ESPU Meeting on Friday 26, April 2019, 17:36 - 18:11
Bruno Nicolino CEZARINO 1, Roberto LOPES 2, Ricardo HAIDAR 2 and Francisco DENES 2
1) University of Sao Paulo, Urology, Sao Paulo, BRAZIL - 2) University of São Paulo Medical School, São Paulo, BRAZIL
INTRODUCTION AND OBJECTIVE
Well-known advantages of minimally invasive surgery (such as smaller incisions, decreased postoperative pain and faster return to normal activity) popularized this approach in the pediatric group. Recently, Gargollo (Gargollo, j.jurol.2010.11.054) first described a robotic approach using umbilicus and Pfannenstiel line to minimize visible scarring called hidden incision endoscopic surgery (HidES) with the obvious advantage of better cosmesis. We present a prospective evaluation of pure laparoscopy HidES nephrectomy, comparing with a matched retrospective cohort of traditional port placement (TPP) laparoscopic nephrectomy.
MATERIAL AND METHODS
Sixteen patients were submitted to HidES laparoscopic nephrectomy: a 5 mm port inside the umbilical scar, 5 mm port at the end of the virtual pfaneistiel line, ipsilateral to the kidney to be removed and a 10 mm port at the suprapubic position. To show non-inferiority of the surgical outcomes as long as better cosmesis, 45 patients age and sex matched submitted to TPP were evaluated.
Both groups were comparable in terms of gender, median age(p>0,05),median weight ( p>0,05), and laterality (p >0,05). No statistical difference was noted in terms of bleeding, operative time, admission, narcotic use and postoperative complications. HidES group had no conversions to classic laparoscopy or open surgery and no adittional port was needed during surgery. TPP group had 3 conversions due to bleeding and 1 accidental punction of a small mesenteric vein ( p>0,05).
Hidden incision endoscopic procedure can be reproducible with pure laparoscopy, being a safe and viable alternative to TPP. HidES is comparable to TPP regarding operative time, bleeding, narcotic administration, hospital stay and complication rate with improved cosmesis.
Istanbul University, Cerrahpasa Medical Faculty, Deptartment of Pediatric Surgery, Division of Pediatric Urology, Istanbul, TURKEY
Preputial flap urethroplasty is a described technique in EEC cases with short urethral plate. But it might be surgically challangic procedure especially in secondary cases. Presented modification (trick) gives a good solution to surgeon in this challenging situation.
First, both end of circumcission line preputial inner surface bring together and sutured with fine absorbable suture.
This manuever creates a epiteleal surface on dorsal face of vetrally located penil skin. Similar to double faced preputial urethroplasty in hypospadias repair, enough width and lenght flap is marked on this surface leaving the suture line on midline. Marked borders of the flap are incised and following a limited dissection from ventral skin both side are sutured.
This end up with a preputeal inner surface tube which connected to ventral penil skin. Proximal end of the tube is anastomosed to distal end of original urethra.
A few milimeter distal tip of neourethra dissected from the ventral skin. This part of neourethra is passed between corporeal bodies at the level of coronal sulcus and anastomosed the tip of glans.
Yutaro HAYASHI, Kentaro MIZUNO and Hidenori NISHIO
Nagoya City University Graduate School of Medical Sciences, Department of Pediatric Urology, Nagoya, JAPAN
Snodgrass et al mentioned that dorsal dartos flap or ventral based dartos flap is suitable to cover the TIP neourethra. Yerkes et al. employed a neourethral reinforcement method based on a spongiosum wrap and insisted that spongioplasty is more effective at covering the neourethra than a dartos flap because it is thicker and contains more vascular tissue. Regarding the spongioplasty procedure, Yerkes et al. and Beaudoin et al. proposed that reconstruction should be performed via the dissection of spongy tissue up to the exterior of the penis followed by its repositioning over the neourethra. Although we followed this method when we started the spongioplasty, we encountered difficulties with the repositioning of the bilateral spongy tissues over the neourethra. Therefore, we modified the original procedure by incising the Buck fascia at 3-4 mm lateral to the spongy tissue and positioning the resultant bilateral tissue wings consisting of the Buck fascia and spongy tissue over the neourethra. We would like to demonstrate our modified spongioplasty.
University of Chicago Medicine, Department of Paediatric Urology, Chicago, USA
The robot assisted laparoscopic reimplantation is getting popular in select patients. Unfortunately the ureteral dissection and suturing is crucial for success and preventing complications. There has been poor resources to learn this and has led to variable success rates and complications . I am planning to present the nuances based on experience over last 10 years of these procedures to optimize the success and reduce the complications.
Emilio MERLINI, C. CARLINI and A. PINI PRATO
S.S. Antonio e Biagio e Cesare arrigo Hospital, Division of Pediatric Surgery, Alessandria, ITALY
Buried penis comprises a spectrum of pathology, including primary and secondary buried penis; the most severe end of the spectrum is represented by buried penis with megaprepuce and difficulties in micturition. Features common to most cases of concealed penis are a tight phimosis and shortage of penile skin, especially on the ventral aspect. Other features include deficient attachment of penile skin to the corpora cavernosa and presence of dysgenetic dartos fibres.
Many procedures described for the treatment of buried penis start with circumcision. In our opinion the paucity of penile skin is further worsened by circumcision and therefore we prefer to treat this malformation avoiding circumcision.
Operation starts with an anterior midline vertical incision including both penile skin and the inner portion of foreskin. Penile shaft is the degloved, isolating corpora cavernosa from surrounding tissues, extending dissection well under pubis. Penile skin acquires a trapezoid shape with an obvious deficiency of ventral skin. The short upper side that is incised at the junction between inner and outer foreskin. Inner foreskin, that is usually redundant, is cut dorsally in the midline to match with the length of the penile skin. Inner prepuce and penile skin are sutured together on the dorsal aspect with three stitches to stabilize the foreskins. Penile skin is secured to the corpora cavernosa with four non reabsorbable 6/0 sutures in order to stabilize the penile skin to the corpora cavernosa. Two sliding flaps of inner foreskin are then rotated ventrally, generously trimmed to match the penile skin, sutured vertically in the midline and diagonally to the penile skin to cover the bare area of the penile shaft. A catheter is inserted for 24 hours to allow for a compressive dressing, the child is then discharged 24 hours later.
We have treated around 20 cases of buried penis according to this procedure with acceptable long term results and no major complication.
Hospital Italiano de Buenos Aires, Buenos Aires, ARGENTINA
The laparoscopic anastomosis of the Uretero Pyelic Junction in cases of UPJO is technically challenging. Different techniques to perform it have been described and almost every technical description includes the pexy of the Renal Pelvis with a stitch to the abdominal wall (Hitch Stitch) in order to stabilaze the Renal Pelvis and facilitate the exposure of the obstruction.
Once the stenotic segment is resected, a posterior and anterior wall of the Renal Pelvis and the Ureter to be anastomosed are presented.
The posterior wall is technically more complex since the suture must be done from within the anastomosis while the anterior border is easier since it is done from the outside. To facilitate the exposure and the approach of the posterior border, we place a second Hitch Stich at hour 6 of the anastomosis enabling the rotation of the same, exposing the posterior border to the anterior, allowing the surget to be made from outside with better visualization and less need to manipulate the tissues.
In our experience in more than 300 laparoscopic pyeloplasties this tip has made the technique simpler and easier to reproduce.
Riley Children's Hospital, Indiana University School of Medicine, Urology, Indianapolis, USA
The ideal management of the newborn with a large prolapsing ureterocele remains controversial due to the many treatment options that are available to the practitioner. Immediate, complete excision with ureteral reimplantation has for the most part been replaced by endoscopic means of decompression. The goal of endoscopic incision is to relieve obstruction of the kidney while avoiding not only vesicoureteral reflux but also the creation of a distal flap of tissue that can obstruct the bladder neck. To avoid these complications we propose a novel approach.
The patient is prepped in the dorsal lithotomy position. The ureterocele is visualized through the cystoscope and a Deflux® needle is used to first decompress the ureterocele and then fill it with radiographic contrast. The needle is then used to puncture the ureterocele between 10-25 times with subsequent dilation of the puncture sites with a 5 French open-ended catheter. In cases where there is proximal ureteral tortuosity and concern over complete upper tract drainage, a JJ stent is placed through one of the dilated openings into the renal pelvis under fluoroscopic guidance. The stent is removed 10 weeks later.
The technique of ureterocele fenestration serves to create multiple small openings that allow egress of urine from the ureterocele while at the same time preventing bladder urine from entering the ureterocele in a retrograde direction. As an adjunct to this technique we now place a double J stent through one of the puncture holes in cases where there is marked upper tract dilation with ureteral tortuosity. This management scheme has proven invaluable in providing reliable drainage while avoiding both vesicoureteral reflux and urethral obstruction. This technique has the potential to serve as the definitive treatment for even the most complex ureteroceles.