Prolonged Ileus Research Articles

948 PERITONEUM PRESERVING RETROGRADE RADICAL CYSTECTOMY FOR ELDERLY AND HIGH RISK BLADDER CANCER PATIENTS

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion II1 Apr 2010948 PERITONEUM PRESERVING RETROGRADE RADICAL CYSTECTOMY FOR ELDERLY AND HIGH RISK BLADDER CANCER PATIENTS Senji Hoshi, Taku Yamamuro, Yukihiko Ogata, Kenji Numahata, and Osamu Sugano Senji HoshiSenji Hoshi More articles by this author , Taku YamamuroTaku Yamamuro More articles by this author , Yukihiko OgataYukihiko Ogata More articles by this author , Kenji NumahataKenji Numahata More articles by this author , and Osamu SuganoOsamu Sugano More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1827AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radical cystectomy is gold standard of treatment of invasive bladder cancer. However, for elderly patients more than 70 yeas old, mortality rate of perioperative time is reported 8.8% (AUA06-Abstract No. 31). The most common postoperative complication is prolonged ileus. For elderly and high risk patients, we are selecting completely extraperitoneal cystectomy, and single stoma bilateral ureterocutaneostomy with Toyoda Method (J Urol, 117, 276). We established easy technique of complete peritoneum preserving retrograde radical cystectomy. At first, prostatic deep vein complex and urethra are dissected. Prostate and seminal vesicle were dissected retrogradely. Bilateral ureters are dissected at the distal end and retrograde cystectomy is done. Peritoneum detachment from bladder is easily done because peritoneum is rising like as a tent and peritoneum bladder adhesion line is easily detected. Operation time is short and no peritoneal defect. Then we compared the time of peritoneum detachment from bladder up to now ante-grade procedure and new technique of retrograde procedure. METHODS Twenty patients of old age male bladder cancer, mean age 75, range 73-83, candidate for radical cystectomy and ureterocutaneostomy were divided randomly. And 10 were performed ante-grade peritoneum detachment (AD) from bladder and 10 were performed retrograde peritoneum detachment (RD). Informed consent was obtained. From the operation video of each patient, operation time of AD and RD was calculated. In all patients, the double barreled single ureterocutaneostomy stoma was created with Toyoda Method (J Urol, 117, 276). Operative time of ureterocutaneostomy was also compared with neoblader diversion (15) or ilial conduit diversion (30). The operations were performed by single surgeon (SH). RESULTS Mean time and range of AD and RD was 25 minutes, 20-38 minutes and 15 minutes, 10-20 minutes, respectively (p<0.01). Operation time requiring peritoneum detachment from bladder with RD was clearly shorter than that with AD. Mean operation time of ureterocutaneostomy was clearly shorter than those of neoblader diversion or ilial conduit diversion(p<0.01). All patients ureterocutaneostomy diversion could drink and eat the next day of the operation and the median length of hospital stay was shorter than those of neoblader diversion or ilial conduit diversion (p<0.01). CONCLUSIONS We established easy and time saving technique of complete peritoneum preserving retrograde radical cystectomy. Yamagata, Japan© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e369 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Senji Hoshi More articles by this author Taku Yamamuro More articles by this author Yukihiko Ogata More articles by this author Kenji Numahata More articles by this author Osamu Sugano More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Association of surgical care practices with length of stay and use of clinical protocols after elective bowel resection: results of a national survey

Background Although management techniques have been proposed to accelerate gastrointestinal recovery after elective bowel resection (BR), most data are derived from single-institution experience. This study assessed the current state of perioperative care for elective BRs and the effect of pathway components on length of stay. Methods A web-based survey was conducted among surgeons regarding their last elective BR. Results Among 207 general and 200 colorectal surgeons, 30% practice in hospitals with a perioperative surgical care pathway intended to accelerate gastrointestinal recovery. Pathway components included early ambulation, early diet progression, early nasogastric tube removal/avoidance, and opioid-sparing pain control. Care practices associated with decreased length of stay included laparoscopic technique, early mobilization, early liquids, and antiemetic use to prevent symptoms associated with prolonged postoperative ileus. Conclusions Few hospitals have pathways but most surgeons likely would implement nationally endorsed guidelines. These data, along with other studies, may lead to well-accepted BR care pathways.

A decade of minimally invasive donation: experience with more than 1200 laparoscopic donor nephrectomies at a single institution

The past decade has seen laparoscopic donor nephrectomy (LDN) transform into a standard of care procedure. Furthermore, LDN has evolved with the introduction of new technologies aimed at increasing efficiency and safety. There are few large, single center experiences detailing the results of LDN, its associated complications, and their management. We performed a retrospective review of 1200 LDN performed at our center for both pediatric and adult recipients. Mean body mass index of donors was 27.1 (range 17-48). Twenty-six percent of kidneys had multiple renal arteries. Greater than 99% were left LDN. Mean length of stay was 1.37 +/- 0.6 d, which decreased to 1.1 +/- 0.5 d for the last 475 cases. The overall complication rate was 5.6%. Among those patients, 1.6% of the patients experienced an intraoperative complication, including eight renovascular injuries; 7/8 renovascular injuries led to open conversion. Four conversions were elective; our overall conversion rate was 0.92%; 4.0% had a post-operative complication; 1.2% required readmission for complication management. Three of 1200 patients have required reoperation for prolonged ileus and internal hernia (2), respectively. There have been no cases of donor renal failure or death. Since 2003, we have routinely used hand-assisted LDN (HALDN). There have been no cases of primary non-function. Urologic complications have been uncommon. Our series supports the safety and efficacy of LDN/HALDN.

Etiology and outcome of acute intestinal obstruction: A review of 367 patients in Eastern India

Background/Aim:The etiology of acute intestinal obstruction, which is one of the commonest surgical emergencies, varies between countries and has also changed over the decades. We aimed to provide a complete epidemiological description of acute intestinal obstruction in a tertiary care hospital in Eastern India.Materials and Methods:This was a retrospective study of patients admitted in our unit with a diagnosis of acute intestinal obstruction between the years 2005 and 2008 at Medical College, Calcutta. The study comprised of 367 patients.Results:Acute intestinal obstruction was the diagnosis in 9.87% of all patients admitted with males (75.20%) grossly outnumbering females. The commonest age group affected was 20-60 years. In our patients, the main cause of obstruction was obstructed hernia followed by malignancy with adhesions coming third. Intestinal tuberculosis was an important cause for obstruction in our patients comprising 14.17% of patients. Conservative management was advocated in 79 patients while the rest underwent surgery. Postoperative complications occurred in 95 patients and of these, 38 patients had a single complication and the rest, more than 1. The main complications were wound infection, basal atelectasis, burst abdomen and prolonged ileus. The mortality rate was 7.35% (27 patients). The highest mortality occurred in those with intestinal tuberculosis.Conclusion:This study demonstrates that the pattern of intestinal obstruction differs from the Western world with obstructed hernias being the most important cause and also emphasizes the fact that intestinal tuberculosis assumes a prominent role. It also highlights the necessity of using universal precautions because of the ever increasing number of HIV patients in those with intestinal obstruction.

Acute sigmoid volvulus in a West African population

Acute sigmoid volvulus is one of the commonest causes of benign large-bowel obstruction. Its incidence varies considerably from one geographic area to another. This study reviews its management in a relatively high-prevalence area. All adult patients with acute sigmoid volvulus seen at the Royal Victoria Teaching Hospital (RVTH), Banjul, between September 2000 and January 2005 were retrospectively studied. Demographic data, clinical features, resuscitative measures, results of investigations, findings at surgery and postoperative course, and complications were retrieved from the patients' clinical records and analyzed. A total of 48 patients, 45 (93.8%) males and 3 (6.3%) females, with a male: female ratio of 14.3:1, age range of 19 to 78 years and mean age of 45.8 +/- 17.6 years underwent treatment for acute sigmoid volvulus. Twenty-one (43.8%) of the patients were aged 40 to 49 years. Two (4.2%) had rectal tube detortion followed by elective sigmoidectomy and primary anastomosis on the same admission, while 24 (50%) had emergency laparotomy, at which bowel decompression, one-stage resection and primary anastomosis without on-table lavage were done. The rest of the patients, 22 (45.8%), had gangrenous sigmoid colons at laparotomy and consequently underwent resection and Hartmann's procedure. Fourteen (29.1%) patients developed wound infection; and 5 (10.4%) had prolonged ileus, which was managed conservatively. There was no anastomotic leak. The mean hospital stay was 11.1 days. There were 5 deaths, giving a mortality rate of 10.4%. Acute sigmoid volvulus in The Gambia is almost exclusively a male disease. Sigmoid colectomy and primary anastomosis can be carried out safely in those with viable colon without on-table colonic lavage.

Surgical experience and results in transperitoneal laparoscopic adrenalectomy

IntroductionLaparoscopic adrenalectomy is currently the gold standard for surgical management of adrenal disease. ObjectivesTo analyze our results after 12 years of experience in this surgery and to compare them to those of the main published series. Material and methodsA descriptive, retrospective study. An analysis was made of 100 adrenalectomies performed from June 1997 to June 2009. Variables analyzed included age, size, side, preoperative diagnosis, operating time, blood loss, conversion to open surgery, mean hospital stay, and pathological report. A Fisher's exact test and a Chisquare test were used to compare categorical data. A Student's t test was used to compare independent group means with a normal distribution. A value of p<0.05 was considered statistically significant. ResultsMean patient age was 53.1 years (± 14.4). Mean lesion size was 3.7cm (± 2.2), and lesions occurred in the left side in 51% of cases. Mean follow-up time was 15 months (± 11.9). Preoperative diagnoses were functional mass (44%), pheochromocytoma (17%), incidentaloma >4cm (20%), metastasis (10%), and adrenal carcinoma (5%). Mean operating time was 145.1min (± 55.6). Mean hematocrit decrease was 6.26 points (± 3.3). Conversion to open surgery was required in 9.6% of patients. Prolonged postoperative ileus occurred in two patients. Transfusion was required in two patients. One patient died from decompensated liver cirrhosis. Eighty percent of complications occurred in the right side. Mean hospital stay was 6 days (± 5.6). In the last 30 procedures, significant differences in operating time (119.1min vs 171.2min) and mean hospital stay (4.1 vs 6.1 days) were found in the group of the last 30 procedures (p<0.05). ConclusionsTransperitoneal laparoscopic adrenalectomy is a feasible and safe surgical procedure in the hands of teams with prior laparoscopic experience. Our efficacy and morbidity results are similar to those reported by other series.

Stapled ileostomy closure results in reduction of postoperative morbidity

Loop ileostomy is widely employed as a defunctioning procedure for left-sided colonic anastomoses. Closure of the stoma carries a risk of morbidity and even mortality. The aim of this prospective trial was to evaluate the ability of stapled stoma closure to decrease the rates of perioperative morbidity. One hundred and nineteen patients (mean age 56.2 +/- 5.4 years) underwent two-stage operations for rectal carcinoma with protective loop ileostomy between 2005 and 2008. All patients were randomly divided into two groups: 56 patients had conventional ileostomy takedown, while in the other 63, a functional end-to-end anastomosis was created using a linear stapler. Groups were comparable in terms of age, gender, body mass index, and other parameters. Mean time of stoma closure using functional end-to-end anastomosis was 68 +/- 7, when compared to 92 +/- 11 min (P = 0.01) for conventional stoma closure. The overall morbidity rate after ileostomy closure using a stapler was 3.2%: one patient (1.6%) developed a wound infection and self-limited bleeding from the anastomotic line, while another patient (1.6%) had an ileal obstruction caused by adhesions and required additional intervention. Conventional ileostomy closure resulted in a 14.3% morbidity rate: six patients (10.7%) had prolonged ileus, 2 (3.6%) had small bowel obstruction, and 2 (3.6%) had wound infections (P = 0.04). Functional end-to-end anastomosis reduces operating time and morbidity compared to conventional ileostomy takedown.

Treatment of Incisional Hernias Adopting an Intra-abdominal Approach With a New Low-density Composite Prosthetic Material: Proceed

The management of incisional hernias remains a challenge for the general surgeon. Repairing by using prosthetic materials has reduced the relapse rate, but intra-abdominal mesh placement continues to be a source of controversy. An evaluation is made of the results of treating incisional hernias with a new intra-abdominal low-density composite mesh through both the open and the laparoscopic approach. A prospective analysis was made on the first 50 patients operated upon for incisional hernia through the open (n=20) or laparoscopic route (n=30), with intra-abdominal repair using the Proceed composite mesh, composed of low-density polypropylene and a hydrophilic antiadherent membrane of oxidized regenerated cellulose. There were no patient deaths. Reintervention proved necessary in one case due to hemoperitoneum caused by a trocar. The mean duration of stay was 3 days, and all patients recovered bowel transit within 24 hours. During follow-up there were no intra-abdominal complications associated with the use of the mesh (intestinal occlusion or subocclusion, prolonged ileus, infections, rejection, fistulas, or relapses). Incision hernia repair using the intra-abdominal low-density composite mesh is safe and well tolerated. Proceed mesh facilitates laparoscopic hernioplasty maneuvering.

A Clinicopathological Review of 324 Appendices Removed for Acute Appendicitis in Durban, South Africa: A Retrospective Analysis

Acute appendicitis remains a common surgical condition and the importance of specific elements in the clinical diagnosis remain controversial. A variety of neoplastic and inflammatory conditions mimic acute appendicitis. The purpose of this study was to determine the presenting pattern of acute appendicitis and to review the pathological diagnosis. This is a retrospective analysis of 324 patients who had appendicectomy for acute appendicitis at Prince Mshiyeni Memorial Hospital (Natal, South Africa) during the period January 2002 to December 2004. Patient demographics, clinical features, white cell count, operative findings, outcome and histology results were recorded on a special patient proforma. A total of 371 patients underwent appendicectomy during this period and 324 (M:F, 3.6:1) were available for analysis. The majority of our patients were in the second decade (43.1%) with only 29.3% presenting within 24 h of onset of symptoms. The most common symptoms were abdominal pain (100%), vomiting (57.4%) and anorexia (49.0%). Generalised and localised abdominal tenderness were present in 62.0% and 19.4% of patients, respectively. Pyrexia was noted in 41.0%. Localised and generalised peritonitis were present in 26.4% and 14.0%, respectively. The most common incisions were lower midline laparotomy (47.2%) and gridiron (37.3%). The negative appendicectomy rate was 17.0%. Acute appendiceal inflammation and gangrenous appendicitis was present in 36.1% and 9.6%, respectively. The perforation rate was 34.0% and there was a direct correlation with delayed presentation. There were no patients with carcinoid tumour or adenocarcinoma. Parasites and other associated conditions were seen in 8.6% of cases. Postoperative complications included: wound sepsis (25.3%), prolonged ileus (6.2%), peritonitis (4.6%) and chest infection (3.4%). Four patients died (1.2%) all from the perforated group. Our patients present late with advanced disease and complications. All surgeons should bear in mind the possibility of parasitic infestations mimicking acute appendicitis and the presence of significant unusual histological findings in our setting justifies routine histopathological examination of appendices.

MP-13.06: Peritoneum Preserving Retrograde Radical Cystectomy for Elderly Bladder Cancer Patients

Radical cystectomy is the gold standard for invasive bladder cancer treatment. Improvements in surgical anesthetic techniques, as well as perioperative care, have reduced the mortality rate of radical cystectomy to 1% to 3% in most contemporary series. However, for elderly patients over 70 years old, the mortality rate in the perioperative period is reported to be 8.8% (AUA06-Abstract No. 31). The most common postoperative complication is prolonged ileus. If radical cystectomy could be performed completely extraperitoneally, the benefit would be immeasurable and we could reduce the morbidity rate and mortality rate.

Mesenteric Cavernous Hemangioma Involving Small Bowel and Appendix: A Rare Presentation of a Vascular Tumor

We report on a case of cavernous hemangioma of the small bowel mesentery. Fewer than five cases of large mesenteric cavernous hemangioma have been reported in the English literature. Cavernous hemangioma of the small bowel mesentery is extremely rare. A 32-year-old black male presented with 1 week of abdominal pain, nausea, vomiting, and anorexia. He had recently undergone computed tomographic guided biopsy of a pelvic mass at another facility. Repeat CT guided biopsy was nondiagnostic, mesenteric angiography was inconclusive, and magnetic resonance imaging was performed as well. Complete workup was performed to localize primary source of abdominal mass and eventual open biopsy was planned resulting in en bloc resection of the mass, which had invaded the terminal ileum and appendix. Final pathologic diagnosis was cavernous mesenteric hemangioma. The patient experienced a prolonged postoperative ileus and was eventually discharged in stable condition, tolerating a regular diet with adequate bowel and urinary function. Diagnosis of cavernous mesenteric hemangioma is difficult and multiple imaging modalities can prove inconclusive. Adequate biopsy can be difficult to obtain even in patients with small body habitus. Standard of care is resection of entire mass en bloc.

Laparoscopic ureteral reimplantation: prospective evaluation of medium-term results and current developments

Laparoscopic ureteral reimplantation is a feasible method for treating ureteral pathology with good preliminary results in the literature. In this study, we review our medium-term results for laparoscopic ureteral reimplantation and discuss current developments of this procedure. Twenty-four laparoscopic ureteral reimplantations were performed between August 2003 and December 2008 for ureteral strictures or ureteral injuries. The mean age was 53.5 years (8 men, 16 women). Patient demographics, preoperative symptoms, radiological imaging, complications, and postoperative outcomes were analyzed. Ten patients underwent vesicopsoas-hitch, nine patients had a vesicopsoas-hitch combined with Boari-flap, and five had Lich-Gregoir extravesical ureteral reimplantations. Success was defined as relief of obstruction on postoperative imaging studies, as well as symptomatic relief. Laparoscopic ureteral reimplantations were successfully performed in all patients. The mean operative time was 215 min (131-351). Mean estimated blood loss was 283 ml (50-550). One patient had an intraoperative bowel injury which was managed laparoscopically during the same procedure. There were two postoperative complications; two prolonged ileus and one deep venous thrombosis (DVT). Mean hospital stay was 8.7 days. Average time to return to normal activity was 2.6 weeks. Postoperative radiological imaging studies showed good drainage, without hydronephrosis, in 23 patients (success rate 95.8 %) at a median follow up interval of 35 months. Laparoscopic ureteral reimplantation is an effective procedure with good medium-term results. We believe that this procedure will become an established treatment option.

Evaluation of the treatment of peritoneal carcinomatosis of colorectal cancer (CRC) with complete cytoreduction and hyperthermic intraperitoneal peroperative chemotherapy (HIPEC) with oxaliplatin: A Belgian multicenter prospective phase II clinical study

4101 Background: Up to 25% of patients with metastatic CRC present with peritoneal carcinomatosis (PC) as the only site of metastases. The concept of Complete Cytoreductive Surgery (CCRS) followed by Hyperthermia and Intraperitoneal Chemotherapy (HIPEC) was developed, aiming for locoregional disease control and long-term survival. Methods: This prospective multicentre registry included 48 patients (M/F ratio 17/31) with PC from CRC, who underwent CCRS and HIPEC with oxaliplatin(460mg/m2). In 72.9% of patients the primary tumor had been previously resected. Median PCI (peritoneal cancer index) was 11 [1–22], with a median of 6 [1–11] abdominal regions involved and a median lesion size score of 3 [1–3]. In 11 cases associated lymph nodes (63.6% mesenteric, 27.3% para-aortic) were resected. To obtain CCRS a median of 2 [2–6] organs needed to be resected, with anterior resection in 45.8%, total colectomy in 8.3% and small bowel resection in 12.5% of cases. A median of 1 [0–6] anastomosis was performed per patient, of which one third were low and 82.1% were performed after HIPEC. Eleven ileostomies and 5 colostomies were constructed. Results: Median operation time was 460min.[125–840], with a median blood loss of 475ml [2- 6000]. HIPEC posed few procedural problems. There was no postoperative mortality. Complication rate was 52.1%, with 18 intra- and 17 extra-abdominal complications. Anastomotic leakage occurred in 10.4% of patients, bleeding in 6.3% and prolonged ileus in 22.9%. Median hospital stay was 20 [5–65] days. Occurrence of intra-abdominal complications significantly affected hospital stay (p=0.0012), but no risk factors for occurrence of postoperative complications could be clearly identified. Median follow-up was 22.7 [3.2–55.7] months, with 91.7% 2-year overall survival. Progression-free survival at 2 years is 64.6%, with PC recurrence in 29.2% of patients and other metastatic disease in 25%. Multivariate analysis only retained the CEA-level as a significant prognostic factor (p=0.0065). Conclusions: CCRS followed by HIPEC for PC of colorectal origin is safe and has longer than expected PFS and OS. No significant financial relationships to disclose.

GS03 **ABDOMINAL WOUND DEHISCENCE – WHO IS REALLY AT RISK?

Aim: 1 Determine the sensitivity and specificity of Webster wound dehiscence (WD) risk scoring system when applied to a population beyond purely a veterans population as in Webster study. 2 Identify additional risk factors associated with abdominal laparotomy WD that was not considered in the Webster study. Method: Bi-centre, retrospective case – control analysis of preoperative and postoperative risk factors associated with abdominal laparotomy WD over seven years (Jan 2000–Dec 2006). 103 patients with abdominal WD were compared to a randomly selected control group of 103 patients with midline laparotomies who were matched to year of operation. Patients were stratified according to the Webster WD risk scoring system and sensitivity and specificity analysis performed. Chi-square analysis was performed on risk factors that were not included in Webster WD Risk scoring model. Results: The overall WD rate is 2.8%. (103/3585 patients). Analysis of risk factors that were not considered by the Webster model within the WD group shows peritoneal sepsis (p = 0.04), prolonged ileus (p = 0.006) and current smoking status (p = 0.01) are significant factors associated with patients scoring highly for developing abdominal WD. Conclusions about the sensitivity and specificity of Webster WD risk scoring model can be drawn once control group data are collated. Conclusion: Webster WD risk scoring system appears to be a valid tool in identifying patients at high risk for WD. Peritoneal sepsis, prolonged ileus and smoking are associated with high risk of developing abdominal WD.

Complications of laparoscopic pyeloplasty

Purpose Ureteropelvic junction obstruction is the most common congenital cause of upper urinary tract obstruction, leads to progressive dilatation of the renal collecting system. With over 100 cases at our centre we retrospectively analysed the complications associated with laparoscopic pyeloplasty. Material and Methods From Jan 2002 to Dec 2007, 107 patients underwent laparoscopic pyeloplasty. 104 of these were dismembered Anderson-Hynes pyeloplasty, 2 Fenger-plasty and 1 vascular hitch for crossing lower pole vessels. 94 of these procedures were through transperitoneal approach, 7 were extraperitoneal and 7 transmesenteric. Nearly all had insertion of DJ at the end of procedure. 6 to 8 weeks later the DJ was removed and 2 weeks later a radioisotope renogram was done. Results Intraoperative complications included wrong port placement in 3, prolonged operating time in 2, inability to dissect the UPJ properly in 1. Postoperative complications included transient subcutaneous emphysema in 1, haematuria in 1, prolonged ileus in 2, prolonged urine drainage in 3, fever 3, UTI in 3 and recurrent UPJ obstruction in 5. Conclusions Laparoscopic pyeloplasty has proven to be safe and effective with comparable results to open surgery.

Mitchell's Detrusor Wrap-Around Bladder Neck (Dwbn), Ileocystoplasty, and the Extramural Serous-Lined Continent Outlet: An Optimal Triad

Purpose Providing continence for children with non compliant bladder and low detrusor leak point pressure secondary to neuropathic dysfunction or bladder exstrophy is a challenging task. A one stage reconstruction triad is presented. Material and Methods Between May 2005 to July 2008, 21 patients underwent DWBN, ileocystoplasty, and extramural serous lined tunnel as continent outlet in one stage. Patients included 15 boys and 6 girls with mean age of 7.6 years. Nine patients had previous complete repair of bladder exstrophy, 4 had staged repair and 8 had neuropathic bladder dysfunction. The ileum was fashioned in the shape of U in 4, S in 13, and W in 4. The appendix was used in 17 and Monti was used in 4. Neo umbilicus was constructed for the outlet in 13. In all patients the continent outlet was located in the umbilicus or a neo-umbilicus. Results Mean follow-up duration was 19 months (range 4-39). Early postoperative complications included prolonged ileus in 1 and urine leak in 1 and both were conservatively managed. Vesicoureteral reflux persisted in 13/21 (62%) patients. All patients were completely dry on CIC except 1. The leakge was through the urethra and was successfully managed by macroplastique injection at the bladder neck. No patient leaked through the continent outlet. Stomal stenosis was encountered in 2 patients with neo-umbilicus and both had stomal revision. No patient had bladder stones or perforation during follow-up. Conclusions Children with urinary incontinence secondary to the combination of a non-compliant bladder and sphincteric deficiency could be optimally managed with this triad. The DWBN provides optimal bladder neck reconstruction. The extramural serous-lined technique has the advantages of a leak-proof continent outlet, ease of catheterization through a straight channel, and the orthotopic position of the outlet in the umbilicus/neo-umbilicus in all patients.

Laparoscopic excision of choledochal cysts in children: an intermediate-term report

To assess the intermediate-term result of the use of the minimally invasive technique in the treatment of choledochal cysts in children. This is a retrospective review of all cases of choledochal cyst treated in the tertiary referral centre. The surgical technique is described and all the medical records were reviewed to assess the intraoperative and postoperative complications and follow-up problems. From October 2000 to April 2008, laparoscopic excision and reconstruction were attempted in 37 patients. Laparoscopic surgery was successfully performed in 34. Conversion was required in three patients due to oozing on cyst dissection (two) and bleeding from small bowel mesentry (one) during the early part of the series. Postoperative complications were observed in 15 patients including subhepatic collection (6), bile leakage (3), minor wound infection (4) and prolonged ileus (2). At a mean follow-up of 4.2 years, four patients developed surgical complications including intrahepatic ductal strictures in a type IV cyst (one), stump pancreatitis (one), terminal ileal obstruction from internal herniation (one) and cholangitis (one). The cosmetic result was good in all patients. We conclude that laparoscopic excision and reconstruction can be safely performed in children with a choledochal cyst with satisfactory intermediate-term results.

Complications of laparoscopic pyeloplasty in children

Laparoscopic pyeloplasty in children has been proven to be safe and effective, with comparable results to open surgery. Due to the extension of laparoscopic indications from ablative to reconstructive procedures requiring endoscopic suturing, most centres have plateaued within their learning curve. Based on our own experience with a little more than 100 cases, we focus on the complications and the definitive learning curve of laparoscopic pyeloplasty in children. A total of 103 laparoscopic pyeloplasties were performed during the period January 2002 to June 2008. Of these, 102 underwent laparoscopic dismembered pyeloplasty and one underwent laparoscopic vascular hitch for crossing lower pole vessels. Intraoperative incidents/complications were analysed using the Satava classification, and the postoperative complications according to the Clavien classification. Intraoperative incidents occurred in 2.91% of the cases, mostly without consequences for the child including faulty port placement needing placement of an extra port and umbilical port side bleed. Postoperative complications occurred in 11.65% children and included prolonged ileus, prolonged urinary leak, fever, haematuria and recurrent ureteropelvic junction (UPJ) stenosis. Recurrent UPJ stenosis occurred in 4.85% of children needing reoperation. Laparoscopic pyeloplasty in children is not only feasible, but safe and effective. Intraoperative incidents occur in up to 3% of the cases, and complications in 12.9-15.8%. Increased experience, training and knowledge regarding the incidence and management of complications will be able to further reduce these in the future.

Vólvulo de ciego: presentación de 18 casos y revisión de la literatura

Introduction Caecal volvulus is the second most frequent location of colonic volvulus after sigmoid colon. It usually shows up as bowel obstruction. Material y method We review our experience of 18 cases of cecal volvulus treated in our centre between 1987 and 2007. Results We studied 8 males (44.4%) and 10 females (55.6%), with a mean age of 63.3 years. As an associated factor it was noted that 10 patients (55.6%) were bedridden. The most common clinical signs were abdominal distensión and tenderness, constipation and vomiting. Simple abdominal X-rays have a low diagnostic accuracy, though they reveal a bowel obstruction. Only 1 patient underwent elective surgery. In 10 patients (55.6%) a right hemicolectomy was performed, in 3 (16.8%) cecostomy, in 3 cecopexy and in 2 (11.2%) devolvulation only. There were complications in 3 patients (16.8%), 2 prolonged ileus and 1 wound infection. There were no recurrences. Conclusions Caecal volvulus is an emergency pathology, requiring surgical treatment. Right hemicolectomy is the treatment of choice both in viable and gangrenous colon. Caecostomy is an alternative treatment in the high risk patient with a viable colon.

Laparoscopic Cystoprostatectomy for Radiation-Induced Hemorrhagic Cystitis

Hemorrhagic cystitis after radiotherapy is a relatively rare event, usually occurring several years after radiation treatment. It can be relentlessly progressive, and treatment options are usually suboptimal. No management strategy is fully successful, and a stepwise progression in treatment intensity is often necessary with cystectomy and urinary diversion being the final management option. Laparoscopic cystoprostatectomy with minilaparotomy ileal conduit urinary diversion was successfully performed in three patients with severe refractory hemorrhagic cystitis secondary to radiation treatment for prostate cancer. More conservative management had failed in all three patients with continued severe and life-threatening bleeding. No intraoperative complications were encountered in spite of the obliteration of tissue planes after radiation treatment. Mean operative time was 4 hours and 45 minutes, including the urinary diversion. Blood loss ranged from 50 to 200 mL. Postoperative recovery was uneventful with the exception of prolonged ileus in one patient, which resolved conservatively. Radiation treatment for prostate cancer is not an absolute contraindication for laparoscopic cystoprostatectomy, which can still be safely performed in some of these patients. Extension of this experience to patients with malignant disease remains to be evaluated.