5th Joint Meeting of ESPU-SPU - Virtual

VD: VIDEO DISPLAY (no presentation)

ESPU-SPU Meeting


VD-1 (VS without presentation)

★ SINGLE INSTITUTION EXPERIENCE WITH COMPLETE PRIMARY REPAIR OF BLADDER EXSTROPHY IN THE GIRL AND CURRENT COLLABORATIVE TECHNIQUE

Joseph BORER 1, Alyssia VENNA 1, Dana WEISS 2, Travis GROTH 3, Aseem SHUKLA 2, Elizabeth ROTH 3, John KRYGER 3, Lauren CULLEN 1, Jen FRAZIER 2, Melissa LINGONGO 3, Douglas CANNING 2 and Michael MITCHELL 3
1) Boston Children's Hospital, Urology, Boston, USA - 2) Children's Hospital of Philadelphia, Urology, Philadelphia, USA - 3) Children's Hospital of Wisconsin, Urology, Milwaukee, USA

PURPOSE

We review our experience with Complete Primary Repair (CPRE) in girls with bladder exstrophy (BE), identify potential risks for retention and detail current CPRE technique.

MATERIAL AND METHODS

All girls with BE post-CPRE at our institution since 1998 were reviewed and grouped by CPRE timing; before (newborn) or after (delayed) 72 hours of age. We recorded operative age, anatomic dimensions, osteotomy, pelvic immobilization and clinical course. Urinary retention was defined as requiring relieving procedure(s) and/or clean intermittent catheterization (CIC).

RESULTS

Twenty-four girls underwent CPRE. In 2012, we changed to performing CPRE at approximately 6-8 weeks of age. Eight (33%) had newborn and sixteen (67%) delayed CPRE (Table). Three (delayed group) experienced retention; 1 required bladder rupture repair/temporary CIC, another required long-term CIC, and 2 of the 3 required bladder neck (BN) incision. Urethral plate length in 3 with retention was 5mm, 16mm and 18mm. Delayed girls had a significantly narrower BN compared to newborns. Continence outcomes >14 years for 6 girls in the newborn group; 1 of 6 (17%) required BN reconstruction. For those with >5 years follow-up in the delayed group 1 of 8 (13%) required BN closure. 

CPRE Characteristics and Outcomes
Newborn CPRE Delayed CPRE
Number of Girls (%) 8 (33) 16 (67)
Age at CPRE: days (range)* 1.75 (1-3) 282 (26-1988)
Osteotomies: number (%)*** 0 (0) 14 (88)
Bladder Neck Width: mm; mean (range)* 20 (18-20) 17 (15-20)
Urethral Plate Length: mm; mean (range) 11 (8-16) 12 (5-18)
Pelvic Immobilization**
     Modified Bryant's Traction 8 4
     Spica Cast 0 12
Urinary Retention post-CPRE: number (%) 0 (0) 3 (19)
*p<0.05, **p<0.001, ***p<0.0001

CONCLUSIONS

Extremes of urethral plate/urethral length and narrower BN potentially increased retention risk. Timing of CPRE and immobilization technique may not impact retention risk. Current CPRE technique includes shorter urethra and wider BN.


VD-2 (VS without presentation)

★ SYNCHRONOUS BILATERAL ROBOTIC ADRENALECTOMY FOR RARE CAUSE OF HYPERCORISOLISM IN CHILDREN

Pauline LOPEZ 1, Alix BESANCON 2, Berenice TULELLI 1, Michel POLAK 2, Sabine SARNACKI 1 and Thomas BLANC 1
1) APHP, Hôpital Necker, Paris, France, Université de Paris, Service de Chirurgie Viscérale et Urologie Pédiatrique, Paris, FRANCE - 2) APHP, Hôpital Necker, Paris, France, Université de Paris, Service d'Endocrinologie Pédiatrique, Paris, FRANCE

PURPOSE

Autonomous secretion of cortisol from the adrenal glands - or ACTH-independent Cushing syndrome - is a rare but challenging condition in children. Because of bilateral micronodular or macronodular adrenal disease, surgical strategy is the definitive treatment to correct hypercortisolism and its complications. Robotic assisted transperitoneal laparoscopic synchronous bilateral adrenalectomy (SBA) has never been reported in children.

MATERIAL AND METHODS

Patients who underwent synchronous bilateral robotic adrenalectomy between 2016 and 2018 were identified. The children were operated in supine position with only one set up working for both sides. Four 8-mm robotic ports were inserted along the abdominal midline with one assistant port. The 30-degree laparoscope was placed through the umbilicus, and the operating trocars were inserted below the xiphoid process, midway between the xiphoid process and the umbilicus and between the umbilicus and symphysis pubis. The procedure was started on the left side. The adrenal veins were dissected and controlled with the vessel sealer without bleeding. After booming the robot, the procedure was done on the right side.

RESULTS

Four children underwent SBA with a robotic assisted transperitoneal laparoscopic approach, two Carney complex in prepubertal girls (9 year-old; 26 and 39 kgs) and two Mac Cune Albright syndrome in infants (7 month-old, 4.6 kgs and 1 year-old, 7 kgs). Neither intra-operative complication nor bleeding occurred. Mean operating time was 300 minutes. One post-operative complication occurred: a retroperitoneal collection in the adrenal bed, needing percutaneous drainage.

CONCLUSIONS

Robotic assisted transperitoneal laparoscopic SBA is a safe and feasible procedure, in children, including infants.


VD-3 (VS without presentation)

★ ROBOTIC-ASSISTED LAPAROSCOPIC REPAIR OF A CONGENITAL RECTOURETHRAL FISTULA WITH DUPLICATED URETHRA

Belinda LI, Wallace W. NEBLETT III, Mark C. ADAMS and John C. THOMAS
Vanderbilt University Medical Center, Pediatric Urology, Nashville, USA

PURPOSE

Congenital rectourethral fistulas are a form of anorectal malformations occurring in less than 1/5000 births. This finding associated with a duplicated urethra is uncommon, with very few reported in the literature. While various techniques are described for this complex repair, the optimal approach remains unclear. We report our experience with a robotic-assisted laparoscopic repair of a congenital rectourethral fistula in an infant with a duplicated urethra.

MATERIAL AND METHODS

The patient is a 2 year old boy who developed a febrile urinary tract infection during an early hospitalization for Tetralogy of Fallot. A renal and bladder ultrasound was normal, but a voiding cystourethrogram (VCUG) revealed several findings. He was noted to have bilateral bladder diverticula, a duplicated urethra, and a rectourethral fistula. A cystoscopy and proctoscopy were performed at 16-months-old which did not identify the fistula tract endoscopically. He was subsequently scheduled for definitive surgical repair using a robotic approach.

RESULTS

The total operative time was 229 minutes with an estimated blood loss of 15 mL. The fistula was identified using a posterior approach by developing the plane between the prostate and rectum. The fistula was divided and the posterior urethra and rectum were closed using multiple layers. The Foley catheter was kept for two weeks and the patient was able to void normally with normal bowel movements.

CONCLUSIONS

Robotic-assisted laparoscopic repair of a congenital rectourethral fistula in an infant is a safe and technically feasible procedure. This approach allows for excellent visualization and fine dissection of the fistula in an otherwise narrow field.


VD-4 (VS without presentation)

★ MINI ENDOSCOPIC COMBINED INTRA-RENAL SURGERY WITH ENDOVIEW PUNCTURE IN A 12 MONTH BOY - A SAFE BUT CHALLENGING PROCEDURE

Erika LLORENS DE KNECHT 1, Yesica QUIROZ 2, Irene GIRÓN 2, Joan PALOU 2 and Anna BUJONS 2
1) FUNDACIO PUIGVERT, Urology, Barcelona, SPAIN - 2) Fundació Puigvert, Pediatric Urology, Barcelona, SPAIN

INTRODUCTION

Associating minipercutaneous nephrolithotomy and retrograde flexible ureteroscopy (fURS) is called Mini Endoscopic Combined Intra-Renal Surgery (miniECIRS). It’s a safe and efficient technique, also in children.

PATIENT AND METHODS

After a second febrile UTI and spontaneous expulsion of stones, a 12 month old boy was diagnosed of an infectious pelvic left stone (16mm) and multiple caliceal stones. He underwent preoperative non-contrast CT scan to establish the morphologic features of the kidney and stone. He was treated with the miniECIRS technique. In Galdakao-modified supine Valdivia position and under general anesthesia a left semi-rigid ureteroscope (4,5F) was performed. Two guidewires and a ureteral access sheet (10.5F) were introduced, and the URSf (Storz Flex-Xc) was ascended. Keeping the same position, puncture of the inferior calix was carried out using a 0º-90º degree fluoroscopy-guided technique. With endovision-control, the percutaneous tract was established. Dilation was achieved using progressive dilators (8-10F) to accommodate a 14F access sheath (semi-closed-circuit vacuum-assisted system). To achieve the stone fragmentation a 275micras Holmium: YAG laser fiber (0,8J-10Hz) was used. Simultaneously, lasertripsy through the URSf was performed. To complete the extraction of the stones a nitinol basket was used. A nephrostomy tube (8,5F) and double J (4,8F) were placed.

RESULTS

The operative time was 180 minutes and blood losses were virtually absent. There were no intra- or post-operative complications and the patient was discharged at the 5th day. After 1 month, double J was removed having a stone free status

CONCLUSIONS

MiniECIRS with endoview puncture is a safe and efficient technique when performed by experienced hands. Therefore, it is an alternative to consider for the treatment of lithiasis in the pediatric population


VD-5 (VS without presentation)

MODIFIED SECOND STAGE OF FOWLER-STEPHENS ORCHIOPEXY IN THE PRESENCE OF A LOOPING VAS DEFERENS.

Vladimir SIZONOV 1, Vladimir ORLOV 1 and Mikhail KOGAN 2
1) Regional Children's Hospital, Pediatric Urology, Rostov-On-Don, RUSSIAN FEDERATION - 2) Rostov State Medical University, Urology, Rostov-On-Don, RUSSIAN FEDERATION

PURPOSE

Testicular rerouting in second stage of the Fowler-Stephens orchiopexy (FSO) makes the ductal artery (DA) the last source of arterial blood supply to the testicle. Testicular mobilization in the area of the internal inguinal ring (IIR) in the presence of a looping vas (LV) is associated with a high risk of damage of DA. The proposed maneuver allows saving the blood supply of the testicle and to facilitate its mobilization.

MATERIAL AND METHODS

The manuever consists of laparoscopically forming a triangular parietal flap: after dissection of the peritoneum at the site of the previous vessels electrocoagulation, incision continues laterally in the direction of the IIR then goes along the anterior semicircle of IIR (the Nuck's diverticulum entrance). Ipsilateral scrototomy is performed, visualizing the Nuck's diverticulum and mobilize it to the level of IIR. Invert the Nuck's diverticulum into the abdominal cavity together with the adjacent LV. Laparoscopically complete mobilization of the testis. Trocar is introduced into the ipsilateral medial fossa through the formed scrotal access. Placement of the testicle into the scrotum (using a clamp introduced through the trocar). Revert the Nuck's diverticulum, immerse the testicle in it. Orchiopexy.

Between 2009-2019, 123 FSO were performed. In 85 cases a LV was discovered or an accurate verification of its pressence could not be performed. 37 patients underwent conventional FSO (group 1) and 48 underwent modified FSO (group 2). Follow up >9 month. 

RESULTS

Testicular atrophy rate in the first group (conventional FSO) was 18.9% and 4.2% in the second group (modified FSO) (p<0.05).

CONCLUSIONS

Performing transcrotal mobilization of the Nuck's diverticulum minimizes the risks of ductal artery damage, especially in patients with LV and in cases when accurate verification of its presence is complicated. This maneuver does not require additional incisions and is easily reproducible.


VD-6 (VS without presentation)

STAGED LAPAROSCOPIC TRACTION ORCHIDOPEXY FOR IMPALPABLE TESTES: PRELIMINARY OUTCOMES

David KEENE 1, Charlotte MELLING 1 and David WILKINSON 2
1) Royal Manchester Children's Hospital, Paediatric Urology, Manchester, UNITED KINGDOM - 2) Royal Manchester Children's Hospital, Paediatric Surgery, Manchester, UNITED KINGDOM

PURPOSE

Intra-abdominal testes commonly have short vascular pedicles which mandate a staged technique. Shehata et al. (J Pediatr Surg 2016;51:211-5) described staged laparoscopic traction orchidopexy (SLTO) to elongate the testicular vessels without division. We report the first UK experience using this principle and modification to enable the mobilisation of the testis to be performed entirely laparoscopically at the 2nd stage.

MATERIAL AND METHODS

Prospective sequential study of all boys operated by 2 surgeons in a single centre (2017-2019) with intra-abdominal testes and a short vascular pedicle.

1st stage procedure was division of the gubernaculum and lateral peritoneal attachments, stretching and securement of the intra-abdominal testis to the contralateral anterior abdominal wall with 2/0 Ticron stitch. The 2nd stage procedure was performed 3 months later with laparoscopic cutting of securing stitch, introduction of an 11mm STEP port trans-scrotally to retrieve the testis and secure testis in a sub-dartos pouch.

Outcomes were the presence of a palpable testis in the scrotum, ultrasound measurement of testicular volume and peri-operative complications. Data is presented as median (IQR).

RESULTS

16 boys were included in the study with 19 impalpable testes; 3/16 (18%) were bilateral. The median age was 2.7 years (2.2-7.9) at 1st stage. Clinical assessment 6 months after 2nd stage has been done in 14/19 testes; 13/14 (93%) patients had a palpable testes in the scrotum, 1/14 (7%) patient required a further inguinal procedure for a high testicular position.

Ultrasound assessment was done in 10/19 testes; median testicular volume was 0.5ml (0.4-1.2). 1 diathermy injury to the bladder necessitated laparoscopic repair. 3/19 testes had a "slipped suture" at the time of the 2nd stage, requiring a repeat 1st stage procedure.

CONCLUSIONS

Staged laparoscopic traction orchidopexy is as a feasible alternative to Fowler-Steven's procedure, with potentially improved testicular outcomes. The complications described should be preventable as the technique evolves.


VD-7 (VS without presentation)

ONE STAGE FOWLER STEPHENS ORCHIDOPEXY FOR PEEPING INTRA-ABDOMINAL TESTIS: A STEP BY STEP VIDEO WITH DETAILS AIMING TO AVOID COMPLICATIONS

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

PURPOSE

The surgical treatment for intra-abdominal testis can be challenging and, in many cases, it requires the ligation of the spermatic vessels in order to achieve adequate length to bring the testis to scrotal position. Fowler and Stephens proposed an original one-stage technique that has been later modified and staged in order to improve outcomes. The objective of this video is to present a didactic description of a single stage open orchidopexy with technical tips and tricks that can potentially avoid testicular atrophy.

MATERIAL AND METHODS

The authors present a 5-min video of a single stage open Fowler- Stephens orchidopexy in an 18-month-old boy with a right peeping intra-abdominal testis. Surgical details are illustrated in didactic steps aiming to facilitate learning and optimize outcomes.

RESULTS

The patient had an uneventful post-operative course. The right testis was palpable in scrotal position and an ultrasound confirmed its viability and normal volume 6 months after the orchidopexy.

CONCLUSIONS

This video provides detailed and informative steps for performing the open Single-Stage Fowler-Stephens orchidopexy for the treatment of a peeping intra-abdominal testis.


VD-8 (VS without presentation)

PER-MITROFANOFF CYSTOLITHOTOMY (PMCL) FOR BLADDER CALCULUS

May BISHARAT, Holly DIGNE-MALCOLM, Alexander CHO and Naima SMEULDERS
Great Ormond Street Hospital NHS Trust, Paediatric Urology, London, UNITED KINGDOM

PURPOSE

We describe the use of the Super-Mini (SMP) system via a pre-existing Mitrofanoff channel for the management of a bladder stone in an augmented bladder. The Hawk SMP System was developed primarily for PCNL access. It consists of a miniaturised 8F nephroscope with a working channel that allows for a laser fibre or stone basket. This nephroscope passes through a unique 14F sheath that allows for continuous irrigation and suction.

MATERIAL AND METHODS

Operative Steps:
Under general anaesthesia, with the patient supine and intravenous antibiotics on induction, a diagnostic mitrofanoscopy is undertaken with a 9.5F cystoscope. A 0.035" PTFE-Nitinol Guidewire
with Hydrophilic Tip is then passed via the mitrofanoff channel as a safety wire. The mitrofanoff tract is then gently dilated serially to 16F before the 14F SMP system is introduced. A holmium-YAG laser is used under direct vision on a "dusting" setting to break the stone into fine fragments without the need for basket retrieval.

Tips:
1) As the stone gets smaller and more mobile or for any larger fragments, the stone can be immobilised by the tip of the SMP sheath to allow accurate delivery of laser energy
2) Fragments can be suctioned under direct vision assisted by the vortex created by the SMP sheath.

RESULTS

The patient was discharged home the following day and CIC via the Mitrofanoff channel was re-started 3 days later. The patient then began an increased regime of bladder washouts to prevent stone recurrence.

CONCLUSIONS

This PMCL procedure utilities the pre-existing Mitrofanoff to access the bladder and avoids the need to create any incisions. The 14F Hawk SMP System will be feasible to be passed through most Mitrofanoff channels and the continuous suction aids stone fragment extraction.


VD-9 (VS without presentation)

TRANSPERITONEAL ROBOTIC-ASSISTED LAPAROSCOPIC TRANSPLANT-TO-NATIVE URETEROURETEROSTOMY AS SECONDARY PROCEDURE AFTER FAILED URETEROVESICAL REIMPLANTATION FOR RENAL TRANSPLANTATION

Fabrizio VATTA, Yves HÉLOURY and Thomas BLANC
Hôpital Necker - Enfants Malades, Service de Chirurgie Viscérale et Urologie Pédiatriques, Paris, FRANCE

PURPOSE

Ureteral complications of renal transplantation, such as vesicoureteral reflux, can dramatically impact renal outcomes in the pediatric transplant population. Our aim was to describe a robotic-assisted laparoscopic transplant-to-native ureteroureterostomy (RALTNUU) as secondary procedure after failed ureterovesical reimplantation for renal transplantation.

MATERIAL AND METHODS

We performed a RALTNUU in a 7-year-old girl (21kg). She had had a deceased donor kidney transplantation 3 years ago for nephronophthisis with extravesical ureteroneocystostomy with stenting. Because of urinary tract infection, voiding cystourethrography was performed and demonstrated the presence of VUR into the transplant ureter. Two years after endoscopic antireflux surgery, rising creatinine and increasing hydronephrosis led to the diagnosis of delayed obstruction.
At the beginning of the procedure, a ureteral stent was inserted in the transplant ureter (blue) and in the native ureter (yellow). The child was operated in supine position. Four 8-mm robotic ports were inserted with one assistant port. When the transplant and native ureters were identified, a dependent portion of the transplant ureter near the renal pelvis was opened longitudinally, at a location permitting enough mobility of the native ureter to avoid tension. An opposing incision was made in the native ureter and side-to-side anastomosis was performed using 6-0 PDS suture.

RESULTS

Console time was 95 min with minimal blood loss. Postoperative course was unremarkable. Serum creatinine decreased from 163 µmol/L to 56 µmol/L and follow-up imaging showed an improvement in hydronephrosis at 6 months follow-up.

CONCLUSIONS

RALTNUU is a feasible approach for the treatment of transplant ureteral obstruction.


VD-10 (VS without presentation)

AN UNUSUAL FLEXIBLE URETEROSCOPY FOR URETERAL STONE IN TRANSPLANTED KIDNEY

Yaqoub JAFAR 1, Delphine DEMEDE 1, Marc BARRAS 1, Guillaume ROSSIGNOL 2, Aurora MARIANI 1, Pierre-Yves MURE 1 and Pierre De MOURIQUAND 1
1) HFME, Pediatric Urology, Bron Cedex, FRANCE - 2) HFME, Pediatric SURGERY, Bron Cedex, FRANCE

PURPOSE

Urolithiasis is observed rarely in renal graft and has an incidence of 0,2 to 3 %. To assess the safety and efficacy of minimally invasive procedure for urolithiasis in transplanted kidney.

MATERIAL AND METHODS

We report the case of an 11 year old boy which presents with a 8 mm ureteric stone in a transplanted kidney. Transplantation was performed with a living donor 1 year before for nephronophthisis. There was no urolithiasis in the father pre-transplant assessment. The ureteral stone was found on ultrasound scan 1 year after the transplantation. The ureter was reimplanted into the bladder using the Lich-Gregoir procedure, forbidding any access using standard ureteroscopy.

RESULTS

A double J stent was first placed as the upper tract was dilated. A 5 mm port was placed through the lateral bladder wall, facing the ureteral meatus in order to introduce a guide in the renal cavities. After introducing a 6Fr sheath into the bladder a flexible ureteroscope was introduced into the ureter. A Dormia basket allowed to remove the stone. A trans-urethral catheter was left in the bladder for 4 days after the surgery. No intraoperative complications occurred.

CONCLUSIONS

Minimally invasive procedures (monotherapy or combination one) for urolithiasis in transplanted kidneys are safe and effective, with a high overall stone-free results.


VD-11 (VS without presentation)

CIRCUMCISION IN BURIED PENIS: PRESERVING THE SHAFT SKIN INTACT

Mohammed ELIFRANJI and Santiago VALLASCIANI
Sidra Medicine, Pediatric Urology, Doha, QATAR

PURPOSE

Buried penis is a condition in which the penis is partially or completely hidden .Different surgical techniques have been described where the removal of the abnormal Dartos attachments and fixation of penile skin to Bucks Fascia are the key steps in the repair. The aim of this video is to illustrate the technical details of an approach already published by one of the authors 

MATERIAL AND METHODS

A case of a toddler with congenital buried penis is presented. Circumcision was requested by the family.The correction was started with coronal incision and complete degloving of the shaft. The dissection of the abnormal dartos at the penoscrotal and the penopubic angles was completed by exteriorizing the shaft through an additional midline scrotal incision leaving the cylinder of penile skin intact. This maneuver avoids any incision of the shaft skin. In addition, it makes easier and precise the fixation sutures of the penopubic and penoscrotal angles. Differently from the original publication, the penopubic fixation was performed without additional skin incisions . 

RESULTS

The patient had stable exteriorization of the shaft after 1 year follow up .

CONCLUSIONS

The present approach allows anatomical restoration of the penopubic and penoscrotal angles preserving the penile skin intact . 


VD-12 (VS without presentation)

ROBOTIC LEFT PHEOCHROMOCYTOMA EXCISION (ADRENECLECTOMY): A CASE REPORT

Aparajita MITRA 1, Satish AGGARWAL 2, Rupa BANERJEE 2 and Gaurav SINGH 2
1) All India Institute of Medical Sciences, Paediatric Surgery, New Delhi, INDIA - 2) SIR GANGARAM HOSPITAL, NEW DELHI, INDIA, PAEDIATRIC SURGERY, New Delhi, INDIA

PURPOSE

We present a case of robotic left pheochromocytoma excision done in a 13 year old boy.

MATERIAL AND METHODS

A thirteen-year-old boy presented with complaints of left back pain and incidentally detected arterial hypertension. He was managed with anti-hypertensives. CECT abdomen revealed well defined arterial enhancing hypervascular mass arising from left adrenal gland. His urinary catecholamines were raised. He underwent robotic left adrenelectomy. Post-surgery his blood pressure gradually reduced.

RESULTS

On 1 year follow up he is doing well and there is no recurrence.

CONCLUSIONS

Video of the procedure will be shown highlighting positioning, docking and technical refinements


VD-13 (VS without presentation)

RETROPERITONEAL PRONE ROBOTIC ASSISTED LAPAROSCOPIC NEPHRECTOMY OF THE LOWER POLE NONFUNCTIONING PELVI-URETERIC JUNCTION OBSTRUCTION IN INCOMPLETE DUPLICATED SYSTEM

Julien GROSSMANN, Aline BROCH, Yves HELOURY and Thomas BLANC
Hopital Necker- Enfants Malades, Paediatric Surgery & Urology, Paris, FRANCE

PURPOSE

Ureteropelvic junction obstruction (UPJO) in a duplicated collecting system, either incomplete or complete, usually affects the lower renal moiety.
Our aim was to describe prone retroperitoneal approach for robotic lower-pole heminephrectomy

MATERIAL AND METHODS

The procedure was performed in a 16-year-old girl (53kg). She was diagnosed with incomplete duplicated system and UPJO. MRI demonstrated a massively dilated lower pole and the renal scan confirmed its nonfunction.
The child was operated in prone position.
The first 8-mm robotic Hasson trocar was inserted under direct visual control along the edge of the sacro-lumbar muscles, at the level of the tip of the 12th rib. The working space was created by blunt dissection
Two additional robotic working ports were placed more lateral on a line below the tip of the 12th rib. One assistant port was inserted
After docking, when the instruments are inserted, the Gerota's fascia was widely opened in a caudo-cranial manner.
The kidney was approached posteriorly. The lower pole renal pelvis was highly dilated with major inflammation.
The duplex polar vascular anatomy was clearly defined.
After clear identification of the ureters of both moieties, the lower pole ureter was transected taking care not to damage the upper pole ureter
Careful dissection of the affected moiety allowed identification of polar vessels. These vessels were divided using Harmonic scalpel. Parenchymal section was performed using the same sealing system. No drainage tube was left in situ

RESULTS

Console time was 240 min with minimal blood loss. Postoperative course was unremarkable. Postoperative doppler ultrasound showed healthy upper pole at 2 months follow-up.

CONCLUSIONS

The prone robotic retroperitoneal approach is feasible and may be interesting for kidney and adrenal surgery


VD-14 (VS without presentation)

ROBOTIC PROXIMAL URETEROURETEROSTOMY FOR FAILED OPEN DISTAL URETEROURETEROSTOMY IN AN INFANT WITH AN ECTOPIC DUPLICATED URETER

Sang Hoon SONG 1, Vinaya BHATIA 2, Jonathan GERBER 2 and Chester J. KOH 2
1) Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Division of Pediatric Urology, Department of Surgery,, Houston, USA - 2) Texas Children's Hospital, Houston, Texas, USA; Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA, Division of Pediatric Urology, Department of Surgery, Houston, USA

PURPOSE

The aim of this study is to describe robotic proximal ureteroureterostomy (UU) for a failed open distal UU in an infant with an ectopic ureter

MATERIAL AND METHODS

A 1 year old female had complete duplication of her right collecting system. The right upper moiety ureter was draining ectopically and appeared obstructed. She underwent an open upper to lower distal UU at another institution, and then had two postoperative pyelonephritis episodes. Her right lower pole hydronephrosis increased on serial ultrasounds. She was referred for a re-do surgical intervention. Right retrograde pyelogram showed a severely dilated distal lower moiety ureter. We proceeded with a robotic proximal UU with robotic distal ureteroplasty to close the distal lower pole ureter at the site of the previous low uretero-ureterostomy procedure. The ureteral closure was performed using 5-0 Monocryl in a running fashion in 2 layers. After undocking the robot, we removed the specimens using a 5 mm scope and 5 mm laparoscopic Bag.

RESULTS

Total operation time was 302 minutes and the console time was 197 minutes. The estimated blood loss was minimal.  There were no complications during the procedure. The patient was discharged on postoperative day 1. At 2 months postoperatively, the retrograde pyelogram showed no signs of extravasation or stricture, so the DJ stent was removed. The patient is symptom-free after DJ stent removal and will be followed up with serial ultrasounds.

CONCLUSIONS

Robot-assisted laparoscopic proximal UU after failed open distal UU is a safe and effective alternative to open UU in infant patients with duplication anomalies.


VD-15 (VS without presentation)

ROBOTIC DISMEMBERED TUBULARIZED FLAP PYELOPLASTY FOR LONG SEGMENTAL URETERAL OBSTRUCTION

Sang Hoon SONG, Jae Hyun HAN and Kun Suk KIM
Asan Medical Center, University of Ulsan College of Medicine, Department of Urology, Seoul, REPUBLIC OF KOREA

PURPOSE

The aim of this study is to describe Robotic dismembered flap pyeloplasty of the ureteropelvic junction obstruction.

MATERIAL AND METHODS

A 22 years old male without previous medical history was diagnosed with ureteropelvic junction obstruction after acute left flank pain. Preoperative Tc-99m MAG3 kidney scans showed delayed T1/2 more than 20min. Abdominal CT showed severe left renal hydronephrosis with anteroposterior pelvic diameter of 38mm. The operation was performed using Da Vinci Si robot system. An obstructed segment of the left ureter at the ureteropelvic junction was found through the transmesenteric approach. Dismembered pyeloplasty was not feasible due to severe tension for the length of an appropriate anastomosis. Further mobilization of upper pole kidney did not yield enough lengths. We planned flap pyeloplasty and manipulate a useful flap by dissecting the anterior pelvis with Potts scissors. The defected site of the posterior wall of ureter was covered widely with a rotational flap after further spatulation. A 4.7Fr ureteral stent was inserted via the assistant port, and the pelvic flap was tubularized and anastomosed to the end of the ureter.

RESULTS

The total operation time was 6 hours and 5 minutes, and the robot console time was 4 hours and 6 minutes. The time taken for ureteral anastomosis was 42 minutes. There was no complication during the operation of the patient with an estimated blood loss less than 50ml. The patient discharged at postoperative day 9. The ureteral stent was removed 8weeks postoperatively. Six months after the operation, hydronephrosis disappeared on ultrasonography and completely resolved obstruction of urinary tract was found on Tc-99m MAG3 with T1/2 of 6.8 min. 

CONCLUSIONS

Robotic Dismembered Tubularized Flap Pyeloplasty is a time consuming and difficult procedure. However, this procedure can be successfully performed robotically to bridge a long upper ureteral defect.


VD-16 (VS without presentation)

ORIGINAL TECHNIQUE OF LAPAROSCOPIC VASCULAR HITCHING IN CHILDREN WITH URETEROPELVIC JUNCTION OBSTRUCTION

Vladimir SIZONOV 1, Mikhail KOGAN 2, Alexey MAKAROV 1 and Vladimir ORLOV 3
1) Regional Children's Hospital, Paediatric Urology, Rostov On Don, RUSSIAN FEDERATION - 2) The Rostov State Medical University, Urology, Urology, Rostov-On-Don, RUSSIAN FEDERATION - 3) Rostov Regional Children's Hospital, Paediatric Urology, Rostov On Don, RUSSIAN FEDERATION

PURPOSE

Chapman and Hellstrom techniques are typically employed for transposition of renal lower pole crossing vessels (CV). Both procedures have their limitations related to anatomic specifics of the pelvis, CV and perivascular tissues.

MATERIAL AND METHODS

514 patients suffering from ureteropelvic junction (UPJ) obstruction underwent surgery in our clinic during the period from 2009 through 2019. A CV was found in 125 (24.3%) patients. CV transposition was considered possible in cases where the diuretic loading test revealed a decrease in the pelvic volume following the correction of vascular compression, absence of structural changes in the UPJ area or hemodynamic abnormalities in the lower renal pole area. 17 (13.6%) of the patients matched the mentioned criteria and underwent the transposition performed according to an original method. After mobilization of the renal pelvis, UPJ and CV, an inverted U-shaped flap was formed from the fascia covering the anterior wall of the pelvis. The fascia of the anterior wall was dissected horizontally on the UPJ level. From the initial and final points of the section, two parallel 15-20 mm incisions were made to the level of the major renal vessels. The fascia was mobilized from the anterior wall of the renal pelvis, then the fascial flap was passed below the CV to form a "hammock". The free edge of the flap was sutured with individual stitches to its base.

RESULTS

During follow-up observation (from 12 to 24 months), absence of symptoms was noted in all 17 patients as well as decreasing hydronephrosis and normalization of diuretic renography findings.

CONCLUSIONS

The method is highly effective, easy to reproduce, and has no limitations typical of the Chapman and Hellstrom techniques.


VD-17 (VS without presentation)

LAPAROSCOPIC AUTOAUGMENTATION

Ali TEKIN, Hasan ÇAYIRLI, İlker Zeki ARUSOĞLU, Uygar BAĞCI and İbrahim ULMAN
Ege University, Pediatric Surgery and Pediatric Urology, Izmir, TURKEY

PURPOSE

In this video, we present a laparoscopic autoaugmentation procedure in a patient with neuropathic bladder.

CASE

A 9-year-old girl with spina bifida was under follow-up with a low-compliant neuropathic bladder and unilateral vesicoureteric reflux. She was incontinent despite regular clean intermittent catheterizations and anticholinergic medication. She also had ongoing urinary infections despite prophylaxis. The video-urodynamic study revealed low capacity, high detrusor leak point pressure, low compliance, and right grade 3 vesicoureteric reflux. She was scheduled for laparoscopic autoaugmentation and cystoscopic subureteric injection.

METHOD

The procedure started with visualization of the urethra and bladder with a 9.5 F cystoscope in the dorsolitotomy position. The bladder was severely trabeculated with multiple diverticula. Subureteric injection of 0.3 ml DxHA was performed. Then, the patient was turned to supine position. A 5 mm port was introduced via umbilicus with two additional working ports under vision. The bladder was distended with saline. The peritoneum was dissected off the bladder, starting with sharp dissection from the anterior abdominal wall. Detrusor was incised vertically at the midline with hook cautery from the lower anterior wall to the trigon level posteriorly. Particular attention was given to preserve bladder mucosa intact. In the early postoperative period, the urinary catheter was kept 20-30 cm above the bladder level to keep it distended. Bladder capacity increased to 300 ml, and the patient was free of urinary infections and dry between CIC intervals at 3 months of postoperative follow-up.

CONCLUSIONS

Laparoscopic autoaugmentation is a practical and effective method for the treatment of poor compliance and volume in selected cases with neuropathic bladder.


VD-18 (VS without presentation)

"Y"/"Λ" DUPLICATION OF THE URETHRA (EFFMAN TYPE II A2)

Bashir AHMED 1, Philip G. RANSLEY 1, Sadaf ABA UMER KODWAVWALA 1, Sajid SULTAN 2 and Syed Adib Ul Hassan RIZVI 1
1) Sindh Institute of Urology & Transplantation, Philips G. Rensley Department of Paediatric Urology, Karachi, PAKISTAN - 2) Sindh Institute of Urology & Transplantation, Philips G Rensley Department of Paediatric Urology, Karachi, PAKISTAN

PURPOSE

The commonest urethral duplication is the so called "Y"/ "λ" type. This video demonstrates one approach utilising the P.A.D.U.A technique, the perineal approach for dorsal limb transposition and a 2nd stage BMG onlay to complete the urethroplasty.

MATERIAL AND METHODS

5 months old boy with typical "Y"/ "λ"- duplication. Patient was voiding through anal opening with good caliber stream. The orthotopic urethra was patent in the penile segment but atretic in the bulbar segment.
Under general anesthesia we performed repeated P.A.D.U.A procedure to identify and dilate the atretic bulbar urethra, starting with a glide wire (0.025) and increasing up to 10FG silicone catheter. The posterior urethral limb was transposed to the perineum. The hidden atretic urethra could be identified between the corpora as a consequence of P.A.D.U.A and was splayed open. Thus the posterior wall of perineal urethrostomy was created by joining the transposed posterior urethra and proximal end of the healthy penile urethra. Patient had protective colostomy for few months. A second stage BMG onlay was performed to close the perineal urethra and successfully allow the patient to void through the terminal meatus.

RESULTS

Follow-up 22m, not potty trained, No post void residual. No voiding symptoms.

CONCLUSIONS

We could successfully restore normal voiding through penile tip with the help of P.A.D.U.A technique by reconstructing the urethra as a staged procedure.


VD-19 (VS without presentation)

HOLMIUM LASER EN BLOC RESECTION OF URETHRAL POLYPS IN PEDIATRIC AGE GROUP: A NOVEL TECHNIQUE.

Ahmed ATWA, Abdelwahab HASHEM, Mohamed EDWAN, Mohamed SOLTAN, Ahmed ABDELHALIM, Tamer HELMY, Ashraf HAFEZ and Mohamed DAWABA
Urology and Nephrology Center,Mansoura University, Mansoura, Egypt., Urology, Mansoura, EGYPT

PURPOSE

To use a new technique for en block resection of urethral polyps in pediatric age group because en bloc resection using diathermy is not feasible in narrow working space caused by large polyps. Moreover, conventional resection is time consuming and yields small chunks of tissue.

MATERIAL AND METHODS

A case report of congenital fibroepithelial polyp (FEP) in pediatric age group who underwent Holmium Laser En Bloc Resection (HoLER).

RESULTS

The operative time was 4.5 minutes from cystoscope introduction till polyp retrieval. The pathology result was benign FEP with no evidence of malignancy. After 1-month follow-up, the boy had adequate urinary stream which was confirmed by uroflowmetery.

CONCLUSIONS

HoLER of urethral polyps in pediatric age group could be used as an alternative to conventional resection especially when working in narrow spaces in close proximity to the urethral sphincter with the advantage of short operative time and intact tissue for pathological examination. A long-term follow-up is warranted.


VD-20 (VS without presentation)

RETROPERITONEOSCOPIC HORSESHOE NEPHRECTOMY FOR DILATED NON-FUNCTIONING RIGHT MOIETY

Clara CHONG, Pankaj MISHRA, Anu PAUL, Arash TAGHIZADEH and Massimo GARRIBOLI
Evelina Children Hospital, Paediatric urology, London, UNITED KINGDOM

PURPOSE

We present a video of Retroperitoneoscopic horseshoe nephrectomy for dilated non-functioning right moiety in a child.

MATERIAL AND METHODS

A 20 month-old boy weighing 12kg with horseshoe kidney and grossly dilated non-functioning right moiety. Serial ultrasound showed worsening dilatation and a DMSA confirmed absence of function. Patient was asymptomatic with no raised blood pressure, pain or history of infection.

The procedure has been performed with the patient in prone position. Transverse 10mm incision was made half-way between 12th rib and iliac crest, lateral to sacrospinal muscles. A dissecting balloon was used to develop the retroperitoneal space and a Hassan port was inserted with insufflation of 12mmHg. A Single 5mm working port was inserted laterally. Vessels have been ligated with 5mm clip applicator. Specific attention was paid to close proximity of IVC to renal vein insertion. Isthmus divided with Harmonic scalpel. Minimal blood loss.

RESULTS

Discharged day 1 post procedure. Follow up ultrasound demonstrated empty right renal bed and normal left moiety.

CONCLUSIONS

Retroperitoneoscopic horseshoe nephrectomy with single working port is a safe and feasible procedure with good cosmetic and functional outcome.


VD-21 (VS without presentation)

PNEUMOVESICOSCOPIC REIMPLANTATION WITH INTRAVESICAL TAILOING OF THE OBSTRUCTIVE MEGAURETER IN CHILDREN

Yuriy RUDIN 1, Diamid MARUKHNENKO 2, Daria GALITSKAJA 2 and Giorgiy LAGUTIN 2
1) N.Lopatkin's Research Institute of Urology and IR - branch "NMRC radiology" MH RF,, Paediatric Urology, Moscow, RUSSIAN FEDERATION - 2) N.Lopatkin's Research Institute of Urology and IR - branch "NMRC radiology" MH RF DERATION, Paediatric Urology, Moskow, RUSSIAN FEDERATION

PURPOSE

Propose a method for intravesical tailoring of the wided ureter during pneumovesicoscopic reimplantation

MATERIAL AND METHODS

During the period from 2014 to 2019, 44 Cohen pneumovesicoscopic cross-trigonal ureteral reimplantations were performed in 39 children (5bilateral) aged 1-12 years.( mean 3.1) PMR 3-4st (14). Obstructive megaureter(24). Ureterocele (3), diverticulum of the bladder (3).   Under cystoscopic control,   midline 5-mm trocar was introduced for  telescope at the dome of the bladder, and 2 - 3 mm trocars were inserted through the anterolateral wall. Intravesical tailoring of the ureter was performed in 9 children. The ureter was fixed to the front wall of the bladder with  loop using a Tahuoka’s needle. The ureter was tailored  with interrupted  vicril 4\0 suture for 6cm distance. Ureteroneocystomy was performed using  5\0 interrupted absorbable sutures. Ureter drainage was performed with an external  J-stent  for 1 month period . The urethral  catheter  10 Ch  was removed  3-4 days after the procedure and the patients were discharged on day 5.

RESULTS

  Mean operating time was 142 min (range 83-235 min). 1 patient required conversion to the open technique. Renal US were obtained in all patients between 3-6-12 months postoperatively, the size of the pelvis and ureter were decreased, VCUG was detected reflux in 3 out of 39 patients (7.6%), endoscopic correction was successful.  

CONCLUSIONS

Our experience seems to confirm that pneumovesicoscopic cross-trigonal ureteral reimplantationcan be performed safely and effectively. And the method of fixing wide ureter to the bladder wall with loop in a Tahuoka's  needle helps speed up narrowing of the ureter  


VD-22 (VS without presentation)

SINGLE-PORT ROBOTIC MITROFANOFF IN A PEDIATRIC PATIENT

Niki PARIKH, Bridget FINDLAY, Timothy BOSWELL, Candace GRANBERG and Patricio GARGOLLO
Mayo Clinic- Rochester, Urology, Rochester, USA

PURPOSE

Pediatric surgery began with single-incision flank surgery and has evolved to standard multi-port laparoscopic and robotic approaches. To decrease visibility of incisions, hidden incision endoscopic surgery was developed. Recent technological advances with the single-port (SP) robot have allowed for transition back to single-incision surgery.

MATERIAL AND METHODS

A 14-year-old paraplegic male with neurogenic bowel and bladder presented with difficulty performing clean intermittent catheterization. The decision was made to perform the first SP robotic Mitrofanoff procedure in a pediatric patient. The SP platform has one 2.5 cm, 4-channel port, a 12X10 mm articulating camera, and 6mm multi-wristed instruments, including the Maryland dissecting forceps, Cadiere forceps, wristed needle driver, and curved scissors.

RESULTS

The port was placed in the patient’s previous gastrostomy tube site, and SP robotic Mitrofanoff was completed successfully without issues with space, triangulation or articulation. There is loss of insufflation with use of laparoscopic instruments through an SP channel, as the seal on the port does not maintain a closed working system. Postoperatively, the patient did not require opioid pain medications and was discharged in <24h without complications.

CONCLUSIONS

Single-port robotic surgery is feasible in pediatric patients, but patient selection is fundamental to success. To optimize use, a 10-cm working distance must be maintained, limiting use to older children and teenagers. To help improve working space a Gel-Port can be utilized, and needles can be placed into the abdomen after incision and prior to port placement to prevent loss of insufflation. Future development of the platform is needed to widen application to smaller patients.


VD-23 (VS without presentation)

SINGLE-PORT ROBOTIC PYELOPLASTY IN A PEDIATRIC PATIENT

Niki PARIKH, Timothy BOSWELL, Bridget FINDLAY, Patricio GARGOLLO and Candace GRANBERG
Mayo Clinic- Rochester, Urology, Rochester, USA

PURPOSE

Pediatric surgery began with single-incision flank surgery and has evolved to standard multi-port laparoscopic and robotic approaches. To decrease visibility of incisions, hidden incision endoscopic surgery was developed. Recent technological advances with the single-port (SP) robot have allowed for the transition back to single-incision surgery.

MATERIAL AND METHODS

A 10-year-old female presented with symptomatic right ureteropelvic junction obstruction and worsening hydronephrosis. The decision was made to perform the first SP robotic pyeloplasty procedure in a pediatric patient. The SP platform has one 2.5 cm, 4-channel port, a 12X10 mm articulating camera, and 6mm multi-wristed instruments, including the Maryland dissecting forceps, Cadiere forceps, wristed needle driver, and curved scissors.

RESULTS

The port was placed in the Pfannenstiel line, and SP robotic pyeloplasty was completed successfully without issues with space, triangulation or articulation. There is loss of insufflation with use of laparoscopic instruments through an SP channel, as the seal on the port does not maintain a closed working system. Postoperatively, the patient did not require opioid pain medications and was discharged in <24h without complications.

CONCLUSIONS

Single-port robotic surgery is feasible in pediatric patients, but patient selection is fundamental to success. To optimize use, a 10-cm working distance must be maintained, limiting use to older children and teenagers. To help improve working space a Gel-Port can be utilized, and needles can be placed into the abdomen after incision and prior to port placement to prevent loss of insufflation. Future development of the platform is needed to widen application to smaller patients.


VD-24 (VS without presentation)

LAPAROSCOPIC LOW URETERO-URETEROSTOMY: INITIAL EXPERIENCE IN ECTOPIC URETER

Daniel CABEZALÍ 1, Cristina TORDABLE 2, Ruben MARTIN 2, Leonor MELERO 2 and Andres GOMEZ 2
1) 12 de Octubre Hospital, Pediatric Surgery. Urology Division, Madrid, SPAIN - 2) 12 DE OCTUBRE HOSPITAL, PEDIATRIC SURGERY. UROLOGY SECTION, Madrid, SPAIN

PURPOSE

In cases with duplication anomalies of the urinary tract and functional ectopic ureter several conservative treatment could be proposed: upper pyelopyelic anastomosis, reimplantation of the two ureters of the same kidney, and lower ureteroureterostomy. We describe our initial experience in laparoscopic low ureteroureterostomy to treat them.

MATERIAL AND METHODS

We performed a laparoscopic low ureteroureterostomy with end- to- side anastomosis in 3 cases with ectopic ureter, without reflux and with a functioning upper pole.  Cystoscopy  and stent placement in the recipient ureter were performed at the beginning of each case. Demographic data, indication, laterality and intraoperative and postoperative complications, length of hospitalization and outcome were recorded.

RESULTS

All patients were female and the mean patient age was 3, 4 and 5 years respectively. The ectopic ureter were on the left side in two cases and on the right side in one and the mean of distal ureter diameter  were 0,7- 0,8 and 2 cm respectively. Ureteral catheters were left for 72 h and the hospital stay were 3 days in one patient and 5 days in two. Mean operative time including cystoscopy was 110 minutes and there were no intra- and no postoperative complications. The ureterohydronephrosis decreased in all  cases and parenchyma function of the upper poles were considered as normal. Actually all the patients are asymptomatic.

CONCLUSIONS

Ureteroureterostomy is a safe and effective technique for the reconstruction of functional ectopic ureter and duplication anomaly  of the urinary tract, even when there is a size discrepancy between the donor and recipient ureter.


VD-25 (VS without presentation)

VESICOSCOPIC KROPP BLADDER NECK PROCEDURE IN A CASE OF REFRACTORY URINARY STRESS INCONTINENCE

Ruben ORTIZ, Alberto PARENTE, Laura BURGOS, Beatriz FERNANDEZ-BAUTISTA and José María ANGULO
Hospital Universitario Gregorio Marañón. Madrid., Pediatric Urology Division, Madrid, SPAIN

PURPOSE

To report a vesicoscopic Kropp bladder neck procedure in a female with refractory stress urinary incontinence.

MATERIAL AND METHODS

We present a 15 year old female with refractory stress urinary incontinence. She had previously received standard urotherapy and biofeedback, anticholinergic (solifenacin 10 mg) treatment and percutaneous tibial-nerve stimulation (PTNS) with no improvement of continence. Two endoscopic bladder neck injection of bulking agent (Deflux ™ and Macroplastique®) were done years before with no long-term success. Preoperative urodynamic study revealed bladder volume of 560 ml, with adequate compliance and no uninhibited contractions. VCUG and lumbosacral Rx were normal. With the patient in supine position, bladder fixation to the anterior abdominal wall is done by percutaneous suture to facilitate the placement of three 5-mm ports under cystoscopic vision. The bladder is insufflated with CO2, then an anterior bladder neck (2 cm long) flap is dissected and sutured on both sides of the bladder catheter (16 Ch) to the posterior bladder neck wall. Bladder catheter is percutaneously fixed through one port.

RESULTS

Operating time was 225 minutes, with hospital stay of 72h. Postoperative period was uneventful and bladder catheter was removed on the 14th postoperative day. Two years after the procedure the patient maintains dry with no UTIs, performing micturition every 4h and with no medication.

CONCLUSIONS

The vesicoscopic approach allows optimal access to the bladder neck. Kropp bladder neck procedure by this route is a feasible, safe and non-invasive technique that may be considered in selected patients.


VD-26 (VS without presentation)

ROBOT-ASSISTED LAPAROSCOPIC (RAL) EXTRAVESICAL URETERAL TAPERING AND REIMPLANTATION FOR OBSTRUCTED MEGAURETER IN CHILDREN.

Waleed EASSA 1, Amr ZOAIER 2, Sherif MIJAHED 3, Fawzy ABUL 2 and Ramnath SUBRAMANIAM 4
1) SABAH AL AHMAD UROLOGY CENTER (SAUC), PEDIATRIC UROLOGY, Kuwait, KUWAIT - 2) Sabah Al-Ahmad Urology Center (SAUC), Kuwait, KUWAIT - 3) Sabah Al-Ahmad Urology Center (SAUC ), Kuwait, KUWAIT - 4) St James's Hospital, Paediatric Urology, Leeds, UNITED KINGDOM

PURPOSE

In this video we demonstrate our technique of Robot-assisted Laparoscopic (RAL) extravesical ureteral Tapering and reimplantation for obstructed megaureter in children step by step highlighting its feasibility. 

MATERIAL AND METHODS

An 8 years old female child suffering left loin pain was diagnosed with left obstructed megaureter.  In complete supine position and after side docking of the Da Vinci Si Robot, three ports were established. The bladder was hitched and the megaureter was identified. The narrow distal segment is dissected down to bladder followed by detrusorotomy. The dilated proximal segment chosen for tailoring is hitched to the abdominal wall, trimmed, tailored using running 5/0 PDS then stented percutaneously. The stenotic distal ureter was divided from the bladder and the neo-ureterovesical anastomosis was fashioned using 5/0 PDS interrupted sutures after passing the lower coil of the stent into the bladder. Detrusorrhaphy was done using interrupted 5/0 Vicryl starting proximally to bury the tailored ureter within the tunnel with a length: width ratio of at least of 3:1. 

RESULTS

The total console time was 126 minutes. No blood loss. Oral NSAIDs were sufficient for control of postoperative pain. The child was fully active in the following morning. Foley was removed in the 1st PO day and the DJ stent after 8 weeks. Ultrasonography 3 months later showed receding hydroureteronephrosis and the MAG3 study showed resolution of obstruction.

CONCLUSIONS

Robot-Assisted Laparoscopic extravesical ureteral tapering and reimplantation for obstructed megaureter in children is feasible if a standardized technique is followed.


VD-27 (VS without presentation)

ROBOTIC MONTI IN A PATIENT WITH A PRIOR MALONE PROCEDURE

Alexandra REHFUSS 1, Molly FUCHS 1, Kristina BOOTH 2, Jennifer SMITH 3, Richard WOOD 2 and Daniel DAJUSTA 1
1) Nationwide Children's Hospital, Urology, Columbus, USA - 2) Nationwide Children's Hospital, Center for Colorectal and Pelvic Reconstruction, Columbus, USA - 3) Nationwide Children's Hospital, Columbus, USA

PURPOSE

Patients with neurogenic bladder often benefit from catheterizable channels to facilitate intermittent catheterization. The appendix is preferentially used to create these channels, however if it is not available ileum can be used to create a Monti channel, for which the robotic approach has not been described. The use of the robotic approach in patients with prior abdominal surgery has been cautioned due to the potential for adhesions which could limit visualization and mobility. We present a case of robotic creation of a Monti channel in a patient with a prior Malone procedure.

MATERIAL AND METHODS

We evaluated a 6-year-old female with a history of sacrococcygeal teratoma, neurogenic bowel and bladder. At 3 years old, she underwent laparoscopic Malone appendicostomy, which was placed at the umbilicus. Three years later she presented with new onset urinary incontinence due to incomplete bladder emptying. She did not tolerate intermittent catheterization per urethra, and it was recommended she undergo creation of a Monti channel.

RESULTS

Patient underwent robotic assisted laparoscopic creation of a Monti channel. Camera port was placed cephalad to the Malone. There were no significant adhesions. Console time was 320 minutes. Blood loss was minimal. She had an uneventful post-operative course and was discharged home on day 4. She is dry on CIC every 3 hours and there have been no complications at 20 months follow up.

CONCLUSIONS

Monti creation using the robotic approach is safe and feasible. Previous abdominal surgery should not deter one from utilizing the robotic approach.


VD-28 (VS without presentation)

ROBOTIC ASSISTED TRANS-VESICOSCOPIC URETERIC REIMPLANTATION IN CHILDREN: A VIDEO ATLAS

M S ANSARI 1, Priyank YADAV 2 and Vinay KAUSHIK 2
1) Sanjay Gandhi Postgraduate Institute of Medical Sciences, Pediatric Urology, Department of Urology and renal transplantation, Lucknow, INDIA - 2) Sanjay Gandhi Postgraduate Institute of Medical Sciences, Division of Pediatric Urology, Department of Urology and Renal Transplanation, Lucknow, INDIA

PURPOSE

The authors here in present the technique and the feasibility of trans- vesicoscopic ureteric re- implantation (TVUR) in children.

MATERIAL AND METHODS

Three children between 2 and 14 years of age with bilateral primary vesicoureteric reflux (VUR)   underwent TVUR at a tertiary referral center in Northern India. The grade of VUR ranged between   II - IV, all 3 bilateral. da Vinci Xi surgical system was used.   All surgeries were performed by a single surgeon. The patient was placed in a dorsal lithotomy position. Four  ports [Two 8-mm working ports were placed in a straight line drawn along the anterior superior iliac spine and one  endoscopic (middle) 12 mm (Intuitive Surgical, Sunnyvale, CA), was placed 2 cm above   the same line and  the fourth assistant port of 3 mm was placed 2 cm below the line. Success was defined as the absence of VUR on direct radionuclide cystogram at 12 weeks.

RESULTS

A total of 3 patients underwent robotic TVUR. The age was 2, 7 and 14 years with urinary bladder capacity of 150, 280 and 400 cc respectively.  The first case done was that of 14 then 7 and the last of 2 years.  The operative time ranged between 190-300 minutes (Median 250).

The procedure could be accomplished in all the cases without any slippage of robotic ports or clashing of arms except in 2-year-old that without any conversion. The 2-yr-old child with bladder capacity of 150 cc posed little difficulty due to space restriction and slight clashing of arms that lengthened the procedure but could be completed successfully. The cystogram done at 12 weeks showed grade I VUR in one of the child and is on follow up.

CONCLUSIONS

Robotic assisted laparoscopic ureteral reimplantation is feasible and offers good success rate.   More number of cases are required to   determine further the costs and benefits of robotic assisted laparoscopic ureteral reimplantation.  


VD-29 (VS without presentation)

LAPAROSCOPIC ROBOT ASSISTED HYSTERECTOMY AND VAGINAL RESECTION IN A MALE ADOLESCENT WITH DSD DIAGNOSIS

Pia LOFGREN 1, Gundela HOLMDAHL 2 and Marie ANDERSSON 3
1) Queen Silvias Childrens hospital, Det of Pediatric Surgery and Urology, Gothenburg, SWEDEN - 2) Queen Silvias Childrens hospital, Dep of pediatric surgery and urology, Gothenburg, SWEDEN - 3) Queen Silvias Childrens hospital, Dep og pediatric surgery and urology, Gothenburg, SWEDEN

PURPOSE

To present a laparoscopic robot assisted hysterectomy in a 17-year-old male with mixed gonadal dysgenesis

MATERIAL AND METHODS

Now 17-year-old male born with ambiguous genitalia and diagnosed with mixed gonadal dysgenesis with chromosomes X0/XY. Hypospadias repair with a Duckett tube, scrotal fixation of a right sided testis and extirpation of left streak gonad and fallopian tube was done early. Reoperation of the hypospadias was done at 7 years of age due to a dilated tube with strictures.
He was followed by the local DSD team and went into spontaneous male puberty with a male identity. Normal sexual function. GH treatment was given due to short stature.
During puberty he developed dribbling of urine, recurrent cystitis and suprapubic pain. Urinary flow and residual results acceptable, but earlier VCUG had shown reflux of urine into the vagina entering posterior urethra and repeated ultrasound showed increasing dilatation of the vagina and uterus.
At MDC and after patient consent, decision was taken to remove uterus and vagina.

RESULTS

Procedure started with endoscopy revealing a grossly dilated uterus and vagina entering with a wide opening into the posterior urethra. Laparoscopic robot assisted hysterectomy and removal of the upper part of vagina, leaving a small residual adjacent to the urethra, was done.
Hospital stay was 2 days and follow up was done 2 months and 1 year postoperatively.
No complications has evolved and the patient is free from symptoms. Uro-flow after 2 months shows normal flow and no residuals.

CONCLUSIONS

For this young man it was relatively easy and feasible to remove uterus and vagina with the laparoscopic robot assisted technique.
Short postoperative stay and good results.


VD-30 (VS without presentation)

LAPAROSCOPIC URETEROPELVIC ANASTOMOSIS BETWEEN MOIETIES, ANOTHER TREATMENT OPTION FOR OBSTRUCTIVE ECTOPIC MEGAURETER

Antonio RECOBER MONTILLA, Ángel Javier GALLEGO FERNÁNDEZ, Rodrigo TEJERINA LÓPEZ, Charlotte STOUT-DORE, Luis Fernando IBAÑEZ CERRATO and Moisés Javier MIELES CERCHAR
Hospital Regional Universitario de Málaga-Hospital Materno Infantil, Pediatric Urology, Málaga, SPAIN

PURPOSE

The aim of this video is to present an effective option for the treatment of a complete duplex kidney with an ectopic, obstructive, functional upper moiety ureter in a horseshoe kidney.

PATIENT AND METHODS

21 Months old girl with a horseshoe kidney associating a complete right duplex kidney with a dilated upper moiety. She also presented a polimalformative syndrome (Biventricular hypertrophy, agenesis of the corpum callosum) and hyperlactatemia.

During follow up, patient presented 3 urinary tract infections (one of them febrile) and an increase of the ureteral size in the successive ultrasounds (2 cm). A MAG-3 scyntigraphy was carried out, showing a 42.47% function of the upper moiety (from a 42.9% right kidney function).

RESULTS

Firstly, a cystoscopy was performed, showing an ectopic right ureter. A JJ catheter was placed. Then, an ureteropelvic laparoscopic anastomosis was carried out between the upper moiety's ureter and the lower moiety's pelvis. The JJ catheter was advanced to the pelvis. Removal of the ureter of the upper moiety was then performed. In post operatory exams the dilatation decreased and patient was asymptomatic.


The anastomosis between systems of the upper and lower moieties is an effective option when both of them work. Given the discordance of size between ureters, we decided to perform an ureteropelvic anastomosis with a satisfactory outcome.

CONCLUSIONS

This procedure is a valid treatment option in a duplex kidney where both moieties work and there is an obstructive ectopic ureter, avoiding ureteral re-implant in an unaltered bladder.


VD-31 (VS without presentation)

APPLICATION OF INDOCYANINE GREEN FOR LYMPHATIC PRESERVATION IN THE TREATMENT OF VARICOCELE

Beatriz FERNÁNDEZ-BAUTISTA, Laura BURGOS, Javier ORDÓÑEZ, Rubén ORTIZ, Alberto PARENTE and Jose María ANGULO
Gregorio Marañón Hospital, Pediatric Urology, Madrid, SPAIN

PURPOSE

The development of new minimally invasive techniques in pediatric surgery has allowed the recent introduction of indocyanine green making easier anatomic dissection.

The aim of the study is to present the use of indocyanine green by intratesticular injection in laparoscopic Palomo surgery with preservation of lymphatic vessels in two patients with varicocele.

MATERIAL AND METHODS

We present two patients (15 and 13 years old) with left varicocele who underwent surgery using a laparoscopic Palomo technique.

A 5 mm umbilical trocar and two accessory trocars are introduced on both flanks in order to dissect spermatic vessels. Once the vessels have been dissected, the injection of 2 ml intratesticular indocyanine green (25 mg solution in 8 ml of bidistilled water) is performed. A few seconds later, the lymphatics appear fluorescent by infrared light. Therefore, the ligation of the spermatic vessels is performed making preservation of the lymphatic vessels much easier.

RESULTS

In both cases hospital stay was less than 24 hours. There were no local complications (hematoma, skin staining, increased scrotal volume).
One year later, no lymphocele or recurrence of varicocele occurred.

CONCLUSIONS

The use of fluorescence with indocyanine green in minimally invasive laparoscopic surgery has proven to be a safe technique that improves the intraoperative localization of anatomical structures.
We present its use in varicocele to prevent lymphatic vessel ligation and reduce some of its long-term complications.


VD-32 (VS without presentation)

ROBOTIC-ASSISTED URETEROCALICOSTOMY : STEP BY STEP TRANSMESOCOLIC APPROACH

Valeska BIDAULT JOURDAINNE, Pauline LOPEZ, Matthieu PEYCELON, Alaa EL GHONEIMI and Annabel PAYE JAOUEN
Pediatric urology department, Robert Debré University Hospital, AP-HP, University of Paris, National Reference Center For Rare Urinary Tract Malformations (MARVU), Paris, FRANCE

PURPOSE

Laparoscopic ureterocalicostomy (LUC) is efficient to treat pediatric ureteropelvic junction obstruction (UPJO), primarily in particular anatomic cases (exaggerated intrarenal pelvis, lower pole calicectasis, kidney malrotations) or after failed pyeloplasty. Robotic-assisted laparoscopy has recently spread through pediatric surgical teams, and can be applied to LUC. This video shows step by step robotic-assisted ureterocalicostomy.

MATERIAL AND METHODS

Among 8 LUC at our center, six patients were done by standard laparoscopic approach, and the last two were done by robotic-assisted procedure (DaVinci© Xi System). The submitted video shows a 14-year old boy who had dismembered open pyeloplasty for left UPJO during early childhood, but 13 years later he had recurrent left renal colic revealing persistant UPJO on MRI, with extreme parenchymal thining (3mm) of inferior calyx. The patient was positionned supine with a lumbar padding under the left flank. We have used three 8mm robotic ports, one AirSeal© 5mm assistant port, and one transparietal 2mm laparoscopic grasper for exposure. Transmesocolic approach of the UPJ was performed. LUC was done between lower calyx and spatulated proximal ureter using a 5/0 absorbable running suture over a JJ stent.

RESULTS

Operative time was 215 minutes. No per-operative complication occurred. The patient was discharged 18 hours after surgery with oral paracetamol, his JJ stent removed after one month, and displayed improvement of pelvic diameter on abdominal ultrasound 2 months later.

CONCLUSIONS

Robotic-assisted ureterocalicostomy is feasible and safe for recurrent UPJO in children.


VD-33 (VS without presentation)

LAPAROSCOPIC URETERO-CALICOSTOMY WITHOUT RESECTION OF URETERO-PELVIC JUNCTION(UPJ) FOR MEGACALICOSIS

Yaqoub JAFAR 1, Daniela Brindusa GORDUZA 1, Aurora MARIANI 1, Marc BARRAS 1, Guillaume ROSSIGNOL 1, Delphine DEMEDE 1 and Pierre Yves MURE 2
1) Hospices Civils de Lyon, Hôpital Mère-Enfant, Department of Pediatric Surgery and Urology, Lyon, FRANCE - 2) Université Claude Bernard Lyon 1, Hospices Civils de Lyon, Hôpital Mère-Enfant, Department of Pediatric Surgery and Urology, Lyon, FRANCE

PURPOSE

Megacalicosis is often challenging to manage. When surgery is indicated, main reported procedures consist in open uretro-calicostmy after division of UPJ. In this video, we describe a laparoscopic approach for uretero-caliceal anastomosis without resection of UPJ.

MATERIAL AND METHODS

A 7 years old boy presented with left pyelonephritis. Renal ultrasound and MRI showed major calyceal dilatation (between 40 to 50 mm) and pelvic dilatation 20 mm. The pre-operative MAG 3 showed a loss of left side renal function (40 %).   

Surgical technique: the patient was positioned in 45°lateral decubitus. Five mm scope and 3.5 mm instruments were used. After exposure of the renal pelvis, drainage through the junction appeared normal. Proximal ureter and inferior calyx were dissected, opened and approximated. Latero- lateral end uretero-calicostomy was then performed. Double J stent was inserted before the end of the anastomosis.

RESULTS

Post-operative course was event free. During follow up (16 month), renal ultrasound showed disappearance of calyceal dilatation and left side renal function was 44% on Mag3 isotopic study.

CONCLUSIONS

Laparoscopic latero- lateral end uretero-calicostomy without resection of UPJ appeared to be a valuable alternative technique to manage megacalicosis in children. This preliminary experience needs to be strengthened by other cases.


VD-34 (VS without presentation)

ROBOTIC BLADDER NECK PLICATION FOR INCONTINENCE TREATMENT

Dario Guido MINOLI 1, Giancarlo ALBO 2, Erika Adalgisa DE MARCO 1, Michele GNECH 1, Alfredo BERRETTINI 1, Emanuele MONTANARI 2 and Gianantonio MANZONI 1
1) Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Paediatric Urology, Milan, ITALY - 2) Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Urology, Milan, ITALY

PURPOSE

The robotic approach allows to easily perform reconstructive procedures in the pelvis. In this video we describe bladder neck plication, robotically assisted, to achieve continence in an adolescent girl.

MATERIAL AND METHODS

A 12 year-old-girl has been evaluated in our Center for persistent total urinary incontinence.

She was initally treated elsewhere for a vaginal ectopic left megaureter with uretero-vescical reimplant and subsequently with multiple bulking agent endosocopic injections.

Cisto-colposcopy revealed a short urethra and a patulous bladder neck. Ectopic ureteric stump was visibile between urethral and vaginal openings. MCU and urodynamic evaluation showed a bladder with incontinence starting from 60ml with a capacity of 200 ml without developing high voiding pressures. A laparoscopic robotic-assisted bladder neck plication was electively selected as already described for incontinence both in epispadias repair and after robotic prostatectomy.

RESULTS

The patient was discharged on 4th post-operative day without complications. After 2 months a MCUG confirmed spontaneous voiding (bladder volume 300cc) without post-void residuals and renal US showed normal upper urinary tracts. After 6 months, she remains completely dry.

CONCLUSIONS

Anatomical access to the bladder neck region is extremely difficult in open surgery especially in adolescent patients. Robotic access is an excellent alternative with optimal anatomical exposure.

Bladder neck plication, compared to full reconstruction ("keel" bladder neck) is a less invasive procedure and ideal to obtain adequate voiding continence in selected patients.


VD-35 (VS without presentation)

ROBOTIC-ASSISTED LAPAROSCOPIC MANAGEMENT OF MULLERIAN DUCT REMNANTS

Dario Guido MINOLI 1, Maria Chiara SIGHINOLFI 2, Erika Adalgisa DE MARCO 3, Michele GNECH 3, Alfredo BERRETTINI 3, Bernardo ROCCO 2 and Gianantonio MANZONI 3
1) Fondazione IRCCS Ca Granda - Ospedale Maggiore Policlinico, Paediatric Urology, Milan, ITALY - 2) Azienda Ospedaliero-Universitaria - Policlinico di Modena, Urology, Modena, ITALY - 3) Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Paediatric Urology, Milan, ITALY

PURPOSE

The robotic approach allows to easily perform reconstructive procedures in the pelvis. In this video we describe the management of a mullerian remnant and its robotic removal in a patient with DSD.

MATERIAL AND METHODS

A 17 year-old-boy with mixed gonadal dysgenesis (45X/46XY) was initially treated elsewhere for severe hypospadias with multiple procedures. In 2011 an MRI revealed a cystic mass between rectum and bladder, defined as a persistent mullerian remnant. In 2017 he was evaluated in our hospital for urethral diverticulum and persistent severe ventral curvature. Despite a successful two-stage Bracka procedure and curvature correction he subsequently complained of urinary incontinence and recurrent UTI related to the large Mullerian remnant. A robotic assisted removal of the vaginal remnant was electively planned.

RESULTS

No postoperative complications were reported. After 1 month a MCUG showed no leak and a spontaneous and complete voiding. Urethro-cistoscopy confirmed complete closure of the vaginal ostium.

CONCLUSIONS

Robotic access to the bladder neck and urethro-prostatic region is an excellent option with ideal anatomical exposure compared to conventional open surgery. The combined endoscopic/robotic identification of the mullerian remnants allowed its complete definition and removal.


VD-36 (VS without presentation)

ROBOT-ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR RENOVASCULAR HYPERTENSION

Campbell GRANT, Charles CONCODORA, Haris AHMED, Paul NOH and Andrew STRINE
Cincinnati Children's Hospital, Pediatric Urology, Cincinnati, USA

PURPOSE

Our patient is a 5 year old girl with a history of hypertension poorly controlled despite medical therapy. A renal ultrasound revealed right lower pole renal scarring and subsequent renal angiography uncovered dysplastic and stenotic segmental intra-renal arteries. Renal vein sampling revealed increased plasma renin activity within the right renal vein. The family elected to proceed
with partial nephrectomy.

MATERIAL AND METHODS

The patient was positioned in a modified flank position with her right side up and the table tilted to the left, taking care to pad all pressure points. The da Vinci® Xi robotic surgery system (Intuitive Surgical) was docked with a 12mm assistant port in the umbilicus, along with three 8mm ports placed one below the umbilicus and two above. Dissection was then carried out until the entire right kidney was freed and the single renal artery and vein were isolated. Renorrhaphy was performed and the specimen was removed through the umbilical incision.

RESULTS

The patient was discharged home on post-operative day two. Two of her three oral agents were restarted in the hospital, while she remained off of her ACE inhibitor. Six months postoperatively the patient remains off of her ACE inhibitor. Pathology was consistent with arterial muscular hypertrophy.

CONCLUSIONS

Robot-assisted laparoscopic partial nephrectomy can be safe and effective for the treatment of renovascular hypertension in children.


VD-37 (VS without presentation)

MULTICYSTIC RENAL DYSPLASIA IN A CROSSED FUSED RENAL ECTOPIA PRESENTED AS ABDOMINAL MASS IN A NEWBORN

Ruben ORTIZ, Laura BURGOS, Beatriz FERNANDEZ-BAUTISTA, Javier ORDOÑEZ and José María ANGULO
Hospital Universitario Gregorio Marañón. Madrid., Pediatric Urology Division, Madrid, SPAIN

PURPOSE

We report an exceptional case of a crossed fused renal ectopia with multicystic dysplasia of the ectopic renal unit that presented as a palpable abdominal mass in a male newborn.

MATERIAL AND METHODS

A two month-old infant was referred to our institution with prenatal diagnosis of right kidney agenesis and abdominal cystic lesion. A palpable mass was identified in the midline meso-hypogastrium, and right testis was non palpable. Ultrasound scan revealed no visualization of the right kidney and a big multicystic abdominal lesion at the place of the palpable mass. Imaging study was completed with MNR that described a multycistic retroperitoneal mass of 8 x 6 x 2 cm that extended from the bladder dome to the lower left renal pole, imprinting on the renal cortex. No other anomalies were seen on left kidney. Right testis was located in the pelvis. Renal scintigraphy-DMSA scan confirmed solitary left kidney with a rounded imprinting on its lower pole, and no vesicoureteral-reflux was seen at the VCUG.
A laparoscopy was indicated at the age of 18 months confirming right to left crossed fused multicystic renal ectopia and right intraabdominal cryptorchidism. Right nephroureterectomy and first-stage orchiopexy were done uneventfully.

RESULTS

Operating time was 120 minutes and the patient was discharged at 24h with oral analgesia. No complications occurred in the postoperative period. The histological study of the nephrectomy revealed multicystic renal dysplasia.

CONCLUSIONS

Multicystic dysplasia in a crossed fused renal ectopia is a very rare entity that may produce unusual imaging findings and abdominal mass at birth. The laparoscopic approach allowed a feasible, safe and definitive diagnosis and treatment.


VD-38 (VS without presentation)

THE GUD (GLANDAR URETHRAL DISASSEMBLY) TECHNIQUE FOR DISTAL HYPOSPADIAS: A STEP-BY-STEP VIDEO PRESENTATION.

Antonio MACEDO JR 1, Sergio OTTONI 2, Gilmar GARRONE 2, Ricardo MATTOS 2 and Marcela LEAL DA CRUZ 2
1) Federal University of São Paulo and NUPEP/CACAU, Urology, São Paulo, BRAZIL - 2) NUPEP/CACAU, Urology, São Paulo, BRAZIL

PURPOSE

We present an alternative procedure for distal hypospadias consisting of urethral mobilization and partial glandar disassembly, named GUD technique (glandar urethral disassembly). We would like to illustrate in this video all the details of the technique in a step-by-step presentation.

MATERIAL AND METHODS

A subcoronal circumcision exposes distal dysplastic urethra. We incise the Buck´s fascia on both sides of distal urethra releasing it partially from the corpora. We keep a thin bridge of urethral plate to the glans and disassembly almost completely the glans from the corpora, except for the tissue connecting the urethra to the tip of the glans. The glans is incised creating two wide wings that are extremely mobile and allow a thorough refurbishment of the glans. The urethra is mobilized and advanced and the urethral plate is folded and sutured to the tip of the glans. The glans wings  embrace the distal urethra producing a conical and better cosmetic glans. We leave a urethral silicone catheter for 5-7 days.

RESULTS

Patient had a favorable clinical outcome and voids comfortably. No complication was seen, the reconfigured glans healed nicely.

CONCLUSIONS

We are convinced that this operation can be regarded as a genuine alternative to distal hypospadias (coronal and subcoronal) but should not be addressed to midshaft forms.


VD-39 (VS without presentation)

AVOIDING PENILE CURVATURE AFTER KOFF URETHRAL MOBILISATION FOR ANTERIOR HYPOSPADIAS

Aurora MARIANI, Yaqoub JAFAR, Marc BARRAS, Guillaume ROSSIGNOL, Daniela GORDUZA, Delphine DEMEDE and Pierre MOURIQUAND
Femme-Mere Hospital, Paediatric Urology, Bron, FRANCE

PURPOSE

The Koff-Beck urethral mobilization is an elegant way to repair anterior hypospadias without urethroplasty and with minimal complications. One criticism of this technique is the risk of creating a iatrogenic curvature. This video shows how to avoid iatrogenic curvature by anchoring the stretched urethra to the anterior surface of the corpora cavernosa.

MATERIAL AND METHODS

After degloving the penis, the whole penile urethra is detached from anterior face of the corpora cavernosa and then moved forward to bring its opening to the tip of the glans. The urethra is lifted with the corpus spongiosum down to the base of the penis and then stretched in order to gain urethral length. The distal hypoplastic urethra is excised and a the stretched urethra is reattached onto the surface of the corpora cavernosa from the base to the tip of the penis with 7/0 PDS sutures. The last stage of the procedure is the meatoplasty, glans plasty and skin cover with or without reconstruction of the foreskin.

RESULTS

Of 368 Koff procedures performed during early life between 1998 and 2020, 81 are now adolescents or adults. Todate, only one required a subsequent surgery for a symptomatic curvature.

CONCLUSIONS

Koff technique does not use any non-urethral tissues and is a valid procedure for distal hypospadias. Iatrogenic curvature seems to be rare. Further studies in adults are needed.


VD-40 (VS without presentation)

VENTRAL GLANS SUBSTITUTION AND FRENULOPLASTY: TECHNICAL REFINEMENT IN HYPOSPADIAS SURGERY

Satish Kumar AGGARWAL 1, Abdul RASHID 2 and Aparajita MITRA 3
1) SIR GANGA RAM HOSPITAL, PEDIATRIC SURGERY, New Delhi, INDIA - 2) SIR GANGARAM HOSPITAL, NEW DELHI, INDIA, PAEDIATRIC SURGERY, New Delhi, INDIA - 3) AIIMS, NEW DELHI, INDIA, PAEDIATRIC SURGERY, New Delhi, INDIA

PURPOSE

In hypospadias repair, a tight ventral glans closure often leads to ischemic complications like fistula and dehiscence. The concept of septum glandis and frenulum separating the ventral glans wings has recently been proposed. The conventional ventral glansplasty does not conform to this concept. We used a robust dartos flap with inner foreskin to recreate the normal simulating normal anatomy.

MATERIAL AND METHODS

Between January 2010 and October 2019, 340 new cases of hypospadias (age range 6 months to 11 years) were operated. Redo cases and proximal hypospadias were excluded. The degree of glans malformation was estimated by the distance between the glanular hillocks. Urethroplasty was performed by modified TIP technique with hinging of urethral plate on the glans and a free inner preputial skin graft over the dorsal raw area on incised plate. Urethral plate was tabularized. The meatal, glans, frenulum complex was recreated using a pedicled flap of dartos on preputial skin tailored to the dimensions of the ventral triangular defect with dartos providing soft-tissue substitution to the glans and overlying inner prepucial skin replacing the frenulum.

RESULTS

The procedure could be completed in all. Complication rate was 3 % [fistula formation in 5, partial skin necrosis in 2 (healed spontaneously), meatal stenosis in 2 (responded to dilatation)]. Out of five fistulae - two healed spontaneously and 3 required fistula closure. Cosmesis was satisfactory to the parents and the surgeon. Uroflowmetry data from 180 patients (>3 years) showed normal flow patterns in 68 %. Follow up ranges from 3 months to 10 years. There has been no case of recurrent chordee or meatal retraction.

CONCLUSIONS

This is a useful technique to achieve tension free glansplasty, particularly where the glans anatomy does not allow tension free ventral closure.
Note: The presentation will include pictures and videos to illustrate the technique


VD-41 (VS without presentation)

PHALLOPLASTY IN BIOLOGICAL MEN WITH PENILE INSUFFICIENCY.

Céline SINATTI 1, Dylan WOLFF 1, Marlon BUNCAMPER 2, Wesley VERLA 1, Karel CLAES 2, Nicolaas LUMEN 1, Marjan WATERLOOS 1, Stanislas MONSTREY 2, Piet HOEBEKE 1 and Anne-Françoise SPINOIT 1
1) University Hospital Ghent, Urology, Ghent, BELGIUM - 2) University Hospital Ghent, Plastic Surgery, Ghent, BELGIUM

PURPOSE

Phalloplasty for penile insufficiency in biological men differs from phalloplasty in trans-men by incorporating native penile tissue. Different techniques have been suggested but are based on small series. The objective of this study is to describe techniques used in a tertiary referral center with over 30 years of phalloplasty experience and to report surgical and functional outcomes.

MATERIAL AND METHODS

Data of biological men undergoing phalloplasty between 2004-2018 were retrospectively collected. Patients with more than 1 year of follow-up were considered for inclusion. Phalloplasty was performed with a radial free forearm (RFFA) or a pedicled anterolateral thigh (ALT) flap. The tube-within-tube technique was used when urethroplasty was required. Descriptive statistics were used. Complications occuring within 30 days postoperative were categorized according to Clavien-Dindo. Functional outcome was assessed by review of electronic patient files.

RESULTS

30 patients, median (IQR) age of 21 (18-30) year, were included. In 16 patients RFFA was used. 19 patients needed urethroplasty. Median (IQR) follow-up was 33 (14-80) months. Within 30 days postoperative, 3 patients (10%) developed partial flap necrosis (Clavien-Dindo III). One patient (3.3%) had graft failure requiring redo phalloplasty (Clavien-Dindo III). Two patients (6.6%) developed an infected hematoma needing drainage (Clavien-Dindo III). One phalloplasty (3.3%) was complicated with hematuria and clot retention requiring bladder irrigation (Clavien-Dindo II). Long-term complications involved fistulas and strictures. Ten patients (33%) developed fistulas, of whom 6 (20%) needed urethroplasty. Seven patients (23%) had (an) urethral stricture(s), all needing urethroplasty or urethrotomy. All patients but one (97%) had erogenous sensitivity in the neo-phallus. All patients with urethroplasty reported normal, antegrade ejaculation. Sixteen (84%) voided through the urethra.

CONCLUSIONS

RFFA and ALT result in good erogenous sensitivity but fistulas and strictures are frequent.


VD-42 (VS without presentation)

VIDEO: DE CASTRO'S NEO-PHALLOPLASTY FOR INFANTS AND CHILDREN

De Castro ROBERTO 1, Kagantsov ILYA 2, Iaquinto MARIANNA 3, Dubrov VITALI 4 and Golovin ANTON 2
1) Petrucciani Clinic, Pediatric and Urologic Surgery, Lecce, ITALY - 2) Republican Childrens Clinical Hospital, Pediatric and Urologic Surgery, Syktyvkar, RUSSIAN FEDERATION - 3) IRCCS Burlo Garofolo, Pediatric and Urologic Surgery, Trieste, ITALY - 4) Republican Pediatric Urological Centre, Pediatric and Urologic Surgery, Minsk, BELARUS

PURPOSE

In 2007 De Castro reported a technique for total-replacement phalloplasty in 4 children affected by penile-agenesis. In the last 12 years, 43 more procedures were carried out by the same surgeon in young patients affected by severe penile inadequacies. The video shows the latest technical details of De Castro’s Phalloplasty, both in penile agenesis (congenital aphallia) and penile traumatic amputation (acquired aphallia).

MATERIAL AND METHODS

From 2001 to 2019, 47 patients have been treated in 17 different Countries. Sixteen penile-agenesis, 14 traumatic/iatrogenic total amputations, 8 rudimentary micropenis, 6 PAIS, and 3 cloacal-exstrophy. The video document the last cases treated for congenital and acquired aphallia.

RESULTS

Modifications have been introduced. Penile urethra is not reconstructed during the phalloplasty. Rectal ending urethra, when present, is divided from the rectum and sited at the perineal area. A rectangular skin-expander is introduced subcutaneously in the lower abdominal wall 3-6 months before phalloplasty. A composite rectangular skin-flap of the lower abdominal wall is designed to reproduce a cylindrical penile body, spherical glans-penis and urethral meatus. Skin-flap lateral ends are elongated with multiple “Z” pasties to obtain a longer dorsal penile aspect. A strip of rectal muscle fascia 3-cm wide is dissected leaving a proximal attachment, tubularized, incorporated in the new phallus and connected with the neo-urethral meatus. When present, corpora cavernosa remnants are lengthened and incorporated inside the skin flap. In PAIS, the micro glans-penis is saved and placed at the scrotal raphe.

CONCLUSIONS

De Castro’s phalloplasty is one of the very few techniques proposed in the literature for total penile reconstruction in pediatric age. It’s a challenging procedure, sometimes temporary, with possible complications, and possible disappointing final outcomes. Several technical refinements were progressively introduced reaching improvements in the final outcomes and opening better prospective for these unlucky children


VD-43 (VS without presentation)

TRANSURETHRAL ORAL MUCOSAL INLAY: A LOW-MORBIDITY TECHNIQUE FOR TREATMENT OF DISTAL URETHRAL STRICTURES

Sarah HECHT, Daniel HAN, Michael ATWELL and Kyle ROVE
Children's Hospital Colorado, Pediatric Urology, Aurora, USA

PURPOSE

Traditional techniques to repair distal urethral strictures require incisions of the glans, penile skin, and urethra, and carry the risks of glans dehiscence and fistula. A novel transurethral urethroplasty technique for fossa navicularis strictures was described several years ago for adults (Nicolavsky et al. Int Urol Nephrol 2016;1823–9.). To our knowledge, this has not been applied in children, in part due to concerns about urethral caliber. We demonstrate feasibility of a transurethral oral mucosal inlay for distal urethral strictures in prepubescent patients.

MATERIAL AND METHODS

The patient is a seven-year-old boy with balanitis xerotica obliterans (BXO) and persistent urinary retention following circumcision (urine residual 130ml). Cystoscopy revealed a 1.5cm fossa navicularis stricture.

Surgical technique: Perimeatal traction sutures and a penile tourniquet are placed. The urethra is incised ventrally and, if needed, dorsally. A wedge of fibrotic tissue is excised. Oral mucosal graft is harvested and prepared. Double-armed 6-0 polydioxanone suture is used. Each arm of the suture is passed through the graft, then through the urethral mucosa at the margin of the urethrotomy, and lastly through the penile ventrum. The graft is parachuted into the urethral defect, and sutures are tied externally. The graft is secured with additional transurethral quilting sutures. A catheter is placed.

RESULTS

The catheter was removed after 10 days. The patient voids with a straight stream. Uroflow demonstrates a bell-shaped curve with no post-void residual.

CONCLUSIONS

Transurethral ventral oral mucosal inlay is feasible in prepubertal children. Pediatric urologists should include this technique in their armamentarium for distal urethral stricture repair, including strictures due to BXO and failed hypospadias repair.


VD-44 (VS without presentation)

ONE-STAGE RECONSTRUCTION OF COMPLETE PENOSCROTAL TRANPOSITION

Matthieu PEYCELON 1, Stoyan PEEV 2, Liza ALI 1, Anca TANASE 3, Valeska BIDAULT 1, Juliane LEGER 4, Annabel PAYE-JAOUEN 1 and Alaa EL GHONEIMI 1
1) Pediatric Urology, Robert-Debré Hospital, AP-HP; University of Paris; National Reference Center for Rare Urinary Tract Malformations (MARVU), Paris, FRANCE - 2) Pediatric Urology, University Hospital Pirogo; Sofia, Bulgaria, Sofia, BULGARIA - 3) Pediatric Radiology, Robert-Debré Hospital, AP-HP; University of Paris; National Reference Center for Rare Urinary Tract Malformations (MARVU), Paris, FRANCE - 4) Pediatric Endocrinology, Robert-Debré Hospital, AP-HP; University of Paris; National Reference Center for Rare Urinary Tract Malformations (MARVU), Paris, FRANCE

PURPOSE

Complete penoscrotal transposition with intact scrotum is a rare congenital malformation in which the scrotum is located cephalad to the penis.  Concomitant malformations are frequently seen. We seek to describe the surgical reconstruction in a single stage.

MATERIAL AND METHODS

A 2.7-kg boy, born at 37-weeks gestation with prenatal diagnosis of unilateral right dysplastic kidney, had acomplete transposition of the external genitalia. A 45mm hypoplastic penis arose beneath the scrotum. The scrotum and testes were well developed. The penile shaft had a 90° counterclockwise torsion with redundancy of skin on the dorsum. Complex curvature with rotation of the corpus cavernosa was noted. Renal and bladder ultrasound identified a right dysplastic kidney  and pelvic MRI revealed an utricule and hypoplastic corpus cavernosa and spongiosum tissue.  Sex hormonal assays were normal, and no gross chromosomal anomalies was detected.

RESULTS

A one-stage surgery was performed at 18 months. The procedure included cystoscopy revealing an abnormal veru montanum, penile degloving, and mobilization of the phallus to cephalad of the scrotum with a scrotoplasty. The complex curvature with rotation of the corpus cavernosa was untreated given the hypoplastic corpus cavernosa. A suprapubic tube remained for 10 days. Postoperative cystoscopy and examination under general anesthesia 15 months after the surgery showed a 15mm prostatic utricle and a normal bladder. The urine stream was weak due to absence of spongiosum tissue around the urethra. Glans diameter was 10mm, and urethral meatus was 1cm under the glans. At 3 years follow-up, the child is continent without stricture or urinary tract infections.

CONCLUSIONS

A patient with a severe form of penoscrotal transposition was successfully managed with a one-stage repair with satisfactory penile position and excellent cosmesis.


VD-45 (VS without presentation)

URETHRO-URETHROSTOMY FOR DUPLICATED URETHRA (TYPE IIA1)

Yichen HUANG
Shanghai Children's Hospital, Urology, Shanghai, CHINA

PURPOSE

To introduce a case of duplicated urethra (Type IIA1) who underwent urethro-urethrostomy.

MATERIAL AND METHODS

The boy was 3 years-old. He was admitted to our hospital due to the anomaly of the penis which presents as dorsal curvature and double apical + epispadiac meatus. The continence was good. In the voiding phase, the stream comes from the ventral meatus with some dribbling from the dorsal one. The VCUG shows Type IIA1 duplicated urethra. The cystoscopy (9.5Fr) shows normal structure such as verumontanum and contracting sphincter from the ventral urethra. The dorsal urethra seems to have contracting sphincter mechanism near the bladder neck as well. Both of the urethrae were wide enough to put a 9.5Fr cystoscope.

RESULTS

The urethro-urethrostomy procedure (the dorsal to the ventral anastomosis) was conducted for him. The dorsal curvature was corrected by releasing the dorsal tension and external rotation of the bilateral corpus cavernosa. He was followed up for 2 years. The continence was good. The penis was straight. The uroflow was 11.2ml/s after 1 year of the surgery.

CONCLUSIONS

The urethral duplication can be very difficult and need to be managed individually. Important factors for this decision are continence, position of the ventral urethra and presence of ventral or dorsal curvature. The urethro-urethrostomy procedure could be conducted for Type IIA1 duplicated urethra with continent and well developed urethrae.


VD-46 (VS without presentation)

ANATOMICAL REPAIR OF EPISPADIAS: TECHNIQUE AND SHORT-TERM OUTCOMES

Arianna MARIOTTO, David J B KEENE, Abdulrahman ALSHAFEI, Mahmood MAREI and Raimondo Maximilian CERVELLIONE
ROYAL MANCHESTER CHILDREN'S HOSPITAL, PAEDIATRIC UROLOGY, Manchester, UNITED KINGDOM

PURPOSE

This study aims to report the short-term outcomes of a novel technique for epispadias repair.

MATERIAL AND METHODS

All patients with primary epispadias and classic bladder exstrophy (CBE) who underwent an anatomical repair of epispadias from 2008 to 2019 were included. The following outcomes were recorded in a prospectively maintained database: type of epispadias, age at surgery, surgical technique and complications. The surgical technique included: 1-degloving of the penis deeply into the scrotum and pubic bones; 2-dissection of corpora cavernosa off the urethra/spongiosum from the prostate to the distal glans without complete dissasembly; 3-urethroplasty in two layers; 4-anatomical glanuloplasty; 5-external corpora rotation; 6-reconstruction of penile skin with preputioplasty, staged preputioplasty or circumcision. An indwelling catheter was routinely kept for three weeks post-operatively.

RESULTS

Eighty-four patients (43 primary epispadias, 41 CBE) underwent epispadias repair. The median age at repair was 1.6 years (1.2-2.5) for primary epispadias and 1.7 years (1.2-2.2) for CBE patients. Median follow-up from surgery was 38 months (20-70). In the primary epispadias group, 20 patients underwent preputioplasty (16 single stage, 4 two stage) and 23 underwent circumcision. In the exstrophy group, 36 patients underwent preputioplasty (17 single stage, 19 two stage) and 5 underwent circumcision. Satisfactory correction of penile chordee was achieved in all patients. Complications included: preputial dehiscence (7%), urethrocutaneous fistulas (6%), and glans dehiscence (4%).

CONCLUSIONS

Anatomical epispadias repair with partial penile disassembly and external corporal rotation is a versatile surgical technique used to reconstruct the penis in primary epispadias and as a component of staged bladder exstrophy repair.


VD-47 (VS without presentation)

INTRAVESICAL PHALLUS IN CLOACAL EXSTROPHY PATIENT TREATED BY THE KELLY PROCEDURE

Jovelino Quintino De Souza LEAO 1, Marc-Davi LECLAIR 2, Fernanda Ghilardi LEAO 1, Giselle Machado Campos OLIVEIRA 1, Luciano Silveira ONOFRE 1, Priscila Cardoso Braz ASCAR 1 and Jose CARNEVALE 1
1) Hospital Infantil Darcy Vargas, Paediatric urology division, Sao Paulo, BRAZIL - 2) HOPITAL MERE-ENFANT . CHU DE NANTES, SERVICE DE CHIRURGIE INFANTILE, Nantes, FRANCE

PURPOSE

Cloacal exstrophy is a rare form of the exstrophy-epispadias complex. Intravesical phallus in such cases is very uncommon, with few cases described in literature, and just one of surgical treatment.
We report a case of intravesical phallus with cloacal exstrophy that was successfully treated by phallic and radical soft tissue mobilization (Kelly procedure).

MATERIAL AND METHODS

GC, RH: 161213, male cloacal exstrophy with apparent aphallia. Initial surgical procedure was intestinal reconstruction, vesical plate and abdominal wall closure. At this time, a small polypoid midline structure on caudal vesical covered plate was identified and maintained untouched. At one year of age, MRI and cystoscopy confirmed that such intravesical structure suggested to be a phallus. Surgical correction of intravesical phallus was done at 2 years of age, revealed phallus positioned on the bladder floor, and completely covered by bladder urothelium. Phallus was surgically splited from the bladder wall by radical soft tissue mobilization and brought to an external normal position. Skin coverage was done using perineal skin flaps to cover the penile shaft, bladder urothelium covering the tip of the phallus being left intact to provide the appearance of a glans penis. The patient was maintained with vesicostomy.

RESULTS

Phallic appearance and position on the lower abdominal surface are very acceptable with good plastic result, after 2 years follow-up.

CONCLUSIONS

The radical soft tissue mobilization (Kelly procedure) of phallic structures in cases of intravesical phallus cloacal exstrophy, may be a suitable surgical alternative to bring penis outside the bladder and abdominal wall.


VD-48 (VS without presentation)

COMPLETE PRIMARY REPAIR OF BLADDER EXSTROPHY IN THE BOY

Evalynn VASQUEZ 1, Alyssia VENNA 2, Dana WEISS 3, Travis GROTH 4, Aseem SHUKLA 3, Elizabeth ROTH 4, John KRYGER 4, Lauren CULLEN 2, Jen FRAZIER 3, Melissa LINGONGO 4, Douglas CANNING 3, Michael MITCHELL 4 and Joseph BORER 2
1) Children's Hospital of Los Angeles, Urology, Los Angeles, USA - 2) Boston Children's Hospital, Urology, Boston, USA - 3) Children's Hospital of Philadelphia, Urology, Philadelphia, USA - 4) Children's Hospital of Wisconsin, Urology, Milwaukee, USA

PURPOSE

Optimal outcome in bladder exstrophy (BE) mandates meticulous surgical reconstruction. Complete Primary Repair of BE (CPRE) in the boy is detailed with specific considerations for safety, careful tissue handling and optimization of outcomes. 

MATERIAL AND METHODS

Boys with BE underwent CPRE with bilateral iliac osteotomy (BIO). Skin hooks, sharp dissection, bipolar electrocautery and hemostatic topical dilute epinephrine were featured where applicable. Urethral tubularization and bladder closure were performed using simple interrupted technique with absorbable sutures incorporating serosa with little or no mucosa-inverting mucosa to decrease fistula risk. Existing fat planes were exploited to facilitate dissection. Urethral plate dissection began ventrally allowing reflection of corpora cavernosa laterally, while employing scissor and bipolar electrocautery to separate spongiosum from cavernosa. Urethral width was maintained proximally to the level of the anatomic bladder neck to promote continence. Glans color/perfusion pre- and post-pubis approximation was carefully assessed. Immobilization via spica cast was preferred.

RESULTS

From February 2013 to February 2020, 44 consecutive boys underwent CPRE, 1 without BIO. Mean age at CPRE was 3 months (0 – 28 months). Ten had hypospadias. No bladder dehiscence occurred. Penopubic skin loss, incisional skin breakdown and wound/fascial separation occurred in 1 boy each. Urethrocutaneous fistula occurred in 6 boys, including 2 with a large penopubic fistula requiring reoperation. 28 boys are 3 or more years post-CPRE. Of 22 queried; 17 have commenced or completed toilet training. Dry intervals (DI) for the 22 boys included; DI <1 hour (8), DI >1-2 hours (7), DI >3 hours (2), unknown (5). Cystometrogram documented normal compliance and detrusor activity.

CONCLUSIONS

In our experience, the principles and techniques discussed promote safety, limit tissue injury, optimize functional and cosmetic outcomes, and facilitate ongoing refinement of the CPRE technique. At early follow-up, normal bladder function is possible post-CPRE in boys with bladder exstrophy.


VD-49 (VS without presentation)

THE SEARCH FOR CONTINENCE IN BLADDER EXSTROPHY: BLADDER NECK TRANSECTION AND A MACEDO CATHETERIZABLE RESERVOIR TO AUGMENT THE NATIVE BLADDER.

Antonio MACEDO JR 1, Sérgio OTTONI 2, Gilmar GARRONE 2, Ricardo MATTOS 2 and Marcela LEAL DA CRUZ 2
1) Federal University of São Paulo and NUPEP/CACAU., Urology, São Paulo, BRAZIL - 2) NUPEP/CACAU, Urology, São Paulo, BRAZIL

PURPOSE

Bladder exstrophy remains one of the most challenging congenital abnormalities in pediatric urology practise. Anatomy repair is not always followed by successful bladder function in regards to storage function and urinary continence. We propose bladder neck transection and bladder augmentation with a catheterizable reservoir technique we described almost two decades ago. We want to describe in this video how we approach these patients.

MATERIAL AND METHODS

We treat bladder exstrophy in stages aiming to restore bladder and penile anatomy in the first two procedures. We tubularize the bladder neck as a way to produce some resistance and increase bladder capacity. At the age of 5-6 years we offer patients the transection of bladder neck and enterocystoplasty to achieve continence. We report on a 6 years old boy that underwent this procedure. We perform the reservoir from 35cm of ileum according to Macedo technique that constructs a catheterizable channel from the same bowel segment from a 3cm width flap from anterior and posterior wall of ileum in the mid part of it. The continence mechanism of the efferent tube is based on angulation and a serous lined tunnel created with 3-4 3.0 prolene sutures. The stoma is placed in the midline, we left ureteral stents, the stoma Foley tube and an additional cystostomy tube to avoid bladder distension.

RESULTS

Patient had an uneventful evolution and is continent performing CIC every 4 hours with 9 months of follow up.

CONCLUSIONS

In spite of continuous development of bladder exstrophy surgery, the urethral continence and voluntary micturition is still not possible in the majority of patients. We discuss with our patients honesty and offer this method as a viable alternative to achieve continence in one more surgery. In our experience, most patients accept urethral transection and suprapubic CIC when educated about results with other alternatives of bladder neck plasty.


VD-50 (VS without presentation)

A MODIFIED BLADDER NECK RECONSTRUCTION TECHNIQUE TO ADDRESS INCONTINENCE IN CHILDREN WITH PRIOR BLADDER EXSTROPHY CLOSURE

Briony VARDA, Lauren CULLEN, Alyssia VENNA and Joseph BORER
Boston Children's Hospital, Pediatric Urology, Boston, USA

PURPOSE

The goal of bladder neck reconstruction for BE patients is to create the perfect balance between bladder outlet resistance and volitional voiding. We demonstrate our modified bladder neck reconstruction (mBNR) technique and early continence outcomes following mBNR.

MATERIAL AND METHODS

In June 2014, we transitioned from Young Dees Leadbetter (YDL) technique to mBNR. The technique involves moving the BN approximately 1.5-2.0 cm cephalad to the native BN. The BN is then gradually tapered to the distal verumontanum resulting in a width of approximately 14-16mm at the verumontanum, 18-20mm at the native BN and 22-24mm at the new BN. Full-thickness midline approximation of tissues incorporates serosa with little mucosa. Midline approximation of redundant detrusor reinforces the closure. Unlike YDL, there is no complete muscle wrap of the BN.

Baseline characteristics were recorded. Change in the rate of continuous incontinence was calculated and dry intervals (DI) reported.

RESULTS

10 mBNRs were performed. Median age at BNR was 8 years (2–10 years). A majority were male (90%). 56% had an expected bladder capacity (EBC) <50%.  8 patients had complications/surgeries after initial BE closure. Preoperatively, 100% had continuous incontinence and a dry interval

Median follow up was 1.5 years (5 months–5 years). Postoperatively, the rate of continuous incontinence decreased by 60% (100% to 40%). A third reported DI ≥2 hours (30%), 20% a 1-2 hour DI, and 50% with DI <1 hour. Only males with EBC <50% (without augment) had continuous incontinence postoperatively. The number of complications/procedures following initial closure was not related to postoperative continence.

CONCLUSIONS

A majority of BE patients had improvement in degree of incontinence after mBNR; recalcitrant incontinence occurred in males with very small capacity bladders.


VD-51 (VS without presentation)

MANAGEMENT OF BLADDER (BE) OR CLOACAL EXSTROPHY (CE) PRIOR TO REPAIR

Lauren CULLEN 1, Alyssia VENNA 1, Rosemary GRANT 1, Douglas CANNING 2, John KRYGER 3, Dana WEISS 2, Aseem SHUKLA 2, Travis GROTH 3, Elizabeth ROTH 3, Brynne BONITATIBUS 2, Coleen ROSEN 3, Michael MITCHELL 3 and Joseph BORER 1
1) BOSTON CHILDREN'S HOSPITAL, UROLOGY, Boston, USA - 2) CHILDRENS HOSPITAL OF PHILADELPHIA, UROLOGY, Philadelphia, USA - 3) CHILDREN'S HOSPITAL OF WISCONSIN, UROLOGY, Milwaukee, USA

PURPOSE

Initial care of bladder, bowel, and surrounding tissue in BE and CE prior to repair is challenging. We report standardized care to increase expertise among caregivers and optimize protection.

METHODS

Fundamental postnatal management includes umbilical soft tie, transparent barrier covering exstrophied tissue, and diaper application. Between birth and BE reconstruction, stepwise care is; 1) Daily gentle soap and water bathing of lower abdomen, 2) delicate drying of para-exstrophy skin, 3) transparent barrier application to para-exstrophy skin on lateral and cephalad borders with caudal border tenting to facilitate egress of urine to diaper, and 4) skin breakdown/ infection symptom surveillance to promptly seek appropriate treatment. Treatment was integrated for para-exstrophy skin compromise.

CE patient care compares but further details separating prolapsed ileum through transparent film.  Management of the bowel stoma, post-stage 1 repair, also includes coverage with dry absorbent gauze, or stoma appliance, appropriate distance from exposed bladder permitting.

RESULTS

From February 2013 through February 2020 we treated 85 patients with BE, CE, or variant. Mainstays of care were routine vigilant hygiene as per above, and use of protective film over exposed tissues and surrounding skin.  Para-exstrophy skin treatment resulted in rapid resolution of fungal infection in 5 patients without compromise to exstrophied tissue.

CONCLUSIONS

These methods provide optimal care and reliable protection of exposed tissues, and serve as an educational guide to all caregivers.


VD-52 (VS without presentation)

GROSS HEMATURIA ASSOCIATED TO BLADDER VASCULAR MALFORMATION IN PROTEUS SYNDROME SUCCESSFULLY TREATED WITH HOLMIUM LASER FULGURATION

Ricardo Haidar BERJEAUT, Bruno Nicolino CEZARINO, Roberto Iglesias LOPES and Francisco Tibor DÉNES
Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Pediatric Urology, Sao Paulo, BRAZIL

PURPOSE

Proteus Syndrome (PS) is a rare condition, caused by mosaic activating AKT1 mutation c.49G>A, p.Glu17Lys and diagnosed by specific diagnostic criteria.  

Frequently, limbs, spine, and skin are affected. When skin grows, it commonly affects the sole of the feet with its cerebriform connective-tissue nevus (an almost pathognomonic sign of the disease). 

In addition to skin lesions, patients could present fatty tissues overgrowth and vascular (capillary, venous or lymphatic) malformations. 

One rarest manifestation of these vascular malformations is hematuria. Our goal is to present the manifestation of hematuria on a PS patient and its endourological treatment.

MATERIAL AND METHODS

We present a case of an eight-year-old boy who during his early childhood was diagnosed with PS. 

He presented at the Emergency Department with 1 week of gross hematuria, without fever, dysuria or urinary retention. During the investigation, CT scan and MRI were performed showing some nodular (polypoid) lesions in the bladder wall with diffusion restriction, contrast gain and no signs of invasion.

Cystoscopy was done under general anesthesia and the vascular malformations were fulgurated with Ho:Yag laser. 

RESULTS

The procedure took 30 minutes and no bleeding occurred. A 12Fr Foley catheter was left with no need for irrigation. The catheter was retrieved 18 hours after the procedure and the patient was then, discharged. After a 6-month follow-up, he had no episodes of hematuria.

CONCLUSIONS

Ho:Yag laser fulguration of bladder vascular malformations in Proteus Syndrome is safe, fast, feasible and can achieve excellent results with minimum morbidity. 


VD-53 (VS without presentation)

PRENATAL ANHYDRAMNIOS IN A GIRL: AN EXCEPTIONAL CASE OF BILATERAL ECTOPIC URETER OBSTRUCTION

Laura BURGOS LUCENA 1, Beatriz FERNÁNDEZ 2, Ruben ORTIZ 2, Javier ORDÓÑEZ 2 and Jose María ANGULO 2
1) Hospital Gregorio Maranon, Paediatric Urology, Madrid, SPAIN - 2) Hospital Gregorio Marañón, Pediatric Urology Department, Madrid, SPAIN

PURPOSE

Aim: Prenatal oligoamnios is usually found in male fetuses, mainly due to posterior urethral valves. An exceptional case of anhydramnios in a female fetus with bilateral ectopic ureter obstruction and impaired renal function is presented.

MATERIAL AND METHODS

Patients and method: Preterm newborn (33+6 weeks) with prenatal diagnosis of bilateral ureterohydronephrosis and double left system. Labor was induced at 33 weeks due to anhydramnios. Despite bladder catheterization, cystoscopy was performed after 9 days of life due to progressive clinical, laboratory and radiological worsening. Findings were a right ectopic ureter draining in the uretro-vaginal wall, a left upper pole ureter draining into the urethra and a left lower pole ureter bulging behind the bladder. Both dilated systems were drained by cystoscopy creating a transurethral neo-orifice (TUNO) into the bladder.

RESULTS

Results
During the first 24 postoperative hours the patient experienced spontaneous diuresis and progressive lower serum creatinine level that drop into normal range within a month of surgery. She was discharged one week after surgery and short-term postoperative ultrasound showed significant improvement in bilateral ureterohydronephrosis,
A year later, the patient remains asymptomatic, without UTI and normal renal function.

CONCLUSIONS

Conclusion
Endoscopic urinary diversion (TUNO) allowed the resolution of acute urinary obstruction in this patient with bilateral complex uropathy. Minimally invasive approach is a valid choice in the diagnostic and management of these patients.


Keywords: ectopic ureter, bilateral obstruction, endoscopic drainage, congenital malformation, female fetus


VD-54 (VS without presentation)

ENDOUROLOGICAL TREATMENT IN TWO CASES OF URETERAL VALVES

Beatriz FERNÁNDEZ-BAUTISTA, Jose María ANGULO, Rubén ORTIZ, Laura BURGOS, Javier ORDÓÑEZ and Alberto PARENTE
Gregorio Marañón Hospital, Pediatric Urology, Madrid, SPAIN

PURPOSE

Congenital ureteral valves are a rare cause of ureteral obstruction that may lead to renal function deterioration. We present two clinical cases treated endoscopically by monopolar electrocautery and laser fibre ablation.

MATERIAL AND METHODS

The first case is a 13-year old male with several episodes of abdominal pain and severe left hydronephrosis. The ultrasound showed a dilated ureter and pelvicalyceal system with an obstructive renogram curve. We performed a retrograde pyelogram, finding a dilated ureter 5 cm up from the vesicoureteral junction with ureteral valves at that location. Ablation of the valves was conducted using monopolar electrocautery.

The second case is a 2-year-old male whose ultrasound proved left ureterohydronephrosis, with renal parenchyma thinning and a 3.3 cm left ureter. Diuretic renogram was obstructive and function was impaired.
A cystoscopy was performed, observing the presence of valves in the ureter at 3 cm form the vesicoureteral junction, conditioning the obstruction.
Complete section of the valves was achieved by a 270-micron holmium laser fibre.

RESULTS

Our patients made an uneventful postoperative recovery and continue to remain completely asymptomatic.
A significant decrease in renal dilatation was observed and renal function recovered in both cases.

CONCLUSIONS

Ureteral valves are an uncommon cause of ureteral obstruction. Advances in endourological techniques allow us to give a minimally invasive approach to these uropathies, obtaining good long-term results in our small series of patients.


VD-55 (VS without presentation)

ANTEGRADE POSTERIOR URETHRAL VALVE ABLATION - DEMONSTRATION OF ANATOMY AND TECHNIQUE

Vikrant KUMBHAR 1, Main MASERWAH 2 and Aruna ABHYANKAR 2
1) Leicester Royal Infirmary, Paediatric Surgery, Leicester, UNITED KINGDOM - 2) Noahs Ark Childrens Hospital, Paediatric Surgery, Cardiff, UNITED KINGDOM

PURPOSE

Antegrade approach to ablation of posterior urethral valves is a useful to achieve early resection in small sized newborns. We had to resort to this approach in ten-year old, with duplicated urethra with valves.

MATERIAL AND METHODS

Case history of index patient. Review of literature

RESULTS

Case:
A child with voiding difficulty, inability to catheterize even post-meatotomy, was referred for further management with SPC drainage. A duplex urethral was suspected from his history.
His urethra associated with normal meatus, later confirmed as dorsal one, was stenotic; barely allowing 4.5 Fr scope. Posterior urethral valves were noted. Stenotic ventral urethral meatus was shrouded in tissues near proximal extent of meatotomy.

An Antegrade resection of vales was safely performed under direct vision with sickle blade as demonstrated in the video. This also unraveled the small opening of the ventral urethra; and confirming the urethral anatomy.

Literature review:
In paediatric age group, scattered reports describe the technique. There is no record of a video demonstration.

CONCLUSIONS

Our video demonstration offers possibly the only record of antegrade appearance of PU Valves and could be a useful adjunct to our knowledge of anatomy and embryology. This approach to resection helped us to establish and demonstrate the suspected diagnosis of duplex urethra in this long-suffering child.


VD-56 (VS without presentation)

NEPHROGENIC BLADDER ADENOMA IN CHILDHOOD: A CASE REPORT

Beatriz FERNÁNDEZ-BAUTISTA, Rubén ORTIZ, Laura BURGOS, Javier ORDÓÑEZ, Alberto PARENTE and Jose María ANGULO
Gregorio Marañón Hospital, Pediatric Urology, Madrid, SPAIN

PURPOSE

Nephrogenic adenoma is a metaplastic urinary tract lesion that can be located anywhere in the urinary tract, although its most frequent location is the bladder (80% of cases) followed by the urethra, ureter and renal pelvis.

The objective is to present the clinical case of a bladder nephrogenic adenoma as a cause of bladder tumor and hematuria in a child with a history of intervention in the urinary tract.

MATERIAL AND METHODS

A 7-year-old boy with a history of left megaureter intervened endoscopically at birth, with subsequent inyection of anti-reflux material for vesicoureteral reflux and finally with ureteral reimplantation due to recurrence (Politano-Leadbetter technique).
Five years later, he presented a hematuria clinic, with ultrasound imaging of a 15x15x32 mm wide-based polypoid lesion in the bladder, with a discrete increase in vascularization.
We performed a cystoscopy where we observed a papillary lesion near to left meatus, bleeding to the contact, and the complete resection was performed with holmium laser.

RESULTS

The pathological anatomy was compatible with nephrogenic adenoma of papillary morphology.
The patient presented a good evolution, with disappearance of symptoms and ultrasound resolution of the lesion after a year of follow-up.

CONCLUSIONS

Nephrogenic bladder adenoma is a rare tumor, especially in children, which is related to chronic irritation or previous urinary tract surgery.
The accepted treatment is cystoscopic resection with fulguration of the implant base to prevent growth and even malignant degeneration.


VD-57 (VS without presentation)

MICROSCOPIC TECHNIQUE FOR ADOLESCENTS WITH KLINEFELTER SYNDROME. A HOPE FOR FERTILITY.

Ma CONCA, S LUJÁN, A POLO, Ja MARCH, A SERRANO and C DOMÍNGUEZ
Universitarian Hospital La Fe, Pediatric Urology, Valencia, SPAIN

PURPOSE

Klinefelter Syndrome (KS) is the most common sex chromosome disorder in males, classically they have been considered infertile, however, assisted reproductive techniques may provide fertilization through sperm search in testicular biopsy. Early recognition of patients during puberty and handling them as soon as possible is important because the possibility of testosterone replacement terapy and introduction of fertility preservation. The objective of this study is to show Micro-Tese technique step by step for adolescents with SK.

MATERIAL AND METHODS

We present a 13-year-old patient with 47 XXY karyotype who was refered for fertility assessment. Presents a thickened penis of pubertal size Tanner IV but small size of the testis. Analytically FSH of 25.9 mU/mL, LH 10.3 mU/mL and T 4.4 ng/mL. Azoospermia was found in the spermiogram. Testicular biopsy Micro-TESE is proposed.

RESULTS

Bilateral micro-TESE was performed under general anesthesia and antibiotic prophylaxis. Middle raphe incision of the scrotum and access by planes until both testicles are exteriorized. Use of 25x 'optical microscope Carl Zeiss Opmi Vario S88. The albuginea layer is incised transversely in the most avascular region. Observe under the microscope those thicker and opaque colored tubules that will be selected as a sample. The surgical time was 60 min.
The biology laboratory reports 6 immobile sperm in the total sample and 2 cryotubes are frozen. Bilateral histology diagnosis was mature arrest. The postoperative course was uncomplicated.

CONCLUSIONS

Micro-TESE for fertility in SK adolescents requires optical magnification to select those seminiferous tubules larger and more opaque that contain germ cells with active spermatogenesis, improving success rates.


VD-58 (VS without presentation)

HIDDEN INCISION URETEROCYSTOPLASTY: STEP-BY-STEP DESCRIPTION OF A NOVEL TECHNIQUE

Roberto LOPES, Daniel SUCUPIRA, Marcos MELLO, Ricardo HAIDAR, Bruno CEZARINO and Francisco DÉNES
University of São Paulo Medical School, Urology, São Paulo, BRAZIL

PURPOSE

20 to 30% of neurogenic bladder patients might need a bladder augmentation, with enterocystoplasty being the gold standard. Ureterocystoplasty ia a good alternative when a large dilated ureter is available. Hidden incision endoscopic surgery (HIDES) has emerged as an alternative approach with better cosmetics. All port sites are hidden at the level of a Pfannenstiel incision, thus renders them nonvisible. This is the first case of HIDES for an ureterocystoplasty.

MATERIAL AND METHODS

A 15 year-old girl with with a lumbosacral MMC corrected at birth and a previous VP shunt had a clinical history of  recurrent UTIs in early childhood. She was using a prophylatic antibiotic and performing clean intermittent catheterization (CIC) every 3 hours with low volumes, being incontinent during intervals. She was under oxybutinin 5 mg 3x/day. Ultrasonography demonstrated a right ureterohydronephrosis with severe parenchymal thinning.  Voiding cystourethrogram demonstrated vesicoureteral reflux grade V and a Christmas’ tree bladder. DMSA scan depicted a non-functioning right kidney. Urodynamics demonstrated a low compliance bladder, continuous leakage at maximum bladder capacity and inability to void. At presentation she was initially constipated but great improvement was observed after PEG.

RESULTS

Ureterocystoplasty was performed using HIDES technique, operative time was 130 min and the patient was discharged at 2nd postoperative day. Patient is completely dry performing CIC every 4 hours with normal volumes (400 cc).

CONCLUSIONS

HIDES ureterocystoplasty should be considered for selected cases. This approach combines the advantages of open and laparoscopic approaches described for augmentation.


VD-59 (VS without presentation)

PRUNE PERINEUM SURGICAL CORRECTION - TREATMENT OF A RARE SYNDROME

Ricardo Haidar BERJEAUT, Bruno Nicolino CEZARINO, Roberto Iglesias LOPES and Francisco Tibor DÉNES
Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Pediatric Urology, Sao Paulo, BRAZIL

PURPOSE

Prune Perineum Syndrome (PPS) is rare, with only three cases described in the literature. Treatment usually requires abdominal and pelvic surgeries due to pelvic floor and bowel malformations. Our goal is to provide a video with steps of the surgical corrections of this rare syndrome.

MATERIAL AND METHODS

We present a case of an 8 months-old boy with PPS (abdominal PBS stigmata, flaccid perineum, hypoplastic penis, penoscrotal transposition, impalpable testes, imperforated anus and vesicocolonic fistula). At our first evaluation, he had already been submitted to a colostomy with mucous fistula and a vesicostomy. 

RESULTS

By the time of this publication, he has been submitted to six surgical procedures. First, osteotomy, followed by definitive colostomy, cystoscopy evaluation, cystoplasty, perineal and abdominal correction with a dual mesh, bilateral orchidopexy, treatment of the vesicocolonic fistula and sigmoidectomy and appendicostomy.

He has 6 years old, walks with no assistance, has satisfactory abdominal tonus which allows him to void partially with Valsalva Maneuver, the clean intermittent catheterization is also performed. He had no UTI since his first surgery.

Although submitted to several procedures, treatment is not yet concluded. A future urethral dilation, and cystostomy might improve his quality of life. And a genitoplasty might be necessary. 

CONCLUSIONS

PPS is a very rare condition, with scarce literature concerning its treatment. Multiple procedures might be necessary to correct malformations and improve patient’s quality of life.