Robotic-assisted laparoscopy vaginal pull-through: A new surgical approach in pediatric surgery

25 septembre 2017

Auteurs : M. Auger-Hunault, H. Lardy, K. Braïk, K. Alzahrani, R. Crenn, N. Magontier, P.Y. Mure, A. Binet
Référence : Prog Urol, 2017, 11, 27, 600-601




 



The congenital adrenal hyperplasia (CAH) is the most frequent cause of disorders of sexual development causing virilization of the female fetus (1/15,000). The surgical treatment is a real challenge and there is no consensus about which approach should be realized even if the actual strategy is the perineal genitoplasty.


Observation


A robotic approach of a high urogenital sinus in a CAH 15-month-old girl, done at the same time as feminizing genitoplasty, was performed. The confluence between urethra and vagina was 1.5cm under the bladder neck. The vagina has good depth and a Fogarty was placed into it, while a Foley catheter was left in the bladder. The robotic-assisted surgical approach was standard: 3-arm version of the Da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) with one camera arm and two instrument arms. The two ureters were visualized but not dissected. Uterine arteries are spared. The proximal part of the vagina is dissected on its anterior wall, up to the urethro-vaginal confluence. The confluence is sectioned, and the dissection is resumed to the rectum. We then realized a Fortunoff flap and the dissection with Hegar dilatators, under laparoscopic control and the vagina was pulled downwards and fixed to the urethra and to the Fortunoff flap. Finally, the external feminizing genitoplasty was realized (Figure 1).


Figure 1
Figure 1. 

Robot assisted operating time: a: retro-vesical dissection of the anterior surface of the vagina (V) with control of the ureters (U) on each side; visualization and sparing of the uterine arteries; b: progressive mobilization of the vagina on its lateral and anterior walls; c: section of the confluence allowing the dissection until the rectum posteriorly; d: vagina pulled through assisted by the a perineal trocar (PT) under laparoscopic control.




The delay of surgery was 300minutes with a 6-minutes docking time, without per- and postoperative complications. The length of stay was 12 days for nursing. Over the 4 years follow-up, no urethra stenosis or diverticulum were observed and the last cystouretrography 4 years after surgery was normal; bladder volume evaluated at 200mL without mictional residue. The perineal function was still satisfying, but will be totally explored at puberty.


Discussion


Hendren and Crawford [1] were the first who describe vaginal pull-through in 7 patients and, even with a perineal approach, the real challenge remains in a good exposure and mobilization of the vagina. Despite the improvement of the surgical technique, the results are not always satisfying. In the 2010s, this vaginal pull-through surgery is revolutionized by the laparoscopy. Moreover, for abdominal or pelvic surgical procedures, robotic-assisted surgery proved to be 18% shorter than traditional surgery [2] and in pediatric urology especially, the robotic-assisted surgery has proved his superiority in a great number of pathologies, if the puboxyphoïde distance is 15cm or more [3]. The robotic-assisted surgery allows a single-step procedure with a significant improvement of the urethro-vaginal junction exposure and urethral dissection is limited, even if the secondary occlusion risk is increased as compared to a perineal approach. However, compared to the laparoscopy, we appreciated the 3-dimensional view, the better visibility of the operation area and the greater range of movement of the instruments.


Conclusion


The robotic-assisted surgery has transfigured minimally invasive procedures and appeared to provide large advantages for both patients and surgeons. The procedures, which need to be more evaluated, are not only feasible but seem to allow us more accuracy and better exposure compared to classic open surgery or laparoscopy.


Disclosure of interest


The authors declare that they have no competing interest.



References



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Finkelstein J.B., Levy A.C., Silva M.V., Murray L., Delaney C., Casale P. How to decide which infant can have robotic surgery? Just do the math J Pediatr Urol 2015 ;  11 : 170






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