Leo Diguilio III

How surgical technology helped a boy recover in time to play baseball

Leo Diguilio III was looking at a lost summer. The Bradley Beach 12-year-old needed surgery to correct a common urological problem, and the procedure would normally require three to six months of recovery. That would mean no baseball this year for an active boy used to playing all summer. Happily, Leo’s season on the diamond was saved, thanks to forward-thinking doctors and the remarkable da Vinci surgical robot. Leo became the first pediatric patient to have his surgery done with the new robotic method at Monmouth Medical Center. Leo is the only child of Mary, 55, a project manager at Wakefern Food Corp., and Leo Jr., 52, who is in financial services. “He’s playing on a couple of baseball teams and he’s a junior lifeguard at the beach, so he’s having a great summer,” Mary DiGuilio reported happily in July. Last winter, however, that seemed unlikely.

Leo’s health problems began about two years ago, when he started to experience periodic bouts of stomach pain and vomiting. “He’d miss a few days of school on and off, and we thought it was a stomach virus—they were always going around,” says DiGuilio. This past school year, he missed a total of four weeks—a few days at a time—through February, and again his doctors always thought it was the flu. In February, however, the vomiting was so severe that Leo grew dehydrated. His parents took him to a hospital emergency room, where ultrasound scans revealed a blockage in his urinary tract. Leo was referred to Thomas S. Vates III, M.D., a pediatric urologist at Monmouth. “He knew what the problem was just by what they told him over the phone,” says DiGuilio.

“Leo had the classic symptoms of a condition called uretero-pelvic junction obstruction,” Dr. Vates explains. UPJ obstruction, as it’s commonly known, is a congenital malformation of the junction between the kidney and the ureter, the tube through which urine flows to the bladder. This blockage can result in kidney damage if not cleared in a surgical procedure called a pyeloplasty.

Normally, Dr. Vates would perform the pyeloplasty with open surgery. He would need to cut an 8- to 10-inch incision in the belly to remove the blockage, repair any damaged portions of the kidney and ureter, and then reattach them to restore normal urine flow. That would require a three- to five-day stay in the hospital on narcotic painkillers, followed by four to six weeks of recovery.

Dr. Ahmed, Dr.Esposito and Dr. Vates

But Dr. Vates had another option. He knew that the da Vinci robot could be used for minimally invasive pyeloplasty on preadolescent and adolescent patients. The operation is successful more than 90 percent of the time when done robotically, and “in terms of recovery, use of pain medication and length of hospital stay, all are significantly reduced with very good results,” Dr. Vates says. Because of Leo’s age and his robust activity level, Dr. Vates thought he’d be a good candidate for the new approach.

His parents jumped at the chance. “To tell him he’d be laid up all summer—we couldn’t see that if there was an alternative,” says DiGuilio. “The robotic operation is a proven procedure, and the quick recovery and lack of scarring would have outweighed any concerns about being the first.”

For the June 15 operation, Dr. Vates enlisted the help of two other urologists, Michael P. Esposito, M.D., and Mutahar Ahmed, M.D., who have a great deal of experience performing robotic surgery. “Dr. Esposito did most of the cutting and sewing, Dr. Ahmed did instrument placement and the major assisting, and I did very minimal assisting,” says Dr. Vates. “I am learning to use the robot in practice sessions, and it is a very interesting approach.”

“Instead of cutting through many layers of muscle, I made four keyhole incisions, each less than 8 millimeters wide, in Leo’s abdomen,” Dr. Esposito explains. Through these incisions, Dr. Ahmed inserted the surgical instruments and camera. Dr. Esposito performed the surgery from a console within the operating room. He donned a special visor to see a magnified, three dimensional image of the surgical site, and manipulated the instruments with fingertip controls.

The operation took about two hours, the same as an open procedure, says Dr. Vates. But instead of spending several days in the hospital, Leo had the surgery on a Monday and was back home Tuesday night. “He got better each day, and by Thursday he said he didn’t want pain medication anymore,” says DiGuilio.

“This procedure is becoming the gold standard of treatment for UPJ obstruction, and any child can have it done robotically,” says Dr. Esposito, who has performed about 50 pediatric pyeloplasties at other institutions. “We plan on developing the pediatric robotic program with Dr. Vates as he attains full proficiency with the robot. He’s fellowship-trained in pediatric urology, so he’s the one to provide care to kids.”

Leo DiGuilio ended up enjoying a summer full of normal 12-year-old fun—swimming, playing at the beach, bike riding and, of course, baseball. “He was thrilled to get back out there on the field,” says his mom. “In his first at-bat in his first game back, he hit a double, and when he got to second base you could see his smile all over the ball field.”

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