A. Paye-Jaouen

Retroperitoneal laparoscopic pyeloplasty in children: long-term outcome and critical analysis of 10-year experience in a teaching center.

BACKGROUND Laparoscopic pyeloplasty in children remains controversial and is not included in most pediatric urology centers because of technical difficulties and lack of long-term results. OBJECTIVE To critically analyze our 10-yr experience with the retroperitoneal approach (RA), with a particular interest on the impact of the learning curve in a teaching center. DESIGN, SETTING, AND PARTICIPANTS Patients who underwent pyeloplasty between 1999 and 2010 at our institution were reviewed (n=390). The diagnosis of ureteropelvic junction obstruction was confirmed by ultrasound and technetium Tc 99m mercaptoacetyltriglycine-3 renal scan or magnetic resonance imaging; the same criteria were used to evaluate the outcome. The lateral RA was selected in children >1 yr of age without abnormal migration or fusion of the kidney (n=104). SURGICAL PROCEDURE Dismembered pyeloplasty and anastomosis were performed using running monofilament 5-0 or 6-0 absorbable suture. All were drained by double-J stent except 20 cases drained by external transanastomotic stent. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We assessed intra- and postoperative morbidity and analyzed the teaching of technique and learning curve. Data are expressed as medians and interquartile range (25th, 75th percentiles) for quantitative variables. RESULTS AND LIMITATIONS Median age was 6.2 yr (2.2-10.3). Thirty-three patients had crossing vessels. Median operative time was 185 min (160-235). Median hospital stay was 2 d (1-2). Redo pyeloplasty was needed in only two children (2%). Median follow-up was 2.1 yr (1.4-4.1). Operative time was <3 h after 35 cases. After 30 cases performed by the same surgeon, standardization of the technique was feasible, which helped in the teaching process because 50% of the final 30 cases were done by trainees. CONCLUSIONS Retroperitoneal dismembered laparoscopic pyeloplasty is a safe, reliable, and efficient procedure with an excellent outcome in selected children according to their indications and age, and the experience of the surgical team. Even if the transmission to trainees is successful, it is still a long learning process and remains a challenging task for a teaching center.

Preliminary experience with external ureteropelvic stent: alternative to double-j stent in laparoscopic pyeloplasty in children.

PURPOSE We assessed whether an external ureteropelvic stent was a feasible and safe alternative to Double-J® stent after laparoscopic pyeloplasty in children, thus avoiding a second general anesthesia. MATERIALS AND METHODS Our study included 22 concurrent age matched children who underwent retroperitoneal laparoscopic pyeloplasty between 2000 and 2008. In group 1 an external ureteropelvic stent was inserted through the renal pelvis, then clamped on postoperative day 2. In group 2 a Double-J stent was antegradely inserted. The ureteropelvic stent was removed at the outpatient clinic on day 10, while the Double-J stent was removed under general anesthesia at 1 month. We retrospectively compared operative time, hospital stay, intraoperative and postoperative complications, and followup. RESULTS Mean±SD age at surgery was 31±9 months in group 1 and 37±12 months in group 2. Mean±SD operative time was slightly shorter in group 1 (190±40 minutes) than in group 2 (205±23 minutes). No intraoperative complications were encountered during placement of stent. Mean±SD hospital stay was 2.18±1.20 days in group 1 and 2.45±0.54 days in group 2. No postoperative complications were reported in group 1. The Double-J stent was noted in the posterior urethra in 1 patient in group 2, requiring cystoscopic repositioning. No patient had urinary tract infection. Median followup was 34 months (range 22 to 56) in group 1 and 35 months (16 to 72) in group 2. CONCLUSIONS The feasibility of external ureteropelvic stenting after laparoscopic pyeloplasty will pave the way to minimizing the use of Double-J stenting and eliminating a second general anesthesia for catheter removal.

Laparoscopic Mitrofanoff procedure in children: Critical analysis of difficulties and benefits

OBJECTIVES The Mitrofanoff principle is an accepted continent urinary diversion. We studied the feasibility and the possible benefits of using a laparoscopic approach in children with significant bladder dysfunction associated with difficulty doing efficient urethral catheterization. PATIENTS AND METHODS A fully laparoscopic Mitrofanoff continent cystostomy was attempted in 15 children with a median age of 9 years (IQR 6), between 2003 and 2013. Before the Mitrofanoff procedure was considered, urodynamic evaluation was done for each patient, to study bladder compliance, detrusor activity, and bladder capacity. The procedure was performed using a transperitoneal four-port approach. A 30-degree down camera angle was optimal for viewing the appendix and the posterior wall of the bladder. The operative steps of the open procedure were replicated laparoscopically. The proximal end of the appendix was spatulated and anastomosed to the posterior wall of the bladder, providing an antireflux mechanism by an extramucosal tunnel. The distal end of the appendix was brought out as the cutaneous umbilical stoma. Some modifications were done because of the high rate of conversion due to early opening of the mucosa (harmonic hook) or difficult anastomosis: (a) use of 5-mm trocars to change the laparoscope position from the left to right subcostal area to better visualize the anastomosis, (b) the anastomosis was suspended at its two ends during suturing; a trans-abdominal traction suture of the bladder was inserted for better exposure of the anastomosis (hitch stitch) and to stabilize the anastomotic line during suturing, (c) use of a monopolar hook to cut the detrusor muscle fibers, to avoid incidental opening of the mucosa, and (d) the window between the appendix and the peritoneum was closed to avoid internal hernia. RESULTS The procedure was totally completed by laparoscopy in 12 cases. Three were converted to an open procedure due to tearing of bladder mucosa (n = 2) or appendix ischemia (n = 1). Median operative time for fully laparoscopic Mitrofanoff was 255 min (IQR 52). Median follow-up was 18 months (IQR 35). No patient required stomal revision. Seven patients were continent, five experienced urinary leakage from urethra n = 1 and/or stoma n = 5. Three patients with stomal urinary leakage were successfully managed by Deflux (dextranomer-based implants) injection in the catheterizable channel. Two patients required an open revision of the appendicovesical anastomosis. The patient with both stomal and urethral urinary leakage also required the implantation of an artificial urinary sphincter 1.5 years after Mitrofanoff. One patient had bladder augmentation. CONCLUSION Although our results of laparoscopic Mitrofanoff procedure in children are unsatisfying in cases of high-pressure bladders in terms of incontinent stoma, we still believe that it is justified to develop this challenging technique with more refinement and improvement, to provide a minimal invasive procedure that may postpone or even avoid bladder augmentation in pediatric age.

Posterior urethral valves and vesicoureteral reflux: can prenatal ultrasonography distinguish between these two conditions in male fetuses?

The objective of the study was to evaluate prenatal sonographic signs that distinguish male fetuses with posterior urethral valves (PUV) from those with vesicoureteral reflux (VUR).

SFCP CO-36 - Dérivation urinaire continente extra-séreuse associée à une entérocystoplastie selon Ghoneim

Objectif La technique de derivation urinaire continente extra-sereuse decrite par Ghoneim et Abu Elenein est une procedure reconnue pour obtenir un reservoir continent catheterisable. Nous avons evalue cette technique chez l’enfant. Methode Etude retrospective monocentrique (2002–013) des patients operes d’une Ileocystoplastie configuree en W associee a une reimplantation de l’appendice, +/- les ureteres, dans un trajet antireflux extra-sereux. Resultats 27 enfants ; 16 garcons, 11 filles, âge moyen 9 ans (1–15) ont ete inclus (16 extrophies vesicales, 2 extrophies cloacales, 5 vessies neurologiques et 4 autres). Ileocystoplastie (25), reservoir ileal (2), derivation par l’appendice (24), tube ileal (2). Avec un suivi moyen de 30 mois (6–133), 26 patients (96%) ont obtenu une continence, avec 3 a 5 catheterismes par jour. 3 patients (11%) ont eu des complications de la derivation: 2 fuites (un traite par Deflux et un repris chirurgicalement) et 1 stenose (dilatation). Lithiases dans le reservoir (2) et une acidose metabolique post-operatoire chez deux enfants. Conclusion Cette technique de derivation urinaire est efficace pour obtenir un agrandissement fiable avec une derivation continente. Comparativement a d’autres techniques, le taux de complication est relativement faible.

SFCP CO-45 - Néphrectomie partielle par rétropéritonéoscopie; peut-on reconsidérer sa mauvaise réputation ?

Objectif La nephrectomie partielle laparoscopique (NPL) reste controversee chez les jeunes enfants en raison de taux eleve des complications et de conversion. Methodes Etude retrospective mono centrique entre 1997–2013. La technique a ete progressivement standardisee:1) position laterale, approche retroperitoneale 2) insertion retrograde de catheter ureteral dans le pole restant, injection de bleu de methylene au cours de la section du parenchyme 3) le pole restant est garde attache au peritoine. L’evaluation est effectuee par echographie Doppler renale +/_ scintigraphie au DMSA. Resultats 58 NPL (43 superieurs) ont ete effectuees a un âge median de 15mois [1–156], duree operatoire 140min [75–270], duree d’hospitalisation 2 jrs, suivi 23mois [6–109]. Une seule conversion (1,7%) (4 mois, 6eme cas). Un seul enfant (1,7%) a eu une perte du pole inferieure restant, (7 ans, 4eme cas). Deux enfants ont eu urinome dont un necessitant un drainage. 25 enfants ont ete operes a un âge Conclusions NPL reste une intervention a risque. Une technique standardisee et maitrisee peut reduire le taux des complications et de conversion. Le principal facteur limitant est la courbe d’apprentissage du chirurgien par rapport a l’âge du patient.

Lessons learnt from two pediatric motor vehicle accidents resulting in anal canal, rectal and gluteal muscle wrenching.

Ano-rectal trauma is common in motor vehicle accidents involving children. Inadequate initial assessment of the extent of lesions may be life threatening. We describe two cases where children were struck by buses that subsequently rolled over them in the prone position, resulting in ano-rectal and gluteal muscle wrenching. The first patient was inadequately assessed. Initial management did not include a diverting stoma, leading to life-threatening necrosis and septic shock. The second benefitted from our previous experience and recovery was uneventful. The distinctive mechanism of trauma in true gluteal muscle and anal canal wrenching is discussed. Gluteal muscle, anal canal and rectal wrenching as a result of rolling force from a motor vehicle is a very serious condition requiring immediate intestinal diversion with a stoma. Immediate repair may be attempted at the same time as stoma creation if the patient is stable. Broad-spectrum antibiotics and close wound monitoring are necessary to avoid muscle necrosis and serious complications.

CL125 - Pyéloplastie sous rétropéritonéoscopie : analyse critique de 10 années d’expérience

Objectifs Analyser 10 annees consecutives de pyeloplastie sous retroperitoneoscopie. Materiels et Methodes 109 enfants ont eu une pyeloplastie sous laparoscopie entre 1998 et 2009. 18 operes par voie transperitoneale sont exclus (rein en fer a cheval n = 7, reprise de pyeloplastie n = 5, rein ectopique n = 4, nephrostomie ou greffon renal n = 1). 91 malades ont ete operes par voie retroperitoneale. L’âge moyen est de 6,3 ans (5 mois–15 ans). L’intervention est realisee en decubitus lateral avec 3 trocars (5-3-3mm). Une JJ etait laissee en place chez 69 et une pyelostomie trans-anastomotique chez 20 malades. Resultats La duree operatoire moyenne etait de 200 min (120-360). 14 ont ete operes en moins de 150 min. L’indication avant un an est : hydronephrose geante et uretere retrocave ( n = 3). Trois malades ont ete convertis en debut d’experience. La duree d’hospitalisation moyenne etait de 2,2 jours (1-8). Deux ont necessite un drainage prolonge par une JJ et un malade a ete repris. La mediane de suivie est de 1 an (6 mois-7 ans). Conlusion Malgre une longue duree operatoire, la pyeloplastie par retroperitoneoscopie est une intervention fiable : 1 % de reprise. L’approche retro ou transperitoneale est notre choix en cas d’anomalie de fusion ou de position et chez l’enfant apres l’âge de la marche.

SFCP-P27 – Urologie – Peut on réduire les examens complémentaires avant traitement endoscopique des urétérocèles ?

Objectifs Le but du traitement de l’ureterocele sur duplication est plutot de reduire le risque de complications infectieuses sur systeme dilate que de conserver une fonction renale du pole superieur difficile a evaluer. Une nouvelle methode de prise en charge en ponctionnant de principe l’ureterocele confirmee a l’echographie a ete faite. Materiels et methodes 41 nouveaux-nes avec diagnostic prenatal d’ure-terocele ont eu une incision endoscopique entre 1997 et 2007 pour dilatation uretero-pyelocalicielle significative. Ont ete colliges les examens radiologiques preoperatoires, le type d’ureterocele, la survenue d’infection pre et postoperatoires, et la necessite d’une seconde intervention. Deux groupes ont ete constitues, groupe 1 : enfants operes apres cystographie retrograde (CGR) associee ou non a une scintigraphie renale, groupe 2 : enfants operes apres juste une echographie post natale. Tous etaient sous antibioprophylaxie. Resultats L’âge median a l’intervention etait de 1 mois (2 jours-6 mois) avec 25 ureteroceles intra vesicales et 16 ureteroceles ectopiques. Le suivi median etait de 42 mois. Groupe 1 : 22 enfants (53,6 %) ont eu une CGR avec 10 reflux vesicoureteral dans le pole inferieur ; 7 d’entre eux avaient eu une infection urinaire preoperatoire (32 %) dont 3 intravesicales et 4 ectopiques. 6 ont eu une scintigraphie renale montrant une absence de fonction polaire superieure pour 2, une fonction a 10 % pour les autres. Six enfants (27,7 %) ont du etre reoperes en raison d’infection et avoir une NPS par retroperitoneoscopie (2 ectopiques, 4 intra) associe a une reimplantation pour 2 (ectopiques). Groupe 2, 19 enfants (46,3 %) ont eu une ponction endoscopique sans CGR ni scintigraphie. 3 d’entre eux ont fait une infection urinaire preoperatoire (15,8 %) et avaient une ureterocele ectopique. Deux patients (10,5 %) ont presente des recidives d’infections urinaires posant l’indication d’une NPS par retroperitoneoscopie. Conclusion Si le diagnostic d’ureterocele est confirme a l’echographie post natale, la realisation d’autres examens complementaires ne changera pas la decision de faire une ponction endoscopique en premiere intention. Afin de diminuer le nombre d’examens invasifs, il nous parait satisfaisant de proceder directement a la ponction endoscopique precoce.

SFCP-P04 – Urologie – Traitement endoscopique des urétérocèles ectopiques sur duplication : mythe ou réalité ?

Objectif Le traitement des ureteroceles (de diagnostic prenatal) sur duplication par ponction endoscopique permet de decomprimer la dilatation uretero-pyelique et d’eviter la survenue d’infection en restant conservateur. Nous analysons les resultats de l’incision endoscopique d’ureterocele quelqu’en soit le type. Materiels et methods 41 enfants avec ureterocele ectopique sur duplication ont ete operes de 1997 a 2007 en raison d’une dilatation significative des cavites pyelocalicielles. Le type d’ureterocele, la presence d’un reflux vesico-ureteral preoperatoire et post operatoire, la survenue d’infection urinaire pre et post operatoire etaient colliges. Resultats 41 enfants ont eu une ponction endoscopique a un âge median de 1 mois (2 jours-6 mois). Tous ces enfants etaient sous antibioprophylaxie des la naissance.16 ureteroceles ectopiques ont eu une ponction endoscopique a la lame froide (plusieurs ponctions), deux d’entre elles etaient prolabees par l’orifice uretral. Le suivi median etait de 42 mois (6-127). On a constate 3 reflux (18,75%) dans le pole inferieur en preoperatoire, aucun reflux dans le pole superieur. En postoperatoire, on a constate l’apparition de 3 reflux dans le pole superieur et l’apparition de 2 reflux dans le pole inferieur. Cinq enfants ont fait une infection urinaire preoperatoire (31,25%). Huit enfants (50 %) ont du etre reoperes en raison de recidive infectieuse, deux ont eu un traitement radical associant une nephrectomie polaire superieure, reimplantation ureterale et ureterocelectomie, six ont eu une NPS par retroperitoneoscopie. Le suivi median etait de 42 mois (6-127). Conclusion La ponction endoscopique d’ureterocele ectopique peut etre le seul geste chirurgical dans 50 % des cas. Ces resultats peuvent probablement etre ameliores grâce a une prise en charge encore plus precoce en post natal c’est-a-dire avant la survenue d’infection.