Pneumovesicoscopic Diverticulectomy In Children And Adolescents: Is Open Surgery Still Indicated?

Main Category: Urology / Nephrology
Also Included In: Pediatrics / Children's Health
Article Date: 13 Jun 2008 - 7:00 PDT

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UroToday.com - A study out of Egypt evaluated the use of a vesicoscopic approach in treating a symptomatic congenital bladder diverticulum in children.

The group operated on 3 boys with an age range of 10-14 years. All were done with a pneumovesicoscopic approach. In all the children, a ureteral catheter was placed cystoscopically followed by intravesical CO2 insufflation at a pressure of 12-15 mmHg. Three trocars were inserted under direct visualization. A purely laparoscopic diverticulectomy was performed. Their bladder defect was closed by interrupted absorbable sutures. They left the bladder to catheter drainage for 2 days.

The mean operative time was 130.3 minutes. The children took in a regular diet immediately postoperatively. There was a minimal amount of blood loss noted. Narcotics were not needed for postoperative pain management and these children were treated just with nonsteriodal analgesics. All the patients were discharged on the second postoperative day after urethral catheter removal and spontaneous voiding. Their mean follow up was 5 months with a range of 3-6 months.

The group concluded that a pneumovesicoscopic diverticulectomy is a safe and feasible approach. It did not require a long hospital stay. They also felt that was not a long learning curve. They go on to postulate that a pneumovesicoscopic approach has the potential to be used in other conditions such as vesicoureteral reflux and may one day replace open surgery. I agree that in the correct patient population, a vesicoscopic approach is not only feasible but successful. I do differ in opinion that it does require a long learning curve. Keeping the pneumovesicum under control as well as manipulating the laparoscopic instruments in a smaller bladder can be quite tedious.

In our experience, as noted in a recent publication on a vesicoscopic approach for ureteral reimplantation due to vesicotueral reflux in the Journal of Urology 176(5):2222-2226, November 2006, we found that a bladder capacity of less than 130 ml was not favorable to a vesicoscopic approach. We also found that maintaining high pressures such as those in this study between 12 and 15 mm of mercury cause too many bladder contractions. We utilize between 8 and 10 mm of mercury for our vesicoscopic approaches with a high flow to maintain the pneumovesicum and not cause the bladder to become irritated.

My take on the vesicoscopic approach is that it is an excellent modality to handle bladder reconstructions, however, it must be done in the appropriate patient and the learning curve is quite high.

Haytham Badawy, Ahmed Eid, Mohammed Hassoun, Aly Abd Elkarim and Salah Elsalmy
Journal of Pediatric Urology 2008
doi: 10.1016/j.jpurol.2007.09.001

Reported by UroToday.com Medical Editor Pasquale Casale, MD

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