Cohen Reimplantation Research Articles

Clinical efficacy of laparoscopic Lich-Gregoir versus transvesicoscopic Cohen reimplantation for ureterobladder junction malformations in children.

To assess the clinical efficacy of laparoscopic Lich-Gregoir (LLG) and transvesicoscopic Cohen reimplantation (TCR) in the treatment of vesicoureteral junction obstruction (VUJO) and vesicoureteral reflux (VUR). This study retrospectively analyzed the clinical data of 66 pediatric patients with VUJO and VUR. They were classified into two groups, undergoing either the laparoscopic Lich-Gregoir operation (LLGO) (n = 35) or transvesicoscopic Cohen reimplantation operation (TCRO) (n = 31). The surgeries were performed between April 2018 and September 2022 at the First Affiliated Hospital of Guangxi Medical University, China. General characteristics, preoperative attributes, postoperative complications, renal function recovery, and improvement of hydronephrosis were compared between the two groups. All surgical procedures were successful with no requirement for reoperation. Both groups were comparable with respect to gender, affected side, weight, and postoperative complications. Nonetheless, the LLGO group contained a greater number of children younger than 12months. The LLGO group demonstrated superiority over the TCRO group regarding the duration of the operation, intraoperative blood loss, and length of postoperative hospital stay. In contrast, postoperative complications, recovery of renal function, and hydronephrosis improvement did not exhibit statistically significant differences between the two groups. Both LLGO and TCRO were demonstrated to be precise, safe, and reliable surgical methods for treating pediatric VUJO and VUR. LLGO ureteral reimplantation offers particular advantages in selecting cases and appears more suitable for children younger than 12months who have a small bladder capacity.

Peadiatric transvesicoscopic dismembered ureteric reimplantation for ectopic upper ureter in duplication anomalies

Ectopic upper pole ureters in duplex kidneys can be managed surgically by ipsilateral distal ureteroureterostomy or reimplantation of both ipsilateral ureters when upper pole shows reasonable function. This study aimed to evaluate the clinical outcomes of transvesicoscopic dismembered upper ureteric reimplantation for patients with ectopic upper pole ureters in duplication anomalies. Between July 2015 and January 2019, laparoscopic transvesicoscopic ureteral reimplantation was performed in 20 patients with ectopic upper pole ureters. An incision was made in the bladder wall at 1.0cm proximal to the lower ureteral orifice of affected side. The upper pole ureter was recognized, and the terminal portion of the upper ureter was ligated and cut. Then the proximal portion of the upper ureter was mobilized, a transverse submucosal tunnel was created and upper ureteric reimplantation was performed with 6/0 absorbable sutures. Patients were followed up with renal ultrasonography and voiding cystourethrogram for clinical outcomes and hydronephrosis trends. Median (range) age at surgery was 22.5 (10-53) months. All of the 20 operations were successful, and none required conversion to an extravesical approach or open surgery. Four patients presented with worsening upper pole hydroureteronephrosis but recovered three to six months postoperatively. Resolution of symptoms and improving hydroureteronephrosis were achieved in all patients and VUR of the upper and lower ureters was not detected at postoperative follow-up. To our knowledge, dismembered reimplantation of upper pole ureters has been reported only in a small series through extravesical technique. In our study, we performed intravesicoscopic upper ureter Cohen reimplantation for duplex system ureteral ectopia. Compared with the extravesical approach, the transvesicoscopic approach leave most of the pelvic structures intact and the creation of a submucosal tunnel for prevention of ureteral reflux is more reliable; in addition, this approach avoids any manipulation of the lower pole ureter compared to ipsilateral ureteroureterostomy. But this method does not seem applicable to children under 6 months of age because of the small bladder capacity. The laparoscopic intravesical technique of dismembered ureteral reimplantation was safe and feasible in our cases and may be an alternative surgical treatment for ectopic upper pole ureters in duplication anomalies.

Robotic Assisted Vesicoscopic Cohen's Reimplantation in Pediatric Patient: Nuances of Technique, Experience, and Outcome.

Aim: Vesicoscopic Cohen's reimplantation closely replicates the open procedure and is reported to have equally good results. Robotic assisted vesicoscopic reimplantation (RAVR) is a new procedure, and the information on technique of RAVR is sparse. We present our technique, experience, and early outcome with RAVR and review of literature. Patients and Methods: We retrospectively evaluated patients with vesicoureteric reflux grade II and above. These patients were subjected to RAVR. Selection criteria for this procedure were age >4 years, preserved renal function, and bladder capacity >250 mL. Patients with previous bladder surgery or urethral issues were excluded. Patients were operated by DaVinci Si system, and the technique is described in detail. Three ports were placed by use of bougie. The ureters were adequately mobilized before placing in submucosal tunnel. Results: Total of 5 ureters were reimplanted in 4 patients (2 females and 1 bilateral). Ureteral tapering was done in 1 patient. Mean port placement time was 25 minutes with 12 minutes of docking time. Mean console time was 70 minutes for unilateral cases and 100 minutes for the bilateral case. There was resolution of reflux in all patients. The mean follow-up duration is 9 months. Conclusions: Robotic assisted vesicoscopic reimplantation is a feasible and safe method of replicating Cohen's reimplantation. There is a learning curve with the procedure, and nuances related to the technique need to be learned by the surgeon. This is the third report on RAVR and provides the necessary technical details required by a robotic surgeon to replicate this procedure.

Comparative Clinical Study Between Modified Ureteral Orthotopic Reimplantation and Cohen Method Under Pneumovesicum in Pediatric Patients With Hydroureteronephrosis

Purpose: To report our initial experience with a modified ureteral orthotopic reimplantation technique under pneumovesicum and compare the outcomes vs. those obtained with the Cohen technique under pneumovesicum for the correction of primary obstructive megaureter (POM) or vesicoureteral reflux(VUR) in pediatric patients.Methods: A total of 46 patients (38 POM and 8 VUR; mean age: 16.24 months) treated with modified ureteral orthotopic reimplantation (OR) and 43 patients (34 POM and 9 VUR; mean age: 22.98 months) treated with Cohen reimplantation (CR) under pneumovesicum were included. We compared the results perioperatively and during follow-up.Results: The mean operative time was significantly shorter in the OR group (OR: 86.86 and 108.18 vs. CR: 95.14 and 124.29 min for unilateral and bilateral cases, respectively). The mean postoperative hospital stay (OR: 5.02 vs. CR: 5.07 days), blood loss (OR: 3.67 vs. CR: 3.84 ml), and follow-up time (OR: 23.17 vs. CR: 23.37 months) did not exhibit significant differences between the two groups. One patient converted to open surgery in the CR group, whereas there was no conversion in the OR group. Postoperative febrile urinary tract infection occurred in two cases in each group. Both infections were controlled using antibiotics. All patients in both groups showed improved hydroureteronephrosis, and all patients with VUR showed reflux resolution post-surgery.Conclusions: Our modified ureteral orthotopic reimplantation technique under pneumovesicum can be safely and effectively performed, achieving a high success rate that is equivalent to that obtained through the Cohen technique under pneumovesicum. Moreover, it involves a simpler procedure and shorter operation time.

Technical challenges of endoscopic treatment for vesicoureteral reflux after Cohen reimplantation

IntroductionThe range of indications for endoscopic treatment of vesicoureteral reflux opens more and more until including correction of secondary reflux (VUR) after ureteral reimplantation. However these cases suppose a technical challenge due to postoperative changes.The aim of this work is to present our experience on endoscopic treatment for VUR in ureteral units with Cohen reimplantation surgery, with special interest in the technical peculiarities of the procedure. Material and methodsA retrospective study of cases of secondary VUR after reimplantation surgery treated by subureteral injection. TechniqueWe put the needle perpendicular to submucous tunnel and inject medially to hole forming a wheal on the anterior face that occludes the meatus. ResultsDuring the 1993–2016 period 21 injections were performed in 15 ureteral units. The ureteral pathology included primary VUR (4), duplex system with lower pole reflux (4), megaureter (3) and ureterocele (2). Average patient age was 5.7 years old (2–12). Successful outcome had been got in 10 ureteral units (66.67%), a decrease of VUR grade in 4 (26.67%) and perseverance/no resolution of grade IV VUR in 1 (6.67%). DiscussionThe anti-reflux mechanism of reimplantation depends on optimizing the submucosous tunnel. This subgroup of patients is small and there are few studies, hindering the agreement on the most appropriate technique. ConclusionEndoscopic treatment of secondary reflux after reimplantation surgery is a procedure with certain technical feature, but safe and effective offering an alternative prior to surgical reoperation.

Editorial Comment to Successful percutaneous flexible ureteroscopy for treatment of distal ureteral stones under modified Valdivia position after Cohen reimplantation.

Editorial Comment to Successful percutaneous flexible ureteroscopy for treatment of distal ureteral stones under modified Valdivia position after Cohen reimplantation.

Consideraciones técnicas en el tratamiento endoscópico del reflujo vesicoureteral tras reimplante tipo Cohen

IntroductionThe range of indications for endoscopic treatment of vesicoureteral reflux opens more and more until including correction of secondary reflux (VUR) after ureteral reimplantation. However these cases suppose a technical challenge due to postoperative changes.The aim of this work is to present our experience on endoscopic treatment for VUR in ureteral units with Cohen reimplantation surgery, with special interest in the technical peculiarities of the procedure. Material and methodsA retrospective study of cases of secondary VUR after reimplantation surgery treated by subureteral injection. TechniqueWe put the needle perpendicular to submucous tunnel and inject medially to hole forming a wheal on the anterior face that occludes the meatus ResultsDuring the 1993-2016 period 21 injections were performed in 15 ureteral units. The ureteral pathology included primary VUR (4), duplex system with lower pole reflux (4), megaureter (3) and ureterocele (2). Average patient age was 5.7 years old (2-12). Succesful outcome had been got in 10 ureteral units (66.67%), a decrease of VUR grade in 4 (26.67%) and perseverance/no resolution of grade IV VUR in 1 (6.67%) DiscussionThe anti-reflux mechanism of reimplantation depends on optimizing the submucosous tunnel. This subgroup of pacients is small and there are few studies, hindering the agreement on the most appropiate technique. ConclusionEndoscopic treatment of secondary reflux after reimplantation surgery is a procedure with certain technical feature, but safe and effective offering an alternative prior to surgical reoperation.

L’évolution à long terme du reflux vésico-rénal chez l’enfant

Le reflux vésico-rénal (RVR) est une pathologie assez fréquente chez l'enfant nécessitant un suivi long pour réduire l'évolution vers l'insuffisance rénale chronique. L'objectif de notre étude est d'analyser les aspects épidémiologiques, le diagnostic, la prise en charge du reflux vésico-rénal et l'évolution à long de terme de cette pathologie. Pour cela on a mené une étude rétrospective portant sur une série de 42 patients hospitalisés au Service de Chirurgie Pédiatrique Viscérale du CHU Hassan II de Fès suspectés porteurs d'un reflux vésico-rénal (RVR) sur une période de 6 ans allant de janvier 2010 à décembre 2015. On a trouvé que l'âge médian au moment du diagnostic était de 3 ans et 2 mois. Le sex ratio était de 1,8 garçon pour fille. Le RVR était retrouvé isolé chez 81%, et secondaire ou associé chez 19%. Le principal mode de révélation était l'infection urinaire (90,4%). La fonction rénale était altérée chez 54,8% des enfants. Le traitement a consisté en une antibiothérapie des IU documentées (90,4%) et une antibio-prophylaxie si récidive, une réimplantation de type COHEN dans 97,62%. L'indication chirurgicale a concerné d'emblée tous les grades IV et V (73,9%), ainsi que les reins altérés, et 26,1% après traitement médical. L'évolution postopératoire précoce et tardive était en général satisfaisante: on a noté 92,68% de disparition du RVR. L'UHN a régressé sauf chez 9,52% patients, 95,23% malades ont normalisé leur fonction rénale. La récurrence des IU a diminué (19,04 % après la chirurgie). La majorité des parents ont jugé positivement l'évolution de l'état général de leurs enfants (54,76 %) après la chirurgie.

Modified ureteral orthotopic reimplantation method for managing infant primary obstructive megaureter: a preliminary study.

To describe a modified ureteral orthotopic reimplantation method in infant with primary obstructive megaureter (POM) and report our initial experience. Thirteen children with POM (range 1-7months) underwent modified transvesical ureteral implantation surgery. Treatment consists of transecting the ureter proximal to the obstruction and performing orthotopic reimplantation in end freely fashion with distal ureter protruding into the bladder, providing dilated ureteral diameter: ureteral exposure length in bladder ratio of 1:1.5-2. All patients underwent repeat ultrasound, radionuclide imaging and voiding cystourethrography. Cystoscopy was conducted in patients at 6months after surgery. The mean operating time was 40min. There were one redo this procedure for recurrent obstruction and one Cohen reimplantation for Grade 5 vesico-ureteral reflux in one bilateral POM. Hydroureteronephrosis improved in other 11 patients, and the ureter diameter was significantly reduced from preoperative measurements. At the time of cystoscopy, thick and large volcanic-shaped ureteral orifice was found and urine ejected intermittently. The proposed 'modified ureteral orthotopic reimplantation' with no tapering or advancement for POM in infants is a simple, feasible and less invasive procedure that had good success rates in this small series. Further, larger studies are required to support or negate the usefulness of this technique.

Evaluation of Mathisen's technique for ureteral reimplantation in children with primary vesicoureteral reflux

Although cross-trigonal ureteral reimplantation (Cohen) is a commonly used technique in children, it represents a non-physiological transfer of the ureteral orifices and may prove challenging with regard to endoscopic ureteral operations in later life. In 1964, Mathisen described an alternative method of ureteral reimplantation with lateralization of the neohiatus, creating an orthotopic course of the submucosal ureter. We have evaluated success and complication rates of both techniques that were applied sequentially at our departments. Forty-eight consecutive patients (83 ureters, 24 males/24 females) following Mathisen reimplantation were compared with 53 consecutive patients (98 ureters, 30 males/23 females) following Cohen reimplantation. Inclusion criteria were primary vesicoureteralreflux (VUR) and no previous intervention. Reflux grades (Mathisen 58 ureters/69.9% VUR ≥ III; Cohen 66 ureters/66.7% VUR ≥ III) and the occurence of other complicating factors (ureteroceles, megaureters, posterior urethral valves) in both groups were comparable. After Cohen's reimplantation there were no immediate complications requiring intervention; during follow-up (mean 28.2 months) three patients (5.6%) suffered febrile urinary tract infections (UTIs), of which one (1.8%) was diagnosed with a persisting VUR. Persistent hydronephroses (≥II SFU) were recorded in six patients (13.2%). After reimplantation using Mathisen's technique, two patients (4.1%) suffered significant intravesical bleeding; during follow-up (mean 23.06 months) four patients (8.3%) suffered febrile UTIs, and seven patients (14.5%) were diagnosed with persisting VUR after a mean follow-up of 10.8 months. The patients with persistent VUR had more commonly high-grade (IV and V) VUR initially, compared to the whole group. Two patients (4.1%) had persistent hydronephroses (≥II SFU). Mathisen's technique for ureteral reimplantation yielded a significantly (p=0.0256 patients, p=0.006 ureterorenal units) lower success rate (85.5% patients, 89.2% ureterorenal units) in comparison with Cohen's technique (98.2% patients, 99% ureterorenal units). Although there was no intervention for obstruction, persistent hydronephrosis was more common in the Cohen group (13.2% vs. 4.1%, n.s.). Despite the advantages of an orthotopic ureteral orifice close to the bladder neck, as achieved by Mathisen's reimplantation, cross-trigonal ureteral reimplantation proved more reliable for VUR correction. As regards optimizing the results, patient selection for either technique could prove essential. Nevertheless, as regards the difficulties with ectopic ureteral orifices in the Cohen technique in the long-term follow-up, the concept of anatomic, orthotopic ureteral reimplantation should be pursued and the technique should be further refined.

Acute urinary retention secondary to giant prolapsed ureterocele in a young adult woman. Case report

Abstract Background Ureterocele is a cystic dilation of the distal ureteral segment. The incidence in women ranges from 1/5000 to 1/12,000. In adults, they are poorly diagnosed and are asymptomatic. Prolapse through the urethra is uncommon, and involves acute urine retention and a reducible vulvar tumour. Clinical case Woman of 24 years old, two previous caesarean and two abortions. She had incomplete bladder emptying, intermittent voiding, bladder straining and tenesmus, three months before admission. After the voiding effort she presented with acute urine retention with sudden onset of tumour in the vulva. The tumour was manually reduced under regional anaesthesia. A cystoscopy was performed, finding an ischaemic de-roofing of the anterior wall of the ureterocele, causing vesicoureteral reflux grade IV. Surgical correction was performed with Cohen re-implantation and insertion of a double-J catheter. The catheter was removed 30 days later, with a successful post-operative course. Discussion Its aetiology is unclear, and most are diagnosed by ultrasound in the prenatal period. The clinical presentation is variable, from urinary tract infection to prolapse. Despite its size, it may cause complications such as ischaemic de-roofing, which if diagnosed soon may be resolved successfully, as with this patient. Conclusion The results and treatment may be favourable when no renal impact or concomitant anatomical changes are present, as is the case of this patient.

Extravesical (modified Gregoir Lich) versus intravesical (Cohen's) ureteric reimplantation for vesicoureteral reflux in children: A single center experience.

Introduction:There are multiple techniques for surgical correction of vesicoureteral reflux (VUR). We compared the outcomes of extravesical versus Cohen's reimplantation for VUR in children.Methods:Records of all children (n = 118) who underwent reimplantation for VUR between 2003 and 2014 were analyzed (male: female = 43:75). Children with secondary VUR, duplication anomalies, and ectopic ureter were excluded from our study. Extravesical reimplantation (EVR) was performed bilateral in 32 children (Group 1a) and unilateral in 19 (Group 1b), while bilateral Cohen's reimplantation was performed in 67 (Group 2). Parameters compared were length of the surgical procedure, average duration of stay in the hospital, postoperative bladder spasms, significant hematuria >72 h, and long-term complications.Results:The mean age at operation was 15 months in Group 1, and 36 months in Group 2. The mean duration of surgery was significantly less (P = 0.0001) in Group 1a (n = 32; mean 104 min; standard deviation [SD] 18 min) compared to Group 2 (n = 67; mean 128 min; SD 15 min). The mean (SD) postoperative stay was significantly lower (P = 0.0001) at 4.5 (1.5) days in Group 1a compared to 6.5 (0.5) days in Group 2. Postoperative bladder spasms were significantly lower (P = 0.03) at 10/32 in Group 1a compared to 37/67 in Group 2. All patients responded well with anticholinergics. Postoperative hematuria and bladder spasms were significantly lower (P = 0.03) in Group 1a compared to Group 2. There was no significant difference in persistent VUR between Group 1 and Group 2. At 1 year follow, none of them had any evidence of ureteral obstruction.Conclusions:EVR has lower operative time, less postoperative discomfort and shorter hospital stay compared to Cohen's reimplantation. Both techniques are equally effective in treating reflux.

‘Mini reimplantation’ for the management of primary obstructed megaureter

The management of primary obstructed megaureter (POM) ranges from temporary double-J stenting to conventional ureteric reimplantation with tapering. Of late, several authors have favored refluxing reimplantation. In the present study the outcomes of 'mini reimplantation', where no tapering or advancement of the ureter was performed, have been analyzed. Records of all children (n = 28) who underwent reimplantation for POM from 2004 to 2014 were retrospectively analyzed. During the initial 5 years, a Cohen's reimplantation with excisional tapering was performed (Group 1, n = 15). Due to complications, the technique was modified in the second 5 years (Group 2, n = 13). In this group, after opening the bladder, the distal narrow segment and grossly dilated POM (around 3-5 cm) were excised (Figure). After closing the detrusor behind the ureter, the ureter was reimplanted again at the original position without tapering or advancement. Bladder mucosa was closed cranial to the new ureteric orifice, providing a ureter:tunnel ratio of 1:2 (mini reimplantation). All patients underwent repeat ultrasonogram and MAG3 renogram, with indirect at 6 months and 1 year after stent removal to exclude obstruction/vesicoureteral reflux (VUR). In Group 1, a significantly higher proportion (P = 0.04) of patients (5/15) had to undergo repeat procedures for complications, compared with none in Group 2. In Group 1, there were two redo reimplants for recurrent obstructions; two nephrectomies for non-functioning kidneys; and one ureterostomy for pyonephrosis. Postoperative Grade 2-3 VUR was encountered in 3/15 patients in Group 1, and 2/13 patients in Group 2. These patients could be managed with antibiotic prophylaxis and no intervention was required. Conventional management of POM involved initial cutaneous ureterostomy, followed by reimplantation with tapering of the ureter. Megaureter reimplantation with and without tapering has been reported to have no significant difference in outcomes between them. To avoid a potentially difficult operation in a small infant bladder, a refluxing reimplantation has been proposed; however, there is a high re-operation rate following this technique. The author feels that the reported technique is superior to the refluxing reimplantation, as there is no need for re-operation. The limitations of this study were the small numbers and short follow-up. However, the proposed 'mini reimplantation' with no tapering or advancement had good success rates in this small series. Further larger studies are required to support or negate the usefulness of this technique.

Challenges in the Management of Bilateral Single-system Ectopic Ureters in Male Infants

To describe our experience of managing bilateral single-system ectopic ureters in boys. We discuss difficulties in diagnosis, importance of appropriate preoperative imaging, and the individualized surgical management for this rare congenital malformation. The first patient aged 3months presented with urosepsis-subsequent imaging demonstrated bilateral single-system ectopic ureters, which were reimplanted at age 7months. The second case was an antenatal diagnosis of bilateral hydronephrosis. Postnatal imaging identified bilateral ectopic single-system ureters. A suprapubic catheter was inserted to ensure optimal bladder drainage. He underwent a Cohen reimplantation at age 7months because of recurrent urinary tract infections. The third patient was born with a duodenal atresia (repaired in the neonatal period) and a complex anorectal malformation, including a pouch colon with a colourethral fistula, a dilated, ectopic left ureter, and a hypoplastic urethra. He was initially managed with a colostomy and suprapubic catheter. At age 14months, he underwent a left nephrouretectomy for a nonfunctioning kidney and posterior sagittal anorectoplasty. The right ureter was noted to be ectopic at this time and was reimplanted. Our series highlights the many challenges for diagnosis and management in boys with this condition because of the diverse presentation and need for appropriate preoperative imaging. Treatment is by bilateral ureteric reimplantation at an appropriate age.

Retrograde Approach to a Diverticular Kidney Stone through a Vesicoureteral Cohen's Reimplantation: A Novel Surgical Technique

Cohen's technique is the standard treatment of vesicoureteral reflux in children. Its disadvantage is still the classic difficulty in subsequent retrograde ureteral access, requiring the use of percutaneous techniques in the treatment of kidney stones. We describe a novel surgical technique for retrograde catheterization of an adult ureter by a flexible ureterorenoscope, thereby facilitating the treatment of a symptomatic diverticular kidney stone. We compare our technique to other methods described in the literature.

VESCICO-URETERAL REFLUX: ENDOSCOPIC TREATMENT, MANAGEMENT AND LONG-TERM FOLLOW-UP

Introduction. Vescicoureteral reflux (VUR) is a dynamic event in which there is a retrograde passage of urine from the bladder to the ureters. It is the most common urological disease in the childhood and it manifests with recurrent urinary tract infections (UTI). The therapeutic strategy provides an antibiotic prophylaxis, invasive surgery (Cohen reimplantation) and minimally invasive surgery (endoscopic subureteral injection). Recently, Endoscopic Subureteral Injection with Deflux became the treat- ment of choice. The purpose of this work was to conduce a retrospective study of our patients with VUR to evaluate the role of endoscopic technique (Deflux and Macroplastique) in the treatment. Materials and Methods. Forty two patients with VUR were treated by us in 65 refluxing units. Twenty were males (47.6%) and 22 (52.4%) females. Sex, age of infiltration, presence of associated diseases, unilaterality and bilaterality, side of pres- entation of VUR and substance used for injection were considered. The follow-up study included urine cultures and periodic renal ultrasound. The mintional cistouretrography was performed after 12 months. The results were statistically evaluated with the Wilcoxson test”, comparing data of patients treated with Deflux and Macroplastique. results. Refluxing ureters underwent endoscopic treatment by submeatal injection were 65, 4.6% with VUR grade I, 12.3% grade II, 43% grade III, 29.23% grade IV and 10.87% gradeV. In 19 patients, amounting to 45.2%, this was a unilateral VUR (84.2% left, 15.78% right) and in 23 patients, equal to 54.76%, a bilateral VUR. Thirdy eight per cent of these patients had associated diseases. At the first follow-up, the cure rate was 81.53%. At the second follow-up, the cure rate, including the 9 children re-infiltrated, was 89.23%. Four patients underwent a further infiltration, so as at the third follow-up, the overall cure rate was 93.84%. In only one patient with bilateral VUR grade IV, it was necessary to perform Cohen ureteral reimplan- tation due to the persistence of VUR after 2 endoscopic infiltration. In another one, due to the clinical severity and the per- sisting of VUR after two endoscopic infiltration, we decided to plan the bilateral reimplant according to Cohen. We have not been demonstrated significant differences based on gender, age of infiltration and the substance used, were not observed. Conclusions. At the moment, ours patients have a regular weight-height growth and they don’t have urinary tract infection or vescicoureteral reflux. The sub-meatal infiltration is a simple, repeatable and reliable techinique whereby results are imme- diate and safe in most cases. For this reason, we conclude that the submeatal infiltration represents the first-line treatment in patients with vescicoureteral reflux.

VESCICO-URETERAL REFLUX: ENDOSCOPIC TREATMENT, MANAGEMENT AND LONG-TERM FOLLOW-UP

Introduction. Vescicoureteral reflux (VUR) is a dynamic event in which there is a retrograde passage of urine from the bladder to the ureters. It is the most common urological disease in the childhood and it manifests with recurrent urinary tract infections (UTI). The therapeutic strategy provides an antibiotic prophylaxis, invasive surgery (Cohen reimplantation) and minimally invasive surgery (endoscopic subureteral injection). Recently, Endoscopic Subureteral Injection with Deflux became the treat- ment of choice. The purpose of this work was to conduce a retrospective study of our patients with VUR to evaluate the role of endoscopic technique (Deflux and Macroplastique) in the treatment. Materials and Methods. Forty two patients with VUR were treated by us in 65 refluxing units. Twenty were males (47.6%) and 22 (52.4%) females. Sex, age of infiltration, presence of associated diseases, unilaterality and bilaterality, side of pres- entation of VUR and substance used for injection were considered. The follow-up study included urine cultures and periodic renal ultrasound. The mintional cistouretrography was performed after 12 months. The results were statistically evaluated with the "Wilcoxson test”, comparing data of patients treated with Deflux and Macroplastique. results. Refluxing ureters underwent endoscopic treatment by submeatal injection were 65, 4.6% with VUR grade I, 12.3% grade II, 43% grade III, 29.23% grade IV and 10.87% gradeV. In 19 patients, amounting to 45.2%, this was a unilateral VUR (84.2% left, 15.78% right) and in 23 patients, equal to 54.76%, a bilateral VUR. Thirdy eight per cent of these patients had associated diseases. At the first follow-up, the cure rate was 81.53%. At the second follow-up, the cure rate, including the 9 children re-infiltrated, was 89.23%. Four patients underwent a further infiltration, so as at the third follow-up, the overall cure rate was 93.84%. In only one patient with bilateral VUR grade IV, it was necessary to perform Cohen ureteral reimplan- tation due to the persistence of VUR after 2 endoscopic infiltration. In another one, due to the clinical severity and the per- sisting of VUR after two endoscopic infiltration, we decided to plan the bilateral reimplant according to Cohen. We have not been demonstrated significant differences based on gender, age of infiltration and the substance used, were not observed. Conclusions. At the moment, ours patients have a regular weight-height growth and they don’t have urinary tract infection or vescicoureteral reflux. The sub-meatal infiltration is a simple, repeatable and reliable techinique whereby results are imme- diate and safe in most cases. For this reason, we conclude that the submeatal infiltration represents the first-line treatment in patients with vescicoureteral reflux.

A simple and safe technique for trocar positioning in vesicoscopic ureteric reimplantation

Anchoring of the urinary bladder to the anterior abdominal wall is essential to prevent perivesical gas leak and dislodgement of trocar. Existing techniques have the risk of going through the peritoneal cavity and injuring the bowel. Our aim was to find a safe technique to anchor the bladder wall to the abdominal wall. Nineteen cases were studied prospectively. A curved urethral dilator was introduced and made to point on the anterior abdominal wall. Abdominal wall was incised over the tip of the dilator till the bladder was seen which was then sutured to the anterior abdominal wall. The bladder was then incised and the trocars were railroaded on the dilator into the bladder. Cohen's reimplantation was then done. Out of the 19 cases, conversion to open was done in two early cases. In one case, the trocar got pulled out, but was easily reintroduced. Mean operating time was 210 min. Mean follow up was 20.9 months. There was a resolution of reflux in 13, reduction in the grade of reflux in 1 and no failures. In five cases, post op MCU is awaited. This technique of fixing the bladder to the anterior abdominal wall is safe and easy to perform. It is recommended while doing vesicoscopic reimplantation.

Minimally Invasive Urologic Surgery in Children: An Overview of What Can Be Done

Laparoscopy has emerged as a feasible and effective alternative for abdominal pathologies in children. Urological minimally invasive surgery is now commonly used for basic operations in most centres and is just beginning to expand its use in more complex operations in several selected centres around the world. We present the current state of the art of minimally invasive surgery in children. We first reviewed all the urological pathologies treated with minimally invasive surgery in our institution. Secondly we reviewed the literature in order to highlight and discuss certain relevant articles and compare them with our own experience. Since beginning to use minimally invasive surgery at our institution we have operated more than 550 cases with urological pathologies. We used three approaches: the transperitoneal, the retroperitoneal and the transvesical approach. Our preferred indications for each approach are discussed. Non palpable testis, varicocele surgery, nephrectomy and adrenalectomy are, in our opinion, established minimally invasive procedures. Hemi-nephrectomy, pyeloplasty and Cohen antireflux surgery are probably excellent indications when minimally invasive surgery is carried out by expert hands. Stone management should not be forgotten in cases of contraindication or failure of ESWL. Even the most complex urological operations may be safely carried out using a minimally invasive approach, although most of the cases described are case reports. More papers are published on ablative or reconstructive urological minimally invasive surgery. Transperitoneal and retroperitoneal approaches are used with the same results. Transvesicoscopic surgery should rapidly grow to become a standard approach for Cohen reimplantation. It is anticipated that technical progress will provide the opportunity for more paediatric urologists to develop a minimally invasive approach.

Pneumothorax in Pediatric Patients After Urological Laparoscopic Surgery: Experience With 4 Patients

Pneumothorax is a rare but known complication of adult urological laparoscopic surgery and has been described occasionally in children as well. The etiologies for pneumothorax during such procedures are discussed as is the management of pneumothorax in this setting. We investigate the occurrence of pneumothorax during laparoscopic pediatric urological procedures in children. Pneumothorax developed during urological laparoscopic procedures in 4 pediatric patients (3 females, 1 male). Patient age ranged from 8 months to 11 years (mean 5.4 years). Laparoscopic surgical procedures performed included right upper pole partial nephrectomy, left upper pole partial nephroureterectomy, removal of left multicystic dysplastic kidney and bilateral Cohen reimplantation of ureters. Procedures were performed with a maximum insufflation pressure of 15 mm Hg. During the same time period as these four cases, a total of 285 laparoscopic urologic procedures were performed at our institution. Pneumothorax was suspected due to decreased oxygen saturations, subcutaneous emphysema, increased respiratory effort and decreased chest lung sounds unilaterally. Pneumothorax was confirmed with chest x-rays. Operative time ranged from 171 to 249 minutes (mean 199.5). Duration of surgery before pneumothorax developed ranged from 75 to 239 minutes (mean 176, median 168). Conservative management of pneumothorax was used in 3 patients and a pigtail chest tube was used in 1. In all cases the estimated blood loss was minimal. Urologists performing laparoscopy in children should be aware of the possibility of a pneumothorax developing during the procedure. Evaluation for decrease in O2 saturation should include a search for pneumothorax in these patients. Close observation generally suffices for management.