Endourology / Laparoscopy (2) - Part 1



Medical University of Gdansk, Pediatric Surgery, Gdansk, POLAND

PURPOSE: Hydrocele formation, the main complication of varicocelectomy is quite common and can cause psychological problems and influence adversely developing teenagers. Identifying the lymphatic vessels that drain the testis and tunica vaginalis with a dye and their preservation should decrease the incidence of postoperative hydroceles. The aim of this study was to evaluate the effectiveness and complication rate of use of Patent Blue to identify lymphatic vessels during laparoscopic varicocelectomy to avoid postoperative hydrocele.

MATERIAL AND METHODS: Forty boys affected by varicocele grade III underwent left-sided laparoscopic varicocelectomy. Average age of the patients was 14,3 years (range 12-16 years). Half of the patients were randomly assigned to lymphatic non-sparing surgery (LNS) group, and 20 patients to lymphatic sparing (LS) group. Before surgery in the LS group, 2 mL of Patent Blue was injected subcutaneously under the tunica dartos on the left side. The blue–stained lymph vessels were readily visualized and preserved during the laparoscopic varicocelectomy.

RESULTS: All varicocelectomies were performed by laparoscopy and no open conversions were necessary. Of 20 patients from LS group lymphatic vessels were visualized in 18 (90%). In the remaining two (10%) the lymphatics could not be identified clearly. No adverse reactions or postoperative scrotal haematoma were found in any of the patients. All patients were discharged the day of surgery. At a mean follow-up of 7 months (range, 3 to 14 months) no recurrent varicocele or testicular volume reduction were detected. Postoperative hydrocele was observed in three patients from NLS group and one case required a surgical repair. No patient from LS group yet developed a reactive hydrocele.

CONCLUSIONS: Staining gonadal lymph vessels with Patent Blue dye is an effective and simple method of visualization and preservation of the lymphatic drainage from the testis and tunica vaginalis. Although the method seems to be useful to avoid hydrocele formation after laparoscopic Palomo procedure in adolescents, a larger series and longer follow up are necessary to its validation.



Holger TILL, Jennifer Dart SIHOE, Chung Kwong YEUNG and Kin Wai CHAN
Chinese University of Hong Kong, Surgery,, Shatin, CHINA

PURPOSE: Pneumovesicoscopic ureteric reimplantation (Cohen’s type) proved to be a safe and beneficial approach to children with significant vesicoureteral reflux (VUR). The present study investigates the feasibility of this method to correct more complex anatomical cases of VUR like paraureteral (Hutch) diverticulum and megaureter.

MATERIAL AND METHODS: Six patients (age 11 months to 8.5 years) had recurrent UTI due to VUR (grade 3-5) associated with Hutch diverticulum (unilateral VUR in 4, bilateral VUR in 2, 1 additional megaureter). Transurethral cystoscopic guidance served for placement of the camera port (5 mm). The bladder was evacuated to install the pneumovesicum (CO2 pressure of 10-12 mmHg). After insertion of two working ports (5mm), the diverticulum could be mobilized and resected. The ureter was followed for 2.5 to 3cm into the extravesical space (the megaureter was then tapered inside the bladder (interrupted 5-0 vicryl). A submucosal tunnel was created (Cohen’s type) and the ureter was drawn through the tunnel and the ureterocystoneostomy was completed (interrupted 5-0 Biosyn). For bilateral VUR, one child received subureteral Deflux injection simultaneously, the other bilateral reimplantation.

RESULTS: All procedures were completed successfully. Mean operating time was 173 min. (range 140-200 min.). Patients were discharged 1.7 days postoperatively without a stent (range 1-3 days). Follow-up after 3 months showed no evidence of significant VUR, no diverticulum recurrence or ureteral obstruction.

CONCLUSIONS: Children with Hutch diverticulum and associated VUR can be corrected effectively by pneumovesicoscopic ureteral reimplantation. The long-term outcome will need further evaluation.



Hisham ABOU-HASHIM, Arnauld BONNARD, Hani MORSI, Olivier HUOT*, Marie-alice MACHER, Yves AIGRAIN and Alaa EL-GHONEIMI
Hopital Robert Debré, AP-HP, University Paris VII, Pediatric Surgery and Urology, Paris, FRANCE - * Hopital Robert Debré, AP-hp, University Paris VII, Pediatric Anesthesia, Paris, FRANCE - † Hopital Robert Debré, AP-HP, University Paris VII, Pediatric Nephrology, Paris, FRANCE - ‡ Hopital Robert Debré, AP-HP, University Paris VII, Pediatric Urology and Surgery, Paris, FRANCE

PURPOSE: We analyzed our experience with retroperitoneal laparoscopic nephrectomy giving special attention to the learning curve, morbidity, and feasibility in a teaching institution

MATERIAL AND METHODS: Between 1996 and 2004, we performed 97 laparoscopic nephrectomies in 84 children. Only 4 were performed through transperitoneal approach while others were through retroperitoneal approach. Mean age was 5 yr (20 days-15 yr). Main indications were pretransplant nephrectomy for arterial hypertension, nephrotic syndrome or uremic hemolytic syndrome (48%) non functioning kidney secondary to obstruction, reflux, or ectopic ureter (30%), and dysplastic multicystic kidney (19%). Bilateral nephrectomy was done in 13 children.

RESULTS: The lateral retroperitoneal approach was feasible in all cases even for those who had previous renal surgery. Conversion was not needed in any patient. No significant blood loss was observed. Mean operative time was 97 minutes (44-180). Learning curve was relatively short, operating time was rapidly reduced to < 2 hours, and was variable depending on the underlying pathology and the size of the kidney. Postoperative course was uneventful. Hospital stay was less than 48 hours in healthy children and it was 5 days in children with terminal renal disease. In the beginning, the procedure was done by one surgeon, then it was expanded to other surgeons of the team and was safely taught to residents and fellows.

CONCLUSIONS: The procedure can be done safely, learning curve is reasonable, teaching is feasible, operating time becomes with experience closer to open surgery without morbidity, and cosmetic results are excellent. At last this procedure may be considered as the gold standard for nephrectomy in children
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