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V7-09 ROBOT-ASSISTED LAPAROSCOPIC URETEROCALICOSTOMY IN THE PEDIATRIC PATIENT
THE JOURNAL OF UROLOGYâ
Vol. 193, No. 4S, Supplement, Sunday, May 17, 2015
RESULTS: In our small cohort we were able to perform this operation on three patients, 8-14 years of age. These patients all had spina bifida with neurogenic bladder and bowel as an underlining diagnosis. Two of these patients had bladder augmentation in the past for a neurogenic bladder. One patient had no other abdominal operations aside from cecostomy tube placement. All patients were discharged home on POD one. Two patients presented with superficial wound infections at the ACE site and were treated with antibiotics. No patients required revision of the stoma or the ACE up to this point. No stool leakage around the ACE was documented on their postoperative visits. Importantly, all three patients were happy with the outcome. CONCLUSIONS: Conversion of cecostomy button to ACE robotically is a safe, simple operation without any major complications in this case series. General patient satisfaction is high with good fecal continence. Source of Funding: none
V7-07 COMBINED ROBOTIC AND OPEN APPROACH TO EXCISION OF ACCESSORY BLADDER AND URETHRAL TRIPLICATION Diana K. Bowen, Alex P. Glaser*, Jonathan W. Bush, Earl Y. Cheng, Edward M. Gong, Chicago, IL INTRODUCTION AND OBJECTIVES: Management of urethral and bladder duplication anomalies focuses on prevention of recurrent infections and preservation of renal function. We describe a case of urethral triplication and bladder duplication, and the combined robotic and open approach to surgical excision. METHODS: A 17 year-old male presented with ten days of intermittent fevers and abdominal pain. He was found to have two accessory urethras e both along the dorsal penile shaft e in addition to a normal orthotopic ventral meatus. A large cavity anterior to the bladder was identified on CT scan and a drain was placed by interventional radiology with return of purulent fluid. He was placed on culture-directed antibiotics and improved. RESULTS: Cystoscopy revealed two accessory urethral channels that were both blind-ending, the more proximal one just under the pubic symphysis. The patient then underwent open excision of the urethral triplication followed by robotic excision of the bladder duplication. Total console time for the robotic portion was 2 hours 18 minutes and estimated blood loss was 30 ml. Final pathology revealed nonkeratinizing squamous lining of the accessory urethras, with chronic inflammation and marked fibrosis of the distal-most channel, but acute inflammation of the proximal channel. The accessory bladder specimen had a urothelial lining with reactive changes and inflammation within the lamina propria. CONCLUSIONS: To our knowledge, this is the first reported case of robotic excision of a urethral/bladder duplication anomaly. There was significant scarring due to the patient’s prior recurrent infections, but visualization with the robotic approach was excellent and the patient healed well with a short recovery time. We conclude that robotic excision of a bladder duplication anomaly is a technically feasible operation. Source of Funding: None
V7-08 ROBOT-ASSISTED LAPAROSCOPIC LOWER TO UPPER PYELOURETEROSTOMY IN THE PEDIATRIC PATIENT Ashley Wietsma*, Patricia Cho, Richard Yu, Boston, MA INTRODUCTION AND OBJECTIVES: Urinary duplication is commonly associated with ureteropelvic junction (UPJ) obstruction of the lower pole moiety. Lower pole UPJ obstruction may resolve spontaneously similar to a single-system obstruction, but if persistent and
e661
symptomatic, it may require surgical correction. Traditional dismembered pyeloplasty is usually feasible with complete duplication. However, partial duplication can be technically challenging especially if the ureteral junction is proximally located resulting in insufficient lower ureteral length. This challenge is overcome by performing a lower to upper pyeloureterostomy. Although current data focuses on open surgical repair, we present a video of robot-assisted laparoscopic pyeloureterostomy to demonstrate the feasibility of this minimally invasive approach in the pediatric population. METHODS: A 6 year old male with a history of left-sided prenatal hydronephrosis presented with an episode of renal colic. An ultrasound during the episode revealed severe hydronephrosis of the left lower pole. Three months later, follow-up ultrasound imaging and MAG3 renal scan revealed improved hydronephrosis of the left lower pole and a differential renal function of 59% on the left with a lower pole diuretic half-time of 3 minutes. The patient was diagnosed with intermittent UPJ obstruction of the left lower pole and surgical treatment was pursued using a robotic approach. RESULTS: Transmesenteric dissection revealed a high partial duplication. After sharply transecting the lower pole ureter, the intrinsic obstruction was noted to extend the length of the lower pole ureter to the lower pole renal pelvis. The short lower pole ureter was excised and a lower to upper pyeloureterostomy was performed. The wide opening of the lower pole pelvis was anastomosed to the upper pole ureter using 5-0 vicryl in a running fashion. A 4.8-French x 16-cm double-J ureteral stent was placed antegrade before completion of the anastomosis. There were no intraoperative complications and the patient was discharged the following day. CONCLUSIONS: Surgical correction of UPJ obstruction in a partial duplex system varies depending on the location of the obstruction and the duplication junction. It requires a full appreciation for the individualized anatomy. Robotic surgery has become integral in urinary reconstruction in the pediatric population because it allows for excellent visualization and dissection of complex anatomy in a confined space. The robotic approach is both feasible and successful in performing a lower to upper pole pyeloureterostomy. Source of Funding: None
V7-09 ROBOT-ASSISTED LAPAROSCOPIC URETEROCALICOSTOMY IN THE PEDIATRIC PATIENT Ashley Wietsma*, Patricia Cho, Richard Yu, Boston, MA INTRODUCTION AND OBJECTIVES: Ureterocalicostomy is a versatile alternative to the traditional Anderson-Hynes pyeloplasty in the treatment of recurrent ureteropelvic junction (UPJ) obstruction, UPJ obstruction associated with anatomic anomalies, such as horseshoe kidney and intrarenal pelvis, and trauma of the UPJ or proximal ureter. Although the robotic approach has become increasingly popular for urologic reconstructive procedures in the adult and pediatric populations, little data has been published on robot-assisted laparoscopic ureterocalicostomy especially in the pediatric population. To illustrate the feasibility of this minimally invasive approach in pediatrics, we present a case series with one representative video of robotic ureterocalicostomy. METHODS: Four patients with an age range of 11 to 22 years (average age 15 years) with equal gender distribution underwent robotassisted laparoscopic ureterocalicostomy for left UPJ obstruction between 2011 and 2014. In all patients, preoperative ultrasound revealed severe hydronephrosis with diffuse cortical thinning. Preoperative renal scans (MAG3 or DMSA) demonstrated decreased differential renal function on the affected left side in a range of 29-40% (average 31%), and obstructive parameters with a diuretic half-time in the range of 19 to greater than 100 minutes (average time 51 minutes). Half of the patients underwent planned, salvage ureterocalicostomy reconstruction due to recurrent UPJ obstruction following traditional pyeloplasties. Utererocalicostomy was indicated as a primary procedure for the other two
e662
THE JOURNAL OF UROLOGYâ
patients due to anatomic abnormalities, an intrarenal pelvis and complex ureteral anatomy. RESULTS: There were no intraoperative complications. Double-J ureteral stents were placed intraoperatively in each patient. Mean hospital stay was 1.5 days. Stents were removed less than 7 weeks postoperatively. Postoperative ultrasound demonstrated persistent, but stable hydronephrosis, an unsurprising result given their history of longstanding obstruction and severe hydronephrosis. Two patients experienced recurrent flank pain, but renography revealed a widely patent anastomosis. CONCLUSIONS: Robotic ureterocalicostomy is a feasible and successful procedure for recurrent and severe UPJ obstruction in pediatric patients. Its versatility allows for its application for both pyeloplasty failure and as an alternative procedure for cases of challenging renal and ureteral anatomy. More data is necessary to quantify the advantages and disadvantages of the robotic approach as compared to open and laparoscopic approaches. Source of Funding: None
Vol. 193, No. 4S, Supplement, Sunday, May 17, 2015
double-J stent was placed. Laparoscopic robot-assisted pyeloureterostomy (RAPU) was performed. A 12 mm umbilical camera port, two 8 mm robotic instrument ports and one 10mm assistant port were placed. The colon was reflected medially. The renal pelvis was identified and the proximal ureter was dissected as it coursed under the inferior vena cava (IVC). The segment of ureter that passed under the IVC was transected and partially excised. This partially excised ureteral segment served as a handle to minimize manipulation during anastomosis. Interrupted 5-0 polygalactin sutures were used to anastomose the ureter anterior to the IVC. A Jackson-Pratt drain was left in place. RESULTS: Console time was 180 minutes. Blood loss was minimal. The patient tolerated the procedure well and no complications occurred. The patient was ready for discharge on post-operative day two. The stent was removed six weeks later. At the three month followup the patient was asymptomatic and the hydronephrosis had improved significantly. CONCLUSIONS: Symptomatic circumcaval ureter is uncommon in children. With a careful characterization of the anatomy circumcaval ureter is well suited to minimally-invasive repair. Source of Funding: none
V7-10 COMBINED LAPAROSCOPIC PYELOLITHOTOMY AND CYSTOLITHOTOMY IN A PEDIATRIC PATIENT Paul Bowlin*, Fahad Alyami, Walid Farhat, Toronto, Canada INTRODUCTION AND OBJECTIVES: Laparoscopy has a welldefined role in the management of pediatric stone disease. The access provided by a laparoscopic approach allows for the management of stones within the kidney, ureter, and bladder, which can often be done in a single operative setting. We describe the techniques for this operation along with several troubleshooting tips. METHODS: Video demonstrating techniques and tips for performing combined laparoscopic pyelolithotomy and cystolithotomy. RESULTS: Not applicable. CONCLUSIONS: Combined laparoscopic pyelolithotomy and cystolithotomy is an effective management option for patients will renal and bladder calculi. Source of Funding: None
V7-11 ROBOT-ASSISTED REPAIR OF A CIRCUMCAVAL URETER IN A CHILD Hubert Swana, Celebration, FL; Diego Aguilar*, Orlando, FL; Alberto DuBoy, Tampa, FL; Mark Rich, Orlando, FL INTRODUCTION AND OBJECTIVES: Circumcaval Ureter or retrocaval ureter is a rare congenital venous anomaly that results from the posterior cardinal vein persisting as the renal segment of the inferior vena cava (IVC) during development. Ureteral compression by the IVC, psoas muscle and vertebrae results in progressive ureteral obstruction and hydronephrosis. Patients present with flank pain or abdominal pain in the third or fourth decades of life with rare cases occuring in children. We present a video demonstrating a Robotassisted Pyeloureterostomy ( RAPU) in a child presenting with a symptomatic circumcaval ureter. METHODS: An 11 year-old male presented with intermittent right flank and abdominal pain. Ultrasound revealed right hydronephrosis and a dilated proximal ureter with an “S-shaped” deformity. Nuclear renal scan was suspicious for right renal obstruction. Cystoscopy and retrograde ureteropyelography again demonstrated proximal ureteral dilation and an “S-shaped” deformity of the ureter. A
V7-12 A NOVEL LAPAROSCOPIC SURGICAL METHOD FOR COEXISTENCE OF TESTICULAR VARICOCELE AND IPSILATERAL HYDROCELE Nobuhiro Takahashi*, Shoji Kudo, Hideki Kobayashi, Satoshi Azuma, Tatsuya Miyamoto, Hidenori Zakohji, Masayuki Takeda, Chuo, Japan INTRODUCTION AND OBJECTIVES: Hydrocele is a common clinical problem in children worldwide, and the main cause is a congenital patent processus vaginalis (PPV). We experienced a pediatric case with left-sided communicating hydrocele and ipsilateral varicocele undergoing simultaneous minimally-invasive laparoscopic repair. METHODS: Case:An 11-year-old boy, with left sided scrotal mass, had been diagnosed as testicular varicocele in a clinic. He was sent to our hospital for minimally-invasive treatment. At the initial visit, not only left-sided testicular varicocele, but also left-sided hydrocele were confirmed. Simultaneous laparoscopic repair of both diseases were planned. Operative procedures: The patient was in a Trendelenburg position (15-degree head-down tilt) under general anesthesia. Laparoscopic repair of the left-sided varicocele using 3 5mm trocars followed by laparoscopic extraperitoneal repair of PPV using 2 small left inguinal incisions were scheduled. Initially, laparoscopic high ligation of testicular veins were performed. For closing PPV, pre-peritoneal space was dissected, and a 5mm left inguinal skin incision was made. Through this incision, a 16 gauge vascular access needle was inserted into the pre-peritoneal space, and a 2-0 silk suture was inserted through the sheath of this 16 gauge needle. The 2-0 silk was trapped by 4-0 nylon suture loop via another 16 gauge needle, and was retracted through the same incision. The 2-0 silk suture was tied in the inguinal incision wound, resulting in partial closure of PPV. The same procedures were performed 6 times from lateral to medial direction. Finally, PPV was almost closed, and additional metal clips for final closure of the median peritoneum were used. RESULTS: Eight months after operation, neither left-sided hydrocele nor varicocele was found. Successful simultaneous minimally-invasive laparoscopic repair was performed in a pediatric case with left-sided communicating hydrocele and ipsilateral varicocele. CONCLUSIONS: This procedure is easy for experienced laparoscopic surgeon, and is a safe procedure.,@
Vol. 193, No. 4S, Supplement, Sunday, May 17, 2015
RESULTS: In our small cohort we were able to perform this operation on three patients, 8-14 years of age. These patients all had spina bifida with neurogenic bladder and bowel as an underlining diagnosis. Two of these patients had bladder augmentation in the past for a neurogenic bladder. One patient had no other abdominal operations aside from cecostomy tube placement. All patients were discharged home on POD one. Two patients presented with superficial wound infections at the ACE site and were treated with antibiotics. No patients required revision of the stoma or the ACE up to this point. No stool leakage around the ACE was documented on their postoperative visits. Importantly, all three patients were happy with the outcome. CONCLUSIONS: Conversion of cecostomy button to ACE robotically is a safe, simple operation without any major complications in this case series. General patient satisfaction is high with good fecal continence. Source of Funding: none
V7-07 COMBINED ROBOTIC AND OPEN APPROACH TO EXCISION OF ACCESSORY BLADDER AND URETHRAL TRIPLICATION Diana K. Bowen, Alex P. Glaser*, Jonathan W. Bush, Earl Y. Cheng, Edward M. Gong, Chicago, IL INTRODUCTION AND OBJECTIVES: Management of urethral and bladder duplication anomalies focuses on prevention of recurrent infections and preservation of renal function. We describe a case of urethral triplication and bladder duplication, and the combined robotic and open approach to surgical excision. METHODS: A 17 year-old male presented with ten days of intermittent fevers and abdominal pain. He was found to have two accessory urethras e both along the dorsal penile shaft e in addition to a normal orthotopic ventral meatus. A large cavity anterior to the bladder was identified on CT scan and a drain was placed by interventional radiology with return of purulent fluid. He was placed on culture-directed antibiotics and improved. RESULTS: Cystoscopy revealed two accessory urethral channels that were both blind-ending, the more proximal one just under the pubic symphysis. The patient then underwent open excision of the urethral triplication followed by robotic excision of the bladder duplication. Total console time for the robotic portion was 2 hours 18 minutes and estimated blood loss was 30 ml. Final pathology revealed nonkeratinizing squamous lining of the accessory urethras, with chronic inflammation and marked fibrosis of the distal-most channel, but acute inflammation of the proximal channel. The accessory bladder specimen had a urothelial lining with reactive changes and inflammation within the lamina propria. CONCLUSIONS: To our knowledge, this is the first reported case of robotic excision of a urethral/bladder duplication anomaly. There was significant scarring due to the patient’s prior recurrent infections, but visualization with the robotic approach was excellent and the patient healed well with a short recovery time. We conclude that robotic excision of a bladder duplication anomaly is a technically feasible operation. Source of Funding: None
V7-08 ROBOT-ASSISTED LAPAROSCOPIC LOWER TO UPPER PYELOURETEROSTOMY IN THE PEDIATRIC PATIENT Ashley Wietsma*, Patricia Cho, Richard Yu, Boston, MA INTRODUCTION AND OBJECTIVES: Urinary duplication is commonly associated with ureteropelvic junction (UPJ) obstruction of the lower pole moiety. Lower pole UPJ obstruction may resolve spontaneously similar to a single-system obstruction, but if persistent and
e661
symptomatic, it may require surgical correction. Traditional dismembered pyeloplasty is usually feasible with complete duplication. However, partial duplication can be technically challenging especially if the ureteral junction is proximally located resulting in insufficient lower ureteral length. This challenge is overcome by performing a lower to upper pyeloureterostomy. Although current data focuses on open surgical repair, we present a video of robot-assisted laparoscopic pyeloureterostomy to demonstrate the feasibility of this minimally invasive approach in the pediatric population. METHODS: A 6 year old male with a history of left-sided prenatal hydronephrosis presented with an episode of renal colic. An ultrasound during the episode revealed severe hydronephrosis of the left lower pole. Three months later, follow-up ultrasound imaging and MAG3 renal scan revealed improved hydronephrosis of the left lower pole and a differential renal function of 59% on the left with a lower pole diuretic half-time of 3 minutes. The patient was diagnosed with intermittent UPJ obstruction of the left lower pole and surgical treatment was pursued using a robotic approach. RESULTS: Transmesenteric dissection revealed a high partial duplication. After sharply transecting the lower pole ureter, the intrinsic obstruction was noted to extend the length of the lower pole ureter to the lower pole renal pelvis. The short lower pole ureter was excised and a lower to upper pyeloureterostomy was performed. The wide opening of the lower pole pelvis was anastomosed to the upper pole ureter using 5-0 vicryl in a running fashion. A 4.8-French x 16-cm double-J ureteral stent was placed antegrade before completion of the anastomosis. There were no intraoperative complications and the patient was discharged the following day. CONCLUSIONS: Surgical correction of UPJ obstruction in a partial duplex system varies depending on the location of the obstruction and the duplication junction. It requires a full appreciation for the individualized anatomy. Robotic surgery has become integral in urinary reconstruction in the pediatric population because it allows for excellent visualization and dissection of complex anatomy in a confined space. The robotic approach is both feasible and successful in performing a lower to upper pole pyeloureterostomy. Source of Funding: None
V7-09 ROBOT-ASSISTED LAPAROSCOPIC URETEROCALICOSTOMY IN THE PEDIATRIC PATIENT Ashley Wietsma*, Patricia Cho, Richard Yu, Boston, MA INTRODUCTION AND OBJECTIVES: Ureterocalicostomy is a versatile alternative to the traditional Anderson-Hynes pyeloplasty in the treatment of recurrent ureteropelvic junction (UPJ) obstruction, UPJ obstruction associated with anatomic anomalies, such as horseshoe kidney and intrarenal pelvis, and trauma of the UPJ or proximal ureter. Although the robotic approach has become increasingly popular for urologic reconstructive procedures in the adult and pediatric populations, little data has been published on robot-assisted laparoscopic ureterocalicostomy especially in the pediatric population. To illustrate the feasibility of this minimally invasive approach in pediatrics, we present a case series with one representative video of robotic ureterocalicostomy. METHODS: Four patients with an age range of 11 to 22 years (average age 15 years) with equal gender distribution underwent robotassisted laparoscopic ureterocalicostomy for left UPJ obstruction between 2011 and 2014. In all patients, preoperative ultrasound revealed severe hydronephrosis with diffuse cortical thinning. Preoperative renal scans (MAG3 or DMSA) demonstrated decreased differential renal function on the affected left side in a range of 29-40% (average 31%), and obstructive parameters with a diuretic half-time in the range of 19 to greater than 100 minutes (average time 51 minutes). Half of the patients underwent planned, salvage ureterocalicostomy reconstruction due to recurrent UPJ obstruction following traditional pyeloplasties. Utererocalicostomy was indicated as a primary procedure for the other two
e662
THE JOURNAL OF UROLOGYâ
patients due to anatomic abnormalities, an intrarenal pelvis and complex ureteral anatomy. RESULTS: There were no intraoperative complications. Double-J ureteral stents were placed intraoperatively in each patient. Mean hospital stay was 1.5 days. Stents were removed less than 7 weeks postoperatively. Postoperative ultrasound demonstrated persistent, but stable hydronephrosis, an unsurprising result given their history of longstanding obstruction and severe hydronephrosis. Two patients experienced recurrent flank pain, but renography revealed a widely patent anastomosis. CONCLUSIONS: Robotic ureterocalicostomy is a feasible and successful procedure for recurrent and severe UPJ obstruction in pediatric patients. Its versatility allows for its application for both pyeloplasty failure and as an alternative procedure for cases of challenging renal and ureteral anatomy. More data is necessary to quantify the advantages and disadvantages of the robotic approach as compared to open and laparoscopic approaches. Source of Funding: None
Vol. 193, No. 4S, Supplement, Sunday, May 17, 2015
double-J stent was placed. Laparoscopic robot-assisted pyeloureterostomy (RAPU) was performed. A 12 mm umbilical camera port, two 8 mm robotic instrument ports and one 10mm assistant port were placed. The colon was reflected medially. The renal pelvis was identified and the proximal ureter was dissected as it coursed under the inferior vena cava (IVC). The segment of ureter that passed under the IVC was transected and partially excised. This partially excised ureteral segment served as a handle to minimize manipulation during anastomosis. Interrupted 5-0 polygalactin sutures were used to anastomose the ureter anterior to the IVC. A Jackson-Pratt drain was left in place. RESULTS: Console time was 180 minutes. Blood loss was minimal. The patient tolerated the procedure well and no complications occurred. The patient was ready for discharge on post-operative day two. The stent was removed six weeks later. At the three month followup the patient was asymptomatic and the hydronephrosis had improved significantly. CONCLUSIONS: Symptomatic circumcaval ureter is uncommon in children. With a careful characterization of the anatomy circumcaval ureter is well suited to minimally-invasive repair. Source of Funding: none
V7-10 COMBINED LAPAROSCOPIC PYELOLITHOTOMY AND CYSTOLITHOTOMY IN A PEDIATRIC PATIENT Paul Bowlin*, Fahad Alyami, Walid Farhat, Toronto, Canada INTRODUCTION AND OBJECTIVES: Laparoscopy has a welldefined role in the management of pediatric stone disease. The access provided by a laparoscopic approach allows for the management of stones within the kidney, ureter, and bladder, which can often be done in a single operative setting. We describe the techniques for this operation along with several troubleshooting tips. METHODS: Video demonstrating techniques and tips for performing combined laparoscopic pyelolithotomy and cystolithotomy. RESULTS: Not applicable. CONCLUSIONS: Combined laparoscopic pyelolithotomy and cystolithotomy is an effective management option for patients will renal and bladder calculi. Source of Funding: None
V7-11 ROBOT-ASSISTED REPAIR OF A CIRCUMCAVAL URETER IN A CHILD Hubert Swana, Celebration, FL; Diego Aguilar*, Orlando, FL; Alberto DuBoy, Tampa, FL; Mark Rich, Orlando, FL INTRODUCTION AND OBJECTIVES: Circumcaval Ureter or retrocaval ureter is a rare congenital venous anomaly that results from the posterior cardinal vein persisting as the renal segment of the inferior vena cava (IVC) during development. Ureteral compression by the IVC, psoas muscle and vertebrae results in progressive ureteral obstruction and hydronephrosis. Patients present with flank pain or abdominal pain in the third or fourth decades of life with rare cases occuring in children. We present a video demonstrating a Robotassisted Pyeloureterostomy ( RAPU) in a child presenting with a symptomatic circumcaval ureter. METHODS: An 11 year-old male presented with intermittent right flank and abdominal pain. Ultrasound revealed right hydronephrosis and a dilated proximal ureter with an “S-shaped” deformity. Nuclear renal scan was suspicious for right renal obstruction. Cystoscopy and retrograde ureteropyelography again demonstrated proximal ureteral dilation and an “S-shaped” deformity of the ureter. A
V7-12 A NOVEL LAPAROSCOPIC SURGICAL METHOD FOR COEXISTENCE OF TESTICULAR VARICOCELE AND IPSILATERAL HYDROCELE Nobuhiro Takahashi*, Shoji Kudo, Hideki Kobayashi, Satoshi Azuma, Tatsuya Miyamoto, Hidenori Zakohji, Masayuki Takeda, Chuo, Japan INTRODUCTION AND OBJECTIVES: Hydrocele is a common clinical problem in children worldwide, and the main cause is a congenital patent processus vaginalis (PPV). We experienced a pediatric case with left-sided communicating hydrocele and ipsilateral varicocele undergoing simultaneous minimally-invasive laparoscopic repair. METHODS: Case:An 11-year-old boy, with left sided scrotal mass, had been diagnosed as testicular varicocele in a clinic. He was sent to our hospital for minimally-invasive treatment. At the initial visit, not only left-sided testicular varicocele, but also left-sided hydrocele were confirmed. Simultaneous laparoscopic repair of both diseases were planned. Operative procedures: The patient was in a Trendelenburg position (15-degree head-down tilt) under general anesthesia. Laparoscopic repair of the left-sided varicocele using 3 5mm trocars followed by laparoscopic extraperitoneal repair of PPV using 2 small left inguinal incisions were scheduled. Initially, laparoscopic high ligation of testicular veins were performed. For closing PPV, pre-peritoneal space was dissected, and a 5mm left inguinal skin incision was made. Through this incision, a 16 gauge vascular access needle was inserted into the pre-peritoneal space, and a 2-0 silk suture was inserted through the sheath of this 16 gauge needle. The 2-0 silk was trapped by 4-0 nylon suture loop via another 16 gauge needle, and was retracted through the same incision. The 2-0 silk suture was tied in the inguinal incision wound, resulting in partial closure of PPV. The same procedures were performed 6 times from lateral to medial direction. Finally, PPV was almost closed, and additional metal clips for final closure of the median peritoneum were used. RESULTS: Eight months after operation, neither left-sided hydrocele nor varicocele was found. Successful simultaneous minimally-invasive laparoscopic repair was performed in a pediatric case with left-sided communicating hydrocele and ipsilateral varicocele. CONCLUSIONS: This procedure is easy for experienced laparoscopic surgeon, and is a safe procedure.,@