30th ESPU Congress - Lyon, France - 2019

VD: VIDEO DISPLAY

ESPU Meeting


VD-1 (VD without presentation)

THE KIDNEY THAT WASN'T

Anne-Sophie BLAIS, Douglas CHEUNG, Fadi ZU'BI, Martin KOYLE and Walid FARHAT
Hospital for Sick Children, Urology, Toronto, CANADA

PURPOSE

A14-year-old girl presented to the Emergency Room with intermittent stabbing pain at the left lower abdomen. The pain was occasionally associated with her menses. Upon investigation, she was found to have a non-functioning dilated large pelvic kidney with normal mullerian organs as described on the ultrasound. She was offered a laparoscopic nephrectomy. Herein we show a video depicting the surgical technique and the unexpected postoperative pathologic findings.

MATERIAL AND METHODS

Using a 3 trocar laparoscopic approach, a transperitoneal nephrectomy was done. We noted an unusual appearance to the kidney with abnormal appearing cystic structures and lobulations. As we dissected further medially, multiple small renal vessels arising from the iliac vessels were clipped and cauterized. On the lateral edge of the kidney, a tubular structure that appeared to be a bifid pelvis was transected. Since the kidney was too large to be placed within the EndoCatch bag, hence we attempted deflating the kidney by aspirating the fluid that looked like old blood. The operative time was 192 minutes.

RESULTS

No operative or postoperative complications were reported. However, the pathology revealed uterine, tubal and ovarian tissues. There was no renal tissue. The patient had normal menstrual cycles postoperatively and the abdominal pain she experienced before the surgery resolved. A postoperative ultrasound showed normal uterus and right ovary. The left ovary was not visualised. The patient was diagnosed with OHVIRA (obstructed hemivagina and ipsilateral renal anomaly) syndrome, a congenital malformation of the urogenital system. In our case, the apparent left pelvic kidney was in fact uterine duplication with an obstructed blind ending hemivagina and left renal agenesis. 

CONCLUSIONS

The diagnosis of OHVIRA was missed and should be considered in cases of a non-functioning dilated pelvic kidney in females who report pain upon menarche and with menses.


VD-2 (VD without presentation)

HARMONIC SCALPEL TECHNIQUE IN ADOLESCENT WITH NON COMMUNICATING HYDROCELE

Mark ZAONTZ 1, Christopher LONG 2, Thomas KOLON 3 and David BEN MEIR 4
1) The Children's Hospital of Philadelphia, Urology, Philadelphia, USA - 2) CHILDREN'S HOSPITAL OF PHILADELPHIA, UROLOGY, Philadelphia, USA - 3) CHILDREN'S HOSPITAL OF PHILADELPHIA, Philadelphia, USA - 4) SCHNEIDER CHILDREN'S HOSPITAL OF ISRAEL, UROLOGY, Nirit, ISRAEL

PURPOSE

Repair of a non communicating hydrocele is generally corrected by using either a "bottle" or "imbrication" technique. This video demonstrates a novel way to correct non communicating hydroceles using a harmonic scalpel technique. The harmonic scalpel has the advantages of completely sealing the encountered lymphatics and blood vessels and allows for trimming the tunica vaginalis around the testis. In this way there is minimal bulk remaining and the procedure can be done safely and quickly.

MATERIAL AND METHODS

In this series we have operated on 36 boys with a mean age of 14.6 years for non communicating hydroceles.

RESULTS

Mean follow up was 13.7 months. There were 2 complications which included 2 wound site seromas thought secondary to analgesic infiltration of the scrotal incision. there were no recurrent hydroceles and minimal post op swelling. As an added benefit we noted that there was minimal post op discomfort and rare need for narcotics.

CONCLUSIONS

We conclude that the harmonic scalpel hydrocele repair is a safe , effective and reproducible technique.


VD-3 (VD without presentation)

NEAR-INFRARED FLUORESCENCE ( NIRF ) IMAGING IN PAEDIATRIC 3D LAPAROSCOPIC NEPHRECTOMY

Ling LEUNG, Ivy Hau Yee CHAN, Patrick Ho Yu CHUNG, Kenneth Kak Yuen WONG and Paul Kwong Hang TAM
LKS Faculty of Medicine, The University of Hong Kong, Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, Hong Kong, HONG KONG

PURPOSE

Near-infrared fluorescence imaging using intraoperative indocyanine green (ICG) has numerous emerging clinical applications, including identification of hilar vessels of the kidney. In paediatric patients requiring nephrectomy, innocent moiety injury during heminephrectomy in duplex kidney and difficulty in locating multicystic dysplastic kidney have been reported. We present our initial experience of using ICG to facilitate nephrectomy in these patients.

MATERIAL AND METHODS

Patients who underwent laparoscopic total or heminephrectomy using NIRF in 2018 were included. Intravenous injection of ICG was given and NIRF was utilized to identify the affected moiety / kidney and the corresponding ureter. Patient demographics, surgical anatomy, indication for operation, peri- and post operative complications were studied. 

RESULTS

Two female patients were identified, with left duplex kidney ( Patient 1, aged 17 months ) and right multicystic dysplastic kidney ( Patient 2, aged 7 years ) respectively. Patient 1 presented with recurrent urinary tract infections, she was diagnosed to have impaired left upper moiety function and an obstructing intravesical ureterocele requiringprior transurethral incision at 7 months old. Patient 2 was antenatally diagnosed and non resolution of multicystic dysplastic kidney (measuring 6.5cm ) was noted. 3D Laparoscopic left upper moiety heminephrectomy and laparoscopic right nephrectomy were performed using NIRF imaging respectively. Hilar vascular anatomy can be delineated by NIRF in both patients. Perfusion of unaffected lower moiety was confirmed by fluorescence of the parenchyma after ligation of the upper pole vessels. Resection of the multicystic dysplastic kidney can be navigated by the fluorescence of its parenchymal components and vascular supply. There were no peri-operative complications, no urinary leaks or postoperative fluid collections.

CONCLUSIONS

Near-infrared fluorescence ( NIRF ) imaging using ICG in paediatric 3D laparoscopic nephrectomy was safe and feasible in paediatric patients with congenital urinary anomalies. It allows superior delineation of resection zones in duplex kidney and accurate localization of multicystic dysplastic kidney.


VD-4 (VD without presentation)

LAPAROSCOPIC URETEROURETEROSTOMY: AN ARROW IN THE QUIVER FOR THE TREATMENT OF DUPLICATION ANOMALIES OF THE URINARY TRACT

Luca MAZZONE, Tim GERWINN, Alice HÖLSCHER, Maya HORST, Daniel Max WEBER and Rita GOBET
University Children's Hospital Zurich, Pediatric Urology, Zurich, SWITZERLAND

PURPOSE

In some patients with duplication anomalies of the urinary tract, surgery is needed to treat obstruction or reflux. The most common approach is the double barrel ureteral reimplantation. Laparoscopic ureteroureterostomy (LUU) can be a valid alternative or a rescue procedure after failed reimplantation. Aim of the video is to present our experience with this technique.

MATERIAL AND METHODS

Charts of all children who underwent LUU (ipsi- and translateral) in our center from 2009 - 2018 were reviewed retrospectively.

RESULTS

Eleven ipsilateral LUU (in one patient bilateral) and one translateral LUU were performed in eleven patients. Median age at surgery was 14 months (range 7 -117months). Mean follow-up was 59 months (12-113 months). LUU was a primary procedure in eight patients (five with obstructive upper pole ureter, three with reflux in the lower pole ureter). In two patients, LUU was done after failed reimplantation and in one after cutaneous ureterostomy. Median operative time including cystoscopy was 185min (133-495min). Operative times diminished from mean 312min in the first five operations to mean 165min the latter six operations. There were no intraoperative complications. Two patients suffered an anastomotic leak, warranting nephrostomy placement in one. Median time to discharge was 6d (2-26d). Anastomotic stenosis did not occur. Two patient had a febrile UTI in the follow-up.

CONCLUSIONS

LUU was done safely and effectively in all patients. A learning curve was observed in regard of operation times. LUU should be considered as an option for the management of duplication anomalies of the urinary tract.


VD-5 (VD without presentation)

TRANSMESENTERIC LAPAROSCOPIC LEFT UPPER POLE PYELOPLASTY

Venkata JAYANTHI
Nationwide Children's Hospital, Section of Urology, Columbus, USA

PURPOSE

Upper pole ureteropelvic junction (UPJ) obstruction in complete duplex systems is relatively uncommon. We present a case of laparoscopic left upper pole UPJ dismembered pyeloplasty to highlight technical concepts for such complex repairs.

MATERIAL AND METHODS

A 4-month-old girl presented with urosepsis and an ultrasound showed pyonephrosis in the left upper pole. An urgent nephrostomy tube was placed to control the sepsis. A subsequent voiding cystourethrogram was normal and a renal scan showed preserved function but poor drainage of the left upper pole. 

At 6 months of age, using 3 mm instruments, laparoscopic repair was performed. A percutaneous holding suture was placed through the epiploic fat on the colon to lift the colon up and away which allowed for a transmesenteric approach to the upper pole. As the upper pole renal pelvis was small and intrarenal, pyelopyelostomy was not an option.  Another holding suture was placed in the upper pole pelvis to maintain exposure and access for the repair. The spatulated upper pole ureter was sutured to the upper pole pelvis with interrupted 5-0 polydioxanone suture and a double J stent left indwelling. No drain was placed but a foley catheter was left for one week, to minimize the potential for an anastomotic leak as the repair was not a water tight closure.

RESULTS

Postoperative imaging performed 6 weeks after surgery showed improvement in upper pole hydronephrosis and a renal scan showed preserved function and good drainage.

CONCLUSIONS

The video highlights several concepts to consider when performing complex laparoscopic renal surgery. Liberal use of percutaneous holding sutures can greatly assist with varied aspects of the procedure. A foley catheter left indwelling for an extended length of time may help prevent a urine leak and obviate the need for a perinephric drain


VD-6 (VD without presentation)

MICROPERCUTANEOS ENDOPYELOTOMY FOR RECURRENT PYELOURETERAL JUNCTION OBSTRUCTION

Alberto PARENTE, Ruben ORTIZ, Laura BURGOS and Jose Maria ANGULO
GREGORIO MARAÑÓN UNIVERSITY HOSPITAL, PEDIATRIC UROLOGY, Madrid, SPAIN

PURPOSE

Several techniques have proven effective in the management of recurrent pyeloureteral obstruction (PUJO). Percutaneous endopyelotomy shows better results in recurrent PUJO compared to primary PUJO. Micro-percutaneous approaches reduce damage to renal parenchyma and facilitate access to renal pelvis.

MATERIAL AND METHODS

In Valdivia position, a 5 or 6 mm high-pressure balloon is placed in the renal pelvis under cystoscopic and fluoroscopic guidance. The  4,8 or 8 Fr microperc puncture needle is placed into the pelvicalyceal system. After appropriate calyceal access, a three-way connector is placed to allow the 300 μm laser fiber (4,8 Fr) or 2,5 Fr monopolar hook (8 Fr) go through. Endopyelotomy is performed with laser fiber or monopolar hook over high-pressure balloon. In order to improve the exposure of the cutting area, the PUJ is introduced into the renal pelvis by pushing the high-pressure balloon. Double J stent is left for 4 weeks. 

RESULTS

Between July 2014 and July 2017, 5 patients with recurrent PUJO were treated in our hospital (4 months, 8m, 18m, 2 years, 4y). Patients presented UTIs with ultrasound deterioration (n=3) or loss of renal function in renogram (n=2). Operative time was 50±21 minutes. Hospital stay after surgery was 24 hours. Nephrostomy was not used. All patients were symptom free. Postoperative ultrasound and renogram showed that endopyelotomy was successful in all patients. We found no postoperative complications.

CONCLUSIONS

Micropercutaneous endopyelotomy is a fairly effective technique to treat recurrent UPJO after failed pyeloplasty in children. In our opinion, it reduces kidney damage without increasing complications.


VD-7 (VD without presentation)

CYSTOSCOPIC INJECTION SCLEROTHERAPY FOR BLADDER VENOUS MALFORMATIONS

Alexander CHO 1, Anand UPASANI 1, Alex BARNACLE 2 and Abraham CHERIAN 1
1) Great Ormond Street Hospital, Paediatric Urology, London, UNITED KINGDOM - 2) Great Ormond Street Hospital, Paediatric Interventional Radiology, London, UNITED KINGDOM

INTRODUCTION

Vascular-malformations of the urinary-bladder are rare in children and their treatment can be challenging. We present the minimally-invasive approach of cystoscopic injection sclerotherapy for the management of bladder venous malformations.

MATERIAL AND METHODS

A 13-year-old girl with Klippel-Trenaunay syndrome and a low-flow pelvic vascular-malformation presented with 5-weeks of frank-haematuria with episodic clot retention. She had previously undergone injection bladder sclerotherapy 18 months ago with no symptoms since.

Under general-anaesthesia, a diagnostic cystoscopy was undertaken. The foci of venous malformations were visualised as small blue exophytic malformations protruding toward the bladder lumen.

Sodium Tetradecyl Suphate (STS-3%) was utilised as a chemical sclerosant. The STS foam was generated by pumping 5mls STS in one syringe backward and forward into another syringe containing 5mls room-air through a two-way connector (Tessari-method).

Under cystoscopic vision using a STING scope (8/9Fr, 120-angled scope, R. Wolf), the primed 23G Deflux needle (Q-med AB, Uppsala, Sweden) was directed into the venous malformation. The needle was elevated after insertion to ensure that the STS does not enter the peritoneal cavity. The Deflux needle markings act as a guide for depth. Adequate sclerotherapy caused visible blanching as the foam displaced the blood from the veins causing sclerosis.

RESULTS

She was managed with simple oral analgesia, no urinary catheter and discharged within 24hrs. Her haematuria resolved within 12 hours with no recurrence after 3 months.

CONCLUSIONS

This minimally invasive approach of cystoscopic injection sclerotherapy is very successful in managing the complications of bladder vascular malformations and thereby avoids extensive surgery.


VD-8 (VD without presentation)

MIV HYPOSPADIAS REPAIR

Mark ZAONTZ 1, Christopher LONG 2 and Jason VAN BATAVIA 1
1) CHILDREN'S HOSPITAL OF PHILADELPHIA, UROLOGY, Philadelphia, USA - 2) CHILDREN'S HOSPITAL OF PHILADELPHIA, Philadelphia, USA

PURPOSE

This video revisits the meatal inversion V flap (MIV)hypospadias repair first described by Decter as an alternative to the MAGPI procedure.  This procedure shown is applicable in cases where the glans wings form a cleft like appearance into the midline as seen in the video. The M incision thus allows the meatus to "elevate" superiorly and to thus allows glans aproximation below the meatus to create a more normal appearance with a more distal meatus.  

MATERIAL AND METHODS

The records of all boys who underwent the MIV procedure were queried from April 2016 through October 2018. Twenty one boys with a median age of 9.2 months underwent the MIV repair. Four boys had 10-25 degrees of ventral penile curvature after degloving and were treated by a single dorsal plication suture in the midline as previously described by Baskin. A urethral stent was left in only 3 boys due to concerns of a hypoplastic urethra. The operative description is highlighted in the video.

RESULTS

There were no complications at a median follow-up of 4.1 months. In all 21 boys there was no evidence of meatal retraction with good positioning of the meatus within the glans.

CONCLUSIONS

The MIV glansplasty procedure is a safe, effective and reproducible technique for proximal glanular/coronal hyposapdias provided the glans configuation as described is present  


VD-9 (VD without presentation)

ROBOT ASSISTED LAPAROSCOPIC EXTRAVESICAL CROSS-TRIGONAL URETERAL RE-IMPLANTATION WITH TAILORING FOR OBSTRUCTIVE MEGA-URETER.

Amos NEHEMAN 1, Jonathan GAL 2, Leon CHERTIN 1, Jaudat GABER 3, Stanislav KOCHEROV 3, Amnon ZISMAN 1, Paul NOH 4 and Boris CHERTIN 3
1) Shamir (Assaf Harofeh) Medical Center, Tzrifin, ISRAEL - 2) Shamir (Assaf Harofeh) Medical Center, Surgical Urology, Tzrifin, ISRAEL - 3) Shaare Zedek Medical Center, Departments of Urology and Pediatric Urology, Jerusalem, ISRAEL - 4) Cincinnati Children's Hospital Medical center, Pediatric Urology, Cincinnati, USA

PURPOSE

In this video we describe a technique of robot assisted extravesical cross-trigonal ureteral re-implantation with intra-corporal tailoring of the ureter.

MATERIAL AND METHODS

We present a multi institutional study of 20 cases, in this video we describe the case of a 1y/o male who was diagnosed with a left mega-ureter prenatally. US scans showed dilation of renal pelvis and ureter (17mm), MAG3 Renal scan indicated 37% function of the left kidney with delayed drainage. 

The patient was placed in the supine position. A Foley catheter was inserted to allow bladder distention. Peritoneal access is obtained with the open Hasson technique. 12mm camera port at the umbilicus, 2 robotic 8mm ports and an assistant 5-10mm ports were placed under vision. The distal ureter was identified and dissected distally to the bladder were it is ligated and transected. Ureteral tailoring was performed over a 7FR UK and sutured with a 3-0 V-Loc™. A transverse trough of 4-5cm is created. Emphasis is made to dissect the detrusor to facilitate a tension free closure over the ureter. Bladder mucosa Is opened and uretero-vesical anastomosis is performed with interrupted 5-0 PDS sutures over DJ stent. Detrusor tunnel is closed incorporating the ureter between the mucosa and the detrusor. Water tight closer is verified.

RESULTS

Console time was 180 min. Patient was discharged on POD1, DJ stent was removed 4 weeks post operatively. Imaging showed improvement in hydronephrosis and renal drainage.

CONCLUSIONS

Robot assisted cross-trigonal ureteral re-implantation with intracorporeal tailoring is safe feasible and reproducible.


VD-10 (VD without presentation)

ROBOT-ASSISTED EMBRYOLOGICAL REMNANT RESECTION IN A 1 YEAR OLD BOY WITH DIFFERENCE OF SEXUAL DEVELOPMENT.

Mieke WATERSCHOOT 1, Ruben DE GROOTE 2, Elise DE BLESER 2, Martine COOLS 3, Erik VAN LAECKE 1, Piet HOEBEKE 1 and Anne-Françoise SPINOIT 1
1) Ghent University Hospital, Paediatric urology, Ghent, BELGIUM - 2) Ghent University Hospital, Urology, Ghent, BELGIUM - 3) Ghent University Hospital, Paediatric endocrinology, Ghent, BELGIUM

PURPOSE

Differences of sexual development are defined as congenital conditions associated with atypical development of chromosomal, gonadal, or anatomical sex. This video shows the robotic resection of a gonadal structure and underdeveloped uterus in a 1 year old DSD boy.

MATERIAL AND METHODS

A newborn diagnosed with 45,X/46,XY DSD was referred to our center for management of penoscrotal hypospadias and a non-palpable testis on the right side. Ultrasound demonstrated an uterus-like structure above the bladder. At the age of one year, a RA diagnostic exploration with concomitant resection was performed.

RESULTS

The child was positioned in a classical robot-adapted supine position. A transurethral catheter Charrière 8 was placed. The camera-trocar was placed in the umbilicus and 2 additional ports were inserted at the right and left mid-clavicular line. During inspection, a nubbin was found at the internal inguinal ring on the right-hand side. This gonadal structure was connected to the round band ligament with a uterus-like structure ending up blind onto the bladder. Total resection of the embryological remnants was performed. The postoperative recovery was marked by a urinary retention successfully treated with clean intermittent catheterisation.

CONCLUSIONS

RA resection of embryological remnants is safe and effective in children aged one year and older.


VD-11 (VD without presentation)

ULTRA-MINI PCNL WITH CLEAR PETRA®️ SUCTION-EVACUATION ACCESS SHEATH AND WARMING IRRIGATION FLUID SYSTEM (ROCAMED®️) FOR STONE TREATMENT IN CHILDREN

Anna BUJONS TUR 1, Erika LLORENS DE KNECHT 1, Sebastian TOBIA GONZALEZ 2, Guilherme LANG MOTTA 1, Yesica QUIROZ MADARRIAGA 1 and Joan PALOU 1
1) Fundació Puigvert, Pediatric Urology, Barcelona, SPAIN - 2) Children's Hospital "Sor Maria Ludovica", Pediátrica Urology, La Plata Buenos Aires, ARGENTINA

PURPOSE

Inadvertent perioperative hypothermia (a drop in core temperature to below 36°C) occurs because of interference with normal temperature regulation by anaesthetic drugs, exposure of skin for prolonged periods and receipt of large volumes of intravenous and irrigation fluids. If the temperature of these fluids is below core body temperature, they can cause significant heat loss. Warming irrigation fluids to core body temperature or above might prevent some of this heat loss and subsequent hypothermia and that is the function of ROCAMED®.

MATERIAL AND METHODS

The video describes prone ultra mini PCNL with Clear Petra® sheet under ROCAMED® system in a 15 month-old boy with a 2cm - 600HU staghorn calculi and one stone of 7mm - 500HU in proximal ureteric.

RESULTS

The surgery was performed without intraoperative complications and perioperative hypothermia was prevented. The patient started the surgery at 35.4 ° C and the final temperature was 36.3 ° C in 60 minutes of procedure, in addition to being free of stones.

CONCLUSIONS

The ROCAMED® system is effective in preventing inadvertent perioperative hypothermia in children, improving the safety of ultra mini PCNL with Clear Petra® sheet and showing promising results with high stone-free rates and low complications.


VD-12 (VD without presentation)

SUPER-MINI PERCUTANEOUS NEPHROLITHOTOMY (PCNL) IN PAEDIATRIC STONE DISEASE.

Eleni PAPAGEORGIOU 1, Alex BARNACLE 2, Simon CHOONG 1 and Naima SMEULDERS 1
1) GREAT ORMOND STREET HOSPITAL FOR CHILDREN NHS FOUNDATION TRUST, DEPARTMENT OF PAEDIATRIC UROLOGY, London, UNITED KINGDOM - 2) GREAT ORMOND STREET HOSPITAL FOR CHILDREN NHS FOUNDATION TRUST, DEPARTMENT OF INTERVENTIONAL RADIOLOGY, London, UNITED KINGDOM

INTRODUCTION

Super-Mini-PCNL (SMP) is advocated in children for renal stones less than 2.5cm, unsuitable for Extracorporeal Shock Wave Lithotripsy (ESWL) or difficult anatomy. In this video we demonstrate two SMP systems: the Hawk® and the Clear-Petra Wellead ®.

MATERIAL AND METHODS

Prospective cohort (March 2017-October 2018).

Technique: After initial cystoscopic insertion of a 5F-Pollack ureteric-catheter (Cook®) over a 0.035Fr Sensor-guidewire (Boston Scientific®) and urethral catheterization, the patient is positioned prone. The desired calyx is accessed under ultrasound guidance using a 5Fr Kellett-needle (Cook®) and the tract serially dilated to 14Fr (Cook®) under fluoroscopic control after wire-exchange (0.035Terumo, Radifocus®  to Sensor, Boston Scientific®). A second guidewire (0.035Sensor, Boston Scientific®) is placed via a 10Fr flexi-tip dual-lumen ureteric catheter (Cook®). Nephroscopy is performed by 7Fr nephroscope for the Hawk® system and by 6/7.5Fr semi-rigid ureteroscope (R.Wolf®) for the Clear-Petra. Lithotripsy is performed by Holmium-YAG-Laser (Cook®) using a high-frequency-low-energy setting. With the sheath-tip placed in proximity, stone fragments are cleared through suction connected to the short-arm of the Y-sheath in both systems. For advancement of the Clear-Petra-sheath within the pelvicalyceal system, the trocar should be replaced to avert infundibular injury. In the absence of hydronephrosis or haematuria, SMP is undertaken tubeless.

RESULTS

The two different systems are illustrated using the 8 SMPs undertaken in 2017-2018 in 7 children, aged 3-15 years, 4 Clear-Petra-Wellead® and 4 Hawk®, for stones (6-18mm) unsuitable for ESWL, instead of RIRS (Retrograde Intra-Renal Surgery), used alone or in combination with standard PCNL.

CONCLUSIONS

This video demonstrates the equipment and technique for SMP in paediatric stone disease.


VD-13 (VD without presentation)

AUTOLOGOUS FAT GRAFTING WITH STEM CELLS TRANSPLANTATION IN AN EXSTROPHIC PATIENT. A CASE REPORT

Anna BUJONS 1, Yesica QUIROZ 1, Erika LLORENS DE KNECHT 2, Guillherme Lang MOTTA 1 and Joan PALOU 3
1) Fundacio Puigvert, Paediatric Urology, Barcelona, SPAIN - 2) Fundacio Puigvert, Barcelona, SPAIN - 3) Fundacio Puigvert, Urology, Barcelona, SPAIN

PURPOSE

Adipose tissue is a reservoir of mesenchymal stem cells that can produce different types of cellular lines, managing architectural remodeling and loose connective regeneration when it's used in scars. Co-transplantation of adipose derived stem cells is an alternative therapeutic approach to enhance the survival and quality of transplanted fat tissue by increasing neovascularization. Lipofilling has been implemented in plastic surgery for breast reconstruction and treatment of burns. The use of the minimally invasive technique would allow treatment of hypertrophic scars and depressed suprapubic area in exstrophic patients to improve the aesthetic appearance of them.

MATERIAL AND METHODS

This video presents the case of a female 16 year old patient of with bladder exstrophy, who initially had an urinary reconstruction with ureterosigmoidostomy and posteriorly bladder augmentation and Mitrofanoff, with a hypertrophic scars and depressed abdominal wall in suprapubic area. We present this procedure for autologous fat grafting with stem cells in the abdominal area.

RESULTS

The lipofilling procedure was carried out successfully, without intraoperative complications in 120 minutes. The liposuction was 250cc and 80cc was used for injection, achieving the improvement of the aesthetic appearance of the scars in a short time. The imaging control was follow up with abdominal wall ultrasound, three months later, increasing its thickness by 42%.

CONCLUSIONS

The autologous fat grafting with stem cells is a safe and feasible procedure in the exstrophic population, with excellent aesthetic results, but we need long term follow up to determine how long the effect of fat grafting remains.


VD-14 (VD without presentation)

ULTRA - MINI PERCUTANEOUS NEPHROLITHOTOMY WITH CLEARPETRA® SHEATH AND HEATED SALINE CONTINUOUS IRRIGATION IN CYSTINE PATIENT.

Anna BUJONS, Luis LADARIA, Erika LLORENS DE KNECHT, Yesica QUIROZ and Guillherme Lang MOTTA
Fundació Puigvert, Paediatric Urology, Barcelona, SPAIN

PURPOSE

The gold standard treatment for stones up to 2cm in renal pelvis is percutaneous nephrolithotomy. Considering the risk of surgical morbidities, advances in technology and smaller access have made minimal invasive treatments possible. The reduced access (<20Fr) worsens visibility and fragment extraction. New percutaneous access sheath ClearPetra® allows 14Fr access and continuous aspiration to solve these difficulties.

Saline continuous irrigation decreases intraoperative body temperature which can lead to hypothermia with several consequences for pediatric patients. Endoflow Rocamed® system allows heated irrigation which solves this problem.

MATERIAL AND METHODS

In Valdivia's position (supine), a fluoroscopy guided percutaneous punction was performed with Chiba's needle in a fifteen year old child. Tract was dilated using Amplatz dilators from 8 to 14 French (Fr). After placement of ClearPetra® sheath (12/14Fr), 9,8Fr nephroscope was used to visualize the pelvicalyceal system. Stone fragmentation was achieved with 120W Holmium laser Lumenis® . ClearPetra® sheath with continuous aspiration allowed correct visibility and the extraction of cystine fragments. During the procedure we used heated saline continuous irrigation with Endoflow pump (Rocamed®) to maintain corporal body temperature between 36 and 37 Celsius grades. A nephrostomy catheter was placed

RESULTS

Surgical time was 180 minutes without intraoperative complications. A double J stent was placed. Cristalographic analysis demonstrated cystine lithiasis. No residual stones were found in x-ray control.

CONCLUSIONS

Ultra-mini perc with ClearPetra® access sheath and continuous aspiration is feasible, save and present minimal complications with stone free rates, and also offers correct visibility in spite off limited access. Endoflow heated irrigation system prevents hypothermia and reduces its risks for the patients.


VD-15 (VD without presentation)

BURIED PENIS CORRECTION: MIDLINE INCISION ROTATION FLAPS (MIRF)

German KOZYREV, Dina MANASHEROVA, Fuad ABDULLAEV and Vasily NIKOLAEV
Russian Children's Clinical Hospital, Department of Urology, Moscow, RUSSIAN FEDERATION

PURPOSE

In the presented video, our objective was to demonstrate a personal technique used for a buried penis repair in a 1-year-2-month-old child.

MATERIAL AND METHODS

The main distinction of this technique from other well-known ones is the midline incision on the volar surface of the penis and a circular incision on corona of glans penis, which serves as a universal approach; degloving and preparation of skin flaps with their rotation to substitute the skin defects on the volar surface (Midline Incision Rotation Flaps – MIRF).

RESULTS

In early and 1 year follow-up, the patient had successful results of the treatment – cosmetic result was close to nature, no scarring and edema were present.

CONCLUSIONS

The developed method of buried penis correction allows to get successful both cosmetic and functional results, and decrease the number of post-operative complications, preventing re-burying of penis and skin lymphostasis.


VD-16 (VD without presentation)

ADVANCEMENT URETHROPLASTY WITHOUT DISMEMBERING URETHRA SPONGY BODY AND GLANS PENIS

Nail AKRAMOV, Aydar ZAKIROV and Elmir KHAERTDINOV
Kazan State Medical University, Pediatric urology, Kazan, RUSSIAN FEDERATION

PURPOSE

There are known special urethral advancement techniques for the distal hypospadias type. They do not include suturing the urethra, which makes the risk of complications comparatively low. Beck in 1898 presented such method. But it's not popular today because of meatostenosis. We demonstrate modified technique that helped us to reduce postoperative complications.

MATERIAL AND METHODS

A 2 years old boy with distal type of hypospadias – distal penile, without chordae. Meatus was opened 8 mm proximal of the glans tip. Incision was made around the meatus with surrounds tissues 2-3 mm. A tourniquet was applied to the base of the penis. Mobilization of the urethra spongy body was started from the middle. We marked special rule – 1 cm of spongy body mobilization allows to advance the meatus distally by 2 mm. Consequently, in this case 4 cm mobilization was required. The urethra was totally dismembered from the cavernous bodies except distal splitted part of the spongy body. This part was saved as the pedicles, and urethra became more movable. There is no need of tunnelisation of the glans. Spongioplasty was performed to cover distal urethra after the latter was fixed in new position. Remaining tissues were sutured in a reverse order. For urinary diversion transurethral catheter was used. Dressing of the penis was not used (optional).

RESULTS

Total operating time was 94 minutes. Diversion catheter was removed 7 days later. Wound healing and functional results were good.

CONCLUSIONS

This modified advancement urethroplasty is a good alternative for treating distal hypospadias.


VD-17 (VD without presentation)

TRANSPERITONEAL LAPAROSCOPIC PYELOPLASTY IN A SIX MONTHS INFANT WITH A RETROCAVAL URETER

Ismail YAĞMUR 1, Bülent KATI 2, Eyyüp Sabri PELIT 3, Mehmet Ogur YILMAZ 3, Halil ÇIFTÇI 3 and Ercan YENI 3
1) Harran University School of Medicine, Urology, Pediatric Urology, Şanlıurfa, TURKEY - 2) Harran University School of Medicine, Urology, Şanlıurfa, TURKEY - 3) Harran University School of Medicine, Urology, Şanlıurfa, TURKEY

PURPOSE

Retrocaval ureter is a rare urinary anomaly. Open or laparoscopic surgery is preferred in the treatment. Due to the rare occurrence of the anomaly, the number of cases undergoing laparoscopic repair is very few in the literature. In this video presentation; We aimed to present a laparoscopic corrective surgery performed in the case of a six-month infant with retrocaval ureter.

MATERIAL AND METHODS

Case:Physical examination revealed a palpable kidney on the upper right side of the abdomen due to antenatal hydronephrosis. The ultrasonography; There was Grade 4 hydronephrosis, anteroposterior diameter of the renal pelvis 52 mm, parenchyma thickness 2.2 mm in the right kidney. Right percutaneous nephrostomy was performed in the case. Retrocaval ureter was suspected on the presence of an inverted J finding on the antegrade pyelograph. Laparoscopic transperitoneal pyeloplasty was performed as a corrective surgery.

CONCLUSIONS

The preference of laparoscopic approach for infants with suspected retrocaval ureter provides both minimally invasive and safe surgical procedures.


VD-18 (VD without presentation)

LAPAROSCOPIC TRANSPERITONEAL PYELOLITHOTOMY IN A CHILD WITH HORSESHOE KIDNEY AND NEPHROLITHIASIS

Ismail YAĞMUR 1, Eyyüp Sabri PELIT 2, Bülent KATI 2, Eser ÖRDEK 2, Halil ÇIFTÇI 2 and Ercan YENI 2
1) Harran University School of Medicine, Urology, Pediatric Urology, Haliliye, TURKEY - 2) Harran University School of Medicine, Urology, Şanlıurfa, TURKEY

PURPOSE

It is aimed to present laparoscopic transperitoneal pyelolithotomy applied in a case of 8 years old girl with a 12 milimeters stone in the left kidney, accompanied by horseshoe kidney and have unsuccessful medical history of Extracorporeal Shock Wave Lithotripsy (ESWL) and Retrograde Intrarenal Surgery (RIRS).

MATERIAL AND METHODS

Using a 3-trocar laparoscopic procedure was applied. Transperitonel aproach was preferred.

RESULTS

The renal stone was extracted using laparoscopic tecnic. Patient was discharged without any complications after three days postoperatively.

CONCLUSIONS

Laparocopic approach can be performed safely in experienced centers in cases in which classical treatment methods such as ESWL and RIRS have failed and urinary system anomalies such as horseshoe kidneys.


VD-19 (VD without presentation)

PREPUTIAL RECONSTRUCTION IN DISTAL HYPOSPADIAS REPAIR - A NEW TECHNIQUE

Jerzy CZYŻ
Warszawski Szpital dla Dzieci (Warsaw Hospital for Children ), Paediatric Surgery, Warszawa, POLAND

PURPOSE

The aim of the hypospadias repair is to restore the normal appearance of the penis. That’s why foreskin preservervation and reconstruction has become a necessary part of the hypospadias surgery. However, in most cases simple reapproximation of the cleft skin margins usually does very little for the final appearance. If the purpose of penile surgery is “normality” it was necessary to develop a technique which fulfil the promise. The video presents the most important steps of the new technique.

MATERIAL AND METHODS

A total number of 562 boys aged from 6 months to 12 years underwent one-stage hypospadias repair with full foreskin reconstruction. TIP, Thiersch-Duplay, Mathieu and Beck procedures were used in 454 88, 6 and 14 cases respectively. The technique consisted of full separation of external and internal preputial laminae and 3-layered reapproximation of the foreskin. Care was taken to equalize the length of dorsal and ventral aspect of the reconstructed prepuce and form a bottle neck-like appearance.

RESULTS

Most patients without complications presented with excellent cosmesis and normal, uncircumcised penis look. Foreskin related complications (preputial fistula or foreskin dehiscence) were noted in 49 cases (8.7%). Secondary phimosis developed in 10 patients (1.8%) and was succesfully treated conservatively with topical steroids.

CONCLUSIONS

Since the distal hypospadias may be regarded as mostly cosmetic defect, proper technique selection is extremely important. Presented technique of preputial reconstruction is feasible in most cases undergoing one-stage hypospadias repair and allows to get a normal look. It must be borne in mind however, that foreskin reconstruction increases an overall complication rate but improved final effect should withstand the test of time.


VD-20 (VD without presentation)

POSTERIOR AND ANTERIOR SAGITTAL ANORECTOPLASTY APPROACHES IN GENITOURINARY ANOMALIES IN CHILDREN

M S ANSARI
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Pediatric Urology, Department of Urology and renal transplantation, Lucknow, INDIA

PURPOSE

Here in the authors present their experience with Posterior [PSARP] and anterior sagittal anorectoplasty   [ASARP] in various genitourinary anomalies.

MATERIAL AND METHODS

Records of pediatric patients with various genitourinary anomalies who underwent PSARP and ASARP for rectourethral fistulae [RUF] both acquired and congenital, RUF  with posterior urethral stricture, RUF with posterior urethral diverticulum, duplication of urethra and rectovestibular fistula were reviewed. The results were reviewed in terms of feasibility and outcome of the two techniques in these conditions.

RESULTS

Between January 2008 to June  2016, 10 patients with a median age of  5.8 yrs underwent PSARP [n=6] and ASARP [n=6]. The indications were  RUF  [7], RUF  with posterior urethral stricture [1], RUF with posterior urethral diverticulum [1], duplication of urethra and rectovestibular fistula [1].   2 patients had recurrence of RUF in   PSARP group who were successfully managed with ASARP approach. None had urinary or faecal incontinence.

CONCLUSIONS

Both PSARP and ASARP gives direct access to RUF sparing the external urinary sphincter area. ASARP provides additional advantage of dealing with associated posterior urethral abnormalities like stricture urethra, diverticulum, duplication of urethra and rectovestibular fistula avoiding trans-sphicteric approach.


VD-21 (VD without presentation)

UPPER LIP GRAFT (ULG) FOR REDO URETHROPLASTIES IN CHILDREN. A STEP BY STEP VIDEO

Tariq ABBAS, Santiago VALLASCIANI, Bruno LESLIE, Abderrahman EL KADHI and Joao Luiz PIPPI SALLE
Sidra Medical and Research Center, Pediatric Urology Division, Doha, QATAR

PURPOSE

Lower lip and cheek are commonly used sources of buccal mucosa grafts for urethroplasty. In recent years, aiming to improve the donor site morbidity, our preference changed to the use of Upper Lip Graft (ULG). The aim of this video is to illustrate the technical details of the ULG harvesting for children

MATERIAL AND METHODS

The perioral area is cleaned and two stay sutures are placed in order to expose the inner surface of the upper lip. Having the midline frenulum spared, the area of mucosa to be harvested is then delineated with marking pen and local submucosal infiltration is done with a solution of bupivacaine plus epinephrine. The edges are incised ant the submucosa plane created with a scissor. The graft is detached, defatted, and then applied with quilting stitches over the recipient site with the standard technique. Hemostasis is secured and the donor site is left open.

RESULTS

From 2015 to 2018, 25 ULG harvests were done in 24 patients. Only one (5%) presented local pain associated to the procedure in the first 24 hours. After minimum 2 months after surgery, none of the patients presented perioral nubmness, difficulty with mouth opening, contraction of the donor site or changes in salivation.

CONCLUSIONS

ULG harvest is easy and a suitable alternative source of oral mucosa for urethroplasty in children.


VD-22 (VD without presentation)

INTRACORPOREAL URETERAL TAPERING REPAIR BY LAPAROSCOPY AND LICH-GREGOIR REIMPLANTATION FOR PRIMARY OBSTRUCTIVE MEGAURETER IN CHILDREN

Arnaud CIMIER
CHU Saint-Etienne, Pediatric surgery, Saint-Priest-En-Jarez, FRANCE

PURPOSE

Laparoscopic-assisted extravesical ureteral reimplantation and extracorporeal ureteral tapering was previously reported in 2017 for the treatment of primary obstructive megaureter (POM).  We recently modified this technique by performing a full intracorporeal laparoscopic ureteral tapering (LIUTR). We reported our early experience with the first two cases.

MATERIAL AND METHODS

Two females aged 15 and 23 months with POM underwent LIUTR in our department in 2018. They both had recurrent febrile urinary tract infections and decreased relative renal function on the side of POM. The surgeon was positioned at the head of the patient. Surgery was performed using a 5mm-30° telescope and two 3mm trocars. The dilated ureter was dissected and sectioned at the level of the uretero-vesical junction. A JJ stent was inserted in the ureter by laparoscopy. A 7cm long ureteral tapering was performed by laparoscopy using a 5/0 continuous suture.  Vesicoureteral anastomosis was carried out after opening the bladder mucosa, by two continuous 5/0 sutures. Extravesical ureteral reimplantation by following Lich Gregoir technique was done. The ureter was placed in the new tunnel, and the detrusor muscle was reapproximated with absorbable sutures. The stent was removed at 6 weeks postoperatively.

RESULTS

LIUTR was completed successfully in both patients without conversion. The operative time was 284 and 224 minutes, respectively.  Both patients were discharged on post-operative day 1.  Both children were asymptomatic with no recurrent febrile UTI after 1 months and 3 months.

CONCLUSIONS

LIUTR may represent a valid treatment of POM, without inconvenient associated with extracorporeal tapering.


VD-23 (VD without presentation)

TRANSPERITONEAL LAPAROSCOPIC REPAIR OF A COLO-URETERAL FISTULA SECONDARY TO A FOREIGN BODY

Catalina TESSI 1, Felicitas LOPEZ IMIZCOZ 2, Javier RUIZ 2, Santiago WELLER 2, Juan Pablo CORBETTA 2, Cristian SAGER 2, Carol BUREK 2 and Juan Carlos LOPEZ 2
1) GARRAHAN HOSPITAL BUENOS AIRES ARGENTINA, UROLOGY, Ciudad Autonoma De Buenos Aires, ARGENTINA - 2) GARRAHAN HOSPITAL BUENOS AIRES ARGENTINA, UROLOGY, Ciudad Autonoma De Buenos Aires, ARGENTINA

PURPOSE

Fistulas between genito-urinary and digestive systems are very rare in the pediatric population. Only a few cases have been reported in the literature and none of them were resolved using a laparoscopic approach.

MATERIAL AND METHODS

A 3-year-old girl with a history of oneepisode of febrile urinary tract infection. Ultrasound and CT scan images revealed a left uretero-hydronephrosis and the presence of an echogenic and linear image in the mid-ureter. Retrograde pyelography and flexible ureteroscopy were performed revealing a 2-cm narrowed ureteral segment secondary to a swollen process and no ureteral stone. A ureteral stent was left in place and a transperitoneal laparoscopic approach was performed using 5-mm instruments. The ureter was dissected and a fistula between the middle ureter and the left colon was identified. A 2-cm foreign body was removed after transecting the fistula. The opening of the fistula in the left colon was closed with separated 4/0 reabsorbable monofilament intracorporeal stiches. The narrowed ureteral segment was resected and a ureteral-ureteral anastomosis was performed. A retrogradeureteral stent was left in place. Hospital stay was 2 days and no postoperative complicationswere observed. 

RESULTS

After a 1-year follow-up, the patient remains asymptomatic with improvement of the hydronephrosis on ultrasonography. Analysis of the foreign body revealed an organic composition compatible with a fish bone.

CONCLUSIONS

Laparoscopic transperitoneal approach is a safe and useful tool for the diagnosis and management of a common and even unusual mid-ureter pathology.


VD-24 (VD without presentation)

A VERY RARE CASE: THREE URETERS AND VUR

Halil TUĞTEPE 1, Arzu CANMEMIŞ 1, Merve YILMAZ 2, Neslihan ÇIÇEK 3, Nurdan YILDIZ 3, Harika ALPAY 3 and Tolga DAĞLI 1
1) Marmara Pendik eğitim araştırma, Department of Paediatric Surgery-Division of Paediatric Urology, Istanbul, TURKEY - 2) Marmara Pendik eğitim araştırma, Istanbul, TURKEY - 3) Marmara Pendik eğitim araştırma, Department of Paediatrics Division of Paediatric Nephrology, Istanbul, TURKEY

PURPOSE

Vesico-ureteral reflux (VUR) is a common pathology for pediatric urologist in patients with recurrent urinary tract infections. Sometimes VUR is detected in patients with some urinary anomalies such as posterior urethral valve, neuropathic bladder or duplex system. Triple ureter is a very very rare anomaly that presented with VUR. We present a video of the management of a patient with triple ureter and VUR.

MATERIAL AND METHODS

A 1.5 year old male patient was evaluated for recurrent febrile UTI and determined to have duplex system of the right ureter with Grade 4 VUR to lower and Grade 3 VUR to the upper pole. DMSA revealed a smaller right kidney but no scarring. Subureteric injection was scheduled. 

RESULTS

Duplex system was confirmed on cystoscopy. The cranially located ureteric orifice was observed to have a mucosal fold medial to the orifice. A 3F ureter catheter was advanced through the fold and a third ureter was therefore located. Fluoroscopic imaging demonstrated the segments from which each ureter originated from. VUR was confirmed for both ureters originating cranially. Subureteric injection was performed to these two ureters.

CONCLUSIONS

Although duplex ureter is a commonly seen anomaly, three ureters is extremely rare. There are only some case reports in literature. We are unaware of a report of three ureters and VUR being observed concurrently.


VD-25 (VD without presentation)

LAPAROSCOPIC-ASSISTED INSERTION OF PERITONEAL DIALYSIS CATHETERS WITH OMENTECTOMY ACROSS TWO TERTIARY CENTRES IN NORTH ENGLAND - TECHNIQUE AND OUTCOMES

Mahmoud MAREI 1, David KEENE 2, Anju GOYAL 2, Alexander TURNER 3 and Ramnath SUBRAMANIAM 3
1) Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds Children's Hospital, Department of Paediatric Urology, Health Education England Sub-Specialty Fellowship in Paediatric Urology, Leeds, UNITED KINGDOM - 2) Manchester University NHS Foundation Trust, The Royal Manchester Children's Hospital, Department of Paediatric Urology, Manchester, UNITED KINGDOM - 3) Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds Children's Hospital, Department of Paediatric Urology, Leeds, UNITED KINGDOM

INTRODUCTION AND AIM

Insertion of peritoneal dialysis catheters (PDC) is prone to complications as displacement, blockage and leakage. Laparoscopic insertion was popularised by the senior author in 2006 (Milliken et al. JPUrol 2006;2(4):308-311) and adopted in two linked tertiary centres. It offers the advantage of sub-fascial tunnelling and controlled positioning of the catheter tip, making it less liable to migration and leakage. This is especially important following previous laparotomies. This work evaluates the outcomes of laparoscopically-guided insertion of PDCs in both centres over the last two years, combined with a video presentation of the technique.

PATIENTS AND METHODS

Thirty PDCs were inserted from August 2016 to August 2018 across both centres. The procedure included an omentectomy either laparoscopically or by delivering the omentum to the umbilical port site (15 cases each), followed by a pre-peritoneal insertion of the catheter using Seldinger technique under laparoscopic control.

RESULTS

The median age was 5.8 years (IQR:0.76-13.7 years). The median follow-up was 9 months. All catheters were inserted laparoscopically and used within 24 hours. No cases of catheter migration or cuff displacement were noted. Mechanical complications occurred in 7 cases (23%), four of which had previous laparotomies or open PDC insertion. Leakage occurred in 1 case and resolved by resting the PDC for 48 hours; early blockage occurred in 3 cases (2 not flushing, 1 not aspirating and all were salvaged laparoscopically); delayed suboptimal drainage occurred in 3 cases (within 12 months) requiring adjustment of the dialysis rates in 2 cases and removal of the PDC in 1 case.

CONCLUSION

Laparoscopic-assisted insertion of peritoneal dialysis catheters with omentectomy is reproducible, has a low incidence of leakage and showed no catheter migration in this series. It is the gold standard approach in our tertiary referral units.


VD-26 (VD without presentation)

LAPAROSCOPIC AUGMENTATION ENTEROCYSTOPLASY

Romy GANDER 1, Marino ASENSIO 1, Gloria Fatou ROYO 1 and Manuel LÓPEZ 2
1) University Hospital Vall d'Hebron. Barcelona, Pediatric Surgery. Pediatric Urology and Renal Transplant Unit, Barcelona, SPAIN - 2) University Hospital Vall d'Hebron. Barcelona, Pediatric Surgery, Barcelona, SPAIN

PURPOSE

The aim of this study is to describe a simplified surgical technique for laparoscopic augmentation enterocystoplasty (LAEC) in children and evaluate the short-term outcomes.

MATERIAL AND METHODS

The procedure was performed in a 14-year-old male with a history of myelomenigocele and secondary neurogenic bladder who presented with recurrent  pyelonephritis. Urodinamics revealed a hypertonic bladder with low compliance and capacity (140 ml). On voiding cystourethrogram a left unilateral grade II vesicoureteral reflux was observed. He received two injections of intravesical botulinum toxin without improvement and was therefore scheduled for LAEC.

RESULTS

 The procedure included: transperitoneal placement of four ports, selection of a 15-cm ileal segment with sufficient mobility, extracorporeal isolation of the bowel segment and termino-terminal anastomosis, extracorporeal suturing of the detubularized bowel into a U-shaped configuration, placement of 4 reference sutures, reintroduction in the peritoneal cavity, bladder opening in a coronal plane, fixation of the ileal patch to the bladder suturing first the 3 posterior reference sutures and followed by watertight anastomosis with running sutures of each quadrant.

Only a urethral catheter was left in place. There were no intra- or postoperative complications. Operative time was: 320 minutes. The patient started oral feeding 12 hours after surgery and was discharged on the 5th postoperative day. With a follow-up of 10 months he remains asymptomatic and current bladder capacity is 360 ml.

CONCLUSIONS

LEC is a complex procedure that requires advanced laparoscopic skills. It reproduces the open technique providing the advantages of laparoscopy, with the disadvantage of prolonging the surgical time. Although short-term results seem encouraging, long-term follow-up is required.


VD-27 (VD without presentation)

TUNICA VAGINALIS FLAP IN A PEDIATRIC PATIENT WITH TESTICULAR RUPTURE DUE TO GUNSHOT

Ahsen KARAGÖZLÜ AKGÜL
Marmara Pendik eğitim araştırma, Department of Paediatric Surgery-Division of Paediatric Urology, Istanbul, TURKEY

PURPOSE

Blast testicular injury from gunshot may result in severe testicular damage and rupture, are rare conditions in paediatric population. The management of these wounds are difficult and 50% result in orchiectomy. A patient with bilateral severe testicular rupture and large tunica albuginea defect that repaired with tunica vaginalis flaps was presented in this study. 

MATERIAL AND METHODS

A 16 years old boy was administered with both ruptured testes that are located out of the scrotum. He was a sheep-man in the field and fired to kill thefox but shot himself. The first examination revealed both tunica albuginea defects and unviable tissues but normal blood supply in testes. He was taken to the operating theatre and the exploration revealed entrance of the wound in the cranial portion of the scrotum on the left side of the penis. Tunica albuginea defects were severe and primer closure could not be achieved, but defect were minimize with a few primer sutures on the tunica albuginea edges. To sacrifice of the viable testicular tissue to close the tunica albuginea was not prefer. Tunica vaginalis flaps sutured to the remaining edges with absorbable sutures. 

RESULTS

At his fourth month follow up, Doppler ultrasound revealed normal blood supply of both testes.

CONCLUSIONS

Severe testicular rupture with tunica albuginea defect sometimes cannot be closed primarily without excision of viable testicular tissue. In these cases, the vascularized tunica vaginalis flaps provides an alternative method to closure without sacrificing viable tissue. 


VD-28 (VD without presentation)

LAPAROSCOPIC REDO PYELOPLASTY WITH CULP DE WEERD TECHNIQUE

Diego GALLEGOS, Virginia TUCHBAUM, Roberto VAGNI, Francisco DE BADIOLA and Juan MOLDES
Hospital Italiano de Buenos Aires, Pediatric Urology, Ciudad De Buenos Aires, ARGENTINA

PURPOSE

The redo pyeloplasty with shortened ureter and fibrosis is always a complex case to resolve. The Culp De Weerd flap pyeloplasty can be used in special cases such as long stenosis of the proximal ureter and fibrosis.
We present a video of the resolution of a complex redo pyeloplasty with this technique.

PATIENT AND METHODS

Clinical Case: A 6 month old patient was operated due to severe hydronephrosis performing a dismembered pyeloplasty. One month later was reoperated because of persistent hydronephrosis with double J stent placement. In two other times a double J stent needed to be inserted. At 25 months, a third open pyeloplasty with double J stent was performed. It presents severe hydronephrosis after double j removal and is therefore referred to our center. Ultrasound showed persistent dilatation. Radiorrenogram had a retentive curve and relative renal function of 39%.
Surgery: we performed a laparoscopic left pyeloplasty in the modified Valdivia position. A pyelography demonstrate a 2.5 cm stenosis. Three mm instrument were used for dissection. An important fibrosis, a dilated pelvis and a long ureteral stenosis was found. A pelvis flap as the Culp de Weerd technique was used to bridge the stenotic segment. A double J stent was left in place for 8 weeks. The surgical time was 3 hours. The patient was discharged from the hospital 48 hours after the surgery.
At 8 month follow up the patient have minor pelvic dilatation on ultrasound and is without symptoms.

CONCLUSIONS

Redo pyeloplasty with pyelic flap could be used as an alternative in cases of long ureteral stenosis with good results.


VD-29 (VD without presentation)

WHEN VISION IS EVERYTHING; ANALYSIS OF A PEDIATRIC SERIES OF LAPAROSCOPIC MANAGEMENT OF RECURRENT PYELOURETERAL OBSTRUCTION.

Ximena RECABAL 1, Pedro José LÓPEZ 2, Francisca YANKOVIC 2, Santiago WELLER 3, Florin DJENDOV 4, Abraham CHERIAN 4, Roberto VAGNI 5, Javier RUIZ 3, Juan Pablo CORBETTA 3, Juan Manuel MOLDES 5, Imran MUSHTAQ 4 and Francisco REED 6
1) Exequiel Gonzalez Cortés Hospital - University of Chile, Pediatric Urology, Santiago, CHILE - 2) Exequiel Gonzalez Cortés Hospital - University of Chile, Santiago, CHILE - 3) Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Pediatric Urology, Buenos Aires, ARGENTINA - 4) Great Ormond Street Hospital, London, UNITED KINGDOM - 5) Hospital Italiano de Buenos Aires, Pediatric Urology, Buenos Aires, ARGENTINA - 6) Hospital Exequiel Gonzalez Cortes, Pediatric Urology, Santiago, CHILE

PURPOSE

Although the Anderson-Haynes pyeloplasty has a low rate of complications, there are cases that require reoperation for recurrent obstruction. Redo pyeloplasty is complex surgery, especially because of the scar tissue from the previous intervention. Our aim was to evaluate patients undergoing laparoscopic redo pyeloplasty, analyzing whether this approach offers advantages for this difficult surgery.

MATERIAL AND METHODS

A retrospective study of all patients undergoing laparoscopic redo pyeloplasty between January 2009-December 2017, with at least 6 months follow-up at 3 international centres for paediatric urology. Demographic data, perioperative characteristics, complications and outcome data were collected.

RESULTS

In the 9 years studied, there were 18 redo surgeries performed laparoscopically. Of those, 9 cases were initially operated open (lumbotomy) and 9 laparoscopically. The average time to reoperation after the first surgery was 18 months (range,3-120 months). The average surgery time was 148min (range 90-240min). In all cases considerable scar tissue was identified at the ureteropelvic junction and transperitoneal laparoscopic vision allowed for the correct identification of the anatomy and to be able to perform a new pyeloureteral anastomosis in a comfortable way. After a follow-up time of 20months all patients are asymptomatic and with improved radiological parameters (US and MAG3).

CONCLUSIONS

The reoperation of a patient is a stress for any surgeon. This series shows that the transperitoneal laparoscopic approach provides good vision and approach to the problem allowing this complex surgery to be carried out effectively and comfortably with an excellent success rate, making it the first option in recurrent PUJO.


VD-30 (VD without presentation)

FIBROEPITHELIAL "OCTOPUS" - A RARE PATHOLOGY ON RETROPERITONEAL LAPAROSCOPIC PYELOPLASTY.

Sherjeel SAULAT, Murtaza AZAD, Anees Ur Rehamn SOOMRO, Saeed QADRI and Faraz KHALID
Tabba Kidney institute, Paediatric Urology, Karachi, PAKISTAN

PURPOSE

Retroperitoneal 3D laparoscopic pyeloplasty is a minimally invasive technique for treating ureteropelvic junction obstruction. We present this video with the purpose to show that sometimes rare tumors like fibroepithelial polyps can cause such obstructions and how to tackle with such unusual situations.

MATERIAL AND METHODS

A 12 year old boy presented with 1 year history of fever, with occasional hematuria and episodes of renal colic. His ultrasound showed left sided hydronephrosis with sagging pelvis. His IVP showed PUJ narrowing on left side with delay in excretion of contrast. A MAG3 nuclear renal scan with lasix demonstrated 51% of total left kidney function. An obstructive drainage pattern with the T1/2 Lasix drainage time never being reached was noted for the left kidney.
A 10mm camera port was placed in left flank 1cm below the tip of 12th rib with two 3mm working ports in Left renal angle and above iliac crest respectively. Renal pelvis and proximal ureter were dissected and moblized. The suspicion started when there was feel of a firm fullness of the ureter from pelvis up to midureter. UPJ was opened and there was emergence of multiple mucosal legs like that of an octopus followed by its main body arising from PUJ. It was completely resected, ureter inspected by a 8 Fr flexible ureterorenoscope and ureteropelvic anastomosis was completed over a 4 Fr DJ stent. He was discharged after 48 hours.

RESULTS

DJ stent was removed 4 weeks later and patient reviewed at three months showed a non hydronephrotic kidney and no hydroureter. He is no more symptomatic and UTI free.

CONCLUSIONS

Retroperitoneal Laparoscopic pyeloplasty is a feasible, safe and efficient technique for the relief of PUJ obstructions. One must be aware of and ready for tackling unusual lesions and growths as the cause of hydronephrosis in pediatric population.


VD-31 (VD without presentation)

LAPAROSCOPIC EXTRAVESICAL REIMPLANTATION FOR THE TREATMENT OF PRIMARY OBSTRUCTIVE MEGAURETER

Cristina TORDABLE, Daniel CABEZALI, Jesús REDONDO, Leonor MELERO and Andrés GÓMEZ
Hospital 12 de Octubre, Urology, pediatric surgery, Madrid, SPAIN

PURPOSE

Reimplantation for treatment of primary obstructive megaureter (POM) can be done by open or laparoscopic surgery, intra or extravesical. We show our experience in laparoscopic extravesical (LE) treatment of POM.

MATERIAL AND METHODS

Three children with POM have undergone surgery using LE reimplant Lich Gregoir. Surgical indication was based on no improvement in the obstructive elimination curve of the MAG-3 renogram after pneumatic dilatation of the ureterovesical junction. The patients were monitored by ultrasound, diuretic renogram and cystography 6 months after the intervention.

RESULTS

The age of the three cases intervened was 1 year and 10 months, 6 and 8 years. Two POM were left (66, 7%) and one right (33.3%). One case required ureteral modeling that was performed according to the Kalicinsky technique. The mean surgical time was 3 h and 16 minutes and there were no surgical complications. The patients were discharged at 3, 4 and 5 days respectively. The ureteral catheter was accidentally left at 24 hours in one case and in the other two it was withdrawn after 7 days on an outpatient basis. The urethral catheter was maintained in all cases for 14 days. In all cases, the control ultrasound showed a decrease in ureteral dilation without vesicoureteral reflux in the cystography and a nonobstructive elimination curve in the diuretic renogram.

CONCLUSIONS

LE approach to POM is a valid and effective technique, with rapid recovery and low hospital stay. A greater number of cases are needed to establish more solid conclusions.


VD-32 (VD without presentation)

LAPAROSCOPIC URETEROCALICOSTOMY FOR URETEROPELVIC JUNCTION OBSTRUCTION WITH INTRARENAL PELVIS IN A 13 YEARS OLD GIRL : TECHNIC AND RESULT

Pauline LOPEZ, Alaa EL GHONEIMI, Matthieu PEYCELON and Annabel PAYE-JAOUEN
Robert Debre University Hospital, APHP, University Paris Diderot. Centre de référence des malformations rares des voies urinaires (MARVU), Pediatric Urology, Pediatric Urology Departement, Paris, FRANCE

PURPOSE

Ureterocalicostomy (UC) for ureteropelvic junction obstruction (UPJO) has been described in children as primary procedure in case of unusual anatomical variation (malrotation, horseshoe kidney, intrarenal pelvis) or secondarily after a failed pyeloplasty. Few cases of laparoscopic UC have been reported. This video describes the technic of ureterocalicostomy for primary UPJO in a 13 years old girl with an intrarenal pelvis and parenchymal thinning.

MATERIAL AND METHODS

Surgical approach was a four ports technique. Anastomosis was performed with 3 mm instruments with a 5/0 absorbable running suture over a double-J stent.

RESULTS

There was no intraoperative complication. The operative time was 129 minutes. Hospital stay was 2 days. Double-J stent was removed during the 4th week postoperative. Delay to ultrasound was 35 days after stent removal and hydronephrosis had totally shrunk. At last follow-up, stable renal function without persistent symptoms was observed.

CONCLUSIONS

Laparoscopic ureterocalicostomy is a feasible and safe approach for the first line treatment of UPJO in case of unusual anatomical variation such as intrarenal pelvis in the pediatric population.


VD-33 (VD without presentation)

LAPAROSCOPIC AND URETHROCYSTOSCOPIC APPROACH OF CROSSED TESTICULAR ECTOPIA IN A 18-MONTH-OLD PATIENT

Alejandro MANZANARES 1, Andrea SORIA GONDEK 1, Maria OVIEDO 1, Maria Pilar ABAD 1, Marta MURILLO 2 and Marta DE DIEGO 1
1) Hospital Universitari Germans Trias i Pujol, Paediatric Surgery, Badalona, SPAIN - 2) Hospital Universitari Germans Trias i Pujol, Paediatric Endocrinology, Badalona, SPAIN

PURPOSE

To present the laparoscopic and urethrocystoscopic approach of a crossed (or transverse) testicular ectopia.

PATIENTS

An 18-month-old male without any medical history presented with non-palpable left testis. The right testicle was palpable and located in the right inguinal canal. The ultrasound imaging revealed the presence of both testicles in the right inguinal canal. His karyotype was 46XY.

RESULTS

Given the suspicion of a transverse testicular ectopia, we performed a laparoscopy. The right peritoneo-vaginal process was wide open. The left (ectopic) testicle was located at the right deep inguinal ring. Its vessels were crossing from the left side. The right (orthotopic) testicle had correctly descended to the scrotum. We identified the presence of Müllerian duct remnants that were intimately close to the left vas deferens and testicle. An urethrocystoscopy was performed to rule out any communication between the urethra and the Müllerian duct remnants. Finally we descended and performed a transeptal orchidopexy of both testicles.

CONCLUSIONS

Crossed testicular ectopia is a rare urologic malformation. To rule out the presence of Müllerian duct remnants is mandatory. In our single experience we did not find any communication between the urethra and those remnants. We do not recommend the excision of Müllerian duct remnants due to the risk of vas deferens or testicular vascularization damage.


VD-34 (VD without presentation)

PEDIATRIC PERCUTANEOUS NEPHROLITHOTOMY (PCNL) WITH ASPIRATION SHEATH FOR STAGHORN LITHIASIS

Tessi CATALINA, Felicitas LOPEZ IMIZCOZ, Javier RUIZ, Santiago WELLER, Cristian SAGER, Carol BUREK and Juan Pablo CORBETTA
GARRAHAN HOSPITAL BUENOS AIRES ARGENTINA, UROLOGY, Ciudad Autonoma De Buenos Aires, ARGENTINA

PURPOSE

The introduction of the aspiration’s sheath (Clear Petra® ) with reduced gauge access (16 Fr) has advantages such as: faster aspiration of fragments without the need of baskets for lithiasis extraction, excellent visibility, low intrarenal pressure. It is our goal to present a video demonstrating the usefulness of Clear Petra® in the treatment of pediatric staghorn lithiasis.

MATERIAL AND METHODS

2-year-old male patient with a history of febrile urinary infections and a positive urine study for phosphate-magnesium.

In renal ultrasound and in CT scan without contrast, incomplete staghorn lithiasis was observed, without ureteral or bladder lithiasis.

It is decided to perform PCNL.

RESULTS

PCNL was performed in the supine position (Valdivia Galdakao modified), entered under fluoroscopic control by lower posterior calyx, dilatation with Alken, placement of Clear Petra® 16 Fr and nephroscopy with MIP M nephroscope (Storz)

Lithiasis fragmentation was performed with Holmium laser with fiber of 940 um with dusting technique with low energy (0.8J) and low frequency (10 hz) combined with the suction component of Clear Petra®

Nephrostomy was placed as urinary diversion.

CONCLUSIONS

The aspiration sheath in stones of infectious origin in pediatric population allows an objective improvement in PCNL times, and avoids the use of forceps or baskets for fragment extraction.

In pediatric population with staghorn lithiasis of infectious origin the use of Holmiun laser applying dusting technique is a very effective method.


VD-35 (VD without presentation)

INDOCYANINE GREEN-ENHANCED FLUORESCENCE FOR ASSESSING RENAL VASCULARIZATION DURING LAPAROSCOPIC NEPHRECTOMY

Alberto PARENTE, Laura BURGOS, Ruben ORTIZ and Jose Maria ANGULO
GREGORIO MARAÑÓN UNIVERSITY HOSPITAL, PEDIATRIC UROLOGY, Madrid, SPAIN

PURPOSE

Sometimes, localizing renal vascularization is not easy due to anatomical variability. It may lead to errors during laparoscopic nephrectomy producing significant bleeding and long surgical time. The indocyanine green (ICG) aided near infrared fluorescence (NIRF) imaging using Striker ENV system provides enhanced real-time visualization of anatomy during minimally invasive surgery. 

MATERIAL AND METHODS

We present 2 patients (3 and 6 years-old) who underwent bilateral laparoscopic nephrectomy due to corticoid resistant hypertension and end-stage renal failure. We found difficulty in localizing renal vascularization. When ENV mode is activated, the system uses fluorescent light to visualize blood flow, tissue perfusion, and biliary ducts. The system illuminates the surgical site by generating light within visible and infrared spectra. After image signals are transmitted from the laparoscope to the camera control unit for processing, the final image is displayed on the monitor. A button on the camera head can be used to shift between visible light and NIR light.

RESULTS

There were no intraoperative complications and blood loss was insignificant. Mean surgical time was 36 ± 10 minutes in both procedures and patients were discharged 24 hours after surgery.

CONCLUSIONS

Although there is no replacement for good surgical technique and judgment, indocyanine green (ICG) aided near infrared fluorescence (NIRF) imaging during nephectomy is a useful real-time way of alerting the surgeon of unexpected anatomy. It could as well contribute to lessen the number of surgical procedures that need to be converting to open surgery.