ESPU Meeting
VD-1 (VD without presentation)
Venkat RAMAKRISHNAN 1, Belinda HSI DICKIE 2 and Hatim THAKER 1
1) Boston Children's Hospital, Urology, Boston, USA - 2) Boston Children's Hospital, Surgery, Boston, USA
PURPOSE
A robot-assisted approach to appendicovesicostomy is a well-established technique for continent catheterizable channel formation. Patients with concurrent bladder and bowel dysfunction pose a unique challenge, traditionally necessitating a split appendix technique that may lead to a compromised vascular supply of one or both channels. Using our novel technique for robot-assisted neoappendicostomy formation, here we present our approach and initial outcomes with combined robot-assisted appendicovesicostomy and neoappendicostomy with a cecal flap.
MATERIAL AND METHODS
A retrospective review of patients who underwent robot-assisted appendicovesicostomy and neoappendicostomy was performed. We recorded demographics, underlying diagnoses, operative details, length of stay, post-operative complications, continence outcomes, and follow-up duration.
RESULTS
Sixteen patients underwent combined robot-assisted appendicovesicostomy and neoappendicostomy for management of neurogenic bladder and bowel secondary to myelomeningocele (n=15) and sacral agenesis (n=1) with a ventriculoperitoneal shunt in place in 10 (62.5%) patients. At time of surgery, patients had a median age of 13 (IQR 11.9, 17.3) years and median BMI of 23.4 (19.7, 29.3) kg/m2. Median operative time was 449 (419.0, 513.0) minutes, including stomal maturation time, with a median length of stay of 7 (6, 8) days to allow return of bowel function and initiation of antegrade enema via the neoappendicostomy. Additional procedures performed at the time of operation included unilateral ureteral re-implantation and bladder neck reconstruction with synthetic sling placement in one patient each. In all patients, the appendicovesicostomy was placed in the umbilical/infra-umbilical location and the appendicostomy in the right lower quadrant. Post-operatively, one patient was readmitted for ileus and three patients developed a urinary tract infection. During the median follow-up of 9.3 (4.5 to 12.2) months, one patient developed fascial stenosis and a false passage of the appendicovesicostomy. Supra-fascial stenosis of the appendicovesicostomy was managed via a passive catheter dilator and steroid cream in 5 patients. One patient underwent revision of their neoappendicostomy due to prolapse and bleeding at the site. All patients achieved stool and urine continence.
CONCLUSIONS
Robotic-assisted creation of Mitrofanoff and neo-Malone channels is feasible in older patients with elevated BMI and mitigates the need for a split-appendix technique.
VD-2 (VD without presentation)
Thomas LOUBERSAC 1, Hortense ALLIOT 2, Marie-Aimée PERROUIN-VERBE 3 and Marc-David LECLAIR 2
1) CHU Nantes, Paediatric Urology, Nantes, FRANCE - 2) University Hospital of Nantes, Nantes Université, Pediatric urology, Nantes, FRANCE - 3) Centre Hospitalo-Universitaire de Nantes, Nantes, France, Urology Department, Nantes, FRANCE
PURPOSE
We present the case of a 16-year-old boy who underwent a robotic-assisted laparoscopic Mitrofanoff from a series of 7 consecutive paediatric cases and to report our surgical technique.
MATERIAL AND METHODS
Since 2017, we have performed Robotic Assisted Laparoscopic Cutaneous Continent Urinary (RALCCUD) in children and all patients were prospectively included.
This is a 16-year-old boy with posterior urethral valves and a non-contractile bladder who requires intermittent clean catheterisation to empty their bladder.
A continent cystostomy is recommended for patients who have difficulty performing self-catheterisation through the urethra. This procedure is proposed due to difficulties in performing self-catheterisation through the urethra. Cystomanometry revealed that the bladder has a large capacity of up to 500 ml with no leakage between catheterisations. Therefore, a Mitrofanoff procedure without enlarging enteroplasty is proposed. The appendix is implanted in the posterior wall of the bladder using the Lich-Gregoire antireflux technique and is anastomosed to the skin in the umbilical position following V-shaped skin plasty.
RESULTS
The procedure took 241 minutes. Blood loss was 50 ml. The patient resumed bowel movements on day one and was discharged from the urology department on day three. The Mitrofanoff catheter was removed on day 21, after which self-catheterisation resumed.
At the 24-month follow-up consultation, there was no leakage from the cystostomy or urethra. Catheterisation was performed without difficulty using a 16 French catheter. There were no complications ≥ Clavien 3.
The median age of the seven children in our study was 16 years (range 8–17). The median follow-up period was 45 months (range 5–99 months). Ultimately, all patients were able to self-catheterise through the stoma. The stomal continence rate was 100% (seven out of seven), with one patient suffering from stomal stenosis that was successfully managed by endoscopic dilatation. The urethral continence rate was also 100%.
CONCLUSIONS
In our experience, robot-assisted laparoscopic Mitrofanoff-type continent cystostomy can be performed with good medium-term functional results.
VD-3 (VD without presentation)
Mahmoud AHMED, Matthieu PEYCELON, Annabel PAYE and Alaa EL-GHONEIMI
Robert Debré University Hospital (APHP), Université Paris Cité, National Reference Center for Rare Urinary Tract Malformations (MARVU), ERN eUROGEN, Pediatric urology, Paris, FRANCE
PURPOSE
Surgical approaches for duplex kidney range from heminephrectomy to minimally invasive ureteral reconstruction. We describe the retroperitoneal robot-assisted laparoscopic (RRAL) ureteropyelostomy in children with duplex systems and upper moiety hydronephrosis. In instances of conserved upper pole function, ipsilateral ureteropyelostomy is a surgical technique for preserving the upper renal pole and its drainage into a healthy renal pelvis. While the majority of published reports on robotic ureteropelvic anastomosis describe a transperitoneal approach, we describe in this video the first report of robot-assisted retroperitoneal approach.
MATERIAL AND METHODS
We present a case of a 18-month-old female patient, antenatally diagnosed with left renal duplex. Ultrasound, at 8 months of age, showed duplex system on the left side, dilated upper moeity. MRU confirmed left duplex system with dilated upper moiety ureter (18mm) and ectopic vaginal insertion; mild dilation of the lower moeity pelvis (8 mm). A retroperitoneal robot-assisted laparoscopic (RRAL) ureteropyelostomy was decided (criteria: preserved upper pole parenchyma, mild dilation of renal pelvis of the lower pole). The child was positioned in lateral position close to the edge of the table, with minimum lateral flexion. Da Vinci Xi© Surgical Robot system was used. The retroperitoneal space is created by blunt dissection using the 0° laparoscope and gas insufflation. Steps of the surgery were the following: identification of both ureters, minimal dissection to free the dilated ureter and transecting it; identification of lower pole pelvis, stabilizing suture between the proximal ends of the anastomosis, Longitudinal incision was made at the lower moiety pelvis by sharp robotic scissor. End to side ureteropelvic anastomosis begins using 6/0 running monofilament absorbable suture without ureteral stent. And finally, the distal part of the ectopic ureter was removed without ligation.
RESULTS
The surgery was successful performed without complications with an operative time of 2 hours and 40 minutes. The patient was discharged on postoperative day-1. After a follow up of 4 years, the patient is asymptomatic with no dilation of the upper urinary tract. The robotic retroperitoneal approach reproduces a well-established open surgery procedure.
CONCLUSIONS
Retroperitoneal robot-assisted laparoscopic ureteropylostomy represents a minimally invasive option for upper tract reconstruction of duplex systems in children. It allows a large ureteropelvic anastomosis and removal of the redundant dilated ureter.
VD-4 (VD without presentation)
Sudhindra JAYASIMHA 1, Florin DJENDOV 2, Gunter DE WIN 3, Karen DEBAETS 3 and Abraham CHERIAN 2
1) Great Ormond Street Hospital, Pediatric Urology, London, UNITED KINGDOM - 2) Great Ormond Street Hospital for Children NHS Foundation Trust, Pediatric Urology, London, UNITED KINGDOM - 3) Universitair Ziekenhuis Antwerpen (UZA), Adolescent and Paediatric Urology, Antwerp, BELGIUM
PURPOSE
Primary uretero-calicostomy is rarely employed for managing PUJ obstruction. We present indications, video of operative technique, and compare outcomes of laparoscopic with open approach.
MATERIAL AND METHODS
This was a two-centre retrospective-study of children(<15 years) undergoing primary uretero-calicostomy(2014-2023). Demographic data, presentation, imaging, surgical details and outcomes were retrieved from electronic database. Variables were presented as median (IQR) and compared with Chi square or Mann-Whitney U-test.
Laparoscopic transperitoneal was compared with open retroperitoneal approach. Salient steps in the laparoscopic approach included proximal ureteric mobilization, PUJ ligation, lower pole calyx incision without parenchymal excision, adequate ureteric spatulation, tension-free urothelium to urothelium anastomosis, JJ stent, and catheterisation for 48 hours. This technique may be employed in preference to pyeloplasty in a malrotated kidney with small extrarenal pelvis and thin renal parenchyma as a primary approach to ensure a dependant anastomosis and adequate drainage.
Differential renal length index (iDRL) was defined as ratio of difference between lengths of hydronephrotic and normal kidney to normal kidney length.
RESULTS
Six each of laparoscopic and open procedures were performed. All kidneys had thin parenchyma and small extra-renal pelvis. Six were posteriorly malrotated. This prompted uretero-calicostomy for dependent anastomosis. Symptomatic resolution with improved APD, iDRL and drainage were noted in 5/6 in each group:
Table 1:
|
Demographics |
|
|||||
|
|
Laparoscopic |
Open |
|
|||
|
N |
6 |
6 |
|
|||
|
Male:Female |
1:5 |
3:3 |
|
|||
|
Age(years) |
12.5(11.25,13) |
2(1.5,3.4) |
|
|||
|
Symptoms |
Pain 3, UTI 3, haematuria 2 |
UTI 3 |
|
|||
|
|
|
|||||
|
Imaging |
|
|||||
|
|
Pre-op |
Post-op |
Pre-op |
Post-op |
P |
|
|
APD(mm) |
39(35,45) |
17.5(11,19.5) |
20(19,23) |
11(9.5,13.5) |
>0.05 |
|
|
iDRL |
30.15(16,37.5) |
16.3(3.2,32.3) |
26.35(14.7,37) |
11(2.1,19.7) |
>0.05 |
|
|
DRF(%) |
39(23.5,44) |
36(25.5,47.75) |
43.5(38.7,49) |
46(44.2,47) |
>0.05 |
|
|
Cortical thickness(mm) |
4.4(4.1,5) |
4(3.5,4.5) |
0.9 |
|||
|
|
|
|||||
|
Results |
P |
|||||
|
Duration(minutes) |
150(120,180) |
270(267.5,292.5) |
0.02 |
|||
|
Hospital stay(days) |
2.5(2,3) |
7(5,9.7) |
0.006 |
|||
|
Follow-up(months) |
25(12,42.25) |
35(23,55) |
0.85 |
|||
|
Failure |
1/6 |
1/6 |
1 |
|||
|
Clavien>IIIa |
0 |
1 |
- |
|||
CONCLUSIONS
Primary ureterocalicostomy is a viable strategy for PUJ obstruction with specific anatomical characteristics. Laparoscopy offers shorter operating time and hospital stay, with comparable success.
VD-5 (VD without presentation)
Guan WU, Jimena CUBILLOS, Ashley LI and David DIAMOND
University of Rochester Medical Center, Urology, Rochester, USA
PURPOSE
Robotic-assisted partial nephrectomy is rarely employed for managing Wilms' tumor, potentially indicated for bilateral disease, solitary kidney or syndromic conditions. This video describes a case of bilateral Wilms' tumor in a 3 year old girl, discovered as a result of abdominal trauma with tumor rupture, necessitating urgent, open unilateral radical nephrectomy. Following a course of radiation and chemotherapy, the lower pole tumor in the contralateral solitary kidney was managed with robotic-assisted partial nephrectomy.
MATERIAL AND METHODS
After careful planning, a robotic-assisted partial nephrectomy was performed with tumor enucleation facilitated by clamping of the renal artery. Hemostasis was achieved with cautery, V-lock renorrhaphy and surgicel.
RESULTS
Pathology of the specimen demonstrated a 1.2 cm Wilms' tumor with negative margins. Further treatment with chemotherapy and surveillance was recommended.
CONCLUSIONS
For the appropriate indications, a nephron-sparing Robotic-assisted partial nephrectomy can provide an excellent, minimally-invasive surgical approach to Wilms' tumor.
VD-6 (VD without presentation)
Coline DESVAUX 1, Aurore HAFFREINGUE 1, Jean-Baptiste MARRET 1, Thierry PETIT 1, Adrien LEE BION 2, Clémence BENARD 3 and Julien ROD 1
1) University Hospital Center Caen Normandy, Department of Pediatric Surgery, Caen, FRANCE - 2) University Hospital Center Caen Normandy, Department of Adult Visceral Surgery, Caen, FRANCE - 3) University Hospital Center Caen Normandy, Department of Pediatric Anesthesiology, Caen, FRANCE
PURPOSE
Video description of the retroperitoneal approach as a conservative surgical alternative for partial adrenalectomy with para-aortic picking in a high-level athlete with syndromic bilateral pheochromocytoma.
MATERIAL AND METHODS
A 16-year-old female patient with secondary hypertension and a typical Menard's triad was evaluated. Functional and morphological imaging compatible with bilateral pheochromocytoma (40 × 25 mm on the right, and two nodules on the left measuring 11 × 8 mm and 16 × 10 mm) with left extra-adrenal para-aortic fixation suggestive of a probable paraganglioma.
Plasma and urinary metanephrines and Chromogranin A levels were markedly elevated.
Diagnosis : bilateral pheochromocytoma due to a MAX gene mutation.
Given the patient's high-level athletic activity, and following national multidisciplinary tumor board recommendation, the decision was made to perform a total transperitoneal right adrenalectomy and a left partial retroperitoneal adrenalectomy with left para-aortic lymph-node picking during the same operative session.
Operative time : 141 min for the right total transperitoneal adrenalectomy.
Second operative time : 201 min for the left partial retroperitoneal adrenalectomy with para-aortic lymph-node picking.
RESULTS
Hypertensive episodes requiring Loxen titration and amine support were more significant during the first (transperitoneal) procedure compared to the retroperitoneal approach.
Postoperative management was uneventful, with discontinuation of antihypertensive therapy on postoperative day 1.
Pathological examination confirmed complete bilateral tumor resection with negative margins.
Clinical course : resumption of sports activities, blood pressure control without medication, and normal metanephrine levels at 6 months.
CONCLUSIONS
The retroperitoneal approach for robot-assisted partial adrenalectomy is valuable for preserving adrenal parenchyma, ensuring better perioperative blood-pressure control, and facilitating lymph-node picking when necessary.
In this case of syndromic bilateral disease with high recurrence risk, the retroperitoneal approach is a useful additional tool to consider in the therapeutic strategy.
VD-7 (VD without presentation)
Gabrielle NORTEY 1, Daniel SALEVITZ 2, Margarett SHNORHAVORIAN 2, Paul MERGUERIAN 2 and Jennifer AHN 2
1) University of Washington, Urology, Seattle, USA - 2) Seattle Children's Hospital, Urology, Seattle, USA
PURPOSE
In patients with a history of bladder exstrophy-epispadias complex, urinary incontinence is a common and bothersome sequela after initial repair, occurring 30-60% of the time. Minimally invasive surgeries for pediatric bladder reconstruction have been described, but there are few reported cases of using robotic-assisted laparoscopy in patients with prior bladder exstrophy repair.
MATERIAL AND METHODS
We began with cystoscopy and intradetrusor botulinum toxin injection. Next the ports were placed, the robot was docked, and we proceeded with dropping the bladder from the anterior abdominal wall, which was challenging due to his prior exstrophy-epispadias repair. The bladder neck was mobilized and transected, then closed using two layers of vicryl suture. The urethral stump was also closed with running vicryl suture, and small intestinal submucosa was placed over the stump as an interposition. The Mitrofanoff was created in the standard fashion and secured to the right lower quadrant after securing the bladder to the anterior abdominal wall. A suprapubic catheter (SPT), Jackson-Pratt drain, and indwelling Mitrofanoff straight catheter were placed. The pediatric surgery team then created a Neo-Malone cecostomy.
RESULTS
Post-operatively the patient did well. By post-op day two he was advanced to regular diet and ambulating. He was discharged on post-op day five and seen 4 weeks after surgery for Mitrofanoff catheter removal. He started clean intermittent catheterization (CIC) at that time and his SPT was removed 2 weeks later. At 3 months post-op he was doing well with CIC and renal ultrasound showed no hydronephrosis.
CONCLUSIONS
Robotic-assisted minimally invasive bladder neck closure and Mitrofanoff channel creation is safe and feasible in patients with history of prior bladder exstrophy-epispadias complex.
VD-8 (VD without presentation)
Dr Waleed EASSA, Amr ZOAIR, Karim ELKAHWAGI and Naser AL SOUDAN
Sabah Al Ahmad Urology center, Urology, Kuwait, KUWAIT
PURPOSE
To present our novel simple and reproducible technique for concealed penis repair, designed for ease of learning and application.
MATERIAL AND METHODS
Between 2017 and 2024, this technique was applied to 449 patients. The procedure begins with division of the frenulum while preserving an 8–10 mm mucous collar. A distal sub-coronal circumferential incision is made, followed by marking fixation points at the penile base (3 and 9 o’clock). The desired skin length for penile shaft coverage is measured, and a proximal circumferential incision is marked, creating a skin sleeve. This sleeve is divided and excised.
Starting from the proximal end of mucous collar laterally, the same length of the skin desired to cover the shaft of the penis is measured and a mark is placed on the shaft.
A 4/0 non-absorbable suture is passed at the fixation points of the skin from inside taking care not to perforate the skin. Then passed through the corresponding mark on the shaft of the penis and tied on both sides.
The wound closure begins at 12 o’clock. Excess ventral skin is excised to form a new median raphe, and the wound is closed circumferentially.
Follow up is carried out after 1 week, 1 month and after a year.
RESULTS
Parents were satisfied regarding the final shape. One patient (0.2%) needed redo repair due to untied anchoring sutures at the penile base.
CONCLUSIONS
Our technique is simple, easy to learn, reproducible and suitable for the diverse presentations of concealed penis, offering a reliable and effective surgical solution.
VD-9 (VD without presentation)
Kenneth SOFTNESS and Joseph BORER
Boston Children's Hospital, Department of Urology, Boston, USA
PURPOSE
Anderson-Hynes dismembered pyeloplasty (AHDP) is the historic gold-standard therapy for congenital ureteropelvic junction (UPJ) obstruction. Advances in minimally invasive surgery (MIS), technical skill, and application in younger patients have resulted in decreasing numbers of open pyeloplasty (OP). Proficiency with the open approach is necessary in settings of absent platform or malfunction, or urgent conversion. We provide videographic representation of OP.
MATERIAL AND METHODS
We present a 13-month-old boy, with progressive hydronephrosis, and nuclear diuretic renogram (MAG3) showing markedly worsened drainage. He underwent OP via flank approach. Key steps include urethral catheter placement, lateral decubitus positioning, skin incision based at tip of 11th or 12th rib, retroperitoneal entry via lumbodorsal fascia, identification of psoas muscle landmark, mobilization of the proximal ureter, renal pelvis, and UPJ, UPJ resection, ureter spatulation, and meticulous anastomosis with simple interrupted technique. A Penrose drain is placed.
RESULTS
The patient tolerated the 2.5-hour procedure well. With decreasing drainage, the Penrose drain was removed several hours after the Foley catheter (to monitor for anastomotic leak), on postoperative day 2. He was discharged home on postoperative day 3. Postoperative imaging revealed decreasing hydronephrosis on ultrasound and significantly improved drainage on MAG3 at 1 and 3 months, respectively. Longer-term, he is asymptomatic, thriving, and hydronephrosis has continued to improve.
CONCLUSIONS
AHDP remains the gold-standard for surgical treatment of UPJ obstruction. Given MIS advances and OP declining volume, thoughtful training paradigms, skill maintenance, and inter-departmental collaboration should be considered to maximize exposure of urology trainees and staff to OP.