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PERCUTANEOUS ENDOSCOPIC TECHNIQUE
FOR COMBINED CONSERVATIVE SURGERY-
BRACHYTHERAPY IN BLADDER NECK/PROSTATIC RMS
Bernardita TRONCOSO SOLAR
1
, Olga SLATER
2
, Peter HOSKIN
3
, Mark GAZE
4
and Naima SMEULDERS
5
1) Great Ormond Street Hospital, Paediatric Urology, London, UNITED KINGDOM - 2) Great Ormond Street Hospital,
Paediatric Oncology, London, UNITED KINGDOM - 3) Mount Vernon Hospital, Clinical Oncology, London, UNITED
KINGDOM - 4) University College London Hospitals, Clinical Oncology, London, UNITED KINGDOM - 5) Great Ormond
Street Hospitalt, Paediatric Urology, London, UNITED KINGDOM
PURPOSE
Today, organ-sparing approaches for localised bladder/prostate rhabdomyosarcoma (BP-RMS) in
children are preferred. To minimise morbidity from radiotherapy, local control is achievable by surgi-
cal excision of the bladder component and brachytherapy to the remaining bladder-neck/prostatic
tumour (BnP), for disease <5cm after neo-adjuvant chemotherapy. In this video we demonstrate
a percutaneous endoscopic technique for debulking of botyroid tumours with limited extension
along the bladder wall prior to brachytherapy.
MATERIAL AND METHODS
Patients for conservative surgery-brachytherapy for BP-RMS are collected prospectively.
Technique: Under cystoscopic vision, suprapubic needle-puncture allows dilatation over a 0.035sen-
sor wire using a NephroMax balloon to a percutaneous 30F Amplatz-Sheath. Through a 24F
Wolf
®
-Nephroscope exophytic tumour polyps are grasped. Holmium-YAG laser energy (Cook
®
5Hz,
0.5-1J, long setting) is applied to the tumour stalks for coagulation and excision. 5F cup-biopsy
forceps allow samples to be taken from surrounding areas to confirm tumour extent histologically
ensuring adequate cover of the residual disease by brachytherapy.
RESULTS
Since November 2014, we offered this technique to two patients (17month-old male, 5year-old fe-
male) with localised embryonal BnP-RMS (diagnosis and pre-surgical sizes: 3.9x2.9x2cm reduced
to 1.6x1.3x0.8cm, and 3.2x2.9x2.5cm to 1.7x1.5x1.1cm, respectively) with post-operative interstitial
brachytherapy (HDR Ir192 paediatric protocol) through ultrasound-guided transperineal catheters
(total 27.5Gy in five fractions over 3 days to a planned volume). At 2years and 6months follow-up,
remaining tumour-bulk is reducing; patients are dry day+night with complete bladder emptying and
no hydronephrosis.
CONCLUSIONS
We propose this minimally invasive technique for debulking of the polypoid component for BnP-
RMS extending upto 1cm from the Bn. Biopsy of the neighbouring urothelium/detrusor provides
confirmation of tumour extent although lymph node sampling is not feasible.