PubMed Health⌕ Search

Biomedical subjects

Steven G Docimo

Publications and source records attributed to Steven G Docimo.

At least 19 recordsLinked to original sources
PubMed2007

Minimally invasive surgery for urologic disease in children.

This article is a comprehensive review of the current indications and recent literature pertaining to laparoscopic techniques in pediatric urology. Basic concepts such as instrumentation, anesthetic considerations, and complications are reviewed. Specific techniques and indications are also explored. As the field of pediatric urology continues to expand, it still lags behind adult urology. With improvements in technology, however, and with new surgeons entering the field with a basic laparoscopic background, pediatric urologic laparoscopy continues to progress. Currently, procedures such as laparoscopic exploration for undescended testicles and laparoscopic nephrectomy are accepted as the 'gold standard', and are performed at most institutions. Other procedures, such as laparoscopic pyeloplasty and laparoscopic reconstructive surgery, have only recently been introduced and are primarily available at centers with surgeons experienced in laparoscopy. It is our hope that minimally invasive surgical approaches to urologic conditions will become available to all children and become commonplace at most institutions.

Child↗
PubMed2006

The cost-effectiveness of dextranomer/hyaluronic acid copolymer for the management of vesicoureteral reflux. 1: substitution for surgical management.

PURPOSE: We examined the cost-effectiveness of dextranomer/hyaluronic acid copolymer injection in patients who would otherwise undergo ureteral reimplantation. MATERIALS AND METHODS: A model for managing vesicoureteral reflux has previously been created. We now update the model to compare the costs of treating vesicoureteral reflux using standard methods (ie ureteral reimplantation after failed medical therapy) with the costs of dextranomer/hyaluronic acid injection. RESULTS: In the first scenario created dextranomer/hyaluronic acid injection is substituted for ureteral reimplantation when surgical intervention would be performed for treatment of breakthrough infection or failure of the reflux to resolve. For dextranomer/hyaluronic acid injection to have equal cost-effectiveness compared to ureteral reimplantation in this scenario success rates for dextranomer/hyaluronic acid injection would need to be 57.8% per ureter for patients with unilateral reflux and 75.3% per ureter for patients with bilateral reflux. However, if increasing grades of reflux require increasing volumes of dextranomer/hyaluronic acid, success rates would need to be 72.5% for patients with unilateral reflux and 93.8% for patients with bilateral reflux. In the second scenario created dextranomer/hyaluronic acid injection is repeated if it fails to resolve the reflux after the first injection. Success rates to obtain equal cost-effectiveness for the repeat dextranomer/hyaluronic acid injection would need to be 0%, 11.4% and 60.3% in patients with unilateral reflux if the respective success rates of the initial injection were 85%, 70% and 55%. Success rates for the second dextranomer/hyaluronic acid injection would need to be 0%, 29.1% and 76.7% per ureter in patients with bilateral reflux if the respective success rates of the initial injection were 85%, 70% and 55%. If increasing volumes of dextranomer/hyaluronic acid were required for increasing grades of reflux, a second dextranomer/hyaluronic acid injection would not be a viable option. CONCLUSIONS: Based on our results, dextranomer/hyaluronic acid injection may be more cost-effective than ureteral reimplantation for children who meet standard criteria for surgical therapy, especially for lower grades of reflux. If increasing grades of reflux require an increased volume of dextranomer/hyaluronic acid, then injection would likely be cost-effective only for grades I and II unilateral and bilateral reflux, and perhaps unilateral grade III reflux.

Child↗
PubMed2006

The cost-effectiveness of dextranomer/hyaluronic acid copolymer for the management of vesicoureteral reflux. 2. Reflux correction at the time of diagnosis as a substitute for traditional management.

PURPOSE: The use of dextranomer/hyaluronic acid copolymer has become increasingly popular as an alternative to ureteral reimplantation in the treatment of vesicoureteral reflux. We compared the cost-effectiveness of performing dextranomer/hyaluronic acid injection at the time of diagnosis of reflux to that of traditional management. MATERIALS AND METHODS: A model to estimate the costs of managing vesicoureteral reflux has previously been created. We updated the model to compare the costs of managing vesicoureteral reflux by traditional methods with the costs of managing reflux if dextranomer/hyaluronic acid injection is performed at the time of diagnosis. The success rate required for dextranomer/hyaluronic acid injection at diagnosis to be as cost effective as traditional management was estimated. We used 2 models of dextranomer/hyaluronic acid injection at diagnosis-injection at diagnosis proceeding to traditional management if injection failed (scenario 1), and injection at diagnosis proceeding to ureteral reimplantation if injection failed (scenario 2). RESULTS: If reflux is stratified by grade in scenario 1, for grades III, IV and V respective success rates of 88.5%, 66.6%, and 55.6% for unilateral reflux and 97.5%, 89.7% and 91.4% for bilateral reflux must be achieved to have equal cost-effectiveness to traditional management, while grades I and II reflux can never achieve equal cost-effectiveness. Stratified by grade for scenario 2, for grades III, IV and V respective success rates of 86.9%, 70.8% and 55.8% for unilateral reflux, and 97.6%, 89.8% and 89.8% for bilateral reflux must be achieved to attain equal cost-effectiveness compared to traditional management. In scenario 2 dextranomer/hyaluronic acid injection at diagnosis for grades I and II unilateral and bilateral reflux can never achieve equal cost-effectiveness compared to traditional management. CONCLUSIONS: Based on the results of this study, in most clinical situations dextranomer/hyaluronic acid injection at the time of diagnosis is unlikely to be as cost effective as traditional management of vesicoureteral reflux.

Adjuvants, Immunologic↗
PubMed2005

Bilateral single system ectopic ureters in a male infant.

Bilateral single-system ureteral ectopia is a rare congenital malformation. We report a case of a male infant with bilateral single-system ectopic ureters without diffuse hydronephrosis, vesicoureteral reflux, or a history of recurrent urinary tract infections. The patient presented for an evaluation of hydronephrosis associated with the upper pole of an apparently duplex left kidney detected by prenatal and postnatal ultrasonography. Cystoscopy revealed two ureteral orifices distal to the bladder neck with a dilated left upper-pole calix and no duplex kidney. No surgical intervention has been planned until his continence status has been clarified.

Humans↗
PubMed2005

Missed testis on laparoscopy despite blind-ending vessels and closed processus vaginalis.

Laparoscopy has become a preferred technique to evaluate a nonpalpable testis. It gives excellent visualization of the anatomy to differentiate a viable or absent testis. We present a case of an intra-abdominal testis that was missed on diagnostic laparoscopy. Despite a closed processus vaginalis, an absent vas deferens, and blind-ending vessels above the internal ring, the testis was missed.

Cryptorchidism↗
PubMed2005

Spontaneous perforation of congenital bladder diverticulum.

A traumatic rupture of the bladder in a healthy child is extremely rare and is usually not considered during evaluation of abdominal pain or sepsis. However, a delay in the diagnosis of bladder perforation can result in morbid and sometimes catastrophic outcomes. We report a delayed diagnosis of spontaneous rupture of a congenital bladder diverticulum in a previously healthy child. This case demonstrates that spontaneous bladder rupture may be a rare cause of abdominal complaints and sepsis when the etiology at first seems unclear.

Diverticulum↗
PubMed2005

Can ultrasonography or uroflowmetry predict which children with voiding dysfunction will have recurrent urinary tract infections?

PURPOSE: It has been suggested that in children with voiding dysfunction improper bladder emptying contributes to recurrent urinary tract infections (UTIs) and progressive renal scarring. Incomplete bladder emptying may be related to bladder-sphincter dyssynergia. Ultrasonography and uroflowmetry are used in the initial evaluation of many children with voiding dysfunction. We determine in children with voiding dysfunction whether incomplete bladder emptying has an important role in the pathogenesis of urinary tract infections and whether abnormal ultrasonography or uroflowmetry can predict which children are at increased risk of recurrent UTIs. MATERIALS AND METHODS: In this retrospective cohort study charts of 148 consecutive patients diagnosed with voiding dysfunction were reviewed for information regarding residual urine volumes on initial post-void ultrasound and the number of urinary tract infections on followup. Initial uroflowmetry curves were blindly reevaluated for this study. RESULTS: Considerable (greater than 10% predicted) post-void residual urine volumes were seen on 15% of ultrasounds, and 78% of uroflowmetry studies were characterized as abnormal. The volume of residual urine (corrected for age) showed a positive correlation with the number of UTIs occurring after the initial visit (r = 0.3, p <0.002). There was no correlation between an abnormal uroflow pattern and number of subsequent UTIs. CONCLUSIONS: Although increased residual urine on post-void ultrasound increases the risk of UTI recurrence in children with voiding dysfunction, it does not allow accurate identification of specific children at risk.

Adolescent↗
PubMed2005

Use of laparoscopy in pediatric urology.

The goal of laparoscopy is to minimize patient morbidity while maintaining successful outcomes. The use of laparoscopy in urology has grown significantly over the past 30 years. Its use has been slower to gain acceptance in pediatrics than in the adult population. Laparoscopic orchidopexies and nephrectomies are commonly performed and have become widely accepted as alternatives to open surgery, if not the gold standard. The more technically demanding procedures, such as laparoscopic pyeloplasty, laparoscopic-assisted bladder reconstruction, and laparoscopic ureteral reimplantation, tend to be performed at selected centers and have yet to achieve widespread acceptance. As laparoscopy is applied more widely in pediatric urology, its potential benefits and drawbacks will be clarified.

Journal Article↗
PubMed2004

Surgical management of children with urolithiasis.

The management of urolithiasis in children poses specific technical challenges that require planning before endoscopy and that affect the risks and outcomes of these procedures. The indications for operative intervention in children and adults are similar:infection, persistent symptoms of flank pain, nausea, and vomiting, as well as the failure to pass a ureteral stone after an appropriate trial of observation (3-6 weeks). Specific adjustments for performing extracorporeal shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, and cystolithotomy in children are discussed.

Child↗
PubMed2004

Laparoscopic assisted reconstructive surgery: a 7-year experience.

PURPOSE: Laparoscopic assisted surgery results in an improved cosmetic appearance by allowing complex reconstruction without a midline upper abdominal incision. We report technique and outcomes in patients undergoing laparoscopic assisted reconstruction during a 7-year period. MATERIALS AND METHODS: A total of 31 consecutive patients with a mean age of 14 years (range 1 to 36) underwent laparoscopic assisted reconstructive surgery through a lower midline or Pfannenstiel incision by a single surgeon (SGD) between June 1995 and July 2002. Diagnoses included myelomeningocele (17), sacral agenesis (2), posterior urethral valves (2), classic bladder exstrophy (5), complicated ectopic ureter with ureterocele (1) and quadriplegia due to trauma (4). A total of 29 patients had 39 continent stomas (antegrade continence enema [ACE] or Mitrofanoff) created as part of the reconstruction. One case was converted to an open procedure due to dense adhesions and was excluded from the study. Continent stoma construction included Mitrofanoff stomas created from appendix (17), ileum (3), sigmoid (5) and bladder (1), and ACE stomas from appendix (12) and ileum (1). Ten patients underwent concurrent Mitrofanoff and ACE procedures. Laparoscopy was used for lysis of adhesions, mobilization of colon and/or harvesting the appendix, nephrectomy in preparation for ureteral augmentation, division of pedicle for gastrocystoplasty takedown and harvesting of omentum for interposition. Bladder augmentation (15), bladder neck reconstruction (7), fascial sling (3), ureteral reimplants (1), revision of epispadias (2) and/or redo orchiopexy (1) were concurrently performed in 19 patients. Data were obtained through chart review and personal communication. RESULTS: Median hospital stay was 6 days (range 2 to 20). Mean followup was 32 months (range 3 to 57). Revisions were required in 3 stomas (7.7%) at a mean of 19 months (range 8 to 36) postoperatively. Minor procedures were required in 10 stomas (25.6%) consisting of indwelling catheterization, dilation, collagen injection and cystoscopy. Of the 39 stomas 37 (94.9%) were continent of urine and/or stool, and easily catheterizable at last followup. Adequate capacity and compliance were maintained in all augmented bladders. No patient experienced delayed small bowel obstruction or other sequela of abdominal adhesions. CONCLUSIONS: At almost 3 years of mean followup laparoscopic assisted reconstructive surgery offers functional outcomes at least equivalent to conventional open surgery in complicated cases with excellent cosmesis. Laparoscopic assisted surgery remains our approach of choice for children and adults who require lower urinary tract reconstruction with a continent catheterizable stoma.

Adolescent↗
PubMed2004

Cost analysis of laparoscopic versus open orchiopexy in the management of unilateral nonpalpable testicles.

PURPOSE: Laparoscopic exploration for the nonpalpable testicle (NPT) has been criticized for increased costs compared with primary inguinal/scrotal exploration, mostly due to high equipment costs and the need for open inguinal/scrotal exploration in many cases. We assessed costs associated with diagnostic laparoscopy vs inguinal/scrotal exploration followed by selective open or laparoscopic treatment for unilateral NPT to identify the most important factors that influence cost. MATERIALS AND METHODS: A comprehensive literature review determined the probabilities of intra-abdominal or inguinal nubbins, blind-ending vas/vessels and intra-abdominal or inguinal gonads in patients with unilateral NPT. The costs of anesthesia, equipment and operating room use were obtained from our institution or derived from the literature. A model was created using computer software to compare the costs of initial scrotal/inguinal approach or initial laparoscopic exploration in a theoretical population of boys with unilateral NPT. We established a set of assumptions and generated a series of 1-way sensitivity analyses to detect cost influencing parameters. RESULTS: Based on the probabilities of intraoperative anatomical gonadal findings, use of reusable laparoscopic equipment and encompassing the ultimate surgical procedure needed initial laparoscopic evaluation was less costly than initial scrotal/inguinal exploration by 69 US dollars on a population basis. One-way sensitivity analyses showed that initial laparoscopic exploration was less costly if the operative time of laparoscopic exploration did not exceed 19 minutes and the cost of disposable laparoscopic equipment was less than 147 US dollars. CONCLUSIONS: On a population basis initial laparoscopic evaluation of the clinically nonpalpable testicle has a cost saving advantage (69 US dollars) over initial inguinal-scrotal exploration when reusable laparoscopic equipment is primarily used, disposable equipment costs are kept low (147 US dollars or less) and operating room time for diagnostic laparoscopy are at national standards (19 minutes or less). These findings hold true for a wide range of probabilities and duration of inguinal exploration time. Given that all of these caveats are easily achievable, cost should not be used as a factor to bias against initial laparoscopic exploration.

Child↗
PubMed2003

The low scrotal approach to the ectopic or ascended testicle: prevalence of a patent processus vaginalis.

PURPOSE: The scrotal approach to undescended testis has been described using a high scrotal incision and including hernia repair. We describe an approach that uses a low scrotal incision with an inguinal incision if a patent processus is identified. We retrospectively reviewed the likelihood of a patent processus in children selected to undergo this technique. MATERIALS AND METHODS: A total of 56 consecutive patients determined by history and physical examination to have ectopic or ascended testes underwent orchiopexy using an initial scrotal approach for a total of 71 undescended testes. Inguinal surgery had previously been done in 5 testes, which were not included in patent processus analysis. Charts were reviewed for testicular position, need for inguinal incision and demographic data. RESULTS: Of the patients 16 (19 testes) were younger than 2 years, 19 (26 testes) were 2 to 6 years old and 17 (21 testes) were older than 6 years. In 20% of the patients an inguinal incision was made for a patent processus vaginalis. The incidence of a patent processus was 26% in those younger than 2 years, 15% in those 2 to 6 years old and 19% in those older than 6 years (p = 0.17). All patients had satisfactory scrotal placement with at least 1 followup examination. CONCLUSIONS: Children with ectopic or ascended testes on physical examination findings may be treated successfully via a low scrotal approach with only 20% requiring concomitant inguinal hernia repair through a standard inguinal incision. Overall 80% of the children avoided an inguinal incision. This technique has become our standard approach to these testes.

Child↗
PubMed2003

Dysfunctional elimination syndrome: is it related to urinary tract infection or vesicoureteral reflux diagnosed early in life?

OBJECTIVE: It has been suggested that urinary tract infections (UTIs) early in life predispose to dysfunctional elimination syndrome (DES). This study evaluated the relationship between early UTI, vesicoureteral reflux (VUR), and DES by comparing two cohorts of school-aged children. METHODS: The UTI cohort (n = 123) included children previously enrolled in a prospective treatment trial conducted between 1992 and 1997. All were diagnosed with a febrile UTI before 2 years of age. The comparison cohort (n = 125) included children who were evaluated for fever in the emergency department between 1992 and 1997, whose urine culture was negative. Dysfunctional elimination symptoms were compared in the two cohorts by having families complete a revised version of the Dysfunctional Voiding Scoring System. RESULTS: Completed questionnaires were received from 248 children. There were no significant differences in selected demographic or clinical characteristics between the two cohorts. DES was present in 22% and 21% of children with and without a history of early UTI, respectively. Among children with UTIs, 18% of those with VUR and 25% of those without VUR had DES. CONCLUSIONS: Dysfunctional elimination is common in a general pediatric population. Neither UTI nor VUR diagnosed before 2 years of age was associated with DES in school-aged children.

Child↗
PubMed2002

The effect of dysfunctional voiding on the costs of treating vesicoureteral reflux: a computer model.

PURPOSE: We created a computer model for evaluating the effect of dysfunctional voiding on the costs of managing vesicoureteral reflux in children. MATERIALS AND METHODS: The literature on vesicoureteral reflux was reviewed to create a set of assumptions regarding the epidemiology, likelihood of resolution, need for operative intervention, risk of infection and appropriate regimen for nonoperative surveillance. Recent literature describing the effect of dysfunctional voiding on the clinical course of vesicoureteral reflux was included in the model to compare the costs of treating vesicoureteral reflux in children with and without dysfunctional voiding. A 5-year management period was considered. RESULTS: Dysfunctional voiding in children with vesicoureteral reflux increased the cost of treatment per patient by 51.2%. The cost per patient increased with increasing grade in those with and without dysfunctional voiding. The difference in costs in the 2 groups increased from 18.7% for grade 1 reflux to 62.1% for grade 5. Sensitivity analysis was performed, in which the risk of urinary tract infection, rate of surgical resolution, incidence of dysfunctional voiding and discount rate varied. The cost in children with dysfunctional voiding remained higher in all scenarios studied, showing the robustness of the model. CONCLUSIONS: Dysfunctional voiding substantially increases the costs of treating children with vesicoureteral reflux due to the higher rate of urinary tract infection in children with dysfunctional voiding. Methods that would decrease the rate of urinary tract infection in children with dysfunctional voiding and vesicoureteral reflux would lead to a significant saving of health care dollars.

Child↗