Simplified experimental ureteroneocystostomy

Laparoscopic nipple invagination combined extravesical (NICE) reimplantation technique in the management of primary obstructed megaureter

AIMS

Villanueva challenged Paquin's 5:1 tunnel length and showed in a computer simulation model that UVJ competence was more sensitive to a 2-mm protrusion of ureteric orifice into the bladder compared to an increase in the intravesical tunnel. Thompson later successfully applied the Shanfield technique of invaginating the spatulated primary obstructed megaureter (POM) laparoscopically, causing a nipple antireflux mechanism. In this study we have reported the outcomes of our modification: Nipple Invagination Combined Extravesical (NICE) reimplantation, in the management of POM.

METHODS

Patients with POM who underwent NICE reimplantation (summary figure) were followed up and outcomes were analysed. There were three modifications in this compared to Shanfield technique: 1. Detrusor myotomy was performed before opening the bladder mucosa. The detrusor edges were closed later over the invaginated ureter as an extravesical reimplantation. 2. The ureter was held invaginated inside the bladder mucosal opening by two sutures at 6 & 12 O' clock positions instead of a single suture, 3. The dilated ureter was not spatulated inferiorly, as it automatically opens out later inside the bladder to form a nipple.

RESULTS

Eleven patients underwent laparoscopic NICE reimplantation; median age: 6 months (5-24); demographics (R: L = 5:6; M:F = 7:4). The mean duration of surgery was 133 min (110-180) and the mean length of hospital stay was 3.6 days (3-5). There were no immediate post-operative complications in the form of leak in any patient. The median follow-up duration was 20 months (18-29). DRF improved in 7 patients while in 4 it remained static; no patient had deterioration. On follow-up VCUG, none had vesico-ureteric reflux (VUR). The nipple effect could be noticed later at follow-up ultrasonograms and at cystoscopy during stent removal.

DISCUSSION

Paquin emphasised on 5:1 ureteral re-implant tunnel length while Lyon felt that the shape of the ureteral orifice was more important. Shanfield introduced a technique of creating a nipple valve effect by invaginating the ureter intravesically. However it was held by a single suture and had no detrusor backing. NICE reimpantation incorporates a short extra vesical reimplant to the Shanfield technique and literally eliminates post-operative VUR. It is simple and could easily be performed laparoscopically even in small infant bladders. The ureteric orifice kept in line enables future upper-tract access. Our preliminary data suggests that the NICE reimplantation for POM is very successful. Limitations are small numbers and short follow-up. Further larger studies are warranted to authenticate this novel technique.

Pediatric laparoscopic mitrofanoff procedure- preliminary results of a simplified technique

INTRODUCTION

Laparoscopic appendicovesicostomy (LA) is a rather new technique and still a challenging procedure even for the most experienced surgeons because it requires advanced laparoscopic experience and surgical skill. The aim of this study is to analyze the short-term results and benefits of laparoscopic LA in children.

MATERIALS AND METHODS

Prospective study of children undergoing LA at our institution between January 2018 and October 2021. The procedure was perfomed using a laparoscopic transperitoneal approach. The distal end of the appendix was spatulated and reimplanted in the bladder by a modified Shanfield technique. The proximal end was brought out as the cutaneous umbilical stoma.

RESULTS

Over the study period 15 patients underwent LA (14 males,1 female). Mean age at intervention was 8.8 years (SD:3.1). Indication for surgery was pain during CIC in 13 (86.7%) and difficulty for CIC in 2 (13.3%). Eight patients (53.5%) presented end-stage renal disease (ESRD). Median operative time was 217.3 min (r:140-300). Two patients (13.3%) experienced early postoperative complications: ileus (1) and internal hernia over the mesoappendix with subsequent intestinal obstruction. Mean hospital stay was 6.8 days (SD:1.7). Four patients (26.7%) experienced late postoperative stoma related complications: stomal stenosis (1), granuloma (1) and inability to catheterize (2). With a mean follow-up of 21.46 months (SD: 13) all except the patent who lost the conduit are continent and on CIC every 3 h.

CONCLUSIONS

We suggest that LA by this technique is effective, safe and reproducible, and is associated with good short-term results. The complication rate is similar to the open procedure being intestinal obstruction due to internal hernia probably the most serious.

Laparoscopic extravesical ureteral reimplantation for correction of primary and secondary megaureters: Preliminary report of a new simplified technique

PURPOSE

To describe a simplified surgical technique for the treatment of primary and secondary obstructed megaureters in children by laparoscopic extravesical ureteral reimplantation (LEUR) and evaluate the short-term outcomes.

METHODS

Prospective study of children with primary and secondary megaureters treated at our institution between 2016 and 2018 by LEUR. A transperitoneal approach was used in all cases. The distal ureter was transected at the level of the stenosis. Detrusor muscle fibers were divided to expose bladder mucosa. The distal ureter was introduced into the bladder to create a valve-like mechanism. The ureter was fixed to the bladder mucosa by four stitches. We analyzed indications for surgery, complications and outcomes. Definition of success was relieved of obstruction and absence of VUR.

RESULTS

Six patients with a mean age of 28.83 months (SD: 21.4) underwent LEUR. Indications for surgery were: infection [2], obstruction [2], decrease in renal differential function [1] and increase in hydronephrosis [1]. There were no intraoperative complications. Resolution of hydronephrosis, obstruction and VUR was achieved in all cases. Mean follow-up was 13 months (SD: 6.67).

CONCLUSION

LEUR for the correction of primary and secondary megaureters by this new technique is safe. The most important advantage is that this technique is simpler and more easily reproducible than conventional LEUR. However, long-term follow-up is required.

TYPE OF STUDY

Prospective, observational.

LEVEL OF EVIDENCE

Level III.

The Shanfield anastomosis revisited: Its applications and early outcome

BACKGROUND

Shanfield first described a simple ureteric implantation technique involving a U-stitch anchoring the spatulated end of the transplant ureter to the interior of the intact bladder through a small stab wound. We present an extrapolation of this principle to Mitrofanoff channels and native ureteric reimplantations and further extend it to a laparoscopic approach in some.

METHODS

A retrospective case-note reviewing the Shanfield ureteric reimplantation in fifteen children between October 2014 and May 2017 was performed.

RESULTS

Fifteen children (females n = 9), median age 6 years (range 8 months-15 years), underwent a Shanfield anastomosis for ureteric (n = 3) or Mitrofanoff (n = 12) implantation into the bladder. Their diagnoses were: vesicoureteric reflux (n = 2), vesicoureteric obstruction (n = 1), neuropathic bladder (n = 4), exstrophy (n = 2, bladder and cloacal), nonneuropathic bladder (n = 3), cloaca (n = 2), and one with failed urethral reconstruction of a Y-duplication. Two ureteric reimplantations and one appendix-Mitrofanoff were undertaken entirely laparoscopically. The bladder was not opened in 9/15, with the remaining six in an ileocystoplasty and one complex cloaca. Fourteen patients were available for follow-up at a median 18.2 (5.8-43.3) months. There was no anastomotic leakage in any, and one stenosis was successfully managed with simple dilatation. One complex patient required a new Mitrofanoff channel.

CONCLUSION

Our preliminary data suggest that the Shanfield anastomosis offers a safe, robust, and simple antireflux implantation technique without the need to formally open the bladder. The technique offers several advantages as it allows overcoming the problem of inadequate tunnelling when the bladder template is deficient. Meanwhile, its simplicity permits it to be faithfully reproduced with laparoscopy in select patients.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

IV.

A mucosal apposition technique for ureteroneocystostomy after renal transplantation in cats

Renal transplantation is a successful treatment for terminal renal failure in cats. However, in the initial clinical study, there was a frequent occurrence of obstruction of the implanted ureter at the bladder wall or stoma. This resulted in the use of a modified "drop-in" technique that had proved effective in the prevention of obstruction in five normal cats. When applied to renal transplant recipients, ureteral obstruction was reduced, but continued to occur. The modified "drop-in" technique was abandoned and replaced with a technique that apposed the cut edge of the ureteral mucosa to the torn edge of the bladder mucosa. This technique is recommended as it has prevented ureteral obstruction in six successive cases. Prevention of ureteral obstruction, and the required corrective surgery, markedly reduces patient morbidity and mortality, length of hospitalization, and expense to the client.