IPEG 2021 - SS6 Genitourinary and Basic Science

Wow. Who doesn't want to work in Switzerland now, right? Samina, that was awesome. Thank you very much for sharing that with us. Um, we're gonna move on straight into the next session, which is entitled GU and Basic Science. Uh, we have three wonderful moderators, Doctor Souad Abdul, uh, Sabine Zundo, and, uh, Lina Perger. Um, please take it away. Thank you very much. I'm so glad to be, uh, starting the, uh, moderating this session with the wonderful doctors. Uh, thank you, Doctor Sabine, for sharing this video with us and your journey in your country, uh, and Doctor Lina. So, um, uh, good morning, good afternoon, and good, good evening for everybody around the world joining in the 2nd, uh, day of, um, the virtual meeting of IPEC. This is, uh, definitely one of a kind. And we're gonna start our session in the genitalary and basic science with Doctor uh Michael Woolnicky. We're gonna talk about the linkage between ureteral teocytes, SK 3 channels expression, and local inflammation among congenital hydronephrosis patients. So go ahead, doctor. Ladies and gentlemen, I would like to present the linkage between urethral teocytes as a-free channel expression and local inflammation among congenital hydronephrosis patients. I have nothing to disclose. Ethropelvic junction obstruction UP is the most common cause of hydronephrosis, but the reason is still unclear. Here we assess the density of thlocytes and and its co-expression of vimentin and small conductance calcium activated. Calcium escal-free channels related to fibrosis, local inflammation, and bunin 1 expression in the urethral wall in hydronephros. Calcium-activated SCA-3 channels are modulators and regulate contractility in the UPJ area by modifying telocyte function. Material. The samples were taken from 20 patients with congenital intrinsic UPJ in period 2017 to 2019. Control group consisted of 18 patients suffered from non-obstructed disease, mostly neoplasms. Routine histology was performed for inflammation assessment and muscle trichrome staining for collagen deposit assessment. Mast cells were visualized with tolut in blue. Tissue specimens were also immune labeled with telocytes, marker sac, CD 34, the DFFR, vimentin, and additionally for ER 3 and 1 in 1. The semi-quantitative analysis of holocytes of identity and V1, as well as an as-free expression was performed using a simple scale with 12, or 3 pluses. The intensive inflammatory and fibrotic processes were observed in the hydronephrosis group in comparison. controls. Moreover, the mast cell count was higher. The density of thlocytes was decreased to 1+ in hydronephrosis group compared to the control group 3. Find in one level expression was elevated in hydronephrosis group. ECA 3 positive cells were revealed in the urethral wall, but no differences between groups were observed. A declined density of holocytes and prevalence of mast cells. And one in one expression accompanied hydronephrosis development and correlated with local inflammation and collagen, collagen accumulation. Both factors contributed to fibrotic transformation in hydronephrosis patients. Thank you very much. Thank you, doctor. uh Welnicky for the uh scientific uh uh uh talk. Um, so, um, the floor is open for discussion if anybody has a question. Uh, to start with, I have one question, uh, for Doctor Wolnicky. So, um, these inflammatory markers, uh, as we know, it's an inflammatory markers for any, um, inflammation, uh, around the body. So how would you know that this inflammation happens due to, uh, hydronephrosis or it's a reason for the hydronephrosis? Actually, we don't know, so we'll try to find a reason. So we think that telocytes decreasing in this area and they are uh stimulators of peristalsis of this area, therefore, they make uh Obstruction. The second is that the fibrosis is increasing and also we noticed that inflammation cells like mast cells are also higher in these patients. Uh, and did you, did you study the, the, the degree of the hydronephrosis with these inflammatory markers? Uh, yes, we try to, uh, compare these groups and we see that, uh, patients with intrinsic, intrinsic hydronephrosis is higher, uh, they, they, they have higher count of the cells than in hydronephrosis with accessory vessels. So we think, uh, it could be, uh, uh, significant for this kind of hydronephrosis. I think it is really important that we understand more about the origin of hydronephrosis. Have you any idea of where this might take us for a treatment? Uh, these patients have, uh, all, all of these patients have, uh, had the operation. Some of them laparoscopic operation and some of them classical. We have, uh, uh, patients, uh, until 2 years old, we made this, uh, by laparoscopy. But are you hoping to use your findings to change treatment? Um, actually not yet, but we, we think that some of the markers on these cells should be stimulate, uh, in the future. Uh, we find some, uh, receptors for progesterone and estrogen, so probably we can stimulate this, this, uh, uh, these markers also escal-free, Scal-free, uh, also, mhm. Mm Great. Any further question? I don't see any uh questions from the floor, so I think if there's no more questions, we can go ahead to the next, uh, uh, study. Thank you very much. Thank you very much. No problem. So our next speaker is Dr. Neil DiSalvo, who's going to be talking about the ureteric pelvic junction obstruction, considerations of the appropriate timing of the correction based on the infant population treated with minimally invasive techniques. So go ahead. Good morning everybody. There is no univocal consensus about timing of intervention and best surgical approach for infants with asymptomatic hydronephrosis. The aim of this study is to compare outcomes between infants who undergo surgical correction early in life with patients who undergo delayed correction with a minimally invasive technique that we first described in 2005. As a matter of fact, our technique, the one trocar-assisted myeloplasty, consists of two phases. First, we do retroperitoneoscopy with a 10 millimeter operative scope. We isolate the ureteropelvic junction with the help of an L dissector and an endopin. The UPJ is then brought out through the lumbar incision using a vessel loop inserted during the vitrorenoscopic phase. The Andersonine spyeloplasty is then performed in a traditional fashion using 6-0 or 7-0 PDS running sutures. The pelvis is then repositioned into the renal lodge. We conducted a retrospective analysis of patients undergoing OTAP in a 13-year range period by creating two homogeneous groups. That is to say, indications for surgery were all the same for all patients. They all had severe adonephrosis. Patients operated on the 1st 90 days of life, 34 patients with one, and patients operated on between 3 and 12 months of life. 34 patients group soon. Considering a minimum of 1 year follow-up, we observed no significant differences between groups in regard to mean operative time, conversion rate to open surgery, mean hospital stay, early complications such as urinary leakage, and Mean anthroposterior diameter reduction rate. Moreover, no statistical improvement was seen between groups in regard to SIP, separate renal function at one-year follow-up renogram. However, a greater urinary flow improvement on renogram was noted in group one. Also, thanks to the hydronephrosis severity score calculated before and one year after surgery, we registered an important improvement in group one patients. In conclusion, we suggest that OTAP is a suitable option for the treatment of newborns and infants affected by UPGO even in the 1st 90 days of life. In our study, there was no significant evidence in terms of In terms of intraoperative data and early postoperative outcomes between patients who underwent an early pyeloplasty and those who underwent a delayed correction. Moreover, we registered a significant improvement in those patients with an impaired SRF that Underwent early correction, especially in terms of urinary flow. Even though the study cannot establish the superiority of early timing of correction, it is evident that further research is needed to clarify this aspect. Thanks for your attention. Thank you very much. Uh, so, um, I don't see any questions in the, um, Uh, on the chat, but maybe, uh, I can start with one question. Um, Doctor, uh, DiSalvo, um, were these patients, uh, operated all by one surgeon, or, um, this is a technique that is unified, uh, over your center? With other surgeons, I mean. Um, Doctor Neil DiSalvo, are you on the floor? I don't think they're able to make it. That's a shame because it would be interesting to um have that question answered. Um, the only difference they saw in the two groups, I wonder whether this really has anything to do with the timing of the surgery or whether it was type of operation surgeon performed because you would think that after the procedure, the flow would be as good as you could expect. So you should not have any impairment in it anymore. Yeah, yeah. Interesting. So, um, can we go to the, uh, next session then? I mean, the next, uh, paper? Hey, can I ask you a question? Yeah. So, uh, Sabine, could you tell us about, uh, what your approach would be? So we do an ultrasound. If there had been prenatal um hydronephrosis, we do an ultrasound after about 4 weeks to verify the prenatal finding. If this still confirms the hydronephrosis, we do a, um, functional study, usually an MRI, and if obstruction, significant obstruction is confirmed, we proceed to operate. And I think it would be interesting to look at our data. Usually the reason to operate is to preserve the function and you don't really expect a gain in function on that side. From some patients we've seen quite a good gain in function which we were always happy to, to see, which persisted over time. And I think it would be interesting to look at our data if early procedures had a, had more gain in function than procedures done later. Because we do see a decrease in function if patients are operated really late, like in their, um, primary school times. Awesome. Uh, Anas has a question. Uh, he wants to ask, um, what's the big advantage of laparoscopic compared to open because the wound size is the same. And in open, you can save time with initial dissection. Uh, could you clear this up? Uh, I don't do this operation, so I defer to you all. I think Sabine you can answer because I don't do this operation as well. But I, I, I think maybe usually the, the, the idea of the laparoscopy, it just gives you better, uh, visualization and maybe uh the dissection is gonna be um in a smaller wounds. Uh, if you, if you do it uh open, maybe the wounds will be, will be further, uh, Uh, increased, but I don't know, uh, this is something I don't do, so I don't know. Sabine, maybe you can answer. So I totally disagree that the wound size would be different. We use 3 millimeter ports for the laparoscopic approach, um, and this can hardly be seen when I see the children, um, in clinic, even years afterwards, and the, Patients I still follow that have been um operated open have growing scars with age proportionate to their body size, and these are up to 78 centimeters in length and can easily be seen in like when wearing bathers or a bikini. So I think it is definitely a difference in cosmesis. I think it's not only the size of the, of the wound, uh, because I totally agree with you, the size of the wound definitely is, is, is smaller and definitely is not going to increase with age, but I mean it's also the dissection of the ureter, dissection of the whole thing. If you needed to have better visualization, definitely with the laparoscopy, it's going to be more easier and visualized better. Um, Marcella just sent in a comment too, um, and of course it is true, I do, um, totally laparoscopic, and I think this is the way we should do, not laparoscopically assisted. Yeah. Awesome. Great. Thank you. So, uh, we'll go to the next, uh, uh, um, uh, research which is, um, uh, about the, uh, robotic assisted laparoscopic pyeloplasty in children with a complex pelvic ureteric junction obstruction, result of a multi-centric European study. It's gonna be, uh, presented to us by Maria Escolino. Go ahead. Good morning. I have nothing to disclose. The surgical management of pediatric patients with difficult perureteric junction obstruction poses important challenges. Also inexpertense. There is very limited evidence in the pediatric literature about. Minimally invasive management of such complex cases with the poor numbers of robotic procedures performed in children. This study aimed to report multistitutional experience with robot-assisted laparoscopic myeloplasty graph in children with complex PUGO. A total of 232 RALP were performed in 4 European Centers of Pediatric Surgery over a five-year period. We included in the study only patients undergoing a complex RAP. RALP was defined as complex when PGO was associated with anatomic abnormalities such as ectopic kidney, renal malrotation, or kidney or duplex anomalies, nephrolithiasis, or was a recurrent PGO after failed to open myeloplasty. We excluded from the study patients younger than 1 year and with the body weight less than 10 kg. 56 patients corresponding to 24% of total cases received complex R and were included in the study. The average age of surgery was 8 years with a body weight of 30 kg. Most patients were symptomatic at the time of surgery, with the main symptoms represented by colic flank pain. The complex PGO was associated with anatomic variations in 36 patients, nephrolithiasis in 4 patients, and the previous failed open myeloplasty in 16 patients. A dismembered Anderson Heins pyeloplasty was performed in 52 cases, whereas an ureterocaicostomy was done in 4 patients. Crossing vessels were identified inoperatively and they crossed in 11 cases. This was an Anderson He's dismembered pyeloplasty performed in a nectopic pelvic kidney, whereas this was a roterocalicostomy performed in a recurrent PUGO. The overall success rate was 96.4%. All patients reported postoperatively resolution of their symptoms and a significant improvement of hydronephrosis at postoperative ultrasound and of renal drainage at postoperative radiogram. The Average operative time, including docking was 178 minutes, whereas the average anastomotic time was 64.8 minutes. All patients were discharged on postoperative day second after removal of a bladder catheter. Uh, no complications occurred inoperatively, whereas two patients required conversion to laparoscopy and, uh, we recorded, uh, coming second postoperative complications in, uh, uh, 12.5% of cases, uh, whereas only two patients presented postoperatively stenosis of ureteropelvic anastomosis requiring radio pyeloplasty and were classified as the turbi lauddindo. So in conclusion, Ralph was safe, feasible, and reported a very good midterm outcomes even in complex cases of POGO. An accurate preoperative planning and the standardized operative technique are key points to manage successfully. These complex cases, despite its higher cost, the Da Vinci robot proved to be, uh, very versatile, uh, easily adapting to patient anatomy and providing a very, uh, important technical advantages and overcoming the potential challenges involved in the minimal invasive management of such complex cases. Thank you. Uh, great. Thank you very much. Um, I think it's interesting, uh, to, uh, to, to have this study as a, as a, a multi-centric, uh, study over four centers with the same technique with the robotic, uh, technique. So I would, um, just ask the doctor if, um, uh, can ask us, can answer this question. How did you assess the skills of the surgeons over the 4 centers? How did you, so that you minimize the, the, the, the, the surgical skills factors for your results to be, to be presented? All procedures were, were, thank you for, uh, for this opportunity and um first of all, the um the sergeants uh who uh performed the, the operations were all senior surgeons who had a great experience uh in uh minimal invasive surgery and uh had the three-year experience of uh robotic surgery. And so they perform at least um 34 procedures per month. Uh, and, um, the, the experience of surgeon in robotics is merely um determined. By the number of cases operated that in general is about 3 or 4 cases per month in high volume, high volume centers. Great, great. It's uh because we, we know that maybe urology, uh, especially in the adults, where the, uh, the, the, the main surgeons who use the robotics. So I'm, I'm, I'm glad that also in pediatric, uh, urologist also, uh, this, this, uh, technique is started and, uh, it's actually doing very well. So, um, uh, what, what was the reason for, there were two cases that has a re-operation or, uh, in your study? Yeah. Yeah, what was the reason for the erasheosis of the anastomosis, but when they were re-operated. Yes, go ahead. When they were re-operated, um, it was found in the recurrent cases crossing vessels that were misdiagnosed in the previous surgery. They were decrossed and then it was performed already dismember the myeloplasty using robotic surgery as well. There has been one question from the audience, and congratulations, Ham them on, on acting, getting your act together and doing the first question in there. The question is, what makes you decide to perform, uh, you reach your Carlustostomy, different, difficult word for me, versus a standard pyeloplasty. In general, um, the ureterocalcostomy is a preferred option when you have a, um, in many cases you have a red pyeloplasty, um, a redo PUGO after a failed open pyeloplasty. There is a significant scarring, uh, that determine, um, encasement of POGO. When you have this condition associated with a huge hydronephrosis or for example a small extra renal pelvis, you can choose to perform a neurethericalcustom instead of dismembered myeloplasty because you don't have an Enough tissue to perform the pyeloplasty, but you have a small external pelvis and a very thin parenchyma at the level of the lower calyx, so you can decide to connect the ureter with the lower pole with the lower calyx. And all, all rterocallicostomies that were performed in the study uh uh were um R um were, were recurrent PuO after failed open pyeloplasty. So uh the main indication was the significant scarring associated with the previous open surgery. OK, thank you. So we're in the interest of time. I think we're gonna move on to the 2nd 3rd of our session. The next presentation is the transperitoneal laparoscopic pyeloplasty in children with recurrent pelvic ureteric junction obstruction, a viable option. This will be presented by Doctor Guntu Mukkala from India. Good morning. Good morning, everybody. Uh, I'm Doctor Chalupati from India. Today, we want to share our experience with the laparoscopic pyeloplasty in children with recurrent PG obstruction. Laparoscopic pyeloplasty was first introduced in 1993. Since then, it has become increasingly popular, and now many others believe that laparoscopic pyeloplasty is the new gold standard in children with PUG obstruction. Only a few reports are available using laparoscopy in children with recurrent PUG obstruction. We did a total number of 75 labs for transparent to new pyeloplastics in our institute during the period from July 2018 to June 2020. Among these 75, 2 children were operated for recurrent fusia obstruction. All 2 children had open myeloplasty earlier and they have become symptomatic and deteriorated renal functions before taking off for redo surgery. All 12 children with a recurrence were thoroughly investigated. And we did transperitoneal pyeloplasty in all 12 children. We found that 7 of the 12 children had associated anomalies. 3 children had anterior crossing vessels, 2 had a duplex kidney with lower MPG obstruction. 2 children had long stenotic, which was diagnosed during retrograde pyelogram. 1 child had gross hydronephrosis with complete intrarenal pelvis. Uh, we did the lower pole calico urethrostomy in this case. Coming to the results, the main operation time was 1180 minutes. All patients were discharged on the 4th post-operative day. The main follow-up was 18 months. All patients had isotoprenal scan before and 8 months after surgery. All 12 children with the recurrence had become asymptomatic after they do pyeloplasty, and further, 11 of the 12 children showed significant improvement in the renal function and the drainage. Open reop pyeloplasty was the gold standard with a reported success rate of 92100%. But the main disadvantage of open re pyeloplasty is its associated morbidity and longer hospital stay. 92% success rate in our series is comparable with open pyeloplasty. This table shows comparison of our data with other authors using transperitoneal laparoscopic pyeloplasty. The main operation time, blood loss, the mean post-operative stay, and success rate are comparable with other authors. This is a 6 year old child um with a recurrent left PUG obstruction. This is CT scan shows left duplex kidney with a lower myieT PUG obstruction. The intraoperative picture showing the lower MT PUG obstruction, the PU junction in the non-dependent position. We did redo laparoscopy, laparoscopic pyeloplasty in this child, um, and placing the PU junction in the dependent position. This is an isotope renal scan of the same child before and after surgery. Um, the split renal function improved from 30 to 49% after redo pyeloplasty. To conclude, laparoscopic pyeloplasty is a viable alternative to open pyeloplasty in children with recurrent PG obstruction. The results are comparable, and the transfer between laparoscopic pyeloplasty gives wider exposure, and the associated anomalies are not missed. Thank you. Thank you very much, uh, Doctor Chalapathy, are you here on the call to answer any questions? Uh, Until we find him, I've just seen that one of our former presidents, Holger, is um on this conference, and I'd like to ask him what he'd do with a recurrence. Would you go open or would you do laparoscopic? No, I will do laparoscopically, of course. Uh, the question I have to, um, uh, the audience though is, um, what about the minimal invasive flank incision, uh, in redo cases? Isn't that an option that serves both purposes except for the lower upper and pole vessels cases? So this is a call to the audience, so please write in our chat room. I'm gonna say that I, I will do whatever Holger says that I should do because I don't actually know any of these things. I love you too, Samir. I don't, I didn't do this, uh, procedure, but it, uh, from sound like from a presentation, uh, he felt like they had a really good visualization laparoscopically and that cited as one of the advantages. So I'm gonna guess that's what Doctor Chalopatha would say. OK, well, so we've got one more question from the audience to the author as well, so I'm not sure if, um, he'll be able to answer if he's not, um, logged on. So what kind of double J was used? Um, Yeah, a depressant or a double J, yeah. What's the kind of double J that you guys use, and do you think this 4-day post-op stay is exceptionally long or short, or what, what do you think? So I think this totally depends on the country and what the system is usually um well insurance is covering as well. So um a 4 day stay I think is um totally OK. You could probably send the kid home sooner with a double J stent. Some hospitals don't use double J's, but external stenting um across the kidney and. Families are a little more reluctant to go home with a bag that drains the urine, so, um, some hospitals, I think, will keep patients on the wards for a bit of a longer time, so maybe even the whole 7 days that the stents in need. Totally depending on, on the family and the system, I think. OK, thank you. So let's uh move on to the next one. It's a comparison of retroperitoneal robotic versus retroperitoneal laparoscopic pyeloplasty for UPJ obstruction in children. This is gonna be presented by Doctor Koga from Jintendo University in Japan. This is a presentation comparing pyeloplasty anastomosis using robotic and laparoscopic surgery in children with UPJO. I, Hirikova, the first author, have nothing to disclosure. Laparoscopic pyeloplasty anastomosis is very technically challenging. Suturing small diameters is a disadvantage. Robotic surgical systems make fine surgery easier. We compared retroperitoneal pyoplasty for UPJO in children using robotic surgery and laparoscopic surgery. 8 patients had a robotic and 34 patients had a laparoscopic. All patients were matched for age and weight at the time of surgery and the diameters anastomosis. Patients' demographics were similar. Difficulty of suturing was scored blindly from interoperative video records using the scale shown. A panel of five independent surgeons was also asked to choose which approach was easier by scoring +1 if robotic was easier, 0 if they seemed the same, or -1 if laparoscopic was easier. Total osmotic time was significantly shorter for robotics. Time taken for one suture was also significantly shorter for a robotic. The coefficient of variation for time taken to place one suture was smaller for a robotic. Robotics scored better than laparoscopic for difficulty of suture. All surgeons gave a score of plus one, so robotic was easier. Overall operative time was similar because it took longer to secure the larger retroperal space needed for robotics. In conclusion, the anatommosis with robotic is more stable, accurate, and would appear to be superior to laparoscopic. Thank you for your attention. Thank you very much. Uh, is Doctor Koga here or maybe any of the co-authors to answer questions? I was wondering if robotic was easier and everybody liked it so much, why there were only 8 of them and they were 30-some laparoscopic. Uh-huh. Thank you, good question. So, Actually, we, uh, also try to the, uh, hepaticogenostomy for cortical cyst. Uh, so I, uh, did the, the, a lot of anastomosis procedures. So laparoscopic surgery required special training and the technical, uh, skills, but robotic surgery, after that, uh, uh, Scarce, so I think it's a stable and the easiest for. Uh, so everybody, uh, gets the, uh, the pills, the useful therobotic. OK. Thank you. There's a question from the audience. Doctor Mosa is asking if you compare the total operative time uh that includes setting up the robot. So total break time is uh uh not significant difference. It's the same. So and setup time is about 10 minutes or 15 minutes. OK. So is this gonna change your practice in the future, you think? You're gonna shift to more robotic? Uh, yeah, uh, I guess, uh, uh, robotic surgery is uh changing to from the laparoscopic surgery, but total operative time is not changed, I feel. Uh, what about, uh, what about the complication compared, uh, between robotic and, uh, and laparoscopy, stenosis, leak? Did you compare that? Yeah, thank you. Uh, good question. So robotic surgery is, uh, no complications. Uh. But uh it's uh just uh only 8 cases. So laparoscopic surgery have a, uh, two complications. One is, uh, leakage, uh, but, uh, and the other one is, uh, laparoscopic, uh, strictures of stenosis. So it required operation. What I like about your study is that, I think I'll just keep going. So what I like about your study that you actually asked the surgeons whether they found it easier to work with the robot and found it less um tiring because if all agree on that and they are less exhausted, I think they will work better. And this will in the long run, lessen complications. Of course there will need to be data, but the same is probably true for 3D laparoscopy. So I think we will need to look more into that, so it might surgeon's comfort not only be good for the surgeon, but for the patient as well. So I would like Yeah Olga, go on. Doctor Koga answered first. Sorry, that was impolite. Go ahead. And I would like to know, Doctor Koga, wonderful, and I truly believe that the wrist and the retroperitoneum is wonderful, but your patients were quite old for UPGOs. What's the limit, age limit down you would try to take the, to get the robot in? So, recently, I, uh, I performed, uh, I do the surgery, the 2 years old, the boys. Maybe, uh, I, we. Yeah, uh, 1.5 years old, it's enough, uh, but, uh, I think, uh, age is not important. The patient, uh, body length is, uh, more important factors. Body, uh, higher length. Well, well, the difference between the, the iliac crest and the 12th rib, the smaller the child, the smaller the space, the less space left for the robot to talk. Yes, of course. OK. Congratulations. Thanks. OK. Thank you very much. Uh let's say we're gonna move on to the next one, which is, uh, micro percutaneous nephrolithotomy in children, a disillusioned or inappropriate expectation. This will be presented by Doctor Ergen, um, from Mis University in Turkey. Hi everyone, dear colleagues, today I'm going to present to you micro PCNL in children, disillusioned or inappropriate expectation. I and my colleague Dr. Blaes have nothing to disclose. The incidence of urinary stone disease appears to be increasing in children and even in infants. After a glittering introduction in 2011, Micropezia seemed to lose its popularity after a short glorious period. In the study, we report our experience of micro PCNL in a selected group of children. Children who underwent micro PCNL are evaluated retrospectively, and bilateral cases and children with confounding factors are excluded. A total of 15 children are enrolled in the study with 9 girls and 6 boys. The involved kidney was right in 10 and left in 5, and the median age was 2.4 years, and the median stone size was 12 millimeters. All patients underwent imaging with X-rays and ultrasonography, but only 7 underwent a CT scan. 12 patients received a preemptive urethral J stent placement and retrograde intrane surgery was attempted in 9, but all were converted to PNN. The irrigation was performed by a pump in 6 and with the saline bag in 9. Solitary access was performed in 10 patients and double access in 5, and the overall storm feed rate was 87%. The analysis of stone compositions was possible in 12 patients with 8 calcium oxalate, 3 uric acid, ammonium urate in 1 patient. There were 2 complications. One was a patient who needed J stent and pleural catheter insertion due to urethral obstruction by the stone fragments and pleural effusion. Another patient needed prolonged antibiotics due to mild neurosepsis. Micro PCNL is a good option of nephro nephrolithotomy, but not every patient is a good candidate. In our experience, it is more difficult to dust the heart stones that may result in bigger fragments and increased complications. Calliceal stones, softer and smaller stones, and infants may be good candidates. Irrigation with sallibeg with or without employing a second excess may improve irrigation and lower pressure, and passive dilation with J stent may improve stone clearance, and success and expectations should be discrete from the adults. Thank you for your patience. Right. Thank you very much. Is Doctor Ergen here to discuss? Oh yeah, there you are. OK, very, very nice. Uh, so, uh, I had a question. Based on your findings, will you narrow down the indication for micro PCNL to, you know, to the patient that is most appropriate for, like, uh, what you found, like the smaller ones and the softer stones and so on. Yes, exactly. Uh, we, actually, this paper is from, uh, I think one year ago, the last patient, and then we were, in that time, we were in our learning curve. So nowadays we are trying to change that. I mean, we try to limit our uh PCNL practice with infants. Mostly because it's harder to perform arrears to these children, and also it is easier to perform the micro micro PCR. I have a question from Doctor Neff. If you could discuss techniques for access of the renal pelvis and how you establish the tract. Yeah, we do that, uh, in the guidance of a scope with a, a 14 or 16 gauge catheter. So, uh, we use scope, not the ultrasound, but nowadays, again, we are trying to include the ultrasound imaging in our study, in our practice. Mhm. Uh, I have a question. It's interesting, uh, doctor, to, um, uh, the study is actually, um, uh, eliminating, um, uh, factors and then just focusing on some patients that really will benefit from this, uh, uh, procedure rather than just override everybody else. So, uh, my question, um, I might not be able to, uh, assess how many years the, the study time. But I don't think you mentioned that. I mean we, we took the, uh, patients like, uh, I think 2 years in 2 years period, but the, uh, last of our patients was 1.5 years ago. I, I don't totally remember that actually. OK, OK. And with that, with this technique, is it, um, did you change the practice, or, uh, maybe further study needed to really, uh, uh, check if this is a, a technique for this type of, uh, of, uh, patients? So these are limitations such as The smaller amount of patients and not subjective, uh, I mean, we, our practice was subjective, so we didn't have any objective criteria to perform res or perform so we are trying to. Establish, as you said, uh, a, a prospective trial that to establish the, the, the base of our study. Hey, thank you. I think we're gonna get to passion over. I was just gonna say that the discussion is great, but I think we need to, um, keep moving. So the next video will be laparoscopic transurethral ureterostomy for unilateral obstructive mega ureter. And Doctor India from Mandelia, um, handed in a beautiful video. Greetings from Sanjay Gandhi PGI Lucknow, India. We'll be sharing our technique of laparoscopic transurethrostomy for a primary obstructive mega ureter. Our patient was a male newborn with antenatally diagnosed bilateral hydrourethrophrosis with normally with normal bladder wall thickness. At birth, there was gross abdominal distention and a normal urinary stream. The serum creatinine was raised. Ultrasound followed by CT urography showed bilateral gross hydrourethronephrosis. The VCUG was normal. The LLEC scan showed features suggestive of right VOG obstruction with 24% function. On day 5 of life, cystoscopy showed absence of the right ureter orifice in the bladder. On exploration, there was a grossly dilated right ureter, ending into an ectopic opening with complete VG obstruction. And right urethrostomy was made, and the baby tolerated the procedure well. At 18 months of age, the urethrostomy was draining well. Ultrasound showed mild right hydronephrosis with residual dilatation of the right ureter. LLlysis showed adequate drainage in both the kidneys, with 27% function in the right kidney. This is the port positions and the patient position for a laparoscopic transurethrourethrostomy. The procedure, it's not running the trust me from the parietal wall. This is Doctor Ankur from India. Uh, it's not running, uh, for me. It's not many for us either. We're trying to address that. 2 seconds. Sorry about that. Yeah. Thanks for jumping in. I've reviewed the video before and it was running perfectly and it was a really good quality, so we should really be able to see that. If we are having technical problems, we might, OK, we're gonna try again. If not, we might jump to the next and give staff time to fix it. OK. India technique. Yeah, let's jump to the next one and then uh we can come back to this. I think this is a good idea because this will allow staff to make sure we are gonna see this video. So, um, the next video is about laparoscopic pyeloplasty once again, a modified technique of urethteropelvic anastomosis by Doctor Kote from India. Can we please see the video? I hope this is gonna be running, the audio is starting a little later so everything should be OK still right now. This is a case of grass hydronephrosis due to PU obstruction. Dissection of the azadine colon and cecum from the retroperitoneum. Dissection of the pelvis continued. The PUJ is held with a tissue grasper dissection continued on either side. And the upper end of the ureter. A little bit of cay is applied. At the expected site of dissection of the. Pelvis. Uh, the pelvis is divided. With a clean cut, with no ragged margins. I get that. As it looks insufficient for the osmosis, so a little bit of a. Pelvis is trimmed to make it adequate for the anastomosis. No. The upper end of the letter. Speculated. Adequately A fiber polyglectin suture taken across the anteriorabum wall with which the anasmosis commenced. Tying both the upper ends of the ureter and the pelvis. On the same stitch Is used as a stay suture. To facilitate the osmosis. So There is no use of any. Prole stitch to the pelvis for holding the suture. Now the suture is Coming inside. And the anastomosisis continued. Inside with not outside. And smoothies continued. A continuous fashion. After reaching the lower corner of the anasmosis. The switcher Comes out. Like this. And the knot is made outside the lumen. The preference digestant is negotiated comfortably across the osmosis. And now the anterior layer of the anasmosis continued. Till it reaches the upper end. The remaining end is cut ureter. This finishes the last one, last. Suture of the osmosis anterior layer and it's again tied to the. Previous feature of the not. This finishes down smoothies. This is the outside state Well, thank you, Doctor Carter for this great video. I think this is really taking minimal invasive surgery one step further by mini invasive tissue handling and this one-day suture aligns, um, what you need to suture up really well. Um, I've just got 11 colleague here Holgo saying that he's totally excited about as well. So, um, Carolina asks whether you used a VO sutra. Are you online to be able to answer that question? From the video, I would think you did not, it looked like a normal suture, not a self-locking to me, but it would be great if you'd be able to. Share this information. I don't think they're online. Then I think we will go on to the next video in the interest of time and try to run it again. Some people could see it, some others could not, so this is why we are repeating it because we want all participants to get all the information, of course. So now, I think they Audio is lacking, at least on my screen. So we can see what we cannot hear. Let's go to the last and 3rd paper of this session. It's gonna be about a review concerning, Concerning a guideline on the management of urethra or pelvic junction obstruction in the era of la laparoscopy. A review of the literature and media analysis was performed by Doctor Jasmine Hoes from Tunisia, and after we've seen that, we'll go back to the video and keep our fingers crossed that it'll be working again. Dear sir, dear colleagues, thank you for giving us the opportunity to present our work entitled Toward Establishing New Guidelines on the Management of the ureteropelvic junction Obstruction in the era of uh of laparoscopy, Review of the literature and meta-analysis. We have nothing to disclose. Despite its apparently simple clinical pathway, there are several aspects in the diagnosis and management of urethro pelvic junction obstruction that are controversial and worthy of discussion, especially after the laparoscopy has changed the approach to this disease. For this, we aim to review the literature to establish guidelines on the management of the urethro pelvic junction obstruction in the era of laparoscopy. We performed a critical review of the literature published between 2003 and 2018 using Madeline, Cochrane, and M-base database. The third strategy used the terms pielplasty, urethropelvic junction obstruction, transposition, and children. We included 50 articles, 10,456 patients, and the mean age of operation was 49 months. The indications for surgery were clinical symptoms in 55.87% renal pelvic anterior posterior diameter, higher than 2 centimeters in 24.43%, impaired renal function lower than 40% in 24.43%, and delayed washout curve on the renal scan in 76.02%. A minimally invasive technique was performed in 82.448%. It was a vascular transposition or ablation of the junction without a dismembered peloplasty in 3.45%. It was retroperitoneal in 7.2% and transperitoneal in 76.23%. It was robotic in the 16.24%. Uh, the vascular transplantation had a high rate of uh of success, accounting for 96.3% when the kinking of the uh the junction is found by a vessel or adhesions. After this review of the literature, we do indicate laparoscopy if the surgery is indicated. If a vessel is found and the age of the junction is noted peroperatively, then we do recommend this review of vascular transposition. If adhesions are found and evidence of the junction is noted peroperatively, we can do elaboration of the kinking. If no. of the junction is found, we perform a dismembered pyeloplasty. After a vascular trans transposition of liberation of the kink king. If we found failure during the follow-up, we do recommend, dismembered peloplasty. Thank you very much for your attention. Thank you Jasmine for this great work and reviewing such a lot of data. I have, however, a few questions or things I think that need to be considered. So only 3.45% of your, the procedures you reviewed were done as a vascular hitch. The others were dismembered, the pyeloplasties. I think it is not quite OK to draw the conclusion that this should always be done if there's a crossing vessel or if there is an obstruction to be seen from the externally. Um, and not a dismembered pyeloplasty being done. Are you here to um answer questions about the review? So, um, I, uh, I totally agree, uh, Sabin with you. I think, um, um, drawing these guidelines should be, uh, really, uh, investigated and, um, having studies, uh, confirming each, uh, each, um, steps to Draw such guidelines, but it's a nice maybe initial step so that maybe further studies and further conclusions can be made to really put these gold standards or guidelines into practice. I think one reason always speaking for the dismembered pyeloplasty is that it is not depending on the surgeon's expertise to look at the tissue and decide whether yes, a vascular hitch will work or will not work, and on the other hand, in, um, cases with a crossing vessel, you still have intrinsic, um, Tissue change in the histology, we actually published that a few years ago, so um if you want to be sure the baby's only gonna be operated once, I think the dismembered pyeloplasty is the better idea. But, Swad, I think you're totally correct that further studies are necessary on that field. So we will give the video the 3rd chance. I hope we are gonna be 3rd time lucky. Greetings from Sanjay Gandhi PGI Luckow India. We'll be sharing our technique of laparoscopic transurtory rostomy for a primary obstructive megaura. Our patient was a male newborn with alternately diagnosed bilateral hydroureter nephrosis with normallyca with normal bladder wall thickness. At birth, there was loss abdominal distention and normal urinary space. The serum creatinine was raised. Ultrasound followed by CT urography showed bilateral gross hydroureterrophrosis. The VCUG was normal. Right in the bladder. On exploration, there was grossly dilated right ureter ending into an ectopic opening with complete UG obstruction. Uh, and right urethrostomy was made, and the baby tolerated the procedure well. At 18 months of age, the urethrostomy was draining well. Ultrasound showed mild right hydronephrosis with residual dilatation of the right ureter. Alysis showed adequate drainage in both the kidneys with 27% function in the right kidney. This is the 4 positions and the patient position for a laparoscopic transurethral urethroscopy. The procedure starts with mobilization of the right urethrostomy from the parietal wall, mobilization of the proximal ureter, preserving its vascularity and anesthesia. The recipient left ureter is mobilized and is hitched to the parietal wall to ensure stability during the anastomosis. A tunnel is created under the rectosigmoid mesentery, going under the inferior mesenteric vessels. Once the tunnel is created, the light. Donor ureter is passed in the tunnel. We make sure that there is no proximal angulation or twist. The end of the right dilated ureter is freshened. A urethrotomy is made on the medial aspect of the left ureter, ensuring equal diameter for the urethrotomy and the diameter of the right ureter. A teacher stent is passed in the recipient ureter to ensure adequate drainage in the post-operative period. An end to side ureter uterostomy is done. With fiber poly electing suture in a running fashion, it is very important to ensure that the anastomosis is tension-free and there is no angulation or kinking as both the kidneys are now dependent on a common ureter for drainage. Following posterior wall, a running is continued on the anterior wall. The anastomosis is completed. The hitch stitch is removed, the peritoneum is closed on either side of the rectosigmoid. A thorough peritoneal lavage is given and then drain is inserted into the pelvis. Post-op course was uneventful. The child was allowed orally after 6 hours. Drain was removed on postoperative day 2, and the foliage on post-operative day 3 and discharged on post-operative day 4. DJ was removed after 4 weeks. The renal parameters are stable as follow. In conclusion, laparoscopic transurethrostomy presents a feasible, safe, and effective option in cases where a bladder reimplantation is difficult, such as in cases of a dilated ureter, offers all the advantages of minimal access surgery. Thank you for your patience here. So thank you Anchor for this great video. It was lagging a bit on my computer and I know that your video was a really high quality, so I think we will need to let our audience know that it is the system at the moment that's the issue and not your video. We will put it into the um IPEC Cinema so you can watch it there in really good quality. Thank you for showing this great video. Um, we have one question from the chat, and that is why do you make an urethral, why don't you make an urethral neo implant into the bladder? I decided for the trans anastomosis. I I had the same question and I'm glad there's, um, more thinking along my lines because I would've been worried to touch the perfectly well working system on the one side and maybe risk stenosis. Could you comment on that? Yeah, uh, thank you very much for the question. Uh, so, uh, we did this case, uh, after we did, uh, another case for a redo, uh, where we had done an extra recycle laparoscopic reimplantation on one side. And, uh, it was in the beginning of our learning curve and we had an obstruction, the VUG obstruction. So, uh, to redo it, we had to do a, a transurethral urethrostomy. And, uh, we thought, why not do it as a primary case. Uh, so it gives us two advantages. One is when the ureter is dilated, you have to tailor the ureter. You have to do, uh, uh, ureter, uh, tailoring by either, you know, in, in folding or by excisional tapering. And secondly, uh, always when you dissect near the bladder neck to make a tunnel, uh, there is some risk of a neurogenic, uh, bladder, which is very well known in bilateral cases. So we just thought maybe we can do it primarily and we have done 4 cases after that. And uh we didn't have any uh issues. Uh, both the kidneys have drained through the common ureter. Only thing on follow-up, we found that the lower uh common ureter was mildly dilated, but it, uh, but with good drainage, so we didn't have any issues with that, so. I think you summarized the issues about the reimplantation and neurogenic bladder and the taration really well, so I think it's, it's still gonna be two fractions, two people, um, like two groups of people preferring either the trans anastomotic or the neo implant. Are there any more questions from the audience? Well, Lena, so what, do you have any comments? No, I think it was a great discussion and uh thank you very much, Sabin for the inputs, Doctor, thank you, Doctor Holger and all the discussions uh really um uh made very well. So I think uh we can conclude this session. Yeah. Thank you very much. I think we can go ahead with the other sessions and thank you so much for letting us, uh, really, uh, be the moderators and, uh, participate in the uh conference. Thank you.