Evolving surgical management of pediatric vesicoureteral reflux: is open ureteral reimplantation still the 'Gold Standard'?

Minimally Invasive versus Open Ureteral Reimplantation in Children: A Systematic Review and Meta-Analysis

PURPOSE

 We performed a systematic review and meta-analysis to compare the safety and efficacy of minimally invasive surgery (MIS) versus open ureteral reimplantation (OUR) in children.

METHODS

 Literature searches were conducted to identify studies that compared MIS (laparoscopic ureteral reimplantation or robot-assisted laparoscopic ureteral replantation) and OUR in children. Parameters such as operative time, blood loss, length of hospital stay, success rate, postoperative urinary tract infection (UTI), urinary retention, postoperative hematuria, wound infection, and overall postoperative complications were pooled and compared by meta-analysis.

RESULTS

 Among the 7,882 pediatric participants in the 14 studies, 852 received MIS, and 7,030 received OUR. When compared with the OUR, the MIS approach resulted in shorter hospital stays (I 2 = 99%, weighted mean difference [WMD] -2.82, 95% confidence interval [CI] -4.22 to -1.41; p < 0.001), less blood loss (I 2 = 100%, WMD -12.65, 95% CI -24.82 to -0.48; p = 0.04), and less wound infection (I 2 = 0%, odds ratio 0.23, 95% CI 0.06-0.78; p = 0.02). However, no significant difference was found in operative time and secondary outcomes such as postoperative UTI, urinary retention, postoperative hematuria, and overall postoperative complications.

CONCLUSION

 MIS is a safe, feasible, and effective surgical procedure in children when compared with OUR. Compared with OUR, MIS has a shorter hospital stay, less blood loss, and less wound infection. Furthermore, MIS is equivalent to OUR in terms of success rate and secondary outcomes such as postoperative UTI, urinary retention, postoperative hematuria, and overall postoperative complications. We conclude that MIS should be considered an acceptable option for pediatric ureteral reimplantation.

Vesicoureteral reflux severity is not associated with unplanned urinary catheterization or length of hospital stay after ureteroneocystostomy

INTRODUCTION

Vesicoureteral reflux (VUR) is a common urologic condition affecting approximately 1% of all children. Surgical success often depends on the grade of VUR, as patients with grades 4 or 5 have been have a greater risk for postoperative complications. Unplanned urinary catheter placement (UCP) postoperatively and prolonged length of hospital stay (LOS) are indicative of unexpected complications. The association between VUR severity and such metrics remain unclear.

OBJECTIVE

The study's objective is to determine if the severity of VUR is associated with higher rates of UCP or prolonged LOS after ureteroneocystostomy (UNC).

STUDY DESIGN

The 2020 National Surgical Quality Improvement Program Pediatric database was analyzed for patients with VUR. A total of 1742 patients were initially evaluated with 1373 meeting exclusion criteria. The patients were divided into 3 groups of varying voiding cystourethrogram (VCUG) or radionuclide cystogram (RNC) severity: VCUG Grade 1 or RNC Grade 1 (Group A), VCUG Grade 2 or 3 or RNC Grade 2 (Group B), and VCUG Grade 4 or 5 or RNC Grade 3 (Group C). Basic statistical analysis was performed, and logistic regression was performed with both UCP and LOS as dependent variables.

RESULTS

Among the 1373 patients, 2.9% were included in Group A, 32.5% were in Group B, and 64.6% were in Group C. Significant differences were found among the groups for mean age, gender, inpatient status, rate of congenital malformation, ureteral stents, and ASA classification. Regarding surgical treatment, differences were also found comparing mean operative time, LOS, laterality and type of procedure, urine culture results, rates of UTI, surgical site infections, postoperative returns to the emergency department, and unplanned procedures and catheterization. Multivariate analysis demonstrated no significant association between the rate of UCP and VUR severity, while postoperative UTI and unplanned procedure were both independent factors associated with UCP postoperatively. Additionally, postoperative UTI, ASA classification, mean operation time, ureteral stent placement, unplanned procedure, and UCP were independent factors found to contribute to LOS.

CONCLUSION

Greater VUR severity does not appear to increase the need for catheterization or prolong hospital stay, while the development of a UTI postoperatively or having an additional unplanned procedure are associated with an increased likelihood of both. The postoperative course after UNC also appears to be influenced more so by other factors such as the operative approach and whether complications arise.

Vesicoscopic vs. Open Ureteral Reimplantation According to Cohen and Leadbetter-Politano for Vesicoureteral Reflux

BACKGROUND

The minimally invasive implementations of the established open methods for the correction of primary vesicoureteral reflux have proven to be successful in terms of feasibility and safety. The aim of this study was to investigate to what extent pediatric patients benefit from vesicoscopic operations.

METHODS

Between 2010 and 2022, 224 children (359 ureters) underwent ureteral reimplantation for vesicoureteral reflux in our clinic. Children, operated on according to the COHEN technique, underwent an open approach in 39 cases, whereas 151 patients were operated on vesicoscopically. A total of thirty-four children have received a ureteral reimplantation according to the LEADBETTER-POLITANO technique: twenty-nine openly and five vesicoscopically. The open and vesicoscopic groups were compared with regards to perioperative data and postoperative course.

RESULTS

The mean operating time was significantly shorter for open than for the vesicoscopic procedures in the COHEN group (99 vs. 149 min, p < 0.001). Similarly, a comparison of ureteral reimplantations, according to LEADBETTER-POLITANO, favored the open procedure, although this was not significant (161 vs. 196 min, p = 0.135). There was no significant difference in the recurrence rate of all the groups. All procedures remained within the accepted range with a success rate of at least 96%. In the postoperative course, a significantly shorter hospital stay (4.1 vs. 7.9 days, p < 0.001 for COHEN-patients; 5.6 vs. 9.2 days for LEADBETTER-POLITANO-patients), as well as a significantly lower need for continuous analgesic administration, was observed for the vesicoscopic approaches of both methods (0.8 days in both vesicoscopic groups vs. 3.7 resp. 3.8 days in open groups, p < 0.001). In addition, the time of bladder drainage was significantly shorter in open techniques (7.2 vs. 1.9 days, p < 0.001 for COHEN-patients; 3 vs. 8.7 days for LEADBETTER-POLITANO-patients).

CONCLUSIONS

For almost all underlying causes, the surgical treatment of vesicoureteral reflux can be performed vesicoscopically, even if bilateral, in one session. Patients benefit significantly from the use of minimally invasive surgery in the postoperative course with faster mobilization, less need for analgesics, a shorter bladder drainage and a reduced hospital stay, compared with its open counterparts.

Pediatric robotic urologic procedures: Indications and outcomes

Introduction

Robotic-assisted laparoscopic surgery (RALS) has revolutionized minimally invasive surgery in pediatric urology. The robotic platform allows surgeons to maintain the benefits of laparoscopic surgery while having enhanced three-dimensional view, dexterity, range of motion, and control of high-resolution cameras. In this review, we summarize the indications and recent outcomes for various pediatric urologic RALS procedures to illustrate the current state of robotics in pediatric urology.

Methods

We systematically searched the PubMed and EMBASE databases. We extrapolated and summarized recent evidence on RALS in pediatric urology patients, with an emphasis on indications and outcomes, with regard to the following procedures and search terms: pyeloplasty, kidney stone surgery, partial nephrectomy, nephroureterectomy, ureteral reimplantation, appendico-vesicostomy, augmentation cystoplasty, bladder neck reconstruction, and Malone antegrade continence enema. Additional Medical Subject Headings terms used to augment the search included "Treatment Outcome" and "Robotic Surgical Procedures."

Results

Increasing usage of RALS has shown many benefits in perioperative and postoperative outcomes. In addition, there is growing evidence that robotic procedures in pediatric urology result in similar or better surgical outcomes when compared to the standard of care.

Conclusions

RALS has shown considerable effectiveness in pediatric urologic procedures and may achieve surgical outcomes comparable to the standard approaches of open or laparoscopic surgery. However, larger case series and prospective randomized controlled trials are still necessary to validate the reported outcomes, in addition to cost analyses and studies on the surgical learning curve. We believe that the continuous evolution of robotic platforms will allow for enhanced care and quality of life for pediatric urology patients.

Vesicoscopic ureteral reimplantation with a modified Glenn-Anderson technique for vesicoureteral reflux

INTRODUCTION

Vesicoureteral reflux (VUR), commonly referred to as urinary reflux, is one of the most common congenital urological anomaly to occur during childhood. Historically, open vesicoureteral reimplantation has been the gold standard in the surgical treatment of VUR. Currently, vesicoscopic ureteral reimplantation is used as a minimally invasive alternative to open ureteral reimplantation. Most vesicoscopic procedures are performed using the transtrigonal Cohen technique. As a non-transtrigonal technique, the vesicoscopic Politano-Leadbetter technique is also performed, but requires dissection outside the bladder under a narrow surgical field, and in boy carries a risk of vas deferens injury.

OBJECTIVE

This study evaluated surgical outcomes and perioperative findings for vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique in children with VUR.

STUDY DESIGN

Eighteen consecutive children who underwent vesicoureteral ureteral reimplantation using a modified Glenn-Anderson technique were included in this study. The surgical procedure was explained and surgical outcomes and perioperative findings were evaluated.

RESULTS

Patients comprised 9 boys and 9 girls with 29 cases of ureteral reflux (7 unilateral cases, 11 bilateral cases). All procedures were performed laparoscopically, with no cases requiring conversion to open surgery. Median operative time was 143 min for unilateral VUR and 194 min for bilateral VUR. Only one case showed a complication (Clavien-Dindo grade 1). The remaining 17 cases showed no complications, with removal of the urethral catheter and discharge 2 days postoperatively. Seventeen of the 18 cases underwent postoperative voiding cystourethrography, showing no VUR in all cases.

DISCUSSION

Vesicoscopic ureteral reimplantation is a minimally invasive alternative to open surgery, with most procedures performed using a transtrigonal Cohen technique. Regardless of whether the surgery is open or laparoscopic, a disadvantage of the Cohen technique is that postoperative transureteral treatment may not be possible. The Politano-Leadbetter technique has been reported as a non-transtrigonal technique. However, this requires dissection outside the bladder under a narrow surgical field, and carries a risk of vas deferens injury in boys. In this study, vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique provided good surgical outcomes with minimal perioperative complications and easy manipulation under a wide field of view.

CONCLUSION

Although many minimally invasive treatments are available, vesicoscopic ureteral reimplantation using a modified Glenn-Anderson technique is safe and effective for patients with VUR 4 years old. To demonstrate the further utility of this procedure, long-term outcomes and safety evaluations are needed in a larger number of cases.

Pediatric robot-assisted extravesical ureteral reimplantation (revur) in simple and complex ureter anatomy: Report of a multicenter experience

BACKGROUND

Robot-assisted extravesical ureteral reimplantation (REVUR) is a well established approach for surgical treatment of pediatric vesicoureteral reflux (VUR). However, further evidence is needed to confirm its efficacy even in case of complex anatomy.

OBJECTIVE

This study aimed to further confirm the evidence that REVUR is safe and effective in both simple and complex ureter anatomy.

STUDY DESIGN

The charts of all patients with VUR, who received REVUR in 6 different institutions over a 5-year period, were retrospectively reviewed. Patients with both simple and complex ureter anatomy were included. Patient demographics, surgical variables, and post-operative results were assessed. VUR resolution was defined as either being resolved VUR on voiding cystourethrogram (VCUG) or clinically without symptoms during the follow-up.

RESULTS

Fifty-seven patients with median age of 6.9 years (range 4.5-12), receiving REVUR in the study period, were included. Eighteen (31.6%) patients had complex anatomy and included prior failed endoscopic injection (n = 13), complete ureteral duplication (n = 2), periureteral diverticulum (n = 2), ectopic megaureter requiring dismembering (n = 1). The median operative time was 155 min for unilateral and 211.5 min for bilateral repairs. The clinical + radiographic VUR resolution rate was 96.5%. Post-operative complications (Clavien 2) included urinary retention following bilateral repair (n = 5, 8.7%), febrile urinary tract infection (UTI) (n = 6, 10.5%) and gross hematuria (n = 3, 5.2%). Comparative analysis between simple and complex cases showed that REVUR was faster in simple cases in both unilateral [p = 0.002] and bilateral repair [p = 0.001] and post-operative urinary retention was more frequent in simple cases [p = 0.004] and in patients with pre-operative bowel and bladder dysfunction (BBD) [p = 0.001] (Table).

DISCUSSION

This series confirmed that the robot-assisted technique was feasible even in cases with complex anatomy using some technical refinements, that justified the longer operative times in both unilateral and bilateral cases. An interesting finding of this study was the correlation emerged between BBD and risk of post-operative urinary retention and VUR persistence. Our results also excluded any significant correlation between complex cases and risk of post-operative urinary retention. The main study limitations included the retrospective and nonrandomized design, the small number of cases and the arbitrary definition of complex anatomy.

CONCLUSION

REVUR was safe and effective for management of VUR in both simple and complex ureter anatomy. Complex REVUR required slightly longer operative times, without significant differences in post-operative mordidity and success rates. Aside from complex anatomy, BBD emerged as the main risk factor associated with surgical failure and post-operative morbidity.

Robot-Assisted versus Trans-Umbilical Multiport Laparoscopic Ureteral Reimplantation for Pediatric Benign Distal Ureteral Stricture: Mid-Term Results at a Single Center

Objective: Robot-assisted laparoscopic ureteral reimplantation (RALUR) and trans-umbilical multiport laparoscopic ureteral reimplantation (TMLUR) are both minimally invasive procedures for benign distal ureteral stricture (DUS). However, TMLUR has rarely been reported in published research, thus the difference in mid-term outcome of these two procedures warrants investigation. Methods: Patients who underwent RALUR or TMLUR for pediatric DUS from April 2017 to November 2020 at our institution were retrospectively analyzed and 56 patients were included in this retrospective comparison. Demographic characteristics, perioperative data and follow-up results were collected and analyzed in RALUR and TALUR groups. Results: RALUR and TMLUR were successfully performed in children aged from 12.0 to 142.0 months, without conversion to open ureteral reimplantation. RALUR took shorter operative time than TMLUR (p = 0.005) with less blood loss (p = 0.001). Meanwhile, patients receiving RALUR encountered a greater financial burden (p < 0.001) with less cosmetic satisfaction than TMLUR. The mean mid-term follow-up time for RALUR and TMLUR was 18.29 months and 24.64 months, respectively. Mid-term follow-up data showed that DUS was relieved with improved renal function after surgery in both groups, with no significant difference. Conclusions: RALUR and TMLUR are both safe and efficient for DUS treatment and achieve comparable mid-term outcomes in children. RALUR can reduce operative time and operative blood loss benefiting from its prominent technical superiority, but may currently bring about greater financial burden, with cosmetic satisfaction remaining to be improved.

Efficacy and safety of robot-assisted laparoscopic, laparoscopic and open surgery in ureteral reimplantation: a network meta-analysis and systematic review

To compare the efficacy and safety between open ureteral replantation (OUR), laparoscopic ureteral replantation (LUR) and robot-assisted laparoscopic ureteral replantation (RALUR). This review produced by the R3.5.0 software with "gemtc" program package and JAGS3.4.0 software based on the Bayesian model. A comprehensive search was done in databases including PubMed, Web of Science, Embase, Cochrane library, Cnki, CBM and WANFANG DATA. Studies that compared OUR, LUR OR RALUR were selected. Summary of Conclusions by ranking of Outcomes. A total of 3949 patients from 29 studies were included. The success rate in OUR, LUR and RALUR was 97.72%, 94.68% and 95.82%. The OR (95% CI) of LUR and RALUR was 0.76 (0.42,1.7) and 0.76 (0.30, 2.6), respectively, compared with OUR. The rate of complications in OUR, LUR and RALUR was 12.78%, 7.94% and 16.32%. The OR (95% CI) of LUR and RALUR was 0.28 (0.16, 0.48) and 0.61 (0.24,1.3), respectively, compared with OUR. The MD (95% CI) of LUR and RALUR for operation time was 22 (2,40) and 46 (7.5,84), respectively, compared with OUR. The MD (95% CI) of LUR and RALUR for hospital stay was - 3.6 (- 4.5, - 2.7) and - 1.1 (- 2.9, 0.58), respectively, compared with OUR. There is no significant difference in the success rates of OUR, LUR, and RALUR. RALUR and OUR has similar complication rates and time of hospital stay, while LUR has fewer complications and faster time to discharge compared to RALUR and OUR. The operative time of OUR is significantly less compared to LUR and RALUR.

Open versus minimally invasive ureteroneocystostomy: trends and outcomes in a NSQIP-P cohort

Although surgical intervention has commonly been performed using an open approach for vesicoureteral reflux (VUR), this is rapidly changing due to adoption of minimally invasive surgery (MIS). Success rates with MIS are similar to open for re-implantation (> 90%); however, open ureteral re-implantation is still widely considered the gold standard. Using national surgical quality improvement program-pediatric (NSQIP-P) data, this manuscript evaluates recent large population trends of open versus robotic-assisted and laparoscopic ureteroneocystostomy for complications and factors associated with worse outcomes. Cases were identified in the 2012-2019 NSQIP-P database using the ureteroneocystostomy operative codes and vesicoureteral reflux post-operative diagnosis codes. A 1:1 propensity score match (PSM) analysis was performed comparing surgical outcomes while matching patients with similar characteristics to reduce bias. A total of 4183 patients were included; 621 patients with MIS and 3562 with open approach. Patients in the MIS approach tended to be older (67 months vs. 53 months) and non-Caucasian (12.9% vs. 6.3%) with no differences in other demographics. After 1:1 PSM, 30-day complications after ureteroneocystostomy showed no significant differences in readmission, reoperation, or extended hospital stay. A multivariate analysis found patients with CNS structural abnormalities (such as spina bifida) had 4.5 times greater odds of experiencing a reoperation (p value < 0.05). Similarly, patients with an ASA above two had 2.0 times greater odds of an UTI (p value < 0.05). The cohorts undergoing open and MIS approaches are well matched overall, without profound differences in outcomes overall.

Vesicoscopic Cross-Trigonal Ureteral Reimplantation for Vesicoureteral Reflux: Intermediate Results

For the treatment of vesicoureteral reflux, the introduction of vesicoscopic procedures offers new perspectives for improving patient comfort and quality. Our aim was to examine whether minimally invasive vesicoscopic cross-trigonal ureteral reimplantation (VCUR) would meet expectations. Between 2012 and 2021, 99 girls and 35 boys with high-grade vesicoureteral reflux (VUR) underwent VCUR. For two boys, we failed to establish the pneumovesicum, leading to conversion to open surgery. The mean age was 4.5 years, ranging from 10 months to 18 years. VCUR was successfully performed in 132 patients, including 75 patients with bilateral VUR and 12 children with double ureters with unilateral or bilateral VUR, corresponding to a total of 229 operated ureters. The mean time of operation was 151 min for all patients. There were no perioperative complications, with the exception of three cases of pneumoperitoneum without consequences. Postoperatively, we recognized three cases of acute hydronephrosis, two of them required transient drainage. Three patients developed extravasation of urine after the postoperative removal of the transurethral catheter, rapidly resolved by new drainage. In two patients, we combined VCUR with laparoscopic heminephrectomy and opposite laparoscopic nephrectomy, respectively. Overall, mean postoperative hospital stay was 4.2 days. We observed recurrent VUR in seven ureters, resulting in a success rate for VCUR of 96.9%. These results demonstrate the feasibility of VCUR and its potential to displace open surgery with high safety and wide applicability.

Armamentarium to treat primary vesicoureteral reflux in children

Primary vesicoureteral reflux often spontaneously resolves in children. However, in select patients, untreated reflux can contribute to recurrent pyelonephritis leading to irreversible renal damage. Management is therefore based on a given child's likelihood of recurrent urinary tract infections and risk of subsequent renal parenchymal injury. Therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose antibiotic prophylaxis to a variety of operative interventions.

Robot‑Assisted Laparoscopic Extra-Vesical Ureteral Reimplantation (Ralur/Revur) for Pediatric Vesicoureteral Reflux: A Systematic Review of Literature

This literature review aimed to assess the outcomes of robot-assisted laparoscopic extra-vesical ureteral reimplantation (RALUR/REVUR) in standard, complex and re-operative cases. Twenty-two studies (period 2008-2019) containing 1362 children receiving RALUR/REVUR, were included. Unilateral repair was faster compared to bilateral (P = .0000). The overall patient success rate was 92%. The mean post-operative complications rate was 10.7%. The mean re-operations rate was 3.9%. The available data show that RALUR/REVUR can be a first line surgical approach for pediatric vesicoureteral reflux at most centers with the caveat that learning curves for the surgeons are expected as with most new surgical procedures.

Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.

A systematic review and meta-analysis comparing outcomes of laparoscopic extravesical versus trans vesicoscopic ureteric reimplantation

OBJECTIVE

When considering treatment for vesico ureteric reflux via inimally invasive surgery there is a dilemma to choose between laparoscopic extravesical (LEVUR) and transvesicoscopic (TVUR) ureteric reimplantation. In this systematic review and meta-analysis we have analyzed the articles on LEVUR and TVUR and compared the outcomes.

METHODS

We searched the databases to identify all papers pertaining to TVUR and LEVUR in the pediatric population. Duplicate publications, review articles, incomplete articles and robotic assistance were excluded. Systematic review was performed to identify patient data, reflux grades, laterality, duration of surgery, time to discharge, success rate and complications. Meta-analysis of heterogeneity was reported with I 2 statistics. Once heterogeneity was found low, the pooled outcomes were compared with students t test and Fishers exact test, wherever appropriate.

RESULTS

After screening a total of 45 articles, 23 articles were included (13 articles on TVUR and 10 articles on LEVUR). The I 2 statistics for TVUR and LEVUR showed low heterogeneity with I 2 of 0% (95% C.I 0-37%) and 25% (95% C.I 0-64%) respectively. With low heterogeneity both were suitable to be considered to have been conducted under similar conditions with possibility of using fixed effect model. The percentage of Grade 5 VUR was significantly higher (p = 0.001; X 2) in TVUR (11.9%) compared to LEVUR (2.2%). The proportion of bilateral reimplantation was significantly higher (p = 0.001; X 2) in TVUR compared to LEVUR (summary table). The success rate of LEVUR was significantly higher at 96.7% compared to TVUR at 93.7% (p = 0.007 X 2). Unilateral/Bilateral TVUR took significantly longer duration of surgery (155/194 min vs 107/161 min) compared to LEVUR (p = 0.001; Fishers). The mean (s.d) time to discharge was longer at 3.2 (1.6) days for TVUR compared to 1.6 (0.4) days for LEVUR (p = 0.001; Fishers). The complication rate was comparable, 7.35% for TVUR and 5.35% for LEVUR (p = 0.167; X 2).

DISCUSSION

In this meta-analysis we found that LEVUR had shorter operating time, higher success, and shorter hospital stay compared to TVUR. A probable explanation could be higher number unilateral VURs and lower number of grade 5 VUR cases in LEVUR group. Both the techniques had comparable overall complication rate: LEVUR had more post-operative urinary retention while TVUR had more port-related problems.