testes. Um we don't use the robot for that because that's overkill. We just do straight laproscopic surgery. Um I call it the old fashioned way. We've been doing it for about 20 years now. And um families are always asking me you're going to do it laparoscopically. And the answer as well. It kind of depends, you know where the money is. It depends where the testicle is. And if the testicles palpable, in other words external ring or inguinal canal, um then I'm going to do classic open surgery with an England decision. This kid is so thin you can see the testicles. So laproscopic surgery for undescended testes is of course reserved for patients who have an abdominal testes. Testes that's inside the abdomen. Not palpable testes as a reminder, what are our indications for undescended testes surgery? Well, I think for bilateral You certainly have can have fertility issues for unilateral fertility is typically never an issue. Um no question. There is an increased cancer risk by just one or 2%. But it's clearly there there's an increased risk of the tactical twisting as well as testicular trauma. And finally for males, I just think it's I feel more normal if it's testes are in the right spot. If the kiddo has a non palpable testes. I think early referral is good because it's unlikely It's never going to descend after six months and laproscopic or cotopaxi for an inter abdominal testes is easier. The younger we do it Of course after six months of age. Why do we want to do early orchid. Fxc. And if you look at the testicular histology which I guess I've looked at a lot now. Um Here's a normal testes. And if um you you can compare that to a patient with a late orchid of pixie with abnormal histology. These are the seminar for his tubules where the sperms made and you can see the fibrosis. All of this stuff between the cells is much more prominent in the patients who have late or cataplexy. They also have kind of less germ cells um and less supporting cells so early or cataplexy. Give us the best chance of preserving fertility. And that's really only jermaine and the kids with the bilateral undescended testes. Well what about imaging? I'm seeing patients in Oakland today with undescended testes. And in spite of us trying to say that ultrasounds not particularly helpful. It doesn't change anything that I do. We still see lots of patients with undescended testes about an ultrasound. You know which is great. We haven't heard anything. It's just I think if we could decrease the amount of testing we do we would probably be better off. So why am I saying that if I find the testes with imaging? Um it's undescended they get surgery. If I don't find the testes with imaging they still get surgery. So imaging doesn't really help me. It's just a good physical exam can reassure families. Um But I think we can reassure them just with a good discussion. When do I image well on the rare occasion a few times a year in a kiddo with a super high B. M. I. Um I can't feel anything and there's just no chance you're going to feel a testicle here. But M. R. I. Is going to tell you that there is a testicle and if the testicles here as opposed to the abdomen, that's going to change my approach. And so it helps me kind of plan for these occasionally tough kids with undescended testes. And that's been well shown in the literature. Just a little bit of terminology as a reminder. Um A retractable testes. It's a normal testis. If you biopsy it's normal uh it'll you can get into the scrotum, it stays there but it's a super bouncy. But by definition attract all testes is normal. So nothing is indicated in respect to other than just close follow up. No surgical indication and undescended testes is not normal. It's not in the correct spot. A retract. I'll flash or normal testes can become undescended. We call that an a sending testes. You can see why this can be confusing. So a sending or undescended testes that testis needs surgery. It's not going to get down there by itself. An ascending to texas. Uh as mentioned previously could have been retracted all there at slight risk to a cent. And typically when I see families and I'm very sure this is retracted and I say, you know if your pediatrician, if there's any issues if there's a question as your kids going through all the growth spurts come back and visit me because there's a rare risk. We think it's less than a few percent of that test is becoming a sending. And when we see that bi modal distribution of undescended testes, like why am I seeing a patient who's five was dismissed. The answer. No, it wasn't missed. This was a patient who had normal testes and one of them became an ascending testes. So our goal is to kind of get them to look like this, which sometimes is easier said than done. But in general, with our minimally invasive techniques and laproscopic cp so we can get super good dissection and get the test is in the right spot. Um We also have been using our minimally invasive approach for disorders of sex development for diagnostic purposes. Uh This is just a kiddo with inter abdominal testes. This is a kiddo with a street going add. Um In both DNE, when do we see this? Well, I think the most common way we see this now is a mom who gets to carry a type prenatally. It's X fly all the ultrasounds show a phenotype of a normal girl. The kids born phenotype is normal female sex. And that would be a diagnosis of what we would call Swire syndrome as I think you're aware of and um this is gonna handle this genesis. And these streets have about a 30 40% chance of developing gonna blast oMA slash cancer later in life. So these are removed. We've also been using laparoscopy a lot for diagnosis. And this is a patient with ovo testicular syndrome. What used to be called the truth from Aphrodite. So the go down is part testes in part ovary and with a high magnification of laparoscopy and ability to biopsy this has been super helpful. So here's a patient with peeping testes, testes that's right between being in the abdomen and inguinal canal. Um I tend to like to approach these laparoscopically because I think it's just an easier and better surgery. And these are just some of the steps to or cataplexy. Um Everybody thinks this is an earthquake in san Francisco or the barrier. But it's not. It's need putting the poured in through the scrotum because I've dissected out this inter abdominal testes. And my next maneuver is I'm gonna grab it through that portal. I put in through the scrotum and I'm gonna pull the testes out through the ports. Uh and get it settled in the scrotum so we can have a successful orchid of Pepsi. So that's now going to go into the poor house. Uh Swivel the poured out like I am doing here. And the testes will then be in the right spot after being able to do a nice um laproscopic dissection mobilizing it, inter abdominal right as I mentioned, we have been um taking care of these historical anomalies. I think the differential diagnosis of a kid who comes in uh you know with some junk on their belly button that's staining. Um You know the clothes. You know we worry about all kinds of things. And most of the time it's basically simply the belly button that's formed the the umbilical tissue after it's been the core has been clamped and cut in the a fallen off. It's basically just granuloma tissue that you can take care of with silver nitrate. But occasionally it's something else ultrasounds helpful to make that diagnosis. It could be kind of an intestinal duplication or remnant. Or we have your ankle cysts. And these are dealt with very nicely either robotically or lab roszke optically. This happens to be I think a little induct attachment with a bowel duplication which we can basically take off here and get rid of this extra stuff here and kiddos and on their way with no further issues. I wanted to again quickly mention disorders of sex development because we found that laparoscopy and now robotics has been very helpful for these severe patients who have congenital adrenal hyperplasia with very high um era general sinus what do I mean by that? When they're born they kind of look more male. Uh as opposed to female but insider ovaries, uterus vagina with basically one common hole here. Um We've been taking advantage of some nice three D. Reconstruction and then robotically we used to try to do all these surges from below. But now we can do a lovely dissection from above to basically mobilize the vagina and um separate. We're attaches to the urethra so now we can have a normal urethra and bring the vagina out to the skin for a normal perennial mm hmm.
