Penile repair in patients with epispadias-exstrophy complex-can we prevent resultant hypospadias?

PURPOSE: Male genitalia reconstruction in patients with exstrophy-epispadias complex often leads to secondary hypospadias, thus requiring additional surgery and resulting in possible complications. We describe a technique of male epispadias repair to prevent resultant hypospadias. MATERIALS AND METHODS: The complete penile disassembly technique is modified by multiple Z-plasties, which enable creation of a funnel-like bladder neck and urethral plate lengthening. A total of 29 patients 2 months to 12 years old presenting with pure epispadias and bladder exstrophy were treated with this technique between 2004 and 2011. These patients were compared to 19 patients 1 day to 11 years old with exstrophy-epispadias treated with the standard penile disassembly technique between 2000 and 2004. RESULTS: Outcome measures were urethral orifice position, penile length and complications. There was no statistically significant difference between the 2 groups regarding penile length or complications. In the study group the urethra reached the tip of the glans in all patients, whereas the creation of intentional hypospadias was necessary in 6 patients (31.5%) in the control group (p <0.05). CONCLUSIONS: The modified technique was effective in obtaining appropriate meatal location without decreasing the penile length. The complication rate was not changed. Creation of resultant hypospadias at genitalia reconstruction in male epispadias should strongly be prevented.

One-port retroperitoneoscopic assisted pyeloplasty versus open dismembered pyeloplasty in young children: preliminary experience.

PURPOSE: We propose 1-port retroperitoneoscopic assisted pyeloplasty as a minimally invasive approach and compare the results to open dismembered pyeloplasty. MATERIALS AND METHODS: All patients 6 months to 5 years old presenting with ureteropelvic junction obstruction between January 2008 and June 2009 were offered 1-port retroperitoneoscopic assisted pyeloplasty. Age matched patients who underwent open dismembered pyeloplasty during 2007 served as controls. The ureteropelvic junction was isolated retroperitoneoscopically and exteriorized through a single operative trocar. Pyeloplasty was performed in an open fashion with Double-J® stenting. Operative time, postoperative pain, surgical complications, hospital stay, ultrasound and mercaptoacetyltriglycine nuclear scan results at 6-month followup were evaluated and compared. Chi-square test and Student's t test were adopted for statistical analysis, with p <0.05 considered statistically significant. RESULTS: A total of 28 children (17 males) with a mean age of 18 months were treated with 1-port retroperitoneoscopic assisted pyeloplasty (18 left side). The control group consisted of 25 patients (11 males) with a mean age of 19 months who underwent open dismembered pyeloplasty (10 left side). Median operative time was 95 minutes (range 70 to 130) in 1-port retroperitoneoscopic assisted pyeloplasty and 72 minutes (58 to 102) in open dismembered pyeloplasty (p <0.05). Median postoperative hospital stay was 2.4 days with the 1-port approach and 6.1 days with the open procedure (p <0.05). Postoperative pain was significantly less in the 1-port group. Skin scar length was 1.4 to 2.9 cm (median 1.7) with 1-port retroperitoneoscopic assisted pyeloplasty and 3.5 to 6.0 cm (4.3) in the open group (p <0.05). CONCLUSIONS: The 1-port retroperitoneoscopic assisted pyeloplasty represents a safe and effective minimally invasive technique to treat hydronephrosis and could be the treatment of choice in young children. The procedure does not require laparoscopic suturing skills, and combines the advantages of open and laparoscopic pyeloplasty.

Bladder injuries following inguinal canal surgery in infants.

PURPOSE: Surgery of the inguinal canal is very common in infancy. Occasionally, injury of the bladder may occur with severe consequences. The aim of this paper was to warn young surgeons of this serious complication. METHODS: During the last 2 years, we observed four cases of bladder injury following surgery on inguinal canal. All were males. The indication for surgery was inguinal hernia in three patients and cryptorchidism in one patient. RESULTS: Two cases presented with urinary peritonitis. One child was referred later for a retracted bladder with reflux. In one child, the lesion was promptly recognized and repaired. Of the four cases, two ruptures of the bladder caused transient sequaele, i.e. persisting catheter drainage, and voiding disorders later. In two cases, there were serious consequences: the bladder had to be partially removed in one child, ending up in temporary ureterostomy and subsequent reconstruction with bladder augmentation. The fourth child developed a small, water clock-shaped bladder with a thick wedge of scarred tissue, and bilateral ureteral reimplantation with bladder augmentation was necessary. CONCLUSIONS: Surgery of the inguinal canal is very common in children and infants, and is often performed by trainees. Awareness of this serious event should be emphasized in training programs.

Robot-assisted laparoscopic ileal bladder augmentation: defining techniques and potential pitfalls.

PURPOSE: Laparoscopic bladder augmentation has been limited because of the extensive suturing required. The use of robot-assisted laparoscopic (RAL) procedures may circumvent this limitation and allow more efficient suturing. The purpose of the study is to define the techniques and the potential pitfalls in performing RAL bladder augmentation in an animal model. MATERIALS AND METHODS: Ten swine underwent RAL bladder augmentation using 20 cm of ileum. In five animals, the bowel anastomosis was performed intracorporeally. In the others, the bowel ends were externalized through one of the ports, and a free-hand bowel anastomosis was performed. The operative time was recorded. The anastomoses were evaluated for patency and leakage. RESULTS: The mean procedure time was 6 hours 44 minutes (range 5 hours 50 min-8 hours 5 min) with a rapid learning curve. We identified minor technical modifications that were helpful, such as placement of "hitch stitches," irrigation of the isolated bowel loop extracorporeally, and leaving the bladder wall attachment intact to maintain bladder suspension. Leakage at the bowel-bowel anastomosis occurred in one animal with use of a stapling technique. Because this could be a potentially fatal complication, we altered our technique to perform the bowel-bowel anastomosis outside the peritoneal cavity. Subsequently, there was no further incidences of bowel leakage, and all anastomoses were patent. The mean bowel-bowel anastomosis time was equivalent to using the two techniques. Leakage at the bowel-bladder anastomosis was seen in two animals, both occurring early in the series. CONCLUSION: RAL bladder augmentation can be safely and efficiently performed. There is a rapid learning curve. We identified minor technical modifications in techniques to help reduce operative time and potential complications. We recommend performing the bowel-bowel anastomosis outside the peritoneum to avoid the risk of leakage. Leakage at the bowel-bladder anastomosis may occur but can be managed with simple catheter drainage.

The endoscopic treatment of incontinence in children.

The achievement of urinary continence in children may be very difficult with some congenital malformations of the lower urinary tract, such as bladder exstrophy, or in some neurogenic dysfunctions, such as neuropathic bladder. Endoscopic injection of bulging substances into the bladder neck or posterior urethra may be regarded as a minimally invasive procedure that may provide a better dry interval in these patients. Endoscopic treatment can be performed as either a primary or adjunctive procedure after open bladder neck surgery. It is also of use to increase the functional bladder capacity in some children. Although longer follow-up is wise, results so far are encouraging. The search for a safe and reliable substance to use is still ongoing, and the new available biodegradable implants seem adequate.

The role of endoscopic treatment of vesicoureteral reflux: a 17-year experience.

PURPOSE: During the last 20 years endoscopic treatment of vesicoureteral reflux (VUR) has gained popularity in European countries. We performed a retrospective analysis of our 17-year experience with more than 1,000 patients treated to assess whether technique, indications or results of endoscopic treatment of VUR have changed over time. MATERIALS AND METHODS: From January 1986 to June 2002, 1,244 patients underwent endoscopic treatment for grades II to IV VUR. Polytetrafluoroethylene was injected as the bulking material in the first 14 cases, after 1989 bovine cross-linked collagen was used in 442 and since 1995 dextranomer/hyaluronic acid copolymer was used in 788. Urinary tract ultrasound was performed 1 and 6 months, and micturition cystourethrogram was done 3 and 12 months after endoscopic treatment. All patients included in the study completed a minimum 12-month followup. RESULTS: Endoscopic treatment was always performed in 1 day. Complications were observed in 0.5% of cases. After 1 or 2 injections the micturition cystourethrogram showed no significant VUR (absent or grade I) in 77% of cases. The success rate was 88%, 75% and 52% for grades II, III and IV VUR, respectively. With increasing experience not only primary VUR, but also secondary reflux was considered eligible for endoscopic treatment, and the number of grade IV VUR cases treated by endoscopy also increased. The presence of voiding dysfunction was identified as a limiting factor in the success of endoscopic treatment. CONCLUSIONS: The short hospital stay, acceptable success rate and absence of significant complications prompt us to consider endoscopic treatment as first choice treatment of VUR rather than long-term prophylaxis and open surgery. Even grade IV VUR and VUR in complex anatomical situations can be successfully treated by endoscopy. Patients with voiding dysfunction should be identified and adequately treated before any endoscopic attempt.

Influence of voiding dysfunction on the outcome of endoscopic treatment for vesicoureteral reflux.

PURPOSE: Some patients with vesicoureteral reflux also experience voiding dysfunction. Dextranomer/hyaluronic acid copolymer (Deflux, Q-MED AB, Uppsala, Sweden) is an effective endoscopic treatment for vesicoureteral reflux. In an open label study we investigated the effect of voiding dysfunction on the efficacy of endoscopic treatment with dextranomer/hyaluronic acid copolymer in patients with vesicoureteral reflux. MATERIALS AND METHODS: A total of 320 children 3 to 11 years old with grade II to IV vesicoureteral reflux confirmed by voiding cystourethrography underwent endoscopic treatment with dextranomer/hyaluronic acid copolymer. Of the patients 50 were re-treated with dextranomer/hyaluronic acid copolymer because of persistent reflux (grade II or greater). The first implantation technique was recorded on videotape. Voiding cystourethrography and micturition details were recorded at the 3 to 6-month followup visit and compared with baseline measurements. RESULTS: At baseline 13 patients had known voiding dysfunction and 18 were misdiagnosed as not having voiding dysfunction. Of the 50 patients who required re-treatment, the initial implant was correctly positioned in 45 according to the videotape. Endoscopic observation at the time of re-treatment revealed no evidence of the implant in 15 patients. The implant was displaced in 27 patients and remained correctly positioned in 3. A total of 27 patients had voiding dysfunction, the majority of whom had urgency and frequency incontinence, had not received any anticholinergic therapy and had a displaced implant. CONCLUSIONS: Uncontrolled voiding dysfunction contributed to endoscopic treatment failure with dextranomer/hyaluronic acid copolymer in our series. Therefore, we suggest that patients with voiding dysfunction be treated at least 6 months before endoscopic therapy with anticholinergics and/or micturition rehabilitation.