Surgical Management of the Urinary Tract for the Prune-Belly (Triad) Syndrome

Urinary reconstruction is tempting based on the impressive abnormal findings that are revealed on imaging. The abnormal appearance of the urinary system by itself is not enough to warrant reconstruction. Reconstruction should only be undertaken when there is clear clinical evidence that stagnant urine leads to urinary tract infections and/or obstruction that is associated with renal compromise. This chapter describes temporary and permanent upper and lower urinary reconstructions. Particular consideration is given to the pathophysiology of prune belly syndrome and the disproportionate dilation and dysfunction of the distal ureter when undertaking ureteral remodeling. The techniques of ureteral folding and formal excisional ureteral tapering are described stressing the importance of vascular preservation. The role of reduction cystoplasty is placed in perspective of short- and long-term benefits. This review contains 18 references. Key Words: Eagle-Barrett syndrome, megacystis, megaureter, prune-belly syndrome, tapered ureteral reimplant, triad syndrome, ureteral reconstruction, urinary diversion, bladder reduction.

Ventricle wall dissection and vascular preservation with the pulsed water jet device: novel tissue dissector for flexible neuroendoscopic surgery

OBJECT Neuroendoscopic surgery allows minimally invasive surgery, but lacks effective methods to control bleeding. Water jet dissection with continuous flow has been used in liver and kidney surgery since the 1980s, and is effective for tissue manipulation with vascular preservation, but involves some potential risks, such as elevation of intracranial pressure during application in the ventricles. The authors previously reported the efficacy of the actuator-driven pulsed water jet device (ADPJ) to dissect soft tissue with vascular preservation in microscopic neurosurgery. This feasibility study investigated the use of the ADPJ to reduce the amount of water usage, leading to more safety with sustained efficacy. METHODS A small-diameter pulsed water jet device was developed for use with the flexible neuroendoscope. To identify the optimal conditions for the water jet, the flow rate, water pressure, and distance between the nozzle and target were analyzed in an in vitro study by using a gelatin brain phantom. A ventricle model was used to monitor the internal pressure and temperature. For ex vivo experiments the porcine brain was harvested and ventricle walls were exposed, and subsequently immersed into physiological saline. For in vivo experiments the cortex was microsurgically resected to make the small cortico-ventricle window, and then the endoscope was introduced to dissect ventricle walls. RESULTS In the in vitro experiments, water pressure was approximately 6.5 bar at 0.5 mm from the ADPJ nozzle and was maintained at 1 mm, but dropped rapidly toward 50% at 2 mm, and became 10% at 3.5 mm. The ADPJ required less water to achieve the same dissection depth compared with the continuous-flow water jet. With the ventricle model, the internal pressure and temperature were well controlled at the baseline, with open water drainage. These results indicated that the ADPJ can be safely applied within the ventricles. The ADPJ was introduced into a flexible endoscope and the ventricle walls were dissected in both the ex vivo and in vivo conditions. The ventricle wall was dissected without obscuring the view, and the vascular structures were anatomically preserved under direct application. Histological examination revealed that both the vessels on the ventricle wall and the fine vessels in the parenchyma were preserved. CONCLUSIONS The ADPJ can safely and effectively dissect the ventricle wall, with vascular preservation in immersed conditions. To achieve the optimal result of tissue dissection with minimal surgical risk, the ADPJ is a potential device for neuroendoscopic surgery of the ventricles.