JSSN_vol25i2-cut.pdf www.jssn.org.npJournal of Society of Surgeons of Nepal J Soc Surg Nep. 2022;25(2) 35 Abstract Ethical Clearance: Financial aid: Authors retain copyright and grant the journal right journal. Outcome analysis of Cohen’s cross trigonal ureteric reimplantation in paediatric age group Suman Bikram Adhikari, Ramnandan P Chaudhary, Tul Maya Gurung, Sanjay Sah, Shovita Rana Department of Paediatric Surgery Ishan Children and Maternity Hospital, Kathmandu, Nepal Dr Suman Bikram Adhikari, Department of Paediatric Surgery Ishan Children and Maternity Hospital, Kathmandu, Nepal Email- sumanchetri@hotmail.com None None Taken Introduction: Cohen’s cross trigonal ureteric reimplantation is the in children with high success rate. The objective of this study was to evaluate and assess the outcome of open Cohen’s procedure in children Methods underwent Cohen’s procedure between March 2010 and February 2020 Results minutes for unilateral repair respectively. The mean length of hospital abdomen in all patients and micturating cystourethrogram in few patients Conclusion: Cohen’s uretric reimplantation is a standard procedure in operative technique should be pursued. Keywords Original article cross trigonal ureteric reimplantation in pediatric age group. J Sosc Surg Nep. 2022; Journal of Society of Surgeons of Nepal J Soc Surg Nep. 2022;25(2) www.jssn.org.np Introduction population.1 remarkable changes in recent years and favors non- in some instances still needs surgical correction like in renal scarring.2-3 In this era of modern technology, laparoscopic ureteric re-implantation or endoscopic procedures involving subureteric transurethral injection are commonly used for quick and minimally invasive and require short hospital stay.4 However, in developing countries like Nepal where are managed with open ureteric reimplantation. Cohen, in and minimal morbidity. The aim of the current study is to evaluate the outcomes of Cohen’s ureteric reimplantation in our part of world. Methods All patients who underwent Cohen’s cross trigonal ureteric reimplantation at Ishan Children and Maternity Hospital were retrospectively reviewed. Approval for this study was time, Clavien- Dindo postoperative complications and postoperative follow-up were documented and analyzed. Study in Children. Data were assessed using the hospital statistics were performed with the same software. Inclusion criteria: • Patients who underwent Cohens uretric reimplantation selected. • Patients who need additional ureteric tapering procedures were also included. • Patients who needed ureteric reimplantation as an • Patient who were lost in follow up Operative technique All ureteric reimplantations were performed using the Cohen cross-trigonal technique. Stents were routinely placed. In all patients, the bladder was accessed using a Pfannenstiel incision and opened vertically. After were dissected and mobilized preserving vessels, nerves and vas in male child. A submucosal tunnel was prepared anchored to the trigonal muscle and mucosal re-adaption was performed using 5/0 polyglactin sutures. In case of megaureter, the ureter was tailored or tapered over 12fr feeding tube, ureteric stent was kept. Bladder was closed in two layers. Abdominal wall was closed in layers using absorbable suture. 8-10F retropubic drain tube and foley catheter was kept. Follow up along with urine C/S was performed at one month during C/S showed no growth. there is chance of introduction of bacteria to urothelium. Results This study consisted of 40 consecutive patients who underwent Cohen’s procedure from March 2010 to February 2020. There were 25 girls and 15 boys. Mean Table 1 Age at surgery (months) Mean 32 (Range: 6-96) Sex Male: Female 15 (37.5%): 25(62.5%) Site of VUR (Left:Right:Bilateral) 10:14:16 Operation time One side (minutes) 249.4(200-290) Operation time both sides (min- utes) 158.3(130-180) Hospital stay (days) Mean 10.55 (7-15) Follow-up (months) Mean 28.13 (7-72) Table 1. Patient characteristics Adhikari SB et al Journal of Society of Surgeons of Nepal J Soc Surg Nep. 2022;25(2) www.jssn.org.np Figure 1 bladder diverticulum in close vicinity to ureteric opening] Figure 2 Figure 3 Perioperative complications Table 2 bladder was re-opened and intravesical clot was removed and haemostasis secured. Another patient developed Hospital Acquired Pneumonia in postoperative period for Figure 1. Indication for Cohens ureteric reimplantation (N=40) Figure 2. VUR vs Non-VUR (N=40) Complications N (%) Clavien-Dindo grade I 4 (10%) Clavien-Dindo grade II 6 (15%) Clavien-Dindo grade III 2 (5%) Clavien-Dindo grade IV 1 (2.5%) Table 3 had ultrasound of kidney, ureter and bladder at 3 months of postoperative period. Among the 24 unilateral procedures, 01 patient with obstructed megaureter had moderate to Discussion damage after acute pyelonephritis has been understood since the mid-to late 20th century.8 Subsequently, ureters swiftly gained popularity and were demonstrated 9 For high-risk patients with reimplantation remains the risk adapted, standard treatment.10 The most commonly used technique for ureteric reimplantation with less complications in children is Cohen’s cross-trigonal reimplantation.9,11,12 Table 2. Complications/follow-up Complications N (%) Febrile UTI 4 (10%) Non-febrile UTI 8 (20%) Ureteric Obstruction 0 (0%) Recurrent VUR 2 (5%) Re-do surgery later 1 (2.5%) Table 3. Late complications during follow up Journal of Society of Surgeons of Nepal J Soc Surg Nep. 2022;25(2) www.jssn.org.np 38 length which was created in the initial phase of practice. tunnel length to- ureteric diameter ratio of up to 1:4-5 was assumed. Therefore, tunnel length was measured arbitrarily in our patients to maintain the aforementioned created by the cross trigonal transfer of the ureter or due to The current study was limited by the retrospective nature of the design. Additionally, there were fewer numbers of reimplantated ureters as this is private children hospital. cases for open reimplantation. Finally, the median follow- up time reported was suboptimal for clinical outcome. Conclusion Cohen’s ureteric reimplantation is a standard procedure in pursued. References 1. injection technique for endoscopic treatment 2. performed as an outpatient therapy. Journal of 3. reimplantation: a minimally invasive technique for 4. Chertin B, Kocherov S, Chertin L, Natsheh A, Farkas 5. There have been many reports on Cohen’s repair with technique, the current institution has had two postoperative 13 and Haid et al14. These two complications were encountered in the early phase of practice. stone formation12,15 make it less popular among some urologist. None of patients in our study had obstructive hydronephrosis and stone formation. grade II complications are more likely to occur after a Cohen’s the form of reactionary haemorrhage for which reoperation associated hospital acquired pneumonia. challenging, thus creating risk factors of lower success rates, were also present. The length of the submucosal tunnel and its relation to the diameter of the ureter is reported to be an important factor in successful ureteric reimplantation. Chung JM, Park CS, Lee SD. Postoperative ureteric obstruction after endoscopic treatment for JM, Tamminen-Möbius TE. International system 8. 9. Cohen SJ. The Cohen reimplantation technique. 10. urology. https://uroweb.org/guideline/paediatric- urology/#3_13. 11. Mure PY, Mouriquand PD. Surgical atlas the Cohen 12. Adhikari SB et al Journal of Society of Surgeons of Nepal J Soc Surg Nep. 2022;25(2) www.jssn.org.np 39 13. intravesical detrusorrhaphy. J Pediatr Surg. 2013;48:1813e8. 14. Haid B, Strasser C, Becker T, Koen M, Berger 15. of surgical complications: a new proposal with of a survey. Ann Surg. 2004;240: 205e13.