Simplified technique for laparoscopic extravesical ureteral reimplantation in the porcine model.

BACKGROUND AND PURPOSE: Laparoscopic intravesical and standard Lich-Gregoir repair have been reported but are technically challenging. Herein, we present our experience with a simplified laparoscopic reimplantation of the ureter to correct vesicoureteral reflux (VUR). MATERIALS AND METHODS: Bilateral VUR was created cystoscopically in six minipigs, as confirmed by a static cystogram 6 weeks later. The laparoscopic extravesical correction of VUR was performed utilizing a full-thickness cystotomy. The ureter was transposed inside the bladder, and a full-thickness bladder closure was performed. No attempt was made to cover the ureter with urothelium. No stents or catheters were utilized postoperatively. Three months after reimplantation, the animals were evaluated with serology, a static cystogram, an intravenous urogram (IVU), and gross pathologic and histopathologic examination. RESULTS: The postoperative cystograms confirmed no reflux in all the reimplanted ureters and residual grade 1 to 3 reflux in the non-reimplanted ureters. All pigs voided normally and were completely continent. Cystoscopic evaluation revealed complete epithelialization over the reimplanted ureter. One surgical complication occurred: the ureter was incorporated into the bladder closure and became obstructed. The IVU in all other pigs demonstrated patent ureters with prompt function. CONCLUSIONS: Laparoscopic reimplantation of the ureter utilizing this modified Lich-Gregoir approach corrected reflux in all animals. The full-thickness bladder incision and intravesical transposition of the ureter greatly simplifies the laparoscopic procedure. This laboratory experience encourages further clinical evaluation in the pediatric population with VUR.

Ileal conduit urinary diversion in patients with previous history of abdominal/pelvic irradiation.

Urinary diversion among patients receiving prior radiation is common. Herein, we present our experience with ileal conduit (IC) diversion in patients with a history of prior abdominal and/or pelvic radiation therapy. We analyzed the charts of 177 patients who underwent IC urinary diversion between 1/1994 and 6/2000, and 36 patients were identified who had previously undergone radiation therapy. Decisions to proceed were based on surgeon preference as determined by intraoperative appearance and viability of the selected bowel segment. Chart review included serum studies, upper tract imaging studies, and complications related to diversion. Durability of diversion was determined by examining the interval between urinary diversion and the need for additional procedures. A total of 30 patients with at least 3 months follow-up were identified. Renal function remained stable in 86% (26/30) with a median follow-up of 21.5 months (range 3-63 months). Hydronephrosis was noted preoperatively in 4 patients (13%) who demonstrated stable upper tracts and serum creatinine in the post-operative period. Three patients (10%) developed unilateral hydronephrosis related to tumor recurrence, with one patient demonstrating a rise in baseline serum creatinine. Hydronephrosis was noted in 5 patients (16%) secondary to development of ureteroenteric stricture. Serum creatinine remained stable in 2 patients without intervention with 2 years follow-up. Intervention for obstruction was necessary in 3 patients at 22, 31, and 61 months following diversion. In one patient, an intraoperative decision to use the colon for urinary diversion was made secondary to appearance of small bowel. Minor complications were noted in 9 patients (30%), while 3 patients (10%) experienced major complications in the immediate post-operative period. Five patients (17%) experienced complications potentially related to the use of ileum for urinary diversion. The use of ileum for urinary diversion among patients with a history of radiation appears technically feasible and a viable treatment alternative. Our data support the use of ileum in the majority of patients as evidence by a low complication rate and a high rate of upper tract preservation. In addition, these data imply that a prior history of abdominal and/or pelvic radiation should not serve as the sole determining factor in the selection of bowel segment utilized during urinary diversion.

Penile and scrotal elephantiasis caused by indolent Chlamydia trachomatis infection.

Isolated penile and scrotal elephantiasis presents a diagnostic and therapeutic challenge. We report a case of chronic penile and scrotal elephantiasis caused by indolent Chlamydia trachomatis infection. The patient improved modestly with long-term doxycycline.