THE PELVIC PLEXUS AND ANTIREFLUX SURGERY: TOPOGRAPHICAL FINDINGS AND CLINICAL CONSEQUENCES

Single-port-plus-one robot-assisted laparoscopic Lich-Gregoir direct nipple ureteral extravesical reimplantation in pediatric primary obstructive megaureter, comparing to laparoscopic cohen

PURPOSE

To compare the effects of a single-port-plus-one robotic laparoscopic-modified Lich-Gregoir direct nipple approach and traditional laparoscopic Cohen in treating pediatric primary obstructive megaureter.

MATERIALS AND METHODS

The clinical data of 24 children with primary obstructive megaureter from January 2021 to November 2021 were analyzed retrospectively. Among them, 12 children (8 boys and 4 girls, the average age were 17.17 ± 6.31 months) treated with the laparoscopic Cohen method were defined as group C. The remaining 12 children (7 boys and 5 girls, the average age was 17.33 ± 6.99 months) underwent single-port-plus-one robotic laparoscopic-modified Lich-Gregoir direct nipple ureteral extravesical reimplantation were defined as group L. The parameters of pre-operation, intraoperative and postoperative were compared.

RESULTS

There were no differences in the patient characteristics and average follow-up time between the two groups (P > 0.05).The obstruction resolution rate was 100% in both groups. The total operation time in group L is slightly longer than that in group C(P < 0.001),but the intraperitoneal operation time of the two groups was comparable(P > 0.05). The postoperative parameters included blood loss, gross haematuria time, indwelling catheterization time and hospitalization time in group L is shorter than group C(P < 0.05). One year post-operation, decreasing in ureteral diameter and APRPD, and increasing in DRF were remarkably observed in both two groups(P < 0.05). Ureteral diameter, APRPD, and DRF were not significantly different both in pre-operation and post-operation between Group L and Group C(P > 0.05).

CONCLUSION

Single-port-plus-one robot-assisted laparoscopic-modified Lich-Gregoir direct nipple approach and traditional laparoscopic Cohen are both dependable techniques for ureteral reimplantation in the treatment of pediatric primary obstructive megaureter. Since Lich-Gregoir can preserve the physiological direction of the ureter and direct nipple reimplantation enhances the effect of anti-refluxing, this technique is favorable for being promoted and applied in robot surgery.

Single-port-plus-one robot-assisted laparoscopic modified Lich-Gregoir direct nipple ureteral extravesical reimplantation in children with a primary obstructive megaureter

Purpose

To introduce a new technique of single-port-plus-one robotic laparoscopic-modified Lich-Gregoir direct nipple ureteral extravesical reimplantation and ascertain its validity in the treatment of pediatric primary obstructive megaureter.

Methods

Between January 2021 and November 2021, we retrospectively analyzed the clinical data of 12 children with primary obstructive megaureter who were admitted to the Department of Pediatric Surgery of Fujian Provincial Hospital. All 12 children were treated with single-port-plus-one robotic laparoscopic Lich-Gregoir direct nipple ureteral extravesical reimplantation. Five of them were female and seven were male, including nine cases were simple obstructive type, while the remaining three cases were obstructive with reflux type. The mean age of the children was 17.33 ± 6.99 (10-36) months and the mean follow-up time was 14.16 ± 1.75 (12-17) months. Changes in preoperative and first-year postoperative parameters were compared.

Results

The mean operative time for all 12 children was 123.58 ± 10.85 (110-145) min, with a mean internal operative time of 101.42 ± 0.85 (90-120) min, a mean operative bleeding time of 2.42 ± 0.67 (2-4) ml, and a mean hematuria duration of 16.08 ± 1.44 (14-19) h. The mean indwelling catheterization time was 2.25 ± 0.45 (2-3) days and the mean hospitalization time was 3.83 ± 0.39 (3-4) days. At the postoperative first year, the ureteral diameter, calyceal diameter, and anterior-posterior renal pelvic diameter were found to be significantly smaller than at the preoperative period (18.83 ± 3.21 mm vs. 6.83 ± 1.27 mm, 13.99 ± 3.58 mm vs. 3.5 ± 2.90 mm, and 34.92 ± 4.25 mm vs. 10.08 ± 1.88 mm, P < 0.001). There was a significant increase in renal cortical thickness and the percentage of differential renal function (3.63 ± 1.66 mm vs. 5.67 ± 1.88 mm, 33.75 ± 2.77 mm vs. 37.50 ± 1.31 mm, P < 0.001). The resolution rate of obstruction was 100% and no child developed DeNovo vesicoureteral reflux.

Conclusion

The technique of modified Lich-Gregoir direct nipple ureteral extravesical reimplantation can help maintain the physiological direction of the ureter and at the same time enhance the effectiveness of antirefluxing in robotic surgery. The design of a single-port-plus-one wound can produce a cosmetic appearance by concentrating and hiding the wound around the umbilicus. This modified reimplantation procedure has the potential to become a promising technique in the robot-assisted treatment of primary obstructive megaureter.

The LUAA Gundeti Technique for Bilateral Robotic Ureteral Reimplantation: Lessons Learned over a Decade for Optimal (Resolution, Urinary Retention, and Perioperative Complications) Trifecta Outcomes

Background

Ureteral reimplantation is the gold standard treatment for high-grade vesicoureteral reflux (VUR) in pediatric patients. Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) using the LUAA technique has emerged as a viable alternative to traditional open and laparoscopic surgical correction.

Objective

To evaluate the outcomes, reflux resolution, urinary retention, and complications associated with bilateral RALUR-EV for primary VUR using the LUAA Gundeti technique in pediatric patients.

Design setting and participants

A retrospective study was conducted at a single academic center, involving 34 consecutive pediatric patients who underwent RALUR-EV for bilateral VUR management between December 2008 and December 2022. The study included only patients who were evaluated with postoperative voiding cystourethrogram (VCUG).

Surgical procedure

The LUAA extravesical ureteral reimplantation technique was performed, involving the identification and mobilization of the ureter, creation of a peritoneal window, dissection close to the neurovascular bundle, Y dissection at the ureterovesical junction, detrusorotomy, detrusorrhaphy with advential inclusion, and apical alignment suture.

Measurements

The primary outcome was radiographic resolution of VUR on VCUG. The secondary outcomes included urinary retention and Clavien-Dindo grade III complications.

Results and limitations

The overall radiographic resolution rate was 85.2%, with success rates of 76.7%, 75%, and 96.7% across the three distinct patient cohorts. The overall Clavien-Dindo grade III complication rate was 5.8%, and transient urinary retention was 8.8%. Resolution of urinary retention occurred within 7-28 d. The study's limitations include the small sample size, single-center design, and retrospective nature.

Conclusions

The LUAA technique demonstrates sustainable outcomes for VUR resolution with a low incidence of transient urinary retention and complications. A thorough understanding of pelvic anatomy is essential for successful dissection and minimization of the risk of complications. Further studies are needed to evaluate the effectiveness of different approaches in reducing the incidence of transient urinary retention following bilateral extravesical reimplantation.

Patient summary

In this study, we examined the results of the Gundeti LUAA surgical technique for treating primary vesicoureteral reflux in children. We identified various essential modifications that increase the likelihood of achieving favorable outcomes.

Modified technique for robot-assisted laparoscopic infantile ureteral reimplantation for obstructive megaureter

PURPOSE

To describe a novel modification of technique to improve efficacy of robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) in infants.

MATERIALS AND METHODS

Between April 2017 and July 2019, sixteen infants with primary obstructive megaureter (POM) (Age range: 4-12 months) underwent robot-assisted ureteral reimplantation were reviewed in this series. In addition to the conventional Lich-Gregoir technique, the detrusor tunnel has been extended to the mobilized anterior bladder wall to guarantee sufficient tunnel length/ureter diameter ratio and avoid ureteral angulation. All patients underwent repeated ultrasound, diuretic renal dynamic imaging and voiding cystourethrography (VCUG) perioperatively and the outcomes were documented.

RESULTS

All operations were completed with robotic assisted approach without conversion. Bilateral and unilateral reimplantation were respectively performed in two and fourteen patients. The mean operative time was 115.0 ± 19.5 min and the mean blood loss was 10.0 ± 1.8 ml. There were no high-grade complications (III-IV on Clavien-Dindo classification) except for one patient. The distal ureteric diameter was reduced from pre operative 1.7 ± 0.5 to 0.6 ± 0.5 cm 6 months post operatively (p < 0.05). One child (6.3%) required the second reimplantation for stenosis. The overall operative success rate was 94.4% (17 of 18 ureters) with a mean follow-up of 15.9 ± 7.4 months with no flux detected.

CONCLUSION

Our preliminary experience suggests that our modified robot-assisted laparoscopic extravesical ureteral reimplantation is feasible in infants with good results.

Characterizing the autonomic neural connections between the abdominal aortic and superior hypogastric plexuses: A multimodal neuroanatomical study

The aortic plexus serves as the primary gateway for sympathetic fibers innervating the pelvic viscera. Damage to this plexus and/or its associated branches can lead to an assortment of neurogenic complications such as bladder dysregulation or retrograde ejaculation. The neuroanatomy of this autonomic plexus has only recently been clarified in humans; as such, the precise function of its constituent fibers is still not clear. Further study into the functional neuroanatomy of the aortic plexus could help refine nerve-sparing surgical procedures that risk debilitating neurogenic complications, while also advancing understanding of peripheral sympathetic circuitry. To this end, the current study employed an in vivo electrostimulation paradigm in a porcine model, in combination with lipophilic neuronal tracing experiments in fixed, post-mortem human tissues, to further characterize the functional neuroanatomy of the aortic plexus. Electrostimulation results demonstrated that caudal lumbar splanchnic nerves provide primary control over the porcine bladder neck in comparison to other constituent fibers within the aortic plexus. Ex vivo human data revealed that the prehypogastric ganglion contains a significant number of neurons projecting to the superior hypogastric plexus, and that these neurons are arranged in a topographic manner within the ganglion. Altogether, these findings suggest that a pivotal sympathetic pathway mediating bladder neck contraction courses through the caudal lumbar splanchnic nerves, prehypogastric and inferior mesenteric ganglia and superior hypogastric plexus.

Comparative Clinical Study Between Modified Ureteral Orthotopic Reimplantation and Cohen Method Under Pneumovesicum in Pediatric Patients With Hydroureteronephrosis

Purpose: To report our initial experience with a modified ureteral orthotopic reimplantation technique under pneumovesicum and compare the outcomes vs. those obtained with the Cohen technique under pneumovesicum for the correction of primary obstructive megaureter (POM) or vesicoureteral reflux(VUR) in pediatric patients. Methods: A total of 46 patients (38 POM and 8 VUR; mean age: 16.24 months) treated with modified ureteral orthotopic reimplantation (OR) and 43 patients (34 POM and 9 VUR; mean age: 22.98 months) treated with Cohen reimplantation (CR) under pneumovesicum were included. We compared the results perioperatively and during follow-up. Results: The mean operative time was significantly shorter in the OR group (OR: 86.86 and 108.18 vs. CR: 95.14 and 124.29 min for unilateral and bilateral cases, respectively). The mean postoperative hospital stay (OR: 5.02 vs. CR: 5.07 days), blood loss (OR: 3.67 vs. CR: 3.84 ml), and follow-up time (OR: 23.17 vs. CR: 23.37 months) did not exhibit significant differences between the two groups. One patient converted to open surgery in the CR group, whereas there was no conversion in the OR group. Postoperative febrile urinary tract infection occurred in two cases in each group. Both infections were controlled using antibiotics. All patients in both groups showed improved hydroureteronephrosis, and all patients with VUR showed reflux resolution post-surgery. Conclusions: Our modified ureteral orthotopic reimplantation technique under pneumovesicum can be safely and effectively performed, achieving a high success rate that is equivalent to that obtained through the Cohen technique under pneumovesicum. Moreover, it involves a simpler procedure and shorter operation time.

Vesicoureteral antireflux surgery with Lich-Gregoir technique without vesical drainage: Long-term results

OBJECTIVE

To describe our long-term experience with patients with vesicoureteral reflux (VUR) who underwent conventional surgery without postoperative bladder drainage.

MATERIAL AND METHODS

Retrospective review of 45 patients surgically treated by extravesical Lich-Gregoir's ureterovesical reimplantation without postoperative bladder drainage between 2010 and 2013.

RESULTS

37 women (82.2%) and 8 men (17.8%). 28 patients with unilateral reflux, and 17 patients with bilateral reflux with a total of 62 operated kidneys. The mean age at surgery was 6 years (2 to 11 years). The main cause of surgical indication was the persistence of reflux in patients older than 6 years (73.3%); with grade III VUR (75.6%) being the most frequent. The mean surgical time was 44minutes (35-70) for unilateral reimplantation, and 70minutes (53-98) for bilateral ones. All patients presented spontaneous urination in the immediate postoperative period, without pain, no hematuria, full incontinence, and without a bladder balloon. None required bladder catheter placement, and hospital discharge was indicated between 7 and 36hours postoperatively (mean 11h). All continued with spontaneous micturitions, without postvoid residual or voiding dysfunction during the 5-year follow-up.

CONCLUSION

The thorough selection of the patients, the detailed surgical gestures, the bladder emptying without instrumentation of the urethra, together with a correct use of analgesics and early ambulation allowed excellent outcomes obtained in these patients managed with a short hospital stay and without bladder drainage, also demonstrating the safety of the procedure at 5 years of follow-up.

Current status of robotic-assisted surgery for the treatment of vesicoureteral reflux in children

PURPOSE OF REVIEW

Although open ureteral reimplantation remains the gold standard for surgical correction of vesicoureteral reflux (VUR), robotic-assisted laparoscopic ureteral reimplantation (RALUR) holds promise and is becoming more widely utilized. The present article outlines primary operative techniques for RALUR, summarizes the current literature with respect to surgical outcomes and costs, and discusses early applications of RALUR to complex and reoperative cases.

RECENT FINDINGS

Intravesical and extravesical techniques for RALUR have been described. Published outcomes vary with respect to operational definitions of surgical success and reporting of complications. Several studies have directly compared RALUR and open reimplant, suggesting equivalent efficacy and safety. Recent noncomparative studies have reported lower VUR resolution rates and higher complication rates for RALUR, particularly in bilateral cases. The application of RALUR to reoperative surgery and cases requiring tapering and dismemberment is under very early investigation. RALUR is consistently associated with lower postoperative analgesic requirements and decreased hospital stay, but longer operative times and higher costs compared to open reimplant.

SUMMARY

Published outcomes after RALUR show mixed results that, on average, may be inferior to open reimplant. Future investigations should seek to identify patient-related and intraoperative factors associated with successful and unsuccessful outcomes.

Extravesical Ureteral Reimplantation Following Lich-Gregoir Technique for the Correction of Vesico-Ureteral Reflux Retrospective Comparative Study Open vs. Laparoscopy

Introduction: The aim is to compare the outcome of open versus laparoscopic Lich-Gregoir technique in patients with vesicoureteral reflux. We report a retrospective multicenter comparative study between open and laparoscopic extra-vesical ureteral reimplantation (EVUR) following Lich-Gregoir (LG) technique for the correction of Vesico-Ureteral Reflux (VUR). Materials and Methods: Between January 2007 and December 2015, 96 patients with VUR (69 females and 27 males) and deterioration of the renal function, underwent EVUR following LG technique. Fifty patients (16 males and 34 females) were operated by open surgery (group A). The mean age was 4.22 years-old, (14-147 months). Laparoscopic approach (group B) was performed in 46 patients (11 males and 35 females). The mean age was 4.19 years-old (15-110 months). We compared the results in relation to degree of VUR, operative time, hospital stay, post-operative pain medications, recovery time, complications, successful rate, recurrence, and follow-up. Statistical analysis was done used Chi square test for categorical variables and the Student t-test for continuous variables. P < 0.05 was considered significant. Results: In both groups no correlation was identified between age or weight and operative time, length of stay or total analgesia used. The mean operative time for group A was 63.2 and 125.4 min for unilateral and bilateral VUR, respectively, and for the group B was 127.90 and 184.5 min, respectively. There was no conversion in the laparoscopic group. Perioperative mucosal perforation of the bladder occurred in 6 patients of group A and 4 patients of group B and was immediately repaired. One patient had to be reoperated for leakage in group B. The mean duration of Morphine, IV and PO analgesia was shorter in group B. The mean hospital stay was 5.46 days for group A and 1.54 days for Group B. The success rate was 98% in group A and 97, 8% in group B. The mean follow-up was 3.67 years for the open and 1.54 years for the laparoscopic group. Transitory voiding dysfunction occurred in bilateral EVUR in one case in each group. Conclusion: Laparoscopic or Open approach for the correction of VUR following Lich-Gregoir technique is effective in unilateral and bilateral VUR with similar results. Laparoscopic approach reduces significantly (p < 0.05 in each item) post-operative pain medication, hospital stay, and allows for a faster return to normal activity.

Precise Characterization and 3-Dimensional Reconstruction of the Autonomic Nerve Distribution of the Human Ureter

PURPOSE

We sought to characterize and 3-dimensionally reconstruct the distribution of the autonomic innervation of the human ureter.

MATERIALS AND METHODS

Three male and 3 female pairs of ureters were evaluated at 2 mm serial transverse sections along the entire length of the ureter. The location of nerve tissue was immunohistochemically identified using the neuronal marker, S100 protein. ImageJ software was used to calculate nerve count and density in the adventitia and smooth muscle. Blender® graphics software was used to create a 3-dimensional reconstruction of autonomic nerve distribution.

RESULTS

Within the adventitia nerve density was highest in the mid and distal ureter (females 2.87 and 2.71 nerves per mm², and males 1.68 and 1.69 nerves per mm²) relative to the proximal ureter (females and males 1.94 and 1.22 nerves per mm², respectively, p >0.0005). Females had significantly higher nerve density throughout the adventitia, especially in the distal ureter (2.87 vs 1.68 nerves per mm², p <0.0005). In smooth muscle the nerve density progressively increased from the proximal to the distal ureter (p >0.0005). Smooth muscle nerve density was similar in the 2 genders (p = 0.928). However, in females nerve density was significantly higher in the first 2 cm of the distal ureter relative to the second 2 cm (3.6 vs 1.5 nerves per mm², p <0.001) but not in males (3.0 vs 2.1 nerves per mm², p = 0.126).

CONCLUSIONS

Nerve density was highly concentrated at the distal ureter in the adventitia and smooth muscle of the male and female human ureters. The female ureter had greater nerve density in the adventitia, and in smooth muscle nerves were significantly concentrated at the ureteral orifice and the ureteral tunnel.

Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation: Technique Modifications Contribute to Optimized Outcomes

BACKGROUND

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is being adopted at large pediatric urology centers in the United States, but currently there is not consensus on surgical technique to facilitate the best possible outcomes.

OBJECTIVE

To describe technique modifications that may lead to improved radiographic vesicoureteral reflux (VUR) resolution.

DESIGN, SETTING, AND PARTICIPANTS

Between December 2008 and February 2015, a single surgeon performed RALUR-EV at an academic medical center. Only children with persistent grade 3-5 VUR at age 5 yr on voiding cystourethrogram (VCUG), those who had breakthrough urinary tract infections, or those with renal scarring were selected to undergo surgical correction of VUR with RALUR-EV. Children undergoing RALUR-EV for obstructive megaureter or ureterovesical junction obstruction were excluded. Fifty-eight patients (83 ureters) fit the inclusion criteria.

SURGICAL PROCEDURE

We highlighted adjustments to our technique, called LUAA to represent length of detrusor tunnel (L), use of a U stitch (U), placement of permanent ureteral alignment suture (A), and inclusion of ureteral adventitia (A) in detrusorraphy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary end point was resolution of VUR on postoperative VCUG.

RESULTS AND LIMITATIONS

Because technique modifications were made at two distinct time points, we generated three patient groups for comparison. We observed complete resolution of VUR in 82% of ureters, including 8 of 12 ureters (67%), 8 of 11 ureters (73%), and 52 of 60 ureters (87%) for technique modification cohorts 1, 2, and 3, respectively. There were no ureteral complications at median follow-up of 30 mo. Retrospective design and possible confounding from the learning curve limit this study.

CONCLUSIONS

Using the standardized LUAA technique, we demonstrated an improvement in outcomes. Given the wide range of published resolution rates following RALUR-EV, there is a need for standardization of technique to facilitate best possible outcomes. We propose the LUAA technique as a new standard for RALUR-EV to achieve this goal.

PATIENT SUMMARY

We examined the safety and efficacy of a minimally invasive surgery in children. We identified several critical adjustments to surgical technique that improve rates of successful outcome.

Laparoscopic extravesical detrusorraphy, a minimally invasive treatment option for vesicoureteral reflux: a single centre experience

INTRODUCTION

Laparoscopy in pediatric patients offers more benefits than was earlier presumed and these widely reported benefits significantly outweigh any concerns regarding the technical difficulties. Laparoscopic correction of vesicoureteral reflux aims to duplicate the excellent results of open surgery while at the same time reducing perioperative morbidity and analgesic requirements, improving cosmesis and shortening hospital stay.

OBJECTIVE

To share our experience of laparoscopic extravesical detrusorraphy, highlight our technical modification of intraoperative minimal "atraumatic" ureteric handling of the ureter, which we hypothesize may decrease ureteral complications, and report our results.

STUDY DESIGN

This was a retrospective chart review of 76 toilet-trained children (98 refluxing units), in the age group of 3-16 years, with Grade I-IV reflux, who underwent laparoscopic detrusorraphy from June 2006 to January 2014. A ureteric catheter is inserted into the refluxing ureter and is tied to the Foleys to drain into a common bag. A three port technique is used. During ureteral dissection, a vascular sling in the form of a Rumel loop is used for atraumatic handling of the ureter. A detrusor tunnel is created with hook electrocautery. A stay suture is later passed through the abdominal wall and slings around the dissected ureter, which helps in holding the ureter approximated against the mucosal trough during detrusorraphy. Detrusor fibers are approximated with 5-0 Vicryl. No drain is placed and the Foley and ureteric catheter(s) are removed after 24 h. Intravenous ketorolac is given every 6 h for the first 24 h. Oral paracetamol is used for analgesia after the first 24 h. Adequate bladder emptying is ensured by assessment of post void residual urine before discharge. Renal USG alone is performed 2 weeks post operatively and repeated after 3 months along with a VCUG (voiding cystourethrography). Success was defined as absence of reflux in the follow-up VCUG done at 3 months.

RESULTS

Mean operative time was 102 ± 26.5 min for unilateral detrusorraphy and 165 ± 18 min for bilateral extravesical detrusorraphy. The mean duration of hospital stay was 1.5 ± 1.7 days. There was one case of urinary retention that was managed with temporary recatheterization. There were no cases of ureteral ischemia, obstruction, hematuria or bladder spasms. Surgery was successful in 97.9% of the refluxing units (96/98). In two patients with grade IV reflux, there was downgrading to grade II on VCUG done at 3 months' follow-up. The reflux resolved at 8 and 14 months' follow-up, respectively.

DISCUSSION

Our technique of atraumatic handling of the ureter, initially with the help of a vascular sling and later with the help of a stay suture passed percutaneously through the abdominal wall, resulted in no ureteric injuries. The postoperative morbidity of this procedure is low because the bladder is not opened, the ureter is not transected, no new UVJ is created and there is no need for placement of a drain. The risk of postoperative bowel adhesions is low as the ureter is dissected out through a narrow peritoneal window, which is again extraperitonealized at the end of the procedure (see figure). The postoperative complications of gross hematuria and bladder spasms, which may be especially encountered in patients undergoing laparoscopic Cohen's, were not seen in our case series.

CONCLUSION

Laparoscopic extravesical detrusorraphy provides a minimally invasive treatment option for treatment of unilateral/bilateral grade I-IV vesicoureteral reflux. The postoperative morbidity is low and the success rate is favorable. Our technical modification of a "vascular sling" around the ureter facilitates atraumatic ureteric handling, which may reduce distal ureteral complications like ureteral ischemia and obstruction.

A modified technique for ureteral reimplantation: intravesical detrusorrhaphy

PURPOSE

To describe the surgical procedure of intravesical detrusorrhaphy, a modified technique of ureteral reimplantation, and report our initial experience.

METHODS

From October 2007 to March 2012, 55 children with vesicoureteral reflux (VUR) and 13 children with obstructive megaureter (OM) underwent intravesical detrusorrhaphy. All surgical procedures were performed via an open intravesical approach. The ureter was mobilized, and the bladder mucosa was separated from the detrusor in a cephalad direction. The separated detrusor was incised vertically and repaired underneath the mobilized ureter to create the submucosal tunnel. The ureteral orifice was anastomosed to its orthotopic position.

RESULTS

Of 31 patients treated with bilateral intravesical detrusorrhaphy, no patient had postoperative urinary retention. Follow-up voiding cystourethrography was performed in 45 patients with 72 reimplanted ureters. VUR was resolved in 41 patients (91.1%) with 68 ureters (94.4%). Among 13 patients with 14 ureters treated for OM, hydroureteronephorosis improved in 11 patients (84.6%) with 12 ureters (85.7%).

CONCLUSIONS

Intravesical detrusorrhaphy is modified technique of ureteral reimplantation, which recreates the neo-ureteric orifice in the orthotopic position and does not produce postoperative urinary retention in bilateral cases. Intravesical detrusorrhaphy is safe and effective in treating patients with VUR or OM.

Is pelvic plexus nerve documentation feasible during robotic assisted laparoscopic ureteral reimplantation with extravesical approach?

PURPOSE

Urinary retention is a known complication of using an extravesical approach for ureteral reimplantation, especially in bilateral cases. The etiology may be secondary damage to pelvic nerves during ureteral dissection. Recent literature suggests that it is possible to visually identify these nerves during a robotic assisted laparoscopic approach. We performed an exploratory study to identify and document them in pediatric patients by means of electrophysiologic recordings.

MATERIAL AND METHODS

Seven consecutive patients undergoing robotic assisted laparoscopic ureteral reimplantation with extravesical approach were prospectively enrolled in the study. Following dissection of the ureter below the level of vas deferens in male and the uterine artery in female, staying close to the adventitia and approaching the ureterovesical junction, the fibers as described in human cadaveric studies were identified dorsomedial to the ureter and preserved. Stimulating and recording electrodes were passed through to record post-synaptic compound muscle action potentials of the bladder.

RESULTS

Even though the nerve fibers were visually identified, we were unable to consistently and reproducibly record compound muscle action potentials after stimulation of putative pelvic plexus fibers at the distal ureter, despite modulation in stimulation intensity, pulse characteristics, signal recording sensitivity and stimulator probe variation.

CONCLUSIONS

In this pilot study, the inconsistent findings raise questions about the exact location of the neurovascular bundle, nature of bladder smooth muscle electrophysiology and the appropriate methodology of evaluation. This may provide a reason to reexamine the intraoperatively expected location of pelvic plexus nerve fibers.

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.

Laparoscopic extravesical transperitoneal approach following the Lich-Gregoir technique in the treatment of vesicoureteral reflux in children

INTRODUCTION

Laparoscopy may have a place in the treatment of vesicoureteral reflux (VUR). We report our initial experience in the treatment of VUR by laparoscopic extravesical transperitoneal approach (LETA) following the Lich-Gregoir technique to describe the evolution and to evaluate the results and benefits of this technique for these patients.

MATERIALS AND METHODS

Between August 2007 and May 2009, 43 renal units in 30 children (23 female and 7 male) with VUR and deterioration of renal function on isotope renography (17 unilateral and 13 bilateral) were treated with LETA. The mean age was 52 (range, 15-183) months. Nine patients had a double total collector system associated with VUR in a lower system. Two of them had a ureterocele with adequate upper polar rein function, and another had a ureterocele with complete deterioration of upper polar rein function.

RESULTS

The mean surgical time was 70 (38-120) minutes in unilateral and 124 (100-180) minutes in bilateral VUR. All procedures were successfully completed laparoscopically, and the reflux was corrected in all patients. At the same time, 1 heminephrectomy and 2 ureterocele were removed by laparoscopy and endoscopy, respectively. We had 1 ureter leakage 15 days postoperation that underwent a redo reimplantation. In cases of bilateral VUR, 1 patient presented postoperative bladder emptying difficulty and required temporary urethral catheterization postoperatively. The mean hospital stay was 24 hours. A cystogram was performed systematically in all patients at 45 days postoperation; none of them presented recurrence of VUR. The follow-up was 11 (range, 2-24) months, without recurrence of VUR.

CONCLUSION

Laparoscopic extravesical transperitoneal approach in the treatment of VUR is a safe and effective approach even in unilateral, bilateral simultaneous, and double total collector system. The technique results in a shorter hospital stay, less postoperative discomfort, and reduced recovery period, with a low morbidity to resolve the VUR and with success rates similar to the open technique.

Neuroanatomy of the male pelvis in respect to radical prostatectomy including three-dimensional visualization

The neuroanatomical structures of the radical prostatectomy (RP) are extensively discussed for their existence, localization and function. Especially structures, e.g. the so-called neurovascular bundle (NVB) that are points of debate in numerous anatomical studies. We review the literature and present our observations in cadaveric specimens, to reconstruct neuroanatomical structures in three dimensions (3D) with the use of appropriate computer applications and produce images of operative fields. We used an internet PubMed survey (http://www.ncbi.nlm.nih.gov) to review recent publications and included back copies of historical neuroanatomical studies from our own library. Our own experimental cadaveric (specimens preserved in Thiel's solution) studies of the autonomic nerve supply of the lower urinary tract were also reviewed. Visualization of the pelvic anatomy and neuroanatomy was done using computer-based software packages. No unified terminology for the structures of the NVBs can be presented to date. The innervation of the smooth muscular structures of the urethra and the complex morphology of urethral sphincter remain unclear. Our cadaveric studies showed that nerves are located on the lateral aspect of the prostate in addition to the NVBs described at the dorsolateral side of the prostate. The neuroanatomical investigations of the male pelvis and visualization of the structures in 3D enable the presentation of operative sites as seen intraoperatively. Moreover, dynamic depiction of the pelvic floor is also possible.

Conservative surgery plus brachytherapy treatment for boys with prostate and/or bladder neck rhabdomyosarcoma: a single team experience

PURPOSE

The aim of this study is to report the results of a conservative surgery + brachytherapy treatment for boys with prostate and/or bladder-neck rhabdomyosarcoma avoiding total cystectomy or prostatectomy and external radiotherapy.

PATIENTS

From 1991 to 2007, 26 boys were operated for a residual mass after chemotherapy (1 for local relapse). All patients underwent a conservative surgical procedure, with bladder-neck and urethra preservation. Surgery was never microscopically complete. Brachytherapy was systematically performed after tumor resection, as a perioperative procedure, consisting of 2 loops encompassing the prostate and the bladder-neck area. A dose of 60 Gy was delivered with low dose rate. Bladder function was evaluated clinically and with urodynamic study for boys with abnormal continence.

RESULTS

Median age at operation was 23 months (9 months-11 years). Seventeen boys underwent a partial prostatectomy associated in 5 with a partial cystectomy. The remaining 9 patients underwent a partial cystectomy with no procedure at the level of the prostate. At a median follow-up of 4 years (10 months-14.5 years), 24 of 26 boys are alive. Only 1 patient relapsed locally out of the brachytherapy field and died. A second boy died from metastatic relapse. Only 1 patient with bladder dysfunction after treatment underwent a total cystectomy. Four patients are too young to be evaluated for bladder function (<4 years of age). Seven patients, aged 4 to 6 years, have daytime continence, 1 has diurnal dribbling. Among 11 boys older than 6 years, 9 (82%) are normally continent (3 after temporary dribbling), 2 have diurnal dribbling treated by bladder education.

CONCLUSION

Even if very long-term sequelae of brachytherapy cannot be evaluated, this conservative combined treatment may allow normal continence in nearly all patients, even after temporary diurnal incontinence and should be discussed as an alternative to external radiotherapy or radical surgery.

Treatment of vesicoureteral reflux after puberty

Vesicoureteral reflux is uncommonly diagnosed and treated after puberty. The natural history of uncorrected VUR after puberty is not documented. Postpubertal patients with recurrent pyelonephritis and VUR should be considered for treatment. Ureteral reimplantation, endoscopic injections, and laparoscopic or robotic ureteral reimplantation may be utilized. Endoscopic injection is an appealing option for these patients. The role of laparoscopic or robotic ureteral reimplantation in these patients is evolving.

Long-term urinary dysfunction after mesorectal excision: A prospective study with intraoperative electrophysiological confirmation of nerve preservation

BACKGROUND

Bladder dysfunctions are well-recognized complications after nerve-sparing mesorectal excision for rectal cancer. This study sought to symptomatically analyze the extent of recovery from major and minor urinary symptoms in patients with signs of bladder denervation.

METHODS

Sixty-two patients with mesorectal excision for rectal cancer were investigated prospectively. Pelvic autonomic nerve preservation (PANP) was assessed macroscopically and with the aid of intraoperative electrical stimulation of pelvic autonomic nerves (INS). Bladder function was evaluated with the International Prostate Symptom Score (IPSS) and the Quality of life index (Qol). Median follow-up was 20 months (range 3-40 months).

RESULTS

Forty-six patients with INS-confirmed preservation of parasympathetic nerves remained unchanged in early and long-term urinary function (IPSS: median 1; range 0-24 and Qol 0; range 0-5). In 15 patients without confirmation of PANP (unilaterally or bilaterally) on INS, voiding function was significantly more impaired postoperatively (IPSS: median 10; range 0-25 and Qol 3; range 0-6) and at long-term follow-up (IPSS: median 9; range 0-25 and Qol 3; range 0-6) (p<0.001). Voiding function was improved in 4 of 10 patients with major and minor symptoms. In 5 of 6 patients with long-term bladder dysfunction INS assessed parasympathetic nerve damage unilaterally (3/5) and bilaterally (2/5).

CONCLUSION

Long-term voiding disturbance after mesorectal excision was found to be a serious complication. INS while monitoring intravesical pressure is a valuable aid in predicting long-term bladder function after TME. The device may serve a secondary preventive function in enabling the initiation of early urologic therapy.

Systematization of the vesical and uterovaginal efferences of the female inferior hypogastric plexus (pelvic): applications to pelvic surgery on women patients

OBJECTIVE

To locate and describe the various efferences of the plexus in order to make it easier to avoid nerve lesions during pelvic surgery on women patients through a better anatomical knowledge of the inferior hypogastric plexus (IHP).

MATERIALS AND METHODS

We dissected 27 formalin embalmed female anatomical subjects, none of which bore any stigmata of subumbilical surgery. The dissection was always performed using the same technique: identification of the inferior hypogastric plexus, whose posterior superior angle follows on from the hypogastric nerve and whose top, which is anterior and inferior, is located exactly at the ureter's point of entry into the base of the parametrium, underneath the posterior layer of the broad ligament.

RESULTS

The IHP is located at the level of the posterior floor of the pelvis, opposite to the sacral concavity. Its top, which is anterior inferior, is at the point of contact with the ureter at its entry into the posterior layer of the broad ligament. The uterovaginal, vesical and rectal efferences originate in the paracervix. Three efferent nerves branch, two of them from its top and the third from its inferior edge: (1) A vaginal nerve, medial to the ureter, follows the uterine artery and divides into two groups: anterior thin, heading for the vagina and the uterus; posterior, voluminous, heading in a superior rectal direction (=superior rectal nerve). (2) A vesical nerve, lateral to the ureter, divides into two groups, lateral and medial. (3) The inferior rectal nerve emerges from the inferior edge of the IHP, between the fourth sacral root and the ureter's point of entry into the base of the parametrium.

CONCLUSION

The ureter is the crucial point of reference for the IHP and its efferences and acts as a real guide for identifying the anterior inferior angle or top of the IHP, the origin of the vaginal nerve, the level of the ureterovesical junction and the division of the vesical nerve into its two medial and lateral branches. Dissecting underneath and inside the ureter and the uterine artery involves a risk of lesion of the vaginal nerve and its uterovaginal branches. Further forward, between the intersection and the ureterovesical junction, dissecting and/or coagulating under the ureter involves a risk of lesions to the vesical nerve, which are likely to explain the phenomena of denervation of the anterior floor encountered after certain hysterectomies and/or surgical treatments of vesicoureteral reflux.

Bladder/Prostate Rhabdomyosarcoma: Past, Present and Future

PURPOSE

The last few decades have witnessed substantial improvement in outcomes in children with bladder/prostate rhabdomyosarcoma. We reviewed relevant historical aspects of treatment, current treatment strategies and new developments. Most importantly we identified areas of existing controversy, which will provide direction for future studies and continued improvements in therapy.

MATERIALS AND METHODS

A database (PubMed, MEDLINE, etc) search was performed from 1966 through January 2005. Approximately 500 citations were identified. Relevant citations were reviewed in detail.

RESULTS

While the reported cure rate has improved to approximately 70% to 80% and bladder preservation rates as high as 60% are reported, substantial controversy continues in certain areas. Specifically the long-term function of preserved bladders, the contribution of radiotherapy to bladder dysfunction, the timing of reconstruction and molecular markers of disease progression are among the areas that require further investigation.

CONCLUSIONS

Substantial progress has been made as a result of multi-institutional collaborative trials. Future combined studies are required to further the treatment of this childhood malignancy.

[Primary vesicoureteral reflux and extravesical ureteral reimplantation in chidren]

PURPOSE

to assess the results of the Lich-Gregoire procedure in the treatment of primary vesicoureteral reflux (VUR).

MATERIALS AND METHODS

In a 2.5-year period, 141 children with primary VUR underwent a vesicoureteral reimplantation using the Lich-Gregoire procedure in 101 patients (158 ureters) and the Cohen procedure in 48 patients (68 ureters). Patients were evaluated retrospectively in a non randomized fashion and data were recorded about: age, indications for surgery, days with the bladder catheter, length of stay, and short and long-term complications.

RESULTS

The control average time was 1.71 years (from 8 months to 3.5 years). A) Early complications. No obstruction was seen in this series. Five children (8.6 of the bilaterally simultaneously operated) showed urinary retention, but only three needed replacement of the bladder catheter and only one of them needed temporary clean intermittent catheterization. Nausea, vomiting, pain and hematuria were sporadic and limited in time. B) Late complications. The long-term results were good (95%). Seven ureters (4.4%) had persistent VUR and 3 children (6.7% of the unilateral cases) had contralateral VUR. Only 3 ureters needed a new surgical treatment (2%) for persistent ipsilateral VUR. Short and long-term complications, days with bladder catheter and length of stay in the hospital were significantly smaller in the group of patients operated with Lich-Gregoire procedure than in patients operated with the Cohen technique.

CONCLUSIONS

The Lich-Gregoire procedure is a technique associated with shorter postoperative hospitalization and less discomfort, pain and hematuria than the intravesical technique. Both techniques were effective in correcting VUR. Extravesical reimplantation can cause transitory bladder dysfunction in a small percentage of the bilateral cases.

Vesicoureteral reflux

Vesicoureteral reflux, the abnormal flow of urine from the bladder into the ureter, is one of the most common congenital anomalies found in children. The association of vesicoureteral reflux with urinary tract infections and renal scarring has important clinical implications. New insights into pathogenesis and new surgical techniques are changing the approach to the management of this disorder.

BILATERAL EXTRAVESICAL URETERAL REIMPLANTATION IN TOILET TRAINED CHILDREN: IS 1-DAY HOSPITALIZATION WITHOUT URINARY RETENTION POSSIBLE?

PURPOSE

Bilateral extravesical ureteral reimplantation has been associated with urinary retention. We developed a critical pathway and modification of surgical technique to determine whether the bilateral extravesical procedure could be performed in toilet trained children with patients discharged home after a 1-day hospitalization and without urinary retention.

MATERIALS AND METHODS

A total of 50 consecutive toilet trained children were evaluated after undergoing bilateral extravesical ureteral reimplantation using a modified technique that limits ureteral dissection, ureteral mobilization and detrusor dissection to as distally as possible so that a 5:1 ratio of tunnel length to ureteral diameter can be accomplished. No surgical dissection occurs in proximity to the obliterated umbilical artery, nor is the artery ligated. Patients follow a strict postoperative critical pathway, and parents receive extensive preoperative and postoperative education. A child is required to fulfill 5 strict criteria to be discharged from the hospital.

RESULTS

Patient age ranged from 1.9 to 12.8 years (mean 4.9), with 37 girls and 13 boys participating. All patients were discharged home on postoperative day 1. All patients were able to void postoperatively without any instances of urinary retention. None of the children had acute urinary tract infections or required rehospitalization. All patients had radiographic resolution of the vesicoureteral reflux on postoperative voiding cystourethrogram.

CONCLUSIONS

To our knowledge this is the first study to demonstrate that bilateral extravesical ureteroneocystostomy can be performed in selected patients without postoperative urinary retention and with uniform hospital discharge in 1 day. The critical pathway and limited dissection extravesical approach are essential for this success.

[Primary vesicoureteral reflux treatment in childhood: comparsion of two systematic review]

Many medical practices are being carried out unawares of their efficiency, or of their actual impact on the health of the patients, therefore it is necessary to consider the support of professional recommendations with scientific evidence.

THE PRIMARY OBJECTIVE

To perform a systematic review (SR) of the therapeutic management of primary VUR in pediatric urology.

MATERIAL AND METHODS

A systematic review has been performed, including scientific evidence-based medicine criteria, of the articles published in all of the available databases. Inclusion criteria concerning basic quality of the articles were considered essential, as well as exclusion criteria to be able to reject the articles.

RESULTS AND DISCUSSION

Subsequently, and following the critic reading of greater than 320 articles, statistical study of the grouped data was performed according to the type of treatment and to the benefits contributed by each treatment, and also to their undesirable effects. Finally we have made a comparison between our results and recent Cochrane Systematic Review. The following Conclusions were drawn from the results obtained and from the analysis of the texts. Both medical and surgical treatment present with similar effectiveness concerning resolution of grades I, II and III of VUR, and the former one is the recommended initial treatment following diagnosis. Endoscopic treatment is exactly as effective as open surgery for grades I, II and III with fewer undesirable effects secondary. There are no differences concerning the efficacy of the different injected substances. Not enough evidences exist for degrees IV and V that may recommend or advise against any of the treatments. In any degree of VUR, open surgical treatment is superior as far as medical treatment is concerned only regarding the number of acute pyelonephritis episodes during followup. This conclusion cannot be applied on endoscopic treatment.

Nerve sparing extravesical repair of bilateral vesicoureteral reflux: description of technique and evaluation of urinary retention

PURPOSE

Prolonged urinary retention remains a controversial and feared complication following bilateral extravesical ureteral reimplantation. We report a modified approach to limit detrusor nerve damage during extravesical correction of bilateral ureteral reflux that significantly reduces this adverse outcome.

MATERIALS AND METHODS

A modified approach to the distal detrusor dissection and ureteral mobilization, along with limited periureteral dissection, was used to perform this technique. A retrospective review of 50 patients undergoing bilateral nerve sparing extravesical ureteral reimplantation (NSEVR) by a single surgeon between 1997 and 2002 was completed. Patient age, vesicoureteral reflux (VUR) grade, length of hospital stay, length of surgery and outcome were evaluated.

RESULTS

The study included 36 girls and 14 boys, with an average age of 4 years 11 months (range 1 to 14 years). Average preoperative VUR grade was 2.61 (range 1 to 5). Average length of surgery when NSEVR was the only procedure performed was 105 minutes (range 54 to 185) and average length of hospital stay was 1.76 days (0 to 3). Transient urinary retention developed in 1 child on postoperative day 1, with a successful trial of voiding the next day. The rate of immediate urinary retention was 2%. There was no long-term urinary retention, voiding dysfunction or urinary tract infections.

CONCLUSIONS

NSEVR for the correction of bilateral VUR is a simple modification that provides a reproducible and minimally invasive approach to treatment. We believe that limited distal ureteral dissection, preservation of the medial ureterovesical hiatus and judicious manipulation of the surrounding tissues result in elimination of long-term urinary retention.

Robotically assisted surgery in pediatric urology

Robotically assisted laparoscopic surgery likely will be a part of pediatric urologic surgery. It will look different than it does now because of technologic and procedural innovations. The inherent value of precise visualization, tissue handling, and reconstruction, coupled with the reduced morbidity of laparoscopic surgery, suggests the potential value of these technologies and methods. Although there is much development to be done, the early results are encouraging. Pediatric urologists specifically, and pediatric surgical practitioners in general, must be involved in the evolution of these techniques and devices, to prevent having to adapt adult surgery-oriented systems to pediatric patients. Pediatric urologists need to be involved in this development actively to guide its course.

Vesicoureteral reflux: surgical approaches

The treatment of vesicoureteral reflux has evolved over the past half-century from primarily surgical to nonoperative treatments. Although the benefits of surgical correction versus medical management are debated, the surgical techniques that have evolved are highly effective in correcting vesicoureteral reflux. Recently, the US Food and Drug Administration has approved an injectable implant of dextranomer/hyaluronic acid copolymer for use in children, making the endoscopic treatment of reflux a potential alternative to open surgical correction. This article reviews the different surgical techniques,postoperative management, and complications, as well as the various implants used in the endoscopic correction of vesicoureteral reflux and their outcomes.

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.

Neuroanatomy of the ureterovesical junction: clinical implications

PURPOSE

The anatomy of the ureterovesical junction is germane to surgical reconstruction in patients with significant reflux. In this study we refine the description of the neuroanatomy of the distal ureter and ureterovesical junction.

MATERIALS AND METHODS

The distal ureter and bladder including the ureterovesical junction from 6 normal human fetuses (3 female and 3 male) at 21 to 40 weeks of gestation were studied using immunohistochemical analysis and 3-dimensional imaging techniques with antibodies against the nonspecific neuronal markers S-100 and nitric oxide synthase (nNOS).

RESULTS

Nerves were observed to occupy the medial aspect of the distal ureter. At the ureterovesical junction the nerves encircled the entire ureter. They traveled just outside Waldeyer's sheath, leaving a safe area for surgical dissection under the sheath. As the ureter tunneled into the bladder, the nerves localized to the lateral wall of detrusor muscle. The nerves originating from the ureter and bladder and innervating the trigonal area were immunoreactive to S-100 and nNOS. nNOS positive nerve fibers arising from the bladder and ureteral nerves were found spreading among the detrusor fibers in the trigonal area.

CONCLUSIONS

A detailed knowledge of the distal ureteral and ureterovesical junction neuroanatomy and the pathway of these nerves in relation to the anatomical landmarks is critical for preserving bladder function. Based on these anatomical dissections, we would recommend careful dissection within Waldeyer's sheath during ureteral reconstructive surgery.

Risk of detrusor denervation in antireflux surgery demonstrated in a neurophysiological animal model

PURPOSE

Earlier anatomical studies have shown a close connection between the ureterovesical junction and detrusor innervation. It prompted us to develop an animal model to demonstrate the risk of partial or complete impairment of this neuronal connection during antireflux surgery.

MATERIALS AND METHODS

Six female Göttinger minipigs were anesthetized and laminectomized. After placement of the S3 sacral nerves into separate electrode compartments of a modified Brindley electrode the lower urinary tract was exposed by an abdominal midline incision. After bladder instillation with 150 ml NaCl 1 bilateral and 2 unilateral stimulations (left and right sides) were performed and intravesical pressure was recorded urodynamically. The left ureter was then prepared circularly in 3 steps 10, 5 and 1 cm, respectively, proximal to the ureterovesical junction. After each preparation step bilateral and unilateral stimulation was repeated. Results were recorded urodynamically and video documented.

RESULTS

Bilateral stimulation before preparation of the left ureter led to a concentric detrusor contraction with an average maximum detrusor pressure of 51 cm H(2)O. Unilateral stimulation resulted in ipsilateralbound bladder tilting with an intravesical pressure of 18 and 19 cm H(2)O on the right and left sides, respectively. After preparation of the left ureter 10, 5 and 1 cm from the ureterovesical junction a maximum detrusor pressure of 17, 10 and 1 cm H(2)O was documented, respectively. While there was almost no stimulation response of the bladder after the last preparation step at 1 cm on the left ureter, the initial bladder pressure of 18 cm H(2)O could be reproduced under stimulation on the right side.

CONCLUSIONS

Analogous to human cadaver studies, we were able to prove neurophysiologically strictly unilateral detrusor innervation, drawing from the pelvic plexus dorsomedial to the ureterovesical junction into the bladder. Preparation of this ureterovesical junction during antireflex surgery, coagulating measures in this area or the affixation of anchor sutures after a Vest suture involves the risk of unilateral or bilateral detrusor decentralization.

Subureteral polydimethylsiloxane injection versus extravesical reimplantation for primary low grade vesicoureteral reflux in children: a comparative study

PURPOSE

We compare the outcome of extravesical ureteral reimplantation to endoscopic polydimethylsiloxane (Macroplastique, Uroplasty, Inc., Minneapolis, Minnesota) subureteral injection for primary low grade vesicoureteral reflux in children.

MATERIALS AND METHODS

Between 1997 and 2000, 180 patients underwent polydimethylsiloxane injection (74, 108 ureters) or extravesical ureteral reimplantation (106, 166 ureters) for low grade vesicoureteral reflux. Low grade reflux was defined as grades I to III. Outcome analysis included success rates, de novo hydronephrosis, voiding efficiency, urinary tract infections and complications.

RESULTS

Mean patient age at surgery for the injection and surgery groups was 60 and 77 months, and mean followup was 12 and 15 months, respectively. Of the patients who underwent single injection 80.6% were cured of reflux at 3 months and 91.6% were cured at last followup. Success rate after reimplantation was 95.8% at 3 months which improved to 98.8% 1 year later. The success rate was significantly different between the injection and reimplantation groups at 3 and 12 months (p <0.01). Postoperative complications in the reimplantation group included transient urinary retention after bilateral surgery in 2 patients (3.3%), suprapubic fluid collections in 2 and wound seroma in 1. No complications occurred in the polydimethylsiloxane group.

CONCLUSIONS

Extravesical ureteral reimplantation has near perfect success with a low but definite complication rate. Polydimethylsiloxane offers high success rates for reflux in an ambulatory setting with no short-term complications. Currently, endoscopic polydimethylsiloxane injection is our preferred mode of therapy for low grade vesicoureteral reflux in children when surgical correction is indicated.