Surgical management of pediatric vesicoureteral reflux: A comparative study between endoscopic, laparoscopic, and open surgery

Our retrospective study compared the results of three surgical procedures for correction of pediatric vesicoureteral reflux (VUR): open Cohen, laparoscopic Lich-Gregoir reimplantation (LEVUR), and endoscopic subureteric injection (STING) procedure. METHODS: We analyzed 90 patients (50 girls, 40 boys, average age 4.86 years) operated in two centers of pediatric surgery for VUR. Exclusion criteria were Grade 1 VUR, Grade 5 VUR with megaureters requiring ureteral tapering, secondary VUR, and patients already operated for VUR. Thirty patients underwent Cohen, 30 LEVUR, and 30 STING procedure. Follow-up included renal ultrasonography and voiding cystourethrography 6 months postoperatively. The statistical analysis was performed using χ(2) Pearson and Fisher tests. RESULTS: Operative time was shorter using STING either for unilateral or bilateral correction (P = .001). Hospitalization was statistically shorter using STING and LEVUR compared to Cohen (P = .001). The pain scores were worse after Cohen (P = .001). Analgesic requirements were higher after Cohen (P = .001). Reflux persistence was higher after STING (10 cases versus 5 Cohen and 4 LEVUR). Cohen presented more complications compared to LEVUR and STING (P = .001). Intraoperative costs were higher for STING procedure (P = .001), while hospitalization costs were significantly higher for Cohen procedure (P = .001). CONCLUSIONS: In children affected by VUR, open Cohen and LEVUR reported a higher success rate than STING procedure. However, Cohen procedure had a very long and painful hospital stay, more complications, more analgesic requirements compared to STING and LEVUR. Comparing the three techniques, it seems that LEVUR presents a high success rate similar to the Cohen procedure, but in addition, it presents the same advantages of STING procedure with no postoperative pain and a lower postoperative morbidity

Retroperitoneal and laparoscopic heminephrectomy in duplex kidney in infants and children

Abstract BACKGROUND: Two main techniques are adopted to perform partial nephrectomy in children: laparoscopy and retroperitoneoscopy. The aim of this paper is to review the larger multicentric experience recently published by our group to review indications, techniques and results of both approaches. METHODS: Data of 102 patients underwent partial nephrectomy in a 5-year period using minimally invasive surgery (MIS) procedures were analyzed. Fifty-two children underwent laparoscopic partial nephrectomy (LPN), and 50 children underwent retroperitoneoscopic partial nephrectomy (RPN). Median age at surgery was 4.2 years. Statistical analysis was performed using χ2 test and Student's t-test. RESULTS: The overall complications rate was significantly higher after RPN (15/50, 30%) than after LPN (10/52, 19%) (χ2 =0.05). In LPN group, complications [4 urinomas, 2 symptomatic refluxing distal ureteral stump (RDUS) and 4 urinary leakages] were conservatively managed. In RPN group, complications (6 urinomas, 8 RDUS, 1 opening of remaining calyxes) required a re-operation in 2 patients. In both groups no conversion to open surgery was reported. Operative time (LPN: 166.2 min vs. RPN: 255 min; P<0.001) and hospitalization (LPN: 3.5 days vs. RPN: 4.1 days; P<0.001) were significantly shorter in LPN group. No postoperative loss of renal function was reported in both groups. CONCLUSIONS: MIS now represents the gold standard technique to perform partial nephrectomy in children with duplex kidney. Our results demonstrate that RPN remains a technically demanding procedure with a significantly higher complications and re-operation rate compared to LPN. In addition, length of surgery and hospitalization were significantly shorter after LPN compared to RPN. LPN seems to be a faster, safer and technically easier procedure to perform in children compared to RPN due to a larger operative space and the possibility to perform a complete ureterectomy in refluxing systems

A prospective randomized comparative study on the use of ventral subcutaneous flap to prevent fistulas in the Snodgrass repair for distal hypospadias.

We evaluated the importance of urethral coverage using vascularized subcutaneous ventral flaps for the prevention of fistulas in patients undergoing distal hypospadias repair. Our prospective study included 130 patients, aged 9 months to 12 years, who underwent distal hypospadias repair using tubularized incised plate urethroplasty (TIPU), from January 2001 through January 2006. Patients were assigned to one of two groups by a computer-generated random selection: 65 patients underwent non-covered urethroplasty (NCU group); another group of 65 patients underwent covered urethroplasty (CU group) with a vascularized subcutaneous ventral flap. The results were evaluated by two pediatric surgeons unaware of the type of treatment each patient had undergone. Successful results were achieved in 99/130 patients (76.2%). We recorded 31 (23.8%) post-operative complications: 20 patients presented with a urethrocutaneous fistula (15 patients in the NCU group and 5 in the CU group); five with urethral stenosis (3 in the NCU and 2 in the CU group); and six with skin dehiscence of the preputioplasty (3 patients in each group). We analyzed the results using the chi2 test and the only statistically significant difference between the two groups (p < 0.05) was in terms of incidence of fistulas. Urethrocutaneous fistulas seem to be the most frequent complication of distal hypospadias after TIPU repair. Urethral coverage should be part of the Snodgrass procedure because it significantly reduces the formation of fistulas. A well-vascularized subcutaneous ventral flap represents, in our experience, a simple and optimal choice for the prevention of fistulas