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Comparative analysis of 3 different approaches for Pediatric Pyeloplasty
ESPU Programme 2008
S17
# S01-3 (O) LAPAROSCOPIC INSERTION OF PERITONEAL DIALYSIS CATHETERS IN CHILDREN - THE NEW GOLD STANDARD? Ramnath SUBRAMANIAM St.James University Hospital, Paediatric Urology, Leeds, UNITED KINGDOM
under vision via a single camera port and seldinger technique. The catheter could then be used immediately as required in the post-operative period. This method is approved by the National institute of clinical excellence (NICE, UK) quoting no increased morbidity in children.
PURPOSE To assess the effectiveness, complication rates and their management using the minimally invasive approach of placing peritoneal dialysis catheters (PDC) in children from an experience of six consecutive years.
RESULTS
and replaced after treating the infection. 4 catheters blocked two weeks post operatively; 3 of them were successfully repaired laparoscopically using an additional 5 mm port to release adhesions. In one case the laparoscope was used to diagnose the problem of a severe inflammatory reaction and the catheter was removed. We have not performed any case of open PDC insertion.
MATERIAL AND METHODS This is an ongoing prospective study conducted for the last six years from 2002. Children with established renal failure requiring insertion of PDC were included. The insertions were performed by or under the supervision of a single consultant surgeon using the laparoscopic technique. Partial omentectomy was performed and the catheter accurately placed in the pelvis
Forty six children with a mean age of 9 years (1.0 e 17.5) had 48 PDC inserted laparoscopically between 2002 and 2007. Mean time for insertion was 27 mins (23 e 33). 18 catheters were used for dialysis within 24 hours. Early complications - a minor leak resolved within 24 hours, 3 exit site infections treated successfully, 1 bloclage due to fibrin clot resolved with urokinase. 2 catheters were removed due to infections
CONCLUSIONS Laparoscopic single port insertion of PDC allows quick, accurate and safe placement of the catheter under vision, immediate use with minimum morbidity and good cosmesis. Laparoscopy allows relook, salvage or revision and deserves to be the gold standard.
# S01-4 (O) COMPARATIVE ANALYSIS OF 3 DIFFERENT APPROACHES FOR PEDIATRIC PYELOPLASTY Luis BRAGA, Armando LORENZO, Mohamed MADHI, Darius BAGLI, Joao PIPPI SALLE, Antoine KHOURY and Walid FARHAT The Hospital for Sick Children, Urology, Toronto, CANADA
PURPOSE
MATERIAL AND METHODS
RESULTS
Anderson Heynes dismembered pyeloplasty is the technique of choice for correction of ureteropelvic junction obstruction (UPJO) in children. The selection of surgical access is mostly driven by surgeon preference and can
A retrospective chart review was conducted for all patients who underwent pyeloplasty between Jan 2005 and Aug 2007. Of 53 laparoscopic pyeloplasties, we selected 29 performed by a single surgeon and compared
The main RESULTS are displayed in the table below:
variables Age (years) Operative time (min) Hospital stay (days) Complications (%) Failure/Redo (%) Follow-up (months)
Lap * (n ¼ 29) 7.9 187.8 2.3 3 (10.3) 1 (3.4) 13.5
Flank (n ¼ 32) 8.0 163.9 3.6 1 (3.1) 1 (3.1) 24.9
Dorsal (n ¼ 22) 7.2 167.7 3.3 1 (4.5) 0 (0) 22.6
p (Anova) 0.49 0.02 < 0.001 0.39 0.67 -
*Mean op. time for the last 10 laparoscopic cases was 155 min (shorter than open operative time).
be performed laparoscopically, through a flank incision, or through a dorsal lumbotomy. A comparative analysis involving these 3 different approaches has not been previously reported.
them to 54 age matched cases who had an open approach (32 flank and 22 dorsal lumbotomy). Age at surgery, operative time, hospital stay, complication and failure rates were evaluated. Statistical analysis was performed using one-way ANOVA test.
CONCLUSIONS Although mean operative time was greater for the laparoscopic group versus open cases, mean hospital stay was significantly shorter. Laparoscopic surgical time
S18 gradually improved over time, reaching those of flank and dorsal lumbotomy patients. Overall, the success rate was
ESPU Programme 2008 similar for the 3 pyeloplasty approaches. Our data do not favour one particular surgical access over the others. Future studies on
cosmesis and pain control may reveal more divergent outcomes for these 3 approaches.
# S01-5 (V) PRONE RETROPERITONEOSCOPIC APPROACH FOR 30 HEMINEPHROURETERECTOMIES; THE SPECIFIC ADVANTAGES Supul HENNAYAKE and Anju GOYAL Royal Manchester Children’s Hospital, Paediatric Urology, Manchester, UNITED KINGDOM
PURPOSE The lateral approach is more widely used in retroperitoneoscopic renal surgery due to familiar orientation and ease of conversion. We present a series of 30 heminephroureterectomies (HNU) where prone approach was utilised extremely effectively with no conversions and low complications.
MATERIAL AND METHODS From November 2003 to October 2007, 31 HNU were performed. Thirty of these, done in prone position, were included in the study. Females constituted 57%. Mean age was 3.1 years (range 0.9-13.3, 60% under 2 years). The upper moieties were excised in 17 patients (9 ureterocels, 8 ectopic ureters)
and lower moieties in 13 (10 reflux, 2 pelviureteric junction obstruction, 1 lower moiety stones). The video demonstrates the important steps and the specific advantages of this approach. Prospectively recorded data and notes were reviewed. Mean follow up was 19 months.
requiring excision of the stump and the ureterocele (this was the third patient of the series). There were no transfusions or conversions. Routine ultra sound showed healthy residual moieties in all.
CONCLUSIONS RESULTS Mean operative duration was 141 min (range 100- 280 min). Drains were used in 50% for a mean of 2 days. Average post-operative stay was 1.7 days (range 0-6 days). One child, undergoing lower HNU, sustained ‘nipping’ of the upper moiety ureter with an endoloop causing incomplete obstruction. This was the 8th patient of the series. Residual ureteric stump was seen in 5; however, only one was symptomatic
With prone approach, the anatomy could be demonstrated quickly and clearly. The dissection could be done with ‘two-hands’ as the kidney is hanging down with no need for retraction. The whole length of the renal vessels could be seen, enabling accurate and meticulous control. The extent of ureteric dissection wasn’t impaired and stump complications were minimal. Prone retroperitoneoscopic approach could be highly recommended for HNU.
S02: VESICOURETERAL REFLUX 1
# S02-1 (O) THE NATURAL HISTORY OF TRANSIENT URODYNAMIC ABNORMALITY OF INFANCY WITH HIGH GRADE PRIMARY VESICIOURETERAL REFLUX: FOLLOW UP TO EARLY CHILDHOOD Biji SREEDHAR, Chung Kwong YEUNG, Sujit Kumar CHOWDHARY and Jennifer Dart Yin SIHOE Chinese University of Hong Kong, Surgery, Kowloon, HONG KONG
The natural history of the bladder in children with severe primary VUR has not been known well. The aim of this study is longitudinal follow up of evolution of bladder function in this cohort.
function was primarily assessed using uroflowmetry and ultrasonosonography and UD assessment was repeated if required. Correlation between UD findings and outcome of VUR and bladder function at a mean follow up period of 4.7yrs was evaluated.
MATERIAL AND METHODS
RESULTS
Infants with primary VUR (grade >III) were recruited. At entry, each patient underwent a voiding cystourethrogram, isotopic renogram and both natural filling and conventional filling urodynamic (UD) studies. UD patterns were classified as normal, overactive, dyssenergic/ dysfunctional, obstructive and hypocontractile. On follow up, bladder
Thirty-five patients (M/F:28/7, meanage:8.65 m) were followed. Bladder function was abnormal in 23(9 Overactive, 4 Obstructive, 5 Dyssenergic/Dysfunctional, 5 underactive) and normal in 12 initially. Among the children with normal bladder function VUR resolved in 11 patients (91.6%) at 24 months and none had VUR. None of the patients with bladder dysfunction achieved
PURPOSE
VUR resolution.Bladder dysfunction resolved in 3 with an early overactive bladder. All children with obstructive pattern initially were treated surgically and achieved complete resolution of VUR and bladder dysfunction at 4.6yrs. Children with dyssenergic and underactive features initially, VUR persisted in all at 24 months. Persistence of bladder dysfunction was observed in all.
CONCLUSIONS Our RESULTS demonstrated that transient UD dysfunction of infancy has persisted into early childhood in a significant proportion of children. An initial urodynamic categorization of the voiding dysfunction and abnormal bladder function revealed
S17
# S01-3 (O) LAPAROSCOPIC INSERTION OF PERITONEAL DIALYSIS CATHETERS IN CHILDREN - THE NEW GOLD STANDARD? Ramnath SUBRAMANIAM St.James University Hospital, Paediatric Urology, Leeds, UNITED KINGDOM
under vision via a single camera port and seldinger technique. The catheter could then be used immediately as required in the post-operative period. This method is approved by the National institute of clinical excellence (NICE, UK) quoting no increased morbidity in children.
PURPOSE To assess the effectiveness, complication rates and their management using the minimally invasive approach of placing peritoneal dialysis catheters (PDC) in children from an experience of six consecutive years.
RESULTS
and replaced after treating the infection. 4 catheters blocked two weeks post operatively; 3 of them were successfully repaired laparoscopically using an additional 5 mm port to release adhesions. In one case the laparoscope was used to diagnose the problem of a severe inflammatory reaction and the catheter was removed. We have not performed any case of open PDC insertion.
MATERIAL AND METHODS This is an ongoing prospective study conducted for the last six years from 2002. Children with established renal failure requiring insertion of PDC were included. The insertions were performed by or under the supervision of a single consultant surgeon using the laparoscopic technique. Partial omentectomy was performed and the catheter accurately placed in the pelvis
Forty six children with a mean age of 9 years (1.0 e 17.5) had 48 PDC inserted laparoscopically between 2002 and 2007. Mean time for insertion was 27 mins (23 e 33). 18 catheters were used for dialysis within 24 hours. Early complications - a minor leak resolved within 24 hours, 3 exit site infections treated successfully, 1 bloclage due to fibrin clot resolved with urokinase. 2 catheters were removed due to infections
CONCLUSIONS Laparoscopic single port insertion of PDC allows quick, accurate and safe placement of the catheter under vision, immediate use with minimum morbidity and good cosmesis. Laparoscopy allows relook, salvage or revision and deserves to be the gold standard.
# S01-4 (O) COMPARATIVE ANALYSIS OF 3 DIFFERENT APPROACHES FOR PEDIATRIC PYELOPLASTY Luis BRAGA, Armando LORENZO, Mohamed MADHI, Darius BAGLI, Joao PIPPI SALLE, Antoine KHOURY and Walid FARHAT The Hospital for Sick Children, Urology, Toronto, CANADA
PURPOSE
MATERIAL AND METHODS
RESULTS
Anderson Heynes dismembered pyeloplasty is the technique of choice for correction of ureteropelvic junction obstruction (UPJO) in children. The selection of surgical access is mostly driven by surgeon preference and can
A retrospective chart review was conducted for all patients who underwent pyeloplasty between Jan 2005 and Aug 2007. Of 53 laparoscopic pyeloplasties, we selected 29 performed by a single surgeon and compared
The main RESULTS are displayed in the table below:
variables Age (years) Operative time (min) Hospital stay (days) Complications (%) Failure/Redo (%) Follow-up (months)
Lap * (n ¼ 29) 7.9 187.8 2.3 3 (10.3) 1 (3.4) 13.5
Flank (n ¼ 32) 8.0 163.9 3.6 1 (3.1) 1 (3.1) 24.9
Dorsal (n ¼ 22) 7.2 167.7 3.3 1 (4.5) 0 (0) 22.6
p (Anova) 0.49 0.02 < 0.001 0.39 0.67 -
*Mean op. time for the last 10 laparoscopic cases was 155 min (shorter than open operative time).
be performed laparoscopically, through a flank incision, or through a dorsal lumbotomy. A comparative analysis involving these 3 different approaches has not been previously reported.
them to 54 age matched cases who had an open approach (32 flank and 22 dorsal lumbotomy). Age at surgery, operative time, hospital stay, complication and failure rates were evaluated. Statistical analysis was performed using one-way ANOVA test.
CONCLUSIONS Although mean operative time was greater for the laparoscopic group versus open cases, mean hospital stay was significantly shorter. Laparoscopic surgical time
S18 gradually improved over time, reaching those of flank and dorsal lumbotomy patients. Overall, the success rate was
ESPU Programme 2008 similar for the 3 pyeloplasty approaches. Our data do not favour one particular surgical access over the others. Future studies on
cosmesis and pain control may reveal more divergent outcomes for these 3 approaches.
# S01-5 (V) PRONE RETROPERITONEOSCOPIC APPROACH FOR 30 HEMINEPHROURETERECTOMIES; THE SPECIFIC ADVANTAGES Supul HENNAYAKE and Anju GOYAL Royal Manchester Children’s Hospital, Paediatric Urology, Manchester, UNITED KINGDOM
PURPOSE The lateral approach is more widely used in retroperitoneoscopic renal surgery due to familiar orientation and ease of conversion. We present a series of 30 heminephroureterectomies (HNU) where prone approach was utilised extremely effectively with no conversions and low complications.
MATERIAL AND METHODS From November 2003 to October 2007, 31 HNU were performed. Thirty of these, done in prone position, were included in the study. Females constituted 57%. Mean age was 3.1 years (range 0.9-13.3, 60% under 2 years). The upper moieties were excised in 17 patients (9 ureterocels, 8 ectopic ureters)
and lower moieties in 13 (10 reflux, 2 pelviureteric junction obstruction, 1 lower moiety stones). The video demonstrates the important steps and the specific advantages of this approach. Prospectively recorded data and notes were reviewed. Mean follow up was 19 months.
requiring excision of the stump and the ureterocele (this was the third patient of the series). There were no transfusions or conversions. Routine ultra sound showed healthy residual moieties in all.
CONCLUSIONS RESULTS Mean operative duration was 141 min (range 100- 280 min). Drains were used in 50% for a mean of 2 days. Average post-operative stay was 1.7 days (range 0-6 days). One child, undergoing lower HNU, sustained ‘nipping’ of the upper moiety ureter with an endoloop causing incomplete obstruction. This was the 8th patient of the series. Residual ureteric stump was seen in 5; however, only one was symptomatic
With prone approach, the anatomy could be demonstrated quickly and clearly. The dissection could be done with ‘two-hands’ as the kidney is hanging down with no need for retraction. The whole length of the renal vessels could be seen, enabling accurate and meticulous control. The extent of ureteric dissection wasn’t impaired and stump complications were minimal. Prone retroperitoneoscopic approach could be highly recommended for HNU.
S02: VESICOURETERAL REFLUX 1
# S02-1 (O) THE NATURAL HISTORY OF TRANSIENT URODYNAMIC ABNORMALITY OF INFANCY WITH HIGH GRADE PRIMARY VESICIOURETERAL REFLUX: FOLLOW UP TO EARLY CHILDHOOD Biji SREEDHAR, Chung Kwong YEUNG, Sujit Kumar CHOWDHARY and Jennifer Dart Yin SIHOE Chinese University of Hong Kong, Surgery, Kowloon, HONG KONG
The natural history of the bladder in children with severe primary VUR has not been known well. The aim of this study is longitudinal follow up of evolution of bladder function in this cohort.
function was primarily assessed using uroflowmetry and ultrasonosonography and UD assessment was repeated if required. Correlation between UD findings and outcome of VUR and bladder function at a mean follow up period of 4.7yrs was evaluated.
MATERIAL AND METHODS
RESULTS
Infants with primary VUR (grade >III) were recruited. At entry, each patient underwent a voiding cystourethrogram, isotopic renogram and both natural filling and conventional filling urodynamic (UD) studies. UD patterns were classified as normal, overactive, dyssenergic/ dysfunctional, obstructive and hypocontractile. On follow up, bladder
Thirty-five patients (M/F:28/7, meanage:8.65 m) were followed. Bladder function was abnormal in 23(9 Overactive, 4 Obstructive, 5 Dyssenergic/Dysfunctional, 5 underactive) and normal in 12 initially. Among the children with normal bladder function VUR resolved in 11 patients (91.6%) at 24 months and none had VUR. None of the patients with bladder dysfunction achieved
PURPOSE
VUR resolution.Bladder dysfunction resolved in 3 with an early overactive bladder. All children with obstructive pattern initially were treated surgically and achieved complete resolution of VUR and bladder dysfunction at 4.6yrs. Children with dyssenergic and underactive features initially, VUR persisted in all at 24 months. Persistence of bladder dysfunction was observed in all.
CONCLUSIONS Our RESULTS demonstrated that transient UD dysfunction of infancy has persisted into early childhood in a significant proportion of children. An initial urodynamic categorization of the voiding dysfunction and abnormal bladder function revealed