Can transient resting of the bladder with vesicostomy reduce the need for a major surgery in some patients?

Temporary vesicostomy in pediatrics: What are the potential predictors of functional and morphological improvement of the upper urinary tract?

INTRODUCTION

Vesicostomy is a simple, well-tolerated, and reversible procedure with few complications that safeguards upper urinary tract (UUT), decreases VUR grade, decreases UTI, and preserves renal function and should be considered in patients with PUV who have undergone prior valve ablation and bladder function not improved, and in myelodysplastic children that do not respond to catheter drainage [1-4].

OBJECTIVE

We evaluated the temporary vesicostomy as a safeguard of the UUT in children with bladder outlet obstruction, bladder dysfunction, and high-grade VUR with sepsis and assessed the possible predictors of the UUT's morphological and functional improvement since these have been rarely explored in previous reviews.

STUDY DESIGN

We evaluated the outcome and complications of temporary vesicostomy who were operated on 69 children at our center from 2014 to 2019.

RESULT

There were 63 (91.3%) boys and 6 (8.7%) girls who underwent vesicostomy at a mean age of 15.38 ± 2.74 months old. Twenty-nine cases (42%) were diagnosed as primary VUR, 23 (33.3%) had posterior urethral valve (PUV), and 5 (7.2%) had voiding dysfunction, while 12 (17.4%) were neurogenic bladder. Twenty-five (36.2%) patients were diagnosed prenatally and the remainder (44, 63.8%) postnatally. All patients were evaluated at least one year postoperatively. UTI was diagnosed in all cases before vesicostomy; 47 (68.1%) had a single episode of UTI and 22 (31.9%) had recurrent episodes of UTI. Mean serum creatinine was 1.75 ± 0.13 (0.7-4.8) mg/dl. Serum creatinine and the rate of UTI significantly improved (p-value <0.01). Seven (10.1%) cases were complicated with prolapse, 8 (11.6%) with stenosis, and 10 (14.5%) with peristomal dermatitis, all of them were males.

DISCUSSION

About 75.4% of cases developed morphological improvement, while 24.6% of cases not improved (p-value = 0.0001). Improvement or stability of glomerular filtration rate (GFR) was seen in 84.1%, while 15.9% deteriorated GFR (p-value = 0.0001). This deterioration is associated with prenatal renal dysplasia. Age less than one year, abdominal swelling, severe HUN, grade V VUR and recurrent UTI before vesicostomy all independently affect functional improvement after vesicostomy.

CONCLUSION

Vesicostomy is a simple, reversible, and well-tolerated surgery with few complications that is indicated in children with bladder outlet obstruction, bladder dysfunction, and high-grade VUR to protect UUT, improve renal function, decrease VUR, hydronephrosis, and febrile UTI. Age less than one year, abdominal swelling, severe HUN, grade V VUR and recurrent UTI before vesicostomy all were predictors that independently affect morphological and functional outcomes after vesicostomy.

Robotic parastomal hernia repair

Introduction and Objective:

Annually, more than one hundred thousand new stomas are created in the United States and near 30-50% of those will develop parastomal hernia ( 1 ). Occasionally parastomal hernias may result in life threatening complications such as bowel obstruction or strangulation requiring urgent surgical intervention ( 2 ). The minimally invasive surgery for these hernias are preferred, specially when the primary case was either laparoscopic or robot-assisted. Our objective is to demonstrate a step-by-step robotic approach with and without mesh placement and their outcomes in two different scenarios: elective and emergency.

Materials and Methods:

We present two cases, a 56-year-old male with three years prior robot-assisted radical cystectomy with ileal conduit and a 82-year-old male with five year post operation of laparoscopic radical cystectomy with bilateral ureterostomies. Both of them had parastomal hernia, the first case was an urgency due to bowel obstruction while the second case was an elective procedure. Using three portals, we choose the primary repair for the first case and placement of a biological mesh within the keyhole technique ( 3 ) for the second one.

Results:

In the first case we had an operative time of 110min, total blood loss of 40cc and for the second case an operative time of 140min with total blood loss of 20cc. Both patients were discharged within 24h and had a follow-up of 2 years with no recurrence.

Conclusions:

The capability for complex sutures and dissection of intracorporeal structures makes the robotic platform a powerful ally ( 4 ) and we believe in its superiority over conventional laparoscopy. Although further studies are required, our initial series suggests that the robotic parastomal hernia repair is feasible and reproducible, with or without mesh placement and could be demonstrated its use for either elective or emergency situations.