ESPU Meeting
VD-1 (VD without presentation)
Beatriz FERNÁNDEZ-BAUTISTA 1, Isabel BADA 1, María Dolores BLANCO 2, Javier ORDÓÑEZ 1, Rubén ORTIZ 1, Laura BURGOS 1 and Jose María ANGULO 1
1) Gregorio Marañón Hospital, Pediatric Urology, Madrid, SPAIN - 2) Gregorio Marañón Hospital, Pediatric Surgery, Madrid, SPAIN
PURPOSE
Urinary incontinence is a common sequel in patients operated on for some pathology of the exstrophy-epispadias complex.
We present our experience in the use of antegrade injection of bulking materials in the bladder neck in three patients of this type.
MATERIAL AND METHODS
We present the case of three patients with pathology of the exstrophy-epispadias complex. Their ages were 5, 7 and 14 years old.
One patient had bladder exstrophy and two patients had complete epispadias.
A cervicourethroplasty was performed in all patients and subsequently retrograde injection of bulking material in the bladder neck due to urinary incontinence.
Despite all treatments, the patients remained incontinent.
In all cases we perform an anterograde injection of bulking material.
To do this, we performed a suprapubic puncture with abocath, guidewire introduction, and subsequently dilation of the path to place the 5-mm Hasson trocar. The cystoscope is inserted through it, injecting the bulking material in quadrants.
RESULTS
Operative time was 40 minutes (35-50).
Hospitalization time was 24 hours. Bladder catheter time was 4 days.
Good analgesic control in all cases. No intra or postoperative complications
Significant symptoms improvement (occasional urinary leakage in one patient)
Two-year median follow-up.
CONCLUSIONS
Antegrade injection of fillers is a minimally invasive and easily reproducible technique when conventional surgery fails.
It significantly reduces the symptoms of urinary incontinence.
It improves vision of the bladder neck compared to other retrograde injection techniques.
Little comorbidity and well tolerated. It presents good results in our small series of patients.
VD-2 (VD without presentation)
Naser AL-SOUDAN AL-ANAZI 1, Neetu KUMAR 2 and Abraham CHERIAN 2
1) Great Ormond Street Hospital, Paediatric Urology, London, UNITED KINGDOM - 2) Great Ormond Street Hospital, Peadiatric Urology, London, UNITED KINGDOM
PURPOSE
OHVIRA (Obstructed HemiVagina and Ipsilateral Renal Anomaly) is a rare female urogenital syndrome. Various surgical approaches were described, such as vaginal septectomy, hemivaginectomy, or hemihysterectomy. This video presents endoscopic management in an infant with hydrocolpos.
MATERIAL AND METHODS
Seven-month-old girl, born at term with no antenatal history, presented with jaundice and lethargy on day-6 of life. Incidentally, the US showed a didelphic uterus with a possible single vaginal vault. She remained well and repeated US 4-months later, confirmed absent right kidney, didelphic uterus with hydrocolpos in the right hemivagina.
RESULTS
The patient underwent cystovaginoscopy, drainage of hydrocolpos and vaginal septum division. The procedure was done under general anaesthesia in the lithotomy position. Cystoscopy with 9.5Fr scope, zero degree, showed a normal cervix and vagina with a bulge on the right side. A skillet needle was introduced under endoscopic vision beside the scope into the bulge, and clear mucous was aspirated. A guide wire was inserted and serially dilated over the wire under endoscopic guidance. This facilitated the scope entry into the right hemivagina, and the right cervix was confirmed. A Ligasure was then introduced, and the septum engaged. This was divided under endoscopic guidance, sparing the very proximal part close to the cervix. No bladder catheter was used. The patient made an uneventful recovery and was discharged on the same day.
CONCLUSIONS
Endoscopic management of OHVIRA is feasible and safe.
VD-3 (VD without presentation)
Antonio MACEDO 1, Rafael Enrique JORDAN BALLADARES 2, Renata CORRÊA 2, Gilmar GARRONE 2, Sergio LEITE OTTONI 2, Ricardo MARCONDES DE MATTOS 2, Ricardo DI MIGUELLI 2 and Marcela LEAL DA CRUZ 2
1) CACAU-NUPEP, Federal university of São Paulo, Pediatric Urology, São Paulo, BRAZIL - 2) CACAU - NUPEP, Pediatric urology, São Paulo, BRAZIL
PURPOSE
Persistent cloaca, defined as confluence of the rectum, the vagina and the urethra into a single common channel, has an estimated incidence of 1/50,000 live births. We describe the buccal mucosa graft vaginoplasty for a 11 year old female with cloaca, who underwent at the age of 11 months a Peña repair.
MATERIAL AND METHODS
We harvested the graft from the lower lip and a second graft from the cheek. Both grafts were submitted to small sections to produce a mesh graft and increase its size. A transverse incision cranial to the anal canal and caudal to the urethra was performed and with eletrocautery, consecutive dissection was promoted to gain profoundity. The mesh-graft was placed over the neovaginal cavity and sutured with 4.0 PDS monofilament suture used to suture and then quilt the graft in place. The vaginal capacity was confirmed by ease of a two-digit insertion. Haemostasis was confirmed before the insertion of a soft vaginal mold. The patient remained with an indwelling urinary catheter. The mold and Foley tube were removed after 14 days postoperatively.
RESULTS
Patient had an excellent postoperative course and had been instructed to perform vaginal dilatation every three hours during the day.
CONCLUSIONS
BMG vaginoplasty is a viable alternative to treat females with cloaca at adolescence.Buccal mucosal grafting has advantages over the use of keratinized skin flaps and intestinal flaps. Buccal mucosa is ideal for female genital reconstruction, given its color, texture, lack of hair and mild mucous production
VD-4 (VD without presentation)
Antonio MACEDO JR 1, Rafael Enrique JORDAN BALLADARES 2, Renata CORRÊA 2, Gilmar GARRONE 2, Sergio LEITE OTTONI 2, Marcela LEAL DA CRUZ 2, Ricardo MARCONDES DE MATTOS 2 and Ricardo DI MIGUELI 2
1) CACAU - NUPEP, Federal University of Sao Paulo, Pediatric urology, São Paulo, BRAZIL - 2) CACAU - NUPEP, Pediatric urology, São Paulo, BRAZIL
PURPOSE
We want to present in this video the versatility of the GUD technique for redos and coronal fistula repair
MATERIAL AND METHODS
In the last 5 years we have adopted and published a technique for treating distal hypospadias (coronal and subcoronal) based on minimal urethral mobilization and maximal glanular disassembly and deconstruction. This procedure is a no urethroplasty alternative because urethra is simply mobilized and adjusted to the glans opened entirely at midline like a book and disconnected to the corpora and disassembled. We have treated primary cases but also redos, doing exactly the same technique. We show the technique in details here by a failed distal hypospadia with urethral meatus placed at coronal level
RESULTS
Patient had an excellent outcome, the urethral stent was left for 10 days. Our current experience with GUD in redos
CONCLUSIONS
The GUD technique is appropriate to primary and preoperative distal hypospadias forms
VD-5 (VD without presentation)
Antonio MACEDO JR 1, Rafael Enrique JORDAN BALLADARES 2, Renata CORRÊA 2, Gilmar GARRONE 2, Sergio LEITE OTTONI 2, Ricardo DI MIGUELI 2, Ricardo MARCONDES DE MATTOS 2 and Marcela LEAL DA CRUZ 2
1) CACAU - NUPEP, Federal University of Sao Paulo, Pediatric urology, São Paulo, BRAZIL - 2) CACAU - NUPEP, Pediatric urology, São Paulo, BRAZIL
PURPOSE
Proximal hypospadias can be treated in one or two stages. We observe a trend to treat proximal hypospadias in two stages, but complete penoscrotal transposition that frequently is associated with proximal hypospadias can be treated in the first or the second procedure. We want to present in this video our preferred approach, that consists of M flap-technique in the initial procedure
MATERIAL AND METHODS
We have treated a scrotal hypospadia with major ventral curvature and complete penoscrotal transposition. We have initiated the surgery designing the M-flaps, that included the U scrotal incision over the hypospadic urethral meatus. After aggressive chordee excision and urethral plate division the penis was assessed for artificial erection. This patient had also bilateral hydrocele, treated in the same setting. We managed to correct curvature without need of corporoplasty. The redundant dorsal foreskin was mobilized to the ventral surface as Thiersch flaps.
RESULTS
Patient had an excellent outcome and awaits second-stage repair
CONCLUSIONS
We are convinced that penoscrotal transposition associated with proximal hypospadias should be treated in the first procedure.
VD-6 (VD without presentation)
Amr ELBAKRY 1, Tyler TRUMP 2, Chad CRIGGER 2, Khaled ALDABEK 2, David ZEKAN 2, Michael OST 2 and Osama AL-OMAR 2
1) West virginia University Hospital, Morgantown, USA - 2) West Virginia University Hospital, Urology, Morgantown, USA
PURPOSE
To present a case demonstrating robotic partial nephrectomy in a pediatric patient.
MATERIAL AND METHODS
4 y.o. girl who presented with persistent hypertension and was found to have incidentally diagnosed right renal mass. US and CT scan were done and confirmed1.5 cm mass in the anterior aspect of the mid-pole of the right kidney. Lab Workup: Urine Metanephrins (184 mcg\24 hr ↑), 24hr Urinary VMA (31.3 mg\g cr ↑). Multidisciplinary evaluation was done, and the consensus was to proceed with partial nephrectomy to exclude reninoma as a cause of hypertension. Also, we could not rule out AML or small Wilms’ tumor. Decision was discussed with the family and they greed on proceeding with robotic partial nephrectomy.
RESULTS
Robotic partial nephrectomy was done safely. Total operative time was 4 hours. ischemia time was 19 minutes. There was minimal blood loss. No known complications. pathology of the mass revealed cystic nephroma. Hypertension improved after the surgery.
CONCLUSIONS
Partial nephrectomy for renal masses can be done safely using robotic approach.
VD-7 (VD without presentation)
Daniel TENNENBAUM 1, Luciana LERENDEGUI 2, Rafael GOSALBEZ 1 and Miguel CASTELLAN 1
1) Nicklaus Children's Hospital, Pediatric Urology, Miami, USA - 2) Jackson Memorial Hospital - UM / Nicklaus Children's Hospital, Pediatric Urology, Miami, USA
PURPOSE
There are different strategies in the construction of a neovagina, with no consensus on which is the best approach. We have previously published our experience with sigmoid Monti vaginoplasty via an open approach. In this video, we present a case of vaginoplasty construction by way of sigmoid Monti vaginoplasty, via an intracorporeal robotic-assisted approach.
MATERIAL AND METHODS
Case report on the use of total intracorporeal robotic-assisted sigmoid "Monti" vaginoplasty.
RESULTS
An 18-year-old transwoman with a long history of gender dysphoria, followed since puberty by a multidisciplinary team, sought definitive gender affirmation surgery. The procedure was performed by two teams working simultaneously, with the external component of the surgery happening whilst the bowel surgery was being performed. The intra-abdominal component of the surgery was performed using one umbilical camera port and 4 additional ports. The neovagina was created using a ~12 cm segment of distal sigmoid colon and detubularized longitudinally before being retubularized to form a Monti cuff by closing the mesenteric edge, while leaving the mesentery in a cephalad position. Dissection into the pouch of Douglas was then performed to advance the neovagina into the perineum, before anastomosis to the surrounding tissues. The postoperative course was uneventful and with adequate pain control, and discharge on postoperative day 6. At 3-month followup the patient reports satisfaction.
CONCLUSIONS
Intracorporeal robotic Monti sigmoid vaginoplasty allows for the construction of a neovagina with a tension-free vascular pedicle, with improved morbidity and quicker time to recovery. This approach allows two surgical teams working simultaneously and preparing the perineum for anastomosis. Our video, the first of it’s kind to the knowledge of the authors, demonstrates that this approach can be performed in a safe and effective manner. Further pursuit of this approach may be warranted in the right clinical environment.
VD-8 (VD without presentation)
Ciro ESPOSITO 1, Lorenzo MASIERI 2, Fulvia DEL CONTE 1, Benedetta LEPORE 1, Annalisa CHIODI 1, Roberto CARULLI 1, Claudia DI MENTO 1, Roberto CARDONE 1 and Maria ESCOLINO 1
1) Federico II University Hospital, Pediatric Surgery, Naples, ITALY - 2) Meyer Children University Hospital, Pediatric Urology, Firenze, ITALY
PURPOSE
This video describes the technique of robot-assisted extravesical ureteral reimplantation (REVUR) with ureteral tailoring and dismembering for complex obstructed megaureter, using technical adaptations that are novel in the pediatric population.
MATERIAL AND METHODS
A 16-year-old boy came to our attention for symptomatic multiple stones in the left pre-vesical ureter and left obstructed megaureter. The cause of the obstructed megaureter was iatrogenic ureteral stricture, secondary to repeated endoscopic subureteric injections for treatment of bilateral 5 grade vesicoureteral reflux (VUR). The patient underwent ureteroscopic laser lithotripsy. At follow-up, persistent left obstructed megaureter and intramural concretions of the bulking agent previously injected were observed. Five months following the ureteroscopy, the patient received REVUR with ureteral tailoring and dismembering.
RESULTS
The operative time was 235 minutes and no intra-operative complications occurred. After surgery, the patient developed gross hematuria that resolved spontaneously at post-operative day (POD) 3rd. The bladder catheter and the drain tube were removed on POD 3rd, and the patient was discharged on POD 4th. The double-J stent was removed under short-duration anesthesia 3 months post-operatively. At follow-up, ultrasound showed improved hydronephrosis and renal scan demonstrated improved drainage of the left kidney. To date, the patient is asymptomatic.
CONCLUSIONS
The robotic approach is versatile and provides immediate adaptations to overcome intra-operative challenges in case of complex ureteral reimplantation requiring tailoring and dismembering. Technical variations may facilitate excellent operative outcome.
VD-9 (VD without presentation)
Amr ELBAKRY 1, Tyler TRUMP 2, Khaled ALDABEK 2, David ZEKAN 2 and Osama AL-OMAR 2
1) West virginia University Hospital, Morgantown, USA - 2) West virginia University Hospital, Urology, Morgantown, USA
PURPOSE
To demonstrate our technique for simultaneous ureteral reimplantation for vesicoureteral reflux, and creation of Mitrofanoff "appendico-vesicostomy" catheterizable stoma using robotic approach.
MATERIAL AND METHODS
Our Patient is an 8 y.o. boy with a history recurrent febrile UTI, and severe dysfunctional voiding causing recurrent urinary retention. Urinary retention was initially managed with indwelling suprapubic catheter. US showing bilateral hydronephrosis (Grade 3 on the right and Grade 1 on the left), which slightly improved after SPT placement. VCUG showed bilateral vesicoureteral reflux (grade 4 on the right and grade 1 on the left). MRI spine was done and was negative. We decided to proceed with robotic right ureteral reimplantation for right grade 4 VUR, with catheterizable stoma creation foe management of urinary retention. The video demonstrates our approach in a stepwise fashion.
RESULTS
The surgery was completed safely in overall time of 4 hours and 40 minutes. we estimated minimal blood loss. there was no complications intraoperatively and in the early postoperative period. Normal follow-up US at 8 months post-op with no hydronephrosis bilaterally. VCUG at 4 months post-op showed complete resolution of bilateral VUR. No febrile UTI was reported after the surgery with follow up of 14 months.
CONCLUSIONS
Robotic approach is a versatile tool that can be employed in complex reconstructive surgeries in pediatric patients.
VD-10 (VD without presentation)
Amr ELBAKRY 1, Katharina MITCHELL 1, Ahmed ABDELHALIM 1 and Osama AL-OMAR 2
1) West virginia University Hospital, Morgantown, USA - 2) West virginia University Hospital, Urology, Morgantown, USA
PURPOSE
To demonstrate the use of indocyanine green (ICG) and immunofluorescence imaging for identification of the lymphatic vessels during laparoscopic lymphatic sparing varicocelectomy in pediatric patients.
MATERIAL AND METHODS
Our standard technique includes using three 5mm laparoscopic ports in linear configuration across the abdomen at the level of the umbilicus. We place the patient in Trendelenburg position. After identification of the gonadal vessels, the posterior peritoneum over the vessels is incised until adequate window is created. Next, we inject 2 cc of indocyanine green (ICG) into the parenchyma of the testicle. Next, we switch to the Overlay Imaging Mode that provides a combination of the immunofluorescence imaging that visualize the ICG, with a background of the standard white light view. This imaging mode allows for detection of the ICG in the lymphatic vessels with the background of the normal laparoscopic view of the surrounding anatomy. This provides an excellent real time identification of the lymphatic vessels during dissection. The lymphatic vessels are dissected and isolated from the gonadal vessels. After creating an adequate window, we perform en bloc ligation of the gonadal veins using three metal clips.
RESULTS
We performed this procedure in 5 patients. Age was ranging from 12 to 18 years old. Average operative time was 59 minutes (range: 49 – 68). All cases were done as an outpatient procedure. No complications were reported.
CONCLUSIONS
The use of ICG via intraparenchymal injection in the testicle in combination overlay immunofluorescence imaging provides excellent view of the lymphatic vessels in real time which facilitates their identification and sparing during laparoscopic varicocelectomy procedure. In our limited case series, this technique was found to safe, effective and reproducible.
VD-11 (VD without presentation)
Luca MAZZONE and Maya HORST
University Children's Hospital Zurich, Pediatric Surgery, Division of Pediatric Urology, Zurich, SWITZERLAND
PURPOSE
Congenital segmental giant megaureter (CSGM) is an extremely rare subtype of megaureter. It is defined by a focal, segmental massive dilatation of the ureter. We present a case of an infant with combined duplex kidney and CSGM, and a possible surgical approach.
MATERIAL AND METHODS
A 17-days-old female presented to the emergency department with increasing abdominal distention. Sonography revealed a left double kidney with dilatation of the upper pole and a cystic mass of 10x10x6 cm of unclear origin. On MRI-urography, the cystic mass was identified as a massive dilation of the middle third of the upper pole ureter. The differential upper pole function was 20% and surgery to decompress and salvage the upper pole was planned. A laparoscopic left end-to-side ureteroureterostomy with resection of the dilated distal ureter was performed at the age of 2 months.
RESULTS
The postoperative course was uneventful and the patient was discharged home on postoperative day two. The inserted transanastomotic ureteral stent was removed after 8 weeks. Follow-up 6 months after ureteral stent removal showed a patent anastomosis with only residual dilatation of the upper pole.
CONCLUSIONS
CSGM is a rare malformation of the urinary tract that may occur in single as well as in duplex renal systems. Adjacent to the dilated segment, normal ureter may be found and an ureteroureterostomy should be considered. A laparoscopic approach allows to avoid the large laparotomy typically needed to resect the massively dilated ureter.
VD-12 (VD without presentation)
Satej MHASKAR 1, Sara LOBO 1, Anis AKHTARKHAVARI 2, Priya RAMACHANDRAN 2 and Abraham CHERIAN 1
1) Great Ormond Street Hospital for Children, Paediatric Urology, London, UNITED KINGDOM - 2) Kanchi Kamakoti CHILDS Trust Hospital, Paediatric Surgery, Chennai, INDIA
PURPOSE
Some patients with neuropathic bowel and bladder need a conduit for Antegrade colonic enema (ACE) and Mitrofanoff to manage faecal and urinary incontinence. The split appendix has been our conventional solution however, not applicable when the appendix is short. Herein we present a video demonstration of an alternate solution.
MATERIAL AND METHODS
The appendix was used mainly for the Mitrofanoff. Size 12 Nelaton catheter introduced via appendicular stump and skirted along the lateral wall of the caecum. Ethicon Endopath 35 mm Linear Stapler was used to create a caecal tube based on the appendicular stump. Stump was plicated at the base with a size 12 Nelaton catheter in situ. Mitrofanoff stoma was placed in the right iliac fossa and ACE was positioned in the umbilicus
RESULTS
Five patients included since September 2019, 4 boys, 1 girl, age: 9y to 18 y. Four patients had spinal dysraphism and one cloacal anomaly.
Two patients had ACE site infection which resolved with antibiotics and wound care. One developed an ACE site granuloma treated effectively with silver nitrate. One patient had ACE site pain at 3 months which resolved subsequently. Our follow up ranged from 2.5 to 37 months. All patients are clean except one who had gastroenterology involvement before the procedure for loose stools.
Unedited video recorded measured 14min 44sec.
CONCLUSIONS
The stapled caecal tube ACE formation is easy, quick, and safe especially when limited by appendicular length needed for the Mitrofanoff channel.
VD-13 (VD without presentation)
Mirjam HARMS, Antonin PROUZA and Maya HORST
University Children's Hospital Zurich, Urology, Zurich, SWITZERLAND
PURPOSE
Since Young presented the classification about posterior urethral valves in 1919 there has been extensive debate about the different types and some even argue, that type II valves don’t exist.
PATIENT
We present the case of a 1 year old boy with a known VACTERL association with duodenal and esophageal atresia and a horseshoe kidney with a normal kidney function. After 9 months of age he suffered from two febrile urinary tract infections. Sonography showed no hydronephrosis and a normal bladder. A VCUG was not possible due to a resistance in the urethra and he was referred to our hospital for a cystoscopy.
RESULTS
Intraoperatively there were mild type I valves and a dilated posterior urethra witch was seemingly blind ending. After suprapubic bladder puncture and application of methylene blue a small opening was seen proximal to the seminal colliculus. The valve expanded from the seminal colliculus up to the ventral bladder neck as decribed by Young as type II valves. They were endoscopically incised with a cold knife until free passage into the bladder was possible. During a second look operation an incision of the type I valve was done and a re-incision of the type II valves. Postoperatively the patient was doing well without any problems with micturition and no further urinary tract infections.
CONCLUSIONS
Although rare, type II valves exist and can sucessfully be treated endoscopically in a similar manner to type I valves.
VD-14 (VD without presentation)
Yesica QUIROZ MADARRIAGA 1, Julio CALDERON 1, Andres KANASHIRO 2 and Anna BUJONS 2
1) Fundacio Puigvert, Paediatric Urology, Barcelona, SPAIN - 2) Fundacion Puigvert, Paediatric Urologyd, Barcelona, SPAIN
PURPOSE
The simultaneous bilateral endoscopic surgery (SBES) is a technique in which a percutaneous nephrolithotomy (PCNL) is performed on one side and a retrograde intrarenal surgery on the other kidney at the same time. All this with the aim of reducing the number of surgeries to the patient by performing both techniques as a single one. The objective of this video is to show the details and steps used in this technique performed in a child urolithiasis.
MATERIAL AND METHODS
A 13-year-old male patient with urolithiasis in both upper urinary tracts: left kidney (LK) 2 stones, one in the renal pelvis of 20mm and in the lower calyx (LC) of 7mm; in the right kidney (RK) one of 7mm. We decided to perform a SBES.
RESULTS
With the patient in a Galdakao-modified Valdivia position a supine PCNL is performed in the LK under fluoroscopic guidance through the lower calyx and dilated with a ballon catheter to 18Fr. Subsequently, an 18Fr percutaneus tract sheath was placed and a 9.5 semirigid short ureteroscope introduced into the collecting system. . On the RK, after performing a 9.5Fr semirigid ureteroscopy, a 10/12 ureteral access sheath was placed and an 8.5Fr flexible ureteroscope was introduced. In order to achieve pulverization of the renal stones we used a 30W Laser Holmium-YAG with a 200um fiber on both sides (2J and 10Hz in LK and 1J and 15Hz in RK). The two kidneys were treated simultaneously and a fluoroscopic c-arm was shared by the two surgeons.
CONCLUSIONS
SBES is feasible in children, but a team of pediatric urologists with experience in endourology is required. Studies with a larger number of patients will be necessary to determine the long-term benefits and safety of this intervention
VD-15 (VD without presentation)
Dario Guido MINOLI 1, Carolina BEBI 1, Michele GNECH 1, Erika Adalgisa DE MARCO 1, Irene PARABOSCHI 1, Stefano Paolo ZANETTI 2, Giancarlo ALBO 2, Filippo MOLINARI 1, Emanuele MONTANARI 2, Gianantonio MANZONI 1 and Alfredo BERRETTINI 1
1) Fondazione IRCCS Ca Granda - Ospedale Maggiore Policlinico, Paediatric Urology, Milano, ITALY - 2) Fondazione IRCCS Ca Granda - Ospedale Maggiore Policlinico, Urology, Milano, ITALY
PURPOSE
We present the case of an 18-month-old female patient brought to the emergency departmentof a foreign hospitaldue to anuria. She was diagnosed with bilateral staghorn kidney stones and Acute Kidney Injury (AKI) (Creatinine 5.47 mg/dL) and underwent bilateral ureteral JJ stent placement.
MATERIAL AND METHODS
The patient was then referred to our centre where we performed a low-dose CT scan, documenting bilateral staghorn stones and dislocation of the proximal end of the right stent in the retroperitoneum. We planned a vacuum-assisted right-sided mini-PCNL (16 Ch ClearPetra set, 12 Ch MIP Storz endoscope and 550 um Ho:YAG laser fiber) and endoscopic JJ stent removal.
RESULTS
We achieved complete clearance of the urolithiasis and visualised the site of exit of the JJ stent from the ureter, 1-2 cm below the uretero-pelvic junction. Unfortunately, we were unable to safely remove the device endoscopically as the proximal pigtail appeared to be stuck and very close to major vessels when pulling the distal end with endoscopic graspers under fluoroscopic vision. We reported no post-operative complications. The stone composition was cystine 100%. A week later we performed a robot-assisted procedure with a transperitoneal approach to remove the dislocated JJ stent. Removal under direct vision was possible. Few weeks later, a left mini-PCNL was performed to obtain complete stone removal.
CONCLUSIONS
The use of miniaturised vacuum-assisted technologies and robotic-assisted surgery greatly aids in the management of complex cases, especially in very young children affected by cystine stones, for whom reducing invasiveness is paramount.
VD-16 (VD without presentation)
Joseph BORER, Marie-Therese VALOVSKA and Hsin-Hsaio (Scott) WANG
BOSTON CHILDREN'S HOSPITAL, UROLOGY, Boston, USA
PURPOSE
Cecoureterocele may cause severe disruption of lower urinary tract (LUT) anatomy and function. With videography, we detail technical aspects of definitive reconstruction including pubic symphysis splitting (PSS) to optimize exposure.
MATERIAL AND METHODS
We reviewed patients with cecoureterocele treated with PSS at our institution since 2011. History, imaging, and evaluation (RUS, VCUG, DMSA, UDS) prior to definitive repair were reviewed. PSS facilitated definitive LUT repair including cecoureterocele excision, bladder floor repair, bladder neck reconstruction (BNR) and urethroplasty. Extensive scar resection, anatomical rehabilitation, and meticulous attention to preservation of muscularis and mucosal tissue facilitated successful reconstruction.
RESULTS
We identified 3 girls with cecoureterocele treated with PSS at definitive repair. One patient presented at our institution with prenatal hydronephrosis and underwent primary repair. Two patients had 3 and 5 surgeries prior to referral including partial nephrectomy, excision of ureterocele, “closure” of ureterocele, bilateral ureteral reimplant, reoperation reimplant, bladder neck Deflux injection, BNR and DVIU. One patient each had either continuous or overflow urinary incontinence at referral. All patients had an associated duplex system and VUR. Age at definitive repair was 0.7, 10, and 15 years. Following definitive reconstruction, average follow-up was 4.8 years (range 0.3-8 years), and both patients with incontinence had improvement by history and VCUG. All were voiding, free of obstruction, and ultimately free of VUR.
CONCLUSIONS
Patients with cecoureterocele may require extensive LUT reconstruction, especially those with severe incontinence and/or obstruction following initial repair. Pubic symphysis splitting provides optimal exposure for complete repair and normal bladder function in these patients.
VD-17 (VD without presentation)
Alberto PARENTE 1, Veronica VARGAS 2, Alvaro ESCASSI 2 and Rosa PAREDES 2
1) REINA SOFÍA UNIVERSITY HOSPITAL, Paediatric Urology, Córdoba, SPAIN - 2) Reina Sofia University Hospital, Paediatric Urology, Cordoba, SPAIN
PURPOSE
To present the creation of a transurethral neo-orifice (TUNO) near the trigone as an initial approach in duplicated ectopic megaureters with preserved moiety function to avoid external urinary diversion.
MATERIAL AND METHODS
We have treated with these technique 4 infants. They presented unilateral duplicated system and ectopic obstructive upper ureter. All patients were symptomatic with at least two urinary infections despite nocturnal antibiotic prophylaxis. Scintigraphy showed a 29±11% moiety partial function.
In all cases the urethrocystoscopy failed to show the meatus of the ectopic ureter. Under ultrasound scan and direct cystoscopic vision the retrovesical ectopic ureter was punctured transvesically. The puncture was done with a 4Fr needle and contrast was instilled in the ectopic ureter to confirm retrograde pyelogram. Through the puncture needle a 0,014''guidewire was inserted into the upper moiety. The punctured site was then dilated with a high-pressure balloon and the neo-meatus edge was coagulated with monopolar electrocautery to achieve cohesion.
RESULTS
Mean operative time was 62 ± 10 minutes. The mean age at treatment was 6.8 ± 2.9 months. There were not perioperative or postoperative complications. Urinary tract infections disappeared in all cases. The assessment done 3 months postoperatively demonstrated a significant decrease in the grade of the hydronephrosis and retrovesical ureter diameter (4 mm vs 20 mm). Moiety function improved in 2 cases.
CONCLUSIONS
Creation of TUNO is a minimally invasive technique successful as the initial management of ectopic ureter. In our experience, it avoids urinary tract infections, decreases ureteral dilatation and preserves parenchyma function.
VD-18 (VD without presentation)
Maria Dolores BLANCO VERDU 1, Beatriz FERNANDEZ BAUTISTA 1, Isabel BADA BOSCH 1, Javier ORDOÑEZ PEREIRA 1, Ruben ORTIZ RODRIGUEZ 1, Alberto PARENTE 2, Laura BURGOS LUCENA 1 and Jose Maria ANGULO MADERO 1
1) HOSPITAL GREGORIO MARAÑON, PEDIATRIC SURGERY, Madrid, SPAIN - 2) HOSPITAL REINA SOFIA, PEDIATRIC SURGERY, Cordoba, SPAIN
PURPOSE
The number of patients with recurrent pyeloureteral junction obstruction (PUJO) is small. However, treatment in these cases remains controversial. Repyeloplasty is the most used treatment for these patients. Endourological techniques are a minimally invasive alternative for failed pyeloplasty. The objective is to present our experience in the use of fiber laser retrograde endopyelotomy.
MATERIAL AND METHODS
We present three patients with recurrent ureteropelvic junction obstruction treated by retrograde endopyelotomy. All had been previously treated by dilation of the ureteropelvic junction with a high-pressure balloon with subsequent worsening of renal dilatation and obstructive curve in the renogram. The technique consists of initially performing a cystoscopy with placement of a high-pressure balloon over a guidewire in the obstructed ureteropelvic junction. Subsequently, a ureterorenoscopy is performed, locating the balloon and performing an endopyelotomy on the lateral and inferior margin to avoid vascular injuries.
RESULTS
Three patients were included. The ages of the patients were 5, 3 and 2 years. The median surgical time was 50 minutes (42-65). Holmium fiber laser was used. A double J catheter exteriorized with thread was left in all patients for 5 days. Bladder catheterization time was 24 hours. The hospital stay was 24 hours. Mean follow-up was 1.5 years (1-2). There was an improvement on ultrasound in all patients.
CONCLUSIONS
Retrograde endopielotomy is minimally invasive technique and an effective technique to treat recurrent PUJO after failed pyeloplasty in children. In our experience, it reduces kidney damage without increasing complications.
VD-19 (VD without presentation)
Thomas LOUBERSAC, Maximilien BARON, Brigitte PERROUIN-VERBE, Bénédicte REISS, Chloe LEFEVRE, Jerome RIGAUD, Marc-David LECLAIR and Marie-Aimée PERROUIN-VERBE
CHU of Nantes, Nantes, FRANCE
PURPOSE
To present the case of the 16 years girl who undergone a robot assisted laparoscopic Mitrofanoff out of series of 5 consecutives pediatrics cases and to report our surgical technic.
MATERIAL AND METHODS
Since 2017, we have performed Robotic Assisted Laparoscopic Continent Urinary Diversion(RALCUD), and all patients were prospectively included.
We report the case of a 16 years old female with a tetraplegia secondary to a spinal cord injury level C5 AIS B. She needed Clean Intermittent Catheterization(CIC), but she was not able to do it by herself. On the urodynamics, the bladder was well inactive by oxybutynin, the bladder capacity was of 500ml and there was no urine leakage during the filling. After a multidisciplinary evaluation, it was decided to perform a RALCUD of Mitrofanoff (Appendicovesicostomy) without bladder augmentation.
The tube was implanted in the posterior bladder wall, according to lich-Gregoire anti-reflux principle and the stoma was brought to the umbilical site.
RESULTS
The surgery lasted 221 min and blood loss were
At the 12 months, there was no leakage from the urethra neither the stoma nor there was no difficulty to catheterize the stoma with a 16 French catheter.
CONCLUSIONS
RALCUD of Mitrofanoff especially with neurogenic bladder seems safe and feasible. It provides short-term very high rate of stomal and urethral continence with a low rate of complications.