We present a case of ureteropelvic junction obstruction secondary to aberrant crossing gonadal vessels in a symptomatic 11-year-old female with horseshoe kidney, treated with a robotic-assisted pyeloplasty.
Diagnostic Evaluation
The patient presented with intermittent right-sided flank pain and vomiting. Renal ultrasound showed right-sided hydronephrosis and an abnormal-shaped kidney. MAG-3 renal scan demonstrated decreased function of the right kidney and no drainage. A MR Urogram showed a horseshoe type kidney with malrotation and an anterior dilated renal pelvis.
Surgical Technique
The patient underwent a robotic-assisted dismembered pyeloplasty. Intraoperatively, the right kidney was confirmed to be malrotated with a large, anteriorly directed renal pelvis. A packet of aberrant crossing gonadal vessels was identified and dissected from the right ureter and surrounding tissue. The ureter was sharply divided at the level of the ureteropelvic junction and transposed above the crossing vessels. A tension free mucosal to mucosal water-tight anastomosis was performed starting at the apex of the incision. A double-J stent was introduced into the ureter. The remainder of the anastomosis was completed with interrupted sutures. There were no intraoperative or postoperative complications.
Conclusions
Robotic-assisted dismembered pyeloplasty is a safe and effective method for UPJO correction in symptomatic patients with complex renal anatomy.
An 11-year-old female presented with intermittent right-sided flank pain and vomiting. The patient underwent a robotic-assisted dismembered pyeloplasty. Intraoperatively, the right kidney was confirmed to be malrotated with a large, anteriorly directed renal pelvis. A packet of aberrant crossing gonadal vessels was identified and dissected from the right ureter and surrounding tissue. The ureter was sharply divided at the level of the ureteropelvic junction and transposed above the crossing vessels. Using a 4-0 Vicryl suture on a RB-1 needle, a tension free mucosal to mucosal water-tight anastomosis was performed starting at the apex of the incision. A 0.038in sensor wire was advanced into the bladder and a 4.8Fr x 20cm double-J stent was introduced over the wire. The sensor wire was removed and the proximal coil of the double-J stent was placed into the renal pelvis. The remainder of the anastomosis was completed with interrupted sutures. There were no intraoperative or postoperative complications.
The indication for this procedure was symptomatic ureteropelvic junction obstruction and decreased renal function.
Contraindications include an active urinary tract infection.
Subxiphoid 8mm port (3rd Arm)
Umbilical 8mm Camera port (2nd Arm)
Right Lower Quadrant Abdominal 8mm port (1st Arm)
Left Upper Quadrant Abdominal 5mm AirSeal port (Assistant Port)
In our case, the patient presented with intermittent right-sided flank pain and vomiting. Pre-operative renal ultrasound was significant for right-sided hydronephrosis and an abnormal-shaped kidney. MAG-3 renal scan showed decreased function of the right kidney and no drainage. Due to her abnormal anatomy, an MR urogram was obtained and showed a horseshoe type kidney with malrotation and an anterior dilated renal pelvis.
Intraoperatively, the right kidney was confirmed to be malrotated with a large, anteriorly directed renal pelvis. A packet of aberrant crossing gonadal vessels was identified and dissected free from the right ureter and surrounding tissue.
In cases of ureteropelvic junction obstruction in asymptomatic patients with preserved renal function, observation and serial ultrasounds is an option. However, indications for surgical intervention include decreased or worsening renal function, recurrent pain, or recurrent UTIs.
Robotic-assisted pyeloplasty has become a popular method of correcting UPJ obstructions and is now the most frequently performed robotic surgery in pediatrics. It confers the minimally invasive advantages of laparoscopic pyeloplasty with reduced technical difficulties.
Robotic-assisted dismembered pyeloplasty is a safe and effective method for UPJO correction in symptomatic patients with complex renal anatomy and variants.
Recurrent UPJ obstruction can occur postoperatively if the obstructive area is incompletely resected or if crossing vessels are inadequately identified. Other complications include ureteral damage, as well as risks of damage to surrounding neurovasculature, which can be mitigated with adequate mobilization and visualization. Placement of ureteral stents helps reduce the risk of urinary leakage and urinoma formation post-operatively. Risks specific to robotic-assisted pyeloplasty include bowel or vessel injury during trochar placement.
There are no conflicts to be disclosed.
Thank you to all who assisted in the surgery and production of this video.
[1] Baskin, L. S., Kogan, B. A., & Stock, J. A. (2005). Handbook of pediatric urology. Philadelphia, PA: Wolters Kluwer.
[2] Das S, Amar AD, Ureteropelvic Junction Obstruction with Associated Renal Anomalies, The Journal of Urology. 1984;131(5):872-874.
[3] Taghavi K, Kirkpatrick J, Mirjalili SA, The horseshoe kidney: Surgical anatomy and embryology, Journal of Pediatric Urology. 2016;12(5):275-280.
[4] Passoni NM, Peters CA, Managing Ureteropelvic Junction Obstruction in the Young Infant, Frontiers in Pediatrics. 2020;8:242.
[5] Morales-López RA., Pérez-Marchán M, Pérez BM, Current Concepts in Pediatric Robotic Assisted Pyeloplasty, Frontiers in Pediatrics. 2019;7:4.
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Institution: University of Arkansas for Medical Sciences
Authors:
Thomas Heye – teheye@uams.edu
Lawrence Greiten MD – lgreiten@uams.edu
Christian Eisenring ACNP-BC -EisenringC@archildrens.org
Title: Nasopharyngeal Papillomatosis- A combined trans nasal transoral coblation assisted approach
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1. Dr Deepa Shivnani- corresponding author
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email- deepa.shivnani14@gmail.com
2. Dr E V Raman
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Here I am presenting a case of 16 yrs old boy, who had nasal block and occasional cough. Nasal endoscopy revealed an exophytic papillomatous growth in the nasopharynx.
MRI showed lesion arising from the nasopharyngeal surface of the soft palate. The lesion was free from the posterior pharyngeal wall. The patient was taken up for the procedure under general anaesthesia.
The transoral approach was followed first. The tissue was taken for histopathological examination followed by a traction suture placed over uvula for better visualisation.
Once exposed, coblation device was used transorally with 45 degree hopkins rod transorally. The tissue was ablated with coblation and coagulation settings of 9:5 respectively.
The base was ablated too, to prevent further recurrence.
Tonsillar pillar retractor was then used for better visualisation and exposure. The coblation was then continued.
The tissue was removed transorally as much as possible then trans nasal approach was performed.
Then, the same coblation device with the same setting was used but the nasal endoscope was changed to O degree Pediatric scope due to space constraints.
The lesion was pushed upward with the help of yankaurs suction tip for better exposure and the remaining tissue was removed with the help of same coblation device.
The lesion was excised completely and successfully with minimal blood loss. The operative area was confirmed with the 70Degree hopkins rod for complete removal of the lesion.
Post operative recovery was uneventful.
Combined transoral trans nasal coblation assisted approach is potential to be safer, easier and less invasive than uvulo palato pharyngoplasty in Pediatric age group specially, in the areas which are difficult to access like nasopharyngeal surface of the soft palate what we showed in this video.
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