Abraham Cherian

Current practice in paediatric hypospadias surgery; A specialist survey

AIM To undertake an online survey of current hypospadias surgery practice among those specialists attending the IVth World Congress of the International Society for Hypospadias and Disorders of Sex Development (ISHID), 2011. MATERIALS AND METHODS An online survey covering 22 separate questions relating to proximal and distal hypospadias surgery was set up, and all delegates registered for the conference were invited to complete this questionnaire anonymously. The data was analysed by three of the authors. RESULTS A total of 162 delegates registered for the conference of whom 74% were paediatric surgeons, paediatric urologists, plastic surgeons and adult/adolescent urologists. 93 delegates completed the online survey, and most of them (57%) were from Europe. The majority of surgeons see over 20 new patients/year (90%) and perform primary hypospadias surgery in over 20 patients/year (76%). The tubularized incised plate (TIP) repair is the most frequent technique used for the management of distal hypospadias (59%); other techniques used included Mathieu, onlay and TIP with graft. A variety of techniques are used for proximal hypospadias, but nearly half of the respondents (49%) preferred a staged approach. Self reported complication rates for distal hypospadias surgery are favourable (less than 10%) for 78% of the respondents. However, proximal hypospadias complication rates are higher. CONCLUSIONS With a majority of paediatric urologists and European delegates responding to our survey, the results suggest that there are differences in the management of proximal and distal hypospadias between surgeons, yet no differences were observed according to the region of their practice. Variations in long-term outcomes appear to be in keeping with the current literature.

Primary bladder exstrophy closure in neonates: challenging the traditions.

PURPOSE We describe a novel approach to neonatal bladder exstrophy closure that challenges the role of postoperative immobilization and pelvic osteotomy. MATERIALS AND METHODS We reviewed the primary management of bladder exstrophy at our institutions between 2007 and 2011. In particular we compared postoperative management in the surgical ward using epidural analgesia to muscle paralysis and ventilation in the intensive care unit. Clinical outcome measures were time to full feed, length of stay, postoperative complications and redo closure. Cost-effectiveness was also evaluated using hospital financial data. Data are expressed as median (range). Significance was explored by Fisher exact test and unpaired t-test. RESULTS A total of 74 patients underwent primary closure without osteotomy. Successful closure was achieved in 70 patients (95%). A total of 48 cases (65%) were managed on the ward (group A) and 26 (35%) were transferred to the intensive care unit (group B). The 2 groups were homogeneous for gestational age (median 39 weeks, range 27 to 41) and age at closure (3 days, 1 to 152). Complications requiring surgical treatment were noted in 4 patients (8.3%) in group A and 3 (11.5%) in group B (p = 0.609). Length of stay was significantly shorter for the group managed on the ward (11 vs 18 days, p <0.0001). Median costs were

Ileal bladder augmentation and vitamin B12: Levels decrease with time after surgery

42,732 for patients admitted to the intensive care unit and

Testicular outcome following laparoscopic second stage Fowler-Stephens orchidopexy.

16,214 for those admitted directly to the surgical ward (p <0.0001). CONCLUSIONS Primary closure of bladder exstrophy without lower limb immobilization and osteotomy is feasible. Postoperative care on the surgical ward using epidural analgesia results in shorter hospitalization.

Retroperitoneoscopic para-aortic lymph node sampling in bladder rhabdomyosarcoma

OBJECTIVE We investigated vitamin B12 deficiency following ileocystoplasty in children. METHODS Patients who underwent ileocystoplasty between December 1993 and September 2006 were included and B12 levels were retrospectively analysed. Patients with a serum B12 of less than 150 pg/ml were considered deficient. The distance of the ileal segment from the ileocaecal valve was recorded. RESULTS There were 105 patients in the series; 61 were male. Mean age at surgery was 7.7 years (SD = 3.9). The mean interval from surgery to most recent B12 level was 50 months (SD = 30). None of the patients were on B12 supplementation. Two patients were B12 deficient, both more than 7 years after surgery; 44% of patients with levels available 7 years after surgery had a B12 below 300 pg/ml. There was a significant negative correlation between B12 level and length of follow up (Spearmans rank, P < 0.01). Twenty patients with an ileal segment sparing 60 cm from the ileocaecal valve had a higher mean B12 (524 vs 419, SEM 60 vs 28). This was not statistically significant. CONCLUSION We demonstrate a reduction in serum B12 level with time following ileocystoplasty. These patients should have their B12 levels measured in the long term.

Primary obstructive megaureter: Cutting balloon endo-ureterotomy

OBJECTIVE To assess outcome after laparoscopic second-stage Fowler-Stephens orchidopexy (L2(nd)FSO). PATIENTS AND METHODS Retrospective review of 94 children (aged 0.75-16 years, median 2.75 years), who underwent L2(nd)FSO for 113 intra-abdominal testes between January 2000 and May 2009: 75 unilateral, 19 bilateral (11 synchronous; 8 metachronous). Follow-up (range 3 months-10.9 years, median 2.1 years) was available for 88 children (102 testes: 71 unilateral, 31 bilateral). RESULTS Testicular atrophy occurred in 9 out of 102 (8.8%), including 8 out of 71 (11.3%) unilateral and 1 out of 31 (3.2%) bilateral intra-abdominal testes (multivariate analysis: p = 0.59). Testicular ascent ensued in 9 out of 102 (8.8%), comprising four (5.6%) unilateral and five (16.1%) bilateral testicles (multivariate analysis: p = 0.11). Of the 18 bilateral testes brought to the scrotum synchronously none atrophied and four (22.2%) ascended, compared to one (7.7%) atrophy and one (7.7%) ascent among the 13 testes brought to the scrotum on separate occasions (Fisher exact test: p = 0.42 and p = 0.37, respectively). Mobilization of the testis through the conjoint tendon tended towards less ascent (multivariate analysis p = 0.08) but similar atrophy (p = 0.56) compared to mobilization through the deep-ring/inguinal canal. Logistical regression analysis identified no other patient or surgical factors influencing outcome. CONCLUSIONS This is the largest series of L2(nd)FSO to date. A successful outcome is recorded in 85 out of 102 (83.3%) testicles. Atrophy occurred in 8.8% and ascent in 8.8%.

Single incision prone retroperitoneoscopic paediatric nephrectomy

Determining lymph node involvement is an important step in the pre-treatment evaluation of non-metastatic rhabdomyosarcoma. We describe retroperitoneoscopy for para-aortic lymph node biopsy in a 4-year-old boy with embryonal rhabdomyosarcoma of the bladder with pelvic and para-aortic lymph node enlargement on magnetic resonance imaging. This technique affords access to the para-aortic region with minimal dissection, permitting quick recovery and early commencement of chemotherapy.

Combination of Surgical Drainage and Renal Artery Embolization: An Alternative Treatment for Xanthogranulomatous Pyelonephritis

OBJECTIVE In this video we will demonstrate endo-ureterotomy using a cutting balloon for vesico-ureteric junction (VUJ) dilatation and stenting of the primary obstructive megaureter. METHOD For the technique, a 0.014 inch guide-wire is endoscopically inserted through the VUJ and allowed to curl in the megaureter. A 3 mm atherotome-bladed cutting balloon is inflated with iohexol contrast solution. Under fluoroscopy or cystoscopically, the stenotic VUJ segment is observed to open and post-dilated with a 4 mm simple balloon before JJ stent placement for six weeks. RESULTS This video demonstrates the equipment and technique of VUJ endo-ureterotomy using a cutting balloon and stenting of the primary obstructive megaureter. CONCLUSION Where intervention for the primary obstructive megaureter is indicated, we propose VUJ endo-ureterotomy as the first line treatment.

External stent in laparoscopic pyeloplasty: The K-wire technique

OBJECTIVE We have previously reported our early experience (2 patients) of single-incision nephrectomy via the retroperitoneal prone route using an advanced access platform (GelPOINT Mini). Here, we review our series to date and also present a detailed video demonstrating the technique. METHOD In the prone position, a single transverse incision was made at the midpoint on a line along the lateral border of erector spinae bounded by the lower border of the 12th rib and iliac crest. Posterior abdominal muscles were split and the deep lumbodorsal fascia incised. The Alexis retractor was positioned and the Gel-Seal cap with low-profile sleeves locked in place. Hilar vessels were divided by endoclip application or harmonic scalpel. The kidney was retrieved directly or via an endobag. The Alexis retractor was removed and wound closed with absorbable sutures. RESULTS Between July 2013 and March 2015, we have used this approach to perform 10 nephrectomies in nine patients (4 male and 5 female). The median age at nephrectomy was 10.9 years (range 2.7-15.9 years). The median kidney length was 7.5 cm (range 3.7-11.5 cm). No complications occurred and none converted to open procedure. CONCLUSION Single incision retroperitoneal nephrectomy is feasible, safe, and provides excellent cosmesis.

Fibroepithelial ureteral polyps as a cause of ureteropelvic junction obstruction in children: A case report

Conventionally, xanthogranulomatous pyelonephritis is treated with antibiotics and drainage of abscess followed by nephrectomy for definitive treatment. Surgical excision of the affected kidney carries risk of significant complications. An alternative treatment modality is described in the form of embolization of the renal artery to devascularise the renal parenchyma and ablate the renal tissue, thus avoiding a major surgical procedure and the significant risks involved.