Um, so we are doing our next session on undescended testes. Sean, why don't you come on up. It's gonna be moderated by Sean St. Peter from Kansas, what is it? Kansas City Mercy no, I get it wrong. Children's Mercy Kansas City. And, uh, we have, I can never remember the order of those words, uh, and we have Doctor Sammy Shahata who is beaming in from Egypt, um, so is he online? Do we have Sammy, are you there? No, yeah, hello Sammy Sammy, my friend, how are you? Good to see you. Thank you for joining. Thank you so much. Looks like you're in Norway, um, but, uh, thanks for joining us. All right, I'm gonna turn things over to you, Sean. Thanks. Hey Sammy. Welcome. Thanks for joining us. Yeah, good. So pleasure. Thank you so much. Um, I'm not sure how many people know about the Shahada technique, but I'm gonna let, um, the video play. Do, do you, do you have anything you'd like to say before we show the video? I'll ask him again maybe. Sammy, can you hear us? Sammy, would you like to say anything before we start the video? Well, it's a great pleasure to join the team here. I am online virtually this time, but I hope next time I'll be meeting you all in person. And I know that there is a big audience online watching this, so it's a great pleasure to join all pediatric surgeons in different countries of the world. So my talk is about, as you mentioned, you don't know how many are practicing the shirata techniques, so maybe we'll get this answer in the poll that will be in 59 seconds. Since the start of my video, we'll know exactly how many audience are practicing the technique, and then let's discuss, can I convince you if you are not doing it, or you give me your feedback. Uh, wait, before we roll the video, I just have a quick question. Sorry, just, sorry, um, how many in this room. Do take care of undescended testicles. Intraabdominal testicles. Well, well, OK, so you want to separate it out. I do because some places the urologists will focus on intraabdominal testes. OK, so that's what his technique's about is the one that won't come right out. So let's start with, I mean, we, we can have fun going through all the different neurologic, uh, thing with the urology pediatric surgery battleground here. Um, because it's different in every institution. But I think this is one of those things like thyroid where not everyone does this at every institution. Some of it goes over. I know we've had some agreements, uh, at least in when in Akron about splitting it up. So I just wanted to know. So it sounds like almost everyone here deals with both inguinal and intraabdominal undescended testes. So perfect. Let's roll the video. Hello everyone, it's my great pleasure to join you today at the update course in pediatric surgery. My topic is updates in the management of intraabdominal cancers. And we'd like to focus on the effect of division of the main blood supply as we see in the power stiffen approach, and which technique is better for intraabdominal testis if we remember the historical techniques for elongation and stretching of the testicular vessel. And we need to look at the potential complications of each of these techniques. And before starting, we'd like to send a pool to the audience and to know which is your preferred technique in the management of high intraabdominal tests, that's for stiffen Jhato technique, lab assisted single stage orthoplepsy or microvascular anastomos. So, uh, is there a way to see the polls? Can we pull them up? Oh, Isa, can you, um, share the poll? I, I don't know if you can zoom in on that or not, but, um, like, uh, but it's hard for us to see. There, oh, nice. OK. Looks like the majority are Fowler Stevens. Sammy Yeah, I expect, but there is a good one quarter, I think, if I can see well, doing the Shahata technique, is that correct? Yeah, there's, there's confusion because lap assisted oropexy is going to involve the Fowler Stevens. So most of us, even if you're dividing the vessels, you're going to be doing that laparoscopically. I think that they kind of fall together as non-shahada and that whether you're doing a lap assisted with or without dividing the vessels, you were not committing to stretching the vessels. So go ahead looks like about 1/3. OK. OK, thank you so much. So we can continue this argument. Maybe I can convince more percentage of people to do the technique. Can we resume the video? Yes. We can see that the most popular techniques right now are the Fowlers defense and charter technique practiced in many centers around the world, and you can see that there are both, they enjoy a similar success rate between 80 and 90% with marginal difference, but probably the main difference is in the preservation or division and interruption of the main testicular blood supply. This important publication by Pepe Sli and as an animal experiment has shown the effect on the volumetric and histological findings in intraabdominal places before and after the division of the spermatic process. They came to the conclusion that ligation during orchiopexy can lead to a significant reduction of spermatogonin. However, no significant changes are observed in the volumetric characteristics of the testicles. That means in simple words, you are bringing down a good sized testes, but it is of poor quality. So here we are looking at, of course we need to be concerned about the success rate, the, the testicular ascent, but again we need to see the effects of the interruption of the main blood supply and if there is possibility for the preservation of the testicular blood supply. We have been performing the rata technique for more than 15 years now, and this is the main concept of the polar stiffens approach. In case you have a high intraabdominal testis, cannot bring it down, so you interrupt, you divide the main testicular blood supply depending on small collaterals to be able to bring it down. And actually the idea for the jihad technique came from this observation, which I'm sure all pediatric surgeons have seen in a case of huge hydrocele or inguinal hernia. You can see remarkable elongation of the sperm metal bone. This time it happened when we don't need it. We don't need for any reason to bring the testis near to the knee of the child, but there are bad needs for having this elongation in high intraabdominal testis. So this is a concept for the Shehata approach that's for the same high intraabdominal testis, you cannot bring it down. Then you fix it with a stitch to the contralateral anterior abdominal wall and leave it there for a period of 2 to 3 months. Allow significant elongation to occur, and then you bring it down without dividing all the testicular vessels. So we have been able to Since the year 2006 until 2020, we have been able to operate on 430 cases with a mean success rate of 88%. We have 7% slip traction which we can successfully do and redo traction. So regarding the complication, we have no case of internal hernia. Adhesions were extremely minimal during the second stage, slip traction in 7%, and smaller or higher in 12%. The worry of surgeons about the occurrence of internal hernia when a cord is crossing the abdominal cavity, actually it has never happened in more than 15 years, in more than 430 cases, and in many centers around the world has never been reported. And it's probably anatomically impossible when we tried during the surgery to bring the bowel behind the cord. It was not possible, so I assure you that this complication does not happen. So the operative time is short in the 1st and 2nd stage, and you can see that the possible mechanism for elongation actually it is in the gentle and gradual abdominal wall movement during respiration and even more likely that this is because of the weight of the bowel, small bowel on the cord of the spermatic vessel that's very gently and gradually. Causing this inundation. So this is our preliminary study in Pediatric Surgery International in 2009. This was a small number of cases, 12 cases, and this is more firm conclusion that in general pediatric surgery 2015 on 140 cases, we got more solid results and longer follow up. We have recently 3 systematic surveys and meta-analysis documenting the results after the Shahato technique and comparing the Shahato technique with a far effect. Have similar or better outcome for the shadow technique, and they need of course further prospective studies. The conclusion that they are both compatible and some studies have shown better results for the shadow. So in conclusion, I can say it is the technique of Shehata is suitable for the majority of intraabdominal tests. It is safe, reproducible, and it leads definitely to effective elongation and most importantly is the preservation of the testicular blood supply. If you compare Shehata versus Stephen, the overtime is much shorter for the Shehata would need. Waiting period is 2 to 3 months compared to 6 months. Adhesions are much less and technically it's much easier and it's more reproducible. So at the end, I thank you so much again for the invitation and I'm happy to take any questions. Thank you so much. All right, Luke, Doctor Shahada, this is a great technique. I've got one coming up next week and I'm gonna use, uh, uh, people hold me to it. I'm gonna use this technique, uh, in the operating room. I've not done it before, but it seems like it's very, uh, approachable, straightforward. One question I had for that. PEI, I mean, I must envision wanting to throw a stitch, uh, through the abdominal wall to catch that testicle on the contralateral side where I want a PEXI and then I can bury that if it's, especially if it's an absorbable suture. Um, is that a reasonable thing to do? A little small 2 or 3 centimeter or 1 millimeter incision, uh, putting that needle through, catching the testicle, coming back out, you know, backing the needle out to keep it all buried. Is that what you propose, um, you know, as a way to fixate against the contralateral wall? Thank you. Thank you so much. Exactly like what you have described, it's a percutaneous stitch, non-absorbable. I prefer Etibo 20. You pass from outside and very gently you go through the tonica albergeni and back and you tie it under. Skin and you leave it for 2 to 3 months for the sake of time. I did not show the video, but it's present now on the web search and on YouTube and I'll be happy to send it to Todd and Sean if anyone would like to see more details, the video will explain everything. That's great. And you could put a link in the chat as well. So that was phenomenal. And yeah, just to add to the discussion, um, we had done a randomized trial. It was a pilot study, small, 13 in one arm, 14 in another, comparing one stage versus two-t Fowler Stevens and those patients who required testicular test, uh, vessel division. And we, we saw no difference. Both groups lost one. So that wrapped up 10 years ago, and since then, we've only been doing laparoscopic single stage and we've not been losing, uh, uh, haven't seen personally a lost testicle since then. So, I thought we'd kind of answered that question. And what Sammy's introducing is an entirely new debate, which is keeping the vessels. Intact the whole time. It pushes us back to two operations, but it means you don't have to divide the vessels. And so what we had migrated to is assess whether you're going to have to divide the vessels before you take down the gubernaculum. So there's 3 blood supplies, one from the vas, one from the gubernaculum, and then of course, the testicular artery. And if it's clear, it's not going to come down and it's usually pretty obvious that you can drag it and it's redundant or it's tight, in which case, leave the gubernaculum, divide the testicular artery, and then you can bring it down on the vase since you keep two of the blood supplies. And the difference is you're not going medial to the epigastric vessels, you're just going straight down the canal, so you preserve your gubernaculum. But I think what Dr. Shahada showed that is critical is decreased spermatagonia. Yeah, yeah. So, I think you really want to try to preserve that testicular vessel if you can. That was the most striking a great theoretical advantage to keeping the artery. It's just that it pushes us back to two operations. And if he's proposing, um, a study that's comparing these two, which I think would be reasonable, I think you would require testicular biopsies to replicate what was seen in an animal study. Yeah, exactly. I feel that the final answer would be if you can compare with biopsy, histological study, you compare Sharata with Fowler, and I think this will give the final clue. But the problem was ethical consideration, of course, and consent for biopsy. This is great. John DeFore, uh, over here just said it's gonna be really hard to go against anything you say because you look like God on the screen there. So, uh, um, this was a phenomenal, uh, session. Any other final comments? Oh. Uh, so an 88% success rate was mentioned, but what's the definition of that success? Is it just just bringing it down, or how much atrophy or size discrepancy would you tolerate to call it a success in that series? Yeah, that's a very good question. Success is defined as a test is in good position and good size, not less than 25%, less than the normal for the age, and with good vascularity by Doppler ultrasound. Awesome. All right, that's great. Thank you so much, Megan and Katie. Awesome. Thank you so much. Uh, good, Sammy, thanks for joining us. I don't know what, what time, Sammy, are you still there? It's, it's 8:30. I'm, I'm going to my, uh, private clinic right now. OK, get to work. Thank you, Sammy. It's so good to see you. Thank you so much. OK. Thank you so much, doctor. Thank you. Um, all right, um, I love, like, this is like very high yield. Like every few minutes I'm learning something new about how to change the practice.
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