Postoperative bladder dysfunction and outcomes after minimally invasive extravesical ureteric reimplantation in children using a laparoscopic and a robot-assisted approach: results of a multicentre international survey.

OBJECTIVES: To assess and compare postoperative bladder dysfunction rates and outcomes after laparoscopic and robot-assisted extravesical ureteric reimplantation in children and to identify risk factors associated with bladder dysfunction. PATIENTS AND METHODS: A total of 151 children underwent minimally invasive extravesical ureteric reimplantation in five international centres of paediatric urology over a 5-year period (January 2013-January 2018). The children were divided in two groups according to surgical approach: group 1 underwent laporoscopic reimplantation and included 116 children (92 girls and 24 boys with a median age of 4.5 years), while group 2 underwent robot-assisted reimplantation and included 35 children (29 girls and six boys with a median age of 7.5 years). The two groups were compared with regard to: procedure length; success rate; postoperative complication rate; and postoperative bladder dysfunction rate (acute urinary retention [AUR] and voiding dysfunction). Univariate and multivariate logistic regression analyses were performed to assess predictors of postoperative bladder dysfunction. Factors assessed included age, gender, laterality, duration of procedure, pre-existing bladder and bowel dysfunction (BBD) and pain control. RESULTS: The mean operating time was significantly longer in group 2 compared with group 1, for both unilateral (159.5 vs 109.5 min) and bilateral procedures (202 vs 132 min; P = 0.001). The success rate was significantly higher in group 2 than in group 1 (100% vs 95.6%; P = 0.001). The overall postoperative bladder dysfunction rate was 8.6% and no significant difference was found between group 1 (6.9%) and group 2 (14.3%; P = 0.17). All AUR cases were managed with short-term bladder catheterization except for two cases (1.3%) in group 1 that required short-term suprapubic catheterization. Univariate and multivariate analyses showed that bilateral pathology, pre-existing BBD and duration of procedure were predictors of postoperative bladder dysfunction (P = 0.001). CONCLUSION: Our results confirmed that short-term bladder dysfunction is a possible complication of extravesical ureteric reimplantation, with no significant difference between the laparoscopic and robot-assisted approaches. Bladder dysfunction occurred more often after bilateral repairs, but required suprapubic catheterization in only 1.3% of cases. Bilaterality, pre-existing BBD and duration of surgery were confirmed on univariate and multivariate analyses as predictors of postoperative bladder dysfunction in this series.

Association Between Body Mass Index and Functional Outcomes in Elderly Patients with Extra-articular Distal Radius Fracture: A Prospective Observational Study.

INTRODUCTION: The association between body mass index (BMI) and functional outcomes is unknown in elderly individuals with distal radius fracture (DRF). OBJECTIVE: The aim of this study is to evaluate if there is association between BMI and functional outcomes in patients older than 60 years with DRF treated conservatively. MATERIALS AND METHODS: A prospective observational study was performed. A total of 228 patients with extra-articular DRF were prospectively recruited. All patients were categorized by their BMI as normal, overweight, or obese. Functional outcomes were assessed after cast removal and at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH), and Patient-Rated Wrist Evaluation (PRWE) questionnaires were used to assess upper limb and wrist/hand function, respectively, while the Jamar Dynamometer was used to assess grip strength. RESULTS: Of the total number of patients, 184 were female (80.7%), 87 were overweight (38.2%), and 111 were obese (48.7%). After cast removal, the correlations between BMI and functional outcomes were DASH 0.06 (p = 0.578), PRWE 0.04 (p = 0.692), and grip strength - 0.02 (p = 0.763). At 1-year follow-up, the correlations were DASH 0.55 (p = 0.036), PRWE 0.32 (p = 0.041), and grip strength - 0.21 (p = 0.043). CONCLUSION: This study suggests that at 1-year follow-up, there was a low-to-moderate association between BMI and poor functional outcomes in elderly patients with extra-articular DRF treated conservatively. LEVEL OF EVIDENCE: Level IV, observational prospective study.

Does pectoralis minor stretching provide additional benefit over an exercise program in participants with subacromial pain syndrome? A randomized controlled trial.

BACKGROUND: Adaptive shortening of the pectoralis minor is one of the biomechanical mechanisms associated with subacromial pain syndrome (SPS). OBJECTIVE: To compare the effects of an exercise program alone with an exercise program in combination with pectoralis minor stretching in participants with SPS. DESIGN: Randomized controlled trial. METHODS: Eighty adult participants with SPS were randomly allocated to two groups. The control group (n = 40) received a 12-week specific exercise program and the intervention group (n = 40) received the same program plus stretching exercises of the pectoralis minor muscle. The primary outcome measure was shoulder function assessed by a Constant-Murley questionnaire, and the secondary outcomes were the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analog scale (VAS), and pectoralis minor resting length. RESULTS: The present study shows no difference between the two interventions according to the Constant-Murley questionnaire (1.5 points; p = 0.58), VAS at rest (0.2 cm; p = 0.11), VAS at movement (0.5 cm; p = 0.08), and pectoralis minor resting length (0.3 cm; p = 0.06). The DASH questionnaire showed greater functional improvement in the control group (5.4 points; p = 0.02). Finally, only pectoralis minor length index showed difference statistical significant in favor of intervention group (0.3%; p = 0.04). CONCLUSION: In the short-term, the addition of a program of stretching exercises of the pectoralis minor does not provide significant clinical benefit with respect to functional improvement or pain reduction in participants with SPS. TRIAL REGISTRATION: Brazilian registry of clinical trials UTN number U1111-1210-3555. Registered 5 March 2018.

Multi-Institution Case Series of Pediatric Patients with Laparoscopic Repair of Morgagni Hernia.

INTRODUCTION: Morgagni Larray hernia (MLH) is a very rare disease, which accounts for less than 5% of all congenital diaphragmatic hernias. Laparoscopic repair has been widely used and accepted as a treatment option for patients with this disease. The purpose of our study is to analyze the outcomes of patients with MLH who underwent laparoscopic repair, and to evaluate their postoperative course for outcome, morbidity, and mortality. MATERIALS AND METHODS: A retrospective chart review was performed of patients who were diagnosed with MLH and treated laparoscopically by 10 board-certified pediatric surgeons. RESULTS: Fourteen patients were included in the study. One patient died 1 month postoperatively due to respiratory complications unrelated to the surgery. Thirteen patients were followed for a median of 1.75 years (interquartile 0.3-6.95). There was a single recurrence, which resulted in a partial resection of the hernia sac and repaired without a mesh. We had a success rate of 92.86%. CONCLUSION: MLH is a rare congenital diaphragmatic hernia that is usually diagnosed incidentally. Laparoscopic repair has high success rates and is a viable option for patients with this pathology.

Laparoscopic extravesical transperitoneal approach for vesicoureteral reflux.

INTRODUCTION: Laparoscopy may have a place in the treatment of vesicoureteral reflux. In this study, we present the results of laparoscopic extravesical transperitoneal treatment in 15 children (19 ureters) of vesicoureteral reflux. MATERIALS AND METHODS: Between January 2001 and February 2004, 15 children (11 with unilateral and 4 with bilateral vesicoureteral reflux) were treated with extravesical reimplantation (Lich- Gregoir technique) via a transperitoneal laparoscopic approach. The mean age was 48.2 months (range 12-62), and there were 14 females and 1 male. Two patients had a double total collector system associated with reflux without ureterocele. RESULTS: The mean surgical time was 110 minutes in unilateral and 180 in bilateral vesicoureteral reflux. All procedures were successfully completed laparoscopically and the reflux was corrected in all but one patient, whose grade III vesicoureteral reflux changed to grade I. We had 3 mucosal perforations without leakage. The longest hospital stay was 72 hours. After follow-up ranging 15-49 months, only one patient had urinary tract infection. CONCLUSION: Laparoscopic extravesical transperitoneal reimplantation for vesicoureteral reflux is a safe and effective approach even in bilateral simultaneous and duplex ureters, with success rates similar to the open technique, and a dramatic reduction in postoperative stay. Mucosal perforation was treated by maintaining a Foley catheter for 3-4 days postoperatively.

Laparoscopic orchiopexy for palpable undescended testes: a five-year experience.

BACKGROUND: Most recent reports of laparoscopic orchiopexy concern nonpalpable testes. We report the results of this approach in patients with undescended palpable testes. MATERIALS AND METHODS: Between January 1999 and September 2004, 28 patients with 30 undescended palpable testes were treated by laparoscopic orchiopexy performed by the same surgeon. Patients with palpable cryptorchidism were included. Patients with nonpalpable testes, retractable, or vanishing testes were excluded. The mean age of the patients was 25 months (range, 8 months-5 years) and the mean weight was 16 kg (range, 8-24 kg). We used a 4-port technique (one 10-mm, two 2-3 mm, and one 5-mm), a 4-mm scope, and 2-3 mm instruments. RESULTS: The mean operative time was 50 minutes. The complication rate was 13.3% (4/28), all in the first two years, at the beginning of the learning curve. The remaining testes were descended by laparoscopy; 5 (16.6%) were peeping testes. We had 10 (33.3%) left and 16 (53.3%) right palpable cryptorchidia cases, plus 4 testes (13.3%) that were bilateral undescended and palpable. No hernia was found in 8 (28.6%) cases; a homolateral hernia was found in 18 (64.3%) cases, and we did not close the processus vaginalis, we only resected the membranes. We found 2 (7.1%) with contralateral hernia in which we did close the processus vaginalis. On follow-up ranging 5 months-5 years, 29 of these testes maintain good size and a correct position, with no recurrent inguinal hernia. CONCLUSION: The laparoscopic approach is a safe way to descend the palpable testicle. Although this is not a large series, it shows that laparoscopic orchiopexy of palpable undescended testes can be done without a higher complication rate than the open procedure (13.3% vs. 12.2%), with several of the advantages of the laparoscopic approach.

Erratum: Thoracoscopic Patch Repair of Congenital Diaphragmatic Hernia in a Neonate Using Spiral Tacks: A Case Report.

[This corrects the article on p. 31 in vol. 4, PMID: 26290813.].

Palpable Undescended Testes: 15 Years of Experience and Outcome in Laparoscopic Orchiopexy.

BACKGROUND AND PURPOSE: Most of the current literature concerning laparoscopy in patients with cryptorchidism reports on those with nonpalpable testes. The purpose of this study is to share our experience and outcome in laparoscopic orchiopexy on patients with palpable undescended testes. PATIENTS AND METHODS: From January 1999 to July 2014, 240 cryptorchid testes were treated of which 192 (155 patients) were palpable and were operated on by laparoscopy. Before starting, the bladder is emptied with a Foley catheter. Four trocars are used: One 5 mm for the lens (45 degree), one 10 mm (transscrotal), and two 3 mm placed at the subcostal midclavicular line for the instruments. We localize the deep inguinal ring and open the peritoneum. The spermatic vessels and vas deferens are dissected in a cephalic direction. The epigastric vessels are dissected and sectioned to facilitate the localization of the testicle inside the canal. Once found, the testis is dissected and taken into the abdominal cavity where the gubernaculum testis is cut. A 10-mm trocar is introduced through the scrotal sac into the peritoneal cavity. The testicle is grabbed and pulled down to the scrotum where it will be fixed with a 5-0 polypropylene suture in the usual manner. RESULTS: Of 192 cryptorchid palpable testes treated with laparoscopy, only one procedure was converted to conventional open orchiopexy because of an ectopic testicle (above the aponeurosis of the oblique muscle). The rest of the testicles could be moved down to the scrotal sac. Our follow-up ranges from 6 months to 15 years, and we have not found atrophy in any of the testicles. To date, only two (0.4%) testicles have reascended. CONCLUSION: Laparoscopy is a great and safe option for patients with palpable undescended testes, regardless of its position in the inguinal canal.

Thoracoscopic Patch Repair of Congenital Diaphragmatic Hernia in a Neonate using Spiral Tacks: A Case Report.

We present a case of congenital diaphragmatic hernia that was successfully treated with spi-ral tacks using thoracoscopy. A newborn female was diagnosed with a diaphragmatic hernia at 20 weeks of gestation. The defect was surgically repaired by thoracoscopy and primary closure. On postoperative day 25, she developed respiratory distress. Chest x-ray showed a recurrence and was taken to the OR for surgical repair with spiral tacks.

Laparoscopic extravesical ureteral reimplantation (LEVUR): a multicenter experience with 95 cases.

INTRODUCTION: Minimally invasive techniques have been used to treat vesicoureteral reflux (VUR) on pediatric patients. The aim of this study is to review the experience of the laparoscopic approach for VUR by the laparoscopic extravesical ureteral reimplantation (LEVUR) Lich-Gregoir technique. MATERIALS AND METHODS: We performed a multicentric retrospective study. From 2001 to 2009, 81 pediatric patients with VUR constituting 95 ureteral units underwent LEVUR. Reflux was grade II in 32%, grade III in 55%, and grade IV in 8%. RESULTS: LEVUR was performed successfully on the 81 patients with 95 ureteral units. Mean operative time was 105 minutes for left-sided reimplants, 70 minutes for right sided, and 180 minutes for bilateral reimplants. Mean hospital stay was 1.6 days. Urinary catheter was kept in place for a mean time of 0.5 days. Follow-up was achieved for at least 1 year with regular clinic visits, urinalysis, ultrasound, and voiding cystourethrogram. Four patients (4.2%) had evidence of recurrent VUR in a follow-up of 6 to 36 months after antireflux surgery. CONCLUSIONS: Although new endoscopic techniques have been widely available for VUR, they have a lower success rate and might require multiple attempts before success. We report that LEVUR has an acceptable success rate (95.8%) and durability compared with open and endoscopic procedures.

Preliminary study of the succession pattern of necrobiont insects, colonising species and larvae on pig carcasses in Temuco (Chile) for forensic applications.

Knowledge regarding the succession patterns of insects that visit carcasses as well as the other arthropod that colonise them and analysis of the parameters that are associated with larvae allow calculation of the minimum postmortem interval (PMI). This information is obtained from experiments carried out under specific geoclimatic conditions, which determine their application in forensic environments under similar conditions. The field study presented here is the first in Chile to analyse the decomposition process of pig carcasses and the associated succession of insects, colonising species and parameters related to larval masses. All of the larvae obtained from daily samples were measured (in mm), and their mean, range, standard deviation and stage of development (instars) were determined. The carcasses reached the dry remains stage in only 11 days. Seven species of Diptera visited the carcass during the process, but only two species colonised it by means of egg deposition followed by development of larvae: Cochliomyia macellaria (Fabricius) and Lucilia sericata (Meigen) (Diptera: Calliphoridae), which exhibited a duration of the development cycle from egg to adult of 21 days. The collected Coleoptera correspond to five predator species (Staphilinidae and Histeridae). From the results of this study, it can be concluded that only some of the insect species present in this region can provide information that can be used in forensic entomology and that analysis of larval masses of colonising species can be a valuable tool for determining the PMI(min) in this region of Chile.

Totally laparoscopic approach for failed conventional orchiopexy.

INTRODUCTION: About 0.2-10% of patients with prior orchiopexy will require reoperation for recurrent cryptorchidism. The most common approach for these patients has been an open inguinal repeat orchiopexy. The aim of this report is to show results and feasibility with the totally laparoscopic approach for failed prior open orchiopexy. SUBJECTS AND METHODS: Nine patients with 11 recurrent undescended testes were treated by the totally laparoscopic orchiopexy approach. We used a four-port technique, starting with laparoscopic dissection of the vas deferens and spermatic vessels as high as possible in order to get adequate length of these structures. The inguinal internal ring was opened, and the testis was dissected to finally bring it into the abdominal cavity. A transcrotal trocar was introduced all the way to the abdominal cavity to finally pull through the testis into the scrotum. RESULTS: Laparoscopic orchiopexy was performed satisfactorily in all but 1 case in a mean time of 90 minutes. We did not experience any perioperative complications. In a mean follow-up of 25 months there has not been any recurrent cryptorchidism or atrophic testis. DISCUSSION: Laparoscopy offers the advantage of achieving an extensive mobilization of spermatic vessels and a careful dissection of the vas deferens. The totally laparoscopic approach for a failed orchiopexy represents a feasible, safe, and successful procedure.

Laparoscopic pediatric inguinal hernia repair: no ligation, just resection.

BACKGROUND: There have been descriptions of several techniques for congenital inguinal hernia (CIH) repair in the pediatric population by doing high ligation of the sac, without a definitive advantage over the open procedure. High recurrence rates have been reported with using these minimally invasive techniques in which the patent processus vaginalis has been ligated and left in place completely or partially. METHODS: With approval of the ethics committee, a proper informed consent was obtained. During July 2003 to April 2008, we performed the inguinal hernia repair on 91 patients (76 males and 15 females), using a laparoscopic technique in which we completely resected the patent processus vaginalis and the parietal peritoneum surrounding the internal inguinal ring. This allowed the peritoneal scar tissue to close the area of the ring. Also, this scarring occurs in the extent of the inguinal canal where the dissection took place, therefore causing the same peritoneal scarring and sealing of the inguinal floor. In this series, a purse string was done only in the cases with an internal ring wider than 10 mm. RESULTS: There were no conversions. Operative time was in the range of 35-72 minutes (average, 40). Close follow-up in the clinic has been 5 months to 4 years without a single recurrence. In 4 cases, 3 months later, we did a laparoscopic evaluation of the contralateral side due to associated cryptorchidism, in which we were able to confirm a complete closure of the interior inguinal ring. Two small hematomas were followed until they were gone, without further need for intervention. DISCUSSION: No recurrences have been observed. We conclude that laparoscopic repair of CIH is feasible using this technique of complete resection of the processus vaginalis and surrounding parietal peritoneum. This series does not conclude on the need for the internal ring to be closed when found to be wider than 10 mm.

Incidence and management of the inguinal hernia during laparoscopic orchiopexy in palpable cryptoorchidism: preliminary report.

During the laparoscopic approach of undescended testis, an associated inguinal hernia is a frequent finding that must be treated at the same time. The objective of this presentation is to show the incidence and management of the inguinal hernia that were found during laparoscopic orchidopexy, reporting how the scar tissue will join the edges of the canal and the parietal peritoneum will grow above. Between January 1999 and December 2002, 31 patients with 33 palpable and nonpalpable undescended testes were treated by laparoscopic orchidopexy. Patients were between 6 months and 9 years. We used four ports, and 2 mm instrument. When an associated inguinal hernia were found we only removed the membranes of the processus vaginalis and did not close the defect. All cases were treated by the same surgeon. The average surgical time was 50 min that included the orchiopexy and the treatment of the associated inguinal hernia. We found inguinal hernia in 23 cases (69.9%). We did not find any inguinal hernia in the opposite side of the undescended testis. In two patients with bilateral undescended testis that were approached in two stages 3 months later we confirmed the closure of the hernia defect. These 23 patients have 21.5 months average follow up and confirm no recurrence. With an average follow up of 21.5 months, we found no inguinal hernia in any of the patients. A larger volume study with longer follow up is needed to confirm that there is no need for closure of the internal inguinal ring during laparoscopic orchidopexy.