ESPU Meeting
VD-1 (VD without presentation)
John WARD 1, Dana WEISS 2, Karl GODLEWSKI 2, Emma WALSH 2 and Aseem SHUKLA 2
1) Lewis Katz School of Medicine at Temple University, Urology, Philadelphia, USA - 2) The Children's Hospital of Philadelphia, Urology, Philadelphia, USA
INTRODUCTION
Cloacal exstrophy (CE) is a complex congenital anomaly involving multiple organ systems. Most outcomes are focused on bowel integrity, abdominal wall closure, bladder capacity and dryness. Moreover, males with CE were often thought to have little viable corporal tissue. This case series highlights the potential for an epispadias repair with six male CE patients during their 2nd stage of closure.
MATERIAL AND METHODS
A prospectively maintained database and video archive was used to identify males who underwent a second-stage CE repair following the initial colostomy and bladder plate reapproximation in the first week of life. Corporal dissection was performed in the second stage to reconstruct a phallic structure.
RESULTS
From 2012 to 2023, 12 patients with CE were treated at a single institution, including 8 males, and of these, 6 underwent a second stage CE repair between 12 and 36 months of age combined with staged pelvic osteotomies. Three patients received preoperative testosterone and all six patients tolerated the staged repair with no significant intraoperative or early postoperative complications. The urethral plates were lifted off the dorsal corpora, and the corpora was dissected to the pubic bone to straighten them. The urethral plates weretubularized into a urethra brought out in the perineum, and an epispadias repair was performed to join the corporal bodies andglans.
CONCLUSIONS
The staged surgical repair of CE, incorporating principles of the complete primary repair of exstrophy, offers a safe and effective strategy for addressing both functional and cosmetic needs of boys with CE. Continued investigation into the psychosocial impact of CE repair andsubsequent penile augmentation needs further attention and is critical to improving patient-centered care.
VD-2 (VD without presentation)
Antonio MACEDO JR 1, Sergio LEITE OTTONI 1, Debora Laena BARROSO SACOMAN 1, Taiane ROCHA CAMPELO 1, Marcela LEAL DA CRUZ 1 and Roberto DE CASTRO 2
1) CACAU NUPEP, Department of Urology, São Paulo, BRAZIL - 2) Petrucciani Private Hospital, Department of Pediatric Urology, Lecce, ITALY
PURPOSE
The De Castro neophalloplasty has changed the paradigm of congenital aphallia treatment, avoiding completely the feminizing genitoplasty for true XY males without a penis. We want to present a 9 months old boy with congenital aphallia treated with the latest refinements and modifications in the technique, avoiding a full quadrangular lower abdominal flap but with some new design in the flap.
MATERIAL AND METHODS
Basically, the lower abdominal flap resembles two joined bottles with 3 triangular deflections in each side to produce a zetaplasty in the dorsal aspect of the neophallus and avoid ventral retractions, one of the most seen late complications in his technique. The flap is approximately 12 to 10 cm large. The new format flap design allows an easier and more aesthetical conformation of the glans and the "fake” neomeatus at the tip of the glans. The zetaplasty helps to create a cylindrical phallus and promote a less tension dorsal suture. The triangular mini flaps can be easily joined at the dorsal midline area and can be secured by 4.0 PDS sutures in the derm. The skin is approximated with 5.0 Monocryl sutures.
RESULTS
Patient had an excellent clinical outcome and has now one year of follow-up.
CONCLUSIONS
This new modification seems to improve aesthetic and functional results and has been used with success by the creator of the methods over the last few years.
VD-3 (VD without presentation)
Grégoire SCHNEIDER 1, Cyril VITARD 2, Sarah ABDELLAOUI 1, Claire LO 1, Tudor ENACHE 1, Jeanne GOULIN 1, Rani KASSIR 1, Daniela GORDUZA 3 and Pierre-Yves MURE 1
1) Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Department of Pediatric Surgery and Urology, Lyon, FRANCE - 2) Hôpital Edouard Herriot, Hospices Civils de Lyon, France, Urologic Surgery and Transplantation Department, Lyon, FRANCE - 3) Saint-Etienne University Hospital, Department of Pediatric Surgery, Saint-Etienne, FRANCE
PURPOSE
Description of the repair of a bifid phallus associated with perineal digestive duplication.
MATERIAL AND METHODS
Video illustration of the surgeries and result of this case.
RESULTS
Result at 6 years old is satisfying with :
a straight and degloved penis
a well reconstructed glans and scrotum
a glanular meatus
CONCLUSIONS
This video illustrate the satisfying repair of a bifid phallus, using a 2-stage urethroplasty.
VD-4 (VD without presentation)
Mark ZAONTZ 1 and Christopher LONG 2
1) The Children's Hospital of Philadelphia, Urology, Philadelphia, USA - 2) Children's Hospital of Philadelphia, Surgery, Philadelphia, USA
PURPOSE
This video will demonstrate the technique to correct a urethral stricture after perineal hypospadias surgery primarily with mobilization and straightening of the torturous proximal urethra.
MATERIAL AND METHODS
This is a 7 year old boy born with perineal hypospadsias and complete penoscrotal transposition status post multistage repair who presents 5 years after his urethroplasty with a slow thin urinary stream. Cystoscopy demonstarted a short and tight urethral stricture at the penoscrotal junction and the urethra proximal to this being torturous. The urethral stricture was repaired primarily with proximal urethtral mobilization, excision of the stricture and straigthening out the proximal urethra.
RESULTS
The patient has healed well and has a markedly improved urinary stream that is well directed without spraying at his 7 month follow-up. He is scheduled for yearly follow-ups through puberty with flow studies and physical exam.
CONCLUSIONS
Primary repair of short urethral strictures after hypospadias surgery can be done successfully but long term follow-up is necessary.
VD-5 (VD without presentation)
Mark ZAONTZ 1 and Christopher LONG 2
1) The Children's Hospital of Philadelphia, Urology, Philadelphia, USA - 2) Children's Hospital of Philadelphia, Surgery, Philadlephia, USA
PURPOSE
A concern for reconstructive surgeons performing proximal hypospadias surgery using Byars Flaps as ventral skin coverage is the risk of developing a torturous urethra due to poor fixation of the Byars Flaps to the dartos layer as opposed to free grafts which are better fixated. To obviate this concern, we have started to quilt the previously placed Byars Flaps at the second stage urethroplasty in the midline of the ventral penile shaft to fixate the ventral shaft and then perform urethroplasty. This video will demonstrate this technique. Additionally, barrier layers over the neourethras are important to reduce complications such as wound breakdown and fistula. The standard commonly used dartos flaps and tunica vaginalis pedicles may not be available. Toward that end we have been using a bio- degradable scaffold of sub intestinal submucosa (SIS) single layer for this purpose as we will demonstrate in this video.
MATERIAL AND METHODS
This is a 4-year-old male presents for a second stage hypospadias repair after successful first stage proximal urethroplasty with dermal patch graft and Byars Flaps. At surgery the midline of the ventral shaft was quilted with interrupted 7-0 Maxon. Next a 2-layer running subcuticular urethroplasty was performed and covered by single layer SIS.
RESULTS
The patient has healed well and at 7-month follow-up enjoys no complication to date and voids with a full well directed urinary stream. Yearly follow-up with physical exam and flow studies will continue through puberty.
CONCLUSIONS
The technique of quilting the ventral midline of the penile shaft may lessen the risk of tortuosity in the setting of a second stage urethroplasty initially staged with Byars Flaps. SIS is a reasonable alternative to other techniques of tissue coverage. It is easy to do with results thus far being equivalent to other forms of barrier layers in our experience.
VD-6 (VD without presentation)
Leah BELAND, Christopher LONG and Mark ZAONTZ
Children's Hospital of Philadelphia, Urology, Philadelphia, USA
INTRODUCTION
The incorporation of a barrier layer between the neourethra and skin is critical in hypospadias repair to minimize the risk of postoperative urethrocutaneous fistulae. Native tissues, such as Dartos or tunica vaginalis, are commonly used for this purpose; however, prior surgeries may limit their availability. In such cases, biologic materials such as porcine small intestine submucosa (SIS) may offer a viable alternative.
PATIENT AND METHODS
Video recording is presented of a 28-month-old male undergoing a second stage urethroplasty for proximal hypospadias repair with the use of an SIS graft as a barrier layer status post first stage repair with dermal patch graft orthoplasty, right orchidopexy and hernia repair, and left inguinal hernia repair. A Thiersch-Duplay urethroplasty is performed in two layers over an 8Fr Zaontz stent. A single layer SIS graft is tailored to cover the neourethra and secured to the Dartos fascia. A Cecil repair is also completed to avoid a waist neck skin deformity in the setting of challenging closure due to proximal shaft ventral skin deficiency.
RESULTS
The stent was removed at 1 week, with follow-up evaluations at 3 and 6 months demonstrating appropriate healing, no evidence of urethrocutaneous fistula formation, and a well-directed urinary stream.
CONCLUSIONS
Rich in collagen and growth factors, SIS integrates with host tissues, promoting regeneration, cell adhesion, and tissue repair. For patients with limited native tissue availability, biologic materials like SIS grafts may provide an effective alternative. Cecil technique is an excellent adjunct for providing adequate skin coverage in the setting of ventral skin deficiency.
VD-7 (VD without presentation)
Slavica PUSICA 1, Jovan DUCIC 2, Marko BENCIC 3, Borko STOJANOVIC 3, Marta BIZIC 3 and Miroslav L. DJORDJEVIC 4
1) Belgrade Center for Urogenital Reconstructive Surgery, Urology, Belgrade, SERBIA - 2) Belgrade Center for Urogenital Reconstructive Surgery, Plastic and Reconstructive Surgery, Belgrade, SERBIA - 3) University Children's Hospital, Faculty of Medicine, University of Belgrade; Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia, Urology, Belgrade, SERBIA - 4) University Children's Hospital, Faculty of Medicine, University of Belgrade; Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia; Icahn School of Medicine at Mt Sinai, US, Urology, Belgrade, SERBIA
PURPOSE
Repair of failed hypospadias still presents a great challenge due to a lack of available tissue for reconstruction. Special attention should be taken for patients who underwent repair during early childhood and present with complications in young adulthood. We present a one-stage repair of failed severe hypospadias previously treated in childhood.
MATERIAL AND METHODS
We present a 23-year-old patient, who underwent several surgeries due to scrotal hypospadias in childhood. He presents with two defects of the penile urethra, absent distal urethra and moderate ventral curvature. Penile degloving is done and urethral defects are dissected. The neurovascular bundle is partially lifted, and ventral curvature is corrected with plication of the tunica albuginea. Previously created penile urethra is opened longitudinally, and longitudinal dorsal island skin flap, 8.5cm long, is harvested and transposed ventrally by buttonhole maneuver. The flap is joined with a previously opened urethra by two longitudinal running sutures. Additionally, two parallel incisions were made on the glans, and glandial urethra is created. Abundant pedicle of the longitudinal flap is fixed to the tunica albuginea laterally, covering the neourethra, and preventing fistula formation. Reconstruction of the penile skin is performed.
RESULTS
Operative time was 90 minutes with minimal blood loss. Postoperatively, urethral catheter and suprapubic tube were placed. Patient reported good stream without fistula formation, six weeks after surgery.
CONCLUSIONS
Transitional urology gains a growing significance in recent years as more people with congenital urologic conditions are reaching maturity and thriving. Surgical technique in failed hypospadias repair is individualized and should include correction of all deformities.
VD-8 (VD without presentation)
Sami CHERIGUI 1, Abubakr ELAWAD 1, Ahmed ALTYEB 1 and Santiago VALLASCIANI 2
1) Sidra Medicine, Pediatric Urology, Doha, QATAR - 2) Sidra Medical and Research Center, Pediatric Urology Division, Doha, QATAR
PURPOSE
Hypospadias without hypospadias is a variant characterised by an apical meatus and hypoplasia of the distal urethra and spongiosum with adherent ventral penile skin to the urothelium. The dissection of the ventral penile skin without damaging the hypoplastic urethra can be challenging. Jednak et al. (BJU Int 2001) proposed an alternative surgical approach for such cases to reduce the risks associated with a long and complex urethroplasty. We present a video illustrating the main technical steps of this surgical approach.
MATERIAL AND METHODS
The approach was utilised by a single surgeon in 7 out of 168 cases of distal hypospadias over a 5-year period (4%) where this particular features were present. In the present video, we present the case of 6 years old male child with a wide glandular meatus, hypoplastic distal urethra reaching the midpenile level, deficient ventral foreskin and ventral penile curvature of 30*. In this series, 4 out of the 7 patients had significant curvature assessed intraoperatively.
The initial incision was made laterally and proximally the hypoplastic urethra and extended dorsally at the coronal level. Complete degloving of the penis was performed. The curvature was then corrected with a dorsal plication. The ventral penile skin deficiency was corrected with Byars flaps that were anastomosed to the lateral sides of the skin covering the hypoplastic urethra.
RESULTS
The child went home on the same day without urethral catheter. He had a regular follow up until 2 years after the repair. The penis appear straight on spontaneous erections. Stream valid and with straight direction.
CONCLUSIONS
Urethroplasty without urethroplasty is a suitable technique for the repair of hypospadias variant. It preserves the native urethra, avoids a complex reconstruction, and achieves the 3 main goals of hypospadias repair: apical meatus, correction of the curvature and homogenous distribution of the penile skin during the prepubertal follow up. It remains to understand the possibility of ventral curvature recurrence at puberty.
VD-9 (VD without presentation)
Craig PETERS
University of Texas Southwestern, Pediatric Urology, Dallas, USA
PURPOSE
Laparoscopic and robotic nephropexy has been well described in the adult population with limited reporting in children or adolescents.
MATERIAL AND METHODS
Our patient is a 14-year-old girl with possible Ehlers-Danlos syndrome presenting with progressive right flank and back pain with prolonged standing. Ultrasound evaluation demonstrated increased renal resistance indices and increased hydronephrosis while standing. Supine and upright intravenous pyelography demonstrated a drop in the location of the kidney of more than 2 vertebral bodies, angulation of the proximal ureter and increased hydronephrosis. Thorough discussion with the family emphasized the limited experience with this procedure in children. Using three port exposure with the DaVinci Xi System, the right kidney lower pole was exposed. Multiple Ethibond® sutures were placed through the renal capsule and retroperitoneal fascial tissues. There was no attempt to manipulate the ureteropelvic junction, which appeared completely normal. She was discharged on post-op day one. No stents or drainage tubes were used.
RESULTS
At one month she stated her symptoms were markedly improved. Upright ultrasound after supine ultrasound demonstrated no movement of the kidney relative to the body wall and liver. At five months follow-up, she continues to be free of her prior symptoms and is very satisfied with the result.
CONCLUSIONS
Symptomatic renal ptosis is uncommon in the adolescent yet seems to be a real entity and in selected cases, robotically assisted nephropexy seems to be a reasonable option for management. Careful preoperative discussion with patient and family is essential.
VD-10 (VD without presentation)
Ali̇ Ekber HAKALMAZ 1, Zeynep Merve GÖKBUGET 1, Savalan KHAMMADLI 1 and Haluk EMİR 2
1) Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Pediatric Surgery, İstanbul, TÜRKIYE - 2) Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, İstanbul, TÜRKIYE
INTRODUCTION
During laparoscopic appendicovesicostomy, pneumoperitoneum is maintained through the umbilical trocar, while the bladder is inflated with air via Foley catheter to facilitate detrusorotomy. However, after incising the mucosa, the bladder may collapse, complicating the surgical procedure and the appendicovesical anastomosis. In this study, we describe a simple and facilitating maneuver to maintain bladder distension. We aim to present the maneuver we use as a practical solution to this challenge.
METHOD
A standard laparoscopic approach is followed until a detrusorotomy incision is made on the posterior bladder wall. The bladder mucosa is then incised to perform the appendicovesical anastomosis; however, as a result, the bladder collapses. At this stage, the CO2 insufflation tube is switched from the umblical trocar to the drainage lumen of the Foley catheter to maintain bladder distension and ensure pneumoperitoneum.
The procedure is completed with the following routine steps: appendicovesical anastomosis, closure of the detrusor over the appendix, fixation of the bladder to the anterior abdominal wall, and creation of an appendix-skin anastomosis for clean intermittent catheterization.
RESULTS
The described maneuver was successfully used in two patients and was found to be effective during laparoscopic appendicovesicostomy.
CONCLUSIONS
CO2 insufflation via Foley catheter after bladder mucosa incision serves as an effective facilitating maneuver that keeps the bladder inflated and maintains pneumoperitoneum during laparoscopic appendicovesicostomy.
VD-11 (VD without presentation)
Roberta Rahal ALBUQUERQUE, Marina Picolo MENEGOLLA, Antônio Euclides De Souza JUNIOR, Iara Regina Siqueira LUCENA, Antônio Rebello Horta GOERGEN, Alissa Fernanda De Souza BRITTO, Renan Desimon CABRAL, Patric Machado TAVARES and Tiago ROSITO
Federal University of Rio Grande do Sul - Hospital de Clinicas de Porto Alegre - Brasil, Urology, Porto Alegre, BRAZIL
PURPOSE
This step-by-step video shows a robotic redo ureteral reimplant with the Politano-Leadbetter technique performed for an 6-year old girl with grade V unilateral reflux. This patient was born with ureterohydronephrosis due to an obstructive megaureter, and, at the age of 6 months, underwent an open ureteral reimplant. However, she evolved with ureteral obstruction and pyonephrosis at the age of 4. After discussion with the family, she underwent an endoscopic dilation, which solved the obstruction but developed a grade V reflux, which was the reasoning for this surgery.
MATERIAL AND METHODS
We present a 5-minute video of a robotic ureteral reimplant using the Politano-Leadbetter technique. To our knowledge, this is the first published video of this technique.
RESULTS
We performed the robotic ureteral reimplant without any significant complications. The surgery console time was 90 minutes. The patient was discharged the next day, and the double J stent was removed after 4 weeks. Since then (6-month follow-up), the patient had no urinary tract infection. A voiding urethrocystogram was performed showing ureteral reflux resolution.
CONCLUSIONS
Ureteral reimplant using the Politano-Leadbetter technique is feasible using the robotic system, with low morbidity and short operative time.
VD-12 (VD without presentation)
Kenichi KOBAYASHI, Kazuyoshi JOHNIN, Yuri MORI and Susumu KAGEYAMA
Shiga university of medical Science, The department of urology, Otsu City, JAPAN
PURPOSE
Ureterovesical fistula is a rare complication of ureteroneocystostomy (UNC). Few studies have described the detailed procedure for correcting ureterovesical fistula following UNC. Pneumovesical UNC is effective in correcting vesicoureteral reflux (VUR) and primary obstructive megaureter (POM). We report a case of pneumovesical closure of a ureterovesical fistula following surgery for POM. To the best of our knowledge, this is the first report of pneumovesical surgery for the closure of a ureterovesical fistula
MATERIAL AND METHODS
A 15-year-old female was referred for recurrent pyelonephritis. She had undergone pneumovesical ureteral tapering and UNC for left POM at the age of 5 years. However, left VUR was detected at the first voiding cystourethrography after UNC; no further intervention was deemed necessary, and the patient was monitored. Follow-up voiding cystourethrography disclosed persistent grade 4 left VUR and static renal scintigraphy showed severe renal scarring on the left kidney. Cystoscopy revealed a normal left neomeatus well placed on the trigone and a ureterovesical fistula at the proximal aspect of the submucosal tunnel. Pneumovesical surgery was performed. The bladder mucosa was incised along the long axis of the ureter around the fistula leaving the neomeatus. The ureter around the fistula was mobilized and isolated. The fistula was closed by suturing in three layers: full thickness of the ureter; bladder muscular layer; and bladder mucosa.
RESULTS
The patient was discharged 5 days after surgery without perioperative complications. She has remained healthy without further pyelonephritis.
CONCLUSIONS
Pneumovesical surgery may be useful for the closure of ureterovesical fistulas.
VD-13 (VD without presentation)
Tijesunimi ONI-THOMAS, Victoria MAXON, Catherine ROBEY and Chad CRIGGER
The James Buchanan Brady Urological Institute, Division of Pediatric Urology, Johns Hopkins University School of Medicine, Baltimore, USA
PURPOSE
The patient is a 12-year-old female with history of classic bladder exstrophy (CBE) and duplicated left collecting system. She desired continence surgery at age 11. Post operatively, she had persistent low volume urinary incontinence. Investigation was negative for fistula. MRI revealed a possible left ectopic ureter from the upper pole moiety. A nephrostomy tube was placed and antegrade nephrostogram confirmed an ectopic left ureter draining to the vagina. The decision was made to proceed with upper to lower pole ureteroureterostomy.
MATERIAL AND METHODS
IC-Green was injected into the left nephrostomy and the ureter was identified in Firefly view. The ectopic ureter was clipped distally and proximally, then divided. Adequate length was obtained. The proximal clip was cut. A 1cm ureterotomy was made on the recipient ureter. The lateral walls of the new end-to-side anastomosis were closed. A 6 Fr x 28 cm DJ Ureteral stent was inserted percutaneously via a 14 Fr angiocatheter. The position of the stent was confirmed by X-ray. The medial aspect of the anastomosis was then performed, completing this new connection.
RESULTS
She was discharged on post-operative day two with the nephrostomy tube capped and a stoma catheter to drainage. The ureteral stent and nephrostomy tube were removed four weeks later. Subsequent renal ultrasound showed no hydronephrosis in the left upper and lower pole moieties.
CONCLUSIONS
Cross sectional imaging is not routinely performed in pediatric patients prior to continence surgery. In a known ureteral duplication, MRI is useful in determining presence of an ectopic ureter. Robot-assisted surgery is safe and feasible in CBE patients with multiple prior abdominal surgeries.
VD-14 (VD without presentation)
Nicolas FERNANDEZ, Connor CHESTNUT, Lauren PONIATOWSKI, Divya JAYVAS, Max JETNZSCH and Margarett SHNORHAVORIAN
Seattle Childrens Hospital - University, Urology, Seattle, USA
PURPOSE
Two-stage Fowler-Stephen laparoscopic orchiopexy is the gold-standard for intra-abdominal testicles. Recent literature has shown that robot-assisted two stage orchiopexies have similar success rates. We hypothesize that indocyanin green (ICG) enhances robotic orchiopexy enabling a more precise dissection. We present the results of 9 patients who underwent robot-assisted ICG enhanced orchiopexy.
MATERIAL AND METHODS
Following a conventional robot-assisted approach, we identified the intra-abdominal testicles and proceeded to dissect off the peritoneum. We identified five landmark regions to guide dissection. Two of these regions included preservation of blood supply of small parallel vessels on the peritoneum (spermatic cord and vas deferens). The other three regions were dissected without preserving blood supply. Dissection was extended over the lateral wall of the bladder.
RESULTS
Out of the 9 patients, 4 were single stage procedures and 5 required a second stage. Two were bilateral. An overall total of 11 orchiopexies were performed. No intraoperative complications were identified and all were outpatient procedures. The mean operative time was 120 minutes for second-stage and 172 minutes for single-stage. All patients had bilateral palpable orthotopic testicles on physical exam at 1 month follow up and no signs of testicular atrophy on ultrasound at 3 months follow up.
CONCLUSIONS
Single-stage ICG guided robotic orchiopexy is a promising approach that can increase the success rate and reduce the need for a second anesthetic. A critical modification of the laparoscopic approach is the ability to precisely and safely dissect the peritoneum off of the vas and spermatic cord using ICG.
VD-15 (VD without presentation)
Nicolas FERNANDEZ, Lucianna COLINDRES and Tom LENDVAY
Seattle Childrens Hospital - University, Urology, Seattle, USA
PURPOSE
Pediatric kidney stone management has unique clinical and surgical nuances. Patients with complex anatomies, have a high risk to develop infective recurrent kidney stones. Scarce information is available for the role of robotics in complex anatomies such as bladder exstrophy patients. We hereby present the case of a bladder exstrophy patient with large stone burden to demonstrate the advantage of robot-assisted lithotomy and concomitant ureteral reimplantation.
MATERIAL AND METHODS
Fourteen-year-old female with history of multiple repairs for bladder exstrophy including two closures, bladder neck closure with SIS and Mitrofanoff creation, bladder augmentation with right side ureter and ureteral reimplantation of right-side solitary kidney. Developed anuria and was found to have a 2-cm ureteral stone located at the distal ureter. Initial endoscopic management was unsuccessful given the complex anatomy and stone recurrence. Prior repairs made the open option unfeasible given the risk for fistula formation. Robotic approach was performed, and lithotomy was completed with simultaneous trans-laparoscopic flexible ureteroscopy. Ureteral reimplantation was then performed to reduce the chances of recurrence with a side-to-side uretero-cystostomy.
RESULTS
Procedure was successfully performed. Patient tolerated the procedure and was discharged 3 days later. Ureteral stent was removed 6 weeks after the procedure and 3 moths after the patient is stone free with no clinical complications.
CONCLUSIONS
Robot assisted lithotomy is an effective surgical alternative for complex anomalies associated to prior abdominal reconstructions associated to kidney stones. The ability to access the anatomy from an intra-abdominal perspective avoids any potential negative results associated to an open approach.
VD-16 (VD without presentation)
Brooke SPRATTE, Sherry ROSS, Richard SUTHERLAND, Timothy BUKOWSKI and Hans ARORA
University of North Carolina, Urology, Chapel Hill, USA
PURPOSE
Indocyanine green (ICG) has been used in robotic urologic procedures to facilitate fast and effective visualization of anatomic structures, enabling more precise surgical performance. This case evaluates the use of ICG in a complex pediatric robotic-assisted surgery for the identification and dissection of a dilated seminal vesicle and prostatic utricle, as well as the reimplantation of a transplant ureter.
MATERIAL AND METHODS
A 16-year-old male with history of Denys-Drash, bilateral Wilms' tumor, and end-stage renal disease, who previously underwent proximal hypospadias repair, left radical nephrectomy, right partial nephrectomy, and recent renal transplant, presented with recurrent urinary tract infections. Imaging revealed grade III reflux in the transplanted kidney and an enlarged prostatic utricle and dilated seminal vesicle. Given concerns that these structures contributed to urinary stasis and recurrent infection, surgical resection of the prostatic utricle and seminal vesicle as well as reimplantation of the transplant ureter was performed.
RESULTS
Intraoperatively, trans-catheter injection of ICG into the urethra enabled accurate identification and precise dissection of the dilated prostatic utricle, right seminal vesicle, and transplant ureter. The dilated structures were successfully removed en bloc, and the transplant ureter reimplanted. Total operative time was 306 minutes, and no intra- or postoperative complications were observed. No recurrent infections have occurred since surgery.
CONCLUSIONS
Intraoperative use of ICUG proved beneficial in identifying complex anatomy, enabling precise resection of a dilated prostatic utricle and seminal vesicle, as well as reimplantation of a transplant ureter. This technique may improve surgical outcomes and reduce complications in similar cases. Further studies are warranted to optimize its application in pediatric urology.
VD-17 (VD without presentation)
David FAWKNER-CORBETT, Stephen GRIFFIN and Ewan BROWNLEE
Southampton Children's Hospital, Department of Paediatric Urology, Southampton, UNITED KINGDOM
PURPOSE
Implementation of robotic technology to complex reconstructive procedures is an emerging field. Ileal conduit urinary diversion represents a long-term management option in the treatment of neuropathic bladder with incontinence. To date there is no reported application of robotic surgery for this procedure in childhood. This video demonstrates the successful undertaking of a robotic ileal conduit procedure confirming feasibility.
MATERIAL AND METHODS
A 6 year old female (15kg) with a syndromic (GATA2B) neurodevelopmental disorder associated with vesicoureteric reflux and recurrent urinary tract infections, where continuation of clean intermittent catheterisation was not tolerated, underwent a robotic-assisted ileal conduit procedure as part of an ongoing study into the efficacy of paediatric robotic surgery (CA-00533/NCT06539442). The CMR Versius platform was used with operative steps outlined and the operative steps are outlined in video form.
RESULTS
Procedure was completed successfully with a 4 port (1 x 10mm, 2 x 5mm, 1 x 15mm) approach in 6hr 15min (Console time 4hr 41min). 1) Left ureteric mobilisation and spatulation 2) passage of left ureter through mesocolic window 3) right ureteric mobilisation and spatulation 4) bilateral JJ stent insertion 5) formation of ureteric plate (Wallace ‘66’ configuration) 6) ileal resection and side-to-side anastomosis 7) uretero-enteric anastomosis 8) mobilisation and formation of urostomy. Patient recovered well with no post operative opiates and a 4 day length of stay, partly due to establishing feeds after concurrent change to gastrostomy feeding.
CONCLUSIONS
We report the first robotic assisted ileal conduit in a paediatric patient using the Versius platform. Although technically challenging, this procedure is feasible.
VD-18 (VD without presentation)
David KIM, Kristina GAM, Anjali SHEKAR, Arieh SHALHAV and Mohan GUNDETI
University of Chicago Medical Center, Urology, Chicago, USA
PURPOSE
We present a surgical video depicting a pediatric robot-assisted right partial nephrectomy for an incidentally detected Bosniak III cyst.
MATERIAL AND METHODS
We describe a case of a 6-year-old female who presented with abdominal pain and was found to have a Bosniak III right renal cyst on ultrasound. Subsequent MRI re-demonstrated this cystic mass with thick enhancing septations.
The patient is placed in the right flank position with all pressure points padded. The robotic ports are placed as depicted in the image. A grasper is inserted to retract the liver, and the right kidney is identified. Gerota's fascia is incised, and the renal hilum is dissected inferiorly and superiorly. A vessel loop is brought around the hilar vessels. An intraoperative ultrasound is used to identify the mass, and the margins are scored with electrocautery. The hilum is then clamped by cinching the vessel loop and applying a bulldog. The mass is then excised coldly. Renorraphy is performed in two layers with running 2-0 PDS suture. The clamp is then released. Hemostasis is confirmed. Nephropexy is then performed.
RESULTS
The patient was discharged home on post-operative day 3. Final pathology revealed a cystic nephroma. The follow renal ultrasound demonstrated a healthy remaining kidney.
CONCLUSIONS
Our video presents a successful pediatric robot-assisted laparoscopic right partial nephrectomy.
VD-19 (VD without presentation)
Emma VAN RESPAILLE 1, Inge VAN DE CAVEYE 1, Joris VANGENEUGDEN 1, Piet HOEBEKE 1, Erik VAN LAECKE 1, Caroline JAMAER 2 and Anne-Françoise SPINOIT 1
1) University Hospital Ghent, Urology, Ghent, BELGIUM - 2) Jessa Hospital Hasselt, Urology, Hasselt, BELGIUM
INTRODUCTION
Robot-assisted (RA) pyeloplasty by the Anderson-Hynes technique is the golden standard for children with ureteropelvic junction (UPJ) stenosis. In redo procedures, modified anatomy might require other techniques and adaptations, seldom reported. This video demonstrates a Heineke-Mikulicz technique in an intra-renal pelvis with scarce pyelum after initial pyeloplasty with pyelum reduction.
PATIENTS AND METHODS
A 15-year-old boy underwent a right-sided pyeloplasty via lumbotomy for asymptomatic UPJ-stenosis after incidental finding. After failure to remove the JJ-stent postoperatively, he presented with his parents for second opinion to get rid of the JJ. Secondary anastomotic stricture of the UPJ was diagnosed, which could not be treated endoscopically. A nephrostomy tube was placed. After a failed attempt to clamp it, A RA redo pyeloplasty was proposed.
The ureter was initially identified and followed upwards into the kidney to identify the UPJ. The latter lies really close to the hilum, with a scarcely dilated pyelum, probably because of previous pyelum reduction. Both ureter and pyelum are suspended with stay sutures. Fibrotic scar tissue is observed at level of the UPJ. Removing the fibrous tissue and broadening of the junction is performed, applying the principle of Heineke-Mikulicz for stenosis. A JJ stent is left in situ for 8 weeks.
RESULTS
The redo pyeloplasty procedure proved its efficiency at follow-up after five months. No more colic-pain was described, and hydronephrosis was fully resorbed on ultrasound.
CONCLUSIONS
In a redo pyeloplasty, variations in technique might be useful, like the Heineke-Mikulicz illustrated here. Using another approach than during the initial procedure plays an important role.
VD-20 (VD without presentation)
Aisha SIEBERT 1, Prathima NANDIVADA 2 and Richard LEE 1
1) Boston Children's Hospital, Pediatric Urology, Boston, USA - 2) Boston Children's Hospital, Pediatric Surgery, Boston, USA
INTRODUCTION
We present robot assisted laparoscopic approach to management of appendico-vesical fistula. 9-year-old male who previously presented with perforated appendicitis, managed conservatively with placement of a 12 Fr transrectal drain and intravenous antibiotics. The family declined interval appendectomy, and the patient experienced no urological symptoms. He re-presented 1 year later with gross hematuria, and recurrent multi-organism bacteruria.
METHODS
A less than 1 cm, discrete soft tissue density with vascular flow was detected by ultrasound. Contrast enhanced MRI and ultrasound with transrectal contrast enhancement were both negative. Cystoscopy revealed a bladder mass on the posterior bladder wall approximately 3 cm cephalad to the trigone. Cold cup biopsy revealed ulceration and granulation tissue, but no malignancy. Cystogram and bilateral retrograde pyelograms were negative. Undiagnosed fistula was still high on the differential.
RESULT
The patient was positioned in dorsal lithotomy with the thighs parallel to the abdomen. Port placement was similar to a robot assisted laparoscopic Mitrofanoff. Three 8 mm ports were placed transversely at the level of the umbilicus 6 cm apart. A 12 mm Airseal was placed in the left upper quadrant at the mid-clavicular line and served as an assistant port. Appendectomy allowed for mobilization of bowel out of the pelvis. The fistulous tract was identified and excised along with a bladder cuff. Repair was performed with omental flap interposition.
CONCLUSIONS
Appendico-vesical fistula is an uncommon complication after conservative management of perforated appendicitis. They may present with gross hematuria, multi-organism urinary tract infection, and vascular bladder mass. Imaging is often negative, and diagnosis is based in a high degree of clinical suspicion. Robot assisted laparoscopy is a reasonable minimally invasive, definitive management strategy.
VD-21 (VD without presentation)
Vidhya TAMIZHVANAN, Adrianna J LEE, Anastasia GLIATIS, Katherine STAHOVIAK and Mohan S GUNDETI
Comer Children's hospital-University of Chicago Medicine, Pediatric Urology, Chicago, USA
PURPOSE
Discoid kidney or Pancake kidney is a rare renal fusion anomaly of the kidneys. The discoid kidney are incidentally detected or may present clinically with PUJ obstruction, recurrent infection, calculi. This video presentation demonstrates the technique involved in management of obstruction in an UNFUSED discoid variant kidney with PUJ obstruction.
MATERIAL AND METHODS
This is a case report of 17year old girl presented with right sided flank pain for 2months, she had one episode of UTI earlier, on imaging she was found to have severe hydronephrosis on right and MAG 3 renogram confirmed obstruction with normal function (48%). With preopertaive diagnosis of right sided PUJ Obstruction, she was planned for Robotic assisted Laparoscopic pyeloplasty.
RESULTS
Intraoperatively a discoid variant kidney with PUJ obstruction on right side (UNFUSED type) was identified. With standard 3 robotic port and one assistant port, pyeloplasty with DJ stenting was completed (demonstrated in the video). Operative time was 126minutes with negligible blood loss. Catheter removed on POD1.Patient is symptom free and awaiting follow up.
CONCLUSIONS
When anatomical variations are encountered during robotic assisted surgery, we should be cognisant about proceeding with reconstruction by adopting certain technical nuances such as ambidextrous suturing, safe and limited manuveribility of renal parenchyma (as shown in the video) aid in reconstruction with good precision and outcome.
VD-22 (VD without presentation)
Allen KUNCHERIA 1, Julia MORALES 1, Srikhar CHILUKURI 2, Sara KOH 1, Raymond YONG 1, Catherine NGUYEN 3, Nora BROADWELL 1, Andrea BALTHAZAR 1, Richard LINK 4 and Chester KOH 1
1) TCH - BCM, Pediatric Urology, Houston, USA - 2) TCH-BCM, Pediatric Urology, Houston, USA - 3) Loma LInda University, Pediatric Urology, Loma Linda, USA - 4) TCH - BCM, Urology, Houston, USA
PURPOSE
We present our technique for robotic bilateral retroperitoneal nephrectomies in children that utilized the experience of our adult urology partners. While several surgical options exist (open, laparoscopic, robotic transperitoneal, etc), we hope to emphasize the feasibility of this procedure as well as the benefits of the collaborative nature of this endeavor.
MATERIAL AND METHODS
In this video, we demonstrate our specific technique for robotic bilateral retroperitoneal nephrectomies in the pediatric population in a 11-year-old female with high grade bilateral vesicoureteral reflux, neurogenic bladder, and renal failure with peritoneal dialysis at a tertiary care children's hospital in conjunction with our adult minimally invasive robotic urologic colleagues.
RESULTS
With the small working spaces in pediatric patients, appropriate port placement is especially important.
CONCLUSIONS
Robotic bilateral retroperitoneal nephrectomies are feasible in the pediatric population despite the concerns for limited working space. The retroperitoneal approach avoids entry into the peritoneal cavity, thereby minimizing the risks of bowel injury, ileus, and tumor seeding as well as allowing uninterrupted peritoneal dialysis. It also avoids the need for large incisions, resulting in less postoperative pain and quicker recovery with "hidden" incisions. Collaborating with experienced minimally invasive adult urologists can be invaluable, as their expertise is applicable to the surgical management of complex pediatric cases.
VD-23 (VD without presentation)
Kyeong KIM, Kwanjin PARK and Youngjae IM
Seoul National University Children's Hospital, Pediatric Urology, Seoul, REPUBLIC OF KOREA
INTRODUCTION
Lower urinary tract reconstruction for a duplex system with ectopic ureterocele traditionally requires open surgery with ureterocelectomy and bladder neck reconstruction. We report our initial experience of the pneumovesicoscopic approach for lower urinary tract reconstruction in two infants.
PATIENTS AND METHODS
We performed pneumovesicoscopic ureterocelectomy, bladder neck reconstruction, and bilateral common sheath reimplantation in two female infants (12 and 19 months old) with a bilateral complete duplex system and unilateral ectopic ureterocele. Both patients previously underwent transurethral incision of ureterocele at 4 and 1 months of age at other hospitals. They subsequently developed recurrent urinary tract infections requiring surgical intervention. The patients presented with left upper moiety hydronephrosis (Grade 4) and high-grade vesicoureteral reflux. The procedure was performed using 5 mm telescope and 3 mm laparoscopic instruments.
RESULTS
Operative time was 245 and 265 minutes, respectively. There were no perioperative complications. At the 6-month follow-up, the first patient showed complete resolution of hydronephrosis with normal post-void residual (12 ml/60 ml estimated bladder capacity). The second patient maintained stable upper tract dilation with acceptable post-void residual (34 ml/90 ml). No postoperative complications including febrile urinary tract infection were observed during follow-up periods.
CONCLUSIONS
Our initial experience indicates that pneumovesicoscopic lower urinary tract reconstruction is technically feasible and safe in infants with duplex system ectopic ureterocele. Despite extensive bladder manipulation, early postoperative bladder function appears well preserved. Longer follow-up and larger series are needed to validate long-term outcomes.
VD-24 (VD without presentation)
Sang Hoon SONG 1, Sangmin LEE 2, Dong-Gi LEE 3 and Kun Suk KIM 1
1) Asan Medical Center, University of Ulsan College of Medicine, Department of Urology, Seoul, REPUBLIC OF KOREA - 2) Asan Medical Center, Department of Urology, Seoul, REPUBLIC OF KOREA - 3) Kyung Hee University Hospital, Department of Urology, Seoul, REPUBLIC OF KOREA
PURPOSE
A nine-year-old female with a history of Sacrococcygeal Teratoma excision presented with precocious puberty, bilateral hydronephrosis, and renal dysfunction with a GFR of 49. Video urodynamic study revealed detrusor overactivity, decreased compliance, vesicoureteral reflux on the right side, bilateral flank pain, and a severely trabeculated bladder with an irregular appearance. No detrusor pressure was observed during the voiding phase. Due to noncompliance with Clean Intermittent Catheterization (CIC), surgical intervention was required to address her condition.
MATERIAL AND METHODS
The patient underwent robotic-assisted augmentation ileocystoplasty with Mitrofanoff formation and right-sided robotic Cohen’s ureteral reimplantation. The ileal segment was harvested extracorporeally, detubularized into a U shape, and sutured to the bladder using barbed sutures. The augmented bladder was tested with saline, ensuring no leakage. The appendix was mobilized and prepared as a Mitrofanoff channel using the VQZ flap technique. A 10Fr urethral catheter and a 20Fr suprapubic cystostomy tube were placed for postoperative management.
RESULTS
The procedure lasted 8 hours with minimal blood loss and no perioperative complications. Three weeks after surgery, a voiding cystourethrogram (VCUG) demonstrated increased bladder capacity with no leakage or vesicoureteral reflux. The patient and her caregivers were trained to perform CIC over two days and successfully established independence in performing CIC through the Mitrofanoff channel. She was discharged on postoperative day 25, with her GFR improved to 82.
CONCLUSIONS
Robotic-assisted ileocystoplasty and Mitrofanoff channel formation offer effective management for complex bladder dysfunction. The approach minimizes perioperative complications, reduces pain, and shortens hospital stays while achieving comparable long-term outcomes to open surgery.
VD-25 (VD without presentation)
Raymond YONG, Nora BROADWELL, Bridget PARK and Niccolo PASSONI
Texas Children's Hospital, Urology, Houston, USA
PURPOSE
We present a 16-month-old female with biopsy proven, fusion negative, intermediate risk bladder rhabdomyosarcoma after presenting with urinary retention. Initial imaging showed a 4 cm intravesical mass arising near the trigone and metastatic workup was negative. She received Vincristine, Dactinomycin and Cyclophosphamide alternating with Vincristine and Irinotecan (VAC/VI) per the ARST 1431 protocol. She was referred to our institution for consideration of surgery to avoid pelvic radiation.
MATERIAL AND METHODS
After multidisciplinary discussion the decision was mad to proceed with robotic radical cystectomy, urethrectomy with ileal conduit and staging pelvic lymph node dissection. The video outlines the steps performed during the surgery. To date this is the youngest reported robotic cystectomy with ileal conduit.
RESULTS
Pathology showed a 4cm residual mass with negative surgical margins. Estimated blood loss was 150ccs. Robotic time was 3.5 hours, overall case time 5 hours. There were no positive pelvic lymph nodes. She was discharged after a 6-day admission and has since been seen in good health. She will continue with adjuvant chemotherapy without plans for adjuvant radiation.
CONCLUSIONS
This shows the importance of a multidisciplinary approach to this rare pathology. We highlight that a robotic approach is feasible and beneficial in the deep pelvic dissection with minimal blood loss. Additionally, this represents a mangement strategy to avoid long term risks of pelvic radiation.
VD-26 (VD without presentation)
Irene PARABOSCHI 1, Ugo Maria PIERUCCI 2, Elena DI BLASI 3, Paola COLLINI 4, Marta PODDA 5, Giovanna GATTUSO 6, Roberto LUKSCH 5, Francesco RIZZETTO 7, Alice Marianna MUNARI 8, Cristina GALLOTTA 9, Tommaso SANTANIELLO 10, Veronica DIOTTO 11, Elena ZOIA 12, Gian Vincenzo ZUCCOTTI 13, Maurizio VERTEMATI 10, Paolo MILANI 10 and Gloria PELIZZO 14
1) University of Milano, Department of Biomedical and Clinical Science, Milano, ITALY - 2) "V. Buzzi" Children's Hospital, Department of Pediatric Surgery, Milano, ITALY - 3) Fondazione IRCSS Istituto Nazionale dei Tumori, Soft Tissue Tumor Pathology Unit, Department of Advanced Diagnostics, Milan, ITALY - 4) Soft Tissue Tumor Pathology Unit, Department of Advanced Diagnostics, Fondazione IRCSS Istituto Nazionale dei Tumori, Milan, ITALY - 5) Fondazione IRCCS Istituto Nazionale Dei Tumori, Pediatric Oncology Unit, Milan, ITALY - 6) Fondazione IRCCS Istituto Nazionale Dei Tumori,, Pediatric Oncology Unit, Milan, ITALY - 7) ASST Grande Ospedale Metropolitano Niguarda, Department of Radiology,, Milan, ITALY - 8) "V. Buzzi" Children's Hospital, Department of Pediatric Radiology, Milan, ITALY - 9) Univesrity of Milan, CIMaINa (Interdisciplinary Centre for Nanostructured Materials and Interfaces), Milan, ITALY - 10) University of Milan, CIMaINa (Interdisciplinary Centre for Nanostructured Materials and Interfaces), Milan, ITALY - 11) Anesthesia and Intensive Care Unit, "V. Buzzi" Children's Hospital, Milan, ITALY - 12) "V. Buzzi" Children's Hospital, Anesthesia and Intensive Care Unit, Milan, ITALY - 13) "V. Buzzi" Children's Hospital, Department of Pediatrics, Milan, ITALY - 14) University of Milan, Department of Biomedical and Clinical Science, Milan, ITALY
PURPOSE
Pediatric solid tumors often require meticulous surgical interventions due to their complex anatomical locations and proximity to vital structures. Emerging technologies, such as Virtual Reality (VR) and Indocyanine Green (ICG) fluorescence-guided imaging, offer promising solutions to enhance surgical precision and outcomes. However, their application in pediatric urology oncology remains underexplored. This case report illustrates the integration of VR and ICG fluorescence imaging in the surgical treatment of neuroblastoma, emphasizing their benefits, limitations, and areas for future advancements.
MATERIAL AND METHODS
A 12-month-old female with a prenatal diagnosis of cloacal malformation, Müllerian anomalies, and a horseshoe kidney presented with a solid retroperitoneal mass discovered during preoperative imaging for her reconstructive surgery. The mass was confirmed as a right adrenal neuroblastoma. After six cycles of chemotherapy, persistent mIBG uptake suggested potential residual tumor viability. Definitive surgical resection was scheduled, incorporating VR and ICG fluorescence to facilitate precise dissection and preservation of critical structures.
RESULTS
The integration of VR allowed for detailed preoperative planning and intraoperative navigation, enhancing anatomical orientation. ICG fluorescence provided real-time visualization of vascular structures, aiding in safe tumor resection. The procedure was completed without complications, and the patient had an uneventful postoperative recovery. Follow-up imaging confirmed no evidence of residual disease.
CONCLUSIONS
VR and ICG fluorescence imaging hold great promise for enhancing surgical precision and safety in pediatric urology oncology. Addressing current limitations, such as the inability to superimpose VR images onto the surgical field and the lack of neuroblastoma-specific fluorescent probes, should be a priority for future advancements to improve outcomes further.
VD-27 (VD without presentation)
Daniel DAJUSTA, Alexandra BAIN, Jacqueline MORIN, Rama JAYANTHI, Molly FUCHS, Daryl MCLEOD and Christina CHING
Nationwide Children's Hospital, Pediatric Urology, Columbus, USA
PURPOSE
Robotic assisted retroperitoneal lymph node dissection (RPLND) is becoming increasingly popular as it offers reduced morbidity with a faster recovery period, which has been demonstrated in recent case series (Clark et al. J Robot Surg 2023; 17: 3045-48). In this video, we demonstrate applying the hidden incision endoscopic surgery (HiDES) port placement technique for a robotic-assisted staging RPLND for a patient with a right paratesticular rhabdomyosarcoma.
MATERIAL AND METHODS
The presented patient underwent a radical right orchiectomy for a paratesticular mass, pathology confirmed embryonal rhabdomyosarcoma. His staging imaging demonstrated no metastatic disease. He was then scheduled for a robotic-assisted modified right template staging RPLND, to be followed by initiation of chemotherapy post-operatively. He was positioned supine on the table and HiDES port placement technique was used with the four robotic arms along the suprapubic line with a 12mm assist port at the umbilicus. The procedure started with isolation and removal of the right spermatic cord structures, followed by dissection and removal of the right gonadal vessels, then proceeding with the para-caval, interaortocaval, and para-aortic lymph node dissections using a split and roll technique.
RESULTS
Total surgery time was 456 minutes, 44 lymph nodes were removed. Post-operatively he was kept on a chyle leak low-fat diet for two weeks. He was discharged home on post-operative day three and chemotherapy was initiated on post-operative day five.
CONCLUSIONS
HiDES port placement can successfully be utilized for robotic-assisted staging RPLNDs in patients with paratesticular rhabdomyosarcoma. This port placement improves scar cosmesis without compromising robotic arm mobility or intra-abdominal dissection.
VD-28 (VD without presentation)
Grace LEE, Jenna WINEBAUM, Micha CHENG, Alex JANG, Max MENG and Yi LI
University of California San Francisco, Urology, San Francisco, USA
PURPOSE
Paratesticular rhabdomyosarcoma is a rare pediatric malignancy treated multimodally with surgery, chemotherapy, and/or radiation. Robotic assisted RPLND is a minimally invasive approach that has been reported as a safe and efficacious in literature.
MATERIAL AND METHODS
A 17-year-old patient with a horseshoe kidney presented with a painless scrotal mass. Left inguinal orchiectomy was performed. Pathology demonstrated a 7.4cm rhabdomyosarcoma, spindle cell/sclerosing type with negative margins. A robotic RPLND was performed to complete staging prior to initiation of chemotherapy.
RESULTS
The patient was positioned in right lateral decubitus position. Three 8mm robot ports were placed para-rectally 7-8cm apart, and an 11mm assist port was placed infraumbilically at midline. The left colon was mobilized. The gonadal vessels were isolated and dissected down to the internal ring. All left perigonadal and peri-iliac tissue were excised. The dissection was carried cranially and the gonadal vein, which traveled over the isthmus of the horseshoe kidney, was ligated and divided at its insertion into the left renal vein. It was then ligated caudally at the internal ring. A modified left template was used, including all para-aortic lymph nodes from the left renal artery to the IMA, which was just above to the horseshoe kidney isthmus. Pathology revealed metastatic rhabdomyosarcoma in the para-aortic nodes.
CONCLUSIONS
Robotic RPLND can be safely performed in the setting of a horseshoe kidney. Complete para-aortic dissection may require working above and below the isthmus to access the nodes posterior to it. Due to medialized ureters, the template may expand beyond the traditional lateral border of the ureters.
VD-29 (VD without presentation)
Merve DEDE 1, Selim OZKAYA 2, Mehmet Ugur YILMAZ 1, Bilge TUREDI SEZER 3, Nizamettin KILIÇ 1 and Selçuk AKIN 4
1) Bursa Uludag University Faculty of Medicine, Pediatric Urology, Nilufer, TÜRKIYE - 2) Batman Training and Research Hospital, Pediatric Surgery, Nilufer, TÜRKIYE - 3) Konya City Hospital, Pediatric Urology, Nilufer, TÜRKIYE - 4) Bursa Uludag University Faculty of Medicine, Plastic Aesthetic and Reconstructive Surgery, Nilufer, TÜRKIYE
PURPOSE
Circumcision is a surgical procedure frequently performed in boys in our country. It can have various complications such as penile amputation.The aim of this study is to present a case of full thickness subcoronal penile amputation during circumcision.
MATERIAL AND METHODS
An 8-year-old male patient who was brought to our center was circumcised at home by a health technician, using razor. It was understood that the penis was full-thickness amputated, distal part sutured with skin sutures only. With the complaint of continued active bleeding and urine coming from the seams, the patient was taken to the emergency department in another center and then he was referred to our center It was possible to take him to the operating room 6 hours after the event. the operation was performed by a team of pediatric urologists and plastic surgeons.1 dorsal penile artery suitable for reanastomosis and the dorsal deep vein were found. Urethral anastomosis was performed with separate sutures using 6/0 Polydioxanone over 10 fr silicone catheter. Vascular anastomoses performed with 7/0 Polydioxanone under microscopic vision. The suturing of Buck's fascia was performed with separate sutures using 5/0 Polydioxanone. Circumcision line was made with separate sutures using 5/0 quick-dissolving sutures.
Under the condition of close bleeding follow-up, pressure-free dressing was applied. Postoperatively, the distal part was covered with heparinized gauze at intervals of 2 hours. To prevent ischemia; pentoxifylline,dextran,oral anticoagulants were used. The patient received regular hyperbaric oxygen therapy on daily basis from third day.
Urethral catheter removed on 25th day.
RESULTS
The patient urinated by squirting in normal calibration. In the follow-up, stenosis responding to dilatations occurred occurred at the anastomotic level.
CONCLUSIONS
Circumcision is still performed by non-physician techinicians in an illegal way in our country. So, serious complications like penile amputation are still seen with this practice. Multidisciplinary approach is needed for successful funcitonal results.
VD-30 (VD without presentation)
Lauren PONIATOWSKI, Thomas S. LENDVAY, Nicolas FERNANDEZ and Jennifer J. AHN
Seattle Children's Hospital, Pediatric Urology, Seattle, USA
PURPOSE
Ureteropelvic junction obstruction (UPJO) is rare after renal transplant, with an incidence of 0.25%. Pyelo-ureterostomy to native ureter and Foley Y-V plasty have been reported in the adult population. The use of robot-assisted techniques in the pediatric population is not well-described. We present a case of robot-assisted right-sided pyelo-ureterostomy for transplant UPJO.
MATERIAL AND METHODS
A 19-year-old female presented with a creatinine of 5.9mg/dL four years after living-related renal transplant. Prior end-stage renal disease was secondary to nephronophthisis. Evaluation showed hydronephrosis without ureteral dilation. Retrograde pyelogram showed narrowing of the ureteropelvic junction and normal caliber native right ureteral stump, ending at the level of the transplant upper pole. Creatinine improved to 1.6mg/dL with stent drainage and biopsy showed no signs of rejection. Decision was made to proceed with robotic-assisted pyelo-ureterostomy. Intra-operatively, open-ended ureteral catheters were placed in the native and transplant ureters. The transplant collecting system had significant surrounding inflammatory tissue intra-operatively. Identification and dissection of the transplant collecting system was assisted by intra-operative ultrasound and indocyanine green (ICG). ICG also helped with early identification of the native ureter. The native ureter was anastomosed to the transplant pelvis in an end-to-side fashion with ureteral stent drainage for 1 month.
RESULTS
The procedure was tolerated well with 20ml EBL. There were no intraoperative complications. The patient has recovered well with creatinine stable at 1.4mg/dL and resolution of hydronephrosis.
CONCLUSIONS
The robot-assisted minimally invasive approach to repairing the rare complication of transplant UPJO is feasible with ultrasound and ICG as helpful adjuncts.
VD-31 (VD without presentation)
Athanasios TYRASKIS, Sharmila SANCHEZ, Ketaki GHARPURE, Naima SMEULDERS and Alexander CHO
Great Ormond Street Hospital, Paediatric Urology, London, UNITED KINGDOM
INTRODUCTION
Scar tissue in patients with prior bladder operations can make sheath placement for percutaneous cystolithotomy (PCCL) challenging. We propose a technique that allows direct visualisation during port and sheath placement without the need of a larger incision.
PATIENTS AND METHODS
Three patients underwent PCCL for bladder calculi. The surgical technique: 14G venflon and 0.035” Sensor Guidewire (Boston-Scientific) with intravesical visualisation introduced into the bladder. The tract was dilated using 7Fr and 9Fr Cook dilatators. A 30F NephroMax™ Balloon (Boston Scientific) failed to create an accessible tract for a 30F Amplatz sheath due to significant scar tissue.
An Ethicon Endopath Xcel® 11mm Optical Trocar with nephroscope within was inserted into the bladder, parallel to the guidewire, to allow safe entry into the bladder under direct vision. This was exchanged for a 30Fr Amplatz sheath and the bladder calculi were cleared with a 24Fr nephroscope and Swiss Master lithoclast (Boston-Scientific).
RESULTS
Age at surgery: 8, 14 and 17-years; Bladder-stones diameter:15mm-36mm. All had previous ileocystoplasty and Mitrofanoff-formation. 2/3 had bladder neck closures. One patient had a previous failed endoscopic-approach and required open-cystolithotomy.
Balloon dilatation failed in all due to scar-tissue but endoscopic PCCL access was achieved for all patients with this modified technique. There were no intra-operative complications and the SPC via the tract was removed after 48-hours. All patients were stone-free and the calculi were predominately calcium phosphate/ magnesium ammonium phosphate.
CONCLUSIONS
Where ballon dilatation fails due to scar tissue, the optical trocar allows for safe entry into the bladder sufficient for a 30Fr sheath.
VD-32 (VD without presentation)
Marcus MAROCCOLO, Danielle MAROCCOLO, Flavia BUZATO and Helio BUSON
HOSPITAL DA CRIANÇA DE BRASILIA, UROLOGY UNIT, Brasilia, BRAZIL
PURPOSE
Supermini perc (SMP) is a minimally invasive percutaneous surgery developed in Guangzhou - China in 2017. The difference between this technique and traditional mini-perc is the reduced size of the sheath (14fr) and the use of irrigation and aspiration through the sheath itself, increasing the effectiveness of the procedure and reducing operative time
MATERIAL AND METHODS
We present a video showing the SMP technique in pediatric patients emphasizing the material used and its functioning as well as the advantages when compared to conventional mini-pcnl
RESULTS
The procedure proved to be effective, fast and safe. Literature data supports its use in stones < 3cm
CONCLUSIONS
SMP is a technique that uses a small tract and a special aspiration sheath, reducing complication rates and can be considered the treatment of choice in pediatric patients when percutaneous renal surgery is required.
VD-33 (VD without presentation)
Patric TAVARES 1, Alissa BRITTO 1, Antonio GORGEN 1, Renan TIMOTEO DE OLIVEIRA 1 and Tiago ROSITO 2
1) Reconstructive and Pediatric's Urology Group, Hospital de Clínicas of Porto Alegre, Porto Alegre, Brazil, Urology, Poa, BRAZIL - 2) Federal University of Rio Grande do Sul - Hospital de Clinicas de Porto Alegre - Brasil, Urology, Porto Alegre, BRAZIL
PURPOSE
Pediatric renal lithiasis is a growing concern, often requiring diverse treatment modalities such as extracorporeal shock wave lithotripsy (ESWL), flexible ureteroscopy, and mini-percutaneous nephrolithotomy (mini-PCNL). Recurrent interventions may lead to complications such as ureteral strictures. This case involves a 16-year-old male patient with recurrent left-sided renal stones managed with multiple treatments. Subsequent procedures resulted in a mid-proximal ureteral stricture, with upstream dilation and left-sided lumbar pain.
MATERIAL AND METHODS
We present a 5-minute video detailing a robotic-assisted ureteroplasty using an oral mucosa graft to correct the ureteral stricture. Preoperative imaging, including magnetic resonance urography and intraoperative pyelography, identified the precise location of the stricture. Robotic dissection of the ureter was performed, isolating the stricture and mobilizing the ureter. An oral mucosa graft was harvested and sutured to reconstruct the ureteral segment, with a distal ureteral catheter placed across the stricture site.
RESULTS
The patient was hospitalized for 2 days postoperatively, with a double-J stent maintained in the reconstructed ureter. Pain management was achieved with symptomatic medication. The patient was discharged without complications. The double-J stent was removed 4 weeks post-surgery, and follow-up with a significant improvement in the previously noted hydronephrosis. The patient reported complete resolution of lumbar pain and remains asymptomatic.
CONCLUSIONS
Robotic-assisted ureteroplasty using an oral mucosa graft is a safe and effective technique for managing ureteral strictures in pediatric patients. This approach ensures durable outcomes, minimizes morbidity, and restores ureteral function, emphasizing its value in complex reconstructive urology.
VD-34 (VD without presentation)
Nicolas FERNANDEZ and Lucianna COLINDRES
Seattle Childrens Hospital - University, Urology, Seattle, USA
PURPOSE
Pediatric kidney stone management has unique clinical and surgical nuances. Surgical management is limited by instrument size, stone burden and urinary tract anomalies. Most common surgical techniques include endoscopic management and extracorporeal shockwave lithotripsy. Limited information is available for the role of robotics. We hereby present the case of a complex anatomical anomaly demonstrating the advantage of robot-assisted lithotomy and concomitant ureteral reimplantation.
MATERIAL AND METHODS
Four-year-old female presenting with gross hematuria and abdominal pain. CT scan demonstrated a 2-cm ureteral stone located at the ureterovesical junction. Initial endoscopic management was scheduled and intraoperatively patient was found to have a large pedunculated ureteral lesion and the impacted stone was found proximal to the lesion. Given the large size of the lesion, endoscopic management was aborted. Biopsy confirmed a benign ureteral papilloma. Patient was then scheduled for dismembered ureteral reimplant, distal ureterectomy bladder cuff resection and lithotomy.
RESULTS
Procedure was successfully performed. Operative time was 277 minutes. Patient tolerated the procedure and was discharged 2 days later. Ureteral stent was removed 3 weeks after the procedure.
CONCLUSIONS
Robot assisted lithotomy is an effective surgical alternative for complex anatomical anomalies associated to kidney stones in the pediatric population.
VD-35 (VD without presentation)
Priscila ASCAR, Luciano ONOFRE, Marcelo ROMBALDI, Bárbara QUEIROZ, Fernanda LEÃO and Jovelino LEÃO
PENSI Research Institute. Sabará Children's Hospital. São Paulo - São Paulo. Brazil., Pediatric Urology, São Paulo, BRAZIL
PURPOSE
Ureteral tumors can occur at any age, but are rare in children. Fibroepithelial polyps are considered benign neoplasms of mesodermal origin, most frequently found within the proximal ureter, especially in ureteropelvic junction.
MATERIAL AND METHODS
We report a 6-year-old male patient case with intermittent abdominal pain and hydronephrosis, who was initially considered to have ureteropelvic junction stenosis, which was not confirmed during videolaparoscopy. The patient underwent pyelography and subsequent ureteroscopy using long 7 Fr semi-rigid scope with dual working channel. Using a 3 Fr grasper through one of the working channels, the polyp was held and a 400 micron laser fiber was introduced for resection through the second working channel.
RESULTS
Histopathological analysis described 0.2 x 0.2 x 0.1 cm ureteral fibroepithelial polyp, without malignancy. A double J catheter was left for two months and at the time of removal of the catheter, new control ureteroscopy was done, with no evidence of strictures. The patient has progressed with no pain and no symptoms after 6 months follow-up.
CONCLUSIONS
Retrograde ascending pyelography performed at the same time of ureteropelvic junction stenosis treatment is a controversial subject, but it adequately details the anatomy, confirms the presence of intrinsic stenosis and rules out the presence of lesions within the ureter. If any images suggestive of endoureteral lesions is found, confirmation and treatment can be performed by ureteroscopy, allowing histopathological analysis to rule out malignant lesions.
VD-36 (VD without presentation)
Vidhya TAMIZHVANAN 1 and Sripathi VENKAT 2
1) Apollo Children's Hospital, Chennai, India, Pediatric Urology, Chennai, INDIA - 2) Apollo Children's hospital, Chennai, india, Department of Pediatric Urology, Chennai, INDIA
PURPOSE
Fraley’s syndrome is caused by the renovascular obstruction of upper pole infundibulum causing dilatation and obstruction of upper pole calyx. It is a rare entity and not frequently encountered in children. This is a case report of Fraley’s syndrome and involves a video demonstration of management of obstruction by robot assisted laparoscopic surgery.
MATERIAL AND METHODS
A 11year boy presented with recurrent left sided flank pain to pediatric urology. Initial two episodes were conservatively, ultrasound showed left mild hydronephrosis? Duplex. The third episode was Dietl’s crisis, acute phase imaging revealed focal dilatation of upper and EC renogram showed delayed IRT and tracer retention of Upper pole raising suspicion of left Duplex and PUJ obstruction of upper moiety.
An intraoperative diagnosis of Fraley’s syndrome was done and decided to proceed with Infundibulopyelostomy. Technical steps explained in the video.
RESULTS
Infundibulopyelostomy completed and child made a good recovery with complete resolution of hydronephrosis within 6months and demonstrated good drainage and function on left side on EC Renogram at one year follow up Operative time was 174min, blood loss 10-20ml, Stent removal 8 weeks later.
CONCLUSIONS
Fraley’s syndrome and robotic management in children under 15yrs of age is not reported so far in literature. This is presented to demonstrate the technical aspects of managing the rare renovascular obstruction with robot assisted laparoscopic surgery.
VD-37 (VD without presentation)
Kenneth SOFTNESS, Peter CAI and Joseph BORER
Boston Children's Hospital, Urology, Boston, USA
PURPOSE
Ureterocalicostomy is an option for reconstruction of an intrarenal or otherwise difficult access ureteropelvic junction obstruction (UPJO). In our patient, findings were consistent with severe left UPJO and concomitant ipsilateral ureterovesical junction obstruction. We planned to first address the UPJO via open dismembered pyeloplasty but opted for ureterocalicostomy given the anatomical finding of an infrarenal UPJO. Our objectives include discussion and videographic representation of open ureterocalicostomy technique.
MATERIAL AND METHODS
A six-month-old boy had pre- and postnatal moderate-severe left hydroureteronephrosis, normal voiding cystourethrogram and diuretic renogram with 44% differential function but no appreciable drainage from the left kidney. In right lateral decubitus position a left flank incision was made and the left kidney and dilated proximal ureter were identified. Intraoperative ureteropyelogram confirmed intrarenal UPJO. At its entry into parenchyma, the dilated ureter was transected and the proximal stump suture ligated. Hilar and lower pole vessels were occluded. Lower pole partial nephrectomy was performed to expose an adequate caliber lower pole calyx. The spatulated proximal ureter was anastomosed to the calyx with simple running and locking technique along posterior then anterior walls, respectively. Vascular occlusion time was 22 minutes. The parenchymal defect was partially approximated; balancing hemostasis and healing while limiting risk of anastomotic occlusion.
RESULTS
The patient was stable throughout postoperative course and was discharged home on postoperative day five. Three-week postoperative ultrasound demonstrated improved left (operated side) hydronephrosis and a widely patent ureterocalicostomy anastomosis.
CONCLUSIONS
Ureterocalicostomy is a safe and successful procedure that is useful when a traditional dismembered pyeloplasty cannot be performed due to anatomical challenges in accessing the UPJO.
VD-38 (VD without presentation)
Camila MORENO BENCARDINO, Catalina SANCHEZ, Ruchit PATEL, Joana DOS SANTOS, Pippi SALLE, Mandy RICKARD and Armando J. LORENZO
The Hospital for Sick Children, Urology, Toronto, CANADA
PURPOSE
Obstructive upper pole ureters have been historically managed with ureterocele puncture, reimplantation or heminephrectomy. We aim to present our experience and outcomes with a stent-free standardized technique for uretero-ureterostomy (UU)
MATERIAL AND METHODS
We reviewed consecutive patients who underwent UU (primary) or after ureterocele incision or ureterostomy (secondary) from 2019-25, capturing demographic variables, indications for surgery, intraoperative findings, postoperative complications and outcomes. The video demonstrates the stepwise surgical technique, emphasizing the use of ultrasound to avoid radiation from fluoroscopy and the stent-free nature of the procedure.
RESULTS
We identified 40 patients (80% female) who underwent UU at a mean age of 11 months +/-13 for primary surgery and 16 months +/-11 for secondary surgery. Mean follow-up was 30 months +/- 25. All patients were managed with a stentless technique and intraoperative ultrasound-guided bubble retrograde pyelogram. UU after failed ureterocele puncture was performed in 6 (15%), and UU for primary UP ectopic ureters in 34 (85%). 95% underwent outpatient surgery or had < 24-hour admission. Preoperative UP APD and maximal UP ureter diameters were 15+/-16mm and 14 +/-8mm. Postoperatively, 10+/-12mm and 8+/-9mm. Complications consisted of 4 infected ureteral stumps and 2 leaks
CONCLUSIONS
This procedure can be performed with high efficacy and safety through careful preparation and precise surgical steps. Using stents, fluoroscopy, and postoperative admission can be avoided in most cases.
VD-39 (VD without presentation)
Catalina SANCHEZ BASTO, Natalia PONZIO, Joao L. Pippi SALLE, Mandy RICKARD, Joana DOS SANTOS and Armando J. LORENZO
Hospital for Sick Children (SickKids), Urology, Toronto, CANADA
PURPOSE
Ureteropelic juntion obtruction (UPJ) is a common cause of antenatal hydronephrosis, often benefiting from a pyeloplasty in infancy. The traditional gold standard is open surgery, however growing interest in minimally invasive techniques (MIT) continue to challenge this notion. Proponents of MIT argue that there is value in post operative parameters and cosmesis. In this video, we showcase a standardized open surgical process and present outcomes and recovery data for infant pyeloplasty.
MATERIAL AND METHODS
We collected the demographics, clinical and radiological information, anesthesia considerations, operative technical details, and post operative data. Intraoperative photographs and videos were captured to document the surgical procedure and highlight key steps of this technique.
RESULTS
In this video, we illustrate the step-by-step surgical process for outpatient infant open pyeloplasty and present outcomes in consecutive cases at a single referral center. These data are presented as a benchmark to compare modern MIS series
CONCLUSIONS
Infant open pyeloplasty remains an effective and safe procedure for UPJ obtruction. With our standarized techique outpatient care is often possible, with very low morbidity and complications. MIS techniques should aim to be equivalent or superior to these results in order to become the new gold standard.
VD-40 (VD without presentation)
María RAMÍREZ-PIQUERAS, Javier ROJAS-TICONA, Verónica MARIJUAN SAHUQUILLO, Carlos DE-LA-SEN MALDONADO, Tania MORATALLA JAREÑO, Esperanza Julieta HERNANDEZ ANSELMI and Maria Soledad FERNÁNDEZ CÓRDOBA
UNIVERSITY HOSPITAL COMPLEX OF ALBACETE, SPAIN, Pediatric Surgery, Albacete, SPAIN
PURPOSE
The association of horseshoe kidney with retrocaval ureter (RCU) is exceptional. RCU is a congenital anomaly related to the persistence of the right subcardinal vein. The development of the inferior vena cava (IVC)involves embryogenesis with emergence and regression of multiple segments of it. Up to 50 types of IVC variations have been described. Pre-surgical differential diagnosis must be taken into account because of possible associated operative complications. The objective of this video is to show the surgery of a child with upper urinary tract obstruction due to a RCU with horseshoe kidney and duplication of the vena cava.
MATERIAL AND METHODS
We present the case of a 9-year-old boy, who presented with lumbar pain and right horseshoe kidney hydronephrosis suggestive of pyeloureteral junction obstruction (PUJO) on ultrasound. Computed tomography showed PUJO, anomaly of the IVC with duplicity and suspected RCU. The 3D reconstruction adequately showed the vascular anatomy without being able to visualize the ureter. It was decided to perform laparoscopic ureteroureterostomy.
RESULTS
Surgery was uneventful, and it is described on video with the aid of figures. The transposed ureter reached the renal pelvis without tension, so it was decided to perform pyeloplasty. The child had urinary leakage which was managed conservatively by opening the transanastomotic catheter with extension and he was discharged on the 6th postoperative day. He is currently without episodes of pain and with ultrasound improvement of the hydronephrosis.
CONCLUSIONS
Laparoscopic approach for CRU is a technique that allows correct visualization of the vascular anatomy and its relationships. The preoperative study using imaging techniques allows the correct identification of vascular anomalies.
VD-41 (VD without presentation)
Christina HO 1, Allison MAYHEW 2, Hans POHL 1, Briony VARDA 1, Andrea BADILLO 3, Melanie BOWSER 3, Butool HISAM 1, Christopher CORBETT 1 and Marc LEVITT 3
1) Children's National Hospital, Pediatric Urology, Washington, USA - 2) Children's National Hospital, Pediatric Gynecology, Washington, USA - 3) Children's National Hospital, Pediatric Colorectal Surgery, Washington, USA
PURPOSE
The aim of this study was to describe a novel urethromeatoplasty technique for cloacal repair patients, focusing on improving long-term functional and cosmetic outcomes in those with complex cloacal anomalies undergoing reconstructive surgery.
MATERIAL AND METHODS
A retrospective case series was conducted on 50 patients with cloacal anomalies who underwent primary cloacal repair between 2020 and 2024. Of these, 24 patients underwent urogenital (UG) sinus separation with vaginal and anorectal pull-through and 17 underwent total urogenital mobilization (TUM). The urethromeatoplasty technique was applied to 6 patients who underwent UG separation and 5 patients who underwent TUM. The procedure involved a modified approach to neomeatus creation, positioning the meatal opening in a more typical location and recreating the vaginal vestibule for both functional and aesthetic optimization. Key components of the technique included careful dissection and reconfiguration of the anterior and posterior urethra to form a patent, orthotopic meatus that was slightly recessed and inferior to the clitoris, in addition to creating well-defined labia minora.
RESULTS
Patient outcomes were tracked postoperatively (mean follow-up of 16 months). On follow-up, all patients had satisfactory cosmetic results and successful neomeatus creation, with minimal scarring and a well-positioned meatus. There were no instances of stenosis or fistula. One patient required clean intermittent catheterization, three patients underwent vesicostomy for bladder management, and seven patients did not require assisted bladder emptying.
CONCLUSIONS
This novel urethromeatoplasty technique offers a promising option for cloacal anomaly repair, combining functional success with improved cosmetic outcomes.