ESPU Meeting
VD-1 (VD without presentation)
Yesica QUIROZ MADARRIAGA, Lucia DIEGUEZ, Rocio JIMENEZ and Anna BUJONS
Fundacio Puigvert, Paediatric Urology, Barcelona, SPAIN
PURPOSE
The gastrointestinal segments are the tissues of choice when performing an augmentation cystoplasty, however they have long-term consequences such as the appearance of bladder stones or even malignancy. Our objective is to describe the surgical technique of percutaneous cystolithotomy in a patient undergoing colocystoplasty.
MATERIAL AND METHODS
We present the case of a 16-year-old female patient with a history of severe abdominal polytrauma in childhood, who at the age of 7 years required a colocystoplasty with Mitrofanoff and bladder neck closure. Since then she has presented multiple episodes of cystolithiasis and during the last controls there is evidence of recurrence of lithiasis. Renovesical ultrasound and abdominal radiography showed multiple lithiasis, the largest of 15mm in diameter. It was decided to perform a percutaneous cytolithotomy.In supine position and under general anesthesia a Mitrofanoff cystoscopy was performed. 7 bladder stones were identified, the biggest one almost 2cm.
Guided percutaneous puncture is performed under direct vision with chiba needle and progressive dilatation is performed on Amplatz guide. A balloon dilator is introduced, which is insufflated up to 20Atmospheres and a 30Fr sheath is advanced. Nephroscope passage and extraction of small lithiasis with N-Perc forceps. To achieve the stone fragmentation a 500micras Holmium: YAG laser fiber (2J-10Hz) was used. A Mitrofanoff catheter (14Fr) was placed
RESULTS
The operative time was 150minutes and blood losses were virtually absent. There were no intra- or post-operative complications and the patient was discharged at the 2 day. After 3 weeks the Mitrofanoff catheter was removed having a stone free status
CONCLUSIONS
Percutaneous cystolithotomy is a plausible procedure in patients with bladder enlargement and closed bladder neck, being only necessary to catheterize through the Mitrofanoff in the postoperative period to avoid the appearance of fistulas, maintaining good urine drainage and closing the percutaneous access in planes.
VD-2 (VD without presentation)
Maria ESCOLINO 1, Paolo CAIONE 2, Annalisa CHIODI 1, Claudia DI MENTO 3, Fulvia DEL CONTE 3, Mariapina CERULO 3, Vincenzo COPPOLA 1 and Ciro ESPOSITO 1
1) Federico II University Hospital, Pediatric Surgery, Naples, ITALY - 2) Salvator Mundi International Hospital, Pediatric Urology, Rome, ITALY - 3) Federico II University Hospital, Naples, ITALY
PURPOSE
In the last 2 decades, single-stage repair of bladder exstrophy-epispadias complex (BEEC) has been proposed at neonatal age or within the first 2 months. We herein report single-stage primary repair of BEEC to demonstrate feasibility and advantages at older patient's age.
MATERIAL AND METHODS
A newborn with prenatal diagnosis of BEEC was followed conservatively till 5 months of age. The parents were instructed to manage the exstrophy plate and maintain it moist using gel and wet gauze. The patient received hormonal stimulation using single im administration of testosterone enanthate at 3 months. Ultrasound (US) showed mild right hydronephrosis and X-ray confirmed wide pubic diastasis (5.5 cm). Surgery was planned at 23 weeks of age and 9.250 kg body weight.
RESULTS
Complete bladder-urethro-genital repair was performed, including bilateral posterior iliac osteotomy, bilateral ureteral reimplantation, bladder closure, bladder neck lengthening and plasty, urethral plate tubularization, periurethral musculature and soft tissue reassembly, with anterior pelvic floor reconstruction, according with personal technique. Surgery lasted approximately 8 hours. The post-operative course was uneventful. Immobilization of lower limbs, adducted at 90° and infra-rotated, was maintained for 4 weeks postoperatively. Suprapubic catheter was removed 5 weeks postoperatively. At 4-month follow-up, the patient was asymptomatic and had intermittent, spontaneous, valid micturition. US showed resolution of hydronephrosis.
CONCLUSIONS
Complete bladder-urethro-genital repair is feasible as single procedure for management of BEEC. Surgery can be postponed from neonatal to older patient's age, influencing positively the surgical outcome. Delayed repair allowed to minimize risk of penile vascular injury, reduce surgical complications and post-operative intensive care.
VD-3 (VD without presentation)
Javier RUIZ, Felicitas LOPEZ IMIZCOZ, Nicolas ROSIERE, Luciana DIAZ ZABALA, Otilia BLAIN, Santiago WELLER, Cristian SAGER, Carol BUREK, Yesica GOMEZ, Tobia SEBASTIAN, Esteban GALLINO and Juan Pablo CORBETTA
Hospital de Pediatria Prof. J. P. Garrahan, Urology, Buenos Aires, ARGENTINA
PURPOSE
Y-type urethral duplication (Effman IIA 2 “y-type”) represents a wide spectrum of urogenital malformations in which the common finding is the presence of an orthotopic steno-atresic urethra and a functional ectopic ventral urethra that ends at the anal margin. The aim of this video is to illustrate a staged reconstruction performing a radical mobilization of the functional ventral urethra in a first stage and posteriorly an autologous graft tubularization (STAG).
MATERIAL AND METHODS
We present a 4-year-old boy with postnatal diagnosis of “y-type” urethral duplication with anal voiding and no other comorbidities. In the first stage the patient was placed in a supine position and the ectopic urethra was separated from the anal margin and then dissected proximally to its prostatic part. A disposable flexible ureteroscope was used in an antegrade way through a cystostomy trocar as a guide during the urethral dissection. The ventral urethra was placed in a peno scrotal position. Six months later, a STAG procedure was performed using preputial and buccal mucosal grafts. The dorsal urethra was not resected, and it was anastomosed to the neourethra near to the glans. After 10 months tubularization of the neourethra was performed.
RESULTS
No major complications were registered. After 6 months follow-up the patients is voiding through a glandular meatus
CONCLUSIONS
Staged reconstruction with the use of autologous grafts is a feasible option in the management of y-type urethral duplication. Supine position can be used for a greater mobilization of the functional urethra to a perineal or peno-scrotal position. Dorsal urethra can be anastomosed distally to the neourethra avoiding dilatations and more complex procedures.
VD-4 (VD without presentation)
Bruno CEZARINO 1, Rafael VILLARES 2, Roberto IGLESIAS 2 and Francisco DENES 2
1) Hospital das Clinicas da Faculdade de Medicina da USP, Urology, Sao Paulo, BRAZIL - 2) Hospital das Clinicas da Faculdade de Medicina da USP, Pediatric Urology, Sao Paulo, BRAZIL
PURPOSE
We the describe the use of indocyanine green during robotic-assisted heminephrectomy (RAHN) in 4 cases of upper or lower moiety exclusion. This technique aims to better understand vascular anatomy of excluded moiety while preserving the remnant renal pole and ureteral vascular supply.
MATERIAL AND METHODS
A retrospective analysis of three pediatric patients(4 renal units) who underwent RAHN with ICG were performed in a mean age of 2.3y ( range 1-7). After habitual patient positioning and trocars placement, we performed artery branch clamping of the excluded pole, administered ICG (0.2mg/kg), and activated the Da Vinci Xi's FireFly system. After confirming anatomical integrity of upper pole vascular supply, we conducted heminephrectomy with ureterectomy.
RESULTS
All four RAHN procedures were completed successfully without intraoperative complications. In one case, the ICG showed abnormal vascularity between upper and lower pole and allowed better control during surgery. This technique enabled clear preservation of vascular supply for the remaining renal moiety and ureteral vascularization. ICG use allowed for precise identification of vascular supply, predicting minimizing the risk of major bleeding linked to anomalous vasculature. No immediate postoperative complications, adverse events or major blood loss were observed. Postoperative recovery was uneventful.
CONCLUSIONS
We describe use of ICG during RAHN in pediatric patients with pole moiety exclusion in 4 surgeries. The technique effectively prevents vascular lesions related to anomalous vasculature and ensures excellent surgical outcomes. Nevertheless, further studies involving larger patient cohorts and long-term follow-up are imperative to confirm the reproducibility and long-term benefits of this approach.
VD-5 (VD without presentation)
Javier RUIZ, Felicitas LOPEZ IMIZCOZ, Juan Pablo CORBETTA, Santiago WELLER, Nicolas ROSIERE, Luciana DIAZ ZABALA, Otilia BLAIN, Cristian SAGER, Carol BUREK and Yesica GOMEZ
Hospital de Pediatria Prof. J. P. Garrahan, Urology, Buenos Aires, ARGENTINA
PURPOSE
Fraley’s syndrome is a rare cause of extrinsic compression of the upper pole infundibulum secondary to a renal vascular variant. Surgical treatment with nephron-sparing procedures is indicated only in symptomatic cases and only few cases have been published in the literature. The aim of this video is to illustrate in a step-by-step fashion the diagnosis and minimally invasive management of this rare entity in a paediatric patient.
MATERIAL AND METHODS
We present a 4-year-old boy with a 6-month history of recurrent left flank pain and isolated upper calix dilation on ultrasound. Nuclear Scan demonstrated tracer retention in the left upper pole and CT scan showed anterior and posterior branches of the apical renal artery. Patient was positioned in a Galdakao-modified supine Valdivia position. A retrograde pyelogram confirmed an obstructed and long upper pole infundibulum. A transperitoneal laparoscopic caliconeopyelostomy was performed ventrally to the upper pole vessels.
RESULTS
Operative time was 90 minutes. Patient was discharge after 48 h. Double-J ureteral stent was removed after 1 month. There were no complications with reduction of the upper pole dilation on ultrasound and resolution of symptoms during follow-up.
CONCLUSIONS
Fraley’s syndrome is rare cause of upper pole obstruction and should be suspected in the presence of recurrent flank pain, haematuria, or urinary tract infection with an isolated upper calix dilatation on images. Laparoscopic nephron-sparing surgery is a feasible option and should be the first line of treatment in paediatric patients.
VD-6 (VD without presentation)
Paul AUSTIN
Texas Children's Hospital, Baylor College of Medicine, Urology, Houston, USA
PURPOSE
Massively enlarged kidneys with autosomal recessive polycystic kidney disease (ARPKD) may impact feeding and respiration in neonates and infants necessitating nephrectomy(ies). Additionally, nephrectomy is necessary to create space for peritoneal dialysis (PD) and bridging prior to kidney transplantation. The purpose of this video is to demonstrate the feasibility and value of a laparoscopic retroperitoneal approach for nephrectomy(ies) in neonates and infants with ARPKD.
MATERIAL AND METHODS
Key surgical steps are described in the video. The neonate is placed in lateral position and key landmarks are marked: a) 11th & 12th ribs, b) iliac crest and c) paraspinal muscle. Three triangulated 5 mm ports are placed in the retroperitoneal space using the landmarks for the dissection. The kidney is morcellated and removed over a 2.5 cm incision off the lateral port site.
RESULTS
Important techniques learned with the limited working space include using insufflation to expand the working space, utilization of a laparoscopic Kittner dissector and usage of bipolar diathermy-based device to seal and divide the vessels. Patient recovery and PD usage was expedited in all cases, and we have successfully used this technique in 3 neonates and 2 infants for stabilization in the NICU and PD implementation.
CONCLUSIONS
The retroperitoneal approach for laparoscopic nephrectomy(ies) in neonates and infants with ARPKD is a good surgical strategy that facilitates recovery and early PD and bridging for future renal transplantation.
VD-7 (VD without presentation)
Javier ROJAS-TICONA, Maria RAMIREZ-PIQUERAS, Veronica MARIJUAN SAHUQUILLO, Esperanza HERNANDEZ ANSELMI, Tania MORATALLA JAREÑO, Alba LARA VALTUEÑA, Carlos DE-LA-SEN-MALDONADO and Marisol FERNANDEZ CORDOBA
University Hospital Complex of Albacete, Spain, Paediatric Surgery, Albacete, SPAIN
PURPOSE
Main indications for ureterocalicostomy are: prior failure of pyeloureteral surgery, severe fibrosis at the pyeloureteral junction, large proximal ureteral stenosis that may compromise a tension-free pyeloureteral anastomosis, and an intrarenal pelvis with significant hydronephrosis. We present a case of a patient treated with laparoscopic ureterocalicostomy.
MATERIAL AND METHODS
A 10-year-old male followed up by pediatric nephrology for right megacalycosis. He was referred to our Service due to flank pain and hydronephrosis. He had no UTIs or antibiotic prophylaxis. Ultrasound showed significant dilation of renal calices and the right pelvis. A contrast CT scan revealed signs of pyeloureteral junction stenosis with thinning of renal parenchyma. The DTPA renogram assessed an obstructive hydronephrosis with decreased right renal function (17%).
RESULTS
Laparoscopic surgery was performed through transperitoneal approach. A perirenal dissection was carried out identifying the right ureter, a mildly dilated renal pelvis and lower posterior and anterosuperior polar vessels. The kidney showed thinning of the parenchyma. The stenosis at the pyeloureteral junction appeared intrinsic to the section. Due to the anatomical difficulty in performing pyeloplasty, an ureterocalicostomy to the lower renal calyx was decided. A 4.5 Fr double-J stent was left transanastomotic and removed after a month. Currently under clinical follow-up, there is sonographic improvement in dilation.
CONCLUSIONS
Laparoscopic ureterocalicostomy is a feasible treatment option when anatomy is inadequate for direct pyeloureteral continuity reconstruction.
VD-8 (VD without presentation)
Sonia PÉREZ-BERTÓLEZ, Isabel CASAL-BELOY, Ángel GALLEGO, Oriol MARTÍN-SOLÉ, Xavier TARRADO and Luis GARCÍA-APARICIO
Hospital Sant Joan de Déu, Pediatric Urology Unit, Department of Pediatric Surgery, Barcelona, SPAIN
PURPOSE
A bladder diverticulum is a herniation of the bladder mucosa between fibers of the detrusor muscle. They are most commonly observed adjacent to the ureteral orifice. We aim to report a pneumovesicoscopic bladder diverticulectomy in a child and describe some key points of the technique.
MATERIAL AND METHODS
A 9-year-old boy referred to the pediatric urology office of our center for recurrent urinary tract infection and hematuria. Ultrasonogram revealed a bladder diverticulum arising from right posterolateral wall. Voiding cystourethrogram (VCUG) confirmed the large bladder diverticulum and showed no abnormality in urethra nor vesicoureteral reflux.
RESULTS
The procedure was carried out under general anesthesia. Initially, cystoscopy was performed and a double J stent was placed in the right ureter for intra-operative identification. The bladder was fixed to the abdominal wall with two percutaneous stitches, one 5mm and two 3mm trocars were inserted under cystoscopic vision. A 10Fr Foley urethral catheter was placed. Then, in supine position, cystoscopic insufflation of the bladder with carbon dioxide was done. The neck of the diverticulum was marked with a monopolar hook and dissection was done carefully inverting the diverticulum. After the excision, the resulting defect in the posterior wall of the bladder and trocar orifices were closed with interrupted absorbable sutures. Patient was discharged on first postoperative day with the Foley catheter. Postoperative ultrasound and VCUG were normal.
CONCLUSIONS
Pneumovesicoscopic diverticulectomy is a feasible procedure. It is associated with shorter hospital stay and rapid recovery with good cosmetic result.
VD-9 (VD without presentation)
Ciro ESPOSITO 1, Lorenzo MASIERI 2, Annalisa CHIODI 1, Claudia DI MENTO 1, Fulvia DEL CONTE 1, Mariapina CERULO 1, Vincenzo COPPOLA 1 and Maria ESCOLINO 1
1) Federico II University Hospital, Pediatric Surgery, Naples, ITALY - 2) Meyer Children Hospital, Pediatric Urology, Florence, ITALY
PURPOSE
Robotic surgery is particularly well-suited to reconstructive surgery involving delicate structures like the ureter. Robotic approach provides excellent visualization and access to the ureter at all levels. We report surgical technique of robot-assisted dismembered extravesical ureteral reimplantation for vaginal ectopic megaureter.
MATERIAL AND METHODS
A 4-year-old girl came to our attention with prenatal diagnosis of right megaureter. At birth right refluxing megaureter with concomitant extravesical ureterocele was confirmed. Hypofunction of right kidney (split renal function <20%) was demonstrated on renal scan. Endoscopic puncture of ureterocele was performed, with mild decompression of the dilated upper tract. At 3 years of age, she developed urinary pseudo incontinence and breakthrough urinary infections. Magnetic resonance imaging showed right vaginal ectopic megaureter. Reconstructive robotic surgery was planned.
RESULTS
A 4-trocar approach was used. The ectopic megaureter was isolated downwards till to the origin from the vagina, ligated and disconnected. Following the detrusorotomy with creation of ureteral flaps, ureteroneocystostomy was performed, ensuring to place a double-J stent before completing the anastomosis. The ureteral flaps were closed over the ureter to create extravesical anti-refluxing tunnel. Post-operative course was uneventful and double-J stent was removed at 4 weeks postoperatively. At 9-month follow-up, the patient is toilet-trained, continent, and asymptomatic.
CONCLUSIONS
Distal ureter and bladder reconstruction using the robotic technique is feasible, safe, and effective to restore the normal anatomy and function. It should be considered a valid minimally invasive alternative to open reconstructive surgery.
VD-10 (VD without presentation)
M S ANSARI 1, Anwesa CHAKRABORTY 2 and Priyank YADAV 2
1) Sanjay Gandhi Postgraduate Institute of Medical Sciences, Pediatric Urology, Department of Urology and renal transplantation, Lucknow, INDIA - 2) Sanjaya Gandhi Post graduate Institute of Medical Sciences, Pediatric Urology, Lucknow, INDIA
PURPOSE
We sought to evaluate the feasibly of robotic assisted trans-vesicoscopic ureteric reimplantation in children and surgeons' work-related musculoskeletal symptoms in comparison to open surgery
MATERIAL AND METHODS
The children under 12 years of age with vesicoureteric reflux (VUR underwent open (Group I) and vesicoscopic robotic assisted ureteric reimplantation (VRAUR) (Group II). 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.
The surgeons related ergonomic parameters recorded in both the groups were generalised pain, neck and back strain/pain along with lower extremity exertion to surgeons. Success was defined as the absence of VUR on direct radionuclide cystogram at 12 weeks.
RESULTS
The two groups had 33 and 21 patients with the mean age of 72 and 84 months in groups I and II respectively. The grades of VUR was comparable in both the groups. The VRAUR 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 Surgeons’ musculoskeletal symptoms recorded were substantially more in Group I as compared to Group II (p value 0.001, CI 95%.
CONCLUSIONS
Robotic assisted laparoscopic ureteral reimplantation is feasible and offers success rate comparable to open surgery. The procedure follows the anatomical principles thus minimizing the possibility of neuro urological damage and subsequent bladder dysfunction.The surgical ergonomics related to musculoskeletal symptoms are more substantial in open surgery.
VD-11 (VD without presentation)
Tal MAY
Schneider children's hospital, Urology, Petach Tikvah, ISRAEL
PURPOSE
To present robotic removal of seminal cyst in a child with Zinner syndrome
MATERIAL AND METHODS
An 11 year old boy presented with dysuria and lower abdominal pain.
Medical history - the patient underwent repair of coarctation of the aorta, orchiopexy, and also has celiac disease.
US and MRI revealed single left kidney and cystic lesion posterior to the urinary bladder.
On cystoscopy- the urethra, bladder neck and the bladder, all were within normail limitis.
Most plausible differential diagnosis following the evaluation, was either a rt. Atrophic kidney or a seminal vesicle cyst.
The boy was scheduled for a robotic assisted procedure.
During the operation course, the cyst was identified, the peritoneum was divided from the cyst.
The vas deferens was identified and was separated from the cyst.
To try to reduce the risk of damaging adjacent structures, and to preserve the vas deferens, we decided to perform unroofing of the cyst, rather than removing it en-bloc. The roof of the cyst was carefully resected. The opening of the seminal cyst that created the cyst was continuously sutured.
The base of the remained the cyst was coagulated, and the roof of the cyst was left open.
RESULTS
Postoperative recovery was uneventful, and the boy was discharged on day 2.
Follow-up one month after the procedure was normal, and the symptoms of dysuria and abdominal pain have disappeared.
US of the urinary tract showed no evidence of the cyst.
CONCLUSIONS
This case present a child with Zinner syndrome which is a rare congenital abnormality of mesonephric duct consisting of:
Unilateral renal agenesis.
Ipsilateral seminal vesicle cyst.
Ipsilateral ejaculatory duct obstruction.
VD-12 (VD without presentation)
Thomas LOUBERSAC 1, Hortense ALLIOT 1, Flavie SADONES 2, Fabrizio VATTA 1, Sebastien FARAJ 1 and Marc-David LECLAIR 1
1) University Hospital of Nantes, Paediatric Urology, Nantes, FRANCE - 2) University Hospital of Nantes, Paediatric Radiology, Nantes, FRANCE
PURPOSE
We report here the case of a 12-year-old female patient who underwent robotic-assisted laparoscopic surgery for a vesico-urethro-vaginal fistula.
MATERIAL AND METHODS
The girl underwent a left nephro-ureterectomy at the age of one year for a symptomatic non-functioning kidney with ureterohydronephrosis. At the age of three she developed total urinary incontinence. Endoscopy revealed a ceco-ureterocele with a vesico-vaginal fistula. Reconstructive surgery was performed with transvesical closure of the vesico-vaginal fistula and urethro-cervicoplasty. Total urinary incontinence recurred at the age of five years. Endoscopy confirmed the recurrence of the vesico-vaginal fistula. Further surgery was performed at the onset of puberty for vulvovaginitis secondary to the fistula. A uro-MRI revealed a vesico-urethrovaginal fistula. Robotic laparoscopic repair of the fistula with omentum interposition was proposed.
RESULTS
The operation was performed under general anaesthesia in the lithotomy position with tredelenburg of 20°. The operation began with a urethrocystoscopy which revealed the fistulous orifice between the vagina, urethra and bladder. A 13F Cystodrain was placed through the fistula between the vagina and the bladder then a 14F urethral catheter.
We began by laparoscopy, dissecting between the bladder and the vagina to the fistula. The fistula was easily found with the cystodrain. The cystic cavity and fistulous tract are resected. The posterior surface of the urethra, bladder and vagina were closed. The robot was placed in the upper abdominal position to free the omentum, which is then interposed between the urethra and vagina. The operation lasted 241 minutes and the patient was discharged on D2. The urethrovesical catheter was removed at D14 after cystography had checked that there was no residual fistula. At 6 months, there was no recurrence of the fistula or urine leakage.
CONCLUSIONS
The cure of vesico-urethro-vaginal fistula by robot-assisted laparoscopy, even after urethro-cervicoplasty, seems possible in children.
VD-13 (VD without presentation)
Bulent ONAL 1, Elif Altınay KIRLI 2, Muhammet DEMIRBILEK 1, Goktug KALENDER 1 and Emre AKKUS 1
1) Istanbul University - Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Urology, Istanbul, TURKEY - 2) Istanbul University-Cerrahpaşa Cerrahpaşa Faculty Of Medicine, Urology, İstanbul, TURKEY
PURPOSE
Publications on robotic surgery applications in pediatric urooncology are limited. However, the technical advantages of robotic systems may be advantageous in pediatric tumors. The video presents technical details of robot-assisted laparoscopic radical cystoprostatectomy, extended lymph node dissection, and ileal loop for bladder embryonal rhabdomyosarcoma.
MATERIAL AND METHODS
The patient is a 26-month-old male patient with macroscopic hematuria. Radiologic evaluation (urinary ultrasound and magnetic resonance imaging) revealed a 3 cm mass lesion originating from the bladder. Although there was a hypointense area in the sacral bone suggesting metastatic involvement, no lymph node of pathologic size was detected. Diagnostic cystoscopy showed that the mass extended from the right half of the trigone to the bladder dome and distally to the prostatic urethra. A double collecting system anomaly was diagnosed on the left. The mass with embryonal rhabdomyosarcoma histology partially responded to chemotherapy.
RESULTS
In this case, the operative time was 450 minutes; the estimated blood loss was 35 cc, transfused during the operation. The length of hospital stay was eight days. No postoperative complications were seen. The patient was tumor-free after the surgery.
CONCLUSIONS
Robot-assisted laparoscopic surgery presents an effective and safe treatment option for bladder tumors in pediatric age. However, a more significant number of reports are needed to assess its reliability.
VD-14 (VD without presentation)
Nicolas FERNANDEZ 1, Hailey SILVERII 2 and Gnapika KOTHAKOTA 2
1) Seattle Childrens Hospital - University, Urology, Seattle, USA - 2) Seattle Childrens Hospital - University, Seattle, USA
PURPOSE
VIDEO attached.
Patients with early bilateral supravesical diversion to treat bladder outlet obstruction present a challenge for reconstruction and un-diversion as the bladder becomes defunctionalized with a severely reduced bladder capacity. In this case, we present a staged robotic approach to ureteral un-diversion that can be considered for safe bladder “re-functionalization.”
MATERIAL AND METHODS
An 11-month-old male referred with a history of posterior urethral valves required bilateral end cutaneous ureterostomies in the neonatal period. On initial evaluation, his bladder capacity was 15 ml. After failing bladder cycling via suprapubic tube, he was recommended staged robot assisted ureteral side to side ureterocystostomy un-diversion while maintaining cutaneous ureterostomies. . The robot-assisted staged operations were completed 10 months apart.
RESULTS
Stage 1: completion of the left side-to-side ureterocystostomy was safely accomplished with a console time of 90 minutes. Six months later, his ultrasound showed stable hydronephrosis and urine within the partially distended bladder. Ten months after stage 1, he presented for stage 2: Videourodynamics and ligation of the left ureterostomy and right side-to-side ureterocystostomty while maintaining the right ureterostomy. Urodynamics demonstrated stable filling with a new capacity of 50 ml from 15ml. Stage 2 was safely completed with a console time of 105 minutes. Four-weeks later, the ultrasound showed stable upper tract with a distended bladder. Normal bladder cycling with no discomfort and volitional voiding. Stable kidney function.
CONCLUSIONS
A staged approach to un-diversion and natural bladder cycling resulted in a 3-fold increase in bladder capacity. This approach demonstrates feasibility in carefully selected patients.
VD-15 (VD without presentation)
Eric KURZROCK
University of California Davis, Urologic Surgery, Sacramento, USA
PURPOSE
After appendicostomy for laparoscopic ACE Malone or Mitrofanoff, stomal stenosis has been reported to occur in 12% to 45% of patients. The objective of this investigation is to analyze outcomes after the utilization of a novel stoma technique that preserves the appendiceal tip and vessels and opens the lumen in a more proximal and vascular area to improve perfusion and decrease stenosis.
MATERIAL AND METHODS
Medical records of patients who underwent the novel stoma technique during ACE or urinary diversion were retrospectively evaluated. Variables such as open or laparoscopic approach, age, gender, body mass index, antegrade continence enema or urinary diversion, cecal and appendiceal adhesions, retrocecal position, cecal imbrication, technique, frequency of catheterization and stenosis were recorded. Stenosis is defined by need for revision surgery and/or indwelling catheter for any length of time. Cox proportional hazards analyses were performed to determine association of covariates.
RESULTS
A total of 44 patients met inclusion criteria with a median age of 9.0 years. The appendix was imbricated in 10% of ACE procedures and all continent diversions. No patient has developed stomal stenosis or obstruction after a median follow up of 4.8 years (range 1 to 10 years). There was no association of stenosis with any variable including surgical approach, laparoscopic or open.
CONCLUSIONS
Stomal stenosis after appendicostomy is lessened by preservation of the distal appendiceal vasculature and tip and opening the lumen in a more proximal location.
VD-16 (VD without presentation)
Ruben ORTIZ, Laura BURGOS, Beatriz FERNANDEZ-BAUTISTA, Javier ORDOÑEZ and Jose Maria ANGULO
University Hospital Gregorio Marañón, Pediatric Urology, Madrid, SPAIN
PURPOSE
To present the technical features and outcomes of endoscopic balloon dilatation (EBD) of primary obstructive megaureter (POM) with associated ipsilateral paraureteral diverticulum.
MATERIAL AND METHODS
Sixteen POM cases with associated paraureteral diverticulum were treated by EBD between 2004 and 2021. In cases of large diverticulum, a careful endoscopic inspection with a ureteral catheter and a hydrophilic guidewire is essential to identify the ureteral meatus. Then the guidewire is introduced into the tortuous ureter and the dilation of the vesicoureteral junction is performed using high-pressure balloon catheters (3F) with a minimum balloon diameter of 5 mm followed by temporary Double-J stent placement. Complications and outcomes were analyzed with a mean follow-up of 7.2 ± 4.4 years.
RESULTS
Median age at treatment was 5 months (2-44) with a median operating time of 15 minutes (10-30) and hospital stay of 1 day. No perioperative complications occurred. Initial renal function was preserved in all cases and 13 ureters showed a non-obstructive pattern on the MAG-3 renogram after the EBD. Three cases presented persistent postoperative hydroureteronephrosis with obstructive pattern and needed another EBD months later. Secondary VUR was identified in 7 cases and treated by endoscopic subureteral injection. Ureteral reimplantation was required in 3 ureters (1 re-stenosis recurrence, 1 persistent VUR, and 1 non-symptomatic persistent hydroureteronephrosis whose parents demanded surgical treatment). The endoscopic approach of POM with associated diverticula had a long-term success rate of 81.25% (13/16).
CONCLUSIONS
The presence of paraureteral diverticulum seems to be a poorer prognostic factor for the success of endoscopic treatment of POM, leading to a higher rate of secondary reflux. Nevertheless, it was a safe and feasible technique with acceptable long-term results.
VD-17 (VD without presentation)
David KIM, Kristina GAM, Hernan LESCAY and Mohan GUNDETI
University of Chicago Medical Center, Urology, Chicago, USA
INTRODUCTION
Duplication of the kidney can lead to lower pole ureteropelvic obstruction. We present a surgical video depicting a left lower pole pyeloplasty without the use of retrograde pyelogram or preoperative stent placement.
MATERIAL AND METHODS
We describe a case of an 11-year old male who presented with abdominal pain and was found to have a duplicated left kidney with grade 3 hydronephrosis of the lower pole. The MAG3 scan showed delayed washout of the left lower pole. The VCUG was negative for vesicoureteral reflux.
The patient is placed in left flank position. All pressure points are padded. The robotic ports are placed as depicted in the image. The colon is dissected away from the left kidney. Gerota's fascia is incised to reveal the left kidney. The two ureters are identified lying adjacent to each other. The pelvis is hitched up with the hitch suture. The UPJ is transected and tunneled out from under the crossing vessel. The ureter is spatulated and the posterior UPJ is reconstructed in the standard fashion. An indwelling stent is introduced through an angiocath. The UPJ reconstruction is then completed.
RESULTS
The patient recovered well and was discharged home the next day. The ureteral stent was removed after 4 weeks. The patient reported he was pain free. The follow up renal ultrasound showed improvement of the left lower pole hydronephrosis.
CONCLUSIONS
Our video presents a lower pole pyeloplasty without requiring the use of retrograde pyelogram or preoperative stent placement.
VD-18 (VD without presentation)
Bernhard HAID 1, Manuela HIESS 2, Sarah Nicole WIMMER 2, Lukas STEINKELLNER 2, Lukas LUSUARDI 3 and Josef OSWALD 2
1) Ordensklinikum Linz, Hospital of the Sisters of Charity, Pediatric Urology, Linz, AUSTRIA - 2) Ordensklinikum Linz, Hospital of the Sisters of Charity, Department of Pediatric Urology, Linz, AUSTRIA - 3) Paracelsus Medical University Salzburg, Department of Urology, Salzburg, AUSTRIA
PURPOSE
Obstruction of an upper pole moiety in duplex kidneys is a relatively rare entity. It is typically caused by vascular obstruction, patients might become symptomatic only in later childhood or adolescence. Because of the need for vascular exposure and more on the right side than on the left side, a ventral, transperitoneal access might of advantage compared to classical, open retroperitoneal surgery. The Intuitive DaVinci Xi robotic surgical system allows for unmatched ease of preparation and reconstruction as well as ideal exposure. This video aims at displaying surgical technique and potential advantages of the laparoscopic, robotic assisted access.
MATERIAL AND METHODS
Two patients, a 13 year old girl and a 11 year old boy presented with symptomatic right upper pole obstruction in duplex kidneys and well-functioning right upper moieties. Both underwent robotic assisted pyeloplasty using a Intuitive Da Vinci Xi platform with three robotic and one assistant trocar (each 8mm) as well as the AirSeal System with a pressure of 7mmHg.
RESULTS
In both patients, as well accessory lower pole vessels as also a compression by the renal vessels were underlying the symptomatic obstruction. In both cases, mobilization and reconstruction of the concerned ureteropelvic junction ventral to the vessels could be achieved.
CONCLUSIONS
Especially in adolescents and for the repair of an upper pole ureteropelvic junction obstruction, a ventral, transperitoneal laparoscopic access might be of advantage. The DaVinci robotic surgical system allowed for an ideal preparation and reconstruction.