Laparoscopic vesicoureteroplasty in children: initial case reports

Does technique or material used affect bladder tissue reactions when injecting teflon or silicone paste?

OBJECTIVES

Submucosal injections of polytetrafluoroethylene (PTFE) and polydimethylsiloxane (PDMS) paste continue to be used for the correction of vesicoureteral reflux and urinary incontinence. Potential distant particle migration and foreign body tissue reactions are thought to be significantly affected by the technique of injection and the paste material used. A study to determine if injection technique, paste material, or pretreatment of the injection site significantly affects local tissue reaction was performed on 44 New Zealand white rabbits.

METHODS

Animals were randomly assigned to undergo four distinct injection treatments into the submucosa or bladder muscularis. Prior to injecting 0.1 cc of the PTFE or PDMS paste, some sites were pretreated with 0.1 cc saline to separate tissue planes, epinephrine to cause vasoconstriction, or doxycycline to provide sclerosis. Pretreatment controls were also performed without injecting PTFE or PDMS paste. Animals were killed, and quadrant bladder biopsies were performed at 1 hour (9), 1 day (9), 7 days (10), 1 month (8), and 6 months (8). A single pathologist, blinded to the injection treatments, performed a histologic evaluation to determine bleb location and the degree of inflammation, fibrosis, and epithelial necrosis.

RESULTS

Seven of the 12 submucosal PTFE injection treatments were found on biopsy to be primarily within the muscularis, compared to 1 of 9 with PDMS paste. Three of the 24 PTFE injections could not be found at autopsy. Of these, two were injected into the muscularis, and all were discovered at least 1 month following injection. Particles were present in all 22 PDMS injection sites that were retrieved. Pretreatments, especially with doxycycline, resulted in significant epithelial necrosis at 1 and 7 days. At 1 and 6 months there were no differences in inflammation or fibrosis between PTFE and PDMS or any pretreatment combinations with saline or epinephrine.

CONCLUSIONS

Correctly injected, silicone (PDMS) paste appears most likely to remain in the submucosal space. Pretreatment injections may cause early epithelial necrosis. PTFE and PDMS elicit similar foreign body reactions over time.

Laparoscopic surgery for bladder carcinoma

Recent utilization of laparoscopy in urology has led to the performance of several pelvic procedures. The successful performance of laparoscopic diverticulectomies and cystectomies for benign pathology has led to speculation about, and utilization of, the laparoscopic approach in the treatment of bladder cancer. Herein, we relay our experience with the laparoscopic approach for bladder surgery and discuss the pros and cons of its current status in the treatment of bladder cancer.

Outcome analysis of bilateral Cohen cross-trigonal ureteroneocystostomy

OBJECTIVES

The perioperative and long-term outcomes of children with vesicoureteral reflux (VUR) treated by cross-trigonal ureteroneocystostomy were ascertained.

METHODS

One hundred ten consecutive children with VUR who underwent bilateral cross-trigonal ureteroneocystostomy were studied retrospectively. Nineteen children with neurovesical dysfunction or megaureters requiring tapered reimplants were excluded. Outcome parameters of the remaining 91 children consisted of operative time, length of hospitalization, days of Foley catheter drainage perioperative complications, correction of reflux, subsequent morbidity, and parental satisfaction.

RESULTS

Of 182 renal units, 11 (6%) had grade 0 VUR, 18 (10%) had grade I, 43 (24%) had grade II, 59 (32%) had grade III, 36 (20%) had grade IV, and 15 (8%) had grade V reflux. The mean operative and hospitalization times were 180 minutes and 5.6 days, respectively. No postoperative complications occurred. Three children were lost to follow-up, and the remaining 88 children had an extended mean follow-up in excess of 3 years. Voiding cystourethrogram documented a 98.3% (173 of 176 renal units) success rate. Sixteen children (18%) experienced nonfebrile clinically symptomatic cystitis episodes and 3 children (3%) experienced one febrile episode each. Telephone parental survey of overall surgical experience revealed a 94% very satisfied, 2% satisfied, and 3% dissatisified rate.

CONCLUSIONS

Cross-trigonal ureteroneocystostomy is a safe and effective technique that is virtually complication free and has high parental satisfaction. The results of this study provide a baseline for comparison of non-operative treatment of reflux as well as laparoscopic and endoscopic techniques.

New laparoscopic suturing device: initial clinical experience

OBJECTIVES

New instrumentation and techniques have enabled laparoscopic surgeons to perform complicated reconstructive procedures. Few centers have attempted these procedures because of the excessive time involved with laparoscopic suturing. The Endo stitch suture device was developed to facilitate suture placement. We clinically compared conventional intracorporeal suturing and Endo Stitch suturing for laparoscopic suture placement and knot tying.

METHODS

Intracorporeal suturing was used to complete laparoscopic dismembered pyeloplasties and bladder neck suspensions. Sutures were placed with either needle holders and graspers or the automatic suture device. A total of 85 maneuvers were assessed. Operative videotapes were reviewed to assess accuracy of suture placement, knot tying, and time to place suture and tie knots. All suturing was performed by an experienced laparoscopist.

RESULTS

Accuracy of stitch placement and knot tying were equivalent. The average time for stitch placement with the Endo Stitch was 43 +/- 27 seconds (n = 41). This was significantly less than the average stitch placement time for conventional suturing, which was 151 +/- 24 seconds (n = 14). The Endo Stitch knot tying was completed in an average of 74 +/- 50 seconds (n = 17), whereas knot tying with the conventional technique took 197 +/- 70 seconds (n = 13). The needle is automatically loaded in the Endo Stitch after each suture and is immediately ready.

CONCLUSIONS

The Endo Stitch device reduced the amount of time needed for placement of stitches and knot tying. Reconstructive laparoscopic procedures requiring multiple suture placement may be completed in a shorter time period using this instrument.

Postoperative hospitalization of children undergoing cross-trigonal ureteroneocystostomy

The hospital records of 145 girls and 41 boys who had undergone ureteroneocystostomy for vesicoureteral reflux were retrospectively reviewed to determine the duration of urethral catheterization and postoperative hospitalization. Children with a complicated urological history or the need for ureteral tapering and stent placement were excluded. The trend in urethral catheter removal was from 2.71 days postoperatively during the first year of the study to 1.18 days during the last year. Postoperative hospitalization decreased from 4 to 2 days. It is now routine practice to remove the urethral catheter on the first postoperative day and discharge the patient from the hospital on the second day. The surgical resolution of reflux was 96%.

Laparoscopic evaluation of indeterminate renal cysts

OBJECTIVES

To determine the efficacy and safety of laparoscopic evaluation of indeterminate renal cysts.

METHODS

Ten patients with indeterminate renal cysts (5 Bosniak type II and 5 Bosniak type III) underwent transperitoneal laparoscopic aspiration of cyst fluid for cytologic analysis with examination, biopsy, and excision of the cyst wall and base.

RESULTS

All procedures were successful and without complications. All the lesions were benign.

CONCLUSIONS

Laparoscopic evaluation of indeterminate renal cysts is safe and effective. The procedure alleviates patient anxiety about the nature of the lesion and obviates years of radiologic surveillance, thus reducing costs.

Fly-casting method of intracorporeal laparoscopic knot tying

A simple technique for intracorporeal knot tying is discussed. Laparoscopic applications in urology initially began as simple diagnostic procedures to examine impalpable undescended testes and as an adjunct to help in management of intersex disorders. Subsequently, extirpative procedures have developed as technology has evolved and lymph node dissection, nephrectomy, and even assisted prostatectomy have been performed. As this experience increases it is only natural that reconstruction be the next step, and indeed case reports of ileal loop creation, pyeloplasty, and vesicoureteroplasty exist.