Progressive Perineal Urethroplasty for Pelvic Fracture Urethral Distraction Defect in Prepubertal Children: The Outcome.

BACKGROUND: Urethroplasty in pediatric patients is a challenging task. In this study, we have tried to assess the complexity and evaluate the outcome of progressive perineal anastomotic urethroplasty in prepubertal children. MATERIALS AND METHODS: Retrospective data of all the prepubertal children who underwent progressive perineal urethroplasty between March 2009 and April 2014 were analyzed. Patients were evaluated with history, examination, essential laboratory investigations, retrograde urethrogram, and voiding cystourethrogram. Before subjecting the patients for definitive surgery, antegrade and retrograde endoscopic assessment was done. The surgery was performed by the transperineal route with the help of ×2.5 magnification. Patients were followed up with uroflowmetry for every 3 months in the 1st year and for every 6 months in the subsequent years. RESULTS: Mean age of the patients was 7.3 (range 5-11) years. Mean urethral distraction defect was 1.7 (range 1-2.5) cm. All the patients were successfully managed by the perineal approach. Crural separation was performed in all the patients while additional inferior pubectomy was required in six patients. Mean operating time was 298 (range 180-400) min. Mean blood loss was 174 (range 100-500) ml. One patient had the left calf hematoma in the immediate postoperative period. Seven out of nine (77.7%) patients had successful urethroplasty. Two patients had failed urethroplasty who were successfully managed by redo-urethroplasty. Transient incontinence was observed in one patient. Erectile function could not be assessed in these patients. CONCLUSION: This study shows the feasibility of progressive perineal urethroplasty by the perineal route in prepubertal children. An endoscopic assessment should be performed before the definitive surgery. Use of loupe helps in performing better anastomosis and hence yielding a better result.

Laparoscopic repair of urogenital fistulae: A single centre experience.

CONTEXT: Sparse literature exists on laparoscopic repair of urogenital fistulae (UGF). AIMS: The purpose of the following study is to report our experience of laparoscopic UGF repair with emphasis on important steps for a successful laparoscopic repair. SETTINGS AND DESIGN: Data of patients who underwent laparoscopic repair of UGF from 2003 to 2012 was retrospectively reviewed. MATERIALS AND METHODS: Data was reviewed as to the aetiology, prior failed attempts, size, number and location of fistula, mean operative time, blood loss, post-operative storage/voiding symptoms and episodes of urinary tract infections (UTI). RESULTS: Laparoscopic repair of 22 supratrigonal vesicovaginal fistulae (VVF) (five recurrent) and 31 ureterovaginal fistulae (UVF) was performed. VVF followed transabdominal hysterectomy (14), lower segment caesarean section (LSCS) (7) and oophrectomy (1). UVF followed laparoscopy assisted vaginal hysterectomy (18), transvaginal hysterectomy (2) and transabdominal hysterectomy (10) and LSCS (1). Mean VVF size was 14 mm. Mean operative time and blood loss for VVF and UVF were 140 min, 75 ml and 130 min, 60 ml respectively. In 20 VVF repairs tissue was interposed between non-overlapping suture lines. Vesico-psoas hitch was done in 29 patients of urterovaginal fistulae. All patients were continent following surgery. There were no urinary complaints in VVF patients and no UTI in UVF patients over a median follow-up of 3.2 years and 2.8 years respectively. CONCLUSION: Laparoscopic repair of UGF gives easy, quick access to the pelvic cavity. Interposition of tissue during VVF repair and vesico-psoas hitch during UVF repair form important steps to ensure successful repair.

Laparoscopic trans-mesocolic pyeloplasty in children: initial experience from a center in India.

The aim of the present study is to report our experience with laparoscopic pyeloplasty via trans-mesocolic approach in children with left pelvi-ureteric junction (PUJ) obstruction. Between May 2007 and May 2008, 12 children aged between five and 16 years, with documented PUJ obstruction on the left side, underwent laparoscopic pyeloplasty via trans-mesocolic approach. The outcome was assessed by post-operative isotope renal scan. The mean age of the study patients was eight years, ranging between five and 16 years. There were five males and seven females in the study. All children underwent Anderson Hynes Pyeloplasty by a single surgeon. All cases were stented with a JJ stent for a period of six weeks post-operatively. The procedures were completed successfully in all patients without need for conversion to open pyeloplasty in any patient. The mean operative time was 95 min, with a range of 80-140 min. The average blood loss was 57 mL. The mean hospital stay was 3.5 days with a range of 2.5 to six days. All children returned back to school within nine days following surgery. The mean follow-up period was 12 months (range, nine to 14 months). Eleven of the patients were completely asymptomatic, while one reported mild flank pain. All children underwent renal scans and renal ultrasound three months after stent removal. Ten had improved function on the scan while in one patient, the function remained the same and, in another, it showed obstructed response to diuretic, although the symptoms had improved. In all the cases, renal ultrasound showed a decrease in the severity of hydronephrosis by at least one degree. These results confirm that laparoscopic pyeloplasty by trans-mesocolic approach in children for left-sided PUJ obstruction is safe and feasible.

Retroperitoneal versus transperitoneal laparoscopic pyeloplasty: our experience.

OBJECTIVE: Laparoscopic pyeloplasty, which has been quoted to have a success rate equivalent to open pyeloplasty for ureteropelvic junction obstruction (UPJO), can be performed transperitoneally and retroperitoneally. The aim of the present study is to report our experience with these 2 routes of laparoscopic pyeloplasty and to further improve our understanding of the merits and demerits of these 2 routes. PATIENTS AND METHODS: A total of 47 laparoscopic pyeloplasties were performed at our center from June 2000 to August 2009. Twelve pyeloplasties were performed transperitoneally and 35 retroperitoneally. RESULTS: In the retroperitoneal group, we had a success rate of 91.5% after a mean follow-up of 22 months, and in the transperitoneal group, we had a success rate of 91.7% after a mean follow-up of 48 months. The mean operative time was 156 min in the retroperitoneal group and 195 min in the transperitoneal group. CONCLUSION: This study shows a success rate comparable with open pyeloplasty and favors the retroperitoneal route with a shorter operative time, less dissection needed, a higher sensitivity of detecting crossing vessels, a decreased risk in visceral injury and an early start of oral feeds.

Laparoscopic and open incisional hernia repair using polypropylene mesh - a comparative single centre study.

INTRODUCTION: Repair of incisional hernias continues to be a challenging surgical procedure for general surgeons. Currently open mesh repair and laparoscopic repair are the two main options available for general surgeon for managing this complication. Laparoscopic repair though offers all the advantages of minimal access surgery but is a costly procedure especially due to the use of costly composite mesh. The present study is aimed to compare the open and laparoscopic repair of incisional hernia and at the same time evaluate the safety and feasibility of using comparatively cheaper polypropylene mesh. METHODS: Between December 2005 and December 2009 80 patients underwent incisional hernia repair, 40 open repairs and 40 laparoscopic repair. The results of the two procedures were compared with a mean follow up of 26 months for open repair and 28 months for laparoscopic repair. RESULTS: Obstetrical or gynecological procedure was the most common index surgery leading to incisional hernia and lower midline incision was the most common site of hernia. The mean defect size in open repair group was 55.2 cm(2) and 62.2 cm(2) in laparoscopic repair group. Polypropylene mesh was used in all cases. We had 1(2.5%) major complication of enterotomy and 1(2.5%) conversion in laparoscopic repair group. Postoperative complications were most commonly seen in open repair group 10(25%) and 2(5%) in laparoscopic repair group. Mean hospital stay in open repair group is 4.33 days and 1.53 days in laparoscopic repair group. We had 1(2.5%) recurrence in both groups. CONCLUSION: Laparoscopic repair of incisional hernia is a much better procedure for curing incisional hernia as compared to open mesh repair and additionally intraperitoneal use of polypropylene mesh was not associated with any significant complication.

Use of rigid nephroscope for laparoscopic common bile duct exploration-a single-center experience.

BACKGROUND: Increasingly, laparoscopic biliary surgeons are undertaking laparoscopic cholecystectomy and laparoscopic common bile duct exploration for patients with cholelithiasis and choledocholithiasis. In laparoscopic common bile duct exploration a flexible choledochoscope is ordinarily used, and with this instrument the surgeon usually fails to remove large impacted stones. In contrast with use of a rigid nephroscope it is possible to remove all common bile duct stones irrespective of size and degree of impaction. The present study evaluates the efficiency of rigid nephroscope for managing common bile duct stones laparoscopically. METHODS: In the present study laparoscopic common bile duct exploration for stones was performed in 80 patients via standard laparoscopic cholecystectomy port sites. Patients with a common bile duct diameter >10 mm were included in this study. The rigid nephroscope was passed through the epigastric port and negotiated into the common bile duct through a choledochotomy. Stones were removed with graspers. Large hard stones were fragmented by pneumatic lithotripsy. RESULTS: Of the 80 patients treated in this manner, 72 (90%) had multiple common bile duct calculi, and 8 (10%) had a solitary common bile duct calculus. Mean common bile duct diameter was 15.3 mm (range: 10-37 mm). Conversion to open common bile duct exploration was necessary in 1 case (1.25%) because of difficult dissection secondary to extensive dense adhesions. In 7 patients (8.75%) a pneumatic lithotripter was used to fragment stones. Choledochotomy was managed by placing a T-tube in 21 (26.25%) patients, by effecting primary closure in 58 (72.5%) patients, and by choledochoduodenostomy in 1 (1.25%) patient. The mean operative time in this series was 83 min (range: 53-135 min). The mean postoperative hospital stay was 4.2 days (range: 3-19 days). One patient (1.25%) developed cholangitis 5 months after laparoscopic common bile duct exploration; the cause was a residual common bile duct stone. CONCLUSIONS: A rigid nephroscope can be used for managing all types of common bile duct calculi irrespective of site, size, composition, or degree of impaction. Its use can be expected to become the standard for laparoscopic common bile duct exploration, especially for removing large calculi from a dilated common bile duct.

Retroperitoneal laparoscopic uretero-pyelostomy for symptomatic yo-yo reflux.

Incomplete ureteric duplication is usually an incidental finding. However, this condition may occasionally be symptomatic and warrant surgical correction. Various surgical procedures are used to treat this condition with varying degrees of success. We present the case report of a 21-year-old female who had right-sided symptomatic incomplete ureteric duplication and was managed by retroperitoneal laparoscopic ureteropyelostomy. To our knowledge, this is the first reported case of such a procedure.