1186 ROBOTIC-ASSISTED BLADDER NECK RECONSTRUCTION, BLADDER NECK SLING AND APPENDICOVESICOSTOMY IN CHILDREN: DESCRIPTION OF TECHNIQUE AND INITIAL RESULTS

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Vol. 185, No. 4S, Supplement, Monday, May 16, 2011

Gender

Laterality

Procedure1

Access (min)

Console (min)

Length of Stay (hours)

Age (yrs)

1

20

F

R

Pyeloplasty

54

135

205

20

2

16

F

L

Pyeloplasty

39

78

158

40

3

19

F

R

Pyeloplasty

35

222

260

19

4

18

M

L

Pyeloplasty

32

80

138

23

5

6

M

L

Pyeloplasty

30

90

133

25

6

10

F

R

Nephroureterectomy

27

137

174

13

7.1*

15

F

L

Re-do Pyeloplasty

25

180

215

59

7.2*

15

F

R

Ureterocalicostomy

21

237

252

60

8

2

M

L

Pyeloplasty

30

55

95

23

9

10

F

L

U-U

15

110

140

18

20

63

110

15

13

45

82

22 16

Procedure2

PT ID

Total Time (min)

TABLE 1

Pyelolithotomy

10

2

F

L

Urachal Remnant

11

13

M

L

Pyeloplasty

12

5

M

L

Nephroureterectomy

12

50

90

13

5

M

L

Nephroureterectomy

22

124

144

20

14

1

M

L

Pyeloplasty

25

72

99

18

15

10

M

R

Pyeloplasty

25

120

130

21

16

4

F

R

Pyeloplasty

29

100

115

25

B

Intravesical Reimplant

60

90

111

26

29

110

147

26

17 Mean

3

F

Appendectomy

10

* Same patient with two separate procedures

in the pediatric urologic literature. We hypothesize that a “closed” access method is technically straight-forward, safe, and can be applied to routine pediatric urologic operations. METHODS: An Institutional Review Board-approved retrospective chart review was performed of all patients undergoing laparoscopic surgery between 2003 and 2010. Data extracted included: age, procedure, previous surgical history, method and location of access, presence or absence of intra-abdominal adhesions, and intra-operative complications. Method of access was classified as either “open” (Hassan) or “closed” which included: the direct technique, optical access with a Visiport, or use of a Veress needle/Step Trocar system. For the direct access technique, an umbilical incision is made and the skin on either side is elevated in a “lifted table” technique. A bladeless trocar is then pushed and twisted with gentle, firm pressure through the rectus fascia. Intra-abdominal position is confirmed visually and the abdomen is then insufflated. In the Veress/Step Trocar group, a Veress needle confirmed intra-abdominal position and the timing of insufflation varied. RESULTS: 668 encounters (631 patients) were identified and average age was 7.53 years (0.13–19.68). The procedures were performed by five surgeons and encompassed a variety of procedures (orchiopexyrelated—179, inguinal hernia repair—180, varicocelectomy—160, ureteral reimplant—31, pyeloplasty—102). A “closed” access technique was utilized in 661/668 encounters (direct—475; Veress/Step—164; Visiport—20). 12.3% of the patients had a history of intra-abdominal surgery and significant adhesions were seen in 14 (2.1%). There was one complication during access—a small liver laceration during initial port placement for a pyeloplasty. The bleeding was minimal and required no intervention. An open technique was chosen in seven patients—five of these had concomitant umbilical hernia repair. CONCLUSIONS: The “closed” technique for laparoscopic access in the pediatric population is safe and feasible even in patients with previous intra-abdominal surgery. We believe the technique is technically straight-forward and efficient. These data support “closed” access techniques as viable alternatives to the Hassan method for routine use in pediatric laparoscopy. Source of Funding: None

1186 ROBOTIC-ASSISTED BLADDER NECK RECONSTRUCTION, BLADDER NECK SLING AND APPENDICOVESICOSTOMY IN CHILDREN: DESCRIPTION OF TECHNIQUE AND INITIAL RESULTS Aditya Bagrodia*, Daniel Dajusta, Joshua Sleeper, Patricio Gargollo, Dallas, TX

Source of Funding: None

1185 “CLOSED” ACCESS IN PEDIATRIC UROLOGIC LAPAROSCOPY—A VIABLE ALTERNATIVE TO “OPEN” ACCESS IN A LARGE, CONTEMPORARY SERIES Eric Nelson*, Harsha Mittakanti, Shelly Bian, Kirk Jackson, David Roth, Lars Cisek, Houston, TX INTRODUCTION AND OBJECTIVES: The use of laparoscopy in pediatric urologic surgery is now routine. Placement of the initial trocar is a critical step and avoidance of bowel and major vessel injury is paramount. The ideal technique for placement has not been explored

INTRODUCTION AND OBJECTIVES: At our institution, management of neurogenic bladder with persistent urinary incontinence despite clean intermittent catheterization (CIC) and maximal anticholinergic therapy (ACT) includes Leadbetter/Mitchell bladder neck reconstruction (BNR), bladder neck sling (BNS) and creation of appendicovesicostomy (APV). We describe robotic-assisted complex reconstruction of the lower urinary tract in children with neurogenic bladder and sphincteric incompetence. METHODS: Four sequential patients with spinal dysraphism, neurogenic bladder, and sphincteric incompetence based on urodynamic parameters (detrusor leak point pressure ⬍50 cm of H2O despite maximal ACT and CIC) had persistent urinary incontinence. They underwent robotic BNR, BNS and APV. All patients underwent a cystogram three weeks post-operatively. Patient characteristics, peri-operative information, and continence status were prospectively collected. RESULTS: Patient characteristics and outcomes are presented in Table 1. Three of four of cases were completed robotically, one required conversion to open Monti channel creation due to marginal appendix. Mean operative time (hours:minutes) was 7:45 (range 5:56 to 12:18); excluding the open conversion, mean was 6:14. Mean LOS was 85.7 hours, or 44.8 hours if Case 2 were excluded. Similarly, estimated blood loss was 117.8 mL vs 40.3 mL. Post-operatively all patients were completely dry on CIC and anticholinergics. None of the bladders demonstrated trabeculation on follow up cystogram. Two patients developed unilateral de novo Grade II vesicoureteral reflux that responded to dose escalation of anticholinergics.

Vol. 185, No. 4S, Supplement, Monday, May 16, 2011

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CONCLUSIONS: Our initial series of robotic appendicovesicostomy with bladder neck reconstruction and sling placement expands the scope of complex robotic reconstruction in children. The preliminary data demonstrates the procedure to be feasible and safe.

Total

7.1⬃

6.1⬃7.0

5.1⬃6.0

4.1⬃5.0

3.1⬃4.0

2.1⬃3.0

⬃2.0

of surgery/ complication rate after PN 2008⬃ 2008⬃ 2004⬃2007 Years Tumor size (cm)

9% 0% 2% 29% (2/23) (0/17) (1/56) (71/241)

100% 93% 80% 67% 22% 14% 5% 60% (26/26) (52/56) (28/35) (24/36) (4/18) (2/14) (2/44) (138/229)

11%

10%

7%

6%

0%

7%

0%

1188 THE WUERZBURG EXPERIENCE: 15 YEARS OF CONTINENT URINARY DIVERSION AND ENTEROCYSTOPLASTY IN CHILDREN AND ADOLESCENTS Andreas Loeser*, Wuerzburg, Germany; Peter C. Rubenwolf, Regensburg, Germany; Antje Beissert, Elmar W. Gerharz, Hubertus Riedmiller, Wuerzburg, Germany

Table: The influence of the tumor size on the use of PN

95% 66% 29% 17% (20/21) (31/47) (10/35) (7/42)

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9% (13/138)

Source of Funding: None

INTRODUCTION AND OBJECTIVES: To assess the long-term results of continent urinary diversion (CUD) and enterocystoplasty (ECP) in children with irreversible lower urinary tract dysfunction (LUTD). METHODS: The study included 44 children with irreversible LUTD who had a CUD or ECP between 1992 and 2007. Patients were followed for the functional outcome of surgery with a focus on complications related to the reservoir, bowel, uretero-intestinal anastomosis and upper urinary tract. Data were collected prospectively and outcomes were evaluated using a standardized protocol. RESULTS: The median (range) follow-up was 7.3 (3.5–17) years. Complete continence was achieved in 94% overall, i.e. in 95% of patients with continent cutaneous diversion, 83% with ECP and all children with continent anal diversion. Upper urinary tract and renal function remained stable in 89% and 95%, respectively. Surgical intervention was required for adhesive small bowel ileus in 6%, stomarelated complications in 39%, ureteric stenosis in 8%, and stone formation in 19%. Of these complications, 54% required only minor interventions; 41% of patients needed prophylactic alkaline substitution. Bowel habits remained unchanged or improved in 68%. CONCLUSIONS: Our results show that CUD and ECP in children are effective procedures with acceptable long-term complication rates. Importantly, this type of surgery should be restricted to carefully selected patients in whom all attempts of restoring the LUT failed. Source of Funding: None

1187 NATIONWIDE REVIEW OF BLADDER AUGMENTATION IN PEDIATRIC HOSPITALS Paul Bowlin*, Georgette Siparsky, Duncan Wilcox, Aurora, CO INTRODUCTION AND OBJECTIVES: The purpose of this study is to review the national Pediatric Health Information System (PHIS) records on pediatric bladder augmentation. We reviewed specific complication rates and follow up care of this large cohort. METHODS: Institutional Review Board (IRB) approval was granted for this retrospective review. We analyzed the database starting on January 1st, 1999 and patients were followed for a minimum of 3 years. We specifically intended to look at first time bladder augmentations so only children born on or after October 1st, 1998 were included. The database was analyzed for post-operative complications including bladder stones and bladder rupture. Additionally we analyzed rates of laboratory follow up including: basic metabolic panels, urine electrolytes, and Vitamin B12 levels. RESULTS: Using the International Classification of Diseases, Ninth Edition (ICD-9) code 57.87, there were 2,676 bladder augmentations performed between January 1st, 1999 and March 31st, 2010. Mean and median ages were 8.5 and 8 years, respectively. 1,250 of the patients were male and 1,426 were female. Average length of stay was 10 days with the median length of stay 8 days. Complication rates were: bladder stones 250 (9.3%), bladder perforation 62 (2.3%). Follow up basic metabolic panels and urine electrolytes were measured in 1,014 (37.8%) of patients and Vitamin B12 levels in 22 (0.8%). CONCLUSIONS: The overall rate of bladder stones and bladder perforation following bladder augmentation in this large pediatric population is 11.6%. This data could be used to create benchmarks for Pediatric Urologists. Source of Funding: None

1189 RE-EPITHELIZATION OF A DEMUCOSALIZED STOMACH PATCH WITH UROTHELIAL CELLS SEEDED SMALL INTESTINE SUBMUCOSA IN BLADDER AUGMENTATION Yuanyuan Zhang*, GuiHua Liu, Winston-Salem, NC; Kropp BP, Oklahoma, OK INTRODUCTION AND OBJECTIVES: A pedicle stomach flap is commonly used as an autograft supplement in gastrocystoplasty for pediatric bladder reconstruction. However, two main problems arise when using stomach flaps: 1) the stomach mucosa causes many complications when an entire stomach flap is used and 2) the stomach graft contracts if a demucosalized stomach flap is used. Botulium Toxin A (Botox A) is widely used for treating severe bladder spasticity. This study is designed to evaluate the possibility of using a demucosalized stomach flap covered with bladder cell-seeded small intestinal submucosa (SIS) for gastrocystoplasty and to determine whether an injection of Botox A into the re-urothelized stomach flap could protect the graft from contraction in a canine bladder reconstruction model. METHODS: Ten adult beagle dogs weighing from 10 –12 Kg were used. The animals were divided into five groups. Gastrocystoplasty was performed using entire stomach flaps as a control (n⫽2, Group I). The other groups consisted of animals repaired with demucosalized stomach flaps alone (n⫽2, Group II), demucosalized flaps covered with unseeded SIS (n⫽2, Group III), demucosalized flaps covered with bladder cell (urothelial and smooth muscle cells) seeded SIS (n⫽2, Group IV) and demucosalized flaps with bladder cell-seeded SIS combined with an injection of Botox A (10 units /ml, 50 units) (n⫽2, Group V). The graft tissue samples were examined histologically and with immunohistochemistry ten weeks after gastrocystoplasty. RESULTS: All dogs survived and their gastric grafts were all viable with a good blood supply. Urothelium (metaplasia) appeared on the top of the stomach mucosa flaps in two animals in Group I. A calicification at the center of one graft was found in an animal in Group II. The stomach flaps were partially covered with urothelium in Groups II and III, and stratified