Abstracts presented in the 8th Biennial meeting of Indian Society for Paediatric Urology, Asian Society for Paediatric Urology in association with Paediatric-Urology chapter of & Delhi chapter of IAPS IAPS

Abstracts presented in the 8th Biennial meeting of Indian Society for Paediatric Urology, Asian Society for Paediatric Urology in association with Paediatric-Urology chapter of & Delhi chapter of IAPS IAPSs presented in the 8th Biennial meeting of Indian Society for Paediatric Urology, Asian Society for Paediatric Urology in association with Paediatric-Urology chapter of & Delhi chapter of IAPS IAPS August 29 to 31 , 2013 th st 01 The feasibility of laparoscopy in the treatment of p ediatric urolithiasis a Vikesh Agrawal, Virender Sekhon, H Acharya, R Chanchalani Department of Surgery Medical College and Hospital, NSCB Jabalpur, Madhya Pradesh, India, 482001 Objective: To assess the feasibility of laparoscopy in the treatment of p ediatric urolithiasis, we report our experience a with the transperitoneal laparoscopic removal of stones. Renal pelvic stones of size >1 cm on ultrasound Methods: were included for laparoscopic pyelolithotomy while smaller stones were managed with shock-wave lithotripsy monotherapy. Intrarenal stones, calyceal stones, complete staghorn stones, multiple stones and kidneys with intrarenal pelvis were excluded. Ureteric stones included for laparoscopic ureterolithotomy were of size >1 cm in the upper, mid or lower ureter, and smaller stones not responding to nonoperative treatment. Results: A total of 22 procedures were performed: 12 pyelolithotomies, and 8 lower and 2 upper ureterolithotomies. Complete removal of calculi was accomplished in 21 (95.45%) procedures. Complications associated with laparoscopic lithotomy included urinoma (4.54%), failure (4.54%) and omental prolapse (4.54%). Conclusion: Laparoscopic lithotomy is safe and feasible in p ediatric urolithiasis with pyelic and ureteric stones, with a minimal complications and failure rate. 02 Laparoscopic pyeloplasty in infants: singlesurgeon experience with 114 operations VVS Chandrasekharam, Rainbow Children's Hospitals, Street No 10 banjara hills, Hyderabad, Andhra Pradesh, India, 500034 Aim: To report our large single-surgeon experience with laparoscopic pyeloplasty in infants. Methods: The records of all infant laparoscopic pyeloplasties over a 4-year period (109 babies, 114 kidneys, mean age 3.8 months, mean weight 5.3 kg) were analyzed. Preoperative evaluation included renal ultrasound and diuretic renogram (using Tc 99m ) in all children. Transperitoneal DTPA laparoscopic pyeloplasty was performed in all babies with 3 ports. Double J stent was used in 102 kidneys. Follow-up renal ultrasound (96 kidneys) was done at 3-6 months and diuretic renogram (66 patients) at 6-12 months after the surgery; data were compared using statistical software. Results: There were 104 unilateral and 5 bilateral pyeloplasties. The mean operating time was 106 min (70145) and median hospital stay was 2 days (2-8). There were no major intraoperative complications. One child (1%) developed urinary leak that spontaneously resolved. At a mean follow-up of 15 months, all children are asymptomatic; ultrasound demonstrated significant reduction in the anteroposterior diameter of renal pelvis in all children (mean pre-operative diameter 34.4 +/13.4 mm versus mean postoperative diameter 10.6 +/5.7, p< 0.0001). On Followup renogram (41 children), there was a significant improvement in the differential function of the operated kidney (preoperative 22.1 +/8.6 % versus postoperative 35.6 +/11.4 %, p< 0.0001). Conclusions: To our knowledge, this is the largest series of infant laparoscopic pyeloplasty till date. Laparoscopic pyeloplasty could be safely and successfully performed even in small infants, with minimal complications and good Journal of Progress in Paediatric May Aug 2013 Vol 16 Issue 1 Urology, — , , 21 results. Significant reduction in hydronephrosis & improvement in differential function can be expected in the majority of children. 03 PUJ obstruction in children: is laparoscopic pyeloplasty the procedure of choice? Aswin Prabhakaran, Mohan Abraham, Naveen Viswanath, S Bindu, P Ramakrishnan, Anup Paliwal, Aisha Naaz, KN Narasimha, Divya Prakash Amrita Institute of Medical Sciences, Amrita Lane, , AIMS Ponekkara, Edappally, Kochi, Kerala, India 682041 Purpose: To determine the efficacy and long-term outcome of laparoscopic pyeloplasty in paediatric patients. Methods: Between August 2004 and December 2012, 99 children (61 males, 38 females; age range 6 to 144 months) underwent laparoscopic pyeloplasty for symptomatic or radiographic obstruction. The various parameters PUJ analysed were operative time, intra and postoperative complications, hospital stay and postoperative outcome. Results: All patients underwent transperitoneal dismembered pyeloplasty. The mean operative time was 179 minutes and postoperative stay was 4.04 days. There were no intraoperative complications. Conversion to open surgery was required in four (4.04%) patients. Postoperatively 8 (8.08%) patients had culture proven urinary tract infection. All 9 patients with recurrent pain became symptom free postoperatively. There was improvement in function in 83 (83.83%) with no deterioration of function in 7 patients. Two patients who showed continued obstruction with deterioration of function underwent a redo pyeloplasty. The mean glomerular filtration rate (ml/min), preoperative and at follow-up were 31.08 and 39.4, respectively. Mean follow-up period was 31 months. Conclusion: Our patients who have undergone laparoscopic pyeloplasty had very good results with low morbidity. We consider this our primary technique for surgical correction of PUJ obstruction in patients older than 6 months. 04 Modified umbilical port laparoscopic pyeloplasty in children Mallikarjuna Reddy, Nerli, Guntaka, P Patne, Hiremath RB AK MB KLES KLES Kidney Foundation, Dr Prabhakar Kore Hospital and , University's Medical College, MRC KLE JN Belgaum, Karnataka, India, 590010 Purpose: Over the past three decades laparoscopic surgery has become a well-established alternative to open surgery in the management of obstruction. Currently several efforts UPJ are being made, aimed at further reducing the morbidity associated with conventional laparoscopy. We report our experience with modified umbilical port laparoscopic pyeloplasty in children. Methods: Children presenting with hydronephrosis secondary to obstruction formed the study group. In UPJ children undergoing the modified umbilical port laparoscopy, a 5 mm endoscopic port was placed on the inferior umbilical crease. The two 3 mm instruments were introduced through puncture sites created a few mm superior and lateral to the endoscopic port, under vision. Total operating time, time taken for insertion of double pig tail catheter, time taken for pyeloplasty anastomosis and complications were noted. Results: During the study period, 4 children underwent conventional multiport laparoscopic pyeloplasty and three children underwent Modified umbilical port laparoscopic pyeloplasty. The Total operating time and the time for insertion of double pigtail catheter was significantly more with the modified umbilical port laparoscopy. Conclusions: Modified umbilical port laparoscopic pyeloplasty reduces the morbidity associated with conventional multiport laparoscopy without the need of expensive multichannel cannulas, curved laparoscopic instruments and longer laparoscopic endoscopes. Though crossing instruments is a factor which prolongs the duration of surgery, but it does not hinder complex suturing needed during pyeloplasty. 05 Laparoscopic extravesical reimplantation of ureter in children Ajay Kumar Guntaka, Mallikarjuna Reddy, Nerli, Pravin RB Patne, Hiremath MB KLES KLES Kidney Foundation, Dr Prabhakar Kore Hospital and , University's Medical College, MRC KLE JN Belgaum, Karnataka, India, 590010 22 Urology, — , , Journal of Progress in Paediatric May Aug 2013 Vol 16 Issue 1 Purpose: Laparoscopic extravesical reimplantation of ureter is likely the most commonly reported procedure for laparoscopic correction of reflux. The technique has a steep learning curve; initial experiences described challenges with exposure of the ureter, trauma to the ureter, and difficulty developing the extravesical tunnel without injuries to the urothelium in addition to long operative times. We report our experience and 5 year follow-up. Methods: During the period Jan 2002 to Dec 2011, children < 18 years of age undergoing laparoscopic repair of VUR formed the study group. Age, gender, grade of , VUR indication, duration of surgery, complications and follow-up was noted in all. Results: During the study period 42 children with a mean age of 11.2 years underwent laparoscopic extravesical reimplantation of the ureter. In 39 cases it was unilateral and in the remaining three, bilateral reimplantation was done. Of these 42 children, 38 were females and the remaining four were males. The indications were persistent in VUR adolescents in 31, recurrent infection in 9, and deterioration of renal unit in 2. The mean surgical time was 76 minutes in unilateral cases and 112 minutes in bilateral cases. There were no major intraoperative complications, except for puncture of the submucosal tunnels in 5 cases. Three children had prolonged postoperative ileus, one child had fever and one child needed preoperative blood transfusion. The mean follow-up was 73 months. During the follow –up period, no children developed . Three children who presented with UTI opposite side needed endoscopic management with VUR Deflux. Conclusions: Although open surgical correction of reflux is still the gold standard against which the endoscopic and laparoscopic approaches are compared, the technical advances and improved results achieved using minimally invasive techniques are gradually becoming an alternative option. Five year follow-up has shown good outcome in our series. 06 Robot assisted laparoscopic removal of staghorn calculus Manas Ranjan Dash, V Sripathi, Thirumallai Ganeshan Apollo Children's Hospital, 15, Mohamed Shafee Road, Thousand Lights, Chennai, Tamil Nadu, India, 600006 Introduction: In a child a large stone burden may necessitate the use of both Percutaneous Nephrolithotomy ( ) and PCNL Extra Corporeal Shock Wave Lithotripsy ( ) as ESWL sandwich therapy to obtain clearance. We describe the use of Robot Assisted Laparoscopic pyelolithotomy combined with URS through the assistant port to obtain complete clearance in a single sitting. Methods: A 10 year old male child presented with a 4.5 cm staghorn stone and two large calculi in the inferior calyces. CT IVU PUJ raised the possibility of a obstruction due to a 'crossing vessel'. In an attempt to do both pyelolithotomy and PUJ correction at the same time, a robotic approach was attempted. Using the Da Vinci Si and three ports the renal pelvis was exposed. obstruction was excluded. Through PUJ a pyelotomy, the 4.5 cms pelvic stone was removed. Using a lithoclast it was broken into 4 fragments and extracted through the assistant port. Through the pyelotomy an ureterorenoscope was introduced and the inferior calyces visualised. It was found that the infundibulae were stenotic. Using a Holmium laser the impacted calculi were fragmented, flushed into the pelvis and extracted. Complete stone clearance could be obtained and the pyelotomy was closed over a 5 Fr 24 cms stent. DJ Discussion: When there is a staghorn pelvic component and large calculi in the anterior and posterior segments of the inferior calyx is a difficult option. It necessitates two PCNL punctures and the infundibular stenosis prevents free access to the pelvic component of the staghorn for which 'sandwich therapy' may be needed with multiple sittings. Both procedures will leave behind multiple fragments. The robotic approach helped us to get complete clearance in one sitting and had the added advantage of avoiding a kidney puncture. 07 Transumbilical laparoendoscopic single-site multiport approach in children: initial experience Nitin Kumar Dhende Grant Government Medical College, R.M. Bhat Marg, Mumbai, Maharashtra, India, 400008 Background: Laparoscopic surgery is now standard approach to treat many anomalies in children. Transumbilical laparoendoscopic single-site multiport approach is used to treat paediatric urological anomalies. This approach definitely gives better cosmetic results than conventional Journal of Progress in Paediatric May Aug 2013 Vol 16 Issue 1 Urology, — , , 23 laparoscopic approach. Methods: Thirty one patients with different urological problems were operated using this approach from June 2011 to June 2013. Out of thirty patients, there were 6 pyeloplasties, 14 female herniotomies, 7orchiopexies, 2 ovarian cystectomies, 1 retroperitoneal teratoma excision and 1 nephrectomy. Out of 31 patients 16 were female and 15 were male patients with the youngest patient being 2 months old. Three ports were used one 5mm for telescope 30degree and two working port of 3mm each. Routine straight working instruments were used. Results: All the patients with herniotomy and orchiopexy were started on oral feeds after 4 hours after surgery. Caudal block analgesia was given to all the patients for analgesia for first 6 hours post surgery. Ovarian cystectomy, nephrectomy and retroperitoneal teratoma patient was started on oral feeds after 24 hours after surgery. Drain was used in two patients i.e. retroperitoneal teratoma and nephrectomy. We found that severity of pain was less as compared to conventional laparoscopic surgeries. There was single scar at the umbilical region and cosmesis was better than conventional laparoscopy. There were no major complications in series. Two patients had umbilical wound infection and were treated with local dressing. Conclusion: Transumbilical laparoendoscopic single-site multiport approach is feasible and safe approach in paediatric urological surgeries in children. However this is small series and initial experience. 08 Urolithiasis in the p ediatric augmented bladder: a incidence and risk factors Sundeep Kisku, Sudipta Sen, Jacob Chacko, Sampath Karl, John Mathai, Reju Thomas, Ravikishore Barla, Pradeep Ninan Christian Medical College Vellore, Department of Paediatric Surgery, Ida, Scudder Road, Vellore, Tamil Nadu, India, 632004 Purpose: Bladder augmentation has become the mainstay of treatment for a variety of urological conditions providing a low pressure continent catheterizable reservoir. Incidence of stones reported in the augmented bladders varies from 7 to 52.5 %. We examine the incidence and risk factor of urinary calculi in our patients with bladder augmentation. A total of 268 children and teenagers underwent Methods: bladder augmentation during Jan 1997Dec 2012. 217(81 %) of them had at least 5 months of follow up after bladder augmentation and their records were reviewed for this study. All our patients have been advised clean intermittent c a t he t e r i z a t i o n a n d da i l y b l a d de r i r r i g a t i o n . Two hundred and seventeen (217) children were Results: followed up for an average of 58.9 months (5-192). There were 143(66%) males and 74(44%) female with an average age of 6.4yrs (0.5-19) yrs. The children were operated for conditions such as exstrophy and incontinent epispadias (83), neurogenic bladders (67), Posterior urethral valve ( ) PUV (32) and misc (35). The type of bowel segment used for augmentation was sigmoid (111), ileocaecal (60), ileum (24), ureter (16) and others (8). Mitrofanoff procedure was done in 202 children {appendix (168), uteter (14), monte (4), miscellaneous (14)}. Bladder neck division was performed in 37 children. Preoperative urinary calculi were observed in 13 chi ldren {bladder s tone (10), kidney s tone (1) , Kidney+ureter+bladder stones (1), and ureter + bladder stones (1)}. Twelve of these were children with exstrophy and one was a child with neurogenic bladder. Postoperative calculi were seen in 16(7.3%) children; ten of them had exstrophy, two had epispadias, two had neurogenic bladder and none had . These calculi were observed in the PUV bladder (13), kidney (2), bladder + kidney (1). Five patients had a bladder neck division. Thirteen children were performing through the appendicular mitrofanoff while CIC 3 children were using the urethral route. Three children (all of them with extrophy) had calculi before the augmentation. Post op recurrent calculi were noted in 2 children (both exstrophy).Calculi were detected at a mean interval of was 58.8 months (10-160 months) following bladder augmentation. Conclusion: Calculi formed in 7.3% of patients following bladder augmentation that had been followed up for 58.9 months (1085 augment years). Calculi were detected at a mean interval of was 58.8 months post operatively. Exstrophy, and previous calculi are predisposing BND factors to develop urinary stones. Daily bladder irrigation probably decreases the risk of stone formation. 09 Our experience of paediatric urolithiasis in northwest rajasthan V Kumar, Bhat, M Singla, Saran, M Bhat, R Upadhay AL RK Department of urology, S.P. medical college, Bikaner, 24 Urology, — , , Journal of Progress in Paediatric May Aug 2013 Vol 16 Issue 1 Rajasthan, India, 334001 Objective: Paediatric urolithiasis has increased globally in the last few decades with an increase in the frequency of kidney stones and a decrease in bladder stones. This retrospective study was done to determine clinical characteristics, evaluation and course of current diagnostic and management strategies in paediatric age group. Methods: This was a retrospective study of 50 children with newly identified urolithiasis between April 2009.and August2012. Cases were reviewed for demographics, presentation, diagnostic methods and findings, anatomic abnormalities and management. Results: Fifty patients (41 male, 09 female) were assessed. Mean age was 8.48 years, with maximum no case in 10-12 years age group (56%) and adult paediatric ratio was 1: 16 (50 children, 807 adult). Youngest patient was 1.5 years old. Suprapubic pain (70%) was the most common presentation followed by flank pain (38%). upper urinary tract stones were found in 28% ( renal stone 12% and urethral stone 16%), lower urinary tract stone stones were found in 66% ( blabber stone 60%, urethral stone 6%) and 3 (6%) patient had both upper tract and lower urinary tract stone, 38 patient (76%) had open surgical procedure and , , with PCCL PCNL URS DJ stenting and endoscopic removal of impacted urethral stone was done in 8%, 4%, 6% and 6% patients respectively. Conclusions: Trends in present study lower urinary tract stone stones were found in 66%( bladder stone 60%, urethral stone 6%) shows that trends in present study still not changed to upper tract. Although treatment modality in present study is predominantly open surgical procedures (76%), trend is changing towards minimal invasive (24%), with advancement in endourology. 10 Single system ectopic ureter: Study of 7 cases from single tertiary care centre Flavia D'souza, Pradnya Bendre, R Mukund, Parag Karkera Bai Jerbai Wadia Hospital for Children, Acharya Donde Marg, Parel, Mumbai, Maharashtra, India, 400012 Purpose: Single-system ectopic ureter ( ) encompasses SSEU a spectrum of malformations involving the bladder trigone, ureter and kidney. The clinical presentation is variable, and both diagnostic and therapeutic problems are common. Methods: We present our experience of single system ectopic ureters treated over the last five years. Results: Spectrum ranged from unilateral ectopia with nonfunctioning kidney which was simplest to treat to extreme of anomaly with bilateral affection with urogenital sinus which was very complex to repair. In the last case the bladder neck and both ureters were opening into vaginalized urogenital sinus. Conclusion: Bilateral ectopic ureters are complex to treat. Bilateral single-system ectopic ureters opening into urogenital sinus present a unique challenge for genitourinary reconstruction because of the absence of the urethra in addition to an incompetent vesical neck and the small capacity of the bladder adds up to the problem of incontinence besides problems associated with vaginal reconstruction. 11 Ureteric atresia with a functioning kidneya unique case (first in the world) Harparkash Singh Miglani Miglani Child surgery Centre, 9-sir Gopal Dass Road, Near Govt. Dental College, Amritsar, Punjab, India, 143001 Ureteric atresia is known with dysplastic Kidneys. No case has been reported in English literature till date where a functioning kidney has been found with a ureteric atresia. We present a case which was diagnosed antenatally but referred to us at the age of 6 months with a provisional diagnosis of left mega ureter or left vesico ureteric junction obstruction. The case was investigated and taken up for surgery for ureteric reimplantation. However the intra operative findings proved beyond doubt that it was ureteric atresia (descriptive photographs). The operative plan was changed and an end to end ureteric anastomosis was made. The patient has been followed up for eight years and his left kidney has shown excellent recovery. The case is being presented as the first in the World. 12 Early elective surgery in unilateral multicystic dysplastic kidney ( ) MCDK Basant Kumar Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, U.P., India, 226014 Purpose: Children with are being now diagnosed MCDK Journal of Progress in Paediatric May Aug 2013 Vol 16 Issue 1 Urology, — , , 25 antenatally with an estimated incidence of 1:4300 live births. In absence of complications, they are increasingly managed conservatively; but because of the long term risk of hypertension; even after involution, they are also followedup throughout child hood. Current literature showed that the risk of hypertension does not justify routine nephrectomy but surgery is still proposed as the treatment of choice because of potential complication of hypertension, infection and malignant changes. Cases Summary: In two antenatally diagnosed children with UMCDK, we experienced that early surgery may cure the hypertension early. These two children diagnosed to develop hypertension within 4 months of age. One child was operated within month of diagnosis and fully cured having normal blood pressure in last one year of follow-up. Other child was initially managed by antihypertensive drugs and latter at 2 year of age, surgery was performed. Her blood pressure is gradually falls and normalizes after 10 month of nephrectomy. Discussion: Current literature recommends non-operative management; because of spontaneous involution, low risk of hypertension / malignancy and nephrectomy is usually not curative in these conditions; hypertension may persist after nephrectomy and no difference in the number of complication in operative vs non-operative groups. While early nephrectomy recommended because it is more costeffective than non-surgical follow-up. Duration of follow-up for surveillance is widely variable and not based on solid BP evidence and leaves patients at risk of infection, hypertension and cancer, especially in those cases lost to follow-up. After spontaneous involution (~ 40% cases) there may still be a risk of . HTN Conclusion: nephrectomy is better option to manage the hypertension in when performed early; especially UMCDK in countries where regular follow-up is difficult. 13 Laparoscopic mitrofanoff appendicovesicostomy: our experience in children with neurogenic bladder Mallikarjuna Reddy, Nerli, Ajay Kumar Guntaka, Pravin RB Patne, Hiremath MB KLES KLES Kidney Foundation, Dr Prabhakar Kore Hospital and , University's Medical College, MRC KLE JN Belgaum, Karnataka, India, 590010 Purpose: The Mitrofanoff principle was originally described as a method to provide an alternative means to access the bladder. It creates a conduit to the bladder through which patients with a sensitive, absent or traumatized urethra can perform clean intermittent catheterization ( ) easily. We CIC report our experience with complete laparoscopic Mitrofanoff appendicovesicostomy to promote a catheterizable abdominal stoma in children with neurogenic bladder. Methods: A 4-port transperitoneal approach was used to c r e a t e a c o m p l e t e l a p a r o s c o p i c M i t r o f a n o f f appendicovesicostomy. Results: Twelve children with a mean age of 14.6 years (range 7–16 years) underwent laparoscopic Mitrofanoff appendicovesicostomy. Mean operative time was 145.6 mins and Mean estimated blood loss was 42 cc. No cases of urinary leaks were noted. There have been no cases of either stomal stenosis or appendicovesical stenosis noted. Conclusions: Pure laparoscopic Mitrofanoff appendicovesicostomy is feasible and is associated with reasonable outcome with early recovery, resumption of normal activities and excellent