RESUMO
OBJECTIVE: Appendicovesicostomy (APV) and Monti ileovesicostomy (Monti) are durable catheterizable channels. While subfascial revision rates vary by channel type, a channel implanted in the anterior (vs posterior) aspect of the bladder may have a lower subfascial revision risk, due to decreased channel mobility and better fascial fixation. The present study aimed to compare long-term durability of anteriorly compared to posteriorly implanted APV and Monti channels in a large international cohort. MATERIALS AND METHODS: A retrospective cohort study was conducted on patients aged ≤21 years and who underwent APV or Monti surgery with an open technique at three high-volume centers (1990-2015). The following were noted: patient demographics, stomal and subfascial revisions, stomal location, channel placement (anterior/posterior), and channel type - APV, spiral Monti to umbilicus (SMU), other Monti channels. Survival analysis and Cox proportional hazards regression were used to separately examine the three channel groups. RESULTS: Of the 675 patients who met inclusion criteria, 387 had an APV (71.3% anterior), 53 had an SMU (13.2% anterior) and 235 had other Monti channels (42.1% anterior). Median age at surgery was 8.8 years for APV (median follow-up: 5.5 years), 9.2 years for other Monti (follow-up: 6.6 years) and 7.9 years for SMU (follow-up: 9.0 years). Patients originated from the USA (67.9%), Argentina (26.4%) and Chile (5.8%). Overall, 76 stomal and 77 subfascial revisions occurred. Risk of stomal revision was 9.3-12.0% at 5 years of follow-up, and was similar between channel types or location (P = 0.57). Risk of subfascial revision at 5 years was 7.4% for APV, 12.7% for all other Monti channels and 25.9% for SMU (P = 0.001). On survival analysis, stomal and subfascial revision rates were similar between anterior and posterior channels for APV (P ≥ 0.16), other Monti channels (P ≥ 0.62) and SMU (P ≥ 0.43) (Summary Fig.). On multivariate regression, channel configuration was not associated with stomal or subfascial revision for APV (P ≥ 0.18) or other Monti channels (P ≥ 0.64). Sex, age, diagnosis, country and stomal location were not associated with revision risk (P ≥ 0.06). DISCUSSION: Contrary to the hypothesis, subfascial revision rates were no different between anterior and posterior channels. Given that many reported outcomes related to genitourinary reconstruction occur rarely and require prolonged follow-up, collaborative research in this area should be encouraged. CONCLUSIONS: The study demonstrated durable long-term results with the APV and Monti techniques in an international cohort. Risks of stomal and subfascial complications were not significantly different between anteriorly and posteriorly implanted channels. As previously reported, Monti channels, particularly SMU, were more prone to undergoing subfascial revisions.
Assuntos
Cistostomia/métodos , Cateterismo Urinário/métodos , Derivação Urinária/métodos , Coletores de Urina , Procedimentos Cirúrgicos Urológicos/métodos , Adolescente , Fatores Etários , Argentina , Criança , Pré-Escolar , Chile , Estudos de Coortes , Cistostomia/efeitos adversos , Seguimentos , Humanos , Internacionalidade , Masculino , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/cirurgia , Modelos de Riscos Proporcionais , Reoperação/métodos , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Adulto JovemRESUMO
La resolución quirúrgica de una obstrucción pieloureteral (OPU), con mayor frecuencia se realiza de forma laparoscópica. Siendo un procedimiento difícil per-se, consideramos que para optimizar tiempos, materiales y esfuerzo es necesario involucrar a todo el equipo quirúrgico. Se evalúa protocolo quirúrgico prospectivo, con ajuste de protocolo a mitad del estudio en post de mejorar los tiempos quirúrgicos. Método: Estudio prospectivo de 12 casos de pacientes >5kg con OPU y MA G3 con dificultad de vaciamiento; en quienes se aplicó el protocolo quirúrgico para pieloplastia laparoscópica (pasos quirúrgicos, características de suturas, pig-tail y material quirúrgico). Todos los casos fueron operados por 2 cirujanos con experiencia laparoscópica urológica avanzada (>5 años); un mismo ayudante y dos instrumentistas. Después de los primeros 6 pacientes (grupo A) se analizó y perfeccionó el protocolo quirúrgico, comparando posteriormente resultados y en especial tiempo quirúrgico con los siguientes 6 (grupo B). Resultados: La serie incluyó 9 hombres. La mediana para edad fue de 9.3 meses. El peso promedio fue 16. 7 kg (20.4 vs 13.1 kg respectivamente). En grupo A se realizaron 4 derechas y 2 izquierdas, y el grupo B fue inverso (4 izquierdas). Tres de doce pacientes presentaban OPU secundaria a vasos aberrantes. El tiempo quirúrgico promedio por grupo fue de 171.2 (120-200 min) vs 141.7 (90-210 min) respectivamente. El seguimiento promedio fue 19.6 meses (13-24 meses), todos los pacientes tuvieron buena evolución, con MA G-3 sin obstrucción al vaciamiento y disminución de la hidronefrosis. Conclusiones: Consideramos que la disminución del tiempo quirúrgico en el segundo grupo se debió tanto a la integración del equipo como al perfeccionamiento del protocolo quirúrgico: en la técnica, colocación de un cuarto trocar, forma de colocar pig-tail, tipo y tamaño de suturas, preparación...
Laparoscopic surgical resolution for an ureteropelvic junction obstruction (UPJO) is being widely used around the world. lt is considered as a hard and difficult procedure per-se, we considered for time, materials and effort Optimization; to involve every single member of the surgical team. A surgical protocol was developed and revised, with some adjustments in the middle looking forward to reduce surgical time. Method: Prospective study including 12 patients <5kg weight with UPJO and difficult emptying MA G-3; to whom a surgical protocol for laparoscopic pyeloplasty was applied (surgical steps, suture characteristics, stent and surgical material). All cases were operated by 2 advanced skilled laparoscopic surgeons (>5 year experience); same assistant surgeon and two different surgical assistants. After the first 6 cases (group A) the protocol was revised and improved, comparing results especially surgical time with group B (n=6). Results: The series included 9 male, median ages was 9.3 months. Average weight was 16. 7 kg (20.4 vs 13.1 kg for each group). Four right-sided pyeloplasties and 2 left-sided were performed in group A, and opposite in group B (4 left-side). Three of twelve patients had UPJO secondary to polar vessels. The mean surgical time was 171.2 ( 120-200 min) vs 141. 7 (90-210 min) respective/y. Mean follow-up was 19.6 months (13-24 mo), all patients had good outcome, without obstruction in the MA G-3 study and regression of the hydronephrosis...
Assuntos
Humanos , Masculino , Feminino , Lactente , Laparoscopia/métodos , Obstrução Ureteral/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Estudos Prospectivos , Seguimentos , Duração da CirurgiaRESUMO
La instalación de catéteres venosos centrales (CVC) para hemodiálisis es parte de la práctica habitual en los servicios de nefrourologia pediátrica. Sin embargo, aún no existen suficientes reportes sobre resultados exitosos con los catéteres de hemodiálisis (HD) en < 15 kg. Nuestro objetivo es reportar la sobrevida y el desarrollo de complicaciones de los CVC insertados en niños <15 kg y evaluar si su uso es seguro en pediatría. Método: Se realizó un seguimiento prospectivo de los pacientes con enfermedad renal crónica terminal (ERC T), con peso < 15 kg, en quienes se instaló un CVC de hemodiálisis tunelizado por punción, entre julio 2006 y junio 2011. Se analizaron variables como: género, enfermedad de base, edad y peso al inicio de HD, resultado de la HD, sitio de inserción, número de catéteres por paciente, motivo de retiro y tiempo de sobrevida del catéter. Resultados: Durante un periodo de 60 meses, se instalaron 31 CVC en 11 pacientes < 15 kg, 8 hombres y 3 mujeres. La principal causa de ERCT es displasia renal. Al inicio de la HD, la edad promedio de los pacientes fue de 27 meses (5-6om) y la media de peso de 10 kg (4. 5-13 kg). El principal sitio de inserción fue la vena yugular interna (90 por ciento). La duración media de HD fue de 312 días (26-840 días).En promedio se requirieron 2.5 catéteres por paciente (rango 1-5). Los factores mecánicos (trombosis, desplazamiento o acodadura), fueron la principal causa de retiro del catéter (39 por ciento), seguidos por las infecciones (13 por ciento). La sobrevida promedio fue de 110 días/catéter (0 a 586)...
Placement of central venous catheters (C VC) for hemodialysis is part of the usual practice of the pediatric nephron urology services. However, there are few data in the literature documenting successful results with the catheters of hemodialysis (HD) in patients weighing less than 15 kg. Our aim is to report the survival and complications of CVC insertion in children weighing less than 15 kg and to assess whether their use is suitable and safe in low-weight pediatric patients. Methods: Prospective follow-up of patients with end-stage renal disease (ESRD), weighing less than 15 kg, in whom a tunneled hemodialysis CVC was inserted, between July 2006 and June 2011. The following data is gathered: gender, underlying cause of chronic kidney disease, age and weight at the beginning of hemodialysis, catheter location, and duration of HD and reason for discontinuing it, number of catheters used per patient, reasons for removal, and catheter survival. Results: During a period of 60 months, 11 CVC were placed in 31 patients weighing less than 15 kg (8 boys and 3 girls). The main cause of ESRD was renal dysplasia. Mean age at start of dialysis was 27 months (5-60 m) and mean weight was 10 kg (4.5-13 kg). The main catheter location was the internal jugular vein (90 percent). The mean duration of HD was 312 days (26-840 days). An average of 2.5 catheters was required per patient (range 1-5). Mechanical factors (thrombosis, displacement or Layering) were the most common cause of central-line removal (39 percent), followed by infections (13 percent). Mean catheter survival was 110 days/ catheter (range 0-586)...