30th ESPU Congress - Lyon, France - 2019

S24: MISCELANEOUS

Moderators: RafaƂ Chrzan (Poland), Jean Paul Capolicchio (Canada)

ESPU Meeting on Saturday 27, April 2019, 11:42 - 12:16


11:42 - 11:47
S24-1 (LO)

★ EXTENDED EXPERIENCE WITH A SPINAL ANESTHESIA PROGRAM FOR COMMON PEDIATRIC UROLOGICAL PROCEDURES

Venkata JAYANTHI 1 and Emmett WHITAKER 2
1) Nationwide Children's Hospital, Section of Urology, Columbus, USA - 2) Nationwide Children's Hospital, Columbus, USA

PURPOSE

Concerns regarding potential neurocognitive effects of general anesthesia (GA) prompted our institution to offer spinal anesthesia (SA) program as an alternative to GA. As a followup to our first report, we wish to present our extended experience with this program for a variety of common pediatric urological procedures.

MATERIAL AND METHODS

We prospectively collected data on all children undergoing SA at our institution since the inception of the program in Sept 2015. We recorded demographics, procedures, time required for placement of the SA, length of surgery, success of lumbar puncture, success of attaining adequate surgical anesthesia, need for supplemental systemic sedation, conversion to GA, and perioperative complications. We then queried the database for all children who underwent surgery by a pediatric urologist.

RESULTS

Since Sept 2015, 526 patients at our institution have undergone a procedure under attempted SA. 410 of them were performed by a pediatric urologist and make up this study population. 373/410 (90%) were able to have the procedure successfully completed under SA while 37 (10%) required conversion to GA. Reasons for conversion included an inability to place the spinal in 15, poor sensory/motor block in 17 and suboptimal surgical conditions in 5. Mean age at surgery was 7.8 months (0 – 38). Average anesthesia start time to procedure start was 17.7 minutes. Mean length of procedure was 37.8 minutes (0 – 100). Intraoperatively 75% received no supplemental sedation or medications. Cases successfully performed included circ/revision/concealed penis in 233, hypospadias in 38, hernia/orchidopexy in 76, cystoscopic procedures (diagnostic, valve ablation, ureterocele puncture, stent removal) in 19, and miscellaneous (vesicostomy/urachal cyst/ureterostomy) in 7. There were no airway manipulations and no intraoperative anesthetic or surgical complications.

CONCLUSIONS

Success rates of SA have increased from our prior report (84% vs 90%). SA allows for the majority of common urologic procedures to be performed without airway manipulation, GA or systemic sedation.


11:47 - 11:50
S24-2 (PP)

COMBINED SPINAL/CAUDAL CATHETER ANESTHESIA: EXTENDING THE BOUNDARIES OF REGIONAL ANESTHESIA FOR COMPLEX PEDIATRIC UROLOGICAL SURGERY

Venkata JAYANTHI 1, Kristen SPISAK 2 and Emmett WHITAKER 3
1) Nationwide Children's Hospital, Section of Urology, Columbus, USA - 2) Dayton Children's Hospital, Anesthesiology, Dayton, USA - 3) Nationwide Children's Hospital, Anesthesiology, Columbus, USA

PURPOSE

Spinal anesthesia (SA) is an established anesthetic technique for short outpatient pediatric urological cases. In order to avoid general anesthesia (GA) we began a program using a combined spinal/caudal catheter technique (SCC).

MATERIAL AND METHODS

We reviewed the charts of all patients scheduled for surgery under SCC and recorded age, diagnosis, procedure, conversion to GA/airway intervention, surgery time, neuraxial and intravenous medications administered, complications and outcomes. The SCC technique usually involved an initial intrathecal injection of 0.5% isobaric bupivacaine followed by placement of a caudal epidural catheter. One hour after the intrathecal injection, 3% chloroprocaine was administered via the caudal catheter to prolong the duration of surgical block. Intraoperative management included either continuous infusion or bolus dosing of dexmedetomidine to optimize surgical conditions.

RESULTS

Overall, 23 children underwent attempted SCC.  SA was unsuccessful in 3 patients and they were converted to GA.  The remaining 20 children all had successful SCC placement, and their average age was 16.5 months (range 3.3 – 43.8 mos.).  Surgeries performed included 11 open ureteral reimplantations, 2 first stage hypospadias repairs, 1 second stage hypospadias repair, 2 feminizing genitoplasties for congenital adrenal hyperplasia, and 1 open pyeloplasty.  Average length of surgery was 108 minutes (range 68 – 172 min). 13/17 (76%) did receive preoperative midazolam and 16/17 (94%) had continuous infusion of dexmedetomidine intraoperatively with boluses as needed. All SCC patients were spontaneously breathing room air during the operation and there were no airway interventions. Only one SCC patient received opioids intraoperatively. There were no intra or perioperative complications. 

CONCLUSIONS

SCC allows for complex surgeries to be performed exclusively under regional anesthesia, thus obviating the need for airway intervention, minimizing or eliminating the use of opioids, and avoiding known and potential risks associated with general anesthesia.  


11:50 - 11:56
Discussion
 

11:56 - 11:59
S24-3 (PP)

THE INDICATIONS DETERMINING CRITERIA FOR SURGERY OF RENAL ASYMPTOMATIC SIMPLE CYSTS IN CHILDREN

Rashit BAYBIKOV 1, Nail AKRAMOV 2 and Aydar ZAKIROV 2
1) Children's Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, Pediatric urology, Kazan, RUSSIAN FEDERATION - 2) Kazan State Medical University, Pediatric urology, Kazan, RUSSIAN FEDERATION

PURPOSE

Nowadays, there are no clear indications for surgical treatment of simple asymptomatic renal cysts (SARC) in children.

MATERIAL AND METHODS

We evaluated changing of the SARC in 145 patients (growth, volume/area/length of the cyst to the corresponding parameters of the kidney) using renal ultrasonography every 6 months from the date of detection throughout 2 years. Considering all the data, we designated a cyst growth ratio of the kidney (CGRK). CGRK can be calculated using the volume or area or length. The statistical processing of the case follow-up data of 145 patients showed no statistically significant differences between using CGRK based on the volume or area or length. Therefore, we have determined that the most simple and efficient way to calculate the CGRK is assessing it according to the length as the easiest measure we can get. The formula: CGRK = [LK2/LR2-LK1/LR1]×100%, where CGRK – the ratio of a cyst growth; LK is the size of the cyst length in mm; LR is the size of the kidney length in mm; 1 – baseline; 2 – data 12 or 24 months later. Having analyzed the literature data and present recommendations, we have developed indications for managing patient with renal cysts using CGRK.

RESULTS

Thus, surgical treatment is indicated if CGRK ≥ 5% and in case of the symptoms onset (pain, renal lump, infection, hypertension, or hematuria). If CGRK < 5% and patient is asymptomatic – observation continues. A computed tomographyserved as a method of differential diagnosis and was used before the surgical treatment. Using CGRK makes the SARC patients managing easier and more adequate. It shows the valid growing size of the cyst, but not the kidneys growing size.

CONCLUSIONS

Thus, the indication for the surgical treatment are not the size but the CGRK ≥ 5%, the symptoms onset and the cysts more than 30% of the kidney area.


11:59 - 12:02
S24-4 (PP)

UROLOGICAL ANOMALIES IN 546 DUTCH PATIENTS WITH ANORECTAL MALFORMATIONS: WHAT CAN WE LEARN FROM SCREENING METHODS?

Liesbeth L. DE WALL 1, Herjan J.J. VAN DER STEEG 2, Hilde KOUWENBERG 1, Barbara B.M. KORTMANN 1, Robert P.E. DE GIER 1, Ward J.H. GOOSSENS 1, Ivo DE BLAAUW 2 and Wout. F.J. FEITZ 1
1) Radboudumc, Pediatric Urology, Nijmegen, NETHERLANDS - 2) Radboudumc, Pediatric Surgery, Nijmegen, NETHERLANDS

PURPOSE

Screening for urological anomalies is advocated in patients with anorectal malformations (ARM). However, the extent and methods used differ with the complexity and within clinical guidelines. Our aim was to investigate the incidence of urological anomalies, the screening methods used and their urological treatment implications in complex versus less complex ARM-s.

MATERIAL AND METHODS

The medical records of 546 patients treated between 1983 and 2018 were evaluated retrospectively. ARM classification , screening methods used, implications for urological treatment and long-term outcome were studied. Perineal and vestibular fistula’s were considered less complex, all other, previously known as “higher” malformations, were considered complex.

RESULTS

Urological anomalies occurred in 57% and significantly more often in complex cases (82% versus 42%, p = 0.000).  The most common anomalies were hydronephrosis (27%), vesico-uretral reflux (VUR) (23%), urinary tract infections (21%) and lower urinary tract (LUT) dysfunction (19%). A voiding cystography(VCUG) and renal ultrasound were performed in 90%. VUR without hydronephrosis and with urological treatment implications occurred in 14%. LUT dysfunction with lumbosacral or spinal anomalies occurred in 28% of the complex cases versus 3% of the less complex malformations (p =0.000). Treatment invasiveness increased with the complexity of the ARM

CONCLUSIONS

Over 80 % of complex ARM-s have associated urological anomalies. In most patients both a renal ultrasound and VCUG were done with 14% VUR and subsequent implications despite a normal ultrasound. Urodynamic studies should be done in all complex cases with lumbosacral or spinal anomalies to promptly diagnose and treat neurogenic bladder dysfunction.


12:02 - 12:07
S24-5 (VP)

★ ROBOTIC APPROACH TO A RENAL ARTERY ANEURYSM IN AN EIGHT YEAR OLD CHILD

Venkat SRIPATHI 1, Thirumalai GANESAN 2, Rajiv PADANKATTI 3 and Margabandhu SARAVANAN 4
1) Apollo Children's Hospital, Department of Pediatric Urology, Chennai, INDIA - 2) Apollo Hospitals, Urology, Chennai, INDIA - 3) Apollo Children's Hospital, Pediatric Surgery, Chennai, INDIA - 4) Apollo Children's Hospital, Nephrology, Chennai, INDIA

PURPOSE

This video demonstrates the approach to a renal artery aneurysm in a severely hypertensive child with renal artery stenosis and a defunct kidney.

MATERIAL AND METHODS

An eight-year old female child presented with severe headache, bilateral papilloedema, MRI evidence of demyelination and accelerated hypertension which needed five drugs for normalisation. There was a bruit over the right renal area with a very high Plasma Renin Activity. Contrast Enhanced CT scan revealed a 4 cms aneurysm of the renal artery with a poorly functioning right kidney. Robotic nephrectomy was planned and the challenge was to access and clip a 5 mm stump of the juxta-aortic renal artery before safely handling the aneurysm. The aneurysm was found to be densely adherent to the anterior wall of the Infereior Vena Cava (IVC) and aorta. To expose the renal artery take off, the IVC had to be lifted after dividing and clipping the first and second lumbar veins. Once the renal artery was clipped the IVC could be rolled away from the aneurysm and renal vein clipped and divided. Residual attachments to the aorta were divided. The procedure was completed in 120 minutes with no blood transfusion. On follow-up eight weeks later, hypertension is under control with one drug and child is symptom free.

RESULTS

Freeing the IVC to approach the aorta and the renal artery take off involves meticulous dissection. We used the Da Vinci Robot to clip the renal artery stump and thereby safely dissect the aneurysmal attachments.

CONCLUSIONS

To our knowledge this is the first report of using robotic assistance to free the IVC and gain access to the aorta in a child with a renal artery aneurysm. The video demonstrates the steps employed


12:07 - 12:16
Discussion