Lisandro Piaggio

Comparison of Laparoscopic and Open Partial Nephrectomy for Duplication Anomalies in Children

PURPOSE We compared the outcome of laparoscopic vs open PN for duplication anomalies at our institution. MATERIALS AND METHODS We retrospectively reviewed the records of all patients undergoing PN within the last 4 years. RESULTS A total of 34 patients (16 females) were divided into 2 groups. Group 1 consisted of 20 patients undergoing open PN between 2000 and 2003, and group 2 consisted of 14 patients undergoing laparoscopic PN between 2003 and 2004. Mean patient age was 21 months in group 1 and 18 months in group 2. Diagnosis was ectopic ureter in 18 patients, ureterocele in 11, VUR in 4 and ureteropelvic junction obstruction in 1. Cystoscopy was performed as part of the procedure in 30% of the patients in group 1 and 100% of those in group 2. Simultaneous lower tract procedures were performed in 3 patients in group 1 and 2 patients in group 2. Mean duration of PN was 115 minutes for group 1 and 180 minutes for group 2. There was no significant bleeding or need for transfusion except in 1 patient in the open group. Median hospitalization was 3 days for group 1 and 2 days for group 2. Mean analgesic requirement was 2.3 doses of opioids and 2 doses of ketorolac for group 1, and 3.2 doses of opioids for group 2. Acetaminophen only was used in 3 of 20 patients in group 1 and 5 of 14 in group 2. There were 2 complications in each group, namely 1 case of ureteral bleeding and 1 lower pole ureteral injury in group 1, and 1 omental hernia and 1 urinoma in group 2. CONCLUSIONS Laparoscopic PN is feasible even in small infants, and the results are comparable to the open procedure. Length of hospitalization was shorter in the laparoscopic group. In our series the learning curve for this technique was rapid, and after a few cases the procedure could be done in the same time as open surgery, with the advantages offered by laparoscopy.

The role of laparoscopic surgery for urinary tract reconstruction in infants weighing less than 10 kg: A comparison with open surgery

PURPOSE To compare the outcome of laparoscopic urinary tract reconstruction (LUTR) in children weighing 10 kg or less with a weight-matched cohort undergoing open urinary tract reconstruction surgery (OUTR). MATERIALS AND METHODS We conducted a retrospective chart review of patients weighing 10 kg or less at the time of surgery who underwent open or laparoscopic pyeloplasty, transuretero-ureterostomy and ipsilateral uretero-ureterostomy between January 2000 and May 2007. The following information was recorded: body weight, age, sex, diagnosis, type of procedure, operative time, estimated blood loss, pre- and postoperative hemoglobin levels, length of hospitalization, length of follow up, use of drains and stents, intraoperative and postoperative analgesic requirement, need for readmission, subsequent procedures, costs, complications and reoperations. RESULTS There were 52 patients divided into two groups: LUTR (n=23) and OUTR (n=29). Median weight (range) and follow up was 6.2 kg (3.9-10) and 9 months and 6.5 kg (4.7-9.6) and 31 months for LUTR and OUTR, respectively. Mean operative time for LUTR (including cystoscopy and stent placement) was 237 min and for OUTR 128 min (P<0.01). There were no differences in blood loss, intra- or postoperative analgesic requirement, results or complications. Mean hospitalization time was shorter for LUTR than OUTR (2 and 3 days, respectively). There were no differences in hospital costs between the two groups. CONCLUSIONS Laparoscopic reconstructive surgery for congenital urological anomalies is safe and effective in small infants and can be performed with outcomes comparable to that of open surgery.

Pediatric laparoscopic pyeloplasty: lessons learned from the first 52 cases.

BACKGROUND AND PURPOSE The use of laparoscopy for pediatric pyeloplasty is increasing. We review our experience with our first 50 cases and describe the main technical points learned during this experience. PATIENTS AND METHODS We retrospectively reviewed the charts of all patients who underwent laparoscopic pyeloplasties (LP) over a 4-year period (January 2004 to January 2008) at our institution. Patient demographics, operative details, hospital stay, outcomes, and complications were examined. RESULTS Fifty-two patients underwent LP from for primary repair of ureteropelvic junction obstruction (UPJO). Thirty-six male and 16 female were operated on at an average age and weight (range) of 51.8 months (3 weeks to 216 months) and 20 kg (3.9-74.2 kg), respectively. Intraoperatively, 47/52 (90%) underwent retrograde ureteropyelography (RUPG), and 51/52 (98%) had a ureteral stent placed during surgery. Nine crossing vessels (17%) were identified at the time of surgery. The anastomoses were performed with a running absorbable suture. Operative time was 248 min (range 120-693 min). The average hospital stay was 3 days (range 1-7). A bladder catheter usually remained indwelling for 2 days and a perirenal drain for 3 days; they were removed before hospital discharge. The stent remained in place on average 39 days (range 11-127 d) and was removed with the patient under a brief general anesthetic. Anastomotic patency was seen in 51/52 (98%) patients determined by improvement on postoperative renal ultrasonography and/or resolution of symptoms. Mean follow-up was 20 months (range 3-50 mos). Complications included recurrence of UPJO necessitating redo LP (1), dislodgement of a nephrostomy (1), stent replacement (1), ileus (2), and vascular injuries treated laparoscopically (2). No patients needed conversion to open surgery. CONCLUSION LP has supplanted open pyeloplasty at our institution. We have noted improved success by performing RUPG to define the anatomy and stent placement at the beginning of the case, using purple 5-0 or 6-0 poliglecaprone suture for the anastomosis and a 5-mm wide-angle lens for visualization. We found no disadvantages for the transperitoneal approach, although we find it necessary to leave a drain. With the increased use of LP in pediatric urology, we hope these observations from our experience will help improve the learning curve for others making this transition.PURPOSE We describe student satisfaction following a unique medical student education initiative-an elective clinical clerkship in laparoscopic urology. MATERIALS AND METHODS An elective 1-month rotation in urologic laparoscopy was approved by the medical school in 2005. Clerkship objectives are to learn the principles of laparoscopy, to assess and improve laparoscopic skills, and to learn the indications for and techniques of urologic laparoscopic surgery. The elective has five components: (1) a once-weekly clinic with a urology attending, (2) completion of a CD-ROM-based laparoscopy course, (3) participation in a laparoscopic skills training lab involving six 1-hour sessions on a box trainer, (4) observing and assisting in urologic laparoscopy cases, and (5) participation in a clinical research project (if desired). Six students have completed the elective to date. RESULTS Overall satisfaction with the clerkship was high, scoring a mean 5 out of a possible 5 on student evaluations. Intentions for residency training included urology for three, obstetrics-gynecology for one, neurosurgery for one, and plastic surgery for one. There were no changes in desired residencies after completion of the clerkship. Performance on the box trainer improved significantly but did not differ from 14 other students who had completed the laparoscopy training lab but were not enrolled in the elective. CONCLUSIONS There is substantial interest among medical students in advanced laparoscopic surgery, and it can support a third- or fourth-year clinical clerkship in laparoscopic urology. Student evaluations revealed very high satisfaction. This elective is of benefit to students interested in urology and other surgical specialties.

Influence of type of conduit and site of implantation on the outcome of continent catheterizable channels

OBJECTIVE Continent catheterizable channels (CCC) using the Mitrofanoff principle are essential for pediatric urinary tract reconstruction. There is controversy over the influence of type of CCC (appendix vs. Yang-Monti) and site of implantation (augmentation vs. native bladder) on outcome. PATIENTS AND METHODS A retrospective record review was conducted of all patients undergoing CCC since 1999, excluding patients who underwent seromuscular colocystoplasty. We analyzed the type of channel, site of implantation, complications requiring re-operation, and the revision rate according to type of CCC, type of stoma, site of implantation (bladder vs. augmentation) and segment used for augmentation (ileum vs. sigmoid colon). RESULTS There were 41 patients with a mean age of 11.2 years and a mean follow-up of 33.3 months. Of these, 33 CCC were constructed with appendix and eight with a Yang-Monti technique (4 ileal, 4 sigmoid); 31 patients also had an enterocystoplasty (19 sigmoid, 9 ileal and 3 others). Overall revision rate was 27%; revision was required in 8/33 (24%) appendiceal and 3/8 (38%) Yang-Monti CCC (P=0.7). Revisions were required in 4/21 CCC implanted in the native bladder and 7/20 implanted in augmented bladder (P=0.3). The majority of revisions were at skin level. CONCLUSIONS Although there was no statistical difference in revision rate according to type of CCC, type of stoma or site of implantation, complications appeared to be more common in patients requiring a more complex reconstruction.

Could prophylactic antibiotics be stopped in patients with history of vesicoureteral reflux

OBJECTIVE To compare the incidence and type of urinary tract infection (UTI) in patients with primary vesicoureteral reflux (VUR) diagnosed after a febrile UTI while they were on prophylactic antibiotics (PA) and after stopping PA. MATERIALS AND METHODS Criteria to discontinue PA were: no UTI during 12+ or more months on PA, old enough to communicate UTI symptoms, potty trained and absence of risk factors for UTI. Patients with at least 1 year of follow up without PA were included (n=77). We recorded: age at which PA was indicated and stopped, time on and off PA, incidence and type of UTI (cystitis vs acute pyelonephritis (APN)), and renal scan results. RESULTS PA was started and stopped at a mean age of 18.5 and 61 months, respectively. Mean time on PA was 39 months (range 12-95): 25 patients had 44 UTI episodes (0.17 episodes/patient/year), and 31 (70%) of them were APN. Mean time of antibiotics was 44.5 months (range 12-162): 13 patients had 24 UTI episodes (0.08 episodes/patient/year), eight (33%) of which were APN (P<0.05). A renal scan was performed in 71 patients after the index infection and repeated in 12. Two patients lost renal function while still on PA. CONCLUSION Discontinuing PA in patients with history of VUR is a safe practice and should be considered as a management option.

Surgical treatment of neuropathic urinary incontinence in 2005. When, what, and how?

We present our current opinions on the surgical treatment of urinary incontinence in children with spina bifida. The age of treatment, preferred treatment modalities and results are discussed. We emphasize the importance of initiating treatment for incontinence at an early age as well as the use of effective surgical techniques.