|Year : 2015 | Volume
| Issue : 2 | Page : 139-142
Laparoscopy-assisted cutaneous ureterostomy at suprapubic creaseline facilitates subsequent reimplantation
Md. Jafrul Hannan
Department of Pediatric Surgery, Chattagram Maa-O-Shishu Hospital Medical College, Chittagong, Bangladesh
|Date of Submission||03-Aug-2013|
|Date of Acceptance||25-Dec-2013|
|Date of Web Publication||24-Mar-2015|
Md. Jafrul Hannan
South Point Hospital, 11, Agrabad Access Road, Chittagong
Source of Support: None, Conflict of Interest: None
Background: Cutaneous ureterostomy is still practiced despite a trend towards primary surgical correction for obstructive or refluxive uropathy. For future open reimplantation, ureterostomy can be created by minimal invasive technique at the end(s) of the suprapubic creaseline. Materials and Methods: From 1 January 2009 to 31 July 2012, seven children were treated with laparoscopy-assisted cutaneous ureterostomy followed by ureteric reimplantation. Indications were primary obstructive megaureter 3, hugely dilated ureters with reflux 3 and posterior urethral valve with poor general health 1. The distal manoeuverable part of tortuous ureter was pulled to the surface at either end of suprapubic creaseline to create the stoma. During reimplantation, this stoma was dismembered and brought inside urinary bladder obviating the need for stoma-site repair. Results: Mean age was 4.6 ± 2.8 years with six males. There were three bilateral cases with total 10 lesions. Mean operating time was 39.8 ± 12.5 minutes. Mean follow-up was 1.7 ± 0.8 years and except for peri-stomal excoriations no major complication occurred. All these were reimplanted 6-12 months after ureterostomy and faring well except in one case. Conclusions: Laparoscopy-assisted cutaneous ureterostomy can be fashioned at suprapubic creaseline to facilitate future reimplantation without much jeopardy and extra scar.
Keywords: Cutaneous ureterostomy in children, cutaneous ureterostomy, laparoscopic ureterostomy, laparoscopy, suprapubic creaseline, ureterostomy
|How to cite this article:|
Hannan M. Laparoscopy-assisted cutaneous ureterostomy at suprapubic creaseline facilitates subsequent reimplantation. J Min Access Surg 2015;11:139-42
| ¤ Introduction|| |
Upper tract urinary diversion is a well-known practice in adults for pelvic malignancy whether it is temporary or permanent. ,, In children, indications are becoming limited nowadays, because definitive primary surgical correction is the preferred treatment option for refluxive or obstructive uropathy.  There are, however, certain situations where definitive surgeries may need to be delayed, e.g., if there is uncontrolled urinary infection, sepsis, deteriorating renal function and presence of hugely dilated ureter. , In these conditions, temporary diversion in the form of cutaneous ureterostomy is considered.  There are several ways of creating cutaneous ureterostomy; however, laparoscopic technique is gaining popularity for temporary loop ureterostomy. ,,,,, In some cases undiversion is done when clinical condition improves and in others ureteric reimplantation is planned for a later date. When ureteric reimplantation is the plan by open technique, ureterostomy can be done by minimal invasive technique and placed at the end(s) of the suprapubic creaseline (pfannentiel incision site). We describe here our experience of this novel technique in a small group of children.
| ¤ Materials and methods|| |
From 1, January 2009 to 31, July 2012, 7 children were treated with laparoscopy-assisted cutaneous ureterostomy (LACU) followed by ureteric reimplantation. Indications for ureterostomy was primary obstructive megaureter in three cases, hugely dilated ureters with grade V refluxes in three cases and posterior urethral valve (PUV) with bilateral grade V refluxes and deteriorating renal function in one case. Under general endotracheal anaesthesia loop ureterostomy was done in all the cases. Three trocars were used in unilateral lesions: Supraumbilical port for camera, right or left flank port for ureter mobilisation and 3 rd port at either right or left end of suprapubic creaseline for stoma [Figure 1]. For bilateral cases 5 trocars were used: Supraumbilical port for camera, one port in each flank for ureteral mobilisation and one port at each end of suprapubic creaseline for stomas [Figure 2]. Five mm 30° telescope and insufflations pressure was kept around 10 mmHg. Patients were kept supine with foot end and procedural sides elevated. Legs of the patient were suspended down to make room for the monitor at the foot end of operating table with the surgeon on the opposite side of lesion/procedure and assistant on the affected side. Urinary bladder was kept catheterised during the procedure. The most distal manoeuverable part of tortuous ureter was mobilised after making a hole in the overlying parietal peritoneum using hook cautery and Maryland forceps. Then the ureter was grasped with a Babcock forceps and pulled to the surface at either end of suprapubic creaseline for creation of stoma through 5-mm or 10-mm trocar depending on the size of ureter [Figure 3]a, b and [Figure 4]. During this pulling of ureter insufflations gas was released so as to reduce the distance between anterior and posterior abdominal walls. Ureteric reimplantation was planned later on when physically and biochemically patients become fit. During reimplantation, the stoma was dismembered by circumferential incisions. Then minor adhesions were released and trans-trigonal reimplantation performed bringing the stoma site inside urinary bladder and discarding the distal portion obviating the need for repair of ureter and leaving no extra scar on skin.
The Ethical Review Committee for Thesis and Research of Chattagram Maa-O-Shishu Hospital Medical College gave permission to conduct this retrospective study. The age, sex, operative techniques, operating time, complications and outcome were evaluated.
| ¤ Results|| |
Ages ranged from 6 months to 9 years (mean 4.6 ± 2.8) with six males and one female. There were three bilateral cases with total 10 lesions. Mean operating time was 39.8 ± 12.5 minutes (range 25-65 minutes) per stoma. There was no major intraoperative complication. Except for peri-stomal excoriations no major complication occurred postoperatively. Ureteric reimplantations were successfully done in all the seven cases 6 - 12 months after ureterostomy needing tapering in one case. Mean follow-up was 1.7 ± 8 years (range, 6 months to 2.5 years). Renal functions were improved in six cases in terms of serum creatinine and isotope renogram studies and one patient deteriorated after reimplantation [Table 1].
| ¤ Discussion|| |
Laparoscopy, these days is a well-accepted modality in the treatment of a wide range of surgical problems in children. ,,,,, The truth is, diagnostic laparoscopy for impalpable testes was the fore-runner of paediatric laparoscopy and now laparoscopy is also widely practiced in other fields of paediatric urology. ,,,,,,,,, Laparoscopic cutaneous ureterostomy can be done either by retroperitoneoscopy or by transperitoneal route and retroperitoneoscopy has the advantage of avoiding possible intra-abdominal adhesions while transperitoneal approach facilitates bilateral procedures. ,
Cutaneous ureterostomy has its own complications including failure, ureteral hernia, retraction and stenosis, acute pyelonephritis and deterioration in renal function. ,, Laparoscopy reduces the risk of hernia, retraction and stenosis by its minimal damage to the abdominal wall layers during procedure.  We did not find any of these complications in our series except persistence of urinary infection in two cases for more than 1 month. However, peri-stomal excoriation developed in all cases which persisted until reimplantation in two cases. We have managed this excoriation applying zinc oxide paste and a pad of soft clothe was applied over that to absorb the urine which was changed frequently. All of our patients were improved clinically and with normal creatinine level (<1.0 mg/dl) after cutaneous ureterostomy [Table 1]. Six patients were doing well after the definitive procedure. The case with poor renal function before ureterostomy also deteriorated after reimplantation. It was managed in the nephrology unit and became stable after a while.
Reports of laparoscopic cutaneous ureterostomy in children are scarce.  Ureters in those occasions were brought out through flank ports which produced more than one scars during subsequent definitive procedure. In our technique we have anticipated future necessity for reimplantation and planned to bring out the ureters in a way so that a need of further scar creation is obviated. The extra length and tortuosity of megaureters allowed us to remove the post-stoma portion of ureter and reimplant the stoma site within the urinary bladder.
Urinary diversion is very infrequently practiced nowadays except in certain situations mentioned earlier. Before starting this practice of cutaneous ureterostomy we used to perform cutaneous vesicostomy in this selected group of patients. So in this study we have got a limitation of not being able to compare open ureterostomy with laparoscopic procedure. Our technique has the advantages over other laparoscopic techniques in that it avoids extra scar in ureter as well as on the skin -4 . Laparoscopy also has got its obvious advantages over open technique including avoiding a big scar. However, we have avoided laparoscopy in two cases during study period considering the very critical condition with renal impairment, electrolyte and acid-base imbalance and opted for cutaneous vesicostomy under local anaesthesia.
| ¤ Conclusions|| |
Laparoscopy-assisted cutaneous ureterostomy can be fashioned at suprapubic creaseline to facilitate future reimplantation without much jeopardy and extra scar.
| ¤ References|| |
Puppo P, Perachino M, Ricciotti G, Bozzo W. Laparoscopic bilateral cutaneous ureterostomy for palliation of ureteral obstruction caused by advanced pelvic cancer. J Urol 1994;8:425-8.
Loisides P, Grasso M, Lui P. Laparoscopic cutaneous ureterostomy: Technique for palliative upper urinary tract drainage. J Endourol 1995;9: 315-7.
Woodhouse CR. Supra-vesical urinary diversion and ureteric re-implantation for malignant disease. Clin Oncol 2010;22:727-32.
Metzelder M, Petersen C, Ure B. Laparoscopic ureterocutaneostomy for urinary diversion in selected infants. Eur J Pediatr Surg 2008;18:86-8.
Rabinowitz R, Barkin M, Schillinger JF, Jeffs RD, Cook GT. Surgical treatment of the massively dilated ureter in children. Part I. management by cutaneous ureterostomy. J Urol 1977;117:658-62.
Rosen MA, Roth DR, Gonzales ET Jr. Current indications for cutaneous ureterostomy. Urology 1994;43:92-6.
Yoshimura K, Maekawa S, Ichioka K, Terada N, Matsuta Y, Okubo K, et al
. Tubeless cutaneous ureterostomy: The Toyoda method revisited. J Urol 2001;165:785-8.
Kim CJ, Wakabayashi Y, Sakano Y, Johnin K, Yoshiki T, Okada Y. Simple technique for improving tubeless cutaneous ureterostomy. Urology 2005;65:1221-5.
Wada Y, Kikuchi K, Imamura T, Suenaga T, Matsumoto K, Kodama K. Modified technique for improving tubeless cutaneous ureterostomy by Ariyoshi method. Int J Urol 2008;15:144-50.
Georgeson KE. Pioneers, cowboys, and desperados: A brief history of pediatric surgical innovation. J Pediatr Surg 2011;46:1-7.
Rothenberg SS, Chang JH, Bealer JF. Minimally invasive surgery in neonates: Ten years' experience. Pediatr Endosurg Innov Tech 2004;8:89-94.
Sato M, Hamada Y, Iwanaka T. Recent progresses of pediatric endoscopic surgery in Japan. JMAJ 2010;53:250-3.
Panteli C, Minocha A, Kulkarni MS, Tsang T. The role of laparoscopy in the management of adnexal lesions in children. Surg Laparosc Endosc Percutan Tech 2009;19:514-7.
Lin T, Pimpalwar A. Minimally invasive surgery in neonates and infants. J Indian Assoc Pediatr Surg 2010;15:2-8.
Jones VS, Cohen RC. Two decades of minimally invasive pediatric surgery-taking stock. J Pediatr Surg 2008;43:1653-9.
Denes FT, Saito FJ, Silva FA, Giron AM, Machado M, Srougi M. Laparoscopic diagnosis and treatment of nonpalpable testis. Int Braz J Urol 2008;34:329-35.
Docimo SG, Moore RG, Adams J, Kavoussi LR. Laparoscopic orchiopexy for the high palpable undescended testis: Preliminary experience. J Urol 1995;154:1513-5.
Kaye JD, Palmer LS. Single setting bilateral laparoscopic orchiopexy for bilateral intra-abdominal testicles. J Urol 2008;180:1795-9.
Sultan RC, Johnson KC, Ankem MK, Barone JG. Laparoendoscopic single site orchiopexy. J Pediatr Surg 2011;46:421-3.
Gill IS, Clayman RV, McDougall EM. Advances in urological laparoscopy. J Urol 1995;154:1275-94.
Lopez M, Melo C, François M, Varlet F. Laparoscopic extravesical transperitoneal approach following the lich-gregoir procedure in refluxing duplicated collecting systems: Initial experience. J Laparoendosc Adv Surg Tech A 2011;21:165-9.
Lopez M, Varlet F. Laparoscopic extravesical transperitoneal approach following the Lich-Gregoir technique in the treatment of vesicoureteral reflux in children. J Pediatr Surg 2010;45:806-10.
Tracy CR, Raman JD, Cadeddu JA, Rane A. Laparoendoscopic single-site surgery in urology: Where have we been and where are we heading? Nat Clin Pract Urol 2008;5:561-8.
Esposito C, Valla JS, Yeung CK. Current indications for laparoscopy and retroperitoneoscopy in pediatric urology. Surg Endosc 2004;18:1559-64.
Lopez M, Guye E, Varlet F. Laparoscopic pyeloplasty for repair of pelvi-ureteric junction obstruction in children. J Pediatr Urol 2009;5:25-9.
Kaynan AM, Winfield HN. A transperitoneal laparoscopic approach to endourology. Curr Urol Rep 2001;2:154-64.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]