Pediatric laparoscopic mitrofanoff procedure- preliminary results of a simplified technique.

INTRODUCTION: Laparoscopic appendicovesicostomy (LA) is a rather new technique and still a challenging procedure even for the most experienced surgeons because it requires advanced laparoscopic experience and surgical skill. The aim of this study is to analyze the short-term results and benefits of laparoscopic LA in children. MATERIALS AND METHODS: Prospective study of children undergoing LA at our institution between January 2018 and October 2021. The procedure was perfomed using a laparoscopic transperitoneal approach. The distal end of the appendix was spatulated and reimplanted in the bladder by a modified Shanfield technique. The proximal end was brought out as the cutaneous umbilical stoma. RESULTS: Over the study period 15 patients underwent LA (14 males,1 female). Mean age at intervention was 8.8 years (SD:3.1). Indication for surgery was pain during CIC in 13 (86.7%) and difficulty for CIC in 2 (13.3%). Eight patients (53.5%) presented end-stage renal disease (ESRD). Median operative time was 217.3 min (r:140-300). Two patients (13.3%) experienced early postoperative complications: ileus (1) and internal hernia over the mesoappendix with subsequent intestinal obstruction. Mean hospital stay was 6.8 days (SD:1.7). Four patients (26.7%) experienced late postoperative stoma related complications: stomal stenosis (1), granuloma (1) and inability to catheterize (2). With a mean follow-up of 21.46 months (SD: 13) all except the patent who lost the conduit are continent and on CIC every 3 h. CONCLUSIONS: We suggest that LA by this technique is effective, safe and reproducible, and is associated with good short-term results. The complication rate is similar to the open procedure being intestinal obstruction due to internal hernia probably the most serious.

Laparoscopic extravesical ureteral reimplantation (LEUR) of obstructed megaureters: STEP-BY-STEP video of a simplified approach.

INTRODUCTION: In this video we aim to describe step-by-step a simplified surgical technique for the treatment of primary and secondary obstructed megaureters in children by laparoscopic extravesical ureteral reimplantation (LEUR). MATERIAL AND METHODS: A transperitoneal approach is used in all cases. The distal ureter is dissected and transected at the level of the stenosis. Detrusor fibers are divided to expose bladder mucosa and the distal ureter is introduced into the bladder to create a valve-like mechanism (modified-Shanfield technique). RESULTS: Between 2016 and 2020, 9 patients underwent LEUR (5 female, 4 male). Mean age at surgery was 31.6 months (SD:22.74) and indications were infection (2), obstruction (3), increase hydronephrosis (2) and decrease in renal differential function (2). The procedure was completed laparoscopically in all cases with a median operative time of 144 min (r: 120-160). The postoperative MAG-3 renogram revealed a non-obstructive pattern in 8/9 patients and MCUG demonstrated absence of VUR in all 8/9. With a mean follow-up of 2.4 years (SD:1.4) all are asymptomatic. CONCLUSIONS: LEUR by this new simplified technique is a feasible treatment of megaureters associated with good short and long-term results.

Laparoscopic extravesical ureteral reimplantation for correction of primary and secondary megaureters: Preliminary report of a new simplified technique.

PURPOSE: To describe a simplified surgical technique for the treatment of primary and secondary obstructed megaureters in children by laparoscopic extravesical ureteral reimplantation (LEUR) and evaluate the short-term outcomes. METHODS: Prospective study of children with primary and secondary megaureters treated at our institution between 2016 and 2018 by LEUR. A transperitoneal approach was used in all cases. The distal ureter was transected at the level of the stenosis. Detrusor muscle fibers were divided to expose bladder mucosa. The distal ureter was introduced into the bladder to create a valve-like mechanism. The ureter was fixed to the bladder mucosa by four stitches. We analyzed indications for surgery, complications and outcomes. Definition of success was relieved of obstruction and absence of VUR. RESULTS: Six patients with a mean age of 28.83 months (SD: 21.4) underwent LEUR. Indications for surgery were: infection [2], obstruction [2], decrease in renal differential function [1] and increase in hydronephrosis [1]. There were no intraoperative complications. Resolution of hydronephrosis, obstruction and VUR was achieved in all cases. Mean follow-up was 13 months (SD: 6.67). CONCLUSION: LEUR for the correction of primary and secondary megaureters by this new technique is safe. The most important advantage is that this technique is simpler and more easily reproducible than conventional LEUR. However, long-term follow-up is required. TYPE OF STUDY: Prospective, observational. LEVEL OF EVIDENCE: Level III.

Hemorrhagic cystitis after hematopoietic stem cell transplantation: A challenge for the pediatric urologist.

OBJECTIVE: Hemorrhagic cystitis (HC) is a serious event that can occur after hematopoietic stem cell transplantation (HSCT). Treatment goals are primarily to preserve life, and then the functionality of the bladder. There is no standard therapeutic approach for HC. Described treatment options provide low success rates and are related to potential life-threatening side effects. The aim of this study was to describe our experience in treatment of HC following HSCT. PATIENTS AND METHODS: This was a retrospective study of patients with HC treated at our institution between January 2010 and October 2016. We analyzed demographics, underlying diagnosis, and treatment modalities. RESULTS: We treated 39 patients with HC. Mean age was 9.4 years (SD 4.20) and 64% were males. Acute leukemia was the most common underlying diagnosis in 27 (69%). Mean time from HSCT to HC onset was 55.46 days (SD 112.35). HC grades were: I (3), II (21), III (8), and IV (7). BK-viuria was present in 34 patients (87.2%). Non-invasive treatment was performed in 28 patients (71.8%). The remaining 11 (28.2%) required urological intervention (all high-grade), consisting of bladder irrigation in all of these. Additional treatments consisted of: intravesical cidofovir (4), intravesical sodium hyaluronate (5), cystoscopy and clot evacuation (4), selective angioembolization (2), percutaneous nephrostomy (1), and open extraction of bladder clots and cutaneous cystotomy (1). Overall, eight patients (20.5%) died as a result of the malignancy (3 in the urological intervention group), and of these four had active HC at death. Mean follow-up was 36.2 months (SD 24.9). CONCLUSION: HC is associated with high morbidity and mortality. Treatment should be individualized and designed to prioritize survival. However, bladder function should be preserved for the future.

Vascular thrombosis in pediatric kidney transplantation: Graft survival is possible with adequate management.

OBJECTIVE: Vascular thrombosis (VT) in pediatric kidney transplantation (KT) is a dreaded event that leads to graft loss in almost 100% of cases. In recent years, VT has become the most common cause of early graft loss. The aim of this study was to analyze our experience in diagnosis and treatment of VT and the impact of a new management protocol on patient outcome. METHODS: We conducted a retrospective study of 176 consecutive KT performed at our institution by the pediatric urology team between January 2000 and December 2015 and identified patients with VT. A protocol of prevention and early detection of VT was introduced in 2012. RESULTS: Out of 176 KT, nine cases of VT were identified (5.1%). The mean recipient age was 5.1 years (SD 4.9 years) and mean weight was 22.28 kg (SD 15.6 kg). Diagnosis was intraoperative in two cases and within the first 24 h after surgery in the remaining seven. Immediate surgical exploration was performed after diagnosis in all. Of the five episodes that occurred before 2012, all developed complete graft ischemia requiring transplantectomy. However, in the four cases diagnosed after 2012, graft perfusion could be restored in three, and abdominal wall closure with a mesh and delayed sequentially closure under ultrasound guidance was performed. With a follow-up of 30, 25, and 20 months, the three recovered grafts are still functioning normally. CONCLUSIONS: Increased awareness and the application of a protocol for prevention, detection and treatment of VT in pediatric KT can prevent graft loss. Immediate surgical intervention is mandatory after diagnosis. Avoiding compartment syndrome with delayed sequential closure may be useful to improve graft survival.

Kidney transplantation in children weighing 15 kg or less is challenging but associated with good outcome.

OBJECTIVE: Pediatric kidney transplantation (KT) in small children is assumed to be related to potential surgical complications that may cause severe morbidity and graft loss. The aim of our study was to analyze the outcome of KT recipients weighing ≤15 kg, focusing on surgical complications, associated morbidity and mortality, as well as allograft loss. METHODS: We reviewed our retrospective institutional database for recipients of KT between January 2000 and December 2014 with body weight ≤15 kg. RESULTS: Forty-four children weighing ≤15 kg, out of a total of 164 children (26.8%), received a deceased donor KT at our center during the study period. Mean weight was 10.10 ± 2.9 kg (3-15 kg), and weight was ≤10 kg in 23 patients (52.3%). The allograft was implanted intraperitoneally in two cases (4.5%) and extraperitoneally in the remaining 42 (95.5%). Two patients received a simultaneous double liver-kidney transplant. Postoperative complications appeared in 10 patients (22.7%) and eight required reintervention. Five allografts (11.4%) were lost secondary to surgical complications. No statistically significant differences in surgical complications were observed when compared with patients weighing >15 kg. Actuarial graft survival was 81% and 73% at 1 and 5 years, respectively. No significant differences in graft survival were observed compared with patients >15 kg. Mean follow-up was 84.95 ± 50 months (1-190 months). CONCLUSIONS: Our results demonstrate that KT in children weighing ≤15 kg is challenging but not associated with increased risk of surgical complications or early graft loss.

Treatment of Post-transplant Lymphocele in Children.

OBJECTIVE: To review our single-center experience in managing posttransplant lymphoceles in pediatric kidney recipients. Lymphoceles are well-known complications after pediatric kidney transplantation (KT). However, there is no standard treatment for lymphoceles, and the literature lacks consensus on which is the most appropriate approach. MATERIALS AND METHODS: We reviewed our retrospective institutional database for recipients of pediatric KT performed between January 2000 and December 2015 who developed lymphoceles. RESULTS: Out of the 176 patients who underwent KT, lymphoceles occurred in 9 (5.1%) patients. The mean age of recipients in this group was 12.8 years (standard deviation [SD] 4.8) (r: 1-17) and the mean body weight was 43.1 kg (SD 18.8) (r: 9.5-69). Mean lymphocele onset was 32.2 days (SD 23.4) (r: 11-85) post transplantation. Six patients presented with increased serum creatinine from the baseline, whereas 3 patients remained asymptomatic. Ultrasound was the primary diagnostic procedure in all patients. Lymphoceles resolved spontaneously in asymptomatic patients (n = 3), and thus these patients were not further treated. All symptomatic patients (n = 6) were treated: 2 underwent percutaneous catheter drainage and 4 underwent transcatheter sclerotherapy (TS). The main sclerosing agent used was povidone-iodine. In 3 patients, TS with povidone-iodine failed, and they underwent additional procedures: 2 underwent TS with polidocanol and 1 underwent open drainage. There was no graft loss in any of the patients, and no recurrence was documented during a follow-up period of mean 30.3 months (SD 15.6) (r: 7-57). CONCLUSION: There is no gold-standard treatment for lymphoceles in children, and reports in the literature on the topic are scarce. Percutaneous catheter drainage with or without TS is safe and effective, although it can lengthen hospitalization and increase morbidity.

Evaluation of the Initial Treatment of Ureteroceles.

OBJECTIVE: To assess the results of the initial therapeutic approach to ureteroceles at our institution and the need for further interventions. PATIENTS AND METHODS: This is a retrospective study of all pediatric cases of ureterocele diagnosed at our center between January 2000 and December 2011. RESULTS: Forty-three patients were analyzed. Initial diagnoses were ureterohydronephrosis in 34 (33 prenatal), febrile urinary tract infection in 5, and prolapsed ureterocele in 3. Expectant management was decided upon in 6 patients (14%). Of these, 1 required surgery. The remaining 37 (86%) initially underwent surgery: transurethral puncture (18), heminephrectomy (14), nephrectomy (3), and reimplantation (2). Twelve (66.6%) of the 18 patients who underwent primary puncture progressed well and required no further intervention. New-onset vesicoureteral reflux to the upper pole appeared after puncture in 3 patients, but none required treatment. Only 6 patients (33.3%) underwent a second procedure. Mean follow-up was 8.5 years (standard deviation: 3.08). CONCLUSION: Early endoscopic puncture is useful for decompression and often the definitive treatment. Although new-onset vesicoureteral reflux into the punctured system is the most common complication, it often resolves spontaneously. Early heminephrectomy in patients with nonfunctioning upper moieties yields excellent results but may not be necessary. Some patients may not need transurethral puncture or any surgical intervention at all.