Pure laparoscopic and robot-assisted laparoscopic reconstructive surgery in congenital megaureter: a single institution experience

Primary non-refluxing megaureter: Natural history, follow-up and treatment

Primary non-refluxing megaureter (PMU) is a congenital dilation of the ureter which is not related to vesicoureteral reflux, duplicated collecting systems, ureterocele, ectopic ureter, or posterior urethral valves and accounts for 5 to 10% of all prenatal hydronephrosis (HN) cases. The etiology is a dysfunction or stenosis of the distal ureter. Most often PMU remains asymptomatic with spontaneous resolution allowing for non-operative management. Nevertheless, in selective cases such as the development of febrile urinary tract infections, worsening of the ureteral dilatation, or reduction in relative renal function, surgery should be considered.

CONCLUSION

Ureteral replantation with excision of the dysfunctional ureteral segment and often ureteral tapering is the gold-standard procedure for PMU, although endoscopic treatment has been shown to have a fair success rate in many studies. In this review, we discuss the natural history, follow-up, and treatment of PMU.

WHAT IS KNOWN

• PMU is the result of an atonic or stenotic segment of the distal ureter, resulting in congenital dilation of the ureter, and is frequently diagnosed on routine antenatal ultrasound.

WHAT IS NEW

• Most often, PMU remains asymptomatic and clinically stable, allowing for non-operative management. • Nevertheless, since symptoms can appear even after years of observation, long-term ultrasound follow-up is recommended, even up to young adulthood, if hydroureteronephrosis persists. • Ureteral replantation is the gold standard in case surgery is needed. In selected cases, however, HPBD could be a reasonable alternative.

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.

Minimally invasive ureteral reimplantation or endoscopic management for primary obstructive megaureter: a narrative review of technical modifications and clinical outcomes

Background and Objective

Primary obstructive megaureter (POM) has various courses in different age populations. Although open ureteral reimplantation (OUR) remains the standard treatment for symptomatic POM, it is highly invasive with potential complications. In recent years, minimally invasive ureteral reimplantation (MIUR), including laparoscopic ureteral reimplantation (LUR) and robotic-assisted laparoscopic ureteral reimplantation (RALUR), and endoscopic management, such as double-J stent insertion, endoureterotomy and endoscopic balloon dilatation (EBD), have been utilized for POM in selected patients. However, few comparable studies between MIUR and endoscopic management have been published to date, and it remains unclear which surgical management is the optimal choice for POM in different age groups. This review provides a comprehensive perspective on technical development and clinical outcomes of MIUR and endoscopic management for POM in pediatric and adult populations.

Methods

The PubMed and Web of Science databases were used to comprehensively search English language articles related to MIUR and endoscopic management for POM in pediatric and adult populations up to March 2022. The technical modifications and the relevant clinical outcomes were reviewed.

Key Content and Findings

MIUR with various technical modifications related to intracorporeal suturing and ureteroneocystostomy with anti-reflux techniques appears to be as safe and effective for POM in different age groups as the open procedure. Double-J stent insertion should be regarded as a temporary option for infants by achieving internal urinary drainage, as it may present limited success rates and various complications. Endoureterotomy using pure cutting current or laser appears to be a safer, easier, and less invasive alternative to open surgical management. While EBD has emerged as a definite treatment for POM in the pediatric population, it is debatable whether EBD can substitute for MIUR in adult patients.

Conclusions

The safety and feasibility of MIUR and endoscopic management in patients from all age groups still need further investigation.

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

Objective: To compare open and robotic approach for treatment of Primary Obstructive Megaureter (POM) in a series of pediatric patients. Materials and Methods: Medical records of all patients who had undergone ureteral reimplantation for POM at our institution, between January 2016 and December 2019, were retrospectively collected and analyzed. Open (Group B) and robotic (Group A) approach were compared. Success was defined as reduction of anteroposterior diameter of pelvis and ureter on postoperative ultrasound scan. Surgical complications were reported according to the Clavien-Dindo Classification. Esthetic results were compared through the Vancouver Scar Scale. Results: Out of 23 patients, 11 belonged to Group A (5M and 6F) and 12 to Group B (9M and 3F). Median age at diagnosis was 38 months in Group A and 46 months in Group B (P = .69). Operative times were comparable (150' Group A and 140' Group B; P = .35), but the hospital stay was significantly shorter in the robotic group (P < .01). Success rate was comparable: 90.9% in Group A and 91.7% in Group B, respectively (P = .95). Incidence of early complications was 9.1% in Group A (grade IIIB) and 8.3% in Group B (grade II) (P = .95). Esthetic evaluation obtained a median score of 1 in Group A and 3 in Group B (P < .01). Conclusions: Our preliminary experience shows that robotic reimplantation can be a safe option in the treatment of POM in pediatric patients with clinical outcomes comparable to the open technique.

Robotic Ureteral Reconstruction in the Pediatric Population

Robot-assisted laparoscopic (RAL) surgery is a safe, minimally invasive technique that has become more widely used in pediatric urology over recent decades. With several advantages over standard laparoscopy, robotic surgery is particularly well-suited to reconstructive surgery involving delicate structures like the ureter. A robotic approach provides excellent access to and visualization of the ureter at all levels. Common applications include upper ureteral reconstruction (e.g., pyeloplasty, ureteropelvic junction polypectomy, ureterocalicostomy, and high uretero-ureterostomy in duplex systems), mid-ureteral reconstruction (e.g., mid uretero-ureterostomy for stricture or polyp), and lower ureteral reconstruction (e.g., ureteral reimplantation and lower ureter-ureterostomy in duplex systems). Herein, we describe each of these robotic procedures in detail.

Laparoscopic ureteral reimplantation with extracorporeal tailoring and direct nipple ureteroneocystostomy for adult obstructive megaureter: long-term outcomes and comparison to open procedure

PURPOSE

To evaluate the long-term outcomes of laparoscopic ureteral reimplantation with extracorporeal tailoring and direct nipple ureteroneocystostomy for adult obstructive megaureter and compare the results with the open procedure.

METHODS

From January 2007 to July 2013, 22 patients underwent laparoscopic and 28 patients underwent open ureteral reimplantation for adult obstructive megaureter. For laparoscopic group, the dilated ureter was delivered out of through a 12-mm port and the distal end was tailored and formed into an antireflux nipple extracorporeally. The ureteral nipple was intracorporeally reimplanted into the posterolateral wall of the bladder. Demographics, complications and follow-up data were analyzed and compared retrospectively between the groups.

RESULTS

Baseline characteristics including age, gender, body mass index, affected side, age at diagnosis and follow-up time were statistically similar for the groups. All of the surgeries were performed successfully, and no major complications occurred. Comparing with the open group, the use of our novel laparoscopic procedure resulted in less estimated blood loss (50.0 vs. 71.0 ml; P = 0.001), less narcotic analgesic (3.0 vs. 18.0 mg; P = 0.01) and shorter hospital stay (5.1 vs. 7.9 days; P < 0.001). Long-term outcomes including rates of recurrent ureteral stricture (4.5 vs. 0%; P = 0.25), rates of vesicoureteral reflux (9.1 vs. 3.6%, P = 0.42) and success rates (86.4 vs. 96.9%; P = 0.45) did not significantly differ between the two groups.

CONCLUSION

Laparoscopic ureteral reimplantation with extracorporeal tailoring and direct nipple ureteroneocystostomy is a safe and equally effective as the open surgery for the long-term outcomes of adult obstructive megaureter.