Urethral diverticulum after laparoscopically-assisted anorectal pull-through (LAARP) for anorectal malformation: is resection of the diverticulum always necessary?

SUMMARY OBJECTIVES: With the increased use of minimally invasive surgery, the urethral diverticulum after anorectal surgery has become an issue. The few cases reported have been managed by surgical excision. We hereby report a case of urethral diverticulum after a laparoscopically-assisted anorectal pull-through (LAARP)procedure with a successful outcome after a period of active surveillance. METHODS: A full-term boy who displayed a high anorectal malformation (ARM) and a rectoprostatic fistula underwent colostomy on the first day. He also showed associated malformations: bilateral low-grade reflux, horseshoe kidney and thoracic hemivertebrae; however, there were no signs of spinal cord tethering. Antimicrobial prophylaxis was started. RESULTS: At the age of 3 months, he underwent a LAARP with a 3 abdominal-port approach. After complete dissection of the distal bowel, the recto-prostatic fistula was identified and tied with metallic clips. A 10 mm trocar was inserted through the centre of the sphincteric complex, which had been previously identified under laparoscopic view during perineal electrical stimulation. The anorectal pull-through was accomplished without tension. The bladder remained stented for 14 days. On the 18th postoperative day, a voiding cystourethrogram (VCUG) showed a 15 X 5 mm image of the diverticulum at the level of the membranous urethra. After 6 months, a new VCUG showed a normal urethra with neither signs of the diverticulum nor strictures; persistence of grade 2 reflux on the right side and resolution of the reflux on the left. When the boy was one year old his colostomy was closed uneventfully. Six months later he had not come into the emergency since the operation and voided with a normal flow. CONCLUSION: This report suggests that LAARP is a feasible approach for ARM, although urethral diverticulum is a major concern. It may evolve without complications, and eventually resolve spontaneously. Active surveillance might be an option in selected asymptomatic patients; however a longer follow-up is advised to constitute better evidence supporting that policy.

Divertículo uretral luego de descenso anorectal asistido por laparoscopia (DARAL) en malformación anorectal: Es siempre necesario resecar el divertículo? / Urethral diverticulum after laparoscopic-assisted anorectal pull-through (laarp) for anorectal malformation: is resecting the diverticulum always necessary?

OBJETIVO: Con el uso cada vez mayor de la cirugía mínimamente invasiva, el divertículo uretral tras la cirugía anorectal se ha convertido en un problema. Los pocos casos descritos se han manejado con extirpación quirúrgica. Nosotros describimos un caso de divertículo uretral tras descenso anorectal asistido por laparoscopía (DARAL) con un resultado exitoso despues de un período de vigilancia activa.MÉTODO: Se trata de un paciente de sexo masculino, nacido a término, portador de una malformación anorectal (MAR) alta con fístula recto-prostática fue sometido a una colostomía el primer día de vida. También portador de malformaciones asociadas; reflujo bilateral de bajo grado, riñón en herradura y una hemi-vértebra torácica; sin embargo, sin signos de médula anclada. Se inició profilaxis antibiótica.RESULTADOS: A los 3 meses de edad, fue sometido a un DARAL con un abordaje abdominal de 3 puertos. Despues de la completa disección del intestino distal, la fístula recto-prostática fue identificada y ligada con clips metálicos. Un trocar de 10mm fue insertado a través del centro del complejo esfinteriano, que fue previamente identificado bajo visión laparoscópica durante la estimulación eléctrica perineal. El descenso anorectal se llevó a cabo sin tensión. La vejiga permaneció drenada con catéter uretral por 14 días. En el 18º día post-operatorio, una cistografía miccional mostró una imagen diverticular de 15 x 5mm a nivel de la uretra membranosa. Despues de 6 meses, una nueva cistografía miccional mostró una uretra normal sin signos de divertículo ni estenosis; persistencia de reflujo grado 2 a derecha y resolución de reflujo a izquierda. Al año de vida la colostomía fue cerrada sin problemas. Seis meses después, se ha mantenido libre de infección urinaria y su micción es con flujo normal(AU)

CONCLUSIÓN: Este artículo sugiere que el DARAL es un abordaje factible para MAR, aunque el divertículo uretral es una de las principales preocupaciones. Puede evolucionar sin complicaciones, y eventualmente resolverse en forma espontánea. La vigilancia activa puede ser una opción en pacientes asintomáticos seleccionados, sin embargo se recomienda un mayor seguimiento para constituir una mejor evidencia que apoye esta medida(AU)

OBJECTIVES: With the increased use of minimally invasive surgery, the urethral diverticulum after anorectal surgery has become an issue. The few cases reported have been managed by surgical excision. We hereby report a case of urethral diverticulum after a laparoscopically-assisted anorectal pull-through (LAARP)procedure with a successful outcome after a period of active surveillance.METHODS: A full-term boy who displayed a high anorectal malformation (ARM) and a recto-prostatic fistula underwent colostomy on the first day. He also showed associated malformations: bilateral low-grade reflux, horseshoe kidney and thoracic hemivertebrae; however, there were no signs of spinal cord tethering. Antimicrobial prophylaxis was started.RESULTS: At the age of 3 months, he underwent a LAARP with a 3 abdominal-port approach. After complete dissection of the distal bowel, the recto-prostatic fistula was identified and tied with metallic clips. A 10 mm trocar was inserted through the centre of the sphincteric complex, which had been previously identified under laparoscopic view during perineal electrical stimulation. The anorectal pull-through was accomplished without tension. The bladder remained stented for 14 days. On the 18th postoperative day, a voiding cystourethrogram (VCUG) showed a 15 X 5 mm image of the diverticulum at the level of the membranous urethra. After 6 months, a new VCUG showed a normal urethra with neither signs of the diverticulum nor strictures; persistence of grade 2 reflux on the right side and resolution of the reflux on the left. When the boy was one year old his colostomy was closed uneventfully. Six months later he had not come into the emergency since the operation and voided with a normal flow(AU)

CONCLUSION: This report suggests that LAARP is a feasible approach for ARM, although urethral diverticulum is a major concern. It may evolve without complications, and eventually resolve spontaneously. Active surveillance might be an option in selected asymptomatic patients; however a longer follow-up is advised to constitute better evidence supporting that policy(AU)

[Varicocele in the adolescent. What is the best surgical option?]. / Varicocele adolescente. Cual es la mejor opción quirúrgica?

OBJECTIVES: To compare three different surgical approaches for the performance of varicocelectomy in the pediatric population, analyzing their effectiveness and secondary complications. METHODS: Over an eight year period 90 varicocelectomies were performed in 89 children with a mean age of 12 years (range 8-16). Patients were divided into three groups, in 21 cases laparoscopic approach was performed (Group 1), in 55 the Palomo's retroperitoneal approach (Group 2) and inguinal approach in 14 cases (Group 3). Preoperative demographic characteristics, and intraoperative data, followup and complications were analyzed. RESULTS: Age, indication and follow-up time were similar in all three groups. Average surgical time were 36 minutes,34 minutes and 30 minutes respectively. Recurrences appeared in one (4%), 5 (9%) and 0 patients respectively. Postoperative hydrocele requiring surgical treatment appeared in 2 (9%), 4 (7%) and 0 respectively, with an incidence of hydrocele of 2 cases (9%), 5 (9%) and 1 (7%) which resolved during follow-up. One patient presented bleeding at the site of trocar insertion which was solved intraoperatively, and another patient in the laparoscopy group had a wound infection. CONCLUSIONS: Comparisons between the three groups reveal that there were not significant differences, although the results were somewhat better in the inguinal approach group. Any technique has adequate results, with a total recurrence rate in our series of 6%, and 6% of hydroceles. The development of methods that will make possible to diminish hydrocele, such as lymphatic preservation, will give better general results.

Varicocele adolescente. ¿Cuál es la mejor opción quirúrgica? / Varicocele in adolescent. What is the best surgical option?

Objetivo: Comparar tres diferentes abordajes para la realización de varicocelectomia en la población pediátrica, analizando su efectividad y complicaciones secundarias. Métodos: En 8 años 90 varicocelectomias fueron realizadas en 89 niños con una media de edad de 12 años (Rango 8-16). Los pacientes se dividieron en 3 grupos, en 21 casos se realizo laparoscópico (Grupo 1), en 55 abordaje retroperitoneal de palomo (Grupo 2) y en 14 casos abordaje inguinal (grupo 3). Se analizaron características demográficas prequirúrgicas, datos intraoperatorios, seguimiento y complicaciones. Resultados: La edad, la indicación y el tiempo de seguimiento fueron similares en los tres grupos. El tiempo quirúrgico fue en promedio de 36 min, 34 min y 30 min en cada uno de los grupos. Recurrencias se presentaron en 1(4%), 5(9%) y 0 respectivamente. Hidrocele postoperatorio que requirió manejo quirúrgico se presento en 2(9%), 4(7%), 0 respectivamente y en 2(9%), 5(9%), 1(7%) se presentaron hidroceles en cada grupo los cuales resolvieron con el tiempo de seguimiento. Se presento en un paciente sangrado del sitio de inserción del trocar el cual se resolvió intraoperatoriamente y en un caso infección de herida quirúrgica en el grupo de laparoscopia. Conclusiones: La comparación de los tres grupos revela que no se presentaron diferencias significativas aunque se presentaron algunos resultados mejores con el inguinal. Cualquier técnica realizada provee resultados adecuados y en nuestra serie se presento recurrencia total del 6% e hidrocele del 6%. El desarrollo de métodos que permitan disminuir el hidrocele como la preservación linfática podrá dar mejores resultados generales (AU)

Objectives: To compare three different surgical approaches for the performance of varicocelectomy in the pediatric population, analyzing their effectiveness and secondary complications. Methods: Over an eight year period 90 varicocelectomies were performed in 89 children with a mean age of 12 years (range 8-16). Patients were divided into three groups, in 21 cases laparoscopic approach was performed (Group 1), in 55 the Palomo's retroperitoneal approach (Group 2) and inguinal approach in 14 cases (Group 3). Preoperative demographic characteristics, and intraoperative data, follow-up and complications were analyzed. Results: Age, indication and follow-up time were similar in all three groups. Average surgical time were 36 minutes,34 minutes and 30 minutes respectively. Recurrences appeared in one (4%), 5 (9%) and 0 patients respectively. Postoperative hydrocele requiring surgical treatment appeared in 2 (9%), 4 (7%) and 0 respectively, with an incidence of hydrocele of 2 cases (9%), 5 (9%) and 1 (7%) which resolved during follow-up. One patient presented bleeding at the site of trocar insertion which was solved intraoperatively, and another patient in the laparoscopy group had a wound infection. Conclusions: Comparisons between the three groups reveal that there were not significant differences, although the results were somewhat better in the inguinal approach group. Any technique has adequate results, with a total recurrence rate in our series of 6%, and 6% of hydroceles. The development of methods that will make possible to diminish hydrocele, such as lymphatic preservation, will give better general results (AU)