ESPU Meeting on Thursday 25, April 2019, 15:58 - 16:46
Delphine DEMÈDE, Sébastien FARAJ, Marc BARRAS, Aurora MARIANI and Pierre MOURIQUAND
Hôpital Mère-Enfants, Paediatric Urology Groupe Hospitalier, Lyon, FRANCE
This overweighted agitated autistic adolescent had a straightforward circumcision under GA for recurrent preputial infections associated with urinary incontinence. The patient scratched his penis after surgery causing a huge hematoma and a retraction of the penile skin. This led to a revision in OR. But the same problem recurred despite various precautions to stop the patient touching his penis. The problem recurred again and we had to sedate the patient in intensive care unit for 4 days during which he bled from a stress gastric ulcer. The adolescent bang his head against the bed causing a scalp tear when sedation was progressively stopped … Eventually, the situation improved despite quite difficult separated parents (father anaesthetist ; mother nurse) who constantly criticized our management of the situation. This case raises an interesting discussion about surgery (even for minor procedures) in incontrolable patients.
Claudia KOH, Supul HENNAYAKE and Tamas CSERNI
Royal Manchester Children's Hospital, Paediatric Urology, Manchester, UNITED KINGDOM
The incidence of prostatic utricle in proximal hypospadias has been reported as up to 33%. A urethral catheter inserted to optimise repair may pass into the utricle. We present a case where a urethral catheter was inadvertently passed into a large undiagnosed urine-filled urticle, leading to postoperative complications.
MATERIAL AND METHODS
An 8Ch urethral catheter was inserted blindly with slight resistance at the posterior urethra at the beginning of a re-do second stage penoscrotal hypospadias repair, and the balloon filled after clearly identifying urine flashback. To aid the insertion of a suprapubic catheter, 120ml of normal saline was flushed through the urethral catheter until the “bladder” was palpable and the suprapubic catheter was placed by Seldinger technique. Both catheters were flushing and draining urine well intraoperatively. Postoperatively, there was urine leak around both catheters which were not draining.
Ultrasound showed a single fluid filled cavity believed to be the bladder. Fluoroscopic contrast study confirmed both catheters were in the same cavity and demonstrated the catheters' patency. Finally, surgical exploration was required, and revealed that both the suprapubic and urethral catheters were located in a large cystic prostatic utricle. The suprapubic catheter was replaced into the bladder and the urethral catheter was left in the prostatic utricle to aid the healing of the hypospadias repair.
Preoperative ultrasound or cystoscopic assessment may be considered before the repair of proximal hypospadias, especially if catheter insertion is problematic.
Alaa EL GHONEIMI
University Hospital Robert Debré, University Paris -Diderot, Department of pediatric Urology, Paris, FRANCE
Proximal hypospadias remains a challenging surgery with uncertain outcomes. We share a major complication of operated perineal hypospadias.
A boy was born with DSD 46XY/X0, perineal hypospadias, persistent significant Mullerian structure. He had many septic complications before surgery due to salpingitis at 3 and 7 months of age, that needed partial removal of Mullerian structures. One stage urethroplasty was done at age of 19 months (mai 2009), when he was free from infection (double face, transverse preputial island flap, Onlay-Tube -Onlay). The postoperative was smooth tell 18 months, until the appearance of UTI and severe dysuria. Cystoscopy showed “floating membranes” in the reconstructed urethra without any organic stenosis. He continued developing dysuria, local infection shortly improved after each calibration and disruption of the membranes. Pathology examination of the membranes was nonspecific. Many procedures were done to treat the recurrent phenomena of dysuria and the floating membranes at each cystoscopy: internal urethrotomy, supplementary removal of Mullerian structures, many dilatations under general anesthesia, local steroid treatment, augmenting the urethroplasty by a free graft at the suspected area of stenosis. Finally, we have decided to divert by perineal urethrostomy. Even with the proximal diversion he had again dysuria and finally developed macroscopic aspect of BXO that was confirmed by total skin biopsy.
The final treatment was removal of the urethroplasty and replacement by staged buccal mucosa graft. Since then the child had a smooth healing and 2 years of follow up without any recurrence of dysuria.
We believe that the phenomena of “floating membrane” in the reconstructed urethra should had alerted us, even without an organic stricture, of an early sign of irreversible inflammatory process and we would have saved years of dilatations, general anesthesia and recurrent severe dysuria. Another question to discuss, should an early total removal of Mullerian structures would have avoided the recurrent episodes of “infection”, “stagnation” “inflammation”?. The endoscopic aspect of different stages of inflammation will be shown.
Emilio MERLINI 1, R. DE CASTRO 1, M. IACQUINTA 2 and B. TADINI 1
1) Cittá della Salute e della Scienza, Division of Paediatric Urology, Turin, ITALY - 2) Clinica Petrucciani, Division of Paediatric Urology, Lecce, ITALY
Ureteral substitution may be partial or total and is generally secondary to inflammation, radiation, traumas tumors or, more frequently to jatrogenic damage to the delicate vascularization of the ureter. The bridging of a distal ureteric loss may be achieved mobilizing the bladder (psoas hitch) or using a Boari flap. When the ureter is to be substituted in its entirety a bowel loop , intact or reshaped according to Yang Monti can be used. The use of appendix is seldom reported in the literature, mainly for partial or total substitution of the right ureter. The total substitution of the left ureter with the appendix in a child has been reported in few cases.
A 2 yrs . old baby affected by high grade VUR in a single Left kidney had been treated conservatively since birth. At 2 yrs an endoscopic treatment was carried out that caused acute obstruction and renal insufficiency 3 days later, after failure of JJ insertion a trans trigonal reimplantation of the ureter was performed, but after 4 days again signs of acute renal failure occurred and a Lt ureterostomy was made .Six month later an undiversion was attempted using a psoas hitch and a Politano Leadbeter type of reimplantation ending in acute obstruction and a nephrostomy tube was inserted and the child referred to our hospital.
At surgery the left ureter was a solid tiny string ,PUJ was completely closed , so the need for a total ureteral substitution was clear. A long and straight appendix was found that was freed from the caecum together with a caecal cuff of tissue, Cecum was freed laterally in order to mobilize it medially. The mesoappendix was very carefully isolated as far as its origin obtaining a long meso with sound vessels. A tunnel was created under the sigmoid taking care to make it very large to avoid pressure over the appendiceal vessels or their kinking. The appendix was then brought under the sigmoid, reaching the left side of the abdomen. The tip of the appendix was cut longitudinally on the lateral aspect and a long anastomosis with the renal pelvis that had been opened on the medial aspect was performed.
The caecal cuff reached quite comfortably the bladder dome that was opened and a large anastomosis between the caecal cuff and the bladder was carried out. The anastomosis was minimally buried with a second row of stitches in a “Lich Gregoir “ fashion, paying much attention not to obstruct the appendix.
After removal of the JJ three months later the child voided normally without any sign of obstruction.
Sindh Institute of Urology & Transplantation, Department of Paediatric Urology, Karachi, PAKISTAN
Bilateral combined superior and inferior pubic ramotomies have been described as one of the options to facilitate secure midline closure in exstrophy patients. From a series of nine cases we describe a horrible complication occurring post ramotomy.
A 13m male with wide diastasis underwent a Kelly procedure with bilateral combined osteotomies. Mobilisation of the pubic bones to the midline was difficult requiring more extensive dissection however midline closure under some tension was achieved. On 8th postoperative day he developed a large incisional hernia with subcutaneous bowel loops and partial wound breakdown. The patient was re-explored through the lower abdominal midline incision. The rectus muscles and the attached bony (butterfly pubic bone) fragments were found completely detached from the obturators and retracted into the upper half of the abdominal incision. There was a large peritoneal defect below with bowel loops prolapsing through it. The bowel was returned and the peritoneal defect closed. The abdominal wall muscle gap was covered with the vicryl mesh. The skin was closed over the mesh in the midline from above the umbilicus to the base of the penis. Fortunately there was uneventful recovery.
In our limited experience of the above technique has many advantages. It doesn’t require additional incisions or the need for an orthopaedic surgeon as compared to the Saltar’s osteotomy as it can be performed by the same paediatric urologist and with the same exposure required for the Kelly or Kureel type of EEC repair. However, there is a learning curve which requires understanding of its limitations and the tolerance limits for mobilisation of the bony elements.
Riley Children's Hospital, Indiana University School of Medicine, Urology, Indianapolis, USA
Cloacal exstrophy is one of the most complex abnormalities that the pediatric urologist is called upon to manage. Despite the nearly universal need for a colostomy and frequent abnormalities of multiple other organ systems, surgeons have generally offered patients the option of creating a continent urinary reservoir with the stated aim of "improving patient quality of life".
Our patient is a boy born with cloacal exstrophy who at birth underwent closure of omphalocele and creation of an end ileostomy. The two bladder halves were approximated in the midline. Two years later he underwent bladder closure and creation of an appendicovesicostomy. A remarkable series of complications ensued. In the initial postoperative period the patient developed a midlinefistula to the bladder (#1). After six months an attempt was made to close the fistula without success. Two years later, the patient developedincontinence through the appendicovesicostomy (#2). Urodynamics demonstrated a small capacity, poorly compliant bladder. A decision was made to re-operate on his bladder and perform a bladder augmentation and a second continent catheterizable channel. In the postoperative period he developedcardiogenic shock (#3). At age six the patient developed a series ofsevere febrile urinary tract infections (#4). A scrotal abscess (#5)subsequently developed which grew the same organism cultured during the previous urinary tract infections. Over the ensuing three years he developed two additionalabdominal abscesses requiring incision and drainage (#6, #7)and aurinary fistula to the left hemiscrotum (#8).
After 12 operations, 8 major complications and over 140 days of combined in hospital stay; the family has elected to proceed with cystectomy and creation of an ileal loop. This case is representative of a large number of our cloacal exstrophy patients who, in an attempt to achieve urinary continence, have developed devastating complications and have required numerous additional operations.
We recommend that surgeons discuss the significant risks of achieving urinary continence in patients with cloacal exstrophy and strongly consider initial management of these complex patients with an ileal chimney or ileal loop.