Laparoscopic Dismemberment, Excisional Tailoring, Reimplantation with Antireflux: Megamanagement for Megaureter

Abstract

Introduction: The key issues for satisfactory reconstruction for obstructive megaureter entail bypassing the pathological segment and reduction of caliber of the dilated ureter and ureteroneocystostomy with antireflux construction. Because of complexity of these surgical exercises, incisional access has been the popular approach for definitive repair of obstructive megaureter.1 We present a video demonstration of laparoscopic reconstruction for obstructive megaureter. Methods: Children were selected after detailed evaluation, including presenting complaints, clinical parameters, and blood profile. The imaging protocol included ultrasonogram (USG), voiding cystourethrogram (VCUG), and magnetic resonance urogram. Renogram was performed to ensure salvagability of the pathological renal unit. Preoperative retrograde pyelogram was performed in all cases. Patients were positioned in Trendelenberg decubitus with shoulder support. Four ports were utilized: one 10-mm camera port and three 3-mm working ports. Ureteric adhesiolysis was carried out with limited usage of electrocautery. Dismemberment was performed at the level of pathological segment and all tortuosities straightened. The optimum length of the ureter for satisfactory reimplantation was determined and excess ureter was removed. Excisional tailoring with intracorporeal suturing was the next exercise. Only the lower 5 cm of the ureter was tapered. Bladder mobilization was then conducted and uretreic reimplantation was performed with placement of a ureteral stent across the ureterovesical anastomosis. An extravesical tunnel was then created and antireflux performed following the Lich Gregoir principle. Postoperatively, patients were allowed orally once comfortable and discharged home once fully ambulatory. Operative and postoperative parameters were recorded. Ureteral stents were removed at 6 weeks. All patients underwent 3 monthly follow-up. At 6 months and 1 year USG and VCUG was repeated. Results and Discussion: Since January 2006 till January 2010, eight cases of laparoscopic tailoring were performed for obstructive megaureter (nine units; seven unilateral and one bilateral). Mean age was 60.6 months. All patients were men. Mean body mass index was 16.44 kg/m2. Presenting complaints were flank pain (n=5) and recurrent urinary infection (n=8). All patients revealed obstructive megaureter in preoperative imaging study. All procedures were completed via laparoscopic approach. Mean operation duration was 158.33 minutes and mean blood loss was 79.16 mL. Mean duration of hospital stay was 2.5 days. No major intraoperative or postoperative happenings were recorded. All patients were asymptomatic at follow-up with stable renal profile. Follow-up imaging revealed decrease in ureteric and upper tract dilatation with satisfactory drainage in all. VCUG at 6 months revealed Grade I vesicoureteric reflux in one patient that resolved at 1 year on conservative management. Laparoscopic tailoring with intracoporeal suturing for obstructive megaureter has been performed by limited operators till date.2 Despite technical constraints, the procedure can be performed laparoscopically even for large caliber megaureters and the procedural morbidity and outcome is appreciable. No competing financial interests exist. Runtime of video: 6 mins 15 secs