Journal of Pediatric Urology (2013) 9, 380e383

Anterior vesical hitch e A step to enhance safety ofpercutaneous access to bladder

Rahul Yadav 1, Divakar Dalela*,1, Apul Goel 1, Satya N. Sankhwar 1,Neeraj K. Goyal 1, Amod K. Dwivedi 1, Deepak S. Nagathan 1

Department of Urology, King George’s Medical University (erstwhile Chattrapati Shahuji Maharaj Medical University),Lucknow 226003, Uttar Pradesh, India

Received 7 June 2012; accepted 4 October 2012Available online 26 October 2012

KEYWORDSAntegrade access;Bladder;Percutaneous surgery

* Corresponding author. Tel.: þ912256543.

E-mail addresses: rahulyadavddrdalela@satyam.net.in (D. Dalela),(A. Goel), sankhwarsn_sn@yahoneerajgoyalk@yahoo.co.in (N.K. Goyco.in (A.K. Dwivedi), deepaknagatNagathan).1 Tel./fax: þ91 522 2256543.

1477-5131/$36 ª 2012 Journal of Pedhttp://dx.doi.org/10.1016/j.jpurol.20

Abstract Purpose: To describe the novel technique of anterior vesical hitch to enhance theefficacy and safety of percutaneous bladder surgery.Materials and methods: The anterior bladderwall is anchored to theanterior abdominalwallwiththe help of a prolene suture passed slightly lateral to the midline midway between the pubicsymphysis and umbilicus. Percutaneous cystolitholapaxy and antegrade posterior urethral valveablationwereperformed after anterior vesical hitch infivepediatricmalepatients. Data collectedincluded operative parameters and complications related to the technique.Results: Mean patient age was 2.9 years (range 1.5e6 years). Three patients had bladder stonesand two had posterior urethral valves. Mean time to achieve bilateral parietal fixation of thebladder was 7 min 20 s. There was no intraoperative slippage of Amplatz sheath or suture cutthrough. No bleeding from the puncture site was encountered. No postoperative complicationrelated to the percutaneous access tract was noted in any patient.Conclusions: The anterior vesical hitch procedure is safe and easy. It prevents slippage of Amplatzsheath during percutaneous access to the bladder lumen.ª 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

9335242329; fax: þ91 522

r@gmail.com (R. Yadav),goelapul1@rediffmail.com

o.co.in (S.N. Sankhwar),al), dramoddwivedi@yahoo.han@rediffmail.com (D.S.

iatric Urology Company. Publishe12.10.006

Introduction

A percutaneous approach to the bladder is one of theways totreat bladder calculus, posterior urethral valves (PUV) andbladder neck contracture, especially in children, to avoidurethral trauma [1,2]. One common problem faced intra-operatively is bladder collapse subsequent to leakage of fluidthrough the Amplatz sheath, risking sheath displacement outof the bladder. A few methods have been described forstabilizing the sheath and to prevent leakage of fluid during

d by Elsevier Ltd. All rights reserved.

Anterior vesical hitch 381

suprapubic access, but none has achieved wide acceptance[3,4]. We describe a technique for stabilizing the anteriorwall of the urinary bladder during antegrade access to thebladder lumen with the help of a 16 gauge epidural needleand laparoscopic port site fascial closure needle (pro MISmedical system, Germany), as shown in Fig. 1A.

Material and methods

The study population consisted of five pediatric patients.Exclusion criteria were neurogenic bladder, thick-walledwith small capacity bladder, history of recurrent or recentUTI, and previous lower abdominal or pelvic surgery.

Technique

The procedure was performed under general anesthesiaafter obtaining informed consent from the patient’s parents.After placing the patient in lithotomy position, ure-throcystoscopywas performed using a 10 Fr rigid cystoscope.

Bladder is filled to capacity with normal saline and theanterior abdominal wall is punctured about 1.5 cm lateral tomidline, midway between pubis and umbilicus, with the helpof an epidural needle. The point of emergence of the needleinto the bladder is watched by a pre-positioned cystoscope.The stylet is removed andapolypropylene (1e0) suturemadeinto a loop (after cutting away its needle) is passed into thebladder (Fig. 1B). Next, a laparoscopic port site fascialclosure needle is introduced into the bladder 1 cm caudal tothe epidural needle puncture site. Guided by cystoscopy

Figure 1 A e Y denotes laparoscopic port site fascial closure nescopic port site fascial closure needle in action. B e Surface view oInset shows cystoscopic view. C e Surface view of engaging proleneneedle. Inset shows cystoscopic view. D e Surface view of two poiparietal fixation on one side.

vision, the loop of the prolene suture is engaged into the hookof the fascial closure needle and is pulled out of the anteriorabdominal wall (Fig. 1C). The exteriorized ends of the pro-lene suture are tied over the anterior abdominal wall. Timetaken to achieve fixation on one side is 3e4 min. The samemaneuver is performed on the opposite side, to achieve ‘twopoint parietal fixation’ of the anterior bladder wall (Fig. 1D).This leads to lifting and anchoring of the bladder toward theanterior abdominal wall.

The standard technique of establishing percutaneoussuprapubic access was undertaken in all the cases. The ure-throcystoscope is removed once initial puncture needle isintroduced into the bladder close to the dome. The tract wasdilated with the help of metal telescopic dilators and anAmplatz sheath was introduced into the bladder. In patientswith bladder stones, a 21 Fr nephroscope along with Swisslithoclast was used to fragment and retrieve the stones. PUVpatients underwent antegrade holmium laser/electro-diathermy valve ablation using a 17/19 Fr cystoscopy sheathand 30� lens. In all PUV cases, an appropriate size infantfeeding tube was kept in the urethra to aid valve ablation.

A suprapubic catheter is put through the same tract atthe end of the procedure and the polypropylene sutures areremoved.

Results

Five young boys (aged 1.5e6 years, mean 2.9) underwentdifferent procedures using the described technique ofanterior vesical hitch. Mean time taken to achieve two

edle. X denotes 16 gauge epidural needle. Inset shows laparo-f passing prolene suture through epidural needle into bladder.suture into the loop of the laparoscopic port site fascial closurent parietal fixation of bladder. Inset shows cystoscopic view of

382 R. Yadav et al.

point parietal fixation was 7 min 20 s. During tract dilata-tion, the prolene sutures remained stable and there was nocase of suture cut through. Three cases had a single bladderstone, mean size 3.2 cm (range 2e4 cm) in largest lineardiameter, on plain skiagram. Two patients underwent valveablation, using holmium laser in one and electrodiathermyin another. No bleeding from puncture site was encoun-tered in any of the cases. All procedures were completedsuccessfully without slippage of Amplatz sheath or anyintraoperative complications. Postoperatively, no patientencountered any problem attributable to anterior vesicalhitch. Suprapubic catheter was removed after 3 days.Average hospital stay of the patient was 4 days.

Figure 2 Points of entry of epidural and laparoscopic portsite fascial closure needle through the anterior abdominalwall, in relation to IEA.

Figure 3 A e Schematic representation of two point parietalfixation of bladder. B e Schematic representation of howstabilized anterior bladder wall is prevented from sagging,despite leakage of fluid through Amplatz sheath.

Discussion

The treatment options available for the management ofbladder calculi include open cystolithotomy, transurethralor percutaneous fragmentation and extraction, and shock-wave lithotripsy. If the calculus is expected to be very hardfrom its radiodensity, too large, multiple, or in a difficultanatomical position, we perform open cystolithotomy.Otherwise, we use an endoscopic approach, either tran-surethral or percutaneous.

The main challenge during any transurethral procedureis to limit the rigid cystoscope dwelling time in the urethra,as a lengthy procedure has the potential to cause urethralinjury with subsequent stricture formation, especially inchildren considering their small urethral caliber [5].Consequently, suprapubic percutaneous access hasemerged as an alternative to the transurethral technique.Different ways have been described to achieve suprapubicaccess. There are many techniques of stabilizing theAmplatz sheath and endoscopic instruments after estab-lishing suprapubic access. Elder used an endotracheal tubeto achieve suprapubic access and inflated the balloon toprevent its slippage out of the bladder during stonemanipulation [3]. Self-retaining laparoscopic trocars havebeen used in the past to achieve percutaneous suprapubicaccess and retrieval of large bladder stones, with goodresults [4].

We used a blunt tipped epidural needle and laparoscopicport site fascial closure needle to avoid cutting action andthus minimize bleeding in the needle path. The point ofentry of these needles is well medial to the course of theinferior epigastric artery (IEA), thus completely obviatingthe risk of rectus hematoma, as shown in Fig. 2. The IEA atthe pubic symphysis level lies on the left at a distance of6.3 � 0.95 cm from the midline and on the right at6.3 � 0.8 cm [6]. At the superior ischial spine level, the IEAis found at a distance of 4.5 � 0.8 cm and 4.5 � 0.9 cm fromthe midline on the left and right side, respectively [6].

Our technique of ‘two point parietal fixation’ preventssagging of the anterior bladder wall as a result of deflationand consequently extrusion of the Amplatz sheath (Fig. 3).With the anterior vesical hitch, different antegradeprocedures can be done without risking the loss of tract,particularly when the procedure is prolonged.

Our technique, by virtue of fixing the bladder wall to theanterior abdominal wall, also permits establishing thepercutaneous tract closer to the dome. This makes access

to the posterior urethra direct and free of angulation, thusenhancing ease of valve ablation using a rigid cystoscope.

We could have ablated the valves with a laser ina retrograde manner but, in our institution, the percuta-neous transvesical approach to PUV is used to demonstrateto residents an alternative way of managing valves if theyrun out of slender pediatric scopes.

Anterior vesical hitch 383

Mean bladder stone burden in our patients was 3.2 cm,so considering the narrow urethra of the children anddifficulty to remove the crushed stone with a 10 Fr cysto-scope if done retrogradely, the bladder calculus wasremoved antegradely.

The indwelling time for hitch sutures ranged from about40 to 90 min. No patient developed pressure necrosis due totension. In none of our cases did we feel the need to re-tiethe knots or adjust tension on the bladder. Average hospitalstay was quite long, as our patients belong to remote areaslacking specialist care so were observed for some moretime in the hospital.

This study had certain limitations. It included a smallnumber of subjects and only pediatric patients. A largerstudy with a wider age group is needed to confirm theefficacy of the technique in percutaneous bladder surgery.

Conclusion

The described technique of anterior vesical hitch issimple and safe. It is another technique in the endouro-logical armamentarium which effectively preventssagging of the anterior bladder wall and loss of tractduring percutaneous bladder surgery. This procedure isnot recommended in cases of previous lower abdominal/pelvic surgery, due to the chance of adhesion of bowel tothe incision site, leading to its injury while passing suturesduring the hitch.

Source(s) of support/funding

None declared.

Disclosures/conflict of interest

None declared.

Permissions

None declared.

Acknowledgments

None declared.

References

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[2] Zaontz MR, Gibbons MD. An antegrade technique for ablation ofposterior urethral valves. J Urol 1984;132(5):982e4.

[3] Elder JS. Percutaneous cystolithotomy with endotracheal tubetract dilation after urinary tract reconstruction. J Urol 1997;157(6):2298e300.

[4] Elbahnasy AM, Farhat YA, Aboramadan AR, Taha MR. Percuta-neous cystolithotripsy using self-retaining laparoscopic trocarfor management of large bladder stones. J Endourol 2010;24(12):2037e41.

[5] Wollin TA, Singal RK,WhelanT, DiceccoR,RazviHA,Denstedt JD.Percutaneous suprapubic cystolithotripsy for treatment of largebladder calculi. J Endourol 1999;13(10):739e44.

[6] Balzer KM, Witte H, Recknagel S, Kozianka J, Waleczek H.Anatomic guidelines for the prevention of abdominal wallhematoma induced by trocar placement. Surg Radiol Anat1999;21(2):87e9.