Laparoscopic vesicoureteroplasty in children: initial case reports

Laparoscopic extravesical transperitoneal approach following the Lich-Gregoir technique in the treatment of vesicoureteral reflux in children

INTRODUCTION

Laparoscopy may have a place in the treatment of vesicoureteral reflux (VUR). We report our initial experience in the treatment of VUR by laparoscopic extravesical transperitoneal approach (LETA) following the Lich-Gregoir technique to describe the evolution and to evaluate the results and benefits of this technique for these patients.

MATERIALS AND METHODS

Between August 2007 and May 2009, 43 renal units in 30 children (23 female and 7 male) with VUR and deterioration of renal function on isotope renography (17 unilateral and 13 bilateral) were treated with LETA. The mean age was 52 (range, 15-183) months. Nine patients had a double total collector system associated with VUR in a lower system. Two of them had a ureterocele with adequate upper polar rein function, and another had a ureterocele with complete deterioration of upper polar rein function.

RESULTS

The mean surgical time was 70 (38-120) minutes in unilateral and 124 (100-180) minutes in bilateral VUR. All procedures were successfully completed laparoscopically, and the reflux was corrected in all patients. At the same time, 1 heminephrectomy and 2 ureterocele were removed by laparoscopy and endoscopy, respectively. We had 1 ureter leakage 15 days postoperation that underwent a redo reimplantation. In cases of bilateral VUR, 1 patient presented postoperative bladder emptying difficulty and required temporary urethral catheterization postoperatively. The mean hospital stay was 24 hours. A cystogram was performed systematically in all patients at 45 days postoperation; none of them presented recurrence of VUR. The follow-up was 11 (range, 2-24) months, without recurrence of VUR.

CONCLUSION

Laparoscopic extravesical transperitoneal approach in the treatment of VUR is a safe and effective approach even in unilateral, bilateral simultaneous, and double total collector system. The technique results in a shorter hospital stay, less postoperative discomfort, and reduced recovery period, with a low morbidity to resolve the VUR and with success rates similar to the open technique.

Robot-assisted laparoscopic nephrectomy and contralateral ureteral reimplantation in children

BACKGROUND

Robot-assisted laparoscopic surgery (RALS) has expanded the role for minimally invasive surgery within pediatrics. RALS may be particularly beneficial for the treatment of children with a refluxing nonfunctioning renal moiety and contralateral vesicoureteral reflux. In this report, we describe a single RALS procedure, which includes both nephrectomy or partial nephrectomy, and contralateral extravesical ureteral reimplantation (EVUR).

METHODS

A retrospective review was performed of four patients who underwent RALS nephrectomy/partial nephrectomy and concurrent EVUR in one setting. Procedures were performed by a single surgeon using a robot-assisted laparoscopic approach. Four ports were used in a transperitoneal approach with patient positioning changed without moving the robotic system between the nephrectomy and reimplant. We described the technique and assessed its safety and efficacy.

RESULTS

All cases were treated with the single RALS approach. Mean patient age was 2.3 years. Three patients underwent a nephrectomy and one a lower pole partial nephrectomy. The mean estimated blood loss was 16 mL, mean operative time was 291 minutes, and mean length of stay was 2.3 days. There was one case of postoperative ureteral obstruction that was treated with 3 weeks of ureteral stenting without further sequela. Overall, the mean follow-up time was 21 months and follow-up renal ultrasonographs and radionuclide cystograms were normal in all patients.

CONCLUSIONS

A single RALS procedure that combines nephrectomy/partial nephrectomy and EVUR offers a novel approach to a clinical dilemma that often requires two operations. In this small series, RALS was safe and efficacious. We recommend routine Double-J stenting for the solitary reimplanted ureter.

Current trends in pediatric minimally invasive urologic surgery

Over the past two decades, laparoscopic and robotic surgery in children has been described as a viable minimally invasive alternative to open surgery for many pediatric urologic conditions. With the goal of reducing the morbidity associated with open surgery, minimally invasive surgery in children is increasingly being performed as laparoscopic and robotic patients appear to be experiencing shorter hospital stays, decreased pain medication requirements, and the potential for improved cosmesis. This article provides an overview of the existing literature in laparoscopic and robotic-assisted laparoscopic urologic surgery in children. Laparoscopic and robotic-assisted laparoscopic surgery appears to be safe and effective in children for a wide range of ablative and reconstructive procedures. Conventional laparoscopic surgery is effective for ablative procedures, while robotic surgery may be ideally suited for reconstructive cases requiring advanced suturing and dissection. Overall, more prospective studies are needed to study the long-term outcomes of minimally invasive surgery in pediatric patients, and the appropriate use of the available technology.

Evolution of laparoscopy in pediatric urology

The use of laparoscopy has evolved over the last 30 years, particularly in the last decade, from merely extirpative or diagnostic procedures to intricate reconstructive procedures on the major genitourinary organs. The development of laparoscopy as a method of treating urological problems has progressed more slowly in children compared with adults; perhaps due to the availability of miniaturized technology, the steep learning curve and the high success of traditional open surgery. This article seeks to provide a comprehensive review of the evolution of laparoscopy from its inception to its present-day applications in the field of pediatric urology, including the current indications and results of various laparoscopic procedures.

Transvesicoscopic Cohen ureteric reimplantation for vesicoureteral reflux in children: a single-centre 5-year experience

PURPOSE

To evaluate our results with a new method of intravesical ureteric reimplantation using laparoscopic pneumovesicum in children.

MATERIALS AND METHODS

Seventy-two patients (mean age 4.2 years, range 0.5-20 years) with primary vesicoureteral reflux (VUR) underwent a laparoscopic transtrigonal ureteric reimplantation with CO(2) pneumovesicum. Ports were inserted suprapubically - 5mm for the camera and two 3-5-mm working ports. Having mobilized the ureter(s) intravesically, a submucosal tunnel is created and ureteric reimplantation performed with 5/0 and 6/0 absorbable sutures. Bladder drainage was maintained for 2-3 days postoperatively. Patients were followed up with clinical assessment and renal ultrasonography+/-voiding cystourethrogram.

RESULTS

Ninety percent had VUR grade > or =3. A total of 113 ureters were reimplanted. The mean operative time was 82min for unilateral and 130min for bilateral reimplantation. Four cases (6%) were converted. Three patients presented with temporary ureteric dilatation without symptoms on follow-up renal ultrasound. Seven patients had postoperative urinary tract infection without persistent reflux on cystography. Follow-up cystogram was performed in 50 patients (81 ureters). Reflux persisted in four patients (8%).

CONCLUSIONS

Laparoscopic ureteric reimplantation with CO(2) pneumovesicum is technically feasible with a high success rate (92%). The role of this new technique in the treatment of VUR remains to be determined.

New porcine model for training for laparoscopic ureteral reimplantation with horn of uterus to mimic enlarged ureter

PURPOSE

To develop a new porcine model with horn of the uterus to mimic an enlarged ureter for training for laparoscopic ureteral reimplantation (LUR) and to evaluate its feasibility.

MATERIALS AND METHODS

Ten female pigs were used in the training. The pig was placed to a dorsal position after an anesthetic was administered. The horn of the uterus near the bladder was dissected, then spatulated and trimmed to replace the enlarged ureter. LUR was performed according to standard operation steps. Four trainees completed the LUR procedure based on a mentor-trainee model to guarantee the success of the procedure and the quality of the anastomoses. The learning curve of operative time was analyzed. The anastomotic stoma was cut off postoperatively and checked extracorporeally. After the course, questionnaire surveys were sent to the trainees to investigate satisfaction of the training and assess the impact of the training on their learning of "real" LUR in future practice.

RESULTS

This model reproduced the key technique steps of LUR. Four LUR procedures were performed on each pig. The operative time declined from 170.0 +/- 10.3 minutes to 90.3 +/- 3.7 minutes (P < 0.01) after the trainees had performed 10 LURs. There was proper stitching in each "ureterovesical" anastomosis. At the end of training, all trainees could accomplish a LUR procedure skillfully on the model; they were satisfied after the course and thought the training was helpful to future practice of LUR.

CONCLUSION

The new model was feasible and cost-effective for training in the basic skills of laparoscopic ureteral reconstruction procedures.

Laparoscopic ureteral reimplantation: prospective evaluation of medium-term results and current developments

OBJECTIVE

Laparoscopic ureteral reimplantation is a feasible method for treating ureteral pathology with good preliminary results in the literature. In this study, we review our medium-term results for laparoscopic ureteral reimplantation and discuss current developments of this procedure.

MATERIALS AND METHODS

Twenty-four laparoscopic ureteral reimplantations were performed between August 2003 and December 2008 for ureteral strictures or ureteral injuries. The mean age was 53.5 years (8 men, 16 women). Patient demographics, preoperative symptoms, radiological imaging, complications, and postoperative outcomes were analyzed. Ten patients underwent vesicopsoas-hitch, nine patients had a vesicopsoas-hitch combined with Boari-flap, and five had Lich-Gregoir extravesical ureteral reimplantations. Success was defined as relief of obstruction on postoperative imaging studies, as well as symptomatic relief.

RESULTS

Laparoscopic ureteral reimplantations were successfully performed in all patients. The mean operative time was 215 min (131-351). Mean estimated blood loss was 283 ml (50-550). One patient had an intraoperative bowel injury which was managed laparoscopically during the same procedure. There were two postoperative complications; two prolonged ileus and one deep venous thrombosis (DVT). Mean hospital stay was 8.7 days. Average time to return to normal activity was 2.6 weeks. Postoperative radiological imaging studies showed good drainage, without hydronephrosis, in 23 patients (success rate 95.8 %) at a median follow up interval of 35 months.

CONCLUSIONS

Laparoscopic ureteral reimplantation is an effective procedure with good medium-term results. We believe that this procedure will become an established treatment option.

Laparoscopic extravesical ureteral reimplantation: technique

Laparoscopic extravesical ureteral reimplantation in children is currently a technically demanding procedure with sparse literature to aid in mastering the learning curve. We present our most recent technique and lessons learned after 20 cases in children 4-15 years of age. The literature is also reviewed to encapsulate the current state-of-the-art.

Laparoscopic ureteral reimplantation: technique and outcomes

PURPOSE

We describe our experience with laparoscopic ureteral reimplantation in 45 adults, and report success rates and complications at intermediate term followup.

MATERIALS AND METHODS

We performed a retrospective chart review of 45 patients who underwent laparoscopic ureteral reimplantation between 1997 and 2007. Demographics, clinicopathological parameters, perioperative course, complications and followup studies were analyzed.

RESULTS

Elective laparoscopic ureteral reimplantation was performed in 35 female and 10 male patients with a mean followup of 24.1 months (range 1 to 76). All patients presented with distal ureteral stricture with a mean stricture length of 3 cm and a mean +/- SD preoperative serum creatinine of 0.91 +/- 0.04 mg/dl. Mean patient age was 47.8 +/- 2.2 years (range 17 to 87). Mean American Society of Anesthesiologists score was 2 (range 1 to 3). Median estimated blood loss was 150 ml. The overall success rate, defined as radiographic evidence of no residual obstruction, symptoms, renal deterioration or need for subsequent procedures, was 96%. Two patients had recurrent strictures and 1 underwent nephrectomy for flank pain and preexisting chronic pyelonephritis.

CONCLUSIONS

According to intermediate followup data laparoscopic ureteral reimplantation can be performed with an excellent success rate and low morbidity. Our data substantiate this technique as an effective method for managing distal ureteral stricture.

Minilaparoscopic nerve-sparing extravesical ureteral reimplantation for primary vesicoureteral reflux: a preliminary report

BACKGROUND

To validate its safety and efficacy, we evaluated our preliminary results of the three-port minilaparoscopic nerve-sparing extravesical ureteral reimplantation for patients with vesicoureteral reflux (VUR).

METHODS

Between July 2005 and February 2007, 9 consecutive patients (4 girls and 5 boys) with a mean age of 3.4 years (range, 7 months to 5 years) underwent a minilaparoscopic nerve sparing extravesical ureteral reimplantation for VUR. A 30-degree 3-mm telescope and two 3-mm trocars were used for the reimplantation. Minimal handling and dissection of the ureter and ureterovescial junction was adhered to spare the nerves.

RESULTS

A total of 14 ureters were reimplanted (4 unilateral and 5 bilateral). Mean follow-up period was 8.7 months. The mean operative time was 170 minutes in unilateral reimplantations and 218 minutes in the bilateral one. There was no intraoperative complication. All patients resumed oral intake in the first postoperative morning. The Foley catheters were removed within 24-36 hours after surgery. None of them had urinary retention after catheter removal. Voiding cystourethrography was done 3-4 months after surgery. A complete resolution of reflux was identified in 11 of 14 units, a downgrading of reflux in 2 of 14 units, and ureterovesical junction stenosis in 1 of 14. Open reimplantation was done for the ureter with postoperative ureterovesical junction stenosis.

CONCLUSIONS

The three-port minilaparoscopic nerve-sparing extravesical ureteral reimplantation was a safe, effective techinique for the treatment of VUR.

Robotic-assisted laparoscopic management of vesicoureteral reflux

Robotic-assisted laparoscopy (RAL) has become a promising means for performing correction of vesicoureteral reflux disease in children through both intravesical and extravesical techniques. We describe the importance of patient selection, intraoperative patient positioning, employing certain helpful techniques for exposure, and recognizing the limitations and potential complications of robotic reimplant surgery. As more clinicians embrace robotic surgery and more urology residents are trained in robotics, we anticipate an expansion of the applications of robotics in children. We believe that it is necessary to develop robotic surgery curricula for novice roboticists and residents so that patients may experience improved surgical outcomes.

Current status of Gil-Vernet trigonoplasty technique

Significant controversy exists regarding vesicoureteral reflux (VUR) management, due to lack of sufficient prospective studies. The rationale for surgical management is that VUR can cause recurrent episodes of pyelonephritis and long-term renal damage. Several surgical techniques have been introduced during the past decades. Open anti-reflux operations have high success rate, exceeding 95%, and long durability. The goal of this article is to review the Gil-Vernet trigonoplasty technique, which is a simple and highly successful technique but has not gained the attention it deserves. The mainstay of this technique is approximation of medial aspects of ureteral orifices to midline by one mattress suture. A unique advantage of Gil-Vernet trigonoplasty is its bilateral nature, which results in prevention from contralateral new reflux. Regarding not altering the normal course of the ureter in Gil-Vernet procedure, later catheterization of and retrograde access to the ureter can be performed normally. There is no report of ureterovesical junction obstruction following Gil-Vernet procedure. Gil-Vernet trigonoplasty can be performed without inserting a bladder catheter and drain on an outpatient setting. Several exclusive advantages of Gil-Vernet trigonoplasty make it necessary to reconsider the technique role in VUR management.

Laparoscopic ureteroneocystostomy and psoas hitch for post-hysterectomy ureterovaginal fistula

PURPOSE

We assessed the results of laparoscopic ureteroneocystostomy with a psoas hitch for iatrogenic lower ureteral injuries leading to a ureterovaginal fistula.

MATERIALS AND METHODS

Between July 2003 and November 2007, 18 patients with iatrogenic lower ureteral injuries during hysterectomy leading to ureterovaginal fistula underwent laparoscopic ureteroneocystostomy with a psoas hitch. Of the patients 17 underwent abdominal or vaginal hysterectomy, while in 1 with a ruptured gravid uterus emergency hysterectomy was done for uncontrolled bleeding. Mean patient age was 35.5 years (range 23 to 45) and mean time to surgery since the injury was 2.2 months (range 1.5 to 3.5). Transperitoneal 3 or 4 port laparoscopic ureteroneocystostomy with a psoas hitch was performed.

RESULTS

Of the procedures 17 were completed successfully. Intraoperative cardiac arrhythmia occurred in 1 patient due to pneumoperitoneum and hypercarbia, requiring open conversion. Mean operative time was 2.5 hours (range 1.9 to 2.8) hours, mean blood loss was 90 ml (range 45 to 150) and total hospital stay was 5.3 days (range 2.9 to 8). The nephrostomy tube was blocked on the table in all patients and it was removed on day 7. At an average followup of 26.4 months (range 3 to 52) postoperative excretory urography did not reveal obstruction in any patient. One patient had vesicoureteral reflux on voiding cystogram.

CONCLUSIONS

Laparoscopic ureteroneocystostomy with a psoas hitch for ureterovaginal fistula secondary to hysterectomy is safe and effective, and associated with a low incidence of postoperative reflux and obstruction.

Treatment of vesicoureteral reflux after puberty

Vesicoureteral reflux is uncommonly diagnosed and treated after puberty. The natural history of uncorrected VUR after puberty is not documented. Postpubertal patients with recurrent pyelonephritis and VUR should be considered for treatment. Ureteral reimplantation, endoscopic injections, and laparoscopic or robotic ureteral reimplantation may be utilized. Endoscopic injection is an appealing option for these patients. The role of laparoscopic or robotic ureteral reimplantation in these patients is evolving.

Laparoscopy in the management of pediatric vesicoureteral reflux

The prevalence of vesicoureteral reflux (VUR) has been estimated as. 4 to 1.8% among the pediatric population. In children with urinary tract infection the prevalence is typically from 30-50% with higher incidence occurring in infancy. When correction of VUR is determined to be necessary, traditionally open ureteral reimplantation by a variety of techniques has been the mainstay of treatment. This approach is justified because surgical correction affords a very high success rate of 99% in experienced hands and a low complication rate. In that context the purpose of this review article is to highlight the use of laparoscopy and robot-assisted techniques to perform ureteric reimplantation for the management of pediatric VUR. A detailed review of recent literature on the subject is performed to find out various aspects of minimally invasive surgery in the treatment of VUR, highlighting evolution of management approaches, operative steps, complications, results and the current status in clinical practice. We also share our experience on the subject.

What is new in surgical treatment of vesicoureteric reflux?

In addition to conventional open surgery and endoscopic techniques, laparoscopic correction of vesicoureteric reflux, sometimes even robot-assisted, is becoming an alternative surgical treatment modality for this condition in a number of centres around the world. At least for a subgroup of patients laparoscopists are trying to develop new techniques in an effort to combine the best of both worlds: the minimal invasiveness of the STING and the same lasting effectiveness as in open surgery. The efficacy and potential advantages or disadvantages of these techniques are still under investigation. The different laparoscopic techniques and available data are presented.

Laparoscopy in paediatric urology: present status

The spectrum of laparoscopic surgery in children has developed dramatically; what was initially used as a diagnostic method to identify an impalpable testis is now commonly used for complex reconstructive procedures such as pyeloplasty. Laparoscopic orchidopexy and nephrectomy are well established and are used at many centres. Laparoscopic partial nephrectomy, adrenalectomy and dismembered pyeloplasty series have reported shorter hospital stays and operative times that are comparable with that of open techniques, and/or decreasing with experience. The initial experiences with laparoscopic ureteric re-implantation and laparoscopically assisted bladder reconstructive surgery are reported, with encouraging results for feasibility, hospital stay, and cosmetic outcome.

Minimally invasive surgery for urologic disease in children

This article is a comprehensive review of the current indications and recent literature pertaining to laparoscopic techniques in pediatric urology. Basic concepts such as instrumentation, anesthetic considerations, and complications are reviewed. Specific techniques and indications are also explored. As the field of pediatric urology continues to expand, it still lags behind adult urology. With improvements in technology, however, and with new surgeons entering the field with a basic laparoscopic background, pediatric urologic laparoscopy continues to progress. Currently, procedures such as laparoscopic exploration for undescended testicles and laparoscopic nephrectomy are accepted as the 'gold standard', and are performed at most institutions. Other procedures, such as laparoscopic pyeloplasty and laparoscopic reconstructive surgery, have only recently been introduced and are primarily available at centers with surgeons experienced in laparoscopy. It is our hope that minimally invasive surgical approaches to urologic conditions will become available to all children and become commonplace at most institutions.

Laparoscopic ureteroneocystostomy with vesicopsoas hitch: nonrefluxing ureteral reimplantation using cystoscopy-assisted submucosal tunneling

PURPOSE

We described laparoscopic nonrefluxing ureteral reimplantation with a psoas hitch using a submucosal tunneling technique combined with cystoscopy.

PATIENTS AND METHODS

We performed this operation on two female patients. The first patient had a right lower-ureteral stricture after a laparoscopy-assisted vaginal hysterectomy, and the second patient had a left distal-ureteral stricture after a left laparoscopic oophorectomy, which was performed for endometriosis. We performed laparoscopic intravesical ureteral reimplantations with a psoas hitch using submucosal tunneling after a submucosal injection of normal saline was provided under cystoscopy.

RESULTS

The operative times were 325 and 280 minutes, respectively. The estimated blood loss was 300 mL in the first case and 120 mL in the second. The hospital stays were 5 and 3 days, respectively. There were no postoperative complications. Follow-up voiding cystourethrography and intravenous urography demonstrated normal compliance and function of the kidneys and ureters with no vesicoureteral reflux.

CONCLUSIONS

Laparoscopic intravesical nonrefluxing ureteroneocystostomy with a psoas hitch is a safe and feasible procedure. Cystoscopic submucosal injection of normal saline during submucosal tunneling is beneficial.

Extraperitoneal Laparoscopic Trigonoplasty for Treatment of Vesicoureteral Reflux: Novel Technique Duplicating its Open Counterpart

PURPOSE

We describe a novel technique of extraperitoneal laparoscopic trigonoplasty for the treatment of vesicoureteral reflux.

MATERIALS AND METHODS

Three boys and 24 girls with 41 refluxing units underwent extraperitoneal laparoscopic trigonoplasty. A 10 mm incision was made below the umbilicus. With sharp, blunt finger dissection and balloon dilation an extraperitoneal space was created. The bladder was opened using a laparoscopic scissors. Two 3Fr ureteral catheters were inserted intracorporeally into the ureters. A transverse superficial incision was made in the epithelium between the ureteral orifices. The medial aspect of the ureters was cleared of the muscles and attachments, and sutured in the midline with 4-zero polyglactin sutures.

RESULTS

Operative time ranged from 60 to 240 minutes (mean 147). Blood loss was less than 50 ml. Adequate extraperitoneal space, bladder opening, epithelial incision, ureteral approximation with secure suturing in the midline and bladder closure were carried out in all cases. Peritoneal perforation was noted in 4 patients while creating the extraperitoneal space, with suturing needed for 1 large perforation. Hospital stay was 1 to 6 days (mean 2.7). At 4 to 19 months of followup (mean 8.2) reflux had resolved in 38 units (93%).

CONCLUSIONS

Extraperitoneal laparoscopic trigonoplasty is technically feasible. Results are comparable to open techniques. The major advantage of this procedure is the avoidance of peritoneum. Other advantages include a shorter hospital stay and good cosmesis. More followup is necessary to establish the long-term results.

[The position of laparoscopic surgery in pediatric urology]

With growing experience in laparoscopic techniques there is a switch in pediatrics from ablative surgery to reconstructive procedures. Besides the established procedures such as laparoscopic nephrectomy and orchidopexy, procedures like heminephrectomy and pyeloplasty have proven practicable and become standard therapies in children and infants. Due to technical advances, as shown for our own patients, the number of treated infants is still increasing. However, laparoscopic reconstructive procedures presuppose a good deal of experience in preparation and suture techniques, and remain reserved for centers with daily experience in laparoscopy. Daily experience with difficult urological laparoscopic procedures in adults will remain more common than in pediatric centres.

Laparoscopic ureteroneocystostomy with psoas hitch

BACKGROUND AND PURPOSE

Laparoscopic extravesical ureteroneocystostomy is an infrequently described technique. Our aim is to describe five cases where we used the intracorporeal freehand suturing technique successfully for performing laparoscopic extravesical transperitoneal ureteral reimplantation with psoas hitch. We describe the preliminary results of these cases.

PATIENTS AND METHODS

We performed this surgery in five female patients. Two patients had a low ureterovaginal fistula after total laparoscopic hysterectomy. The other three patients had undergone laparoscopic radical hysterectomy.

RESULTS

The average surgical time was 220 minutes. The average blood loss was 150 mL. The average stay was 3 days, and the average time to starting oral intake was 12 hours. No intraoperative or postoperative complications occurred. The urinary catheter was removed after 3 weeks and the double j stent after 6 weeks. Follow-up urography showed good clearance of the kidney and ureter. There was no reflux on the postoperative cystogram.

CONCLUSION

Laparoscopic extravesical ureteroneocystostomy with intracorporeal freehand suturing technique and psoas hitch is a feasible procedure in females for managing ureterovaginal fistulas after laparoscopic gynecologic surgeries. The patients need not be subjected to open surgery because this complication can be repaired laparoscopically, thus minimizing the morbidity.

Laparoscopic Extravesical Transperitoneal Approach for Vesicoureteral Reflux

INTRODUCTION

Laparoscopy may have a place in the treatment of vesicoureteral reflux. In this study, we present the results of laparoscopic extravesical transperitoneal treatment in 15 children (19 ureters) of vesicoureteral reflux.

MATERIALS AND METHODS

Between January 2001 and February 2004, 15 children (11 with unilateral and 4 with bilateral vesicoureteral reflux) were treated with extravesical reimplantation (Lich- Gregoir technique) via a transperitoneal laparoscopic approach. The mean age was 48.2 months (range 12-62), and there were 14 females and 1 male. Two patients had a double total collector system associated with reflux without ureterocele.

RESULTS

The mean surgical time was 110 minutes in unilateral and 180 in bilateral vesicoureteral reflux. All procedures were successfully completed laparoscopically and the reflux was corrected in all but one patient, whose grade III vesicoureteral reflux changed to grade I. We had 3 mucosal perforations without leakage. The longest hospital stay was 72 hours. After follow-up ranging 15-49 months, only one patient had urinary tract infection.

CONCLUSION

Laparoscopic extravesical transperitoneal reimplantation for vesicoureteral reflux is a safe and effective approach even in bilateral simultaneous and duplex ureters, with success rates similar to the open technique, and a dramatic reduction in postoperative stay. Mucosal perforation was treated by maintaining a Foley catheter for 3-4 days postoperatively.

Laparoscopic ureteral reimplantation: A simplified dome advancement technique

Laparoscopic Boari flap reimplantation has been used to treat long distal ureteral strictures. This technique requires extensive bladder mobilization and complex intracorporeal suturing. This demonstrates a novel laparoscopic bladder dome advancement approach for ureteral reimplantation. This technique obviates the need for bladder pedicle dissection and simplifies the required suturing.

Laparoscopic extravesical ureteral reimplantation in adults using intracorporeal freehand suturing: report of two cases

BACKGROUND AND PURPOSE

Laparoscopic extravesical neoureterocystostomy is an infrequently described technique in adults. It is a technically demanding procedure, especially when the intracorporeal freehand suturing technique is used. Our aim is to describe two cases where we used the intracorporeal freehand suturing technique successfully for performing laparoscopic extravesical transperitoneal ureteral reimplantation. We describe the preliminary results of these cases.

PATIENTS AND METHODS

We performed this surgery in two female patients. The first patient had a low ureterovaginal fistula after abdominal hysterectomy. We performed a laparoscopic extravesical neoureterocystostomy by the refluxing technique. The second patient had a lower-third ureteral stricture. We performed a laparoscopic extravesical neoureterocystostomy with detrusorrhaphy and supported it with a psoas hitch.

RESULTS

The average surgical time was 235 minutes. The average blood loss was 50 mL. The average stay was 48 hours, and the average time to starting oral intake was 12 hours. The average requirement for postoperative analgesia was one injection of diclofenac sodium, followed by oral ibuprofen. Follow-up urography showed good clearance of the kidney and ureter. The second patient, in whom the detrusorrhaphy was performed, did not show any reflux on the postoperative cystogram.

CONCLUSION

Laparoscopic extravesical neoureterocystostomy using intracorporeal freehand suturing technique, combining detrusorrhaphy and psoas hitch, is a feasible procedure in adults for various indications. The detrusorrhaphy was effective in preventing reflux, but the long-term results need to be evaluated.

Laparoscopic ureteroneocystostomy for distal ureteral injuries

OBJECTIVES

To present our initial experience with laparoscopic ureteroneocystostomy in patients with traumatic disruption of the distal ureter owing to gynecologic procedures. Reconstructive laparoscopic procedures are still evolving.

METHODS

Six patients with ureterovaginal fistula in whom endoscopic management had failed underwent laparoscopic ureteroneocystostomy with a psoas hitch between July 2003 and December 2004.

RESULTS

All procedures were completed successfully. No intraoperative or postoperative complications were noted. Postoperative intravenous urography did not reveal any evidence of obstruction. No reflux was seen in 5 of the 6 patients during micturating cystography.

CONCLUSIONS

Laparoscopic ureteroneocystostomy is a safe and feasible minimally invasive option for patients with gynecologic distal ureteral injury.

Laparoscopic treatment of refluxing segmental megaureter

We discuss the case of a 13-year old boy with urinary infection who was preoperatively diagnosed with left vesicoureteral reflux associated with paraurethral saccule. Laparoscopic Lich-Gregoir anti-reflux surgery was then proposed. Intraoperatively, we observed segmental megaureter that was successfully treated by the proposed technique without ureteral modeling, contrary to the rule that respects the 3-5 times ratio between the submucous path and the ureteral diameter.

Laparoscopic ureteroneocystostomy for benign lower ureteric stricture: case study and literature review

The surgical treatment of distal ureteric strictures depends on their length and aetiology. Laparoscopic procedures in this setting are uncommon. We describe a laparoscopic non-refluxing ureteroneocystostomy for a symptomatic distal ureteric stricture performed on a 26-year-old man. The operation was carried out successfully without complication. Blood loss was 100 ml with an operating time of 250 min. He was discharged on the fourth day and returned to work after 11 days. Retrograde ureterography and cystography after 1 month showed no evidence of obstruction or reflux. At 3 months, an intravenous urogram showed excellent drainage and at 6 months the patient remained asymptomatic. We advocate the use of laparoscopic ureteroneocystostomy for benign distal ureteric stricture refractory to endoscopic procedures. In symptomatic patients, it is a feasible, safe, minimally invasive procedure with all the added benefits of laparoscopy compared with open repair. A non-refluxing anastomosis is preferable. Reconstructive and intracorporeal suturing skills are needed to carry out this procedure.

Trigonoplasty to treat secondary vesicoureteral reflux in neurogenic bladders

OBJECTIVES

The effectiveness of Gil-Vernet's trigonoplasty, with technical modifications, was studied in treating vesicoureteral reflux (VUR) in neurogenic bladders.

METHODS

Modified Gil-Vernet's trigonoplasty, making the transmural ureters advance over the midline and cross each other in the trigone, was applied in patients with neurogenic bladder dysfunction and VUR, diagnosed by voiding cystourethrogram. Most of the patients were sufficiently followed up by cystourethrogram.

RESULTS

26 patients with neurogenic bladder dysfunction were diagnosed as having 43 refluxing units and underwent modified Gil-Vernet's trigonoplasty. Reflux was grade I in 5 units, grade II in 7, grade III in 5, grade IV in 18, and grade V in 8, with unilateral reflux in 9 patients and bilateral reflux in 17. Surgery was successful in 95.3% of 43 refluxing units. 22 patients were followed 3-6 months after the operation, and the cure rate was 90.9% (no reflux under voiding cystourethrogram). 18 patients were followed up for more than 2 years without recurrence of VUR.

CONCLUSIONS

Modified Gil-Vernet's trigonoplasty might be a useful technique in the management of patients with VUR secondary to neurogenic bladder dysfunction.

Laparoscopic and robotic approach to genitourinary anomalies in children

The evolution of laparoscopic surgery in pediatric urology has been long and slow, but is emerging steadily and seems to be here to stay. This article reviews the basic applications of laparoscopic methods in pediatric urology, including diagnostic and operative procedures. The new horizons of robotic assistance for laparoscopic surgery make highly accurate and efficient reconstructive procedures possible.

Laparoscopic Extravesical Reimplantation for Postpubertal Vesicoureteral Reflux

BACKGROUND AND PURPOSE

Postpubertal vesicoureteral reflux is a rare occurrence. In the adolescent group, its repair can be a challenging open procedure. We present our preliminary experience with laparoscopic extravesical ureteral reimplantation for postpubertal vesicoureteral reflux.

PATIENTS AND METHODS

Six female patients with a mean age of 18.7 years presented with recurrent urinary tract infection secondary to vesicoureteral reflux. The indications for treatment were febrile urinary tract infection, recurrent pyelonephritis, renal scarring, and breakthrough urinary tract infection. The reflux was unilateral in all patients at the time of treatment, but one patient had previously experienced bilateral reflux and had persistent left-sided reflux following subureteral injection of Durasphere. This patient underwent bilateral laparoscopic extravesical ureteral reimplantation.

RESULTS

The mean operative times for the unilateral and bilateral procedures were 1.75 hours and 3.75 hours, respectively. The average length of stay in the hospital was 36 hours; five patients went home in <24 hours. The mean time to resumption of full activity was 8 days. All six patients had resolution of vesicoureteral reflux, as shown by radiographic studies, with a mean follow-up of 11.4 months.

CONCLUSION

Laparoscopic extravesical ureteral reimplantation for postpubertal vesicoureteral reflux has excellent outcomes with minimal postoperative morbidity. Long-term radiographic follow-up is needed.

Rapid Communication: Pure Robot-Assisted Laparoscopic Ureteral Reimplantation for Ureteral Stricture Disease: Case Report

BACKGROUND AND PURPOSE

The role of the da Vinci robot is slowly being defined in minimally invasive urologic surgery. We report its use in the management of ureteral stricture disease.

CASE REPORT

A 42-year-old man with recurrent kidney stone disease was found to have a left distal-ureteral stricture. After failure of endoscopic treatment, a robot-assisted laparoscopic ureteral reimplantation was performed. The total operative time was 210 minutes. The estimated blood loss was <50 mL. There were no intraoperative or postoperative complications. Total analgesic use was 30 mg of morphine. The hospital stay was 5 days.

CONCLUSION

Pure robot-assisted laparoscopic ureteral reimplantation is a safe and feasible approach to the management of ureteral stricture disease.

A new endoscopic ureteral reimplantation for primary vesicoureteral reflux (endoscopic trigonoplasty II)

PURPOSE

We describe a new technique of endoscopic antireflux surgery. The principle of the procedure is to make a reliable muscular backing and elongate the intramural ureter.

MATERIALS AND METHODS

We performed this new endoscopic surgery in 8 female patients in whom 4, 1, 8 and 1 refluxing ureters (total 14) were diagnosed with grades I to IV reflux, respectively. The operation consists of 3 steps. Two 5 mm. locking trocars are placed into the bladder. Irrigation is done with 3% D-sorbitol solution and the bladder wall is incised upward along each side of the ureter using a resectoscope to make a 2 to 3 cm. U-shaped bladder flap, including the ureter. Under pneumobladder the incised muscle is sutured to make a muscular bed with a needle holder via the urethra and forceps via the abdominal trocar. The U flap is fixed with 2 distal anchor sutures on the embedded muscular layer and 4 additional sutures are placed to approximate the mucosa of the U-shaped flap and bladder.

RESULTS

Mean operative time was 245 minutes. Ureteral injury occurred in 2 patients. A Foley catheter remained indwelling for 3 to 5 days (mean 4.1). Reflux resolved in 12 of the 14 ureters (86%) 12 months postoperatively. Vesicoureteral reflux persisted in 1 case because of insufficient fixation and recurred in 1 because of ureterovesical fistula. The patients were satisfied with better cosmesis and minimal postoperative discomfort.

CONCLUSIONS

We believe that procedure is feasible for female patients with primary vesicoureteral reflux.

Extraperitoneal laparoscopic Lich-Gregoir antireflux plasty for primary vesicoureteral reflux

We performed laparoscopic Lich-Gregoir antireflux plasty on 4 patients with primary vesicoureteral reflux. All procedures were conducted using the extraperitoneal approach. The average surgical time was 230 min. There were no complications. After surgery, voiding cysturethrograms showed no reflux in all patients.

Laparoscopic correction of vesicoureteral reflux using the Lich-Gregoir technique: initial experience and technical aspects

We report two female cases with vesicoureteral reflux (VUR) who underwent laparoscopic correction of VUR by the Lich-Gregoir technique. One patient was 10 years of age, with international grade III reflux of the left ureter; the other was 27 years of age, with grade II reflux of the right ureter. The respective operating times were 6 h 40 min and 6 h 10 min. There were no complications during surgery. Although post-surgical ultrasonography revealed mild hydronephrosis in the adult patient, the condition resolved spontaneously 2 months after surgery. The disappearance of reflux was confirmed in both cases by voiding cystography 6 months after surgery.

Management of ureteral stricture disease during laparoscopic ureteroneocystostomy

BACKGROUND AND PURPOSE

Laparoscopic surgery has many applications in urology. The surgical management of obliterative ureteral stricture disease using laparoscopy has not been widely reported. We recently implemented this technique in an adult patient with an obliterative ureteral stricture.

METHODS

A transperitoneal refluxing right ureteral reimplantation was performed using the Endostitch device. Placement of the new ureteral orifice in the bladder was monitored by simultaneous cystoscopy and laparoscopy. The anastomosis was performed without tension, torsion, or angulation and was stented for 4 weeks.

RESULTS

The operative time was 233 minutes. The blood loss was minimal. There were no intraoperative complications, and the postoperative hospital course was uneventful.

CONCLUSION

Laparoscopic ureteral reimplantation is a safe and feasible technique. Cystoscopic determination of the neoureteral orifice is helpful. The Endostitch device is a useful adjunct in this procedure.

A transperitoneal laparoscopic approach to endourology

Although endoscopic methods have become the preferred means of management for many diseases facing the genitourinary surgeon, a laparoscopic approach might be considered comparable or advantageous in select circumstances. In the literature, laparoscopists reporting their work have favored the transperitoneal approach; however, there are clear advantages and disadvantages to both transperitoneal and retroperitoneal laparoscopy. Intracorporeal suturing remains the most time-consuming aspect of reconstructive surgery, and research emphasis has been on suturing devices and novel anastomotic techniques. Laparoscopic pyeloplasty is efficacious and should be considered, particularly in the case of a capacious renal pelvis, crossing vessel, or failed previous endopyelotomy. Laparoscopic pyelolithotomy is uniquely suitable for patients with aberrant anatomy, such as a horseshoe kidney, and may be performed concurrently with pyeloplasty for ureteropelvic junction obstruction. The use of laparoscopic extravesical ureteral reimplantation awaits further development in both open and subtrigonal injection techniques. Its use in colposuspension is undetermined and requires further study as suturing technology improves. During laparoscopic exploration, it is possible to address intraoperative injuries to the ureter and bladder laparoscopically. In summary, laparoscopic surgery of the urinary tract is a "work in progress," but it offers promise for some of the most challenging of circumstances. As the technology advances and the clinical experience widens, the indications and contraindications for these techniques will be better established.

Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux: recent technical advances

Ureteral reimplantation is an effective treatment for primary vesicoureteral reflux. Recent efforts have been directed toward reducing the perioperative morbidity of open reimplantation. We have refined the technique of laparoscopic extravesical ureteral reimplantation with emphasis on minimal tissue dissection, achieving reliable detrusor closure, and downsizing ports and instruments. With our current technique, excellent results comparable to those of established open procedures are achieved, while postoperative discomfort and the recovery period are significantly reduced. The laparoscopic technique of ureteral reimplantation is described, with emphasis on key technical modifications crucial to the ease of performance and a successful outcome.

Percutaneous endoscopic trigonoplasty in children: long-term outcomes and modifications in technique

PURPOSE

Long-term outcomes of a minimally invasive method of correcting vesicoureteral reflux are presented with a discussion of the modification in our original technique.

PATIENTS AND METHODS

A total of 29 children (46 refluxing ureters), 14 months to 18 years old, underwent percutaneous endoscopic trigonoplasty (PET) between December 1994 and June 1996. Follow-up ranged from 19 to 37 months. Reflux was grade 1 in 2, grade 2 in 16, grade 3 in 19, grade 4 in 8, and grade 5 in 1. The technique was a Gil-Vernet method in the first 23 patients and Cohen reimplantation in the last 6 patients.

RESULTS

Resolution of reflux was observed to decrease from 63% to 47% with long-term (30-37 months') follow-up using the Gil-Vernet technique. Resolution was greater with unilateral reflux than bilateral reflux (83% v. 27%, respectively). The Cohen technique resulted in resolution of reflux in 83%; however, the operating time nearly doubled when compared with the Gil-Vernet group. In both groups, failure was unrelated to grade of reflux, age, operative sequence, or bladder instability.

CONCLUSIONS

Although showing an improvement in resolution of reflux over the Gil-Vernet PET procedure, the Cohen PET reimplant has a lower success rate than traditional open operative reimplants. The PET also requires more operating time and two operating surgeons. Despite some advantages in the promptness of recovery, we do not recommend PET by either technique at this time. Future modifications may make this approach more tenable.

Feasibility of total intravesical endoscopic surgery using mini-instruments in a porcine model

BACKGROUND AND OBJECTIVES

The aim of minimally invasive approaches to vesicoureteral reflux, such as endoscopic trigonoplasty, is to lower the morbidity of open procedures without compromising the results. Initial successes have not been sustained, mainly because of trigonal splitting, which results in the ureteral orifices returning to their preoperative positions. This study was designed to address trigonal splitting by mobilizing the ureters before repositioning them and to evaluate the feasibility of accomplishing this intravesically with 2- to 3-mm endoscopic mini-instruments.

METHODS

Bilateral vesicoureteral reflux was surgically created in 10 minipigs. After radiologic confirmation of success 4 weeks later, modified trigonoplasty was performed by endoscopic intravesical mobilization of both ureters and incision of the trigonal mucosa using 2-mm instruments. The ureteral orifices were then advanced toward the midline and sutured in place. The initial surgical techniques were modified to permit the entire procedure to be performed endoscopically in the last four minipigs. Cystograms and intravenous urograms were obtained 4 weeks later.

RESULTS

Two minipigs died postoperatively. Six of the remaining eight had persistent reflux, including three of the four in the group treated completely by endoscopic means. None of the dissected ureters showed evidence of stricture or necrosis.

CONCLUSIONS

Although the procedure was not successful in correcting reflux in this model, this study demonstrates the feasibility of endoscopic ureteral mobilization. With current instrumentation, there is no significant technical obstacle to complete intravesical endoscopic surgery, including ureteral reimplantation.

Laparoscopic surgery in children

The surgeon should be aware of the extensive applications of endoscopic surgery in the pediatric patient. The ability to provide surgical care in association with either outpatient or short-stay hospitalizations appear to be cost-effective and appropriate state-of-the-art medical care. Because the array of surgical instruments continues to evolve, new and innovative endoscopic procedures will continue to become increasingly available.