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Combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy
Journal of Pediatric Urology (2013) 9, e94ee97
CASE REPORT
Combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy L. Harper a,*, O. Abbo a, S. Prost a, J.L. Michel a, J.L. Soubirou b, F. Sauvat a a b
Department of Pediatric Surgery, CHR F Guyon, Bellepierre, Saint-Denis de La Reunion, Reunion Department of Pediatric Anesthesiology, CHR F Guyon, Bellepierre, Saint-Denis de La Reunion, Reunion
Received 29 February 2012; accepted 2 October 2012 Available online 8 November 2012
KEYWORDS Laparoscopicassisted; Nephrectomy; Augmentation ureterocystoplasty; Mitrofanoff; Appendicovesicostomy
Abstract Conventional and robotic-assisted laparoscopy is being used for more and more complex urological procedures in children. There have recently been reports of laparoscopic or laparoscopic-assisted appendicovesicostomies in children. We report a case of combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy in a 5-year-old boy with valve bladder syndrome. ª 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Effective bladder voiding is essential to preserve upper renal tract function. In boys with valve bladder syndrome this is sometimes not achievable because of severe bladder dysfunction. Clean intermittent catheterization through the urethra is a viable option, however in boys with posterior urethral valves (PUV), this is sometimes not possible because of urethral sensitivity. For these children,
* Corresponding author. Department of Pediatric Anesthesiology, CHR F Guyon, Bellepierre, Saint-Denis de La Reunion, Reunion E-mail address: [email protected] (L. Harper).
the Mitrofanoff appendicovesicostomy is a classic and efficient alternative. Some boys with PUV also have diminished bladder compliance though the pop-off effect of massive reflux into a non-functioning kidney has served well to preserve contralateral kidney function. In these patients, augmentation ureterocystoplasty by reconfiguration of the refluxing ureter will provide adequate compliance without the long-term side-effects of enterocystoplasty [1]. Traditionally, combining nephrectomy, ureterocystoplasty and appendicovesicostomy would require two incisions and an intraperitoneal approach for dissection of the appendix. Though the procedure could feasibly be performed solely through a Pfannenstiel incision, this would make the nephrectomy rather more challenging and would still
1477-5131/$36 ª 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jpurol.2012.10.004
Combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomye95 require intraperitoneal dissection of the appendix. We describe a combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy.
Patient and method The patient was a 5-year-old boy with a history of posterior urethral valves, chronic compensated renal insufficiency and dysfunctional voiding with chronic urinary retention and wetting. Retrograde cystourethrogram showed a lobulated, thick-walled, low capacity bladder with high-grade unilateral reflux on the right-hand side (Fig. 1). Renal DMSA scan showed the right kidney to be non-functional. Urodynamic evaluation showed a fairly compliant bladder, though this was due to massive reflux in the non-functioning kidney, and the near absence of detrusor contractions. We decided to perform a combined laparoscopic-assisted right-hand side nephrectomy with augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy. The procedure began with a 3-port transperitoneal approach with the patient in the supine position. A 10 mm laparoscopic camera port was placed through the umbilicus, a 5-mm laparoscopic port was placed in the midline above the umbilicus and the second 5 mm port was placed in the right iliac fossa, where the appendicovesicostomy orifice would later be (Fig. 2). The lateral peritoneum was opened and the colon was mobilized medially. The right ureter and kidney were dissected and the renal pedicle was identified. Renal vessels were ligated individually using endoscopic clips. The proximal ureter was mobilized preserving its vascularization (Fig. 3). After the right kidney and proximal ureter were completely liberated, we turned to the appendix using the same port position. The appendix was identified and judged to have sufficient length and diameter to fulfill its future role as a catheterizable
Figure 1
Preoperative cystogram.
Figure 2 Drawing showing port placement. One 10 mm port in the umbilicus, and two 5-mm ports.
conduit. The mesentery of the appendix was identified and mobilized to obtain adequate mobility. A window was made in the mesentery, at the level of the appendiceal base, preserving its blood supply. The appendix and its mesentery
Figure 3 Drawing illustrating dissection of the right kidney and ureter (laparoscopic).
e96 were then separated from the cecum (Fig. 4). After exsufflation of the pneumoperitoneum we then accessed the bladder through a Pfannenstiel incision. Lateral dissection of the bladder and right ureter allowed us to recover the ureter and right kidney extraperitoneally. We also recovered the appendix through a small button-hole incision in the peritoneum. The kidney was removed and the ureter was incised. The incision was continued on the bladder dome so as to obtain a bivalved bladder. The appendix, with its tip spatulated, was implanted within a submucosal tunnel along the right postero-lateral wall of the bladder above the right ureteral orifice. The ureter was then doubled on itself to form a cup which was anastomosed to the bladder using two running absorbable sutures. The appendix was then passed through the abdominal muscles and delivered through a small incision in the right lower abdomen where a VQZ stomal flap was then created (Fig. 5). The bladder was drained through a 12 F Foley urethral catheter and a 10 F feeding tube through the appendicovesicostomy. Estimated blood loss was <50 ml and total operating time was 290 min the urethral catheter was removed after 7 days and the catheter in the Mitrofanoff was removed after 21 days after having performed a control cystogram (Fig. 6). At one-year follow-up, the patient was dry with spontaneous voiding several times a day as well as clean intermittent catheterization twice a day. His post-void residual urine volume (PVR) as measured by sonography was estimated to be 20 ml. He showed no dilatation of the left upper urinary tract. We have not planned to perform urodynamic studies for the moment. These will be performed, if upper urinary tract dilatation, or a significant increase in PVR appear.
Figure 4 Drawing illustrating dissection of the appendix (laparoscopic).
L. Harper et al.
Figure 5 Drawing illustrating appendicovesicostomy (open).
ureterocystoplasty
and
Discussion Children with history of PUV often suffer from dysfunctional voiding and end up at some stage requiring CIC. In these patients urethral sensitivity is intact and urethral catheterization can be uncomfortable. The Mitrofanoff appendicovesicostomy is a well-known alternative in these cases.
Figure 6
Postoperative cystogram at 21 days.
Combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomye97 Furthermore these boys often have poorly compliant bladders requiring augmentation. In our patient, though urodynamic evaluation showed relatively good compliance, and no hyperactivity, this was due to massive reflux into the non-functioning kidney. The measured compliance was that of the right upper urinary tract as much as the bladder. We believed that once the uretero-nephrectomy was performed and the pop-off mechanism was eliminated, the bladder alone would be poorly compliant and potentially damage the remaining kidney’s function. We also believed the child could still void at least partially spontaneously after augmentation, and would not be condemned to rely solely on catheterization. When a refluxing mega-ureter is available it seems to be an elegant material for augmentation thus avoiding the long-term complications associated with enterocystoplaties [1]. This is even truer when the reflux is unilateral into a non-functioning kidney. This is why we chose the ureter in our case. A recent review has demonstrated the feasibility of lower urinary tract surgery in children, and laparoscopy has been accepted as a standard approach for nephrectomies in children for a while [2]. There are case reports and three series of robotic-assisted laparoscopic appendicovesicostomies in children [3e7]. There are also several reports of pure laparoscopic appendicovesicostomies [8e10], or combined procedures including appendicovesicostomy and concurrent augmentation, nephrectomy, orchiopexy and cecostomy placement [11e13]. We did not use robotic-assisted laparoscopy for the simple reason that we do not possess a Robot. Though robotic-assisted surgery certainly has advantages, it is interesting to note that this surgery can be performed relatively easily using conventional laparoscopy. Indeed, even within the community of pediatric surgeons performing complex laparoscopic procedures, only a fraction of these surgeons have permanent access to robotic-assisted surgery. Some of the published reports describe a purely intraperitoneal technique. We deliberately chose not to perform a total intraperitoneal procedure because we are uneasy with the idea of having an intraperitoneal conduit and its potential complications. Performing the ureterocystoplasty fully laparoscopically and therefore intraperitoneally would have obviated the benefit of remaining extraperitoneal. In our institution, when performing isolated kidney surgery in children, our preferred approach is through retroperitoneoscopy. However, in this case, we chose to perform the nephrectomy transperitoneally so as not to change the patient’s position during surgery and because of the concomitant appendiceal dissection. We found no difficulty in performing the nephrectomy and appendiceal surgery using a 3-port technique. Total operative time was no longer than it would have been by conventional open surgery. At follow-up, the child voids spontaneously several times a day, completed by CIC twice a day. He is well and shows no dilatation of the left upper urinary tract on sonography. We believe this combination of laparoscopy and open extra-peritoneal surgery is a valuable option for performing
combined nephrectomy, ureterocystoplasty and appendicovesicostomy in children.
Conflict of interest None.
Funding None.
Ethical approval None required.
References [1] Youssif M, Badawy H, Saad A, Hanno A, Mokhless I. Augmentation ureterocystoplasty in boys with valve bladder syndrome. J Ped Urol 2007;3:433. [2] Traxel EJ, Minevich EA, Noh PH. A review: the application of minimally-invasive surgery to pediatric urology: lower urinary tract reconstructive procedures. Urology 2010;76:115. [3] Wille MA, Zagaja GP, Shalhav AL, Gundeti MS. Continence outcomes in patients undergoing robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy. J Urol 2011;185:1438. [4] Nguyen HT, Passerotti CC, Penna FJ, Retik AB, Peters CA. Robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy: preliminary experience in a pediatric population. J Urol 2009;182:1528. [5] Lendvay TS, Shnorhavorian M, Grady RW. Robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy and antegrade continent enema colon tube creation in a pediatric spina bifida patient. J Laparoendosc Adv Surg Tech A 2008;18: 310. [6] Pedrasa R, Weiser A, Franco I. laparoscopic appendicovesicostomy (Mitrofanoff procedure) in a child using the da Vinci Robotic system. J Urol 2004;171:1652. [7] Storm DW, Fulmer BR, Sumfest JM. Laparoscopic robotassisted appendicovesicostomy: an initial experience. J Endourol 2007;21:1015. [8] Jordan GH, Winslow BH. Laparoscopically-assisted continent catheterizable cutaneous appendicovesicostomy. J Endourol 1993;7:517. [9] Casale P, Feng WC, Grady RW, Joyner BD, Lee RS, Mitchell ME. Intracorporeal laparoscopic appendicovesicostomy: a case report of a novel approach. J Urol 1899;2004:171. [10] Hsu TH, Shortliffe LD. Laparoscopic Mitrofanoff appendicovesicostomy. Urology 2004;64:802. [11] Rosito T, Andreoni CR, Iizuca F, Ortiz V, Macedo Jr A. Combined laparoscopic appendicovesicostomy (Mitrofanoff) with nephrectomy and orchiopexy in an 8-year-old boy. J Ped Urol 2008;4:317. [12] Lorenzo AJ, Chait PG, Wallis MC, Raikhlin A, Farhat WA. Minimally invasive approach for treatment of urinary and fecal incontinence in selected patients with spina bifida. Urology 2007;70:568. [13] Gundeti MS, Eng MK, Reynolds WS, Zagaja GP. Pediatric robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy: complete intracorporeal-initial case report. Urology 2008;72:1144.
CASE REPORT
Combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy L. Harper a,*, O. Abbo a, S. Prost a, J.L. Michel a, J.L. Soubirou b, F. Sauvat a a b
Department of Pediatric Surgery, CHR F Guyon, Bellepierre, Saint-Denis de La Reunion, Reunion Department of Pediatric Anesthesiology, CHR F Guyon, Bellepierre, Saint-Denis de La Reunion, Reunion
Received 29 February 2012; accepted 2 October 2012 Available online 8 November 2012
KEYWORDS Laparoscopicassisted; Nephrectomy; Augmentation ureterocystoplasty; Mitrofanoff; Appendicovesicostomy
Abstract Conventional and robotic-assisted laparoscopy is being used for more and more complex urological procedures in children. There have recently been reports of laparoscopic or laparoscopic-assisted appendicovesicostomies in children. We report a case of combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy in a 5-year-old boy with valve bladder syndrome. ª 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Effective bladder voiding is essential to preserve upper renal tract function. In boys with valve bladder syndrome this is sometimes not achievable because of severe bladder dysfunction. Clean intermittent catheterization through the urethra is a viable option, however in boys with posterior urethral valves (PUV), this is sometimes not possible because of urethral sensitivity. For these children,
* Corresponding author. Department of Pediatric Anesthesiology, CHR F Guyon, Bellepierre, Saint-Denis de La Reunion, Reunion E-mail address: [email protected] (L. Harper).
the Mitrofanoff appendicovesicostomy is a classic and efficient alternative. Some boys with PUV also have diminished bladder compliance though the pop-off effect of massive reflux into a non-functioning kidney has served well to preserve contralateral kidney function. In these patients, augmentation ureterocystoplasty by reconfiguration of the refluxing ureter will provide adequate compliance without the long-term side-effects of enterocystoplasty [1]. Traditionally, combining nephrectomy, ureterocystoplasty and appendicovesicostomy would require two incisions and an intraperitoneal approach for dissection of the appendix. Though the procedure could feasibly be performed solely through a Pfannenstiel incision, this would make the nephrectomy rather more challenging and would still
1477-5131/$36 ª 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jpurol.2012.10.004
Combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomye95 require intraperitoneal dissection of the appendix. We describe a combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy.
Patient and method The patient was a 5-year-old boy with a history of posterior urethral valves, chronic compensated renal insufficiency and dysfunctional voiding with chronic urinary retention and wetting. Retrograde cystourethrogram showed a lobulated, thick-walled, low capacity bladder with high-grade unilateral reflux on the right-hand side (Fig. 1). Renal DMSA scan showed the right kidney to be non-functional. Urodynamic evaluation showed a fairly compliant bladder, though this was due to massive reflux in the non-functioning kidney, and the near absence of detrusor contractions. We decided to perform a combined laparoscopic-assisted right-hand side nephrectomy with augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy. The procedure began with a 3-port transperitoneal approach with the patient in the supine position. A 10 mm laparoscopic camera port was placed through the umbilicus, a 5-mm laparoscopic port was placed in the midline above the umbilicus and the second 5 mm port was placed in the right iliac fossa, where the appendicovesicostomy orifice would later be (Fig. 2). The lateral peritoneum was opened and the colon was mobilized medially. The right ureter and kidney were dissected and the renal pedicle was identified. Renal vessels were ligated individually using endoscopic clips. The proximal ureter was mobilized preserving its vascularization (Fig. 3). After the right kidney and proximal ureter were completely liberated, we turned to the appendix using the same port position. The appendix was identified and judged to have sufficient length and diameter to fulfill its future role as a catheterizable
Figure 1
Preoperative cystogram.
Figure 2 Drawing showing port placement. One 10 mm port in the umbilicus, and two 5-mm ports.
conduit. The mesentery of the appendix was identified and mobilized to obtain adequate mobility. A window was made in the mesentery, at the level of the appendiceal base, preserving its blood supply. The appendix and its mesentery
Figure 3 Drawing illustrating dissection of the right kidney and ureter (laparoscopic).
e96 were then separated from the cecum (Fig. 4). After exsufflation of the pneumoperitoneum we then accessed the bladder through a Pfannenstiel incision. Lateral dissection of the bladder and right ureter allowed us to recover the ureter and right kidney extraperitoneally. We also recovered the appendix through a small button-hole incision in the peritoneum. The kidney was removed and the ureter was incised. The incision was continued on the bladder dome so as to obtain a bivalved bladder. The appendix, with its tip spatulated, was implanted within a submucosal tunnel along the right postero-lateral wall of the bladder above the right ureteral orifice. The ureter was then doubled on itself to form a cup which was anastomosed to the bladder using two running absorbable sutures. The appendix was then passed through the abdominal muscles and delivered through a small incision in the right lower abdomen where a VQZ stomal flap was then created (Fig. 5). The bladder was drained through a 12 F Foley urethral catheter and a 10 F feeding tube through the appendicovesicostomy. Estimated blood loss was <50 ml and total operating time was 290 min the urethral catheter was removed after 7 days and the catheter in the Mitrofanoff was removed after 21 days after having performed a control cystogram (Fig. 6). At one-year follow-up, the patient was dry with spontaneous voiding several times a day as well as clean intermittent catheterization twice a day. His post-void residual urine volume (PVR) as measured by sonography was estimated to be 20 ml. He showed no dilatation of the left upper urinary tract. We have not planned to perform urodynamic studies for the moment. These will be performed, if upper urinary tract dilatation, or a significant increase in PVR appear.
Figure 4 Drawing illustrating dissection of the appendix (laparoscopic).
L. Harper et al.
Figure 5 Drawing illustrating appendicovesicostomy (open).
ureterocystoplasty
and
Discussion Children with history of PUV often suffer from dysfunctional voiding and end up at some stage requiring CIC. In these patients urethral sensitivity is intact and urethral catheterization can be uncomfortable. The Mitrofanoff appendicovesicostomy is a well-known alternative in these cases.
Figure 6
Postoperative cystogram at 21 days.
Combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomye97 Furthermore these boys often have poorly compliant bladders requiring augmentation. In our patient, though urodynamic evaluation showed relatively good compliance, and no hyperactivity, this was due to massive reflux into the non-functioning kidney. The measured compliance was that of the right upper urinary tract as much as the bladder. We believed that once the uretero-nephrectomy was performed and the pop-off mechanism was eliminated, the bladder alone would be poorly compliant and potentially damage the remaining kidney’s function. We also believed the child could still void at least partially spontaneously after augmentation, and would not be condemned to rely solely on catheterization. When a refluxing mega-ureter is available it seems to be an elegant material for augmentation thus avoiding the long-term complications associated with enterocystoplaties [1]. This is even truer when the reflux is unilateral into a non-functioning kidney. This is why we chose the ureter in our case. A recent review has demonstrated the feasibility of lower urinary tract surgery in children, and laparoscopy has been accepted as a standard approach for nephrectomies in children for a while [2]. There are case reports and three series of robotic-assisted laparoscopic appendicovesicostomies in children [3e7]. There are also several reports of pure laparoscopic appendicovesicostomies [8e10], or combined procedures including appendicovesicostomy and concurrent augmentation, nephrectomy, orchiopexy and cecostomy placement [11e13]. We did not use robotic-assisted laparoscopy for the simple reason that we do not possess a Robot. Though robotic-assisted surgery certainly has advantages, it is interesting to note that this surgery can be performed relatively easily using conventional laparoscopy. Indeed, even within the community of pediatric surgeons performing complex laparoscopic procedures, only a fraction of these surgeons have permanent access to robotic-assisted surgery. Some of the published reports describe a purely intraperitoneal technique. We deliberately chose not to perform a total intraperitoneal procedure because we are uneasy with the idea of having an intraperitoneal conduit and its potential complications. Performing the ureterocystoplasty fully laparoscopically and therefore intraperitoneally would have obviated the benefit of remaining extraperitoneal. In our institution, when performing isolated kidney surgery in children, our preferred approach is through retroperitoneoscopy. However, in this case, we chose to perform the nephrectomy transperitoneally so as not to change the patient’s position during surgery and because of the concomitant appendiceal dissection. We found no difficulty in performing the nephrectomy and appendiceal surgery using a 3-port technique. Total operative time was no longer than it would have been by conventional open surgery. At follow-up, the child voids spontaneously several times a day, completed by CIC twice a day. He is well and shows no dilatation of the left upper urinary tract on sonography. We believe this combination of laparoscopy and open extra-peritoneal surgery is a valuable option for performing
combined nephrectomy, ureterocystoplasty and appendicovesicostomy in children.
Conflict of interest None.
Funding None.
Ethical approval None required.
References [1] Youssif M, Badawy H, Saad A, Hanno A, Mokhless I. Augmentation ureterocystoplasty in boys with valve bladder syndrome. J Ped Urol 2007;3:433. [2] Traxel EJ, Minevich EA, Noh PH. A review: the application of minimally-invasive surgery to pediatric urology: lower urinary tract reconstructive procedures. Urology 2010;76:115. [3] Wille MA, Zagaja GP, Shalhav AL, Gundeti MS. Continence outcomes in patients undergoing robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy. J Urol 2011;185:1438. [4] Nguyen HT, Passerotti CC, Penna FJ, Retik AB, Peters CA. Robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy: preliminary experience in a pediatric population. J Urol 2009;182:1528. [5] Lendvay TS, Shnorhavorian M, Grady RW. Robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy and antegrade continent enema colon tube creation in a pediatric spina bifida patient. J Laparoendosc Adv Surg Tech A 2008;18: 310. [6] Pedrasa R, Weiser A, Franco I. laparoscopic appendicovesicostomy (Mitrofanoff procedure) in a child using the da Vinci Robotic system. J Urol 2004;171:1652. [7] Storm DW, Fulmer BR, Sumfest JM. Laparoscopic robotassisted appendicovesicostomy: an initial experience. J Endourol 2007;21:1015. [8] Jordan GH, Winslow BH. Laparoscopically-assisted continent catheterizable cutaneous appendicovesicostomy. J Endourol 1993;7:517. [9] Casale P, Feng WC, Grady RW, Joyner BD, Lee RS, Mitchell ME. Intracorporeal laparoscopic appendicovesicostomy: a case report of a novel approach. J Urol 1899;2004:171. [10] Hsu TH, Shortliffe LD. Laparoscopic Mitrofanoff appendicovesicostomy. Urology 2004;64:802. [11] Rosito T, Andreoni CR, Iizuca F, Ortiz V, Macedo Jr A. Combined laparoscopic appendicovesicostomy (Mitrofanoff) with nephrectomy and orchiopexy in an 8-year-old boy. J Ped Urol 2008;4:317. [12] Lorenzo AJ, Chait PG, Wallis MC, Raikhlin A, Farhat WA. Minimally invasive approach for treatment of urinary and fecal incontinence in selected patients with spina bifida. Urology 2007;70:568. [13] Gundeti MS, Eng MK, Reynolds WS, Zagaja GP. Pediatric robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy: complete intracorporeal-initial case report. Urology 2008;72:1144.