Possibilities of pneumovesicoscopy in children

The goal of this video is to illustrate the surgical possibilities of pneumovesicoscopy in children. The principle is to insufflate the bladder with CO2 and to introduce 3 trocars in this natural cavity. The patient is placed across the table to provide an access to the perineum and a good ergonomic position for the surgeon who stands at the patient's head. A camera holder is useful to get a stable image.

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Possibilities of pneumovesicoscopy in children

Authors

Abstract

The goal of this video is to illustrate the surgical possibilities of pneumovesicoscopy in children. The principle is to insufflate the bladder with CO2 and to introduce 3 trocars in this natural cavity. The patient is placed across the table to provide an access to the perineum and a good ergonomic position for the surgeon who stands at the patient's head. A camera holder is useful to get a stable image.

Classification

contribution

Keywords

Pneumovesicoscopy, children, vesicoureteral reflux, megaureter, incontinence, ureterocele, congenital bladder diverticulum

Media type

Surgical video

Duration

09'41''

Publication

2011-03

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E-publication

WeBSurg.com, Mar 2011;11(03).
URL: http://www.websurg.com/doi-vd01en3235.htm

Possibilities of pneumovesicoscopy in children

1. Introduction 00'19''

The goal of this video is to illustrate the surgical possibilities of pneumovesicoscopy in children. The principle is to insufflate the bladder with CO2 and to introduce 3 trocars in this natural cavity. The patient is placed across the table to provide an access to the perineum and a good ergonomic position for the surgeon who stands at the patient’s head. A camera holder is useful to get a stable image.

2. Technique in case of vesicoureteral reflux 00'46''

The most frequent indication is the vesicoureteral reflux. All the steps of the classical Cohen technique could be reproduced: catheterization, dissection through the hiatus with hooks or scissors, mobilization by blunt dissection. The dissection of the ureter may have enlarged its vesical hiatus to such an extent that it should be narrowed with 1 or 2 sutures. During this step, the ureter could be fixed to the detrusor to avoid any retraction in the perivesical space. The submucosal tunnel is created by opening and closing the scissors. The ureter is gently threaded through this new tunnel. The terminal part of the ureter is usually resected. The ureter is spatulated, if needed. The anastomosis between the bladder wall and the ureter is carried out with 5/0 or 6/0 separated stitches whatever the system is, single or duplex. Finally, the mucosal incision around the original orifice is closed by a running suture. A transurethral or suprapubic catheter is left in place for 2 days.

3. Technique in case of megaureter 02'48''

The second more frequent indication for using pneumovesicoscopy is an obstructive megaureter. If the ureter is not too large, the same technique used for reflux is suitable. In case of a very large ureter, an extraction out of the bladder could be necessary to make the manipulation and the dissection easier. This extraction could be realized through the urethra in girl or through a lateral trocar. Once the ureter is exteriorized, a classical tailoring is possible as in open surgery, in that case, according to the Hendren’s technique. The ureter is then reintroduced in the bladder and reimplanted as usual.

4. Technique in case of ureterocele 04'13''

Some rare cases of duplex system with ureterocele —only 5 cases in our experience— need a total correction as in this example of prenatal diagnosis. A neonatal endoscopic incision was performed with a very good result on the ureterocele and upper pole dilatation, but recurrent urinary tract infection occurred due to reflux in the upper pole, which was a non-functioning pole on the DMSA scintiscan. So a complete correction was decided. The first step was an upper pole nephrectomy and ureterectomy by retroperitoneoscopic approach. The second step during the same general anesthesia was a pneumovesicoscopy in order to resect the ureterocele, taking care to preserve the ureter of the lower pole. The bladder floor was repaired and the ureter was reimplanted according to the Leadbetter technique. We have had good results in our 5 cases.

5. Technique in case of congenital bladder diverticulum 06'56''

Another rare indication for using pneumovesicoscopy is the congenital bladder diverticulum, especially if associated with reflux like in this example, which needed at the same time removal of the diverticulum and correction of the reflux. The cystoscopic exploration confirmed that the right orifice was located on the edge of the diverticulum. The diverticulum was dissected together with the right ureter, taking care not to injure the vas deferens. The diverticulum was then resected, the bladder floor repaired and the ureter reimplanted.

6. Technique in case of incontinence 08'29''

Another possibility of pneumovesicoscopy described by CK Yeung is bladder neck surgery for incontinence. CK Yeung described good results with this technique but we have no personal experience. In conclusion, more than 140 cases have been operated under pneumovesicoscopy with good results. However, this technique is still a challenging procedure. Its expansion is limited by the technical difficulties, especially in the small bladder. More than 50 cases were needed to standardize the procedure. Only few centres routinely use this technique, that is an indirect sign that more efforts are needed to facilitate the suturing technique to teach and train the new generation of surgeons.