Retrograde ureteral access after cross-trigonal ureteral reimplantation: A straightforward technique

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.

Successful percutaneous flexible ureteroscopy for treatment of distal ureteral stones under modified Valdivia position after Cohen reimplantation

Introduction

Endoscopic retrograde access to the upper urinary tract after Cohen reimplantation for the treatment of vesicoureteral reflux in children is usually difficult.

Case presentation

We experienced a case involving a few large ureteral stones in the right distal ureter after Cohen reimplantation. We initially failed retrograde access using flexible cystoscope. Therefore, we performed antegrade flexible ureteroscopy through the 10- to 12-Fr access sheath from the middle calyx to treat the few ureteral stones (>1.5 cm) in the right ureter with the patient in the modified Valdivia position. This one-stage procedure was successful. The patient achieved a stone-free status without major complications.

Conclusion

The herein-described approach that was implemented after Cohen reimplantation was successful. We believe that recent endourologic developments contributed to the good outcome in this case.

A Simple and Novel Method to Attain Retrograde Ureteral Access after Previous Cohen Cross-Trigonal Ureteral Reimplantation

Objective

To describe a simple, novel method to achieve ureteric access in the Cohen crossed reimplanted ureter, which will allow retrograde working access via the conventional transurethral method.

Materials and Methods

Under cystoscopic vision, suprapubic needle puncture was performed. The needle was directed (bevel facing) towards the desired ureteric orifice (UO). A guidewire (with a floppy-tip) was then inserted into the suprapubic needle passing into the bladder, and then easily passed into the crossed-reimplanted UO. The distal end of the guidewire was then removed through the urethra with cystoscopic grasping forceps. The straightened ureter then easily facilitated ureteroscopy access, retrograde pyelogram studies, and JJ stent insertion in a conventional transurethral method.

Results

The UO and ureter were aligned in a more conventional orthotopic course, to allow for conventional transurethral working access.

Conclusion

A novel method to access the Cohen crossed reimplanted ureter was described. All previously published methods of accessing the crossed ureter were critically appraised.

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.