EARLY EXPERIENCE WITH THE LAPAROSCOPIC BOARI FLAP AT A SINGLE INSTITUTION

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.

Laparoscopic ureteroneocystostomy for mid and lower ureteric strictures: Experience from a tertiary center

Purpose:

The purpose of this study is to evaluate our experience of laparoscopic ureteroneocystostomy for mid and lower ureteral stricture in a tertiary center in North India.

Materials and Methods:

A total of 20 laparoscopic ureteroneocystostomy were performed with or without bladder flap procedures in 20 patients (13 females and 7 males) with various etiologies such as ureteric stricture, ureterovaginal fistula, endometriosis, and distal ureteric tumor at our hospital in a time frame from August 2013 to January 2017. Eight cases each presented after laparoscopic/open hysterectomy and postureterorenoscopic stone removal while two cases each presented secondary to endometriosis and distal ureteric tumor. Simple laparoscopic ureteroneocystostomy in 4, psoas hitch in 9, and Boari flap was done in 7 cases.

Results:

The mean patient age was 44.2 years (range 19–65), mean surgical time was 184.25 min (115–250 min.), mean amount of bleeding was 153.25 mL (90–250 mL), and mean hospital stay was 3.05 days (2–7 days). Female-to-male ratio was 1.3:0.7. There was one conversion to open during laparoscopic Boari reimplant because of inadvertent injury to external iliac vein. The mean follow-up was 22.35 months (6–45). All the patients were asymptomatic with the resolution of hydronephrosis on ultrasound and without any significant obstruction on renal scan.

Conclusions:

Laparoscopic ureteroneocystostomy with or without bladder flap (Boari) provides good functional outcomes with excellent success rates and minimal morbidity comparable to open surgery in patients with ureteric stricture.

Laparoscopic ureteral reimplantation with Boari flap for the management of long- segment ureteral defect: A case series with review of the literature

OBJECTIVE

The incidence of ureteral stricture is showing a rising trend due to increased use of laparoscopic and upper urinary tract endoscopic procedures. Boari flap is the preferred method of repairing long- segment ureteral defects of 8-12 cm. The procedure has undergone change from classical open (transperitoneal and retroperitoneal) method to laparoscopic surgery and recently robotic surgery. Laparoscopic approach is cosmetically appealing, less morbid and with shorter hospital stay. In this case series, we report our experience of performing laparoscopic ureteral reimplantation with Boari flap in 3 patients.

MATERIAL AND METHODS

This prospective study was conducted between January 2011 December 2014. The patients with a long- segment ureteral defect who had undergone laparoscopic Boari flap reconstruction were included in the study. Outcome of laparoscopic ureteral reimplantation with Boari flap for the manangement of long segment ureteral defect was evaluated.

RESULTS

The procedure was performed on 3 patients, and male to female ratio was 1:2. One patient had bilateral and other two patient had left ureteral stricture. The mean length of ureteral stricture was 8.6 cm (range 8.2-9.2 cm). The mean operative time was 206 min (190 to 220 min). The average estimated blood loss was 100 mL (range 90-110 mL) and mean hospital stay was 6 days (range 5 to 7 days). The mean follow up was 19 months (range 17-22 months). None of the patients experienced any complication related to the procedure in perioperative period.

CONCLUSION

Laparoscopic ureteral reimplantation with Boari flap is safe, feasible and has excellent long term results. However, the procedure is technically challenging, requires extensive experience of intracorporeal suturing.

Laparoscopic extravesical ureteral reimplantation (LEVUR): a systematic review

BACKGROUND

Laparoscopic ureteral reimplantation is a feasible method for treating ureteral pathology with good preliminary results in the literature. In this study, we review medium term results for laparoscopic ureteral reimplantation and discuss current developments of this procedure.

METHODS

Medline and Embase databases were searched using relevant key terms to identify reports of paediatric laparoscopic extravesical ureteral reimplantation (LEVUR). Literature reviews, case reports, series of <3 children and adult studies (age >20 years) were excluded.

RESULTS

Five studies were assessed, overall, 69 LEVUR were performed in children. Despite different surgical technique, in all case the technique was respected. Patient demographics, preoperative symptoms, radiological imaging, complications, and postoperative outcomes were analyzed. Median success rate was 96%. Complications were reported in five cases.

CONCLUSIONS

This study is limited by the data given in the individual series: varied criteria used for patient selection and outcome as well as inconsistent pre- and post-operative imaging data precluded a meta-analysis. But it demonstrates that the laparoscopic ureteral reimplantation is an effective procedure with good medium-term results. We believe that in well selected patients this procedure will become an established treatment option.

Ureteral strictures revisited…trying to see the light at the end of the tunnel: a comprehensive review

A ureteral stricture is a rather rare urological event defined as a narrowing of the ureter causing a functional obstruction and renal failure, if left untreated. The aim of this review article is to summarize and discuss current knowledge on the incidence, pathogenesis, management, and follow up of proximal, mid, and distal ureteral strictures.

Laparoscopic ureteral replacement by Boari flap: multi-institutional experience in 30 cases

INTRODUCTION

The Boari flap is an excellent technique for replacement of distal ureteral injuries. There are few reports with the use of laparoscopic surgery, especially with long term results. Our goal is to present the results of a multi-institutional study of 30 cases.

MATERIAL AND METHODS

We analyzed 30 patients treated between December 2001 and January 2009 who underwent a laparoscopic intracorporeal Boari flap, in three Latin American centers. In all cases the same surgical technique was employed. The database was recorded prospectively and analyzed retrospectively.

RESULTS

The mean age was 43.2 years (range 9 to 71 years). Most were women (22 of 30) with a slight predominance of left-side lesions (17 of 30). The most common cause of ureteral injury was hysterectomy in 14 patients (46.6%) and endoscopic ureterolithotomy in 9 patients (30%). The mean length of ureteral resection was 7 cm. (5 to 20 cm). The average operative time was 161.16 min (90 to 280 min). The average estimated blood loss was 123 mL. (0 to 500 mL), and hospital stay was 4.86 days (2 to 10 days). There were no intraoperative complications or conversion to open surgery. Postoperative complications occurred in 5 patients (16.6%), Clavien 1 in 2 patients (6.6%) and Clavien 3 in three patients (10%). The success rate was 96.6% (29 patients) with a mean follow up of 32 months (5 to 60 months).

CONCLUSIONS

Laparoscopic Boari flap in our hands had good short and long term results.

Single-surgeon experience with robot-assisted ureteroneocystostomy for distal ureteral pathologies in adults

PURPOSE

To demonstrate our technical approach for robot-assisted ureteroneocystostomy (R-UNC) for benign and malignant distal ureteral pathologies.

MATERIALS AND METHODS

Between January 2009 and January 2013, a total of 10 patients underwent R-UNC in the distal ureter by a single surgeon. Indications for R-UNC were as follows: idiopathic (3), fistula (2), iatrogenic (2), malignancy (2), and chronic vesicoureteral reflux (1).

RESULTS

Tension-free anastomosis was attained in all 10 R-UNC procedures. A psoas hitch was performed in 6/10 cases (60%). Intravesical and extravesical reimplantations were completed in 5/10 (50%) and 5/10 cases (50%), respectively. A nonrefluxing ureter was constructed in 2/10 cases (20%). The patients' mean age was 52.9±16.6 years, their mean body mass index was 30.8±6.3 kg/m(2), the mean operative time was 211.7±69.3 minutes, mean estimated blood loss was 102.5±110.8 mL, and mean length of stay was 2.8±2.3 days. There were no intraoperative complications. There was one Clavien-Dindo grade I and one Clavien-Dindo grade II postoperative complication. The mean postoperative follow-up duration was 28.5±15.5 months. Two patients had recurrence of ureteral strictures at 3 months postoperatively and were managed successfully with balloon dilation.

CONCLUSIONS

Our technique for R-UNC demonstrates good perioperative outcomes. However, underlying periureteral inflammation and pelvic adhesions may predispose patients for stricture recurrence after R-UNC.

Laparoscopic reconstruction of iatrogenic-induced lower ureteric strictures: Does timing of repair influence the outcome?

CONTEXT

Influence of timing of repair on outcome following laparoscopic reconstruction of lower ureteric strictures

AIMS

To assess the influence of timing of repair on outcome following laparoscopic reconstruction of lower ureteric strictures in our adult patient population.

SETTINGS AND DESIGN

Single surgeon operative experience in two institutes. Retrospective analysis.

MATERIALS AND METHODS

All patients were worked up in detail. All patients underwent cystoscopy and retrograde pyelography prior to laparoscopic approach. Patients were categorised into two groups: early repair (within seven days of inciting event) and delayed repair (after two weeks). Operative parameters and postoperative events were recorded. Postprocedure all patients were evaluated three monthly. Follow-up imaging was ordered at six months postoperatively. Improvement in renal function, resolution of hydronephrosis and unhindered drainage of contrast through the reconstructed unit on follow-up imaging was interpreted as a satisfactory outcome.

STATISTICAL ANALYSIS USED

Mean, standard deviation, equal variance t test, Mann Whitney Z test, Aspin-Welch unequal variance t test.

RESULTS

Thirty-six patients (37 units, 36 unilateral and 1 simultaneous bilateral) underwent laparoscopic ureteral reconstruction of lower ureteric stricture following iatrogenic injury - 21 early repair (Group I) and 15 delayed repair (Group II). All patients were hemodynamically stable at presentation. Early repair was more technically demanding with increased operation duration. There was no difference in blood loss, operative complications, postoperative parameters, or longterm outcome.

CONCLUSIONS

In hemodynamically stable patients, laparoscopic repair of iatrogenically induced lower ureteric strictures can be conveniently undertaken without undue delay from the inciting event. Compared to delayed repairs, the procedure is technically more demanding but morbidity incurred and outcome is at par.

Laparoscopic reconstructive urology

Objective:

Laparoscopic reconstructive urology is undergoing rapid change. We review the current status of laparoscopic reconstructive urology, with particular respect to pyeloplasty and reconstructive ureteric surgery.

Methods:

An extensive Medline search of reconstructive laparoscopic procedures was undertaken. The initial reports and large series reports of a range of procedures was examined and summarised. The most commonly practised procedure within this remit is laparoscopic pyeloplasty. Several series of over 100 patients have been published. Success rates average over 90% for laparoscopic pyeloplasty with a low complication rate. Much less common laparoscopic reconstructive urological procedures include ureteric re-implantation, Boari flap, urinary diversion and transuretero-ureterostomy. The results of these are encouraging.

Conclusions:

Laparoscopic pyeloplasty may be safely performed by either the transperitoneal or retroperitoneal routes with excellent results. It should be considered the “gold standard” for the management of UPJ obstruction, especially in those patients with significant hydronephrosis, renal impairment or a crossing vessel. Laparoscopic ureteric reimplantation, Boari flap, urinary diversion and transuretero-ureterostomy have been performed by experienced laparoscopic urologists with encouraging results.

Role of laparoscopy in reconstructive surgery

PURPOSE OF REVIEW

Despite increasing laparoscopic expertise in reconstructive surgery, open procedures still represent the gold standard. Robot-assisted techniques increasingly replace laparoscopy. However, laparoscopy is also developing: by improvement of ergonomics, new instruments, and techniques further reducing access trauma. We evaluated the actual role of laparoscopy focusing on main indications of urologic reconstructive surgery.

RECENT FINDINGS

We analysed the current literature (PubMed/Medline) concerning indications, perioperative results, complications, and long-term outcome of laparoscopy for pyeloplasty, ureteral reimplantation, stone surgery, management of vesico-vaginal fistula, sacrocolpopexy (including evidence level). For all indications, laparoscopy provides the advantages of less postoperative pain, blood loss, shorter convalescence, and minimal disfigurement. However, it requires expertise with endoscopic suturing. Most experience (N > 1000) exists with laparoscopic pyeloplasty and sacrocolpopexy which can be considered as valuable options (IIB). Concerning ureteral reimplantation and repair of vesico-vaginal fistula, only a limited number of cases were reported (N < 150) (III). Laparoscopic stone surgery may gain importance particularly in developing countries. Robot-assistance will definitively increase the application of laparoscopic techniques providing optimal ergonomics, whereas the role of single-port surgery will be limited.

SUMMARY

Laparoscopy will increasingly be used for reconstructive urologic surgery. This trend will be supported by the widespread use of the DaVinci device.

[Treatment of distal ureteral stricture by laparoscopic ureterovesical reimplantation]

INTRODUCTION

to analyse the results achieved to treat iliac or pelvic ureteric stricture using laparoscopic reimplantation of the ureter in a psoic bladder.

MATERIAL AND METHOD

in a four-year period, we performed laparoscopic ureteral reimplantation in a psoic bladder in 6 patients (right/left 1:1; male/female 1:2; mean age 59.2 years, range 47-87). In 4 cases the lesion was iatrogenic and in 2 cases idiopathic. Ureteral resection with bladder cuff and cystorraphy followed by ipsilateral lymph node dissection was performed in idiopathic cases or those with history of previous urothelial tumour (4 cases in total) before ureteral reimplantation. Bladder was extensively mobilized and fixed to minor psoas tendon before performing ureteroneocystostomy. Mixed intra and extravesical technique with submucosal tunnel (Politano) was used in a case and in the remaining 5 cases extravesical technique with submucosal tunnel (Goodwin) was used. Mean follow-up was 26 months (range 18-34).

RESULTS

there was no need to convert to open surgery. Time of surgery was 230 minutes in the case treated with Politano ureteroneocystostomy and 120 (range 75-150) in those treated purely extravesically. The mean hospital stay was 3.2 days (range 2-5). There were no intra or postoperative complications. Histologic assessment always revealed ureteral fibrosis and in 2 cases accompanying granulomatous inflammation and dysplasia. No patient suffered re-stricture or impairment in renal function during follow-up.

CONCLUSIONS

laparoscopic ureteral reimplantation is an effective and safe minimally invasive technique to treat benign distal stricture of the ureter. Simplicity of extravesical reimplantation has an advantage over its intravesical counterpart.

Laparoscopic ureteral reimplantation: prospective evaluation of medium-term results and current developments

OBJECTIVE

Laparoscopic ureteral reimplantation is a feasible method for treating ureteral pathology with good preliminary results in the literature. In this study, we review our medium-term results for laparoscopic ureteral reimplantation and discuss current developments of this procedure.

MATERIALS AND METHODS

Twenty-four laparoscopic ureteral reimplantations were performed between August 2003 and December 2008 for ureteral strictures or ureteral injuries. The mean age was 53.5 years (8 men, 16 women). Patient demographics, preoperative symptoms, radiological imaging, complications, and postoperative outcomes were analyzed. Ten patients underwent vesicopsoas-hitch, nine patients had a vesicopsoas-hitch combined with Boari-flap, and five had Lich-Gregoir extravesical ureteral reimplantations. Success was defined as relief of obstruction on postoperative imaging studies, as well as symptomatic relief.

RESULTS

Laparoscopic ureteral reimplantations were successfully performed in all patients. The mean operative time was 215 min (131-351). Mean estimated blood loss was 283 ml (50-550). One patient had an intraoperative bowel injury which was managed laparoscopically during the same procedure. There were two postoperative complications; two prolonged ileus and one deep venous thrombosis (DVT). Mean hospital stay was 8.7 days. Average time to return to normal activity was 2.6 weeks. Postoperative radiological imaging studies showed good drainage, without hydronephrosis, in 23 patients (success rate 95.8 %) at a median follow up interval of 35 months.

CONCLUSIONS

Laparoscopic ureteral reimplantation is an effective procedure with good medium-term results. We believe that this procedure will become an established treatment option.

Expanding the horizons: robot-assisted reconstructive surgery of the distal ureter

OBJECTIVES

To report our single-center experience with robotic ureteroneocystostomy for the treatment of distal ureteral obstruction.

METHODS

We performed robot-assisted laparoscopic ureteroneocystostomies between May 2005 and October 2007. We retrospectively collected information on patient demographics, and compared renal scans with furosemide washout and radiographic imaging before and after repair to determine radiographic success. Statistical analysis was performed using statistical software via paired Student's t test analysis.

RESULTS

Eight robot-assisted laparoscopic ureteroneocystostomies on seven patients were performed over a 30-month period. The etiology of the ureteric stricture was iatrogenic injury after hysterectomy in three patients, impacted stone in three, and infiltrative endometriosis in one. Mean stricture length was 2.2 cm. Right ureteroneocystostomy was performed in five patients and on the left in one, while one patient had bilateral disease. Mean operative time was 247 minutes (range 120-480), and average blood loss was 109 mL (range 50-200). Mean length of hospital stay was 2 days. All the procedures were completed successfully robotically without open conversion. Of the seven patients, one patient experienced recurrent symptoms. Subsequent imaging confirmed an anastomotic narrowing, which was treated by balloon dilation. There were no intraoperative or postoperative complications. Subsequent (99m)Tc-mercaptoacetyltriglycine scans showed no evidence of obstruction. After a mean follow-up of 18 months (range 5-31), relative renal function of the entire group of patients improved after ureteroneocystostomy, although this did not achieve statistical significance (p = 0.26).

CONCLUSIONS

Robotic ureteroneocystostomy is a safe and effective treatment option for the management of distal ureteric stricture disease.

Technical modifications to laparoscopic Boari flap

INTRODUCTION

To describe technical modifications to the laparoscopic Boari flap ureteroneocystostomy procedure.

TECHNICAL CONSIDERATIONS

Removal of ureteral stents with conversion to percutaneous nephrostomy drainage before surgery allowed for optimization of tissue quality and visualization during operative repair. Adherence to specific dimensional ratios during flap excision consistently provided for adequate tissue for successful Boari flap construction. A mucosal modification to the Boari flap allowed for an increase in the circumference of the anastomosis and provided an additional means to fortify the suture line and promote healing. Raised mucosal flaps on the Boari flap facilitated construction of a nonrefluxing anastomosis. Finally, a 2-mm needlescopic port placed at the level of the anastomosis facilitated simplified intracorporeal double-J ureteral placement.

CONCLUSIONS

Laparoscopic Boari flap ureteroneocystostomy is an effective treatment of distal ureteral stricture disease. The technical modifications describe in this report aim to contribute to increased success rates in patients who undergo this procedure.

Case Report: Laparoscopic Boari Flap

A Boari flap may be required to bridge long defects of the middle and lower ureter to the bladder. Laparoscopic construction of a Boari flap was performed in a patient with a ureteral stricture secondary to iatrogenic injury. The salient steps performed were spatulation of the transected ureteral end, fashioning of a Boari flap from the bladder, end-to-side anastomosis of the ureter to the flap, placement of a stent with the aid of a suction cannula, and closure of the flap over the stent. A Boari flap can be accomplished laparoscopically with minimal morbidity.

Ureteral reimplantation for management of ureteral strictures: a retrospective comparison of laparoscopic and open techniques

OBJECTIVES

To compare the results of laparoscopic ureteral reimplantation with a previous series of open surgery.

MATERIALS AND METHODS

We compared ten patients who underwent laparoscopic vesicopsoas-hitch with (n=4) or without Boari-flap (n=6) technique for ureteral obstructions with ten patients treated by open ureteroneocystostomy for similar pathologies. Patient demographics, preoperative symptoms, radiologic imaging, and postoperative outcomes were analyzed. Postoperative observation time averaged 17 mo (range: 9-23) in the laparoscopic and 65 mo (range: 18-108) in the open group. Success was defined as relief of obstruction in postoperative imaging studies and relief of pain.

RESULTS

Mean length of stricture (28.5 vs. 25 mm) was comparable in both groups. In laparoscopy versus open surgery, mean operative time (228 vs. 187 min) was longer, blood loss (370 vs. 610 ml) and analgesic requirement (4.9 vs. 21.5mg) were significantly lower, and mean time to oral intake (1.5 vs. 2.9 d), hospital stay (9.2 vs. 19.1 d), and convalescence time (2.3 vs. 4.2 wk) were significantly shorter. Success rates yielded 10 of 10 after laparoscopy and 8 of 10 after open surgery. No intra- or postoperative major complications occurred in the laparoscopic series. After open surgery, two patients had major postoperative complications, including urinary extravasation with abdominal haematoma and anastomostic stricture, respectively.

CONCLUSIONS

Laparoscopic ureteroneocystostomy is feasible, providing functional outcomes comparable to open surgery while offering the advantages of a minimal invasive technique (e.g., less postoperative analgesics, and shorter hospitalization and convalescence). Nevertheless, it requires a high level of laparoscopic expertise and should be carried out only in specialist centers.

[Complications of laparoscopic urological procedures]

Laparoscopic urology has evolved considerably during last decade as well as number and spectrum of surgical related complications. Experiences reported by laparoscopic trained groups allow preventing, promptly recognizing, and safe and efficient management of the laparoscopic related complications. We present our complications in all patients undergoing urological laparoscopic procedures from November 1992 to June 2005. A literature search was conduced to evaluate complications of every laparoscopic procedure.