Minimally Invasive Extravesical Ureteral Reimplantation For Vesicoureteral Reflux

An Inguinal Approach to Complex Extravesical Ureteral Reimplantation

OBJECTIVE

To report our experience in applying the Lich-Gregoir extravesical ureteral reimplantation (EVR) approach to complex cases (megaureter, duplex systems) through a small inguinal incision, with the goal of minimizing invasiveness.

MATERIALS AND METHODS

We reviewed the records of all patients who underwent common sheath or tapered EVR through an inguinal incision. Patient characteristics and reflux grade were obtained, and outcomes were assessed. The technique involved a 2-cm incision made in the lowest inguinal skin crease, standard cord exposure and lateral retraction, and opening the floor of the canal to isolate the ureter. Excisional tapering was performed with the ureter dismembered from the bladder and then reimplanted via detrusorrhaphy, whereas common sheath reimplantation was performed with advancement fixation sutures and the ureters in situ.

RESULTS

Twenty-eight patients (15 males and 13 females) with a median age of 1.7 years (range: 0.9-4.8 years) were included. Fifteen patients had ureteral tapering, 12 underwent common sheath reimplantation, and 1 child had both. Success was seen in 94% for tapering and 92% for common sheath reimplants, with a mean follow-up of 29.6 months. There were no postoperative obstructions, urinary leaks, or wound infections.

CONCLUSION

The inguinal approach can safely and effectively be applied to cases of extravesical ureteral tapering and common sheath reimplantation.

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.

Parent and patient perceptions of robotic vs open urological surgery scars in children

PURPOSE

Cumulative evidence shows that robot-assisted laparoscopic surgery is safe and at least as efficacious as open surgery for several pediatric urological procedures. Scars resulting from robotic surgery are often assumed to have a cosmetic advantage. However, no study has clearly demonstrated that parents and patients consistently prefer such scars.

MATERIALS AND METHODS

We developed 3 distinct surveys consisting of photographs and diagrams of scars resulting from open and robot-assisted laparoscopic surgery for ureteral reimplantation, pyeloplasty and bladder augmentation. Surveys were distributed to parents of patients being evaluated for 1 of the 3 procedures. The surveys evaluated information such as scar preference, reason for preference and demographics. Patients older than 7 years also completed surveys.

RESULTS

Robot-assisted laparoscopic surgical scars were preferred by parents for all procedures studied (85% for ureteral reimplant, 63% for pyeloplasty and 93% for bladder augmentation). Patients also preferred the robotic scars (76%, 62% and 91%, respectively). Patients and parents did not differ significantly in scar preference or in rating of factors affecting decision. Scar size was important or very important to 80% of parents for reimplant, 83% for pyeloplasty and 86% for bladder augmentation. However, the majority of parents would ultimately base their choice of surgical approach on clinical efficacy rather than scar preference.

CONCLUSIONS

Parents and patients prefer robot-assisted laparoscopic surgical scars to open surgical scars for pediatric ureteral reimplantation, pyeloplasty and bladder augmentation. Scar appearance is an important influence on the decisions of parents and patients, and should be discussed when surgical treatment is presented.

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.

Update on childhood urinary tract infection and vesicoureteral reflux

Urinary tract infection (UTI) is a leading cause of serious bacterial infection in young children. Vesicoureteral reflux (VUR), a common pediatric urologic disorder, is believed to predispose to UTI, and both are associated with renal scarring. The complex interaction of bacterial virulence factors and host defense mechanisms influence renal damage. However, some renal parenchymal abnormalities associated with VUR are noninfectious in origin. Long-term, renal parenchymal injury may be associated with hypertension, pregnancy complications, proteinuria, and renal insufficiency. Optimal management of VUR and UTI is controversial because of the paucity of appropriate randomized controlled trials; there is a need for well-designed studies. The recently launched Randomized Intervention for children with VesicoUreteral Reflux (RIVUR) study hopefully will provide insight into the role of antimicrobial prophylaxis of UTI in children with VUR.

"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.

Endoscopic treatment of reflux: management pros and cons

PURPOSE OF REVIEW

The goal of this review is to contrast the issues in favor of and against the use of endoscopic injection therapy in an attempt to highlight the current state of flux and draw attention to areas that merit further research.

RECENT FINDINGS

Current publications have mostly addressed the expanding use of endoscopic injection therapy for vesicoureteral reflux treatment, generally reporting short-term success rates and endpoints. This growing body of literature is presented in the context of perceived benefits vs. disadvantages in comparison with other available treatment modalities.

SUMMARY

The management of vesicoureteral reflux has changed dramatically in the past decade, mostly because of the increasing acceptance of endoscopic injection therapy as an adequate, minimally invasive, and effective form of therapy. Recent advances in the composition of injectable materials have allowed for easier placement with a perceived favorable safety profile. In particular, dextranomer/hyaluronic acid has become the injectable material of choice, with quick acceptance and widespread use soon after its introduction in different countries. As we critically evaluate the evolving treatment options, the presented literature helps draw attention to some of the challenges we face and the need for long-term and carefully planned prospective studies to support our interventions.

Current indications for laparoscopy and retroperitoneoscopy in pediatric urology

Laparoscopy has raised great interest in the past few years in the field of pediatric urology. It has evolved from a simple diagnostic maneuver to complex operative procedures. The aim of this study was to review urologic laparoscopy literature and provide a critical review of this field to establish current indications for videosurgery in pediatric urology. In general, from an anatomic point of view, retroperitoneoscopy seems to be more suitable than the transperitoneal laparoscopic approach for reaching the upper urinary tract. It also is less invasive and complies with the criteria for open renal surgery. With respect to current indications for videosurgery in pediatric urology, the authors have identified several well-established clinical procedures, although no large series have been published for any of the procedures, except for the treatment of varicocele, nonpalpable testis, and nephrectomy. In conclusion, the data reviewed suggest that videosurgery is a safe and feasible technique in pediatric urology if performed by expert surgeons, and that it certainly will develop further in the next few years.

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

OBJECTIVES

To analyze and compare the different ureteral reimplantation techniques to clarify the decision making for surgical treatment of vesicoureteral reflux.

METHODS

From July 1995 to December 2000, 218 patients underwent antireflux surgery. The first 92 cases (143 ureters) were performed with the transvesical technique of Cohen (group 1), the next 37 cases (49 ureters) with the conventional extravesical technique (group 2), and the last 89 cases (113 ureters) with the new minimally invasive technique (group 3). The surgical time, length of hospital stay, postoperative side effects, frequency of pain control, and voiding cystogram findings to ensure the cessation of reflux for all patients were retrospectively analyzed.

RESULTS

The success rates were similar among the different procedures. All patients in group 1 required a suprapubic cystostomy, and three had blood clot retention. Four patients in group 2 had bladder inefficiency. The surgical time ranged from 139 to 181 minutes in group 1, 58 to 94 minutes in group 2, and 40 to 61 minutes in group 3. The length of hospital stay ranged from 2.8 to 5.5 days in groups 1 and 2, and no hospital stay was needed in group 3. The frequency of analgesic administration was significantly less in group 2 compared with group 1; however, no analgesia was required in group 3.

CONCLUSIONS

The results from our comparison show that the minimally invasive technique can be used as a simple and highly effective interventional procedure with less morbidity for the patient.