Technical description of the “LUAA” technique for robotic ureteric reimplantation

Abstract

IntroductionIn todays era of minimally invasive surgery, the robotic assisted laparoscopic ureteral reimplantation (RALUR) is being popularly performed at many centres world-over in the pediatric age group. Gundeti et al. published the “LUAA” technique to optimize the results. Through this article, we share the step-by-step technical details of the “LUAA” (L-length of ureteric tunnel, U- the u stitch at UVJ, A- placement of the ureteral apical alignment suture and A- ensuring inclusion of adequate ureteral adventitia in detrusorrhaphy) for bilateral ureteric reimplantation. MethodsA 4 years girl presented with recurrent urinary tract infections (UTI) in spite of appropriate antibiotic chemoprophylaxis for one year. Her ultrasound of the renal system showed bilateral hydronephrosis. Her voiding cystourethrogram (VCUG) was suggestive of bilateral vesico-ureteric reflux (VUR) with right grade 4 and left grade 3 reflux. The DMSA scan showed right side renal scars. For this, she underwent robotic assisted laparoscopic ureteral reimplantation- bilateral (RALUR-b) by the LUAA technique. After the usual port placement, ureteric identification and mobilization of the ureters on either side, certain steps during detrusorrhaphy have been protocolised. These included ensuring adequate length (L) by marking of the ureteric tunnels bilaterally. Secondly securing the ureter at the UVJ by the U stitch (U) taken at the inverted Y limb of the detrusor tunnel at the UVJ. This spares the dorso-medial neurovascular bundles at the UVJ. Thirdly placing the apical alignment stitch for the ureteric tunnel (A). Lastly ensuring adequate ureteric adventitia (A) being taken in alternate bites during continuous suturing from the proximal end (UVJ) to the apex of the ureteric tunnel. ResultsThe surgery was performed in 150 min (incision to closure). The Foleys catheter was removed after 48 h. The patient was discharged once she passed urine after the catheter removal. Oral analgesic was continued for 4 days. ConclusionThe “LUAA” technique allows us to follow the critical steps in stepwise fashion. It ensures uniformity and reproducibility of RALUR, especially in bilateral cases of VUR. It will allow us to standardize the procedure of RALUR, especially in the pediatric cases and ensure satisfactory results. However long term results of the LUAA technique would add weightage to this technique.