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Pneumovesicoscopic diverticulectomy in children and adolescents: Is open surgery still indicated?
Journal of Pediatric Urology (2008) 4, 146e149
Pneumovesicoscopic diverticulectomy in children and adolescents: Is open surgery still indicated? Haytham Badawy*, Ahmed Eid, Mohammed Hassouna, Aly Abd Elkarim, Salah Elsalmy Section of Pediatric Urology, Department of Urology, University of Alexandria, Alexandria, Egypt Received 18 July 2007; accepted 4 September 2007 Available online 5 November 2007
KEYWORDS Laparoscopy; Pneumovesicoscopic; Transvesical; Bladder; Diverticulectomy
Abstract Objectives: Surgical treatment of a congenital bladder diverticulum is indicated in symptomatic children. Diverticulectomy can be performed by an open or a laparoscopic approach. We report our recent experience in using the pneumovesicoscopic approach for accomplishing vesical diverticulectomy. Methods: We operated on three boys with a mean age of 11.6 years (10e14 years) during August 2006 to February 2007. In all children, a ureteric catheter was introduced first by cystoscopy followed by intravesical CO2 insufflation at a pressure of 12e15 mmHg. Three trocars were inserted under visual control in the bladder. Diverticulectomy was performed. The defect was closed by interrupted sutures. Bladder drainage was achieved using a urethral catheter for 2 days. Results: The mean operative time was 133.3 min (100e180 min). Oral intake began after a mean of 5.3 h (4e6 h). Minimal blood loss was encountered. Non-steroidal analgesics were used only during the 1st day postoperatively with no need for morphia. All patients were discharged on the 2nd day postoperatively after removal of the urethral catheter and tube drain. The mean follow-up period was 5 months (3e6 months). Conclusion: Pneumovesicoscopic diverticulectomy is a feasible procedure. It does not require a long learning curve, and is associated with shorter hospital stay and rapid recovery with good cosmetic aspect. Pneumovesicoscopy has the potential to be used in the treatment of other conditions such as vesicoureteral reflux, and may replace open surgery. ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. Tel.: þ20 12 369 0597/20 3 575 8575; fax: þ20 3 545 9804. E-mail address: [email protected] (H. Badawy).
Congenital bladder diverticulum has several presentations. Prenatal diagnosis during routine ultrasound has been reported. UTI, haematurea, and urine retention are the main postnatal presentations [1,2]. Radiological diagnosis
1477-5131/$30 ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2007.09.001
Pneumovesicoscopic diverticulectomy of such a congenital anomaly is achieved by ultrasound together with a VCUG identifying the exact anatomy of the diverticulum and diagnosing associated VUR, which has been reported in up to 50% of cases [1]. Surgical treatment of congenital bladder diverticulum consists of excision of the diverticulum with or without ureteral reimplantation. Different surgical approaches have been described including the extravesical and transvesical approaches. Open diverticulectomy whether by the extravesical or intravesical approach is not an easy procedure. It necessitates a relatively large lower abdominal incision, with excessive dissection to remain in the retroperitoneal space between the bladder and the peritoneum if the extravesical approach is used. If the transvesical approach is chosen, the morbidity of a large bladder incision and excessive dissection around the diverticular hiatus calls for a minimally invasive technique [3,4]. Laparoscopic diverticulectomy has been reported as a minimally invasive procedure using either the transperitoneal or extraperitoneal approach [5,6]. To date, there are no data in the literature describing the pneumovesicoscopic approach for bladder diverticulectomy in children. Here, we report our experience with the pneumovesicoscopic diverticulectomy in children and adolescents.
Patients and methods We operated on three boys with a mean age of 11.6 years (10e14 years) during the period from August 2006 to February 2007. The first patient, aged 14 years, presented with repeated urine retention and lower urinary tract obstructive symptoms. Ultrasound revealed normal upper urinary tract and a huge bladder diverticulum. His VCUG revealed one large diverticulum, two smaller diverticulae and no VUR. The second patient, aged 10 years, presented with
Figure 1
147 recurrent cystitis and haematurea. The third patient, aged 11 years, presented with recurrent cystitis. Their ultrasounds revealed normal upper tract and a large single bladder diverticulum. VCUG revealed a large bladder diverticulum with no VUR in these two children (Fig. 1). All patients were examined carefully to exclude any associated connective tissue disease such as Ehlers-Danlos syndrome. Pneumovesicoscopic diverticulectomy was performed in all children. General anaesthesia was used. Cystoscopy was done in all children. In the first child, the mouth of the large diverticulum was seen in the posterior wall of the bladder on the left side extending about 1 cm from the catheterized meatus of the left ureter (Fig. 2). In the second child, cystoscopy revealed the mouth of a single diverticulum located near the left ureteric meatus which had been catheterized. In the third child, the diverticulum was identified in the right side of the posterior bladder wall. The right ureteric meatus had been identified and catheterized. Cystoscopic insufflation of the bladder with carbon dioxide was done in all patients. The pressure was adjusted to range from 12 mmHg to a maximum of 15 mmHg. Under cystoscopic control, access to the bladder was achieved. In all children, the first trocar was inserted 1 cm below the umbilicus in the midline after fixing the bladder to the anterior abdominal wall by a number 1 vicryl suture on a large curved needle under cystoscopic control, in order to immobilize the bladder and facilitate trocar entry. Two 5-mm balloon trocars were inserted in the bladder in the midclavicular line opposite to the site of the diverticular mouth. Dissection of the diverticulum was started by sharply creating the plane between the detrusor muscle and the mucous membrane of the diverticulum, and continuing the dissection in this plane using a monopolar hook and Kelly forceps. Further development of this plane was helped by the insufflated gas. Dissection was done carefully near the
a. Ascending cystogram antero-posterior view. b. Micturating cystourethrogram showing huge bladder diverticulum.
148
H. Badawy et al.
Figure 2 Pneumovesicoscopic view of opening of bladder diverticulum beside ureteric orifice.
ureter to leave it intact and not to disturb its submucosal tunnel guided by the ureteric catheter in all cases. In all children, complete dissection of the diverticulum was performed and the diverticulum was inverted inside the bladder and completely freed. The resulting defect in the posterior wall of the bladder was closed by interrupted sutures. A small tube drain was inserted at the bed of the diverticulum from one of the trocars under laparoscopic guidance. In all patients, a urethral catheter was left for 2 days after removal of the trocars. All patients were discharged home 48 h after the procedure. Ultrasound was performed routinely prior to discharge. VCUG was to be performed 6 months following the procedure. All patients were kept on suppressive therapy until the time of VCUG.
Results The mean operative time was 133.3 min (100e180 min). Oral intake began after a mean of 5.3 h (4e6 h). Minimal blood loss was encountered, so blood transfusion was not indicated. The haematurea disappeared during the 1st day postoperatively. Non-steroidal analgesics were used only during the 1st day postoperatively with no need for morphia. All patients were discharged on the 2nd day postoperatively after removal of the urethral catheter and tube drain. The mean follow-up period was 5 months (3e6 months). All symptoms were relieved in the three patients following the diverticulectomy. Ultrasound prior to discharge and follow-up ultrasound revealed normal bladder and upper urinary tract in all patients. VCUG revealed normal bladder and no VUR (Fig. 3).
Discussion Congenital bladder diverticulum has several presentations including recurrent UTI, haematurea, urine retention and lower urinary tract obstructive symptoms [2,7]. Different surgical modalities are used to treat this pathology. Open diverticulectomy is performed by either the transvesical or the extravesical route. Ureteral re-implantation is
Figure 3 Follow-up ascending cystogram showing no diverticulum and no reflux.
indicated in the presence of associated VUR, or when the ureter is too near to the diverticulum, or if the ureter is opening inside the diverticulum [3,4]. Laparoscopic diverticulectomy is used as a minimally invasive treatment in the management of bladder diverticulum. Both the transperitoneal and retroperitoneal approaches are used. In the transperitoneal approach, violation of the peritoneum is considered a major drawback of the procedure. In both approaches, identification of the diverticulum from the outer surface of the bladder is difficult [5,6]. The pneumovesicoscopic approach is a novel technique in which insufflation of the gas is performed and trocars are inserted inside the bladder for undergoing bladder surgery. No peritoneal violation is encountered and identification of the mouth of the diverticulum from inside the bladder is very easy to accomplish. Pneumovesicoscopy was used previously for ureteral re-implantation in children. Holger et al. first reported pneumovesicoscopic diverticulectomy with ureteral reimplantation in 2005 [8]. Vito Pansadoro et al. reported pneumovesicoscopic diverticulectomy in adults [9]. As in any laparoscopic diverticulectomy, we start by inserting a ureteric catheter to visualize the ureteric orifice during the whole procedure. Insufflation of CO2 is performed regularly. For achieving bladder access, an ordinary trocar was inserted in all cases after fixing the bladder by a vicryl suture to the anterior abdominal wall. The remaining trocars are inserted in the same way. Easy identification of the diverticular orifice is achieved using the pneumovesicoscopic approach. Dissection is aided
Pneumovesicoscopic diverticulectomy by the CO2 entering the correct surgical plane between the diverticulum and the detrusor muscle. The mean operative time was 133.3 min. The procedure was accomplished in 180 min in the first patient, and the operative time decreased gradually to 100 min in the last patient, reflecting a relatively rapid learning curve and confirming the feasibility of the technique. The operative time is comparable to that of open diverticulectomy and also to the time taken by both the transperitoneal and extraperitoneal approaches [3e6]. Rapid oral intake, minimal analgesic need, short hospital stay and rapid recovery are the major advantages of the procedure. Avoiding violation of the peritoneum and easy identification of the bladder diverticulum, coupled with easy dissection and wide working space, are the major advantages over the trans- and extraperitoneal approaches. The defect in the posterior bladder wall created by the dissection of the diverticulum was closed by interrupted absorbable sutures. Intravesical suturing is not difficult but necessitates correct insertion of the trocars, being well directed towards the diverticular mouth and aligned with the surgeon’s arms. Haematurea following the procedure was a major concern; however, it disappeared during the 1st day postoperatively owing to the proper suturing of the posterior wall, good hydration and proper postoperative drainage by a urethral catheter.
Conclusion Pneumovesicoscopic diverticulectomy is an easy and feasible procedure. It does not require a long learning curve,
149 and is associated with shorter hospital stay and rapid recovery with good cosmetic aspect. Pneumovesicoscopy has the potential to be used in the treatment of other conditions such as VUR. This technique can be considered a useful addition to the urological armamentarium with a short learning curve and excellent results.
References [1] Dokucu I, Lortat-Jacob S, Re ´villon Y. Diverticule conge ´nital ge ´ant de vessie: a ` propos de 12 cas. 62e`me congre `s de la SFCP, 21e23 September 2005. [2] Shukla AR, Bellah RA, Canning DA, Carr MC, Snyder HM, Zderic SA. Giant bladder diverticula causing bladder outlet obstruction in children. J Urol 2004;172:1977e9. [3] Yu TJ. Extravesical diverticuloplasty for repair of a paraureteral diverticulum and the associated refluxing ureter. J Urol 2002;168:1135e7. [4] Pieretti RV, Pieretti-Vanmarcke RV. Congenital bladder diverticula in children. J Pediatr Surg 1999;34:468e73. [5] Fukatsu A, Okamura K, Nishimura T, Ono Y, Ohshima S. Laparoscopic extraperitoneal bladder diverticulectomy: an initial case report. Nippon Hinyokika Gakkai Zasshi 2001;92:636e9. [6] Jarrett TW, Pardalidis NP, Sweetser P, Badlani GH, Smith AD. Laparoscopic transperitoneal bladder diverticulectomy: surgical technique. J Laparoendosc Surg 1995;5:105e11. [7] Sarihan H, Abes M. Congenital bladder diverticula in infants. Eur Urol 1998;33:101e3. [8] Holger T, Jennifer S, Yeung C, Chan K. Pneumovesicoscopic Ureteral Reimplantation in Children with Vesicoureteral Reflux and Paraureteral (hutch) Diverticulum. ESPU-AAP meeting, Upsala, Sweden 2005. [9] Pansadoro V, Emiliozzi P, Federico G, Martini M, Pansodoro A, Pizzo M, Scarpone P (Rome, Italy). Transvesical laparoscopic diverticulectomy. EAU meeting, Paris, France, 5e8 April 2006.
Pneumovesicoscopic diverticulectomy in children and adolescents: Is open surgery still indicated? Haytham Badawy*, Ahmed Eid, Mohammed Hassouna, Aly Abd Elkarim, Salah Elsalmy Section of Pediatric Urology, Department of Urology, University of Alexandria, Alexandria, Egypt Received 18 July 2007; accepted 4 September 2007 Available online 5 November 2007
KEYWORDS Laparoscopy; Pneumovesicoscopic; Transvesical; Bladder; Diverticulectomy
Abstract Objectives: Surgical treatment of a congenital bladder diverticulum is indicated in symptomatic children. Diverticulectomy can be performed by an open or a laparoscopic approach. We report our recent experience in using the pneumovesicoscopic approach for accomplishing vesical diverticulectomy. Methods: We operated on three boys with a mean age of 11.6 years (10e14 years) during August 2006 to February 2007. In all children, a ureteric catheter was introduced first by cystoscopy followed by intravesical CO2 insufflation at a pressure of 12e15 mmHg. Three trocars were inserted under visual control in the bladder. Diverticulectomy was performed. The defect was closed by interrupted sutures. Bladder drainage was achieved using a urethral catheter for 2 days. Results: The mean operative time was 133.3 min (100e180 min). Oral intake began after a mean of 5.3 h (4e6 h). Minimal blood loss was encountered. Non-steroidal analgesics were used only during the 1st day postoperatively with no need for morphia. All patients were discharged on the 2nd day postoperatively after removal of the urethral catheter and tube drain. The mean follow-up period was 5 months (3e6 months). Conclusion: Pneumovesicoscopic diverticulectomy is a feasible procedure. It does not require a long learning curve, and is associated with shorter hospital stay and rapid recovery with good cosmetic aspect. Pneumovesicoscopy has the potential to be used in the treatment of other conditions such as vesicoureteral reflux, and may replace open surgery. ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. Tel.: þ20 12 369 0597/20 3 575 8575; fax: þ20 3 545 9804. E-mail address: [email protected] (H. Badawy).
Congenital bladder diverticulum has several presentations. Prenatal diagnosis during routine ultrasound has been reported. UTI, haematurea, and urine retention are the main postnatal presentations [1,2]. Radiological diagnosis
1477-5131/$30 ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2007.09.001
Pneumovesicoscopic diverticulectomy of such a congenital anomaly is achieved by ultrasound together with a VCUG identifying the exact anatomy of the diverticulum and diagnosing associated VUR, which has been reported in up to 50% of cases [1]. Surgical treatment of congenital bladder diverticulum consists of excision of the diverticulum with or without ureteral reimplantation. Different surgical approaches have been described including the extravesical and transvesical approaches. Open diverticulectomy whether by the extravesical or intravesical approach is not an easy procedure. It necessitates a relatively large lower abdominal incision, with excessive dissection to remain in the retroperitoneal space between the bladder and the peritoneum if the extravesical approach is used. If the transvesical approach is chosen, the morbidity of a large bladder incision and excessive dissection around the diverticular hiatus calls for a minimally invasive technique [3,4]. Laparoscopic diverticulectomy has been reported as a minimally invasive procedure using either the transperitoneal or extraperitoneal approach [5,6]. To date, there are no data in the literature describing the pneumovesicoscopic approach for bladder diverticulectomy in children. Here, we report our experience with the pneumovesicoscopic diverticulectomy in children and adolescents.
Patients and methods We operated on three boys with a mean age of 11.6 years (10e14 years) during the period from August 2006 to February 2007. The first patient, aged 14 years, presented with repeated urine retention and lower urinary tract obstructive symptoms. Ultrasound revealed normal upper urinary tract and a huge bladder diverticulum. His VCUG revealed one large diverticulum, two smaller diverticulae and no VUR. The second patient, aged 10 years, presented with
Figure 1
147 recurrent cystitis and haematurea. The third patient, aged 11 years, presented with recurrent cystitis. Their ultrasounds revealed normal upper tract and a large single bladder diverticulum. VCUG revealed a large bladder diverticulum with no VUR in these two children (Fig. 1). All patients were examined carefully to exclude any associated connective tissue disease such as Ehlers-Danlos syndrome. Pneumovesicoscopic diverticulectomy was performed in all children. General anaesthesia was used. Cystoscopy was done in all children. In the first child, the mouth of the large diverticulum was seen in the posterior wall of the bladder on the left side extending about 1 cm from the catheterized meatus of the left ureter (Fig. 2). In the second child, cystoscopy revealed the mouth of a single diverticulum located near the left ureteric meatus which had been catheterized. In the third child, the diverticulum was identified in the right side of the posterior bladder wall. The right ureteric meatus had been identified and catheterized. Cystoscopic insufflation of the bladder with carbon dioxide was done in all patients. The pressure was adjusted to range from 12 mmHg to a maximum of 15 mmHg. Under cystoscopic control, access to the bladder was achieved. In all children, the first trocar was inserted 1 cm below the umbilicus in the midline after fixing the bladder to the anterior abdominal wall by a number 1 vicryl suture on a large curved needle under cystoscopic control, in order to immobilize the bladder and facilitate trocar entry. Two 5-mm balloon trocars were inserted in the bladder in the midclavicular line opposite to the site of the diverticular mouth. Dissection of the diverticulum was started by sharply creating the plane between the detrusor muscle and the mucous membrane of the diverticulum, and continuing the dissection in this plane using a monopolar hook and Kelly forceps. Further development of this plane was helped by the insufflated gas. Dissection was done carefully near the
a. Ascending cystogram antero-posterior view. b. Micturating cystourethrogram showing huge bladder diverticulum.
148
H. Badawy et al.
Figure 2 Pneumovesicoscopic view of opening of bladder diverticulum beside ureteric orifice.
ureter to leave it intact and not to disturb its submucosal tunnel guided by the ureteric catheter in all cases. In all children, complete dissection of the diverticulum was performed and the diverticulum was inverted inside the bladder and completely freed. The resulting defect in the posterior wall of the bladder was closed by interrupted sutures. A small tube drain was inserted at the bed of the diverticulum from one of the trocars under laparoscopic guidance. In all patients, a urethral catheter was left for 2 days after removal of the trocars. All patients were discharged home 48 h after the procedure. Ultrasound was performed routinely prior to discharge. VCUG was to be performed 6 months following the procedure. All patients were kept on suppressive therapy until the time of VCUG.
Results The mean operative time was 133.3 min (100e180 min). Oral intake began after a mean of 5.3 h (4e6 h). Minimal blood loss was encountered, so blood transfusion was not indicated. The haematurea disappeared during the 1st day postoperatively. Non-steroidal analgesics were used only during the 1st day postoperatively with no need for morphia. All patients were discharged on the 2nd day postoperatively after removal of the urethral catheter and tube drain. The mean follow-up period was 5 months (3e6 months). All symptoms were relieved in the three patients following the diverticulectomy. Ultrasound prior to discharge and follow-up ultrasound revealed normal bladder and upper urinary tract in all patients. VCUG revealed normal bladder and no VUR (Fig. 3).
Discussion Congenital bladder diverticulum has several presentations including recurrent UTI, haematurea, urine retention and lower urinary tract obstructive symptoms [2,7]. Different surgical modalities are used to treat this pathology. Open diverticulectomy is performed by either the transvesical or the extravesical route. Ureteral re-implantation is
Figure 3 Follow-up ascending cystogram showing no diverticulum and no reflux.
indicated in the presence of associated VUR, or when the ureter is too near to the diverticulum, or if the ureter is opening inside the diverticulum [3,4]. Laparoscopic diverticulectomy is used as a minimally invasive treatment in the management of bladder diverticulum. Both the transperitoneal and retroperitoneal approaches are used. In the transperitoneal approach, violation of the peritoneum is considered a major drawback of the procedure. In both approaches, identification of the diverticulum from the outer surface of the bladder is difficult [5,6]. The pneumovesicoscopic approach is a novel technique in which insufflation of the gas is performed and trocars are inserted inside the bladder for undergoing bladder surgery. No peritoneal violation is encountered and identification of the mouth of the diverticulum from inside the bladder is very easy to accomplish. Pneumovesicoscopy was used previously for ureteral re-implantation in children. Holger et al. first reported pneumovesicoscopic diverticulectomy with ureteral reimplantation in 2005 [8]. Vito Pansadoro et al. reported pneumovesicoscopic diverticulectomy in adults [9]. As in any laparoscopic diverticulectomy, we start by inserting a ureteric catheter to visualize the ureteric orifice during the whole procedure. Insufflation of CO2 is performed regularly. For achieving bladder access, an ordinary trocar was inserted in all cases after fixing the bladder by a vicryl suture to the anterior abdominal wall. The remaining trocars are inserted in the same way. Easy identification of the diverticular orifice is achieved using the pneumovesicoscopic approach. Dissection is aided
Pneumovesicoscopic diverticulectomy by the CO2 entering the correct surgical plane between the diverticulum and the detrusor muscle. The mean operative time was 133.3 min. The procedure was accomplished in 180 min in the first patient, and the operative time decreased gradually to 100 min in the last patient, reflecting a relatively rapid learning curve and confirming the feasibility of the technique. The operative time is comparable to that of open diverticulectomy and also to the time taken by both the transperitoneal and extraperitoneal approaches [3e6]. Rapid oral intake, minimal analgesic need, short hospital stay and rapid recovery are the major advantages of the procedure. Avoiding violation of the peritoneum and easy identification of the bladder diverticulum, coupled with easy dissection and wide working space, are the major advantages over the trans- and extraperitoneal approaches. The defect in the posterior bladder wall created by the dissection of the diverticulum was closed by interrupted absorbable sutures. Intravesical suturing is not difficult but necessitates correct insertion of the trocars, being well directed towards the diverticular mouth and aligned with the surgeon’s arms. Haematurea following the procedure was a major concern; however, it disappeared during the 1st day postoperatively owing to the proper suturing of the posterior wall, good hydration and proper postoperative drainage by a urethral catheter.
Conclusion Pneumovesicoscopic diverticulectomy is an easy and feasible procedure. It does not require a long learning curve,
149 and is associated with shorter hospital stay and rapid recovery with good cosmetic aspect. Pneumovesicoscopy has the potential to be used in the treatment of other conditions such as VUR. This technique can be considered a useful addition to the urological armamentarium with a short learning curve and excellent results.
References [1] Dokucu I, Lortat-Jacob S, Re ´villon Y. Diverticule conge ´nital ge ´ant de vessie: a ` propos de 12 cas. 62e`me congre `s de la SFCP, 21e23 September 2005. [2] Shukla AR, Bellah RA, Canning DA, Carr MC, Snyder HM, Zderic SA. Giant bladder diverticula causing bladder outlet obstruction in children. J Urol 2004;172:1977e9. [3] Yu TJ. Extravesical diverticuloplasty for repair of a paraureteral diverticulum and the associated refluxing ureter. J Urol 2002;168:1135e7. [4] Pieretti RV, Pieretti-Vanmarcke RV. Congenital bladder diverticula in children. J Pediatr Surg 1999;34:468e73. [5] Fukatsu A, Okamura K, Nishimura T, Ono Y, Ohshima S. Laparoscopic extraperitoneal bladder diverticulectomy: an initial case report. Nippon Hinyokika Gakkai Zasshi 2001;92:636e9. [6] Jarrett TW, Pardalidis NP, Sweetser P, Badlani GH, Smith AD. Laparoscopic transperitoneal bladder diverticulectomy: surgical technique. J Laparoendosc Surg 1995;5:105e11. [7] Sarihan H, Abes M. Congenital bladder diverticula in infants. Eur Urol 1998;33:101e3. [8] Holger T, Jennifer S, Yeung C, Chan K. Pneumovesicoscopic Ureteral Reimplantation in Children with Vesicoureteral Reflux and Paraureteral (hutch) Diverticulum. ESPU-AAP meeting, Upsala, Sweden 2005. [9] Pansadoro V, Emiliozzi P, Federico G, Martini M, Pansodoro A, Pizzo M, Scarpone P (Rome, Italy). Transvesical laparoscopic diverticulectomy. EAU meeting, Paris, France, 5e8 April 2006.