Search

Background: Renal biopsy continues to be a pivotal tool in the clinical assessment of persistent microscopic hematuria, proteinuria, hypertension and other renal diseases. The percutaneous needle biopsy is the first choice procedure. Unfortunately, some clinical conditions, such as severe hypertension, bleeding disorders, anticlotting medications, anatomical abnormality and very young age children reduce the use of the percutaneous approach in favor to the open surgery. We think that retroperitoneal laparoscopic biopsy is a suitable alternative. Patients and Methods: From January 1998 to March 1999 we performed retroperitoneal laparoscopic biopsy in 22 patients, aged 2 to 22 years (mean age: 12 years). Preoperative indication to renal biopsy included 7 significant proteinuria, 4 persistent hematuria, 3 systemic hypertension, 6 renal failure and 2 Shoenlein-Henoch syndrome. The retroperitoneal approach is performed with the patient in lateral position. Two trocars are used: the first, a 10 mm trocar, is positioned under direct vision (Visiport[R]) along the posterior axillary line of lumber region and a 15 m[H.sub.2]O pressure is set up. A blunt dissection of the retroperitoneal virtual space is carried out before positioning the second trocar (5 mm diameter), 3 to 5 centimeters medially to the first one. As the lower renal pole is freeded from the fat tissue, biopsy forceps are used to grasp the parenchymal specimen. Bleeding control is ensured under direct vision, if necessary fulgurating the biopsy site with bipolar electrocantery. Results: retroperitoneal laparoscopic biopsy was successfully performed in 21 patients. One 19 years old boy was converted in open surgery during the procedure for difficult endoscopic identification of the kidney (obesity). The mean operative time was 50 minutes (range from 30 mins to 110 mins). In all patients blood loss was minimal and the mean hospital stay was 1.3 days postoperatively. One minor intraoperative complication occurred in this series (a small peritoneal opening) without postoperative consequences. No pain medication was required after hospital discharge and the patients were back to their usual activity in 4 to 6 days. Conclusion: The retroperitoneal laparoscopic biopsy is a simple and safe technique for renal biopsy in childhood. It is required a not extensive laparoscopic experience and provides a good parenchymal specimen. We believe that the retroperitoneal approach has less morbidity than open surgery and it is the first choice technique in pediatric patients when percutaneous needle biopsy is contraindicated or not suitable., P. Caione, MD, S. Micali, MD, A. Lais, MD, E. Matarazzo, MD, N. Capozza, MD. Division of Pediatric Urology, Bambino Gesu Children's Hospital, Research Institute, Rome, [...]

Background: Achievement of continence is one of the main goals of reconstruction in exstrophy-epispadias complex (EEC). It has been postulated that all the normal components of the lower genito-urinary tract are present in the EEC, albeit they are displaced laterally and incompletely developed. The total disassembly technique for epispadias restores normal anatomical relationship of the male external genitalia components, with good cosmetic and functional results. Its extension to the complete primary repair of exstrophy allows deeper positioning of the bladder neck and posterior urethra within the pelvic diaphragm. Nevertheless, poor attention has been devoted so far in identifying and repositioning the urethral sphincteric mechanism. We consider the identification of the urethral striated sphincteric complex by bipolar electric stimulator and its appropriate reassembly as a main step in the repair of EEC. Methods: Nine consecutive patients (7 males and 2 females), 1 to 9 years old had bladder and urethrogenital repair during the last 4 years: three of them had EEC complete repair in one time (1 male newborn and 2 females), 4 were exstrophies previously closed and 2 boys had incontinent epispadias. In the male EEC patients, after bladder plate closure, mobilization of the urethral wedge and glans with splitting of corporeal bodies is performed. Accurate dissection is carried out on each side of the bladder neck and posterior urethra, laterally to the prostatic tissue which must stay joined with the proximal urethral wedge as one unit. A vertical midline incision is performed posteriorly and extended to the perineal body looking for the anterior pelvic floor musculature (which is displaced laterally), and the anorectal sphincter complex (which lies posteriorly). The use of bipolar electric stimulator is essential in order to detect the muscular fibers of the pelvic diaphragm and mobilize them around the tubularized urethral wedge at the level of the prostatic tissue. The bulbocavernosa are reapproximated along the midline over the posterior urethra, completing the reassembly of anterior pelvic floor musculature. In the 2 female patients both the urethral plate and the vagina are mobilized posteriorly through the midline dissection of the perineal body. Looking for the delicate muscular fibers of the pelvic floor which normally surround the female urogenital complex. No attempt is made in this phase to perform any bladder neck plasty or antireflux surgery, in order not to interfere with the lower tract functional maturation. Results: At 4 to 42 months of follow-up all patients revealed good cosmetic appearance. Cyclic micturition with urinary stream and dry intervals of 30 to 90 minutes were observed in 7 out of 9 patients (77.7%), whereas the remaining 2 patients still present continuous dribbling. No significant upper tract dilatation has been observed, but febrile tract urinary infection occurred in 4 patients, despite all being are on antibiotic chemoprophylaxis. One year after surgery, a cystogram under anesthesia was performed. Bladder capacity ranged from 35 cc to 80 cc. Grade 1 to 4 reflux was present in all patients. A meatal and distal urethral stricture occurred in one male exstrophy newborn, who required surgical meatotomy and re-do glansplasty. No urethral fistulas were observed. Conclusion: Early restoration of bladder-urethral physiologic balance in a coordinated activity is feasible for a progressive achievement of voluntary micturition control in EEC patients. Careful division of the anterior aspect of the perineal membrane and midline reassembly of the pelvic diaphragm muscles is completed by the surgical reconfiguration of the urethral sphincteric complex around the posterior urethra. We believe that urethral sphincteric mechanism behaves similarly to the muscular complex in anorectal malformations from the embryological, anatomical and functional standpoint. The correct reconfiguration of the pelvic anatomy in a normal fashion on the midline is the key for the achievement of voluntary continence. Therefore, neither trigone surgery nor bladder neck plasty is performed at this stage, to avoid any damage to the neuromuscular maturation of the trigone and bladder basement during the initial steps of the lower tract functional development. The accurate identification of the striated sphincteric structures, utilizing the bipolar stimulator and its reassembly around the posterior urethra could allow for better results in terms of restoration of normal bladder function in a coordinated fashion, looking for voluntary urinary continence in EEC patients., P. Caione, MD, N. Capozza, MD, A. Lais, MD, E. Matarazzo, MD. Div. of Pediatric Urology, Dept. of Surgery, Bambino Gesu Children's Hospital- Research Institute-Rome, [...]

Background: It has been previously reported the disappointing onset of contralateral vesico-ureteric reflux (VUR) after unilateral successful repair of primary VUR. Different pathogenetic hypoteses and different surgical strategies have been proposed for this phenomenon which occurs in 10% to 27% of unilateral VUR repairs. Little attention has been spent to the behaviour of congenital obstructive megaureter (COM) in relationship with the onset of contralateral reflux after unilateral reimplatation with or without tapering. Methods: Fifty-eight patients, aged from 2 to 10 years (mean: 3.2 years) underwent ureteral tapering and reimplantation for unilateral COM (42 left and 16 right side). Reimplantations were performed cross-trigonal in 57 cases and longitudinal according to Politano-Leadbetter in 1 case; 47 ureteral tapering were performed according to combined Hendren and Starr techniques and 11 were Kalicinski repairs. All patients underwent preoperative renal ultrasound (US), DTPA nuclear scan, pyelogram (IVP) and voiding cysto-urethrogram (VCUG) to role out the presence of VUR. The control group is composed of 98 age-matched children with unilateral VUR who underwent unilateral reimplant with or without ureteral tapering. [chi square] was used for statistical analysis. Results: Follow-up ranges from 6 months to 4 1/2 years. All children of both groups underwent a VCUG 6 months postoperatively and US at 3-6-12 months follow-up. In the study group a newly developed contralateral reflux was detected in 1 child with COM who underwent a Kalicinski ureteral tapering and cross-trigonal reimplantation (1.7%). In the control group we had 11 cases of newly developed contralateral reflux (11.2%). The difference was statistically significant (p [is less than] 0.005). Conclusion: These results indicate that vesico-ureteral reimplantation for unilateral COM repair is not responsible of the onset of newly diagnosed contralateral reflux. The single case observed remains unexplained. In this regard COM behaves differently from primary VUR. The occurrence of contralateral reflux after successful unilateral VUR repair is significantly high (11.2%) and it is independent from age, sex and technique of reimplantation and/or ureteral tapering / plication. The difference between the study group (unilateral COM) and the control group (unilateral VUR) regarding the postoperative contralateral reflux onset is highly significant (p [is less than] 0.005). Our results confirm the hypoteses that the functional anatomy of the trigone is preserved in primary megaureter, whereas the uretero-vesical junctions appear bilaterally impaired in VUR. Thus, the onset of contralateral VUR is not significant in COM repairs and seems a consequence of the primitive trigonal impairment in primary VUR, rather than the effect of the bladder fibers distorsion during the ureteral reimplantation. These results should differentiate the surgical strategy of primary VUR from COM., P. Caione, MD, L. Asili(*), MD, N. Capozza, MD, A. Lais, MD, E. Matarazzo, MD. Div. of Pediatric Urology, Dept. of Surgery, Bambino Gesu Children's Hospital, Research Institute, Rome, Italy-(*)Dept. [...]