Report of New Technique: Transvesicoscopic Politano-Leadbetter Ureteral Reimplantation

Abstract

Introduction: Advancements in endoscopic treatment and laparoscopic correction as minimally invasive surgical procedures have allowed them to increasingly replace open ureteral reimplantation in the management of high-grade vesicoureteral reflux (VUR). Most transvesicoscopic ureteroneocystostomies have been performed via the transtrigonal Cohen procedure, which lengthens the ureter across the bladder base to the opposite side. However, the Cohen procedure has the distinct disadvantage of making future transurethral endourological cannulation and stone operation practically impossible.1–3 We report our initial experience with transvesicoscopic ureteroneocystostomy through the Politano-Leadbetter technique, which uses a more orthotopic ureteral location. Materials and Methods: A 21-year-old man underwent bilateral laparoscopic transvesicoscopic Politano-Leadbetter ureteral reimplantation. The refluxing ureters were grade IV on the left and grade II on the right according to voiding cystourethrography (VCUG). Dissection and mobilization of the ureters is the same as in conventional transvesicoscopic reimplantation. In the extended supine position, we created a pneumovesical space and used three 5-mm working ports. We placed a tagging suture on the bladder mucosa at the inferior edge of the right ureteral orifice with a 5-0 monofilament. The ureters were mobilized with hook electrocautery. Mobilization of the ureters was continued until an adequate ureteral length of 2.5–3 cm was obtained, and the terminal part of the ureter was resected. The location of the new hiatus was selected in a straight line superior to the original orifice. The new hiatus was created blindly by passing a Diamond-Flex® laparoscopic articulating circular retractor (Snowden-Pencer, CareFusion, Waukegan, IL) from the original hiatus behind the bladder to perforate through the posterior wall of the bladder at the new hiatal orifice. The right ureter was extracted through the neohiatus, and the ureter was brought through the new tunnel to the original hiatus. Ureterovesical anastomosis was performed with intracorporeal suturing using 5-0 monofilament sutures at four points per ureteral orifice. The mucosal defect was closed with 5-0 absorbable interrupted sutures. Results and Conclusion: The whole procedure was accomplished without intraoperative or postoperative complication. The operative time was 175 minutes, and blood loss was minimal. Left ureteral stents were indwelled, but no drain was used. The patient was discharged 5 days after the operation. After 3 months, the bilateral reflux disappeared on the VCUG. The results from this case indicate that transvesicoscopic Politano-Leadbetter ureteral reimplantation appears to be an effective and safe treatment for high-grade VUR. The Politano-Leadbetter procedure creates a new ureteric orifice in a normal anatomical position, allowing ureteroscopic procedures. We used a laparoscopic circular retractor to create a neohiatus close to the bladder wall above the old orifice incision of the bladder mucosa. After preparation of a neohiatus by this unique method, a free suture was used to guide the ureter. The passage of the extravesically mobilized ureter through the neohiatus was achieved by pulling the free suture end intravesically. In the end, a submucosal tunnel preparation from the old to the new hiatus. The cross-trigonal technique is popular among pediatric urologists. In this technique, the ureter is detached from its attachments and moved across the trigone. This achieves a longer tunnel, while using the initial hiatus. The primary limitation of the technique is ureteral access following the procedure. In the proposed Politano-Leadbetter technique, the ureter is brought outside the bladder through a new orifice. The operator must be very careful not to trap the ureter or other tissue or to perforate the peritoneal space and its organs when the ureter is rerouted outside the bladder. The ureter is then brought into the neohiatus and down the new tunnel. This laparoscopic Politano-Leadbetter reimplantation technique is technically more complex and requires sufficient bladder capacity. Our new technique is an optional treatment to replace the open reimplantation approach. No competing financial interests exist. Runtime of video: 4 mins 25 secs