Laparoscopic ureteral reimplantation with extracorporeal tailoring and direct nipple ureteroneocystostomy for adult obstructive megaureter: long-term outcomes and comparison to open procedure

Endoscopic Management of Adult Primary Obstructive Megaureter: Techniques and Long-term Outcomes

Background and objective

Few studies on endoscopic management of primary obstructive megaureter (POM) in adult patients have been reported. Our objective was to describe our technique and long-term outcomes for endoscopic management of adult POM.

Methods

We included 76 adult POM patients undergoing endoscopic management between September 2015 and January 2024. Under endoscopic control, the stricture was dilated to 24-30 Fr while maintaining a balloon pressure of 25-35 atm for 3 min. An additional incision of the stenotic ring using either an electrode or holmium laser was performed in 39 patients. Data for patient characteristics, intraoperative variables, surgical complications, and follow-up results were analyzed. A descriptive statistical analysis was performed. Surgical success was defined as no tubes or stents in the body, stable or improved symptoms and renal function, and the absence of reflux or obstruction during the follow-up period.

Key findings and limitations

All procedures were completed without conversion to open or laparoscopic surgery. The median operative time was 45 min (range 16-165) with median estimated blood loss of 2 ml (range 0-150). The median postoperative hospital stay was 3 d (range 1-15). No intraoperative complication occurred. At median postoperative follow-up of 42 mo (range 3-100) the overall success rate was 92.1%. Restenosis of the vesicoureteral junction (Clavien-Dindo grade III) occurred in five patients (6.6%), and high-grade vesicoureteral reflux occurred in one patient (1.3%), all of whom required secondary reconstruction surgery.

Conclusions and clinical implications

The results indicate that our endoscopic management for adult POM is safe and effective, with favorable long-term outcomes. This approach could potentially serve as a first-line treatment option for adult POM.

Patient summary

Primary obstructive megaureter (POM) occurs when the flow of urine is blocked because of a narrow segment in the tube between the kidney and bladder (ureter), which causes widening of the ureter further up. For our minimally invasive technique, a telescope is inserted through the urethra and bladder to reach the ureter for surgical treatment. Our results show that this is a safe procedure for POM in adults.

Megaureter in adults: a review of the current literature

OBJECTIVE

Megaureter (MU) is an uncommon condition in adults. The aim is to present a review of the current literature.

MATERIALS AND METHODS

A literature search was conducted to explore the current literature including case reports on MU in adults in the period 2003-2023. Each case was characterised in terms of the eight categories: sex, age, etiology, location, symptoms, diagnostic tool used, type of treatment and follow-up.

RESULTS

There was no meta-analysis but two reviews. Total, 39 case reports were included based on 35 articles. The most common observations for the first four categories were male (sex), age below 40 (age), obstructed MU (etiology) and left-sided MU (location). Almost every patient appeared with symptoms, most frequently flank pain, abdominal pain and recurrent urinary tract infections. CT scan and transabdominal ultrasonography are the most commonly used diagnostic tools. Most cases underwent either laparoscopic or open surgical treatment with ureteral reimplantation as the most performed surgical procedure. A majority of the patients had an uneventful follow-up.

CONCLUSION

MU in adults is a rare condition presenting with heterogeneous symptoms. CT scan and transabdominal ultrasonography should be used as diagnostic tools. Nearly all patients underwent surgical treatment with an uneventful follow-up. Complications such as stone formation and altered function of the affected kidney are common. Surgical treatment is recommended and is determined by consideration of age, symptoms, ureteral extension and progressive loss of renal function.

Robotic urologic surgery using the KangDuo-Surgical Robot-01 system: A single-center prospective analysis

BACKGROUND

The KangDuo-Surgical Robot-01 (KD-SR-01) system is a new surgical robot recently developed in China. The aim of this study was to present our single-center experience and mid-term outcomes of urological procedures using the KD-SR-01 system.

METHODS

From August 2020 to April 2023, consecutive urologic procedures were performed at Peking University First Hospital using the KD-SR-01 system. The clinical features, perioperative data, and follow-up outcomes were prospectively collected and analyzed.

RESULTS

A total of 110 consecutive patients were recruited. Among these patients, 28 underwent partial nephrectomy (PN), 41 underwent urinary tract reconstruction (26 underwent pyeloplasty, 3 underwent ureteral reconstruction and 12 underwent ureterovesical reimplantation [UR]), and 41 underwent radical prostatectomy (RP). The median operative time for PN was 112.5 min, 157.0 min for pyeloplasty, 151.0 min for ureteral reconstruction, 142.5 min for UR, and 138.0 min for RP. The median intraoperative blood loss was 10 mL for PN, 10 mL for pyeloplasty, 30 mL for ureteral reconstruction, 20 mL for UR, and 50 mL for RP. All procedures were successfully completed without conversion, and there were no major complications in any patient. The median warm ischemia time of PN was 17.3 min, and positive surgical margin was not noted in any patient. The overall positive surgical margin rate of RP was 39% (16/41), and no biochemical recurrence was observed in any RP patient during the median follow-up of 11.0 months. The surgical success rates of pyeloplasty and UR were 96% (25/26) and 92% (11/12) during the median follow-up of 29.5 months and 11.5 months, respectively.

CONCLUSION

The KD-SR-01 system appears feasible, safe, and effective for most urological procedures, based on our single-center experience.

Comparison of split-cuff nipple and modified Lich-Gregoir ureteroneocystostomy in iatrogenic distal ureteral injuries: tertiary care center experience

PURPOSE

In this study, we aimed to compare the results of split-cuff nipple and modified Lich-Gregoir ureteroneocystostomy, which are the most commonly used techniques in stage ≥ 3 iatrogenic distal ureteral injuries.

METHODS

The files of patients who were treated for iatrogenic distal ureteral injuries in our clinic between January 2013 and January 2019 were retrospectively reviewed. A total of 60 patients who underwent either intra-vesical split-cuff nipple ureteroneocystostomy (Group A) or extra-vesical modified Lich-Gregoir ureteroneocystostomy (Group B) operations were included in the study. The success of ureteroneocystostomy was defined as no additional surgery requirement, no progression of hydronephrosis on imaging, and normal contrast transition on imaging.

RESULTS

Thirty-four patients underwent split-cuff nipple and 26 patients underwent modified Lich-Gregoir ureteroneocystostomy. The treatment was successful in 53 (88.3%) patients and failed in seven (11.7%). Complications occurred in 19 (31.7%) patients, of whom 14 (23.3%) had minor and five (8.3%) had major complications. The rate of postoperative complications was significantly higher in Group A than in Group B (p = 0.019). There was no significant difference between Group A and Group B in terms of the success ratio (p = 1), rate of major complications (p = 0.372), and postoperative hospitalization times (p = 0.254).

CONCLUSION

In this study, a higher complication rate was found in patients with iatrogenic ureteral injuries who underwent ureteroneocystostomy with the split-cuff ureteral nipple technique compared to those who underwent this operation with the modified Lich-Gregoir technique. However, no significant difference was observed between these two techniques in terms of treatment success and major complications.

Efficacy and safety of robot-assisted laparoscopic, laparoscopic and open surgery in ureteral reimplantation: a network meta-analysis and systematic review

To compare the efficacy and safety between open ureteral replantation (OUR), laparoscopic ureteral replantation (LUR) and robot-assisted laparoscopic ureteral replantation (RALUR). This review produced by the R3.5.0 software with "gemtc" program package and JAGS3.4.0 software based on the Bayesian model. A comprehensive search was done in databases including PubMed, Web of Science, Embase, Cochrane library, Cnki, CBM and WANFANG DATA. Studies that compared OUR, LUR OR RALUR were selected. Summary of Conclusions by ranking of Outcomes. A total of 3949 patients from 29 studies were included. The success rate in OUR, LUR and RALUR was 97.72%, 94.68% and 95.82%. The OR (95% CI) of LUR and RALUR was 0.76 (0.42,1.7) and 0.76 (0.30, 2.6), respectively, compared with OUR. The rate of complications in OUR, LUR and RALUR was 12.78%, 7.94% and 16.32%. The OR (95% CI) of LUR and RALUR was 0.28 (0.16, 0.48) and 0.61 (0.24,1.3), respectively, compared with OUR. The MD (95% CI) of LUR and RALUR for operation time was 22 (2,40) and 46 (7.5,84), respectively, compared with OUR. The MD (95% CI) of LUR and RALUR for hospital stay was - 3.6 (- 4.5, - 2.7) and - 1.1 (- 2.9, 0.58), respectively, compared with OUR. There is no significant difference in the success rates of OUR, LUR, and RALUR. RALUR and OUR has similar complication rates and time of hospital stay, while LUR has fewer complications and faster time to discharge compared to RALUR and OUR. The operative time of OUR is significantly less compared to LUR and RALUR.

Indocyanine green fluorescence imaging for laparoscopic complex upper urinary tract reconstructions: a comparative study

Background

To describe our technique for using an intraureteral injection of indocyanine green (ICG) and visualization under near-infrared fluorescence (NIRF) to facilitate challenging upper urinary tract reconstructions (UUTRs) and to present the comparative outcomes.

Methods

We collected 36 patients who underwent laparoscopic UUTRs between April 2019 and March 2020, and we divided the patients into two groups based on the use of ICG (ICG group and non-ICG group). Demographic characteristics, perioperative outcomes, and functional outcomes were compared between the two groups.

Results

There were 18 cases in the ICG group and 18 cases in the non-ICG group, respectively. There were no differences in the baseline characteristics between the two groups. The intraoperative time to identification of the ureter (TIU; 20.9±11.7 vs. 30.0±14.6 min, P=0.03) and length of postoperative hospital stay (LPHS; 11.1±3.0 vs. 16.6±10.0 days, P=0.03) were significantly shorter in the ICG group. There was also a trend for lesser time for locating the stricture (43.0±27.9 vs. 55.4±18.6 min, P=0.14) and lower estimated blood loss (EBL) in the ICG group patients (88.3±75.4 vs. 91.7±46.2 mL, P=0.22). During the mean 3.8-month follow-up for the ICG group and the 6.2-month for the non-ICG group, there was a trend for more severe complications in the non-ICG group.

Conclusions

Visualizing intraureteral ICG under NIRF is useful in challenging UUTRs, allows for rapid ureteral identification and accurate real-time delineation of the ureteral stricture margins, and provides encouraging follow-up outcomes compared with those in the non-ICG group.

Lich-Gregoir vesico-ureteral reimplantation for duplex kidney anomalies in the pediatric population: a retrospective cohort study between laparoscopic and open surgery

BACKGROUND

The aim of the study is to compare the Lich-Gregoir vesico-ureteral reimplantation in laparoscopy and open surgery.

METHODS

In this case control study, we enrolled pediatric patients who were diagnosed with unilateral duplex kidney and had underwent surgical treatment. The surgical treatments were either conventional open surgery or laparoscopic surgery. We collected the basic demographic data and extracted the operative-related statistics such as operation time, blood loss, length of hospital stay, pain level, and post-operative complications. The two groups were compared using Student's t-test.

RESULTS

A total of 90 subjects were enrolled. Of the enrolled subjects, 35 underwent open surgery and 55 underwent laparoscopic surgery. There were no observable difference in the basic demographics between two groups (P>0.05). The duration of operation in laparoscopic surgery group was significantly shorter than in the open surgery group (95.60±5.25 vs. 108.70±3.12 min, P=0.040). It was also noted that the amount of blood loss, length of hospital stay, drainage level, and the mean visual analog scale in laparoscopic group were significantly lower (P<0.05). The total incidence of complications in the laparoscopic and open surgery groups were 16.36% and 37.14%, respectively.

CONCLUSIONS

Laparoscopic Lich-Gregoir vesico-ureteral reimplantation surgery management can be successful, clinically effective, and safe for pediatric population with functional duplex kidneys, and is better than the open surgery techniques.

[Review of upper urinary modified minimal invasive surgical technology]

Upper urinary surgery is an important area of urology surgery. Open surgery used to be the gold standard of upper urinary surgery. With the development of medical techniques, minimal invasive surgeries including laparoscopic and robot assisted-laparoscopic surgery have gradually replaced the open surgery. Because of the complexity and diversity of upper urinary diseases, surgeries sometimes are difficult, and minimal invasive surgeries require higher surgical abilities of urologists than open surgeries. In recent years, depending on our surgical experience and international reports, our team from three Chinese medical centers summarizes techniques of upper urinary minimal invasive surgeries. For malignant diseases, such as renal and ureteral carcinomas, it's important to totally remove the tumor first, and then to avoid the surgical injuries. We summarize surgical experience of retroperitoneal laparoscopic partial nephrectomy for moderately complex renal hilar tumors. Our team modified minimal invasive techniques for some complex tumors, including ring suture technique for renal hilar tumors, internal suspension technique for renal ventral tumors, and combination retroperitoneal laparoscopic surgery with mini-flank incision for complex renal tumors. While for begin diseases, urologists should focus on the resections and surgical injuries at the same time. We have reported the novel technique of laparoscopic aspiration for central renal angiomyolipoma, making the surgery simple and available. For reconstruction surgeries, operations should be based on several principals. We generalize it as "4TB principals", which include "tension-free", "water-tight", "thin suture", "no touch of the key area" and "protecting the blood supply". Depending on the localization, length, and etiology of the strictures, different techniques are required. Our team summarize the pyeloplasty, ureteral reimplantation and ileal ureter replacement based on our surgical experience. For infant upper urinary surgeries, our team has made invasive surgeries that can be used in complex diseases, such as duplex kidney. Based on years of surgical techniques, our modified surgeries achieve a better subjective cosmetic result than the traditional surgeries. In the future, the standardized, practical, simple and individual minimal invasive surgical technique will become the main direction in the future researches.