Ureteral Reimplantation for Primary Obstructive Megaureter in Pediatric Patients: Is It Time for Robot-Assisted Approach?

Advancements in Surgical Management of Megaureters

PURPOSE OF REVIEW

To review and describe the recent evolution of surgery for the various types of pediatric megaureter.

RECENT FINDINGS

Megaureter management first relies on determining the underlying cause, whether by obstruction, reflux, or a combination, and then setting appropriate surgical indications because many cases do not require surgery as shown by observation studies. Endoscopic balloon dilation has been on the rise as a major treatment option for obstructive megaureter, while refluxing megaureters can also be treated by laparoscopic and robotic techniques, whether extravesically or transvesicoscopically. During ureteral reimplantation, tapering is sometimes necessary to address the enlarged ureter, but there are also considerations for not tapering or for tapering alternatives. Endoscopic and minimally invasive surgeries for megaureter have been the predominant focus of recent megaureter literature. These techniques still need collaborative prospective studies to better define which surgeries are best for patients needing megaureter interventions.

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.

High-pressure balloon dilatation of primary obstructive megaureter in children: a systematic review

OBJECTIVE

We aimed to evaluate the effectiveness and complication rates of endoscopic high-pressure balloon dilatation (HPBD) in treating primary obstructive megaureter (POM) in children based on current literature. Specifically, we wanted to clarify the evidence on the use of HPBD in children under one year of age.

METHODS

A systematic search of the literature was performed via several databases. The preferred reporting items for systematic reviews and meta-analyses guidelines were followed. The primary outcomes studied in this systematic review were the effectiveness of HBPD in relieving obstruction and reducing hydroureteronephrosis in children. The secondary outcome was to study the complication rate of endoscopic high-pressure balloon dilatation. Studies that reported one or both of these outcomes (n = 13) were considered eligible for inclusion in this review.

RESULTS

HPBD significantly decreased both ureteral diameter (15.8 mm [range 2-30] to 8.0 mm [0-30], p = 0.00009) and anteroposterior diameter of renal pelvis (16.7 mm [0-46] to 9.7 mm [0-36], p = 0.00107). The success rate was 71% after one HPBD and 79% after two HPBD. The median follow-up time was 3.6 years (interquartile range 2.2-6.4 years). A complication rate of 33% was observed, but no Clavien-Dindo grade IV-V complications were reported. Postoperative infections and VUR were detected in 12% and 7.8% of cases, respectively. For children under one year of age, outcomes of HPBD seem to be similar to those in older children.

CONCLUSIONS

This study indicates that HPBD appears to be safe and can be used as the first-line treatment for symptomatic POM. Further comparative studies are needed addressing the effect of treatment in infants, and also long-term outcomes of the treatment. Due to the nature of POM, identifying those patients who will benefit from HPBD remains challenging.

Robotic ureteral reimplantation and uretero-ureterostomy treating the ureterovesical junction pathologies in children: technical considerations and preliminary results

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR) and robotic ureteroureterostomy (RUU) are two mini-invasive surgical techniques that have begun to be performed in pediatric urology in recent years. RALUR has been employed especially for VUR treatment, while RUU is considered principally in case of complex doubled ureteral systems. Our aim is to discuss the safety and feasibility of these approaches in children, focusing on technical considerations and supporting their use in different anomalies and pathologies of the ureterovesical junction. We retrospectively collected data about 58 patients who underwent 44 dismembered RALUR (D-RALUR), 28 non-dismembered RALUR (ND-RALUR) and 5 RUU between May 2020 and December 2021. Indications for surgery were primary or secondary vesicoureteral reflux, megaureter, secondary UVJ obstructions, complicated doubled ureteral systems. Mean age was 3.5 years (range 0.6-12.9) and mean weight 17.1 (range 7.2-80). No intraoperative complications occurred nor conversion to open approach were reported. Major postoperative complications were reported in 11.7% of cases with a higher incidence for ND-RALUR. Mean hospital stay was 2.14 days (range 1-8). Success rate at the short-term follow-up was 91.9% for D-RALUR, 96.3% for ND-RALUR and 100% for RUU. RALUR and RUU are two feasible and safe procedures to perform in children. RALUR represents the most required and adequate technique in the treatment of UVJ pathologies, however, in selected cases RUU could represent an effective alternative that has to be considered.