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Laparoscopy-assisted ureterostomy— technique
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MODEL
Journal of Pediatric Urology (xxxx) xxx xxx
Video Bank
Laparoscopy-assisted ureterostomyd technique M. Asimakidou a, G. De Win b, A. Cherian a,* a
Dept of Paediatric Urology, Great Ormond Street Hospital for Children, UK
b
Dept of Urology, Antwerp University Hospital, Antwerp, Belgium * Corresponding author. Consultant Paediatric Urologist Great Ormond Street Hospital for Children NHS Foundation Trust London WC1N 3JH United Kingdom. [email protected]. uk (A. Cherian) Keywords Ureterostomy; Laparoscopy; Minimally invasive surgery Received 15 April 2019 Accepted 13 May 2019 Available online xxx
Summary Introduction Urinary tract anomalies in children at times pose challenges in which immediate urinary diversion is required before definitive reconstruction. Open cutaneous ureterostomy technique is a well-established approach for this scenario. We describe the laparoscopy-assisted alternative. Material and methods Transperitoneal laparoscopy is performed with three ports. One trans-umbilical 5mm port for vision and two 3mm working instruments, one of which is through the proposed ureterostomy site minimising scarring. The position of the third port is carefully checked both externally and internally. Laparoscopic identification of the dilated ureter is quick and easy. The redundant ureter is mobilised and excess excised if needed. The ureteric loop is then exteriorised and the ureterostomy fashioned externally. Proximal and distal patency is checked both externally and laparoscopically. Results Nineteen patients underwent the procedure for primary VUR (nZ6), neuropathic bladder 7,
Introduction Urinary tract anomalies in children at times raise troublesome situations in which immediate urinary diversion is required before definitive reconstruction. Recurrent urinary tract infections in the context of high-grade vesicoureteric reflux, bladder outlet obstruction and high-pressure neurogenic bladder are some examples. Ensuring the safety of upper tracts is always paramount. Urinary diversion in the form of a cutaneous ureterostomy has been used for many years as a temporising measure. The open technique is a well-established approach for the creation of a ureterostomy [1]. In this video, we describe the laparoscopy-assisted alternative to this method [2].
posterior urethral valve 4, and vesico-ureteric obstruction 2. The mean operative time was 40 minutes. the patients received three doses of perioperative antibiotics and were discharged in 72 hours (mean). At three months, clinical and ultrasound review have shown satisfactory and stable upper tracts and no episodes of UTI.
Discussion The laparoscopic view gives the benefit of direct visualisation and identification with adequate dissection in order to bring the ureter to the surface in a tensionless manner. A redundant ureter can be easily addressed to correct tortuosity or redundancy appropriately. Bladder drainage can be ensured with careful dissection of the distal ureter and inspection at the end of the procedure.
Conclusion Laparoscopy-Assisted ureterostomy formation is easy and quick to perform. It is feasible even in the smallest of babies, assures the shortest segment of ureter to the bladder providing prompt drainage in a refluxing ureterostomy setting. Our early experience is promising with potential benefits.
Supplementary video related to this article can be found at https://doi.org/10.1016/j. jpurol.2019.05.013
Material and methods Transperitoneal laparoscopy is performed in Trendelenburg position. The site of the ureterostomy is carefully planned to provide easy access and adequate dependent drainage into a nappy. Three ports are utilised for this technique. The transumbilical port facilitates the insertion of a 5-mm, 30-degree camera. A second port (3 mm) is inserted to the contralateral paraumbilical side, and the third port (3 mm) is inserted at the site of the expected ureterostomy site. The position of the third
https://doi.org/10.1016/j.jpurol.2019.05.013 1477-5131/ª 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Asimakidou M et al., Laparoscopy-assisted ureterostomyd technique, Journal of Pediatric Urology, https:// doi.org/10.1016/j.jpurol.2019.05.013
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MODEL
2 port is carefully checked both externally and internally to ensure the correct positioning of the ureterostomy [3]. The ureter is usually dilated and very easily identified. It is mobilised laparoscopically until adequate length is achieved in order for the ureter to reach the expected stoma site without tension. The ureteric loop is then exteriorised, and the ureterostomy is fashioned externally as it is for the open technique. Once the ureterostomy is in place, proximal and distal patency is checked both externally and laparoscopically.
Results This approach was utilised in 19 patients (Primary VUR 6, neuropathic bladder 7, posterior urethral valve 4, vesicoureteric junction 2,) and took 40 minutes (mean). Three doses of perioperative antibiotics were given and discharged in 72 hours(mean). All have had a minimum 3 month clinical and ultrasound review with satisfactory and stable upper tracts and further UTI.
Discussion The laparoscopy-assisted technique is easy, safe and quick [4]. The laparoscopic view gives the surgeon the benefit of direct identification and adequate dissection to bring the ureter to the surface in a tensionless manner. In addition, a redundant ureter and ureteric kinks can be easily identified and addressed. Bladder drainage and easy access to the bladder through the distal limb can be ensured with careful dissection of the distal ureter and inspection at the end of the procedure. If an end ureterostomy is required, then the ureter can be divided laparoscopically and exteriorised. The internal distal ureteric stump is closed with the use of an endoloop.
M. Asimakidou et al.
Conclusion Laparoscopic assistance in ureterostomy formation has potential benefits.
Author statements Ethical approval None sought.
Funding None declared.
Competing interests None declared.
References [1] Shubha AM, Das K. Retaining the refluxing lower ureteral stump of a non-functioning kidney to preserve contralateral renal function. J Pediatr Urol 2015;11. 150.e1e156.e1. [2] Vanderbruggen W. Laparoscopy-assisted cutaneous ureterostomy in children: early experience. J Laparoendosc Adv Surg Tech A 2019 Feb;29(2):286e91. [3] Hannan MJ. Laparoscopy-assisted cutaneous ureterostomy at suprapubic crease line facilitates subsequent reimplantation. J Minimal Access Surg 2015;11:139e42. [4] Metzelder M, Petersen C, Ure B. Laparoscopic ureterocutaneostomy for urinary diversion in selected infants. Eur J Pediatr Surg 2008;18:86e8.
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jpurol.2019.05.013.
Please cite this article as: Asimakidou M et al., Laparoscopy-assisted ureterostomyd technique, Journal of Pediatric Urology, https:// doi.org/10.1016/j.jpurol.2019.05.013
MODEL
Journal of Pediatric Urology (xxxx) xxx xxx
Video Bank
Laparoscopy-assisted ureterostomyd technique M. Asimakidou a, G. De Win b, A. Cherian a,* a
Dept of Paediatric Urology, Great Ormond Street Hospital for Children, UK
b
Dept of Urology, Antwerp University Hospital, Antwerp, Belgium * Corresponding author. Consultant Paediatric Urologist Great Ormond Street Hospital for Children NHS Foundation Trust London WC1N 3JH United Kingdom. [email protected]. uk (A. Cherian) Keywords Ureterostomy; Laparoscopy; Minimally invasive surgery Received 15 April 2019 Accepted 13 May 2019 Available online xxx
Summary Introduction Urinary tract anomalies in children at times pose challenges in which immediate urinary diversion is required before definitive reconstruction. Open cutaneous ureterostomy technique is a well-established approach for this scenario. We describe the laparoscopy-assisted alternative. Material and methods Transperitoneal laparoscopy is performed with three ports. One trans-umbilical 5mm port for vision and two 3mm working instruments, one of which is through the proposed ureterostomy site minimising scarring. The position of the third port is carefully checked both externally and internally. Laparoscopic identification of the dilated ureter is quick and easy. The redundant ureter is mobilised and excess excised if needed. The ureteric loop is then exteriorised and the ureterostomy fashioned externally. Proximal and distal patency is checked both externally and laparoscopically. Results Nineteen patients underwent the procedure for primary VUR (nZ6), neuropathic bladder 7,
Introduction Urinary tract anomalies in children at times raise troublesome situations in which immediate urinary diversion is required before definitive reconstruction. Recurrent urinary tract infections in the context of high-grade vesicoureteric reflux, bladder outlet obstruction and high-pressure neurogenic bladder are some examples. Ensuring the safety of upper tracts is always paramount. Urinary diversion in the form of a cutaneous ureterostomy has been used for many years as a temporising measure. The open technique is a well-established approach for the creation of a ureterostomy [1]. In this video, we describe the laparoscopy-assisted alternative to this method [2].
posterior urethral valve 4, and vesico-ureteric obstruction 2. The mean operative time was 40 minutes. the patients received three doses of perioperative antibiotics and were discharged in 72 hours (mean). At three months, clinical and ultrasound review have shown satisfactory and stable upper tracts and no episodes of UTI.
Discussion The laparoscopic view gives the benefit of direct visualisation and identification with adequate dissection in order to bring the ureter to the surface in a tensionless manner. A redundant ureter can be easily addressed to correct tortuosity or redundancy appropriately. Bladder drainage can be ensured with careful dissection of the distal ureter and inspection at the end of the procedure.
Conclusion Laparoscopy-Assisted ureterostomy formation is easy and quick to perform. It is feasible even in the smallest of babies, assures the shortest segment of ureter to the bladder providing prompt drainage in a refluxing ureterostomy setting. Our early experience is promising with potential benefits.
Supplementary video related to this article can be found at https://doi.org/10.1016/j. jpurol.2019.05.013
Material and methods Transperitoneal laparoscopy is performed in Trendelenburg position. The site of the ureterostomy is carefully planned to provide easy access and adequate dependent drainage into a nappy. Three ports are utilised for this technique. The transumbilical port facilitates the insertion of a 5-mm, 30-degree camera. A second port (3 mm) is inserted to the contralateral paraumbilical side, and the third port (3 mm) is inserted at the site of the expected ureterostomy site. The position of the third
https://doi.org/10.1016/j.jpurol.2019.05.013 1477-5131/ª 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Asimakidou M et al., Laparoscopy-assisted ureterostomyd technique, Journal of Pediatric Urology, https:// doi.org/10.1016/j.jpurol.2019.05.013
+
MODEL
2 port is carefully checked both externally and internally to ensure the correct positioning of the ureterostomy [3]. The ureter is usually dilated and very easily identified. It is mobilised laparoscopically until adequate length is achieved in order for the ureter to reach the expected stoma site without tension. The ureteric loop is then exteriorised, and the ureterostomy is fashioned externally as it is for the open technique. Once the ureterostomy is in place, proximal and distal patency is checked both externally and laparoscopically.
Results This approach was utilised in 19 patients (Primary VUR 6, neuropathic bladder 7, posterior urethral valve 4, vesicoureteric junction 2,) and took 40 minutes (mean). Three doses of perioperative antibiotics were given and discharged in 72 hours(mean). All have had a minimum 3 month clinical and ultrasound review with satisfactory and stable upper tracts and further UTI.
Discussion The laparoscopy-assisted technique is easy, safe and quick [4]. The laparoscopic view gives the surgeon the benefit of direct identification and adequate dissection to bring the ureter to the surface in a tensionless manner. In addition, a redundant ureter and ureteric kinks can be easily identified and addressed. Bladder drainage and easy access to the bladder through the distal limb can be ensured with careful dissection of the distal ureter and inspection at the end of the procedure. If an end ureterostomy is required, then the ureter can be divided laparoscopically and exteriorised. The internal distal ureteric stump is closed with the use of an endoloop.
M. Asimakidou et al.
Conclusion Laparoscopic assistance in ureterostomy formation has potential benefits.
Author statements Ethical approval None sought.
Funding None declared.
Competing interests None declared.
References [1] Shubha AM, Das K. Retaining the refluxing lower ureteral stump of a non-functioning kidney to preserve contralateral renal function. J Pediatr Urol 2015;11. 150.e1e156.e1. [2] Vanderbruggen W. Laparoscopy-assisted cutaneous ureterostomy in children: early experience. J Laparoendosc Adv Surg Tech A 2019 Feb;29(2):286e91. [3] Hannan MJ. Laparoscopy-assisted cutaneous ureterostomy at suprapubic crease line facilitates subsequent reimplantation. J Minimal Access Surg 2015;11:139e42. [4] Metzelder M, Petersen C, Ure B. Laparoscopic ureterocutaneostomy for urinary diversion in selected infants. Eur J Pediatr Surg 2008;18:86e8.
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jpurol.2019.05.013.
Please cite this article as: Asimakidou M et al., Laparoscopy-assisted ureterostomyd technique, Journal of Pediatric Urology, https:// doi.org/10.1016/j.jpurol.2019.05.013