Vol. 179, No. 4, Supplement, Monday, May 19, 2008
and should be addressed with careful preoperative counseling and close follow-up. Source of Funding: None
1195 GASTROCYSTOPLASTY UNDER ATTACK – DO VIABLE INDICATIONS REMAIN? Samy M Heshmat*, William DeFoor, Pramod Reddy, Eugene Minevich, Shumyle Alam, Curtis A Sheldon. Cincinnati, OH. INTRODUCTION AND OBJECTIVE: The use of gastric tissue continues to be highly controversial in pediatric bladder augmentation. Many surgeons have abandoned its use due to hematuria-dysuria syndrome and metabolic derangements. In addition, recent reports have indicated an elevated risk of malignant transformation. The aim of this study is to evaluate our long-term results with this procedure and review its current indications in light of these contemporary concerns. METHODS: A retrospective cohort study was performed of all patients who underwent a continent lower urinary tract reconstruction with a gastric segment at a single institution. The patch was harvested high on the gastric fundus well away from the antrum in all cases by a single surgeon. Surveillance cystoscopy under anesthesia has been SHUIRUPHG RQ DQ DQQXDO EDVLV LQ SDWLHQWV EHJLQQLQJ ¿YH \HDUV DIWHU their procedure. RESULTS: From 1989 to 2007, 63 patients (21 males and IHPDOHV ZHUHLGHQWL¿HG0HGLDQDJHDWWLPHRIUHFRQVWUXFWLRQZDV 5.0 years and median follow up was 6.8 years (range 3 months - 18 years). 36 patients (57%) had severe congenital bladder malformations, many of whom had associated hindgut anomalies. 13 patients had end stage renal disease requiring subsequent renal transplantation. Urinary continence was reported in 91% of patients and upper tract dilatation was stable or improved in 88% of patients. No patients experienced metabolic alkalosis. Hematuria-dysuria syndrome occurred in 12% of patients, including two who had severe hematuria with clots while anuric on dialysis that resolved after transplantation. One patient had ischemic patch contraction and developed a bladder stone. One sensate patient underwent excision of the gastric segment due to severe dysuria. One patient had a bladder perforation after a motor vehicle crash. None of the patients in our series developed a neoplasm after their gastrocystoplasty. Four patients with suspicious lesions underwent cystoscopic biopsy that GHPRQVWUDWHGFKURQLFLQÀDPPDWLRQZLWKRXWG\VSODVLD CONCLUSIONS: Despite multiple recent discouraging reports regarding an unacceptably high rate of complications with gastrocystoplasty, our data indicates that it continues to have a selected role in patients with the most devastating pelvic anomalies who require bladder augmentation and have a paucity of other available intestinal tissue for reconstruction. Surveillance cystoscopy is recommended due to the uncertainty regarding the long-term risk of malignancy in these patients. Source of Funding: None
1196 RENAL TRANSPLANTATION WITH LIVE RELATED DONORS IN PEDIATRIC PATIENTS WITH SEVERE LOWER URINARY TRACT DYSFUNCTION AND AUGMENTED BLADDERS Eduardo Ruiz*, Juan Moldes, Javier Escalante Cateriano, Francisco de Badiola, Carlos Giuseppucci, Mauricio Urquizo Lino, Carlos Favre, Carlos Giudice, Edurne Ormaechea, Jorge Ferraris. Buenos Aires, Argentina. INTRODUCTION AND OBJECTIVE: We reviewed our experience with renal transplantation (tx) with live related donors in pediatric patients with end stage renal disease (ESRD) because of severe postobstructive or neurogenic vesical dysfunction METHODS: From 1988 to 2007 we haved performed 35 renal tx i(males 87,5%) between 1 and 21 years of age ( median 12 years ) and and an average weight of 32 kg (r: 11-79kg). The etiology of bladder dysfunction was posterior urethral valves in 16, prune belly syndrome in 7, neurogenic bladder (NB) and anorectal malformation in 5, NB and myelomeningocele in 3, NB without a clear diagnosis in 2, and NB with associated urogenital sinus and cerebral palsy in 1 each. Previous urological procedures in preparation for tx were a Mitrofanoff urinary
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stoma in 14, bladder augmentation in 11 and unilateral nephrectomy in 10 pts. Mother was the most frequent donor in 23 ( 65,7%). Nephrectomy in 5, ureterocystoplasty in 4 and Mitrofanoff and orchidopexy in 2 each one , were the most common simultaneous procedures. RESULTS: Patient survival was 97,4% with a median follow up of 60 months (r: 6-234 ). Graft survival was 100%. Actual average serum creatinine is 1.25 mg/dl (r: 0,4-3.9). There was a very serious vascular complications because of a mycotic aneurysm of the aorta with death 1 week after Tx, 1 moderate lymphocele resolved spontaneously. Three patients required a reoperation because of urological complications and recovered uneventfully. Voiding is spontaneous in 45,6 % of patients. Ten other surgical procedures were done between 8 and 23 months after W[EHFDXVHRIUHSHDWHGXULQDU\LQIHFWLRQVDQGUHÀX[LQWRWKHQDWLYHRU transplanted kidney (5 nephroureterectomies, 3 ureteral reimplantations, 1 endoscopic subureteral injection and 1 mitrofanoff) No patient has required a postoperative augmentation or dyalisis replacement therapy until now. CONCLUSIONS: Patients with severe vesical dysfunction with or without bladder augmentation had similar Tx results as non urological pediatric patients, but required more associated surgical procedures before, during and after Tx. Aggressive treatment of urinary infection, REVWUXFWLRQDQGUHÀX[LQWKHSRVWRSHUDWLYHSHULRGKDVEHHQHVVHQWLDO to maintain good graft function. Nephrectomy, ureterocystoplasty and an urinary ostoma can be performed simultaneously with a renal tx in selected patients, without an increased number of surgical complications. Source of Funding: None
1197 RETROPERITONEOSCOPIC NATIVE NEPHRECTOMY IN CHILDREN WITH END-STAGE RENAL DISEASE Hiroshi Asanuma*, Seiichirou Shishido, Hiroyuki Satoh, Masaki Muramatsu, Hiroaki Tamura. Kiyose-shi, Japan. INTRODUCTION AND OBJECTIVE: Native nephrectomy is indicated before renal transplantation (RT) in children with endstage renal disease (ESRD) when it is associated with drug-resistant hypertension, recurrent symptomatic urinary tract infections, prevention of recurrent focal segmental glomerulosclerosis (FSGS) and/or high risk of Wilms tumor. Retroperitoneoscopic nephrectomy has been described as minimally invasive surgery with a high success rate and low incidence of complications. Nevertheless, the safety of the procedure has not been widely evaluated in pediatric patients with ESRD. In this study we reviewed our experience with retroperitoneoscopic native nephrectomy (RNN) in uremic children. METHODS: Between 2001 and 2007, 15 RNN (left 11, right 4) were carried out in 11 children with ESRD (unilaterally 7, bilaterally 4) before a planned RT. In the patients performed unilateral RNN contralateral kidney was removed at the time of RT. Patients age ranged from 4 to 20 years (mean 12.9 years), with 4 boys and 7 girls participating. The indications for surgery included renal hypertension in 4 patients, FSGS in 1, hypertension and FSGS in 2, WT-1 gene anomaly in 2 and urinary tract anomaly with recurrent infections in 2. Eight patients continued regular peritoneal dialysis (PD) before surgery. RNN used either 3 or 4 ports and pneumoretroperitoneum was maintained at 6 to 10 mmHg. A percutaneous suction drain was placed for 2 or 3 days. Their data were retrospectively evaluated. R E S U LT S : T h e m e a n o p e r a t i v e d u r a t i o n w i t h pneumoretroperitoneum was 113 minutes (range 65 to 226 minutes). All 15 procedures were successfully performed without open exploration. There was no child required a blood transfusion. Three patients developed a peritoneal tear, however, no patient required a period of hemodialysis postoperatively. Two patients had hyperkalemia (> 6.5 mEq/l) during operation, which was recovered by glucose-insulin therapy and immediate PD after surgery. No patient developed wound infection or postoperative hematoma. RT could be performed 3 to 4 weeks after RNN in most patients. CONCLUSIONS: RNN should be considered as the procedure of choice in children managed by PD in preparation for RT. The high success rate, low morbidity, early recovery and short duration between