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

Vesicoscopic vs. Open Ureteral Reimplantation According to Cohen and Leadbetter-Politano for Vesicoureteral Reflux

BACKGROUND

The minimally invasive implementations of the established open methods for the correction of primary vesicoureteral reflux have proven to be successful in terms of feasibility and safety. The aim of this study was to investigate to what extent pediatric patients benefit from vesicoscopic operations.

METHODS

Between 2010 and 2022, 224 children (359 ureters) underwent ureteral reimplantation for vesicoureteral reflux in our clinic. Children, operated on according to the COHEN technique, underwent an open approach in 39 cases, whereas 151 patients were operated on vesicoscopically. A total of thirty-four children have received a ureteral reimplantation according to the LEADBETTER-POLITANO technique: twenty-nine openly and five vesicoscopically. The open and vesicoscopic groups were compared with regards to perioperative data and postoperative course.

RESULTS

The mean operating time was significantly shorter for open than for the vesicoscopic procedures in the COHEN group (99 vs. 149 min, p < 0.001). Similarly, a comparison of ureteral reimplantations, according to LEADBETTER-POLITANO, favored the open procedure, although this was not significant (161 vs. 196 min, p = 0.135). There was no significant difference in the recurrence rate of all the groups. All procedures remained within the accepted range with a success rate of at least 96%. In the postoperative course, a significantly shorter hospital stay (4.1 vs. 7.9 days, p < 0.001 for COHEN-patients; 5.6 vs. 9.2 days for LEADBETTER-POLITANO-patients), as well as a significantly lower need for continuous analgesic administration, was observed for the vesicoscopic approaches of both methods (0.8 days in both vesicoscopic groups vs. 3.7 resp. 3.8 days in open groups, p < 0.001). In addition, the time of bladder drainage was significantly shorter in open techniques (7.2 vs. 1.9 days, p < 0.001 for COHEN-patients; 3 vs. 8.7 days for LEADBETTER-POLITANO-patients).

CONCLUSIONS

For almost all underlying causes, the surgical treatment of vesicoureteral reflux can be performed vesicoscopically, even if bilateral, in one session. Patients benefit significantly from the use of minimally invasive surgery in the postoperative course with faster mobilization, less need for analgesics, a shorter bladder drainage and a reduced hospital stay, compared with its open counterparts.

Vesicoscopic ureteral reimplantation with a modified Glenn-Anderson technique for vesicoureteral reflux

INTRODUCTION

Vesicoureteral reflux (VUR), commonly referred to as urinary reflux, is one of the most common congenital urological anomaly to occur during childhood. Historically, open vesicoureteral reimplantation has been the gold standard in the surgical treatment of VUR. Currently, vesicoscopic ureteral reimplantation is used as a minimally invasive alternative to open ureteral reimplantation. Most vesicoscopic procedures are performed using the transtrigonal Cohen technique. As a non-transtrigonal technique, the vesicoscopic Politano-Leadbetter technique is also performed, but requires dissection outside the bladder under a narrow surgical field, and in boy carries a risk of vas deferens injury.

OBJECTIVE

This study evaluated surgical outcomes and perioperative findings for vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique in children with VUR.

STUDY DESIGN

Eighteen consecutive children who underwent vesicoureteral ureteral reimplantation using a modified Glenn-Anderson technique were included in this study. The surgical procedure was explained and surgical outcomes and perioperative findings were evaluated.

RESULTS

Patients comprised 9 boys and 9 girls with 29 cases of ureteral reflux (7 unilateral cases, 11 bilateral cases). All procedures were performed laparoscopically, with no cases requiring conversion to open surgery. Median operative time was 143 min for unilateral VUR and 194 min for bilateral VUR. Only one case showed a complication (Clavien-Dindo grade 1). The remaining 17 cases showed no complications, with removal of the urethral catheter and discharge 2 days postoperatively. Seventeen of the 18 cases underwent postoperative voiding cystourethrography, showing no VUR in all cases.

DISCUSSION

Vesicoscopic ureteral reimplantation is a minimally invasive alternative to open surgery, with most procedures performed using a transtrigonal Cohen technique. Regardless of whether the surgery is open or laparoscopic, a disadvantage of the Cohen technique is that postoperative transureteral treatment may not be possible. The Politano-Leadbetter technique has been reported as a non-transtrigonal technique. However, this requires dissection outside the bladder under a narrow surgical field, and carries a risk of vas deferens injury in boys. In this study, vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique provided good surgical outcomes with minimal perioperative complications and easy manipulation under a wide field of view.

CONCLUSION

Although many minimally invasive treatments are available, vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique is safe and effective for patients with VUR 4 years old. To demonstrate the further utility of this procedure, long-term outcomes and safety evaluations are needed in a larger number of cases.

Conversions in pediatric robot-assisted laparoscopic surgery

BACKGROUND

New technology attracts necessary concerns regarding safety and effectiveness, including the risk and circumstances of conversions. This study analyses our 11-year experience of conversions from a dedicated pediatric robot-assisted laparoscopic surgery service.

METHODS

Consecutive patients were evaluated from a prospective database for the period March 2006 to May 2017. Descriptive and quantitative data for conversions were analysed. Variables were investigated including year of surgery, patient age, operation type, surgeon, and experience.

RESULTS

A total of 539 children underwent 601 procedures. There were 45 different types of procedures. Mean (± SD) age was 7.0 ± 5.2 years, and youngest 4 weeks old. There were 31 conversions (5.8%). Conversion rates were significantly higher in younger children, with rates of 10.0%, 6.1% and 4.2% for age groups 0-2, 2-6, and 6-18 years respectively (p = 0.01). There was a significant difference in conversion rates amongst procedures (p<0.001). Intravesical (9/26, 34.6%), liver cyst (2/8, 25.0%) and choledochal cyst (8/60, 13.3%) procedures were the highest. The most frequent reason for conversion was anesthetic related issues caused by dilated intestine and/or inadequate muscle relaxation (16/31, 52%). Three conversions were attributable to mechanical failures, none attributed to intraoperative complication.

CONCLUSIONS

Conversion rates are low even in the learning phase and comparable favourably to conventional laparoscopy, supporting the safety and effectiveness of robot-assisted technology for advanced laparoscopy in children. The importance of optimization of surgical conditions cannot be overemphasised.

Pneumovesicoscopic ureteral reimplantation with intravesical tailoring of obstructive megaureter in pediatric patient

INTRODUCTION

According to available data, there are only few articles describing pneumovesicoscopic (PNV) ureteral reimplantation (UR) for obstructive megaureter without tailoring and with ex vivo tailoring in children.

AN OBJECTIVE

To present our experience of the PNV UR using intravesical ureteral tailoring for symptomatic primary obstructive megaureter in children.

STUDY DESIGN

Between 2014 and 2020, 42 patients (mean age: 3.1 years) underwent a correction of primary obstructive megaureter (POM) via a vesicoscopic approach. Nine of them with the megaureter (diameter > 25 mm) underwent the intravesical ureteral tailoring. The analysis included only 9 patients who underwent intravesical tailoring of the ureter using the original technique. The dilated ureter is fixed intravesical by the loop in extended position. This simplifies the tailoring step of the ureter. The tailoring is performed by continuous suture (Star).

RESULTS

43 UR were analyzed (1 bilateral, 1 with diverticulum, 1 with ureterocele). The mean operative time was 142 min (83-235 min). The mean manipulation time for intravesical tailoring of the megaureter was 18 min. After the surgery, the average kidney function doesn't reduce. We observed an increase in renal function by an average of 7% in three patients after the surgery. One patient required a conversion. It was in the early stages of mastering the technique. All patients underwent US 1-3 weeks 3-6-12 months after the operation, the size of the pelvic system and ureter decreased. Eight patients are asymptomatic, and only one has the clinical changes (a persistent leukocyturia, the size of the pelvic-ureteric segment, and the ureter remain unchanged or increased). According to the VCUG vesicoureteral reflux was detected in this case. An endoscopic correction used successful.

DISCUSSION

This possibility of applying our technique is confirmed according to folow-up data and should be used in other researches. The drainage of the ureter with an external stent for 1 month helps to form properly the neo-ureterovesical anastomosis and to prevent episodes of ureteral obstruction as a result the incidence of urinary tract infections reduces in the postoperative period.

CONCLUSIONS

The use of the Tuohy needle with the loop simplifies the fixation of the ureter. This helps to make the intravesical tailoring of the megaureter easier and faster. It is original and less traumatic for the ureter than existing methods.

Surgical management of vesicoureteral junction obstruction (VUJO) in children: A comparative study between transvesicoscopic Cohen reimplantation and transumbilical laparoendoscopic single-site (TU-LESS) Lich-Gregoir techniques

BACKGROUND

There are many reports on the application of minimally invasive technology in the correction of children's VUJO, but there is no report on the treatment of children's VUJO by the TU-LESS Lich-Gregoir method. We aimed to comparatively analyze the therapeutic outcomes of transvesicoscopic ureteral reimplantation Cohen procedure (TUR-C) and TU-LESS surgery Lich-Gregoir procedure (TU-LESS-LG) in pediatric VUJO.

METHODS

The data of 49 children with VUJO admitted from January 2016 to January 2020 were retrospectively analyzed. Based on different surgical methods, they were divided into the TUR-C group (23 cases) and the TU-LESS-LG group (26 cases). The demographic characteristics, perioperative characteristics, postoperative complications, the recovery of renal function, and the improvement of hydronephrosis were compared between the two groups.

RESULTS

There were no statistical differences in demographic characteristics and preoperative data between the two groups. The TU-LESS-LG group was superior to the TUR-C in terms of average operation time and postoperative hospital stay. There was no statistical difference between the two groups in terms of postoperative complications, postoperative recovery of renal function, and improvement of hydronephrosis.

CONCLUSION

The two surgical methods can achieve a similar curative effect in the treatment of VUJO. The TU-LESS-LG has more advantages in operation time, postoperative hospital stays, the wider age selection range of cases, megaureter tapering, and cosmetic incision, but the operation is more difficult.

Vesicoscopic Cross-Trigonal Ureteral Reimplantation for Vesicoureteral Reflux: Intermediate Results

For the treatment of vesicoureteral reflux, the introduction of vesicoscopic procedures offers new perspectives for improving patient comfort and quality. Our aim was to examine whether minimally invasive vesicoscopic cross-trigonal ureteral reimplantation (VCUR) would meet expectations. Between 2012 and 2021, 99 girls and 35 boys with high-grade vesicoureteral reflux (VUR) underwent VCUR. For two boys, we failed to establish the pneumovesicum, leading to conversion to open surgery. The mean age was 4.5 years, ranging from 10 months to 18 years. VCUR was successfully performed in 132 patients, including 75 patients with bilateral VUR and 12 children with double ureters with unilateral or bilateral VUR, corresponding to a total of 229 operated ureters. The mean time of operation was 151 min for all patients. There were no perioperative complications, with the exception of three cases of pneumoperitoneum without consequences. Postoperatively, we recognized three cases of acute hydronephrosis, two of them required transient drainage. Three patients developed extravasation of urine after the postoperative removal of the transurethral catheter, rapidly resolved by new drainage. In two patients, we combined VCUR with laparoscopic heminephrectomy and opposite laparoscopic nephrectomy, respectively. Overall, mean postoperative hospital stay was 4.2 days. We observed recurrent VUR in seven ureters, resulting in a success rate for VCUR of 96.9%. These results demonstrate the feasibility of VCUR and its potential to displace open surgery with high safety and wide applicability.

A Comparative Study of the Ergonomic Risk to the Surgeon During Vesicoscopic and Robotic Cross-Trigonal Ureteric Reimplantation

Background: Maintenance of the body posture and precise repetitive movements during minimally invasive surgeries predispose the surgeons to the risk of musculoskeletal disorders (MSDs). The present study was designed to estimate the ergonomic risk of MSDs in a single surgeon while performing vesicoscopic ureteric reimplantation. Materials and Methods: All children with primary vesicoureteric reflux (VUR) undergoing vesicoscopic ureteric reimplantation through the laparoscopic (Group 1) or robotic (Group 2) approaches from July 2015 to October 2019 were included. Data, including age at the time of surgery, gender, the severity of VUR (grade), number of ureters involved (unilateral or bilateral), and procedural details, were recorded. Rapid Entire Body Assessment (REBA) tool was used for the ergonomic risk assessment of each procedure. The REBA scores were graded as negligible (1), low (2-3), medium (4-7), high (8-10), and very high (11 or more). The risk index was considered as normal (1 or less) and high (>1). The ergonomic risk associated with both approaches was compared. Results: A total of 16 patients (Male:Female = 9:7) were included in the present study. Groups 1 and 2 had 11 and 5 patients, respectively. The average (range) age of the children belonging to Group 1 was significantly lesser than Group 2 (3 versus 7.5 years; P = .0004). The average duration of surgery was significantly longer in Groups 1 versus 2 (P = .03). The average REBA scores associated with the laparoscopic and robotic approaches were 13 and 5, respectively (P = .0006). The risk indices in both approaches were 3.25 and 1.25, respectively. Conclusion: In a limited cohort of patients, we observed an overall high risk of MSD to the surgeon while performing vesicoscopic ureteric reimplantation. The associated ergonomic risk was significantly less with the robotic (medium risk category) versus laparoscopic approach (very high risk category).

Ureteral reimplantation aligned laparoscopically: Pneumovesicoscopic Politano-Leadbetter reimplantation in children

INTRODUCTION

Ureteroneocsytostomy is a well-established procedure for correction of certain ureterovesical conditions like vesicoureteral reflux and ureterevesical obstruction. Amazing developments in technology paved the way for minimally invasive surgery and conventional procedures are increasingly being performed minimal invasively during the recent decades. Although Politano-Leadbetter ureteroneocystostomy is an anatomical repair, lost its popularity against Cohen's technique as it is more challenging to perform and requires extravesical dissection which may increase the complication rates.

OBJECTIVE

In this study, we evaluated our results and feasibility of laparoscopic intravesical (pneumovesicoscopic) repair of certain ureterovesical conditions by Politano-Leadbetter principle in children.

STUDY DESIGN

Twenty one children who underwent pneumovesicoscopic uretero-neocystostomy are enrolled in the study. Surgical procedure is described and surgical duration, complications, conversion rate and success rates are evaluated.

RESULTS

Fourteen (67%) of the patients were girls and 7 were boys (33%). Median age at operation was 6 years (1.5-15 years). Main indications for surgery were vesicoureteral reflux, megaureter and bladder diverticulum. Fourteen of the patients underwent bilateral (67%) intervention while the 5 left (24%) and 2 right (9%). Four patients were converted to open surgery (16%; 4/25). Median surgical duration was 265 min (190-320 min) for bilateral and 180 min (115-260 min) for unilateral procedures. Success rates confirmed by a contrast study were 92% for VUR.

DISCUSSION

It appears that minimally invasive intravesical surgery fails to keep up with the other minimally invasive procedures secondary to restricted working field in the bladder, technically demanding procedures and well-documented high succes rates of open counterpart techniques. Although developing relatively slower, minimally invasive technology offers better vision, better cosmesis, lesser pain and lesser tissue disturbance. Although cross-trigonal reimplantation is the most popular technique, Politano-Leadbetter technique provides an anatomical alignment of ureters and is a good option for caudally located ectopic ureters. In our study, pneumovesicoscopic approach provided anatomical reimplantation, identification and sparing of vas deferens and better cosmesis. Major limitations of our study are the limited number of cases, longer operation times, higher complication rates and short follow up duration which we hope to improve with increasing experience.

CONCLUSION

Although not brilliant as its open counterpart yet, initial results of pneumovesicoscopic reimplantation with Politano-Leadbetter technique is promising and growing experience would further improve the results and lower the complication and conversion rates.

Pneumovesicoscopic correction of primary vesicoureteral reflux (VUR) in children. - Our Initial experience

Purpose The main objective of our prospective,descriptive,monocentric,longitudinal study is to demonstrate the feasibility of vesicoscopic cross-trigonal ureteral reimplantation under CO2 pneumovesicum in treatment on primary vesicoureteral reflux,analyze results and specify the age limit of this approach.

METHODS

A total of 60 patients underwent transvesicoscopic ureteral reimplantation (33 boys, 27 girls) by the same surgeon from Mai 2011 to Mai 2015. All patients had primary vesicoureteral reflux,and surgery was performed because of breakthrough urinary tract infection despite antibiotic prophylaxis, persistent high grade of vesicoureteral reflux especially in association with significant renal scarring, mean age at operation was 47.47month (6 month-12 years). Of the 60 patients, 34 had bilateral reflux and 26 had unilateral reflux. The reflux grade in the total of 94 ureters was grade IV, V in 59.57%, grade III in 35.11% and grade II in 5.32% in association with contralateral high grade vesicoureteral reflux.

RESULTS

The transvesicoscopic procedure was successfully completed in all patients without perioperative complication except one case of pneumoperitoneum that required exsufflation by open laparoscopy. The mean overall operative time decreased significantly with an average of 58.43 +/- 11.26 minutes for unilateral reimplantation and 101.18+/- 26.5 minutes for bilateral reimplantation.The postoperative hospital stay was 3 days for all patients.The mean follow-up period was 03 years.Cystography was performed 3 month after surgery in all patients and showed the disappearance of vesicoureteral reflux in 57/60 patients (95%) or 91/94 of ureters (97%). Persistent vesicoureteral reflux was documented in 3 of 94 ureters and had resolved spontaneously at 12 month after reimplantation.

CONCLUSION

Our preliminary results indicate that vesicoscopic ureteral reimplantation is safe and effective procedure with minimal morbidity when compared to traditional open method. It can be apply in children under 12 months. Key words: Primary vesicoureteral reflux, surgical treatment of primary vesicoureteral reflux,vesicoscopic Cross-Trigonal Ureteral Reimplantation, childre.

A systematic review and meta-analysis comparing outcomes of laparoscopic extravesical versus trans vesicoscopic ureteric reimplantation

OBJECTIVE

When considering treatment for vesico ureteric reflux via inimally invasive surgery there is a dilemma to choose between laparoscopic extravesical (LEVUR) and transvesicoscopic (TVUR) ureteric reimplantation. In this systematic review and meta-analysis we have analyzed the articles on LEVUR and TVUR and compared the outcomes.

METHODS

We searched the databases to identify all papers pertaining to TVUR and LEVUR in the pediatric population. Duplicate publications, review articles, incomplete articles and robotic assistance were excluded. Systematic review was performed to identify patient data, reflux grades, laterality, duration of surgery, time to discharge, success rate and complications. Meta-analysis of heterogeneity was reported with I 2 statistics. Once heterogeneity was found low, the pooled outcomes were compared with students t test and Fishers exact test, wherever appropriate.

RESULTS

After screening a total of 45 articles, 23 articles were included (13 articles on TVUR and 10 articles on LEVUR). The I 2 statistics for TVUR and LEVUR showed low heterogeneity with I 2 of 0% (95% C.I 0-37%) and 25% (95% C.I 0-64%) respectively. With low heterogeneity both were suitable to be considered to have been conducted under similar conditions with possibility of using fixed effect model. The percentage of Grade 5 VUR was significantly higher (p = 0.001; X 2) in TVUR (11.9%) compared to LEVUR (2.2%). The proportion of bilateral reimplantation was significantly higher (p = 0.001; X 2) in TVUR compared to LEVUR (summary table). The success rate of LEVUR was significantly higher at 96.7% compared to TVUR at 93.7% (p = 0.007 X 2). Unilateral/Bilateral TVUR took significantly longer duration of surgery (155/194 min vs 107/161 min) compared to LEVUR (p = 0.001; Fishers). The mean (s.d) time to discharge was longer at 3.2 (1.6) days for TVUR compared to 1.6 (0.4) days for LEVUR (p = 0.001; Fishers). The complication rate was comparable, 7.35% for TVUR and 5.35% for LEVUR (p = 0.167; X 2).

DISCUSSION

In this meta-analysis we found that LEVUR had shorter operating time, higher success, and shorter hospital stay compared to TVUR. A probable explanation could be higher number unilateral VURs and lower number of grade 5 VUR cases in LEVUR group. Both the techniques had comparable overall complication rate: LEVUR had more post-operative urinary retention while TVUR had more port-related problems.

Pneumovesicoscopic bladder tumor resection in a young boy whose urethra was too small to use a resectoscope

OBJECTIVE

To describe our experience with pneumovesicoscopic bladder tumor resection in a young boy whose urethra was too small to use a resectoscope.

METHODS

An 11-year-old boy presented with gross hematuria. The patient was found to have a 2 cm-sized bladder tumor on ultrasound. The patient's urethra was too small to use a pediatric resectoscope, making it impossible to perform a transurethral resection of the bladder tumor. Therefore, pneumovesicoscopic bladder tumor resection was performed. En-bloc resection was performed successfully using 3 mm laparoscopic instruments, and the tumor was safely retrieved within an endo-bag made with a surgical glove.

RESULTS

On postoperative day 1, the Foley catheter was removed and the patient was discharged. The pathology report described bladder papillary urothelial carcinoma, grade II/III without lamina propria invasion. The patient underwent follow-up with ultrasonography and urine cytology every three to six months. There was no recurrence for 21 months after surgery.

CONCLUSION

This video demonstrates a pneumovesicoscopic approach for the treatment of bladder tumor in a young patient whose urethra was too small to use a resectoscope. Pneumovesicoscopic bladder tumor resection is technically feasible and safe.

Guidelines for the medical management of pediatric vesicoureteral reflux

Urinary tract infection is a bacterial infection that commonly occurs in children. Vesicoureteral reflux is a major underlying precursor condition of urinary tract infection, and an important disorder in the field of pediatric urology. Vesicoureteral reflux is sometimes diagnosed postnatally in infants with fetal hydronephrosis diagnosed antenatally. Opinions vary regarding the diagnosis and treatment of vesicoureteral reflux, and diagnostic procedures remain debatable. In terms of medical interventions, options include either follow‐up observation in the hope of possible spontaneous resolution of vesicoureteral reflux with growth/development or provision of continuous antibiotic prophylaxis based on patient characteristics (age, presence/absence of febrile urinary tract infection, lower urinary tract dysfunction and constipation). Furthermore, there are various surgical procedures with different indications and rationales. These guidelines, formulated and issued by the Japanese Society of Pediatric Urology to assist medical management of pediatric vesicoureteral reflux, cover the following: epidemiology, clinical practice algorithm for vesicoureteral reflux, syndromes (dysuria with vesicoureteral reflux, and bladder and rectal dysfunction with vesicoureteral reflux), diagnosis, treatment (medical and surgical), secondary vesicoureteral reflux, long‐term prognosis and reflux nephropathy. They also provide the definition of bladder and bowel dysfunction, previously unavailable despite their close association with vesicoureteral reflux, and show the usefulness of diagnostic tests, continuous antibiotic prophylaxis and surgical intervention using site markings.

Robotic Ureteral Reimplantation

Minimally invasive techniques have gained popularity in pediatric surgery. Among these, is the robotic approach for ureteral reimplantation in children with vesico-ureteral reflux. We describe main indications of this surgery, our surgical technique as well as trouble shooting of anatomical variants and the post-operative management. We also provide a description of other techniques described in the literature and a brief review of outcomes of published series.

A Novel Technique for Bladder Wall Fixation in Pneumovesicoscopic Surgery: T-Bar

Background: As a relatively new approach, popularity of pneumovesicoscopic surgery is increasing, but slower than expected due to complex nature of the procedure with efforts to overcome the difficult steps of the procedure. Bladder fixation is one of the crucial steps of the procedure. In this study, we present a novel and simple T-bar technique to overcome this difficulty. Methods: We retrospectively evaluated 24 consecutive patients (39 ureters) who underwent pneumovesicoscopic surgery with fixation of the bladder wall between December 2017 and September 2019. Results: Fixation by transabdominal suture (TS) was performed in 3 patients, while fixation by thread loops with needle in 3 and T-bar device in 18. Tearing of the bladder wall was encountered in 2 patients in TS, in 2 patients with thread loop groups, but none in the T-bar group. Conversion to open surgery was necessary in 3 patients in the T-bar group, but only 1 was related with the fixation technique. Conclusions: T-bar technique is an inexpensive and simple solution providing stable and reliable bladder wall and working port fixation during pneumovesicoscopy.

Comparison of open and pneumovesical approaches for Politano-Leadbetter ureteric reimplantation: a single-center long-term follow-up study

PURPOSE

To report our experience with the laparoscopic pneumovesical approach for Politano-Leadbetter ureteric reimplantation and to compare the results to those obtained using a traditional open approach.

METHODS

We retrospectively reviewed the medical records of 52 patients who underwent Politano-Leadbetter ureteral reimplantation between 2012 and 2017. The peri-operative parameters, postoperative outcomes, and complication rates of patients who underwent the open approach for the Politano-Leadbetter procedure and those who underwent the laparoscopic pneumovesical approach were compared.

RESULTS

During the study period, 52 ureteric reimplantation procedures were analyzed. Among these, 28 and 24 patients underwent surgery using the open and pneumovesical approaches, respectively. The mean operative time did not differ between the groups (143.64 min vs. 128.12 min, P = 0.092). However, the pneumovesical group had a shorter duration of hospital stay (5.08 days vs 7.43 days, P = 0.001) and required less morphine analgesic for pain than did the open group (7.7% vs 32.1%, P = 0.027). No significant differences in the success rates (94.9% vs 92.5%, P = 0.512) or procedure-related complications were noted between the pneumovesical and open techniques.

CONCLUSIONS

The transvesicoscopic Politano-Leadbetter technique with pneumovesicum is safe and effective for ureteric reimplantation and is comparable to the open approach.

Transvesicoscopic Politano-Leadbetter ureteral reimplantation in children with vesicoureteral reflux: A novel surgical technique

Purpose

We introduce our novel procedure for transvesicoscopic ureteral reimplantation using the Politano-Leadbetter technique (TVUR-PL). We describe the detailed surgical procedure and report operative outcomes.

Materials and Methods

We report a retrospective analysis of operative outcomes of TVUR-PL performed in children with vesicoureteral reflux (VUR) from January 2017 to July 2018. The analyzed operative outcomes included patient demographics, operative times, intra- and postoperative complications, indwelling duration of urethral Foley catheter, hospital length of stay, and treatment success.

Results

A total of 47 patients (17 males, 30 females) underwent TVUR-PL during the study period, including 18 unilateral and 29 bilateral cases (76 ureters). All operations were successfully completed without open conversion. The median operative time was 121 minutes for unilateral cases and 178 minutes for bilateral cases. The median duration of placement of a urethral Foley catheter was 2 days. There were no intra- or postoperative complications. Only one patient (1/47 patients, 2.1%), who had no postoperative VUR on voiding cystourethrography, experienced febrile urinary tract infection during the follow-up period.

Conclusions

Our novel TVUR-PL technique is a safe and effective minimally invasive surgical treatment option for children with VUR. The main advantage of our new operation is that it allows us to maintain the natural direction of the ureter after surgery.

Vesicoscopic cross-trigonal ureteral reimplantation: High success rate for elimination of primary reflux

INTRODUCTION

Open ureteral reimplantation (UR) is the gold standard for the surgical management of vesicoureteral reflux (VUR). There have been increasing reports on robot-assisted UR, but this approach remains controversial due to reports suggesting increased complications and reduced success compared with open repair. This study presented extensive experience with vesicoscopic ureteral reimplantation (VR) for primary reflux. In this procedure, cross-trigonal reimplantation was performed in a manner analogous to open repair under carbon dioxide 'pneumovesicum'.

OBJECTIVE

To review outcomes of vesicoscopic cross-trigonal ureteral reimplantation and compare them with other minimally invasive approaches for the correction of reflux.

STUDY DESIGN

All patients who underwent VR at the current institution were retrospectively reviewed. The following were recorded for each patient: age, sex, grade of reflux, operative time, outcome, and complications.

RESULTS

The series consisted of 182 consecutive patients who underwent VR. There were 165 girls and 17 boys. Mean age was 7.03 years (range 16 months-38.2 years). Fifteen had failed prior injection therapy. Of the 182 patients, 135 underwent bilateral repairs and 47 unilateral. Mean operative time for bilateral repairs was 197 (112-284) minutes and 169 (99-288) for unilateral. Major complications included two ureteral obstructions: one resolved with stent placement and the other underwent re-operative reimplantation. Postoperative voiding cystourethrogram (VCUG) was obtained in 100 patients and was normal in 93 (93%). Four of these failures occurred in the first 30 patients. Of the last 49 patients tested, 48 were normal, suggesting a 98% effective success rate after the learning curve.

DISCUSSION

Vesicoscopic ureteral reimplantation is an approach that completely recreates all aspects of open cross-trigonal repair. Complications were uncommon and success rates were very high in the current study.

CONCLUSIONS

Vesicoscopic ureteral reimplantation is a minimally invasive procedure for the definitive repair of primary reflux. After the learning curve at the current institution, success rates were found to be equivalent to open repair and were higher than published reports of robot-assisted procedures.

Laparoscopic Approach for Intravesical Surgery Using Pneumovesicum in Urology: Literature Review

Minimally invasive laparoscopic surgical procedures are increasingly being used in the management of various urological diseases. In particular, the laparoscopic approach for intravesical surgery using pneumovesicum (LPV) is a minimally invasive alternative with potential advantages including decreased morbidity, shorter hospital stays, and improved cosmesis. We review the applications of LPV in urology, summarize data for different surgical approaches, and provide an overview of patient management, as well as other considerations. This narrative review focused primarily on articles indexed in PubMed, Google Scholar, Scopus, and Embase databases. No formal search strategy was used, and no meta-analysis of data was performed.

Incidence of ureterovesical obstruction and Cohen antireflux surgery after Deflux® treatment for vesicoureteric reflux

AIM

The purpose of this study was to determine the incidence of ureteric obstruction (UB) and requirement for Cohen antireflux surgery (CAS) after Deflux^Ⓡ treatment (DT) for vesicoureteric reflux (VUR).

METHODS

Between 2011 and 2017, 494 ureters (VUR severity ≤ grade III: N=291 or >grade IV: N=203) were treated by DT at a mean age of 4.5 (range: 0.2-24) years. Epidural Catheter Assistance (ECA) was used to exclude UB by injecting diluted indigo carmine solution (1-3mL) into an epidural catheter inserted into a ureter after DT and confirming dye flow within 15min. ECA+: N=181 ureters; ECA-: N=313 ureters.

RESULTS

In ECA+, UB was detected in 5/181 (2.7%) ureters (grade II: N=1, III: N=3, and IV: N=1) treated by leaving the ECA catheter in situ overnight (N=4) or double J stent (DJS) insertion for 1month (N=2). After mean follow-up of 1.9years, one grade III DJS case has residual grade II VUR. In ECA-, 3/313 (0.9%) cases developed UB. One resolved, and one required DJS. CAS was required for 17/494 (3.4%) ureters and hindered by DT in 5/17 (29.4%) ureters. All are sequelae-free after mean follow-up of 1.8years.

CONCLUSIONS

UB may be more frequent than reported (3.3% versus 0.6%-1.8%). ECA identifies potential UB.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Lessons learned over a decade of pediatric robotic ureteral reimplantation

The da Vinci robotic system has improved surgeon dexterity, ergonomics, and visualization to allow for a minimally invasive option for complex reconstructive procedures in children. Over the past decade, robot-assisted laparoscopic ureteral reimplantation (RALUR) has become a viable minimally invasive surgical option for pediatric vesicoureteral reflux (VUR). However, higher-than-expected complication rates and suboptimal reflux resolution rates at some centers have also been reported. The heterogeneity of surgical outcomes may arise from the inherent and underestimated complexity of the RALUR procedure that may justify its reclassification as a complex reconstructive procedure and especially for robotic surgeons early in their learning curve. Currently, no consensus exists on the role of RALUR for the surgical management of VUR. High success rates and low major complication rates are the expected norm for the current gold standard surgical option of open ureteral reimplantation. Similar to how robot-assisted laparoscopic surgery has gradually replaced open surgery as the most utilized option for prostatectomy in prostate cancer patients, RALUR may become a higher utilized surgical option in children with VUR if the adoption of standardized surgical techniques that have been associated with optimal outcomes can be adopted during the second decade of RALUR. A future standard of RALUR for children with VUR whose parents seek a minimally invasive surgical option can arise if widespread achievement of high success rates and low major complication rates can be obtained, similar to the replacement of open surgery with robot-assisted laparoscopic radical prostectomy as the new strandard for men with prostate cancer.

Initial experiences of laparoscopic intravesical detrusorraphy using the Politano-Leadbetter technique

INTRODUCTION

Minimally invasive laparoscopic surgical procedures are increasingly being used for the management of vesicoureteral reflux.

OBJECTIVE

We present our experience of the laparoscopic Politano-Leadbetter technique performed under pneumovesicum conditions, which allows an orthotopic ureteral location after vesicoureteral reflux correction. Our procedure recreates the new ureteric orifice in a normal anatomical position with potential less morbidity and better cosmesis.

STUDY DESIGN

Our series comprises ten cases. The three 5 mm ports were introduced through bladder wall under cystoscopic vision. A 5-0 monofilament traction suture was used and dissection was carried out. After the ureteral mobilization, the location of the new hiatus was selected in a straight line superior to the original orifice. Dissection of the submucosal tunnel was started from the new hiatus and advanced to the original hiatus and the ureter was gently drawn passed through the tunnel. The ureter was rolled up and muscle fibers were incised until ureter could freely move from the base of the new hiatus. Finally, after spatulation of the terminal part of the ureter, ureterovesical anastomosis was performed with intracorporeal suturing using 5-0 monofilament sutures.

RESULTS

The average operative time was 125 min, with an average of 93 min for unilateral and 133 min for bilateral reimplantation. Blood loss was minimal and drains were used selectively. Removal of urethral catheter was decided empirically after hematuria stopped. Mean catheterization time was 5.1 days. The mean postoperative hospital stay was 6.2 days.

DISCUSSION

This study had limitations: the small number of cases, follow-up period is relatively short and data on the pre-operative bladder capacity, catheter-related morbidity, pain control and cosmesis are lacking. But most cases showed positive clinical results including acceptable operating time and good resolution rate with minimal complication. Our Politano-Leadbetter transvesicoscopic ureteric reimplantation is safe and useful in the resolution of VUR, even though the laparoscopic ureteric reimplantation is technically demanding even for experienced pediatric surgeons. Considering the main advantages of endoscopic surgery, our new vesicoscopic technique could be an optional treatment to the open reimplantation and has merits because whole the procedure are performed within the bladder, so there is no risk of intraperitoneal organ injury.

CONCLUSION

Though the role of this new technique in the treatment of VUR remains to be determined, the technique could be an optional treatment to replace other surgical methods as a less invasive and effective therapeutic method.

Retrospective study to determine the short-term outcomes of a modified pneumovesical Glenn-Anderson procedure for treating primary obstructing megaureter

INTRODUCTION

Primary obstructive ureter (POM) is an upper urinary tract malformation in children. Transvesicoscopic ureteral reimplantation is increasingly being used as the first choice to correct POM, replacing the open extravesical approach. Although several procedures have been reported, there is no universally accepted technique for endoscopic ureteral reimplantation.

OBJECTIVE

To report on several modifications of the Glenn-Anderson ureteral advancement technique to make it suitable for a laparoscopic pneumovesical approach to treatment of POM.

PATIENTS AND METHODS

From February 2006 to December 2013, 63 children with POM, 45 male and 18 female (median age 4.2 years; range 2 months-14 years), underwent modified transvesicoscopic ureteral implantation surgery. The technique was modified by repositioning of the hiatus proximally to afford greater "tunnel" length, and use of a trough rather than a tunnel, avoiding the challenges of more adherent mucosa in the trigone. Ureter diameter was followed over a 12-month period post surgery. Voiding cystourethrography (VCUG), intravenous urogram (IVU), or radionuclide imaging were conducted in patients who still had ureteral dilation at 6 months and 12 months after surgery.

RESULTS

The procedure was successfully performed in 62/63 patients. The mean operating time was 105 min. Twelve months after surgery 90% of ureters were considered cured and 10% were considered improved. In patients who showed improvement ureters, the ureter diameter was significantly reduced from preoperative measurements as early as 1 month post surgery.

DISCUSSION

The Glenn-Anderson technique advances the ureteral orifice distal to the trigone near the bladder neck and allows relatively easy access to the upper urinary tract. However, the submucosal tunnel produced is relatively short, and the surgery is not recommended for patients with a small trigone or megaureter because of anatomical considerations. This study made two major modifications to the traditional Glenn-Anderson procedure: (1) the bladder wall was incised superiorolaterally to move the hiatus proximally along the course of the ureter and the detrusor muscle was sutured to the seromuscular layer of the ureter, and (2) a mucosal groove rather than tunnel was used for advancement from the ureteral hiatus to the bladder neck. This approach preserves conventional endourologic access to the upper tracts; however, the stabilizing distal stitch does leave the suture line in proximity to the mucosal suture line, a theoretical disadvantage from the standpoint of ureterovesical fistula.

CONCLUSIONS

These preliminary results indicate that this modified transvesicoscopic ureteral implantation is an effective procedure with minimal morbidity.

Vesicoscopic ureteral reimplant: is there a role in the age of robotics?

Vesicoscopic ureteral reimplantation is a challenging procedure to learn but does have outcomes equivalent to standard open repair. Children objectively have less pain than after an open cross-trigonal repair. Operative times compare favorably to other forms of minimally invasive surgery.

Carbon dioxide insufflation causes upper urinary tract injury in the early period of an experimental vesicoureteral reflux model

PURPOSE

Ureteral reimplantation via pneumovesicum is a new aspect of vesicoureteral reflux management. We aimed to determine the effects of carbon dioxide (CO2) insufflation on the upper urinary tract in an experimental model.

MATERIALS AND METHODS

Thirty New Zealand rabbits were allocated into five groups of six rabbits each. Right ureters were cannulated for CO2 insufflation in four groups. The pressures and durations of CO2 insufflation in the respective groups were as follows: Group A (10 mm Hg, 2 h); B (12 mm Hg, 2 h); C (10 mm Hg, 4 h); and D (12 mm Hg, 4 h) and control (E). Blood gas analysis, urea and creatinine levels were measured from renal veins and aorta. Histopathological evaluation of the renal parenchyma and ureters was scored.

RESULTS

Significant histopathological changes were detected in the ipsilateral ureter and renal parenchyma exposed to CO2 insufflation, predominantly observed in groups insufflated for longer durations, p < 0.05. Blood gases drawn separately from renal veins were significantly more acidotic, and serum urea and creatinine levels were increased in all the groups, p < 0.05.

CONCLUSIONS

CO2 causes significant histopathological and biochemical changes in the early period. Long-term results are required to determine whether permanent renal injury occurs.

Current surgical management of vesicoureteral reflux

Vesicoureteral reflux (VUR), a common congenital urinary tract anomaly, refers to retrograde flow of urine from the bladder into the upper urinary tract. The main goal in the treatment of pediatric VUR is to preserve renal function by preventing pyelonephritis. Many surgical management options are available for pediatric VUR. Open ureteral reimplantation has a high success rate but is invasive and is associated with postoperative pain and morbidity. Endoscopic therapy is minimally invasive but has the disadvantages of decreased short-term success and recurrence of reflux over the long term. Laparoscopic or robotic ureteral reimplantation has become increasingly popular owing to its effectiveness and minimal invasiveness, but long-term outcomes have yet to be documented. Urologists should make an effort to select the appropriate surgical strategy by taking into consideration the individual characteristics of the patient such as age, gender, grade of reflux at presentation, status of renal parenchyma, combined bladder and ureteral circumstances, functional status of the bladder and bowel, and preferences of the patients' family.

Vesicoscopic bladder neck procedure in children: what we have learned from the first series

OBJECTIVE

To assess the results of endoscopic bladder neck procedure on the anterior bladder wall in children.

MATERIALS AND METHODS

Surgery is done in the lithotomy position using three 5-mm ports. The bladder is insufflated with CO2. A U-shaped incision is made around the bladder neck. A mucosal strip is tabularized around a 12 French catheter and covered with the second layer of mucosa. Twenty procedures were performed on 18 patients (mean age, 9.8 years), and the follow-up period was >1 year (mean, 34 months). Mean operation time was 149 minutes. Twelve patients had neurogenic lower urinary tract dysfunction. Fifteen patients failed earlier bladder neck surgery, predominantly fascia sling suspension. Preoperatively, all patients had low detrusor leak point pressure. Clean intermittent catheterization (CIC) was resumed through the urethra in 11 patients and through a stoma in 6 patients.

RESULTS

Two patients needed conversion because of CO2 leakage. Six patients were dry, and 4 improved in the short term (3-6 months). After 1 year of follow-up, 2 patients were dry, and 6 improved. In the long term, 1 (9%) out of 11 patients who were catheterized through the urethra was dry, and 3 of the 11 patients (27%) improved. Of the 6 patients with a CIC stoma, 1 (17%) was dry, and 3 (50%) improved.

CONCLUSIONS

Endoscopic bladder neck surgery is, for most patients, a minor operation, but the long-term results are disappointing. The construction of a continent channel for CIC can improve the outcome when anterior bladder neck plasty is performed.

Observational, medical or surgical management of vesicoureteric reflux

The clinical management of vesicoureteric reflux includes observational, medical and surgical procedures. The choice of management is often a joint decision made between the paediatric nephrologist and urologist. The use of prophylactic antibiotics has become increasingly debated. In recent years, the surgical treatment of reflux (including endoscopic intervention or ureteral reimplantation) has mainly been limited to cases of high-grade reflux. There are several important risk factors that influence the final outcome which need to be identified and treated. The aim of reflux management is no longer to treat imperatively, but rather to avoid renal damage. It is perhaps time to revise the classic saying 'diagnosed reflux - treated reflux' with a new objective 'diagnosed reflux - evaluated reflux'.

CONCLUSION

The management and follow-up of childhood reflux is a joint decision between the paediatric urologist and nephrologist and should be decided on a case-by-case basis.

Robotic paediatric urology

What's known on the subject? and What does the study add? Robot assisted laparoscopic surgery (RALS) is slowly gaining acceptance in the field of paediatric urology. Accumulating data on safety and efficacy when performing paediatric robotic urologic procedures has led paediatric urologists to gradually embrace increasingly more complex reconstructive surgeries. Indeed, the unique and delicate movements generated by the robotic system make this technology ideal for children who often require reconstructive procedures. We critically review the current role of RALS in paediatric urology and to analyse the published data, with a special emphasis on the most common applications. We also propose a structured plan to expedite training and the surgical 'learning curve'.

OBJECTIVES

To critically review the current role of robot-assisted laparoscopic surgery (RALS) in paediatric urology and to analyse the published data, with a special emphasis on the most common applications. One of the greatest benefits of RALS has been the ability to truly spread the application of minimally invasive surgery to paediatric surgical patients. The unique attributes of the robotic interface make this technology ideal for children with congenital anomalies, who often require reconstructive procedures. We also propose a structured plan to expedite training and the surgical 'learning curve'.

PATIENTS AND METHODS

Currently, almost all urological surgical procedures in children have been performed with the assistance of the robotic interface. The most commonly performed procedures include pyeloplasty, nephrectomy/hemi-nephrectomy and surgery for vesico-ureteric reflux. Initial series of bladder augmentation and appendicovesicostomy are available.

RESULTS

Initial results with RALS are encouraging and have shown safety similar to open procedures, and outcomes at least equivalent to standard laparoscopy. Accumulating data have consistently shown that postoperative analgesia requirements and overall hospital stay are decreased. However, operative durations are significantly longer than their open counterparts, but this is decreasing as experience accumulates.

CONCLUSIONS

RALS is already part of paediatric urological surgery. Larger single-institution case series and comparative studies with the open approach and multi-institutional meta-analyses will help to identify the benefits of RALS in paediatric urology.

The evolving role of laparoscopic surgery in paediatric urology

OBJECTIVES

We review the various applications of laparoscopic and robotic-assisted laparoscopy in paediatric urology, as the laparoscopic and robotic approach in this population is gradually being recognised.

METHODS

We searched PubMed for human studies in English that were published between 1990 and the present, focusing on laparoscopic nephrectomies and partial nephrectomies, laparoscopic and robotic pyeloplasties and ureteric reimplantation, laparoscopic orchidopexy and varicocelectomy. We also reviewed robotic-assisted laparoscopic urological major reconstructions. Key articles were reviewed, extracting the indications, techniques, and the advantages and disadvantages.

RESULTS AND CONCLUSIONS

Laparoscopy has a defined place in modern paediatric urological surgery. Laparoscopic nephrectomies, pyeloplasties and abdominal exploration for the evaluation and management of impalpable undescended testicles have become the standard of care. Robotic-assisted laparoscopic surgery is developing as a safe and effective option even for infant patients.

Transvesicoscopic ureteral reimplantation in children with bilateral vesicoureteral reflux: surgical technique and results

OBJECTIVES

To report our initial experience with transvesicoscopic cross-trigonal ureteral reimplantation (TVUR), describing stepwise the surgical procedure and determining critical aspects of this surgery in the actual surgical field.

SUBJECTS AND METHODS

Between September 2008 and April 2010, 48 patients with bilateral vesicoureteral reflux (VUR) underwent TVUR. To identify the critical aspects affecting the surgical difficulty, we divided our TVUR procedure into four steps: TVUR set-up, mobilization of ureters, creation of submucosal tunnels, and ureterovesical anastomosis. To evaluate the evolution of our TVUR, we analyzed changes in the operative time and complications versus increase in surgeon experience (dividing our cases into three groups: the first third, the second third, and the last third). Changes in operative time for all four steps of TVUR were analyzed separately, as well as change in overall operative time.

RESULTS

Of a total of 48 cases, 45 patients underwent TVUR successfully except for 3 cases of open conversion. Among the 45 cases, the mean overall operative time was 155.6 min. In 1 patient, proximal migration of the ureteral catheter occurred. No other perioperative complications were observed. The mean postoperative hospital stay was 1.6 days. The VUR resolution rate was 96.4%. Upon analysis of our results by step, Step 4 (ureterovesical anastomosis) required the largest portion of the overall operative time in most cases. During the early period of our TVUR, we encountered several technical difficulties. However, the operative times for all four steps were stabilized with increasing number of cases, without deteriorating surgical outcomes.

CONCLUSIONS

Our report demonstrates that TVUR might potentially be a safe and effective alternative to open ureteral reimplantation in children with VUR, with a shorter learning curve than expected.

Transvesicoscopic cross-trigonal ureteroneocystostomy in children: a single-center experience

PURPOSE

To evaluate the safety and efficacy of transvesicoscopic ureteric reimplantation in children.

PATIENTS AND METHODS

Seventeen ureteric units in 11 patients underwent a transvesicoscopic 'Cohen' ureteroneocystostomy in 2003-2007 and the results were retrospectively analyzed. There were four boys and seven girls. All patients had vesicoureteric reflux (VUR), except for one with paraostial diverticula. Six patients underwent bilateral and five unilateral transvesicoscopic reimplantation (a total of 17 units).

RESULTS

The procedure was successfully completed in all patients. Mean operation time was 217 min in unilateral cases and 306 min in bilateral cases without perioperative complications, except for pneumoperitoneum development in two cases. In the early postoperative period, two patients developed macroscopic hematuria. Mean hospital stay was 3.8 days (3-5 days), except for one patient who suffered from urinary tract infection and needed longer hospitalization. Mean follow-up period was 4.5 years (3-7 years). One patient with bilateral VUR had passive unilateral grade I VUR on postoperative cystogram, giving a success rate of 91% (94% of ureters). This patient was followed conservatively. One patient had recurrent urinary tract infections without reflux.

CONCLUSION

Transvesicoscopic cross-trigonal ureteroneocystostomy can be safely performed with a high success rate in children.

Pediatric laparoscopic and robot-assisted laparoscopic surgery: technical considerations

Laparoscopy has become an effective modality for the treatment of many pediatric urologic conditions that need both extirpative and reconstructive techniques. Laparoscopic procedures for urologic diseases in children, such as pyeloplasty, orchiopexy, nephrectomy, and bladder augmentation, have proven to be safe and effective with outcomes comparable to those of open techniques. Given the steep learning curve and technical difficulty of laparoscopic surgery, robot-assisted laparoscopic surgery (RAS) is increasingly being adopted in pediatric patients worldwide. Anything that can be performed laparoscopically in adults can be extended into pediatric practice with minor technical refinements. We review the role of laparoscopic and RAS in pediatric urology and provide technical considerations necessary to perform minimally invasive surgery successfully.

A new technique for retrograde flexible ureteroscopy after Cohen cross-trigonal ureteral reimplantation

PURPOSE

Retrograde ureteral access after cross-trigonal ureteral reimplantation can be challenging. We present our experience with retrograde ureteral catheterization and flexible ureteroscopy after Cohen cross-trigonal reimplantation in patients presenting with ureteral stones.

MATERIALS AND METHODS

Cystoscopy is performed and a Tiemann ureteral catheter is inserted into the involved ureteral orifice. A retrograde ureterography is performed and hydrophilic guide wire is passed up to the kidney. A dual-lumen ureteral access sheath is then passed under x-ray control underneath the ureteral stone. The flexible ureterorenoscope is passed under x-ray control up to the stone which is then fragmented with a holmium laser.

RESULTS

From June 2006 to June 2010, this technique was successful in 8 patients without acute or delayed sequelae.

CONCLUSIONS

Where the endourological expertise is readily available, the ureter can be accessed retrogradely even after Cohen cross-trigonal ureteral reimplantation in a safe, straightforward and effective modality.

The utilization of stents in the management of primary obstructive megaureters requiring intervention before 1 year of age

OBJECTIVE

To analyse the long-term outcome of 16 infants with primary obstructive megaureter managed by (endoscopic or open) stenting over a 10-year period.

METHODS

A retrospective case-note and imaging review was performed between 1997 and 2007. Data are presented as medians (range) and were compared using the Mann-Whitney test.

RESULTS

Sixteen infants with 19 obstructed megaureters were stented at a median age of 24 weeks, for a median of 6 months. One-third of stents were inserted endoscopically. Complications (stent migration, stone formation or infection) occurred in 31.6%. One infant was excluded due to a co-existent pelviureteric junction obstruction. Drainage improved in 10 ureters (56%) following stent removal. Of the remaining renal units, 6 were reimplanted, and 2 underwent a nephrectomy due to deterioration in renal function following stent removal. Resolution of the vesicoureteric junction obstruction occurred in 4 of 6 infants following endoscopic stent insertion, and in 6 of 12 infants following open stent insertion (P=0.60). There was no difference in the length of time that ureters were stented in the resolved (7.5 (6-15) months) versus the reimplanted (6.0 (1-18) months) group (P=0.13).

CONCLUSIONS

Of obstructive megaureters managed by stenting for a median of 6 months, 56% did not require further surgery. However, morbidity occurred in one third of patients, and function deteriorated after removal of stent in two patients who later required a nephrectomy.

Single-surgeon experience with transvesicoscopic ureteral reimplantation in children with vesicoureteral reflux

OBJECTIVES

To review our initial experience with transvesicoscopic ureteral reimplantation (TVUR) in children with vesicoureteral reflux and to evaluate the learning curve for the feasibility and reproducibility of TVUR.

METHODS

TVUR was performed in 28 consecutive patients with a mean age of 6.0 years. Cohen's classic technique was reproduced using a laparoscopic technique with two 3-mm working ports and a 5-mm camera port.

RESULTS

TVUR was successfully completed in 26 patients. In 2 patients, TVUR was converted to open intravesical reimplantation. The postoperative vesicoureteral reflux resolution rate was 94.6% (35 of 37 ureters). The mean operative time for TVUR was 166 minutes for unilateral reimplantation and 189 minutes for bilateral reimplantation. When the operation times of the first 13 and the last 13 patients were compared, the mean operative time had decreased significantly for the last 13 patients compared to that for the first 13 patients (140 vs 220 minutes). The mean postoperative hospital stay was also significantly shorter for the last 13 patients than for the first 13 patients (1.08 vs 1.69 days).

CONCLUSIONS

TVUR is currently performed at only at a few centers because of the technical difficulties and the potentially steep learning curve. However, our results have indicated rapid improvement in the operative time within a short period, suggesting a shorter learning curve for TVUR than expected. TVUR is a reproducible procedure and is a reasonable option for the treatment of vesicoureteral reflux.

Laparoscopic extravesical transperitoneal approach following the lich-gregoir procedure in refluxing duplicated collecting systems: initial experience

INTRODUCTION

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Nephropathy with renal scarring is still the most concerning issue in VUR. Surgical correction to eliminate VUR is an important part of its management and this need is increasing for duplicated collecting systems (DCS). Laparoscopy may have a place in the treatment of VUR. We report our initial experience in the treatment of refluxing DCS by laparoscopic extravesical transperitoneal approach (LETA) following Lich-Gregoir technique. The aim of this study was to describe the evolution and evaluate the results and benefits of this technique.

MATERIALS AND METHODS

Between August 2007 and January 2010, 60 renal units in 43 children with VUR and deterioration of renal function on isotope renography were treated with LETA following the Lich-Gregoir procedure. Twelve patients had refluxing DCS in a lower polar system; three of them had bilateral VUR. Three cases of refluxing DCS were associated to obstruction. Two of them presented an ectopic ureterocele with adequate split renal function and another had an ectopic ureterocele with complete deterioration of upper polar renal function. Their mean age was 36 months (range: 15-80 months).

RESULTS

The mean surgical time was 90 minutes (38-140 minutes) in unilateral and 144 minutes (120-200 minutes) in bilateral VUR including cystoscopy. All procedures were successfully completed laparoscopically and the reflux was corrected in all patients. One-stage laparoscopic heminephroureterectomy with excision of ureterocele and ureteric reimplantation was done in 1 case, and ureterocele excision and ureteric reimplantation by LETA were done in 2 cases. The mean hospital stay was 27 hours. A cystogram was performed systematically in all patients at 45 days postoperatively; none of them presented recurrence of VUR. The follow-up period was 11 months (range: 2-24 months), without recurrence of VUR.

CONCLUSION

LETA following the Lich-Gregoir procedure in refluxing DCS is a safe and effective approach even in unilateral, bilateral simultaneous, and split renal function in duplicated systems. When refluxing DCS is associated with obstruction and total deterioration of upper polar function, heminephroureterectomy with excision of ureterocele and ureteric reimplantation can be safely and effectively performed in a single-stage laparoscopic procedure, which minimizes the hazards of traditional open surgical reconstruction. A shorter hospital stay, decreased postoperative discomfort, reduced recovery period, and a low morbidity to resolve VUR in DCS are the benefits of this technique, with success rates similar to the open technique.