Ureteral reimplantation for vesicoureteral reflux: comparison of minimally invasive extravesical with transvesical and conventional extravesical techniques

Extravesical vs. intravesical ureteric reimplantation for primary vesicoureteral reflux: A systematic review and meta-analysis

PURPOSE

This study aims to compare the outcomes of extravesical (EVUR) and intravesical (IVUR) ureteric reimplantation for primary vesicoureteral reflux (VUR) via systematic review and meta-analysis.

METHODS

Literature review from Medline, Embase, and Cochrane since inception to March 2022 was performed. Meta-analysis was conducted on eligible randomized controlled trials (RCT) and observational cohort studies (OCS) comparing outcomes between EVUR and IVUR.

RESULTS

Twelve studies were included, comprising 577 patients (778 ureters) operated by EVUR and 395 patients (635 ureters) by IVUR. Pre-operative VUR grade, postoperative VUR persistence and hydronephrosis was not statistically significant. EVUR had shorter operative time [mean differences (MD) -22.91 min; 95% confidence interval (CI), -44.53 to -1.30, P = 0.04] and hospital stay (MD -2.09 days; 95% CI, -2.82 to -1.36, P < 0.00001) compared to IVUR. Bilateral EVUR had higher risk of postoperative acute urinary retention (ARU) (8.1%) compared to bilateral IVUR (1.7%) (OR = 4.40; 95% CI, 1.33-14.58, P = 0.02). No patient undergoing unilateral EVUR or IVUR experienced ARU.

CONCLUSION

Both EVUR and IVUR are equally effective in correcting primary VUR. Operative time and hospital stay are shorter after EVUR compared to IVUR. However, bilateral EVUR is associated with higher risk of postoperative ARU.

Comparison of Cohen and Lich-Gregoir ureteral reimplantation in the surgical management of primary unilateral vesicoureteral reflux in children

OBJECTIVE

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Various intravesical and extravesical techniques have been described for the surgical correction of VUR. The aim of our study was to compare the results of open intravesical and extravesical procedures for unilateral primary VUR in children.

METHODS

Between January 2012 and August 2018, 38 children with primary VUR who underwent open ureteral reimplantation surgery were retrospectively reviewed. The Cohen (intravesical) and the Lich-Gregoir (extravesical) approach were grouped as groups A and B, respectively. The groups were compared for age, gender, preoperative reflux grade, presence of lower urinary tract symptoms, operation time, discomfort and pain, analgesic requirements, duration of hematuria, postoperative complications, and hospital stay. All the parameters were statistically compared.

RESULTS

There were 38 patients in this study. Group A had 18 patients, and group B had 20 patients. The mean operative time was significantly shorter in group B than in group A. The mean hospital stay was also shorter in group B. The urethral foley stay period was 4.7±0.9 days 2±0 days (p = 0.000*), respectively, for group A and B. Macroscopic hematuria was seen in group A. The objective pain scale was worse after intravesical surgery. Analgesic requirements were higher in group A (p =0.131).

CONCLUSION

Intravesical and extravesical ureteroneocystostomy methods are equally successful and feasible in the treatment of primary unilateral VUR. The Cohen technique is associated with a longer and more painful hospital stay, gross hematuria, and longer operative time, compared to the Lich-Gregoir technique.

Comparison of intravesical (Cohen) and extravesical (Lich-Gregoir) ureteroneocystostomy in the treatment of unilateral primary vesicoureteric reflux in children

INTRODUCTION

Various intravesical and extravesical techniques have been described for the surgical correction of vesicoureteral reflux (VUR). Among those techniques Cohen (intra-vesical) and Lich-Gregoir (extra-vesical) are the most commonly used ones. However, there are limited studies that compare those two surgical techniques in the literature.

OBJECTIVE

In this study, we aim to compare the outcomes of the open intravesical and extravesical procedures for unilateral primary VUR in children.

METHODS

We analyzed the records of 118 consecutive children with primary VUR who underwent open ureteral reimplantation surgery by single surgeon from January 2011 to October 2015 at our institution. Among them, intravesical reimplantation was group A, and extravesical reimplantation procedure was group B. We retrospectively analyzed the clinical data of both groups, including age, sex, preoperative reflux grade, presence of lower urinary tract symptoms (LUTS), operative time, postoperative complications and hospitalization period. Success of surgery was defined as the resolution of the VUR as determined by voiding cystourethrography 6 -12 months after surgery. All the parameters were statistically compared.

RESULTS

A total of 58 patients were found eligible for the study. In 23 cases intravesical (group A) and in 35 cases extravesical (group B) procedure were performed. The operative time in group A was significantly higher than group B (110.3±16.9 and 87±29.8 min, respectively, p = 0.002). The mean hospital stay was also longer in group A (2.8±0.8 and 1.2±0.6 days, respectively, p = 0.007). The ureteral catheterization periods were 14.1±6.1 days for group A and there was no ureteral catheter placement in group B. The success rate of the two groups were comparable (100% vs 94.9%, p = 0.513). No intraoperative complications were detected in either group. The number of febrile urinary tract infections were similar between the groups after a mean follow up of 18.2 months (p = 0.746).

DISCUSSION

Our results confirmed that both Cohen and Lich-Gregoir procedures had equivalent success and complication rates. Lich-Gregoir technique was found superior to Cohen technique in terms of hospital stay and operative time. Moreover, it avoids the necessity of urethral and ureteral stenting which probably might increase the comfort of the patients postoperatively. The main limitations of our study are unrecorded pain scores and amount of analgesics taken the after surgery and retrospective analysis of the data.

CONCLUSION

Both the open intravesical and extravesical ureteroneocystostomy procedures are equally effective in the treatment of primary unilateral VUR. Any of the techniques can be opted by the surgeons depending on their surgical experience.

Robot-assisted extravesical ureteral reimplantation (revur) for unilateral vesico-ureteral reflux in children: results of a multicentric international survey

PURPOSE

This multicentric international retrospective study aimed to report the outcome of robot-assisted extravesical ureteral reimplantation (REVUR) in patients with unilateral vesico-ureteral reflux (VUR).

METHODS

The medical records of 55 patients (35 girls, 20 boys) underwent REVUR in four international centers of pediatric robotic surgery for primary unilateral VUR were retrospectively reviewed. Patients' average age was 4.9 years. The preoperative grade of reflux was III in 12.7%, IV in 47.3% and V in 40%. Twenty-six patients (47.3%) presented a loss of renal function preoperatively and 10 (18.1%) had a duplex system.

RESULTS

Average robot docking time was 16.2 min (range 5-30). Average total operative time was 92.2 min (range 50-170). No conversions or intra-operative complications were recorded. All patients had a bladder Foley catheter for 24 h post-operatively. Average hospital stay was 2 days (range 1-3). Average follow-up length was 28 months (range 9-60). We recorded three (5.4%) postoperative complications: 1 small urinoma resolved spontaneously (II Clavien) and 2 persistent reflux, only one requiring redo-surgery using endoscopic injection (IIIb Clavien).

CONCLUSION

REVUR is a safe and effective technique for treatment of primary unilateral VUR. The procedure is easy and fast to perform thanks to the 6° of freedom of robotic arms. The learning curve is short and it is useful to begin the robotics experience with a surgeon expert in robotic surgery as proctor on the 2nd robot console. The high cost and the diameter of instruments remain the main challenges of robotics applications in pediatric urology.

Prolonged urinary retention can and does occur after any type of ureteral reimplantantion

OBJECTIVE

Transient urinary retention has been recognized as a complication of bilateral ureteroneocystostomy (UNC), when performed extravesically. The objective of this study was to review a collective surgeons' experiences of unilateral extra- and unilateral and/or bilateral intra-vesical ureteral reimplanation, where urinary retention greater than 6 weeks, or what we have termed, "prolonged urinary retention" (PUR), occurred.

MATERIALS AND METHODS

We retrospectively reviewed charts to identify PUR after any open or robotic reimplant, other than bilateral extravesical, between 1998 and 2015 as reported by five surgeons.

RESULTS

During the review period, ten cases were documented where PUR was encountered. Bilateral Cohen reimplants (5), unilateral extravesical open reimplant with ureteral tapering (3), unilateral Cohen reimplant (1) and unilateral extravesical robotic reimplant with tapering (1) were associated with PUR. Younger males predominated (70%). The mean age at operation of the patients was 3.1 years. Eventually 7/10 patients were able to void normally, with periods ranging from 6 weeks to 8 years. The remaining three patients are still unable to void more than 5 years after UNC. A majority of the samples (6/10) were suspected to have bowel and bladder dysfunction (BBD), but neurologically all were normal.

CONCLUSION

PUR can occur as a potential complication following any type of UNC and is associated with the risk of significant morbidity, including permanent urinary retention. Patients and caregivers should be counseled accordingly.

Unilateral extravesical ureteral reimplantation via inguinal incision for the correction of vesicoureteral reflux: a 10-year experience

Introduction and Objective:

Multiple options exist for the surgical management of vesicoureteral reflux (VUR). We report on our 10-year experience using the inguinal approach to extravesical ureteral reimplantation (EVR).

Materials and Methods:

Patient characteristics of age, gender, and reflux grade were obtained and outcomes of operative time, hospital stay, and radiographic resolution were assessed.

Results:

71 girls and 20 boys with a mean age of 74 months (range 14-164) underwent inguinal EVR via a 3.5-cm inguinal mini-incision. Mean follow up was 10.9 months (range 0.4-69.7). Average grade of reflux was 2.80. Average operative time was 91 minutes (range 51-268). The procedure was successful in 87 of 91 patients (95.6%). The 3 cases of reflux that persisted were all grade 1 and managed expectantly. Contralateral reflux developed in 9 cases, all of which resolved after treatment with either Deflux or ureteral reimplant. There were 4 case of urinary retention that resolved after a brief period of CIC or indwelling catheterization. There were no cases of ureteral obstruction. Most patients were discharged on post-operative day 1 (85/91) and no hospitalization extended beyond 3 days.

Conclusions:

The inguinal approach to extravesical ureteral reimplantation should be considered as a potentially minimally invasive alternative to endoscopic and robotic treatment of VUR with a success rate more comparable to traditional open approaches. We feel it is the method of choice in cases of unilateral VUR requiring surgical correction.

Extravesical (modified Gregoir Lich) versus intravesical (Cohen's) ureteric reimplantation for vesicoureteral reflux in children: A single center experience

INTRODUCTION

There are multiple techniques for surgical correction of vesicoureteral reflux (VUR). We compared the outcomes of extravesical versus Cohen's reimplantation for VUR in children.

METHODS

Records of all children (n = 118) who underwent reimplantation for VUR between 2003 and 2014 were analyzed (male: female = 43:75). Children with secondary VUR, duplication anomalies, and ectopic ureter were excluded from our study. Extravesical reimplantation (EVR) was performed bilateral in 32 children (Group 1a) and unilateral in 19 (Group 1b), while bilateral Cohen's reimplantation was performed in 67 (Group 2). Parameters compared were length of the surgical procedure, average duration of stay in the hospital, postoperative bladder spasms, significant hematuria >72 h, and long-term complications.

RESULTS

The mean age at operation was 15 months in Group 1, and 36 months in Group 2. The mean duration of surgery was significantly less (P = 0.0001) in Group 1a (n = 32; mean 104 min; standard deviation [SD] 18 min) compared to Group 2 (n = 67; mean 128 min; SD 15 min). The mean (SD) postoperative stay was significantly lower (P = 0.0001) at 4.5 (1.5) days in Group 1a compared to 6.5 (0.5) days in Group 2. Postoperative bladder spasms were significantly lower (P = 0.03) at 10/32 in Group 1a compared to 37/67 in Group 2. All patients responded well with anticholinergics. Postoperative hematuria and bladder spasms were significantly lower (P = 0.03) in Group 1a compared to Group 2. There was no significant difference in persistent VUR between Group 1 and Group 2. At 1 year follow, none of them had any evidence of ureteral obstruction.

CONCLUSIONS

EVR has lower operative time, less postoperative discomfort and shorter hospital stay compared to Cohen's reimplantation. Both techniques are equally effective in treating reflux.

Ureteroneocystostomy in primary vesicoureteral reflux: critical retrospective analysis of factors affecting the postoperative urinary tract infection rates

INTRODUCTION

To determine the parameters affecting the outcome of ureteroneocystostomy (UNC) procedure for vesicoureteral reflux (VUR).

MATERIALS AND METHODS

Data of 398 patients who underwent UNC procedure from 2001 to 2012 were analyzed retrospectively. Different UNC techniques were used according to laterality of reflux and ureteral orifice configuration. Effects of several parameters on outcome were examined. Disappearance of reflux on control VCUG or absence of any kind of UTI/symptoms in patients without control VCUG was considered as clinical improvement.

RESULTS

Mean age at operation was 59.2 ± 39.8 months and follow-up was 25.6 ± 23.3 months. Grade of VUR was 1-2, 3 and 4-5 in 17, 79, 302 patients, respectively. Male to female ratio was 163/235. UNC was performed bilaterally in 235 patients and intravesical approach was used in 373 patients. The frequency of voiding dysfunction, scar on preoperative DMSA, breakthrough infection and previous surgery was 28.4%, 70.7%, 49.3% and 22.4%, respectively. Twelve patients (8.9%) with postoperative contralateral reflux were excluded from the analysis. Overall clinical improvement rate for UNC was 92%. Gender, age at diagnosis and operation, laterality and grade of reflux, mode of presentation, breakthrough infections (BTI) under antibiotic prophylaxis, presence of voiding dysfunction and renal scar, and operation technique did not affect the surgical outcome. However, the clinical improvement rate was lower in patients with a history of previous endoscopic intervention (83.9% vs. 94%). Postoperative UTI rate was 27.2% and factors affecting the occurrence of postoperative UTI were previous failed endoscopic injection on univariate analysis and gender, preoperative BTI, postoperative VUR state, voiding dysfunction on multivariate analysis. Surgery related complication rate was 2% (8/398). These were all low grade complications (blood transfusion in 1, hematoma under incision in 3 and prolonged hospitalization secondary to UTI in 4 patients). In long term, 12 patients are under nephrologic follow-up because of hypertension in 5, increased serum creatinine in 5, proteinuria in 1 and hematuria in 1 patient and all these patients had preoperative scarred kidneys.

CONCLUSIONS

Despite its invasive nature, UNC has a very high success rate with a negligible percent of complications. In our cohort, the only factor that negatively affected the clinical improvement rate was the history of previous antireflux interventions where the predictive factors for postoperative UTI were previous failed endoscopic injection, female gender, preoperative BTI, persistent VUR and voiding dysfunction.

The retroperitoneal, inguinal approach to distal part of the ureter

Introduction

The inguinal approach to the distal part of the ureter allows the surgeon to perform various types of procedures and is considered to be one of the minimally invasive techniques in pediatric surgery. We aim to describe our initial experience with the surgery of the distal ureter performed through an inguinal mini–incision.

Material and methods

Between March 2012 and June 2013, 8 patients were treated using a minimally invasive inguinal technique. The indications for surgical correction were single system primary obstructive megaureter, obstructive megaureter of the upper pole in a duplex kidney and distal ureteral stones. In all patients with single system obstructive megaureter and significant hydronephrosis, ureterocutaneostomy was performed. In one patient with duplex system primary obstructive megaureter and significant hydronephrosis of the upper pole, ureteroureterostomy of the dilated ureter to the normal caliber ureter in the distal part was performed. In the second patient with duplex system primary obstructive megaureter and reduced marker excretion of the upper pole in renal scintigraphy, ureterocutaneostomy was performed. In both cases of distal ureteral stones, deposits were removed by a simple incision.

Results

We did not observe any perioperative or postoperative complications. The imaging studies have shown that ureteral dilatation decreased in all but one child in whom the upper pole and the ureter were resected due to lack of function.

Conclusions

The inguinal approach allows for the adequate visualization of the distal ureter, creating the conditions for implementation of the various procedures, reduces the risk of retrovesical plexus injury and minimizes visible scars.

Laparoscopic reconstruction for obstructive megaureter: single institution experience with short- and intermediate-term outcomes

PURPOSE

To narrate our experience with laparoscopic reconstruction of obstructive megaureter (MGU) and assess the intermediate-term outcome achieved.

PATIENTS AND METHODS

Patients were evaluated in detail including presenting complaints, biochemical profile, and imaging (ultrasonography [USG], diuretic renography [DR], magnetic resonance urography [MRU], and voiding cystourethrography [VCUG]). All patients with a diagnosis of obstructive MGU and salvageable renal unit were offered laparoscopic reconstruction. The standard laparoscopic exercise included ureteral adhesiolysis until the pathologic segment, dismemberment, straightening of the lower ureter, excisional tapering, and a nonrefluxing ureteroneocystostomy. Operative and postoperative parameters were recorded. Patients were evaluated postprocedure on a 3-month schedule. Follow-up imaging included USG and VCUG at 6 months and 1 year postprocedure and then at yearly intervals. MRU and DR were repeated at 1 year postprocedure.

RESULTS

Twelve patients (13 units-11 unilateral, and 1 bilateral) underwent laparoscopic tailoring and reimplantation for obstructive MGU. Mean age was 98.6 months. All patients were male. Mean body mass index was 17.69 kg/m(2). Presenting complaints were flank pain (n=8) and recurrent urinary infection (n=12). All procedures were completed via a laparoscopic approach. Mean operation duration was 183 minutes, and mean blood loss was 75 mL. Mean duration of hospital stay was 2.1 days. No major intraoperative or postoperative happenings were recorded. All patients were asymptomatic at follow-up with stable renal profile. Follow-up MRU revealed a decrease in ureteral and upper tract dilatation with satisfactory drainage in all. Follow-up VCUG demonstrated grade I vesicoureteral reflux in one patient. Eight patients completed 3-year follow-up with a satisfactory outcome.

CONCLUSION

Laparoscopic reconstruction of obstructive MGU offers satisfactory immediate- and intermediate-term outcome without undue prolonged morbidity.

The inguinal approach to extravesical ureteral reimplantation is safe, effective, and efficient

INTRODUCTION

Minimally invasive surgery implies a percutaneous or endoscopic approach rather than an incision, regardless of size. However, open approaches to various procedures using a mini-incision should assume the same appellation. We report our experience with extravesical ureteral reimplant (EVR) performed through an inguinal mini-incision.

MATERIALS AND METHODS

Patient characteristics of age, gender, and reflux grade were obtained, and outcomes of recurrent urinary tract infection, time of surgery, time of hospitalization and radiographic resolution were assessed. The technique involved a 2 cm incision made in the lowest inguinal skin crease, standard hernia exposure, opening of the floor of the inguinal canal to isolate the ureter, detrussorhaphy.

RESULTS

30 girls and 15 boys with a mean age of 64 months (range 20-180), and mean followup of 18 months (range 3-36) underwent unilateral inguinal mini-incision EVR. Reflux grades represented were 7, 13, 18, 5, and 2 for Grades I through V respectively. Common sheath reimplantations were performed in twelve duplicated systems, and tapering performed in three patients. The average time of surgery was 75 min. All but 2 patients were discharged within 24 h; postoperative imaging was normal in all cases. Three patients had febrile UTIs following discontinuation of prophylactic antibiotics.

CONCLUSION

The inguinal approach to EVR is safe, effective, efficient, and well-tolerated. Through several maneuvers learned as the experience with EVR grew, we present a realizable approach to minimally invasive ureteral reimplantation with application in most pediatric urologic practice.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

"Open" minimally invasive surgery in pediatric urology

Minimally invasive surgery (MIS) offers alternative operative approaches to standard open surgical techniques. However, MIS has been defined primarily as substituting laparoendoscopic alternatives for the traditional open surgical approach. The concept of MIS methodology may also be applied to open surgery in an effort to decrease incision size, potentially reduce morbidity and enhance convalescence, without compromising 'gold standard' outcomes. Pediatric urological applications of open MIS include pediatric renal surgery, ureteral reimplantation, ureteral surgery, inguinal-scrotal and genital surgery. A thorough review of the pediatric urology literature was performed and studies were identified describing open MIS, including outcomes and complications.

[Long-term experience with Cohen ureteral reimplantation in bilateral vesicoureteral reflux in childhood]

INTRODUCTION

In bilateral VUR, Cohen cross-trigonal ureteric reimplantation is a popular but also controversial surgical approach. We present our own experience in a retrospective analysis.

PATIENTS AND METHODS

Between 1990 and 2005, 41 children (26 girls, 15 boys) with bilateral reflux [92 renal units (RU)] underwent ureteric reimplantation. The mean age was 4.5 (0.3-12) years. Eight patients had ureteral duplication (six unilateral, two bilateral); 12 of 41 patients had no intraoperative ureteral stenting. Seven patients had prior surgery for VUR. A successful result was defined as absence of VUR, significant UVJ obstruction, or voiding dysfunction throughout the follow-up.

RESULTS

The mean follow-up was 7.8 (0.5-15) years. Eight patients (19.5%) had 13 complications. One patient had an intraoperative small bowel lesion (2%). Six patients (14.6%) had UTI. Four patients (9.8%) showed transient UVJ obstruction. Three required a temporary percutaneous nephrostomy. Two of these patients had no intraoperative ureteral stenting. Recurrence of VUR was found in 2 patients (4.8%) and 2/92 RU (2.2%), respectively. Complications were more frequent in high-grade VUR, ureter duplex, or unstented ureteral reimplantation. Prior surgery for VUR did not influence the postoperative outcome. Postoperative voiding disorders were not observed.

CONCLUSIONS

Two unilateral recurrences of VUR were observed, requiring a reoperation in one patient. A reoperation for UVJ obstruction was not necessary. Related to 92 RU the surgical success rate was 97.8%. Intraoperative ureteral stenting has to be considered with respect to the current discussion of shortening inpatient procedures. In our experience, the perioperative risk was elevated in patients with high-grade VUR or ureteral duplication.

Intravesical Robotically Assisted Bilateral Ureteral Reimplantation

An efficient laparoendoscopic technique for bilateral intravesical ureteral reimplantation would offer the certainty of cure provided by open surgery with the reduced morbidity of laparoscopy. We have assessed the clinical utility of robotically assisted intravesical bilateral ureteral reimplantation in children. Ports are placed in the dome of the bladder, and the procedure is performed in a fashion identical to that used for open transtrigonal reimplantation. A catheter is left in place for 1 or 2 days. With modifications in port placement using the VersaStep radially dilating sheath system, we have not had any port-site leakage. One patient has unilateral persisting low-grade reflux. This technique may be a useful option for antireflux surgery and should be further refined.