619 MODIFICATIONS IN TECHNIQUE LEADING TO IMPROVED SUCCESS OF ROBOTIC EXTRAVESICAL URETERAL REIMPLANATION

Abstract

INTRODUCTION AND OBJECTIVES: While initial series have reported high failure rates, success of robotic assisted laparoscopic extravesical ureteral reimplantation (RALUR) has now approached that of open surgery. Improved success is often accredited to increased experience without indicating any improvement to technique. We review the outcomes of our first patients to have RALUR and analyze success based on changes in our technique that have occurred over time. METHODS: Between November 2008 and June 2011, a single surgeon, MSG, performed RALUR on a total of 22 patients (35 ureters) with vesicoureteral reflux (VUR). Retrospective analysis of our prospectively maintained database was performed. Only patients with successful completion of RALUR and postoperative voiding cystourethrogram (VCUG) were included in analysis. Success was defined as complete resolution of VUR on VCUG. The surgical technique for RALUR and subsequent modifications were placed into the following categories: Use of simple interrupted stitches and detrussoraphy length (DL) of 3 cm (1), Running stitch with DL of 4 cm (2), Running stitch, incorporation of ureteral adventitia with detrussoraphy closure, and DL of 5 cm (3) (Figure1). RESULTS: 20 patients (8 unilateral and 12 bilateral ureters) fit inclusion criteria. On preoperative VCUG, 12 ureters had grade 3 and 18 ureters grade 4 VUR. In patients with bilateral VUR, one had unilateral grade 1 and one had unilateral grade 2 VUR. Average age at surgery was 5.2 years (range 2.8 – 7.9 years). Mean operative time was 193 minutes for unilateral and 216 minutes for bilateral surgery. Average length of stay was 2.2 days (range 1 to 4 days). One patient was discharged with a catheter for transient urinary retention. No patient required readmission after discharge. Overall, resolution of VUR was seen in 25 of 32 ureters (78%). Resolution of VUR based on surgical technique was 8 of 13 ureters (62%), 6 of 8 ureters (75%), and 11 of 11 ureters (100%) for techniques 1, 2, and 3 respectively. Average follow up was 337 days (range 98 to 889 days). De novo postoperative hydronephrosis was seen in 9 ureters (28%) and resolved in all cases. CONCLUSIONS: Improvement in surgical technique including use of a running stitch, incorporation of ureteral adventitia into closure of detrussoraphy and increasing DL have helped in improving our success of RALUR.